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Intergenerational Effects of Gulf War: Research Update

This update discusses the National Academy of Medicine report on intergenerational effects of military service and the development of an analytic tool for studying Gulf War illnesses. It also explores the potential for a FACA committee and the future use of the Individual Longitudinal Exposure Record. The pros and cons of exposure registries are highlighted, along with the prevalence of selected health conditions in Gulf War veterans. The ongoing chart review project aims to develop and validate case definitions for Gulf War illness.

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Intergenerational Effects of Gulf War: Research Update

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  1. Gulf War Program Update:Research Advisory Committee on Gulf War Illnesses12 June 2019 Peter D. Rumm, MD, MPH, FACPM Director, Pre-911 Era Programs Post-Deployment Health Services

  2. OUTLINE • National Academy of Medicine (NAM) report on Intergenerational Effects of Military Service in review • Review of the registries • Gulf War data from the Registry • Gulf War illness case definition studies • Chart Review • Development of analytic tool

  3. NAM REPORT • NAM report “Gulf War and Health, Volume 11: Generational Health Effects of Serving in the Gulf War • Review in accordance with VA Directive 0215 • Certification letter sent to Congress sent noting that further review of the proposed NAESM Health Monitoring Research Program (HMRP) on intergenerational effects is needed • Large scale study over generations looking for intergenerational effects / birth defects associated with serving in the Gulf War Theater of Operations • Exploratory discussions to determine how the NAM report recommendation can be used in response to PL 114-315, sections 633-634 on toxic exposures/inter-generational effects. • May lead to a FACA committee similar to this one.

  4. PDHS REGISTRY / SURVEILLANCE PROGRAMS* • Ionizing Radiation Registry (IRR) (18.000) • Agent Orange Registry (AOR) (720,000) • Gulf War Registry (180,000) • Depleted Uranium Follow-Up Program (6,000) • Toxic Embedded Fragment Surveillance Center (18,000) – 2nd Gulf War only • Airborne Hazards and Open Burn Pit Registry (185,000 – fastest growing) The Individual Longitudinal Exposure Record (ILER) is the future. • ILER is in pilot now; initial general use in Oct 2019. *Registries including GW Veterans

  5. EXPOSURE REGISTRIES - PROS AND CONS • Registries are one strategy for collecting information on occupational exposure and disease in populations • A registry can be a valuable tool for surveillance, epidemiology and prevention of disease • Registries have a number of actual and potential limitations that need to be considered. Self selection, missing data, recall and other biases. Arrandale et. al. Designing exposure registries for improved tracking of occupational exposure and disease. Can J Public Health. 2016 Jun 27;107(1):e119-25.

  6. PREVALENCE IN GWR

  7. PREVALENCE IN GWR

  8. PREVALENCE IN GWR

  9. STUDY GROUP OVERVIEW Data sources: • Persian Gulf War and Gulf War Era Veterans Roster • Gulf War Registry • VHA healthcare utilization data from CDW inpatient, outpatient, and fee for service files *Persian Gulf War and Gulf War Era Veterans Roster Note: All VHA encounters occurred between 2008 - 2018.

  10. DRAFT RESULTS: SELECTED HEALTH CONDITIONS BY STUDY GROUP (2008-2018)

  11. CMI and RELATED HEALTH CONDITIONS in GW VETERANS OR indicates odds ratio; aOR indicates adjusted odds ratio (adjusted for age, gender, and race/ethnicity); CI indicates confidence interval†The CDW data was pulled for inpatient, outpatient, and fee for service medical record data on 2/22/2019. *Prevalence of Chronic Multisymptom Illness was assessed using CDW data from 2018 only to ensure only current chronic cases were captured. Chronic Multisymptom Illness cases were identified using a modified CDC and Kansas case definition criterion. **Prevalence for Chronic Fatigue Syndrome, Fibromyalgia, Gastrointestinal Disorders, and Depression was assessed using CDW data from 2008-2018. 1Gastrointestinal Disorders include irritable bowel syndrome, dyspepsia, abdominal pain syndrome, as well as stomach and duodenal ulcers.

  12. CHART REVIEW-CASE DEFINITION PROJECT • Utilizes two cohorts of GW Veterans for development and validation of a chart abstraction process to identify and confirm GWI status according to three base case definitions (Kansas, CDC, CMI CPG) • WRIISC patients at NJ, CA, DC; n = 800 • CSP 585 cohort; n = 1200 • The initial focus is on VHA electronic medical records. Pending time and resources, the chart abstraction of the CSP 585 cohort may include private sector medical records.

  13. METHODS • Chart Abstraction, using the Chart Review program, will focus on the following: • Symptoms • Occupational / Environmental Exposures • Deployment/Military history • Diagnosis of CMI • Analyses of relative performance of multiple case definitions (Kansas, CC, CPG), including new case definitions created from review of preliminary findings in ChartReview. • Applying different and adapted case definitions to a randomly selected derivation sample, calculating agreement (Kappa scores), sensitivity/ specificity/PPV/NPV relative to an arbitrary gold standard case status (ie Kansas criteria, clinician diagnosis) • What is the intended use for the case definition? • Clinical at VA and potentially for benefits

  14. POINTS OF CONSIDERATION • Which case definitions of GWI (Kansas, CDC, CMI CPG? • GW (ODSS) only vs. more general case definition (of CMI) that could be applied to any cohort? • Which symptoms should be included? • Symptom onset temporally associated with exposure or latent manifestations of symptoms? • How latent? • Should there be exclusionary conditions? (Kansas definition) • How to account for aging and age-related chronic conditions and symptoms?

  15. QUESTIONS? • Contact either Peter Rumm, MD, MPH or Shanna Smith, DrPH at Peter.Rumm@va.gov or Shanna.Smith@va.gov

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