Mr. Chairman, thank you for the opportunity to update the Subcommittee on the Centers for Disease Control and Prevention's (CDC) research programs pertaining to Gulf War veterans' illnesses and to discuss the General Accounting Office's (GAO) report, "Gulf War Illnesses: Management Actions Needed to Answer Basic Research Questions." I am Dr. Drue Barrett, Chief of the Veterans' Health Activity Working Group in the Division of Environmental Hazards and Health Effects of the National Center for Environmental Health (NCEH). I serve as CDC's liaison to the Department of Health and Human Services (HHS) on Gulf War issues and I am a member of the Research Working Group of the Persian Gulf Veterans Coordinating Board. NCEH has been designated as the lead Center at CDC for addressing Gulf War veterans' health concerns, however other Centers within CDC have also been involved in this effort, most notably, the National Center for Infectious Diseases.
The purpose of my testimony is to update the Committee on the extent of CDC's Gulf War research activities, the productivity of our research efforts, and how our research has been coordinated with the research being conducted by other Federal agencies.
Completed CDC-funded Gulf War Studies:
Before describing our current studies, I would like to review the results from two completed CDC-funded studies because these studies are pertinent to questions raised by the GAO regarding the success of the federal government in documenting the symptoms of Gulf War veterans. The Iowa study, conducted in collaboration with the Iowa Department of Public Health and the University of Iowa, was one of the first population-based epidemiologic studies to document that Gulf War veterans are reporting more medical and psychiatric conditions than their non-deployed military peers. In fact, this study was recently described by the Institute of Medicine as "perhaps the strongest study on Gulf War veterans' experience of symptoms related to deployment in the Gulf." The 3,695 subjects who completed this study were selected from a larger population of almost 29,000 military personnel who listed Iowa as their home of record. Furthermore, the subjects in this study were specifically selected to represent individuals from all four branches of the military, and include both regular military personnel and National Guard and reservists. Seventy-six percent of the eligible study subjects completed the detailed telephone interviews. This study is also one of the first controlled epidemiological studies to evaluate the health consequences of the Gulf War. The study included a carefully selected comparison group of military personnel who were not deployed to the Persian Gulf but who served during the time of the Gulf War. The Iowa study found that the Gulf War military personnel were more likely than those who did not serve in the Gulf War to report symptoms suggestive of cognitive dysfunction, depression, chronic fatigue, post-traumatic stress disorder, and respiratory illness (asthma and bronchitis). The conditions identified in this study appear to have had a measurable impact on the functional activity and daily lives of these Gulf War veterans. Among Gulf War veterans, minimal differences were observed between the National Guard or reserve troops and the regular military personnel.
The results of the Iowa study were published in the Journal of the American Medical Association in 1997. In addition, a number of other manuscripts from the Iowa study have been published, are in press, or are currently in the process of peer review. These include an article on quality of life and health service utilization among military personnel reporting multiple chemical sensitivities, published in 1999 in the Journal of Occupational and Environmental Medicine, and an article on symptom prevalence and risk factors of multiple chemical sensitivities, in press in the Archives of Internal Medicine. Manuscripts are currently being considered at peer-reviewed journals on the topics of defining a Gulf War syndrome, the relationship between post-traumatic stress disorder and physical health status, and self-reported injuries among Gulf War veterans.
Likewise, the CDC Air Force study has significantly contributed to our understanding of the health consequences of the Gulf War. This study organized symptoms reported by Air Force Gulf War veterans into a case definition, characterized clinical features, and evaluated risk factors. The cross-sectional questionnaire was sent to 3723 currently active volunteers from four Air Force populations. Clinical evaluations were performed on 158 Gulf War veterans from one unit, irrespective of health status. A case was defined based on reporting one or more chronic symptoms from at least 2 of 3 categories (fatigue, mood-cognition and musculoskeletal) and was further characterized as mild-to-moderate or severe depending on the severity of the reported symptoms. The prevalence of mild-to-moderate and severe cases were 39% and 6%, respectively, among 1155 Gulf War veterans versus 14% and 0.7% among 2520 non-deployed veterans. Fifty-nine (37%) clinically evaluated Gulf War veterans were non-cases, 86 (54%) were mild-to-moderate cases and 13 (8%) were severe cases. The key observation of the study was that Air Force Gulf War veterans were significantly more likely to meet criteria for severe and mild-to-moderate illness than were non-deployed personnel. There was no association between the chronic multisymptom illness and risk factors specific to combat in the Gulf War (month of season of deployment, duration of deployment, duties in the Gulf War, direct participation in combat, or locality of Gulf War service). The finding that 15% of non-deployed veterans also met illness criteria was equally important and suggests that the multisymptom illness observed in this population is not unique to Gulf War service. The clinical evaluation component of the study found that neither mild-to-moderate nor severe cases were associated with clinically significant abnormalities on physical examination or routine laboratory tests. However, Gulf War veterans classified as having mild-to-moderate and severe illness had a significant decrease in functioning and well-being compared with non-cases.
The results from this study were published in CDC's Morbidity and Mortality Weekly Report in 1995 and in the Journal of the American Medical Association in 1998. In addition, an article from the Air Force study examining the relationship between deployment stressors and chronic multisymptom illness is currently in press in the Journal of Nervous and Mental Disorders.
Current CDC-funded Gulf War Studies:
CDC is currently funding a follow-up to the Iowa study focusing on evaluating self-reported symptoms of asthma. This study involves a detailed clinical evaluation of a sample of subjects who completed the initial telephone survey. This evaluation includes a physical examination; tests of lung functioning; questions regarding medical, occupational, and exposure history; assessment of functional status and quality of life; and assessment of psychiatric history and personality functioning. The examinations are being conducted at the University of Iowa Hospitals and Clinics in Iowa City, Iowa. This study is in its final phases of data collection and we anticipate that results should be available later this year.
The University of Iowa has also been funded by the Department of Defense (DoD) to conduct validation studies of additional health outcomes among participants of the telephone survey. These include validation of depression, cognitive dysfunction, and fibromyalgia. CDC is providing technical assistance to DoD and the University of Iowa for this study.
We are also funding the Boston University School of Public Health to conduct a study examining the relationship between cognitive function and symptom patterns among Gulf War veterans. In one component of this study, functional magnetic resonance imaging (fMRI) is being used to examine possible differences in brain activation patterns between Gulf War veterans and era controls with different levels of symptoms. A second component of the study is using a new data-driven mathematical technique, Logical Analysis of Data, to examine how Gulf War veterans' symptoms cluster together. This may provide useful information for determining etiology or for developing a case definition. Finally, this study also includes a component examining the neuropsychological functioning of a sample of Danish Gulf War troops. Investigators are currently in the data collection phase for the fMRI component of this study and in the data analysis phase for the other two components. We anticipate that this study will be complete by the end of this year.
Finally, CDC is funding the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School to conduct a study examining case definition issues. The study will assess the persistence and stability of Gulf War veterans symptoms over time, compare the performance of data-driven case definitions to existing definitions for medically unexplained symptoms, and examine the role of psychiatric conditions in Gulf War veterans' unexplained illnesses. We originally expected that this study would be completed in late 2000, however the process of protocol development and clearance took somewhat longer than we anticipated. Thus, we expect that this study will require an additional year to complete.
CDC is collaborating with DoD and the Department of Veterans Affairs (VA) on a number of projects including a study of health outcomes among Saudi Arabia National Guard members and a study of Amyotrophic Lateral Sclerosis (ALS) among Gulf War veterans. This collaboration has included providing input on study protocols, reviewing human subjects issues, and assisting in laboratory assessments.
Future Gulf War Research Planning:
In addition to these current research projects, CDC, in collaboration with other HHS agencies, recently sponsored a conference to develop future Gulf War research recommendations. On February 28 through March 2, 1999, CDC brought together scientists, clinicians, veterans, veterans' service organizations, Congressional staff, and other interested parties to discuss and make recommendations regarding the direction of future research on undiagnosed illnesses among Gulf War veterans and their links with multiple chemical and environmental exposures.
Concurrent workgroups were convened in order to develop research recommendations in four areas: pathophysiology, etiology, and mechanisms of action; assessment and diagnosis of illnesses; treatment; and prevention of illnesses in future deployments. This conference highlighted the importance of including veterans in the process of planning and implementing research. Veterans and scientists alike expressed that they found the process useful and that future similar efforts should be encouraged. A report is soon to be released that summarizes the outcome of each of the four workgroup sessions. It is anticipated that this report will be of interest to a broad range of individuals and organizations and may provide the basis for development of new research collaborations and exchanges. Recommendations for new research will need to be considered in light of the existing research portfolio of the Research Working Group in order to avoid unnecessary duplication of efforts.
Coordination of Federal Research Efforts:
Finally, I would like to address the issue of coordination of federal research efforts. There has been HHS representation on the Persian Gulf Veterans Coordinating Board Research Working Group since its inception. In addition to CDC, the Office of the Secretary, the National Institutes of Health, and the Agency for Toxic Substances and Disease Registry are represented. Through its membership, HHS has been involved in providing guidance and coordination for DoD, VA, and HHS research activities relating to Gulf War veterans. Specifically, this has included assessing the state and direction of research, review of government research concepts as they are developed, identification of gaps in factual knowledge and conceptual understanding, and providing recommendations regarding research direction.
The Research Working Group also serves as a forum for research data exchange among the three departments and among federally funded investigators. CDC's role in this area has included providing information on the status of projects for a research database of all VA, DoD, and HHS research activities, input on the Annual Report to Congress on federally sponsored Gulf War Veterans' Illnesses research, and participation on the planning committee for the federal investigators meeting where new research results are shared.
An intensive research effort to address Gulf War veterans' health concerns has been mounted by federal agencies and non-governmental scientists. As of 1999, there have been 145 federally-funded research projects on Gulf War veterans' illnesses with a cumulative expenditure of $133.5 million for research from FY94 through FY99. These projects represent a broad spectrum of research efforts, ranging from small pilot studies to large-scale epidemiology studies addressing mechanistic, clinical, and epidemiological issues. Similar efforts have been initiated in other coalition countries, most notably in the United Kingdom and Canada. In addition, numerous review panels and expert committees have evaluated the available data on Gulf War veterans' illnesses. As noted in the GAO report, despite these extensive research and review efforts, many questions remain regarding the health impact of the Gulf War. However, these remaining questions do not reflect scientific indifference; instead they reflect the complexity of assessing and predicting the health impact of military deployments. Despite this complexity, the federal research effort continues in an effort to uncover the causes of illnesses among Gulf War veterans so that effective treatment approaches can be developed and similar illnesses in future deployments can be prevented.
Mr. Chairman, this concludes my testimony. I would be happy to answer any questions the Subcommittee may have.
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