5.26
Gulf War deployment-related exposures and
health outcomes at follow up
The associations between Gulf War-deployment related exposures and health outcomes at
follow up are shown in the following Tables.
The association between taking PB during the Gulf War and health outcomes at follow up
are shown in Table 1, which indicates that there are some statistically significant
associations between use of PB and number of health symptoms, multisymptom illness and
IBS at follow up. Those participants who were categorised as having ‘high uptake’ PB
exposure based on their deployment group, had an increased risk of IBS at follow up
compared to those who were categorised as ‘low uptake’ PB exposure based on their
deployment group. Using self-reported PB exposure categories, Gulf War veterans who
reported taking ‘any’ number of PB tablets, and those who reported taking 1-80 PB tablets,
also had a greater risk of having IBS at follow up, compared to Gulf War veterans who
reported that they did not take any PB tablets. Gulf War veterans who reported taking ‘any’
number of PB tablets, also those who reported taking 81-180 PB tablets, or >180 PB tablets,
had a higher health symptom count on average compared to Gulf War veterans who
reported no PB tablets. Gulf War veterans who reported that they did not know whether they
took PB tablets or not, however, also had a higher health symptom count on average
compared to Gulf War veterans who reported no PB tablets. Gulf War veterans who
reported taking 81-180 PB tablets were at increased risk of multisymptom illness compared
with Gulf War veterans who reported none.
The association between number of vaccinations received as part of the Gulf War
deployment and health outcomes at follow up are shown in Table 2. Table 2 indicates that
there are some statistically significant associations between self-reported numbers of Gulf
War vaccinations and SF-12 defined physical health status, average health symptom count,
average neuropathic symptom count, risk of multisymptom illness and risk of chronic fatigue.
Compared with Gulf War veterans who reported receiving no vaccinations, those who
reported 10 or more vaccinations had a significantly higher average health symptom and
neuropathic symptom count, a higher risk of multisymptom illness and a higher risk of
chronic fatigue. For every increment of one vaccine reported to be received during the Gulf
War, there was on average a 1.03-fold increase in average health symptom count, a 10%
increase in risk of multisymptom illness and a 16% increase in risk of chronic fatigue.
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The association between anti-malarials taken as part of the Gulf War deployment and health
outcomes at follow up are presented in Table 3. There were no clear associations between
anti-malarials and health outcomes at follow up. Compared with Gulf War veterans who
reported no anti-malarials, those who reported ‘any’ anti-malarials and those who did not
know whether they took anti-malarials or not, both had a slightly higher health symptom
count and neuropathic symptom count on average. There were no associations between
anti-malarials and any of the other health outcomes shown in Table 3.
The association between exposure to pesticides during the Gulf War deployment and health
outcomes at follow up are presented in Table 2. Based on self-reported exposure to
pesticides, but not possible exposure based on deployment group, there were statistically
significant associations between pesticide exposure and poorer SF12 physical health status,
higher average health symptom count, higher risk of multisymptom illness and higher risk of
chronic fatigue. Compared to Gulf War veterans who reported no Gulf War-related pesticide
exposure, veterans who reported pesticide exposure scored an average of three points
lower on the SF12 PCS, approximately 1.3 times higher on their health symptom count, and
had approximately double the risk of multisymptom illness and chronic fatigue.
The association between exposure to intense smoke, and SMOIL, during the Gulf War
deployment and health outcomes at follow up are presented in Table 5 and Table 6
respectively. There was no association between deployment-based exposure to intense
smoke and any of the health outcomes in Table 5, including asthma and chronic bronchitis at
follow up. Relative to Gulf War veterans who reported no SMOIL exposure, veterans who
reported any, low or high SMOIL exposure had lower SF12 PCS scores and higher health
symptom counts. For every increase in reported SMOIL exposure category from ‘none’ to
‘low’ to ‘high’, SF12 PCS score decreased by an average of 2.1 points and there was a 1.2fold increase in average health symptom count. There was also a marginally significant
association between reported low SMOIL exposure and increased risk of IBS, however there
was no association between reported high SMOIL exposure and IBS and there was no dose
response association.
As presented in Table 7, there were no statistically significant associations between likely
exposure to oil in water during the Gulf War deployment, based on deployment group, and
SF12 physical health status, average health symptom count and ROME III-defined IBS at
follow up.
The associations between exposure to dust during the Gulf War deployment and health
outcomes at follow up are presented in Table 8. There was no clear pattern to the
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associations between dust and health outcomes at follow up. Self-reported exposure to dust
during the Gulf War, but not exposure level based on deployment group, was associated
with poorer physical health status at follow up and higher average health symptom count.
However, high dust exposure based on deployment group, relative to low dust exposure,
was associated with lower risk of symptom-based chronic bronchitis. There was no
association between Gulf War-related dust exposure and doctor-confirmed asthma at follow
up.
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Table 1 Association between use of PB during the Gulf War and health outcomes at follow up in Gulf War veterans
Level of PB
exposure
Health symptom
count
SF12 PCS score
Neuropathic symptom Multisymptom illness
count
(N=203)
Chronic fatigue
(N=86)
CFQ case
(N=232)
Rome III IBS case
(N=90)
Mean
(sd)
Adj diff
(95% CI)
Mean
(sd)
Adj ratio*
(95% CI)
Mean
(sd)
Adj ratio†
(95% CI)
n (%)
Adj RR
(95% CI)
n (%)
Adj RR
(95% CI)
n (%)
Adj RR
(95% CI)
n (%)
Adj RR
(95% CI)
Low uptake
46.9 (10.5)
0.0
16.1 (11.1)
1.0
2.1 (2.8)
1.0
92 (26.9)
1.0
42 (12.2)
1.0
113 (32.9)
1.0
34 (10.2)
1.0
High uptake
46.5 (10.1) -0.54 (-2.2,1.2) 17.8 (12.4) 1.1 (<1.0-1.2)
2.3 (3.1)
0.9 (0.7-1.2)
111 (31.6)
1.2 (0.9-1.6)
44 (12.5)
0.9 (0.6-1.4)
119 (33.8)
1.0 (0.8-1.2)
56 (16.4)
1.7 (1.1-2.7)
None
47.4 (10.5)
1.0
1.7 (2.5)
1.0
48 (24.4)
1.0
20 (10.2)
1.0
54 (27.4)
1.0
17 (8.9)
1.0
Any
46.7 (10.0)
-1.0 (-3.0,1.0) 18.1 (12.3)
1.3 (1.1-1.5)
2.3 (3.1)
1.2 (0.9-1.6)
110 (31.4) 1.3 (<1.0-1.9)
45 (14.3)
1.1 (0.7-1.9)
121 (34.6)
1.2 (0.9-1.6)
55 (16.2)
1.9 (1.1-3.3)
1-80 tablets
48.0 (9.0)
0.2 (-2.4, 2.8) 15.2 (11.6)
1.1 (0.9-1.4)
1.6 (2.2)
0.9 (0.6-1.4)
24 (28.9)
1.3 (0.8-2.0)
8 (9.6)
1.0 (0.5-2.1)
25 (30.1)
1.1 (0.7-1.6)
13 (16.5)
2.2 (1.1-4.8)
81-180
tablets
46.6 (9.4)
-1.3 (-4.0, 1.4) 18.5 (12.5)
1.4 (1.1-1.7)
2.4 (3.0)
1.0 (0.6-1.5)
28 (37.8)
1.7 (1.1-2.6)
11 (14.9)
1.4 (0.7-2.8)
26 (35.1)
1.2 (0.8-1.8)
11 (15.1)
1.9 (0.9-4.0)
>180
tablets
46.9 (11.0)
-1.0 (-4.4, 2.4) 17.9 (12.4)
1.3 (1.1-1.6)
2.2 (3.2)
1.1 (0.7-1.8)
21 (32.8)
1.5 (0.9-2.4)
8 (12.5)
1.1 (0.5-2.6)
24 (37.5)
1.3 (0.8-2.0)
8 (12.9)
1.5 (0.6-3.7)
1.05 (0.83-1.34)
-
1.03 (0.67-1.61)
-
1.04 (0.82-1.32)
-
0.86 (0.56-1.32)
1.5 (0.8-2.6)
57 (38.8)
1.4 (>1.0-1.9)
18 (12.7)
1.5 (0.8-3.2)
Deploymentbased
metric
Self-report
based
metric
Dose
response§
Don’t know‡
-
0.0
14.0 (11.1)
-0.42 (-2.19, 1.35)
-
1.08 (0.97-1.22)
45.7 (10.7) -2.5 (-4.9, 0.02) 18.2 (10.8)
1.3 (1.1-1.6)
2.7 (3.2)
1.12 (0.89-1.40)
-
1.4 (1.1–2.0) 45 (31.3)
1.4 (<1.0-2.1)
21 (14.3)
* Calculated using negative binomial regression
† Calculated using zero inflated negative binomial regression due to the approximately 40% of participants with no neuropathic symptoms. Adjusted for age (<20; 20-24; 25-34; >=35 years), service branch (Navy; Army;
Air Force) and rank (CO, NCO, enlisted ranks) each estimated as at August 1990, and alcohol (AUDIT score > 10) and self-reported doctor-diagnosed diabetes
‡ Reference category is those who reported ‘none’
§ Dose response per categorical increase in number of PB tablets taken in those who reported taking at least one
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Table 2 Association between vaccinations for the Gulf War deployment and health outcomes at follow up in Gulf War veterans
Level of vaccination
exposure
SF12 PCS score
Health symptom count
Neuropathic symptom
count
Multisymptom illness
(N=203)
Chronic fatigue (N=117)
Mean (sd) Adj diff (95% CI)
Mean (sd)
Adj ratio*
(95% CI)
Mean (sd)
Adj ratio†
(95% CI)
n (%)
Adj RR (95%
CI)
n (%)
Adj RR (95% CI)
Low
46.4 (10.1)
0.0
16.6 (11.1)
1.0
2.3 (3.0)
1.0
47 (30.0)
1.0
22 (13.8)
1.0
Medium
46.9 (10.4)
0.7 (-2.9, 3.0)
15.6 (10.9)
1.0 (0.8-1.2)
1.9 (2.4)
1.1 (0.7-1.6)
36 (27.3)
1.0 (0.6-1.5)
15 (11.4)
1.1 (0.5-2.4)
High
46.7 (10.4)
0.5 (-1.4, 2.3)
17.5 (12.2)
1.0 (0.9-1.2)
2.3 (3.1)
1.0 (0.8-1.3)
120 (29.8)
1.0 (0.7-1.3)
49 (12.1)
0.8 (0.5-1.3)
None
45.7 (11.1)
0.0
16.9 (12.0)
1.0
2.1 (3.0)
1.0
31 (27.4)
1.0
15 (13.3)
1.0
Any
47.7 (9.8)
1.7 (-0.6, 4.0)
15.8 (11.4)
0.9 (0.8-1.1)
2.0 (2.6)
1.0 (0.8-1.4)
117 (27.6)
1.1 (0.8-1.5)
49 (11.5)
0.9 (0.5-1.5)
1-4
48.4 (9.6)
2.3 (-0.2, 4.8)
14.4 (10.4)
0.9 (0.7-1.0)
1.6 (2.2)
1.0 (0.7-1.4)
35 (20.6)
0.8 (0.5-1.2)
16 (9.4)
0.7 (0.4-1.4)
5-9
48.0 (9.8)
1.8 (-0.6, 4.3)
15.8 (11.3)
0.9 (0.8-1.1)
1.9 (2.6)
1.0 (0.7-1.4)
64 (29.1)
1.1 (0.8-1.7)
22 (10.0)
0.8 (0.4-1.4)
10 or more
43.0 (9.8)
-3.0 (-7.1, 1.0)
23.3 (14.4)
1.4 (1.1-1.7)
1.9 (2.6)
1.8 (1.1-2.9)
18 (52.9)
2.1 (1.3-3.3)
11 (32.4)
2.5 (1.2-5.0)
-
-0.39 (-0.80, 0.01)
-
1.03 (1.01-1.06)
-
not computed
-
1.10 (1.03-1.16)
-
1.16 (1.05-1.28)
Don’t know‡
44.5 (10.7)
-1.3 (-4.3, 1.7)
19.9 (11.9)
1.1 (0.9-1.3)
3.0 (3.7)
1.3 (0.9-1.9)
54 (35.1)
1.3 (0.9-2.0)
22 (14.2)
1.0 (0.5-1.9)
No clustering
47.0 (10.2)
0.0
16.3 (11.5)
1.0
2.0 (2.7)
1.0
135 (27.9)
1.0
57 (11.8)
1.0
Any clustering
47.9 (9.8)
0.5 (-1.9, 2.9)
16.1 (12.1)
1.01 (0.8-1.2)
2.0 (3.0)
1.1 (0.7-1.5)
20 (27.4)
1.0 (0.7-1.5)
11 (15.1)
1.4 (0.8-2.6)
Deployment-based
metric
Self-report based
metric
Dose response§
* Calculated using negative binomial regression
† Calculated using zero inflated negative binomial regression due to the approximately 40% of participants with no neuropathic symptoms. Adjusted for age (<20; 20-24; 25-34; >=35 years), service branch (Navy; Army;
Air Force) and rank (CO, NCO, enlisted ranks) each estimated as at August 1990, and alcohol (AUDIT score > 10) and self-reported doctor-diagnosed diabetes
‡ Reference category is those who reported ‘none’
§ Dose response per unit increase in number of vaccinations in those who received at least one
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Table 3 Association between anti-malarial tablets taken during the Gulf War deployment and health outcomes at follow up in Gulf War veterans
Level of antimalarial exposure
Self-report based
metric
None
Any
Don’t know‡
SF12 PCS score
Health symptom count
Neuropathic symptom
count
Multisymptom illness
(N=203)
Chronic fatigue (N=117)
Mean (sd)
Adj diff
(95% CI)
Mean (sd)
Adj ratio*
(95% CI)
Mean (sd)
Adj ratio†
(95% CI)
n (%)
Adj RR
(95% CI)
n (%)
Adj RR
(95% CI)
48.2 (9.7)
46.1 (10.9)
0.0
-1.6 (-3.6, 0.5)
14.6 (11.0)
17.7 (12.5)
1.0
1.2 (>1.0-1.3)
1.6 (2.3)
2.4 (3.2)
1.0
1.5 (1.1-2.0)
42 (25.9)
88 (31.8)
1.0
1.2 (0.9-1.6)
13 (8.0)
43 (15.5)
1.0
1.8 (<1.0-3.3)
46.3 (10.0)
-1.7 (-3.8, 0.4)
17.5 (11.2)
1.2 (>1.0-1.4)
2.4 (3.0)
1.5 (1.1-2.0)
72 (28.8)
1.1 (0.8-1.5)
30 (12.0)
1.4 (0.7-2.6)
* Calculated using negative binomial regression
† Calculated using zero inflated negative binomial regression due to the approximately 40% of participants with no neuropathic symptoms. Adjusted for age (<20; 20-24; 25-34; >=35 years), service branch (Navy; Army;
Air Force) and rank (CO, NCO, enlisted ranks) each estimated as at August 1990, and alcohol (AUDIT score > 10) and self-reported doctor-diagnosed diabetes
‡ Reference category is those who reported ‘none’
Table 4 Association between exposure to pesticides during the Gulf War and health outcomes at follow up in Gulf War veterans
Level of exposure
to pesticides
Deployment-based
metric
Unlikely
Possible
Self-report based
metric
No
Yes
SF12 PCS score
Health symptom count
Neuropathic symptom
count
Multisymptom illness
(N=203)
Chronic fatigue (N=117)
Mean (sd)
Adj diff
(95% CI)
Mean (sd)
Adj ratio*
(95% CI)
Mean (sd)
Adj ratio†
(95% CI)
n (%)
Adj RR
(95% CI)
n (%)
Adj RR
(95% CI)
46.8 (10.3)
44.3 (10.9)
0.0
-0.5 (-5.2, 4.3)
16.8 (11.7)
19.5 (13.6)
1.0
1.0 (0.7-1.4)
2.2 (2.9)
3.1 (4.0)
1.0
1.0 (0.6-1.8)
193 (29.1)
10 (33.3)
1.0
0.7 (0.4-1.4)
80 (12.0)
6 (20.7)
1.0
1.8 (0.7-4.5)
47 7 (9.8)
43.9 (11.0)
0.0
-3.1 (-5.0, -1.2)
15.5
20.8
1.0
1.3 (1.1-1.5)
2.0 (2.8)
2.9 (3.4)
1.0
1.1 (0.9-1.4)
120 (23.7)
79 (44.1)
1.0
1.8 (1.4-2.3)
47 (9.3)
39 (21.7)
1.0
2.3 (1.6-3.5)
* Calculated using negative binomial regression
† Calculated using zero inflated negative binomial regression due to the approximately 40% of participants with no neuropathic symptoms. Adjusted for age (<20; 20-24; 25-34; >=35 years), service branch (Navy; Army;
Air Force) and rank (CO, NCO, enlisted ranks) each estimated as at August 1990, and alcohol (AUDIT score > 10) and self-reported doctor-diagnosed diabetes
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Table 5 Association between intense smoke exposure during the Gulf War and health outcomes at follow up in Gulf War veterans
Level of smoke
exposure
SF12 PCS score
Mean (sd)
Adj diff (95% CI)
Health symptom count
Mean (sd)
Adj ratio*
(95% CI)
Rome III IBS case (N=90)
Self-reported doctor
Symptom-based-Chronic
confirmed Asthma (N=87)
bronchitis (N=144)
Adj RR
(95% CI)
n (%)
n (%)
Adj RR†
(95% CI)
n (%)
Adj RR†
(95% CI)
Deployment-based
metric
Low
High
46.6 (10.2)
0.0
17.0 (11.9)
1.0
85 (13.8)
1.0
81 (12.7)
1.0
133 (20.9)
1.0
47.2 (11.4)
0.6 (-2.6, 3.7)
16.1 (10.1)
0.9 (0.8-1.1)
5 (8.9)
0.6 (0.3-1.5)
5 (9.3)
0.7 (0.3-1.5)
11 (19.6)
1.0 (0.6-1.8)
* Calculated using negative binomial regression
† Adjusted for age (<20; 20-24; 25-34; >=35 years), service branch (Navy; Army; Air Force) and rank (CO, NCO, enlisted ranks) each estimated as at August 1990, atopy at baseline and current smoking status (never;
former; current smoker)
Table 6 Association between SMOIL exposure during the Gulf War and health outcomes at follow up in Gulf War veterans
Level of SMOIL
exposure
SF12 PCS score
Mean (sd)
Adj diff (95% CI)
Health symptom count
Mean (sd)
Adj ratio*
(95% CI)
Rome III IBS case (N=90)
Self-reported doctor
Symptom-based-Chronic
confirmed Asthma (N=87)
bronchitis (N=144)
Adj RR
(95% CI)
n (%)
n (%)
Adj RR†
(95% CI)
Self-report based
metric
None
Any
Low
High
Dose response§
n (%)
Adj RR†
(95% CI)
48.3 (9.5)
0.0
14.9 (10.3)
1.0
34 (10.7)
1.0
35 (10.7)
1.0
60 (18.3)
1.0
-2.9 (-4.4, -1.4)
1.2 (1.1-1.4)
45.3 (10.8)
18.8 (12.8)
55 (15.7)
1.4 (<1.0-2.2)
50 (14.0)
1.3 (0.8-1.9)
82 (22.9)
1.2 (0.8-1.6)
-2.8 (-4.4, -1.2)
1.2 (1.1-1.3)
1.5 (>1.0-2.3)
45.3 (10.8)
18.4 (12.6)
49 (16.8)
39 (13.2)
1.2 (0.7-1.8)
65 (22.0)
1.1 (0.8-1.6)
-3.4 (-6.4, -0.5)
1.4 (1.1-1.6)
45.3 (10.8)
20.5 (13.4)
6 (10.2)
0.9 (0.4-2.1)
11 (18.0)
1.7 (0.9-3.1)
17 (27.4)
1.6 (<1.0-2.6)
-2.14 (-3.33, -0.94)
1.18 (1.10-1.28)
1.17 (0.89-1.55)
1.26 (0.93-1.71)
1.22 (0.96-1.55)
* Calculated using negative binomial regression
† Adjusted for age (<20; 20-24; 25-34; >=35 years), service branch (Navy; Army; Air Force) and rank (CO, NCO, enlisted ranks) each estimated as at August 1990, atopy at baseline and current smoking status (never;
former; current smoker)
§ Dose response per categorical increase in SMOIL where participants are categorised as either “none’, “low” or “high”
Table 7 Association between exposure to oil in water during the Gulf War and health outcomes at follow up in Gulf War veterans
Level of exposure
to oil in water
SF12 PCS score
Mean (sd)
Deployment-based
metric
Unlikely
Possible
Adj diff (95% CI)
46.8 (10.4)
0.0
46.1 (10.1)
-0.9 (-2.8, 1.0)
* Calculated using negative binomial regression
Health symptom count
Rome III IBS case
Mean (sd)
Adj ratio* (95% CI)
n (%)
Adj RR (95% CI)
16.7 (11.5)
17.8 (12.8)
1.0
1.0 (0.9-1.2)
65 (12.4)
25 (16.8)
1.0
1.3 (0.8-2.1)
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Table 8 Association between dust exposure during the Gulf War and health outcomes at follow up in Gulf War veterans
Level of dust
exposure
Deployment-based
metric
Low
High
Self-report based
metric
Absent
Present
SF12 PCS score
Health symptom count*
Self-reported doctor
confirmed Asthma (N=87)
Symptom-based-Chronic
bronchitis (N=144)
Mean (sd)
Adj diff (95% CI)
Mean (sd)
Adj diff (95% CI)
n (%)
Adj RR† (95% CI)
n (%)
Adj RR† (95% CI)
46.7 (10.2)
46.7 (10.3)
0.0
-0.1 (-1.9, 1.7)
16.6 (10.8)
17.1 (12.1)
1.0
1.0 (0.9-1.2)
24 (13.1)
62 (12.2)
1.0
1.0 (0.6-1.5)
52 (63.4)
92 (45.5)
1.0
0.7 (0.6-0.9)
48.0 (9.6)
0.0
15.4 (10.5)
1.0
46 (12.5)
1.0
68 (46.3)
1.0
-2.9 (-4.4, -1.3)
1.2 (1.1-1.4)
45.1 (11.0)
18.7 (12.9)
39 (12.4)
1.1 (0.7-1.6)
76 (56.3)
1.3 (<1.0-1.6)
* Calculated using negative binomial regression
† Adjusted for age (<20; 20-24; 25-34; >=35 years), service branch (Navy; Army; Air Force) and rank (CO, NCO, enlisted ranks) each estimated as at August 1990, atopy at baseline and current smoking status (never;
former; current smoker)
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Table 9 shows that there was no statistically significant association between possible exposure to
gastroenteritis outbreaks during the Gulf War, based on deployment group, and ROME III-defined IBS
at follow up.
Table 9 Association between possible exposure to gastroenteritis outbreaks during the Gulf War
and health outcomes at follow up in Gulf War veterans
Level of exposure to
gastroenteritis outbreak
Deployment-based
metric
Unlikely
Possible
Rome III IBS case (N=90)
n (%)
Adj RR (95% CI)
28 (10.9)
62 (14.8)
1.0
1.3 (0.8-2.0)
Table 10 shows the associations between Gulf War deployment era, and MSEQ score, with health
outcomes at follow up. Compared with those Gulf War veterans whose deployment ended prior to the
combat phase of the Gulf War, veterans whose deployment included the combat phase had a higher
risk of multisymptom illness, alcohol disorder as measured by AUDIT caseness, 12 month major
depression and a higher average health symptom count (for the latter two health outcomes the
differences only just met statistical significance). Gulf War veterans whose deployment commenced
after the combat phase were at greater risk of 12 month alcohol disorder compared to Gulf War
veterans whose deployment ended prior to the combat phase.
Increasing number of reported Gulf War-related stressors, as indicated by increasing MSEQ score, was
strongly associated with decreased SF12 mental health status score, increased average health
symptom and neuropathic symptom count, increased depressive symptom severity score, and
increased risk of multisymptom illness, chronic fatigue, 12 month major depression, 12 month PTSD,
alcohol disorder as measured by AUDIT caseness (the association with CIDI-defined alcohol disorder
was only marginal), and psychological distress as measured by GHQ-12 caseness. The greatest risk
was amongst those who reported 12 or more Gulf War-related stressors. Those Gulf War veterans
were at six times greater risk of multisymptom illness, five times greater risk of 12 month PTSD, three
times greater risk of 12 month major depression and irritable bowel syndrome, and double the risk of
chronic fatigue, for example, compared with those veterans who reported four or fewer Gulf Warrelated stressors. Every increase in MSEQ score of one Gulf War-related stressor was associated with
increased morbidity on a number of measured outcomes including a 13% increase in 12 month PTSD,
a 9% increase in multisymptom illness, a 7% increase in chronic fatigue and a 6% increase in 12 month
major depression.
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Table 10 Association between Gulf War deployment era and MSEQ score with health outcomes at follow up in Gulf War veterans
Gulf War
deployment
exposure
SF12 MCS score
Health symptom count
Neuropathic symptom
count
Multisymptom illness
(N=203)
Chronic fatigue (N=86)
Irritable Bowel Syndrome
(N=90)
Adj ratio† (95%
CI)
n (%)
Adj RR (95%
CI)
n (%)
Adj RR (95%
CI)
n (%)
Adj RR (95% CI)
2.1 (2.9)
1.0
44 (22.5)
1.0
27 (13.7)
1.0
17 (9.0)
1.00
1.1 (>1.0-1.3)
2.3 (3.0)
0.9 (0.7 – 1.1)
133 (32.0)
1.4 (1.1-1.9)
48 (11.5)
0.8 (0.5-1.3)
61 (15.0)
1.65 (0.99-2.73)
1.0 (0.9-1.2)
2.1 (3.0)
0.8 (0.5 – 1.3)
26 (32.1)
1.3 (0.8-2.0)
11 (13.6)
0.9 (0.5-1.8)
12 (15.2)
1.58 (0.82-3.06)
10.3 (8.4)
1.0
1.1 (1.8)
1.0
14 (9.0)
1.0
13 (8.4)
1.0
10 (6.5)
1.00
14.9 (9.7)
1.5 (1.3-1.7)
1.7 (2.7)
1.2 (0.9 – 1.7)
43 (20.9)
2.4 (1.3-4.2)
19 (9.2)
1.0 (0.5-2.0)
24 (12.1)
1.88 (0.91-3.87)
19.5 (12.4)
1.9 (1.6-2.2)
2.9 (3.4)
1.7 (1.2 – 2.4)
62 (35.6)
4.0 (2.3-6.8)
21 (12.0)
1.3 (0.7-2.6)
29 (17.2)
2.65 (1.31-5.37)
-10.3 (-12.9, -7.8)
23.3 (12.3)
2.3 (2.0-2.7)
3.1 (3.3)
1.9 (1.4 – 2.8)
84 (53.5)
6.1 (3.6-10.4)
33 (20.9)
2.3 (1.2-4.3)
27 (17.7)
2.86 (1.42-5.77)
-0.72 (-.08, -0.56)
-
1.06 (1.05-1.07)
-
1.05 (1.03-1.09)
Mean (sd)
Adj diff (95% CI)
Mean (sd)
Adj ratio* (95% CI) Mean (sd)
before combat
46.6 (11.1)
0.0
15.5 (11.0)
1.0
during combat
45.7 (12.3)
-0.5 (-2.5, 1.5)
17.6 (12.1)
after combat
46.9 (11.4)
-0.0 (-3.0, 2.9)
17.1 (11.8)
51.2 (9.3)
0.0
5-8
47.5 (11.0)
-3.8 (-6.0, -1.7)
9-12
44.6 (12.3)
-6.9 (-9.3, -4.5)
>12
40.9 (12.4)
-
Deployment era
MSEQ score
0-4
Dose
response‡
Gulf War
deployment
exposure
12 month Major depression
(N=63)
n (%)
Deployment era
before combat
during combat
after combat
MSEQ score
0-4
5-8
9-12
>12
Dose response†
PHQ-9 depressive
symptom score
Adj RR (95% CI)
Median
(IQR)
1.04 (1.02 – 1.07)
-
12 month PTSD (N=47)
Adj diff (95% CI)
n (%)
Adj RR (95% CI)
-
1.09 (1.08-1.11)
12 month Alcohol
disorder (N=40)
n (%)
Adj RR (95% CI)
-
1.07 (1.04-1.10)
AUDIT case (N=199)
n (%)
Adj RR (95% CI)
GHQ-12 case (N=264)
n (%)
Adj RR (95% CI)
11 (6.1)
1.0
3 (1-6)
0.0
10 (5.5)
1.0
5 (2.8)
1.0
42 (21.5)
1.0
81 (41.1)
1.0
46 (11.9)
1.9 (>1.0-3.6)
4 (0-8)
1 (-0.1-2.1)
32 (8.3)
1.4 (0.7-2.8)
27 (7.0)
2.4 (0.9-6.4)
134 (32.4)
1.5 (1.1-2.0)
155 (37.4)
0.9 (0.7-1.1)
6 (7.5)
1.3 (0.5-3.8)
4 (1-7)
1 (-0.7, 2.7)
5 (6.3)
0.7 (0.2-2.3)
8 (10.0)
3.5 (1.1-10.9)
23 (28.1)
1.4 (0.9-2.2)
28 (34.2)
0.8 (0.6-1.2)
7 (4.8)
1.0
1 (0-4)
0.0
0
-
5 (3.5)
1.0
33 (21.3)
1.0
36 (23.2)
1.0
17 (8.7)
1.9 (0.8-4.4)
3 (0-6)
1 (-0.3-2.3)
11 (5.6)
1.0§
10 (5.1)
1.4 (0.5-4.1)
50 (24.3)
1.1 (0.7-1.6)
73 (35.3)
1.5 (1.1-2.2)
16 (10.1)
2.2 (0.9-5.2)
4 (2-8)
2 (0.6-3.4)
12 (7.6)
2.2 (>1.0-4.9)
11 (7.0)
1.9 (0.7-5.5)
58 (33.5)
1.5 (1.1-2.2)
75 (42.9)
1.9 (1.3-2.6)
23 (15.6)
3.2 (1.4-7.4)
7 (3-12)
5 (3.6-6.4)
24 (16.3)
4.6 (2.3-9.1)
14 (9.5)
2.5 (0.9-6.7)
57 (36.5)
1.6 (1.1-2.4)
80 (51.3)
-
0.36 (0.27-0.46)
-
1.13 (1.10-1.17)
-
1.05 (>1.00-1.10)
-
1.06 (1.02-1.09)
1.04 (1.02-1.06)
2.2 (1.6-3.1)
1.04 (1.03-1.06)
* Calculated using negative binomial regression
† Calculated using zero inflated negative binomial regression due to the approximately 40% of participants with no neuropathic symptoms. Adjusted for age (<20; 20-24; 25-34; >=35 years), service branch (Navy; Army;
Air Force) and rank (CO, NCO, enlisted ranks) each estimated as at August 1990, and alcohol (AUDIT score > 10) and self-reported doctor-diagnosed diabetes
‡ The dose response slope is the expected proportionate increase in the adj RR (or adj difff) per unit increase in the MSEQ score
§ Because there are no PTSD cases with an MSEQ score of 0-4, the reference category for this regression was MSEQ score 0-8
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5.26.1
Key findings
There were a number of statistically significant associations between Gulf War deployment
exposures and health outcomes at follow up. Typically, significant associations were found
for self-report based-metrics of exposure level rather than metrics based on deployment
group.
The use of pyridostigmine bromide during the Gulf War was associated with an increased
number of health symptoms, multisymptom illness and IBS at follow up. Gulf War veterans
who were categorised as having ‘high uptake’ of PB exposure based on their deployment
group, compared with ‘low uptake’, and those who reported taking ‘any’ number of PB
tablets, or 1-80 PB tablets, compared with none, had a greater risk of having IBS at follow up.
Gulf War veterans who reported taking ‘any’ number, 81-180 PB tablets, or >180 PB tablets,
had a higher health symptom count on average compared to veterans who reported no PB
tablets. Gulf War veterans who reported that they did not know whether they took PB tablets
or not, however, also had a higher health symptom count on average compared to veterans
who reported no PB tablets. Gulf War veterans who reported taking 81-180 PB tablets were
at increased risk of multisymptom illness compared with veterans who reported no PB
tablets.
Compared with Gulf War veterans who reported receiving no vaccinations, those who
reported 10 or more vaccinations as part of the Gulf War deployment had a significantly
higher average health symptom and neuropathic symptom count, and a higher risk of
multisymptom illness and chronic fatigue at follow up. For every increment of one vaccine
reported to be received during the Gulf War, there was a 1.03-fold increase in average
health symptom count, a 10% increase in multisymptom illness risk and a 16% increase
chronic fatigue risk.
Compared to Gulf War veterans who reported no Gulf War-related pesticide exposure,
veterans who reported pesticide exposure scored an average of three points lower on the
SF12 PCS, approximately 1.3 times higher on their health symptom count, and had
approximately double the risk of multisymptom illness and chronic fatigue.
Relative to Gulf War veterans who reported no SMOIL exposure, veterans who reported any,
low or high SMOIL exposure had lower SF12 PCS scores and higher health symptom counts.
For every increase in reported SMOIL exposure category from ‘none’ to ‘low’ to ‘high’, SF12
PCS score decreased by an average of 2.1 points and there was a 1.2-fold increase in
average health symptom count.
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There was no clear pattern to the associations between dust and health outcomes at follow
up. Self-reported exposure to dust during the Gulf War was associated with poorer physical
health status at follow up and higher average health symptom count. However, high dust
exposure based on deployment group, relative to low dust exposure, was associated with
lower risk of symptom-based chronic bronchitis. There was no association between Gulf
War-related dust exposure and doctor-confirmed asthma at follow up.
Compared with those Gulf War veterans whose deployment ended prior to the combat
phase of the Gulf War, veterans whose deployment included the combat phase had a higher
average health symptom count, depressive symptom severity, multisymptom illness risk and
major depression risk. Gulf War veterans whose deployment commenced after the combat
phase were at greater risk of alcohol disorder compared to veterans whose deployment
ended prior to the combat phase.
Increasing number of reported Gulf War-related stressors, as indicated by increasing MSEQ
score, was associated with decreased mental health status score, and increased average
health symptom and neuropathic symptom count, depressive symptom severity, and risk of
multisymptom illness, chronic fatigue, major depression, PTSD, AUDIT alcohol disorder and
psychological distress at follow up.
There were no clear patterns to the associations observed between anti-malarials and health
outcomes at follow up. There were no statistically significant associations between
deployment-based metrics for likely exposure to oil in water, intense smoke, or possible
exposure to gastroenteritis outbreaks during the Gulf War deployment, and health outcomes
at follow up.
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