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NEWS FROM THE FRONT

 September 2018

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INTRODUCTION

Tropical infections will continue to pose a significant threat to U.S. forces as they deploy to 

diverse locations around the globe, despite a century of formal research and advances in 

countermeasures. Over the last one hundred years morbidity from tropical infections has at 

times surpassed combat casualties; non-battle injuries were six times more common than battle 

injuries during the 21st century conflicts.1 The Department of Defense (DoD) recognizes the 

continual need, (just as the need was acknowledged more than a century ago), that medical 

personnel should have some level of training in recognizing, diagnosing and treating relevant 

tropical diseases while serving in an austere environment. The DoD offers several tropical

medicine courses to accomplish this mission. One of the more historical courses was held at the 

Walter Reed Army Institute of Research (WRAIR) in Washington, D.C., which was founded in 

1893 as the first Army Medical School; the Tropical 

Medicine Course at that school was launched in 1941 and 

persevered until 1993. The Navy also ran a separate 

program, The Navy’s Medicine in the Tropics Course and 

in the 1990s it became a joint Army-Navy endeavor and is 

now known as the U.S. Military Tropical Medicine (MTM) 

Course, Navy Medicine Professional Development Center, 

at the Uniformed Services University (USU) in Bethesda, Md. In 2010, due 

to operational needs of the Special Operations Command and the newly 

formed Africa Command, the WRAIR course was re-established. The USU 

and WRAIR courses have different goals and target distinct audiences, yet 

they are complementary in nature and share some of the same lecturers and 

faculty.2

The current Director of the MTM Program is Dr. Nehkonti Adams, LCDR, USN. Medical 

providers in Djibouti recently had the privilege to attend one of the MTM’s mobile training 

courses at Camp Lemonnier, Djibouti (CLDJ) and spent three days under the tutelage of Dr. 

Adams. During the span of the three days, several of the instructors repeatedly used the phrase 

“history does not repeat itself, but it does rhyme.” As we explore the evolution of tropical 

medicine and during that process review diseases associated with military campaigns, we clearly 

see this “rhyming” in action as we recognize a world today, not identical but similar, to one a 

century earlier.

 

1 Beaumier, Coreen M., Gomez-Rubio, Ana Maria, Hotez, Peter J., Weina, Peter J., “United States Military 

Tropical Medicine: Extraordinary Legacy, Uncertain Future.” PLoS Neglected Tropical Diseases 7(12) (Dec 2013),

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3873258/ (accessed May 29, 2018).

2 Coldren, Rodney L. COL, Brett-Major, David M. CDR, Hickey, Patrick W. LTC, Garges, Eric Maj, Weina, Peter 

J. COL, Corrigan, Paula COL, Quinnan, Gerald RADM, “Tropical Medicine Training in the Department of Defense.” 

Military Medicine 177, 4:361 (2012) 

https://www.researchgate.net/publication/224976084_Tropical_Medicine_Training_in_the_Department_of_Defe

nse (accessed June 2, 2018).
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MAJOR TROPICAL DISEASES IN U.S. MILITARY WARS AND CONFLICTS –

HIGHLIGHTS (See tables in Annex A, all of the following extracted from articles in U.S.

National Library of Medicine National Institutes of Health3). 

Statistics of morbidity and mortality from tropical diseases, especially during early wars vary 

somewhat, however studies show a prevalence of certain major tropical diseases during U.S. 

conflicts throughout history. Additionally, some conditions have longer-term health 

ramifications, even if treated. 

Cases of malaria were rampant during World War I, II, Korean War and Vietnam War. There 

were reported cases during Operations Desert Shield and Storm, UN Operation Restore Hope in 

Somalia, Operations Enduring Freedom, Iraqi Freedom and New Dawn, Operation Sheltering 

Sky and USAID efforts in Liberia. During conflicts 2001-present (as of 2013) malaria incidence 

of occurrence was 52.4 cases per 1,000, diagnosed with a median time of 233 days AFTER 

return to the U.S. In 2003, 44% of 268 Marines deployed to Liberia became infected with 

malaria, 40 had to be evacuated, four of them with severe symptoms. In 2009 a Seabee deployed 

to Liberia died from malarial complications (P. falciparum). The number of cases were 

substantially less than earlier conflicts, however still occurred and resulted in loss of man days 

and life. The sequelae of malarial relapse was initially an issue, however with treatment of the 

dormant life stages in the liver now available, recurrences are few. Those who are/were 

unfortunate to have contracted P. falciparum type with cerebral infection have risk of longer 

term neurological effects. 

Dysentery and diarrhea afflicted over 700,000 troops during WWII. Diarrheal disease occurred 

in greater than 50% of U.S. troops during Operations Desert Shield/Storm, in 77% of soldiers in 

Iraq and 54% of those in Afghanistan. There is increasing evidence that bacterial intestinal 

infections increase risk for autoimmune illness, gastrointestinal complications and extraintestinal infectious disease may trigger certain chronic diseases.4

Dengue was the third most frequently reported tropical infection during WWII, cause of up to 

80% of fevers during the Vietnam War, smaller numbers reported during Operation Restore 

Hope in Somalia and Operation Uphold Democracy in Haiti.

Leishmaniasis cases were reported during WWII; cutaneous and visceral cases were reported 

during Operations Desert Shield/Storm and during deployments into Iraq and Afghanistan. 

Cutaneous leishmaniasis was also a considerable problem for those training in the jungles in 

Panama. During Operation Iraqi Freedom, more than 1,700 personnel were diagnosed with 

 

3 Beaumier, Coreen M., Gomez-Rubio, Ana Maria, Hotez, Peter J., Weina, Peter J., “United States Military 

Tropical Medicine: Extraordinary Legacy, Uncertain Future.” PLoS Neglected Tropical Diseases 7(12) (Dec 2013), 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3873258/ (accessed May 29, 2018).

4 Ternhag A., Torner Anna, Svensson A., Ekdahl K., Johan G., “Short-and Long-term Effects of Bacterial 

Gastrointestinal Infections.” Medscape Family Medicine

https://www.medscape.com/viewarticle/568616?pa=bDlRw9xP9bFVoO8tOZCsLKN8b9LJlF62qZbRdXjM1B0fkJ4%2F

UVHag52NAaiSnCGD8SIvl8zjYv73GUyW5rsbWA%3D%3D (accessed June 4, 2018).
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leishmaniasis and many required evacuation for treatment.5 There are several types of 

leishmaniasis, depending on parasite. Skin sores from the cutaneous type can heal on their own, 

however this can takes months to years. Some types of cutaneous leishmaniasis may spread to 

the mucus membranes and this may not be noticed until years after the skin ulcers have healed. 

Again depending on type of leishmaniasis parasite, some types if untreated can lead to visceral 

(internal organs) infection and often are fatal.6 Depending on the type of parasitic strain, 

treatment can have side effects and may require hospitalization for monitoring.

Hookworms infected greater than 20% of the U.S. forces during Operation Urgent Fury in 

Grenada.

As we can see, the major tropical infections inflicting harm upon U.S. troops during past and 

more recent conflicts include intestinal infections by bacteria and amebic dysentery, soiltransmitted worms (e.g. hookworm), vector-borne diseases including malaria (falciparum and 

vivax) and dengue, and both types of leishmaniasis. The U.S. Army Medical Research and 

Materiel Command (MRMC), who is responsible for ensuring U.S. forces are able to remain in 

peak health and are equipped to protect themselves from disease and injury especially on the 

battlefield,7 applies Armed Forces Medical Intelligence to quantitative algorithms to identify the 

most significant infectious disease risks to deployed troops.8 The MRMC’s most recent expert 

panel in April 2010, by utilizing this algorithmic method, determined the top priorities of 

infectious disease threats are malaria, bacteria-caused diarrhea, dengue fever and leishmaniasis.9 

Although accuracy of data and methods of gathering differ, one can see a similar thread of 

disease through military history. 

 

5

“Military Infectious Diseases Research Program (MIDRP).” 

http://mrmc.amedd.army.mil/index.cfm?pageid=medical_r_and_d.midrp.overview (accessed June 2, 2018).

6

“Parasites – Leishmaniasis.” Centers for Disease Control and Prevention

https://www.cdc.gov/parasites/leishmaniasis/gen_info/faqs.html (accessed June 4, 2018).

7

“About MRMC”, last modified Date: 18 Jun 2013, http://mrmc.amedd.army.mil/index.cfm?pageid=

about.overview (accessed May 31, 2018).

8 Burnette WN., Hoke CH. Jr., Scovill J., Clark K., Abrams J., Kitchen LW., Hanson K., Palys TJ., Vaughn DW., 

“Infectious Diseases Investment Decision Evaluation Algorithm: A quantitative Algorithm For Prioritization of 

Naturally Occurring Infectious Disease Threats to the U.S. Military.” PubMed.gov U.S. National Library of Medicine 

National Institutes of Health, Abstract: (2008 Feb; 173(2), https://www/ncbi.nlm.nih.gov/pubmed/18333494

(accessed May 28, 2018).

9 Beaumier, Coreen M., Gomez-Rubio, Ana Maria, Hotez, Peter J., Weina, Peter J., “United States Military 

Tropical Medicine: Extraordinary Legacy, Uncertain Future.” PLoS Neglected Tropical Diseases 7(12) (Dec 2013), 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3873258/ (accessed May 29, 2018).
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MILITARY TROPICAL MEDICINE COURSE in Djibouti

The Navy Medicine Professional Development Center 

joined with CJTF-HOA Surgeon Cell to offer a three 

day MTM course 15-17 May 2018. In addition to the 

Director, Dr. Adams, there were also lecturers from 

the WRAIR, 6th Fleet Force Health Protection Office, 

HOA Surgeon Cell, HOA’s Civil Affairs Functional 

Specialty Unit (FxSP), and the Naval Medical 

Research Unit (NAMRU) in Ghana; the speakers were 

all graduates of the MTM Program. 

Out of the five “W’s”, the WHO and the WHY are worth further discussion. Medical 

professionals from all U.S. military services, foreign militaries and local personnel have attended 

past courses. The most recent course in May 2018 included personnel from AFRICOM, 

USARAF, USMC providers in country providing support to security cooperation efforts, medical 

personnel from nearby Japanese and French camps, civilian medical personnel supporting HOA 

tactical units downrange and the Medical Officer from the U.S. Embassy Djibouti. The end state 

of the MTM course is to increase Force Health Protection (FHP) and troop readiness, just as FHP 

was a primary end state for Britain and U.S. interests in tropical diseases more than a century 

ago. A more immediate objective in achieving the end state is to provide medical personnel 

relevant knowledge and understanding to address medical issues specific to deployment areas, 

especially for those who may be a considerable distance from a military base.10 U.S. Air Force 

Captain Marilou Mote, a previous CJTF-HOA Environmental Health Officer stated “knowing 

the risks can help them determine between illnesses that share some of the same symptoms, like 

the flu versus malaria.” The course includes not only information about cause, symptoms, 

diagnosis and treatment, but also focuses on counter-measures. ‘An ounce of prevention is worth 

a pound of cure’ and prevention and FHP is an important force multiplier.11 Secondarily, the 

three days of fellowship with other providers gave opportunity to share knowledge and 

experiences, to build networking and to enhance alliances with our multi-national and 

governmental partners that otherwise may not have occurred.

The three-day course is conducted every six months at CLDJ, in order to incorporate medical 

personnel as they rotate into theater; medical professionals from all geographic regions and 

experiences are welcome to attend. As LCDR Nehkonti Adams, Director so aptly stated, “The 

world is becoming more interconnected, in that our militaries are participating in more 

 

10 Cunningham, Jill LCDR, “Military Tropical Medicine Course Provides Valuable Training.” The Journal (24 

Aug 2017) http://www.dcmilitary.com/journal/features/military-tropical-medicine-course-provides-valuabletraining/article_102089cf-9cba-5c5b-b2b7-7c3abeb9e08f.html (accessed May 21, 2018).

11 “Military Infectious Diseases Research Program (MIDRP).” 

http://mrmc.amedd.army.mil/index.cfm?pageid=medical_r_and_d.midrp.overview (accessed June 2, 2018).
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humanitarian, disaster relief and crisis-response missions. Preparing our practitioners in cases of 

tropical medicine is essential to mission success. The program must involve providers across the 

services, as well as foreign militaries and civilian collaborators in order to succeed.” 
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Annex-A, Major Tropical; Diseases in U.S. Military Wars and Conflicts

MAJOR TROPICAL DISEASES IN U.S. MLITARY WARS AND CONFLICTS

War/

Conflict

Years Major Areas Tropical Disease Estimated or Reported Number of Cases

World War I 1917-18 Americas and 

Caribbean

Malaria 27,203 malarial admissions

World War II 1942-45 South Pacific, 

especially New 

Guinea, the 

Philippines, other 

Pacific Islands

Dysentery and diarrhea

Malaria

Dengue

Hookworm

Lymphatic filariasis

Sandfly fever

Scrub typhus

Amebic dysentery

Schistosomiasis

Endemic typhus

Leishmaniasis

Strongyloidiasis

756,849

 

572,950

121,608

19,943

14,009

12,634

7,421

4,504

1,672

893

361

Not determined
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MAJOR TROPICAL DISEASES IN U.S. MLITARY WARS AND CONFLICTS

War/

Conflict

Years Major Areas Tropical Disease Estimated or Reported Number of Cases

Korean War 1950-53 Korea Malaria

Hantaan virus

Japanese encephalitis

>34, 864 admissions

1,600 cases w/renal syndrome

Not determined

Vietnam War 1964-73 Vietnam Malaria

Dengue

Chikungunya

Hepatitis A

Scrub Typhus

Melioidosis

Leptospirosis

Amebic dysentery

Hookworm

Strongyloidiasis

65,053 admissions

Up to 80% of fevers of unknown origin

Not determined

Not determined

Not determined

Not determined

Not determined

Not determined

Not determined

Not determined

MAJOR TROPICAL DISEASES IN U.S. MLITARY WARS AND CONFLICTS

War/Conflict Years Major Areas Tropical Disease Estimated or Reported 

Number of Cases

Operation Urgent Fury 1983 Grenada Hookworm >20%

Jungle Training 

Panama

1980’s Panama Cutaneous 

leishmaniasis

Not determined
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MAJOR TROPICAL DISEASES IN U.S. MLITARY WARS AND CONFLICTS

War/

Conflict

Years Major Areas Tropical Disease

Estimated or Reported Number 

of Cases

Operations Desert 

Shield and Storm 

1991-92 Iraq, Kuwait, Saudi 

Arabia

Diarrhea

Cutaneous 

leishmaniasis

Visceral leishmaniasis

Malaria

Q fever

>50%

19

12

7

3

MAJOR TROPICAL DISEASES IN U.S. MLITARY WARS AND CONFLICTS

War/

Conflict

Years Major Areas Tropical Disease

Estimated or Reported Number of 

Cases

UN Operation Restore 

Hope 

1992-93 Somalia Malaria

Dengue

112

Not determined

Operation Uphold 

Democracy 1994 Haiti Dengue 342 seropositive

MAJOR TROPICAL DISEASES IN U.S. MLITARY WARS AND CONFLICTS

War/

Conflict

Years Major Areas Tropical 

Disease

Estimated or Reported Number of Cases

Operations 

Enduring 

Freedom, Iraqi 

Freedom, New 

Dawn

2001-present 

(as of 2013) Afghanistan

Iraq

Diarrhea

Q fever

Malaria

Cutaneous 

leishmaniasis 

(various 

subtypes)

Visceral 

leishmaniasis

Brucellosis

77% Iraq; 54% Afghanistan

Outbreaks in Iraq

Vivax type attack rate of 52.4 cases per 1,000 

soldiers among Army Rangers deployed to 

eastern Afghanistan

0.23% of deployed US ground forces in 

Operation Iraqi Freedom; 2.1% among a 2004 

survey of 15,549 US military personnel deployed 

to one or more operations

At least 9 cases 

 

3 cases