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

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