Identification of Neurobehavioral Symptoms After the Al Asad, Iraq, Theatre Ballistic Missile Attack of 2020

Introduction: On January 8, 2020, Al Asad Air Base was attacked with more than 12 Theatre Ballistic Missiles from Iran. To date, this is the largest ballistic missile attack on American service members. Soldiers began to report post-concussive symptoms and sleep changes. The goal of this study is to characterize neurobehavioral symptoms among these soldiers. Methods: A survey performed 4-6 weeks after the attack assessed blast exposure, neurobehavioral symptom inventory (NSI), and sleep habits before and after the event. A latent class analysis (LCA) informed by the presence of the most common persistent NSI symptoms was executed. The resultant profiles assessed the soldier’s location, and if on the base distance to the missile strikes and self-reported sleep duration. Results: In total, 593 service members and contractors completed the survey; 85% were 40 years of age or younger. The LCA identified three distinct classes: ‘Minimally Affected’ (60.5%), ‘Moderately Affected’ (28.8%), and ‘Profoundly Affected’ (10.7%). Overall, the most commonly reported persistent symptoms were ‘difficulty sleeping’ (32.7%), ‘feeling anxious’ (25.7%), and ‘headache’ (22.3%). The Moderately and Profoundly Affected classes had substantially elevated probabilities of persistent neurobehavioral symptoms, significantly reduced sleep duration, and were more likely to be closer or more exposed to the missile strikes than those in the Minimally Affected class. Conclusion: More than 80% of the soldiers reported some form of blast exposure. Three phenotypic classes characterized by increasing likelihood of persistent neurobehavioral symptoms were identified. Increased proximity to the missile strike was associated with a greater number and/or persistence of mental and physical symptom burden after the attack. Soldiers exposed to theatre ballistic missile attacks should be screened promptly and until symptom resolution.