50856 Federal Register / Vol. 73, No. 168 / Thursday, August 28, 2008 / Notices 

Office, Office of Thrift Supervision, 

1700 G Street, NW., Washington, DC 

20552, by fax to (202) 906–6518, or by 

e-mail to 

infocollection.comments@ots.treas.gov. 

OTS will post comments and the related 

index on the OTS Internet site at http:// 

www.ots.treas.gov. In addition, 

interested persons may inspect 

comments at the Public Reading Room, 

1700 G Street, NW., by appointment. To 

make an appointment, call (202) 906–

5922, send an e-mail to 

public.info@ots.treas.gov, or send a 

facsimile transmission to (202) 906–

7755. 

FOR FURTHER INFORMATION CONTACT: For 

further information or to obtain a copy 

of the submission to OMB, please 

contact Ira L. Mills at 

ira.mills@ots.treas.gov (202) 906–6531, 

or facsimile number (202) 906–6518, 

Regulations and Litigation Division, 

Chief Counsel’s Office, Office of Thrift 

Supervision, 1700 G Street, NW., 

Washington, DC 20552. 

SUPPLEMENTARY INFORMATION: OTS may 

not conduct or sponsor an information 

collection, and respondents are not 

required to respond to an information 

collection, unless the information 

collection displays a currently valid 

OMB control number. As part of the 

approval process, we invite comments 

on the following information collection. 

Title of Proposal: Consumer 

Complaint Form. 

OMB Number: 1550–0NEW. 

Form Number: 1723. 

Description: The OTS Consumer 

Complaint form provides a model for 

the public to provide information to 

OTS to assist with the investigation of 

their complaint. The data collected via 

the form or letter is critical to 

investigating a complaint and will be 

used to create a record of the 

consumer’s contact and will be entered 

into a database of information that can 

be incorporated into the OTS’s 

supervisory process. 

Type of Review: New Collection. 

Affected Public: Individuals or 

households. 

Estimated Number of Respondents: 

1,180. 

Estimated Number of Responses: 

1,180. 

Estimated Burden Hours per 

Response: 15 minutes. 

Estimated Frequency of Response: On 

occasion. 

Estimated Total Burden: 295 hours. 

Clearance Officer: Ira L. Mills, (202) 

906–6531, Office of Thrift Supervision, 

1700 G Street, NW., Washington, DC 

20552. 

Dated: August 22, 2008. 

Deborah Dakin, 

Senior Deputy Chief Counsel, Regulations and 

Legislation Division. 

[FR Doc. E8–19958 Filed 8–27–08; 8:45 am] 

BILLING CODE 6720–01–P 

DEPARTMENT OF VETERANS 

AFFAIRS 

Determination of Presumption of 

Service Connection Concerning 

Illnesses Discussed in National 

Academy of Sciences Report on Gulf 

War and Health 

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, Public Law 105–

277, title XVI, 112 Stat. 2681–742 

through 2681–749 (codified in part at 38 

U.S.C. 1118), has determined that there 

is no basis to establish a presumption of 

service connection at this time for any 

of the diseases, illnesses, or health 

effects discussed in the December 20, 

2004, report of the National Academy of 

Science, titled ‘‘Gulf War and Health, 

Volume 3. Fuels, Combustion Products, 

and Propellants’’ based on exposure to 

fuels, combustion products, or 

propellants during service in the Persian 

Gulf during the Persian Gulf War. This 

determination does not in any way 

preclude VA from granting service 

connection for any disease, including 

those specifically discussed in this 

notice, nor does it change any existing 

rights or procedures. 

FOR FURTHER INFORMATION CONTACT: 

Rhonda F. Ford, Chief, Regulations Staff 

(211D), Compensation and Pension 

Service, Veterans Benefits 

Administration, Department of Veterans 

Affairs, 810 Vermont Avenue, NW., 

Washington, DC 20420, (202) 461–9739. 

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 

(codified 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 

National Academy of Sciences (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 Persian Gulf during the 

Gulf War. Congress directed NAS to 

identify agents, hazards, medicines, and 

vaccines to which service members may 

have been exposed during service in the 

Persian Gulf during the Gulf War. 

Congress mandated that NAS 

determine, to the extent possible: (1) 

Whether there is a statistical association 

between exposure to the agent, hazard, 

medicine, or vaccine and the illness, 

taking into account the strength of the 

scientific evidence and the 

appropriateness of the scientific 

methodology used to detect the 

association; (2) the increased risk of 

illness among individuals exposed to 

the agent, hazard, medicine, or vaccine; 

and (3) whether a plausible biological 

mechanism or other evidence of a causal 

relationship exists between exposure to 

the agent, hazard, medicine, or vaccine 

and the illness. 

Section 1118 provides that whenever 

the Secretary determines, based on 

sound medical and scientific evidence, 

that a positive association (i.e., the 

credible evidence for the association is 

equal to or outweighs the credible 

evidence against the association) exists 

between 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 Southwest Asia 

theater of operations during the Persian 

Gulf War and the occurrence of a 

diagnosed or undiagnosed illness in 

humans or animals, the Secretary will 

publish regulations establishing 

presumptive service connection for that 

illness. If the Secretary determines that 

a presumption of service connection is 

not warranted, the Secretary is to 

publish a notice of that determination, 

including an explanation of the 

scientific basis for that determination. 

The Secretary’s determination must be 

based on consideration of the NAS 

reports and all other sound medical and 

scientific information and analysis 

available to the Secretary. 

Although section 1118 does not 

define ‘‘credible evidence,’’ it does 

instruct the Secretary to take into 

consideration whether the results (of 

any report, information, or analysis) are 

statistically significant, are capable or 

replication, and withstand peer review. 

See 38 U.S.C. 1118(b)(2)B). Simply 

comparing the number of studies that 

report a significantly increased relative 

risk to the number of studies that report 

a relative risk that is not significantly 

increased is not a valid method for 


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determining whether the weight of 

evidence overall supports a finding that 

there is or is not a positive association 

between exposure to an agent, hazard, 

or medicine or vaccine and the 

subsequent development of the 

particular illness. Because of differences 

in statistical significance, confidence 

levels, control for confounding factors, 

and other pertinent characteristics, 

some studies are clearly more credible 

than others, and the Secretary has given 

the more credible studies more weight 

in evaluating the overall weight of the 

evidence concerning specific illnesses. 

II. Prior National Academy of Sciences 

Reports 

NAS issued its initial report titled, 

Gulf War and Health, Volume 1: 

‘‘Depleted Uranium, Sarin, 

Pyridostigmine Bromide, Vaccines,’’ on 

January 1, 2000. In that report, NAS 

limited its analysis to the health effects 

of depleted uranium, the chemical 

warfare agent sarin, vaccinations against 

botulism toxin and anthrax, and 

pyridostigmine bromide, which was 

used in the Gulf War as a pretreatment 

for possible exposure to nerve agents. 

On July 6, 2001, VA published a notice 

in the Federal Register announcing the 

Secretary’s determination that the 

available evidence did not warrant a 

presumption of service connection for 

any disease discussed in that report. See 

66 FR 35702 (2001). 

NAS issued its second report titled, 

‘‘Gulf War and Health, Volume 2: 

Insecticides and Solvents,’’ on February 

18, 2003. In that report, NAS focused on 

the health effects of insecticides and 

solvents that were shipped to the 

Persian Gulf during the Persian Gulf 

War. The pesticides considered by NAS 

were organophosphorous compounds 

(malathion, diazinon, chlorpyrifos, 

dichlorvos, and azamethiphos), 

carbamates (carbaryl, propoxur, and 

methomyl), pyrethrins and pyrethyroids 

(permethrin and d-phenothrin), lindane, 

and N,N-diethyl-3-methylbenzamide 

(DEET). NAS considered 53 solvents in 

eight groups: Aromatic hydrocarbons 

(including benzene), halogenated 

hydrocarbons (including 

tetrachloroethylene and dry-cleaning 

solvents), alcohols, glycols, glycol 

esters, esters, ketones, and petroleum 

distillates. On August 24, 2007, VA 

published a notice in the Federal 

Register announcing the Secretary’s 

determination that the available 

evidence did not warrant a presumption 

of service connection for any disease 

discussed in that report. 72 FR 48734 

(2007). 

III. Gulf War and Health, Volume 3. 

Fuels, Combustion Products, and 

Propellants 

NAS issued a third report, titled ‘‘Gulf 

War and Health, Volume 3. Fuels, 

Combustion Products, and Propellants,’’

on December 20, 2004. In that report, 

NAS focused on the health effects of 

hydrazines, red fuming nitric acid, 

hydrogen sulfide, oil-fire byproducts, 

diesel-heater fumes, and fuels (for 

example, jet fuel and gasoline). 

In its report, NAS classified the 

evidence of an association between 

exposure to a specific agent and a 

specific health outcome into five 

categories: 

• Sufficient Evidence of a Causal 

Association: This category means the 

evidence is sufficient to conclude that 

there is a causal association between 

exposure to a specific agent and a 

specific health outcome in humans. The 

evidence is supported by experimental 

data and fulfills the guidelines for 

sufficient evidence of an association. 

The evidence must be biologically 

plausible and satisfy several of the 

guidelines used to assess causality, such 

as: Strength of association, doseresponse relationship, consistency of 

association, and a temporal relationship. 

NAS did not find any health 

outcomes that met the criteria for this 

category. 

• Sufficient Evidence of an 

Association: This category means the 

evidence is sufficient to conclude that a 

consistent association has been 

observed between exposure to a specific 

agent and a specific health outcome in 

human studies in which chance and 

bias, including confounding, could be 

ruled out with reasonable confidence. 

For example, several high-quality 

studies report consistent associations, 

and the studies are sufficiently free of 

bias, including adequate control for 

confounding. 

NAS found sufficient evidence of an 

association between exposure to 

combustion products and lung cancer. 

• Limited/Suggestive Evidence of an 

Association: This category means the 

evidence is suggestive of an association 

between exposure to a specific agent 

and a specific health outcome, but the 

body of evidence is limited by the 

inability to rule out chance and bias, 

including confounding, with 

confidence. For example, at least one 

high-quality study reports an 

association that is sufficiently free of 

bias, including adequate control for 

confounding. Other corroborating 

studies provide support for the 

association, but they were not 

sufficiently free of bias, including 

confounding. Alternatively, several 

studies of lower quality show consistent 

associations, and the results are 

probably not due to bias, including 

confounding. 

NAS found limited/suggestive 

evidence of an association between 

exposure to combustion products and 

cancers of the nasal cavity and 

nasopharynx; cancers of the oral cavity 

and oropharynx; laryngeal cancer; 

bladder cancer; low birthweight/ 

intrauterine growth retardation (with 

exposure during pregnancy); preterm 

birth (with exposure during pregnancy); 

and incident asthma. 

NAS found limited/suggestive 

evidence of an association between 

exposure to hydrazines and lung cancer. 

• Inadequate/Insufficient Evidence: 

This category means the evidence is of 

insufficient quantity, quality, or 

consistency to permit a conclusion 

regarding the existence of an association 

between exposure to a specific agent 

and a specific health outcome in 

humans. 

NAS found inadequate/insufficient 

evidence of an association between 

exposure to fuels and cancers of the oral 

cavity and oropharynx; cancers of the 

nasal cavity and nasopharynx; 

esophageal cancer; stomach cancer; 

colon cancer; rectal cancer; hepatic 

cancer; pancreatic cancer; laryngeal 

cancer; lung cancer; melanoma; 

nonmelanoma skin cancer; female breast 

cancer; male breast cancer; female 

genital cancers (cervical, endometrial, 

uterine, and ovarian cancers); prostatic 

cancer; testicular cancer; nervous 

system cancers; kidney cancer; bladder 

cancer; Hodgkin’s disease; nonHodgkin’s lymphoma; multiple 

myeloma; myelodysplastic syndromes; 

adverse reproductive or developmental 

outcomes (including infertility, 

spontaneous abortion, childhood 

leukemia, central nervous system (CNS) 

tumors, neuroblastoma, and PraderWilli syndrome); peripheral neuropathy; 

neurobehavioral effects; Multiple 

Chemical Sensitivity symptoms; 

nonmalignant respiratory disease; 

chronic bronchitis; asthma; emphysema; 

dermatitis (irritant and allergic); and 

sarcoidosis. 

NAS found inadequate/insufficient 

evidence of an association between 

exposure to combustion products and 

esophageal cancer; stomach cancer; 

colon cancer; rectal cancer; hepatic 

cancer; pancreatic cancer; melanoma; 

female breast cancer; male breast cancer; 

female genital cancers (cervical, 

endometrial, uterine, and ovarian 

cancers); prostatic cancer; testicular 

cancer; nervous system cancers; ocular 

melanoma; kidney cancer; nonVerDate Aug<31>2005 17:36 Aug 27, 2008 Jkt 214001 PO 00000 Frm 00102 Fmt 4703 Sfmt 4703 E:\FR\FM\28AUN1.SGM 28AUN1

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Hodgkin’s lymphoma; Hodgkin’s 

disease; multiple myeloma, leukemia; 

myelodysplastic syndromes; preterm 

births (based on exposure during a 

specific time period during pregnancy, 

such as the first trimester); low birth 

weight and intrauterine growth 

retardation (based on exposure before 

gestation or during a specific period 

during pregnancy, such as the first 

trimester); specific birth defects, 

including cardiac effects (with maternal 

or paternal exposure before conception 

or maternal exposure during early 

pregnancy); all childhood cancers 

identified, including acute lymphocytic 

leukemia, leukemia, neuroblastoma, and 

brain cancer; neurobehavioral effects; 

post-traumatic stress disorder; nervous 

system subgroupings (or individual 

nervous system diseases); Multiple 

Chemical Sensitivity symptoms; chronic 

bronchitis (less than 1 year of exposure); 

emphysema; chronic obstructive 

pulmonary disease; ischemic heart 

disease or myocardial infarction (less 

than 2 years of exposure); dermatitis 

(irritant and allergic); and sarcoidosis. 

NAS found inadequate/insufficient 

evidence of an association between 

exposure to hydrazines and 

hematopoietic and lymphopoietic 

cancers; digestive tract cancers; 

pancreatic cancer; bladder cancer; 

kidney cancer; emphysema; ischemic 

heart disease or myocardial infarction; 

and hepatic disease. 

NAS found inadequate/insufficient 

evidence of an association between 

exposure to nitric acid and stomach 

cancer; melanoma; lymphopoietic 

cancers; pancreatic cancer; laryngeal 

cancer; lung cancer; bladder cancer; 

multiple myeloma; and cardiovascular 

diseases. 

• Limited/Suggestive Evidence of No 

Association: This category means the 

evidence is consistent in not showing an 

association between exposure to a 

specific agent and a specific health 

outcome after exposure of any 

magnitude. A conclusion of no 

association is inevitably limited to the 

conditions, magnitudes of exposure, and 

length of observation in the available 

studies. The possibility of a very small 

increase in risk after exposure studied 

cannot be excluded. 

NAS did not find any health 

outcomes that met the criteria for this 

category. 

A. Combustion Products 

1. Sufficient Evidence of an Association 

NAS found sufficient evidence of an 

association between combustion 

products and lung cancer. NAS found 

that there was evidence of associations 

between exposure to ambient air 

pollution, engine exhausts, and heating 

sources (coal) and lung cancer. Cohort 

and case-control studies showed 

consistently that risks increased with 

increasing ambient air pollution. There 

was evidence from both cohort and case 

control studies that increasing exposure 

to engine exhausts and its components 

such as polycyclic aromatic 

hydrocarbons (PAHs) increased the risk 

of lung cancer. 

Based on 82 epidemiological studies, 

NAS derived a positive finding of 

‘‘sufficient evidence of an association’’

between exposure to combustion 

products and lung cancer. The 

epidemiological studies included cohort 

studies on the health effects of ambient 

air pollution on people dwelling in 

cities, workers exposed to motor vehicle 

exhaust, and case-control studies of 

lung cancer patients. The case-control 

studies were of lung cancer patients 

who were exposed in their occupation, 

or in their homes or daily lives to indoor 

air pollution from combustion products 

from wood, coal, kerosene or gas 

burning stoves or heaters over years. 

Relevant occupational exposures 

included working as a bus, taxi, or truck 

driver, or as a miner or railroad worker. 

NAS pointed out that lung cancer 

from all causes is the leading cause of 

cancer death among both men and 

women, and that smoking may be 

responsible for 80% of lung cancer 

cases. Nevertheless, NAS concluded 

that ‘‘there was evidence of associations 

between exposure to ambient air 

pollution, engine exhausts, and heating 

sources (coal) and lung cancer.’’ Cohort 

and case-control studies showed 

consistently that risks increased with 

increasing ambient air pollution. There 

was evidence from both cohort and 

case-control studies that increasing 

exposure to engine exhausts and to its 

components increased the risk of lung 

cancer. 

The Secretary has determined that, 

although there is sufficient evidence of 

an association between combustion 

products and lung cancer, VA does not 

consider this exposure to be ‘‘associated 

with’’ the 1991 Gulf War. Please see 

section IV for further detail. 

2. Limited/Suggestive Evidence of an 

Association 

NAS found limited/suggestive 

evidence of an association between 

exposure to combustion products and 

cancers of the nasal cavity and 

nasopharynx; cancers of the oral cavity 

and oropharynx; laryngeal cancer; 

bladder cancer; low birthweight/ 

intrauterine growth retardation and 

exposure during pregnancy; preterm 

birth and exposure during pregnancy; 

and incident asthma. 

The results of the studies of the 

relationship between combustion 

products and cancers of the nasal cavity 

and nasopharynx were inconsistent, and 

indirect methods were used to assess 

exposure. However, positive 

associations were reported between 

combustion products (particularly wood 

smoke) and cancer of the nasopharynx. 

NAS’s positive finding of ‘‘limited/ 

suggestive evidence of an association’’

between exposure to combustion 

products and cancers of the nasal cavity 

and nasopharynx was based on 4 

epidemiological case-control studies. 

These studies involved patients with 

nasal cavity and nasopharynx cancer, 

who were exposed regularly to 

combustion products, by virtue of their 

occupation or in their daily lives, over 

many years. Relevant exposures 

included exposure to fumes from the 

burning of wood and other materials, 

use of fuels, and occupational exposures 

such as working as a motor vehicle 

driver. Although NAS found these 

studies showed inconsistent results, 

they concluded that positive 

associations were reported by studies 

conducted in China between 

combustion products (particularly wood 

smoke) and cancer of the nasopharnyx. 

NAS’s positive finding of ‘‘limited/ 

suggestive evidence of an association’’

between exposure to combustion 

products and cancers of the oral cavity 

and oropharynx was based on 9 

epidemiological case-control studies. 

These epidemiological studies were of 

oral cavity and oropharynx cancer 

patients who were exposed to ambient 

air pollution in the cities where they 

lived, or who were exposed over many 

years due to their occupation or to 

indoor pollution in their homes due to 

combustion products from wood, coal, 

kerosene or gas burning stoves or 

heaters. Occupational exposures 

included working as a motor vehicle 

driver or railroad employee. NAS 

concluded that results of several studies 

suggested an association between 

cancers of the oral cavity and 

oropharynx and exposure to combustion 

products. 

NAS’s positive finding of ‘‘limited/ 

suggestive evidence of an association’’

between exposure to combustion 

products and laryngeal cancer was 

based on one epidemiological cohort 

study of workers exposed to diesel 

exhaust, and 16 epidemiological casecontrol studies of patients with 

laryngeal cancer. These studies involved 

people who were exposed to 

combustion products due to their 

occupations as railway workers, motor 


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vehicle drivers, or as city commuters 

exposed to ambient air pollution. The 

studies also included people who used 

wood and other fuel burning stoves 

regularly. Several studies reported 

positive findings, including two studies 

regarding exposure to the emissions of 

fossil-fuel stoves and one study 

regarding exposure to wood-stove 

emissions. Several studies reported 

small increases in laryngeal-cancer risk 

for some exposures; however, overall, 

the results were inconsistent. NAS 

concluded that the epidemiologic 

literature overall provided limited/ 

suggestive evidence of an association 

between exposure to combustion 

products and laryngeal cancer. 

NAS found ‘‘limited/suggestive 

evidence of an association’’ between 

exposure to combustion products and 

bladder cancer. Studies that assessed 

the relationship between exposure to 

combustion products and bladder 

cancer have not been consistently 

positive, and no studies assessed 

measurements of exposure. One pooled 

analysis of occupational exposures 

found questionably increased risks in 

exhaust-related occupations, and the 

risk was increased with higher 

exposures to polycyclic aromatic 

hydrocarbons (PAHs) and benzopyrene, 

which are combustion products. A 

slightly increased risk was observed for 

diesel exhaust. In a related study, 

similar findings were noted with some 

exposures to exhausts and PAHs. A 

more detailed assessment of PAH 

exposures based on expert review of 

work-history information found 

apparently stable associations with 

average and cumulative PAH exposures 

and total duration of PAH exposures. 

Taken together, the results constituted 

limited or suggestive evidence of an 

association between combustion 

products and bladder cancer, but the 

lack of exposure measurements and the 

heterogeneity of results precludes 

classifying the association as sufficient. 

NAS’s positive finding of ‘‘limited/ 

suggestive evidence of an association’’

between exposure to combustion 

products during pregnancy and low 

birthweight or intrauterine growth 

retardation was based on 8 

epidemiological studies of pregnant 

women. These women were exposed to 

ambient air pollution ‘‘smog’’ in heavily 

polluted cities in the Czech Republic 

where coal was burned, and in urban 

cities located in South Korea, China, 

Canada, and the United States. 

Two studies found evidence of a 

relationship between low birthweight or 

intrauterine growth retardation and 

combustion-product exposure. Their 

analyses controlled for several known 

risk factors, including maternal 

smoking. Several other studies reviewed 

by NAS provided supportive evidence 

of a relationship, but most were unable 

to adjust for maternal smoking. 

NAS’s positive finding of ‘‘limited/ 

suggestive evidence of an association’’

between exposure to combustion 

products during pregnancy and preterm 

birth was based on four epidemiological 

studies. The studies that found evidence 

of a relationship between preterm birth 

and combustion-product exposure were 

based primarily on maternal residence 

during pregnancy. Most of these studies 

controlled for several known risk factors 

for preterm birth (such as maternal age, 

race, education, and access to prenatal 

care), but none of the studies could 

completely control for maternal 

smoking, which is an important risk 

factor for preterm birth. 

NAS’s positive finding of ‘‘limited/ 

suggestive evidence of an association’’

between exposure to combustion 

products and asthma was based 

primarily on two studies, which 

evaluated an association between 

asthma and exposure to combustion 

products in ambient air pollution. NAS 

also relied on a study of veterans of the 

1991 Gulf War that found an association 

between oil-well fire smoke and asthma, 

and a study associating ‘‘biomass 

combustion’’ and asthma among people 

over 60 years old living in India. 

The epidemiological studies found 

that new cases of asthma were 

associated with combustion-product 

exposure in air pollutants. A study of 

Gulf War veterans using an objective 

exposure-measurement method, found 

an association between oil-well fire 

smoke and asthma in Gulf War veterans, 

but could not distinguish between new 

cases arising after the war and 

exacerbation of pre-existing conditions. 

Although the other key Gulf War study 

found no relationship between exposure 

and asthma, its definition of asthma was 

inadequate. Other studies of biomassfuel combustion and outdoor air 

pollution supported a relationship 

between combustion exposure and 

asthma. 

The Secretary has determined that, 

although there is limited/suggestive 

evidence of an association between 

exposure to combustion products and 

cancers of the nasal cavity and 

nasopharynx; cancers of the oral cavity 

and oropharynx; laryngeal cancer; 

bladder cancer; low birthweight/ 

intrauterine growth retardation (with 

exposure during pregnancy); preterm 

birth (with exposure during pregnancy); 

and incident asthma, VA does not 

consider this exposure to be ‘‘associated 

with’’ the 1991 Gulf War. Please see 

section IV for further detail. 

3. Inadequate/Insufficient Evidence 

NAS found inadequate/insufficient 

evidence between exposure to 

combustion products and esophageal 

cancer; stomach cancer; colon cancer; 

rectal cancer; hepatic cancer; pancreatic 

cancer; melanoma; female breast cancer; 

male breast cancer; female genital 

cancers (cervical, endometrial, uterine, 

and ovarian cancers); prostatic cancer; 

testicular cancer; nervous system 

cancers; ocular melanoma; kidney 

cancer; non-Hodgkin’s lymphoma; 

Hodgkin’s disease; multiple myeloma, 

leukemia; myelodysplastic syndromes; 

preterm births (based on exposure 

during a specific time period during 

pregnancy, such as the first trimester); 

low birth weight and intrauterine 

growth retardation (based on exposure 

before gestation or during a specific 

period during pregnancy, such as the 

first trimester); specific birth defects, 

including cardiac effects (with maternal 

or paternal exposure before conception 

or maternal exposure during early 

pregnancy); all childhood cancers 

identified, including acute lymphocytic 

leukemia, leukemia, neuroblastoma, and 

brain cancer; neurobehavioral effects; 

post-traumatic stress disorder; nervous 

system subgroupings (or individual 

nervous system diseases); Multiple 

Chemical Sensitivity symptoms; chronic 

bronchitis (less than 1 year of exposure); 

emphysema; chronic obstructive 

pulmonary disease; ischemic heart 

disease or myocardial infarction (less 

than 2 years of exposure); dermatitisirritant and allergic; and sarcoidosis. 

NAS reviewed five studies of 

combustion products and esophageal 

cancer, and concluded that no 

consistent association was observed in 

those studies. 

NAS reviewed six studies of 

combustion products and stomach 

cancer. Two of the studies reported an 

increased risk for stomach cancer, but 

the method used to assess exposure was 

limited and there were no adjustments 

for confounders. 

Studies of exposure to combustion 

products and colon cancer reported 

positive associations for exposure to 

some combustion products, but not to 

others. Further, a number of the positive 

findings were limited, due to their large 

confidence intervals. NAS found that 

the evidence of an association was 

inadequate because of the small number 

of studies available. 

With regard to rectal cancer, NAS 

found the studies’ results were 

inconsistent, and the number of studies 

was small. NAS also noted that any 


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positive studies failed to include at least 

one high-quality study supported by an 

adequate exposure assessment. 

NAS noted only one relevant study 

that evaluated exposure to combustion 

products and hepatic cancer. Although 

associations were noted for some 

occupations, there were few cases with 

relevant exposure, and the study did not 

consider all pertinent risk factors. 

The four reviewed studies of 

combustion-product exposure and 

pancreatic cancer generally did not 

provide evidence of an association. One 

study found an association between 

exposure to coal combustion products 

and increased risk of pancreatic cancer, 

but it did not find a link between nine 

other types of combustion products and 

pancreatic cancer. 

Studies regarding melanoma 

addressed exposure to combustion 

products but their reliability is limited 

because they failed to adjust for 

exposure to sunlight, a major risk factor 

for melanoma. Overall, the studies did 

not report significant findings of 

association for most types of exposure. 

Two studies found isolated effects of 

specific exposures (propane exhaust and 

being a traffic administrator, 

respectively) that were not among the 

major exposures considered by NAS. 

NAS reviewed three studies 

concerning nonmelanoma skin cancer 

and combustion products. The studies 

generally did not report statistically 

significant findings of an association. 

NAS found that for the more common 

type of nonmelanoma skin cancer (basal 

cell carcinoma), the findings were 

largely negative. Two of the studies 

stated findings regarding squamous cell 

carcinoma, with one finding a 

statistically significant association for 

one type of exposure (diesel fumes), but 

not others, and one study finding no 

association. 

The two studies involving female 

breast cancer and exposure to 

combustion products essentially had 

negative results. 

Of the two reviewed studies regarding 

exposure to combustion products and 

male breast cancer, one did not find an 

association between PAH exposure and 

male breast cancer, and the other, 

although reporting a positive 

association, was limited by its method 

of exposure assessment. 

NAS reviewed three studies regarding 

exposure to fuels or combustion 

products and cervical, endometrial, 

uterine, or ovarian cancer, and found 

that they provided inadequate support 

for an association. 

NAS reviewed four prostate cancer 

studies that measured the relationship 

between occupations having potential 

for exposure to combustion products or 

PAHs or having more rigorously derived 

estimates of exposure to such agents and 

prostatic cancer. Although the studies 

reported several positive associations, 

NAS noted that the results were not 

consistently positive. For example, one 

study showed results contrary to a doseresponse relationship, while another 

study showed an increased risk in 

firefighters and railroad workers but not 

in other transportation or trucking 

workers. 

Testicular cancer studies did not 

provide enough relevant data to draw 

any sort of conclusion about exposure to 

fuels or combustion products and 

testicular cancer. 

Data on combustion products and 

brain cancer (nervous system cancers) 

were too sparse to determine whether an 

association exists. 

Three studies of ocular melanoma 

reported increased, but imprecise, risks 

of ocular melanoma in occupations 

related to transportation. The reliability 

of these studies is limited by their small 

size, lack of statistical significance, and 

lack of adequate exposure assessment. 

Although some studies of exposure to 

combustion products and kidney cancer 

suggested a possible association based 

on job title, NAS found that the results 

were not consistently positive, with 

some studies showing no increased risk. 

Further, the results of some studies 

showing positive associations were 

limited by considerations of statistical 

significance and other factors. 

Studies on non-Hodgkin’s lymphoma 

(NHL) had no firmly positive findings. 

In the study with the most objective 

exposure assessment, there was no 

indication of an association with any of 

the fuels or their combustion products. 

The studies regarding Hodgkin’s 

disease (HD) were limited by their small 

numbers of cases and the nonspecificity 

of their exposure assessments. Further, 

the three primary studies reviewed by 

NAS showed findings of no association. 

NAS reviewed ten studies concerning 

multiple myeloma and exposure to 

combustion products. Three of the 

studies the NAS found to be among the 

most sizable or significant reported only 

marginally increased risks and are just 

barely suggestive of an association. 

Other studies showed no association, 

and yet other studies are limited due to 

imprecise estimates of increased 

multiple-myeloma risk in association 

with exhaust exposure and concerns 

regarding exposure assessments. NAS 

concluded that the literature overall 

provided insufficient evidence of an 

association. 

NAS reviewed six studies of leukemia 

and exposure to combustion products. 

Four of the studies showed no findings 

of a statistically significant increased 

risk. In the other two studies, the 

apparent associations were related to 

separate types of leukemia, and the 

authors of the studies noted that any 

increase in leukemia risk was difficult 

to attribute specifically to exhaust 

because of concurrent exposure to fuels 

and benzene. The exposure assessments 

in all the studies were based on 

information from sources of 

questionable reliability (personal 

interviews or medical records) or had a 

low degree of specificity for combustion 

products. 

NAS reviewed two studies regarding 

myelodysplastic syndromes and 

exposure to combustion products. One 

study found no significant evidence of 

an association. The other study found 

stable evidence of an association for the 

not particularly substance-specific 

occupation of machine operator. 

Further, the reliability of that study is 

limited because the analyses by 

researchers were rudimentary and failed 

to adjust for possible confounders when 

the information was available. 

As noted above in section III.A.2, 

NAS found limited/suggestive evidence 

of an association between exposure to 

combustion products during pregnancy 

and preterm birth. NAS similarly found 

limited/suggestive evidence of an 

association between exposure to 

combustion products during pregnancy 

and low birth weight or intrauterine 

growth retardation. However, NAS also 

found that there was inadequate/ 

insufficient evidence of an association 

between combustion products exposure 

at any specific point during pregnancy 

(such as the first trimester) and these 

reproductive effects. Although several of 

the studies NAS reviewed reported 

results for exposure at different stages of 

pregnancy, there were no consistent 

findings as to whether the risks were 

greater with exposure early or late in 

pregnancy. Additionally, none of the 

studies completely controlled for the 

significant risk factor of smoking during 

pregnancy. 

One study of an association between 

maternal exposure to air pollutants and 

the risk of birth defects reported 

relationships between certain cardiac 

defects and increasing exposure to CO 

and O3. NAS discussed two studies that 

examined the association between 

paternal employment as a firefighter and 

the risk of cardiac birth defects. One of 

the studies found no evidence of an 

association, while the other found some 

evidence that certain cardiac defects 

were associated with paternal 

employment as a firefighter. Both 

studies had limitations due to size, 


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potential confounding and/or 

inadequate information about duration 

of paternal firefighting. In a study of 

maternal or paternal exposures among 

residents of Rotorua, New Zealand, a 

city with high geothermal exposure to 

hydrogen sulfide, no excess birth 

defects were reported in comparison 

with residents in the rest of New 

Zealand. 

NAS discussed eleven studies of the 

association between combustionproducts exposure and childhood 

cancers, including acute lymphocytic 

leukemia, leukemia, neuroblastoma, and 

brain cancer. All of the studies were 

limited by their inability to validate 

employment history and by the lack of 

details on specific assessments of 

exposure to combustion products. The 

exposure groups were broad and 

included many diverse occupations 

where exposure to other chemicals was 

noted in addition to combustion 

products. Six of the studies found no 

association between combustion 

products exposure and the studied 

childhood cancers. One study reported 

general findings of associations for a 

variety of childhood cancers, while the 

remaining four studies contained mixed 

findings, reporting positive associations 

for certain types of cancers. 

All of the studies on neurobehavioral 

effects and combustion-product 

exposure suffered from significant 

methodological limitations. Several Gulf 

War studies reported positive 

relationships between self-reported 

exposure and self-reported 

neuropsychologic, cognitive, or mood 

symptoms or multiple unexplained 

symptoms, but the lack of objective 

measurement of exposure limits the 

reliability of those findings. Among two 

non-veteran studies reporting positive 

findings for certain neurobehavioral 

effects, one study did not have a control 

group, and the other had serious 

limitations, especially in subject 

selection. 

NAS identified no studies showing an 

association between combustionproducts exposure and post-traumatic 

stress disorder (PTSD). Although several 

studies addressed the prevalence of 

PTSD among firefighters, the result is 

most likely attributable to the hazardous 

nature of the job rather than exposure to 

combustion products. Only a few Gulf 

War studies have examined whether 

self-reported combustion-product 

exposure was related to PTSD as an 

outcome measure, and none has found 

such a relationship. None of the studies 

with objectively measured oil-well fire 

smoke examined PTSD as an outcome 

measure. 

Regarding nervous system disease 

subgroupings (or individual nervous 

system diseases), NAS excluded studies 

involving only overbroad and 

nonspecific health outcomes and 

focused on individual neurologic 

diseases or subgroupings of nervoussystem diseases. Only two identified 

studies examined nervous-system 

subgroupings in relation to combustionproducts exposure. One study found 

exposure-response relationships with 

nervous-system subgroupings in a 

hospital discharge survey. The 

limitation of this study was assignment 

of exposure (residence only) and 

potential for exposure misclassification. 

The other study did not find a 

relationship between combustion 

product exposure and multiple 

sclerosis. No other studies of nervous 

system subgroups or the individual 

diseases met NAS’s criteria for 

inclusion. 

Although NAS reviewed several 

studies of Multiple Chemical Sensitivity 

(MCS) in Gulf War veteran or civilian 

samples, those studies provided 

relatively little evidence that MCS was 

associated with combustion-products 

exposure in service. Several studies 

involved questionnaires on which 

veterans or civilians self-reported that 

exposure to certain combustion 

products (e.g., tobacco smoke, car 

exhaust) are among the factors that can 

trigger their symptomatology. However, 

NAS noted that most of the studies did 

inquire as to the first onset of 

symptoms. Further, the studies 

generally were limited by methodologic 

concerns, including self-reported 

exposures and symptoms and the 

possibility of recall bias. 

Although the studies reviewed by 

NAS indicated a probable relationship 

between long-term (over 1 year) 

exposure to combustion products and 

chronic bronchitis, a key unresolved 

issue was whether shorter-term 

exposures (less than 1 year) can cause 

the condition. NAS found inadequate 

published data that addressed the effect 

of shorter term combustion-product 

exposures (less than 1 year) on the risk 

of developing chronic bronchitis. Even 

if it could be shown that long-term 

exposure to combustion products 

caused chronic bronchitis, it might be 

expected to cease after exposure without 

long-term health consequences. NAS 

found inadequate published data to 

evaluate the natural history of chronic 

bronchitis after cessation of exposure to 

combustion products. 

A study found that mortality due to 

emphysema was not considerably 

increased among workers exposed to 

diesel exhaust. This result was found 

after adjustments for the effects of 

smoking were made. Likewise, a study 

of veterans exposed to oil-well fires also 

did not find a relationship with 

emphysema. Other studies that included 

emphysema in the analysis were 

methodologically inadequate. 

NAS did not identify any high-quality 

studies that evaluated the effect of 

exposure to combustion products on the 

risk of chronic obstructive pulmonary 

disease (COPD), as defined by objective 

evidence of irreversible airflow 

obstruction with spirometry. Several 

studies of biomass-smoke exposure used 

measures of airflow obstruction but had 

methodologic limitations that precluded 

clear conclusions about the connection 

between combustion exposure and 

COPD. 

There was relatively consistent 

epidemiologic evidence of the relation 

between ischemic heart disease 

(including myocardial infarction) and 

long-term exposure to fossil-fuel 

combustion products, including motorvehicle exhaust and combustion-derived 

fine particulate matter. However, the 

increased risk was small in absolute 

terms, and there was no adequate 

epidemiologic evidence to support the 

role of relatively short exposures 

(similar to that experienced in the Gulf 

War), followed by an exposure-free 

period, and then development of 

ischemic heart disease events. 

Accordingly, NAS found inadequate/ 

insufficient evidence to determine 

whether an association exists between 

short-term exposure (less than 2 years) 

to combustion products and the 

development of ischemic heart disease 

after an exposure-free period of months 

or years. 

Rashes were frequently reported by 

Gulf War veterans, but only one study 

of Gulf War veterans searched for 

relationships between dermatitis and 

self-reported exposure during the Gulf 

War. No exposure to combustion 

products or any other self-reported 

exposure was related to dermatitis, 

defined as rashes, eczema, or skin 

allergies. 

NAS identified three epidemiologic 

studies on the relationship between 

occupational or residential exposure to 

fires and sarcoidosis, all of which had 

significant methodologic limitations. 

One study had numerous limitations, 

such as inadequate description of how 

the cases without biopsy confirmation 

were diagnosed and the lack of control 

for employment history (besides 

farming), recall bias, and lack of 

measurement of pollutant 

concentrations. The authors noted that 

sarcoidosis could be associated with a 

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handling, namely contact with smoke, 

ash, wood particles, or wood molds. 

Another study was limited by the lack 

of specific exposure assessment and of 

analysis of duration or frequency of 

exposure to combustion products. There 

was no control for potential 

confounders, such as race or familiar 

aggregation of sarcoidosis. In addition, 

there was no way to determine the role 

of combustion products or exposure to 

other toxicants, allergens, or infectious 

agents. The third study was limited by 

the small sample, the low statistical 

power, the lack of a risk estimate for 

firefighters versus police officers, the 

lack of exposure assessment for 

combustion products, and the lack of 

assessment of coexposures to other 

chemicals in the workplace. 

Based on the information and analysis 

in the NAS report, the Secretary has 

determined that there is insufficient 

credible evidence to conclude that there 

is a positive association between 

exposure to combustion products and 

esophageal cancer; stomach cancer; 

colon cancer; rectal cancer; hepatic 

cancer; pancreatic cancer; melanoma; 

nonmelanoma skin cancer; female breast 

cancer; male breast cancer; female 

genital cancers (cervical, endometrial, 

uterine, and ovarian cancers); prostatic 

cancer; testicular cancer; nervous 

system cancers; ocular melanoma; 

kidney cancer; non-Hodgkin’s 

lymphoma; Hodgkin’s disease; multiple 

myeloma, leukemia; myelodysplastic 

syndromes; preterm births (based on 

exposure during any specific time 

period during pregnancy, such as the 

first trimester); low birth weight and 

intrauterine growth retardation (based 

on exposure before gestation or during 

any specific period during pregnancy, 

such as the first trimester); specific birth 

defects, including cardiac effects (with 

maternal or paternal exposure before 

conception or maternal exposure during 

early pregnancy; all childhood cancers 

identified, including acute lymphocytic 

leukemia, leukemia, neuroblastoma, and 

brain cancer; neurobehavioral effects; 

post-traumatic stress disorder; nervous 

system disease subgroupings (or 

individual nervous system diseases); 

MCS symptoms; chronic bronchitis (less 

than 1 year of exposure); emphysema; 

chronic obstructive pulmonary disease; 

ischemic heart disease or myocardial 

infarction (less than 2 years of 

exposure); dermatitis-irritant and 

allergic; and sarcoidosis. Further, as 

explained in section IV of this notice, 

VA does not consider the combustionproducts exposures underlying the NAS 

findings to be exposures ‘‘associated 

with’’ the 1991 Gulf War. Therefore, a 

presumption of service connection is 

not warranted for any such illness based 

upon exposure to combustion products 

during service in the Gulf War. 

B. Hydrazines 

1. Limited/Suggestive Evidence of an 

Association 

NAS found limited/suggestive 

evidence of an association between 

exposure to hydrazines 

(monomethylhydrazine ‘‘MMH,’’ and 

unsymmetrical (1,1-)dimethylhydrazine 

‘‘UDMH’’) used as rocket propellants, 

and lung cancer. This conclusion was 

based primarily on one high-quality 

study, as discussed below. 

An occupational study of a U.S. 

cohort of aerospace workers engaged in 

testing rockets using hydrazine fuel 

demonstrated an association between 

hydrazine exposure and risk of lung 

cancer. Several sources of potential 

confounding, including sex and 

radiation exposure, were controlled by 

study design. Other potentially 

confounding variables were controlled 

in multivariate analysis, including age, 

pay type, and time since hire or transfer. 

Although the smoking status of most 

workers was unknown, there was 

indirect evidence that smoking did not 

confound the results. 

Two other studies of lung cancer were 

limited by small sample size and 

inadequate study power. In addition, 

another study was limited by its failure 

to control for coexposure to other 

carcinogenic substances, including 

asbestos and PAHs. The lack of internal 

control subjects and the lack of 

information on smoking constitute 

major limitations for both studies. 

Consequently, there was inadequate 

evidence to evaluate the consistency of 

the association between hydrazine and 

lung cancer beyond the study of the U.S. 

cohort. 

NAS stated in its report that U.S. 

military personnel could have been 

exposed to UMDH during Operation 

Desert Storm if UMDH was used as a 

rocket fuel in Scud missiles launched by 

Iraq and the U.S. military personnel 

were in the vicinity of the Scud missiles 

when they disintegrated. However, NAS 

stated that hydrazines were apparently 

not used in Scud missiles during the 

1991 Gulf War even though Iraq had 

apparently experimented with UDMH as 

a rocket fuel. NAS further stated that it 

was not aware of any other potential use 

of hydrazines that could have resulted 

in exposure of U.S. service personnel. 

Based on information and analysis in 

the NAS report and from DoD, VA does 

not consider exposure to hydrazines to 

be exposures ‘‘associated with’’ the 1991 

Gulf War. Please see section IV for 

further detail. Therefore, a presumption 

of service connection is not warranted 

for lung cancer based upon exposure to 

hydrazine during service in the 1991 

Gulf War. 

2. Inadequate/Insufficient Evidence 

NAS found inadequate/insufficient 

evidence between hydrazines and 

hematopoietic and lymphopoietic 

cancers; digestive tract cancers; 

pancreatic cancer; bladder cancer; 

kidney cancer; emphysema; ischemic 

heart disease or myocardial infarction; 

and hepatic disease. 

NAS noted that relatively few studies 

existed concerning the health effects of 

hydrazine exposure, and that lung 

cancer was the only health outcome 

represented in all three cohort studies 

reviewed by the committee. NAS further 

noted that individual findings in those 

studies also reported somewhat 

increased mortality from cancer at sites 

other than the lung (hematopoietic and 

lymphopoietic, bladder and kidney, 

digestive tract, and pancreas) and from 

two noncancer conditions (emphysema 

and ischemic heart disease). NAS 

concluded, however, that the few 

available studies do not provide 

adequate or consistent evidence of an 

association between exposure to 

hydrazines and any of those other 

health outcomes. 

Based on the information and analysis 

in the NAS report, the Secretary has 

determined that there is insufficient 

credible evidence to conclude that there 

is a positive association between 

exposure to hydrazines and 

hematopoietic and lymphopoietic 

cancers; digestive tract cancers; 

pancreatic cancer; bladder cancer; 

kidney cancer; emphysema; ischemic 

heart disease or myocardial infarction; 

and hepatic disease. Further, as 

explained in section IV of this notice, 

VA does not consider exposure to 

hydrazines to be exposures ‘‘associated 

with’’ the 1991 Gulf War. Therefore, a 

presumption of service connection is 

not warranted for any such illness based 

upon exposure to hydrazine during 

service in the 1991 Gulf War. 

C. Fuels—Inadequate/Insufficient 

Evidence 

NAS found inadequate/insufficient 

evidence of an association between 

exposure to fuels and cancers of the oral 

cavity and oropharynx; cancers of the 

nasal cavity and nasopharynx; 

esophageal cancer; stomach cancer; 

colon cancer; rectal cancer; hepatic 

cancer; pancreatic cancer; laryngeal 

cancer; lung cancer; melanoma; 

nonmelanoma skin cancer; female breast 


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cancer; male breast cancer; female 

genital cancers (cervical, endometrial, 

uterine, and ovarian cancers); prostatic 

cancer; testicular cancer; nervous 

system cancers; kidney cancer; bladder 

cancer; Hodgkin’s disease; nonHodgkin’s lymphoma; multiple 

myeloma; myelodysplastic syndromes; 

adverse reproductive or developmental 

outcomes (including infertility, 

spontaneous abortion, childhood 

leukemia, CNS tumors, neuroblastoma, 

and Prader-Willi syndrome); peripheral 

neuropathy; neurobehavioral effects; 

MCS symptoms; nonmalignant 

respiratory disease; chronic bronchitis; 

asthma; emphysema; dermatitis-irritant 

and allergic; and sarcoidosis. 

NAS reviewed five studies regarding 

cancer of the oral cavity and oropharynx 

and fuels. NAS found that the three 

occupational cohort studies it reviewed 

each had limited statistical power and 

were therefore uninformative. NAS 

further concluded that the two casecontrol studies it reviewed failed to 

report any consistent relationship 

between fuel exposure and cancers of 

the oral cavity and oropharynx. 

NAS found little information 

available on exposure to fuels and 

cancers of the nasal cavity and 

nasopharynx, and that the two studies it 

reviewed failed to provide convincingly 

positive findings. 

NAS found that studies of an 

association between fuel exposure and 

esophageal cancer were few and results 

were inconsistent and inadequate to 

support an association. Some of the 

studies were unreliable because they 

analyzed esophageal cancer and 

stomach cancers together, and NAS 

therefore could not determine which 

specific cancer type may have been 

associated with fuel exposure. Other 

studies showed no evidence of 

association. 

NAS also found that studies of an 

association between fuel exposure and 

stomach cancer were inconsistent and 

inadequate to support an association. As 

noted above, some of the studies were 

unreliable because they analyzed 

esophageal cancer and stomach cancers 

together in relation to fuel exposure and 

NAS could not determine which 

specific cancer type may have been 

associated with fuel exposure. Other 

studies showed no evidence of 

association. 

NAS found that the studies 

concerning fuel exposure and colon 

cancer provided no consistent evidence 

of an association. Although some 

studies showed increased risk of colon 

cancer, the increases were modest and 

the confidence intervals in several 

instances included the null. Three 

studies analyzed colon cancer and rectal 

cancer together and, therefore, NAS 

could not determine whether exposure 

to fuels may have been associated with 

a specific type of cancer. 

NAS found that the studies reporting 

positive associations between fuels and 

rectal cancer were not consistent and 

the number of studies was small. 

Furthermore, the positive studies failed 

to include at least one high-quality 

study supported by an adequate 

exposure assessment. Some studies 

found no evidence of association 

between fuel exposure and rectal 

cancer. 

NAS noted only one relevant study 

that evaluated exposure to fuels and 

hepatic cancer in which there were few 

cases with relevant exposure, and the 

study did not consider all pertinent risk 

factors. 

NAS found only two relevant studies 

on the risk of pancreatic cancer posed 

by fuel exposure. One study found no 

association. The other study reported an 

association, but the results were 

imprecise, due in part to a large 

confidence interval that included the 

null. 

NAS found that the results regarding 

exposure to fuels and laryngeal cancer 

were inconsistent. Two studies 

reviewed by NAS reported a modest 

increase in the risk of laryngeal cancer 

associated with exposure to fuels, but 

the reliability of those findings is 

limited because the exposures in both 

studies were self-reported. Another 

study reported an increased, but 

imprecise, risk of laryngeal cancer in 

vehicle mechanics, but found no 

increase in garage and gasoline-station 

workers. 

NAS found the results of studies of 

fuel exposure and lung cancer risk were 

inconsistent. One study reported an 

association between kerosene and 

crude-oil exposure and squamous-cell 

lung cancer, between diesel-fuel 

exposure and nonadenocarcinoma, and 

between heating-oil exposure and oatcell lung cancer. Two studies did not 

find an association in workers most 

likely to have been exposed to fuels. 

The studies examined by NAS 

addressing melanoma and exposure to 

fuels were not adjusted for sun 

exposure, a major risk factor for 

melanoma, and the workers—

particularly the exploration, drilling, 

and pipeline workers—may have 

received considerable sun exposure 

while performing their jobs. But the one 

case-control study with fairly reliable 

exposure analysis did not support an 

association in workers likely to have 

been exposed to fuels. 

Of the available epidemiologic studies 

regarding nonmelanoma skin cancer 

that met NAS’s criteria, one study 

reported one borderline association 

between fuel exposure and squamouscell carcinoma. The other two reports 

reviewed by NAS had methodologic 

limitations and did not provide reliable 

evidence of an association. For the more 

common type of nonmelanoma skin 

cancer (basal cell carcinoma), the 

findings were largely negative. 

NAS reviewed three studies 

concerning fuel exposure and female 

breast cancer. One study found no 

increased risk of breast cancer, while 

the other two found only an 

insignificant increase in risk. 

NAS found no studies assessing the 

possible relationship of male breast 

cancer to fuel exposure alone. NAS 

reviewed one study that reported a 

positive finding regarding combined 

exposure to fuels and combustion 

products and male breast cancer. NAS 

found, however, that the method used to 

assess exposure in that study was 

limited. 

NAS reviewed three studies 

concerning fuel exposure and female 

genital cancers. The studies failed to 

provide any significant evidence of an 

association between exposure to fuels 

and cervical, endometrial, uterine, or 

ovarian cancer. 

NAS reviewed several studies 

regarding an association between fuel 

exposure and prostatic cancer. Only one 

of those studies reported a positive 

association between a fuel-related 

exposure and prostatic cancer. That 

study found an association between 

exposure to diesel fuel and prostate 

cancer, but did not find significant 

evidence of an association for other 

types of fuel exposure. The other reports 

reviewed by NAS were negative for any 

association. 

Only one study addressed the 

association between fuel exposure and 

testicular cancer, and it found no 

evidence of an association. NAS 

concluded that there was not enough 

relevant data to draw any sort of 

conclusion about exposure to fuels and 

testicular cancer. 

Several studies reported sporadic 

associations between fuel exposure and 

nervous system cancers (brain cancer), 

but the results were limited by several 

factors, including wide confidence 

intervals that include the null. In some 

studies, the increased risk was found 

only among workers likely to have 

lesser fuel exposure, while no increased 

risk was seen among workers likely to 

have greater fuel exposure. None of the 

studies could be considered a highquality study supported by an adequate 


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exposure assessment. Additionally, 

some studies found no evidence of 

association. 

No key study that was positive for an 

association between exposure to fuels 

and kidney cancer was identified. NAS 

found the uniformly negative results of 

a study of a comprehensive sample of 

renal cell carcinoma cases in the 

petroleum industry with excellent 

exposure assessment to be compelling. 

NAS reviewed several studies 

concerning fuel exposure and bladder 

cancer. Several of the studies found no 

evidence or no significant evidence of 

an association. Other studies provided 

evidence of a relationship between fuel 

exposure and bladder cancer, but the 

relationship was not consistently 

increased in any study with a detailed 

and specific exposure assessment. The 

positive findings in some studies were 

further limited by the methods used to 

estimate exposure and the difficulty in 

segregating fuel exposure from 

combustion-product exposure in some 

instances. 

Regarding Hodgkin’s disease, the 

studies were limited by their small 

numbers of cases and the nonspecificity 

of their exposure assessments. Of the 

five studies reviewed by NAS, two 

found no evidence of an association 

between fuel exposure and Hodgkin’s 

disease, one found an insignificant 

increase only among males. The other 

two studies showed evidence of an 

association, but were limited by wide 

confidence intervals and the lack of any 

relationship to a specific job or duration 

of employment. 

Studies on non-Hodgkin’s lymphoma 

had no firmly positive findings. The 

most well conducted studies showed no 

evidence of association. 

NAS found no consistent relationship 

between exposure to fuels and multiple 

myeloma in the studies reviewed. Most 

studies reported no association. 

NAS reviewed two studies that 

showed evidence of an association 

between myelodysplastic syndrome and 

exposure to petroleum-related 

substances. However, a significantly 

larger study using similar methods and 

procedures failed to produce consistent 

results. The larger study reported only 

a modest increased risk, with 

confidence intervals including the null, 

and did not find any evidence of a doseresponse relationship with duration or 

intensity of exposure. 

NAS determined that it was difficult 

overall to reach conclusions on the 

epidemiologic studies of adverse 

reproductive outcomes and exposure to 

fuels. The assessment of findings was 

limited by the small number of studies 

available on each health outcome, the 

possibility of recall bias, and the lack of 

specificity of exposure to the agents of 

concern in this report. NAS found no 

adequate studies regarding the 

relationship between fuel exposure and 

female infertility. NAS found one study 

concerning fuel exposure and male 

fertility, and that study showed no effect 

on sperm measures among persons 

exposed to jet fuels. NAS found only 

one study on fuel exposure and 

spontaneous abortion. The study 

showed a significant increase in 

spontaneous abortion among women 

living in an area where water used for 

drinking, cooking, and bathing was 

contaminated by nearby oil fields, 

however, the finding was potentially 

limited by recall bias and methods of 

estimating exposure. NAS identified one 

study showing an increased risk of 

childhood leukemia in the offspring of 

men exposed to petroleum for 1,000 

days or more before conception, and one 

study showing an increased risk of 

childhood leukemia based on maternal 

exposure to fuels during pregnancy. The 

latter study was potentially limited by 

recall bias, interviewer bias, controlselection procedures, and lack of 

validation for other risk factors. NAS 

noted that three other occupational 

studies showed no relationship between 

parental employment in a field 

involving fuel exposure and childhood 

leukemia. With respect to childhood 

cancers of the central nervous system, 

NAS identified one study showing no 

increase in neuroblastoma based on 

maternal exposure to fuels during 

pregnancy, but moderate increases 

based on paternal exposures. The study 

authors were unable to distinguish 

between paternal exposures occurring 

before or after conception. Another 

study showed an increased risk of 

neuroblastoma based on maternal or 

paternal exposures, although the study 

authors noted several limitations on the 

interpretation of the data, including 

bias, chance, and self-reporting of 

exposure information. NAS noted that 

two studies showed a possible 

association between parental exposure 

to hydrocarbons and the occurrence of 

Prader-Willi Syndrome in offspring, 

although neither study collected 

information on potential confounders. A 

third study found no association 

between exposure to hydrocarbons and 

Prader-Willi Syndrome in offspring. In 

view of the minimal and indeterminate 

data, NAS concluded that there was 

inadequate/insufficient evidence of an 

association between parental fuel 

exposure and adverse reproductive or 

developmental outcomes. 

Regarding neuropathy, NAS reviewed 

two studies, in which certain 

neurological symptoms were more 

prevalent among subjects with higher 

exposures to jet fuels, while other 

neurological symptoms were either not 

increased or were more prevalent among 

controls. NAS concluded that, although 

certain symptomatic differences were 

apparently related to exposure, there 

were no objective measures to support 

a relationship between jet-fuel exposure 

and neuropathy. The limitations of the 

studies included small samples and the 

lack of internal nonexposed groups of 

controls. 

Regarding neurobehavioral effects, 

NAS found that several studies of Gulf 

War veterans found a relationship 

between the veterans’ self-reported fuel 

exposure and their self-reported 

neuropsychologic, cognitive, or nonspecific symptoms, but that these 

studies provided weak evidence of any 

relationship, due to recall bias. NAS 

also discussed a study of increased 

neurologic and cognitive abnormalities 

among persons who engaged in ‘‘petrolsniffing,’’ but found those results 

inconclusive because the effects were 

most likely due to exposure to lead 

rather than the fuels themselves. 

NAS found that studies of MCS in 

Gulf War veteran or civilian samples 

generally provided relatively little 

evidence that MCS was associated with 

fuel exposure in service. Several studies 

involved questionnaires on which 

veterans or civilians self-reported that 

exposure to fuels are among the factors 

that can trigger their symptomatology. 

The studies generally were limited by 

methodologic concerns, including selfreported exposures and symptoms and 

the possibility of recall bias. Further, 

NAS noted that most of the studies did 

not address the factors relating to the 

first onset of symptoms as distinguished 

from subsequent recurrence of 

symptoms. The only study addressing 

first onset was an occupational study 

that incorporated objective exposure 

measurement and found a relationship 

between symptoms of MCS and fuel 

exposure. However, because the study 

was limited by the small sample and 

lack of a matched control group of 

workers, NAS found that it did not meet 

the criteria for a primary study that 

could support an association. 

Regarding respiratory diseases, the 

studies generally did not report specific 

respiratory disease outcomes and 

exposure assessment, so it was difficult 

to reach a conclusion as to a 

relationship between respiratory disease 

outcomes and exposure to fuels. 

However, NAS noted that most of the 

studies it reviewed showed 


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standardized mortality ratios of 1.0 or 

less in study populations, showing no 

increased risk of death due to 

nonmalignant respiratory disease, 

asthma, chronic bronchitis, or 

emphysema in populations exposed to 

fuels. 

Regarding irritant contact dermatitis, 

many fuels (for example, gasoline and 

kerosene) were generally acknowledged 

skin irritants, as indicated by the studies 

reviewed by NAS. Irritant contact 

dermatitis was evident soon after 

exposure but usually disappeared soon 

after removal of the irritant. There are 

few epidemiologic studies, however, of 

exposure to fuels and irritant and 

allergic contact dermatitis. Accordingly, 

NAS concluded that there was 

inadequate/insufficient evidence of an 

association between fuel exposure and 

chronic irritant and allergic contact 

dermatitis after cessation of exposure. 

The NAS report does not identify any 

studies concerning the possible 

relationship between exposure to fuels 

and sarcoidosis. However, NAS 

concluded, presumably based on the 

absence of relevant studies, that there is 

inadequate/insufficient evidence of an 

association between fuel exposure and 

sarcoidosis. 

Based on the information and analysis 

in the NAS report, the Secretary has 

determined that there is insufficient 

credible evidence to conclude that there 

is a positive association between 

exposure to fuels and cancers of the oral 

cavity and oropharynx; cancers of the 

nasal cavity and nasopharynx; 

esophageal cancer; stomach cancer; 

colon cancer; rectal cancer; hepatic 

cancer; pancreatic cancer; laryngeal 

cancer; lung cancer; melanoma; 

nonmelanoma skin cancer; female breast 

cancer; male breast cancer; female 

genital cancers (cervical, endometrial, 

uterine, and ovarian cancers); prostatic 

cancer; testicular cancer; nervous 

system cancers; kidney cancer; bladder 

cancer; Hodgkin’s disease; nonHodgkin’s lymphoma; multiple 

myeloma; myelodysplastic syndromes; 

adverse reproductive or developmental 

outcomes (including infertility, 

spontaneous abortion, childhood 

leukemia, CNS tumors, neuroblastoma, 

and Prader-Willi syndrome); peripheral 

neuropathy; neurobehavioral effects; 

Multiple Chemical Sensitivity 

symptoms; nonmalignant respiratory 

disease; chronic bronchitis; asthma; 

emphysema; dermatitis-irritant and 

allergic; and sarcoidosis. Therefore, a 

presumption of service connection is 

not warranted for any such illness based 

upon exposure to fuels during service in 

the 1991 Gulf War. 

D. Nitric Acid—Inadequate/Insufficient 

Evidence 

NAS found inadequate/insufficient 

evidence between nitric acid and 

stomach cancer; melanoma; 

lymphopoietic cancers; pancreatic 

cancer; laryngeal cancer; lung cancer; 

bladder cancer; multiple myeloma; and 

cardiovascular diseases. 

Generally, on the basis of NAS’s 

review of the epidemiologic evidence, 

no available studies directly examined 

the association between exposure to 

nitric acid and long-term human health 

effects. Most studies were able only to 

investigate the health effects of nitric 

acid in combination with other strong 

inorganic acids, such as sulfuric acid, or 

other known carcinogens such as 

asbestos: that is, an independent 

assessment of nitric acid exposure was 

impossible because workers were 

exposed simultaneously to such 

mixtures. As a result, the health effects 

associated with exposure to nitric acid 

alone cannot be assessed. 

It appears that NAS stated 

conclusions with respect to nitric acid 

and nine disease categories because 

certain studies state findings with 

respect to those disease categories in 

populations that potentially were 

exposed to a group of carcinogens that 

may have included nitric acid. As 

explained above, however, NAS 

concluded that the existing data are not 

sufficiently specific to nitric acid and, 

therefore, do not provide reliable 

evidence of an association between 

exposure to nitric acid and the 

occurrence of any disease. 

Based on the information and analysis 

in the NAS report, the Secretary has 

determined that there is insufficient 

credible evidence to conclude that there 

is a positive association between 

exposure to nitric acid and stomach 

cancer; melanoma; lymphopoietic 

cancers; pancreatic cancer; laryngeal 

cancer; lung cancer; bladder cancer; 

multiple myeloma; and cardiovascular 

diseases. Therefore, a presumption of 

service connection is not warranted for 

any such illness based upon exposure to 

nitric acid during service in the 1991 

Gulf War. 

IV. VA Response to the National 

Academy of Sciences Report 

In order to facilitate action on the 

2004 update report from NAS, VA 

established the 2005 Gulf War Health 

Effects Task Force to consider and 

develop recommendations for the 

Secretary of Veterans Affairs. The Task 

Force consisted of top Departmental 

officials, specifically the Under 

Secretaries for Health and Benefits, the 

General Counsel, and the Assistant 

Secretary for Policy and Planning. The 

review provided the basis for the 

Secretary’s determination regarding 

health outcomes related to service in the 

Gulf War. 

A. 1991 Gulf War Hazard Exposure Data 

Although the statutes necessarily 

contemplate that NAS would evaluate 

non-veteran studies concerning the 

health effects of various exposures, they 

also require NAS to attempt to relate its 

findings to the actual experiences of 

Gulf War veterans. 

For example, Public Law 105–277, 

§ 1603(e)(1)(B) directs NAS to evaluate 

and summarize ‘‘the increased risk of 

the illness among human or animal 

populations’’ including but not limited 

to Gulf War veterans. Public Law 105–

368, § 101(c)(1)(C) directs NAS to 

‘‘identify the illnesses * * * for which 

there is scientific evidence of a higher 

prevalence among populations of Gulf 

War veterans when compared with 

other appropriate populations of 

individuals.’’ The statute goes on to 

require that for each illness NAS finds 

to be more prevalent in Gulf War 

veterans or to be associated with a 

possible Gulf War hazardous exposure, 

NAS ‘‘shall determine (to the extent 

available scientific evidence permits) 

whether there is scientific evidence of 

an association of that illness with Gulf 

War service or exposure during Gulf 

War service to one or more agents, 

hazards, or medicines or vaccines.’’

Public Law 105–368, § 101(e)(1). 

Public Law 105–368, § 101(e)(1)(E), 

(F) directs NAS to consider ‘‘in any case 

where information about exposure 

levels is available, whether the evidence 

indicates that the levels of exposure of 

the studied populations were of the 

same magnitude as the estimated likely 

exposures of Gulf War veterans; and 

* * * whether there is an increased risk 

of illness among Gulf War veterans in 

comparison with appropriate peer 

groups.’’

Congress further provided that ‘‘[i]n 

conducting the review and evaluation 

* * * [NAS] shall * * * assess the 

latency period, if any, between service 

or exposure to any potential risk factor 

(including an agent, hazard, or medicine 

or vaccine [reviewed]) * * * and the 

manifestation of such illness.’’ Public 

Law No. 105–368, § 101(c)(3). 

Determinations concerning the 

increased risk of illness among Gulf War 

veterans, as well as the latency periods 

for manifestation of illness, necessarily 

require consideration of the degree and 

the duration of exposure to the relevant 

environmental hazards. Findings based 

on non-veterans dwelling in cities or 


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typical civilian occupational studies 

may not necessarily support findings 

specific to Gulf War service because of 

differences in the magnitude and 

duration of exposure between these 

groups. 

NAS concluded in its report that it 

was essentially unable to respond to 

Congress’ charge to relate their 

literature-based health findings to the 

actual exposure magnitude and duration 

for Gulf War veterans. NAS explained: 

To estimate the magnitude of risk of a 

particular health outcome among Gulf War 

veterans, the committee would need to 

compare the rates of disease or other health 

effects in veterans exposed to the putative 

agents with the rates in those who were not 

exposed. That would require information 

about the specific agents to which individual 

veterans were exposed and about their doses. 

However, there is a paucity of data regarding 

the agents and doses to which individual 

Gulf War veterans were exposed. * * * 

Because of the lack of various kinds of data 

on veterans, the committee could not 

extrapolate from the exposures in the studies 

it reviewed to the exposures of Gulf War 

veterans. Therefore, it could not determine 

the likelihood of increased risk of adverse 

health outcomes among Gulf War veterans 

due to exposure to the agents examined in 

this report. 

‘‘Gulf War and Health, Volume 3. Fuels, 

Combustion Products, and Propellants,’’

pp.16–17 (December 20, 2004). 

NAS further noted that the studies it 

reviewed often ‘‘included people whose 

exposures had been over a lifetime 

(such as to air pollution in their 

communities) or included workers 

employed in a particular industry over 

many years.’’ NAS stated: ‘‘In contrast, 

the exposures of veterans in the Persian 

Gulf were of relatively short duration 

with varying intensity. Therefore, the 

exposures experienced during the Gulf 

War might only approximate the 

exposures described in the occupational 

and environmental literature reviewed 

in this report.’’ ‘‘Gulf War and Health, 

Volume 3. Fuels, Combustion Products, 

and Propellants,’’ p. 17 (December 20, 

2004). 

As such, NAS was unable to relate 

their health findings to the actual 

exposures experienced by Gulf War 

veterans. However, some relevant data 

is available. 

1. Gulf War Exposure to Combustion 

Products 

In its September 2000 report, 

‘‘Environmental Exposure Report: Oil 

Well Fires’’ the Department of Defense 

(DoD) summarized its investigations on 

exposure of Gulf War veterans to oilwell-fire smoke and related combustion 

products during the 1991 Gulf War. The 

report describes how from January 

through late February 1991, retreating 

Iraqi forces set fire to more than 600 

Kuwaiti oil-wells, creating huge 

columns of smoke. These fires were 

brought under control within 9 months. 

The report concludes that, although 

the oil-well fires produced smoke 

plumes, the actual exposure to 

combustion products of U.S. service 

members in that region was generally 

unremarkable. Furthermore, unlike 

many Gulf War environmental hazards 

of concern, the results of extensive 

monitoring efforts by various agencies 

for air pollutants and combustion 

products from the 1991 Gulf oil-well 

fires are available to support the report’s 

conclusions about such exposure. The 

report also concludes that some 

individual veterans who were near the 

oil-well fires could have been exposed 

to high levels of large particulates, 

primarily as material deposited directly 

to skin or clothing rather than through 

inhalation. 

According to the report, 

For about eight months immediately after 

the ground war, U.S. and international 

organizations conducted comprehensive air 

monitoring to characterize the contaminants 

of concern and, by measuring their relative 

concentrations in the atmosphere, lay the 

groundwork for assessing their likely shortand long-term impacts to human health and 

the environment. * * * Ground-level and 

airborne-based monitoring platforms 

collected numerous samples. The U.S. Army 

Environmental Hygiene Agency conducted 

the most comprehensive monitoring program, 

including taking more than 4,000 samples. 

In general, the monitoring results were 

consistent among the various organizations 

involved. * * * the maximum observed 

concentrations of air contaminants, other 

than particulate matter, were similar to levels 

found in U.S. suburbs and generally lower 

than those found in large urban areas. 

Overall, * * * monitoring data show the 

pollutant concentrations present in the 

environment, particularly in areas where U.S. 

troops and civilians were located, fell below 

NIOSH [National Institute for Occupational 

Safety and Health], OSHA [Occupational 

Safety and Health Administration], or ACGIH 

[American Conference of Government 

Industrial Hygienists] recommended 

exposure limits for hazardous substances in 

the workplace. 

The DoD report states: 

At the time of the destruction, the medical 

and environmental community feared 

exposure to the fires would result in 

catastrophic acute and chronic health effects. 

However, the fires’ high combustion 

efficiency, the nature and amount of the 

smoke’s contaminants, the lofting effect 

created by solar heating, and the local wind 

and weather conditions combined to reduce 

the fires’ impact on military and civilian 

populations. 

Results of air monitoring studies indicated, 

except for particulate matter, air 

contaminants were below levels established 

to protect the health of the general 

population. However, there were self-reports 

by a number of veterans who complained of 

acute symptoms they allege were a result of 

their proximity to the burning oil wells. 

The DoD report points out that 

exposures to the fires by U.S. service 

members were quite short compared to 

civilians dwelling in U.S. cities exposed 

to urban ‘‘smog’’ and indoor air 

pollution, or workers exposed to engine 

exhaust: ‘‘Fortunately, the time period 

during which military and civilian 

populations were subjected to the fires’

pollution was relatively short.’’

Nevertheless, some 1991 Gulf War 

troops apparently reported various 

short-term adverse health symptoms 

that could have been related to 

exposures to oil fire smoke. The report 

characterized these as follows: ‘‘Several 

troops reported significant short-term 

exposures to oil fire smoke, soot, and 

unburned oil, usually after having been 

totally enveloped in oil-well-fire fallout. 

At times troops reported being soaked 

with unburned oil.’’ ‘‘Several 

monitoring sites observed high levels of 

airborne particulates, sand, and soot. 

Analysis of samples, however, indicated 

the particles were mostly sand-based 

materials typical for this region of the 

world. In the particulate matter samples, 

PAH and toxic metal concentrations 

were low.’’ Finally, ‘‘[w]hile smoke 

plumes occasionally touched the 

ground, enveloping nearby personnel, 

few were in those areas for extended 

periods of time.’’

DoD’s finding that the oil-well fires 

did not result in significant unique 

exposures has been confirmed by 

several other sources. The Presidential 

Advisory Committee on Gulf War 

Veterans’ Illnesses noted that, while the 

oil well fires were burning, numerous 

U.S. and international agencies 

performed extensive air monitoring; 

these groups included a U.S. 

Interagency Air Assessment team 

comprised of scientists from the 

Environmental Protection Agency, the 

National Oceanographic and 

Atmospheric Administration, and the 

Department of Health and Human 

Services; and a group of scientists from 

twelve countries engaged in a datacollection effort overseen by the World 

Meteorological Organization. The 

Presidential Advisory Committee stated 

that ‘‘[a]ll groups found that levels of 

nitrogen oxides, carbon monoxide, 

sulfur dioxide, hydrogen sulfide, other 

pollutant gases, and [PAHs] were lower 

than anticipated and did not exceed 

those seen in urban air in a typical U.S. 

industrial city.’’ Presidential Advisory 

Committee on Gulf War Veterans’

Illnesses: Final Report (Washington, DC: 


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U.S. Government Printing Office, 

December 1996). The Presidential 

Advisory Committee further noted that 

biological samples taken from persons 

deployed in the vicinity of the oil-well 

fires generally revealed lower levels of 

volatile organic compounds (VOCs), 

polycyclic aromatic carbons, and lead 

than in reference populations located 

elsewhere, except in the case of 

firefighters, who had significantly 

elevated levels of VOCs in comparison 

to the reference population. 

NAS’s finding linking oil-well-fire 

smoke and lung cancer was based 

primarily on studies of workers exposed 

to engine exhaust on the job and to 

civilians exposed to ‘‘smog’’ and indoor 

air pollution from heaters and stoves in 

the cities in which they dwelled. Health 

effects from these relatively long-term 

exposures may not be relevant to effects 

from short-term but intense exposures 

experienced by some veterans of the 

1991 Gulf War who became heavily 

covered with fallout from oil well fires. 

Apart from the oil-well fires, exposure 

to combustion products could also have 

occurred through more routine 

operations that involve burning fuels. 

The 1996 Final Report of the 

Presidential Advisory Committee stated 

that ‘‘[o]perating the vehicles and 

machinery used in the Gulf War 

involved exposure to petroleum-based 

material,’’ and that ‘‘[p]etroleum fuels 

also were used for burning wastes and 

trash, dust suppression, and fueling 

stoves and tent heaters. The Presidential 

Advisory Committee stated that ‘‘none 

of these uses is unique to the Gulf War,’’

but that such uses probably led to 

increased petroleum vapor and 

combustion product exposures. With 

respect to the use of heaters, the 

Committee noted that ‘‘[b]urning leaded 

fuels indoors without proper 

ventilation—e.g., heaters in tents—

could have caused increased lead 

exposure,’’ and that ‘‘[k]erosene heaters, 

widely used in the United States, also 

could have been significant sources of 

exposure to nitric oxides, sulfur 

dioxide, inorganic combustion gases, 

carbon monoxide, and particles when 

used with inadequate ventilation.’’

2. Gulf War Exposure to Hydrazine 

Rocket Propellants 

In January 2005, VA’s Under 

Secretary for Health formally requested 

DoD’s Assistant Secretary of Defense for 

Health Affairs to provide all available 

information about possible exposures of 

U.S. service members to hydrazine 

rocket fuels during the 1991 Gulf War. 

DoD’s response in an April 8, 2005, 

letter from the Assistant Secretary of 

Defense was that the best available 

information indicated it was unlikely 

there was any exposure to hydrazine 

among U.S. military personnel in the 

Gulf. U.S. missiles and other munitions 

did not employ hydrazine during the 

Gulf War. Also, investigations indicated 

Iraq had not switched to hydrazine as a 

propellant for Scud missiles. 

Accordingly, there was no basis upon 

which to conclude that U.S. veterans of 

the Gulf War were exposed to hydrazine 

from either U.S. or Iraqi missiles. 

A very small number of personnel 

working with the U.S. Air Force F–16 

aircraft might have had minimal 

exposure to hydrazine. F–16 aircraft are 

equipped with a sealed tank (bottle) of 

hydrazine as an emergency propellant to 

be employed in the event of engine stall. 

When employed, the hydrazine is 

consumed. F–16 squadrons deployed 

with spare bottles during the Gulf War. 

If used, the bottles would have been 

returned to the U.S., Europe, or Turkey 

to be refilled and shipped back. The Air 

Force has long been keenly aware of the 

potential health hazards of hydrazine, 

so refilling operations are conducted in 

a manner consistent with the strictest of 

occupational health standards. 

DoD’s August 1999 report, 

‘‘Information Paper: Inhibited Red 

Fuming Nitric Acid,’’ concluded that 

the rocket fuel used by Iraqi forces in 

Scuds and several smaller missiles 

during the 1991 Gulf War was a type of 

kerosene and red fuming nitric acid 

(also known as IRFNA). DoD states that 

apparently Iraq had experimented with 

hydrazine rocket fuels including 

UDMH, however, it concluded that 

these fuels were not used during that 

conflict: 

The missile fuel that Iraq used in its older 

Soviet systems was a specially refined 

kerosene-like substance (called kerosene in 

the literature). Some improved missiles used 

UDMH in combination with IRFNA. The 

Soviet Union used UDMH in their Scuds, but 

we have no evidence that Iraq used UDMH. 

Therefore, it is unlikely that any U.S. 

service members were exposed to 

hydrazine rocket fuels during the 1991 

Gulf War. 

B. VA Determination on Combustion 

Products and Hydrazines 

Based upon the evidence currently 

available, VA has determined that a 

presumption of service connection is 

not warranted at this time for any 

disease based upon an association with 

exposure to combustion products or 

hydrazines during service in the Gulf 

War. This determination is based on the 

conclusion that current evidence does 

not establish that service in the Gulf 

War entailed exposures to combustion 

products that were unique to Gulf War 

service when compared to other military 

and civilian populations and that could 

be expected to produce the increased 

risk of adverse health effects based on 

the findings set forth in the NAS report. 

The best evidence currently available 

indicates that hydrazines were used in 

limited circumstances during the Gulf 

War and that hydrazine exposure 

generally would not have occurred. 

With respect to combustion products, 

although the 1991 oil well fires were the 

product of a unique event, the best 

evidence currently available indicates 

that they did not result in combustionproducts exposures that were unique in 

kind or degree when compared to 

exposures incurred generally by other 

military and civilian populations as the 

result of ambient air pollution, vehicle 

exhaust, and other means. Currently 

available evidence further indicates that 

other potential means of exposure to 

combustion products, such as through 

proximity to vehicles, aircraft, or the use 

of fuel-based heaters, did not differ 

significantly in the Gulf War from 

similar exposures occurring in other 

military and civilian populations 

generally. 

In the absence of unique exposures 

associated with Gulf War service that 

could be correlated to the increased 

risks of health effects discussed in the 

NAS report, a generally applicable 

presumption of service connection is 

not warranted based on exposure to 

combustion products or hydrazines in 

the Gulf War. The governing statute 

requires VA to establish presumptions 

when the Secretary determines that an 

illness is associated with exposure to 

substances or hazards ‘‘known or 

presumed to be associated with service 

in the Southwest Asia Theater of 

operations during the Persian Gulf 

War.’’ 38 U.S.C. 1118(b)(1)(B)(i). 

VA has determined that hydrazines 

were used during the 1991 Gulf War 

only under extremely limited 

conditions, and, therefore, hydrazines 

are not substances or hazards 

‘‘associated with’’ service in the 1991 

Gulf War. Consequently, VA need not 

establish a presumption of service 

connection for any disease identified in 

the NAS report as associated with such 

exposure. 

VA has determined that combustion 

products, the prevalence and use of 

which in the Gulf War did not differ 

significantly from the prevalence and 

use of such substances in other military 

and civilian populations, are not 

substances or hazards ‘‘associated with’’

service in the 1991 Gulf War, because 

they are not unique to such service. 

Consequently, VA need not establish 

presumptions of service connection for 


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any of the eight diseases that NAS 

associated with exposure to combustion 

products in its report. 

This approach is similar to that taken 

in our notice concerning the 2002 NAS 

report on insecticides and solvents. 

Public Law 105–277 specifically 

directed NAS to consider combustion 

products, fuels, and propellants among 

the substances to which veterans may 

have been exposed in their service in 

the 1991 Gulf War. The statute does not 

specifically identify these agents as 

substances ‘‘associated with’’ such 

service. Although Congress directed 

NAS to consider them in its reports, the 

language and structure of the statute 

indicates that Congress delegated to VA 

the responsibility for determining, based 

on NAS reports and other available 

information, whether such substances 

were ‘‘associated with’’ Gulf War service 

for the purpose of establishing 

presumptions under the statute. 

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 

military or civilian life in general that 

are not unique to service in the Gulf 

War. The phrase ‘‘associated with’’

clearly connotes a direct relationship, 

and the requirement that the substance 

or hazard be associated with service at 

a particular time and place indicates an 

intent to distinguish between substances 

and hazards associated with general 

military or civilian life and those unique 

to service at the specified time and 

place. If civilian and military 

populations are commonly exposed to a 

substance, we believe it would be 

unreasonable to conclude that the 

substance is ‘‘associated with’’ service 

in the Persian Gulf during the Gulf War 

merely because it was present during 

such service. We do not believe that 

Congress intended VA to establish 

presumptions for the known health 

effects of all substances common to 

military or civilian life. Rather, the 

requirement that the substance be 

‘‘associated with’’ Gulf War service 

makes clear that VA’s task is to focus on 

the unique exposure environment in the 

Persian Gulf during the Persian Gulf 

War. 

This reading of the statutory language 

comports with the clear purpose of both 

Public Law 105–277 and Public Law 

105–368. Both statutes reflect 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. It is 

by now well known that many Gulf War 

veterans have reported a variety of 

similar symptoms that cannot presently 

be identified with a known diagnosis or 

cause and that were not considered 

‘‘diseases’’ for the purposes of the 

statutes generally authorizing VA to pay 

compensation for service-connected 

disability or death due to disease or 

injury. Congress responded initially to 

that situation by authorizing VA to pay 

compensation for ‘‘undiagnosed illness’’

in such veterans. The process 

established by Public Law 105–277 and 

Public Law 105–368 reflects a further 

effort to bridge the existing gaps in 

medical and scientific knowledge and to 

ensure that Gulf War veterans may 

obtain compensation for diagnosed or 

undiagnosed illnesses that may have 

been caused by the unique exposures or 

hazards of service during the Gulf War. 

Establishing presumptions of service 

connection for illnesses associated with 

exposures or hazards specifically related 

to Gulf War service obviously would 

further that objective. In contrast, 

establishing presumptions of service 

connection for the exclusive benefit of 

Gulf War veterans based solely on the 

well-known health effects of exposures 

shared in common with the general 

veteran population would not 

significantly further the purposes of 

those statutes. Moreover, establishing 

such presumptions would create 

significant inequities in the veterans’

benefits system that Congress could not 

have intended. 

Public Law 105–277 requires VA to 

establish presumptions of service 

connection, when the statutory 

requirements are met, exclusively for 

veterans who served in the Southwest 

Asia theater of operations during the 

Persian Gulf War. If the statute were 

construed to require presumptions 

based on exposure in the Persian Gulf 

War to substances to which other 

veterans serving at other times and 

places are commonly exposed at similar 

levels, it would raise significant 

concerns of fairness and reasonableness. 

For example, veterans exposed or 

presumably exposed to combustion 

products during the Gulf War might be 

entitled to presumptive service 

connection for certain diseases 

associated with such exposure, while 

veterans who served stateside and had 

equal or greater combustion product 

exposure would not be entitled to 

presumptive service connection for 

those diseases. The fact that most 

service members, and most civilians, 

routinely incur some degree of 

background exposure to the substances 

NAS considered further underscores the 

arbitrariness that would attach to 

establishing presumptions for a limited 

class of veterans based on such common 

exposures. Apart from the fact that it is 

generally unnecessary to establish 

presumptions of service connection for 

health effects that are well documented 

in the medical literature, establishing 

presumptions applicable only to a small 

percentage of the veteran population 

potentially exposed to the relevant 

substances would have significant 

adverse effects on the veterans benefits 

system. Providing by statute and 

regulation for the disparate treatment of 

similarly situated veterans would 

substantially undermine confidence in 

the objectivity and fairness of the 

veterans benefits system. Additionally, 

establishing different adjudicative rules 

for the claims of similarly situated 

veterans without any reasoned basis for 

the distinction would undoubtedly 

cause confusion to the VA personnel 

responsible for deciding claims, as well 

as to veterans and their representatives 

in presenting and supporting their 

claims. 

We do not believe that Congress 

intended VA to establish presumptions 

unique to Gulf War veterans based on 

the well-known health effects of 

exposures common to military and 

civilian life outside the Gulf War theater 

of operations. As explained above, the 

language and purpose of Public Law 

105–277 and Public Law 105–368 

indicate that Congress did not intend 

such a result, and we believe it is 

reasonable to presume that Congress did 

not intend arbitrary or unfair 

distinctions. We note that statutes 

generally must be construed to avoid 

serious constitutional concerns. See 

Edward J. DeBartolo Corp. v. Florida 

Gulf Coast Building & Construction 

Trades Council, 485 U.S. 568, 575 

(1988). We cannot say it is beyond 

Congress’ power to establish 

presumptions exclusively for Gulf War 

veterans based on exposures not known 

to differ significantly from service 

outside the Gulf War. However, the 

apparent unfairness, in our view, of that 

result supports the conclusion that 

Congress did not intend such a result. 

We recognize that Public Law 105–

277 and Public Law 105–368 both 

required NAS to consider the health 

effects of exposure to fuels, combustion 

products, and propellants as part of its 

investigations of illnesses potentially 

associated with Gulf War service. 

However, the direction to consider those 

substances does not compel the 


jlentini on PROD1PC65 with NOTICES
Federal Register / Vol. 73, No. 168 / Thursday, August 28, 2008 / Notices 50869 

conclusion that those substances, 

considered in isolation, are themselves 

agents ‘‘known or presumed to be 

associated with service in the Southwest 

Asia theater of operations during the 

Persian Gulf War’’ for purposes of VA’s 

duty to establish presumptions of 

service connection. Section 1603 of 

Public Law 105–277 describes the scope 

of NAS’ inquiry. Section 1603(c)(1) 

directs NAS to ‘‘identify the biological, 

chemical, or other toxic agents, 

environmental or wartime hazards, or 

preventive medicines or vaccines to 

which members of the Armed Forces 

who served in the Southwest Asia 

Theater of operations during the Persian 

Gulf War may have been exposed by 

reason of such service.’’ Section 1603(d) 

of that statute provides that, in 

identifying substances to which Gulf 

War veterans ‘‘may have been exposed,’’

NAS will consider, among other things, 

oil fire byproducts. In contrast, section 

1602 of Public Law 105–277 does not 

direct the Secretary to establish 

presumptions of service connection for 

the health effects of every substance to 

which Gulf War veterans ‘‘may have 

been exposed,’’ but requires 

presumptions only for the health effects 

of exposure to substances known or 

presumed to be ‘‘associated with’’

service in the Gulf War. Congress used 

different language in section 1602 and 

1603 of Public Law 105–277, and we 

must conclude that the different 

language was intended to have different 

meanings. See Bank of America 

National Trust & Savings Ass’n v. 203 

N. LaSalle St. Partnership, 526 U.S. 434, 

450 (1999); Russello v. United States, 

464 U.S. 16, 23 (1983). Congress 

reasonably defined the scope of NAS’

inquiry broadly, to include 

consideration of all substances to which 

veterans may have been exposed during 

the Gulf War, irrespective of whether 

the exposures were unique to Gulf War 

service or common to all service. In 

defining VA’s regulation-writing 

obligations, however, Congress 

reasonably required VA to establish 

presumptions of service connection 

only for the health effects of substances 

that are ‘‘associated with’’ Gulf War 

service. As noted above, that limitation 

furthers Congress’ purpose of 

establishing presumptions for the 

unique health concerns of Gulf War 

veterans and also avoids the inequity of 

establishing presumptions exclusively 

for Gulf War veterans based on 

exposures that are common to most 

veterans. 

Our conclusion that the hydrazines 

and combustion products in question, in 

isolation, cannot at this time be 

determined to be ‘‘associated with’’ Gulf 

War service is not intended to suggest 

that they are irrelevant to further 

investigations of Gulf War veterans’

health or that they may not in any 

circumstance form the basis for 

presumptions of service connection 

under Public Law 105–277. In the event 

future evidence links any illnesses to a 

combination of exposures associated 

with Gulf War service, whether or not 

including exposure to fuels, combustion 

products, and propellants, VA may 

establish presumptions of service 

connections for such illnesses pursuant 

to Public Law 105–277. 

This determination also in no way 

prevents veterans from obtaining service 

connection for the health effects 

discussed in the NAS report where the 

potential for above-normal exposures 

was present in service. Under 

established current procedures, VA 

develops and considers evidence 

concerning events or aspects of service 

that may contribute to the incurrence of 

an illness. Accordingly, if a veteran’s 

occupation in service, such as a 

firefighter or mechanic, entailed abovenormal exposure to combustion 

products, VA will give due 

consideration to that unique exposure in 

determining whether service connection 

is warranted for a health effect known 

to be associated with such exposure. 

Similarly, if a veteran served in a role 

that may have involved exposure to 

hydrazines, VA will evaluate that factor 

in determining whether service 

connection is warranted for a disease 

associated with such exposure. These 

standards apply to claims by veterans of 

any period of service, and are not 

dependent upon any presumption of 

service connection. A presumption of 

service connection is not needed for the 

purpose of establishing a link between 

exposure to combustion products or 

hydrazines and any disease identified in 

the NAS report as associated with such 

exposures, because those health effects 

are generally well known and, in any 

event, the NAS report itself provides 

significant additional evidence of such 

an association. Accordingly, the 

determination not to establish a 

generally applicable presumption based 

on the NAS report will not preclude the 

grant of benefits to any individual 

whose service entailed the type of 

exposure NAS found to be associated 

with an increased risk of disease 

incurrence. 

V. Conclusion 

After careful review of the findings of 

the 2004 NAS report, ‘‘Gulf War & 

Health Vol. 3: Fuels, Combustion 

Products, and Propellants,’’ and other 

pertinent information including reports 

from DoD on potential exposure of U.S. 

service members, the Secretary has 

determined that the scientific evidence 

presented in the 2004 NAS report and 

other information available to the 

Secretary indicates that no new 

presumption of service connection is 

warranted for any of the illnesses 

described in the 2004 NAS report. 

Approved: August 21, 2008. 

James B. Peake, 

Secretary of Veterans Affairs. 

[FR Doc. E8–19971 Filed 8–27–08; 8:45 am] 

BILLING CODE 8320–01–P 

DEPARTMENT OF VETERANS 

AFFAIRS 

Voluntary Service National Advisory 

Committee; Notice of Meeting 

The Department of Veterans Affairs 

(VA) gives notice under Public Law 92–

463 (Federal Advisory Committee Act) 

that the Executive Committee to the 

Department of Veterans Affairs 

Voluntary Service (VAVS) National 

Advisory Committee (NAC) will meet 

October 6–7, 2008, at the Marriott West 

Chase, Houston, Texas. The sessions 

will begin at 8 a.m. each day and end 

at 4:30 p.m. on October 6 and at noon 

on October 7. The meeting is open to the 

public. 

The NAC consists of 63 national 

organizations and advises the Secretary, 

through the Under Secretary for Health, 

on the coordination and promotion of 

volunteer activities within VA health 

care facilities. The Executive Committee 

consists of 18 representatives from the 

NAC member organizations. 

On October 6, agenda topics will 

include: NAC goals and objectives, 

minutes of April 2008 NAC meeting, 

Veterans Health Administration update, 

VAVS update on the Voluntary Service 

program’s activities since the 2008 NAC 

annual meeting, Parke Board update, 

evaluations of the 2008 NAC annual 

meeting and plans for the 2009 NAC 

annual meeting (to include workshops 

and plenary sessions). On October 7, 

agenda topics will include: 

Recommendations from the 2008 NAC 

annual meeting, subcommittee reports, 

standard operating procedure revisions, 

2010 NAC annual meeting planning, 

and new business. 

No time will be allocated at this 

meeting for receiving presentations from 

the public. However, interested persons 

may either attend or file statements with 

the Committee. Written statements may 

be filed either before the meeting or 

within 10 days after the meeting and 

addressed to: Ms. Laura Balun, 


jlentini on PROD1PC65 with NOTICES