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U.S. Casualties in Operation Iraqi Freedom May 2005 - History

U.S. Casualties in Operation Iraqi Freedom May 2005 - History


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U.S. Casualties in Operation Iraqi Freedom
May 2005

82Total Casualties
#Service MemberAgeDate
1Spc. Derrick J. Lutters2401 May 2005
2Sgt. John E. McGee3602 May 2005
3Maj. John C. Spahr4202 May 2005
4Capt. Kelly C. Hinz3002 May 2005
5Staff Sgt. Tommy S. Little4702 May 2005
6Sgt. Stephen P. Saxton2403 May 2005
7Staff Sgt. William J. Brooks3003 May 2005
8Lance Cpl. Michael V. Postal2107 May 2005
9Sgt. Aaron N. Cepeda Sr.2207 May 2005
10Lance Cpl. Lance T. Graham2607 May 2005
11Sgt. Michael A. Marzano2807 May 2005
12Petty Officer Third Class Jeffery L. Wiener3207 May 2005
13Sgt. Gary A. Eckert Jr.2408 May 2005
14Spec. Steven R. Givens2608 May 2005
15Cpl. Dustin A. Derga2408 May 2005
16Lance Cpl. Lawrence R. Philippon2208 May 2005
17Staff Sgt. Thor H. Ingraham2408 May 2005
18Pfc. Nicolas E. Messmer2008 May 2005
19U/I pending notification of next-of-kin09 May 2005
20Pfc. Baldwyn1909 May 2005
21Lance Cpl. Taylor B. Prazynski2009 May 2005
22Lance Cpl. Marcus Mahdee2009 May 2005
231st Sgt. Michael J. Bordelon3710 May 2005
24Staff Sgt. Kendall H. Ivy II2811 May 2005
25U/I pending notification of next-of-kin11 May 2005
26Lance Cpl. Wesley G. Davids2011 May 2005
27Lance Cpl. John T. Schmidt III2111 May 2005
28Staff Sgt. Samuel T. Castle2611 May 2005
29Pfc. Christopher R. Dixon1811 May 2005
30Lance Cpl. Nicholas B. Erdy2111 May 2005
31Lance Cpl. Jonathan W. Grant2311 May 2005
32Lance Cpl. Jourdan L. Grez2411 May 2005
33U/I pending notification of next-of-kin12 May 2005
34Sgt. Andrew R. Jodon2712 May 2005
35Pfc. Kenneth E. Zeigler II2212 May 2005
36Sgt. John M. Smith2212 May 2005
37Pfc. Travis W. Anderson2813 May 2005
38Sgt. Charles C. Gillican, III3514 May 2005
39Sgt Jacob M. Simpson2416 May 2005
40Pfc. Wesley R. Riggs1917 May 2005
41Sgt. Antwan L. Walker2218 May 2005
42Pfc. Wyatt D. Eisenhauer2619 May 2005
43Spec. Bernard L. Sembly2519 May 2005
44Sgt. Robin V. Fell2219 May 2005
45Sgt. Brad A. Wentz2120 May 2005
46Sgt. Kurt D. Schamberg2620 May 2005
47Sgt. Benjamin C. Morton2422 May 2005
481st Lt. Seesan2522 May 2005
49Spc. Tyler L. Creamean2122 May 2005
50Sgt. Carl J. Morgain4022 May 2005
51Sgt. John B. Ogburn III4522 May 2005
52Sgt. Kenneth J. Schall2222 May 2005
53Sgt. Charles T. Wilkerson3022 May 2005
54Spec. Bryan Edward Barron2623 May 2005
55Spec. Audrey Daron Lunsford2923 May 2005
56Staff Sgt. Saburant Parker4323 May 2005
57Sgt. Daniel Ryan Varnado2323 May 2005
58Spc. Joshua T. Brazee2523 May 2005
59Sgt. Christopher S. Perez3023 May 2005
60Staff Sgt. Russell J. Verdugo3423 May 2005
61Sgt. Charles A. Drier2824 May 2005
62Spec. Dustin C. Fisher2224 May 2005
63Pfc. Jeffrey R. Wallace2024 May 2005
64Sgt. 1st Class Peter J. Hahn3124 May 2005
65Sgt. First Class Randy D. Collins3624 May 2005
66Sgt. Alfred B. Siler3325 May 2005
67Sgt. David N. Wimberg2425 May 2005
68CW4 Matthew Scott Lourey4026 May 2005
69CW2 Joshua Michael Scott2826 May 2005
70Maj. Ricardo A. Crocker3926 May 2005
71Sgt. Mark A. Maida2227 May 2005
72First Sgt. Michael S. Barnhill3928 May 2005
73Spc. Phillip N. Sayles2628 May 2005
74Lt. Col. Albert E. Smart4128 May 2005
75Staff Sgt. Victor M. Cortes III2929 May 2005
76Maj. William Downs4030 May 2005
77Capt. Jeremy Fresques2630 May 2005
78Capt. Derek Argel2830 May 2005
79Staff Sgt. Casey Crate2630 May 2005
80Cpl. Jeffrey B. Starr2230 May 2005
81Sgt. 1st Class Steven M. Langmack3331 May 2005
82Sgt. Miguel A. Ramos3931 May 2005

Repeated concussion among U.S. military personnel during Operation Iraqi Freedom.

Traumatic brain injury (TBI) is one of the predominant injuries of the current military conflicts in Iraq and Afghanistan, with prevalence ranging from 15 to 20 percent depending on the diagnostic criteria and patient population [1-7]. A majority of these injuries, 85 percent in one study, are mild concussions resulting from exposure to blasts [1-4,7]. Because military personnel with mild injuries are often returned to full duty status shortly after the injury-causing event, understanding the lasting effects on cognitive and physical functions, as well as the risks associated with repeat injury, is of significant importance [8].

Although research describing the effects of repeated concussions in military populations is limited, civilian literature points to several detrimental physical, cognitive, and emotional health effects of incurring multiple concussions [9-13]. Evidence exists that some aspects of neurocognitive function do not recover as quickly in those who have experienced multiple concussions, and some studies suggest a permanent reduction in cognitive performance [14-15]. One recent study showed greater reduction in neurological activity among persons with two concussions, with reduced time between concussive events acting as an important mediator [16].

The aims of the present study were to (1) provide a descriptive analysis of repeated concussion in U.S. military personnel, (2) identify whether decreased time between events is associated with increased severity of the second event, and (3) identify predictors of postinjury utilization of mental health and neurology outpatient services following the second concussive event.

The present study was an analysis of servicemembers with repeated concussions that were reported in the Expeditionary Medical Encounter Database (EMED) (formerly the Navy-Marine Corps Combat Trauma Registry). The EMED is a deployment health database maintained by Naval Health Research Center (NHRC), San Diego, California, and consists of documented clinical encounters of deployed military personnel from all service branches (a more extensive description of the EMED can be found elsewhere [17]).

Clinical EMED records were completed by medical providers stationed at forward-deployed Navy-Marine Corps military treatment facilities that were located in Iraq to treat Operation Iraqi Freedom casualties. Unique aspects of the EMED include detailed information regarding the injury incident, which is collected at or near the point of occurrence, as well as the inclusion of persons with otherwise mild injuries who are subsequently returned to duty. Clinical records are provided to NHRC, and professional coders review the records and assign codes using the Abbreviated Injury Scale (AIS) Injury Severity Score (ISS) and International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9CM) [18-20].

For the present study, eligible personnel were servicemembers who sustained two or more provider-diagnosed concussions during Operation Iraqi Freedom from March 2004 to April 2008. A concussion was defined by the presence of an ICD-9-CM code of 850.0 to 850.9. Severity of concussion was defined using the AIS, which is a scoring system that details the severity of each injury and is categorized into nine different body regions (i.e., head, neck, face, torso, abdomen, spine, upper limb, lower limb, and external) [18]. All personnel in the study sustained concussions corresponding to a maximum head AIS of 1 (minor injury) or 2 (moderate injury). At the time of the present study, 113 of 14,653 individuals in the EMED with combat or noncombat injury met the inclusion criteria and comprised the study sample. Overall injury severity for each servicemember was determined with the ISS, which is derived from the AIS and ranges from 0 to 75 [19]. Because of a small number of individuals with more than two concussive events (n = 6), analysis was restricted to the first two events.

Age, military rank, branch of service, and occupational specialty at the time of the initial concussive event were abstracted from the EMED clinical record and validated with information from the Defense Manpower Data Center, which maintains administrative records for all military personnel. Military rank was categorized as junior enlisted (E1-E3), midlevel enlisted (E4-E5), senior enlisted (E6-E9), and officer/warrant officer. Branch of service was categorized into Marine Corps, Army, and Navy. Occupation was defined as infantry or other/unknown based on indication of an infantry-related job specialty (general infantry, rifleman, mortarman, missileman, or machine gunner).

Type of injury was categorized as combat, injury as a result of hostile action, or noncombat, defined as injury resulting from nonhostile action. Injury mechanism was indicated on the EMED clinical record and was categorized into "blast" or "nonblast." Loss of consciousness (LOC) information was available for 73.4 percent (83 of 113) of initial concussive events and 74.3 percent (84 of 113) of second concussive events.

Time between events was calculated by subtracting the dates of injury for the first and second concussive event for each individual. This difference in injury dates was then used to establish three cutoff points in order to explore how time between events might be associated with injury severity and healthcare utilization. As per previous literature, the first and second cutoff points explored differences between those with concussive events that occurred (1) less than or equal to 2 weeks or greater than 2 weeks apart and (2) less than or equal to 3 months or greater than 3 months apart [21]. We used a third cutoff point, median time between events, in order to apportion comparison groups equally.

Severity of Second Injury

A variable was created to indicate whether the second concussive event was more severe than the first event according to the head AIS (i.e., head AIS increased from 1 to 2).

Because the most common symptoms after a concussion are cognitive (decreased memory, attention, and concentration), somatic (headache, fatigue, insomnia, dizziness, tinnitus, and sensitivity to noise or light), and affective (depression, irritability, and anxiety), utilization of mental health and neurology services was examined [22]. Utilization of mental health and neurology outpatient services was identified from the Standard Ambulatory Data Record (SADR) database. The SADR electronic database contains a Medical Expense and Performance Reporting System code for each outpatient visit, which indicates the type of clinic for each patient encounter.

It is standard practice for military personnel to be referred for a follow-up visit postinjury. To capture true utilization of healthcare due to continuing problems beyond the initial follow-up, we defined utilization as two or more visits to mental health (identified as psychology, psychiatry, mental health, or substance abuse) or neurology clinics within 24 months of the second concussion. Mental health and neurology utilization were examined separately. Personnel with more than two documented concussions (n = 6) were restricted from this analysis. Other types of healthcare utilization were examined for descriptive purposes and included primary care, general medicine/surgery, physical or occupational therapy, audiology, and other.

All statistical analyses were performed using SPSS, version 17.0 (SPSS Inc Chicago, Illinois). Comparisons between concussive events were conducted using Wilcoxon signed rank and McNemar tests for dependent samples. The association of time between events and increased severity at the second concussive event was assessed using chi-square and Fisher exact tests. Healthcare utilization was described by number of clinic visits in the first and second years following the second concussive event. Age-adjusted logistic regression analysis was used to examine the predictive effect of concussion severity and time between events on utilization of mental health and neurology outpatient services.

Demographic statistics for the study sample are summarized in Table 1. The study sample consisted of 113 servicemembers injured during deployment in Operation Iraqi Freedom. The median age was 21 years (range 18-39) and consisted primarily of Marines (92.0%). Overall, 94.7 percent (n = 107) experienced two concussive events and 5.3 percent (n = 6) experienced three or four. At the time of the first event, the majority were in infantry positions and junior enlisted.

Types of concussion at the first and second event are detailed in Table 2. Of those in which presence or absence of LOC could be confirmed, a majority did not experience LOC at either the first (57 of 83, 69%) or second (51 of 84, 61%) event. Overall, 68 individuals had confirmed presence or absence of LOC for both concussive events. Of these, more than half (14 of 23) who experienced LOC at their first event also experienced confirmed LOC at their second, compared with only 29 percent (13 of 45) of personnel without LOC at their first event, although this difference was not statistically significant (McNemar p-value = 0.52).

Results shown in Table 3 compare injury-specific characteristics of the first and second concussive events. For both the first and second event, over 90 percent were combat-related and caused by blast mechanisms. No statistical differences were found between the first and second event by type and mechanism of injury or maximum head AIS and ISS. Overall, 16 percent (18 of 113) had an increase in head AIS at the second concussive event.

The median time between events was 40 days (range 2-753, interquartile range 20-75), with 19 percent (22 of 113) of repeated concussive events occurring within an interval of 2 weeks and 87 percent (98 of 113) occurring within 3 months. As shown in Table 4, the time between repeated concussive events at the median, 2-week, and 3month intervals was not associated with an increase in head AIS from the first to second event.

Healthcare utilization for the 107 personnel with only two concussions is shown in Table 5. General medicine/ surgery accounted for the largest proportion of healthcare visits in the first year following repeat concussion, while primary care visits accounted for the largest proportion in the second year. Table 6 displays both unadjusted and adjusted results of the mental health and neurology utilization regression analysis. Utilization of mental health and neurology outpatient services was indicated for 17 percent (n = 18) and 33 percent (n = 35) of personnel, respectively. In age-adjusted logistic regression analysis, time between events was not associated with an increase in clinic utilization. Severity of second concussive event, however, was significantly associated with mental health (odds ratio [OR] = 4.74, 95% confidence interval [CI] = 1.52-14.75, p-value = 0.01) and neurology (OR = 3.41, 95% CI = 1.32-8.75, p-value = 0.01) clinic utilization. Results did not change after including severity of first event, severity of second event, time between events, and age together in one multivariable model.

Concussions are common among U.S. military personnel serving in Iraq and Afghanistan. Though multiple studies have detailed the occurrence of combat-related TBI, the present study extends the analysis to those with repeated concussive events. A key finding was the high proportion of repeated concussions that occurred within a short period of time, as high as 20 percent within 2 weeks and 87 percent within 3 months of the first event. One previous study among professional football players found repeated concussions occurred among 4 percent and 20 percent of the sample at 2 weeks and 3 months, respectively [21]. Another study in college football players found that 9 of 12 players who had within-season concussions experienced the repeat concussion within 1 week of the initial concussion [23]. Unfortunately, neither of these studies assessed the effect of time between concussions on concussion severity or healthcare utilization.

In our analysis, healthcare utilization was not statistically associated with severity of the initial concussive event. A statistically positive association was found, however, between increased severity of the second event and mental health and neurology clinic utilization. These findings suggest that the most recent concussive event, as opposed to cumulative effects of concussions, may be more predictive of subsequent healthcare utilization. Alternatively, comparing personnel with multiple concussions to personnel with a single concussive event may be more effective in elucidating any cumulative effects and should be a focus of future research. Because a recent policy change proposed by the Chairman of the Joint Chiefs of Staff would restrict personnel to noncombat duty following their third concussion, further research is needed on the effects of repeated concussions among combat veterans. An extension of the present analysis to those servicemembers with one and more than two concussive events is warranted, in part to assess the public health implications of a concussion-limit policy and also to more clearly define the effects of two concussions, a topic on which civilian studies have yielded mixed findings [14,24-26].

Little is known about the mediating effect of time between concussive events. The time interval between the first and second concussion in the present analysis did not statistically affect healthcare utilization following the second event. It should be noted, however, that those who experienced a repeat concussion less than 3 months after their initial concussion trended toward higher odds of utilizing mental health and neurology services, but the small sample size may have limited our ability to detect a statistical association. A recent study among professional football players found no association of time between repeat concussions and number of reported postconcussive symptoms [21]. Another study found similar results, though time between events was analyzed as a dichotomous variable of less than or greater than 6 months, which may have diluted any association [27]. One recent study found evidence of a mediating effect of time, but this study used electroencephalography to directly measure brain function [14]. The severity measure used in the present study (AIS) may not have been sensitive or specific enough to show an association, and healthcare utilization may be more a reflection of willingness to present for care. As indicated by the aforementioned research, a mediating effect of time may be better studied with neurological tests or rates of self-reported symptoms following the first and subsequent concussive events. More focused research may eventually lead to policies similar to the "return-to-play" guidelines implemented in high school and collegiate athletics [28].

The greatest strength of this study was the use of provider-diagnosed cases of concussion. Most similar studies rely on self-report information, which may be subject to recall bias. Additionally, the EMED data allowed for abstraction of injury dates, from which time between events was calculated. This capability is unique because accurate dates of injury for mild concussion may not be otherwise documented, particularly in such an austere environment. The ability to link EMED data with electronic medical databases also allowed for the examination of long-term healthcare utilization.

The primary limitation of this study was the small sample size. It is possible that the lack of a larger sample precluded significant findings. In addition, only personnel who reported to and were treated at Navy-Marine Corps facilities were included in the present analysis. As such, Marines were likely overrepresented in the sample, and untreated injuries or injuries treated at other facilities, such as U.S. Army Combat Support Hospitals, were not represented. In addition, information regarding LOC was often not indicated thus missing data precluded any detailed assessment of this variable. Information related to the underlying cause of blast-related concussion, whether due to blast overpressure or resulting blunt trauma, was not available for analysis at the time of this study and may have affected results. Given adequate sample size, future research should incorporate a thorough assessment of the physical cause of concussion. Finally, although the healthcare utilization data were contingent on remaining in military service, results did not change when excluding personnel who were discharged from the military during the 2-year follow-up period (n = 3).

This is the one of the first reports of repeated concussion among military personnel in a combat-deployed setting. Although the relationship of time between events and health outcomes remains unclear, further study on the cumulative effects of multiple concussive events among military personnel is warranted and may be strengthened by a larger sample size, in addition to cognitive and neurological testing. Military personnel are at risk for repeated concussion. Detailed postconcussion outcome analysis and assessment is essential in order to improve overall well-being, maximize force readiness, and refine clinical management and treatment protocols.

Servicemembers who return to duty after a concussion are at risk of another concussion. Repeat concussions are known to have negative effects in civilians, but research in military personnel is limited. We studied the effects of repeat concussions in 113 combat veterans. We found that repeat concussions often occur within a short period of time, but time does not appear to affect severity of the second concussion or healthcare utilization. Only more severe repeat concussions were related to higher utilization of mental health and neurology services. Additional research should investigate the effects of repeat concussion on other health-related outcomes.

Study concept and design: A. J. MacGregor, A. L. Dougherty, R. H. Morrison, K. H. Quinn, M. R. Galarneau.

Acquisition of data: A. J. MacGregor, R. H. Morrison, K. H. Quinn, M. R. Galarneau.

Analysis and interpretation of data: A. J. MacGregor, A. L. Dougherty, R. H. Morrison.

Drafting of manuscript: A. J. MacGregor, A. L. Dougherty, R. H. Morrison.

Critical revision of manuscript for important intellectual content: A. L. Dougherty, K. H. Quinn, M. R. Galarneau.

Final approval of published version: A. J. MacGregor, A. L. Dougherty, R. H. Morrison, K. H. Quinn, M. R. Galarneau.

Financial Disclosures: The authors have declared that no competing interests exist.

Funding/Support: This material was based on work supported by the Congressionally Directed Medical Research Programs, Department of Defense (proposal PT090804 under work unit 61024).

Additional Contributions: The authors thank Science Applications International Corporation for its contribution to this work. They would especially like to thank data analysts Jay Walker and Kevin Heltemes for their assistance with this project. They would also like to thank Dr. Karl Van Orden for assistance with study design and Dr. Mary Clouser for assistance with manuscript review.

Institutional Review: This research was approved by the Institutional Review Board at NHRC. This research has been conducted in compliance with all applicable Federal regulations governing the protection of human subjects in research (protocol NHRC.2003.0025).

Participant Follow-Up: The authors do not plan to notify participants of the publication of this study because of a lack of contact information.

Disclaimer: The views and opinions expressed herein are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or U.S. Government.

Abbreviations: AIS = Abbreviated Injury Scale CI = confidence interval EMED = Expeditionary Medical Encounter Database ICD-9-CM = International Classification of Diseases, 9th Revision, Clinical Modification ISS = Injury Severity Score LOC = loss of consciousness NHRC = Naval Health Research Center OR = odds ratio SADR = Standard Ambulatory Data Record TBI = traumatic brain injury.

Submitted for publication January 29, 2011. Accepted in revised form August 9, 2011.

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Andrew J. MacGregor, PhD, MPH Amber L. Dougherty, MPH * Rosemary H. Morrison, MPH Kimberly H. Quinn, BS Michael R. Galarneau, MS

Department of Medical Modeling, Simulation, and Mission Support, Naval Health Research Center, San Diego, CA


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  • The Fight For The High Ground: The U.S. Army And Interrogation During Operation Iraqi Freedom I, May 2003-April 2004
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GEN David Petraeus' year-end letter to the troops

GEN Petraeus' letter is copied from the excellent Small Wars Journal.

HEADQUARTERS
MULTI-NATIONAL FORCE – IRAQ
BAGHDAD, IRAQ
APO AE 09342-1400

Soldiers, Sailors, Airmen, Marines, Coast Guardsmen, and Civilians of Multi-National Force-Iraq:

As 2007 draws to a close, you should look back with pride on what you, your fellow troopers, our Iraqi partners, and Iraqi Coalition civilians have achieved in 2007. A year ago, Iraq was racked by horrific violence and on the brink of civil war. Now, levels of violence and civilians and military casualties are significantly reduced and hope has been rekindled in many Iraqi communities. To be sure, the progress is reversible and there is much more to be done. Nonetheless, the hard-fought accomplishments of 2007 have been substantial, and I want to thank each of you for the contributions you made to them.

In response to the challenges that faced Iraq a year ago, we and our Iraqi partners adopted a new approach. We increased our focus on securing the Iraqi people and, in some cases, delayed transition of tasks to Iraqi forces. Additional U.S. and Georgian forces were deployed to theater, the tours of U.S. unites were extended, and Iraqi forces conducted a surge of their own, generating well over 100,000 more Iraqi police and soldiers during the year so that they, too, had additional forces to execute the new approach. In places like Ramadi, Baqubah, Arab Jabour, and Baghdad, you and our Iraqi brothers fought—often house by house, block by block, and neighborhood by neighborhood—to wrest sanctuaries away from Al Qaeda-Iraq, to disrupt extremist militia elements, and to rid the streets of mafia-like criminals. Having cleared areas, you worked with Iraqis to retain them—establishing outposts in the areas we were securing, developing Iraqi Security Forces, and empowering locals to help our efforts. This approach has not been easy. It has required steadfastness in the conduct of tough offensive operations, creative solutions to the myriad problems on the ground, and persistence over the course of many months and during countless trying situations. Through it all, you have proven equal to every task, continually demonstrating an impressive ability to conduct combat and stability operations in an exceedingly complex environment.

Your accomplishments have given the Iraqi people new confidence and prompted many citizens to reject terror and confront those who practice it. As the months passed in 2007, in fact, the tribal awakening that began in Al Anbar Province spread to other parts of the country. Emboldened by improving security and tired of indiscriminate violence, extremist ideology, oppressive practices, and criminal activity, Iraqis increasingly rejected Al Qaeda-Iraq and rogue militia elements. Over time, the desire of Iraqis to contribute to their own security has manifested itself in citizens volunteering for the police, the Army, and concerned local citizen programs. It has been reflected in citizens providing information that has helped us find far more than double the number of arms and weapons caches we found last year. And it has been apparent in Iraqi communities now supporting their local security forces.

As a result of your hard work and that of our Iraqi comrades-in-arms—and with the support of the local populace in many areas—we have seen significant improvements in the security situation. The number of attacks per week is down some 60 percent from a peak in June of this year to a level last seen consistently in the early summer of 2005. With fewer attacks, we are also seeing significantly reduced loss of life. The number of civilian deaths is down by some 75 percent since its height a year ago, dropping to a level not seen since the beginning of 2006. And the number of Coalition losses is down substantially as well. We remain mindful that the past year’s progress has been purchased through the sacrifice and selfless service of all those involved and that the new Iraq must still contend with innumerable enemies and obstacles. Al Qaeda-Iraq has been significantly degraded, but it remains capable of horrific bombings. Militia extremists have been disrupted, but they retain influence in many areas. Criminals have been apprehended, but far too many still roam Iraqi streets and intimidate local citizens and Iraqi officials. We and our Iraqi partners will have to deal with each of these challenges in the New Year to keep the situation headed in the right direction.

While the progress in a number of areas is fragile, the security improvements have significantly changed the situation in many parts of Iraq. It is now imperative that we take advantage of these improvements by looking beyond the security arena and helping Iraqi military and political leaders as they develop solutions in other areas as well, solutions they can sustain over time. At the tactical level, this means an increasing focus on helping not just Iraqi Security Forces—with whom we must partner in all that we do—but also helping Iraqi governmental organizations as they endeavor to restore basic services, to create employment opportunities, to revitalize local markets, to refurbish schools, to spur local economic activity, and to keep locals involved in contributing to local security. We will have to do all of this, of course, while continuing to draw down our forces, thinning our presence, and gradually handing over responsibilities to our Iraqi partners. Meanwhile, at the national level, we will focus on helping the Iraqi Government integrate local volunteers into the Iraqi Security Forces and other employment, develop greater ministerial capacity and capability, aid displaced persons as they return, and, most importantly, take the all-important political and economic actions needed to exploit the opportunity provided by the gains in the security arena.

The pace of progress on important political actions to this point has been slower than Iraqi leaders had hoped. Still, there have been some important steps taken in recent months. Iraq’s leaders reached agreement on the Declaration of Principles for Friendship and Cooperation with the United States, which lays the groundwork for an enduring relationship between our nations. The United Nations Security Council approved Iraq’s request for a final renewal of the resolution that authorizes the Coalition to operate in Iraq. Iraq’s leaders passed an important Pension Law that not only extends retirement benefits to Iraqis previously left out but also represents the first of what we hope will be additional measures fostering national reconciliation. And Iraq’s leaders have debated at length a second reconciliation-related measure, the Accountability and Justice Bill (the de-Ba’athification Reform Law), as well as the 2008 National Budget, both which likely will be brought up for a vote in early 2008. Even so, all Iraqi participants recognize that much more must be done politically to put their country on an irreversible trajectory to national reconciliation and sustainable economic development. We will, needless to say, work closely with our Embassy teammates to support the Iraq Government as it strives to take advantage of the improved security environment by pursing political and economic progress.

The New Year will bring many changes. Substantial force rotations and adjustments already underway will continue. One Army brigade combat team and a Marine Expeditionary Unit have already redeployed without replacement. In the coming months, four additional brigades and two Marine battalions will follow suit. Throughout that time, we will continue to adapt to the security situation as it evolves. And in the midst of all the changes, we and our Iraqi partners will strive to maintain the momentum, to press the fight, and to pursue Iraq’s enemies relentlessly. Solutions to many of the tough problems will continue to be found at your level, together with local Iraqi leaders and with your Iraqi Security Force partners, in company and battalion areas of operation and in individual neighborhoods an towns. As you and your Iraqi partners turn concepts into reality, additional progress will emerge slowly and fitfully. Over time, we will gradually see fewer bad days and accumulate more good days, good weeks, and good months.

The way ahead will not be easy. Inevitably, there will be more tough days and tough weeks. Unforeseen challenges will emerge. And success will require continued hard work, commitment, and initiative from all involved. As we look to the future, however, we should remember how far we have come in the past year. Thanks to the tireless efforts and courageous actions of the Iraqi people, Iraq’s political and military leaders, the Iraqi Security Forces, and each of you, a great deal has been achieved in 2007. Thus, as we enter a new year, we and our Iraqi partners will have important accomplishments and a newfound sense of hope on which we can build.

As always, all or your leaders, our fellow citizens back home, and I deeply appreciate the dedication, professionalism, commitment, and courage you display on a daily basis. It remains the greatest of honors to serve with each of you in this critical endeavor.


Operation Iraqi Freedom: Military Objectives Met

The falling statue of Saddam Hussein in Baghdad is an evocative image. It signals that the U.S.-led military action against the Hussein regime has been a success. This signal of success is backed by tangible evidence of a successful military operation in more substantive terms. This evidence is found in a review of the mission objectives for Operation Iraqi Freedom as they relate to the responsibilities of the military in meeting these objectives.

At the outset of Operation Iraqi Freedom, Secretary of Defense Donald Rumsfeld set eight mission objectives for the operation. Accounting for the fact that military is not solely responsible for meeting these objectives, it is now clear that it has conducted a successful military campaign. While civilian authorities still have significant tasks ahead of them to secure the mission objectives the military has made possible, it is now clear that the military has done its job and done it very well.

Eight Mission Objectives
At this point in time, it is appropriate to review each of the mission objectives and explain how the military has met its responsibilities and what steps are necessary by civilian authorities to secure the objectives. The eight mission objectives for Operation Iraqi Freedom are:


Gulf War and Health: Volume 5: Infectious Diseases (2007)

Several diseases and agents have been reported in the published literature or in the popular press to have infectious components and to have caused illnesses in veterans of the Gulf War, Operation Iraqi Freedom (OIF), and Operation Enduring Freedom (OEF). This chapter provides information on each of those diseases and agents&mdashAl Eskan disease, idiopathic acute eosinophilic pneumonia, wound and nosocomial infections (for example, infections caused by Acinetobacter baumannii), mycoplasmas, and biologic-warfare agents.

AL ESKAN DISEASE

In the early 1980s, King Khalid of Saudi Arabia attempted to settle Bedouins in a group of villages, including one in Riyadh called Al Eskan (Korenyi-Both et al. 1992). However, the villages were never used until the US military came to the region for Operation Desert Shield (ODSh) and Operation Desert Storm (ODSt). The 316th Station Hospital personnel lived in Al Eskan village from January 12 until March 12, 1991. Korenyi-Both and colleagues observed among the troops a vague systemic illness (causing primarily respiratory symptoms) that they termed Al-Eskan disease or Desert Storm pneumonitis (Korenyi-Both et al. 1997 Korenyi-Both et al. 1992 Korenyi-Both et al. 2000). Their investigations ascribe the illness to an immune response to sand-particle exposure (Korenyi-Both et al. 1997 Korenyi-Both et al. 2000). However, the hypotheses and conclusions of those researchers have not been uniformly accepted and have generated considerable debate (Clooman et al. 2000 Kilpatrick 2000).

During ODSh and ODSt, about 697,000 US troops were deployed. It is not possible to determine the exact number of troops affected by Al Eskan disease. However, data on respiratory illnesses in troops are available those data are summarized in detail in Chapter 4. Respiratory symptoms were more common in those with a history of lung disease, smoking, and longer deployment and they were more common in those with less outdoor exposure and most prominent in personnel who slept in air-conditioned facilities.

Among the 282 316th Station Hospital personnel who lived in the Al Eskan village, the prevalence of respiratory illness was 43% (Korenyi-Both et al. 1992). During the period September-March of 1992, the marines reported respiratory illness in 2.3% of troops, and the Air Force reported 2.6%. A brigade of a separate mechanized infantry (1,800 soldiers) conducted training in the same region of Saudi Arabia over five summer seasons and reported respiratory

illness in 0.2% of the soldiers. Al Eskan disease or a similar illness has not been reported in troops deployed to OIF or OEF.

Description of Acute Illness

Al Eskan disease was first reported in 1992 (Korenyi-Both et al. 1992). The disease is characterized by sudden or insidious onset of chills, fever, sore throat, hoarseness, nausea and vomiting, and generalized malaise and then respiratory tract complaints, including increasingly severe dry cough or expectoration of tan sputum. Some patients experience symptoms of gastroenteritis. Physical findings are minimal, and x-ray pictures on occasion reveal &ldquoatypical pneumonitis&rdquo. The disease appears to be self-limited, and less than 1% of patients with the complaints had a relapse. Systematic description and precise case definition of Al Eskan disease are unavailable.

Long-Term Adverse Health Outcomes

No data link Al Eskan disease to any specific chronic illness. In their initial report, Korenyi-Both et al. (1992) indicated that most patients had recovered within 6 weeks and that the relapse rate was less than 1%. They argued later that exposure to sand particles can serve as a source of pneumoconiosis and can stimulate a severe and perhaps chronic allergic immune response (Korenyi-Both et al. 1997 Korenyi-Both et al. 2000). They refer to such a chronic immune response as the &ldquosecond phase of Al Eskan disease&rdquo, which they imply might explain some of the health problems noted in Gulf War veterans (Korenyi-Both et al. 1997).

Pathogenesis

Military personnel deployed to the Persian Gulf are inevitably exposed to sand. Working at the Armed Forces Institute of Pathology, Irey (1994) reported birefringent sand particles in the lungs of some of 86 casualties from the Kuwait theater of operations. However, the author found no long-term lung inflammation.

Korenyi-Both et al. demonstrated that although many sand grains were agglomerated, 18% of the sample included dispersed particles in the range of 0.1-0.25 µm such particles would be expected to bypass lung defenses (Korenyi-Both et al. 1992). The sand material was extremely rich in calcium and silicon. Sand from Iraq had a calcium-to-silicon ratio of 4.2:1, and sand from Kuwait had a ratio of 3.75:1 (Korenyi-Both et al. 1997). Both the size of the sand grains and their composition differ considerably from those of sand samples harvested from other sites (for example, sand taken from Hawaii). Cultures of the sand showed some filamentous fungi, yeast, and staphylococcal species. No mycobacteria or chlamydia specimens were recovered. Contamination of sand with weapons of chemical warfare has been proposed but not studied (Korenyi-Both et al. 2000).

Korenyi-Both et al. have argued that Al Eskan disease is most likely a form of acute silicosis aggravated by the pulmonary immune response and perhaps other genetic and environmental factors (Korenyi-Both et al. 1997 Korenyi-Both et al. 1992 Korenyi-Both et al. 2000). However, there are no clinical data to support that hypothesis and no reports of chronic lung disease consistent with silicosis in veterans.

Treatment

Korenyi-Both et al. (1992) indicate that cephalosporin antibiotics and expectorants were useful and that no response to the quinolone antibiotic ciprofloxacin was observed. Supporting data were not presented.

Summary

There is no evidence that the syndrome or disease observed in troops in Al Eskan village was caused by a communicable microbial pathogen. Indeed, Koryeni-Both et al. have argued that the disease is caused by exposure to the unique sand dust of the central and eastern Arabian Peninsula and in particular to the silica in the sand. They note that given the sand-mediated damage to helicopters in the fields and silicosis in Somali camels, sand-mediated disease in humans would be expected. More than 13 years have passed since the initial description of Al Eskan disease appeared in the literature, but little progress has been made in linking chronic respiratory diseases in military personnel to exposure to Persian Gulf sand.

IDIOPATHIC ACUTE EOSINOPHILIC PNEUMONIA

Idiopathic acute eosinophilic pneumonia (IAEP) is a syndrome characterized by a febrile illness, diffuse pulmonary infiltrates, and pulmonary eosinophila (Allen et al. 1989 Badesch et al. 1989 Philit et al. 2002). Patients with IAEP have no history of asthma, allergy, or chronic lung disease and no discernable infection. Relapse is uncommon after recovery.

Severe pneumonia was reported in 19 military personnel deployed in OIF, 10 of whom had IAEP (Shorr et al. 2004). Prospective surveillance from March 2003 to March 2004 led to detection of eight additional cases of IAEP (Shorr et al. 2004). Twelve patients required mechanical ventilation, and two died. Given that 183,000 personnel were deployed in Iraq during the study period, the incidence rate of IAEP was calculated as 9.1/100,000 person-years. Of the 18 patients, 15 were in the Army, two in the Navy, and one in the Marines 16 were men. The peak incidence of IAEP was in the summer months.

Description of Acute Illness

Patients with IAEP present with fever, diffuse pulmonary infiltrates, cough, shortness of breath, and, not infrequently, respiratory failure. The case definition of IAEP requires recovery of pulmonary eosinophils in high concentration in bronchial lavage (Allen et al. 1989 Badesch et al. 1989 Philit et al. 2002). In six lavage specimens recovered from military recruits, eosinophils made up 24-75% of the cells recovered (Shorr et al. 2004). Peripheral blood eosinophilia may or may not be present and may increase during the course of illness (Shorr et al. 2004). Lung biopsies reveal acute and organizing alveolar damage with eosinophils filling alveolar and interstitial air spaces (Tazelaar et al. 1997).

Long-Term Adverse Health Outcomes

Most IAEP patients who survive the acute illness make a complete recovery. Twelve of 16 military IAEP survivors were evaluated 1-4 months after diagnosis none required corticosteroid therapy (Shorr et al. 2004). Three patients reported mild residual dyspnea and one

had wheezing. Pulmonary-function tests showed that forced vital capacity was 97% of predicted, and forced expiratory volume 94% of predicted. However, mean carbon monoxide diffusing capacity was 82% of predicted.

Pathogenesis

In many cases, IAEP has been associated with cigarette smoking and exposure to dust (Badesch et al. 1989 Pope-Harman et al. 1996 Rom et al. 2002). Shorr et al. (2004) found that the most common exposures in the IAEP-diagnosed military patients were cigarette-smoking (100%), exposure to dust or sand (94%), convoy operations (70%), and exposure to the local population (71%). However, cases were different from controls only in their tobacco exposure. All the patients were smokers and 14% were new smokers, whereas only 67% of controls were smokers and only two of seventy-two controls were new to smoking (OR 1.22, p < 0.001). Other investigators have related cigarette-smoking to IAEP (Badesch et al. 1989 Shintani et al. 2000 Watanabe et al. 2002).

Treatment

Corticosteroids are the mainstay of therapy for IAEP and most patients respond quickly to it (Allen et al. 1989 Badesch et al. 1989 Philit et al. 2002). Some patients with IAEP require mechanical ventilation.

Summary

Eighteen soldiers deployed to OIF developed IAEP. By definition, no causative pathogens were detected or implied by the immune response of soldiers with IAEP (Allen et al. 1989 Shorr et al. 2004). Toxocara canis and other helminthic pathogens known to produce eosinophilic pneumonia were specifically excluded (Roig et al. 1992 Shorr et al. 2004). Survey results failed to identify a common source of environmental, drug, or toxin exposure (Shorr et al. 2004). Rapid detection of this condition is essential for a positive outcome. IAEP would not be expected to have long-term adverse health outcomes.

WOUND AND NOSOCOMIAL INFECTIONS (INCLUDING INFECTIONS WITH ACINETOBACTER SPP.)

Soldiers can experience a wide variety of exposures to pathogens from explosives or combat (wound infections) or in health-care settings (nosocomial infections). Trends in casualty rates in modern US military warfare indicate rising wounded-to-killed ratios in the most recent wars (Department of Defense, 2005). Military personnel who might have been killed in an earlier era may now live to be hospitalized because of the use of body armor, better helmets, and more rapid emergency care. These soldiers with serious wounds can carry organisms of environmental origin (for example, from soil or water) into the hospital setting. Organisms of environmental origin that are prevalent in wound infections can colonize fomites and be transmitted to others via hospital personnel.

Nosocomial infections in military hospitals may have different microbial profiles from those in civilian hospitals in that they represent soil or water organisms prevalent in wounds suffered in explosions or combat. Nosocomial organisms that are familiar in civilian settings can

also be seen in soldiers, given the conditions prevalent in intensive-care units (ICUs) and hospital wards when universal precautions are not adhered to.

Concerns Regarding Acinetobacter baumannii

One condition that is more prevalent in OEF and OIF troops than in civilian settings is infection with Acinetobacter calcoaceticus-baumannii complex, a well-recognized cause of wound infection in general and among military troops in particular (CDC 2004 Davis et al. 2005). The complex is also a cause of nosocomially-acquired infection when wounded, infected soldiers are intermingled with other patients in the ICU, emergency room, or hospital ward. Acinetobacter spp. infection has been discovered in wounds from OEF and OIF and in European and American hospitals because of nosocomial transmission (CDC 2004 Davis et al. 2005 Joly-Guillou 2005). It is likely that wound infections become a nidus for nosocomial transmission to others, particularly in an ICU setting, because of suboptimal handwashing by hospital personnel (Joly-Guillou 2005). A. baumannii is the species isolated most often.

Acinetobacter spp. infection was described decades ago as a cause of postsurgical urinary tract infections, but in the early 21st century is seen more often as an extremity wound infection, a respiratory tract infection, or bacteremia (CDC 2004 Davis et al. 2005 Joly-Guillou 2005). The human body louse has been reported to be a likely vector (La Scola and Raoult 2004). Multiple-drug-resistant A. baumannii has been reported in troops deployed in OIF and OEF (CDC 2004 Davis et al. 2005 Zapor and Moran 2005), in Israelis hospitalized in Tel-Aviv (Abbo et al. 2005), in patients in a Brazilian tertiary referral hospital (Reis et al. 2003), and in South Korean hospital patients (Lee et al. 2003). Environmental sources are ubiquitous, including soil and river water worldwide, including in the United States (Ash et al. 2002). Examples of extremity infections include osteomyelitis, postburn lesions, open fractures, and deep wounds. The origin of Acinetobacter spp. infection can therefore be the original soil contamination due to the injury, a hospital, or, very rarely, a community source unrelated to a known wound. A patient&rsquos history and epidemiologic circumstances can indicate which source is most likely to be responsible.

Although most Acinetobacter spp. infections are not life-threatening, multiple-drug-resistant strains are now prevalent among US military troops returning from OEF and OIF (CDC 2004 Davis et al. 2005). Extended use of combination antibiotics to which the organisms are sensitive was successful in curing all patients in a case series of 23 infected US soldiers reported in 2005 (Davis et al. 2005). Among the 38 isolates obtained from these 23 men, susceptibility varied from 3% to 29% for amoxicillin-clavulanate, cefepime, cefotetan, ceftazidime, ceftriaxone, ciprofloxacin, gentamicin, tobramycin, and trimethoprim and sulfamethoxazole. About half the 38 isolates were sensitive to amikacin and to ampicillin and sulbactam. Imipenem was effective against 89% of the multiple-drug-resistant strains. Colistin was effective against 100%, but only three isolates were tested (Davis et al. 2005). To minimize the risk of nosocomial A. baumannii spread, Iraqi-based US military facilities now isolate new wound patients until results of colonization swabs are known (Davis et al. 2005). Earlier generation antibiotics that are not in widespread current use (including colistin and polymyxin B) have been administered to multiple-drug-resistant A. baumannii patients. However, A. baumannii resistant to polymyxin B was reported in Brazil in 2003 (Reis et al. 2003).

The Brooke Army Medical Center experience in San Antonio suggested a median of 6 days and a maximum of 12 days between an OIF- or OEF-acquired war injury and the presentation of Acinetobacter spp. in a defined wound or bone infection (bone, draining

purulence, or wound) (Davis et al. 2005). Of blood, urine, wound, or sputum specimens obtained from March 2003 to May 2004, 145 of 24,114 (0.6%) were positive for Acinetobacter spp. Among those sampled were 237 active-duty patients with injuries, 151 of whom had been deployed to OEF or OIF. Blood, wound, sputum, urine, and skin cultures were obtained on 84 of those deployed soldiers, and 48 of them (32%) were Acinetobacter spp.-positive. Thirty of the 237 patients were judged to have either wound injuries or related osteomyelitis the wound or bone infections represented 63% of the culture positives, 36% of all OEF- or OIF-deployed men who were cultured and hospitalized, and 20% of all those with injuries who had been deployed to OEF or OIF. Those results demonstrate that Acinetobacter spp. is a common cause of wound infection or related osteomyelitis in men hospitalized for their war-related injuries from OEF and OIF. That no soldier had more than 12 days between injury and infection is informative, although a larger series would be needed to assess more accurately what a maximal incubation period might be.

Another contemporaneous case series of 102 patients with A. baumannii bacteremia was published the cases presented in 2002-2004 at the Landstuhl Regional Medical Center (which accounted for about 78% of the patients), Walter Reed Army Medical Center (WRAMC), Brooke Army Medical Center (BAMC), National Naval Medical Center, and the US Navy hospital ship Comfort (Joly-Guillou 2005). The typical patient was a male soldier who experienced a traumatic injury in Iraq. In this multihospital series and the BAMC series, A. baumannii bacteremia was common in OEF and OIF returnees who were hospitalized for injuries, but it was rare before the start of OEF and OIF (CDC 2004 Davis et al. 2005 Zapor and Moran 2005). No late manifestations (months after injury) were reported in either case series (CDC 2004 Davis et al. 2005).

Death from A. baumannii is unusual. The only four deaths at WRAMC from 2003 to 2004 attributable to A. baumannii were in immunosuppressed patients whose ages were 35 years (renal transplantation and nosocomial pneumonia), 72 years (prolonged hospitalization with congestive heart failure), 78 years (diabetes and prior malignancy), and 84 years (in nursing home, mental status changes, and nosocomial pneumonia) (Zapor and Moran 2005). Fifty-three multiple-drug-resistant A. baumannii cases were seen at WRAMC in the 2003-2004 period, 34 in civilians and 19 in active-duty personnel. Zapor and Moran assert that successful reduction of risk to noncombatants and combatants alike who share hospital wards with infected combatants will require more rigorous universal precautions with thorough education of staff, patients, and family members.

Emerging infectious diseases, by definition, may arise from unanticipated sources. A previously unrecognized Acinetobacter-like organism from dog and cat bites was reported in 2002 (Kaiser et al. 2002). It is possible that organisms will emerge from southwest and south-central Asia that are not recognized as threats to soldiers or civilians. Hospital-based microbiologic and epidemiologic surveillance should be conducted on newly recognized organisms, as was done with the reports of drug-resistant A. baumannii in US military hospitals (CDC 2004 Davis et al. 2005).

Other Wound Infections

Nearly any war-theater injury, whether combat-derived or otherwise, may result in infection. The risk of infection is inherent in military service, training, readiness activities, transport, or combat (Zapor and Moran 2005). Men and women deployed to OEF and OIF face the risk of being injured by explosive devices of many types, including improvised explosives,

mortars, and grenades. Torso injuries are less common than in prior conflicts because of widespread use of body armor, but it does not protect the extremities or head. Infections of skin and orthopedic wounds of the extremities are the most common reported causes of inpatient consultations for OEF and OIF returnees at WRAMC (Zapor and Moran 2005).

A BAMC wound-bacteriology survey was conducted in 2004 at a Combat Support Hospital in Baghdad, Iraq (Zapor and Moran 2005). It covered 49 soldiers who had 61 wounds, primarily blast injuries of the extremities. Eighteen of the soldiers (with 20 wounds) underwent wound lavage, had antibiotics administered at the time of the injury, or both. Of the 40 bacteria obtained from 30 wounds, most were obtained from soldiers before they received antibiotics. Gram-positive commensal skin bacteria, such as Staphylococcus spp. and Micrococcus spp. were found in 93% of isolates. Less common were gram-negative bacterial genera, such as Pseudomonas, Chryseobacterium, and Escherichia. Two isolates demonstrated broad antibiotic resistance both were methicillin-resistant Staphylococcus aureus. To reconcile the differences in the bacteriologic profiles noted in this unpublished survey with those at stateside military hospitals (the latter see more Acinetobacter spp. and extended-spectrum -lactamase-producing lactose-fermenters), Zapor and Moran recommended larger field hospital surveys from multiple locations, using best-practice sampling and microbiologic methods (Davis et al. 2005 Zapor and Moran 2005).

Wound infections occur shortly after the wounds themselves, with exceptions, such as infections associated with chronic osteomyelitis that are rare with modern medical care. Therefore, making an epidemiologic link to service in the war theater is rarely difficult. Current military medical practices include surgical debridement of wounds, probing of deep tissues, and cultures of wounds, bone, deep tissues, skin, and other fluids to find and treat infection. Such aggressive management prevents chronic osteomyelitis in the vast majority of wounded soldiers. If a stateside civilian, military, or Department of Veterans Affairs (VA) medical facility encounters chronic osteomyelitis, it is the one clear example of an infection that may result from underdetection and undertreatment or from hospital acquisition. That condition can theoretically manifest far from the war and later, although it will be rare, as judged from the near absence of modern case reports. Each case must be evaluated as to the epidemiologic, clinical, and microbiologic characteristics of the infectious disease to judge whether it is linked to the war or is community-acquired.

Other Nosocomial Infections

Many potential nosocomial organisms may go unrecognized if an outbreak is not apparent and not investigated. Observant clinical providers may reveal outbreaks that might otherwise be missed. For example, a nebulizer from a local manufacturer in Saudi Arabia caused an outbreak of Burkholderia cepacia in US National Guard troops deployed in the Middle East (Balkhy et al. 2005). US manufacturing adhering to Food and Drug Administration requirements would have been expected to virtually eliminate contaminated respiratory products for US troops, but the overseas pharmaceutical plant that made the inhalant medication was not under such scrutiny. Another example is a keratoconjunctivitis outbreak caused by adenovirus type 8 in troops in a hospital setting, but that may have been mistaken for a community-acquired organism if seen out of the context of the outbreak (Colon 1991). Given the relatively short time between exposure and symptoms, most nosocomial conditions would be associated temporally with active military duty in southwest and south-central Asia and would not present any confusion for

stateside medical staff if the troops have not been disbursed if they have been, the nosocomial origin of the condition might be masked by the &ldquoisolated&rdquo cases seen by many practitioners.

Other causes of nosocomial infections in OEF- and OIF-deployed troops and civilian military employees include those familiar in civilian settings, such as infections caused by methicillin-resistant Staphylococcus aureus (LaMar et al. 2003) and anaerobes (Brook and Frazier 1993). The origin of those infections (southwest and south-central Asia) is evident from the temporal association with deployment, as was the case in the 1991 Gulf War with Irish troops (Humphreys et al. 1988) and in the present conflicts among US troops (CDC 2004 Davis et al. 2005 Zapor and Moran 2005).

Returning soldiers may serve as a nidus of organisms that can infect others in the same hospital or rehabilitation unit. A number of prevention research projects have evaluated colonization rates, including those among family members of returning soldiers (Fishbain et al. 2003 Kenner et al. 2003). Unrecognized sources of contamination of the hands of hospital workers are also being investigated, for example, computer keyboards in an ICU (Bures et al. 2000). Nosocomial risks that have been recognized in US military facilities also may be of importance in the field setting, depending on the specific circumstances of the field hospital or clinic (Blatt et al. 1993 Conger et al. 2004 Cumberland and Jones 1987 John 1977 Lamarque et al. 1992).

Given the rarity of chronic infections related to wounds, the committee believes that unrecognized wound or nosocomial infections will pose a diagnostic dilemma for returning veterans only in the most unusual circumstances, such as a late-presenting osteomyelitis. A penetrating injury of an extremity (from stepping on a pressure-detonated mine) resulted in chronic osteomyelitis and later squamous-cell carcinoma in a Vietnam veteran in 1987 (Coy 1994). Cultures taken 20 years after the injury (and after 18 years of draining of a sinus tract) grew Bacteroides fragilis, Proteus vulgaris, P. aeruginosa, and Enterococcus faecalis the patient had been treated with cleocin, erythromycin, and tobramycin (no culture sensitivity results were presented) (Coy 1994). No details were given as to why those complications were manifest and so unsuccessfully managed.

Regional Experiences in Non-Americans

A number of reports of A. baumannii and other wound infections have come from countries neighboring Iraq or Afghanistan. The reports may provide lessons that inform the care of US troops, especially in the evolution of antibiotic resistance in environmentally acquired A. baumannii.

In 2002, A. baumannii infection occurred in 21 patients in a trauma ICU in Qatar the outbreak was attributed to poor infection-control management and environmental contamination (El Shafie et al. 2004). The organism was sensitive only to amikacin among 17 antibiotics tested, including the carbapenems (El Shafie et al. 2004). In a series of 36 patients infected with 38 strains of A. baumannii in January 2000-August 2001 in a Turkish teaching hospital, only the carbapenems and colistin were fully efficacious against all strains in the laboratory (Ayan et al. 2003). A devastating earthquake in the Marmara region of Turkey in 1999 resulted in the hospitalization of 630 trauma victims at one hospital, of whom 240 were hospitalized for more than 48 hours. Of the 240, 41 patients (17%) had 43 nosocomial infection episodes that resulted in analysis of 143 culture specimens. In the 48 specimens with positive results (34% of specimens), A. baumannii was most common (31%), followed by S. aureus (19%), P. aeruginosa (15%), E. coli (13%), Klebsiella pneumoniae (13%), other Pseudomonas spp. (6%),

and Stenotrophomonas (now called Xanthomonas) maltophilia (4%) (Oncul et al. 2002). Mortality was high, and antibiotic resistance was common, including methicillin resistance in all nine S. aureus strains and resistance to all tested antibiotics, such as carbapenems, in two A. baumannii strains and one P. aeruginosa strain (Oncul et al. 2002).

In a 1999 outbreak, 12 of 170 (7%) ICU patients in a Turkish hospital acquired A. baumannii infection of 25 strains isolated, all were carbapenem-resistant, and the ICU had to be closed and disinfected because of environmental contamination and continuing transmission (Aygun et al. 2002). Wound infections in a Saudi Arabian hospital were assessed in the hot summer months of an unspecified year, possibly 1994 or 1995 of 2331 wounds, 193 (8%) were infected with 283 bacterial strains, and the most prevalent organisms were S. aureus (35% of strains), E. coli (31%), P. aeruginosa (25%), and Klebsiella spp. (10%) (Abussaud 1996). Neonatal ICUs have also experienced multiple-drug-resistant Acinetobacter spp. infections in the Middle East one series of seven Saudi neonates (of whom three died) demonstrated sensitivity only to imipenem and resistance to 12 other antibiotics tested (probably in 2002 or 2003) (Manzar 2004).

One hundred and fifty-seven patients (96% men) at a military hospital in Turkey in 1994-1999 were admitted because of maxillofacial fractures (Ortakoglu et al. 2004). The precipitating events were from traffic accidents (44%), combat (27%), falls (17%), work accidents (10%), and sports (3%). Infectious complications occurred in local wounds and with osteomyelitis due to delayed primary treatment or delayed evacuation. Organisms of concern were not detailed, nor were the treatment experiences of the infected patients.

In two ICUs in Saudi Arabia and Kuwait where gram-negative bacterial isolates were studied in 1994-1995, A. baumannii isolates made up 42 of 207 isolates from 172 patients they were much more common in Kuwaiti isolates (33%) than in Saudi isolates (8%) (Rotimi et al. 1998). Detailed susceptibility testing suggested that all 42 A. baumannii isolates were sensitive to imipenem (both sites) and that all 33 isolates in Kuwait were sensitive to ciprofloxacin and 89% (eight of nine isolates) in Saudi Arabia (Rotimi et al. 1998).

War in Lebanon in 1984 was associated with A. baumannii infection in 36 patients with isolates obtained from sputum, wounds, blood, urine, ulcer swab, or vaginal swab (Matar et al. 1992) the organisms were largely sensitive to minocycline, imipenem, and ciprofloxacin at that time.

Osteomyelitis was common in 210 patients with maxillofacial injuries seen at the Mostafa-Khomeini Hospital in Tehran, Iran, during the 1981-1986 Iran-Iraq war (Akhlaghi and Aframian-Farnad 1997). Missile or blast hits accounted for 94% of cases, and motor-vehicle accidents 6%. Twenty-four persons (11%) had infectious complications: eight with mandibular and one with maxillary osteomyelitis, one with cervical abscess, six with foreign-body infections (four in silicone implants), and eight with other infections. The authors attributed the high incidence of osteomyelitis to the inability to evacuate and promptly treat patients with wounds, something that will occur only rarely in US military troops (such as in capture after injury with later release). No organisms or treatment approaches were presented in the Iranian series, although the surgical antibiotics used were limited to cephalotin, gentamycin, ampicillin, and penicillin.

Afghan guerrilla combatants and civilians seen in a Pakistani hospital in 1985-1987 also had very high wound- and bone-infection rates, which were attributed to the long time between injury and medical attention (Bhatnagar et al. 1992). In 1274 patient records reviewed, about 50% of the patients had musculoskeletal injuries. Comminuted fractures and foreign bodies were

each seen in 6% of patients. Wound infections were seen in 14% of the men, and chronic osteomyelitis in 11%, most often in the femur or tibia. No microbiologic data or infection-treatment outcomes were reported.

Those experiences from non-Americans in Afghanistan, Iraq, and neighboring nations suggest that the experience of US military with A. baumannii and combat-related wound infections in southwest and south-central Asia is not unique.

Summary

Both wound infections and nosocomial infections are hazards for US personnel deployed to OEF and OIF. Given modern medical and surgical treatment and the ability to evacuate injured military personnel rapidly, most infections will be seen within days or weeks of wounds. Longer-term adverse health outcomes are possible but unlikely.

MYCOPLASMAS

Mycoplasmas are ubiquitous microorganisms found as commensal colonizers and as pathogens in plants, insects, and animals. They are the smallest known free-living organisms (150-250 nm) (Baum 2005 Murray et al. 2005). They are pleomorphic and filamentous and have a deformable membrane, which allows them to pass through filters that retain bacteria. They are fastidious and difficult to culture on cell-free media at the same time, because of their common presence as nonpathogenic colonizers, they are common contaminants of cell cultures. The propensity for contamination of cell cultures can lead to false conclusions about the association of mycoplasmas with a variety of clinical syndromes (Baum 2005). Furthermore, the major antigenic determinants of mycoplasmas are glycolipids and proteins in the cell membrane, which are serologically cross-reactive with bacteria and human tissues (Murray et al. 2005). Mycoplasmas lack a cell wall, so they are resistant to antibiotics that inhibit cell-wall synthesis, such as penicillins, cephalosporins, and glycopeptides, for example, vancomycin. However, they have been shown to be sensitive to a variety of antibiotics that act at sites other than the cell wall, such as doxycycline, clindamycin, and quinolones (Hayes et al. 1993).

Taxonomically, mycoplasmas are assigned to their own class, Mollicutes. Mycoplasmas that can infect humans are members of the family Mycoplasmataceae. Sixteen species of mycoplasma have been found to colonize humans, and five of them have been associated with disease. Mycoplasma pneumoniae is a common cause of tracheobronchitis and pneumonia and can cause outbreaks in crowded settings such as would be found in military deployments (McDonough et al. 1996). M. pneumoniae has also been associated with numerous extrapulmonary manifestations, including a variety of rashes, cardiac abnormalities, aseptic meningitis and meningoencephalitis, and arthralgias. M. hominis has been associated with a variety of genitourinary infections (primarily pelvic inflammatory disease). M. fermentans (incognitus strain) and M. penetrans have been associated with a severe multisystem disease in both healthy people and people with AIDS (Lo et al. 1989). Culture of M. fermentans on cell-free media (which decrease the risk of contamination) has been extremely difficult, and this has led to controversy over whether the organisms are true pathogens or merely contaminants. M. fermentans has been found in the blood of 11% of HIV-seropositive patients but not in seronegative patients (Hawkins et al. 1992). Although Montagnier, codiscoverer of HIV, at one time postulated that M. fermentans and other mycoplasmas were cofactors for progression to

AIDS, no increase in prevalence of M. fermentans was seen with later-stage AIDS (Cotton 1990 Hawkins et al. 1992). The authors speculated that mycoplasmas may survive as colonizers of mucosal surfaces for many years and that acquisition may be related to high-risk sexual behaviors associated with acquisition of HIV infection.

Mycoplasmas and &ldquoGulf War Illness&rdquo

There have been no reports of cases of M. hominis infection in troops deployed to southwest and south-central Asia. There are no published reports of cases of M. pneumoniae infection however, search results from a Department of Defense Gulf War hospitalization database identified 5 cases of this infection (see Chapter 4). Nicolson and Rosenberg-Nicolson have suggested that many of the symptoms of &ldquoGulf War Illness&rdquo (GWI) could be explained by &ldquoaggressive pathogenic mycoplasma infections, such as Mycoplasma fermentans or Mycoplasma penetrans, and they should be treatable with multiple courses of antibiotics, such as doxycycline (100-200 mg/day) or macrolides&rdquo (Nicolson and Rosenberg-Nicolson 1995). Nicolson et al. (2003) hypothesized that the source of the infections may have been contamination of the multiple vaccines received by troops before and during deployment. They noted a study by Steele (2000) that found chronic symptoms consistent with GWI in 34.2% of Gulf War veterans who reported receiving vaccines during the war, 11.5% of Gulf War-era veterans (people in the military in 1990-1991 who did not serve in the Gulf War) who reported receiving vaccines, and 3.7% of Gulf War-era veterans who did not receive vaccines. Steele suggested that vaccines used during the war may have contributed to GWI.

Nicolson et al. (2003) noted anecdotally that 55 of 73 Gulf War veterans with whom they spoke &ldquoindicated that they had good responses to doxycycline and eventually returned to normal duty.&rdquo Nicolson et al. referred to an article by Lo et al. (1991), who discovered M. fermentans (incognitus strain), as evidence of the ability of the organism to cause chronic infections. Nicolson et al. further suggested that the presence of similar symptoms in family members supported the possibility of a transmissible agent. Nicolson and Nicolson (1996) reported a sampling of veterans with GWI and 21 healthy controls with a gene-tracking technique. The technique was designed by the authors to detect hybridization signals of M. fermentans DNA in nuclear fractions from the blood cells of subjects. Of 30 subjects, 14 had evidence of infection of leukocytes with this test method (65% were infected with M. fermentans only) 11 of the 14 responded to multiple cycles of antibiotics to which mycoplasmas are sensitive. Four of the successfully treated veterans were retested results were negative for M. fermentans gene sequences. Further studies by Nicolson et al. (2002) using polymerase chain reaction (PCR) to detect mycoplasma found a 9-fold increase in mycoplasma infections and an 18-fold increase in M. fermentans compared with healthy control subjects. Other investigators have found similar rates of positivity in patients with chronic fatigue syndrome who had no exposure to multiple vaccinations or deployment to the Gulf War (Teixeira et al. 2006). Using their gene-tracking technique, Nicolson and Nicolson (1996) claim to have detected &ldquohighly unusual DNA sequences&rdquo that &ldquoincluded a portion of a retrovirus genome (the HIV-1 env gene), but not all of the genes that make up the virus.&rdquo They speculated further that &ldquothe presence of the viral envelope gene in the mycoplasma could be due to genetic manipulation, or much less likely natural causes,&rdquo and they went on to say that &ldquothe mycoplasmas that we have found in Gulf War veterans are not naturally occurring organisms, or to be more specific, they could have been genetically manipulated to be more invasive and pathogenic (potent biological weapons).&rdquo

Independent attempts to confirm the results of Nicolson and colleagues have been unsuccessful. Gray et al. (1999) studied serum from symptomatic and asymptomatic Gulf War veterans who had given prewar and postwar blood samples. They used immunoblot banding for M. fermentans at the University of Alabama Diagnostic Mycoplasma Laboratory, and none of the banding profiles was associated with reported symptoms in veterans. The study revealed that 10.9% of Gulf War veterans and 9.3% of nondeployed veterans who served in the military during the same period as the Gulf War veterans had prewar antibodies to M. fermentans. Of those without pre-existing antibodies, 19.2% of Gulf War veterans and 13.7% of nondeployed veterans developed serologic evidence of new M. fermentans infections.

A matched case-control study was conducted to determine the prevalence of M. fermentans antibodies in military personnel before and after Gulf War deployment and seroconversion rates in veterans with and without complaints of GWI (Lo et al. 2000). The study found a predeployment prevalence of M. fermentans-specific antibodies of 4.8% in veterans with GWI and 5.2% in controls no difference in rates of seroconversion (1.1% in GWI cases and 1.2% in controls) during deployment was found. Lo et al. noted that their serologic test has been shown to be highly sensitive and specific and that most patients, including immunocompromised patients with AIDS, produce detectable species-specific antibodies to M. fermentans. That specificity suggests that the results are not an artifact of intracellular infections that do not yield antibody responses. Lo et al. also noted that &ldquoit is difficult to assess the validity and specificity of the NGT [nuclear gene tracking] testing [of Nicolson and colleagues, as discussed above], as there is no precedent for identifying any viral, mycoplasmal, or bacterial infection in clinical specimens using this uncommon technique.&rdquo

A report prepared for the US Senate Committee on Veterans Affairs Special Investigation Unit on Persian Gulf War Illness stated in part that &ldquoM. fermentans has been at times suspected of causing various diseases in humans and, therefore, the center of some controversy&rdquo but that &ldquothis organism is considered to be a member of the normal human flora&rdquo (Dybvig, 1998). Dybvig noted that the NGT method used by Nicolson and colleagues was &ldquoan inappropriate diagnostic method for detection of M. fermentans&rdquo and that neither the specificity nor the sensitivity of the test had been established. He noted further that &ldquoM. fermentans DNA resides within the mycoplasmal cell and would not be present in the material assayed by this procedure, namely, host nucleoprotein.&rdquo Dybvig also wrote that genetic engineering of M. fermentans was not technically feasible at the time of his report and certainly did not occur before the Gulf War.

Because of the conflicting data related to M. fermentans infections and their possible association with GWI and the suggestion of possible benefits of treatment with doxycycline, the VA conducted a randomized placebo-controlled trial to determine whether doxycycline given at 200 mg/day for 12 months could improve functional status of persons with GWI (Donta et al. 2004). In the trial, 491 deployed Gulf War veterans with GWI and detectable mycoplasma DNA in the blood were randomized to receive either doxycycline or a placebo for 12 months. Of the participants, 324 (66%) had an M. fermentans infection, 197 (40.1%) had an M. genitalium infection, and 53 (10.8%) had an M. pneumoniae infection, either singly or in combination as detected with PCR testing. Although a higher fraction of doxycycline participants than controls showed improvement at 3 months (21.5% vs 9.9%), there was no statistically significant difference at 9, 12, and 18 months. Overall, there was no statistically significant difference between the doxycycline-treated and placebo groups on the primary outcome measures. There was a trend toward fewer unscheduled clinic visits and hospitalizations among doxycycline-treated veterans than placebo subjects, but this was not related to the presence of mycoplasma

infections. Rates of mycoplasma positivity decreased significantly during the 18-month study but did not differ between treatment and placebo groups. Specifically, 55% of the doxycycline-treated participants and 58.2% of the placebo subjects had negative results on tests for any mycoplasma species at 6 months of treatment, and 90% and 86.6%, respectively, had negative results at 18 months. Participants in the doxycycline group had a higher incidence of nausea and photosensitivity. The accompanying editorial by Wesseley (2004) noted that &ldquowe are fortunate that it was large enough and conducted diligently enough to give an unequivocal answer for both its primary and secondary end points. Doxycycline treatment has no effect on the health of symptomatic Gulf War veterans.&rdquo

Summary

Several studies by Nicolson and colleagues report a link between M. fermentans and health problems in Gulf War veterans (Nicolson et al. 2002 Nicolson et al. 2003 Nicolson and Rosenberg-Nicolson 1995 Nicolson and Nicolson 1996). However, other investigators were not able to duplicate their work and there are concerns about the NGT technique used by Nicolson et al. (Dybvig, 1998 Gray et al. 1999 Lo et al. 2000). In addition, a well-conducted randomized placebo-controlled trial in which doxycycline was administered to veterans with GWI and mycoplasma infection did not improve the health status of the treated veterans (Donta et al. 2004). After reviewing the evidence on mycoplasmas, the committee believes that mycoplasma infection is not related to the symptoms reported by Gulf War veterans. Mycoplasmas are known to cause other types of acute and long-term adverse health outcomes, as noted in Table 3.1.

BIOLOGIC-WARFARE AGENTS

Biologic warfare (BW) is defined as the use of microorganisms or toxic products derived from microorganisms to inflict mass casualties in military and civilian populations (Horn 2003). Living microorganisms can multiply in a living target host and cause adverse health effects but require an incubation period of 24 hours to 6 weeks between infection and the appearance of symptoms (Rosenbloom et al. 2002). Toxins cannot reproduce themselves but are more lethal and act relatively quickly.

At the time of the Gulf War, Iraq had an active BW program. Iraq&rsquos BW program probably began sometime in the middle 1970s with studies on Clostridium botulinum, bacillus spores, and influenza virus (Leitenberg 2001 Roffey et al. 2002). In the middle 1980s, the program began &ldquoin earnest&rdquo, and as many as 30 agents might have been investigated for potential use as biologic weapons (Roffey et al. 2002 Zilinskas 1997).

Iraq conducted intensive study of five bacterial strains (four strains of Bacillus anthracis and one of Clostridium perfringens), one fungal strain (wheat cover smut), five viruses (Congo-Crimean hemorrhagic virus, yellow fever virus, enterovirus 17, human rotavirus, and camelpox virus), and four toxins (aflatoxin, botulinum toxin, ricin, and tricothecenes) (Zilinskas 1997). Bacillus anthracis, aflatoxin, botulinum toxin, and possibly ricin were weaponized (Roffey et al. 2002 Zilinskas 1997). Iraq is reported to have manufactured almost 10,000 L of botulinum toxin during the 1980s and 1990s (Han and Zunt 2003).

Iraq developed bombs, missile warheads, aerosol generators, and helicopter and jet spray systems for dispersal of BW agents (Leitenberg 2001). Iraqi sources reported that aflatoxin, botulinum toxin, and Bacillus anthracis were loaded in missiles and air-delivery bombs in


ABSTRACT

The forward resuscitative surgery system (FRSS) is the Navy’s most forward-deployed echelon II medical unit. Between March and August 2003, six FRSS teams were deployed in support of Operation Iraqi Freedom (OIF). During the combat phase of OIF (March 21 to May 1, 2003), a total of 34 Marine Corps and 62 Iraqi patients underwent treatment at a FRSS. FRSS teams were assigned two distinct missions “forward” FRSS teams operated with combat service support elements in direct support of regimental combat teams, and “jump” FRSS teams served as a forward element of a surgical company. This article presents the experiences of the FRSS teams in OIF, including a discussion of time to presentation from wounding, time to operation, time to evacuation, and lessons learned from the deployment of the FRSS.


New Jersey Fallen Heroes Memorial

In Honor of all those from New Jersey who gave their lives in the fight against terrorism during Operation Enduring Freedom and Iraqi Freedom. In Humble gratitude, we remember their sacrifice.
Governor's Message

Welcome to the New Jersey Fallen Heroes Memorial website. Please use this site as a resource and a portal to honor New Jersey's brave men and women in uniform who dedicated their lives to defend our freedom.

All Americans who enjoy the blessings of liberty owe a tremendous debt of gratitude and appreciation to those who serve and have served in the Armed Forces of the United States. Together as a State, we grieve the loss of family, friends and loved ones, but take solace in the knowledge that these soldiers and their valiant sacrifices will never be forgotten.

We are eternally grateful for these fallen heroes, who represent our Nation's greatest values of patriotism, bravery and loyalty. Please take the time to pay tribute to these individuals and I encourage you to visit the beautiful War Memorial Building located in Trenton.

How to Submit

If you have any comment and concerns about the content of this memorial, or wish to submit a memorial for a fallen hero

Memorial In Trenton

The memorial pays tribute to the brave New Jerseyans who perished while in service to their country

Resources

Find more information about support and programs for veterans

In Memoriam

But on the battlefield their feet stood fast, and in an instant at the height of their fortune, they passed away from the scene, not of their fear, but of their glory.


Índice

Durante la guerra Irán-Irak, Sadam Husein llevó a cabo la conocida Operación al-Anfal, una serie de matanzas sistemáticas en la región kurda, calificada por diferentes países como genocidio, [ 20 ] ​ ya que se calcula el asesinato de alrededor de 100 000 civiles y la destrucción de más de 4000 aldeas. [ 21 ] ​ En 1988, el ejército iraquí baazista utilizó armas químicas, en concreto gas mostaza, sarin, tabun y VX, contra civiles kurdos, produciendo una masacre en el ataque químico a Halabja. Se estima que por lo menos 5000 kurdos murieron en el ataque. [ 22 ] ​ A pesar de las dramáticas consecuencias del conflicto, se logró evitar la ruptura del país o incluso una guerra civil de imprevisibles consecuencias. La ONU medió en el conflicto y ordenó el alto al fuego para luego continuar con las inspecciones y las presiones a Irak, para que colaborara con las tareas de las comisiones delegadas de las Naciones Unidas para la verificación del desarme iraquí.

El 3 de agosto de 1990, tropas iraquíes invadían Kuwait con vehículos armados e infantería ligera. El 16 de enero de 1991, una coalición internacional liderada por Estados Unidos y bajo el mandato de las Naciones Unidas atacó a las tropas iraquíes estacionadas en Kuwait, iniciando lo que se conoce como la guerra del Golfo. El ejército iraquí opuso una débil resistencia inicialmente y no pudo evitar ser expulsado de Kuwait. Con la capital del país devastada por los bombardeos, Husein tuvo que enfrentarse a una guerra civil. Los kurdos reclamaron sus derechos y las regiones chiitas del sur se alzaron en armas. Sin embargo, el temor a que la caída del presidente iraquí desestabilizara la zona llevó a los vencedores a no apoyar estos movimientos. [ 23 ] ​

A partir de ese momento, las Naciones Unidas, a través de su Consejo de Seguridad, impuso una serie de obligaciones a Irak, entre ellas la aceptación incondicional de la destrucción de sus armas químicas, biológicas y misiles balísticos de largo alcance bajo supervisión internacional. [ 24 ] ​ Además, estableció un bloqueo económico para presionar al país asiático.

El 15 de mayo siguiente, el Consejo de Seguridad rectifica y aprueba un sistema de flexibilización de duro embargo, el cual consistía en la concesión a Irak de la posibilidad de exportar petróleo cuyos beneficios estarían destinados a la compra de alimentos, medicinas y otras materias básicas para la población civil. Este programa, económicamente administrado por la ONU, se popularizó como el programa "petróleo por alimentos" y se hizo oficial el 14 de abril de 1995 con una nueva resolución. [ 25 ] ​

El gobierno de Sadam Husein se resistió a colaborar activamente con los inspectores de la ONU a causa de las sospechas de espionaje. [ 26 ] ​ Estados Unidos mantuvo un embargo comercial durante años a pesar de las consecuencias para la población iraquí. Los constantes bombardeos a los que el país era sometido de forma intermitente durante años por parte de la Fuerza Aérea estadounidense causaron víctimas entre la población iraquí. [ 27 ] ​

En 1998, tras una crisis previa el año anterior, se produce la completa expulsión de los inspectores internacionales por parte del gobierno iraquí, el 31 de octubre. Unos días después, el 17 de noviembre, cambia de opinión, decide negociar y solicita el regreso. [ 27 ] ​ Tras el informe de Richard Butler denunciando la falta de colaboración de Bagdad, [ 28 ] ​ Naciones Unidas ordena la salida de Irak a todos sus inspectores.

El 2 de marzo de 2000, Hans Blix asume el cargo de director ejecutivo de la UNMOVIC, la Comisión de las Naciones Unidas de Vigilancia, Verificación e Inspección.

El Eje del Mal y la guerra contra el terrorismo Editar

Meses después del inicio de la invasión y ocupación estadounidense de Afganistán, el presidente de Estados Unidos, George W. Bush, situó a Irak como eje del mal, [ 29 ] ​ un término reminiscente al Eje Roma-Berlín-Tokio o equiparable al Telón de Acero durante la Guerra Fría. Además acusó al gobierno de Sadam Husein de tener armas de destrucción masiva, [ 19 ] ​ y de tener vínculos con Al Qaeda, vínculos que tampoco se han podido confirmar. [ 30 ] ​

El 29 de noviembre de 2001 se aprobó la lista de artículos que las próximas inspecciones examinarían y su procedimiento de análisis, y fijaba el 30 de mayo de 2002 como fecha en la que se comenzaría a aplicar. Asimismo, se subrayaba la obligación de Irak de cooperar con la aplicación de las resoluciones. [ 31 ] ​

En el 2007 Alan Greenspan, expresidente del banco central estadounidense (la Reserva Federal), aseguró en su libro de memorias que el verdadero motivo para invadir Irak no eran las razones expresadas públicamente, que eran relativas a las supuestas armas de destrucción masiva y acabar con las supuesta relación entre el gobierno baasí iraquí y la organización guerrillera Al Qaeda, sino controlar las reservas de petróleo y evitar que la Unión Europea o potencias emergentes como China e India se acercaran a esas gigantescas reservas de petróleo. [ 32 ] ​ [ 33 ] ​ [ 34 ] ​

La resolución 1441 Editar

En la importante resolución 1441, [ 35 ] ​ aprobada en la sesión celebrada el 8 de noviembre de 2002, el Consejo decidió ordenar a Irak la realización de las inspecciones referidas a la existencia de armas de destrucción masiva.

Para ello daba un plazo de 30 días, a partir del día de la publicación de la resolución, para presentar una completa declaración de todos los aspectos de los programas para el desarrollo de armas químicas, biológicas, nucleares, misiles balísticos, etc., además de solicitar que Irak no realizaría ningún acto o amenaza contra cualquier Estado Miembro que adoptara medidas para hacer cumplir sus resoluciones.

Realizado el informe, el Consejo se reuniría nuevamente para examinarlo y adoptar las decisiones que pudieran corresponder. La resolución afirma «se ha advertido reiteradamente a Irak que, de seguir infringiendo sus obligaciones, se expondrá a graves consecuencias». No obstante, la resolución excluía autorizar el uso de la fuerza, lo que en todo caso requeriría de una nueva resolución que nunca llegó a aprobarse.

Se forma la coalición Editar

Tras presionar al Consejo de Seguridad de Naciones Unidas, con la presentación de supuestas pruebas, para que aprobara una resolución apoyando explícitamente la invasión, el presidente de los Estados Unidos, George W. Bush, obtuvo el apoyo de un grupo de países para formar una alianza para invadir Irak con el fin de derrocar al gobierno de Sadam Husein. Esta coalición, que se autodenominó Coalición de la voluntad, estaba formada por los gobiernos de Estados Unidos, el Reino Unido, España, Portugal, Italia, Polonia, Dinamarca, Australia, Hungría y Ucrania.

La mayoría de la población de estos países, así como la opinión pública mundial, fue mayoritariamente contraria, haciéndose notar especialmente en las manifestaciones mundiales contra la guerra de Irak. Bush recibió también el apoyo de los gobiernos de la República Checa, Eslovaquia, Eslovenia, los estados bálticos de Estonia, Letonia y Lituania, Colombia en América, las islas mediterráneas de Malta y Chipre, el estado de Israel o el de Kuwait.

Francia, Alemania, China y Rusia manifestaron su oposición a medidas de fuerza contra Irak y fueron partidarios de una salida negociada a la crisis. Francia, Rusia y China, miembros permanentes del Consejo de Seguridad, abogaban por la continuidad de la labor de los inspectores y anunciaron su intención de vetar cualquier documento que legitimase explícitamente el ataque. Durante estas demostraciones se produjeron varios roces entre Estados Unidos y los países que se oponían a la invasión. Pero, al final, los que se oponían a la guerra cedieron y se mantuvieron neutrales desde el inicio de la invasión.

El 16 de marzo de 2003, se produjo la Cumbre de las Azores, donde los líderes de los Estados Unidos, Reino Unido, España y Portugal anunciaron un ultimátum al gobierno baasí de Sadam Husein para que procediera al desarme.

El entonces jefe del Gobierno español, José María Aznar, aludió a que la intervención respondía a la convicción de que aquel gobierno constituía una amenaza para sus vecinos y para los propios países occidentales. Recordó que en ocasiones las intervenciones militares se hacen bajo el mandato de las Naciones Unidas, como en el caso de Afganistán en 2001, y en otras ocasiones, sin mandato de las Naciones Unidas, como en el caso de la guerra de Bosnia en 1992. Afirmó también que España no participaría en esa guerra sino que únicamente apoyaba a los aliados, pero que en ningún caso el ejército español participaría en la invasión. [ 36 ] ​

La guerra no contó con el mandato del Consejo de Seguridad de las Naciones Unidas, lo que ha generado que expertos del derecho internacional condenen la guerra como invasión ilegal. [ 37 ] ​ [ 38 ] ​ [ 39 ] ​ [ 40 ] ​ Así lo expresó el entonces Secretario General de las Naciones Unidas, Kofi Annan. [ 41 ] ​ Sin embargo, ni los miembros de la Corte Penal Internacional pueden juzgar a los invasores en caso de considerarlo una agresión porque el Estatuto de Roma indica que hay que encontrar una definición de este crimen, lo que no pasó antes de 2009 y en cualquier caso, no se puede juzgar un supuesto delito que se cometió antes de que existiera la ley que lo castiga.

El fiscal británico Peter Goldsmith emitió un documento el 7 de marzo de 2003, donde manifestaba sus dudas respecto a la legalidad de la invasión, y en 2005 afirmó públicamente que la acción militar fue ilegal. [ 42 ] ​ Para el profesor en derecho Nicholas Grief sería posible fincar cargos criminales contra George W. Bush, invocando la Carta de Núremberg de 1945 que estableció el concepto de crímenes contra la paz. Esta postura, no obstante, ha sido rechazada por los gobiernos que realizaron la invasión. La mayoría de los expertos en derecho internacional consideran que es inviable cualquier tipo de iniciativa en contra de los dirigentes de la coalición, puesto que entonces se podrían iniciar acciones contra todos los líderes que han realizado alguna operación militar sin apoyo de las Naciones Unidas.

Los defensores de la intervención aluden a las ya citadas resoluciones del Consejo de Seguridad, especialmente a la 1441 para avalar sus acciones, y recuerdan otras intervenciones sin mandato de las Naciones Unidas que han sido reconocidas posteriormente como necesarias. Tal es el caso, por ejemplo, de la guerra de Kosovo. Sin perjuicio de las diferentes opiniones sobre el inicio del conflicto, las Naciones Unidas hicieron suya la situación, en el momento en que las fuerzas ocupantes empezaron a actuar bajo el paraguas de la organización. Así, en octubre del mismo año de la invasión, se recomendó en su resolución 1511, a los estados miembros que presten a la fuerza multinacional presente en Irak, toda la asistencia necesaria, incluyendo la militar. [ 43 ] ​ [ 44 ] ​

Algunos consejeros legales aseguran que la invasión ha quedado justificada legalmente en otras resoluciones existentes. Por ejemplo, el profesor Anthony Aust, anterior Consejero Legal de la cancillería británica, opinó que las resoluciones anteriores brindaban la justificación necesaria para invadir Irak y por lo tanto no era necesario buscar legalidad en resoluciones posteriores.Pero hay gente, no se ha especificado la cantidad exacta, tanto estadounidenses como iraquíes, que piensan que es un abuso de poder y una masacre, que se busca solo para conseguir beneficios personales. [ 45 ] ​

El 20 de marzo de 2003, sin que mediara alguna declaración de guerra por alguna de las partes, comenzó el ataque de la coalición contra Irak. Para el ataque, los estadounidenses habían dispuesto de 225 000 soldados, 800 tanques M1 Abrams, 600 vehículos de combate de infantería M2/M3 Bradley, 100 helicópteros AH-64 Apache, 200 helicópteros AH-1 SuperCobra, 100 helicópteros de transporte CH-47 Chinook, UH-60 Black Hawk y CH-53 Sea Stallion, 50-60 F-14 Tomcat, 90 F-15 Eagle, 75 F-16 Fighting Falcon, 180-220 McDonnell Douglas F/A-18 Hornet, 50 A-10, 36 bombarderos B-1B, B-52 y B-2, 60 Harrier AV-8B y 4 grupos de combate marítimos que incluían a los portaaviones Constellation, Harry S. Truman, A. Lincoln y T. Roosevelt. Para proteger a Israel, las fuerzas de los Estados Unidos desplegaron tres baterías de misiles Patriot en Jordania.

Con la intención de defender al país, Saddam Husein ordenó dividir Irak en cuatro secciones y encargó la defensa de cada región a una persona de su entera confianza. Para combatir, los iraquíes disponían, en teoría, de un ejército de 327 000 hombres, 400 000 reservistas y 2200 carros de combate de origen ruso y chino, de los cuales unos 700 eran T-72, 500 T-62, 500 T-54/T-55, 350 Tipo 69 y 150 Tipo 59. Para misiones de reconocimiento, los iraquíes contaban con una gran variedad de vehículos ligeros de diversos orígenes que ascendían a 500 unidades, entre los que se encontraban 100 tanques anfibios PT-76, mientras que el resto se componía de BRDM-2 con misiles 9K11 Malyutka, ERC-90 Sagaie, Panhard AML-90, EE-9 Cascavel, EE-3 Jararaca, OT-65 Otter, FV 601 Saladin y FV 701 Ferret. Además, las fuerzas mecanizadas tenían en su inventario 3300 transportes blindados, habiendo 900 BMP-1 y BMP-2, siendo el resto M-113, BTR-152, BTR-50, BTR-60, M3 Panhard, EE-11 Urutu, OT-62 y OT-64. La artillería remolcada poseía cañones Oto Melara M-56 de 105 mm, D-74, D-30 y M-30 de 122 mm, M-46 y Tipo 59 de 130 mm, ML-20 y D-1 de 152 mm, y G5, GHN-45 y M-114 de 155 mm, sumando un total de 1900 piezas. 3000 cañones antiaéreos, entre 640 y 760 lanzaderas de misiles antiaéreos, entre 70 y 90 helicópteros de combate y 300 aviones de combate de los cuales la mitad estaban fuera de servicio debido a la falta de reparaciones y mantenimiento adecuado. La mayoría de estos aparatos eran Mikoyan-Gurevich MiG-21, MiG-23 y MiG-25 de fabricación soviética y cincuenta Mirage F-1 franceses. Antes de la guerra, el ejército iraquí había hecho destruir varios de sus misiles Al-Samud como muestra de cooperación en un intento por detener el conflicto.

Un percance obligó a replantear los planes de invasión al negársele al ejército estadounidense la entrada desde Turquía lo que hubiera permitido realizar una rápida maniobra en tenaza para tomar Bagdad. A pesar de todo, fuerzas especiales tuvieron contacto con las milicias kurdas y se planeó un ataque coordinado con los guerrilleros desde el norte, con apoyo de tropas aerotransportadas siempre y cuando las operaciones en el sur marcharan según lo previsto.

La invasión empezó con bombardeos sobre Bagdad mediante misiles Tomahawks lanzados desde buques y submarinos, a lo que le seguirían ataques aéreos con cazas y bombarderos pesados. La respuesta de los iraquíes no se hizo esperar, y las fuerzas desplegadas cerca de la frontera con Kuwait iniciaron un duelo artillero con elementos de la 1.ª División Acorazada de los Estados Unidos. A los pocos minutos, los iraquíes lanzaron tres misiles, llamados Al-Samud contra Kuwait. Uno de estos proyectiles fue interceptado por un misil Patriot y explotó en el aire los otros dos lograron superar a los Patriot e impactaron en la zona norte de Kuwait, sin causar daños importantes o víctimas. Posteriormente, se adentró en el desierto una columna estadounidense formada por numerosos tanques Abrams, vehículos blindados Humvee y helicópteros artillados Apache y Blackhawk. Tras pasar la frontera de Irak, curiosamente, la Fuerza Aérea de Irak no realizó ni una sola salida para defender el país. Esto ocurrió debido al mal estado en que se encontraban las aeronaves por culpa del embargo que sufría Irak desde 1991. De entrada, en los primeros dos día de la ofensiva, varios helicópteros de la coalición fueron derribados por el sistema SAM Strela ruso operado por los iraquíes. El sistema de radar de Irak continuó funcionando en los primeros día de la invasión pese al fuerte bombardeo estadounidense, aunque poco después dejó de funcionar.

Se cree que durante los primeros siete días de la guerra, el Ejército Iraquí habría logrado degradar la señal de la red de satélites GPS o Navstar y por eso muchos misiles no pudieron hacer blanco sobre las coordenadas exactas de sus objetivos. Se especula que tal vez técnicos rusos o ucranianos colaboraron con el ejército iraquí para crear una pantalla distorsionadora, empleando equipos portátiles anti-GPS, la cual tendría un alcance horizontal de entre 20 y 150 kilómetros y vertical de 30 a 50 kilómetros. Debido a esto, las fuerzas estadounidenses únicamente habrían podido usar misiles de crucero que podían ser guiados hasta sus blancos sin la necesidad de señales GPS, misiles infrarrojos o de guía láser, pero la precisión de todas estas armas podía ser fácilmente disminuida por tormentas de arena o simples medidas de interferencia como la quema de zanjas rellenas de petróleo, mezcladas con arena y trozos de aluminio. (AVIÓN REVUE, en su número 41 de 2003)

El 24 de marzo, el portavoz de la Casa Blanca Ari Fleisher, acusó a Rusia de haber vendido dispositivos de alta tecnología a Bagdad. Asimismo, el Pentágono denunció que la empresa rusa Aviaconversiya era la que había suministrado los equipos. La acusación fue negada inmediatamente por los rusos, quienes sostuvieron que dichos equipos de interferencia habían sido fabricados fuera de Rusia. Los militares estadounidenses negaron que la interferencia de los satélites GPS hubiera afectado los misiles lanzados por aeronaves o buques estadounidenses y restaron importancia al asunto, pero el 25 de marzo, el coronel Víctor Renuart, jefe de Operaciones del Comando Central, afirmó con importancia que las fuerzas estadounidenses habían logrado destruir seis equipos de interferencia instalados en vehículos o camiones todo terreno.

Las fuerzas invasoras encontraron poca resistencia, que se concentró principalmente en Um Qasr, puerto clave para afianzar la entrada de tropas y pertrechos, que se tomó enseguida. Los estadounidenses avanzaron rápidamente sin encontrar oposición destacable hasta la llegada al puente de Nasiriya, punto donde el Ejército Iraquí esperaba detener a las fuerzas invasoras. Las bajas para la coalición fueron mucho mayores, llegando a superar treinta muertes. De Nasirya llegaron las primeras imágenes de estadounidenses abatidos. La televisión iraquí mostró a cinco prisioneros estadounidenses que fueron capturados. El 27 de marzo, unos mil paracaidistas estadounidenses llegaron al norte de Irak para sumarse a los guerrilleros kurdos. A pesar del tiempo perdido en Nasiriya, la resistencia iraquí pronto fue doblegada y el largo convoy invasor prosiguió su travesía por el desierto. Sin embargo, la columna de la Tercera División de infantería de marines fue resquebrajada en varios puntos, principalmente en las ciudades de Najaf y Kerbala, y en Nasirya. Las fuerzas invasoras frenaron su avance debido a una fuerte tormenta de arena y eso permitió que varias unidades iraquíes se replegaran del campo de batalla donde estaban siendo apabulladas. Pese a los continuos reveses militares, el gobierno de Irak insistía en mostrarse optimista y por eso trasladaba rápidamente a los periodistas a los sitios donde podían verse restos de tanques estadounidenses quemados.

Las operaciones de combate llevadas a cabo por la Coalición no estuvieron exentas de errores y problemas que cobraron la vida de varios efectivos. El 2 de abril, un F/A-18 Hornet estadounidense fue abatido sobre los cielos de Bagdad por las propias fuerzas estadounidenses. Uno de los casos más polémicos fue el ocurrido en el Hotel Palestina de Bagdad, donde se alojaban la mayoría de periodistas internacionales y que el 8 de abril recibió disparos de un tanque Abrams estadounidense. En esta acción perdieron la vida los periodistas José Couso de España y Taras Protsyuk de Ucrania. Se discutió largamente si los soldados en cuestión sabían de los huéspedes del hotel, pudiendo disparar a conciencia contra los periodistas para evitar "testigos molestos", o si simplemente dispararon al confundir las cámaras de televisión con posibles lanzamisiles u otros artefactos militares. Paralelamente, mientras se desarrollaban los principales combates en el sur y centro de Irak, unos mil soldados turcos penetraron algunos kilómetros en el norte para vigilar las acciones de los kurdos que luchaban contra las fuerzas iraquíes. Apoyados por aviones y tropas de la Coalición, los guerrilleros kurdos se lanzaron sobre las principales ciudades y poblados del norte del país, pero el ejército iraquí respondió lanzando 37 misiles tierra-tierra.


The list was last updated at 3:22 PM EST Thursday, November 2, 2006
Source: DefenseLINK

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