Categories of Association

The committee attempted to express its judgment of the available data clearly and precisely. It agreed to use the categories of association that have been established and used by previous Committees on Gulf War and Health and other IOM committees that have evaluated vaccine safety, effects of herbicides used in Vietnam, and indoor pollutants related to asthma. Those categories of association have gained wide acceptance over more than a decade by Congress, government agencies (particularly VA), researchers, and veterans groups.

The five categories below describe different levels of association and present a common message: the validity of an observed association is likely to vary with the extent to which common sources of spurious associations could be ruled out as the reason for the association. Accordingly, the criteria for each category express a degree of confidence based on the extent to which sources of error were reduced. The committee members read each of each the studies carefully, noted the studies’ findings and limitations, and discussed the classification of each study (primary or secondary) in plenary session. The committee then discussed the weight of the evidence and reached consensus on the categorization of association to be assigned for each health outcome considered in this report.

Sufficient Evidence of a Causal Relationship

Evidence is sufficient to conclude that a causal relationship exists between being deployed to the Gulf War and a health outcome. The evidence fulfills the criteria for sufficient evidence of a causal association in which chance, bias, and confounding can be ruled out with reasonable confidence. The association is supported by several of the other considerations used to assess causality: strength of association, dose-response relationship, consistency of association, temporal relationship, specificity of association, and biologic plausibility.

Sufficient Evidence of an Association

Evidence suggests an association, in that a positive association has been observed between deployment to the Gulf War and a health outcome in humans; however, there is some doubt as to the influence of chance, bias, and confounding.

Limited/Suggestive Evidence of an Association

Some evidence of an association between deployment to the Gulf War and a health outcome in humans exists, but this is limited by the presence of substantial doubt regarding chance, bias, and confounding.

Inadequate/Insufficient Evidence to Determine Whether an Association Exists

The available studies are of insufficient quality, validity, consistency, or statistical power to permit a conclusion regarding the presence or absence of an association between deployment to the Gulf War and a health outcome in humans.

Limited/Suggestive Evidence of No Association

There are several adequate studies, covering the full range of levels of exposure that humans are known to encounter, that are consistent in not showing an association between exposure to a specific agent and a health outcome at any level of exposure. A conclusion of no



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