Office of Public Health &Environmental Hazards

Environmental Exposure Concerns of Veterans:

Agent Orange and BeyondWhat You Need to Know Caring for Veterans with Post Deployment

Health Concerns:Past, Present and Future

March 30-31, 2011

Ron Teichman, MD, MPH, FACP, FACOEM

Ron Teichman, MD, MPH, FACP, FACOEM

Associate Director – Clinical, Education and Risk Communication

War Related Illness and Injury Study Center (WRIISC)

VA New Jersey Health Care System – East Orange, NJ With the NJ WRIISC for 7 years Board certified in Internal Medicine and in Occupational

and Environmental Medicine

Disclaimer

The views expressed in this presentation are those of the author and do not necessarily represent the position of the Department of Veterans Affairs or the United States Government

I have no known conflicts of interest other than that I work for the Department of Veterans Affairs

Environmental Exposure Concerns of Veterans –

Are exposure concerns of Veterans new? What combat and military exposures are

Veterans concerned about?

Combat/Military exposures -

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 – 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

Vietnam – Agent OrangePresumptively Service Connected

Conditions

Prostate Cancer Respiratory Track Cancer Diabetes Mellitus-Type II B Cell Leukemias Ischemic Heart Disease Parkinson’s Disease Next – HTN?

All sequelae thereof!

Presumptions

Why?

Okay, so exposures are not new.

Are exposure concerns new?

Prevalence (%) of exposure concerns common to Vietnam,

Persian Gulf and Bosnia-Kosovo

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From Schneiderman, Lincoln, Wargo, et. al., APHA, 12-14-05

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

NOT GULF WAR SYNDROME GW1 Veterans have more symptoms than other groups.

These symptoms occur in no consistent cluster Most researchers have been unable to correlate specific

exposures to symptoms Symptoms may include:

Confusion Rash Cough

Headache SOB Fatigue

Memory problems Chest pain Parasthesia

Joint pains Diarrhea Sleep disorder

Muscle aches Abdominal pain Irritability

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.

Perspective

23,532,000 US Veterans alive today. Total US service members deployed to Operation

Enduring Freedom/Operation Iraqi Freedom/ Operation New Dawn (OEF/OIF/OND)=2,100,000

Total US service members separated, i.e., now Veterans = 1,250,663 (~5% of total Veteran population)

OEF/OIF Veterans that have received some health care from VA over 9 years = 625,384 ~ 50% of returnees

Through 3rd Quarter FY 2010

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

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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

Combat/Military exposures -

Burning trash Harsh Weather Conditions Poor Sanitary Conditions Pesticides and Insects Hazardous Weapons Systems Occupational Chemical Hazards

Which war am I talking about?

Okay, so we know that combat and military exposures are not new.

We know what some of the exposure concerns have been over the years and conflicts.

Later we’ll talk about: What do we know about some of the more

common exposures of concern to the newest Veterans?

How to conduct an environmental exposure assessment of Veterans.