After returning from the desert in May 2003, I resumed my prior job as chief of the Medical Division at USAMRIID. By then U.S. forces had advanced throughout Iraq. I had some difficulty refocusing at first on the daily minutiae of administration after dealing with the more serious life-or-death issues in the desert. I almost welcomed a new challenge that awakened me from my postdeployment doldrums.
Sometimes I found myself serving as a nexus or a tripwire for responding to or sounding the alarm about infectious disease crises elsewhere in the military. There had been occasional reports of pneumonia among troops deployed to the Middle East for the war. In March 2003 there had been some email chatter when two severely ill soldiers were treated for pneumonia at the Landstuhl Regional Medical Center in Germany after being evacuated from Iraq. These cases were deemed to be the normal background disease incidence. Not an outbreak.
On June 17, 2003, a soldier with severe pneumonia was in the process of being evacuated from Iraq to Germany, but he died before leaving the country.
Around this time, the air force transferred a new infectious disease physician to work in my division. Lieutenant Colonel Janice Rusnak was a quiet, medium-height blonde who loved horses.
The air force had a position for an infectious disease doctor at the Landstuhl Regional Medical Center in Germany, the first stop for ill and wounded soldiers and marines evacuated from Afghanistan and Iraq. In the summer of 2003, when the physician rotated out of Landstuhl for his next assignment, the air force tagged Janice to cover for a couple of months until a replacement arrived.
In late June we at USAMRIID had some dialogue with personnel at the Twenty-Eighth Combat Support Hospital in Iraq about a severely ill soldier they were caring for with pneumonia. In an update email I received on June 26 from a doctor at the CSH, he wrote, “He [the ill soldier] will be leaving tonight to Germany.” A picture of the patient’s chest X-ray was attached to the email.
While she was in Germany, Janice usually received advanced warning of incoming infectious disease–related air evacuations, but I sent her a heads-up email anyway: “Looks like he may be on his way to you shortly.” The chest X-ray looked bad, with a whiteout of both lungs, so I copied Colonel (Dr.) Tim Endy, my fellow USAMRIID division chief in Virology. He forwarded my email on to some of his infectious disease colleagues in case they had ideas about possible causes. For the same reason, I also sent the note to my USAMRIID colleagues, writing “Impressive CXR [chest X-ray] findings.”
The soldier arrived in Landstuhl, and Janice was asked to evaluate him. Janice rode the elevator to the ICU, where the patient was being cared for. She got out and turned left toward the ICU, which had a long central corridor, with an open bay on the left and single-patient rooms on the right. When she entered the ICU, she asked the nurse where the soldier with pneumonia on a ventilator, recently evacuated from Iraq, was located.
“Which one?” the nurse responded. “We have three.”1
Whoa! Janice thought immediately, feeling like her stomach had jumped up into her throat. Three young soldiers requiring ventilators at the same time? Janice evaluated the patient she was asked to see and wrote up her recommendations, but she was particularly concerned because this patient was the third case of severe pneumonia in the past month from the same CSH in Iraq. One of those prior cases was the soldier who had died a mere ten days earlier. Now there were two additional cases on ventilators from Iraq? Janice wanted to know what might be causing such a severe illness in young, healthy soldiers.
On June 30 Janice copied Tim Endy and me on an email she sent to doctors in Iraq describing the situation: “There are currently three young (ages 20–22 years) AD [active duty] intubated with ARDS [acute respiratory distress syndrome] in the ICU.”
Tagged onto that note was an earlier one written by someone at the CSH in Iraq: “We have another patient that just arrived today with the same clinical findings. . . . We’re getting pretty anxious now suspecting a trend.”
Janice alerted the chiefs of Pulmonology and of Medicine at Landstuhl about the possibility of an outbreak. She started to review charts of pneumonia cases that had come through Landstuhl from Iraq during the prior six months. She also put together a panel of labs for testing on anyone with “Iraq pneumonia.”
Back at USAMRIID, we were hearing rumors of seventeen other pneumonia patients.
This scared me. It could be nothing. We always hope it is. But it could also be a disaster. Was I hearing the hoofbeats of zebras?
Three things make up the “epidemiologic triangle,” and all three must align to start an outbreak: a pathogen, a host (like a human) infected by the pathogen, and an environment that facilitates spread. The third factor is the most important for triggering the chain reaction for an outbreak. Ebola might kill an occasional, undiagnosed victim in the jungle, but move that victim to a hospital, and the epidemiologic triangle forms, causing the disease to explode.
I worried that the epi-triangle pieces had aligned. Something lurking in the desert was facilitating spread. Janice’s cases could be the sentinel for a bigger disaster on the way.
I wasn’t the only one thinking along those lines.
A few minutes after receiving Janice’s email, my phone rang, with Tim Endy on the line. He was in the middle of his month-long rotation as the consulting infectious disease physician at Walter Reed Army Medical Center. “Mark,” he said, “We’re following a woman in the ICU with the same thing.” She had also been medically evacuated from Iraq.
Shit!
I felt that familiar queasiness of impending doom in the pit of my stomach. This could be real. I set the phone down and considered the possibilities. The Severe Acute Respiratory Syndrome (SARS) virus had circled the globe mere months previously. Was SARS staging a comeback? SARS could spell disaster for our battlefield forces. Also, in 1992 Saudi Arabian physicians described a “new clinicopathological entity, Desert Storm pneumonitis or Al Eskan disease . . . when the mixture of fine Saudi dust and pigeon droppings triggered a hyperergic [allergic] lung condition.”2 Could this be Al Eskan or another new disease? Even more worrisome: could this be the Iraqi biological weapon attack that we all feared?
The army pulled our SMART-IND team out of the desert because the risk for bioweapon attack had abated. Was that a mistake?
I could not sit on this.
With my public health background and USAMRIID position I bridged the Army’s public health and infectious disease communities. I fired off an email to two leaders: Colonel Bob Defraites, the lead preventive medicine physician at the army surgeon general’s office and Dr. Bruno Petruccelli at the Army Center for Health Promotion.
“Bruno and Bob: . . . Some of these cases are particularly concerning and unusual in their severity and rapidity of onset. . . . I’m thinking an EPICON [epidemiologic consultation] investigation might be useful. What do you think?”
I followed up immediately with a phone call. “Bob, Mark Kortepeter here. I think we have a problem. Look at the email I just forwarded to you.”
Bob set up a call for a small group to confer and decide how to respond.
The first thing you do in a cardiac arrest in the hospital is take your own pulse. For an outbreak investigation, we first take a step back and tease fact apart from rumor to decide whether there really is an outbreak. Then we try to make a diagnosis and determine how many patients really have the problem and whether it is the same problem. Next decide whether the disease frequency is different from the norm and who might be at risk.
Word spread quickly, and the vast military infectious disease and preventive medicine network began to mobilize. Doctors in-country told us that soldiers had numerous exposures to rodents, mosquitoes, sandflies, fleas, and ticks, which raised lots of possibilities for infections. Dr. Charles Hoke, former consultant to the surgeon general for infectious diseases offered several potential diagnoses—“tularemia, plague, typhus, malaria, hantavirus pulmonary syndrome, SARS”—but in the desert, they had no ability to get bacterial cultures, do Gram stains, or get antibody testing, and the choice of antibiotics was limited. By the time the soldiers arrived in Germany, any antibiotics they might have received already made it too late to pick up the offending organisms with a bacterial culture. We were flying blind.
We had a teleconference the next day to do what any public health team would do at the start of an outbreak: describe the disease, develop a case definition, and generate a differential diagnosis.
We came up with a case definition:
Onset of illness in a deployed service member since 1 March while stationed in Iraq or Kuwait with:
- 1) any radiographic sign of pneumonitis or pneumonia OR
- 2) severe respiratory distress requiring intubation OR
- 3) sudden unexplained death
Armed with this case definition, Bob’s team at the surgeon general’s office conducted a preliminary review of the surveillance data. Approximately one hundred personnel had been treated for pneumonia. Among those, fourteen soldiers and one marine had developed severe pneumonia that required medical evacuation to Landstuhl. There appeared to be no geographic link.
Preliminary lab data came up negative for a cause, even from an autopsy conducted on the June 17 death. Labs were forwarded to Landstuhl and to USAMRIID for additional testing.
The lead medical general in-theater emailed the growing list of addresses on the email string, currently at nine, “I am in favor of an EPICON/EPIAID [epidemiologic consultation]. . . . I am concerned that something is going on here, although on the surface we cannot find any patterns.” In two days the email list would grow to thirty-two, a week later to sixty-three, as the urgency increased, and the network expanded.
We all had similar concerns. During our initial telephone conference, we discussed the possibility of launching an investigative team. In the next week, sentiments for a team shifted back and forth. Numerous docs weighed in on potential causes, and some disagreed whether this was pneumonia or pulmonary edema. More information rolled in about possible exposures after an interview with a victim, which expanded the list of potential diagnoses: “The buildings they stay in were filled with three feet of trash including feces of both human and animals. There are pigeons all over the place-like you would not believe. They sleep outside because it is too hot to sleep in the ‘cleaned’ building . . . loads of mosquito bites . . . dead cats and dogs, few dead horses, few dead people in the streets. He routinely patrols through knee high sewage.”
The environment was an infectious disease doctor’s nightmare.
On July 12 the next shoe dropped. A second soldier died.
No more time to wait. Bruno Petruccelli sent out an urgent note in advance of a scheduled telephone conference on July 16: “Please remove the word ‘standby’ [for the team]. . . . It’s now ASAP to deploy.”
Four days later, the first investigative team launched to Germany.
On August 1 the news hit Promed, the online outbreak alert notification system: “Army sends team to probe Iraq Illness.”
The second team shipped out August 5 for Iraq.
An average of 183,000 military personnel had moved through Iraq during this period. The teams sent to Germany and Iraq had to tease apart the potential for a natural versus an engineered attack. They sorted through patient records, lab results, radiographic results, and interviewed staff and patients looking for clues. They administered questionnaires covering a battery of possible risks: tobacco use, vaccines received, sleeping locations, contact with prisoners, water sources, use of medications, insect repellents, contacts with chemicals, illicit drugs. Team members collected samples of tobacco products for testing for contamination with paraquat, bacteria, fungi, and specific threats like ricin, strychnine, and other toxins.3
After months of work, including a myriad of laboratory tests, the investigation of desert pneumonia discovered that nineteen soldiers who had deployed to Iraq and surrounding countries had developed severe pneumonia and required a ventilator to survive. Two died. The peak occurred in June and July, which was why they hit our radar screen then. Several had been infected with common bacteria like pneumococcus. Strangely, ten had elevated levels of eosinophils, a white blood cell that spikes with allergies or parasite infections. In those patients antibiotics didn’t work. Even before the epidemiology investigation had concluded, the Medical Division chief and one of the pulmonary doctors at Landstuhl elected to treat some soldiers who had elevated eosinophils or wheezing with steroids, and it seemed to help.
The only common risk identified among the ill was smoking. Fourteen of them had begun smoking after deploying. Could another exposure on top of the cigarettes and desert dust have led to the pneumonia, as in the case of Al Eskan disease years earlier? We never determined conclusively why so many had gotten sick and why then.
Even so the good news was that this wasn’t a bioweapon attack, but we were right to be concerned. When I first read Janice’s emails about soldiers with pneumonia, my experience and position gave me the confidence and authority to pick up the phone and reach out to my public health contacts to kick-start an investigation. We could then leverage the infectious disease and preventive medicine communities and the sophisticated lab testing available through the military’s lab network. Everyone came together to run this to ground.
Having the ability to respond rapidly works for natural disease outbreaks like pneumonia in the desert as well as our next disaster brewing over the horizon in an African country most people have probably never heard of.