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RE: ENDEMIC INFECTIOUS DISEASES
PRESIDENTIAL ADVISORY COMMITTEE ON GULF WAR VETERANS' ILLNESSES: FINAL REPORT  [December 1996]
During WWII, British military units were stationed in the Gulf region and based on this experience documented the nature of endemic infectious diseases. Thus, the U.S. command was concerned about diseases, including shigellosis, malaria, sandfly fever, and cutaneous leishmaniasis.6,65,90,187 For example, cutaneous leishmaniasis, known locally as the Baghdad boil, is endemic to that area; 80 to 90 percent of people in some parts of Southwest Asia have scars from previous attacks.187 During WWII, rates of sandfly fever were 3 to 10 percent of all troops in the Middle East, and in some units it exceeded 50 percent.187 Infectious diseases during the Gulf War, however, were not a major cause of sickness or lost work time.90 During the Gulf War, only one death due to infectious disease (meningococcal meningitis) was reported.342,343

Experts attribute the lack of a problem with infectious diseases during the Gulf War to a comprehensive infrastructure of medical care and preventive medicine efforts.90,185,271,273,293 DOD took measures to minimize infectious disease risk, including strict monitoring of drinking water purity, inspecting food sources and supplies, maintaining field camp sanitation, and instituting an insect vector control program. U.S. service members received booster doses of routine vaccinations, including typhoid, meningococcus and, during the fall, influenza. Immune gamma globulin was used to prevent Hepatitis A, and the small number of troops who entered Iraq near the Euphrates River valley received drug prophylaxis for malaria.

Most of the combat troops were isolated in barren desert locations, distant from rivers, oases, and urban areas. Additionally, maximum troop deployment occurred during the cooler winter months, which provided the least favorable conditions for the transmission of insect-borne diseases.90,185 Indeed, the majority of the 12 individuals who developed viscerotropic leishmaniasis had been deployed to urban areas.145

 

Diagnosis of infectious diseases in-theater.
Short-term diarrhea was a common symptom among troops in-theater. Most cases were mild, traveler's-type diarrhea that resolved spontaneously without antibiotics after a few days.64,90 Gastroenteritis among outpatients decreased from four percent per week early in the deployment to less than 0.5 percent per week after U.S. medical command tightened control of food sources-especially imposing a ban on locally-grown fresh fruits and vegetables. The most common organisms identified in service members with diarrhea severe enough to warrant cultures were Shigella sonnei and Escherichia coli. DOD reports no confirmed cases in-theater of food-borne, diarrheal diseases, such as cholera, typhoid fever, or giardiasis.90

DOD medical personnel evaluated U.S. service members for several diseases transmitted by insects, including leishmaniasis, sandfly fever, malaria, dengue, Sindbis, West Nile fever, Rift Valley fever, and Congo-Crimean hemorrhagic fever.90,293 As noted, sandfly fever had been a major concern, but no cases were seen during the Gulf War. DOD reports detecting seven cases of malaria and one case of West Nile fever, a mosquito-borne viral illness. No rickettsial illnesses and no cases of other arthropod-borne viral illnesses were identified.

Viscerotropic leishmaniasis (VL) and cutaneous leishmaniasis (CL) are the only endemic infectious diseases demonstrated to cause chronic morbidity among a number of Gulf War service members. These diseases are transmitted through the bites of sand flies; person-to-person infection does not occur. Thirty-two cases of leishmaniasis were diagnosed among U.S. troops, consisting of 12 cases of VL and 20 cases of CL.145,277 CL causes a characteristic ulcerative or nodular skin rash that can persist for more than a year without treatment. And, while VL can be difficult to confirm, it is not considered to be a cause of widespread illness in Gulf War veterans. All veterans diagnosed with VL, except one, have experienced the signs characteristic of the disease.90,146,293

It is unlikely that veterans in the Registry or CCEP who have unexplained illnesses are suffering from VL. The incidence of VL during the Gulf War and the five years since has been low (12 of 697,000), and other sandfly-borne infectious diseases in the troops have been absent.90,278 Additionally, individuals with unexplained illnesses also lack signs and symptoms characteristic of VL. VL can sometimes occur following a prolonged incubation period (more than 18 to 24 months); there is also a risk of activation of latent infections in immunosuppressed persons.65,90,146 To date, DOD and VA report that delayed onset of VL has not occurred.

From August 1990 through July 1991, the U.S. Army deployed approximately 347,000 individuals to the Gulf region. Based on information from U.S. Army field hospitals, the only infectious diseases that caused 30 or more each of approximately 14,000 admissions were pneumonia, intestinal infections, inflammation of the testes and/or epididymus, chicken pox, and kidney infections.342,343

 

Conclusion
What do we conclude about the risks of infectious diseases to Gulf War veterans?

Based on a review of the rates and types of the diseases diagnosed during and after the Gulf War, the Committee concludes it is unlikely that infectious diseases endemic to the Gulf region are responsible for long term health effects in Gulf War veterans, except in a small, known number of individuals.

 

 
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