Chronic Multisymptom Illness in Gulf War Veterans Case Definitions Reexamined (2014) / Chapter Skim
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3 Studies of Symptoms in Gulf War Veterans
3 Studies of Symptoms in Gulf War Veterans
Pages 31-66
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From page 31... ...
Table 3.1, summarizing all the studies reviewed, is at the end of the chapter. GENERAL LIMITATIONS OF GULF WAR STUDIES The cohort studies of Gulf War veterans and their derivatives have contributed greatly to our understanding of veterans' health but are subject to limitations that are commonly encountered in observational epidemiologic studies.
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There are two major types of bias: selection bias and information bias. Selection bias involves a systematic error -- in how subjects are identified, recruited, included, or excluded or in how they participate in a study -- that leads to a distortion of a true association.
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Military unit–based studies are generalizable only to members of that unit and not to the broader veteran or military population Large populationbased studies of Gulf War veterans have been conducted in each of the three major countries that participated in the Gulf War coalition: the United States, Canada, and the United Kingdom (Cherry et al., 2001; Goss Gilroy Inc., 1998; Kang et al., 2000; Unwin et al., 1999)
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From page 34... ...
That bias has the potential to occur in most of the major cohorts that compare deployed veterans with nondeployed personnel. The healthy-warrior effect is a form of selection bias in that chronically ill or less fit members of the armed forces might be less likely to have been deployed than more fit members.
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. Department of Veterans Affairs Study VA conducted a study that used the National Health Survey of Gulf War Veterans and Their Families to estimate the prevalence of symptoms and other health outcomes (including reproductive outcomes in spouses and birth defects in children)
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Gulf War veterans reported higher prevalences of all 48 symptoms on the health inventory. The most frequently reported were runny nose, headache, unrefreshing sleep, anxiety, joint pain, back pain, fatigue, ringing in ears, heartburn, difficulty in sleeping, depression, and difficulty in concentrating (see Table 3.2)
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Gulf War veterans also had higher rates of functional impairment, of limitations of activities, of at least one clinic or doctor visit, and of hospitalization. The Iowa Study The Iowa study was a cross-sectional survey of a sample of 4,886 military personnel who listed Iowa as their home of record at the time of enlistment (Iowa Persian Gulf Study Group, 1997)
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Kansas Gulf War veterans reported greater prevalences of 10 physician-diagnosed conditions than Kansas nondeployed veterans: skin conditions, stomach or intestinal conditions, depression, arthritis, migraine headaches, chronic fatigue syndrome (CFS) , bronchitis, PTSD, asthma, and thyroid conditions.
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. On the basis of the CDC case criteria, the study found that 47.2% of Gulf War veterans and 19.8% of nondeployed veterans had chonic multisymptom illness (OR = 3.26, 95% CI 2.48–4.28)
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From page 40... ...
reported higher prevalences of symptoms and diminished functioning than did either comparison group. Gulf War veterans were 2–3 times more likely than comparison subjects to have met symptom-based criteria for chronic fatigue, posttraumatic stress reaction, and CDC-defined chronic multisymptom illness (CMI; Fukuda et al., 1998)
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(2004) reported that 61% of responding Gulf War veterans and 37% of responding nondeployed veterans reported at least one new medical symptom or disease since 1990.
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. MILITARY UNIT–BASED STUDIES Hawaii and Pennsylvania Active-Duty and Reserve Study One of the first epidemiologic studies of US Gulf War veterans examined the psychologic and physical health of active-duty and reserve Army, Navy, Air Force, and Marine Corps personnel from bases in Pennsylvania and Hawaii (Stretch et al., 1995)
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Ft. Devens and New Orleans Cohort Studies The symptom experience of two deployed cohorts of Gulf War veterans was studied by Boston-based researchers (Proctor et al., 1998; Wolfe et al., 1998)
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(1999) excluded Gulf War veterans who were no longer active at the time of the study in 1994– 1995.
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Three demographically similar Air Force units were used as comparison groups: Unit A consisted of 538 personnel from the Pennsylvania Air National Guard who had a mission different from that of the index unit, Unit B consisted of 838 members of a US Air Force Reserve unit, and Unit C consisted of 1,680 active-duty Air Force personnel from Florida who had a mission similar to that of the index unit. Questionnaires regarding military characteristics, demographics, health status, and 35 specific symptoms previously identified to be of concern were distributed and completed by 3,675 participants (taken together these units included 1,155 Gulf War veterans and 2,520 nondeployed veterans)
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DOD instituted the Comprehensive Clinical Evaluation Program (CCEP) , and VA instituted the Persian Gulf Registry and Uniform Case Assessment Protocol (UCAP)
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(2003) conducted a health survey in 1995 of 1,161 participating Gulf War veterans who represented a random sample of a VA registry that covered seven states.
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Studies since the mid-1990s have found a higher prevalence of self-reported and clinically verified symptoms in Gulf War veterans than in nondeployed Gulf War–era veterans or other control groups. Australian, Canadian, Danish, United Kingdom, and United States Gulf War veterans report higher rates and greater severity of nearly all symptoms or sets of symptoms than their nondeployed counterparts; that finding was reported consistently in every study reviewed by this committee.
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Includes frequently severe were back 2002: 225 NGVs any person who pain, runny nose, joint pain, were actually served in the headaches being anxious, GWVs. Some US military on difficulty in getting to sleep, misclassification active duty, in feeling tired, skin rash, excessive in original sample.
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. Iowa Persian Gulf Study Iowa Persian Cross-sectional Iowa listed as home Telephone interview GWVs reported significantly Age, sex, race, Response rate Gulf Study study; interviews of record on initial using higher prevalence of symptoms branch of 76%.
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Canadian Veteran Study Goss Gilroy Cross-sectional All Canadian Gulf Survey of chronic GWVs reported higher Income and Response rate Inc., 1998 postal survey, War veterans. conditions and prevalence of symptoms of rank were 73% GWVs, 51
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region, excluding Most frequent symptoms were education, Authors note that special forces, feeling unrefreshed after sleep, rank, 800 Bosnian compared with irritability or outbursts of anger, employment, veterans later 39,217 personnel headache, fatigue, sleeping civilian or moved to GWV who served in difficulties, forgetfulness, joint military status group. Bosnia in 1992– stiffness, loss of concentration, Extensive 1997 and 250,000 flatulence or burping, and pain assessment of era cohort in without swelling or redness in selection bias.
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When Response rate fatigue score >8; compared with two groups of 71.6%. 50% sample of nondeployed veterans, SF-36 GWVs, with scores was worse, GHQ was worse, and 4–8, all 4–8 in fatigue was worse in GWVs, and Bosnia and era; 1 in they had 10.7 total symptoms in 8 sample of vs 7.9 and 6.4 in NDVs.
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. Danish Peacekeeper Studies Ishoy et al., Cross-sectional Danish Gulf War Questionnaire on Deployed veterans reported None Response rates 1999 study with veterans stationed neuropsychologic, higher prevalence (p < 0.05)
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assessment, compared with questionnaire, unrefreshed after sleep (adjusted Response rates: conducted in 26,411 Australian functional OR = 1.6, 95% CI 1.3–1.8) , 80.5% GWVs, 2000–2002 Defense Force impairment, 44-item fatigue (adjusted OR = 1.6, 95% 56.8% NDVs.
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National Guard US cohorts of deployed veterans Army, Navy, was headache (OR = 4.2)
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30% of sample indicated that their physical health had become either "worse" or "much worse" since their return. Seabee Studies Haley et al., Cross-sectional Active and retired Self-reported Survey results indicated 6 No assessment of 1997 survey, members of exposure to symptom factors (called selection bias.
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current alcohol survey. drinking Pennsylvania Air National Guard Study Fukuda et Cross-sectional Everyone on base Survey of 35 GWV vs NDV: mild to moderate Rank, sex, age, Response rates: al., 1998 survey conducted when survey was symptoms, in-person cases 39% vs 14%, severe cases smoking status 61.6% index unit, in 1995 conducted was interview.
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Unit C, 1,680 active-duty Air Force from Florida with missions similar to those of index. Women in the Air Force Pierce, 1997 Cross-sectional Stratified random Health survey At time 1, symptoms more Age Response rates: survey conducted sample of women sex-specific health frequent in GWVs vs NDVs 82% at time 1, in 1993 (Time 1)
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and rheumatologic Persian Gulf reported pain, and SF- patients and was widely Self-selected Fischbach, referrals Registry from 36 for health-related distributed. Widespread pain sample, no control 1998 South Texas quality of life.
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Ozakinci et Cross-sectional Derivative of Mailed survey and Compared with time 1, there was Sex, rank, race, Response rate: al., 2006 assessment, Hallman et al. telephone interview.
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NOTE: ANG = Air National Guard; CCEP = Comprehensive Clinical Evaluation Program; CDC = Centers for Disease Control and Prevention; CFS = chronic fatigue syndrome; CI = confidence interval; CMI = chronic multisymptom illness; DOD = Department of Defense; GHQ = Global Health Questionnaire; GI = gastrointestinal; GVMAP = Gulf Veterans Medical Assessment Programme; GWS = Gulf War syndrome; GWV = Gulf War veteran; IBS = irritable bowel syndrome; ICD-10 = International Statistical Classification of Diseases and Related Health Problems, 10th Revision; MCS = multiple chemical sensitivity; NDV = nondeployed veteran; OR = odds ratio; PTSD = posttraumatic stress disorder; RR = relative risk; SSID = signs, symptoms, and ill-defined conditions; VA = Department of Veterans Affairs.
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1998. Musculoskeletal manifestations, pain, and quality of life in Persian Gulf War veterans referred for rheumatologic evaluation.
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1997. A comprehensive clinical evaluation of 20,000 Persian Gulf War veterans.
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1998. Signs, symptoms, and ill-defined conditions in Persian Gulf War veterans: Findings from the comprehensive clinical evaluation program.
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