Several sub-Saharan militaries have large percentages of troops with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome. With the arrival of avian influenza in Africa, the potential exists that some of those soldiers might also become infected with H5N1, the virus responsible for the disease. Two possible scenarios have been postulated regarding how such a coinfection of HIV and H5N1 might present. (1) Soldiers already weakened by HIV/acquired immunodeficiency syndrome rapidly succumb to H5N1. The cause of death is a “cytokine storm,” essentially a runaway inflammatory response. (2) The weakened immune system prevents the cytokine storm from occurring; however, H5N1 is still present, replicating, and being shed, leading to the infection of others. A cytokine storm is particularly dangerous for individuals of military age, as evidenced by the large number of soldiers who died during the 1918 influenza epidemic. If large numbers of sub-Saharan soldiers suffer a similar fate from avian influenza, then military and political instability could develop.
Introduction
A vlan Influenza, also known as bird flu, is caused by viruses that normally infect only birds and, less frequently, pigs.1 Although the viruses are highly species specific, they have on rare occasions crossed the species barrier to infect humans. Such is the case with avian influenza A (H5N1), the present cause of much concern. The World Health Organization (WHO) reports that human infections caused by direct transmission of avian influenza viruses from birds, H5N1, is responsible for the largest number of cases of severe disease or death.2 A devastating pandemic could ensue if the virus eventually acquires the ability to be easily transmitted among humans.3
This increased transmissibility might occur through an antigenie shift, where two different influenza strains genetically recombine to form a new subtype. In the past, this mechanism, involving viruses other than H5N1, has been responsible for several major influenza outbreaks, including the Asian (H2N2) and Hong Kong (H3N2) influenza pandemics of 1955 and 1968, respectively.4
The relatively recent arrival of H5N1 in Africa, where human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) is endemic in many countries, raises both concerns and uncertainties, including those of a military nature. Currently, it is not known what the outcome would be if people with HIV/AIDS became coinfected with H5N1. Because many sub-Saharan African militaries have large percentages of soldiers with HIV/AIDS, especially in comparison with their corresponding civilian populations, questions exist regarding what effect avian influenza might have on such troops, as well as their comrades, and whether it could affect military capabilities.5
If large numbers of sub-Saharan troops are killed or incapacitated by the avian flu, then it is possible that some countries would suffer internal instability. Other countries might take advantage of such situations, with the result that regional conflicts could erupt. Besides the enormous human toll that could result from the fighting, important exports to the United States, including oil, could be significantly disrupted.
With several peacekeeping missions involving African troops, there is an additional concern that they could be responsible for disseminating H5N1 to other regions. Their close contact with civilian populations in host countries, and the potentially large number of subsequent fatalities from the disease, could cause instability in countries originally spared from avian influenza.
By examining medical, military, and political scenarios that might occur if large numbers of African troops become coinfected with HIV/AIDS and H5N1, it is hoped that measures can be developed to mitigate or even prevent the worst possible outcomes. In an era of increasing globalization, providing effective interventions would probably benefit not only the countries of Africa but also other nations, including the United States.
Geographic Spread of the Disease
H5N1 has been significantly more widespread in poultry and wild birds than in people. The virus possibly arose in birds in southern China before 1997.6 By mid-2003, large numbers of birds in Asia were infected, although this initially went undetected and unreported. The disease continued to spread among birds, and it is now considered endemic in many parts of Vietnam and Indonesia, as well as some areas of Cambodia, China, Thailand, and possibly the Lao People’s Democratic Republic. Other countries in Asia and Europe have also reported infected poultry and/or wild birds, although not to the extent that the disease would be considered endemic. Three countries, namely, Japan, the Republic of Korea, and Malaysia, had outbreaks of H5N1 in poultry but were able to control them, at least initially, through methods such as destroying the birds. Indeed, killing infected poultry is considered one of the cornerstones in the strategy to combat avian influenza. Because the disease appears to be transmitted to people via prolonged contact with H5N1positive birds, methods such as destroying these animals possibly help to prevent the spread of disease to other flocks as well as to humans. It should be noted that, although birds at least are a large reservoir of the virus and likely are a direct vector for human infection, animals such as dogs and cats, which feed on infected birds, are being considered as possible intermediate mammalian vectors, which is why South Korea, in attempting to control an outbreak of H5N1, plans to cull them.7
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