V. CONCLUSIONS AND LESSONS LEARNED

A. Conclusions Related to Potential Health Outcomes

This report reflects the current body of knowledge on the use of pesticides, levels of exposure experienced by various groups of Gulf War veterans, potential health effects associated with these exposures, and lessons learned on the use, application, and management of pesticides by military personnel. The findings and conclusions reached in this report will benefit pesticide handling and management activities in future deployments, and will also provide some indication as to where DoD may wish to conduct additional research to better define health risks under conditions that previously may not have been suspect.

The following conclusions relate to pesticide use and exposure during the Gulf War:

Additional details are provided in the following subsections.

1. Pest-borne Diseases

There was a low incidence of pest-borne diseases among servicemembers due in part to the effective pest management programs implemented by the military. These programs resulted from the establishment of a comprehensive infrastructure of preventive medicine and related activities. The PM resources controlled disease-bearing insects and rodents through proper sanitation procedures and pesticide use. Medical personnel documented only 40 cases of pest-borne diseases, which is remarkable considering the hundreds of thousands of cases of malaria, sand fly fever, and leishmaniasis that occurred in US forces during World War II in the region.

2. Pesticide Overexposures

It is likely that at least 41,000 servicemembers overall may have had some overexposure to pesticides. The conclusion that some personnel may have been overexposed, and the estimated total of possibly overexposed individuals is the synthesis of information from several areas.

The HRA demonstrates that the opportunity for exposure to some pesticides existed and suggests that some veterans may have been exposed to levels of pesticides that exceeded the levels of concern defined in this report. The HRA is a scientifically peer-reviewed retrospective assessment used to estimate exposures and assess the likelihood that certain acute effects occurred. The HRA is useful in conjunction with other information in judging the potential for chronic adverse effects, and may provide useful information for future studies. However, investigators and peer reviewers consider many of the assumptions that were included in the HRA to be very conservative, thus tending to overestimate exposures.

Approximately 30,500 members of the general military population may have been at elevated risk for short-term health effects because of exposure to pest strips. Another group of about 7,000 of the general military population may have been overexposed to pesticides applied during spraying operations. According to the RAND survey, up to 54,000 servicemembers used or witnessed the use of fly baits, and may therefore have been exposed. Those who applied fly baits frequently, did not use gloves, and did not wash up after application may have been overexposed. It is important to remember, however, that, investigators uncovered no evidence that the majority of veterans were exposed to unhealthful levels of pesticides.

Pesticide applicators were probably one of the more highly pesticide-exposed groups. There were perhaps 3,500 to 4,500 individuals who worked as pesticide applicators during the Gulf War. These included trained and certified pesticide applicators, field sanitation teams, and the military police that conducted delousing operations.

There appear to have been a small number of veterans who experienced symptoms of pesticide exposure during deployment. Investigators interviewed over 40 Gulf War veterans who described cases of possible symptomatic pesticide exposure in themselves or others, and several recounted instances where medical treatment was required. These reports vary substantially in the level of detail provided and intensity of the signs and symptoms described, and investigators have been unable to corroborate them with hospital and medical records generated during deployment.

Finally, some individuals are more susceptible than others to the effects of pesticides. Thus, if two individuals undergo the same exposure, one may exhibit signs and symptoms of overexposure, while the other does not. This may be due to several factors, including genetic make-up. For example, some people are inherently more efficient than others at detoxifying and clearing pesticides from their bodies.

3. Potential for Pesticides to Cause Long-term Symptoms

The scientific literature demonstrates that organophosphate and carbamate pesticides have the potential, at least in cases of severe poisoning, to cause long-term symptoms similar to those reported by some veterans. However, there is conflicting information in the literature regarding whether long-term effects occur in individuals who did not experience acute symptoms near the time of exposure. Some sources suggest that unless individuals had symptoms of serious pesticide toxicity at the time of exposure, health effects months or years later are unlikely. On the other hand, RAND concludes from their literature review that short-term symptoms are not necessarily a precursor to long-term effects.

According to the RAND literature review, some of the general long-term symptoms reported by some veterans with undiagnosed illnesses and also reported in highly pesticide-exposed civilians include memory and concentration problems, irritability, pain, fibromyalgia, chronic fatigue, and sleep disorders.

4. Potential for Pesticides to Contribute to Veterans’ Illnesses

Overexposure to pesticides, particularly organophosphates and carbamates, may have contributed to the unexplained illnesses reported by some Gulf War veterans. The HRA and RAND survey have documented the potential for pesticide overexposures and exposures above the levels of concern among those who served in the Gulf. The scientific literature provides evidence that organophosphate and carbamate pesticides are capable of causing dose-related toxic effects on the nervous system that may be followed by long-term symptoms like some of those in some Gulf War veterans. Some epidemiologic studies of Gulf War veterans have noted an association between self-reports of pesticide exposure and reports of symptoms. Although these studies do not specify the identity of pesticides or the levels of exposure, and the reported symptoms vary from one study to another, the findings are at least compatible with the possibility of a pesticide contribution to some reported symptoms.

5. Areas for Further Research

Further research is needed in several key areas, including the effects of low-level pesticide exposures; pesticide interactions with other chemical compounds; and epidemiologic studies focused on Gulf War and/or other military pesticide applicators. First, because most pesticide exposures were low level and did not produce signs and symptoms near the time of exposure, it is important to know whether these types of exposures might produce long-term health effects. While some sources suggest that unless individuals had symptoms of serious pesticide toxicity at the time of exposure, health effects months or years later are unlikely, other sources suggest that acute symptoms are not necessarily a precursor to long-term health effects. Second, the HRA does not account completely for some potentially important combined exposures. While it considered combinations of organophosphate and carbamate pesticides, it does not account for additional concurrent exposures to DEET, permethrin, pyridostigmine bromide, or low levels of nerve agents, which may have occurred. Organophosphate and carbamate pesticides are characterized by the same toxic mechanism as that of pyridostigmine bromide and nerve agents: the inhibition of acetylcholinesterase. Some personnel may have been exposed to varying combinations of these anticholinesterase and other chemicals. Third, investigators were unable to locate a single epidemiologic study of military pesticide applicators. Such a study could be highly useful in helping to better characterize the link, if any, between pesticide exposures during the Gulf War, and chronic health effects.

B. Lessons Learned

During the course of this pesticide exposure investigation, analysts identified several lessons. The recommended areas for improvements are: host nation pesticide application; delousing procedures; training; supply distribution; local purchase procedures; personal protective equipment; record-keeping procedures; occupational medical surveillance; communications; command support; and the use of dichlorvos pest strips. In 1992 the Armed Forces Pest Management Board also identified supply problems, communication difficulties, and inconsistent command support as problem areas.[134]

1. Host Nation Application

a. Observation

Host nation contractors frequently applied pesticides in and around areas where US servicemembers were quartered. Some US servicemembers indicated concerns with what they perceived as unsafe and improper handling procedures, or use of unknown or unsafe pesticides. An analysis of the Gulf War by the British Ministry of Defence identified a similar problem with pesticide applications by host nation personnel or by non-British servicemembers. The British have since adopted a procedure requiring monitoring of host nation applications.[135]

b. Recommendations

The appropriate changes in doctrine and policy will address the recommendations.

2. Delousing

a. Observation

Delousing personnel at times lacked adequate training, dependable lindane dispersal equipment, proper personal protective equipment, and effective oversight by PM personnel. In March 1994, the Armed Forces Pest Management Board sent out a message directing that all military stocks of one percent lindane dust be turned in for disposal, as DoD was changing the procedures for mass delousing. The message outlined three reasons for this action: 1) DoD is revising its delousing procedures; the indiscriminate application to all individuals without determining whether anyone is infected with lice is not a sound pest management practice; 2) Lindane is very persistent in the environment and has "suggestive evidence of carcinogenicity" according to the EPA; and 3) discontinuing the use of lindane is consistent with the pesticide reduction goals established by the Defense Environmental Security Council.[136]

b. Recommendation

3. Training and Experience

a. Observation

The pesticides exposure investigation uncovered a number of incidents of pesticide misuse. Among these were personnel wearing flea and tick collars as personal repellents. Additionally, the inappropriate uses of pesticides (e.g., use of fly baits on dining tables and under cots) occurred on an individual basis.

The military placed inadequate emphasis on field sanitation supplies, equipment, preparation, and training prior to deployment. In-theater field sanitation team training varied from several hours to a few days, and appears to have included only a brief discussion on pest control and pesticide issues. Further, the level of experience and hands-on training for pesticide applicators varied considerably, with many applicators having little or no application experience prior to their deployment to the Gulf. Some had expired certifications or had never been certified.

b. Recommendations

4. Supply Distribution and Local Purchase

a. Observation

Supply distribution problems affected the availability of pesticide supplies and pest control equipment. These problems resulted in the purchase of pesticides on the local market, some of which were not labeled in English, possibly leading to improper or inappropriate use among US forces.

b. Recommendations

5. Equipment and Facilities

a. Observation

Pesticide applicators, including field sanitation team members, were ill-prepared to accomplish their mission because of missing or inoperable pest control equipment and inadequate personal protective equipment, including coveralls, goggles, and respiratory protection. There was also insufficient water for cleanup, along with a lack of cleanup and laundry facilities, which resulted in applicators wearing contaminated uniforms for extended time periods. In some instances, the inability to store equipment and pesticides properly contributed to concerns of equipment maintenance and pesticide stability.

b. Recommendations

6. Record Keeping

a. Observation

Little information is known about which pesticide products military units actually had in their possession at the outset of the Gulf War. Similarly, while there is some information on which pesticides were turned in to the supply system, the amounts retained or disposed of are unknown. Since little documentation exists on the levels of pesticides actually applied, the information in this report on pesticide usage was largely obtained through veteran recall.

In 1996, Department of Defense Instruction 4150.7, "DoD Pest Management Program," initiated the requirement to record, report, and archive pesticide use. This requirement states, "Ensure that any pesticide applications, excluding arthropod skin and clothing repellents, performed during military operations are recorded using DD Form 1532-1, ‘Pest Management Maintenance Report,’ or a computer generated equivalent. The DoD Components shall establish a method to archive these records for permanent retention." In response to an August 1997 memorandum from the Under Secretary of Defense (Acquisition and Technology), the Army, Navy and Air Force.[140] described the procedures in place for recording, reporting and archiving information on pesticide application. In addition, the Armed Forces Pest Management Board (AFPMB) issued an information paper, "DoD and Service Policy and Guidance on Recording, Reporting, and Archiving Pesticide Use During Military Operations,"[141] in May 2000. The paper provides a summary of DoD service policy and guidance related to pesticide use during military operations.

b. Recommendations

7. Occupational Medical Surveillance

a. Observation

The services had inconsistent requirements for occupational health surveillance of pesticide applicators. Investigators found no evidence that an occupational medical surveillance program was in effect immediately before, during, or after personnel deployed to the Gulf.

Some steps have been taken to address the occupational health surveillance issue, but additional action is needed. DoD Manual 6055.5-M, "Occupational Medical Surveillance," [142] revised in May 1998, provides requirements for implementing a medical surveillance program. The pesticide applicator evaluations include the worker’s medical and occupational history, a physical examination (including a complete neurological exam), and cholinesterase testing.

b. Recommendations

8. Communications

a. Observation

Communication within the deployed PM community was frequently difficult. The PM leadership of the component services met periodically in Al Jubayl but some individuals were unable to attend and there was no formal system to disseminate the information developed in these sessions throughout the theater. In the Air Force, pest management was a civil engineering function, not a PM function.

b. Recommendations

9. Command Support

a. Observation

Command support for PM varied from poor to excellent. Historically, three times as many US soldiers have been lost to disease and nonbattle injury as to enemy action. The ultimate objective of a military force—success in battle—demands that servicemembers maintain a constant state of good health. Many early-deploying Army units did not have trained field sanitation team members. This is an indicator that PM and field sanitation were not given adequate emphasis prior to deployment.

To conserve the fighting strength, military leaders must emphasize effective PM and field sanitation measures during training and when deployed on contingency missions. As a minimum, the importance of the DoD Repellent System needs to be understood and emphasized.

b. Recommendations

10. Use of Dichlorvos Pest Strips

a. Observation

Use of dichlorvos pest strips resulted in exposures that exceeded levels of concern. Even when dichlorvos-containing pest strips are used according to current label directions and military guidance, many personnel may be exposed to unhealthful levels consistent with the findings of the HRA. The lowest dichlorvos concentration estimated in the HRA was almost fifty times the draft 1-year military air exposure guidelines.[143] Similarly, the August 9, 2000, EPA Office of Pesticide Programs (OPP) risk assessment found that all residential uses of pest strips are "of concern," even for adults. The pest strips are still listed on the March 2002 Contingency Pesticide List, and both the March 2002 version of the Contingency Pest Management Guide and the January 2001 guidance on filth flies recommend indoor uses for pest strips.[144,] [145,] [146]

It is also noteworthy that the registrants have signed a consent order with the California Department of Pesticide Regulation agreeing to modify the label to specify that pest strips not be used in areas of the home where people will be present for extended periods of time.[147] In 1995, OPP proposed cancellation of all uses for dichlorvos in areas intended for regular occupancy. OPP will take final action pending the resolution of complex economic and legal issues. From a military health standpoint, however, there is no reason for DoD to delay action.

b. Recommendation


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