Summary Annex: Conclusions

This Summary Annex lists the full conclusions about possible relationships between military exposures experienced during deployment to Southwest Asia or Afghanistan after September 11, 2001, and mental, behavioral, and neurologic outcomes and chronic multisymptom illness (CMI). The exposures of interest are burn pits, dust and particulate matter (PM), exhaust, fuels, incinerator emissions, metals, mold, radiation, and solvents.¹ The outcomes are adjustment disorders, attention disorders, anxiety disorders, depression, posttraumatic stress disorder, serious mental illness (including a composite measure of schizophrenia and psychosis and bipolar disorder), sleep disorders, substance use disorders (SUD),² nonfatal suicide attempts and intentional self-harm, amyotrophic lateral sclerosis, dementia, multiple sclerosis, Parkinson’s disease, and CMI. Evidence supporting the conclusions came from two sources—the results of the committee’s analyses using Department of Veterans Affairs and Department of Defense data

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¹ Literature on PM was used to support analytic results on exposure to dust and PM, exhaust, and incinerator emissions. Conclusions relying on the data analyses alone or together with the literature refer to dust and PM, exhaust, and incinerator emissions, whereas conclusions that possible risk-conferring relationships exist relying solely on the literature refer to PM alone. The committee did not make conclusions about whether inadequate/insufficient evidence of a possible risk-conferring relationship exists based on the literature alone, so there are no conclusions on whether inadequate or insufficient evidence exists for PM alone.

² SUD includes alcohol-related disorders; opioid-related disorders; cannabis-related disorders; sedative-, hypnotic-, or anxiolytic-related disorders; cocaine-related disorders; other stimulant-related disorders; hallucinogen-related disorders; nicotine dependence; inhalant-related disorders; and other psychoactive substance–related disorders.

and the epidemiologic literature, both of which had important limitations. Key limitations are related to inconsistencies in how the exposures and outcomes were measured, data gaps, and reliance on literature in the general population that in some circumstances may have limited relevance for military populations and deployment settings. In addition, analysis results are based on a sample of post-9/11 veterans who served in Southwest Asia or Afghanistan and received care at Veterans Health Administration (VHA), which limits generalizability. The committee synthesized these two sources of evidence and determined that either a possible risk-conferring relationship exists, meaning that a link may exist between experiencing a given military exposure and developing a mental, behavioral, or neurologic outcome or CMI, or that there was inadequate or insufficient evidence of such a relationship. Recognizing the shortcomings in the evidence, these conclusions are specific to post-9/11 veterans who served in Southwest Asia or Afghanistan and received care at VHA and can be interpreted as weak evidence of potentially meaningful signals for additional investigation.

MENTAL AND BEHAVIORAL HEALTH OUTCOMES

Conclusion 6-1: Based on its analysis of the available data, the committee finds there is a possible risk-conferring relationship between exposure to dust and particulate matter (PM), exhaust, or incinerator emissions and adjustment disorders. The committee does not find a possible risk-conferring relationship between exposure to burn pits, fuels, metals, mold, radiation, or solvents and adjustment disorders.

Based on the literature review, there is insufficient evidence of a possible risk-conferring relationship between exposure to PM or metals and adjustment disorders. There is no identified literature on the relationship between exposure to burn pits, fuels, mold, radiation, or solvents and adjustment disorders.

Synthesizing the committee’s data analysis and literature review, the committee concludes there is a possible risk-conferring relationship between exposure to dust and PM, exhaust, or incinerator emissions and adjustment disorders. The committee further concludes there is inadequate or insufficient evidence of a possible risk-conferring relationship between exposure to burn pits, fuels, metals, mold, radiation, or solvents and adjustment disorders.

Conclusion 6-2: Based on its analysis of the available data, the committee does not find a possible risk-conferring relationship between exposure to burn pits, dust and particulate matter (PM), exhaust, fuels, incinerator emissions, metals, mold, radiation, or solvents and attention disorders.

Based on the literature review, there is mixed evidence of a possible risk-conferring relationship between exposure to PM or metals and attention disorders. There is insufficient evidence of a possible risk-conferring relationship between exposure to mold and attention disorders. There is no identified literature on the relationship between exposure to burn pits, fuels, radiation, or solvents and attention disorders.

Synthesizing the committee’s data analysis and literature review, the committee concludes there is inadequate or insufficient evidence of a possible risk-conferring relationship between exposure to burn pits, dust and PM, exhaust, fuels, incinerator emissions, metals, mold, radiation, or solvents and attention disorders.

Conclusion 6-3: Based on its analysis of the available data, the committee does not find a possible risk-conferring relationship between exposure to burn pits, dust and particulate matter (PM), exhaust, fuels, incinerator emissions, metals, mold, radiation, or solvents and anxiety disorders.

Based on the literature review, there is mixed evidence of a possible risk-conferring relationship between exposure to PM or metals and anxiety disorders. There is inadequate and insufficient evidence of a possible risk-conferring relationship between exposure to radiation and anxiety disorders. There is no identified literature on the relationship between exposure to burn pits, fuels, mold, or solvents and anxiety disorders.

Synthesizing the committee’s data analysis and literature review, the committee concludes there is inadequate or insufficient evidence of a possible risk-conferring relationship between exposure to burn pits, dust and PM, exhaust, fuels, incinerator emissions, metals, mold, radiation, or solvents and anxiety disorders.

Conclusion 6-4: Based on its analysis of the available data, the committee does not find a possible risk-conferring relationship between exposure to burn pits, dust and particulate matter (PM), exhaust, fuels, incinerator emissions, metals, mold, radiation, or solvents and depression.

Based on the literature review, there is suggestive evidence of a possible risk-conferring relationship between exposure to PM and depression. There is mixed evidence of a possible risk-conferring relationship between exposure to metals and depression. There is limited evidence of a possible risk-conferring relationship between exposure to solvents and depression. There is insufficient evidence of a possible risk-conferring relationship between radiation and depression. There is no identified literature on the relationship between exposure to burn pits, fuels, or mold and depression.

Synthesizing the committee’s data analysis and literature review, the committee concludes there is a possible risk-conferring relationship between exposure to PM and depression. The committee further concludes there is inadequate or insufficient evidence of a possible risk-conferring relationship between exposure to burn pits, dust, exhaust, fuels, incinerator emissions, metals, mold, radiation, or solvents and depression.

Conclusion 6-5: Based on its analysis of the available data, the committee finds there is a possible risk-conferring relationship between exposure to dust and particulate matter (PM), exhaust, incinerator emissions, or solvents and posttraumatic stress disorder (PTSD). The committee does not find a possible risk-conferring relationship between exposure to burn pits, fuels, metals, mold, or radiation and PTSD.

Based on the literature review, there is insufficient evidence of a possible risk-conferring relationship between exposure to PM or metals and PTSD. There is no identified literature on the relationship between exposure to burn pits, fuels, mold, radiation, or solvents and PTSD.

Synthesizing the committee’s data analysis and literature review, the committee concludes there is a possible risk-conferring relationship between exposure to dust and PM, exhaust, incinerator emissions, or solvents and PTSD. The committee further concludes there is inadequate or insufficient evidence of a possible risk-conferring

relationship between exposure to burn pits, fuels, metals, mold, or radiation and PTSD.

Conclusion 6-6: Based on its analysis of the available data, the committee finds there is a possible risk-conferring relationship between exposure to exhaust and a composite outcome measure of schizophrenia and psychosis. The committee does not find a possible risk-conferring relationship between exposure to burn pits, dust and particulate matter (PM), fuels, incinerator emissions, metals, mold, radiation, or solvents and this outcome.

Based on the literature review, there is suggestive evidence of a possible risk-conferring relationship between exposure to PM and schizophrenia and psychosis. There is mixed evidence of a possible risk-conferring relationship between exposure to metals and schizophrenia. There is inadequate and insufficient evidence of a possible risk-conferring relationship between exposure to radiation and schizophrenia. There is no identified literature on the relationship between exposure to burn pits, fuels, mold, or solvents and schizophrenia and psychosis. There is also no identified literature on the relationship between exposure to metals or radiation and psychosis.

Synthesizing the committee’s data analysis and literature review, the committee concludes there is a possible risk-conferring relationship between exposure to exhaust or PM and schizophrenia and psychosis. The committee further concludes there is inadequate or insufficient evidence of a possible risk-conferring relationship between exposure to burn pits, dust, fuels, incinerator emissions, metals, mold, radiation, or solvents and a composite outcome of schizophrenia and psychosis.

Conclusion 6-7: Based on its analysis of the available data, the committee does not find a possible risk-conferring relationship between exposure to burn pits, dust and particulate matter (PM), exhaust, fuels, incinerator emissions, metals, mold, radiation, or solvents and bipolar disorder.

Based on the literature review, there is mixed evidence of a possible risk-conferring relationship between exposure to PM and bipolar disorder. There is insufficient evidence of a possible risk-conferring relationship between exposure to metals and bipolar disorder. There

is no identified literature on the relationship between exposure to burn pits, fuels, mold, radiation, or solvents and bipolar disorder.

Synthesizing the committee’s data analysis and literature review, the committee concludes there is inadequate or insufficient evidence of a possible risk-conferring relationship between exposure to burn pits, dust and PM, exhaust, fuels, incinerator emissions, metals, mold, radiation, or solvents and bipolar disorder.

Conclusion 6-8: Based on its analysis of the available data, the committee does not find a possible risk-conferring relationship between exposure to burn pits, dust and particulate matter (PM), exhaust, fuels, incinerator emissions, metals, mold, radiation, or solvents and sleep disorders.

Based on the literature review, there is suggestive evidence of a possible risk-conferring relationship between exposure to PM and sleep disorders. There is mixed evidence of a possible risk-conferring relationship between exposure to metals or solvents and sleep disorders. There is limited evidence of a possible risk-conferring relationship between exposure to burn pits or mold and sleep disorders. There is inadequate and insufficient evidence of a possible risk-conferring relationship between exposure to radiation and sleep disorders. There is no identified literature on the relationship between exposure to fuels and sleep disorders.

Synthesizing the committee’s data analysis and literature review, the committee concludes there is a possible risk-conferring relationship between exposure to PM and sleep disorders. The committee further concludes there is inadequate or insufficient evidence of a possible risk-conferring relationship between exposure to burn pits, dust, exhaust, fuels, incinerator emissions, metals, mold, radiation, or solvents and sleep disorders.

Conclusion 6-9: Based on its analysis of the available data, the committee finds there is a possible risk-conferring relationship between exposure to dust and particulate matter (PM), exhaust, or incinerator emissions and substance use disorders (SUD). The committee does not find a possible risk-conferring relationship between exposure to burn pits, fuels, metals, mold, radiation, or solvents and SUD.

Based on the literature review, there is mixed evidence of a possible risk-conferring relationship between exposure to PM and SUD. There is insufficient evidence of a possible risk-conferring relationship between exposure to metals and SUD. There is inadequate and insufficient evidence of a possible risk-conferring relationship between exposure to radiation and SUD. There is no identified literature on the relationship between exposure to burn pits, fuels, mold, or solvents and SUD.

Synthesizing the committee’s data analysis and literature review, the committee concludes there is a possible risk-conferring relationship between exposure to dust and PM, exhaust, or incinerator emissions and SUD. The committee further concludes there is inadequate or insufficient evidence of a possible risk-conferring relationship between exposure to burn pits, fuels, metals, mold, radiation, or solvents and SUD.

Conclusion 6-10: Based on its analysis of the available data, the committee finds there is a possible risk-conferring relationship between exposure to dust and particulate matter (PM), exhaust, or incinerator emissions and nonfatal suicide attempts and intentional self-harm. The committee does not find a possible risk-conferring relationship between exposure to burn pits, fuels, metals, mold, radiation, or solvents and nonfatal suicide attempts and intentional self-harm.

Based on the literature review, there is mixed evidence of a possible risk-conferring relationship between exposure to PM and nonfatal suicide attempts and intentional self-harm. There is insufficient evidence of a possible risk-conferring relationship between exposure to metals and nonfatal suicide attempts and intentional self-harm. There is no identified literature on the relationship between exposure to burn pits, fuels, mold, radiation, or solvents and nonfatal suicide attempts and intentional self-harm.

Synthesizing the committee’s data analysis and literature review, the committee concludes there is a possible risk-conferring relationship between exposure to dust and PM, exhaust, or incinerator emissions and nonfatal suicide attempts and intentional self-harm. The committee further concludes there is inadequate or insufficient evidence of a possible risk-conferring relationship between exposure to burn pits, fuels, metals, mold, radiation, or solvents and nonfatal suicide attempts and intentional self-harm.

NEUROLOGIC OUTCOMES

Conclusion 7-1: Based on its analysis of the available data, the committee finds there is a possible risk-conferring relationship between exposure to exhaust and amyotrophic lateral sclerosis (ALS). The committee does not find a possible risk-conferring relationship between exposure to burn pits, dust and particulate matter (PM), fuels, incinerator emissions, metals, mold, radiation, or solvents and ALS.

Based on the literature review, there is suggestive evidence of a possible risk-conferring relationship between exposure to solvents and ALS. There is mixed evidence of a possible risk-conferring relationship between exposure to PM and ALS. There is limited evidence of a possible risk-conferring relationship between exposure to metals and ALS. There is insufficient evidence of a possible risk-conferring relationship between exposure to burn pits, fuels, or radiation and ALS. There is no identified literature on the relationship between exposure to mold and ALS.

Synthesizing the committee’s data analysis and literature review, the committee concludes there is a possible risk-conferring relationship between exposure to exhaust or solvents and ALS. The committee further concludes there is inadequate or insufficient evidence of a possible risk-conferring relationship between exposure to burn pits, dust and PM, fuels, incinerator emissions, metals, mold, or radiation and ALS.

Conclusion 7-2: Based on its analysis of the available data, the committee does not find a possible risk-conferring relationship between exposure to burn pits, dust and particulate matter (PM), exhaust, fuels, incinerator emissions, metals, mold, radiation, or solvents and dementia.

Based on the literature review, there is suggestive evidence of a possible risk-conferring relationship between exposure to PM and dementia. There is mixed evidence of a possible risk-conferring relationship between exposure to metals or radiation and dementia. There is limited evidence of a possible risk-conferring relationship between exposure to solvents and dementia. There is insufficient evidence of a possible risk-conferring relationship between exposure to fuels and dementia. There is no identified literature on the relationship between exposure to burn pits or mold and dementia.

Synthesizing the committee’s data analysis and literature review, the committee concludes there is a possible risk-conferring relationship between exposure to PM and dementia. The committee further concludes there is inadequate or insufficient evidence of a possible risk-conferring relationship between exposure to burn pits, dust, exhaust, fuels, incinerator emissions, metals, mold, radiation, or solvents and dementia.

Conclusion 7-3: Based on its analysis of the available data, the committee does not find a possible risk-conferring relationship between exposure to burn pits, dust and particulate matter (PM), exhaust, fuels, incinerator emissions, metals, mold, radiation, or solvents and multiple sclerosis (MS).

Based on the literature review, there is suggestive evidence of a possible risk-conferring relationship between exposure to solvents and MS. There is limited evidence of a possible risk-conferring relationship between exposure to PM, fuels, or metals and MS. There is insufficient evidence of a possible risk-conferring relationship between exposure to radiation and MS. There is no identified literature on the relationship between exposure to burn pits or mold and MS.

Synthesizing the committee’s data analysis and literature review, the committee concludes there is a possible risk-conferring relationship between exposure to solvents and MS. The committee further concludes there is inadequate or insufficient evidence of a possible risk-conferring relationship between exposure to burn pits, dust and PM, exhaust, fuels, incinerator emissions, metals, mold, or radiation and MS.

Conclusion 7-4: Based on its analysis of the available data, the committee finds there is a possible risk-conferring relationship between exposure to dust and particulate matter (PM) or exhaust and Parkinson’s disease. The committee does not find a possible risk-conferring relationship between exposure to burn pits, fuels, incinerator emissions, metals, mold, radiation, or solvents and Parkinson’s disease.

Based on the literature review, there is mixed evidence of a possible risk-conferring relationship between exposure to PM, metals, or

solvents and Parkinson’s disease. There is limited evidence of a possible risk-conferring relationship between exposure to fuels and Parkinson’s disease. There is insufficient evidence of a possible risk-conferring relationship between exposure to radiation and Parkinson’s disease. There is no identified literature on the relationship between exposure to burn pits or mold and Parkinson’s disease.

Synthesizing the committee’s data analysis and literature review, the committee concludes there is a possible risk-conferring relationship between exposure to dust and PM or exhaust and Parkinson’s disease. The committee further concludes there is inadequate or insufficient evidence of a possible risk-conferring relationship between exposure to burn pits, fuels, incinerator emissions, metals, mold, radiation, or solvents and Parkinson’s disease.

CHRONIC MULTISYMPTOM ILLNESS

Conclusion 8-1: Based on its analysis of the available data, the committee finds there is a possible risk-conferring relationship between exposure to dust and particulate matter (PM) and chronic multisymptom illness (CMI). The committee also finds there is some evidence of a potential risk-conferring relationship between exposure to exhaust, incinerator emissions, or solvents and CMI. The committee does not find a possible risk-conferring relationship between exposure to burn pits, fuels, metals, mold, or radiation and CMI.

Based on the literature review, there is insufficient evidence of a possible risk-conferring relationship between exposure to burn pits, PM, metals, or mold and CMI. There is no identified literature on the relationship between exposure to fuels, radiation, or solvents and CMI.

Synthesizing the committee’s data analysis and literature review, the committee concludes there is a possible risk-conferring relationship between exposure to dust and PM and CMI. The committee further concludes there is inadequate or insufficient evidence of a possible risk-conferring relationship between exposure to burn pits, exhaust, fuels, incinerator emissions, metals, mold, radiation, or solvents and CMI.