gulf war and health, volume 4:
TRANSCRIPT
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
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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.
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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.
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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.
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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).
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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.
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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).
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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)
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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.
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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.)
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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.
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• 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).
Conclusions: Outcomes with Objective Measures or Diagnostic Medical Tests (cont.)
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• 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.
Conclusions: Outcomes with Objective Measures or Diagnostic Medical Tests (cont.)
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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
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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.”
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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.
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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.
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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)
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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.
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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.
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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.