2010-24360. Presumptions of Service Connection for Persian Gulf Service

AGENCY:

Department of Veterans Affairs.

ACTION:

Final rule.

SUMMARY:

The Department of Veterans Affairs (VA) amends its adjudication regulations concerning presumptive service connection for certain diseases. This amendment implements a decision of the Secretary of Veterans Affairs that there is a positive association between service in Southwest Asia during certain periods and the subsequent development of certain infectious diseases in response to an October 16, 2006, report of the National Academy of Sciences (NAS), titled “Gulf War and Health Volume 5: Infectious Diseases.” The intended effect of this amendment is to establish presumptive service connection for these diseases and to provide guidance regarding long-term health effects associated with these diseases.

DATES:

Effective Date: This amendment is effective September 29, 2010.

Applicability Date: The provisions of this regulatory amendment apply to all applications for benefits pending before VA on or received by VA on or after September 29, 2010.

FOR FURTHER INFORMATION CONTACT:

Thomas J. Hernandez, Regulations Staff (211D), Compensation and Pension Service, Veterans Benefits Administration, Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, [phone]. (This is not a toll-free number.)

SUPPLEMENTARY INFORMATION:

On March 18, 2010, VA published a proposal in the Federal Register (75 FR 13051) to implement a decision of the Secretary of Veterans Affairs that there is a positive association between service in Southwest Asia during certain periods and the subsequent development of certain infectious diseases. We proposed to revise the title of the regulation to better reflect the content of the regulation and better reflect the authorizing statute (38 U.S.C. 1117); to establish presumptions of service connection for nine infectious diseases becoming manifest within a specified time after service in the Southwest Asia theater of operations or Afghanistan during certain time periods; and to reorganize the regulation to make clear the criteria applicable to each of the presumptions in the regulation.

VA provided a 60-day comment period that expired on May 17, 2010. VA received 18 comments in response to the proposed rule. Of these, five comments expressed general agreement with and support for this amendment. We also received a number of comments from veterans regarding their individual claims for veterans benefits. We do not respond to these comments in this notice as they are beyond the scope of this rulemaking. For the reasons explained in this notice, this final rule contains no changes from the proposed rule.

One commenter suggested that presumptive service-connection be granted for service in Turkey during the Persian Gulf War. The areas considered in the NAS review on which this rule is based were those areas of south-central and southwest Asia generally corresponding to the theaters of operations for the 1991 Gulf war, Operation Enduring Freedom (OEF), and Operation Iraqi Freedom (OIF) as designated by Executive Order. Executive Order 12744 (Jan. 12, 1991); 60 FR 6665 (Feb. 3, 1995); Executive Order 13239 (Dec. 12, 2001). Turkey was not included in that review. We therefore make no change based on this comment. Although the NAS report did not include Turkey in the list of geographic areas where the nine infectious diseases are endemic, we note that no veteran is prevented from attempting to establish service connection on a direct basis by presenting evidence linking the veteran's post-service disability to an infection contracted during service or any other circumstance in service.

One commenter suggested that VA recognize myalgic encephalomyelitis, neurasthenia, multiple chemical sensitivities, and chronic mononucleosis as “medically unexplained chronic multisymptom illnesses” under 38 CFR 3.317(a)(2)(i)(B). The purpose of this rulemaking is to add presumptions for infectious diseases based on findings by NAS in “Gulf War and Health Volume 5: Infectious Diseases.” That report did not address the issue of “medically unexplained chronic multisymptom illnesses.” The comment, therefore, is outside of the scope of this rulemaking.

One commenter recommended that the rule authorize specific treatment for certain diseases. The purpose of this rule is to amend adjudication regulations. Treatment protocols for diseases and disabilities are outside the scope of this regulation, and, outside the scope of 38 CFR part 3. For this reason, we make no change based on this comment.

This same commenter suggested that infections with Mycoplasma species be added to the list of presumptive infectious diseases. The NAS did not include Mycoplasma species among the nine infectious diseases they selected. The recent NAS report specifically focused on scientific and medical literature addressing the incidence of long-term health effects in individuals who had been diagnosed with the primary infectious disease and stated findings with respect to only the strength of the evidence for associations between the primary infectious diseases and the secondary health effects. The NAS evaluated the published, peer-reviewed scientific and medical literature on long-term health effects associated with infectious diseases pertinent to service in Southwest Asia and those known to have been of special concern to veterans deployed to that area. The NAS identified over 20,000 potentially relevant scientific reports, and focused on 1,200 that had the necessary scientific quality.

The NAS initially identified approximately 100 diseases that are known to be endemic to Southwest Asia. Because those diseases would in most instances become manifest within a relatively short time after infection, NAS eliminated from consideration any disease that had never been reported in any U.S. troops within a reasonable period following Persian Gulf deployments. The NAS also eliminated from consideration any diseases not known to produce long-term health effects. On that basis, the NAS limited the list of diseases to the nine that:

(1) Are prevalent in Southwest Asia,

(2) Have been diagnosed among U.S. troops serving there, and

(3) Are known to cause long-term adverse health effects.

NAS did not include mycoplasma infection among the conditions meeting these criteria. NAS addressed mycoplasma infections as an issue of special concern to Gulf War Veterans because some studies have suggested that such infections may be linked to Gulf War Veterans' health problems. However, after reviewing the evidence, NAS concluded that mycoplasma infections are not related to the symptoms reported by Gulf War Veterans. For these reasons, we make no change based on this comment.

One commenter suggested that the time period allowed for presumptive service-connection be enlarged due to possible delays in seeking treatment. The diseases with 1-year presumptive periods are consistent with the general 1-year presumptive period for tropical diseases currently in 38 U.S.C. 1112(a)(2). The diseases with 1-year presumptive periods are also consistent with medical principles, reflected in the NAS report, that those diseases ordinarily would be manifest within a short period following infection. We believe the 1-year presumptive period would be sufficient to encompass infectious diseases that are likely to have resulted from infection during service in the Southwest Asia theater of operations or Afghanistan, and we, therefore, make no change based on this comment.

One commenter was concerned that the proposed rule does not address effective dates for claims previously denied service-connection for a condition that is now presumptively service-connected. The commenter also averred that the effective dates under the proposed rule should be governed by 38 CFR 3.816. The effective date for the addition of presumptive diseases is mandated by statute; it is not at the discretion of the Secretary of Veterans Affairs. Section 1118, title 38, United States Code, provides detailed instructions as to promulgation of regulations relating to presumptions of service connection for illnesses associated with service in the Persian Gulf during the Persian Gulf War. The statute prescribes that when the Secretary determines that such a presumption is warranted, “the Secretary shall * * * issue proposed regulations setting forth the * * * determination.” 38 U.S.C. 1118(c)(2). The Secretary must then “issue final regulations” which “shall be effective on the date of issuance.” 38 U.S.C. 1118(c)(4). Under 38 U.S.C. 5110(g), the effective date of an award based on a new presumption in a VA regulation may not be earlier than the effective date of the new presumption.

Section 3.816 applies only to class members of the United States District Court class-action case Nehmer v. United States Department of Veterans Affairs, No. CV-86-6160 TEH (N.D. Cal.). See 38 C.F.R. 3.816(a)(1) (defining Nehmer class members). Section 3.816 is the result of a stipulation and order in the Nehmer case, and it operates outside the statutory bounds that govern other claims for service connection. Section 3.816 will not apply to any claims under 38 CFR 3.317, and we make no change to the rule based on this comment.

One commenter suggested that examples of possible neurological symptoms for West Nile virus be included in the regulation. Identifying the symptoms or findings that may support a diagnosis of any of the infectious diseases is a factual issue to be addressed based on medical evidence in individual cases and is beyond the scope of this rule. As no examples of symptoms are provided for any other disease, and the commenter did not explain what distinguishes West Nile virus from other infectious diseases such that its symptoms should be listed, we make no change based upon this comment.

One commenter suggested that the term “affirmative evidence” should be replaced with the term “clear and convincing evidence” describing evidence required to rebut the presumption. The general evidentiary standard governing VA factual determinations on issues material to the resolution of claims is set out in 38 U.S.C. 5107. Although § 5107 does not explicitly state an evidentiary standard, VA interprets it to provide a “preponderance of the evidence” standard. “The `clear and convincing' standard is `reserved to protect particularly important interests in a limited number of civil cases.' ” Thomas v. Nicholson, 423 F.3d 1279, 1283 (Fed. Cir. 2005) quoting California ex rel Cooper v. Mitchell Bros.' Santa Ana Theater, 454 U.S. 90, 93 (1981). In veterans' cases, Congress has established specific, heightened evidentiary standards for certain determinations, e.g., 38 U.S.C. 1111 and 1154(b), but notably Congress did not do so for determinations under 38 U.S.C. 1117 or 1118. Therefore, VA makes no changes based upon this comment.

The same commenter suggested that a medical opinion should not be requested by VA when existing medical evidence is sufficient for rating purposes. Section 5125 provides that,“[f]or purposes of establishing any claim for benefits under chapter 11 or 15 of [title 38], a report of a medical examination administered by a private physician that is provided by a claimant in support of a claim for benefits * * * may be accepted without a requirement for confirmation by an examination by a physician employed by the Veterans Health Administration [(VHA)] if the report is sufficiently complete to be adequate for the purpose of adjudicating such claim.” See also 38 CFR 3.326. Because this matter is addressed by those authorities and is beyond the scope of this rule, VA makes no change based upon this comment.

One commenter suggested that presumptive service-connection should be extended to complications of anthrax immunization. The charge to NAS that resulted in “Gulf War and Health Volume 5: Infectious Diseases” was to evaluate the published, peer-reviewed scientific and medical literature on long-term health effects associated with infectious diseases pertinent to service in Southwest Asia. We make no change based on this comment because it is outside of the scope of this rulemaking.

Moreover, NAS previously issued a report titled, Gulf War and Health, Volume 1: “Depleted Uranium, Sarin, Pyridostigmine Bromide, Vaccines,” on January 1, 2000. In that report, NAS limited its analysis to the health effects of depleted uranium, the chemical warfare agent sarin, vaccinations against botulism toxin and anthrax, and pyridostigmine bromide. On July 6, 2001, VA published a notice in the Federal Register announcing the Secretary's determination that the available evidence did not warrant a presumption of service connection for any disease discussed in that report. See 66 FR 35702 (2001).

One commenter suggested that the presumptive period in 38 CFR 3.317(a)(1)(i), in which certain disabilities due to undiagnosed illnesses manifest to a degree of 10 percent or more are attributable to service in the Southwest Asia theater of operations, be extended indefinitely. Public Law 103-446 directed the Secretary to prescribe by regulation the period of time (presumptive period) following service in the Southwest Asia theater of operations determined to be appropriate for the manifestation of an illness warranting payment of compensation. It further directed that the Secretary's determination of a presumptive period be made only following a review of any credible medical or scientific evidence and the historical treatment afforded disabilities for which manifestation periods have been established and taking into account other pertinent circumstances regarding the experiences of veterans of the Persian Gulf War. Because the purpose of this rulemaking was to add presumptions for infectious diseases, any issue regarding undiagnosed illnesses was neither raised nor addressed in the proposed rulemaking and is, therefore, outside of the scope of this rulemaking. In the Federal Register of December 5, 2007 (72 FR 68507), VA extended the presumption period for undiagnosed illnesses to December 31, 2011, and stated that VA may consider further extensions in the future.

For clarity, we have made several changes to the proposed rule. Regarding section 3.317(c)(1), we have added the introductory words “Except as provided by paragraph (c)(4) of the section,” in order to notify claimants that the presumptions can be rebutted. We also changed the phrase “becomes manifest in a Persian Gulf veteran, as defined in paragraph (e)(1) of this section or a veteran who served on active military, naval, or air service in Afghanistan on or after September 19, 2001,” to the phrase “becomes manifest in a veteran with a qualifying period of service.” This change mirrors the language in paragraph (c)(3)(ii) and avoids restating a definition already provided in the regulation. Regarding paragraph (e), we are moving the phrase “during the Persian Gulf War” from paragraph (e)(1) to (e)(2), as it read in the previous rule. In the proposed rule, we explained that we intended to redesignate current paragraph (d) as paragraph (e), but in doing so we inadvertently moved the phrase “during the Persian Gulf War” from (1) to (2). The changes that we have made to the final rule are nonsubstantive.

Paperwork Reduction Act

This document contains no provisions constituting a collection of information under the Paperwork Reduction Act (44 U.S.C. 3501-3521).

Regulatory Flexibility Act

The Secretary hereby certifies that this final rule will not have a significant economic impact on a substantial number of small entities as they are defined in the Regulatory Flexibility Act, 5 U.S.C. 601-612. This final rule would not affect any small entities. Only VA beneficiaries could be directly affected. Therefore, pursuant to 5 U.S.C. 605(b), this final rule is exempt from the initial and final regulatory flexibility analysis requirements of sections 603 and 604.

Executive Order 12866

Executive Order 12866 directs agencies to assess all costs and benefits of available regulatory alternatives and, when regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety, and other advantages; distributive impacts; and equity). The Executive Order classifies a “significant regulatory action,” requiring review by the Office of Management and Budget (OMB), as any regulatory action that is likely to result in a rule that may: (1) Have an annual effect on the economy of $100 million or more or adversely affect in a material way the economy, a sector of the economy, productivity, competition, jobs, the environment, public health or safety, or State, local, or tribal governments or communities; (2) create a serious inconsistency or otherwise interfere with an action taken or planned by another agency; (3) materially alter the budgetary impact of entitlements, grants, user fees, or loan programs or the rights and obligations of recipients thereof; or (4) raise novel legal or policy issues arising out of legal mandates, the President's priorities, or the principles set forth in the Executive Order.

The economic, interagency, budgetary, legal, and policy implications of this final rule have been examined, and it has been determined to be a significant regulatory action under the Executive Order because it is likely to result in a rule that will raise novel legal or policy issues arising out of legal mandates, the President's priorities, or the principles set forth in the Executive Order.

Unfunded Mandates

The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C. 1532, that agencies prepare an assessment of anticipated costs and benefits before issuing any rule that may result in the expenditure by State, local, and tribal governments, in the aggregate, or by the private sector, of $100 million or more (adjusted annually for inflation) in any year. This final rule would have no such effect on State, local, and tribal governments, or on the private sector.

Catalog of Federal Domestic Assistance Numbers and Titles

The Catalog of Federal Domestic Assistance program numbers and titles for this rule are 64.009, Veterans Medical Care Benefits; 64.100, Automobiles and Adaptive Equipment for Certain Disabled Veterans and Members of the Armed Forces; 64.101, Burial Expenses Allowance for Veterans; 64.106, Specially Adapted Housing for Disabled Veterans; 64.109, Veterans Compensation for Service-Connected Disability; and 64.110, Veterans Dependency and Indemnity Compensation for Service-Connected Death.

Signing Authority

The Secretary of Veterans Affairs, or designee, approved this document and authorized the undersigned to sign and submit the document to the Office of the Federal Register for publication electronically as an official document of the Department of Veterans Affairs. John R. Gingrich, Chief of Staff, Department of Veterans Affairs, approved this document on July 7, 2010, for publication.

List of Subjects in 38 CFR Part 3

• Administrative practice and procedure
• Claims
• Disability benefits
• Health care
• Pensions
• Radioactive materials
• Veterans
• Vietnam

Dated: September 23, 2010.

Robert C. McFetridge,

Director, Regulation Policy and Management, Office of the General Counsel, Department of Veterans Affairs.

For the reasons set out in the preamble, VA is amending 38 CFR part 3 as follows:

PART 3—ADJUDICATION

Subpart A—Pension, Compensation, and Dependency and Indemnity Compensation

1. The authority citation for part 3, subpart A continues to read as follows:

Authority: 38 U.S.C. 501(a), unless otherwise noted.

2. Revise § 3.317 to read as follows:

§ 3.317

Compensation for certain disabilities occurring in Persian Gulf veterans.

(a) Compensation for disability due to undiagnosed illness and medically unexplained chronic multisymptom illnesses. (1) Except as provided in paragraph (a)(7) of this section, VA will pay compensation in accordance with chapter 11 of title 38, United States Code, to a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability, provided that such disability:

(i) Became manifest either during active military, naval, or air service in the Southwest Asia theater of operations, or to a degree of 10 percent or more not later than December 31, 2011; and

(ii) By history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis.

(2)(i) For purposes of this section, a qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following):

(A) An undiagnosed illness;

(B) The following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms:

(1) Chronic fatigue syndrome;

(2) Fibromyalgia;

(3) Irritable bowel syndrome; or

(4) Any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness.

(ii) For purposes of this section, the term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained.

(3) For purposes of this section, “objective indications of chronic disability” include both “signs,” in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification.

(4) For purposes of this section, disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest.

(5) A qualifying chronic disability referred to in this section shall be rated using evaluation criteria from part 4 of this chapter for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar.

(6) A qualifying chronic disability referred to in this section shall be considered service connected for purposes of all laws of the United States.

(7) Compensation shall not be paid under this section for a chronic disability:

(i) If there is affirmative evidence that the disability was not incurred during active military, naval, or air service in the Southwest Asia theater of operations; or

(ii) If there is affirmative evidence that the disability was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations and the onset of the disability; or

(iii) If there is affirmative evidence that the disability is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs.

(b) Signs or symptoms of undiagnosed illness and medically unexplained chronic multisymptom illnesses. For the purposes of paragraph (a)(1) of this section, signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to:

(1) Fatigue.

(2) Signs or symptoms involving skin.

(3) Headache.

(4) Muscle pain.

(5) Joint pain.

(6) Neurological signs or symptoms.

(7) Neuropsychological signs or symptoms.

(8) Signs or symptoms involving the respiratory system (upper or lower).

(9) Sleep disturbances.

(10) Gastrointestinal signs or symptoms.

(11) Cardiovascular signs or symptoms.

(12) Abnormal weight loss.

(13) Menstrual disorders.

(c) Presumptive service connection for infectious diseases. (1) Except as provided in paragraph (c)(4) of this section, a disease listed in paragraph (c)(2) of this section will be service connected if it becomes manifest in a veteran with a qualifying period of service, provided the provisions of paragraph (c)(3) of this section are also satisfied.

(2) The diseases referred to in paragraph (c)(1) of this section are the following:

(i) Brucellosis.

(ii) Campylobacter jejuni.

(iii) Coxiella burnetii (Q fever).

(iv) Malaria.

(v) Mycobacterium tuberculosis.

(vi) Nontyphoid Salmonella.

(vii) Shigella.

(viii) Visceral leishmaniasis.

(ix) West Nile virus.

(3) The diseases listed in paragraph (c)(2) of this section will be considered to have been incurred in or aggravated by service under the circumstances outlined in paragraphs (c)(3)(i) and (ii) of this section even though there is no evidence of such disease during the period of service.

(i) With three exceptions, the disease must have become manifest to a degree of 10 percent or more within 1 year from the date of separation from a qualifying period of service as specified in paragraph (c)(3)(ii) of this section. Malaria must have become manifest to a degree of 10 percent or more within 1 year from the date of separation from a qualifying period of service or at a time when standard or accepted treatises indicate that the incubation period commenced during a qualifying period of service. There is no time limit for visceral leishmaniasis or tuberculosis to have become manifest to a degree of 10 percent or more.

(ii) For purposes of this paragraph (c), the term qualifying period of service means a period of service meeting the requirements of paragraph (e) of this section or a period of active military, naval, or air service on or after September 19, 2001, in Afghanistan.

(4) A disease listed in paragraph (c)(2) of this section shall not be presumed service connected:

(i) If there is affirmative evidence that the disease was not incurred during a qualifying period of service; or

(ii) If there is affirmative evidence that the disease was caused by a supervening condition or event that occurred between the veteran's most recent departure from a qualifying period of service and the onset of the disease; or

(iii) If there is affirmative evidence that the disease is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs.

(d) Long-term health effects potentially associated with infectious diseases. (1) A report of the Institute of Medicine of the National Academy of Sciences has identified the following long-term health effects that potentially are associated with the infectious diseases listed in paragraph (c)(2) of this section. These health effects and diseases are listed alphabetically and are not categorized by the level of association stated in the National Academy of Sciences report (see Table to § 3.317). If a veteran who has or had an infectious disease identified in column A also has a condition identified in column B as potentially related to that infectious disease, VA must determine, based on the evidence in each case, whether the column B condition was caused by the infectious disease for purposes of paying disability compensation. This does not preclude a finding that other manifestations of disability or secondary conditions were caused by an infectious disease.

(2) If a veteran presumed service connected for one of the diseases listed in paragraph (c)(2) of this section is diagnosed with one of the diseases listed in column “B” in the table within the time period specified for the disease in the same table, if a time period is specified or, otherwise, at any time, VA will request a medical opinion as to whether it is at least as likely as not that the condition was caused by the veteran having had the associated disease in column “A” in that same table.

Table to § 3.317—Lo ng-Term Health Effects Potentially Associated With Infectious Diseases

A	B
	Disease
Brucellosis	• Arthritis.
	• Cardiovascular, nervous, and respiratory system infections.
	• Chronic meningitis and meningoencephalitis.
	• Deafness.
	• Demyelinating meningovascular syndromes.
	• Episcleritis.
	• Fatigue, inattention, amnesia, and depression.
	• Guillain-Barré syndrome.
	• Hepatic abnormalities, including granulomatous hepatitis.
	• Multifocal choroiditis.
	• Myelitis-radiculoneuritis.
	• Nummular keratitis.
	• Papilledema.
	• Optic neuritis.
	• Orchioepididymitis and infections of the genitourinary system.
	• Sensorineural hearing loss.
	• Spondylitis.
	• Uveitis.
Campylobacter jejuni	• Guillain-Barré syndrome if manifest within 2 months of the infection.
	• Reactive Arthritis if manifest within 3 months of the infection.
	• Uveitis if manifest within 1 month of the infection.
Coxiella burnetii (Q fever)	• Chronic hepatitis.
	• Endocarditis.
	• Osteomyelitis.
	• Post-Q-fever chronic fatigue syndrome.
	• Vascular infection.
Malaria	• Demyelinating polyneuropathy.
	• Guillain-Barré syndrome.
	• Hematologic manifestations (particularly anemia after falciparum malaria and splenic rupture after vivax malaria).
	• Immune-complex glomerulonephritis.
	• Neurologic disease, neuropsychiatric disease, or both.
	• Ophthalmologic manifestations, particularly retinal hemorrhage and scarring.
	• Plasmodium falciparum.
	• Plasmodium malariae.
	• Plasmodium ovale.
	• Plasmodium vivax.
	• Renal disease, especially nephrotic syndrome.
Mycobacterium tuberculosis	• Active tuberculosis.
	• Long-term adverse health outcomes due to irreversible tissue damage from severe forms of pulmonary and extrapulmonary tuberculosis and active tuberculosis.
Nontyphoid Salmonella	• Reactive Arthritis if manifest within 3 months of the infection.
Shigella	• Hemolytic-uremic syndrome if manifest within 1 month of the infection.
	• Reactive Arthritis if manifest within 3 months of the infection.
Visceral leishmaniasis	• Delayed presentation of the acute clinical syndrome.
	• Post-kala-azar dermal leishmaniasis if manifest within 2 years of the infection.
	• Reactivation of visceral leishmaniasis in the context of future immunosuppression.
West Nile virus	• Variable physical, functional, or cognitive disability.

(e) Service. For purposes of this section:

(1) The term Persian Gulf veteran means a veteran who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War.

(2) The Southwest Asia theater of operations refers to Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations.

(Authority: 38 U.S.C. 1117, 1118).