Chapter Nine: Conclusions and Recommendations
This report reviews infectious diseases from the standpoint of those
infections or potential infections known or thought to be present in the
Persian Gulf during the Gulf War. To highlight potential causes of
illness in Gulf War veterans, the review documents that some veterans
were exposed to infectious diseases. Some of these diseases are common
and generally self-limited (e.g., gastroenteritis, mild respiratory
infections). These infections were identified and routinely treated in
the Gulf. Other infections have been detected in a small group of
veterans (e.g., Leishmania); however, findings do not suggest
that these infections are a common cause of undiagnosed illness among
those who served in the Gulf War. Leishmania is challenging to
diagnose and efforts to develop better diagnostic tests should continue
to be encouraged.
There remains controversy about the extent to which Mycoplasma
might contribute to illness experienced by veterans. Consequently, some
specific recommendations exist with respect to further investigation
into Mycoplasma as a possible etiology for some cases of illness
among Gulf War veterans.
- Testing of nucleoprotein gene tracking should proceed as planned.
Efforts should be made to standardize testing procedures across
different institutions, emphasizing sensitive, specific, and reliable
testing methods. Antibody testing should be compared to PCR (and perhaps
nucleoprotein gene tracking) for sensitivity and abandoned if it is
confirmed to have a low sensitivity.
- Further efforts should be made to evaluate ill PGW veterans and
healthy controls for the presence of Mycoplasma using PCR (and
possibly nucleoprotein gene tracking, pending results of reliability
tests). At least one control group should consist of healthy
nonveterans, since cofactors associated with development of illness, or
latency to illness for Mycoplasma, are not well defined.
- Efforts should be made to quantitatively characterize symptom
frequencies in ill Gulf War veterans who test positive for Mycoplasma
fermentans (using PCR) and in those who test negative.
- Tests of treatment with antibiotics should be performed upon ill
Gulf War veterans in whom PCR testing for Mycoplasma is positive,
even though mycoplasma has not been confirmed as an etiology. There are
few treatments available where existing evidence suggests benefit;
therefore, it is particularly important that promising treatments be
given careful consideration and controlled testing.
- Thus, a randomized controlled double blind treatment trial of
antibiotics, of adequate duration, would be useful in ill Gulf War
veterans, following testing for Mycoplasma (with PCR) and for
herpes-virus 6. Outcome measures should include symptoms, quality of
life, and post-treatment Mycoplasma test results. At least one
powered subset should consist of veterans who test positive for
Mycoplasma and negative for herpes-virus 6. Even if
Mycoplasma per se is not confirmed to be a source of
illness, there is merit to such a treatment trial in the face of reports
of marked benefit with antibiotic therapy.
 Since this writing, such a study is now
under way with many of the characteristics advised here.