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Medical Issues Relating to Symptoms Among Gulf War Veterans

Contents

Vaccinations
Medical Recordkeeping During the Gulf War
Information Capture of Data from Gulf War Hospital Inpatient Records
Deployment Health Surveillance
Additional Information Sources

Many Gulf War veterans have experienced a variety of physical symptoms and illnesses in the years since the Gulf War. In response to veterans' concerns, the Department of Defense established a task force in June 1995 to investigate incidents and circumstances during the war that might be related to veterans' symptoms. The Office of the Special Assistant - now known as the Deployment Health Support Directorate - assumed responsibility for these investigations on November 12, 1996, and continues to gather information on medical questions and issues related to the troops who served there.

To inform the public about the progress of this office, the Department of Defense (DoD) publishes on the Internet and elsewhere accounts related to the possible causes of medically undiagnosed physical symptoms among Gulf War veterans, along with documentary evidence or personal testimony used in compiling the accounts. The following is a summary of the reports we have published concerning our investigations into medical issues and providing information related to illnesses of Gulf War veterans.

Concern by some Gulf War veterans that vaccines may have contributed to their unexplained illnesses led to the vaccine use study.

Vaccinations

Since their return from Southwest Asia for Operations Desert Shield and Desert Storm, some US military personnel have developed medically undiagnosed physical symptoms that may relate to their service during their deployment. A number of veterans and others have expressed concern that the use of vaccines may have contributed to these symptoms. The Special Assistant examined this issue, and in December 2000, published the Vaccine Use During the Gulf War information paper, which addresses military vaccination policies and practices during and after the Gulf War, as well as plans for future deployments.

Vaccines are commonly-used health interventions that broadly benefit populations, as well as individuals. Because of its unique and diverse mission, the military employs vaccines as critical countermeasures against infectious diseases and biological warfare agents. Differences in vaccination policies among the military services reflect variations in their respective training cycles, missions, and expected levels of exposure. Military vaccine programs are also constantly updated to incorporate advances in preventive medicine, as well as in response to changing health threats.

During the Gulf War, anthrax and botulinum toxoid vaccines were used to protect US forces against the threat of Iraq's biological agents. Administration of these vaccines during Operations Desert Shield and Desert Storm was characterized by several difficult issues: lacking sufficient quantities of the vaccines; prioritizing military units for vaccination; using the investigational botulinum toxoid vaccine; obtaining informed consent; providing Service members with information about the vaccines dealing with operational security considerations; and documenting vaccines in health records.

Military personnel today are facing increasingly routine deployments overseas, exposures to environmentally hazardous battlefields, and risks associated with biological warfare agents. The Gulf War experience has brought shortfalls in vaccine administration to light and generated improvements in force health protection. Ensuring adequate production sources and maintaining sufficient stockpiles of safe and effective vaccines - especially vaccines in investigational status - remain daunting challenges, as does the communication of associated health risks to Service members. Importantly, progress has been demonstrated in vaccine tracking and documentation for deployments, and robust research on military vaccine development is ongoing. The Department of Defense should continue to build upon lessons learned from the Gulf War to ensure that advances in vaccine development and administration keep pace with changing health threats to military personnel.

Medical Recordkeeping During the Gulf War

Following the return of American Service members deployed to Southwest Asia during Operations Desert Shield and Desert Storm, veterans reported physical symptoms that believed may have been related to their service in the Gulf War, yet defied medical diagnoses. Medical records from this deployment did not provide substantial support in explaining these symptoms. The Special Assistant examined this issue and in August 1999, published the Military Medical Recordkeeping During and After the Gulf War information paper. This paper addresses recordkeeping policies and practices before, during, and after the Gulf War.

The Gulf War experience taught us that it is not enough to simply care for casualties; we must fully document health care to better address Service members' and veterans' post-deployment health concerns..

Military medical recordkeeping policies at the time of the Gulf War tended to be service-specific and published by the respective military Surgeons General. Prior to Operations Desert Shield and Desert Storm, these policies focused almost exclusively on the care of deployed forces during peacetime and less with recordkeeping under deployment conditions. During the Gulf War, some services deployed with abbreviated health records, while others typically deployed with their full, original records. The Department of Defense issued supplemental guidance on the documentation of immunizations (anthrax and botulinum toxoid) that were investigational or required some measures of operational security. Analysts with the Special Assistant found documentation of deployment medical information in individual health records to be problematic, mainly due to post-service disposition policies.

Post-Gulf-War medical recordkeeping policy continues to be made for each military service and the military health system as a whole. The Department of Defense (Health Affairs), the Joint Staff, and the military medical services are increasingly focusing on force health protection and the documentation of medical surveillance activities in support of continuing operational deployments in Bosnia, Kosovo, and Southwest Asia. Cooperation has also increased among the Department of Defense, the Department of Veterans Affairs, and the National Archives and Records Administration on issues involving the transfer and storage of medical records.

Groundwork continues for the development of an automated deployment health information device (e.g., a personal information carrier or "medical dog tag"), as well as a computer-based patient record system for all military beneficiaries. The Department of Defense views these as technological solutions to both the medical recordkeeping deficiencies associated with the Gulf War and a presidential mandate to create a force health protection program incorporating a comprehensive medical record for each military Service member.

While DoD has progressed in the addressing of medical recordkeeping shortfalls associated with the Gulf War, work continues on the significant challenges of documenting health care and other health-related matters associated with military deployments.

Information Capture of Data from Gulf War Hospital Inpatient Records

Data from over 28,000 records of admissions to US military hospitals in the KTO and evacuee admissions to hospitals in Germany was entered in the Inpatient Treatment Records Database. This database will help further medical research into undiagnosed illnesses of Gulf War veterans.

Responding to concerns raised by veterans, the Department of Defense, the Department of Veterans Affairs, and other organizations both inside and outside of government have conducted investigations into possible causes of medically undiagnosed physical symptoms in Gulf War veterans. All of these investigations have one thing in common: they examined illnesses that have been identified and diagnosed, and reported symptoms during the post-Gulf-War period. However, a large grouping of records and documentation for illnesses and injuries unequivocally attributed to service during the Gulf War had not been studied. These were the surviving hospital inpatient treatment records from the Gulf War archived at the National Personnel Records Center (NPRC) in St. Louis, Missouri. In June 1998, the Special Assistant began an effort to establish an Inpatient Treatment Records Database inventory of all Gulf War inpatient hospital treatment records archived at the NPRC. Efforts to locate, document, and inventory these records concluded in October 1999, with approximately 28,000 records identified and inventoried. With this new database, veteran contact managers within the Special Assistant assisted Gulf War veterans in obtaining copies of an existing inpatient record for the purpose of assisting to establish eligibility for VA benefits.

In January 2000, the Special Assistant directed a theater-wide review of inpatient treatment records be conducted archived at the Records Center. The data capture operation was conducted at the NPRC's research facility in St. Louis, from November 2000 through May 2001. At the conclusion of the operation, the Gulf War Inpatient Record Database contained 28,007 records of admissions to US military hospitals in the Kuwait theater of operations (KTO) and evacuee admissions to hospitals in Germany. For this study, KTO unit location data was linked to each US military patient. Unit location data is maintained and provided by the US Armed Services Center for Unit Records Research (CURR). By linking the patient diagnosis with the date of admission with the unit location data, the analysts at Special Assistant were able to produce an "epidemiological snapshot" of US troops deployed for Operations Desert Shield and Desert Storm.

Deployment Health Surveillance

Deployment Health Surveillance ensures a fit and healthy force.

The goal of deployment health surveillance is to ensure a fit and healthy force and to prevent illness, disease,adverse stress responses, and injuries from degrading mission effectiveness. As defined by the Centers for Disease Control and Prevention, health surveillance is the ongoing, systematic collection, analysis, and interpretation of health data essential to planning, implementation, and evaluation of public health practice. Medical surveillance of all Service members before, during, and after military deployments is mandated by Public Law 105-85, Section 765. The Deployment Health Support Directorate seeks to facilitate the operational awareness of Deployment Health Surveillance in today's military medical system.

Several new memorandums and directives provide procedures for conducting health surveillance in support of deployments. These include:

  • Department of Defense Directive 6490.2: This directive establishes the policy for routine joint medical surveillance for all military members during deployments and designates the Secretary of the Army as the Executive Agent for medical surveillance during deployments.
  • Department of Defense Instruction 6490.3: This instruction institutes the policy, prescribes procedures, and assigns responsibility for joint military medical surveillance in support of deployments. Additionally, it describes medical surveillance activities during major deployments, or those in which there is a significant risk of health problems.
  • Joint Staff Memo on Deployment Health Surveillance and Readiness: This memorandum specifies the Joint Chiefs of Staff standardized procedures for assessing health readiness and conducting health surveillance in support of unified command deployments.

The Assistant Secretary of Defense (Health Affairs) issued a policy memorandum requiring both pre- and post-deployment health questionnaires in order to assess a Service member's state of health before and after deployment. The Pre-Deployment Health Assessment (DD 2795) should be administered at the Service member's home station or at the mobilization processing station before deployment. The Post-Deployment Health Assessment (DD 2796) should be administered before exiting the theater of operations. Copies of the health assessments are to be placed in the Service member's permanent medical record.

Additional Information Sources

The following web links provide additional information related to medical and health-related issues facing today's DoD Service members.

  • Army Medical Surveillance Activity (AMSA): AMSA is the central resource for the Army providing regularly scheduled epidemiological analyses and reports to policy makers, medical planners, and researchers. It identifies and evaluates obstacles to medical readiness by linking various databases that communicate information relevant to soldiers' experience that has the potential to affect soldiers' health.
  • Composite Health Care System II (CHCS II): This DoD (Health Affairs) web site is a medical and dental clinical information system that will generate and maintain a comprehensive, life-long, computer-based patient record for beneficiaries under the Military Health System (MHS). CHCS II enables the MHS to determine the deployment status of units, demand management effectiveness, and disease prevalence, management and outcomes.
  • Deployment Medication Information Sheets: The Deployment Medication Information Sheets are provided to Service members with information on vaccines and other preventive medications they will receive in preparation for movement and/or during deployment.
  • Deployment Environmental Surveillance Program: The US Army's Center for Health Prevention and Preventive Medicine formed the Deployment Environmental Surveillance Program (DESP) in 1996 to serve as a single point of contact for deployment environmental surveillance issues as part of the Center's Executive Agency for medical surveillance databases and deployment surveillance analysis. The DESP's mission is to develop a system capable of providing commanders and other decision makers pertinent information needed to detect, assess, and counter environmental threats as part of a Comprehensive Military Medical Surveillance Program (CMMS). The strategic goal of the CMMS program is to allow commanders and preventive medicine personnel to determine the most likely causes of disease and non-battle injuries and focus intervention efforts towards high risk areas under the overall force health protection for deployed US Forces.
  • HOOAH 4 HEALTH: This web site is specifically designed to address the force health protection and readiness requirements of the US Army and its Reserve Component. The HOOAH 4 HEALTH program centers around four elements: body, mind, spirit, and environment.
  • The Official DoD Anthrax Information Web Site: This DoD web site holds comprehensive information on the anthrax disease and its vaccine provided for US military forces.
  • US Navy Deployment Medical Surveillance Homepage: The US Navy Bureau of Medicine has designated the Naval Environmental Health Center as the lead agency of deployment medical surveillance issues within the US Navy. This office specializes in deployment issues including entomology, environmental health, and epidemiology.
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