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CCEP Report on 18,598 Participants

April 2, 1996


Approximately 697,000 U.S. service members deployed to the Persian Gulf in 1990/1991 for Operations Desert Shield/Storm (ODS/S). The vast majority of troops returned from this large deployment healthy. In response to Gulf War veterans' concerns about the potential health effects of service in ODS/S, the Departments of Defense (DoD) and Veterans Affairs (VA) developed similar, comprehensive clinical evaluation programs to provide them care and to understand the nature of their illnesses. The DoD Comprehensive Clinical Evaluation Program (CCEP) provides a systematic, in-depth medical evaluation for DoD beneficiaries (Persian Gulf War veterans now on active duty or retired; members of the full-time National Guard who are Persian Gulf veterans; Persian Gulf War veterans who are members of the Ready Reserve/Individual Ready Reserve/Standby Reserve/Reserve who are placed on orders by their units; and eligible family members of such personnel) who are experiencing illnesses that may be related to their service in the Persian Gulf. As of early December 1995, more than 27,000 individuals had enrolled in the program. Approximately 21,000 of these participants requested an examination of which , and 18,598 had completed the evaluation process and had the their records information about their health have been verified and entered into the CCEP database.

This descriptive case series report summarizes the diagnostic results of over 18,000 systematic clinical evaluations completed through the Comprehensive Clinical Evaluation Program (CCEP). The CCEP was designed primarily as a clinical rather than a research program. Self-selection of patients, recall bias, inability to validate self-reported exposures, and the lack of an appropriate comparison or control group limit the ability to generalize the relevance of CCEP findings to other Persian Gulf veterans. However, the large size of the CCEP cohort and the thoroughness of the CCEP examinations provide considerable clinical insight towards understanding the nature of these veterans' illnesses and health concerns. Ongoing and planned epidemiologic studies by the Department of Defense, Veterans Affairs, and Health and Human Services which involve control/comparison populations, will characterize further any health consequences of the Persian Gulf War.

Based on the evaluation of 18,598 participants, our findings include:

CCEP participants report a wide variety of symptoms spanning multiple organ systems in no consistent, clinically apparent pattern. In the clinical literature, only a limited number of studies of symptoms of patients in other clinical and survey settings have been published. These other study populations are not completely analogous to the CCEP population, since they generally involve older patients and more women than found in the CCEP. However, these studies of outpatient practice and the general U.S. population suggest that the types of symptoms being reported in the CCEP are not unique and are similar in nature to those seen in other groups of patients.

Symptoms such as fatigue, joint pain, headache, or sleep disturbances are common among CCEP participants. Published studies involving patients with these types of generalized symptoms have shown that 20-75% of them lack a clear-cut or discrete physical explanation or "cause" after a thorough medical evaluation. Similarly, it is likely that some CCEP participants may also lack a discrete physical explanation for their generalized symptoms.

The distribution of primary diagnoses seen in CCEP participants spans many different organ systems as categorized according to the International Classification of Diseases-Ninth Revision, Clinical Modification (ICD-9-CM). However, over half (65%) of the primary diagnoses of CCEP participants are concentrated in four diagnostic groups: "Psychological Conditions," "Symptoms, SignsSigns, Symptoms, Ill-Defined Conditions," "Musculoskeletal and Connective Tissue Diseases" and "Healthy" (V65.5).

Gulf War veterans who have participated in the CCEP are experiencing real symptoms and illnesses with real consequences, although the vast majority of participants are apparently able to function in their jobs. Severe disability, measured in terms of reported lost workdays, is not a major characteristic of CCEP participants. Relatively few CCEP participants report missing had not missed work because of illness or injury during the 90 days prior to their initial evaluation. Determination of the extentdegree to which the CCEP disability experience reflects the overall disability experience of Persian Gulf veterans is limited by the fact that many Persian Gulf War veterans are no longer on active duty.

Comparisons of CCEP participants with patients in outpatient medical settings are limited because of differences in patient populations. However, some existing clinical studies provide a context in which to consider the following CCEP findings.

- The most common psychological conditions found in CCEP participants are: tension headache; nonspecific, mild, or stress-related anxiety and/or depression; and posttraumatic stress disorder (PTSD). The prevalence of psychological diagnoses among CCEP participants may be higher than that observed in other patients seen in general medical practice.

- CCEP diagnoses include a group of common medical conditions not classified elsewhere in the ICD-9-CM coding system (e.g., sleep apneas), generalized symptoms, abnormal laboratory tests, and nonspecific physical findings. These diagnoses, which are categorized as "Symptoms, SignsSigns, Symptoms and Ill-Defined Conditions" according to the ICD-9-CM coding system, may occur more frequently in the CCEP than amongthey do patients seen in general medical practice.

- Musculoskeletal and connective tissue diseases (joint pain, osteoarthritis, backache) are common diagnoses seen in CCEP participants. These conditions appear to occur more frequently in the CCEP population than they do in patients seen in general medical practice.

The evaluation of reproductive risks to men and women from environmental exposures is a complex and emotional issue. Some CCEP participants self-report experiencing adverse reproductive events since the Gulf War. However, these reports have not been validated review of medical record or other sources of information. Reproductive studies of other groups of Persian Gulf veterans, which have involved review of medical databases and records and related databases, have to date found no evidence of increased reproductive problems. Clearly this is an important issue, which the Department will study further.

To date, there is no clinical evidence for a previously unknown, serious illness or "syndrome" among Persian Gulf veterans participating in the CCEP. A unique illness or syndrome among Persian Gulf veterans evaluated through the CCEP, capable of causing serious impairment in a high proportion of veterans at risk, would probably be detectable in the population of 18,598 patients. However, an unknown illness or a syndrome that was mild or affected only a small proportion of veterans at risk might not be detectable in a case series, no matter how large.

DoD will continue to provide comprehensive high quality health care to eligible Persian Gulf veterans and their family members and will continue its efforts to understand any health consequences of service in the Persian Gulf War. The Department is committed to a continuing exchange of relevant information with other government agencies, researchers, and Gulf War veterans to further understand this important public health issue.



Iraq invaded Kuwait on August 2, 1990. Subsequent implementation of Operation Desert Shield occurred at a rapid pace, and approximately 697,000 U.S. service members were deployed to the Persian Gulf region over the next five months. Fortunately, hostilities did not begin immediately, and medical personnel had an opportunity to assess medical threats, formulate effective surveillance efforts, and design preventive programs to keep non-battle morbidity and mortality at the lowest possible levels.[1],[2] By the time Operation Desert Storm began in January 1991, the soldiers, sailors, airmen, and marines in this operation were, in many respects, more closely monitored for the emergence of medical problems, and better protected from environmental threats, than service members in any previous campaign. These measures were successful; the Gulf War had a lower disease non-battle injury (DNBI) rate than any major conflict in U.S. history.[3],[4]

Since Operations Desert Shield/Storm (ODS/S), some Gulf War veterans have reported persistent symptoms that they believe are related to their experience in the Persian Gulf War. These symptoms most commonly included fatigue, joint pain, sleep problems, loss of memory, rash, or headache. In response to veterans' concerns about their health following ODS/S, the Departments of Defense (DoD) and Veterans Affairs (VA) developed similar comprehensive clinical evaluation programs. As of early December 1995, the DoD had enrolled over 27,000 participants eligible for DoD health care in the Comprehensive Clinical Evaluation Program (CCEP).

In December 1994, the DoD issued its preliminary status report on the first 1,000 patients to complete the CCEP.[5] Since that report, the Department has continued an aggressive outreach effort to provide evaluation and care to veterans who are experiencing illnesses that they feel may be related to their service in the Persian Gulf. On March 10, 1995, the DoD provided updates of the results of 2,076 medical evaluations accomplished through the CCEP[6] and in August 1995 presented a report on 10,020 participants. [7] This report summarizes program activities through December 6, 1995, and includes the clinical findings from 18,598 participants who have requested and completed their CCEP evaluations. Additionally, this report updates information provided in previous reports and presents recent results from the CCEP in order to further describe the clinical characteristics of CCEP participants.

Potential Health Risks Associated with Persian Gulf Deployment

A number of questions have arisen about the possible impact of certain environmental exposures and preventive medicine measures on service members during ODS/S. To better understand the health concerns among Gulf War veterans and provide the most effective treatments of their illnesses, a review of potential health risks associated with service in the Persian Gulf is necessary. These risks include physical and psychological stress, possible reactions to prophylactic drugs and vaccines, infectious diseases, and exposures to environmental hazards. [8] In addition, there has been a concern among some veterans that chemical and biological weapons may be associated with some of their symptoms. As observed in studies of veterans of other wars, readjustment disorders and posttraumatic stress disorder (PTSD) have been common problems among Persian Gulf veterans.[9] ,[10],[11],[12],[13]

DoD Actions and Initiatives

The DoD began to assess the health consequences of the Persian Gulf War while troops were still deployed in the Gulf region. As early as February 1991 a medical workshop convened in Dayton, Ohio, to consider the medical effects that might occur among troops exposed to crude oil released from damaged wells during the course of Operation Desert Storm.[14] In May 1991 the DoD deployed a team of physicians, scientists, and engineers to the Persian Gulf region to establish monitoring stations in both Kuwait and Saudi Arabia to assess the potential environmental health risks to service members. The Kuwaiti Oil Fire Health Effects Working Group was formed in August 1991 to provide technical oversight of the Department's efforts to conduct a comprehensive health risk assessment of effects of exposures to smoke from the Kuwaiti oil well fires.[15] Additionally, an Expert Panel on Petroleum Toxicity met in June 1991 at the Uniformed Services University of Health Sciences (USUHS) to review and discuss scientific information pertaining to health effects that might be expected to result from exposure to the oil well fires.[16]

While these scientific/technical reviews were in progress, the Department was also conducting field investigations of groups of veterans with health complaints. During 1992 "clusters" of military personnel presented with nonspecific symptoms they attributed to their Gulf War service, which resulted in two field investigations. The Army investigated one such cluster among members of the 123rd Army Reserve Command in Indiana. In April 1992 the investigators concluded that the paucity of abnormal physical or laboratory findings, the types of symptoms reported, the association of onset of symptoms with redeployment, and the results of the psychiatric evaluation suggested that many of the symptoms were likely to be stress-related.[17] The Navy conducted a similar investigation of a reserve Seabee battalion (Naval Reserve Mobile Construction Battalion 24) from November 1993 to October 1994. Many members of this unit complained of symptoms that they believed were related to their service in the Persian Gulf. Although investigators confirmed that a significant number of individuals had experienced an array of nonspecific symptoms since returning from the Gulf, no common syndrome or diagnosis was identified in this group of veterans.[18]

Initially, the three Services began to identify military members with possible Gulf War-related medical conditions through routine health surveillance programs designed to track reportable diseases. In August 1992 the Army Surgeon General directed clinicians to identify individuals with medical conditions that might be related to service in the Persian Gulf. In October 1992 the Assistant Secretary of Defense (Health Affairs) requested the Services to provide reports of the numbers of personnel who had been evaluated for complaints attributed to service in the Persian Gulf. By April 1993 a total of 264 individuals were reported by the three Services. The diseases reported were distributed across 62 different categories. By January 1994 the Services had identified approximately 400 individuals with Gulf War-related health complaints and/or medical problems.

Concurrent with clinical activities and preliminary epidemiological field investigations, the Department organized several independent reviews of health issues involving Persian Gulf veterans. In September 1993 the Army Surgeon General enlisted the assistance of Dr. Jay Sanford, an expert in infectious diseases and former president of the USUHS, to assess clinical case histories of Gulf War veterans. The goal was to define a standard symptom complex to aid physicians in diagnosis. Dr. Sanford completed his review and submitted his preliminary findings on January 27, 1994. Dr. Sanford concluded that the cases available for review at the time lacked the consistent clinical findings necessary to establish a case definition which meets the criteria of being sensitive enough to identify individuals with a new illness but specific enough to exclude individuals with other known illnesses.[19]

By late 1993 it had become evident to the Department that there was a need to have independent scientific bodies review the development of "unexplained illnesses" among Gulf War veterans. In February 1994 the Department tasked the Defense Science Board (DSB) to examine the possible exposure of personnel to chemical and biological weapons agents and other hazardous material during the Gulf War and its aftermath. The DSB Task Force on Persian Gulf War Health Effect, chaired by Dr. Joshua Lederberg, a Nobel laureate, concluded in its June 1994 report that "there is no persuasive evidence that any of the proposed etiologies caused chronic illness on a significant basis."[4] The National Institutes of Health (NIH) Technical Assessment Workshop on the Persian Gulf Experience and Health, a panel of non-federal experts formed to assess existing data on the "unexplained illnesses" being reported by Persian Gulf veterans, was convened from April 27-29, 1994, by the DoD, VA, and Department of Health and Human Services (HHS). Among its conclusions, the panel indicated that "the complex biological, chemical, physical, and psychosocial environment of the Persian Gulf theater of operations appears to have produced complex, adverse health effects ... there is no single disease or syndrome apparent, but rather multiple illnesses with overlapping symptoms and causes."[20]

In response to the magnitude of veterans' concerns and the uncertainty surrounding the nature of some of their illnesses, the Assistant Secretary of Defense (Health Affairs) announced a three-point plan, on May 11, 1994.[21] The plan included:

1. The development of an aggressive, comprehensive, clinical diagnostic program to offer intensive examinations to veterans who do not have clearly defined diagnoses,

2. An initial independent review of DoD clinical and research efforts concerning the Persian Gulf War by Dr. Harrison C. Spencer, Dean of The Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana, and

3. The creation of a forum of national medical and public health experts to review, comment, and advise DoD concerning the results of the clinical evaluation program.

This plan represents the Department's fundamental approach to meeting the health needs of Gulf War veterans. The CCEP offers in-depth medical examinations through a program which provides prioritized access to clinical care through the Military Health Services System (MHSS). Dr. Spencer of Tulane provided an initial review of the issue of "unexplained illnesses" and recommended development of a standardized clinical protocol even in the absence of a specific case definition. External review of the Department's clinical program, both design and implementation, has been a key component in the overall approach to providing care to Gulf War veterans. External scientific review has been provided by the Institute of Medicine (IOM), National Academy of Sciences. The IOM Committee on the DoD Persian Gulf Syndrome Comprehensive Clinical Evaluation Program has provided ongoing consultation regarding the CCEP. DoD clinicians have presented the results from the CCEP to the IOM expert committee on three occasions. This collaborative process has proven successful in enhancing the quality of care provided through the CCEP and in characterizing the clinical nature of illnesses being experienced by CCEP participants.

CCEP Specialized Care Center (SCC)

A Specialized Care Center (SCC) opened at Walter Reed Army Medical Center in March 1995 for the intensive treatment of symptomatic Persian Gulf War veterans. Referrals are accepted from clinicians who have evaluated veterans in the CCEP. Clinicians are requested to refer motivated individuals to the SCC who are suffering from persistent symptoms that interfere with their ability to perform their duty or to meet fitness and retention standards.

Patients come to the SCC for four-week treatment periods in groups of four to six and reside on the grounds of Walter Reed as outpatients. They receive treatment from a multidisciplinary team that includes fitness trainers, nutritionists, occupational and physical therapists, art and recreation therapists, internists, social workers, psychiatrists, and psychologists. The program is rigorous, beginning at 0600 each morning and extending into the evening.

Thirty-five veterans have entered the program, with only one failing to complete the four weeks. Five patients have completed a program specifically tailored to veterans with PTSD. Nearly all patients have shown improvement in their health and a significant improvement in their level of fitness. The latter is demonstrated by an average two-minute decrease in the time required to complete a two-mile run. Although not overwhelmed with patients, the SCC continues to accept referrals as needed. A second SCC is scheduled to open at Wilford Hall Medical Center, Lackland AFBSan Antonio, Texas in mid, in May 1996. Patients who have completed the SCC programs will receive follow-up as clinically indicated.

Institute of Medicine Review

As noted above, the Department of Defense asked the IOM to establish a committee to evaluate the CCEP. The IOM was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of appropriate professions to examine policy pertaining to the health of the public. The IOM Committee has reviewed the clinical evaluation protocol and commented on the interpretation of the CCEP results. In addition, the Committee has provided recommendations relevant to the conduct of the clinical evaluations in the future. The Committee's recent report, released January 4, 1996, included the following recommendations and comments:[22]

The CCEP clinical protocol is a thorough, systematic approach to the diagnosis of a wide spectrum of diseases.

The DoD is encouraged to emphasize in its future reports psychosocial stressors that can produce physical and psychological effects.

There is currently no clinical evidence in the CCEP for a previously unknown, serious illness among Persian Gulf War (PGW) veterans. Several large research studies currently being conducted by DoD and the VA may provide more definitive answers as to the possibility of a new or unique Persian Gulf syndrome.

Interpretations based on comparisons with other populations should be made with great caution and only with the explicit recognition of the limitations of the CCEP as a self-selected case series.

The results of the CCEP can and should be used for several purposes, including education, improving the medical protocol itself, and evaluating patient outcomes.

Persian Gulf Veterans' Coordinating Board

The Persian Gulf Veterans Coordinating Board, consisting of the Secretaries of Defense, Veterans Affairs, and Health and Human Services was established on January 21, 1994 by President Clinton to merge the expertise and capabilities of the departments and coordinate all efforts on behalf of Persian Gulf veterans. The Coordinating Board is composed of three working groups with representation from each of the agencies that focus on issues of research, clinical care, disability evaluation, and compensation.

What's New in This Report

Since June 1994 over 19,000 Persian Gulf veterans have completed medical their evaluations within the DoD CCEP worldwide. This report encompasses the results on 18,598 CCEP participants and is largely consistent with results of previous CCEP reports. For example, the frequency distribution of self-reported exposures, symptoms and diagnoses have remained relatively constant since the CCEP began.

This report reflects recommendations from the IOM and other consultants to DoD. Areas that have been explored in greater detail include analysis of a subpopulation of the National Ambulatory Medical Care Survey (NAMCS), which resembles the CCEP population in terms of sex and age; characterization in greater detail of those individuals with more than one diagnosis; an evaluation of disability associated with CCEP participants; analysis and examination of the reproductive questionnaire that was introduced in January 1995; review of the distribution of diagnostic categories over time intervals; and further analysis of unit identification codes (UICs) as a surrogate measure of occupational exposure and location within the Persian Gulf theater of operation.


Participants may enroll in the CCEP by calling a toll-free number (1-800-796-9699), which provides information and referrals to individuals requesting medical evaluations or by contacting their local military medical treatment facility (MTF). All MHSS eligible beneficiaries are eligible for the CCEP. For eligibility in the CCEP, a PGW veteran (or dependent) must have been eligible for DoD health care in June 1994 or later.

Once an individual is referred, the CCEP provides a two-phase, comprehensive medical evaluation, with Phase I being conducted at one of 184 local MTFs. Phase II (when required) is conducted at one of 14 regional medical centers (RMCs). The medical review includes questions about family history, health, occupation, and unique exposures in the Gulf War, as well as a structured review of symptoms.

Once a participant has completed the examination process, copies of examination results are forwarded to the CCEP Program Management Team (PMT), where they undergo quality assurance procedures, and the data are entered into the master CCEP database.

Additionally, for those CCEP participants suffering from chronic, debilitating symptoms, the DoD has established an SCC at Walter Reed Army Medical Center and will have a second center opening in midMay 1996 at Wilford Hall Medical Center, Lackland AFB, in Texas.

The data, which were initially entered into a relational database, were translated into a statistical formatpackage data set to be reviewed and analyzed for this report. Various validity checkstests were conducted to ensure that the data were appropriate for interpretation. Statistical tests and descriptive analyses were conducted on various categories of participants, including those in theater during the Persian Gulf War, their spouses, and their children. Moreover, the CCEP participants who were in theater were compared to the PGW population as a whole and were stratifiedbroken down by units to compare those units with higher CCEP participation rates to those units with lower CCEP participation rates. Specific analyses concerning were run on self-reported exposures, physician-elicited symptoms, diagnoses, self-reported reproductive outcomes, self-reported lost workdays, physical evaluation boards (PEBs), and program satisfaction were conducted. Additionally, a comparative analysis with the NAMCS data was conducted using age, sex, race, ethnicity, and diagnostic code variables to more closely match the CCEP populations.

See Appendix B: Methods for more specific information regarding the methods used in data analyses.


Program Status

Figure 1 summarizes the categories of CCEP participants as of early December 1996. Of the 20,796 participants who requested medical examinations through the CCEP, 18,598 records have been entered into the CCEP computerized database (Figure 1). Eighty-seven percent (87%) of CCEP evaluations were completed at Phase I and 13% at Phase II.

Figure 1. Disposition of CCEP Participants as of December 6, 1995

Figure 1.  Disposition of CCEP Participants as of December 6, 1995


Demographic characteristics of the in-theater CCEP participants are shown in Table 1 along with comparable data for the total PGW participants. The total PGW participants are defined as all active duty personnel plus all Reserves/Guard who were actually in the Gulf War theater. The Army is more heavily represented in the CCEP database than other military branches. Also, higher percentages of women and blacks are found in the CCEP database when compared to all PGW participants. The age distribution of CCEP participants differs from the total Gulf War participants in that the CCEP participants have a higher percentage of individuals in the two oldest age groups (44.3%) than the total PGW participants (28%). With the exception of the youngest age group, the CCEP participants are spread approximately uniformly across the remaining four groups.

Table 1. Demographic Characteristics of CCEP Participants and Persian Gulf War Participants

   Characteristics         CCEP Participants           Total PGW Participants    

                              N=18,075#                     N=697,000*          



 Male                             88                           93

 Female                           12                            7                




 White                            57                           70

 Black                            32                           23                


 Hispanic                          6                            5

 Other/No Data                     5                            2                




 Mean                             30                           26‡

 Median                           29                           24‡

In Groups(%)                           

 17-20                            10                           11

 21-25                            23                           38                


 26-30                            23                           22

 31-35                            22                           13

 36-65                            22                           15                


 Other/No Data                     1                                             




 Enlisted                         88                           89                


 Officer                          11                           10

 Other/No Data                     1                            1                




 Air Force                        10                           12                


 Army                             81                           50

 Marines                           4                           15

 Navy                              4                           23                


 Other/No Data                     1                           ---               




 Active                           83                           83

 Reserve Component††              13                           17      


 Other/No Data                     4                           ---               



# Includes only CCEP members in theater.
* Source: Desert Shield/Storm Participation Report Vols. 1 & 2. Defense Manpower Data Center, DoD, 1994.
† Participant's Age as of 2 August 1990.
†† Because most RC PGW participants are not military health care beneficiaries, these differences are expected.
‡ Mean and median age and marital status for PGW veterans are for Active Component members only.

Self-Reported Exposures

The self-reported responses to a checklist of 25 exposures are summarized in Table 2. Most participants reported at least one exposure. Only 0.2% of CCEP participants reported no exposure. The median number of self-reported exposures was ten.

The most frequent self-reported environmental exposures include passive cigarette smoke (88%), diesel/other fuels (88%), pyridostigmine bromide tablets (74%), oil smoke (71%), tent/heater fumes (70%), and personal pesticide use (66%). Least often self-reported exposures were suspected nerve gas/nerve agents (6%), suspected mustard/blistering agents (2%) and wounded in combat (2%). Nearly one-third (31%) of the CCEP in-theater participants indicate they are current smokers, smoking an average of 15 cigarettes per day.

Five questions were related to exposures associated with combat. Ten percent of the participants reported none of these, 40% reported one or two, and 21% four or five. The most frequently reported of these exposures were witnessing a chemical alarm, witnessing a casualty, and witnessing SCUD attacks. Only 21.7% self-reported being wounded in combat.

Table 2. Self-Reported Exposure History(N=18,075)

        Exposures Recalled By                          Response               

            Participants                       Number          Percent*      

Cigarette Smoke (Passive)                     15,993            88           

Diesel/Other Fuels                            15,910            88           

Pyridostigmine Bromide                        13,287            74            

Oil Fire Smoke                                12,763            71             

Tent/Heater Fumes                             12,651            70             

Personal Pesticide Use                        11,891            66             

Ate Non-U.S. Foods                            11,848            66             

Had Anthrax Immunization                       8,881            49            

Solvent                                        8,708            48            

Chemical Agent Resistant Coating (CARC)                   

Paint                                          8,444            47                                  

Other Paint                                    7,755            43             

Microwaves                                     6,124            34            

Bathed in/Drank Non-U.S. Water                 5,835            32           

Had Botulism Immunization                      4,696            26            

Took Oral Medicine to Prevent Malaria          3,926            22             

Ate Contaminated Food                          3,773            21            

Bathed in Contaminated Water                   3,579            20             

Depleted Uranium                               2,793            15            

Nerve Gas/Nerve Agents                         1,056            61            

Mustard Gas/Blistering Agents                    429            25             

Chemical Alarm                                11,806            65             

Witnessed Casualty                            10,124            56             

Witnessed SCUD Attack                          9,743            54            

Witnessed Actual Combat                        6,746            37             

Wounded in Combat                                314             2             

* Percent of participants who answered Yes or No (excludes unknown).

Physician-Elicited Symptoms

Table 3 summarizes the frequency distribution of positive responses to the Provider-Administered Symptom Questionnaire. The most frequently reported chief complaints were: fatigue (10%), joint pain (11%), headache (7%), and/or memory loss (4%). The percentages of patients reporting any of the major complaints included fatigue (47%), joint pain (49%), headache (39%), memory loss (34%), sleep disturbance (32%), rash/dermatitis (31%), and/or difficulty concentrating (27%).

Table 3. Symptom Frequency for CCEP Participants (N=18,075)

   Symptoms Reported By Participants       Chief Complaint    Any Complaint  

                                                 (%)          (%)                


Joint Pain                                        11          49                 

Fatigue                                           10          47                 

Headache                                          7           39                 

Memory Loss                                       4           34                 

Sleep Disturbance                                 2           32                 

Rash/Dermatitis                                   7           31                 

Difficulty Concentrating                          *           27                 

Depression                                        1           23                 

Muscle Pain                                       1           21                 

Diarrhea                                          2           18                 

Dyspnea                                           3           18                 

Abdominal Pain/Gastrointestinal                   3           17                 

Hair Loss                                         *           12                 

Bleeding Gums                                     *           8                  

Weight Loss                                       *           7                  

Allergies                                         *           *                  

Back Pain                                         2           2                  

Chest Complaints                                  2           2                  

Cough                                             1           1                  

Dizziness                                         1           1                  

Nausea                                            *           *                  

Sinus                                             1           1                  

Mood Swings                                       1           1                  

Insomnia                                          *           *                  

Other Chief Complaint Categories                  7           7                  

Representing <1% of Population                                                


Chief Complaints Not Categorized                  3           3                  

People with No Chief Complaints                   31                             

People with No Chief or Any Complaints                  10  

* less than 1%

The distribution of dates of onset of symptoms reported by the CCEP participants is presented in Table 4. Among those reporting a known date of onset, the most common period of onset for all symptoms is the nine-month interval after the Gulf War. Between 23% and 31% of participants who recalled a date of onset for at least one of their symptoms remembered it starting during this period. However, it is noteworthy that for all symptoms, no date of onset was recalled/recordedis remembered by over half of all participants. Thus, for over half the symptoms reported, no date of onset can be ascertained. Lacking data collected in closer proximity to the date of onset, the effects of recall bias cannot be discounted, which makesand the appropriate interpretation of theseis data difficultis not clear.

Table 4. Frequency of Date of Onset by Symptom*

   Symptoms      Number   Number    < Aug     Aug     Mar     Jan     Jan  Jan   Jan    

   Reported by    Rept.    with      1990      90      91      92      93      94   95    

   Participants   Symptom  Date               thru    thru    thru    thru   thru  into   

                             of                Feb     Dec     Dec     Dec    Dec  Dec    

                            Onset              91      91      92      93      94   95  

                                       %        %       %       %       %       %   %   

Joint Pain       8,384     3,516       7       15      23      21      15      14   5

Fatigue          8,135     3,283       2       16      31      22      14      11   3     

Headache         6,743     2,699       6       18      25      19      14      13   5

Memory Loss      5,960     2,385       2       15      27      23      16      14   3      

Sleep Loss       5,887     2,405       4       20      30      19      12      12   3   

Rash             5,124     2,230       5       21      29      18      10      11   5   

Concentration    4,899     1,834       2       16      30      21      15      13   3   

Depression       4,140     1,583       4       18      29      20      13      13   6   

Muscle Pain      3,900     1,418       4       17      28      20      13      14   4

Diarrhea         3,304     1,237       4       24      30      16      9       11   6

Shortness of     

Breath           3,028     1,492       4       14      25      20      15      17   7                                                                

Abdominal Pain   3,007     1,167       5       19      24      19      12      14   7

Hair Loss        2,145      872        7       16      29      20      12      12   4

Bleeding Gums    1,500      559        5       16      25      20      15      14   5

Weight Loss      1,235      469        3       19      25      15      11      17  10

CCEP Diagnoses

Table 5 presents the 23 ICD-9-CM diagnostic codes for primary diagnoses occurring with a frequency of 1% or higher. The healthy diagnosis includes those participants seeking consultation without complaint or sickness as well as those diagnosed as normal or healthy. The specific diagnoses span various categories including psychological conditions; symptoms, signs and ill-defined conditions; and the musculoskeletal, nervous, respiratory, digestive, skin, and circulatory systems. Other than healthy, the frequency of each diagnosis was relatively low, with the highest (tension headache) at 3.4%, and the second highest (fatigue, not specified as chronic) at 3.3%. Appendix C presents additional information on the diagnoses assigned.

Table 5. Primary Diagnoses Occurring in Greater Than 1% of CCEP Participants (N=18,075)

           Primary Diagnosis ICD-9 CM Code                  Number    Percent  

  																	  Of Total 

Healthy (V65.5)*                                            1762        9.7      

Tension Headache (307.81)                                   622         3.4      

Fatigue, Not Specified as Chronic (780.71)                  595         3.3      

Depressive Disorder Not Elsewhere Classified (311.)         525         2.9      

Prolonged Posttraumatic Stress Disorder (309.81)            501         2.8      

Headache (784.0)                                            495         2.7      

Migraine, Unspecified (346.9)                               480         2.7      

Pain in Joint Involving Multiple Sites (719.49)             437         2.4      

Asthma, Unspecified (493.9)                                 401         2.2      

Lumbago (724.2)                                             356         2.0      

Pain in Joint Involving Lower Leg (719.46)                  323         1.8      


Other General Symptoms (780.9)                              305         1.7      

Irritable Colon (564.1)                                     291         1.6      

Allergic Rhinitis, Cause Unspecified (477.9)                286         1.6      

Osteoarthrosis, Unspecified (715.9)                         272         1.5      

Malaise and Fatigue (780.7)                                 267         1.5      

Other and Unspecified Sleep Apnea (780.57)                  252         1.4      

Gastroesophageal Reflux Disease (GERD) (530.81)             251         1.4      

Major Depressive Disorder, Single Episode (296.2)           242         1.3      

Contact Dermatitis and Other Eczema, Unspecified (692.9)    227         1.3      

Other Insomnia (780.52)                                     210         1.2      

Neurotic Depression (300.4)                                 196         1.1      

Essential Hypertension (401.9)                              193         1.1      


* This code includes those participants seeking consultation without complaint or sickness as well as those diagnosed as normal and/or healthy.

The frequency distribution by category of diagnoses assigned by the CCEP is presented in Table 6. The order of these diagnoses was determined by usual clinical practice, basing the ranked order on the most severe conditions relative to the patient's chief complaints. The most prevalent primary diagnostic categories, accounting for 67.7% of the participants, were psychological conditions (18.4%);: musculoskeletal and connective tissue diseases (18.3%);: symptoms, signssigns, symptoms, and ill-defined conditions (17.9%);: respiratory diseases (6.8%);: and digestive system diseases (6.3%). An additional 9.7% received a diagnosis of healthy. . CCEP clinicians have generally relied upon the common standard medical practice of determining primary diagnosis based upon the severity of illness relative to the participant's chief complaint.

When both primary and secondary diagnoses were considered, the same general patterns were observed. The most common categories were musculoskeletal diseases (found in 47.2% of participants); symptoms, signssigns, symptoms, and ill-defined conditions (43.1%); psychological conditions (36.0%); digestive system diseases (20.4%); skin and subcutaneous diseases (19.9%); respiratory diseases (17.5%); and nervous system diseases (17.8%).

Table 6. Frequency Distribution of Primary Diagnoses and Any Diagnoses (N=18,075)

Diagnostic Categories  (ICD-9-CM Code)      Male     Female      All Part.   All


                                          Primary    Primary      Primary    Any 

                                         Diagnosies  Diagnosis   Diagnosis 


                                          N=15,944   N=2,131      N=18,075 


                                            (%)      (%)            (%)      (%) 


Psychological Conditions  (290-319)      18.3        19.1        18.4        36.0

Symptoms, SignsSigns, Symptoms, and      18.1        16.5        17.9        43.1

Ill-Defined Conditions*  (780-799)                                               

Musculoskeletal System Diseases          

      (710-739)                         18.6        15.9        18.3         47.2


Healthy  (V65.5)                         9.9         8.6         9.7         10.2

Respiratory System Diseases (460-519)    6.9         6.1         6.8         17.5

Digestive System Diseases (520-579)      6.5         4.9         6.3         20.4

Skin and Subcutaneous Tissue Diseases    6.3         6.0         6.2         19.9


Nervous System Diseases (320-389)        5.3         8.8         5.7         17.8

Infectious Diseases  (001-139)           2.6         2.5         2.6         9.0 

Circulatory System Diseases (390-459)    2.3         1.6         2.2         8.0 

Endocrine Disorders (240-279)            1.9         2.7         2.0         7.9 

Genitourinary System Diseases (580-679)  1.0         3.6         1.3         5.4 

Injury and Poisoning  (800-999)          0.8         0.9         0.8         3.2 

Neoplasm  (140-239)                      0.8         0.8         0.8         2.9 

Blood and Blood Organ Diseases           0.4         1.6         0.5         3.0 


Other V Codes                            0.2         0.4         0.3         10.3

Congenital Anomalies and Conditions of   0.2         0.2         0.2         1.1 

the Perinatal Period  (740-779)                                                  


* Includes conditions categorized according to ICD-9-CM nomenclature of cases

for which no diagnosis is classifiable elsewhere no more specific diagnosis can

be made; signs or symptoms that prove to be transient; cases in which a more

precise diagnosis was not available for any other reason.

Up to seven diagnoses, including healthy, could be reported (one primary and up to six secondary). Among the participants, 19.9 percent had only l diagnosis, 18.7 percent had 2, the median was 3, the mean was 3.4, and 9.1 percent were given 7 diagnoses. This distribution is presented in Figure 2.

Figure 2. Frequency Distribution of Diagnoses among 18,075 CCEP Participants

Figure 2.  Frequency Distribution of Diagnoses among 18,075 CCEP Participants

The frequencies of primary diagnoses for four periods sincebetween the initiation of the CCEP and until and December 6, 1995 are presented in Table 7. Over time, there have been some changes in the frequency of diagnosis for most diagnostic categories. The proportion with a primary diagnosis of musculoskeletal/connective tissue disorder has steadily increased, from 16.1% in the first period, to 20% in the last. The proportion with psychological conditions was stable for the first two periods, then declined for the third and was stable through the fourth. The proportion with ill-defined conditions has steadily decreased, from 20.9% in the first period, to 15.2% in the fourth. For other diagnostic groupings, there were no patterns evident over time, or the numbers of diagnoses were too few for meaningful interpretation.

Table 7. Frequency of Primary Diagnoses Over Time (N=18,075)


   Diagnostic Categories      Jun 94    Dec 94      Mar 95      Jul 95     Jun 94


                              thru       thru        thru        into       into 

                              Nov 95    Feb 95      Jun 95      Dec 95     Dec 95


                              N=1782    N=8723      N=3639      N=3931    


                               (%)       (%)         (%)         (%)         (%) 


Psychological Conditions      19.9       20.0        17.6        17.6       18.4 


Musculoskeletal Diseases      16.1       18.2        18.6        20.0       18.3 


Symptoms, SSigns, Symptoms,   20.9       18.3        17.6        15.2       17.9 


and Ill-Defined Conditions*                                                      

Healthy   (V65.5)†            8.0       10.2        10.2         10.5       


Respiratory System Diseases   6.4        5.8         7.3         6.5         6.8

Digestive System Diseases     6.8        6.3         6.0         6.3         6.3

Skin and Subcutaneous         4.9        6.0         6.8         6.5         6.2

Tissue Diseases                                                                 

Nervous System Diseases       6.5        5.0         5.3         6.2         5.7

Infectious Diseases           2.5        2.7         2.5         2.9         2.6

Circulatory System Diseases   2.1        1.8         2.2         2.5         2.2

Endocrine Disorders           2.0        2.1         1.9         2.3         2.0

Genitourinary Diseases        1.3        1.4         1.4         1.1         1.3

Neoplasm                      1.0        0.6         0.8         0.7         0.8

Injury and Poisoning          0.5        0.8         0.9         0.9         0.8

Blood and Blood Organ         0.6        0.5         0.5         0.6         0.5


Other V Codes                 0.3        0.2         0.2         0.3         0.2

Congenital Anomalies and      0.2        0.3         0.2         0.3         0.2

Conditions of the Perinatal                                                      


* Includes conditions categorized according to ICD-9 nomenclature of cases for

which no diagnosis is classifiable elsewhere; no morenomore specific diagnosis

can be made; signs or symptoms that prove to be transient; and cases in which a

more precise diagnosis was not available for any other reason.

† This code includes those participants seeking consultation without complaint or sickness as well as those diagnosed as normal and/or healthy.

Examination of the Top Three Primary Diagnostic Categories

Psychological conditions; symptoms, signs, and other ill-defined conditions; and musculoskeletal diseases diagnostic categories account for over 50% of all primary diagnoses among the 18,075 participants covered by this report. The distribution of these diagnoses is presented in greater detail in Table 8, Table 9, and Table 10.

About Eighteen percent (18.4%) of CCEP patients had a primary diagnosis of a psychological condition. The most frequent diagnoses of this group are summarized in Table 8. Tension headache, depression, anxiety disorders, adjustment reactions, and somatoform disorders were the most frequently recorded psychological diagnoses. It is important to realize that the common diagnosis of tension headache is included in this category.

Table 8. Number and Percent of Primary Diagnoses of Psychological Conditions (ICD-9-CM Codes 290-319) (N=3,321)

Specific Diagnoses (ICD-9-CM Code)               Number            Percent     

Tension Headache (307.81)                        622                 18.7        

Depressive Disorder, NEC  (311)                  525                 15.8        

Prolonged Posttraumatic Stress Disorder          501                 15.1        


Major Depressive Disorder  (296.2)               289                 8.7         

Adjustment Reaction  (309)                       231                 7.0         

Neurotic Depression  (300.4)                     196                 5.9         

Somatization Disorder  (300.81)                  114                 3.4         

Anxiety State  (300.00)                          92                  2.8         

Alcohol Dependence and Abuse  (303 and 305)      52                  1.6         

Sleep Disorder  (307.4)                          91                  2.7         

Unspecified Psychophysiological Malfunction      49                  1.5         


Tobacco Use Disorder  (305.1)                    44                  1.3         

Unspecified Acute Reaction to Stress (308.9)     37                  1.1         

Panic State  (300.01)                            33                  1.0         

Organic Brain Syndrome                           100                 3.0         

Generalized Anxiety Disorder  (300.02)           26                  0.8         


Other                                            319                 9.6         

Total                                           3,321               100.0       


Almost Eighteen percent (17.9%) of participants had a primary diagnosis of symptoms, signs, and ill-defined conditions (Table 9). Most diagnoses in this category involved conditions such as malaise and fatigue, sleep disturbance, and/or headache.

Table 9. Number and Percent of Primary Diagnoses of Symptoms, Signs, and Ill-Defined Conditions (ICD-9-CM Codes 780-799) (N=3,239)

Specific Diagnoses (ICD-9-CM Code)            Number            Percent         

Malaise and Fatigue (780.7)                    862               26.6            

Sleep Disturbances (780.5)                     574               17.7            

Headache (784.0)                               495               15.3            

Other General Symptoms (780.9)*                305                9.4            

Dyspnea and Painful Respirations (786.09,      181                5.6            


Rash (782.0, 782.1)                            159                4.9            

Syncope (780.2), Seizures (780.3) & Vertigo    94                 2.9        


Other Chest Pain (786.50, 786.59)              70                 2.2            

Abdominal Pain (789.0)                         43                 1.3            

Nonspecific Reaction to Tuberculin Test        44                 1.4            


Cough (786.2)                                  36                 1.1            

Other                                          376               11.6            

Total                                          3239              100.0           


* The category "Other General Symptoms" (ICD-9-CM code 780.9) consists

almost exclusively of  reported problems with memory (137 out of 144).

About Eighteen percent (18.3%) of CCEP patients had a primary diagnoses in the category of musculoskeletal and connective tissue conditions (Table 10). Pain in joints, osteoarthrosis, and backache accounted for over 50% of all diagnoses in this group.

Table 10. Number and Percent of Primary Diagnoses of Musculoskeletal Conditions

(ICD-9-CM Categories 710-739) (N=3,307)

Specific Diagnoses (ICD-9-CM Code)                             Number        


Pain in Joint (719.4)                                            992           


Lumbago and Backache, Unspecified (724.2 and 724.5)              411           


Osteoarthosis, Unspecified (715.89 - 715.99)                     405           


All Other Diagnoses Related to the Spine (720-724.9              269           


except the above)                                                                

Myalgias and Myositis, Unspecified (729.1)                       228           


Diseases and Disorders of Shoulder Region (726.10, 726.2)        118           


Other Specified Disorders of Lower Leg Joint (mostly             109           


patello-femoral syndrome) (719.86)                                               

Osteoarthrosis, Localized (715.1-715.39)                         56            


Chrondromalacia of Patella (717.7)                               37            


Tietze's Disease (733.6)                                         33            


Unspecified Arthropathy (716)                                    32            


Other and Unspecified Disorders of Soft Tissue (729.9)           29            


Rheumatoid Arthritis (714)                                       26            


Lateral Epicondylitis (726.32)                                   24            


Pain in Limb (729.5)                                             21            


Flat Foot (734)                                                  19            


Enthesopathy of Hip Region (726.5)                               19            


Enthesopathy of Unspecified Site (726.90)                        17            


Plantar Fascial Fibromatosis                                     17            


Other                                                           445           


Total                                                          3307          


The frequency of the most prevalent primary diagnostic categories for the five age groups is shown in Table 11. The frequency of psychological conditions shows some decrease with increasing age. This trend is also seen for the healthy ICD-9-CM diagnosis. The musculoskeletal conditions ICD-9-CM category seems to show increases with increasing age. The four most frequent diagnoses represent from 63% to 65% of the diagnoses in each age group.

Table 11. Frequency of Most Prevalent Primary Diagnoses by Age Group (N=18,075)

 Diagnostic           17 - 20    21 - 25    26 - 30    31 - 35    36 - 65  


 Category                                                                   No


                      N=1,717    N=4,141    N=4,141    N=4,031    N=3,938   


                        (%)        (%)        (%)        (%)         (%)      


Psychological           21         20         18         18          17        25


Symptoms, Signs and     16         18         18         18          19        16

Ill-Defined Conditions                                                           

Musculoskeletal         15         16         18         20          20        18

System Diseases                                                                  

Healthy                 13         11         11          9           7         7

Other Medical           35         35         35         35          37        34



*	Includes ages underuner 17 and over 65.

Table 12 shows that the four most frequent primary diagnostic categories represent 65.1% of males and 60.5% of females. The distribution of diagnosis is similar in men and women.

Table 12. Frequency of Most Prevalent Primary Diagnoses by Sex (N=18,067*)

  Diagnostic  Category         Male N=15,937     Female N=2,130   

                                  (%)                  (%)         

Psychological Conditions         18.3                 19.1              

Symptoms, Signs and              18.1                 16.6              

Ill-Defined Conditions                                                  

Musculoskeletal System Diseases  18.6                 15.9              

Healthy                          10.1                  8.9               

Other Medical Conditions         34.9                 39.5  


*	No data is available for 8 participants.

Table 13 shows the frequency of the most prevalent primary diagnostic categories for each military branch. The four most prevalent primary diagnostic categories represent 66.1% of CCEP participants from the Army, 59.5% of Navy participants, 57.7% of Air Force and 58.1% of Marines. Army participants are more heavily represented in musculoskeletal and psychological conditions and among the healthy than participants from other services. Distribution of diagnoses are similar among the services. The Air Force participants appear to have a higher percentage of signs, symptoms, and ill-defined conditions than the other services.

Table 13. Frequency of Most Prevalent Primary Diagnoses by Military Branch (N=18,075)

  Diagnostic                Army        Navy       Air Force      Marine   


  Category                                                        Corps     No


                          N=14,588     N=750       N=1,714        N=781     N=242

                             (%)          (%)         (%)          (%)      (%)  



Psychological Conditions   18.9        18.0         15.1          16.1       16.1


Symptoms, Sign &           17.7        19.3         19.9          17.4      


Ill-Defined Conditions                                                           

Musculoskeletal System     19.0        13.9         15.0          16.5       16.5



Healthy                    10.4        8.3          7.6           8.1        11.6


Other Medical Conditions   33.9        40.5         42.3          41.9       41.3


Neoplasms were a primary diagnosis in almost 1% of the participants. A primary diagnosis of malignant disease (Table 14) was found in 52 (0.3 %) of in-theater CCEP participants. The most frequently diagnosed malignant neoplasms were skin cancers and lymphomas.

Table 14. 52 Cases of Malignant Neoplasms by Sex in CCEP Participants (N=18,075)

                 Category                         Number Of Diagnoses         

                                                 Male            Female        

Skin                                              9                ---

       Basal Cell                                 5                ---

       Malignant Melanoma                         3                ---     

       Squamous Cell                              1                ---           


Hodgkin's Disease                                 8                ---         

Non-Hodgkin's Lymphoma                            4                 1          

Brain                                             5                ---         

Thyroid                                           1                 1          

Prostate                                          1                ---         

Testicular and Other Male Gonadal                 4                ---         

Chronic Myelogenous Leukemia                      4                ---         

Chronic Lymphocytic Leukemia                      2                ---         

Acute Myelogenous Leukemia                       ---                1          

Colon                                             1                ---         

Breast                                           ---                2          

Cervix Uteri                                     ---                1          

Ovary                                            ---                1          

Stomach                                          ---                1          

Lung                                              3                ---         

Bladder                                           1                ---         

Kidney                                            1                ---         

Total                                             44                8          

Distribution of Primary Diagnosis Based upon Chief Complaint

The primary diagnoses associated with the leading chief complaints were examined, and they are presented in Figure 3. Among those participants with a chief complaint of fatigue, the most common diagnostic group was symptoms, signssigns, symptoms, and ill-defined conditions;, followed by psychological conditions; and musculoskeletal system and connective tissue diseases. Within the diagnostic group of symptoms, signssigns, symptoms, and ill-defined conditions, 49% had a primary ICD-9 diagnosis of malaise and fatigue (780.7).

Nearly two-thirds of participants with a chief complaint of joint pain received a primary diagnosis in the musculoskeletal system and connective tissue disease category;, followed by of symptoms, signssigns, symptoms, and ill-defined conditions; and psychological conditions. All other diagnoses accounted for 20% of the total. Among those with a primary diagnosis in the "musculoskeletal system and connective tissue disease" category, 20% had a diagnosis involving multiple sites, and another 20% had a diagnosis involving unspecified sites. There was no apparent clustering of diagnosis apparentby anatomic site.

Figure 3. Distribution of Primary Diagnoses Based upon Chief Complaint

Figure 3.  Distribution of Primary Diagnoses Based upon Chief Complaint

The most common category for those with a chief complaint of headache was psychological conditions (31%), followed by symptoms, signssigns, symptoms, and ill-defined conditions (23%), and nervous system and sense organs diseases (23%). Among those with a diagnosis within the category of psychological conditions diagnosis, 67% had a specific diagnosis of tension headache (307.81); among those with a diagnosis within the category symptoms, signssigns, symptoms, and ill-defined conditions, 73% had a diagnosis of headache (784.0); and among those with a diagnosis in the nervous system and sense organs category, 77% had a diagnosis of migraine headache (346.0 to 346.9). Thus, among those with a chief complaint of headache, 55% were assigned a primary diagnosis of headache.

Over 40% of CCEP participants with a chief complaint of rash/dermatitis received a diagnosis in the skin and subcutaneous tissue group, followed by symptoms, signssigns, symptoms, and ill-defined conditions (13% ), followed by infectious and parasitic diseases (12%), psychological conditions (8%), and all other diagnostic groups (24%). Within the skin and subcutaneous tissue group, 27% had a diagnosis of unspecified contact dermatitis; within the symptoms, signssigns, symptoms, and ill-defined conditions 50% had a diagnosis of rash.

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