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 “we 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.”

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’s 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 “in earnest”, 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



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