The Pre- and Post-deployment Health Assessment forms try to address the first and third aims. 2. Obtaining accurate, timely, and complete information at baseline. Although the cohort of deployed personnel is inherently well defined, obtaining accurate, timely, and complete information on all of the participants has not been achieved despite strenuous attempts to do so. Recent reports from the Army Medical Surveillance Activity (AMSA) highlighted some of the deficiencies of the recent experience in using the Post-deployment Health Assessment forms (MSMR 2002a, MSMR 2002b). Only about one-third of completed pre-deployment forms could be matched with post-deployment forms. The information was incomplete and the question on exposure concerns, in particular, seemed to be misunderstood by many of the respondents. All positive responses about health concerns should be followed up with more detailed interviews and medical examinations but apparently are not. Obviously, it would be desirable if all of the forms could have been linked to records of sites of deployment and specific exposure information obtained during deployment. This would eliminate biases in recalling putative hazardous exposures if sought after the occurrence of illness. 3. Assembling comparison groups. The key analytic comparisons to be made are of subsequent health events among personnel with different histories of exposures. In addition to the exposure information obtained for deployed troops, it would be desirable to assemble comparison groups among military personnel who were not deployed and among reserve units that were not activated. These would allow, for example, estimates of the health impact of deployment among those without specific exposures. 7 4. Active and passive surveillance. The ascertainment of symptoms and illnesses after discharge is a formidable task and would require a great deal of effort and resources. Passive surveillance, the ascertainment of health outcomes from routinely collected administrative data might be possible for veterans using the VA health systems but would be extremely difficult for those using private sector health care providers. A system of active surveillance, periodic contact with the veterans, would be more feasible but presents major challenges. Contact by telephone or mail requires maintaining an up-to-date roster of addresses and phone numbers. Obtaining the longterm cooperation of the veterans, following up on positive responses, and providing feedback to the participants would be important components of the tracking system. It will be important to clearly explain the purposes of the study and to provide assurances of confidentiality. 5. Disease definition. Most epidemiologic studies have a relatively clear concept of the outcomes they are concerned with and go to great lengths to establish standards for defining these outcomes. One of the lessons learned from previous deployments is that new symptoms and diseases may occur following deployment that do not fit into current classification systems. These may involve physical manifestations as well as psychological ones. It is important that methods be in place to capture these emerging conditions and analyze them properly. Concerns have also been voiced about possible effects on the families and progeny of the veterans from possible residual contamination after discharge or from genetic effects of noxious exposures. 6. Medical records. Most of the expert committees stressed the importance of upgrading the medical record keeping capacity of the surveillance system. Methods must be created to obtain information in real time in the field, transfer it to a centrally maintained data repository, and link the information to individual level records. Quality control measures must be in place to assure that all records are accounted for, that individual items are completed, and that editing and coding procedures are adhered to. If systematic deficiencies are uncovered, they should be corrected as soon as feasible. Structural problems in the design of the instruments may be uncovered that require major overhauls. As mentioned earlier, the AMSA analyses revealed a major problem with the question on exposure concerns and recommended major revision of this question. But even such items as sex were not completed for a significant number of forms. An expert group recommended that the pre- and postdeployment health assessment forms be dropped altogether. (IOM 1999b). The Health Enrollment Assessment Review Questionnaire (HEAR) has been suggested as a more useful form. I recommend that the potential of Computer Assisted Personal Interviews (CAPI) be explored as a substitute for paper-and-pencil forms. These may facilitate obtaining more complete and detailed information. Mr. Chairman, I will close my remarks at this point and will be pleased to respond to any questions you may have. Thank you. 10 References Executive Office of the President National Science and Technology Council (NSTC). Presidential Review Directive 5. A National Obligation. Improving the health of our military, veterans, and their families. 1998. IOM (Institute of Medicine), 1996. Health Consequences of Service During the Persian Gulf War: Recommendations for Research and Information Systems. Washington, DC: National Academy Press. IOM (Institute of Medicine), 1998. Adequacy of the VA Persian Gulf Registry and IOM (Institute of Medicine), 1999a. Gulf War Veterans: Measuring Health. Washington, DC: National Academy Press. IOM (Institute of Medicine), 1999b. Strategies to Protect the Health of Deployed U.S. Forces: Medical Surveillance, Record Keeping, and Risk Reduction.. Washington, DC: National Academy Press. 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