Clare M. Mahan

Illnesses among United States veterans of the Gulf War: a population-based survey of 30,000 veterans.

Despite numerous studies on veterans of the 1990 to 1991 Gulf War, the fundamental questions of how healthy they are and how their health compares with that of their military peers who were not deployed to the Gulf have not been fully answered. We conducted a health survey in which the health outcomes of a population-based sample of 15,000 Gulf veterans representing various military branches and unit components (regular, reserve, National Guard) were compared with those of 15,000 non-Gulf veterans who were randomly sampled to mirror the number in the same military strata in the Gulf veteran group. In comparison with their peers, Gulf veterans had a higher prevalence of functional impairment, health care utilization, symptoms, and medical conditions and a higher rate of low general health perceptions. A longitudinal follow-up of the health of these veterans will be needed to detect changes in health status and to detect diseases with a long latency period.

Health of US veterans of 1991 Gulf War: a follow-up survey in 10 years.

Objective: To assess periodically the health status of a cohort of 1991 Gulf War veterans by comparing various health outcomes with those of their military peers who were not deployed to the Gulf. Methods: We conducted a follow-up health survey to collect health information among population-based samples of 30,000 veterans (15,000 Gulf War veterans and 15,000 Gulf Era veterans) using a structured questionnaire. Results: Gulf veterans reported significantly higher rates of unexplained multi-symptom illness, chronic fatigue syndrome-like illness, posttraumatic stress disorder, functional impairment, health care utilization, a majority of selected physical conditions and all mental disorders queried during the survey than did Gulf Era veteran controls. Conclusions: Fourteen years after deployment, 1991 Gulf War veterans continue to report a higher prevalence of many adverse health outcomes, compared with Gulf Era veterans.

Vital status ascertainment through the files of the Department of Veterans Affairs and the Social Security Administration

Veterans of US military service are a valuable resource for epidemiologic studies, and the Department of Veterans Affairs (VA) files provide an effective way to gather mortality information on veterans, so long as these files provide reasonably complete death reporting. To determine the completeness of VA death reporting, we assembled an independent sample of known veteran deaths among males born between 1936 and 1955 and assessed the performance of VA death reporting in this sample. We also compared VA death ascertainment to Social Security Administration (SSA) ascertainment. Based on the more than 4300 deaths in our study, we found VA death reporting to be approximately 90% complete by itself and 96% complete when used in conjunction with SSA death reporting. In addition, we found no evidence that VA death reporting changed substantially after passage of the Omnibus Budget Reconciliation Act of 1981, which limited eligibility for VA death benefits. Because veterans make up a large segment of the US population, our findings have particular relevance for studies in which mortality is a primary end point.

The Gulf War era multiple sclerosis cohort: age and incidence rates by race, sex and service

We characterize here a new nationwide incident cohort of multiple sclerosis from the US military-veteran population. This cohort provides an update to the only other US nationwide incidence study of multiple sclerosis performed during the 1970s. Medical records and data from the Department of Defense and Department of Veterans Affairs for cases of multiple sclerosis who served in the military between 1990, the start of the Gulf War era, and 2007 and who were service-connected for this disorder by the Department of Veterans Affairs from 1990 on, were reviewed. A total of 2691 patients were confirmed as having multiple sclerosis: 2288 definite, 190 possible, 207 clinically isolated syndrome and six neuromyelitis optica. Overall racial categories were White, Black and other, which included all Hispanics. There were 1278 White males and 556 females; 360 Black males and 296 females; and 200 others, 153 (77%) of whom were Hispanic. Mean age at onset of 30.7 years did not differ significantly by race or sex. Age at onset was 17-50 years in 99%, the same age range as 99% of the military. Average annual age specific (age 17-50 years) incidence rates per 100 000 for the entire series were 9.6 with 95% confidence interval of 9.3-10.0. Rates for Blacks were highest at 12.1 with confidence interval 11.2-13.1, Whites were 9.3 (interval 8.9-9.8) and others 6.9 (interval 6.0-7.9). For 83 Hispanics defined for 2000-07, the rate was 8.2 (interval 6.5-10.1). Much smaller numbers gave rates of 3.3 for Asian/Pacific Islanders and 3.1 for native Americans. Rates by sex for Whites were 7.3 and 25.8 male and female, respectively, for Blacks 8.4 and 26.3, and for Hispanics 6.6 and 17.0. Rates by service were high for Air Force (10.9) and Army (10.6), medium for Navy (9.1) and Coast Guard (7.9), and low for Marines (5.3). Relative risk of multiple sclerosis was 3.39 female:male and 1.27 Black:White. These new findings indicate that females of all races now have incidence rates for multiple sclerosis some three times those of their male counterparts and that among these groups, Blacks have the highest and others (probably including Hispanics) the lowest incidence rates regardless of sex or service. The low rate for Marines is unexplained. This Gulf War era multiple sclerosis cohort provides a unique resource for further study.

Evidence for a Deployment-Related Gulf War Syndrome by Factor Analysis

Abstract To identify a syndrome unique to Gulf War veterans, the authors applied an exploratory factor analysis to the 47-symptom correlation matrix of 10,423 Gulf War and 8,960 non-Gulf War veteran respondents. A separate factor analysis was performed for Gulf War and non-Gulf War veterans, and the resulting 6 factors were compared between the 2 groups. Five of the factors were very similar in the 2 groups; however, 1 of the factors in the Gulf War group, but not the non-Gulf War group, contained a cluster of symptoms consistent with neurological impairment. Symptoms specific to this factor were blurred vision, loss of balance/dizziness, tremors/shaking, and speech difficulty. The Gulf War veterans who had all of the aforementioned symptoms (n = 277) also reported exposures to several putative risk factors at a rate 3 or more times higher than other Gulf War veterans. This finding suggests a possible syndrome related to Gulf War deployment, which requires objective supporting clinical evidence.

Mortality in US Army Gulf War Veterans Exposed to 1991 Khamisiyah Chemical Munitions Destruction

OBJECTIVES We investigated whether US Army Gulf War veterans who were potentially exposed to nerve agents during the March 1991 weapons demolitions at Khamisiyah, Iraq, are at increased risk of cause-specific mortality. METHODS The cause-specific mortality of 100487 exposed US Army Gulf War veterans was compared with that of 224980 unexposed US Army Gulf War veterans. Exposure was determined with the Department of Defense 2000 plume model. Relative risk estimates were derived from Cox proportional hazards models. RESULTS The risks of most disease-related mortality were similar for exposed and unexposed veterans. However, exposed veterans had an increased risk of brain cancer deaths (relative risk [RR]=1.94; 95% confidence interval [CI]=1.12, 3.34). The risk of brain cancer death was larger among those exposed 2 or more days than those exposed 1 day when both were compared separately to all unexposed veterans (RR=3.26; 95% CI=1.33, 7.96; RR=1.72; 95% CI=0.95,3.10, respectively). CONCLUSIONS Exposure to chemical munitions at Khamisiyah may be associated with an increased risk of brain cancer death. Additional research is required to confirm this finding.

Longitudinal Health Study of US 1991 Gulf War Veterans: Changes in Health Status at 10-Year Follow-up

The authors assessed changes in the health status of US 1991 Gulf War-era veterans from a 1995 baseline survey to a 2005 follow-up survey, using repeated measurement data from 5,469 deployed Gulf War veterans and 3,353 nondeployed Gulf War-era veterans who participated in both surveys. Prevalence differences in health status between the 2 surveys were estimated for adverse health indices and chronic diseases for each veteran group. Persistence risk ratios and incidence risk ratios were calculated after adjustment for demographic and military service characteristics through Mantel-Haenszel stratified analysis. At 10-year follow-up, deployed veterans were more likely to report persistent poor health, as measured by the health indices (functional impairment, limitation of activities, repeated clinic visits, recurrent hospitalizations, perception of health as fair or poor, chronic fatigue syndrome-like illness, and posttraumatic stress disorder), than nondeployed veterans. Additionally, deployed veterans were more likely to experience new onset of adverse health (as measured by the indices) and certain chronic diseases than were nondeployed veterans. During the 10-year period from 1995 to 2005, the health of deployed veterans worsened in comparison with nondeployed veterans because of a higher rate of new onset of various health outcomes and greater persistence of previously reported adverse health on the indices.

Health effects in army gulf war veterans possibly exposed to chemical munitions destruction at khamisiyah, Iraq: Part I. Morbidity associated with potential exposure

In March 1991, U.S. troops detonated the Khamisiyah, Iraq, ammunition depot, possibly releasing two chemical warfare agents, sarin and cyclosarin. The long-term health effects associated with possible exposure to these chemical warfare agents are unknown. This study was undertaken to investigate whether possible exposure was associated with morbidity among Army Gulf War veterans using morbidity data for 5,555 Army veterans who were deployed to the Gulf region. Responses to 86 self-assessed health measures, as reported in the 1995 Department of Veterans Affairs National Health Survey of Gulf War Era Veterans, were evaluated. We found little association between potential exposure and health, after adjustment for demographic variables, and conclude that potential exposure to sarin or cyclosarin at Khamisiyah does not seem to have adversely affected self-perceived health status, as evidenced by a wide range of health measures.

Cancer mortality among the highest exposed US atmospheric nuclear test participants

Of the estimated 205,000 military personnel who participated in the US atmospheric nuclear weapons testing program from 1945 to 1962, less than 1% had ionizing radiation doses that met or exceeded the current federal occupational guideline for dose of 5 rem (roentgen equivalents in humans) in a 12-month period. The objective of this study was to determine whether veterans who received the highest gamma radiation doses (n = 1010) have experienced increased cancer mortality compared with a group of Navy veterans who received a minimal radiation dose as participants of HARDTACK I (n = 2870). Mortality from all causes of death (relative risk, 1.22; 95% confidence interval, 1.04 to 1.44) and from all lymphopoietic cancers (relative risk, 3.72; 95% confidence interval, 1.28 to 10.83) was significantly elevated among the 5-rem cohort compared with the Navy controls. The lack of statistically significant excesses in deaths from many of the known radiogenic cancers suggests that the observed excess mortality may be the result of many factors, of which radiation exposure was only one.

Selected Health Conditions Among Overweight, Obese, and Non-Obese Veterans of the 1991 Gulf War: Results from a Survey Conducted in 2003- 2005

BACKGROUND: Several health conditions and concerns have been reported to be increased among Gulf War veterans including post-traumatic stress disorder (PTSD), chronic fatigue syndrome (CFS), CFS-like illness, and unexplained multi-symptom illness (MSI). As the cohort of Gulf War veterans advance in age, they are likely to be at risk of not only certain deployment-related health conditions but also chronic diseases associated with lifestyle factors. METHODS: To clarify relationships between PTSD, CFS-like illness, MSI, and obesity, we analyzed data from a cross-sectional survey of health information among population-based samples of 15,000 Gulf War veterans and 15,000 veterans who served during the same era. Data had been collected from 9,970 respondents in 2003-2005 via a structured questionnaire or telephone survey. RESULTS: Based upon body mass index (BMI) estimated from self-reported information about height and weight, the percentages of Gulf War and Gulf Era veterans who were overweight (BMI 25 to ≤ 29.9), were 46.8% and 48.7%, respectively. The percentages who were obese (BMI ≥ 30) were 29.6% and 28.3%, respectively. Without adjustment for Gulf deployment status (Gulf War vs Gulf Era), age, sex, or other factors, PTSD, MSI, CFS-like illness, and other chronic health conditions were more common among obese veterans than those who were normal weight (BMI 18.5 to ≤ 24.9). In multivariate analyses, PTSD was positively associated with obesity after adjustment for age, sex, Gulf deployment status, rank, income, education, and current smoking. In the model for PTSD, the adjusted odds ratio for obesity was 1.5 (95% CI 1.2-1.8). No associations were observed between BMI categories and CFS-like illness or MSI in multivariate analysis. CONCLUSIONS: Gulf War and Gulf Era veterans who were obese were more likely to have certain chronic health conditions including PTSD. Associations between Gulf status and CFS-like illness and MSI identified in the 2003-2005 follow-up survey were not accounted for by group differences in the prevalence of overweight or obesity.