ENVIRONMENTAL HEALTH CONCERNS OF THE PERSIAN GULF WAR Roscoe C. Young, Jr, MD, Raylinda E. Rachal, MD, and John W. Huguley, 111, MD New Orleans, Louisiana and Washington, DC
Environmental health concerns in the Persian Gulf are peculiar to the geography of the region. Prevention of heat and solar injury deserves primary consideration, but cold injury also may occur in the desert. Immunizations are recommended against a number of diseases, while malarial chemoprophylaxis is necessary in Iraq and Kuwait. In addition to malaria, other parasitic diseases deserve consideration. Diarrheal diseases, diseases from the desert dust, and products of infected desert animals are of concern. Additional natural hazards are venomous bites from scorpions and desert snakes. Finally, threats of enemy action necessitated protection from nuclear biological and chemical weapons and LASER eye/skin injury. Unexploded ordinance will constitute a continuing hazard into the future. (J Nati Med Assoc. 1992;84:417-424.) Key words * Persian Gulf * Desert Shield/Stormimmunization * diarrheal diseases * parasitic infestation * venomous bites * chemical warfare casualties From the College of Pharmacy, Xavier University of Louisiana, New Orleans, Louisiana, and the Medical Clinic, Walter Reed Army Medical Center, Washington, DC. Presented at the Aerospace and Military Medicine Section, the 96th Annual Convention and Scientific Assembly of the National Medical Association, July 27-August 1, 1991, Indianapolis, Indiana. Work done while deployed on Operation Desert Shield/Storm, during the Persian Gulf War, while assigned to the 1 1 5th Mobile Army Surgical Hospital, District of Columbia Army National Guard, and the 31st Combat Support Hospital 332nd Medical Battalion, 2nd COSCOM in support of VII (US) Corps. The material contained herein is unclassified, and opinions expressed are those of the authors and do not necessarily reflect those of the Department of the Army, the National Guard Bureau, or the Army Medical Corps. Requests for reprints should be addressed to Dr Roscoe C. Young, Jr, Xavier University, COP, 7325 Palmetto St, New Orleans, LA 70125. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 5
Almost half a century has elapsed since the Second World War, when American fighting forces were deployed to a desert environment where they took the offensive in the North African campaign in 1943. The end of the 20th century witnessed another such deployment of American fighting forces when 540 000 Americans were deployed to the Persian Gulf during Operation Desert Shield/Storm in 1990 and 1991. Health hazards encountered by these American troops included those peculiar to fighting forces deployed in a field environment and the desert climate as well as to those presented by a hostile adversary. Proper precautionary measures minimized the danger to the troops, and early treatment of affected patients returned them to duty promptly. Saudi Arabia (Figure 1) is approximately the size of Alaska and Texas combined. The climate is hot, with temperatures reaching 1 30°F during the day in the summer; however, in the winter, the temperature may dip below the freezing mark during the night. Such extremes in temperature are characteristic of desert regions, and the relative humidity inland may be lower than 6%. Saudi Arabia is one of the most bleak desert countries in the world, lacking rivers, streams, or lakes. Dry riverbeds or wadis may be seen. Southern Arabia is a region of giant sand dunes that are often several hundred feet high and miles in length, eternally shifting, pushed by hot desert winds (the shamal). The sand is a fine clay dust, laden with microorganisms, that pervades every orifice, nook, and cranny. Located to the northeast of Saudi Arabia is Kuwait, which has an area of approximately 7780 square miles. Like Saudi Arabia, the climate in Kuwait is very hot, except for a short winter season that may be comfortable. Prior to the Gulf War, Europeans and Americans in Kuwait worked predominantly in the oil industry. Iraq, to the north, is roughly two thirds the size to Texas. The weather is very hot in summer and 417
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TABLE 1. PREVENTION OF HEAT INJURY* Heat Water Condition WBGT Intake Work/Rest Category lndext (IF) (Quart/Hr) Cycle (Min) 1 78-81.9 1/2 Continuous 2 82-84.9 1/2 50/10 3 1 85-87.9 45/15 4 88-89.9 1 1/2 30/30 5 >90 >2 20/40
Figure 1. Map showing geography of Southwest Asia.
moderately cold in winter. Kurds in the northern mountains see snow. The Tigris and Euphrates rivers, almost paralleling one another, flow to the southeast before joining to drain into the Persian Gulf. These rivers embrace Mesopotamia, which is a fertile valley. One bank of the common delta is shared with Iran to the east. I
HEALTH CONCERNS Solar/Heat Injury
Abbreviations: WBGT= wet bulb globe temperature. *Adapted from references 2-4 and TWX Immunization and Preventive Medicine Requirements for Deployment to Persian Gulf Region, dated 14 Aug 90, unclassified. tMOPP gear, body armor adds 1 0°F to the WBGT index.
heat stroke, which can result in death. Heat stroke is caused by the paralysis of heat-regulating mechanisms. Instant and continuous rapid cooling of the patient to bring core temperatures within normal range is indicated. Placement of urinary catheter and Swan Ganz catheter, attention to the airway, cutaneous massage, and hydration are essential. For heat syncope, exhaustion, and cramps, rest and the replacement of salt and water is indicated.2'5
Cold Injury
Of paramount importance in the Persian Gulf Region are solar injury and heat injury, especially during the long hot summers. Sunburn may render a soldier* incapable of mission performance and in the future may lead to skin cancer, especially in the fair skinned. Lip balm, sunscreen, and sunglasses were recommended. Desert ranger hats (also called boonie hats) were selected to offer adequate solar protection to the back of the head and neck. Heat injury was minimized by command emphasis on water discipline. Appropriate work/rest cycles were essential. These cycles included the amount of water to be consumed and depended on the air temperature, wind, humidity, and radiant temperature. The wet bulb globe temperature (WBGT) thermometer was used to calculate the heat condition/category, from which water consumption and work/rest cycles were calculated (Table).2-4 Adaptation to the heat required a 2- to 3-week adjustment period. The different types of heat injuries seen in the Persian Gulf War included heat stroke, heat syncope, heat exhaustion, and heat cramps. The most serious of these is
During the winter months and the cold, windswept nights, duty in the desert on the perimeter of the area of operations or on board ship can result in cold injury. Dehydration is even more common in cold weather. At least five instances of frostbite were recorded among soldiers between January and March 1991, and exposure was the rule among enemy prisoners of war. Cold injury can involve all or part of the body (hypothermia versus local cold injury, respectively). Hypothermia is present when the core temperature falls below 92°E J waves in the electrocardiogram are diagnostic signs of hypothermia. Hypothermia may be accidental or caused by immersion. Local cold injuries from immersion are trenchfoot and frostbite, the most serious of local cold injuries. Recommended treatment of all cold injuries is slow continuous rewarming. Cardiopulmonary resuscitation with airway establishment and continuous monitoring in an intensive care setting are necessary treatments for hypothermia.5
*The term soldier is used generically to represent any US service person.
Recommended immunizations included tetanus and diphtheria boosters of 0.5 mL given intramuscularly every 10 years, typhoid fever given every 3 years, and
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a single dose of meningococcal vaccine, (quadrivalent ACYW 135, Connaught Laboratories, Swiftwater, Pennsylvania). Immune globulin (IG) was the recommended hepatitis A vaccine. The dose volume for IG depends on the body weight and the length of stay, eg, for a 70-kg soldier staying more than 3 months, the dose was 5 mL intramuscularly. Hepatitis B vaccine (HBV) was given in three intramuscular doses., The second dose was given 1 month after the first and the third dose 6 months after the first. The dosage of this vaccine depends on the vaccine type. The adult dose for plasma-derived vaccine is 20 jig and 10 ,g for recombinant DNA
vaccine.6
When cholera vaccine is necessary, it should be given in a primary series, two doses of 0.5 mL a week to a month apart. A booster dose of 0.5 mL may be given at 6 months. Yellow fever vaccine is not required for deployment to the Middle East.4 In certain areas, malaria prophylaxis must be given. The dose given was a weekly 500-mg tablet of chloroquine phosphate. If chloroquine phosphate is medically contraindicated, 100 mg of doxycycline may be given daily for 4 weeks. Malaria prophylaxis is required in western and southwestern Saudi Arabia (along the Red Sea Coast), Oman, and Iraq. Malaria in Iraq is caused exclusively by Plasmodium vivax. In Saudi Arabia and Oman, Plasmodium falciparum predominates but chloroquine resistance has not been reported.4'6 The search for a malaria vaccine continues and may be nearing comple-
tion.7 Two insect repellents were available against the anopheles mosquito vector: DEET for direct skin application and permethrin for application to the
uniform.4
Atmospheric Pollution Atmospheric pollution was a serious problem in the Persian Gulf. During the war, approximately 600 oil wells in Kuwait were set afire. Despite efforts to control the fires, by August 1991 at least half the wells continued to burn. It was not until November 1991 that the last fire was extinguished. One million barrels of oil weighing a million tons were burning daily, spewing 50 000 tons of sulfur dioxide, which is the chief constituent of acid rain, and 100 000 tons of sooty smoke into the atmosphere.8 Using the Massachusetts standard, the Environmental Protection Agency found excessive levels of 1,4 dichlorobenzene, which harms the liver, kidneys, and respiratory system, and 1,2 dichlorobenzene, which harms the liver and kidneys. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 5
Diethylphthalate and dimethylphthalate, both of which attack the respiratory system, also were present.9 Daytime temperatures beneath the sun-blocking smoke were 15°C or 27°F below normal, suggesting a miniature nuclear winter.9'10 Prior to and during the war, open incineration of human feces and trash facilitated by the addition of fuel3 constituted another atmospheric pollution hazard. Additional contributors were the emissions of internal combustion engines, trucks and tracked vehicles that used diesel fuel, and aircraft including helicopters, which burn a kerosene-like fuel. Ever-present electricpower generators contributed to noise pollution, in addition to releasing hydrocarbon emissions.
Diarrheal Diseases Diarrheal diseases include "traveler's diarrhea," shigellosis, salmonellosis, cholera, and amebic dysentery. Diarrheal diseases are enteric diseases making attention to personal hygiene mandatory. Construction of improvised field devices is an important facet of military doctrine.3 Bottled water was provided during the Gulf War by contract with Saudi Arabia. Because ice cubes are made of water, they should not be used unless made from bottled water. Soldiers were advised to avoid street vendors, as towns and cities were placed "off-limits." Warnings were issued against consumption of raw fruit, raw seafood, rare meat, and unpasteurized dairy products. Enterotoxigenic Escherichia coli is responsible for 50% to 75% of traveler's diarrhea, but shigellosis, vibrio parahemolyticus, rotaviruses, Endameba histolytica, and Giardia lamblia also may cause diarrhea.5 Lopramide hydrochloride was successful in treating the majority of cases. Although cholera was not a problem before and during the war, in its aftermath 49 cases have been reported in Iraq in June 1991, bringing the total of known cases among the natives to 324.11 The Harvard Study Team'2 reported that as a result of the Persian Gulf War, children in Iraq are dying of preventable disease. Destruction of that country's infrastructure has resulted in devastating long-term consequences for health with alarming increases in typhoid fever and severe gastroenteritis in addition to cholera. High levels of severe malnutrition in the form of marasmic kwashiorkor continue to be reported in pediatric patients.
Amebic Dysentery An outbreak of amebic dysentery occurred in one unit. It is unknown whether it was contracted from 419
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native food in off-limits areas or from catered salads. This form of dysentery is caused by the protozoan parasite E histolytica, which may cause a diarrheal illness as well as extraintestinal complications. Carriers are more frequent. The organism exists in the trophozoite and the cyst form. Trophozoites inhabit the wall of the colon. Extraintestinal complications result in amebic hepatitis or abscess. Diagnosi's is by identification of the organism in stool or tissues or by sigmoidoscopy. Trophozoites may be identified in wet smears microscopically. They may exhibit ameboid motion and may contain erythrocytes undergoing digestion within their cytoplasm. Encystation may occur during unfavorable conditions. Smears or stools may be stained with D'Antoni's iodine solution and examined under the microscope. Precysts, young uninucleate cysts, binucleate cysts, and mature quadrinucleate cysts may be seen.13 A skin test, the Moan test, may be helpful in diagnosing pleuropulmonary disease. Treatment is metronidazole. lodoquinol or doxycyline may be used as adjunct therapy. Chloroquine for hepatic abscess or emetine for tissue infestation has also been given.5
Diseases Endemic to the Middle East Sheep, goats, camels, and dogs are domesticated animals and often reservoirs of human disease. Q fever is a rickettsial disease contracted from the slaughtering of infected livestock. The etiologic agent is Coxiella burnetti, the only rickettsial disease for which an insect vector is not required in its transmission. It is contracted through direct inhalation. Symptoms may consist of fever, headache, photophobia, and an atypical pneumonia characterized by a dry hacking cough.'4 Recovery is usual, but the disease may be fatal. Like all rickettsial disease, it causes a vasculitis. The treatment is an initial dose of 1200 mg of doxycycline by mouth, with a maintenance dose of 100 mg a day. Chlamydial pneumonia is caused by Chlamydia psittaci (TWAR strain) which is associated with sporadic and epidemic atypical pneumonia in adults.5 Like other organisms, chlamydial organisms may be deposited in the dust by desert animals and inhaled by humans during the shamals or ingested because of a failure to wash hands (after handling dusty fomites) before eating. Symptoms are those of conjunctivitis and pneumonia. Productive cough, fever, general malaise, and weakness are present. Chlamydial pneumonia is treated with ciprofloxin, a fluoroquinolone antimicrobial. There is a high incidence of primary drug resistance 420
to tuberculosis in the native population, which may be as high as 10%. The incidence of primary drug resistance in the United States is lower, but is increasing because of the acquired immunodeficiency syndrome (AIDS) epidemic, substance abuse, and inner-city poverty and crowding. In the Middle East, tuberculosis may be contracted by inhaling droplet nuclei of Mycobacterium tuberculosis or by drinking raw milk/ dairy products infected with Mycobacterium bovis. Fever of unknown origin that occurs in the indigenous population may be due to tuberculosis, so the physician must have a high index of suspicion for the disease. Because of the delayed immune response, one quarter of the patients may be PPD negative for a month or longer, so the TB skin test if negative may not be a useful diagnostic tool. Treatment often consists of three or four drugs-isoniazid, rifampin, ethambutol, and pyrazinamide-administered concurrently as initial therapy. Brucellosis is also called undulant or Malta fever. In Saudi Arabia, Iran, and Iraq, the seasonal incidence of spring and summer corresponds to products of conception in the desert. Native bedouins drink raw milk and eat raw meat. The disease may be contracted by inhalation of Brucella melitensis, a gram-negative rod. Symptoms consist of fever, weakness, malaise, and night sweats. Hepatitis may cause nausea and vomiting. Two percent or 3% of patients may die of endocarditis. Diagnosis is made by culture of body fluids and tissues. Febrile agglutination tests are helpful.5 Treatment is with doxycycline and rifampin for 6 weeks. Other specific respiratory conditions endemic to the Persian Gulf region included allergic disorders. Among the most common were exacerbations of chronic sinusitis and asthma through the asthma, asthmatic bronchitis syndrome. These may be due to aeroallergens and infections previously discussed that are disseminated in the desert dust. In fact, soldiers who had outgrown childhood asthma had renewed attacks in the desert environment and required early redeployment. Phlebotomus or sandfly fever is transmitted by the bite of the sandfly, Phlebotomus papatasii. The etiology is an "arbovirus." In the Middle East, the disease occurs during the hot dry season. Swarming flies are ubiquitous in southwest Asia. These are small urban flies that can penetrate ordinary house screens. The females bite, usually at night. Symptoms, which last 3 days, consist of headache, fever, malaise, and myalgia, and are usually self-limiting; rarely, phlebotomus may be complicated by aseptic meningitis.5 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 5
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Nondiarrheal infectious diseases were far less frequent among US service personnel than expected. The US Navy Forward Laboratory at Marine Corps Surgical Support Facility in Saudi Arabia performed enzymelinked immunosorbent assay (ELISA) tests on sera from 37 soldiers with nondiarrheal febrile illness and on 102 controls. Neither phlebotomus fever, typhus, nor Q fever were discovered. A single instance of West Nile fever was diagnosed in a hospitalized soldier with self-limiting illness consisting of acute fever and
arthralgia. 15
Parasitic Diseases of Persian Gulf Region Malaria is a protozoan disease transmitted by the bite of the Anopheles mosquito, characterized by fever, rigors, splenomegaly, and anemia. It is characterized by a chronic relapsing course. Malaria caused by P vivax may be found in the Euphrates River valley, and in fact at least five cases had occurred among United States service personnel in that area by May 1991. The malarial parasite cycle has an asexual phase in humans and a sexual phase in the Anopheles mosquito. Parasites breed in the mosquito, which injects sporozoites into the host while feeding. The sporozoites invade the liver cells where they are transformed into merazoites, which emerge to enter erythrocytes. The merazoites multiply in erythrocytes and are transformed again into sexual gametocytes that are taken up by the mosquito during feeding. Sexual reproduction of parasites in the mosquito produces sexual infective sporozoites.5'7"13 Algid malaria, characterized by shock, cerebral malaria with convulsions and coma, respiratory failure of adult respiratory distress syndrome, and black water fever are syndromes of poor prognosis. Treatment of active disease is chloroquine phosphate for chloroquine-sensitive P falciparum. For P vivax, primaquine phosphate should be administered in addition to chloroquine. Because 22 Operation Desert Shield/Storm soldiers were infested with leishmania, the Pentagon announced a temporary ban on blood donations from soldiers who served in the Persian Gulf.'6 Cutaneous leishmaniasis, endemic to the region, is caused by a protozoan of the genus Leishmania transmitted also by the bite of the sandfly, P papatasii. Dogs and jackals serve as the natural reservoir. The disease has also been called Oriental sore or Baghdad boil. It causes a single red pruritic papule on the face with central ulceration enlarging up to 2 cm, and heals by scarring in 1 to 2 years. Biopsy with microscopic examination with Wright stain may be used to demonstrate organisms of JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 5
Leishmania tropica in the cytoplasm of mononuclear cells.'3 For treatment, it is best to wait until ulceration takes place, which indicates the development of immunity, then administer a pentavalent antimonial such as sodium antimony gluconate.5 Schistosomiasis or snail fever is caused by schistosomes. These trematode parasites occur in freshwater streams and irrigation canals of Iraq. Species include Schistosoma mansoni and Schistosoma haematobium. Soldiers were advised against bathing or washing laundry in freshwater streams. Shistosomes or blood flukes have a complicated life cycle involving humans and a planorbid snail.17 Life cycles of two principal Middle East schistosomes that cause "snail fever" follow parallel patterns. Cercariae, free-swimming late larval forms, enter a human host by penetrating the unbroken skin. They mature and mate in the liver, and then migrate to the venous system of the lower abdomen. Predilection of the adult S haematobium for the bladder and of the adult S mansoni for the intestine is responsible for characteristic differences in the manifestations of chronic schistosomiasis. Schistosome eggs excreted into fresh water develop into miracidia, free-swimming first-stage larvae, which infect an intermediate snail host in which they close their life cycle by developing and multiplying into a new generation of cercariae. Diagnosis is made by finding characteristic ovoid ova with terminal and lateral spines in urine or stool specimens, respectively. The morphology of schistosome ova is not only diagnostic for species identification, but also determines the drug dosage. Praziquantel is the drug of choice for treatment.17 Typhus fever is an epidemic disease caused by Rickettsia prowazekii. The agent is transmitted by the body louse, Pediculus humanus var corporis, but more recently other insect vectors and nonhuman animal reservoirs have been implicated. Like other rickettsial diseases, R prowazekii causes a vasculitis and a skin rash and headache. Diagnosis is best made by serologic tests with cross agglutination to proteus OXK, OX2, and OX19. Murine (endemic) typhus is caused by Rickettsia mooseri transmitted by the rat flea Xenopsylla cheopis. Prevention is good personal hygiene. Delousing with lindane powder will eliminate lice.3'4 A viable vaccine is effective, but not available commercially. Active treatment is with chloramphenicol or doxycycline.5
Scorpions The scorpion, genus Centruroides, is a poisonous 421
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W.
East snakes from Naval Environmental Medical Unit #7, Cairo, Egypt.4 Inflammation may require surgical debridement and fasciotomy.18 The kangaroo rat, a rodent uniquely adapted for life in the desert, does not need to drink water. It obtains enough water from the digestion of foodstuff This rodent is in the food chain of snakes, and its presence attracts them. The rat is also a reservoir for disease transmission to man.
Persistent Chemical Agents
Figure 2. Casualty being evacuated by medics to a waiting helicopter. Note the protective eye wear, protective mask carriers, and chemical protective overgarments. The medic on the left is wearing a desert night parka for protection against cold desert night winds. Photograph by David C. Turnley/Detroit Free Press/Black Star. Reprinted with permis. sion from Triumph in the Desert. Copyright ©1991, Random House Inc.
eight-legged arthropod also found in the Middle East desert. The sting is venomous and will cause death in small animals and children. Following a sting, there is local paresthesia, restlessness, neurologic excitability, lacrimation, rhinorrhea, and salivation. Perspiration may occur; convulsions and coma may follow. Early spring rains in the desert brought scorpions out. Soldiers were reminded to shake out their boots each morning before dressing. Active treatment consists of specific antivenom made from goat serum. Adrenergic blockers may manage symptoms because of catecholamine release.5 Dusting the area with lindane powder kills scorpions.3'4
Poisonous Snakes Two poisonous snakes can be found in the Persian Gulf: the poisonous puff adder, which is nonpoisonous in the United States,5 and the Palestine viper. Desert snakes burrow beneath the sand to keep cool in the heat of the day and return to the surface to feed at night. They seek warmth in sleeping bags with humans. Because of snakes and scorpions, it was necessary not to sleep directly on the ground. Cots became a life support measure. Venom is neurotoxic and hemolytic. Active treatment is specific antivenom. It was available for Middle 422
The nuclear capability of Iraq was underestimated and is currently being reassessed. The real threat to coalition forces was chemical and biological agents. These lend themselves to a variety of delivery systems: terrorists, artillery, aircraft, and rockets. The SCUD missile capability has already been demonstrated. Chemical agents include the vesicant or blister agents and nerve agents (organophosphates); designated HD and VX (Soman), respectively, they come in the form of droplets. For VX, a droplet the size of a pinhead absorbed through the skin equivalent to 10 pug is lethal for 50% of people exposed (LD50). Nerve agents as a vapor are 25 times more toxic than cyanide.19'20 Protection with mask, chemical-protective overgarment, CPOG or MOPP suit (Figure 2), detection, decontamination procedures, and treatment constituted training for these agents. Dimercaprol or British antilewisite (BAL) is therapy for vesicants. Preexposure dosing with pyridostigmine (PD) tablets gave protection from nerve agents. Pyridostigmine tablet administration was not entirely without adverse effects. Susceptible individuals included those with latent asthma, chronic obstructive lung disease, and coronary artery disease. Symptoms consisting of wheezing, dyspnea, nausea, and diarrhea disappeared following discontinuation of the medication. Active treatment consists of the mark I injector kit containing atropine sulphate and pralidoxime chloride (2 PAM Chloride) by use of autoinjectors. These control nicotinic effects of parasympathetic overbalance. Muscarinic effects may be controlled by the use of diazepam.19,21 Caution was indicated in avoiding heat injury while wearing the MOPP suit.22 An adversary counts on the element of surprise. Knowledge of the use of chemical detector kit and alarms are essential but because nerve agents, the most deadly of the chemicals, are colorless and odorless, the only indication of their presence may be the effect of the agent on another soldier. Soldiers were taught to look for miotic pupils, rhinorrhea, salivation, and labored breathing by observing one another. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 5
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Biological Warfare Agents Biological warfare (BW) agents of significance include toxin from Clostridium botulinum, which causes botulism, and Bacillus anthracis by aerosol, which causes anthrax pneumonia. Biological warfare agents use the same delivery systems as chemical warfare agents. The similarity of the two is extended to include the protective benefit of the mask and MOPP suit. Clostridium botulinum toxin produces respiratory muscle paralysis and is nearly as poisonous as a nerve agent. A small amount of toxin introduced into the water supply or food chain by terrorists or guerrillas can kill the entire population of a city with 200 000 inhabitants.5 Exotoxin is produced during the growth and autolysis of C botulinum, a strictly anaerobic spore forming gram-positive rods. Botulinum toxins are the most potent poisons known. They are simple proteins that differ chemically but have similar effect on neuromuscular transmission. They are heat labile. The toxin exerts a fatal effect by blocking peripheral neuromuscular transmission of cholinergic nerves causing a descending muscle paralysis. They inhibit or bind with acetylcholine. Symptoms are dysphonia, dysphagia, and respiratory muscle weakness, which leads to respiratory failure and death.5 Anthrax pneumonia is caused by aerosol dissemination of B anthracis and is also known as woolsorter's disease. It is a highly fatal disseminated infection characterized by cyanosis, dyspnea, and hemoptysis. There may be a biphasic illness. In the second stage, dyspnea, cyanosis, stupor, and shock may develop. Chest radiograph may show mediastinal widening or pleural effusions. Pathologically, fulminating pulmonary edema and mediastinitis are present.'4 Recommended treatment is ciprofloxin. Response to penicillin (used previously) has been poor. Most patients died within 24 hours despite treatment. Other biological agents include triosthesenes (yellow rain), a biotoxin from a type of bread mold, alleged to have been used in the Vietnam War.23 The present status of this fungal biotoxin as a BW agent is uncertain.
Laser Eye Injuries The laser is a relatively recent innovation used by modern military forces on the battlefield as rangefinders and target designators. These devices produce a narrow beam of intense light that can damage eyes or skin.24 Laser eye injuries must be distinguished from chemical eye injuries, which they often resemble. Laser injury may be suspected when spontaneous fires occur and optical instruments are damaged. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 5
Soldiers have been trained to report laser injuries immediately to competent authority. Special goggles are available for protection. Sunglasses or ordinary eye wear give some measure of protection. Squinting, fog, or obscurant smokes are effective. Soldiers were advised not to look at the light or use binoculars. Only hardened optical systems were safe.24 Treatment of laser eye injuries depends on the part of the eye damaged. Evacuation to the rear may be necessary with operative management by an ophthalmologist.
Duds, Mines and Booby Traps Unexploded ordinance, duds, land mines, mines floating at sea, and booby traps will present a hazard to all persons for the next 25 or 30 years in contested areas of the Middle East. Although extensive minesweeping operations by coalition forces have continued since the cessation of hostilities, many armed explosives remain undetected. Survival will depend on minesweeping operations combined with educating the remaining soldiers through posters, publications, avoidance of the most heavily mined areas, and command influence. These affirmative actions are expected to minimize future deaths and maiming.
CONCLUSION The harsh ecology of the desert, unchanged since Biblical times, combined with 20th century technological advances in warfare, posed environmental health hazards unparalleled in the history of mankind. Literature Cited 1. Cleveland RL. The World Today Series: The Middle East and South Asia 1988. 22nd ed. Washington, DC: Sky Corp Stryker-Post Publications; 1988. 2. US Department of Army field manual FM 21-10. Prevention of Heat Injury. Training Doctrine Command: Ft Monroe, Va. Not dated. 3. US Department of Army field manual FM 21-10-1. Field Sanitation. Training Doctrine Command: Ft Monroe, Va. Not dated. 4. Teletype communication from the US Forces Command Commander [TWX from FORSCOM CDR]. Immunization and Preventive Medicine Requirements for Deployment to Preventive Gulf Region. US Forces Command, Ft McPherson, Ga: August 14, 1990. 5. Braunwald E, Isselbacher KJ, Petersdorf RG, Wilson JD, Martin JB, Fauci AS. Harrison's Principles of Intemal Medicine. 11th ed. New York, NY: McGraw Hill Book Co; 1987. 6. Centers for Disease Control. Health Information for International Travel 1988. Atlanta, Ga: Centers for Disease Control; 1988. US Dept of Health and Human Services publication CDC 88-8280. 7. Ronnie J. Proteins 2, malaria 0. Malaria free mice offer 423
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clues for developing a human vaccine. Sci Am. 1991:24-25. 8. Horgan J. Up in flames; Kuwait's burning oil wells are sad test of theories. Sci Am. 1991:17-24. 9. Wald ML. High levels of toxic substances found in Kuwait oil fire smoke. NY Times Intl. July 16, 1991 :A-4. 10. Limage SS, Suomi VE, Veldon C, Tripoli G. Satellite observations of smoke from oil fires in Kuwait. Science.
1991;252:1536-1539. 11. Cholera outbreak. Houston Chronicle. June 2, 1991 :3A. 12. Armijo-Hussein NA, Benjamin E, Moodie R, Passey M, Devin J, Donsiger S. Harvard study team special report: the effect of the Gulf Crisis on the children of Iraq. N Engl J Med.
1991;325:977-980. 13. Belding DE. Textbook of Clinical Parasitology. 2nd ed. New York, NY: Appleton-Century-Crofts; 1952. 14. Guenther CA, Welch MH. Pulmonary Medicine. Philadelphia, Pa: JB Lippincott Co; 1977. 15. Richards AL, Hyams KC, Merrill BR, Dasch Ga, Woody JN, Ksiazek TG. Medical aspects of Operation Desert Storm. N Engl J Med. 1991;325:970. 16. Waite JJ. Gulf war parasite halts troop blood drive. USA Today November 13, 1991 Al.
17. King CH. Acute and chronic schistosomiasis. Hosp Pract. 1991;26:95-106. 18. Sprenger TR, Bailey WJ. Snakebite treatment in the United States. Int J Dermatol. 1986;25:479-484. 19. US Armed forces pamphlet for Army (TM8-285), Navy (NAVMED P-5041), and Air Force (AFM 160-12). Treatment of Chemical Agent Casualties and Conventional Military Chemical Injuries. Not dated. 20. United States Army Medical Research Institute for Chemical Defense (USAMRICD) Technical Memorandum 90-1. Clinical Notes on Chemical Casualty Care. Not dated. 21. Sidell FR. Medical aspects of nerve agent exposure. Medical Bulletin PB. August 1988:3-B. 22. Kobrick JL, Johnson RF, McMenemy DJ. Effects of nerve agent antidote and heat exposure on soldier performance in the BDU and MOPP IV ensembles. Milit Med. 1990;155:159162. 23. Seagrave S. Yellow Rain: A Joumey Through the Terror of Chemical Warfare. New York, NY: M Evans & Co; 1981. 24. FM 8-50. Prevention and Medical Management of Laser Injuries. Aug 1990.
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Environmental health concerns in the Persian Gulf are peculiar to the geography of the region. Prevention of heat and solar injury deserves primary consideration, but cold injury also may occur in the desert. Immunizations are recommended against a number of diseases, while malarial chemoprophylaxis is necessary in Iraq and Kuwait. In addition to malaria, other parasitic diseases deserve consideration. Diarrheal diseases, diseases from the desert dust, and products of infected desert animals are of concern. Additional natural hazards are venomous bites from scorpions and desert snakes. Finally, threats of enemy action necessitated protection from nuclear biological and chemical weapons and LASER eye/skin injury. Unexploded ordinance will constitute a continuing hazard into the future. (J Nati Med Assoc. 1992;84:417-424.) Key words * Persian Gulf * Desert Shield/Stormimmunization * diarrheal diseases * parasitic infestation * venomous bites * chemical warfare casualties From the College of Pharmacy, Xavier University of Louisiana, New Orleans, Louisiana, and the Medical Clinic, Walter Reed Army Medical Center, Washington, DC. Presented at the Aerospace and Military Medicine Section, the 96th Annual Convention and Scientific Assembly of the National Medical Association, July 27-August 1, 1991, Indianapolis, Indiana. Work done while deployed on Operation Desert Shield/Storm, during the Persian Gulf War, while assigned to the 1 1 5th Mobile Army Surgical Hospital, District of Columbia Army National Guard, and the 31st Combat Support Hospital 332nd Medical Battalion, 2nd COSCOM in support of VII (US) Corps. The material contained herein is unclassified, and opinions expressed are those of the authors and do not necessarily reflect those of the Department of the Army, the National Guard Bureau, or the Army Medical Corps. Requests for reprints should be addressed to Dr Roscoe C. Young, Jr, Xavier University, COP, 7325 Palmetto St, New Orleans, LA 70125. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 5
Almost half a century has elapsed since the Second World War, when American fighting forces were deployed to a desert environment where they took the offensive in the North African campaign in 1943. The end of the 20th century witnessed another such deployment of American fighting forces when 540 000 Americans were deployed to the Persian Gulf during Operation Desert Shield/Storm in 1990 and 1991. Health hazards encountered by these American troops included those peculiar to fighting forces deployed in a field environment and the desert climate as well as to those presented by a hostile adversary. Proper precautionary measures minimized the danger to the troops, and early treatment of affected patients returned them to duty promptly. Saudi Arabia (Figure 1) is approximately the size of Alaska and Texas combined. The climate is hot, with temperatures reaching 1 30°F during the day in the summer; however, in the winter, the temperature may dip below the freezing mark during the night. Such extremes in temperature are characteristic of desert regions, and the relative humidity inland may be lower than 6%. Saudi Arabia is one of the most bleak desert countries in the world, lacking rivers, streams, or lakes. Dry riverbeds or wadis may be seen. Southern Arabia is a region of giant sand dunes that are often several hundred feet high and miles in length, eternally shifting, pushed by hot desert winds (the shamal). The sand is a fine clay dust, laden with microorganisms, that pervades every orifice, nook, and cranny. Located to the northeast of Saudi Arabia is Kuwait, which has an area of approximately 7780 square miles. Like Saudi Arabia, the climate in Kuwait is very hot, except for a short winter season that may be comfortable. Prior to the Gulf War, Europeans and Americans in Kuwait worked predominantly in the oil industry. Iraq, to the north, is roughly two thirds the size to Texas. The weather is very hot in summer and 417
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TABLE 1. PREVENTION OF HEAT INJURY* Heat Water Condition WBGT Intake Work/Rest Category lndext (IF) (Quart/Hr) Cycle (Min) 1 78-81.9 1/2 Continuous 2 82-84.9 1/2 50/10 3 1 85-87.9 45/15 4 88-89.9 1 1/2 30/30 5 >90 >2 20/40
Figure 1. Map showing geography of Southwest Asia.
moderately cold in winter. Kurds in the northern mountains see snow. The Tigris and Euphrates rivers, almost paralleling one another, flow to the southeast before joining to drain into the Persian Gulf. These rivers embrace Mesopotamia, which is a fertile valley. One bank of the common delta is shared with Iran to the east. I
HEALTH CONCERNS Solar/Heat Injury
Abbreviations: WBGT= wet bulb globe temperature. *Adapted from references 2-4 and TWX Immunization and Preventive Medicine Requirements for Deployment to Persian Gulf Region, dated 14 Aug 90, unclassified. tMOPP gear, body armor adds 1 0°F to the WBGT index.
heat stroke, which can result in death. Heat stroke is caused by the paralysis of heat-regulating mechanisms. Instant and continuous rapid cooling of the patient to bring core temperatures within normal range is indicated. Placement of urinary catheter and Swan Ganz catheter, attention to the airway, cutaneous massage, and hydration are essential. For heat syncope, exhaustion, and cramps, rest and the replacement of salt and water is indicated.2'5
Cold Injury
Of paramount importance in the Persian Gulf Region are solar injury and heat injury, especially during the long hot summers. Sunburn may render a soldier* incapable of mission performance and in the future may lead to skin cancer, especially in the fair skinned. Lip balm, sunscreen, and sunglasses were recommended. Desert ranger hats (also called boonie hats) were selected to offer adequate solar protection to the back of the head and neck. Heat injury was minimized by command emphasis on water discipline. Appropriate work/rest cycles were essential. These cycles included the amount of water to be consumed and depended on the air temperature, wind, humidity, and radiant temperature. The wet bulb globe temperature (WBGT) thermometer was used to calculate the heat condition/category, from which water consumption and work/rest cycles were calculated (Table).2-4 Adaptation to the heat required a 2- to 3-week adjustment period. The different types of heat injuries seen in the Persian Gulf War included heat stroke, heat syncope, heat exhaustion, and heat cramps. The most serious of these is
During the winter months and the cold, windswept nights, duty in the desert on the perimeter of the area of operations or on board ship can result in cold injury. Dehydration is even more common in cold weather. At least five instances of frostbite were recorded among soldiers between January and March 1991, and exposure was the rule among enemy prisoners of war. Cold injury can involve all or part of the body (hypothermia versus local cold injury, respectively). Hypothermia is present when the core temperature falls below 92°E J waves in the electrocardiogram are diagnostic signs of hypothermia. Hypothermia may be accidental or caused by immersion. Local cold injuries from immersion are trenchfoot and frostbite, the most serious of local cold injuries. Recommended treatment of all cold injuries is slow continuous rewarming. Cardiopulmonary resuscitation with airway establishment and continuous monitoring in an intensive care setting are necessary treatments for hypothermia.5
*The term soldier is used generically to represent any US service person.
Recommended immunizations included tetanus and diphtheria boosters of 0.5 mL given intramuscularly every 10 years, typhoid fever given every 3 years, and
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a single dose of meningococcal vaccine, (quadrivalent ACYW 135, Connaught Laboratories, Swiftwater, Pennsylvania). Immune globulin (IG) was the recommended hepatitis A vaccine. The dose volume for IG depends on the body weight and the length of stay, eg, for a 70-kg soldier staying more than 3 months, the dose was 5 mL intramuscularly. Hepatitis B vaccine (HBV) was given in three intramuscular doses., The second dose was given 1 month after the first and the third dose 6 months after the first. The dosage of this vaccine depends on the vaccine type. The adult dose for plasma-derived vaccine is 20 jig and 10 ,g for recombinant DNA
vaccine.6
When cholera vaccine is necessary, it should be given in a primary series, two doses of 0.5 mL a week to a month apart. A booster dose of 0.5 mL may be given at 6 months. Yellow fever vaccine is not required for deployment to the Middle East.4 In certain areas, malaria prophylaxis must be given. The dose given was a weekly 500-mg tablet of chloroquine phosphate. If chloroquine phosphate is medically contraindicated, 100 mg of doxycycline may be given daily for 4 weeks. Malaria prophylaxis is required in western and southwestern Saudi Arabia (along the Red Sea Coast), Oman, and Iraq. Malaria in Iraq is caused exclusively by Plasmodium vivax. In Saudi Arabia and Oman, Plasmodium falciparum predominates but chloroquine resistance has not been reported.4'6 The search for a malaria vaccine continues and may be nearing comple-
tion.7 Two insect repellents were available against the anopheles mosquito vector: DEET for direct skin application and permethrin for application to the
uniform.4
Atmospheric Pollution Atmospheric pollution was a serious problem in the Persian Gulf. During the war, approximately 600 oil wells in Kuwait were set afire. Despite efforts to control the fires, by August 1991 at least half the wells continued to burn. It was not until November 1991 that the last fire was extinguished. One million barrels of oil weighing a million tons were burning daily, spewing 50 000 tons of sulfur dioxide, which is the chief constituent of acid rain, and 100 000 tons of sooty smoke into the atmosphere.8 Using the Massachusetts standard, the Environmental Protection Agency found excessive levels of 1,4 dichlorobenzene, which harms the liver, kidneys, and respiratory system, and 1,2 dichlorobenzene, which harms the liver and kidneys. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 5
Diethylphthalate and dimethylphthalate, both of which attack the respiratory system, also were present.9 Daytime temperatures beneath the sun-blocking smoke were 15°C or 27°F below normal, suggesting a miniature nuclear winter.9'10 Prior to and during the war, open incineration of human feces and trash facilitated by the addition of fuel3 constituted another atmospheric pollution hazard. Additional contributors were the emissions of internal combustion engines, trucks and tracked vehicles that used diesel fuel, and aircraft including helicopters, which burn a kerosene-like fuel. Ever-present electricpower generators contributed to noise pollution, in addition to releasing hydrocarbon emissions.
Diarrheal Diseases Diarrheal diseases include "traveler's diarrhea," shigellosis, salmonellosis, cholera, and amebic dysentery. Diarrheal diseases are enteric diseases making attention to personal hygiene mandatory. Construction of improvised field devices is an important facet of military doctrine.3 Bottled water was provided during the Gulf War by contract with Saudi Arabia. Because ice cubes are made of water, they should not be used unless made from bottled water. Soldiers were advised to avoid street vendors, as towns and cities were placed "off-limits." Warnings were issued against consumption of raw fruit, raw seafood, rare meat, and unpasteurized dairy products. Enterotoxigenic Escherichia coli is responsible for 50% to 75% of traveler's diarrhea, but shigellosis, vibrio parahemolyticus, rotaviruses, Endameba histolytica, and Giardia lamblia also may cause diarrhea.5 Lopramide hydrochloride was successful in treating the majority of cases. Although cholera was not a problem before and during the war, in its aftermath 49 cases have been reported in Iraq in June 1991, bringing the total of known cases among the natives to 324.11 The Harvard Study Team'2 reported that as a result of the Persian Gulf War, children in Iraq are dying of preventable disease. Destruction of that country's infrastructure has resulted in devastating long-term consequences for health with alarming increases in typhoid fever and severe gastroenteritis in addition to cholera. High levels of severe malnutrition in the form of marasmic kwashiorkor continue to be reported in pediatric patients.
Amebic Dysentery An outbreak of amebic dysentery occurred in one unit. It is unknown whether it was contracted from 419
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native food in off-limits areas or from catered salads. This form of dysentery is caused by the protozoan parasite E histolytica, which may cause a diarrheal illness as well as extraintestinal complications. Carriers are more frequent. The organism exists in the trophozoite and the cyst form. Trophozoites inhabit the wall of the colon. Extraintestinal complications result in amebic hepatitis or abscess. Diagnosi's is by identification of the organism in stool or tissues or by sigmoidoscopy. Trophozoites may be identified in wet smears microscopically. They may exhibit ameboid motion and may contain erythrocytes undergoing digestion within their cytoplasm. Encystation may occur during unfavorable conditions. Smears or stools may be stained with D'Antoni's iodine solution and examined under the microscope. Precysts, young uninucleate cysts, binucleate cysts, and mature quadrinucleate cysts may be seen.13 A skin test, the Moan test, may be helpful in diagnosing pleuropulmonary disease. Treatment is metronidazole. lodoquinol or doxycyline may be used as adjunct therapy. Chloroquine for hepatic abscess or emetine for tissue infestation has also been given.5
Diseases Endemic to the Middle East Sheep, goats, camels, and dogs are domesticated animals and often reservoirs of human disease. Q fever is a rickettsial disease contracted from the slaughtering of infected livestock. The etiologic agent is Coxiella burnetti, the only rickettsial disease for which an insect vector is not required in its transmission. It is contracted through direct inhalation. Symptoms may consist of fever, headache, photophobia, and an atypical pneumonia characterized by a dry hacking cough.'4 Recovery is usual, but the disease may be fatal. Like all rickettsial disease, it causes a vasculitis. The treatment is an initial dose of 1200 mg of doxycycline by mouth, with a maintenance dose of 100 mg a day. Chlamydial pneumonia is caused by Chlamydia psittaci (TWAR strain) which is associated with sporadic and epidemic atypical pneumonia in adults.5 Like other organisms, chlamydial organisms may be deposited in the dust by desert animals and inhaled by humans during the shamals or ingested because of a failure to wash hands (after handling dusty fomites) before eating. Symptoms are those of conjunctivitis and pneumonia. Productive cough, fever, general malaise, and weakness are present. Chlamydial pneumonia is treated with ciprofloxin, a fluoroquinolone antimicrobial. There is a high incidence of primary drug resistance 420
to tuberculosis in the native population, which may be as high as 10%. The incidence of primary drug resistance in the United States is lower, but is increasing because of the acquired immunodeficiency syndrome (AIDS) epidemic, substance abuse, and inner-city poverty and crowding. In the Middle East, tuberculosis may be contracted by inhaling droplet nuclei of Mycobacterium tuberculosis or by drinking raw milk/ dairy products infected with Mycobacterium bovis. Fever of unknown origin that occurs in the indigenous population may be due to tuberculosis, so the physician must have a high index of suspicion for the disease. Because of the delayed immune response, one quarter of the patients may be PPD negative for a month or longer, so the TB skin test if negative may not be a useful diagnostic tool. Treatment often consists of three or four drugs-isoniazid, rifampin, ethambutol, and pyrazinamide-administered concurrently as initial therapy. Brucellosis is also called undulant or Malta fever. In Saudi Arabia, Iran, and Iraq, the seasonal incidence of spring and summer corresponds to products of conception in the desert. Native bedouins drink raw milk and eat raw meat. The disease may be contracted by inhalation of Brucella melitensis, a gram-negative rod. Symptoms consist of fever, weakness, malaise, and night sweats. Hepatitis may cause nausea and vomiting. Two percent or 3% of patients may die of endocarditis. Diagnosis is made by culture of body fluids and tissues. Febrile agglutination tests are helpful.5 Treatment is with doxycycline and rifampin for 6 weeks. Other specific respiratory conditions endemic to the Persian Gulf region included allergic disorders. Among the most common were exacerbations of chronic sinusitis and asthma through the asthma, asthmatic bronchitis syndrome. These may be due to aeroallergens and infections previously discussed that are disseminated in the desert dust. In fact, soldiers who had outgrown childhood asthma had renewed attacks in the desert environment and required early redeployment. Phlebotomus or sandfly fever is transmitted by the bite of the sandfly, Phlebotomus papatasii. The etiology is an "arbovirus." In the Middle East, the disease occurs during the hot dry season. Swarming flies are ubiquitous in southwest Asia. These are small urban flies that can penetrate ordinary house screens. The females bite, usually at night. Symptoms, which last 3 days, consist of headache, fever, malaise, and myalgia, and are usually self-limiting; rarely, phlebotomus may be complicated by aseptic meningitis.5 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 5
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Nondiarrheal infectious diseases were far less frequent among US service personnel than expected. The US Navy Forward Laboratory at Marine Corps Surgical Support Facility in Saudi Arabia performed enzymelinked immunosorbent assay (ELISA) tests on sera from 37 soldiers with nondiarrheal febrile illness and on 102 controls. Neither phlebotomus fever, typhus, nor Q fever were discovered. A single instance of West Nile fever was diagnosed in a hospitalized soldier with self-limiting illness consisting of acute fever and
arthralgia. 15
Parasitic Diseases of Persian Gulf Region Malaria is a protozoan disease transmitted by the bite of the Anopheles mosquito, characterized by fever, rigors, splenomegaly, and anemia. It is characterized by a chronic relapsing course. Malaria caused by P vivax may be found in the Euphrates River valley, and in fact at least five cases had occurred among United States service personnel in that area by May 1991. The malarial parasite cycle has an asexual phase in humans and a sexual phase in the Anopheles mosquito. Parasites breed in the mosquito, which injects sporozoites into the host while feeding. The sporozoites invade the liver cells where they are transformed into merazoites, which emerge to enter erythrocytes. The merazoites multiply in erythrocytes and are transformed again into sexual gametocytes that are taken up by the mosquito during feeding. Sexual reproduction of parasites in the mosquito produces sexual infective sporozoites.5'7"13 Algid malaria, characterized by shock, cerebral malaria with convulsions and coma, respiratory failure of adult respiratory distress syndrome, and black water fever are syndromes of poor prognosis. Treatment of active disease is chloroquine phosphate for chloroquine-sensitive P falciparum. For P vivax, primaquine phosphate should be administered in addition to chloroquine. Because 22 Operation Desert Shield/Storm soldiers were infested with leishmania, the Pentagon announced a temporary ban on blood donations from soldiers who served in the Persian Gulf.'6 Cutaneous leishmaniasis, endemic to the region, is caused by a protozoan of the genus Leishmania transmitted also by the bite of the sandfly, P papatasii. Dogs and jackals serve as the natural reservoir. The disease has also been called Oriental sore or Baghdad boil. It causes a single red pruritic papule on the face with central ulceration enlarging up to 2 cm, and heals by scarring in 1 to 2 years. Biopsy with microscopic examination with Wright stain may be used to demonstrate organisms of JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 5
Leishmania tropica in the cytoplasm of mononuclear cells.'3 For treatment, it is best to wait until ulceration takes place, which indicates the development of immunity, then administer a pentavalent antimonial such as sodium antimony gluconate.5 Schistosomiasis or snail fever is caused by schistosomes. These trematode parasites occur in freshwater streams and irrigation canals of Iraq. Species include Schistosoma mansoni and Schistosoma haematobium. Soldiers were advised against bathing or washing laundry in freshwater streams. Shistosomes or blood flukes have a complicated life cycle involving humans and a planorbid snail.17 Life cycles of two principal Middle East schistosomes that cause "snail fever" follow parallel patterns. Cercariae, free-swimming late larval forms, enter a human host by penetrating the unbroken skin. They mature and mate in the liver, and then migrate to the venous system of the lower abdomen. Predilection of the adult S haematobium for the bladder and of the adult S mansoni for the intestine is responsible for characteristic differences in the manifestations of chronic schistosomiasis. Schistosome eggs excreted into fresh water develop into miracidia, free-swimming first-stage larvae, which infect an intermediate snail host in which they close their life cycle by developing and multiplying into a new generation of cercariae. Diagnosis is made by finding characteristic ovoid ova with terminal and lateral spines in urine or stool specimens, respectively. The morphology of schistosome ova is not only diagnostic for species identification, but also determines the drug dosage. Praziquantel is the drug of choice for treatment.17 Typhus fever is an epidemic disease caused by Rickettsia prowazekii. The agent is transmitted by the body louse, Pediculus humanus var corporis, but more recently other insect vectors and nonhuman animal reservoirs have been implicated. Like other rickettsial diseases, R prowazekii causes a vasculitis and a skin rash and headache. Diagnosis is best made by serologic tests with cross agglutination to proteus OXK, OX2, and OX19. Murine (endemic) typhus is caused by Rickettsia mooseri transmitted by the rat flea Xenopsylla cheopis. Prevention is good personal hygiene. Delousing with lindane powder will eliminate lice.3'4 A viable vaccine is effective, but not available commercially. Active treatment is with chloramphenicol or doxycycline.5
Scorpions The scorpion, genus Centruroides, is a poisonous 421
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W.
East snakes from Naval Environmental Medical Unit #7, Cairo, Egypt.4 Inflammation may require surgical debridement and fasciotomy.18 The kangaroo rat, a rodent uniquely adapted for life in the desert, does not need to drink water. It obtains enough water from the digestion of foodstuff This rodent is in the food chain of snakes, and its presence attracts them. The rat is also a reservoir for disease transmission to man.
Persistent Chemical Agents
Figure 2. Casualty being evacuated by medics to a waiting helicopter. Note the protective eye wear, protective mask carriers, and chemical protective overgarments. The medic on the left is wearing a desert night parka for protection against cold desert night winds. Photograph by David C. Turnley/Detroit Free Press/Black Star. Reprinted with permis. sion from Triumph in the Desert. Copyright ©1991, Random House Inc.
eight-legged arthropod also found in the Middle East desert. The sting is venomous and will cause death in small animals and children. Following a sting, there is local paresthesia, restlessness, neurologic excitability, lacrimation, rhinorrhea, and salivation. Perspiration may occur; convulsions and coma may follow. Early spring rains in the desert brought scorpions out. Soldiers were reminded to shake out their boots each morning before dressing. Active treatment consists of specific antivenom made from goat serum. Adrenergic blockers may manage symptoms because of catecholamine release.5 Dusting the area with lindane powder kills scorpions.3'4
Poisonous Snakes Two poisonous snakes can be found in the Persian Gulf: the poisonous puff adder, which is nonpoisonous in the United States,5 and the Palestine viper. Desert snakes burrow beneath the sand to keep cool in the heat of the day and return to the surface to feed at night. They seek warmth in sleeping bags with humans. Because of snakes and scorpions, it was necessary not to sleep directly on the ground. Cots became a life support measure. Venom is neurotoxic and hemolytic. Active treatment is specific antivenom. It was available for Middle 422
The nuclear capability of Iraq was underestimated and is currently being reassessed. The real threat to coalition forces was chemical and biological agents. These lend themselves to a variety of delivery systems: terrorists, artillery, aircraft, and rockets. The SCUD missile capability has already been demonstrated. Chemical agents include the vesicant or blister agents and nerve agents (organophosphates); designated HD and VX (Soman), respectively, they come in the form of droplets. For VX, a droplet the size of a pinhead absorbed through the skin equivalent to 10 pug is lethal for 50% of people exposed (LD50). Nerve agents as a vapor are 25 times more toxic than cyanide.19'20 Protection with mask, chemical-protective overgarment, CPOG or MOPP suit (Figure 2), detection, decontamination procedures, and treatment constituted training for these agents. Dimercaprol or British antilewisite (BAL) is therapy for vesicants. Preexposure dosing with pyridostigmine (PD) tablets gave protection from nerve agents. Pyridostigmine tablet administration was not entirely without adverse effects. Susceptible individuals included those with latent asthma, chronic obstructive lung disease, and coronary artery disease. Symptoms consisting of wheezing, dyspnea, nausea, and diarrhea disappeared following discontinuation of the medication. Active treatment consists of the mark I injector kit containing atropine sulphate and pralidoxime chloride (2 PAM Chloride) by use of autoinjectors. These control nicotinic effects of parasympathetic overbalance. Muscarinic effects may be controlled by the use of diazepam.19,21 Caution was indicated in avoiding heat injury while wearing the MOPP suit.22 An adversary counts on the element of surprise. Knowledge of the use of chemical detector kit and alarms are essential but because nerve agents, the most deadly of the chemicals, are colorless and odorless, the only indication of their presence may be the effect of the agent on another soldier. Soldiers were taught to look for miotic pupils, rhinorrhea, salivation, and labored breathing by observing one another. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 5
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Biological Warfare Agents Biological warfare (BW) agents of significance include toxin from Clostridium botulinum, which causes botulism, and Bacillus anthracis by aerosol, which causes anthrax pneumonia. Biological warfare agents use the same delivery systems as chemical warfare agents. The similarity of the two is extended to include the protective benefit of the mask and MOPP suit. Clostridium botulinum toxin produces respiratory muscle paralysis and is nearly as poisonous as a nerve agent. A small amount of toxin introduced into the water supply or food chain by terrorists or guerrillas can kill the entire population of a city with 200 000 inhabitants.5 Exotoxin is produced during the growth and autolysis of C botulinum, a strictly anaerobic spore forming gram-positive rods. Botulinum toxins are the most potent poisons known. They are simple proteins that differ chemically but have similar effect on neuromuscular transmission. They are heat labile. The toxin exerts a fatal effect by blocking peripheral neuromuscular transmission of cholinergic nerves causing a descending muscle paralysis. They inhibit or bind with acetylcholine. Symptoms are dysphonia, dysphagia, and respiratory muscle weakness, which leads to respiratory failure and death.5 Anthrax pneumonia is caused by aerosol dissemination of B anthracis and is also known as woolsorter's disease. It is a highly fatal disseminated infection characterized by cyanosis, dyspnea, and hemoptysis. There may be a biphasic illness. In the second stage, dyspnea, cyanosis, stupor, and shock may develop. Chest radiograph may show mediastinal widening or pleural effusions. Pathologically, fulminating pulmonary edema and mediastinitis are present.'4 Recommended treatment is ciprofloxin. Response to penicillin (used previously) has been poor. Most patients died within 24 hours despite treatment. Other biological agents include triosthesenes (yellow rain), a biotoxin from a type of bread mold, alleged to have been used in the Vietnam War.23 The present status of this fungal biotoxin as a BW agent is uncertain.
Laser Eye Injuries The laser is a relatively recent innovation used by modern military forces on the battlefield as rangefinders and target designators. These devices produce a narrow beam of intense light that can damage eyes or skin.24 Laser eye injuries must be distinguished from chemical eye injuries, which they often resemble. Laser injury may be suspected when spontaneous fires occur and optical instruments are damaged. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 5
Soldiers have been trained to report laser injuries immediately to competent authority. Special goggles are available for protection. Sunglasses or ordinary eye wear give some measure of protection. Squinting, fog, or obscurant smokes are effective. Soldiers were advised not to look at the light or use binoculars. Only hardened optical systems were safe.24 Treatment of laser eye injuries depends on the part of the eye damaged. Evacuation to the rear may be necessary with operative management by an ophthalmologist.
Duds, Mines and Booby Traps Unexploded ordinance, duds, land mines, mines floating at sea, and booby traps will present a hazard to all persons for the next 25 or 30 years in contested areas of the Middle East. Although extensive minesweeping operations by coalition forces have continued since the cessation of hostilities, many armed explosives remain undetected. Survival will depend on minesweeping operations combined with educating the remaining soldiers through posters, publications, avoidance of the most heavily mined areas, and command influence. These affirmative actions are expected to minimize future deaths and maiming.
CONCLUSION The harsh ecology of the desert, unchanged since Biblical times, combined with 20th century technological advances in warfare, posed environmental health hazards unparalleled in the history of mankind. Literature Cited 1. Cleveland RL. The World Today Series: The Middle East and South Asia 1988. 22nd ed. Washington, DC: Sky Corp Stryker-Post Publications; 1988. 2. US Department of Army field manual FM 21-10. Prevention of Heat Injury. Training Doctrine Command: Ft Monroe, Va. Not dated. 3. US Department of Army field manual FM 21-10-1. Field Sanitation. Training Doctrine Command: Ft Monroe, Va. Not dated. 4. Teletype communication from the US Forces Command Commander [TWX from FORSCOM CDR]. Immunization and Preventive Medicine Requirements for Deployment to Preventive Gulf Region. US Forces Command, Ft McPherson, Ga: August 14, 1990. 5. Braunwald E, Isselbacher KJ, Petersdorf RG, Wilson JD, Martin JB, Fauci AS. Harrison's Principles of Intemal Medicine. 11th ed. New York, NY: McGraw Hill Book Co; 1987. 6. Centers for Disease Control. Health Information for International Travel 1988. Atlanta, Ga: Centers for Disease Control; 1988. US Dept of Health and Human Services publication CDC 88-8280. 7. Ronnie J. Proteins 2, malaria 0. Malaria free mice offer 423
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clues for developing a human vaccine. Sci Am. 1991:24-25. 8. Horgan J. Up in flames; Kuwait's burning oil wells are sad test of theories. Sci Am. 1991:17-24. 9. Wald ML. High levels of toxic substances found in Kuwait oil fire smoke. NY Times Intl. July 16, 1991 :A-4. 10. Limage SS, Suomi VE, Veldon C, Tripoli G. Satellite observations of smoke from oil fires in Kuwait. Science.
1991;252:1536-1539. 11. Cholera outbreak. Houston Chronicle. June 2, 1991 :3A. 12. Armijo-Hussein NA, Benjamin E, Moodie R, Passey M, Devin J, Donsiger S. Harvard study team special report: the effect of the Gulf Crisis on the children of Iraq. N Engl J Med.
1991;325:977-980. 13. Belding DE. Textbook of Clinical Parasitology. 2nd ed. New York, NY: Appleton-Century-Crofts; 1952. 14. Guenther CA, Welch MH. Pulmonary Medicine. Philadelphia, Pa: JB Lippincott Co; 1977. 15. Richards AL, Hyams KC, Merrill BR, Dasch Ga, Woody JN, Ksiazek TG. Medical aspects of Operation Desert Storm. N Engl J Med. 1991;325:970. 16. Waite JJ. Gulf war parasite halts troop blood drive. USA Today November 13, 1991 Al.
17. King CH. Acute and chronic schistosomiasis. Hosp Pract. 1991;26:95-106. 18. Sprenger TR, Bailey WJ. Snakebite treatment in the United States. Int J Dermatol. 1986;25:479-484. 19. US Armed forces pamphlet for Army (TM8-285), Navy (NAVMED P-5041), and Air Force (AFM 160-12). Treatment of Chemical Agent Casualties and Conventional Military Chemical Injuries. Not dated. 20. United States Army Medical Research Institute for Chemical Defense (USAMRICD) Technical Memorandum 90-1. Clinical Notes on Chemical Casualty Care. Not dated. 21. Sidell FR. Medical aspects of nerve agent exposure. Medical Bulletin PB. August 1988:3-B. 22. Kobrick JL, Johnson RF, McMenemy DJ. Effects of nerve agent antidote and heat exposure on soldier performance in the BDU and MOPP IV ensembles. Milit Med. 1990;155:159162. 23. Seagrave S. Yellow Rain: A Joumey Through the Terror of Chemical Warfare. New York, NY: M Evans & Co; 1981. 24. FM 8-50. Prevention and Medical Management of Laser Injuries. Aug 1990.
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