Presumptions of Service Connection for Persian Gulf Service, 59968-59972 [2010-24360]

Agencies

• DEPARTMENT OF VETERANS AFFAIRS

[Federal Register Volume 75, Number 188 (Wednesday, September 29, 2010)]
[Rules and Regulations]
[Pages 59968-59972]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2010-24360]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 3

RIN 2900-AN24


Presumptions of Service Connection for Persian Gulf Service

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

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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, (202) 461-9428. (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

[[Page 59969]]

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 Sec.  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

[[Page 59970]]

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.

0
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

0
1. The authority citation for part 3, subpart A continues to read as 
follows:

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


0
2. Revise Sec.  3.317 to read as follows:


Sec.  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

[[Page 59971]]

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 Sec.  3.317). If a veteran who has or had an infectious 
disease identified in column A also has a condition

[[Page 59972]]

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 Sec.   3.317--Lo ng-Term Health Effects Potentially Associated
                        With Infectious Diseases
------------------------------------------------------------------------
                                                      B
                 A                 -------------------------------------
                                                   Disease
------------------------------------------------------------------------
Brucellosis.......................   Arthritis.
                                     Cardiovascular, nervous,
                                     and respiratory system infections.
                                     Chronic meningitis and
                                     meningoencephalitis.
                                     Deafness.
                                     Demyelinating
                                     meningovascular syndromes.
                                     Episcleritis.
                                     Fatigue, inattention,
                                     amnesia, and depression.
                                     Guillain-Barr[eacute]
                                     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-Barr[eacute]
                                     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-Barr[eacute]
                                     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).

[FR Doc. 2010-24360 Filed 9-28-10; 8:45 am]
BILLING CODE 8320-01-P