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On 29 April 1996, a 21-year-old white male, active-duty Army soldier was admitted to Walter Reed Army Medical Center (WRAMC) due to severe iron deficiency anemia. Upon admission his hemoglobin (Hb) was 7.6 g/dL, with a hypochromic, microcytic anemia of seven months duration, intermittent diarrhea, and symptoms of hypovolemia. The patient was born and raised in Michigan. He entered basic training at Ft. McClellan, Alabama, in 1993 and completed advanced individual training there. In January 1994, he was stationed at Ft. Drum, New York. Since his arrival, his only travel outside the continental United States was to the Jungle Operations Training Center (JOTC), Panama, in June 1995. While in Panama, he spent his first week in the cantonment area in classroom training. During the second week, he was outside the cantonment area during the day but returned to the barracks to sleep. During the third week, he was out of the cantonment area for 4-5 days. During this time, he slept on his sleeping mat, taking off only his BDU blouse. He recalled only limited direct contact with soil, e.g., placing his hand on the ground while rising to a standing position. During the exercise, he typically sat or laid on the ground fully clothed with sleeves down while awaiting the arrival of patrolling forces. He noted that the ground in the training areas smelled of feces, though he did not see formed stool. While in the field, he slipped into and immediately climbed out of a small, deep hole filled with chest deep water. The barracks in Panama were infested with insects upon the unit's arrival, but they were cleaned soon thereafter. He ate at several local establishments without gastrointestinal problems. Two weeks after his return from Panama, he experienced non-bloody, brown, watery diarrhea lasting approximately seven days. He was evaluated at the Troop Medical Clinic (TMC) and returned to duty. He continued to have sporadic loose bowel movements approximately every two weeks., Pub. in Medical Surveillance Monthly Report (MSMR), v2 n6, p1-16, July 1996.

Following a joint training exercise at Ft Bragg (Operation "Purple Star") and Camp Lejeune (Operation "Royal Dragon"), twenty-eight British paratroopers from a unit of 400 (7%) developed a rash illness of unknown etiology. The total contingency involved in the joint exercise, which took place between 25 April and 20 May 1996, included approximately 10,000 soldiers. Only one British unit developed symptoms; there were no reported cases among U.S. soldiers who participated in the exercise. The epidemiologist/microbiologist at the Royal Haslar Hospital, in conjunction with the Communicable Disease Surveillance Centre (CDSC), conducted an outbreak investigation and determined that two distinct types of skin rashes were involved, with the date of onset of symptoms approximately 5 June 1996. Preliminary data from a questionnaire was analyzed and it was determined that The affected soldiers parachuted into the Camp Mackall area located on Ft Bragg and bivouacked around the Luzon Drop Zone, a heavily forested area. Nymphal ticks were removed by some of the British soldiers, all of whom carried tick identification cards and were instructed in the use of permethrin-impregnated uniforms. Three soldiers had a febrile illness associated with a petechial rash resembling Rocky Mountain Spotted Fever (RMSF) and the remaining 25 soldiers had a rash described as a localized, expanding circular rash, similar to erythema migrans (EM). The involved soldiers were treated with Doxycycline 200 mg daily for 14 days. All clinical cases had serological tests for a variety of possible infective agents including Lyme, RMSF, Ehrlichia, and Leptospira. Only one specimen was found positive for RMSF. All serological tests for Borrelia burgdorferi (tickborne spirochete causing Lyme disease) were negative. The final results of the data analysis are pending and a case-control study to delineate other risk factors is underway., Pub. in Medical Surveillance Monthly Report (MSMR), v2 n7, p1-12, September 1996.

The morning of 3 September 1996, the Environmental Health Epidemiology Technician at Ft. Belvoir notified the Community Health Nursing Department of a 3-year-old child that had a positive stool culture with Shigella sonnei. It was also learned that the child was enrolled in a daycare center on post. This was of particular concern because daycare centers, particularly those with diapered children, are considered ideal settings for the spread of shigellosis. The director of the daycare center was notified about the potential spread of shigella among children at the daycare center. Later that day, the director called the community health nurse about another child with diarrhea from the same preschool room. It was also discovered that the father of this child had been experiencing diarrhea for approximately 4 days. During the afternoon of 3 September 1996, the daycare center was inspected and the director informed the community health nurse that an employee from the same preschool room had called in sick that day. A telephone call to this individual confirmed that she was symptomatic with diarrhea. The employee also mentioned that 2 other employees from the same preschool room had been sick with diarrhea over the weekend. The community health nurse recommended that all individuals symptomatic with diarrhea submit stool specimens., Pub. in Medical Surveillance Monthly Report (MSMR), v2 n9, p1-12, November 1996.

Outbreaks of febrile acute respiratory disease (ARD) have occurred throughout the history of the military, particularly during fall-winter seasons. ARD outbreaks, sometimes massive, have often disrupted training and overwhelmed local medical support at mobilization and basic training centers. In the 1960s, it was demonstrated that adenoviruses, particularly types 4 and 7, were predominant causes of ARD among Army basic trainees. In 1966, a surveillance system was established at Army training centers to monitor the safety, efficacy, and side effects of the then new adenovirus vaccines . For more than thirty years since then, the Army has conducted surveillance of febrile acute respiratory diseases among basic trainees. For this program, a case of ARD is defined as a trainee who is hospitalized with fever (oral temperature > 100.5F) and a sign or symptom of acute respiratory tract inflammation. Figure 1 shows the large decline in ARD rates among Army trainees following 1984, the year the Army began year-round use of adenovirus vaccines. Since then, ARD rates have declined slowly but persistently culminating in the lowest annual rate ever recorded in 1996 (0.19 per 100 trainee-weeks). Figure 2 is an overlay of plots of weekly ARD rates at individual training centers during the last ten years. This display shows that ARD outbreaks have been infrequent, particularly in the last five years. In addition, figure 2 shows that the seasonally adjusted baseline (around which rates of individual centers vary) and magnitudes of fall-winter peaks have slowly but persistently declined over the past decade. In this edition, there is a detailed update of the Army's ARD surveillance experience for calendar years 1995 and 1996., Medical Surveillance Monthly Report (MSMR). Volume 2, Number 10, December 1996