1 15 30 https://www.nal.usda.gov/exhibits/speccoll/files/original/6668260c8540d1f879895f3a9dc71b06.pdf f0ea474860bff3574a152f942225f20c PDF Text Text Item D Number 02417 Author Apricena, Matteo Corporate Author RODOrt/ArtidO TItiB Typescript: Survey of Mortality in the Seveso Area: 1975-1981 Journal/Book Title Yeer 000 ° Month/Day Color 0 Number of Images 11 Deecnptm Notes Friday, October 05, 2001 Page 2417 of 2422 �SURVEY OF MORTALITY BF THE SEVESO AREA 1975-1981 — Mr. Matteo Apricena (Special Department) - Dr. Luigi Falliva (Special Department) - Dr Rcsella Gnioldi (Special Department) - Dr Riccardo Puntoni (Cancer Institute-Genoa) - Dr Eraanuele Stagnaro (Cancer InstitLite—Genoa) - Dr Marina Vercelli (Cancer Institute-Genoa) Coordinators: - Prof. Leonardo Santi (Cancer Institute-Genoa) - Dr Giulio Doricotti (until 30/6/32) - Dr Luigi Meaasa (since 30/6/82) �STUDY OF MORTALITY IN THE SEVESO AREA (1975-1981) In previous mortality surveys we emphasised several times the problems arising from the characteristics of the reports presented, both positive and negative. The first survey, done at Communal level in the period 197579, presented serious limitations in regard to use of the data for an assessment of the damage attributable to the ICMESA accident. This was because of the characteristics of the population under study defined only on administrative criteria: the residents in each Commune. In the second survey deaths were distributed between zones A, 3 and R. This study, though more concretely related to the potential risk of exposure to dioxin, presented limitations due to the mobility of people, limitations due to the use of the dioxin present in the soil as sole potential indicator of risk. This version, updated to 1981, gives the data processed in a third way, in order to arrive at further, more precise indications on the possible correlation between the accident of July 1976 and the specific mortality rates by sex, age and cause in the following years. This study is divided into three parts: one using as denominators the inhabitants of each of the 11 Communes; one with the residents in zones A, B, R and one breaking down the population into 6 belts from 31 to S6 (see figure). The definition of these belts is at present at a preliminary stage and is based mainly on the cases of chloracne and of acute skin lesions that occurred in every square with a side of about ~T km in the whole area under study. The division into belts is not at all final �events occurring- in tlie area under study. Tl'.e definition of tliese rislc areas is still under study and a preliminary version should emerge by tiie end of t2ie year. In addition to the definition of the exposed, that is the denominator necessar3/r for the calculation of rates, there "/as -the problem of the numerators, that is the definition of the causes of death . For the period. 1975-1 979 all the causes (?3%v' ?/ere of course traced ex post by ISTAT personnel in P.ome. These data have already been coded by the ISTAT personnel. all the causes of death have been traced, of ISTAT, at the 11 Communes. From 10 of photostats of ISTAT form D4/D5 '.vhile from to get only transcriptions. Since 1 January i93C "'ith the authorisation them vs have obtained one we have been able In the case of deaths occurring outside the 11 Communes rve are notified only of the place of death and periodically, by "/riting to the offices of the Commune in "/hich death occurred, it has been possible to retrieve information on the cause of death. The information for the entire ceriod is no~* over 59/= complete. Since January 19SC the coding of the causes of death has been handled by our personnel 'l epidemiologist!1, "*ho codes all three causes of death. �Our analysis of the data yielded some differences between the two periods, in our view to be attributed to a different criterion of definition of the cause of death first diagnosed. These doubts are stated in the text when these criteria are thought to have altered the trend. The causes of death have been grouped in 55 categories as per attached list. At this stage of the survey we were still tied to citizens' residence and so it is not yet a cohort study but a survey of mortality on citizens resident each year in the areas reported (communes, zones, belts). The next version of the survey would logically be targeted on citizens resident on 10 July 1976, excluding immigrants and retrieving information on emigrants. The present study gives the crude and standardised rates in each commune, zone and belt by cause of death, sex, age-group and year of death. We have also calculated the expected rates on the basis of the mortality both in the zones outside R and in the belts considered blank (S_+Sg) for the purpose of internal comparison. The causes of death are stated in detail in the attached tables The population resident each year in the area has been reconstructed through the Special Department computer, which stores the registry office data for all 220 000 residents, including births, deaths and changes of address. In the attached printout the population is broken down by commune, zone and belt for each year. �Comment on the tables INFECTIVE AND PARASITIC DISEASES (000-136, A1-A44). There are no significant increases through time or differences between communes, zones or belts . ALL TUMORS (140-239, A45-A61)(including benign). The rate ranges from 207 cases per 100 000 inhabitants in 1978 to 246 in 1982 in males and from 131 in 1977 to 175 cases in 1981 in females. The general trend is upward within the limits expected for the Italian population. There are no noteworthy differences by commune, zone or belt. ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES EXCLUDING DIABETES MELLITUS (240-246, 251-279, A62-A63, A65-A66) - No noteworthy differences. DIABETES MELLITUS (250, A64) - There is a noteworthy increase in the years 1980-81. In our'view, the difference is largely due to an overestimate compared to ISTAT because from 1980 onwards the disease codes have been applied by our epidemiologists, who have always regarded diabetes, when present with other cardiovascular causes, as the primary cause of death, as in fact was indicated by the ISTAT coders. The rates from 1980 on seem to be twice the 1979 rate without difference by commune or zone. In the two belts S1-I-S2 we find an increase in deaths since 1977 in females, constant in time at 40 cases per 100 000 compared to•the expected 24 cases. DISEASES OF THE NERVOUS SYSTEM AND SENSORY ORGANS (370-389, A? 2A79) . The trend is constant through time and, given the small number of deaths, there are no differences even at territorial level. RHEUMATIC FEVER AND CHRONIC RHEUMATIC HEART DISEASE (390-398, A8CA81) - Mothina noteworthy. �HYPERTENSION ( 0 - 0 , AS2) - Here again, the increase noted in 4044 1980-81 is probably due to a coding overestimate. At all events there are no important differences territorially. It should, however, be mentioned that the mortality rate of females is slightly higher in the belts S1+S2 and S3+S4 as from 1977 compared to the zones rated blank. ISCHEMIC HEART DISEASE (410-414, A83) AND OTHER HEART DISEASES (420-429, A84) - As stated earlier, there is a peak in 1976 for females, but it does not seem to be attributable to the accidenx as the distribution of deaths was homogeneous throughout 1976 before and after 10 July, At territoral level there are no significant differences. There is a slight decline through time. CIRCULATORY DISEASES OF THE BRAIN (430-438, A 85) - The time trend is downward with 70 deaths per 100 000 inhabitants in the past few years compared to 100—110 in 1976. DISEASES OF THE ARTERIES, ARTERIOLES AND CAPILLARIES ( 4 - 4 , 4048 A86) - The time trend is constant and there are no noteworthy differences within the territory attributable to the ICMSSA accident. -EMBOLISM AND VENOUS THROMBOSIS (450-453, A87) - Nothing noteworthy. OTHER DISEASES OF THE CIRCULATORY SYSTEM (454-458, A88) - Nothing noteworthy. ACUTE RESPIRATORY TRACT INFECTIONS, INFLUENZA OR GRIPPE AND PNEUMONIA ( 6 - 8 , A89-A92) AND BRONCHITIS, EMPHYSEMA AND ASTHMA 4046 ( 9 - 9 , A93) AND OTHER DISEASES OF THE RESPIRATORY SYSTEM (5004043 519, A94-A96) - The time trend is downward. PEPTIC ULCER (531-533, A98) - Nothing noteworthy. �APPENDICITIS AND INTESTINAL OCCLUSION, HERNIA AND PERITONITIS (54C-543, 550-554, 560-576-568, A100, A101, A104-0) - Nothing noteworthy. CIRRHOSIS OF THE LIVER AND OTHER DISEASES OF THE LIVER AND GALLBLADDER (570-573, 576, A101.1), OTHER DISEASES OF THE DIGESTIVE TRACT (520-530, 534-537, 561-567, 569, 574, 575, 577, A97, A99, A103, A104.2, A104.9) - The time trend is constant. There are no differences of any interest either between communes or between zones A , 3 , R or betwent belts. GENITOURINARY TRACT DISEASES (580-629, A105-A111) - Nothing significant. The number of cases is tiny. CONGENITAL MALFORMATIONS AND SOME CAUSES OF PERINATAL MORBIDITY AND MORTALITY (740-749, A126-135). The time trend is stable. Within the territory there were 5 cases in zone B for 1980-81 • against 1.34 expected, with a relative risk of 3.7 and in belts S1+S2 there were 7 cases among males in 1981 against 2.55 expected, with a relative risk of 2.75. This could, however, be a random phenomenon, as will be explained in detail in the study on malformations now approaching completion. ILL-DEFINED MORBID SYMPTOMS, OTHER DISEASES AND CAUSES NOT FOUND - There is nothing noteworthy apart from, a slightly rising trend of ill-defined symptoms for the years 1980-81, perhaps due to differences of coding. The number of cases is very small. ACCIDENTS, POISONING, INJURIES (300-999, A138-A150) - The time trend is stable.As to territorial distribution, there is nothing noteworthy either between communes or belts. In zone A there were 5 cases in the two years 1976-1977 compared to the 0.5 expected and the 3 deaths in 1976 from injury occurred before 10 July. �DEATHS FROM ALL CAUSES - Tiie apparent excess in zone A in 1976 is distributed equally before and.after the accident. TUMORS - With regard to the trend of individual tumor types, it may be said that the situation reflects that of northern Italy, taking into account the socioeconomic status of the area under study. No dioxin-related differences were found either between communes or between zones or between belts. The time trends are very close to the nationwide trends for tumors of the stomach and a slight increase for intestinal tumors, especially in females . There was a small increase in hepatic tumors. For respiratory tract tumors there was an increase in line with that of industrialised areas, especially in females. Tumors of the breast are likewise on the increase, as throughout northern Italy6 Tumors of the uterus show a decline. There is an appreciable decline in prostatic tumors while the trend of bladder tumors is stationary. • Nothing noteworthy for the moment for lymphomas and leukemias. Discussion From the purely statistical angle the data we have reported yield no information that suggests that the ICMESA accident appreciably altered the specific mortality rates by sex, age and cause in the population resident in the area monitored. This statement refers mainly to the trend within the area under study. 3y that we mean that with the level of sensitivity pertaining to a mortality study based on the compulsory notification of death (ISTAT form D4/D5) no significant clusters were observed within the area either in space or time that could be attributed to the accident. �To understand clearly tlie characteristics and limitations cf •mortality survey's ~enerallv and of this one in particular, one • needs to consider the following points. In the first place, any study hinging on causes of, death is obviously concerned only with, serious diseases with a high lethality rate. To be recorded these diseases must be easily diagnosed and not confused with more frequent causes of death. In the case of deaths from rare or infrequent diseases, if these diseases do not present precisesigns and symptoms they may easily be missed by the physician who completes the ISTAT form. Other problems bearing more particularly on our study concern the controls and the definition of exposed and nonexposed. or at any rate of more or less exposed persons. The IT.VO aspects to some extent merge in that as soon as one decides to make an internal comparison it is obviously important to define the potential exposure of the area. Migration within and outside the area further compound the problem. In our study we have sought to define the areas in different ways with the aim of identifying the best possible definition of the areas at risk. Our impression at the moment is that by taking the resident population year by year we have reached the highest level of sensitivity attainable in a situation like the one with which we are dealing in the Seveso area. As stated in the report on priority activities, the mortality survey cf residents must new be followed by a closer investigation: on the cohort of 1C/7/7S. "ith the data currently available such a study, which could hardly be achieved in 1930, now becomes relatively simple. In short, we think that the next mortality s-v.dy should be handled �- definition of the cohort of residents as at 10 July 1976; - better use of the indicators of exposure for the definition of belts; - conduct of external comparisons using the ISTAT tapes available up to 1978; - review of the coding system with the ISTAT operators. �10 11 12 I 1 = VERY HIGH RISK BELT 2= HIGH RISK BELT 3= MEDIUM-HIGH RISK BELT = MEDIUM-LOW RISK BELT 13 14 15 16 17 18 � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 095 Folder The folder containing the original item. 2417 Series The series number of the original item. Series IV Subseries IV Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Apricena, Matteo Luigi Falliva Rosella Ghioldi Riccardo Puntoni Emanuele Stagnaro Marina Vercelli Leonardo Santi Giulio Dorigotti Luigi Meazza Title A name given to the resource Typescript: Survey of Mortality in the Seveso Area: 1975-1981 Subject The topic of the resource mortality trends Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 069 Folder The folder containing the original item. 1869 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Bender, Gerald C, Jr. Title A name given to the resource Memorandum: to Interested Persons from Gerald C. Bender, Jr., regarding Wisconsin Mortality Study, July 23, 1985 Subject The topic of the resource state-funded Vietnam veterans study mortality trends cancer risk assessment alcohol use ao_seriesIII https://www.nal.usda.gov/exhibits/speccoll/files/original/b677371336f0a60017b46af9dd5a1d6f.pdf a3e56005c1947ba2597cabb4591043d8 PDF Text Text Item ID Number 01868 Author Shepard, Barclay M. Corporate Author ROpOTt/ArUdO TltlB Critique of West Virginia Mortality Study Journal/Book Title Year 1986 Month/Day February 4 Color a Number of Images 36 UOSCrtytOn NOtBS ltem inlcudes critique, as well as attached 1) M. L. Neighbors Diversified Maritime Services, Inc. advertisement and 2) Vietnam-Era Veterans Mortality Study, West Virginia Residents 1968-1983, Preliminary Report, January 1986. Wednesday, July 11, 2001 Page 1869 of 1870 �FEB 04 1986 Critique of West Virginia Mortality Study The West Virginia Department of Health has recently completed a mortality study (copy attached) of Vietnam-era veterans based on the recipients of a state bonus. The State offered a differential bonus to all West Virginia residents who served in the military during the Vietnam era with a larger amount going to those who served "incountry". 41,059 in-country (Vietnam veterans) and 41,782 non-incountry (non-Vietnam) veterans received the bonus. The list of bonus recipients was matched against state vital statistic records resulting in 1225 male Vietnam-era veterans who had died between 1968 and 1983. For each deceased male veteran a copy of the Report of Separation From Active Duty (DD 214) was reviewed to determine dates and place of service. The latter was determined by receipt of at least one of the three medals awarded for service in the Southeast Asia theater of operations. In addition, cause of death information was obtained on each deceased veteran. Of the 1225 deceased veterans, 615 were in the group of Vietnam veterans and the remaining 610 were non-Vietnam veterans, i.e., veterans who served elsewhere during the same period of time. When comparing causes of death between all veterans in the group and non-veterans of similar age only those classified as accidents, poisoning, and violence were elevated among the veteran group. Deaths due to cancer were statistically the same in both groups. Other causes of death were lower in the veteran group, a commonly observed phenomenon known as the "healthy veteran effect". A stated by the authors, the study has a number of limitations which must be kept in mind when interpreting the results: "In spite of the intense publicity given to the bonus campaign, it is likely that many veterans or their survivors never applied for the bonus. Thus, those veterans who did qualify for a bonus represent an unknown proportion of the actual number of West Virginia males'who served in the military during the Vietnam era. It cannot be assumed that the proportion was similar for both [groups]. Furthermore, because the mortality tape identified only residents of West Virginia who died during the study period, deaths in that period among veterans who no longer resided in West Virginia at the time of their demise would not have been counted among the 1,225 veterans deaths ascertained. . . With respect to a comparison between in-country and era . veterans, it cannot be assumed that similar proportions of the respective candidate population qualified for the bonus or that the death rates among in-country veterans who were no longer West Virginia residents were similar to those among era veterans who were no longer residents." �There were 145 cancer deaths of which 71 were in the group of Vietnam veterans and 74 were among the non-Vietnam veterans. In comparing specific types of cancers between these two veteran groups, only Hodgkin's disease, testicular cancer, and soft tissue sarcoma were elevated in the Vietnam veteran group. In each instance, however, the number of actual cases was small, i.e., 5 cases of Hodgkin's disease, 3 testicular cancers and 3 soft tissue sarcomas. As the authors state: "These findings must be interpreted cautiously ... since ... the site- specific cancer deaths were derived from a relatively small number . . and would . therefore be subject to ... large random fluctuations". In addition to the stated limitations of the study, as pointed out by the authors, there has been no systematic review of military personnel records, except for the DD 214 reviews as noted above, to validate the Vietnam service status of the study subjects. Because of the interest and concern over the relationship between soft tissue sarcoma and exposure to the phenoxy herbicides, the authors have now requested a review of the personnel records of the 3 veterans recorded as having this diagnosis. All.three of these were reported to have occurred in the in-country veteran group. The first of these is now known to have served in Thailand, not Vietnam, and would not have been exposed to Agent Orange. This is an example of the serious effect of misclassification especially when dealing with small numbers of subjects. In addition, there has been no systematic review of hospital or other clinical records to validate cause of death information or confirm the specific cancer diagnosis. Again, when dealing with relatively small numbers, a few errors in diagnosis can significantly alter the conclusions. In summary, this study appears to have been well designed and well conducted as far as it goes. As noted by the authors, however, it has inherent limitations and additional data are needed to validate some of the conclusions. BARCLAY M. SHEPARD, M.D. Director, Agent Orange Projects Office �«J£. tLAet&Ad&Ht- 1 January 1986 ANNOUNCEMENT M. L. NEIGHBORS, DIVERSIFIED MARITIME SERVICES, INC., announces that it is now able to offer part time consultative service or representation in the Washington, DC area to additional firms or persons that are engaged or have an interest in maritime related business ventures or business involving the disposal of chemical waste. Such work may also be arranged for in locations other than the Washington DC area as mutually agreed, and on either a prime or sub-contract basis. Among services offered are: A. Maintaining continuous contact with federal agencies having jurisdiction or control over maritime or chemical waste disposal ventures, and submittal of reports on matters of client interest. Rapid "feed-back" on specific information of more urgent interest can also be provided. B. Projection of U.S. chemical waste disposal requirements, in general or with specificity. C. Assisting in the initiation of either a maritime project or a project involving chemical waste disposal (except services involving the disposal of chemical waste by incineration at sea cannot be provided until after 30 November, 1986). CORPORATE EXPERIENCE INCLUDES: Nineteen years involvement with Department of Defense vessel charters and military cargo movement contracts. Thirteen years involvement with various offices of the Environmental Protection Agency that are responsible for regulating chemical waste disposal. This work included interaction with other federal agencies and with commercial firms offering alternative types of chemical waste disposal service. Written inquiries should be addressed to M. L. Neighbors, DMS Inc., 777 Fourteenth St., Suite 747, Washington, DC, 20005. Further information may also be obtained from Mr. Neighbors at phone number 564 1568 (area code 301 if calling from outside metro area). �WEST VIRGINIA HEALTH DEPARTMENT �VIETNAM-ERA VETERANS MORTALITY STUDY WEST VIRGINIA RESIDENTS 1968 - 1983 Preliminary Report January 1986 Arch A. Moore, Jr. Governor David K. Heydinger, M.D. Director, Department of Health �Alan P. Holmes, B.S.E.E., M.B.A. Principal Investigator WEST VIRGINIA DEPARTMENT OF HEALTH VIETNAM-ERA VETERANS MORTALITY STUDY COMMITTEE Charles Bailey Assistant Director, Health Statistics Center Roy C. Baron, M.D., M.P.H. Medical Epidemiologist Edward Bosanac, Ph.D. Research Consultant John Brough, Dr. P.H. Director, Preventive Health Services Charles Conroy, M.A. Agent Orange Program Coordinator Acting Director, Community Health Services Loretta Haddy, M.A., M.S. State Epidemiologist Alan P. Holmes, M.B.A. Director, Health Statistics Center ACKNOWLEDGEMENTS Sandra Y. Pope, Administrative Assistant, Agent Orange Program Eugenia Thoenen, Publications Coordinator, Health Statistics Center Thomas N. Leonard, Programmer/Analyst, Health Statistics Center Betty Jo Berry, Secretary, Health Statistics Center We would also like to thank Col. John W. Moon and the staff of , the West Virginia Department of Veterans' Affairs for their invaluable assistance in providing data used in this study. For further information, contact Charles Conroy, Agent Orange Program Coordinator 1800 Washington Street, East Charleston, WV 25305 Telephone: (304) 348-3210 �Vietnam-Era Veterans Mortality Study West Virginia Residents 1968-1983 The Agent Orange Assistance Program, established in 1982 by the West Virginia legislature, requested the Health Statistics Center of the Department of Health to conduct a study of the causes of death among state Vietnam veterans from 1968 through 1983.* The purpose of the study was to compare the mortality pattern among veterans with that of nonveterans in order to generate hypotheses regarding any differences in the causes of death among the former. A comparison of the causes of death among veterans who served in Vietnam with those among veterans who did not serve in Vietnam was also undertaken in order to speculate whether the Vietnam experience might be associated with a distinct mortality pattern. METHODS Identification of West Virginia Veterans West Virginia residents who served in the military during the years of the Vietnam Conflict were identified from the list *The Vietnam era is generally defined as extending from 1964 until 1973. For the purposes of this study, however, only those deaths from 1968 were considered because of the small number of deaths occurring before that year, in addition to difficulties imposed by cause-of-death coding changes over the longer interval. �of applicants for a military service bonus offered by the state Department of Veterans' Affairs in 1974. To qualify for a bonus, veterans had to meet the following criteria: 1) they must have rendered active service in the armed forces at some time between August 1, 1964, and March 28, 1973, inclusive, or have been recipients of the Vietnam armed forces expeditionary medal if they saw active service prior to August 1; 2) they must have been residents of West Virginia for at least six months prior to entry into active service; 3) they must have actively served for a period of at least ninety days unless discharged because of a servicerelated disability, and 4) they must have been honorably discharged. Efforts to notify eligible veterans or their survivors about the bonus program included one national public awareness campaign conducted in November 1975 and one conducted in July 1976. Public service announcements were issued over the television networks, and notices were posted in every major newspaper in the country and organizations on service advertised networks the bonus overseas. legislation Veterans' in their publications, and some offered assistance in filing for the bonus as a promotional device in their membership campaigns. Three different bonuses were offered. Veterans who did not serve in Vietnam ("out-of-country" or era veterans) were to receive up to $300 (Type 3 bonus); Vietnam veterans ("in-country" veterans) were to receive up to $400 (Type 4 bonus), and surviving relatives of veterans who died while in the service during the period designated by the legislature were to receive �$500 (Type 5 bonus). In West Virginia, the Department of Veterans' reported a total of 86,247 initial applicants. Affairs Of those who applied for the bonus, 83,730 veterans or survivors (97%) were eligible (Figure 1). Of these, 41,782 qualified for the Type 3 (Vietnam-era) bonus, 41,059 qualified for the Type 4 (Vietnam) bonus, and 889 qualified for the Type 5 bonus. Since this was to be a study of mortality following discharge from the service, the Type 5 bonus recipients were excluded from subsequent analyses. Names of the Type 3 and Type 4 qualifiers were, entered onto a computer tape, referred to as the "bonus tape." Identification of Veteran and Nonveteran Deaths A complete listing of West Virginia resident deaths from 1968 through 1983 was prepared from records maintained by the Health Statistics Center and entered onto a "mortality tape." The names on this list were then compared with those on the bonus tape in order to identify veterans who died during this period. For deaths from 1968 through 1978, the information had to be matched by name since social security numbers were not included on the mortality tape for these years. Any possible match generated in this manner was searched by hand and confirmed by comparing the social security number on the death certificate with that on the veteran application. From 1979 through 1983, it was possible to match by social security number. �FIGURE 1 WV VIETNAM VETERAN MORTALITY STUDY SELECTION OF STUDY POPULATION 1968-83 Bonus Tape 83,730 1 1 1 In -Country Vietnam 41,059 Not-in-Country Era 41,782 No-Match Death File 41,169 Females Era 3 Nonwhite Males Era 30 MatchedDeath File Era 613 Males Era 610 White Males Era 580 No-Match Death File 40,444 Died in Service 889 MatchedDeath File Vietnam 615 Females Vietnam 0 Males Vietnam 615 Nonwhite Males Vietnam 36 White Males Vietnam 579 �There were 1,234 initial matches between the bonus tape and the mortality tape, 614 Vietnam-era (Type 3) veterans and 620 in-country (Type 4) veterans. The veterans' discharge forms (DD-214s) were then manually checked to verify their in-country status.* This review reclassification of resulted several in records, the deletion leaving 1,228 and/or deceased veterans who qualified, 613 for the Type 3 bonus and 615 for the Type 4 bonus. Three of the deceased veterans, all Type 3 bonus recipients, were female. They were excluded from the final tape; the subsequent analyses included only deceased male veterans. Of the 1,225 male veterans who died (Table 1), 1,159 were white and 66 were nonwhite (65 black and 1 Hawaiian). nonwhite veterans were Type 3 (5%) and 36 were Type 4 Thirty (6%). Because nonwhite veterans constituted a small percentage of those who died, the study combined the mortality patterns of white and nonwhite veterans. For nonveteran males, deaths were identified from the mortality tape by deleting the records of all remaining female deaths and those of the 1,225 male veteran deaths. thus four groups defined for analysis: died; (2) male Vietnam-era-only There were (1) all male veterans who (Type 3) veterans who died; *In-country status was determined by the receipt by the veteran of one of three service medals (the Vietnam service medal, the Vietnam campaign medal, or the Vietnam expeditionary medal) as noted on the DD-214. These medals were awarded to military personnel who served in the Southeast Asia theater of operations. �TABLE 1 TYPE 3 AND TYPE 4 MATCHES BETWEEN BONUS TAPE AND MORTALITY TAPE BY YEAR 1968-83 YEAR VIETNAM-ERA (Type 3) IN-COUNTRY (Type 4) TOTAL 1968 4 13 17 1969 14 16 30 1970 17 22 39 1971 16 33 49 1972 26 31 57 1973 33 22 55 1974 25 29 54 1975 50 47 97 1976 47 46 93 1977 50 40 90 1978 54 35 89 1979 53 44 97 1980 58 51 109 1981 53 70 123 1982 55 59 114 1983 56 56 112 TOTAL 610 615 1,225 �(3) male in-country (Type 4) Vietnam veterans who died, and (4) all other West Virginia males (nonveterans) who died from 1968-83. DEMOGRAPHIC PROFILE OF DECEASED VETERANS Age Distribution The average age at death was 35.3 for all veterans, 35.1 for era veterans and 35.4 for in-country veterans. Table 2 shows that the distribution of deaths by age for Type 3 and Type 4 veterans was similar. Tables 3 and 4 present the distributions of age at death by race for Vietnam-era and Vietnam veterans, respectively. Among white Type 3 veterans, the average age at death was 35.3, among nonwhites 31.3. For Type 4 veterans, the mean age at death for whites was 35.5, with 33.5 that for nonwhites. �TABLE 2 ALL VIETNAM-ERA VETERANS Age Distribution by Type of Service VIETNAM-ERA (Type 3) TOTAL IN- COUNTRY (Type 4) AGE GROUP f % % * 4 I 15-19 4 0.7 1 0.2 5 0.4 20-24 82 13.4 92 14.9 174 14.2 25-29 139 22.8 125 20.3 264 21.5 30-34 137 22.4 143 23.2 280 22.9 35-39 83 13.6 61 9.9 144 11.7 40-44 42 6.9 53 8.6 95 7.7 45-49 36 5.9 60 9.8 96 7.8 50-54 40 6.6 33 5.4 73 6.0 55-59 24 3.9 32 5.2 56 4.6 60-64 12 2.0 12 2.0 24 2.0 65-69 9 1.5 3 0.5 12 1.0 70-74 2 0.3 0 0.0 2 0.2 TOTAL 610 100.0 615 100.0 1,225 100.0 Average Age at Death 35.4 35.1 8 35.3 �TABLE 3 VIETNAM-ERA VETERANS (TYPE 3) Age Distribution by Race WHITE TOTAL NONWHITE AGE GROUPS % # % # % 1 19 4 0.7 0 0.0 4 0.7 20-24 77 13.3 5 16.7 82 13.4 25-29 131 22.6 8 26.7 139 22.8 30-34 127 21.9 10 33.3 137 22.4 35-39 79 13.6 4 13.3 83 13.6 40-44 42 7.2 0 0.0 42 6.9 45-49 33 5.7 3 10.0 36 5.9 50-54 40 6.8 0 0.0 40 6.6 55-59 24 4.2 0 0.0 24 3.9 60-64 12 2.1 0 0.0 12 2.0 65-69 9 1.6 0 0.0 9 1.5 70-74 2 0.3 0 0.0 2 0.3 TOTAL 580 100.0 30 100.0 610 100.0 Average Age at Death 35.3 31.3 35.1 �TABLE 4 IN-COUNTRY VIETNAM VETERANS (TYPE 4) Age Distribution by Race NONWHITE WHITE TOTAL AGE GROUPS % # # % t Z 19 0 0.0 1 2.8 1 0.2 20-24 87 15.0 5 13.8 92 14.9 25-29 114 19.7 11 30.5 125 20.3 30-34 135 23.3 8 22.2 143 23.2 35-39 59 10.2 2 5.6 61 9.9 40-44 51 8.8 2 5.6 53 8.6 45-49 59 10.2 1 2.8 60 9.8 50-54 29 5.0 4 11.1 33 5.4 55-59 30 5.2 2 5.6 32 5.2 60-64 12 2.1 0 0.0 12 2.0 65-69 3 0.5 0 0.0 3 0.5 70-74 0 0.0 0 0.0 0 0.0 TOTAL 579 100.0 36 100.0 615 100.0 Average Age at Death 35.5 33.5 10 35.4 �Branch of Service Review of the DD-214 forms showed that 718 (59%) of the deceased veterans had served in the army, 210 (17%) had served in the air force, 167* (14%) had served in the navy, and 120 (10%) had served in the marines (Table 5). Seventy-five percent of the in-country veterans who died had been in either the army or the marines, in contrast to 62% of the era veterans. Twenty-five percent of in-country veterans had served in either the air force or the navy, in contrast to 37% of, the era veterans. For 10 veterans, the branch of service was not recorded on the discharge forms. *Includes 3 coast guard veterans. 11 �TABLE 5 ALL VIETNAM-ERA VETERANS Branch of Service by Type of Service VIETNAM-ERA (Type 3) IN-COUNTRY (Type 4) TOTAL BRANCH OF SERVICE % * t % * % Army 340 55.7 378 61.5 718 58.6 Air Force 127 20.8 83 13.5 210 17.2 16.1 69 11.2 167 13.6 Navy 98* Marines 39 6.4 81 13.2 120 9.8 Unknown 6 1.0 4 0.6 10 0.8 610 100.0 615 100.0 TOTAL *Includes 3 coast guard veterans 12 1,225 100.0 �ANALYTIC METHODS In spite of the intense publicity given to the bonus campaign, it is likely that many veterans or their never applied for the bonus. survivors Thus, those veterans who did qualify for a bonus represent an unknown proportion of the actual number of West Virginia males who served in the military during the Vietnam era. It cannot be assumed that the proportion was similar for both Type 3 (era) and Type 4 (in-country) qualifiers. Furthermore, because the mortality tape identified only residents of West Virginia who died during the study period, deaths in that period among veterans who no longer resided in West Virginia at the time of their demise would not have been counted among the 1,225 veteran deaths ascertained. Because of these limitations, the records provide neither complete information about the total candidate population nor a comprehensive estimate of the force veterans who did qualify. the veteran and the of mortality among the With respect to a comparison between nonveteran groups, the data would underestimate the relative force of mortality among the veterans, if such a comparison were made. With respect to a comparison between in-country and era veterans, it cannot be assumed that similar proportions of the respective candidate population qualified for the bonus or that the death rates among in-country veterans who were no longer West Virginia residents were similar to those among era veterans who were no longer residents. 13 �The method of choice for a study of mortality when there is incomplete data on the population at risk is a proportionate mortality analysis. In this type of study the proportion of all deaths due to the disease(s) of interest in the study population is compared with the proportion of all deaths due to the disease(s) of interest in the comparison (referent) population. Such proportional rates do not express the risk of dying from a disease since the incidence is not measured against a population base. They simply suggest that there may be a difference worth investigating further. The validity of such a study rests on the assumption that there is no association between the study factor, i.e., veteran status, and the occurrence of other diseases. Since we cannot make this assumption, such an analysis is used to generate hypotheses or to conduct preliminary tests of etiologic hypotheses without collecting much additional data. The relationship between the proportion of deaths due to a specified cause in a study population and the proportion derived from the referent population is expressed as a proportionate mortality ratio (PMR). The PMRs in this study are standardized to adjust for selected confounding variables. When the veteran group and its subgroups were compared with the nonveteran group, adjustments were made by stratifying on age at death by 5-year intervals (15-19, 20-24, . . . etc.) and on year of death by 2-year intervals stratum, (1968-69, 1970-71, expected deaths were . . . 1982-83). For each calculated by determining the percentage the cause of death of interest contributed to all 14 �causes in the referent population and multiplying this result by the total deaths from all causes in the study population. The standardized PMR statistic (sPMR) is the ratio of the number of deaths of interest observed in the study population summed over all strata, multiplied by 100, and then divided by the expected values summed over all strata. Stratification by age only and not by year of death was done when the in-country (study) group of veterans was compared to the era (referent) group. This was done in order to avoid losing data from the study group when respective strata in the referent group had no deaths. An sPMR greater than 100 indicates that the cause of interest contributes a greater percentage of all deaths in the study population than in the referent population; an sPMR less than 100 indicates that the cause contributes a smaller percentage of all deaths in the study population than in the referent population, and an sPMR of 100 indicates that the cause of interest contributes the same percentage of all deaths in both groups. expected frequencies against confidence p-value for each cause of interest were tested the null hypothesis, i.e., proportionate mortality interval expressing The observed and structure, around the each each exact sPMR by group has the same calculating a 95% and also a one-tailed probability of finding the difference between the observed and expected frequencies. RESULTS In the period 1968 through 1983, there were 1,225 deaths among males who had served in the military during the Vietnam 15 �Conflict. Six hundred fifteen of the men served at least a portion of their duty in Vietnam (in-country, Type 4 veterans) and 610 had no experience in Vietnam (era, Type 3 veterans). For both groups combined, 716 deaths (58%) were from external causes (injury from accidents, poisoning, or violence), 237 (19%) were from cardiovascular neoplasms, 48 (4%) disease, were 145 from (12%) were nonmalignant from diseases malignant of the gastrointestinal system, 24 (2%) were from nonmalignant diseases of the respiratory system, 5 (-=1%) were from allergic, metabolic, and endocrine disorders, and 50 (4%) were from all other causes. With nonveteran West Virginia male deaths from 1968 through 1983 as a reference, Table 6 demonstrates the number of observed and expected deaths in each cause-of-death category for all veterans together and for in-country and era veterans separately. For all veterans, the observed distribution of deaths over these categories was significantly different from the expected (Chi square Goodness of Fit •» 50.2 with 6 degrees of freedom, p<10~8). Accidents, significantly poisoning, greater and proportion violence of accounted all veteran for a deaths than expected (sPMR excess), while deaths from allergic, metabolic, and endocrine conditions and from all other causes accounted for significantly smaller-than-expected deaths (sPMR deficits). For 16 proportions of all veteran cardiovascular, digestive, and �TABLE 6 ALL CAUSES OF MORTALITY Vietnam Veterans vs. Nonveterans West Virginia, 1968-83 ALL VETERANS vs. NONVETERANS IN- COUNTRY VETERANS vs. NONVETERANS ALL CAUSES °/. Accidents, Poisoning, and Violence (80E9) E0-99 716, '626.74 Cardiovascular Disease (9-5) 3049 237, '251.5 Malignant Neoplasms (140-209) sPMR (95Z CI) °/ 'E sPMR ERA VETERANS vs. NONVETERANS (95Z CI) ° / sPMR (95Z CI) (106-130) 354, '318.1 111* (100-124) 'E (106-123) 362. '308.6 117** 94 (83-107) 114, '129.1 88 (73-106) 123, '122.4 100 (84-120) 145, '142.4 102 (86-120) 71, '73.6 96 (75-122) 74, '88 6. 108 (85-136) Diseases of the Digestive System (520-577) 48, '56.7 85 (62-112) 29, '29.0 100 (67-144) 19, '27.8 68 (41-107) Diseases of the Respiratory System (460-519) 24. '29 3. 73 (47-108) 12, '16.7 72 (37-125) 12, '16.2 74 (38-129) 38* (10-96) 52** (33-77) 114** y Allergic, Metabolic, and Endocrine Diseases (240-279) All Other Causes (Residual) '19 2. 50. '29 9. 23** (7-53) 'll.2 9** (-=1-47) '06 1. 54** (40-71) 26. '68 4. 56** (36-81) 24, '61 4. Goodness of Fit X2. -50.2 odt p- 1 ' 08 *polsson p value*.05 **poisson p value£.001 �respiratory diseases, the standardized proportionate mortality ratios were less than unity when all veterans were compared with nonveterans, but the observed numbers of deaths in these categories were not significantly lower than the expected. proportion of veteran The deaths due to malignant neoplasms was similar to that of nonveterans. The pattern of death for in-country and era veterans evaluated separately relative to the nonveteran population was similar in both instances to the pattern observed for the groups combined. In a separate contrast with era veteran deaths as the standard (not shown), no difference was. observed in the overall mortality pattern between in-country and era veterans (Chi square Goodness of Fit = 7.0 with 5 degrees of freedom, p - .22). In order to evaluate more specific causes of death within the leading categories, the contrasts were repeated to obtain standardized proportionate category-specific mortality ratios for external causes (injury), cardiovascular diseases, and malignant neoplasms separately. Table 7 shows the distribution of injury deaths for veterans contrasted with nonveterans over five causes: motor vehicle accidents, non-motor-vehicle accidents, suicide, homicide, and all other external causes. Homicide accounted for a significantly smaller-than-expected proportion of the injury deaths among veterans. The standardized proportionate injury mortality ratio for motor-vehicle-related deaths among veterans was greater than 100 but was not a statistically significant 18 �TABLE 7 INJURY MORTALITY Vietnam Veterans vs. Nonveterans West Virginia, 1968-83 ALL VETERANS vs. NONVETERANS ° / sPMR (95Z CD 315, '9. 206 108 (97-121) 201, '0. 293 96 (83-110) 104 (85-125) ACCIDENTS. POISONING, AND VIOLENCE (E800-999) Motor Vehicle (E810-E825) Ron-Motor Vehicle (E800-E809, E826-E949) Suicide (E9SO-E9S9) HoBiclde (E960-E969) All Other Causes (E970-E999) IN-COUNTRY VETERANS vs. NONVETERANS 'E 111 '107.2 63. '81.5 77* (59-99) 26. '74 2. 95 (62-139) Goodness of Fit X^.--6.78 P-.15 *poisson p value-=.05 sPMR 107 (115 9-2) 100, '105.1 95 (77-116) 111 (85-144) sPMR (95Z CI) 154. '4. 105 110 (318 9-2) 101, '0. 142 97 (79-118) / '54.2 96 (72-126) 35, '14 4. 85 (59-118) 87 (45-152) (95Z CI) 161, '5. 101 ERA VETERANS vs. NONVETERANS °'E / 5 9 / '53.0 28. '02 4. 1 4 / '13.6 70* 103 (46-101) (56-173) Goodness of Fit XJ^-5.43 P-.25 °'E / 5 2 12 / '38 1. Goodness of Fit X2df-2.71 p-,61 �excess. For non-motor-vehicle fatalities, suicide, and all other causes, the expected numbers were similar to the observed. The overall pattern for veterans was not significantly different from nonveterans (Chi square Goodness of Fit » 6.78 with 4 degrees of freedom, p =.15). Separate comparisons of the in-country and era veteran populations with nonveterans similarly overall difference in the distribution reflected no of injury deaths; the ratios in each of these contrasts were similar to those observed for the combined veteran group. Among the cardiovascular causes of mortality there were no veteran deaths from either (Table 8), hypertension or rheumatic heart disease (p-=.005), fewer-than-expected veteran deaths from cerebrovascular disease (difference not significant), and more-than-expected veteran deaths due to ischemic heart disease (difference standardized not significant). proportionate cardiovascular The individual disease mortality ratios for in-country and era veterans were similar to the corresponding mortality ratios derived for the combined group. Proportionate cancer mortality ratios comparing veterans to nonveterans are shown in Table 9. veterans and respiratory the system nonveteran excess contributed population, accounted proportion of veteran cancer by In the comparison between all for deaths in-country identical to that contributed by 20 a era neoplasms significantly than of greater expected. veterans veterans. was the The virtually Melanoma of �TABLE 8 CARDIOVASCULAR DISEASE MORTALITY Vietnam Veterans vs. Nonveterans West Virginia, 1968-83 ALL VETERANS vs. NONVETERANS CARDIOVASCULAR DISEASES (390-459) Ischemic Heart Disease (410-414) Cerebrovascular Disease (430-438) °/. sPMR (95Z CI) 158. '141.5 112 (95-131) 18, '50 2. 72 (43-114) Hypertension (400-405) °65 '. Rheumatic Heart Disease (390-398) °/5.4 All Other Cardiovascular Diseases (415-429, 440-459) IN-COUNTRY VETERANS vs. NONVETERANS 61 '86 5. 0** 0** 104 *poisson p valuer .05 **poisson p value «.005 °/ 'E sPMR (95Z CI) °'E / sPMR (952 CI) / '67.7 111 (87-139) 83, '40 7. 112 (89-139) 73 (32-144) 10, '40 1. 71 (34-131) 75 8 / '09 1. - °/3.4 0* - °>1.9 0 / '30.2 103 (80-134) ERA VETERANS vs. NONVETERANS 31 - °/3.0 0* - °/3.5 0* (70-146) 30 '84 2. 106 - (71-151) �TABLH. » CANCER MORTALITY Vietnam Veteran* vs. Nonveterans West Virginia. 1968-83 IN-COUNTRY VETERANS vs. NONVETERANS ALL VETERANS vs. NONVETERANS MALIGNANT NEOPLASMS (140-209) sPHR (951 CD 135* (102-174) 123 (91-162) 462* (6-9) 1897 21, '69 2. 78 (819 4-1) 12, '. 66 182* (94-318) 79 (38-145) 6 128 (46-276) 7 123 (50-254) °>E Respiratory System "4. '31 (160-163) Trachea, Bronchus, 50 and Lung '07 4. (162) Larynx (161) Digestive Organs and Peritoneum (150-159) to to Malignant Melanoma of the Skin (172) Lymphoms (200-203, 208-209) '13 '. 10 / '12.7 Hodgklns Disease (201) /4.7 Hale Genital Organs (185-187) Leukemia (204-207) >,.7 6 /13.1 3 /0.7 % sPHR (951 CD 131* (87-187) 29, '09 2. 139* (93-199) 118 (76-174) 25. '19.5 128 (83-189) 49 2* (95-1349) 49 2* (95-1349) 77 (37-142) % 7 . 4 148 (40-378) %9 . 205* (89-406) 7 >6.2 113 (45-233) % 4 . 47 (10-136) % 4 . 208 (69-497) >/2.4 42 (1-233) 4 182 (49-461) %* . 83 (18-254) (17-100) 3 48 (10-139) V. 44 (9-129) (36-334) 2 /1.4 143 (17-508) 2 118 (5-435) (11-102) '41 /. 24 (-1-137) 3 51 (10-148) 250 (52-731) % 7 . 429* (90-1271) 200 (5-1071) 46* 129 */10 Soft and Connective Tissue (171) 3 Bone (170) 2 /K4 143 (18-531) Urinary Organs (188-189) 2 /5.6 36 (4-129) /15.6 103 (59-166) 16 / '21.2 (951 CD 10, '13.0 Brain i Nervous System (191-192) All Other Halfgnancle. 25 sPNR (911 3-4) 4 /1.2 29, '22.2 NONVETERANS 79 Oral Cavity (140-149) >3.1 °>E ERA VETERANS 40* •polaaon p value*.05 11, '14.0 /2.7 /2.2 /6.3 '05 '. V, '77 '. 0* 78 /1.7 /5.9 °OS '. V . 2 - (29-170) '. 27 ' , V 0 - 125 (3-663) 74 (10-305) 127 360-231) �TABLE 10 CANCER MORTALITY FOR VIETNAM VETERANS In-Country Veterans vs. Era Veterans West Virginia, 1968-83 OBSERVED, 'EXPECTED Respiratory System (160-163) (95Z CI) 93 (63-134) NS 110 (55-197) NS 7 280 (113-577) 0.014 5 833 (271-1945) 0.0004 222 (62-579) NS 500 (103-1461) 0.023 (12-118) 0.066 - - 29, '31.0 n Digestive Organs and Peritoneum (150-159) Lymphoma (200-203. 208-209) to Hodgklns Disease (201) POISSON p VALUE (Fisher's exact) sPMR / '10.0 '2.5 '. 06 U) Male Genital Organs (185-187) *!. /. Cancer of the Testls (186) V . Malignant Melanoma of the Skin (172) VT 46 Soft and Connective Tissue (171) \ oo Leukerolas (204-207) 3 Oral Cavity (140-149) 2 / All Others /1.9 2.4 8 / '12.7 158 (33-461) NS 83 (10-301) NS 63 (27-124) NS �the skin also accounted for a significantly greater-than-expected proportion of cancer deaths among all veterans, but the contribution of in-country veterans to this excess was trivial in comparison with that of era veterans. Deaths from leukemias and malignant neoplasms of the nervous system each occurred less frequently than expected among both veteran groups. tissue tumors, For soft a significant difference between observed and expected deaths was not found for all veterans combined. These tumors occurred only among in-country veterans and not among era veterans, however. When in-country veterans alone were contrasted with nonveterans, they had a significantly elevated standardized proportionate cancer mortality .ratio for soft tissue tumors. The contrast between in-country and era veteran cancer deaths shows the difference in the observed (3) and expected (0) soft tissue tumors for in-country veterans (Table 10). In-country veterans also have significantly elevated standardized proportionate contrasted cancer with era mortality ratios veterans. The for lymphoma difference is when more specifically attributable to Hodgkin's disease, for which there were five deaths in this group, compared with an expected 0.6. Finally, there was a statistically significant excess in the sPMR from testicular cancer among the in-country veterans. Discussion The present study demonstrates that the mortality experience 24 �among persons who served in the military during the Vietnam Conflict differs substantially from that of nonveterans. It also suggests that there may be important differences between the veterans who served in Vietnam and those who did not with respect to their cancer mortality experience. Differences in the mortality experience between veteran and nonveteran groups are influenced by a selection bias initiated at the time of induction to the military service. assure that healthy individuals In order to serve in the military, the preinduction screening process excludes persons with preexisting conditions such as diabetes and allergies, asthma, hypertension, have substantially metabolic disorders, rheumatic heart disease, and clinically apparent malignancies. veterans other lower Because of this selection, mortality rates than the nonveteran population for many years following their induction. This is known as the "healthy veteran effect." In the present study, this selection bias is the most plausible hypothesis to account for the significant sPMR deficits observed among veterans for mortality from allergic, metabolic, and endocrine disorders, all other causes, rheumatic heart disease, and hypertension. Moreover, it may also have contributed to the less prominently diminished sPMRs among veterans for cardiovascular, digestive, and respiratory diseases. While real differences in the mortality rates between veteran and nonveteran groups for selected causes are reflected 25 �in the sPMRs, proportionate they also mortality complicate the for other interpretation causes. Since of the proportionate contribution from all separate causes must sum to 100, the proportionate contributions among "healthy" veterans from causes that are not screened by the induction process become artificially inflated relative to their contribution among the "unhealthy" population. Injury, the leading cause of death for both veterans and nonveterans, played a significantly greater role among veterans, accounting for 58% of their deaths as opposed to an expected 51%. Since the study did not adjust for discrepancies in the health status between veterans and nonveterans, part of the excess in injury among veterans must be due to the relative absence of deaths from conditions that would exclude persons from military service. While an excess of these deaths araong nonveterans reciprocally diminishes the proportion of their mortality attributable to injury, there may be a real difference in life style and the propensity veterans and nonveterans. for risk-taking behavior between An evaluation of injury mortality alone, performed to eliminate distortion from the healthy veteran bias, showed only that homicide was significantly less important as a cause nonveterans. of injury death among veterans than On the other hand, while not significant, among the difference between the observed and expected number of veteran deaths from motor-vehicle accidents would suggest that this is at least one area where veterans may be at a substantially greater 26 �risk of death than nonveterans. This issue, however, and previous assertions that veterans are at greater risk of death from suicide cannot be adequately addressed by this analysis in the absence of more complete data on the populations at risk. While malignancies as a group accounted for similar proportions of veteran and nonveteran deaths, deaths from tumors of the respiratory system were a significantly more prominent cause of cancer death among veterans than among nonveterans. probable explanation for this finding would be A a greater prevalence of smoking among military as compared with nonmilitary personnel, but this cannot be substantiated from the limited information available on death certificates. In general, the pattern of death among in-country veterans from all causes, and within the subcategories of "accidents, poisoning, and violence" and "cardiovascular diseases," were similar to those observed for all veterans combined, and there were no substantial differences in the mortality patterns between in-country and era veterans for these categories. Among cancer deaths, however, there was strong statistical evidence to suggest that .Hodgkin's disease, cancer of the testis, and soft tissue tumors were more common among veterans who served in Vietnam than among veterans who did not. cautiously, however, These findings must be interpreted since the expected proportions of site-specific cancer deaths for in-country veterans were derived from a relatively small number (74) of cancer deaths among era 27 �veterans and would therefore be subject to considerably large random fluctuations. At the same time, the difference between the observed and expected numbers of soft tissue tumors among in-country veterans supports similar proportionate mortality findings study conducted in a previous by the Massachusetts Department of Public Health. Neither the Wisconsin study nor the New York study found significant differences between in-country and era veterans in the occurrence of soft tissue sarcomas. These studies, however, and the present one are limited by the absence of precise exposure data, unknown sizes of the candidate populations at risk, and insufficient follow-up time to account for latency from in-country veterans. exposures that might have been unique to Also, by including deaths from as early as 1968, the present study may have been biased against finding an excess occurrence of cancers with long latency periods. This study only suggests the possibility that the risk of death from soft tissue sarcomas, Hodgkin's disease, and testicular cancer are elevated among veterans who served in Vietnam. We are currently awaiting the records of the in-country veterans who died from these tumors in order to speculate about possible exposure histories and to generate hypotheses that may have some biologic plausibility. To take advantage of latency periods, cancer-specific proportionate mortality studies could be repeated in several years. Also, by excluding deaths that occurred in the late-Vietnam and early post-Vietnam period, and by improving ascertainment of exposure histories, studies can 28 �focus more sharply on etiologic hypotheses relating to possible exposures in Vietnam. On the other hand, since proportionate mortality studies are more useful to explore than to confirm hypotheses, it is recommended that more precise risk-assessment studies of Vietnam cohorts be performed using national data to further test the hypothesis that Hodgkin's disease, testicular malignancies, and soft tissue tumors may be important causes of cancer mortality among veterans who served in Vietnam. 29 �BIBLIOGRAPHY Dienstfrey, Stephen J., and James J. Bryne. Veterans in the United States; A Statistical Portrait from the 1980" Gensus. Washington, D.C.: Veterans Administration, 1985. "Final Toll for U.S. in Indb-China." (Sept. 24, 1973): 73. U.S. News £ World Report Kogan, Michael D., and Clapp, Richard W. Mortality among Vietnam Veterans in Mas sachuse t1s, 1972-1983. Boston: Massachusetts Department of Public Health, 1985. Lawrence, Charles E. et al. "Mortality Patterns of New York State Vietnam Veterans." American Journal of Public Health 75 (March 1985): 277-79. ' Shottenfeld, David, and Joseph F. Fraumeni, Jr., Cancer Epidemiology and Prevention. Philadelphia: W.B. Saunders Company, 1982. 30 � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 069 Folder The folder containing the original item. 1868 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Shepard, Barclay M. Date A point or period of time associated with an event in the lifecycle of the resource February 4 1986 Title A name given to the resource Critique of West Virginia Mortality Study Subject The topic of the resource state-funded Vietnam veterans study mortality trends study criticism study protocol ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 069 Folder The folder containing the original item. 1866 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Lawrence, Charles E. Andrew A. Reilly Phillip Quickenton Peter Greenwald William F. Page Amy J. Kuntz Source A related resource from which the described resource is derived American Journal of Public Health Date A point or period of time associated with an event in the lifecycle of the resource 1985-03-01 Title A name given to the resource Mortality Patterns of New York State Vietnam Veterans Subject The topic of the resource state-funded Vietnam veterans study mortality trends cancer risk assessment ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 069 Folder The folder containing the original item. 1864 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Greenwald, Peter Vito Logrillo Description An account of the resource <strong>Corporate Author: </strong>State of New York Department of Health, Office of Public Health Date A point or period of time associated with an event in the lifecycle of the resource 1980-11-01 Title A name given to the resource Proportional Mortality of Vietnam Veterans, Other Veterans and Matched Controls in New York State, Exclusive of New York City Subject The topic of the resource state-funded Vietnam veterans study mortality trends cohort study ao_seriesIII https://www.nal.usda.gov/exhibits/speccoll/files/original/bc54fa583efffdef8051d9f49a71404e.pdf 208c08c339cf33fd3b1a079fcdbc1162 PDF Text Text ItomDNunber °1861 Author Bangert, Joseph V. Corporate Author Commonwealth of Massachusetts Agent Orange Progra RdDOrt/ArtldO TltlO Health Survey of Massachusetts Vietnam Veterans, Summary Journal/Book Title Year 1986 Month/Day June Color 0 Number of Images 12 Descrlpton Notes Wednesday, July 11, 2001 Page 1862 of 1870 �COMMONWEALTH OF MASSACHUSETTS AGENT ORANGE PROGRAM Office of the Commissioner of Veteran's Services 100 Cambridge Street Boston, MA 02202 "Health Survey of Massachusetts Vietnam Veterans" SUMMARY June, 1986 �FOREWORD The Commonwealth of Massachusetts Agent Orange Program, a program of the Office of the Commissioner of Veterans' Services, was provided funding by the 1983 Massachusetts Legislature for the purpose of conducting, "medical and scientific testing related to the possible health effects of Agent Orange on Massachusetts Vietnam Veterans." In January, 1984, the Agent Orange Program, Office of the Commissioner of Veterans' Services (OCVS) was implemented to survey programmatic, medical and scientific options. The Agent Orange Program instituted the Agent Orange Medical /Scientific Advisory Board to provide technical recommendations, oversight and review of proposals and implemented medical and scientific programs and studies. In January, 1985, the Massachusetts Agent Orange Program, in cooperation with the Massachusetts Department of Public Health published the "Mortality Among Massachusetts Vietnam Veterans, 1972-1983" written by Michael Kogan, M.A., and Richard Clapp, M.P.H., as the first step in the Commonwealth's attempt to find some answers to the complex questions surrounding the issue of Agent Orange. This mortality study provides a stable foundation for our continued ongoing efforts to provide scientific, technical, verifiable data regarding the effects of Agent Orange where none had been previously available. The Massachusetts Agent Orange Program's "Health Survey of Massachusetts Vietnam Veterans, 1986" is the second step in our program's continuing efforts to determine the needs of Massachusetts Vietnam Veterans and their families. This survey utilized the "American Legion," or "Stellman questionnaire," with minor modifications. The survey results, contained within, are the result of over 2,000 Massachusetts Vietnam Veterans and their families, and dependents who took the time out to complete a rather detailed and complex form. Only 1,500 of the 2,000 questionnaires were included in the Massachusetts survey as they were chosen on the completedness of the questionnaire, and those filled out by Massachusetts veterans who had not been in the Vietnam theatre were excluded. The analysis of the data collected by the Massachsuetts Agent Orange Program was compiled and analyzed by Mr. Frank J. Bove, M.S., an epidemiologist and PhD candidate with Harvard University School of Public Health. We are indebted to the hard work of this young scientist. The Massachusetts Agent Orange Program also acknowledges the leadership role of Governor Michael S. Dukakis of Massachusetts as well as that of Commissioner of Veterans' Services, John Halachis in their ongoing committment to this program and its importance for the more than 50,000 Massachusetts Vietnam Veterans. We also acknowledge the General Court of the Commonwealth of Massachusetts, and in particular to Senator Fran Doris, Representative Thomas Vallely and former Representative Tom Lynch who took the leadership in bringing the Massachusetts Agent Orange Program into being. We would be remiss if we did not acknowledge the pioneering role of Mr. Christopher Gregory, the former Director of the Agent Orange Program in getting the program on line. We shall continue first and foremost to aggressively and independently survey and test Massachusetts Vietnam Veterans who bore the brunt of battle and will never be forgotten. Jsefob/V. Bangert, Director Massachusetts Agent Orange Program r �SUMMARY Fifteen hundred Vietnam veterans in Massachusetts completed health questionnaires in January 1985. The respondents were those who filed a claim against the $180 million proposed out of court settlement reached by attorneys' representing the seven chemical manufacturers of Agent Orange and Vietnam veterans. Although not a random sample of the more than 50,000 Massachusetts Vietnam veterans, the findings indicate a considerable amount of illness among the respondents including tumors, neurobehavioral problems, reproductive difficulties and birth defects among their offspring. These findings are consistent with the observed symptoms and disease found among those exposed to 2,4-D, 2,4,5-T and 2,3,7,8-TCDD (Dioxin) in the workplace or the environment. INTRODUCTION Concern about the long-term effects of exposure to Agent Orange is widespread among Vietnam veterans in the U.S. and Australia, as well as among the citizens of Vietnam. In southern Vietnam, recent studies report a variety of persistent clinical problems including recurring bouts of headaches, depression and anxiety, asthenia, loss of libido, GI disorders and adverse reproductive outcomes. Studies of workers exposed to dioxin contaminated substances have found elevated rates of lymphomas and soft tissue sarcomas. Neurologic and liver effects have also been reported. Table 1 lists the findings of some of these occupational studies. Table 2 lists the findings of a Massachusetts Departments of Public Health and Veterans Services study of mortality among Vietnam veterans. This study found elevated rates of soft tissue sarcomas, kidney cancer, motor vehicle accidents and suicides. Table 3 lists findings from other studies of Vietnam veterans. This survey of the health of Massachusetts Vietnam veterans is part of an on-going research program that was sparked by the findings of previous studies as well as the concerns raised by veterans. The results of this survey are consistent with those in the studies mentioned above. METHODS AND SUBJECTS In January, 1985, The Massachusetts Agent Orange Program instituted a large-scale media campaign to alert Vietnam veterans �of the court-imposed deadline for filing a claim against the proposed $180 million settlement reached by attorneys for the seven manufacturers of Agent Orange and Vietnam veterans. About 2,000 veterans filed claims during a two day period at the state's Office of Veterans Services. The American Legion health questionnaire was distributed to those filing claims. In addition, some 300 questionnaires were mailed to veterans who phoned the Agent Orange Program requesting to participate in the health survey. Approximately 1800 questionnaires were returned to the Agent Orange Program, fifteen hundred of these were selected based on the criteria of completedness and actual service in Vietnam. Staff of the Agent Orange Program as well as trained volunteers, all of whom were Vietnam veterans, assisted respondents with any questions or difficulties they encountered with the questionnaire. Concerning the birth outcome data requested by the questionnaire, if the veterans were not sure of the information being asked, they were provided with a self-addressed envelope and permitted to take the questionnaire home to consult with their spouses. RESULTS Analysis of the questionnaire data was performed using DBASE III. Over a quarter of the respondents stated that they were diagnosed with tumors (cancerous, benign, fatty or other). Nine were diagnosed with Hodgkins Disease. Nearly 22% of the respondents indicated that one or more of their children had birth defects. Out of 1907 live births reported in the questionnaires, 462 (24%) had at least one birth defect and 160 had more than one defect. Thirty-seven spina bifida, other brain or spine defects were reported. Table 4 presents the data on other congenital malformations. Nearly one-third of the respondents indicated a decrease in libido and 22% reported fertility difficulties (see Table 4). Nearly two-thirds of the respondents indicated persistent problems with tiredness, over half reported persistent headaches and difficulties with memory or concentration, and almost half reported nervous disorders (see Table 5). Seventy-three percent of the respondents answered yes to the question: "Have you or your family ever noticed a personality change?". Eighty-two percent of the respondents claimed they regularly had at least one of the following problems: depression, violent rage, anxiety and irritability. Most had more than one problem. Two hundred and seventy-five respondents reported suffering from mental Illness or a breakdown. Symptoms of peripheral neuropathy in the lower or upper extremities were reported in over two-thirds of the veterans. Indications of asthenia were found in over half of the questionnaires (see Table 5). �Many respondents reported GI disorders. Over a third stated they had repeated nausea without flu or other sickness. Over 25% reported repeated bouts with diarrhea. One-third indicated that they regularly experienced loss of appetite and 20% reported weight loss. CONCLUSION We reemphasize that the questionnaires were not randomly distributed and were completed on a volunteer basis by a selfselected group of MA veterans. This means that we cannot base a valid, scientific study on the information contained in these questionnaires. However, the questionnaires clearly indicate considerable disease and suffering among a relatively young group of people (93% under age 45, 80% under age 40). The symptoms and disease found are consistent with findings from other studies of people exposed to dioxin, 2,4-D and 2,4,5-T. REFERENCES Ashe WF, Suskind RR (1949,1950)tReports on chloracne cases, Monsanto Chemical Co., Nitro, W.VA. Baader EW, Bauer AJ (1951):Industrial intoxication due to pentachlorophenol. Indus Med Surg 20:289-290. Barr MM (1982) :letter to editor. ANZ J. Psych. 16: 88-89. » Barr MM (1983): Apparent progressive axonal dying back neuropathy in Vietnam veterans. Neuroscience Letters, Abstracts suppl. ll:s.29. Dugois P, et.al. (1956): Acne chlorlque au 2,4,5-T. Lyon Med 88:446-447. Erickson JD, et.al. (1984): Vietnam veterans1 risks for fathering babies with birth defects. JAMA 252:903-912. Goldman PJ (1973): Schwetst akute chlorakne, eine massenintoxikation durch 2,3,6,7-TCDD. Der Hautarzt 24:149-152. �Moses M, et.al. (1984): Health Status of workers with past exposure to 2,3,7,8-TCDD in the manufacture of 2,4,5-T: Comparison of findings with and without chloracne. Am J Ind Med 5:161-182. Pazderova-Vejlupkov J, et.al (1980): Chronic poisoning by 2,3,7,8-TCDD. Prac Lek 32::204-209. NIH Library Translation. Pazderova-Vejlupkov J, et.al (1981): The development and prognosis of chronic intoxication by TCDD in men. Arch Env Health 36:5-11. Poland AP, et.al. (1971): Health survey of workers in a 2,4-D and 2,4,5-T plant. Arch Env Health 22:316-327. Stellman S, Stellman J (1980): Health problems among 535 Vietnam veterans potentially exposed to toxic herbicides. Am J Epi 112:444 (abstract). Susklnd RR (1953): A clinical and environmental survey, Monsanto Chemical Co., Nitro, W.VA.. Report of the Kettering Laboratory, July. Suskind RR (1977): Chloracne and associated health problems in the manufacture of 2,4,5-T. Report to the NIEHS/IARC Joint Conference, Lyon, France. January. Telegina KA, Bikbulatova LJ (1970): Affection of the folllcular apparatus of the skin in workers employed in the production of the butyl ester of 2,4,5-T. Vestnik Derm Ven 44:35-39. �TABLE 1 REPORTED OCCUPATIONAL EXPOSURES TO DIOXIN-CONTAMINATED SUBSTANCES RESULTING IN HUMAN ILLNESS* Year,place & chemical(s) Type of exposure & number of cases Neurological effects Other effects References 1949 W.VA TCP, 2,4,5-T explosion 117 production 111 nervousness, irritability, insomnia, personality change,depression, headache,pain & weakness in lower extremities, per ipheral neuropathy fatigue, [Ashe & weight Suskind, loss, 1949, weakness, 1950; decreased Suskind, libido,im - 1953; Suskind, potence 1977] . 1949 Germany TCP production, industrial lab 17 pain & weakness,paresthesia,polyneuritis in lower extremities fatigue, decreased libido, impotence 1952 Germany TCP production 31 pain & weakness,paresthesia in lower extremities, memory & concentration deficits,sleep disturbances, apathy,dulled emotional response fatigue, [Susmyocardial kind, damage 1977] 1953 Germany TCP explosion 55 hearing impairment, peripheral neuropathy fatigue, [Golddrowsiness, man, myocardial 1973] damage 1956 France TCP production 17 peripheral neuropathy 1964 USSR TCP 2,4,5-T production 128 headache,memory loss, sleeplessness [Baader & Bauer, 1951] [Dugois, et.al., 1956] fatigue, [Telejoint pain gina & Bikbulatova, 1970] �TABLE 1 (continued) Year,place & chemical(s) Type of exposure & number of cases Neurological effects Other effects References 1965-68 Czechoslovakia TCP 2,4,5-T production 80 pain & weakfatigue, [Pazderoness in lower weight va-Vejlupkov, loss extremities/ somnolence, et.al., 1980; headache, insomnia,peri19811 pheral neuropathy, emotional & psychiatric disorders 1969 NJ TCP 2,4,5-T 2,4-D production 73 weakness in lower extremities,hypomania *adapted from Moses/et.al.,1984 [Poland, et.al. ' 1971] �TABLE 2 Standardized Proportional Mortality Ratios for Selected Causes of Death for Vietnam Veterans Compared with Either Non-Vietnam-Veterans or Non-Veteran Males ICO NO* CAUSE OF DcATH OBSERVES VIETNAM VETERAN DEATHS All Causes COMPARISON GROUP NON- VIETNAM VETERANS PMR 95% C.I. NON-VETERAN MALES PMR 95% C.I. 840 140-239 All Neoplasms 153-154 Colo-Rectal 162 Lung, Bronchus 171 Connective Tissue 9 880 189 Kidney 9 183 (96,348) 353 (191,651) 139 88 (75,103) 87 (74,102) 28 111 (77,160) 138 (96,199) • 129 95 (78,115) 112 (94,134) 8 113 (56,228) 85 (42,172) 98 (66,146) 102 (72,145) 25 (513,1510) 473 (262,855) 390-429 'Circulatory System 439-459 (except Cerebrovascular) 430-438 Cerebrovascular Disease 571 Cirrhosis of the Liver 29 94 (65,136) 90 (61,132) • E800-E999 All external causes 428 108 (98,119) H3 (103,124) E810-E825 Motor vehicle accidents 169 110 (95,127) 127 (106,152) E950-E958 Recorded suicides 102 93 (77,112) 118 (98,143) 799.9, Estimated suicides*1* E850-E869, E950-E958, 163 113 (96,132) 140 (120,163) 31 80 (56,114) 66 (46,94)' E980-E982 E960-E969 Homicides International Classification of Diseases, 9th Revision, code number. **See reference (6) for discussion of this category. Note that there were 13 deaths in the category 799.9. �TABLE 3 REPORTS ON THE HEALTH STATUS OF VIETNAM VETERANS Reference Exposed Health Effects Stellman & Vietnam Veterans 535 congenital malformations, GI disturbances,pain in joints,sleep and psychological disturbances Barr/1982; 1983 Vietnam Veterans Australia, 120 peripheral neuropathy, insomnia,depress ion, Irritability,lassitude, memory loss,headaches, attempted suicides Erickson, et.al. 1984 Vietnam Veterans 696 congenital malformations: spina bifida,cleft lip, impaired hearing,clubfoot Stellman, 1980 �TABLE 4 CONGENITAL MALFORMATIONS Total Number Birth Defect Prevalence * BDMP Incidence Rate * Spina Bifida,other brain or spine defects 37 195 18.4 clubfoot 24 126 24.5 cleft lip/palate 17 89 13.4 missing, deformed or extra toes/fingers 31 163 Down's Syndrome 11 58 7.9 hip abnormalities 21 111 27.0 heart defect 60 defect of the digestive system 35 hearing disorders 63 cerebral palsy 27.2** 6 other skeletal defects Condition requiring special education or care 46 122 * per 10,000 live births ** polydactyly and syndactyly OTHER REPRODUCTIVE PROBLEMS Problem Number % Loss of libido 487 32.4% Infertility 330 22.0% Infertility and saw physician 246 16.4% low birth weight children 162 8.1% (under 5.5 Ibs.) �10 TABLE 5 NEUROBEHAVIORAL DYSFUNCTION Problem Number % persistent tiredness (saw physician) 957 270 63.7% 18.0% persistent headaches (saw physician) 773 338 51.5% 22.5% nervous disorders (saw physician) 684 356 45.5% 23.7% difficulty with memory or concentration (saw physician) 786 165 52.3% 11.0% mental illness or breakdown (receiving some disability) 275 132 18.3% 8.8% 1233 1015 82.1% 67.6% 321 21.4% regularly depressed, get into a violent rage, anxious or irritable (more than one behavioral problem) Sensory symptoms of early stage peripheral neuropathy asthenia (need hands to rise from chair, can't climb stairs without holding onto railing, unable to do tasks requiring holding arms at shoulder level, difficulty grasping tools) 775 51.6% � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 069 Folder The folder containing the original item. 1861 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Bangert, Joseph V. Description An account of the resource <strong>Corporate Author: </strong>Commonwealth of Massachusetts Agent Orange Program Date A point or period of time associated with an event in the lifecycle of the resource 1986-06-01 Title A name given to the resource Health Survey of Massachusetts Vietnam Veterans, Summary Subject The topic of the resource state-funded Vietnam veterans study mortality trends congenital birth defects industrial exposure ao_seriesIII https://www.nal.usda.gov/exhibits/speccoll/files/original/f2c540321d7fff75fbd4b41bf057c04c.pdf a6ba1af182f3b53496f94f69023ab06e PDF Text Text Item ID Number 01359 Author Kogan, Michael D. Corporate Author Massachusetts Office of Commissioner of Veterans Ser Ronnrt/ArtldB Tltta Mortality Among Vietnam Veterans in Massachusetts, ^ 1972-1983 Journal/Book Tltte Year 1985 MOUth/Day January 18 Color ° Number of Imagos 33 DBSCrlptOD NotOS Duplicate does not include cover. Wednesday, July 11, 2001 Page 1860 of 1870 �Mortality among Vietnam veterans in Massachusetts, 1972-1983 The Commonwealth of Massachusetts Michael S. Dukakis, Governor Office of the Commissioner of Veterans' Services Agent Orange Program January 18, 1985 �FOREWORD The Office of the Commissioner of Veterans' Services was provided funding by the 1983 Massachusetts Legislature for the purpose of conducting "medical and scientific testing related to Agent Orange." In January of 1984, the Agent Orange Program of the Office of the Commissioner of Veterans' Services was implemented to survey programmatic, medical and scientific options. The Agent Orange Program instituted an Agent Orange Medical Scientific Advisory Board to provide technical recommendations, oversight and review of proposal and implemented medical and scientific programs and studies. As recommended by the Agent Orange Program and the Agent Orange Medical and Scientific Advisory Board, the attached study, "Mortality Among Vietnam Veterans in Massachusetts, 1972-1983" compiled by Michael Kogan, M.A., and Richard Clapp, M.P.H., was contacted as the first step in the Conroonwealth's attempt to find some answers to the complex questions surrounding the issue of Agent Orange. This mortality study provides a stable foundation for our continued ongoing efforts to provide scientific, technical, verifiable data regarding the effects of Agent Orange where none has been previously available. As highlighted in the study summary, "Deaths due to motor vehicle accidents, suicides and kidney cancer were significantly elevated among Vietnam Veterans compared to non-veteran males for the study period 1972-1983." As further stated, "Elevated risk of death due to motor vehicle accidents and suicide lends support to the hypothesis that Vietnam Veterans have had a greater incidence of traumatic death since the end of the conflict than other non-veteran males." This office is designing, preparing and directing this mortality study equally emphasizing the preparation of an administrative and program response to all study findings. Relative to the significant findings of elevated death due to cancer and traumatic-stress related death, I feel strongly that the Office of the Comnissioner of Veterans' Services response to the study focus primarily on the incidence of traumatic-stress related death among Vietnam veterans. Further study and research regarding cancer incidence and cancer death among Vietnam Veterans will be aggressively pursued by this office. In an attempt to appropriately respond to the traumatic-stress related deaths highlighted by the study, it is necessary to assess the needs of those living Vietnam Veterans who display stressed behavior. For this reason, the Office of the Commissioner of Veterans' Services through the Agent Orange Program has engaged McLean Hospital to provide a behavioral study of Vietnam Veterans. The purpose of the study is to examine the possible behavioral consequences of exposure to Agent Orange and to determine whether this exposure is responsible for any of the symptoms that are often referred to as Post-Traumatic-Stress-Disorder. The Office of the Commissioner of Veterans' Services feels most strongly that the priority in dealing with the Vietnam Veterans is in researching, defining and treating Post-Traumatic-Stress. It is my fear that Post-Traumatic-StressDisorder is the root of a host of problems facing not only the Vietnam Veteran but also their families, spouses, children, neighbors and employers. �ACKNOWLEDGMENTS The Massachusetts Agent Orange Program, directed by Chris Gregory, was substantially responsible for assembling a blue ribbon Medical/Scientific Advisory Board. The credentials of the board members are consistent with the highest standards of medical services found in the Boston area. Because of his sincere and unrelenting drive to seek the answers to the health predicament caused by Agent Orange, State Representative Thomas Vallely, a Vietnam Veteran himself, provided the board with his own personal experience as well as the need for public awareness of the perils of exposure to Agent Orange. This study would not have been possible without the wisdom and commitment of the General Court of Massachusetts, and, in particular, the dedicated efforts of State Senator Francis D. Doris, Chairman of the Special Commission on the Concerns of the Vietnam Veteran. The Senator's sympathetic efforts have been the bench mark for legislative support. The support of the Department of Public Health and its personnel under the direction of Commissioner Bailus Walker was significant. Dr. Walker's commitment to public issues is consistent with his concern for the potential for harm to humans exposed to Agent Orange. Many staff members of the Office of the Commissioner of Veterans' Services worked diligently in the publication of the mortality study and developed a program to generate public awareness. They are: Joe Bangert, Research Assistant for the Agent Orange Program; Martin Burke, Public Information Specialist; Linda Wiggins, Administrative Assistant, for the long and arduous hours of secretarial duties; the sound counsel of Maryann Argento, and last, but not least, Dennis O'Brien, for whatever else needed to be done. The Office of the Commissioner of Veterans' Services will continue to work to uncover the complexities of exposure to Agent Orange and its harmful effects upon Veterans of Vietnam and their families in the areas of behavior, birth defects and mortality. Expanded mortality studies to address any new hypotheses brought by this study will be forthcoming. �MORTALITY AMONG VIETNAM VETERANS IN MASSACHUSETTS, 1972-1983 MICHAEL D. KOGAN, M.A. RICHARD W. CLAPP, M.P.H. January 18, 1985 Massachusetts Office of Commissioner of Veterans Services Agent Orange Program Massachusetts Department of Public Health Division of Health Statistics and Research �Summary The patterns of death among Vietnam veterans, other veterans who did not serve 1n Vietnam, and non-veteran males from Massachusetts were studied by compiling death certificate Information. Veteran status was based on whether or not the decedent's name appeared on a 11st of Massachusetts veterans who served from 1958-1973 and received a bonus. This bonus 11st was supplied by the Office of the Commissioner of Veterans Services. Only those with an honorable discharge were eligible for the bonus. Persons whose name on the death certificate matched that on the bonus 11st were Identified as Vietnam veterans if they received a $300 bonus, or as non-Vietnam veterans if they received a $200 bonus. to be a non-veteran. If there was no match, the decedent was presumed Analyses of the mortality patterns of Vietnam veterans compared to non-Vietnam veterans and to other males who died during the time period (1972-1983) of the study were conducted. Deaths due to motor vehicle accidents, suicides, and kidney cancer were significantly elevated among Vietnam veterans compared to non-veteran males for the study period 1972-1983. Deaths due to stroke and connective tissue cancer were significantly elevated among Vietnam veterans compared to both non-Vietnam veterans and non-veteran males. Deaths due to circulatory system diseases, other than stroke, were lower among the Vietnam veterans compared to non-Vietnam veterans. Elevated risk of death due to motor vehicle accidents and suicide lends support to the hypothesis that Vietnam veterans have had a greater incidence of traumatic death since the end of the conflict than other non-veteran males. The excess cancers of connective tissue and kidney are based on only nine death's from each type. More years of follow-up would be �Introduction The Agent Orange Program 1n the Office of the Commissioner of Veterans Services (OCVS) requested that a mortality study be conducted comparing the causes of death among Vietnam veterans to those of non-veteran Massachusetts residents. non-Vietnam veterans and This study was motivated by a concern that Vietnam veterans may be at increased risk of dying from violent, preventable causes, such as motor vehicle accidents, homicide, and suicide. The list of Massachusetts veterans whose mortality experience was evaluated was supplied on computer tape by the OCVS. In August 1984, the study .was initiated using mortality information from the statewide data base collected by the Massachusetts Department of Public Health, Division of Health Statistics and Research. Using computer-record linkage techniques and manual matching, the study group and two comparison groups were assembled. The pro- portionate mortality and mortality odds ratio were chosen as the methods for comparing the mortality experience among the three groups because information on the number of years since Vietnam service was not available for the Vietnam veterans on the OCVS computer tape. were not available. In addition, the ages of the veterans This study is a first step in analyzing Vietnam veterans' experience of one particular health outcome (mortality). Therefore, it can be used only to draw very general conclusions and to develop hypotheses for further studies. �necessary to adequately assess these findings, and further Investigation, using other sources of Information, 1s recommended. These results are based on the limited Information available from death certificates. Information on such potential confounding factors as smoking and drinking habits, and complete histories of occupational exposures, was unavailable and therefore could not be controlled for 1n the analysis. Nevertheless, the results justify Intensified efforts to reduce deaths due to stress-related or self-destructive behavior among Vietnam veterans. �Methods The mortality experience of Vietnam veterans was compared to that of Vietnam-Era veterans who did not serve In Vietnam and to the general Massachusetts white male population during the period 1972-83. A computerized file of Massachusetts mortality data 1s available from the Division of Health Statistics and Research of the Massachusetts Department of Public Health (MDPH). The mortality data for Vietnam and non-Vietnam veterans was obtained by linking the statewide computerized mortality files with the computerized list of veterans who applied for a military service bonus, available from the Massachusetts Office of Veterans Services. Eligibility for the bonus was based on the following criteria: (1) veterans must have served for at least six months between July 1, 1958 and April 1, 1973; (2) they must have been Massachusetts residents for at least six months Immediately prior to entering the service; (3) they must have applied for the bonus; and (4) they must have been honorably discharged. Veterans received a bonus of $300 if they went to Vietnam, or $200 If they did not. It has been estimated that 95% of all eligible Massachusetts residents received the bonus.(l) The mortality and veterans files were linked by matching social security numbers for the years 1972-76 and 1980-83. For the years 1977-79, social security numbers were not entered on the MDPH computerized files, although they continued to be recorded on death certificates. For these three years, the computer files were linked by matching names. The resulting output was then verified by hand-checking social security numbers on death certificates with those from the veterans file. �The computer linkage provided Information on age at death, sex, race, cause of death, year of death, and Vietnam service. classified Cause of death was according to the appropriate revisions of the International Classification of Diseases and converted to the Ninth Revision Codes.(2) Systematic validation procedures were used to assess the accuracy of the computerized information on cause of death and veteran status, compared to the information from the veterans bonus applications and the death certificates. The cause of death codes on the mortality file were found to be more than 99% accurate when compared to death certificates, as were the veteran status codes on the veterans file. Because white males accounted for about 98% of the veteran decedents, cause of death data for non-whites or female veterans would be very sparse. This report, therefore, is restricted to an analysis of white male mortality patterns, although information on other groups may be pursued in further studies.1 The number of deaths from specific causes among Vietnam veterans was compared with the expected number of deaths based upon the actual mortality experience of both non-Vietnam veterans and all other males in Massachusetts. Veteran deaths were not Included in the Massachusetts white male comparison group. These numbers were derived from calculations of time-cause-specific proportionate mortality within 10-year age groups. The ratios of observed to *Appendix A lists the non-white deaths by age at death, cause of death and year of death. �expected numbers of deaths were summarized using the standardized proportionate mortality ratio (sPMR).(3) The statistical significance of the dif- ferences was assessed using the Mantel-Haenszel Chi test with one degree of freedom.(4) For cases in which the observed number of deaths was greater than five, but the expected number of deaths was less than five, the Poisson distribution was used to determine statistical significance. SPMRs were calculated for both the entire study period (1972-83) and the last six or eight years of the study period, depending upon which time frame offered sufficient numbers for statistical stability. Also, the last half of the study period was analyzed separately because any significant effect in the last six or eight years might have been diluted by looking at the whole study period only. For causes of death for which the sPMR was statistically significant, the standardized mortality odds ratio (sMOR) was also calculated according to the method described by Miettinen.(B) The sMOR was used to confirm the results of, and to correct for biases Inherent in, the sPMR method. The sMOR compares the odds for the exposed population—the number of deaths from the cause of interest compared with the number (auxiliary) causes—with the expected (nonexposed) population.(6) of deaths odds from derived selected from reference a comparison The sMOR approach 1s essentially equivalent to the case-control approach, in which cases are all deaths from the disease of interest, controls are all deaths from the auxiliary causes, and the exposure of interest is Vietnam service. (7) The sMOR analysis was carried out using all circulatory disease, except rheumatic heart disease (ICDA 390-459), as the auxiliary cause. All cir- �dilatory disease was chosen on the assumption that 1t was unrelated to the exposure of Interest (Vietnam service). There were sufficient numbers of deaths due to this auxiliary cause that statistically stable results could be calculated. Although accidents and violent deaths comprised the largest cause of death category (e800-e999), they were not chosen as the auxiliary causes of death because they had previously been found to be higher for Vietnam veterans compared to other males. Including these causes of death would have Introduced bias Into the sMOR analysis. The differences between the two ratios of observed and expected deaths were assessed by using the Mantel-Haenszel Chi test with one degree of freedom. The standardized mortality ratio (SMR) 1s another method for calculating the ratio of observed to expected deaths. It 1s sometimes viewed as a pre- ferable method to the sPMR or the sMOR because the SMR 1s calculated by taking the ratio of the mortality rate in the exposed group to the mortality rate in the nonexposed group for a comparable follow-up per1od.(3) However, in this study it was not possible to calculate SMRs because neither the calendar years of Vietnam service nor the ages of the veterans were recorded on the veterans file. Date of birth was available for approximately 67% of the veterans on the veterans file. This Information was added to the original veterans file by the Massachusetts Registry of Motor Vehicles, which matched the veterans files with a computerized 11st of Massachusetts driver's license holders in 1983. An estimated death rate using only those veterans where a date of birth was listed would have been subject to selection bias, because it would have �8 excluded veterans who died, moved out of state, or did not hold a driver's license. Therefore, age-specific mortality rates for the veterans could not be calculated from the information available on the computerized files. �Results The numbers of deaths that occurred during the study period (1972-83) among both Vietnam veterans and non-Vietnam veterans are presented, by age group and calendar year, 1n Tables 1 and 2. The distribution of deaths suggests that Vietnam veterans, as a group, are probably younger than the non-Vietnam veterans. Tables 3 and 4 present the results of the standardized proportionate mortality ratio (sPMR) analysis comparing Vietnam veterans to non-Vietnam veterans and to all other non-veteran Massachusetts white males for specified causes of death. The sPMRs and their chi values are included in the tables, and p-values are given for all statistically significant findings (p£.05). Uncommon causes of death for Vietnam veterans are not presented because statistically stable comparisons could not be made. A minimum of seven observed Vietnam veteran deaths was used as a criterion for calculating an sPMR. Two methods of accounting for suicide deaths are used. The first method includes only those deaths that were recorded as suicides on death certificates. However, it has been estimated that the actual suicide rate is three times the reported rate.(8) Therefore, a second calculation, known as an "estimated suicide rate," was used which includes all poisonings (ICDA codes e850-e869, e980-e982), recorded suicides (ICDA codes e950-e958), and unknown causes of death (ICDA code 799.9).(9) The analyses presented were carried out on 766 deaths from specific causes out of the total 840 deaths in the Vietnam veterans group. �10 TABLE 1 DISTRIBUTION OF DEATHS BY AGE AND CALENDAR YEAR FOR WHITE MALE VIETNAM VETERANS. 1972-1983 AGE AT DEATH YEAR OF DEATH 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 TOTAL 20-29 49 40 48 48 41 22 18 17 8 1 2 0 294 30-39 6 6 8 14 8 18 22 34 57 57 52 53 335 40-49 8 8 9 15 12 4 4 9 6 13 10 8 106 50-59 1 2 5 3 4 2 8 8 11 7 12 16 79 60+ 1 0 1 1 1 3 1 2 0 3 4 9 26 TOTAL 65 56 71 81 66 49 53 70 82 81 80 86 840 TABLE 2 DISTRIBUTION OF DEATHS BY AGE AND CALENDAR YEAR FOR WHITE MALE NON-VIETNAM VETERANS, 1972-1983 AGE AT DEATH YEAR OF DEATH 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1932 1983 TOTAL 20-29 52 52 42 51 60 24 14 17 20 17 7 6 362 30-39 37 68 73 83 94 52 70 59 77 66 64 67 810 40-49 19 24 24 36 40 31 26 49 75 95 105 112 636 50-59 26 22 40 39 34 30 29 37 43 38 36 46 420 60+ 3 14 12 16 15 3 11 22 36 40 55 60 287 TOTAL 137 180 191 225 243 140 150 184 251 256 267 291 2515 �11 TABLE 3 OBSERVED AND EXPECTED NUMBERS, STANDARDIZED PROPORTIONATE MORTALITY RATIOS AND CHI VALUES COMPARING VIETNAM VETERANS TO NON-VIETNAM VETERANS BY SPECIFIC CAUSES OF DEATH FOR PERIODS 1972-83 AND 1976-83 OR 1978-83* CAUSE OF DEATH ANALYSIS OBSERVED EXPECTED SPMR CHI VALUES (ICDA CODES, 9th REV.) PERIOD DEATHS DEATHS ALL CAUSES 840 ALL NEOPLASMS (140-239) 1972-83 129 136.15 95 -.52 1972-83 8 7.07 113 .34 1972-83 1976-83 25 21 25.49 22.44 98 94 -.10 -.30 CONNECTIVE TISSUE (171) 1972-83 9 1.02 880 7.89 (p<.0001) KIDNEY CANCER (189) 1972-83 9 4.91 183 1.84 CIRCULATORY SYSTEM (EXCEPT CEREBROVASCULAR) 1972-83 (390-429, 439-459) - 1978-83 139 85 158.54 106.54 88 80 -1.55 -2.08 (p-.03) CEREBROVASCULAR DISEASE 1972-83 1978-83 (430-438) 28 19 25.17 11.56 111 164 .56 2.19 (p«.02) CIRRHOSIS OF LIVER (571) 1972-83 1976-83 29 24 30.81 19.03 94 126 -.33 1.15 ALL EXTERNAL CAUSES (6800-6999) 1972-83 1978-83 428 202 396.09 181.51 108 111 1.60 1.52 MOTOR VEHICLE ACCIDENTS 1972-83 (e810-e825) 1978-83 169 74 153.17 61.38 110 121 1.27 1.61 1972-83 1978-83 102 55 109.92 55.65 93 99 -.75 -.09 (ESTIMATED SUICIDES*** (799.9, e850-e869, 6950-6958, e980-e982) 1972-83 1978-83 163 94 144.75 76.01 113 124 1.51 2.06 HOMICIDE (6960-6969) 1972-83 1976-83 31 20 38.73 18.82 80 106 -1.24 .27 153-154) LUNG, BRONCHUS (162) RECORDED SUICIDES ( e950-e958) (P-.03) *SEE PAGE 6 FOR FURTHER EXPLANATION OF STUDY PERIOD ANALYSIS. **SIGNIFICANCE BASED ON POISSON DISTRIBUTION. ***ESTIMATED SUICIDES BASED ON UNKNOWN CAUSES OF DEATH, RECORDED SUICIDES, AND POISONINGS. (9) �12 TABLE 4 OBSERVED AND EXPECTED NUMBERS, STANDARDIZED PROPORTIONATE MORTALITY RATIOS AND CHI VALUES COMPARING VIETNAM VETERANS TO THE MASSACHUSETTS WHITE MALE POPULATION BY CAUSE OF DEATH FOR PERIODS 1972-83 AND 1976-83 OR 1978-83* CAUSE OF DEATH ANALYSIS OBSERVED EXPECTED SPMR CHI VALUES (ICDA CODES, 9th REV.) PERIOD DEATHS DEATHS ALL CAUSES 840 ALL NEOPLASMS (140-239) 1972-83 1976-83 129 102 115.69 87.57 112 116 1.24 1.54 COLO-RECTAL (153-154) 1972-83 8 9.38 85 -.45 LUNG, BRONCHUS (162) 1972-83 1976-83 25 21 24.44 19.79 102 106 .11 .27 CONNECTIVE TISSUE (171) 1972-83 9 1.90 473 5.14(p«.0001)** KIDNEY CANCER (189) 1972-83 9 2.55 353 4.04 (p-.OOl)** CIRCULATORY SYSTEM (EXCEPT CEREBROVASCULAR) 1972-83 (390-429, 439-459) 1978-83 139 85 159.98 104.43 87 81 CEREBROVASCULAR DISEASE 1972-83 (430-438) 1978-83 28 19 20.25 10.95 138 174 1.72 2.43 (p».015) CIRRHOSIS OF LIVER (571) 1972-83 1976-83 29 24 32.07 23.61 90 102 -.54 .8 0 i ALL EXTERNAL CAUSES \(e800-e999) 1972-83 1978-83 428 202 377.66 166.11 113 122 2.59 (p-.OlO) 2.78 (p«.005) MOTOR VEHICLE ACCIDENTS 1972-83 (e8 10-e825) 1978-83 169 67 133.26 50.98 127 131 3.10 (p<.003) 2.24 (p-.025) RECORDED SUICIDES Ke950-e958) 1972-83 1978-83 102 55 86.16 41.80 118 132 1.71 2.04 (p«.041) ESTIMATED SUICIDES*** (799.9, e850-e869, e950-e958, e980-e982) 1972-83 1978-83 163 94 116.21 59.56 140 158 4.34 4.46 (p<.001) (p<.001) 1972-83 1976-83 31 20 46.71 28.09 66 71 HOMICIDE (e960-e969) . '. .. -1.66 -1.90 -2.30 (p«.021) -1.52 *SEE PAGE 6 FOR FURTHER EXPLANATION OF STUDY PERIOD ANALYSIS. **SIGNIFICANCE BASED ON POISSON DISTRIBUTION. ***ESTIMATED SUICIDES BASED ON UNKNOWN CAUSES OF DEATH, RECORDED SUICIDES, AND POISONINGS. (9) �13 Table 3 focuses on the proportionate mortality experience of Vietnam veterans compared to non-Vietnam veterans. Although the proportion of deaths from all neoplasms was not unusual, the sPMR for connective and other softtissue neoplasms was significantly elevated (sPMR-880). All of the nine connective tissue neoplasms were sarcomas of five different types. This finding for this cause of death had the most significant p-value in the study. There was significantly less circulatory system disease among Vietnam veterans for the six years from 1978-1983 (sPMR«80) compared to non-Vietnam veterans. Conversely, cerebrovascular disease among Vietnam veterans was significantly elevated during the same time period ($PMR«164). The sPNR for estimated suicides was significantly higher than expected for the final six years of the study period (sPMR«124). Table 4 displays the proportionate mortality ratios of Vietnam veterans compared to the non-veteran Massachusetts white male population. there were no significant differences Once again, In the proportion of all neoplasms. However, the sPMR for connective and other soft-tissue neoplasms was significantly elevated (sPMR«473), as was the sPMR for kidney cancer (sPMR*353). The patterns for causes of death found 1n Table 4 are similar to those in Table 3. There was a greater than expected proportion of cerebrovascular disease among Vietnam veterans compared to the state's white male population as a whole during the second half of the study period (sPMR»174). All major categories of violent death were significantly elevated for Vietnam veterans, with the exception of homicides (sPMR«66). These categories included motor �14 vehicle accidents (sPMR*127), estimated suicides (sPMR«140), and all external causes (sPMR-113). Recorded suicides were elevated for the final six years of the study period (sPMR»132). The standardized mortality odds ratio (sNOR) was computed for each cause of death for which the sPNR was statistically significant. The sMOR results are presented In Table 5. The sMOR for circulatory system disease was not computed because circulatory disease was used as the auxiliary cause of death for the sMOR analysis. Instances. The sMOR findings differed from the sPMR findings 1n only two Homicide was not found to be significantly lower for Vietnam veterans compared to the state's white males (sMOR«.82), and estimated suicide was not significantly (sMOR*1.46). elevated when compared to non-Vietnam veterans Table 6 summarizes the causes of death for which the findings were significant using both analytic methods. �15 TABLE 5 STANDARDIZED MORTALITY ODDS RATIOS AND CHI VALUES COMPARING VIETNAM VETERANS TO EITHER NON-VIETNAM VETERANS OR THE MASSACHUSETTS WHITE MALE POPULATION BY SPECIFIC CAUSES OF DEATH FOR 1972-83 AND 1976-83 OR 1978-83* CAUSE OF DEATH ANALYSIS COMPARISON SMOR CHI VALUES (ICDA CODES, 9th REV.) GROUP PERIOD CONNECTIVE TISSUE CANCER 1972-83 NON-VIETNAM 5.16 4.18(p<.001) VETERANS (171) MASSACHUSETTS WHITE MALES MASSACHUSETTS WHITE MALES MASSACHUSETTS WHITE MALES 5.87 4.98(p<.001) 4.04 4.27(p<.001) 1.44 2.52(p».012) 1978-83 MASSACHUSETTS WHITE MALES 1.29 1.96(p-.05) 1972-83 MASSACHUSETTS WHITE MALES 1.65 3.85(p<.001) 1978-83 MASSACHUSETTS WHITE MALES MASSACHUSETTS WHITE MALES 1.39 3.10(p-.002) 1.46 2.09(p=.037) 1.40 1.50 1972-83 MASSACHUSETTS WHITE MALES NON-VIETNAM VETERANS 1.46 1.53 1978-83 NON-VIETNAM VETERANS 1.46 1.06 1972-83 MASSACHUSETTS WHITE MALES 1.73 3.11(p-.002) 1978-83 1.69 2.43(p-.015) 1972-83 MASSACHUSETTS WHITE MALES MASSACHUSETTS WHITE MALES 1976-83 MASSACHUSETTS WHITE MALES 1972-83 KIDNEY CANCER (189) 1972-83 ALL EXTERNAL CAUSES (e800-e999) 1972-83 MOTOR VEHICLE ACCIDENTS ( 6810-6825) RECORDED SUICIDES (e950-e958) 1972-83 1978-83 ESTIMATED SUICIDES** (799.9, e850-e869, 6950-6958, e980-e982) HOMICIDES (e960-e969) .82 -1.62 .78 -.75 *SEE PAGE 6 FOR FURTHER EXPLANATION OF STUDY PERIOD ANALYSIS. **ESTIMATED SUICIDES BASED ON UNKNOWN CAUSES OF DEATH , RECORDED SUICIDES, ' AND POISONINGS. (9) �16 TABLE 6 SUMMARY TABLE FOR STATISTICALLY SIGNIFICANT CAUSES OF DEATH FOR PERIODS 1972-83 AND 1976-83 OR 1978-83* STANDARDIZED MORTALITY ODDS RATIOS AND STANDARDIZED PROPORTIONATE MORTALITY RATIOS COMPARING VIETNAM VETERANS TO EITHER NON-VIETNAM VETERANS OR THE MASSACHUSETTS WHITE MALE POPULATION CAUSE OF DEATH ANALYSIS COMPARISON GROUP SMOR SPMR (ICDA CODES, 9th REV.) PERIOD (xlOO) CONNECTIVE TISSUE CANCER 1972-83 NON-VIETNAM 516 880 VETERANS (171) 1972-83 MASSACHUSETTS 587 473 WHITE MALES KIDNEY CANCER 404 1972-83 MASSACHUSETTS 353 (189) WHITE MALES CIRCULATORY SYSTEM 1972-83 NON-VIETNAM 88 (EXCEPT CEREBROVASCUVETERANS LAR)**( 390-429, 439-459) 1978-83 NON-VIETNAM 80 VETERANS CEREBROVASCULAR DIS1972-83 NON-VIETNAM 111 VETERANS EASES** (430-4 38) 164 1976-83 NON-VIETNAM VETERANS 138 1972-83 MASSACHUSETTS WHITE MALES 174 1976-83 MASSACHUSETTS WHITE MALES 144 ALL EXTERNAL CAUSES 113 1972-83 MASSACHUSETTS (e800-e999) WHITE MALES 129 1978-83 MASSACHUSETTS 122 WHITE MALES 127 MOTOR VEHICLE ACCIDENTS 1972-83 165 MASSACHUSETTS (e81 0-e999) WHITE MALES 131 1978-83 MASSACHUSETTS 139 WHITE MALES 146 118 RECORDED SUICIDES 1972-83 MASSACHUSETTS ( e950-e958) WHITE MALES 140 132 1978-83 MASSACHUSETTS WHITE MALES 140 ESTIMATED SUICIDES*** 1972-83 MASSACHUSETTS 173 (799.9, 6850-6869, WHITE MALES 158 169 6950-6958, 6980-6982) 1978-83 MASSACHUSETTS WHITE MALES *SEE PAGE 6 FOR FURTHER EXPLANATION OF STUDY PERIOD ANALYSIS. **SMORs NOT CALCULATED FOR CIRCULATORY DISEASE SINCE IT WAS USED AS AUXILIARY CAUSE. ***ESTIMATED SUICIDES BASED ON UNKNOWN CAUSES OF DEATH , RECORDED SUICIDES AND POISONING. (9) �17 Discussion This study was carried out using death certificates as the source of the health outcome Information. Information. There are Inherent problems 1n relying on such Other studies have assessed the accuracy of death certificate Information by comparing the stated cause of death on the death certificate to either clinical data or autopsy findings.(10,11) The accuracy of death certificates has generally been about 90%. approximately 85-90% reliable Death certificates seem to be for the general diagnosis of malignant neoplasms, although there may be underreporting of malignant neoplasms of about 10%.(11) This study did not attempt to confirm cause of death using hospital or other records. However, the effect of misclassifying cause of death due to inaccuracies on the death certificate would most likely be one of diluting the magnitude of the effects seen in the comparisons. Further problems with death certificate studies Involve lack of knowledge about other factors related to the cause of death. For example, there is no information on death certificates concerning potential confounding factors such as smoking, alcohol consumption, and dietary habits. In addition, death certificate studies may be biased due to differential access to good quality medical care. In this study, Vietnam veterans may not have had as good access to medical care as the non-veteran white males to whom they were compared. On the other hand, the non-veteran comparison group includes some individuals who were unable to serve in the military because of health problems. This potential bias, referred to as the "healthy veteran effect," would tend to dilute the magnitude of the associations between veterans and non-veterans.(12) �18 The method of Identifying deceased veterans by computer file-linking represents a potential source of bias. The primary Unking method (social security number) has been found 1n other mortality studies to be more than 90% accurate in Identifying deaths In a study population.(13) However, some studies have found a 20% false negative rate (missing deaths) when matching was done using names, as 1t was In this study for the years 1977-79.(14) Nevertheless, there 1s no reason to suspect that there 1s any systematic bias between the study group and the non-Vietnam veteran comparison group. However, m1sclass1f1ed social security numbers, names, or veterans who died out of state would only reduce the magnitude of the excess mortality seen 1n the Vietnam veterans compared to the Massachusetts male population. Another potential source of bias Is that only honorably discharged veterans were Included 1n the study population. veterans were more non-Vietnam veterans. likely to It Is not known 1f Vietnam have been dishonorably discharged than Once again, this potential bias would tend to dilute the magnitude of the associations between Vietnam service and specific causes of death. The standardized proportionate mortality ratio (sPMR) as a method of analysis has been criticized by various authors.(3,5,15) The major criticisms of the sPMR approach concern the summary nature of the statistic. Because the sPMR for all causes must equal 100, the statistic cannot give any Information about the total force of mortality.(15) Secondly, the sPMRs for two or more causes are Interdependent, since the sum of the expected numbers must equal the sum of the observed numbers.(3) Therefore, any sPMR greater than the null �19 may be an underestimate If more than one specific cause of death 1s estimated. It has also been pointed out that sPMRs tend to be more easily Interpreted for uncommon causes of death, because they are less dependent upon how common are the other causes, relative to the cause of Interest.(3,5) The sMOR has certain advantages relative to the sPNR. When the auxiliary cause(s) of death 1s unrelated to the exposure, the mortality odds ratio 1s Interpretable as the observed-to-expected ratio. When standardized for age and time, the mortality odds ratio becomes the standardized mortality odds ratio and the observed-to-expected ratio becomes the standardized mortality ratio. In contrast, the sPMR can be quantitatively Interpreted as the stan- dardized mortality ratio only when the sum of the mortality rate(s) of Interest and the rate for the auxiliary cause(s) of death 1s the same for both the exposed and nonexposed.(6) In this study, the sPMR analysis Identified specific causes of death for which there were significant differences between Vietnam veterans and the comparison groups. The sMOR analysis was used to confirm these findings. The results of the study are strengthened by the fact that the sMOR analysis, using a specific auxiliary cause, differed from the sPMR analysis in only two Instances. In order to Interpret the meaning of the findings 1n this study, it Is necessary to keep two other factors 1n mind. First, the study group of Vietnam veterans was assembled from a 11st of those who received a bonus after they had presented proof of Vietnam service and honorable discharge. No �20 Information about length of service (beyond the six month required minimum), precise location of service, or specific exposures to toxic substances, such as Agent Orange, was available from these records. Furthermore, no correction was made for possible social class differences between the Vietnam veterans and the two comparison groups. However, the Vietnam veterans findings for three causes of death which are highly correlated with social class—lung cancer, colo-rectal cancer, and cirrhosis of the liver—did not, 1n this Instance, differ significantly from those of the comparison groups. Three significant findings presented In Table 6, specifically suicides, estimated suicides, and motor vehicle accidents, are all similar In that the causal factor may be a behavioral one. It may be that social stress, which could not be directly measured 1n this study, was higher for Vietnam veterans compared to non-Vietnam veterans and other non-veteran white males. Depression 1s a major risk factor for suicide (8), and previous studies of Vietnam veterans stress disorder have documented post-traumatic and associated depression, as well as elevated rates of suicide, among those who served in combat.(16,17,18) It 1s certainly plausible that the findings in this study may be due, at least in part, to Increased stress experienced by Vietnam veterans. No significant differences were found between Vietnam veterans and the two comparison groups with respect to death due to malignant neoplasms as a whole (ICDA 140-239). The significant elevation of connective tissue cancer was based on only nine deaths; all of these were sarcomas of five different types. Table 7 lists the nine cases by hlstologlcal type. Previous studies �21 have reported that soft-tissue sarcomas were associated with exposure to phenoxyacetic acids such Orange.(19,20) as 2,4-D and 2,4,5-T, the components of Agent For all of the cases with the possible exception of case 9, occupational exposure as obtained from the death certificate did not seem to be significant. A more recent study of upstate New York Vietnam veterans reported no excess of soft-tissue sarcomas diagnosed through 1980.(21) The present study was not based on either adequate numbers of deaths or adequate exposure Information to help resolve this Important Issue. Nevertheless, the highly significant excess of this rare malignancy in Vietnam veterans 1s important new Information. The latency period for soft-tissue sarcoma in adults is probably sufficiently long that several more years of observation will be necessary before any conclusive findings can be made. �22 TABLE 7 CASE-SPECIFIC INFORMATION FOR CONNECTIVE TISSUE CANCER DEATHS AMONG VIETNAM VETERANS BY HISTOLOGIC TYPE AND OCCUPATION YEAR CASE AGE AT YEAR YEAR OF HISTOLOGIC OCCUPATION ON DEATH INDUCTED DISCHARGED DEATH DEATH CERTIF. TYPE 1 30 1969 1971 1975 FIBROSARCOMA DATA PROCESSING 2 28 1967 1970 1976 SYNOVIAL SARCOMA MANAGER 3 30 1965 1967 1976 LIPOSARCOMA MENTAL HEALTH ASSISTANT 4 32 1967 1972 1977 FIBROSARCOMA MANAGER 5 30 1964 1967 1977 FIBROSARCOMA ENGINEER'S AIDE 6 32 1970 1971 1978 FIBROSARCOMA CIVIL ENGINEER 7 32 1970 1971 1982 EPITHELIOID SARCOMA GRAPHICS 8 29 1971 1974 1982 SARCOMA, NOS FIREFIGHTER 9 39 1961 1966 1983 HEMANGIOPERI- PICKER CYTOMA Kidney cancer 1s less rare than soft-tissue sarcomas and was found to be significantly males. elevated 1n Vietnam veterans compared to non-veteran white Possible confounding due to cigarette smoking, analgesic use or other known risk factors among veterans should be considered, but Information on those risk factors was unavailable In this study. Further studies may also shed light on this finding. Finally, the significantly lower number of deaths among Vietnam veterans due to circulatory system disease (excluding stroke) for the time period 1978-83 may be a reflection of the "healthy veteran effect."(12) �23 Conclusions The findings in this study support the hypothesis that white male Vietnam veterans are at greater risk of death due to self-Inflicted or stress-related conditions than the non-veteran white male population in Massachusetts. The results would support an effort to reduce early or untimely deaths among Vietnam veterans due to suicide or motor vehicle accidents, which are largely preventable. Although the numbers of cancer deaths are small, the finding of excess deaths due to connective tissue sarcoma and kidney cancer warrants further study using the cancer incidence records from the Massachusetts Cancer Registry, and, if available, Information on possible exposures to Agent Orange, as reflected in detailed military service histories, as well as histories of other exposures to potential carcinogens. �24 Acknow!edgements We would like to acknowledge the following people for their Invaluable assistance 1n various aspects of the study: Sharon L. Rosen, Ph.D.; David N. Gute, Ph.D.; Christopher Gregory; the Medical-Scientific Advisory Board of the Agent Orange Program (Louis Bartoshesky, M.D.; John McCahan, M.D.; John Cutler, M.D., Ph.D.; Robert Weiss, Ph.D.; John Constable, M.D.; Ralph Timperi, M.P.H.); Gall Grady; Lynne Whitton; Pam English; Shelley J. Allison, M.P.H.; Linda Wiggins; Susan Mullen; and Masahiru Takeuchi. Special thanks to George A. Lareau for word processing the manuscript. Drs. Harris Pastides, Letitla Davis, James Robins, Robert Dubrow and Adrian Ostfeld reviewed or commented on drafts of the report. �25 References 1. Feeney R: Personal communication. Military Archivist, Massachusetts. 2. Manual of the International Statistical Classification of Disease, Injuries and Causes of Death, Ninth Revision. Geneva: WHO, 1975. '3. Monson RR: Occupational Epidemiology. Boca Raton, FL: CRC Press, 1980. 4. Mantel N, Haenszel W: Statistical aspects of the analysis of data from retrospective studies of disease. Journal of the National Cancer Institute 1959; 22:719-748. 5. Miettlnen OS, Wang J: An alternative to the proportionate mortality ratio. American Journal of Epidemiology 1981; 114:144-148. 6. Splegelman D, Wang J, Wegman D: Interactive electronic computing of the mortality odds ratio. American Journal of Epidemiology 1983; 118:599-607. 7. Dubrow R, Wegman D: Occupational characteristics of white male Massachusetts state cancer victims, 1971-73. NIOSH Pub No 84-109, 1984. 8. Healthy People: The surgeon general's report on health promotion and disease prevention. DHEW (PHS) Publication No 79-55071, 1979. 9. McClure GMG: Trends In suicide rates for England and Wales, 1975-80. British Journal of Psychiatry 1984; 144:119-126. 10. Alderson MR, Meade TW: Accuracy of diagnosis on death certificates compared with that in hospital records. British Journal of Preventive and Social Medicine 1967; 21:22-29. 11. Engel L, Strauchen J, et al: Accuracy of death certification in an autopsied population with specific attention to malignant neoplasms and vascular diseases. American Journal of Epidemiology 1980; 111:99-112. 12. Seltzer CC, Jablon S: Effects of selection on mortality. Journal of Epidemiology 1974; 100:367-72. American 13. Alvey W, Aziz F: Quality of mortality reporting in SSA linked data: some preliminary results. Proceedings of the Section on Survey Research Methods, American Statistical Association, Washington, DC, 1979; 275-279. 14. Roget E, Feinlelb M, et al: On the feasibility of linking census samples to the National Death Index for epidemiologic studies: a progress report. American Journal of Public Health 1983; 73:1265-1269. 15. Mil ham S: Methods in occupational mortality studies. Occupational Medicine 1975; 17:581-585. Journal of �26 16. levy C: Spoils of War. Boston, MA: Houghton-Mifflin, 1974. 17. Shatan C: The grief of soldiers. 1973; 43(4). 18. U.S. Congress, House Committee on Veteran Affairs. Presidential review memorandum on Vietnam-era veterans, H.R. 38, 10 October 1978. 19. Hardell L and Sandstrom A: Case-control study: soft-tissue sarcomas and exposure to phenoxyacetic adds on chlorophenols. British Journal of Cancer 1978; 39:711-717. 20. Eriksson M, Hardell L, et al: Soft-tissue sarcomas and exposure to chemical substances: a case-referent study. British Journal of Industrial Medicine 1981; 38:27-33. 21. Greenwald P, Kovasznay B, et al: Sarcomas of soft tissue after Vietnam service. Journal of the National Cancer Institute 1984; 73:1107-1109. American Journal of Ortho-psychiatry �27 APPENDIX A NON-WHITE VE TERAN DEATHS BY YEAR OF DEATH, VETERAN STATUS, YEAR OF DEATH 1972 1973 1974 1975 1976 1977 1978 VETERAN STATUS Vietnam Vietnam Non-Vietnam Non-Vi etnam Non-Vietnam Non-Vi etnam Non-Vietnam Non-Vi etnam Vietnam Vietnam Non-Vietnam Non-Vietnam Non-Vietnam Non-Vietnam Non-Vietnam Non- Vietnam Vietnam Non-Vietnam Non-Vietnam Non-Vietnam Non-Vietnam Non-Vietnam Vietnam Vietnam Non-Vietnam Non- Vietnam Non- Vietnam Non-Vi etnam Non-Vietnam Non-Vietnam Non-Vietnam Non-Vietnam Vietnam Non-Vietnam Non-Vietnam Non-Vietnam Non- VI etnam Vietnam Vietnam Vietnam Non-Vietnam CAUSE OF DEATH AND AGE AT DEATH CAUSE OF DEATH (ICDA CODES. 9th REV.) AGE AT DEATH Motor vehicle collision (e812.0) Suicide by hanging (e953.0) Metastatic cancer without specification (199.0) Disease of aortic valve (395.9) Acute myocardlal Infarction (410) Cardlomyopathy (425) Fall out of building (e882) Homicide by knife (e966) Lymphosarcoma (200.1) Accidental drowning (e910.9) Rectal cancer (154.1) Myocardlal Insufficiency (428) Cirrhosis of liver, unspecified (571 .9) Suicide by firearms (e955.4) Homicide by firearms (e965.4) Homicide by firearms (e965.4) Legal Intervention by firearms (e970 i Sigmoid colon cancer (153.3) Brain cancer (191) Acute myocardlal Infarction (410) Motor vehicle traffic accident (e815,,0) Watercraft accident (e830.0) Motor vehicle collision (e812.0) Motor vehicle collision (e812.0) Acute myocardlal infarction (410) NoncolHslon traffic accident (e816.0) Accident by electric current (e925.9) Homicide by firearms (e965.4) Stomach cancer (151.9) Stomach cancer (151.9) Disease of mitral valve, rheumatic (394.0) Acute myocardial Infarction (410) Accidental poisoning, opiates 1.853.6, Bronchus and lung cancer (162.9) Essential hypertension (401) Atherosclerotic heart disease (414.0) Subarachnoid hemorrhage (430) Chronic nephritis (582) Unknown and unspecified cause of death (799.9) Homicide by knife (e966) Bronchus and lung cancer (162.9) 31 28 33 45 43 43 47 32 22 24 31 21 57 32 25 27 27 53 36 56 41 27 29 24 41 31 36 31 33 56 29 40 25 53 52 42 37 29 27 27 32 �28 APPENDIX A (continued) NON-WHITE VETERAN DEATHS BY YEAR OF DEATH, VETERAN STATUS. CAUSE OF DEATH AND AGE AT DEATH YEAR OF VETERAN CAUSE OF DEATH AGE AT DEATH DEATH (ICDA CODES, 9th REV.) STATUS 1979 Vietnam Volume depletion (276.5) 52 Vietnam Ischemic heart disease (414.9) 53 Non-Vietnam Chronic monocytic leukemia (206.1) 40 Non-Vietnam Pneumonitis due to Inhalation 54 of food (507.0) Non-Vietnam Passenger 1n motor vehicle collision (e812.1) 36 Vietnam Colon cancer (153.9) 42 1980 Vietnam 36 Intracerebral hemorrhage (431) Vietnam Motor vehicle collision (e812.0) 36 Non-Vietnam Bronchus and lung cancer (162.9) 45 Non-Vietnam Diabetes mellltus (250.0) 66 Non-Vietnam Epilepsy (345.9) 46 Non-Vi etnam Acute myocardial Infarction (410) 45 Non-Vietnam Chronic renal failure (585) 53 Vietnam Rectal cancer (154.1) 53 1981 Acute edema of lung (518.4) Vietnam 38 Motor vehicle collision (e812.0) Vietnam 32 43 Non-Vietnam Palate cancer (145.5) Non-Vietnam Larynx cancer (161.9) 57 56 Non-Vietnam Bronchus and lung cancer (162.9) 63 Non-Vietnam Bronchus and lung cancer (162.9) Non-Vietnam Alcohol dependence syndrome (303) 38 Non-Vietnam Acute myocardial Infarction (410) 52 37 Non-Vietnam Intracerebral hemorrhage (431) 27 Non-Vietnam Accidental drowning (e910.1) 28 Non-Vietnam Suicide due to firearms (e955.4) Atherosclerotic heart disease (414.0) 42 1982 .- Vietnam 38 Alcohol cirrhosis of the liver (571.2) Vietnam Drowning, undetermined 1f Vietnam 33 accidental (e984) 64 Non-Vietnam Bronchus and lung cancer (162.9) 45 Non-Vietnam Volume depletion (276.5) 36 Non-Vietnam Atherosclerotic heart disease (414.0) 64 Non-Vietnam Cardlomyopathy (425) 32 Non-Vietnam Acute edema of lung (518.4) Cardiomyopathy (425) 33 Vietnam 1983 35 Myocarditis (429) Vietnam 49 Non-Vietnam Acute myocardial infarction (410) 52 Non-Vietnam Acute myocardial Infarction (410) 52 Non-Vietnam Cerebral Infarction (434.9) 32 Non-Vietnam Suicide by firearms (e955.4) 40 Non-Vietnam Homicide by firearms (e965.4) � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 069 Folder The folder containing the original item. 1859 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Kogan, Michael D. Richard W. Clapp Description An account of the resource <strong>Corporate Author: </strong>Massachusetts Office of Commissioner of Veterans Services, Agent Orange Program; Massachusetts Department of Public Health, Division of Health Statistics and Research Date A point or period of time associated with an event in the lifecycle of the resource January 18 1985 Title A name given to the resource Mortality Among Vietnam Veterans in Massachusetts, 1972-1983 Subject The topic of the resource state-funded Vietnam veterans study mortality trends suicide ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 066 Folder The folder containing the original item. 1787 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Form: Vietnam Veterans Newspaper Locator File Subject The topic of the resource mortality trends veteran health and hygiene ao_seriesIII https://www.nal.usda.gov/exhibits/speccoll/files/original/afc503475f8dac9b1e8778f4ed94b544.pdf b83094460edb1cb45fadfba3dadf3216 PDF Text Text Item ID Number °1786 Author Breslin, Patricia Corporate Author Report/Article Title Proportionate Mortality Study of US Army and US Marine Corps Veterans of the Vietnam War JOlirnal/BOOk TltlB Journal of Occupational Medicine Year 1988 Month/Day Ma Color a Number of Images v 8 Descriptor Notes Monday, June 11, 2001 Page 1787 of 1793 �Proportionate Mortality Study of US Army and US Marine Corps Veterans of the Vietnam War Patricia Breslin, ScD; Han K. Kong, DrPH; Yvonne Lee, MSc; Vicki Burt, ScM; and Barclay M. Shepard, MD The patterns of mortality among 84,835 US Army and Marine Corps Vietnam veterans were compared with that of 86,685 non-Vietnam veterans using standardized proportional mortality ratios. The veterans were a random sample of deceased Vietnam-era veterans identified in a Veterans Administration computerized benefit file. Military service information was obtained from military personnel records, and cause of death information from death certificates. Statistically significant excess deaths were observed among Army Vietnam veterans for motor vehicle accidents, non-motor vehicle accidents, and accidental poisonings. Similar findings have been reported in other studies of Vietnam veterans. Suicides were not elevated among Vietnam veterans. The Marine Corps Vietnam veterans appeared to have an increased mortality from lung cancer and non-Hodgkin's lymphoma. Although exposure to several environmental factors may be speculated, this study did not investigate possible etiologic factors for these elevated malignancies. here concern in the United States that postTserviceismortality among Vietnam are disproportionveterans is unusually high and certain causes of death ately elevated. Traumatic deaths such as motor vehicle accidents, suicides, and homicides are often cited as possible health outcomes associated with military service in Vietnam.1'6 Concern also persists that, as a result of exposure to Agent Orange and other chemicals in Vietnam, Vietnam veterans may be at increased risk for soft tissue sarcomas and other cancers.7"9 ApproxiFrom the Office of Environmental Epidemiology, Veterans Administration, Washington DC 20006-3868. Address correspondence to VA Office of Environmental Epidemiology (10B/AO8) Biddell Bldg, Rm 401, 1730 K St NW, Washington DC 80006-3868. 0096-1736/88/3006-4ia$oa.OO/0 Copyright © by American Occupational Medical Association 412 mately 2 million US military personnel served a oneyear tour in Vietnam during the Vietnam war. Findings of mortality studies of Vietnam veterans reported to date are not consistent with each other.1"6 Whether the variations among the studies are the result of the relatively small number of deaths analyzed, therefore reflecting lack of adequate statistical power, or whether they suggest an underlying difference in the mortality experience among the different Vietnam veteran study populations is not obvious. The number of deaths analyzed in these studies ranged from 246 to 923. In view of the public concern about the potential adverse health effects of military service in Vietnam and inconsistent findings in the scientific literature, a proportional mortality study of Vietnam veterans was undertaken. Approximately one third of all deaths which have occurred among the Vietnam veterans who served in tho US Army or Marine Corps was analyzed in the study. Materials and Methods Selection of Study Subjects Study subjects were restricted to ground troops, men who served in the US Army or Marine Corps at anytime from July 4, 1965 through March 1, 1973. Data published by the US Department of Defense indicate that over 80% of those who served in Vietnam were ground troops.10 Those having served in the Air Force, Navy, or Coast Guard were excluded because it is difficult to determine whether personnel who were considered to have served in the Vietnam theatre of operation were Mortality Study of Vietnam War Veterans/Breslin et al �ever actually "in country" Vietnam. Female veterans were also excluded from the study. It was determined that at least 50,000 eligible cases would be needed for the study in order to obtain adequate statistical power. The sample size of 50,000 deceased Vietnam era veterans would provide statistical power of over 90% for detecting a twofold increased relative risk of non-Hodgkin's lymphoma or lung cancer. The study would have excellent power to detect small increases in certain common causes of death. Potential study subjects who were reported to be deceased as of July 1,1982 were randomly selected from the Veterans Administration Beneficiary Identification and Record Locator Subsystem (BIBLS). The VA maintains the automated information retrieval system to identify and locate records of veterans who have received any of a wide variety of veterans' benefits including death benefits to their families. A study by the National Academy of Sciences indicates that the names of at least 94% of all deceased Vietnam-era veterans identified through independent means are in BIBLS.11 A subfile of 186,000 deceased Vietnam-era veterans who served in the Army or Marine Corps and whose service dates included the period 1964-1975 was assembled from BIBLS. If the service data (branch, service dates) were missing in BIBLS, veterans whose birth dates were between 1935 and 1957 (inclusive) were selected because of the high likelihood that they may have served during the Vietnam era. To achieve the desired sample size of approximately 50,000 eligible veterans, a random sample of 75,617 names was selected from the target population. Extra names were selected to allow for the exclusion of ineligible cases. The military personnel records for all 75,617 potential study subjects were requested from the National Personnel Becord Center in St. Louis, MO. Demographic data and information on military service such as branch of service, length of service, rank at discharge, and military occupational specialty were abstracted. In addition, for those who served in Southeast Asia, dates of service, principal duty, and unit addresses while in the theatre of combat were obtained. Of the 75,617 Vietnam-era veterans selected, 22,332 (29.5%) veterans were found to be ineligible upon reviewing their military personnel records. The ineligible cases included duplicate names; men who did not serve in the military from July 4, 1965 through March 1, 1973; men who served in the Navy, Coast Guard, or Air Force; men who were killed in action or were reported missing in action and subsequently declared dead; men who died in service before 1974; men who died of warrelated injuries; and all women. Eligibility for the study could not be determined for 1,032 veterans (1.4%) and they were excluded. The final sample consisted of 52,253 men who died between July 4, 1965 and July 1, 1982 and who served in the US Army or Marine Corps during the period July 4, 1965 through March 1, 1973. Death certificates were available from the VA files for about 70% of the sample; for the remaining 16,000 cases, the veteran's death certificate was requested from the state of his last known residence. The place of the veteran's death was identified by checking files of the VA, Social Security Administration, Internal Bevenue Service, and National Center for health Statistics National Death Index. Although death certificates were the preferred source of information, casualty reports issued by the Department of Defense were also used for active duty personnel or reservists who died outside the country and for whom no death certificate could be obtained. Most of these deaths were accidents and probably little additional information would have been obtained from the death certificate if it were available. Death certificates were the source of cause of death information for 96.9% of all cases. This was equally true for both those who served in Vietnam and those who did not. The underlying causes of death were coded by experienced nosologists at the National Center for Health Statistics using the International Classification of Diseases, 8th Bevision (ICDA8).ia The nosologists had no knowledge of the military service status of the veteran. Cause of death was ascertained for 51,421 veterans or 98.4% of the men determined to be eligible for the study. The cause of death for the remaining 1.6% was not obtained for one of the following reasons: the veteran died overseas and no certificate or cause of death information was available or the veteran's place of death had not been identified, and therefore the death certificate could not be located. Of the 51,421 men for whom military service data and cause of death information were available, 26,685 had not served in Southeast Asia; 24,235 had served in Vietnam. The remaining 501 were either known to have served elsewhere in Southeast Asia or their place of service in Southeast Asia was unknown. Analyses of mortality data were based on 24,235 Vietnam veterans and 26,685 non-Vietnam veterans. These procedures used to select the subjects are outlined in the Figure. Statistical Analyses The deaths observed among the Vietnam veterans were compared with expected numbers computed by applying the age- and race-specific proportions of deaths for each cause among the non-Vietnam veterans to the total number of deaths in the study group. Differences between observed and expected number of deaths for each cause were summarized in the form of the proportional mortality ratio (SPMB) which is the ratio of the number of deaths observed to that expected.13 The statistical significance of each ratio was tested by a xa with 1 df.14 The 95% confidence intervals for the SPMBs were also computed.10 Proportional mortality ratios standardized for age and race (SPMBs) were calculated separately for Army and Marine Corps Vietnam veterans for all major causes of death and for selected causes of death. The PMB analysis by branch of service was performed because these groups might have had different types of environmental exposure in Vietnam either by virtue of the Journal of Occupational Medicine/Volume 30 No. 5/May 1988 413 �Veterans Administration Beneficiary Identification and Record Locator Subsystem TABLE 1 Racial Characteristics of the 50,920 Deceased Vietnam-era Veterans by Branch and Vietnam Service Army Race Service in Vietnam Yes (N = 19,708), No (N = 22,904), Yes (N = 4,527), No (N = 3,781), 78.1 19.2 2.7 79.5 17.7 83.5 13.7 82.5 14.9 2.8 2.8 2.6 White Black Other Unknown Totals Random Sample (75,617) Marines Service in Vietnam Deceased Vietnam-era Veterans Army Marine Corps or Branch Unknown (186,000) * 100 * 100 100 100 •Less than 0.1%. Military Records Not Found (1,032) Qualified for Study (52,253) TABLE 2 Military Rank of the 50,920 Deceased Vietnam-era Veterans by Branch and Vietnam Service Army Cause of Death Unknown (832) Served in Thailand or Elsewhere in Southeast Asia (501), Excluded from Study Cause of Death Known (51,421) Served in Vietnam (24,235) Rank Served Places Other than Southeast Asia (26,685) Figure. Selection process of study subjects. location of their units or the types of duties they performed. Unlike the Army units, the Marine Corps units were primarily located within the I Corps area of South Vietnam. South Vietnam was divided into four tactical combat zones, I Corps being in the northernmost part of South Vietnam. Results The demographic characteristics of the sample are given in Tables 1 and 3. More than 50% of the veterans died at ages 25 through 34. Some died at ages less than 85 (5.5% of Vietnam and 11.7% of non-Vietnam veterans) and some died at ages older than 65 (0.74% of Vietnam and 8.6% of non-Vietnam veterans). There seemed to be no remarkable differences in the major cause of death categories between the men who served in Vietnam and their counterparts who did not serve in Vietnam with a few exceptions (Table 3). Deaths from external causes (ICDA codes E800-E989) were relatively more frequent among veterans who served in Vietnam than among those who did not. However, this excess is statistically significant only for Army veterans (PMB, 1.03; P< .01). More than half of all the deaths in the study population were due to accidents, accidental poisonings, or violence. Within this broad category, approximately 35% of the deaths were due to motor vehicle accidents 414 Enlisted Warrant officer Officer Unknown Totals Marines Service in Vietnam Service in Vietnam Yes No Yes No (N = 19,708), (N = 22,904), (N = 4,527), (N = 3,781), 92.8 93.4 93.6 95.8 2.1 5.1 1.0 5.5 0.9 5.5 0.3 3.9 * 100 * 100 * 100 100 •Less than 0.1%. (Table 4). Although the magnitude of the relative excess of motor vehicle accidents was about the same in both branches, only the SPMR for Army veterans was statistically significant (PMR, 1.05; P< .085). "Other transport accidents" were seen to be in excess primarily among Army personnel (PMR, 1.36; P < .01); 51% of these were aircraft accidents. Of the men who died in aircraft accidents, 88% had been helicopter pilots or crewmen and 84% of these had served in Vietnam. Many of these died while working as helicoptor pilots or crewmen in civilian life; others died in aircraft accidents while still in the military after the war. The category of "accidental poisonings" was elevated among both Army and Marine Corps veterans who served in Vietnam. In reviewing a sample of 100 of these deaths, it was found that 98% of these deaths were due to narcotic overdose, mostly heroin. Among enlisted Vietnam veterans, veterans with combat-related military occupations died from homicide significantly more frequently than veterans with non-combat-related military occupations: 9% excess for Army veterans (P < .05), 84% excess for Marine Corps veterans (P< .01). It also appeared that the excess deaths from motor vehicle accidents and accidental poisonings were greater during the first ten-year period of observations than the later years of observation for both Army and Marine Corps Vietnam veterans (Table 5). Deaths coded as suicide were relatively less frequent among those who served in Vietnam than among those who did not serve in Vietnam for both Army and Marine Corps veterans. Mortality Study of Vietnam War Veterans/Breslin et al �TABLE 3 Number of Deaths and Proportional Mortality Ratios (PMRs) Among Vietnam Veterans by Major Causes and Branch Army* Cause (ICDA No.) All other causes (210-228, 290315,740-759,780-796) Infective and parasitic diseases (000-136) Malignancies (140-209, 230-239) Endocrine, nutritional, and metabolic (240-279) Blood and blood-forming organs (280-289) Nervous systems and sense organs (320-389) Circulatory diseases (390-458) Respiratory diseases (460-519) Digestive diseases (520-577) Genitourinary diseases (580-629) Skin and subcutaneous tissues (680-709) Musculoskeletal and connective tissues (71 0-738) Accidents, poisonings, and violence (E800-989) Observed Marinest 95% Confidence Interval PMR Observed PMR 95% Confidence Interval 150 0.94 0.63-1.01 19 1.02 0.89-1.17 0.97 0.85 0.93-1.02 0.67-1.08 521 22 1.20 0.66 1 .0-1 .45 0.22-2.01 32 0.68 0.45-1 .03 8 3.22 0.51-20.5 167 0.95 0.77-1.18 27 0.86 0.17-4.44 0.98 0.93 0.99 0.77t 0.76 0.95-1 .01 0.69-1.25 0.94-1 .04 0.60-0.99 0.05-11.19 647 62 169 13 2 0.98 0.95 0.87 0.67 0.50 0.86-1.12 0.75-1 .21 0.70-1.08 0.33-1.35 0.06-4.18 7 0.87 0.22-3.41 2,880 1.00 709 0.91 127 0.80 2,452 135 3,578 406 1,001 80 8 29 10,984 1.55 0.8-3.0 1.03§ 1.02-1.04 * Army: deaths observed = 19,708. Expected numbers are based on 22,904 deaths in Army non-Vietnam veteran comparison group, t Marines: deaths observed = 4,527. Expected numbers are based on 3,781 deaths in Marine non-Vietnam veteran comparison group. :(:P<.05forx 2 with1cff. § P < .01 for x2 with 1 df. TABLE 4 Number of Deaths from Accidents, Accidental Poisonings, and Violence and Proportional Mortality Ratios (PMRs) Among Vietnam Veterans, by Branch Army* Cause (ICDA No.) Motor vehicle accidents (E810E827) Other transportation accidents (E800-E807, E830-E845) Accidental poisonings (E850E877) All other accidents/injury (E880E949, E970-E989) Suicide (E950-E959) Homicide (E960-E969) Marinest Observed PMR 95% Confidence Interval Observed PMR 95% Confidence Interval 3,884 1.05$ 1.01-1.09 1,011 1.07 0.97-1.18 493 1.36§ 1.19-1.56 117 0.75 0.56-1.01 461 1.15$ 1.02-1.30 120 1.10 0.93-1.30 2,323 1.05 0.99-1.11 593 1.01 0.98-1 .04 2,003 0.93§ 1.01 0.88-0.98 0.73-1.40 542 497 0.93 0.98 0.86-1.01 0.89-1 .08 1,816 * Army: deaths observed = 19,708. Expected numbers are based on 22,904 deaths in Army non-Vietnam veteran comparison group, t Marines: deaths observed = 4,527. Expected numbers are based on 3,781 deaths in Marine non-Vietnam veteran comparison group, t P<.025 for x 2 with 1 df. §P<.01for x 2 with1df. When all malignancies were grouped together, Vietnam veterans did not exhibit an excess of cancer when compared to their counterparts who did not serve in Vietnam. Differences between the services, however, were seen for specific cancer sites among those who served in Vietnam relative to men who did not (Table 6). The most interesting differences were the statistically significant elevation for lung cancer (PMR, 1.58; P< .025) and non-Hodgkin's lymphoma (PMR, S.10; P < .025) seen in the Marines who served in Vietnam relative to Marines who served elsewhere. The risk for soft tissue sarcoma was not elevated among Vietnam veterans as a whole or in any subgroup of these veterans. Discussion For most major causes, the distribution of deaths for veterans who served in Vietnam is not markedly different from those who did not serve in Vietnam except for selected malignancies and "accidents, accidental poisonings, and violence." Four states have conducted mortality studies of Vietnam era veterans: Wisconsin,1 West Virginia,8 New York,8 and Massachusetts.4 The Centers for Disease Control also reported the postservice mortality of US Army Vietnam veterans." The results of these studies were similar to what was seen here. They Journal of Occupational Medicine/Volume 30 No. 5/May 1988 415 �TABLE 5 Deaths from Selected Causes Among Enlisted Vietnam Veterans Who Died Between 1965 and 1982, and Who Had Only One Tour of Duty* Army Marines 1965-1975 1976-1982 1965-1975 Cause (ICDA No.) Observed Observed 717 34 1.11f 0.65 2,053 201 1.06 1.10 167 11 77 342 212 232 89 Motor vehicle accidents Other transport accidents Accidental poisonings All other accidents/injury Suicide Homicide Cancers (140-209, 230-239) PMR PMR 1.14 1.00 1.00 0.92 0.74t 255 1,186 1,089 1,008 655 1.09 1.05 0.94 1.03 0.87f 25 82 57 68 25 1976-1982 PMR Observed PMR 1.18 1.04 611 48 1.01 0.82 2.26f 1.01 0.65 1.27 0.61 1 Observed 71 364 368 314 176 1.04 0.93 1.05 0.91 1.31 * PMR, proportional mortality ratio of observed to expected numbers of deaths. Expected number was generated based on deaths from nonVietnam veterans with similar characteristics. tP<.05forx 2 with1df. TABLE 6 Number of Deaths from Malignancies Among Vietnam Veterans by Branch of Service Army* Cause (ICDA No.) Observed All other causes (000-136, 210E989) All malignancies Buccal (140-1 49) Esophagus (150) Stomach (151) Intestines and other gastrointestinal (152-1 54, 158, 159) Liver, bile ducts (155-1 56) Pancreas (157) Upper respiratory (160-161) Lung (162) Bone (170) Soft tissue (171) Melanoma of the skin (1 72) Prostate (185) Testis(186) Bladder (188) Kidney (189) Brain (191) Other nervous system (192) Thyroid and endocrine (193-194) Non-Hodgkin's lymphoma (200, 202) Hodgkin's disease (201) Multiple myeloma (203) Leukemia (204-207) Other cancers (163, 173-4, 187, PMR 17,256 0.97 0.92 1.24 1.12 0.96 34 82 29 632 27 30 145 30 90 9 55 116 43 15 108 1.04 0.87 1.14 1.03 0.82 0.99 1.02 0.92 1.12 0.56 0.87 0.97 0.558 0.59 0.81 92 18 202 281 1.16 0.77 0.88 1.03 95% Confidence Interval 1.00 2,452 71 46 88 209 Marinesf Observed PMR 95% Confidence Interval 4,006 0.98 0.93-1 .01 0.47-1.82 0.78-1.98 0.85-1.47 0.70-1.32 521 13 5 17 33 1.20 1.95 0.39 0.82 1.26 1.0-1.45 0.54-7.04 0.11-1.41 0.41-1.64 0.71-2.24 0.77-1.41 0.64-1.18 0.63-2.07 0.39-1.71 0.80-1.23 0.91-1.14 0.55-1.23 0.84-1.5 0.27-1.18 0.50-1.52 0.29-3.20 0.38-0.79 0.30-1.17 0.63-1.04 6 18 1 130 11 8 36 5 26 4 13 25 11 4 35 1.21 1.63 0.18 1.58* 1.38 0.71 0.94 1.29 1.29 2.41 0.89 1.07 0.93 0.57 2.10* 0.52-2.83 0.46-5.75 0.03-1.32 1 .09-2.29 0.09-21 .48 0.38-1.32 0.59-1.50 0.16-10.3 0.47-3.57 0.09-66.35 0.54-1 .46 0.16-7.14 0.49-1 .78 0.10-3.37 1.17-3.79 0.73-1.85 0.23-2.53 0.73-1 .06 0.93-1.14 22 2 42 54 1.33 0.45 1.14 1.07 0.67-2.63 0.01-17.13 0.18-7.14 0.60-1.91 190, 195-9, 208-9, 230-9) * Army: deaths observed = 19,708. Expected numbers based on 22,904 deaths in Army non-Vietnam veteran comparison group, t Marines: deaths observed = 4,527. Expected numbers based on 3,781 deaths in Marine non-Vietnam veteran comparison group, t P<. 025 for x2 with 1 off. §P<.01 for x 2 with 1 df. also reported that Vietnam veterans were more likely to die from "accidents, accidental poisonings, and violence" or from a few selected malignancies than their counterparts who did not go to Vietnam. However, within these two broad categories, the findings reported by these studies were not consistent with each other or with what was found here. It should be noted that the data in the state reports were not strictly comparable to the data given in this report. They differed from this 416 study in that numbers of deaths studied were much smaller—less than 1,000-and they included Vietnamera veterans from all branches of service. They also differed somewhat in the analytical methods and used different types of veteran comparison populations. Furthermore, military personnel records of the state study subjects were not reviewed to verify Vietnam service status. The New York,3 Massachusetts,4 and CDC8 studies Mortality Study of Vietnam War Veterans/Breslin et al �reported nonstatistically significant elevations of risk for suicide when veterans with service in Vietnam were compared with other Vietnam-era veterans. In this study no excess of suicides was seen among the veterans who served in Vietnam when compared with other Vietnam-era veterans. The ratio of observed to expected deaths among the Army and Marine Corps veterans who served in Vietnam relative to their counterparts who did not serve in Vietnam was less than one; for veterans who had served in the Army, the deficit was statistically significant at P< .01. Simon16 reported an association between attempted suicide and combat experience in World War II veterans. In our study there was no data element that indicated whether a man had been in combat. As a surrogate measure, enlisted men whose military occupational specialties would be likely to involve combat, ie, rifleman, artilleryman etc, were compared to the other enlisted men who had served in Vietnam. Among the enlisted men who served in Vietnam, those with "combat-related" occupational specialties in both branches of service had relatively fewer suicides than "non-combat" Vietnam veterans in the same branch of service (Army: N = 590, PMR = 0.96; Marines: N = 228, PMR = 0.83). For the Marines, the deficit was statistically significant atP<.05. It is known that suicides are under-reported on death certificates but there was no reason to believe that they were more underreported among veterans who served in Vietnam than among those who did not. Nor was there any reason to believe that suicide was more apt to be underreported among those likely to have been in combat in Vietnam than among other veterans. Several researchers suggested that 1.6% to 5% of motor vehicle accidents may be suicides.17'18 In our study, motor vehicle accidents were relatively less frequent among Vietnam veterans with combat-related occupational specialties than among those with noncombat occupations (Army: N = 1,205, PMR = 0.99; Marines: N = 466, PMR = 0.94). Even if one assumes that some of the motor vehicle accidents are "hidden" suicides, it is unlikely that these could account for the overall deficit in suicides among Vietnam veterans since the possible "hidden" suicides among motor vehicle accidents are reportedly relatively small. The apparent excess of drug-related deaths attributable to heroin use among Vietnam veterans is of concern. This observation was consistent with that of Rohrbaugh et al,19 who found that, whereas Vietnam veterans were no more likely than other Vietnam-era veterans to use drugs in general, they were more likely to use opiates than other illicit drugs. The CDC also reported that accidental drug poisonings were substantially elevated among Vietnam veterans. One of the major concerns of Vietnam veterans has been the possibility of developing cancer as a result of exposure to Agent Orange, a mixture of two phenoxy herbicides. Some studies have shown an association between soft tissue sarcomas and exposure to phenoxy herbicides.7'20'21 Although data from Wisconsin,1 West Virginia,2 and Massachusetts4 indicated that veterans who served in Vietnam may have an increased risk of soft tissue sarcoma, no excess of soft tissue sarcomas was seen among the Vietnam veterans in our study. No association between soft tissue sarcoma and military service in Vietnam was found by Greenwald et alsa in a case control study of 881 men with soft tissue sarcoma from New York State, nor was any association found between military service in Vietnam and 234 cases of soft tissue sarcoma occurring among Vietnam-era veterans admitted to Veterans Administration hospitals,23 or 817 soft tissue sarcoma cases referred to the Armed Forces Institute of Pathology.84 The veterans who served in the Marine Corps in Vietnam were seen to have a statistically significant (P < .085) excess of non-Hodgkin's lymphoma when compared with Marines who did not serve in Vietnam. West Virginia veterans with service in Vietnam had a statistically significant excess of Hodgkin's disease when compared with other Vietnam-era veterans.2 None of the other state studies indicated any excess of lymphomas among veterans with service in Vietnam.1'3'* Non-Hodgkin's lymphoma has been associated with exposure to phenoxy herbicides,8'9 arsenicals,86 dapsone,26 and certain viruses.27 The men who served in Vietnam had the potential for exposure to all of these agents. Agent Blue, a herbicide used in Vietnam, was an organic arsenical compound and dapsone, a sulfone, was used as an antimalarial drug by some of the troops in Vietnam. Dapsone26 has been shown to cause lymphomas in laboratory animals. Dapsone was given mainly to troops stationed in I Corps and the central highland areas of Vietnam where falciparum malaria was prevalent. Most of the Marines in Vietnam served in I Corps. It will be interesting to see whether the Army troops who were stationed in I Corps also exhibit an excess of lymphomas. The data necessary for this analysis are now being collected. Lung cancer was significantly elevated (PMR, 1.58; P < .085) among Marines who served in Vietnam relative to Marines who did not serve in Vietnam. The veterans from New York3 with service in Vietnam also had relatively more lung cancer than other Vietnamera veterans but the excess was not statistically significant. Although tobacco is the etiologic agent most commonly associated with lung cancer, this disease has also been associated with exposure to other substances such as arsenic28 and phenoxy herbicides.80'29 A survey of more than 89,000 Vietnam-era veterans in Wisconsin indicated that they were nearly twice as likely to be cigarette smokers as were men in the general population.1 There are no smoking histories available for the Marines in this study. If the lung cancer deaths in this study are associated with an increased use of tobacco by the men who served in Vietnam, lung cancer deaths should also be increased among Army troops in Vietnam. They were not. The present study has certain inherent limitations that make it difficult to draw firm conclusions. First, Journal of Occupational Medicine/Volume 30 No. 5/May 1988 417 �risk estimates obtained from PMR analyses can approximate the results from studies of cause-specific mortality rates or the standardized mortality ratio (SMR).30 However, PMRs may be inflated for certain causes when the overall mortality rate of the study group is lower than that of the comparison population. This would have been the case if the US general population had been chosen for the comparison population in this study. It was shown that the selection process for military service exerted a profound effect on the mortality of veterans after separation from service. The number of deaths among the World War II male Army veterans was only 83.5% of the expected number at concurrent death rates for US white men.31 A recent study published by the CDC showed that the mortality among the Vietnam veteran study population was 17% higher than the rate among the non-Vietnam veteran comparison populations.5 These suggested that SPMRs for lung cancer and nonHodgkin's lymphoma reported in this study could have been biased toward underestimating the risks. Second, it is possible that, with so many comparisons being made, the few significant elevations observed could be interpreted as chance findings. Findings from this study need to be replicated by other Vietnam veteran studies. Third, no exposure data on individual veterans were available so as to evaluate the possible etiologic factors of the malignancies which appeared to be elevated among Marine Vietnam veterans. Additional work needs to be done to find characteristics that may point to possible etiologic factors. Fourth, the observation period in this study, a maximum of 17 years, may have been still insufficient to observe the risk of dying from diseases with a long latency period. A periodic monitoring of Vietnam veteran mortality patterns is warranted. Despite the limitations described above, the present study is the largest mortality study of Vietnam veterans reported to date encompassing approximately one third of all deaths which have occurred among the US Army and Marine veterans who served in Vietnam. Having an equally large number of non-Vietnam veterans whose characteristics are well-defined and are similar to the study population except for service in Vietnam should be considered a major strength. Furthermore, unlike other PMR studies of Vietnam veterans, in this study military personnel records for almost all (98.6%) potential study subjects were retrieved and reviewed to determine eligibility of the veteran. Therefore, the chance of misclassification of the most important study variable, namely service in Vietnam, is minimal. In summary, the study shows no significant differences in the major cause of death between Vietnam veterans and non-Vietnam veterans with a few exceptions. Accidental and drug-related deaths were relatively more frequent among Army Vietnam veterans. Suicides were less frequent among Vietnam veterans. Vietnam veterans who served in the Marine Corps were seen to have statistically significant excess of lung cancer and non-Hodgkin's lymphoma. 418 Acknowledgments The Veterans Administration wishes to acknowledge the assistance and support received from many individuals and agencies without which the VA mortality study could not have been successfully completed. We are grateful to Gilbert Beebe, PhD (NIH), Chin Long Chiang, PhD (UC Berkeley), Joseph Fleiss, PhD (Columbia University), the late Bernard Greenberg, PhD (University of North Carolina), the late Abraham Lillenfeld, MD (Johns Hopkins University), and Richard Monson, MD (Harvard University) for their reviews of the study protocol and the many suggestions and recommendations made on the conduct of the study. We also would like to acknowledge the contributions of David Peterson and Carolyn Brooks of the National Archives Records Administration; Paul Gray, National Personnel Records Center; Richard Christian, US Army and Joint Services Environmental Support Group; Robert Bilgrad, National Center for Health Statistics, National Death Index; and the Social Security Administration; the National Institute for Occupational Safety and Health; and the Internal Revenue Service. John Ward of Westat and Elaine Kokiko of Moshman Associates assisted us in the collection of military service data and death certificates, respectively. The guidance provided by William Page, PhD (National Academy of Sciences) and Alvin Young, PhD (White House Office of Science and Technology Policy) in planning for the study is greatly appreciated. References 1. Anderson HA, Hanrahan LP, Jensen M, et al: Wisconsin Vietnam Veteran Mortality Study, Final Report. State of Wisconsin Dept of Health and Social Services, Division of Health, 1986. 8. Bailey C, Baron BC, Basanao E, et al: West Virginia Vietnam Era Veterans Mortality Study. West Virginia Residents 1968-1988, Preliminary Report. West Virginia Health Dept, 1986. 3. Lawrence CE, Reilly AA, Quickenton P, et al: Mortality patterns of New York State Vietnam veterans. Am J Public Health 1985:75:377-879. 4. Kogan MD, Clapp RW: Mortality Among Vietnam Veterans in Massachusetts, 1978-83. Massachusetts Office of Commissioner of Veterans Services, Agent Orange Program, Massachusetts Dept of Public Health, Division of Health Statistics, 1985. 5. The Centers for Disease Control: Postservice mortality among Vietnam veterans. JAMA 1987;857:790-795. 6. Hearst N, Newman TB, Hully SB: Delayed effects of the military draft on mortality: A randomized natural experiment. N Eng-1 J Mod 1986;314:680-684. 7. Hardell L, Sandstrom A: Case control study: Soft tissue sarcoma and exposure to phenoxyacetic acids of chlorophenols. Br J Cancer 1979;39:711-717. 8. Hardell L, Ericksson M, Lenner P, et al: Malignant lymphoma and exposure to chemicals especially organic solvents, chlorophenols and phenoxy acids: A case-control study. Br J Cancer 1981;43:169176. 9. Hoar SK, Blair A, Holmes FF, et al: Agricultural herbicide use and risk of lymphoma and soft-tissue sarcoma. JAMA 1986;856:11411146. 10. Dept of Defense, Directorate for Information, Operations, and Reports: Selected Manpower Statistics, Fiscal Year 1981. 11. National Academy of Sciences Commission on the Life Sciences Medical Follow-up Agency: Ascertainment of Mortality in the U.S. Vietnam Veteran Population. Report of Contract V101 (93) P-937, Washington, DC, 1985. 18. Eighth Revision International Classification of Disease, Adapted for Use in the United States. US Public Health Service, Washington, DC. 13. Monson RR: Analysis of relative survival and proportional mortality. Comp Blamed Res 1974;7:385-338. 14. Mantel N, Haenszel W: Statistical aspects of the analysis of data from retrospective studies of disease. JNCI 1959;88:719-748. 15. Spiegelman D, Wang JD, Wegman D: Epidemiologlc programs for computers and calculators. Am J Epidemiol 1983;118:599-607. 16. Simon W: Attempted suicide among veterans. J Nerv Ment Dls 1950;lll:451-468. Mortality Study of Vietnam War Veterans/Breslin et al �17. Huffine GL: Equivocal single-auto traffic fatalities. Life Threatening Behav 1971;l:83-95. 18. Schmidt QW, Shaffer JW, Zlotowitz HI, et al: Suicide by vehicular crash. Am J Psychiatry 1977;184:176-177. 19. Rohrbaugh M, Bads O, Press S, et al: Effects of Vietnam Experience on Subsequent drug use among servicemen. Int J Addict 1974;9:S6-40. SO. Lynge E: A followup study of cancer incidence among workers in manufacture of phenoxy herbicides in Denmark. Br J Cancer 1985:58:859-870. 21. Erickson M, Hardell L, Berg NO, et al: Soft tissue sarcomas and exposure to chemical substances: A case referrant study. Br JInd Med 1981:38:87-33. 88. Greenwald P, Kovasznay B, Collins DN, et al: Sarcoma of soft tissues after Vietnam service. JNCI 1984;73:1107-1109. 83. Rang H, Weatherbee L, Breslin P, et al: Soft tissue sarcoma and military service in Vietnam: A case comparison group analysis of hospital patients. J Occup Med 1986:88:1815-1818. 34. Rang HK, Enzinger FW, Breslin P, et al: Soft tissue sarcoma and military service in Vietnam: A case control study. JNCI 1987;79:693-«99. 85. Axelson O, Dahlgren E, Jansson CD, et al: Arsenic exposure and mortality: A case referrent study for a Swedish copper smelter. BrJInd Med 1978;35:8-15. 86. National Cancer Institute Carcinogenesis Technical Report; Series No. 80: Bioassay of dapsone for possible carcinogenicity. DHEW publication No. NIH 77-880. Washington, DC 1977. 87. Schottenfeld D, Fraumeni <TF: Cancer Epidemiology and Prevention. Philadelphia, W. B. Saunders Co, 1988, pp 770-771. 88. Ott MG, Holder BB, Goldon HL, et al: Respiratory cancer and occupational exposure to arsenicals. Arch Environ Health 1974:89:850-855. 89. Zack JA, Oaffey WR: A mortality study of workers employed at the Monsanto Company plant in Nitro, West Virginia. Environ Sci Res 1983:86:575-591. 30. Decoufle P, Thomas TL, Pickle LW: Comparison of the proportionate mortality ratio and standardized mortality ratio risks measures. Am JEpidemiol 1980;lll:863-869. 31. Seltzer CC, Jablon S: Effects of selection on mortality. Am J Epidemlol 1974:100:367-378. Journal of Occupational Medicine/Volume 30 No. 5/May 1988 419 � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 066 Folder The folder containing the original item. 1786 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Breslin, Patricia Han K. Kang Yvonne Lee Vicki Burt Barclay M. Shepard Source A related resource from which the described resource is derived Journal of Occupational Medicine Date A point or period of time associated with an event in the lifecycle of the resource 1988-05-01 Title A name given to the resource Proportionate Mortality Study of US Army and US Marine Corps Veterans of the Vietnam War Subject The topic of the resource VA Mortality Study mortality trends cancer risk assessment ao_seriesIII https://www.nal.usda.gov/exhibits/speccoll/files/original/df8d66e51c40779e9d002e14c30e9caf.pdf a7bbaebbe750a995b0af55bc3d939eb6 PDF Text Text Item ID Number 01735 Author Keller, Carl A. Corporate Author RODOrt/ArtlOlO TitlO Typescript: Review of Vietnam Veterans Mortality Study, September 14,1987 Journal/Book Title oooo Month/Day Color Number of Images n 1 Doscripton Notes Monday, June 11, 2001 Page 1786 of 1793 �REVIEW OF VIETNAM VETERANS MORTALITY STUDY A study of proportionate mortality among U.S. Army and Marine veterans who served between July 4, 1965 and March 1, 1973 and died before March 1, 1982 was reported by the Veterans Administration. The study included 19708 Army and 4527 Marine veterans who had served in Vietnam and 22904 Army and 3781 Marine veterans who had not served in Southeast Asia during tis period. The study included a random sample of about one-third of the potentially elligible veterans who had died during this period. The selection of study subjects and recovery of information on them appears to have been unbiased and appropriate. The major findings from this study included a statistically significant excess of accidental and drug related deaths and paucity of suicides among Army veterans who had served in Vietnam compared to those who had not served in Southeast Asia. In addition, there was a statistically significant excess of lung cancer and non-Hodgkins lymphoma among Marine veterans who had served in Vietnam compared to those who had not. Several other findings were not mentioned in either the conclusions nor in the narrative, but are evident in the tables. These include a statisically significant decrease in mortality due to genitourinary diseases and cancer of the extra-cranial nervous system among Army Vietnam veterans. In addition, there appears to have been a signifcant decrease in cancer deaths among enlisted Army veterans with only one tour of duty in Vietnam, and among similar Marine veterans before 1975. There was also a significant increase in accidental poisonings among enlisted Marine Vietnam veterans dying before 1975. The authors computed Standardized Proportionate Mortality Ratios (SPMR) and tested with the Chi-Square statistic (not presented in the tables). According to the reference used to justify this procedure (ref # 13), Professor Monson suggests using the Poisson approximation of the variance of the expected deaths, i.e., that the expected number of deaths approximates the variance. If this procedure is applied to the information which can be deduced from the observed number of deaths and the SPMR as given in the tables, several additional SPMRs appear to be statistically significant. These include an excess of all cancer deaths among Marine veterans who served in Vietnam, particularly single tour enlisted Marines after 1975. Other possibly significant findings would include a decrease in deaths due to infectious diseases and diseases of the blood, an increase in deaths due to musculoskeletal and connective tissue diseases, and a decrease in deaths from thyroid cancer and non-Hodgkins lymphoma among Army Vietnam veterans. While there is no way to determine which statistical procedures are "correct", these results indicate that more significant findings are available in these data than have been dicussed in the manuscript. While this does not make it any easier to interpret the results, it does serve to point out the selective nature of the findings which have been emphasized in the manuscript. In particular, the inclusion of one-seventh of the abstract and considerable dicussion in the narrative to Agent Orange is misleading. Other possible explanations for the findings should receive relatively more emphasis. Carl A. Keller, Ph.D. Epidemiologist, NIEHS � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 066 Folder The folder containing the original item. 1785 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Keller, Carl A. Title A name given to the resource Typescript: Review of Vietnam Veterans Mortality Study, September 14, 1987 Subject The topic of the resource VA Mortality Study mortality trends study criticism cancer risk assessment ao_seriesIII https://www.nal.usda.gov/exhibits/speccoll/files/original/5fe0008ae62b2a9f36880208141d9b06.pdf 1f5fb5c0167e5b0bed2ddb443362fd91 PDF Text Text Item ID Number 01775 Author Breslin, Patricia Corporate Author Report/ArtlGlO TltlO Typescript: A Preliminary Report: The Vietnam Veterans Mortality Study, October 1986 Journal/Book Title 000 Year ° Month/Day Color n Number of Images 10 ° Dascplpton Notes Monday, June 11, 2001 Page 1777 of 1793 �A PRELIMINARY REPORT THE VIETNAM VETERANS MORTALITY STUDY Patricia Breslin, Sc.D Yvonne Lee, M.Sc. Han Rang, DrPH Vicki Burt, M.Sc. Barclay Shepard, MD Office of Environmental Epidemiology Veterans Administration Washington DC 20420 October 1986 �SUMMARY The patterns of mortality among 24,235 veterans of the Army and Marine Corps who served in Vietnam and 26,685 Vietnam era veterans who served in the Army and Marine Corps other than in Southeast Asia were investigated using standardized proportional mortality ratios (SPMRs). The study subjects were a random sample of Vietnam era veteran deaths taken from the Veterans Administration's Beneficiary Indentification and Record Locator Subsystem (BIRLS). Data on the type of military service, place and dates of military service, military occupational speciality code, principal duties, and other demographic information were obtained from the military record. Cause of death information came from death certificates (97%), Department of Defense Reports of Casuality, or VA records. All cause of death information was coded by experienced nosologists using ICDA-8. The veterans who had served in Vietnam were seen to have died from accidents, violence and trauma significantly more frequently than those who did not serve in Vietnam. The excesses seem to be among deaths from motor vehicle accidents and accidental drug poisonings. A closer investigation revealed that the accidental drug poisonings were predominantly heroin overdoses. Deaths coded as suicides were not in excess among those who served in Vietnam. The Marines who served in Vietnam appear to have an excess of mortality from malignancies. Part of this excess seems to be lung cancer and non-Hodgkins lymphomas (NHL). Marines with combat related MOSCs have a greater risk for NHL than those with either direct combat support or indirect combat support MOSCs. The excess for NHL among Marines is also seen if general population mortality data or if U.S. cancer mortality data are used as comparisons. Standardized mortality odds ratios were also calculated for the NHL deaths among Marines using all cardiovascular deaths among Marines who did not serve in Southeast Asia as a comparison population. SMOR's were elevated for Marines with combat related MOSCs and for Marines whose first tour of duty was 1967-1969. Additional data are being collected. Analyses are planned that will investigate the relationship between the place the Veteran served in Vietnam and the herbicide spray patterns in Air Force records. �INTRODUCTION In response to growing concerns about the potential adverse health effects of military service in Vietnam, studies have been undertaken by governments, veterans organizations and others in the United States and Australia. To address some of these concerns, the Veterans Administration undertook a mortality study of Vietnam veterans based on deaths known to it. The study was designed and and the original contracts for data collection were let by the Veterans Administration's Office of Reports and Statistics and subsequently transferred to the Agent Orange Projects Office to be completed. This is a preliminary report on some of the data from the study. The purpose of the study was to compare the mortality patterns of men who served in Vietnam with those of men who served in the military during the same era but who did not serve in Southeast Asia. SOURCES OF DATA Ideally one would like to be able to do a cohort study in which one could assess the relative risks of death from all causes or from specific causes for military personnel who served in Vietnam compared to military personnel who did not serve in Vietnam. Unfortunately, there is no complete roster of persons who served in the military during that era. Another approach had to be taken. The Veterans Administration maintains an automated information system used to identify and to locate records of veterans who have received or are receiving veterans benefits such as compensation, pensions, loan guarantees, or education as well as records for veterans whose beneficiaries have received a death benefit. This system is known as the Beneficiary Identification and Record Locator Subsystem (BIRLS) and contains more than 38 million names. Until October 1981, the Veterans Administration was authorized to pay a lump sum benefit for all eligible veteran deaths. The number of eligible veterans was large and included those who served during the Vietnam era. Although this system does not provide a complete list of all veterans, it is believed to be a reasonably complete source for veteran deaths. Beebe and Simon (1) assessed the completeness of the file for World War II veterans and found that 98% of independently ascertained deaths were known to the VA and BIRLS has been used as a source of data in other mortality studies of veterans. (2,3,4) This study was undertaken with the assumption that the BIRLS file would be able to provide a similarly complete list of Vietnam era veterans' deaths. The National Academy of Sciences(5), under contract to the Veterans Administration, has assessed the completeness of this file for Vietnam era veterans. Its findings and their implications for this study are discussed in Appendix A-l. �If a reasonably complete roster of Vietnam era veterans' deaths could be assembled and they could be classified as to whether or not they served in Vietnam, they could form the data base for a proportional mortality study (PMR analysis). Although the data in the BIRLS record do not consistently indicate whether or not the veteran has served in Vietnam, they do provide several advantages toward obtaining this information. The basic BIRLS record format may contain information such as social security number, service number, branch of service, dates of enlistment and discharge etc. These are data items needed to identify the veteran in the military record system. As the name indicates, BJERLS is a file used to locate the VA claim folder for the veteran. It is the paper record of veterans' claims for benefits or claims made in his or her behalf. For deceased veterans, the file contains some kind of notification of death. In many cases this is the death certificate issued by the state or country where the veteran died or a DD1300, a Department of Defense form, Report of Casualty, issued in the event of death to an active member of the armed forces or reserve. The cause of death should be available for most veterans in these files. Given the type of data readily available, a proportional mortality analysis was planned using a sample of the Vietnam era veterans' deaths found in BIRLS. The purpose of the study was to describe the proportional mortality patterns of men who served in the Army or Marine Corps during a portion (1965-1973) of the Vietnam era (1965-1975). The study will compare the mortality patterns of servicemen who served in Vietnam with those of servicemen who did not serve in Southeast Asia. SELECTING THE TARGET POPULATION Proceeding under the assumption that the BIRLS system had the potential for yielding a reasonably complete roster of Vietnam Era veterans' deaths, it was necessary to devise strategies to select these deaths from among all deaths recorded in BIRLS. The objectives of the selection process were to obtain as complete a list as possible. This list would include all the Vietnam era veterans and would exclude veterans who had not served in the military during the Vietnam era. In the first stage, the attempt was made to provide as complete a list as possible. To do this, all veterans whose service dates included the period 1964-1975 were selected. For those records where the service dates were missing, persons whose birth dates were given as falling between 1935 and 1957 inclusive were selected. This yielded about 815,000 records. Recalling the purpose of the study, to compare the mortality patterns of men who served in Vietnam with those who did not serve in Vietnam, additional criteria were introduced based on time of service and branch of service. �The Vietnam era, as defined by the Veterans Administration, was Aug. 5, 1964 to May 7, 1975. Prior to July 1965 and after January 1973 there were relatively few troops in Vietnam. If one sampled deaths among those who served before 1965 or after Jan. 1, 1973 there would be relatively few decedents who had served in Vietnam. Therefore, the study population was limited to military personnel who were in the armed forces on or after July 4, 1965 but before March 1, 1973. Data published by the Department of Defense(6) indicate that 81% of those who served in Vietnam were in the Army or Marine Corps. For these branches of service duty in Vietnam meant, in most cases, service "in country". For those in the Air Force or Navy, Vietnam service is not so clear cut. It may be difficult to determine whether Navy personnel who were considered to have service in the Vietnam theatre of operations were ever actually "in country" or if Air Force personnel who flew missions over Vietnam or to Vietnam were ever "in country". Hence the study population was further limited to persons serving in the Army or Marine Corps between July 4, 1965 and March 1, 1973. Since this was to be a proportional mortality study and deaths related to combat could only occur among those with service in Southeast Asia and not among those who did not serve in Southeast Asia, deaths in service before the end of 1973 were excluded. The study population as defined by these criteria consisted of 186,000 names of military personnel who served in the Army or Marine Corps or unknown branch any time between July 4, 1965 and March 1, 1973 or whose year of birth was between 1934 and 1957 inclusive. SAMPLE SELECTION Power calculations done by the Office of Reports and Statistics of the Veterans Administration(7) suggested that at least 50,000 eligible cases would be needed for the study. It was assumed that some of the cases selected from the target population of 186,000 would be ineligible for the study based on branch or time of service, (these would be cases included in the target population because these data items were not recorded in the BIRLS) therefore, 60,000 names were selected from the target population by simple random sampling. It was assumed that the extra 10,000 names would allow for the ineligible and the final sample for analysis would be at least 50,000 names. A small sample of the records classified a priori as ineligible for the study by the selection criteria was taken in order to evaluate these criteria. The analysis of this "quality control" sample indicated that about 1% of the deaths of eligible males may have been excluded from the target population file because of incomplete or erroneous data in BIRLS. In order to spread the work load over time, the 60,000 records were randomly divided into 4 batches to be processed at intervals of three months. The returns for the first batch suggested that the proportion of ineligible cases among those sampled was larger than the 16% allowed for in the 60,000, and if 50,000 eligible cases were to be obtained, the later batches would have to be increased in size. While the first two batches were in process, a committee of experts �(Appendix A-2) was convened. Because of the relative youth of the deaths in the study, the committee suggested that deaths occurring later in the study time frame i.e. after 1975 should be more heavily sampled in the later batches in order to enhance the possibility of seeing a broader spectrum of chronic diseases. Given the need to increase the sample size, and the recommendations of the expert committee, it was decided to select only deaths after 1975 and increase the sample size of the last two batches. Ultimately, 75617 records were selected. Using the results of the quality control sample and the outcome of the military records searches done on the cases selected, it was estimated that there should have been about 144,450 deaths of men meeting the study criteria in BIRLS and that this study included about" 36% of them. MILITARY RECORDS Military records for discharged veterans are kept in the National Personnel Record Center (NPRC) in St. Louis, MO. Although the military records are not automated, there is a computerized "register" that can be used to locate a veteran's record. To use this register, one needs the veteran's name, branch of service, social security number, birth date, and if available, service number. For most subjects this information was available in BIRLS. A computer tape containing the requisite information was sent to the contractor responsible for the military records searching and abstracting. The tape was matched to the register and the file locations for the required cases were obtained. Attempts were made to locate records for persons not found by computer match by manually searching other unautomated files. Records for which a location was determined were requested from the NPRC and abstracted by the contractor. The types of data obtained from these records are given in appendix B-l. For some persons whose military record could not be located or obtained at NPRC, VA records were searched for evidence of eligibility, such as branch, time, and place of service. Abstracted records were returned to the VA project staff on computer tape. The staff of the study project then 'edited* the tape as far as possible looking for inconsistencies among military occupational specialty codes (MOSC), branch and grade codes. For veterans who had served in Southeast Asia, more data elements were abstracted from the military record. Any apparent inconsistencies such as disagreement between unit address and branch of service were resolved. CAUSE OF DEATH INFORMATION It had been assumed at the inception of the study that for most cases a death certificate had been filed with the VA by the next of kin in order to obtain some veteran's benefit or that there would be some other form such as DD1300, Report of Casualty that would indicate the cause of death in the veteran's VA file. To obtain this death �information, the records selected were sorted by the location of the record given in the BIRLS file. Lists of names with requisite identifying information were sent to the locations of record. The instructions issued to these offices were to locate the record, search for a death certificate or cause of death information, and send a copy of the death certificate or other document to the contractor responsible for coding the cause of death information. For about 30% of the names selected the request was returned with no codeable cause of death information. These were cases where the file was not found; the file had been transferred elsewhere; the file contained no death certificate or other document showing cause of death; the death certificate in the file did not show a cause of death; or an incorrect certificate was returned (sometimes certificates for other family members, marriage certificates, baptismal certificates etc. were sent). Every conceivable approach was taken to obtain cause of death information for these cases. Death certificates were the preferred source of information but Reports of Casualty issued by the military in the event of death active duty personnel or reservists were accepted if the death occurred out of the country and no death certificate could be obtained. It should be noted that most of these cases were accidents and probably little additional information would have been obtained from the death certificate if it were available. For cases where files had been transferred, the request was re-submitted to the new location. If the file was missing, VA records were researched to look for duplicate files in other locations. If BIRLS indicated that the veteran carried insurance, death certificates were requested from the insurance carrier. Arrangements were made with state vital statistics registrars to obtain death certificates from state records. For cases where a death certificate was returned without a cause of death (cases marked "pending" further investigation or certificates from New York City that did not include the portion of the certificate that contained the cause of death information) a request was made of the jurisdiction issuing the certificate to send an amended certificate. BIRLS files were searched for evidence of last known state of residence and requests were directed to that state. If the year of death was 1979 or later the name, birth date and social security number were submitted for a National Death Index search. If the records indicated that the veteran died while on active duty, a request was made to the contractor abstracting military records to look for a death certificate or DD1300 in the military record. The predominant source of information on the cause of death for all cases was the death certificate or an abstract of the death certificate. This was true for both those who served in Vietnam and those who did not. �SOURCE OF CAUSE OF DEATH INFORMATION Death certificates or abstracts DD 1300 VA Forms/records 96.95% 2.13% .92% DEATH CERTIFICATE CODING All information contained on the death certificate was coded for inclusion in the data base. Demographic information, geographic information and information on occupation and industry were coded using standard codes. « All cause of death information was coded by trained nosologists using the International Classification of Diseases, 8th Revision (ICDA-8)(8) for entry into the Automated Classification of Medical Entities (ACME)(9) system. All certificates for selected causes of death were reviewed by a senior staff member on the study. It was found that the cause of death information was consistently and accurately coded. A few questionable codes were re-submitted to the nosologist for review. Because the version of ACME used in this study was the earliest attempt to automate the assignment of the underlying cause of death on death certificates, occasionally there were re-submitted to the nosologist for review. Because the version of ACME used in this study was the earliest attempt to automate the assignment of the underlying cause of death on death certificates, occasionally there were codes erroneously assigned by the computer. Many of the cases questioned by the project staff member fell into this category. Consequently, an experienced nosologist, knowledgeable about the ACME system and its inadequacies, re-reviewed the cause of death coding on all certificates. DATA MERGING The data tapes containing the information abstracted by the contractors were matched to the original BIRLS data to confirm that the cases abstracted were the cases selected. Non-matches were culled from the tapes to be reviewed and if necessary, re-abstracted. This merge was straight forward for the military information. The military record abstract contained an identification number based on the alphabetical sequence of the names in each batch and this was known to the study staff. In the case of the death certificate abstracts, there was no such common number available on the tape and matches had to be attempted by social security number, name or VA claim number. This was not as straight forward as it may seem. Nearly 18,000 cases could not be matched by these means and had to be matched by someone looking at the data in both files and manually entering the matching file numbers. (For 15% of the eligible cases, there were no matching social security numbers between BIRLS and the death certificate data.) Once it was determined that all death certificate abstracts that could be matched to BIRLS had been identified, the military record file and the death certificate files �were matched. Again, checks were run looking for differences in names,social security numbers, and birth dates. Dates of death recorded on the death certificate abstracts were matched with dates of death given in BIRLS. Alldiscrepancies were investigated. Most mismatches were found in time to be researched and included in the study; some were not and are now classified among the missing certificates. Where demographic data from the military abstract data did not match the BIRLS data for the case, there was no time to have these re-abstracted. These cases are counted among the search completed and not found cases. CHARACTERISTICS OF THE SAMPLE The final sample consisted of 75617 names; of these 69.1% (52253) were found to be eligible for inclusion in the study by virtue of branch of service or time of service. DISTRIBUTION OF SAMPLE BY ELIGIBILITY STATUS Names Selected Found Eligible Found Ineligible Not found 75617 52253 22332 1032 100.0% 69.1% 29.5% 1.4% The ineligible count includes duplicate names; men who did not serve in the military during the Vietnam Era; men who served in the Navy, Coast Guard or Air Force; men who were killed in action or reported missing in action and subsequently were declared dead; men who died in service before 1974; men who died of war related injuries; and all women. It should be noted that there were only 340 women identified. No women in this had served in Southeast Asia and not all had served during the Vietnam era. Of the 52253 men determined to be eligible for the study, cause of death was ascertained for 51421 or 98.4%. The remaining 832 names (1.6%) were cases where the cause of death was pending; the veteran died overseas and the certificate available had no cause of death; the veteran was probably still alive; and cases where the place of death had not been identified. STATUS OF ELIGIBLE CASES Eligible by branch and time of service Cause of death known Cause of death not found 52253 51421 832 100.0% 98.4% 1.6% �Of the 51421 men for whom military service data and cause ofdeath information was available, 24736 were known to have served in Southeast Asia: 24235; were identified as having served in Vietnam; 450 were known to have served in Thailand, and for 51 the unit with which they served is known but the place of service (i.e. Vietnam or elsewhere in Southeast Asia) has yet to be resolved. PLACE OF MILITARY SERVICE No service in Southeast Asia 26685 Served in Vietnam 24235 Served in Thailand only 450 Place of service in Southeast Asia unk. 51 51.9% 47.1% 0.9% 0.1% This report will be based on 50920 deaths, 24235 men who served in Vietnam and 26685 men who did not serve in Southeast Asia. METHODOLOGY Jablon and Seltzer(2) concluded from their studies of veteran populations that it was hazardous to compare "selected cohorts" to the general population since these screened populations may vary systematically or confound the interpretation of an exposure hence there is a need to compare veterans to veterans. In this report we have heeded this advice and will use the Vietnam Era veterans who did not serve in Southeast Asia as a comparison group for those who served in Vietnam. Of the 50920 men in this report, 83.6% had served in the Army; 47.6% had served in Vietnam (another 1% had served elsewhere in Southeast Asia). The Marines were more apt to have served in Vietnam (54.5% of the Marines and 46.2% of the Army had served in Vietnam). These proportions are close to what those that can be estimated from published data. According to Department of Defense figures(6), 8,844,000 men had served in the military between 4 Aug. 1964 and 27 Jan. 1973, Of these, 5,162,000 were in the Army or Marine Corps. Veterans Administration (9) figures indicate that 3,169,000 Vietnam era veterans served in Vietnam. If 81% of these were in the Army or Marine Corps(6) then 2,535,000 Army or Marine Corps veterans were in Vietnam. Therefore 2535/5162 or 49.1% of Army or Marine Corps personnel during that period served in Southeast Asia. PLACE OF SERVICE BY BRANCH SERVED IN VIETNAM YES NO Army Marine Corps 19708 4527 TOTALS 24235 22904 3781 26685 TOTAL 42612 8308 50920 �Of the 50920 deaths used in this report, 79.6% were white, 17.7% were black and 2.7% were of other racial groups. Proportional mortality ratios,standardized for age, race, and branch of service (SPMRs) were calculated for all major causes of death among all men who served in Vietnam. To calculate a proportional mortality ratio for a particular cause of death, the deaths were first divided into two groups which were those who served in Vietnam and those who did not. Within each of these groups the deaths were then divided by branch of service and within branch of service, they were divided by race. Within each racial group they were divided into 10 age groups (20-24, 25-29, . . . 60-64, 65+). The the proportion of deaths from the cause of interest was calculated for each age group in the comparison group (veterans who did not go to Vietnam). These proportions were then multiplied by the total number of deaths in the corresponding age-race group in the Vietnam service group to obtain the number of deaths that would be expected to be seen among the veterans with Vietnam service if they had the same proportional distribution of deaths by age,race,branch and cause as those veterans who did not go to Vietnam. These expected numbers for a specific cause are then added to give the total number of deaths that would be expected if the veterans who had served in Vietnam had the same age,race,branch,specific proportional mortality as those veterans who did not serve in Vietnam. Mathematically this process can be expressed as : d(i,j,k,+) X D(i,j,k,l) Expected(+,+,+,!)= where d(i,j,k,+) = the number of deaths from all causes in the ith branch, jth race and kth age group among veterans who served in Vietnam. D(i,j,k,l) = the number of deaths from the 1th cause in the ith branch, jth race, and kth age group among veterans who did not serve in Vietnam. D(i,j,k,+) = the number of deaths from all causes in the ith branch, jth race, and kth age group among The SPMR (standardized proportional mortality ratio) is obtained for each cause by dividing the observed number of deaths from that cause in veterans with Vietnam service by the expected number (O/E). The O/E (observed to expected ratio) indicates whether the group of interest has relatively more deaths (greater than 1) or relatively fewer deaths (O/E less than 1) than expected from a specific cause. In the tables presented here the expected numbers were rounded in printing the table. The Mantel-Haenszel chi-square statistic (11) was calculated for each category to indicate whether the deviation from unity is "statistically significant", that is, whether or not such �10 differences are likely to be seen by chance. (The 0/E ratio and SPMR have been used interchangeably in this report.) The disadvantages of proportionate mortality analysis are well known. If the overall mortality in the exposed population is different from that of the non-exposed population the SPMR will not approximate the standardized mortality ratio (SMR). That is, if the overall mortality rate is less among those who did not serve in Southeast Asia the the SPMRs will under estimate the cause specific risks for those who did go to Vietnam. A cause specific SMPR is also dependent on the relative distribution of other causes of death. For example, if men who served in Vietnam had a higher mortality rate for accidents than the referent population, then the SPMR for some other cause might be depressed. , All major causes of death were looked at separately among all men with service in Vietnam and in subgroups of that population. SPMRs were calculated separately for the men who served in the Army and for those who served in the Marine Corps because the branches might have had different types of "exposures" in Vietnam either by virtue of the location of their units or the types of duties they were assigned. For example, it is known that virtually all of the Marines in Vietnam were stationed in I Corps (the northern provinces of Vietnam). It is well known that mortality patterns tend to differ by race. For this reason, SPMR's were calculated separately for whites and non-whites. Most of the non-whites were blacks. There were too few persons of other races to consider them separately. Rather than excluding them from consideration, they were grouped with the blacks for the purpose of these preliminary analyses. Conceivably, enlisted men might have different experiences or exposures than officers. Thus, these two groups were considered separately. Certainly one might expect that men who were in combat might differ from those who were not. There was no data element that would indicate whether the man had been in combat. As a surrogate measure for combat, those with "combat" related MOSCs were compared with those who served in Vietnam with non-combat related MOSCs in each branch. Combat related MOSCs were those occupations where the primary duty would involve direct offensive and defensive action against an armed hostile force, for example: rifleman, field artilleryman, tank crew member etc. The MOSC groupings used here are those used in the Wisconsin study(12). They can be found in Appendix B-2. Data from all these analyses are presented in this report. Certainly many other subgroups might be identified as the analyses of this data set continue. RESULTS AND DISCUSSION If one looks at the deaths by major disease groups, there would seem to be no remarkable differences between the men who served in Vietnam and their counterparts who did not serve in Vietnam except for "accidents, violence, and trauma (E800-E989) which is"significantly" in excess among those who served in Vietnam. Deaths from "musculoskeletal and connective tissue diseases (710-730)" also �11 can be seen to be consistently elevated across the several subgroups but the differences are not seen to be "statistically" significant. The only other major disease category seen in significant excess is that of diseases of the nervous system and sense organs (380-389) in the marines with combat related MOSCs where the SPUR is 2.28 based on 17 cases observed. ACCIDENTS, VIOLENCE AND TRAUMA Since over half of all the deaths in the study population are due to accidents, violence, or trauma and because they are seen to be in excess, they bear investigation. Within this broad category, motor vehicle accidents account for most of the deaths and they are significantly in excess among all the sub populations except the Marines. A cursory investigation was carried out to see if the men who were in Vietnam were more likely to have civilian jobs that would put them at higher risk of having a motor vehicle accident. The proportion of men with jobs that might require driving a motor vehicle was the same in the two groups. "Other transport accidents" are seen to be in excess primarily among Army personnel who are not enlisted men. Investigation revealed that these were occurring with greatest relative frequency among warrant officers who had MOSCs that indicated they were helicopter pilots and that helicopter crashes were a leading cause of death in this cause category. It was found that many of these men were killed while at work as helicopter pilots. These accident would not seem to be related to their "Vietnam experience" except for the correlation of MOSC, Vietnam service and civilian occupation. Most of the men with an MOSC that indicated that they were helicopter pilots had served in Vietnam. The category of "accidental poisonings" was elevated among all groups. They seem to be a particular problem among white, Army enlisted personnel. A sample from all of these deaths was drawn and the death certificates were reviewed for more information. It was found that on 98 of 100 certificates the death was due to narcotic overdose, mostly heroin. The accidents coded as "other accidents and injury" suggest they might be related to occupation but these have not been looked at in detail. Death by suicides is relatively less frequent in all of the sub groups presented here except for nonwhite servicemen where the observed number exceeds the expected number by less than 1%. Deaths by homicide are in excess among officers and those with combat experience. A preliminary investigation revealed that men who had service in Vietnam were more likely to have had a civilian job such as guard, policemen, etc., that would put them at risk of violent death. �12 MALIGNANCIES The possibility of excess malignancies occurring among the men who served in Vietnam and who may have been exposed to herbicides has long been a concern to veterans. When all malignancies are grouped together, Marines, non-whites, and officers who served in Vietnam exhibit an excess of cancer when compared to their counterparts who did not serve in Southeast Asia. The excesses are not statistically significant but they suggest that there could be a problem in a subgroups of these men. SPMRs FOR ALL MALIGNANCIES GROUP All All All All All All All OBS. cases Army Marines white servicemen non-white servicemen enlisted officers 0/E 2973 2452 1.00 .97 1.20 .99 1.06 .99 1.04 521 2480 492 2566 318 The men with combat related MOSCs were not seen to have more malignancies than those who served with non-combat related MOSCs. SPMRs FOR ALL MALIGNANCIES AMONG COMBAT RELATED MOSCs BRANCH Army Marines OBS. 0/E 550 158 .76 .98 This might suggest that if there is an "environmental" factor associated with military service in Vietnam that is related to the slight excesses seen in overall malignancies, it is not confined only to men who had a high probability of being in combat. Differences between the services are seen for specific cancer sites among those who served in Vietnam . The most outstanding differences are the significant excess of deaths from lung cancer and non-Hodgkins lymphoma seen in the Marines. The SPMRs for these malignancies are also elevated among Army personnel although the excess are not seen as statistically significant. �13 SPMRs FOR SELECTED MALIGNANCIES BY BRANCH ARMY SITE All sites Lung Non-Hodgkins Lymphoma OBS 2452 632 92 MARINES 0/E .97 1.03 1.16 OBS 521 130 35 O/E 1.20 1.58* 2 .10* Soft tissue sarcomas have been of particular interest to those studying the health or mortality of Vietnam veterans since they are a type of tumor that has been reported to be associated with exposure to phenoxy-herbicides by Swedish investigators(13). They are not elevated in this population. In each group the O/E ratio is 1.00 or less. Some marked differences in the ratios of observed numbers of deaths to expected numbers of deaths have been noted between the men who served in the Army and those who served in the Marine Corps among both those who served in Vietnam and those who did not. Cause specific standardized proportional mortality ratios are dependent upon the relative distribution of other causes of death. The SPMR for the group of external causes of death (accidents, etc..) is higher among those who went to Vietnam relative to those who did not go to Vietnam in both those who served in the Army and those who served in the Marine Corps. This can occur either because those who went to Vietnam had higher relative risks of dying from external causes of death or because they have lower overall mortality rates than their counterparts who did not serve in Vietnam. It might be expected that in comparison to the general population there would be relatively fewer deaths from circulatory diseases and certain other diseases in the military population because among these causes of death are conditions that would make one ineligible for military service. On the other hand the selection process for military service can not screen out persons likely to have an accident or to suffer from a malignancy in the future. It would be expected that any comparison with the general population there would be lower death rates for some diseases among those who served in the military. Consequently, the proportional mortality ratios will be less than 1 for these causes. Conversely, the proportional mortality ratios for diseases occurring at approximately the same rate or higher than in the general population will be elevated. Standardized proportional mortality ratios were calculated for white male veteran deaths occurring in the years 1978 to 1981 using the 1978 U.S. white male mortality data (14) for four broad groups of causes of death: all malignancies, circulatory diseases, external causes, and all other. As expected, the groups of causes that are unlikely to be screened out at entry into the military service have relatively larger observed to expected ratios than those for �14 categories that include conditions that would lessen the likelihood of military service. SPMRs FOR SELECTED CAUSES OF DEATH WHITE VETERANS No Vietnam Service Army Malignancies Circulatory dis. External causes All other Marines .99 .87 .88 .78 1.10 . .1.16 .88 .66 1978-1981 Vietnam Service Army .98 .96 1.14 .69 Marines 1.04 .87 1.17 .60 U.S. white male mortality for 1978 were uses as a comparison. No significance tests were done. When compared to the U.S. white male mortality for 1978, the proportion of deaths from external causes tends to be the same for the Marines who went to Vietnam as for those who didn't go. There still appears to be an excess of malignancies among Marines who went to Vietnam when compared to the general population. The deaths among the Marine veterans are distributed differently than those among the Army veterans when compared to deaths among the U.S. white male population. One explanation might be the difference in the ages of the two populations. The mean age of death for the Army veterans was the same for those who went to Vietnam (36.3 years) as for those who did not go (36.2 years). The mean age of death for the Marine Corps veterans was less than that of the Army veterans. The mean age of death for Marines who did not serve in Vietnam was younger (30.9 years) than that of the marines who had served in Vietnam (34.4 years). Mortality rates for most causes of death are related to age. Younger populations will die relatively more frequently from accidents, etc. than older populations. The SPMRs were recalculated for this same group of deaths excluding all external causes of death. When all external causes of death were removed, there is less difference between the distribution of the Army deaths and the Marine deaths among both those who went to Vietnam and those who did not. OBSERVED TO EXPECTED RATIOS FOR SELECTED CAUSES OF DEATH WHITE VETERANS 1978-1981 EXCLUDING EXTERNAL CAUSES OF DEATH No Vietnam Service Army All malignancies Circulatory dis. External causes All other Marines Vietnam Service Army Marines 1.09 .93 1.15 .95 1.09 1.06 1.35 1.01 1.01 .93 .82 .76 U.S. white male mortality for 1978 used as a comparison. No significance tests were done. �15 One might question whether the excess mortality from non-Hodgkins lymphoma or lung cancer might be artifacts of the apparent excess deaths from external causes among Marine veterans who did not go to Vietnam thereby yielding a relatively smaller proportion of expected deaths from malignancies among these men thus increasing the 0/E ratios in the internal comparisons presented in this report. The expected numbers of malignancies were calculated using U.S. mortality data and using only the distribution of specific malignancies(15) within all malignancies. OBSERVED AND EXPECTED NUMBERS OF DEATHS FOR SELECTED MALIGNANCIES, WHITE MALES, 1973-1981, ARMY No Vietnam Service OBS. EX1 EX2 All malignancies Ca-colon Ca-lung , bronchus Hodgkins Lymphoma Non-Hodgkins Lymphoma Leukemia 2061 133 488 72 122 192 1964 142 446 94 113 188 154 495 91 115 184 Vietnam Service OBS. EX1 EX2 1773 107 443 65 84 152 1753 125 410 83 101 163 128 433 79 100 157 EX1 = Expected numbers based on 1973-81 total white male mortality EX2 = Expected numbers based on 1973-81 white male cancer mortality OBSERVED AND EXPECTED NUMBERS OF DEATHS FOR SELECTED MALIGNANCIES, WHITE MALES, 1973-1981 MARINES No Vietnam Service OBS. EX1 EX2 All malignancies Ca-colon Ca-lung , bronchus Hodgkins Lymphoma Non-Hodgkins Lymphoma Leukemia 226 10 40 11 8 21 264 17 41 18 17 35 15 46 11 13 24 Vietnam Service OBS. EX1 EX2 409 18 103 17 29 36 392 27 79 22 24 42 29 91 20 25 36 EX1 = Expected numbers based on 1973-81 total white male mortality EX2 = Expected numbers based on 1973-81 white male cancer mortality �16 When the influence of the external causes death is removed from the standardized proportional mortality ratios by calculating the expected numbers using only the proportional distribution within all malignancies as a comparison, the apparent increase in lung cancer and in NHL still exists. Since the SPMSs using the internal comparisons were elevated for a subset of Marines, those with combat related MOSCs, expected numbers for this population were calculated using the U.S. mortality as in the tables above. OBSERVED AND EXPECTED NUMBERS OF DEATHS FOR SELECTED MALIGNANCIES, WHITE MALES, 1973-1981 MARINES WITH COMBAT MOSCs No Vietnam Service OBS. EX1 EX2 All malignancies Ca-colon Ca-lung , bronchus Hodgkins lymphoma Non-Hodgkins lymphoma Leukemia 35 3 4 0 1 5 51 3 6 4 4 7 2 4 2 2 4 Vietnam Service OBS. EX1 EX2 136 5 20 6 14 17 133 9 19 10 9 18 9 24 8 9 17 EX1 = Expected numbers based on 1973-81 total white male mortality EX2 = Expected numbers based on 1973-81 white male cancer mortality The observed numbers of NHL are not as different from the expected numbers in those who did not serve in Vietnam as they are among those who served in Vietnam. The results are similar for black males who served in the Army. Therefore, the excess mortality from NHL seen using the internal comparisons is probably not an artifact. OBSERVED AND EXPECTED NUMBERS OF DEATHS FOR SELECTED MALIGNANCIES, BLACK MALES, 1973-1981 ARMY WITH COMBAT MOSC'S No Vietnam Service OBS. EX1 EX2 All malignancies Ca-colon Ca-lung , bronchus Hodgkins Lymphoma Non-Hodgkins Lymphoma Leukemia 290 37 76 5 8 21 253 18 71 9 9 21 21 60 10 10 24 Vietnam Service OBS. EX1 EX2 344 30 48 10 18 21 281 20 86 8 9 29 24 106 9 11 23 EX1 = Expected numbers based on 1973-81 total black male mortality EX2 = Expected numbers based on 1973-81 black male cancer mortality �17 ADDITIONAL ANALYSIS FOR NON-HODGKIN'S LYMPHOMA The SPMR for non-Hodgkin's lymphoma in Marines who went to Vietnam when compared to those who didn't go to Vietnam was 2.10 based on 35 observed cases. This is significantly greater than 1 using the Mantel Haenszel(ll) chi-square statistic. Case control analyses (16) were carried out to examine the relationship between mortality from non-Hodgkin's lymphoma (NHL) to service in Vietnam. The controls for these analyses were all cardiovascular deaths (ICDA-8 codes: 390.0-458.9) among Marines who did not go to Southeast Asia. These were chosen because in this mortality study and several others (12,18,19,20 ) no association was found between Vietnam service and cardiovascular mortality. Also, no biologic hypothesis exists suggesting a relationship between service in Vietnam and cardiovascular mortality. In case control analysis, if the exposure of interest is not a risk factor for the selected control group the standardized mortality odds ratio (SMOR) is equivalent to the SMR. All SMOR analyses were standardized by age. AGE SPECIFIC MORTALITY ODDS RATIOS FOR NON-HODGKIN'S LYMPHOMA MARINES Age Group OBS MOR (LCI,UCI) 20-29 30-39 40-49 50-59 60+ Overall 7 23 2 2 1 35 2.28 5.11 0.28 0.95 1.58 2.08 (0.64,8.18) (1.51,17.3)* (0.04,2.03) (0.08,10.7) (0.05,48.8) (1.21,3.60) * p-value for Mantel-Haenszel chi square < .01. (Cardiovascular deaths among Marines who did not go to Southeast Asia are the control population.) Marines age 30 through 39 at death had a mortality odds ratio of 5.11 with a lower 95% level of 1.51. The overall SMOR for Marines was 2.08 with a lower 95 percent confidence level of 1.21. The data collected from the military records included information on military occupational speciality and dates of service in Vietnam. The most usual tour of duty in Vietnam was 13 months for the Marines. If the difference between the date the veteran first went to Vietnam and the date he last left Vietnam was greater than 13 months for a Marine there is a strong possibility that the veteran served more that one tour of duty in Vietnam. Marines thus classified as having one tour had a significantly elevated SMOR of 2.44 for NHL. �18 STANDARDIZED MORTALITY ODDS RATIOS FOR NON-HODGKIN'S LYMPHOMA AMONG MARINES BY LENGTH OF SERVICE IN VIETNAM OBS 1 tour 1+ tours 20 15 SMOR (LCI,UCI) 2.44 (1.33,4.47) 1.74 (0.93,3.27) (Cardiovascular deaths among Marines who did not go to Southeast Asia are the control population) Herbicides were used in Vietnam in greatest volume in 1967 through 1969. The standardized mortality odds ratios are highest in both groups among those who first went to Vietnam during that time interval. The elevation is significant in the Marines but not in the Army personnel. STANDARDIZED MORTALITY ODDS RATIOS FOR NON-HODGKIN'S LYMPHOMA AMONG MARINES BY FIRST YEAR IN VIETNAM OBS 1965-66 1967-69 1970+ 16 17 2 SMOR(LCI,UCI) 1.76 (1 .02, 4. 95) 2.54 (1 .22, 5. 25) 1.88 (0 .42, 8. 36) (Cardiovascular deaths among Marines who did not go to Southeast Asia are the control population) Military Occupation Specialty Codes (MOSCs) were categorized as combat troops, direct support of combat troops, and indirect support of combat troops. A description of the categories of MOSC appear in the Appendix B-2. Combat related MOSCs had the highest SMOR for military occupations at 3.25. The SMOR by MOSC decreases from combat to indirect support assignments. STANDARDIZED MORTALITY ODDS RATIOS FOR NON-HODGKIN'S LYMPHOMA AMONG MARINES BY MOSC GROUPS OBS Combat Direct Support Indirect Support SMOR(LCI,UCI) 17 11 7 3.25 (1.45,7.32) 1.70 (0.89,3.23) 1.37 (0.94,2.25) (Cardiovascular deaths among Marines who did not go to Southeast Asia are the control population) �19 Several studies have revealed an association between herbicide use and non-Hodgkin's lymphoma. A report of a recent population based case control study done by the National Cancer Institute (21) presents an odds ratio of 2.2 ( Confidence interval:1.2-4.1) for farmers ever using phenoxyacetic acids. A matched case control study done in Sweden (xx) of malignant lymphomas (Hodgkin's and NHL ) found a relative risk of 4.8 for those exposed to phenoxy acids. Because agent orange and other herbicides used in Vietnam contained phenoxyacetic acids, an attempt will be made to try to relate the location of the units in which these men served to the known herbicide spray patterns. STATE VIETNAM VETERANS MORTALITY STUDIES Wisconsin, West Virginia, New York and Massachusetts (12,18,20,17) have done mortality studies of Vietnam Era veteran. The Air Force "Ranch Hand Study" (19) includes a cohort mortality analysis. Although the results of these studies are suggestive of possible excess mortality for some causes of death, they are not strictly comparable to the data given in this report. They differ from this study in several ways. They included all Vietnam era veterans from all branches of services, some used only men with service "in country" Vietnam; other chose all who served in Southeast Asia as service in Vietnam. Wisconsin, New York and West Virginia used other Vietnam era veterans, all other state veteran and non veterans as comparison populations for SPMR analyses. Massachusetts used all other state veterans who applied for veteran bonuses and served between 1958 and 1973 as their comparison group. In the Ranch Hand Study, a standardized mortality ratio (SMR) analysis was done comparing "Ranch Banders" (i.e. men who were involved with herbicide spraying) with cargo flight crews who did not handle herbicides. The findings reported by the state studies are somewhat inconsistent with each other and with what was found here. For example, Wisconsin and Massachusetts both seen to have an excess of soft tissue sarcoma among those who went to Vietnam when compared to all other veterans. Since each state used somewhat different methods and populations, a series of tables comparable to those done for the total study population was done for each of these states using all U.S. veterans who did not serve in Southeast Asia as a comparison group for veterans from each state who had served in Vietnam. Only tables for white servicemen were done to illustrate the differences one might see when comparing more homogeneous groups and holding the comparison group constant. �20 SPMRs FOR SELECTED EXTERNAL CAUSES OF DEATH BY STATE WHITE SERVICEMEN WI NY OBS All ext causes Motor veh ace. Ace. poison Suicide All malignancies Ca-intestines Ca-soft tissue Ca-testes Cirrhosis-alcholic Cirrhosis-other 412 137 31 70 79 10 1 1 26 20 O/E 0.83 .73* 1 .65* .64* 1 .01 1.87* 0.70 0.23 3 .17 1.95* OBS O/'E 214 1.04 105 1. 34* 4 0. 45 49 1. 08* 34 1.03 3 1. 31 3 5. 11* 5 2. 86* 4 1. 01 1 0.23 M[A OBS 0/E 172 48 27 38 26 1 2 2 2 9 0.99 0.74* 3 .67* 0.98 0.82 0.44 3 .81* 1.40 0.56 2.10* Vi'V OBS 0/E 11 0.96 7 0.92 5 0.92 0 0.60* 30 0.92 2 0.85 1 1.95 2 1.69* 7 1.89 3 0.64 * P<0.05 for chi-square with 1 degree of freedom All U.S. veterans who did not go to Vietnam were the comparison group Cause of death groups consistent with grouping used in other tables In the largest category of deaths, that for accidents, suicide and trauma, great variation is seen among the states. When some states seem to have significant excess deaths for a particular subgroup another may show significant deficits for the same subgroup. Similar results can be found among other causes of death. These data are shown for selected causes where at least one state's data indicate a significant excess. Whether these variations among the states are the result of sampling error or whether they suggest an underlying difference in the mortality experience among states is not obvious. There were sufficient deaths from California in the study population to permit a comparison of SPMRs one could observe using different comparison populations. Using deaths from external causes as an example, it can be seen that white California veterans as a group have a different mortality experience then than of all white U.S. servicemen in the study population. When using all U.S. white veterans from the study population with no service in Southeast Asia as a comparison group, the white California veterans with no Vietnam service have significantly more deaths from accidental poisoning (drug overdose) and relatively more suicides than other veterans. When the California veterans with Vietnam service are compared to Vietnam era veterans from California who did not serve in Vietnam, these excesses diminish. Suicides are fewer than expected and the deaths from drug overdose are only slightly more than expected. �21 COMPARISONS OF SPMR'S FOR SELECTED CAUSES OF DEATH IN CALIFORNIA DBS All ext. causes 1232 Motor veh. ace. 446 Ace. poisoning 97 Suicides 280 All malignancies 245 Ca-intestines 11 Ca-soft tissue 18 Ca-testes 17 Cirrhosis-alcoholic 48 Cirrhosis-other 45 O/E1 1.05* 1.00 2.17* 1.07 .93 .56 .97 1.77* . «9.14* 1.48 0/E2 1.02 0.99 1.06 0.92 .94 .42 .56 2.87* 1.14 1.06 * p<0.05 for chi-square with 1 degree of freedom 0/E1 = All U.S. veteran who did not serve in Vietnam used as a comparison group. 0/E2 = California veterans who did not serve in Vietnam used as a comparison group. CONCLUSIONS The results of the preliminary analysis of some of the data from the Vietnam Veterans Mortality Study indicate that veterans who served in Vietnam were more likely to die from accidents, violence, or trauma than their counterparts who did not serve in Southeast Asia. In particular, they were more likely to die from motor vehicle accidents or from drug overdoses. There was no evidence that there are excess numbers of suicides among those who served in Vietnam. The SMPRs suggest that there might be some causes of death that should be investigated further. One of these causes, non-Hodgkins lymphoma, was submitted to further analysis. The excess of NHL-among Marines are seen using the U.S. mortality data as a comparison. Standardized mortality odds ratios using cardiovascular deaths among all Marines who did not serve in Vietnam as a control, indicate elevated risks for Marines with combat related military occupational speciality codes and for Marines who served in Vietnam for the first time between 1967 and 1969. The data collection for this study has been extended to include veteran deaths from 1982-1984. When these data are available for analysis they will be added to the data presented here and re-analyzed. One such analysis will look at the location of the unit in which a man served in Vietnam relative to the herbicide spray patterns recorded by the Air Force. �REFERENCES 1. Beebe, G.W. and Simon, A.H. Ascertainemnt of mortality in U.S. veteran population. Amer. Jour, of Epid.:89:636-643. 2. Seltzer, C. C. and Jablon, S. Effects of selection on mortality. Amer. Jour. Bpid.:100:367-370. 3. Seltzer, C. C. and Jablon, S.H. Army rank and subsequent mortality by cause: 23 year follow-up. Amer. Jour. Epid.: 105:559-566 4. Robinette, C. D. and Fraumini, J.F. Asthma and subsequent mortality in World War II veterans. J. Chron. Dis. :31:619-624 5. Ascertainment of Mortality in the U.S. Vietnam Veteran Population. Report of contract V101 (93) P-937, National Academy of Sciences Commission on the Life Sciences Medical Follow-up Agency, Washington, DC., 1985. 6. Selected Manpower Statistics, Fiscal Year 1981, Directorate for Information, Operations, and Reports, Department of Defense. 7. Protocol for the Vietnam Veterans Mortality Study. Office of Reports and Statistics, Statistical Policy and Research Service, Veterans Administration, Washington,DC., 1983. 8. Eighth Revision International Classification of Disease, Adapted for Use in the United States. Public Health Service Washington, DC. 9. Instructions for Medical Classification of Death Records for Automated Classification of Medical Entities, 1976-1978 U.S.Dept. of Health .Education and Welfare, Public Health Service, Washington DC, 1977 10. 1979 National Survey of Veterans. Reports and Statisics Service, Office of the Controller, Veterans Admnistration, Washington, DC, 1980. 11. Mantel, N. and Haenszel, W. "Statistical aspects of the analysis of data from retrospective studies of disease," Journal of the National Cancer Institute:28:947 (1962) 12. Wisconsin Vietnam Veteran Mortality Study, Final Report. State of Wisconsin Department of Health and Social Services, Division of Health, 1986. �13. Kardell, L., et al. "Malignant Lyntphoma and exposure to Chemicals Especially Organic Solvents, Chlorophenols and Phenoxy Acids: A Case-Control Study". British Journal of Cancer:43, 169-76. 1981. 14. Vital Statistics of the United States, 1978, Mortality. U.S. Dept. Health and Human Services, Public Health Service, National Center for Health Statistics, Rockville, MD 15. SEER Program Report, Cancer Incidence and Mortality in the United States 1973-1981. NIH Publication 85-1837, U.S. Dept. Health and Human Services, Public Health Service ,National Cancer Institute, Bethesda, MD, 1984 16. Miettinen, 0. £• and Wang, J. "An Alternative to the Proportionate Mortality Ratio". Amer.Jour. of Epid.:114 : 144-48, 1981. 17. Mortality Patterns Among Vietnam Veterans in Massachusetts 1972-83. Massachusetts Office of Commissioner of Veterans Services, Agent Orange Program, Massachusetts Department of of Public Health, Division of Health Statistics, 1985. 18. West Virginia Vietnam Bra Veterans Mortality Study. West Virginia Residents 1968-1983, Preliminary Report. West Virginia Health Department, 1986. 19. An Epidemiologic Investigation of Health Effects in Air Force Personnel Following Exposure to Herbicides, Baseline Mortality Study.The Surgeon General, United States Air Force. June 30, 1983. 20. Mortality Patterns Among Vietnam and Vietnam Era Veterans, New Yor State Department of Health, draft report submitted to the Veterans Administration for review, 1983. 21. Hoar, 8. K., et al. "Agricultural Herbicide Use and Risk of Lymphoma and Soft-Tissue Sarcoma". Journal of the American Medical Association : 1986. �APPENDIX A �APPENDIX A-l The National Research Council (NRC) tested the completeness of BIRLS as a source of Vietnam era veterans deaths by selecting a sample of men who died in 1980 from the vital statistics records of 8 states. The names and social security numbers of the men were matched against the military records files at NPRC to ascertain military service; 3583 Vietnam era veterans were identified. Of these 3583, 88.8% were found to be recorded in BIRLS as dead; 5.3% were found in BIRLS with no death recorded and 5.9% were not found in BIRLS. The researcher used the social security number and name given on the death certificate to search the BIRLS file. It was the experience of the investigators in the VA's Vietnam Veterans Mortality Study that some veterans had more than one social security number or the name found on the death certificate was not the name in the BIRLS file. It was also found that some men* particularly those who served in the Vietnam era, may have h«d more than one BIRLS file. About the time the military switched from assigning service number to using social security numbers as the service number, the VA changed from assigning claims file numbers to using social security numbers as a claim file number. As a result of change in the VA's method of assigning claims file numbers, some veterans were found to have a BIRLS file under a claim number and another under a social security number. If the record filed under a claim number did not contain the social security number the second file might not be found by the method used by the National Research Council. This would be a particular problem for men with common names. Both of these two records may or may not have recorded the death. Frequently when these cases were encountered in this mortality study, one BIRLS record would have a death date and the other would not. Unfortunately no record was kept of the relative frequency of this problem. An attempt was made to evaluate the findings of the NRC report using materials that were available in the mortality study. All cases for whom a death certificate was available and for whom the military service history was known were searched for cases where: the social security number on the death certificate did not match the social security number in BIRLS; the name in BIRLS did not match the name on the death certificate; the birth date on BIRLS did not match the birth date (or age) on the death certificate. For 9.5% of all certificates the social security number of the death certificate did not match the social security number in BIRLS; for 51% of those with unmatched social security numbers, the names and/or birth dates did not match. These data suggest that 4.8% to 9.5% of the deaths BIRLS might not be found using the methods used by substract these number from the 11.2% not found by 1.7% to 6.6% of Vietnam era veterans may not be in known to be in NRC. If we NRC then perhaps BIRLS. �APPENDIX A-2 CONSULTANTS: Gilbert W. Beebe, PH.D., Clinical Epidemiology Branch, National Cancer Institute, NIH, Bethesda, MD. Chin Long Chaing, PH.D., Professor of Biostatistics, School of Public Health, University of California, Berkeley, CA. Joseph L. Fleiss, PH.D., Professor of Biostatistics, School of Public Health, Columbia University, New York, NY. Bernard G. Greenberg,PH.D., Professor of Biostatistiow, School of Public Health, University of Noeth Carolina, NC. Abraham M. Lilienfeld, M.D. Professor of Epidemiology, Johns Hopkins School of Hygiene and Public Health, Baltimore, MD. Richard Monson, M.D., School of Public Health, Harvard University, Boston, MA. �The 9.5% of deaths that night have been lost were arrayed by cause of death and Vietnam service. No differences were seen before these two groups. Therefore we feel that the BIRLS did provide a fairly complete roster of Vietnam era veteran deaths for this study. �APPENDIX B �APPENDIX B-l M . 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Duty. ll_l_l_l_l_l_l_l_l_l ran 3T) <xtr"~"~"~" 1 1 1 (an OD 1 on 1 1 L. —'—'—'—I—'— — —L.i— —'—'—I—' """' LJ—l— —l—l—l—l—l— —l—l—l—!_'—l—i—l—l—'_l I—I I l_l_I I l_l_l_l_l_l—I—I—I—I CO Tr t ftm 1 T* "• <mi C?Di fZD""i i i i i LJ— —1—1—'—' o») '—'—'—' '»*"• **»' LJ—'—'—'_'_•_'_<—i—i i i i i "~ ~" "~ ~" (an LJ_ on 1 '— '_' '— i i— i i—i—i— LJ— '— L.L-' 'w* LJ—L.'—'—'—i—L-'—'—L-1—' ' '—»— '— »— L.L.' '_'_' '—'—'—'~"'— i—'— '_'— '— '—LJ—«— i I— >—i— '—'— I—I—i—'—i L ~™ ' �APPENDIX B-2 Explanation of MOS Codes The Military Occcupational Speciality code at time of discharge was obtained from the military record for all persons in the study. If a man had served in Southeast Asia his MOS and principle duty for each assignment in Vietnam was abstracted. The MOS coding scheme for the Army personnel had changed during the period of service covered by the study. Translation tables were built using materials supplied by the U.S. Army and Joint Service Environmental Support Group. Some codes could not be translated from the materials supplied. Some codes were missing. The codes are more complete for those'"who served in Vietnam because the description of the principal duties or title made it possible to assign a MOSC at least the 2-digit level. It was noticed during the review of these codes that for the men who had served in Vietnam the MOS at their first assignment in Vietnam was more descriptive of the type of duties assigned to him during his tour of duty in Vietnam than his MOS at discharge. After consultation with staff at the Environmental Support Group it was decided to use the MOS of the first assignment in Vietnam to characterize the man's duties in Vietnam. The MOSC for the men with service in Vietnam grouped into three categories, combat, direct support, and indirect, support based on probability of combat. (These are the same groupings used in the Wisconsin Vietnam veterans mortality study.) The definitions of these groups are: Combat: Occupations such as infantry, artillery, armor, etc., whose primary duties and objectives involve direct offensive and defensive actions against an armed hostile enemy force. Direct Support: Occupations whose primary function is the direct support of combat troops and whose duties and objectives may at times involve limited direct and extensive indirect combat with an armed hostile force, such as counterintelligence, logistics, engineering, ordnance disposal, etc. Indirect Support: Occupations such as musicians, data processing, legal services, food services, etc., whose primary function is indirect support of combat and direct support occupations and whose duties and objectives do not involve direct or indirect contact with an armed hostile force. Three coding schemes are used for Army personnel: one for enlisted men, one for officers, and another for warrant officers. The coding scheme used by the Marine Corps is different from that of the Army. �ARMY CODES The coding schemes for both the officers and enlisted men use the first two characters of the code to designate an occupational field (i.e., medical,infantry, intelligence). The first three digits are used to designate an occupational field for army warrant officers. Army enlisted MOS codes are five characters long. The first two characters represent a career group; the third character, which is alpha, indicates a specialty; the fourth number is the skill level or grade and the fifth represents special qualifications such as "Ranger" or "Special Forces." An example of an Army MOS and its breakdown is as follows: MOS « 91B2s - 91 represents the medical career group. B, the third alpha character, represents the specialty (medical specialist). 2, the fourth character, indicates the grade or rank. 8, the fifth character, indicates special qualification for special forces. The occupational codes for officers are slightly different in that a three character code is used. For example, 11A indicates infantry officer. Army Enlisted MOS Divided Into Combat, Direct Support and Indirect Support Army Combat: Direct Support: 11, 12, 13, 14, 15, 16, 17, 19 21, 22, 23, 24, 25, 26, 31, 36, 45, 54, 55, 61, 62, 63, 64, 67, 68, 90, 95, 96, 97, 98 Indirect Support: 32, 33, 34, 35, 41, 42, 43, 44, 46, 51, 52, 53, 56, 57, 65, 66, 70, 71, 72, 73, 74, 75, 76, 81, 82, 83, 84, 91, 92, 93, 94, 00, 01, 02, 03, 04, 05, 09 Army Officer MOS Divided Into Combat, Direct Support and Indirect Support Army Combat: 10, 11, 12, 13, 14, 15, 21, 33 Direct Support : 19, 25, 26, 27, 28, 30, 31, 34, 35, 36, 37, 48, 54, 74, 75, 81, 91, 93, 94, 95 Indirect Support: 00, 40, 41, 42, 43, 44, 45, 46, 49, 51, 52, 53, 55, 56, 60, 61, 62, 63, 64, 65, 66, 67, 68, 70, 71, 72, 73, 82, 92, 97 �Marine Codes The military occupational speciality codes for Marines are similar for officers and enlisted men. They codes are based on a four-digit system. For example: Marine MOS 0311 .rifleman; MOS 0302 infantry officer. Marine Enlisted MOS Divided Into Combat, Direct Support and Indirect Support Combat: 03, 08, 18, 86, 87, XX Direct Support: 02, 13, 14, 21, 23, 25, 26, 35, 57, 60, 61, 62, 63, 64, 65, 70, 72, 81, 82, 85, 99 Indirect Support: 01, 04, 11, 15, 28, 30, 31, 33, 34, 40, 41, 43, 44, 46, 55, 58, 59, 68, 73, 80, 84, 88, 89, 90, 98 Marine Officer Mos Divided into Combat, Direct support, and Indirect Support Combat: 03, 08, 18, 75 Direct Support: 02, 04, 13, 14, 20, 25, 28, 35, 57, 58, 59, 62, 65, 67, 71, 73, 99 Indirect Support: 01, 15, 25, 28, 30, 31, 32, 33, 34, 40, 41, 43, 44 46, 49, 55, 60, 68, 70 �APPENDIX C �A SUIXAIT OF TABLES C1-C36 CAICEI UJOI OIGAI STSTIIS CI1CDUT01T, IESFIIATOIT AID DIGESTIVE STSTEIS 1CCID1HS, SUICIDE, VIOL1IC1 AID THOU fllfBf Our I SIT! OIS 0/1 SILICTED DISUSES ACCDRS, HOLmAUIA ion AIIY in nuns OIS 0/1 SELECTED DISEASES 13164 -1.03 CAIDIAC U1EST OIS 0/1 EITSIIAL CADSES 273 1.23 IIOTOI TEI ACCDRS ion. nus ACC. IACC. POISOIII6S ACCDRS, IIOLWAUIA low 1.03 KOMI Til ACCDRS ion. nus ACC. un IACC. NIIOIIKS OIS 0/1 4197 1.05 6io us 511 1.14 3SI4 1.05 493 1.36 461 1.15 II1ICI IAIIIIS . LU1G lOMDUIS LYIPHOI1 130 1.51 35 2.10 _______ ____._..__.____._.._______. KCDRS, TIOimiQIi 11074 1.02 CAIDIAC AUEST I8ITE IACI loniiTi inSCQLOKOIfECTIU TIS 14 3.i2 ALL Onn CAUlIi 2790 i.of IKCDRS, TIOL+TUni nn uccom, vioLmiuu 32(( 1.02 CAIDIAC AIIIST EILISTED IN orricni OTB CA 3) 1.2! ciiDioiTOPini UIT COI1AT IOSC UPPE1 1SSP 11 2,35 ALL Onil CAUSES ICOIllAT 1 STATUS I mill COIBiT KOSC IIElfOOS SYS+SEISE 016 17 2.21 IirLUEHAiPIEtniOIIA 212 1.23 IIOTOI Til ACCDRS (On. THIS ACC. IACC. POISOIIKf 42(4 1.04 54S 1.11 4(4 1.13 3977 1.13 IIOTOI III ACCDRS 1 (32 1.11 249 1.25 IIOTOI TEI ACCDRI IACC. POISOIIKS IALL On ACC./IMOTT K (.21 ion. TUII ACC. 4((4 1.02 IALL «I ACC./XWnT IMIICIDI IS 2.39 HOMICIDE 4757 1.06 5(1 1.15 2S15 1.05 114 i.(( 7(2 1.09 (31 1.09 2I( 1.24 �APPENDIX C DEATHS FROM CANCERS TABLE TABLE TABLE TABLE TABLE TABLE TABLE TABLE C-l C-2 C-3 C-4 C-5 C-6 C-8 C-9 - ALL ALL ALL ALL ALL ALL ALL ALL CASES ARMY MARINES WHITE SERVICEMEN NON-WHITE SERVICEMEN ENLISTED MEN ENLISTED ARMY IN VIETNAM,COMBAT MOSC VS. NON-COMBAT MOSC ENLISTED MARINES IN VIETNAM,COMBAT MOSC VS. NOW-COMBAT MOSC SELECTED CAUSES OF DEATH BY ORGAN SYSTEM TABLE TABLE TABLE TABLE TABLE TABLE TABLE TABLE TABLE C-10 C-ll C-12 C-13 C-l4 C-l5 C-16 C-17 C-18 - ALL ALL ALL ALL ALL ALL ALL ALL ALL CASES ARMY MARINES WHITE SERVICEMEN NON-WHITE SERVICEMEN ENLISTED MEN OFFICERS ENLISTED ARMY IN VIETNAM, COMBAT MOSC VS. NON-COMBAT MOSC ENLISTED MARINES IN VIETNAM, COMBAT MOSC VS. NON-COMBAT MOSC DEATHS FROM SELECTED DISEASES OF THE CIRCULATORY, RESPIRATORY AND DIGESTIVE SYSTEMS TABLE TABLE TABLE TABLE TABLE TABLE TABLE TABLE TABLE C-l9 C-20 C-21 C-22 C-23 C-24 C-25 C-26 C-27 - ALL ALL ALL ALL ALL ALL ALL ALL ALL CASES ARMY MARINES WHITE SERVICEMEN NON-WHITE SERVICEMEN ENLISTED MEN OFFICERS ENLISTED ARMY IN VIETNAM, COMBAT MOSC VS. NON-COMBAT MOSC ENLISTED MARINES IN VIETNAM, COMBAT MOSC VS. RON-COMBAT MOSC �DEATHS FROM ACCIDENTS, SUICIDES AND TRAUMA TABLE TABLE TABLE TABLE TABLE TABLE TABLE TABLE TABLE C-28 C-29 C-30 C-31 C-32 C-33 C-34 C-35 C-36 - ALL ALL ALL ALL ALL ALL ALL ALL ALL CASES ARMY MARINES WHITE SERVICEMEN NON-WHITE SERVICEMEN ENLISTED MEN OFFICERS ENLISTED ARMY IN VIETNAM, COMBAT MOSC VS. NON-COMBAT MOSC ENLISTED MARINES IN VIETNAM,COMBAT MOSC VS. NON-COMBAT MOSC �TABLE C-l DEATHS FROM CANCERS (140-208, 230-239) ALL CASES OBSERVED EXPECTED 0/E M-H CHI-SQUARE 1.00 1.00 1.02 1.06 0.99 1.06 0.95 0.97 1.09 0.93 0.91 1.00 0.96 1.16 0.74 0.87 0.98 0.60 0.59 0.96 1.19 0.72 0.92 1.03 0.239 0.009 0.114 0.306 0.000 0.144 0.342 0.000 0.660 0.131 0.157 0.175 0.134 0.780 1.545 0.389 0.001 9.697* 2.696 0.385 0.801 0.292 1.437 0.196 CAUSE ALL OTHER CAUSES (000-136 , 210-228 , 240-E989) CA - BUCCAL (140-149) CA - ESOPHAGUS (150) CA - STOMACH (151) CA - INTESTINES & OTHER 01 (152-154,158,159) CA - LIVER, BILE DUCTS (155-156) CA - PANCREAS (157) CA - UPPER RESPIRATORY (160-161) CA - LUNG (162) CA - BONE (170) CA - SOFT TISSUES (171) CA - MELANOMA OF THE SKIN (172) CA - PROSTATE (185) CA - TESTIS (186) CA - BLADDER (188) CA - KIDNEY (189) CA - BRAIN (191) CA - OTHER NERVOUS SYSTEM (192) CA - THYROID & ENDOCRINE (193-194) CA - NON-HODGKINS LYMPHOMA (200,202) CA - HODGKINS DISEASE (201) CA - MULTIPLE MYELOMA (203) CA - LEUKEMIA (204-207) OTH CA ( 163 , 173-4 ,187,190, 195-9 , 208-9 , 230-9 ) 21262 84 51 105 242 40 100 30 762 38 38 181 35 116 13 68 141 54 19 143 114 20 244 335 21265 84 50 99 244 38 105 31 697 41 42 180 36 100 18 78 143 90 32 150 96 28 266 324 TOTAL NUMBER OF CASES OBSERVED « 24235 EXPECTED NUMBERS ARE BASED UPON 26685 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM �TABLE C-2 DEATHS PROM CANCERS (140-208, 230-239) ALL ARMY OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-136 , 210-228 , 240-E989) CA - BUCCAL (140-149) CA - ESOPHAOUS (150) CA - STOMACH (151) CA - INTESTINES & OTHER 01 (152-154,158,159) CA - LIVER, BILE DUCTS (155-156) CA - PANCREAS (157) CA - UPPER RESPIRATORY (160-161) CA - LUNG (162) CA - BONE (170) CA - SOFT TISSUES (171) CA - MELANOMA OF THE SKIN (172) CA - PROSTATE (185) CA - TESTIS (186) CA - BLADDER (188) CA - KIDNEY (189) CA - BRAIN (191) CA - OTHER NERVOUS SYSTEM (192) CA - THYROID & ENDOCRINE (193-194) CA - NON-HOD6KINS LYMPHOMA (200,202) CA - HODGKINS DISEASE (201) CA - MULTIPLE MYELOMA (203) CA - LEUKEMIA (204-207) OTH: CA (163,173-4,187,190,195-9,208-9,230-9) 17256 17173 71 46 88 209 34 82 29 632 27 30 145 30 90 9 55 116 43 15 108 92 18 202 281 TOTAL NUMBER OF CASES OBSERVED • 19708 EXPECTED NUMBERS ARE BASED UPON 22904 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OP FREEDOM 77 37 78 217 33 94 25 614 33 30 142 32 80 16 63 120 78 25 133 79 23 229 273 1.00 0.92 1.24 1.12 0.96 1.04 0.87 1.14 1.03 0.82 0.99 1.02 0.92 1.12 0.56 0.87 0.97 0.55 0.59 0.81 1.16 0.77 0.88 1.03 1.631 0.060 0.813 0.677 0.062 0.062 0.805 0.183 0.000 0.286 0.008 0.118 0.100 0.557 2.353 0.242 0.003 10.503* 2.312 2.761 0.388 0.188 1.809 0.319 �TABLE C-3 DEATHS FROM CANCERS (140-208, 230-239) ALL MARINES OBSERVED EXPECTED 0/E M-H CHI-SQUARE 0.98 1.95 0.39 0.82 1.26 1.21 1.63 0.18 1.58 1.38 0.71 0.94 1.29 1.29 2.41 0.89 1.07 0.93 0.57 2.10 1.33 0.45 1.14 1.07 3.831 1.038 2.148 0.318 0.632 0.196 0.582 2.844 5.800* 0.051 1.160 0.067 0.059 0.239 0.268 0.210 0.005 0.050 0.384 6.116* 0.679 0.186 0.019 0.053 CAUSE ALL OTHER CAUSES (000-136 , 210-228 , 240-E989 ) CA - BUCCAL (140-149) CA - ESOPHAGUS (150) CA - STOMACH (151) CA - INTESTINES & OTHER 01 (152-154,158,159) CA - LIVER, BILE DUCTS (155-156) CA - PANCREAS (157) CA - UPPER RESPIRATORY (160-161) CA - LUNG (162) CA - BONE (170) CA - SOFT TISSUES (171) CA - MELANOMA OF THE SKIN (172) CA - PROSTATE (185) CA - TESTIS (186) CA - BLADDER (188) CA - KIDNEY (189) CA - BRAIN (191) CA - OTHER NERVOUS SYSTEM (192) CA - THYROID & ENDOCRINE (193-194) CA - NON-HODGKINS LYMPHOMA (200,202) CA - HODGKINS DISEASE (201) CA - MULTIPLE MYELOMA (203) CA - LEUKEMIA (204-207) OTHI CA (163,173-4,187,190,195-9,208-9,230-9) 4006 13 5 17 33 6 18 1 130 11 8 36 5 26 4 13 25 11 4 35 22 2 42 54 TOTAL NUMBER OF CASES OBSERVED - 4527 EXPECTED NUMBERS ARE BASED UPON 3781 OBSERVATIONS IN COMPARISON OROUF * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM 4092 7 13 21 26 5 11 6 83 8 11 38 4 20 2 15 23 12 7 17 17 4 37 51 �TABLE C-4 DEATHS PROM CANCERS (140-208, 230-239) ALL WHITE SERVICEMEN OBSERVED EXPECTED 0/E M-H CHI-SQUARE 1.00 1.05 0.87 0.99 1.04 1.31 0.97 0.94 1.09 0.99 0.92 0.98 0.71 1.22 0.85 0.79 1.00 0.62 0.59 0.89 1.22 0.65 0.89 0.99 0.797 0.085 0.157 0.018 0.270 0.882 0.072 0.071 0.371 0.018 0.194 0.046 1.475 1.180 0.737 0.856 0.014 8.107* 1.893 1.436 1.001 0.689 1.581 0.027 CAUSE ALL <OTHER CAUSES (000-136, 210-228 , 240-E989) CA - BUCCAL (140-149) CA - ESOPHAGUS (150) CA - STOMACH (151) CA - INTESTINES & OTHER GI (152-154,158,159) CA - LIVER, BILE DUCTS (155-156) CA - PANCREAS (157) CA - UPPER RESPIRATORY (160-161) CA - LUNG (162) CA - BONE (170) CA - SOFT TISSUES (171) CA - MELANOMA OF THE SKIN (172) CA - PROSTATE (185) CA - TESTIS (186) CA - BLADDER (188) CA - KIDNEY (189) CA - BRAIN (191) CA - OTHER NERVOUS SYSTEM (192) CA - THYROID & ENDOCRINE (193-194) CA - NON-HODGKINS LYMPHOMA (200,202) CA - HODGKINS DISEASE (201) CA - MULTIPLE MYELOMA (203) CA - LEUKEMIA (204-207) OTH CA (163,173-4,187,190,195-9,208-9,230-9) 16697 16671 64 35 75 193 29 85 25 616 34 34 176 23 110 12 55 128 50 15 120 101 16 212 272 TOTAL NUMBER OF CASES OBSERVED - 19177 EXPECTED NUMBERS ARE BASED UPON 21335 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM 61 40 75 185 22 87 27 565 34 37 179 33 90 14 70 128 81 25 134 83 24 238 273 �TABLE C-5 DEATHS FROM CANCERS (140-208, 230-239) ALL NON-WHITE SERVICEMEN OBSERVED EXPECTED 0/E M-H CHI-SQUARE 0.99 0.87 1.65 1.27 0.84 0.70 0.84 1.16 1.11 0.60 0.87 3.36 3.21 0.61 0.29 1.59 0.86 0.44 0.58 1.50 1.03 1.24 1.13 1.25 0.723 0.103 1.917 0.755 1.008 0.512 0.764 0.389 0.383 0.419 0.007 2.582 3.441 0.528 1.383 0.351 0.215 1.755 0.820 2.117 0.015 0.408 0.004 2.133 CAUSE ALL OTHER CAUSES (000-136 , 210-228 , 240-E989 CA - BUCCAL (140-149) CA - ESOPHAGUS (150) CA - STOMACH (151) CA - INTESTINES & OTHER 61 (152-154,158,159) CA - LIVER, BILE DUCTS (155-156) CA - PANCREAS (157) CA - UPPER RESPIRATORY (160-161) CA - LUNG (162) CA - BONE (170) CA - SOFT TISSUES (171) CA - MELANOMA OF THE SKIN (172) CA - PROSTATE (185) CA - TESTIS (186) CA - BLADDER (188) CA - KIDNEY (189) CA - BRAIN (191) CA - OTHER NERVOUS SYSTEM (192) CA - THYROID & ENDOCRINE (193-194) CA - NON-HODGKINS LYMPHOMA (200,202) CA - HODGKINS DISEASE (201) CA - MULTIPLE MYELOMA (203) CA - LEUKEMIA (204-207) OTH! CA (163,173-4,187,190,195-9,208-9,230-9) 4565 20 16 30 49 11 15 5 146 4 4 5 12 6 1 13 13 4 4 23 13 4 32 63 4595 23 10 24 59 16 18 4 132 7 5 1 4 10 3 8 15 9 7 15 13 3 28 50 TOTAL NUMBER OF CASES OBSERVED - 5058 EXPECTED NUMBERS ARE BASED UPON 5350 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM �TABLE C-6 DEATHS FROM CANCERS (140-208, 230-239) ALL ENLISTED MEN OBSERVED EXPECTED 0/E M-H CHI-SQUARE 1.00 0.95 1.00 1.08 0.96 1.00 0.89 1.24 1.10 0.89 0.99 1.00 1.30 1.16 0.70 0.81 0.97 0.49 0.46 1.00 1.20 0.55 0.91 0.99 0.957 0.136 0.150 0.392 0.122 0.029 0.953 0.689 0.785 0.327 0.001 0.113 0.564 0.932 1.612 0.911 0.105 14.323* 4.965* 0.077 0.677 1.599 1.280 0.065 CAUSE ALL OTHER CAUSES (000-136 , 210-228 , 240-E989) CA - BUCCAL (140-149) CA - ESOPHAGUS (150) CA - STOMACH (151) CA - INTESTINES & OTHER GI (152-154,158,159) CA - LIVER, BILE DUCTS (155-156) CA - PANCREAS (157) CA - UPPER RESPIRATORY (160-161) CA - LUNG (162) CA - BONE (170) CA - SOFT TISSUES (171) CA - MELANOMA OF THE SKIN (172) CA - PROSTATE (185) CA - TESTIS (186) CA - BLADDER (188) CA - KIDNEY (189) CA - BRAIN (191) CA - OTHER NERVOUS SYSTEM (192) CA - THYROID & ENDOCRINE (193-194) CA - NON-HODGKINS LYMPHOMA (200,202) CA - HODGKINS DISEASE (201) CA - MULTIPLE MYELOMA (203) CA - LEUKEMIA (204-207) OTH CA (163,173-4,187,190,195-9,208-9,230-9) 19962 71 40 93 206 34 80 19937 75 29 660 34 37 153 29 110 12 57 117 38 14 131 104 14 219 284 TOTAL NUMBER OF CASES OBSERVED - 22528 EXPECTED NUMBERS ARE BASED UPON 25022 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM 40 86 214 34 90 23 598 38 37 153 22 95 17 70 121 78 30 131 87 25 239 287 �TABLE C-7 DEATHS FROM CANCERS (140-208, 230-239) ALL OFFICERS OBSERVED EXPECTED 0/E M-K CHI-SQUARE 1.00 1.26 0.99 0.96 1.38 2.22 0.97 0.00 1.20 1.44 0.26 0.88 0.61 1.07 3.55 2.12 0.75 1.19 5.73 0.42 0.73 2.06 0.95 1.29 1.654 1.260 0.000 0.411 1.664 1.054 0.075 6.076* 0.606 0.335 2.314 0.003 0.817 0.035 0.085 0.712 0.002 0.220 2.120 2.345 0.252 0.632 0.013 4.492* CAUSE ALL OTHER CAUSES (000-136 , 210-228 , 240-E989) CA - BUCCAL (140-149) CA - ESOPHAGUS (150) CA - STOMACH (151) CA - INTESTINES & OTHER 61 (152-154,158,159) CA - LIVER, BILE DUCTS (155-156) CA - PANCREAS (157) CA - UPPER RESPIRATORY (160-161) CA - LUNG (162) CA - BONE (170) CA - SOFT TISSUES (171) CA - MELANOMA OF THE SKIN (172) CA - PROSTATE (185) CA - TESTIS (186) CA - BLADDER (188) CA - KIDNEY (189) CA - BRAIN (191) CA - OTHER NERVOUS SYSTEM (192) CA - THYROID & ENDOCRINE (193-194) CA - NON-HODGKINS LYMPKOMA (200,202) CA - HODGKINS DISEASE (201) CA - MULTIPLE MYELOMA (203) CA - LEUKEMIA (204-207) OTH[ CA (163,173-4,187,190,195-9,208-9,230-9) 938 10 8 7 32 5 13 0 77 4 1 25 5 5 1 9 18 13 5 9 7 4 21 39 TOTAL NUMBER OF CASES OBSERVED • 1256 EXPECTED NUMBERS ARE BASED UPON 1405 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM 942 8 8 7 23 2 13 7 64 3 4 28 8 5 0 4 24 11 1 21 10 2 22 30 �TABLB C-8 DEATHS FROM CANCERS (140-208, 230-239) ALL ARMY ENLISTED MEN IN VIETNAM, COMBAT MOSC VS. NON-COMBAT MOSC OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-136 , 210-228 , 240-B989) CA - BUCCAL (140-149) CA - ESOPHAGUS (150) CA - STOMACH (151) CA - INTESTINES & OTHER GI (152-154,158,159) CA - LIVER, BILE DUCTS (155-156) CA - PANCREAS (157) CA - UPPER RESPIRATORY (160-161) CA - LUNG (162) CA - BONE (170) CA - SOFT TISSUES (171) CA - MELANOMA OF THE SKIN (172) CA - PROSTATE (185) CA - TESTIS (186) CA - BLADDER (188) CA - KIDNEY (189) CA - BRAIN (191) CA - OTHER NERVOUS SYSTEM (192) CA - THYROID & ENDOCRINE (193-194) CA - NON-HODGKINS LYMPHOMA (200,202) CA - HODGKINS DISEASE (201) CA - MULTIPLE MYELOMA (203) CA - LEUKEMIA (204-207) OTH CA (163 , 173-4 , 187 , 190 , 195-9 , 208-9 , 230-9 ) 4972 14 10 25 39 9 11 11 135 6 6 26 3 28 2 11 30 10 1 33 25 3 55 57 TOTAL NUMBER OF CASES OBSERVED - 5522 EXPECTED NUMBERS ARE BASED UPON 12767 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM 4947 16 8 18 49 8 17 5 122 8 10 43 5 28 2 13 29 9 4 28 28 3 54 68 1.01 0.87 1.23 1.42 0.79 1.17 0.64 2.35 1.11 0.72 0.59 0.61 0.56 1.00 1.02 0.88 1.05 1.06 0.24 1.16 0.88 1.00 1.02 0.84 0.752 0.177 0.382 2.074 1.713 0.247 1.720 4.264* 0.911 0.483 1.404 4.971* 0.763 0.004 0.012 0.050 0.065 0.083 2.144 0.507 0.174 0.008 0.012 1.409 �TABLB C-9 DEATHS FROM CANCERS (140-208, 230-239) ALL ENLISTED MARINES IN VIETNAM, COMBAT MOSC VS. NON-COMBAT MOSC OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-136 , 210-228 , 240-E989) CA - BUCCAL (140-149) CA - ESOPHAGUS (150) CA - STOMACH (151) CA - INTESTINES & OTHER 61 (152-154,158,159) CA - LIVER, BILE DUCTS (155-156) CA - PANCREAS (157) CA - UPPER RESPIRATORY (160-161) CA - LUNG (162) CA - BONE (170) CA - SOFT TISSUES (171) CA - MELANOMA OF THE SKIN (172) CA - PROSTATE (185) CA - TESTIS (186) CA - BLADDER (188) CA - KIDNEY (189) CA - BRAIN (191) CA - OTHER NERVOUS SYSTEM (192) CA - THYROID & ENDOCRINE (193-194) CA - NON-HOD6KINS LYMPHOMA (200,202) CA - HODGKINS DISEASE (201) CA - MULTIPLE MYELOMA (203) CA - LEUKEMIA (204-207) OTH CA (163 , 173-4 , 187 , 190 , 195-9 , 208-9 , 230-9) 1743 4 2 8 6 4 4 0 23 4 0 14 1 10 0 4 9 5 1 17 8 0 18 13 TOTAL NUMBER OF CASES OBSERVED - 1898 EXPECTED NUMBERS ARE BASED UPON 2341 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM 1740 2 1 2 10 1 5 1 31 5 4 13 2 12 1 4 9 2 0 12 11 0 15 14 1.00 2.06 2.33 3.74 0.60 3.46 0.75 0.00 0.74 0.87 0.00 1.06 0.53 0.82 0.00 1.11 0.98 2.48 2.52 1.43 0.73 0.00 1.17 0.92 0.468 0.105 0.581 4.343* 1.806 0.670 0.306 0.857 2.270 0.047 3.900* 0.010 0.377 0.106 0.598 0.088 0.040 1.521 0.000 0.863 0.383 0.199 0.469 0.160 �TABLE C-10 SELECTED CAUSES OF DEATH BY ORGAN SYSTEM ALL CASES OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (210-28,290-315,740-59,780-96) 859 938 0.92 1.998 INFECTIVE & PARASITIC DISEASES (000-136) 146 177 0.82 2.831 2973 2971 1.00 0.252 157 193 0.81 2.256 40 50 0.81 1.835 194 207 0.94 0.256 CIRCULATORY DISEASES (390-458) 4225 4319 0.98 1.538 RESPIRATORY DISEASES (460-519) 468 500 0.94 0.350 1170 1202 0.97 0.654 GENITOURINARY DISEASES (580-629) 93 124 0.75 5.411* SKIN & SUBCUTANEOUS TISSUES (680-709) 10 15 0.69 0.229 MUSCULOSKELETAL 6 CONNECTIVE TISSUES (710-738) 36 27 1.34 1.203 13864 13514 1.03 14.758* CANCERS (140-209, 230-239) ENDOCRINE, NUTRITIONAL & METABOLIC (240-279) BLOOD & BLOOD-FORMING ORGANS (280-289) NERVOUS SYSTEMS & SENSE ORGANS (320-389) DIGESTIVE DISEASES (520-577) ACCIDENTS, VIOLENCE & TRAUMA (E800-989) TOTAL NUMBER OF CASES OBSERVED - 24235 EXPECTED NUMBERS ARE BASED UPON 26685 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM �TABLE C-ll SELECTED CAUSES OF DEATH BY ORGAN SYSTEM ALL ARMY OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (210-28,290-315,740-59,780-96) 709 778 0.91 2.314 INFECTIVE & PARASITIC DISEASES (000-136) 127 159 0.80 3.473 2452 2535 0.97 1.631 135 159 0.85 1.790 32 47 0.68 3.429 167 176 0.95 0.222 CIRCULATORY DISEASES (390-458) 3578 3655 0.98 1.468 RESPIRATORY DISEASES (460-519) 406 435 0.93 0.232 1001 1008 0.99 0.161 80 104 0.77 4.288* 8 11 0.76 0.040 29 19 1.55 1.694 10984 10623 1.03 18.154* CANCERS (140-209, 230-239) ENDOCRINE, NUTRITIONAL & METABOLIC (240-279) BLOOD & BLOOD-FORMING ORGANS (280-289) NERVOUS SYSTEMS & SENSE ORGANS (320-389) DIGESTIVE DISEASES (520-577) GENITOURINARY DISEASES (580-629) SKIN 6 SUBCUTANEOUS TISSUES (680-709) MUSCULOSKELETAL & CONNECTIVE TISSUES (710-738) ACCIDENTS, VIOLENCE & TRAUMA (E800-989) TOTAL NUMBER OF CASES OBSERVED - 19708 EXPECTED NUMBERS ARE BASED UPON 22904 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM �TABLE C-12 SELECTED CAUSES OF DEATH BY ORGAN SYSTEM ALL MARINES OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE 150 160 0.94 0.000 19 19 1.02 0.080 521 436 1.20 3.688 22 33 0.66 0.527 8 2 3.22 1.538 27 31 0.86 0.034 CIRCULATORY DISEASES (390-458) 647 663 0.98 0.089 RESPIRATORY DISEASES (460-519) 62 65 0.95 0.176 169 194 0.87 1.588 13 19 0.67 1.265 SKIN & SUBCUTANEOUS TISSUES (680-709) 2 4 0.50 0.409 MUSCULOSKELETAL & CONNECTIVE TISSUES (710-738) 7 8 0.87 0.040 2880 2891 1.00 0.057 ALL OTHER CAUSES (210-28,290-315,740-59,780-96) INFECTIVE & PARASITIC DISEASES (000-136) CANCERS (140-209, 230-239) ENDOCRINE, NUTRITIONAL & METABOLIC (240-279) BLOOD & BLOOD-FORMING ORGANS (280-289) NERVOUS SYSTEMS & SENSE ORGANS (320-389) DIGESTIVE DISEASES (520-577) GENITOURINARY DISEASES (580-629) ACCIDENTS, VIOLENCE & TRAUMA (E800-989) TOTAL NUMBER OF CASES OBSERVED - 4527 EXPECTED NUMBERS ARE BASED UPON 3781 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM �TABLE C-13 SELECTED CAUSES OF DEATH BY ORGAN SYSTEM ALL WHITE SERVICEMEN OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (210-28,290-315,740-59,780-96) 553 618 0.90 1.909 INFECTIVE & PARASITIC DISEASES (000-136) 105 119 0.88 0.404 2480 2507 0.99 0.822 111 125 0.89 0.585 27 28 0.98 0.108 149 157 0.95 0.086 CIRCULATORY DISEASES (390-458) 3360 3413 0.98 0.711 RESPIRATORY DISEASES (460-519) 332 356 0.93 0.054 DIGESTIVE DISEASES (520-577) 888 859 1.03 0.166 68 86 0.79 2.497 8 10 0.80 0.004 22 23 0.96 0.014 11074 10877 1.02 6.269* CANCERS (140-209, 230-239) ENDOCRINE, NUTRITIONAL & METABOLIC (240-279) BLOOD & BLOOD-FORMING ORGANS (280-289) NERVOUS SYSTEMS & SENSE ORGANS (320-389) GENITOURINARY DISEASES (580-629) SKIN & SUBCUTANEOUS TISSUES (680-709) MUSCULOSKELETAL 6 CONNECTIVE TISSUES (710-738) ACCIDENTS, VIOLENCE & TRAUMA (E800-989) TOTAL NUMBER OF CASES OBSERVED - 19177 EXPECTED NUMBERS ARE BASED UPON 21335 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM �TABLE C-14 SELECTED CAUSES OF DEATH BY ORGAN SYSTEM ALL NON-WHITE SERVICEMEN OBSERVED EXPECTED O/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (210-28,290-315,740-59,780-96) 306 320 0.96 0.250 41 58 0.71 4.313* 493 463 1.06 0.723 ENDOCRINE, NUTRITIONAL & METABOLIC (240-279) 46 67 0.68 2.467 BLOOD & BLOOD-FORMING ORGANS (280-289) 13 22 0.59 2.995 NERVOUS SYSTEMS & SENSE ORGANS (320-389) 45 50 0.90 0.263 CIRCULATORY DISEASES (390-458) 865 906 0.95 1.138 RESPIRATORY DISEASES (460-519) 136 145 0.94 0.548 DIGESTIVE DISEASES (520-577) 282 343 0.82 5.168* 25 38 0.67 3.432 2 5 0.44 0.785 14 4 3.62 4.668* 2790 2637 1.06 11.619* INFECTIVE & PARASITIC DISEASES (000-136) CANCERS (140-209, 230-239) GENITOURINARY DISEASES (580-629) SKIN & SUBCUTANEOUS TISSUES (680-709) MUSCULOSKELBTAL & CONNECTIVE TISSUES (710-738) ACCIDENTS, VIOLENCE & TRAUMA (E800-989) TOTAL NUMBER OF CASES OBSERVED • 5058 EXPECTED NUMBERS ARE BASED UPON 5350 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM �TABLE C-15 SELECTED CAUSES OF DEATH BY ORGAN SYSTEM ALL ENLISTED MEN OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (210-28,290-315,740-59,780-96) 823 884 0.93 1.082 INFECTIVE & PARASITIC DISEASES (000-136) 137 166 0.83 2.404 2566 2592 0.99 0.984 145 177 0.82 1.949 36 46 0.78 2.089 178 191 0.93 0.262 CIRCULATORY DISEASES (390-458) 3738 3796 0.98 0.576 RESPIRATORY DISEASES (460-519) 444 470 0.95 0.297 1077 1100 0.98 0.435 82 117 0.70 6.726* 9 14 0.66 0.277 27 24 1.13 0.082 13266 12953 1.02 12.871* CANCERS (140-209, 230-239) ENDOCRINE, NUTRITIONAL & METABOLIC (240-279) BLOOD & BLOOD-FORMING ORGANS (280-289) NERVOUS SYSTEMS & SENSE ORGANS (320-389) DIGESTIVE DISEASES (520-577) GENITOURINARY DISEASES (580-629) SKIN & SUBCUTANEOUS TISSUES (680-709) MUSCULOSKBLETAL & CONNECTIVE TISSUES (710-738) ACCIDENTS, VIOLENCE & TRAUMA (E800-989) TOTAL NUMBER OF CASES OBSERVED - 22528 EXPECTED NUMBERS ARE BASED UPON 25022 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM �TABLE C-16 SELECTED CAUSES OF DEATH BY ORGAN SYSTEM ALL OFFICERS OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE 27 37 0.74 1.823 9 8 1.15 0.031 318 307 1.04 1.654 ENDOCRINE, NUTRITIONAL & METABOLIC (240-279) 7 12 0.60 1.383 BLOOD & BLOOD-FORMING ORGANS (280-289) 4 4 0.98 0.002 11 9 1.16 0.028 CIRCULATORY DISEASES (390-458) 338 370 0.91 2.309 RESPIRATORY DISEASES (460-519) 19 20 0.93 0.000 DIGESTIVE DISEASES (520-577) 71 71 1.00 0.006 GENITOURINARY DISEASES (580-629) 6 5 1.23 0.032 SKIN & SUBCUTANEOUS TISSUES (680-709) 0 1 0.00 1.319 MUSCULOSKELETAL 6 CONNECTIVE TISSUES (710-738) 6 2 2.72 1.488 440 403 1.09 0.692 ALL OTHER CAUSES (210-28,290-315,740-59,780-96) INFECTIVE & PARASITIC DISEASES (000-136) CANCERS (140-209, 230-239) NERVOUS SYSTEMS & SENSE ORGANS (320-389) ACCIDENTS, VIOLENCE & TRAUMA (E800-989) TOTAL NUMBER OF CASES OBSERVED • 1256 EXPECTED NUMBERS ARE BASED UPON 1405 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM �TABLE C-17 SELECTED CAUSES OF DEATH BY ORGAN SYSTEM ALL ARMY ENLISTED MEN IN VIETNAM, COMBAT MOSC VS. NON-COMBAT MOSC OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE 216 205 1.05 0.372 30 37 0.82 1.193 550 575 0.96 0.752 ENDOCRINE, NUTRITIONAL 6 METABOLIC (240-279) 41 32 1.29 1.378 BLOOD & BLOOD-FORMING ORGANS (280-289) 10 9 1.18 0.104 NERVOUS SYSTEMS & SENSE ORGANS (320-389) 47 46 1.01 0.001 CIRCULATORY DISEASES (390-458) 796 842 0.95 2.439 RESPIRATORY DISEASES (460-519) 108 107 1.01 0.067 DIGESTIVE DISEASES (520-577) 243 270 0.90 1.824 26 18 1.44 1.780 2 2 0.99 0.008 10 5 2.08 2.745 3443 3374 1.02 3.295 ALL OTHER CAUSES (210-28,290-315,740-59,780-96) INFECTIVE & PARASITIC DISEASES (000-136) CANCERS (140-209, 230-239) GENITOURINARY DISEASES (580-629) SKIN & SUBCUTANEOUS TISSUES (680-709) MUSCULOSKELETAL & CONNECTIVE TISSUES (710-738) ACCIDENTS, VIOLENCE & TRAUMA (E800-989) TOTAL NUMBER OF CASES OBSERVED - 5522 EXPECTED NUMBERS ARE BASED UPON 12767 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM �TABLE C-18 SELECTED CAUSES OF DEATH BY ORGAN SYSTEM ALL ENLISTED MARINES IN VIETNAM, COMBAT MOSC VS. NON-COMBAT MOSC OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE 63 77 0.82 1.387 7 13 0.55 1.186 155 158 0.98 0.468 ENDOCRINE, NUTRITIONAL & METABOLIC (240-279) 9 7 1.25 0.059 BLOOD & BLOOD-FORMING ORGANS (280-289) 0 6 0.00 5.000* 17 7 2.28 4.479* CIRCULATORY DISEASES (390-458) 175 193 0.91 1.376 RESPIRATORY DISEASES (460-519) 28 16 1.70 1.963 DIGESTIVE DISEASES (520-577) 67 52 1.29 2.187 GENITOURINARY DISEASES (580-629) 2 5 0.41 1.709 SKIN & SUBCUTANEOUS TISSUES (680-709) 1 1 1.04 0.005 4 1 3.79 1.613 1362 1.01 0.586 ALL OTHER CAUSES (210-28,290-315,740-59,780-96) INFECTIVE & PARASITIC DISEASES (000-136) CANCERS (140-209, 230-239) NERVOUS SYSTEMS & SENSE ORGANS (320-389) MUSCULOSKELETAL 6 CONNECTIVE TISSUES (710-738) ACCIDENTS, VIOLENCE & TRAUMA (E800-989) 1370 TOTAL NUMBER OF CASES OBSERVED - 1898 EXPECTED NUMBERS ARE BASED UPON 2341 OBSERVATIONS IK COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM �TABLE C-19 DEATHS FROM SELECTED DISEASES OF THE CIRCULATORY, RESPIRATORY AND DIGESTIVE SYSTEMS ALL CASES OBSERVED EXPECTED O/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-398, 580-B989) HYPERTENSIVE DISEASE (400-404) ACUTE MYOCARDIAL INFARCTION (410) OTHER ISCHEMIC HEART DISEASE (411-414) CARDIOMYOPATHY (425) CARDIAC ARREST (427.2) CERBBROVASCULAR DISEASES (430-438) DIS OF ARTERIES, ARTBRIOLES, CAPILLARIES (440-448) DIS OF VEINS, LYMPHATICS & OTHERS (450-458) OTH HEART DISEASES (420-424,426-427.1,427.3-429) UPPER RESPIRATORY (460-466, 500-508) INFLUENZA & PNEUMONIA (470-486) CHRONIC BRONCHITIS & EMPHYSEMA (491-492) OTHER RESPIRATORY (490, 493, 510-519) DIS OF ESOPHAGUS, STOMACH, DUODENUM (530-537) CIRRHOSIS - ALCOHOLIC (571.0) CIRRHOSIS - OTHER/UNSPECIFIED (571.8, 571.9) DISEASES OF PANCREAS (577) OTH DIGESTIVE DISEASES (520-529, 540-570, 572-576) 19936 19883 61 123 77 141 1059 1116 142 273 520 142 133 196 7 254 52 95 80 424 449 80 209 TOTAL NUMBER OF CASES OBSERVED - 24235 EXPECTED NUMBERS ARE BASED UPON 26685 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM 126 222 518 139 127 183 10 258 56 96 70 405 480 94 235 1.00 0.80 0.87 0.95 1.13 1.23 1.00 1.02 1.05 1.07 0.68 0.98 0.93 0.99 1.15 1.05 0.94 0.85 0.89 0.222 1.284 0.716 2.088 1.820 4.805* 0.006 0.334 0.494 0.413 1.207 0.002 0.029 0.020 0.496 0.005 0.228 1.050 1.390 �TABLE C-20 DEATHS FROM SELECTED DISEASES OF THE CIRCULATORY, RESPIRATORY AND DIGESTIVE SYSTEMS ALL ARMY OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-398, 580-E989) HYPERTENSIVE DISEASE (400-404) ACUTE MYOCARDIAL INFARCTION (410) OTHER ISCHEMIC HEART DISEASE (411-414) CARDIOMYOPATHY (425) CARDIAC ARREST (427.2) CEREBROVASCULAR DISEASES (430-438) DIS OF ARTERIES, ARTERIOLBS, CAPILLARIES (440-448) DIS OF VEINS, LYMPHATICS & OTHERS (450-458) OTH HEART DISEASES (420-424,426-427.1,427.3-429) UPPER RESPIRATORY (460-466, 500-508) INFLUENZA & PNEUMONIA (470-486) CHRONIC BRONCHITIS & EMPHYSEMA (491-492) OTHER RESPIRATORY (490, 493, 510-519) DIS OF ESOPHAGUS, STOMACH, DUODENUM (530-537) CIRRHOSIS - ALCOHOLIC (571.0) CIRRHOSIS - OTHER/UNSPECIFIED (571.8, 571.9) DISEASES OF PANCREAS (577) OTH DIGESTIVE DISEASES (520-529, 540-570, 572-576) 16061 50 102 877 113 229 436 126 111 170 5 227 46 82 60 374 390 67 182 16023 67 112 949 95 194 437 126 109 148 10 230 53 76 55 337 421 74 191 TOTAL NUMBER OF CASES OBSERVED - 19708 EXPECTED NUMBERS ARE BASED UPON 22904 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM 1.00 0.74 0.91 0.92 1.19 1.18 1.00 1.00 1.02 1.15 0.49 0.98 0.87 1.08 1.09 1.11 0.93 0.90 0.95 0.236 1.584 0.325 3.182 1.827 3.006 0.178 0.142 0.458 1.210 1.988 0.007 0.033 0.085 0.138 0.277 0.332 0.440 0.383 �TABLE C-21 DEATHS FROM SELECTED DISEASES OF THE CIRCULATORY, RESPIRATORY AND DIGESTIVE SYSTEMS ALL MARINES OBSERVED EXPECTED O/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-398, 580-E989) HYPERTENSIVE DISEASE (400-404) ACUTE MYOCARDIAL INFARCTION (410) OTHER ISCHEMIC HEART DISEASE (411-414) CARDIOMYOPATHY (425) CARDIAC ARREST (427.2) CEREBROVASCULAR DISEASES (430-438) DIS OF ARTERIES, ARTERIOLES, CAPILLARIES (440-448) DIS OF VEINS, LYMPHATICS & OTHERS (450-4S8) OTH HEART DISEASES (420-424,426-427.1,427.3-429) UPPER RESPIRATORY (460-466, 500-508) INFLUENZA & PNEUMONIA (470-486) CHRONIC BRONCHITIS & EMPHYSEMA (491-492) OTHER RESPIRATORY (490, 493, 510-519) DIS OF ESOPHAGUS, STOMACH, DUODENUM (530-537) CIRRHOSIS - ALCOHOLIC (571.0) CIRRHOSIS - OTHER/UNSPECIFIED (571.8, 571.9) DISEASES OF PANCREAS (577) OTH DIGESTIVE DISEASES (520-529, 540-570, 572-576) 3881 10 21 178 26 43 79 15 21 25 2 30 9 10 19 56 61 11 30 3876 10 24 162 30 28 82 11 15 30 0 33 3 18 16 74 60 13 43 TOTAL NUMBER OF CASES OBSERVED - 4527 EXPECTED NUMBERS ARE BASED UPON 3781 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM 1.00 1.00 0.89 1.10 0.86 1.54 0.96 1.40 1.40 0.83 0.91 2.60 0.55 1.22 0.76 1.01 0.87 0.70 0.009 0.128 0.090 1.060 0.005 1.942 0.114 1.272 0.234 0.426 0.754 0.050 0.433 1.909 0.323 1.677 0.002 0.331 2.249 �TABLE C-22 DEATHS FROM SELECTED DISEASES OF THE CIRCULATORY, RESPIRATORY AND DIGESTIVE SYSTEMS ALL WHITE SERVICEMEN OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (0-398, 580-989) HYPERTENSIVE DISEASE (400-404) ACUTE MYOCARDIAL INFARCTION (410) OTHER ISCHEMIC HEART DISEASE (411-414) CARDIOMYOPATHY (425) CARDIAC ARREST (427.2) CEREBROVASCULAR DISEASES (430-438) DIS OF ARTERIES, ARTERIOLES , CAPILLARIES (440-448) DIS OF VEINS, LYMPHATICS & OTHERS (450-458) OTH HEART DISEASES (420-424,426-427.1,427.3-429) UPPER RESPIRATORY (460-466, 500-508) INFLUENZA & PNEUMONIA (470-486) CHRONIC BRONCHITIS & EMPHYSEMA (491-492) OTHER RESPIRATORY (490, 493, 510-519) DIS OF ESOPHAGUS, STOMACH, DUODENUM (530-537) CIRRHOSIS - ALCOHOLIC (571.0) CIRRHOSIS - OTHER/UNSPECIFIED (571.8, 571.9) DISEASES OF PANCREAS (577) OTH DIGESTIVE DISEASES (520-529, 540-570, 572-576) 15967 28 100 842 93 212 372 116 89 131 6 167 40 59 62 320 342 60 171 15991 40 107 885 71 173 369 110 88 132 8 177 50 60 51 287 358 52 168 TOTAL NUMBER OF CASES OBSERVED - 19177 EXPECTED NUMBERS ARE BASED UPON 21335 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM 1.00 0.70 0.94 0.95 1.30 1.23 1.01 1.05 1.01 0.99 0.74 0.94 0.81 0.98 1.21 1.11 0.96 1.14 1.02 0.126 1.090 0.172 2.102 2.629 4.616* 0.034 0.351 0.206 0.007 0.842 0.031 0.456 0.010 0.677 0.513 0.029 0.480 0.008 �TABLE C-23 DEATHS FROM SELECTED DISEASES OF THE CIRCULATORY, RESPIRATORY AND DIGESTIVE SYSTEMS ALL NON-WHITE SERVICEMEN OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-398, 580-E989) HYPERTENSIVE DISEASE (400-404) ACUTE MYOCARDIAL INFARCTION (410) OTHER ISCHEMIC HEART DISEASE (411-414) CARDIOMYOPATHY (425) CARDIAC ARREST (427.2) CEREBROVASCULAR DISEASES (430-438) DIS OF ARTERIES, ARTERIOLES, CAPILLARIES (440-448) DIS OF VEINS, LYMPHATICS & OTHERS (450-458) OTH HEART DISEASES (420-424,426-427.1,427.3-429) UPPER RESPIRATORY (460-466, 500-508) INFLUENZA & PNEUMONIA (470-486) CHRONIC BRONCHITIS & EMPHYSEMA (491-492) OTHER RESPIRATORY (490, 493, 510-519) DIS OF ESOPHAGUS, STOMACH, DUODENUM (530-537) CIRRHOSIS - ALCOHOLIC (571.0) CIRRHOSIS - OTHER/UNSPECIFIED (571.8, 571.9) DISEASES OF PANCREAS (577) OTH DIGESTIVE DISEASES (520-529, 540-570, 572-576) 3977 38 22 212 47 61 140 26 41 63 1 87 9 37 20 105 112 18 42 3869 35 32 234 58 49 151 31 37 52 4 88 9 34 20 117 125 42 73 TOTAL NUMBER OF CASES OBSERVED • 5058 EXPECTED NUMBERS ARE BASED UPON 5350 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM 1.03 1.10 0.69 0.91 0.81 1.25 0.93 0.83 1.11 1.21 0.26 0.99 1.06 1.09 1.00 0.89 0.90 0.43 0.58 5.124* 0.011 1.463 0.312 0.104 0.452 0.861 0.083 0.227 0.891 1.772 0.004 0.011 0.001 0.025 0.745 0.334 8.649* 5.999* �TABLE C-24 DEATHS FROM SELECTED DISEASES OF THE CIRCULATORY, RESPIRATORY AND DIGESTIVE SYSTEMS ALL ENLISTED MEN OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-398, 580-E989) HYPERTENSIVE DISEASE (400-404) ACUTE MYOCARDIAL INFARCTION (410) OTHER ISCHEMIC HEART DISEASE (411-414) CARDIOMYOPATHY (425) CARDIAC ARREST (427.2) CEREBROVASCULAR DISEASES (430-438) DIS OF ARTERIES, ARTERIOLES, CAPILLARIES (440-448) DIS OF VEINS, LYMPHATICS & OTHERS (450-458) OTH HEART DISEASES (420-424,426-427.1,427.3-429) UPPER RESPIRATORY (460-466, 500-508) INFLUENZA & PNEUMONIA (470-486) CHRONIC BRONCHITIS & EMPHYSEMA (491-492) OTHER RESPIRATORY (490, 493, 510-519) DIS OF ESOPHAGUS, STOMACH, DUODENUM (530-537) CIRRHOSIS - ALCOHOLIC (571.0) CIRRHOSIS - OTHER/UNSPECIFIED (571.8, 571.9) DISEASES OF PANCREAS (577) OTK DIGESTIVE DISEASES (520-529, 540-570, 572-576) 18653 54 107 912 127 249 475 124 116 181 7 245 48 89 72 396 414 74 185 18612 71 120 969 120 200 470 119 112 171 10 239 55 91 66 372 429 89 214 TOTAL NUMBER OF CASES OBSERVED - 22528 EXPECTED NUMBERS ARE BASED UPON 25022 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM 1.00 0.76 0.89 0.94 1.06 1.25 1.01 1.04 1.04 1.06 0.70 1.02 0.88 0.98 1.09 1.06 0.97 0.83 0.86 0.154 1.581 0.696 2.040 0.579 4.845* 0.004 0.303 0.165 0.487 1.029 0.156 0.280 0.054 0.113 0.174 0.010 1.126 2.085 �TABLE C-25 DEATHS FROM SELECTED DISEASES OF THE CIRCULATORY, RESPIRATORY AND DIGESTIVE SYSTEMS ALL OFFICERS OBSERVED EXPECTED O/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-398, 580-E989) HYPERTENSIVE DISEASE (400-404) ACUTE MYOCARDIAL INFARCTION (410) OTHER ISCHEMIC HEART DISEASE (411-414) CARDIOMYOPATHY (425) CARDIAC ARREST (427.2) CBREBROVASCULAR DISEASES (430-438) DIS OF ARTERIES, ARTERIOLES , CAPILLARIES (440-448) DIS OF VEINS, LYMPHATICS & OTHERS (450-458) OTH HEART DISEASES (420-424,426-427.1,427.3-429) UPPER RESPIRATORY (460-466, 500-508) INFLUENZA & PNEUMONIA (470-486) CHRONIC BRONCHITIS & EMPHYSEMA (491-492) OTHER RESPIRATORY (490, 493, 510-519) DIS OF ESOPHAGUS, STOMACH, DUODENUM (530-537) CIRRHOSIS - ALCOHOLIC (571.0) CIRRHOSIS - OTHER/UNSPECIFIED (571.8, 571.9) DISEASES OF PANCREAS (577) OTH DIGESTIVE DISEASES (520-529, 540-570, 572-576) 930 7 16 108 16 15 27 15 12 11 0 12 2 6 7 25 28 5 14 TOTAL NUMBER OF CASES OBSERVED - 1256 EXPECTED NUMBERS ARE BASED UPON 1405 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM 916 3 19 111 3 22 34 22 15 13 0 15 1 5 3 18 30 3 18 1.02 2.23 0.85 0.97 6.21 0.69 0.79 0.67 0.80 0.88 0.00 0.80 2.61 1.33 2.74 1.40 0.92 1.75 0.77 0.024 0.284 0.521 0.014 9.622* 0.511 0.575 0.293 0.277 0.247 0.079 0.278 0.198 0.060 2.123 0.409 0.079 0.270 0.159 �TABLE C-26 DEATHS FROM SELECTED DISEASES OF THE CIRCULATORY, RESPIRATORY AND DIGESTIVE SYSTEMS ALL ARMY ENLISTED MEN IN VIETNAM, COMBAT MOSC VS. NON-COMBAT MOSC OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-398, 580-E989) HYPERTENSIVE DISEASE (400-404) ACUTE MYOCARDIAL INFARCTION (410) OTHER ISCHEMIC HEART DISEASE (411-414) CARDIOMYOPATHY (425) CARDIAC ARREST (427.2) CEREBROVASCULAR DISEASES (430-438) DIS OF ARTERIES, ARTERIOLES, CAPILLARIES (440-448) DIS OF VEINS, LYMPHATICS & OTHERS (450-458) OTH HEART DISEASES (420-424,426-427.1,427.3-429) UPPER RESPIRATORY (460-466, 500-508) INFLUENZA & PNEUMONIA (470-486) CHRONIC BRONCHITIS & EMPHYSEMA (491-492) OTHER RESPIRATORY (490, 493, 510-519) DIS OF ESOPHAGUS, STOMACH, DUODENUM (530-537) CIRRHOSIS - ALCOHOLIC (571.0) CIRRHOSIS - OTHER/UNSPECIFIED (571.8, 571.9) DISEASES OF PANCREAS (577) OTH DIGESTIVE DISEASES (520-529, 540-570, 572-576) 4664 11 22 179 35 52 107 36 21 41 1 61 9 24 9 108 88 18 36 TOTAL NUMBER OF CASES OBSERVED • 5522 EXPECTED NUMBERS ARE BASED UPON 12767 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM 4595 14 20 206 26 56 115 25 31 50 2 64 10 24 17 96 103 19 50 1.02 0.81 1.10 0.87 1.34 0.93 0.93 1.43 0.67 0.83 0.57 0.95 0.94 1.00 0.53 1.13 0.85 0.94 0.71 4.556* 0.405 0.204 2.436 2.067 0.391 0.599 2.950 2.512 1.199 0.260 0.130 0.017 0.096 3.029 1.470 1.814 0.025 2.874 ��TABLE C-28 DEATHS FROM ACCIDENTS, SUICIDES AND TRAUMA (E800-E989) ALL CASES OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE 10373 10734 0.97 15.535* 4897 4643 1.05 9.355* OTH. TRANSPORT. ACC. (E800-E807 ,E830-E845) 610 517 1.18 9.730* ACC. POISONINGS (E850-E877) 581 508 1.14 6.349* ALL OTH ACC. /INJURY (E880-E949 , E970-E989) 2917 2788 1.05 3.313 SUICIDE (E950-E959) 2543 2735 0.93 9.851* HOMICIDE (E960-E969) 2314 2310 1.00 0.009 ALL OTHER CAUSES (000-799) MOTOR VEH ACCIDENTS (E810-E827) TOTAL NUMBER OF CASES OBSERVED - 24235 EXPECTED NUMBERS ARE BASED UPON 26685 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM �TABLE C-29 DEATHS FROM ACCIDENTS, SUICIDES AND TRAUMA (E800-E989) ALL ARMY OBSERVED EXPECTED O/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-799) 8728 9097 0.96 18.774* MOTOR VER ACCIDENTS (B810-E827) 3884 3693 1.05 7.502* OTH. TRANSPORT. ACC . (E800-E807 , E830-E845) 493 361 1.36 19.394* ACC. POISONINGS (E850-E877) 461 399 1.15 5.068* ALL OTH ACC. /INJURY (E880-E949 , E970-E989) 2323 2202 1.05 2.761 SUICIDE (E950-E959) 2003 2152 0.93 6.633* HOMICIDE (E960-E969) 1816 1804 1.01 0.004 TOTAL NUMBER OF CASES OBSERVED - 19708 EXPECTED NUMBERS ARE BASED UPON 22904 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM �TABLE C-30 DEATHS FROM ACCIDENTS, SUICIDES AND TRAUMA (E800-B989) ALL MARINES OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-799) 1647 1638 1.01 0.040 MOTOR VEH ACCIDENTS 1011 948 1.07 1.778 OTH. TRANSPORT. ACC . (E800-E807 , B830-E845) 117 156 0.75 3.551 ACC. POISONINGS (E850-E877) 120 109 1.10 1.289 ALL OTH ACC. /INJURY (E880-E949 , E970-E989) 593 585 1.01 0.523 SUICIDE (E950-E959) 542 583 0.93 3.321 HOMICIDE (E960-E969) 497 507 0.98 0.163 (E810-E827) TOTAL NUMBER OF CASES OBSERVED • 4527 EXPECTED NUMBERS ARE BASED UPON 3781 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM �TABLE C-31 DEATHS FROM ACCIDENTS, SUICIDES AND TRAUMA (E800-E989) ALL WHITE SERVICEMEN OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-799) 8109 8312 0.98 6.487* MOTOR VER ACCIDENTS 4264 4107 1.04 4.169* OTH. TRANSPORT. ACC . (E800-E807 , E830-E845) 548 463 1.18 8.333* ACC. POISONINGS (E850-E877) 464 411 1.13 4.414* ALL OTH ACC. /INJURY (E880-B949 , E970-E989) 2341 2253 1.04 1.745 SUICIDE (E950-E959) 2247 2442 0.92 9.974* HOMICIDE (E960-E969) 1204 1189 1.01 0.015 (E810-E827) TOTAL NUMBER OF CASES OBSERVED - 19177 EXPECTED NUMBERS ARE BASED UPON 21335 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM �TABLE C-32 DEATHS FROM ACCIDENTS, SUICIDES AND TRAUMA (E800-E989) ALL NON-WHITE SERVICEMEN OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE 2269 2422 0.94 11.547* 632 536 1.18 9.172* 62 54 1.15 1.446 ACC. POISONINGS (E850-E877) 117 97 1.21 2.054 ALL OTH ACC. /INJURY (E880-E949 , E970-E989) 575 536 1.07 1.936 SUICIDE (E950-E959) 295 293 1.01 0.309 1108 1120 0.99 0.112 ALL OTHER CAUSES (000-799) MOTOR VEH ACCIDENTS (E810-E827) OTH. TRANSPORT. ACC . (E800-E807 , E830-E845) HOMICIDE (E960-B969) TOTAL NUMBER OF CASES OBSERVED - 5058 EXPECTED NUMBERS ARE BASED UPON 5350 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM �TABLE C-33 DEATHS FROM ACCIDENTS, SUICIDES AND TRAUMA (E800-E989) ALL ENLISTED MEN OBSERVED EXPECTED O/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-799) 9264 9586 0.97 13.473* MOTOR VEH ACCIDENTS (E810-E827) 4757 4492 1.06 10.730* OTH. TRANSPORT. ACC . (E800-E807 , E830-B845) 420 417 1.01 0.257 ACC. POISONINGS (E850-E877) 568 495 1.15 6.427* ALL OTH ACC. /INJURY (E880-E949 , E970-E989) 2815 2673 1.05 4.457* SUICIDE 2428 2586 0.94 7.965* 2276 2277 1.00 0.023 (E950-E959) HOMICIDE (E960-E969) TOTAL NUMBER OF CASES OBSERVED - 22528 EXPECTED NUMBERS ARE BASED UPON 25022 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM �TABLE C-34 DEATHS FROM ACCIDENTS, SUICIDES AND TRAUMA (E800-E989) ALL OFFICERS OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-799) 816 846 0.96 0.753 MOTOR VEH ACCIDENTS (E810-E827) 113 102 1.11 0.389 OTH. TRANSPORT. ACC. (E800-E807 , E830-E845) 114 69 1.66 4.156* ACC. POISONINGS (E850-E877) 13 7 1.81 0.935 ALL OTH ACC. /INJURY (E880-K949 , B970-B989) 76 91 0.83 1.195 SUICIDE (E950-E959) 96 121 0.79 1.996 HOMICIDE (B960-E969) 28 13 2.22 3.109 TOTAL NUMBER OF CASES OBSERVED • 1256 EXPECTED NUMBERS ARE BASED UPON 1405 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM �TABLE C-35 DEATHS FROM ACCIDENTS, SUICIDES AND TRAUMA (E800-E989) ALL ARMY ENLISTED MEN IN VIETNAM, COMBAT MOSC VS. NON-COMBAT MOSC OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-799) 2081 2151 0.97 3.433 MOTOR VEH ACCIDENTS (E810-E827) 1205 1217 0.99 0.088 93 119 0.78 4.189* ACC. POISONINGS (E850-E877) 153 142 1.08 0.746 ALL OTH ACC. /INJURY (E880-E949 , E970-K989) 762 696 1.09 4.694* SUICIDE (E950-E959) 590 613 0.96 0.684 HOMICIDE (E960-E969) 638 583 1.09 3.924* OTH. TRANSPORT. ACC. (E800-E807 ,E830-E845) TOTAL NUMBER OF CASES OBSERVED - 5522 EXPECTED NUMBERS ARE BASED UPON 12767 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM �TABLE C-36 DEATHS PROM ACCIDENTS, SUICIDES AND TRAUMA (E800-E989) ALL ENLISTED MARINES IN VIETNAM, COMBAT MOSC VS. NON-COMBAT MOSC OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-799) 528 536 0.98 0.586 MOTOR VEH ACCIDENTS 466 496 0.94 0.573 OTH. TRANSPORT. ACC. (E800-E807 ,E830-B845) 34 32 1.05 0.036 ACC. POISONINGS 67 53 1.26 2.116 ALL OTH ACC. /INJURY (E880-E949 , E970-E989) 289 276 1.05 0.758 SUICIDE (E950-E959) 228 274 0.83 4.599* HOMICIDE (E960-E969) 286 230 1.24 7.034* (E810-E827) (E850-E877) TOTAL NUMBER OF CASES OBSERVED - 1898 EXPECTED NUMBERS ARE BASED UPON 2341 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM �APPENDIX D �APPENDIX D DEATHS IN CALIFORNIA, MASSACHUSETTS, NEW YORK, WISCONSIN AND WEST VIRGINIA USING ALL U.S. VETERANS.AS COMPARISON GROUP DEATHS IN CALIFORNIA TABLE D-l: DEATHS FROM ACCIDENTS, SUICIDES AND TRAUMA TABLE D-2: DEATHS FROM CANCERS TABLE D-3: DEATHS FROM SELECTED DISEASES OF THE CIRCULATORY, RESPIRATORY AND DIGESTIVE SYSTEMS TABLE D-4: SELECTED CAUSES OF DEATH BY ORGAN SYSTEM DEATHS IN MASSACHUSETTS TABLE D-5: DEATHS FROM ACCIDENTS, SUICIDES AND TRAUMA TABLE D-6: DEATHS FROM CANCERS TABLE D-7: DEATHS FROM SELECTED DISEASES OF THE CIRCULATORY, RESPIRATORY AND DIGESTIVE SYSTEMS TABLE D-8: SELECTED CAUSES OF DEATH BY ORGAN SYSTEM DEATHS IN NEW YORK TABLE D-9 : DEATHS FROM ACCIDENTS, SUICIDES AND TRAUMA TABLE D-10: DEATHS FROM CANCERS TABLE D-ll: DEATHS FROM SELECTED DISEASES OF THE CIRCULATORY, RESPIRATORY AND DIGESTIVE SYSTEMS TABLE D-12: SELECTED CAUSES OF DEATH BY ORGAN SYSTEM DEATHS IN WISCONSIN TABLE D-13: DEATHS FROM ACCIDENTS, SUICIDES AND TRAUMA TABLE D-14: DEATHS FROM CANCERS TABLE D-l5: DEATHS FROM SELECTED DISEASES OF THE CIRCULATORY, RESPIRATORY AND DIGESTIVE SYSTEMS TABLE D-16: SELECTED CAUSES OF DEATH BY ORGAN SYSTEM DEATHS IN WEST VIRGINIA TABLE D-17: DEATHS FROM ACCIDENTS, SUICIDES AND TRAUMA TABLE D-18: DEATHS FROM CANCERS TABLE D-l9: DEATHS FROM SELECTED DISEASES OF THE CIRCULATORY, RESPIRATORY AND DIGESTIVE SYSTEMS TABLE D-20: SELECTED CAUSES OF DEATH BY ORGAN SYSTEM �DEATHS IN CALIFORNIA USING NON-VIETNAM SERVICE VETERANS WHO DIED IN CALIFORNIA AS COMPARISON GROUP TABLE D-21: DEATHS FROM ACCIDENTS, SUICIDES AND TRAUMA TABLE D-22: DEATHS FROM CANCERS TABLE D-23: DEATHS FROM SELECTED DISEASES OF THE CIRCULATORY, RESPIRATORY AND DIGESTIVE SYSTEMS TABLE D-24: SELECTED CAUSES OF DEATH BY ORGAN SYSTEM �TABLE D-l DEATHS FROM ACCIDENTS, SUICIDES AND TRAUMA (E800-E989) ALL WHITE SERVICEMEN WHO DIED IN CALIFORNIA OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-799) 795 851 0.93 8.622* MOTOR VEH ACCIDENTS 446 446 1.00 0.001 OTH. TRANSPORT. ACC. (E800-E807 , E830-E845) 54 51 1.06 0.301 ACC. POISONINGS (E850-E877) 97 45 2.17 52.662* ALL OTH ACC. /INJURY (E880-E949 , E970-E989) 197 242 0.81 9.686* SUICIDE (E950-E959) 280 262 1.07 1.480 HOMICIDE (E960-E969) 158 130 1.22 5.518* (E810-E827) TOTAL NUMBER OF CASES OBSERVED - 2027 EXPECTED NUMBERS ARE BASED UPON 21335 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM ALL U.S. VETERANS WITH NO VIETNAM SERVICE USED AS COMPARISON GROUP �TABLE D-2 DEATHS FROM CANCERS (140-208, 230-239) ALL WHITE SERVICEMEN WHO DIED IN CALIFORNIA OBSERVED EXPECTED 0/E M-H CHI-SQUARE 1.01 1.33 1.01 1.22 0.56 0.97 0.98 0.60 1.16 1.01 0.67 0.97 0.00 1.72 0.62 0.68 1.00 0.26 0.60 0.66 1.11 1.69 1.05 0.62 1.623 0.135 CAUSE ALL OTHER CAUSES (000-136 , 210-228 , 240-E989) CA - BUCCAL (140-149) CA - ESOPHAGUS (150) CA - STOMACH (151) CA - INTESTINES & OTHER GI (152-154,158,159) CA - LIVER, BILE DUCTS (155-156) CA - PANCREAS (157) CA - UPPER RESPIRATORY (160-161) CA - LUNG (162) CA - BONE (170) CA - SOFT TISSUES (171) CA - MELANOMA OF THE SKIN (172) CA - PROSTATE (185) CA - TESTIS (186) CA - BLADDER (188) CA - KIDNEY (189) CA - BRAIN (191) CA - OTHER NERVOUS SYSTEM (192) CA - THYROID & ENDOCRINE (193-194) CA - NON-HODGKINS LYMPHOMA (200,202) CA - HODGKINS DISEASE (201) CA - MULTIPLE MYELOMA (203) CA - LEUKEMIA (204-207) OTH CA (163,173-4,187,190,195-9,208-9,230-9) 1782 7 5 10 11 2 9 2 67 4 3 18 0 17 1 5 13 2 2 9 10 5 25 18 TOTAL NUMBER OF CASES OBSERVED - 2027 EXPECTED NUMBERS ARE BASED UPON 21335 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM ALL U.S. VETERANS WITH NO VIETNAM SERVICE USED AS COMPARISON GROUP 1765 5 5 8 20 2 9 3 58 4 4 19 3 10 2 7 13 8 3 14 9 3 24 29 0.056 0.141 2.815 0.008 0.001 0.280 0.525 0.000 0.520 0.001 3.374 4.545* 0.468 0.850 0.014 4.092* 0.625 1.155 0.082 1.969 0.008 4.159* �TABLE D-3 DEATHS FROM SELECTED DISEASES OF THE CIRCULATORY, RESPIRATORY AND DIGESTIVE SYSTEMS ALL WHITE SERVICEMEN WHO DIED IN CALIFORNIA OBSERVED EXPECTED O/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-398, 580-E989) HYPERTENSIVE DISEASE (400-404) ACUTE MYOCARDIAL INFARCTION (410) OTHER ISCHEMIC HEART DISEASE (411-414) CARDIOMYOPATHY (425) CARDIAC ARREST (427.2) CEREBROVASCULAR DISEASES (430-438) DIS OF ARTERIES, ARTERIOLES , CAPILLARIES (440-448) DIS OP VEINS, LYMPHATICS & OTHERS (450-458) OTH HEART DISEASES (420-424,426-427.1,427.3-429) UPPER RESPIRATORY (460-466, 500-508) INFLUENZA & PNEUMONIA (470-486) CHRONIC BRONCHITIS & EMPHYSEMA (491-492) OTHER RESPIRATORY (490, 493, 510-519) DIS OF ESOPHAGUS, STOMACH, DUODENUM (530-537) CIRRHOSIS - ALCOHOLIC (571.0) CIRRHOSIS - OTHER/UNSPECIFIED (571.8, 571.9) DISEASES OF PANCREAS (577) OTH DIGESTIVE DISEASES (520-529, 540-570, 572-576) 1684 3 5 100 12 6 36 9 6 15 2 17 6 4 5 48 45 12 12 1705 5 12 TOTAL NUMBER OF CASES OBSERVED • 2027 EXPECTED NUMBERS ARE BASED UPON 21335 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM ALL U.S. VETERANS WITH NO VIETNAM SERVICE USED AS COMPARISON GROUP 86 7 15 37 10 9 14 1 18 5 7 5 29 37 6 19 0.99 0.66 0.42 1.17 1.64 0.39 0.97 0.91 0.70 1.04 2.43 0.93 1.24 0.55 0.95 1.67 1.23 2.08 0.63 1.266 0.234 3.928* 1.584 2.609 5.540* 0.098 0.160 1.146 0.212 0.118 0.028 0.032 1.148 0.000 9.414* 1.482 7.322* 1.961 �TABLE D-4 DEATHS FROM DISEASES OF SELECTED ORGAN SYSTEMS ALL WHITE SERVICEMEN WHO DIED IN CALIFORNIA OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE 59 64 0.93 0.213 3 11 0.26 6.010* 245 262 0.93 1.639 ENDOCRINE, NUTRITIONAL & METABOLIC (240-279) 3 13 0.23 7.646* BLOOD & BLOOD-FORMING ORGANS (280-289) 3 3 1.09 0.023 13 16 0.82 0.303 CIRCULATORY DISEASES (390-458) 314 342 0.92 3.206 RESPIRATORY DISEASES (460-519) 32 38 0.84 0.879 116 88 1.32 8.491* GENITOURINARY DISEASES (580-629) 4 10 0.42 2.394 SKIN & SUBCUTANEOUS TISSUES (680-709) 1 1 0.97 0.000 MUSCULOSKELBTAL 6 CONNECTIVE TISSUES (710-738) 2 3 0.66 0.306 1232 1177 1.05 8.307* ALL OTHER CAUSES (210-28,290-315,740-759,780-796) INFECTIVE & PARASITIC DISEASES (000-136) CANCERS (140-209, 230-239) NERVOUS SYSTEMS & SENSE ORGANS (320-389) DIGESTIVE DISEASES (520-577) ACCIDENTS, VIOLENCE & TRAUMA (B800-E989) TOTAL NUMBER OF CASES OBSERVED - 2027 EXPECTED NUMBERS ARE BASED UPON 21335 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM ALL U.S. VETERANS WITH NO VIETNAM SERVICE USED AS COMPARISON GROUP �TABLE D-6 DEATHS FROM CANCERS (140-208, 230-239) ALL WHITE SERVICEMEN WHO DIED IN MASSACHUSETTS OBSERVED EXPECTED O/E M-H CHI-SQUARE 1.02 0.00 2.43 1.04 0.44 0.00 0.00 0.00 0.84 0.00 3.81 0.00 0.00 1.40 0.00 2.46 1.14 0.00 5.95 1.59 0.81 0.00 0.29 0.84 1.204 0.700 0.804 0.002 0.729 0.269 1.015 0.204 0.152 0.503 4.089* 2.543 0.369 0.226 0.148 1.717 0.029 1.163 7.982* 0.606 0.041 0.262 1.745 0.097 CAUSE ALL OTHER CAUSES (000-136, 210-228 , 240-E989) CA - BUCCAL (140-149) CA - ESOPHAGUS (150) CA - STOMACH (151) CA - INTESTINES & OTHER 01 (152-154,158,159) CA - LIVER, BILE DUCTS (155-156) CA - PANCREAS (157) CA - UPPER RESPIRATORY (160-161) CA - LUNG (162) CA - BONE (170) CA - SOFT TISSUES (171) CA - MELANOMA OF THE SKIN (172) CA - PROSTATE (185) CA - TESTIS (186) CA - BLADDER (188) CA - KIDNEY (189) CA - BRAIN (191) CA - OTHER NERVOUS SYSTEM (192) CA - THYROID & ENDOCRINE j( 193-194) CA - NON-HODGKINS LYMPHOMA (200,202) CA - HODGKINS DISEASE (201) CA - MULTIPLE MYELOMA (203) CA - LEUKEMIA (204-207) OTHI CA (163,173-4,187,190,195-9,208-9,230-9) 251 0 1 1 1 0 0 0 5 0 2 0 0 2 0 2 2 0 2 3 1 0 1 3 TOTAL NUMBER OF CASES OBSERVED 277 EXPECTED NUMBERS ARE BASED UPON 21335 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM ALL U.S. VETERANS WITH NO VIETNAM SERVICE USED AS COMPARISON GROUP 245 1 0 1 2 0 1 0 6 1 1 3 0 1 0 1 2 1 0 2 1 0 3 4 �TABLE D-7 DEATHS FROM SELECTED DISEASES OF THE CIRCULATORY, RESPIRATORY AND DIGESTIVE SYSTEMS ALL WHITE SERVICEMEN WHO DIED IN MASSACHUSETTS OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-398, 580-E989) HYPERTENSIVE DISEASE (400-404) ACUTE MYOCARDIAL INFARCTION (410) OTHER ISCHEMIC HEART DISEASE (411-414) CARDIOMYOPATHY (425) CARDIAC ARREST (427.2) CEREBROVASCULAR DISEASES (430-438) DIS OF ARTERIES, ARTERIOLES, CAPILLARIES (440-448) DIS OF VEINS, LYMPHATICS & OTHERS (450-458) OTH HEART DISEASES (420-424,426-427.1,427.3-429) UPPER RESPIRATORY (460-466, 500-508) INFLUENZA & PNEUMONIA (470-486) CHRONIC BRONCHITIS & EMPHYSEMA (491-492) OTHER RESPIRATORY (490, 493, 510-519) DIS OF ESOPHAGUS, STOMACH, DUODENUM (530-537) CIRRHOSIS - ALCOHOLIC (571.0) CIRRHOSIS - OTHER/UNSPECIFIED (571.8, 571.9) DISEASES OF PANCREAS (577) OTH DIGESTIVE DISEASES (520-529, 540-570, 572-576) 227 0 2 13 0 3 5 0 0 2 0 2 0 3 1 2 9 1 7 TOTAL NUMBER OF CASES OBSERVED 277 EXPECTED NUMBERS ARE BASED UPON 21335 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM ALL U.S. VETERANS WITH NO VIETNAM SERVICE USED AS COMPARISON GROUP 238 0 1 10 1 2 5 1 1 2 0 2 1 1 1 4 4 1 2 0.95 0.00 1.68 1.27 0.00 1.41 1.07 0.00 0.00 1.17 0.00 0.84 0.00 3.69 1.49 0.56 2.10 1.59 3.21 3.950* 0.476 0.580 0.843 0.974 0.382 0.020 1.322 1.158 0.046 0.118 0.059 0.546 5.600* 0.156 0.669 5.086* 0.211 10.245* �TABLE D-8 DEATHS FROM DISEASES OF SELECTED ORGAN SYSTEMS ALL WHITE SERVICEMEN WHO DIED IN MASSACHUSETTS OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (210-28,290-315,740-59,780-96) 9 9 1.04 0.015 INFECTIVE & PARASITIC DISEASES (000-136) 1 2 0.59 0.272 26 32 0.82 1.212 ENDOCRINE, NUTRITIONAL & METABOLIC (240-279) 2 2 1.27 0.107 BLOOD & BLOOD-FORMING ORGANS (280-289) 0 0 0.00 0.403 NERVOUS SYSTEMS & SENSE ORGANS (320-389) 3 2 1.34 0.254 CIRCULATORY DISEASES (390-458) 39 41 0.95 0.119 RESPIRATORY DISEASES (460-519) 7 4 1.59 1.542 18 11 1.67 4.892* GENITOURINARY DISEASES (580-629) 0 1 0.00 1.086 SKIN & SUBCUTANEOUS TISSUES (680-709) 0 0 0.00 0.150 MUSCULOSKELETAL & CONNECTIVE TISSUES (710-738) 0 0 0.00 0.308 172 173 0.99 0.024 CANCERS (140-209, 230-239) DIGESTIVE DISEASES (520-577) ACCIDENTS, VIOLENCE & TRAUMA (800-989) TOTAL NUMBER OF CASES OBSERVED 277 EXPECTED NUMBERS ARE BASED UPON 21335 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM ALL U.S. VETERANS WITH NO VIETNAM SERVICE USED AS COMPARISON GROUP �TABLE D-9 DEATHS FROM ACCIDENTS, SUICIDES AND TRAUMA (E800-E989) ALL WHITE SERVICEMEN WHO DIED IN NEW YORK OBSERVED EXPECTED O/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-799) 334 253 1.32 46.536* MOTOR VEH ACCIDENTS 137 188 0.73 18.820* OTH. TRANSPORT. ACC. (E800-B807 , E830-E845) 17 21 0.82 0.615 ACC. POISONINGS (E850-E877) 31 19 1.65 7.811* 106 101 1.05 0.267 SUICIDE (E950-E959) 70 109 0.64 16.492* HOMICIDE (E960-E969) 51 55 0.94 0.272 (E810-E827) ALL OTH ACC. /INJURY (E880-E949 , E970-E989) TOTAL NUMBER OF CASES OBSERVED • 746 EXPECTED NUMBERS ARE BASED UPON 21335 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM ALL U.S. VETERANS WITH NO VIETNAM SERVICE USED AS COMPARISON GROUP �TABLE D-10 DEATHS FROM CANCERS (140-208, 230-239) ALL WHITE SERVICEMEN WHO DIED IN NEW YORK OBSERVED EXPECTED 0/E M-H CHI-SQUARE 1.00 0.00 2.79 0.87 1.87 1.71 1.38 2.16 1.23 0.00 0.70 0.15 0.00 0.23 0.00 0.63 1.21 0.00 0.00 1.37 1.60 0.00 1.26 1.14 0.007 1.395 2.215 0.042 3.865* 0.239 0.315 0.661 0.652 1.428 0.121 5.045* 0.453 2.476 0.335 0.231 0.219 3.147 0.817 0.633 1.326 0.593 0.595 0.124 CAUSE ALL OTHER CAUSES (000-136 , 210-228 , 240-E989) CA - BUCCAL (140-149) CA - ESOPHAGUS (150) CA - STOMACH (151) CA - INTESTINES & OTHER 61 (152-154,158,159) CA - LIVER, BILE DUCTS (155-156) CA - PANCREAS (157) CA - UPPER RESPIRATORY (160-161) CA - LUNG (162) CA - BONE (170) CA - SOFT TISSUES (171) CA - MELANOMA OF THE SKIN (172) CA - PROSTATE (185) CA - TESTIS (186) CA - BLADDER (188) CA - KIDNEY (189) CA - BRAIN (191) CA - OTHER NERVOUS SYSTEM (192) CA - THYROID & ENDOCRINE (193-194) CA - NON-HODGKINS LYMPHOMA (200,202) CA - HODGKINS DISEASE (201) CA - MULTIPLE MYELOMA (203) CA - LEUKEMIA (204-207) OTH! CA (163,173-4,187,190,195-9,208-9,230-9) 667 0 2 2 10 1 3 1 15 0 1 1 0 1 0 1 6 0 0 7 6 0 12 10 TOTAL NUMBER OF CASES OBSERVED 746 EXPECTED NUMBERS ARE BASED UPON 21335 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM ALL U.S. VETERANS WITH NO VIETNAM SERVICE USED AS COMPARISON GROUP 668 1 1 2 5 1 2 0 12 1 1 7 0 4 0 2 5 3 1 5 4 1 10 9 �TABLE D-ll DEATHS FROM SELECTED DISEASES OF THE CIRCULATORY, RESPIRATORY AND DIGESTIVE SYSTEMS ALL WHITE SERVICEMEN WHO DIED IN NEW YORK OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-398, 580-E989) HYPERTENSIVE DISEASE (400-404) ACUTE MYOCARDIAL INFARCTION (410) OTHER ISCHEMIC HEART DISEASE (411-414) CARDIOMYOPATHY (425) CARDIAC ARREST (427.2) CEREBROVASCULAR DISEASES (430-438) DIS OF ARTERIES, ARTERIOLES, CAPILLARIES (440-448) DIS OF VEINS, LYMPHATICS & OTHERS (450-458) OTH HEART DISEASES (420-424,426-427.1,427.3-429) UPPER RESPIRATORY (460-466, 500-508) INFLUENZA & PNEUMONIA (470-486) CHRONIC BRONCHITIS & EMPHYSEMA (491-492) OTHER RESPIRATORY (490, 493, 510-519) DIS OF ESOPHAGUS, STOMACH, DUODENUM (530-537) CIRRHOSIS - ALCOHOLIC (571.0) CIRRHOSIS - OTHER/UNSPECIFIED (571.8, 571.9) DISEASES OF PANCREAS (577) OTH DIGESTIVE DISEASES (520-529, 540-570, 572-576) 589 1 3 35 6 6 15 2 3 12 0 6 1 1 2 29 20 6 9 TOTAL NUMBER OF CASES OBSERVED • 746 EXPECTED NUMBERS ARE BASED UPON 21335 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM ALL U.S. VETERANS WITH NO VIETNAM SERVICE USED AS COMPARISON GROUP 652 1 2 23 3 5 12 3 3 4 0 6 1 2 2 9 10 2 6 0.90 0.91 1.26 1.54 2.37 1.21 1.23 0.68 1.11 2.68 0.00 0.99 0.98 0.46 1.16 3.17 1.95 3.20 1.63 47.769* 0.006 0.143 6.607* 4.190* 0.196 0.602 0.299 0.023 11.912* 0.309 0.000 0.000 0.607 0.052 37.872* 8.301* 7.472* 2.107 �TABLE D-12 DEATHS FROM DISEASES OF SELECTED ORGAN SYSTEMS ALL WHITE SERVICEMEN WHO DIED IN NEW YORK OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (210-28,290-315,740-59,780-96) 54 23 2.34 39.423* INFECTIVE & PARASITIC DISEASES (000-136) 12 4 2.78 12.564* CANCERS (140-209, 230-239) 79 78 1.01 0.006 ENDOCRINE, NUTRITIONAL & METABOLIC (240-279) 3 4 0.80 0.139 BLOOD & BLOOD-FORMING ORGANS (280-289) 0 1 0.00 1.209 NERVOUS SYSTEMS & SENSE ORGANS (320-389) 7 6 1.18 0.185 CIRCULATORY DISEASES (390-458) 106 94 1.13 1.862 RESPIRATORY DISEASES (460-519) 7 10 0.67 1.135 64 27 2.35 46.341* GENITOURINARY DISEASES (580-629) 1 3 0.35 1.179 SKIN & SUBCUTANEOUS TISSUES (680-709) 0 0 0.00 0.385 MUSCULOSKBLETAL £ CONNECTIVE TISSUES (710-738) 1 1 1.08 0.002 412 494 0.83 47.099* DIGESTIVE DISEASES (520-577) ACCIDENTS, VIOLENCE & TRAUMA (E800-B989) TOTAL NUMBER OF CASES OBSERVED 746 EXPECTED NUMBERS ARE BASED UPON 21335 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM ALL U.S. VETERANS WITH NO VIETNAM SERVICE USED AS COMPARISON GROUP �TABLE D-13 DEATHS FROM ACCIDENTS, SUICIDES AND TRAUMA (E800-E989) ALL WHITE SERVICEMEN WHO DIED IN WISCONSIN OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-799) 100 108 0.93 1.105 MOTOR VEH ACCIDENTS (E810-E827) 105 78 1.34 12.196* OTH. TRANSPORT. ACC. (E800-E807 , E830-E845) 4 9 0.45 2.762 ACC. POISONINGS (E850-B877) 4 8 0.50 2.071 ALL OTH ACC. /INJURY (E880-E949 , E970-E989) 45 42 1.06 0.194 SUICIDE (E950-E959) 49 45 1.08 0.314 7 23 0.31 11.870* HOMICIDE (E960-E969) TOTAL NUMBER OF CASES OBSERVED 314 EXPECTED NUMBERS ARE BASED UPON 21335 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM ALL U.S. VETERANS WITH NO VIETNAM SERVICE USED AS COMPARISON GROUP �TABLE D-14 DEATHS FROM CANCERS (140-208, 230-239) ALL WHITE SERVICEMEN WHO DIED IN WISCONSIN OBSERVED EXPECTED 0/E M-H CHI-SQUARE 1.00 0.00 3.32 0.00 1.31 0.00 1.13 0.00 0.96 0.00 5.11 0.69 0.00 2.86 0.00 1.36 1.46 0.00 0.00 0.93 1.32 0.00 1.01 0.54 0.037 CAUSE ALL OTHER CAUSES (000-136 , 210-228 , 240-E989) CA - BUCCAL (140-149) CA - ESOPHAGUS (150) CA - STOMACH (151) CA - INTESTINES & OTHER GI (152-154,158,159) CA - LIVER, BILE DUCTS (155-156) CA - PANCREAS (157) CA - UPPER RESPIRATORY (160-161) CA - LUNG (162) CA - BONE (170) CA - SOFT TISSUES (171) CA - MELANOMA OF THE SKIN (172) CA - PROSTATE (185) CA - TESTIS (186) CA - BLADDER (188) CA - KIDNEY (189) CA - BRAIN (191) CA - OTHER NERVOUS SYSTEM (192) CA - THYROID & ENDOCRINE (193-194) CA - NON-HODGKINS LYMPHOMA (200,202) CA - HODGKINS DISEASE (201) CA - MULTIPLE MYELOMA (203) CA - LEUKEMIA (204-207) OTH CA (163 , 173-4 , 187 , 190 , 195-9 , 208-9 , 230-9) 280 0 1 0 3 0 1 0 5 0 3 2 0 5 0 1 3 0 0 2 2 0 4 2 TOTAL NUMBER OF CASES OBSERVED 314 EXPECTED NUMBERS ARE BASED UPON 21335 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM ALL U.S. VETERANS WITH NO VIETNAM SERVICE USED AS COMPARISON GROUP 281 1 0 1 2 0 1 0 5 1 1 3 0 2 0 1 2 1 0 2 2 0 4 4 0.619 1.590 0.968 0.219 0.229 0.011 0.229 0.014 0.548 9.287* 0.264 0.198 5.557* 0.131 0.092 0.422 1.338 0.336 0.012 0.154 0.276 0.000 0.789 �TABLE D-15 DEATHS FROM SELECTED DISEASES OF THE CIRCULATORY, RESPIRATORY AND DIGESTIVE SYSTEMS ALL WHITE SERVICEMEN WHO DIED IN WISCONSIN OBSERVED EXPECTED O/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-398, 580-E989) HYPERTENSIVE DISEASE (400-404) ACUTE MYOCARDIAL INFARCTION (410) OTHER ISCHEMIC HEART DISEASE (411-414) CARDIOMYOPATHY (425) CARDIAC ARREST (427.2) CEREBROVASCULAR DISEASES (430-438) DIS OF ARTERIES, ARTERIOLES, CAPILLARIES (440-448) DIS OF VEINS, LYMPHATICS & OTHERS (450-458) OTH HEART DISEASES (420-424,426-427.1,427.3-429) UPPER RESPIRATORY (460-466, 500-508) INFLUENZA & PNEUMONIA (470-486) CHRONIC BRONCHITIS & EMPHYSEMA (491-492) OTHER RESPIRATORY (490, 493, 510-519) DIS OF ESOPHAGUS, STOMACH, DUODENUM (530-537) CIRRHOSIS - ALCOHOLIC (571.0) CIRRHOSIS - OTHER/UNSPECIFIED (571.8, 571.9) DISEASES OF PANCREAS (577) OTH DIGESTIVE DISEASES (520-529, 540-570, 572-576) 278 0 2 6 2 3 6 3 1 2 0 1 1 2 0 4 1 0 2 TOTAL NUMBER OF CASES OBSERVED 314 EXPECTED NUMBERS ARE BASED UPON 21335 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM ALL U.S. VETERANS WITH NO VIETNAM SERVICE USED AS COMPARISON GROUP 274 0 1 10 1 2 5 1 1 2 0 3 0 1 1 4 4 1 2 1.02 0.00 1.78 0.61 1.81 1.42 1.16 2.41 0.86 1.02 0.00 0.39 2.29 2.19 0.00 1.01 0.23 0.00 0.85 0.599 0.452 0.677 1.603 0.727 0.350 0.133 2.450 0.024 0.000 0.132 0.956 0.650 1.272 0.807 0.001 2.612 0.784 0.051 �TABLE D-17 DEATHS FROM ACCIDENTS, SUICIDES AND TRAUMA (E800-E989) ALL WHITE SERVICEMEN WHO DIED IN WEST VIRGINIA OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE 113 108 1.05 0.617 57 55 1.04 0.099 OTH. TRANSPORT. ACC. (E800-B807 , E830-E845) 5 6 0.81 0.217 ACC. POISONINGS (E850-E877) 5 5 0.92 0.039 ALL OTH ACC. /INJURY (E880-E949 , B970-K989) 40 30 1.33 3.713 SUICIDE (E950-E959) 20 33 0.60 6.218* HOMICIDE (E960-E969) 14 16 0.86 0.319 ALL OTHER CAUSES (000-799) MOTOR VEH ACCIDENTS (E810-E827) TOTAL NUMBER OP CASES OBSERVED 254 EXPECTED NUMBERS ARE BASED UPON 21335 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM ALL U.S. VETERANS WITH NO VIETNAM SERVICE USED AS COMPARISON GROUP �TABLE D-18 DEATHS FROM CANCERS (140-208, 230-239) ALL WHITE SERVICEMEN WHO DIED IN WEST VIRGINIA OBSERVED EXPECTED 0/E M-H CHI-SQUARE 1.01 2.62 0.00 2.17 0.85 0.00 0.00 3.47 1.13 1.95 0.00 0.00 3.17 1.69 0.00 1.07 1.11 0.00 0.00 0.00 0.92 0.00 0.93 1.17 0.183 1.928 0.423 1.290 0.048 0.261 1.036 1.668 0.110 0.459 0.504 2.525 1.396 0.577 0.162 0.006 0.022 1.093 0.339 1.799 0.007 0.274 0.015 0.101 CAUSE ALL OTHER CAUSES (000-136 , 210-228 , 240-E989) CA - BUCCAL (140-149) CA - ESOPHAGUS (150) CA - STOMACH (151) CA - INTESTINES & OTHER GI (152-154,158,159) CA - LIVER, BILE DUCTS (155-156) CA - PANCREAS (157) CA - UPPER RESPIRATORY (160-161) CA - LUNG (162) CA - BONE (170) CA - SOFT TISSUES (171) CA - MELANOMA OF THE SKIN (172) CA - PROSTATE (185) CA - TESTIS (186) CA - BLADDER (188) CA - KIDNEY (189) CA - BRAIN (191) CA - OTHER NERVOUS SYSTEM (192) CA - THYROID & ENDOCRINE (193-194) CA - NON-HODGKINS LYMPHOMA (200,202) CA - HODGKINS DISEASE (201) CA - MULTIPLE MYELOMA (203) CA - LEUKEMIA (204-207) OTH: CA (163,173-4,187,190,195-9,208-9,230-9) 224 2 0 2 2 0 0 1 8 1 0 0 1 2 0 1 2 0 0 0 1 0 3 4 TOTAL NUMBER OF CASES OBSERVED 254 EXPECTED NUMBERS ARE BASED UPON 21335 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM ALL U.S. VETERANS WITH NO VIETNAM SERVICE USED AS COMPARISON GROUP 222 1 0 1 2 0 1 0 7 1 1 2 0 1 0 1 2 1 0 2 1 0 3 3 �TABLE D-19 DEATHS FROM SELECTED DISEASES OF THE CIRCULATORY, RESPIRATORY AND DIGESTIVE SYSTEMS ALL WHITE SERVICEMEN WHO DIED IN WEST VIRGINIA OBSERVED EXPECTED O/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-398, 580-E989) HYPERTENSIVE DISEASE (400-404) ACUTE MYOCARDIAL INFARCTION (410) OTHER ISCHEMIC HEART DISEASE (411-414) CARDIOMYOPATHY (425) CARDIAC ARREST (427.2) CBREBROVASCULAR DISEASES (430-438) DIS OF ARTERIES, ARTERIOLES, CAPILLARIES (440-448) DIS OF VEINS, LYMPHATICS & OTHERS (450-458) OTH HEART DISEASES (420-424,426-427.1,427.3-429) UPPER RESPIRATORY (460-466, 500-508) INFLUENZA & PNEUMONIA (470-486) CHRONIC BRONCHITIS & EMPHYSEMA (491-492) OTHER RESPIRATORY (490, 493, 510-519) DIS OF ESOPHAGUS, STOMACH, DUODENUM (530-537) CIRRHOSIS - ALCOHOLIC (571.0) CIRRHOSIS - OTHER/UNSPECIFIED (571.8, 571.9) DISEASES OF PANCREAS (577) OTH DIGESTIVE DISEASES (520-529, 540-570, 572-576) 204 0 0 14 2 3 13 1 1 2 0 2 0 2 0 7 3 0 0 TOTAL NUMBER OF CASES OBSERVED 254 EXPECTED NUMBERS ARE BASED UPON 21335 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM ALL U.S. VETERANS WITH NO VIETNAM SERVICE USED AS COMPARISON GROUP 213 1 1 11 1 2 5 1 1 2 0 2 1 1 1 4 5 1 2 0.96 0.00 0.00 1.26 2.07 1.41 2.76 0.70 0.88 1.19 0.00 0.84 0.00 2.44 0.00 1.89 0.64 0.00 0.00 2.640 0.552 1.441 0.782 1.065 0.384 14.218* 0.132 0.015 0.058 0.111 0.057 0.632 1.657 0.653 2.938 0.626 0.671 2.097 �TABLE D-20 DEATHS FROM DISEASES OF SELECTED ORGAN SYSTEMS ALL WHITE SERVICEMEN WHO DIED IN WEST VIRGINIA OBSERVED EXPECTED O/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (210-28,290-315,740-759,780-796) 6 8 0.74 0.558 INFECTIVE & PARASITIC DISEASES (000-136) 0 2 0.00 1.634 30 32 0.93 0.185 ENDOCRINE, NUTRITIONAL & METABOLIC (240-279) 1 2 0.61 0.242 BLOOD & BLOOD-FORMING ORGANS (280-289) 0 0 0.00 0.386 NERVOUS SYSTEMS & SENSE ORGANS (320-389) 2 2 0.94 0.008 CIRCULATORY DISEASES (390-458) 57 44 1.29 5.239* RESPIRATORY DISEASES (460-519) 5 5 1.08 0.033 11 11 0.98 0.003 GENITOURINARY DISEASES (580-629) 1 1 0.85 0.025 SKIN & SUBCUTANEOUS TISSUES (680-709) 0 0 0.00 0.111 MUSCULOSKBLBTAL 6 CONNECTIVE TISSUES (710-738) 0 0 0.00 0.287 141 146 CANCERS (140-209, 230-239) DIGESTIVE DISEASES (520-577) ACCIDENTS, VIOLENCE & TRAUMA (E800-989) TOTAL NUMBER OF CASES OBSERVED 254 EXPECTED NUMBERS ARE BASED UPON 21335 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM ALL U.S. VETERANS WITH NO VIETNAM SERVICE USED AS COMPARISON GROUP 0.96 0.648 �TABLE D-21 DEATHS FROM ACCIDENTS, SUICIDES AND TRAUMA (E800-989) ALL WHITE SERVICEMEN WHO DIED IN CALIFORNIA OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-799) 796 823 0.97 0.532 MOTOR VEH ACCIDENTS 446 449 0.99 0.074 OTH. TRANSPORT. ACC. (E800-807 , E830-845) 54 55 0.98 0.001 ACC. POISONINGS (E850-877) 97 91 1.06 0.485 ALL OTH ACC. /INJURY (E880-949 ,E970-989) 196 156 1.26 4.203* SUICIDE (E950-959) 280 305 0.92 1.515 HOMICIDE (E960-969) 158 147 1.07 0.125 (E810-827) TOTAL NUMBER OF CASES OBSERVED • 2027 EXPECTED NUMBERS ARE BASED UPON 2080 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM NON-VIETNAM SERVICE VETERANS WHO DIED IN CALIFORNIA USED AS COMPARISON GROUP �TABLE D-22 DEATHS PROM CANCERS (140-208, 230-239) ALL WHITE SERVICEMEN WHO DIED IN CALIFORNIA OBSERVED EXPECTED 0/E M-H CHI-SQUARE 1.01 2.15 2.73 1.72 0.42 0.71 1.12 9.00 1.38 1.32 0.56 0.70 0.00 2.87 0.48 0.63 0.78 0.76 0.24 0.52 1.43 1.62 0.85 0.74 0.966 0.740 0.634 0.435 4.141* 0.078 0.105 0.352 2.017 0.016 0.722 0.161 3.898* 5.384* 1.236 0.999 0.254 0.260 3.154 1.675 0.316 1.037 0.649 2.013 CAUSE ALL OTHER CAUSES (000-136, 210-228 , 240-E989) CA - BUCCAL (140-149) CA - ESOPHAGUS (150) CA - STOMACH (151) CA - INTESTINES & OTHER 61 (152-154,158,159) CA - LIVER, BILE DUCTS (155-156) CA - PANCREAS (157) CA - UPPER RESPIRATORY (160-161) CA - LUNG (162) CA - BONE (170) CA - SOFT TISSUES (171) CA - MELANOMA OF THE SKIN (172) CA - PROSTATE (185) CA - TESTIS (186) CA - BLADDER (188) CA - KIDNEY (189) CA - BRAIN (191) CA - OTHER NERVOUS SYSTEM (192) CA - THYROID & ENDOCRINE (193-194) CA - NON-HODGKINS LYMPHOMA (200,202) CA - HODGKINS DISEASE (201) CA - MULTIPLE MYELOMA (203) CA - LEUKEMIA (204-207) OTH CA ( 163 , 173-4 , 187 , 190 , 195-9 , 208-9 , 230-9) 1782 7 5 10 11 2 9 2 67 4 3 18 0 17 1 5 13 2 2 9 10 5 25 18 1767 3 2 6 26 3 8 0 49 3 5 26 5 6 2 8 17 3 8 17 7 3 29 24 TOTAL NUMBER OF CASES OBSERVED - 2027 EXPECTED NUMBERS ARE BASED UPON 2080 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM NON-VIETNAM SERVICE VETERANS WHO DIED IN CALIFORNIA USED AS COMPARISON GROUP �TABLE D-23 DEATHS FROM SELECTED DISEASES OF THE CIRCULATORY, RESPIRATORY AND DIGESTIVE SYSTEMS ALL WHITE SERVICEMEN WHO DIED IN CALIFORNIA OBSERVED EXPECTED O/E M-H CHI-SQUARE CAUSE ALL OTHER CAUSES (000-398, 580-E989) HYPERTENSIVE DISEASE (400-404) ACUTE MYOCARDIAL INFARCTION (410) OTHER ISCHEMIC HEART DISEASE (411-414) CARDIOMYOPATHY (425) CARDIAC ARREST (427.2) CEREBROVASCULAR DISEASES (430-438) DIS OF ARTERIES, ARTERIOLES , CAPILLARIES (440-448) DIS OF VEINS, LYMPHATICS & OTHERS (450-458) OTH HEART DISEASES (420-424,426-427.1,427.3-429) UPPER RESPIRATORY (460-466, 500-508) INFLUENZA & PNEUMONIA (470-486) CHRONIC BRONCHITIS & EMPHYSEMA (491-492) OTHER RESPIRATORY (490, 493, 510-519) DIS OF ESOPHAGUS, STOMACH, DUODENUM (530-537) CIRRHOSIS - ALCOHOLIC (571.0) CIRRHOSIS - OTHER/UNSPECIFIED (571.8, 571.9) DISEASES OF PANCREAS (577) OTH DIGESTIVE DISEASES (520-529, 540-570, 572-576) 1684 4 4 98 12 6 34 10 6 14 2 18 6 4 5 53 43 12 12 1711 6 5 100 10 3 36 8 11 10 1 17 1 4 5 46 41 3 10 TOTAL NUMBER OF CASES OBSERVED • 2027 EXPECTED NUMBERS ARE BASED UPON 2080 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM NON-VIETNAM SERVICE VETERANS WHO DIED IN CALIFORNIA USED AS COMPARISON GROUP 0.98 0.70 0.74 0.98 1.18 1.99 0.93 1.31 0.53 1.43 3.59 1.05 8.88 1.01 1.06 1.14 1.06 3.96 1.24 0.560 0.200 1.136 0.189 0.454 1.851 0.058 0.005 0.762 2.156 0.014 0.011 2.447 0.003 0.354 0.302 0.001 4.740* 0.014 �TABLE D-24 DEATHS FROM SELECTED ORGAN SYSTEMS ALL WHITE SERVICEMEN WHO DIED IN CALIFORNIA OBSERVED EXPECTED 0/E M-H CHI-SQUARE CAUSE 59 50 1.19 1.097 3 18 0.17 6.259* 245 260 0.94 0.966 ENDOCRINE, NUTRITIONAL & METABOLIC (240-279) 3 25 0.12 11.714* BLOOD & BLOOD-FORMING ORGANS (280-289) 3 1 2.12 0.659 13 20 0.66 0.019 (390-458) 314 304 1.03 0.135 RESPIRATORY DISEASES (460-519) 32 25 1.28 0.200 116 103 1.12 0.462 GENITOURINARY DISEASES (580-629) 4 10 0.41 0.282 SKIN & SUBCUTANEOUS TISSUES (680-709) 1 5 0.19 1.937 MUSCULOSKELBTAL & CONNECTIVE TISSUES (710-738) 2 3 0.65 0.629 1232 1204 1.02 0.591 ALL OTHER CAUSES (210-28,290-315,740-759,780-796) INFECTIVE & PARASITIC DISEASES (000-136) CANCERS (140-209, 230-239) NERVOUS SYSTEMS & SENSE ORGANS (320-389) CIRCULATORY DISEASES DIGESTIVE DISEASES (520-577) ACCIDENTS, VIOLENCE & TRAUMA (E800-989) TOTAL NUMBER OF CASES OBSERVED - 2027 EXPECTED NUMBERS ARE BASED UPON 2080 OBSERVATIONS IN COMPARISON GROUP * P<0.05 FOR CHI-SQUARE WITH 1 DEGREE OF FREEDOM NON-VIETNAM SERVICE VETERANS WHO DIED IN CALIFORNIA USED AS COMPARISON GROUP � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 066 Folder The folder containing the original item. 1776 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Breslin, Patricia Yvonne Lee Han Kang Vicki Burt Barclay Shepard Title A name given to the resource Typescript: A Preliminary Report: The Vietnam Veterans Mortality Study, October 1986 Subject The topic of the resource VA Mortality Study mortality trends lymphomas ao_seriesIII https://www.nal.usda.gov/exhibits/speccoll/files/original/0b3b4e39b54c0e21e0862d51dbdd07d8.pdf dc7521f9bc623c1d1751220869506a01 PDF Text Text Item ID Number 01775 Author Burt vickiL ' Office of Environmental Epidemiology, Department of Su Roport/Artide TltlB Typescript: Non-Hodgkin's Lymphoma in the Vietnam Veterans Mortality Study, September 1986 Journal/Book Title 000 Yoar ° Month/Day Color n Number of Images 14 Dosorlpton Notes Monday, June 11, 2001 Page 1776 of 1793 �NON-HODGKIN'S LYMPHOMA IN THE VIETNAM VETERANS MORTALITY STUDY Vicki L. Burt Patricia Breslin Han Rang Yvonne Lee Michael Feil Office of Environmental Epidemiology Department of Surgery and Medicine Veterans Administration Washington, D. C. 20306-6000 September, 1986 �INTRODUCTION This paper describes the findings related to non-Hodgkin's lymphoma(NHL) in the Vietnam Veteran Mortality Study conducted by the Veterans Administration. This study was undertaken in response to concerns that elements of the veterans' experience, including herbicide exposure, may make the Vietnam veteran group more susceptible to various diseases. This proportionate mortality analysis is of deaths found in the Veterans Administration Beneficiary Identification and Records Locator Subsystem(BIRLS). This system includes all veterans whose beneficiaries receive a death benefit. This file contains a relatively complete roster of veterans' deaths. The Office of Environmental Epidemiology requested an ascertainment of mortality in the United States Vietnam era veteran population by the National Academy of Science. Results of this study showed 97.6 percent of deaths among veterns who served in Vietnam were recorded in BIRLS and 82.5 percent of the other Vietnam era veterans' deaths were shown in BIRLS. Of those not serving in Vietnam the distribtion of causes of death is not different between the 82.5 percent present and the 17.5 percent not found in BIRLS for cancer or other causes. See Appendix for distribution of causes of death. METHODS Study Population Proceeding under the assumption that the BIRLS system had the potential for yielding a reasonably complete roster of deceased Vietnam era veterans, it was necessary to devise strategies to select these deaths from among all deaths recorded in BIRLS. The selection process was done in several stages. First, it was necessary to obtain as complete a list as possible of all veterans who were likely to have served during the Vietnam era. To do this, all veterans whose service dates included the period 1964-1975 were selected. In addition, for those records where the service dates were missing, veterans whose birthdates were given as falling between 1935 and 1957 inclusive were selected. This yielded about 815,000 records. Recalling the purpose of the study, to compare the mortality patterns of men who served in Vietnam with those who did not serve in Vietnam, additional criteria were introduced based on time of service and branch of service. The Vietnam era as defined by the Veterans Administration, was August 5, 1964 to May 7, 1975. Prior to July 1965 and after January 1973 there were relatively few troops in Vietnam. Thus, if one sampled deaths among those who served before 1965 or after January 1, 1973, there would be relatively few decedents who had �served in Vietnam. Thus the study population was limited to military personnel who were in the Armed Forces on July 4, 1965 or who entered service after that date but before March 1, 1973. Data published by the Department of Defense indicate that 81 percent of those who served in Vietnam were in the Army or Marine Corps. For these branches of service, duty in Vietnam meant, in most cases, service "in country". For those in the Air Force or Navy, Vietnam service often is not so clear cut. It may be difficult to determine whether Navy personnel who were considered to have Vietnam service were ever actually "in country" of if Air Force personnel who were in the Vietnam theatre of operations and flew missions over Vietnam or to Vietnam were ever "in country". Hence the study population was limited even furthur to persons who served in the Army or Marine Corps between the dates given above. Since this was to be a proportional mortality study and deaths related to the operations of war could only occur in those who served in Southeast Asia and not among those who served elsewhere, deaths occuring among personnel on active duty before the end of 1973 wre excluded. The target population as defined by these criteria consisted of 186,000 veterans who died between July 4, 1965 and February 1982 when the study was initiated. In order to achieve adequate statistical power, it was determined that the study should consist of at least 50,000 eligible cases. It was assumed that some of the cases selected from the target population would not meet the criteria for the study. Therefore the sample size was increased to allow for these anticipated losses. Ultimately, 76,517 names of veterans were randomly selected from the target population. Military records were searched for all these names (Table 1). Records were found for all but 1032(1.4%) of the names selected; 52,283 of the veterans whose records were found were determined to meet the criteria of the study. That is, they had served with the Army or Marine Corps any time between July 4, 1965 and March 1, 1973. For those men who met the criteria of the study, dates, place of service, military occupation; type of discharge and other demographic data were abstracted from their military records. Cause of death information has been obtained for 51,421 (98.4%) of the 52,283 men who were determined to be eligible for the study(Table 2). The cause of death in all cases was coded by trained nosologists using the International Classification of Disease, 8th edition (ICDA-8). All data given in this report will be based on the 51,421 veterans for whom both military service data and cause of death information are available. Abstracted Information Items of information abstracted from the death certificates �were: age at last birthday, date of death, underlying cause of death, sex, state of death, race, and histology type if cause of death was cancer. From the military record the following information was obtained: date first in service, date last in service, branch, date of birth, sex, race, military occupation specialty codes(MOSC), education level, and whether served in Southeast Asia or not. For those serving in Southeast Asia additional information was collected: date first in Southeast Asia, date last in Southeast Asia, units served in, and countries served in. STATISTICAL ANALYSIS Proportionate mortality ratios, standardized for age(SPMRs) were calculated. Categories of age were: less than 20, 2024,...,60-64 and 65 and over. SPMRs for categories of cancer are presented in this paper. Vietnam era veterans that did not serve in Southeast Asia were the reference population. Of the 51,421 veterans' deaths in this study 24,736 had served in Southeast Asia, 26,685 had not(Table 3). Southeast Asia veterans that did not go to Vietnam were at most 1.8 percent. SPMRs were calculated for the following subgroups: all army, all marines, and white and nonwhite for army and marines. The Mantel-Haenszel chi-square statistic was calculated for each category to indicate whether the deviation from unity was likely to be seen by chance. A more detailed analysis of non-Hodgkin's lymphoma(NHL) for Marine Corps veterans and black Army veterans is presented. Case control analyses(Miettinen and Wang) were carried out to examine the relationship between mortality from non-Hodgkin's lymphoma and service in Southeast Asia. Controls for this analysis were all cardiovascular deaths(ICDA-8 codes: 390.0458.9). These were chosen because both in this mortality study and several others (Anderson, et al; Holmes, et al; Kogan and Clapp; and The Surgeon General, USAF) no association was found between Vietnam service and cardiovascular mortality. Also, no biologic hypothesis exists suggesting a relationship between service in Vietnam or synonymously Southeast Asia and cardiovascular mortality. All analyses were standardized by age to control for confounding by age. The disadvantages of the SPMR are well known. For example, if the overall mortality rate is different in the exposed and. non-exposed populations the SPMR will not approximate the standardized mortality ratio(SMR). That is, if the overall mortality rate is less in other Vietnam era veterans then the cause specific SPMRs will be overestimated for the Southeast Asia veterans. Also, the cause specific SPMR is dependent on the relative distribution of other causes of death. For example, if Southeast Asia veterans had a higher mortality rate for accidents than the referrent population, then the SPMR for cancer might be abnormally decreased. The case control analysis is not dependent on this second factor. Also, in case control analysis, if the �exposure of interest is not a risk factor for the selected control group the standardized mortality odds ratio(SMOR) is equivalent to the SMR. Because of the relative homogeneity of several variables (education, type of discharge, and grade) and correlation of others, it was not felt that significant information would be gained from a multivariate analysis. RESULTS The SPMRs presented in Table 4 reveal that only those for lung cancer and non-Hodgkin's lymphoma in Marines are significantly greater that 1 using the Mantel-Haenszel chi-square statistic. The results in the following Tables refer only to NHL, detailed analysis of lung cancer deaths in the Marine Corps wil be presented in a separate paper. Nineteen of twenty-four nonwhite Southeast Asia veterans whose race was not white veterans with NHL were black Army veterans, 3 were in the Marine Corps, and 2 were Army Southeast Asia veterans with race unknown. The SPMR of 1.53 for nonwhite Southeast Asia veterans has a chisquare statistic of 2.30 and corresponding p-value of 0.14. Because the majority are black Army veterans and despite the lack of statistical significance for the nonwhite category, parallel analyses of NHL were done for the subgroup, black Army veterans, as well as for the Marine Corps. The black Marines are included in the Marine analysis. Those with unknown race were excluded from furthur analysis. The comparison group for the MORs and SMORs in Tables 5-7f are all cardiovascular deaths. Table 5 presents the age distribution of NHL deaths in these two subgroups. In Table 6 age specific MORs are presented. Marines age 30 through 39 at death have a mortality odds ratio of 5.07 and lower 95% level of 1.49. An overall SMOR, 2.05, standardized for age is presented in Table 7a. The lower 95 percent confidence level is 1.81. Tables 7b-7g present SMORs for various categories of data collected for these individuals. Grade in service, education level and type of discharge are not presented because of lack of variation of these variables. Ninety-seven percent of the individuals of Table 5 were enlisted personnel, 96 percent were honorable discharges, and more that three quarters had a high school education with other education levels sparsely distributed. Because the values for the categories in Tables 7d and 7e are only present for Southeast Asia veterans all other Vietnam era veterans served as the comparison group for each category. In Tables 7b, 7c, and 7f all veterans have recorded data for the categories therefore the comparison group is all other Vietnam era veterans for that specific category. In Table 7g each ICDA-8 code was compared to all cardiovascular deaths. Military Occupation Specialty Codes(MOSCs) were categorized as combat troops, direct support of combat troops, and indirect �MOSCs(Table Ic) had the highest SMOR for military occupations at 6.23. A description of the categories of MOSC appear in the Appendix. Our data base included the dates a veteran first and last served in Southeast Asia. If the difference between these two dates was greater than 13 months there is a significant likelihood this veteran went to Southeast Asia more that once, therefore this analysis is presented as a potential proxy for more than one tour in Southeast Asia. Table 7e presents SMORs by the first year the veteran was in Southeast Asia. Because of the different volumes and contamination of herbicides used during the Vietnam conflict, veterans deaths were categorized by year of first Southeast Asia service. The overwhelming majority of herbicides were applied in 1967 through 1969. Southeast Asia veterans first going to Southeast Asia these years had the highest SMORs. Table 7f is a categorizaion of the interval between first going in the military and final discharge. Some veterans may have had 2 or more non-contiguous enlistments. Because this is relatively rare the greater than 4 years category may represent veterans that made the military a "career1. These individuals serving more that 4 years did not have an increased SMOR. Table 7g presents SMORs by ICDA-8 coding. The Marine Corps SMOR for ICDA-8 code 200 is elevated. This code includes reticulum-cell sarcoma and lymphosarcoma. In contrast, black Army veterans have a SMOR of 3.82 for ICDA-8 code 202(giant follicular lymphoma, mycosis fungoides, and other lymphomas). DISCUSSION Numerous studies have, revealed an association between herbicide use and NHL. A recent population based case control study(Hoar, et al) presented an odds ratio of 2.2(CI 1.2-4.1) for farmers ever using phenoxyacetic acids. A matched case control study(Hardell, et al) of malignant lymphomas(Hodgkin's disease and NHL) showed a calculated relative risk of 4.8 for exposure to phenoxy acids. In that study persons with concommittant high-grade exposure to chlorophenols were excluded. Because Agent Orange and other herbicides used in Vietnam contain phenoxyacetic acids, it is essential to attempt to associate a level of exposure to one or more of these agents to a particular individual. Future efforts of the Office of Environmental Epidemiology include associating location of a Southeast Asia veteran's unit with known spraying missions. Also, an additional sample of veterans' deaths from 1982-1984 is being prepared. From this furthur data we hope to see if disproportionate deaths from NHL continues to occur among veterans with Southeast Asia exposure. �BIBLIOGRAPHY Anderson, Henry A., et al. Wisconsin Vietnam Veteran Mortality Study. March, 1986. Decoufle, Pierre, Thomas, Terry L. an Pickle, Linda W. "Comparison of the Proportionate Mortality Ratio and Standardized Mortality Ratio Risk Measures." American Journal of Epidemiology 111: 263-69, 1980. Directorate for Information, Operations and Reports. Department of Defense Selected Manpower Statistics Fiscal Year 1981. Hardell, L., et al. "Malignant Lymphoma and Exposure to Chemicals Especialy Organic Solvents, Chlorophenols and Phenoxy Acids: A Case-Control Study". British Journal of Cancer 43: 169-76. 1981. Hoar, S. K., et al. "Agricultural Herbicide Use and Risk of Lymphoma and Soft-Tissue Sarcoma". Journal of the American Medical Association 256: 1141-47. September 5, 1986. Holmes, Alan P., et al. West Virginia Vietnam-Era Veterans Mortality S tudy. January, 1986. Kogan, Michael D. and Clapp, Richard W. Mortality Among Vietnam Veterans in Massachusetts. 1972-1983. January 25, 1985. Kupper, L. L., et al. "On the Utility of Proportional Mortality Analysis." Journal of Chronic Disease 31: 15-22, 1978. Lawrence, Charles E. et al. "Mortality Patterns Among Vietnam and Vietnam Era Veterans." American Journal of Public Health 75: 277-79, 1985. Milham, Jr., Samuel. "Methods of Occupational Mortality Studies." Journal of Occupational Medicine 17: 581-85. Miettinen, O. S. and Wang, J. "An Alternative to the Proportionate Mortality Ratio". Amerian Journal of Epidemiology 114: 144-48. 1981. National Academy of Sciences, National Research Council, Commission on Life Sciences, Medical Follow-up Agency. Ascertainment of Mortality in the U. S. Vietnam Veteran Population. 1985. Public Health Service. Eighth International Classification of Diseases Adapted to the United States. Spiegelman, D., Wang, J., and Wegman, D. "Epidemiologic Programs for Computers and Calculators". American Journal of Epidemiology 118: 599-607. 1983. The Surgeon General, United States Air Force. An Epidemiologic Investigation of Health Effects in Air Force Personnel Following Exposure to Herbicides. June 30, 1983. APPENDIX 1. The following is a description of the Military Occupation Service Codes. The exact codes used are identical to those used in the Wisconsin Vietnam Veteran Mortality Study (Anderson,et al). �Combat. Occupations with primary duty involving direct offensive and defensive actions against an armed hostile enemy force. For example: rifleman, assaultman, field artillary batteryman, or mortar man. Direct. Occupations with combat troops that may involve indirect contact with an armed electrical systems technician, field radio operator. primary duty involving support of limited direct and/or extensive hostile force. For example: bulk fuel specialist, wireman or Indirect. Occupations with primary duty involving indirect support of combat and/or direct support troops that does not involve contact with an armed hostile force. For example: cook, aircraft ballistics computer technician, radar repairman, and clerk. 2. The following are ICDA-8 codes associated with the categorization of cancer mortality in Table 4. Category Other causes Buccal Esophagus Stomach Intestines, etc. Liver, biliary Pancreas Upper resp. Lung Bone Soft tissue Melanoma Prostate Testis Bladder Kidney Brain Other nervous system Thyroid and endocrine Non-Hodgkin's lymphoma Hodgkin's Multiple Myeloma Leukemia Other cancer ICDA-8 Code 0-136,210-228,240-989 140-149 150 151 152-154,158,159 155-156 157 160-161 162 170 171 172 185 186 188 189 191 192 193-194 200,202 201 203 204-207 163,173-174,187,190,195199,208-209,230-239 �3* The following is the distribution of caus,es of death from the National Academy of Sciences Ascertainment of Mortality in the U. S. Vietnam Veteran Population for all veterans not • going to Vietnam. Forty-five percent of these veterans were Vietnam era veterans. The 'other1 category includes cardiovascular disease. Cause Cancer Other Motor Vehicle Suicide Homocide Other Trauma Unknown Total Found in BIRLS No.(%) 97(9.7) 231(23.0) Not Found in Birls No.(%) 237(23.6) 163(16.2) 123(12.2) 42(4.2) 112(11.1) 23(9.6) 58(24.2) 52(21.7) 25(10.4) 38(15.8) 13(5.4) 31(12.9) 1005(100.0) 240(100.0) �TABLE 1: The Study Sample—Military Records Search. Number Percent 75617 100.0% 1032 1.4% Records found, ineligible 22302 29.5% Records found, eligible 52283 69.1% All names selected Records not found Ineligibility was based on: a. wrong branch of service, b. wrong time of service Table 2: Results of Death Certificate Search. Number 52283 Coded cause of death Table 3; 1.6% 51421 No cause of death 100.0% 862 Eligible cases Percent 98.4% Distribution of Eligible Deaths by Branch of Service, Race, and Place of Service. Army Marines Other Service Southeast Asia 15734 1 Nonwhite 4399 18215 3943 3120 4689 760 661 20133 22904 4603 3781 Southeast Asia White 1 Nonwhite includes unknown race. Other Service �Table 4; Standardized Proportionate Mortality Ratios (SPMRs) by Branch of Service and Race. 1 2 SPMR Army Marines Other causes Buccal Esophagus Stomach Intestines, etc. Liver, biliary Pancreas Upper resp. Lung Bone Soft tissue Melanoma Prostate Testis Bladder Kidney Brain Other nervous Thyroid, endo. Non-Hodgkin ' s Hodgkin ' s Multiple Myeloma Leukemia Other cancer 1.00 0.92 1.29 1.13 0.97 0.98 2.21 0.39 0.81 1.25 1.20 1.62 0.18 1.57* 1.35 0.70 0.93 1.29 1.26 2.39 0.95 1.05 0.92 0.56 2.08* 1.37 0.45 1.12 1.06 1.01 0.88 1.19 1.03 0.86 1.03 1.04 0.89 1.11 0.61 0.89 0.96 0.55* 0.58 0.82 1.15 0.80 0.88 1.03 White Nonwhite 1.00 1.09 0.90 0.99 1.05 1.28 0.98 0.99 1.09 1.03 0.93 0.99 0.68 1.20 0.90 0.83 0.99 0.62* 0.58 0.89 1.22 0.68 0.89 1.00 * p-value for Mantel-Haenszel chi-square 1 degree of freedom < .05. 1 See Appendix from respective ICDA-8 codes. 2 Nonwhite includes unknown race. 0.99 0.85 1.72 1.33 0.82 0.69 0.82 1.13 1.11 0.59 1.06 3.33 3.16 0.60 0.28 1.56 0.85 0.43 0.57 1.53 1.01 1.21 1.14 1.23 �Table 5; Age Distribution of Non-Hodgkin's Lymphoma. Black Army Marines SE Asia Service Non SE Asia Service SE Asia Service Non SE Asia Service 20-29 7 4 4 3 30-39 23 3 13 4 40-49 2 2 2 1 50-59 2 1 0- 1 60+ 1 0 0 0 35 10 19 10 Total 1 Table 6: Age Specific Mortality Odds Ratios for Non-Hodgkin's Lymphoma. Marines Black Army MOR(LCI,UCI) MOR(LCI,UCI) 20-29 2.17(0.60,7.75) 3.15(0.67,14.8) * 30-39 5.07(1.49,17.2) 2.86(0.92,8.86) 40-49 0.28(0.04,2.02) 0.53(0.07,3.85) 50-59 0.95(0.08,10.7) 60+ 1.58(0.05,48.8) ** * p-value for Mantel-Haenszel chi square < .01. ** number of exposed cases is one. 1 Cardiovascular deaths are the control population. �1 Table 7a; Overall Standardized Mortality Odds Ratio for Non-Hodgkin's Lymphoma. Marines SMOR(LCI,UCI) 2.05(1.81,2.30) Black Army SMOR(LCI,UCI) 1.78(0.93,3.42) 1 Cardiovascular deaths are the control population. Table 7b; 1 Standardized Mortality Odds Ratio for Non-Hodgkin's Lymphoma by Year of Death. Marines SMOR(LCI,UCI) Black Army SMOR(LCI,UCI) 1965-76 2.70(0.80,9.19) 0.58(0.00,280.) 1977-79 1.79(0.51,6.21) 1.79(0.64,5.06) 1980-82 2.57(0.94,7.06) 2.90(0.76,11.0) 1 Cardiovascular deaths are the control population. Table 7c; 1 Standardized Mortality Odds Ratio for Non-Hodgkin's Lymphoma by Military Occupation Specialty Code(MOSC). Marines SMOR(LCI,UCI) Combat Black Army SMOR(LCI,UCI) Direct 6.23(1.28,30.2) 2 0.72( , ) 2.20(0.58,8.38) 1.35(0.58,3.15) Indirect 2.31(0.39,13.9) 1.95(0.57,6.73) 1 Cardiovascular deaths are the control population. 2 Confidence interval not calculated. �Table 7d: Standardized Mortality Odds Ratio for Non-Hodgkin's Lymphoma by Potential Tours of Service in Southeast Asia. Marines SMOR(LCI,UCI) Black Army SMOR(LCI,UCI) LE 13 MO 2.39(1.26,4.53) 1.73(0.79,3.80) GT 13 MO 1.23(0.78,1.93) 1.92(0.91,4.05) 1 Cardiovascular deaths are the control population, Table 7e: Standardized Mortality Odds Ratio for Non-Hodgkin's Lymphoma by First Year in Southeast Asia. Marines SMOR(LCI,UCI) Black Army SMOR(LCI,UCI) 1965-66 1.76(1.02,3.03) 1.89(0.72,4.95) 1967-69 2.51(1.22,5.21) 1.96(0.94,4.10) 1970+ 1.68(0.39,7.18) 0.73(0.11,4.81) * Number of exposed cases is one. 1 Cardiovascular deaths are the control population. Table 7f: Standardized Mortality Odds Ratio for Non-Hodgkin's Lymphoma by Potential Years in Military Service. Marines SMOR(LCI,UCI) Black Army SMOR(LCI,UCI) LE 4 YRS 3.61(1.49,8.73) 2.93(1.29,6.66) GT 4 YRS 0.85(- 0.55(0.12,2.57) 1 Cardiovascular deaths are the control population. 2 Confidence interval not calculated. �1 Table 7q; Standardized Mortality Odds Ratio for Non-Hodgkin's Lymphoma by ICDA-8 Code. Marines SMOR(LCI,UCI) Black Army SMOR(LCI,UCI) Code=200 2.33(1.12,4.85) 1.12(0.65,1.92) Code=202 1.85(0.82,4.18) 3.82(1.15,12.7) 1 Cardiovascular deaths are the control population, � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 066 Folder The folder containing the original item. 1775 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Burt, Vicki L. Patricia Breslin Han Kang Yvonne Lee Michael Feil Description An account of the resource <strong>Corporate Author: </strong>Office of Environmental Epidemiology, Department of Surgery and Medicine, VA Title A name given to the resource Typescript: Non-Hodgkin's Lymphoma in the Vietnam Veterans Mortality Study, September 1986 Subject The topic of the resource VA Mortality Study lymphomas cancer risk assessment mortality trends ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 066 Folder The folder containing the original item. 1773 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Carroll, Ray Title A name given to the resource Letter: from Ray Carroll to Maurice [LeVois], August 26, 1982 Subject The topic of the resource study protocol mortality trends ao_seriesIII https://www.nal.usda.gov/exhibits/speccoll/files/original/a2014b3553892ab52b1151ea01b44fa8.pdf 5ec475115a2c1e9c6816c01d86c0142f PDF Text Text Item ID Number 01744 Author Boyle, Collen A. Corporate Author Center for Environmental Health and Injury Control, CD RODOrt/ArtlOlO Title Typescript: Postservice Mortality Among Vietnam Veterans, February 1987 Journal/Book Title Year 000 ° Month/Day Color '"' Number of Images 148 Descripton Notes CEH#86-oo76 Monday, June 11, 2001 Page 1745 of 1793 �CEH # 8 - 0 6 607 POSTSERVICE MORTALITY AMONG VIETNAM VETERANS Coleen A. Boyle, Pierre Decoufle, Robert 7. Delaney, Frank DeStefano, Melinda L. Flock, Martha I. Hunter, M. Riduan Joesoef, John M. Karon, Marilyn L. Kirk, Peter M. Layde, Daniel L. McGee, Linda A. Moyer, Daniel A. Pollock, Philip Rhodes, Mark J. Scally, Robert M. Worth. February 1987 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE Centers for Disease Control Center for Environmental Health Atlanta, Georgia 30333 �FEB l 3 1987 AGENT Utwwt rhuucuio UFFICt (10X2) �ACKNOWLEDGEMENTS Many other individuals and organizations have provided invaluable support to the study. These include the Agent Orange Working Group and its Science Panel; Army Reserve Personnel Center, U.S. Army and Joint Services Environmental Support Group, Department of Defense; National Personnel Records Center, National Archives and Records Administration; General'Services Administration; Veterans Administration; National Center for Health Statistics; Social Security Administration; Internal Revenue Service; Institute of Medicine, National Academy of Sciences; other staff members of the Centers for Disease Control, and outside consultants who contributed their unique expertise. �TABLE OF CONTENTS Page ACKNOWLEDGEMENTS SUMMARY 1. INTRODUCTION 1.1 Ganeral Background of the Study 1.2 Previous Mortality Studies of Vietnam Veterans 1.3 Rationale and Research Questions 2. STUDY GROUP DEFINITION, DATA COLLECTION. AND FOLLOW-UP 2.1 2.2 2.3 2.4 2.5 Criteria for Inclusion Sample Size and Power .Selection of Veterans Collection of Data from Military Personnel Files Vital Status Ascertainment 2.5.1 Inservice Deaths 2.5.2 Postservice Deaths 2.6 Determination of Cause of Death 2.6.1 Death Certificates 2.6.2 Medical Review Panel - Supplementary Records 3. METHODS OF ANALYSIS 3.1 Definition of Critical Variables 3.1.1 Place of Service 3.1.2 Coyariates 3.1.3 Cause-of-Death Categorization 3.2 .Internal Comparisons 3.3 External Comparisons 4. RESULTS 4.1 Distribution of Covariates for Vietnam and Non-Vietnam Veterans 4.2 Analysis of All-Cause Mortality 4.2.1 Crude Results 4.2.2 Consideration of Covariates 4.2.3 Influence of Inservice Deaths 4.2.4 Influence of Incomplete Follow-up 4.3 Analysis of Cause-Specific Mortality 4.3.1 Cause of Death Based on Death Certificates 4.3.2 Cause of Death Based on Medical Review 4.3.3 Consideration of Covariates 4.4 Comparison of Veteran and U.S. Death Rates 5. DISCUSSION 5.1 Strengths and Limitations 5.2 Comparison with Previous Mortality Studies of Vietnam Veterans 5.3 Possible Interpretations and Conclusions , �6. REFERENCES / APPENDIX A: APPENDIX B: APPENDIX C: APPENDIX D: APPENDIX E: APPENDIX F: Detailed Distributions of Veteran Characteristics Detailed Examination of All-Cause Mortality by Selected Covariates Detailed Characteristics of Men Killed in Action Mortality from Motor Vehicle Accidents, Suicide; and Drug-Related Causes by Selected Covariates Details of Medical-Review-Panel Findings Cox Regression Model �SUMMARY ; This report presents results of the mortality component of the Vietnam Experience Study (VES). The VES is a historical cohort study in which the. health of 9,324 Vietnam veterans is compared with that of 8,989 Vietnam-era veterans who served in Korea, Germany, or the United States. Eligibility for the study was limited to male U.S. Army veterans who first entered military service between 1965 and 1971, served a single term of enlistment, and were discharged in the enlisted pay grades E-l to E-5. Participants were randomly selected from computerized lists of accession numbers of military personnel files of Army veterans discharged during the relevant time period. Ascertainment of deaths occurring after discharge from active duty and before January 1, 1984 was done using several methods, ranging from computer linkages to personal contact with next-of-kin, resulting in practically complete death ascertainment for both cohorts. In addition to an analysis based on death-certificate cause of death, a medical review panel independently assigned an underlying cause of death using information from supplemental sources, including hospital records, autopsy reports, personal physician contacts, and coroner and law enforcement files. Veterans of service in Vietnam were found to experience a 17% higher rate of postservice mortality than veterans who served in Korea, Germany, or the United States. As expected in such a study of young men, the majority of deaths in both cohorts were due to external causes. The most noteworthy pattern of overall mortality was the changing difference between Vietnam and non-Vietnam veterans over time. During the first 5 years postdischarge, mortality among Vietnam veterans was 1.45 times the death rate of non-Vietnam veterans (95X 01=1.08-1.95). During the succeeding years, there was virtually no difference between the two groups (RR=1.01, 95X 01=0.79-1.28). This pattern was generally consistent across most demographic and military subgroups of veterans. However, there was some indication 'that Vietnam veterans with some physical impairment at entry into service, those who were drafted into service, and those discharged before 1970 were at an especially high risk of dying during the first 5 years after discharge compared with their non-Vietnam counterparts. When the data were stratified by type of military unit and military occupational specialty, the relative risks of mortality were similar for those more or less likely to have engaged in combat. Unlike the finding of especially high excess mortality among Australian Vietnam veterans who served in the Engineer Corps, no excess was found among engineers in this study. External causes accounted for most of the increased mortality in 'the early postservice period. Deaths due to motor vehicle accidents (MVA) were significantly increased during this time (RR=1.93, 95X 01=1.16-3.22). A more detailed examination of MVA deaths did not indicate any particular factor that could explain the overall excess in Vietnam veterans. The increased risk did not appear to be related to elevated blood alcohol levels at the time of death, and the risk was evident regardless of the type of MVA. Drug use information on MVA victims was limited, and the medical review panel identified only one drug-related MVA death from available supplementary records. Suicide and homicide showed similar increases (RRs=1.72, 95X 01=0.76-3.88 and 1.52, 95X 01=0.59-3.91, respectively) in the early follow-up period but the rate ratios were not statistically different from 1.0. Mortality from accidental poisoning was elevated throughout the follow-up period, although the number of such deaths was small. Most of these involved �the use of illicit drugs. When all drug-related deaths identified by the medical review panel were analyzed together, there appeared to be an increasing relative risk with number of years since discharge. The only natural cause of death category for which the mortality rate among Vietnam veterans differed from that among non-Vietnam veterans was circulatory system diseases. Vietnam veterans had a surprising deficit in such deaths relative to non-Vietnam veterans (RR=0.49, 95% 01=0.25-0.99). Statistical adjustment for potential confounders had little effect on the results, except for suicide where adjustment increased the RR in the early postservice period to 2.54 (death certificate data). These results are similar to previous observations of increased mortality from external causes among World War II and Korean War combat veterans. In contrast, broader cross sections of World War II veterans, including combat and noncombat groups, showed no difference, or even a deficit, in postdischarge traumatic deaths, as did non-Vietnam veterans in this study. Although the influence of factors specific to the Vietnam experience cannot be completely ruled out, our findings and those of prior studies suggest that the postservice.excess of traumatic deaths among Vietnam veterans is probably related to unusual stresses the veterans endured while -stationed in a war zone. The pattern of drug-related mortality among Vietnam veterans seems to differ from that of external causes of death. The drug-related excess is most pronounced among draftees, among those whose jobs involved combat operations, and among those who served in Vietnam during 1968 and 1969, the years of heaviest combat activity. Thus, the increased death rate from drug-related causes among Vietnam veterans may be linked to intensity of combat exposure rather than to a general effect of the Vietnam experience. This mortality assessment of Vietnam veterans is an incomplete evaluation of their health experience. Additional data on the present and past health status of living Vietnam veterans will be forthcoming from the health interview and the medical, psychological, and laboratory evaluation components of the VES. Furthermore, since this group of veterans has not yet reached the age-span where chronic diseases have an important impact on mortality, continued monitoring of mortality among VES participants may provide additional insights. -2- �1. INTRODUCTION In response to Vietnam veterans' concerns about their health, the Centers for Disease Control (CDC) has proposed three distinct, but related, epideroiologic studies: a) The Vietnam Experience Study (VES) is a historical cohort study to ascertain whether adverse health effects are associated with service in Vietnam. b) The Agent Orange Study is a historical cohort study to ascertain whether men with possible exposure to the phenoxy herbicide code-named Agent Orange while in Vietnam, have experienced any health problems related to that exposure. c) The Selected Cancers Study is a concurrent, population-based case-control study to ascertain whether Vietnam veterans are at increased risk of particular types of cancer that occur too infrequently to be evaluated adequately in the two cohort studies. The first two studies include three methods of health assessment: a mortality-assessment, health interviews of living veterans, and a clinical, psychological, and laboratory assessment of a random sample of those who complete the health interview. This report presents results of the mortality component of the VES. 1.1. GENERAL BACKGROUND OF THE STUDY Many Vietnam veterans believe that their service in Vietnam and, more specifically, their exposure to Agent Orange have increased their risks for a wide variety of illnesses. Health concerns include dermatologic conditions, cancer, and congenital anomalies among their offspring. Unfortunately, little objective evidence about the physical health of Vietnam veterans is available. In response to these concerns and the lack of objective data, the United States Congress passed two laws mandating that the Veterans Administration (VA) conduct epidemiologic studies of the health of veterans of the Vietnam conflict. Public Law 96-151 (1979) specifies the conduct of an epidemiological study of U.S. veterans to assess the possible health effects of exposure to herbicides and associated dioxins during the Vietnam conflict.1 Public Law 97-72 (1981) expands this mandate to include the study of other environmental exposures that may have occurred in Vietnam.2 In January 1983, the responsibility for the design, conduct, and analysis of studies responsive to these laws, first assigned to the VA, was transferred by an Interagency Agreement to CDC. In May 1983, CDC prepared a draft protocol that underwent extensive peer review,* and in November 1983, issued a revised protocol.^ * This included formal reviews by the Office of Technology Assessment Agent Orange Advisory Panel, the DHHS Advisory Committee on Special Studies Relating to Possible Long-Term Health Effects of Phenoxy Herbicides and Contaminants ("Ranch Hand Panel"), the Agent Orange Working Group Science Panel, and a Centers for Disease Control Ad Hoc Review Panel.4 •"«*«•» �1.2. PREVIOUS MORTALITY STUDIES OF VIETNAM VETERANS When tine present study was designed, little was known about the long-term physical health consequences, including death, of military service in Vietnam. Since that time, six mortality studies of Vietnam veterans have been reported. Five were conducted in the United States, and the sixth dealt with Australian military personnel who served in Vietnam. The first of the five mortality studies of U.S. servicemen was conducted by the U.S. Air Force.5 It was a retrospective cohort study of Air Force personnel involved in the aerial herbicide spraying operation in Vietnam designated "Operation Ranch Hand." Although the differences were not statistically significant. Ranch Hand flight crews had slightly lower death rates than other Air Force personnel of similar military rank and occupation, and Ranch Hand ground personnel had slightly higher death rates than the comparison group. However, since the principal concern of the Ranch Hand Study was the adverse health effects of herbicide exposure in this unique group of veterans, the relevance of the Ranch Hand results to our study is questionable. Four other mortality studies of U.S. Vietnam male veterans were conducted by the State health departments of Massachusetts, New York, Wisconsin, and West Virginia.6'9 All were death certificate-based proportionate mortality studies, which are useful in detecting unusual patterns in cause-specific deaths. However, without actual mortality rates it is difficult to determine whether an increased frequency for one cause of death reflects a true rise in risk for that cause or a deficit in other causes of death. In addition, the Massachusetts and West Virginia studies are based on nonrandom samples of deaths, and it is unclear whether some selectivity in identifying deaths occurred. The Massachusetts study compared causes of death among Vietnam veterans with those'among Vietnam-era veterans who did not serve in Vietnam and among nonveteran males from Massachusetts.6 Vietnam service was determined from a computer-based list of veterans who had applied for a military service bonus awarded by the Massachusetts Office of Veterans Services. The most striking finding of the study was a markedly increased number of connective tissue cancers in Vietnam veterans (9 observed versus 1 expected, based on the mortality pattern of non-Vietnam veterans). No other causes of death were significantly elevated in Vietnam veterans. The study by the New York State Department of Health compared ., cause-specific mortality patterns of New York State Vietnam veteran's with those for non-Vietnam veterans.? Vietnam service status was determined by matching the computer-based record systems of the Defense Manpower Data Center (Department of Defense) and the VA Beneficiary Identification and Record Locator Subsystem (BIRLS). The strongest association with Vietnam service involved deaths from nonmotor-vehicle injuries of transport. The Wisconsin study examined mortality among Vietnam veterans, other Vietnam-era veterans, veterans not of the Vietnam era, and nonveterans within the State of Wisconsin.8 Deaths among Vietnam era veterans were identified from a Wisconsin Department of Veteran Affairs Graves Registration File, and Vietnam status was determined from military personnel files. Relative to other Vietnam-era veterans, those who served in Vietnam had excess mortality from cancer of the pancreas, diseases of the genitourinary system, and pneumonia. An excess of connective tissue cancer was noted when Vietnam veterans were compared with veterans not of the Vietnam era (5 deaths observed �I versus 0.3 expected). No significant excess was noted, however, when Vietnam veterans were compared with other Vietnam era veterans or with nonveterans (5 deaths observed versus 3 expected). The West Virginia study examined causes of death among deceased Vietnam-era veterans who had been given a military service bonus by the State Department of Veterans Affairs.9 Among 615 such veterans who had served in Vietnam there was a slightly larger proportional mortality ratio (PMR=1.11) for suicide and for motor-vehicle accidents (PMR=1.07), using for comparison the general male population of the same age. Non-Vietnam veterans exhibited about the same results for motor-vehicle accidents, but their suicide experience was not unusual. Both Vietnam and non-Vietnam veterans experienced increased mortality from cancer of the respiratory tract, but increases in relative frequency of death from cancer of connective tissues (3 observed versus 0.7 expected) and Hodgkin's disease (5 observed versus 2.4 expected) were confined to Vietnam veterans. When Vietnam veterans were compared directly with non-Vietnam veterans, these excesses persisted, and, in addition, there were more deaths among Vietnam veterans from testicular cancer (3 observed versus 0.6 expected). The study of Australian Vietnam veterans was a retrospective follow-up of mortality from 1965 to 1981 among 19,205 Vietnam veterans and 25,677 veterans who did not serve in Vietnam.10 Both groups had a lower overall mortality rate than the general population of Australian men of similar age, but Vietnam veterans had a 29% higher overall death rate than those who did not serve in Vietnam. Interestingly, the excess was due mainly to an increased rate among Vietnam veterans in the Engineer Corps (rate ratio=2.5). In addition to an overall elevated death rate, Vietnam veterans had increased death rates for digestive system diseases, diseases of the circulatory system and external causes. The death rates from neoplasms (all types combined) were similar in "the two groups;^ 1.3. RATIONALE AND RESEARCH QUESTIONS Aside from the obvious importance of studying premature deaths because of the human tragedy they represent, there are several methodologic reasons why a detailed study of mortality is essential in a comprehensive evaluation of the health consequences of military service in Vietnam. First, death is an objective health outcome, not subject to some of the potential biases of1 self-reported health information. Second, the prevalence of certain health outcomes can be assessed accurately only if deaths due to them are included in the analysis. For example, a sizeable proportion of people with cardiovascular diseases and certain cancers die within a short time after the onset of the disease, as do those with very serious intentional or unintentional injuries, thus becoming unavailable for interview or examination in a subsequent study. This would lead to a serious underestimation of rates for such conditions in a retrospective study, unless mortality is included. Finally, a study of mortality may be the only feasible mechanism for continued surveillance of the study cohort after the current VES ends. This is critical for serious health effects which may first become manifest more than 15 years after service in Vietnam. At the time the VES was conceived, the research objective was simply to examine the relationship between Vietnam service and deaths from all causes combined as well as specific causes of death. This objective stemmed from the rationale that the "Vietnam Experience" was a generic term for a wide range of —5— �health-influencing exposures operating among those who served in the military in Vietnam. Included in the "experience" are known exposures, such as the psychological stresses of war, possible exposure to various infectious diseases prevalent in Vietnam, possible misuse of drugs and alcohol, and possible exposure to the defoliant Agent Orange, as well as many unknown exposures. These factors are unmeasured in this study; therefore, it is not possible to examine directly their relation to mortality.. However, based on the observed patterns of mortality, speculation on the possible influence of one component relative to the others may be possible. As a result of the recently reported findings from the mortality studies of Vietnam-era veterans reviewed above, special attention will be focused on the relationship of Vietnam service to deaths from external causes, specifically, motor vehicle accidents, suicide and other external causes of death. Moreover, the risk of death associated with Vietnam service will be examined in various subgroups, particularly type of unit and military occupational specialty. Although previous studies suggest a relationship between service in Vietnam and several natural causes of death, for example, soft-tissue -cancers, the numbers of these deaths expected in our cohort are too few to address these questions adequately. �2. STUDY GROUP DEFINITION, DATA COLLECTION, AND FOLLOW-UP The present study employs a historical cohort design to evaluate the risk of death among U.S. Army veterans who served in Vietnam relative to a comparison cohort of Army veterans who served during the same time period but not in Vietnam. This type of study involved identifying a cohort of Vietnam-era veterans, determining those veterans who died after discharge from active duty, and collecting detailed information on the nature and circumstances of each death. . 2.1. CRITERIA FOR INCLUSION The primary objective in defining the study and reference groups was to obtain two cohorts that were as similar as possible with regard to major health-influencing factors other than Vietnam service. Achieving this objective does not result in a representative sample of all military personnel who served in Vietnam. Comparability, however, was considered of paramount importance to increase the likelihood that any differences between the cohorts in mortality or morbidity after discharge was the result of service in Vietnam rather than the result of differences in preexisting health-related factors. To achieve this objective, only veterans meeting the following criteria were included In the study: a) U.S. Army veterans. The majority of military personnel who served in Vietnam were in the Army. Air Force and Navy personnel involved in the conflict were often stationed in various other parts of Southeast Asia near Vietnam. Marine Corps personnel were deployed in ways very similar to Army troops but in smaller numbers, and a very high proportion of all Marine Corps personnel of the Vietnam era spent time in Vietnam, thus making it difficult to find an adequately large comparison group of Marines without experience in Vietnam. b) Male veterans. On the basis of the sample size and selection process described below, too few women would be included for any meaningful conclusions to be drawn regarding the health of female Vietnam veterans. c) Military occupational specialty (MOS) other than "duty soldier" and "trainee." During the early stages of the study, we found that men with behavior or conduct problems were given the military occupational specialty of "duty soldier" (MOS 57A10). The probability of assignment to Vietnam for someone with this MOS may have been based more on the personal characteristics of the individual than on his specific training. A military occupational speciality of trainee ( 9 0 ) indicates that the individual never left basic or advanced 080 training in the United States. d) Single term of enlistment in the Army. Veterans who reenlisted may be very different in background characteristics from those- not choosing to do so. Further, reenlistment carried with it more opportunity to serve in the country of one's choice. Again, these characteristics may be associated with subsequent health. It should be noted that because of the method of sample selection, men who subsequently entered another branch of the military could be included in the cohort. e) Minimum of 16 weeks of active service time. Army regulations stated that servicemen could not be sent to duty stations such as Vietnam until 11 they had completed at least 16 weeks of active service time. —7— �f) Pay grade E-1 to E-5 at discharge. In many combat specialties the vast majority of career soldiers had at least one tour of duty in Vietnam, making it difficult to identify a comparison group of their peers who did not have Vietnam service. g) Entered military service for the first time between January I, 1965, and December 31, 1971. This corresponds to the period when a substantial number of single-term volunteer or drafted soldiers were assigned to duty in Vietnam. Before and after this period, the majority of servicemen in Vietnam were advisors (career enlisted men and officers), who were few in number and who are disqualified for one or more of the reasons given above. h) Duty stations for men in the comparison group limited to the United States, Germany, and Korea. On the basis of a pretest conducted by CDC in May of 1983, the vast majority of draftees and single-term volunteers who did not serve in Vietnam were assigned to these locations. More importantly, it was felt that the assignment process for other foreign countries worked differently than for the U.S., Germany, and Korea. Therefore, those who served elsewhere may be quite different in their background characteristics from those who served in Vietnam, Germany, Korea, and the United States. 2.2. SAMPLE SIZE AND POWER The VES was designed principally to assess morbidity associated with service in Vietnam; mortality is being examined for the reasons described in Section 1.3. Power computations for the health interview phase suggested that a sample size of 6000 for each cohort was necessary to detect a relative risk of 2.0 for conditions that occur with a prevalence of 5/1000 or greater in the unexposed population (assuming the probabilities of Type I and Type II errors are 0.05).* To obtain 6,000 completed interviews in both the Vietnam and non-Vietnam groups, the starting sample size had to account for the possibility of an estimated 15 percent non-location rate and a 15 percent interview refusal rate. Thus, the minimum number of veterans to be selected for each cohort was estimated to be 8300 (i.e., 8,300 x 0.85 x 0.85). Given about 8,500 servicemen in each of the two cohorts, the minimum detectable relative risks for overall mortality and selected causes of death are presented in Table 1. Adequate power exists to detect as statistically significant moderate increases in overall mortality and certain common causes of death. For example, the study has 95 percent power to detect a relative risk of-1.3 for overall mortality and 1.5 for deaths due to accidents. The study has good power to detect moderate increases in risk of suicide, circulatory disease, and malignant neoplasms. The study's power to detect relative increases for less frequent causes of death is limited unless a large risk is associated with Vietnam service. Additionally, the study has reasonable power to detect differences in risk for total mortality in certain subgroups of veterans. For example, if only 10% of veterans are in a subgroup of interest, a minimum relative risk of 2.0 can be detected for all causes. 2.3. SELECTION OF VETERANS Vietnam-era veterans were randomly selected from a set of computer tapes containing "accession numbers," each of which refers to a unique military personnel record on file at the National Personnel Records Center (NPRC) in St. Louis, Missouri. NPRC supplied CDC with a restricted range of -8- �approximately five million accession numbers for U.S. Army veterans whose service records were received by NPRC between September 1964 and June 1977. NPRC estimated that the vast majority of discharged U.S. Army Vietnam-era veterans would be included in this set. From a pilot test conducted in September 1983, it was estimated that approximately 40% of Army veterans randomly selected from the NPRC files would meet the eligibility criteria outlined above and that approximately half of these would have served in Vietnam. Thus, to identify 16,000 to 17,000 qualified veterans, the required starting sample size was approximately 43,000 veterans. A random number generating program was used to select the sample of approximately 43,000 accession numbers from this universe. The sample was split into 12 equal random samples for ease of processing. The decision to disqualify short-term men (less than 16 weeks of active service time), trainees, and "duty soldiers" was made after the original sample had been drawn. In'order to make up for these losses, we added two additional random samples of approximately 3,500 each to the list originally drawn. Personnel records corresponding to these numbers were pulled and reviewed for the inclusion criteria listed above. As outlined in Figure 1, 99% (N=48,513) of the random numbers generated corresponded to a unique accession number on the NPRC computer tapes. Of these, 1,355 referred to records that could not be located after several attempts. Apparently, many of these were missing because of a subsequent reenlistment after an earlier discharge. Of the 47,158 veterans whose records were located and reviewed, 61% were excluded because they failed to meet one or more of the inclusion criteria outlined above, but less than 1% were excluded because information necessary to determine study eligibility or to categorize them with respect to critical factors, such as duty station, was missing. Thus, 18,581 men qualified for the study (9,558 Vietnam and 9,023 non-Vietnam veterans). 2.4. COLLECTION OF DATA FROM MILITARY PERSONNEL FILES Each month for 14 consecutive months, lists containing 3,500 accession numbers were sent to NPRC. NPRC located the corresponding military records (201 files) and sent them to the Army Reserve Personnel Center, formerly known as the Reserve Component Personnel and Administration Center (RCPAC), aLso located in St. Louis, Missouri. Each file was reviewed there for certain eligibility criteria, and a data abstraction form was initiated. Data abstraction forms and files of veterans who appeared to meet the criteria for the study were forwarded to the U.S. Army and Joint Services Environmental Support Group (ESG) in Washington, O.C., where a second qualification process was completed. Detailed information was then abstracted from the files of those veterans found to be qualified for the study. A majority of the data for the study were taken from the Department of Defense Form 214 and Department of the Army Form 20. All data abstraction forms were then sent to CDC for keying and editing. Information abstracted from the personnel files can be grouped into two types. The first type consists of data collected at time of entry into the Army. Variables include demographics, such as date of birth, race, and birthplace, and preservice characteristics, such as physical and mental health as determined by the entrance physical examination, and measures of general intelligence and aptitude. -9- �The second type of characteristics abstracted from the military personnel records describes the veteran's military experience. These include the date of entry, location and dates of each tour of duty, types of units, military occupational specialty during each tour, total length of active military service, indications of misconduct, date of separation from active duty, and type of discharge (character of service). A more detailed description of entry and military history characteristics is presented in Appendix A. Finally, names and addresses of next-of-kin were abstracted for use in locating living veterans for the health interview and examination phases of the study. Military records of veterans ascertained to have died after discharge were .independently rereviewed to verify that duty stations had been accurately recorded. All of them were found to have been correctly classified as "Vietnam" or "non-Vietnam" in the initial abstraction process. 2.5. VITAL STATUS ASCERTAINMENT Although men were identified by date of entry into the Army, this report examines mortality after separation from active duty. Follow-up began the day the veteran was separated from active service and terminated on the date of his death or December 31, 1983, whichever came first. Follow-up was terminated at the end of 1983 because identification of deaths from the various tracing sources after that date was not complete. Veterans who died on active duty are excluded from the study but some data on them are given here for completeness. 2.5.1. Inservice Deaths Inservice deaths were identified during the review of military personnel files to determine study eligibility. Any veteran who died during active military service, regardless of the manner or circumstances of his death, has a "casualty report" (Form 1300) placed in his military personnel file. This process was necessary to remove the decedent from the active military rolls as well as to activate payment of benefits to his survivors. Table 2 presents the numbers of inservice deaths by the manner of death. Overall, 234 (2.4%) of Vietnam veterans were found to have died during active service, but only 34 ( . % of the comparison group had died in service. The 04) possible effect of this disproportionate depletion of the cohorts on the postservice mortality experience is examined later. * The narrative summary from the casualty report, which described the manner and circumstances of death, was used to place inservice deaths in respective categories. A "hostility-related" death is defined as one resulting from direct or indirect contact with hostile enemy action. The "implements of war-related" death category includes deaths not directly or indirectly related to enemy action, but from the operations or implements of war, such as "killed by friendly fire." Finally, an "other" category includes deaths not related to war operations or to enemy action, such as those from motor vehicle accidents, drownings, and natural causes. The majority of inservice deaths among Vietnam veterans was due to hostility-related causes. The rates of inservice deaths not due to war-related activities are identical in the two cohorts (i.e., 3.7 deaths per 100. ,0) Although not shown, only 3 of the 68 deaths assigned to the "other" cause of death category were due to natural causes. All three are among Vietnam -10- �veterans and thair causes are malaria (ICD-9,084.0). malignant neoplasm of connective or soft tissue (ICD-9,171.9), and unknown or unspecified cause (ICD-9,799.9). The remaining deaths in the "other" category were due to external causes, with a majority of these attributed to motor-vehicle accidents (11 Vietnam and 19 non-Vietnam). 2.5.2. Postservice Deaths Deaths occurring after separation from active duty were identified with the assistance of several Federal agencies. Computer tapes containing the names, social security numbers, and dates of birth of all veterans not known to have died in service were submitted simultaneously to the following agencies: o Veterans Administration - Beneficiary Identification and Record Locator Subsystem (BIRLS) o Social Security Administration o Internal Revenue Service (through special arrangement with the National Institute for Occupational Safety and Health) o National Center for Health Statistics (NCHS) - National Death Index Each of these agencies receives notifications (in different degrees of completeness) of deaths and maintains this information in computer-based files. In addition to these, two other sources were used to identify postservice deaths. The first is the "casualty report" described previously, which is also filed for any veteran who dies while in reserve status, a period of up to 4 years following date of separation from active duty for draftees and up to 3 years for volunteers. It is also filed for those veterans who are currently receiving military benefits at the time of death. The second additional source of postservice deaths was the locating and contacting procedures used for the health interview component of the VES. Names of next-of-kin and address information obtained from military personnel files and the various Federal agencies were used to locate veterans not identified as deceased by other sources. Several mechanisms were used to ascertain their present address and telephone number, including Directory Assistance telephone tracing, credit bureau checks, local directories, and contacts with relatives and neighbors. All tracing and follow-up activities were done by persons who had no knowledge of the veterans' military ' background, including countries of service. Four percent of all postservice deaths were identified solely through these means. As shown in Table 3, confirmation of vital status was finally established for 93.6X of the Vietnam cohort and 91.9X of the non-Vietnam cohort. Since the proportion of veterans with uncertain vital status was small and similar for the two cohorts, these men were considered alive at the end of follow-up for analytic purposes. 2.6. DETERMINATION OF CAUSE OF DEATH For veterans who died during the follow-up period, a copy of their death • certificate was obtained from the appropriate state or local vital statistics office. Successful retrieval of death certificates was achieved for all but nine deaths. Underlying cause and contributing causes of death were determined from the death certificate by an experienced nosologist and, independently, by a panel of physicians using all available supplemental medical and law enforcement information. -11- �: 2.6.1 Death Certificates Underlying causes of death were determined and coded by 'an experienced nosologist at the National Center for Health Statistics. Causes of death were coded to both the Eighth and Ninth revisions of the International Classification of Diseases.12,13 jne Eighth Revision was used when the mortality experience of Vietnam and non-Vietnam veterans was compared with that of the U.S. general male population, and the Ninth Revision was used when the mortality of Vietnam veterans was compared directly to that of non-Vietnam veterans. The nosologist had no knowledge of whether the decedent had served in Vietnam. The reproducibility of the cause-of-death coding was examined through a blind resubmission to the nosologist of a 10% random sample of deaths due to external causes and a 10% sample coded to nonexternal causes. There was 98% agreement between initial and repeat cause-of-death codes. 2.6.2. Medical Review Panel - Supplementary Records To provide an assessment of the cause of death independent of the one given on the death certificate, a special review was undertaken by a medical panel consisting of two physicians and a registered nurse. The nurse used the death certificate information to obtain pertinent medical and legal documentation describing the nature and circumstances of each death. Sources for record retrieval included hospitals, law enforcement agencies, coroners or medical examiners, and private physicians. For each death, any source that was deemed important for determining the nature and circumstance of the death, with the exception of interviews with next-of-kin, was pursued. Next-of-kin were contacted only when their permission was required for release of medical records. Only deaths for which all available records were successfully retrieved were reviewed. The nurse synthesized the available information into a summary statement which also indicated the sources and availability of pertinent records. Before meetings of the medical review panel, the case summaries were reviewed by the two physicians, and each independently assigned an underlying cause of death. The physicians were not aware of the place of military service and the death certificate cause of death. Significant diseases known to be present at the time of death were listed as "other significant conditions." For external causes of death they judged the intentionality and manner of death (accident, suicide, homicide, undetermined). One physician was assigned as "primary reviewer" for each death and reported his determination of the underlying cause of death, other significant conditions, and manner of death as well his rationale. If the other panelist disagreed, the evidence and reasoning in support of each point of view was presented. Additional information could be requested from the nurse, and final resolution of the disagreement was occasionally deferred until a subsequent medical panel meeting, held after the case had been reviewed by outside experts in the fields of forensic pathology and nosology. A cause of death was assigned only after a consensus was reached. All causes of death and other significant conditions were coded according to the Ninth Revision of the International Classification of Diseases. -12- �3. METHODS OF ANALYSIS 3.1. DEFINITION OF CRITICAL VARIABLES 3.1.1. Place of Service To be included in the subgroup of Vietnam veterans, an individual had to have served in Vietnam any time during his term of enlistment. Although the normal maximum tour in Vietnam was designated by the Army as 12 months*1, no minimum time was placed on the actual number of months a veteran had to have served in Vietnam to be included in the study. For example, if a veteran was wounded in Vietnam, having served only 4 months of his 12-month tour, he was still included in the Vietnam cohort. A small number of men managed to serve two terms of duty in Vietnam within their term of enlistment. A non-Vietnam veteran had to have served at least one tour of duty in Germany, Korea, or the United States and to have never served in the Army in Vietnam. Most comparisons presented here are between veterans who served in Vietnam and those-who served elsewhere. Analyses using veterans who served only in the United States or in Germany or Korea as the comparison group are not presented unless they help elucidate a particular finding observed with all non-Vietnam veterans. A 3.1.2. Covariates Table 4 presents a list of all covariates considered and their categorizations used in the analysis. All were obtained from veterans' military personnel files. Several of the variables need an explanation: - PULHES. The term PULHES is an acronym for six categories that describe the physical and mental health of the veteran at entry into the service. The categories are physical capacity or stamina, upper extremities, lower extremities, hearing and ears, eyes and visual acuity, and psychiatric functioning. Each category was rated on a four-point scale, ranging from a score of one, indicating nc impairment, to a score of four, indicating maximum impairment, which was below Army retention standards.** - Composite Measure of Physical/Psychological Functioning. This represents a summary measure of the PULHES results. The veteran was given an overall rating of physical and psychological health based on his separate ratings in the six categories of the PULHES. Any ' impairment on one or more of the individual components would result in a rating of some impairment on the summary measure. For analytic purposes, the composite measure was dichotomized into "no impairment" and anything other than no impairment. This composite rating was used to determine eligibility for military service as well as eligibility for specific military occupational specialties. In controlling for preservice health, the composite index, rather than the components of the PULHES, was used. - Army Classification Battery. This is a series of aptitude tests given at entry into the service to aid in assigning a military occupational specialty. The battery consisted of five separate tests, each measuring a different area of aptitude. The areas are verbal ability, arithmetic reasoning, general information, general technical, and pattern analysis. The tests were scored numerically, and the possible range of scores was from 0 to 200. Scores on the -13- �various components were highly correlated. Of the five tests, the general technical (GT) test bias considered to be the best single test for indicating aptitude. - Armed Forces Qualification Test (AFQT). This is an aptitude test that served two functions: 1) to determine whether the individual met the minimum qualification criteria for military service, and 2) if qualification criteria were met, to aid in the placing of individuals in military occupational specialties. This test was numerically scored with a possible range of scores from 0 to 100. - Military Occupational Specialty CMOS). This describes the job or jobs for which the veteran was trained or the one(s) he actually held while in the Army. Assignment of "primary" MOS was based on an individual's civilian education and other training and work experience, as well as on his performance on Army aptitude tests.15 For the purpose of this analysis all MOSs were divided into two broad categories, "tactical" and "all others." Tactical includes infantrymen, armored vehicle crewmen, combat engineers, and artillery crewmen.16 (A more detailed distribution of MOS is provided in Appendix A, Table 4.) When considering the possible confounding effects of MOS, we used the MOS for which the veteran was trained (Primary MOS). When the potential modifying effect of MOS was examined, the job the veteran actually held (Duty MOS) was used. Potential confounders in this study are primarily variables measured before service (entry characteristics). Characteristics measured during service or at discharge have the potential of being part of the "Vietnam experience", and controlling for them may alter the effect of Vietnam service. However, certain military service characteristics examined in this study (pay grade at discharge, type of discharge, and absence without official leave (AWOL) or confinement time) could also be associated with background characteristics. Since the role of these factors is unclear and prior studies suggest that at least one of them (pay grade) is an important predictor of mortality1^, both their possible modifying and confounding potential were examined. 3.1.3. Cause-of-Death Categorization Each of the 15 major subgroups of the International Classification of Diseases, Ninth Revision was examined, with the exception of the groups pertaining to complications of pregnancy and childbirth and to conditions originating in the perinatal period. Neither was applicable to the study population. Because we anticipated that the majority of deaths would be attributed to external causes, a more detailed breakdown of external causes of death (shown in Table 5), was examined. The categorization includes deaths due to motor-vehicle accident, accidental poisonings, suicides, homicide, injury of undetermined intentionality, and a category of all other external causes. Because of the expected underascertainment of suicide on the basis of death certificates and the potential for the underascertainment to be different for Vietnam than for non-Vietnam veterans, a broader definition was also examined. This includes accidental poisonings (E850-E869, E929.2), recorded suicides (E950-E959), injuries of undetermined intentionality (E980-E989), and unknown cause of death (799.9).18 -14- �There is no comprehensive classification of alcohol or drug-related deaths in the ICD-9 nomenclature. Rather, alcohol-specific and drug-specific conditions are contained within various ICD-9 categories. For example, alcohol-dependence syndrome is included in the category of mental disorders and alcoholic liver disease, in the digestive system category. For estimating the extent of substance abuse in this study, special categories of alcohol- and drug-related deaths were developed. These are shown in Tables 6 and 7. Alcohol-related deaths encompass three categories: (1) Nontraumatic deaths in which either the underlying cause or a contributing cause is an alcohol-specific medical, neurologic, or psychiatric disease. (2) Deaths attributed to accidental poisoning by alcohol and other accidental deaths in which a contributing cause was nondependent abuse of alcohol or excessive blood level of alcohol. Excessive blood level of alcohol is not defined quantitatively in the ICD-9 manual. Although IUCH8 policy is to code as "excessive blood alcohol" (ICD-9, 790.3) any citation on the death .certificate of a blood alcohol concentration greater than zero, the medical review panel definition was a blood alcohol concentration greater than or equal to 100 mgX. (3) Deaths due to suicide, homicide, or injury of undetermined intentionality with a contributing cause of nondependent abuse of alcohol or excessive blood level of alcohol. Drug-related deaths included deaths with an underlying or contributing cause of drug dependence or nondependent abuse of drugs other than alcohol or tobacco, deaths due to accidental poisoning by drugs, suicide where the mode of death was drugs, and deaths with intentionality undetermined but where the- mode was drugs. 3.2. INTERNAL COMPARISONS The analysis was approached in stages. The first stage addresses the hypotheses under study without adjustment or consideration of any covariates. The second stage of the analysis focuses on the concept of effect modification. This is concerned with identifying subgroups of Vietnam veterans that are at unusually high or low risk. Of particular' interest here, in light of the finding for Australian Vietnam veterans, is whether the effect of Vietnam service on subsequent mortality is different for men who served in engineering units compared with other units. The final stage in the analysis determines whether any covariates, alone or in combination, could explain or mask any associations between service in Vietnam and the subsequent likelihood of dying. The analytic approach used in stage one is a simple comparison of the relative frequency of death among Vietnam veterans with the relative frequency among veterans who did-not serve in Vietnam. The mortality rates are based on person-years at risk since discharge from active duty. In this study veterans enter follow-up at different points in time, depending on their dates of separation from active duty. This could potentially affect the distribution of follow-up time for the two cohorts under study. The person-year approach takes into account these differing lengths of follow-up. The person-year approach also assumes a constant death rate over time. If the rate changes appreciably during the -15- �follow-up period, rates can be calculated separately for smaller time intervals within which the assumption may be more reasonable. Unadjusted rate ratios (RR) were computed from the crude death rates (Vietnam/non-Vietnam). Ninety-five percent confidence intervals (CZ) around the RRs were computed by using the procedures described by Laird and Oliver.19 In stage two, the exploration of effect modification, we attempted to identify high-risk subgroups that could provide insight into the nature of any Vietnam service-mortality association. All covariates listed in Table 4 were examined for their potential modifying effect by stratifying the data by the various levels of the covariate. Homogeneity of the rate ratios was assessed through chi-square tests for interaction derived from multivariate regression models.19 The criteria for lack of homogeneity of the rate ratios across the various levels of the modifying factor, which is evidence for possible effect modification, is a chi-square statistic with an associated p-value less than or equal to 0.05. The objective of the third stage of the analysis is to examine confounding. Preservice differences in health-related factors could possibly mask or explain the association between Vietnam and mortality. Since relatively few covariates are measured at entry into the service, all are examined for their potential confounding effects. The influence of a potential confounder was evaluated by fitting a multivariate model that incorporated only that covariate and a term for Vietnam service. The analytic tool used in stages two and three of the analysis is the Cox regression model, which is often referred to as the proportional hazards model.20 This technique allows for the adjustment of confounders and the examination of the behavior of effect modifiers. It also accounts for differing periods of follow-up by comparing, for every death, the covariates of the deceased individual with those of individuals who have been followed for a similar period of time. The Cox procedure directly models the rate ratio rather than the absolute rate of mortality, thus avoiding the need to estimate an unknown underlying hazard function. The widely used software package PHGLM provided estimates of the parameters,- standard errors, and likelihood ratio tests of hypotheses.21 The underlying assumption for the proportional hazards model is that the ratio of hazard functions (death rates) for the two groups (Vietnam, and non-Vietnam) is constant over the entire follow-up period. Serious violations of this assumption may result in misleading estimates of the effect of Vietnam service on mortality. For example, if the rate ratio is greater than one at some times and less than one at other times, the estimated parameter would be an average which may falsely indicate no difference in the mortality experience between the two groups. This assumption was checked (Appendix F), and if the effect of Vietnam service on mortality appeared to vary over time, separate models were formed for shorter time periods for which the proportionality assumption appeared more reasonable. All adjusted rate ratios were obtained from Cox regression models stratified on primary MOS (tactical versus nontactical) and enlistment status and adjusted for other potential confounders.22 Stratification, instead of adjustment for MOS and enlistment status, is based on a priori and empirical knowledge that these factors are important determinants of duty location and mortality. Use of stratification, instead of -16- �adjustment, reduces the number of parameters to be estimated which could be important in the cause-specific analysis where there are relatively few deaths. The rate ratio estimated from the stratified model is a valid summary of relative mortality in the two cohorts only if the rate ratios in the strata are similar. The uniformity of the four stratum-specific RRs was checked and is presented in Appendix F. In the cause-specific analyses, a modification of the above analytic approach was necessary because of the small number of deaths in many of the disease categories. If a category contained less than 10 deaths (Vietnam and non-Vietnam cohorts combined), rate ratios were not computed, and no formal conclusions were drawn about comparative risks in the two cohorts. In addition, a smaller set of covariates were examined for their potential modifying or confounding effects. Other analytic techniques used include standard chi-square statistics for 2x2 and Rx2 tables and the t-statistic for the difference between two means. Additionally, the "percent agreement" and kappa statistic are used to quantify and judge the level of agreement between the medical review cause of death and cause of death from the death certificate. The "percent agreement" is the number of deaths assigned to a particular cause-of-jdeath category by both the medical review panel and the death certificate divided by the total number of deaths assigned to that category by the death certificate. The kappa statistic is a measure of inter-rater concordance which corrects for agreement expected by chance alone.23 Me used the following criteria when interpreting the kappa statistic: a kappa greater than 0.75 represents excellent agreement beyond chance, values between 0.40 and 0.75 represent fair to good agreement and values below 0.40 represent poor agreement.24 All references to "statistical significance" imply that a particular ratio or difference is statistically different from the null value at the alpha=0.05 level, assuming a two-sided test of significance. 3.3. EXTERNAL COMPARISONS The standardized mortality ratio (SMR) adjusted for age, race, and calendar period was used to compare the death rates among Vietnam and non-Vietnam veterans with the rates in the total U.S. male population. The SMR is the ratio of observed deaths among cohort members to the * expected number of deaths based on the U.S. mortality experience. The purpose of comparing the two veteran cohorts to the U.S. male general population is to evaluate the anticipated "healthy veteran effect" for natural causes of death.25 since all cohort members were initially selected into Army service on the basis of a certain level of physical fitness, one would expect their subsequent mortality from natural causes to be less than that of the general population, which includes men who do not meet the minimum physical requirements of the Army. This expected deficit should be most pronounced in the time period closest to separation from active duty and might eventually disappear with the passage of time as the veterans age. The SMR calculations were done by using a software package containing U.S. death rates updated through 1980.26 Ninety-five percent confidence limits for the SMRs were calculated with the Rothman-Boice programs.2? -17- �4. RESULTS This chapter is divided into four sections. In the first section, the preservice and military service characteristics of the Vietnam and non-Vietnam cohorts are examined. This provides an understanding of differences existing at entry into the service and differences that may have developed as a result of military service. The second section examines the all-cause mortality experience of the Vietnam group relative to veterans who served in Germany, Korea and the United States. Presented in the third section are results of the cause-specific mortality analyses, including analyses based on cause of death determined from death certificates and on medical review cause of death. The last section contains the results of comparisons of each cohort with the mortality of men of the same age and race in the U.S. general population in the same time period. 4.1. DISTRIBUTION OF COVARIATES FOR VIETNAM AND NON-VIETNAM VETERANS Ideally, to determine the increase in mortality associated with service in Vietnam, one would like to compare two groups of veterans who are similar with respect to all factors that could influence mortality,, except for service in Vietnam. Because this ideal can rarely be attained, except in experimental situations, it is important at the outset to understand any differences in possible health-influencing factors that may exist between Vietnam veterans and veterans who served elsewhere. Caution needs to be exercised, however, when interpreting the statistical significance of differences between the two groups. The large sample sizes tend to make even small between-cohort differences in these factors "statistically significant." The characteristics of the two cohorts as determined at entry into the Army and those determined during military service are summarized in Table 8. Appendix A contains the actual distributions of all of the characteristics by cohort, with, results of tests of statistical significance of differences for each characteristic. There is no difference in the racial distribution between the two cohorts, but there are slightly fewer draftees among Vietnam veterans than among non-Vietnam veterans (63.7% versus 65.6%) and more Vietnam veterans entered service before 1969. Of the five physical health components measured at entry, significant differences are noted for two: Vietnam veterans had slightly fewer visual (25.5% versus 28.7%) and hearing (5.6% versus 6.7%) impairments. No difference is seen for the assessment of psychiatric ' functioning. On the tests of general aptitude taken at entry, the mean scores of Vietnam veterans were slightly but "significantly" lower for all components of the Army Classification Battery, and Vietnam veterans also scored slightly lower on the Armed Forces Qualification Test. The second section of Table 8 contains the military service characteristics, where differences between the two cohorts are greater. More Vietnam than non-Vietnam veterans were in tactical operations jobs (34.3% versus 27.4%), and more Vietnam veterans (26.6%) were assigned to infantry units than were non-Vietnam veterans (14.6%). Veterans in the Vietnam cohort tended to stay on active duty slightly longer than other veterans (mean=26.1 months versus 25.3 months). Vietnam veterans had fewer instances of AWOL or other "bad" time (11.6% versus 13.3%) and fewer nonhonorable discharges (2.7% versus 8.9%); they were also less likely to be discharged at lower grades (E1-E3) (11.5% versus 20.2%). These differences will be considered in subsequent analyses. -18- �4.2. ANALYSIS OF ALL-CAUSE MORTALITY 4.2.1 Crude Results Table 9 presents the total numbers of deaths, crude mortality rates, and rate ratios comparing Vietnam veterans to veterans who served in Germany, Korea, or the United States. The mean number of years of follow-up was similar for Vietnam (13.7 years) and non-Vietnam veterans (13.5 years). Of the 9,324 Vietnam veterans, 246 died during follow-up, compared with 200 of the 8,989 non-Vietnam veterans. Overall, Vietnam veterans had a 17X excess in postservice all-cause mortality relative to veterans who did not serve in Vietnam. This modest excess is not statistically significant. Table 10 presents relative mortality by the number of years since discharge from active duty. The excess in the relative death rate appears to be limited to the first 5-year period after discharge, during which Vietnam veterans have a 45% higher mortality rate than non-Vietnam veterans. After the initial 5-year period, there is no difference.in the mortality experience between the two cohorts. The test for the time-dependent effect of Vietnam service yields borderline significance (X2=3.60, p=0.057), suggesting that the relative mortality of Vietnam veterans in the first 5 years may be different from that seen later. Figure 2 displays graphically the change over time in the relative mortality rate associated with Vietnam service. The hazard rates among Vietnam veterans remain higher than those for non-Vietnam veterans through year 6 of follow-up. After year 6 the hazard rates are similar. To determine whether the time-specific increase in mortality among Vietnam veterans is consistent across the two major subgroups of the comparison cohort, separate analyses were done using veterans with other foreign service (Germany or Korea) as one comparison and veterans with service only in the United States as a second comparison. A similar pattern of excess all-cause mortality limited to the first 5 years after discharge was found in both comparisons (Table 11). The excess was somewhat greater with veterans who served only in the United States used for comparison (RR=1.57) than with veterans having other foreign service (RR=1.37). . i '• 4.2.2. Consideration of Covariates. Because the increased rate of mortality associated with Vietnam service appears to be limited to the first 5 years of follow-up, all covariates are examined with respect to two time periods, <5 years and 64- years. (See Appendix F for an examination of the proportional hazards assumption within these two time periods.) Table 12 presents a summary of the tests for effect modification. (Refer to Appendix B for details.) There is some suggestion that during the first 5 years of follow-up the effect of Vietnam service is modified by general health status at entry (p=0.08), enlistment status (p=0.10) and year of discharge from active duty (p=.06). Among those with a poorer composite index of health at entry, the effect of Vietnam service on mortality is greater (RR=2.12) than among those with better health at entry (RR=1.20). An 80% increase in relative mortality associated with service in Vietnam is apparent among draftees, but only a 10% increase is observed among those who volunteered for the Army. Finally, a twofold increase in mortality was found among Vietnam veterans discharged before 1970 compared with only a 16X increase for those discharged in 1970 or later. In the later follow-up period, pay grade was identified as an effect modifier (pa.02). Although there is heterogeneity in the RRs across the various pay grades, no particular -19- �pattern appears to be associated with this heterogeneity. (See Appendix B, Table 13.) For the total follow-up period, only pay grade at discharge was identified as potentially modifying the effect of Vietnam service on the subsequent rate of mortality (p=.02). There is some variation in the RRs for Vietnam service across the various levels of the other covariates in Table 12, but the variation does not represent a statistically significant departure from homogeneity. Statistical adjustment for each covariate separately has little effect on the estimate of the RR in either postservice period (Table 13) or for the total follow-up period with two exceptions: type of discharge and pay grade at discharge. After adjustment for type of discharge and pay grade, the rate ratios are increased by at least 0.10 in the initial follow-up period and for the total follow-up period. Confounding was further investigated by including all of the covariates listed in Table 13 in models for the separate time periods. Because of the strong correlation between AWOL/confinement time, type of discharge, and pay grade at'discharge, only one was included in the model. Pay grade was chosen because it appeared, in Table 13, to have the strongest influence of the three on the Vietnam-mortality association. This model yielded adjusted rate ratios of 1.53 (95X CInl.12-2.10) for the early follow-up period, 0.99 (95X CI=0.77-1.28) for the remaining years of follow-up, and 1.18 (95X CI=0.97-1.44) for all years of follow-up. In addition, a reduced model was formed that incorporated a smaller set of covariates that will be used for adjustment in the cause-specific analyses where the numbers of deaths are considerably smaller. This model included the following variables: age at discharge and race (both well—established predictors of mortality), HOS and enlistment status (a priori and possibly empirical predictors of duty location and mortality), GT score and pay grade (empirically the strongest predictors of all-cause mortality of the remaining covariates), and year of discharge. The RRs obtained from the reduced model (Table 14) are roughly of the same magnitude as the unadjusted RRs. Results from the Cox model also indicate that Vietnam service has a greater effect on mortality among those discharged before age 21 compared to those discharged at age 21 or older (p=0.02) and among veterans discharged before 1970 compared to those discharged during 1970 or later (p=0.05). 4.2.3. Influence of Inservice Deaths. < As shown in Figure 1, the rate of inservice deaths among Vietnam veterans was more than 6 times the rate among non-Vietnam veterans. The majority of deaths among Vietnam veterans (83X) were a result of war-related activities (Table 2). This unusual inservice mortality experience among Vietnam veterans may have been selective, that is, it may have eliminated either the healthiest or the least healthy members from the cohort. Such an event might bias our estimate of the effect of Vietnam service on postservice mortality. To examine this possibility, we compared the entry characteristics of Vietnam veterans who died in service as a result of hostile enemy action with characteristics of Vietnam veterans who were alive at discharge from active service (Table 15). There are few differences of note. The two groups are similar in terms of race, enlistment status, the ratings on the individual components of the PULHES profile (with the exception of visual acuity and the composite measure of physical health), and scores on all the Army aptitude tests. For visual acuity and the composite physical health measure, those -20- �killed by hostile enemy action were less likely to have any impairment on either measure compared with those discharged alive. (See Appendix C for detailed tables.) To examine this further, we performed a worst case analysis by assuming that those killed by enemy action had survived and that their postservice mortality experience was worse than that of the remaining Vietnam group. For example, if those killed in action had experienced twice the overall postservice death rate of the actual Vietnam study group, the result would be 10 additional deaths in the Vietnam group, and none among non-Vietnam veterans. However, the "new" RR would be essentially the same as the original one (RR=1.19). 4.2.4. Influence of Incomplete Follow-up As described in Section 2.5, the proportion of veterans with uncertain vital status was small and similar between the two cohorts (less than 9% in both cohorts). Because of this, we assumed that all those with uncertain vital status were alive at close of follow-up. Our assumption would lead to biased rate ratios if the probability of dying among Vietnam veterans with uncertain vital status was different from that of veterans who served elsewhere. By examining the entry and military service characteristics of men with known and uncertain vital status (Table 16), it can be seen that although men with uncertain vital status are very different from those with known vital status in the same cohort, the characteristics of the "uncertain status" groups are similar between cohorts. The characteristics associated with uncertain vital status may be linked to a more unstable lifestyle. In particular, men with uncertain vital status are more likely to be non-white, have lower GT scores, and have a nonhonorable discharge and lower pay grade at discharge. Thus, regardless of cohort status, these men may live a more transient existence with few ties to institutions and relatives, making them more difficult to trace. Since several of these characteristics are also strongly related to mortality (see Appendix B), death rates may indeed be higher among these men but, given the similarity in their characteristics between cohorts, it seems unlikely that there would be a different effect of Vietnam service in this group. In any case, we can estimate the possible effect of a differential rate of mortality. For example, if Vietnam veterans with uncertain vital status had twice the death rate of Vietnam veterans' with known status and if the two status groups among non-Vietnam veterans had similar rates, the RR would only increase from 1.17 to 1.22. On the other hand, if Vietnam veterans with uncertain status had a much better survival rate (i.e., approximately one-half the death rate of other men), the revised RR would be 1.12. Thus, two extreme situations produce results that are not very different from the original finding. 4.3. ANALYSIS OF CAUSE-SPECIFIC MORTALITY 4.3.1. Cause of Death Based on Death Certificates Of the 446 veterans identified as deceased in the time period from date of discharge from active duty to December 31, 1983, death certificates were obtained for 437 (98X). For five of the nine deaths for which death ' certificates were not obtained, casualty reports were available indicating the death occurred while the veteran was on reserve status or receiving veterans benefits. For the remaining four deaths, the location and date of death were available and confirmed through other sources. -21- �Displayed in Table 17 are the numbers of deaths, crude death rates and unadjusted rate ratios comparing Vietnam veterans with non-Vietnam veterans for 11 major ICD-9 cause-of-death groupings. The four major groupings not shown had no deaths assigned to them (diseases of the blood and blood-forming organs; endocrine, metabolic, and nutritional diseases; diseases of the skin; and diseases of the musculoskeletal system). Of the categories shown, only four contained sufficient numbers for formal analysis. For two of these cause-of-death categories, Vietnam veterans appear to be dying at different rates than non-Vietnam veterans: diseases of the circulatory system (51% decrease) and external causes of death (25X increase). In one additional category mortality appears to be different between the two groups, that is, deaths due to genitourinary conditions. However, it is based on only four deaths, too few for formal analysis. Two of these deaths were attributed to urinary tract infection, one to renal disease (unspecified), and one to renal failure, and all were among Vietnam veterans. Neoplasms; Table 18 shows mortality from neoplasms (all types) among Vietnam veterans relative to non-Vietnam veterans by time since discharge. A nonsignificant decrease in the relative rate of death is seen in both follow-up periods. We also divided the latter time period into smaller units, (6-10 years and 11+ years) to assess risks in the more recent years that would correspond to a longer latent period for these diseases. Only 7 deaths from neoplasms occurred in the 11+ year follow-up period, 2 among Vietnam veterans and 5 among non-Vietnam veterans, suggesting a deficit among Vietnam veterans. In examining the specific types of neoplasms (Table 19), there does not appear to be any site-specific associations with service in Vietnam. The three deaths among Vietnam veterans from neoplasms of uncertain behavior were all due to brain tumors, but the one among non-Vietnam veterans was a bronchial adenoma. Circulatory system diseases: Table 20 shows that regardless of the time since discharge, there is a deficit of circulatory disease deaths among Vietnam servicemen relative to those not serving in Vietnam. In Table 21, results for specific types of circulatory disease deaths are presented. The deficit among Vietnam veterans does not appear to be limited to any one type of circulatory disease but extends to all major types. Mental disorders: Although there were too few deaths in each follow-up interval for formal analysis, Vietnam service did not appear to be associated with the likelihood of dying from mental disorders in either time period. All deaths except one in this category were related to abuse of drugs or alcohol. Drug and alcohol-related mortality will be discussed in more detail later in this Section and also in Section 4.3.2. External causes of death; Table 22 presents mortality from specific types of external causes. Vietnam veterans were more likely than non-Vietnam veterans to die in motor vehicle accidents (MVA), from accidental poisonings, and from injuries that were undetermined whether accidentally or purposely inflicted. Vietnam service does not appear to be associated with deaths from other accidental causes, suicide, or homicide. There are 13 accidental poisoning deaths among Vietnam veterans and 5 in the non-Vietnam group. Nine Vietnam veterans died from drug intoxication compared with four non-Vietnam veterans. Of the remaining four accidental poisoning deaths among Vietnam veterans, three were due to carbon monoxide poisoning and one to a work-related toxic gas exposure; the other non-Vietnam veteran death was due to poisoning by an unspecified substance. -22- �Deaths undetermined whether accidentally or purposely inflicted among Vietnam veterans include four poisonings, three deaths by shotgun wound to the head (not stated as self-inflicted), and one in a fire. In this same category, there is one death by drowning and another due to narcotic poisoning among non-Vietnam veterans. Deaths from MVAs, other accidents, suicide, and homicide contain adequate numbers for further exploration (Table 23). Deaths due to MVAs are significantly elevated among Vietnam veterans in the first five years after discharge (RRsl.93). After 5 years, the excess is considerably less, although still somewhat elevated (RR=1.16). No association is seen in either time period for accidental deaths other than those from motor vehicles or poisonings. For deaths due to suicide, a 72% nonsignificant increase is seen among Vietnam veterans in the initial 5 years of follow-up, but a deficit is seen thereafter. Because of possible inaccuracy in the recording of suicide on death certificates, we broadened the definition to include all accidental poisonings (E850-E869), reported suicides (E950-E959), injuries undetermined whether accidentally or purposely inflicted (E980-E989), and ill-defined and unknown causes of death (799.9). The main difference between the results for this new category and the previous one is the slight, non-significant elevation in risk now seen in the later, follow-up period. (RR=1.12). Finally, an early postservice excess is seen for deaths due to homicide but the relative risk drops below 1.0 thereafter. There were no postservice deaths due to war-related injuries. In Appendix D, the consistency of the association between Vietnam service and deaths due to flVAs and suicide is examined with respect to age at separation, race, duty MOS, enlistment status, GT score, pay grade at discharge, and year of discharge. In general, the RRs are increased in the first 5 years postservice and are close to 1.0 thereafter. There is some nonsignificant variation among the various subgroups, but the overall patterns are similar to what is observed for total mortality. Drug- and alcohol-related deaths: Twenty-one deaths meet the criteria outlined in Section 3.1.3 for an alcohol-related death (Table 24). Over the entire follow-up period, there is a 27% increase (nonsignificant) in alcohol-related deaths among Vietnam veterans relative to non-Vietnam < veterans. When the rate ratios are examined by time since discharge, a 73% nonsignificant increase is seen in the later period of follow-up. Because information on alcohol use may not be consistently reported on death ' certificates for external causes, deaths from alcohol-related diseases are examined separately. Alcohol-related diseases include alcoholic psychoses (291.0-291.9), alcohol dependence syndrome (303), nondependent abuse of alcohol (305.0), alcoholic polyneuropathy, (357.5), alcoholic cardiomyopathy (425.5), alcoholic gastritis (535.3), alcoholic liver disease (571.0-571.3), and excessive blood level of alcohol (790.3). Nine of the 21 alcohol-related deaths are due to these causes; 3 occurred among Vietnam veterans and 6 in the non-Vietnam group. Table 24 also shows that Vietnam service appears to be strongly associated with the likelihood of dying from a drug-related death. Overall, the rate of drug-related deaths among Vietnam veterans is 2.1 times that for non-Vietnam veterans. Furthermore, increased mortality among Vietnam veterans is seen not only in the first 5 years after discharge, but also in the subsequent time period. -23- �4.3.2. Cause of Death Based on Medical Review This section presents a re-analysis of selected ICD-9 cause-of-death categories based on review, by a panel of physicians, of available information relevant to the cause of death beyond the death certificate. It also includes a detailed examination of deaths associated with the use of alcohol and drugs as determined by the panel. First, a brief examination of differences between underlying causes of death derived from death certificates and those determined by the medical review panel is presented. Further detail is provided in Appendix E. To arrive at the best judgment of underlying cause of death, we sought all pertinent documentation that might help to determine the nature and circumstances of the death. Information was obtained for 426 of the 446 total deaths: 95% (n=233) of Vietnam veteran deaths and 97% (n=193) of deaths among non-Vietnam veterans. Law enforcement records, autopsy reports, medical examiners' reports, and hospital records were the most common sources of information used by the medical review panel (Table 25). More supplemental records were available for non-Vietnam veterans than for Vietnam veterans from every source except hospitals and physicians. Significant differences in the availability of records between the cohorts are noted for law enforcement records, medical examiner's reports, and histopathology reports. The total number of available records also differed somewhat by cohort (Table 26). Four or more different types of records were obtained for 50% of non-Vietnam veteran deaths versus 45X of Vietnam veteran deaths. The percent agreement and kappa statistic, quantifying agreement between the medical-review-panel cause of death and that from the death certificate, are presented in Table 27 for major cause-of-death categories. A more . detailed examination of the agreement between medical-review-panel assignment of causes of death and death-certificate underlying causes is presented in Appendix E. Overall, there is good•agreement (82%, kappa=0.79) between death-certificate and medical-review cause of death. Exceptionally good agreement is found for deaths due to neoplasms, MVAs, suicide, and homicide; for both Vietnam and non-Vietnam veterans, the kappa statistics for these causes are greater than 0.90. Poorer agreement is apparent for other causes of death, but most kappa values are based on small numbers and, therefore, are subject to considerable variation. All kappa values, however, are statistically significant at the 0.01 level, indicating that although agreement is poor in some categories, it is better than expected by chance alone. Table 28 presents cause-specific mortality rates by cohort as determined by the medical review panel. For categories where formal analysis was possible, an elevated rate ratio for Vietnam veterans is seen for deaths due to neoplasms, mental disorders, and external causes. Additionally, a lower death rate for Vietnam veterans is noted for circulatory diseases. None of the differences are statistically significant. When rate ratios based on medical review were compared with those based on death certificates, two differences are apparent for causes with substantial numbers of deaths. The first category is neoplasms, with the rate ratio derived from medical review of 1.21, and a rate ratio of 0.82 from death certificates. This difference is primarily the result of two neoplasm deaths among non-Vietnam veterans being reclassified elsewhere and the opposite situation occurring among Vietnam veterans. (Details are available in Appendix E.) -24- �» When examining neoplastic deaths by time since discharge (Table 29), the rate ratio is similar in both periods'of follow-up. Furthermore, among those followed for 11 or more years, there is no suggestion of differential, mortality (three deaths among Vietnam veterans versus five among non-Vietnam veterans). Examination of specific types of cancer (Table 30) shows more deaths among Vietnam veterans from brain cancer, leukemia, and non-Hodgkin's lymphomas, all in very small numbers. The increase in the total number of malignant neoplasm deaths through medical review is primarily the result of confirming the malignancy of three brain tumors, all among Vietnam veterans. The nature of the tumor was not specified on the death certificate for any of the three. Finally, the three non-Hodgkin's lymphoma deaths among Vietnam veterans are the result of reclassifying two deaths among Vietnam veterans to lymphosarcoma (ICO-9, 200). These deaths were classified by the death certificate to cardiac arrest (ICD-9, 427.5) and acute lymphoid leukemia (ICO-9, 204.0). Further deatils are given in Appendix E. Mental disorders is the second cause-of-death category for which there is a difference between the rate ratios obtained from medical review and-death certificates. With the medical-review cause of death, a threefold risk is evident among Vietnam veterans, but the rate ratio is close to unity according to death-certificate causes of death. All "mental disorder" deaths, by either classification, involved alcohol or drugs. Differences in classification of these deaths is the result, in most cases, of a greater specificity in terminology used by the medical review panel. For example, in two cases the review panel cited alcoholic liver damage, unspecified (ICD-9, 571.3) as the underlying cause, whereas the death certificate wording limited the classification to alcohol dependence syndrome (ICD-9, 303). Alcohol- and drug-related deaths determined from medical review are examined in more detail below in this section. Table 31 examines relative mortality for specific external causes of death as determined from medical review. These results are identical to those found from the death certificate analysis. Vietnam veterans are more likely than non-Vietnam veterans to die in motor vehicle accidents, from accidental poisonings and from injuries undetermined whether accidentally or purposely inflicted. The overall rate ratios are not significantly elevated for deaths due to suicide, homicide, and all other external causes. However, further exploration of external causes of death by time since discharge indicates the same pattern for MVAs, suicide, and homicide as seen in the death certificate results; the rate ratios are elevated in the first 5 years after discharge and are close to 1.0 for the remainder of follow-up. Supplemental information collected for the medical review panel allowed further exploration of MVA deaths. Daytime and nighttime motor—vehicle-crash deaths as well as single and multiple vehicle events all occurred more frequently among Vietnam veterans during the early postdischarge period (Table 32). Me also examined the role of alcohol and drug use in motor vehicle accident deaths. Drug use information on MVA deaths was limited; the medical review panel identified only one drug-related MVA death. Blood alcohol level information or the suspected involvement of alcohol was available for 82 (62%) of the 132 medically reviewed MVA deaths. Table 33 shows that in the initial follow-up period, there is a weak relationship between Vietnam service and alcohol-related MVAs (RR=1.35) in contrast to a stronger relationship for MVAs that are not alcohol-related (RR=2.25). The pattern of risk for MVAs with -25- �"unknown alcohol involvement" is similar to that for "no alcohol involvement." The agreement between the death certificate and medical review panel for alcohol- and drug-related deaths is presented in Table 34. Twenty-one deaths are defined as "alcohol-related" from death certificates and 133 from medical review. This lack of agreement is evident regardless of the specific type of alcohol-related death; the kappa statistic ranges from 0.11 for accidental causes to 0.44 for alcohol-related natural causes of death. The overall agreement for drug-related deaths is much better than that for alcohol-related deaths, but for specific categories the agreement is poor. Overall there is a slight excess of alcohol-related deaths among Vietnam veterans (Table 35), due mainly to accidents. Deaths from alcohol-related natural causes and deaths due to alcohol-related suicide, homicide and injuries of undetermined intentionality are not associated with service in Vietnam. The distribution of drug-related deaths by cohort is presented in Table 36. Overall, Vietnam veterans are 1.6 times as likely to die from drug-related deaths as non-Vietnam veterans. Suicide by drugs is a very minor component of this excess. Moreover, as shown in Table,37, when the follow-up interval is subdivided into three time periods, the RRs appear to increase over time, with a substantial excess of drug-related deaths in the most recent years of observation. Although based on a small number of deaths, the drug-related mortality excess appears to be limited to Vietnam veterans who were drafted into service and those whose jobs involved tactical or combat operations (see Appendix D, Table D-3). Additionally, there is some suggestion that those discharged during 1970 or after had a greater excess of drug-related deaths. However, when we examine the year in which the veteran served in Vietnam as opposed to his date of discharge, it appears that the drug-related excess is especially high among Vietnam veterans who were stationed in Vietnam during 1968 or 1969 (RR=4.93, 95X CI=1.14-21.34). The rate of drug-related deaths is similar between Vietnam and non-Vietnam veterans serving before (RR=1.20) and after (RR=0.71) that time period. 4.3.3. Consideration of Covariates Table 38 presents adjusted rate ratios based on a Cox regression model for cause-specific death categories with sufficient numbers of deaths for formal analysis. Adjusted values are based on a model stratified on MOS and enlistment status, and including age, race, GT score, pay grade at discharge and year of discharge. Rate ratios based on death-certificate cause of death and medical-review cause of death are both presented. In the early follow-up period, adjustment increases the RR for suicide based on death-certificate cause of death from 1.72 to 2.54 and, based on the medical review data, from 1.64 to 2.47. Pay grade at discharge and GT score are the covariates that have the greatest effect on the adjusted suicide estimate. Adjustment also had some effect on the RR for alcohol- and drug-related deaths based on the death-certificate data. For alcohol-related deaths, the RR increased from 1.73 to 2.23 in the later follow-up period while the RR for drug-related deaths in the initial follow-up period increased from 1.93 to 2.86. 4.4. COMPARISON OF VETERAN AND U.S. DEATH RATES Presented in Table 39 are the observed and expected numbers of deaths from all causes for the two veteran cohorts stratified by the number of years since -26- �discharge from active military service. Over the total follow-up period, both groups of veterans have a significantly lower mortality rate for "natural causes" than the general U.S. male population. However, during the first 5 years after discharge, Vietnam veterans have a higher death rate from external causes whereas non-Vietnam veterans have a lower rate relative to the general population. In the later time period both groups of veterans show a similar deficit in external cause mortality. Standardized mortality ratios for major natural cause-of-death categories are given in Table 40. Among Vietnam veterans the SMRs for most natural causes of death are below 1.0, with the exception of deaths due to diseases of the genitourinary system (SMR=2.53, 95X CI=0.82-5.89). For diseases of the circulatory system, the deficit of deaths in Vietnam veterans is much greater (52X) than for non-Vietnam veterans (13X). Both cohorts experienced lower-than-expected mortality for diseases of the digestive system and neoplasms. The SMRs for specific external causes (Table 41) show an excess of deaths among Vietnam veterans due to accidental causes, mainly from motor vehicle accidents. Suicide mortality is at the same level as that in the general populatign in the Vietnam cohort. Among non-Vietnam veterans, the SMRs for specific external causes are all at or below 1.00, indicating no excess of deaths relative to the general population experience. -27- �5. DISCUSSION The findings described here raise a number of issues related to the interpretation of and conclusions about the postservice mortality experience of Vietnam veterans. Among these are the strengths and limitations of the study, findings from previous studies of Vietnam veterans, and prior investigations of veterans of other wars. These topics are reviewed here, and a number of summary comments are made regarding mortality risks of Vietnam veterans.- Some of the concluding remarks are speculative, since available data do not allow further inferences. Other comments represent our best judgment about relationships between mortality and the Vietnam experience, given the totality of data examined. 5.1. STRENGTHS AND LIMITATIONS This study began with a carefully defined cohort of Vietnam-era soldiers, and various methods were used to ascertain deaths occurring after separation from active duty. Vietnam and non-Vietnam veterans were chosen according to a stringent-set of criteria to ensure-maximum comparability. A comparison of entry and military-service characteristics for the two groups of veterans has confirmed their general similarity. Adjustment for residual differences in background characteristics between the two groups did not appreciably alter most relative mortality estimates. This indicates that differences in known background characteristics do not account for the observed pattern of relative mortality among Vietnam veterans. However, the possibility exists that other, unmeasured differences between the two cohorts could affect the estimate of the effect of Vietnam service on mortality. Through the multiple overlapping sources of death ascertainment, virtually all deaths that occurred in the U.S.A. should have been identified, but some that occurred elsewhere may have been missed. Confirmation of death was obtained from copies of official death certificates, which were recovered for all but 2% of the deaths. A distinct advantage of this study is the special attempt to locate all presumably living men for the purpose of conducting health interviews; in most cohort mortality studies these persons are not individually traced. This component of the study provided verification of vital status on 94% of Vietnam veterans and 92X of those serving elsewhere. Furthermore, background and military-service characteristics of those with unconfirmed vital status are similar between the two cohorts, suggesting that mortality rates in these subgroups are not likely to be very different. Me attempted to keep misclassification of cohort status and cause of death to a minimum.- After death certificates were coded, the correspondence between the ICD codes and the actual medical statements on the certificates was verified independently by two CDC staff persons. Any discrepancies were resolved with the nosologist. An evaluation of the reproducibility of cause of death coding by the nosologist indicated excellent agreement between the original codes and a sample of blind repeats. To minimize misclassification of cohort status, we verified duty location for all postservice deaths. A special feature of this study is the special independent medical review of causes of deaths by reference to supplemental medical and legal documents recovered for 97% of deaths for which death certificates were obtained. This process clarified general or vague terms on death certificates, assured that as much information as possible was considered in cause-of-death determinations, and permitted use of similar criteria to determine underlying cause of death for the two cohorts. This was especially valuable for -28- �identifying deaths that were alcohol or drug-related. Through the medical review effort many more alcohol-related deaths were found than were derived from death certificates alone and half again as many drug-related deaths. These larger numbers of "cases" produced more reliable risk estimates and the standardization of criteria produced more valid results. Interestingly, the number of suicide deaths derived from death certificates (n=29) was about the same as from the medical review (n=32) and the adjusted rate ratios based on the two sources are similar in both follow-up periods (RRs=2.54 and 2.47 in the early interval and RRs=0.57 and 0.74 in the later interval). Any observational study has limitations. Perhaps the most important one here is the restricted sample size and limited number of deaths in this young population for most major cause of death categories, and especially for specific diseases or conditions. With the exception of the relatively common external causes of death, this study could detect, as statistically significant, only substantial elevations in cause-specific death rates. Nevertheless, numbers of deaths from some causes are significant to identify patterns' of risk that are informative. This is important in interpreting the findings for drug-related deaths, suicide, and homicide. The extent of underreporting in our data, in particular for deaths which are alcohol- or drug-related, may be substantial. If alcohol- or drug-related deaths were more or less likely to be reported among Vietnam veterans than non-Vietnam veterans, the resulting rate ratios would reflect this reporting bias. In our data, however, only drug-related deaths appeared in excess among Vietnam veterans; if reporting was differential, we might expect both alcohol and drug deaths to be in excess. A methodologic issue of concern in the analysis of these data was the choice of relevant covariates as possible confounders. In particular, some of the military service variables such as "pay grade at discharge" and "AWOL/confinement time" are measured during or after the military experience and could be affected differentially by it in the two cohorts. If this was the case, adjustment for that covariate could introduce a bias in the RR estimate. Pay grade was retained in the reduced model (e.g.. Table 38) since it is a strong determinant of mortality in these data and in prior studies of Army veterans.17'28 The biggest shift in the relative mortality estimate caused by including a military service covariate in the Cox model, namely pay grade, occurred for suicide. , Another potential limitation of this study is the relatively short time that has elapsed since the Vietnam conflict. If the "Vietnam experience" does place veterans at an increased risk for certain fatal chronic diseases, the time interval between exposure and death may be longer than our current 10-15 years of follow-up. Continued monitoring of mortality in VES participants, therefore, may provide additional insights. 5.2. COMPARISON WITH PREVIOUS MORTALITY STUDIES OF VIETNAM VETERANS The present findings can be viewed against the results of five previous mortality studies of Vietnam veterans. Four are proportional mortality studies6'9, which may not be directly comparable to this study because of incompleteness of data and inherent limitations of the analytic method.29 The fifth, a cohort study of Australian Vietnam veterans, is very similar in design to our study and, thus, is a more appropriate comparison.10 The U.S. Air Force's "Ranch Hand Study" is not discussed here, since its principal concern is the adverse health effects of herbicide exposure in a unique group of veterans.5 -29- �Two of the proportional mortality studies were conducted using fairly well-defined populations.'''® The results of one included nonsignificant increases in suicide, homicide, accidental poisonings and nonmotor vehicle accidents of transport among Vietnam veterans relative to other Vietnam-era veterans. However, deaths due to MVAs were not elevated.? Time since discharge was not considered in that study and this was critical in elucidating the pattern of external cause mortality in our study. In the other study, only deaths from suicide and motor-vehicle accidents were examined, and neither occurred more frequently among Vietnam veterans.8 The two other proportional mortality studies were conducted by using deaths occurring among veterans registered for a military service bonus in their respective states6'9, and it is unclear what bias may have been introduced through this selection process. In one of the studies, a nonsignificant increase in deaths from MVAs among Vietnam veterans was found.6 The excess in overall mortality among Australian Vietnam veterans was mainly confined to men who had served in the Engineer Corps, a finding the investigators could not entirely explain.*0 A similar variation in risk is not seen in the present study, although the number of'men assigned to Engineer units is relatively small. The 30% excess of external-cause mortality among Australian Vietnam veterans relative to non-Vietnam veterans is similar to what is seen in our study. Although the Australian investigators do not examine external cause mortality by time since discharge, there is a suggestion of a decline in relative mortality from all causes with increasing time since discharge. Deaths from suicide, homicide, and accidental poisoning also occur more frequently among Australian Vietnam veterans. MVA mortality is not elevated overall, but an excess in the youngest age group is suggested. The authors conclude that although modest, the consistency of the results across several external cause-specific categories may indicate that.the association is, in fact, real. The results of our study are in agreement with those of the Australian study, that is, no association was found between service in Vietnam and mortality due to neoplasms (all types combined). In several of the proportional mortality studies, however, investigators found an increased frequency of deaths from connective-tissue and other soft-tissue cancers among Vietnam veterans.6'8'9 There are no such deaths in the present study, and only two among Australian Vietnam veterans, but small sample sizes' in both studies preclude the detection of increased risks for these rare malignancies. For this reason, these tumors and others are being examined in CDC's Selected Cancers Study.3 One surprising finding is the lower mortality rate from cardiovascular disease (CVO) among Vietnam veterans. This result is evident regardless of time since discharge and applies to several major types of circulatory disease". The lower rate might be explained as a by-product of some kind of selection process taking place in the final assignments to Vietnam, which might correlate with cardiovascular fitness established during basic or advanced training. In fact, the STIR results suggest that the CVD deficit may be the result of an unusually high rate in the comparison group. CVO mortality in the non-Vietnam cohort is only slightly below that of the general population, whereas we expected it to be much lower.25 Various indices of CVD morbidity measured in the other components of the VES may help in -30- �elucidating the mortality findings. Contrary to our findings for CVD, Australian Vietnam veterans experienced a significant 90% increase in deaths from such causes.10 The investigators speculate that this increase may have resulted from health-influencing behaviors, such as cigarette smoking and excess alcohol intake, which Vietnam veterans may have acquired more easily than non-Vietnam veterans because of the stressful environment of the war zone and/or the availability of these substances. Australian Vietnam veterans have an excess of deaths from alcohol-related natural causes, but no increases in deaths from alcohol-related external causes or any type of drug-related mortality. These findings are contrary to ours and may reflect differences in use of drugs and alcohol by American and Australian troops. In contrast 5 to the reportedly heavy use of illicit drugs by American troops in Vietnam,3* '31 drug use among Australian soldiers was reported to be uncommon, while alcohol use was heavy.10 Another point that can be raised here is the relationship between the present findings for drug-related deaths and two factors: (1) the reported heavy use of drugs (especially narcotics) among servicemen in Vietnam in the latter part of the conflict (1969-1971)30'31 and (2) surveys of postservice drug use^by veterans in which no association with service in Vietnam or combat exposure was found.31'32 With respect to the first point, our results do not show a relationship between total mortality or any specific cause of death and discharge from the Army in 1970 or later, a time period that would include men who were in Vietnam in the early 1970s. On the contrary, the overall mortality excess is greatest among Vietnam veterans discharged in the late 1960s, and drug-related deaths are most excessive among Vietnam veterans who were in Vietnam in the late 1960s. Regarding the second point, it would appear that the drug-related findings are at variance with findings in two surveys of drug use among living Vietnam veterans.31'32 One possibility for the discordant results is response bias on the part of interviewed Vietnam veterans whereby actual drug use is concealed. Admittedly, this would have had to operate in two independent surveys. Another consideration is the time frame for the studies. Since the-greatest part of our excess occurs 11 or more years after discharge, it could be a delayed response that affects a susceptible subgroup of Vietnam veterans and is completely masked when use habits are studied in living veterans at earlier points in time. Also,.one of the surveys was conducted with veterans returning from Vietnam in late 197131, while the drug-related excess in our study was found among those serving in Vietnam during the late 1960's. 5.3. POSSIBLE INTERPRETATIONS AND CONCLUSIONS The increase in early postdischarge mortality from external causes (i.e., MVA, suicide and homicide) among Vietnam veterans seen in this study has at least three possible explanations: 1) It reflects a peculiarity of the process of selecting men for assignment, • whereby those sent to Vietnam tended to have characteristics that placed them at increased risk of dying from external causes shortly after discharge from active duty. 2) It is a result of the psychological and physical stresses associated with military duty in a combat zone, a set of circumstances not unique to the Vietnam conflict. 3) It is a consequence of the uniqueness of the Vietnam conflict, some combination of environment and experience that exerted special effects -31- �while men were serving there and/or after their return to an unsupportive and sometimes hostile social climate in the U.S.A. The first of these possibilities appears doubtful for several reasons. In our data, no important differences were apparent in background characteristics between Vietnam and non-Vietnam veterans (e.g., race, age, aptitude test scores) at the time of entry into the Army. On the other hand, the non-Vietnam group had a higher prevalence of nonhonorable discharges, lower pay grades at discharge, and more AWOL or confinement time while in the Army, characteristics that might be associated with risk-taking behavior. Furthermore, if Vietnam veterans tended to have a greater predisposition (by selection) toward traumatic events than non-Vietnam veterans, it might be expected to manifest itself in increased relative mortality from such causes throughout the entire period of observation, rather than being confined to the first few years after discharge, as was observed here. Further doubt about such selective factors is raised by a survey of high-school boys which showed that those who subsequently served in Vietnam were similar to those who served elsewhere-in the military with respect to family background, early academic abilities and achievements, and adolescent personality .traits.33 The second possible explanation has some basis in the light of previous studies of postservice mortality among U.S. veterans who served in other war zones. Increased postdischarge mortality from external causes was observed in two groups of World Mar II combat veterans and one group of Korean War combat veterans, when compared with the general U.S. male population, even though older men and officers were included.34 In contrast, broader cross sections of World War II veterans, including both combat and noncombat groups, showed no difference, or even a slight deficit, in postdischarge traumatic deaths, 25,34 as did non-Vietnam veterans in our study. The third possible explanation for the present findings, the unique elements of the Vietnam conflict, seems plausible on the surface, since the Vietnam conflict was characterized by a number of special features. Among these were: (1) entry to, and exit from, the war zone in a very compressed time period, with little or no time for adjustment (the "jet-age war" phenomenon); (2) individual replacement after predetermined 12-month tours of duty (associated with reduced morale and cohesiveness within units); (3) fighting an enemy that was hard to distinguish from one's allies; and (4) fighting for "body counts" rather than for territory. On top of this, returning Vietnam veterans encountered an indifferent and sometimes hostile reception at home. This is in direct contrast to the experience of most World War II and Korean War veterans who were sent overseas "for the duration" as members of pre-formed units that trained and stayed together. Warfare was more "conventional", and objectives could be more easily understood. Furthermore, the World War II and Korean veterans returned to a generally more supportive homeland. In spite of these contrasts in military experience, however, the same pattern of excess postservice mortality due to external causes seen in Vietnam veterans is also 'found among men returning from combat areas in the two previous wars. Thus, increased external cause mortality seen here among Vietnam veterans may be one of the unfortunate sequelae of unusual stresses endured while stationed in a hostile fire zone. Although this explanation is very suggestive, it should be noted that certain features of our data do not support this conclusion. Namely, Vietnam veterans who were likely to have engaged in combat did not have a higher rate of mortality than Vietnam veterans who were less likely to have done so. We -32- �might expect just the opposite if the excess mortality observed here is the result of the psychological and physical .stresses associated with military duty in a combat zone. Also, the findings for the World War II and Korean Mar Army veterans are not particularly enlightening for deaths due to suicide and homicide, because of small number of such deaths and the lack of data on suicide and homicide risks according to time period after discharge. In addition, the influence of factors specific to the Vietnam experience in explaining this early postservice external mortality excess cannot be completely ruled out. Indeed, cross sectional surveys 32,33,35-37 natfa uncovered a variety of psychosocial and economic problems among Vietnam veterans that may be the precursors for certain types of traumatic deaths, such as suicide. If the MVA excess among Vietnam veterans is causally related to their experience in a combat zone, it may be consistent with one or more theories of young driver risk-taking behavior.38 According to these theories, unusual risk-taking on the part of young drivers may be: (1) an outlet for stress, aggression, hostility, or frustration. Could service in Vietnam have created these feelings? (2) ,a physiological need for increased arousal that makes some people seek ways of increasing their stimulation. Could service in Vietnam have produced a desire for sensation- or thrill-seeking? (3) an attempt by some persons to increase the level of perceived driving risk to some higher target level that they find acceptable. Could service in Vietnam have produced an acceptance of increased risk in everyday life? Whatever the explanation is, factors responsible for the MVA results were operable only in the first few years after discharge. Thus, this may have been the critical period in which those most affected by the Vietnam experience succumbed. The pattern of drug-related mortality among Vietnam veterans in this study appears different from the pattern of external causes (i.e., MVAs, suicide, homicide). Excess drug-related deaths increase with time since discharge, and certain subgroups of Vietnam veterans seem to be at especially high risk, namely, draftees and those whose job was in tactical operations (i.e., combat-related activities). Examination of , risks in relation to the calendar year men were in Vietnam shows the largest excess associated with 1968 and 1969, the years of heaviest • combat. Thus, the increased death rates from drug-related causes among Vietnam veterans may be linked to intensity of combat exposure rather than to a general, across-the-board effect of the Vietnam experience. The mortality assessment of Vietnam veterans presented here is an incomplete evaluation of the health experience of this group. Additional data on the present and past health status of living Vietnam veterans will be forthcoming from the health interview and medical, psychological, and laboratory evaluation components of the VES. Because this group of veterans has not yet reached the age span where chronic diseases have an important impact on mortality, continued monitoring of mortality among VES participants may provide additional insights. -33- �REFERENCES -34- �» J. 1. Veterans Health Programs Extension and Improvement Act of 1979. Law 96-151 [H.R. 3892]; December 20, 1979, 93 STAT 1092-1098. 2. Public Veterans' Health Care, Training, and Small Business Loan Act of 1981. Public Law 97-72 [H.R. 3499];November 3, 1981, 95 STAT 1047-1063. 3. Centers for Disease Control: Protocol for Epidemiologic Studies of the Health of Vietnam Veterans. Atlanta, Centers for Disease Control, November, 1983. 4. Centers for Disease Control: Responses to Scientific Reviews of the Centers for Disease Control's Draft Protocols for Epidemiologic Studies of the Health of Vietnam Veterans. Atlanta, Centers for Disease Control, November, 1983. 5. Lathrop GO, Moynahan Pfl, Albanese RA, Wolfe WH: Project Ranch Hand II. An Epidemiologic Investigation of Health Effects in Air Force Personnel Following Exposure to Herbicides: Baseline Mortality Study Results. San Antonio, Brooks Air Force Base, U.S. Air Force School of Aerospace Medicine, 1983. 6. Kogan MD, Clapp RW: Mortality Among Vietnam Veterans in Massachusetts, 1972-1983. Boston, Massachusetts Department of Public Health, 1985. 7. Lawrence CE, Reilly AA, Quickenton P, et al: Mortality patterns of New York State Vietnam veterans. Am J Public Health 1985;75:277-279. 8. Anderson HA, Hanrahan LP, Jensen M, et al: Wisconsin Vietnam Veteran Mortality Study. Madison, Wisconsin Division of Health, 1985. 9. Holmes AP: West Virginia Vietnam-Era Veterans Mortality Study. Charleston, West Virginia Health Department, 1986. 10. Fett MJ, Dunn M, Adena MA, et al: Australian Veterans Health Studies: The Mortality Report. Part I: A Retrospective Cohort Study of Mortality Among Australian National Servicemen of the Vietnam Conflict Era, and an Executive Summary of the Mortality Report. Canberra, Australian Government Publishing Service, 1984. 11. Department of the Army: U.S. Army Replacement System Overseas Service. Assignments, Details and Transfers. AR 614-30. Washington, D.C., Department of the Army, September, 1967. 12. U.S. Department of Health, Education, and Welfare: International Classification of Diseases, Adapted for Use in the United States. Eighth Revision. PHS Publication No. 1693. Washington, D.C., U.S. Government Printing Office, 1967. -35- : �13. World Health Organization: Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death. Ninth Revision. Geneva, World Health Organization, 1977. 14. Department of the Army: Medical Service. Standards of Medical Fitness. AR 40-501. Washington, D.C., Department of the Army, December, 1960. 15. Department of the Army: Enlisted Personnel Selection, Training, and Assignment System Grades E-l Through E-9. AR 614-200. Washington, D.C., Department of the Army, June, 1970. 16. Department of the Army: Enlisted Military Occupational Specialities. AR 611-201. Washington, D.C., Department of the Army, January, 1967. 17. Keehn RJ: Military rank at separation and mortality. Armed Forces and Society 1978;4:283-292. 18. McClure GMG: Trends in suicide rates for England and Wales, 1975-1980. Br J Psych 1984;144:119-126. 19. Laird N, Oliver D: Covariance analysis of censored survival data using log-linear analysis techniques. J Am Stat Assoc 1981;76:231-241. 20. Cox DR, Oakes D: Analysis of Survival Data. London, Chapman and Hall, 1984. 21. Harrell FE: The PHGLM Procedure. In Joyner SP (ed): SUGI Supplemental Library User's Guide. Gary, N.C., SAS Institute, Inc, 1983. 22. Kalbfleisch JD, Prentice RL: The Statistical Analysis of Failure Time Data. New York, John Wiley & Sons, 1980. 23. Fleiss JL: Statistical Methods for Rates and Proportions, Second Edition. New York, John Wiley & Sons, 1981. 24. Landis JR, Koch GG: The measurement of observer agreement for categorical data. Biometrics 1977;33:159-74. 25. Seltzer CC, JabIon S: Effects of selection on mortality. Am J Epidemiol 1974;100:367-372. 26. Monson RR: Analysis of relative survival and proportional mortality. Comp Biomed Res 1974;7:325-332. 27. Rothman KJ, Boice JD: Epidemiologic Analysis with a Programmable Calculator. Washington, D.C., U.S. Government Printing Office, 1979. 28. Seltzer CC, JabIon S: Army rank and subsequent mortality by cause: 23-year follow-up. Am J Epidemiol 1977;105:559-566. 29. Wong 0, Decoufle P: Methodological issues involving the standardized mortality ratio and proportionate mortality ratio in occupational studies. J Occup Med 1982;24:299-304. -36- �30. Ritter C, Clayton RR, Voss HL: Vietnam military .service and marijuana use. Am J Drug Alcohol Abuse 1985;11:119-130. 31. Robins LN, Helzer JE, Davis DH: Narcotic use in Southeast Asia and afterward. Arch Gen Psychiatry 1975; 32:955-961. 32. Yager T, Laufer R, Gallops M: Some problems associated with war experience in men of the Vietnam generation. Arch Gen Psychiatry 1984; 41:327-333. 33. Card JJ: Lives after Vietnam. 1983. Lexington, Mass., D.C. Heath and Company, 34. Nefzger MO: Follow-up studies of World Mar II and Korean Mar prisoners. I. Study plan and mortality findings. Am J Epidemiol 1970;91:123-138. 35. Fischer V, Boyle JM, Bucuvalas M, et al: Myths and Realities: A Study of Attitudes Toward Vietnam Era Veterans. New York, Louis Harris and Associates, Inc., 1980. 36. Helzer JE, Robins LN, Davis DH: Depressive disorders in Vietnam returnees. J Nerv Ment Dis 1976;163:177-185. 37. Louis Harris and Associates, Inc.: A Study of the Problems Facing Vietnam Era Veterans on Their Readjustment to Civilian Life. U.S. Senate Committee Print No. 7. Washington, D.C., U.S. Government Printing Office, 1972. 38. Johan BA: Accident risk and risk-taking behavior among young drivers. Accid Anal & Prev 1986; 18":255-271. -37- �FIGURE 1. Selection of Study Group. * Excluded from study. + Eighty-three percent (N = 194) of active duty deaths among Vietnam veterans were due to war-related activities. �FIGURE 2. Mortality Rates* of Vietnam and Non-Vietnam Cohorts by Years Since Discharge * Mortality rates are three-year moving averages. �VIETNAM-ERA ARMY PERSONNEL RECORDS FILED AT NPRC BETWEEN SEPT 1964 AND JUNE 1977 Approx. 4,900,000 RANDOM SAMPLE 48.513 i RECORDS NOT FOUND* 1,355 QUALIFIED FOR STUDY 18.581 VIETNAM 9,558 NOT QUALIFIED 28.571 NON-VIETNAM 9.023 DIED ON ACTIVE DUTY 34 i DIED ON ACTIVE DUTY * 1 234 VIETNAM COHORT 9,324 NON-VIETNAM COHORT 8.989 �Smoothed Mortality Rates of Vietnam-Era Veterans by Years Since Discharge Figure 2 3 I I I I I I I I 2.4 ! L a! 1.2 i 0.6 J L J 1 10 Years Since Discharge 15 �TABLE 1. Smallest Relative Risks Detectable with 95% Power for Selected Causes of Death* Cause of death Deaths* /1000 Rate ratio4"*" All causes 35.5 1.3 Accidents 13.2 1.5 Homicide 4.6 2.0 Suicide 4.3 2.0 Diseases of heart 3.1 2.3 Malignant neoplasms 2.9 2.3 Cirrhosis of liver 1.1 3.5 Cerebrovascular diseases 0.6 4.9 * Adapted from 1983 CDC Protocol3 (Table 1, p. 43) + Expected deaths over 17 years (1968-1984) based on 1978 U.S. •age-specific rates for males as applied to a hypothetical cohort . of men aged 22 at initiation of follow-up. <H " Vietnam cohort relative to non-Vietnam cohort, with 8500 in each cohort. Calculated by Arc Sin approximation, alpha = 0.05 (two-sided). �TABLE 2. Number of Deaths During Active Military Service Among Vietnam and Non-Vietnam Veterans, by Manner of Death Non-Vietnam Vietnam Manner of death (X) (X) No. 181 (77.3) 0 ( 0.0) Implements of war related 13 ( 5.6) 1 ( 2-9) Other 35 (15.0) 5 ( 2.1) Hostility related Unknown Total No. 234 (100.0) 33 0 34 (97.1) ( 0.0) (100.0) �\ TABLE 3. Vital Status of Vietnam and Non-Vietnam Veterans at End of Follow-up (December 31, 1983) Vital status Vietnam No. (X) Known dead* 246 (.) 26 200 (.) 22 Known alive 8,488 (91.0) 8,067 (89.7) 590 (6.3) 722 (.) 80 9,324 (0.) 100 8,989 (0.) 100 Status uncertain Total Non-Vietnam No. () % * Includes 9 veterans (7 Vietnam and 2 non-Vietnam) for whom death certificates were not recovered but for whom sufficient information was obtained to be certain that they had died. �TABLE 4. Covariates Considered and Associated Categorizations Employed in the Analysis Variable Categories for analysis Race White, Nonwhite Place of birth Northeast, Midwest, South, West + Enlistment status Volunteer, Draftee PULHES categories: Physical capacity or stamina No Impairment, Some Impairment Upper extremities No Impairment, Some Impairment Lower extremities * No Impairment, Some Impairment Hearing acuity and ears No Impairment, Some Impairment Eyes and visual acuity No Impairment, Some Impairment Psychiatric functioning No Impairment, Some Impairment Composite index of physical and psychological health No Impairment, Some Impairment Army Classification Battery: Verbal ability ' Arithmetic reasoning Continuous measure range from 1-200 Continuous measure range from 1-200 Pattern analysis Continuous measure range from 1-200 General information Continuous measure range from 1-200 General technical (GT) Continuous measure range from 1-200 Armed Forces Qualification Test (AFQT) Continuous measure range from 1-100 Military occupational specialty (MOS) Tactical, Other Type of unit Infantry, Engineer, Armor, Cavalry, Artillery, Other Months of active duty 0-11, 12-23, 244- �TABLE 4. (continued) Variable Categories for analysis AWOL or confinement time Ever, Never Type of discharge Honorable, Nonhonorable Pay grade at discharge E1-E3, E4-E5 Age at discharge from active duty <21. 21+ years44" Year of discharge from active duty - Before 1970, 1970 and later * Unknown values excluded from analyses. + Foreign places of birth included with West category. 41 4 When rate ratios are adjusted for age at separation, age is treated as a continuous variable. �TABLE 5. External Causa-of-Death Subcategories and Associated ICD-9 Codes Used in Mortality Analyses Sub-category ICD-9 codes Specific causes 1. Motor vehicle accident E810-825, E929.0 Motor vehicle traffic & nontraffic accidents; Late effects of motor vehicle accidents 2. Accidental poisoning E850-869, E929.2 Accidental overdose of drugs; poisoning by solids, liquids, gases & vapors; Late effects of accidental poisoning 3. Suicide E950-959 4. Homicide E960-969 5. Injury of undetermined intentionality E980-989 6. Other external causes E800-807, E826-849 Railway accidents; Recreational vehicle, water transport and air transport accidents E870-879 E880-888 E890-899 E900-909 E910-915 E916-928 E929.1. E929.3-929.9 E930-949 E970-978 Injuries undetermined whether accidentally or purposely inflicted Surgical and medical misadventures and complications Accidental falls Accidental fires and flames Accidents from natural & environmental factors Submersion & suffocation Other accidents Late effects of the above accidents Adverse effects of drugs in therapeutic use Legal intervention �TABLE 6. Alcohol-Related Deaths Based oh ICD-9 Diagnoses Cited as Either Underlying or Contributing Causes of Death ' Disease category Underlying cause Medical, neurologic and psychiatric Alcoholic psychoses (291.0-291.9) Alcohol dependence syndrome (303) Nondependent abuse of alcohol (305.0) Alcoholic polyneuropathy (357.5) Alcoholic cardiomyopathy (425.5) Alcoholic gastritis (535.3) Alcoholic liver disease (571.0-571.3) Excessive blood level of alcohol (790.3) Accidents (Unintended trauma) Contributing cause Accidental poisoning by alcohol (E860.0-E860.9) Any other accident Other trauma Nondependent abuse of alcohol (305.0) or Excessive blood level of alcohol (790.3) Suicide, homicide or injury of undetermined intentionality Nondependent abuse of alcohol (305.0) or Excessive blood- level of alcohol (790.3) �TABLE 7. Drug-Related Deaths/Based on ICD-9 Diagnoses Cited as Either Underlying or Contributing Causes of Death Disease category Drug dependence and abuse .' ; • , < Accidental poisoning by drugs Underlying cause Contributing cause Drug psychoses (292.0-292.9) Drug dependence (304.0-304.9) or Nondependent abuse of drugs other than alcohol or tobacco (305.2-305.9) Any other natural cause or any traumatic cause except accidental poisoning by a drug of abuse*. Suicide by drugs or poisoning by drugs of undetermined intentionality Drug dependence (304.0-304.9) or Nondependent abuse of drugs other than alcohol or tobacco (305.2-305.9) Accidental poisoning by a drug of abuse* Accidental poisoning by a drug of abuse* Suicide by drugs Suicide by drugs or poisoning by (E950.0-E950.5) drugs, intentionality or Poisoning by drugs, undetermined intentionality undetermined (E980.6-E980.5) Suicide by drugs (E950.0-E950.5) or Poisoning by drugs, intentionality undetermined (E980.0-E980.5) * Includes the following drug categories: Opiates and related narcotics (E850.0) Salicylates (E850.1) - . Aromatic analgesics, not elsewhere classified (E850.2) Other non-narcotic analgesics (E850.5) Other analgesics, antipyretics and antirheumatics (850.8) Barbiturates (E851) Sedatives and hypnotics (E852.0-E852.9) Tranquilizers (E853.0-E853.9) Other psychotropic drugs (E854.0-E854.3) Other central nervous system depressants (E855.1) Local anesthetics (E855.2) Glues and adhesives (E866.6) Nitrogen oxides (E869.0) 10 �i TABLE 8. Summary of Differences in Entry and Military-Service I Characteristics Between Vietnam and Non-Vietnam Veterans Characteristic Vietnam Non-Vietnam Race (X white) 86.8 86.5 Region of birth (X ME, «w) 49.3 50.4 Year of entry (X before 1969) 72.1 60.6 Age at entry • (mean, in years) 20.3 20.5 Enlistment status (X draftee) 63.7 65.6 Health status at entry (X with some impairment) Physical capacity 0.9 1.2 Upper extremity 0.7 0.9 Lower extremity 2.6 2.7 Hearing 5.6 6.7 25.5 Visual acuity Psychiatric functioning 0.2 Overall physical health 32.1 28.7 0.2 36.0 General Aptitude Tests (mean scores): Verbal ability 104.4 106.9 Arithmetic reasoning 101.5 103.8 Pattern analysis 101.7 103.5 General information 100.3 100.8 General technical 103.1 105.5 50.4 52.3 Armed Forces Qualification 11 �TABLE 8. (continued) Characteristic Vietnam Non-Vietnam Primary MOS (X tactical operations) 34.3 27.4 Type of unit (X infantry) 26.6 14.6 Duration of active duty (mean, in months) 26.1 25.3 AWOL or confinement time : ; X with some "bad" time) ( 11.6 13.3 Type of discharge (X nonhonorable) 2.7 11.5 Pay grade at discharge (X E1-E3) 12 8.9 20.2 �TABLE 9. Number of Men, Deaths, Person-Years at Risk, and Crude Death Rates/1000 Person-Years Among Vietnam and Non-Vietnam Veterans and Rate Ratios (1965-1983) - Number of men Number of deaths Person-years , postdischarge Crude death rate Rate ratio (95X CI) Non-Vietnam Vietnam 9.324 8,989 246 200 127,897 121,330 1.7 1.9 1.17 (0.97-1.41) 13 1.00 �TABLE 10. Number of Deaths, Person-Years, and Crude Death Rates/1000 Person-Years Among Vietnam and Non-Vietnam Veterans and Rate Ratios, by Time Since Discharge (1965-1983) Years since discharge Vietnam No. Persondeaths years Non-Vietnam Rate/ No. Person- Rate/ 1 0 . deaths years 00 1000 Rate ratio 95X CI 1.45 1.08 - 1.96 1 5 110 46,350 2.37 73 44,747 1.63 6-10 72 45,855 1.57 74 44,233 1.67 0.94 0.68 - 1.30 11+ 64 35,692 1.79 53 32,350 1.64 1.09 0.76 - 1.57 246 127,897 1.92 1.65 1.17 0.97-1.41 All years 200 14 121,329 �TABLE 11. Number of Deaths, Person-Years, and Crude Death Rates/1000 Person-Years Among Vietnam Veterans, Veterans with Other Foreign t Service (Germany or Korea), and Veterans with No Foreign Service and Rate Ratios, by Time Since Discharge (1965-1983) Cohort Years since No. Persondischarge deaths years Vietnam < 5 Rate/ 1000 Rate ratio 95% CI —_ 6-10 11+ 110 72 64 46,350 45,855 All years 246 2.4 1.6 1.8 35,692 127,897 ^ - - 1.9 — Germany/ Korea 15 6-10 11+ All years 44 47 31 122 25,485 25,210 18,381 69,076 1.7 1.9 1.7 1.8 1.37* 0.84 1.06 1.08 0.97 0.58 0.69 0.88 — - 1.95 1.22 1.63 1.35 United States service only < 5 6-10 11+ All years 29 27 22 78 19.262 19,023 13.969 52,254 1.5 1.4 1.6 1.5 1.57+ 1.11 1.14 1.29 1.05 0.71 0.70 1.00 - 2.37 1.72 1.85 1.66 * Rate ratios for Vietnam veterans are relative to veterans with other foreign service (Germany or Korea). + Rate ratios for Vietnam veterans are relative to veterans with U.S. service only. 15 �TABLE 12. Summary of Results of Chi-Squara Tests (p-values) for Effect Modification of Entry and Military.Characteristics, by Time Since Discharge (All-Cause Mortality) Characteristic Years since discharge 6+ All years. years years Race 0.70 0.78 0.89 Age at discharge 0.45 0.15 0.81 Duty MOS 0.84 0.37 0.54 Enlistment status 0.10 0.52 0.14 Region of birth 0.82 0.70 0.97 Composite index of health 0.08 0.38 0.60 GT score 0.92 0.50 0.60 Type of unit 0.77 0.48 0.52 Duration of active duty 0.20 0.81 0.36 AMOL/confinement time 0.14 0.63 0.18 Year of discharge 0.06 0.69 0.43 Type of discharge 0.39 0.78 0.45 Pay grade at discharge 0.78 0.02 0.02 <5 16 �TABLE 13. Summary of Rate Ratios for Vietnam Service Adjusted for the Specified Characteristic, by Time Since Discharge (All-Cause Mortality) Characteristic Years since discharge All en15 years years years (Unadjusted) 1.45* 1.01 1.17 Race 1.45* 1.00 1.17 Age at discharge 1.51* 1.01 1.19 Primary MOS 1.44* 1.00 1.16 Enlistment status 1.44* 0.99 1.15 Region of birth 1.45* 0.97 1.16 Composite index of health 1.45* 1.00 1.16 GT score 1.42* 0.97 1.13 Type of unit 1.37* 1.00 1.13 Duration of active duty 1 . 42* 0.95 1.12 AWOL/confinement time 1.50* 1.02 1.19 Year of discharge 1.46* 1.00 1.17 Type of discharge 1.59* 1.09 1.28* Pay grade at discharge 1.66* 1.14 1.32* * Ninety-five percent confidence interval excludes 1.00. 17 �TABLE 14. Regression Coefficients, Standard Errors (SE), and Associated P-Values from Reduced Cox Regression Models*, by Time Since Discharge (All-Cause Mortality) Years since discharge £ 5 years Covariate (category) Cohort (Vietnam/ other) 6+ years Coeff.(SE)RR+p-value 1.58 Coeff. (SE) RR <0.01 0.036 (0.127) 1.04 0.457 (0.155) Age at discharge (in years) -0.079 (0.048) 0.10 0.022 Race (white/ other) -0 .227 (.0) 022 0.26 GT score (in units) 08 004 -0 . 0 ( . 0 ) Pay grade (E4-E5/ other) -0 .740 Year of -0.056 discharge «1970/1970+) p-value Coeff.(SE)RRp-value 0.78 0.207 (.9) 008 (0.036) 0.54 -0.015 (0.029) 0.59 -0.588 (0.154) <0.0l -0.449 (0.122) <0.01 00 .6 -0.012 (.0) 003 <0.01 -0.010 ( . 0 ) 003 <0.01 (0.176) <0.01 -0.664 (0.147) <0.01 -0.692 (0.113) <0.01 (0.155) 0.72 -0.276 (0.137) 00 .4 -0.177 (.0) 012 00 .8 *Model stratified by MOS and enlistment status. +RR - rate ratio. All years 1.23 0.03 �TABLE 15. Summary of Entry and Military Service Characteristics For Vietnam Veterans Killed in Service and Those Discharged Alive Killed in action* (N=181) Characteristic Discharged .alive (AN9324) Race ( white) % 86.2 86.8 Enlistment status (X draftee) 64.6 63.7 Physical health (X impaired) Overall physical capacity Eyes and vision ;Hearing and ears 0.0 11.1 4.4 0.9 25.5 5.6 0.0 0.2 Psychological health (X impaired) Aptitude tests: GT score (mean) AFQT (mean) 103.1 48.4 104.4 50.4 Duty MOS (X tactical) 86.2 34.5 Type of unit (X infantry) 70.1 26.6 * Inservice deaths from causes other than hostile enemy action are excluded. 19 �TABLE 16. Distribution of Selected Characteristics Among Vietnam and Non-Vietnam Veterans, by Vital Status at End of Follow-Up Characteristic Vietnam Status Status certain uncertain (N=590) (N=8734) Non-Vietnam .Status Status uncertain certain (N=8267) (N=722) Race (X nonwhite) 27.5 12.1 27.0 12.3 Enlistment status (X draftees) 56.3 64.2 53.1 66.7 Physical health (X with any impairment) 29.3 32.6 31.6 36.8 GT score (mean) 96.4 103.6 96.6 106.3 Primary MOS (X tactical) 35.9 34.2 29.8 27.2 Discharge status (X nonhonorable) 11.4 2.1 29.9 7.1 Age at discharge (mean) 21.7 22.0 21.5 22.1 10.2 53.5 17.3 Pay* grade at 31.4 discharge (X E1-E3) 20 �TABLE 17. Number of Deaths by Cause (from Death Certificate) and Crude Death Rates/100,000 Person-Years Among Vietnam and Non-Vietnam Veterans and Unadjusted Rate Ratios (1965 - 1983) Underlying cause of death (ICD-9)* Vietnam No. Rate/ deaths 1000 0.0 Infectious and parasitic diseases . (001-139) Neoplasms (140-239) Non-Vietnam No. Rate/ deaths 100,000 0.8 12 Rate ratio+ 95% CI 0.8 9.4 14 11.5 0.82 0.38-1.76 0.95 0.33-2.70 0.49 0.25-0.99 Mental disorders (290-319) 5.5 5.8 Diseases of nervous system (320-389) 1.6 0.8 Diseases of circulatory system (390-459) 12 9.4 23 19.0 Diseases of respiratory system (460-519) 3.9 3.3 Di'seases of digestive system (520-579) 3.9 2.5 Diseases of genitourinary system (580-611) 3.1 Congenital anomalies (740-759) 0.8 0.8 21 �TABLE 17. (continued) Underlying cause of death (ICD-9)* Vietnam No. Rate/ deaths 100,000 Symptoms, signs and illdefined conditions (780-799) External causes (E800-E999) - Non-Vietnam No. Rate/ 100,000 deaths . 1.6 188 Rate ratio* 95X CI 0.8 147.0 143 117.9 1.25 1.00-1.55 No death certificate * No deaths were categorized to diseases of blood and blood-forming organs; endocrine, metabolic, or nutritional diseases; diseases of the skin; or diseases of the musculoskeletal system. Therefore, these categories are not shown. + If the total number of deaths for a cause-of-death category in both groups combined was less than 10, rate ratios are not shown. 22 �TABLE 18. Number of Deaths Due to Neoplasms (from Death Certificate) and Crude Death Rates/100,000 Person-Years Among Vietnam and Non-Vietnam Veterans and Rate Ratios, by Time Since Discharge (1965-1983) Years since discharge 15 6+ All years No. deaths Vietnam Rate 100,000 Non-Vietnam Rate No. 100,000 deaths Rate ratio 95X CI 5 10.8 6 13.4 0.81 0.25-2.64 7 8.6 8 10.4 0.82 0.30-2.27 12 9.4 14 11.5 0.81 . 0.38-1.76 23 �TABLE 19. Number of Deaths Due to Neoplasms (from Death Certificate)* Among Vietnam and Non-Vietnam Veterans, by Type and Site of Neoplasm (1965-1983) Neoplasm type/site (ICD-9) Vietnam Cancer of colon and rectum (153-154) 0 Cancer of liver (155) 1 Cancer of lung X162) 0 Cancer of skin (172-173) 1 Cancer of testis (186) 2 Cancer of brain (191) 0 Hodgkin's disease (201) Non-Vietnam 0 Lymphosarcoma and other malignant 1 -neoplasm of lymphoid tissue (200, 202) Leukemia (204-208) 3 Malignant neoplasms of unspecified site (199) 1 Neoplasms of uncertain behavior or nature (235-239) 3 * Because of small numbers of deaths in all categories, rates and rate ratios are not presented. 24 �TABLE 20. Number of Deaths Due to Circulatory System Diseases (from Death Certificate) and Crude Death Rates/100,000 Person-Years Among Vietnam and Non-Vietnam Veterans and Rate Ratios, by Time Since Discharge (1965-1983) Years since discharge No. deaths I5 0 6+ 12 12 Vietnam Rate/ 1000 0,0 All years Non-Vietnam No. Rate/ deaths 100,000 Rate ratio 95X CI 5 11.2 14.7 18 23.5 0.63 0.30-1.30 9.4 23 19.0 0.49 0.25-0.99 25 �TABLE 21. Number of Deaths Due to Circulatory System Diseases (from Death Certificate) and Crude Death Rates/100,000 Person-Years Among Vietnam and Non-Vietnam Veterans and Rate Ratios, by Type of Circulatory System Disease (1965-1983) Circulatory disease (ICD-9) Vietnam No. Rate/ deaths 100,000 Non-Vietnam Rate/ No. deaths 100^000 Hypertensive disease (401-405) Rate ratio* 95X CI 0.60 0.23-1.56 1.7 Ischemic heart disease (410-414) 5.5 Other heart disease (420-529) 3.1 4.1 Cerebrovascular disease (430-438) 0.8 2.5 11 9.1 Diseases of the arteries (440-448) 0.8 Other disorders of circulatory system (459) 0.8 If the total number of deaths for a cause-of-death category in both groups combined was less than 10, the rate ratio is not shown. 26 �TABLE 22. Number of Deaths Due to External Causes (from Death Certificate) and Crude Death Rates/100,000 Person-Years Among Vietnam and Non-Vietnam Veterans and Rate Ratios, by Specific Cause (1965-1983) External cause (ICD-9) Motor-vehicle accidents (E810-E825) Vietnam No. Rate/ deaths 100,000 Rate ratio 95% CI 63.3 81 Accidental 13 poisonings • CE850-E869) Non-Vietnam No. Rate/ deaths 1000 0,0 . 52 42.9 1.48 1.04- 2.09 10.2 5 4.1 2.47 0.88- 6.92 24.2 31 25.6 0.95 0.58- 1.56 Other accidents* 31 Suicide 29 22 . 7 28 23.1 0.98 0.58- 1.65 26 20.3 25 20.6 0.99 0.57- 1.71 8 6.3 2 1.6 3.79 0.81-17.87 • (E950-E959) Homicide (E960-E969) Undetermined (E980-E989) * Includes accidental deaths other than motor vehicle accidents and accidental poisonings. 27 �TABLE 23. Numbers of Deaths From External Causes (from Death Certificate) Among Vietnam and Non-Vietnam Veterans Combined and Unadjusted Rate Ratios, by Specific Cause and Time Since Discharge (1965-1983) External cause <_ 5 years No. Rate deaths ratio Years since discharge 6+ years 95% CI No. Rate 951 CI deaths ratio Motor vehicle accident 66 1.93 1.16-3.22 67 1.16 0.72-1.87 Other accidents* 23 1.05 0.46-2.39 39 0.89 0.48-1.67 25 1.72 0.76-3.88 32 0.64 0.32-1.30 Suicide** 39 1.72 0.90-3.32 46 1.12 0.63-2.00 Homicide 18 1.52 0.59-3.91 33 0.78 0.39-1.55 Suicide * * Number of deaths and RRs for "All years" of follow-up are presented in Table 27. * Includes accidental deaths other than motor vehicle accidents and 'accidental poisonings. •^.Includes: accidental poisonings (E850-869), suicides (E950-959), injury undetermined whether accidentally or purposefully inflicted (E980-989) and ill-defined or unknown cause of death (799.9). 28 �TABLE 24. Number of Deaths Among Vietnam and Non-Vietnam Veterans Combined and Unadjusted Rate Ratios* for Drug- and Alcohol-Related Causes (from Death Certificate), by Time Since Discharge (1965-1983) Years since discharge 6+ years <. 5 years Cause* No. Rate deaths ratio Alcoholrelated 4 Drugrelated 15 - 1.93 95% CI No. Rate deaths ratio 95X CI All years No. Rate deaths ratio 95% CI - 17 1.73 06-.6 .446 21 1.27 05-.0 .230 0.66-5.64 11 2.50 0.66-9.44 26 2.13 0.93-4.91 If the total number of deaths for a cause-of-death category in both groups combined was less than 10, the rate ratio is not shown. See Section 3.1.3 for definitions of alcohol- and drug-related causes of death. 29 �TABLE 25. Information Sources Used by Medical Review Panel to Determine Cause of Death, by Place of Service Source of information Vietnam No. (X of all deaths deaths) Non-Vietnam No. (X of all deaths deaths) Law enforcement record* 124 (53.2) 121 (62.7) Autopsy report 125 (53.7) 114 (59.1) Alcohol level 126 (54.1) 108 (60 5.) Medical examiner's report* 117 (02 5.) 115 (59.6) Hospital record 109 (46.8) 85 (40 4.) Toxicologic report 78 (33.5) 76 (39.4) Coroner's repor't 81 (34.8) 69 (35.8) Histopathology report* 9 ( 3.9) 17 ( 8.8) Physician's. record 3 ( 1.3) 2 ( 1.0) Other* 5 ( 2.2) 2 ( 1.0) * p<0.05 (difference between percents for Vietnam and non-Vietnam veterans) + Cther sources of information were records obtained from the U.S. Bureau of Indian Affairs, the U.S. Bureau of Prisons, the National Personnel Records Center of the National Archives and Records Administration, local fire departments, funeral homes, and a single unsolicited verbal report from a next of kin who was contacted by telephone for permission to obtain medical records. 30 �TABLE 26. Number of Information Sources Available to Medical Review Panel, by Place of Service Number of sources* Vietnam Non-Vietnam No. deaths No. deaths X 1 39 16.7 20 10.4 2 43 18.5 41 21.2 3 47 20.2 35 18.1 4 41 17.6 19 9.8 5 36 15.5 46 23.8 6 22 9.4 28 14.5 7 5 2.2 4 2.1 Total 233 100.0 193 X 100.0 * The number of information sources available to the medical review panel differed significantly between cohorts (xg = 14.41, p = 0 0 ) .2. 31 �TABLE 27. Percent Agreement and Kappa Statistic Between Death-Certificate and MecH MedicalReview-Panel Cause of Death, by Selected Cause-of-Death Category and P/lace of Service Vietnam Percent kappa* agreement Non-Vietnam kappa* Percent agreement Cause of death (ICD-9) No. deaths DC MR* Neoplasms (140-239) 12 14 100.0 0.92 13 11 84.6 0.91 7 12 28.6 0. 18 7 4 28.6 0.35 19 78.3 0.84 Mental disorders No. deaths DC MR* (290-319) Circulatory diseases (390-459) 11 10 81.8 0.85 Respiratory diseases (460-519) 5 2 20.0 0.28 50.0 0.66 Digestive diseases (520-579) 5 6 40.0 0.35 100.0 0.49 Motor-vehicle 78 accidents (E810-E825) 80 98.7 0.96 52 52 96.2 0.95 46.2 0.43 5 5 60.0 0.59 23 Accidental poisonings (E850-E869) . 13 13 Surcide (E950-E959) 28 32 100.0 0.92 26 28 100.0 0.96 Homicide (E960-E969) 26 24 88.5 0.91 25 25 96.0 0.95 Undetermined inten8 tionality (E980-E989) 6 12.5 0.12 2 3 50.0 '0.39 40 34 65.0 0.65 34 38 85.3 0.76 Other causes * DC = number of deaths determined from death certificate; MR = number of deaths determined by medical review panel. + All kappa values are statistically significant (p<0.01). 32 �TABLE 28. Number of Deaths .and Crude Death Rates/100,000 Person-Years Among Vietnam and Non-Vietnam Veterans, by Cause of Death (From Medical Review) (1965-1983) Cause of death* (ICD-9) Vietnam No. Rate/ deaths 100,000 Infectious diseases (001-139) Neoplasms (140-239) Non-Vietnam No. Rate/ deaths 100,000 0.8 14 10.9 11 Endocrine, nutritional, and metabolic disorders (240-279) Mental disorders (290-319) 9.1 1.21 0.55-2.66 2.85 0.92-8.82 0.50 0.23-1.07 0.95 0.31-2.94 0.8 10 9.4 3.3 0.8 12 Diseases of nervous system (320-389) Diseases of circulatory system (390-459) Rate 95% CI ratio* 2.5 19 7.8 15.7 Diseases of respiratory system (460-519) 1.6 1.6 Diseases of digestive system (520-579) 4.7 4.9 Diseases of genitourinary system (580-611) 2.3 0.8 33 �TABLE 28. (continued) Cause of death* (ICD-9) Vietnam No. Rate/ deaths 1 0 0 0 0,0 Diseases of musculoskeletal system (710-739) 1.6 Rate 95% CI ratio* 0.8 Symptoms, signs and ill-defined conditions (780-799) Non-Vietnam _ No. Rate/ deaths 1 0 0 0 0,0 External causes (E800-E999) 181 1.6 141.5 144 118.7 1.19 0.96-1.48 Cause-of-death categories that have no deaths assigned to them are not listed above. If total number of deaths for a cause-of-death category in both groups combined was less than 10, the rate ratio is not shown. 34 �: TABLE 29. Number of Deaths Due to Neoplasms (From Medical Review) and rom Crude Death Rates/100,000 Person-Years Among Vietnam and Non-Vietnam Veterans and Rate Ratios, by Time Since Discharge (1965-1983) Years since discharge No. deaths Vietnam Rate/ 100,000 Non-Vietnam No. Rate/ deaths 100,000 Rate ratio* 95X CI <S 5 10.8 4 8.9 - 6+ 9 11.0 7 9.1 1.21 0.45-3.24 14 10.9 11 9.1 1.21 0.55-2.66 All years - * If total number of deaths for a cause-of-death category in both groups combined was less than 10, the rate ratio is not shown. 35 �TABLE 30. Number of Neoplastic Deaths (From Medical Review Panel) Among Vietnam and Non-Vietnam Veterans, by Specific Type (1965-1983) Neoplasm type* (ICD-9) Vietnam Non-Vietnam Cancer of liver (155) 1 0 Cancer of lung (162) 0 2 Cancer of skin (172) 1 2 Cancer of testis (186) » Cancer of brain (191) 2 2 3 1 Cancer of ill-defined site (195) 1 0 Cancer of unspecified site (199) 0 1 Lympho sarcoma (0) 20 3 1 Hodgkin's disease (201) 0 1 Leukemia (204-208) 2 1 Neoplasms of uncertain behavior (235-238) 1 0 * . Because of the small numbers of deaths in all categories, rates and rate ratios are not presented. 36 �TABLE 31. Number of Deaths from External Causes (From Medical Review) and Crude Death Rates/100,000 Person-Years Among Vietnam and Non-Vietnam Veterans and Rate Ratios, by Specific External Cause (1965-1983) External cause (ICD-9) Vietnam No. Rate/ deaths 100,000 Non-Vietnam No. Rate/ deaths 100,000 Rate ratio* 95% CI Motor vehicle accidents (E810-E825) 80 62.6 52 42.9 1.46 1.03-2.07 Accidental poisonings (E850-E869) 13 10.2 5 4.1 2.47 0.88-6.92 Other accidents 26 20.3 31 25.6 0.80 0.47-1.34 Suicide (E950-E959) 32 25.0 28 23.1 1.08 0.65-1.80 Homicide (E960-E969) 24 18.8 25 20.6 0.91 0.52-1.59 Injuries of 6 undetermined intentionality (E-980-E989) 4.7 3 2.5 * if total number.of deaths for a cause-of-death category in both groups combined was less than 10, the rate ratio is not shown. 37 �TABLE 32. Number of Motor-Vehicle-Accident (MVA) Deaths (From Medical Review) Among Vietnam and Non-Vietnam Veterans and Unadjusted Rate Ratios, by Type of MVA and Time Since Discharge (1965-1983) Type of MVA death <_ 5 years Years since discharge 6+ years No. Rate 95% CI deaths ratio No. Rate 95% CI deaths ratio Daytime* 16 2.90 0.93-8 .98 24 1 .11 Nighttime* 24 1.93 0.83-4 .51 29 1 .16 0.56-2 . 0 4 Single vehicle"*"*" 27 2.76 1. 17-6 .52 34 1 .19 Multiple vehicles** 14 2.41 0.76-7 .70 19 1 .04 0.42-2 .57 * MVAs occurring between 6:00 a.m. and 8:59 p.m. + MVAs occurring between 9:00 p.m. and 5:59 a.m. ++ ICD-9. E815.0, E815.2, E816.0, and E816.2. ** ICD-9, E811.0, E811.2, E812.0, E812.2, E813.0, and E813.2. 38 0.50-2 .48 0.60-2 .34 �TABLE 33. Number of Motor-Vehicle-Accident (MVA) Deaths (From ' Medical Review ) Among Vietnam and Non-Vietnam Veterans and Unadjusted Rate Ratios, by Alcohol Involvement and Time Since Discharge (1965-1983) Alcohol involvement Years since discharge 6+ years £ 5 years No. Rate deaths ratio 95X CI No. Rate deaths ratio 95X CI All years No. Rate deaths ratio 95X CI Yes* 24 1.35 0 0.60-3 . 4 29 1.16 4 0.56-2 . 0 53 1.23 0.72-2.13 NQ+ 10 2.25 0.58-8 .71 19 1.04 0.42-2 .57 29 1.34 0.64-2.81 Unknown-H- 31 2.36 1.08-5 .13 19 1.29 0.52-3 .21 50 1.84 1.03-3.31 * MVA deaths (ICD-9, E810-E825, E929.0) for which either nondependent abuse of alcohol (ICD-9, 305.0) is cited as a contributing cause of death or for which there is a recorded blood alcohol level of at least 100 mgX. + MVA deaths for which alcohol abuse is not cited as a contributing cause of death and for which there is a recorded blood alcohol level of less than 100 mgX. 4+ MVA deaths for which alcohol abuse is not cited as a contributing cause of death and for which there is no recorded blood alcohol level. 39 �TABLE 34. Number and Type of Alcohol- and Drug-Associated Deaths Based on Death Certificates and Medical Review, with Associated Percent Agreement and Kappa Statistic No. deaths Death Medical certificate review Cause of death* Percent agreement Kappa statistic Alcohol-associated Natural causes 9 30 100.0 0.44 Accidents 8 65 62.5 0.11 Suicide, homicide. injury of undetermined intentionality 4 38 75.0 0.13 21 133 85.7 0.16 Total - Drug-as soc iated Drug dependence and abuse Accidental poisoning by drugs • 8 28 62.5 0.26 10 10 50.0 0.49 12.5 0.19 92.3 0.71 SUicide or poisoning 8 by drugs, intentionality undetermined Total * 26 40 See Section 3.1.3 for definitions of alcohol- and drug-associated deaths. 40 �TABLE 35. Number and Type of Alcohol-Associated Deaths (From Medical Review) and Crude Death Rates/100,000 Person-Years Among Vietnam and Non-Vietnam Veterans and Rate Ratios (1965-1983) Type of death* Vietnam No. Rate/ deaths 100,000 Non-Vietnam Rate/ No. deaths 1000 0,0 Rate ratio 951 CI Natural causes 16 12.5 14 11.5 1.08 0.53-2.22 Accidents 37 28.9 28 23.1 1.25 07-.5 .720 19 Suicide, homicide, and injury of undetermined intentionality 14.9 19 15.7 0.95 0.50-1.79 72 56.3 61 50.3 1.12 0.80-1.57 Total # See Section 3.1.3 for definitions of alcohol-associated deaths. 41 �TABLE 36. Number and Type of Drug-Associated Deaths (From Medical Review) and Crude Death Rates/100,000 Person-Years Among Vietnam and Non-Vietnam Veterans and Rate Ratios (1965-1983) Type of death* No. deaths Vietnam Rate/ 100,000 Non-Vietnam No. Rate/ deaths 100,000 Dependence and abuse 17 13.3 11 Accidental poisoning by drugs 6 4.7 Suicide or poisonings by drugs, undetermined intentionality 2 1.6 25 19.5 Total drugassociated deaths Rate ratio 95X CI 9.1 1.47 0.69-3.13 4 3.3 1.42 04-.4 .050 0 - - - 1.58 0.83-3.00 15 12.4 See Section 3..1.3 for definitions of drug-related deaths. 42 �TABLE 37. Number of Drug-Associated Deaths* (From Medical Review) and Crude Death Rates/100,000 Person-Years Among Vietnam and Non-Vietnam Veterans and Rate Ratios, by Time Since Discharge (1965-1983) Years since discharge No. deaths Vietnam Rate/ 100,000 Non-Vietnam No. Rate/ deaths 100,000 Rate ratio"1" 95% CI 10 21.6 8 17.9 1.21 04-.6 .830 6-10 8 17.4 5 11.3 1.54 0.50-4.71 11+ 7 19.6 2 6.2 - 25 19.5 15 12.4 £5 All years 1.58 0.83-3.00 * See Section 3.1.3 for definition of drug-associated deaths. + If the total number of deaths for a cause-of-death category in both groups combined was less than 10, the rate ratio is not shown. 43 �TABLE 38. Unadjusted and Adjusted* Rate Ratios Based on Death Certificate and Medical Review Cause of Death, by Selected Cause of Death and Time Since Discharge (1965-1983) Death Certificate Medical Review <5 years 6+ years Unadjusted Adjusted RR RR Unadjusted Adjusted RR RR Cause of death* Neoplasms <5 years 6+ years Unadjusted Adjusted Unadjusted Adjusted RR RR RR RR 0.83 Circulatory diseases 0.82 0.68 1.21 1.07 06 .0 0.81 0.60 0.56 0.51 Motor vehicle accidents 1.93 1.98 1.16 1.22 1.89 1.96 1.16 1.22 Suicide 1.72 2. 54 0.64 0.57 1.64 2.47 0.78 0.74 Homicide 1 .52 1. 6 4 0.78 0.85 1.38 1.35 0.73 0.82 1.73 2.23 1.42 1.67 0.99 0.97 2.50 2.99 1.21 1.56 2.02 2.57 Alcoholrelated Drugrelated * 1.93 2.86 Adjusted values are from a Cox Proportional Hazards Model, stratified on MOS and enlistment status, and controlled for age, race, GT score, year of discharge, and pay grade at discharge. i "*" If the total number of deaths for a cause-of-death category in' both groups combined was less than 10, the rate ratio is not shown. �TABLE 39. Observed and Expected Numbers of Deaths by Cause (From Death Certificate) Among Vietnam and Non-Vietnam Veterans and Standardized Mortality Ratios, by Time Since Discharge (1965-1983) * Years since Cause of death** discharge (ICDA-8) <5 Vietnam Non-Vietnam All natural causes (0-9) 0076 Observed Expected4* SMR"1"195% CI 13 24.2 0.54 0.29-0.92 16 23.4 0.68 0.39-1.11 External causes (E800-E999) • Observed Expected SMR 95% CI 92 72.5 1.27 1.02-1.56 55 69.4 0.79 0.60-1.03 All natural causes (000-796) Observed Expected SMR 95% CI External causes (E800-E999) Observed Expected SMR 95% CI 96 102.7 0.93 0.76-1.14 88 96.6 0.91 0.73-1.12 All All natural years causes (0-9) 0076 Observed Expected SMR 95% CI 51 90.0 0.57 0.42-0.75 55 86.8 0.63 0.48-0.82 Observed Expected SMR 95% CI 188 175.2 1.07 0.93-1.24 143 166.0 0.86 0.73-1.01 6+ External causes (E800-E999) 38 65.8 0.58 0.41-0.79 39 63.4 0.62 0.44-0.84 * Excludes 9 deaths (7 Vietnam, 2 non-Vietnam) for which death certificates were not recovered. + Expected number is based on the mortality rates among U.S. males, standardized for age, calendar year, and race. **"*" SMR=Observed deaths/expected deaths 45 , �TABLE 40. Observed and Expected Deaths by Specific Natural Cause (From Death Certificate) Among Vietnam and Non-Vietnam Veterans and Standardized Mortality Ratios (1965-1983) Cause of death* (ICDA-8) Observed deaths Infectious diseases (000-136) 1 Neoplasms (140-239) 12 Vietnam Expected* deaths SMR++ (95X CI) 2.3 21.0 Observed deaths Non-Vietnam Expected deaths SMR (95% CI) 1 2.2 0.57 (.010) 03-.0 14 20.1 07 .0 (0.38-1.17) 0.87 (.920) 02-.5 8 5.4 1.49 (0.64-2.91) 1 4.2 Mental disorders (290-315) 5 5.7 Diseases of nervous system (320-389) 2 4.4 Diseases of circulatory system (390-458) 12 24.8 0.48 (0.25-O.85) 21 24.0 Diseases of respiratory system (460-519) 5 .. 60 0.84 (.719) 02-.6 4 5.7 6 10.8 0.56 (0.20-1.21) 3 10.3 2.0 2.53 (0.82-5.79) 1 1.9 1 - — — Diseases of digestive system (520-577) Diseases of genito"urinary system (580-611) 5 Congenital anomalies (740-759) 1 46 0.87 (0.54-1.34) •• - - �TABLE 40. (continued) Cause of death* (ICDA-8) Symptoms, signs and ill-defined conditions (780-796) Observed deaths Vietnam Expected* deaths 6.7 SMR++ ( 5 CI) 9% Observed deaths Non-Vietnam Expected SMR (95X CI) deaths 6.3 * Because causes of death are coded to the Eighth Revision of the International Classification of Diseases, the numbers of deaths for certain causes may not agree with the numbers coded according to the Ninth Revision (see Section 4.3.1). Categories not listed had no deaths assigned to them. + Expected number based on the mortality rates among U.S. males and standardized for age, calendar year, and race. ++ SMR = Observed deaths/expected deaths. fewer than five observed deaths. 47 SMRs are not computed for categories with �TABLE 41. Observed and Expected Numbers of Deaths (From Death Certificate) for Specific External Causes Among Vietnam and Non-Vietnam Veterans and Standardized Mortality Ratios (1965-1983) External cause (ICDA-8) Observed deaths Vietnam Expected* deaths SMR+ (95% CI) Observed deaths Non-Vietnam Expected deaths SMR (95% CI) All accidents (E800-E949) 125 103.8 1.20 .00-1.43) (1 88 98.2 0.90 72-1.10) (. 0 Motor vehicle accidents (E810-E827) 81 63.2 1.28 .02-1.59) (1 52 59 . 8 0.87 ( .65-1.14) 0 .44 40.6 1.08 ( .79-1.46) 0 36 38.4 0.94 ( .66-1.30) 0 Suicide (E950-E959) 29 29.3 0.99 ( .66-1.42) 0 28 27.8 1.01 ( .67-1.45) 0 Homicide and all other external causes (E960-E999) 34 42.3 0.80 ( .55-1.12) 0 27 40.2 0.67 ( .44-0.98) 0 Other accidents * + Expected number based on the mortality rates among U.S. males and standardized • for age, calendar year and race. SMR = Observed deaths/expected deaths. 48 �APPENDIX A Detailed Distributions of Veteran Characteristics �TABLE A-l. Descriptive Characteristics of Vietnam Experience Study Veterans at Time of Entry Into U.S. Army, by Duty Location Characteristic Total Race: White Black Other Unknown Place of birth: Northeast Midwest South West Foreign Unknown Vietnam No. 9324 8097 1156 63 8 % 100.0 86.8 12.4 0.7 0.1 Total Non-Vietnam X No. Germany /Korea No. % 8989 100.0 5120 7776 1123 85 5 86.5 12.5 . 0.9 0.1 4403 666 49 2 100.0 86.0 13.0 1.0 00 . United States Only % No. 3869 100.0 3373 457 36 3 87.2 11.8 09 . 0.1 (X2- 4.22, p-0.12) 1769 2827 2205 2193 312 18 19.0 30.3 23.6 23.5 3.3 0.2 (X2- 4.62, p-0.10) (X2- 3.17, p-0.21) 1781 2751 2047 1988 393 29 1006 1607 1188 1147 160 12 775 1144 859 841 233 17 C ^ . 19.8 30.6 22.8 22.1 4.4 0.3 V m*J * «• 19.6 31.4 23.2 22.4 3.1 0.2 V P « . *« 20.0 29.6 22.2 21.7 60 . 0.4 V • -w (X2-21.28, p<0.001) (X2- 7.42, p-0.19) (X2-55.81, p<0.001) 3201 62.5 1919 37.5 (X2- 2.11, p-0.15) 2698 69.7 1171 30.3 (X2-43.49, p<0.001) Enlistment status: Draftee 5943 Volunteer 3381 63.7 36.3 5899 65.6 3090 34.4 (X2- 7.12, p-0.01) Age at entry: 17 18 19 20 21+ 4.8 10.5 37.1 23.7 24.0 590 748 1967 2001 t.U<JJ 2683 443 979 3459 2200 2235 66 . 8.3 33.0 22.3 £.7*7 29.9 (X2-134.39, p<0.001) 7.6 357 9.1 465 34.7 1777 21.9 1174 26.3 U-»» 1347 f.\l»J (X2-49.38, p<0.001) 233 6.0 283 7.3 1190 30.8 827 .21.4 1336 34.5 (X2-187.80, p<0.001) �TABLE A-l. (Continued) Characteristic Year of entry: 1965 1966 1967 1968 1969 1970 1971 Vietnam No. 1112 1997 1659 1953 1702 650 208 Total Non-Vietnam Z 11.9 21.4 17.8 21.0 18.3 7.4 2.2 No. 1271 1925 983 1318 1357 1227 953 Z 14.1 21.4 10.4 14.7 15.1 13.7 10.6 (X2-995 .06, p<0.001) Germany /Korea No. Z 673 1151 632 790 729 650 495 13.1 22.5 12.3 15.4 14.2 12.7 9.7 (X2-626 .24, p<0.001) United States Only No. Z 598 774 306 528 628 577 458 15.5 20.0 7.9 13.7 16.2 14.9 11.8 (X2-950 .91, p<0.001 �TABLE A-2. Physical and Mental Profile of Vietnam Experience Study Veterans At Time of Entry into U.S. Army, by Duty Location Characteristic Total Total Non-Vietnam No. X Vietnam No. 9324 100.0 8989 100.0 Germany/Korea No. % 5120 100.0 United States Only No. % 3869 100.0 Physical Capacity or Stamina: • No impairment 9230 Mild-significant 85 Unknown 9 99.0 0.9 0.1 8877 106 6 98.8 1.2 0.1 3.17, p-0.06) 5053 98.7 63 1.2 4 0.1 (X2- 3.31, p-0.07) 3824 98.8 43 1.1 2 0.1 (X2- 1.13, p-0.29) Upper Extremities: No impairment 9247 Mild-significant 68 Unknown 9 99.2 0.7 0.1 8904 79 6 99.1 0.9 0.1 .28, p-0.26) 5073 99.1 43 0.8 4 0.1 (X2- 0.53, p-0.47) 3831 99.0 36 0.9 2 0.1 (X2- 1.41, p-0.24) Lower Extremities: No impairment 9075 Mild-significant 240 Unknown 9 97.3 2.6 0.1 8743 97.3 240 2.7 6 0.1 (X2- 0.16, p-0.69) 4982 97.3 134 2.6 4 0.1 (X2- 0.02, p-0.88) 3761 97.2 106 2.7 2 0.1 (X2- 0.29, p-0.59) Hearing Acuity and Ears: No impairment 8794 Mild-significant 521 Unknown 9 94.3 5.6 0.1 8378 93.2 605 6.7 6 0.1 (X2-10.32, p-0.001) 4763 93.0 353 6.9 4 0.1 (X2- 9.91, p-0.002) 3615 93.4 252 6.5 2 0.1 (X2- 4.22, p-0.04) Eyes and Visual Acuity: No impairment 6934 Mild-significant 2381 Unknown 9 74.4 25.5 0.1 6404 71.2 2579 28.7 6 0.1 (X2-22.95, p<0.001) 3677 1439 71.8 28.1 4 0.1 1.18, p<0.001) 2727 70.5 1140 29.5 2 0.1 (X2-21.44, p<0.001) �TABLE A-2. (Continued) Characteristic Vietnam No. Z Total Non-Vietnam No. % ' Germany/Korea No. Z United States Only No. Z * Psychiatric Functioning: No impairment 9300 Mild-significant IS Unknown • 9 99.7 0.2 0.1 8962 99.7 0.2 21 6 0.1 (X2- 1 .23, p-0.27) 5105 99.7 11 0.2 4 0.1 (X2- 0.54, p-0.46) 3857 99.7 10 0.3 2 0.1 <X2- 1 .37, p-0.24) Composite Index of Health: No impairment 6297 Mild-significant 2990 Other than minor 26 Unknown 11 67.5 32.1 0.3 0.1 5712 63.5 3232 36.0 . 36 0.4 9 0.1 (X2-33 .47, p<0.001) 3270 63.9 1823 35.6 20 0.4 7 0.1 (X2-20 .43, p<0.001) 2442 63.1 1409 36.4 16 04 . 2 0.1 (X2-25 .13, p<0.001) �TABLE A-3. Mean Scores of Vietnam Experience Study Veterans on Aptitude Tests Given as Part of the Entrance Examination for the U.S. Army, by Duty Location No. Vietnam Mean SD Verbal ability 9136 104.4 21.9 8863 1 6 9 22.1 0. (t— 7.55, p<0.001) 5067 105.2 22.1 (t— 2.17, p-0.03) 3796 1 9 0 21.9 0. (t— 11.00, p<0.001) Arithmetic reasoning 9135 101.5 21.5 8865 103.8 22.1 (t— 7.26, p<0.001) 5068 102.3 21.8 (t— 2.13, p-0.03) 3797 105.9 22.3 (t— 10.6, p<0.001) Pattern analysis 9136 101.7 22.5 8864 103.5 22.3 (t— 5.42, p<0.001) 5068 102.8 2 . 20 (t— 2.66, p-0.008) 3796 1 4 6 22.7 0. (t— 6.52, p<0.001) General information 9117 100.3 18.4 8844 1 0 8 18.5 0. (t— 1.85, p-0.07) 5060 1 0 2 18.3 0. (t- 0.30, p-0.77) 3784 101.6 18.9 (t— 3.68, p<0.001) General technical 9200 103.1 19.9 8914 105.5 2 . 04 (t— 8.08, p<0.001) 5087 1 4 0 2 . 0. 02 (t— 2.52, p-0.01) 3827 107.6 2 . 06 (t— 11.5, p<0.001) 9280 50.4 25.5 8950 52.3 26.0 (t—5.06, p<0.001) 5102 50.8 25.7 (t—0.97 p-0.33) 3848 54.3 26.3 (t—7.94, p<0.001) Aptitude Test Total Non-Vietnam No. Mean SD Germany/Korea No. Mean SD United States Only No. Mean SD Army Classification Battery: Armed Forces Qualification Test �TABLE A-4. Military-Service Characteristics of Characteristic Vietnam Z No. Total 9324 Military Occupational Specialty*: Tactical Missile and fire control electronic maintenance General electronics maintenance Precision maintenance Auxiliary services Motors Clerical Graphics General technical Special assignment Vietnam Experience Study Veterans, by Duty Location Total Non-Vietnam Z No. 100.0 Germany/Korea No. Z 100.0 8989 5120 * 100.0 United States Only No. Z 3869 100.0 3196 48 34.3 0.5 2462 166 27.4 1.6 1577 116 30.8 2.3 885 50 22.9 1.3 591 6.3 621 6.9 431 84 . 190 49 . 147 1.6 162 1.8 93 1.8 69 1.8 441 4.7 333 3.7 199 3.9 134 3.5 1776 1763 106 1002 19.1 18.9 1.1 10.8 1223 1907 170 1579 13.6 21.2 1.9 17.6 761 992 82 685 14.9 19.4 1.6 13.4 462 915 88 894 11.9 23.7 2.3 23.1 254 2.7 366 4.1 184 36 . 182 4.7 A (X2-442.5, p<0.001) ** M �TABLE A-4. (Continued) Characteristic Type of Unit: Infantry Engineer Armor Cavalry Artillery Other Unknown Vietnam Z No. Total Non-Vietnam No. Z Germany/Korea No. Z United States Only No. Z • 906 14.6 17.7 6.0 368 7.2 5.7 376 7.3 2.3 127 2.5 16.3 1061 20.7 2264 54.8 44.2 04 . 18 0.4 p<0.001) (X2-892 .3 ,, p<0.001) 2477 911 123 792 1021 3920 80 26.6 9.8 1.3 8.5 11.0 42.0 09 . 1313 542 508 203 1462 4926 35 (X2-1223.2, , Number of Months of Active Duty: 484 1-12 13-24 6208 2632 25-36 0 37+ 5.1 66.6 28.2 00 . 445 5.0 70.3 6315 1946 21.6 283 3.1 (X2-436.0, p<0.001) *Job specialty for which the man was trained. 62 1.2 3560 69.5 1367 26.7 131 2.6 (X2-19.8, p-0.003) 407 174 132 76 401 2662 17 (X2-1045 .2, 10.5 4.5 3.4 2.0 10.4 68.8 0.4 p<0.001) 383 9.9 2755 71.2 579 15.0 152 3.9 (X2-1070.9 , p<0.001) �TABLE A-5. Military Characteristics of Vietnam Experience Study Veterans at Discharge from Active Duty, by Duty Location Total Non-Vietnam No. Z Vietnam Characteristic Total * Ever AUOL or Confinement -Time: No Yes Unknown No. 9324 100 0. 8989 100.0 8163 1081 80 87.5 11.6 0.9 7744 1197 86.2 13.3 48 0.5 (X2-11.9, p<0.001) Type of Discharge: Honorable Other Unknown 9067 249 8 97.2 2.7 0.1 Pay Grade at Discharge: E-l 249 E-2 212 E-3 614 E-4 4608 E-5 3641 2.7 2.3 6.6 4. 94 39.1 Age at Discharge: <19 19 20 21 11 173 841 3421 22 23 24 25+ 2374 1094 632 778 0.1 1.9 9.0 36.7 25.5 11.7 6.8 8.3 8183 91.0 802 89 . 4 0.1 (X2-333.6, p<0.001) 649 499 668 7.2 5.6 7.4 4278 47.6 32.2 2895 (X2-387.7, p<0.001) 172 320 774 1.9 3.6 86 . 2776 2032 1145 3. 09 22.6 12.7 755 84 . 1015 11.3 (X2-319.3, p<0.001) Germany/Korea No. Z 5120 100 0. 4668 91.2 422 8.2 30 0.6 (X2-40.5, p<0.001) 4866 9. 50 252 4.9 2 0.1 (X2-51.0, p<0.001) 185 3.6 180 3.5 362 7.1 2642 51.6 1751 34.2 (X2-53.7, p<0.001) 68 152 421 1704 1268 661 378 468 (X2-128.5, 1.3 3.0 8.2 33.3 2. 48 12.9 74 . 9.1 p<0.001) United States Only No. Z 3869 100 0. 3076 775 18 (X2-158.8, 79.5 2. 00 0.5 p<0.001) 3317 85.7 550 14.2 2 0.1 ( 2 6 0 8 p<0.001) X- 4 . , 464 319 306 12.0 8.3 7.9 1636 42.3 1144 29.6 (X2-786.0, p<0.001) 104 168 353 2.7 4.3 9.1 1072 27.7 19.8 12.5 764 484 377 547 9.7 14.1 (X2-499.2, p<0.001) �TABLE A-5. (Continued) Characteristic Year of Discharge: 1965-1966 1967-1968 1969-1970 1971-1972 1973-1974 1975-1977 Vietnam Z No. Total Non-Vietnam No. Z Germany /Korea No. Z United States Only No. Z • 21 2482 4011 2571 234 5 0.2 26.6 43.0 27.6 2.5 0.1 94 2787 2395 2811 856 46 (X2-864.4, 1.1 31.0 26.6 31.3 9.5 0.5 p< 0.001) 22 1516 1565 1521 488 8 (X2-483.2, 04 . 29.6 30.6 29.7 9.5 0.2 p<0.001) 72 1.9 1271 32.9 830 21.5 1290 33.3 368 9.5 38 1.0 (X2-884.9, p<0.001) �VIETNAM EXPERIENCE STUDY — Mortality APPENDIX B Detailed Examination of All-Cause Mortality by Selected Covariates 11 �In this section, we present a detailed examination of factors that might modify the effect of Vietnam service on mortality. Because the increased rate of mortality associated with service in Vietnam appears to be limited to the first 5 years of follow-up, and because covariates potentially can have different effects in different time periods, all covariates are examined with respect to time since discharge. 1. Entry Characteristics Race (Table B-l): The effect of Vietnam service on mortality in the early postservice period is slightly higher for whites (RR=1.50) than for persons of races other than white (RR=1.30) but the test for effect modification is not significant. After the first 5 years of follow-up, there is little or no effect of Vietnam service on mortality in whites or in nonwhites. Region of birth (Table B-2): Although the rate ratios appear to vary somewhat among the various regions of birth, the variation is not statistically significant. In general, regardless of where they were born, Vietnam veterans were more likely to die within the first 5 years after discharge than non-Vietnam veterans. After 5 years, again regardless of region of birth, little increase in the relative rate of mortality among Vietnam veterans is seen. GT score (Table B-3): Overall, level of performance on the GT test does not appear to modify the effect of Vietnam service on mortality. Although not shown, similar conclusions can be drawn from an examination of the potential modifying effect of the other components of the Army Classification Battery and the Armed Forces Qualification Test. Physical health profile (Table B-4): In the first 5 years after discharge, the rate ratios associated with service in Vietnam appear to differ somewhat among those with and without physical impairment. Among those with some type of- physical impairment, over a twofold increase in the rate of mortality was found for those who served in Vietnam relative to those who had not. In contrast, there is only a 20% increase among veterans with no impairment in functioning. This departure from homogeneity is of borderline significance (X^S.10, p = 0.08). After the initial 5 years, the rate ratios are 1.1 for veterans with no impairment and 0.9 for those with any impairment. Although not shown, the patterns for the individual physical components mirror those seen with the summary measure. » Enlistment status (Table B-5): The rate ratios in the first 5 years after discharge differ somewhat among those who volunteered for military service compared to those who were drafted. Vietnam veterans who were drafted into service were 1.8 times more likely to die in the first five years postservice, but Vietnam veterans who volunteered were only 1.1 times more likely. The test of effect modification is of borderline significance (p=0.09). After the first 5 years, both rate ratios are at or below 1.0, indicating no association between Vietnam service and likelihood of dying in that time period for either volunteers or draftees. 2. Military and Discharge Characteristics Military occupational speciality (Table B-6): The categorization of MOS into "tactical" and "nontactical" jobs is a rough surrogate for combat exposure; Vietnam veterans assigned a tactical MOS are more likely to have experienced combat tharv those with nontactical MOSs. In general, service 12 �in a tactical MOS does not appear to influence the effect of Vietnam service on likelihood of dying. In the intial follow-up period, service in Vietnam has a slightly greater effect on mortality among those with a nontactical MOS. The opposite pattern is apparent after five years. Neither difference is statistically significant. Type of unit (Table B-7): In the first 5 years after discharge, the death rate is increased among Vietnam veterans who served in each type of unit except engineering units. The rate ratios are especially high among those in the infantry (RR=2.02) and armor (RR=2.07). The overall test for effect modification is, however, not statistically significant. In addition, Vietnam veterans assigned to engineering units do not appear to be at greater risk of dying than Vietnam veterans in other units. Only 23% of men in engineering units, however, had an MOS that could be classified as an actual engineering occupation. When the analysis was restricted to such veterans, similar results were found. flWOL or confinement time (Table B-8): In the first five years after discharge.the rate ratio associated with service in Vietnam is higher among those who never had AWOL or confinement time than for those who had been AWOL or had served confinement time, but this difference is not statistically significant. After 5 years both rate ratios are close to unity. Duration of active duty (Table B-9): Vietnam veterans who served less than 12 months of active duty in the Army had an appreciably higher relative death rate than those serving more than 12 months. Although further exploration was not possible because of the small numbers, this departure from homogeneity is not statistically significant. Age at discharge (Table B-10): The effect of Vietnam service on mortality is somewhat stronger among those who were less than 21 years at the time of.discharge than among those 21 years or older. The reverse is true in the later follow-up period. This finding may be the result of chance fluctuation, since the tests for effect modification in both follow-up periods are nonsignificant. Year of discharge (Table B-ll): A modifying effect of borderline significance (p=0.06) is seen for year of discharge during the initial follow-up period. For those discharged before 1970, and who therefore served sometime between 1965 and 1969, the death rate among Vietnam veterans is more than twice that of veterans who did not serve in , Vietnam. In contrast, the increase for those discharged in 1970 and after is only 16%. There is no difference in the rate ratios for those discharged before and after 1970 in the 6-plus-year follow-up period, both ratios being about 1.00. The results in the first 5 years after discharge may be due to differences in the characteristics of Vietnam veterans who served before 1970 compared with those who served later. For example, those serving earlier were younger at discharge and more likely to have been drafted than those serving later. When these and other factors are controlled, the excess risk in Vietnam veterans discharged before 1970 is still apparent. Type of discharge (Table B-12): There is no significant difference in the relative rate of mortality associated with Vietnam service between honorably or nonhonorably discharged veterans in either follow-up interval, although, in the initial postservice period, Vietnam veterans with honorable discharges had higher relative mortality than Vietnam 13 ' �veterans with nonhonorable discharges. These estimates, however, are based on small numbers of deaths and, therefore, are unstable. Pay grade at discharge (Table B-13): In the earlier follow-up interval, all rate ratios are greater than 1.0. Although a lower pay grade is associated with a higher rate of mortality, this effect is seen among both Vietnam and non-Vietnam veterans. Consequently, a test of interaction comparing the relative rates among the five categories in the first 5-year period is not statistically significant. Although there does not appear to be any consistent pattern across categories, the chi-square test indicates a lack of homogeneity among the five pay grade categories in the later and total follow-up period. 14 �TABLE B-l. Number of Deaths, Crude Rates/1000 Person-Years, and Rate Ratios, by Cohort Status, Race, and Time Since Discharge (1965-1983) Years since discharge Race £5 White Nonwhite 6+ White Vietnam Non-Vietnam No. Rate/ No. Rate/ deaths 1000 deaths 1000 89 21 99 2.2 3.5 Rate . 95% CI ratio 57 1.5 1.50 1.08-2.09 16 2.7 1.30 0.68-2.50 1.4 94 1.4 0.99 0.74-1.31 Nonwhite 3.6 33 3.3 1.07 0.67-1.71 White 188 1.7 151 1.4 1.18 0.95-1.46 Nonwhite All years < 37 58 3.5 49 3.1 1.15 0.78-1.68 Tests for effect modification of race: <5 years: 6+ years : All years: 15 X2 = 0.15, p = 0.70 X2 s 0.08, p = 0.78 X2 = 0.02, p = 0.89 �TABLE B-2. Number of Deaths, Crude Rates/1000 Person-Years and Rate Ratios, by Cohort Status, Region of Birth, and Time Since Discharge (1965-1983) Vietnam Non-Vietnam Rate/ No . Rate/ Rate No. deaths 1000 deaths 1000 ratio . Years since discharge Region of birth* £5 Northeast 16 1.8 15 1.7 1.07 0.53 - 2.17 Midwest 37 2.6 23 1.7 1.57 0.93 -2.64 South 25 2.3 16 1.6 1.45 0.78 -2.72 West 32 2.6 19 1.6 1.60 0.91 -2.83 Northeast 25 1.6 18 1.2 1.37 0.75 - 2.51 Midwest 36 1.5 34 1.5 1.00 0.62 -1.59 South 39 2.0 37 2.1 0.96 0.61 -1.50 West 36 1.7 38 1.9 0.87 0.55 - 1.38 41 1.7 33 1.4 1.23 0.78 -1.95 Midwest 73 1.9 57 1.5 1.22 0.86 -1.73 South 64 2.1 53 1.9 1.11 0.77 West 68 2.0 57 1.8 1.11 0.78 -1.58 6+ All years Northeast 95% CI -1.59 "Foreign places of birth grouped with West category. Tests for effect modification of region of birth: <5 years: 6+- years: All years: 16 X2 = 0.91, p = 0.82 X2 = 1.42, p = 0.70 X2 = 0.27| p = 0.97 �TABLE B-3. Number of Deaths, Crude Rates/1000 Person-Years and Rate Ratios, by Cohort Status, General Technical Test (GT) Score, and Time Since Discharge (1965-1983) Years since discharge GT score Vietnam Non-Vietnam No. Rate/ No. Rate/ deaths 1 0 0 0 deaths 1 0 00 Rate 95% CI ratio <100 3.0 37 2.1 1.41 0.93-2. 12 48 1.8 35 1.3 1.43 <100 73 2.1 68 2.3 0.90 0.64-1.25 100+ 61 1.3 58 1.2 1.07 0.75-1.53 <100 133 2.4 105 2.3 1.07 0.83-1.39 1004- 6+ 60 100+ £5 109 1.5 93 1.2 1.20 0.91-1.58 0.92-2.20 A All years Tests for effect modification of GT score: <_5 years: 6+ years: All years: 17 X2 = 0.004, p = 0 .95 X2 = 0.53, p = 0.47 X2 = 0.33, p = 0.57 �TABLE B-4. Number of Deaths, Crude Rates/1000 Person-Years and Rate Ratios, by Cohort Status, Composite Index of Health, and Time Since Discharge (1965-1983) Years since discharge Composite index of health Vietnam Non-Vietnam No. Rate/ No. Rate/ deaths 1000 deaths 1000 Rate ratio 95% CI All years 69 2.2 52 1.8 1 .20 0.84 - 1.73 41 2.7 21 1 .3 2.12 1. 25 - 3.59 No impairment 100 1 .8 82 1 .7 1 .08 0.80 - 1.44 Some impairment 6+ No impairment Some impairment £5 36 1 .4 45 1 .6 0.85 0.55 - 1.32 No impairment 169 2.0 134 1 .7 1 .12 0.90 - 1.41 77 1 .9 66 1 .5 1 .25 0.90 - 1.74 Some impairment Tests for effect modification of composite index of health: <5 years: X2 = 3.10, p = 0.08 6+ years: X2"= 0.78, p = 0.38 All years: X2 = 0.27, p = 0.60 18 �TABLE B-5. Number of Deaths, Crude Rates/1000 Person-Years and Rate Ratios, by Cohort Status, Enlistment Status and Time Since Discharge (1965-1983) Vietnam Non-Vietnam No. Rate/ No. Rate/ Rate deaths 1000 deaths 1000 ratio 95% CI 2.6 36 2.4 1.09 0.70 - 1.70 67 2.3 37 1 .3 1. 80 1 .21 - 2.69 Volunteers 57 2.1 54 2.3 0.91 0.63 - 1.32 Draftees 79 1.5 73 1.4 1.06 0.77 - 1.45 Volunteers 100 2.3 90 2.3 0.98 0.74 - 1.30 Draftees 146 1 .8 110 1 .3 1. 31 1 .02 - Years since discharge Enlistment status i5 Volunteers 43 Draftees 6+ All years Tests for effect modification of enlistment status: <5 years: 6+ years: All years: 19 1.67 X2 = 2.72, p = 0.09 X2 = 0.34, p = 0.55 X2 = 2.20, p = 0.14 �TABLE B-6. Number of Deaths, Crude Rates/1000 Person-Years and Rate Ratios, by Cohort Status, Military Occupational Specialty (MOS) Category and Time Since Discharge (1965-1983) Vietnam No. Rate/ deaths 1000 Non-Vietnam No. Rate/ deaths 1000 Years since discharge MOS* category 15 Tactical 39 2.4 24 Nontactical 71 2.3 Tactical 53 Nontactical Tactical 6+ All years Nontactical Rate ratio 95X CI 2.0 1.19 0.71-1.97 49 1.5 1.58 1 . 10-2 . 27 1.8 36 1.8 1.04 0.68-1.59 83 1.6 91 1.6 0.97 0.72-1.30 92 2.1 60 1.9 1.10 0.79-1.52 154 1.8 140 1.6 1.18 0.94-1.48 *Based on MOS assignment held while on active duty. Tests for effect modification of MOS: <.5 years: X2 6+ years: X2 All years: X2 20 0.81, p = 0.37 0.08, p = 0.78 0.12, p = 0.73 �TABLE B-7. Number of Deaths, Crude Rates/1000 Person-Years and Rate Ratios, by Cohort Status, Type of Unit and Time Since Discharge (1965-1983) Years since discharge Type of unit Non-Vietnam Vietnam No. Rate/ No. Rate/ deaths 1000 deaths 1000 Rate ratio 95X CI Infantry 10 1 .5 2.02 1.01 - 4.06 Engineer 8 1 .8 5 1 .9 0.95 0.31 - 2.90 2 3 .3 4 1 .6 2.07 0.38 - 11.3 Cavalry 13 3 .3 2 2.0 1. 68 0.38 - 7.43 Artillery 14 2 .8 17 2.3 1. 18 0.58 - 2.39 Other 33 1 .7 35 1 .4 1. 18 0.74 - 1.91 Infantry 37 1 .7 20 1 .8 0.94 0.55 _ | 63 Engineer 13 1 .6 10 2.2 0.74 0.32 - 1.68 2 1 .9 7 1 .6 1. 19 0.25 - 5.74 Cavalry 15 2.2 3 1 .8 1. 23 0.36 - 4.26 Artillery 22 2.4 18 1 .4 1. 72 0.92 - 3.20 Other 46 1 .3 67 1 .6 0.84 " 0.58 - 1.22 Infantry 75 2.2 30 1 .7 1. 30 0.85 - 1.98 Engineer 21 1 .7 15 2.1 0.81 0.42 - 1.56 4 2.4 11 1 .6 1. 51 0.48 - 4.75 Cavalry 28 2.6 5 1 .9 1. 40 0.54 - 3.64 Artillery 36 2.5 35 1 .8 1.46 0.91 - 2.32 Other 6+ 3 .1 Armor £5 38 79 1 .5 102 1 .5 0.96 0.71 - 1.28 Armor All years Armor Tests for effect modification of type of unit: £5 years: 6+ years: All years: 21 X2 = 2.5, p = 0.77 X2 = 4.5, p = 0.48 X2 = 4.2, p = 0.52 �TABLE B-8. Number of Deaths, Crude Rates/1000 Person-Years and Rate Ratios, by Cohort Status, Presence of AWOL or Confinement Time, and Time Since Discharge (1965-1983) Years since discharge Vietnam Non-Vietnam AWOL or No. confinement No. Rate/ Rate/ deaths 1000 deaths 1000 time Rate ratio .95% CI 3.6 21 3.5 1.00 0.54 - 1.86 91 2.2 51 1.3 1.70 1.20 -2.39 Ever 30 3.5 34 3.7 0.92 0.56 - 1.51 106 1.5 93 1.4 1.06 0.80 - 1.40 Ever 49 3.5 55 3.7 0.95 0.65 - 1.40 Never All years 19 Never 6+ Ever Never <5 197 1.8 144 1.4 1.28 1.03 -1.59 Tests for effect modification of AWOL or confinement time: <5 years: 6+ years: All years: X2 - 2.13, p - 0.14 X2 - 0.23, p - 0.63 X2 - 1.76, p - 0.18 �TABLE B-9. Number of Deaths, Crude Rates/1000 Person-Years and Rate Ratios, by Cohort Status, Duration of Active Duty, and Time Since Discharge (1965-1983) Years since Duration of discharge active duty (in months) Vietnam No. Rate/ deaths 1000 Non-Vietnam No. Rate/ deaths 1000 Rate ratio 95Z CI 9.2 3 1.5 6.17 1.03 - 36.86 66 2.2 42 1.4 1.59 1.08 - 2.34 24+ 42 2.6 28 2.3 1.16 0.72 - 1.86 <12 1 2.5 6 1.6 1.57 0.19 - 13.07 12-23 72 1.3 77 1.4 0.92 0.67 - 1.27 24+ 63 2.4 44 2.3 1.04 0.71 - 1.53 3 4.9 9 1.6 3.13 0.85 - 11.54 12-23 138 1.6 119 1.4 1.15 0.90 - 1.47 24+ 6+ 2 12-23 <5 105 2.5 72 2.3 1.08 0.80 - 1.46 <12 All years <12 Tests for effect modification of duration of active duty: <5 years: 6+ years: X2 - 3.20, p - 0.20 X2 - 0.41. p - 0.81 All years: - 2.02, p - 0.36 �TABLE B-10. Number of Deaths, Crude Rates/1000 Person-Years and Rate Ratios, by Cohort Status, Age at Discharge and Time Since Discharge (1965-1983) Years since discharge Age at discharge <5 Vietnam Non-Vietnam No. Rate/ No. Rate/ deaths 100& ' deaths 1000 Rate ratio 95% CI 28 All years 21+ 3.0 1.83 1.02 - 3.27 82 2.0 54 1.4 1.41 1.00 - 1.99 1.8 27 2.7 0.67 0.36 - 1.26 121 1.7 100 1.5 1.10 0.84 - 1.43 43 21+ 19 15 21+ 5.5 3.2 46 2.8 1.14 0.75 - 1.73 203 1.8 154 1.5 1.21 0.98 - 1.49 Tests for effect modification of age at discharge: <5 years: X2 6+ years: X2 All years: X2 0.56, p - 0.45 2.09, p - 0.15 0.06, p - 0.81 �TABLE B-ll. Number of Deaths, Crude Rates/1000 Person-Years and Rate Ratios, by Cohort Status, Year of Discharge and Time Since Discharge (1965-1983) Years since Year of discharge discharge Vietnam No. Rate/ deaths 1000 Non-Vietnam No. Rate/ deaths 1000 Rate ratio 95X CI 2.5 24 1.2 2.05 1.27 - 3.32 55 2.3 49 2.0 1.16 0.79 - 1.70 Before 1970 62 1.4 60 1.5 0.96 0.67 - 1.36 74 2.0 67 2.0 1.06 0.76 - 1.47 Before 1970 117 1.7 84 1.4 1.27 0.96 - 1.6~9 1970+ All years 55 1970+ 6+ Before 1970 1970+ £5 129 2.1 116 2.0 1.10 0.85 - 1.41 Tests for effect modification of year of discharge: 25 <5 years: 6+ years: All years: X2 = 3.42, p = 0.06 X2 = 0.16, p = 0.69 X2 = 0.62, p =0.43 �TABLE B-12. Number of Deaths, Crude Rates/1000 Person-Years and Rate Ratios, by Cohort Status, Type of Discharge, and Time Since Discharge (1965-1983) Years since discharge Type of discharge Vietnam No. Rate/ deaths 1000 <5 Honorable 104 2.3 56 1.4 1.68 1.21 - 2.32 5 4.1 17 4.3 0.94 0.35 - 2.55 128 1.6 102 1.4 1.11 0.86 - 1.45 8 4.4 25 4.3 1.02 0.46 - 2.25 232 1.9 158 1.4 1.31 1.07 - 1.61 13 4.2 42 4.3 0.99 0.53-1.84 Other 6+ Honorable Other All years Honorable Other Non-Vietnam No. Rate/ Rate deaths 1000 ratio 95% CI Tests for effect modification of type of discharge: £5 years: X2 = 0.73, p = 0.39 6+ years: X2 = 0.08, p = 0.78All years: X2 = 0.56, p = 0.45 26 �TABLE B-13. Number of Deaths, Crude Rates/1000 Person-Years and Rate Ratios, by Cohort Status, Pay Grade at Discharge and Time Since Discharge (1965-1983) Vietnam Years since Pay grade at No. Rate/ discharge discharge deaths 1000 Non-Vietnam No. Rate/ deaths 1000 Rate ratio 95X CI El 3.4 1.42 0.52 - 3.84 6 5.8 5 2.0 2.86 0.87 - 9.36 19 6.3 11 3.3 1.89 0.90 - 3.98 52 2.3 29 1.4 1.67 1.06 - 2.63 E5 27 1.5 17 1.2 1.26 0.69 - 2.32 El 5 2.6 24 5.2 0.51 0.20 - 1.34 E2 12 7.2 7 1.6 4.40 1..73 - 11.17 E3 16 3.0 16 2.9 1.06 0.53 - 2.12 ' E4 68 1.7 50 1.4 1.20 0.84 - 1.73 E5 35 1.1 30 1.2 0.95 0.58 - 1.54 El 11 3.5 35 4.5 0.79 0.40 - 1.56 E2 18 6.6 12 1.8 3.74 1.80 - 7.77 E3 35 4.2 27 3.0 1.39 0.84 - 2.30 E4 120 1.9 79 1.4 1.37 1.03 - 1.82 E5 All years 11 E4 * 4.9 E3 6+ 6 E2 <5 62 1.2 47 1.2 1.06 0.73 - 1.55 Tests for effect modification of pay grade at discharge: £5 years: X2 = 1.77, p = 0.78 6+ years: X2 = 12.22, p = 0.02 All years: X2 = 11.75, p = 0.02 27 �VIETNAM EXPERIENCE STUDY — Mortality APPENDIX C Detailed Characteristics of Men killed in Action 28 �TABLE C-l. Descriptive Characteristics of Vietnam Veterans, by Vital Status at Discharge from Active Duty Characteristic Total Race: White Black Other Unknown Place of Birth: Northeast Midwest South West Other Unknown Enlistment Status: Draftee Volunteer Killed in Action* No. X Discharged Alive No. X 181 100.0 9324 100.0 156 23 2 0 86.2 12.7 8097 1156 86.8 12.4 1.1 0.0 63 8 0.7 0.1 24 52 38 57 7 3 13.3 28.7 21.0 31.5 1769 2827 2205 2193 3.9 1.7 312 18 117 64 64.6 35.4 5943 3381 X2+ (p-value) 19.0 30.3 0.50 (.8 07) 8.75 (.7 00) 23.7 23.5 3.3 0.2 63.7 36.3 0.06 (.0 08) "Deaths in service from causes other than hostile enemy action are excluded. "'The chi-square statistic tests the similarity of the distributions of each characteristic between those killed in action and those discharged alive, after the unknown category has been excluded. 29 �\ TABLE C-2. Physical Profile of Vietnam Veterans, by Vital Status at Discharge from Active Duty / Characteristic Total Physical Capacity or Stamina: No impairment Mild-significant impairment Unknown Upper Extremities: No impairment Mild-significant impairment Unknown Lower Extremities: No impairment Mild-significant impairment Unknown Hearing and Ears : ' No impairment Mild-significant impairment Unknown Killed in fiction* No. X Discharged Alive No. X 181 100.0 9324 100.0 181 0 100.0 9230 85 99.0 9 X2+ (p-value) 0.1 0 0.0 0.0 ' 0.9 181 0 100 0. 9247 0.0 68 99.2 0.7 0 0.0 9 9075 240 97.3 2.6 0.0 9 0.1 4.4 8794 521 94.3 5.6 0.0 9 0.1 1.33 (.5 02) 0.1 0.5 1.67 (.0 02) 180 1 0 173 8 0 99.5 95.6 30 2.94 (.9 00) 0.47 .05) (.0 �TABLE C-2. (continued) Characteristic Eyes and Visual Acuity: No impairment Mild-significant impairment Unknown Psychological Functioning: No impairment Mild-significant impairment Unknown Composite Measure of Physical Health: No impairment Minor impairment Other than'minor impairment Unknown Killed in Action* No. % Discharged Alive No. X 161 20 89.0 11.1 6934 2381 0 0.0 181 0 100.0 0.0 0 0.0 153 28 0 84.5 15.5 0.0 6297 2990 67.5 26 0.3 0 0.0 11 (p-value) 0.1 74.4 25.5 19.79 (<0.001) 0.1 9300 15 99.7 0.2 0.29 (.9 05) 0.1 32.1 23.44 (<0.001) *Deaths in service from causes other than hositle enemy action are excluded. "*" The chi-square statistic tests the similarity of the distributions of each characteristic between those killed in action and those discharged alive, after the unknown category has been excluded. 31 �TABLE C-3. Aptitude Test Scores of Vietnam Veterans, by Vital Status at Discharge from Active Duty Aptitude Test Army Classification Battery : Verbal Ability Arithmetic Reasoning Pattern Analysis General Information General Technical Armed Forces Qualification Test Killed in Action* No.+ Mean SO Discharged Alive No.+ Mean SD 177 103. 1 22. 1 9136 104.4 177 100. 3 20. 1 9135 101.5 21 .5 21 .9 177 101. 7 20.6 9136 101.7 22 .5 99.6 19. 6 9117 100.3 18 .4 179 101. 6 19.5 9200 103.1 19 .9 180 26. 3 9280 50.4 25 .5 175 48. 4 t-statstic4"* (p-value) 0.79 ( .43) 0 0.71 ( .47) 0 0 0. 0 .00) 0.48 ( .63) 0 0.98 ( .33) 0 (1 1 .05 ( .29) 0 "Deaths in service from causes other than hostile enemy action are excluded. •(-Number of veterans for whom test scores were available. •"The t-statistic tests the differences between the mean scores of those killed in action and those discharged alive. 32 �TABLE C-4. Military Service Characteristics of Vietnam Veterans, by Vital Status at Discharge from Active Duty Characteristic Total Military Occupational Specialty: Tactical operations Other and unknown Type of Unit: Infantry Engineer Armor Cavalry Artillery Other Unknown Killed in Action* No. X Discharged Alive No. X 181 100.0 9324 100.0 156 86.2 3217 34.5 25 13.8 6107 65.5 127 70.2 2477 2 2 1.1 911 26.6 9.8 23 7 19 1.1 12.7 3.9 10.5 792 1021 1 0.6 X2+ (p- value) 123 3920 80 1.3 8.5 11.0 42.0 0.9 Deaths in service from causes other than hostile enemy action are excluded. The chi-square statistic tests the similarity of the distributions of each characteristic between those killed in action and those discharged alive, after the unknown category has been excluded. 33 207.21 (<0.001) 192.54 (<0.001) �I VIETNAM EXPERIENCE STUDY I — Mortality APPENDIX D Mortality from Motor Vehicle Accidents, Suicide and Drug-Related Causes by Selected Covariates 34 �1 TABLE 0-1. Number of Deaths Due to Motor Vehicle Accidents (as Determined by Death Certificate) Among Vietnam and Non-Vietnam Veterans and Rate Ratios, by Time Since Discharge and Selected Characteristics (1965-1983). Characteristic Time Since Discharge <. 5 years 6+ years No. Rate 95% CI deaths ratio No. Rate 95% CI deaths ratio Race: White Other 57 9 1.92 1.11-3.35 1.98 0.49-7.91 60 7 1.31 0.78-2.19 0.38 0.07-1.96 GT score: <100 100+ 33 33 2.00 0.95-4.21 1.82 0.89-3.71 35 32 0.79 0.41-1.53 1.70 0.83-3.48 Enlistment status: Draftee Volunteer 42 24 2.22 1.15-4.27 1.52 0.67-3.48 41 26 1.52 0.81-2.86 0.74 0.34-1.60 Duty MOS: Tactical Other 28 38 1.39 0.64-3.01 2.31 1.16-4.58 22 45 1.08 0.46-2.53 1.18 0.66-2.13 Age at discharge: <21 years 21+ years 9 57 1.55 0.42-5.78 2.02 1.16-3.53 13 54 1.03 0.35-3.07 1.22 0.71-2.10 Year of discharge: <1970 1970+ 37 29 2.79 1.26 1.31-5.90 0.61-2.64 32 35 1.54 0.75-3.15 0.90 0.47-1.75 Pay grade at discharge: E1-E3 E4-E5 17 49 3.12 1.16-8.43 1.80 0.99-3.26 18 49 0.63 0.23-1.77 1.60 0.89-2.89 35 �TABLE D-2. Number of Deaths Due to Suicide (as Determined by Death Certificate) Among Vietnam and Non-Vietnam Veterans and Rate Ratios, by Time Since Discharge and Selected Characteristics (1965-1983). Characteristic Time Since Discharge <. 5 years No. deaths Race: White Other Rate ratio* 95X CI No. deaths 6+ years Rate 95X CI ratio* GT score: <100 100+ 2.06 0.84-5.05 30 0.62 0 .30-1.30 — 22 3 — 2 8 17 1.48 0.57-3.91 18 0.63 0.65 0 .22-1.81 0 .25-1.68 Enlistment status . 14 Draftee Volunteer 11 1.79 1.60 0.60-5.35 0.47-5.46 13 19 1.14 0.40 0 .38-3.39 0 .15-1.05 Duty MOS Tactical Other 5 20 1.98 0.79-4.97 9 23 0.80 0.35-1.82 Age at discharge: <21 years 4 21+ years 21 2.33 09-.0 .060 10 22 0.13 1.09 0 .02-1.06 0 . 47-2 . 52 16 0.55 0.74 0 .20-1.53 0. 8 2 0 2-.0 Year of discharge <1970 1970+ 9 16 Pay grade at discharge: E1-E3 E4-E5 8 17 14 1.32 0.49-3.56 16 _ 7 2.09 0.74-5.93 25 0.67 0 .30-1.48 *RRs are not computed for categories with less than 10 deaths among Vietnam and non-Vietnam veterans combined. 36 �TABLE D-3. Number of Drug-Associated Deaths (as Determined by Medical Review) Among Vietnam and Non-Vietnam Veterans and Rate Ratios, by Selected Characteristics (1965-1983). Characteristic Number of Deaths Vietnam Non-Vietnam Rate ratio* 95% CI Race: White Other 18 7 10 5 1.70 1.35 0.79-3.69 0.43-4.26 GT score: <100 100+ 13 12 11 4 1.00 3.09 0.45-2.24 1.00-9.57 11 14 1 14 10.81 0.88 Duty MOS: Tactical Other 8 17 1 14 — 1.27 — 0.63-2.58 Age at discharge: <21 years 21+ years 8 17 10 5 0.97 3.12 0.38-2.47 1.15-8.45 Year of discharge: <1970 1970+ 5 20 4 11 — 1.79 — 0.86-3.74 Pay grade at discharge: E1-E3 E4-E5 10 15 11 4 1.52 3.22 0.64-3.57 1.07-9.71 Enlistment status: Draftee * Volunteer 1.39-83.79 0.42-1.85 *RRs are not computed for categories with less than 10 deaths among Vietnam and non-Vietnam veterans combined. 37 �VIETNAM EXPERIENCE STUDY — Mortality APPENDIX £ Details of Medical-Review-Panel Findings 38 �The following is a description of medical review panel findings for all deaths in which cause of death via medical review differed from cause as determined by death certificate (see Table E-l and £-2 for the cross-classification of death certificate and medical review cause of death). 1. Infectious diseases. The two deaths attributed to infectious diseases by the death certificates were both classified elsewhere by the panel. In one case, an alcoholic man died as an immediate consequence of an overwhelming infection. The death certificate underlying cause of death was septiciemia due to other gram-negative organisms (ICD-9, 038.4). The panel attributed the fatal infection to impaired host defense mechanisms associated with the decedent's alcoholism and cited alcohol dependence syndrome as the underlying cause of death (ICD-9, 303). In the other case, an intravenous drug abuser with acquired immunodeficiency disorder died as a result of pneumocystis carinii pneumonia. The death certificate diagnosis was pneumocystosis (ICD-9, 136.3), while the panel attributed the death to deficiency of cell-mediated immunity (ICD-9, 279.1). 2. Neoplasms. The panel recategorized 2 of the 25 deaths that had been attributed to neoplasm according to the death certificate (see Table E-3). The'panel determined that both deaths were caused by operative misadventures on the basis of hospital records and autopsy findings. In one case, the panel attributed the death to an accidental cut during a • surgical operation (ICD-9, E870.0). The cut, to the mesenteric vein, complicated an operation to remove a colon cancer. Further complications led to additional bowel resections. "Short bowel syndrome" developed, and the veteran eventually died as a consequence of severe dehydration and malabsorption. At autospy, no metastatic lesions were detected. In the other case, the veteran had previously undergone an operation to remove a bronchial adenoma. During a subsequent operation to repair a bonchopleural fistula, the endotracheal tube was not correctly placed, and he had a cardiac arrest (ICD-9, E876.3). The pathologist who performed the autopsy attributed the death to "respiratory insufficiency" and noted that "the death of this patient is not related to the tumor itself." The panel cited a neoplasm as the underlying cause of two deaths attributed to nonneoplastic causes according to the death certificates (see Table E-3). One is discussed below in section "16. Other external cause." The panel determined that a pineal gland neoplasm was the cause of death, but the death certificate determination was "head trauma," coded as an accident of unspecified cause. The other death is discussed below in section "5. Circulatory diseases." The panel attributed the death to Burkitt's tumor (ICD-9. 200.2); the death certificate attributed it to "cardiopulmonary arrest" (ICD-9, 427.5). In 23 cases both the panel and death certificate determinations resulted in deaths being coded as neoplasms, but in 11 the.determinations did not agree to the fourth digit of the ICD-9 code (see Table E-3). In each of the 11 cases, the lack of complete agreement can be attributed to statements on the death certificate that lack precision or do not contain available diagnostic information. The major features of a tumor, according to the ICD-9 classification system, are its anatomic location, whether it is benign or malignant, and 39 �whether it is a primary or secondary lesion. The underlying cause of death on three death certificates was "brain tumor," and each was appropriately coded as neoplasm of unspecified nature (ICD-9, 239.6). On the basis of its review of hospital records pertaining to these cases, the panel included the specific cerebral site and the malignant nature of the three tumors in its cause-of-death determinations (see Table E-3). Two other deaths were due to malignant neoplasm, unspecified site (ICD-9, 199.1), according to the death certificates; the panel localized one to the bronchus and lung (ICD-9, 162.9), and the other to the head, neck, and face (ICD-9, 195.0). The panel, on the basis of medical records, localized a death attributed to malignant melanoma, site unspecified (ICD-9, 172.9) according to the death certificate to the scalp and neck (ICD-9, 172.4). The panel, using hospital records and an Autopsy report, described a malignant testicular tumor as affecting an undescended testicle (ICD-9, 186.0), but the affected testicle was not specified as to its descent on the death certificate (ICD-9, 186.9). Another death was due to metastatic carcinoma of unknown primary site, which secondarily involved the liver. The death certificate described the cause of death simply as "liver cancer," which resulted in the appropriate code for malignant neoplasm of the liver, not specified as primary or secondary (ICD-9, 155.2). If the death certificate had mentioned that the "liver cancer" was secondary, then the death would have been coded differently by ICD-9 rules. The panel, on the basis of hospital records and histopathology reports, correctly attributed the death to malignant neoplasm of unspecified primary site (ICD-9, 199.1). In three cases of malignant neoplasms of lymphatic and hematopoietic tissue, the tumor histology, which was available from medical records, allowed the panel to arrive at more accurate or specific diagnoses than did the original certifiers (see Table E-3). In one instance, "leukemia" was listed as the cause of death on the certificate, and this resulted in. the appropriate code for leukemia of unspecified cell type (ICD-9, 208.9). The panel had access to the decedent's hospital record, which documented acute myeloid leukemia (ICD-9, 205.0) on several bone marrow aspirates. In a second case, the underlying cause on the death certificate was "terminal Hodgkin's disease," which was appropriately coded to Hodgkin's disease unspecified (ICD-9, 201.9). Antemortem lymph node biopsy findings allowed the panel to specify the Hodgkin's disease -» as nodular sclerosis type (ICD-9, 201.5). In the third case, the decedent had a lymphoblastic lymphoma which was subsequently complicated by leukemia. The decedent died in the hospital, and the diagnosis was "lymphoblastic lymphoma with leukemia." The death certificate cause-of-death statement mentions only the lymphoblastic leukemia which was appropriately coded as acute lymphoid leukemia (ICD-9, 2 4 0 . On 0.) the basis of the medical record, the panel cited lymphoblastic lymphoma (ICD-9, 200.1) as the underlying cause of death. 3. Mental disorders. Fourteen deaths were attributed to mental disorders as a result of death certificate findings, and the panel categorized 10 elsewhere (see Table E-4). In one of the cases, the death certificate was improperly completed and the coded cause of death, simple schizophrenia (ICD-9, 295.0), was the first diagnosis in ft continuous statement which contained a total of five diagnoses. The last listed cause of death, "episodes of G.I. bleeding," which could not be coded as 40 �the underlying cause according to ICD-9 rules, was similar to the panel's determination, hemorrhage of gastrointestinal tract, unspecified (ICD-9, 578.9). In the remaining nine recategorized cases, death was due to either substance dependence or abuse according to the coded death certificates. In all nine cases the panel's determinations included diagnoses pertaining to misuse of drugs or alcohol, but the diagnostic reasoning or descriptive terms differed significantly from those used on the death certificates. Consequently, the underlying cause of death the panel assigned is categorically different from that assigned on the basis of the death certificate. The ICD-9 rules governing selection of the underlying cause of death give preference to diagnostic terms that provide the most specificity regarding the site or nature of the fatal condition. For example, alcoholic liver disease (ICD-9, 571.0-571.3) is preferred to alcohol dependence syndrome (ICD-9, 303). In two cases, the panel cited alcoholic.liver damage, unspecified (ICD-9, 571.3), whereas the death certificate findings were coded as alcohol dependence syndrome (ICD-9, 303). In another case, the panel cited alcoholic fatty liver (ICD-9, 571.0), whereas the certificate was coded as nondependent abuse of alcohol (ICD-9, 305.0). In two additional cases, both coded to alcohol dependence syndrome (ICD-9, 303) on the basis of death certificates, the panel cited alcohol dependence as contributing to death, but specified compression of the brain stem (ICD-9, 348.4) and pneumococcal pneumonia (ICD-9, 481.0) as the underlying causes of death. In the first case, hospital records indicate that the decedent's rapid neurological deterioration was due to a "cerebral abscess/neoplasm 'or infarction," with no clear causal connection with alcoholism.' In the second case, the panel determined that an alcoholic man died as a direct result of pneumococcal pneumonia. In this case the panel was mistaken; the priority placed on alcohol dependence on the death certificate is more reasonable, because the infection that the veteran did not survive was probably secondary to impaired host defense mechanisms associated with alcoholism. The original death certifiers attributed the other 4 recategorized deaths in the mental disorder category to either drug dependence or drug abuse. The ICD-9 manual defines drug dependence as a "compulsion to take a drug on a continuous or periodic basis in order to experience its psychic effects, and sometimes to avoid the discomfort of its absence.'.' The manual also states that the diagnosis of nondependent abuse of drugs (ICD-9, 305.0-305.9) is only appropriate "when no other diagnosis is possible." A drug abuse code should not be selected as the underlying cause of death if either drug dependence or drug poisoning is a possible cause of death. The panel adhered to the ICD-9 drug-related definitions and diagnostic preferences, which accounts for the recategorization of these 4 deaths. In 3 deaths attributed to drug dependence on the basis of death certificates, the corresponding panel diagnoses were accidental poisonings, because the panel had no information to document compulsion to use drugs at the time of death. The coded death certificate cause of death in one instance was other drug dependence (ICD-9, 304.6) and in the other two cases it was unspecified drug dependence (ICD-9, 304.9). The 41 �corresponding panel determinations were accidental poisoning by glue (ICD-9, E866.6), accidental poisoning by other drugs (ICD-9, E858.8), and accidental poisoning by unspecified drugs (ICD-9, E858.9). Finally, the original death certifier attributed a death to unspecified nondependent drug abuse (ICD-9, 305.9), but the panel, which adhered to the ICD-9 preference for the accidental poisoning diagnosis, classified it as an accidental poisoning by opiates and narcotics (ICD-9, E850.0). In addition to the 10 recategorized deaths described above, the panel attributed to mental disorders 12 deaths that were placed in other disease categories on the basis of the death certificates (see Table E-4). These 12 deaths are discussed in detail in the following sections: 1. Infectious diseases, 6. Respiratory diseases, 7. Digestive diseases, 12. Accidental poisonings, and 15. Injury of undetermined intentionality. In most of the 12 cases, both the death certificate and panel diagnoses pertained to misuse of drugs or alcohol, but the specific ICD-9 codes were categorically different. *• Diseases of the nervous system and sense organs. The panel disagreed wit'h the original death certifier on one of the three deaths attributed to neurologic disorders. The decedent was a previously healthy man who had overwhelming speticemia and meningitis due to Haemophilus influenzae. There was no recognizable primary source of infection and no obvious defect in host-defense mechanisms. The pathologist who performed the autopsy described the primary diagnosis as "overwhelming speticemia and meningitis'with Haemophilus influenzae, type B." The physician who completed the death certificate cited "Haemophilus influenzae meningitis" as the underlying cause, appropriately coded to ICD-9, 320.0. In view of the absence of a primary source of infection, the panel attributed the death to septicemia due to other gram-negative organisms (ICD-9, 038.4), which placed the death in the infectious disease category. 5. Circulatory diseases. The panel categorized elsewhere 7 of the 34 deaths coded on the basis of death certificates to circulatory disease. • In four, the panel's findings differed from the diagnosis of either cardiac arrest (ICD-9, 427.5) or myocardial infarction (ICD-9, 410) cited on the death certificates. In one case, described briefly in section "2. Neoplasm," the panel determined that Burkitt's tumor (ICD-9, 200.2) was .« the cause of death. The veteran had had several antemortmem bone marrow biopsies that established the diagnosis of Burkitt's lymphoma. He received two courses of chemotherapy and subsequently died as a direct consequence of an intracerebral hemorrhage. At autopsy, no tumor was found, and the death certifier stated that the death was due to "cardiopulmonary arrest," although she mentioned "probably Burkits1 (sic) lymphoma" as a nonunderlying cause of death. The panel attributed the absence of tumor at postmortem examination either to an incomplete dissection or to the effects of chemotherapy. In view of the poor prognosis associated with disseminated Burkitt's lymphoma, the panel cited the neoplasm as the underlying cause of death. In another death described as "cardiopulmonary arrest" on the death certificate, the panel diagnosis was sudden death within 24 hours of onset of symptoms <ICD-9, 798.2). An emergency room record stated that 42 �the decedent had gone to bed complaining of "epigastric discomfort and nausea" and that his mother found him dead 3 hours later. No autopsy was done. In the case of both recategorized myocardial infarctions (ICD-9, 410.0), the coroners who completed the death certificates stated that the deaths were due to a "heart attack." Both veterans had died at home and in neither instance was an autopsy performed. In each case, the panel based its diagnosis, sudden death within 24 hours of onset of symptoms (ICD-9, 798.2), on the medical history contained in the coroner's records. The remaining three circulatory disease deaths, for which the panel and death certificate determinations differ, were originally attributed to hypertensive renal disease, not specified as benign or malignant (ICD-9, 403.9); cardiovascular disease, unspecified with mention of arterioslclerosis (ICD-9, 429.2); and compression of the superior vena cava (ICD-9, 459.2). In the first death, the only information available to the panel was an emergency room record indicating that the decedent had a cardiac arrest as a result of chronic renal failure. The record contained no information on the etiology of the kidney disease, so the panel determination was renal failure, unspecified (ICD-9, 586.0), which placed the death in the genitourinary disease category. The original death cert^fier apparently was aware that the renal disease had been attributed to hypertension, and this causal sequence is indicated on the death record. In the second death, the medical examiner apparently cited "arteriosclerotic heart disease" as the cause of death on the basis of the decedent's past medical history. The panel attributed the death to a hemorrhage of the gastrointestinal tract, unspecified (ICD-9, 578.9). The police records show- that the decedent was found at home, with "a great deal of blood on his facial area, and also in the bathroom sink." There was no evidence for a traumatic death. The panel inferred that gastrointestinal hemorrhage was the most likely cause of death on the basis of the medical examiner's report that the decedent was an - alcoholic.' No autopsy was performed. The third death, which the original death certifier attributed to superior vena cava syndrome, resulted from a crush injury that occurred when the automobile the veteran was repairing fell on his chest. The panel listed struck by falling object (ICD-9, E916) as the cause of death, in accordance with ICD-9 underlying cause selection rules, which give preference to the circumstances that resulted in injury rather than to the anatomic • location of the injury. 6. Respiratory diseases. The panel recategorized 6 of the 9 deaths originally attributed to respiratory disease. In 4 cases, the death certificate findings were bronchopneumonia, organism unspecified (ICD-9, 485). The corresponding panel-determined causes of death were: glomerulonephritis, not otherwise specified (ICD-9, 583.9), systemic lupus erythematosus (ICD-9, 710.0). passenger on a motorcycle involved in a collision with another motor vehicle (ICD-9, 812.3), and accidental poisoning by other drugs (ICD-9, E858.8). In the first case, the medical record documented that at the time of his death the veteran was receiving hemodialysis for end-stage renal disease due to glomerulonephritis of undetermined etiology. The panel attributed his fatal pneumonia to impaired host defenses associated with severe chronic renal failure. In the second case, the veteran was found on autopsy to have systemic lupus 43 �erythematosus with renal and central nervous system involvement, and the panel determined that lupus was responsible for susceptibility to the fatal infection. In the third case, the death certificate was improperly completed and did not reflect the coroner's autopsy-determined cause of death, "accidental-motorcycle fatality." In the fourth case, the decedent was admitted to a hospital following an "overdose with cardiopulmonary arrest." He died 7 days later in the hospital, following a hospital course complicated by pneumonia. The panel attributed the death to poisoning by a mixture of drugs. In another recategorized respiratory disease death, the death certificate determination was acute edema of the lung, unspecified (ICD-9, 518.4). while the panel diagnosis was morphine-type drug dependence (ICD-9, 304.0). The decedent had many prior hospitalizations for medical problems due to heroin dependency. He was found dead at home, and autopsy findings included evidence of a recent intravenous injection and pulmonary edema. The toxicologic analysis of body fluids showed no evidence of morphine but the panel, on the basis of the medical history and autopsy findings, attributed the death to drug dependence. In the final recategorized case, the death certificate determination of "hemorrhagic interstitial pneumonitis," appropriately coded as other alveolar and parietoalveolar pneumopathy (ICD-9, 516.8), omitted available diagnostic information. The veteran had received an antemortem diagnosis of Goodpasture's syndrome, a disorder which affects both the kidneys and the lungs, and the diagnosis was confirmed at autospsy. The panel attributed the death to hypersensitivity angiitis (ICD-9, 446.2), an entity classified as a circulatory disease and the correct ICD-9 code for Goodpasture's syndrome. 7. Digestive diseases. The death certificates attributed seven deaths to digestive diseases, but the panel attributed three of the seven to alcohol dependence syndrome (ICD-9, 303). In the first case, the death certificate citation was "alcoholic hepatitis," appropriately coded to acute alcoholic hepatitis (ICD-9, 571.1). The panel, on the basis of the hospital record and autopsy report, determined that the decedent, at the time of his death, had many complications of alcoholism, but the panel did not attribute the death to a particular alcohol-related disease. The panel listed alcohol dependence syndrome as the underlying cause of death, which placed the case in the mental disorder category. « The second and third cases were both coded as acute pancreatitis (ICD-9, , 577.0) on the basis of the death certificates, neither one of which mentioned that the decedents were dependent on alcohol. The panel used available medical records to establish that in both cases, pancreatitis was a direct sequel of alcohol dependence, and classified the deaths accordingly. 8. Genitourinary diseases. The panel, using the available diagnostic information, recategorized three of the four deaths that the original death certifiers had attributed to genitourinary diseases. In one case, the underlying cause on the death certificate was coded as renal failure, unspecified (ICD-9, 586), but the panel's determination was coded as alcoholic cirrhosis of the liver (ICD-9, 571.2). The panel had access to the record of the hospitalization during which the veteran died, and the record indicated that both renal failure and coma were secondary to liver disease. The pathologist who performed the autopsy attributed the death 44 �to "cirrhosis of the liver, advanced (history of ethanol use)." The . second recategorized death was coded as a urinary tract infection, site unspecified (ICD-9, 599) on the basis of the death certificate, but the panel diagnosis was late effects of motor vehicle accident (ICD-9, E929.0). The decedent was quadraplegic and incontinent of urine after a motor vehicle accident that occurred 4 years before his death. The panel attributed the immediate cause of death, urinary tract infection, to his traumatic neurologic impairment. The third recategorized death was also coded as a urinary tract infection, site unspecified (ICD-9, 599) on the basis of the death certificate. The certificate did not contain the primary discharge diagnosis listed on the hospital record, "suicidal drug overdose with cardiac and subsequent respiratory arrest." The panel used the medical history of a self-inflicted mixed drug poisoning to describe the death as suicide by other specified drugs (ICD-9, E950.2). 9. Congenital anomalies. The panel, on the basis of autopsy findings, categorized elsewhere two deaths attributed to congenital disorders, on the death certificates. Before death, one veteran had had a diagnosis of and surgical treatment for a congenital cerebral arteriovenous malformation. His death was preceded by rupture of the aneurysm and rapid neurological deterioration. The nosologist coded the underlying cause of death as congenital anomaly of cerebral vessels (ICD-9, 747.8) on the basis of the death certificate statement that the decedent was "status post removal right frontal arteriovenous malformation." The postmortem examination records, which were available to the panel, indicated that the fatal cerebrovascular event began prior to the decedent's operation, and the panel cited the appropriate cause of death, subarachnoid hemorrhage (ICD-9, 430). In the other death, the coded death certificate cause was coarctation of the aorta (ICD-9, 747.1). At autopsy the death was shown to be due to rupture of a surgically implanted aortic graft. The postmortem findings are reflected in the panel's determination of the underlying cause, late complication of aortic graft placement (ICD-9, E878.1). 10. Symptoms, signs and ill-defined conditions. Autopsy results account for the diagnostic disagreement in one of the two deaths placed in the signs, symptoms and ill-defined conditions category on the basis of the death certificates. The death certificate shows "pending further study" as the underlying cause, which was coded to other unknown and « unspecified cause of mortality (ICD-9, 799.9). No revised death certificate was available. The panel based its determination, alcoholic cirrhosis of the liver (ICD-9, 571.2), on the autopsy report. 11. Motor vehicle accidents. The panel recategorized three motor vehicle traffic deaths. In two instances, the panel assigned the deaths to suicide by crashing of a motor vehicle (ICD-9, E958.5). In one, police records indicated that the veteran repeatedly drove his car into the path of oncoming traffic and made no effort to avoid a collision with an oncoming truck. In the other, police records contained a report of a distress call from the veteran's spouse following a domestic quarrel. The spouse was concerned about his self-destructive intentions. The panel recategorized the third motor vehicle death as a homicide on the basis of a coroner's report. The decedent, a pedestrian, had "confronted" the driver of a motor vehicle immediately before he was struck by the vehicle and dragged for "about six blocks." The death 45 �certificate listed "auto-pedestrian" as the underlying cause and "homicide" as the manner of death. The certificate did not contain a statement of intentionality in either the "cause of death" or the "circumstances of injury" sections, and, as a result, the nosologist coded the fatality as a motor vehicle accident, in accordance with the coding practices of the National Center for Health Statistics. 12. Accidental poisoning. The panel categorized elsewhere 9 of the 18 deaths attributed to accidental poisoning according to the death certificates. In 4 cases of heroin or morphine-type drug poisoning, the panel recategorized the deaths to chronic morphine dependence (ICD-9, 304.0) on the basis of historical and postmortem evidence of drug dependence. In two instances of accidental poisoning by motor vehicle exhaust gas (ICD-9, E868.2), law enforcement records were not available, and the panel could not characterize the decedents' intentions. Consequently, the panel's underlying cause of death for both was poisoning by motor vehicle gas, undetermined whether accidentally or purposely inflicted (ICD-9, £982.0). The causes of death on the death certificates in two other accidental poisoning fatalities were "apparent accidental drug overdose" and "intoxication of unknown origin," which the nosologist coded as accidental poisoning by unspecified drugs (ICD-9, E858.9) and accidental poisoning by unspecified substance (ICD-9, 866.9), respectively. In the first case, the panel attributed the death to drug dependence, unspecified (ICD-9, 304.9) on the basis of hospital records. In the second case, an autopsy showed that the decedent aspirated gastric material, a finding that warranted toxicologic investigation, according to the pathologist. Mo toxicologic results were available to the panel, and it determined that the cause of death was inhalation of food causing obstruction of the respiratory tract (ICD-9, E911). In the ninth recategorized accidental poisoning, the death certificate cited "synergistic action of alcohol and diazepam" as the underlying cause of death, which was coded as accidental poisoning by benzodiazepine-based tranquilizer (ICD-9, E853.1). The panel had access to the medical history, autopsy results, and toxicologic analysis—all of which indicated that death resulted from aspiration of gastric contents as a consequence of alcohol intoxication (ICD-9, 305.0). 13 • Suicide. The panel categorized all 54 of the suicides listed on the death certificates as suicides. The panel identified an additional » six suicides, which are discussed in sections 8. Genitourinary diseases, * 11. Motor vehicle accidents, and 16. Other external causes. 14 • Homicide. For 47 homicides, the panel agreed with the categorization based on the death certificates. In four deaths, disagreements between the certificates arid panel occurred. In one case, the veteran was shot in the head by a "friend" while the two men were "fooling around." The "friend" was charged with involuntary manslaughter, and the death certificate lists "homicide" as the manner of death. The panel attributed the death to an accident caused by a handgun (ICD-9, 922.0). In three other recategorized deaths, the certificates cite homicide as the underlying cause but do not mention that the decedents were killed by law enforcement agents. Consequently, the death certificate codings, each of which was assault by unspecified firearm (ICD-9, E965.4), differ from the panel's codings, each of which was injury due to legal intervention by firearms (ICD-9, E970.0). 46 �15. Injury of undetermined intentionality. The panel assigned to other categories 8 of the 10 deaths coded as injuries of undetermined intentionality according to the death certificates. In five deaths, drug poisoning was listed on the certificate as the underlying cause of death and "undetermined" as the manner of death. The panel recategorized all five. It determined that three of the deaths were accidental drug poisonings on the basis of either medical examiner interviews with family and friends, which indicated the absence of suicidal intent, or law enforcement investigations, which documented that recreational drugs were being used at the death scene. The panel recategorized the other two deaths to natural causes. In one case, police records included reports of a scene investigation and an interview with the decedent's brother that provided sufficient evidence for the panel to cite morphine-type drug dependence (ICD-9, 304.0) as the underlying cause of death. In the other case, "acute multiple drug intoxication" was cited as the underlying cause on the death certificate. The panel, on the basis of a review of the hospital record and autopsy findings, attributed the death to renal failure due to acute tubular necrosis (ICD-9, 584.5). There was no historical or laboratory evidence to support a toxic .etiology. In a sixth case, "ethanol poisoning" was cited as the underlying cause on the death certificate, and "undetermined" was listed as the manner of death. The veteran had been drinking alcohol with two friends, who had been "teasing" him into drinking to excess according to police records. The decedent died at home and was found to have a lethal blood alcohol level. Criminal charges were not filed against the friends, and the panel attributed the death to accidental poisoning by alcoholic beverages (ICD-9, E860.0). In two other deaths, injury by firearm and injury by fire were listed as causes on the certificate. In the firearm injury death, despite a coroner's jury finding that the victim was shot by his wife, the certificate specifies that the manner of death was "undetermined." The • panel attributed the death to assault by an unspecified firearm (ICD-9, £965.4). Similarly, in the fire injury death, the coroner's autopsy report describes the death as an "accident," but the manner was "undetermined" according to the death certificate. In the absence of any evidence to suggest either homicide or suicide, the panel attributed the death to accident caused by smoke and fumes from a conflagration (ICD-9, E890.2). 16. Other external causes. The panel recategorized 14 of 61 deaths that had been placed in the other external cause group on the basis of death certificate determinations. Of the 14, the panel attributed 11 to the specific external cause categories discussed above and 3 to natural causes. The panel categorized as suicides three deaths that the original death certifiers had categorized as accidents. In one case, involving a drowning, medical examiner's records describe the decedent as a newlywed in "extreme financial difficulty" who "walked off his job without notice" and was found drowned in a lake 3 days later. The panel inferred self-destructive intent from the victim's life circumstances, and cited suicide by drowning (ICD-9, E954) as the underlying cause of death. In the second case, in which the veteran was crushed by a train, the panel based the diagnosis of suicide on eyewitness accounts that the the 47 �decedent "ran out from buses and laid on the tracks in front of (a) train." In the third case, a death from a self-inflicted gunshot wound, the death certificate apparently was not amended after the medical examiner's determination of suicide. For five other death certificate-determined causes in this category, the panel could not rule out either suicide or homicide, and it placed these deaths in the accident of undetermined intentionality category. Law enforcement records raised the possiblity that two of the five deaths might have been suicides. In one case, a gun hobbyist cleaning a revolver sustained a lethal head injury, and the trajectory of the bullet was consistent with either an intended or unintended injury. In the other case, the fatal self-inflicted gunshot wound occurred immediately after a domestic quarrel that reportedly involved the issue of the paternity of one of the decedent's children. A third death involved an alcohol dependent man who was observed to be lying on the railroad tracks before being crushed by a train. The panel could not rule out suicidal intent and listed the underlying cause of death as injury by lying before moving object, intentionality undetermined (ICD-9, E988.0). In the fourth case, -the original death certifier attributed the death to an accident caused by fire. The coroner subsequently reported that he could not rule out "foul play," and the panel cited injury by fire, intentionality undetermined (ICD-9, E988.1) as the underlying cause of death. The fifth case was that of a veteran who drowned, and the panel had no information other than an emergency room report that the decedent was dead on arrival as a result of drowning. The panel could not exclude self-inflicted injury, so it attributed the death to drowning, intentionality undetermined (ICD-9, E984). The panel considered three other deaths to be motor vehicle accidents. In two, the anatomic sites of the injury, but not the circumstances of injury, were stated on the death certificate. The panel, on the basis of medical records, assigned these two deaths to the - motor vehicle accident category. In the third, a fatal accident involving the driver of a "skidder" was coded to accident caused by lifting machine and appliance (ICD-9, E919.2) on the basis of medical statements in the death certificate. The panel coded it to motor vehicle traffic accident due to loss of control without collision on the highway (ICD-9, E816.0). As stated earlier, the panel recategorized 3 of these deaths to natural causes. Two had been coded to an accidental fall (ICD-9, E888) on the basis of the death certificates, but the panel, on the basis of medical documentation of antecedent seizure activity, coded them to other categories. In one case, the decedent injured his head during an observed alcohol withdrawal seizure; the panel therefore attributed the death to alcohol dependence syndrome (IC&-9, 303). In the other case, the decedent, known to have epilepsy, sustained a fatal head injury during an observed seizure; the panel therefore diagnosed generalized convulsive epilepsy (ICD-9, 345.1). The third death, attributed to "head trauma" on the death certificate, had been coded to unspecified accident (ICD-9, E928.9). The panel, on the basis of the autopsy report, coded it to pineal gland neoplasm (ICD-9, 237.1); The pathologist who performed the autopsy concluded that the onset of the decedent's head trauma was a 48 �coincidence. The post-mortmem examination showed "no signs of traumatic injury to the skull or brain." 49 �TABLE E-l. Comparison of Death Certificate and Medical Review Panel Results by Major Cause of Death Category* Death certificate Medical review panel Infec- Neotious plasm Endocrine Mental NerDls. vous Circu- Respir- Diges- Genito- Muscu- 111Exterlatory atory Total tive urinary loskel. defined nal Infectious Diseases 0 0 1 1 0 0 0 0 0 0 0 0 2 Neoplasms 0 23 0 0 0 0 0 0 0 0 0 2 25 Mental Disorders 0 0 0 4 1 0 4 0 0 0 4 14 Nervous System 1 0 0 0 2 0 0 0 0 0 0 0 3 Circulatory System 0 1 0 0 0 27 0 1 1 0 3 1 34 Respiratory System 0 0 0 1 0 1 3 0 1 1 0 2 9 Digestive System 0 0 0 3 0 0 0 4 0 0 0 0 7 Genitourinary 0 0 0 0 0 0 0 1 1 0 0 2 4 Congenital 0 0 0 0 0 1 0 0 0 0 0 1 2 Ill-Defined 0 0 0 0 0 0 1 0 0 1 0 2 External Causes 0 1 0 7 1 0 0 1 1 0 0 313 324 Total 1 16 4 29 4 12 4 1 4 325 426 1 0 1 25 1 *Categories not shown have no deaths assigned to them. �TABLE E-2. Comparison of Death Certificate and Medical Review Panel Results for Major External-Cause-of-Death Categories Death certificate MVA Medical review panel Accidental Other poisoning ace. Suicide Homicide Undetermined Total Motor-vehicle 127 accidents (MVA) 0 0 2 1 0 130 Accidental poisoning 0 9 1 0 0 2 12 Other accidents 3 0 47 3 0 5 58 Suicide 0 0 0 54 0 0 54 Homicide 0 0 4 0 47 0 51 Undetermined 0 4 1 0 1 2 8 130 13 53 59 49 9 313 Total 51 �TABLE E-3. Case Deaths Due to Neoplasms in Which the Death Certificate and Medical Review Panel Determinations Disagree ICD-9 Death certificate cause ICD-9 153.6 Malignant neoplasm of ascending colon E870.0 Accidental cut during surgical operation 235.7 Neoplasm of uncertain behavior, respiratory tract E876.3 Endotracheal tube wrongly placed during anesthesia Medical review cause E928.9 Unspecified accident 237.1 Neoplasm of uncertain behavior of pineal gland 4 427.5 Cardiac arrest 200.2 Burkitt's tumor 5 239.6 Neoplasm of unspecified nature, brain 191.2 Malignant neoplasm of brain, temporal lobe 6 239.6 Neoplasm of unspecified nature, brain 191.2 Malignant neoplasm of brain, unspecified 7 239.6 Neoplasm of unspecified nature, brain 191.1 Malignant neoplasm of brain, frontal lobe 8 199.1 Malignant neoplasm, unspecified site 162.9 Malignant neoplasm of bronchus and lung 9 199.1 Malignant neoplasm unspecified site 195.0 Malignant neoplasm of head, face and neck 10 172.9 Malignant melanoma 172.4 Malignant melanoma of scalp and neck 11 186.9 Malignant neoplasm of testes, unspecified 186.0 Malignant neoplasm of testes, undescended 12 208.9 Leukemia of unspecified cell type 205.0 Acute myeloid leukemia 13 204.0 Acute lymphoid leukemia 200.1 Lymphosarcoma 14 155.2 Malignant neoplasm of liver, unspecified origin 199.1 Malignant neoplasm, unspecified site 15 201.9 Hodgkin's disease, unspecified 201.5 Hodgkin's disease, nodular sclerosis 52 �TABLE E-4. Deaths Due to Mental Disorders in Which the Death Certificate and Medical Review Panel Determinations Disagree Case ICD-9 Death certificate cause ICD-9 Medical review cause 295.0 Simple schizophrenia 578.9 Gastrointestinal tract hemorrhage, unspecified 303 Alcohol dependence 571.3 Alcoholic liver damage, unspecified 303 Alcohol dependence 571.3 Alcoholic liver damage, unspecified 4 303 Alcohol dependence 348.4 Compression of brain 5 303 Alcohol dependence 481.0 Pneumococcal pneumonia 6 305.0 Nondependent abuse of 571.0 Alcoholic fatty liver alcohol 304.6 Other drug dependence E866.6 Accidental poisoning by glue 304.9 Unspecified drug dependence E858.8 Accidental poisoning by other drugs 304.9 Unspecified drug dependence E858.9 Accidental poisoning by other drugs, unspecified 10 305.9 Nondependent abuse of drugs E850.0 Accidental poisoning by opiates 11 038.4 Septicemia due to other gram negative organisms 303 Alcohol dependence 12 518.4 Acute edema of lung, unspecified 304.0 Morphine type drug dependence 13 571.1 Acute alcoholic hepatitis 303 Alcohol dependence 53 �TABLE E-4. (continued) Case ICD-9 Death certificate cause ICD-9 Medical review cause 14 577.0 Acute pancreatitis 303 Alcohol dependence 15 577.0 Acute pancreatitis 303 Alcohol dependence 16 E850.0 Accidental poisoning by opiates 304.0 Morphine type drug dependence 17 E850.0 Accidental poisoning by opiates 304.0 Morphine type drug dependence 18 E850.8 Accidental poisoning by other analgesics 304.0 Morphine type drug dependence 19 E850.8 Accidental poisoning by other analgesics 304.0 Morphine type drug dependence 20 E853.2 Accidental poisoning by benzodiazepine tranquilizer 305.0 Nondependent abuse of alcohol 21 E858.9 Accidental poisoning by unspecified drugs 304.9 Unspecified drug dependence 22 E980 304.0 Morphine type drug dependence Poisoning by analgesics, intentionality undetermined 54 �VIETNAM'EXPERIENCE STUDY — Mortality APPENDIX F The Cox Regression Model 55 �The Cox proportional hazards regression procedure models the risk of death and, correspondingly, the risk ratio when comparing two cohorts. The model/ assumes that the risk ratio is constant during the period of follow-up modeled. The model contains an underlying risk function, which may depend on time. This function is assumed to be modified by various covariates under consideration, such as in this study, Vietnam status, age, and race. When there are several groups defined by potential confounders, a stratified analysis can be done to allow different underlying risk functions in the different groups. With a stratified analysis, the proportional hazards assumption (that of a constant risk ratio) must hold in each group (stratum). If the intent is to estimate a •common risk ratio over the strata, the risk ratio for the various strata should be similar. Let XQ< X}, ..., Xp be the covariates of interest b0, bj, ..., bp be unknown regression coefficients, to be estimated. In particular, let XQ be 1 if an individual served in Vietnam and 0 otherwise. Then the Cox model estimates the rate ratio for an individual with covariates XQ, ..., Xp relative to one with covariates YQ, ..., Yp as log (RR) = bo(Xo-Yo) + ... + bp(Xp-Yp) The risk ratio for service in Vietnam is estimated as exp(bo). The SAS program PHGLf|2 was used to provide estimates of the parameters, their standard errors, and likelihood ratio statistics for tests of hypotheses. The program also computes a statistic to test the proportional hazards assumption^. This statistic has a distribution which is approximately that of a standard normal variable. Table F-l contains values of the test statistic for the proportional hazards assumption for the simple model with cohort (service in Vietnam) -as the only covariate. The values of this statistic for the model including the covariates age, race, GT score, year of discharge, and pay grade at discharge were very similar. The assumption appears reasonable within each time period and stratum, with a departure of marginal significance only for the first five * years of follow-up for volunteers with a tactical MOS (2=2.02, p=.04). The proportional hazards assumption does seem reasonable during this period for the model with the four strata combined (Z=1.35, p=.18). For the remaining period of follow-up, the assumption seems very well satisfied. If there is a modest departure from uniformity in the first time period, the estimate obtained from the model will be an average measure over this interval. , The validity of the proportionality assumption was also checked for the cause-specific analyses. There was substantial evidence for non-proportionality only for deaths due to homicide, according to the clinical review, in the later time period (2=2,7). Table F-2 contains the estimates of the regression coefficients for .cohort (service in Vietnam) and their standard errors. The standard errors are interpreted as those from a standard normal distribution. There is some variability among strata in the rate ratio for the first five years of follow-up. In particular, the rate ratio is less than 1 for one of the four strata, that of volunteers with a tactical MOS. However, this is the smallest stratum, with less than half the number of men and about half the number of deaths as the next smallest stratum. In addition, this rate ratio is not significantly less than 1, and the difference between the largest and smallest coefficients is not particularly large compared to their standard errors. Therefore, it is reasonable to use the estimate from the stratified model as a summary estimate, regarding it as an average of the effects in the four strata. Relatively small numbers of deaths in many strata makes this homogeneity check unreliable for the cause-specific analyses. 56 �REFERENCES / 1. Kalbfleisch JD, Prentice RL: The Statistical Analysis of Failure Time Data. New York, John Wiley & Sons, 1980. 2. Harrell FE: The PHGLM Procedure. IN: Joyner SP, ed, SUGI Supplemental Library User's Guide. Gary, N.C., SAS Institute, Inc., 1983. 3. Harrell FE, Lee KL: Verifying Assumptions of the Cox Proportional Hazards Model. IN: Proceedings of the Eleventh Annual SAS Users Group International Conference, Atlanta, GA, February 9-12, 1986, 823-828. Gary, N.C., SAS Institute, Inc., 1986. 57 �TABLE F-l. .Test Statistics* for Validity of Proportionality Assumption for Cox Regression Model Stratified on Enlistment Status and MOS, by Time Since Discharge. Stratum Years since discharge <_ 5 years 6+ years All years Tactical Draftee 0.5 0.2 -0.9 Volunteer 2.0 -0.4 1.2 -0.1 -1.4 0.8 -0.1 -1.0 1.4 -0.1 -1.4 • Nontactical Draftee Volunteer All strata -0.1 ~ *Test statistic has approximately a standard normal distribution. Results shown are for a model that includes place of service but no covariates. 58 �TABLE F-2. Uniformity of Vietnam Effect Over Strata for Cox Regression Models Stratified on Enlistment Status and MOS, by Time Since Discharge (All-Cause Mortality) Stratum Years since discharge <5 years Beta 6+ years SE Beta All years SE Beta SE Vietnam service only: Tactical Draftee. Volunteer 0.77 -0.22 0.36 0.42 0.16 0.29 0.27 0.40 0.40 0.05 0.22 0.29 Nontactical Draftee „ Volunteer 0.48 0.23 0.25 0.27 -0.03 -0.22 0.21 0.22 0.17 0.04 0.16 0.17 All strata 0.37 0.15 -0.02 0.12 0.14 0.10 Vietnam service plus covariates:* Tactical Draftee Volunteer 0.86 -0.39 0.37 0.45 0.25 0.10 0.28 0.42 0.49 -0.13 0.22 0.31 Nontactical Draftee Volunteer 0.49 0.47 0.26 0.28 0.00 -0.13 0.21 0.23 0.20 0.11 0.16 0.18 All strata 0.45 0.16 0.03 0.13 0.20 0.10 ^Covariates include age at discharge, race, General Technical test score and pay grade. 59 � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 064 Folder The folder containing the original item. 1744 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Boyle, Collen A. Pierre Decoufle Robert J. Delaney Frank DeStefano Melinda L. Flock Martha I. Hunter M.Riduan Joesoef John M. Karon Marilyn L. Kirk Peter M. Layde Daniel L. McGee Linda A. Moyer Daniel A. Pollock Philip Rhodes Mark J. Scally Robert Worth Description An account of the resource <strong>Corporate Author: </strong>Center for Environmental Health and Injury Control, CDC, Public Health Service, DDHS, Atlanta Title A name given to the resource Typescript: Postservice Mortality Among Vietnam Veterans, February 1987 Subject The topic of the resource Vietnam Experience Study mortality trends study protocol ao_seriesIII https://www.nal.usda.gov/exhibits/speccoll/files/original/eda1ab0ba8cd79035b18e79b26b04f62.pdf cd6d46a606e7b3f8913bfe99ef4a1cbc PDF Text Text Item ID Number 01742 Author Corporate Author RopOrt/ArtiClB TitlO Postservice Mortality Among Vietnam Veterans: The Centers for Disease Control Vietnam Experience Study Journal/Book Titlo JAMA Year 1987 Month/Day February 13 Color n Number of ImaDBS 28 DOSCTiptOn NOtOS Includes an undated, pre-publication typescript of the article. Monday, June 11, 2001 Page 1743 of 1793 �Reprinted from the JAMA" Journal of the American Medical Association February 13, 1987, Volume 257 Copyright 1987, American Medical Associatbn Postservice Mortality Among Vietnam Veterans The Centers for Disease Control Vietnam Experience Study The postservice mortality (through December 1983) of a cohort of 9324 US Army veterans who served in Vietnam was compared with that of 8989 Vietnam-era Army veterans who served in Korea, Germany, or the United States. Over the entire follow-up period, total mortality in Vietnam veterans was 17% higher than for other veterans. The excess mortality occurred mainly in the first five years after discharge from active duty (rate ratio, 1.45; 95% confidence interval, 1.08 to 1.96) and involved motor vehicle accidents, suicide, homicide, and accidental poisonings. Thereafter, mortality among Vietnam veterans was similar to that of other Vietnam-era veterans, except for drug-related deaths, which continued to be elevated. An unexpected finding was a deficit in deaths from diseases of the circulatory system among Vietnam veterans. The excess in postservice mortality due to external causes among Vietnam veterans is similar to that found among men returning from combat areas after World War II and the Korean War. (JAMA 1987;257:790-795) MANY Vietnam veterans have been concerned that their health, and that of their children, has been affected by their service in Southeast Asia and possible exposure to the herbicide Agent Orange. To address these concerns, the US Congress directed that appropriate epidemiologic studies be conducted.1'2 The Centers for Disease Control (CDC) has proposed three complementary efforts to assess the health of Vietnam veterans: the Agent Orange Study, the Selected Cancers Study, and the Vietnam Experience Study (VES).3 The VES is a historical cohort study designed to identify the possible adverse health effects of having served in the military in Vietnam. It has three components: (1) an assessment of postservice mortality, (2} a detailed health interview, and (3) a comprehensive medical, psychological, and laboratory evaluation. Although Agent Orange is among the many factors that could have From the Center for Environmental Health. Centers for Disease Control, Atlanta. Reprint requests to Centers for Disease Control, 1600 Cliflon Rd (C-25), Atlanta, GA 30333 (Coloon A. Boyle, PhD). 790 JAMA, Feb 13,1987—Vol 257, No. 6 adversely affected those who served in Vietnam, it is not the main focus of this study. This report is an abbreviated version of the results of the postservice mortality component, published in detail elsewhere.4 SUBJECTS AND METHODS Study Participants Participation was restricted to men who served in the US Army. To increase comparability between those who served in Vietnam and those who served elsewhere, we selected only veterans who (1) entered military service for the first time between January 1965 and December 1971, (2) served only one term of enlistment, (3) had at least 16 weeks of active service time, (4) earned a military occupational specialty (MOS) other than "trainee" or "duty soldier," and (5) had a pay grade no higher than E5 on discharge from active duty. To be eligible for the Vietnam cohort, a veteran had to have served at least one tour of duty in Vietnam. For the comparison cohort, tours of duty were limited to the United States, Germany, or Korea. The VES was designed principally to assess morbidity associated with ser- vice in Vietnam; mortality was examined for completeness. Thus, the sample size for the VES, about 9000 Vietnam and 9000 non-Vietnam veterans, was based on statistical power requirements for the morbidity components.3 Nevertheless, this sample size provides statistical power of 90% for detecting a 30% relative increase in allcause mortality, but more limited power for detecting cause-specific increases, particularly for deaths due to natural causes, which in this age group are rare.'1 Potential participants were randomly selected from almost 5 million US Army veterans whose service records were received by the National Personnel Records Center (NPRC) between September 1964 and June 1977. Personnel of the NPRC believe that this group includes the vast majority of US Army Vietnamera veterans who fulfill the study criterion of a single term of enlistment. The Figure outlines the process of participant selection. To achieve the desired sample size of 18 000 veterans with the above study criteria (proportion estimated from a pretest), we randomly selected 48 513 service records. Of the 47158 records located and reviewed, 60.6% were excluded during the qualification process; these included less than 200 records that did not contain critical data needed to determine eligibility. Characteristics of eligible men as of entry into service and details of their military experience were abstracted from the records. Altogether, 9558 Vietnam and 9023 non-Vietnam veterans qualified for the study. The 234 Vietnam and 34 non-Vietnam veterans who had died during active duty were excluded. Vital Status Ascertainment Follow-up began the day the veteran was discharged alive from active duty CDC Vietnam Experience Study—Postservice Mortality �Vietnam-Era Army Personnel Records Filed at NPRC, Sept 1964-June 1977 (About 4.9 Million) I I Random Sample (48 513) [Records Not Found'(1355)j [ Qualified for Study (18581)] Vietnam (9558) I Not Qualified (28577) [Non-Vietnam (9023)[ I Died on Active Duty (34) Died on Active Dutyt (234) I 34)] Vietnam Cohort (9324) [ I Non-Vietnam Cohort (8989) Selection of study group. NPRC indicates National Personnel Records Center; asterisk, excluded from study; and dagger, 83% (N = 194) of active-duty deaths among Vietnam veterans were due to war-related activities. ratio (RR) was formed by dividing the crude mortality rate among Vietnam veterans by that for non-Vietnam veterans. The 95% confidence intervals (CIs) for the RRs were computed using procedures described by Laird and Oliver.7 The Cox proportional hazards regression model8 was used to consider possible effect modification and confounding by selected covariates. Adjusted RRs were obtained from Cox models stratified on primary MOS and enlistment status (volunteer or draftee), and adjusted for other selected covariates. Two MOS categories were used in the model and can be described roughly as "tactical" (infantry, armor, artillery, and combat engineers) and "other" (all other specialties). Additional covariates considered in the Cox models, chosen on the basis of their associations with mortality in the univariate analyses," included race, age at discharge, Army General Technical Test score (a general aptitude test taken at entry into the service), pay grade at discharge, and year of discharge. Comparisons were also made between the mortality experience of each veteran cohort and that of the US male population utilizing Monson's software package.9 Results are expressed as a standardized mortality ratio (SMR) adjusted for age, race, and calendar year. RESULTS and ended on the date of his death or Dec 31, 1983, whichever came first. To identify those who had died after discharge, we checked files of the US Army, Veterans Administration (Beneficiary Identification and Record Locator Subsystem), Social Security Administration, Internal Revenue Service, and National Center for Health Statistics (National Death Index). For the interview component of the VES, an attempt was made to locate and contact all veterans not identified as deceased by the above sources. Through this method, vital status was confirmed for 93.6% of Vietnam veterans and 91.9% of those who served elsewhere. Entry and military service characteristics of Vietnam veterans whose vital status was uncertain were similar to those of non-Vietnam veterans with uncertain vital status. All men with uncertain vital status were assumed to be alive at the end of 1983. For all but nine of the 446 men reported to have died after discharge, copies of official death certificates were obtained. The other nine deaths were confirmed through other sources. Underlying causes of death were coded according to both the eighth and ninth revisions6'6 of the International Classification of DisJAMA, Feb 13,1987—Vol 257, No. 6 eases (ICD) by an experienced nosologist at the National Center for Health Statistics who had no knowledge of whether the decedent had served in Vietnam. Medical Review Panel To address limitations of death certificate-based diagnoses, a review panel of two physicians determined the underlying cause of death, using pertinent medical and legal documents describing the nature and circumstances of each of 426 deaths for which additional information could be obtained. Sources included hospitals, law enforcement agencies, coroners or medical examiners, and private physicians. All causes of death and other significant conditions were coded by the medical review panel according to the Ninth Revision of the ICD. To estimate the influence of substance abuse on mortality in this study, special categories of alcohol- and drug-related deaths were developed, and deaths were so classified by the review panel when appropriate. Analyses Crude death rates were based on person-years at risk since discharge from active duty. An unadjusted rate There were some differences in both preinduction and military service characteristics between the Vietnam and non-Vietnam cohorts (Table 1). In general, however, the preinduction differences were small. Differences in some of the military service characteristics, such as a greater percentage of Vietnam veterans with tactical MOS classifications and infantry unit assignments, reflect war-related military requirements in Vietnam. All-Cause Mortality Over the entire follow-up period, the mortality among Vietnam veterans was 17% higher than the rate among nonVietnam veterans (Table 2). Most of this excess, however, was due to higher mortality among Vietnam veterans during the first five years of follow-up (RR, 1.45; 95% CI, 1.08 to 1.96). By the sixth year, the two cohorts had similar mortality rates that remained so through the end of follow-up (RR, 1.01; 95% CI, 0.79 to 1.28). Because of the variation in relative mortality with time, time-specific results will be presented when appropriate. To determine whether the association between Vietnam service and mortality was uniform or varied across different CDC Vietnam Experience Study—Postservice Mortality 791 �Table 1.—Differences in Selected Characteristics Between Vietnam and Non-Vietnam Veterans at Entry Into Service and During Military Service Table 3.—Number of Deaths Among Vietnam and Non-Vietnam Veterans and Unadjusted Rate Ratios (RRs), by Selected Characteristics and Years Since Discharge From Active Duty, 1965 Through 1983 Vietnam (N=9324) At entry into service Race,* % white Age at entry (mean) Enlistment status,* % draftee Year of entry into service, % before 1969 Non-Vietnam (N=8989) 86.8 86.5 20.3 Characteristic 20.5 Characteristic* 65.6 Race White 63.7 Years Since Discharge From Active Duty s5 Nonwhite 72.1 Army General Technical Test score (mean, scaled to 100) During military service Primary military occupational specialty, t % tactical operations 60.6 105.5 Type of discharge, % honorable 34.3 27.4 26.6 Type of unit, % infantry 97.2 91.0 88.5 79.8 Year of discharge, % before 1970 48.1 44.6 *Race and enlistment status were the only two characteristics that were not significantly different (P>.05) between the Vietnam and the non-Vietnam groups. tThe job specialty for which the man was trained in the Army. No. RR No. RR 79 1.09 111 0.91 190 0.98 104 1.80 152 1.06 256 1.31 GT test scoref 97 1.42 141 0.90 238 1.08 <100 100 + 83 1.43 119 1.07 202 1.20 Duty MOSt 63 1.19 Tactical 89 1.04 152 1.10 Other 120 1.58 174 0.97 294 1.18 Age at discharge <21 47 1.83 42 0.67 89 1.14 14.6 Pay grade at discharge, % E4 or E5 RR All Years 146 1.50 193 0.99 339 1.18 37 1.30 70 1.07 107 1.14 Enlistment status Volunteer Draftee 103.1 No. 6+ 21 + 136 1.41 221 1.10 357 1.21 Pay grade at discharge E4-E5 125 1.50 183 1.10 308 1.24 E1-E3 58 1.95 80 1.16 138 1.44 Year of discharge 79 2.05 122 0.96 201 1.27 <1970 104 1.16 141 1.06 245 1.10 1970 + "There was no evidence of statistically significant effect modification for any of these characteristics (P>.OS). tArmy General Technical Test (GT) scores were missing for six veterans. ^Determined from principal military occupational specialty (MOS) held while on tour of duty. Table 2.—Number of Deaths, Person-Years, and Death Rates Among Vietnam and Non-Vietnam Veterans and Unadjusted RRs by Years Since Discharge From Active Duty, 1965-1983* Non-Vietnam Vietnam ==5 No. of Deaths PersonYears Ratef No. Of Deaths PersonYears 95% Cl 46350 2.4 73 44747 Ratef 1.6 RR 110 Years Since Discharge 1.45 1.08-1.96 6+ 136 81547 1.7 127 76582 1.7 1.01 0.79-1.28 All years 246 127897 1.9 200 121 329 1.7 1.17 0.97-1.41 *RR indicates rate ratio; Cl, confidence interval. tCrude death rate per 1000 person-years. subgroups of veterans, separate analyses were done within these groups (Table 3). Although the results indicated a consistent pattern of elevated mortality associated with Vietnam service limited to the first five years after discharge, there was some variation in the RR among various subgroups of veterans. Tests for effect modification, however, were not statistically significant (P>.05). Possible confounding by selected covariates (age at discharge, race, Army General Technical Test score, pay grade at discharge, and year of discharge) was assessed by including them in stratified Cox models. In the first five years after discharge, adjustment for these characteristics increased the RR to 1.58 (95% Cl, 1.16 to 2.14). In the later 792 JAMA, Feb 13,1987—Vol 257, No. 6 follow-up period, adjustment changed the RR to 1.04 (95% Cl, 0.81 to 1.33). Results from the Cox model also indicated that Vietnam service had a greater effect on mortality among those who were discharged before age 21 years than those discharged at age 21 years or older (P = .02) and among veterans discharged before 1970 compared with those discharged during 1970 or later (P = . 05). Cause-Specific Mortality Death Certificates.—Only four major cause-of-death categories contained sufficient numbers of deaths for formal analysis (Table 4). Rates for Vietnam veterans appeared to differ from rates for non-Vietnam veterans in two of these categories: diseases of the circu- latory system (51% decrease in the death rate) and external causes of death (25% increase in the death rate). The deficit in circulatory disease deaths was evident regardless of time since discharge and type of circulatory disease. There were no differences in mortality from mental disorders or neoplasms. Deaths from specific types of neoplasms were too few for meaningful comparisons. The excess in external causes of death is examined further in Table 5. Vietnam veterans had significantly higher mortality from motor vehicle accidents (MVAs) (RR, 1.48; P = .03) than nonVietnam veterans. The excess was most pronounced in the first five years after discharge from active duty (RR, 1.93; P = .01). After that period, MVA rates were similar in the two cohorts (RR, 1.16). The RRs for suicide and homicide were somewhat increased in the early postdischarge period but not in the later years of follow-up. Accidental poisoning deaths (mostly by drugs) were substantially more common among Vietnam veterans than other veterans over the entire follow-up period (RR, 2.47; P = .08). No postservice deaths were attributed to war injuries (ICD-9, E990-E999). Adjustment for selected covariates did not materially alter the pattern of cause-specific mortality, except for suicide in the earlier follow-up period, where the adjusted RR was 2.59 (95% Cl, 1.09 to 6.17). Medical Review Panel.—The medical review analysis was based on 233 (95%) of Vietnam veteran deaths and 193 (97%) of deaths among non-Vietnam veterans. On average, slightly fewer supplemental medical and legal records were recovered for each Vietnam veteran death (mean, 3.3 records) than for each non-Vietnam veteran death (mean, 3.7 records). Overall agreement between the medical review panel diagnoses and death certificate diagnoses, however, was good (82%; K = 0.79) and did not differ significantly between the two veteran cohorts. The medical review analyses indicated differences in only two ICD-9 categories that were not evident from the death certificate analysis. The RR for mental disorders from the medical review panel analysis was 2.85 (95% Cl, 0.92 to 8.82) compared with 0.95 from the death certificate analysis. Most mental disorder deaths were related to alcohol or drugs and are examined in more detail in Table 6. The RR for neoplasms based on medical review panel diagnoses was 1.21 (95% Cl, 0.55 to 2.66) compared with 0.82 based on death certificates. This difference was CDC Vietnam Experience Study—Postservice Mortality �Table 4.—Number of Deaths by Cause (From Death Certificate), Death Rates Among Vietnam and NonVietnam Veterans, and Unadjusted RRs, 1965 Through 1983* Vietnam Underyllng Cause of Death (/CD-9)t Non-Vietnam No. Rate* Infectious and parasitic diseases (001 -139) No. 95% Cl RR§ Rate* 1 0.8 1 0.8 12 9.4 14 11.5 0.82 0.38-1 .76 Mental disorders (290-31 9) 7 5.5 7 5.8 0.95 0.33-2.70 Diseases of nervous system (320-389) 0.49 0.25-0.99 Neoplasms (140-239) 2 1.6 1 0.8 Diseases of circulatory system (390-459) 12 9.4 23 19.0 Diseases of respiratory system (460-51 9) 5 3.9 4 3.3 Diseases of digestive system (520-579) 5 3.9 3 2.5 Diseases of genitourinary system (580-611) 4 3.1 0 Congenital anomalies (740-759) 1 0.8 1 0.8 Symptoms, signs, and ill-defined conditions (780-799) 2 1.6 1 0.8 188 147.0 143 117.9 External causes (E800-E999) General Population Comparison 1 .25 1 .00-1 .55 2 7 No death certificate *RR indicates rate ratio; Cl, confidence interval. f/CD-9 indicates International Classification of Diseases, ninth revision. No deaths were categorized to diseases of blood and blood-forming organs; endocrine, metabolic or nutritional diseases; diseases of the skin; or diseases of the musculoskeletal system. Therefore, these categories are not shown. tCrude death rate per 100000 person-years. §lf the total number of deaths for a cause-of-death category in both groups combined was less than ten, RRs are not shown. Table 5.—Number of Deaths From Specific External Causes (From Death Certificate) Among Vietnam and Non-Vietnam Veterans and Unadjusted RRs, by Years Since Discharge From Active Duty, 1965 Through 1983* Years Since Discharge From Active Dutyt All Years 64- External Cause of Death (/CD-9) No. RR 95% Cl Motor vehicle accident (E810-E825, E929.0) 66 1.93 1.16-3.22 further refinement of the later follow-up period suggests the upward trend in drug-related mortality continues into the most recent years. Further, Vietnam service seems to be associated with an especially high rate of drug-related mortality among those drafted into service, those whose jobs were in tactical or combat operations, and those who served during 1969. Again, as in the death certificate results, adjustment for selected covariates increased the RR for suicide in the early follow-up period to 2.56 (95% Cl, 1.11 to 5.87). No other RR presented in the medical review results was materially altered by adjustment. No. RR 95% Cl No. RR 95% Cl 67 1.16 0.72-1.87 133 1.48 1.04-2.09 Both groups of veterans had a significantly lower overall mortality rate for "natural causes" than the general US male population (Table 7). During the first five years after discharge, Vietnam veterans had a higher death rate from external causes, whereas non-Vietnam veterans have a lower rate relative to the general population. In the later time period both groups of veterans showed a similar deficit in external cause mortality. Although these data are not presented in Table 7, over the entire followup period, Vietnam veterans had a striking deficit of circulatory disease deaths (SMR, 0.48; 95% Cl, 0.25 to 0.85), whereas non-Vietnam veterans had only a slight deficit (SMR, 0.87; 95% Cl, 0.54 to 1.34). Accidental poisoning (E850-E869, E929.2) 11 1.69 0.49-5.77 7 ... ... 18 2.47 0.88-6.92 COMMENT Other accidents* 23 1.05 0.46-2.37 39 0.89 0.48-1.67 62 0.95 0.58-1 .56 Suicide (E950-E959) 25 1.72 0.76-3.88 32 0.64 0.32-1.30 57 0.98 0.58-1.65 Homicide (E960-E969) 18 1.52 0.59-3.91 33 0.78 0.39-1.55 51 0.99 0.57-1.71 10 3.79 0.81-17.87 The intent of this study was to assess the effect of military service in Vietnam on subsequent mortality. The "Vietnam experience" includes a wide variety of possible health-influencing factors such as psychological stresses associated with war, infectious diseases prevalent in Vietnam, and exposure to the herbicide Agent Orange. The modest excess of deaths among Vietnam veterans was concentrated in the first five years after discharge, where all-cause mortality was 45% higher than in the non-Vietnam group. External causes accounted for most of this increase, with the largest elevation in relative mortality due to MVAs. A more detailed examination of MVA deaths did not indicate any particular factor that could explain the overall excess in Vietnam veterans. The increased risk did not appear to be related to elevated blood alcohol levels at the time of death, and the excess was apparent across various types of MVAs. Drug-use information on MVA victims was limited; the medical review panel Undetermined intentlonality (E980-E989) 4 6 *RR indicates rate ratio; Cl, confidence interval; /CD-9, International Classification of Diseases, ninth revision. tTime-specific RRs are not presented for categories with less than ten deaths in both Vietnam and non-Vietnam groups combined. ^Includes /CD-9 categories E800 to E807, E826 to E849, E870 to E928, E929.1, E929.3 to E929.9, E930 to E949, E970 to E978, and E990 to E999. primarily the result of two deaths from neoplasms among non-Vietnam veterans being reclassified elsewhere by the medical review panel and the opposite occurrence among Vietnam veterans. There was no particular type of neoplasm in excess in the Vietnam cohort. Supplemental information collected for the medical review allowed further exploration of MVA deaths. Single- and multiple-vehicle crash deaths as well as daytime and nighttime events all occurred more frequently among Vietnam veterans during the early postdischarge period. Vietnam veterans had a modest excess of alcohol-related MVA deaths JAMA, Feb 13,1987—Vol 257, No. 6 during this period (RR, 1.35; 95% Cl, 0.60 to 3.04). Alcohol-related natural causes of death were too few for formal analysis in the early postdischarge period, but the RR in the later period showed no difference between the two groups (Table 6). A modest elevation in alcohol-related traumatic deaths among Vietnam veterans was limited to the first five years after discharge. For drug-related deaths, the RR was slightly elevated during the early postdischarge period and more elevated during the later follow-up period. Although the number of deaths is too small for formal analysis, CDC Vietnam Experience Study—Postservice Mortality 793 �Table 6.—Number of Deaths From Alcohol and Drug-Related Causes (From Medical Review) Among Vietnam and Non-Vietnam Veterans and Unadjusted RRs, by Years Since Discharge From Active Duty, 1965 Through 1983* Years Since Discharge From Active Duty s5 Cause of Death Alcohol-related natural causesf Alcohol-related traumatic causes:): Drug-related causes§ No. All Years 6+ RR 95% Cl No. 95% Cl No. RR 95% Cl 25 5 RR 0.87 0.40-1.90 30 1.08 0.53-2.22 42 1.29 0.70-2.37 61 1.04 0.63-1.71 103 1.13 0.77-1 .67 18 1.21 0.48-3.06 22 2.01 0.82-4.94 40 1.58 0.83-3.00 'RR indicates rate ratio; Cl, confidence interval. tincludes the following diagnoses determined to be the underlying or contributing cause of death: alcoholic psychoses (291.0 to 291.9); alcohol dependence syndrome (303); nondependent alcohol abuse (305.0); alcoholic polyneuropathy (357.5); alcoholic cardiomyopathy (425.5); alcoholic gastritis (535.3); alcoholic liver disease (571.0 to 571.3); and excessive blood level of alcohol (790.3). ^Includes deaths in which the underlying cause is accidental poisoning by alcohol (E860.0 to E860.9) or any traumatic death (E800 to E989) in which either nondependent abuse of alcohol (305.0) or excessive blood level of alcohol (790.3) is a contributing cause of death. §Deaths for which one of the following drug-specific diagnoses is the underlying or contributing cause of death: drug psychoses (292.0 to 292.9); drug dependence (304.0 to 304.9); nondependent abuse of drugs (305.2 to 305.9); accidental poisoning by drugs (E850.0 to E850.2, E850.5, E850.8, E851-E854, E855.1 to E855.2, E866.6, and E869.0); suicide by drugs (E950.0 to E950.5); and poisoning by drugs, intentionality undetermined (E980.0 to E980.5). Table 7.—Observed and Expected Numbers of Deaths by Cause Among Vietnam and Non-Vietnam Veterans and SMRs, by Years Since Discharge From Active Duty, 1965 Through 1983* Years Since Discharge -~5 Cause of Deathf (ICDA-8) All natural causes (000-796) External causes (E800-E999) 6+ All natural causes (000-796) External causes (E800-E999) All years All natural causes (000-796) External causes (E800-E999) Observed Expected^ SMR 95% Cl Observed Expected SMR 95% Cl Observed Expected SMR 95% Cl Observed Expected SMR 95% Cl Observed Expected SMR 95% Cl Observed Expected SMR 95% Cl Vietnam 13 Non- Vietnam 24.2 23.4 0.54 0.29-0.92 16 0.68 0.39-1.11 92 55 72.5 69.4 1.27 1.02-1.56 0.79 0.60-1.03 38 39 65.8 63.4 0.58 0.41-0.79 96 102.7 0.93 0.76-1.14 0.62 0.44-0.84 88 96.6 0.91 0.73-1.12 51 55 90.0 86.8 0.57 0.42-0.75 0.63 0.48-0.82 188 143 175.2 166.0 1.07 0.93-1.24 0.86 0.73-1.01 *SMR indicates standardized mortality ratio; Cl, confidence interval; and ICDA-8, International Classification of Diseases, Adapted for Use in the United States, eighth revision. •(•Excludes nine deaths (seven Vietnam, two non-Vietnam) for which death certificates were not recovered. ^Expected number is based on the mortality rates among US men, standardized for age, calendar year, and race. identified only one drug-related MVA death. Suicide and homicide also occurred somewhat more frequently among Vietnam veterans during the early postdischarge period. Accidental poisoning deaths (mainly by drugs) were elevated throughout the entire follow-up period, although the number of such deaths was small. By the sixth year after discharge, 794 JAMA, Feb 13,1987—Vol 257, No. 6 both all-cause and external-cause mortality among Vietnam veterans had fallen to levels found in the non-Vietnam group, except for deaths due to drug abuse, where the rate was actually higher in the more recent follow-up period. These findings are unlikely to be the result of a serious flaw in study design or execution. The study groups were selected in a manner that minimized dif- ferences in their preservice characteristics; vital status was verified for 93% of all participants; death certificates were recovered for 98% of deaths; and supplemental medical and legal documents, which allowed an independent assessment of cause of death by standardized criteria, were obtained for 96% of deaths. Moreover, the pattern of excess deaths was remarkably consistent across various subgroups of Vietnam veterans and appears not to be an artifact of confounding. It should be noted, however, that sample size constraints limited our ability to detect excesses in mortality in subgroups of veterans and for the less frequent causes of death in this relatively young group. Our findings can be viewed against the results of five previous mortality studies of Vietnam veterans. Four10'13 are proportional mortality studies, which may not be directly comparable with this study because of incompleteness of data and inherent limitations of this analytic method.14 The fifth, a cohort study of Australian Vietnam veterans, is very similar in design to our study and thus is a more appropriate comparison.16 The US Air Force "Ranch Hand" study is not discussed here, since its principal concern is the adverse health effects of herbicide exposure in a unique group of veterans.16 The 30% excess of external-cause mortality among Australian Vietnam veterans relative to non-Vietnam veterans is similar to what is seen here.16 Although the Australian investigators did not examine external cause mortality by time since discharge, there was a suggestion of a decline in relative mortality with increasing time since discharge in their all-cause mortality results. Deaths from suicide, homicide, and accidental poisoning also occurred more frequently among their Vietnam veterans. Mortality from MVA was not elevated overall, but an excess in the youngest age group was suggested. Findings for external-cause mortality from the four proportional mortality studies are not consistent with our results. A nonsignificant increase in deaths from MVA among Vietnam veterans relative to other veterans was present in only one of the studies.12 The relative frequencies of suicide and homicide were not unusual, although there was one instance of a nonsignificant increase in both of these causes." Accidental poisonings were analyzed in only one of the studies, and the result was a small, nonsignificant elevation among Vietnam veterans.11 Australian Vietnam veterans had an excess of deaths from alcohol-related CDC Vietnam Experience Study—Postservice Mortality �natural causes, but no increases in deaths from alcohol-related external causes or drug-related mortality. These discordant findings may reflect differences in in-service use of drugs and alcohol by American and Australian troops. In contrast to the reportedly heavy use of illicit drugs by American troops in Vietnam,17'18 drug use among Australian soldiers was reported to be uncommon and alcohol use, heavy.15 Our finding of increased mortality from drug-related causes in the later followup period was not consistent with surveys indicating little or no influence of Vietnam service or combat exposure on postdischarge drug use.18'19 The lower mortality from cardiovascular diseases (CVDs) among Vietnam veterans is surprising. The lower rate might be explained as a by-product of some kind of selection process taking place in the final assignments to Vietnam, which might correlate with cardiovascular fitness established during basic or advanced training. Indeed, the SMR results suggest that the CVD deficit may be the result of an unusually high rate in the comparison group; CVD mortality in the non-Vietnam cohort was only slightly below that of the general population, whereas we expected it to be much lower.20 A completely opposite result was found in the Australian study, where CVD mortality was 90% higher among Vietnam veterans than non-Vietnam veterans.15 Various indexes, of CVD morbidity measured in the other components of the VES may help in further elucidating the mortality findings. In the Australian study most of the excess in all-cause mortality among Vietnam veterans was confined to members of the Engineer Corps.15 This pattern was not found in the present study, but the number of men assigned to engineer units was relatively small. Furthermore, possible differences between US and Australian engineering units in training and composition may make this comparison inappropriate. The excess in postservicc externalcause mortality among Vietnam veterans seen here could be due to some peculiarity in the assignment of men to Vietnam whereby those who were sent tended to have characteristics that placed them at increased risk of dying from external causes after discharge from active duty. This explanation appears doubtful for several reasons. Most importantly, if Vietnam veterans tended to have an inherent predisposition to traumatic events, it might be expected to manifest itself in increased mortality from such causes throughout the period of observation, not just in the first few years, as observed here. Alternatively, our findings may reflect consequences of the unique environment and experience of serving in Vietnam and returning to an unsupportive and sometimes hostile climate in the United States. This explanation might seem plausible given the unique military and social environment of the Vietnam conflict. However, the present results are similar to previous observations of postservice mortality in Army veterans. Indeed, increased mortality from external causes has been seen in two groups of World War II combat veterans and one group of Korean War combat veterans, when compared with the general US male population, even though older men and officers were included.21 In contrast, broader cross-sections of World War II veterans, including combat and noncombat groups, showed no difference or even a deficit in postdischarge traumatic deaths,20'21 as did non-Vietnam veterans in our study. Although the influence of factors specific to the Vietnam experience cannot be completely ruled out, our findings and previous studies suggest that the postservice excess of traumatic deaths among Vietnam veterans is probably due to unusual stresses endured while stationed in a hostile fire zone. The mortality assessment of Vietnam veterans presented here is an incomplete evaluation of the health experience of this group. Additional data on the present and past health status of living Vietnam veterans will be forthcoming from the health interview and medical, psychological, and laboratory evaluation components of the VES. Because this group of veterans has not yet reached the age where chronic diseases have an important impact on mortality, continued monitoring of mortality among VES participants may provide additional insights. The VES Mortality Study Staff consisted of Coleen A. Boyle, PhD, Pierre Decoufle, ScD, Robert J. Delaney, Frank DeStefono, MD, Melinda L. Flock, MSPH, Martha I. Hunter, M. Riduan Joesoef, MD, PhD, John M. Karon, PhD, Marilyn L. Kirk, Peter M. Layde, MD, Daniel L. McGee, PhD, Linda A. Moyer, RN, Daniel A. Pollock, MD, Philip Rhodes, MS, and Robert M. Worth, MD, PhD. Many other individuals and organizations provided invaluable support to the study. These include The Agent Orange Working Group and its Science Panel; Army Reserve Personnel Center, US Army and Joint Services Environmental Support Group, Department of Defense; NPRC, National Archives and Records Administration; General Services Administration; Veterans Administration; National Center for Health Statistics; Social Security Administration; Internal Revenue Service; National Academy of Sciences; other staff members of the CDC; and outside consultants who contributed their unique expertise. A more comprehensive report of the findings from this study has been published in the form of a monograph by the CDC. Copies can be obtained from the CDC, Atlanta, GA 30333. References 1. Veterans Health Programs Extension and Improvement Act of 1979, Public Law 96-151 (HR 3892), Dec 20, 1979, 93 STAT 1092-1098. 2. Veterans' Health Care, Training, and Small Business Loan Act of 1981, Public Law 97-72 (HR 3499), Nov 3, 1981, 95 STAT 1047-1063. 3. Protocol for Epidemiologic Studies of the Health of Vietnam Veterans. Atlanta, Centers for Disease Control, November 1983. 4. Post-service Mortality Among Vietnam Veterans. Atlanta, Centers for Disease Control, 1987. 5. International Classification of Diseases, Adapted for Use in the United States, rev 8, PHS publication 1693. US Dept of Health, Education, and Welfare, 1967. 6. Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death, rev 9. Geneva, World Health Organization, 1977. 7. Laird N, Oliver D: Covariance analysis of censored survival data using log-linear analysis techniques. JAmStatAssoc 1981;76:231-241. 8. Cox DR, Oakes D: Analysis of Survival Data. London, Chapman & Hall, 1984. 9. Monson RR: Analysis of relative survival and proportional mortality. Comp Biomed Res 1974;7: JAMA, Feb 13,1987—Vol 257, No. 6 325-332. 10. Anderson IIA, Hanrahan LP, Jensen M, et al: Wisconsin Vietnam Veteran Mortality Study. Madison, Wis, Wisconsin Division of Health, 1985. 11. Lawrence CE, Reilly AA, Quickenton P, et al: Mortality patterns of New York State Vietnam veterans. Am J Public Health 1985;75:277-279. 12. Kogan MI), Clapp RW: Mortality Among Vietnam Veterans in Massachusetts, 1972-1983. Boston, Massachusetts Dept of Public Health, 1985. 13. Holmes AP: West Virginia Vietnam-Era Veterans Mortality Study. Charleston, WVa, West Virginia Health Dept, 1986. 14. Wong 0, Decoufle P: Methodological issues involving the standardized mortality ratio and proportionate mortality ratio in occupational studies. J Occup Med 1982;24:299-304. 15. Fott MJ, Dunn M, Adena MA, et al: Australian Veterans Health Studies: The Mortality Report: Part I. A Retrospective Cohort Study of Mortality Among Australian National Servicemen of the Vietnam Conflict Era, and an Executive Summary of the Mortality Report. Canberra, Australia, Australian Government Publishing Service, 1984. 16. Lathrop GD, Moynahan PM, Albanese RA, et al: Project Ranch Hand II. An Epidemiologic Investigation of Health Effects in Air Force Personnel Following Exposure to Herbicides: Baseline Mortality Study Results. San Antonio, Tex, Brooks Air Force Base, US Air Force School of Aerospace Medicine, 1983. 17. Ritter C, Clayton RR, Voss HL: Vietnam military service and marijuana use. Am J Drug Alcohol Abuse 1985;11:119-130. 18. Robins LN, Helzer JE, Davis DH: Narcotic use in Southeast Asia and afterward. Arch Gen Psychiatry 1975;32:955-961. 19. Yager T, Laufer R, Gallops M: Some problems associated with war experience in men of the Vietnam generation. Arch Gen Psychiatry 1984; 41:327-333. 20. Seltzer CC, Jablon S: Effects of selection on mortality. Am J Epidemiol 1974;100:367-372. 21. Nefzger MD: Follow-up studies of World War II and Korean War prisoners: I. Study plan and mortality findings. Am J Epidemiol 1970;91: 123-138. CDC Vietnam Experience Sludy— Postsorvice Mortality Printed and Published in the United States of America 795 �Postservice Mortality Among Vietnam Veterans The Centers for Disease Control Vietnam Experience Study Published in February 13, 1987 issue of The Journal of the American Medical Association. �ABSTRACT The postservice mortality (through December 1.983) of a cohort of 932.4 US Army veterans who served in Vietnam was compared with that of 0989 Vietnam-era Army veterans who served in Korea, Germany, or the United States. Over the entire follow-up period, total mortality in Vietnam veterans was 17% higher than for other veterans. The excess mortality occurred mainly in the first five years after discharge from active duty (rate ratio,.1.45; 95% confidence interval, 1.08 to 1.96) and involved motor vehicle accidents, suicide, homicide, and accidental poisonings. Thereafter, mortality among Vietnam veterans was similar to that of other Vietnam-era veterans, except for drug-related deaths, which continued to be elevated. An unexpected finding was a deficit in deaths from diseases of the circulatory system among Vietnam veterans. The excess in postservice mortality due to external causes among Vietnam veterans is similar to that found among men returning from combat areas after World War II and the Korean War. �INTRODUCTION Many Vietnam veterans have been concerned that their health, and that of their children, has been affected by their service in Southeast Asia and possible exposure to the herbicide Agent Orange. To address these concerns, the US Congress directed that appropriate epidemiologic studies be conducted.1'^ The Centers for Disease Control (CDC) has proposed three complementary efforts to assess the health of Vietnam veterans: the Agent Orange Study, the Selected Cancers Study, and the Vietnam Experience Study (VES).^ The VES is a historical cohort study designed to identify the possible adverse health effects of having served in the military in Vietnam. It has three components: 1) an assessment of postservice mortality, 2) a detailed health interview, and 3) a comprehensive medical, psychological, arid laboratory evaluation. Although Agent Orange is among the many factors that could have adversely affected those who served in Vietnam, it is not the main focus of this study. This report is an abbreviated version of the results of the postservice mortality component, published in detail elsewhere"./l �SUBJECTS AMD METHODS Participation was restricted to men who served in the US Army. To increase comparability between those who served in Vietnam and those who served elsewhere, we selected only veterans who 1) entered military service for the first time between January 1965 and December 1971, 2) served only one term of enlistment, 3) had at least 16 weeks of active service time, 4) earned a military occupational specialty (MOS) other than "trainee" or "duty soldier," and 5) had a pay grade no higher than E5 on discharge from active duty. To be eligible for the Vietnam cohort, a veteran had to have served at least one tour of duty in Vietnam. For the comparison cohort, tours of duty were limited to the United States, Germany, or Korea. The VES was designed principally to assess morbidity associated with service in Vietnam; mortality was examined for completeness. Thus, the sample size for the VES, about 9000 Vietnam and 9000 non-Vietnam veterans, was based on statistical power requirements for the morbidity components. 3 Nevertheless, this sample size provides statistical power of 90% for detecting a 30% relative increase in all-cause mortality, but more limited power for detecting cause-specific increases, particularly for deaths due to natural causes, which in this age group are Potential participants were randomly selected from almost 5 million US Army veterans whose service records were received by the National Personnel Records Center (IMPRC) between September 1964 and June 1977. Personnel of the WPRC believe that this group includes the vast majority of US Army Vietnam-era veterans who fulfill the study criterion of a single term of enlistment. The figure outlines the process of participant selection. To achieve the desired sample size of 18000 veterans with the above study criteria (proportion estimated from a pretest), we randomly selected 48513 service records. Of the 47158 records located and reviewed, 60.6% were excluded during the qualification process; these included less than 200 records that did not contain critical data needed to determine eligibility. Characteristics of eligible men as of entry into service and details of their military experience were abstracted from the records. Altogether, 9558 Vietnam arid 9023 non-Vietnam veterans qualified for the study. The 234 Vietnam and 34 non-Vietnam veterans who had died during active duty were excluded . Follow-up began the day the veteran was discharged alive from active duty and ended on the date of his death or Dec 31, 1983, whichever came first. To identify those who had died after discharge, we checked files of the US Army, Veterans Administration (Beneficiary Identification and Record Locator Subsystem), Social Security Administration, Internal Revenue Service, and National Center for Health Statistics (National Death Index). For the interview component of the VES, an attempt was made to locate arid contact all veterans not identified as deceased by the above sources. Through this method, vital status was confirmed for 93.6% of Vietnam veterans arid 91.9% of those who served elsewhere. Entry and military service �characteristics of Vietnam veterans whose vital status was uncertain were similar to those of non-Vietnam veterans with uncertain vital status. All men with uncertain vital status were assumed to be alive at the end of 1983. For all but nine of the 446 men reported to have died after discharge, copies of official death certificates were obtained. The other nine deaths were confirmed through other sources. Underlying causes of death were coded according to both the Eighth and Ninth Revisions'1"-1' ^ of the I.nJ;£mat_i_onal Q.3^As..ific.ati_qn......of.....Diseases ....ID1 by an experienced nosologist at the National ...(C. Center for Health Statistics who had no knowledge of whether the decedent had served in Vietnam. To address limitations of death certificate-based diagnoses, a review panel of two -physicians determined the underlying cause of death, using pertinent medical and legal documents describing the nature and circumstances of each of 426 deaths for which additional information could be obtained. Sources included hospitals, law enforcement agencies, coroners or medical examiners, and private physicians. All causes of death and other significant conditions were coded by the medical review panel according to the Ninth Revision of the I.QQ' T° estimate the influence of substance abuse on mortality in this study, special categories of alcohol- and drug-related deaths were developed, and deaths were so classified by the review panel when appropriate. Analyses Crude death rates were based on person-years at risk since discharge from active duty. An unadjusted rate ratio (RR) was formed by dividing the crude mortality rate among Vietnam veterans by that for non.....Vietnam veterans. The 95% confidence intervals (CIs) for each RRs were computed usiricj the procedures described by Laird and Oliver.''' The Cox proportional hazards regression model8 was used to consider possible effect modification and confounding by selected covariates. Adjusted RRs were obtained from Cox models stratified on primary MOS and enlistment status (volunteer or draftee), arid adjusted for other selected covariates. Two MOS categories were used in the model and can be described roughly as "tactical" (infantry, armor, artillery, arid combat engineers) arid "other" (all other specialties). Additional covariates considered in the Cox models, chosen on the basis of their associations with mortality in the univariate analyses, ^ included race, age at discharge, Army General Technical Test score (a general aptitude test taken at entry into the service), pay grade at discharge, and year of discharge. Comparisons were also made between the mortality experience of each veteran cohort and that of the US male population utilizing Morisori's software package.9 Results are expressed as a standardized mortality ratio (SMR) adjusted for age, race, and calendar year. �RESULTS There were some differences in both pre induction and military service characteristics between the Vietnam and non-Vietnam cohorts (Table 1). In general, however, the preinduction differences were small, Differences in some of the military service characteristics, such as a greater percentage of Vietnam veterans with tactical MOS classifications arid infantry unit assignments, reflect wai— related military requirements in Vietnam. Over the entire follow-up period, the mortality among Vietnam veterans was 17% higher than the rate among non-Vietnam veterans (Table 2). Most of this excess, however, was due to higher mortality among Vietnam veterans during the first five years of follow.....up (RR, 1.45; 95% CI, 1.08 to 1.96). By the sixth year, the two cohorts had similar mortality rates that remained so through the end of follow-up (RR, 1.01; 95% CI, 0.79 to 1.28). Because of the variation in relative mortality with time, time— specif ic results will be presented when appropriate . To determine whether the association between Vietnam service and mortality was uniform or varied across different subgroups of veterans, separate analyses were done within these groups (Table 3). Although the results indicated a consistent pattern of elevated mortality associated with Vietnam service limited to the first five years after discharge, there was some variation in the RR among various subgroups of veterans. Tests for effect modification, however, were not statistically significant (P>.05). Possible confounding by selected covariates (age at discharge, race, Army General Technical Test score, pay grade at discharge, and year of discharge) was assessed by including them in stratified Cox models. In the first five years after discharge, adjustment for these characteristics increased the RR to 1.58 ( . % CI, 1.16 to 2.14). In the later follow-up period, adjustment 95 changed the RR to 1.04 (95% CI, 0.81 to 1.33). Results from the Cox model also indicated that Vietnam service had a greater effect on mortality among those who were discharged before age 2.1. years than to those discharged at age 21 years or older (P=.02) and among veterans discharged before 1970 compared with those discharged during 1970 or later (P=.05). Death Certificates. -• Only four major cause— of-death categories contained sufficient numbers of deaths for formal analysis (Table 4). Rates for Vietnam veterans appeared to differ from rates for non-Vietnam veterans in two of these categories: diseases of the circulatory system (51% decrease in the death rate) and external causes of death (25% increase in the death rate). The deficit in circulatory disease deaths was evident regardless of time since discharge and type of circulatory disease. There were no differences in mortality from mental disorders or neoplasms. Deaths from specific types of neoplasms were too few for meaningful comparisons. The excess in external causes of death is examined further in Table 5. Vietnam veterans had significantly higher mortality from motor vehicle accidents (MVAs) (RR, 1.48; P=.03) than non-Vietnam veterans. The excess was most pronounced in the first five years after discharge from active duty �(RR, 1,93; P-.Ol). After that period, MVA rates were similar in the two cohorts (RR, 1.16). The RRs for suicide and homicide were somewhat increased in the early postdischarge period but not in the later years of follow-up. Accidental poisoning deaths (mostly by drugs) were substantially more common among Vietnam veterans than other veterans over the entire follow up period (RR, 2.47; P-.08). No postservice deaths were attributed to war injuries (ICD-9, E990-E999). Adjustment for selected covariates did riot materially alter the pattern of cause-specific mortality, except for suicide in the earlier follow-up period, where the adjusted RR was 2.59 (95% CI, 1.09 to 6.17). Medical Review Panel, ••••• The medical review analysis was based on 233 (95%) of Vietnam veteran deaths and 193 (97%) of deaths among non Vietnam veterans. On average, slightly fewer supplemental medical and legal records were recovered for each Vietnam veteran death (mean, 3.3 records) than for each non-Vietnam veteran death (mean, 3,7 records). Overall agreement between the medical review panel diagnoses and death certificate diagnoses, however, was good (82%; kappa = 0.79) and did not differ significantly between the two veteran cohorts. The medical review analyses indicated differences in only two ICID 9 categories that were not evident from the death certificate analysis. The RR for mental disorders from the medical review panel analysis was 2.85 (95% CI, 0.92 to 8.82) compared with 0.95 from the death certificate analysis. Most mental disorder deaths were related to alcohol or drugs and are examined in more detail in Table 6. The RR for neoplasms based on medical review panel diagnoses was 1,21 (95% CI, 0.55 to 2.66) compared with 0.82 based on death certificates. This difference was primarily the result of two deaths from neoplasms among non Vietnam veterans being reclassified elsewhere by the medical review panel and the opposite occurrence among Vietnam veterans. There was no particular type of neoplasm in excess in the Vietnam cohort. Supplemental information collected for the medical review allowed further exploration of MVA deaths. Single- and multiple-vehicle crash deaths as well as daytime and nighttime events all occurred more frequently among Vietnam veterans during the early postdischarge period. Vietnam veterans had a modest excess of which were alcohol-related MVA deaths during this period (RR, 1.35; 95% CI, 0,60 to 3.04). Alcohol-related natural causes of death were too few for formal analysis in the early postdischarge period, but the RR in the later period showed no difference between the two groups (Table 6). A modest elevation in alcohol-related traumatic deaths among Vietnam veterans was limited to the first five years after discharge. For drug-related deaths, the RR was slightly elevated during the early postdischarge period and more elevated during the later follow up period. Although the number of deaths is too small for formal analysis, further refinement of the later follow-up period suggests the upward trend in drug related mortality continues into the most recent years. Further, Vietnam service seems to be associated with an especially high rate of drug-related mortality among those drafted into service, those whose jobs were in tactical or combat operations, and those who served during 1969. �Again, as in the death certi Ficate results, adjustment for selected covariates increased the RR for suicide in the early follow-up period to 2.56 (95% CI, 1.11 to 5,87), No other RR presented in the medical review results was materially altered by adjustment. Gener.aJ Both groups of veterans had a significantly lower overall mortality rate for "natural causes" than the general US male population (Table 7). During the first five years after discharge, Vietnam veterans had a higher death rate from external causes, whereas non-Vietnam veterans have a lower rate relative to the general, population. In the later time period both groups of veterans showed a similar deficit in external cause mortality. Although these data are not presented in Table 7, over the entire follow.....up period, Vietnam veterans had a striking deficit of circulatory disease deaths (SMR, 0,48; 95% CI, 0.25 to 0.85), whereas non.....Vietnam veterans had only a slight deficit (SMR, 0.87; 95% CI, 0.54 to 1.34). �COMMENT The intent of our study was to assess the effect of military service in Vietnam on subsequent mortality. The "Vietnam experience" includes a wide range of possible health influencing factors such as psychological stresses associated with war, infectious diseases prevalent in Vietnam and exposure to the herbicide Agent Orange. The modest excess of deaths among Vietnam veterans was concentrated in the first five years after discharge, where all-cause mortality was 45% higher than in the non-Vietnam group, External causes accounted for most of this increase, with the largest elevation in relative mortality due to MVAs. A more detailed examination of MVA deaths did not indicate any particularfactor that could explain the overall excess in Vietnam veterans. The increased risk did not appear to be related to elevated blood alcohol levels at the time of death, and the excess was apparent across various types of MVAs. Drug-use information on MVA victims was limited; the medical review panel identified only one drug-related MVA death. Suicide and homicide also occurred somewhat more frequently among Vietnam veterans during the early postdischarge period. Accidental poisoning deaths (mainly by drugs) were elevated throughout the entire follow-up period, although the number of such deaths was small. By the sixth year after discharge, both all-cause and external-cause mortality among Vietnam veterans had fallen to levels found in the non-Vietnam group, except for deaths due to drug abuse, where the rate was actually higher in the more recent follow-up period. These findings are unlikely to be the result of a serious flaw in study design or execution. The study groups were selected in a manner that minimized differences in their preservice characteristics; vital status was verified for 93% of all participants; death certificates were recovered for 98% of deaths; and supplemental medical and legal documents, which allowed an independent assessment of cause of death by standardized criteria, were obtained for 96% of deaths. Moreover, the pattern of excess deaths was remarkably consistent across various subgroups of Vietnam veterans and appears not to be an artifact of confounding. It should be noted, however, that sample size constraints limited our ability to detect excesses in mortality in subgroups of veterans and for the less frequent causes of death in this relatively young group. Our findings can be viewed against the results of five previous mortality studies of Vietnam veterans. Four10""1^ are proportional mortality studies, which may not be directly comparable with this study because of incompleteness of data and inherent limitations of this analytic method. 1 ^ The fifth, a cohort study of Australian Vietnam veterans, is very similar in design to our study and thus is a more appropriate comparison.^ The US Air Force "Ranch Hand" study is not discussed here, since its principal concern is the adverse health effects of herbicide exposure in a unique group of veterans.16 The 30% excess of external cause mortality among Australian Vietnam veterans relative to non-Vietnam veterans is similar to what is seen here.^ Although the Australian investigators did riot examine external cause mortality by time since discharge, there was a suggestion of a decline in relative �mortality with increasing time since discharge in their all-cause mortality results. Deaths from suicide, homicide, and accidental poisoning also occur more frequently among their Vietnam veterans, Mortality from MVA was not elevated overall, but an excess in the youngest age group was suggested. Findings for external-cause mortality from the four proportional mortality studies are not consistent with our results. A nonsignificant increase in deaths from MVA among Vietnam veterans relative to other veterans was present in only one of the studies.^ The relative frequencies of suicide and homicide were not unusual, although there was one instance of a nonsignificant increase in both of these causes .•*••'• Accidental poisonings were analyzed in only one of the studies, and the result was a small, nonsignificant elevation among Vietnam veterans.^ Australian Vietnam veterans had an excess of deaths from al.cohol--reJ.ated natural causes, but no increases in deaths from alcohol related external causes or drug-related mortality. These discordant findings may reflect differences in in-service use of drugs and alcohol by American arid Australian troops. In contrast to the reportedly heavy use of illicit drugs by American troops in Vietnam, I'7'-'-^ drug use among Australian soldiers was reported to be uncommon and alcohol use, heavy.^ Our finding of increased mortality from drug-related causes in the later follow-up period was not consistent with surveys indicating little or no influence of Vietnam service on postdischarge drug use. ^ ^ ' The lower mortality from cardiovascular diseases (CVDs) among Vietnam veterans is surprising. The lower rate might be explained as a by-product of some kind of selection process taking place in the final assignments to Vietnam, which might correlate with cardiovascular fitness established during basic or advanced training. Indeed, the SMR results suggest that the CVD deficit may be the result of an unusually high rate in the comparison group; CVD mortality in the non-Vietnam cohort was only slightly below that of the general population, whereas we expected it to be much lower.20 A completely opposite result was found in the Australian study, where CVD mortality was 90% higher among Vietnam veterans than non-Vietnam veterans.^ Various indexes of CVD morbidity measured in the other components of the VES may help in further elucidating the mortality findings. In the Australian study most of the excess in all-cause mortality among Vietnam veterans was confined to members of the Engineer Corps.^ This pattern was not found in the present study, but the number of men assigned to engineer units was relatively small. Furthermore, possible differences between US and Australian engineering units in training and composition may make this comparison inappropriate. The excess in postservice external-cause mortality among Vietnam veterans seen here could be due to some peculiarity in the assignment of men to Vietnam whereby those who were sent tended to have characteristics that placed them at increased risk of dying from external causes after discharge from active duty. This explanation appears doubtful for several reasons. Most importantly, if Vietnam veterans tended to have an inherent predisposition to traumatic events, it might be expected to manifest itself in increased mortality from such causes throughout the period of observation, not just in the first few years, as observed here. �10 Alternatively, our findings may reflect consequences of the unique environment arid experience of serving in Vietnam and returning to an unsupportive and sometimes hostile climate in the United States. This explanation might seem plausible given the unique military and social environment of the Vietnam conflict. However, the present results are similar to previous observations of postservice mortality in Army veterans. Indeed, increased mortality from external causes has been seen in two groups of World War II combat veterans and one group of Korean War combat veterans, when compared with the general US male population, even though older men and officers were included. 21 In contrast, broader cross-sections of World War II veterans, including combat and noncombat groups, showed no difference or even a deficit in postdischarge traumatic deaths,20,21 as (-j-jd non-Vietnam veterans in our study. Although the influence of factors specific to the Vietnam experience cannot be completely ruled out, our findings and previous studies suggest that the postservice excess of traumatic deaths among Vietnam veterans is probably due to unusual stresses endured while stationed in a hostile fire zone. The mortality assessment of Vietnam veterans presented here is an incomplete evaluation of the health experience of this group. Additional data on the present and past health status of living Vietnam veterans will be forthcoming from the health interview and medical, psychological, and laboratory evaluation components of the VES. Because this group of veterans has not yet reached the age where chronic diseases have an important impact on mortality, continued monitoring of mortality among VES participants may provide ad d i t i o na1 i n s i g h t s . �11 ACKNOWLEDGEMENTS The VES Mortality Study Staff consisted of Coleen A. Boyle, PhD, Pierre Decoufle, ScD, Robert J. Delaney, Frank DeStefano, MD, Melinda L. Flock, MSPII, Martha I. Hunter, M. Riduan Joesoef, MD, PhD, John M. Karon, PhD, Marilyn L. Kirk, Peter M. Layde, MD, Daniel L. McGee, PhD, Linda A. Moyer, RIM, Daniel A. Pollock, MD, Philip Rhodes, MS, and Robert M. Worth, MD, PhD. Many other individuals and organizations provided invaluable support to the study. These include The Agent Orange Working Group and its Science Panel; Army Reserve Personnel Center, US Army and Joint Services Environmental Support Group, Department of Defense; MPRC, National Archives and Records Administration; General Services Administration; Veterans Administration; National Center for Health Statistics; Social Security Administration; Internal Revenue Service; National Academy of Sciences; other staff members of the CDC, and outside consultants who contributed their unique expertise. A more comprehensive report of the findings from this study has been published in the form of a monograph by the CDC, Copies can be obtained from the CDC, Atlanta, GA 30333. �12. REFERENCES H e . a lt-h !^t.99.ra!M .il^Grision and Improvement Act of 1979, Law96-~15'l.......( M R......3li?2)"......6e"c~20"........1979",.......93......STAT ...... ~ 2. Public Veterans' Health _......___......_^ , and . _ Business _ _ Act of 1981, „ . . _.....— —.......Care,, Tra i n i rig....._......._Small ......„_....... Loan . .......... _.. „ . _ _ 3 , [r°.t..9I t°L iEMi!M£l9<3.ic Studies of the Health of Vinetnam yc|tejrans . !...-9£.. Atlanta, Centers for Disease Control, November i.983. . ... .. c3 r Disease Control, 1987, States, rev 8, Welfare, 1967. PUS publication .1.693. i.ec! for Use in_..the Unitecl US Dept of Health, Education, and ..9f ..i...l0t r n a t i o n a 1 S t a t i s ti. c a 1 C la s s if i c a t i o n o f D i s e as e s , ... ..be,...e _.a!.ldjl§.y.?..§A...9f P.?a.th, rev 9. Geneva, World Health Organization, 97..................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . " 7. Laird l\l, Oliver D; Covariance analysis of censored survival data using log-linear analysis techniques . .J_Am Stat Ass_oc 1981; 76 : 231.....2.41 . 8. Cox DR, Oakes D: Ajlollisi.s_.....9.f. itlC.y,i.V..al Q.a.t.a.- London, Chapman and Hall, 1984. 9. Monson RR: Analysis of relative survival and proportional mortality. s. 1974; 7: 325-3 32. Qomg 10. Anderson HA, l-lanrahan LP, Jensen M, et al: W..ij.conj_ij;i^V]i^^nami Veteran Mortality/ S.ty_dy . Madison, Wise, Wisconsin Division of Health, 1985. 11. Lawrence CE, Reilly AA, Quickenton P, et al: Mortality patterns of l\lew York State Vietnam veterans, Am_J.....PubllS.......Health 1985; 75 : 277-2.79 . 12. Kogan MD, Clapp RW: Mortality Amoj'ig Vietnam yeterans; in..Massiacjui]Sj3t1;;_si, l Z 2 i 9 3 . Bos ton , M ! a h s ! t l.r.8 a7TVe:^ ....... •——••- 1 3 . HO ime s AP : Charleston, W VA, West Virginia Health Department, 1986. 14. Wong 0, Decoufle P: Methodological issues involving the standardized mortality ratio and proportionate mortality ratio in occupational studies. 1 9 8 2. ; 2 4 : 2, 9 9.....3 04 , 15. Fett MJ, Dunn M, Aderia MA, et al: .CL^ ...^ Ay.st;ra_l.ian_ Vete_ra_ri_3......Health......S_tyd_i_e_sj:......The . . . . . ^ St_u_(iy_ of Q9b9C a a a e - 6 L t b ? ! ! . . £ s . . t Re po r; t . Canberra, A u s t ra 1 i a , . . . . !!9L<.i.l Australian Government Publishing Service, 1984. �13 16. Lathrop GD, Moynahan PM, Alfoanese RA, et al: £roj.ectRanch Hand II. An ! [ i i . 5 i . 9 i I D 5 ! ^ l : i . i £ °f...ii?!.l?.i.tb...JLffl;i!.£i5 illD...LCQiCS.® E§lisonnej. iE^!!.9l£c ..i..l.3^iD Foil owing Ex.J2£l^ureto..JJ..Ii-^rM.9..M£.?....;. !3<as£l.ine.!J£!r.^£il.tl......S..t.y..dj/ !l§..s.y.lt_s. San Antonio, Tex, Brooks Air Force Base, US Air Force School of Aerospace Medicine, 1983. 17. Ritter C, Clayton RR, Voss ML: Vietnam military service and marijuana use, Am J D.ru_g_Alcoh£ 1__Abuse 1985; 11: 119•-130. 18. Robins l...l\l, Helzer JE, Davis DH: Narcotic use in Southeast Asia and afterward . .Arch .Gen Psychiatry 1975; 32 : 955 961. 19. Yager "I", Laufer R, Gallops M: Some problems associated with war experience in men of the Vietnam generation. A.r_cJ;i__Gen Psjf£hia_t_r\f 1984; 41:327-333 . 2.0. Seltzer CC, Jablon S: Effects of selection on mortality. Am J Epjidemio1 1974;!00:36 7-372. 21. Wefzger MD: Follow up studies of World War II and Korean War prisoners. I. Study plan and mortality findings. Am J_.E£_ideipi_o_l 1970; 91: 123-138 . �VIETNAM-ERA ARMY PERSONNEL R E C O R D S FILED AT NPRC BETWEEN SEPT 1964 AND JUNE 1977 Approx. 4,900,000 RANDOM SAMPLE 48,513 QUALIFIED FOR STUDY 18,581 RECORDS NOT FOUND 1,355 Ll NOT Q U A L I F I E D 28,577 NON-VIETNAM 9,023 DIED ON ACTIVE OUT 234 DIED ON ACTIVE DUTY 34 VIETNAM COHORT 9,324 NON-VIETNAM COHORT 8,989 Selection of s t u d y g r o u p , NPRC indicates N a t i o n a l Personnel Records Center; a s t e r i s k , excluded f r o m s t u d y ; and dagger, eighty-three percent (N=194) of a c t i v e d u t y deaths among V i e t n a m veterans were due to war-related activities. �fable 1. Differences in Selected Characteristics Between Vietnam and Won Vietnam Veterans at Entry Into Service and During Military Service Character:!, stic Vietnam (N=9324) Won-Vietnam (N=8989) _Ate_ntry_...into service Race/' (% white) 86.8 86.5 Age at entry, (mean) 20.3 20.5 Enlistment status/' ( draftee) % 63.7 65.6 Year of entry into service, (% before 1969) 72.1 60.6 103.1 105.5 Army General Technical Test score (mean, scaled to 100) During military service Primary mi 1 itary occupational specialty"1" % tactical operations 34 .3 27, ,4 Type of unit, % infantry 26..6 14,.6 Type of discharge, % honorable 97, 2 , 91, 0 Pay grade at discharge, % E4 or E5 88,,5 79, ,8 Year of discharge, % before 1970 ,1 48, 44. 6 Race and enlistment status were the only two characteristics that were not significantly different (P>.05) between the Vietnam and the non-Vietnam groups, + The job specialty for which the man was trained in the Army. �Table 2, Years Since Discharge Number of Deaths, Person-Years, and Death Rates Among Vietnam and Won Vietnam Veterans and Unadjusted RRs by Years Since Discharge From Active Duty, 1965--1983'x' 6-1- All years V i §t na m Person-years 110 <5 l\lo. of deaths _ 46,350 2.4 73 44,747 1.6 1.45 1.08 1.96 136 81,547 1.7 127 76,582 1.7 1.01 0.79-1.28 246 127,897 1.9 200 121,32.9 1.7 1.17 0.97-1.41 Rate'1" l\lo. deaths _N o n;-V let n am. Person-years Rate4' RR indicates rate ratio; CI, conPidence interval. "'" Crude death rate per 1000 person years. RR 95% CI �Table 3, Number of Deaths Among Vietnam and Won Vietnam Veterans and Unadjusted Rate Ratios (RRs), by Selected Characteristics and Years Since Discharge from Active Duty, 1965-1903 Y e a r s S i nee D i s c h a r < From Active Duty 30 <5 All years 6-1- Characteristic 'K' No. RR No. RR No. RR Race White Won white 146 37 1 .50 1 .30 193 70 0.99 1 .07 339 107 1 .18 1 .14 Enlistment status Volunteer Draftee 79 104 1 .09 1 .80 11 1 152 0 .91 1 .06 190 256 0 .98 1 .31 97 83 1 .42 l .43 141 1:1.9 0.90 1 .07 238 202 1 .08 1 ,2.0 63 120 l .'19 l ,58 89 174 1 .04 0,97 152 294 1 . 10 1. 1 8 47 136 l .83 l ,41 42 221 0.67 1 , 10 89 357 1 .14 1 .2.1 125 58 l .50 l . 95 183 80 1 .10 1 .16 308 138 1 .24 1 .44 79 2.05 122 0.96 201 1.27 104 1.16 141 1 .06 2.45 1. 10 GT test score"'" < .1.00 100+ Duty MOS + Tactical Other Age at discharge 21+ Pay grade at discharge E4 - E5 El - E3 Year of discharge <1970 1970-1- There was no evidence of statistically significant effect modification for any of these characteristics (P>0.05). Army General Technical Test (GT) scores were missing for six veterans. + Determined from principal military occupational specialty (MOS) held while on tour of duty. �Table 4. Number oP Deaths by Cause (from Death Cerlif'icato), Death Rates Among Vietnam and Won Vietnam Veterans, and Unadjusted RRs, 1965 190;i'K Underlying cause of death (ICD 9)+ Infectious and parasitic diseases (001 139) Vietnam No. Won Vietnam Rate? No. Rate + RR§ 95% CI 1 0.8 1 0.8 12 9.4 14 11.5 0.82 0.38-1.76 Mental disorders (290-319) 7 5.5 7 5.8 0.95 0.3 3 --2. 70 Diseases of nervous system (320 389) 2 1.6 J. Diseases of circulatory sy s tern (390 459) 12 9,4 23 19.0 0.49 0.25--0.99 Diseases of respiratory system ' (460 519) 5 3.9 4 3.3 Neoplasms (140 239) Diseases of digestive system (520-579) 3.9 Diseases of genitourinary system (580-611) 0.8 ri ft \J , O 3.1 Congenital anomalies (740-759) ! 2.5 0.8 �Table 4. Number of Deaths by Cause (From Death Certificate), Death Rates ftrnong Vietnam and Won.....Vietnam Veterans, and Unadjusted R R s , 1965.....1903* (continued) Symptoms, signs, and :i. 1 !-•d e f i ne d c o n d i t i o n s (780.....799) External causes (E800-E999) 0.8 1.6 188 147.0 143 117.9 1.25 1.00.....1.55 l\lo death certificate \f. RR indicates rate ratio; CI, confidence interval, + ICD 9 indicates International Classification of Diseases, ninth revision. l\lo deaths were categorized to diseases of blood and blood-forming organs; endocrine, metabolic or nutritional diseases; diseases of the skin; or diseases of the rnusculoskeletal system. Therefore, these categories are not shown. T Crude death rate per 100,000 person-years. § If the total number of deaths for a cause-of-death category in both groups combined was less than ten, RRs are not shown. �Table 5. Number of Deaths From Specific External Cause:; (K'rom Death Certificate) Among Vietnam and Won Vietnam Veterans and Unadjusted RRs, by Years Since Discharge From Active Duty, .1.96.5-1983*' External cause of d e <5 a t Years Since Q_i_3charge From Acti ye Duty+ 6+ h ~ ~ Motor vehicle accident (E810--E825, E929.0) 66 1.93 1.16--3.22 67 Accidental poisoning (E8SO-E869, E92.9.2) 11 1.69 0.49 5.77 Other , accidents+ 23 1.05 Suicide (E950 E959) 25 Homicide (E960 E969) 18 Undetermined intentional:!, ty (E980 E989) 4 All Years 1.16 0.72-1.87 133 1.48 1.04 2.09 7 - - 18 2.47 0.88 6.92 0.46 2.37 39 0.89 0.48 1.67 62 0.95 0.58 1.56 1.72 0.76-3.88 32 0.64 0.32 1.30 57 0.98 0.58 1.65 1.52 0.59 3.91 33 0.78 0.39-1.55 51 0.99 0.57-1.71 - 6 - 10 3.79 0.81-17.87 *' RR indicates rate ratio; CI, confidence interval; ICO-9, International Classification of Diseases, ninth revision. "'" Time-specific RRs are not presented for categories with less than 10 deaths in both Vietnam and non-Vietnam groups combined. £ Includes ICD-9 categories E800 to E807, E826 to E849, E870 to E928, E92.9.1, E929.3 to E929.9, E930 to E949, E970 to £978, and E990 to E999. �"fable 6. Number of Deaths From Alcohol and .Drug-Related Causes (From Medical Review) Among Vietnam and Mori-Vie tnam Veterans and Unadjusted RRs, by Years Since Discharge From Active Duty, 1965.....1983* ............... Years_ S.ln£g_P_i^_chair3_e From Active Duty <5 6-1fill Years Cause of death o Alcohol.....related natural causes"1" 5 ..... Alcohol.....related traumatic causes t 42 1,29 Drug related causes§ 18 1.2.1. * + ~ ••••• " 25 0.87 0.40.....1.90 30 0.70-2.37 61 1.04 0.63-1.71 103 0.48 3.06 22 2.01 0.82-4.94 40 1.08 0.53-2.22 1.13 0.77.....1.67 1.58 0.83-3.00 RR indicates rate ratio; C.I, confidence interval. Includes the following diagnoses determined to be the underlying or contributing cause of death: alcoholic psychoses (291.0 to 291,9); alcohol dependence syndrome (303); nondependent alcohol abuse (305.0); alcoholic polyneuropathy (357.5); alcoholic cardiomyopathy (42.5.5); alcoholic gastritis (535.3); alcoholic liver disease (571.0 to 571.3); and excessive blood level of alcohol (790.3). + Includes deaths in which the underlying cause is accidental poisoning by alcohol (E860.0 to E860.9) or any traumatic death (E800--E989) in which either nondependent abuse of alcohol (305.0) or excessive blood level of alcohol (790.3) is a contributing cause of death. § Deaths for which one of the following drug-specific diagnoses is the, underlying or contributing cause of death; drug psychoses (292.0 to 292.9); drug dependence (304.0 to 304.9); nondependent abuse of drugs (305.2 to 305.9); accidental poisoning by drugs (E850.0 to E850.2, E8S0.5, E850.8, E851-E8S4, E855.1 to E855.2, E866.6 and E869.0); suicide by drugs (E950.0 to E950.5); and poisoning by drugs, intentionality undetermined (E980.0 to E980.5). �Table 7. Years since discharge Observed and Expected Numbers of Deaths by Cause Among Vietnam and Mori Vietnam Veterans and SMRs, y by Years Since Discharge From Active Duty, 1965--1983 Cause of De ath+ (ICOA--8) Vietnam Won Vietnam 16 23 . 4 0.68 0.39-1. 11 13 24 . 2 0 . 54 0.29 0.92 Observed Expected SMR 95% CI 92 72.5 1 . 2.7 1.02-1.56 55 69.4 0.79 0.60 1.03 All natural causes (000 796) Observed Expected SMR 95% CI 38 65.8 0.58 0.41-0.79 39 63.4 0.62 0.44-0.84 Observed Expected SMR 95% CI 96 .1.02 . 7 0.93 0.76-1.14 88 96.6 0,91 0.73-1.12 All natural causes (000 796) Observed Expected SMR 95% CI 51 90.0 0,57 0.42 0.75 55 86.8 0.63 0.48 0.82 External causes (E800-E999) All years Observed Expected IJI SMR 95% CI External causes (E800--E999) 6+ All natural causes (000 796) External causes (E800 E999) <5 Observed Expected SMR 95% CI 188 175.2 1 . 07 0,93-1.24 143 166.0 0.86 0.73-1.01 SMR indicates standardized mortality ratio; CI, confidence interval; and ICDA 8, International Classification of Diseases, Adapted for Use in the United States, eighth revision. "'" Excludes nine deaths (seven Vietnam, two non Vietnam) for which death certificates were not recovered. T Expected number is based on the mortality rates among US men, standardized for age, calendar year, and race. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 064 Folder The folder containing the original item. 1742 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Source A related resource from which the described resource is derived JAMA Date A point or period of time associated with an event in the lifecycle of the resource February 13 1987 Title A name given to the resource Postservice Mortality Among Vietnam Veterans: The Centers for Disease Control Vietnam Experience Study Subject The topic of the resource Vietnam Experience Study mortality trends veteran psychological health ao_seriesIII