By Stephen Spotswood
WASHINGTON – Servicemembers returning from Iraq and Afghanistan are exhibiting symptoms consistent with chronic multisymptom illness (CMI), formerly known as Gulf War Syndrome, according to a recent report from the Institute of Medicine (IoM).
The report – the ninth volume in an ongoing investigation IoM has conducted into CMI at the bequest of VA – delves into possible causes of the illness and how VA and other health agencies should approach treatment of veterans. It also notes that this disease does not seem to be limited to 1991 Gulf War veterans.
“Preliminary data suggest that CMI is occurring in veterans of the Iraq and Afghanistan wars as well,” the report stated.
If indeed CMI is not relegated to those who served in the 1991 Gulf War, this makes the need to identify patients with the illness and to find treatment modalities much more immediate for the VA, which has struggled to understand the disease for over two decades.
No Single Cause
CMI is defined by the presence of chronic symptoms in more than one of six categories: fatigue, mood and cognition, musculoskeletal, gastrointestinal, respiratory, and neurologic. As many as 250,000 of the 700,000 veterans who served in the Gulf War have shown symptoms of CMI.
Because of the wide range of possible symptoms and the nearly incalculable ways they can be blended, two patients with CMI rarely present with an identical disease. This has made it difficult to nail down the causes and characteristics of the illness.
Most research into the causes of CMI has focused on military-specific toxicants to which veterans might have been exposed during service. Those include combustion products, pesticides, solvents, biological exposures such as infectious agents and vaccines and low-levels of chemical weapon agents such as sarin, as well as physical exposures such as depleted uranium.
Previous IoM reports have not found enough evidence to provide a strong causal relationship between CMI and any single agent.
“Despite many years of research, there is no consensus among physicians, researchers, and others as to the cause of CMI in 1991 Gulf War veterans, and there is a growing belief that a causal factor or agent may not be identified,” a 2010 IoM report stated. The current report did not contradict that.
Studies conducted in the last few years, however, seem to be narrowing the causal factors.
A Baylor University study released in 2011 found that CMI rates were significantly higher in those veterans serving in areas of Iraq and Kuwait that saw ground combat, compared with veterans who remained on board ship during the war. These veterans would have been exposed to a wider variety of environmental toxicants.
That study also found higher rates of CMI among those who used pyridostigmine bromide pills – issued by the military as a protective measure in the event of nerve gas attack – and among those who wore pesticide-treated uniforms or used skin pesticides.
Evidence from a study conducted at the University of Texas Southwestern Medical Center, Dallas, suggests CMI stems from damage to the body’s autonomic nervous system.
Prior studies in rodents have shown that exposure to low-level sarin nerve agent can cause this kind of long-term damage. Studies have suggested that U.S. bombings of Iraqi munitions factories released a plume of sarin gas that could have affected troops.
Similar concerns have been raised about environmental toxicants impacting Iraq and Afghanistan veterans, most notably the smoke from burn pits – open-air waste disposal pits at military sites, which have been linked to bronchitis and chronic obstructive pulmonary disorder (COPD). Legislation recently was passed requiring VA to establish a burn-pit registry that would help pinpoint veterans that could have been exposed to burn-pit smoke.
Other environmental hazards have been seen in both the Gulf War and the more recent wars in Iraq and Afghanistan. Those include sand, dust, particulates, exposure to chemicals used by the military, chemical fires, regionally-specific infectious diseases and depleted uranium.
Identifying Therapies, Patients
According to the IoM report, no single therapy can help all CMI patients. Because the disease presents so differently from patient to patient, VA’s efforts would best be spent crafting individual therapies.
“Based on the voluminous evidence we reviewed, our committee cannot recommend using one universal therapy to manage the health of veterans with chronic multisymptom illness, and we reject a ‘one size fits all’ treatment approach,” said IoM committee Chair Bernard Rosof, MD, board of directors chair at Huntington, NY, Hospital. “Instead, we endorse individualized health-care management plans as the best approach for treating this very real, highly diverse condition.”
Some of the techniques that VA has developed in recent years to treat Iraq and Afghanistan veterans might be useful in this effort, the report noted. Specifically, VA’s use of post-deployment patient-aligned care teams (PD-PACTs) – a strategy that emerged from VA’s treatment of polytrauma victims – could be utilized to improve CMI care.
The committee also recommended that VA create a position of “CMI champion” at each VA medical center. Champions would be knowledgeable about available therapeutic options and have easy access to a team of consulting clinicians. That person would provide physicians with the best information and advice on how to treat patients with CMI.
The IoM committee also suggested VA should be doing more to identify patients with CMI symptoms by having the VA’s electronic health record system prompt providers to ask patients about pertinent symptoms. Veterans also should undergo a comprehensive health examination immediately after they leave active duty, the report recommended, and the results of those exams should be made available to a patient’s physicians inside and outside of VA to ensure continuity of care.
In a move to keep the benefits door open for Gulf War veterans that have yet to be diagnosed, VA has extended the claims filing period for presumptive service-connection for Gulf War veterans suffering from CMI. The claims period, which had been set to expire at the end of 2012, has been extended to Dec. 31, 2016.