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Abigail E. Mitchell, Laura B. Sivitz, Robert E. Black, Editors
Committee on Gulf War and Health: Infectious Diseases
Board on Population Health and Public Health Practice

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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National
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Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this
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COMMITTEE ON GULF WAR AND HEALTH: INFECTIOUS DISEASES
ROBERT E. BLACK, MD, MPH, Edgar Berman Professor and Chair, Department of
International Health, Johns Hopkins University, Bloomberg School of Public Health,
Baltimore, MD
MARTIN J. BLASER, MD, Frederick H. King Professor of Internal Medicine, Chair of the
Department of Medicine, and Professor of Microbiology, New York University School of
Medicine, New York
RICHARD D. CLOVER, MD, Dean and Professor, School of Public Health and Information
Sciences, University of Louisville, KY
MYRON S. COHEN, MD, J. Herbert Bate Distinguished Professor of Medicine and
Microbiology, Immunology and Public Health, University of North Carolina School of
Medicine, Chapel Hill
JERROLD J. ELLNER, MD, Professor and Chair of the New Jersey Medical School at the
University of Medicine and Dentistry of New Jersey, Newark
JEANNE MARRAZZO, MD, MPH, Associate Professor, Department of Medicine, University
of Washington School of Medicine, Seattle
MEGAN MURRAY, MD, ScD, MPH, Assistant Professor of Epidemiology, Harvard
University, School of Public Health, Boston, MA
EDWARD C. OLDFIELD III, MD, Director, Division of Infectious Diseases, Eastern Virginia
Medical School, Norfolk
RANDALL R. REVES, MD, MSc, Professor, Division of Infectious Diseases, University of
Colorado Health Sciences Center, Denver
EDWARD T. RYAN, MD, Director, Tropical and Geographic Medicine Center, Massachusetts
General Hospital, and Associate Professor of Medicine, Harvard Medical School, Boston,
MA
STEN H. VERMUND, MD, PhD, Amos Christie Chair and Director, Vanderbilt University
Institute for Global Health, and Professor of Pediatrics, Medicine, Preventive Medicine,
and Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville,
TN
DAWN M. WESSON, PhD, Associate Professor, Tulane School of Public Health and Tropical
Medicine, New Orleans, LA
v
STAFF
ABIGAIL E. MITCHELL, PhD, Senior Program Officer

LAURA B. SIVITZ, MSJ, Senior Program Associate
DEEPALI M. PATEL, Senior Program Associate
MICHAEL J. SCHNEIDER, MPH, Senior Program Associate
PETER JAMES, Research Associate
DAMIKA WEBB, Research Assistant
DAVID J. TOLLERUD, Program Assistant
RENEE WLODARCZYK, Program Assistant
NORMAN GROSSBLATT, Senior Editor
ROSE MARIE MARTINEZ, ScD, Director, Board on Population Health and Public Health
Practice
vi
REVIEWERS
This report has been reviewed in draft form by persons chosen for their diverse
perspectives and technical expertise in accordance with procedures approved by the National
Research Council’s Report Review Committee. The purpose of this independent review is to
provide candid and critical comments that will assist the institution in making its published
report as sound as possible and to ensure that the report meets institutional standards of
objectivity, evidence, and responsiveness to the study charge. The review comments and draft
manuscript remain confidential to protect the integrity of the deliberative process. We wish to
thank the following for their review of this report:
Lawrence R. Ash, Professor Emeritus, Department of Epidemiology, University of California,

Los Angeles School of Public Health
Michele Barry, Tropical Medicine and International Health Programs, Yale University School
of Medicine
Herbert DuPont, School of Public Health, University of Texas Health Science Center at
Houston and St. Luke’s Episcopal Hospital
Robert Edelman, Travelers’ Health Clinic, University of Maryland
David Hill, National Travel Health Network and Centre, Hospital for Tropical Diseases, London
Richard T. Johnson, Department of Neurology, The Johns Hopkins Hospital
Arthur Reingold, Division of Epidemiology, University of California, Berkeley
Philip K. Russell, Professor Emeritus, Johns Hopkins School of Public Health
Mark Wallace, Independent Infectious Diseases Consultant and United States Navy, Retired
Although the reviewers listed above have provided many constructive comments and
suggestions, they were not asked to endorse the conclusions or recommendations nor did they
see the final draft of the report before its release. The review of this report was overseen by
George Rutherford, Institute of Global Health, University of California, San Francisco, and
Elaine L. Larson, School of Nursing, Columbia University. Appointed by the National Research
Council, they were responsible for making certain that an independent examination of this report
was carried out in accordance with institutional procedures and that all review comments were
carefully considered. Responsibility for the final content of this report rests entirely with the
authoring committee and the institution.
vii
PREFACE
Infectious diseases have been a problem for military personnel throughout history. The
consequences in previous conflicts have ranged from frequent illnesses disrupting daily activities
and readiness to widespread deaths. Preventive measures, early diagnosis, and treatment greatly
limit the exposures and acute illnesses of troops today in comparison with those in armies of the
past, but infections and consequent acute illnesses still occur. In addition, long-term adverse
health outcomes of some pathogens are increasingly recognized.
The deployment of about 700,000 US troops to the Persian Gulf region in the Gulf War
of 1991 potentially exposed them to pathogens that they had not encountered at home. After
returning from that short campaign, some veterans reported symptoms and expressed the concern
that they may have been exposed to biologic, chemical, or physical agents during their service in
the Persian Gulf. In response to those concerns, the US Department of Veterans Affairs (VA)
commissioned the Institute of Medicine (IOM) to review the scientific evidence on possible
long-term adverse health outcomes of exposure to specific biologic, chemical, and physical
agents and to draw conclusions on the strength of that evidence with regard to delayed and
chronic illnesses of the veterans.
The authorizing legislation for the work of IOM included several infectious diseases
endemic in the Persian Gulf region. In the charge to our committee, VA asked that we not limit
consideration to those diseases but rather include all infectious exposures that had been
documented in troops and consider their possible long-term adverse health outcomes. It further
requested that the time and geographic dimensions of the committee’s work be widened to
include military personnel deployed as part of Operation Enduring Freedom (OEF) in
Afghanistan and Operation Iraqi Freedom (OIF) in the Persian Gulf region. OEF began in 2001,
and OIF in 2003; they continued as this report went to press. The number of military personnel
involved in the more recent conflicts now exceeds that in the 1991 Gulf War. Furthermore, they
have remained for much longer periods on the average than in the Gulf War, and many have
been deployed for more than one tour in this region. Thus, the potential for exposure to endemic
pathogens is greater in these troops than in those deployed to the Gulf War. Because the possible
exposures are relatively recent, there has been only a short time to observe long-term adverse
health outcomes. The committee needed to rely on observations from the Gulf War, information
on infectious diseases in OEF and OIF, and evidence in the scientific literature to allow
conclusions to be drawn on possible long-term adverse health outcomes. With further time to
observe the possible consequences of infectious exposures, the knowledge base will increase.
Given the continuing presence of troops in the areas and the variable nature of infectious
diseases, the exposures may change.
Valuable contributions were made to this study by a number of people who shared their
expertise on infectious diseases. On behalf of the committee, I thank several of them—K. Craig
Hyams, MD, MPH, chief consultant, Occupational and Environmental Health Strategic
Healthcare Group, VA; Michael Kilpatrick, MD, deputy director, Deployment Health Support,
Department of Defense (DOD); and Alan Magill, MD, science director, Walter Reed Army
Institute of Research, for presenting information on infectious diseases that have been diagnosed
in military personnel during the Gulf War, OIF, and OEF and Richard Reithinger, PhD,
ix
x PREFACE
infectious diseases consultant, for presenting information on infectious diseases that are endemic
in southwest and south-central Asia to the committee at its May 26, 2005 meeting. I also thank
William Winkenwerder, Jr., MD, MBA, assistant secretary for defense for health affairs, and his
staff at DOD’s Deployment Health Support for expeditiously providing information to the
committee on DOD health-related policies. Finally, the committee is grateful for the insight
provided by representatives of veteran service organizations, veterans, and others who spoke
with the committee or sent in written testimony.
I am grateful for the great expertise the committee members brought to bear on this
subject. Furthermore, the report would not have been successfully completed without the diligent
and expert contributions of the IOM staff, led by Abigail Mitchell and including Laura Sivitz,
Deepali Patel, Michael Schneider, Peter James, Damika Webb, David Tollerud, and Renee
Wlodarczyk.
Robert E. Black, MD, MPH, Chair

CONTENTS
Summary ....................................................................................................................................1
Methodology .........................................................................................................................1
Identifying the Pathogens to Study.....................................................................................2
Development of Conclusions..............................................................................................3
Summary of Conclusions ......................................................................................................4
Sufficient Evidence of a Causal Relationship ....................................................................4
Sufficient Evidence of an Association................................................................................5
Limited or Suggestive Evidence of an Association............................................................6
Inadequate or Insufficient Evidence to Determine Whether an Association Exists...........6
Limited or Suggestive Evidence of No Association...........................................................7
Department of Defense Policies on Tuberculin Skin Testing and Predeployment and
Postdeployment Serum Collection ...................................................................................7
1 Introduction...........................................................................................................................9
Identifying the Infectious Diseases to Study.......................................................................13
The Committee’s Approach to Its Charge ..........................................................................15
Organization of the Report..................................................................................................16
References ...........................................................................................................................16
2 Methodology .......................................................................................................................19
Identifying the Infectious Diseases to Study.......................................................................19
Geographic Boundaries ....................................................................................................19
Infectious Diseases Endemic to Southwest and South-Central Asia
That Have Long-Term Adverse Health Outcomes .....................................................20
Direct Attribution to Military Service in Southwest and South-Central Asia ..................24
Timing of Appearance of Long-Term Adverse Health Outcomes ...................................27
The Infectious Diseases to Be Studied for Strength of Association
with Long-Term Adverse Health Outcomes...............................................................27
Comments on Diseases and Agents of Special Interest
to Gulf War, OEF, and OIF Veterans ..........................................................................28
Review and Evaluation of the Literature ............................................................................29
Selection of the Literature ................................................................................................29
Amassing the Literature....................................................................................................29
Reviewing the Literature ..................................................................................................29
Categories of Strength of Association.................................................................................30
Origin and Evolution of the Categories ............................................................................30
Sufficient Evidence of a Causal Relationship ..................................................................30
Sufficient Evidence of an Association..............................................................................31
Limited or Suggestive Evidence of an Association..........................................................31
Inadequate or Insufficient Evidence to Determine Whether an Association Exists.........31
xi
xii CONTENTS
Limited or Suggestive Evidence of No Association.........................................................31

References.........................................................................................................................31
3 Infectious Diseases Endemic to Southwest and South-Central Asia

That Have Long-Term Adverse Health Outcomes .............................................................35
References ...........................................................................................................................60
4 Infectious Diseases Diagnosed in US Troops Who Served in the Persian Gulf War,
Operation Enduring Freedom, or Operation Iraqi Freedom................................................61
Diarrheal Disease ................................................................................................................62
Enteric Infections in the Gulf War....................................................................................62
Gastroenteritis in Operation Enduring Freedom and Operation Iraqi Freedom ...............69
Respiratory Disease.............................................................................................................74
Mild Acute Respiratory Disease in the Gulf War.............................................................74
Severe Acute Respiratory Disease in the Gulf War..........................................................76
Respiratory Disease in Operation Enduring Freedom and Operation Iraqi Freedom ......76
Insect-Borne Diseases .........................................................................................................78
Leishmaniasis ...................................................................................................................78
Malaria..............................................................................................................................82
West Nile Fever ................................................................................................................84
Brucellosis...........................................................................................................................84
Chicken Pox (Varicella)......................................................................................................85
Meningococcal Disease.......................................................................................................85
Nosocomial Infections ........................................................................................................85
Gulf War ...........................................................................................................................85
Operation Enduring Freedom and Operation Iraqi Freedom............................................86
Q Fever................................................................................................................................88
Q Fever Contracted During the Gulf War ........................................................................89
Q Fever Contracted During Operation Enduring Freedom
and Operation Iraqi Freedom .......................................................................................89
Viral Hepatitis .....................................................................................................................90
Tuberculosis ........................................................................................................................90
Department of Defense Medical Databases ........................................................................91
Department of Defense Policy Regarding Predeployment
and Postdeployment Serum Collection ..........................................................................93
References ...........................................................................................................................94
5 Levels of Association Between Select Diseases and

Long-Term Adverse Health Outcomes .............................................................................101
Diarrheal Diseases:
Campylobacter, Non-typhoid Salmonella, and Shigella Infections .............................103
Campylobacter Infection ................................................................................................103
Nontyphoidal Salmonella Infection................................................................................108
Shigella Infection............................................................................................................110
CONTENTS xiii
Brucellosis.........................................................................................................................112
Transmission and Endemicity of Brucellosis .................................................................113
Acute Brucellosis............................................................................................................114
Treatments for Brucellosis and Related Long-Term Toxicity........................................115
Coinfection .....................................................................................................................115
Long-Term Adverse Health Outcomes of Brucellosis ...................................................115
Leishmaniasis....................................................................................................................118
Transmission of Leishmaniasis.......................................................................................119
Endemicity in Southwest and South-Central Asia..........................................................120
Acute Leishmaniasis.......................................................................................................120
Diagnosis of Leishmaniasis ............................................................................................121
Treatments for Leishmaniasis and Related Long-Term Toxicity...................................121
Coinfection by Leishmania Parasite and Human Immunodeficiency Virus ..................122
Long-Term Adverse Health Outcomes of Leishmaniasis ..............................................122
Malaria ..............................................................................................................................123
Transmission of Malaria .................................................................................................124
Acute Malaria .................................................................................................................125
Treatments for Malaria and Related Long-Term Toxicity .............................................125
Coinfection with Plasmodium Spp. and Human Immunodeficiency Virus ...................126
Long-Term Adverse Health Outcomes of Infection with Plasmodium Spp...................126
Q Fever (Infection by Coxiella burnetii) ..........................................................................129
Transmission of Coxiella burnetii ..................................................................................129
Acute Q Fever.................................................................................................................130
Diagnosing Q Fever........................................................................................................131
Coinfection with Coxiella burnetii and Human Immunodeficiency Virus ....................131
Long-Term Adverse Health Outcomes of Q Fever ........................................................132
Tuberculosis ......................................................................................................................135
Transmission of Tuberculosis.........................................................................................135
Risk of Progression from Latent Tuberculosis Infection to Active Tuberculosis ..........137
Treatment for Latent Tuberculosis Infection to Prevent Active Tuberculosis ...............140
Active Tuberculosis ........................................................................................................140
Late Manifestations of Active Tuberculosis...................................................................142
Potential Relationships Between Tuberculosis and Military Service.............................144
West Nile Virus Infection .................................................................................................149
Transmission of West Nile Virus Infection ....................................................................150
Acute West Nile Fever....................................................................................................151
Diagnosis of West Nile Fever.........................................................................................151
Treatment of West Nile Virus Infection .........................................................................152
Long-Term Adverse Health Outcomes of Infection with West Nile Virus....................152
Recommendation ............................................................................................................155
References .........................................................................................................................155
xiv CONTENTS
6 Diseases and Agents of Special Concern to Veterans of the Gulf War, Operation Iraqi
Freedom, and Operation Enduring Freedom.....................................................................181
Al Eskan Disease ..............................................................................................................181
Description of Acute Illness ...........................................................................................182
Long-Term Adverse Health Outcomes...........................................................................182
Pathogenesis ...................................................................................................................182
Treatment........................................................................................................................183
Summary.........................................................................................................................183
Idiopathic Acute Eosinophilic Pneumonia........................................................................183
Description of Acute Illness ...........................................................................................183
Long-Term Adverse Health Outcomes...........................................................................183
Pathogenesis ...................................................................................................................184
Treatment........................................................................................................................184
Summary.........................................................................................................................184
Wound and Nosocomial Infections (Including Infections with Acinetobacter Spp.) ......184
Concerns Regarding Acinetobacter baumannii ..............................................................185
Other Wound Infections .................................................................................................186
Other Nosocomial Infections..........................................................................................187
Regional Experiences in Non-Americans.......................................................................188
Summary.........................................................................................................................190
Mycoplasmas ....................................................................................................................190
Mycoplasmas and “Gulf War Illness” ............................................................................191
Summary.........................................................................................................................193
Biologic-Warfare Agents ..................................................................................................193
Summary ...........................................................................................................................194
References .........................................................................................................................194
Appendix Biographical Sketches for Members of the Committee .......................................201
Index ......................................................................................................................................205
SUMMARY
Thousands of US veterans of the Persian Gulf War have reported an array of unexplained
illnesses since the war ended in 1991. Many veterans have believed that the illnesses were
associated with their military service in southwest Asia during the war. In response, the US
Congress legislated in 1998 that the Department of Veterans Affairs (VA) use a specific
procedure to determine the illnesses that warrant presumption of a connection to Gulf War
service (Public Law [PL] 105-277, Persian Gulf War Veterans Act). Moreover, VA must
financially compensate Gulf War veterans in whom the determined illnesses are diagnosed (PL
105-368, Veterans Programs Enhancement Act). To reach those determinations, the law states,
VA must obtain independent evaluations of the scientific evidence of associations between
illnesses and exposures to various chemical, physical, and biologic substances connected to
military service in southwest Asia during the war. The law instructs VA to obtain the scientific
evaluations from the National Academy of Sciences (NAS). NAS assigned the task of evaluating
the associations to the Institute of Medicine (IOM).
This report is the fifth volume produced by IOM for VA in response to the congressional
mandate.1 A committee of nationally recognized experts in infectious diseases was appointed and
charged with evaluating the scientific and medical literature on long-term adverse human health
outcomes associated with selected infectious diseases pertinent to Gulf War veterans. The
conclusions herein characterize the long-term adverse health outcomes associated with infection
by the following pathogens: Brucella species (spp.), the cause of brucellosis; Campylobacter
spp., nontyphoidal Salmonella spp. and Shigella spp., which cause diarrheal disease; Coxiella
burnetii, the cause of Q fever; Leishmania spp., the cause of leishmaniasis; Mycobacterium
tuberculosis, which causes tuberculosis; Plasmodium spp., the cause of malaria; and West Nile
virus, the cause of West Nile fever. The committee identified those pathogens through the
process outlined below. The committee then developed conclusions by studying the relevant
published evidence, deliberating to reach consensus, and responding to a formal process of peer
review.2
METHODOLOGY
IOM appointed the Committee on Gulf War and Health: Infectious Diseases in January
2005. The committee considered infections that US troops might have contracted in southwest
Asia during the Persian Gulf War. At VA’s request, the committee also examined infections that
might have afflicted US military personnel deployed to south-central and southwest Asia for
Operation Enduring Freedom (OEF)3 and Operation Iraqi Freedom (OIF).4 Thus, the
committee’s deliberations covered infectious diseases known to occur in Saudi Arabia, Kuwait,
Iraq, Afghanistan, and most countries along their borders (Yemen, Oman, United Arab Emirates,
1
Earlier IOM reports in this series present conclusions about long-term adverse health outcomes associated with
exposure to depleted uranium, pyridostigmine bromide, sarin, vaccines, insecticides, solvents, propellants,
combustion products, and fuels.
2
A detailed description of how IOM studies are conducted appears at www.iom.edu/?id=32248.
3
OEF began on October 7, 2001, in Afghanistan.
4
OIF began on March 19, 2003.
1
2 GULF WAR AND HEALTH
Qatar, Bahrain, Jordan, Israel, Lebanon, Syria, Iran, Turkmenistan, Uzbekistan, Tajikistan,
Kyrgyzstan, and Pakistan).
Identifying the Pathogens to Study
The committee first identified about 100 naturally occurring pathogens that could
potentially have infected US troops during their service in the Gulf War, OEF, or OIF. The
identified pathogens comprise viruses, bacteria, helminths, and protozoa that have been reported
in southwest and south-central Asia, have historically caused outbreaks of illness in military
populations, or have generated particular concern among US veterans of the Persian Gulf War.
As required by PL 105-277 and PL 105-368, the pathogens include Escherichia coli, Shigella
spp., Leishmania spp., and the Phlebovirus pathogens that cause sand fly fever.
Definition of Long-Term Adverse Health Outcome

The committee then developed a set of criteria for determining which infectious diseases
to evaluate for strength of association with specific long-term adverse health outcomes. Long-
term adverse health outcomes include secondary diseases or conditions (sequelae) caused by
primary diseases, reactivation or recrudescence of diseases, and delayed presentation of diseases.
A long-term adverse health outcome, the committee agreed, should have one or more of the
following characteristics:
• Significant interruption of normal physical and mental function outside the timeframe of acute
infection.
• Persistent organ dysfunction or damage.
• Reproductive effects in military personnel, including birth defects in their offspring.
In addition, a long-term adverse health outcome could be reversible, related to secondary

transmission,5 or both.
Development of Inclusion Criteria

Given that definition, the committee identified about 90 infectious diseases that have
long-term adverse health outcomes and that were any of the following:
• Endemic in southwest or south-central Asia during the period in question.

• Diagnosed in US troops during the three deployments under study.
• Of special concern to Gulf War, OIF, or OEF veterans.
• Historically reported among military populations.
Many of the diseases have never been reported in US military personnel in close temporal
relationship to deployment to southwest or south-central Asia for the Gulf War, OEF, or OIF.
Even so, the committee could not rule out the possibility that one or more people contracted an
unreported disease during deployment. Consequently, the committee created a tabular summary
of such diseases’ acute and long-term characteristics.
5
In this context, secondary transmission means the spread of a pathogen directly from a primary human host to one
or more other humans.
SUMMARY 3
The committee further defined its infections of focus according to the likelihood that the
primary infection would be subacute or the infected person would be asymptomatic for days to
years, and the adverse health outcome would begin months to years after infection. In such cases,
diagnosis of the long-term adverse health outcome during military service in Asia would be
unlikely, and such infections were candidates for in-depth review and conclusions. In contrast,
military medical personnel would probably diagnose adverse health outcomes that are manifest
during the acute illness or shortly after a person’s deployment.
Finally, the committee examined the likelihood that the candidate infections would have
occurred specifically during military deployment to southwest and south-central Asia during the
three operations in question. The risk of contracting the disease in the theater of operations must
have been equal to or greater than the risk of contracting it in the United States. Moreover, given
the natural history of the disease or infection, it must have been diagnosed in US troops in
appropriate temporal relationship to deployment.
By applying those criteria to the dozens of infectious diseases recognized initially, the
committee identified the group that required in-depth evaluation and conclusions: brucellosis,
Campylobacter infection, leishmaniasis, malaria, Q fever, salmonellosis, and shigellosis. Two
other diseases did not meet all the criteria but still merited in-depth evaluation: tuberculosis and
West Nile virus infection.
Tuberculosis (TB) could cause long-term adverse health outcomes in US troops and
veterans deployed to southwest and south-central Asia, where TB is highly endemic. TB has a
long history of activation and transmission in military settings. Moreover, about 2.5% of military
personnel deployed to OEF and OIF and given predeployment and postdeployment skin tests for
TB converted from negative to positive; that is, these troops acquired new TB infections during
deployment.6 Therefore, although the committee found no published reports of active TB cases
among the troops in question, conclusions about the long-term adverse health outcomes of TB
infection are quite pertinent.
Unlike TB, West Nile virus (WNV) has been reported in troops deployed to southwest
and south-central Asia, where the virus is endemic. The long-term adverse health outcomes
associated with WNV infection are usually manifest during the acute illness—a characteristic
that disqualified other diseases from comprehensive evaluation in this report. Nevertheless,
dramatic changes in the epidemiology of WNV since the mid-1990s led the committee to make
an exception for WNV and to review it in depth.
In addition, a small set of biologic agents, infections, and diseases that failed to meet the
committee’s inclusion criteria nevertheless raised serious questions that merited discussion: Al
Eskan disease, biowarfare agents, idiopathic acute eosinophilic pneumonia, mycoplasmal
infection, and wound infection (including wound infection caused by Acinetobacter baumanii,
the most notable pathogenic colonizer of wounds during OEF and OIF).
Development of Conclusions
Identifying the Literature to Review and Evaluate

Conducting extensive searches of the biomedical and epidemiologic peer-reviewed
literature on the diseases identified for study yielded about 20,000 potentially relevant
6
Kilpatrick ME. 2005. Presentation to IOM Committee on Gulf War and Health: Infectious Diseases. Washington,
DC.
references. On closer examination, some 1,200 references appeared to provide the requisite types
and quality of scientific evidence for this study.
Assessing the Strength of the Evidence

By evaluating the evidence in the published scientific literature, the committee
determined the relationships between each of the nine diseases of interest and specific adverse
health outcomes that might appear weeks to years after the primary infection. Those relationships
are conceived in terms of the strength of association between the primary infection and a specific
long-term adverse health outcome.
The committee framed its conclusions in categories, described below, that qualitatively
rank the strength of the evidence of an association. Used by many previous IOM committees,
including those in the Gulf War and Health series, this five-tier framework was adapted from the
system used by the International Agency for Research on Cancer to evaluate evidence of the
carcinogenicity of various agents.
SUMMARY OF CONCLUSIONS
Sufficient Evidence of a Causal Relationship
The evidence is sufficient to conclude that there is a causal relationship

between exposure to a specific agent and a specific health outcome in
humans. The evidence is supported by experimental data and fulfills the
guidelines for sufficient evidence of an association (defined below). The
evidence must be biologically plausible and must satisfy several of the
guidelines used to assess causality, such as strength of association, a dose–
response relationship, consistency of association, and a temporal
relationship.
The committee concludes that there is sufficient evidence of a causal relationship between
• Coxiella burnettii infection (Q fever) and osteomyelitis.

• Malarial infection and
o Ophthalmologic manifestations, particularly retinal hemorrhage and scarring,
recognized for the first time months or years after the infection.
o Hematologic manifestations weeks or months later, particularly anemia after
falciparum malaria and splenic rupture after vivax malaria.
o Renal disease, especially the nephrotic syndrome that may occur weeks to months
after acute infection.
o Late presentation of disease (Plasmodium malariae) or relapse of disease
(Plasmodium ovale or Plasmodium vivax) months to years after acute infection.
• Mycobacterium tuberculosis infection and occurrence of active TB months to decades after
infection.
SUMMARY 5
Sufficient Evidence of an Association
The evidence from available studies is sufficient to conclude that there is

an association. A consistent association has been observed between
exposure to a specific agent and a specific health outcome in human
studies in which chance and bias, including confounding, could be ruled
out with reasonable confidence. For example, several high-quality studies
report consistent associations and are sufficiently free of bias, including
adequate control for confounding.
The committee concludes that there is sufficient evidence of an association between
• Brucellosis and
o Arthritis and spondylitis; arthritis usually is manifest within 12 months of the acute
illness, and spondylitis might be manifest later.
o Hepatic abnormalities, including granulomatous hepatitis.
o Chronic meningitis and meningoencephalitis.
o Uveitis.
o Orchioepididymitis and infections of the genitourinary system.
o Cardiovascular, nervous, and respiratory system infections.
• Campylobacter jejuni infection and Guillain-Barré syndrome (GBS) if GBS is manifest within
2 months of the infection.
• Campylobacter infection and reactive arthritis (ReA) if ReA is manifest within 3 months of
the infection; most cases of ReA are manifest within 1 month of the infection.
• Coxiella burnetii infection (Q fever) and
o Endocarditis years after primary infection.
o Vascular infection years after primary infection.
o Chronic hepatitis years after primary infection.
• Plasmodium malariae infection and manifestation of immune-complex glomerulonephritis
years to decades later.
• Plasmodium falciparum infection and recrudescence weeks to months after the primary
infection, but only in the case of inadequate therapy.
• Nontyphoid Salmonella infection and ReA if ReA is manifest within 3 months of the
infection.
• Shigella infection and
o Hemolytic-uremic syndrome (HUS) if HUS is manifest within 1 month of the
infection; most cases of HUS are manifest within 10 days of the infection.
o ReA if ReA is manifest within 3 months of the infection; most cases of ReA are
manifest within 1 month of the infection.
• Active TB and long-term adverse health outcomes due to irreversible tissue damage from
severe forms of pulmonary and extrapulmonary TB.
• Visceral leishmaniasis (kala-azar) and
o Delayed presentation of the acute clinical syndrome.
o Reactivation of visceral leishmaniasis in the context of future immunosuppression.
o Post-kala-azar dermal leishmaniasis (PKDL) if PKDL occurs generally within 2 years
of the initial infection.
• West Nile virus infection and variable physical, functional, or cognitive disability, which may
persist for months or years or be permanent.
Limited or Suggestive Evidence of an Association
The evidence from available studies suggests an association between

exposure to a specific agent and a specific health outcome in human
studies, but the body of evidence is limited by the inability to rule out
chance and bias, including confounding, with confidence. For example, at
least one high-quality study reports an association that is sufficiently free
of bias, including adequate control for confounding. Other corroborating
studies provide support for the association, but they were not sufficiently
free of bias, including confounding. Alternatively, several studies of less
quality show consistent associations, and the results are probably not due
to bias, including confounding.
The committee concludes that there is limited or suggestive evidence of an association
between
• Brucellosis and
o Myelitis-radiculoneuritis, demyelinating meningovascular syndromes, deafness,
sensorineural hearing loss, and GBS.
o Papilledema, optic neuritis, episcleritis, nummular keratitis, and multifocal
choroiditis.
o Fatigue, inattention, amnesia, and depression.
• Campylobacter jejuni infection and development of uveitis if uveitis is manifest within 1
month of infection.
• Coxiella burnetii infection and post-Q-fever chronic fatigue syndrome years after the primary
infection.
• Plasmodium falciparum infection and neurologic disease, neuropsychiatric disease, or both
months to years after the acute infection.
• Plasmodium vivax and Plasmodium falciparum infections and demyelinating polyneuropathy
and GBS.
Inadequate or Insufficient Evidence to Determine Whether an Association Exists
The evidence from available studies is of insufficient quantity, quality, or

consistency to permit a conclusion regarding the existence of an
association between exposure to a specific agent and a specific health
outcome in humans.
For some potential long-term adverse health outcomes of the nine identified diseases, the
evidence of an association is inadequate, insufficient, or both. The committee presents these
potential long-term adverse health outcomes and their characteristics in tabular form in the body
of the report.
SUMMARY 7
Limited or Suggestive Evidence of No Association
Evidence from well-conducted studies is consistent in not showing an

association between exposure to a specific agent and a specific health
outcome after exposure of any magnitude. A conclusion of no association
is inevitably limited to the conditions, magnitudes of exposure, and length
of observation in the available studies. The possibility of a very small
increase in risk after exposure cannot be excluded.
For many potential long-term adverse health outcomes of the nine identified diseases,
there is no evidence of an association. In this report, the committee focused on identifying
positive associations between specific infectious diseases and specific long-term adverse health
outcomes and did not present the numerous long-term adverse health outcomes for which there is
no association.
DEPARTMENT OF DEFENSE POLICIES ON TUBERCULIN SKIN TESTING AND

PREDEPLOYMENT AND POSTDEPLOYMENT SERUM COLLECTION
Each branch of the US military has polices regarding tuberculin skin testing and
treatment of latent TB infection (LTBI). The most effective way to mitigate TB transmission and
activation is to identify and treat for LTBI. In addition, the only way to determine whether
military personnel and reservists have become infected with M. tuberculosis during their service
is to test all personnel for TB shortly before and after deployment. Such testing would make it
possible to trace cases of active TB to periods of military service if that is when infection
occurred.
Department of Defense (DOD) policy specifies that predeployment serum specimens for
medical examinations will routinely be collected within 1 year of deployment and that
postdeployment serum specimens for medical examinations will be collected no later than 30
days after arrival at the demobilization site, home station, or in-patient medical treatment facility.
The committee agrees with DOD’s overall policy regarding collection and use of serum
specimens. However, for banked serum specimens to be most useful for determining whether
infectious exposures occurred during deployment, the predeployment specimens need to be
collected before travel. Current policy allows for collection of predeployment serum specimens
up to 1 year after deployment. If the collection of serum is not done until after deployment, it
would be difficult to ascertain whether any signs of infection found in the “predeployment”
specimen are due to exposure during the current deployment or before it.
1
INTRODUCTION
Five days after the Iraqi invasion of Kuwait on August 2, 1990, the United States
deployed troops to Operation Desert Shield (ODSh). The United States attacked Iraqi armed
forces by air on January 16, 1991, and this marked the beginning of Operation Desert Storm
(ODSt). The ground war began on February 24, 1991, and ended 4 days later. The official cease-
fire took effect on April 11, 1991, and the last troops to participate in the ground war arrived
back in the United States on June 13, 1991. In this report, ODSh and ODSt are also referred to
collectively as the Gulf War.
About 697,000 US troops were deployed to the Persian Gulf during ODSh and ODSt.
Figure 1.1 depicts the size of the US military presence in the Persian Gulf from August 1990
through June 1991. The war was considered to be a successful military operation, and there were
few injuries and deaths.
Shortly after returning to the United States, a number of veterans started reporting a
variety of symptoms—fatigue, headache, muscle and joint pain, sleep disturbances, and
cognitive difficulties (Persian Gulf Veterans Coordinating Board 1995). The veterans were
concerned that they might have been exposed to chemical, biologic, or physical agents during
their deployment to the Persian Gulf and that those exposures might be responsible for their
unexplained illnesses.
9
10
Approximate Number of Troops Deployed

(Thousands)
600
500
400
300
200
100
0
Operation Desert Shield (ODSh) Period of Combat
August September October November December January February March April May June July
1990 1991
8/7/90: First US troops arrive in 1/16/91: 4/11/91: 6/13/91: Last US troops
Arabian Peninsula for Operation Desert Operation Desert Official to participate in ground
Shield Storm (ODSt) cease-fire war arrive back in US
begins takes effect
FIGURE 1.1 Operation Desert Shield and Operation Desert Storm: key dates and size of US military presence in theater.
SOURCE: DOD 2006; IOM 2000; PAC 1996.
INTRODUCTION 11
In response to the concerns of the Gulf War veterans about their unexplained illnesses,
the US Department of Veterans Affairs (VA) asked the Institute of Medicine (IOM) to conduct a
study to evaluate the scientific literature on chemical, biologic, and physical agents to which
military personnel in the gulf were potentially exposed and possible long-term adverse health
outcomes. In addition, Congress passed two laws in 1998—the Persian Gulf War Veterans Act
(PL 105-277) and the Veterans Programs Enhancement Act (PL 105-368)—that called for the
review of the scientific literature on specified agents with regard to long-term adverse health
outcomes. That legislation directs IOM to study a number of diverse chemical, biologic, and
physical agents (listed in Box 1.1). IOM divided the task into several reviews. It has completed
four reports: Gulf War and Health, Volume 1: Depleted Uranium, Pyridostigmine Bromide,
Sarin, Vaccines (IOM 2000); Gulf War and Health, Volume 2: Insecticides and Solvents (IOM
2003); Gulf War and Health Volume 3: Fuels, Combustion Products, and Propellants (IOM
2005); and Gulf War and Health, Volume 4: Health Effects of Serving in the Gulf War (IOM
2006). The present report is the fifth volume in the series. An additional, related report has also
been published: Gulf War and Health: Updated Literature Review of Sarin (IOM 2004).
Since VA asked IOM to conduct the above-mentioned study and PL 105-277 and PL
105-368 were enacted, the United States has again entered into military conflicts in southwest
and south-central Asia—Operation Enduring Freedom (OEF) and Operation Iraqi Freedom
(OIF). Therefore, VA has asked IOM to make this report relevant to the military personnel
serving in OEF and OIF in addition to those who served in the 1991 Gulf War.
BOX 1-1 Agents Specified in PL 105-277 and PL 105-368
• The following organophosphorus pesticides:

o Chlorpyrifos
o Diazinon
o Dichlorvos
o Malathion
• The following carbamate pesticides:
o Proxpur
o Carbaryl
o Methomyl
• The carbamate pyridostigmine bromide used as nerve-agent prophylaxis
• The following chlorinated hydrocarbons and other pesticides and repellents:
o Lindane
o Pyrethrins
o Permethrins
o Rodenticides (bait)
o DEET (repellent)
• The following low-level nerve agents and precursor compounds at exposures below those which produce
immediately apparent incapacitating symptoms:
o Sarin
o Tabun
• The following synthetic chemical compounds:
o Mustard agents at exposures below those which cause immediate blistering
o Volatile organic compounds
o Hydrazine
o Red fuming nitric acid
o Solvents
• The following sources of radiation:
o Depleted uranium
o Microwave radiation
o Radio frequency radiation
• The following environmental particulates and pollutants:
o Hydrogen sulfide
o Oil fire byproducts
o Diesel heater fumes
o Sand micro-particles
• Diseases endemic to the region (including the following):
o Leishmaniasis
o Sand fly fever
o Pathogenic Escherichia coli
o Shigellosis
• Time compressed administration of multiple live, ‘‘attenuated’’ and toxoid vaccines
INTRODUCTION 13
IDENTIFYING THE INFECTIOUS DISEASES TO STUDY
In accordance with PL 105-277 and PL 105-368, IOM appointed the Committee on Gulf
War and Health: Infectious Diseases and tasked it to review, evaluate, and summarize the peer-
reviewed scientific and medical literature on long-term adverse health outcomes associated with
selected infectious diseases pertinent to service in the Gulf War. The infectious diseases can
include, but are not limited to, pathogenic Escherichia coli infection, shigellosis, leishmaniasis,
and sand fly fever.
VA is also concerned about potential long-term adverse health outcomes of infectious
diseases in veterans of OEF and OIF. As of October 2005, about 1.2 million US troops have been
deployed to OEF or OIF (see Figure 1.2). VA asked IOM to evaluate infectious diseases
pertinent to service in OEF and OIF.
It should be noted that the charge to IOM was not to determine whether a unique Gulf
War syndrome or Gulf War illness exists or to make judgments about whether individual
veterans were exposed to specific pathogens. Nor was the charge to focus on broader issues, such
as the potential costs of compensation for veterans or policy regarding compensation; such
decisions are the responsibility of the secretary of veterans affairs.
14
Approximate Number of Troops Deployed

(Thousands)
450
400
350
300
250
200
150
100
50
September January May Sept January May Sept January May September January May September
2001 2002 2003 2004 2005
10/7/01 3/19/03
Operation Enduring Operation Iraqi
Freedom begins Freedom begins
FIGURE 1.2 Operation Enduring Freedom and Operation Iraqi Freedom: key dates and size of US military presence in theater.
SOURCE: Personal Communication, Michelle Rudolph, Branch Chief, Defense Manpower Data Center, December 15, 2005.
INTRODUCTION 15
THE COMMITTEE’S APPROACH TO ITS CHARGE
A brief overview of how the committee approached its charge is presented here. A more
comprehensive explanation is provided in Chapter 2.
The committee identified numerous infectious diseases to which Gulf War, OIF, and OEF
military personnel might have been exposed during their deployment. Dozens of infectious
diseases are endemic to southwest and south-central Asia, which includes Iraq, Kuwait, and
Afghanistan. The committee then determined which of the endemic infectious diseases are
known to have long-term adverse health outcomes. To determine which infectious diseases to
review in depth, the committee took several factors into account, including which ones were
diagnosed in military personnel who served in the Gulf War, OEF, or OIF and in veterans after
they returned home, as well as the prevalence of the infectious diseases in southwest and south-
central Asia compared with their prevalence in the United States.
Overall, the incidence of infectious diseases among Gulf War military personnel was low
(Hyams et al. 1995). Acute diarrheal and acute respiratory diseases were the major causes of
morbidity from infectious diseases (Hyams et al. 1995; Hyams et al. 2001). The outbreaks of
diarrhea were due primarily to enterotoxigenic Escherichia coli and Shigella sonnei. Some 12
cases of viscerotropic leishmaniasis and 20 cases of cutaneous leishmaniasis were diagnosed in
Gulf War military personnel (Hyams et al. 1995; Hyams et al. 2001). Other reported infectious
diseases included Q fever (three cases), West Nile fever (one case), and malaria (seven cases)
(Hyams et al. 1995; Hyams et al. 2001).
Infectious diseases reported in troops who served in OEF and OIF as of December 2005
are visceral and cutaneous leishmaniasis, malaria, diarrheal disease, respiratory disease,
tuberculosis infection (but not active tuberculosis), Q fever, brucellosis, and Acinetobacter
baumannii infection (Kilpatrick 2005). Chapter 4 reviews the literature on infectious diseases
that have been diagnosed in military personnel during or shortly after returning from the Gulf
War, OIF, or OEF.
The committee identified for comprehensive evaluation nine infectious diseases known to
have long-term adverse health outcomes that were diagnosed in military personnel who served in
the Gulf War, OEF, or OIF. Some information is presented on a number of other infectious
diseases as well because they are endemic to southwest and south-central Asia, although there
have been no reported cases in military personnel through December 2005. It is possible that
military personnel have become infected but that no diagnosis was made either because no acute
symptoms were present or because the symptoms were mild and the soldier who had them did
not seek medical care. We also present information on diseases and agents of special concern to
veterans of the Gulf War, OEF, and OIF (Al Eskan disease, acute eosinophilic pneumonia,
Acinetobacter baumannii infection, mycoplasmas, and biological warfare agents).
After determining which infectious diseases it would evaluate, the committee had to
identify the relevant literature for review. The committee relied primarily on peer-reviewed
published literature in developing its conclusions. It also consulted other material, such as
surveillance reports, technical reports, and textbooks, and it obtained additional information from
experts in infectious diseases of southwest and south-central Asia, from Deployment Health
Support at the Department of Defense (DOD), from Walter Reed Army Institute of Research,
from the VA Occupational and Environmental Health Strategic Healthcare Group, and from
veteran service organizations and Gulf War veterans. The committee focused on medical and
scientific data on long-term adverse health outcomes related to the infectious diseases it selected
for study.
The final step in the committee’s evaluation process was to weigh the evidence on the
infectious diseases and their long-term adverse health outcomes and to develop conclusions
about the strength of the evidence. The conclusions are assigned to categories of association,
which range from sufficient evidence of a causal relationship to insufficient or inadequate
evidence of an association.
This report includes discussion of acute diseases with potential long-term adverse health
outcomes caused by known pathogens. The committee acknowledges that there might be
clinically important pathogens that cannot be detected with available cultivation techniques
(Relman 2002). Because the extent to which such pathogens might contribute to acute illnesses
in military personnel is unknown, it is not possible to define a relationship between them and an
acute illness or long-term adverse health outcome.
ORGANIZATION OF THE REPORT
Chapter 2 lays out the committee’s process for selecting the infectious diseases to study
and reviewing and evaluating the evidence on them. Chapter 3 presents, in tabular format, the
endemic infectious diseases of southwest and south-central Asia that are known to have long-
term adverse health outcomes. Chapter 4 summarizes the body of literature on infectious diseases
that have been diagnosed in military personnel serving in the Gulf War, OIF, and OEF. The
committee’s comprehensive evaluations of selected infectious diseases are presented in Chapter
5, which also contains the committee’s conclusions. The final chapter, Chapter 6, presents
information about diseases and agents of special concern to veterans of the Gulf War, OIF, and
OEF that have an infectious component or have been implicated as a cause of “Gulf War
illness”.
REFERENCES
DOD (Department of Defense). 2006. US Department of Defense Official Website. [Online].

Available: http://www.defenselink.mil/ [accessed March 2006].
Hyams KC, Hanson K, Wignall FS, Escamilla J, Oldfield EC, 3rd. 1995. The impact of
infectious diseases on the health of US troops deployed to the Persian Gulf during operations
Desert Shield and Desert Storm. Clinical Infectious Diseases 20(6):1497-1504.
Hyams KC, Riddle J, Trump DH, Graham JT. 2001. Endemic infectious diseases and biological
warfare during the Gulf War: A decade of analysis and final concerns. American Journal of
Tropical Medicine and Hygiene 65(5):664-670.
IOM (Institute of Medicine). 2000. Gulf War and Health, Volume 1: Depleted Uranium, Sarin,
Pyridostigmine Bromide, Vaccines. Washington, DC: National Academy Press.
IOM. 2003. Gulf War and Health, Volume 2: Insecticides and Solvents. Washington, DC: The
National Academies Press.
IOM. 2004. Gulf War and Health: Updated Literature Review of Sarin. Washington, DC: The
INTRODUCTION 17
IOM. 2005. Gulf War and Health, Volume 3: Fuels, Combustion Products, and Propellants.
Washington, DC: The National Academies Press.
IOM. 2006. Gulf War and Health, Volume 4: Health Effects of Serving in the Gulf War.
Kilpatrick ME. 2005. Presentation to IOM Committee on Gulf War and Health: Infectious
Diseases. Washington, DC.
PAC (Presidential Advisory Committee). 1996. Presidential Advisory Committee on Gulf War
Veterans’ Illnesses: Final Report. Washington, DC: US Government Printing Office.
Persian Gulf Veterans Coordinating Board. 1995. Unexplained illnesses among Desert Storm
veterans. A search for causes, treatment, and cooperation. Persian Gulf Veterans
Coordinating Board. Archives of Internal Medicine 155(3):262-268.
Relman DA. 2002. New technologies, human-microbe interactions, and the search for previously
unrecognized pathogens. Journal of Infectious Diseases 186(2 Suppl):S254-S258.
2
METHODOLOGY
This chapter articulates the committee’s approach to its task. Of the dozens of pathogens
known to exist in southwest and south-central Asia, the committee identified the ones that are
known to cause long-term adverse health outcomes and infected at least one US veteran who
served in southwest or south-central Asia in the period 1991-December 2005. The committee
then oversaw a formal, comprehensive literature review that identified about 1,200 peer-
reviewed studies about the late complications and latent and chronic infections that might be
associated with primary infection by each of the pathogens. Those studies constituted the
evidence from which the committee drew conclusions about the relationship between each
primary infection and specific long-term adverse health outcomes in humans. Finally, the
committee ranked the strength of the relationships through the five-category system presented at
the end of this chapter.
IDENTIFYING THE INFECTIOUS DISEASES TO STUDY
Geographic Boundaries
As required by law, the committee considered infectious diseases that might have
afflicted US troops who served in the 1991 Gulf War (PL 105-277 and PL 105-368).
Additionally, in response to a request by the Department of Veterans’ Affairs, the committee
considered infectious diseases that might have afflicted US troops during Operation Enduring
Freedom (OEF) or Operation Iraqi Freedom (OIF). Thus, the committee’s preliminary
deliberations covered infectious diseases known to occur specifically in Iraq, Kuwait, and
Afghanistan and in the geographic region that includes the Arabian Peninsula, Syria, Lebanon,
Israel, Iran, Qatar, Pakistan, Tajikistan, Kyrgyzstan, Uzbekistan, and Turkmenistan (Figure 2.1).
The term southwest and south-central Asia refers to that region throughout this report.
19
Uzbekistan
Kyrgyzstan
Turkmenistan
Tajikistan
Lebanon Syria
Iraq Afghanistan
Israel Iran
Jordan
Kuwait Pakistan
Qatar
Bahrain Qatar
Saudi United
Arabia Arab
Oman Emirates
Yemen
FIGURE 2.1 Southwest and South-Central Asia. The committee’s preliminary deliberations covered infectious
diseases known to occur specifically in Iraq, Kuwait, and Afghanistan and in the geographic region that includes the
Arabian Peninsula, Syria, Iran, Qatar, Pakistan, Tajikistan, Kyrgyzstan, Uzbekistan, and Turkmenistan.
SOURCE: The National Academies Press.
Infectious Diseases Endemic to Southwest and South-Central Asia That Have Long-Term
Adverse Health Outcomes
The committee approached its task by first identifying infectious diseases that could have
affected US troops deployed to southwest and south-central Asia. The committee members drew
upon their collective knowledge of infectious diseases, which stems from both professional
experience (Appendix A) and information gathered specifically for this study. The committee
acquired information from numerous sources about illnesses diagnosed in troops deployed to
southwest and south-central Asia, infectious diseases known to occur in that region, and
conditions of special interest to veterans. The information came from peer-reviewed journal
articles, surveillance and technical reports, presentations by physicians and scientists, and
veterans and representatives of veterans’ groups.
METHODOLOGY 21
Approximately 100 infectious diseases were identified for preliminary consideration

(Table 2.1), including the four diseases specified in the legislation that directs the committee’s
work (Box 2.1).
TABLE 2.1 Diseases and Etiologic Agents Considered by the Committee for Evaluation
Disease Etiologic Agent
Bacterial diseases
Acinetobacter infection Acinetobacter baumanii and other Acinetobacter species
Actinomycosis Actinomyces spp.
Anthrax Bacillus anthracis
Bartonellosis Bartonella spp.
Cat-scratch disease B. henselae
Trench fever B. quintana
Botulism Clostridium botulinum
Brucellosis Brucella spp.
Campylobacteriosis Campylobacter spp.
Capnocytophaga infection Capnocytophaga spp.
Chlamydia
Genital infections Chlamydia trachomatis
Pneumonia Chlamydia pneumoniae
Cholera (including vibrio infections) Vibrio spp.
Diphtheria Corynebacterium diphtheriae
E. coli gastroenteritis Escherichia coli
Enterotoxigenic E. coli
Shiga toxin-producing E. coli
Enteroaggregative E. coli
Enteroinvasive E. coli
Enterohemorrhagic E. coli
Enteropathogenic E. coli
Ehrlichioses Ehrlichia spp.
Enteric fever
Paratyphoid fever Salmonella enterica serovar Paratyphi A,B,C
Typhoid fever Salmonella enterica serovar Typhi
Enterococcal infection (vancomycin-resistant) Enterococcus spp.
Gas gangrene Clostridium perfringens
Hemophilus meningitis Haemophilus influenzae
Helicobacter infection Helicobacter pylori
Klebsiella infection Klebsiella spp.
Legionnaire’s disease Legionella spp.
Leptospirosis Leptospira spp.
Listeriosis Listeria monocytogenes
Lyme disease Borrelia burgdorferi
Melioidosis Burkholderia pseudomallei
Meningococcal infection Neisseria meningitidis
Moraxella infection Moraxella catarrhalis

Mycoplasma infection Mycoplasma spp.
Nocardiosis Nocardia spp. or aerobic actinomycetes
Nontuberculous mycobacterial infection Mycobacteria spp. (except M. tuberculosis complex)
Pasteurella infection Pasteurella spp.
Pertussis (whooping cough) Bordetella pertussis
Plague Yersinia pestis
Plesiomonas shigelloides infection Plesiomonas shigelloides
Pneumococcal disease Streptococcus pneumoniae
Pseudomonas infection Pseudomonas aeruginosa
Q fever Coxiella burnetii
Rat bite fever Spirillum minus
Relapsing fever Borrelia spp.
Rickettsioses
Boutonneuse fever Rickettsia conorii
Louse-borne typhus Rickettsia prowazekii
Marine typhus Rickettsia typhi
Ehrlichiosis Ehrlichia chafeensis
Anaplasmosis Anaplasma phagocytophilum
Salmonellosis (non-typhoid) Salmonella spp. (except serovar Typhi)
Shigellosis Shigella spp.
Staphylococcal infection Staphylococci spp.
Methicillin-resistant Staphylococcus aureus S. aureus (methicillin-resistant)
(MRSA) infection
Stenotrophomonas infection Stenotrophomonas maltophilia.
Streptococcal infection (group A) Streptococcus pyogenes
Tetanus Clostridium tetani
Tuberculosis Mycobacterium tuberculosis
Tularemia Francisella tularensis
Yaws (nonvenereal treponemal infection) Treponema pertenue
Yersiniosis Yersinia enterocolitica
Fungal diseases
Aspergillosis Aspergillus spp.
Cryptococcus Cryptococcus spp.
Histoplasmosis Histoplasmosis capsulatum
Mucormycosis Fungi of the order Mucorales
Helminthic diseases
Ascariasis Ascaris lumbricoides
Echinococcosis Echinococcus spp.
Enterobiasis Enterobius vermicularis
Filariasis Wuchereria bancrofti
Hookworm disease Necator americanus and Ancylostoma duodenale
Onchocerciasis Onchocerca volvulus
Schistosomiasis Schistosoma mansoni and S. haematobium
METHODOLOGY 23

Strongyloidiasis Strongyloides stercoralis
Tapeworm disease (taeniasis) Taenia spp. and Diphyllobothrium latum
Cysticercosis T. solium (Cysticercus cellulosae)
Trichinosis Trichinella spiralis
Trichuriasis Trichuris trichiura
Protozoan diseases
Amebiasis Entamoeba histolytica
Cryptosporidiosis Cryptosporidium parvum
Cyclosporiasis Cyclospora cayetanensis
Giardiasis Giardia lamblia
Isosporiasis Isospora bella
Leishmaniasis Leishmania spp.
Malaria Plasmodium spp.
Microsporidiosis Microsporidia spp.
Toxoplasmosis Toxoplasma gondii
Viral diseases
Adenoviral infection Adenovirus
Avian influenza Influenza virus H5N1
Chickenpox (varicella) Human herpesvirus 3 (varicella-zoster virus)
Crimean-Congo hemorrhagic fever Crimean-Congo hemorrhagic fever virus, genus
Nairovirus
Dengue Dengue virus, genus Flavivirus
Dengue fever
Dengue hemorrhagic fever, dengue shock
syndrome
Hantavirus hemorrhagic fever with renal syndrome genus Hantavirus
and hantavirus pulmonary syndrome
Influenza Influenza virus
Rabies Rabies virus
Retroviral diseases Human T-cell lymphotropic virus I (HTLV-I), HTLV-II,
human immunodeficiency virus (HIV)-1
Rift Valley fever Rift Valley fever virus, genus Phlebovirus
Sand fly fever Sand fly virus, genus Phlebovirus
Sindbis virus disease Sindbis virus, genus Alphavirus
Viral enteritis Various viruses
Rotavirus infection group A Rotavirus
Norovirus infection Norovirus
Viral hepatitis Hepatitis viruses
West Nile fever West Nile virus, genus Flavivirus
Miscellaneous diseases
Acute eosinophilic pneumonia Origin undetermined; not necessarily infectious
Idiopathic enteropathy Origin undetermined; not necessarily infectious
Madura foot (mycetoma)
Actinomycetoma Various actinomycetes bacteria

Eumycetoma Various fungi
Nosocomial infection Acinetobacter baumannii and other pathogens
Sexually transmitted diseases (STDs) Haemophilus ducreyi, herpes simplex virus, HIV, human
papillomavirus, HTLV, chancroid, Chlamydia
trachomatis, Neisseria gonorrhoeae, Treponema pallidum,
Trichomonas vaginalis, and others
Wound-associated bacterial infection Acinetobacter baumannii, Staphylococcus aureus, and
other pathogens
NOTE: The term infection refers to a primary infection that leads to disease.
SOURCE: CDC 2005; Heymann 2004; Mandell et al. 2005.
BOX 2.1 The Four Diseases Specified in PL 105-277 and PL 105-368
Leishmaniasis
Sand fly fever
Pathogenic Escherichia coli infection
Shigellosis
Though present in southwest or south-central Asia, some of the diseases on the

committee’s preliminary list do not have long-term adverse health outcomes. The committee’s
next step was to identify infectious diseases endemic in southwest and south-central Asia that
have potential long-term adverse health outcomes, including secondary diseases or conditions
(sequelae) caused by primary diseases, reactivation or recrudescence of diseases, and delayed
presentation of diseases. Only diseases with known or possible long-term adverse health
outcomes were selected from Table 2.1 for further evaluation.
The process began with the development of consensus on the meaning of long-term
adverse health outcomes. Such health outcomes, the committee agreed, should have one or more
of the following characteristics:
• Substantial interruption of normal physical and mental functioning occurring outside the
timeframe of acute infection.
• Organ dysfunction or damage with a persistent effect.
• Reproductive effects in military personnel, including birth defects in offspring of military
personnel.
A long-term adverse health outcome may be reversible. The committee also considered the
potential for secondary transmission of the pathogen.
The application of these criteria to the infectious diseases listed in Table 2.1 generated
the infectious diseases contained in Box 2.2: infectious diseases that are endemic to southwest
and south-central Asia and have long-term adverse health outcomes.
Direct Attribution to Military Service in Southwest and South-Central Asia
The committee examined the likelihood that the candidate infections would have
occurred specifically during military deployment to southwest and south-central Asia during the
METHODOLOGY 25
three operations in question. The risk of contracting a disease in the theater of operations must
have been equal to or greater than the risk of contracting it in the United States. Moreover, given
the natural history of the disease or infection, it must have been diagnosed in US troops in
appropriate temporal relationship to deployment.
Chapter 4 comprises a review of infectious diseases that have been reported in US troops
in close temporal relationship to the operations under study. On the basis of that review, the
committee determined that many of the diseases in Box 2.2 have never been reported in US
military personnel in close temporal relationship to deployment to southwest or south-central
Asia during the Gulf War, OEF, or OIF. Nevertheless, it is impossible to prove that US troops
did not contract any of the unreported diseases during deployment. Thus, the committee
summarizes the acute and long-term characteristics of these unreported diseases in tabular form
in Chapter 3 and excludes them from further analysis.
BOX 2.2 Infectious Diseases That Are Endemic in Southwest and South-Central Asia and Have Long-Term
Adverse Health Outcomes
Type of Etiologic Agent
Bacterium Virus Protozoan Helminth
More prevalent in southwest or More prevalent in More prevalent in More prevalent in
south-central Asia than in the southwest or south- southwest or south- southwest or south-
United States central Asia than in the central Asia than in central Asia than in
Anaplasmosis United States the United States the United States
Anthrax Crimean-Congo Amebiasis Ascariasis
Boutonneuse fever hemorrhagic fever Cryptosporidiosis Cysticercosis
Brucellosis Dengue fever Cyclosporiasis Echinococcosis
Campylobacter infection Dengue hemorrhagic fever Giardiasis Enterobiasis
Chancroid Dengue shock syndrome Isosporiasis Filariasis
Cholera Hepatitis A Leishmaniasis Hookworm disease
E. coli gastroenteritis Hepatitis B Malaria Onchocerciasis
Ehrlichiosis Hepatitis C Microsporidiosis Schistosomiasis
Enteric fever Rift Valley fever Toxoplasmosis Strongyloidiasis
Helicobacter infection Sand fly fever
Leptospirosis Sindbis
Lymphogranuloma venereum
Melioidosis Potentially more
Plague prevalent among troops
Q fever in war theater than
Rat bite fever among US adult
Relapsing fever population
Salmonellosis (nontyphoid) Adenovirus infection
Shigellosis Avian influenza
Syphilis Hantaviral hemorrhagic
Tuberculosis fever with renal
Typhus group (louse-borne and syndrome
murine) Hantavirus pulmonary
Yaws syndrome
Yersinia enterocolitica infection Influenza
Viral enteritis
Potentially more prevalent among West Nile fever
troops in war theater than among
US adult population
Gonorrhea
Trichomoniasis
Bacterial diseases against which Of special concern to US

military personnel were immunized troops
and for which vaccines are highly Genital herpes
or fully protective Human immunodeficiency
Diphtheria virus-1
Tetanus Human T-cell
lymphotropic virus
Bacterial diseases against which infection (I)
military personnel were immunized Human papillomavirus
and for which vaccines are partly
protective Viral disease not more
Meningococcal disease endemic in war theater
Pertussis (whooping cough) than among U.S. adult
population
Bacterial diseases not more Chickenpox (varicella)
endemic in war theater than among
US adult population
Infections caused by
Actinomyces
Bartonella
Capnocytophaga
Chlamydia pneumoniae
Clostridium botulinum
Clostridium perfringens
Francisella tularensis
Legionella
Listeria monocytogenes
Moraxella catarrhalis
Nocardia
Non-cholera Vibrio
Non-tuberculosis mycobacteria
Pasteurella
Plesiomonas shigelloides
Staphylococcus
Streptococcus
Streptococcus pneumoniae
Lyme disease
Antibiotic-resistant or common
nosocomial infections
Infections caused by
Acinetobacter (Multiple drug-
resistant)
Enterococcus (vancomycin-resistant)
Klebsiella (multiple drug-resistant)
Pseudomonas aeruginosa
Staphylococcus aureus (methicillin-
resistant)
Stenotrophomonas maltophilia
Of special concern to US troops

Mycoplasma infection (atypical
pneumonia)
NOTE: The term infection refers to a primary infection that leads to disease.
METHODOLOGY 27
Timing of Appearance of Long-Term Adverse Health Outcomes
Next, the committee determined the likelihood that a disease’s long-term adverse health
outcomes would have been manifest and diagnosed during a person’s term of military service.
If the onset of adverse health outcomes typically occurs during the acute illness, the
committee reasoned, the long-term effects would probably be detected, diagnosed, and reported
during the patient’s term of military service. Likewise, diseases that have an acute phase—
meaning that signs and symptoms become evident suddenly within hours or days of infection—
are readily diagnosed during military service if the individual seeks medical care; in such cases,
the physician would probably be cognizant of possible long-term adverse health outcomes.
Finally, pre-existing conditions that were mild or latent before deployment but became
reactivated or exacerbated during deployment also would probably be diagnosed during the
patient’s military service. Therefore, infectious diseases with one or both of the following
characteristics were not comprehensively evaluated in this study; instead, their acute and long-
term health outcomes are summarized in tabular form in Chapter 3:
• Onset of long-term adverse health outcomes typically occurs during the acute illness.
• The disease is a preexisting infection that becomes reactivated or exacerbated during
deployment.
In contrast, the committee determined, there are other infectious diseases whose long-
term adverse health outcomes were unlikely to be diagnosed during military service in southwest
and south-central Asia. Such diseases have the following characteristics:
• The primary infection is subacute or the infected person is asymptomatic for days to years.
• Long-term adverse health outcomes begin months to years after infection.
Because a subacute infection may go unnoticed and undiagnosed, the committee reasoned, the
primary disease might not be reported. Furthermore, if long-term adverse health outcomes begin
months or even years after infection, the condition would be more likely to be diagnosed after
the person completes military service, and the diagnosing physician may not attribute the
patient’s signs and symptoms to an infection acquired during deployment, particularly if the
disease is uncommon in the United States, and thus more likely to be misdiagnosed. Infectious
diseases that fit those criteria qualified for in-depth study.
The Infectious Diseases to Be Studied for Strength of Association with Long-Term Adverse
Health Outcomes
The committee identified nine infectious diseases (Box 2.3) known to have long-term
adverse health outcomes and to be potentially acquired by infected veterans during their military
deployment to southwest and south-central Asia from 1991 to 2005. The committee conducted
comprehensive reviews of the literature on the potential long-term adverse health outcomes of
these diseases to determine the strength of association between the primary infection and the
health outcome in humans.
BOX 2.3 Infectious Diseases with Long-Term Adverse Health Outcomes

Studied for Strength of Association
Brucellosis
Campylobacteriosis
Leishmaniasis
Malaria
Q fever
Salmonellosis
Shigellosis
Tuberculosis
West Nile fever
Reasons for Excluding E. coli and Sand Fly Fever from In-Depth Study
Two of the infectious diseases named in PL 105-277 and PL 105-368—E. coli and sand
fly fever—do not fulfill the above criteria for in-depth evaluation.
E. coli
Diarrheal infections were among of the most common ailments diagnosed in military
personnel in regional theaters, and pathogenic E. coli is a well-recognized cause of diarrheal
syndromes. The committee considered various infections related to pathogenic E. coli, focusing
its attention on the role of pathogenic E. coli in diarrheal diseases. The unifying clinical
syndrome associated with the various E. coli infections is a diarrheal illness that in healthy adults
is usually transient without long-term adverse health outcomes. Therefore, the committee
summarizes the health outcomes of E. coli infections in Chapter 3.
Sand Fly Fever
There are no published reports of sand fly fever in military personnel who served in the
Gulf War; however, results from a search, requested by the Institute of Medicine (IOM), of a
Department of Defense Gulf War hospitalization database identified five cases of this disease
(the database and the search results are described in Chapter 4). As of December 2005, sand fly
fever has not been found in military personnel serving in OIF and OEF. Sand fly fever is
associated with a long-term adverse health outcome; however, the onset of the health outcome
typically occurs during the acute illness. Therefore, the committee summarizes the health
outcomes of sand fly fever in Chapter 3.
Comments on Diseases and Agents of Special Interest to Gulf War, OEF, and OIF Veterans
Several diseases and agents are of special interest to veterans of the Gulf War, OEF, and
OIF. There is concern among Gulf War veterans that their symptoms might be connected to
infection with Mycoplasma fermentans from contaminated vaccines (Nicolson et al. 2003) or
exposure to biologic-warfare agents. In addition, during the Gulf War, troops stationed at Al
Eskan Village, Saudi Arabia, developed respiratory illnesses at a high rate (Korenyi-Both et al.
1997; Korenyi-Both et al. 1992). The disease was termed Al Eskan disease and it has been
hypothesized that a pathogen might be the cause. More recently, idiopathic acute eosinophilic
pneumonia (IAEP) has been diagnosed in 18 military personnel serving in OIF or OEF (Shorr et
al. 2004). IAEP is a syndrome characterized by febrile illness, diffuse pulmonary infiltrates, and
pulmonary eosinophila (Allen et al. 1989; Badesch et al. 1989; Philit et al. 2002). There is also a
METHODOLOGY 29
discussion of wound-associated infections (for example, infections caused by Acinetobacter

baumannii) that appear to be more prevalent in OIF and OEF personnel than in civilian
populations (Davis et al. 2005). Chapter 6 discusses Al Eskan disease, IAEP, wound-associated
infections, mycoplasmas, and biologic-warfare agents.
REVIEW AND EVALUATION OF THE LITERATURE
Selection of the Literature
The committee adopted a policy of basing its conclusions primarily on peer-reviewed,

published literature. Non-peer-reviewed publications provided additional information for the
committee and raised issues that were researched further in the peer-reviewed literature.
Although the process of peer review by fellow professionals ensures high standards of
quality, it does not guarantee the validity of a study or the generalizability of its results.
Accordingly, committee members read each study critically and considered its relevance and
quality.
Amassing the Literature
The committee oversaw a multistep process for amassing a robust collection of scientific
literature about the long-term adverse health outcomes of the diseases listed in Box 2.3. The
process began with a search of PubMed, a database created and managed by the National Library
of Medicine that includes more than 15 million citations of biomedical publications from the
1950s to the present. The PubMed search focused on journal articles published through
December 2005 that contain information about late complications, long-term sequelae, and latent
infections related to the relevant infectious diseases and etiologic agents identified by the
committee. Additional studies were identified from the reference lists of topical technical reports,
textbooks, and other documents. Further PubMed searches identified pertinent articles on Al
Eskan disease, IAEP, wound-associated infections, mycoplasmas, and biologic-warfare agents.
Those initial searches generated about 20,000 articles.
Reviewing the Literature
On closer examination of that large body of literature, a subset of about 1,200 articles
appeared to provide the types and quality of scientific evidence that the committee needed to
accomplish its task. After securing the full text of those articles, the committee reviewed and
assessed them for evidence of associations between primary infections by the etiologic agents of
interest and specific long-term adverse health outcomes in humans.
The committee included several types of studies, including epidemiologic studies, case
reports, and case series. Ideally, epidemiologic studies should have methodologic details, a
control or reference group, reasonable adjustment for confounders, and statistical power to detect
effects. Review articles, technical reports, and textbooks were used for background information.
The committee relied heavily on studies that focused on human adult populations.
Because the IOM task concerns adults who may have become infected during military service,
studies of children were generally excluded unless the studies dealt with reproductive outcomes.
One exception is that studies of children were included if they provided information about adult
diseases; for example, a study on cerebral malaria in children might be reviewed if it provided
information about the disease in adults.
CATEGORIES OF STRENGTH OF ASSOCIATION
The committee’s goal was to use the evidence in the medical and scientific literature to
determine the relationships between the infectious diseases of interest and specific adverse health
outcomes that might appear months to years after primary infections. Those relationships,
presented in Chapter 5, are conceived in terms of the “strength of association” between a primary
infection and a specific long-term adverse health outcome. The committee ranks strength of
association qualitatively using a five-tier system, presented below in full.
Origin and Evolution of the Categories
A brief historical overview of the committee’s categories of association will elucidate

their scientific roots. The International Agency for Research on Cancer (IARC), part of WHO,
established criteria in 1971 to evaluate the human carcinogenic risk posed by chemicals (IARC
1998). First published in 1972, IARC’s evaluations are scientific, qualitative judgments by ad
hoc working groups about the evidence of carcinogenicity or noncarcinogenicity provided by the
available data. The working groups express their qualitative judgments in terms of five
categories of the relative strength of the evidence that a substance or exposure is carcinogenic
(IARC 1999a). Agencies in 57 countries use IARC’s published evaluations—a reflection of the
widespread acceptance of the categorization scheme as it has been updated and applied to about
900 agents, mixtures, and exposures (IARC 1999b; IARC 2005).
In the early 1990s, an IOM committee adopted IARC’s categories in evaluating the
adverse health outcomes of pertussis and rubella vaccines (IOM 1991). Later IOM committees
used the categories, with some modifications, in evaluating the safety of childhood vaccines
(IOM 1994a), the health outcomes of herbicides used in Vietnam (IOM 1994b; IOM 1996; IOM
1999; IOM 2001; IOM 2003b), and the relationship between indoor pollutants and asthma (IOM
2000a). The present committee’s predecessors also adapted and used the categories in evaluating
the health effects of outcomes given to US troops and of chemical exposures that may have
occurred during the Gulf War (IOM 2000b; IOM 2003a; IOM 2004; IOM 2005).
The five categories of strength of association used in this report are presented and defined
below.
Sufficient Evidence of a Causal Relationship
Evidence from available studies is sufficient to conclude that there is a causal relationship
between exposure to a specific agent and a specific health outcome in humans. The evidence
includes supporting experimental data and fulfills the guidelines for sufficient evidence of an
association (see next category). The association is biologically plausible, and the evidence
satisfies several of the guidelines used to assess causality, such as strength of association, dose-
response relationship, consistency of association, and a temporal relationship.
METHODOLOGY 31
Sufficient Evidence of an Association
Evidence from available studies is sufficient to conclude that there is an association. A

consistent association has been observed between exposure to a specific agent and a specific
health outcome in several high-quality human studies in which chance and bias, including
confounding, could be ruled out with reasonable confidence.
Limited or Suggestive Evidence of an Association
Evidence from available studies suggests an association between exposure to a specific

agent and a specific health outcome, but the body of evidence is limited by the inability to rule
out chance and bias, including confounding, with confidence. For example, at least one high-
quality study that is sufficiently free of bias, including adequate control for confounding, reports
an association, while other studies provide support for the association but are not sufficiently free
of bias, including confounding. Alternatively, several studies of lesser quality are consistent in
showing an association, and the results are probably not due to bias, including confounding.
Inadequate or Insufficient Evidence to Determine Whether an Association Exists
Evidence from available studies is of insufficient quantity, quality, or consistency to

permit a conclusion regarding the existence of an association between exposure to a specific
agent and a specific health outcome in humans.
Limited or Suggestive Evidence of No Association
Evidence from well-conducted studies is consistent in not showing an association

between exposure of any magnitude to a specific agent and a specific health outcome in humans.
A conclusion of no association is inevitably limited to the conditions, magnitudes of exposure,
and length of observation in the available studies. The possibility of a very small increase in risk
after the exposure studied cannot be excluded.
REFERENCES
Allen JN, Pacht ER, Gadek JE, Davis WB. 1989. Acute eosinophilic pneumonia as a reversible
cause of noninfectious respiratory failure. New England Journal of Medicine 321(9):569-574.
Badesch DB, King TE Jr., Schwarz MI. 1989. Acute eosinophilic pneumonia: A hypersensitivity
phenomenon? American Review of Respiratory Disease 139(1):249-252.
CDC (Centers for Disease Control and Prevention). 2005. Health Information for International
Travel 2005-2006. Centers for Disease Control and Prevention. Atlanta, GA: US Department
of Health and Human Services, Public Health Service.
Davis KA, Moran KA, McAllister CK, Gray PJ. 2005. Multidrug-resistant Acinetobacter
extremity infections in soldiers. Emerging Infectious Diseases 11(8):1218-1224.
Heymann DL. 2004. Control of Communicable Diseases Manual. Washington, DC: American
Public Health Association.
IARC (International Agency for Research on Cancer). 1998. Preamble to the IARC Monographs.
[Online]. Available: http://www-cie.iarc.fr/monoeval/background.html [accessed July 19,
2005].
IARC. 1999a. Evaluation. Preamble to the IARC Monographs. [Online]. Available: http://www-
cie.iarc.fr/monoeval/eval.html [accessed August 3, 2005].
IARC. 1999b. Objective and Scope. Preamble to the IARC Monographs. [Online]. Available:
http://www-cie.iarc.fr/monoeval/objectives.html [accessed August 3, 2005].
IARC. 2005. Monographs on the Evaluation of Carcinogenic Risks to Humans. [Online].
Available: http://www-cie.iarc.fr/ [accessed August 3, 2005].
IOM (Institute of Medicine). 1991. Adverse Effects of Pertussis and Rubella Vaccines.
Washington, DC: National Academy Press.
IOM. 1994a. Adverse Events Associated With Childhood Vaccines: Evidence Bearing on
Causality. Washington, DC: National Academy Press.
IOM. 1994b. Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam.
Washington, DC: National Academy Press.
IOM. 1996. Veterans and Agent Orange: Update 1996. Washington, DC: National Academy
Press.
Press.
IOM. 2000a. Clearing the Air: Asthma and Indoor Air Exposures. Washington, DC: National
Academy Press.
IOM. 2000b. Gulf War and Health, Volume 1: Depleted Uranium, Sarin, Pyridostigmine
Bromide, Vaccines. Washington, DC: National Academy Press.
Press.
IOM. 2003a. Gulf War and Health, Volume 2: Insecticides and Solvents. Washington, DC: The
IOM. 2003b. Veterans and Agent Orange: Update 2002. Washington, DC: The National
Academies Press.
IOM. 2004. Gulf War and Health: Updated Literature Review of Sarin. Washington, DC: The
IOM. 2005. Gulf War and Health, Volume 3: Fuels, Combustion Products, and Propellants.
Korenyi-Both AL, Korenyi-Both AL, Molnar AC, Fidelus-Gort R. 1992. Al Eskan disease:
Desert Storm pneumonitis. Military Medicine 157(9):452-462.
Korenyi-Both AL, Korenyi-Both AL, Juncer DJ. 1997. Al Eskan disease: Persian Gulf
syndrome. Military Medicine 162(1):1-13.
Mandell GL, Bennett JE, Dolin R. 2005. Principles and Practice of Infectious Diseases. 6th ed.
Philadelphia, PA: Elsevier Churchill Livingstone.
Nicolson GL, Nasralla MY, Nicolson NL, Haier J. 2003. High prevalence of mycoplasma
infections in symptomatic (Chronic Fatigue Syndrome) family members of mycoplasma-
positive Gulf War illness patients. Journal of the Chronic Fatigue Syndrome 11(2):21-36.
METHODOLOGY 33
Philit F, Etienne-Mastroianni B, Parrot A, Guerin C, Robert D, Cordier JF. 2002. Idiopathic

acute eosinophilic pneumonia: A study of 22 patients. American Journal of Respiratory and
Critical Care Medicine 166(9):1235-1239.
Shorr AF, Scoville SL, Cersovsky SB, Shanks GD, Ockenhouse CF, Smoak BL, Carr WW,
Petruccelli BP. 2004. Acute eosinophilic pneumonia among US Military personnel deployed
in or near Iraq. Journal of the American Medical Association 292(24):2997-3005.
3
INFECTIOUS DISEASES ENDEMIC TO SOUTHWEST AND SOUTH-

CENTRAL ASIA THAT HAVE LONG-TERM ADVERSE HEALTH
OUTCOMES
In Chapter 2, the committee developed an extensive list of infectious diseases that are
endemic to southwest and south-central Asia (Table 2.1) and then narrowed the list to diseases or
syndromes with known long-term adverse health outcomes (Box 2.2). Although most diseases in
that subset have not been reported in military personnel deployed to southwest and south-central
Asia, they have historically been diagnosed in local populations and thus pose a theoretical risk
to US troops deployed to the region. Also, given the nature and duration of Operation Iraqi
Freedom and Operation Enduring Freedom, some of the diseases in Box 2.2 could be diagnosed
after a person’s deployment or period of military service.
The committee decided that the most effective way to give additional information on the
diseases listed in Box 2.2 would be to present them in tables containing
• A description of the acute syndrome in adults,

• A description of the potential long-term adverse health outcomes in adults with clinical
disease,
• The frequency with which the long-term adverse health outcomes occur in adults with clinical
disease,
• The delay, if any, between acute infection and onset of long-term adverse health outcomes.
Tables 3.1-3.4 categorize the infections of interest by type of pathogen (viral, bacterial,
helminthic, or protozoan), and Table 3.5 describes sexually transmitted diseases. The infectious
diseases with long-term adverse health outcomes that have been diagnosed in military personnel
and that the committee reviewed in depth (see Chapter 5) are also included here.
35
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*** START OF THE PROJECT GUTENBERG EBOOK WORK OF THE

COLORED LAW AND ORDER LEAGUE, BALTIMORE, MD. ***
Officers of the
Colored Law and Order League
Baltimore, Md.
President—Rev. John A. Holmes

Vice-President—John W. Rich
Secretary—Heber E. Wharton
Treasurer—Dr. Thomas S. Hawkins
Executive Committee
Rev. John A. Holmes
Harry T. Pratt
Dr. Whitfield Winsey
Heber E. Wharton
Josiah A. Diggs
Mason A. Hawkins
Rev. John T. Jenifer
W. C. McCard
W. Ashbie Hawkins
Dr. J. H. N. Waring
PRESS OF
E. A. Wright Bank Note Co.
PHILADELPHIA, PA.
Work of the Colored Law and
Order League :: Baltimore, Md.
by James H. N. Waring
Committee of Twelve
FOR THE ADVANCEMENT OF THE INTERESTS OF THE NEGRO RACE
Cheyney, Pa.
MAP
SHOWING
LOCATION OF SALOONS
A map of the lower Druid Hill Avenue District. In this district there were forty-two
saloons, fifteen churches, twelve schools, one home for old people, one home for
friendless children, the colored Y. M. C. A. and the colored Y. W. C. A.
Work of the Colored Law and Order League of Baltimore
HE Atlanta riot had sent a thrill of horror throughout the

country, and colored people generally, whenever they
met, were eagerly and anxiously discussing it, not only
because of the desolation it left behind it, and the
misery and suffering it had entailed to the families of
the victims, but because as they discussed it they saw in their own
neighborhoods more or less of the causes which led to that
unfortunate affair.
With the colored people here in Baltimore it was for a long time a
common topic of conversation. True, Baltimore had no incendiary
press to inflame the passions of the poor whites of the city, nor had
she a class of hysterical women to take fright at the sudden
appearance of a black face, nor was there here that loose attitude
toward law and order which permits the disorderly elements of the
population to disregard and defy the authorities in their enforcement
of the laws of the city and State. But there were sections of the city,
where the colored people in large numbers reside, infested with
saloons kept principally by white men of the lowest type; there were
dens of vice in too large numbers scattered throughout the city—all
of which were exercising a demoralizing effect upon the colored
youth and furnishing schools of crime for colored children. These
places appeared to have a quasi-police protection, and as it
appeared later, in the testimony before the Liquor License Board, at
least one policeman regarded the saloons about which there had
been complaint from the best citizens of the town, white and black,
as “less troublesome than the colored churches in the
neighborhood.”
There were saloons of the lowest type in the most densely
populated colored residence neighborhoods, and some of the public
schools were within 300 feet of from two to eight of them. It was
such conditions as these that laid the foundation for the trouble in
Atlanta, and surely the existence of similar conditions in Baltimore
justified the apprehensions felt by many of Baltimore’s best colored
citizens.
THE DISTRICT SURROUNDING PUBLIC SCHOOL No. 105
This district is infested with dives and disorderly houses. The small dots indicate
the disorderly houses; the large dots liquor saloons; the crosses around them are
liquor saloons which have disorderly houses connected with them; the small
triangles are houses that are suspected.
In this district some of the women who keep these houses have their names
printed over the doors.
Finally, after some casual conferences and informal discussions at

promiscuous meetings and gatherings, Rev. John Hurst, one of the
most useful of Baltimore’s colored men, took the initiative and called
together at his house a number of representative colored men to
discuss the situation more formally. At this meeting there were
present: W. Ashbie Hawkins, one of the leading lawyers of the city;
Dr. Howard E. Young, one of the leading druggists; Dr. Whitfield
Winsey, a physician who has practised among the colored people for
about thirty years; Dr. Thomas S. Hawkins, one of the younger
physicians, and a man who has always been prominent in every
movement looking toward the betterment of the condition of the
colored people; Heber E. Wharton, a vice-principal of one of the
public schools; Harry T. Pratt, a grade supervisor in the public
schools; Rev. J. Albert Johnson, who has recently been made a
bishop in the A. M. E. Church; Rev. E. F. Eggleston, pastor of Grace
Presbyterian Church; and Dr. J. H. N. Waring, principal of the
Colored High and Training School. This group of men, after an
informal discussion of the situation, decided to organize into a
committee of ten, and elected Rev. Mr. Hurst as chairman of this
committee, a position in which he served through the whole
campaign with tact and firmness and wisdom. Later Dr. Hurst, who
moved to Washington to live, was succeeded by Rev. John A.
Holmes, who took up the fight with the same earnestness,
intelligence and zeal which have characterized his entire life in this
community.
It was from this little band of men, all of whom were colored, that
the Law and Order League grew. The larger body was likewise made
up entirely of colored men, all of them deeply interested in the
general development of the whole colored population and fully
determined, so far as lay in their power, to make the best possible
contribution to good citizenship in Baltimore. The membership of the
League was composed not only of the best colored men of the city,
but they were the men who are always foremost in any movement
for civic betterment, and men who are occupying the most
prominent and influential positions in the city.
MAP showing LOCATION of

SALOONS and DISORDERLY HOUSES
● SALOONS
• DISORDERLY HOUSES
× BOTH
Public School No. 105 surrounded by houses of prostitution and saloons.

At this meeting in October, 1906, it was decided to investigate the
conditions in colored neighborhoods, and learn more in detail of the
environments of their homes and schools and churches, to study the
sanitary conditions of colored neighborhoods and to collect all the
reliable data possible to be used in the effort to improve conditions
among the colored people. It was thought best to limit the size of
this committee to the ten men who met at Dr. Hurst’s house. They
divided themselves up into sub-committees to study and report on
the sanitary conditions in colored neighborhoods, to investigate the
school conditions with special reference to their surroundings, and to
secure such printed matter and collect such reliable statistics as they
might need in their future work.
At the subsequent meetings reports from these committees
brought out many interesting and startling facts. In Baltimore, as in
most other cities, the colored people are grouped together in certain
neighborhoods whose white population is very small and composed
of the degraded rum-seller or the small shopkeeper, who has no
social antipathy toward his black neighbors so long as business is
good.
MAP SHOWING LOCATION OF SALOONS
A poor white neighborhood in Baltimore, in a section composed of four blocks,

with 36 saloons.
It was reported that there were at least three neighborhoods in

the city in which the conditions with reference to schools for colored
children and housing of colored families were deplorable in the
extreme.
There was the Caroline and Bank Streets district, in which a
colored school was surrounded by a network of saloons and houses
of prostitution. It was found that within a block of the school there
were nine saloons and no less than forty-seven houses of ill-repute.
It was learned that it was most difficult to keep girls in this school
after they became thirteen or fourteen years of age. So powerful
were the influences of this neighborhood upon them that at thirteen
some of them passed from the school to the houses of prostitution
and to lives of shame. In a tour of inspection of this neighborhood
young girls were pointed out one after another, who, the previous
year, had been pupils of the school. One mother, who had recently
moved to Baltimore from the country, told how she had rescued her
twelve-year-old daughter from one of those dens, and how a
policeman, to whom in her agony and distress she had appealed,
threatened to arrest her for disorderly conduct!
Public School No. 116, surrounded by eleven saloons, 8 of which are within 300
feet of the school premises.
The Rogers Avenue district, in which another colored school was

located, while not quite so bad so far as the number of saloons and
questionable houses was concerned, was yet a neighborhood
infested with both kinds of places, and the block just below the
school, on the street through which nearly half of the children must
pass on their way to and from school, was lined on both sides with
houses of prostitution, over whose doors, in some cases, the women
who kept them had their names printed. Such a condition as this
existed nowhere else in the city, and made this particular street a
demoralizing influence which was different from any other and in
many ways more powerful for harm than any other which was
found.
(Click on the map for a slightly-larger version.)
DRUID HILL AVENUE DISTRICT
Deaths due to tuberculosis in ten years, 1891–1900, inclusive, in all 11,542. The
tuberculosis map of Baltimore City. The lower Druid Hill Avenue district is
outlined on the map. This is the tuberculosis center of Maryland and the City of
Baltimore.
The Druid Hill Avenue district is the largest and most populous
colored neighborhood in Baltimore, if not in the world. It probably
contains more homes owned and occupied by colored people than
any similar residential neighborhood anywhere. It extends from
Eutaw Street to North Avenue, and with the adjacent streets covers
an area a mile and a half long by from one-sixteenth to one-half a
mile wide. The upper part of this district is as fine a colored
neighborhood as one would wish to see, and is comparatively free
from nuisances of any kind.
In the lower Druid Hill Avenue district, which was the largest
district studied, it was found that in a section seven blocks long and
two blocks wide there were located forty-two saloons, fifteen
churches, twelve schools, one home for old people, one home for
friendless children, the Colored Young Men’s Christian Association
and the Colored Young Women’s Christian Association. This section
was honeycombed with gambling dens, known not only to the
initiated, but carrying on unblushingly a business which was known
to the citizens if not to the police. There were numerous dance
houses, clubs and billiard halls which were in actual practice only
assignation places for girls and young women, and to which many of
them owed their downfall.
The Health Office furnished a map which showed that the lower
Druid Hill Avenue district was the “tuberculosis centre” for the city of
Baltimore and the State of Maryland. From “A Study on Housing
Conditions in Baltimore,” an investigation prepared under the
direction of the Association for the Improvement of the Condition of
the Poor and the Charity Organization Society, the following is
quoted, showing the bad conditions of health, sanitation and morals
with reference to one alley in this district:
“The Biddle Alley district, of all sections of the city, holds the record for
the tuberculosis death rate. In the year 1906 eight deaths from
tuberculosis occurred in families known to the agent of the Federated
Charities, and according to the statement made a short time ago by a
Health Department official, there is not a house on Biddle Alley in which
there has not been at least one case of tuberculosis.”
“From morning until midnight the beer can circulates with a regularity
that is almost monotonous.”
“Another striking characteristic of the occupants of this district is what
appears to be in many cases an entirely undeveloped moral sense.”
“Gambling is also prevalent and there is reason to believe that the
cocaine habit hastens the decay of many of these degenerates.”
As to the sanitary conditions, the report states further:

“Of the two hundred and fifteen houses in the Biddle Alley district,
seventy-one had leaking roofs.”
“Dirty, dark, damp and dilapidated are adjectives that fairly describe
nearly two-thirds of the four hundred and thirty-eight basements and
cellars included in the investigation.”
“In several cellars in the Biddle Alley district the surface drainage from
the adjoining alley or street was found to be oozing through the
foundation walls.”
“A basement apartment in the Biddle Alley district had no light or
ventilation except that afforded by a window 3½ feet square in area,
placed so high in the wall that it was necessary to stand on a chair to
take measurements. The walls and ceiling of this dungeon-like apartment
were damp and in bad repair. From the physical condition of the
occupant it seemed likely he was suffering from tuberculosis in its
incipient stage.”
One of the most conspicuous features of the houses lining the

small streets and alleys in the lower Druid Hill Avenue district were
the stacks of washing, tons of which are gathered weekly from the
best homes of the city, to be laundered in this neighborhood reeking
with filth, infected with tuberculosis and other infectious diseases,
and presenting the most unwholesome conditions from which the
family wash could possibly be sent home. And yet hundreds of white
families are in this way subjecting the members of their households
to these great dangers.
One interesting fact which developed in connection with the
investigation of these conditions was the attempt on the part of the
keepers of these places to bulldoze and browbeat the committee out
of their work. The writer received a warning from the keeper of one
of these dives that unless his activities ceased personal injury would
be visited upon him. Another man, who kept a business which was
patronized by many of these divekeepers, lost all of that business on
account of his connection with the Law and Order League. Another
man, who kept a store, was forced to give up active work for the
League because he could not afford the loss which threatened him if
he continued. Others, who were weaker or who could not stand the
financial loss which activity in the work of the League entailed upon
them, began to hedge and criticise and finally openly assail the
League as a movement which was seriously affecting the business
interests of the colored people.
It was found that these saloons were meeting places of the idle,
loafing element among the colored people, of the crap shooters, of
dissolute women, and many of the saloonkeepers did not hesitate to
sell liquors to women and children. One of the discoveries in this
lower Druid Hill Avenue district was that in the small streets, which
were practically alleys, there were three of these saloons—two in
one alley, and one at the intersection of two other alleys.
The saloon which is kept by a white man for colored trade is
usually the lowest possible type of saloon. The cheapest grades of
liquors are dispensed. Many of them have back entrances and
depend upon their Sunday trade for a large part of their revenue.
The writer has frequently seen a string of Sunday drinkers filing
through the back gates into some of these saloons. Other members
of the League had also seen these Sunday violations of the law, and
there were many outsiders, particularly women, who were the wives
and mothers of men and boys whose earnings went largely to the
saloonkeepers instead of to the support of their families, who were
ready to testify that for many of the saloons Sunday was the busiest
day. On one occasion a colored man interested in assisting the
committee bought a pint of whisky from one of these saloons, and
then telephoned the police that this saloonkeeper was selling liquor
on Sunday. A raiding party was immediately sent out from the
station house, and when the place was reached everything was as
quiet as the most exact observance of Sunday closing law would
seem to require. It was evident that in some mysterious way the
proprietor had received a tip that the raiding party was coming. And
so it happened with nearly every attempt at raiding for Sunday
selling. The places would be found either absolutely empty and quiet
or those in the places would swear that they were mere visitors. It
was rather openly asserted about at least one saloon that there was
a secret door from it into the adjoining house. At any rate, in this
district detection and conviction seemed well nigh impossible.
The alley saloon, being off the thoroughfare, has advantages for
conducting this sort of an illicit business with far greater safety and
with more profit than the saloon which is out on the front street, and
hence alley saloon franchises, so far from being undesirable, are
eagerly sought by that type of white men who will run a place for
that class of trade.
In one of these saloons it developed that, in addition to the bar, a
dance hall was run by the proprietor. Nightly orgies of half-drunken
men and women made this neighborhood particularly objectionable
to surrounding residents. One high school girl, who was compelled
to leave school on account of her condition, was said to have met
her ruin in this place. A member of this committee, who for a while
lived next door to this saloon, saw the proprietor go out of the
saloon one night about midnight, and apparently put something
down by the side of the lamp post on the opposite corner. Shortly
afterward a policeman came along and picked it up and went on. At
the hearing before the Liquor Board the sergeant and night officer
on this beat testified in the strongest terms to the good character of
this place. One white business man across the street said that his
best customers had been run off by the people who patronized this
dive.
When the sub-committees made these reports it was decided to
undertake the work of cleaning up the lower Druid Hill Avenue
neighborhood alone, and to leave the work in the other
neighborhoods to a future movement. It was felt that by centering
all of their efforts upon the one neighborhood there was more hope
of success than there would be from undertaking the work in all of
them at the same time. It was decided to make a most earnest
effort to secure the removal of the saloons from the alleys and the
vicinities of the schools and churches in this lower Druid Hill Avenue
district. They decided to make charts and secure pictures showing
the conditions in this neighborhood and publish them, as far as
possible. A sub-committee was appointed to carry these plans into
execution.
As the committee progressed in its labor of collecting statistics and
came gradually to the point of action, the absolute dependence of
the colored people generally upon the mercies of the whites, and the
helplessness of the committee acting by itself became more and
more apparent. Liquor Boards in the past almost totally ignored the
protests of colored churches and colored individuals. Police Boards
were but little less inclined to consider their complaints. There had
been and still was a general feeling that the colored people were
either of themselves so criminal or were so disposed to shield and
protect their criminals that they were not taken seriously when
protesting against lawlessness and lawbreaking.
The committee early realized that in undertaking to secure these
reforms they would have to contend with the powerful saloon
interests, which were most firmly intrenched, and would have to
work without the co-operation of the police department, whose
efforts should always be on the side of law and order. And so they
saw that it would be necessary to form a combination with the best
white people of the city and if possible bring them into active co-
operation in this work. The most important work, then, was to
secure the active interest of leading white men. A sub-committee
was appointed for this purpose, and they visited the late Dr. Daniel
C. Gilman, ex-President of Johns Hopkins University, and one of
Baltimore’s most distinguished citizens; Mr. Douglas H. Wylie, at that
time President of the Chamber of Commerce; Mr. Eugene Levering,
President of the Commercial National Bank and one of the most
distinguished philanthropists of Baltimore; Bishop Paret, the head of
the Episcopal Church in this diocese; Mr. Joseph Packard, at that
time President of the Board of School Commissioners and one of
Baltimore’s leading citizens; Mr. Robert H. Smith, a leading lawyer;
Mr. John C. Rose, United States District Attorney, who as legal
adviser and advocate performed most helpful service for this
committee; Mr. Isaac Cate, a retired capitalist; Mr. John M. Glenn,
who is now Secretary of the Sage Foundation, and who threw
himself most heartily into the work; Judge Alfred S. Niles, a member
of the Supreme Bench of Baltimore City, and Mr. W. Hall Harris, the
city postmaster.
The committee was encouraged by the heartiness with which, with
one or two exceptions, our request for co-operation was met by all
of these men. The committee was not only impressed with the
sympathetic interest which their mission raised, but they were struck
with the frequency with which certain questions entered into nearly
all of these conferences.
MALES OF MARYLAND ENGAGED IN GAINFUL

OCCUPATION
A common belief is that colored men will not work. The United States census
shows more colored men at work in Maryland than whites.
For instance, there was a query as to why the colored man will not
work. They intimated that in some cases the conditions of vice and
immorality grew out of the laziness and idleness of the men of this
neighborhood as well as out of the environments of the saloons and
dives. A study of the statistics prepared by the United States Census
Bureau, however, shows that a larger percentage of the colored men
of Maryland are at work than of the whites.
A = Farm homes owned free of debt.

B = Farm homes owned but mortgaged.
C = Farm homes rented.
A = Farm homes owned free of debt.

B = Farm homes owned but mortgaged.
C = Farm homes rented.
The progress in home-getting since emancipation has been rapid in Maryland.
The committee was also asked why there is so little home life
among the colored people. It is true that the home life is not as
desirable among colored people as it ought to be and as most of us
would have it; but the influx of the colored population from the
alleys and small streets of south and east Baltimore into the more
desirable neighborhoods of northwest Baltimore, particularly upper
Druid Hill Avenue and the adjacent streets, shows an upward
movement along this line, and the fact that there is a most healthy
and promising growth of the home spirit. Not only this, but statistics
from the United States Census Bureau show that out in the country
districts of Maryland the colored people are procuring homes for
themselves. While it is true that there is a scarcity of labor, it is also
true that there has been a phenomenal increase in the number of
farm homes in the State of Maryland. At the present time the
colored farmers of the State own fifty-seven per cent. of the farm
lands they are tilling.
The committee was also asked why there was so much immorality
among colored women and girls. The exhibition of the charts
showing the conditions surrounding the colored public schools,
particularly the Caroline and Bank Streets neighborhood and the
Rogers Avenue neighborhood, are complete answers to this
question. It was not difficult to see that girls who attended school
among such surroundings as these could not in the very nature of
the case have high ideas of virtue and morality. It was found that at
least five of the colored city schools are surrounded by such
conditions. Little girls and boys receive daily object lessons in
prostitution, gambling, drunkenness, profanity and thieving.
Another distressing question which the committee was constantly
called upon to meet was—Why is the colored jail population so
large? The statistics show that about three-fourths of the population
in the Baltimore jail and the Maryland Penitentiary are colored men
and women—a most disgraceful showing on the part of the colored
people. The committee could only admit that the undue proportion
of colored criminals in the jail and the penitentiary is a reflection
upon the citizenship of the colored people.
ISAAC WINDER
Educating a Negro is cheaper than hanging him.
The committee made the general plea, though, to the white men
upon whom they called, that the colored children should have the
opportunity as a result of their environments and the general
advantages offered them, to grow up into decent citizenship. These
gentlemen were shown the conditions which surrounded our
schoolhouses, and readily admitted the handicap which such
surroundings imposed upon little children. We were able to show
them that the Colored High School, which the city has maintained for
about twenty-five years, has in all of its history furnished but one
inmate for the penitentiary or the jail. Those who are graduated
from this school not only do not join this jail population, but they are
engaged in such occupations in this community as prove their
usefulness to the people with whom they are associated and of
whom they are a part, and at the same time the wisdom of a liberal
policy of education.
The committee was able to show another striking illustration of
the value of education in presenting the history of the notorious Ike
Winder, who murdered a tollgate keeper in Baltimore county. To
arrest, try, imprison, recapture and execute Ike Winder cost the
State two thousand dollars more than it cost to educate one of the
graduates of the Colored High School. The State not only lost in this
expenditure the money involved in the expense connected with the
case, but lost the economic value of an educated citizen. The
educated, trained graduates of the high school exert a most helpful
influence in the community. Assuming that Winder, if he had
graduated from the High School, would have been like the other
graduates, the State lost also the moral influence of this kind of
citizen.
EDUCATION VS. IGNORANCE.
The educated man is a more valuable citizen than the ignorant one.
The facts presented to these men as they were visited formed the
basis of a plea for co-operation between the best whites and blacks
of the city, and the formulation of a plan of action to be mutually
worked out by them. Dr. Gilman, who had taken such an enthusiastic
interest in the matter, offered the use of his home and invited a
conference of gentlemen, which marked an epoch in the approach to
the ideal working relation between the best people of both races.
There were present at this meeting: Postmaster W. Hall Harris; Dr. J.
H. Hollander, a Johns Hopkins professor and one of the noted
sociologists of the age; Dr. Bernard C. Steiner, librarian of the Pratt
Library; Professor Charles W. Hodell, of the Woman’s College;
Lawyers A. M. Tyson and P. C. Hennighausen, R. H. Smith, John C.
Rose, Joseph Packard, Mr. Douglas M. Wylie, Professor James H. Van
Sickle, the Superintendent of Public Instruction; Bishop Paret, Judge
Heuisler, of the Supreme Court; Mr. John M. Glenn, Mr. Eugene
Levering, Dr. Ira Remsen, President of Johns Hopkins University;
Dean Griffin, of Johns Hopkins University, and Dr. Gilman. Many of
these men had been visited by the sub-committee and had had the
matter partially explained to them, but at this gathering in Dr.
Gilman’s house the committee was able to present in detail the
charts which had been prepared, many pictures which had been

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Gulf War and Health Insecticides and Solvents 1st Edition

Gulf War and Health Volume 8 Update of Health Effects of

The Gulf War 1991 Alastair Finlan

Child and Adolescent Health and Health Care Quality

War in the Persian Gulf Reference Library Primary Sources

War in the Persian Gulf Reference Library 2 Biographies

Health Insurance is a Family Matter Insuring health 1st

Committee on Gulf War and Health: Infectious Diseases

Board on Population Health and Public Health Practice

International Standard Book Number-10: 0-309-10106-9 (Book)

Library of Congress Control Number: 2006934962

Copyright 2007 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America.

ABIGAIL E. MITCHELL, PhD, Senior Program Officer

Lawrence R. Ash, Professor Emeritus, Department of Epidemiology, University of California,

Robert E. Black, MD, MPH, Chair

Limited or Suggestive Evidence of No Association.........................................................31

3 Infectious Diseases Endemic to Southwest and South-Central Asia

5 Levels of Association Between Select Diseases and

Identifying the Pathogens to Study

Definition of Long-Term Adverse Health Outcome

In addition, a long-term adverse health outcome could be reversible, related to secondary

Development of Inclusion Criteria

• Endemic in southwest or south-central Asia during the period in question.

Identifying the Literature to Review and Evaluate

Assessing the Strength of the Evidence

Sufficient Evidence of a Causal Relationship

The evidence is sufficient to conclude that there is a causal relationship

• Coxiella burnettii infection (Q fever) and osteomyelitis.

Sufficient Evidence of an Association

The evidence from available studies is sufficient to conclude that there is

Limited or Suggestive Evidence of an Association

The evidence from available studies suggests an association between

Inadequate or Insufficient Evidence to Determine Whether an Association Exists

The evidence from available studies is of insufficient quantity, quality, or

Limited or Suggestive Evidence of No Association

Evidence from well-conducted studies is consistent in not showing an

DEPARTMENT OF DEFENSE POLICIES ON TUBERCULIN SKIN TESTING AND

Approximate Number of Troops Deployed

BOX 1-1 Agents Specified in PL 105-277 and PL 105-368

• The following organophosphorus pesticides:

IDENTIFYING THE INFECTIOUS DISEASES TO STUDY

Approximate Number of Troops Deployed

THE COMMITTEE’S APPROACH TO ITS CHARGE

ORGANIZATION OF THE REPORT

DOD (Department of Defense). 2006. US Department of Defense Official Website. [Online].

IDENTIFYING THE INFECTIOUS DISEASES TO STUDY

Approximately 100 infectious diseases were identified for preliminary consideration

Disease Etiologic Agent

Disease Etiologic Agent

Disease Etiologic Agent

BOX 2.1 The Four Diseases Specified in PL 105-277 and PL 105-368

Though present in southwest or south-central Asia, some of the diseases on the

Direct Attribution to Military Service in Southwest and South-Central Asia

Bacterial diseases against which Of special concern to US

Of special concern to US troops

Timing of Appearance of Long-Term Adverse Health Outcomes