Health Consequences of Service During the Persian Gulf War Recommendations for Research and Information Systems (1996) / Chapter Skim
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Health Outcomes
Health Outcomes
Pages 67-116
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From page 67... ...
With the broad question of what adverse health consequences veterans have suffered as a result of their service, the range of relevant experiences is also very broad. The strength of evidence for or against increased risks of specific health outcomes among those who served in the Persian Gulf (PG)
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From page 68... ...
, and other federal agencies have expanded the scope and scientific rigor of investigations into the health of PGW veterans in an effort to systematically develop a body of knowledge about their health experiences and risks associated with exposures described in the previous chapter. The committee and other investigators are seeking to determine whether the risk of illnesses was increased among PGW veterans and what research should be carried out to make such determinations.
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From page 69... ...
The DVA and various units of the DoD also have undertaken a variety of scientific studies of the health status of PGW veterans. The number and scope of these studies have increased rapidly over the past several years, but few studies had been completed as of May 1996.
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From page 70... ...
at San Diego has undertaken two studies of hospitalization rates, one in PGW veterans who remained on active duty and a second in residents of California who separated from military service after the PGW. Preliminary findings from the first study found no consistent evidence of increased risk of hospitalization for any cause among PGW veterans compared with nondeployed veterans, even after adjusting for a possible healthy worker effect, as suggested by a 10% lower hospitalization rate of PGW veterans prior to deployment.
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From page 71... ...
None of the four pilot studies have detected increased rates of adverse reproductive outcomes in PGW veterans. Given the preceding overview, the committee has not identified scientific evidence to date demonstrating adverse health consequences specifically of PGW service other than the documented incidents of leishmaniasis, combatrelated or injury-related mortality or morbidity, and increased risk of psychiatric sequelae of deployment.
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From page 72... ...
We have organized the accumulated evidence by study type and endpoint into the following sections: mortality studies, hospitalization studies, diagnosed diseases in PG veterans, studies of self-reported symptoms (outbreaks and surveys) , adverse reproductive outcome studies, mental health studies, and women's health studies.
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From page 73... ...
, and homicide (N= 103~. By using the experience of nondeployed veterans to generate expected mortality rates for those deployed, relative risk (RR)
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From page 74... ...
This is an important finding, and further follow-up will be appropriate for evaluating possible differences between groups for medical conditions with longer latency periods. HOSPITALIZATION STUDIES Computerized hospital discharge data provide a resource for assessing whether PGW veterans were at increased risk of hospitalization after the war relative to appropriate comparison groups and for investigating the distribution
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From page 75... ...
To date, one study of the hospitalization experience of POW veterans has reported preliminary findings (Coate et al., 1995~. These investigators, at the NHRC in San Diego, used a retrospective cohort design to compare prewar and postwar hospitalization rates of 547,076 regular Army, Navy, Marine, and Air Force active duty troops deployed to the PG between August 8, 1990, and July 31, 1991, with those of 618,335 nondeployed veterans.
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From page 76... ...
Diseases with latency periods longer than 3 years would not be detected by this study, nor would illnesses that did not lead to hospitalization. Increased hospitalizations due to public awareness of the putative Gulf War Syndrome would have been limited to PGW veterans.
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From page 77... ...
or a "principal reason for hospitalization." A second limitation of both study designs is that even an examination of the entire PGW veteran cohort would be unlikely to detect the health effects of exposures that affected only a small geographical or occupational subset of the cohort or were rare events. When taken together, however, completed studies of mortality and hospitalization rates of PGW veterans provide no evidence of an association for any widespread or common environmental exposure or other threat to health of sufficient severity to increase the risk of early death or hospitalization among a large segment of the cohort of deployed troops in the 2 to 3 years after deployment.
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From page 78... ...
Leishmaniasis has been associated with service in the PG. DoD and DVA have established registries to which active duty service personnel (DoD)
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From page 79... ...
DVA Persian Gulf Health Registry Data from the DVA PGHR have been analyzed separately for women (N= 5,429)
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From page 80... ...
and Male (N = 42,725) Veterans in the Persian Gulf Health Registry Women Men Diagnosis No.
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From page 81... ...
Committee on the DoD Persian Gulf Syndrome Comprehensive Clinical Evaluation Program. This committee, separate from ours, was established in July 1994, at the request of DoD.
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From page 82... ...
Complaint" (%) Joint pain 49 11 Fatigue 47 10 Headache 39 7 Loss of memory 34 4 Sleep disturbance 32 2 Rash/dermatitis 31 7 Difficulty concentrating 27 <1 Depression 23 1 Muscle pain 21 1 Diarrhea 18 2 Shortness of breath 18 3 Abdominal pain or gastrointestinal symptoms 17 3 SOURCE: DoD, 1996.
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From page 83... ...
Predictors of Enrollment in the Persian Gulf Health Registry The availability of databases containing information on Army soldiers, including Army reserve and National Guard, who were deployed to the POW theater and the information on those who registered in the DVA PGHR have led to an investigation of possible determinants of registration. A population of 50,000~0,000 Army soldiers (including reserve and National Guard)
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From page 84... ...
A few well-done cluster studies can be useful at the early stages of an investigation to help define the problem and to rule out some statistical flukes that have been misinterpreted and some possible etiologies. That phase of research on the reported Gulf War Syndrome has been completed.
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From page 85... ...
The morbidity assessments reported in this investigation do not include data collected by civilian providers, so only a portion of the health records are available for a limited subset of participants. This study is useful in documenting the absence of a common underlying malady or environmental exposure among a group of reservists who initially appeared to have similar medical problems.
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From page 86... ...
began an investigation of a report of unexplained illnesses among veterans of the POW who belonged to a unit of the Pennsylvania Air National Guard. The initial cluster investigation expanded into a study being conducted in three stages.
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From page 87... ...
Preliminary findings by CDC investigators found that 42% of PGW veterans and 13% of nondeployed troops in the study met the working case definition. Investigators concluded that this symptom complex was very common among PGW veterans, whereas the prevalence rates were similar for nondeployed veterans and a civilian population involved in a study of chronic fatigue syndrome (Reeves, 1995~.
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From page 88... ...
First, because these studies were initiated in response to reports of unusual medical problems in the three units, they do not provide information about the prevalence of such problems in the larger cohort of troops deployed to the Gulf. Because symptoms are self-reported, it is difficult to determine whether the higher rates represent true differences or whether they result from recall bias among troops aware of the general public debate about a Gulf War Syndrome as well as the medical concerns of others in their unit.
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From page 89... ...
In some studies, the survey was supplemented by examination of all or a subset of study participants. These studies provide information on the frequency of self-reported symptoms and illnesses of soldiers deployed to the Gulf theater and may be of value in identifying diagnoses or illnesses of special concern.
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From page 90... ...
The demographic characteristics of deployed and nondeployed respondents were similar. Veterans who had been deployed to the Gulf had higher mean scores on all five dimension scales of the Hopkins psychological symptoms profile (somatization, obsessive-compulsive disorder, interpersonal sensitivity, anxiety, or depression)
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From page 91... ...
Findings and associations detected in specific study populations may serve to define needs for studies of other PG veteran populations. D VA National Health Survey The National Health Survey of PG veterans and their family members, funded by DVA, is a mailed survey that will compare self-reported prevalence of health outcomes between 15,000 PG and 15,000 PG-era veterans randomly selected from the DMDC database, oversampling for women and reserve troops.
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From page 92... ...
The statistical power analysis indicates that the study can detect a 50% rate increase in the "exposed" group; exposure is not specified but is assumed to be "service in the PG." Available information on health consequences indicates that a 50% increase may be unrealistically high. The actual power of the Iowa study to detect a smaller increase will be substantially lower than the 80% indicated in the analysis.
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From page 93... ...
To study reproductive health consequences of PG service and determine the potential for further productive research, one must consider how environmental exposure might exert such effects. These pathways or mechanisms help to define how reproductive health might be influenced by some aspect of having served in the POW.
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From page 94... ...
Thus, differences in reported data may simply reflect differences in reporting standards. Structural damage to the developing fetus can result in congenital malformations, whereas reduced growth and low birth weight may reflect a range of fetal insults.
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From page 95... ...
Much of the scientific literature on environmental exposures and reproductive outcomes has been based on studies of special, often high-risk, populations. Thus, direct comparisons of rates of adverse outcomes in those special studies with the rates among POW veterans may be misleading.
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From page 96... ...
. Reports of clusters of adverse reproductive outcomes (particularly miscarriages or birth defects)
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From page 97... ...
Reproductive Outcome Studies in PG Populations Pilot Studies Although many studies of PGW veterans are in progress, four pilot projects have evaluated the possibility of adverse reproductive health experiences, and three larger population-based studies are under way. The pilot projects include studies of: (1)
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From page 98... ...
NHRC Studies A study of the reproductive health of veterans is currently in progress at the NHRC in San Diego. A multifaceted study of the health of PGW veterans ("Epidemiologic Studies of Morbidity Among Gulf War Veterans: A Search for Etiologic Agents and Risk Factors")
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From page 99... ...
Approximately 9,500 live births are expected to have occurred to PGW veterans in the selected states. This is an ambitious study for this research team, proposing to conduct record linkage on a scale not previously attempted in the United States.
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From page 100... ...
If the results of those studies provide specific leads to an increased risk of particular outcomes, such leads should be pursued with more detailed research and larger samples to evaluate exposures encountered in the war. It is also possible that some specific exposures producing known reproductive health consequences will be identified as having occurred, which would warrant more focused study of reproductive outcomes.
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From page 101... ...
Issues in Studies of Mental Health Investigators have begun to. study some of the questions concerning the mental health of POW veterans and possible associations with service in the PG.
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From page 102... ...
Mental Health: Comparison of Deployed and Nondeployed Troops A diagnosis of PTSD is usually made by means of a clinical interview, but algorithms have been developed to identify persons likely to have PTSD by using data obtained by questionnaire, such as the Impact of Event Scale (IES) or the Brief Symptom Inventory (BSI)
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From page 103... ...
In a comparative survey, conducted in 1993, of PG active duty personnel and reserve troops from Hawaii and Pennsylvania, reserve troops scored higher than active duty troops on the avoidance and intrusion scales of the IES, but their scores were remarkably lower than those of active duty personnel in the XVIIIth Airborne Corps and the VIIth Corps, who were studied in 1991-1992 and who had engaged in main-force actions during the ground war. These lower scores in the Pennsylvania and Hawaii samples may reflect attenuation due to passage of another year since ODS, a difference in combat exposure, or other unidentified factors (USAMRMC, 19941.
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From page 104... ...
Data collected in 1993 revealed that mean scores on a trauma scale constructed from the BSI and the GSI/BSI were essentially the same for personnel deployed in those two areas but significantly lower than scores for the group deployed to the Gulf theater. Thus, activation by itself did not seem to account for psychological symptom levels, which were connected specifically to deployment to the Gulf (Marlowe, 1995~.
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From page 105... ...
Factors Increasing Vulnerability to PTSD and Other Psychiatric Disorders Although combat exposure has a strong influence on development of PTSD, the majority of troops exposed to combat or other major stressors did not develop PTSD. Thus, assessment of vulnerability may aid understanding of how to prevent or attenuate the likelihood of developing PTSD.
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From page 106... ...
(WRAIR, 1992~. As identified by active duty troops deployed to the Gulf from Pennsylvania and Hawaii, sources of support that were somewhat helpful included family, friends, chaplains, and unit members.
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From page 107... ...
This was the case when demographic factors such as age, rank, education, marital status, and branch of services were controlled (Stretch et al., 1 9951. An algorithm of physical and psychological symptoms was calculated as a proxy indicator for Gulf War Syndrome (GWS)
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From page 108... ...
When all health symptoms were included in a regression model, anxiety and PTSD were significant predictors of health symptoms, but combat exposure was not. Of interest is that PTSD symptoms of emotional numbing and physiologic hyperarousal were significantly related to the number of health symptoms reported.
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From page 109... ...
Discussion of Mental Health Issues In addition to the literature reviewed above, the committee discussed several psychosocial variables that could influence the incidence of unexplained illnesses among POW veterans. These included the role of suggestion in shaping symptoms and the role of concerns regarding health care.
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From page 110... ...
However, this also meant that having a diagnosis did not guarantee treatment if the illness was not considered service connected, especially for reserve and National Guard troops who were left to prove the connection. Some persons suggested to the committee that certain known syndromes and physical illnesses could explain some veterans' undiagnosed illnesses.
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From page 111... ...
Issues of leadership or management and training raised by having women serve with men in combat roles also may have significant health effects. Health consequences of combat service for women, gender differences in health, and health issues related to men and women serving in combat situations are all considerations in our recommendations for further action.
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From page 112... ...
Women deployed to the PGW reported significantly more general and gender-specific health problems than those deployed elsewhere. Common health problems included skin rash, cough, depression, unintentional weight loss, insomnia, and memory problems.
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From page 113... ...
Precombat-abused male veterans did not differ from the nonabused in PTSD symptoms (Engel et al., 19939. Still another study of reserve troops found no overall gender differences in PTSD indicators (Mississippi PTSD Scale, Beck Depression Inventory, and SCL-90-R)
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From page 114... ...
One study of women and men immediately after their return from the Gulf demonstrated that both women and men experienced war zone stress related to combat exposure. No significant gender differences in the Lauder combat scores (describing the kinds of combat stressors to which people were exposed)
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From page 115... ...
, commanders, and family support personnel from National Guard and reserve forces; by using participant observation in selected units; and by examining cultural artifacts such as documents, journals, and newspapers. This research involved interviewing in great detail this nonrandomly selected small group of individuals in a very open-ended fashion.
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From page 116... ...
(1993) found that precombat abuse led to higher rates of PTSD symptoms in female POW veterans and that deployed women with a prior history of abuse had greater PTSD symptomatology than those without a history of abuse.
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