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Human adenovirus type 4 (HAdV-E4) frequently causes epidemics among military and civilian populations. We conducted a systematic review of 144 peer-reviewed articles reporting HAdV-E4 infections, published during the years 1960-2020. More than 24 500 HAdV-E4 infections, including 27 associated deaths, were documented. HAdV-E4 infections were reported from all geographic regions of the world except Central America and the Caribbean. The number of publications reporting civilian infections tripled in the last decade, with a steady increase in reported civilian infections over time. Infections commonly caused respiratory and ocular disease. North America reported the most infections, followed by Asia and Europe. The majority of deaths were reported in the United States, followed by China and Singapore. Civilians seem to increasingly suffer HAdV-E4 disease, with recent epidemics among US college students. Public health officials should consider seeking emergency use authorization for the adenovirus vaccine such that it might be available to mitigate civilian epidemics., (© The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Given their lack of immunity and increased exposure, military personnel have the potential to serve as carriers or reservoirs for infectious diseases into or out of the deployment areas, but, to our knowledge, the historical evidence for such transmission events has not previously been reviewed. Using PubMed, we performed a systematic review of published literature between 1955 and 2018, which documented evidence for military personnel transporting infectious pathogens into or out of deployment areas. Of the 439 articles screened, 67 were included for final qualitative and quantitative review. The data extracted from these articles described numerous instances in which thousands of military service members demonstrated potential or actual transmission and transportation of multiple diverse pathogens. These data underscore the immense importance preventive medical professionals play in mitigating such risk, how their public health efforts must be supported, and the importance of surveillance in protecting both military and civilian populations., (Published by Oxford University Press for the Infectious Diseases Society of America 2019.)

Background: Streptococcus pneumoniae infections have periodically caused significant morbidity and outbreaks among military personnel, especially trainees. This study evaluated the effectiveness of the 23-valent polysaccharide pneumococcal vaccine (PPV23) in reducing pneumonia in healthy military trainees., Methods: From 2000-2003, 152723 military trainees from 5 US training camps were enrolled in a double-blind, placebo-controlled trial of PPV23. Participants were closely monitored during basic training for radiographically confirmed pneumonia etiology and loss-of-training days. Participants were also followed using electronic medical encounter data until 1 June 2007 for three additional outcomes: any-cause pneumonia, any acute respiratory disease, and meningitis., Results: Comparison of demographic data by study arm suggested the randomization procedures were sound. During basic training, 371 study participants developed radiographically confirmed pneumonia. None had evidence of S. pneumoniae infection, but other etiologies included adenovirus (38%), Chlamydophila pneumoniae (9%), and Mycoplasma pneumoniae (8%). During the follow-up period, many study participants, in both the vaccine and placebo groups, had clinical encounters for the medical outcomes of interest. However, Cox's proportional hazard modeling revealed no evidence of a protective vaccine effect during recruit training (radiographically confirmed pneumonia) or up to 6.7 years after enrollment (any-cause pneumonia, any acute respiratory disease, or meningitis)., Conclusions: Data from this large, double-blind, placebo controlled trial do not support routine use of PPV23 among healthy new military trainees. This clinical trial was registered at clinicaltrials.gov (registration number NCT02079701, http://www.clinicaltrials.gov/ct2/show/NCT02079701?term=NCT02079701&rank=1)., (Published by Elsevier Ltd.)

Background: In late 2011, after a 12-year hiatus, oral vaccines against adenovirus types 4 (Ad4) and 7 (Ad7) were again produced and administered to US military recruits. This study examined the impact of the new adenovirus vaccines on febrile respiratory illness (FRI) and adenovirus rates and investigated if new serotypes emerged. FRI rates and their associated hospitalizations had markedly risen since vaccine production ceased in 1999., Methods: From 1996 to 2013, the Naval Health Research Center conducted FRI surveillance at 8 military recruit training centers in the United States. During this period, 58 103 FRI pharyngeal swab specimens were studied, yielding 37 048 adenovirus-positive cases, among which 64% were typed., Results: During the 2 years after reintroduction of the vaccines, military trainees experienced a 100-fold decline in adenovirus disease burden (from 5.8 to 0.02 cases per 1000 person-weeks, P < .0001), without evidence that vaccine pressure had increased the impact of adenovirus types other than Ad4 and Ad7. Although the percentage of type 14 increased following reintroduction of the vaccination, the actual number of cases decreased. We estimate that the vaccines prevent approximately 1 death, 1100-2700 hospitalizations, and 13 000 febrile adenovirus cases each year among the trainees., Conclusions: These data strongly support the continued production and use of Ad4 and Ad7 vaccines in controlling FRI among US military trainees. Continued surveillance for emerging adenovirus subtypes is warranted., (Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2014. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Capacity-building initiatives related to public health are defined as developing laboratory infrastructure, strengthening host-country disease surveillance initiatives, transferring technical expertise and training personnel. These initiatives represented a major piece of the Armed Forces Health Surveillance Center, Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) contributions to worldwide emerging infectious disease (EID) surveillance and response. Capacity-building initiatives were undertaken with over 80 local and regional Ministries of Health, Agriculture and Defense, as well as other government entities and institutions worldwide. The efforts supported at least 52 national influenza centers and other country-specific influenza, regional and U.S.-based EID reference laboratories (44 civilian, eight military) in 46 countries worldwide. Equally important, reference testing, laboratory infrastructure and equipment support was provided to over 500 field sites in 74 countries worldwide from October 2008 to September 2009. These activities allowed countries to better meet the milestones of implementation of the 2005 International Health Regulations and complemented many initiatives undertaken by other U.S. government agencies, such as the U.S. Department of Health and Human Services, the U.S. Agency for International Development and the U.S. Department of State.

Background: Combat-intense, lengthy, and multiple deployments in Iraq and Afghanistan have characterized the new millennium. The US military's all-volunteer force has never been better trained and technologically equipped to engage enemy combatants in multiple theaters of operations. Nonetheless, concerns over potential lasting effects of deployment on long-term health continue to mount and are yet to be elucidated. This report outlines how findings from the first 7 years of the Millennium Cohort Study have helped to address health concerns related to military service including deployments., Methods: The Millennium Cohort Study was designed in the late 1990s to address veteran and public concerns for the first time using prospectively collected health and behavioral data., Results: Over 150,000 active-duty, reserve, and National Guard personnel from all service branches have enrolled, and more than 70% of the first 2 enrollment panels submitted at least 1 follow-up survey. Approximately half of the Cohort has deployed in support of operations in Iraq and Afghanistan., Conclusion: The Millennium Cohort Study is providing prospective data that will guide public health policymakers for years to come by exploring associations between military exposures and important health outcomes. Strategic studies aim to identify, reduce, and prevent adverse health outcomes that may be associated with military service, including those related to deployment.

Background: Prostate cancer is the most common cancer among US men, however, the etiology remains unclear. Yet, one consistency is that black non-Hispanic men are at increased risk for prostate cancer compared to white, non-Hispanic men. The goal of this study was to assess relations between demographic and other potential prostate cancer risk factors in the context of the US military healthcare system, which provides equal access to all US servicemen., Methods: Military healthcare and demographic data were used to describe risk factors for prostate cancer in the US military from September 1993 to September 2003. Cox's proportional hazards regression was employed to model the time to prostate cancer hospitalization., Results: Four hundred eight first prostate cancer hospitalizations were identified among 2,761,559 servicemen. The adjusted rate per 100,000 persons rose from 1.41 to 3.62 for white non-Hispanic men and 1.43 to 6.08 for black non-Hispanic men by the end of the study. The increasing incidence over time for combined race/ethnic groups was similar to trends reported in the Surveillance, Epidemiology, and End Results Program for the US civilian population. No association was observed between occupation and prostate cancer hospitalization. However, black non-Hispanic men were at increased risk compared with white non-Hispanic men (hazard ratio = 2.72, 95% confidence interval: 2.12, 3.49)., Conclusions: No association was observed between occupation and prostate cancer hospitalization. In this relatively young cohort, black non-Hispanic race/ethnicity was found to be predictive of prostate cancer, and this association existed regardless of access to care and socioeconomic status.

The Department of Defense (DoD) Global Laboratory-Based Influenza Surveillance Program was initiated in 1997 to formally consolidate and expand existing influenza surveillance programs within the DoD and in areas where DoD was working. Substantial changes in 2008 provided an opportunity to review the operation of the surveillance program as it existed during seven complete influenza seasons (1998-2005); the review was conducted in 2008. A unique aspect of the DoD program was the global reach for specimen collection and the ability to rapidly ship, process, and evaluate specimens from 27 countries. The resulting epidemiologic data combined with the culture results from >46,000 patients provided information that was shared with similar national and international programs, such as those of the CDC. Likewise, selected influenza isolates were molecularly characterized and shared with the CDC to be compared with other surveillance programs. Timeliness of the samples contributed to the information available for annual influenza vaccine selection.

Almost 60% of American households were connected to the Internet in 2001, when the Millennium Cohort Study, the largest longitudinal study ever undertaken by the Department of Defense, was launched. To facilitate survey completion, increase data integrity, and encourage cohort retention while maintaining the highest standards of participant privacy, an online questionnaire was made available on the World Wide Web in addition to a traditional paper questionnaire sent via US mail. Over 50% of 77,047 participants chose to enroll in the study via the Web, affording substantial cost savings to the project. Using multivariable logistic regression, the authors compared the demographic and health characteristics of Web responders with those of paper responders. Web responders were slightly more likely to be male, to be younger, to have a high school diploma or college degree, and to work in information technology or another technical occupation. Web responders were more likely to be obese and to smoke more cigarettes and were less likely to be problem alcohol drinkers and to report occupational exposures. Question completion rates were 98.3%, on average, for both Web and paper responders. Web responders provided more complete contact information, including their e-mail addresses. These results demonstrate the value of survey research conducted over the Internet in concert with traditional mail survey strategies.

Background: Military recruits receiving training are vulnerable to acute respiratory disease and a significant proportion of illness is due to unidentified pathogens. While some countries use surveillance programs to monitor such illness, few data exist for recruits of the British Armed Forces., Objectives: Through active surveillance of approximately 1000 Royal Navy trainees during 2001, we sought to describe and determine the aetiology of acute respiratory illness., Methods: Standard viral culture was used together with serology and a novel highly sensitive real-time PCR and molecular beacon probe assay for RSV detection., Results: Among 54 Royal Navy recruits with respiratory symptoms adenovirus was identified in 35%, influenza viruses in 19% and RSV in 14% of this group. All of the recruits were absent from training for almost a week, most of whom were confined to the sickbay., Conclusions: This study is the first to document adenovirus and RSV as important causes of acute respiratory illness among Royal Navy trainees. The study findings demonstrate the clinical significance and challenges of diagnosing RSV infection in young adults.

Background: Recently, numerous studies have revealed an increase in complementary and alternative medicine (CAM) use in US civilian populations. In contrast, few studies have examined CAM use within military populations, which have ready access to conventional medicine. Currently, the prevalence and impact of CAM use in US military populations remains unknown., Methods: To investigate CAM use in US Navy and Marine Corps personnel, the authors surveyed a stratified random sample of 5,000 active duty and Reserve/National Guard members between December 2000 and July 2002. Chi-square tests and multivariable logistic regression were used to assess univariate associations and adjusted odds of CAM use in this population., Results and Discussion: Of 3,683 service members contacted, 1,446 (39.3%) returned a questionnaire and 1,305 gave complete demographic and survey data suitable for study. Among respondents, more than 37% reported using at least one CAM therapy during the past year. Herbal therapies were among the most commonly reported (15.9%). Most respondents (69.8%) reported their health as being very good or excellent. Modeling revealed that CAM use was most common among personnel who were women, white, and officers. Higher levels of recent physical pain and lower levels of satisfaction with conventional medical care were significantly associated with increased odds of reporting CAM use., Conclusion: These data suggest that CAM use is prevalent in the US military and consistent with patterns in other US civilian populations. Because there is much to be learned about CAM use along with allopathic therapy, US military medical professionals should record CAM therapies when collecting medical history data.

Objective: In response to health concerns of military members about deployment and other service-related exposures, the Department of Defense (DoD) initiated the largest prospective study ever undertaken in the U.S. military., Study Design and Setting: The Millennium Cohort uses a phased enrollment strategy to eventually include more than 100,000 U.S. service members who will be followed up through the year 2022, even after leaving military service. Subjects will be linked to DoD and Veterans Affairs databases and surveyed every 3 years to obtain objective and self-reported data on exposures and health outcomes., Results: The first enrollment phase was completed in July 2003 and resulted in 77,047 consenting participants, well representative of both active-duty and Reserve/Guard forces. This report documents the baseline characteristics of these Cohort members, describes traditional, postal, and Web-based enrollment methods; and describes the unique challenges of enrolling, retaining, and following such a large Cohort., Conclusion: The Millennium Cohort was successfully launched and is becoming especially relevant, given current deployment and exposure concerns. The Cohort is representative of the U.S. military and promises to provide new insight into the long-term effects of military occupations on health for years to come.

Much attention has been given to the impact of deployment on the health of veterans from the 1991 Gulf War. Whereas increases in self-reported symptoms have been common, no specific exposures have been implicated. Some have suggested that stress from deployment is the chief cause for multisymptom conditions among Gulf War veterans, but comparisons with the health of other recent deployers have not been made. We sought to examine the impact of several large military deployments on hospitalization experience. Hospitalization records were examined for all active duty personnel deployed exclusively to the Gulf War, Southwest Asia after the Gulf War, or Bosnia. Cox's hazard modeling was used to assess time until first post-deployment hospitalization, separation from active duty, or December 31, 2000, whichever occurred first, while controlling for influential covariates and temporal changes. Personnel deployed to Southwest Asia after the 1991 Gulf War were at a slight increased risk for any-cause hospitalization and for 3 of the 14 major diagnostic categories when compared with veterans of the 1991 Gulf War. Personnel deployed to Bosnia were at a decreased risk for any-cause hospitalization and 12 of the 14 major diagnostic categories when compared with Gulf War veterans. These findings do not fully explain the complexity of postdeployment health experiences. Although the risk for hospitalization may be associated with regional deployment, it is unlikely that Gulf War veterans are at greater risk of hospitalization due to a specific exposure-related disease.

The authors conducted an extensive search for published works concerning healthcare utilization and mortality among Gulf War veterans of the Coalition forces who served during the 1990-1991 Gulf War. Reports concerning the health experience of US, UK, Canadian, Saudi and Australian veterans were reviewed. This report summarizes 15 years of observations and research in four categories: Gulf War veteran healthcare registry studies, hospitalization studies, outpatient studies and mortality studies. A total of 149728 (19.8%) of 756373 US, UK, Canadian and Australian Gulf War veterans received health registry evaluations revealing a vast number of symptoms and clinical conditions but no suggestion that a new unique illness was associated with service during the Gulf War. Additionally, no Gulf War exposure was uniquely implicated as a cause for post-war morbidity. Numerous large, controlled studies of US Gulf War veterans' hospitalizations, often involving more than a million veterans, have been conducted. They revealed an increased post-war risk for mental health diagnoses, multi-symptom conditions and musculoskeletal disorders. Again, these data failed to demonstrate that Gulf War veterans suffered from a unique Gulf War-related illness. The sparsely available ambulatory care reports documented that respiratory and gastrointestinal complaints were quite common during deployment. Using perhaps the most reliable data, controlled mortality studies have revealed that Gulf War veterans were at increased risk of injuries, especially those due to vehicular accidents. In general, healthcare utilization data are now exhausted. These findings have now been incorporated into preventive measures in support of current military forces. With a few diagnostic exceptions such as amyotrophic lateral sclerosis, mental disorders and cancer, it now seems time to cease examining Gulf War veteran morbidity and to direct future research efforts to preventing illness among current and future military personnel.

Background and Methods: The high burden of respiratory infections in military populations is well documented throughout history. The primary pathogen responsible for morbidity among US recruits in training was shown to be adenovirus. Highly efficacious oral vaccines were used for 25 years, but vaccine production ceased in 1996, and available stores were depleted by early 1999. Surveillance for acute febrile respiratory illness was performed at eight military recruit training sites throughout the United States from July 1999 through June 2004 to document rates after loss of the vaccines. Laboratory diagnoses complimented the surveillance efforts., Results: Over the 5 years, nearly 12 million person-weeks were followed and an estimated 110,172 febrile respiratory illness cases and 73,748 adenovirus cases were identified. Rates of illness were highest at the Navy and Air Force training centers, with average annual rates of 1.20 and 1.35 cases per 100 recruit-weeks, respectively. Adenoviral-associated illness rates peaked in weeks 3-5 of training, depending upon service., Conclusions: The burden of adenoviral illness among US recruit populations has returned to high levels since loss of the vaccines. Restoration of an effective adenovirus vaccine effort within the military is anticipated by 2008, potentially reducing the adenovirus morbidity suffered in this vulnerable population. Efforts to determine the burden of adenovirus and potential benefits of vaccination in civilian populations are being renewed.

Background: There has been considerable publicity that the 1991 Gulf War may have caused a wide array of health problems in military personnel. Although post-war health outcomes have been studied in US, British, Canadian, Danish, and other deployed troops, this issue has not been previously evaluated in coalition forces native to the Gulf region., Methods: A collaborative team of US and Saudi health researchers was assembled, data sources evaluated, and hospitalizations among Saudi Arabian National Guard (SANG) soldiers between 1991 and 1999 analysed. Multivariate modelling was used to evaluate differences between 8342 soldiers exposed to combat at Al Khafji and a comparison group of 7270 soldiers in the Riyadh area., Results: Among 15 612 SANG soldiers, we identified 148 with at least one hospitalization over the 9 years following the war. The adjusted rate of hospitalization was higher in the combat-exposed group (risk ratio (RR) = 1.80, 95% confidence interval (CI) 1.25-2.59). No unusual patterns of diagnoses were found and, because the overall number of hospitalizations was low, the absolute difference in risk was found to be very small., Conclusions: This is the first reported epidemiological investigation of post-war hospitalizations among coalition forces native to the Gulf region that participated in the 1991 Gulf War. A very small increase in hospitalizations was identified in SANG soldiers exposed to combat at Al Khafji. However, because of data limitations, the clinical relevance of this finding should be interpreted with caution. Future collaborative studies to better understand the health effects of deployment should be encouraged.

Epidemics of community-acquired pneumonia (CAP) are a frequent cause of morbidity among Russian military trainees. We evaluated azithromycin prophylaxis against CAP. In 2001-2002, incoming military trainees were randomized to 1 of 3 trial arms by training group: azithromycin, 500 mg per week for 8 weeks (R1); azithromycin, 1500 mg once at enrollment (R2); or no therapy (R3). During the 22 weeks of training, CAP was diagnosed in 20.2% of 678 subjects in the R3 group, 8.6% of 508 subjects in the R1 group, and 10.3% of 507 subjects in the R2 group. Throat carriage cultures revealed that the proportion of Streptococcus pneumoniae isolates with resistance to macrolides correspondingly increased during the study, from 0% (all) to 40% (R1) and 22.6% (R2) by week 20. Azithromycin prophylaxis is effective against CAP in a healthy population of young men at transient high risk of disease; however, azithromycin use must be tempered with the possible concomitant risk of selection for resistant endemic pathogens.

Infections of adenovirus type 4 (Ad4) and Ad7 were discovered among previously vaccinated individuals through febrile respiratory illness surveillance at military recruit camps. Genetic analysis was performed on these isolates and a sample of adenovirus isolates from unvaccinated patients. Antigenic regions of the adenovirus hexon gene from 21 vaccinated and 31 unvaccinated patients were sequenced and compared to homologous regions of Ad4 and Ad7 vaccine strains and of other representative hexon sequences archived in GenBank. The phylogenetic distribution of sequences from vaccinated individuals closely resembled those from unvaccinated individuals. The most common Ad7 strain was the Ad7d2 hexon genotype, and the most common Ad4 strain was a genotype nearly identical to the recently discovered Z-G 95-873 Ad4 variant. Near exclusive isolation of Ad4 since 1999 indicates that the Ad4 variant is currently responsible for the vast majority of adenovirus morbidity in military recruit camps. Different ratios of nonsynonymous to synonymous nucleotide substitution rates in known antigenic regions compared to nonantigenic regions indicated positive selection for diversity in the antigenic regions and purifying selection in the nonantigenic regions.

Purpose: To enumerate Gulf-War (GW) exposed conceptions and to compare reproductive outcomes of GW-exposed pregnancies with postwar conceptions of women Gulf War veterans (GWV) and women nondeployed veterans (NDV)., Methods: Deployment data and inpatient records from 153 military hospitals identified servicewomen who were pregnant between August 1990 and May 1992 and belonged to military units that were deployed to the Gulf War. Postal surveys were used in 1997 and 1998 to elicit reproductive history; responses were validated against military hospitalization records. Reproductive outcomes of GW-exposed pregnancies were compared with postwar conceptions of women GWVs and NDVs., Results: 3285 women had a pregnancy-related admission; of these, 1558 completed the questionnaire. Self-reported reproductive outcomes and dates, gestational data, and individual deployment dates identified 415 Gulf War-exposed pregnancies, 298 GWV postwar conceptions, and 427 NDV conceptions. Compared with NDV conceptions, adverse reproductive outcomes were similar among GW-exposed pregnancies. However, spontaneous abortions [NDV: 9.1%, GWV postwar: 22.8%, adjusted odds ratio (OR)=2.92, 95% confidence interval (CI): 1.9, 4.6] and ectopic pregnancies (NDV: 1.4%, GWV postwar: 10.7%, adjusted OR=7.70, 95% CI, 3.0, 20) were elevated for GWV postwar conceptions., Conclusion: GW-exposed conceptions and nondeployed conceptions had similar outcomes. However, GWV postwar conceptions were at increased risk for ectopic pregnancies and spontaneous abortions.

Antibiotic resistance and emm gene types were examined from 692 Group A streptococci isolates from eight United States military basic training sites between 1998 and 2001. Macrolide resistance was associated with geographic sites and emm type. These data are useful for vaccine development initiatives and antimicrobial treatment considerations.

Background: Streptococcus pneumoniae is the leading cause of bacterial pneumonia in all age groups. Identifying outbreaks of pneumococcal disease and key risk factors may lead to improvements in vaccination and prevention strategies for high-risk groups. A significant outbreak of S. pneumoniae pneumonia that occurred among Marine recruits is reported here., Methods: An outbreak was investigated using standard microbiologic procedures and epidemiologic evaluation to define the extent of the outbreak, determine the microbiologic causative agent(s), identify risk factors for the development of disease, and institute preventive measures against further cases of pneumonia among recruits., Results: Fifty-two cases of radiographically confirmed pneumonia occurred among 3367 Marine recruits over a 2-week period in November 2000. Twenty-five of these cases occurred in a single company of 481 men, with an attack rate of 5.2%. Twelve of the 25 cases were caused by S. pneumoniae, serotypes 4 and 9v. The outbreak rapidly ended following isolation of cases, prophylaxis with oral azithromycin, and administration of the 23-valent pneumococcal vaccine., Conclusions: This outbreak of pneumococcal disease occurred in the setting of intense military training and a crowded environment. The use of the pneumococcal vaccine year-round in military trainees and other high-risk populations to reduce pneumococcal disease should be considered.

Context: In the United States, the annual incidence of myocarditis is estimated at 1 to 10 per 100,000 population. As many as 1% to 5% of patients with acute viral infections involve the myocardium. Although many viruses have been reported to cause myopericarditis, it has been a rare or unrecognized event after vaccination with the currently used strain of vaccinia virus (New York City Board of Health)., Objective: To describe a series of probable cases of myopericarditis following smallpox vaccination among US military service members reported since the reintroduction of vaccinia vaccine., Design, Setting, Participants: Surveillance case definitions are presented. The cases were identified either through sentinel reporting to US military headquarters surveillance using the Defense Medical Surveillance System or reports to the Vaccine Adverse Event Reporting System using International Classification of Diseases, Ninth Revision. The cases occurred among individuals vaccinated from mid-December 2002 to March 14, 2003., Main Outcome Measure: Elevated serum levels of creatine kinase (MB isoenzyme), troponin I, and troponin T, usually in the presence of ST-segment elevation on electrocardiogram and wall motion abnormalities on echocardiogram., Results: Among 230,734 primary vaccinees, 18 cases of probable myopericarditis after smallpox vaccination were reported (an incidence of 7.8 per 100,000 over 30 days). No cases of myopericarditis following smallpox vaccination were reported among 95,622 vaccinees who were previously vaccinated. All cases were white men aged 21 years to 33 years (mean age, 26.5 years), who presented with acute myopericarditis 7 to 19 days following vaccination. A causal relationship is supported by the close temporal clustering (7-19 days; mean, 10.5 days following vaccination), wide geographic and temporal distribution, occurrence in only primary vaccinees, and lack of evidence for alternative etiologies or other diseases associated with myopericarditis. Additional supporting evidence is the observation that the observed rate of myopericarditis among primary vaccinees is 3.6-fold (95% confidence interval, 3.33-4.11) higher than the expected rate among personnel who were not vaccinated. The background incidence of myopericarditis did not show statistical significance when stratified by age (20-34 years: 2.18 expected cases per 100,000; 95% confidence interval [CI], 1.90-2.34), race (whites: 1.82 per 100,000; 95% CI, 1.50-2.01), and sex (males: 2.28 per 100,000; 95% CI, 2.04-2.54)., Conclusion: Among US military personnel vaccinated against smallpox, myopericarditis occurred at a rate of 1 per 12 819 primary vaccinees. Myopericarditis should be considered an expected adverse event associated with smallpox vaccination. Clinicians should consider myopericarditis in the differential diagnosis of patients presenting with chest pain 4 to 30 days following smallpox vaccination and be aware of the implications as well as the need to report this potential adverse advent.

Background: Epidemiologic studies of birth defects among infants of Gulf War veterans (GWV) have been limited to military hospitals, anomalies diagnosed among newborns, or self-reported data. This study was conducted to measure the prevalence of birth defects among infants of GWVs and nondeployed veterans (NDV) in states that conducted active case ascertainment of birth defects between 1989-93., Methods: Military records of 684,645 GWVs and 1,587,102 NDVs were electronically linked with 2,314,908 birth certficates from Arizona, Hawaii, Iowa, and selected counties of Arkansas, California, and Georgia; 11,961 GWV infants and 33,052 NDV infants were identified. Of these, 450 infants had mothers who served in the Gulf War, and 3966 had NDV mothers., Results: Infants conceived postwar to male GWVs had significantly higher prevalence of tricuspid valve insufficicieny (relative risk [RR], 2.7; 95% confidence interval [CI], 1.1-6.6; p = 0.039) and aortic valve stenosis (RR, 6.0; 95% CI, 1.2-31.0; p = 0.026) compared to infants conceived postwar to NDV males. Among infants of male GWVs, aortic valve stenosis (RR, 163; 95% CI, 0.09-294; p = 0.011) and renal agenesis or hypoplasia (RR, 16.3; 95% CI, 0.09-294; p = 0.011) were significantly higher among infants conceived postwar than prewar. Hypospadias was significantly higher among infant sons conceived postwar to GWV women compared to NDV women (RR, 6.3; 95% CI, 1.5-26.3; p = 0.015)., Conclusion: We observed a higher prevalence of tricuspid valve insufficiency, aortic valve stenosis, and renal agenesis or hypoplasia among infants conceived postwar to GWV men, and a higher prevalence of hypospadias among infants conceived postwar to female GWVs. We did not have the ability to determine if the excess was caused by inherited or environmental factors, or was due to chance because of myriad reasons, including multiple comparisons. Although the statistical power was sufficient to compare the combined birth defects prevalence, larger sample sizes were needed for less frequent individual component defects.

Context: Gulf War veterans' illnesses (GWVI), multisymptom illnesses characterized by persistent pain, fatigue, and cognitive symptoms, have been reported by many Gulf War veterans. There are currently no effective therapies available to treat GWVI., Objective: To compare the effectiveness of cognitive behavioral therapy (CBT), exercise, and the combination of both for improving physical functioning and reducing the symptoms of GWVI., Design, Setting, and Patients: Randomized controlled 2 x 2 factorial trial conducted from April 1999 to September 2001 among 1092 Gulf War veterans who reported at least 2 of 3 symptom types (fatigue, pain, and cognitive) for more than 6 months and at the time of screening. Treatment assignment was unmasked except for a masked assessor of study outcomes at each clinical site (18 Department of Veterans Affairs [VA] and 2 Department of Defense [DOD] medical centers)., Interventions: Veterans were randomly assigned to receive usual care (n = 271), consisting of any and all care received from inside or outside the VA or DOD health care systems; CBT plus usual care (n = 286); exercise plus usual care (n = 269); or CBT plus exercise plus usual care (n = 266). Exercise sessions were 60 minutes and CBT sessions were 60 to 90 minutes; both met weekly for 12 weeks., Main Outcome Measures: The primary end point was a 7-point or greater increase (improvement) on the Physical Component Summary scale of the Veterans Short Form 36-Item Health Survey at 12 months. Secondary outcomes were standardized measures of pain, fatigue, cognitive symptoms, distress, and mental health functioning. Participants were evaluated at baseline and at 3, 6, and 12 months., Results: The percentage of veterans with improvement in physical function at 1 year was 11.5% for usual care, 11.7% for exercise alone, 18.4% for CBT plus exercise, and 18.5% for CBT alone. The adjusted odds ratios (OR) for improvement in exercise, CBT, and exercise plus CBT vs usual care were 1.07 (95% confidence interval [CI], 0.63-1.82), 1.72 (95% CI, 0.91-3.23), and 1.84 (95% CI, 0.95-3.55), respectively. The OR for the overall (marginal) effect of receiving CBT (n = 552) vs no CBT (n = 535) was 1.71 (95% CI, 1.15-2.53) and for exercise (n = 531) vs no exercise (n = 556) was 1.07 (95% CI, 0.76-1.50). For secondary outcomes, exercise alone or in combination with CBT significantly improved fatigue, distress, cognitive symptoms, and mental health functioning, while CBT alone significantly improved cognitive symptoms and mental health functioning. Neither treatment had a significant impact on pain., Conclusion: Our results suggest that CBT and/or exercise can provide modest relief for some of the symptoms of chronic multisymptom illnesses such as GWVI.

In the winter of 1998-1999 an outbreak of pneumococcal pneumonia occurred among Ranger students undergoing high-intensity training. Thirty pneumonia cases (attack rate = 12.6%) were identified among a group of 239 students. Eighteen students were hospitalized; Streptococcus pneumoniae-positive cultures were detected in 11 (61.1%) of these 18 hospitalized cases. Pneumococci were also identified in throat swabs of 30 (13.6%) of 221 nonhospitalized students surveyed. Serum antipneumolysin seroconversions were detected in 30 (18.3%) of 164 students tested. An association between development of serum antipneumolysin antibody and pneumococcal pharyngeal carriage/colonization was found. Of 30 seroconverters, eight (26.7%) had S. pneumoniae-positive cultures compared with only 17 (12.7%) of 134 nonseroconverters (relative risks = 2.02, 95% confidence interval = 1.02-4.02, p = 0.05). The outbreak was controlled by administrating lowdose, oral azithromycin prophylaxis (250 mg weekly for 2 weeks) and was associated with a 69% reduction in pneumococcal carriage and a 94% reduction in pneumonia rates.

Background: Tuberculosis (TB) is a re-emerging infectious disease threat worldwide. To protect the health and readiness of US military personnel, policies exist to screen for and treat latent TB infection at the time of service entrance., Results: of this screening programme have not been recently described., Methods: Multivariate regression techniques were used to evaluate demographic and medical data associated with TB infection among all young adults entering US Navy enlisted service between 1 October 1997 and 30 September 1998. Results A total of 44,128 adults (ages 17-35, 81% male) were screened for TB during this 12-month period. The prevalence of latent TB infection was 3.5%. Place of birth was very strongly associated with TB infection, with foreign-born recruits eight times more likely to have a reactive tuberculin skin test or history of infection. Those who reported their race as 'Asian/Pacific Island' had 3.8 times the odds of having evidence of TB infection compared with 'Caucasian' recruits, even after adjusting for place of birth., Conclusions: The prevalence of TB infection among Navy recruits was last reported as 2.5% nearly 10 years ago. The apparent increase to 3.5% in this large cohort is likely due to a concurrent increase in the number of foreign-born recruits, and it serves to underscore the importance of comprehensive screening and treatment of latent TB infections in this population.

Does military service, in particular operational deployment, result in a higher risk of chronic illness among military personnel and veterans? The Millennium Cohort Study, the largest Department of Defense prospective cohort study ever conducted, will attempt to answer this question. The probability-based sample of 140,000 military personnel will be surveyed every 3 years during a 21-year period. The first questionnaire, scheduled for release in summer 2001, will be sent to 30,000 veterans who have been deployed to southwest Asia, Bosnia, or Kosovo since August 1997 and 70,000 veterans who have not been deployed to these conflict areas. Twenty thousand new participants will be added to the group in each of the years 2004 and 2007 to complete the study population of 140,000. The participants will have the option of completing the study questionnaire either on the paper copy received in the mail or through the World Wide Web-based version, which is available at www.MillenniumCohort.org. This will be one of the first prospective studies ever to offer such an option. The initial survey instrument will collect data regarding demographic characteristics, self-reported medical conditions and symptoms, and health-related behaviors. Validated instruments will be incorporated to capture self-assessed physical and mental functional status (Short Form for Veterans), psychosocial assessment (Patient Health Questionnaire), and post-traumatic stress disorder (Patient Checklist-17). Information obtained from the survey responses will be linked with other military databases, including data on deployment, occupation, vaccinations, health care utilization, and disability. In addition to revealing changes in veterans' health status over time, the Millennium Cohort Study will serve as a data repository, providing a solid foundation upon which additional epidemiological studies may be constructed.

Streptococcus pneumoniae causes severe morbidity and mortality worldwide and poses a significant threat to the health and readiness of U.S. military personnel. Although a vaccine to prevent pneumococcal infections has been available for almost 25 years, its use has been limited. Recently, increasing antibiotic resistance among S. pneumoniae strains has emerged, prompting health care professionals to reevaluate the benefit of administering pneumococcal vaccine. The Naval Health Research Center, in collaboration with professionals from numerous civilian and military organizations, has initiated a rigorous double-blind, placebo-controlled trial investigating the operational value of vaccinating young adults as they enlist in the military.

Military Special Forces trainees undergo intense psychological and physical stressors that often lead to respiratory infection. During 1998-2000, 477 Navy Special Forces trainees were enrolled in a double-blind trial of oral azithromycin (1 g given weekly) plus a placebo injection, compared with benzathine penicillin G (1.2 million U) plus azithromycin placebo tablets. Among the 464 subjects with complete data, 44 developed acute respiratory infection (20 with pneumonia) during the 2 weeks of most intense training; of these subjects, 12 (27.3%) had evidence of Chlamydia pneumoniae infection and 7 (15.9%) had evidence of Mycoplasma pneumoniae infection. Trainees who received azithromycin were less likely than were trainees who received benzathine penicillin G to develop acute respiratory infection (risk ratio, 0.50; 95% confidence interval [CI], 0.28-0.92) and less likely at the end of training to report episodes of breathing difficulty (odds ratio [OR], 0.59; 95% CI, 0.34-1.01) or sore throat (OR, 0.66; 95% CI, 0.41-1.05). Compared with benzathine penicillin G prophylaxis, weekly oral azithromycin was superior in preventing respiratory infection in this population at transient high risk.

To provide surveillance among US military personnel and their beneficiaries, 157 invasive Streptococcus pneumoniae clinical isolates were collected systematically from 7 large military hospitals between August 1997 and August 1999. The isolates were studied for antibiotic resistance, and 120 were serotyped and subjected to arbitrarily primed polymerase chain reaction (AP-PCR). Fifty (31.9%) of 157 isolates had intermediate or high-level resistance to penicillin, and 15.9% had multidrug resistance. The most common serotypes were 4, 6B, 9V, 14, 19F, and 23F. Those serotypes associated with penicillin resistance were 6B, 9V, 19A, and 19F. Most invasive disease cases were caused by serotypes included in the currently available 23- and 7-valent pneumococcal vaccines. By use of AP-PCR, 4 DNA groups were correlated with health care site (P< or =.0001). These results are valuable in assessing appropriate use of antibiotics and vaccines against S. pneumoniae in both military personnel and their families.

Midshipmen at the U.S. Naval Academy have recently suffered epidemics of upper respiratory tract infections. Seeking to determine cause, in June 1998 we enrolled 1,243 (99.5%) of 1,249 new midshipmen (plebes) and followed them during their first 11 months of training. Eighty-five plebes sought medical attention for acute respiratory disease. Using culture, serologic studies, and polymerase chain reaction, considerable evidence for respiratory pathogen infection was found among the ill subjects: Chlamydia pneumoniae in 41 (52.6%), Mycoplasma pneumoniae in 19 (25.3%), influenza in 11 (14.2%), Streptococcus pneumoniae in 6 (7.3%), and adenovirus in 1 (1.2%). Additionally, 873 (81%) the 1,077 plebes who completed an end-of-year questionnaire complained of having one or more respiratory symptoms (> 12 hours) during their first year of school. Of these, 132 (15%) reported that the symptoms significantly affected their performance. Study results suggest that respiratory infections were frequent, had a significant adverse impact on training, and were often attributable to bacterial pathogens.

Throughout history, respiratory diseases have been a frequent cause of morbidity in U.S. populations. Because of stress, crowding, and naïve immune systems, military training populations are particularly prone to acute respiratory disease epidemics. An examination of the history of respiratory illness at the U.S. Naval Academy revealed that, in the earliest decades at the school, respiratory illness was a primary cause of both disease and mortality. With the advent of antibiotics and vaccines, most respiratory disease mortality has been reduced. However, even today, morbidity remains significant. Health concerns regarding respiratory diseases are heightened by emerging and reemerging respiratory disease agents that have increased antibiotic resistance and/or increased virulence. Enhanced surveillance and rapid diagnostic capabilities, placed in military settings, will increase knowledge of the epidemiology of many respiratory diseases. These strategies can lead to earlier treatment and prevention measures, thus halting the further transmission of disease and decreasing both morbidity and mortality. During the most recent history of the Naval Academy, acute respiratory infections have remained a primary cause of medical morbidity.

Since the Vietnam War, concern regarding the association of military exposures and birth defects has grown. The possibility of such associations remains a source of unease. To determine if such an association exists, birth defects surveillance among military families must be conducted. This project compared health record abstraction (active surveillance) with screening of Department of Defense electronic medical data (passive surveillance) to detect birth defects among San Diego County military families during the period January 1, 1997, through June 30, 1998. A total of 171 of 5,351 infants (3.2%) were identified as having a major defect, consistent with national civilian rates. There was approximately 80% concurrence between passive and active surveillance birth defect data, suggesting that a hybrid system of electronic data, supplemented with active surveillance in a specific region, represents a feasible and cost-effective surveillance program for the geographically dispersed military population.

Background: The U.S. Department of Defense (DoD) is challenged with monitoring and protecting the health and wellbeing of its service members. The growing number of women on active duty and the diverse hazardous exposures associated with military service make reproductive health issues a special concern of DoD. To address this concern, the DoD Birth Defects Registry was established at the DoD Center for Deployment Health Research located at the Naval Health Research Center, San Diego, California., Methods: The registry captures comprehensive data on healthcare utilization to calculate the prevalence of birth defects in the children of military beneficiaries. Population-based electronic surveillance is supplemented by active case validation efforts., Results: Since its establishment in 1998, the registry has captured data on more than 90,000 births that occur in military families each year. Detailed analyses, to include linking registry data with military occupational exposure data (e.g., anthrax vaccination), are underway., Conclusions: The DoD Birth Defects Registry provides important reproductive health information on the geographically dispersed military population. This program is expected to complement civilian public health programs and be especially valuable to military members and their families.

Background: Gulf War veterans (GWVs) have expressed concern about possible teratogenic exposures. However, epidemiologic studies on birth defects prevalence among their progeny have been limited to military hospitals, anomalies diagnosed among newborns, or self-reported data. To measure the prevalence of selected birth defects among infants of GWVs and nondeployed veterans (NDVs) in Hawaii, using birth defects surveillance records., Methods: Personal identifiers of 684,645 GWVs and 1,587,102 NDVs and their families were matched against birth certificate records of 99,545 live births reported to the State of Hawaii Department of Health between 1989 and 1993 to identify births to military personnel. These births were matched with records from the Hawaii Birth Defects Program., Results: A total of 17,182 military infants (3,717 GWV infants and 13,465 NDV infants) were identified. Of these, 367 infants (2.14/100 live births) were identified with one or more of 48 major birth defects diagnoses. The prevalence of the 48 birth defects were similar for GWV and NDV infants during the prewar and postwar periods, and among GWV infants who were conceived before and after the Gulf war., Conclusions: The results must be interpreted with caution because of the small number of affected infants in each birth defects category. This study demonstrated the feasibility of measuring birth defects prevalence among military infants through multiple data linkage. Further, it included live births to parents who had separated from the military, births in civilian hospitals, and birth defects diagnosed through the first year of life.

Sarcoidosis has been associated with various demographic risk factors, yet findings may be falsely influenced by effects such as socioeconomic status. We used univariate and multiple logistic regression to compare demographic data from military sarcoidosis hospitalizations with similar data from the general military population from 1981 to 1995. A total of 626 first hospitalizations for sarcoidosis were identified. After adjusting for pay grade, blacks had seven-fold increased odds of sarcoidosis hospitalization compared with whites. The oldest age group had five times the odds of the youngest age group. A southeastern United States home of record was associated with increased risk. Multivariate modeling permitted us to determine independent risk factors for sarcoidosis hospitalization, in contrast to previous studies that focused mainly on unadjusted rates. These findings are useful in identifying populations at high risk for sarcoidosis.

Since the Persian Gulf War ended in 1991, veterans have reported diverse, unexplained symptoms. Some have wondered if their development of systemic lupus erythematosus, amyotrophic lateral sclerosis, or fibromyalgia might be related to Gulf War service. The authors used Cox proportional hazard modeling to determine whether regular, active-duty service personnel deployed to the Persian Gulf War (n = 551,841) were at increased risk of postwar hospitalization with the three conditions compared with nondeployed Gulf War era service personnel (n = 1,478,704). All hospitalizations in Department of Defense facilities from October 1, 1988, through July 31, 1997, were examined. With removal of personnel diagnosed with any of the three diseases before August 1, 1991, and adjustment for multiple covariates, Gulf War veterans were not at increased risk of postwar hospitalization due to systemic lupus erythematosus (risk ratio (RR) = 0.94, 95% confidence interval (CI): 0.65, 1.35). Because of the small number of cases and wide confidence limits, the data regarding amyotrophic lateral sclerosis were inconclusive. Gulf War veterans were slightly at risk of postwar hospitalization for fibromyalgia (RR = 1.23, 95% Cl: 1.05, 1.43); however, this risk difference was probably due to the Gulf War veteran clinical evaluation program beginning in 1994. These data do not support Gulf War service and disease associations.

In May 1997, a large, persistent epidemic of adenovirus type 4-associated acute respiratory disease began at Fort Jackson, South Carolina, the largest army basic training center. The epidemic lasted until December and declined when vaccine administration resumed. More than 1,000 male and female trainees were hospitalized; 66.1% of those hospitalized had an adenovirus type 4 isolate.

To investigate reports on war-related morbidity, 527 active-duty Gulf War veterans and 970 nondeployed veterans from 14 Seabee commands were studied in 1994 with a questionnaire, sera collection, handgrip strength, and pulmonary function testing. The questionnaire assessed postwar symptoms, war exposures, and screened for chronic fatigue syndrome, post-traumatic stress disorder, and psychological symptoms suggesting neurosis (Hopkins Symptom Checklist). Sera were tested with four nonspecific reactant assays: C-reactive protein, transferrin, ferritin, and haptoglobin. Gulf War veterans reported a higher prevalence for 35 of 41 symptoms, scored higher on psychological symptom scales, were more likely to screen for post-traumatic stress disorder, had lower handgrip strength, and had higher serum ferritin assay results. Numerous comparisons of these morbidity outcomes with 30 self-reported exposures demonstrated many associations, but no unique exposure or group of exposures were implicated. Morbidity data are consistent with other postwar observations, but the etiology for morbidity findings remains uncertain.

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.

We studied whether regular, active-duty servicemen deployed to the Persian Gulf War were at increased risk of testicular cancer compared with nondeployed Gulf War-era servicemen from August 1991 through March 31, 1996, using a Cox proportional hazards model for survival analysis with covariates. Race was an important predictor of hospitalization for testicular cancer [rate ratio (RR) = 0.19; 95% confidence interval (CI) = 0.12-0.29 for blacks, and RR = 0.59; 95% CI = 0.39-0.91 for Hispanics, other, and unknown (combined), relative to whites]. Age effects were modest (RR = 1.19; 95% CI = 0.91-1.56 for those of ages 22-25 years, and RR = 1.24; 95% CI = 0.96-1.59 for those of ages 26-31 years, compared with those of ages 17-21 years). Risk also varied with occupation (RR = 1.56; 95% CI = 1.23-2.00 for those in electronic equipment repair; RR = 1.26; 95% CI = 1.01-1.58 for those in electrical/mechanical repair; and RR = 1.42; 95% CI = 0.93-2.17 for those in construction-related trades, compared with those in other occupations). Deployment status was not important (RR = 1.05; 95% CI = 0.86-1.29 for the deployed compared with the nondeployed). There was an increase in testicular cancer in the deployed group in the immediate postwar period that was consistent with a previous report of a standardized RR of 2.12; 95% CI = 1.11-4.02 (compared with the nondeployed group) in the last 5 months of 1991, but by 4 years after the end of deployment, the cumulative risks for the two groups were not different. An additional analysis suggested that the immediate postwar increase in the deployed was likely due to regression to the mean after a healthy serviceman selection effect for deployment and the deferment of care during deployment.

Since the Persian Gulf War ended in 1991, many veterans have sought medical evaluation in the Department of Veterans Affairs Persian Gulf Veterans' Health Registry (VA registry) or the Department of Defense's Comprehensive Clinical Evaluation Program (DoD registry). Using combined data collected from 1993 to 1997 from the VA and DoD registries, the authors compared the characteristics of registry participants (n=74,653) with those of all Gulf War veterans (n=696,531) to determine the personnel most likely to seek medical evaluation. Using multiple logistic regression, the authors found that service branch and type were strongly associated with registry participation, with Army (adjusted odds ratio (OR)=4.7, 95% confidence interval (CI) 4.6-4.9) and National Guard (OR=2.6, 95% CI 2.5-2.6) personnel at highest odds compared with reference category personnel. Registry participants also were more likely to have been stationed in the Gulf War theater during the fighting (OR=2.2), to be older (>31 years/<22 years OR=2.1), to have been an enlisted person (OR=2.0), to have been construction workers (OR=1.3), to be female (OR=1.3), and to have been hospitalized during the 12-month period before the war (OR=1.2). These findings are useful in generating hypotheses regarding postwar morbidity. They also suggest that subpopulations of Gulf War veterans have a higher prevalence of symptoms and merit further study.

Persian Gulf War veterans have reported a variety of symptoms, many of which have not led to conventional diagnoses. We ascertained all active-duty U.S. military personnel deployed to the Persian Gulf War (552,111) and all Gulf War era military personnel not deployed (1,479,751) and compared their postwar hospitalization records (until 1 April 1996) for one or more of 77 diagnoses under the International Classification of Diseases (ICD-9) system. The diagnoses were assembled by the Emerging Infections Program, Centers for Disease Control and Prevention, and are here termed "unexplained illnesses." Deployed veterans were found to have a slightly higher risk of hospitalization for unexplained illness than the nondeployed. Most of the excess hospitalizations for the deployed were due to the diagnosis "illness of unknown cause" (ICD-9 code 799.9), and most occurred in participants of the Comprehensive Clinical Evaluation Program who were admitted for evaluation only. When the effect of participation in this program was removed, the deployed had a slightly lower risk than the nondeployed. These findings suggest that active-duty Gulf War veterans did not have excess unexplained illnesses resulting in hospitalization in the 4.67-year period following deployment.

Recent coccidioidomycosis outbreaks among military personnel have alarmed public health officials. We used computerized hospitalization records to identify risk factors for coccidioidomycosis hospitalizations among active-duty United States Navy and Marine Corps personnel for the years 1981 to 1994. Primary pulmonary disease was the most common form of disease, accounting for 82 (73%) of the 113 first admissions. Crude annual rates of primary pulmonary disease increased markedly in 1992 and 1993 in concert with an epidemic in the United States. Demographic data from the pulmonary admissions were combined with that of a 2% random sample of the entire Navy and Marine Corps population for multivariate risk factor modeling. Persons from junior paygrades, older age groups, and those reporting a race/ethnicity other than Caucasian or Hispanic were most likely to be hospitalized with this disease. These risk factor data should be considered in designing coccidioidomycosis surveillance and prevention programs.

One hundred twenty male U.S. Marine Corps trainees with histories of at least 7 days of cough underwent evaluation for Bordetella pertussis infection by culture, B. pertussis-specific polymerase chain reaction (PCR) analysis, and serology. Antibody levels in preexposure, acute-phase, and convalescent-phase serum samples were measured in a microagglutination assay and in enzyme linked immunosorbent assays (ELISAs) for IgG and IgA antibodies to pertussis toxin, filamentous hemagglutinin, pertactin, and fimbriae types 2 and 3. Culture and PCR analysis revealed that none of the patients were positive for B. pertussis; however, 20 of 120 trainees had serological evidence of B. pertussis infection. Of these cases, one was confirmed by a rise in the level of antibody to pertussis toxin, and six were classified as probable by increases in levels of antibodies measured by two or more assays. Of the 20 individuals with serological evidence of infection, 16 had rises in levels of antibodies to fimbriae or agglutinating antibodies. The utility of ELISA for detecting antibodies to fimbriae and the microagglutination assay for diagnosing pertussis in adults should be evaluated by application to larger and more diverse study populations. These results indicate that pertussis should be considered in the diagnosis of coughing illness in military populations.