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Subject: Post-Operations Desert Shield/Desert Storm (ODS/DS) | Unit: |
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Post Operations Desert Shield/Desert Storm (ODS/DS) Medical Issues Filename:623rpt.93s 15 September 1993 INFORMATION PAPER SUBJECT: Post Operations Desert Shield/Desert Storm (ODS/DS) Medical Issues 1. PURPOSE: To provide information on the above subject. 2. FACTS: a. Background. (1) Many preventive measures were taken to protect U.S. service personnel from diseases and environmental threats known to exist in the Persian Gulf area. (2) For protection against infectious diseases endemic to Southwest Asia, deployment recommendations by the Army Medical Department were that soldiers be current with polio, typhoid, diphtheria tetanus, influenza and meningococcal immunizations. In addition, soldiers were given immune serum globulin to protect against infectious hepatitis and some soldiers were given chloroquine chemoprophylaxis to protect against malaria. All of the above products are licensed by the Food and Drug Administration (FDA). (3) Preventive medicine guidance was published (e.g., "The Threat of Disease and Non Battle Injury to U.S. Military Personnel on Operation Desert Shield") and widely distributed in order to minimize disease and non battle injury (DNBI). A second book, "Diagnosis and Treatment of Diseases of Tactical Importance to U.S. CENTCOM Forces," was distributed to assist medical personnel in the early diagnosis and treatment of the diseases found in Southwest Asia (SWA). (4) Preventive medicine assets were deployed to SWA to monitor the incidence of DNBI. The DNBI rate during Operation Desert Shield (1 Sept 90 through 15 Jan 91) was 0.34 hospital admissions per 1000 soldiers per day and during Operation Desert Storm (16 Jan 91 through 3 Jun 91) was 0.40/1000/day. These rates were dramatically lower than reported during previous exercises and conflicts. Four leading causes of admissions in theater included non battle trauma, heat injury (however, no death was attributed to heat injury), diarrhea, and respiratory problems. There were 31 cases of leishmaniasis (some of which were diagnosed after returning from SWA, see below for additional details), 7 malaria, 2 meningococcal disease (including one death) and 1 case of Q fever. No cases of sandfly fever, hepatitis A, schistosomiasis, plague, rabies, brucellosis, toxoplasmosis, trachoma, or anthrax were diagnosed. 5. (U) No confirmed CBW detections. The determination that CW is present is a two step process: detection and confirmation. Detection is characterized by alarms sounding. The equipment is very sensitive by design, causing the resulting problem of many false alarms. A conservative estimate of the number of false alarms during the Gulf War crisis would number in the hundreds, if not, thousands. It is very important to point out that despite this large number of supposed detections, the second step, confirmation, using simple wet chemlstry equipment and techniques available at the platoon level, never resulted in a single confirmation, except for the Czech reports on 19 and 24 January 91. In this case, the U.S. can not independently verify these events, and essentially, is taking the Czechs at their word based on assessments of their technical competence and sensitivity of equipment. 6. (U) Advanced laboratory analysis of suspected CW samples all proved negative. Before, during, and after the war, a variety of soil, liquid and air samples were analyzed. This analysis took place at state of the art labs in the U.S. and UK. All samples were found negative. 7. (U) Long term low level exposure defies the laws of physics. A popular theory suggests the cause of the mystery illness to be long term exposure of our troops to low, i.e. undetectable, levels of CW. The law of diffusion states that any substance, particularly a gas or liquid, naturally moves from an area of greater concentration to lesser concentration. If in one area or time the concentration is low as in the Czech detection at some other area or time the concentration must be high. Therefore, other detections would be expected near by, possibly resulting in casualties; this did not happen. Further, the only possible explanation for long term low level exposure below detection range is the deliberate, continuous, release of very small amounts of agent throughout the area where exposure was to have occurred; in this case, much of the Saudi Arabian peninsula. The facts simply do not support this theory. 8. The Czech detection was not the result of a release from bombed CBW targets. In addition to the law of diffusion, the weather during the time further argues against this possibility. The winds were in the wrong direction and it rained throughout the region the day before the detection. Even under ideal conditions, our models indicate that 80 tons of nerve agent would have to have been released from the closest known bombed CBW target, An Nasiriyah, to register at the low levels detected by the Czechs 140 miles away. Such an 80 ton release of nerve agent in Iraq would have resulted in an area of certain death or casualty that covers hundreds of square kilometers. Also, detection equipment all over the area would have alarmed and some additional confirmations would have been expected; neither happened. Even a release caused by a bomb from coalition aircraft striking a secondary target an unknown CW storage site or convoy near the border for example must still obey the law of diffusion. People nearby would die or become casualties, detection alarms would sound and confirmations would be made. As stated before, this simply did not happen. RECOMMENDATION: (U) None. Prepared by: (b)(6) . POSITION PAPER SUBJECT:: (U) Gulf War Health Issue; Evidence against use of chemical or biological warfare (CBW) during Desert Storm PURPOSE: (U) To provide the Secretary of Defense the basis of DIA's assessment that no chemical or biological weapons were used during Desert Storm, and are therefore not the cause of the Gulf War Mystery Illness. MAJOR POINTS: (U) DIA's assessment that no chemical or biological weapons were used during Desert Storm/Shield is based on the following: 1. (b)(1) sec 1.3(a)(4) During its war with Iran, Iraq moved chemical munitions from production and filling facilities in Samarra, to intermediate storage areas in southern Iraq, and finally, to forward deployment areas. This activity was accomplished within a relatively short period (roughly 2 3 weeks), just prior to Iraqi use of CW on the battlefield. The Iraqis operated in this way in order to overcome a short shelf life problem due to low purity levels they had with their nerve agent. 2. Unanimous statements of (b)(1) sec 1.3(a)(4) POWs stating no intent. (b)(1) sec 1.3(a)(4) POW's unanimously opined that there was no intent to use CBW against the coalition for two main reasons: the fear of massive retaliation we created the ambiguity of possible retaliation with nuclear weapons and, their belief that the coalition was far better prepared to fight in a CBW environment than Iraq, thus there was no advantage in their using CW. 3. (U) No CBW munitions found in the Kuwaiti Theater of Operations (KTO) to this day. Immediately after the ground war, a massive effort to collect and destroy remaining Iraqi equipment was underway. Thorough searches of the entire occupied Iraqi territory and Kuwait were accomplished. Not one chemical munition nor any bulk agent was ever found. Moreover, the Tampa based firm CMS Inc., primary U.S. contractor for unexploded ordinance removal in Kuwait, stated recently that to date, the company had discovered and removed over 14,000 tons of all types of ordinance (including 350,000 mines) and found no CBW weapons. 4. (U) No CBW related casualties reported. (U) During the entire Persian Gulf crisis, not one soldier, sailor or airman was treated, hospitalized, or died, as a result of CBW exposure. If CBW had been used, even on a limited basis, this most certainly would not be the case. The army private, mentioned on the recent NBC news program NOW, who received the Bronze Star after experiencing burns while searching bunkers, is the only known case with symptoms similar to CBW exposure. However, advanced laboratory analysis of his flak jacket, shirt, the swab used to clean his wound, and subsequent urinalysis indicate conclusively that this was not a CW event. Subject: Technical procedures used to Detect Chemical Agent during Desert Shield/Desert Storm 1. Detection of nerve agent during Desert Storm was accomplished using a biochemical technique, while determination of mustard agent depended on wet chemical qualitative annlytical procedures 2. Detection of nerve agent on the 19th of January, 1991 occurred at three separate locations by two separate Czechoslovak NBC Detachments. The first Chemical detachment detected a G type agent while on convoy about 37 kilometers north west of Hafr al Batin and 40 kilometers from the Iraqi border. This unit detected chemical agents at two separate locations. The second NBC detachment was located approximately 45 kilometers north east of Hafr al Batin and 40 kilometers from the Kuwait border. 3. Both units detected the initial presence of nerve agent using (b)(1) sec 1.3(a)(4) monitor/alarm which detects only organophosphate type agents. (b)(1) sec 1.3(a)(4) , and were operating in a semi continuous mode. This unit uses a wet chemical/colohmetric procedure by which the enzyme system Butyryl Cholinesterase (BChE) containing solution is deposited on a cotton tape, which is then drawn through an air aspiration port exposing the enzyme to the possible agent. Following this exposure, the tape is then transported to another station, where a solution with the indicator phenyl red is deposited on the tape. Presence of a chemical agent in the air inhibits the enzyme from further reaction which results in no color change; absence of an agent causes a reaction which is registered as a color change from red to yellow. As operated, this unit has a reported sensitivity to nerve agent of 3.0 x 10 6 mg/l (of air sampled). 4. Following the initial alarm by the (b)(1) sec 1.3(a)(4) , the troops donned their protective gear and made follow up tests using the (b)(1) sec 1.3(a)(4) unit. While this unit also uses BChE enzyme inhibition for subsequent identification, the unit is somewhat more sensitive due to the means of air sampling. However, because the basic chemistry is identical to the (b)(1) sec 1.3(a)(4) does not independently confirm the first nerve agent. This system could register a positive result for any cholinesterase inhibiting organophosphate compound, which would include many agricultural insecticides. There were no other independent tests performed at the site of the detection to indicate that the chemical detected was in fact a nerve agent. An air sample was collected on a dried silica gel substrate and preserved for subsequent testing at a field laboratory located in King Kahlid Military City (KKMC).At present there is no information whether the enzyme testing was also used in this subsequent testing, however, it is likely that it was. 5. The (b)(1) sec 1.3(a)(4) could be operated for either a one minute or a three minute sample interval. When operated for a one minute interval the sensitivity of this unit is reported to be 5.0 x 105 mg/l. When operated for the three minute interval, the sensitivity of this unit is reported to be 5.0 x 0 7 mg/l (of air sample). When the Czechoslovaks initially attempted to verify the (b)(1) sec 1.3(a)(4) alarm using the one minute sample time, the results were negative, and it was only after subsequent air sampling for three minutes that they obtained the positive results. This would place the concetration of the suspected nerve agent in the air between 5.0 x 10 5 5.0 x 10 7 mg/1. These concentraticns are so low that they are not felt to represent any threat to personnel. 6. Following the initial alarm, there were four subsequent (b)(1) sec 1.3(a)(4) , and subsequent processing and refitting the unit lasted perhaps another 7 minutes. The first three of these tests continued to register positive for chemical agent. The fourth test was negative, at which point the all clear was sounded. A total time of appfoximately 40 minutes elapsed between the initial alarm and the all clear. The time between the initial detections at the 1st and 2nd NBC detachments was about 30 minutes. 7. The reporting of these determinations was made through proper channels, up through the brigade headquarters to the joint command in KKMC. A situation report was also forwarded through Saudi military to Riyadh. 8. Some four to five days following the detection of the nerve agents north of Hafr al Batin, the 3rd detachment located at KKMC was approached by the Saudi Liaison Officer with a request for them to bring their reconnaissance vehicle out into the desert to inspect an area. The location which they were taken to was about one to two kilometers north or west of KKMC. When approaching the actural location, they were asked by the Saudi Liaison Officer if they shouldn't suit up in their protective gear. The Czechoslovaks thought this was strange but they did suit up. Upon disembarking their vehicles they found a "wet area" on the desert floor which was irregular in shape and measured about 60 centimeters by 200 centimeters (60 cm x 200 cm), much like a "puddle" of liquid which is poured onto the ground and then seeps into the earth. This area was tested using the (b)(1) sec 1.3(a)(4) unit and mustard agent was identified as present. They then used the (b)(1) sec 1.3(a)(4) portable laboratory which used a complex chemical molecule based on benzoic acid, phenol, and other aromatic chemicals. This test confirmed the initial detection of the mustard agent by the (b)(1) sec 1.3(a)(4) . Because these tests used different chemical indicators for the determination, it is likely that this detection of mustard was accurate and that the contamination of this oil was with mustard age. 9. The situation report of this action was forwarded through the joint headquarters KKMC, as were the previous reports. There were no indications that this contamination was the result of any military action; there was no debris, impact crater or any other visible evidence that anyone had been to this site previously. There was no previous, nor subsequent, request like this one by the Saudi's. There was no follow up action beyond the filing of the SITREP, and the notification of the Czechoslovak Ministry of Defense. 10. Czechoslovak unit did not experience any problems with their detectors, in particular (b)(1) sec 1.3(a)(4) , as a result of environmental contaminants. The Czech unit tested this equipment subsequently to determine its sensitivity after the time of the burning oil fires. However, the chemical agents were detected prior to the oil fires. Morever, in a test, the Czechoslovak, set up the (b)(1) sec 1.3(a)(4) on a lab bench located less than 2 feet from the top of a 55 gallon oil drum containing burning oil. The results of this test indicated that there were no problems with the equipment, and that the emissions caused from these units did not result in any false positive detections. (12) REPORTED DISEASE CLUSTERS BY TUSKEEGEE VA MEDICAL CENTER: Two clusters of illness (Hepatitis B and HTLV I/II) were the subjects of media reports about veterans seen at the Tuskeegee, Alabama VA Medical Center. A team from the VA central office and a Navy epidemiologist investigated and found no evidence to support the reports. (13) MULTIPLE CHEMICAL SENSITIVITY: The Army Medical Department (AMEDD) is evaluating the role of multiple chemical sensitivity in causing some of the unexplained symptoms reported by ODS/DS veterans and has requested funding for a research facility to study mulLiple chemical sensitivity. c. The military health care system has sought extensive consultation from within and with outside agencies and individual experts in addressing the issue of post ODS/DS medical symptoms. The health and well being of our service personnel is of paramount concern to the military leadership and the Army Medical Department and the Department of Veterans Affairs will continue their investigations and treatment of symptomatic veterans who served in Southwest Asia in support of Operations Desert Shield/Desert Storm. Prepared by: Office Of The Army Surgeon General, (i) In order to determine the existence and prevalence of chronic long term illnesses, conditions or symptomatology directly related to or associated with service in SWA, the Office of The Surgeon General sent out a worldwide message in August 1992 to active duty medical treatment facilities (07100Z AUG 92. Subject: New Operations Desert Shield/Desert Storm (ODS/DS) Requirement for special Telegraphic Reporting System MED 16). This message required that clinicians who identify or suspect that a chronic medical or psychiatric condition is related to service in SWA must notify the local Preventive Medicine Service for assistance in gathering epidemiological information and in preparing the electronic report to be sent to OTSG. (ii) Since August 1992, a total of 89 case reports (as of 14 September 1993) have been received at OTSG. (iii) The cumulative data gathered through this surveillance system will be tabulated and published at appropriate intervals. (10) POST TRAUMATIC STRESS DISORDER: (a) The Conference Report on the FY 92 Defense Appropriations Act directed the Department of Defense to study the effects of the Gulf War on active duty, guard, and reserve personnel and their families who are located in Greensburg, Pennsylvania, and in the State of Hawaii. This is to specifically determine if personnel are showing signs of significant psychological distress brought on by abrupt changes in their lives. The Walter Reed Army Institute of Research (WRAIR) has already completed a similar study on Army active duty, guard, and reserve personnel and their families during the pre deployment, deployment, and post deployment phases of the Gulf War. DOD asked WRAIR to perform its survey on this focused population to determine what its mental health needs may be as a result of the war. WRAIR will use the data base from the former study which is derived from a larger population to assess this particular population's needs. (b) Between March and May 1993, WRAIR surveyed units and individuals in Hawaii and Pennsylvania. Also the Department of Veterans affairs will collect additional data on ODS/DS veterans using local DVA facilities in the target area. The final report of the study will be completed by November 1993. (11) EXPOSURE TO LOW LEVEL CHEMICAL WARFARE AGENTS: A press report quoting Senator Donald W. Riegle, Jr. in the 10 Sept 1993 Washington Post concerning alleged low level exposure to chemical agents emitted from destroyed Iraqi facilities ties these alleged exposures to post ODS/DS medical symptoms. This matter is being investigated but as of this date the AMEDD has no information to confirm this. the private petroleum industry. The panel concluded that "there is no scientifically supportable reason to believe that the unexplained illnesses are related to petroleum exposure" (for several reasons: diversity of complaints; delayed onset of symptoms; lack of common exposure; and lack of similar cases in long term oil industry workers). ( 9 ) MYSTERY ILLNESS: (a) "Unexplained" or "Mystery Illnesses" have been widely publicized. There have been media reports of individuals and groups of individuals with symptoms of fatigue, joint pain, hair loss, bleeding gums, headaches, rashes, and memory loss . These have been investigated. Some are due to common medical and dental problems expected in any civilian population; some are difficult to diagnosis specifically even after extensive civilian, Department of Veterans Affairs and/or military medical center diagnostic workups. (b) Active duty soldiers are evaluated through existing medical channels. Reservists and other veterans with ODS/DS related symptoms are eligible for care at Department of Veterans Affairs (VA) medical treament facilities and are added to the VA Persian Gulf Registry. Approximately 8000 ODS/DS veterans (all services) have had medical evaluations at VA facilities and 3800 are on the Persian Gulf Registry. Approximately 250 of these service personnel may be in the category of "Mystery Illness". Each VA medical facility has appointed an "Environmental Physician" point of contact for ODS/DS related medical problems to facilitate patient management. (c) Working Group (b)(6) ( i) A working group of nationally recognized physician experts, headed by (b)(6) is being assembled to review and analyze medical records of ODS/DS veterans with unexplained symptoms. This workirg group will collaborate with the three services and the VA. ( ii) The working group will establish a working "case def inition" for post ODS/DS unexplained illness . (iii) (b)(6) in New Orleans and review his diagnostic and therapeutic approach to post ODS/DS unexplained illness and chronic fatigue syndrome. (d) Summary Results of Special Surveillance Program. DU. They are undergoing medical evaluation at the Boston VA Medical Center. If all of their medical tests are negative, we will conclude that all other category two soldiers needn't be tested, because their exposures were less than the exposures of the 144th S&S Company. In this category, 24 hour urine specimens are also being collected to test for uranium exposure. If any of the 144th S&S Company soldiers test positive, the medical evaluation program for category two soldiers will be broadened. (4) VACCINES AGAINST BIOLOGICAL WARFARE AGENTS: The anthrax vaccine, which is licensed by the FDA, was given to approximately 150,000 individuals. The botulinum toxoid vaccine, which is not FDA licensed but which has been used safely for over 25 years, was given to approximately 8,000 individuals. Both may cause minor local or systemic side effects, but no long term adverse health effects have been documented. MEDICATION AGAINST CHEMICAL WARFARE AGENTS: Pyridostigmine bromide (PB) has been licensed in the U.S. (as Mestinon and Regonol) since 1955 for treatment of myasthenia gravis. It can be used prophylactically as a nerve agent antidote and was used by tens of thousands of soldiers during the Gulf War. There are some minor side effects but no known long term adverse effects have been documented. (6) MICROWAVE: It was widely reported in the news media that microwave exposure from communications equipment was the cause of unusual symptoms being reported by some individuals. That was quickly discounted by experts in the field because of the late onset of symptoms; no eye or skin injury; and no indication that equipment was not used in a safe manner. (7) OIL WELL FIRES: Smoke from the Kuwaiti oil well fires caused some acute respiratory tract irritation, bronchitis, and wheezing. The potential for long term health effects was recognized early and the U.S. Army Environmental Hygiene Agency began conducting two large scientific studies, while the fires were still burning, to determine the level of exposure to the smoke (Quantitative Health Risk Assessment Study) and to estimate future long term health effects, if any (llth Armored Cavalry Regiment Medical Surveillance Study). The final report is due out in 1993, but at this point no significant long term health effects have been identified or are expected. (8) PETROCHEMICAL EXPOSURE: Petrochemical toxicity as a cause of the unusual symptoms reported by some veterans was suggested by several clinical ecologists and was widely publicized. The Army Surgeon General's office in August 1992 convened an expert panel on petroleum eXposure composed of experts in toxicology, occupational medicine, internal medicine, and epidemiology from governmental and academic institutions and from b. Post ODS/DS Medical Issues. (l) LEISHMANIASIS (19 Cutaneous, 12 Viscerotropic): The last case of viscerotropic leishmaniasis was diagnosed at Walter Reed Army Medical Center in May 1993 and the last case of cutaneous leishmaniasis in April 1993. In addition to the 31 cases of leishmaniasis reported above, there are another 50 to 100 individuals from all services who have been evaluated and had bone marrow examinations at Walter Reed Army Medical Center. Even though viscerotropic leishmaniasis may be suspected, the parasite has not been identified. Most of these individuals continue to be followed or have recovered. A system for getting suspected active duty or reserve component cases into Walter Reed Army Medical Center was established early and has generally worked well. The risk of transmitting the parasite by blood transfusion is thought to be low and the DOD moratorium on donations from Gulf War veterans was lifted 1 January 1993. Civilian blood banks also lifted their ban on that date. No case of transfusion caused leishmaniasis has been reported since lifting the moratorium. (2) TUBERCULOSIS: Tuberculosis skin testing was recommended for returnees. This office received reports of positive skin tests in 1 5 of individuals in some returning units, but it was felt that most were probably positive before departure. Predeployment skin testing was not required. No cases of active tuberculosis secondary to service in SWA have been documented. (3) DEPLETED URANIUM: Soldiers who received unusual exposures to depleted uranium (DU) fall into two categories: (l) those who were inside battlefield vehicles when hit by a DU munition, and (2) those who received less significant exposures (e.g., through vehicle recovery operations or by fighting fires in which DU munitions were involved). (a) Within category one, thirty five soldiers received injuries; twenty two of the thirty five soldiers are suspected of retaining DU fragments. No significant long term adverse health effects are expected, but those 35 soldiers, and their crewmembers who were not injured, are being offered participation in a program through which they will undergo periodic medical evaluation (at least annually) for five years. After five years, a review will be made of the test results and decisions will be made regarding continued medical evaluation. As the first step in the investigation of these soldiers, 24 hour urine specimens are being collected to test for uranium exposure. (b) Within category two, twenty seven soldiers of the 144th Supply and Services Company (Army National Guard) are being used as a sentinel population, because they incurred the greatest potential in catgory two for receiving significant exposures to XDATE:1955 XDATE:1 SEPT 90 XDATE:JANUARY, 1991 XDATE:15 JAN 91 XDATE:16 JAN 91 XDATE:24 JANUARY 91 XDATE:3 JUN 91 XDATE:AUGUST 1992 XDATE:1993 XDATE:1 JANUARY 1993 XDATE:APRIL 1993 XDATE:MAY 1993 XDATE:10 SEPT 1993 XDATE:14 SEPTEMBER 1993 XDATE:15 SEPTEMBER 1993 XDATE:NOVEMBER 1993 XDATE:950925 PERSON:AL BATIN PERSON:WALTER REED PERSON:DONALD W. RIEGLE FACIL:ARMY MEDICAL DEPARTMENT FACIL:TUSKEEGEE VA MEDICAL CENTER FACIL:ALABAMA VA MEDICAL CENTER FACIL:DEPARTMENT OF VETERANS AFFAIRS FACIL:ACTIVE DUTY MEDICAL TREATMENT FACILITIES FACIL:ARMY INSTITUTE OF RESEARCH FACIL:MEDICAL TREAMENT FACILITIES FACIL:VA MEDICAL FACILITY FACIL:BOSTON VA MEDICAL CENTER FACIL:U.S. ARMY ENVIRONMENTAL HYGIENE AGENCY EQUIP:CHEMICAL AGENT EQUIP:NERVE AGENT EQUIP:STORM 1 EQUIP:RECONNAISSANCE VEHICLE COUNTRY:U.S. COUNTRY:IRAQ COUNTRY:KUWAIT COUNTRY:IRAN MILUNIT:BRIGADE HEADQUARTERS MILUNIT:OFFICE OF THE ARMY MILUNIT:LLTH ARMORED CAVALRY REGIMENT MILUNIT:ARMY NATIONAL GUARD
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