Exposures of Veterans: Agent Orange and Beyond What Have We Learned? Exposure Concerns of Veterans...
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Exposures of Veterans: Agent Orange and Beyond What Have We Learned? Exposure Concerns of Veterans – What You Need to Know Ron Teichman, MD, MPH, FACP, FACOEM Associate Director – Clinical, Education and Risk Communication War Related Illness and Injury Study Center VA New Jersey Health Care System – East Orange, NJ
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Transcript of Exposures of Veterans: Agent Orange and Beyond What Have We Learned? Exposure Concerns of Veterans...
Exposures of Veterans:Agent Orange and BeyondWhat Have We Learned?
Exposure Concerns of Veterans – What You Need to Know
Ron Teichman, MD, MPH, FACP, FACOEMAssociate Director – Clinical, Education and Risk
CommunicationWar Related Illness and Injury Study Center
VA New Jersey Health Care System – East Orange, NJ
Environmental Exposures of
Veterans:Agent Orange and Beyond
What Have We Learned?
Not much…
Not much…
Burning trash Harsh Weather Conditions Poor Sanitary Conditions Pesticides and Insects Hazardous Weapons Systems Occupational Chemical Hazards
Which war am I talking about?
Which one?
Korean War (1950-1953)
Vietnam (1961-1975) Grenada (1983) Panama (1989) First Gulf War/Desert
Storm (1990-91)
Maybe one of these?
Somalia (1993) Bosnia (1993-95) Kosovo (1998-99) Operation Enduring Freedom/OEF (2001-
present) Operation Iraqi Freedom/OIF (2003-
present)
Vietnam Conflict
Signature environmental exposure??
Vietnam Conflict
Signature environmental exposure?? Correct – Agent Orange!
Vietnam Conflict
Signature environmental exposure?? Correct – Agent Orange! Other exposures?
Vietnam Conflict
Signature environmental exposure?? Correct – Agent Orange! Other exposures? Napalm Malaria, insects, insecticides Burning trash Poor hygiene and sanitary conditions
Vietnam Conflict
Signature environmental exposure?? Correct – Agent Orange!
At this point it is probably not worth debating who knew what when about the dioxins in these defoliants, or who knew what when about the long term health consequences of exposure
Vietnam Conflict
Signature environmental exposure?? Correct – Agent Orange!
Bottom Line is that the Veterans that were exposed are paying the price with their health and their lives!
Vietnam – Agent OrangePresumptively Service Connected
Conditions Acute and Sub-acute Peripheral Neuropathy AL Amyloid Chloracne Chronic Lymphocytic Leukemia Hodgkin’s Disease Multiple Myeloma Non-Hodgkin's Lymphoma Porphyria Cutanea Tarda Soft tissue Sarcoma Prostate Cancer Respiratory Track Cancer
Vietnam – Agent OrangePresumptively Service Connected
Conditions Diabetes Mellitus-Type II B Cell Leukemias Ischemic Heart Disease Parkinson’s Disease Next – HTN? All sequelae thereof!
Presumptions
Why?
Prevalence (%) of exposures common to Vietnam, Persian
Gulf and Bosnia-Kosovo
0102030405060708090
Lo
cal f
oo
d
Har
sh
wea
ther
Inse
ct b
ites
Pe
tro
chem
. fu
els
Mis
sile
/war
far
e
Bu
rnin
g tr
ash
&
fece
s
Pe
rce
nta
ge
Pre
va
len
ce
Vietnam
Persian Gulf
Bosnia-Kosovo
Top ten environmental exposures of concern: Gulf
War1. Protective gear/alarms (82.5%)
2. Diesel, kerosene, other petrochems (80.6%)
3. Oil well fire smoke (66.9%)
4. Local food (64.5%)
5. Insect bites (63.7%)
6. Harsh weather (62.5%)
7. Smoke from burning trash or feces (61.4%)
8. Within 1 mile of missile warfare (59.9%)
9. Repellants and pesticides (47.5%)
10. Paint, solvents (36.5%)
From Schneiderman, Lincoln, Wargo, et. al., APHA, 12-14-05
Multi-System, Medically Unexplained Symptoms
More possible causes than symptoms Anthrax vaccine Bites from insects and rodents Pesticides and fleas collars Oil well fires Multiple vaccinations Pyridostigmine Bromide Sarin gas (Nerve agent) MOPP suits Etc., etc., etc.
OEF/OIF
Total number of US service members deployed to OEF/OIF = 1,700,000
Total number of US service members separated, i.e., Veterans = 1,016,213
Received some health care from VA = 454,121; ~ 45% of returnees
Percentage of OEF/OIF service members who endorsed Exposure
Concerns on PDHA and PDHRA (9/07-10/08)
Active component Pre-Deployment n=245,378 0.0% Post-Deployment n=224,511 16.2% Reassessment n=189,933 21.2%
Reserve component Pre-Deployment n=85,843 0.0% Post-Deployment n=75,174 24.9% Reassessment n=96,886 34.8%
Frequency of exposure concerns rise after 3-6 monthsMSMR Vol. 15 / No. 7 – Sept. 2008
Top five Concerns of Veterans from Afghanistan and Iraq
1. Sand
2. Noise
3. Smoke from trash
4. Vehicle exhaust
5. JP8 or other fuelMSMR Vol. 12 / No. 8 – Nov. 2006
Frequency of OEF/OIF service member exposure concern
reported on the PDHRA (9/05-8/06)
MSMR Vol. 12 / No. 8 – Nov. 2006
San
d
No
ise
Sm
oke
fro
m t
rash
Veh
icle
exh
aust
JP8
or
Fu
el
Sm
oke
fro
m o
il fi
re
Exc
essi
ve v
ibra
tio
n
Ind
ust
rial
po
lluti
on
Pes
tici
de
trea
ted
un
ifo
rm
DE
ET
on
ski
n
Bla
st /
Veh
icle
acc
iden
t
So
lven
ts
30.0
25.0
20.0
15.0
10.0
5.0
0.0
Per
cen
t
Reserve
Active
San
d
No
ise
Sm
oke
fro
m t
rash
Veh
icle
exh
aust
JP8
or
Fu
el
Sm
oke
fro
m o
il fi
re
Exc
essi
ve v
ibra
tio
n
Ind
ust
rial
po
lluti
on
Pes
tici
de
trea
ted
un
ifo
rm
DE
ET
on
ski
n
Bla
st /
Veh
icle
acc
iden
t
So
lven
ts
30.0
25.0
20.0
15.0
10.0
5.0
0.0
Per
cen
t
Reserve
Active
Top ten environmental exposures of concern: OEF/OIF1. Smoke from burning trash or feces (44.6%)-72. Sand and dust storms (41.5%)-63. Gasoline, Jet Fuel, Diesel Fuel (21.1%)-24. Depleted Uranium (19.0%)5. Paint, solvents, other petrochems (15.2%)-106. Oil well fire smoke (14.9%)-37. Contaminated food and water (14.4%)-48. Anthrax Vaccine (14.2%)9. Multiple Vaccinations (13.9%) [8+9>3]10. Vehicular Exhaust (10.3%)
Seen at NJ WRIISC, n=612. 1889 concerns, range 0-15
Not much…
Burning trash Harsh Weather Conditions Poor Sanitary Conditions Pesticides and Insects Hazardous Weapons Systems Occupational Chemical Hazards
Which war am I talking about?
But wait!
Maybe there’s hope!
Maybe there’s hope!
The last decade has seen change happening at an increasing rate
Brand new initiatives Entirely new programs New ways of doing what we’ve always
done
Didn’t you say there’s hope?
Integrated Care Initiatives Exposure monitoring and tracking Better communications Medical surveillance Long term research program Making information available
The Hope
War Related Illness and Injury Study Center – WRIISC
Post Deployment Integrated Care Initiative – PDICI
Deployment Health Working Group Medical surveillance program Millennium Cohort Study POEMS
The War Related Illness and Injury Study Center
(WRIISC) A National program in the Department of Veterans Affairs
(VA), established in 2001 to address post-deployment health issues from the First Gulf War.
About the WRIISC
The mission of the WRIISC is to improve the health of Veterans with war related illnesses and injuries through clinical assessments, education, risk communication and research.
A key element of our mission is to provide education to providers on deployment related healthcare issues such as exposures and medically unexplained symptoms.
WRIISC Services
Clinical Education/Risk
Communication Research
WRIISC
Unlike most VA programs, we were designed to be flexible to address the needs of post-deployment Veterans
The VA was positively prescient!
WRIISC
We are able to focus on: The Past The Present and The Future
WRIISC
Integrating our Clinical Expertise and Services with our
Research Interests and Findings with our Educational and Risk Communication
Expertise and Services allows for The maximum positive impact on the
Veterans of this country!
WRIISC
Collaborations Tri-WRIISC educational programs with EES
being held regionally Tri-WRIISC educational national satellite
broadcast in July Caring for GW1 Veterans VHI being revised with
WRIISC collaboration Caring for Vietnam Veterans VHI being revised
with WRIISC collaboration
WRIISC
Collaborations – continued EAS Regional Symposiums being held with
WRIISC collaboration DHWG has WRIISC representation PDICI/Rural Health Initiative Training modules
being prepared with WRIISC collaboration Joint VA/DoD/Academia pulmonary exposure
panel with WRIISC representation
Post-Deployment Integrated Care Initiative (PDICI)
Based on three premises The health care risks and health care needs of combat
Veterans differ from those of non-combat Veterans The health care needs of combat Veterans are best
served by clinicians familiar with the unique health risks of combat.
The health care needs of combat Veterans are best served in a setting utilizing multidisciplinary resources and integrated care.
PDICI
Mission/Goals
Promote the integration of post-combat care services both within VA and between VA/DoD and other community providers into a coherent and maximally effective system of post-combat care and support for our returning combat Veterans and their families
PDICI
Mission/GoalsTo take the lessons learned and approaches developed in the area of post-deployment care and apply them to the implementation of contingency plans for effective and immediate post-combat care for Veterans returning from any future deployments and with all Veterans with complex needs
DoD/VA Deployment Health Working Group (DHWG)
Coordinate efforts to: increase health surveillance information sharing track research initiatives on deployment health
issues create joint health risk communication products
DHWG
Environmental Exposure Surveillance Data Transfer Agreement between DoD and VA on
sharing of environmental health data US Army scientists provided a detailed presentation in
May 2009 on 24 exposure incidents in OEF and OIF Full-day workshop in 11/09 on DoD and VA responses to
environmental exposure incidents in OIF & OEF VA is working with DoD and the Marine Corps to develop
data usable for VA to contact VA eligible personnel who were stationed at Camp Lejeune, NC.
Developing a Medical Surveillance Program
There are several known exposure “scenarios” in the current conflicts in Iraq and Afghanistan where we can utilize medical surveillance to reduce morbidity and mortality
Most of the offending agent(s) can be identified or surmised
Developing a Medical Surveillance Program
The questions become: What can and should we do? How do we determine if individuals are
or will develop health outcomes related to these exposures?
VA has established a pilot medical surveillance program for one of these scenarios
Developing A Medical Surveillance Program - What
happened at Qarmat Ali
Approximately 600 National Guard troops rotated guard duty at a water treatment facility used for oil extraction at Qarmat Ali, Iraq between April and October 2003
Entire presentation in just a short while Remember, this is precedent setting.
Developing a Medical Surveillance Program for Veterans
Can this approach be utilized for other known exposure scenarios in Iraq?
Burn Pits Sulfur fires/sulfur rain Emergency blood transfusions
Millennium Cohort Study
Began in 2001 Tri-annual questionnaires until 2022 150,000 participants, 50,000 more in 2010 10,000 spouses of participants in 2010 Army, Navy, Air Force, Marines, (USCG?) Active duty, Reserves, National Guard Men, Women, Ethnicities, Demographics
Millennium Cohort Study
Physical and psychological health Complementary and alternative medicine Occupational exposures Smoking and drinking habits Health problems being experienced Pre-deployment, post-deployment, non-
deployed, post-service Framingham Study of the DoD and VA
POEMS
Periodic Occupational Environmental Monitoring Summaries
CHPPM/PHC Not service member specific, but site
specific for a base camp
POEMS Describes OEH exposures/hazards
Airborne pollutants Water contaminants Infectious diseases Noise, temperature
Discusses health implications Acute and chronic health effects
Recommendations for action/follow up/surveillance
POEMS
Only a few available at present Plan is to prepare many more Plan is to provide access to health care
providers [email protected]
What have we learned?
There is a huge universe of things we don’t know about Service Members and Veterans’ health
To pay attention to environmental exposures of Service Members in theater
The dangers of unbridled exposures in theater The importance of monitoring the health of
Veterans before they get sick The cost of not knowing (presumptions)
What have we learned?
The need for DoD and VA to work much more closely and for there to be a “hand off” of medical and exposure information
The importance of how we speak with combat Veterans
Combat Veterans are different To address the post-combat health of deployed
Veterans using a more holistic, multi-dimensional approach
What have we learned?
That research and clinical services can work very well together, each informing the other
The importance of working together to prevent illness and misery in our Veterans
The value of flexibility
What have we learned?
Veterans do not come home from war… They come home with war.
This educational program is part of the process of learning these important messages and you are all part of the future of VA Health Care.
Thank you for your dedication to helping our Veterans.
Thank you
