8. Reported Gulf War and other exposures
One of the aims of our study is to investigate the relationship between excess risks of any physical and psychological health outcomes and Gulf War related exposures and experiences. To do this we need to investigate not only those exposures and experiences related to the Gulf War but also other exposures and experiences in military and civilian life which may influence health outcomes.
This chapter presents the exposures and experiences self-reported by male Gulf War veterans in relation to the Gulf War deployment, and by male participants in both study groups in relation to other active deployments, other military postings and any civilian occupations.
Also presented, are our methods of using the exposures and experiences data reported by Gulf War veterans to develop metrics of exposure. These metrics will be used to identify subgroups of Gulf War veterans in subsequent chapters to investigate associations between exposure types and health outcomes.
8.1 Aims
The primary aim of this analysis is to describe those service and exposure characteristics of male Gulf War veterans which may be related to health outcomes. Specifically the analysis aims to describe some service characteristics such as service type and operation, and the nature and extent of self reported preventive medical interventions, psychological stressors and chemical and environmental exposures reported by male Gulf War veterans in relation to their Gulf War deployment. The selection of these exposures and experiences has been guided by the literature review of Gulf War exposures in chapter 3.
A secondary aim is to use Gulf War related exposure information to identify exposure categories in Gulf War veterans, and to identify subgroups of Gulf War veterans according to exposure type and level, for use in other analyses.
A final aim is to describe the exposures of Gulf War veterans and the comparison group in relation to other active deployments, military postings and any civilian occupations to assess important differences in the nature of the Gulf War deployment.
8.2 Research questions
1. What chemical and environmental exposures, psychological stressors, immunisations and preventive medications do Australian Gulf War veterans report experiencing in relation to the Gulf War?
2. Is the reporting of chemical and environmental exposures or psychological stressors related to age, rank or service type?
3. Do Australian Gulf War veterans differ from the comparison group with respect to their number of active deployments other than the Gulf War?
4. Are Australian Gulf War veterans and comparison group subjects similar in relation to their chemical and environmental exposures and psychological stressors experienced outside of the Gulf War?
8.3 Results
8.3.1 Service characteristics of the Gulf War deployment
Table 8.1 presents numbers of male Gulf War veterans according to several service characteristics of the Gulf War deployment. Most of the data were drawn from self-reported information except for deployment dates, which were drawn from the DVA Nominal Roll for the Gulf War conflict and were used to determine which Gulf War veterans completed their deployment(s) before or after the commencement of the air war on 17th January 1991 and subsequent ground war.
About one quarter of veterans had completed their deployment before the air war started. There were almost four times as many veterans deployed to frigates or destroyers compared to the numbers deployed to supply ships. About half of the Army veterans were on Operation Habitat.
|
Metric
|
n | (%) |
|---|---|---|
|
Service Type
|
||
| Navy |
1232
|
(86.5)
|
| Army |
87
|
(6.1)
|
| Air Force |
105
|
(7.4)
|
| Total |
1424
|
(100)
|
|
Type of Ship
|
||
| Supply ship |
236
|
(20.3)
|
| Frigate or destroyer |
929
|
(79.7)
|
| Total |
1165
|
(100)
|
|
Army
|
||
| Operation Habitat |
43
|
(50.6)
|
| Other Army, not Operation Habitat |
42
|
(49.4)
|
| Total* |
85
|
(100)
|
|
Gulf War deployment completed before
air war started (Jan 17th 1991) |
||
| Yes |
331
|
(23.3)
|
| No |
1092
|
(76.7)
|
| Total |
1423
|
(100)
|
*Two Army veterans did not indicate whether or not they were on Operation Habitat
Further ship and service groupings are shown in Table 8.2 along with some specific primary duties reported by Gulf War veterans in those subgroups.
Some Army personnel deployed with ships and are included in the ships’ numbers. The Task Group Medical Support Elements deployed to United States Naval Ship (USNS) Comfort were made up of mainly Navy personnel but included Army and Air Force personnel. Operation Habitat was mainly Army. Most veterans identified the name and type of ship that they were on, but did not indicate whether they were involved in any of the other specific duties listed on the postal questionnaire. Relatively few veterans identified combat or combat support as their primary duty, but most of those who did were deployed with Damask II. Most veterans who were primarily engaged in medical and environmental health duties were deployed to USNS Comfort or were on Operation Habitat. Almost all of the Air Force veterans stated that they were aircrew on transport duties, some of whom evacuated civilians. Most of the veterans classified as ‘Other Navy’ or ‘Other Army’ were on logistic support staff duties or a range of other activities but were not attached to ships. There were no veterans who reported being on submarines.
Veterans can be divided into groups on the basis of the service type, individual ship, and type of ship or date of completion of their deployment. These groups will predict exposure to some extent, but there will have been considerable intra-group variation for individual exposures and experiences. The exposures experienced by veterans on ships, for example, will differ for those who spent their time primarily above, or primarily below decks. Army veterans on Operation Habitat will have experienced different exposures to those Army veterans deployed on a ship or those carrying out support staff duties.
Table 8.2 Gulf War veterans sub-grouped by Operation, by ship in which they deployed, other service characteristics and by self reported primary duties during Gulf War
go to table 8.28.3.2 Other active deployments
Participation in active deployments, other than the Gulf War, were self-reported by participants in the postal questionnaire. Active deployments were defined as war or peacekeeping deployments and these specifically excluded training exercises or ‘goodwill’ visits. To facilitate accurate reporting of active deployments, participants were provided with a list of 26 active ADF deployments in recent history from which to choose. Participants could nominate additional active deployments which were not included on the list. These were checked by the study team and deployments in peaceful regions such as New Zealand, Canada and USA were excluded.
Table 8.3 presents those Gulf War veterans and comparison group subjects who reported involvement in one or more active deployment other than the Gulf War deployment. These represented 44% of the Gulf War veterans and 33% of the comparison group. Gulf War veterans (16.5%) were more likely than the comparison group (12.4%) to have been deployed on more than one other deployment.
|
Number of other active
deployments |
Gulf War veterans (n) |
Gulf War veterans (%) |
Comparison group (n) |
Comparison group (%) |
|---|---|---|---|---|
| Ever on active deployment |
625
|
(43.9)
|
514
|
(33.2)
|
| On 1 active deployment |
390
|
(27.4)
|
321
|
(20.7)
|
| On 2 active deployments |
133
|
(9.3)
|
118
|
(7.6)
|
| On 3 active deployments |
69
|
(4.8)
|
44
|
(2.8)
|
| On 4 or more active deployments |
33
|
(2.3)
|
31
|
(2.0)
|
Table 8.4 identifies the active deployments in which Gulf War veterans and comparison group subjects reported having been involved in. These are ordered in decreasing frequency, as reported by Gulf War veterans. The most common deployments reported were those to the Gulf region but outside the time period used to define the Gulf War for the purposes of our study. The next most common deployments were to East Timor, to the Solomon Islands and to Bougainville (New Guinea). The most common deployments nominated in the category presented as ‘Other’, were to the Gulf of Oman and North West Indian Ocean in the early 1980s and to the Red Sea between 1991 and 1993. Gulf War veterans were more likely than the comparison group to have deployed to the Gulf region outside the time of the Gulf War. In relation to other active deployments, the two groups were similar.
| Active Deployments: | Gulf War veterans (n) |
Gulf War veterans (%) |
Comparison group (n) |
Comparison group (%) |
|---|---|---|---|---|
| Gulf (not between 2/8/90 & 4/9/91) |
146
|
(10.3)
|
85
|
(5.5)
|
| East Timor 1999 --> |
141
|
(9.9)
|
135
|
(8.7)
|
| Solomon Islands |
64
|
(4.5)
|
52
|
(3.4)
|
| Bougainville 1997 --> |
63
|
(4.4)
|
54
|
(3.5)
|
| Vietnam |
50
|
(3.5)
|
53
|
(3.4)
|
| Malaysia |
41
|
(2.9)
|
73
|
(4.7)
|
| Egypt |
37
|
(2.6)
|
13
|
(0.8)
|
| Somalia 1994 |
36
|
(2.5)
|
41
|
(2.6)
|
| Southern Ocean |
30
|
(2.1)
|
16
|
(1.0)
|
| Cambodia 1993 -1999 |
25
|
(1.8)
|
16
|
(1.0)
|
| Sinai 1982-1986 & Sinai 1993 --> |
25
|
(1.8)
|
22
|
(1.4)
|
| Kuwait 1998 --> |
19
|
(1.3)
|
13
|
(0.8)
|
| Papua New Guinea 1997-1998 |
19
|
(1.3)
|
19
|
(1.2)
|
| Middle East 1956 --> |
12
|
(0.8)
|
13
|
(0.8)
|
| Thailand |
12
|
(0.8)
|
12
|
(0.8)
|
| Gulf of Oman 1999 |
11
|
(0.8)
|
1
|
(0.1)
|
| Rwanda |
9
|
(0.6)
|
6
|
(0.4)
|
| Namibia 1989-1990 |
6
|
(0.4)
|
3
|
(0.2)
|
| Korea 1953 --> |
4
|
(0.3)
|
1
|
(0.1)
|
| Afghanistan |
2
|
(0.1)
|
3
|
(0.2)
|
| Balkans |
2
|
(0.1)
|
4
|
(0.3)
|
| Operation Relex |
2
|
(0.1)
|
4
|
(0.3)
|
| Former Rep of Yugoslavia 1997 --> |
1
|
(0.1)
|
2
|
(0.1)
|
| Western Sahara |
1
|
(0.1)
|
5
|
(0.3)
|
| Angola |
0
|
(0.0)
|
1
|
(0.1)
|
| Mozambique 1994 --> |
0
|
(0.0)
|
2
|
(0.1)
|
| Other* |
217
|
(15.2)
|
136
|
(8.8)
|
* Reported deployments to regions such as New Zealand, North America or northern European countries (except Northern Ireland) were excluded.
8.3.3 Immunisations and preventive medications reported for the Gulf War deployment
Immunisations (referred to as vaccinations in the postal questionnaire) and preventive medications were reported in the postal questionnaire by Gulf War veterans in relation to their Gulf War deployment. Gulf War veterans estimated the numbers of immunisations received, the time period over which they received those immunisations (eg all in one session, across 1 week, across 2-4 weeks or over a period longer than 4 weeks) and whether those immunisations were received before deployment to the Gulf and/or in transit to the Gulf and/or while in the Gulf.
In relation to preventive medications, Gulf War veterans reported any use of anti-nerve agent pills including pyridostigmine bromide (NAPS), antimalarial tablets or anti-biological warfare tablets including ciprofloxacin or ciproxin.
Table 8.5 shows the estimated numbers of immunisations received by Gulf War veterans as part of their Gulf War deployment. Eight percent of veterans reported receiving no immunisations and 24% reported that they did not know how many immunisations they had received. The median estimated number of immunisations was six with the range being from 0 to 21 immunisations.
Veterans who had their WHO vaccination books reported higher numbers of immunisations than subjects who did not have their vaccination books. They were also less likely to report that they had not received any immunisations.
| Total number of immunisations received | ||||||||
|---|---|---|---|---|---|---|---|---|
| Don’t know | No immunisations |
1-5 immunisations |
>5 immunisations |
|||||
| n | (%) | n | (%) | n | (%) | n | (%) | |
|
All Subjects (N=1418)
|
342 | (24.1) | 119 | (8.4) | 398 | (28.1) | 559 | (39.4) |
| Subjects with WHO vaccination books (n=726) | 75 | (10.3) | 35 | (4.8) | 252 | (34.7) | 364 | (50.1) |
| Subjects without WHO vaccination books (n=692) | 267 | (38.6) | 84 | (12.1) | 146 | (21.1) | 195 | (28.2) |
Veterans who reported receiving clusters of immunisations, defined as more than five immunisations within a period of one week or less, are shown in Table 8.6. These were sub-divided into those veterans reporting clusters of immunisations received before deployment to the Gulf, and those reporting clusters of immunisations received in transit to the Gulf or while they were in the Gulf.
| Gulf War veterans reporting clustered immunisations | ||
|---|---|---|
| n | (%) | |
| Total (N=1113) | 151 | (13.6) |
| Before deploying to the Gulf | 113 | (10.2) |
| In transit to/while in the Gulf | 35 | (3.2) |
Almost 14% of Gulf War veterans reported receiving immunisations in clusters. Three quarters of these veterans reported receiving these clusters of immunisations before deployment to the Gulf, whilst one quarter reported receiving them in transit to or when they were in the Gulf.
From a provided list of types of immunisations, Gulf War veterans reported which ones they believed they had received as part of the Gulf War deployment. The results are shown in Table 8.7. For almost all listed immunisations, more than 30% of the veterans did not know whether they had received them or not. More than 60% of veterans believed they had received immunisations for typhoid, cholera, and hepatitis B. Almost 50% believed that they had been immunised against plague but a further 38% were unsure. 15% reported immunisation against anthrax but 58% were unsure.
The receipt of anthrax immunisation was analysed by ship. Between 3.6% and 7.9% of veterans who deployed to USNS Comfort, and on Damask I and III reported receiving anthrax immunisation. However, a higher percentage of veterans who deployed with Damask II reported receiving anthrax immunisation, 14.2 to 28.1%. The highest percentage (28.1%) reporting receipt of anthrax immunisation was for veterans on HMAS Brisbane.
| Immunisations received | |||
|---|---|---|---|
| Type of immunisation |
Yes
n (%) |
No
n (%) |
Don’t know
n (%) |
| Hepatitis B | 903 (66.0) | 87 (6.4) | 379 (27.7) |
| Typhoid | 861 (63.3) | 85 (6.3) | 414 (30.4) |
| Cholera | 849 (62.4) | 68 (5.0) | 444 (32.6) |
| Plague | 641 (48.1) | 185 (13.9) | 507 (38.0) |
| Diphtheria, Tetanus (ADT) | 465 (36.0) | 266 (20.6) | 560 (43.4) |
| Polio (oral Sabin) | 407 (31.5) | 304 (23.5) | 581 (45.0) |
| Hepatitis A (Havrix) | 312 (24.7) | 309 (24.4) | 643 (50.9) |
| Anthrax | 192 (15.3) | 331 (26.3) | 736 (58.5) |
| Tuberculosis (BCG) | 189 (15.2) | 393 (31.6) | 660 (53.1) |
| Smallpox | 130 (10.5) | 401 (32.2) | 713 (57.3) |
| Measles, Mumps, Rubella (MMR) | 89 (7.2) | 430 (34.8) | 716 (58.0) |
| Pertussis | 60 (4.9) | 415 (33.8) | 752 (61.3) |
| Any other | 155 (13.5) | 236 (20.6) | 753 (65.8) |
More than half of the veterans who answered the questions about preventive medications believe they took NAPS, less than half believe they took antimalarials and almost 6% believe they took anti-biological warfare tablets (Table 8.8). Not all veterans who reported taking the NAPS or anti-biological warfare tablets provided sufficient information regarding quantity or duration to allow the total numbers to be calculated. Of the 456 subjects who did provide information about the quantity of NAPS taken, one third had taken more than 180 pills over the course of their deployment. If the tablets were taken at the recommended dose of one tablet three times per day, 180 pills equate to taking the tablets for a total duration of 2 months. A surprisingly high number of veterans, 38% were unsure of whether they had taken antimalarials. More than half did not know whether they had taken anti-biological warfare tablets.
Approximately 13% of veterans (n=179) reported having a ‘significant’ reaction to an immunisation or medication (data not shown).
|
Preventive medications (N=1418)
|
||
|---|---|---|
|
n
|
(%)
|
|
|
Anti-nerve agent pills (NAPS)
|
||
| No | 371 | (26.2) |
| Don’t know | 318 | (22.4) |
| Yes | 728 | (51.4) |
| 1-80 pills taken | 152 | (33.3)* |
| 81-180 pills taken | 156 | (34.2)* |
| > 180 pills taken | 148 | (32.5)* |
|
Anti-biological warfare tablets
|
||
| No | 540 | (38.2) |
| Don’t know | 793 | (56.1) |
| Yes | 81 | (5.7) |
| 1-21 days | 15 | (25.4)† |
| 22-80 days | 24 | (40.7)† |
| >80 days | 20 | (33.9)† |
|
Antimalarials
|
||
| No | 283 | (20.0) |
| Don’t know | 544 | (38.2) |
| Yes | 586 | (41.5) |
* Percentage of the 456 subjects who provided this information
† Percentage of the 59 subjects who provided this information
8.3.4 Self-reported psychological stressors during Gulf War service and during non-Gulf War service
Psychological stressors experienced by Gulf War veterans during the Gulf War deployment, and by all study participants during military service activities in general were assessed with the Military Service Experience (MSE) section of the postal questionnaire. The MSE questionnaire comprised 44 items, each representing a potentially stressful activity or experience, possibly relevant to ADF military service experience. The questions covered such themes as actual or threatened physical threat, exposure to, or responsibility for the death or suffering of others, feelings of helplessness and lack of control, poor preparation, malevolent environment, lack of support and lack of unit cohesion.
A complete description of the development and design of the MSE questionnaire is provided at section 5.6.1.2.4 [chapter 5].
The frequency of positive (‘Yes’) responses to individual items on the MSE questionnaire are shown in Table 8.9 for Gulf War veterans in relation to Gulf War service, and for Gulf War veterans and comparison group subjects in relation to military service outside of the Gulf War (non-Gulf War service). The 44 items are shown in decreasing order of frequency for Gulf War veterans in relation to Gulf War service; ie the most frequently reported Gulf War experiences are shown at the top of Table 8.9. A graphical presentation of the data in Table 8.9 is shown in Figure 8.1.
Table 8.9 Military Service Experience questionnaire items reported by Gulf War veterans in relation to the Gulf War deployment, and by Gulf War veterans and the comparison group in relation to non-Gulf War military service
Go to table 8.9Figure 8.1 Frequency of MSE questionnaire items reported by Gulf War veterans in relation to the Gulf War deployment, and by Gulf War veterans (GWV) and the comparison group (CG) in relation to non-Gulf War military service
8.3.4.1 Psychological stressors during Gulf War service
The MSE item reported most frequently for Gulf War service was being on board a ship or aircraft passing through hostile waters or airspace (Table 8.9). Four out of the next five MSE items reported most frequently for Gulf War service involved personal fear or threat; they were fear of artillery attack, threat of chemical or biological attack, fear of death or injury below the waterline on a ship, and fear for one’s life. Other frequently reported items included feelings of separation from family and significant others, responsibility for detecting incoming attack, close encounters with undetonated mines, other exploding rockets or mines, a near miss incident with imminent danger of death or injury and inadequate or faulty equipment.
Some military service experiences were much more likely to be reported in relation to Gulf War service than in relation to any non-Gulf War service. Figure 8.1 shows that seven out of the eight MSE items most frequently reported by Gulf War veterans during Gulf War service, were quite unique to this ADF deployment and infrequently reported by either group in relation to non-Gulf war service. Gulf War veterans, during Gulf War service, were eight times more likely to report being on formal alert for or under threat from nuclear, chemical or biological agent attack, than Gulf War veterans or comparison group subjects in relation to non-Gulf War service. MSE items reported more than four times more commonly during Gulf War service include experiences in relation to exposure to nuclear, chemical or biological warfare, being in fear of artillery, missile, SCUD or bomb attack, encountering undetonated mines, sea-mines or booby traps, carrying out duties wearing full protective clothing (NBC suits) and fearing death, injury or entrapment below the waterline on a ship. Common MSE items reported more than twice as often during Gulf War service were experiences in relation to responsibility for detecting incoming attacks or for spotting mines where a mistake could place the lives of others at risk, fear for one’s life and being on a ship or aircraft passing through hostile waters or airspace.
In contrast, many of the remaining MSE items were much less likely to be reported during Gulf War service, when compared with those reported during non-Gulf service by both the Gulf War veterans and the comparison group. Items reported less than half as often include ship collisions or damage, leadership decisions resulting in death or injury, handling of human bodies, attack by civilians, bandits or local militia, sexual harassment, witnessing of violent attacks on civilians, sitting with or caring for someone dying, living in squalid, unsanitary or disease ridden conditions and sustainment of an injury requiring medical treatment.
The MSE questionnaire was scored by summing the number of ‘Yes’ responses for each person. Subjects received a score ranging from 0 to 44. Table 8.10 shows that Gulf War veterans, in relation to the Gulf War, answered ‘Yes’ to more MSE items than they or the comparison group did in relation to non-Gulf War service.
| Military Service Experience questionnaire | ||||||
|---|---|---|---|---|---|---|
| Gulf War service | Non-Gulf War service | |||||
| Gulf War veterans (N=1420) |
Gulf War veterans (N=1389) |
Comparison group (N=1547) |
||||
|
Median
|
Range
|
Median
|
Range
|
Median
|
Range
|
|
| Median MSE item score | 8 | 0-33 | 5 | 0-33 | 6 | 0-35 |
| Categories of MSE item score | n | (%) | n | (%) | n | (%) |
| 0 - 4 | 320 | (23) | 600 | (43) | 585 | (38) |
| 5 – 8 | 415 | (29) | 352 | (25) | 414 | (27) |
| 9 – 12 | 316 | (22) | 242 | (17) | 273 | (18) |
| >12 | 369 | (26) | 195 | (14) | 275 | (18) |
For Gulf War service, median MSE questionnaire scores are shown for Gulf War veterans across age categories, service type and rank categories in Table 8.11. MSE questionnaire items were reported most frequently by the younger age groups, by the Army and by the lowest ranked group.
| Gulf War service MSE questionnaire score | ||
|---|---|---|
| Gulf War veterans | ||
| Median | (Range) | |
|
Age
|
||
| < 20 |
10
|
(0-25)
|
| 20-24 |
8
|
(0-28)
|
| 25-34 |
8
|
(0-33)
|
| >= 35 |
7
|
(0-30)
|
|
Service Type
|
||
| Navy |
8
|
(0-33)
|
| Army |
11
|
(1-30)
|
| Air Force |
4
|
(0-29)
|
|
Rank
|
||
| Officer |
8
|
(0-27)
|
| Other rank-supervisory |
8
|
(0-30)
|
| Other rank-non supervisory |
9
|
(0-33)
|
8.3.4.2 Psychological stressors during non-Gulf War service
In relation to military service outside of the Gulf War (non-Gulf War service), Gulf War veterans and comparison group subjects had similar rates of many of the experiences itemised in the MSE questionnaire (see Table 8.9 and Figure 8.1). Some non-Gulf War service experiences, however, were reported noticeably more often by comparison group subjects, in relation to lack of leadership, faulty or inadequate equipment, a ‘near miss’ with imminent danger of being injured or killed, and an injury requiring medical treatment. Gulf War veterans were somewhat more likely to report being on a ship or aircraft passing through hostile waters or airspace, during non-Gulf War service, relative to the comparison group.
8.3.5 Self reported chemical and environmental exposures during the Gulf War and other active deployments
In relation to the Gulf War deployment and other active deployments, study participants responded to a 28 item chemical and environmental exposure questionnaire. A broad range of exposures were covered, including depleted uranium, CARC paint, contaminated food or water, dust storms, intense smoke, fuels, solvents, sunscreens, exhaust emissions, insects, pesticides, insect repellents and chemical warfare agents. Questions about the use of respirators and wearing of NBC suits were also included.
The results are shown in Table 8.12 and Figure 8.2. The table and figure are ordered in decreasing frequency for items reported by Gulf War veterans in relation to their Gulf War deployment.
| Gulf War deployment | Non-Gulf War deployments | |||||
|---|---|---|---|---|---|---|
| Gulf War veterans (N=1424)* | Gulf War veterans (N=625)* | Comparison group (N=514)* | ||||
|
Exposures
|
n | (%)* | n | (%)* | n | (%)* |
| Sunscreen when outdoors |
1170
|
(82.7)
|
534
|
(87.7)
|
429
|
(84.0)
|
| Solvents, oils, diesel or other fuel on the skin |
1116
|
(78.9)
|
494
|
(81.0)
|
390
|
(76.3)
|
| Exposed to solvents |
1111
|
(78.6)
|
469
|
(77.0)
|
343
|
(67.1)
|
| Refuelling |
1107
|
(78.4)
|
473
|
(77.7)
|
342
|
(66.9)
|
| Ate locally sourced, non-military issue food |
1101
|
(78.2)
|
485
|
(79.5)
|
323
|
(63.5)
|
| Bitten by flies, sand flies, fleas, mosquitoes etc |
956
|
(67.7)
|
502
|
(82.4)
|
412
|
(80.6)
|
| Engine exhaust irritated the eyes |
847
|
(60.2)
|
415
|
(68.0)
|
309
|
(60.7)
|
| Locally sourced, military issue food |
803
|
(57.4)
|
397
|
(65.0)
|
256
|
(50.5)
|
| Use of respiratory protective equipment (RPE) |
783
|
(55.7)
|
174
|
(29.1)
|
72
|
(14.3)
|
| Swum or bathed in local lakes, rivers or the sea |
752
|
(53.4)
|
424
|
(69.4)
|
341
|
(66.7)
|
| Exposed to dust storms |
666
|
(47.5)
|
228
|
(37.6)
|
152
|
(30.0)
|
| Used a chemical protective suit (NBC suit) |
646
|
(45.9)
|
121
|
(20.4)
|
39
|
(7.7)
|
| Exposed to intense smoke |
585
|
(41.8)
|
172
|
(28.3)
|
122
|
(24.1)
|
| Drank water from local taps or wells |
569
|
(40.5)
|
271
|
(44.4)
|
218
|
(42.7)
|
| Used a personal insect repellent |
363
|
(25.7)
|
221
|
(36.1)
|
253
|
(49.8)
|
| Entered, or inspected, captured or destroyed enemy equipment including tanks |
320
|
(23.2)
|
95
|
(15.7)
|
69
|
(13.5)
|
| Lived/worked in an area where pesticide sprayed/fogged |
276
|
(19.6)
|
201
|
(33.1)
|
212
|
(41.5)
|
| Contact with depleted uranium shell casings |
269
|
(19.3)
|
86
|
(14.2)
|
27
|
(5.3)
|
| Showered in water with fuel in it |
209
|
(14.9)
|
108
|
(17.7)
|
94
|
(18.4)
|
| Drank water with oil in it |
174
|
(12.4)
|
83
|
(13.6)
|
81
|
(15.9)
|
| Applied pesticides |
161
|
(11.4)
|
110
|
(17.8)
|
107
|
(20.9)
|
| In an area where chemical warfare agents had probably been used |
152
|
(10.8)
|
34
|
(5.6)
|
27
|
(5.3)
|
| Stung or bitten by spiders, scorpions or other bugs |
122
|
(8.7)
|
97
|
(15.9)
|
98
|
(19.2)
|
| Clothing or uniforms treated with pesticides |
68
|
(4.8)
|
76
|
(12.6)
|
96
|
(18.8)
|
| Tent treated with pesticides |
41
|
(2.9)
|
45
|
(7.5)
|
64
|
(12.6)
|
| Sleeping bag treated with pesticides |
24
|
(1.7)
|
26
|
(4.3)
|
43
|
(8.4)
|
| Contact with wet CARC paint |
18
|
(1.3)
|
6
|
(1.0)
|
11
|
(2.2)
|
| Wore a flea collar |
6
|
(0.4)
|
1
|
(0.2)
|
1
|
(0.2)
|
* The value of N from which each percentage is derived, varies depending on the numbers of participants who answered each item
Figure 8.2 Frequency of chemical and environmental exposure questionnaire items reported by Gulf War veterans (GWV) in relation to the Gulf War deployment, and by Gulf War veterans and the comparison group (CG) in relation to non-Gulf War active deployments
8.3.5.1 Self-reported chemical and environmental exposures during the Gulf War
Many items, representing several different types of exposures, were reported by large proportions of Gulf War veterans in relation to the Gulf War deployment (Figure 8.2). More than 70% of Gulf War veterans, for example, reported exposure to sunscreens, solvents, fuels and locally sourced foods. More than 60% of veterans reported exposure to insects and engine exhausts.
Some specific items were notably more common in the Gulf War deployment than in non-Gulf War active deployments. Figure 8.2 identifies exposures that veterans reported experiencing more or less frequently during the Gulf War deployment compared to other deployments. Exposure to dust storms, intense smoke, entering or inspecting destroyed enemy equipment and contact with depleted uranium shell casings were more commonly reported as experiences during the Gulf War deployment than during other deployments.
Being in an area where chemical warfare agents had probably been used, and the related use of personal protective equipment, were reported by less than 11% of Gulf War veterans but were reported twice as commonly during the Gulf War deployment as during non-Gulf War active deployments. Being in an area where chemical warfare agents had probably been used was, however, reported by half of Operation Habitat personnel. Only 1.5% of veterans reported being near Khamisiyah when it was demolished, which could have involved exposure to low levels of chemical warfare agents. The most common reason identified by 43% of the veterans for believing that they had been in an area where chemical warfare agents had been used, was because the veterans had been “told so”. Only three veterans reported feeling ill at the time. Reasons for use of respiratory protective equipment (RPE) and chemical protective clothing were most commonly reported as “for training” (39% and 52% respectively) or because “alarms went off” (35% and 32% respectively).
Using responses to the items on the chemical and environmental questionnaire (Table 8.12), Gulf War veterans were given a chemical and environmental exposure score (C&E score). This was calculated for each veteran by summing the ‘yes’ responses to the 28 items. Subjects received a C&E score of between 0 and 28. The mean C&E scores are shown in Table 8.13 for the total Gulf War veteran population, for subgroups of service type, rank and age and for veterans whose deployment ended before or after the commencement of the air war on 17th January 1991.
Gulf War veterans reported exposure to an average of 10.2 chemical and environmental exposure questionnaire items. Mean C&E score were highest for Army veterans and lowest for Air Force veterans. However, mean C&E score varied little across subgroups of rank and age and did not differ according to whether subjects completed their deployment before or after commencement of the air war.
| C&E score | ||
|---|---|---|
| Mean | (SD) | |
|
Total Gulf War veterans
|
10.2
|
(4.2)
|
|
Service type
|
||
| Navy |
10.4
|
(3.9)
|
| Army |
12.0
|
(5.0)
|
| Air Force |
6.5
|
(4.6)
|
|
Rank
|
||
| Officers |
9.4
|
(4.5)
|
| Other ranks-supervisory |
10.4
|
(4.3)
|
| Other ranks-non supervisory |
10.5
|
(3.8)
|
|
Age
|
||
| <20 years |
10.5
|
(3.7)
|
| 20 - <25 years |
10.5
|
(3.8)
|
| 25 - <35 years |
10.2
|
(4.3)
|
| >=35 years |
9.5
|
(4.9)
|
|
Deployment era
|
||
| Deployment complete before 17th Jan 1991 |
9.6
|
(3.9)
|
| Deployment completed after 17th Jan 1991 |
10.5
|
(4.3)
|
8.3.5.2 Self-reported chemical and environmental exposures on other active deployments
Many exposures most commonly reported in relation to the Gulf War deployment, were also most commonly reported in relation to non-Gulf War active deployments by both study groups (Figure 8.2). When on non-Gulf War active deployments, Gulf War veterans more often reported slightly higher levels of exposures than the comparison group, although the frequencies of report were similar for most items. Gulf War veterans, in relation to non-Gulf War active deployments, reported more refuelling, eating locally sourced food, engine exhaust which irritated the eyes, use of personal protective equipment including NBC suits, contact with depleted uranium shell casings and exposure to dust storms. In non-Gulf War active deployments, Gulf War veterans were less likely than the comparison group to report exposure to personal insect repellents, living or working in pesticide sprayed or fogged areas, and having their clothing, sleeping bags or beds treated with pesticides.
Several exposures which were reported infrequently by Gulf War veterans in relation to the Gulf War deployment, were also reported infrequently in relation to non-Gulf War active deployments by both study groups (Figure 8.2).
8.3.6 Development of chemical and environmental exposure metrics related to the Gulf War deployment
Several exposure metrics were constructed from responses to the chemical and environmental exposures questionnaire, and from other questions in the postal questionnaire for use in subsequent health outcome results chapters of this report. These are yes/no exposure metrics and are shown in Table 8.14. Some metrics identify small groups of veterans, for example few veterans were exposed to pesticides during the Gulf War, whilst self-reported exposures to solvents was very common.
|
Exposure metric
|
Yes | (%) |
|---|---|---|
| Solvent exposure |
1111
|
(78.6)
|
| SMOIL any |
754
|
(53.9)
|
| SMOIL Low |
627
|
(44.8) )
|
| SMOIL High |
127
|
(9.1
|
| Dust storms |
666
|
(47.5)
|
| Pesticides |
380
|
(27.0)
|
| Insect repellent |
363
|
(25.7)
|
| Possible DU exposure |
218
|
(15.5)
|
| In area where chemical warfare agent used |
152
|
(10.8)
|
There was a single question in the questionnaire about exposure to each of the following exposures; solvents, smoke from oil well fires (SMOIL), dust storms, insect repellent and being in an area where chemical warfare agents had been used. Gulf War veterans were considered to have self-reported a particular exposure if they answered yes to that question. More than half of the Gulf War veterans reported exposure to SMOIL. These veterans can be divided into a large group who had ‘low’ exposure and a smaller group, who were classified as having had ‘high’ exposure because they reported exposure to SMOIL for more than five hours per day on ten or more days in total.
Other metrics were more complex. There were seven questions about pesticide use, and Gulf War veterans were considered to be exposed if they answered yes to any one question.
A small number of Gulf War veterans were considered to have self-reported possible depleted uranium (DU) exposure because they reported being at Camp Doha when the tank compound caught fire and were involved in the subsequent clean up operations, or they reported being in Kuwait, or in the areas of the battle zones after 17th January 1991 and they reported contact with destroyed enemy equipment or contact with DU shells. 10.8% of veterans reported having been in an area where chemical warfare agents had probably been used.
If a veteran did not know whether he had experienced a specific exposure, for the purpose of this metric, he was grouped with those who reported no exposure. For most of the exposures, veterans could be expected to recall significant exposure for example to SMOIL or to fuels. If they had been unaware of exposure to these agents, the exposure would probably have been low. There was, however, a higher proportion of veterans stating ‘don’t know’ for chemical warfare exposure than for most other exposures.
The Gulf War veterans were divided into those whose deployment was completed before 17th January, the date when the air war started, and those whose Gulf War service was not completed by this date. The proportion of each of these groups categorised as exposed using our exposure metrics are presented in Table 8.15. SMOIL exposure was reported by 63.7% of the group whose deployment was not complete by 17th January but 22.1% of veterans whose deployment was completed by this date also reported this exposure.
As expected, veterans whose deployment was not completed by 17th January were more likely to report exposure to DU and/or having been in an area where chemical weapons had been used. A similar proportion of both groups of veterans reported exposure to solvents and insect repellents. Differences in rates of pesticide use may be accounted for by differences in the groups who were deployed within the two time frames, for example Operation Habitat took place in May and June 1991. 84.9% of Operation Habitat personnel used or were exposed to pesticides compared to 25.2% of other veterans.
|
Exposure metric
|
Deployment completed before January 17th 1991 (N=331) | Deployment not completed before January 17th 1991 (N=1092) | ||
|---|---|---|---|---|
| Yes | (%) | Yes | (%) | |
| Solvent exposure |
257
|
(78.1)
|
853
|
(78.7)
|
| SMOIL any |
72
|
(22.1)
|
682
|
(63.7)
|
| Dust storms |
132
|
(40.2)
|
533
|
(49.7)
|
| Pesticides |
65
|
(20.2)
|
313
|
(29.0)
|
| Insect repellent |
80
|
(24.2)
|
282
|
(26.1)
|
| Possible DU exposure |
26
|
(7.9)
|
192
|
(17.9)
|
| In area where chemical warfare agent used |
11
|
(3.4)
|
141
|
(13.1)
|
8.3.7 Other occupational exposures during the whole military career and during civilian careers
Participants were asked to state whether they had ever been members of the Country Fire Authority. 81 (6.1%) of Gulf War veterans and 87 (6%) of the comparison group reported that they had been members of the Country Fire Authority.
For all military postings of three months or more, participants reported whether they regularly worked with or handled pesticides, solvents, fuels or engine exhaust. The results are shown in Table 8.16.
For all civilian jobs held for six months or more, participants reported whether they worked with, handled or were otherwise exposed to pesticides, solvents, fuels, engine exhaust, infectious diseases or trauma to others (such as violence, grief or death of others). These results are shown in Table 8.17.
| Military occupational exposures | ||||
|---|---|---|---|---|
| Gulf War veterans | Comparison group | |||
| n | (%) | n | (%) | |
| Pesticides |
274
|
(19.2)
|
246
|
(15.9)
|
| Fuels |
884
|
(62.1)
|
937
|
(60.5)
|
| Engine Exhaust |
852
|
(59.8)
|
919
|
(59.4)
|
| Solvents |
1053
|
(73.9)
|
1048
|
(67.7)
|
| Civilian occupational exposures | ||||
|---|---|---|---|---|
| Gulf War veterans | Comparison group | |||
| n | (%) | n | (%) | |
| Pesticides |
123
|
(8.9)
|
148
|
(9.8)
|
| Fuels |
370
|
(26.6)
|
459
|
(30.2)
|
| Engine Exhaust |
354
|
(25.5)
|
459
|
(30.1)
|
| Solvents |
417
|
(30.0)
|
508
|
(33.4)
|
| Infectious diseases |
137
|
(9.9)
|
119
|
(7.9)
|
| Trauma |
153
|
(11.0)
|
138
|
(9.2)
|
Very similar proportions of the two study groups reported exposure for each of the items. Exposures to fuels, solvents and engine exhausts were fairly high in both study groups for both their military postings and any civilian occupations. For military exposures, prevalence was consistently higher for the Gulf War veterans, but there was no consistent direction in relation to civilian exposures.
8.4 Discussion
Male Gulf War veterans report experiencing a range of chemical and environmental exposures, psychological stressors, immunisations and preventive medications in relation to the Gulf War deployment. Some of these exposures, such as to SMOIL and taking NAPS tablets are exclusive to the Gulf War deployment and highlight its unique nature. Several other exposures were experienced much more frequently during the Gulf War deployment compared to other deployments for example the use of RPE or NBC suits which are significant stressors in themselves. A number of psychological stressors such as fearing death or injury, fear of attack and of exposure to nuclear, chemical or biological warfare were much more common experiences during the Gulf War compared to the remainder of the veterans’ military careers. There were a number of chemical and environmental exposures that were frequently experienced both during the Gulf War and also frequently during other deployments. These include exposure to fuel, solvents and sunscreen.
Psychological stressors during the Gulf War were most commonly associated with fear of death or injury, threat of attack or being in a hostile environment. These were notably more common during the Gulf War deployment than during other non-Gulf War military service. Threat in relation to nuclear, biological or chemical attack or artillery or SCUD or other bomb attack, encountering of undetonated mines including sea mines and fear of entrapment below the waterline on a ship were particularly unique to the Gulf War environment and rarely reported during non-Gulf War service. Actual incidents such as killing someone, coming under direct attack, witnessing dead or maimed persons or violent attacks and handling human remains, whilst likely to be extremely stressful events for those who experienced them, were relatively rare during the Gulf War deployment for Australian veterans. These items have been reported much more commonly by overseas Gulf War ground forces.[20, 21]
The lack of actual incidents should not minimise the significance of stressors described more commonly by Australian Gulf War veterans. When considering mental disability claims the Repatriation Medical Authority (RMA) define ‘severe stressors’ as including threat of serious injury or death, threat to another person’s physical integrity and engagement with the enemy. The RMA criteria for posttraumatic stress disorder, for example, derived from DSM-IV,[308] includes exposure to a traumatic event in which the person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the integrity of self or others. The response must involve fear, helplessness or horror. Stressors involving fear and threat are common in the Australian Gulf War deployment based on self-reported responses to the MSE questionnaire. Other common stressors reported by Australian Gulf War veterans, including being overwhelmed by the level of destruction, devastation or disease and an inability to protect oneself or others from harm, may well be consistent with a response involving helplessness or horror.
The fact that some psychological stressors were relatively rare during non-Gulf War service should be considered in the light of evidence that only 44% of Gulf War veterans and one third of the comparison group had been on a warlike active deployment other than the Gulf War. Active deployments are the most likely period of a military career to result in these kinds of stressful experiences.
Ten percent of Australian veterans reported having been immunised against smallpox during the Gulf War period. This is very unlikely as it was not in use as an immunisation during the Gulf War period, although individuals may have been immunised at some time in the past. Neither smallpox, nor plague, nor anthrax immunisations were listed as recommended immunisations on the message telex sent by the Surgeon General ADF, see chapter 1. Almost 50% of Australian veterans believed that they had been immunised against plague compared to 26% of UK veterans.[21] 15% of Australian veterans reported immunisation against anthrax (another 58% were unsure) compared to 57% of UK veterans.[21] The percentage is much higher for veterans who deployed in Damask II than on other deployments. Those veterans who were deployed with US and UK forces may have received immunisations with the forces from those countries.
Australian Gulf War veterans were more likely to report having been immunised in preparation for the Gulf War compared to UK Gulf War veterans. Only 8% report receiving no immunisations but 40% of UK veterans reported receiving no immunisations.[21] A similar proportion of Australian and UK veterans received more than 6 immunisations, 27% of Australians compared to 30% of UK veterans (but only 19% of the UK Navy veterans).[28] Australian Gulf War veterans were more likely than UK veterans to have retained their record of immunisation. 32% of UK veterans had their immunisation records[21] compared to 51% of Australian veterans.
Fifty one percent of Australian veterans recalled taking NAPS. This is at the low end of the range reported in UK and US veterans of whom between 52% and 82% recalled taking PB.[16, 19, 21, 28, 33, 35, 38]
Australian Gulf War veterans reported exposure to several chemical and environmental exposures at similar rates to veterans from other countries. It might be expected that a mainly naval contingent would have had less exposure to some types of agents, eg dust storms or insect repellent, than would personnel on land. The data presented here refer to whether or not there was any exposure, however, rather than the extent of exposure.
The proportion of Australian veterans reporting exposure to SMOIL, pesticides, petroleum products or eating contaminated or local food were, in each case, within the ranges reported for Danish, UK or US veterans.[16, 19-21, 28, 32, 33, 35, 36, 38, 41, 46]
The majority of Australian Gulf War veterans, like US and UK veterans, recalled wearing chemical protective clothing or had heard chemical alarms.[20, 21] If the electronic alarm activated, ADF personnel in the vicinity should have used chemical protective clothing including RPE. Australian ships’ logs recorded chemical alarm activation, some were exercises and the remainder were found to be false alarms.[2] About 10% of veterans considered that they may have been exposed to chemical warfare agents. This is within the range reported by US veterans.[16, 20, 33, 35, 38, 351]
Higher exposures to local water, paint, solvents and skin exposure to solvents, diesel or petrochemicals were reported by Australian veterans compared to studies of overseas veterans.[20, 21, 33] This may be because many of the Navy veterans were involved in refueling from supply ships or working in ship’s engine rooms. A high proportion (40%), reported drinking water from local taps or wells compared with 2 to 31% of US personnel,[20] but this is similar to rates in other ADF deployments.
Exposure to repellents was reported by 25.6% of Australian veterans. This value is at the low end of the range reported for other countries’ veterans.[19-21, 28, 38, 94]
CARC paint was only used by one unit of US soldiers and some civilians in the USA but up to half of US veterans reported exposure to CARC.[20, 33, 46] It is unlikely that any members of the ADF were involved, although 1.3% reported contact. Veterans may recall painting or spraying vehicles and believed or suspected that this was CARC paint.
The exposure metrics developed for use in the health outcomes results chapters that follow, rely on self-reported exposure during the Gulf War. They do not take into account exposures that an individual may have had outside the Gulf. Many of these metrics are based on a single question and thus do not differentiate individuals by extent or frequency of exposure. This may result in some misclassification of individuals, grouping those with very low exposure with others who were more highly exposed. This is important because such non-differential misclassification tends to reduce any observed odds ratios.[352]
Reporting of chemical and environmental exposures was not related to age or rank but there was some relationship with service types; with Air Force veterans less likely to report exposures. Psychological stressors were reported most frequently by the younger age groups and by the Army.
Male Gulf War veterans were more likely than the comparison group to have experienced one or more active deployments other than the Gulf War. However, adding the number of deployments as we have done in our study, assumes that all deployments are similar; but it is probable that some deployments were more stressful or involved more exposures than others.
Gulf War veterans and comparison group subjects who went on other deployments are similar in relation to their chemical and environmental exposures reported from these deployments. Gulf War veterans and comparison group subjects are similar in the occupational exposures reported in association with the rest of their military and civilian histories. The two groups are similar in respect of the psychological stressors experienced outside of the Gulf War.
Self-reported exposure and experiences recalled over ten years may be unreliable. Reliability of the recall of self-reported occupational exposures improves if people are prompted with a list of exposures which we did in our study.[252] In relation to exposure reporting during the Gulf War there are no gold standards against which reports can be prepared. There is almost no available documentation of what exposures veterans experienced during their Gulf War service. However we can make some assessment of the reliability of the reported exposures by comparing the rates of reports among veterans whose deployments were or were not completed by 17th January. Over 20% of veterans whose deployment was completed by 17th January reported exposure to SMOIL. This exposure is unlikely considering that the oil wells were set on fire by the retreating Iraqis, starting probably in late January.[81] The rates of report for solvent exposure or insect repellent use are similar for those veterans whose deployments were and were not complete by 17th January (Table 8.15). We would not have expected these to differ. Few veterans whose deployments were completed before 17th January report possible DU exposure, this is consistent with the fact that the open hostilities had not commenced. Some differences in exposure reporting rates between the two groups could be accounted for by differences in weather, for example dust storms, others could be attributable to different duties carried out by the ADF before and after the ground war. Operation Habitat personnel are in the latter group and they are more likely to report being in an area where chemical weapons had been used and are more likely to have used pesticides.
If over-reporting was a major problem amongst Gulf War veterans, we would expect to find some increase in reporting of exposures over the whole range of exposures. This is generally not evident in relation to reports of exposures during non-Gulf War service. However, a number of veterans reported having plague, anthrax and smallpox immunisations. They were not listed on the ADF telex and it is unlikely that smallpox immunisation was available at this time. The similarly low rate of anthrax immunisations reported by those deployed on USNS Comfort, Damask I and Damask III and the higher rate reported by those deployed on Damask II suggest that the immunisation was more likely to have been used on Damask II. The similarity in recall of most chemical and environmental exposures between the Gulf War veterans’ and comparison group in their on deployments other than the Gulf War and the Gulf War veterans’ during the Gulf War suggests that over-reporting of these exposures is not a major factor. Gulf War veterans responded ‘Yes’ to slightly fewer stressors, in relation to non-Gulf War service, than the comparison group. This again is suggestive that Gulf War veterans as a whole do not over-report most exposures.
Many veterans will have been co-exposed to several chemical and environmental exposures, to immunisations and medications and to psychological stressors. For example some veterans reported that they used RPE and protective clothing when exposed to SMOIL, dust storms or after hearing chemical alarms. The identification of which of these co-existing exposures or experiences is associated with any specific health outcome could therefore be problematic.
In choosing which exposure metrics to apply in subsequent health outcome chapters we have applied the following general principles.
- Subanalyses by exposure within the Gulf War group were normally only carried out where there was a difference in health outcome between the Gulf War veterans and the comparison group.
- There needed to be sufficient prevalence of exposure in the Gulf War group to warrant any subanalyses.
- There needed to be a plausible biological link between the health outcome and the exposure being investigated.
- Subanalyses were also carried out where there was an a priori reason to do so, for example if other studies of Gulf War veterans had found an association between a health outcome and an exposure or experience.
8.4.1 Summary of findings
In summary and relation to the specific research questions for this chapter:
Male Gulf War veterans report experiencing a range of chemical and environmental exposures, psychological stressors, immunisations and preventive medications in relation to the Gulf War. Among the most frequently reported exposures are:
- typhoid and cholera immunisations,
- taking NAPS tablets,
- psychological stressors, such as being in hostile waters or air space, being in fear of artillery, missile, SCUD or bomb attack, experiencing the threat of nuclear, biological or chemical agent attack, being on a ship and in fear of death, injury or entrapment below the waterline,
- sunscreen, solvents, fuel, SMOIL, dust storms, and the use of RPE and NBC protective equipment.
The exposures that were first encountered by ADF personnel in relation to the Gulf War or were unique to the Gulf War are NAPS tablets, exposure to SMOIL, DU, threat of nuclear, biological or chemical agent attack and consequent use of NBC suits and RPE.
C&E exposure scores are not related to age or rank but there is some relation with service type. Psychological stressors were reported most frequently by the younger age groups and by the Army.
Male Gulf War veterans were more likely than the comparison group to have experienced one or more active deployments other than the Gulf War.
Gulf War veterans and comparison group subjects who went on other deployments are similar in relation to their chemical and environmental exposures reported from these deployments and in the occupational exposures reported in association with the rest of their military and civilian histories. The two groups are similar in respect of the psychological stressors experienced outside of the Gulf War.
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