Tim A. Bullman

Mortality among U.S. veterans of the Persian Gulf War.

BACKGROUND Since the 1990-1991 Persian Gulf War, there has been persistent concern that U.S. war veterans may have had adverse health consequences, including higher-than-normal mortality. METHODS We conducted a retrospective cohort study of postwar mortality according to cause among 695,516 Gulf War veterans and 746,291 other veterans. The follow-up continued through September 1993. A stratified, multivariate analysis (with Cox proportional-hazards models) controlled for branch of service, type of unit, age, sex, and race in comparing the two groups. We used standardized mortality ratios to compare the groups of veterans with the general population of the United States. RESULTS Among the Gulf War veterans, there was a small but significant excess of deaths as compared with the veterans who did not serve in the Persian Gulf (adjusted rate ratio, 1.09; 95 percent confidence interval, 1.01 to 1.16). The excess deaths were mainly caused by accidents (1.25; 1.13 to 1.39) rather than disease (0.88; 0.77 to 1.02). The corresponding rate ratios among 49,919 female veterans of the Gulf War were 1.32 (0.95 to 1.83) for death from all causes, 1.83 (1.02 to 3.28) for accidental death, and 0.89 (0.45 to 1.78) for death from disease. In both groups of veterans the mortality rates were significantly lower overall than those in the general population. The adjusted standardized mortality ratios were 0.44 (95 percent confidence interval, 0.42 to 0.47) for Gulf War veterans and 0.38 (0.36 to 0.40) for other veterans. CONCLUSIONS Among veterans of the Persian Gulf War, there was a significantly higher mortality rate than among veterans deployed elsewhere, but most of the increase was due to accidents rather than disease, a finding consistent with patterns of postwar mortality among veterans of previous wars.

Posttraumatic stress disorder and the risk of traumatic deaths among Vietnam veterans

Vietnam veterans have been reported to be at increased risk for posttraumatic stress disorder (PTSD) and deaths due to traumatic causes after service in the Vietnam War. This study evaluated whether an association exists between PTSD and traumatic deaths among Vietnam veterans. Mortality risk of 4,247 Vietnam veterans from the Agent Orange Registry (AOR) with a diagnosis of PTSD relative to that of 12,010 Vietnam veterans from the AOR with no diagnosis of PTSD was calculated using the Cox proportional hazards model. Mortality experience of both groups was also compared with U.S. males. The PTSD veterans were more likely than the non-PTSD veterans to die from suicide (relative risk = 3.97, 95% confidence interval [Cl] = 2.20–7.03) and from accidental poisoning (relative risk = 2.89, CI = 1.03–8.12). The standardized mortality ratio for suicides was 6.74 (CI = 4.4–9.87) among PTSD veterans and 1.67 (CI = 1.05–2.53) among non-PTSD veterans. Among Vietnam veterans on the AOR, PTSD is associated with a significant increased risk for suicide and accidental poisoning.

Is There an Epidemic of Suicides among Current and Former U.S. Military Personnel

Recently, there have been reports in the news media of increased risk of suicide among current and former U.S. military personnel, particularly those who are serving or have served in either Afghanistan or Iraq, as part of Operations Enduring Freedom or Iraqi Freedom (OEF/OIF) (1). This review examines relevant published studies and government reports that address suicide among current and former U.S. military and summarizes literature of suicide among the general population to provide some context.

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.

A Fifty Year Mortality Follow-up Study of Veterans Exposed to Low Level Chemical Warfare Agent, Mustard Gas

PURPOSE To determine if there is an increased risk of any cause specific mortality associated with low level mustard gas exposure among World War II Navy veterans. METHODS A retrospective mortality follow-up study was conducted comparing the mortality of World War II Navy veterans who received low-level non-lethal exposures of mustard gas to that of World War II Navy veterans who were not exposed. This study identified 1545 Navy recruits stationed at Bainbridge, Maryland, between 1944-1945, who voluntarily participated in mustard gas chamber tests. These veterans were exposed to mustard gas while wearing protective clothing and masks. Control veterans consisted of 2663 Navy veterans who served at the same location and time as the exposed, but did not participate in chamber tests. Cause specific mortality risks associated with mustard gas exposure and level of mustard gas exposure were examined using adjusted and unadjusted relative risk estimates. RESULTS There was no excess of any cause specific mortality associated with varying levels of mustard gas exposures among Navy veterans subject to the chamber tests. CONCLUSIONS The levels of mustard gas exposures experienced by World War II veterans, which were sufficient to cause skin reactions (erythema, vesicles, and ulceration), were not associated with any increased risk of cause specific mortality.

Neurological mortality among U.S. veterans of the Persian Gulf War: 13-year follow-up

BACKGROUND This study focuses on long-term mortality, specifically brain cancer, amyotrophic lateral sclerosis (ALS), Parkinsons disease, and multiple sclerosis (MS) of 621,902 veterans who served in the 1990-1991 Persian Gulf War (GW), and 746,248 non-GW veterans. METHODS Follow-up began with the date the veteran left the GW theater or May 1, 1991 and ended with the date of death or December 31, 2004. Cox proportional hazard models were used for analyses. RESULTS Adjusted mortality rate ratios (aRR) of GW veterans compared to non-GW veterans were not statistically significant for brain cancer (aRR = 0.90, 95% confidence interval (CI): 0.73, 1.11), MS (aRR = 0.61, 95% CI: 0.23, 1.63), Parkinsons disease (aRR = 0.71, 95% CI: 0.17, 2.99), or ALS (aRR = 0.96, 95% CI: 0.56, 1.62). GW veterans potentially exposed to nerve agents for 2 or more days and GW veterans exposed to oil well fire smoke were at increased risk for brain cancer mortality (aRR = 2.71, 95% CI: 1.25, 5.87; aRR = 1.81, 95% CI: 1.00, 3.27; respectively). CONCLUSIONS The risk of death due to ALS, MS, Parkinsons disease, and brain cancer was not associated with 1991 GW service in general. However, GW veterans potentially exposed to nerve agents at Khamisiyah, Iraq, and to oil well fire smoke had an increased risk of mortality due to brain cancer.

Risk of testicular cancer associated with surrogate measures of Agent Orange exposure among Vietnam veterans on the Agent Orange Registry.

A case-control analysis was undertaken to examine the association between various surrogate measures of Agent Orange exposure and testicular cancer among Vietnam veterans. Study subjects were selected from the Department of Veterans Affairs Agent Orange Registry. The case patients consisted of 97 veterans with a diagnosis of testicular cancer, and 311 veterans without any clinical diagnosis served as a comparison group. The surrogate measures were branch of service, type of duty, corps area, and location of the individuals unit in relation to recorded Agent Orange spray tracts. Only Navy veterans had a statistically significant increased risk of testicular cancer (odds ratio (OR) = 2.60; 95% confidence interval (CI), 1.08 to 6.24). Risk of testicular cancer was not significantly increased for ground troops (OR = 0.46; 95% CI, 0.25 to 0.86), for combat duty (OR = 0.91; 95% CI, 0.52 to 1.58), for service in the III Corps area (OR = 1.10; 95% CI, 0.66 to 1.84), and for being close to spray tracts within 90 days/8 km (OR = 0.99; 95% CI, 0.54 to 1.84) or 3 days/2 km (OR = 1.39; 95% CI, 0.50 to 3.80). The study results are not consistent with the hypothesis that Agent Orange may be a risk factor for testicular cancer among Vietnam veterans.

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.

Posttraumatic stress disorder among Vietnam veterans on the agent orange registry a case-control analysis

Some of the readjustment problems of Vietnam veterans have been attributed to posttraumatic stress disorder (PTSD). This case-control study compared demographic and military characteristics of 374 Vietnam veterans who had PTSD with 373 healthy Vietnam veterans. Veterans were chosen from the Agent Orange Registry, a Department of Veterans Affairs computerized database of approximately 200,000 Vietnam veterans who volunteered for a physical examination. Case patients and control subjects were frequently-matched by age, year of Registry examination, and race. Crude odds ratios (OR) were used to evaluate the risk of PTSD associated with certain characteristics of Vietnam service, as there was no apparent confounding by other military factors. Being wounded in Vietnam (OR, 2.33; 95% confidence interval (CI), 1.49-3.65) and having a combat job in Vietnam (OR, 1.54; 95% CI, 1.15-2.06) were the only risk factors for PTSD. Those who had noncombat jobs but were wounded had the highest risk of PTSD (OR, 3.56; 95% CI, 1.26-10.06).

Findings From the Department of Veterans Affairs Qarmat Ali Medical Surveillance Program.

OBJECTIVE To review the Veterans Affairs (VA) medical surveillance program for Veterans with potential hexavalent chromium (CrVI) exposure that occurred during 2003. METHODS Retrospective review of medical records of the 124 Veterans that participated in standardized, in-person clinical evaluations for possible CrVI exposure during the incident in question. The evaluations were reviewed to define population level effects. In addition, a mortality analysis was conducted for the 808 unique personal identifiers available to Veterans Health Administration. RESULTS Mean reported number of days exposed was 21 (median 10). A history of respiratory (n = 78) and skin (n = 38) symptoms were reported during the period of exposure. No abnormalities that were specific to chromium exposure (e.g., nasal septum perforation) were found. Eight deaths occurred between 2005 and 2012. CONCLUSIONS The lack of severe nasal abnormalities in the VA evaluations supports a time-limited peak exposure. However, the overall low participation rate (15%) severely compromises any ability to generalize to the entire potentially exposed population. Regardless, since the actual level of exposure to CrVI will never be known with certainty, the VA will continue to monitor these Veterans with periodic evaluations to identify and manage any pathologic findings that might be associated with past CrVI exposure.