DoD Reports Progress in Pneumonia Investigation
August 22, 2003

The Department of Defense announced today progress on the investigation of a number of cases of pneumonia among military members deployed for military operations in Southwest Asia.

“From what we have learned so far, it appears there are a series of unusual pneumonia cases that have occurred in Southwest Asia. These cases do not represent an epidemic, and it is not being spread through person-to-person contact. We are making significant progress in eliminating a number of possible causes, such as SARS and vaccines. Our investigatory process is helping to determine if there is a single explanation, or if there are multiple cases,” said Dr. William Winkenwerder, assistant secretary of defense for health affairs. “Understanding the cause is important to prevent future cases.”

To date, the investigation has found evidence that two of the non-fatal cases were associated with Streptococcus pneumoniae, the most common cause of bacterial pneumonia. Col. Bruno Petruccelli, director, epidemiology and disease surveillance at the U.S. Army Center for Health Promotion and Preventive Medicine, said, “There is evidence that 10 of the cases have shown a higher than usual number of blood cells of one specific type called eosinophils. An increase in this type of white blood cell can occur in a variety of medical conditions, for example, infections, asthma, hay fever and allergies. Medical personnel are trying to determine why some of the 19 patients with severe pneumonia showed an increase in these cells.”

Petruccelli also said, “It is our duty to patients and family members to ensure that we have done everything we can to understand what has happened. We must take whatever time is needed to do a thorough job of gathering and analyzing information about these pneumonia cases. Our work is progressing well.”

No other common infectious agents, evidence of exposure to chemical or biological weapons, severe acute respiratory syndrome (SARS), or environmental toxins have been identified. Among the several hundred thousand deployed servicemembers in Southwest Asia over the past six months, approximately 100 have developed pneumonia. The rate is consistent with what might be expected for a healthy population of similar ages to our service members. The concern, however, is about the smaller number of servicemembers, now identified as 19 cases, who developed severe pneumonia. Two servicemembers have died from the disease, the first in Iraq on June 17 and the second in Germany on July 12. The Office of the Armed Forces Medical Examiner is determining specific cause or causes of death.

From March – August 2003, 17 soldiers, one Marine, and one sailor have developed pneumonia serious enough to warrant medical evacuation for ventilator (respirator) support. Fourteen of these members responded to standard treatment for pneumonia, recovered from their illness, and returned to duty. Three remain hospitalized.

Two of the 19 serious cases became ill in March, two in April, one in May, six in June, four in July, and four so far in August. Of the serious cases no two individuals (18 men and one woman) were from the same unit. Thirteen of the cases became ill in Iraq and six were in other Central Command countries, including Kuwait, Qatar, Uzbekistan, and Djibouti.

Among the investigative efforts underway are two Army Epidemiological Consultation (EPICON) teams. One team is in Iraq looking for commonalities among the cases-for example, time, place or symptoms-and whether anything in the nature of the cases is unusual when compared with similar DoD members, whether deployed or not, and U.S. civilian populations. A second team has been at Landstuhl Regional Medical Center, Germany, where most of the pneumonia cases have been treated following medical evacuation from Southwest Asia.

A scientist from the Centers for Disease Control and Prevention (CDC) has joined the consultative team at the Walter Reed Army Institute of Research, where all information from the Germany and Iraq EPICON teams is being gathered, analyzed and evaluated. The Department also has engaged the expertise of several members of the Armed Forces Epidemiology Board (AFEB), which is an advisory committee of eminent civilian scientists and physicians. These Board members are providing the Department with consultative expertise during the investigation. The CDC’s associate director for epidemiologic science, and a member of the AFEB, is also involved in this investigative review. The EPICON teams and other investigators will make preventive or corrective recommendations based upon their findings.

Pneumonia is a common illness worldwide in all populations. In the Army, for example, pneumonia is serious enough to warrant hospitalization for about 9 of every 10,000 soldiers each year, resulting in 450-500 total cases Army-wide. According to U.S. medical statistics for the year 2000, this rate is very similar to the rate for the general population of those between the ages of 15 and 45 (10.5 of 10,000 per year). Therefore, the approximately 100 total cases of pneumonia do not exceed a normal, expected rate for this disease, despite the harsh environmental conditions found in Southwest Asia. While death from pneumonia is rarely seen in young, otherwise healthy populations — such as the military, it does occur. For example, from 1998 through 2002, 17 Army members (worldwide) have died from pneumonia or from complications of pneumonia.

Winkenwerder said, “Our work is progressing well in the continuing investigation of these pneumonia cases. So far, we are able to rule out several sources of this illness — such as SARS. However, we are deeply saddened at the loss of our service members, and we share in the desire of their families, friends and commanders to identify the cause of this illness. We are committed to providing world-class care for our people and we will pursue this pneumonia investigation until answers are found.