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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War, 2016. Washington, DC: The National Academies Press. doi: 10.17226/21840.
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GULF WAR and HEALTH

VOLUME 10

Update of Health Effects of
Serving in the Gulf War, 2016

Committee on Gulf War and Health, Volume 10:
Update of Health Effects of Serving in the Gulf War

Board on the Health of Select Populations

Institute of Medicine

Deborah Cory-Slechta and Roberta Wedge, Editors

images

THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War, 2016. Washington, DC: The National Academies Press. doi: 10.17226/21840.
×

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

This study was supported by Contract No. VA241-P-2024 between the National Academy of Sciences and the Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-38041-6
International Standard Book Number-10: 0-309-38041-3
Digital Object Identifier: 10.17226/21840

Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.

Copyright 2016 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2016. Gulf War and health: Volume 10: Update of health effects of serving in the Gulf War, 2016. Washington, DC: The National Academies Press. doi: 10.17226/21840.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War, 2016. Washington, DC: The National Academies Press. doi: 10.17226/21840.
×
Image

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Ralph J. Cicerone is president.

The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president.

The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president.

The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine.

Learn more about the National Academies of Sciences, Engineering, and Medicine at www.national-academies.org.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War, 2016. Washington, DC: The National Academies Press. doi: 10.17226/21840.
×

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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War, 2016. Washington, DC: The National Academies Press. doi: 10.17226/21840.
×

COMMITTEE ON GULF WAR AND HEALTH, VOLUME 10: UPDATE OF HEALTH EFFECTS OF SERVING IN THE GULF WAR

DEBORAH A. CORY-SLECHTA (Chair), Professor of Environmental Medicine, University of Rochester, NY

ROBERT H. BROWN, JR., Chair and Professor of Neurology, University of Massachusetts Medical School

ALBERTO CABAN-MARTINEZ, Assistant Professor, University of Miami Miller School of Medicine, FL

JAVIER I. ESCOBAR, Associate Dean for Global Health, Professor of Psychiatry and Family Medicine, Rutgers Robert Wood Johnson Medical School, NJ

SCOTT FISHMAN, Professor of Anesthesiology and Pain Medicine, Professor of Psychiatry and Behavioral Medicine, Chief, Division of Pain Medicine in Department of Anesthesiology and Pain Medicine, University of California, Davis, School of Medicine

MARY A. FOX, Assistant Professor, Bloomberg School of Public Health, Johns Hopkins University, MD

HERMAN J. GIBB, Consultant, Gibb Epidemiology Consulting, LLC, VA

ROGENE F. HENDERSON, Senior Biochemist and Toxicologist Emeritus, Lovelace Respiratory Research Institute, NM

CLIFFORD JACK, Professor, Diagnostic Radiology, Mayo Clinic, MN

HOWARD M. KIPEN, Professor and Chair (Interim) of Environmental and Occupational Medicine, Acting Associate Director at Environmental and Occupational Health Sciences Institute, and Director of Clinical Research and Occupational Medicine Division at Rutgers School of Public Health, NJ

KENNETH W. KIZER, Director, Institute for Population Heath Improvement, University of California, Davis, Health System, and Distinguished Professor, University of California, Davis, School of Medicine and the Betty Irene Moore School of Nursing

JOEL KRAMER, Professor of Neuropsychology, University of California, San Francisco, School of Medicine

FRANCINE LADEN, Professor of Epidemiology, Harvard School of Public Health, MA

JAMES M. NOBLE, Assistant Professor of Neurology at Columbia University Medical Center, Taub Institute for Research on Alzheimer’s Disease and the Aging Brain and the G.H. Sergievsky Center, Columbia University, NY

ANBESAW SELASSIE, Associate Professor, Department of Public Health Sciences, Medical University of South Carolina

NANCY F. WOODS, Professor of Biobehavioral Nursing and Dean Emeritus, School of Nursing, University of Washington

Study Staff

ROBERTA WEDGE, Study Director

CARY HAVER, Associate Program Officer

ANNE STYKA, Program Officer (from January 2015)

NICOLE FREID, Senior Program Assistant

CHRISTIE BELL, Financial Officer

FREDERICK ERDTMANN, Director, Board on the Health of Select Populations

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War, 2016. Washington, DC: The National Academies Press. doi: 10.17226/21840.
×

This page intentionally left blank.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War, 2016. Washington, DC: The National Academies Press. doi: 10.17226/21840.
×

Reviewers

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. 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 for 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 individuals for their review of this report:

Katie M. Applebaum, George Washington University

F. DuBois Bowman, Columbia University

Patricia A. Janulewicz-Lloyd, Boston University School of Public Health

Kevin C. Kiley, Albany Medical Center

Kurt Kroenke, Indiana University

Carol S. North, University of Texas Southwestern Medical Center

Martin Philbert, University of Michigan School of Public Health

Marguerite R. Seeley, Gradient Corporation

Lawrence Steinman, Stanford University

Simon Wessley, King’s College London

Christina Wolfson, McGill University

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 Harold C. Sox, Patient-Centered Outcomes Research Institute, and Maryellen L. Giger, University of Chicago. They were 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 authoring committee and the institution.

Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War, 2016. Washington, DC: The National Academies Press. doi: 10.17226/21840.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War, 2016. Washington, DC: The National Academies Press. doi: 10.17226/21840.
×

Preface

The last nine Institute of Medicine committees that prepared the Gulf War and Health series of reports have diligently assessed the evidence for possible health effects associated with exposures experienced by veterans during the Gulf War. All the prior committees, as well as the current committee, have sought to identify diseases and health conditions caused by Gulf War exposures to help the Department of Veterans Affairs (VA) care for those veterans who were harmed. Several volumes in this series have recommended carefully designed research endeavors in the hope of finally understanding the long-term health effects caused by the war.

Unfortunately, all of the Gulf War and Health committees have faced similar challenges in their attempts to identify the health effects that are clearly the result of deployment to the Gulf War. Foremost among these is the ever unknowable impact of the various chemical exposures that occurred during the 1990–1991 Gulf War, whether alone or in combination with other environmental, chemical, and/or genetic factors. Objective exposure data gathered during and after the war have been, and are expected to continue to be, unavailable.

Studies of Gulf War illness specifically, the most frequently reported health outcome in these veterans, have been hampered by the relatively amorphous nature of the disorder and its multiple definitions over the past two decades, including chronic multisymptom illness, Gulf War syndrome, and multiple unexplained physical symptoms. Even though the evidence base for Gulf War illness has increased over the past few years, it has provided little new information that has increased our understanding of the disease or how to effectively treat or manage it.

The committee’s discussions also included the potential significance of both time and aging, both of which can present substantial difficulties for research efforts. Specifically, the time that has elapsed since the war—25 years—brings with it the potential to impact veterans’ recall of events, including the frequency, duration, and intensity of their exposures during their service. At the same time, advancing age can provoke new health concerns and the development of new diseases long after the war. In any population, it can be difficult to distinguish aging-related effects from those caused by a war many years ago. The committee emphasized that some health consequences with a long latency period, such as some cancers and neurodegenerative conditions, may not yet be fully described or be characterized

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War, 2016. Washington, DC: The National Academies Press. doi: 10.17226/21840.
×

by Gulf War illness. While the symptoms of Gulf War illness are expected to have developed soon after the deployment, similar symptoms, such as headache or cognitive problems, appearing 20 years after the war are unlikely to be related to Gulf War service but may be caused by other exposures or conditions that are entirely unrelated to the Gulf War. Thus, it is ever more important that any future research endeavors use well-designed protocols to minimize the effects of time and aging on the interpretation of Gulf War veterans’ health.

The committee did take note of research focused on the determination of potential biomarkers for Gulf War illness; this focus highlights the importance of exploring all avenues of research that might prove fruitful in diagnosing and treating veterans with this debilitating illness. Critical to both the diagnosis and treatment of Gulf War illness, however, is acknowledging the brain–body continuum. This committee concurs with the findings of previous Gulf War and Health committees in that Gulf War illness is not a psychosomatic illness, and it is cognizant of the residual stigma associated with having a mental health disorder and veterans’ frustration of being told that their persistent and disabling symptoms are “all in their heads.” Nevertheless, as the committee has tried to emphasize, there is a requisite interconnectedness of the physiological systems of the body and the brain, such that dysfunctions of either have consequences that can extend to both. In the same context, the committee has also tried to reiterate that although Gulf War illness should not be called a psychosomatic disorder, this does not mean that it or any chronic disease, including cancer, diabetes, and heart disease, does not have psychological components that might be amenable to mental health therapies as well as other treatments. For example, many investigations into biomarkers of Gulf War illness acknowledge this brain–body continuum by looking for explanations of the illness in brain functioning. The committee believes it would be a disservice to Gulf War veterans to ignore treatments that might address the mental health and neurocognitive components of Gulf War illness.

The committee would like to acknowledge and give sincere thanks to Dr. Ralph Loren Erickson and Dr. Robert Bossarte of VA; Dr. Beatrice Golomb and Dr. Roberta White from the VA Research Advisory Committee on Gulf War Veterans’ Illnesses (RAC); Ronald Brown and James Bunker from the National Gulf War Resource Center, Mr. James Binns and Dr. Lea Steele, former RAC members; Anthony Hardie, David Hatfield, Remington Nevin, Denise Nichols, Daniel Sullivan, Peter Sullivan, and the other Gulf War veterans for their presentations to the committee which it found both illuminating and moving. The committee would also like to thank Dr. Carolyn Clancy, Under Secretary for Health of VA, for her informative remarks.

The committee gained valuable insight and context from the many veterans who attended the committee’s first and second meetings or participated by phone. Their experiences and concerns echoed the seriousness of their health conditions even 25 years after the Gulf War. Their needs and concerns resonated with the committee as it endeavored to review the evidence objectively. The committee sincerely thanks the many individual veterans and veteran service organization representatives who took the time and made the effort to inform the committee’s deliberations.

I would like to express my sincere gratitude to the expert committee members for their thoughtfulness, insights, and hard work. I know I speak for the entire committee in expressing many thanks to Roberta Wedge for efficiently guiding the report through its various stages and keeping the committee organized and moving forward; to Cary Haver and Anne Styka for their research efforts; to Nicole Freid for her administrative support, and to the National Academies Research Center’s Daniel Bearss for creating and executing the literature search strategy and Ellen Kimmel for fact checking.

Deborah A. Cory-Slechta, Chair

Committee on Gulf War and Health, Volume 10: Update of Health Effects of Serving in the Gulf War

Page xiii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War, 2016. Washington, DC: The National Academies Press. doi: 10.17226/21840.
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Acronyms and Abbreviations

AChE acetylcholinesterase
ACR American College of Rheumatology
AFQT Armed Forces Qualifying Test
ALS amyotrophic lateral sclerosis
ANCOVA analysis of covariance
AUDIT Alcohol Use Disorders Identification Test
BAI Beck Anxiety Inventory
BARS Behavioral Assessment and Research System
BChE butyrylcholinesterase
BDI Beck Depression Inventory
BIRLS Beneficiary Identification Records Locator System
BMI body mass index
BSI Brief Symptom Inventory
CAPS Clinician Administered PTSD Scale
CATSYS Coordination Ability Test System
CCD Canadian Cancer Database
CCEP Comprehensive Clinical Evaluation Program
CDC Centers for Disease Control and Prevention
CES Combat Exposure Scale
CFS chronic fatigue syndrome
CI confidence interval
CIDI Composite International Diagnostic Interview
CMD Canadian Mortality Database
CMI chronic multisymptom illness
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War, 2016. Washington, DC: The National Academies Press. doi: 10.17226/21840.
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CMV cytomegalovirus
CNS central nervous system
COD cause of death
COPD chronic obstructive pulmonary disease
COSHPD California Office of Statewide Health Planning and Development
Cr creatinine
CVLT California Verbal Learning Test
CWP chronic widespread pain
DASA Defence Analytical Services Agency (United Kingdom)
DEET N,N-diethyl-meta-toluamide
DFP di-isopropyl fluorophosphate
DMDC Defense Manpower Data Center
DMSO dimethyl sulfoxide
DNA deoxyribonucleic acid
DoD Department of Defense
DSM Diagnostic and Statistical Manual of Mental Disorders
DU depleted uranium
EBV Epstein-Barr virus
EEG electroencephalography
FA fractional anisotrophy
FARS Fatality Analysis Reporting System
FEV1 forced expiratory volume in 1 second
fMRI functional magnetic resonance imaging
FSH follicle stimulating hormone
FUS/TLS fused in sarcoma/translated in sarcoma
FVC forced vital capacity
GAD generalized anxiety disorder
GAO Government Accountability Office
GHQ-12 12-item General Health Questionnaire
GI gastrointestinal
GW Gulf War
GWV Gulf War veteran
HFM hemifacial macrosomia
HIV human immunodeficiency virus
HLA human leukocyte antigen
HPA hypothalamic-pituitary-adrenal axis
HR hazard ratio
IBS irritable bowel syndrome
ICD International Statistical Classification of Diseases and Related Health Problems
IOM Institute of Medicine
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War, 2016. Washington, DC: The National Academies Press. doi: 10.17226/21840.
×
IPGWSG Iowa Persian Gulf War Study Group
LH luteinizing hormone
MANOVA multivariate analysis of variance
MCH mean corpuscular hemoglobin
MCS multiple chemical sensitivity
MCV mean corpuscular volume
MD mean diffusivity
MDD major depressive disorder
ME myalgic encephalomyelitis
mmHg millimeters of mercury
mmol millimoles
MRI magnetic resonance imaging
MRR mortality rate ratio
MS multiple sclerosis
NAA N-acetyl aspartate
NART National Adults Reading Test
NAS National Academy of Sciences
NDI National Death Index
NDV nondeployed veteran
NHS National Health Survey of Gulf War Veterans and Their Families
NIFS Nuclear Industry Family Study
NIH National Institutes of Health
NIS Neuropathy Impairment Score
NS not significant
ODD other demyelinating disease
ODTP Oregon Dual Task Procedure
OR odds ratio
PASAT Paced Auditory Serial Addition Test
PB pyridostigmine bromide
PC phosphatidyl choline
PCA principal components analysis
PCL-C PTSD Checklist–Civilian
PCL-M PTSD Checklist–Military
PFT pulmonary function test
Pg picogram
PHQ Patient Health Questionnaire
PIR proportional incidence ratio
P.L. Public Law
Pmol picomoles
PMR proportional morbidity ratio
PON1 paraoxonase-1
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War, 2016. Washington, DC: The National Academies Press. doi: 10.17226/21840.
×
POW prisoner of war
PRIME-MD Primary Care Evaluation of Mental Disorders
PTSD posttraumatic stress disorder
QoLI Quality of Life Index
RAC VA Research Advisory Committee on Gulf War Veterans’ Illnesses
RNA ribonucleic acid
RR relative risk (or risk ratio as indicated in text)
SCID Structured Clinical Interview for DSM-III-R
SCL symptom checklist
sd standard deviation
SEER Surveillance, Epidemiology, and End Results Program
SEID systemic exertion intolerance disease
SF-12 12-Item Short Form Health Survey
SF-36 36-Item Short Form Health Survey
SIR standardized incidence ratio
SMR standardized mortality ratio
SMRR summary mortality rate ratio
SNAP Special Needs Assessment Profile
SRR standardized rate ratio
SSA Social Security Administration
TBI traumatic brain injury
TOMM Test of Memory Malingering
UK United Kingdom
U.S. United States
VA Department of Veterans Affairs
WAIS-R Wechsler Adult Intelligence Scale-Revised
WCST Wisconsin Card Sorting Test
WMS Wechsler Memory Scale
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War, 2016. Washington, DC: The National Academies Press. doi: 10.17226/21840.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War, 2016. Washington, DC: The National Academies Press. doi: 10.17226/21840.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War, 2016. Washington, DC: The National Academies Press. doi: 10.17226/21840.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War, 2016. Washington, DC: The National Academies Press. doi: 10.17226/21840.
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For the United States, the 1991 Persian Gulf War was a brief and successful military operation with few injuries and deaths. However, soon after returning from duty, a large number of veterans began reporting health problems they believed were associated with their service in the Gulf. At the request of Congress, the Institute of Medicine (IOM) has been conducting an ongoing review of the evidence to determine veterans' long-term health problems and potential causes. The fourth volume in the series, released in 2006, summarizes the long-term health problems seen in Gulf War veterans. In 2010, the IOM released an update that focuses on existing health problems and identifies possible new ones, considering evidence collected since the initial summary.

Gulf War and Health: Volume 10, the final volume of the series, is an update of the scientific and medical literature on the health effects associated with deployment to the Gulf War that were identified in Volumes 4 and 8. This report reviews and evaluates the associations between illness and exposure to toxic agents, environmental or wartime hazards, or preventive measures and vaccines associated with Gulf War service, and provides recommendations for future research efforts on Gulf War veterans.

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