“Gulf War and Health: Generational Health Effects of Serving in the Gulf War” (2018)

During the Gulf War and Post-9/11 conflicts, servicemembers were potentially exposed to many hazardous agents and situations including: pesticides, fuels, vaccines, chemical and nerve agents, oil-well-fire smoke, dust, high temperatures and heat stress, depleted uranium, and pyridostigmine bromide.  While there is a growing body of research regarding veterans’ health effects as they relate to exposures during periods of deployment, there is currently a very limited amount of information available on specific effects that exposures may have on veterans’ descendants.  To address the gaps in data and knowledge, as well as veterans’ concerns about the health of their children and grandchildren, VA requested the eleventh update of the Gulf War and Health series of reports.  This report assesses the available evidence on the reproductive, developmental, and overall generational health effects related to exposures that may have occurred during the Gulf War and Post-9/11 conflicts, and offers VA guidance on how to continue moving forward with research in this area.

How Was the Report Developed? 

To develop this report, a committee of the National Academies of Sciences, Engineering, and Medicine conducted a review of the available research on possible generational health effects that may be the result of exposures experienced by veterans in the Gulf War and the Post-9/11 wars.  The report uses five categories to describe the different strengths of association between exposure to a specific toxicant and a generational health effect.  The following categories are listed from strongest association to weakest association in decreasing order:

• “Sufficient Evidence of a Causal Relationship: evidence is sufficient to conclude that a causal relationship exists between being exposed to a toxicant and a reproductive or developmental effect in humans.

• Sufficient Evidence of an Association: evidence suggests a positive association between an exposure and a reproductive or developmental effect in humans; however, there is some doubt as to the influence of chance, bias, and confounding.

• Limited/Suggestive Evidence of an Association: some evidence of an association between exposure and a reproductive or developmental effect in humans exists, but this is limited by the presence of substantial doubt regarding chance, bias, and confounding.

• Inadequate/Insufficient Evidence to Determine Whether an Association Exists: the available studies are of insufficient quantity, quality, validity, or statistical power to permit a conclusion regarding the presence or absence of an association between an exposure and a reproductive or developmental effect in humans.

• Limited/Suggestive Evidence of No Association: there are several adequate studies that are consistent in not showing an association between an exposure and a reproductive or developmental effect.”

Findings and Conclusions 

The committee came to more than 50 conclusions establishing associations between exposure and generational health effects according to the above-mentioned categories.  Significant findings in the report include, but are not limited to:

• No toxicant had sufficient evidence of a causal association, nor did any toxicant have limited/suggestive evidence of no association between exposure and reproductive or developmental effects.

• There was sufficient evidence of an association between prenatal exposure to particulate matter and adverse pregnancy outcomes, such as low birth weight and preterm birth, and prenatal exposure to benzene and childhood leukemia

• There was limited/suggestive evidence of an association between sulfur mustard and reproductive effects in men, and between prenatal exposure to particulate matter and pregnancy-induced hypertensive disorders, and respiratory or neurodevelopmental effects in children

Health Monitoring and Research Program

Moving forward, to help determine if veterans’ descendants are at risk for health effects resulting from the veterans’ exposures during deployment, the committee has proposed creating a health monitoring and research program (HMRP).  The report includes the committee’s recommended framework for development of an HMRP, including the following focuses:

• The collection, storage, and maintenance of comprehensive baseline and longitudinal data and biospecimens from veterans, their partners, and their descendants;
• A detailed characterization and assessment of exposures during and after deployment; and
• The development, evaluation, standardization, and interoperability of biomarkers of exposure, susceptibility, and biological effects.

The committee suggests that pilot programs are conducted to determine the feasibility of collection strategies, to establish the linkages for appropriate use of data, to assess response rates among veterans and their descendants, or to test surveys or other data collection methods.  Additionally, the committee stresses the importance of an HMRP that includes participant recruitment at the time of enlistment in order to ensure a sufficient sample size.  By adopting this approach, a baseline of health status, including information on lifestyle and environment as well as biological samples, can be established prior to deployment.  Having this information is crucial, as the report indicates that in order to understand the potential impact of deployment exposures on veterans and their descendants, all reproductive and developmental outcomes in the broader context of the veterans’ lives must be considered.

While an HMRP dedicated to this area of research is certainly beneficial, the report outlines several considerations that must be addressed in order to implement it on a larger scale, including:

• Financial and human resource costs
• Availability and expertise of adequately trained personnel
• Time required for project completion
• Ready access to well-curated data
• Maintenance of confidential human health data
• Ethical considerations for investigations that include parents and children
• Implementation of appropriate health and risk communication strategies between and among organizations and veterans and their families