New IOM Panel Finds Nine Conditions Caused by or Associated with 1991 Gulf War Service

Written by Anthony Hardie, 91outcomes.com

(91outcomes.com) - A myriad of physical and mental health conditions are associated with the 1991 Gulf War, says a new report released April 9, 2010 by the Institute of Medicine (IOM), which also found that Gulf War Illness is real.  

The report, entitled, “Gulf War and Health: Volume 8: Update of Health Effects of Serving in the Gulf War, found five broad types of physical and mental health outcomes caused by the 1991 Gulf War and four more for which their is limited but suggestive evidence of causation.

Among the physical ailments the IOM found to have "sufficient evidence of a causal relationship" are "multisymptom illness" (commonly referred to as Gulf War Illness), functional gastrointestinal disorders such as irritable bowel syndrome (IBS) and dyspepsia (upset stomach), and chronic fatigue syndrome.  

The IOM panel also found sufficient evidence of a causal relationship between Gulf War service and PTSD,  and other psychiatric disorders that persist at least 10 years after deployment.

The panel also found "limited/suggestive evidence of a causal relationship" between 1991 Gulf War service and  ALS, fibromyalgia and chronic widespread pain, "self-reported" sexual difficulties, and mortality "from external causes, primarily motor-vehicle accidents" in the early years following Gulf War deployment.  

The panel noted a long list of conditions for which inadequate research currently exists to determine whether or not there is a clear association with Gulf War service, as well as a shorter list of conditions for which current research suggests are not associated with Gulf War service.

Generally, the U.S. Department of Veterans Affairs (VA) follows IOM panel recommendations as a basis for new "presumptive" conditions for the purposes of VA service-connected disability claims.  Conditions for which there is "sufficient evidence of a causal relationship" are the most likely for new VA presumptions.  Conditions for which there is "limited/suggestive evidence of a causal relationship" may or may not be made presumptive by VA.

The verbatim list from the new IOM panel is posted below.

The panel also noted that 

***

Summary of Findings Regarding Associations Between Deployment to the Gulf War and Specific Health Outcomes

Sufficient Evidence of a Causal Relationship

·      PTSD.
  Sufficient Evidence of an Association

·      Other psychiatric disorders, including generalized anxiety disorder, depression, and substance abuse, particularly alcohol abuse. These psychiatric disorders persist for at least 10 years after deployment.

·      Gastrointestinal symptoms consistent with functional gastrointestinal disorders such as irritable bowel syndrome and functional dyspepsia.

·      Multisymptom illness.

·      Chronic fatigue syndrome. 


Limited/Suggestive Evidence of an Association

·      ALS.

·      Fibromyalgia and chronic widespread pain.

·      Self-reported sexual difficulties.

·      Mortality from external causes, primarily motor-vehicle accidents, in the early years after deployment. 


Inadequate/Insufficient Evidence to Determine Whether an Association Exists

·      Any cancer.

·      Diseases of the blood and blood-forming organs.

·      Endocrine, nutritional, and metabolic diseases.

·      Neurocognitive and neurobehavioral performance.

·      Multiple sclerosis.

·      Other neurologic outcomes, such as Parkinson’s disease, dementia, and Alzheimer’s disease.

·      Incidence of cardiovascular diseases.

·      Respiratory diseases.

·      Structural gastrointestinal diseases.

·      Skin diseases.

·      Musculoskeletal system diseases.

·      Specific conditions of the genitourinary system.

·      Specific birth defects.

·      Adverse pregnancy outcomes such as miscarriage, stillbirth, preterm birth, and low birth weight.

·      Fertility problems. 


Limited/Suggestive Evidence of No Association

·      Peripheral neuropathy.

·      Mortality from cardiovascular disease in the first 10 years after the war.

·      Decreased lung function in the first 10 years after the war.

·      Hospitalization for genitourinary diseases.

*SOURCE:  National Academy of Sciences, Institute of Medicine, “Gulf War and Health: Volume 8: Update of Health Effects of Serving in the Gulf War,” April 2010, p. 8 (Box S-1). 

***

IOM criteria for evidence of relationship to the 1991 Gulf War

Sufficient Evidence of a Causal Relationship

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

Sufficient Evidence of an Association

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

Limited/Suggestive Evidence of an Association

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

Inadequate/Insufficient Evidence to Determine Whether an Association Exists

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

Limited/Suggestive Evidence of No Association

There are several adequate studies, covering the full range of levels of exposure that humans are known to encounter, that are consistent in not showing an association between exposure to a specific agent and a health outcome at any level of exposure. A conclusion of no association is inevitably limited to the conditions, levels of exposure, and length of observation covered by the available studies. In addition, the possibility of a very small increase in risk at the levels of exposure studied can never be excluded. 

*SOURCE:  National Academy of Sciences, Institute of Medicine, “Gulf War and Health: Volume 8: Update of Health Effects of Serving in the Gulf War,” April 2010, pp. 5-6.

Gulf War Syndrome real, Institute of Medicine concludes

By Janet Raloff

(Science News) - Hundreds of thousands of U.S. veterans who claim to suffer from Gulf War Syndrome just received powerful new ammunition against arguments that their symptoms are trivial, if not altogether fictional. On April 9, the Institute of Medicine – the health arm of the National Academy of Sciences – issued a report that concludes military service in the Persian Gulf War has not only been a cause of post-traumatic stress disorder in some veterans but also is “associated with multisymptom illness.”

That multisymptom illness is IOM’s moniker for what the vets refer to as Gulf War Syndrome.

"It is clear that a significant portion of the soldiers deployed to the Gulf War have experienced troubling constellations of symptoms that are difficult to categorize," according to neuroscientist Stephen L. Hauser of the University of California, San Francisco. He chaired the IOM committee that issued the new report.

"Unfortunately,” Hauser said, “symptoms that cannot be easily quantified are sometimes incorrectly dismissed as insignificant and receive inadequate attention and funding by the medical and scientific establishment.  Veterans who continue to suffer from these symptoms deserve the very best that modern science and medicine can offer to speed the development of effective treatments, cures, and – we hope – prevention.”

The new report argues that medicine’s trouble in defining the nature or precise cause(s) of Gulf War Syndrome does not negate its existence. Indeed, the IOM’s new analysis “began with the premise that multisymptom illness is a diagnostic entity.” Its analysis then investigated evidence to determine whether a link exists between multiple, unexplained symptoms and Gulf War deployment.

And IOM’s report now concludes that Gulf War Syndrome is real, based on data documenting a high rate of symptoms in former U.S. troops who had served in the Gulf War nearly two decades ago. High-quality surveys of Gulf War vets from other nations, such as the United Kingdom and Australia, show many of those men also have been suffering similar chronic symptoms, which could include everything from gastrointestinal illness and mental confusion, to attacks of sudden vertigo, intense uncontrollable mood swings, fatigue and sometimes numbness – or the opposite, constant body pain.

Last month, a team of researchers headed by Robert Haley of the University of Texas Southwestern Medical Center at Dallas reported new brain-imaging confirmation of Gulf War illnesses, which it described as a trio of syndromes with puzzling symptoms.

Like the UT Southwestern scientists, the IOM committee could not pin down the source of the vets’ symptoms. Equally puzzling was why some troops sustained major chronic illness after a short tour of duty while others from their military units incurred no such symptoms after many years in the field. Indeed, it may prove difficult – if not impossible – to reconstruct what happened nearly 20 years after the fact, the IOM committee noted.

But there’s certainly a suspicion, it said, that multisymptom Gulf War Syndrome(s) may reflect interactions between environmental exposures and genes, such that genetics predisposed many troops to illness. IOM now recommends that research commence immediately to investigate that genetics angle. And there should be a big enough population to study this in, IOM says, with more than one-third of the 700,000 Gulf War vets claiming multisymptom illnesses associated with their military service.

The report also calls for a substantial commitment to improve identification and treatment of multisymptom illness in Gulf War veterans. That would, of course, first require that the Department of Veterans Affairs acknowledge these syndromes as real disease.

WASHINGTON POST: Up to 250,000 Gulf War veterans have 'unexplained medical symptoms'

Written by David Brown, Washington Post Staff Writer

(Washington – Washington Post) - As many as 250,000 veterans of the first Gulf War "have persistent unexplained medical symptoms" whose cause may never be found, although genetic testing and functional brain imaging may eventually shed some light on the problem.

That is one of the conclusions of a new review of research on the constellation of physical complaints originally known as "Gulf War syndrome" experienced by many soldiers soon after the United States drove invading Iraqi forces out of Kuwait in early 1991.

The review, by the National Academy of Science's Institute of Medicine, found that the only illness clearly caused by the Gulf War is post-traumatic stress disorder (PTSD). It is present in 2 to 15 percent of Gulf War veterans (depending on how it is diagnosed), and about three-times more common in them than in soldiers who served at the same time but were deployed elsewhere.

The 12-member panel of medical experts also found "evidence of an association" between Gulf War service and anxiety disorder, alcohol abuse, dyspepsia, irritable bowl syndrome, and "multisymptom illness" (its term for Gulf War syndrome) although not clearly a causal one.

Among the features of "multisymptom illness" are fatigue, muscle and joint pain, poor sleep, moodiness, lack of concentration, and in some people, skin rash and diarrhea. A survey of 10,000 veterans conducted in 2005 found that 37 percent of those who were in the Gulf had the illness, compared to 12 percent deployed elsewhere.

An increase in vague symptoms and persistent pain has also been seen in some non-American groups, including British troops who served in the Gulf, and Danish peacekeepers who were there after the war.

"We concluded that these symptoms are highly prevalent, persistent, and apparently disabling in this veteran population, even two decades after the war," said Stephen L. Hauser, the panel chairman and a professor of neurology at the University of California at San Francisco. "They defy efforts, thus far, to fully understand their cause."

The 289-page report released Friday was generally praised by advocates for more attention to Gulf War veterans, and those who believe there is a cause to be found for Gulf War syndrome.

Paul Sullivan, director of Veterans for Common Sense, in Washington, said his organization will now ask Secretary of Veterans Affairs Eric K. Shinseki to propose regulations that will provide disability benefits and free medical care to all veterans suffering from "multisymptom illness."

"This is a huge victory for Gulf War veterans," said Sullivan, a 47-year-old former Army scout who said he has been ill since his Gulf service.

Two years ago, the VA-appointed Research Advisory Committee on Gulf War Veterans' Illnesses issued a report saying that toxic exposures were probably the cause of Gulf War illness.

Its chairman, James Binns, asserted Friday that the two reports "agree on the most important things -- that the multisymptom illness that affects so many Gulf War veterans is a terrible, distinct illness, and that this nation can and should launch a Manhattan Project-style research program to identify treatments and prevent this from happening again."

The Institute of Medicine panel, whose members are academic physicians and epidemiologists, reviewed 1,000 studies, focusing particular attention on 400 completed since the institute's last review of Gulf War illnesses in 2006.

Many veterans think exposure to pesticides, medicines and environmental toxins damaged soldiers' brain and immune systems, causing chronic illness.

The panel called for "genome-wide association studies," which scan large numbers of people looking for gene variations shared by sufferers of a single disease. It also said that sensitive brain imaging and tests for overstimulation of the immune system are promising tools for future research.

IOM Concurs Gulf War service linked to Multisymptom Illness in 250,000 Veterans

Second U.S. Government report to say Gulf War Syndrome is real

ORIGINAL 91OUTCOMES ARTICLE:  http://www.91outcomes.com/2010/04/iom-concurs-gulf-war-service-linked-to.html

(WASHINGTON – IOM RELEASE) -- Military service in the Persian Gulf War is a cause of post-traumatic stress disorder in some veterans and is also associated with multisymptom illness; gastrointestinal disorders such as irritable bowel syndrome; substance abuse, particularly alcoholism; and psychiatric problems such as anxiety disorder, says a new report from the Institute of Medicine, the latest update in a series of reports on the Gulf War and veterans' health. 

There is some evidence that service during the conflict is linked to fibromyalgia and chronic widespread pain, amyotrophic lateral sclerosis, sexual difficulties, and death due to causes such as car accidents in the early years after deployment, but the data are limited, said the committee that wrote the report.

There is a pressing need to answer lingering questions, such as why some veterans suffer a range of symptoms whereas others experience specific, isolated health problems or no ill health, and why some veterans who were not on the ground during the conflict or who arrived after combat ended have multisymptom illness, while others who served on the ground during the height of the battle have experienced few or no symptoms. 

The dearth of data on veterans' pre-deployment and immediate post-deployment health status and lack of measurement and monitoring of the various substances to which veterans may have been exposed make it difficult -- and in many cases impossible -- to reconstruct what happened to service members during their deployments nearly 20 years after the fact, the committee noted.

The report calls for a substantial commitment to improve identification and treatment of multisymptom illness in Gulf War veterans.  The path forward should include continued monitoring of Gulf War veterans and development of better medical care for those with persistent, unexplained symptoms.  Researchers should undertake studies comparing genetic variations and other differences in veterans experiencing multisymptom illness and asymptomatic veterans. 

It is likely that multisymptom illness results from the interactions between environmental exposures and genes, and genetics may predispose some individuals to illness, the committee noted.  There are sufficient numbers of veterans to conduct meaningful comparisons given that nearly 700,000 U.S. personnel were deployed to the region and more than 250,000 of them suffer from persistant, unexplained symptoms.  A consortium involving the U.S. Department of Veterans Affairs, U.S. Department of Defense, and National Institutes of Health could coordinate this effort and contribute the necessary resources.

The committee's review updates a 2006 IOM report that cataloged health effects occurring at higher rates among Gulf War veterans, and takes into account data and information generated since 2005.  This report takes a different approach to the issue of multisymptom illness than the 2006 study, which looked at analyses of unexplained illness and symptoms reported by veterans to determine whether they are experiencing a unique syndrome that could be defined by the symptoms.  The current study began with the premise that multisymptom illness is a diagnostic entity.  It examined the evidence to determine whether a link exists between multiple, unexplained symptoms and Gulf War deployment and, if so, how strong the association is.  The committee concluded that multisymptom illness is linked to Gulf War service, based on the availability of a number of good-quality surveys documenting increased reporting and occurrence of multiple, unexplained symptoms among veterans from several countries that sent troops, including the United Kingdom and Australia.

The data are not strong enough to draw conclusions about what chemical, drug, pollutant, or other substance could have caused these symptoms, the committee said.  Many questions remain about the underlying cause or causes of the complex of symptoms experienced by some veterans and about the adequacy of studies that have looked at the potential contributions of various substances to this disorder. 

"It is clear that a significant portion of the soldiers deployed to the Gulf War have experienced troubling constellations of symptoms that are difficult to categorize," said committee chair Stephen L. Hauser, professor and chair, department of neurology, University of California, San Francisco.  "Unfortunately, symptoms that cannot be easily quantified are sometimes incorrectly dismissed as insignificant and receive inadequate attention and funding by the medical and scientific establishment.  Veterans who continue to suffer from these symptoms deserve the very best that modern science and medicine can offer to speed the development of effective treatments, cures, and -- we hope -- prevention.  Our report suggests a path forward to accomplish this goal, and we believe that through a concerted national effort and rigorous scientific input, answers can be found."

The report was sponsored by the U.S. Department of Veterans Affairs.  Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public.  The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies.  A committee roster follows.

Copies of Gulf War and Health, Vol. 8: Health Effects of Serving in the Gulf War Update 2009 are available from the National Academies Press; tel. 202-334-3313 or 1-800-624-6242 or on the Internet at http://www.nap.edu.  Reporters may obtain a copy from the Office of News and Public Information (contacts listed above). 

====================

Summary of Findings Regarding Associations Between Deployment to the Gulf War and Specific Health Outcomes

Sufficient Evidence of a Causal Relationship
• PTSD.

Sufficient Evidence of an Association
• Other psychiatric disorders, including generalized anxiety disorder and substance abuse, particularly alcohol
abuse. These psychiatric disorders persist for at least 10 years after deployment.
• Gastrointestinal symptoms consistent with functional gastrointestinal disorders such as irritable bowel syndrome
and functional dyspepsia.
• Multisymptom illness. (Affects 250,00, or 36% of veterans of hte 1991 Gulf War

Limited/Suggestive Evidence of an Association
• ALS.
• Fibromyalgia and chronic widespread pain.
• Self-reported sexual difficulties.
• Mortality from external causes, primarily motor-vehicle accidents, in the early years after deployment.

Inadequate/Insufficient Evidence to Determine Whether an Association Exists
• Any cancer.
• Diseases of the blood and blood-forming organs.
• Endocrine, nutritional, and metabolic diseases.
• Neurocognitive and neurobehavioral performance.
• Multiple sclerosis.
• Other neurologic outcomes.
• Incidence of cardiovascular diseases.
• Respiratory diseases.
• Structural gastrointestinal diseases.
• Skin diseases.
• Musculoskeletal system diseases.
• Specific conditions of the genitourinary system.
• Specific birth defects.
• Adverse pregnancy outcomes such as miscarriage, stillbirth, preterm birth, and low birth weight.
• Fertility problems.

Limited/Suggestive Evidence of No Association
• Peripheral neuropathy.
• Mortality from cardiovascular disease in the first 10 years after the war.
• Decreased lung function in the first 10 years after the war.
• Hospitalization for genitourinary diseases.

IOM Concurs Gulf War service linked to Multisymptom Illness in 250,000 Veterans

Second U.S. Government report to say Gulf War Syndrome is real

(WASHINGTON – IOM RELEASE) -- Military service in the Persian Gulf War is a cause of post-traumatic stress disorder in some veterans and is also associated with multisymptom illness; gastrointestinal disorders such as irritable bowel syndrome; substance abuse, particularly alcoholism; and psychiatric problems such as anxiety disorder, says a new report from the Institute of Medicine, the latest update in a series of reports on the Gulf War and veterans' health. 

There is some evidence that service during the conflict is linked to fibromyalgia and chronic widespread pain, amyotrophic lateral sclerosis, sexual difficulties, and death due to causes such as car accidents in the early years after deployment, but the data are limited, said the committee that wrote the report.

There is a pressing need to answer lingering questions, such as why some veterans suffer a range of symptoms whereas others experience specific, isolated health problems or no ill health, and why some veterans who were not on the ground during the conflict or who arrived after combat ended have multisymptom illness, while others who served on the ground during the height of the battle have experienced few or no symptoms. 

The dearth of data on veterans' pre-deployment and immediate post-deployment health status and lack of measurement and monitoring of the various substances to which veterans may have been exposed make it difficult -- and in many cases impossible -- to reconstruct what happened to service members during their deployments nearly 20 years after the fact, the committee noted.

The report calls for a substantial commitment to improve identification and treatment of multisymptom illness in Gulf War veterans.  The path forward should include continued monitoring of Gulf War veterans and development of better medical care for those with persistent, unexplained symptoms.  Researchers should undertake studies comparing genetic variations and other differences in veterans experiencing multisymptom illness and asymptomatic veterans. 

It is likely that multisymptom illness results from the interactions between environmental exposures and genes, and genetics may predispose some individuals to illness, the committee noted.  There are sufficient numbers of veterans to conduct meaningful comparisons given that nearly 700,000 U.S. personnel were deployed to the region and more than 250,000 of them suffer from persistant, unexplained symptoms.  A consortium involving the U.S. Department of Veterans Affairs, U.S. Department of Defense, and National Institutes of Health could coordinate this effort and contribute the necessary resources.

The committee's review updates a 2006 IOM report that cataloged health effects occurring at higher rates among Gulf War veterans, and takes into account data and information generated since 2005.  This report takes a different approach to the issue of multisymptom illness than the 2006 study, which looked at analyses of unexplained illness and symptoms reported by veterans to determine whether they are experiencing a unique syndrome that could be defined by the symptoms.  The current study began with the premise that multisymptom illness is a diagnostic entity.  It examined the evidence to determine whether a link exists between multiple, unexplained symptoms and Gulf War deployment and, if so, how strong the association is.  The committee concluded that multisymptom illness is linked to Gulf War service, based on the availability of a number of good-quality surveys documenting increased reporting and occurrence of multiple, unexplained symptoms among veterans from several countries that sent troops, including the United Kingdom and Australia.

The data are not strong enough to draw conclusions about what chemical, drug, pollutant, or other substance could have caused these symptoms, the committee said.  Many questions remain about the underlying cause or causes of the complex of symptoms experienced by some veterans and about the adequacy of studies that have looked at the potential contributions of various substances to this disorder. 

"It is clear that a significant portion of the soldiers deployed to the Gulf War have experienced troubling constellations of symptoms that are difficult to categorize," said committee chair Stephen L. Hauser, professor and chair, department of neurology, University of California, San Francisco.  "Unfortunately, symptoms that cannot be easily quantified are sometimes incorrectly dismissed as insignificant and receive inadequate attention and funding by the medical and scientific establishment.  Veterans who continue to suffer from these symptoms deserve the very best that modern science and medicine can offer to speed the development of effective treatments, cures, and -- we hope -- prevention.  Our report suggests a path forward to accomplish this goal, and we believe that through a concerted national effort and rigorous scientific input, answers can be found."

The report was sponsored by the U.S. Department of Veterans Affairs.  Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public.  The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies.  A committee roster follows.

Copies of Gulf War and Health, Vol. 8: Health Effects of Serving in the Gulf War Update 2009 are available from the National Academies Press; tel. 202-334-3313 or 1-800-624-6242 or on the Internet at http://www.nap.edu.  Reporters may obtain a copy from the Office of News and Public Information (contacts listed above). 

VIDEO: Conference on Gulf War Veterans' Illness

The State of Wisconsin Department of Veterans Affairs (WDVA) was host to the 2008 Conference on Gulf War Veterans‚ Illnesses in conjunction with the 17th anniversary of the beginning of 1991 Persian Gulf War.

Wisconsin remains the first state in the nation, through 2005 Wis. Act 37, to designate an annual Gulf War Illnesses Recognition Day in recognition of those who still suffer from post-deployment health issues.

Video coverage of the conference is as follows:

01.17.08 | 2008 Conference on Gulf War Veterans' Illness (Opening Remarks) Watch | Listen

WDVA Secretary John A. Scocos, the opening speaker, presents a Proclamation from Governor Jim Doyle proclaiming Jan. 17, 2008 as Gulf War Illnesses Recognition Day in Wisconsin.

01.17.08 | 2008 Conference on Gulf War Veterans' Illness (Presentation One) Watch | Listen

In conjunction with the 2008 Conference on Gulf War Veterans‚ Illness, Anthony Hardie, WDVA Executive Assistant who has testified before Congress and served in an advisory capacity on Gulf War veterans‚ health issues for numerous governmental bodies and non-profits, presents, Lost in the Shuffle: Veterans of the 1991 Persian Gulf War.

01.17.08 | 2008 Conference on Gulf War Veterans' Illness (Presentation Two) Watch | Listen

As part of the 2008 Conference on Gulf War Veterans‚ Illness, Dane B. Cook, Ph.D., William S. Middleton Memorial Veterans Hospital/ Exercise Psychology Laboratory, UW-Madison and Aaron Stegner, Ph.D., Exercise Psychology Laboratory, UW-Madison, present information on research they are conducting on the issue of Gulf Veterans and Pain.

IOM to Release 8th Report in Gulf War and Health Series this Week

Veterans groups skeptical of earlier reports, citing  biased VA contracting

Written by Anthony Hardie, Publisher/Editor

(91outcomes.com) This week, the Institute of Medicine (IOM), part of the National Academy of Sciences, will release the first of two parts of its eighth report in its “Gulf War and Health” series, Update of Health Effects of Serving in the Gulf War. 

The IOM has conducted the series of studies -- mandated by the Persian Gulf War Veterans Act of 1998 and modeled after Agent Orange legislation -- to examine the scientific and medical literature on the potential health effects of veterans’ 1991 Gulf War exposures. 

However, most of IOM’s previous Gulf War reports have come under fire from veterans groups and the powerful, congressionally-chartered Research Advisory Committee on Gulf War Veterans’ Illnesses (RAC-GWVI), which have called the reports biased against veterans because they have led to very few presumptive conditions for veterans of the 1991 Gulf War. 

Veterans groups and the RAC-GWVI have faulted U.S. Department of Veterans Affairs contracting authorities rather than IOM scientists, noting that IOM study committees have been contractually forced by VA authorities to specifically exclude considering critically important animal and other types of studies that are key to studying health outcomes of exposures to toxic substances present in the Gulf War. 

The IOM reports are used by the VA to determine presumptive conditions for service-connected disability compensation and health care for the conditions.

Last month, VA Secretary Eric Shinseki used IOM study results to presumptively connect long-term health effects associated with nine rare infectious diseases endemic to the Persian Gulf region. 

Shinseki also announced a rewrite of the rules related to Gulf War veterans’ illnesses to help with disability and health care claims by the 175,000 to 210,000 of the 697,000 veterans of the war believed to be affected by chronic multi-symptom illness.

IOM has conducted several previous public meetings related to the new report, as the committee has met to deliberate on published studies relevant to the issues at hand.

The IOM will host a public briefing on the new report on Friday, April 9, 2010, from 1:00 to 2:00 p.m. (Eastern Time).  The briefing will be held in Room 700 in the National Academies Keck Center, 500 5th Street NW, Washington, DC. The building is located about one block from the Judiciary Square Metro station.

Information regarding the project can be found on the National Academies website at: http://www8.nationalacademies.org/cp/projectview.aspx?key=49036. If you are interested in attending, please email Joe Goodman (jgoodman@nas.edu)  as space is limited.  If you cannot attend in person and would like to listen to the briefing via telephone, please respond via email; a call-in number will be sent the week of the briefing to those who wish to listen. 

According to Committee staff, this briefing is related to the release of the committee’s initial report (first phase of a two-phase study). A second report is scheduled to be completed and released in about 30 months, and will go more in-depth into the readjustment issues identified in the initial report.

Previous reports in the IOM Gulf War and Health series have included:

1.  Gulf War and Health: Volume 1.  Depleted Uranium, Sarin, Pyridostigmine Bromide, and Vaccines, January 1, 2000. 

This first study by IOM reviewed the scientific literature on depleted uranium, chemical warfare agents (sarin and cyclosarin), pyridostigmine bromide, and vaccines (anthrax and botulinum toxoid)

2.  Gulf War and Health Volume 2. Insecticides and Solvents, Feb 18, 2003. 

This report provides a comprehensive assessment of the available scientific literature on potential health effects of exposure to certain biological, chemical, and environmental agents associated with the Gulf War. In this second study, the committee evaluated the published, peer-reviewed literature on exposure to insecticides and solvents thought to have been present during the 1990-1991 war.

Because little information exists on actual exposure levels a critical factor when assessing health effects the committee could not draw specific conclusions about the health problems of Gulf War veterans. However, the study found some evidence, although usually limited, to link specific long-term health outcomes with exposure to certain insecticides and solvents.

3.  Gulf War and Health: Volume 3.  Fuels, Combustion Products, and Propellants.  Released 2005. 

This volume evaluates the long-term, human health effects associated with exposure to selected environmental agents, pollutants, and synthetic chemical compounds believed to have been present during the Gulf War. The committee specifically evaluated the literature on hydrogen sulfide, combustion products, hydrazine and red fuming nitric acid. Both the epidemiologic and toxicologic literature were reviewed.

4.  Gulf War and Health: Volume 4.   Health Effects of Serving in the Gulf War, Released: September 12, 2006. 

This report differs from the previous work of IOM in that it summarizes in one place the current status of health effects in veterans deployed to the Persian Gulf irrespective of exposure information.  The charge to this IOM committee was to review, evaluate, and summarize peer-reviewed scientific and medical literature addressing the health status of Gulf War veterans. 

The committee found that although veterans of the first Gulf War report significantly more symptoms of illness than soldiers of the same period who were not deployed, studies have found no cluster of symptoms that constitute a syndrome unique to Gulf War veterans. 

The committee did find evidence that suggests there may be an elevated rate of the rare disorder amyotrophic lateral sclerosis (ALS) among Gulf War veterans. However, there does not appear to be an increase in mortality and hospitalizations among Gulf War veterans. Evidence regarding rates of testicular cancer, brain cancer, and certain birth defects among Gulf War veterans is inconsistent and the committee recommended further surveillance for those health outcomes.

5.  Gulf War and Health: Volume 5.  Infectious Disease.  Released: November 3, 2006. 

This report reviewed long-term adverse human health effects associated with selected infectious diseases pertinent to Gulf War veterans.  The infectious diseases include, but are not limited to, diseases caused by pathogenic Escherichia coli, shigellosis, leishmaniasis, and sandfly fever.

6.  Gulf War and Health: Volume 6.  Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress, Released: November 15, 2007.   

This study comprehensively reviewed, evaluated, and summarized the peer-reviewed scientific and medical literature regarding the association between stress and long-term adverse health effects in Gulf War veterans, specifically the physiologic, psychologic, and psychosocial effects of stress.

The study was not limited to veterans of the 1991 Gulf War but also is applicable to veterans of Operation Iraqi Freedom and Operation Enduring Freedom.

7.  Gulf War and Health: Volume 7. Long-term Consequences of Traumatic Brain Injury, Released:  December 3, 2008. 

This report assesses the possible long-term health outcomes of traumatic brain injury (TBI), detailing numerous outcomes that might be associated with mild, moderate, and severe injuries. These include: neurologic, endocrine, psychologic outcomes, in addition to problems with social functioning. 

Recommendations are provided for study of blast injuries and the report suggests methods of data-gathering for future research to improve our understanding of blast injuries which ultimately would improve veteran care.

 

Additional IOM reports relevant to Gulf War veterans:

Gulf War Veterans: Treating Symptoms and Syndromes, Released: July 26, 2001

Potential health consequences of service in the Gulf War have been a concern since U.S. troops returned home. Research and investigations to date indicate there is no single illness or syndrome common to all ill veterans. Questions have arisen as to whether there are effective treatments for the problems ill veterans are experiencing, and whether these veterans are receiving appropriate care.

In response to Section 105 of this legislation, the Department of Veterans Affairs asked the Institute of Medicine to convene a committee that would:

• Identify and describe approaches for assessing treatment effectiveness;
• Identify illnesses and conditions among veterans of the Gulf War, using data obtained from the VA and the DoD Gulf War Registries, as well as information in published articles; and
• For these identified conditions and illnesses, identify validated models of treatment (to the extent that such treatments exist), or identify new approaches, theories, or research on management of patients with these conditions if validated treatments models are not available.

The congressional legislation specifically requested that the Academy study address undiagnosed illnesses as well as any other chronic illness deemed to warrant review. 

Gulf War and Health: Updated Literature Review of Sarin Released: August 20, 2004

In a report released in 2000, the IOM revealed that exposure to the chemical warfare agent sarin can cause short-term symptoms such as severe cramping, difficulty breathing, twitching, pinpoint pupils and heavy sweating. However, there was not enough evidence to draw conclusions as to whether long-term health effects are associated with low-dose exposures.

In response to veterans' ongoing concerns and recent publications in the literature, IOM updated its 2000 report. In the report, Gulf War and Health: Updated Literature Review of Sarin, the committee concluded that there is still not enough evidence to determine whether exposure to low doses of sarin are associated with long-term health problems.

Gulf War and Health: Updated Literature Review of Depleted Uranium, Released: July 30, 2008.

In this most recent report, the committee concluded that there is still not enough evidence to determine whether exposure to depleted uranium is associated with long-term health problems.

Epidemiologic Studies of Veterans Exposed to Depleted Uranium: Feasibility and Design Issues, Released: July 30, 2008.

Depleted uranium, a component of some weapons systems, has been in use by the U.S. military since the 1991 Gulf War. Military personnel have been exposed to depleted uranium as the result of friendly fire incidents, cleanup and salvage operations, and proximity to burning depleted uranium-containing tanks and ammunition. Under a Congressional mandate, the Department of Defense sought guidance from the Institute of Medicine in evaluating the feasibility and design of an epidemiologic study that would assess health outcomes of exposure to depleted uranium.

The study committee examined several options to study health outcomes of depleted uranium exposure in military and veteran populations and concluded that it would be difficult to design a study to comprehensively assess depleted uranium-related health outcomes with currently available data. The committee further concluded that the option most likely to obtain useful information about depleted uranium-related health outcomes would be a prospective cohort study if future military operations involve exposure to depleted uranium.

The book contains recommendations aimed at improving future epidemiologic studies and identifying current active-duty military personnel and veterans with potential DU exposure.

=================

Background:  The Persian Gulf War Veterans Act of 1998, Public Law 105-277, title XVI, 112 Stat. 2681-742 through 2681-749 (codified at 38 U.S.C. 1118), and the Veterans Programs Enhancement Act of 1998, Public Law 105-368,112 Stat. 3315, previously directed the Secretary to seek to enter into an agreement with the NAS IOM to review and evaluate the scientific literature regarding associations between illness and exposure to specific toxic agents, environmental or wartime hazards, or preventive medicines or vaccines to which service members may have been exposed during service in the Southwest Asia theater of operations during the Persian Gulf War.

6 Simple Ways to Improve Symptoms of Fibromyalgia, a condition common in Gulf War veterans

Written by January W. Payne, U.S. News & World Report.

Fibromyalgia affects about 2 percent of the U.S. population--more women than men--and often, those who have the condition are afraid to exercise because they fear worsening their symptoms. But experts say that regular physical activity actually helps fibromyalgia sufferers. The problem? The condition's hallmarks--widespread body pain and fatigue--make it tough to work out. So how can people with fibromyalgia be encouraged to exercise without fear of making their pain and fatigue worse? A new study shows that taking small steps can help improve pain and functioning of those with fibromyalgia, as long as it's done in moderation.

[Read A New Fibromyalgia Remedy: Antiviral Drugs.]

The goal of the new study, published Monday in Arthritis Research & Therapy, was to "see if we can get [people with fibromyalgia] to be more active throughout the day," says Kevin Fontaine, associate professor of medicine in the division of rheumatology at the Johns Hopkins University School of Medicine. "The goal is to get them to accumulate 30 minutes of activity most days of the week," which can be accomplished in two-to-three-minute increments over the course of the day. The study's 84 participants were randomized to a "lifestyle physical activity" group or to a control group. Those in the lifestyle group--who, for example, were encouraged to walk more and take the steps instead of the elevator--increased their average daily steps by 54 percent by the end of the study and reported improvements in physical functioning and less pain. "Even if they just walk to their mailbox, that's better than doing nothing," Fontaine says. "If they do a little bit, they realize that they can manage the pain."

Still, because fibromyalgia symptoms can vary from day to day, each individual has to know his or her own limitations. "People have good days and bad days, and on good days, they tend to overdo it," Fontaine says. "So if you're having a bad day, try to do a little bit, and if you're having a good day, don't do too much."

[Quiz: How bad is your pain?]

Fontaine says that anyone with fibromyalgia can make the small daily lifestyle changes that the study showed can help. He recommends the following six activities to get started, done at a pace intense enough to make you breathe heavily but not so much so that you can't hold a conversation:

Buy a pedometer, and walk more. Walking is a total body exercise, and you can moderate the pace and control the intensity, Fontaine says. Wearing a pedometer allows you to easily monitor your progress.

[Read: We're Born to Walk.]

Move about while watching TV. Raise your arms over your head, or move them from side to side, Fontaine advises. Or sit in a chair and lift your legs one at a time at the knee. Other options: Make circles with your arms for a minute or two while sitting in a chair. The goal is "even on your worst day, try at the end of the day to say to yourself, 'I did something,' " he says.

Take the steps. If you work in an office building, take the steps instead of the elevator once or twice a day, adjusting your routine based on what's easier for your body. For example, if you find going up the steps to be easier than going down, take the steps up and the elevator down, he says. "Stairs are one of the more intense daily lifestyle activities," and you can build up your tolerance over time, walking two to three flights after several weeks even if you can't tackle one flight at the beginning, Fontaine says.

Do yardwork or garden. But make adjustments to fit your needs. That means if your back tends to bother you, consider sitting on a bench while gardening rather than bending over while standing up. Also, "if you have a big yard and you can't do your whole yard at once, just spend five minutes using the mower" at a time, Fontaine suggests. "One of the problems is that people spend the whole day doing yardwork, and then they have a flare-up for the next few days," he says, so instead of doing four hours of outside work at one time, break the task up into pieces--say, 20 minutes at a time three or four times per week until the work is completed.

Do housework--and make it fun. Turn on music while you vacuum or clean so you move a bit quicker while you work. "Whatever activity you're doing, think of a way to make it a little bit more taxing than it would be otherwise," advises Fontaine.

Finally, if you'd like to step up your routine a bit but don't feel ready for joint-pounding exercise, consider water or aqua exercise. Warm water can be especially therapeutic, Fontaine says. A 2008 study published in Archives of Physical Medicine and Rehabilitation found that exercise in a warm pool three times a week for 16 weeks improved many fibromyalgia symptoms in a group of previously unfit women.

[Read Aquatic Exercises May Ease Fibromyalgia.]

Short Bursts of Physical Activity May Reduce Chronic Pain Symptoms

Written by Laurie Barclay, MD, Freelance writer and reviewer, Medscape, LLC

(Medscape) — Short bursts of physical activity in a lifestyle physical activity (LPA) intervention may reduce fibromyalgia (FM) symptoms and improve physical function, according to the results of a randomized trial reported online in the March 29 issue of Arthritis Research & Therapy.

"Fibromyalgia is estimated to occur in 2% of the U.S. general population, affecting about eight times more women than men," said lead author Kevin R. Fontaine, PhD, from Johns Hopkins University School of Medicine, in Baltimore, Maryland, in a news release. "Although exercise has been shown to be beneficial, the symptoms often create obstacles that deter many from exercising consistently enough to derive benefits."

The goal of this study was to assess the effects in 84 minimally active adults with FM of accumulating at least 30 minutes of self-selected LPA on perceived physical function, pain, fatigue, body mass index, depression, tenderness, and the 6-minute walk test. Participants were assigned to either LPA or a FM education control (FME) group receiving information and support.

In the LPA intervention, participants were taught to perform LPA intense enough to cause heavy breathing without preventing conversation. Suitable moderate-intensity physical activities included climbing stairs, gardening, and walking. The goal was to accumulate 30 minutes of self-selected moderate-intensity LPA at 5 to 7 days per week.

A total of 73 (87%) of the 84 participants completed the 12-week trial. Average daily steps in the LPA group increased by 54%. Perceived functional deficits and pain were significantly less in the LPA group vs the FME group (P = .032 and P = .006, respectively). The groups did not differ on 6-minute walk test performance (P = .067), fatigue, depression, body mass index, or tenderness.

"The nature of fibromyalgia's symptoms, the body pain and fatigue, make it hard for people with this malady to participate in traditional exercise," Dr. Fontaine said. "We've shown that LPA can help them to get at least a little more physically active, and that this seems to help improve their symptoms."

Limitations of this study include inability to determine how LPA compares with a traditional no-treatment control group; use of self-reported outcomes; and use of pedometers to assess LPA, which failed to quantify cycling or water exercise. In addition, muscle strength was not measured during the trial, and persons with other comorbid conditions were excluded.

"Accumulating 30 minutes of LPA throughout the day produces clinically relevant changes in perceived physical function and pain in previously minimally active adults with FM," the study authors conclude. "However, the LPA intervention only moved the participants from the sedentary to low physical activity category. This suggests that it is essential to encourage FM patients to increase the duration of their physical activity in ways that do not compromise their ability to sustain the increased level of activity over the intermediate- and long-term."

The National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases supported this study. One of the study authors (Daniel J. Clauw, MD) has acted as a consultant for Pfizer, Lilly, Forest Laboratories, Cypress Biosciences, Pierre Fabre, UCB, and Wyeth, and has received grant support from Pfizer, Cypress Bioscience, and Forest.

Arthr Res Therapy. Published online March 29, 2010

DoD: VA to Intensify Gulf War Illness Outreach, Care

Written by Donna Miles, American Forces Press Service

(WASHINGTON – DoD) – Veterans Affairs Secretary Eric K. Shinseki yesterday announced promising news for veterans of the Persian Gulf War experiencing the broad range of symptoms referred to as Gulf War Illnesses.

Acting on recommendations from a task force he stood up to identify gaps in service, Shinseki said VA plans to reconnect with veterans who deployed during the Gulf War in 1990 and 1991 to ensure they get the best information and care possible.

As part of that outreach, VA’s Gulf War Veterans’ Illnesses Task Force recommended improved data-sharing with the Defense Department to notify veterans of potential exposures, monitor their long-term health and provide additional follow-up.

The task force also recommended that VA strengthen training for clinicians and claims processors so they’re better postured to diagnose, treat and process disability claims related to Gulf War Illnesses, and reenergize its research and medical surveillance efforts.

The task force’s report will redefine how VA addresses the concerns of veterans deployed during the Gulf War, Shinseki said. “Our mission at VA is to be advocates for veterans,” he said. “This report’s action plans provide a roadmap to transform the care and services we deliver to Gulf War veterans.”

The new recommendations come on the tail of a VA proposal announced last month to presume nine specific infectious diseases to be service-connected for anyone who served in Southwest Asia after Aug. 2, 1990, or in Afghanistan after Sept. 18, 2001.

That ruling, once adopted, will impact veterans who deployed to Iraq and Afghanistan. It will relieve those suffering from the designated diseases from the burden of proving their ailments are linked to service in the Persian Gulf or Afghanistan to receive VA health care and disability payments.

The nine diseases are: brucellosis, Campylobacter jejuni, Coxiella burnetii (Q fever), malaria, Mycobacterium tuberculosis, nontyphoidal Salmonella, Shigella, visceral leishmaniasis (kala-azar) and West Nile virus.

During an interview with American Forces Press Service, Shinseki called the proposed ruling a positive step in taking care of Gulf War veterans suffering numerous symptoms and diagnoses yet to be pinpointed to any specific exposure.

“We can’t historically go back and decide what actually caused [Gulf War Illness],” he said. “We spent $350 million trying to find the cause, and we haven’t arrived at a clear answer.”

Rather than simply waiting for researchers to come up with a cause-and effect solution, Shinseki pressed VA to come up with a plan to compensate affected veterans now.

“My request was, ‘Can we agree that something happened?’” he said. “We have enough evidence here, symptomatically, that something happened. It may be a combination of things. We may never be able to answer exactly what caused this.

“But we can deal with the problem,’ he said. “So let’s take care of people.”

Shinseki took a similar approach to Agent Orange, a defoliant used during the Vietnam War that many veterans blame for causing a variety of illnesses and diseases.

VA previously presumed 12 diseases to be service-connected based on Agent Orange exposure. In October, Shinseki proposed adding three more diseases to the list: hairy-cell leukemia and other B-cell leukemias, Parkinson's disease and ischemic heart disease.

Shinseki said he based his decision on a report by the National Academy of Science's Institute of Medicine citing compelling new evidence of a connection between the three illnesses and Agent Orange exposure.

“That was not an independent decision by the VA,” Shinseki emphasized. “The Institute of Medicine is designated by Congress as the impartial determiner of whether or not there is sufficient evidence to make the decision like the one I made…. And they gave me enough information for me to say, ‘I can see the tie.’ So the decision was made.”

Shinseki, a former Army chief of staff and Vietnam veteran, had long criticized past practices that put the burden on veterans to prove that the variety of illnesses many suffered was linked to Agent Orange exposure. Too often, he said, this created an adversarial relationship between VA and veterans.

“It was important to clearly let the Vietnam veterans know that they have not been forgotten,” he said. “We are dealing with our responsibilities here.”

VA Gulf War Task Force Draft Report available in 91outcomes.com Library

The March 29, 2010 Final Draft Report of the U.S. Department of Veterans Affairs Gulf War Veterans’ Illnesses Task Force is available in the online library of 91outcomes.com.

To read the report:

• Visit the library (File name: VA_Gulf_War_Task_Force_03-29-2010.pdf), or
• View the report online,  or
• Download it. 

Public notice of the Gulf War Veterans’ Illnesses Task Force Draft Written Report has been posted on the Federal Register at: http://www.regulations.gov/search/Regs/home.html#documentDetail?R=0900006480ace153. 

The public will be able to review the notice, download the draft written report, and submit comments for the next 30 days.

The Task Force members reviewed existing literature and consulted with Veterans, Veterans’ advocates, program managers, Gulf War subject matter experts, and other stakeholders in developing the perceptions and recommendations presented. 

General information relating to the Department of Veterans Affairs benefits and services related to the Gulf War may be found at www.publichealth.va.gov/exposures/gulfwar/  or the toll free helpline at: 1-800-749-8387.  You may also submit your ideas on VAs discussion board at: www.yourgulfwarvoice.uservoice.com.