Increased evidence of testicular cancer among veterans of the 1991 Gulf War.
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Gulf War↗
Biomedical subjects
Gregory C Gray
Publications and source records attributed to Gregory C Gray.
In-theater hospitalizations of US and allied personnel during the 1991 Gulf War.
The postwar morbidity of Gulf War veterans has been closely examined. However, data have not been available to evaluate morbidity suffered during the 1991 Gulf War. In this report, the authors examine archived records of hospitalizations in US military facilities in the Kuwaiti theater of operations or those medically evacuated to facilities in Europe. Using multivariable logistic regression modeling, the authors determined that service personnel at greatest odds for "in-theater" hospitalization were enlisted, female, White, Reservist, Army, and health care workers. No increase in odds was observed for oil well fire smoke exposure or possible exposure to the nerve agent hazard areas. Although these data may be incomplete, they represent the best-known data reflecting in-theater hospitalizations during the Gulf War of 1991 and show remarkable similarities in risk factors to those for postwar hospitalization.
Adolescent↗
Two regimens of azithromycin prophylaxis against community-acquired respiratory and skin/soft-tissue infections among military trainees.
Epidemics of community-acquired pneumonia (CAP) are a frequent cause of morbidity among Russian military trainees. We evaluated azithromycin prophylaxis against CAP. In 2001-2002, incoming military trainees were randomized to 1 of 3 trial arms by training group: azithromycin, 500 mg per week for 8 weeks (R1); azithromycin, 1500 mg once at enrollment (R2); or no therapy (R3). During the 22 weeks of training, CAP was diagnosed in 20.2% of 678 subjects in the R3 group, 8.6% of 508 subjects in the R1 group, and 10.3% of 507 subjects in the R2 group. Throat carriage cultures revealed that the proportion of Streptococcus pneumoniae isolates with resistance to macrolides correspondingly increased during the study, from 0% (all) to 40% (R1) and 22.6% (R2) by week 20. Azithromycin prophylaxis is effective against CAP in a healthy population of young men at transient high risk of disease; however, azithromycin use must be tempered with the possible concomitant risk of selection for resistant endemic pathogens.
Adult↗
After more than 10 years of Gulf War veteran medical evaluations, what have we learned?
Since the 1991 Gulf War, more than 10 years and 1 billion dollars of health evaluations and research have been invested in understanding illnesses among Gulf War veterans. We examined the extensive published healthcare utilization data in an effort to summarize what has been learned. Using multiple search techniques, data as of June 2003 from four different national Gulf War health registries and numerous hospitalization and ambulatory care reports were reviewed. Thus far, published reports have not revealed a unique Gulf War syndrome nor identified specific exposures that might explain postwar morbidity. Instead, they have demonstrated that Gulf War veterans have had an increase in multi-symptom condition, injury, and mental health diagnoses. While these diagnoses are similar to those experienced by other comparable military populations, their explanation is not fully understood. New strategies to identify risk factors for, and to reduce, such postdeployment conditions are summarized.
Ambulatory Care↗
Conception and pregnancy during the Persian Gulf War: the risk to women veterans.
PURPOSE: To enumerate Gulf-War (GW) exposed conceptions and to compare reproductive outcomes of GW-exposed pregnancies with postwar conceptions of women Gulf War veterans (GWV) and women nondeployed veterans (NDV). METHODS: Deployment data and inpatient records from 153 military hospitals identified servicewomen who were pregnant between August 1990 and May 1992 and belonged to military units that were deployed to the Gulf War. Postal surveys were used in 1997 and 1998 to elicit reproductive history; responses were validated against military hospitalization records. Reproductive outcomes of GW-exposed pregnancies were compared with postwar conceptions of women GWVs and NDVs. RESULTS: 3285 women had a pregnancy-related admission; of these, 1558 completed the questionnaire. Self-reported reproductive outcomes and dates, gestational data, and individual deployment dates identified 415 Gulf War-exposed pregnancies, 298 GWV postwar conceptions, and 427 NDV conceptions. Compared with NDV conceptions, adverse reproductive outcomes were similar among GW-exposed pregnancies. However, spontaneous abortions [NDV: 9.1%, GWV postwar: 22.8%, adjusted odds ratio (OR)=2.92, 95% confidence interval (CI): 1.9, 4.6] and ectopic pregnancies (NDV: 1.4%, GWV postwar: 10.7%, adjusted OR=7.70, 95% CI, 3.0, 20) were elevated for GWV postwar conceptions. CONCLUSION: GW-exposed conceptions and nondeployed conceptions had similar outcomes. However, GWV postwar conceptions were at increased risk for ectopic pregnancies and spontaneous abortions.
Abortion, Spontaneous↗
Streptococcus pneumoniae in Saudi Arabia: antibiotic resistance and serotypes of recent clinical isolates.
During 2000, 154 clinical Streptococcus pneumoniae isolates were collected from or through three major hospitals serving the Western, Central, and Eastern regions of the Kingdom of Saudi Arabia. Ninety-one (59.1%) of the 154 isolates were resistant to penicillin with 23 strains (14.9%) highly resistant. Resistance was more prevalent among isolates obtained from patients <10 years of age and from isolates cultured from blood and cerebral spinal fluid. Decreased sensitivity to ceftriaxone, erythromycin, trimethoprim-sulphamethoxazole, and levofloxacin was found in 14.9, 15.6, 9.7, and 1.3% of isolates, respectively. There were no significant differences in the resistance pattern between isolates obtained from patients in the three different geographical areas. Serotypes of 116 isolates revealed the most prevalent types to be (descending order) 4, 3, 19F, 9V, 6A, 19A, 14 and 23F, comprising 75% of all strains typed; 9.5% of isolates were nontypable. S. pneumoniae isolates from Saudi Arabia have become more resistant to penicillin and other antimicrobials over the past 20 years.
Adolescent↗
The postwar hospitalization experience of Gulf War veterans participating in U.S. health registries.
In response to concerns that Gulf War veterans were experiencing increased morbidity resulting from wartime exposures in the Gulf War, the Department of Veterans Affairs and the Department of Defense (DoD) initiated clinical registries to provide systematic health evaluations for self-referred Gulf War veterans. The authors used Cox's proportional hazard modeling with data from all DoD hospitals to estimate the probability of hospitalization resulting from any cause, resulting from diagnosis in a major diagnostic category, and resulting from a specific diagnosis of interest. After adjusting for other risk factors, registry participants were 1.43 times more likely to have a postwar hospitalization than registry nonparticipants (95% confidence interval, 1.40-1.46). These findings support the hypothesis that registry participants were more likely to experience postwar morbidity than veterans who chose not to enroll in the health registries.
Adult↗
Molecular analysis of adenovirus isolates from vaccinated and unvaccinated young adults.
Infections of adenovirus type 4 (Ad4) and Ad7 were discovered among previously vaccinated individuals through febrile respiratory illness surveillance at military recruit camps. Genetic analysis was performed on these isolates and a sample of adenovirus isolates from unvaccinated patients. Antigenic regions of the adenovirus hexon gene from 21 vaccinated and 31 unvaccinated patients were sequenced and compared to homologous regions of Ad4 and Ad7 vaccine strains and of other representative hexon sequences archived in GenBank. The phylogenetic distribution of sequences from vaccinated individuals closely resembled those from unvaccinated individuals. The most common Ad7 strain was the Ad7d2 hexon genotype, and the most common Ad4 strain was a genotype nearly identical to the recently discovered Z-G 95-873 Ad4 variant. Near exclusive isolation of Ad4 since 1999 indicates that the Ad4 variant is currently responsible for the vast majority of adenovirus morbidity in military recruit camps. Different ratios of nonsynonymous to synonymous nucleotide substitution rates in known antigenic regions compared to nonantigenic regions indicated positive selection for diversity in the antigenic regions and purifying selection in the nonantigenic regions.
Adenovirus Infections, Human↗
Global genetic diversity of human metapneumovirus fusion gene.
We analyzed 64 human metapneumovirus strains from eight countries. Phylogenetic analysis identified two groups (A and B, amino acid identity 93%-96%) and four subgroups. Although group A strains predominated, accounting for 69% of all strains, as many B as A strains were found in persons >3 years of age.
Adolescent↗
Upper respiratory tract infections (URI).
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Disease Outbreaks↗
Gulf War veterans and Iraqi nerve agents at Khamisiyah: postwar hospitalization data revisited.
Chemical warfare agents were demolished by US soldiers at Khamisiyah, Iraq, in March 1991. The authors investigated postwar morbidity for Gulf War veterans, contrasting those who may have been exposed to low gaseous levels of nerve agents and those unlikely to have been exposed. Cox regression modeling was performed for hospitalizations from all causes and hospitalizations from diagnoses within 15 categories during the period March 10, 1991, through December 31, 2000, for the duration of active-duty status. After adjustment for all variables in the model, only two of 37 models suggested that personnel possibly exposed to subclinical doses of nerve agents might be at increased risk for hospitalization from circulatory diseases, specifically cardiac dysrhythmias. Of the 724 hospitalizations for cardiac dysrhythmias, 203 were in the potentially exposed group, slightly higher than expected (risk ratio = 1.23, 95% confidence interval: 1.04, 1.44). The increase was small in comparison with potential observational variability, but the findings are provocative and warrant further evaluation. Veterans possibly exposed to nerve agents released by the Khamisiyah demolition were not found to be at increased risk for hospitalizations from any other chronic diseases nearly 10 years after the Gulf War.
Adolescent↗
Myopericarditis following smallpox vaccination among vaccinia-naive US military personnel.
CONTEXT: In the United States, the annual incidence of myocarditis is estimated at 1 to 10 per 100,000 population. As many as 1% to 5% of patients with acute viral infections involve the myocardium. Although many viruses have been reported to cause myopericarditis, it has been a rare or unrecognized event after vaccination with the currently used strain of vaccinia virus (New York City Board of Health). OBJECTIVE: To describe a series of probable cases of myopericarditis following smallpox vaccination among US military service members reported since the reintroduction of vaccinia vaccine. DESIGN, SETTING, PARTICIPANTS: Surveillance case definitions are presented. The cases were identified either through sentinel reporting to US military headquarters surveillance using the Defense Medical Surveillance System or reports to the Vaccine Adverse Event Reporting System using International Classification of Diseases, Ninth Revision. The cases occurred among individuals vaccinated from mid-December 2002 to March 14, 2003. MAIN OUTCOME MEASURE: Elevated serum levels of creatine kinase (MB isoenzyme), troponin I, and troponin T, usually in the presence of ST-segment elevation on electrocardiogram and wall motion abnormalities on echocardiogram. RESULTS: Among 230,734 primary vaccinees, 18 cases of probable myopericarditis after smallpox vaccination were reported (an incidence of 7.8 per 100,000 over 30 days). No cases of myopericarditis following smallpox vaccination were reported among 95,622 vaccinees who were previously vaccinated. All cases were white men aged 21 years to 33 years (mean age, 26.5 years), who presented with acute myopericarditis 7 to 19 days following vaccination. A causal relationship is supported by the close temporal clustering (7-19 days; mean, 10.5 days following vaccination), wide geographic and temporal distribution, occurrence in only primary vaccinees, and lack of evidence for alternative etiologies or other diseases associated with myopericarditis. Additional supporting evidence is the observation that the observed rate of myopericarditis among primary vaccinees is 3.6-fold (95% confidence interval, 3.33-4.11) higher than the expected rate among personnel who were not vaccinated. The background incidence of myopericarditis did not show statistical significance when stratified by age (20-34 years: 2.18 expected cases per 100,000; 95% confidence interval [CI], 1.90-2.34), race (whites: 1.82 per 100,000; 95% CI, 1.50-2.01), and sex (males: 2.28 per 100,000; 95% CI, 2.04-2.54). CONCLUSION: Among US military personnel vaccinated against smallpox, myopericarditis occurred at a rate of 1 per 12 819 primary vaccinees. Myopericarditis should be considered an expected adverse event associated with smallpox vaccination. Clinicians should consider myopericarditis in the differential diagnosis of patients presenting with chest pain 4 to 30 days following smallpox vaccination and be aware of the implications as well as the need to report this potential adverse advent.
Adult↗
Cognitive behavioral therapy and aerobic exercise for Gulf War veterans' illnesses: a randomized controlled trial.
CONTEXT: Gulf War veterans' illnesses (GWVI), multisymptom illnesses characterized by persistent pain, fatigue, and cognitive symptoms, have been reported by many Gulf War veterans. There are currently no effective therapies available to treat GWVI. OBJECTIVE: To compare the effectiveness of cognitive behavioral therapy (CBT), exercise, and the combination of both for improving physical functioning and reducing the symptoms of GWVI. DESIGN, SETTING, AND PATIENTS: Randomized controlled 2 x 2 factorial trial conducted from April 1999 to September 2001 among 1092 Gulf War veterans who reported at least 2 of 3 symptom types (fatigue, pain, and cognitive) for more than 6 months and at the time of screening. Treatment assignment was unmasked except for a masked assessor of study outcomes at each clinical site (18 Department of Veterans Affairs [VA] and 2 Department of Defense [DOD] medical centers). INTERVENTIONS: Veterans were randomly assigned to receive usual care (n = 271), consisting of any and all care received from inside or outside the VA or DOD health care systems; CBT plus usual care (n = 286); exercise plus usual care (n = 269); or CBT plus exercise plus usual care (n = 266). Exercise sessions were 60 minutes and CBT sessions were 60 to 90 minutes; both met weekly for 12 weeks. MAIN OUTCOME MEASURES: The primary end point was a 7-point or greater increase (improvement) on the Physical Component Summary scale of the Veterans Short Form 36-Item Health Survey at 12 months. Secondary outcomes were standardized measures of pain, fatigue, cognitive symptoms, distress, and mental health functioning. Participants were evaluated at baseline and at 3, 6, and 12 months. RESULTS: The percentage of veterans with improvement in physical function at 1 year was 11.5% for usual care, 11.7% for exercise alone, 18.4% for CBT plus exercise, and 18.5% for CBT alone. The adjusted odds ratios (OR) for improvement in exercise, CBT, and exercise plus CBT vs usual care were 1.07 (95% confidence interval [CI], 0.63-1.82), 1.72 (95% CI, 0.91-3.23), and 1.84 (95% CI, 0.95-3.55), respectively. The OR for the overall (marginal) effect of receiving CBT (n = 552) vs no CBT (n = 535) was 1.71 (95% CI, 1.15-2.53) and for exercise (n = 531) vs no exercise (n = 556) was 1.07 (95% CI, 0.76-1.50). For secondary outcomes, exercise alone or in combination with CBT significantly improved fatigue, distress, cognitive symptoms, and mental health functioning, while CBT alone significantly improved cognitive symptoms and mental health functioning. Neither treatment had a significant impact on pain. CONCLUSION: Our results suggest that CBT and/or exercise can provide modest relief for some of the symptoms of chronic multisymptom illnesses such as GWVI.
Adult↗
Prevalence of birth defects among infants of Gulf War veterans in Arkansas, Arizona, California, Georgia, Hawaii, and Iowa, 1989-1993.
BACKGROUND: Epidemiologic studies of birth defects among infants of Gulf War veterans (GWV) have been limited to military hospitals, anomalies diagnosed among newborns, or self-reported data. This study was conducted to measure the prevalence of birth defects among infants of GWVs and nondeployed veterans (NDV) in states that conducted active case ascertainment of birth defects between 1989-93. METHODS: Military records of 684,645 GWVs and 1,587,102 NDVs were electronically linked with 2,314,908 birth certficates from Arizona, Hawaii, Iowa, and selected counties of Arkansas, California, and Georgia; 11,961 GWV infants and 33,052 NDV infants were identified. Of these, 450 infants had mothers who served in the Gulf War, and 3966 had NDV mothers. RESULTS: Infants conceived postwar to male GWVs had significantly higher prevalence of tricuspid valve insufficicieny (relative risk [RR], 2.7; 95% confidence interval [CI], 1.1-6.6; p = 0.039) and aortic valve stenosis (RR, 6.0; 95% CI, 1.2-31.0; p = 0.026) compared to infants conceived postwar to NDV males. Among infants of male GWVs, aortic valve stenosis (RR, 163; 95% CI, 0.09-294; p = 0.011) and renal agenesis or hypoplasia (RR, 16.3; 95% CI, 0.09-294; p = 0.011) were significantly higher among infants conceived postwar than prewar. Hypospadias was significantly higher among infant sons conceived postwar to GWV women compared to NDV women (RR, 6.3; 95% CI, 1.5-26.3; p = 0.015). CONCLUSION: We observed a higher prevalence of tricuspid valve insufficiency, aortic valve stenosis, and renal agenesis or hypoplasia among infants conceived postwar to GWV men, and a higher prevalence of hypospadias among infants conceived postwar to female GWVs. We did not have the ability to determine if the excess was caused by inherited or environmental factors, or was due to chance because of myriad reasons, including multiple comparisons. Although the statistical power was sufficient to compare the combined birth defects prevalence, larger sample sizes were needed for less frequent individual component defects.
Adult↗
Varicella susceptibility and vaccine use among young adults enlisting in the United States Navy.
Primary varicella infection, or chicken pox, is a threat to all young adults who join the United States (U.S.) military if they fail to develop immunity prior to enlistment. Historically, outbreaks of chicken pox have caused marked morbidity and impaired military readiness. In December 1996, the U.S. Navy began performing serologic testing for varicella among all new recruits, and vaccinating those found to be sero-negative. We evaluated results of the screening program in its first 4 years, and used multivariable logistic regression modeling to describe factors associated with varicella susceptibility. Cases of chicken pox were tracked among all military services before and after program implementation. More than 190,000 young adults enlisted in the U.S. Navy between 1997 and 2000. Recruits originated from all 50 states and several foreign countries; 84% were male, and their average age was 19 years. Seven percent were found to be susceptible (sero-negative) to varicella. In multivariable modeling, race/ethnicity was associated with susceptibility, but age, gender, and home state were not. The overall incidence of chicken pox in the Navy was reduced by more than 80% after initiation of the screening-vaccination program. A successful varicella screening-vaccination program has been implemented in the U.S. Navy. Results of serologic screening undertaken on this large number of young adults may be useful in tracking the changing epidemiology of varicella in the general population in the post-vaccine era.
Adolescent↗
Halting a pneumococcal pneumonia outbreak among United States Marine Corps trainees.
BACKGROUND: Streptococcus pneumoniae is the leading cause of bacterial pneumonia in all age groups. Identifying outbreaks of pneumococcal disease and key risk factors may lead to improvements in vaccination and prevention strategies for high-risk groups. A significant outbreak of S. pneumoniae pneumonia that occurred among Marine recruits is reported here. METHODS: An outbreak was investigated using standard microbiologic procedures and epidemiologic evaluation to define the extent of the outbreak, determine the microbiologic causative agent(s), identify risk factors for the development of disease, and institute preventive measures against further cases of pneumonia among recruits. RESULTS: Fifty-two cases of radiographically confirmed pneumonia occurred among 3367 Marine recruits over a 2-week period in November 2000. Twenty-five of these cases occurred in a single company of 481 men, with an attack rate of 5.2%. Twelve of the 25 cases were caused by S. pneumoniae, serotypes 4 and 9v. The outbreak rapidly ended following isolation of cases, prophylaxis with oral azithromycin, and administration of the 23-valent pneumococcal vaccine. CONCLUSIONS: This outbreak of pneumococcal disease occurred in the setting of intense military training and a crowded environment. The use of the pneumococcal vaccine year-round in military trainees and other high-risk populations to reduce pneumococcal disease should be considered.
Adolescent↗
National Department of Defense surveillance data for antibiotic resistance and emm gene types of clinical group A streptococcal isolates from eight basic training military sites.
Antibiotic resistance and emm gene types were examined from 692 Group A streptococci isolates from eight United States military basic training sites between 1998 and 2001. Macrolide resistance was associated with geographic sites and emm type. These data are useful for vaccine development initiatives and antimicrobial treatment considerations.
Adolescent↗
An outbreak of pneumococcal pneumonia among military personnel at high risk: control by low-dose azithromycin postexposure chemoprophylaxis.
In the winter of 1998-1999 an outbreak of pneumococcal pneumonia occurred among Ranger students undergoing high-intensity training. Thirty pneumonia cases (attack rate = 12.6%) were identified among a group of 239 students. Eighteen students were hospitalized; Streptococcus pneumoniae-positive cultures were detected in 11 (61.1%) of these 18 hospitalized cases. Pneumococci were also identified in throat swabs of 30 (13.6%) of 221 nonhospitalized students surveyed. Serum antipneumolysin seroconversions were detected in 30 (18.3%) of 164 students tested. An association between development of serum antipneumolysin antibody and pneumococcal pharyngeal carriage/colonization was found. Of 30 seroconverters, eight (26.7%) had S. pneumoniae-positive cultures compared with only 17 (12.7%) of 134 nonseroconverters (relative risks = 2.02, 95% confidence interval = 1.02-4.02, p = 0.05). The outbreak was controlled by administrating lowdose, oral azithromycin prophylaxis (250 mg weekly for 2 weeks) and was associated with a 69% reduction in pneumococcal carriage and a 94% reduction in pneumonia rates.
Adult↗