Gulf War and Health Volume 8: Update of Health Effects of Serving in the Gulf War (2010) / Chapter Skim
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3 MAJOR COHORT STUDIES
3 MAJOR COHORT STUDIES
Pages 39-70
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From page 39... ...
GENERAL LIMITATIONS OF GULF WAR COHORT STUDIES AND DERIVATIVE STUDIES The cohort studies of Gulf War veterans and their derivative studies have contributed greatly to our understanding of veterans' health, but they are beset by limitations that are commonly encountered in epidemiologic studies (see Chapter 2) , including lack of representativeness, selection bias, lack of control for potential confounding factors, self-reports of exposures, lack of a diagnosis by a health professional for some health effects, and outcome misclassification.
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In population-based studies of Gulf War veterans, the cohort might be the entire deployed population, as in studies of Canadian and Australian veterans, or a random selection from the population of interest, as in several studies of US and UK veterans. The committee, in evaluating major cohort studies, gave greater weight to Gulf War studies that were population based.
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ORGANIZATION OF THIS CHAPTER This chapter describes the major cohort studies and their derivative studies used by the Update committee to provide the evidence for the conclusions presented in Chapter 4. For each separately assembled cohort, the reference study is described first, followed by a summary of any derivative studies cited in Chapter 4 or Appendix A
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42 GULF WAR AND HEALTH TABLE 3-1 Reference and Derivative Studies for the Major Gulf War Cohorts Cohort/Reference Study Derivatives Purpose/Outcome VA National Health Survey of Gulf War Veterans and Their Families/Kang et al., 2000 Volume 4 Davis et al., 2004 Presence of distal symmetric polyneuropathy Eisen et al., 2005 Numerous health outcomes and general health assessment Kang et al., 2001 Self-reported birth defects Kang et al., 2002 Association of symptom clusters with self-reported exposures Kang et al., 2003 Prevalence of PTSD and chronic fatigue syndrome Kang et al., 2005 Role of sexual assault and harassment on the risk of PTSD Karlinsky et al., 2004 Pulmonary function and self-reported respiratory symptoms New Kang et al., 2009 Self-reported general health status Page et al., 2005a,b Possible exposure at Khamisiyah and self-reported morbidity Blanchard et al., 2005 Prevalence of chronic multisymptom illness Toomey et al., 2007 Prevalence of psychiatric disorders, symptom self-report, and quality of life status Toomey et al., 2009 Neuropsychological functioning Iowa Veterans/Iowa Persian Gulf Study Group, 1997 Barrett et al., 2002 Association between PTSD and self-reported physical Volume 4 health status Black et al., 1999 Impact of multiple chemical sensitivity on quality of life and utilization of health services Black et al., 2000 Risk factors and prevalence of multiple chemical sensitivity Black et al., 2004a Prevalence of psychiatric disorders Black et al., 2004b Prevalence and risk factors for anxiety disorders Doebbling et al., 2000 Factor analysis of self-reported symptoms (Definition of Persian Gulf War Syndrome) Lange et al., 2002 Exposure to Kuwait oil fires and risk of asthma and bronchitis New Ang et al., 2006 Identification of predictors of chronic widespread pain Black et al., 2006 Prevalence of borderline personality disorder Forman-Hoffman et al., Prevalence of self-reports of symptoms of chronic 2007 widespread pain UK Veterans: University of London/Unwin et al., 1999 Volume 4 Hotopf et al., 2003a,b Neurologic assessments Macfarlane et al., 2000 Self-reported exposure and mortality Macfarlane et al., 2003 Incidence of cancer Reid et al., 2001 Self-reported exposure and multiple chemical sensitivity and chronic fatigue syndrome
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MAJOR COHORT STUDIES 43 Cohort/Reference Study Derivatives Purpose/Outcome Rose et al., 2004 Neuromuscular symptoms evaluated through objective tests Sharief et al., 2002 Neuromuscular symptoms evaluated by objective tests Nisenbaum et al., 2004 Factor analysis of self-reported symptoms Macfarlane et al., 2005 Self-reported exposure and mortality New Stimpson et al., 2006 Self-report of chronic widespread pain Ismail et al., 2008 Prevalence of chronic fatigue and related disorders through assessment UK Veterans: University of Manchester/Cherry et al., 2001a,b Volume 4 None New None UK Veterans: London School of Hygiene and Tropical Medicine/Maconochie et al., 2003 Volume 4 Doyle et al., 2004 Prevalence of miscarriage, stillbirth, and congenital malformations Maconochie et al., 2004 Self-report of fertility problems Simmons et al., 2004 Self-report of medical symptoms or disease New None Danish Peacekeepers/Ishoy et al., 1999b Volume 4 Proctor et al., 2003 Prevalence of neuropsychologic symptoms and neurobehavioral performance Ishoy et al., 1999a Prevalence of gastrointestinal symptoms and diseases, skin disease, and respiratory symptoms and function Ishoy et al., 2001a,b Self-report of sexual dysfunction and birth defects New None Australian Veterans/Sim et al., 2003 Volume 4 Kelsall et al., 2004a Association between self-reported exposures with numerous symptoms and medical conditions Ikin et al., 2004 Prevalence of psychiatric disorders McKenzie et al., 2004 Psychological health and functioning Kelsall et al., 2004b Self-reported exposure and respiratory health status Kelsall et al., 2005 Self-report of exposures and neurological symptoms Forbes et al., 2004 Factor analysis of self-reported symptoms New Kelsall et al., 2006 Self-reported exposure and prevalence of chronic fatigue syndrome Kelsall et al., 2007 Self-reported birth defects and other pregnancy outcomes Oregon and Washington Veterans/McCauley et al., 1999a Volume 4 Bourdette et al., 2001 Prevalence of unexplained illness
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44 GULF WAR AND HEALTH Cohort/Reference Study Derivatives Purpose/Outcome Spencer et al., 2001 Self-reported exposure and unexplained illness New None Canadian Veterans/Goss Gilroy, 1998 Volume 4 Statistics Canada, 2005 Mortality rate and cancer incidence New None Kansas Veterans Study/Steele et al., 2000 Volume 4 None New None Fort Devens and New Orleans Cohorts/Proctor et al., 1998 Volume 4 White et al., 2001 Self-reported exposure and neuropsychological functioning Proctor et al., 2001a Assessment of health-related quality of life Proctor et al., 2001b Overlap between symptoms of chronic fatigue and chemical sensitivity, and the case definition for chronic multisymptom illness New Proctor et al., 2006 Possible exposure at Khamisiyah and neuropsychological functioning Seabee Veterans/Haley et al., 1997b Haley and Kurt, 1997; Volume 4 Self-reported exposure to neurotoxicants and nervous Haley et al., 1997a system-based syndromes Haley et al., 1999 Genetic susceptibility and risk of neurologic damage New Haley et al., 2009 Gray et al., 1999 Volume 4 Gray et al., 2002 Self-report of symptoms and general health status Knoke et al., 2000 Self-report of symptoms New Phillips et al., 2009 Exposure to vaccines and chronic multisymptom illness Pennsylvania Air National Guard Veterans/Fukuda et al., 1998 Volume 4 Nisenbaum et al., 2000 Self-reported exposures and chronic multisymptom illness Nisenbaum et al., 2004 Factor analysis of self-reported symptoms New None Hawaii and Pennsylvania Active-Duty and Reserve/Stretch et al., 1995 Volume 4 Stretch et al., 1996a Prevalence of psychiatric disorders Stretch et al., 1996b Prevalence of PTSD
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This three-phase retrospective study, the National Health Survey of Gulf War Veterans and Their Families, was designed to be representative of the nearly 700,000 US veterans sent to the Persian Gulf and 800,680 veterans who were not deployed but who were in the military between September 1990 and May 1991. In the first phase, begun in 1995, the VA mailed questionnaires to a stratified random sample of 15,000 Gulf War and 15,000 veterans not deployed to the Gulf War identified by the Defense Manpower Data Center (DMDC)
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determined by medical history, physical examination by a neurologist, blood tests, and standardized electrophysiologic assessment of motor and sensory nerves in the cohort of 1061 deployed veterans and 1128 nondeployed veterans from the National Health Survey of Gulf War Veterans and Their Families. Spouses of deployed (n = 484)
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The Update committee identified six studies (Blanchard et al., 2005; Kang et al., 2009; Page et al., 2005a,b; Toomey et al., 2007, 2009) published after Volume 4 that used data from the VA National Health Survey of Gulf War Veterans and Their Families.
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conducted a 10-year follow-up general health assessment using the population of the National Health Survey of Gulf War Veterans and Their Families (15,000 Gulf War deployed and 15,000 nondeployed)
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The Iowa study assessed exposure–symptom relationships by asking veterans to report on their deployment exposures including to solvents or petrochemicals, smoke or combustion products, lead from fuels, pesticides, ionizing or nonionizing radiation, chemical warfare agents, PB use, infectious agents, and physical trauma. The authors concluded that no exposure to any single agent was related to the medical conditions found to be more prevalent in Gulf War veterans (Iowa Persian Gulf Study Group, 1997)
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(2000) used factor analysis to attempt to determine if the symptoms reported by Gulf War veterans after their deployment were different than those reported by nondeployed veterans and if the symptoms seen in the deployed veterans could possibly constitute a unique Gulf War syndrome.
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United Kingdom Veteran Studies Three reference studies of UK Gulf War veterans were identified in Volume 4: Cherry et al.
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(2002) conducted a case-control study examining neuromuscular symptoms in 49 Gulf War veterans with more than four neuromuscular symptoms and lower functioning according to the SF-36 compared with 26 healthy Gulf War-deployed veterans, 13 symptomatic Bosnian veterans, and 22 symptomatic nondeployed controls.
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; however, the participation rates were low (47.3% and 37.5% of male and female Gulf War veterans, respectively, and 57.3% and 45.6% of male and female nondeployed veterans)
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(2004) indicated that 61% of Gulf War veterans reported at least one new medical symptom or disease since 1990 compared with 37% of nondeployed veterans.
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The Update committee identified two new derivative studies of the Australian Gulf War veterans. Kelsall et al.
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The Update committee did not identify any additional derivative studies on the Danish Gulf War veterans. Reference Study Military personnel from Denmark were involved in peacekeeping or humanitarian missions occurring predominantly after the Gulf War ceasefire, but were located in the same areas as other coalition forces who served in Gulf War combat (Ishoy et al., 1999b)
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Oregon and Washington Veteran Studies One reference study discussed in Volume 4 examined Gulf War veterans who listed Oregon or Washington as their residence at the time of their deployment (McCauley et al., 1999a) ; two derivative studies were also described in that volume (Bourdette et al., 2001; Spencer et al., 2001)
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. Canadian Gulf War Veterans Study In Volume 4 the Canadian Gulf War Veterans Study was not included in the presentation of major cohort studies.
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Reference Study The symptom experience of two deployed cohorts of Gulf War veterans was studied by Boston-based researchers. The first, an army cohort based in Fort Devens, Massachusetts, was surveyed longitudinally at three time points (1991, 1993-1994, and 1997)
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(2001b) assessed 180 deployed veterans from the Fort Devens cohort and 46 Germany deployed veterans for symptoms of chronic fatigue and chemical sensitivity to assess the prevalence of the symptoms and whether there was an overlap between these symptoms and the case definition of chronic multisymptom illness.
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In 1994, 1497 study subjects were enrolled: 527 Gulf War veterans and 970 nondeployed veterans. The participation rate of eligible Seabees was 53%.
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Further details from these studies are discussed in Chapter 4. Hawaii and Pennsylvania Active Duty and Reserve Study Reference Study One of the first epidemiologic studies of US Gulf War veterans was a congressionally mandated study evaluating the psychologic and physical health of active-duty and reserve army, navy, air force, and marine personnel from bases in Pennsylvania and Hawaii (Stretch et al., 1995)
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2002. Posttraumatic stress disorder and self-reported physical health status among U.S.
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2004. Clinical and laboratory assessment of distal peripheral nerves in Gulf War veterans and spouses.
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2003b. Paraoxonase in Persian Gulf War veterans.
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2003. Post-traumatic stress disorder and chronic fatigue syndrome-like illness among Gulf War veterans: A population-based survey of 30,000 veterans.
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2006. Medically evaluated psychological and physical health of Australian Gulf War veterans with chronic fatigue.
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1998. Health status of Persian Gulf War veterans: Self-reported symptoms, environmental exposures and the effect of stress.
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2001. Multiple chemical sensitivity and chronic fatigue syndrome in British Gulf War veterans.
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1996b. Post-traumatic stress disorder symptoms among Gulf War veterans.
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