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News Conference on Recent Cases of Pneumonia Among Deployed Servicemembers

Presenters: David Tornberg, DASD (Clinical and Program Policy)
August 05, 2003

(News Conference to discuss the recent cases of pneumonia among servicemembers deployed to the U.S. Central Command area of operations. Participating were David Tornberg, deputy assistant secretary of defense for clinical and program policy; Bryan Whitman, deputy assistant secretary of defense for public affairs; and Army Col. Robert DeFraites, Office of the Army Surgeon General.)

Whitman: Good morning, and thank you for joining us this morning. There has been some interest in the last couple of days on some force health protection issues and some cases of pneumonia. And so, I thought that it might be useful to bring to you a couple of experts on this issue.

Today, we have Dr. David Tornberg, who is the deputy assistant secretary of Defense for Clinical and Program Policy, as well as Colonel Robert DeFraites from the Office of the Army Surgeon General, that have offered to come down here and spend some time with you and answer your questions.

So with that, let's go ahead and get started.

Tornberg: Good morning. I'd like to thank you all for coming. The purpose, of course, of the briefing today, as was indicated, is to update you and provide you with, hopefully, some comprehensive information on the pneumonia cases that we have recently experienced.

The health, safety, well-being of our fighting men and women are of critical importance to us. They're of utmost importance, and we'll spare nothing to safeguard their well-being. Military medicine, I'm happy to say, is poised to provide the finest of care to our fighting men and women.

As you know, there have been some cases of pneumonia and sadly, there have been two deaths. We're deeply concerned about the deaths. We'd like a comprehensive understanding to be available to the families, to the husbands, to the wives of our servicemen so they better understand the nature of these conditions. And we'd like to assure you that we're sparing no effort to further analyze and diagnose the nature of this condition.

The Army has been taking the lead in providing the health care services, and is involved in the epidemiological investigation of these conditions. I'm happy to have with us today Colonel Bob DeFraites, chief of preventive medicine in the Office of the Surgeon General of the Army, who will provide you more details on the nature of these conditions today.

Thank you.

Bob?

DeFraites: Thanks, Dr. Tornberg.

Good morning, everyone.

A primary mission of the Army Medical Department is to protect the health of the troops and to take care of them and give them the best possible care, regardless of where they are deployed worldwide. Whenever we send soldiers in harm's way, we're committed to bringing them back whole.

We're very saddened in the Medical Department at the loss of life of any of our soldiers, including the two that have unfortunately lost their lives due to the pneumonia that they acquired while they were deployed.

We offer our deepest sympathy to their families.

In response to this, the Army Surgeon General has chartered two epidemiological consultation teams to study the case of the pneumonia, to make sure we do everything possible to avoid new ones and provide the best of care to those who become ill. Epidemiological consultation is a regular tool available to the Army Surgeon General. He can charter a team at any time to study any kind of medical problem that occurs anywhere in the Army, and he's chosen to do so in this situation.

I want to go a little bit into some of the background information about what we know so far about pneumonia in the Army. Since the 1st of March, we have seen about a hundred cases of pneumonia total in the troops that have been deployed in Southwest Asia in support of Operation Iraqi Freedom and Enduring Freedom. That number of about a hundred is about -- given the population that's deployed, is about the amount that one might expect in a population of troops deployed, based on our background information and experience that we have -- between 4(00) and 500 cases of pneumonia every year in the Army worldwide. That's fairly standard, and surprising it may seem that otherwise young, healthy adults still do get pneumonia in the Army.

Of the hundred cases since March, 15 of them have been serious enough to warrant respirator support. In other words, they needed to be put on a ventilator to help them breathe for a certain period of time. Of those 15, two unfortunately have died, one in June and one in July.

The -- what we know about these cases so far, the 15 cases -- 14 of them are soldiers and one's a Marine. And they have occurred fairly -- on a fairly spread-out pattern in time since March. We had two cases in March, two in April, one in May, six in June and four in July. The last confirmed case that we have had occurred on the 30th of July.

The other interesting thing about these 15 cases of more severe pneumonia is that they've occurred all throughout the Southwest Asia region. Even though 10 of the 15 occurred in Iraq -- that's where the majority of troops are, of course -- they have occurred as far away as Uzbekistan and Qatar.

And also the fact that two have died, I think, is probably the one issue that has prompted the commissioning of our epidemiology -- epidemiologic consultation.

Though death, unfortunately, just like pneumonia, occurs in the Army in this day and age, so does death due to pneumonia. In the five years ending calendar year 2002, the Army lost 17 soldiers due to complications with pneumonia. So even in this day and age, we still, unfortunately, lose some soldiers due to pneumonia.

The other issue with the 15 cases is that we have been able to identify streptococcal pneumonia. That's a very common cause of pneumonia. It has been -- we've found that to be the case that we can attribute to at least two of these cases so far that we've studied. But the investigation continues. The other thing that's true is that we've found no evidence of anthrax, smallpox or any other biological agent attributed -- that we can attribute the pneumonia.

Now, I mentioned the epidemiological consultation teams, otherwise known as EPICON teams. The surgeon general has chartered two teams. One team of two physicians is already been posted to Landstuhl Regional Medical Center in Germany to assist the physicians there in reviewing the cases. Since most of the cases of the severe cases came to Landstuhl, that's a good place to do some record review and also review the laboratory findings from these cases. And so, we have two of our doctors assisting in the investigation there at Landstuhl. The other team of six individuals -- four officers and two enlisted personnel -- is now in the central region -- they're in theater right now, and they'll be moving into Iraq, and they'll be assisting with the investigation there in Iraq.

The teams consist of -- both have infectious disease, preventive medicine expertise. In addition, the team that's going to Iraq also has laboratory officers and technicians that can assist with laboratory evaluation. That includes patient specimens, and it also includes specimens from the environment.

Pneumonia is a very common condition in the United States in general. There are two basic types of pneumonia: those that are -- pneumonia that's caused by infection and pneumonia that can be caused by non-infectious causes.

Of the infectious causes, there's a long list of bacteria, viruses, parasites and fungi that can cause a pneumonia. The most common cause of pneumonia in the United States is bacterial pneumonia, and I already mentioned that two of our 15 cases we know already have that very common bacteria that causes pneumonia worldwide.

Of the non-infectious causes, there are -- that can be caused by environmental conditions such as dusts or metals or smoke, such as even exacerbated by tobacco smoke.

So the investigation is going to be focused on kind of the infectious conditions that I mentioned, some of the non-infectious conditions, and also look at some of the host factors of the patients or that soldiers themselves of -- whether is anything in their makeup or their background that might explain why they may have gotten severe pneumonia.

Again I want at reiterate that the deployment of these epidemiological consultation teams is a tool that the surgeon general evokes on a fairly regular basis. Normally we have -- it's hard to say on a yearly basis, but about two to three epidemiological consultations every year, and so this is a fairly typical tool that the surgeon general of the Army invokes to address a condition like this.

I think we are -- we are sufficiently concerned about especially the more severe pneumonias that the epidemiological consultation was warranted. Additional study, anything that we can do to learn more about the risk factors for these conditions, these more serious illnesses, especially the two tragic deaths, you know, we want to gain as much as we can; if nothing else, to learn better how to protect soldiers against this particular type of infection or, if it's non-infectious, whatever is causing the pneumonia, and also to learn more so that if in no other small way, perhaps this will offer some small comfort to those who have lost some soldiers due to this condition.

Thanks for your attention.

Q: Colonel?

DeFraites: Yes?

Q: You talked about non-bacterial causes. How many cases do you have of non-bacterial causes of pneumonia? And can you tell us what caused it?

DeFraites: Well, pneumonia typically in the United States and, really, around the world, the way pneumonia presents itself is the patient comes in with typical symptoms of cough, fever, and then on physical examination or x-ray, the doctor diagnoses pneumonia and usually just treats. The typical approach is not really to try to find out what bacteria or virus might be causing it. And nine times out of 10, or 90 times out of 100, that's good enough. It's only when it gets more complicated does the physician pursue a diagnosis more aggressively.

So in these cases we really have only identified the two infectious causes so far. There may be other studies that we have done, as I mentioned, for smallpox and for anthrax so far have been negative. In addition, we have looked for the bacteria that causes Legionnaires' Disease, and that doesn't seem to be playing a factor. But the investigation's not completed yet, so I really can't say more about what -- you know, it's not 100 percent -- we haven't --

Q: You've actually identified a cause in two cases, the two cases --

DeFraites: A positive cause that we could say, yes, this bacterium caused these guys to be sick with pneumonia; in two cases, that's correct.

Q: Are you speculating out down the road about what caused any of the other cases you see?

DeFraites: No, not speculating about any of it. That's what the investigation is for, really.

Q: Are you seeing anything that was similar from the first Gulf War, or are there any lessons learned that you took from the first Gulf War, with pneumonia cases, that were given to the troops now?

I don't know whether there was -- all the oil smoke maybe caused more cases in the first Gulf War, and there isn't as much oil smoke this time. Are there any similarities or differences that you may be seeing between the two?

DeFraites: Well, we've taken this problem as it presented itself, as a pneumonia problem. And as such, there really was no precedent in the Gulf War.

I would say, though, in general, I think we're better postured to recognize these problems earlier and respond in a timely way. And in this case, this investigation really started probably about the same time as the first soldier died. As I said, these cases have been kind of spread out over time and so really didn't show a pattern. But then with the first death, it really kicked off the investigation. But we think we're well on our way to understanding what's going on here.

Q: Have you determined the cause of death for the two cases? And will you release their names?

DeFraites: The cause of death of the two soldiers who have died is still being studied. The pathology report, the postmortem examination, is still not quite completed. We expect it to be done really within the next week or 10 days. And we're factoring that into our investigation.

In interest of the privacy of the families and the patients, we're really not going to be releasing their names.

Q: Colonel, I want to make sure I understood when you said at the beginning the hundred or so cases generally -- that would be the typical number of pneumonia for a year?

DeFraites: No. What I meant by the hundred cases that I talked about is that's the -- that's all pneumonias in Southwest Asia that have required at least treatment in a hospital, of which 15 of them are more severe, needing the respirator.

That a hundred -- again, I was using it as a benchmark in comparison with our worldwide experience every year of the 4(00) to 500 soldiers who need to be admitted to a hospital somewhere around the world -- the Army's deployed all around the world -- somewhere, for pneumonia. And I use that in perspective as saying: Are we seeing more cases in general than we might expect? Despite the harsh

environment, the answer is no, not totally. But again, we're still concerned about these more severe ones.

Q: And the 15 that you sort of identified as the more severe ones -- is that the focus of the investigation right now? Are the other 85 or so not really involved?

DeFraites: Well, they're all involved. Our priority is definitely on the 15, but the -- we know who the other hundred are. Fortunately, they all --

Q: Yeah.

DeFraites: -- you know, they all responded to treatment and are doing well. So --

Q: And the last part -- I'm sorry -- is the non-bacteria thing.

During the Afghan war, where U.S. troops went to Uzbekistan, there was a lot of anecdotal evidence of troops becoming ill because they were breathing in the dust that had been for years treated with chemicals and such like that. Is this one of the things when you refer to non- biological potential factors, is this something you'd be looking at? Because you did say there was one in Uzbekistan, as well.

DeFraites: Yes, I did. Really, the focus of the investigation on the non-infectious causes includes any of the environmental conditions like the dust or, you know, what the soldier might have been doing in his occupation -- you know, it might give us some clues of an exposure he may have experienced that might explain why he got pneumonia. So, the dust -- certainly, everyone's seen the pictures, and whoever has been there understands what -- that the dust is an issue. It's always been an issue. Why it might be contributing to these cases is one of the focus of the investigation, if it does at all.

Q: Could you state all the countries in which the troops have gotten sick? Can you also at least give us the ages and the genders of the two who died, and an age range of the 15 involved? And just one last thing. Is there any evidence of connection? I mean, are these random cases, or do you see --

DeFraites: Well, I'm glad you brought the question up about the connection, because that really is what an epidemiologist does, is look for these trends. And you know, we have an epidemiological consultation team. We have epidemiologists involved, and so they're looking for these trends.

And I think what we have so far is that we've got, spread out in time, as I mentioned, you know, with the two cases in March, the two in April, the one in May, the six in June and the four in July -- and all of these -- 10 out of the 15 severe cases have occurred in Iraq, but of course, that's where most of the troops are. But they've been spread out -- all of these countries in Southwest Asia. I can't off the top of my head remember what -- how many are spread out to these other countries, but it includes Kuwait, Qatar and Uzbekistan. I don't know if there's any other country that -- from which we have a case right now.

And I don't have the information on the age ranges with me right now. We have that, but I just don't have it with me.

Q: How about those two that died?

DeFraites: But, I mean, they're all active-duty military people. So, it falls in that age range. And I'm not going to -- really, in the interest of the patients' family, I'm not going to talk about specifics about those fatal cases.

There was something I wanted to finish saying, though, about your first question. Oh! In terms of the trends of -- and whether or not these are sporadic cases, the other thing that's key, other than being spread out -- separated by space and time, is also that there's no evidence that -- of any other kind of individual relationship of one case to another to suggest that there could be person-to-person spread. There's no evidence that this is spread from one person to another.

It does seem to be sporadic in nature.

Q: Can you at least say if they're all men, the 15 --

DeFraites: Oh, I'm sorry. I can say that. Fourteen are men and one is a woman.

Q: Colonel, could you also reiterate again the significance of this, that you're really more concerned about the serious cases than on the particular number? And also, are you able to definitively rule out, then, SARS or biological or chemical weapons attacks?

DeFraites: The -- we do have data from several of the cases that have been negative for the SARS virus, the coronavirus. So we don't think this has anything to do with SARS.

And again, SARS, if you remember, was very definitely spread from person to person. So we feel very reassured, from the pattern of cases that we have, that this isn't acting at all like SARS, plus we have the negative finding on several of the cases. So SARS was another agent I should have mentioned that we don't feel is playing any role here.

Q: And biological or chemical -- can you definitively rule out a possibility of biological or chemical weapons?

DeFraites: Based on all the information we have to date, there's been no positive findings of any anthrax or smallpox or any other biological weapons. So yeah, I've -- pretty close to ruling it out.

Q: And what about -- again, just to clarify, the significance of this is that you're concerned about the serious cases, not necessarily the number? Is that correct?

DeFraites: Well, we're concerned about both. I think if the number gets, you know -- starts increasing, we're concerned about that. But really we're approaching this from a prevention and a treatment focus, to see -- is there something we can intervene -- some way we can intervene to protect the health of the troops and then to treat them better. And so that's why we're -- that's the main reason we're studying these more severe cases, because they've required more treatment. And if there's some way we can intervene and learn more about living better or healthier in this particular very harsh --

admittedly very harsh environment, that it'd be -- we think it would be a great benefit to the troops.

Q: This has gone up also to 102, right? So have you had any increase recently or -- I had thought that it had gone up from a hundred to 102.

DeFraites: We are getting a couple of more cases admitted to the hospitals. Of the not severe -- the last confirmed severe case we had was on the 30th of July -- there have been several other soldiers with pneumonia. Of this -- that's why I'm saying it's about a hundred. I don't mean to imply that it's exactly 100. It's about a hundred. It could be 102 now. I haven't checked the list lately to see what it is.

Q: How many of the hundred were in Iraq? And also, two people have died. Is that unusual? I understand the hundred -- it's more or less what you would expect in a force of that size. But how about the deaths?

DeFraites: Well, right now, to answer your first question, I'm not exactly sure how many of the hundred are in -- what's the distribution of those hundred cases.

Again, the focus has been mainly on the 15.

In terms of the deaths, from an epidemiological perspective it is very difficult to interpret the two deaths in terms of whether that's something you expect. I mean, it's concerning enough that it's -- it's hard to say. Like I said, in the Army we have, unfortunately, experienced about -- well, 17 cases of fatal pneumonia in the Army over a five-year period. So if you do the division, it comes out to about three a year. So two occurring in one area of the world in about a month was enough to cause us concern. I haven't -- I don't know statistically who that works out, but it was enough to cause us to be concerned.

Q: Colonel --

DeFraites: (Actually we were,) though, already starting to be concerned with the first death. We didn't really wait for the second one.

Q: Colonel, can I follow on that question, because talking about the two that died, you said epidemiologically statistically. But individually, have you tracked these individuals who died? Were they treated early enough? Did they get the proper treatment? Were they moved forward? How have you looked at those two individuals who died?

DeFraites: I'm glad you brought that up, because that's exactly what the focus of the investigation of those cases is. It includes their exposures, what might have started their illness, and also how were they treated once they got sick.

Q: And are you far enough along that you can draw any conclusions? Were they--

DeFraites: No. That requires the post-mortem examination and a full analysis of the tissues to know what the cause of death was; then go back and see, you know, given that as a cause of death, then how did the treatment stack up compared to that.

Q: And you'll come back and report that to us when you find that out?

DeFraites: That's all part of our investigation, yeah.

Q: Did it start in Kuwait, maybe? You said it happened maybe in March. Did that start in Kuwait and maybe all of the soldiers belonged to some specific unit?

DeFraites: Well, that's what -- that's the other factor that indicates -- I'm glad you brought that up, because I neglected to mention that all of these 15 severe cases are all from different military units. So, aside from the separation in time and space, it does look like they have different units.

You are correct the early cases, of course, before the outbreak of hostilities did occur in Kuwait; however, that doesn't include the soldier who was in -- Uzbekistan, which really had nothing to do with Operation Iraqi Freedom.

Q: Are there any steps underway now to prevent further infections or further spread?

DeFraites: Well, we've put some messages out to -- the question was about preventive -- what can you do to prevent pneumonia. We have put messages out to the field in terms of trying to intervene. Not knowing exactly, you know, what particular causative agent, there are still some prudent things that can be done.

And so, we put messages to the field. We're very concerned about soldiers not becoming dehydrated in this intense heat and dust that they're experiencing in the deployed environment. So, we're trying to emphasize that they stay well-hydrated and that they also protect themselves against the dust as best they can, using either their cravats or some type of dust mask. But of course, that's uncomfortable, and it's hard to do 24 hours a day.

Also, when they're handling dust, if they're in an area where they've got to do sweeping, we recommend that they wet down the area first and do more like wet sweeping than raising big clouds of dust, just in case that's a factor.

And finally, we all know that definitely, cigarette smoking is a risk factor for pneumonia, no matter what age, no matter what population. And so, you know, we're also putting that message out there along. We emphasize that normally to the troops anyway. But this is even a more reason to avoid cigarette smoking.

Q: The two confirmed bacteria cases, are they related in any way in space and time, as well? And did they contribute to either of the deaths?

DeFraites: No, no. None of the -- no two of the cases share any common unit or exact day or time.

Q: They're not the ones who died?

DeFraites: The two known bacterial pneumonia cases are not the ones who died. They both recovered.

Q: What did the two who died die from?

DeFraites: Well, that's what we're still studying -- their deaths with the post-mortem.

Q: (Off mike.) -- bacterial, or --

DeFraites: Right now, that's the focus of the investigation. Right.

Q: Why is it taking so long to determine?

DeFraites: I think we're being very prudent and very careful, whenever we have a death that we investigate, that we look at

all the tissues. There's much more -- it's easy -- actually, it's easy to make the diagnosis if a bacterial grows out of a blood culture. That's easy. You've got it. If you don't get a positive blood culture, it gets much tougher, because now you're looking at other -- that non-bacterial could be virus, could be fungus, could be a parasite or it could be one of these non-infectious causes.

Q: Can we assume that you don't have something growing out of a culture very quick and easy in the case of the two who died?

DeFraites: That's true. At this time, we don't.

Tornberg: It could be mechanical in these two cases.

DeFraites: I don't want to engage in any --

Tornberg: (Off mike.) -- and that's the purpose of the investigation. A forensic exam, however, and that's what we're doing in the case of a death, extends for a significant period of time. You want to have a conclusive diagnosis. And you have to consider all elements of information before you -- you don't want to hastily come up with a theory.

Q: Were both of these in Iraq -- both of the deaths in Iraq?

DeFraites: No.

Q: Were was the other one? Or what -- can you tell us what country?

DeFraites: Well, I'd rather not talk about specifics about these -- about the two cases.

Q: (Off mike.) -- if it's not Iraq, it's either Afghanistan or Uzbekistan or Qatar.

Tornberg: They were from -- they were soldiers who served in Iraq.

Q: They were soldiers who had served in Iraq, but they were no longer in Iraq at the time of death?

Tornberg: One was and one was not.

Q: Okay. Can you tell us where the other one was?

Tornberg: No, we cannot. We cannot. We're trying to accommodate you and reasonably answer your questions. But there are privacy (elements ?).

Q: Okay. (Off mike.) -- tell me what you can.

Tornberg: Right.

Q: Colonel, you mentioned that the six-person team is in the region, but not in Iraq yet. Is that -- did I understand you correctly?

DeFraites: As of today, I don't believe they've made it into Iraq to date.

Q: Where are they right now? And when do you --

DeFraites: I'd rather not say where a specific team -- for security purposes, I'd rather not say where they are.

Q: Can you say when they're going to arrive inside Iraq?

DeFraites: I believe they're supposed to be in Iraq tomorrow -- last I heard. It all depends on transportation a lot in that theater. So it's hard to say for sure.

Whitman: There's time for one more, if there is one.

Q: You had mentioned the 17 deaths over a five-year period from pneumonia in the Army. In this calendar year, aside from those two cases, has the Army had any other cases?

DeFraites: No, I'm not aware of any other pneumonia deaths. Some of the deaths -- determination, just like in these two cases, takes a long time before the final diagnosis can be made, based on pathology examinations, toxicology. So right -- as of right now, I'm not aware of any other pneumonia deaths in the Army.

Q: In the Army, or would that include Marines? Would you --

DeFraites: No, just Army is what I can speak to. Just the Army.

Q: Are there other diseases which have claimed the lives of Army soldiers in the Central Command area of operation?

DeFraites: I don't have that information with me today. I can only address the ones that we're looking at in terms of pneumonia.

Q: One more. I'm sorry. I just cut you off --

Whitman: No, no --

Q: Okay. Okay. Thank you very much.

Whitman: Thank you.

DeFraites: Thank you.

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