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Title: Gulf War and Health, Volume 4: Health Effects of Serving in the Gulf War


1
Gulf War and Health, Volume 4 Health Effects of
Serving in the Gulf War
  • Kelley Brix, M.D.
  • DoD Force Health Protection and
  • Readiness Programs
  • October 26, 2006

2
Gulf War and Health, Volume 4 Health Effects of
Serving in the Gulf War
  • 259-page report published on September 12, 2006
    by the Institute of Medicine (IOM) of the
    National Academy of Sciences
  • In 1998, Congress mandated that the Department of
    Veterans Affairs (VA) use a specific procedure to
    determine the illnesses that warrant a
    presumption of connection to service in the 1991
    Gulf War.
  • This mandate required VA to contract with the
    National Academy of Sciences to conduct a
    comprehensive review and evaluation of the
    available scientific and medical information
    regarding the health status of Gulf War
    veterans.
  • Since 1998, VA has fulfilled this Congressional
    mandate by contracting with IOM to perform
    literature reviews on the health of Gulf War
    veterans.

3
IOM Reports Gulf War and Health, Volumes 1, 2,
and 3
  • The first three IOM reviews focused on the
    potential health effects of environmental
    exposures during the 1991 Gulf War, such as oil
    well fire smoke and depleted uranium.
  • The first three IOM reviews were published in
    2000, 2003, and 2005.

4
Goal of Gulf War and Health, Volume 4
  • This book differs from Volumes 1, 2, and 3
    because it focuses on the current health status
    of Gulf War veterans, regardless of exposure
    information.
  • The current report, however, takes a different
    approach, which is to identify the adverse health
    effects, if any, that are occurring among Gulf
    War veterans and thus might warrant further
    attention, either on the individual level or for
    the Gulf War veterans as a whole.
  • There was no attempt to associate diseases or
    symptoms with specific biological or chemical
    agents potentially encountered during the war.
  • In particular, the report focuses on health
    outcomes that are more prevalent in Gulf War
    veterans than in non-deployed veterans.

5
Gulf War and Health, Volume 4 Exhaustive Review
of Medical Literature
  • Page 11 states An impressive body of literature
    details the veterans symptoms and illnesses.
  • An extensive search of the literature led to the
    retrieval of more than 4000 potentially relevant
    references (through October 2005).
  • Ultimately, the committee focused on about 850
    relevant studies for review and evaluation.
  • Includes data from veteran populations from the
    US, UK, Canada, Denmark, and Australia (all the
    countries that have performed cohort studies,
    except for France).

6
Conclusions Outcomes Based Primarily on
Symptoms or Self-reports
  • No unique syndrome, unique illness, or unique
    pattern of symptoms in 1991 Gulf War (GW)
    veterans.
  • GW veterans report higher rates of nearly all
    symptoms or patterns of symptoms than
    non-deployed veterans.
  • Multi-symptom based medical conditions that
    occurred more frequently in GW veterans
  • Chronic fatigue syndrome (CFS)
  • Fibromyalgia (FM)
  • Multiple chemical sensitivity
  • VA already provides presumption of service
    connection for CFS and FM in GW veterans.

7
Conclusions Outcomes Based Primarily on
Symptoms or Self-reports (cont.)
  • GW veterans were at increased risk for a number
    of psychiatric illnesses, in particular
  • Posttraumatic stress disorder (PTSD)
  • Anxiety disorders (e.g., panic disorder)
  • Depression
  • Substance abuse
  • GW veterans were at increased risk of
    co-morbidity (the presence of two or more
    psychiatric illnesses at the same time).

8
Conclusions Outcomes Based Primarily on
Symptoms or Self-reports (cont.)
  • Studies of GW veterans vs. non-deployed veterans
    have not demonstrated differences in cognitive
    and motor tests, as determined on
    neuropsychological testing.
  • GW veterans have reported higher rates of skin
    conditions (rashes) than non-deployed veterans.
  • Medical exams in the VA National Health Survey
    showed that GW veterans had an increased rate of
    only 2 skin conditions, out of many conditions
  • Warts
  • Atopic dermatitis (skin rashes due to an allergic
    reaction)

9
Conclusions Outcomes with Objective Measures or
Diagnostic Medical Tests
  • Mortality studies have demonstrated a slight
    increase in deaths due to motor vehicle accidents
    in GW veterans, compared to non-deployed
    veterans.
  • Studies that followed death rates for a longer
    time period showed that the increased accident
    rates were likely to be limited to the first few
    years after the war.
  • No difference in death rates due to cancer, heart
    disease, infectious diseases, or other natural
    causes.
  • The rates of hospitalization were the same in GW
    veterans and non-deployed veterans, overall.

10
Conclusions Outcomes with Objective Measures or
Diagnostic Medical Tests (cont.)
  • The overall rates of cancer were the same in GW
    veterans and non-deployed veterans.
  • Studies of testicular cancer showed inconsistent
    results.
  • One study showed an increased death rate due to
    brain cancer
  • Increased rate in GW veterans who were possibly
    exposed due to the demolitions at Khamisiyah,
    compared to GW veterans who were not exposed.
  • IOM questioned the validity of this study.
  • The latency period for cancer (time period
    between possible exposure and onset of disease)
    may not have been reached yet in GW veterans. (It
    is usually at least 15 to 20 years.)

11
Conclusions Outcomes with Objective Measures or
Diagnostic Medical Tests (cont.)
  • Studies indicate that GW veterans might be at
    increased risk for amyotrophic lateral sclerosis
    (ALS).
  • ALS is an extremely rare neurological disease,
    which occurs in about one person in 100,000.
  • VA already provides presumption of service
    connection for ALS in GW veterans.
  • There is no increase in the rate of peripheral
    neuropathy in GW veterans, compared to
    non-deployed veterans.
  • This is a type of damage to the nerves in the
    arms and legs.
  • Conclusions were based on medical exams and
    specialized nerve tests.

12
Conclusions Outcomes with Objective Measures or
Diagnostic Medical Tests (cont.)
  • Overall, there is no consistent pattern of one or
    more birth defects in offspring of GW veterans.
  • No increase in the rate of birth defects,
    overall.
  • Only one type of birth defect was increased in
    more than one study (urinary tract abnormalities).

13
Conclusions Outcomes with Objective Measures or
Diagnostic Medical Tests (cont.)
  • There is no difference in the rates of
    cardiovascular disease or diabetes in GW veterans
    and non-deployed veterans.
  • Four objective studies of respiratory disease,
    such as asthma, used pulmonary function tests.
  • All four showed no differences in the rates of
    respiratory disease in GW veterans and
    non-deployed veterans.

14
IOM Recommendations
  • IOM did not recommend that further medical
    studies be performed in GW veterans, in general
    terms. Instead, they recommended quite targeted
    follow-up studies.
  • IOM recommended that continued surveillance be
    performed for specific health outcomes
  • Cancer (due to delay in onset for 15 to 20 years
    after exposure)
  • ALS
  • Birth defects and other adverse pregnancy
    outcomes
  • Psychiatric illnesses
  • Mortality
  • IOM had 2 general recommendations for future
    deployments
  • Pre- and post- deployment screening of health
    status
  • Assessment of environmental exposures

15
Overall Conclusions and Recommendations
  • Some studies do point to psychiatric disorders
    and neurologic end points that might be
    associated with Gulf War service and for which it
    might be possible to develop new approaches to
    prevention and clinical treatment that could
    benefit not only Gulf War veterans but also
    veterans of later conflicts.
  • Our committee does not recommend that more such
    studies be undertaken for the Gulf War veterans,
    but there would be value in continuing to monitor
    the veterans for some health end points,
    specifically cancer, especially brain and
    testicular cancers, neurologic diseases including
    amyotrophic lateral sclerosis (ALS), and causes
    of death.

16
Use of IOM Report in 2 Ways
  • Physicians in VA, DoD, and in private practice
    could use this report to consider the diseases
    that have an increased prevalence in Gulf War
    veterans. This could be useful in diagnosis and
    treatment.
  • VA is Congressionally mandated to consider the
    conclusions in the IOM report. Within 60 days of
    release of this IOM report, the Secretary of the
    VA is required to submit a report to Congress
    that determines whether or not a presumption of
    service connection is warranted for each illness
    covered in the report.

17
Gulf War and Health, Volume 4 Relevant
Headlines in Newspapers
  • This IOM report stimulated considerable interest
    in the media for a few days in September 2006.
  • Newspaper coverage was negative, oversimplified,
    and did not report the conclusions completely.

18
Additional IOM Reports on Gulf War Veterans
  • IOM has completed or is currently working on 3
    other reports related to the health of Gulf War
    veterans.
  • A report on infectious diseases was published on
    October 16, 2006.
  • Within the next few months, IOM will publish
  • a report on the long-term effects of
    psychological and physiological stress
  • a report on amyotrophic lateral sclerosis (ALS)

19
Gulf War and Health, Volume 5 Infectious
Diseases
  • 201-page report published on October 16, 2006 by
    the Institute of Medicine (IOM) of the National
    Academy of Sciences
  • In January 2005, IOM appointed a committee to
    review and evaluate the medical literature on the
    long-term effects of infections that US troops
    might have contracted in southwest and
    south-central Asia during the 1991 Gulf War,
    Operation Enduring Freedom, or Operation Iraqi
    Freedom.
  • This report covers infectious diseases known to
    occur in Iraq, Saudi Arabia, Kuwait, Afghanistan,
    and most of the countries along their borders.

20
Gulf War and Health, Volume 5 Infectious
Diseases (cont.)
  • The committee identified about 100 viruses,
    bacteria, fungi, and parasites that could have
    potentially infected servicemembers during their
    service in the 1991 Gulf War, OEF, or OIF.
  • The committee narrowed its review to nine
    diseases that merited in-depth evaluation due to
    their potential for long-term effects.
  • The nine diseases also met one or more of four
    criteria
  • endemic in southwest Asia or south-central Asia
  • diagnosed in US servicemembers during one or more
    of the three deployments
  • of special concern to Gulf War, OEF, or OIF
    veterans or
  • historically reported among military populations.

21
Gulf War and Health, Volume 5 Infectious
Diseases (cont.)
  • The nine diseases were
  • bacterial diarrheas caused by Campylobacter,
    Salmonella, or Shigella
  • brucellosis
  • leishmaniasis
  • malaria
  • Q fever
  • tuberculosis
  • West Nile fever
  • The committee described 34 potential,
    medically-recognized, long-term effects of these
    infections.
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