Review of the VA Persian Gulf Registry Data

Of the veterans entered on the VA Persian Gulf Registry, Table 3 describes the distribution of demographic characteristics for 7,427 whose data was available for analysis. Although the number of veterans actually registered continues to increase, the task force was provided data from VA based on analysis of the first 7,247 records to be compiled. Demographic characteristics of those who came to VA for an examination do not appear substantially different from those troops deployed in the Gulf area. However, the military characteristics of the registry participants are significantly different when compared to the characteristics of the entire cohort of deployed troops (Table 4). Even after considering eligibility status for the registry examination, those who served in national guard and reserve units are more likely to have participated in the registry examination than those who served in their counterpart active units. Their rate of registry participation was severalfold greater than their counterparts (see Figure 1, Appendix D). Distribution of time of arrival, departure from and length of stay in the theater for the veterans on the VA registry is not significantly different from those of the overall Persian Gulf War participants (Figures 2-4, Appendix D).

Table 3

Distribution of Demographic Characteristics of 7,427 Veterans on the Persian Gulf Registry and of 696,562 participants in the Persian GulfWar

Table 4

Distribution of Military Characteristics of 7,427 Veterans on the Persian Gulf Registry and of 696,562 participants in the Persian GulfWar

A wide variety of complaints were made by the registry participants, although only 3 could be entered in each veteran's computer file for centralized analysis. Table 5 lists the ten most frequent complaints among the veterans. Skin rash, fatigue, muscle and joint pain, headache and loss of memory are most frequently mentioned; complaints listed are subjective symptoms reported by the registry participants, and may or may not have been objectively verified by physical examination. It is important to note that information from all veterans on the Persian Gulf Registry has been included. Many of these veterans have received appropriate medical diagnoses for their complaints, so this table does not accurately represent the most frequent complaints for those veterans with unexplained illness. It can also be noted that 1,294 veterans (17.4%) expressed no specific complaints at all.

Table 5

Ten Most Frequent Complaints Among 7,427 Veterans on the Persian Gulf Registry

Table 6 lists the distribution of major categories of diagnosis as reported by VA environmental physicians, by military unit status. There seems to be no significant variation in occurrence of major categories of medical problems, or any specific medical conditions (Table 7 by unit status despite much higher rates of participation and a significantly greater proportion of individuals with complaints among veterans who served in the reserve or guard units. Similarly, distribution of the same categories of medical conditions by branch of service does not vary substantially (Table 8). It was originally assumed that troops who served in one branch of service (e.g., Army) might have different environmental exposures in the Gulf area than troops in another branch of service (e.g., Navy) leading to different patterns of complaints and medical conditions.

Table 6

Percentage Distribution of Diagnosis for 7,427 Veterans on the Persian Gulf Registry by Military Unit Status

Table 7

Percentage Distribution of Selected Diagnoses for 7,427 Veterans on the Persian Gulf Registry by Military Unit Status

Table 8

Percentage Distribution of Diagnoses for 7,427 Veterans on the Persian Gulf Registry by Branch

Table 9 describes 19 cases of cancer reported in the registry (18 males and 1 female). There is no discernible demographic, military or pathological pattern to the distribution of cancer cases. Because it is a self-selected group of individuals, it would be difficult to make a meaningful comparison with a general population. Whether the observation of 19 cancer cases out of 7,427 examinations reflects an abnormal rate of occurrence is unknown. Furthermore, because of the long latency period associated with cancer originating from environmental exposures, it is too early to evaluate the cancer risk related to Persian Gulf service. Likewise, it is unknown whether some or all of the cancers were present prior to Persian Gulf deployment.

Table 9

Distribution of Cancer Cases by Site Among 7,427 Veterans on the Persian Gulf Registry

Table 10 summarizes veterans' responses to a question about birth defects in children conceived before service in the Persian Gulf War and in children conceived after veterans returned from the war. According to the registry of 7,427 veterans, 209 veterans reported having children with birth defects: 115 as having been conceived before Persian Gulf war service and 94 after the war. The nature of the birth defects, however, is not defined or verified and the occurrences of birth outcomes are based on self-reports.

Table 10

Self-Reported Incidence of Birth Defects Among Veteran's Children

In analyzing and describing the registry data, it is necessary to recognize many limitations related to the source of the data and therefore to exercise great caution in its use. The veterans in the registry are a self-selected group of veterans who are concerned about the possible adverse health effects of service in the Gulf area and who were willing to come to VA hospitals for physical examinations. Many veterans who are covered by civilian health insurance may be seeking their health care through a civilian health care provider. In addition, a majority of troops who served in the war are still in service with active units, and they would not yet seek medical care from a VA hospital. Therefore, the registry participants may not be representative of either the troops deployed in the Gulf area overall or of those who are eligible for medical care from VA. One cannot be sure whether certain symptoms and diseases in the registry participant population are under-represented or over-represented. A valid external comparison of health outcomes from this group to another population is difficult to make for this reason.

In spite of the several limitations to the VA registry, it serves as a useful tool in suggesting areas for further in-depth reviews and study. The registry can provide an opportunity to identify possible adverse health trends on which to base the design and conduct of appropriate epidemiologic studies.

1. VA Hospital Discharge Data for Persian Gulf War Veterans

The Patient Treatment File (PTF) is a computerized hospital discharge abstract system of inpatient records, including patients' demographic data, surgical and procedural transactions, and patient movement and diagnosis. One PTF record is prepared for each discharged VA inpatient by the discharging station. Over one million veterans are treated as inpatients in VA hospitals each year. The PTF record contains information on such variables as name, Social Security number, date of birth, sex, marital status, period of military service and discharge diagnosis. Military service during the Persian Gulf era is noted on the record but actual service in the Persian Gulf area is not documented. The PTF was matched with the Persian Gulf War roster of veterans prepared by the DMDC, and VA inpatients who served in the Persian Gulf area were identified. The Task Force was presented data, as of September 30, 1993, that compared the data from 6092 Persian Gulf veterans and 6265 era veterans (those in service during the same period but not actually deployed to the Gulf) treated in VA hospitals on an inpatient basis.

Table 11 describes the demographic characteristics of 6092 Persian Gulf veterans and 6265 era veterans who were treated in VA hospitals. Women veterans constituted 7.6% of the Persian Gulf veteran patients, whereas 14% of era veteran patients were women. The 7.6% figure may be a simple reflection of the gender distribution of the troops deployed in the Persian Gulf area: 7.2% of the deployed troops were women and 8.8% of the troops excluding those who were still on active duty as of September 30, 1993, were women. Otherwise, the racial distribution, marital status and age distribution of the two groups were similar.

Table 11

Demographic Characteristics of 6,092 Persian Gulf Veterans and 6,265 Era Veterans Treated in VA Hospitals on an Inpatient Basis

Table 12 describes the distribution of military characteristics of these patients. This distribution is also a reflection of the characteristics of the troops deployed in the Persian Gulf area. For example, the distribution of Army troops deployed in the area by unit status is 76% in active units, 13% in reserve units and 11% in national guard units. Excluding those who were still on active duty, the distribution is 60% in active units, 22% in reserve units and 18% in national guard units. In the PTF, the distribution of Army Persian Gulf veteran patients by unit status is 58% in active units, 23% in reserve units and 19% in national guard units. Unlike the Persian Gulf Registry, veterans who served in the reserve or guard units are not over-represented in the VA inpatient population. It could not be determined whether Persian Gulf War veterans were over-represented in the VA inpatient population because different eligibility rules covered hospital admission for different service era veterans.

Table 12

Distribution of Military Characteristics of 6,092 Persian Gulf Veterans Treated in VA Hospitals on an Inpatient Basis, 696,662 Participants in the Persian Gulf War, and 371,197 Potentially Eligible for VA Medical Care

*As of September 30,

Table 13 lists the distribution of major categories of discharge diagnosis. There appears to be no significant variation between the type of medical conditions for which the two groups of patients were treated. One possible exception is that relatively more Persian Gulf veterans were treated for adjustment disorders including PTSD than the era veteran patients. A separate review of the discharge diagnoses for women veteran patients also showed similar results (Table 14)

Table 13

Distribution of 6,092 Persian Gulf Veterans and 6,265 Era Veterans Treated on an Inpatient Basis By Selected Diagnostic Group

Note: These tabulations represent primary diagnosis from all inpatient visits, with some veterans having more than one inpatient stay. Percentages are of either the total number of diagnoses for Persian Gulf Veterans (7365) or the total number of diagnoses for the Era Veterans (7688).

Table 14

Distribution of 463 Women Persian Gulf Veterans and 902 Women Era Veterans Treated on an Inpatient Basis By Selected Diagnostic Group

Note: These tabulations represent primary diagnosis from all inpatient visits, with some veterans having more than one inpatient stay. Percentages are of either the total number of diagnoses for Persian Gulf Veterans (585) or the total number of diagnoses for the Era Veterans (1134).

Persian Gulf veterans who received inpatient medical care at VA hospitals are similar to overall troops deployed in the Persian Gulf area with respect to their demographic and military characteristics. The types of medical conditions for which they were treated were also similar to other veteran patients who were in the military during the same period. No one category of medical condition is either over-represented or under-represented among the Persian Gulf veteran patients in comparison to the era veterans, with the possible exception of mental disorders. The reason for the apparent variation needs to be evaluated further.

Because the rules and regulations governing the eligibility of VA hospital admission may affect the Persian Gulf veterans and the era veterans differently, one needs to be cautious of a simple comparison of these two groups of veterans. On December 20, 1993, legislation was enacted into law which authorized priority health care for Persian Gulf veterans for both outpatient and inpatient treatment (Public Law 103-210). The same priority consideration is not authorized for the era veterans.

2. VA Referral Centers

In August 1992, the Department of Veterans Affairs established three referral centers at its medical centers in Houston, Texas, West Los Angeles, California and Washington, DC to evaluate cases of undiagnosed illnesses being reported by veterans of the Persian Gulf conflict. These centers were selected for three major reasons: because of their geographic location (East Coast, Middle U.S., and West Coast), because of their own special clinical expertise, and finally because of their geographic proximity to other centers for military medicine, occupational health and toxicology.

A Persian Gulf veteran, whose condition has evaded diagnosis at the local VA facility, can be transferred to one of the designated centers for tertiary consultation, diagnosis, and management. The transfer of a Gulf War veteran is a mutual decision made by the physicians at the originating medical center and the referral center of jurisdiction. Because of the multisystem nature of many of the veterans health complaints, these evaluations are often quite extensive, involving consultations by multiple subspecialty services and entire array of diagnostic tests.

As of February 1994, the Centers have admitted 84 Persian Gulf veterans under the Referral Center Program. The predominant complaints include skin rash, chronic fatigue, muscle aches and spasms, joint pain, diarrhea, abdominal pain, shortness of breath, chronic cough, weakness, dizziness, headache, and memory loss. These symptoms occur singly or, more often, in combination. VA investigations of the health problems of these individuals have resulted in the diagnosis of a diverse group of disease entities including: asthma, inflammatory bowel diseases, irritable bowel syndrome, gastrointestinal parasitic infection with giardia, gastritis, abnormal liver function tests, rheumatologic conditions including Reiter's Syndrome, Sjogren's syndrome and fibromyalgia, idiopathic thrombocytopenic purpura (ITP), a pituitary tumor with neuroendocrine dysfunction, cases of dizziness due to vestibulitis or vestibular dysfunction, CNS vasculitis, sleep disorders, compression neuropathies and various common skin conditions including nevi, warts and fungal infections. Psychiatric diagnoses included major depression, post-traumatic stress disorder (PTSD), somatization disorder and panic disorder. Psychiatric conditions were listed as one of the discharge diagnoses in 20 of the 84 patients admitted to the referral center programs. It is the VA's best medical judgment that these diagnoses do not point to a single inciting cause or agent. Some of these cases still remain undiagnosed at present.

3. Depleted Uranium (DU) Surveillance Program

During the Persian Gulf War, 15 Bradley Fighting Vehicles and 9 Abrams tanks were mistakenly attacked and struck by DU munitions. Some crew members who survived sustained wounds and have retained fragments of presumed DU shrapnel. An initial check by the Army Office of The Surgeon General has revealed that there were 22 soldiers clearly identified whose records indicate that they have imbedded fragments that might contain DU. There are additionally 13 soldiers who were wounded and hospitalized but were not specifically identified as having shrapnel. Other crew members (in addition to the 35 already discussed) were either not wounded during the incident or received first aid for minor wounds in the battlefield. The latter two groups of soldiers might have inhaled DU or experienced DU contamination of wounds.

The concern for these soldiers centers principally on the possibility that fragments could serve as a reservoir for absorbable uranium. Animal and human studies have shown uranium to be nephrotoxic.

The Department of Veterans Affairs has recently established a clinical surveillance program at the Baltimore VAMC (Veterans Affairs Medical Center) to identify individuals with retained depleted uranium (DU) fragments, DU contaminated wounds or significant amounts of inhaled DU. This clinical surveillance will provide early detection of untoward health effects related to the presence of DU, an epidemiologic follow-up program and provide recommendations for treatment to participating veterans and the physicians caring for them.

Patients will undergo a thorough clinical evaluation including exposure history and review of systems, administration of health status questionnaire, neuropsychiatric test battery and laboratory testing. Lab tests obtained will include CBC, platelet count, free erythrocyte protoporphyrin to assess bone marrow effects. Bilirubin, transaminases and alkaline phosphatase will assess liver injury. CPK and aldolase will be measured to assess muscle injury. Particular focus will be placed on measures of renal injury. Serum will be analyzed for creatinine, BUN, electrolytes, glucose, calcium and phosphorus. A 24-hour urine will be collected for measurements of creatinine, glucose, beta-2-microglobulinuria, and urine protein. Fragment size will be estimated using plain x-rays and MRI. Blood and urine uranium levels will also be measured. Finally, individuals will undergo whole body counting at the Environmental Protection Agency (EPA) laboratory at Las Vegas, Nevada.

In addition, 27 other veterans from the 144th Supply and Service Company (Army National Guard) performed clean-up of contaminated vehicles. As they entered and re-entered vehicles over a three-week period, it is believed that they had the potential to inhale or ingest depleted uranium residues. Because of this potential risk, a screening program was instituted for this Company. Twelve of the twenty-seven individuals have undergone whole-body counting at the Boston VA Medical Center, all with negative results. Urine samples were also analyzed for depleted uranium; all had negative results. The remaining fifteen individuals have been contacted and have chosen not to be tested.

4. Birmingham Pilot Program

The Birmingham VA Medical Center has been designated by the Secretary of the Department of Veterans Affairs as a Center for Persian Gulf Veterans Chemical Agent Pilot Site. The Birmingham VAMC will begin testing Persian Gulf veterans from Alabama and Georgia who believe that they may have been exposed to chemical-biological warfare agents. The Birmingham VAMC program will administer a clinical symptom screening survey, perform detailed occupational health exams for veterans with positive symptom survey and administer a neuropsychological testing battery in order to assess potential health effects of CBW exposure.