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Can epidemiology clear the fog of war? Lessons from the 1990-91 Gulf War
Abstract
Despite over US $200 million having been spent researching illnesses following the 1990-91 Persian Gulf War, the nature and cause of such illnesses remains controversial. In this narrative review, we discuss some of the methodological issues that have affected epidemiological studies on this topic. These include low-response rates, ascertainment bias, recall bias, problems identifying suitable control groups, and problems defining the outcomes to study. From this we argue that difficulties have arisen partly owing to the significant delay between the point at which illnesses were first identified by veterans and the reporting of epidemiological studies and that health surveillance should be routine following future deployments.
... However, these studies face a number of methodological challenges, including difficulties of tracking service personnel after they return to civilian life, low participation rates, and problems of recall and survivorship bias. 12 Studies from the first Gulf War have similar limitations. 13 High-quality empirical data are lacking on the burden of illness and disability over remaining lifetimes. ...
... The age structure of the peacetime defence forces was obtained from the Department of Veterans' Affairs (DVA) estimates. 12 ...
... Studies of military personnel can be confounded by factors such as "healthy warrior" effects, which arise if those who are healthier are more likely to be deployed. 12 Unfortunately, we have very little information that would enable us to account for these differences and the degree to which these factors could impact on long-term disability claims. Another potential confounding difference is that Vietnam veterans included a significant number of conscripts, whereas the nondeployed controls were entirely volunteers. ...
Recent combat operations have involved large numbers of personnel. Long-term health effects of military deployment remain largely unknown.
To examine patterns and trends in long-term disability among combat veterans and to relate disability to aspects of wartime experience.
A total of 60,228 Australian military personnel deployed between 1962 and 1975 during the Vietnam War, and 82,877 military personnel who were not deployed overseas.
Accepted physician-assessed disability claims were evaluated over follow-up periods up to 50 years after deployment, and compared with age-matched controls. Multivariable analysis was used to examine differences by service branch, rank, age, and deployment duration.
The steepest rise in disability incidence was observed among Vietnam veterans starting in the 1990s, around 20-30 years after deployment for most veterans. After 1994, when Statements of Principles were introduced to guide evaluation of disability claims, the hazard ratio for disability incidence was 1.53 (95% confidence interval, 1.32-1.77) compared with the prior period. By January 2011, after an average follow-up of 42.5 years, 69.7% (95% confidence interval, 69.4%-70.1%) of veterans had at least 1 war-related disability. Many veterans had multiple disabilities, with leading causes being eye and ear disorders (48.0%), mental health conditions (47.9%), and musculoskeletal disorders (18.4%). For specific categories of disability, relative risks for accepted claims among veterans compared with controls were highest for mental health disorders, at 22.9 (21.9-24.0) and lowest for injuries, at 1.5 (1.4-1.6) with a relative risk for any disability of 3.7 (3.7-3.8). Veterans with service of >1 year were 2.5 (2.2-2.7) times more likely to have a mental health disability than those who served <100 days, and 2.3 (2.1-2.5) times more likely to have other disabilities.
Long-term effects of deployment into military conflicts are substantial, and likelihood of war-related disability is associated with service history. If similar patterns follow from more recent conflicts, significant additional resources will be needed to prevent and treat long-term health conditions among veterans.This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivitives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. http://creativecommons.org/licenses/by-nc-nd/3.0.
... However, unlike previous veterans, Gulf War veterans were subject to a variety of potentially harmful environmental exposures, both natural and man-made [33]. Researchers generally report lower rates of PTSD among Gulf War veterans than among military personnel from other wars [32,33,38,39,53]. ...
... A curious outlier, the Iowa Persian Gulf Study Group [30] reported PTSD prevalence estimates of 1.9% in a (n=3,969) sub-sample of GW veterans. Such an anomalous result has been suggested to be the consequence of a study participation bias and response bias which may have occurred given the contemporary media emphasis on reporting the less specific, somatically focused symptoms of "Gulf War Syndrome" at the time [53][54][55]. The variable course of the disorder, coupled with methodological, exposure and cohort differences have influenced the heterogeneity of PTSD prevalence rates among Gulf war veterans, as they have done in Vietnam veterans. ...
... Participants who are voluntarily assessed and remain anonymous may have fewer disincentives for candid self appraisal; whereas those who are compulsorily screened may have more incentives to minimize distress including stigma from disclosure, avoidance of delays to post-deployment reunion, and the possibility of long-term consequences to future employment opportunities in and outside the military [17]. Alternatively, combat veterans who are ill may assign more salience to memories of combat, whereas those who are well may minimize combat exposure [53,55]. It is possible that veterans who most strongly associate their symptoms with their war experience may be prone to inflate the relationship between these variables [71]. ...
The aim of the present study was to provide a critical review of prevalence estimates of combat-related post-traumatic stress disorder (PTSD) among military personnel and veterans, and of the relevant factors that may account for the variability of estimates within and across cohorts, including methodological and conceptual factors accounting for differences in prevalence rates across nations, conflicts/wars, and studies. MEDLINE and PsycINFO databases were examined for literature on combat-related PTSD. The following terms were used independently and in combinations in this search: PTSD, combat, veterans, military, epidemiology, prevalence. The point prevalence of combat-related PTSD in US military veterans since the Vietnam War ranged from approximately 2% to 17%. Studies of recent conflicts suggest that combat-related PTSD afflicts between 4% and 17% of US Iraq War veterans, but only 3-6% of returning UK Iraq War veterans. Thus, the prevalence range is narrower and tends to have a lower ceiling among combat veterans of non-US Western nations. Variability in prevalence is likely due to differences in sampling strategies; measurement strategies; inclusion and measurement of the DSM-IV clinically significant impairment criterion; timing and latency of assessment and potential for recall bias; and combat experiences. Prevalence rates are also likely affected by issues related to PTSD course, chronicity, and comorbidity; symptom overlap with other psychiatric disorders; and sociopolitical and cultural factors that may vary over time and by nation. The disorder represents a significant and costly illness to veterans, their families, and society as a whole. Further carefully conceptualized research, however, is needed to advance our understanding of disorder prevalence, as well as associated information on course, phenomenology, protective factors, treatment, and economic costs.
... Firstly, there are immediate operational reasons to help minimize or reduce disease and battle and non-battle injuries which may result in decreased mission performance (Hauschild 2000). Secondly, there is evidence that, following deployment, the most symptomatic members of the military are most likely to leave (Hotopf & Wessely 2005), so if exposure(s) cause symptoms, a Defence Force will lose trained and experienced members. Last but not least, a Defence Force has a duty of care to, as far as possible, look after the health of its members, including the quality of life during and after deployment. ...
... Most of the Gulf War veterans' studies started some years after the conflict e.g. the UK studies started in 1996 (Hotopf & Wessely 2005) and in Australia in 2000 (Ikin et al. 2004). In these studies, veterans were asked to recall exposures remote in time, up to a decade previously. ...
... Use of the refined plume model in 2000 increased the precision of the model's application to (smaller) company-based rather than (larger) battalion-based assessment (Bullman et al. 2005). Some studies compared the recall of immunizations for those with and without records and showed that they were broadly similar (Cherry et al. 2001; Kelsall et al. 2004b; Hotopf & Wessely 2005). Significant over-reporting of exposure has been identified by comparing self reports with location (The Iowa Persian Gulf Study Group 1997; Glass et al. in press) or on period served in the Gulf, e.g. ...
A variety of exposures have been investigated in Gulf War veterans' health studies. These have most commonly been by self-report in a postal questionnaire but modelling and bio-monitoring have also been employed. Exposure assessment is difficult to do well in studies of any workplace environment. It is made more difficult in Gulf War studies where there are a number and variety of possible exposures, no agreed metrics for individual exposures and few contemporary records associating the exposure with an individual. In some studies, the exposure assessment was carried out some years after the war and in the context of media interest. Several studies have examined different ways to test the accuracy of exposure reporting in Gulf War cohorts. There is some evidence from Gulf War studies that self-reported exposures were subject to recall bias but it is difficult to assess the extent. Occupational exposure-assessment methodology can provide insights into the exposure-assessment process and how to do it well. This is discussed in the context of the Gulf War studies. Alternative exposure-assessment methodologies are presented, although these may not be suitable for widespread use in veteran studies. Due to the poor quality of and accessibility of objective military exposure records, self-assessed exposure questionnaires are likely to remain the main instrument for assessing the exposure for a large number of veterans. If this is to be the case, then validation methods with more objective methods need to be included in future study designs.
... GWI, a type of MUS, is characterized by chronic, disabling physical and neurocognitive symptoms and was the signature illness after Operation Desert Shield/Storm [20]. Upon return from combat, veterans with GWI described being marginalized by the medical community who they generally felt viewed GWI as a psychological condition and who under-appreciated the severity of GWI [21][22][23][24]. Some veterans were also concerned that the government was covering up the cause GWI, further complicating communication with medical providers [24]. ...
... The goal of this study was to identify patients' perspectives of the most useful thing a medical provider has told them about their MUS. We examined this question among 210 Veterans with Gulf War Illness (GWI), a type of MUS that is marked by significant disability and for which there has been documented distrust of medical providers [21][22][23][24]. We found three primary themes: acknowledgement and validation, specific recommendations for managing GWI or its symptoms and that nothing a provider has said has been helpful. ...
Background
Communication between patients and providers about persistent “medically unexplained” physical symptoms (MUS) is characterized by discordance. While the difficulties are well documented, few studies have examined effective communication. We sought to determine what veterans with Gulf War Illness (GWI) perceive as the most helpful communication from their providers. Veterans with GWI, a type of MUS, have historically had complex relationships with medical providers. Determining effective communication for patients with particularly complex relationships may help identify the most critical communication elements for all patients with MUS.
Methods
Two hundred and-ten veterans with GWI were asked, in a written questionnaire, what was the most useful thing a medical provider had told them about their GWI. Responses were coded into three categories with 10 codes.
Results
The most prevalent helpful communication reported by patients was when the provider offered acknowledgement and validation (N = 70). Specific recommendations for managing GWI or its symptoms (N = 48) were also commonly reported to be helpful. In contrast, about a third of the responses indicated that nothing about the communication was helpful (N = 63). There were not differences in severity of symptoms, disability or healthcare utilization between patients who found acknowledgement and validation, specific recommendations or nothing helpful.
Conclusions
Previous research has documented the discord between patients and providers regarding MUS. This study suggests that most patients are able to identify something helpful a provider has said, particularly acknowledgement and validation and specific treatment recommendations. The findings also highlight missed communication opportunities with a third of patients not finding anything helpful.
... Certainly, there is reason to be concerned about the potential for instability of recall and various memory biases. 1,[33][34][35] Thus, recall or report bias cannot be excluded in the ascertainment of combat experiences, PTSD symptom severity or the time of onset for PTSD symptoms. Data show that military veterans' reports of combat exposure and other military hazards can change over time 36 and may even be subject to exaggeration. ...
... Such longitudinal epidemiological research should take the form of routine health surveillance among veterans deployed to war zones and other relevant populations. 33 Findings will have relevance to ongoing efforts to refine PTSD diagnostic criteria and development of services and benefits for veterans. ...
Only limited empirical data support the existence of delayed-onset post-traumatic stress disorder (PTSD).
To expand our understanding of delayed-onset PTSD prevalence and phenomenology.
A cross-sectional, epidemiological design (n = 747) incorporating structured interviews to obtain relevant information for analyses in a multisite study of military veterans.
A small percentage of veterans with identified current PTSD (8.3%, 7/84), current subthreshold PTSD (6.9%, 2/29), and lifetime PTSD only (5.4%, 2/37) met criteria for delayed onset with PTSD symptoms initiating more than 6 months after the index trauma. Altogether only 0.4% (3/747) of the entire sample had current PTSD with delayed-onset symptoms developing more than 1 year after trauma exposure, and no PTSD symptom onset was reported more than 6 years post-trauma.
Retrospective reports of veterans reveal that delayed-onset PTSD (current, subthreshold or lifetime) is extremely rare 1 year post-trauma, and there was no evidence of PTSD symptom onset 6 or more years after trauma exposure.
... 28,50 Fourth, caution must be exercised in interpreting self-report data from active duty personnel, given possible biases in reporting. [53][54][55] Despite these shortcomings, our preliminary results lay the groundwork for further explorations of neuropsychological and neurological measures that exhibit some sensitivity to the effects of blast. We hope that our study will motivate prospective longitudinal studies necessary to test the causal impact of blast exposure on health and performance in military personnel exposed to repeated low-level blast. ...
Introduction
We assessed the utility of a battery of neuropsychological, neurocognitive, physiological (balance, ataxia, postural tremor), and neuroimaging measures for studying the effects of blast waves in breachers—a population repeatedly exposed to low-level blast during military training and operations.
Materials and Methods
Data were collected from four nonoverlapping samples, in the course of similarly structured 4-day breacher training exercises in successive years involving a combination of indoor and outdoor blast events. In all cases, self-report and neuropsychological measures were administered once at baseline (i.e., 1 day before the start of training). In years 1-2, neurocognitive and physiological measures were administered daily before and after training. In years 3-4, neurocognitive data were collected once at baseline. In Year 4, we introduced 3 modifications to our design. First, in addition to breachers, we also collected data from sex—and age-matched military controls at the same time points. Second, we assessed balance, ataxia, and postural tremor immediately following blast exposure “in the field,” enabling us to quantify its acute effects. Third, structural magnetic resonance imaging (MRI) scans were acquired before and after the 4-day training exercise to explore differences between breachers and controls at baseline, as well as possible training-related changes using voxel-based morphometry. These design modifications were made to enable us to test additional hypotheses in the context of the same training exercise.
Results
At baseline, scores on the “Rivermead Post Concussion Symptoms Questionnaire,” “RAND SF-36” (physical functioning, role limitation due to physical health, social functioning, energy/fatigue, general health), and “Short Musculoskeletal Function Questionnaire” distinguished breachers from controls. Also at baseline, the MRI data revealed that there was greater regional gray matter volume in controls compared to breachers in the right superior frontal gyrus. Balance, ataxia, and postural tremor did not exhibit sensitivity to the acute effects of blast in the field, nor did neurocognitive measures to its cumulative or daily effects.
Conclusion
Our exploratory results suggest that self-report neuropsychological measures and structural MRI hold promise as sensitive measures for quantifying the long-term, cumulative effects of blast exposure in breachers. We discuss the limitations of our study and the need for prospective longitudinal data for drawing causal inferences regarding the impact of blast exposure on breachers’ health and performance.
... Безперечно, крім вказаних вище суспільно-асоційованих факторів, які впливають на виставлення військовослужбовцям діагнозу ПТСР, а також традиційних етіологічних факторів (інтенсивність та тривалість боєзіткнень, попередній бойовий досвід, окремі особистісні особливості, нещасні випадки у дитинстві, обтяженість психіатричного сімейного анамнезу, рівень психологічного і фізичного здоров'я з попередніми відхиленнями в поведінковій сфері перед участю у бойових діях [49,50,51,52,53,54,55,56,67]), в якості вкрай важливих факторів слід також розглядати рівень соціальної та морально-психологічної підтримки після їх повернення додому [57,58,59]. Такі післявоєнні чинники включають в себе індивідуальні обставини особистісного життя, побутові стресові фактори, рівень соціальної підтримки, а також загальний соціальний та політичний клімат в суспільстві. ...
Актуальність. У зв’язку з викликами сьогодення ПТСР є серйозною проблемою загальної і, особливо, військової психіатрії. Діагноз «ПТСР» є, в першу чергу, етіологічно обумовленим, але також значний вплив, як на розвиток, так і на клінічне оцінювання цього стану, мають такі «немедичні» чинники, як суспільні та сімейно-побутові.
Методи й матеріали. Матеріал дослідження – сучасні публікації, присвячені вивченню соціально-психологічних, сімейних та суспільно-громадських чинників, які відіграють роль у формуванні ПТСР та впливають на використання зазначеного діагнозу при огляді посткомбатантів. Метод дослідження – бібліографічно-аналітичний.
Результати. Згідно з даними північноамериканських авторів, кількість ветеранів, які отримали інвалідність у зв’язку з ПТСР, з 1999 р. по 2004 р. зросла на 79,5%, при тому, що інвалідність з приводу інших захворювань серед них зросла лише на 12,2%. Соціальна політика інвалідності заохочує ветеранів до отримання психіатричних діагнозів, в першу чергу – ПТСР. У суспільстві діагноз «ПТСР» часто використовується для виправдання кримінальної поведінки військовослужбовців та посткомбатантів. Ще одна проблема лежить в тому, що інша частина посткомбатантів, навпаки, приховують симптоми ПТСР, боячись побутової стигматизації «психічно хворого» та зіпсування своєї кар’єри. Крім громадських чинників, які впливають на використання діагнозу «ПТСР», важливими «немедичними» факторами є сімейні аспекти життя посткомбатантів. На розвиток ПТСР та його перехід у проланговану форму негативно впливає відсутність військовослужбовіців вдома більш шести місяців, неможливість дистанційного спілкування з близькими під час участі в бойових діях, відсутність сім’ї, а у одружених, як це не парадоксально, присутність у складі сім’ї дітей.
Висновки. Внаслідок впливу соціально-асоційованих чинників існують певні частини посткомбатантів, одна з яких схильна до симуляції або агравації симптомів ПТСР, а друга, навпаки, схильна до дисимуляції постстресової психопатологічної симптоматики. Серед сімейних чинників, які слід вважати в якості умовно-патогенних, особливу увагу треба приділяти відсутності можливості спілкування з близькими під час ведення бойових дій, відсутність їх вдома протягом більш шести місяців та присутність в родинах військовослужбовців дітей. Для вдосконалення якості діагностичної та реабілітаційної роботи необхідно найскоріше проведення науково- огрунтованої адаптації сучасних закордонних психологічних тестів, спрямованих на діагностику ПТСР та розробка специфічних вітчизняних методик.
... There is evidence that many of the GW-related exposures are highly intercorrelated [25,26]. Moreover, studies that have assessed the myriad of GW-related exposures without controlling for the confounding effects of concurrent exposures have tended to report that nearly all of the GW-related experiences queried are linked to poor health outcomes in GW veterans [27,28]. In contrast, studies that have accounted for the effects of concurrent exposures have identified only a limited number of significant risk factors for GWI [5,[29][30][31]. ...
Objectives:
Veterans of the 1991 Gulf War (GW) were exposed to a myriad of potentially hazardous chemicals during deployment. Epidemiological data suggest a possible link between chemical exposures and Parkinson’s disease (PD); however, there have been no reliable data on the incidence or prevalence of PD among GW veterans to date. This study included the following 2 questions: 1. Do deployed GW veterans display PD-like symptoms? and 2. Is there a relationship between the occurrence and quantity of PD-like symptoms, and the levels of deployment-related exposures in GW veterans?
Material and methods:
Self-reports of symptoms and exposures to deployment-related chemicals were filled out by 293 GW veterans, 202 of whom had undergone 3 Tesla volumetric measurements of basal ganglia volumes. Correlation analyses were used to examine the relationship between the frequency of the veterans’ self-reported exposures to deployment-related chemicals, motor and non-motor symptoms of PD, and the total basal ganglia volumes.
Results:
Healthy deployed GW veterans self-reported few PD-like non-motor symptoms and no motor symptoms. In contrast, GW veterans with Gulf War illness (GWI) self-reported more PD-like motor and non-motor symptoms, and more GW-related exposures. Compared to healthy deployed veterans, those with GWI also had lower total basal ganglia volumes.
Conclusions:
Although little is known about the long-term consequences of GWI, findings from this study suggest that veterans with GWI show more symptoms as those seen in PD/prodromal PD, compared to healthy deployed GW veterans. Int J Occup Med Environ Health. 2019;32(4):503–26
... Epidemiologic studies that relied on veterans' self-reported exposures during deployment suffered from recall bias, but some studies still noted poor health outcomes. 72,73 Some studies pointed to a limited number of significant risk factors for GWI. [74][75][76] Other studies found many exposures to be highly correlated, suggesting that confounding errors were present in the studies that evaluated associations between exposure and GWI. ...
History of Army Occupational Health, 1991-2015.
... Seventeen veterans expressed initial interest in participating in the study, however seven did not respond to contact to arrange an interview. This is consistent with difficulties recruiting veterans to participate in other research studies (Hotopf & Wessely, 2005). ...
Background: Many UK military veterans experiencing mental health and well-being difficulties do not engage with support services to get the help they need. Some mental health clinics employ Peer Support Workers (PSWs) to help veteran patients engage, however it is not known how the role influences UK veteran engagement.
Aims: To gain insight into the role of peer support in UK veteran engagement with mental health and well-being services.
Method: A qualitative study based on 18 semi-structured interviews with veterans, PSWs and mental health clinicians at a specialist veteran mental health and well-being clinic in Scotland.
Results: Four themes of the PSW role as positive first impression, understanding professional friend, helpful and supportive connector, and an open door were identified across all participants. The PSWs’ military connection, social and well-being support and role in providing veterans with an easily accessible route to dis-engage and re-engage with the service over multiple engagement attempts were particularly crucial.
Conclusions: The Peer Support role enhanced veteran engagement in the majority of instances. Study findings mirrored existing peer support literature, provided new evidence in relation to engaging UK veterans, and made recommendations for future veteran research and service provision.
... 7 A considerable problem in the epidemiological research concerning deployed service members participating in the 1991 Gulf War and later conflicts has been that nondeployed comparison populations sometimes are unsuitable as a result of differences in health between deployed and nondeployed service members. 8,9 Recent research demonstrates that civilian populations might be a useful reference for exploring the health of particular subgroups within the military, such as those in a particular military occupation or those who have been deployed to a particular geographical area. [10][11][12] Another possible difficulty in the Gulf War health research is the fact that most health outcomes are self-reported. ...
Background:
Gulf War veterans (GWVs) have an elevated risk of reporting symptoms of mental disorders as compared with nondeployed military controls. A difficulty in the Gulf War health research is that most health outcomes are self-reported; therefore, it is highly relevant to study objective outcomes in this line of research. The Danish National Prescription Registry provides an opportunity to use the prescription of drugs as an objective evaluation of the impact of mental health disorders at the individual level. In this study, we investigated the prescription of drugs and postdeployment hospitalizations for mental disorders among GWVs compared with a control population of nonveterans (NVs).
Methods:
A prospective registry study including a cohort of 721 GWVs and a control cohort of 3,629 NVs. Main outcome measures were incidence of (1) use of antidepressants, (2) use of anxiolytic/hypnotic medication, and (3) number of postdeployment psychiatric contacts. The association between outcomes and GWVs status was studied by using time-to-event analysis. The index date was the return date from the last deployment to the Gulf. The follow-up period was the time from index date until December 31, 2014.
Findings:
GWVs had an elevated average risk over time for use of both types of medication compared with NV. For use of antidepressants the average hazard rate (HR) was 2.56, with 95% confidence interval (CI) = 2.04-3.21 (p < 0.0001); for use of anxiolytic/hypnotic medication the corresponding results were HR = 1.78, CI = 1.37-2.31 (p < 0.0001). The interaction with time was statistically significant with HR increasing with time for both outcomes. Incident use of antidepressants in GWVs after 10 years was two times higher than among NV, after 20 years it was nearly four times higher than among NV. Incident use of anxiolytic/hypnotic medication was one and a half that of NV after 10 years, but nearly three times that of NV after 20 years. There was no difference in rate of postdeployment psychiatric contacts.
Discussion/impact/recommendations:
The findings of increased use of antidepressants and anxiolytic or hypnotic medicine among GWVs compared with NVs were rather surprising since we recently, by using the same study population, found that deployment to the Persian Gulf was not associated with increased sickness absence or reduced labor market attachment. However, our results indicate that the mental health of the Danish GWVs is worse than in NV, and that this unfavorable difference increased with time. A possible explanation is that veterans have a high motivation for being in work, and that the deployment-related mental problems they may have acquired do not impair their ability to work, when treated properly. Furthermore, registry-based research in GWVs could include other outcomes, e.g., the use of pain medication, and other military comparison groups, e.g., veterans deployed to other areas than the Persian Gulf in addition to NV. The method of surveillance of military personnel with register data pertinent to health and monitoring outcomes compared with suitable control populations is highly recommended as a tool in the prevention of deployment-related health problems.
... For symptoms reported as experienced since the first 5 years after visiting Porton Down, three of the top five, and six of the top ten, symptoms are similar to those reported by the Gulf War veterans. The significance of this similarity is unclear because there is considerable overlap in symptom patterns reported following wars and other potentially harmful experiences [18]. The older age of many of the PDVSG membership and the long interval since visiting Porton Down does not rule out post-traumatic stress disorder, which can occur in later life [19]. ...
b>Background There has been a Human Volunteer Programme at the British chemical weapons research facility at Porton Down since the First World War, in which some of the participants were exposed to chemical warfare agents.
Aim To identify any striking specific morbidity patterns in members of the Porton Down Veterans Support Group (PDVSG).
Methods A self-completed postal questionnaire was prepared including health immediately after the visits to Porton Down, subsequent diagnoses and hospital admissions, symptoms in, and after, the first 5 years after the visits, fatigue symptoms and current quality of life, measured using the SF-36.
Results Responses were received from 289 of 436 (66%). Results reported here relate to 269 male respondents of mean age 66.8 years. Sixty-six per cent reported their first visit to Porton Down in the 1950s. The most common diagnoses or hospital admissions reported were diseases of the circulatory system. In the first 5 years after their visits the most common symptoms were headache, irritability or outbursts of anger and feeling un-refreshed after sleep. In the later period, most common symptoms were fatigue, feeling un-refreshed after sleep and sleeping difficulties. Sixty-five per cent met the definition for a case of ‘fatigue’. Current quality of life dimensions were consistently lower than age-specific estimates from general population samples.
Conclusions Members of the PDVSG responding to this survey reported poorer quality of life than the general population. Despite there being no clear pattern of specific morbidities, we cannot rule out ill-health being potentially associated with past experience at Porton Down<br /
... A n extensive body of literature on the health impacts of military deployments reaches as far back as the US Civil War (1)(2)(3). In addition to investigating mental health (4-6), a number of largely cross-sectional studies have examined mild traumatic brain injury (mTBI) among returning personnel (5,(7)(8)(9)(10)(11)(12). ...
Objectives:
Many recent studies of service members returning from deployment have focused on the health impacts of mild traumatic brain injury (mTBI), including persistent postconcussive symptoms (PCS). However, cross-sectional study designs have made it difficult to understand the role of mental health in the etiology of persistent PCS.
Methods:
Participants were 3319 military personnel (primarily men [90%] of 25-34 years [54%]) who had completed health surveys at basic training and after deployment, on average, 4.6 years later. Negative binomial regression was used to assess the association of PCS with demographic covariates, premilitary mental health and somatic symptoms, combat experiences and mTBI during deployment, in addition to postdeployment mental health and non-PCS somatic symptoms.
Results:
Premilitary mental health and somatic symptoms predicted PCS even when adjusting for other variables, yielding an elevated incidence rate ratio (IRR) for posttraumatic stress disorder (PTSD; IRR = 1.23, 95% confidence interval [CI] = 1.06-1.41) and somatic symptoms (mild versus minimal somatic symptoms: IRR = 1.43, 95% CI = 1.31-1.55; moderate/severe versus minimal somatic symptoms: IRR = 1.69, 95% CI = 1.43-2.06), but not for depressive symptoms. When postdeployment mental health and somatic symptom measures were added to the model, the effect of premilitary somatic symptoms remained significant.
Conclusions:
Findings point to potential etiological contributions of premilitary characteristics, particularly a tendency to experience somatic symptoms and PTSD, as well as mTBI and combat experiences, to the development of PCS. PCS were also strongly related to concurrent postdeployment mental health.
... There is controversy over whether the psychiatric needs of trauma-exposed populations can be accurately addressed using the PTSD construct, or indeed the new DSM category of 'trauma and stress related illnesses'. 5,9,41 Degree of exposure to trauma is associated with risk of PTSD 27 but also non-PTSD psychiatric diagnosis. 29 Our results support the finding that non-PTSD psychiatric diagnosis have a higher prevalence than PTSD in trauma-exposed populations -for example, of those with three or more traumatic events 40.4% had a non-PTSD psychiatric diagnosis and 13.3% had PTSD. ...
Background:
Most studies of post-traumatic stress disorder (PTSD) in low- and middle-income countries (LMICs) have focused on 'high-risk' populations defined by exposure to trauma.
Aims:
To estimate the prevalence of post-traumatic stress disorder (PTSD) in a LMIC, the conditional probability of PTSD given a traumatic event and the strength of associations between traumatic events and other psychiatric disorders.
Method:
Our sample contained a mix of 3995 twins and 2019 non-twins. We asked participants about nine different traumatic exposures, including the category 'other', but excluding sexual trauma.
Results:
Traumatic events were reported by 36.3% of participants and lifetime PTSD was present in 2.0%. Prevalence of non-PTSD lifetime diagnosis was 19.1%. Of people who had experienced three or more traumatic events, 13.3% had lifetime PTSD and 40.4% had a non-PTSD psychiatric diagnosis.
Conclusions:
Despite high rates of exposure to trauma, this population had lower rates of PTSD than high-income populations, although the prevalence might have been slightly affected by the exclusion of sexual trauma. There are high rates of non-PTSD diagnoses associated with trauma exposure that could be considered in interventions for trauma-exposed populations. Our findings suggest that there is no unique relationship between traumatic experiences and the specific symptomatology of PTSD.
... Ideally, epidemiological studies should be planned before military action is contemplated to avoid difficulties in assessing exposures and health effects afterwards [17]. It then would be feasible to collect additional data on e.g., potentially hazardous exposures during deployment and lifestyle factors such as smoking habits and physical activity. ...
Suspicion has been raised about an increased cancer risk among Balkan veterans because of alleged exposure to depleted uranium. The authors conducted a historical cohort study to examine cancer incidence among Dutch Balkan veterans. Male military personnel (n=18,175, median follow-up 11 years) of the Army and Military Police who had been deployed to the Balkan region (1993-2001) was compared with their peers not deployed to the Balkans (n=135,355, median follow-up 15 years) and with the general Dutch population of comparable age and sex. The incidence of all cancers and 4 main cancer subgroups was studied in the period 1993-2008. The cancer incidence rate among Balkan deployed military men was 17% lower than among non-Balkan deployed military men (hazard ratio 0.83 (95% confidence interval 0.69, 1.00)). For the 4 main cancer subgroups, hazard ratios were statistically non-significantly below 1. Also compared to the general population cancer rates were lower in Balkan deployed personnel (standardised incidence rate ratio (SIR) 0.85 (0.73, 0.99). The SIR for leukaemia was 0.63 (0.20, 1.46). The authors conclude that earlier suggestions of increased cancer risks among veterans are not supported by empirical data. The lower risk of cancer might be explained by the 'healthy warrior effect'.
... Because drop-out rates are usually rather high in longitudinal research of military personnel (e.g., due to the high turnover rate; Hotopf & Wessely, 2005), strategies for retaining participants were used, such as developing positive relationships (e.g., informing participants about the progress of the study, giving information about names and roles of research personnel), selecting and training suitable research personnel, testing participants at their military base, and obtaining information from participants to facilitate relocating them (cf. Grant, Raper, Kang, & Weaver, 2008). ...
... Epidemiologic studies have therefore evaluated risk factors for GWI based on veterans' own reports of their exposures during deployment. Some studies have suggested that nearly all of the many experiences and exposures queried appear to be linked to poor health outcomes (Barrett et al. 2002;Hotopf and Wessely 2005). Others have identified only a limited number of significant risk factors for GWI (Haley and Kurt 1997;Nisenbaum et al. 2000;Wolfe et al. 2002). ...
At least one-fourth of U.S. veterans who served in the 1990-1991 Gulf War are affected by the chronic symptomatic illness known as Gulf War illness (GWI). Clear determination of the causes of GWI has been hindered by many factors, including limitations in how epidemiologic studies have assessed the impact of the complex deployment environment on veterans' health.
We sought to address GWI etiologic questions by evaluating the association of symptomatic illness with characteristics of veterans' deployment.
We compared veteran-reported wartime experiences in a population-based sample of 304 Gulf War veterans: 144 cases who met preestablished criteria for GWI and 160 controls. Veteran subgroups and confounding among deployment variables were considered in the analyses.
Deployment experiences and the prevalence of GWI differed significantly by veterans' location in theater. Among personnel who were in Iraq or Kuwait, where all battles took place, GWI was most strongly associated with using pyridostigmine bromide pills [odds ratio (OR) = 3.5; 95% confidence interval (CI): 1.7, 7.4] and being within 1 mile of an exploding SCUD missile (OR = 3.1; 95% CI: 1.5, 6.1). For veterans who remained in support areas, GWI was significantly associated only with personal pesticide use, with increased prevalence (OR = 12.7; 95% CI: 2.6, 61.5) in the relatively small subgroup that wore pesticide-treated uniforms, nearly all of whom also used skin pesticides. Combat service was not significantly associated with GWI.
Findings support a role for a limited number of wartime exposures in the etiology of GWI, which differed in importance with the deployment milieu in which veterans served.
... Furthermore, GW veterans are more commonly single, less educated, and/or with a lower socioeconomic status and exhibit a higher participation rate in surveys as compared to nondepioyed comparison groups. 31,32 A major limitation is the fact that most previous studies have been conducted on Soldiers who have left the Gulf War Region and have been in their native country for some time. ...
Although Iraqis sustained the gravest exposure conditions during the 1991 Gulf War (GW), little is known about the possible relationship between environmental exposures during the GW and long-term health in Iraqis.
To study the relationship between distance from Kuwait during the GW and somatic health among Iraqi Soldiers vs civilians.
A survey questionnaire was distributed to a sample of 742 GW veterans and 413 civilians in Iraq. The odds ratios were calculated for somatic disorders as a function of distance from Kuwait during the GW, as well as a self-reported environmental exposure index.
Soldiers reported a significantly higher prevalence of somatic disorders as compared to civilians. Soldiers closest to Kuwait reported significantly more somatic disorders as compared to Soldiers deployed further away from Kuwait.
Iraqi GW veterans are at an increased risk of numerous somatic disorders. Soldiers are at an increased risk compared to civilians, suggesting that war-associated exposures are of etiologic relevance.
... Nevertheless, these response rates were consistent with other military epidemiological studies. 34 Investigation of the differences between the responders and nonresponders in the three studies was undertaken. Ex-serving and enlisted people were under-represented in the respondent group. ...
The operational tempo of the Australian Defence Force has increased over the last two decades. We examine the relationship between health of personnel and the frequency and duration of their deployment. Self-reported health measures (number of symptoms, Kessler Psychological Distress Scale, and Post Traumatic Stress Disorder Checklist) were compared for people who had never deployed to those who had deployed only once and for those who had deployed at least twice with at least one deployment to East Timor and one deployment to Afghanistan or Iraq. Comparisons were also made between people who had deployed for at least one month and those who had deployed for longer periods. Frequency of deployment but not duration of deployment was associated with poorer health.
... Because drop-out rates are usually rather high in longitudinal research of military personnel (e.g., due to the high turnover rate; Engelhard, van den Hotopf & Wessely, 2005), strategies for retaining participants were used, such as developing positive relationships (e.g., informing participants about the progress of the study, giving information about names and roles of research personnel), selecting and training suitable research personnel, testing participants at their military base, and obtaining information from participants to facilitate relocating them (cf. Grant, Raper, Kang, & Weaver, 2008). ...
... Practically every outcome and exposure surveyed have statistically significant associations. [56][57][58] Consistency of recall after 2 to 4 years is only modest, with kappa values mostly from 0.35 to 0.55. 59 Gulf war veterans with improving health perception recall fewer wartime health hazard exposures over time, whereas those with worsening health perception recall new wartime health hazards over time. ...
Postencephalitic parkinsonism has been considered unique among disorders with parkinsonian features because it is believed to have a unitary etiology associated with the virus that presumably caused encephalitis lethargica. Careful analysis of the historical record, however, suggests that this relationship is more complex than commonly perceived. In most cases, the diagnosis of acute encephalitis lethargica was made post hoc, and virtually any catarrh-like illness was considered to have represented encephalitis lethargica, often after an oral history-taking that was undoubtedly subject to patient recall and physician bias. Also, postencephalitic parkinsonism and oculogyric crises were not recognized as sequelae to encephalitis lethargica until well after other sequelae such as movement disorders and mental disturbances had been identified (see previous paper). We suggest here that the relationship between encephalitis lethargica and postencephalitic parkinsonism is not simplistic, i.e., encephalitis lethargica was not solely responsible for the etiology of postencephalitic parkinsonism, thus aligning the latter with most other parkinsonian disorders that are now believed to have multiple causes.
... Although clearly much public concern exists, the problem as stated above is the palpable lack of credible epidemiological evidence. This is partly because of the many practical methodological 83 problems with conducting epidemiology studies in Iraq, as mentioned above and recently discussed by Hotopf and Wessely for example 68 . ...
This article describes uranium and depleted uranium (DU), their similar isotopic compositions, how DU arises, its use in munitions and armour-proofing, and its pathways for human exposures. Particular attention is paid to the evidence of DU's health effects from cell and animal experiments and from epidemiology studies. It is concluded that a precautionary approach should be adopted to DU and that there should be a moratorium on its use by military forces. International efforts to this end are described.
... Firstly, stigma is known to influence the decision to come forward for mental health assessment, (Corrigan 2004) and some may have chosen not to report sick. Secondly, there may be a 'well warrior effect' (Hotopf & Wessely 2005) operating as those military personnel who deploy to operational theatres may be less susceptible to the effects of mental ill-health than those who do not. In a study of 4500 UK Armed Forces personnel, examined the role of psychological symptoms in the employability of medically downgraded personnel. ...
UK Forces are currently engaged in high tempo, high intensity operations in both Iraq and Afghanistan. Concern has been raised about the impact of current operations upon the mental health of Service personnel. Using data gathered from deployed Field Mental Health Teams, a random sample of UK based non-deployed Community Mental Health Teams and services dedicated to mobilising, de-mobilising and to de-mobilised Reserve Forces, this paper explores the current mental health burden for UK Forces. At present, operationally related psychological disorders do not appear to be a substantial concern for Regular Forces, although for the minority that suffer such problems they are both distressing and of occupational relevance. Proportionately there are more mobilised Reserve Forces seeking help for mental health problems than Regular Forces on operations, but the overall burden that they currently place upon the Defence Mental Health Services is small. There is at present no evidence of an epidemic of mental health problems amongst either Regular or Reserve Forces veterans of the Op TELIC deployment, however, this may change in the future given the evolving nature and fluctuating intensity of operational activity.
... Additionally, in a larger study that ran alongside this sample (but did not overlap) we found no evidence of nonresponse bias (Tate et al., 2007). We advise caution in results based on questionnaire completion because it may inflate estimates of PTSD (Hotopf & Wessely, 2005), but in our study the prevalence of PTSD was low as has been shown in our larger survey (Hotopf et al., 2006). In conclusion, we have shown that information on predeployment psychological health is unlikely to be a major cause of recall bias for PTSD and psychological distress. ...
In a prospective study, we evaluated pre- and postdeployment psychological health on recall of risk factors to assess recall bias. Measures of the General Health Questionnaire (GHQ), PTSD Checklist (PCL), and symptom clusters from the PCL were obtained from 681 UK military personnel along with information on traumatic and protective risk factors. Postdeployment psychological health was more important in explaining recall of traumatic experiences than predeployment psychological health. Predeployment intrusive cluster scores were highly associated with traumatic exposures. Postdeployment, but not predeployment GHQ showed small effects for most risk factors. With the exception of intrusive thoughts, there is insufficient evidence to suggest predeployment psychological status would be useful in correcting for recall bias in subsequent cross-sectional studies.
... We do not anticipate that many of these complex scientific and political issues will be resolved in the near future. Improved research capability and a more rapid response to health concerns will assist, but the difficulties in conducting research in the military context in general, and the emotionally charged atmosphere that continues to exist around unexplained illnesses in particular, will remain (Neutra 1985;Roht et al. 1985;David & Wessely 1995;Hotopf & Wessely 2005). As a result, numerous unconfirmed and controversial hypotheses about the effects of low-level exposures will flourish, just as they did after the Gulf campaign. ...
Of Britain's recent wars, the Falklands campaign of 1982 was anomalous in many respects, fought to defend a colony with a small but a loyal population, 8000 miles away, but it was also relatively straightforward. It involved high-level diplomacy and consultations at the United Nations, but it was decided on the battlefield in a series of short, but intense engagements conducted by elite units, starting at sea, with civilians at risk only towards the end. The politics were uncomplicated: the British territory had been taken in a clear act of aggression by an unsavoury military junta. The British forces were sent into action on a patriotic mission without having to worry about allies. Domestic public opinion was largely in favour of a robust response, and gave enthusiastic backing to the forces, while inter-national opinion was also generally supportive, although anxious, when the response looked over robust. As it is well known, the campaign was a military success. Furthermore, in the aftermath of the war, there was little debate or controversy concerning any long-term impact on health. Only the possible impact of the conflict on the mental health of service personnel became a cause of concern, and this did not surface for some years. The initial impression was of only a very few acute psychiatric casualties, which was not surprising, since the cause was clear-cut, morale was high, engagements were few, civilian massacres were absent, and the campaign was successful. It was also thought that the long sea voyages to and from the conflict made adjusting both to the prospects of combat and then its aftermath easier. It took time before concerns developed about the appearance of post-traumatic stress disorder (PTSD) in veterans of the campaign, as more began to report symptoms blamed on the conflict. Claims were made about the distressed state of many veterans'lives, not just PTSD, but also alcoholism and crime. By 2000, allegations were being made that increasing numbers of veterans were committing suicide, although the absence of any systematic monitoring made it impossible to determine the true rate of PTSD and/or suicide. In 2002, a group action with which some 2000 veterans were associated, including a number of veterans from the Falklands (notably Welsh Guardsmen who had been aboard
... If the multi-symptom illnesses seen in Gulf War veterans are caused by a single or small number of agents, it is necessary to identify hazards to which many veterans would have been exposed. Some hazards which have attracted considerable interest as potential causes such as depleted uranium are-from an epidemiological perspective-inherently unlikely to be a major cause of illness, as too few personnel could have been exposed to cause the health effect observed (Hotopf & Wessely 2005). This is one reason why medical counter measures (MCM) against nuclear, biological and chemical attack which theoretically were available to all deployed personnel are an important potential cause. ...
One candidate cause of Gulf War illness is vaccination against infectious diseases including medical counter-measures against biological weapons. One influential theory has suggested that such mass-vaccination caused a shift in immune response to a Type 2 cytokine pattern (Th2), which it was suggested was accompanied by a chronic fatigue syndrome-like illness. This article critically appraises this theory. We start by examining epidemiological evidence, which indicates that single vaccines are unlikely to be a substantial cause of Gulf War illness, but that there was a modest relationship with multiple vaccines, which was strongest in those vaccinated while deployed to the Gulf. These relationships may be affected by recall bias. We conclude by examining the results of immunological studies carried out in veterans or in a relevant setting in vitro. The balance of evidence from immunological studies on veterans returning from the War, including those developing multi-symptom illness, is that the immune response has not become polarized towards Th2. In summary, the epidemiological evidence for a multiple vaccine effect on Gulf War-related illness remains a potentially important aetiological lead, but mechanistic studies available at this stage do not identify any immunological basis for it.
... It is my opinion that this is unlikely to change with the passage of time, and that the delay in commencing serious scientific study of the problem has meant that any chances that once existed of providing better answers on aetiology have probably vanished. Unlike many health problems, the window of opportunity to properly investigate post-deployment health problems is brief (Hotopf & Wessely 2005). Perhaps time will prove this pessimistic prediction wrong, and there is no denying that we have learned much about post-deployment physical and psychological health problems and their management. ...
... Comparison with civilian groups is inappropriate for the reasons given. Comparison with non-deployed service personnel could be complicated by the 'healthy warrior effect' [18]. Data on the prevalence of psychological distress, physical symptom reporting, PTSD and excessive alcohol consumption, not collected in the context of a specific deployment, could serve as a useful baseline. ...
To assess the prevalence of psychological symptoms during periods of relatively low deployment activity and the factors associated with each psychological health outcome.
A survey of 4500 randomly selected UK service personnel was carried out in 2002. The questionnaire included the General Health Questionnaire (GHQ-12), the post-traumatic stress disorder checklist (PCL), 15 symptoms and an assessment of alcohol intake.
A total of 20% were above cut-offs for GHQ-12, 15% for symptoms, 12% for alcohol intake and 2% for PCL. Gender, age, excessive drinking and smoking were independently associated with most outcomes of interest. Number of deployments was independently associated with multiple symptoms and excessive drinking. High post-traumatic stress disorder score was more frequent in the Army and in lower ranks.
Psychological symptoms are highly prevalent in UK Armed Forces. Many risk factors are associated with measures of psychological ill-health.
... For symptoms reported as experienced since the first 5 years after visiting Porton Down, three of the top five, and six of the top ten, symptoms are similar to those reported by the Gulf War veterans. The significance of this similarity is unclear because there is considerable overlap in symptom patterns reported following wars and other potentially harmful expe- riences [18]. The older age of many of the PDVSG membership and the long interval since visiting Porton Down does not rule out post-traumatic stress disorder, which can occur in later life [19]. ...
There has been a Human Volunteer Programme at the British chemical weapons research facility at Porton Down since the First World War, in which some of the participants were exposed to chemical warfare agents.
To identify any striking specific morbidity patterns in members of the Porton Down Veterans Support Group (PDVSG).
A self-completed postal questionnaire was prepared including health immediately after the visits to Porton Down, subsequent diagnoses and hospital admissions, symptoms in, and after, the first 5 years after the visits, fatigue symptoms and current quality of life, measured using the SF-36.
Responses were received from 289 of 436 (66%). Results reported here relate to 269 male respondents of mean age 66.8 years. Sixty-six per cent reported their first visit to Porton Down in the 1950s. The most common diagnoses or hospital admissions reported were diseases of the circulatory system. In the first 5 years after their visits the most common symptoms were headache, irritability or outbursts of anger and feeling un-refreshed after sleep. In the later period, most common symptoms were fatigue, feeling un-refreshed after sleep and sleeping difficulties. Sixty-five per cent met the definition for a case of 'fatigue'. Current quality of life dimensions were consistently lower than age-specific estimates from general population samples.
Members of the PDVSG responding to this survey reported poorer quality of life than the general population. Despite there being no clear pattern of specific morbidities, we cannot rule out ill-health being potentially associated with past experience at Porton Down.
This volume of the Official History of Australian Peacekeeping, Humanitarian and Post-Cold War Operations is the first comprehensive study of Australia's role in the peacekeeping and peace enforcement operations that developed at the end of the Cold War. It recounts vital missions including Namibia (1989–90), Iran (1988–90) and Pakistan/Afghanistan (1989–93), and focuses primarily on Australia's reaction to Iraq's invasion of Kuwait in 1990, including its maritime interception operations, and its controversial participation in the 1991 Gulf War. With exclusive access to Australian Government records and through extensive interviews, David Horner explains the high-level political background to these activities and analyses the conduct of the missions. He brings to life the little-known, yet remarkable stories of many individuals who took part. This is an authoritative and compelling history of how members of the Australian Defence Force engaged with the world at a crucial time in international affairs.
This volume of the Official History of Australian Peacekeeping, Humanitarian and Post-Cold War Operations is the first comprehensive study of Australia's role in the peacekeeping and peace enforcement operations that developed at the end of the Cold War. It recounts vital missions including Namibia (1989–90), Iran (1988–90) and Pakistan/Afghanistan (1989–93), and focuses primarily on Australia's reaction to Iraq's invasion of Kuwait in 1990, including its maritime interception operations, and its controversial participation in the 1991 Gulf War. With exclusive access to Australian Government records and through extensive interviews, David Horner explains the high-level political background to these activities and analyses the conduct of the missions. He brings to life the little-known, yet remarkable stories of many individuals who took part. This is an authoritative and compelling history of how members of the Australian Defence Force engaged with the world at a crucial time in international affairs.
Background: Posttraumatic stress disorder (PTSD) and dissociation have long been associated with each other. In recent years, studies have examined support for the dissociative subtype of PTSD in several different populations. To date, no study has examined whether this subtype exists in UK Armed Forces military veterans residing in Northern Ireland. Northern Ireland has a history of prolonged civil conflict, differentiating the veterans who live in the region from veterans who live in the remainder of the United Kingdom; and increasing the likelihood that they will experience mental health difficulties. Methods: Data was collected through a cross-sectional, self-report survey from military veterans living in Northern Ireland. The effective sample for the current study was 834 veterans (90.38% males, mean age 55.81 years). A latent profile analysis of PTSD and dissociative indicators was conducted to examine the existence of the dissociative PTSD subtype. Results: Four quantitatively different latent profiles were identified; Non-symptomatic, Low PTSD, Moderate PTSD and High PTSD. There was no evidence of a dissociative PTSD subtype. Several military-type variables differentially predicted membership in the latent profiles, including combat exposure, length of service, physical injuries during service and having been medically discharged. Conclusions: The results do not support the Subtype model of the relationship between PTSD and dissociation. However, they have important implications for clinicians working with veterans in the region, as it appears that dissociation is an integral part of the PTSD presentation in Northern Irish veterans.
Multiple studies indicate that United States veterans have an increased risk of developing amyotrophic lateral sclerosis (ALS) compared to civilians. However, the responsible etiological factors are unknown. In the general population, specific occupational (e.g. truck drivers, airline pilots) and environmental exposures (e.g. metals, pesticides) are associated with an increased ALS risk. As such, the increased prevalence of ALS in veterans strongly suggests that there are exposures experienced by military personnel that are disproportionate to civilians. During service, veterans may encounter numerous neurotoxic exposures (e.g. burn pits, engine exhaust, firing ranges). So far, however, there is a paucity of studies investigating environmental factors contributing to ALS in veterans and even fewer assessing their exposure using biomarkers. Herein, we discuss ALS pathogenesis in relation to a series of persistent neurotoxicants (often emitted as mixtures) including: chemical elements, nanoparticles and lipophilic toxicants such as dioxins, polycyclic aromatic hydrocarbons and polychlorinated biphenyls. We propose these toxicants should be directly measured in veteran central nervous system tissue, where they may have accumulated for decades. Specific toxicants (or mixtures thereof) may accelerate ALS development following a multistep hypothesis or act synergistically with other service-linked exposures (e.g. head trauma/concussions). Such possibilities could explain the lower age of onset observed in veterans compared to civilians. Identifying high-risk exposures within vulnerable populations is key to understanding ALS etiopathogenesis and is urgently needed to act upon modifiable risk factors for military personnel who deserve enhanced protection during their years of service, not only for their short-term, but also long-term health.
Aims:
Gulf War Illness (GWI) remains a significant health concern for many veterans. The relation of pre-war health conditions and symptoms to GWI could aid in developing a more accurate case definition of GWI. The objective of this study was to investigate pre-war predictors of GWI in a population-based sample of Gulf War veterans using two definitions of GWI.
Main methods:
Data come from the 1995-1997 National Health Survey of Persian Gulf War Era Veterans, a survey of a representative sample of deployed and non-deployed US veterans. Using two definitions of GWI (CDC/Kansas and a newly developed 3-domain definition), we conducted a series of multivariable logistic regression analyses to assess the associations of demographic, lifestyle factors, and pre-war medical conditions and symptoms to subsequent GWI.
Key findings:
All pre-war symptom predictor domains were significantly and positively associated with GWI using a new 3-domain definition with aORs for individual domains ranging from 2.17 (95% CI = 1.99-2.38) for dermatologic conditions to 3.06 (95% CI = 2.78-3.37) for neurological conditions. All symptom predictor domains were associated with significantly increased likelihood of GWI using the CDC/Kansas definition, with aORs ranging from 2.54 (95% CI = 2.31-2.81) for inflammatory conditions to 3.22 (95% CI = 2.94-3.55) for neurological conditions. These estimates were attenuated but remained significant after inclusion of all significant symptom predictor domains.
Significance:
Results from this study suggest that demographic/lifestyle factors and pre-war medical conditions are strong predictors of GWI. Additional research is needed to confirm these findings, and to clarify the unique characteristics of this common, but still poorly understood illness.
Gulf War illness (GWI) is a chronic and multi-symptomatic disorder affecting veterans who served in the Gulf War. The commonly reported symptoms in GWI veterans include mood problems, cognitive impairment, muscle and joint pain, migraine/headache, chronic fatigue, gastrointestinal complaints, skin rashes, and respiratory problems. Neuroimaging studies have revealed significant brain structure alterations in GWI veterans, including subcortical atrophy, decreased volume of the hippocampus, reduced total grey and white matter, and increased brain white matter axial diffusivity. These brain changes may contribute to or increase the severities of the GWI-related symptoms. Epidemiological studies have revealed that neurotoxic exposures and stress may be significant contributors to the development of GWI. However, the mechanism underlying how the exposure and stress could contribute to the multi-symptomatic disorder of GWI remains unclear. We and others have demonstrated that rodent models exposed to GW-related agents and stress exhibited higher extracellular glutamate levels, as well as impaired structure and function of glutamatergic synapses. Restoration of the glutamatergic synapses ameliorated the GWI-related pathological and behavioral deficits. Moreover, recent studies showed that a low-glutamate diet reduced multiple symptoms in GWI veterans, suggesting an important role of the glutamatergic system in GWI. Currently, growing evidence has indicated that abnormal glutamate neurotransmission may contribute to the GWI symptoms. This review summarizes the potential roles of glutamate dyshomeostasis and dysfunction of the glutamatergic system in linking the initial cause to the multi-symptomatic outcomes in GWI and suggests the glutamatergic system as a therapeutic target for GWI.
The Coronavirus SARS-CoV-2 has spread rapidly since the first cases hit Wuhan, China at the end of 2019, and has now landed in almost every part of the world. By mid-February 2020, China, South Korea, Singapore, Taiwan, and – to some extent – Japan began to contain and control the spread of the virus, while conversely, cases increased rapidly in Europe and the United States. In response to the pandemic, many countries have had to introduce drastic legally mandated lockdowns to enforce physical separation, which are ravaging economies worldwide. Although it will be many months or even years before the final verdict can be reached, we believe that it is already possible to identify 12 key lessons that we can learn from to reduce the tremendous economic and social costs of this pandemic and which can inform responses to future crises. These include lessons around the importance of transparency, solidarity, coordination, decisiveness, clarity, accountability and more.
This study investigated the challenges and facilitators of occupational epidemiology (OE) research in the UK, and evaluated the impact of these challenges. Semi-structured in-depth interviews with leading UK-based OE researchers, and a survey of UK-based OE researchers were conducted. Seven leading researchers were interviewed, and there were 54 survey respondents. Key reported challenges for OE were diminishing resources during recent decades, influenced by social, economic and political drivers, and changing fashions in research policy. Consequently, the community is getting smaller and less influential. These challenges may have negatively affected OE research, causing it to fail to keep pace with recent methodological development and impacting its output of high-quality research. Better communication with, and support from other researchers and relevant policy and funding stakeholders was identified as the main facilitators to OE research. Many diseases were initially discovered in workplaces, as these make exceptionally good study populations to accurately assess exposures. Due to the decline of manufacturing industry, there is a perception that occupational diseases are now a thing of the past. Nevertheless, new occupational exposures remain under-evaluated and the UK has become reliant on overseas epidemiology. This has been exacerbated by the decline in the academic occupational medicine base. Maintaining UK-based OE research is hence necessary for the future development of occupational health services and policies for the UK workforce.
Prevalence PTSD Onset and Course Sociopolitical and Cultural Factors Compensation and Pension Evaluations and Treatment Planning Implications Clinical Assessment with Veterans Working within the Veterans Affairs System Conclusion
This volume of the Official History of Australian Peacekeeping, Humanitarian and Post-Cold War Operations is the first comprehensive study of Australia's role in the peacekeeping and peace enforcement operations that developed at the end of the Cold War. It recounts vital missions including Namibia (1989-90), Iran (1988-90) and Pakistan/Afghanistan (1989-93), and focuses primarily on Australia's reaction to Iraq's invasion of Kuwait in 1990, including its maritime interception operations, and its controversial participation in the 1991 Gulf War. With exclusive access to Australian Government records and through extensive interviews, David Horner explains the high-level political background to these activities and analyses the conduct of the missions. He brings to life the little-known, yet remarkable stories of many individuals who took part. This is an authoritative and compelling history of how members of the Australian Defence Force engaged with the world at a crucial time in international affairs.
The combat stress and its psychopathological consequences have been an interesting subject for psychologists and psychiatrists for more than one hundred years. The specificity of the battlefield stressors as well as their consequences has profoundly changed since then. There are many publications on the subject available now, but most of them are of a very fragmentary character. At the same time there is a demand for contemporary Polish publications about the combat stress. The article contains a short history of the combat stress subject in psychiatry and psychology, the contemporary presentation of the subject and ways of applying this term. The authors' intension was to show the correlations between the approach to combat stress and such factors as the type of military operations, recent knowledge about stress reactions and possibilities of curing them. Epidemiology of the stress reactions in the battlefield was shown for the last decades' wars and its influence on the research on stress reactions in the domain of psychology and psychiatry. It was emphasized that researchers and practitioners still have much to do about the combat stress. One of the most important goals of the article was to show the Polish perspective of the combat stress compared to the world mainstream in the research and practice. The authors have also shown the most important contemporary Polish publications about the combat stress.
ABSTRACT This initial study is aimed to measure the performance of incorporating pyriproxyfen in natural materials with low environmental impact to obtain slow release formulations that can be used as larvicidal or autocidal ovitraps avoiding hatched Aedes aegypti (L.) eggs to emerge as adults. Hollow candles made of beeswax or paraffin:stearin 1:1 mixture containing pyriproxyfen 0.01 and 0.05% were prepared and used as holding water containers for larval bioassay. Pyriproxyfen was released quickly into the larvae-breeding water. Ae. aegypti larvae were introduced immediately after the addition of tap water to the hollow candles (t = 1 min) or after 1, 4, and 8 h. More than 40% of the larvae did not emerge as adults for t = 1 min, reaching 80-100% when the larvae were added after 1 or 4 h, respectively. The hollow candles were kept at room temperature, and water was replaced every 15 d. Bioassays performed every 30 d showed that the residual activity obtained for both matrices and both concentrations of pyriproxyfen was higher than 360 d, with 100% inhibition of adult emergence.
Veterans of the 1990-1991 Gulf War have been reported to have an increased incidence of amyotrophic lateral sclerosis (ALS) compared to personnel who were not deployed. An excess of ALS cases was diagnosed in Gulf War veterans younger than 45 years of age. Increased ALS among Gulf War veterans appears to be an outbreak time-limited to the decade following the Gulf War. Seeking to identify biologically plausible environmental exposures, we have focused on inhalation of cyanobacteria and cyanotoxins carried by dust in the Gulf region, particularly Qatar. Cyanobacterial crusts and mats are widespread in the deserts of Qatar, occupying up to 56% of the available area in some microhabitats. These cyanobacterial crusts, which help bind the desert sands, are dormant throughout most of the year, but during brief spring rains actively photosynthesize. When disturbed by vehicular traffic or other military activities, the dried crusts and mats can produce significant dust. Using HPLC/FD, an amino acid analyzer, UPLC/MS, and triple quadrupole LC/MS/MS we find that the dried crusts and mats contain neurotoxic cyanobacterial toxins, including beta-N-methylamino-L-alanine (BMAA) and 2,4 diaminobutyric acid (DAB). If dust containing cyanobacteria is inhaled, significant exposure to BMAA and other cyanotoxins may occur. We suggest that inhalation of BMAA, DAB, and other aerosolized cyanotoxins may constitute a significant risk factor for the development of ALS and other neurodegenerative diseases.
A sizable literature has analyzed the frequency of alcohol consumption and patterns of drinking among veterans. However, few studies have examined patterns of alcohol use in veterans of the first Gulf War or factors associated with problem drinking in this population. We examined the frequency and patterns of alcohol use in male and female veterans who served in the 1991 Gulf War or during the same era and the relationships between alcohol use and selected health conditions.
We analyzed data from a follow-up survey of health information among population-based samples of 15,000 Gulf War and 15,000 Gulf Era veterans. Data had been collected from 9,970 respondents during 2003 through 2005 via a structured questionnaire or telephone survey.
Posttraumatic stress disorder (PTSD), major depressive disorder (MDD), unexplained multisymptom illness (MSI), and chronic fatigue syndrome (CFS)-like illness were more frequent among veterans with problem drinking than those without problem drinking. Approximately 28% of Gulf War veterans with problem drinking had PTSD compared with 13% of Gulf War veterans without problem drinking. In multivariate analysis, problem drinking was positively associated with PTSD, MDD, unexplained MSI, and CFS-like illness after adjustment for age, sex, race/ethnicity, branch of service, rank, and Gulf status. Veterans who were problem drinkers were 2.7 times as likely to have PTSD as veterans who were not problem drinkers.
These findings indicate that access to evidence-based treatment programs and systems of care should be provided for veterans who abuse alcohol and who have PTSD and other war-related health conditions and illnesses.
Concerns have been raised about the psychological effect of continued combat exposure and of repeated deployments. We examined the consequences of deployment to Iraq and Afghanistan on the mental health of UK armed forces from 2003 to 2009, the effect of multiple deployments, and time since return from deployment.
We reassessed the prevalence of probable mental disorders in participants of our previous study (2003-05). We also studied two new randomly chosen samples: those with recent deployment to Afghanistan, and those who had joined the UK armed forces since April, 2003, to ensure that the final sample continued to be representative of the UK armed forces. Between November, 2007, and September, 2009, participants completed a questionnaire about their deployment experiences and health outcomes.
9990 (56%) participants completed the study questionnaire (8278 regulars, 1712 reservists). The prevalence of probable post-traumatic stress disorder was 4.0% (95% CI 3.5-4.5; n=376), 19.7% (18.7-20.6; n=1908) for symptoms of common mental disorders, and 13.0% (12.2-13.8; n=1323) for alcohol misuse. Deployment to Iraq or Afghanistan was significantly associated with alcohol misuse for regulars (odds ratio 1.22, 95% CI 1.02-1.46) and with probable post-traumatic stress disorder for reservists (2.83, 1.23-6.51). Regular personnel in combat roles were more likely than were those in support roles to report probable post-traumatic stress disorder (1.87, 1.26-2.78). There was no association with number of deployments for any outcome. There was some evidence for a small increase in the reporting of probable post-traumatic stress disorder with time since return from deployment in regulars (1.13, 1.03-1.24).
Symptoms of common mental disorders and alcohol misuse remain the most frequently reported mental disorders in UK armed forces personnel, whereas the prevalence of probable post-traumatic stress disorder was low. These findings show the importance of continued health surveillance of UK military personnel.
UK Ministry of Defence.
The Australian Government has supported the establishment of a Deployment Health Surveillance Program for the Australian Defence Force. Although some health screening mechanisms already exist for Australian Defence Force personnel, until now health data have been used largely for clinical management at an individual level and have not been aggregated to identify trends in health and risk factors in the shorter or longer term. We identify challenges for and potential benefits of health surveillance in the military context, describe features of the Program and progress to date. Retrospective and cross-sectional projects based on deployments to the Near North Area of Influence since 1997 are under way. A planned prospective model of health surveillance for those deploying to the Middle East promises more timely attention to any emerging health problems for military personnel and veterans.
In the last 15 years, the US and UK have fought two major wars in the Persian Gulf region. Controversy has arisen over the nature and causes of health problems among military veterans of these two wars. Toxic exposures have been hypothesised to cause the majority of the long-term health problems experienced by veterans of the 1991 Gulf War. The assessment of these toxic exposures and the resolution of controversy about their health effects provide a unique case study for understanding how toxicological disputes are settled in the US. Neither clinical examination of ill war veterans nor scientific research studies have been sufficient to answer contentious questions about toxic exposures. Numerous expert review panels have also been unable to resolve these controversies except for the US National Academy of Sciences Institute of Medicine (IOM). The IOM has conducted exhaustive and independent investigations based on peer-reviewed scientific literature related to potential health risks during the two Gulf Wars. In four recent studies, IOM committees identified a wide range of previously documented illnesses associated with common occupational and environmental exposures after considering thousands of relevant publications; however, they did not identify a new medical syndrome or a specific toxic exposure that caused widespread health problems among Gulf War veterans. These IOM studies have, therefore, added little to our basic knowledge of environmental hazards because most of the health effects were well known. Nevertheless, this expert review process, which is on-going, has been generally acceptable to a wide range of competing interests because the findings of the IOM have been perceived as scientifically credible and independent, and because none of the postulated toxicological risks have been completely ruled-out as possible causes of ill health among veterans.
Elevated alcohol use disorders have been observed in 1991 Gulf War veterans from a variety of countries. This study used a self-report instrument, the Alcohol Use Disorders Identification Test (AUDIT), to ascertain whether any subgroups of 1232 male Royal Australian Navy (RAN) Gulf War veterans were at higher risk of hazardous or harmful alcohol use. Recursive partitioning/classification and regression tree (CART) analysis, followed by logistic regression, found five subgroups among the veterans, with differing risks of AUDIT caseness. The highest risk subgroup comprised current smokers. The other two high risk groups both consisted of former or never smokers of lower rank who were (1) not married, or (2) married, with a current diagnosis of major depression. The above subgroups were over three times as likely to exhibit AUDIT caseness than those who were former or never smokers of higher rank. The findings have important implications for effective development of public health initiatives designed to encourage safe alcohol use among veterans.
Concerns have been raised about the mental and physical health of UK military personnel who deployed to the 2003 war in Iraq and subsequent tours of duty in the country.
We compared health outcomes in a random sample of UK armed forces personnel who were deployed to the 2003 Iraq war with those in personnel who were not deployed. Participants completed a questionnaire covering the nature of the deployment and health outcomes, which included symptoms of post-traumatic stress disorder, common mental disorders, general wellbeing, alcohol consumption, physical symptoms, and fatigue.
The participation rate was 62.3% (n=4722) in the deployed sample, and 56.3% (n=5550) in the non-deployed sample. Differences in health outcomes between groups were slight. There was a modest increase in the number of individuals with multiple physical symptoms (odds ratio 1.33; 95% CI 1.15-1.54). No other differences between groups were noted. The effect of deployment was different for reservists compared with regulars. In regulars, only presence of multiple physical symptoms was weakly associated with deployment (1.32; 1.14-1.53), whereas for reservists deployment was associated with common mental disorders (2.47, 1.35-4.52) and fatigue (1.78; 1.09-2.91). There was no evidence that later deployments, which were associated with escalating insurgency and UK casualties, were associated with poorer mental health outcomes.
For regular personnel in the UK armed forces, deployment to the Iraq war has not, so far, been associated with significantly worse health outcomes, apart from a modest effect on multiple physical symptoms. There is evidence of a clinically and statistically significant effect on health in reservists.
RAND Health The RAND testimony series contains the statements of RAND staff members as prepared for delivery. CT-164 DUO QUALHT IKSPIOTED 1 20000204 060 RAND is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions or policies of its research sponsors.
Objective:
To assess the prevalence of self-reported symptoms and illnesses among military personnel deployed during the Persian Gulf War (PGW) and to compare the prevalence of these conditions with the prevalence among military personnel on active duty at the same time, but not deployed to the Persian Gulf (non-PGW).
Design:
Cross-sectional telephone interview survey of PGW and non-PGW military personnel. The study instrument consisted of validated questions, validated questionnaires, and investigator-derived questions designed to assess relevant medical and psychiatric conditions.
Setting:
Population-based sample of military personnel from Iowa.
Study participants:
A total of 4886 study subjects were randomly selected from 1 of 4 study domains (PGW regular military, PGW National Guard/Reserve, non-PGW regular military, and non-PGW National Guard/Reserve), stratifying for age, sex, race, rank, and branch of military service.
Main outcome measures:
Self-reported symptoms and symptoms of medical illnesses and psychiatric conditions.
Results:
Overall, 3695 eligible study subjects (76%) and 91% of the located subjects completed the telephone interview. Compared with non-PGW military personnel, PGW military personnel reported a significantly higher prevalence of symptoms of depression (17.0% vs 10.9%; Cochran-Mantel-Haenszel test statistic, P<.001), posttraumatic stress disorder (PTSD) (1.9% vs 0.8%, P=.007), chronic fatigue (1.3% vs 0.3%, P<.001), cognitive dysfunction (18.7% vs 7.6%, P<.001), bronchitis (3.7% vs 2.7%, P<.001), asthma (7.2% vs 4.1%, P=.004), fibromyalgia (19.2% vs 9.6%, P<.001), alcohol abuse (17.4% vs 12.6%, P=.02), anxiety (4.0% vs 1.8%, P<.001), and sexual discomfort (respondent, 1.5% vs 1.1%, P=.009; respondent's female partner, 5.1% vs 2.4%, P<.001). Assessment of health-related quality of life demonstrated diminished mental and physical functioning scores for PGW military personnel. In almost all cases, larger differences between PGW and non-PGW military personnel were observed in the National Guard/Reserve comparison. Within the PGW military study population, compared with veterans in the regular military, veterans in the National Guard/Reserve only reported more symptoms of chronic fatigue (2.9% vs 1.0%, P=.03) and alcohol abuse (19.4% vs 17.0%, P=.004).
Conclusions:
Military personnel who participated in the PGW have a higher self-reported prevalence of medical and psychiatric conditions than contemporary military personnel who were not deployed to the Persian Gulf. These findings establish the need to further investigate the potential etiologic, clinical, pathogenic, and public health implications of the increased prevalence of multiple medical and psychiatric conditions in populations of military personnel deployed to the Persian Gulf.
The factorial similarity of Psychoticism (P), Extraversion (E), Neuroticism (N), and Social Desirability (L), as measured by the Eysenck Personality Questionnaire, was assessed using gender- specific data collected from 34 countries. As in an earlier study using data from 24 countries (Eysenck et al., 1985), the Kaiser-Hunka-Bianchini (KHB) procedure was utilised as a measure of factorial similarity. However, given the recent evidence concerning the flawed interpretation of the original KHB coefficients, two other coefficients were used to make an assessment of factorial similarity: a congruence coefficient computed from the KHB maximally congruent orthogonalised factors, and a congruence coefficient computed from the oblique factor patterns of the U.K. target and foreign country matrices. The results of these procedures (using the U.K. factor matrices as targets, toward which each country’s factor pattern is rotated) indicated that: (1) the Eysenck factors are strongly replicable across all 34 countries (2) the modified KHB similarity procedure is sound, given the nature of these particular comparisons (3) in comparison to the oblique pattern matrix congruences, those computed over the KHB maximally congruent matrices were found to be optimal both in terms of size and variation. It was concluded that contrary to pessimistic observations made elsewhere, concerning the validity of the factor comparisons based upon ‘original’ KHB coefficients, the analyses in this paper conclusively demonstrate a significant degree of factorial similarity with the U.K. data, across the 34 comparison countries.
The objective of this study was to measure the prevalence of multiple chemical sensitivity (MCS) and chronic fatigue syndrome (CFS) in British Gulf War veterans and to investigate their association with reported exposures and psychologic morbidity. In 1997–1998, the authors undertook a cross-sectional survey of three cohorts of British military personnel comprising Gulf veterans ( n = 3,531), those who had served in Bosnia ( n = 2,050), and those serving during the Gulf War but not deployed there (Era cohort, n = 2,614). MCS and CFS were defined according to operational criteria. The prevalence of MCS in the Gulf, Bosnia, and Era cohorts was 1.3%, 0.3%, and 0.2%, respectively. For CFS, the prevalence was 2.1% (Gulf cohort), 0.7% (Bosnia cohort), and 1.8% (Era cohort). In Gulf veterans, MCS was strongly associated with exposure to pesticides (adjusted odds ratio = 12.3, 95% confidence interval: 5.1, 30.0). Both syndromes were associated with high levels of psychologic morbidity. These findings suggest that CFS and MCS account for some of the medically unexplained illnesses reported by veterans after deployment to the Gulf. MCS was particularly associated with Gulf deployment and self-reported exposure to pesticides, findings that merit further exploration given the controversial status of this diagnosis and the potential for recall bias in a questionnaire survey.
Since the Persian Gulf War ended in 1991, many veterans of that conflict have reported diverse, unexplained symptoms. To evaluate the health of Gulf War veterans, we studied their postwar hospitalization experience and compared it with that of other military personnel serving at the same time who did not go to the Persian Gulf.
Using a retrospective cohort approach and data from Department of Defense hospitals, we studied hospitalizations of 547,076 veterans of the Gulf War who were serving in the Army, Navy, Marine Corps, and Air Force and 618,335 other veterans from the same era who did not serve in the Persian Gulf. Using multivariate logistic-regression models, we analyzed risk factors for hospitalization both overall and in 14 broad diagnostic categories during three periods from August 1991 through September 1993 (a total of 45 specific comparisons).
After the war, the overall odds ratio for hospitalization of the Gulf War veterans was not higher than that of the other veterans, even after adjustment for selection effects related to deployment. In 16 of the 42 comparisons involving specific diagnoses, the risk of hospitalization among Gulf War veterans differed significantly from that among other veterans. Among these 16 comparisons, Gulf War veterans were at higher risk in 5: neoplasms (largely benign) during 1991, diseases of the genitourinary system during 1991, diseases of the blood and blood-forming organs (mostly forms of anemia) during 1992, and mental disorders during both 1992 and 1993. The differences were not consistent over time and could be accounted for by deferred care, postwar pregnancies, and postwar stress.
During the two years after the Persian Gulf War, there was no excess of unexplained hospitalization among Americans who remained on active duty after serving in that conflict.
There has been suspicion that service in the Persian Gulf War affected the health of veterans adversely, and there have been claims of an increased rate of birth defects among the children of those veterans.
We evaluated the routinely collected data on all live births at 135 military hospitals in 1991, 1992, and 1993. The data base included up to eight diagnoses from the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) for each birth hospitalization, plus information on the demographic characteristics and service history of the parents. The records of over 75,000 newborns were evaluated for any birth defect (ICD-9-CM codes 740 to 759, plus neoplasms and hereditary diseases) and for birth defects defined as severe on the basis of the specific diagnoses and the criteria of the Centers for Disease Control and Prevention.
During the study period, 33,998 infants were born to Gulf War veterans and 41,463 to non-deployed veterans at military hospitals. The overall risk of any birth defect was 7.45 percent, and the risk of severe birth defects was 1.85 percent. These rates are similar to those reported in civilian populations. In the multivariate analysis, there was no significant association for either men or women between service in the Gulf War and the risk of any birth defect or of severe birth defects in their children.
This analysis finds no evidence of an increase in the risk of birth defects among the children of Gulf War veterans.
The purpose of this study was to determine if Gulf War veterans with complaints of severe fatigue and/or chemical sensitivity (n = 72) fulfill case definitions for chronic fatigue syndrome (CFS) and/or multiple chemical sensitivity (MCS) and to compare the characteristics of those veterans who received a diagnosis of CFS (n = 24) to a group of non-veterans diagnosed with CFS (n = 95). Thirty-three veterans received a diagnosis of CFS with 14 having MCS concurrently; an additional six had MCS but did not fulfill a case definition for CFS. The group of fatigued veterans receiving a diagnosis of CFS was comprised of significantly fewer women and fewer Caucasians than the civilian group, and significantly fewer veterans reported a sudden onset to their illness. Veterans with CFS had a milder form of the illness than their civilian counterparts based on medical examiner assessment of the severity of the symptoms, reported days of reduced activity, and ability to work. Since CFS in veterans seems less severe than that seen in civilians, the prognosis for recovery of veterans with this disorder may be better.
To investigate reports on war-related morbidity, 527 active-duty Gulf War veterans and 970 nondeployed veterans from 14 Seabee commands were studied in 1994 with a questionnaire, sera collection, handgrip strength, and pulmonary function testing. The questionnaire assessed postwar symptoms, war exposures, and screened for chronic fatigue syndrome, post-traumatic stress disorder, and psychological symptoms suggesting neurosis (Hopkins Symptom Checklist). Sera were tested with four nonspecific reactant assays: C-reactive protein, transferrin, ferritin, and haptoglobin. Gulf War veterans reported a higher prevalence for 35 of 41 symptoms, scored higher on psychological symptom scales, were more likely to screen for post-traumatic stress disorder, had lower handgrip strength, and had higher serum ferritin assay results. Numerous comparisons of these morbidity outcomes with 30 self-reported exposures demonstrated many associations, but no unique exposure or group of exposures were implicated. Morbidity data are consistent with other postwar observations, but the etiology for morbidity findings remains uncertain.
We review the concept and importance of functional somatic symptoms and syndromes such as irritable bowel syndrome and chronic fatigue syndrome. On the basis of a literature review, we conclude that a substantial overlap exists between the individual syndromes and that the similarities between them outweigh the differences. Similarities are apparent in case definition, reported symptoms, and in non-symptom association such as patients' sex, outlook, and response to treatment. We conclude that the existing definitions of these syndromes in terms of specific symptoms is of limited value; instead we believe a dimensional classification is likely to be more productive.
More than 68000 of the 700000 veterans of the Gulf War have become members of the Veteran Affairs' Gulf War Registry. In 1995, we undertook a questionnaire study of the symptoms and medical histories reported by a randomly selected subsample of 1935 of these veterans to characterize their complaints. All results reported were based on questionnaire responses without face-to-face evaluation or physical examinations. Inasmuch as initial registry symptoms overlapped those of Chronic Fatigue Syndrome and Multiple Chemical Sensitivities, we also included standard questions for these syndromes in the questionnaire. A total of 1161 (60%) individuals responded, and there were no major demographic biases; therefore, 15.7% of registry veterans qualified for Chronic Fatigue Syndrome in accordance with the 1994 Centers for Disease Control definition. In addition, 13.1% qualified for multiple chemical sensitivities in accordance with a widely used definition, and 3.3% of the respondents had both conditions. There were no effects of gender, race, branch, duty status (active or reserve), or rank, although Multiple Chemical Sensitivities was somewhat more prevalent in women and African Americans. The data gleaned in this study suggested that the unexplained symptom syndromes of Chronic Fatigue and Multiple Chemical Sensitivities may characterize an appreciable portion of the complaints of those who volunteered for the Veterans Affairs' Gulf War Registry, and further investigation is warranted.
To explore the relation between ill health after the Gulf war and vaccines received before or during the conflict. To test the hypothesis that such ill health is limited to military personnel who received multiple vaccines during deployment and that pesticide use modifies any effect.
Cross sectional study of Gulf war veterans followed for six to eight years after deployment.
UK armed forces.
Military personnel who served in the Gulf and who still had their vaccine records.
Multisymptom illness as classified by the Centers for Disease Control and Prevention; fatigue; psychological distress; post-traumatic stress reaction; health perception; and physical functioning.
The response rate for the original survey was 70.4% (n=3284). Of these, 28% (923) had vaccine records. Receipt of multiple vaccines before deployment was associated with only one of the six health outcomes (post-traumatic stress reaction). By contrast five of the six outcomes (all but post-traumatic stress reaction) were associated with multiple vaccines received during deployment. The strongest association was for the multisymptom illness (odds ratio 5.0; 95% confidence interval 2.5 to 9.8).
Among veterans of the Gulf war there is a specific relation between multiple vaccinations given during deployment and later ill health. Multiple vaccinations in themselves do not seem to be harmful but combined with the "stress" of deployment they may be associated with adverse health outcomes. These results imply that every effort should be made to maintain routine vaccines during peacetime.
The Department of Veterans' Affairs, Jackson, Mississippi, and the Mississippi State Department of Health conducted a collaborative investigation of an apparent increase in the numbers of birth defects and other health problems among children born to veterans of two Mississippi National Guard units who had served in the Persian Gulf War. The medical records of all children conceived by and born to veterans of the two units after deployment were reviewed; observed numbers of birth defects and other health problems were compared with expected numbers using rates from birth defect surveillance systems and previous surveys. The total number of all types of birth defects was not greater than expected, but whether the number of specific birth defects was greater than expected could not be determined. The frequency of premature birth, low birth weight, and other health problems appeared similar to that in the general population.
Since the 1991 Gulf War, more than 10 years and $1 billion dollars of health evaluations and research have been invested in understanding illnesses among Gulf War veterans. We examined the extensive published healthcare utilization data in an effort to summarize what has been learned. Using multiple search techniques, data as of June 2003 from four different national Gulf War health registries and numerous hospitalization and ambulatory care reports were reviewed. Thus far, published reports have not revealed a unique Gulf War syndrome nor identified specific exposures that might explain postwar morbidity. Instead, they have demonstrated that Gulf War veterans have had an increase in multi-symptom condition, injury, and mental health diagnoses. While these diagnoses are similar to those experienced by other comparable military populations, their explanation is not fully understood. New strategies to identify risk factors for, and to reduce, such postdeployment conditions are summarized.
In response to the health concerns of Gulf War veterans, the Department of Defense instituted the Comprehensive Clinical Evaluation Program (CCEP). Although and designed as a research study, the CCEP provided valuable clinical data. An analysis was conducted of CCEP findings from systematic and comprehensive examinations of 20,000 U.S. Gulf War veterans. Among 20,000 participants, the types of primary and secondary diagnoses varied widely. Also, among veterans with an ICD-9-CM diagnosis of 'symptoms, signs, and ill- defined conditions,' no single subcategory of illness predominated, and no characteristic physical sign or laboratory abnormality wa identified. In total, there were 74 (0.4%) cases of connective tissue disease; 52 (0.3%) noncutaneous malignancies; 42 (0.2%) peripheral neuropathies; 14 (0.07%) case of interstitial pulmonary fibrosis; 12 (0.06%) cases of renal insufficiency; and no new cases of viscerotropic leishmaniasis. No clinical indication of a new or unique illness was identified in this self-referred population, and the types of physiologic disease that could result from postulated hazardous wartime exposures were uncommon.
The authors conducted factor analysis on survey data from 1,779 Persian Gulf War veterans. Their purposes were to: 1) determine whether factor analysis identified a unique Gulf War syndrome among veterans potentially exposed to chemical warfare agents; 2) compare the findings of factor analysis with those from an epidemiologic analysis of symptom prevalence; and 3) observe the behavior of factor analysis when performed on dichotomous data. The factor analysis identified three factors, but they were not unique to any particular deployment group. A unique pattern of illness was not found for the larger group of veterans potentially exposed to chemical warfare agents; however, veterans who had witnessed the demolition of chemical warfare agents at the Khamisiyah site in Iraq had a greater prevalence of dysesthesia. An analysis of the performance of dichotomous variables in factor analysis showed that the standard criteria used to determine the number of relevant factors and the dominant variables within them may be inappropriate. While Gulf War veterans appear to suffer an increased burden of illness, there is insufficient evidence to identify a unique syndrome in this population of deployed servicemen and women. Furthermore, the results provide evidence that factor analysis may make a limited contribution in this area of research.
Objective.—
The purpose of this study was to test the hypothesis that the patients with chronic fatigue who have the highest number of medically unexplained physical symptoms over their lifetime would also have the highest prevalence of current and lifetime affective and anxiety disorders, lifetime affective symptoms, and the most functional disability. A further goal was to use this information to modify the current case definition to better identify a subgroup of patients with chronic fatigue syndrome who are less likely to have psychiatric illness.Design.—
Two hundred eighty-five consecutive patients with chronic fatigue were interviewed with the National Institute of Mental Health Diagnostic Interview Schedule and completed four self-rating questionnaires measuring psychologic distress, functional disability, and the tendency to amplify symptoms. Based on previously published data, patients were divided into four groups with a progressively higher number of lifetime medically unexplained physical symptoms. The prevalence of current and lifetime psychiatric disorders, lifetime psychologic symptoms, and extent of functional impairment was then compared in these four groups of patients.Main Results.—
The prevalence of current and lifetime psychiatric diagnosis and lifetime depressive symptoms increased linearly with the number of lifetime physical symptoms that the patient experienced. The extent of impairment in activities of daily living and the tendency to amplify symptoms also increased linearly with the number of medically unexplained physical symptoms.Conclusion.—
The patients with the highest numbers of medically unexplained physical symptoms had extraordinarily high rates of current and lifetime psychiatric disorders. These data suggest that the current case definition for chronic fatigue syndrome inadvertently selects for patients with the highest prevalence of lifetime psychiatric diagnoses. A recommendation based on these results is to modify the case criteria for chronic fatigue syndrome to include patients with fatigue and few physical symptoms and to identify and consider excluding patients with high numbers of physical complaints.(Arch Intern Med. 1992;152:1604-1609)
Shortly after the end of the Gulf War in March 1991, media reports began to emerge that veterans were experiencing a variety of medically unexplained symptoms, including fatigue, headache, aches and pains, and cognitive disturbances. In January 1992, the press reported an “outbreak” of unexplained symptoms among members of the 123rd Army Reserve Unit in Indiana. Soon, other veterans reported similar symptoms, and public concern grew regarding a “mystery illness” or “Gulf War syndrome.” Subsequent investigation of the reserve unit found no evidence for an outbreak of a unique disease (1). Although, well-defined diseases have been identified among some Gulf War veterans (e.g., 12 cases of viscerotropic leishmaniasis) (2), a substantial proportion of Gulf War veterans’ health complaints involves nonspecific symptoms, which are not readily explained medically.
Research in the area of Persian Gulf War Unexplained Illnesses (PGWUI) is heavily dependent on self-reports of exposures. The Portland Environmental Hazards Research Center (PEHRC) conducted a population-based case-control study utilizing techniques to measure the magnitude of potential error in self-reports of exposure. While it is impossible to verify most exposures in the Persian Gulf War (PGW), results of our study reveal significant overreporting of exposures that can be verified based on the time period served in the Persian Gulf. Test-retest reliability estimates indicate inconsistency in frequency and rate of self-reported exposures during the PGW. Unexplained illness in PGW veterans has received much political and scientific attention. Self-reported exposures in surveys returned preceding and following media reports on particular exposure such as nerve gas or pesticides are presented. These results are useful in the interpretation of findings related to the PGWUI and in the design of future investigations.
Research in the area of Persian Gulf War Unexplained Illnesses (PGWUI) is heavily dependent on self-reports of exposures. The Portland Environmental Hazards Research Center (PEHRC) conducted a population-based case-control study utilizing techniques to measure the magnitude of potential error in self-reports of exposure. While it is impossible to verify most exposures in the Persian Gulf War (PGW), results of our study reveal significant overreporting of exposures that can be verified based on the time period served in the Persian Gulf. Test-retest reliability estimates indicate inconsistency in frequency and rate of self-reported exposures during the PGW. Unexplained illness in PGW veterans has received much political and scientific attention. Self-reported exposures in surveys returned preceeding and following media reports on particular exposure such as nerve gas or pesticides are presented. These results are useful in the interpretation of findings related to the PGWUI and in the design of future investigations.
Many servicemen and women began suffering from a variety of symptoms and illnesses soon after the 1991 Gulf War. Some veterans believe that their illnesses are related to toxic exposures during their service, though scientific research has been largely unable to demonstrate any link. Disputes over the definition, etiology, and treatment of Gulf War - related illnesses (GWRIs) continue. The authors examine the roles of science, policy, and veteran activism in developing an understanding of GWRIs. They argue that the government's stress-based explanation of GWRIs and its insistence on a scientific link between service in the gulf and veteran illnesses forced veterans to shift from pleas for care, treatment, and compensation on moral grounds to engagement in the scientific process and debates over the interpretation of scientific findings. The authors compare the experiences of veterans to those of breast cancer activists to explain the stages of illness contestation in general.
Symptoms of a functional somatic syndrome have been noted in individual persons and groups for more than a century. Often associated with war, the syndrome has received diverse names and many proposed but unproved etiologies, including exposure to trauma, stress, chronic infection, psychosomatic, chemical, or environmental causes. In recent years, when attributed to agent X, the syndrome could be called the Blame-X syndrome. The clinical, legal, and other problems associated with the syndrome are a reflection of nosologic difficulties in identifying and choosing titles for apparently “new” ailments. The difficulties arise from the complex overlap of symptoms, diseases, and laboratory abnormalities found with modern technology, and from the frequent abandonment of pathophysiologic demands for appropriate correlation of symptoms and objective abnormalities. An important principle in naming apparently new ailments is to avoid etiologic titles until the etiologic agent has been suitably demonstrated. A premature causal name can impair a patient's recovery from the syndrome, and impede research that might find the true cause.
To assess the long-term health consequences of the 1991 Persian Gulf War, the authors compared cause-specific mortality rates of 621,902 Gulf War veterans with those of 746,248 non-Gulf veterans, by gender, with adjustment for age, race, marital status, branch of service, and type of unit. Vital status follow-up began with the date of exit from the Persian Gulf theater (Gulf veterans) or May 1, 1991 (control veterans). Follow-up for both groups ended on the date of death or December 31, 1997, whichever came first. Cox proportional hazards models were used for the multivariate analysis. For Gulf veterans, mortality risk was also assessed relative to the likelihood of exposure to nerve gas at Khamisiyah, Iraq. Among Gulf veterans, the significant excess of deaths due to motor vehicle accidents that was observed during the earlier postwar years had decreased steadily to levels found in non-Gulf veterans. The risk of death from natural causes remained lower among Gulf veterans compared with non-Gulf veterans. This was mainly accounted for by the relatively higher number of deaths related to human immunodeficiency virus infection among non-Gulf veterans. There was no statistically significant difference in cause-specific mortality among Gulf veterans relative to potential nerve gas exposure. The risk of death for both Gulf veterans and non-Gulf veterans stayed less than half of that expected in their civilian counterparts. The authors conclude that the excess risk of mortality from motor vehicle accidents that was associated with Gulf War service has dissipated after 7 years of follow-up. Language: en
PURPOSE: We evaluated an association between veterans' Gulf War service and reported adverse pregnancy outcomes.METHODS: We conducted a health survey in which selected reproductive outcomes of a population-based sample of 15,000 Gulf War veterans representing four military branches and three unit components (active, reserve, and National Guard) were compared to those of 15,000 non-Gulf veteran controls.RESULTS: Male Gulf veterans, compared with their non-Gulf veteran controls, reported a significantly higher rate of miscarriage (odds ratio [OR] = 1.62; 95% confidence interval [CI] = 1.32–1.99). Female Gulf veterans also reported more miscarriages than their respective controls, although their excess was not statistically significant (OR= 1.35; CI = 0.97–1.89). Both men and women deployed to the Gulf theater reported significant excesses of birth defects among their liveborn infants. These excess rates also extended to the subset of “moderate to severe” birth defects [males: OR= 1.78 (CI = 1.19–2.66); females: OR = 2.80 (CI = 1.26–6.25)]. No statistically significant differences by deployment status were found among men or women for stillbirths, pre-term deliveries or infant mortality.CONCLUSION: The risk of veterans reporting birth defects among their children was significantly associated with veteran's military service in the Gulf War. This observation needs to be confirmed by a review of medical records to rule out possible reporting bias.
The age-standardized mortality ratio (SMR) is a relative index of mortality, expressing the mortality experience of the study population relative to that of a comparison ("standard") population. With the general population as the "standard", the SMR for an occupational population will underestimate the mortality experience of that latter population (since it comprises individuals necessarily healthy enough to be employable --and whose mortality risk is therefore initially lower than the general population average). However, this "healthy worker effect" does not equally to all groups within the study population. Therefore, if one attempts to adjust for this effect, the summary nature of the SMR must be recognized, and allowance must be made for variation in the healthy worker effect between different age groups, different races, different work-status groups, different causes of death, and different elapsed-time periods of observation.
The purpose of this study was to test the hypothesis that the patients with chronic fatigue who have the highest number of medically unexplained physical symptoms over their lifetime would also have the highest prevalence of current and lifetime affective and anxiety disorders, lifetime affective symptoms, and the most functional disability. A further goal was to use this information to modify the current case definition to better identify a subgroup of patients with chronic fatigue syndrome who are less likely to have psychiatric illness.
Two hundred eighty-five consecutive patients with chronic fatigue were interviewed with the National Institute of Mental Health Diagnostic Interview Schedule and completed four self-rating questionnaires measuring psychologic distress, functional disability, and the tendency to amplify symptoms. Based on previously published data, patients were divided into four groups with a progressively higher number of lifetime medically unexplained physical symptoms. The prevalence of current and lifetime psychiatric disorders, lifetime psychologic symptoms, and extent of functional impairment was then compared in these four groups of patients.
The prevalence of current and lifetime psychiatric diagnosis and lifetime depressive symptoms increased linearly with the number of lifetime physical symptoms that the patient experienced. The extent of impairment in activities of daily living and the tendency to amplify symptoms also increased linearly with the number of medically unexplained physical symptoms.
The patients with the highest numbers of medically unexplained physical symptoms had extraordinarily high rates of current and lifetime psychiatric disorders. These data suggest that the current case definition for chronic fatigue syndrome inadvertently selects for patients with the highest prevalence of lifetime psychiatric diagnoses. A recommendation based on these results is to modify the case criteria for chronic fatigue syndrome to include patients with fatigue and few physical symptoms and to identify and consider excluding patients with high numbers of physical complaints.
The aim was to investigate the pattern of age specific non-response bias in a two phase survey of disablement in the community. It seeks to examine patterns of response in different age groups to a household based postal questionnaire, and the implication of such trends for the estimation of prevalence of reported dependence. It also looks at the effect that the readiness to respond during the first phase postal questionnaire had on participation in the interview based second phase of the study.
A two stage survey of disablement in the population was undertaken. A first phase postal questionnaire was sent to 25,168 households in Calderdale, West Yorkshire, England, to ascertain the prevalence of physical disability. The second phase comprised in depth interviews with a sample of individuals identified in the first phase as being disabled.
A total of 21,889 postal questionnaires were returned (87%) representing households containing 42,826 people aged 16 years and over. A disproportionately stratified random sample of 950 respondents reporting disability was taken for the second phase. Of these 891 were still available, and 838 (94%) were interviewed.
A study of the timing of response to a postal questionnaire showed that patterns differed for different age groups. The estimated prevalence of those aged 65 years and over who were dependent was steady over time whereas for those in the 16-64 age range the estimated prevalence fell as the survey progressed, indicating a tendency for those who were dependent to respond sooner. Examination of the relationship of responses at phase 1 and phase 2 showed that response to invitation to interview was much less in those who had responded later, and presumably more reluctantly, in the first phase.
These findings raise questions about how different patterns of response might be indicative of bias which could differentially affect final age specific prevalence estimates. They also have methodological implications for the follow up of reluctant responders both to increase the response rate and to secure cooperation in the second phase of a two phase survey.
Synopsis
This study uses methods of latent trait analysis to examine the relationships between psychiatric symptoms that constitute the common psychiatric disorders encountered in primary-care settings. Two highly correlated symptom dimensions of anxiety and depression are shown to underlie these disorders. Neurovegetative sysmptoms of depression are shown to be on the same dimension as psychic symptoms of depression, but to represent a more severe manifestation of depression.
The epidemiology of diseases associated with chemical waste disposal sites has often been delayed for years after the affected community became aware of the exposure. Frequently, this has resulted in an aroused neighborhood community that is distrustful of those public agencies and officials responsible for protecting their health. It is thus important that positive steps be taken to alleviate the antagonism and to involve the community in an active and constructive role in the epidemiology study. This paper presents a case history of such an incident and highlights some of the lessons learned. The first steps were to involve and inform the community. A citizen and industry advisory committee was formed to participate in the work, publish a newsletter, and conduct regular community meetings. The newsletter and the community meetings were used to identify problems and to explain them; to describe uncertainties of a scientific as well as of political or financial nature; to involve community leaders, including those distrustful; to conduct an epidemiologic census and a neighborhood environmental exposure survey. The end results were a defusing of the antagonism toward authorities, complete acceptance by the community of the merit of the report, a higher quality of report than might otherwise have been possible, and the freedom to move toward alleviating the problems of the disposal site.
The complexities of the chronic fatigue syndrome and the methodologic problems associated with its study indicate the need for a comprehensive, systematic, and integrated approach to the evaluation, classification, and study of persons with this condition and other fatiguing illnesses. We propose a conceptual framework and a set of guidelines that provide such an approach. Our guidelines include recommendations for the clinical evaluation of fatigued persons, a revised case definition of the chronic fatigue syndrome, and a strategy for subgrouping fatigued persons in formal investigations.
Since the 1990-1991 Persian Gulf War, there has been persistent concern that U.S. war veterans may have had adverse health consequences, including higher-than-normal mortality.
We conducted a retrospective cohort study of postwar mortality according to cause among 695,516 Gulf War veterans and 746,291 other veterans. The follow-up continued through September 1993. A stratified, multivariate analysis (with Cox proportional-hazards models) controlled for branch of service, type of unit, age, sex, and race in comparing the two groups. We used standardized mortality ratios to compare the groups of veterans with the general population of the United States.
Among the Gulf War veterans, there was a small but significant excess of deaths as compared with the veterans who did not serve in the Persian Gulf (adjusted rate ratio, 1.09; 95 percent confidence interval, 1.01 to 1.16). The excess deaths were mainly caused by accidents (1.25; 1.13 to 1.39) rather than disease (0.88; 0.77 to 1.02). The corresponding rate ratios among 49,919 female veterans of the Gulf War were 1.32 (0.95 to 1.83) for death from all causes, 1.83 (1.02 to 3.28) for accidental death, and 0.89 (0.45 to 1.78) for death from disease. In both groups of veterans the mortality rates were significantly lower overall than those in the general population. The adjusted standardized mortality ratios were 0.44 (95 percent confidence interval, 0.42 to 0.47) for Gulf War veterans and 0.38 (0.36 to 0.40) for other veterans.
Among veterans of the Persian Gulf War, there was a significantly higher mortality rate than among veterans deployed elsewhere, but most of the increase was due to accidents rather than disease, a finding consistent with patterns of postwar mortality among veterans of previous wars.
To identify risk factors of factor analysis-derived Gulf War-related syndromes.
A cross-sectional survey.
A total of 249 Gulf War veterans from the Twenty-fourth Reserve Naval Mobile Construction Battalion.
Participants completed standardized booklets measuring self-reported wartime exposures and present symptoms.
Associations of factor analysis-derived syndromes with risk factors for chemical interactions that inhibit butyrylcholinesterase and neuropathy target esterase.
Risk of syndrome 1 ("impaired cognition") was greater in veterans who reported wearing flea collars during the war (5 of 20, 25%) than in those who never wore them (7 of 229, 3%; relative risk [RR], 8.7; 95% confidence interval [CI], 3.0-24.7; P<.001). Risk of syndrome 2 ("confusion-ataxia") increased with a scale of advanced adverse effects from pyridostigmine bromide (chi2 for trend, P<.001), was greater among veterans who believed they had been involved in chemical weapons exposure (18 of 108, 17%) than in those who did not (3 of 141, 2%; RR, 7.8; 95% CI, 2.3-25.9; P<.001), and was increased in veterans who had been in a sector of far northeastern Saudi Arabia on the fourth day of the air war (6 of 21, 29%) than in those who had not been (15 of 228, 7%; RR, 4.3; 95% CI, 1.9-10.0; P=.004). Effects of perceived chemical weapons exposure and advanced adverse effects from pyridostigmine were synergistic (Rothman S, 5.3; 95% CI, 1.04-26.7). Risk of syndrome 3 ("arthro-myo-neuropathy") increased with an index of frequency and amount of government-issued insect repellent containing 75% DEET (N,N-diethyl-m-toluamide) in ethanol applied during the war (chi2 for trend, P<.001) and with advanced adverse effects from pyridostigmine (chi2 for trend, P<.001).
Some Gulf War veterans may have delayed, chronic neurotoxic syndromes from wartime exposure to combinations of chemicals that inhibit butyrylcholinesterase and neuropathy target esterase.
To search for syndromes in Persian Gulf War veterans.
Two hundred forty-nine (41%) of the 606 Gulf War veterans of the Twenty-fourth Reserve Naval Mobile Construction Battalion living in 5 southeastern states participated; 145 (58%) had retired from service, and the rest were still serving in the battalion.
Participants completed a standardized survey booklet measuring the anatomical distributions or characteristics of each symptom, a booklet measuring wartime exposures, and a standard psychological personality assessment inventory. Two-stage factor analysis was used to disentangle ambiguous symptoms and identify syndromes.
Factor analysis-derived syndromes.
Of 249 participants, 175 (70%) reported having had serious health problems that most attributed to the war, and 74 (30%) reported no serious health problems. Principal factor analysis yielded 6 syndrome factors, explaining 71% of the variance. Dichotomized syndrome indicators identified the syndromes in 63 veterans (25%). Syndromes 1 ("impaired cognition," characterized by problems with attention, memory, and reasoning, as well as insomnia, depression, daytime sleepiness, and headaches), 2 ("confusion-ataxia," characterized by problems with thinking, disorientation, balance disturbances, vertigo, and impotence), and 3 ("arthro-myo-neuropathy," characterized by joint and muscle pains, muscle fatigue, difficulty lifting, and extremity paresthesias) represented strongly clustered symptoms; whereas, syndromes 4 ("phobia-apraxia"), 5 ("fever-adenopathy"), and 6 ("weakness-incontinence") involved weaker clustering and mostly overlapped syndromes 2 and 3. Veterans with syndrome 2 were 12.5 times (95% confidence interval, 3.5-44.8) more likely to be unemployed than those with no health problems. A psychological profile, found in 48.4% of those with the syndromes, differed from posttraumatic stress disorder, depression, somatoform disorder, and malingering.
These findings support the hypothesis that clusters of symptoms of many Gulf War veterans represent discrete factor analysis-derived syndromes that appear to reflect a spectrum of neurologic injury involving the central, peripheral, and autonomic nervous systems.
Gulf War (GW) veterans report nonspecific symptoms significantly more often than their nondeployed peers. However, no specific disorder has been identified, and the etiologic basis and clinical significance of their symptoms remain unclear.
To organize symptoms reported by US Air Force GW veterans into a case definition, to characterize clinical features, and to evaluate risk factors.
Cross-sectional population survey of individual characteristics and symptoms and clinical evaluation (including a structured interview, the Medical Outcomes Study Short Form 36, psychiatric screening, physical examination, clinical laboratory tests, and serologic assays for antibodies against viruses, rickettsia, parasites, and bacteria) conducted in 1995.
The cross-sectional questionnaire survey included 3723 currently active volunteers, irrespective of health status or GW participation, from 4 air force populations. The cross-sectional clinical evaluation included 158 GW veterans from one unit, irrespective of health status.
Symptom-based case definition; case prevalence rate for GW veterans and nondeployed personnel; clinical and laboratory findings among veterans who met the case definition.
We defined a case as having 1 or more chronic symptoms from at least 2 of 3 categories (fatigue, mood-cognition, and musculoskeletal). The prevalence of mild-to-moderate and severe cases was 39% and 6%, respectively, among 1155 GW veterans compared with 14% and 0.7% among 2520 nondeployed personnel. Illness was not associated with time or place of deployment or with duties during the war. Fifty-nine clinically evaluated GW veterans (37%) were noncases, 86 (54%) mild-to-moderate cases, and 13 (8%) severe cases. Although no physical examination, laboratory, or serologic findings identified cases, veterans who met the case definition had significantly diminished functioning and well-being.
Among currently active members of 4 Air Force populations, a chronic multisymptom condition was significantly associated with deployment to the GW. The condition was not associated with specific GW exposures and also affected nondeployed personnel.
To review the clinical findings in the first 1000 veterans seen in the Ministry of Defence's Gulf war medical assessment programme to examine whether there was a particular illness related to service in the Gulf.
Case series of 1000 veterans who presented to the programme between 11 October 1993 and 24 February 1997.
Gulf war veterans.
Diagnosis of veterans' conditions according to ICD-10 (international classification of diseases, 10th revision). Cases referred for psychiatric assessment were reviewed for available diagnostic information from consultant psychiatrists.
588 (59%) veterans had more than one diagnosed condition, 387 (39%) had at least one condition for which no firm somatic or psychological diagnosis could be given, and in 90 (9%) veterans no other main diagnosis was made. Conditions characterised by fatigue were found in 239 (24%) of patients. At least 190 (19%) patients had a psychiatric condition, which in over half was due to post-traumatic stress disorder. Musculoskeletal disorders and respiratory conditions were also found to be relatively common (in 182 (18%) and 155 (16%) patients respectively).
Many Gulf war veterans had a wide variety of symptoms. This initial review shows no evidence of a single illness, psychological or physical, to explain the pattern of symptoms seen in veterans in the assessment programme. As the veterans assessed by the programme were all self selected, the prevalence of illness in Gulf war veterans cannot be determined from this study. Furthermore, it is not known whether the veterans in this study were representative of sick veterans as a group.
UK veterans of the Gulf War report more ill health than servicemen who were not deployed to the Gulf War. We investigated whether the pattern of symptom reporting by veterans of the Gulf War differed from that in active servicemen who had not fought in the Gulf War or who had fought in other conflicts.
We used a population-based cross-sectional design. We sent a standardised survey that asked about 50 physical symptoms to three UK military cohorts; men who had served in the Gulf War, those who had served in the Bosnia conflict, and men who had been in active service but not deployed to the Gulf War (Era cohort). We used exploratory factor analysis to identify underlying factors and describe the factor structure of the symptoms reported in the Gulf War cohort. Confirmatory factor analysis was used to test the fit of this factor structure in the Bosnia and Era cohorts.
Three factors in the Gulf War cohort together accounted for about 20% of the common variance. We labelled the factors mood, respiratory system, and peripheral nervous system, according to the symptoms that loaded on to them. In the confirmatory factor analysis, the factor structure identified in the Gulf War cohort fitted reasonably well in the Bosnia and Era cohorts.
Although results from complex modelling procedures need to be interpreted with caution, our findings do not support a unique Gulf War syndrome. The mechanisms behind increased self-reporting of symptoms need further investigation.
Various symptoms in military personnel in the Persian Gulf War 1990-91 have caused international speculation and concern. We investigated UK servicemen.
We did a cross-sectional postal survey on a random sample of Gulf War veterans (Gulf War cohort, n=4248) and, stratified for age and rank, servicemen deployed to the Bosnia conflict (Bosnia cohort, n=4250) and those serving during the Gulf War but not deployed there (Era cohort, n=4246). We asked about deployment, exposures, symptoms, and illnesses. We analysed men only. Our outcome measures were physical health, functional capacity (SF-36), the general health questionnaire, the Centers for Disease Control and Prevention (CDC) multisymptom criteria for Gulf War illness, and post-traumatic stress reactions.
There were 8195 (65.1%) valid responses. The Gulf War cohort reported symptoms and disorders significantly more frequently than those in the Bosnia and Era cohorts, which were similar. Perception of physical health and ability were significantly worse in the Gulf War cohort than in the other cohorts, even after adjustment for confounders. Gulf War veterans were more likely than the Bosnia cohort to have substantial fatigue (odds ratio 2.2 [95% CI 1.9-2.6]), symptoms of post-traumatic stress (2.6 [1.9-3.4]), and psychological distress (1.6 [1.4-1.8]), and were nearly twice as likely to reach the CDC case definition (2.5 [2.2-2.8]). In the Gulf War, Bosnia, and Era cohorts, respectively, 61.9%, 36.8%, and 36.4% met the CDC criteria, which fell to 25.3%, 11.8%, and 12.2% for severe symptoms. Potentially harmful exposures were reported most frequently by the Gulf War cohort. All exposures showed associations with all of the outcome measures in the three cohorts. Exposures specific to the Gulf were associated with all outcomes. Vaccination against biological warfare and multiple routine vaccinations were associated with the CDC multisymptom syndrome in the Gulf War cohort.
Service in the Gulf War was associated with various health problems over and above those associated with deployment to an unfamiliar hostile environment. Since associations of ill health with adverse events and exposures were found in all cohorts, however, they may not be unique and causally implicated in Gulf-War-related illness. A specific mechanism may link vaccination against biological warfare agents and later ill health, but the risks of illness must be considered against the protection of servicemen.
Most medical specialities have defined medically unexplained syndromes such as fibromyalgia, to categorize patients with prominent but unexplained symptoms. Other such syndromes include irritable bowel syndrome, chronic fatigue syndrome and atypical chest pain. In this chapter we present evidence to suggest that fibromyalgia is not a unique clinical entity, but shares much with these other syndromes. We use historical, clinical and epidemiological evidence to illustrate this idea. The historical data emphasize the essentially arbitrary way in which fibromyalgia developed. The clinical evidence shows the considerable overlap between patients with fibromyalgia and those with other unexplained syndromes. From an epidemiological perspective we emphasize the strong associations between symptoms such as myalgia and fatigue. We conclude by suggesting that fibromyalgia is one of many medically unexplained syndromes which have more similarities than differences between them.
Armed forces personnel who served in the Gulf War report more current ill-health than those who were not deployed. There has been concern expressed that they may also experience higher mortality rates.
A retrospective cohort study was done including all 53462 UK Gulf War veterans (Gulf cohort) and a comparison group equivalent in size of personnel who were not deployed but matched for age, sex, rank, service, and level of fitness (Era cohort). Individuals were identified on central registers of the Office for National Statistics and information on death among cohort subjects, including cause of death, obtained. Follow-up extended from April 1, 1991 (the end of the Gulf War) until March 31, 1999.
There were 395 deaths among the Gulf cohort and 378 deaths amongst the Era cohort (mortality rate ratio [MRR] 1.05, 95% CI 0.91-1.21). Mortality from "external" causes was higher in the Gulf cohort (Gulf 254, Era 216; MRR 1.18 [0.98-1.42] while mortality from "disease-related" causes was lower (Gulf 122, Era 141; 0.87 [0.67-1.11]). The higher mortality rate from "external" causes in the Gulf cohort was principally due to higher mortality rates from accidents. There was, however, no excess of deaths recorded as suicide in the Gulf cohort.
This follow-up of veterans of the Gulf war has shown, 8 years after the end of the conflict, that although they have experienced higher mortality rates than a comparison cohort, the excess mortality rate is very small and does not approach statistical significance. The excess is related mainly to accidents rather than disease, a pattern that is consistent both with US veterans of the Gulf war and veterans from other conflicts.
Concerns have been raised about whether veterans of the Gulf War have a medical illness of uncertain etiology. We surveyed veterans to look for evidence of an illness that was unique to those deployed to the Persian Gulf and was not seen in comparable military controls.
A population-based sample of veterans (n = 1,896 from 889 units) deployed to the Persian Gulf and other Gulf War-era controls (n = 1799 from 893 units) who did not serve in the Gulf were surveyed in 1995-1996. Seventy-six percent of eligible subjects, including 91% of located subjects, answered questions about commonly reported and potentially important symptoms. We used factor analysis, a statistical technique that can identify patterns of related responses, on a random subset of the deployed veterans to identify latent patterns of symptoms. The results from this derivation sample were compared with those obtained from a separate validation sample of deployed veterans, as well as the nondeployed controls, to determine whether the results were replicable and unique.
One half (50%) of the deployed veterans and 14% of the nondeployed controls reported health problems that they attributed to military service during 1990-1991. Compared with the nondeployed controls, the deployed veterans had significantly greater prevalences of 123 of 137 (90%) symptoms; none was significantly lower. Factor analysis identified three replicable symptom factors (or patterns) in the deployed veterans (convergent correlations > or =0.85). However, these patterns were also highly replicable in the nondeployed controls (convergent correlations of 0.95 to 0.98). The three factors also accounted for similar proportions of the common variance among the deployed veterans (35%) and nondeployed controls (30%).
The increased prevalence of nearly every symptom assessed from all bodily organ systems among the Gulf War veterans is difficult to explain pathophysiologically as a single condition. Identification of the same patterns of symptoms among the deployed veterans and nondeployed controls suggests that the health complaints of Gulf War veterans are similar to those of the general military population and are not consistent with the existence of a unique Gulf War syndrome.