Federal Register / Vol. 76, No. 72 / Thursday, April 14, 2011 / Notices 21099 

deemed ‘‘best qualified’’ will have to 

undergo a Federal Bureau of 

Investigation (FBI) fingerprint check. 

‘‘Federally-registered lobbyists cannot be 

members of the IRSAC.’’ 

Equal opportunity practices will be 

followed for all appointments to the 

IRSAC in accordance with the 

Department of the Treasury and IRS 

policies. ‘‘The IRS has special interest in 

assuring that women and men, members 

of all races and national origins, and 

individuals with disabilities are 

adequately represented on advisory 

committees: and therefore, extends 

particular encouragement to 

nominations from such appropriately 

qualified candidates.’’ 

Dated: April 6, 2011. 

Candice Cromling, 

Director, National Public Liaison. 

[FR Doc. 2011–8992 Filed 4–13–11; 8:45 am] 

BILLING CODE 4830–01–P 

DEPARTMENT OF VETERANS 

AFFAIRS 

Determinations Concerning Illnesses 

Discussed In National Academy of 

Sciences Reports on Gulf War and 

Health, Volumes 4 and 8 

AGENCY: Department of Veterans Affairs. 

ACTION: Notice. 

SUMMARY: As required by law, the 

Department of Veterans Affairs (VA) 

hereby gives notice that the Secretary of 

Veterans Affairs, under the authority 

granted by the Persian Gulf War 

Veterans Act of 1998, has determined 

that there is no basis to establish any 

new presumptions of service connection 

at this time for any of the diseases, 

illnesses, or health effects discussed in 

the September 12, 2006, and April 9, 

2010, reports of the Institute of 

Medicine of the National Academy of 

Sciences (NAS), respectively titled Gulf 

War and Health, Volume 4: Health 

Effects of Serving in the Gulf War 

(Volume 4) and Gulf War and Health, 

Volume 8: Update of Health Effects of 

Serving in the Gulf War (Volume 8). 

FOR FURTHER INFORMATION CONTACT: 

Gerald Johnson, Regulations Staff 

(211D), Compensation and Pension 

Service, Veterans Benefits 

Administration, Department of Veterans 

Affairs, 810 Vermont Avenue, NW., 

Washington, DC 20420, telephone (202) 

461–9727. (This is not a toll-free 

number.) 

SUPPLEMENTARY INFORMATION: 

I. Statutory Requirements 

The Persian Gulf War Veterans Act of 

1998, Public Law 105–277, title XVI, 

112 Stat. 2681–742 through 2681–749 

(set out as a note under 38 U.S.C. 1117 

and codified in part at 38 U.S.C. 1118), 

and the Veterans Programs 

Enhancement Act of 1998, Public Law 

105–368, 112 Stat. 3315, directed the 

Secretary to seek to enter into an 

agreement with the NAS to review and 

evaluate the available scientific 

evidence regarding associations between 

illnesses and exposure to toxic agents, 

environmental or wartime hazards, or 

preventive medicines or vaccines to 

which service members may have been 

exposed during service in the Southwest 

Asia theater of operations during the 

Persian Gulf War. Under this agreement, 

Congress directed NAS to identify 

agents, hazards, medicines, and 

vaccines to which service members may 

have been exposed during the Persian 

Gulf War. Congress required NAS, to the 

extent that available scientific data 

permits meaningful determinations, to 

determine for each substance or hazard 

identified: (1) Whether a statistical 

association exists between exposure to 

the substance or hazard and the 

occurrence of illnesses, (2) whether 

there is an increased risk of the illness 

among exposed human or animal 

populations, and (3) whether a plausible 

biological mechanism or other evidence 

of a causal relationship exists. Public 

Law 105–277, 112 Stat. 2681–747. 

In addition, Congress authorized VA 

to compensate Gulf War Veterans for 

diagnosed or undiagnosed illnesses that 

are determined by VA to warrant a 

presumption of service connection 

based upon a positive association with 

exposure, as a result of Gulf War 

service, to a toxic agent, an 

environmental or wartime hazard, or a 

preventive medication or vaccine 

known or presumed to be associated 

with Gulf War service. 38 U.S.C. 1118. 

Thus, upon receipt of each NAS report, 

VA must determine whether a 

presumption of service connection is 

warranted for any disease or illness 

discussed in the report. A presumption 

of service connection is warranted if VA 

determines, based on sound medical 

and scientific evidence, that there is a 

positive association between the 

exposure of humans and animals to a 

biological, chemical, or other toxic 

agent, environmental or wartime hazard, 

or preventive medicine or vaccine 

known or presumed to be associated 

with service in the Southwest Asia 

theater of operations during the Gulf 

War and the occurrence of a diagnosed 

or undiagnosed disease or illness in 

humans and animals. 38 U.S.C. 1118(b). 

If the Secretary determines that a 

presumption of service connection is 

not warranted, the Secretary shall 

publish in the Federal Register a notice 

of the determination. 38 U.S.C. 

1118(c)(3)(A). Accordingly, this notice 

announces VA’s determination that no 

new presumptions of service connection 

are warranted for any disease or illness 

discussed in Volume 4 and Volume 8. 

II. NAS Reports: Gulf War and Health 

Series 

The NAS has issued eight numbered 

reports and two unnumbered ‘‘updates’’ 

in the Gulf War and Health series, 

which examine the health effects of 

exposure to specific chemical agents, 

environmental and wartime hazards, 

and preventive medicines and vaccines. 

Federal Register notices have been 

published on four of the eight numbered 

reports and two unnumbered updates 

announcing the Secretary’s 

determination that the available 

evidence does not warrant a 

presumption of service connection for 

any of the diseases discussed in the four 

reports: Gulf War and Health, Volume 1: 

Depleted Uranium, Sarin, 

Pyridostigmine Bromide, and Vaccines 

(66 FR 35702 (2001)); Gulf War and 

Health, Volume 2: Insecticides and 

Solvents (72 FR 48734 (2007)); Gulf War 

and Health: Updated Literature Review 

of Sarin (73 FR 42411 (2008)); Gulf War 

and Health, Volume 3: Fuels, 

Combustion Products, and Propellants 

(73 FR 50856 (2008)); Gulf War and 

Health, Volume 5: Infectious Diseases 

(74 FR 15063 (2009)); Gulf War and 

Health: Updated Literature Review of 

Depleted Uranium (75 FR 10867 (2010)); 

and Gulf War and Health, Volume 6: 

Physiologic, Psychologic, and 

Psychosocial Effects of DeploymentRelated Stress (76 FR 2447 (2011)). 

The Volume 4 report is covered in 

this notice. The findings for Gulf War 

and Health, Volume 7: Long-Term 

Consequences of Traumatic Brain Injury 

are currently under review. The latest 

report, Volume 8, will also be covered 

in this notice. Based on Volume 4 and 

Volume 8, VA published a proposed 

rule on November 17, 2010 to clarify 

that FGIDs fall within the scope of the 

existing presumption of service 

connection for medically unexplained 

chronic multisymptom illnesses. 75 FR 

70162. Aside from that clarification, VA 

has determined that no other changes to 

the existing presumptions relating to 

multisymptom illness, nor any new 

presumptions, are warranted at this 

time. 

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21100 Federal Register / Vol. 76, No. 72 / Thursday, April 14, 2011 / Notices 

III. Gulf War and Health, Volume 4: 

Health Effects of Serving in the Gulf 

War 

The NAS issued its Volume 4 report 

on September 12, 2006. This study 

differs from previous NAS work in that 

it compiles, evaluates, and summarizes 

in one location peer-reviewed scientific 

and medical literature on the current 

status of health effects in Veterans 

deployed to the Persian Gulf 

irrespective of exposure information, 

i.e., health responses associated with 

deployment in the Gulf War Theatre 

alone. The purpose of the study was to 

inform VA of illnesses among Gulf War 

Veterans that might not be immediately 

evident. Based on this NAS report, the 

Secretary has determined that the 

scientific evidence presented in this 

report and other information available 

to the Secretary indicates that no new 

presumption of service connection is 

warranted at this time for any of the 

illnesses described in Volume 4. 

The NAS committee for Volume 4 

(NAS committee) was charged to 

review, evaluate, and summarize 

scientific and medical literature 

addressing the health status of Gulf War 

Veterans. The committee’s objective was 

to determine the prevalence of diseases 

and symptoms in the Gulf War Veteran 

population, based primarily on studies 

comparing the health status of deployed 

Gulf War Veterans with the health status 

of their nondeployed counterparts. This 

information is useful in identifying 

areas of concern and needs of the Gulf 

War Veteran population, and may assist 

in guiding VA’s actions in the areas of 

health care, compensation, and 

research. Because this was a disease 

prevalence study, the NAS committee 

generally did not attempt to associate 

diseases or symptoms with specific 

biological or chemical agents or other 

specific hazards of Gulf War service. 

However, the NAS committee did 

review certain studies that assessed 

exposures in Veterans and the influence 

of exposure information on the 

interpretation of Veterans’ health. 

The NAS committee conducted 

extensive searches of epidemiologic 

literature and extracted 850 potentially 

relevant epidemiologic studies for 

evaluation from a composite of over 

4000 relevant references. The NAS 

committee based its conclusion on only 

peer-reviewed published scientific and 

medical literature. The process of peer 

review by fellow professionals increased 

the likelihood of high quality analysis, 

but did not guarantee the validity of a 

study. The NAS committee presumed 

neither the existence nor the absence of 

illnesses associated with deployment. It 

characterized and weighed the strengths 

and limitations of available evidence. 

The NAS committee read each study 

critically and considered its relevance 

and quality; however, the committee did 

not collect original data nor did it 

perform any secondary data analysis. 

After securing the full text of the 

selected peer-reviewed epidemiologic 

studies, the NAS committee divided 

them into primary and secondary 

studies. Primary studies included 

information about specific health 

outcomes, demonstrated rigorous 

methods, described its methods in 

sufficient detail, included a control or 

reference group, had the statistical 

power to detect effects, and included 

reasonable adjustments for confounders. 

Secondary studies provided background 

information or ‘‘context’’ for the report. 

There was no attempt to link health 

outcomes to exposures other than 

deployment to the Persian Gulf theater, 

for which there is no known animal 

model, and, because the NAS committee 

assessed disease prevalence rather than 

causation, it did not comprehensively 

review toxicologic, animal, or 

experimental studies. The NAS 

committee did evaluate the key animal 

and epidemiologic studies cited in the 

Research Advisory Committee on Gulf 

War Veterans’ Illnesses (RAC) report. 

Epidemiologic studies that attempted to 

associate health effects with specific 

exposures, such as oil-well–fire smoke 

or nerve-gas agents, were also 

considered by the committee. 

The committee’s full report may be 

viewed at: http://www.iom.edu/CMS/ 

3793/24597/36955.aspx. 

IV. Gulf War and Health, Volume 8: 

Update of Health Effects of Serving in 

the Gulf War 

The NAS issued its latest report, 

Volume 8, on April 9, 2010. The charge 

to the NAS update committee for 

Volume 8 (NAS update committee) was 

to review, evaluate, and summarize the 

literature on the health outcomes noted 

in Volume 4 that seemed to have higher 

incidence or prevalence in Gulf War 

deployed Veterans, namely: cancer 

(particularly brain and testicular), 

amyotrophic lateral sclerosis and other 

neurological diseases (such as 

Parkinson’s disease and multiple 

sclerosis), birth defects and other 

adverse pregnancy outcomes, and post 

deployment psychiatric conditions. The 

NAS update committee also reviewed 

studies of cause-specific mortality in 

Gulf War Veterans and examined 

literature to identify emerging health 

outcomes. The NAS update committee 

limited its review to epidemiological 

studies of health outcomes published 

subsequent to the literature search for 

Volume 4 and those studies included in 

Volume 4. In order for a study to be 

considered, the NAS update committee 

required the study to compare the 

health status of Gulf War Veterans to 

nondeployed Veterans or Veterans 

deployed in other locations. 

The NAS update committee 

conducted extensive searches of 

epidemiological literature published 

since 2005, employing the same search 

strategies as used for Volume 4, and 

retrieved over 1,000 potentially relevant 

references. The titles and the abstracts 

of the studies were assessed and then 

narrowed down to focus on 400 

potentially relevant epidemiological 

studies for the review. Similar to the 

policy utilized in the Volume 4 review, 

the NAS update committee used only 

peer-reviewed published literature as 

the basis for its conclusions, with the 

exception of some governmental reports. 

As noted in regard to Volume 4, the 

process of peer review by fellow 

professionals increases the probability 

of a high quality study, but does not 

guarantee its validity. The NAS update 

committee did not collect any original 

data or perform any secondary data 

analysis. 

The NAS update committee also 

reviewed the studies that had been 

included in Volume 4 as either primary 

or secondary studies. In Volume 4, the 

NAS committee did not make 

determinations as to the strength of the 

association between deployment to the 

Gulf War and the specific health effects. 

Therefore, the NAS update committee 

was asked to make such determinations 

during its review. To make these 

determinations, the NAS update 

committee reviewed the studies 

included in Volume 4 to ensure that 

they would still be classified as either 

primary or secondary studies. 

The NAS update committee 

collectively reviewed all of the relevant 

studies cited in Volume 4 as well as the 

new studies identified from the updated 

literature. The NAS update committee 

weighed the evidence, reached a 

consensus and assigned a category of 

association for each health outcome 

considered in the report. This review 

provides an update on the health effects 

of serving in the Southwest Asia theater 

of operations during the Persian Gulf 

War. The purpose of this report was to 

determine the strength of associations 

between being deployed to the Gulf War 

and specific health effects. Specifically, 

the NAS update committee determined 

whether there was sufficient evidence of 

a causal relationship, sufficient 

evidence of an association, limited/ 

suggestive evidence of an association, 

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Federal Register / Vol. 76, No. 72 / Thursday, April 14, 2011 / Notices 21101 

inadequate/insufficient evidence to 

determine whether an association exists, 

or limited/suggestive evidence that no 

association exists between the health 

outcome and deployment to the Gulf 

War. 

The committee’s full report may be 

viewed at: http://www.iom.edu/Reports/ 

2010/Gulf-War-and-Health-Volume-8- 

Health-Effects-of-Serving-in-the-GulfWar.aspx. 

V. Report Summaries for Volume 4 and 

Volume 8 

The different approaches used by the 

NAS committee in evaluating Volume 4 

and the NAS update committee in 

evaluating Volume 8 are reflected in the 

separate conclusions reached by each 

committee. The task of the NAS 

committee was to catalog the health 

outcomes that appeared to have greater 

prevalence in Veterans who had been 

deployed to the Gulf War in comparison 

with Veterans in the military at that 

time who were not deployed to the Gulf 

War. In Volume 4, the NAS committee 

did not specifically evaluate the 

strength of the association between Gulf 

War deployment and the specific health 

outcomes. The Volume 4 studies 

generally did not associate any observed 

health effects with exposure to specific 

hazards of Gulf War service, and 

therefore provide no basis for 

establishing new presumptions under 

38 U.S.C. 1118 based on exposure to 

specific agents, hazards, or medicines 

associated with Gulf War service. 

The NAS update committee reviewed 

epidemiologic studies of health 

outcomes published after the literature 

search conducted for the Volume 4 

report as well as the studies included in 

Volume 4. The purpose of this report 

was to determine the strength of 

associations between being deployed to 

the Gulf War and specific health effects. 

The NAS update committee reviewed 

only studies that compared the health 

status of Gulf War Veterans with those 

of non-deployed Veterans and Veterans 

deployed to other locations, and then 

characterized the strength of the 

evidence for an association between 

Gulf War deployment and the specific 

health outcome. Based on the NAS 

update committee’s findings, VA 

determined that Volume 8 did not 

present a basis for establishing new 

presumptions under 38 U.S.C. 1118 

based on exposure to specific agents, 

hazards, or medicines associated with 

Gulf War service. Specific findings of 

Volume 4 and Volume 8 are discussed 

below. 

Multisymptom Illness 

The NAS committee for Volume 4 

found that Veterans of the Gulf War 

report higher rates of symptoms or sets 

of symptoms than their non-deployed 

counterparts. The committee found that 

29 percent of Gulf War Veterans meet a 

case definition of ‘‘multisymptom 

illness,’’ compared to 16 percent of nondeployed Veterans. Among the 

symptoms most often reported by Gulf 

War Veterans are fatigue, memory loss, 

confusion, inability to concentrate, 

mood swings, somnolence, 

gastrointestinal symptoms, muscle and 

joint pains, and skin conditions. Gulf 

War Veterans also reported more 

instances of chronic multisymptom 

illness, including chronic fatigue 

syndrome, fibromyalgia, and multiple 

chemical sensitivity. 

Under current law at 38 U.S.C. 1117 

and 38 CFR 3.317, Gulf War Veterans 

are entitled to compensation for chronic 

disabilities associated with signs or 

symptoms of disabilities such as those 

described above or associated with 

chronic multisymptom illness. The 

findings in Volume 4 support the 

policies of the current presumptions 

and warrant no change to the existing 

regulatory presumptions of service 

connection in 38 CFR 3.317. 

In a November 2008 report, the RAC, 

a Federal advisory committee 

established to provide research 

recommendations to VA, indicated that 

current medical and scientific evidence 

provides support for the theory that the 

increased symptomatology reported by 

Gulf War Veterans may be attributable 

to exposure to pyridostigmine bromide 

(PB) in pills given to U.S. troops as a 

protection against nerve gas and 

pesticides. The RAC found that several 

studies provide evidence of an 

association, including a dose-response 

relationship, between PB and 

multisymptom illnesses consistent with 

‘‘Gulf War Illness,’’ and between 

pesticide exposure and such 

multisymptom illness. The RAC noted 

also that animal studies had identified 

significant effects of exposure to 

combinations of PB, pesticides, sarin, 

and stress, at dosage levels similar to 

those experienced by Veterans in the 

Gulf War, although there is relatively 

little information from human studies 

concerning the effects of such combined 

exposures. 

The NAS update committee for 

Volume 8 reviewed the literature cited 

in the RAC report, but disagreed with 

the RAC’s conclusion that chronic 

multisymptom illness is caused by 

exposure to PB and pesticides. The NAS 

update committee concluded that 

current available evidence was not 

sufficient to establish a causative 

relationship between multisymptom 

illness and any specific drug, toxin, 

plume or other agent, either alone or in 

combination. The NAS update 

committee noted that some studies had 

found associations between selfreported exposures to PB, pesticides, 

nerve gas, and mixtures thereof, but that 

several well-designed studies have 

concluded that no associations exist for 

such exposures. The update committee 

also stated that, although some studies 

have found that central nervous system 

(CNS) disorders may persist following 

acute pesticide exposure, there is no 

evidence that Gulf War Veterans 

experienced such acute exposures and 

no significant evidence of chronic CNS 

effects from low-level exposures. Based 

on its review of the available evidence 

from both human and animal studies, 

the NAS update committee found 

insufficient support for the conclusion 

that pesticides, PB, insect repellants, or 

combinations thereof are responsible for 

multisymptom illnesses in Gulf War 

Veterans. 

Based on review of the information in 

the reports of the NAS and the RAC, VA 

has determined that the evidence for an 

association between multisymptom 

illnesses and specific exposures, such as 

PB, pesticides, and combinations 

thereof, is not equal to or greater than 

the evidence against such an 

association. VA emphasizes, however, 

that this conclusion has no effect on 

VA’s ability under existing law to 

provide compensation for such 

illnesses. Under 38 U.S.C. 1117 and 38 

CFR 3.317, VA pays compensation for 

such illness without regard to its cause. 

VA will continue to evaluate 

developments regarding the possible 

causes of Gulf War Veterans’ chronic 

multisymptom illnesses, which may 

affect the understanding and treatment 

of these illnesses. 

The NAS update committee accepted 

multisymptom illness as a diagnostic 

entity and assessed the association 

between symptom reporting indicative 

of multisymptom illness and 

deployment to the Gulf War, instead of 

attempting to determine whether there 

appears to be a unique illness that could 

be defined by the symptoms. Most 

studies indicate an increased reporting 

of multisymptom illness among 

deployed Gulf War Veterans, which 

occurred in multiple studies from 

several countries, but were subjective 

with inconsistent findings on physical 

examinations and laboratory testing 

requiring further analysis. The NAS 

update committee determined that there 

is sufficient evidence of an association 

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21102 Federal Register / Vol. 76, No. 72 / Thursday, April 14, 2011 / Notices 

between deployment to the Gulf War 

and chronic multisymptom illness, but 

noted that the basis for the relationship 

is unclear, and recommended further 

research. These findings support the 

policy in existing law to provide 

compensation for Gulf War Veterans’ 

chronic multisymptom illnesses. 

Psychiatric Symptoms 

The NAS committee concluded that 

deployment places Veterans at 

increased risk for symptoms that meet 

the diagnostic criteria for certain 

psychiatric illnesses, including posttraumatic stress disorder (PTSD), 

anxiety, depression, and substance 

abuse. In Volume 6, the NAS committee 

explained that the increased risk of 

psychiatric symptoms has been 

associated with deployment during any 

period of war and is thus not limited to 

Gulf War deployments. 

The NAS update committee 

determined that there is sufficient 

evidence of association between 

deployment to the Gulf War and several 

other psychiatric disorders, including 

generalized anxiety disorders, 

depression, and substance abuse. The 

results of long-term follow-up studies 

indicate that psychiatric disorders were 

still evident 10 years after deployment 

and were shown to be more than two 

times higher in deployed Veterans 

compared to non-deployed Veterans. 

The NAS update committee further 

noted that an inference can be made that 

the high prevalence of medically 

unexplained disability reported by Gulf 

War Veterans cannot be reliably 

attributed to any known psychiatric 

disorder. Lastly, the NAS update 

committee determined that traumatic 

war exposure experienced during 

deployment in the Gulf War is causally 

related to PTSD. The NAS update 

committee explained that though the 

evidence available from the Gulf War is 

somewhat limited, it is sufficient to 

support the conclusion of a causal 

relationship between combat exposure 

and the development of PTSD. The NAS 

committee further noted that similar 

evidence obtained from other wars is 

also supportive of their conclusion that 

combat exposure and PTSD in the Gulf 

War are causally related. 

VA regulations at 38 CFR 4.125(a) 

require that mental disorders, including 

PTSD, be diagnosed in accordance with 

the Diagnostic and Statistical Manual: 

Fourth Edition (DSM–IV). Under the 

DSM–IV, the diagnosis of PTSD requires 

evidence of a pre-morbid traumatic 

exposure. In order for PTSD to be 

service connected, that traumatic 

exposure must have occurred during a 

period of military service. The NAS 

Update committee did not find a causal 

relationship between mere deployment 

to the Gulf War theater and PTSD, nor 

did it find PTSD to be associated with 

exposure to a particular toxic agent, 

hazard, medicine, or vaccine. Rather, it 

found a causal relationship between 

PTSD and the traumatic war exposures 

experienced during deployment to this 

war zone. Further, these types of 

exposures are not unique to the Gulf 

War, but are common to all episodes of 

combat. Consequently, we do not 

believe there is a sound basis for 

establishing a presumption of service 

connection for PTSD that is limited to 

Veterans of Gulf War combat service. 

Such a presumption would treat Gulf 

War combat Veterans differently than 

combat Veterans of other wars, without 

a rational basis for such disparate 

treatment. 

Although the NAS committee found 

PTSD to be associated with ‘‘traumatic 

war exposure,’’ and the NAS update 

committee found a causal relationship 

between ‘‘traumatic war exposures’’ 

experienced during Gulf War 

deployment and PTSD, PTSD could not 

be associated with the types of exposure 

outlined in 38 U.S.C. 1118, involving 

exposure to hazardous substances 

known or suspected to be associated 

with Gulf War service. VA interprets the 

use of the phrase ‘‘traumatic war 

exposures’’ used in the reports as being 

a general reference to the exposures to 

the dangers of service in a combat area, 

including risk of death or injury due to 

enemy attacks. Accordingly, VA does 

not believe that the reference to 

‘‘traumatic war exposures’’ identifies an 

association between PTSD and a 

specific ‘‘exposure’’ within the meaning 

of section 1118. 

VA also concludes that it is 

unnecessary to create a presumption for 

PTSD for all combat Veterans based on 

VA’s general rulemaking authority. VA’s 

current regulations afford combat 

Veterans essentially the same liberalized 

standard of proof that a presumption 

would provide. When a Veteran has 

been validly diagnosed with PTSD, 

service connection will be granted if the 

PTSD is associated with an in-service 

‘‘stressor.’’ As noted above, the Veteran 

must identify a stressor before a valid 

diagnosis of PTSD can be made. Under 

VA regulations at 38 CFR 3.304(f), if a 

Veteran engaged in combat and the 

claimed stressor relates to combat, VA 

will accept the Veteran’s lay statement 

as sufficient evidence of the stressor. 

Further, under a recent amendment to 

that regulation, even if the Veteran did 

not engage in combat the Veteran’s own 

statements alone may establish the 

occurrence of the claimed in-service 

stressor if the claimed stressor is related 

to the Veteran’s fear of hostile military 

or terrorist activity and is confirmed as 

adequate to support a diagnosis of 

PTSD, the Veteran’s symptoms are 

related to the claimed stressor, and the 

claimed stressor is consistent with the 

places, types, and circumstances of the 

Veteran’s service. 75 FR 39843 (July 13, 

2010). Accordingly, a Veteran whose 

claimed stressor relates to the perils of 

deployment to a war zone generally 

need not submit any evidence of a 

stressor beyond the statements made for 

purposes of the diagnosis of PTSD. A 

presumption of service connection for 

PTSD based on traumatic war exposures 

in the Gulf War theater would neither 

increase the likelihood of a legitimate 

claim being accepted, nor speed the 

process by which claims are 

adjudicated. 

For similar reasons, VA has 

determined that the finding of increased 

prevalence of other psychiatric 

disorders in Gulf War Veterans does not 

warrant a presumption of service 

connection under section 1118. In 

Volume 4 and Volume 8, NAS found 

that psychiatric disorders are associated 

with deployment to the Gulf War, but 

did not find such disorders to be 

associated with any particular type of 

exposure during the Gulf War. In its 

Volume 6 report, NAS found that an 

increased risk of psychiatric disorders is 

associated with deployment to any war 

zone, and that the prevalence and 

severity of those disorders were 

associated with the level of combat 

experienced. This suggests that the 

increased prevalence of psychiatric 

disorders is more likely associated with 

the inherent perils of combat in any war 

than with exposure to specific agents, 

hazards, medicines, or vaccines 

associated with the Gulf War. 

Section 1118(a)(2)(A) and (b)(1)(B) 

require VA to determine whether a 

presumption of service connection is 

warranted by reason of a disease having 

a positive association with exposure to 

a biological, chemical, or other toxic 

agent, environmental or wartime hazard, 

or preventive medicine or vaccine 

‘‘known or presumed to be associated 

with service in the Armed Forces in the 

Southwest Asia theater of operations 

during the Persian Gulf War.’’ We 

conclude that the statutory phrase 

‘‘associated with service in the Armed 

Forces in the Southwest Asia theater of 

operations during the Persian Gulf War’’ 

is most reasonably construed to refer to 

a relationship between the substance or 

hazard and the specific circumstance of 

service in the Southwest Asia theater of 

operations during the Persian Gulf War, 

as distinguished from features of 

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military service that are not unique to 

service in the Gulf War. Section 1118 

reflects the Government’s commitment 

to addressing the unique health issues 

presented by Gulf War Veterans, by 

establishing a process for identifying 

diseases and illnesses that may be 

associated with Gulf War service. The 

requirement that the substances or 

hazards at issue be ‘‘associated with’’ 

Gulf War service makes clear that VA’s 

task is to examine the unique exposure 

environment in the Persian Gulf during 

the Persian Gulf War. Establishing 

presumptions of service connection 

under section 1118 applicable only to 

Gulf War Veterans based on the general 

circumstance of deployment which is 

shared by significant other groups of 

Veterans would not significantly further 

the statute’s purpose, but would create 

significant inequities in the Veterans’ 

benefits system that Congress could not 

have intended. 

VA has also decided not to establish 

a presumption of service connection for 

psychiatric disorders in Veterans of any 

period of deployment to a combat zone 

under VA’s general rulemaking 

authority. The category of psychiatric 

disorders encompasses a diverse array 

of diagnoses. Further, psychiatric 

disorders are widespread and may be 

triggered by many life events, including 

those occurring before and after service. 

Although the NAS reports indicate that 

psychiatric disorders are associated 

with combat deployment, they provide 

no basis for evaluating whether 

Veterans’ psychiatric disorders are more 

likely caused by wartime deployment 

than by any of the many other risk 

factors that are also associated with 

such disorders or for evaluating possible 

differences in the degree to which the 

numerous specific types of psychiatric 

disorders may be associated with 

wartime deployment. Accordingly, a 

general presumption of service 

connection for psychiatric disorders 

would be overly broad. 

VA believes that VA psychiatric 

examinations are a more effective way 

of evaluating whether psychiatric 

disorders are related to military service 

than applying a broad presumption that 

would apply to all Veterans deployed to 

the Gulf War. VA routinely provides 

psychiatric examinations to Veterans 

claiming service connection for 

psychological disorders and believes 

that this process is effective. 

Cardiovascular Disease, Diabetes, 

Arthralgia or Hospitalization 

The NAS committee concluded that 

the evidence did not show that Gulf War 

Veterans have an increased risk of 

cardiovascular disease, diabetes, 

arthralgia, or hospitalization in 

comparison to non-deployed Veterans. 

The NAS update committee found that 

there is limited or suggestive evidence 

of no association between Gulf War 

deployment and mortality from 

cardiovascular disease in the first 10 

years after war. The NAS update 

committee further found that there is 

insufficient or inadequate evidence to 

determine whether an association exists 

between Gulf War deployment and 

endocrine, nutritional, and metabolic 

diseases, including diabetes, and Gulf 

War deployment and musculoskeletal 

system diseases, including arthralgia. 

The NAS update committee did not 

review hospitalization as a separate 

category as reviewed in Volume 4; 

rather, the committee included 

hospitalization as a factor in each 

specific health outcome reviewed. 

In order for a presumption to be 

warranted the Secretary must establish 

that there is a ‘‘positive association’’ 

between ‘‘the exposure of humans or 

animals to a biological, chemical or 

other toxic agent, environmental or 

wartime hazard, or preventive medicine 

or vaccine known or presumed to be 

associated with service in the Armed 

Forces in the Southwest Asia theater of 

operations during the Persian Gulf War; 

and [] the occurrence of a diagnosed or 

undiagnosed illness in humans or 

animals.’’ 38 U.S.C. 1118(b)(1)(B). An 

association is considered ‘‘positive’’ if 

the credible evidence for an association 

is equal to or outweighs the credible 

evidence against the association. 38 

U.S.C. 1118(b)(3). For the conditions 

listed above, the NAS committee 

concluded that there was not an 

increased risk, and the update 

committee found that there was 

inadequate or insufficient evidence to 

determine whether an association exists 

or limited or suggestive evidence of no 

association with deployment to the Gulf 

War. Therefore, VA concludes that the 

evidence of an association for these 

conditions does not equal or outweigh 

the credible evidence against an 

association. Based on this analysis, VA 

has determined that no presumptions of 

service connection are warranted for 

any of the above-mentioned outcomes 

based on Gulf War service. 

Cancer 

The NAS committee concluded that 

the evidence did not show that Gulf War 

Veterans have an increased overall risk 

of cancer. However, in one study in 

Volume 4 an association of brain-cancer 

mortality with possible nerve-agent 

exposure was observed. The NAS 

committee noted that this finding 

should be interpreted with caution due 

to concerns about the exposure 

modeling and the fact that the study 

period was not within what is believed 

to be the usual latency period for brain 

cancer. Further, Volume 4 reported 

mixed results as to whether an 

association exists between testicular 

cancer and deployment to the Gulf War. 

The NAS update committee 

determined that there was insufficient 

or inadequate evidence of an association 

between Gulf War exposures and brain 

cancer. The NAS update committee did 

not identify any new studies relating to 

testicular cancer. The NAS update 

committee noted that many Veterans of 

the Gulf War are still too young for 

cancer diagnoses and that the follow-up 

period following the Gulf War has 

probably been too short to expect 

significant results. Thus, the NAS 

update committee recommends further 

follow-up in order to make a conclusion 

about whether there is an association 

between deployment during the Gulf 

War and cancer outcomes. Based on the 

information provided in Volume 4 and 

Volume 8, the Secretary has determined 

that no new presumptions relating to 

cancer are warranted at this time. 

Mortality From External Causes 

The NAS committee noted that 

studies provided evidence that Gulf War 

Veterans had an increased risk of 

transportation-related injury and 

mortality in the first several years after 

such service when compared to nondeployed service members. The NAS 

committee found no evidence that this 

result was related to a specific exposure 

in Gulf War service or that it was related 

to a specific disease or illness. 

The NAS update committee identified 

four new studies of external cause 

mortality and determined that the 

evidence indicates a modestly higher 

mortality from transportation-related 

causes among Gulf War deployed 

Veterans than other Veterans. The 

increase was due to motor-vehicle 

accidents which diminished or 

disappeared over time. The NAS update 

committee concluded that there is 

limited or suggestive evidence of an 

association between deployment to the 

Gulf War and increase in mortality from 

external causes primarily motor vehicle 

accidents, in the early years after 

deployment. 

VA notes that VA and other 

researchers have documented this 

transitory post-combat-deployment 

health effect among Veterans of other 

combat deployments, including 

Vietnam. Further, the findings of 

Volume 4 and Volume 8 do not identify 

an ‘‘illness’’ or a specific identified risk 

factor (e.g., a particular exposure) 

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known or suspected to be associated 

with Gulf War service. Without these 

conditions, 38 U.S.C. 1118 does not 

authorize VA to establish a presumption 

for the increased risk of transportationrelated injury or death. Because this 

phenomenon has not been connected to 

a disease or injury incurred or 

aggravated in service, VA has no 

statutory authority to compensate 

Veterans or their survivors through a 

new presumption, absent new 

legislative authority. See 38 U.S.C. 501 

and 1110. Thus, after careful review of 

the findings of mortality from external 

causes, primarily motor vehicle 

accidents, in the early years after 

deployment, the Secretary has 

determined that the scientific evidence 

presented in Volume 4 and Volume 8 

indicates that no presumption of service 

connection is warranted at this time. 

Skin Conditions 

The NAS committee found that some 

studies provided evidence that Gulf War 

Veterans have a higher incidence of 

certain skin conditions (atopic 

dermatitis and warts) than nondeployed Veterans, but that the findings 

were not consistent among the relevant 

studies. The NAS committee identified 

no evidence linking those conditions to 

any particular exposure in Gulf War 

Service. The NAS update committee 

determined that there was insufficient 

or inadequate evidence of an association 

between deployment to the Gulf War 

and skin disorders and noted that the 

inconsistency in the studies suggests 

that the few positive findings may be 

due to chance. Based on the 

inconsistent evidence of an association 

between deployment to the Gulf War 

and skin disorders and because these 

skin conditions have not been attributed 

to any particular exposure in the Gulf 

War, VA has determined that no new 

presumption of service connection is 

warranted for dermatological 

conditions. 

Amyotrophic Lateral Sclerosis 

The NAS committee and the NAS 

update committee found that some 

studies indicate that Gulf War Veterans 

may have an increased risk of 

amyotrophic lateral sclerosis (ALS). In 

another report issued in November 

2006, titled Amyotrophic Lateral 

Sclerosis in Veterans: Review of the 

Scientific Literature, a separate NAS 

committee concluded that there is 

evidence of an increased risk of ALS in 

Veterans of all periods of service. 

In September 2008, VA issued 

regulations establishing a presumption 

of service connection for ALS following 

any period of qualifying service. 73 FR 

54691 (Sept. 23, 2008). Because this 

presumption applies to all Gulf War 

Veterans, there is no need for a separate 

presumption that is applicable only to 

Gulf War Veterans. 

Other Diseases of the Nervous System 

The NAS committee found that 

available studies generally did not 

provide evidence of an increased 

prevalence among Gulf War Veterans of 

peripheral neuropathy. The NAS update 

committee found that available studies 

generally did not provide evidence of an 

increased prevalence among Gulf War 

Veterans of peripheral neuropathy, 

multiple sclerosis, other neurological 

diseases such as Alzheimer’s disease, 

dementia and Parkinson’s disease, or 

other neurological outcomes. The NAS 

update committee therefore concluded 

that there was inadequate or insufficient 

evidence to determine whether an 

association exists between deployment 

to the Gulf War and multiple sclerosis, 

other neurological diseases, or other 

neurological outcomes, and that there is 

limited or suggestive evidence of no 

association between such deployment 

and peripheral neuropathy. Based on 

the committees’ findings, the Secretary 

has determined that no new 

presumptions are warranted for these 

conditions. 

Neurocognitive and Neurobehavioral 

Performance 

The NAS committee defined primary 

studies as ‘‘high quality studies that 

used neurobehavioral tests that had 

previously been used to detect adverse 

effects in population-based research on 

occupational groups.’’ The findings 

compared neurobehavioral performance 

in deployed Veterans and non-deployed 

Veterans. The NAS committee 

concluded that the primary studies of 

Veterans deployed to the Gulf War 

compared to Veterans not deployed to 

the Gulf War do not demonstrate 

differences in cognitive and motor 

measures as determined through 

neurobehavioral testing. However, the 

NAS committee did conclude that Gulf 

War Veterans who had at least one 

symptom commonly reported by Gulf 

War Veterans (such as fatigue, memory 

loss, confusion, inability to concentrate, 

mood swings, somnolence, 

gastrointestinal distress, muscle or joint 

pain, or skin or mucous membrane 

complaints) had poorer performance on 

cognitive tests than returning Veterans 

who did not report any such symptoms. 

The NAS update committee reviewed 

two additional studies that were 

classified as secondary. Primary studies 

of deployed Gulf War Veterans versus 

non-deployed Veterans did not 

demonstrate differences in cognitive 

and motor measures to determine the 

neurobehavioral testing. The NAS 

update committee concluded that there 

is inadequate or insufficient evidence to 

determine if an association exists 

between deployment to the Gulf War 

and neurocognitive and neurobehavioral 

performance. 

Decreased neurocognitive or 

neurobehavioral performance is not in 

itself a disease or illness for which 

service connection may be established. 

Further, Volume 4 and Volume 8 did 

not find evidence of an association 

between such decreased performance 

and any Gulf War exposure. 

Accordingly, VA has determined that no 

presumption relating to neurocognitive 

and neurobehavioral performance is 

warranted at this time. 

Sexual Dysfunction 

The NAS committee reviewed one 

primary study on self-reported sexual 

dysfunction in Volume 4. In this study 

the self-reported sexual problems were 

verified through physician interviews. 

The NAS committee found that Gulf 

War Veterans consistently report an 

increased prevalence of sexual problems 

when compared to nondeployed 

Veterans. 

The NAS update committee did not 

consider any new primary studies, but 

considered seven additional secondary 

studies in Volume 8. The NAS update 

committee noted that in one study, 

assessing exposures specific to Gulf War 

service, there was no association 

between nerve agent exposure and 

reported sexual problems among 

Veterans deployed to the Gulf War. The 

NAS update committee further noted 

that all of the studies relied exclusively 

on survey responses except for the 

primary study reviewed in Volume 4. 

The NAS update committee 

acknowledged that studies assessing the 

prevalence of sexual problems are 

generally limited to self-reported 

symptoms, but warned that these 

studies should be interpreted with 

caution given concerns about their 

susceptibility to selection and reporting 

biases. The NAS update committee 

concluded that there was limited or 

suggestive evidence of an increased 

prevalence of self-reported sexual 

difficulties among Gulf War Veterans. 

Although the NAS update committee 

found limited or suggestive evidence of 

an increase in self-reported sexual 

dysfunction, it did not find an increase 

in any specific or verified disease, nor 

did it find evidence associating any 

such condition with a particular Gulf 

War exposure. Accordingly, VA has 

determined that a presumption of 

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service connection for sexual 

dysfunction is not warranted at this 

time. 

Other Genitourinary Outcomes 

The NAS committee did not discuss 

other genitourinary conditions in 

Volume 4. In Volume 8, the NAS update 

committee found that studies showed an 

increased incidence of self-reported 

genitourinary symptoms or diseases 

among Veterans of Gulf War 

deployments. It found that such studies 

were limited by self-reported outcomes, 

lack of clinical confirmation, potential 

recall bias, and generally poor response 

rates. The NAS update committee 

identified no reports based on 

confirmed diagnoses showing increased 

incidence of genitourinary conditions 

among Veterans of Gulf War 

deployments. The NAS update 

committee also found that 

hospitalization studies provide evidence 

that hospitalizations for genitourinary 

conditions were not increased in that 

population. Accordingly, the NAS 

update committee concluded that there 

was inadequate or insufficient evidence 

to determine whether an association 

exists between Gulf War deployment 

and specific conditions of the 

genitourinary system, and that there is 

limited or suggestive evidence of no 

association between Gulf War 

deployment and hospitalization for 

genitourinary diseases. Accordingly, VA 

has determined that a presumption of 

service connection for genitourinary 

conditions is not warranted at this time. 

Fertility Problems 

In Volume 4 and Volume 8, the NAS 

committee and the NAS update 

committee assessed fertility problems 

such as semen parameters, 

hospitalization for infertility or 

genitourinary system diseases, selfreported difficulties in achieving a 

pregnancy, and serum concentrations of 

reproductive hormones in males. The 

NAS committee reviewed two primary 

studies in Volume 4. The NAS 

committee found that, although it 

appears that there is no difference in the 

prevalence of male fertility problems or 

infertility between Veterans deployed to 

the Gulf War and nondeployed 

Veterans, it is difficult to draw any 

conclusions due to the small number of 

available studies. 

The NAS update committee 

additionally reviewed one primary 

study and four secondary studies in 

Volume 8. The NAS update committee 

found that there was no evidence of 

significant differences in concentrations 

of male reproductive hormones between 

Gulf War Veterans and nondeployed 

Veterans, but noted that this question 

was only addressed by one study. The 

NAS update committee further noted 

that, although it appears that infertility 

problems are reported more frequently 

among Gulf War Veterans compared to 

their nondeployed counterparts, these 

findings should be interpreted with 

caution because of the small number of 

available studies and their susceptibility 

to reporting bias and selective 

participation. The NAS update 

committee concluded that there was 

inadequate or insufficient evidence to 

determine whether an association exists 

between deployment to the Gulf War 

and fertility problems. Based on the 

NAS committee and the NAS update 

committee’s findings, VA has 

determined that no presumption of 

service connection for fertility problems 

is warranted at this time. 

Adverse Pregnancy Outcomes 

The NAS committee and the NAS 

update committee reviewed studies 

concerning adverse pregnancy 

outcomes, such as the prevalence of 

spontaneous abortions, stillbirths, 

ectopic pregnancies, preterm births, low 

birth weight, and macrosomia, in the 

pregnancies of Gulf War deployed and 

nondeployed men and women. In 

Volume 4, the NAS committee reviewed 

one primary study and two secondary 

studies. The primary study was the only 

study of adverse pregnancy outcomes 

that used hospital discharge records 

rather than relying exclusively on selfreported outcomes. 

In Volume 8, the NAS update 

committee reviewed five additional 

secondary studies evaluating the effect 

of deployment on adverse pregnancy 

outcomes. The NAS update committee 

found that one of the primary studies 

reviewed in Volume 4 noted an 

increased risk of spontaneous abortion 

and ectopic pregnancy among activeduty personnel admitted to military 

hospitals for pregnancy-related 

diagnoses, but that these results may not 

be generalized to Veterans who have left 

service or to pregnancy-related 

admissions to nonmilitary hospitals. 

The NAS update committee observed 

that such findings for spontaneous 

abortion were not replicated in the four 

secondary studies of female Veterans 

reviewed in Volume 8. The NAS update 

committee further observed that, in 

Volume 8, the one secondary study that 

addressed ectopic pregnancies did not 

indicate any increased incidence among 

either male or female Veterans of Gulf 

War deployments. The NAS update 

committee found that, among males 

reporting on their female partners, there 

was no consistent association for 

abortions, spontaneous abortion, 

preterm birth or low birth weight, but 

three studies showed a modest increase 

in self reported miscarriages among 

deployed males reporting on their 

female partners. The NAS update 

committee concluded that there was 

inadequate or insufficient evidence to 

determine whether an association exists 

between deployment to the Gulf War 

and adverse pregnancy outcomes. Based 

on the NAS committee and the NAS 

update committee findings, VA has 

determined that a presumption of 

service connection for adverse 

pregnancy outcomes is not warranted at 

this time. 

Birth Defects 

In Volume 4, a study identified birth 

defects among infants of military 

personnel born from January 1, 1989, to 

December 31, 1993, from populationbased birth defect registries in six 

States: Arizona, Hawaii, Iowa, Arkansas, 

California, and Georgia. The study 

compared 48 selected congenital 

anomalies diagnosed from birth to the 

age of 1 year between Gulf War 

Veterans’ and non-deployed Veterans’ 

infants conceived before, during or after 

the war; and between infants conceived 

by Gulf War Veterans before and after 

the war. The study found three cardiac 

defects and one kidney defect among 

infants conceived after the war to Gulf 

War Veteran fathers. The study also 

found a higher prevalence of 

hypospadias, a genitourinary defect 

among sons conceived post-war to Gulf 

War Veteran mothers compared to their 

non-deployed counterparts. Aortic valve 

stenosis, coarctation of aorta, and renal 

agenesis and hypoplasia were also 

elevated among infants conceived by 

Gulf War Veteran fathers post-war 

compared to those conceived prior to 

the war. 

The NAS update committee reviewed 

the studies identified in the Volume 4 

report and considered a study by Doyle 

et al. (2004) as a primary study due to 

medical confirmation of self-reported 

outcomes. The Doyle study was 

considered a secondary study in the 

Volume 4 report. The study evaluated 

the prevalence of self-reported birth 

defects among the offspring of Veterans 

deployed to the Gulf and among the 

offspring of non-deployed Veterans who 

responded to a postal questionnaire. No 

significant associations with birth 

defects were found for infants of 

mothers deployed to the Gulf, although 

the analyses were limited. 

Based on the primary studies of both 

reports and the availability of medical 

confirmation in those studies, there is 

some suggestion of increased risk of 

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birth defects among the offspring of Gulf 

War Veterans. However, there is no 

consistent pattern of higher prevalence 

of birth defects among offspring of male 

or female Gulf War Veterans, and no 

single defect, except urinary tract 

abnormalities, has been found in more 

than one well-designed study. The NAS 

update committee concluded there is 

inadequate or insufficient evidence to 

determine whether an association exists 

between deployment to the Gulf War 

and specific birth defects. Accordingly, 

VA has determined that there is no basis 

for a presumption relating to birth 

defects of the offspring of Veterans 

deployed to the Gulf War. VA notes 

further that it has no authority under 38 

U.S.C. 1118 or other statutes to pay 

benefits for disability in the children of 

Gulf War Veterans. 

Respiratory Symptoms 

The NAS committee found that the 

reporting of respiratory symptoms, but 

not specific respiratory illnesses, is 

more prevalent in deployed Gulf War 

Veterans than in their non-deployed 

counterparts. The NAS committee 

identified five primary studies that 

examined the association between 

pulmonary conditions and deployment 

to the Gulf War. The committee found 

that respiratory symptoms, but not 

specific respiratory illnesses, are more 

prevalent in deployed Gulf War 

Veterans than in their non-deployed 

counterparts. Two of these studies 

analyzed data of Gulf War Veterans and 

non-deployed Veterans derived from a 

cohort of randomly selected participants 

from a previous 1995 study who had 

completed the earlier mailed 

questionnaire on self-reports of health 

conditions. One study reported on the 

prevalence of self-reported asthma, 

bronchitis, and emphysema and found 

no significant differences between the 

Gulf War Veterans and non-deployed 

Veterans after adjusting for smoking and 

demographic variables. An additional 

study applied spirometry and symptom 

interviews to a random selection of Gulf 

War deployed Veterans compared to 

non-deployed Veterans. A 2004 study 

found that only a history of smoking 

and wheezing among the respiratory 

outcomes studied were significantly 

elevated in the deployed Veterans. 

Spirometric measurements also show no 

significant difference between the Gulf 

War deployed Veterans compared to 

non-deployed Veterans. The study also 

looked at the effect of potential 

exposure to the Khamisiyah nerve gas 

releases by selectively comparing 

Veterans deployed into the geographic 

areas potentially affected, and no 

significant differences were noted in the 

measured pulmonary functions of these 

Veterans when compared to nondeployed Veterans who were not 

exposed to the nerve gas. The last study 

examined the pulmonary function 

parameters of Gulf War Seabees and 

non-deployed Seabees and found no 

significant difference between the two 

groups, but respiratory symptoms and 

shortness of breath were more common 

among deployed Veterans compared 

with non-deployed Veterans. 

Additional primary studies examined 

the association between exposure to 

smoke from the Kuwaiti oil-well fires 

and respiratory outcomes. One study 

examined the effect of exposure to oilwell–fire smoke using exposure 

estimates based on troop locations and 

National Oceanographic and 

Atmospheric Administration modeling. 

The NAS committee found that the risk 

of physician-diagnosed asthma 

increased with increasing exposure and 

self-reported exposure. There were no 

pulmonary function tests conducted and 

the study did not distinguish 

preexisting asthma from new onset 

asthma. 

The NAS committee found that no 

study using objective estimates of 

exposure to nerve agents due to the 

destruction of a munitions site at 

Khamisiyah, Iraq, in 1991 found any 

increased risk of respiratory disease or 

other problems with pulmonary 

function. Based on the information in 

Volume 4, VA has determined that a 

presumption of service connection for 

respiratory disease with exposures at 

Khamisiyah is not warranted at this 

time. 

The NAS update committee identified 

three additional primary studies of 

respiratory outcomes and the 

deployment to the Gulf War. The 

studies found a non-significant increase 

in respiratory disease hospitalizations 

for Veterans deployed to Southwest 

Asia after the Gulf War and no excess 

deaths due to diseases of the respiratory 

system among Gulf War Veterans versus 

non-deployed Veterans. The third study 

identified no increase in mortality risk 

due to respiratory diseases among 

Veterans exposed to the chemical 

munitions destruction at Khamisiyah 

compared to the unexposed Veterans. 

One study found a non-significant 

increase in respiratory disease 

hospitalizations for Veterans deployed 

to Southwest Asia after the Gulf War as 

compared to Gulf War Veterans. The 

NAS update committee found that 

studies based on self-reported 

symptoms and self-reported diagnoses 

related to respiratory disease have 

inconsistently but frequently shown an 

increase among Gulf War Veterans. 

There appears to be no increase in 

respiratory disease among Gulf War 

Veterans when examined with objective 

measures of disease. Pulmonary 

function studies and mortality studies 

have shown no significant excess of 

lung function abnormalities or of death 

due to respiratory disease among Gulf 

War Veterans. The NAS update 

committee concluded that there is 

inadequate or insufficient evidence to 

determine whether an association exists 

between deployments to the Gulf War 

and respiratory disease. The NAS 

update committee further concluded 

that there is limited or suggestive 

evidence of no association between 

deployment to the Gulf War and 

decreased lung function in the first 10 

years after the war. 

Current VA regulations at 38 CFR 

3.317 provide a presumption of service 

connection for chronic disability due to 

signs or symptoms affecting the 

respiratory system. Because chronic 

respiratory signs and symptoms are 

already included in § 3.317 and because 

an association between deployment to 

the Gulf War and either respiratory 

disease or decreased lung function 

could not be established, VA has 

determined that a presumption of 

service connection for respiratory 

disease is not warranted at this time. 

Diseases of the Blood and BloodForming Organs 

The NAS committee in Volume 4 did 

not specifically address blood diseases. 

The NAS update committee in Volume 

8 found that available studies did not 

show an increased incidence of diseases 

of the blood and blood-forming organs 

in Gulf War Veterans. Accordingly, the 

NAS update committee concluded that 

there was inadequate or insufficient 

evidence to determine whether an 

association exists between deployment 

to the Gulf War and such diseases. 

Based on the NAS update committee’s 

findings, the Secretary has determined 

that no new presumption relating to 

diseases of the blood and blood-forming 

organs is warranted at this time. 

Structural Gastrointestinal Diseases 

The NAS committee and the NAS 

update committee found that studies 

showed an increased incidence of selfreported gastrointestinal symptoms or 

disorders among Veterans of Gulf War 

deployments. As noted above, the NAS 

update committee found sufficient 

evidence of an association between 

deployment to the Gulf War and 

functional gastrointestinal disorders and 

VA has addressed that finding in a 

separate rulemaking. 75 FR 70162 

(proposed Nov. 17, 2010). The NAS 

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update committee also found that there 

was inadequate or insufficient evidence 

to determine whether an association 

exists between Gulf War deployment 

and structural gastrointestinal diseases, 

such as peptic ulcer and inflammatory 

bowel disease (which includes 

ulcerative colitis and Crohn’s disease). 

Although some of the reviewed studies 

found increased incidence of self 

reports of certain structural 

gastrointestinal diseases, the NAS 

update committee noted that the lack of 

diagnostic testing to validate those 

results was a significant confounding 

factor, because physicians not 

infrequently place an organic disease 

label (such as gastritis or peptic ulcer) 

on a patient’s symptoms without 

performing diagnostic studies. The NAS 

update committee also noted that 

studies did not find an increased 

incidence of hospitalization or death 

due to gastrointestinal disease in 

Veterans of Gulf War deployments. 

Based on these findings, the Secretary 

has determined that no new 

presumption relating to structural 

gastrointestinal diseases is warranted at 

this time. 

VI. Conclusion 

After careful review of the findings of 

Volume 4 and Volume 8, the Secretary 

has determined that the scientific 

evidence presented in these reports 

indicates that no new presumption of 

service connection is warranted at this 

time for any of the illnesses described 

in the NAS 2006 and NAS update 

committee’s 2010 reports. It is important 

to note that VA’s determination that 

presumptions of service connection are 

not warranted at this time for the health 

effects in question is not intended to 

suggest that they are irrelevant to further 

investigations of Gulf War Veterans’ 

health or that they may not in any 

circumstances form the basis for 

presumptions of service connection 

under Public Law 105–277. In the event 

future evidence links any illnesses to 

exposures associated with Gulf War 

service, VA may establish presumptions 

of service connection for such illnesses 

pursuant to Public Law 105–277. It is 

equally important to note that VA’s 

determinations not to establish 

presumptions do not in any way 

preclude claimants from seeking and 

establishing service connection for these 

diseases and illnesses or any other 

diseases or illnesses that may be shown 

by evidence in an individual case to be 

associated with service in the Gulf War. 

Signing Authority 

The Secretary of Veterans Affairs, or 

designee, approved this document and 

authorized the undersigned to sign and 

submit the document to the Office of the 

Federal Register for publication 

electronically as an official document of 

the Department of Veterans Affairs. John 

R. Gingrich, Chief of Staff, Department 

of Veterans Affairs, approved this 

document on March 31, 2011, for 

publication. 

Dated: April 8, 2011. 

William F. Russo, 

Deputy Director, Regulations Policy and 

Management, Department of Veterans Affairs. 

[FR Doc. 2011–8937 Filed 4–13–11; 8:45 am] 

BILLING CODE P 

DEPARTMENT OF VETERANS 

AFFAIRS 

Veterans’ Rural Health Advisory 

Committee; Notice of Meeting 

The Department of Veterans Affairs 

(VA) gives notice under Public Law 92– 

463 (Federal Advisory Committee Act) 

that the Veterans’ Rural Health Advisory 

Committee will conduct a 

teleconference meeting on Thursday, 

April 21, 2011, from 2 p.m. to 4 p.m., 

in Room GL20, 1722 I Street, NW., 

Washington, DC. The toll-free number 

for the meeting is 1–800–767–1750, and 

the access code is 57165#. The meeting 

is open to the public. 

The purpose of the Committee is to 

advise the Secretary of Veterans Affairs 

on health care issues affecting enrolled 

Veterans residing in rural areas. The 

Committee examines programs and 

policies that impact the provision of VA 

health care to enrolled Veterans residing 

in rural areas and discusses ways to 

improve and enhance VA services for 

these Veterans. 

The Committee will discuss the 

Committee’s Annual Report to the VA 

Secretary, VA Veteran Centers services, 

rural women Veteran health care, and 

the meeting agenda and planning for the 

Committee’s upcoming June 2011 

meeting in Helena, Montana. 

A 15-minute period will be reserved 

at 3:40 p.m. for public comments. 

Individuals who wish to address the 

Committee are invited to submit a 1–2 

page summary of their comments for 

inclusion in the official meeting record. 

Members of the public may also submit 

written statements for the Committee’s 

review to Christina White, Designated 

Federal Officer, Department of Veterans 

Affairs (10A5A), 810 Vermont Avenue, 

NW., Washington, DC 20420 or e-mail at 

rural.health.inquiry@va.gov. Any 

member of the public wishing to attend 

or seeking additional information 

should contact Ms. White at (202) 461– 

7100. 

Dated: April 11, 2011. 

By direction of the Secretary. 

William F. Russo, 

Director of Regulations Management, Office 

of General Counsel. 

[FR Doc. 2011–9087 Filed 4–13–11; 8:45 am] 

BILLING CODE P 

DEPARTMENT OF VETERANS 

AFFAIRS 

Advisory Committee on Prosthetics 

and Special-Disabilities Programs; 

Notice of Meeting 

The Department of Veterans Affairs 

(VA) gives notice under Public Law 92– 

463 (Federal Advisory Committee Act) 

that a meeting of the Advisory 

Committee on Prosthetics and SpecialDisabilities Programs will be held on 

May 3–4, 2011, in room 230, at VA 

Central Office, 810 Vermont Avenue, 

NW., Washington, DC. The sessions will 

convene at 8:30 a.m. on both days, and 

will adjourn at 4:30 p.m. on May 3 and 

at 12 noon on May 4. The meeting is 

open to the public. 

The purpose of the Committee is to 

advise the Secretary of Veterans Affairs 

on VA’s prosthetics programs designed 

to provide state-of-the art prosthetics 

and the associated rehabilitation 

research, development, and evaluation 

of such technology. The Committee also 

provides advice to the Secretary on 

special disabilities programs which are 

defined as any program administered by 

the Secretary to serve Veterans with 

spinal cord injuries, blindness or visual 

impairments, loss of extremities or loss 

of function, deafness or hearing 

impairment, and other serious 

incapacities in terms of daily life 

functions. 

On May 3, the Committee will be 

briefed by the Acting Assistant Deputy 

Under Secretary for Clinical Operations 

and Management; Chief Consultant for 

Social Work Service; Director of Blind 

Rehabilitation Service; and Chief 

Consultant for Spinal Cord Injury & 

Disorders Strategic Healthcare Group. 

On May 4, the Committee will be 

briefed by the Chief Consultant for Care 

Coordination, and Chief Consultant for 

Rehabilitation Services. 

No time will be allocated for receiving 

oral presentations from the public. 

However, members of the public may 

submit written statements for review by 

the Committee to Mr. Larry N. Long, 

Designated Federal Officer, Veterans 

Health Administration, Patient Care 

Services, Rehabilitation Services (117D), 

Department of Veterans Affairs, 810 

Vermont Avenue, NW., Washington, DC 

20420, or by e-mail at lonlar@va.gov. 

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