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Introduction

The 1991 Persian Gulf War was largely considered a brief and successful military operation with few casualties, but veterans returning from the war theater reported health problems that they attributed to exposures during their service in the war. Commonly reported symptoms included fatigue, sleep disturbance, and cognitive difficulties.

The United States has since engaged in other conflicts in the Persian Gulf region, including the Iraq War (Operation Iraqi Freedom). The Iraq War began in March 2003 with the arrival of US and British troops in Iraq. Although major combat operations ended in May 2003, US and coalition troops continue to be deployed to Iraq to fight the insurgency and to assist in reconstruction efforts. About 1.5 million US troops have been deployed to Operation Iraqi Freedom and to Operation Enduring Freedom in Afghanistan (PCCWW, 2007).

Exposure to depleted uranium (DU) is of concern for active duty and veteran populations because it is used by the US military in the war theater. Exposure to DU can occur as a result of friendly-fire incidents, cleanup operations, and accidents. In recent conflicts, exposure to DU was a concern to veterans participating in a retrospective review of veterans’ health and exposure concerns (Helmer et al., 2007).

Section 716 of the 2007 John Warner National Defense Authorization Act mandated that the Department of Defense (DOD), the Department of Veterans Affairs (VA), and the Department of Health and Human Services “conduct a comprehensive study of the health effects of exposure to depleted uranium munitions on uranium-exposed soldiers and on children of uranium-exposed soldiers who were born after the exposure of the uranium-exposed soldiers to depleted uranium.” In response, DOD requested guidance from the Institute of Medicine



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1 Introduction The 1991 Persian Gulf War was largely considered a brief and successful military operation with few casualties, but veterans returning from the war theater reported health problems that they attributed to exposures during their service in the war. Commonly reported symptoms included fatigue, sleep disturbance, and cognitive difficulties. The United States has since engaged in other conflicts in the Persian Gulf region, including the Iraq War (Operation Iraqi Freedom). The Iraq War began in March 2003 with the arrival of US and British troops in Iraq. Although major combat operations ended in May 2003, US and coalition troops continue to be deployed to Iraq to fight the insurgency and to assist in reconstruction efforts. About 1.5 million US troops have been deployed to Operation Iraqi Freedom and to Operation Enduring Freedom in Afghanistan (PCCWW, 2007). Exposure to depleted uranium (DU) is of concern for active duty and veteran populations because it is used by the US military in the war theater. Exposure to DU can occur as a result of friendly-fire incidents, cleanup operations, and acci- dents. In recent conflicts, exposure to DU was a concern to veterans participating in a retrospective review of veterans’ health and exposure concerns (Helmer et al., 2007). Section 716 of the 2007 John Warner National Defense Authorization Act mandated that the Department of Defense (DOD), the Department of Veterans Affairs (VA), and the Department of Health and Human Services “conduct a comprehensive study of the health effects of exposure to depleted uranium muni- tions on uranium-exposed soldiers and on children of uranium-exposed soldiers who were born after the exposure of the uranium-exposed soldiers to depleted uranium.” In response, DOD requested guidance from the Institute of Medicine 

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 FEASIBILITY AND DESIGN OF STUDIES OF DU-EXPOSED VETERANS (IOM) in evaluating the feasibility and design of an epidemiologic study that would assess health outcomes related to exposure to DU. THE COMMITTEE’S TASK In response to DOD’s request, IOM entered into a contract to conduct the following study: An IOM committee will examine and make recommendations regarding the critical elements needed for an epidemiologic study of veterans who were exposed to DU while on active duty. Those might include veterans who • were exposed to smoke from fires resulting from the burning of vehicles containing DU munitions or fires at depots at which DU munitions were stored, • worked in environments containing DU dust or residue from DU munitions, • were within a structure or vehicle when it was struck by DU munitions, • climbed on or entered equipment or structures struck by DU munitions, or • were medical personnel who provided initial treatment to members of the armed forces who were exposed to DU. The committee also will identify elements needed to study veterans’ children who were born after parental exposure to DU. THE COMMITTEE’S APPROACH TO ITS TASK To approach its task, the committee first considered the necessary elements of a comprehensive epidemiologic study to assess exposure to DU and related health outcomes. The committee then evaluated DOD’s available data and re- search efforts and identified limitations and data gaps in the databases. Finally, it identified options for further study of potential health outcomes in DU-exposed military personnel and veterans. The committee views a well-designed epidemiologic study as a two-stage process. The first stage is a comprehensive assessment of exposure to DU that permits identification of the exposed and unexposed components of the study population. The second stage should incorporate the exposure information into a prospective study to assess intermediate health outcomes and ultimately the relationship of exposure to the health outcomes of interest (see Figure 1-1). Regarding the first stage, the committee offers recommendations for ad- dressing the major gaps in available exposure information and provides guid- ance for assessing exposure of active-duty personnel and veterans to DU. The exposure-investigation stage of the process is instrumental in identifying study

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 INTRODUCTION Stage II: Stage I: Exposure Assessment Outcome Assessment Comparison of Intermediate Exposed and Individual- Health Outcomes and Disease Unexposed Study Level Exposure Among Exposed and Unexposed Populations Study Populations FIGURE 1-1 Stages of an epidemiologic study of DU exposure. populations for an epidemiologic study that includes comparison groups. A well- conducted and comprehensive exposure assessment feeds into the second stage of an epidemiologic study, the outcome assessment, which is designed to understand exposure as it is related to a health effect or disease. During the second stage, the occurrence of the health outcome in the population of interest is assessed, and appropriate statistical analyses are conducted to determine whether there is a potential association between exposure to DU and development of the outcome. Accurate exposure information is critical in this evaluation. ORGANIZATION OF THE REPORT Chapter 2 of the report describes critical elements needed to conduct an epidemiologic study of DU. Chapter 3 provides a review of DOD’s available databases and identifies gaps in and limitations of the databases. Chapter 4 lays out options for further study of potential health outcomes in DU-exposed military personnel and veterans and provides several additional recommendations. REFERENCES Helmer, D. A., M. Rossignol, M. Blatt, R. Agarwal, R. Teichman, and G. Lange. 2007. Health and exposure concerns of veterans deployed to Iraq and Afghanistan. Journal of Occupational and Environmental Medicine 49(5):475-480.

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 FEASIBILITY AND DESIGN OF STUDIES OF DU-EXPOSED VETERANS PCCWW (Report of the President’s Commission on Care for America’s Returning Wounded War- riors). 2007. Report of the president’s commission on care for America’s returning wounded warriors report. http://www.pccww.gov/ (accessed October 13, 2007).