Gulf War Program Update: - PowerPoint Presentation

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Gulf War Program Update:Research Advisory Committee on Gulf War Illnesses 12 June 2019

Peter D. Rumm, MD, MPH, FACPMDirector, Pre-911 Era ProgramsPost-Deployment Health Services

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OUTLINENational Academy of Medicine (NAM) report on Intergenerational Effects of Military Service in review

Review of the registriesGulf War data from the RegistryGulf War illness case definition studiesChart ReviewDevelopment of analytic tool

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NAM REPORTNAM report “Gulf War and Health, Volume 11: Generational Health Effects of Serving in the Gulf War

Review in accordance with VA Directive 0215Certification letter sent to Congress sent noting that further review of the proposed NAESM Health Monitoring Research Program (HMRP) on intergenerational effects is neededLarge scale study over generations looking for intergenerational effects / birth defects associated with serving in the Gulf War Theater of OperationsExploratory 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.

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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) – 2

nd Gulf War onlyAirborne 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

PDHS

REGISTRY / SURVEILLANCE PROGRAMS*

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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. EXPOSURE REGISTRIES - PROS AND CONS

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PREVALENCE IN GWR

PREVALENCE IN GWR

PREVALENCE IN GWR

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STUDY GROUP OVERVIEW

*Persian Gulf War and Gulf War Era Veterans Roster

Note: All VHA encounters occurred between 2008 - 2018.

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

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

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CMI and RELATED HEALTH CONDITIONS in GW VETERANS

Gulf War I Registry Veterans

vs.

Gulf War I Era non-deployed Veterans

Post-Gulf War I Registry Veterans

vs.

Gulf War I Era non-deployed Veterans

Gulf War I non-Registry Veterans

vs.

Gulf War I Era non-deployed

Veterans

Condition

OR (95% CI)

aOR (95% CI)

OR (95% CI)

aOR (95% CI)

OR (95% CI)

aOR (95% CI)

Chronic Multisymptom Illness*

2.0 (1.9, 2.0)

1.8 (1.7, 1.9)

1.9 (1.8, 2.0)

1.3 (1.2, 1.4)

1.0 (0.9, 1.0)

1.0 (0.9, 1.0)

Chronic Fatigue Syndrome

8.0 (7.3, 8.7)

7.9 (7.1, 8.7)

5.0 (4.5, 5.6)

3.9 (3.5, 4.4)

1.8 (1.6, 2.0)

1.9 (1.7, 2.1)

Fibromyalgia

3.4 (3.2, 3.5)

3.6 (3.4, 3.7)

2.9 (2.8, 3.0)2.6 (2.5, 2.7)0.9 (0.8, 0.9)1.0 (1.0, 1.1)Gastrointestinal Disorders12.2 (2.2, 2.3)2.1 (2.1, 2.2)2.2 (2.1, 2.2)1.7 (1.7, 1.8)0.9 (0.9, 0.9)1.0 (0.9, 1.0)Depression2.4 (2.4, 2.4)2.2 (2.2, 2.3)2.5 (2.5, 2.6)1.8 (1.8, 1.9)1.1 (1.0, 1.1)1.1 (1.0, 1.1)

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.

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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.

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Gastrointestinal Disorders include irritable bowel syndrome, dyspepsia, abdominal pain syndrome, as well as stomach and duodenal ulcers.

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 = 800CSP 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.

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CHART REVIEW-CASE DEFINITION PROJECT

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

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METHODS

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?

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POINTS OF CONSIDERATION

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

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QUESTIONS?