guerra do golfo - consequências-20 anos depois
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From Wikipedia, the free encyclopedia
Gulf War illness
Classification and external resources
pyridostigmine, a nerve agent antidote
and one of the implicated toxins
ICD-9 V65.5 (inconclusive)
also nonstandard "DX111"
MeSH D018923
Gulf War syndrome (GWS) or Gulf War illness (GWI) affects veterans and civilians
who were near conflicts during, or downwind of a chemical weapons depot demolition
after, the 1991 Gulf War.[1][2]
A wide range of acute and chronic symptoms have
included fatigue, loss of muscle control, headaches, dizziness and loss of balance,
memory problems, muscle and joint pain, indigestion, skin problems, immune system
problems, and birth defects.[3]
Roughly one in four of the 697,000 veterans who served
in the first Gulf War are afflicted with the controversial disorder, a condition with
serious consequences.[4]
Exposure to toxic chemicals is the cause of the illness. Several specific causes have
been investigated, including pyridostigmine bromide nerve gas antidote,
organophosphate pesticides, chemical weapons, and depleted uranium. Causes which
have been ruled out include post traumatic stress disorder, anthrax vaccinations,[4]
and
smoke from oil well fires. Antidote pills given to protect troops from nerve agents and
insect repellents used during deployment were most closely linked. Exposure to the
destruction of the Khamisiyah weapons depot, where large quantities of the chemical
weapon sarin was stored, is negatively correlated with motor speed.[5]
Epidemiological
evidence is consistent with increased risk of birth defects in the offspring of persons
exposed to depleted uranium.[6]
Methods of preventing or treating Gulf War syndrome vary. While the treatment of
sarin exposure has been studied,[7]
other acetylcholinesterase inhibitors such as
pyridostigmine bromide and organophosphate insect repellents may or may not involve
similar management. Uranium can be decontaminated from steel surfaces[8]
and
aquifers.[9]
Diplomatic reconciliation is a means of prevention of some mental
effects.[10][11]
Contents
1 Classification
2 Signs and symptoms
3 Causes
o 3.1 Pyridostigmine bromide nerve gas antidote
o 3.2 Organophosphate pesticides
o 3.3 Sarin nerve agent
o 3.4 Depleted uranium
o 3.5 Ruled out
3.5.1 Anthrax vaccine
3.5.2 Combat stress
3.5.3 Oil well fires
4 Diagnosis
5 Management
o 5.1 Acetylcholinesterase inhibitors
5.1.1 Nerve agent antidote and insect repellent
5.1.2 Sarin
o 5.2 Uranium exposure
6 Epidemiology
7 Controversy
8 See also
9 References
10 External links
Classification
Medial ailments associated with Gulf War Syndrome has been recognized by both the
US Department of Defense, Department of Veterans Affairs, and Veterans
Administration.[12]
Since so little concrete information was known about this condition
the Veterans administrations originally classified individuals with related ailments
believed to be connected to their service in the Persian Gulf a special non-ICD-9 code
DX111, as well as ICD-9 code V65.5.[13]
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.[14]
French troops also served to the North and West of all other combat troops,
away and upwind of major combat engagements[15]
.
A 2001 study of 15,000 February 1991 U.S. Gulf War combat veterans and 15,000
control veterans found that the Gulf War veterans were 1.8 (fathers) to 2.8 (mothers)
times more likely to have children with birth defects.[16]
After examination of children's
medical records two years later, the birth defect rate increased by more than 20%:
"Dr. Kang found that male Gulf War veterans reported having infants with likely birth
defects at twice the rate of non-veterans. Furthermore, female Gulf War veterans were
almost three times more likely to report children with birth defects than their non-Gulf
counterparts. The numbers changed somewhat with medical records verification.
However, Dr. Kang and his colleagues concluded that the risk of birth defects in
children of deployed male veterans still was about 2.2 times that of non-deployed
veterans."[17]
In a study of U.K. troops, "Overall, the risk of any malformation among pregnancies
reported by men was 50% higher in Gulf War Veterans (GWV) compared with Non-
GWVs."[18]
Excess prevalence of general symptoms[19]*
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%
Graph showing the rate per 1,000 births of congenital malformations observed at Basra
University Hospital, Iraq[20]
Excess prevalence of recognized medical conditions[21]
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%
Although Gulf War illness is the most prominent condition affecting Gulf War veterans,
it is just one health issue to be addressed in the larger context of the health of Gulf War
veterans. Other Gulf War-related health issues of importance include rates of
diagnosable medical conditions and post-war mortality among Gulf War veterans, and
questions related to the risk of birth defects and other health problems in veterans’
family members.
The three studies most representative of Gulf War era veterans in the U.S. and U.K.
have all indicated significant excess rates of birth defects in children of Gulf War
veterans. News articles have reported that rates of cancer and birth defects in Iraq
increased dramatically during the 1990s, specifically in regions where the greatest
quantity of depleted uranium was used in the Gulf War. Conference reports describing
an increased incidence of congenital anomalies in Basrah and increased numbers of
cancer cases, both in Iraqi military personnel who served in the war and in four Iraqi
hospitals, lend some support to these contentions.[4]
Results from two studies, using different methods in different groups of symptomatic
veterans, indicate that Gulf War illness is associated with a low-level, persistent
immune activation, reflected in elevated levels of the cytokines IL-2, IFN-γ and IL-10.
In addition, several studies have reported that NK cell numbers and/or cytotoxic activity
are significantly reduced in veterans with Gulf War illness.[22]
Causes
The United States Congress mandated the National Academies of Science Institute of
Medicine to provide nine reports on Gulf War Syndrome since 1998.[23]
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.[24]
Pyridostigmine bromide nerve gas antidote
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 1,500 mg a day, far in
excess of the 90 mg 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.[25]
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.[4]
Organophosphate pesticides
The use of organophosphate 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.[26]
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.[27]
Pesticide use during the Gulf War has also been associated
with neurocognitive deficits and neuroendocrine alterations in Gulf War veterans in
clinical studies conducted following 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.‖[4]
Sarin nerve agent
Many of the symptoms of Gulf War syndrome are similar to the symptoms of
organophosphate, mustard gas, and nerve gas poisoning.[28][29]
Gulf War veterans were
exposed to a number of sources of these compounds, including nerve gas and
pesticides.[30]
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.[31]
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.[32]
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 [33][34]
Depleted uranium
Major Gulf War engagements 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. Munitions made from it often burn when they impact a hard target, producing
toxic combustion products. Roughly 320 tons of DU were used during the February,
1991 conflict.[35]
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.
The use of DU in munitions is controversial because of questions about potential long-
term health effects.[36]
Normal functioning of the kidney, brain, liver, heart, and
numerous other systems can be affected by uranium exposure, because in addition to
being weakly radioactive, uranium is a toxic metal.[37]
Because uranium is a heavy
metal and chemical toxicant with nephrotoxic (kidney-damaging),[38]
teratogenic (birth
defect-causing),[39][40]
immunotoxic,[41]
and potentially carcinogenic[42]
properties,
uranium exposure is associated with a variety of illnesses.[43]
The chemical
toxicological hazard posed by uranium dwarfs its radiological hazard because it is only
weakly radioactive, and depleted uranium even less so. DU has recently been
recognized as a neurotoxin.[44]
In 2005, depleted uranium was shown to be a neurotoxin
in rats.[45]
Epidemiological evidence is consistent with increased risk of birth defects in
the offspring of persons exposed to DU.[6]
Early studies of depleted uranium aerosol exposure assumed that uranium combustion
product particles would quickly settle out of the air[46]
and thus could not affect
populations more than a few kilometers from target areas,[47]
and that such particles, if
inhaled, would remain undissolved in the lung for a great length of time and thus could
be detected in urine.[48]
Uranyl ion contamination has been found on and around
depleted uranium targets.[49]
In 2001, a study was published in Military Medicine that found DU in the urine of Gulf
War veterans.[50]
Another study, published by Health Physics in 2004, also showed DU
in the urine of Gulf War veterans.[51]
A study of UK veterans who thought they might
have been exposed to DU showed aberrations in their white blood cell chromosomes.[52]
Mice immune cells exposed to uranium exhibit abnormalities.[53]
In the Balkans war zone where depleted uranium was also used, an absence of problems
is seen by some as evidence of DU munitions' safety. "Independent investigations by the
World Health Organization, European Commission, European Parliament, United
Nations Environment Programme, United Kingdom Royal Society, and the Health
Council of the Netherlands all discounted any association between depleted uranium
and leukemia or other medical problems."[35]
In Italy, controversy over the health risks
associated with the use of DU continues, with a Senate investigation committee was due
to release its report into 'Balkan Syndrome' by the end of 2007.[54]
Since then, there has
been a resurgence of interest in the health effects of depleted uranium, especially since
it has recently been linked with neurotoxicity.[44]
The aerosol produced during impact and combustion of depleted uranium munitions can
potentially contaminate wide areas around the impact sites or can be inhaled by civilians
and military personnel.[55]
During a three week period of conflict in 2003 Iraq, 1,000 to
2,000 tonnes of DU munitions were used, mostly in cities.[56]
Depleted uranium may
have been standard ordnance in the arsenals of both sides during the 2008 South Ossetia
war.
Military personnel examine the remains of a Scud during the Gulf War.
Ruled out
Several potential causes beyond vaccinations, stress, and oil well fires—explained in
more detail below—have been ruled out. Other ruled-out potential causes include Scud
missile fuel and infectious diseases. Limited evidence from several sources suggests
that an association with the combined effects of multiple neurotoxicant exposures and
receipt of multiple vaccines can not be ruled out.[57]
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.[58]
During Operation Desert Storm, 41% of U.S. combat soldiers and 75% of
UK combat soldiers were vaccinated against anthrax.[59]
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.[60]
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.[61]
While recent studies
have demonstrated the vaccine’s is highly reactogenic [62]
, 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.[4]
Combat stress
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, according to a Veterans
Administration review committee.
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.[63]
Diagnosis
Multisymptom illness is more prevalent in Gulf War I veterans than veterans of
previous conflicts, but the pattern of comorbidities is similar for actively deployed and
nondeployed military personnel.[64]
Management of potentially comorbid toxic
exposures requires awareness of the toxins involved.[7]
Exposure to the destruction of
the Khamisiyah weapons depot, where large quantities of the chemical weapon sarin
was stored, is negatively correlated with motor speed.[5]
Epidemiological evidence is
consistent with increased risk of birth defects in the offspring of persons exposed to
depleted uranium[6]
and uranium exposure has also been associated with increased
cancer rates.[65][66][67][68][69][70]
Management
Diplomatic reconciliation is one means of prevention,[10][11]
beyond battlefield air
quality management, which often conflicts with established tactical policy. For
example, most organized armies practice "secure and hold" tactics which require
occupation of areas before they can be decontaminated.
Acetylcholinesterase inhibitors
Nerve agent antidote and insect repellent
In 2008, a paper published in the Proceedings of the National Academy of Sciences
suggested that excess illnesses in Gulf War veterans could be explained in part by their
exposure to organophosphate and carbamate acetylcholinesterase inhibitors.[71]
A
federal report released in November, 2008, agreed, stating that exposure to two
substances "are causally associated with Gulf War illness":[72]
pyridostigmine bromide, an acetylcholinesterase inhibitor intended to protect
against nerve agents,[73]
and
pesticides and insect repellents (often acetylcholinesterase inhibitors)
Sarin
Exposure to sarin, a nerve gas, is a possible comorbidity. Chemical weapons classified
as nerve agents are also strong acetylcholinesterase inhibitors. A 2004 review discusses
symptoms, signs, and treatment of nerve agent exposure.[7]
Uranium exposure
Genotoxic mutagens such as uranium should be treated with chelation therapy[74]
or
other means shortly after exposure.[75]
Incorporated uranium becomes uranyl ions,
which accumulate in bone, liver, kidney, and reproductive tissues. Uranium can be
decontaminated from steel surfaces[8]
and aquifers.[9]
Epidemiology
Epidemiologic studies have been performed evaluating many suspected factors for Gulf
War illness as seen in veteran populations. Below is a summary of epidemiologic
studies of veterans displaying multisymptom illness and their exposure to suspect
conditions from the 2008 U.S. Veterans Administration report.[76]
A fuller understanding of immune function in ill Gulf War veterans is needed,
particularly in veteran subgroups with different clinical characteristics and exposure
histories. It is also important to determine the extent to which identified immune
perturbations may be associated with altered neurological and endocrine processes that
are associated with immune regulation.[22]
No studies that have evaluated birth
outcomes and birth defects among Gulf War veterans and their children have assessed
whether there is any connection between reproductive outcomes and uranium exposure
in the Gulf War.[77]
Very limited cancer data have been reported for U.S. Gulf War
veterans in general, and no published research on cases occurring after 1999. Because of
the extended latency periods associated with most cancers, it is important that cancer
information be brought up to date and that cancer rates be assessed in Gulf War veterans
on an ongoing basis. In addition, cancer rates should be evaluated in relation to
identifiable exposure and location subgroups.[78]
Epidemiologic Studies of Gulf War Veterans: Association of Deployment
Exposures With Multisymptom Illness[79]
Preliminary Analysis
(no controls for
exposure)
Adjusted Analysis (controlling
for effects of exposure)
Clinical
Evaluation
s
GWV
populatio
n in
which
associatio
n was
assessed
GWV
populatio
n in which
associatio
n was
statisticall
y
significant
GWV
populatio
n in
which
associatio
n was
assessed
GWV
populatio
n in which
associatio
n was
statisticall
y
significant
Dose
response
effect
identified
?
Pyridostigmine
bromide 10 9 6 6 ✓
Associated
with
neurocognitiv
e and HPA
differences in
GW vets
Pesticides 10 10 6 5 ✓
Associated
with
neurocognitiv
e and HPA
differences in
GW vets
Physiological
Stressors 14 13 7 1
Chemical
Weapons 16 13 5 3
Associated
with
neurocognitiv
e 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/Particulat
es 3 3 3 1
Depleted
Uranium 5 3 1 0
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."[80]
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 Gulf War
veterans.[81]
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.[82]
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.[83]
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.[84]
See also
Beyond Treason an 89-minute 2005 documentary that covers the Gulf War
syndrome.
Environmental issues with war
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External links
Research
Research Advisory Committee on Gulf War Veterans' Illnesses, publishers of
the 2008 Gulf War Illness and the Health of Gulf War Veterans: Scientific
Findings and Recommendations (7.4 MB PDF)
Uranium Medical Research Centre, founded in 1997 by Dr. Asaf Durakovic,
M.D., formerly Chief of Professional Clinical Services in the U.S. Army's 531st
Medical Detachment during the Desert Shield phase of the 1991 Gulf War and
former Veteran's Administration official
Associations
American Gulf War Veterans Association
National Gulf War Resource Center
Veterans of Modern Warfare
Video
Conspiracy Test: Gulf War Illness investigative report by the Discovery Channel
- part 1, part 2, part 3, part 4, part 5
Categories: Gulf War syndrome | Genetic disorders | Immune system disorders |
Military personnel | Neurological disorders | Syndromes | Gulf War
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• Gulf war syndrome: is it due to a systemic shift in cytokine balance towards a Th2
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• Change in immune parameters seen in Gulf War veterans but not in civilians with
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Frequently Asked Questions
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