Skip directly to site content Skip directly to page options Skip directly to A-Z link Skip directly to A-Z link Skip directly to A-Z link
Volume 5, Number 3—June 1999
Synopsis

Respiratory Diseases among U.S. Military Personnel: Countering Emerging Threats

On This Page
Adenoviruses
Influenza
Streptococcus pyogenes
Research and Disease Control
Conclusions
Cite This Article
Figures
Figure 1
Figure 2
Figure 3
Downloads
Article
RIS [TXT - 2 KB]
Article Metrics
Metric Details
199
citations of this article
EID Journal Metrics on Scopus
Author affiliations: *Naval Health Research Center, San Diego, California, USA; †Naval Medical Center, San Diego, California, USA; and; ‡Walter Reed Army Institute of Research, Washington, DC, USA

Cite This Article

Abstract

Emerging respiratory disease agents, increased antibiotic resistance, and the loss of effective vaccines threaten to increase the incidence of respiratory disease in military personnel. We examine six respiratory pathogens (adenoviruses, influenza viruses, Streptococcus pneumoniae, Streptococcus pyogenes, Mycoplasma pneumoniae, and Bordetella pertussis) and review the impact of the diseases they cause, past efforts to control these diseases in U.S. military personnel, as well as current treatment and surveillance strategies, limitations in diagnostic testing, and vaccine needs.

Figure 1

Thumbnail of Hospitalization rates for acute respiratory disease per 10,000 persons, 1991 to 1994: U.S. army recruits vs. young adults in U.S. nonfederal hospitals. U.S. army recruit estimates are converted from percentage febrile acute respiratory disease rates per 100 trainee-week figures (8). On average, recruits were 19 years old. U.S. national nonfederal estimates were taken from first-listed diagnoses with the International Classification of Diseases codes 460 to 466 (9) among persons of a

Figure 1. Hospitalization rates for acute respiratory disease per 10,000 persons, 1991 to 1994: U.S. army recruits vs. young adults in U.S. nonfederal hospitals. U.S. army recruit estimates are converted from percentage febrile...

Respiratory infections, the most common cause of acute infectious disease in U.S. adults (1), are also the leading cause of outpatient illness and a major cause (25% to 30%) of infectious disease hospitalization in U.S. military personnel (2,3). Because of crowded living conditions, stressful working environment, and exposure to respiratory pathogens in disease-endemic areas, military trainees and newly mobilized troops are at particularly high risk for respiratory disease epidemics (2, 4-6). For example, before vaccines were used, more than 80% of military trainees had respiratory infections, and as many as 20% were hospitalized during the 2 months of recruit training (7). Although respiratory disease control is improved, epidemics continue to occur, and respiratory disease in military trainees continues to exceed that in U.S. civilian adults (Figure 1). The recent loss of adenovirus vaccine (types 4 and 7) production, changes in the susceptibility of pathogens to antimicrobial drugs, and emerging respiratory pathogens threaten to increase the military population's vulnerability to respiratory diseases.

We review the changing epidemiology and control of six major respiratory disease pathogens of special concern to the military.

Adenoviruses

Respiratory disease agents discovered in adenoidal tissue in U.S. soldiers in the 1950s were associated with rhinitis, pharyngitis, conjunctivitis, pneumonitis, and atypical pneumonia and were subsequently designated as adenoviruses (14). In 1958, adenoviruses caused hospitalization of an estimated 10% of military recruits (15). Adenoviral disease was highest during winter, accounting for 90% of all recruits hospitalized with pneumonia (16,17) and 72% of all respiratory disease (17). Military recruits had a greater chance of acquiring adenoviral infections than similar civilian populations, with most infections occurring during the first 3 weeks of military training (16,18,19). Of the 47 adenoviral serotypes, types 4 and 7 accounted for most military respiratory disease epidemics. A 1965 study of a typical epidemic at Fort Dix, New Jersey, established the need for vaccines (20).

In 1971, the Department of Defense (DoD) began routine use of live, enteric-coated types 4 and 7 vaccines, which have remained very effective (6). Vaccine development for other serotypes that cause only infrequent epidemics was begun, but no vaccine became licensed. Recently, the sole manufacturer of the adenovirus type 4 and type 7 vaccines ceased production, so neither vaccine is available. The unavailability of adenovirus vaccines threatens a sharp increase in numbers of acute respiratory disease epidemics in the military, especially among recruits (6). Recently, two recruit centers where the vaccines were not available had large acute respiratory disease epidemics (21,22).

Figure 2

Thumbnail of Department of Defense medical treatment facilities and recruit training camps participating in surveillance for emerging respiratory disease pathogens: invasive Streptococcus pneumoniae (typing and antibiotic sensitivity studies); Streptococcus pyogenes (typing and antibiotic sensitivity studies); and adenovirus (typing studies).

Figure 2. Department of Defense medical treatment facilities and recruit training camps participating in surveillance for emerging respiratory disease pathogens: invasive Streptococcus pneumoniae (typing and antibiotic sensitivity studies); Streptococcus pyogenes (typing and antibiotic...

The ecologic and pathologic features of adenoviruses in military populations are poorly understood (23,24). Most available surveillance data are more than 20 years old (7,20). To better understand the distribution of adenovirus serotypes, risk for infection, and agent dynamics following vaccine loss, triservice adenovirus surveillance has been established at five military training centers (Figure 2) (25). Early data indicate that types 4 and 7 vaccines remain effective, but nonvaccine serotypes are prevalent and should be considered in new vaccine development strategies. More than 55% of 3,212 throat cultures from symptomatic trainees from October 1996 to May 1998 yielded adenoviruses. Most prevalent were types 4 (46%), 7 (32%), 3 (13%), and 21 (5%). Among trainees with acute respiratory infection symptoms, nonvaccinated personnel were at greater risk of having a culture positive for adenovirus types 4 and 7 (odds ratio = 41.2; 95% confidence interval = 18.7 to 113.2) than vaccinated personnel. Capability to isolate and identify adenoviruses has improved, but simple rapid molecular diagnostic techniques have not yet been developed.

Influenza

Since an annual influenza vaccine policy was adopted for active-duty personnel in the 1950s, massive influenza epidemics have largely ended. However, the potential for illness and death due to new viral strains remains. During the last 3 months of 1918, an influenza A pandemic affected 106,897 (18.8%) of 569,470 navy personnel, with an estimated case-fatality rate of 4.5%. The case-fatality rate was particularly high among military trainees, especially those who had pneumonia. For example, during a 30-day period beginning in September 1918, 9,623 (21.5%) of 44,605 navy trainees (Illinois) had influenza, and 924 died; the case-fatality rate was highest (48%) among those with pneumonia (26). At autopsy, streptococcal organisms were often associated with pneumonia, which suggests that pathogens in the training camps may have exacerbated the influenza illnesses and deaths during this pandemic.

Even with annual use of influenza vaccine, laboratory-based surveillance is critical. During February 1996, a U.S. navy ship with a 600-person crew had an estimated 42% influenza A attack rate, although more than 95% of the crew had received the annual influenza vaccine (K. Earhart, pers. comm.). The annual vaccine for that winter (A/Johannesburg/33/94-like [H3N2] and A/Texas/36/91-like [H1N1]) did not protect against the A/Wuhan/359/95 [H3N2] strain that infected the crew.

Figure 3

Thumbnail of Military sites in the United States participating in Department of Defense influenza surveillance. The focus of surveillance at etiology-based sites is to determine the viral causes of influenzalike illnesses; the focus of population-based sites is to closely monitor for influenzalike illness epidemics.

Figure 3. Military sites in the United States participating in Department of Defense influenza surveillance. The focus of surveillance at etiology-based sites is to determine the viral causes of influenzalike illnesses; the focus...

The recent outbreak of H5N1 influenza A in Hong Kong prompted a review of capability to detect new influenza strains (27); only the air force was conducting a laboratory-based surveillance program (28). Since the Hong Kong outbreak, a cooperative global influenza surveillance network has been formed. Worldwide, more than 20 medical treatment facilities and laboratories from all services are collecting influenza isolates for typing (Figure 3) (29). Additionally, in the United States, military training sites at high risk for influenza are monitored so that epidemics might be quickly detected. This early warning system allows public health officials to modify vaccine antigens, use antiviral drugs, and take other measures to reduce illness.

Streptococcus pneumoniae

Before penicillin was introduced, complications of S. pneumoniae infections were frequent and often fatal. Large epidemics of pneumonia occurred in crowded military populations, particularly after influenza outbreaks, especially during winter. In 1918, a 1-month epidemic of S. pneumoniae in a military camp in Illinois resulted in 2,349 hospital admissions with a 50% death rate (30). From the 1960s to the 1980s, military epidemics of pneumococcal disease were very rare. However, in recent years, military pneumococcal epidemics have occurred in southern California (31), in North Carolina (32), and among a ship's crew in the Mediterranean Sea (4).

S. pneumoniae infections have various clinical features, including pneumonia, meningitis, empyema, bacteremia, conjunctivitis, sinusitis, arthritis, and otitis media. Since the introduction of penicillin, epidemics of respiratory disease caused by S. pneumoniae are much less frequent but remain a threat. To counter outbreaks, the military has used mass prophylaxis with benzathine penicillin G (1.2 million units) intramuscularly (31). However, the efficacy of this intervention and its impact on antibiotic resistance have not been fully evaluated (33). In 1991, the Armed Forces Epidemiological Board recommended pneumococcal vaccine (23-valent polysaccharide) for populations at high risk for S. pneumoniae infection. However, because of the cost and uncertainty about efficacy in healthy young adults, the vaccine is given only to trainees at one marine corps installation.

During the last 20 years, penicillin-resistant S. pneumoniae (intermediate and highly resistant strains), as well as multidrug-resistant strains, have been reported with increasing frequency throughout the world. Recently, investigators from Korea reported that 70% of 131 clinical civilian pneumococcal isolates were penicillin-resistant (34). On the basis of limited surveillance data, the public health threat of penicillin-resistant S. pneumoniae to U.S. military personnel and their dependents is increasing (35). Walter Reed Army Medical Center, Washington, D.C., reported an increase in the percentage of penicillin-resistant S. pneumoniae isolates from 0% in 1990 to 36.2% in 1994 (36).

In winter 1989-90, an outbreak among marine trainees at Camp Pendleton, California, resulted in 128 reported cases of pneumonia, one of the largest epidemics since the development of antibiotics. The epidemic triggered mass prophylaxis with benzathine penicillin G and administration of pneumococcal vaccine (31). Soon after, other smaller epidemics of pneumococcal pneumonia occurred among U.S. army rangers (32) and among the crews of two navy ships in Italian waters (4). As we write (March 1999), another pneumococcal pneumonia outbreak among army trainees is under epidemiologic investigation. These recent pneumococcal epidemics may be evidence of a changing epidemiologic threat. Pneumococcal pneumonia, which was checked when antibiotics became available in the 1950s, seems to have reemerged.

Increasing antibiotic resistance and epidemics prompted surveillance for invasive S. pneumoniae disease (Figure 2). Early data from patients hospitalized in military hospitals in the United States are consistent with data from civilian U.S. populations. On average, 35% of isolates have full or partial resistance to penicillin (35,37). Thus far, nearly all invasive isolates are of types included in the 23-valent vaccine. A cost-effectiveness analysis projected that using this vaccine among new navy and marine corps personnel would result in a lifetime savings of approximately $9 million (38).

Streptococcus pyogenes

U.S. military populations have frequently had large S. pyogenes–caused epidemics of pharyngitis and acute rheumatic fever, accompanied by other concomitant diseases, such as pneumonia, sepsis, polymyositis, necrotizing fasciitis, scarlet fever, and glomerulonephritis (5,39). Historically, because of cramped living conditions, military recruits have been at high risk for streptococcal disease (2,5,39,40). Illness was especially high in World War II, with the navy reporting approximately one million streptococcal infections and more than 21,000 cases of acute rheumatic fever (5,41).

In 1948, Massell et al. (42) reported that the treatment of acute pharyngitis infection with oral penicillin prevented acute rheumatic fever. Further studies confirmed the effectiveness of a single intramuscular injection of benzathine penicillin G in preventing a broad range of acute and chronic sequelae of streptococcal infections (5,40,43). These early successes led to mass antimicrobial prophylaxis with benzathine penicillin G in training populations at high risk to interrupt and prevent outbreaks of acute disease and their sequelae (44). This control strategy was generally very effective. However, a 1989 epidemic of S. pyogenes pharyngitis among marine corps trainees demonstrated that benzathine penicillin G prophylaxis for nonpenicillin-allergic trainees alone might not protect against epidemics in closely contained populations, especially those with longer training periods, as unprotected penicillin-allergic recruits may serve as S. pyogenes reservoirs. This finding led to the navy's adoption of oral erythromycin as prophylactic therapy for penicillin-allergic recruits (39,45). Another study has shown that 500 mg of azithromycin taken orally each week is, by serologic evidence, an effective prophylactic intervention against S. pyogenes (33).

Since the development of antibiotic prophylaxis, civilian and military epidemics of S. pyogenes disease have declined and then reemerged (39,46,47). Epidemics of acute rheumatic fever have occurred throughout the United States (46-48). In addition, an estimated 10,000 cases of severe S. pyogenes disease, such as necrotizing fasciitis and streptococcal toxic shock, occur nationwide each year (49-52). Increases in invasive streptococcal disease among some U.S. populations have been attributed to changes in the prevalence of virulent strains of S. pyogenes (53).

Although antibiotic prophylaxis remains effective, S. pyogenes persists as a leading cause of bacterial respiratory illness among military personnel (5,39,47,48,54). Risk factors associated with S. pyogenes infection include recent entry to the military, crowding, lack of prophylaxis, close contact with an S. pyogenes carrier, and close contact with a trainee who has not received antibiotic prophylaxis (39).

Prophylactic use of oral erythromycin or azithromycin may promote macrolide resistance among endemic streptococci. The Naval Medical Center, San Diego, California, found 5(10%) of 50 consecutive clinical isolates collected during March and April 1997 resistant to erythromycin. While frequently reported in Europe and Japan, macrolide resistance has been uncommon in U.S. military populations (T. Ferguson, R. Haberberger, pers. comm.) and infrequent in isolates from civilians in the United States (55).

Triservice surveillance has been established to define antibiotic resistance patterns and determine which serotypes of S. pyogenes are causing clinical disease (Figure 2). Data from eight sentinel military medical treatment facilities will be used to monitor resistance and develop alternate prophylactic strategies, rapid diagnostic tests, and vaccines.

Mycoplasma pneumoniae

During World War II, acute pneumonia in military personnel was frequently milder than lobar pneumonia. Chest radiographs showed substantial pulmonary involvement, yet patients did not have high fever, pleuritic chest pain, or rigors characteristic of pneumonia caused by S. pneumoniae. In 1943, these infections were recognized as primary atypical pneumonia, which accounted for an estimated 68% of atypical pneumonias among marine trainees (56) and infected as many as 44% of recruits over a 3-month training period (57). In 1944, samples from a patient with atypical pneumonia showed M. pneumoniae (57,58), and soon thereafter, M. pneumoniae was identified as an important cause of acute respiratory disease in U.S. military personnel (59).

A common cause of pharyngitis and bronchopneumonia, M. pneumoniae may also cause fulminant pneumonia, cardiac disease, arthritis, dermatologic conditions, and central nervous system disease (60). Crowded military populations are at particularly high risk for infection. In the 1970s, up to 57% of U.S. recruits had evidence of acute infection (61), and from the 1960s through the 1990s, as many as 56% of pneumonia cases among recruits were due to M. pneumoniae (62-64). Because culture and diagnostic tests for M. pneumoniae are not commonly available at military facilities, M. pneumoniae is often not recognized, and ineffective antibiotics are prescribed (62).

Few options are available for combating M. pneumoniae epidemics. More than 25 years ago, several studies suggested that preexisting antibody titers might prevent infection (65,66), and vaccine candidates were tested with mixed success (64,67,68). In 1965, preventing disease with a 10-day course of oxytetracycline (69) (4 times a day) among close contacts was successful but impractical. More recently, weekly oral azithromycin (500 mg) had a 64% protective efficacy (by serologic tests) against M. pneumoniae in U.S. marines (33).

Reliable diagnostic tests and enhanced surveillance efforts are needed to assess the epidemiology and impact of M. pneumoniae on military populations. With the exception of serologic tests, few rapid diagnostic tests are commercially available.

Bordetella pertussis

Before vaccines were available, B. pertussis caused considerable illness in children. With the effectiveness of whole-cell childhood vaccines, disease incidence increased among older children and adults, whose childhood vaccine immunity had waned (70-74). B. pertussis infection in adults, while generally mild (75), can be incapacitating. No pertussis vaccines are available for adults.

B. pertussis also affects military populations; a 1989 study of marine trainees who reported 7 or more days of cough showed that 18% had acute B. pertussis infection (73). The potential for military epidemics of B. pertussis is demonstrated by outbreaks among other confined populations, such as those receiving general or institutionalized medical care, which have attack rates as high as 91% (76,77). Infection in adults is often difficult to verify since culture and polymerase chain reaction diagnostic tests may be negative (73). While often used epidemiologically, serologic methods are not standardized, nor are they routinely performed by clinical laboratories (78). Hence, many epidemics are monitored by clinical case definitions.

Some clinicians have observed a prophylactic benefit in administering oral erythromycin to close contacts of patients (78). However, erythromycin prophylaxis is not without side effects, and its value has been questioned (76,79). New acellular pertussis vaccines, now approved only for use among infants and children, are being studied for use in adults (80).

Research and Disease Control

Trainees entering military service receive influenza vaccine and adenovirus types 4 and 7 vaccines when available. Mass antibiotic chemoprophylaxis is also often used to prevent acute respiratory disease and control epidemics, particularly those caused by S. pyogenes infections. After initial training, military personnel receive annual influenza vaccine and periodic tuberculosis screening.

Almost all respiratory illnesses, including pneumonia, are treated empirically (4,62), often with penicillin or a macrolide (62). Without accurate laboratory diagnoses and an early warning system to detect changes in acute respiratory disease rates and antibiotic resistance, more respiratory disease epidemics are likely to occur in military populations. A Global Emerging Infections Surveillance and Response System has been established to address this problem. Surveillance data will be used to direct acute respiratory disease research, training, and education. Under the system, DoD has recently established modest surveillance programs for influenza, adenovirus, S. pyogenes, and S. pneumoniae at a number of U.S. military recruit training camps and special facilities, in collaboration with other federal, state, and civilian organizations. Recruit sites were chosen for their long history of respiratory disease epidemics and the possibility of monitoring the impact of mass antibiotic prophylaxis. Tertiary referral medical centers were chosen to participate because they were more likely to detect unusual and antibiotic-resistant strains of respiratory pathogens. Limited samples of clinical influenza A, adenovirus, S. pyogenes, and S. pneumoniae isolates are being studied. However, new diagnostic tools and vaccines are still needed (Table).

Current capacity to control respiratory pathogens at most military medical treatment facilities, United States
Pathogen Culture Rapid diagnostic tests Prophylaxis Vaccinea
Streptococcus pyogenes Available Antigen detection available and used Benzathine penicillin G (5), erythromycin (45), or azithromycin (33) Needed
Streptococcus pneumoniae Available but not sensitive Needed Azithromycin (33) Available but seldom used among military personnel
Mycoplasma pneumoniae Not available Serologic tests are available Azithromycin (33) Needed
Influenza Not availableb Needed Amantadine Vaccine available and routinely used
Adenovirus Not availableb Needed Not available Types 4 and 7 vaccines effective but not available
Bordetella pertussis Available but not sensitive Needed Erythromycin prophylaxis is of questionable value (79) Needed

aWhile a number of civilian populations, such as the institutionalized, may have similar needs these vaccine needs are particularly urgent for crowded military trainees.
bSome medical treatment facilities have access to culture support.

Conclusions

Military personnel, because of crowding and unique stressors, are subject to respiratory disease epidemics. Their risk often exceeds that of their civilian peers. Adenovirus, influenza virus, S. pyogenes, S. pneumoniae, and B. pertussis are particularly problematic. Pathogen control measures, many of which were developed more than 20 years ago, are threatened by loss of vaccine production, changes in pathogen virulence, changes in pathogen antibiotic sensitivity, changes in population immunity, and lack of laboratory infrastructure to identify respiratory disease pathogens and evaluate new diagnostic and control measures.

Strong, laboratory-based surveillance programs are needed to quickly identify new problems. The surveillance programs must be supported by fast, accurate diagnostic laboratory tests. Surveillance data must then be used to direct the development and evaluation of new interventions, particularly vaccines.

Captain Gray is a medical epidemiologist and chief, Emerging Illness Division, Naval Health Research Center, San Diego. His work involves surveillance and epidemiologic studies of respiratory disease. He also studies illness among veterans of the Persian Gulf War.

Top

Acknowledgments

We acknowledge the contributions of Drs. Richard Haberberger and Gale Chapman, Tom Ferguson, Tim Driscoll, David Trump, Christie Beadle, and Theodore Woodward.

Collaborators in Department of Defense surveillance for respiratory disease pathogens include Patrick Kelley, Lisa Keep, Ramy Mahmoud, Annette Hamilton, Maria Hook, Beverly Watts, Mills McNeill, Laura Trent, Linda Canas, William Corr III, Sandra Williams, Kelly McKee Jr., Debra Prantl, Rose Marie Hendrix, Jane Lindner, Johnnie Conolly, Michael Escalara, Gerald Sandifer, Robert Greenup, Barbara Workman, Denise Clayton, David Niebuhr, Gretchen Demmin, Maritza Johnson, Jeffrey Gunzenhauser, Mary Meyers, Mark Kotepeter, Crystal Chatman-Brown, Alice Washington, Megan Ryan, Thomas Hatley, Becky Christian, Julie Wohlrabe, Sharon Urban, Stephanie Thorn, Dennis Butterworth, James Bean, Beverly Southerland, John Newsome, Edward Gastaldo, Juan Rivas, Walter Cole, Roger Batchelor, Marianne Jesse, Jim Blanks, Roger Gibson, Ron Hale, Royce Brockett, Pulak Goswami, Marieta Malasig, Marie Hudspeth, Julie Hochwalt, Mary Sorenson, Jason Unruh, Paul Sato, Colleen McDonough, Heather Taylor, Rosana Magpantay, Tuan Pham, Chris Barrozo, Pam Plobette, Debbie Kamens, Jeff LeClair, Cassandra Morn, Farukh Khambaty, Janet Yother, and Susan Hollingshead.

This represents report no. 98-22, supported by the Office of Naval Research, Washington, DC, under DoD/HA reimbursable - 6609.

Top

References

  1. Garibaldi  RA. Epidemiology of community-acquired respiratory tract infections in adults. Incidence, etiology, and impact. Am J Med. 1985;78:32–7. DOIPubMedGoogle Scholar
  2. Gray  G. Acute respiratory disease in the military. Federal Practioner. 1995;12:27–33.
  3. Pazzaglia  G, Pasternack  M. Recent trends of pneumonia morbidity in U.S. Naval personnel. Mil Med. 1983;148:647–51.PubMedGoogle Scholar
  4. Gray  G, Mitchell  B, Tueller  J, Cross  E, Amundson  D. Adult pneumonia hospitalizations in the U.S. Navy: rates and risk factors for 6,522 admissions, 1981-1991. Am J Epidemiol. 1994;139:793–802.PubMedGoogle Scholar
  5. Thomas  RJ, Conwill  DE, Morton  DE, Brooks  TJ, Holmes  CK, Mahaffey  WB. Penicillin prophylaxis for streptococcal infections in the United States Navy and Marine Corps recruit camps, 1951-1985. Rev Infect Dis. 1988;10:125–30.PubMedGoogle Scholar
  6. Gaydos  CA, Gaydos  JC. Adenovirus vaccines in the U.S. military. Mil Med. 1995;160:300–4.PubMedGoogle Scholar
  7. Dudding  BA, Top  FH, Winter  PE, Buescher  EL, Lamson  TH, Leibovitz  A. Acute respiratory disease in military trainees: the adenovirus surveillance program, 1966-1971. Am J Epidemiol. 1973;97:187–98.PubMedGoogle Scholar
  8. Brundage  JF, Gunzenhauser  JD, Longfield  JN, Rubertone  M, Ludwig  S, Rubin  F, Epidemiology and control of acute respiratory diseases with emphasis on group A beta-hemolytic streptococcus: a decade of U.S. Army experience. Pediatrics. 1996;97:964–70.PubMedGoogle Scholar
  9. U.S. Department of Health and Human Services. The international classification of diseases. 9th revision. Clinical modification. Washington: U.S. Department of Health and Human Services; 1989.
  10. Graves  EJ. National hospital discharge survey: annual summary, 1991. Vital Health Stat 13. 1993;:1–62.PubMedGoogle Scholar
  11. Graves  EJ. National hospital discharge survey: annual summary, 1992. Vital Health Stat 13. 1994;:1–63.
  12. Graves  EJ. National hospital discharge Survey: annual summary, 1993. Vital Health Stat 13. 1995;:1–63.
  13. Graves  EJ, Gillum  BS. National hospital discharge survey: annual summary, 1994. Vital Health Stat 13. 1997;i-v:1–50.
  14. Enders  J, Bell  J, Dingle  J, Francis  T Jr, Hilleman  M, Huebner  R, Adenoviruses: group name proposed for new respiratory tract viruses. Science. 1956;124:119–20. DOIPubMedGoogle Scholar
  15. Hilleman  M. Efficacy of and indications for use of adenovirus vaccine. Am J Public Health. 1958;48:153–8. DOIGoogle Scholar
  16. Miller  LF, Tytel  M, Pierce  WE, Rosenbaum  MJ. Epidemiology of nonbacterial pneumonia among naval recruits. JAMA. 1963;185:92–9.
  17. Hilleman  M, Gauld  R, Butler  R, Stallones  R, Hedberg  C, Warfield  M, Appraisal of occurrence of adenovirus-caused respiratory illness in military populations. Am J Hyg. 1957;66:29–41.PubMedGoogle Scholar
  18. Grayston  J. Studies in civilian populations. American Reviews of Respiratory Disease 1963;88 supl:94-109.
  19. McNamara  MJ, Pierce  WE, Crawford  YE, Miller  LF. Patterns of adenovirus infection in the respiratory diseases of naval recruits. Am Rev Respir Dis. 1962;86:485–97.PubMedGoogle Scholar
  20. Top  FH Jr. Control of adenovirus acute respiratory disease in U.S. Army trainees. Yale J Biol Med. 1975;48:185–95.PubMedGoogle Scholar
  21. Goswami  P, Hawksworth  A, McDonough  C, Morn  C, Mullen  M, Ryan  M, An epidemic of adenovirus infections among military recruits. Atlanta (GA): American Society for Microbiology; 1998.
  22. McNeill  K, Hendrix  R, Benton  F, Gray  G, Gaydos  J. The first reported outbreak of respiratory disease due to adenovirus type 4 in otherwise healthy young women. Proceedings of the International Conference on Emerging Infectious Diseases; 1998 Mar 8-11; Atlanta, Georgia.
  23. Grayston  JT, Woolridge  RI, Loosli  CG, Gundelfinder  BF, Johnson  PB, Pierce  WE. Adenovirus infections in naval recruits. J Infect Dis. 1959;104:61–70.PubMedGoogle Scholar
  24. Foy  HM. Adenoviruses. In: Evans AS, editor. Viral infections of humans. New York: Plenum Medical Book Company; 1989. p. 77-94.
  25. Gray  G, Goswami  P, Hawksworth  A, Callahan  J, Greenup  R, Hendrix  R, National adenovirus surveillance and typing among high risk military populations. Proceedings of the International Conference on Emerging Infectious Diseases; 1998 Mar 8-11; Atlanta, Georgia.
  26. Surgeon General  USN. Annual report of the Surgeon General, U.S. Navy to the Secretary of the Navy for the fiscal year 1919. Washington: Government Printing Office; 1919.
  27. Update: isolation of avian influenza A(H5N1) viruses from humans—Hong Kong, 1997-1998. MMWR Morb Mortal Wkly Rep. 1998;46:1245–7.PubMedGoogle Scholar
  28. Williams  R, Cox  N, Regnery  H, Noah  D, Khan  A, Miller  J, Meeting the challenge of emerging pathogens: the role of the United States Air Force in global influenza surveillance. Mil Med. 1997;162:82–6.PubMedGoogle Scholar
  29. Gambel  J, Shlim  D, Canas  L, Cox  N, Regnery  H, Scott  R, Partnerships for detecting emerging infectious diseases: Nepal and global influenza surveillance. Emerg Infect Dis. 1998;4:128–30. DOIPubMedGoogle Scholar
  30. Hirsch  EF, McKinney  M. An epidemic of pneumococcus bronchopneumonia. J Infect Dis. 1919;24:594–617.
  31. Reichler  M, Reynolds  R, Schwartz  B, Musher  D, Pratt  G, Hohenhaus  J, Epidemic of pneumococcal pneumonia at a military training camp. In: Proceedings of the 31st Interscience Conference on Antimicrobial Agents and Chemotherapy of the American Society for Microbiology; 1991 September 29 - October 2; Chicago, Illinois.
  32. Musher  D, Groover  J, Reichler  M, Riedo  F, Schwartz  B, Watson  D, Emergence of antibody to capsular polysaccharides of Streptococcus pneumoniae during outbreaks of pneumonia: association with nasopharyngeal colonization. Clin Infect Dis. 1997;24:441–6.PubMedGoogle Scholar
  33. Gray  G, McPhate  D, Leinonen  M, Cassell  G, Deperalta  E, Putnam  S, Weekly oral azithromycin as prophylactic therapy against bacterial causes of acute respiratory disease. Clin Infect Dis. 1998;26:103–10. DOIPubMedGoogle Scholar
  34. Lee  HJ, Park  JY, Jang  SH, Kim  JH, Kim  EC, Choi  KW. High incidence of resistance to multiple antimicrobials in clinical isolates of Streptococcus pneumoniae from a university hospital in Korea. Clin Infect Dis. 1995;20:826–35.PubMedGoogle Scholar
  35. Barile  A, Driscoll  T, Harley  D, Haberberger  R, Wallace  M. Increasing incidence of penicillin-resistant Streptococcus pneumoniae. Proceedings of the IDSA 35th Annual Meeting [abstract]; 1997 September 13-16; San Francisco, California.
  36. Fairchok  MP, Ashton  WS, Fisher  GW. Carriage of penicillin-resistant pneumococci in a military population in Washington, DC: risk factors and correlation with clinical isolates. Clin Infect Dis. 1996;22:966–72.PubMedGoogle Scholar
  37. Hawksworth  A, Goswami  P, Kelley  P, Gray  G. National Department of Defense surveillance for emerging respiratory pathogens. Proceeding of the International Conference on Emerging Infectious Diseases; 1998 Mar 8-11; Atlanta, Georgia.
  38. Pepper  P. Cost effectiveness of the pneumococcal vaccine in the Navy and Marine Corps. Stanford: Stanford University; 1998.
  39. Gray  GC, Escamilla  J, Hyams  KC, Struewing  JP, Kaplan  EL, Tupponce  AK. Hyperendemic Streptococcus pyogenes infection despite prophylaxis with penicillin G benzathine. N Engl J Med. 1991;325:92–7.PubMedGoogle Scholar
  40. Gunzenhauser  JD, Brundage  JF, McNeil  JG, Miller  RN. Broad and persistent effects of benzathine penicillin G in the prevention of febrile, acute respiratory disease. J Infect Dis. 1992;166:365–73.PubMedGoogle Scholar
  41. Naval Medical Research Unit No. 4. History and accomplishments. An introduction to NAMRU-4. Great Lakes (IL): Naval Medical Research Unit No. 4; 1972.
  42. Massell  BF, Dow  JW, Jones  TD. Orally administered penicillin in patients with rheumatic fever. JAMA. 1948;138:1030.
  43. Davis  J, Schmidt  WC. Benzathine penicillin G effectiveness in the prevention of streptococcal infections in a heavily exposed population. N Engl J Med. 1957;256:339–42.PubMedGoogle Scholar
  44. Denny  F. A 45-year perspective on the Streptococcus and rheumatic fever: the Edward H. Kass lecture in infectious disease history. Clin Infect Dis. 1994;19:1110–22.PubMedGoogle Scholar
  45. Fujikawa  J, Struewing  JP, Hyams  KC, Kaplan  EL, Tupponce  AK, Gray  GC. Oral erythromycin prophylaxis against Streptococcus pyogenes infections in penicillin-allergic military recruits: a randomized clinical trial. J Infect Dis. 1992;166:162–5.PubMedGoogle Scholar
  46. Veasy  L, Wiedmeier  S, Orsmond  G, Ruttenberg  H, Boucek  M, Roth  S, Resurgence of acute rheumatic fever in the intermountain area of the United States. N Engl J Med. 1987;316:421–7.PubMedGoogle Scholar
  47. Wallace  MR, Garst  PD, Papadimos  TJ, Oldfield  EC. The return of acute rheumatic fever in young adults. JAMA. 1989;262:2557–61. DOIPubMedGoogle Scholar
  48. Acute rheumatic fever among Army trainees—Fort Leonard Wood, Missouri. MMWR Morb Mortal Wkly Rep. 1988;37:519–22.PubMedGoogle Scholar
  49. Riseman  JA, Zamboni  WA, Curtis  A, Graham  DR, Konrad  HR, Ross  DS. Hyperbaric oxygen therapy for necrotizing fasciitis mortality and the need for debridements. Surgery. 1990;108:847–50.PubMedGoogle Scholar
  50. American Academy of Pediatrics. Committee on Infectious Diseases. Severe Invasive Group A Streptococcal Infections: A Subject. Rev Pediatr. 1998;101:136–40.
  51. Stevens  D, Tanner  M, Winship  J, Swarts  R, Ries  K, Schlievert  P, Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A. N Engl J Med. 1989;321:1–7.PubMedGoogle Scholar
  52. Hoge  CW, Schwartz  B, Talkington  DF, Breiman  RF, MacNeil  EM, Englender  SJ. The changing epidemiology of invasive group A streptococcal infections and the emergence of streptococcal toxic shock-like syndrome. JAMA. 1993;269:384–9. DOIPubMedGoogle Scholar
  53. Schwartz  B, Facklam  R, Breiman  R. Changing epidemiology of group A streptococcal infection in the USA. Lancet. 1990;:1167–71. DOIPubMedGoogle Scholar
  54. Gunzenhauser  JD, Longfield  JN, Brundage  JF, Kaplan  EL, Miller  RN, Brandt  CA. Epidemic streptococcal disease among Army trainees, July 1989 through June 1991. J Infect Dis. 1995;172:124–31.PubMedGoogle Scholar
  55. Coonan  KM, Kaplan  EL. In vitro susceptibility of recent North American group A streptococcal isolates to eleven oral antibiotics. Pediatr Infect Dis J. 1994;13:630–5. DOIPubMedGoogle Scholar
  56. Chanock  RM, Mufson  MA, Bloom  HH, James  WD, Fox  HH, Kingston  JR. Eaton agent pneumonia. JAMA. 1961;175:213–4.PubMedGoogle Scholar
  57. Commission on Acute Respiratory Diseases. Epidemiology of atypical pneumonia and acute respiratory disease at Fort Bragg, North Carolina. Am J Public Health. 1944;34:335–46. DOIGoogle Scholar
  58. Eaton  MD, Meiklejohn  G, Van Herick  W. Studies on the etiology of primary atypical pneumonia: a filterable agent transmissible to cotton rats, hamsters, and chick embryos. J Exp Med. 1944;79:649–68. DOIPubMedGoogle Scholar
  59. Chanock  RM, Rifkind  MD, Kravetz  HM, Knight  V, Johnson  KM. Respiratory disease in volunteers infected with Eaton agent: a preliminary report. Proc Natl Acad Sci U S A. 1961;47:887–90. DOIPubMedGoogle Scholar
  60. Cassell  G. Severe mycoplasma disease—rare or underdiagnosed? West J Med. 1995;:172–5.PubMedGoogle Scholar
  61. Edwards  EA, Crawford  YE, Pierce  WE, Peckinpaugh  RO. A longitudinal study of Mycoplasma pneumoniae infections in Navy recruits by isolation and seroepidemiology. Am J Epidemiol. 1976;104:556–62.PubMedGoogle Scholar
  62. Gray  GC, Duffy  LB, Paver  RJ, Putnam  SD, Reynolds  RJ, Cassell  GH. Mycoplasma pneumoniae: a frequent cause of pneumonia among U.S. Marines in southern California. Mil Med. 1997;162:524–6.PubMedGoogle Scholar
  63. Gray  GC, Hyams  KC, Wang  SP, Grayston  JT. Mycoplasma pneumoniae and Chlamydia pneumoniae strain TWAR infections in U.S. Marine Corps recruits. Mil Med. 1994;159:292–4.PubMedGoogle Scholar
  64. Mogabgab  WJ. Protective effects of inactive Mycoplasma pneumoniae vaccine in military personnel 1964-1966. Am Rev Respir Dis. 1968;97:359–65.PubMedGoogle Scholar
  65. McCormick  DP, Wenzel  RP, Senterfit  LB, Bean  WE. Relationship of pre-existing antibody to subsequent infection by Mycoplasma pneumoniae in adults. Infect Immun. 1974;9:53–9.PubMedGoogle Scholar
  66. Steinberg  P, White  R, Fuld  S, Gutekunst  R, Chanock  R, Senterfit  L. Ecology of Mycoplasma pneumoniae infections in Marine recruits at Parris Island, South Carolina. Am J Epidemiol. 1969;:62–73.PubMedGoogle Scholar
  67. Wenzel  RP, Craven  RB, Davies  JA, Hendley  JO, Hamory  BH, Gwaltney  JM. Field trial of an inactivated Mycoplasma pneumoniae vaccine. J Infect Dis. 1976;134:571–6.PubMedGoogle Scholar
  68. Smith  C, Friedewald  W, Chanock  R. Inactivated Mycoplasma pneumoniae vaccine. JAMA. 1967;:353–8. DOIPubMedGoogle Scholar
  69. Jensen  KJ, Senterfit  LB, Scully  WE, Conway  TJ, West  RF, Drummy  WW. Mycoplasma pneumoniae infections in children, and epidemiologic appraisal in families with oxytetracycline. Am J Epidemiol. 1967;86:419–32.PubMedGoogle Scholar
  70. Bass  JW, Stephenson  SR. The return of pertussis. Pediatr Infect Dis J. 1987;6:141–4. DOIPubMedGoogle Scholar
  71. Pertussis outbreaks—Massachusetts and Maryland, 1992. MMWR Morb Mortal Wkly Rep. 1993;42:197–200.PubMedGoogle Scholar
  72. Pertussis outbreak—Vermont, 1996. MMWR Morb Mortal Wkly Rep. 1997;46:822–6.PubMedGoogle Scholar
  73. Jansen  DL, Gray  GC, Putnam  SD, Lynn  F, Meade  BD. Evaluation of pertussis infection among US Marine Corps trainees. Clin Infect Dis. 1997;25:1099–107. DOIPubMedGoogle Scholar
  74. Mink  CM, Cherry  JD, Christenson  P, Lewis  K, Pineda  E, Shlian  D, A search for Bordetella pertussis infection in university students. Clin Infect Dis. 1992;14:464–71.PubMedGoogle Scholar
  75. Jenkinson  D. Natural course of 500 consecutive cases of whooping cough: a general practice population study. Lancet. 1995;310:299–302.
  76. Cherry  J. Nosocomial pertussis in the nineties. Infect Control Hosp Epidemiol. 1995;16:553–5. DOIPubMedGoogle Scholar
  77. Skekett  R, Wassilak  S, Adkins  W, Burstyn  D, Manclark  C, Berg  J, Evidence for a high attack rate and efficacy of erythromycin prophylaxis in a pertussis outbreak in a facility for the developmentally disabled. J Infect Dis. 1988;157:434–40.PubMedGoogle Scholar
  78. Weber  D, Rutala  W. Management of healthcare workers exposed to pertussis. Infect Control Hosp Epidemiol. 1994;15:411–5. DOIPubMedGoogle Scholar
  79. Dodhia  H, Miller  E. Review of the evidence for the use of erythromycin in the management of persons exposed to pertussis. Epidemiol Infect. 1998;120:143–9. DOIPubMedGoogle Scholar
  80. Advisory Committee on Immunization Practices. Pertussis vaccination: use of acellular pertussis vaccines among infants and young children. MMWR Morb Mortal Wkly Rep. 1996;46:1–25.

Top

Figures

Top

Cite This Article

DOI: 10.3201/eid0503.990308

Table of Contents – Volume 5, Number 3—June 1999

EID Search Options
presentation_01 Advanced Article Search – Search articles by author and/or keyword.
presentation_01 Articles by Country Search – Search articles by the topic country.
presentation_01 Article Type Search – Search articles by article type and issue.

Top

Comments

Please use the form below to submit correspondence to the authors or contact them at the following address:

Gregory C. Gray, Naval Health Research Center, Emerging Illness Division, P.O. Box 85122, San Diego, CA 92186-5122, USA; fax: 619-553-7601

Send To

10000 character(s) remaining.

Top

Page created: December 10, 2010
Page updated: December 10, 2010
Page reviewed: December 10, 2010
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
file_external