IOM Studies Veterans' Health
WASHINGTON, July 23, 1998 (GulfLINK) - On May 7, 1998 a newly-constituted Institute of Medicine Committee met in Washington, D.C. to grapple with the question of how to measure the change in health status of Gulf War veterans. Co-chaired by Dan Blazer II, M.D., Ph.D., M.P.H., and Isabel V. Hoverman, M.D., this new committee was formed partially in response to a 1997 General Accounting Office report, Gulf War Illnesses: Improved Monitoring of Clinical Progress and Re-examination of Research Emphasis Needed. It is funded by the departments of Defense and Veterans Affairs. The workshop was held to help the committee identify questions regarding the current health status of Gulf War veterans. Committee members intend to examine the information and material obtained during this and other meetings in an effort to develop study designs and methods that could be used to measure the health of Gulf War veterans. According to its charter, the Institute of Medicine is tasked to advise the federal government in identifying issues of medical care, research and education. During the daylong workshop, committee members, many with extensive backgrounds in health outcomes research and epidemiology, listened to presentations by governmental and private health care researchers on the data that are currently available on reported illnesses. Topics included veterans' health problems, completed population-based studies, research undertaken in the United Kingdom, and an overview of the databases that currently exist for measuring the health of veterans and appropriate research protocols.
Defense Department and Veterans Affairs' representatives reviewed their respective Gulf War illnesses clinical evaluation programs for the audience.
Col. Bruce Jones, director, epidemiology and disease surveillance, U.S. Army Center for Health Promotion and Prevention outlined the history and composition of DoD's Comprehensive Clinical Evaluation Program. Established in June 1994 in response to veterans' health concerns and reports of illnesses, the program provides an in-depth medical evaluation for Gulf War veterans who are in one of the active or Reserve components, or are retired. Currently, 48,000 participants have registered with the program. Of those who registered, approximately 35,000 requested examinations and 13, 343 declined. To date, 94 percent of the exams requested have been completed.
"The four most common self-reported exposures listed by Gulf War veterans participating in the CCEP are diesel fuel, passive cigarette smoke, pyridostigmine bromide and oil fire smoke," said Jones. "Participants also report that the 10 most common symptoms they experience include joint pain, fatigue, headache, memory loss, sleep disturbance, difficulty concentrating, rash, muscle pain, depressed mood and shortness of breath."
Jones also noted the limitations of the database.
"The CCEP is a clinical registry comprising a self-selected population. There is neither an adequate control group nor information on pre-existing conditions, diagnostic criteria, laboratory evaluations or treatment readily available for comparison," he said.
Frances Murphy, M. D., M.P.H., director of Gulf War health programs for the VA, focused on what the VA has learned from its database. The department instituted voluntary, free health examinations in 1992 and made them available at every major VA medical facility for all veterans concerned about their health.
More than 68,000 exams have been completed. The most frequent complaints include fatigue, skin rash, headache, muscle/joint pain, memory loss, shortness of breath and sleep disturbance.
Murphy also emphasized the limitations of the VA and DoD registries. Both were designed as health care programs, not as research databases, she said.
"The Registry was never intended to be used as a longitudinal health care database," Murphy emphasized. " It is not standardized the way a research database would be."
Murphy said VA's current findings indicate there is no medical or scientific evidence of a "Gulf War Syndrome." She explained that health complaints involve multiple organ systems with a wide spectrum of medical diagnoses with no clustering evident within a particular medical diagnostic category.
The IOM plays an important oversight role in the coordination and management of the large Gulf War veterans federal research effort. In their 1995 report, Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Action, the IOM emphasized the importance of population-based studies in the DoD/VA research portfolio. To better inform its current project work on the health status of Gulf War veterans, the new IOM Committee heard from a panel reporting on the findings of three completed population-based studies.
Dr. David Schwartz, Iowa Persian Gulf Study Group principal investigator, explained the elements of the population-based study of military personnel from Iowa. Constructed as a cooperative agreement with the Centers for Disease Control and Prevention, the Iowa Department of Public Health and the University of Iowa College of Medicine, Iowa City, the study assessed the prevalence of self-reported symptoms and illnesses among Gulf War veterans compared to non-deployed military personnel on active duty at the same time. This study was published in the Journal of the American Medical Association in January 1997.
Using a randomly selected population of 4,886 Iowa veterans, investigators chose the study subjects from one of four domains: Gulf War regular military, National Guard and Reserve and non-Gulf War regular military, National Guard and Reserve personnel. An hour-long telephone interview survey consisting of questions designed to assess relevant medical and psychiatric conditions elicited a 76 percent response rate from Persian Gulf Veterans compared with a 73 percent from non-Gulf veterans.
The study concluded that Gulf veterans report specific medical and psychiatric conditions at higher rates than their military peers who were not deployed. Conditions identified in the study appear to have had a measurable impact on the functional activity and daily lives of Gulf War veterans. Minimal differences were observed between National Guard and Reserve members and active military troops. In terms of rate differences, the basic findings of the study indicated that cognitive dysfunction was reported 10 - 11 percent more frequently in Gulf War veterans than among non-Gulf veterans; fibromyalgia nine percent more frequently, depression six percent more frequently and anxiety three percent more frequently in Gulf War versus non-Gulf War veterans. Assessment of health-related quality of life demonstrated diminished mental and physical functioning scores for Gulf War military personnel. In almost all cases, larger differences between Gulf War and non-Gulf War military personnel were observed in the National Guard and Reserve comparison.
Schwartz believes three factors contribute to the strength of the Iowa study: it was hypothesis-driven and identified certain questions and medical outcomes of prior interest to the medical community, it used a control group and series of validated questions extracted from other studies that were administered by phone and the investigative team consisted of more than 25 experienced investigators.
Schwartz acknowledged one of the central weaknesses of the study was that it was Iowa-based and somewhat difficult to generalize to other populations. However, he emphasized that Iowa participants were troops who were stationed throughout the Gulf region and they were represented in 25 percent of the units who deployed; therefore, their experiences were probably representative of exposures that occurred throughout the Gulf War theater.
The study has also attracted some criticism because the findings are based on self-reported symptoms. In response, Schwartz said this type of initial first-step was important. To address the limitations of the self-report telephone survey, researchers will take initial findings further with a second case validation study on selected participants who will be invited back to Iowa. Researchers intend to evaluate well-defined disorders such as asthma, depression, cognitive dysfunction and fibromyalgia, through medical exams and lab tests. He informed the Committee that investigators are interested in pursuing other studies examining health service utilization, women's health issues and health-related quality of life issues.
Dr. Han K. Kang, director of epidemiology at the Department of Veterans Affairs, presented findings of the VA study Mortality among U.S. Veterans of the Persian Gulf War. This study was published in November 1996 in the New England Journal of Medicine. Using a study population of U.S. men and women on active duty from August 1, 1990 through September 1993, the VA studied mortality rates among U.S. troops stationed in the Gulf region and compared them with those of U.S. troops serving elsewhere during Operation Desert Storm and Desert Shield.
The study found that the mortality rate ratio was higher among deployed groups. The higher rate of morality was due mainly to external causes such as motor vehicle accidents and trauma rather than natural causes. Additionally, the study found that the overall mortality risk experienced by both groups of veterans was 50 percent less than that expected for civilian counterparts.
"These findings are very much in line with what has been reported in [ medical ] literature for other war-time veterans.... The literature shows similar findings for World War II veterans and Korean War veterans," said Kang.
The VA has continued these follow-on mortality studies as part of their research program.
Kang also provided an update of the VA National Survey of Persian Gulf Veterans. The National Survey is designed to determine the prevalence of symptoms and illnesses using a random sampling of 15,000 deployed veterans compared to non-deployed veterans. The study also seeks to estimate and compare the prevalence of various reproductive outcomes among spouses and birth defects among children of Gulf War veterans and those non-deployed veterans. Now in the third phase of the study, the VA will invite 2,000 veterans who responded to the postal survey and underwent a telephone interview, along with family members, to one of the VA medical centers to participate in a comprehensive medical examination as well as lab testing.
Greg Gray, M. D., principal investigator for several research studies conducted by the Naval Research Center, spoke on their research and findings. The vast array of veteran health concerns, he said, led Naval Research investigators to focus on three groups of studies: veterans' symptoms, hospitalization rates and birth outcomes. The hospitalization study, published November, 1996 in the New England Journal of Medicine, concluded that two years after the Gulf War there was no excess of unexpected hospitalization among Gulf War veterans when compared with non-deployed veterans.
In keeping with the comprehensive nature of the workshop, Col. John Graham, British
Gulf Health liaison officer, was invited to present an overview of the British government's program and research efforts.
Since 1993, the U.K. has operated a clinical evaluation program for Gulf War veterans comparable to the DoD and VA registries. Of the more than 50,000 British troops deployed to the Gulf, approximately 2,500 have reported illnesses, said Graham. Psychological conditions predominate among those enrolled in the Medical Assessment Program; one-fifth of those participating have been diagnosed with post traumatic stress disorder.
Graham said British researchers are asking a key question - "Are Gulf War veterans more ill than their peers who did not deploy and, if so, what are they suffering from?"
Two epidemiological studies waiting funding by the Ministry of Defense aim to address this question as well as the question of reproductive health of British Gulf War veterans and their children.
The panel also heard presentations on the capabilities of the VA and DoD databases. The VA is involved in efforts to create a single consolidated database from the VA and DoD Gulf War registries. Presenters indicated that while each database had limitations, they were valuable for defining groups of Persian Gulf veterans and a starting point for more in-depth research studies.
The Committee will meet again in July. An interim report summarizing the May 7 workshop will be released in August. The study will continue until June 1999, when a final report will be released.