Mortality among US and UK veterans of the Persian Gulf War: a review.

Mortality data on Gulf War veterans was reviewed as a means of evaluating the long term consequences of the war. Studies were located from searches of Medline, Proceedings of the Conference on Federally Sponsored Gulf War Veterans' Illnesses Research, Proceedings of the American Public Health Association Annual Meetings, Annual Reports to Congress, and personal contacts with knowledgeable investigators. Data on study design, methods, and results were obtained from published studies of both US and UK veterans who served in the Persian Gulf. The methodology and results of studies are summarised and evaluated. Additional research recommendations based on reviewed studies are presented. It is concluded that in both US and UK studies, mortality from external causes was higher, while mortality from all illnesses was lower among Gulf War veterans in comparison to those of non-Gulf War veterans. Increased mortality from external causes is consistent with patterns of postwar mortality observed in veterans of previous wars. Further follow up of Gulf War veterans and their controls is warranted for evaluating the mortality risk from diseases with longer latency periods.

Mortality among US veterans of the Persian Gulf War: 7-year follow-up.

To assess the long-term health consequences of the 1991 Persian Gulf War, the authors compared cause-specific mortality rates of 621,902 Gulf War veterans with those of 746,248 non-Gulf veterans, by gender, with adjustment for age, race, marital status, branch of service, and type of unit. Vital status follow-up began with the date of exit from the Persian Gulf theater (Gulf veterans) or May 1, 1991 (control veterans). Follow-up for both groups ended on the date of death or December 31, 1997, whichever came first. Cox proportional hazards models were used for the multivariate analysis. For Gulf veterans, mortality risk was also assessed relative to the likelihood of exposure to nerve gas at Khamisiyah, Iraq. Among Gulf veterans, the significant excess of deaths due to motor vehicle accidents that was observed during the earlier postwar years had decreased steadily to levels found in non-Gulf veterans. The risk of death from natural causes remained lower among Gulf veterans compared with non-Gulf veterans. This was mainly accounted for by the relatively higher number of deaths related to human immunodeficiency virus infection among non-Gulf veterans. There was no statistically significant difference in cause-specific mortality among Gulf veterans relative to potential nerve gas exposure. The risk of death for both Gulf veterans and non-Gulf veterans stayed less than half of that expected in their civilian counterparts. The authors conclude that the excess risk of mortality from motor vehicle accidents that was associated with Gulf War service has dissipated after 7 years of follow-up.

A mortality follow-up study of WW II submariners who received nasopharyngeal radium irradiation treatment.

BACKGROUND: During World War II, large numbers of submarine trainees received nasopharyngeal radium irradiation therapy to treat aerotitis media or middle ear barotrauma. METHODS: Using a life table and the Cox proportional hazards model, mortality risk of 1, 214 submariners believed to have received treatment for aerotitis media was compared to 3,176 "untreated" submariners. RESULTS: "Treated" submariners had a significant increased mortality risk for all causes (odds ratio (OR) = 1.32; 95% confidence interval (CI) = 1. 14-1.53) and circulatory diseases (OR = 1.51; 95% CI = 1.20-1.90), and a non-significant increased mortality risk of head and neck cancer (OR = 1.40; 95% CI = 0.54-3.58). CONCLUSIONS: While the excess risk was not statistically significant by conventional standards, the finding does suggest that those who received NP radium irradiation therapy may be at increased risk of death due to head and neck cancers. Due to the lack of data the role of risk factors other than radium exposure cannot be assessed.

A case-control study of lung cancer among Vietnam veterans.

Because of concerns among veterans over Agent Orange exposure, the Department of Veterans Affairs (VA) has conducted a series of studies of specific cancers among Vietnam veterans. Lung cancer is the topic of investigation in this report. The VA's Patient Treatment File (PTF) was used to identify 329 Vietnam era veterans with a diagnosis of lung cancer made between 1983 and 1990. The PTF is a computerized hospitalized database of inpatient records, including patients' demographic data, and diagnoses. A record is created for each patient discharged from any one of the VA's Medical Centers. Variables abstracted from the military record include education, race, branch of service, Military Occupational Specialty Code, rank, and units served within Vietnam. Two hundred sixty-nine controls were randomly selected from the PTF file of men hospitalized for a reason other than cancer. A second control group numbering 111 patients with colon cancer was also selected from the PTF file. Data were also gathered on exposure to Agent Orange through the location of each individual ground troop veteran's unit in relation to an area sprayed and the time elapsed since that area was sprayed. The crude odds ratio between service in Vietnam and lung cancer was of borderline significance (odds ratio = 1.39 with 95% confidence interval = 1.01-1.92). The relationship disappeared when the confounder year of birth was considered. We conclude from these data that there is no evidence of increased risk in lung cancer associated with service in Vietnam at this time.

Mortality among U.S. veterans of the Persian Gulf War.

BACKGROUND: Since the 1990-1991 Persian Gulf War, there has been persistent concern that U.S. war veterans may have had adverse health consequences, including higher-than-normal mortality. METHODS: We conducted a retrospective cohort study of postwar mortality according to cause among 695,516 Gulf War veterans and 746,291 other veterans. The follow-up continued through September 1993. A stratified, multivariate analysis (with Cox proportional-hazards models) controlled for branch of service, type of unit, age, sex, and race in comparing the two groups. We used standardized mortality ratios to compare the groups of veterans with the general population of the United States. RESULTS: Among the Gulf War veterans, there was a small but significant excess of deaths as compared with the veterans who did not serve in the Persian Gulf (adjusted rate ratio, 1.09; 95 percent confidence interval, 1.01 to 1.16). The excess deaths were mainly caused by accidents (1.25; 1.13 to 1.39) rather than disease (0.88; 0.77 to 1.02). The corresponding rate ratios among 49,919 female veterans of the Gulf War were 1.32 (0.95 to 1.83) for death from all causes, 1.83 (1.02 to 3.28) for accidental death, and 0.89 (0.45 to 1.78) for death from disease. In both groups of veterans the mortality rates were significantly lower overall than those in the general population. The adjusted standardized mortality ratios were 0.44 (95 percent confidence interval, 0.42 to 0.47) for Gulf War veterans and 0.38 (0.36 to 0.40) for other veterans. CONCLUSIONS: Among veterans of the Persian Gulf War, there was a significantly higher mortality rate than among veterans deployed elsewhere, but most of the increase was due to accidents rather than disease, a finding consistent with patterns of postwar mortality among veterans of previous wars.

The risk of suicide among wounded Vietnam veterans.

OBJECTIVES: This study was undertaken to determine whether an association exists between combat trauma and risk of postservice suicide among Vietnam veterans. METHODS: Risk of suicide for 34,534 veterans who were wounded in Vietnam was evaluated for severity of wound and number of times wounded. RESULTS: There was a trend of increasing risk of suicide with increased occurrence of combat trauma, the highest relative risk (1.82, 95% confidence interval [CI] = 1.12, 2.96) being observed for those veterans who were wounded more than once and hospitalized for a wound. In comparison with the US male general population, veterans hospitalized because of a combat wound or wounded more than once had a significantly increased risk of suicide (standardized mortality ratios [SMRs] of 1.22 [95% CI = 1.00, 1.46] and 1.58 [95% CI = 1.06, 2.26], respectively). Those wounded more than once and hospitalized had the highest increased risk of suicide (SMR = 1.73, 95% CI = 1.10, 2.60). CONCLUSIONS: This study suggests that, among wounded Vietnam veterans, there is an increased risk for suicide associated with increased occurrence of combat trauma.

Posttraumatic stress disorder and the risk of traumatic deaths among Vietnam veterans.

Vietnam veterans have been reported to be at increased risk for posttraumatic stress disorder (PTSD) and deaths due to traumatic causes after service in the Vietnam War. This study evaluated whether an association exists between PTSD and traumatic deaths among Vietnam veterans. Mortality risk of 4,247 Vietnam veterans from the Agent Orange Registry (AOR) with a diagnosis of PTSD relative to that of 12,010 Vietnam veterans from the AOR with no diagnosis of PTSD was calculated using the Cox proportional hazards model. Mortality experience of both groups was also compared with U.S. males. The PTSD veterans were more likely than the non-PTSD veterans to die from suicide (relative risk = 3.97, 95% confidence interval [CI] = 2.20-7.03) and from accidental poisoning (relative risk = 2.89, CI = 1.03-8.12). The standardized mortality ratio for suicides was 6.74 (CI = 4.4-9.87) among PTSD veterans and 1.67 (CI = 1.05-2.53) among non-PTSD veterans. Among Vietnam veterans on the AOR, PTSD is associated with a significant increased risk for suicide and accidental poisoning.

The effects of mustard gas, ionizing radiation, herbicides, trauma, and oil smoke on US military personnel: the results of veteran studies.

Late effects of exposure to certain environmental hazards as a consequence of their active military service have become an issue of particular concern to veterans and the public at large. Approximately one out of four Americans is a veteran or a family member of a veteran. The US military develops and uses increasingly complex and sophisticated weaponry. As the military technology changes, so do the kinds of health issues to be addressed. The changing composition of military personnel, most notably the increasing number of women veterans and their expanding role into combat-related activities, will affect both the health issues to be addressed and the kind of health care to be provided. The emerging role of the military as peace-keepers in hostile but nonwar zones and as disaster-relief workers, endemic to the area and to psychological stressors unrelated to combat. The formation of a registry of military personnel exposed to potentially serious long-term health hazards would be highly advisable, whenever feasible. Such an exposure registry could serve as the basis for future medical surveillance and response to affected veterans and help avoid the kind of difficulty experienced in addressing health concerns of WWII veterans exposed to mustard gas and Vietnam veterans exposed to Agent Orange. Close cooperation between the Department of Veterans Affairs and the Department of Defense is essential in the identification of potential hazards and follow-up of affected individuals. Growing public awareness of potential occupational and environmental hazards, publicity surrounding such suspected health risks, and the limited scientific knowledge about low-level exposure to toxic substances may all lead to misunderstanding, unwarranted fear, and suspicion of government coverup. Establishment of an exposure registry of veterans may be seen as a government commitment to address the future effects of potential hazards.

Risk of testicular cancer associated with surrogate measures of Agent Orange exposure among Vietnam veterans on the Agent Orange Registry.

A case-control analysis was undertaken to examine the association between various surrogate measures of Agent Orange exposure and testicular cancer among Vietnam veterans. Study subjects were selected from the Department of Veterans Affairs Agent Orange Registry. The case patients consisted of 97 veterans with a diagnosis of testicular cancer, and 311 veterans without any clinical diagnosis served as a comparison group. The surrogate measures were branch of service, type of duty, corps area, and location of the individual's unit in relation to recorded Agent Orange spray tracts. Only Navy veterans had a statistically significant increased risk of testicular cancer (odds ratio (OR) = 2.60; 95% confidence interval (CI), 1.08 to 6.24). Risk of testicular cancer was not significantly increased for ground troops (OR = 0.46; 95% CI, 0.25 to 0.86), for combat duty (OR = 0.91; 95% CI, 0.52 to 1.58), for service in the III Corps area (OR = 1.10; 95% CI, 0.66 to 1.84), and for being close to spray tracts within 90 days/8 km (OR = 0.99; 95% CI, 0.54 to 1.84) or 3 days/2 km (OR = 1.39; 95% CI, 0.50 to 3.80). The study results are not consistent with the hypothesis that Agent Orange may be a risk factor for testicular cancer among Vietnam veterans.

Posttraumatic stress disorder among Vietnam veterans on the Agent Orange Registry. A case-control analysis.

Some of the readjustment problems of Vietnam veterans have been attributed to posttraumatic stress disorder (PTSD). This case-control study compared demographic and military characteristics of 374 Vietnam veterans who had PTSD with 373 healthy Vietnam veterans. Veterans were chosen from the Agent Orange Registry, a Department of Veterans Affairs computerized database of approximately 200,000 Vietnam veterans who volunteered for a physical examination. Case patients and control subjects were frequently-matched by age, year of Registry examination, and race. Crude odds ratios (OR) were used to evaluate the risk of PTSD associated with certain characteristics of Vietnam service, as there was no apparent confounding by other military factors. Being wounded in Vietnam (OR, 2.33; 95% confidence interval (CI), 1.49-3.65) and having a combat job in Vietnam (OR, 1.54; 95% CI, 1.15-2.06) were the only risk factors for PTSD. Those who had noncombat jobs but were wounded had the highest risk of PTSD (OR, 3.56; 95% CI, 1.26-10.06).

Proportionate mortality among US Army Vietnam veterans who served in military region I.

A proportionate mortality study was conducted to determine if the post-service mortality experience of 6,668 Army Vietnam veterans who served in Military Region I (I Corps) was different from that of 27,917 Army non-Vietnam veterans. These veterans served in the US military between 1965 and 1973 and had died as of December 31, 1984. Statistically significant excesses of deaths were observed for motor vehicle accidents and accidental poisonings, with accidental poisonings having the largest elevation. Suicides and deaths due to any other major disease categories including malignant neoplasms were no more frequent among the I Corps veterans than their counterparts.

Combat experience and postservice psychosocial status as predictors of suicide in Vietnam veterans.

The authors examined potential risk factors for suicide among 38 Vietnam veterans using 46 Vietnam veterans who died from motor vehicle accidents as a comparison group. The veterans were selected from Los Angeles County Medical Examiner's file (1977-1982). Data for these veterans were obtained from military service records, the coroner's reports, and the psychological autopsy conducted with the decedents' family members. No military service factor was associated with suicide. The characteristics of Vietnam veteran suicide cases were not substantially different from non-Vietnam veteran suicide cases with respect to known demographic risk factors. The psychological profile of Vietnam veteran suicide cases are also similar to non-Vietnam veteran suicide cases in most instances. Symptoms related to posttraumatic stress disorder were observed more frequently among suicide cases than accident cases. However, suicides were not associated with specific combat experiences or military occupation. The extent of combat experience in Vietnam per se as measured in this study is not a good predictor of suicide death.