Service Connection for Certain Disabilities Associated With Gulf War

http://www.warrelatedillness.va.gov/paloalto/conferences/january-2009/handouts/abrams-handout.pdf

http://www.queri.research.va.gov/ptbri/abstracts.cfm?Project_ID=2141698783&UnderReview=no

Team approach to diagnosis and management of traumatic brain injury and its comorbidities

http://www.rehab.research.va.gov/jour/07/44/7/pagevii.html

Sarin and chemical weapons long term health effects

http://www.ehponline.org/members/1994/102-1/munro-full.html

January 1994 National Institute of Health Report VARO calls this internet trash attempt to get hard copy from the NIH before submitting to VA.

Gulf War Syndrome Researchers Blame Sarin Gas and Toxic Exposures
Lourdes Salvador August 26, 2009 Toomey and colleagues, researchers at the Boston Veterans Administration Healthcare System, confirmed that Gulf War deployment is associated with subtle declines of motor speed and sustained attention as influenced by exposure to toxicants during deployment.

Toomey found that exposure to sarin gas released during the Khamisiyah destruction is correlated with long-term reduced motor speed in veterans that has not resolved after 10 years. Self-reported exposure to these toxicants is also significantly associated with attention deficits.

• Ten years after the war, deployed veterans are still in poor health and perform significantly worse on cognitive tests than non-deployed veterans. Gulf War veterans complaints include:
  
  Poor cognition.
  Slowed motor function.
  Memory Loss
  Chronic Fatigue
  Skin Rash
  Hair Loss
  Headache
  Muscle pain
  Gastrointestinal Disorders
  Cardiovascular Changes
  Chemical Sensitivity

These health alterations point to potential long-term, permanent impairment from toxicant exposure.

The symptoms of Gulf War veterans are analogous to a group of multi-system illnesses increasingly
seen in the general population, notably: multiple chemical sensitivity (MCS), chronic fatigue
syndrome (CFS), and fibromyalgia (FM). These illnesses all share a common pattern of initiation and,
thus, they may share a common etiology (cause) in long-term, permanent impairment from toxic exposure.

Section D - Service Connection for certain Disabilities Associated with Gulf war (GW) Service, Updated 9/5/08

Section D. Service Connection for Certain Disabilities Associated With Gulf War (GW) Service Overview

In this Section This section contains the following topics:

 Topic Name See Page
13 General Information on Certain Disabilities Associated With GW Service 2-D-2
14 Rating Claims for Service Connection for Certain Disabilities Associated With GW Service 2-D-6
15 General Information About Rating Decisions Addressing Certain Disabilities Associated With GW Service 2-D-10
16 Granting Service Connection for Certain Disabilities Associated With GW Service 2-D-13
17 Denying Service Connection for Certain Disabilities Associated With GW Service 2-D-19

• 13. General Information on Certain Disabilities Associated With GW Service
  
  Introduction This topic contains background information on certain disabilities associated with Gulf War (GW) service,
  including the provisions of the GW Veterans’ Benefits Act
  

•  ? the GW Veterans’ Act of 1998
  ? the Veterans Education and Benefits Expansion Act of 2001, and
  ? 38 CFR 3.317
  • definition of
  ? a GW veteran, and
  ? the Southwest Asia theater of operations
  • definition of a qualifying chronic disability
  • presumptive period for manifestation of disability under 38 CFR 3.317
  • qualifying disabilities, and
  • provisions of the requirement for chronicity.
  
  Change Date September 5, 2000

a. Provisions of the GW Veterans’ Benefits Act On November 2, 1994, Congress enacted the “Persian Gulf War
Veterans’ Benefits Act,” Title I of the “Veterans’ Benefits Improvements Act of 1994,” Public Law (PL) 103-446.

The statute added a new section, 38 U.S.C. 1117, authorizing the Department of Veterans Affairs (VA) to
compensate any Gulf War (GW) veteran suffering from a chronic disability resulting from an undiagnosed illness
or combination of undiagnosed illnesses which manifested either

• during active duty in the Southwest Asia theater of operations during the GW, or
• to a degree of 10 percent or more within a presumptive period following service in the Southwest Asia theater of
operations during the GW.

b. Provisions of the GW Veterans’ Act of 1998 The “Persian Gulf War Veterans’ Act of 1998,” PL 105-277, authorized
VA to compensate GW veterans for diagnosed or undiagnosed disabilities that are determined by VA regulation to
warrant a presumption of service connection based on a positive association with exposure to one of the following
as a result of GW service:

• a toxic agent
• an environmental or wartime hazard, or
• a preventive medication or vaccine.

Note: This statute added 38 U.S.C. 1118.

c. Provisions of the Veterans Education and Benefits Expansion Act of 2001 The “Veterans Education and Benefits
Expansion Act of 2001,” PL 107-103, expanded the definition of “qualifying chronic disability” under 38 U.S.C. 1117
to include, effective March 1, 2002, not only a disability resulting from an undiagnosed illness but also

• a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs and symptoms, and
• any diagnosed illness that is determined by VA regulation to warrant presumption of service connection.

d. Provisions of 38 CFR 3.317 38 CFR 3.317, which implements 38 U.S.C. 1117, defines GW service and “qualifying
chronic disability,” and provides

• a broad, but non-exclusive, list of signs and symptoms which may be representative of undiagnosed or chronic,
multi-symptom illnesses for which compensation may be paid, and
• the presumptive period for service connection.

e. Definition: GW Veteran A GW veteran, under 38 CFR 3.317, is a veteran who served on active military,
naval, or air service in the Southwest Asia theater of operations during the GW.

Per 38 U.S.C. 101(33), the GW extends from August 2, 1990, through a date yet to be determined by law
or Presidential proclamation.

13. General Information on Certain Disabilities Associated With GW Service, Continued

f. Definition: Southwest Asia Theater of Operations The Southwest Asia theater of operations includes the
following locations and the airspace above them:

• Iraq
• Kuwait
• Saudi Arabia
• the neutral zone between Iraq and Saudi Arabia
• United Arab Emirates
• Bahrain
• Qatar
• Oman
• the Gulf of Aden
• the Gulf of Oman
• the Persian Gulf
• the Arabian Sea, and
• the Red Sea.

g. Definition: Qualifying Chronic Disability Qualifying chronic disability, under 38 CFR 3.317, means a
chronic disability resulting from any of the following or any combination of the following:

• an undiagnosed illness
• a medically unexplained chronic multi-symptom illness, such as chronic fatigue syndrome, fibromyalgia,
and irritable bowel syndrome, that is defined by a cluster of signs or symptoms, and/or
• any diagnosed illness that is determined by VA regulation to warrant a presumption of service connection.

Reference: For more information on the requirement that disabilities be chronic in nature, see M21-1MR,
Part IV, Subpart ii, 2.D.13.j.

h. Presumptive Period for Manifestation of Disability Under 38 CFR 3.317 The presumptive period for
manifestation of qualifying chronic disability under 38 CFR 3.317

• begins on the date following last performance of active military, naval, or air service in the Southwest
Asia theater of operations during the GW, and
• extends through December 31, 2011.

i. Qualifying Disabilities 38 CFR 3.317 specifies the following 13 categories of signs or symptoms
that may represent a qualifying chronic disability:

• abnormal weight loss
• cardiovascular signs or symptoms
• fatigue
• gastrointestinal signs or symptoms
• headache
• joint pain
• menstrual disorders
• muscle pain
• neurologic signs or symptoms
• neuropsychological signs or symptoms
• signs or symptoms involving the skin
• signs or symptoms involving the upper and lower respiratory system, and
• sleep disturbances.

Notes:
• The list of 13 illness categories is not exclusive.
• Signs or symptoms not represented by one of the listed categories may also qualify for consideration
under 38 CFR 3.317.
• A disability that is affirmatively shown to have resulted from a cause other than GW service may not
be compensated under 38 CFR 3.317

j. Determining Chronicity To qualify, the claimed disability must be chronic, that is, it must have persisted
for a period of six months.

Measure the six-month period of chronicity from the earliest date on which all pertinent evidence
establishes that the signs or symptoms of the disability first became manifest.

Note: If a disability is subject to intermittent episodes of improvement and worsening within a six-month
period, consider the disability to be chronic.

14. Rating Claims for Service Connection for Certain Disabilities Associated With GW Service

Introduction This topic contains information about rating claims for service connection for certain
disabilities associated with GW service, including information on

• rating a symptoms as a single or multiple issue
• information required to decide the issue of service connection for an undiagnosed illness
• the relevancy of
? medical evidence
? the veteran’s testimony, and
? lay evidence
• lay evidence consisting of non-medical indicators
• the veracity of lay evidence
• determining inclusion in the Veterans Heath Administration (VHA) Persian Gulf Health Registry, and
• considering the need for a future examination.

Change Date December 13, 2005

a. Rating Symptoms as a Single or Multiple Issue The decision to rate multiple symptoms or signs
together as a single issue or separately as multiple issues depends on the outcome most favorable
to the veteran.

Although rating multiple manifestations under a single body system will in most cases provide the
maximum benefit, be alert to symptoms affecting fundamentally different body systems that may
clearly warrant separate consideration.

Notes:
• If service connection for several symptoms or signs is denied for the same reason, consider such
symptoms and signs as a single issue.
• Assign one hyphenated diagnostic code (DC) in the coded conclusion to each issue that is separately
considered, whether service connection is awarded or denied.
Continued on next page

b. Information Required to Decide the Issue of Service Connection for an Undiagnosed Illness The following
information is required in order to determine whether service connection for an undiagnosed illness is in order:

• when the illness arose
• whether the illness was severe enough to warrant the assignment of a compensable evaluation at any
time during the presumptive period, unless manifested while in the Southwest Asia theater, and
• whether the illness chronically persisted for at least six months.

c. Relevancy of Medical Evidence When the object of service connection is identification of a diagnosed illness,
medical evidence is of paramount importance because a physician specializes in identifying disabilities through
diagnoses.

The concept of “objective indications” expressed in 38 CFR 3.317 makes clear that the evidence required for
undiagnosed illnesses, or illnesses which are outside the scope of medical understanding, is not so dependent
on formal medical evidence.

d. Relevancy of the Veteran’s Testimony When combined with an examining physician’s inability to make a diagnosis, the veteran’s testimony that he/she is experiencing the symptoms described may be sufficient to establish the existence of the illness.

e. Relevancy of Lay Evidence Lay statements from knowledgeable individuals may be accepted as evidence of
objective indications of chronic disability. Lay evidence is credible if

• its source was in a position to know the alleged facts, and
• it is not contradicted by evidence of record that is more credible.

A lay person’s statement regarding the veteran’s complaints, when they began, how long they lasted,
and the severity of the observed symptoms/illness, may be sufficient to satisfy the requirements for
objective indications of chronic disability.

14. Rating Claims for Service Connection for Certain Disabilities Associated With GW Service, Continued

f. Lay Evidence Consisting of Non-Medical Indicators Lay evidence may consist of non-medical indicators, such as

• time lost from work
• evidence that the veteran sought medical treatment for his/her symptoms, and
• relevant observations, such as changes in the veteran’s
? appearance
? physical abilities, and/or
? mental or emotional status.

g. Veracity of Lay Evidence Do not

• dismiss any evidence as self-serving, as it is reasonable to expect claimants to provide evidence they
believe best supports their claim, and/or
• attempt to corroborate the evidence unless there is affirmative reason to doubt the credibility of the evidence.

Example: If lay evidence indicates the veteran lost a certain amount of time from employment, accept that
statement without further development if the statement is otherwise credible.

h. Determining Inclusion in the VHA Persian Gulf Health Registry In all cases, ask the veteran if he/she was

• included in the Veterans Heath Administration (VHA) Persian Gulf Health Registry, and
• examined as part of the Registry, and, if so, where he/she was examined.

If he/she has been examined, secure examination results from the appropriate VA medical center (VAMC).
Continued on next page

14. Rating Claims for Service Connection for Certain Disabilities Associated With GW Service, Continued

i. Considering the Need for a Future Examination Because the course of an undiagnosed illness cannot be
predicted, monitor it by establishing the necessary controls for a future examination within 24 months of the
last examination of record.

At the expiration of the control period, review the evidence of record to determine whether reexamination
is necessary.

15. General Information About Rating Decisions Addressing Certain Disabilities Associated With GW Service

Introduction This topic contains general information about rating decisions for certain disabilities associated
with GW service, including information on

• properly stating the issue
• language for the Decision section of the rating decision
• referencing relevant dates in the rating decision
• termination or reduction of benefits, and
• results from VA-sponsored research projects.

Change Date December 13, 2005

a. Properly Stating the Issue State the issue in the rating decision as “Service connection for [specify signs or symptoms]
as due to a qualifying chronic disability.”

b. Language for the Decision Section of the Rating Decision For every disability for which service connection was
considered, state the following in the Decision section of the rating decision: “Service connection for [disability]
is denied,” or “Service connection for [disability] is awarded with an evaluation of [percent] percent effective [date].”

Note: The earliest effective date for entitlement to service connection under the provisions of 38 CFR 3.317 is
November 2, 1994.

c. Referencing the Relevant Dates in the Rating Decision In the Reasons for Decision section of the rating decision,
explicitly refer to any date that is pertinent to the decision.

This particularly includes the

• dates during which the veteran served in the Southwest Asia theater of operations, and
• earliest date that a qualifying chronic disability may have become manifest.

15. General Information About Rating Decisions Addressing Certain Disabilities Associated With GW Service,
Continued

d. Termination or Reduction of Benefits Situations may arise that will require termination or reduction of payments
previously awarded under 38 CFR 3.317.

Follow the normal procedures for reduction of benefits or severance of service connection outlined in M21-1MR,
Part I, 2.

Notes:
• Termination or reduction of benefits paid under 38 CFR 3.317 does not preclude continuation of payments if
entitlement is established under other regulations governing the establishment of service connection based on
incurrence or aggravation during service, or on a presumptive basis.
• 38 CFR 3.500 was amended by the addition of 38 CFR 3.500(y), which specifically requires that severance of
service connection or reduction of benefits under 38 CFR 3.105
(d) or 38 CFR 3.105
(e) be effective the first of
the month, 60 days after final notice of the adverse action has been issued to the veteran.

Example: A physician diagnoses a previously undiagnosed illness for which compensation was paid under
38 CFR 3.317.

e. Results From VA-Sponsored Research Projects Effective December 27, 2001, if a GW veteran participates in
a VA-sponsored medical research project, service connection established for a disability under 38 U.S.C. 1117
or 38 U.S.C. 1118 is protected, regardless of the project’s findings.

Exception: Service connection is not protected if the original award was based on fraud, or military records
clearly show that the veteran did not have the requisite service or character of discharge.

Note: A list of VA-sponsored medical research projects for which service connection is protected is published
in the Federal Register.

16. Granting Service Connection for Certain Disabilities Associated With GW Service

Introduction This topic contains information about granting service connection for certain disabilities associated
with GW service, including information on

• establishing service connection for a qualifying chronic disability that manifested during the GW
• establishing service connection for a compensable qualifying chronic disability that arose during the presumptive
period
• evaluating the level of impairment by analogy
• using hyphenated diagnostic codes (DCs)
• assigning appropriate DCs, and
• examples of analogous evaluations.

Change Date December 13, 2005

a. Establishing Service Connection for Qualifying Chronic Disability That Manifested During the GW Establish
service connection if the qualifying chronic disability, per M21-1MR, Part IV, Subpart ii, 2.D.13.i, became manifest,
whether to a compensable degree or not, while the claimant was on active service in the Southwest Asia theater
of operations during the GW.

Include the following sentence in the Reasons for Decision: “Service connection is established for [disability] as
due to an undiagnosed illness which began in the Southwest Asia theater of operations during the Gulf War.”

b. Establishing Service Connection for a Compensable Qualifying Chronic Disability That Arose During the
Presumptive Period Establish service connection if the qualifying chronic disability arose to a compensable
degree after the veteran last served in the Southwest Asia theater of operations during the GW, regardless
of the veteran’s active duty status at the time.

If service connection is established during the presumptive period, include the following statement in the
Reasons for Decision: “Service connection may be presumed for disabilities resulting from undiagnosed
illnesses or diagnosed illnesses which arose to a compensable degree after service in the Southwest Asia
theater of operations during the Gulf War. Service connection for [disability] has been awarded on the basis
of this presumption.”

c. Evaluating Level of Impairment by Analogy Evaluate the level of impairment of chronic undiagnosed
disabilities by drawing an analogy to an existing DC in the rating schedule per 38 CFR 4.27.

Precede a discussion of the evaluation criteria in the Reasons for Decision section of the rating decision
with the following statement: “Since the disability at issue does not have its own evaluation criteria assigned
in VA regulations, a closely related disease or injury was used for this purpose.”
Continued on next page

16. Granting Service Connection for Certain Disabilities Associated With GW Service, Continued

d. Using Hyphenated DCs Use hyphenated DCs for all undiagnosed conditions.

The table below describes each of the codes that comprise a complete hyphenated DC

Reference: For more information on analogous DCs, see
• M21-1MR, Part IV, Subpart ii, 2.D.16.f, and
• M21-1MR, Part IV, Subpart ii, 2.D.16.g.


Code Description Example Reference
First DC Should always be one of the DCs established for GW undiagnosed illness 8863, for diseases analogous
to systemic diseases For more information on DCs, see

• M21-1MR, Part IV, Subpart ii, 2.D.16.e, and
• M21-1MR, Part IV, Subpart ii, 2.D.16.f.

Second DC Use the DC that most closely fits the evaluating criteria 6354, for systemic disease For more
information on analogous codes, see M21-1MR, Part IV, Subpart ii, 2.D.16.g.


e. Creating Appropriate DCs In order to properly identify and track disabilities for which service connection is
granted or denied based on the Persian Gulf War Veterans’ Act, a DC series beginning with “88” has been established.

The 88 code is the first element of an analogous code. The second two digits of the 88 code are assigned according
to the body system of the analogous code that it precedes.

References: For more information on
• DCs, see M21-1MR, Part IV, Subpart ii, 2.D.16.f, and
• analogous codes, see M21-1MR, Part IV, Subpart ii, 2.D.16.g.

16. Granting Service Connection for Certain Disabilities Associated With GW Service, Continued

f. List of Appropriate DCs for GW-Related Disabilities The table below lists the first element in a hyphenated
analogous code and the type of undiagnosed condition to which each code refers.

If the condition is analogous to … And the analogous code begins with … Then the first DC is …
musculoskeletal diseases 50 8850
amputations 51 8851
joints, skull, and ribs 52 8852
muscle injuries 53 8853
diseases of the eye 60 8860
hearing loss 61 8861
ear and other sense organs 62 8862
systemic diseases 63 8863
nose and throat 65 8865
trachea and bronchi 66 8866
tuberculosis 67 8867
lungs and pleura 68 8868
heart diseases 70 8870
arteries and veins 71 8871
upper digestive system 72 8872
lower digestive system 73 8873
genitourinary system 75 8875
gynecological system 76 8876
hemic and lymphatic system 77 8877
skin 78 8878
endocrine system 79 8879
central nervous system 80 8880
miscellaneous neurological 81 8881
cranial nerve paralysis 82 8882
cranial nerve neuritis 83 8883
cranial nerve neuralgia 84 8884
peripheral nerve paralysis 85 8885
peripheral nerve neuritis 86 8886
peripheral nerve neuralgia 87 8887
epilepsies 89 8889
psychotic disorders 92 8892
organic mental 93 8893
psychoneurotic 94 8894
psychophysiologic 95 8895
dental and oral 99 8899

g. Examples of Analogous Codes The table below contains examples of analogous codes that may be used when
evaluating undiagnosed illnesses manifest by the 13 signs or symptoms found in 38 CFR 3.317. The second code
should be a DC with rating criteria by which manifestations of the illness can most accurately be evaluated.

Note: This list does not contain all possible analogous codes.

Reference: For more information on the 13 signs or symptoms of an undiagnosed illness, see 38 CFR 3.317.

If the symptom is … Then the hyphenated DC is …
abnormal weight loss 8873-7328, (resection of intestine).
cardiovascular signs or symptoms 8870-7013, (tachycardia).
cardiovascular signs or symptoms 8870-7005, (arteriosclerotic heart disease (ASHD)).
fatigue 8863-6354, (chronic fatigue syndrome).
fatigue 8877-7700, (anemia).
gastrointestinal signs or symptoms • 8873-7305, (ulcer), or
8873-7319, (irritable bowel syndrome).
headache 8881-8100, (migraine headaches).
joint pain 8850-5002, (rheumatoid arthritis).
menstrual disorders 8876-7622, (uterus displacement).
muscle pain 8850-5021, (myositis).
neurologic signs or symptoms 8885-85__, (peripheral neuropathy).

16. Granting Service Connection for Certain Disabilities Associated With GW Service, Continued

g. Examples of Analogous Codes (continued)

If the symptom is … Then the hyphenated DC is …
neuropsychological signs or symptoms 8893-9300, (organic mental disorder).
signs or symptoms involving the respiratory system (upper or lower) • 8865-65__, (respiratory system)
• 8866-66__, (respiratory system), or
• 8868-68__, (respiratory system).
signs or symptoms involving the skin 8878-7806, (eczema).
sleep disturbances 8894-9400, (generalized anxiety).

17. Denying Service Connection for Certain Disabilities Associated With GW Service

Introduction This topic contains information on denying service connection for certain disabilities associated
with GW service, including information on

• discussing the denial in the rating decision
• addressing
? diagnosed illnesses
? an illness that is not chronic
? an illness attributable to some other etiology
? a condition that is not shown by the evidence of record, and
? a qualifying chronic disability that is less than 10-percent disabling.

Change Date September 5, 2008

a. Discussing the Denial in the Rating Decision Begin a discussion of the denial of service connection in the
Reasons for Decision section of the rating decision with a description of the general requirements for service
connection under 38 CFR 3.317, including the following statement:

“Service connection may be established for disability resulting from undiagnosed illness or a medically
unexplained chronic multi-symptom illness that is defined by a cluster of symptoms, or a diagnosed illness
that is determined by VA regulation to warrant a presumption of service connection which manifested itself
either during active service in the Southwest Asia theater of operations during the Gulf War, or to a degree
of ten percent or more after the date on which the veteran last performed service in the Southwest Asia
theater of operations during the Gulf War.”

b. Addressing Diagnosed Illnesses Service connection may not be granted under 38 CFR 3.317 for an illness
having a known clinical diagnosis unless it meets the criteria for a qualifying chronic disability shown in
M21-1MR, Part IV, Subpart ii, 2.D.13.g. However, service connection under other provisions of the law must
be considered.

If service connection for a claimed undiagnosed illness is denied on this basis, include the following language
in the Reasons for Decision section of the rating decision: “Service connection for [claimed disability] is denied
because this disability is determined to result from a known clinical diagnosis of [diagnosed disability], which
neither occurred in, nor was caused or aggravated by, service.”

c. Addressing an Illness That Is Not Chronic The fact that a claimed disability is not found on the veteran’s last
VA examination does not necessarily preclude his/her entitlement to compensation under 38 CFR 3.317.

The requirement for chronicity is fulfilled if the disability has persisted for at least six months. Disabilities subject
to episodic improvement and worsening within a six-month period are considered chronic.

If the disability does not meet the six-month requirement, include the following statement under the Reasons for
Decision section of the rating decision: “The disability must have persisted for a period of at least six months.
Service connection for [disability] is denied since this disability was first manifested on [date] and lasted less
than six months.”
Continued on next page

17. Denying Service Connection for Certain Disabilities Associated With GW Service, Continued

d. Addressing an Illness That Is Attributable to Some Other Etiology Service connection under 38 CFR 3.317 may
not be established if there is affirmative evidence that an undiagnosed illness was not incurred during active service
or was caused by some intercurrent circumstance.

Important: Affirmative evidence that the illness is caused by willful misconduct or alcohol or drug abuse will also
preclude entitlement.

Include the following statement under the Reasons for Decision section of the rating decision if service connection
is denied on this basis: “Service connection under this provision is precluded if there is affirmative evidence that
the disability was unrelated to service in the Gulf War. Service connection for [disability] is denied because
evidence established that this disability resulted from [unrelated event, accident, injury, etc.].”

e. Addressing a Condition That Is Not Shown to Exist by the Evidence of Record If the evidence of record fails to
show that a condition exists or has existed in the past, include the following statement in the Reasons for Decision
section of the rating decision: “There is no evidence that the condition ever existed.”

f. Addressing a Qualifying Chronic Disability That Is Less Than 10-Percent Disabling If the veteran fails to qualify
for service connection because the severity of the qualifying chronic disability is noncompensable, include the
following statement in the Reasons for Decision section of the rating decision: “Service connection for [disability]
is denied since this disability neither arose during service in the Southwest Asia theater of operations, nor was it
manifested to a compensable degree after the last date of service in the Persian Gulf theater during the Gulf War.”

Reference: For more information on qualifications for service connection, see M21-1MR, Part IV, Subpart ii, 2.D.13.a

http://www.warms.vba.va.gov/M21_1MR.html

Section E - Claims for Service Connection for Disabilities Associated with Gulf War (GW) Service, Updated 9/29/06
--------------------------------------
Section E. Claims for Service Connection for Certain Disabilities Associated With Gulf War (GW) Service
Overview

In this Section This section contains the following topics:

Topic Topic Name See Page

18. Developing Claims for Service Connection for Certain Disabilities Associated With GW Service 1-E-2
19 Evidence Required to Process Claims Based on GW Service 1-E-4


Introduction This topic contains information on developing claims for service connection for certain disabilities
associated with Gulf War (GW) service. It includes information on

• initial development action on a new claim
• requesting service department records, and
• the action to take when no disability is claimed.

Change Date September 29, 2006

a. Initial Development Action on a New Claim When preparing the initial development letter for any new claim
for service connection for a disability resulting from GW service

• use the GW special issue screen in Modern Awards Processing-Development (MAP-D) to request evidence from
the veteran, and
• enclose the attachment, “Submitting Evidence for Claims About Gulf War Undiagnosed Illnesses,” if necessary.

Reference: For more information on claims for service connection for disabilities associated with Gulf War service,
see M21-1MR, Part IV, Subpart ii, 2.D.

18. Developing Claims for Service Connection for Certain Disabilities Associated With GW Service, Continued

b. Requesting Service Department Records In addition to service medical records (SMRs), request

• clinical records, if the veteran furnishes information on the application about specific inpatient treatment, and
• the dates of service in the Southwest Asia theater of operations during the GW (beginning August 2, 1990), if
this information is not already of record.

Notes:
• Concurrently request clinical records and SMRs, if both are needed.
• Confirm the veteran’s service in the Southwest Asia theater of operations by calling the veteran’s Reserve or
National Guard unit if
? the veteran is, or was, at the time of service in Southwest Asia, a member of a Reserve or National Guard unit,
or
? this information is not received following usual service department requests.

Important: Be sure to document the telephone call to the veteran’s Reserve or National Guard unit on Report of
Contact, VA Form 119.

References: For more information on requesting
• clinical records, see M21-1MR, Part III, Subpart iii, 2.B.12.c, and
• SMRs, see M21-1MR, Part III, Subpart iii, 2.

c. Action to Take When No Residual Disability Is Claimed A claim is not substantially complete if a veteran alleges
exposure to environmental hazards during service, but does not claim service connection for a specific disability.
In cases such as these

• inform the veteran that he/she must identify a specific disability, since exposure in and of itself is not a disability,
and
• ask the veteran to identify the disability(ies) that resulted from exposure to environmental hazards during service.

Important:
• Do not
? process the claim as a denial, or
? establish end product (EP) control for the incomplete claim.
• Whenever possible, telephone the veteran to obtain the information needed to substantiate the claim.


19. Evidence Required to Process Claims Based on GW Service

Introduction This topic contains information on the evidence required to process claims that are based on service
in the GW theater of operations. It includes information on

• requesting medical evidence
• evidence supporting a claim for SC for an undiagnosed illness
• nonmedical indications of a disability
• lay statements
• determining the credibility of a lay statement, and
• medical examinations.

Change Date December 13, 2005

a. Requesting Medical Evidence Request reports of all private and Department of Veterans Affairs (VA) medical
treatment that is indicated by the veteran, both during and after service, including records such as

• statements or reports from
? doctors
? hospitals
? laboratories
? medical facilities, and
? mental health clinics
• x-rays, and
• physical therapy records.

Note: If the veteran indicates that a GW Registry examination has been conducted, request the examination report
from the appropriate medical facility.
Continued on next page

19. Evidence Required to Process Claims Based on GW Service, Continued

b. Evidence Supporting a Claim for Service Connection for an Undiagnosed Illness If the disability claimed is an
undiagnosed illness, evidence supporting the claim may be either medical evidence or nonmedical indications that
can be independently observed or verified.

c. Nonmedical Indications of a Disability Nonmedical indications of a disability include

• events such as time lost from work, and/or
• evidence
? that a veteran has sought medical treatment for his or her symptoms, and/or
? affirming changes in the veteran’s appearance, physical abilities, and mental or emotional attitude.

The provisions of 38 CFR 3.317 state that the nonmedical indicators must be independently verifiable. This means
that it must be possible to obtain verification of the nonmedical indicators from an independent source.

d. Lay Statements Lay statements(statements from persons not trained in a medical profession) may be especially
important in cases where an undiagnosed illness

• is manifested solely by the symptoms which the veteran reports, and
• might not be verifiable by medical examination.
Continued on next page

19. Evidence Required to Process Claims Based on GW Service, Continued

e. Determining the Credibility of a Lay Statement A lay statement that is based on personal observation or
experience is credible if the

• person making the statement is/was in a position to know the facts attested to
• statement is sufficiently specific to address the facts, and
• statement is not contradicted by evidence of record that is more credible.

On occasion, the lay statement may require clarification. Generally, however, unless there is reason to doubt
statement’s credibility, do not attempt to corroborate it.

f. Medical Examinations When an undiagnosed illness is claimed, a thorough medical examination report is
essential to

• rule out known diagnoses, and
• provide an accurate picture of the claimed disability for rating purposes, where possible.

Order specialist examinations, as appropriate, such as

• pulmonary function studies for breathing problems
• neurological evaluations for headaches, or
• psychiatric/neuropsychiatric examinations for memory loss or fatigue.

Notes:
• Ask the veteran to identify the specific areas affected if multiple joint or muscle pain is alleged.
• When nonspecific complaints are presented, the examiner must address these issues.

Example: The examiner should provide answers to the following questions to document nonspecific complaints:

• (1) Are there clinical, objective indicators for the following symptoms?:
? (a) fatigue: ______ Yes _____ No
? (b) joint pain: ______ Yes _____ No
? (c) [List all alleged symptoms.]
• (2) Are any of the aforementioned symptoms attributable to a “known” clinical diagnosis? Please specify.

Persian Gulf War syndrome (GWS) or Persian Gulf War illness (GWI) is an illness reported by combat veterans
of the 1991 Persian Gulf War typified by a range of medically unexplained symptoms. It has not always
been clear whether these symptoms were related to Gulf War service, or the occurrence of illnesses in Gulf War
veterans is higher than comparable populations.

Symptoms attributed to this syndrome have been wide-ranging, including chronic fatigue, loss of muscle control,
headaches, dizziness and loss of balance, memory problems, muscle and joint pain, indigestion, skin problems,
shortness of breath, and even insulin resistance. Brain cancer deaths, amyotrophic lateral sclerosis (also known
as Lou Gehrig's disease) and fibromyalgia are now recognized by the Defense and Veterans Affairs departments
as potentially connected to service during the Persian Gulf War.

Since the end of the Persian Gulf War, the U.S. Department of Veterans Affairs (VA) and the British Ministry of
Defence have conducted numerous studies on Persian Gulf War Veterans. The latest studies have determined
that while the physical health of deployed veterans is similar to that of non-deployed veterans, there is an increase
in 4 out of the 12 medical conditions reportedly associated with Persian Gulf War syndrome - fibromyalgia, chronic
fatigue syndrome, eczema, and dyspepsia.[4] They have also concluded that while mortality was significantly higher
in deployed veterans, most of the increase was due to automobile accidents.

In the United States in 2008, the federally mandated Research Advisory Committee on Gulf War Veterans' Illnesses
released a 452-page report, indicating that roughly 1 in 4 of the 697,000 veterans who served in the first Persian
Gulf War are afflicted with the disorder.

The report implicated exposure to toxic chemicals as the cause of the illness. The report states that "scientific
evidence leaves no question that Persian Gulf War illness is a real condition with real causes and serious
consequences for affected veterans."

Contents

1 Medical problems by soldier nationality
2 Possible causes
2.1 Nerve gas medication and insect repellents
2.2 Oil well fires
2.3 Anthrax vaccine
2.4 Chemical weapons
2.5 Depleted uranium
2.6 Infectious diseases
3 Controversy
3.1 Evidence for
3.2 Evidence against
3.3 Iraq War
4 See also
5 References
6 External links

Medical problems by soldier nationality

Summary of the Operation Desert Storm offensive ground campaign, February 24-28, 1991, by nationality
(click for detail).About 30 percent of the 700,000 U.S. servicemen and women in the first Persian Gulf War
have registered in the Persian Gulf War Illness database set up by the American Legion. Some still suffer a
wide range of serious health impairing symptoms

The tables below apply only to coalition forces involved in combat. Since each nation's soldiers generally served
in different geographic regions, epidemiologists are using these statistics to correlate effects with exposure to
the different suspected causes.

U.S. and UK, with the highest rates of excess illness, are distinguished from the other nations by higher rates of
pesticide use, use of anthrax vaccine, and somewhat higher rates of exposures to oil fire smoke and reported chemical alerts.

France, with possibly the lowest illness rates, had lower rates of pesticide use, and no use of anthrax vaccine.

French troops also served to the North and West of all other combat troops,
away and upwind of major combat engagements.

Excess prevalence of general symptoms

Symptom U.S. UK Australia Denmark

Fatigue 23% 23% 10% 16%
Headache 17% 18% 7% 13%
Memory problems 32% 28% 12% 23%
Muscle/joint pain 18% 17% 5% 2% (<2%)
Diarrhea 16% 9% 13%
Dyspepsia/indigestion 12% 5% 9%
Neurological problems 16% 8% 12%
Terminal tumors 33% 9% 11%
Excess prevalence of recognized medical conditions Condition U.S. UK Canada Australia
Skin conditions 20 ?20-21% 21% 04 ?4-7% 4%
Arthritis/joint problems 06 ?6-11% 10% 0 ?(-1)-3% 2%
Gastro-intestinal (GI) problems 15 ?15% 05 ?5-7% 1%
Respiratory problem 04 ?4-7% 2% 02 ?2-5% 1%
Chronic fatigue syndrome 01 ?1-4% 3% 0%
Post-traumatic stress disorder 02 ?2-6% 9% 06 ?6% 3%
Chronic multi-symptom illness 13 ?13-25% 26%

Possible causes:

Graph showing the rate per 1,000 births of congenital malformations observed at Basra University Hospital, Iraq
Nerve gas medication and insect repellents
In 2008, a paper published in the Proceedings of the National Academy of Sciences suggested that excess illnesses
in Gulf War veterans could be explained in part by their exposure to organophosphate and carbamate
acetylcholinesterase inhibitors. A federal report released in November, 2008, agreed, stating that exposure
to two substances "are causally associated with Gulf War illness":

pyridostigmine bromide, an acetylcholinesterase inhibitor intended to protect against nerve agents, and
pesticides and insect repellents (often acetylcholinesterase inhibitors)
Chemical weapons classified as nerve gases are also strong acetylcholinesterase inhibitors.

Oil well fires

During the war, many oil wells were set on fire, and the smoke from those fires was inhaled by large numbers of
soldiers, many of whom suffered acute pulmonary and other chronic effects, including asthma and bronchitis.
However, firefighters who were assigned to the oil well fires and encountered the smoke, but who did not take
part in combat, have not had GWI symptoms.

Anthrax vaccine

During Operation Desert Storm, 41% of U.S. combat soldiers and 57-75% of UK combat soldiers were vaccinated
against anthrax. The early 1990s version of the anthrax vaccine was a source of several serious side effects
including GWI symptoms. Like all vaccines, it often caused local skin reactions, some lasting for weeks or months.
While the Food and Drug Administration (FDA) approved the vaccine, it never went through large scale clinical
trials, unlike almost all other vaccines in the United States.

One study found that deployed Persian Gulf War Syndrome patients are significantly more likely to have antibodies to the experimental vaccine adjuvant squalene (95 percent) than asymptomatic Gulf War veterans (0 percent; p<.001),
which raises the possibility that squalene was used experimentally (squalene is not approved for use as an adjuvant
in the United States) in the Anthrax vaccine given to soldiers prior to deployment in the Persian Gulf War to
better induce immunity.

The potential implication that the Anthrax vaccine given to soldiers immediately prior to the Gulf War was correlated
with Persian Gulf War Syndrome prompted the Department of Defense to task the Armed Forces Epidemiological
Board (AFEB) to review Asa, Cao, & Garry's methods. The AFEB found several shortcomings that called into question
the validity of the results; namely questionable positive controls, the unproven specificity of the ASA assay, and
the potential that the researchers were not blind in their knowledge of patient illness/wellness.

The Department of Defense published a study in 2009 which found no relationship between squalene antibodies and
symptoms. The researchers concluded "We found no association between squalene antibody status and chronic
multisymptom illness. The etiology of Gulf War syndrome remains unknown, but should not include squalene antibody
status."

Research into the vaccine used after 1997 suggests that specific vaccine lots used in immunization during the
Anthrax Vaccine Immunization Program program initiated in 1997 likely contain squalene because " the incidence
of [anti-squalene antibodies] in personnel in the blinded study receiving these lots was 47% (8/17) compared to
an incidence of 0% (0/8; P < 0.025) of the AVIP participants receiving other lots of vaccine."

Even after the war, troops that had never been deployed overseas, after receiving the anthrax vaccine, developed
symptoms similar to those of Persian Gulf War Syndrome. The Pentagon failed to report to Congress 20,000 cases
where soldiers were hospitalized after receiving the vaccine between 1998 and 2000.

Despite repeated assurances that the vaccine was safe and necessary, a U.S. Federal Judge ruled that there was
good cause to believe it was harmful, and he ordered the Pentagon to stop administering it in October 2004.
The ban was lifted in February 2008 after the FDA re-examined and approved the drug again. Anthrax vaccine is
the only substance suspected in Persian Gulf War syndrome to which forced exposure has since been banned to
protect troops from it.

Subsequent anthrax vaccines, however, have met with approval. On December 15, 2005, the Food and Drug
Administration, released a Final Order finding that the current anthrax vaccines are safe and effective.
The anthrax vaccine currently used is not the same vaccine that was issued during the First Gulf War.

Chemical weapons

Many of the symptoms, other than low cancer incidence rates, of Gulf War syndrome are similar to the symptoms
of organophosphate, mustard gas, and nerve gas poisoning. Persian Gulf War veterans were exposed to
a number of sources of these compounds, including nerve gas and pesticides.

Over 125,000 U.S. troops and 9,000 UK troops were exposed to nerve gas and mustard gas when an Iraqi depot in
Khamisiyah, Iraq was bombed in 1991.

One of the most unusual events during the build-up and deployment of British forces into the desert of Saudi Arabia
was the constant alarms from the NIAD detection systems deployed by all British forces in theatre. The NIAD is a
chemical and biological detection system that is set up some distance away from a deployed unit, and will set off
an alarm automatically if an agent is detected.

During the troop build-up, these detectors were set off on a large number of occasions, making the soldiers don
their respirators. Many reasons were given for the alarms, ranging from fumes from helicopters, fumes from
passing jeeps, cigarette smoke and even deodorant worn by troops manning the NIAD posts.

Although the NIAD had been deployed countless times in peacetime exercises in the years before the Gulf War,
the large number of alarms was, to say the least, very unusual, and the reasons given were something of a joke
among the troops.

The Riegle Report said that chemical alarms went off 18,000 times during the Gulf War. The United States did not
have any biological agent detection capability during the Gulf War. After the air war started on January 16, 1991,
coalition forces were chronically exposed to low (nonlethal) levels of chemical and biological agents released
primarily by direct Iraqi attack via missiles, rockets, artillery, or aircraft munitions and by fallout from allied
bombings of Iraqi chemical warfare munitions facilities.

Chemical detection units from the Czech Republic, France, and Britain confirmed chemical agents. French detection
units detected chemical agents. Both Czech and French forces reported detections immediately to U.S. forces. U.S.
forces detected, confirmed, and reported chemical agents; and U.S. soldiers were awarded medals for detecting
chemical agents.

Some, including Richard Guthrie, an expert in chemical warfare at Sussex University, have argued that a likely
cause for the increase in birth defects was the Iraqi Army’s use of teratogenic mustard agents. Plaintiffs in a
long-running class-action lawsuit continue to assert that sulphur mustards might be responsible. Both
chemical agents, at the exposure levels required to cause such birth defects, would be likely to produce elevated
levels of cancer not seen in Gulf War veterans.

In 1997, the US Government released an unclassified report that stated, "The US Intelligence Community (IC)
has assessed that Iraq did not use chemical weapons during the Gulf War. However, based on a comprehensive
review of intelligence information and relevant information made available by the United Nations Special Commission
(UNSCOM), we conclude that chemical warfare (CW) agent was released as a result of US postwar demolition of
rockets with chemical warheads in a bunker (called Bunker 73 by Iraq) and a pit in an area known as Khamisiyah.

" See Khamisiyah: A Historical Perspective on Related Intelligence by the Persian Gulf War Illnesses Task Force
(9 April 1997) Khanisiya was the location of an Iraqi chemical weapons storage facility bombed during the
first Gulf War.

There is also speculation that residual chemical agents from the Iran–Iraq war caused environmental contamination
and chronic exposure amongst the troops,[citation needed] consistent with the increased observation of birth
defects amongst the Iraqis bracketing the period of the Gulf War.

Depleted uranium

Approximate area and major clashes in which DU rounds were used.Depleted uranium (DU) was used in tank kinetic
energy penetrator and autocannon rounds on a large scale for the first time in the Gulf War. DU munitions often burn
when they impact a hard target, producing toxic combustion products.

The toxicity, effects, distribution, and exposure involved have all been the subject of a lengthy and complex debate.

Because uranium is a heavy metal and chemical toxicant with nephrotoxic (kidney-damaging), teratogenic
(birth defect-causing), and potentially carcinogenic properties, uranium exposure is associated with
a variety of illnesses. The chemical toxicological hazard posed by uranium dwarfs its radiological hazard
because it is only weakly radioactive, and depleted uranium even less so.

Early studies of depleted uranium aerosol exposure assumed that uranium combustion product particles would
quickly settle out of the air and thus could not affect populations more than a few kilometers from target
areas, and that such particles, if inhaled, would remain undissolved in the lung for a great length of time
and thus could be detected in urine. Uranyl ion contamination has been found on and around depleted uranium targets.

DU has recently been recognized as a neurotoxin. In 2005, depleted uranium was shown to be a neurotoxin in rats.

In 2001, a study was published in Military Medicine that found DU in the urine of Gulf War veterans. Anothe
study, published by Health Physics in 2004, also showed DU in the urine of Gulf War veterans. A study of UK
veterans who thought they might have been exposed to DU showed aberrations in their white blood cell
chromosomes. Mice immune cells exposed to uranium exhibit abnormalities.

A 2001 study of 15,000 February 1991 U.S. Gulf War combat veterans and 15,000 control veterans found that the
Gulf War veterans were 1.8 (fathers) to 2.8 (mothers) times more likely to have children with birth defects.
After examination of children's medical records two years later, the birth defect rate increased by more than 20%:

"Dr. Kang found that male Gulf War veterans reported having infants with likely birth defects at twice the rate of
non-veterans. Furthermore, female Gulf War veterans were almost three times more likely to report children with
birth defects than their non-Gulf counterparts. The numbers changed somewhat with medical records verification.
However, Dr. Kang and his colleagues concluded that the risk of birth defects in children of deployed male veterans
still was about 2.2 times that of non-deployed veterans."

In a study of U.K. troops, "Overall, the risk of any malformation among pregnancies reported by men was 50%
higher in Gulf War Veterans (GWV) compared with Non-GWVs."

In the Balkans war zone where depleted uranium was also used, an absence of problems is seen by some as
evidence of DU munitions' safety. "Independent investigations by the World Health Organization, European
Commission, European Parliament, United Nations Environment Programme, United Kingdom Royal Society,
and the Health Council of the Netherlands all discounted any association between depleted uranium and leukemia
or other medical problems."

In Italy, controversy over the health risks associated with the use of DU continues, with a Senate investigation
committee due to release its report into 'Balkan Syndrome' by the end of 2007. Since then, there has been a
resurgence of interest in the health effects of depleted uranium, especially since it has recently been linked with
neurotoxicity.

Infectious diseases

Along with possible confounding problems caused by exposure to more than one of the substances listed above,
comorbidities with infectious diseases have also not been ruled out. Suspected diseases include leishmaniasis,
from sandfly bites, and mycoplasma infections.