GULF WAR and HEALTH
Abigail E. Mitchell, Laura B. Sivitz, Robert E. Black, Editors
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This study was supported by Contract V101(93)P-2155 between the National Academy of Sciences and the Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
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COMMITTEE ON GULF WAR AND HEALTH: INFECTIOUS DISEASES
ROBERT E. BLACK, MD, MPH, Edgar Berman Professor and Chair,
Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
MARTIN J. BLASER, MD, Frederick H. King Professor of Internal Medicine, Chair of the Department of Medicine, and Professor of Microbiology,
New York University School of Medicine, New York
RICHARD D. CLOVER, MD, Dean and Professor,
School of Public Health and Information Sciences, University of Louisville, KY
MYRON S. COHEN, MD, J. Herbert Bate Distinguished Professor of Medicine and Microbiology,
Immunology and Public Health, University of North Carolina School of Medicine, Chapel Hill
JERROLD J. ELLNER, MD, Professor and Chair of the New Jersey Medical School at the University of Medicine and Dentistry of New Jersey,
JEANNE MARRAZZO, MD, MPH, Associate Professor,
Department of Medicine, University of Washington School of Medicine, Seattle
MEGAN MURRAY, MD, ScD, MPH, Assistant Professor of Epidemiology,
Harvard University, School of Public Health, Boston, MA
EDWARD C. OLDFIELD III, MD, Director,
Division of Infectious Diseases, Eastern Virginia Medical School, Norfolk
RANDALL R. REVES, MD, MSc, Professor,
Division of Infectious Diseases, University of Colorado Health Sciences Center, Denver
EDWARD T. RYAN, MD, Director,
Tropical and Geographic Medicine Center, Massachusetts General Hospital, and Associate Professor of Medicine, Harvard Medical School, Boston, MA
STEN H. VERMUND, MD, PhD, Amos Christie Chair and Director,
Vanderbilt University Institute for Global Health, and Professor of Pediatrics, Medicine, Preventive Medicine, and Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, TN
DAWN M. WESSON, PhD, Associate Professor,
Tulane School of Public Health and Tropical Medicine, New Orleans, LA
ABIGAIL E. MITCHELL, PhD, Senior Program Officer
LAURA B. SIVITZ, MSJ, Senior Program Associate
DEEPALI M. PATEL, Senior Program Associate
MICHAEL J. SCHNEIDER, MPH, Senior Program Associate
PETER JAMES, Research Associate
DAMIKA WEBB, Research Assistant
DAVID J. TOLLERUD, Program Assistant
RENEE WLODARCZYK, Program Assistant
NORMAN GROSSBLATT, Senior Editor
ROSE MARIE MARTINEZ, ScD, Director, Board on Population Health and Public Health Practice
This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards of objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following for their review of this report:
Lawrence R. Ash, Professor Emeritus, Department of Epidemiology, University of California, Los Angeles School of Public Health
Michele Barry, Tropical Medicine and International Health Programs, Yale University School of Medicine
Herbert DuPont, School of Public Health, University of Texas Health Science Center at Houston and St. Luke’s Episcopal Hospital
Robert Edelman, Travelers’ Health Clinic, University of Maryland
David Hill, National Travel Health Network and Centre, Hospital for Tropical Diseases, London
Richard T. Johnson, Department of Neurology, The Johns Hopkins Hospital
Arthur Reingold, Division of Epidemiology, University of California, Berkeley
Philip K. Russell, Professor Emeritus, Johns Hopkins School of Public Health
Mark Wallace, Independent Infectious Diseases Consultant and United States Navy, Retired
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by George Rutherford, Institute of Global Health, University of California, San Francisco, and Elaine L. Larson, School of Nursing, Columbia University. Appointed by the National Research Council, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
Infectious diseases have been a problem for military personnel throughout history. The consequences in previous conflicts have ranged from frequent illnesses disrupting daily activities and readiness to widespread deaths. Preventive measures, early diagnosis, and treatment greatly limit the exposures and acute illnesses of troops today in comparison with those in armies of the past, but infections and consequent acute illnesses still occur. In addition, long-term adverse health outcomes of some pathogens are increasingly recognized.
The deployment of about 700,000 US troops to the Persian Gulf region in the Gulf War of 1991 potentially exposed them to pathogens that they had not encountered at home. After returning from that short campaign, some veterans reported symptoms and expressed the concern that they may have been exposed to biologic, chemical, or physical agents during their service in the Persian Gulf. In response to those concerns, the US Department of Veterans Affairs (VA) commissioned the Institute of Medicine (IOM) to review the scientific evidence on possible long-term adverse health outcomes of exposure to specific biologic, chemical, and physical agents and to draw conclusions on the strength of that evidence with regard to delayed and chronic illnesses of the veterans.
The authorizing legislation for the work of IOM included several infectious diseases endemic in the Persian Gulf region. In the charge to our committee, VA asked that we not limit consideration to those diseases but rather include all infectious exposures that had been documented in troops and consider their possible long-term adverse health outcomes. It further requested that the time and geographic dimensions of the committee’s work be widened to include military personnel deployed as part of Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF) in the Persian Gulf region. OEF began in 2001, and OIF in 2003; they continued as this report went to press. The number of military personnel involved in the more recent conflicts now exceeds that in the 1991 Gulf War. Furthermore, they have remained for much longer periods on the average than in the Gulf War, and many have been deployed for more than one tour in this region. Thus, the potential for exposure to endemic pathogens is greater in these troops than in those deployed to the Gulf War. Because the possible exposures are relatively recent, there has been only a short time to observe long-term adverse health outcomes. The committee needed to rely on observations from the Gulf War, information on infectious diseases in OEF and OIF, and evidence in the scientific literature to allow conclusions to be drawn on possible long-term adverse health outcomes. With further time to observe the possible consequences of infectious exposures, the knowledge base will increase. Given the continuing presence of troops in the areas and the variable nature of infectious diseases, the exposures may change.
Valuable contributions were made to this study by a number of people who shared their expertise on infectious diseases. On behalf of the committee, I thank several of them—K. Craig Hyams, MD, MPH, chief consultant, Occupational and Environmental Health Strategic Healthcare Group, VA; Michael Kilpatrick, MD, deputy director, Deployment Health Support, Department of Defense (DOD); and Alan Magill, MD, science director, Walter Reed Army Institute of Research, for presenting information on infectious diseases that have been diagnosed in military personnel during the Gulf War, OIF, and OEF and Richard Reithinger, PhD,
infectious diseases consultant, for presenting information on infectious diseases that are endemic in southwest and south-central Asia to the committee at its May 26, 2005 meeting. I also thank William Winkenwerder, Jr., MD, MBA, assistant secretary for defense for health affairs, and his staff at DOD’s Deployment Health Support for expeditiously providing information to the committee on DOD health-related policies. Finally, the committee is grateful for the insight provided by representatives of veteran service organizations, veterans, and others who spoke with the committee or sent in written testimony.
I am grateful for the great expertise the committee members brought to bear on this subject. Furthermore, the report would not have been successfully completed without the diligent and expert contributions of the IOM staff, led by Abigail Mitchell and including Laura Sivitz, Deepali Patel, Michael Schneider, Peter James, Damika Webb, David Tollerud, and Renee Wlodarczyk.
Robert E. Black, MD, MPH, Chair