IJE Advance Access originally published online on January 24, 2006
International Journal of Epidemiology 2006 35(2):479-487; doi:10.1093/ije/dyi318
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Article |
Health consequences of the first Persian Gulf War on French troops
1 Department of Epidemiology, Public Health and Development (INSERM U593), Victor Segalen University Bordeaux 2, Bordeaux, France
2 Clinic of Occupational Diseases, Cochin Hospital, AP-HP, Paris 5 University, Paris, France
3 Laboratory of Occupational and Environmental Health, Victor Segalen Bordeaux 2 University, Bordeaux, France
* Corresponding author: INSERM U593, Université Victor Segalen Bordeaux 2, case no.11, 146, rue Léo-Saignat, 33076 Bordeaux Cedex, France. E-mail: Roger.Salamon{at}isped.u-bordeaux2.fr
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Abstract |
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Summary Since 1993, many studies on the health of Persian Gulf War Veterans (PGWV) have been undertaken. These studies have concluded that there has been an increased mortality due to external causes, no excess of recognized diseases, and no effect on PGWV children. When compared with the non-deployed, PGWV have reported a higher frequency of infertility as well as different symptoms, but a specific Gulf War syndrome was not identified. In October 2000, the French government asked an independent working group to analyse the scientific literature on PGWV health. The group concluded that an exhaustive study of French PGWV was to be undertaken. The objectives of this study were to describe the exposures of PGWV in the operations theatre, to report on the symptoms and diseases that occurred in PGWV and their children during and after the military campaign, and to explore the possibility of a Gulf War syndrome. This exhaustive cross-sectional study, which included all civilians and troops who served in the Gulf from August 1990 to July 1991, began in January 2002. Data were collected by postal self-administered questionnaires. A standardized clinical evaluation was performed by 27 clinics of occupational diseases and nine military hospitals. Symptoms and diseases which appeared after the campaign are described.
To date, among 20 261 PGWV, 5666 participated in the study (28%). The most frequent symptoms described since the return from the Gulf were headaches (83%), neurological or psychological symptoms, and back pain. Apart from well-known symptoms associations (respiratory, neurocognitive, psychological and musculo-skeletal syndromes), no other cluster was highlighted by our analysis.
Keywords Gulf War, cross-sectional study, epidemiology, Gulf War Veterans, Gulf War syndrome
Accepted 20 December 2005
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Background |
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From August 1990 to April 1991, the conflict with Iraq involved troops of a coalition constituted of almost 40 countries, mainly the United States (700 000 personnel), the United Kingdom (50 000) and France (20 000). The French troops were deployed nearby the US and UK troops and faced the same exposures.1 However, French participants, as opposed to US and UK troops, did not receive vaccines against anthrax, botulism, or plague, which have been associated with the self-reporting of post-deployment symptoms.1,2
Since 1993, many studies on the health of Persian Gulf War Veterans (PGWV) have been undertaken, mainly in the US and the UK. US and UK mortality studies showed a lower mortality from all illnesses among Gulf War Veterans in comparison with non-deployed veterans, and an increased mortality due to external causes. This is consistent with the patterns of post-war mortality already observed in veterans of previous wars.3–6 Some authors found an association between Gulf War service and reported infertility,7,8 or miscarriage,9 but no effect was described on PGWV's children.10–13
Compared with non-deployed veterans, PGWV have been reported to have no excess of recognized diseases,6,14–37 but were two to three times more likely to report fatigue, cognitive difficulties, headaches, myalgia and arthralgia, mood disturbance, and sleep problems.6,14–37
Several studies, based on statistical factor analysis have been carried out to determine relationships among symptoms.38–50 In these studies, factor structures were similar whether veterans were deployed or not deployed in the Gulf War.40–42,49 Despite different symptoms inventories and differences in statistical analyses, studies on Gulf War illness generally report from three to seven factors: (i) mood, cognition, fatigue, psychological symptoms; (ii) respiratory condition; (iii) neurological condition; (iv) musculoskeletal pain; (v) peripheral nervous system; (vi) gastrointestinal disorder; and (vii) mixed somatic complaints. However, no specific Gulf War syndrome has been retained.38–50
Among those French PGWV who benefited from a close medical follow-up (general practitioners, psychiatrists) before 2000, no atypical acute pathological phenomenon was described.51 Since the military health network observed no new or unexplained pathology in the last decade, no specific monitoring or study of French PGWV was conducted. However, the first demand for compensation for a health problem related to the Gulf War was filed in 1995. In June 2000, a French Association of Gulf War Victims (Avigolfe) was founded. The Working Group in charge of the analysis of health data from French Gulf War Veterans, headed by one of us, was created in October 2000 by the French government. This group recommended an epidemiological study of all French PGWV in order to describe their complaints and to objectively measure their disorders through a standardized clinical examination.
The French Ministry of Defense, in collaboration with the Ministry of Health, solicited the INSERM in January 2002 to conduct an exhaustive investigation of all French PGWV (French Study on Persian Gulf War and its Health Consequences). The aim of this descriptive study was, mainly, to examine self-reported symptom data among Gulf War Veterans, to describe the main forms of exposure reported in the theatre, symptoms and diseases that appeared during and after the Persian Gulf mission, and to determine if unexpected statistical associations of such symptoms could suggest the presence of a new specific syndrome.
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Methods |
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Population study
The French study on the Persian Gulf War and its health consequences was a cross-sectional exhaustive study which included all civilians and military personnel who served in the Persian Gulf from August 1990 to July 1991. The population list was established from several sources:
- a census conducted within the different military units between 2000 and 2001, provided by the army staff headquarters (nominative list of troops active at that time),
- the list of all decorated subjects for Persian Gulf War Operations, provided by the History Department of the Army (list created in 1991),
- a census of participating organizations for civilians.
In order to complete the nominative list, we also consulted operational records of regiments and their archives. The launch of the study was published in the newspapers. Finally, several subjects willing to participate to the study spontaneously contacted us and were added to the list, once we verified their participation in the Gulf War.
Current addresses were missing for many people. In order to retrieve missing addresses, the senior staffs of each army and the retirement pensions departments were contacted. Nominative lists were compared with telephone directories and all individuals were contacted by telephone in order to verify the eligibility criteria.
An explanatory letter stating the objectives of our study, of the study's objective, a consent form, a standardized postal questionnaire, a free-of-charge response envelope, and the list of the medical centres participating in the study were sent to all participants for whom a presumptive address was available.
The procedure for sending the questionnaire to every person eligible to participate was established independently from the army staff headquarters. It would have been possible to make the questionnaire available at military bases, but the nominal control and sending out of reminders would not have been possible, given the size of the military population and possible transfers between units.
People who did not answer the first letter or whose letter did not return stamped ‘return to sender’ within a 6-month period, received a reminder (an informative letter, a reply coupon listing reasons for not returning the questionnaire or refusal, and a prepaid envelope).
The National Commission of Data Processing and Civil Liberty approved this study, in agreement with article 15 paragraph 3 of the Law of January 6, 1978, concerning data processing, files, and civil liberty.
Questionnaire
Participants completed a 12-page postal self-administered questionnaire. The choice of a self-administered questionnaire was made due to the size of the population and their geographic distribution. Moreover, it gave participants a wider scope for answers than a controlled interview and they could take their time to answer the questions.
The questionnaire was developed on the basis of information already published in the authorities' reports (Working Group, Information Mission), and with reference to questionnaires used in PGWV morbidity studies. The questionnaire was reviewed by the Working Group's experts. Since the document needed to be as comprehensible as possible, it was pre-tested on five subjects of the target population and some questions were rephrased. It explored the following fields:
- socio-demographic characteristics (gender, date of birth, military, professional and civil status);
- military history (army, date of joining army, foreign operations before and after the Gulf War);
- living conditions during Persian Gulf mission, dates of departure and return, places of operation, and exposure (sandstorms, smokes from oil well fires, chemical or bacteriological alerts, vaccinations, medication);
- health: diseases and symptoms appearing before, during and after the war. A list of 49 symptoms appearing after the mission was rated according to the Hopkins Symptom Checklist.52 The frequencies of the symptoms were coded in five levels (never, less than once a month, one to three times a month, less than once a day, daily), except to six of them which were coded yes or no. Perceived stress was assessed with the four items of the Cohen and Williamson scale.53 The ICD-10-CM was used to code the self-reported disease;
- children's health (miscarriages, number of ill children and diagnosis before and after the mission).
The questionnaire included 118 closed questions and 20 open questions concerning foreign operations and the illnesses present in participants or in their children before, during, or after the conflict. Furthermore, the inclusion of open questions obviously made data collection and analysis more difficult, but provided more substantial data (locations and exposures during the foreign operations, living conditions during the Gulf War mission...). Also, participants were allowed to provide further information if they wished to do so.
Medical examination
A free standardized clinical evaluation was performed by the 27 clinics of occupational disease in University Hospital centres and nine clinics of internal medicine in Military Hospitals. The participant of the study contacted one of the centres for an examination. When necessary, a consultation was conducted in French overseas departments and territories. These records were based on standardized clinical and para-clinical tests. Complementary tests were carried on when subjects presented specific signs.
A consultation report was regularly sent by all centres to the INSERM Unit 593 (laboratory exams results, exposures during the mission, medical diseases, and present health status), as well as data obtained by the Mini International Neuropsychiatric Interview.54 The following syndromes were specified: fibromyalgia,55 chronic fatigue syndrome,56 post-traumatic stress disorders,54 multiple chemical sensitivity,57 and macrophagic myofasciitis.58
On reception, the questionnaires and medical findings were made anonymous, coded, keyboarded and then analysed.
Statistical analyses
Statistical analyses were performed using SAS (SAS/STAT computers programs Cary, NC, SAS Institute, 2000) statistical software. The frequency distributions of the demographics and military service informations were examined. The response rates were very different among the branches of service. For this reason, living conditions and exposures during the mission were described stratified by branches of services.
In order to analyse the associations of symptom frequencies, we constructed the Pearson's correlation matrix among the 43 symptoms coded in five levels. We excluded respondents with missing values for any symptom and respondents who did not have any symptom at all. Principal components analysis was applied to the correlation matrix. Retained factors were defined by the Kaiser criterion (eigenvalues >1). Moreover, a factor was retained if it had at least two symptom frequencies that loaded >0.30 on this factor. The factor loading can be interpreted as a correlation coefficient measuring the association between the symptom frequencies and the factor.
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Results |
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The survey began in February 2002. Data collection was completed in June 2004.
According to data obtained from the Ministry of Defense, a total of 20 261 French troops were deployed in the Gulf from August 1990 through July 1991. A current address was available for only 52% (10 478 subjects) and, among these, 5666 (54%) participated to our study (Figure 1). They belonged to different branches of service: 2695 served in the Army, 770 in the Navy, 1895 in the Air Force and 306 in other branches of service. The participation rate was 28% (5666/20 261) and varied according to the branch of service: 21% in the Army, 34% in the Air Force, and 41% in the Navy. Moreover, it was very difficult to contact people who had retired from the army between 1991 and 2002. The refusal rate was relatively low (5% of people contacted by June 2004), mainly because participants were only briefly present in the theatre or because they perceived themselves in good health. Only 1008 participants (18%) underwent a clinical examination.
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Most of the 5666 subjects who completed the questionnaire were male (99.5%), with an average age of 41 years (standard deviation: 6 years) at the time of the completion of the survey, and 71% of respondents were still in service (73% in the Army, 87% in the Navy, 63% in the Air Force).
The average duration of deployment among respondents was 118 days, mainly in Saudi Arabia (76%) and in Iraq (33%). During their mission, subjects reported exposure mostly to sandstorms (74%) and chemical or bacteriological alerts (63%) (Table 1). The frequencies of self-reported exposures were very different among branches of service, for example 91% of military serving in the Army were exposed to sandstorms whereas only 25.5% of military serving in the Navy were exposed.
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While deployed in the Gulf, subjects suffered from the following symptoms and diseases, mainly diarrhoea (36%), headaches (28%), and difficulty to sleep (27%). Only 154 subjects were medically evacuated due to trauma or gastro-intestinal infection.
Concerning self-reported medical diagnoses occurring after their mission (Table 2), 13.4% reported respiratory pathologies, 12.8% ophthalmic diseases, and 12.1% osteo-articular problems. Sixty-four cases of malignant disease were reported. Psychological problems, mainly anxiety or depression, were noted by 7% of responders. Nonetheless, 86% of respondents considered themselves in good health.
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The most frequent symptoms described since the return from the Gulf were headaches (82.9% of participants), neurological or psychological symptoms, and back pain (Table 3). The highest frequencies were reported in the Army and the lowest in the Navy.
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A principal component analysis was performed for those subjects (n = 5509) who reported at least a symptom for several consecutive months. Seven factor axes were retained because their eigenvalue was >1 (Kaiser criterion) and, at least for two symptoms, the factor loading was >0.30. These seven factors represented 49.2% of the explained variance (Table 4). Results from this analysis showed associations between six clusters of symptoms:
- Factors 1 and 2 showed two associations:
- the association of neurocognitive symptoms (including difficulty to find words, memory difficulty, difficulty with speech, and confusion);
- orthogonally, the association of respiratory symptoms (wheezing, persistent cough, and sore throat).
- the association of neurocognitive symptoms (including difficulty to find words, memory difficulty, difficulty with speech, and confusion);
- Factors 1 and 3 showed two associations:
- the association of psychological symptoms (depression and panic or anxiety attacks);
- orthogonally, the association of musculo-skeletal symptoms (muscle pain, joint pain, joint stiffness, and joint swelling).
- the association of psychological symptoms (depression and panic or anxiety attacks);
- For Factors 1 and 4, there was an association between auditive disorders and tinnitus;
- For Factors 1 and 7, there was an association between rapid heart rate and shortness of breath.
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The other symptoms had loaded only with the first factor, which constitutes a ‘general’ factor of symptoms without any specific interpretation. Apart from these nosologic associations, no other cluster, involving disparate organ symptoms, was highlighted by our analysis.
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Discussion |
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To our knowledge, this study is the first study on French Gulf War Veterans, who experienced different risks during their mission. Its aim was, mainly, to describe self-reported symptom data among Gulf War Veterans and the association of symptoms. The data obtained by a self-administrated questionnaire and the clinical examination were very important to investigate the potential health impact of the Gulf War and to compare it with that reported by US and UK veterans.
Twelve years after the Gulf War, we were able to contact 52% of French PGWV, and 54% of them accepted to participate in this study. The frequencies of symptoms presented were slightly higher than those already published. Headaches after the mission have been described in 13–75% of veterans15,16,19,22,24–26,29,32,36 as opposed to 83% in our study. Back pain has been reported by 28–44% of veterans16,19,24,36 as opposed to 63% in our sample. Sleeping disorders have been reported by 6–56% of veterans,14,15,19,21–26,29,36 as opposed to 71% in our survey. Conversely, memory disorders, irritability, and fatigue were found with the frequencies similar to those reported in other studies.15,19–26,31,36 Even if French troops did not face the same exposures as US or UK troops, a ‘new’ symptoms cluster, involving disparate organ symptoms, was not highlighted by our analysis. In our study, the associations of symptoms were quite similar to those derived among other PGWV and appropriate non-deployed control veterans.39–50
If the only aim of the survey had been to investigate the existence of a specific Gulf War syndrome, then only a randomized sample could have been recruited as opposed to the entire population. However, this was not the case since the French Government wanted to offer the opportunity to all French PGWV to benefit from a free medical examination. Taking into account these elements as well as the fact that the study began 10 years after the mission, the epidemiological responses that can be drawn from this study are certainly limited and are only an appraisal of respondents' health.
The study limitations mainly concern selection and information bias. The study aimed to be exhaustive, and thus include all military and civil personnel who participated in the Persian Gulf War between 1990 and 1991. The nominal lists of people concerned were transmitted by the military services. A first selection bias could have been due to the fact that lists could have been incomplete, although it is not plausible that a subject could have been at the operations theatre without the military services being aware of his presence. Also, some subjects could not be contacted. A second selection bias could be due to a massive media coverage of complaints lodged due to health consequences of the Gulf War in foreign countries, so respondents, with health disorders or at least worried about them, were more willing to participate in our study. However this bias is compensated by the fact that is 71% respondents were still in service, reported as the ‘healthy-soldier effect’ in other studies.3,59
An information bias is inherent to observational studies measuring exposure which precede the study for 10 years and therefore health events which occurred after exposures. However, it is probable that symptoms or serious diseases, requiring specific care or of unusual frequency or intensity, were notified more often than events considered as slight or benign, or needing simple self-medication. Conversely, exposures may probably be more affected by information bias, particularly risks encountered during the Gulf War mission or during previous operations dating back more than 10 years. Finally, individuals with a general tendency towards negative perceptions of life may over-report exposures and symptoms, leading to a spurious association between exposure and symptoms.60,61 One solution to avoid this would be to consider collective and not individual exposure according to a location or an activity performed there (aerial offensive, forward push).
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Conclusion |
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Until 2000, France did not receive any specific complaints and no study on French PGWV was undertaken. This first French survey on PGWV started in February 2002. Fourteen years after the end of the Gulf War (in 1990–91), it is very difficult to describe deployment circumstances, living conditions, and exposures and to link them to illnesses. Further studies, based on data collected, are in progress and results will be published in the near future.
KEY MESSAGES
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Acknowledgments |
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The French Study on Persian Gulf War and its Health Consequences was funded by the French Ministry of Defense. We gratefully acknowledge the contribution of Véronique Bigorie, Brigitte Manoux, Evelyne Mouillet, Eric Pin, Valérie Mazou, Sylvain Maurisset and Maria Winnock. Lastly, but most importantly, we sincerely thank the Gulf War Veterans for their participation.
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References |
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