Chapter V.
Epidemiological
and Population Studies II:
Gulf War
Veterans and
Gulf War
Syndrome
(Return to: TOP; Table of Contents; Author Index)
Summary:
Following the first Gulf War in 1991 in which
depleted uranium weapons were used in a battlefield arena for the first time,
US and UK veterans in large numbers began reporting an unusual set of illnesses
that later became known as “Gulf War
Syndrome” (GWS). Unfortunately, these
soldiers had been exposed to a large number of potentially toxic agents in
addition to depleted uranium. These included pyridostigmine bromide, numerous
immunizations of which some were not approved for human use, chemical and
biological warfare agents, pesticides and heavy smoke from oil well fires. Not
surprisingly, the reported symptoms vary greatly among the affected veterans.
It has thus been difficult to pin down a single causative factor in these
illnesses.
It is a documented fact that the US military has
every intention of continuing the use of depleted uranium weapons and has
actively and purposefully opposed efforts to study what effects, if any, inhalation of aerosolized depleted uranium particles might have on human health. After the 1991 Gulf
War, the contingent of veterans being studied for DU exposure was restricted to
33 soldiers who were suspected of having embedded
DU fragments resulting from friendly
fire. MA McDiarmid and her coworkers at the Veterans’
It is also a fact that given reassurances from the
Department of Defense in the US and the Ministry of Defense in Great Britain
that exposure to depleted uranium is relatively harmless, studies into
causative factors for GWS (and its related Balkan syndrome resulting from the
conflict in Bosnia, Kosovo, Serbia and Yugoslavia in the late 1990s) have often purposely omitted DU as one possible culprit. Unfortunately, the few population studies that
have been done on US veterans have been performed by the Veterans’
Administration and by military research labs, neither of which can be construed
to be free of a conflict of interest.
Careful scrutiny of the studies presented in
Chapters I through III in this volume should convince even the casual reader
that this oversight is not warranted. Recent
court rulings in Scotland and Italy on behalf of veterans exposed to DU have
finally opened the door to official recognition that exposure to depleted uranium
may have drastic consequences to human health.
Details:
In 1994, Douce (1)
summarized much of the anecdotal reports that had been appearing relating to
soldiers’ ill health and the appearance of an undiagnosed “wasting disease”
among Iraqi children and suggests that, whatever the cause, it appears that one
of the targets is the immune system. McDiarmid (2) reported in 1995 the presence of
sister chromatid exchanges in soldiers deployed to
McDiarmid (6), in her continuing studies at the US Veterans
Administration of 1991 Gulf War veterans with embedded fragments, determined
that for low concentrations of urinary uranium, spot uranium urinary analysis
showed poor correlation with the more accurate 24-hour timed collection
samples. Petruccelli (7) writes
on the health effects of veterans’ exposure to the oil fires during that
conflict. Hooper (8), also of the VA,
notes that the 33 veterans being studied showed significantly higher urinary
uranium both 2 years and 4 years after the conflict, but none showed renal
disfunction. In 2000, McDiarmid (9), (15) reported that elevated urinary
uranium in 29 of the veterans still in the embedded fragment study was observed
7 years following the conflict, still with no renal disfunction, but with
definite signs of neurocognitive degeneration and “subtle perturbations in the
reproductive and central nervous systems”. In 2001, McDiarmid (10) expanded the original cohort under study
to 169 veterans, divided into 19 groups based on probable DU exposure levels
during the Gulf War (based on answers given in questionaires) and found 12
veterans with elevated urinary uranium levels (later reduced to 9 veterans
after a second round of tests). Her conclusion was that only those with
embedded DU fragments showed any statistical correlation to elevated urinary
uranium. In 2004, McDiarmid (26) expanded
the human cohort to 227 volunteers and arrived at the same conclusion.
McClain (12),
of the Armed Forces Radiobiology Research Institute (AFRRI), in 2001 published
a review of on-going research into the effects of embedded DU fragments in rats
and reported extensive distribution of DU throughout the body over time,
including in bone, kidney, muscle and liver tissues, and that it could enter fetal
tissue by crossing the placental barrier and that it exhibited
neurophysiological deterioration in the subjects. He also reviewed Miller’s
work that showed DU to be mutagenic and capable of transforming human
osteoblast cells to a tumorigenic phenotype. As a result of these investigations, McClain
(16) proposed altering existing
medical protocol that avoids surgical removal of embedded fragments if those
fragments contain DU. These observations help explain those of Durakovic (11) who had been working with veterans
complaining of GWS since the early 1990s and had concluded early on that DU
might be one causitive factor.
In December of 2001, McDiarmid (13) reported on a cohort of 50
embedded DU fragment veterans, all showing elevated urinary uranium and
statistically correlated “perturbations in central nervous system function and
a general measure of mutagen exposure” and concluded that “Observations in this
group of veterans prompt speculation about the health effects of DU in other
exposure scenarios.” Hodge (14), of
AFRRI, proposed using ICP-MS to assay veterans’ urine samples and use isotope
ratios to identify DU specifically in order to “mitigate the concerns of
exposed individuals.”
The British Royal Society (17) published a summary in 2002 of two
papers compiled by their Working Group on the Health Hazards of Depleted
Uranium Munitions covering the potential radiotoxicity and chemotoxicity of DU
exposure. Horan (18) used mass
spectroscopy to determine specific presence of DU in 27 American, Canadian and
British Gulf War veterans and identified its presence in 14 of the 27 patients.
Macfarlane (22a) reported no significant
increase in cancer incidence among over 50,000 UK troops from Operation Freedom
when compared to a similar number of UK troops who were not involved in that
operation. Sztajnkrycer (25) voices his opinion in Military
Medicine that there is no evidence of environmental contamination or adverse
health effects resulting from use of DU munitions, despite rodent research
pointing to potential carcinogenicity of DU exposure. Greenburg (27) conducted a survey to determine
who among returning soldiers might desire DU testing. 24% requested to be
tested, and Greenburg observed a correlation that those requesting testing were
in generally poorer health than the others.
In 2003, Toohey (20) reported attempting to correlate
urinary uranium excretion data from the VA studies with time and/or fragment
characteristics and was unable to determine significant correlations.
Lagercrantz (21) studied Swedish
veterans of the Balkan conflict and could identify no increase in cancer among
Swedish veterans by 2002.
(Return to: TOP; Table of Contents; Author Index)
1. Desert Storm syndrome: sick soldiers and dead children? by I. Douce, Medical Educational Trust, London, Med War. Vol. 10(3), Jul-Sep. 1994 (pp. 183-194).
Ill-health has been reported by many soldiers and others deployed in the
Persian Gulf during the Gulf War of 1991. Iraqi children have also been
reported as suffering from an undiagnosed wasting disease. Little conclusive
information has come to light; this paper reviews what is known at present,
largely from anecdotal reports. Symptoms reported differ from post-traumatic
stress syndrome as reported after previous conflicts; some are suggestive of a
direct effect on the immune system. Various possible causes are examined,
including post-traumatic stress disorder, infection, prophylactic medication,
exposure to chemical and biological warfare agents, exposures resulting from
oil spills and fires, and exposure to depleted uranium ammunition. The latter
was used extensively for the first time in the Gulf War, and is manufactured
and test-fired in Britain. The passive role of the British government in
following up such reports is noted, in contrast with the more active official
responses in the United States. It is suggested that Desert Storm Syndrome is
one example of multiple assault upon the body's immune system.
[Douce199407MWv10n3p183]. ( PMID: 7935166 [PubMed - indexed for
MEDLINE])
2. Increased frequencies of sister chromatid exchange in soldiers deployed to Kuwait, by MA McDiarmid, et al., Mutagenesis Vol. 10, 1995 (pp. 263-265).
[McDiarmid1995xxMv10nxp263].
3. Al Eskan disease: Persian Gulf syndrome, by AL Korenyi-Both, et al., Office of the State Surgeon, Pennsylvania National Guard, Department of Military and Veteran's Affairs, Commonwealth of Pennsylvania 17003-5003, USA. Mil Med. Vol. 162(1), Jan. 1997 (pp. 1-13).
This article examines the potential relationship between Al Eskan
disease and the Persian Gulf syndrome. Al Eskan disease, reported in Military
Medicine in 1992, is a novel and previously unreported condition triggered by
the exceptionally fine sand dust of the Central and Eastern Saudi Arabian
peninsula. We repeat our study of the pathogenesis of Al Eskan disease to
include the ultrastructural and microanalytical study of the sand,
aerobiological studies of the Kingdom of Saudi Arabia, and the etiology,
symptoms, and prevalence of the disease. We conclude that immunodepression
resulting from the continued presence of sand particles less than 1 micron in
diameter in the lungs and bodies of Persian Gulf veterans explains not only the
symptoms of the hyperegic lung condition of phase I and the symptoms of phase
II of Al Eskan disease, but also provides an important clue to a common factor
in most cases of Persian Gulf illnesses. We include a discussion of most of the
commonly suspected agents in the Persian Gulf syndrome. In this case, we
conclude that each of these factors, such as oil well fires, old-world
diseases, or depleted uranium, are probably adjuvant or contributing causes.
The only common exposure that would lead to recognition of the Persian Gulf
syndrome as a single medical condition, rather than a catch-all phrase for
unrelated conditions, appears to be exposure to the ubiquitous, fine sand of
the area, and a resulting immunosuppression that is aggravated by opportunistic
infections and other nonmicrobial ailments.
[KorenyiBoth199701MMv162n1p1]. (PMID: 9002695 [PubMed - indexed for
MEDLINE])
4. Al Eskan disease: Persian Gulf syndrome, by PA Charp. Mil Med. Vol. 162(3), Mar. 1997 (pp. ii).
Comment on: Mil Med. 1997 Jan;162(1):1-13.
[Charp199703MMv162n3pii]. (PMID: 9121655 [PubMed - indexed for
MEDLINE])
5. Gulf War
syndrome--a model for the complexity of biological and environmental
interaction with human health, by GA Jamal.University Department of
Neurology, Southern General Hospital NHS Trust, Glasgow. Adverse Drug React Toxicol Rev. Vol. 17(1),
Mar. 1998 (pp. 1-17).
Since the end of the Gulf War, tens of thousands of American, Canadian
and British soldiers who participated in that war have claimed to be suffering
from a variety of incapacitating symptoms which are generally termed as Gulf
War Syndrome (GWS). The symptoms are multiple but mainly consist of excessive
tiredness, muscle and joint pain, loss of balance, sensory symptoms, neurobehavioural
manifestations, diarrhoea, bladder dysfunction, sweating disturbances, and
respiratory, gastrointestinal, musculoskeletal and skin manifestations. These
veterans have been exposed to a variety of damaging or potentially damaging
risk factors including environmental adversities, pesticides such as
organophosphate chemicals, skin insect repellents, medical agents such as
pyridostigmine bromide (NAPS), possible low-levels of chemical warfare agents,
multiple vaccinations in combinations, depleted uranium, and other factors. A
large number of basic research findings, clinical epidemiological studies, and
case control studies are reviewed to try and link them together to produce a
coherent picture and to demonstrate the complexity of the interaction of
biological systems, environmental and genetic factors, combinations of drugs
and toxins with human health. The findings of these studies so far have
demonstrated that many of the previous assumptions made about the 'safety' of
certain drugs and toxic substances or vaccines must be radically reviewed. Many
of the findings have far reaching implications not only in terms of explanation
of what might have gone wrong during the Gulf War, but also have wider
implications for many occupational groups who are exposed daily to some of
these risk factors. More open-mindedness and much less prejudice are required
concerning the basic biology of interactions of the above factors and their
effects on cell functions and wider intelligent research is urgently required with
high priority. This review highlights the importance of intelligent research
for answers for a new phenomenon, and demonstrates the necessity for a
combination of this approach with high quality epidemiological research. The
reader will notice an emerging clear picture that the majority (if not all) of
these advances have been achieved from studies funded by independent or charity
organizations rather than by the responsible authorities who are supposed and
are duty bound to take on this task.
[Jamal199803ADRTRv17n1p1]. (PMID: 9638279 [PubMed - indexed for MEDLINE])
6. The utility of spot collection for urinary uranium determinations in depleted uranium exposed Gulf War veterans, by MA McDiarmid, et al., Occupational Health Project, Baltimore, MD 21201, USA, Health Phys. Vol. 77(3), Sept. 1999 (pp. 261-264).
The
utility of spot urine collections for uranium bioassay determinations was
examined in a small cohort of depleted uranium exposed Gulf War veterans. Some
members of the group are excreting elevated concentrations of urinary uranium
resulting from the metabolism of retained metal fragments, the residua of
several friendly fire incidents. Uranium determinations were performed on both
24-h timed collections and spot urine samples using kinetic phosphorescence
analyzer (KPA) methodology. Results ranged from non-detectable to 30.7 mcg
g(-1) creatinine in a 24-h collection. A creatinine-standardized spot sample
and a 24-h uncorrected sample both correlated highly (R2=0.99) with a
creatinine corrected 24-h collection, presumed to be the best estimate of the
urinary uranium measure. This relationship was upheld when the population was
stratified by uranium concentration into a high uranium group (> or = 0.05
mcg U/g creatinine) but for the lower uranium group (< 0.05 mcg U/g
creatinine) more variability and a lower correlation was seen. The uncorrected
spot sample, unadjusted for volume, concentration or creatinine had the lowest
correlation with the 24-h creatinine adjusted result, especially at lower urinary
uranium concentrations. This raises questions regarding the representativeness
of such a sample in bioassay programs.
[McDiarmid199909HPv77n3p261].
(PMID: 10456496 [PubMed - indexed for MEDLINE]).
7. Health effects of the 1991 Kuwait oil fires: a survey of US army troops, by B.P. Petruccelli, et al., Journal of Occupational and Environmental Medicine Vol. 41, 1999 (pp. 433-439).
[Petruccelli1999xxJOEMv41nxp433]
8. Elevated urine uranium excretion by soldiers with retained uranium shrapnel, by FJ Hooper, et al., Baltimore Veterans Administration Medical Center, Department of Medicine, University of Maryland School of Medicine, 21201, USA., Health Phys. Vol. 77(5), Nov. 1999 (pp. 512-519).
The
use of depleted uranium in munitions has given rise to a new exposure route for
this chemically and radioactively hazardous metal. A cohort of U.S. soldiers
wounded while on or in vehicles struck by depleted uranium penetrators during
the Persian Gulf War was identified. Thirty-three members of this cohort were
clinically evaluated, with particular attention to renal abnormalities,
approximately 3 y after their injury. The presence of retained shrapnel was
identified by x ray, and urine uranium concentrations were measured on two
occasions. The absorption of uranium from embedded shrapnel was strongly
suggested by measurements of urine uranium excretion at two time intervals: one
in 1993/1994 and one in 1995. Mean urine uranium excretion was significantly
higher in soldiers with retained shrapnel compared to those without shrapnel at
both time points (4.47 vs. 0.03 microg g(-1) creatinine in 1993/1994 and 6.40
vs. 0.01 microg g(-1) creatinine in 1995, respectively). Urine uranium
concentrations measured in 1995 were consistent with those measured in
1994/1993, with a correlation coefficient of 0.9. Spot urine measurements of
uranium excretion were also well correlated with 24-h urine collections (r =
0.95), indicating that spot urine samples can be reliably used to monitor
depleted uranium excretion in the surveillance program for this cohort of
soldiers. The presence of uranium in the urine can be used to determine the
rate at which embedded depleted uranium fragments are releasing biologically
active uranium ions. No evidence of a relationship between urine uranium excretion
and renal function could be demonstrated. Evaluation of this cohort continues.
[Hooper199911HPv77n5p512].
(PMID: 10524504 [PubMed - indexed for MEDLINE])
9. Health effects of depleted uranium on exposed Gulf War veterans, by MA McDiarmid, et al., Department of Veterans Affairs Medical Center, Baltimore, Maryland, USA. mmcdiarm@medicine.umaryland.edu. Environ Res. Vol. 82(2), Feb. 2000 (pp. 168-180).
A
small group of Gulf War veterans possess retained fragments of depleted uranium
(DU) shrapnel, the long-term health consequences of which are undetermined. We
evaluated the clinical health effects of DU exposure in Gulf War veterans
compared with nonexposed Gulf War veterans. History and follow-up medical
examination were performed on 29 exposed veterans and 38 nonexposed veterans.
Outcome measures employed were urinary uranium determinations, clinical
laboratory values, and psychiatric and neurocognitive assessment. DU-exposed
Gulf War veterans with retained metal shrapnel fragments are excreting elevated
levels of urinary uranium 7 years after first exposure (range 0.01-30.7
microg/g creatinine vs 0.01- 0.05 microg/g creatinine in the nonexposed). The
persistence of the elevated urine uranium suggests on-going mobilization from a
storage depot which results in a chronic systemic exposure. Adverse effects in
the kidney, a presumed target organ, are not present at this time, though other
effects are observed. Neurocognitive examinations demonstrated a statistical
relationship between urine uranium levels and lowered performance on
computerized tests assessing performance efficiency. Elevated urinary uranium
was statistically related to a high prolactin level (>1.6 ng/ml; P=0.04).
More than 7 years after first exposure, DU-exposed Gulf War veterans with
retained metal fragments continue to excrete elevated concentrations of urinary
uranium. Effects related to this are subtle perturbations in the reproductive
and central nervous systems. Copyright 2000 Academic Press.
[McDiarmid200002ERv82n2p168].
( PMID: 10662531 [PubMed - indexed for MEDLINE]).
10. Urinary uranium concentrations in an enlarged Gulf War veteran cohort, by MA McDiarmid, et al., Occupational Health Project, Baltimore 21201, USA. Health Phys. Vol. 80(3), Mar. 2001 (pp. 270-273).
Depleted
uranium was first used on a large scale as a major component of munitions and
armaments employed by the U.S. armed forces during the Gulf War in 1991. In
response to concern that exposure to depleted uranium may have been a cause of
health problems suffered by returning veterans of that war, an already existing
surveillance program following depleted uranium "friendly fire"
victims was enlarged to assess the wider veteran community's exposure to depleted
uranium. Between August 1998 and December 1999, 169 Gulf War veterans submitted
24-h urine samples for determination of urinary uranium concentration and
questionnaires describing their potential exposures to depleted uranium while
in the Gulf War theatre. Depleted uranium exposure assessment was determined
from 30 separate questionnaire items condensed into 19 distinct exposure
scenarios. Results of urine uranium analysis were stratified into high and low
uranium groups with 0.05 microg uranium/g creatinine being the cut point and
approximate upper limit of the normal population distribution. Twelve
individuals (7.1%) exhibited urine uranium values in the high range, while the
remaining 157 had urine uranium values in the low range. A repeat test of urine
for 6 of these 12 produced uranium results in the low range for 3 of these
individuals. Exposure scenarios of the high and low uranium groups were similar
with the presence of retained shrapnel being the only scenario predictive of a
high urine uranium value. Results emphasize the unlikely occurrence of an
elevated urine uranium result and consequently any uranium-related health
effects in the absence of retained depleted uranium metal fragments in the
veterans.
[McDiarmid200103HPv80n3p270].
(PMID: 11219540 [PubMed - indexed for MEDLINE]).
11. On depleted uranium: gulf war and Balkan syndrome, by A. Durakovic, Nuclear Medicine Division and Clinical PET, King Faisal Specialist Hospital and Research Centre, Riyadh, Kingdom of Saudi Arabia, TAhaideb@kfshrc.edu.sa. Croat Med J. Vol. 42(2), Apr. 2001 (pp. 130-134).
The
complex clinical symptomatology of chronic illnesses, commonly described as
Gulf War Syndrome, remains a poorly understood disease entity with diversified
theories of its etiology and pathogenesis. Several causative factors have been
postulated, with a particular emphasis on low level chemical warfare agents,
oil fires, multiple vaccines, desert sand (Al-Eskan disease), botulism,
Aspergillus flavus, Mycoplasma, aflatoxins, and others, contributing to the
broad scope of clinical manifestations. Among several hundred thousand veterans
deployed in the Operation Desert Storm, 15-20% have reported sick and about
25,000 died. Depleted uranium (DU), a low-level radioactive waste product of
the enrichment of natural uranium with U-235 for the reactor fuel or nuclear
weapons, has been considered a possible causative agent in the genesis of Gulf
War Syndrome. It was used in the Gulf and Balkan wars as an armor-penetrating
ammunition. In the operation Desert Storm, over 350 metric tons of DU was used,
with an estimate of 3-6 million grams released in the atmosphere. Internal
contamination with inhaled DU has been demonstrated by the elevated excretion
of uranium isotopes in the urine of the exposed veterans 10 years after the
Gulf war and causes concern because of its chemical and radiological toxicity
and mutagenic and carcinogenic properties. Polarized views of different
interest groups maintain an area of sustained controversy more in the
environment of the public media than in the scientific community, partly for
the reason of being less than sufficiently addressed by a meaningful objective
interdisciplinary research.
[Durakovic200104CMJv42n2p130].
(PMID: 11259733 [PubMed - indexed for MEDLINE]).
12. Biological effects of embedded depleted uranium (DU): summary of armed forces radiobiology research institute research, by DE McClain, et al., Armed Forces Radiobiology Research Institute, Bethesda, MD 20889-5603, USA. mcclain@mx.afrri.usuhs.mil . Sci Total Environ. Vol. 274(1-3), Jul. 2001 (pp. 115-118).
The
Persian Gulf War resulted in injuries of US Coalition personnel by fragments of
depleted uranium (DU). Fragments not immediately threatening the health of the
individuals were allowed to remain in place, based on long-standing treatment
protocols designed for other kinds of metal shrapnel injuries. However,
questions were soon raised as to whether this approach is appropriate for a
metal with the unique radiological and toxicological properties of DU. The
Armed Forces Radiobiology Research Institute (AFRRI) is investigating health
effects of embedded fragments of DU to determine whether current surgical
fragment removal policies remain appropriate for this metal. These studies
employ rodents implanted with DU pellets as well as cultured human cells
exposed to DU compounds. Results indicate uranium from implanted DU fragments
distributed to tissues far-removed from implantation sites, including bone,
kidney, muscle, and liver. Despite levels of uranium in the kidney that were
nephrotoxic after acute exposure, no histological or functional kidney toxicity
was observed. However, results suggest the need for further studies of
long-term health impact, since DU was found to be mutagenic, and it transformed
human osteoblast cells to a tumorigenic phenotype. It also altered
neurophysiological parameters in rat hippocampus, crossed the placental
barrier, and entered fetal tissue. This report summarizes AFRRI's depleted
uranium research to date.
[McClain200107STEv274n1to3p115].
( PMID: 11453287 [PubMed - indexed for MEDLINE]).
13. Surveillance of depleted uranium exposed Gulf War veterans: health effects observed in an enlarged "friendly fire" cohort, by MA McDiarmid, et al.; Depleted Uranium Follow-Up Program., Department of Medicine, University of Maryland School of Medicine, 405 W. Redwood Street, Baltimore, MD 21201, USA. mmcdiarm@medicine.umaryland.edu . J Occup Environ Med. Vol. 43(12), Dec. 2001 (pp. 991-1000).
To
determine clinical health effects in a small group of US Gulf War veterans (n =
50) who were victims of depleted uranium (DU) "friendly fire," we performed
periodic medical surveillance examinations. We obtained urine uranium
determinations, clinical laboratory values, reproductive health measures,
neurocognitive assessments, and genotoxicity measures. DU-exposed Gulf War
veterans with retained metal shrapnel fragments were excreting elevated levels
of urine uranium 8 years after their first exposure (range, 0.018 to 39.1
micrograms/g creatinine for DU-exposed Gulf War veterans with retained
fragments vs 0.002 to 0.231 microgram/g creatinine in DU exposed but without
fragments). The persistence of the elevated urine uranium suggests ongoing
mobilization from the DU fragments and results in chronic systemic exposure.
Clinical laboratory outcomes, including renal functioning, were essentially
normal. Neurocognitive measures showing subtle differences between high and low
uranium exposure groups, seen previously, have since diminished. Sister
chromatid exchange frequency, a measure of mutation in peripheral lymphocytes,
was related to urine uranium level (6.35 sister chromatid exchanges/cell in the
high uranium exposure group vs 5.52 sister chromatid exchanges/cell in the low
uranium exposure group; P = 0.03). Observed health effects were related to
subtle but biologically plausible perturbations in central nervous system
function and a general measure of mutagen exposure. The findings related to
uranium's chemical rather than radiologic toxicity. Observations in this group
of veterans prompt speculation about the health effects of DU in other exposure
scenarios.
[McDiarmid200112JOEMv43n12p991].
( PMID: 11765683 [PubMed - indexed for MEDLINE]).
14. Detection of depleted uranium in biological samples from Gulf War veterans, by SJ Hodge, et al., Armed Forces Radiobiology Research Institute, 8901 Wisconsin Avenue, Bethesda, MD 20889-5603, USA. Mil Med. Vol. 166(12 Suppl.), Dec. 2001 (pp. 69-70).
During
the Persian Gulf War, soldiers may have inhaled, ingested, and/or experienced
wound contamination by depleted uranium (DU), which is used in military
projectiles and armor. DU is produced by depleting natural uranium of 234U and
235U during the uranium-enrichment process. Although the long-term effects of
significant DU exposures require investigation, many veterans express fears
about its impact on health. An assay by which DU exposure can be assessed would
not only be a useful research tool, but the information could help mitigate the
concerns of exposed individuals. In this study, urine samples from individuals
enrolled in the Depleted Uranium Follow-Up Program at the Baltimore Veterans
Administration Medical Center were examined for uranium content. Isotopic
composition of urine uranium was determined by measuring the 235U/238U ratio,
using an inductively coupled plasma mass spectrometer. Using this method, natural
and depleted uranium could be readily differentiated. By demonstrating the
absence of DU in soldiers who suspect exposure by inhalation or ingestion, the
assay should reduce psychological stress in these individuals.
[Hodge200112MMv166n12Suppp69].
(PMID: 11778443 [PubMed - indexed for MEDLINE]).
15. Health effects and biological monitoring results of Gulf War veterans exposed to depleted uranium, by MA McDiarmid, et al., Department of Veterans Affairs Medical Center, 10 North Greene Street, Baltimore, MD 21201, USA. Mil Med. Vol. 167(2 Suppl), Feb. 2002 (pp. 123-124).
A small group of Gulf War veterans have retained fragments of depleted uranium (DU) shrapnel, the long-term health consequences of which are undetermined. We evaluated the clinical health effects of DU exposure in Gulf War veterans compared with nonexposed Gulf War veterans. History and follow-up medical examinations were performed on 29 exposed veterans and 38 nonexposed veterans. Outcome measures used were urinary uranium determinations, clinical laboratory values, and psychiatric and neurocognitive assessment. Gulf War veterans with retained DU metal shrapnel fragments were found to be still excreting elevated levels of urinary uranium 7 years after first exposure to DU (range for exposed individuals is 0.01-30.7 micrograms/g creatinine vs. 0.01-0.05 microgram/g creatinine in the nonexposed). The persistence of the elevated urine uranium suggests ongoing mobilization of uranium from a storage depot, resulting in chronic systemic exposure. Adverse effects in the kidney, a presumed target organ, were not seen at the time of the study; however, other subtle effects were observed in the reproductive and central nervous systems of the DU-exposed veterans.
[McDiarmid200202MMv167n2suppp123]. (PMID: 11873493 [PubMed - indexed for MEDLINE]).
16. Depleted uranium: a radiochemical toxicant?, by DE McClain, Armed Forces Radiobiology Research Institute, 8901 Wisconsin Avenue, Bethesda, MD 20889-5603, USA. Mil Med. Vol. 167(2 Suppl), Feb. 2002 (pp. 125-126).
The
first large-scale combat use of depleted uranium (DU) weapons occurred during
the Gulf War, and some U.S. personnel were wounded by DU fragments. Established
fragment removal policies dictated that embedded metal fragments be left in
place unless doing so posed unacceptable additional risks. However, questions
were raised as to whether these policies are appropriate for a metal
that--unlike lead, steel, or others--is chemically toxic and emits low-level radiation.
Data from research currently under way indicate that long-term exposure to
embedded DU fragments may present a level of risk that requires modification of
established policies. Our understanding of DU health effects and of the
possible mechanisms by which DU might affect tissues is evolving. Understanding
more about the long-term response of tissues exposed to DU could facilitate
future development of treatments for DU injuries.
[McClain200202MMv167n2suppp125].
(PMID: 11873494 [PubMed - indexed for MEDLINE]).
17. The health effects of depleted uranium munitions: a summary, by Royal Society Working Group on the Health Hazards of Depleted Uranium Munitions., The Royal Society, London, UK. J Radiol Prot. Vol. 22(2), Jun. 2002 (pp. 131-139).
There
has been a substantial amount of public discussion on the health effects of the
use of depleted uranium (DU) munitions. In response to this concern the Royal
Society set up an independent, expert working group to investigate the health
effects of DU munitions. The Royal Society has now produced two reports, and
this summary covering the key conclusions and recommendations from both
reports. The part I report considered the increased risks of radiation-induced
cancer from exposures to DU on the battlefield. Part II dealt with the risks
from the chemical toxicity of uranium, non-malignant radiation effects from DU
intakes, the long-term environmental consequences of the deployment of DU
munitions and responses to part I including issues arising at a public meeting
to discuss the part I report.
[RoyalSoc200206JRPv22n2p131].
(PMID: 12148788 [PubMed - indexed for MEDLINE]).
18. The quantitative analysis of depleted uranium isotopes in British, Canadian, and U.S. Gulf War veterans, by P Horan, et al., Department of Earth Sciences, Memorial University of Newfoundland, St. Johns, Canada. horan@morgan.ucs.mun.ca. Mil Med. Vol. 167(8), Aug. 2002 (pp. 620-627).
The
purpose of this work was to determine the concentration and ratio of uranium
isotopes in allied forces Gulf War veterans. The 27 patients had their 24-hour
urine samples analyzed for 234U, 235U, 236U, and 238U by mass spectrometry. The
urine samples were evaporated and separated into isotopic dilution and
concentration fraction by the chromatographic technique. The isotopic
composition was measured by a thermal ionization mass spectrometer using a
secondary electron multiplier detector and ion-counting system. The uranium
blank control and SRM960 U isotopic standard were analyzed by the same
procedure. Statistical analysis was done by an unpaired t test. The results
confirm the presence of depleted uranium (DU) in 14 of 27 samples, with the
238U:235U ratio > 207.15. This is significantly different from natural uranium
(p < 0.008) as well as from the DU shrapnel analysis, with 22.22% average
value of DU fraction, and warrants further investigation.
[Horan200208MMv167n8p620].
(PMID: 12188230 [PubMed - indexed for MEDLINE]).
19. Battlefield use of depleted uranium and the health of veterans, by JP Bolton, et al., Surgeon General's Department, St Giles Court, St Giles High Road, London WC2H 8LD. J R Army Med Corps. Vol. 148(3), Sept. 2002 (pp. 221-229).
Depleted
uranium munitions have been used in recent military operations in both the Gulf
and the Balkans and there have been concerns that exposure to depleted uranium
may be a cause of 'Gulf War Syndrome' and cancer clusters. We recount the
properties of depleted uranium, its military uses and the situations in which
personnel may be exposed. Following a review of scientific literature, the
health effects of depleted and natural uranium exposure are described and the
major outcomes of research into Gulf Veterans' Illnesses are summarised. We
conclude that, although there is the potential for uranium exposures to cause
renal damage or lung cancer, the risk of harm following depleted uranium
exposure in military settings seems to be low. We advise on the management of
casualties exposed to depleted uranium and suggest control measures that may be
appropriate to protect personnel who provide casualty care.
[Bolton200209JRAMCv148n3p221].
(PMID: 12469421 [PubMed - indexed for MEDLINE]).
20. Excretion of depleted uranium by Gulf War veterans, by RE Toohey, Oak Ridge Institute for Science and Education, Oak Ridge, TN 37830, USA. tooheyr@orau.gov. Radiat Prot Dosimetry. Vol. 105(1-4), 2003 (pp. 171-174).
During
the Persian Gulf War, in 1991, approximately 100 US military personnel had
potential intakes of depleted uranium (DU), including shrapnel wounds. In 1993,
the US government initiated a follow-up study of 33 Gulf War veterans who had
been exposed to DU, many of whom contained embedded fragments of DU shrapnel in
their bodies. The veterans underwent medical evaluation, whole-body counting,
and urinalysis for uranium by kinetic phosphorescence analysis (KPA). Data are
available from seven individuals who exceeded the detection limit for
whole-body counting and also had elevated urinary uranium. Urinary excretion
rates, in microg U g(-1) creatinine, were determined in 1997 and 1999. The body
contents, in mg DU, were determined in 1997; it is assumed there were no
significant decreases in total body content in the interim. For the 1997 data,
the mean fractional excretion was (2.4 +/- 2.8) x 10(-5) g(-1) creatinine, and
for the 1999 data, the mean was (1.1 +/- 0.6) x 10(-5) g(-1) creatinine.
However, these means are not significantly different, nor is there any
correlation of excretion rate with body content. Thus, human data available to
date do not provide any basis for determining the effects of particle surface
area, composition and solubility, and biological processes such as
encapsulation, on the excretion rate.
[Toohey2003xxRPDv105n1to4p171].
(PMID: 14526951 [PubMed - in process]).
21. Depleted uranium a cancer risk that disappeared. Leukemia alarm regarding Balkan veterans came to nothing. [Article in Swedish], by B Lagercrantz, barbro.lagercrantz@hkv.mil.se. Lakartidningen Vol. 100(4), Jan. 2003 (pp. 219-221).
After
alarming reports in the international press in January 2001, about leukemia in
war veterans returning from the Balkans after possible exposure to depleted
uranium, a follow-up was conducted of the Swedish personnel that had served in
the Balkans. Questionnaires, analysis of uranium in urine, and coordination
with The National Board of Health and Welfare's cancer register showed no
correlation between service in the Balkans and cancer or other illnesses.
Several did however experience anxiety, insomnia and fatigue that may have been
caused by the stressful environment and/or the anxiety arising from the
depleted uranium-debate. To lower the risk for unjustified anxiety and to be
better prepared for the physical environment, the Swedish Armed Forces are
working on better risk analysis before mission as well as increased health
examinations both before and after mission.
[Lagercrantz200301Lv100n4p219].
(PMID: 12580006 [PubMed - indexed for MEDLINE]).
22. Undiagnosed illnesses and radioactive warfare, by A Durakovic, Uranium Medical Research Center, 3430 Connecticut Avenue/11854, Washington, DC 20008, USA. asaf@umrc.net. Croat Med J. Vol. 44(5), Oct. 2003 (pp. 520-532).
The
internal contamination with depleted uranium (DU) isotopes was detected in
British, Canadian, and United States Gulf War veterans as late as nine years
after inhalational exposure to radioactive dust in the Persian Gulf War I. DU
isotopes were also identified in a Canadian veteran's autopsy samples of lung,
liver, kidney, and bone. In soil samples from Kosovo, hundreds of particles,
mostly less than 5 microm in size, were found in milligram quantities. Gulf War
I in 1991 resulted in 350 metric tons of DU deposited in the environment and
3-6 million grams of DU aerosol released into the atmosphere. Its legacy, Gulf
War disease, is a complex, progressive, incapacitating multiorgan system
disorder. The symptoms include incapacitating fatigue, musculoskeletel and
joint pains, headaches, neuropsychiatric disorders, affect changes, confusion,
visual problems, changes of gait, loss of memory, lymphadenopathies,
respiratory impairment, impotence, and urinary tract morphological and functional
alterations. Current understanding of its etiology seems far from being
adequate. After the Afghanistan Operation Anaconda (2002), our team studied the
population of Jalalabad, Spin Gar, Tora Bora, and Kabul areas, and identified
civilians with the symptoms similar to those of Gulf War syndrome.
Twenty-four-hour urine samples from 8 symptomatic subjects were collected by
the following criteria: 1) the onset of symptoms relative to the bombing raids;
2) physical presence in the area of the bombing; and 3) clinical
manifestations. Control subjects were selected among the sympotom-free
residents in non-targeted areas. All samples were analyzed for the
concentration and ratio of four uranium isotopes, (234)U, (235)U, (236)U and
(238)U, by using a multicollector, inductively coupled plasma ionization mass
spectrometry. The first results from the Jalalabad province revealed urinary
excretion of total uranium in all subjects significantly exceeding the values
in the nonexposed population. The analysis of the isotopic ratios identified
non-depleted uranium. Studies of specimens collected in 2002 revealed uranium
concentrations up to 200 times higher in the districts of Tora Bora, Yaka Toot,
Lal Mal, Makam Khan Farm, Arda Farm, Bibi Mahro, Poli Cherki, and the Kabul
airport than in the control population. Uranium levels in the soil samples from
the bombsites show values two to three times higher than worldwide
concentration levels of 2 to 3 mg/kg and significantly higher concentrations in
water than the World Health Organization maximum permissible levels. This
growing body of evidence undoubtedly puts the problem of prevention and
solution of the DU contamination high on the priority list.
[Durakovic200310CMJv44n5p520].
(PMID: 14515407 [PubMed - in process]).
22a. Incidence of
cancer among UK Gulf war veterans: cohort study, by Macfarlane GJ, et
al., Unit of Chronic Disease
Epidemiology, School of Epidemiology and Health Sciences, University of
Manchester, Manchester M13 9PT. G.Macfarlane@man.ac.uk.
BMJ Vol. 327 (7428), Dec. 2003 (pp. 1357-1358).
OBJECTIVES:
To determine whether incidence rates of cancer are higher in UK service
personnel who were deployed in the Gulf war than in those not deployed and
whether any increased risk of cancer is related to self reported exposures to
potentially hazardous material during the period of deployment. DESIGN: A
cohort study with follow up from
23. Detection of depleted uranium in urine of veterans from the 1991 Gulf War, by RH Gwiazda, et al., Environmental Toxicology, University of California, Santa Cruz, CA 95064, USA. gwiazda@etox.ucsc.edu. Health Phys. Vol. 86(1), Jan. 2004 (pp. 12-18).
American soldiers involved in "friendly fire" accidents
during the 1991 Gulf War were injured with depleted-uranium-containing
fragments or possibly exposed to depleted uranium via other routes such as
inhalation, ingestion, and/or wound contamination. To evaluate the presence of
depleted uranium in these soldiers eight years later, the uranium concentration
and depleted uranium content of urine samples were determined by inductively
coupled plasma mass spectrometry in (a) depleted uranium exposed soldiers with
embedded shrapnel, (b) depleted uranium exposed soldiers with no shrapnel, and
(c) a reference group of deployed soldiers not involved in the friendly fire
incidents. Uranium isotopic ratios measured in many urine samples injected
directly into the inductively coupled plasma mass spectrometer and analyzed at
a mass resolution m/delta m of 300 appeared enriched in 235U with respect to
natural abundance (0.72%) due to the presence of an interference of a polyatomic
molecule of mass 234.81 amu that was resolved at a mass resolution m/delta m of
4,000. The 235U abundance measured on uranium separated from these urines by
anion exchange chromatography was clearly natural or depleted. Urine uranium
concentrations of soldiers with shrapnel were higher than those of the two
other groups, and 16 out of 17 soldiers with shrapnel had detectable depleted
uranium in their urine. In depleted uranium exposed soldiers with no shrapnel,
depleted uranium was detected in urine samples of 10 out of 28 soldiers. The
median uranium concentration of urines with depleted uranium from soldiers
without shrapnel was significantly higher than in urines with no depleted
uranium, though substantial overlap in urine uranium concentrations existed
between the two groups. Accordingly, assessment of depleted uranium exposure
using urine must rely on uranium isotopic analyses, since urine uranium
concentration is not an unequivocal indicator of depleted uranium presence in
soldiers with no embedded shrapnel.
[Gwiazda200401HPv86n1p12]
24. Health effects of depleted uranium on exposed Gulf War veterans: a 10-year follow-up, by MA McDiarmid, et al., Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA. mmcdiarm@medicine.umaryland.edu. J Toxicol Environ Health A. Vol. 67(4), Feb. 27, 2004 (pp. 277-296).
Medical surveillance of a group of U.S. Gulf War veterans who were
victims of depleted uranium (DU) "friendly fire" has been carried out
since the early 1990s. Findings to date reveal a persistent elevation of urine
uranium, more than 10 yr after exposure, in those veterans with retained
shrapnel fragments. The excretion is presumably from ongoing mobilization of DU
from fragments oxidizing in situ. Other clinical outcomes related to urine
uranium measures have revealed few abnormalities. Renal function is normal
despite the kidney's expected involvement as the "critical" target
organ of uranium toxicity. Subtle perturbations in some proximal tubular
parameters may suggest early although not clinically significant effects of
uranium exposure. A mixed picture of genotoxic outcomes is also observed,
including an association of hypoxanthine-guanine phosphoribosyl transferase
(HPRT) mutation frequency with high urine uranium levels. Findings observed in
this chronically exposed cohort offer guidance for predicting future health
effects in other potentially exposed populations and provide helpful data for hazard
communication for future deployed personnel.
[McDiarmid200402JTEHAv67n4p277]. (PMID: 14713562 [PubMed - indexed for
MEDLINE]).
25. Chemical and radiological toxicity
of depleted uranium, Sztajnkrycer MD, et al., Department of Emergency Medicine, Mayo Clinic, Rochester, MN 55905,
USA. Mil Med. Vol. 169 (3), March 2004 (pp. 212-216).
A
by-product of the uranium enrichment process, depleted uranium (DU) contains
approximately 40% of the radioactivity of natural uranium yet retains all of
its chemical properties. After its use in the 1991 Gulf War, public concern
increased regarding its potential radiotoxicant properties. Whereas in vitro
and rodent data have suggested the potential for uranium-induced
carcinogenesis, human cohort studies assessing the health effects of natural
and DU have failed to validate these findings. Heavy-metal nephrotoxicity has
not been noted in either animal studies or Gulf War veteran cohort studies despite
markedly elevated urinary uranium excretion. No significant residual
environmental contamination has been found in geographical areas exposed to DU.
As such, although continued surveillance of exposed cohorts and environments
(particularly water sources) are recommended, current data would support the
position that DU poses neither a radiological nor chemical threat.
[Sztajnkrycer200403MMv169n3p212] (PMID: 15080241 [PubMed - indexed for
MEDLINE]).
26. Biologic monitoring for urinary
uranium in gulf war I veterans, by McDiarmid MA, et al., Department of Medicine, University of
Maryland School of Medicine, 2nd Floor, 05 W. Redwood Street, Baltimore, MD
21201, USA. mmcdiarm@medicine.umaryland.edu
. Health Phys. Vol. 87 (1), July 2004 (pp. 51-56).
Biologic
monitoring for total uranium in urine of Gulf War I veterans concerned about
past exposure to depleted uranium (DU) has been offered by the Departments of
Veterans Affairs and Defense since the late 1990's. DU, a component of
27. Screening for depleted uranium in
the United Kingdom armed forces: who wants it and why?, by Greenberg N,
et al.,
Academic Department of Psychological Medicine, New Medical School, King's
College Hospital, London, UK. Sososanta@aol.com.
J Epidemiol Community Health. Vol. 58 (7), July 2004 (pp. 558-561).
BACKGROUND:
Depleted uranium (DU) use has been implicated in the poor health of many
service personnel who have served in the Gulf and the Balkans. Although the
health related risks are thought to be small the
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