Health Consequences of Service During the Persian Gulf War Initial Findings and Recommendations for Immediate Action (1995) / Chapter Skim
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Pages 18-62
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From page 18... ...
, the committee had learned of and evaluated the activities listed in Appendix E The committee sought to determine what is currently known about the health status of POW veterans, and about their opportunities for exposures to various agents present in their environment and through their occupations in the Persian Gulf.
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From page 19... ...
of the DoD was charged to review scientific and medical evidence relating to long-term health effects of exposure to low levels of neurotoxic agents. The Task Force on Persian Gulf War Health Effects of the DSB first met in December 1993.
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From page 20... ...
The board released an interim report of activities April 1994, and an updated report in May 1994. PL 102-585 also requires that the President of the United States designate an appropriate department or agency of the federal government to coordinate all research activities undertaken or funded by the Executive branch on the health consequences of military service in the Persian Gulf theater of operations during the Persian Gulf War (see Appendix C)
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From page 21... ...
further research on leishmaniasis, which has been mentioned as a possible cause of illness in PG veterans (NIH Technology Assessment Workshop Panel, 1994~. Reports of a complex of signs and symptoms among PG veterans that could not be attributed to a known diagnosis have led to concerns about a "mystery illness" or "Gulf War Syndrome." Even though these reports remain controversial, veterans, their families, and veteran service organizations have organized support for persons reporting such signs and symptoms.
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From page 22... ...
Other responses, especially the creation of the VA Persian Gulf Health Registry, represent efforts to identify and provide care to those self-identified as experiencing health problems consequential to Gulf War service. Though these efforts may be seen as responsive to community concerns and may also provide care to those who are ill, the methods used to select participants and collect data make these undertakings intrinsically unsuitable for systematic study of the health effects of the Gulf War.
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From page 23... ...
Because no control populations are studied, no attributions of health outcomes to Gulf War service or specific exposures can be made. Moreover, although studies of groups of individuals reporting illness sometimes can yield insight about either the characteristics of the illness or the exposures shared by those affected, these early studies of Gulf War veterans have not achieved either of these objectives.
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From page 24... ...
HEALTH-OUTCOME-BASED ACTIVITIES COMPLETED OR WELL UNDERWAY Constructing a Case Definition During and since the Persian Gulf War, a proportion of returned American service personnel have reported conditions that they attribute to their assignment to the Arabian peninsula and its environs, including their experiences during and after the military campaign continuum called Operation Desert Shield and Desert Storm. Most of these medical problems have been diagnosed and treated in the usual way.
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From page 25... ...
The question thus is not whether there are any "mystery illnesses" among the returning service personnel, but whether the number or characteristics of such conditions exceeds what one might expect if the same persons had not served in the Gulf War. In short, it is not enough to point to a small number of fully confused "mystery illnesses;" a control population is needed to provide U.S.-based background rates of such conditions.
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From page 26... ...
In particular, a study should be large enough to identify patterns of exposure or Gulf War experience among those complaining of Gulf War illness. A provisional case definition also may have a role in clinical management of Gulf War veterans.
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From page 27... ...
Outbreak Investigations In response to reports of outbreaks of unexplained signs and symptoms in Gulf War veterans, the DoD conducted two outbreak investigations to determine whether further study of these groups was necessary, or whether these particular "clusters" showed any indicators of common exposures that could be pursued as a connection to the presenting signs and symptoms. These "hot pursuit" studies, in which investigators focused on reported clusters of symptoms or illnesses among Persian Gulf War veterans, are similar in many respects to the frequent "cluster studies" of illness in the United States with a possible environmental cause (Caldwell, 1990~.
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From page 28... ...
The problem here is that the group coming to clinical evaluation is a small subset of a larger deployed force, and its representativeness to the larger deployed unit is unclear.
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Subsets of the deployed may be "hyper-susceptible," on either a biological or an immunological basis or both if exposed or in adjusting to the stresses of this very disruptive, potentially life-threatening activation to military duty. This study is useful in documenting the absence of a common underlying malady or environmental exposure among a group of reservists who initially appeared to have similar medical problems.
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From page 30... ...
Somewhat reassuring, however, is that this one study of aspects of a Gulf War-related illness did not show alarming patterns of disease or exposure, other than the possible impact of stress on the troops. The second "hot pursuit" investigation reported by the DoD involved the Reserve Naval Mobile Construction Battalion 24 (Seabees)
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From page 31... ...
The committee has reviewed the systems that have been put into place to collect data relevant to the follow-up of Gulf War veterans. Major ongoing efforts include the PG Family Support Centers, the Persian Gulf Health Registry Examination ("Health Registry Exam")
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. The Assistant Secretary of Defense for Health has initiated a program of standard assessments for Gulf War veterans who are still in active military status.
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It is not surprising that some Gulf War veterans developed manifestations of PTSD, either immediate or delayed (that is, onset more than six months after the stressful experience)
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From page 34... ...
contributes to the difficulty in estimating the prevalence of problems. The Fort Devens Reunion Survey, Boston VA Medical Center, was one of the earliest efforts to collect empirical data on returning military personnel following the conclusion of Operation Desert Storm.
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These assessments demonstrate a wide range of military-related and nonmilitary-related (family) stressors, and differences between the wartime experiences of active duty service members and reservists.
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From page 36... ...
tropica and resulting infection with leishmania: the occurrence of either cutaneous or visceral leishmaniasis; and the possibility that some component of unexplained illness may result from leishmania infection. One investigator has estimated that 5 to 6 percent of Gulf War veterans are infected with leishmania, which can lead to chronic illness (Magill, 1994~.
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From page 37... ...
Reproductive health outcomes linked to Persian Gulf War service have been noted prominently in the news media, but have received only limited scientific attention. To date, there are two evaluations that are complete or nearly complete: The Mississippi Cluster Study and a review of Army data by the Army Surgeon General's Office (PGVCB, 1994~.
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From page 38... ...
Surveillance of reproductive health is included in the DoD and VA clinical examinations. Information obtained by the VA Health Registry examination includes data about birth defects among children conceived before and after Gulf War deployment.
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From page 39... ...
This study will be useful in determining whether there are any unusual acute mortality causes in veterans of the Persian Gulf War, as compared with veterans of the same era who did not serve in the Persian Gulf; however, insuff~cient time has passed to observe any excess mortality from chronic diseases. VA Health Survey Study Plans The VA has indicated plans to conduct a health survey to estimate the prevalence of various symptoms and other health outcomes among Persian Gulf veterans and Persian Gulf-era veterans and their spouses and children in relation to certain environmental exposures.
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From page 40... ...
Of the 20,000 Iowa residents who served in the Gulf War, 3,500 were reservists or National Guard members and 16,800 were on active duty. Current plans call for the study sample to include approximately 2,000 Persian Gulf veterans and PG-era veterans, both men and women, and will include active duty, reserve, and national guard personnel who listed Iowa as their home of residence.
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From page 41... ...
Some details of the individually proposed studies follow: Seabees Study This study will assess health conditions, environmental exposures, and potential confounders among 2,250 active Seabees (two battalions of a total of 1,500 PG veterans and one battalion of 750 who were not deployed to the
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From page 42... ...
There is a good data system for evaluating the hospitalization of active duty service personnel; however, these data systems do not track non-DoD hospitalizations and outpatient visits.
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Nevertheless, given the scarcity of informative data on reproductive health outcomes among PG veterans, either completed or in progress, analyses of available data are justified. ASSESSMENTS OF EXPOSURE Environmental Only limited information is available to study possible links between environmental exposures and the unusual medical conditions that have been reported to be associated with service in the Persian Gulf War.
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From page 44... ...
Sanitary conditions in the Gulf theater need a systematic review that is not yet possible from available records. However, the following has been reported as a summary of the sanitary conditions.
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From page 45... ...
. The report that no signs of unexpected causes of death among sheep or camels were noted is not consistent with a report the committee received in the public meeting, where one veteran described his investigation of an episode of widespread unexplained sheep deaths (IOM public meeting, March 1, 19941.
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From page 46... ...
. It appears that approval of the use of diesel fuel for firing stoves was based on work undertaken at the Natick Research and Development Center before the Gulf War(Riley, 1992~.
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From page 47... ...
A GIS is being developed to integrate information on airborne and soil-based exposures, on meteorological conditions throughout the study interval, and on individual troop movements during Operation Desert Storm. Results from a pilot project in developing the GIS indicate that the approach should prove useful (USAEHA, 1994a)
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From page 48... ...
When individual exposures can be estimated, the effects of different levels of exposures to pollution from the oil fires can be estimated by using troop location during the largest part of the time in the Persian Gulf region. For example, the prevailing winds (from northwest in Kuwait and from northnorthwest in Saudi Arabia)
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From page 49... ...
It will then be possible and important to consider more specific questions about symptoms and health outcomes, including any effects of troop location and troop movement, and the time-courses of each of these. Because accurate information on exposure of individual persons is not available, epidemiological assessment of differences in illness or symptoms reported by different troops in various locations holds the greatest promise for indicating health problems related to chemical exposures.
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Autopsy Studies Some battlefield casualties were further examined at autopsy for possible connections between exposures and mortality or morbidity. The Armed Forces Institute of Pathology examined 85 corpses of troops who died in the Gulf War theater.
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Also, the elevated blood lead levels might indicate higher exposures to a variety of petroleum combustion and evaporation contaminates. If surviving troops suffered from acute lead poisoning, blood lead levels today would not be abnormal, but X-ray florescence might show that blood and bone levels are still increased.
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From page 52... ...
Welding/Cutting: Chromates, ozone, nitrogen dioxides, heated metal USAEHA industrial hygiene sampling showed increases in personal or general air monitoring results of outdoor occupational environment from selected locations, but these increased levels still did not exceed recommended standards. Threat of Chemical and Biological Warfare Agents Direct and indirect statements to this committee by several Gulf War veterans and groups speaking on their behalf have ranged from worried concern to firm statements that troops were exposed to unspecified war agents, chemical, biological, or both.
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From page 53... ...
Therefore, the committee believes that the illnesses that have been reported are not the result of chemical, biological, or toxin warfare, or accidental exposures to stored weapons or research material. The committee believes further that, in light of this negative evidence from highly placed sources, claims of exposure to chemical or biological warfare agents should not be made or given credence in the absence of reliable data to the contrary.
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From page 54... ...
DoD vaccinated some troops against anthrax and botulism, which were considered the biological warfare agents most likely to be encountered. These vaccines were not administered together.
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From page 55... ...
All active duty Army personnel receive one additional vaccine, as well as boosters to two of the basic training immunizations. Seven other vaccines, excluding anthrax and botulinum toxoids, are given for deployment to high-risk areas, to alert forces, as required by host country, or as directed by the surgeon general.
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From page 56... ...
These are examples of disease that clearly can be attributed to the vaccine. We have ng evidence that vaccines in general cause the non-specific complaints associated with service during Operation Desert Storm.
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From page 57... ...
All of the side effects noted above have been reported in PG military personnel taking PB for varying periods, including up to 50 percent in the U.S. Army Medical Research Institute of Chemical Defense (USAMRICD)
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From page 58... ...
First, the reactions of women may differ from those of men, especially if they are on birth control pills; the effects of PB on women have not been studied. Second, the troops were not screened for those conditions that are contraindications to use of PB, including asthma, peptic ulcer disease, liver disease, kidney disease, or hypersensitivity to PB, though predeployment medical examinations should assume that these conditions, other than sensitivity, were present in few of the troops on active duty.
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From page 59... ...
The DSB Task Force recommended doing a study of the effects of the drug and its metabolites to determine whether they cause long-te~m effects. The DSB Task Force believed that this was necessary because PB can prevent or ameliorate serious consequences of chemical warfare and must therefore be kept in the military's pharmacopoeia.
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From page 60... ...
During the Persian Gulf War, few personnel were exposed to DU. A friendly fire incident wounded 35 U.S.
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From page 61... ...
As of May 13, 1994, the VA Central Office reported that a group of six "distinguished and internationally renowned scientists was selected to be the ad hoc Scientific Review Committee for the proposals." They were selected on their reputation as "outstanding in the field of environmental science." The committee was to operate much like an NIH study section group; it was to "exclusively make judgment on the scientific quality of each proposal." These environmental research centers were established in July 1994, in the Veterans Affairs Medical Centers in Boston, Massachusetts; East Orange, New Jersey; and Portland, Oregon. The environmental centers are expected to be fully funded by October 1, 1994.
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From page 62... ...
62 HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR: INITIAL FINDINGS AND RECOMMENDATIONS There is a concern about funding levels for these studies and whether there is going to be sufficient funding to keep these studies going.
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