TAB P -- DoD and VA Medical Surveillance Programs for Gulf War Veterans

In 1993, the Office of the Army Surgeon General reviewed the medical records of soldiers hospitalized for wounds from friendly fire incidents in the Gulf War and provided the Baltimore Veterans Affairs Medical Health Care System-Baltimore Division (VAMHCS-BT) with a list of 68 individuals. The VA contacted 48 of these individuals and invited them to participate. Of these, 33 agreed to participate.[618]

Since 1993, the VAMHCS-BT DU Follow-up Program has followed these 33 individuals, who were manning US Army vehicles at the time they were struck by DU munitions. The objectives of this follow-up program were to provide ongoing clinical surveillance of Gulf War veterans with known or suspected embedded DU fragments, DU contaminated wounds or significant amounts of inhaled DU; to detect health effects, if any, from DU exposure; and to provide recommendations for treatment to participating veterans and physicians caring for them. The VA and the DoD were concerned that embedded DU fragments could dissolve over time, potentially leading to toxic effects in the kidneys and other organs.[619]

The 33 individuals evaluated at VAMHCS-BT in 1993 and 1994 underwent a comprehensive medical and psychological evaluation. They also underwent a full-body x-ray survey, looking for retained metallic fragments. During the 1993/1994 examination, the veterans provided 24-hour urine samples. In 1995, VAMHCS-BT collected spot urine samples and a second set of samples over a 24-hour period from 20 of these 33 veterans.[620]

Many of the 33 individuals participating in the Baltimore program had persistent impairments directly related to their wounds, which included severe burns, amputations, fractures, and concussions.[621] Fifteen veterans had multiple tiny DU fragments scattered in their muscles and soft tissues. These fragments cannot be surgically removed without causing extensive damage to the surrounding tissues. X-rays and computed tomographic scans showed no evidence of granuloma formation[622] around the fragments.[623] Localized concentrations of uranium can deliver alpha radiation to the cells immediately surrounding the fragment. Despite this, VAMHCS-BT did not observe any significant localized effects from the DU fragments.[624]

In 1993-1994, VAMHCS-BT found that the uranium levels in the urine of the 33 participants ranged from 0.003 to 22.48 micrograms uranium per gram of creatinine (a metabolic waste used to measure renal function). In the 15 veterans with retained fragments, the mean uranium level was about 150 times higher than the mean uranium level of the 18 veterans with no fragments (4.47 vs. 0.03 micrograms of uranium per gram of creatinine).[625] The 18 veterans without DU fragments may have had short-term inhalation exposure to DU during the first minutes after impact and may also have sustained wound contamination with DU oxides. Nonetheless, the mean urine level in the veterans without fragments was similar to the mean levels of unexposed populations in previous studies.[626] Urine uranium levels measured in 1995 were very similar to those measured in 1993-1994, indicating that; "…mobilization of DU from shrapnel is occurring on a slow but ongoing steady basis."[627] Spot urine uranium measurements were also similar to the samples taken over a 24-hour period, indicating that spot urine samples can be reliably used to monitor DU excretion in the VAMHCS-BT participants.[628]

Doctors found that all measures of kidney function were within normal limits (including retinol-binding protein and �2-microglobulin which are specific tests for the type of proximal tubular damage caused by uranium), and that there were no correlations between the levels of urinary uranium, DU fragment status, and renal function.[629] Although the study suggested that continued medical surveillance was necessary, it also concluded that, "These data show no evidence of adverse clinical outcomes associated with uranium exposure at this time in these individuals."[630]

In 1997, 29 of the 33 DU-exposed servicemen returned to VAMHCS-BT for a comprehensive three-day follow-up evaluation, including a medical and occupational history, a detailed physical examination, clinical laboratory tests of blood and urine, a uranium exposure assessment, a psychiatric assessment, neurocognitive evaluations, genotoxicity studies, and whole-body radiation counting.[631] In addition to the 29, VAMHCS-BT also evaluated 38 Gulf War veterans who were not exposed to DU.[632]

Overall, the 1997 follow-up tests showed that the majority of DU-exposed veterans without fragments continued to have normal levels of urinary uranium. For those individuals with retained DU fragments, urinary uranium levels remained high and there were subtle elevations of prolactin levels and abnormalities on computerized neurocognitive testing.[633]

About 90 percent of the DU-exposed group and 71 percent of the non-exposed group reported one or more active medical problems. (Seventy-six percent of the DU-exposed group sustained injuries, compared to 14 percent of the non-exposed group.)[634]

In the DU-exposed group, urine concentrations ranged from 0.01 to 30.74 micrograms of uranium per gram of creatinine. In the non-exposed group, the range was 0.006 to 0.047. The range in the non-exposed group generally agreed with concentrations in previous studies of unexposed populations.[635]

In the DU-exposed group, there was a high correlation between the 24-hour urine uranium levels in 1994 and 1997, indicating "…a persistent, steady-state excretion of uranium and suggests that excretion is not significantly lowering the level of uranium (e.g. the total amount of uranium in the body) in those with retained metal fragments."[636]

The VA doctors found no abnormalities in kidney function. They found no statistical relationships between urine uranium levels and several kidney function tests, including two specific tests for proximal tubular damage -- the type of kidney damage caused by high exposures to uranium in laboratory animals.[637]

In addition to using urine uranium concentration to measure dose, VAMHCS-BT also used gamma-ray spectrometry to measure the radioactivity in the body. [638] In nine veterans, the spectroscopy indicated the presence of uranium above the analytical method limit of detection.[639] These spectroscopy findings correlated well with the urine tests -- all nine veterans who had been singled out by the spectroscopy had also been defined by the urine tests as being in the high uranium exposure group (i.e., having a urine level of more than 0.10 microgram of uranium per gram of creatinine). Of the two methods, the urine tests are more sensitive relative to kidney risk, since spectroscopy doesn't detect uranium in some individuals who have elevated urinary levels.[640] The estimated annual effective whole body radiation dose produced by the uranium released by the embedded DU fragments for the nine individuals is below the estimated background exposure to the general population (0.360 rem) and only one individual is receiving a higher radiation dose than the Nuclear Regulatory Commission's annual exposure guideline for the general population (0.1 rem per year).[641] The general public exposure guideline of 0.1 rem is in addition to the 0.360 rem background exposure that individuals receive during their daily lives.

The DU-exposed group has undergone neurocognitive testing two times, in 1994 and 1997. In 1994, the group of 33 individuals performed normally on standard "pen-and-pencil" tests evaluating attention, memory, and problem solving. On computerized tests, however, VAMHCS-BT found a statistical relationship between elevated urine uranium and poorer performance on the tests.[642]

When VAMHCS-BT re-assessed 29 of the 33 DU-exposed veterans in 1997, it compared the performance of DU exposed veterans to the non-exposed veterans. The results of the 1997 study were similar to the 1994 study -- there was no worsening of performance over time and no worsening of the results of the exposed group. Again, there was the same statistical relationship between elevated urinary uranium and poorer performance on computerized neurocognitive tests, but in the words of the VAMHCS-BT's study director, "The principal caveat of the assessment was that the number of individuals with elevated uranium values was small and it appeared that a few veterans with complex histories may have contributed appreciably to the observed variance."[643] The standard, validated neurocognitive tests indicated no such relationship.[644]

VAMHCS-BT also evaluated semen characteristics, including volume, sperm count, concentration, morphology, and motility, and found that elevated urine uranium had no apparent effect on these semen characteristics.[645] In addition, uranium concentrations in the semen were determined for 22 veterans (17 DU-exposed veterans and 5 non-exposed veterans). VAMHCS-BT found uranium concentrations greater than the analytical limit of detection (1.1ng/ejaculate) in 5 of the 17 DU-exposed veterans and in none of 5 non-exposed veterans.[646] This finding is consistent with previous studies of heavy metal (e.g., lead) concentrations in the semen of other populations.[647] Since the VAMHCS-BT's analysis of uranium in Gulf War veterans' semen is the first analysis with this focus to be published, the clinical significance of the VAMHCS-BT's finding is uncertain, because the concentration that might be found in the general population is unknown. In addition, there was also a relationship between urine uranium levels and prolactin levels. However, most of the prolactin levels were within normal limits. The VA also noted that at least 20 children had been born to this group with no birth abnormalities.[648]

To assess the possibility that DU causes reproductive damage, the VAMHCS-BT cultured white blood cells to determine the frequencies of chromosomal aberrations and sister chromatid exchanges (SCE), but found no statistical differences between the low and high uranium exposure groups -- i.e., both the low and high exposure groups demonstrated frequencies of chromosomal aberrations and SCE similar to the frequencies reported in previously published studies of control populations.[649] Although the VAMHCS-BT acknowledges that further study is required to fully assess the reproductive health effects of DU exposure, it notes that there have been "no known birth defects in the approximately 20 pregnancies fathered by the DU-exposed group since their return (1991-present) from the Gulf."[650]

VAMHCS-BT diagnosed no cases of cancer in the 33 DU-exposed veterans, but since the latency period for the onset of cancers from environmental exposure is at least fifteen to twenty years, none would be expected at this point.

In 1999, VAMHCS-BT invited the original 33 DU-exposed veterans to participate again in the same thorough evaluation. Twenty-one of the 33 agreed to participate during the period of March to July 1999. Also, as part of the expanded DU Medical Follow-up Program initiated by DoD and the VA in 1998, 30 new friendly-fire victims were added to the Baltimore program in 1999. Six of the 30 new individuals had suffered significant traumatic injuries. Each of the new individuals underwent full-body x-ray screening, reproductive tests, and neurocognitive tests.[651]

Initial x-ray examinations have indicated that 4 of the 30 new veterans have embedded DU fragments. These four are the only new veterans who have elevated urinary uranium levels (i.e., more than 0.05 microgram of uranium per gram of creatinine). The evaluation of the data collected in 1999 is ongoing.[652]

The Department of Veterans Affairs initiated another follow-up program in 1992 to evaluate the exposures of the 144th Service and Supply Company, the Army National Guard unit from New Jersey that operated the damaged equipment yard at King Khalid Military City. Approximately 27 members of this unit were exposed to DU for several weeks before being informed that some of the equipment in the yard had DU contamination. VAMHCS-BT evaluated 12 volunteers from the 144th in 1992. Eight of the 12 underwent urine testing and whole-body radiation counting, and the four others underwent only the whole-body radiation counting. Although these individuals were potentially exposed to DU dust on and off over several weeks, the tests showed no residual body-burdens of DU above background levels.[653] In 1993, thirteen members of the 144th also provided urine samples to the US Army Center for Health Promotion and Preventive Medicine (USACHPPM). Both USACHPPM and the Environmental Measurements Laboratory of New York, New York analyzed these samples. These tests were consistent with the Boston VA tests -- uranium levels were within normal background levels.[654,655]

In July, 1998, the Department of Defense (DoD) and the Department of Veterans Affairs (DVA) expanded the DU medical follow-up program to evaluate veterans who received the largest DU exposures during the Gulf War and to ensure that Gulf War veterans with higher-than-normal levels of uranium in their bodies are identified and given appropriate medical monitoring. In addition to the examination Gulf War veterans receive through the Comprehensive Clinical Evaluation Program (CCEP) or the Department of Veterans Affairs (VA) Gulf War Registry, this program requires participants to submit a 24-hour urine sample to establish a urinary uranium level and a detailed DU-exposure questionnaire. The notification and medical evaluation aspects of the program are described below. This program was also opened to any Gulf War veteran with a concern about possible DU exposure.

A.  Identification and Notification of Gulf War Veterans with Potential DU Exposure

Initially, this office's investigators concentrated on locating the soldiers in Level I. We have identified all of the 104 survivors who were in or on top of vehicles at the time they were penetrated by DU munitions. In addition to the 33 evaluated and monitored at VAMHCS-BT beginning in 1993, we have notified 66 soldiers for this new follow-up program. Two of the 104 survivors have subsequently died, one in a motorcycle accident and one from suicide.[656] We are still trying to contact the last three of the original 104. Additionally, we are continuing to identify soldiers who entered burning DU-contaminated US vehicles to perform rescue operations immediately after impact. To date, we have identified 45 soldiers in this category and notified 36. We are continuing to attempt to locate the remaining soldiers that we have identified, but thus far have been unable to contact them.

Interviewers contacted the identified individuals by telephone to inform the veterans about the availability of the DoD and VA DU medical screening programs and to encourage them to enroll in the VA Registry or DoD's Comprehensive Clinical Evaluation Program (CCEP) program. Interviewers also gathered important information necessary for estimating exposure doses.

After the initial emphasis on locating the individuals in Level I, the Office of the Special Assistant expanded its efforts to contact individuals from Level II, whose duties required them to make numerous trips into equipment contaminated with DU. This group included members of the Battle Damage Assessment Team, Logistics Assistance Representatives, members of the 144th Service and Supply Company, unit maintenance personnel who performed maintenance on or in DU-contaminated vehicles, EOD and unit personnel who unloaded equipment and munitions from DU-contaminated equipment, and Radiation Control team members. The number of individuals identified and notified in each category as of November 22, 1999 is summarized below in Table P-1. The "total population" is the estimated number of veterans who may have been exposed while performing the indicated mission. Those "identified" are members of the population who we have identified by social security number and who, through first- or second-hand information, we believe to have been exposed to DU.

Table P-1. Level II notification status

Job Categories

Total Population Identified


Maintenance and Equipment Recovery




144th Service & Supply
























* 27 members of the 144th were initially identified as having worked in the Storage Yard. However, additional veterans, including one from the 556th Corps Supply Company, have been added to the total as they have been identified.

The total number of veterans notified of the expanded DU Follow-Up Program is 219 (66 friendly fire victims, 36 rescuers, and 117 Level II veterans). Because eight veterans have declined to participate, the number of names actually referred for follow-up is 211. Veterans who were not targeted as Level I and II candidates, but are concerned about their possible DU exposures, will still be able to obtain a DU medical evaluation from a DoD or VA physician at the appropriate facility closest to them. Thus far, almost 400 veterans have taken advantage of this opportunity, bringing the total to over 600.[657]

B.  DoD and VA Medical Evaluation Program for Gulf War Veterans with Potential DU Exposures

The DU medical evaluation program consists of three elements:

The registry exam includes:

The additional DU exposure questionnaire includes:

After collecting the 24-hour urine sample in a special container, the participants send these specimens to the Baltimore VA Medical Center, where they are analyzed by a single laboratory monitoring uranium. VAMHCS-BT mails the results and their interpretation to the individual veteran, with a copy to the examining physician. Recommendations for follow-up depend on whether the urinary uranium level is normal or elevated.

The more than 117,000 examinations performed in the CCEP and VA Gulf War Registry have diagnosed many recognized medical problems (e.g. hypertension, asthma, arthritis, or diabetes mellitus). Therefore, it is not uncommon that some of the veterans enrolling in the DU medical evaluation program would have health problems unrelated to DU exposure. Veterans who have chronic health problems receive follow-up primary care at the appropriate military medical treatment facility or VA medical center.

C.  Emerging Results of DoD and VA Medical Evaluation Program for Gulf War Veterans with Potential DU Exposure

As of September 30, 2000, DoD and VA identified a total of 662 individuals for the DU Follow-up Program -- 606 since the program started in August 1998 and 56 before it started. The program has mailed out 550 urine specimen collection kits and received back 322 specimens, which have been submitted for analysis. To date, 11 individuals have initially tested above the screening guideline of 50 nanograms of uranium per gram of creatinine (ng/g creatinine) since August 1, 1998. Seven individuals have submitted follow-up samples and three of the follow-up samples were also elevated on the follow-up. Four individuals have either not resubmitted samples for analysis or their results are pending.[658]

A total of 126 individuals in Levels I and II have either been brought to Baltimore for an evaluation or been mailed a kit for the 24-hour urine sample.[659] To date, all the individuals in Levels I and II known to have an elevated urine uranium level are participating in the Baltimore program.

A total of 47 DU-exposed individuals completed CCEP evaluations between 1994 and 1999, including 21 in Level I and 26 in Level II. Out of the 47 individuals, the CCEP has the urinary uranium test results for 15. One veteran -- wounded in a friendly fire incident and participating in the Baltimore program -- had slightly elevated levels. The other 14 tests were within normal limits (less than 50 nanograms uranium/gram creatinine).

| First Page | Prev Page | Next Page |