Your comments will be appreciated. Alice Osherman

Gulf War Conference in Atlanta, 1999 Part 2 Recommendations for research
projects

Fourteen pages of recommendations that were made at the meeting have now
been received by all the participants.  I have taken the liberty to cite
here ones that were noted by an asterisk in the report as new, or as
what might be of particular interest to us.

1. Summary of the Pathophysiology/Etiology Workgroup

Environmental Exposures, which should be investigated with respect to
individual vs. Combined effects, dose response relationships, time and
duration of exposures:

Vaccines, pesticides, insect repellents, petroleum, carbon monoxide,
paint, infectious agents.

Human Studies :

Neurological, CNS, neuromuscular, aging, immunological, pulmonary,
dermal, gastrointestinal, and other organ system studies, chemical
sensitivity, and treatment-driven research strategies.

Animal Studies:

Synergistic, subclinical, low-level, chronic and multi-generational
exposures, and delayed expressions of environmental insults.

Development of Biomarkers:

Susceptibility to chemical sensitivity, biomarkers of stress, and for
chemical agent exposures.

New Methodologies:

QSAR approach to molecular interactions, imaging techniques,
alternative to animal systems
( cell and tissue culture)

Special Needs:

Centralized Gulf War research library and data repository (electronic
access), and controlled environment medical research units

2.  Summary of Assessment/Diagnosis Workgroup:

Case Definition:

*Establish a process by which case definitions can be developed for
symptom based illnesses such as Gulf War illnesses and can be compared
to existing definitions of disorders such as multiple chemical
sensitivity (MCS), fibromyalgia, and chronic fatigue syndrome (CFS)
(short term)

*Delineate the definitions of Gulf War illnesses that are implicit in
existing studies, and compare methods of diagnostic determination of
these studies. (Short term)

Chronic Multi-System Disorders:

*Compare the prevalence and overlap of several different conditions (
e.g.Gulf War illnesses, CFS, FM, somatization, sick building syndrome,
post-traumatic stress disorder, neurasthenia) in G.W. vets to prevalence
in other relevant populations.

*Use lab models to explore illnesses and symptoms experienced by G.W.
vets...looking for markers of illness.

*Investigate barriers preventing Department of Veteran Affairs (VA)
physicians from applying the diagnoses of chronic multi-system
disorders, reliability of VA application of these diagnoses, and the
potential for training physicians how to apply the diagnoses. (Long
term)

Well Defined Disorders:

Medical disorders in research protocols should be classified using
International classification of disease criteria (ICD-9)

Any research into MCS should consider the possible overlap with other
well-defined !CD-9 disorders whose signs or symptoms are already
associated with chemical exposures in published literature.

Overlap of conditions:

* Evaluate the overlap between specific chronic multi-system conditions
and other such conditions as well as well-defined conditions. (Long
term)

* Explore the existence of relationships between pre-existing disorders
( both
well -defined and chronic multi-system disorders) and the expression of
chronic multi-system disorders after Gulf war service. (Long term)

* Explore determinants of patient treatment seeking. Do they affect the
characteristics of the study populations when treatment seeking patients
are the subjects? Explore characteristics of patients seeking care at
different types of health care facilities. (Long term)

Biomarkers:
Identification of biomarkers is necessary for comparison of Gulf
War-related disorders to other disorders , identificatin of genetic
pllymorphisms for ssceptibility to disorders, and definitive diagnosis
of disorders.

*Develop biomarkers for past toxicant exposures. (Long term)

*Study existing biomarkers and perform new research on existing
biomarkers for single disorders and for combinations of chronic
multi-system disorders. (Long term)

Assessment and Diagnosis

* Assessment techniques employed in research should reflect specific
hypotheses about relationships between chemical exposures and structural
changes or functional abnormalities. (Long term)

* Development of new laboratory tests of chemical effects is
recommended. Studies should include evaluation of reliability,
repeatability, validity and specificity. (Long term)

* Combinations of assessments and diagnostic techniques aimed at
evaluation of the same organ systems should be employed in research.

* Clinically non-routine assessment probes are recommended in research
such as environmental control units, carbon dioxide challenges, blind
olfactory challenges, autonomic nervous system assessments, and response
to treatment. (Long term)

*A research project assessing longitudinal health changes across time in
a normal population is suggested.

Validation:

Identification of appropriate populations for validation of study
results on Gulf war populations should consider groups deployed
elsewhere, non-deployed personnel, and other exposed populations.

General Recommendations:

It is recommended that the DOD should continue to declassify and
disseminate all relevant classified scientific field investigations and
clinical studies to enable a better understanding of Gulf War veterans'
illnesses and their possible causes.

3. Summary of Treatment Workgroup

OVERALL CHARGE:

Develop short term (now) and longer term strategies to bring new
treatments to improve the health of all Gulf War veterans.
Develop ways to educate physicians and all other health care
professionals to understand the needs of Gulf War veterans.



OVERALL NEEDS:

Urgent need for treatment ; review process needs to be expedited and
less stringent.

If alternative causes and treatments found, all veterans should be
screened for these conditions and treated appropriately.

Pharmacologic Treatment:

Test symptom-based treatments.

Examine role of sub-clinical adrenal and thyroid abnormalities.

Consider trials of nutritional supplements/vitamins.

Treatment for Toxic Exposures and Intolerances:

Detoxification; testing for Intolerances to and avoiding inhalants,
foods, drugs

Short Term Recommendations:

Immediate implementation.

Utilize existing clinics as appropriate.

Long Term :

Environmental control unit(s) for research and treatment

NonPharmacologic (NP) treatment

Challenge: Current structure of VA-DOD care does not accommodate NP
strategies well. Response: Alter structure / organization of services.

Short term: 
Population based needs assessment:

Consider ALL vets of Gulf War; information needs, information
capabilities; health needs

Self- help literature to target vet's identified needs; empanel veterans
based on need and use primary care practice teams.

Innovative care strategies: alternative medicine and pilot
studies--randomized control trials


"MACRO" Treatment

Purpose: To establish a central body to coordinate communications,
education and outreach efforts necessary for effective conduct of
treatment trial and research programs for Gulf War-related illness. This
would facilitate communication channels between service members, vets,
coordinators, health care professionals, researchers and administrators.

4. Summary of Prevention Workgroup:

Key Prevention Messages:

Evaluate effectiveness and evidence of what has already been done. 

Assess other national and international models of prevention strategies
and outcomes.

Hierarchy of controls: 

SUBSTITUTION
ENGINEERING 
ADMINISTRATIVE
   Health Education
    Risk communications
    Surveillance
Environmental
Medical/ biomonitoring
Record keeping and registries
Exposure
Disease
   Work Practices
   Personal Protective Equipment

Substitution:

Identify less toxic substances and their interactive effects; restrict
number of pesticides, and optimize vaccine potency, formulation, dose
and duration.

Health Education:

Determine appropriate instructional strategies; Identify barriers to
understanding the importance and impact of health education messages.

Environmental Surveillance:

Develop exposure limits that take into account the multiple operating
environment; develop enhanced instrumentation for nuclear, biological,
chemical and environmental exposure. 
Medical/ biomonitoring surveillance:

Develop data gathering tool that spans the life of the service member,
that accompanies person from DoD to VA to civilian life, and that links
both the exposure and health outcome.

Validate self-reported environmental exposures (e.g., Canada)

Develop methods of surveillance for "low level" exposure.

Work practices:

Evaluate existing health hazard protocols and develop metrics to compare
work practice risks.

Explore the impact on negative health outcomes of varied work
organization structures.( Reserve forces vs. Full- time)