Gulf War Illness: A brief history

IOM, June 26, 2013

Roberta F. White, PhD Boston University School of Public Health RAC--Gulf War Illnesses

From Gulf War Syndrome to CMI to Gulf War Illness

 Early timeline
1991: Ft Devens Survey
Focus: PTSD, psychiatric symptoms, health symptoms (HS36, short version)

1993: VA OPH clinical funding (Boston)

Foci: PTSD, multiple chemical sensitivity, chronic fatigue syndrome, chemical exposures

1994-1999: VA Environmental Hazards Centers, Haley syndrome studies

Three centers
New Jersey (CFS/MCS) Portland (case definition) Boston (high symptom reporters, exposure-outcome)

 Early findings: Devens cohort

PTSD, CFS, MCS rates too low to explain the excess health complaints seen (1-6%, depending on diagnosis) Self-reported exposures related to increased symptom reporting and decreased scores on cognitive tests
SCUD missiles Nerve gas agents Pesticides Pyridostigmine bromide

 Studies over time: multiple researchers

Regardless of case definition used, increased health symptom reporting was seen in deployed GW veterans relative to controls of all types Case definitions varied widely, many were too broad Exposure-outcome relationships were demonstrated for adverse health effects and levels of chemical exposures: pesticides, PB, sarin

 Studies over time

Modeled levels of exposure to sarin, pesticides, PB and mixtures of pesticides/PB predicted lower scores on certain cognitive tests Higher exposures also predicted lower brain matter volumes and disrupted white matter connectivity on brain MRIs Levels of stress and PTSD diagnosis did not explain health symptoms or cognitive outcomes

 Studies over time

Chronic multi-symptom illness from CDC/Fukuda emerged as one case definition of Gulf War Illness

 IOM 2010 report conclusions

Epidemiologic studies comparing veterans who were deployed to the Gulf War with veterans who were in the military during the Gulf War have confirmed that deployed veterans have a greater prevalence of a number of medical conditions, illnesses and symptoms. This has also been seen in deployed veterans from many countries that formed the coalition forces (p.71). (C)urrent estimates (are) that more than 250,000 US Gulf War veterans have persistentmedical symptoms (p.262)

 IOM 2010 report conclusions

the excess of unexplained medical symptoms reported by deployed Gulf War veterans cannot be reliably ascribed to any known psychiatric disorder (p. 109). (T)here is sufficient evidence of an association between deployment to (the) Gulf War and chronic multi-symptom illness The committee accepted that multi-symptom illness was a diagnostic entity (p.204)

 IOM 2010 report conclusions

It is likely that Gulf War illness results from an interplay of genetic and environmental factors (p. 261)

 VA physician treatment guidelines summary:

What we do know is that chronic multisymptom illness is real and cannot be reliably ascribed to any known psychiatric disorder. Specifically, it cannot be ascribed to somatiform disorder, PTSD or depression. http://www.publichealth.va.gov/docs/vhi/caringfor-gulf-war-veterans-vhi.pdf

 Case definition implications of body of literature: Gulf War Illness

Exposures
Gulf theater exposure, 1990-1991

Individual symptoms and symptom clusters (Physiological indicators when available: brain, GI, immunological, genetic)