The Gulf War

[The following are excerpts from the "Investigation of a Suspected Outbreak of an Unknown Disease Among Veterans of Operation Desert Shield/Storm" by R.F. DeFraites, E.R. Wanat II, A.E. Norwood, S. Williams, D. Cowan, T. Callahan. 123rd Army Reserve Command, Fort Benjamin Harrison, Indiana. Walter Reed report, April 1992. The full report can be obtained by calling the National Technical Information Center at 703-487-4650.]

DeFraites Study


I. EXECUTIVE SUMMARY

In early spring 1992, 125 veterans of Operation Desert Shield/Storm (ODS/S) assigned to the 123d Army Reserve Command (ARCOM) reported a wide variety of non-specific symptoms including fatigue, joint pains, skin rashes, headaches, loss of memeory, mood changes, diarrhea, bleeding and painful gums, and loss of hair. Most of these symptoms were first noticed after the soldiers returned home after the deployment to southwest (SW) Asia. Although several had been medically evaluated, no unifying diagnosis, other than a suspected reaction to stress had emerged. On 11-12 April, seventy-nine 123d ARCOM soldiers with symptoms or concerns were evaluated by a multidisciplinary medical team. Each soldier completed a medical questionnaire and a brief symptom inventory, and was interviewed by an epidemiologist, an occupational medicine physician and a psychiatrist. All were examined by an oral pathologist and had blood drawn for laboratory testing. There was no evidnce of an outbreak or cluster of any unique disease process. Very few soldiers gave histories that suggested any known hazardous exposures. Because of the wide variety of experiences during the deployment, ther ewere very few exposures common to the entire group. Reported symptoms did not correspond with known health effects of those exposures. Positive objective findings on physical examination and laboratory screening testing wre very limited, and were similar to those found in soldiers from Fort Lewis, WA, and Fort Bragg, NC, who were not deployed to SW Asia. Dental examination revealed gingivitis, periodontal disease, caries, and other chronic oral conditions as likely causes for the dental symptoms. Results of specific testing for leishmaniasis, brucellosis, and other agents indicated no role for them in causing the symptoms reported by this group. Although no confirmed pathogens have yet been isolated from those soldiers with diarrhea, some chronic diarrhea could conceivably have been related to the deployment and may require additional evaluation. The paucity of abnormal physical or laboratory findings, the types of symptoms reported, the association of onset of the symptoms with redeployment, and results of the psychiatric evaluation suggest that many of the symptoms are likely to be stress-related. These may represent a stress reaction to redeployment and subsequent readjustment to civilian life.
Additional medical evaluation of these soldiers is indicated only on an individual basis. Stress management intervention with full command support is warranted. Additional epidemiological evaluation may be necessary, but only if specific diagnosable medical conditions emerge from this group.

IX. SUMMARY OF MAJOR FINDINGS AND CONCLUSIONS

  1. Following screening of 79 soldiers of the 123d ARCOM and extensive medical evaluation of six, no single diagnosis or medical cause has emereged which can account for the majority if the reported symptoms.

  2. Ruled out as major factors: Leishmaniasis (All 78 screened, two possible positive), brucellosis (none positive out of six with the most prominent symptoms tested), Lyme disease (non positive out of two with joint pains as major complaint tested), hypothyroidism (none positive out of five tested)

  3. The evaluation of 79 soldiers on 11-12 April can be summarized as follows:
    1. Subjective findings.
      1. Fatigue was most common (70%) symptom. Other systemic symptoms like feversihness, abdominal pain, and diarrhea were much less common.

      2. One typical pattern for these symptoms was the onset of fatigue and associated symptoms (memory loss, sleep disturbance, etc.) afer redeployment from SW Asia. There was one exception to this trend: diarrhea with onset during the deployment was slightly more common than reported with other symptoms.

      3. Morbidity and disability associated with these symptoms were low.
        1. Musculoskeletal injury, (or recovery from elective surgery) was the largest single medical cause of lost time from work/duty/school: 59.7% of total sick days during deployment, 43.8% since returning home.

        2. There has been a low number of lost work days due to all non-injury illnesses since returning from SW Asia: 45.6% of soldiers interviewed reported no loss of work due to any non-injury illness, and 85% have lost 10 days or less. Six individuals (7.6%) accounted for 48% of all work days lost due to illness since redeployment.

        3. We found no association between most individual symptoms (or groups of symptoms) and lost time from work due to illness. Exceptions of this were soldiers with abdominal pain and irritability (mood changes).

    2. Objective findings
      1. Reported hair loss by 21.5% was manifested primarily as diffuse thinning of the hair.

      2. Skin rashes were representative of dermatological conditions found in general population.

      3. Oral and dental complaints stem from poor preventive care and suboptimal hygienic practices over years. There was abundant objective evidence of chronic neglect of teeth.

      4. The proportion of 123d ARCOM soldiers with elevated blood pressure (15%), elevated liver enzyme (ALT) (11.5%), or low hermatocrit (6.4%) was not markedly different that that of comparison populations of healthy active duty soldiers not deployed to SW Asia.

      5. Enteric parasites were not ruled out: Chronic persistent diarrhea may require additional individual evaluation to make diagnosis.

    3. Specific exposures
      1. There was no association of anthrax vaccine, nerve agent antidote, or malaria pills with any symptom or lost work days.

      2. We have no evidence that hazardous exposures to microwaves, chemicals, or radiation occurred. The types and pattern of the symptoms reported and available objective evidence also do not support any link with these exposures.

    4. Measures of stress were the most striking positive findings of our evaluation. These soldiers reported very high levels of stress, to which many of the subjective symptoms, and some of the objective ones, such as high blood pressure and loss of hair amy be attributable. Post-traumatic stress disorder, on the other hand, seemed to be present in a very few of these soldiers.

  4. CONCLUSIONS
    1. There is at present no objective evidence to suggest an outbreak of any disease in 123d ARCOM. We feel that the documentable medical problems and illnesses found in this group are typical of what one would expect in the general population.

    2. Musculoskeletal injuries and their sequelae were the most important medical problems experienced by this group, during and since the deployment.

    3. Stress associated with post-deployment adjustment to civilian life is a plausible etiology for the many of the symptoms reported, especially sleep disturbances, depression, forgetfulness, and cognitive difficulties. In general, these symptoms have been worrisome, but not debilitating.

    4. Association of any illness, injury, or symptom with the deployment must be made on an individual basis. In this group, the only problems which seem directly related to the deployment were some of the injuries. To date we have found no objective evidence of disease which could be proven to be related directly to deployment to SW Asia.

    5. Chronic or persistent diarrhea may be associated with the deployment, although no specific agent has been identified. However, diarrhea and other gastrointestinal symptoms with onset now or in the future are much less likely to related to known enteric pathogens from SW Asia.



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