those who reported exposure to antibiologic warfare prophylaxis, pesticide handling, smoke from oil-well fires, or Scud missiles, versus the self-reported unexposed. Results also indicate that those who handled pesticides and those exposed to depleted uranium were at higher risk of death due to external causes and death due to disease-related causes, respectively; however, neither of these was statistically significant. See Chapter 4 for additional detail.

The Update committee identified two new studies based on the University of London study. Stimpson and colleagues (2006) used the same population and methods described in Unwin et al. (1999) to specifically examine the prevalence of reported pain and its association with deployment status. Ismail and colleagues (2008) assessed the prevalence of chronic fatigue syndrome by implementing a two-phase study approach that was a continuum of the Unwin et al. (1999) (phase I) cohort above. Phase II consisted of a random sampling of the 244 veterans (Gulf War and Bosnia deployed, and era veterans) who screened positive for a physical disability (score less than or equal to 72.2 on the SF-36) in the Unwin study; 111 (45.5%) were Gulf War deployed and 133 (54.5%) were non-Gulf veterans (Bosnia: n = 54, era: n = 79). See Chapter 4 for more detail.

University of Manchester Veteran Study

Seven years after the Gulf War, the University of Manchester study surveyed a random sample of all UK veterans, distinct from that of Unwin et al. (1999), who deployed between September 1990 and June 1991, as indentified by the Ministry of Defense (Cherry et al., 2001a,b). Eligible deployed veterans (n = 9505) were divided into two groups—main cohort (n = 4755) and validation cohort (n = 4750) to permit replication of analysis and to assess consistency. The control population (n = 4749) was nondeployed veterans in good general health. Veterans were sent a questionnaire about the extent to which they were burdened, within the last month, by any of 95 symptoms. By asking them to mark their answers on a visual analogue scale, investigators sought to determine the degree of symptom severity. Investigators also sought to determine areas of peripheral neuropathy by asking veterans to shade body areas on two mannequins in which they were experiencing pain or numbness and tingling. Deployed veterans reported greater symptom severity on almost all symptoms. Findings from this reference study are discussed in Chapter 4.

No derivative studies were identified for this UK cohort in Volume 4 or by the Update committee.

London School of Hygiene and Tropical Medicine Veteran Study
Reference Study

The third United Kingdom study was a very large mail survey that began in August 1998 (with reminders until 2001). It was conducted by researchers from the London School of Hygiene and Tropical Medicine (Maconochie et al., 2003). The study was designed to assess reproductive outcomes among Gulf War veterans and also contained open-ended questions regarding general health. The exposed cohort consisted of all UK Gulf War veterans, and the unexposed cohort consisted of a random sample of nondeployed UK military personnel from the same period. The number of surveys returned in the study was large (25,084 from Gulf War veterans and 19,003 from non-Gulf War veterans); however, the participation rates were low (47.3% and 37.5% of male and female Gulf War veterans, respectively, and 57.3% and 45.6% of male and female nondeployed veterans). The survey included items on reproductive and child health, exposure history, current health, and health of sexual partners; it was supplemented by



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