Title: Gulf War and Health, Volume 4: Health Effects of Serving in the Gulf War
1Gulf 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
2Gulf 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.
3IOM 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.
4Goal 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.
5Gulf 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).
6Conclusions 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.
7Conclusions 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).
8Conclusions 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)
9Conclusions 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.
10Conclusions 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.)
11Conclusions 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.
12Conclusions 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).
13Conclusions 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.
14IOM 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
15Overall 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.
16Use 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.
17Gulf 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.
18Additional 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)
19Gulf 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.
20Gulf 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.
21Gulf 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.