Original Research

Health Care Use Among Iraq and Afghanistan Veterans With Infectious Diseases

Qualified veterans were no more likely to take advantage of health care services after the VA presumptive infectious disease determination streamlined the qualification process.

Author and Disclosure Information



In 2010, the VA gave presumptive status to 9 infectious diseases that are endemic to southwest Asia and Afghanistan. This classification relieves the veteran of having to prove that an illness was connected to exposure during service in a specific region. The purpose of this secondary analysis is to determine the impact of the presumptive infectious disease (PID) ruling by the VHA by assessing the pre- and postruling health care use of veterans diagnosed with one of the infectious diseases.


As of December 2012, 1.6 million veterans who served in Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) were eligible to receive VHA care. The number of combat related injuries is commonly released to the public, but figures related to noncombat illnesses, such as infectious diseases, are reported less frequently. Sixteen percent of the 899,752 OEF/OIF/OND veterans who received VHA care through December 2012 were diagnosed with an infectious disease.1

Long-term disability stemming from any type of illness, disease, or injury is potentially compensable through VA disability compensation programs. The disability must be service-connected for a veteran to receive compensation; that is, it must be determined to be a likely by-product of “an illness, disease or injury incurred or aggravated while the soldier was on active military service.”2 The benefit application process takes time, because service connection must be established prior to determining entitlement to disability benefits.2

Congress mandated that the VA determine the illnesses that justified a presumption of service-connection based on exposure to hazards of Iraq and Afghanistan service. In response, the VA requested that the Institute of Medicine (IOM) conduct a review of the scientific and medical literature to determine the diseases related to hazards of service in southwest Asia and Afghanistan.

In a 2006 report, the IOM identified several diseases that were relevant to and known to have been diagnosed among military personnel during and after deployment in these regions. On September 29, 2010, responding to the report, VA added brucellosis, Campylobacter jejuni, Coxiella burnetti (Q fever), malaria, Mycobacterium tuberculosis (TB), nontyphoid Salmonella, Shigella, visceral leishmaniasis, and West Nile virus to the list of presumptive illnesses.3 The final rule was published in the Federal Register and is codified in 38 C.F.R. § 3.317(c).4

Classifying an illness as presumptive relieves the veteran of having to prove that their illness was connected to exposure during service in a specific region, “…[shifting] the burden of proof concerning whether a disease or disability was caused or aggravated due to service from the Veteran to the VA.”5 Based on latency periods, 7 of the 9 diseases must manifest to a > 10% degree of disability within a year of separation from a qualifying period of service. No date boundary was set on the period of presumption for TB or visceral leishmaniasis.6


Veterans are eligible for VHA care when they separate from active-duty service, or they are deactivated at the completion of their reserve or guard tour. Veterans eligible for health care were identified using a roster file from the DoD Defense Manpower Data Center (DMDC). This file also contained demographic (eg, sex, race) and service (eg, branch, rank) information. Inpatient and outpatient health care data were extracted from the VHA Office of Public Health’s quarterly files.

Study Population

OEF/OIF/OND veterans whose roster file records indicated a deployment to Iraq, Kuwait, Saudi Arabia, the neutral zone (between Iraq and Saudi Arabia), Bahrain, Qatar, The United Arab Emirates, Oman, Gulf of Aden, Gulf of Oman, waters of the Persian Gulf, the Arabian Sea, the Red Sea, and Afghanistan were eligible for the study. These veterans had to have separated from service between June 28, 2009, and December 29, 2011, and sought VHA care within a year of separation. Veterans with a human immunodeficiency virus diagnosis, an illness that is highly correlated with TB, were excluded from the study, as were deceased and Coast Guard veterans.

The final study population of 107,030 OEF/OIF/OND veterans was further divided into 2 mutually exclusive study groups by assessing the ICD-9-CM code in the first diagnostic position. The first group, the PID group, was given priority. To be included in this group, a veteran must have been diagnosed with ≥ 1 of the following presumptive diseases within a year of separation (ICD-9-CM codes): Brucellosis (023), Campylobacter jejuni (008.43), Coxiella burnetti/Q fever (083.0), malaria (084), nontyphoid Salmonella (003), Shigella (004), or West Nile virus (066.4). For TB (010-018) and visceral leishmaniasis (085.0), a diagnosis could occur any time after separation.


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