Amyotrophic Lateral Sclerosis in Veterans: Review of the Scientific Literature

Committee on the Review of the Scientific Literature on Amyotrophic Lateral Sclerosis in Veterans

Board on Population Health and Public Health Practice

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
www.nap.edu



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Amyotrophic Lateral Sclerosis in Veterans: Review of the Scientific Literature Amyotrophic Lateral Sclerosis in Veterans: Review of the Scientific Literature Committee on the Review of the Scientific Literature on Amyotrophic Lateral Sclerosis in Veterans Board on Population Health and Public Health Practice INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Amyotrophic Lateral Sclerosis in Veterans: Review of the Scientific Literature THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract V101(93)P-1637, Task Order 25 and Task Order 30, between the National Academy of Sciences and the Department of Veterans Affairs. Any opinions, findings, or conclusions expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-10: 0-309-10254-5 International Standard Book Number-13: 978-0-309-10254-4 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624–6242 or (202) 334–3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2006 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Amyotrophic Lateral Sclerosis in Veterans: Review of the Scientific Literature “Knowing is not enough; we apply, Willing is not we do.” —Goethe INSTITUTE MEDICINE OF OF THE NATIONAL ACADEMIES Advising the Nation. Improving Health.

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Amyotrophic Lateral Sclerosis in Veterans: Review of the Scientific Literature THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J.Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A.Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V.Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J.Cicerone and Dr. Wm. A.Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Amyotrophic Lateral Sclerosis in Veterans: Review of the Scientific Literature COMMITTEE ON THE REVIEW OF THE SCIENTIFIC LITERATURE ON AMYOTROPHIC LATERAL SCLEROSIS IN VETERANS RICHARD T.JOHNSON, MD (Chair), Distinguished Service Professor of Neurology, Microbiology, and Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD WALTER G.BRADLEY, DM, FRCP, Professor and Chair, Department of Neurology, Miller School of Medicine at the University of Miami, FL BEATE R.RITZ, MD, PhD, MPH, Professor and Vice Chair, Department of Epidemiology, University of California, Los Angeles School of Public Health, Los Angeles WALTER A.ROCCA, MD, MPH, Professor of Epidemiology and Neurology, Mayo Clinic College of Medicine, Rochester, MN JEREMY M.SHEFNER, MD, PhD, Professor and Chair, Department of Neurology, State University of New York, Upstate Medical University, Syracuse CHRISTINA WOLFSON, PhD, Professor of Epidemiology and Biostatistics, McGill University, Montreal, Canada STAFF ABIGAIL MITCHELL, PhD, Senior Program Officer MICHAEL SCHNEIDER, MPH, Senior Program Associate DEEPALI PATEL, Senior Program Associate PETER JAMES, Research Associate DAMIKA WEBB, Research Assistant RENEE WLODARCZYK, Program Assistant NORMAN GROSSBLATT, Senior Editor ROSE MARIE MARTINEZ, ScD, Director, Board on Population Health and Public Health Practice

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Amyotrophic Lateral Sclerosis in Veterans: Review of the Scientific Literature REVIEWERS This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards of objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following for their review of this report: CARMEL ARMON, MD, MSC, MHS, Tufts University and Baystate Medical Center, Boston, MA CARLO DELUCA, PHD, Neuromuscular Research Center, Boston University, MA LAWRENCE GOLDSTEIN, PHD, Department of Cellular and Molecular Medicine, University of California, San Diego and Howard Hughes Medical Institute CLIFTON L.GOOCH, MD, EMG Laboratory of New York Presbyterian Hospital and Columbia Neuropathy Research Center, Columbia University College of Physicians and Surgeons, NY FREYA KAMEL, MD, MPH, National Institute of Environmental Health Sciences, Research Triangle Park, NC LORENE NELSON, PHD, Department of Health Research and Policy, Stanford University, CA M.DONALD WHORTON, MD, MPH, Executive Vice President and Epidemiologist, WorkCare, Inc., Alameda, CA Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Elena Nightingale, Scholar-in-Residence, Institute of Medicine. Appointed by the National Research Council, she was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the author committee and the institution.

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Amyotrophic Lateral Sclerosis in Veterans: Review of the Scientific Literature CONTENTS     Summary   1      Methodology   2      Conclusion   3      Recommendations   4 1   Introduction   7      The Department of Veterans Affairs Request for This Study and the Statement of Task   8      Previous Institute of Medicine Work on Veterans’ Issues   9      The Committee’s Approach to Its Charge   10      Categories of Association   11      Origin and Evolution of the Categories   11      Sufficient Evidence of a Causal Relationship   12      Sufficient Evidence of an Association   12      Limited and Suggestive Evidence of an Association   12      Inadequate or Insufficient Evidence to Determine Whether an Association Exists   13      Limited and Suggestive Evidence of No Association   13      Organization of the Report   13      References   13 2   Evidence Regarding Amyotrophic Lateral Sclerosis in Veterans   19      Studies on Amyotrophic Lateral Sclerosis in the Veteran Population   19      Smith et al. 2000   26      Kang and Bullman 2001   27      Haley 2003   28      Horner et al. 2003 and Coffman et al. 2005   29      Weisskopf et al. 2005   32      Conclusion   34      References   35

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Amyotrophic Lateral Sclerosis in Veterans: Review of the Scientific Literature 3   Recommendations   37      Recommendation 1: Use Data from Other Epidemiologic Studies   37      Recommendation 2: In-Depth Analysis of Existing Risk-Factor Studies   39      Recommendation 3: Conduct Additional Epidemiologic Studies of the Association Between Military Service and Amyotrophic Lateral Sclerosis   40      References   41 A   Examples of Risk Factors Possibly Relevant to Military Service   43      Physical Activity   43      Cigarette-Smoking and Alcohol Consumption   44      Trauma   45      Transmissible Agents   46      Lead   47      Pesticides   48      Environmental Toxicants   48      References   48 B   Possible Conceptual Models Linking Military Service and Amyotrophic Lateral Sclerosis   53