Gulf War syndrome

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Military personnel examine the remains of a Scud during the Gulf War.

Gulf War syndrome (GWS) or Gulf War illness (GWI) is an illness reported by combat veterans of the 1991 Persian Gulf War typified by a range of medically unexplained symptoms.[1][2] Symptoms attributed to this syndrome have been wide-ranging and include acute and chronic ailments. These include fatigue, loss of muscle control, headaches, dizziness and loss of balance, memory problems, muscle and joint pain, indigestion, skin problems. [3]

Since the end of the Gulf War, the U.S. Department of Veterans Affairs (VA) and the British Ministry of Defence have conducted numerous studies on Gulf War Veterans. The latest studies have determined that while the physical health of deployed veterans is similar to that of non-deployed veterans, there is an increase in 4 out of the 12 medical conditions reportedly associated with Gulf War syndrome [4] While the exact source of veteran health complaints remains unknown, several possible causes have been investigated including post traumatic stress disorder, vaccinations, exposure to chemical weapons, smoke from oil well fires, pesticides, and depleted uranium. [5]

In the United States in 2008, the federally mandated Research Advisory Committee on Gulf War Veterans' Illnesses released a 452-page report indicating that roughly 1 in 4 of the 697,000 veterans who served in the first Gulf War are afflicted with the disorder. The report stated that "scientific evidence leaves no question that Gulf War illness is a real condition with real causes and serious consequences for affected veterans." , [5] The report concluded that use of pyridostigmine bromide pills, given to protect troops from effects of nerve agents, and pesticide use during deployment were the two conditions most closely linked to illness[5] . Researchers have also recently narrowed impaired neuropsychological function to individuals exposed to the destruction of the Khamisiyah weapons depot where large quantities of the neurotoxin Sarin was stored. [6]

Contents

[edit] Classification

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[edit] Signs and symptoms

Summary of the Operation Desert Storm offensive ground campaign, February 24-28, 1991, by nationality (click for detail).

About one-fourth of the 697,000 U.S. servicemen and women in the first Gulf War have shown symptoms related to Gulf War Syndrome.

U.S. and UK, with the highest rates of excess illness, are distinguished from the other nations by higher rates of pesticide use, use of anthrax vaccine, and somewhat higher rates of exposures to oil fire smoke and reported chemical alerts. France, with possibly the lowest illness rates, had lower rates of pesticide use, and no use of anthrax vaccine.[7] French troops also served to the North and West of all other combat troops, away and upwind of major combat engagements[8] .

Excess prevalence of general symptoms[9]*
Symptom U.S. UK Australia Denmark
Fatigue 23% 23% 10% 16%
Headache 17% 18% 7% 13%
Memory problems 32% 28% 12% 23%
Muscle/joint pain 18% 17% 5% 2% (<2%)
Diarrhea 16% 9% 13%
Dyspepsia/indigestion 12% 5% 9%
Neurological problems 16% 8% 12%
Terminal tumors 33% 9% 11%
Excess prevalence of recognized medical conditions[10]
Condition U.S. UK Canada Australia
Skin conditions 20-21% 21% 4-7% 4%
Arthritis/joint problems 6-11% 10% (-1)-3% 2%
Gastro-intestinal (GI) problems 15% 5-7% 1%
Respiratory problem 4-7% 2% 2-5% 1%
Chronic fatigue syndrome 1-4% 3% 0%
Post-traumatic stress disorder 2-6% 9% 6% 3%
Chronic multi-symptom illness 13-25% 26%

[edit] Causes

The United States Congress mandated the National Academies of Science Institute of Medicine to provide nine reports on Gulf War Syndrome since 1998. [11]

Aside from the many physical and psychological issues involving any war zone deployment, Gulf War veterans were exposed to a unique mix of hazards not previously experienced during wartime. These included pyridostigmine bromide pills given to protect troops from the effects of nerve agents, depleted uranium munitions, and anthrax and botulinum vaccines. The oil and smoke that spewed for months from hundreds of burning oil wells presented another exposure hazard not previously encountered in a warzone. Military personnel also had to cope with swarms of insects, requiring the widespread use of pesticides.

United States Veterans Affairs Secretary Anthony Principi's panel found that pre-2005 studies suggested the veterans' illnesses are neurological and apparently are linked to exposure to neurotoxins, such as the nerve gas sarin, the anti-nerve gas drug pyridostigmine bromide, and pesticides that affect the nervous system. The review committee concluded that "Research studies conducted since the war have consistently indicated that psychiatric illness, combat experience or other deployment-related stressors do not explain Gulf War veterans illnesses in the large majority of ill veterans," the review committee said.[12]

[edit] Nerve gas medication

The US military issued pyridostigmine bromide pills, PB, to protect against exposure to nerve gas agents such as sarin and soman. PB was used to pretreat nerve agent poisoning and is not a vaccine however taken before exposure to nerve agents, PB was thought to increase the efficacy of nerve agent antidotes. PB had been used since 1955 for patients suffering from myasthenia gravis with dosed up to 1,500mg a day, far in excess of the 90mg given to soldiers, and was considered safe by the FDA at either level for indefinite use and its use to pretreat nerve agent exposure has recently been approved. [13]

About half of U.S. Gulf War veterans report using PB during deployment, with greatest use among Army personnel. Concerns have been raised about the possibility of increased health problems from PB when it is combined with other risk factors.

Given both the large body of epidemiological data on myasthenia gravis patients and follow up studies done on veterans it was concluded that while it was unlikely that health effects reported today by Gulf War veterans are the result of exposure solely to PB, use of PB was causally associated with illness. [5]

[edit] Pesticide use

The use of pesticides and insect repellants during the first Gulf War is credited with keeping rates of pest-borne diseases low. Pesticide use is one of only two exposures consistently identified by Gulf War epidemiologic studies to be significantly associated with Gulf War illness.[14] Multisymptom illness profiles similar to Gulf War illness have been associated with low-level pesticide exposures in other human populations. In addition, Gulf War studies have identified dose-response effects, indicating that greater pesticide use is more strongly associated with Gulf War illness than more limited use. [15]Pesticide use during the Gulf War has also been associated with neurocognitive deficits and neuroendocrine alterations in Gulf War veterans in clinical studies conducted follownf the end of the war. The 2008 report concluded that “all available sources of evidence combine to support a consistent and compelling case that pesticide use during the Gulf War is causally associated with Gulf War illness.”[5]

[edit] Chemical weapon exposure

Iraq-gwi-map.jpg

Many of the symptoms of Gulf War syndrome are similar to the symptoms of organophosphate, mustard gas, and nerve gas poisoning.[16][17] Gulf War veterans were exposed to a number of sources of these compounds, including nerve gas and pesticides.[18]

Chemical detection units from the Czech Republic, France, and Britain confirmed chemical agents. French detection units detected chemical agents. Both Czech and French forces reported detections immediately to U.S. forces. U.S. forces detected, confirmed, and reported chemical agents; and U.S. soldiers were awarded medals for detecting chemical agents. The Riegle Report said that chemical alarms went off 18,000 times during the Gulf War. After the air war started on January 16, 1991, coalition forces were chronically exposed to low but nonlethal levels of chemical and biological agents released primarily by direct Iraqi attack via missiles, rockets, artillery, or aircraft munitions and by fallout from allied bombings of Iraqi chemical warfare munitions facilities. [19]

In 1997, the US Government released an unclassified report that stated, "The US Intelligence Community (IC) has assessed that Iraq did not use chemical weapons during the Gulf War. However, based on a comprehensive review of intelligence information and relevant information made available by the United Nations Special Commission (UNSCOM), we conclude that chemical warfare (CW) agent was released as a result of US postwar demolition of rockets with chemical warheads at several sites including Khamisiyah". Over 125,000 U.S. troops and 9,000 UK troops were exposed to nerve gas and mustard gas when the Iraqi depot in Khamisiyah was destroyed . " [20]

Recent studies have confirmed earlier suspicions that exposure that sarin, in combination with other contaminants such as pesticides and PB were related to reports of veteran illness. Estimates range from 100,000 to 300,000 individuals exposed to nerve agents [21][22]

[edit] Oil well fires

During the war, many oil wells were set on fire in Kuwait by the retreating Iraqi army, and the smoke from those fires was inhaled by large numbers of soldiers, many of whom suffered acute pulmonary and other chronic effects, including asthma and bronchitis. However, firefighters who were assigned to the oil well fires and encountered the smoke, but who did not take part in combat, have not had GWI symptoms.[23]

[edit] Anthrax vaccine

Iraq had loaded anthrax, botulinum toxin, and aflatoxin into missiles and artillery shells in preparing for the Gulf War and that these munitions were deployed to four locations in Iraq.[24] During Operation Desert Storm, 41% of U.S. combat soldiers and 75% of UK combat soldiers were vaccinated against anthrax.[25] Like all vaccines, the early 1990s version of the anthrax vaccine was a source of several side effects. Reactions included local skin irritation, some lasting for weeks or months.[26] While the Food and Drug Administration (FDA) approved the vaccine, it never went through large scale clinical trials, unlike most other vaccines in the United States.[27] While recent studies have demonstrated the vaccine’s is highly reactogenic [28], there is no clear evidence or epidemiological studies on gulf War veterans linking the vaccine to gulf War Syndrome. Combining this with the lack of symptoms from current deployments of individuals who have received the vaccine led the Committee on Gulf War Veterans’ Illnesses to conclude that the vaccine is not a likely cause of Gulf War illness for most ill veterans. [5]

[edit] Depleted uranium

Major Gulf War enagagements in which DU rounds were used.

Depleted uranium (DU) was widely used in tank kinetic energy penetrator and autocannon rounds for the first time in the Gulf War. DU is a dense, weakly radioactive metal with physical properties that make it particularly useful in weapons. Munitions often burn when they impact a hard target, producing toxic combustion products. Roughly 320 tons of DU were used during the conflict. [29] After military personnel began reporting unexplained health problems in the aftermath of the Gulf War, questions were raised about the health effect of exposure to depleted uranium.

Sandia National Laboratory commissioned a two year study on the health effects of depleted uranium exposure during the Gulf War. The study found no epidemiological evidence for increase in birth defects and that claims of adverse chronic health risks from DU exposure were not supported follow up studies on veterans. [30] A RAND Corporation study concluded that the evidence does not suggest long-term excess morbidity or mortality for DU exposure found in veterans.[31]

The 2008 Research Advisory Committee on Gulf War Veterans’ Illnesses similarly concluded that while there were unanswered questions about the long term effects of DU exposure, it was not likely a primary cause of Gulf War Syndrome. [5]

[edit] Diagnosis

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[edit] Management

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[edit] Epidemiology

Epidemiologic studies have been performed evaluating many suspected factors for Gulf War illness as seen in veteran populations. Below is a summary of all epidemiologic studies of veterans displaying multisymptom illness and their exposure to suspect conditions. [32]

Epidemiologic Studies of Gulf War Veterans: Association of Deployment Exposures With Multisymptom Illness[33]
Preliminary Analysis (no controls for exposure) Adjusted Analysis (controlling for effects of exposure) Clinical Evaluations
GWV population in which association was assessed GWV population in which association was statistically significant GWV population in which association was assessed GWV population in which association was statistically significant Dose response effect identified?
Pyridostigmine bromide 10 9 6 6 ✓ Associated with neurocognitive and HPA differences in GW vets
Pesticides 10 10 6 5 ✓ Associated with neurocognitive and HPA differences in GW vets
Physiological Stressors 14 13 7 1
Chemical Weapons 16 13 5 3 Associated with neurocognitive and HPA differences in GW vets
Oil Well Fires 9 8 4 2 ✓
Number of Vaccines 2 2 1 1 ✓
Anthrax Vaccine 5 5 2 1
Tent Heater Exhaust 5 4 2 1
Sand/Particulates 3 3 3 1
Depleted Uranium 5 3 1 0

[edit] Controversy

Similar syndromes have been seen as an after effect of other conflicts — for example, 'shell shock' after World War I, and post-traumatic stress disorder (PTSD) after the Vietnam War. A review of the medical records of 15,000 American Civil War soldiers showed that "those who lost at least 5% of their company had a 51% increased risk of later development of cardiac, gastrointestinal, or nervous disease."[34]

A November 1996 article in the New England Journal of Medicine found no difference in death rates, hospitalization rates or self-reported symptoms between Persian Gulf veterans and non-Persian Gulf veterans. This article was a compilation of dozens of individual studies involving tens of thousands of veterans. The study did find a statistically significant elevation in the number of traffic accidents suffered by Persian Gulf vets vs. non-Persian Gulf vets. [35] An April, 1998 article in Emerging Infectious Diseases similarly found no increased rate of hospitalization and better health overall for veterans of the Persian Gulf War vs. Veterans who stayed home. James D. Knoke and Gregory C. Gray, Naval Health Research Center, San Diego, California, USA, Emerging Infectious Diseases 1998 Oct-Dec;4(4):707-9, Hospitalizations for unexplained illnesses among U.S. veterans of the Persian Gulf War.[36]

Despite these studies, on November 17, 2008 a congressionally appointed committee called the Research Advisory Committee on Gulf War Veterans' Illnesses, staffed with independent scientists and veterans appointed by the Department of Veterans Affairs, announced that the syndrome is a distinct physical condition. The committee recommended that Congress increase funding for research on Gulf War veterans' health to at least $60 million per year.[37] In January 2006, a study led by Melvin Blanchard and published by the Journal of Epidemiology, part of the "National Health Survey of Gulf War-Era Veterans and Their Families", stated that veterans deployed in the Persian Gulf War had nearly twice the prevalence of chronic multisymptom illness, a cluster of symptoms similar to a set of conditions often called Gulf War Syndrome.[38]

[edit] See also

[edit] References

  1. ^ Iversen A, Chalder T, Wessely S. "Gulf War Illness: lessons from medically unexplained symptoms." Clin Psychol Rev. 2007 Oct;27(7):842-54.
  2. ^ Gronseth GS. "Gulf war syndrome: a toxic exposure? A systematic review." Neurol Clin. 2005 May;23(2):523-40.
  3. ^ University of Virginia. Gulf War Syndrome
  4. ^ Annals of Internal Medicine. Gulf War Veterans' Health: Medical Evaluation of a U.S. Cohort. June 7, 2005
  5. ^ a b c d e f g Gulf War Illness and Health of Gulf War Veterans
  6. ^ Journal of the International Neuropsychological Society. Neuropsychological functioning of U.S. Gulf War veterans 10 years after the war.
  7. ^ Research Advisory Committee on Gulf War Veterans’ Illnesses December 12-13, 2005 Committee Meeting Minutes (page 78)
  8. ^ Research Advisory Committee on Gulf War Veterans’ Illnesses December 12-13, 2005 Committee Meeting Minutes (page 68)
  9. ^ Research Advisory Committee on Gulf War Veterans’ Illnesses December 12-13, 2005 Committee Meeting Minutes (page 70), This table applies only to coalition forces involved in combat.
  10. ^ Research Advisory Committee on Gulf War Veterans’ Illnesses December 12-13, 2005 Committee Meeting Minutes (page 71)
  11. ^ VA Press Release
  12. ^ Research Advisory Committee on Gulf War Veterans’ Illnesses 2004 Report
  13. ^ PBS Frontline. PYRIDOSTIGMINE BROMIDE Use in the First Gulf War
  14. ^ U.S. Department of Defense, Office of the Special Assistant to the Undersecretary of Defense (Personnel and Readiness) for Gulf War Illnesses Medical Readiness and Military Deployments. Environmental Exposure Report: Pesticides Final Report. Washington, D.C. April 17, 2003.
  15. ^ Krengel M, Sullivan K. Neuropsychological Functioning in Gulf War Veterans Exposed to Pesticides and Pyridostigmine Bromide. Fort Detrick, MD: U.S. Army Medical Research and Materiel Command; August, 2008. W81XWH-04-1-0118
  16. ^ Friis, Robert H.; Thomas A. Sellers (2004). Epidemiology for Public Health Practice. Jones & Bartlett Publishers. ISBN 0763731706. 
  17. ^ Spektor, Dalia M.; Richard A. Rettig, Lee H. Hilborne, Beatrice Alexandra Golomb, Grant N. Marshall, L. M. Davis, Cathy Donald Sherbourne, Naomi H. Harley, William S. Augerson, Gary Cecchine, United States Dept. of Defense (1998). A Review of the Scientific Literature as it Pertains to Gulf War Illnesses. Rand Corporation. ISBN 0833026801. 
  18. ^ "Campaigners hail 'nerve gas link' to Gulf War Syndrome - Scotsman.com News". News.scotsman.com. http://news.scotsman.com/topics.cfm?tid=847&id=1311632004. Retrieved 2009-11-24. 
  19. ^ The Riegle Report
  20. ^ Khamisiyah: A Historical Perspective on Related Intelligence by the Persian Gulf War Illnesses Task Force (9 April 1997)
  21. ^ Beatrice Alexandra Golomb.Acetylcholinesterase inhibitors and Gulf War illnesses
  22. ^ Navy Times. Review says chemicals caused Gulf War illness
  23. ^ Research Advisory Committee on Gulf War Veterans’ Illnesses December 12-13, 2005 Committee Meeting Minutes (pages 148, 154, 156)
  24. ^ Anthony H. Cordesman. Iraq and the War of Sanctions: Conventional Threats and Weapons of Mass Destruction
  25. ^ Research Advisory Committee on Gulf War Veterans’ Illnesses December 12-13, 2005 Committee Meeting Minutes (page 73.)
  26. ^ GAO-01-92T Anthrax Vaccine: Preliminary Results of GAO's Survey of Guard/Reserve Pilots and Aircrew Members
  27. ^ The Clarion-Ledger: Mississippi's News Source
  28. ^ Pharmacoepidemiology and Drug Safety.Short-term reactogenicity and gender effect of anthrax vaccine: analysis of a 1967-1972 study and review of the 1955-2005 medical literature
  29. ^ Global Security. ``Depleted Uranium``
  30. ^ Al Marshal, Sandia National Laboratory. An Analysis of Uranium Dispersal and Health Effects Using a Gulf War Case Study, Albert C. Marshall, Sandia National Laboratories
  31. ^ Harley NH, Foulkes EC, Hilborne LH, Hudson A, Anthony CR. A Review of the Scientific Literature As It Pertains to Gulf War Illnessess: Depleted Uranium. Vol 7. Arlington, VA: National Defense Research Institute (RAND); 1999
  32. ^ Gulf War Illness and Health of Gulf War Veterans (page 220-221)
  33. ^ Gulf War Illness and Health of Gulf War Veterans (page 222)
  34. ^ Enserink, M. (2001). "MEDICINE: Gulf War Illness: The Battle Continues". Science 291 (5505): 812. doi:10.1126/science.291.5505.812. PMID 11225619.  edit
  35. ^ New England Journal of Medicine. Disease and Suspicion after the Persian Gulf War. Volume 335:1525-1527, November 14, 1996
  36. ^ [http://www.cdc.gov/ncidod/eid/vol4no2/knoke.htm EID Vol. 4 No. 2: Hospitalizations for Unexplained Illnesses among U.S. Veterans of the Persian Gulf War
  37. ^ News Services, "Gulf War Syndrome Is Real, Panel Concludes", Washington Post, November 18, 2008, p. 14.
  38. ^ Record: Study finds multisymptom condition is more prevalent among Persian Gulf vets

[edit] External links

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