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. 2017 Jan;107(1):60–67. doi: 10.2105/AJPH.2016.303502

Tuberculosis Screening and Control in the US Military in War and Peace

James D Mancuso 1,✉
PMCID: PMC5308149  PMID: 27854533

Abstract

Tuberculosis (TB) has a well-established association with military populations, but the association of increased TB risk during armed conflict is less certain. This historical review focuses on the evolution of screening practices, the changing epidemiology of TB, and the risk of TB among US military service members during armed conflict from 1885 to the present. Overall, deployed soldiers were not at increased risk for TB compared with nondeployed soldiers in any of these conflicts, and the risk of TB in the US military largely reflected that of the underlying US population. Nevertheless, there are focal risk groups with higher rates of TB in the military, including prisoners of war. Although the principles of TB control in the military conform to those used in the civilian population, unique military exposures during both times of peace and of armed conflict require additional screening, surveillance, and control measures.

War and armed conflict have a long and well-established impact on morbidity and mortality from tuberculosis (TB).1 Increases in TB infection, disease, and death are seen in times of war, forced population displacement, and natural disasters.2 These crises result in conditions that promote the transmission and reactivation of TB, including population crowding and immunosuppression from famine and other infectious conditions.

Studies demonstrating increased morbidity and mortality from TB during war have largely focused on civilian populations. TB also has a long and well-established association with military populations, but the association of increased TB risk during armed conflict is less certain. The French Army physician Jean-Antoine Villemin found that TB was more frequent among soldiers stationed in barracks than among troops in the field, stating that “we observe that the army, decimated by TB in garrison, is almost free in war conditions.”3 Similarly, during World War I, Sir William Osler declared that “In a majority of cases, the germ enlists with the soldier. A few, very few, catch the disease in infected billets or barracks.”4 In fact, TB was never noted to be one of the “war epidemics” first described by Prinzing.5

A superb account of TB in the US military during World Wars I and II has recently been published.6 This historical review instead focuses on the evolution of screening practices, the changing epidemiology of TB, and the differences in TB risk among US military service members serving overseas during major armed conflicts from 1885 to the present. First, I examine screening and other control measures used by the US military to prevent TB infection and disease. Second, I describe TB trends within both military and civilian populations. Third, I assess the risk of TB infection, disease, and mortality during these conflicts, comparing those serving overseas (hereafter called “deployed” service members) with civilian and military populations remaining in the United States.

OVERVIEW, 1885 TO THE PRESENT

A summary comparison of rates of TB disease (i.e., “active” TB) and mortality in the US Army and the general population is presented in Figure 1; TB trends in the US Navy have been shown to be similar.7 TB rates have had a thousand-fold decline in morbidity and mortality in both military and civilian populations from 1885 to the present. Since World War II, Army rates have generally been lower than civilian rates, attributable in large part to the “healthy warrior” effect, a phenomenon analogous to the “healthy worker” effect.8 This effect arises as a result of the moderately restrictive standards for entry into military service.9 Other than World War I, armed conflict showed very little impact on declining TB trends. Next, we look more closely at the data from each conflict.

FIGURE 1—

FIGURE 1—

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Comparison of Tuberculosis Incidence and Mortality in US Civilian and Army Populations

PRE–WORLD WAR I—THE HYGIENE ERA

During the Civil War, the rate of admissions for TB was 924 per 100 000 and the death rate was 261 per 100 000.10 By the time of the Spanish-American War, the death rate was 197 per 100 000, but TB was still the leading cause of death in both military and civilian populations. Despite advances in medicine and increased focus on prevention,11 TB control measures prior to World War I were rudimentary. No screening program to identify those with tuberculosis was in place, and delays or failures in TB diagnosis were common. After the Spanish-American War, the rate of TB increased to more than 400 per 100 000, as seen in Figure 1, but this was attributed largely to the change in policy to retain TB patients and send them for “cure” rather than discharge them from the Army.12 The military converted Fort Stanton and Fort Bayard, installations in New Mexico, into sanatoriums modeled after others of the era (Figure A, available as a supplement to the online version of this article at http://www.ajph.org) for this purpose.13 Whereas soldiers who were native Filipinos or American Indians had rates of TB disease of up to eight times higher than the rest of the Army,14 TB rates were only slightly higher among troops deployed to the Philippines, Puerto Rico, and Cuba than among those based in the United States.

The main limitation of data from this era was the limited diagnostic capabilities available. Most cases were diagnosed clinically without the use of laboratory or x-ray, and no standardization of clinical diagnosis existed. The substantial variability and imprecision of these statistics were noted by Major Greenwood even at the time.15 Nevertheless, the Army Surgeon General’s Report from 1910 concluded that “a large proportion of the cases developing in the Army are recurrences of old and arrested infections acquired before enlistment.”16

WORLD WAR I—THE ERA OF PHYSICAL EXAMINATION SCREENING

Programmatic screening for tuberculosis in the US military began in World War I. Although declining, TB was still a leading cause of death in the United States.17 Additionally, the French experience of heavy disability losses from TB was of great concern.18 In the United States, the National TB Association (NTA) and its president, Herman Biggs, argued that “tuberculosis under the conditions of modern warfare is greatly to be dreaded,” and that “any man with even a very limited amount of pulmonary tuberculosis . . . is almost certain to break down under the physical strain of military training and army life and . . . become active [TB].”19 Others believed that tropical diseases such as malaria and dysentery would weaken soldiers’ immune system, making them more susceptible to TB in war conditions. These factors resulted in an NTA resolution urging the military to establish a comprehensive program of TB control.20

Colonel George Bushnell (Figure B, available as a supplement to the online version of this article at http://www.ajph.org), himself a TB patient, led the Army’s TB control efforts in World War I. He led the Army to publish Circular No. 20, “Screening Standards for Tuberculosis,” which established programmatic TB screening of all recruits by the “best available experts” using a standardized physical examination.21 Bushnell’s leadership led to a large effort with hundreds of clinicians involved; 22 596 of 3.3 million potential accessions were rejected from service, a prevalence of 687 per 100 000.22 His experiences during this screening process led him to claim that “given a sufficiently thorough and efficient examination, tuberculosis could practically be eliminated from an army.”23

However, there were limitations to screening by physical examination without the use of laboratories or x-rays. Its potential problems with sensitivity and specificity were discussed in Circular 20, in which Colonel Bushnell stated, “[t]here will probably be many cases . . . which have been diagnosticated on the ground of subjective symptoms . . . which are normal or indicate unimportant and healed lesions.”24 He also recognized that “men who desire to serve their country may conceal from patriotic motives, symptoms of tuberculosis,” while on the other hand also recognizing that the motives of pension and discharge could result in diagnostic bias in the opposite direction. Finally, he noted variability in diagnosis between providers, despite efforts at standardization.25

Despite these efforts to keep TB out of the Army, the risk of TB disease and death during World War I remained high, as shown in Figure 1 and Figure C (available as a supplement to the online version of this article at http://www.ajph.org). The rate of TB in the US military during the war rose to a peak of 1168 per 100 000.26 This dramatic increase suggested the possibility that overseas service resulted in excess TB risk among soldiers. However, as seen in Figure 2, the rate of disease remained lower among soldiers serving in Europe than among those in the United States throughout the conflict. Also evident are the peaks at the beginning and end of the war, when cases were discovered during military induction and discharge examinations.28 Colonel Bushnell concluded that “the care exercised in the United States in the elimination of tuberculosis from our Army was abundantly rewarded by the absence of any extensive prevalence of the disease among the troops in France” and that “the number of soldiers who had incurred manifest tuberculosis disease as the result of military service . . . is probably considerably less than 1 in 10.”29

FIGURE 2—

FIGURE 2—

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Comparison of Tuberculosis Rates Among Deployed and Nondeployed US Army Soldiers During World War I

Source. Office of the Surgeon General.27

WORLD WAR II—THE ERA OF RADIOGRAPHIC SCREENING

Colonel Esmond Long (Figure D, available as a supplement to the online version of this article at http://www.ajph.org), also a TB patient, led the Army’s TB control efforts in World War II. TB had been the leading cause of disability after World War I, costing more than $1 billion in hospitalization, vocational, and compensation payments after the war.30 Attempting to reduce this, the military began a universal preinduction chest x-ray screening program in World War II (Figure 3). Although the focus of the screening was to detect and exclude from military service those who had TB disease, it also included early diagnosis, hospitalization, and repeat screening at time of military discharge.32 As part of these efforts, 15.1 million men were examined by x-ray at induction into military service, leading to 129 000 rejections (0.86%).33 Although chest x-ray screening was felt to be an improvement over the physical exam screening performed in World War I, it also had significant limitations. Long concluded that the initial peak in TB incidence was attributable to “imperfections in the screening procedure,” including either no screening or poor-quality screening, which were more common at the beginning of the war.34 Another important finding was that 50% of TB cases occurring during military service had radiographic evidence of TB at time of induction35; many others likely had latent TB infection without radiographic abnormalities.

FIGURE 3—

FIGURE 3—

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Chest X-Ray Screening for Tuberculosis During World War II

Source. US Army Medical Department.31

Still, the rate of TB disease and death during World War II was one tenth those seen in World War I, as shown in Figure 1 and Figure C. This dramatic decline is probably attributable not only to the declining incidence of TB in the general US population, but also to the improved screening methods of identifying TB cases and excluding them from entry into service. The peak incidence of TB at the beginning and end of the war (Figure 2), when cases were discovered during induction and discharge examinations, was also similar to that seen in World War I. As it was in World War I, the rate of TB among deployed soldiers in World War II was consistently lower than among nondeployed soldiers (Figure 4).

FIGURE 4—

FIGURE 4—

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Comparison of Tuberculosis Incidence Among Deployed and Nondeployed US Army Soldiers During World War II

Source. Adapted from Long.36

aJanuary–June.

Colonel Long’s conclusions regarding low TB risk among US forces during overseas service in World War II were generally similar to those of Colonel Bushnell during World War I. His assessment differed in his recognition that deployment could result in TB transmission in certain risk groups. Colonel Long stated that “[f]oreign service per se did not affect the incidence of tuberculosis significantly, although the abnormally great exposures in certain theaters was associated with increased rates of breakdown.”37 He noted that among US military veterans, those who had been prisoners of war (POWs) had a risk of TB 3.5 times higher than those who had not. Other risk groups in the US military included Filipino scouts, medical personnel, and enemy POWs, with rates of up to 6900 per 100 000.38 Additionally, the rate of TB found at separation from service in 1945 and 1946 was consistently higher among those with foreign service than those without.39 Although some of this difference was attributed to cases missed at induction and to less-effective case finding in overseas war settings, Long found it likely that some degree of deployment-related transmission played a role, particularly in the later years of the war.40

After the war, TB control program leaders expressed interest in moving beyond the chest x-ray because of its variability between radiologists and unsatisfactory performance in identifying TB. Colonel Long noted that “in order to exclude all infected men, it would have been necessary to exclude also many men . . . who did not have tuberculosis.”41 He suggested that “[t]he hope for substantial improvement in screening efficiency rests on the use of . . . the tuberculin skin test.”

THE KOREAN WAR—AN ERA OF TRANSITION

Just a few years after World War II, US military forces were involved in the Korean conflict. As seen in Figure 1, the incidence of TB continued its decline in both military and civilian populations. The chest x-ray continued to be the Army’s primary screening tool. TB disease was highly endemic in the Korean population, with rates among enemy POWs of 4300 per 100 000 and mortality of 300 per 100 000.42 Despite this potential for exposure, no excess TB in military forces was observed, with consistently lower rates among deployed soldiers over the course of the war (Figure E, available as a supplement to the online version of this article at http://www.ajph.org). This led Colonel Charles Leedham, the Army’s TB expert in Korea, to observe that “In spite of widespread exposure to tuberculosis in the Far East, American troops came away practically unscathed.”43

THE VIETNAM WAR—THE ERA OF SKIN TEST SCREENING

By the time of the Vietnam War, TB rates in the United States had declined to 23 per 100 000.44 The US strategy for TB screening shifted toward the identification and treatment of latent TB infection (LTBI) in both civilian45 and military46 populations. The diagnostic test used to identify LTBI was the TB skin test, either using the TB tine test or the Mantoux method tuberculin skin test (TST). The prevalence of LTBI was much greater than that of TB disease, but its consequences were much less. LTBI was not contagious, as was TB disease, but it indicated a risk of progression to TB disease of up to 10% over a lifetime.47 The Navy began testing all recruits with the TST in 1948; in the following decades, a collaborative arrangement between the US Navy and the Public Health Service resulted in the Navy Recruit Study, which provided some of the seminal data on TB in the United States.48

The limitations of the TST had been recognized almost since its development in 1907. In their classic historical review, Edwards and Edwards remarked that “the story of the tuberculin test is punctuated with the unexpected, with periods of high hopes broken by periods of doubt and disillusion about its usefulness as a diagnostic test.”49 Testing for LTBI in the Army during the Vietnam War was not consistently performed or reported. The Army did not begin routine testing of all recruits until 1968, and even then the TB tine test was used.50 By 1972, however, concerns with the poor specificity of the TB tine test led the Army to switch to the use of the TST to “verify” each positive TB tine.51 This led to variability in the estimates of TB risk resulting from these conflicts. For example, Sowell found a 4.9% risk of TB tine conversion at time of redeployment,52 although he admitted to methodological problems that would be recognized in later pseudoepidemics of TST conversions.53 By contrast, annual testing in the Navy using only the TST showed that deployed sailors and marines had a lower risk of TST conversion (1.0%) than those who were not deployed (1.7%).54 The limitations of the skin test, the low-prevalence setting of the US military, and the methodological differences between these studies make these data difficult to interpret.

Although skin testing was the primary screening tool for LTBI, case finding and surveillance for TB disease continued as well. However, the diagnosis of TB disease during this era focused on mycobacterial culture and drug susceptibility, rather than the chest x-ray or clinical diagnosis used in previous eras. Although the rate of TB disease in the US military continued to decline during this period (Figure 1), one analysis documented 36 cases originating from exposure in Vietnam between 1965 and 1969.55 Drug-resistant TB was also noted among soldiers returning from the Vietnam conflict.56 However, as seen in Figure F (available as a supplement to the online version of this article at http://www.ajph.org), the rate of TB was again lower among the 2.7 million deployed soldiers than among nondeployed soldiers throughout most of the conflict. Additionally, the vast majority of military TB cases were attributable to traditional risk factors of foreign birth and tuberculosis infection existing prior to service.57 Finally, the rate of multidrug-resistant TB among deployed US service members was similar to that found among the general US population.58 Adding further complexity to the situation, several outbreaks of TB were noted and documented in sailors during this era, but these were attributable to activation of latent infection and subsequent onboard transmission within the closed environment of Navy ships,59 rather than exposures in Vietnam or other endemic regions.

IRAQ AND AFGHANISTAN—THE ERA OF TARGETED TESTING

Beginning in 2001 and 2003, the US military engaged in conflicts in Afghanistan and Iraq, countries that are TB-endemic.60 Despite the potential for exposure, the rate of TB disease in the military continued to decline after 2001 (Figure G, available as a supplement to the online version of this article at http://www.ajph.org) and remained about eight times lower—0.4 per 100 000 in 2012—than in the general US population,61 largely because of the “healthy warrior effect.” Deployment to TB-endemic countries has not been demonstrated to significantly increase the risk of TB disease in most average-risk service members.62 Nevertheless, other focal TB exposures associated with military service have been identified.63 Deployment to TB-endemic areas is estimated to be responsible for 24% of cases in the active component military, but activation of untreated LTBI existing prior to entry into military service is still the most important source of TB disease. Improvements in administrative and engineering controls since the Vietnam era dramatically reduced risk of shipboard transmission, although transmission can still occur if diagnosis is delayed.64

The occurrence of newly acquired LTBI resulting from deployment was also a concern because of the potential future reactivation to TB disease. These concerns resulted in an Army policy of requiring one predeployment TST and two more after deployment.65 More than one million service members deployed to these areas after 2001,66 resulting in millions of additional TSTs.67 Some early data suggested that transmission indeed was occurring. For example, during one deployment to Afghanistan, a unit reported TST conversions in 15% of their soldiers.68 However, a detailed investigation found that these consisted mostly of false positives, and pseudoepidemics of TST conversions were subsequently found to be common in deployed settings. In a recent study, LTBI incidence occurring after deployment was estimated to be 0.6%, which was the same as that seen among the nondeployed military population.69 However, this study again had significant methodological limitations noted by the authors, including an inability to assess groups which may have had increased risk of LTBI, such as health care workers, those guarding detainees, and personnel embedded into host nation units.

Furthermore, the TST no longer seemed to correlate well with risk of progression to TB disease during this period. Figure 5, constructed from multiple sources of US Navy data,70 superimposes prevalent TST reactions among new recruits with the incidence rates of TB disease. Although the prevalence of TST reactors initially had a strong correlation with TB disease, these trends began to diverge in the 1990s. This finding suggests that the TST may not reflect the same risk of activation to TB disease as in previous eras. This might be because of a greater proportion of false positive TSTs, a lower risk of progression attributable to treatment of LTBI, or other host or pathogen factors.

FIGURE 5—

FIGURE 5—

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Incidence of Tuberculosis (TB) Disease and Prevalence of Tuberculin Skin Test (TST) Reactors in the US Navy

Note. PY = person-years.

Because of concerns of adverse medication effects (particularly hepatotoxicity) from unnecessary treatment of false positives, the Centers for Disease Control and Prevention recommends targeted testing for LTBI. This means that “tuberculin testing programs should be conducted only among groups at high risk and discouraged in those at low risk.”71 The military has now moved to targeted testing in all three services to align with this recommendation, testing only those at increased risk for TB infection or progression to TB disease.72 Initial enthusiasm for improved specificity of the interferon-gamma release assays (IGRAs) was tempered by findings that these tests performed no better than the TST in the low-prevalence setting of the military.73 Their use is therefore not a substitute for targeted testing.74

CONCLUSIONS

Throughout its history, TB has posed a threat to the health of the US military in times of both peace and war. Although the rate of TB disease in the US military has generally been low, reflecting that of the general US population, the military has also had unique challenges to TB control. Deployment to TB-endemic areas, other overseas military service in TB-endemic areas, and residence in congregate settings such as basic training and aboard naval vessels have been less common but still important sources of TB infection and disease. Although overall military service during armed conflict has not been seen to increase the risk of TB, there are groups within these deployed populations that are likely to have focal exposures and increased risk.

The principles of TB control in the US military have generally agreed with and conformed to those of the civilian US population.75 Nevertheless, the unique military exposures during both times of peace and of armed conflict have required additional screening, surveillance, and control measures. Although the need for these additional measures has been consistent throughout history, the methods used for TB screening and control during these conflicts have evolved because of changes in definitions and diagnostics. The changing epidemiology of TB seen in the military likely reflects temporal changes in risk, changes in diagnostics, and also perhaps the changing nature of military conflicts. Although these limitations affect the comparability of surveillance data between eras, most of these issues are common to all surveillance data. This report attempts to account for some of these changes by demonstrating consistency in findings over time, particularly in comparisons between deployed and nondeployed populations and between military and civilian populations.

What can other TB control programs learn from the US military’s experience with TB during armed conflict? The US military is tantalizingly close to TB elimination, defined as an incidence of less than one per million population.76 Nevertheless, as the disease becomes increasingly rare, the challenge is not only to maintain program focus, resources, and expertise, but also to carefully target program activities toward the ultimate goal of TB elimination. The US military must continue to consider TB a serious public health threat if it is to avoid resurgences similar to those seen in the latter part of the 20th century.

ACKNOWLEDGMENTS

I thank Naomi Aronson, Lisa Keep, and Yescenia Wilkins for their helpful reviews and comments on the article while in preparation.

ENDNOTES

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