* Become familiar with the long history of concerns about exposure to environmental hazards among U.S. veterans returning from war.
* Give examples of exposures of concern to troops returning from the wars in Iraq and Afghanistan, including recent published literature on these concerns.
* Discuss Department of Defense tools for collecting data on the frequency and nature of exposure concerns, as well as the new program being implemented at the Department of Veterans Affairs (VA).
The Department of Veterans Affairs (VA) reports that as of September 30, 2011, there are 1,396,477 US Veterans of Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND).1 The public media and segments of the medical literature are rife with headlines, articles, first-person stories, scientific studies, and theories about the health effects of various chemicals and other substances that military service members may have been exposed to during the recent and current wars in Iraq (OIF—May 2003 to August 2010 and OND—September 2010 to the present) and Afghanistan (OEF October 2001 to the present).2–40 This article seeks to review what we currently know about environmental exposures of OEF/OIF and the VA's responses to this threat.
Historically, there has been poor documentation of environmental exposures occurring during deployment. For example, the members of the armed services that served on the ground in Vietnam are presumed to have been exposed to Agent Orange, but there has been no attempt to quantify the actual Veterans either directly affected or those concerned. The Department of Defense (DOD), with the Central Intelligence Agency, developed several models in an attempt to identify troops that might have been exposed to chemical warfare agents released when an ammunition bunker at Khamasiyah, Iraq, was destroyed following the Gulf War. The analyses and modeling identified 1100, then 20,000, then 99,000, and then 102,000 personnel potentially affected (there was approximately 66% overlap between the latter two figures). Notifications were sent to at least the first three of these groups. Nevertheless, no direct contact was made with these Veterans to assess their exposure or their concern about exposure.41
POSTDEPLOYMENT HEALTH ASSESSMENT AND POSTDEPLOYMENT HEALTH REASSESSMENT
In part as a result of concerns about the effects of deployment on health, on January 31, 2002, the DOD began systemwide implementation of a Post-Deployment Health Evaluation and Management System. This system requires Service members to complete two health assessments—a Pre-Deployment Health Assessment (PDA-DD2795) and a Post-Deployment Health Assessment (PDHA—DD2796).42 The PDA is to be completed within 30 days before deployment. The PDHA is to be completed during medical outplacing or within 30 days of returning to the United States and has been used before, during, and immediately after embarking on transportation back to the United States, as well as during demobilizations at larger bases. In June 2005, a Post-Deployment Health Reassessment (PDHA-DD2900) was added to the program.43 This form is to be completed 3 to 6 months after a Service member's return from a combat deployment. These health assessments are the best indicators of rates of environmental exposure concerns during OEF/OIF.
The relevant question on the PDHA is, “While you were deployed, were you exposed to: (mark all that apply)?”44 with column headings for responses of No, Sometimes, and Often. There are 22 exposures asked (Fig. 1). The PDHRA (Revised January 2008) has a related question of “Do you have any persistent major concerns regarding the health effects of something you believe you may have been exposed to or encountered while deployed?”, with response options of yes and no. It goes on to state, “If NO, skip to question 11” and “If YES, please mark the item(s) that best describe your concern.”45 This time there are 24 exposures asked about (Fig. 2).
The PDHAs and PDHRAs completed by service members between September 2007 and August 2008 (Table 1) show that (1) National Guard and Reserve Troops reported more exposure concerns than the Active Duty component; (2) exposure concerns are more frequent 3 to 6 months after returning from deployment than immediately postdeployment; and (3) 20% to 33% of service members have concerns about exposures at 3 to 6 months after their return.5 In fact, these three trends persist, although with varying magnitudes, whether the time period of September 2007 to August 2008 is reviewed,5 or September 2005 to August 2006,6 or January 2003 to September 2006.7
The exposures of concern identified on the PDHRA between September 2005 and August 2006 were sand, noise, smoke from burning trash, vehicle exhaust, and JP8 and other jet fuels.8 The top-12 most commonly endorsed exposures of concern are shown in Figure 1. Once again, for all 12 exposures, the Reserve component members endorsed exposure concerns more often than the Active component members.
There are no studies addressing the possible causes of these trends; however, several possible factors come to mind. Active component Service members are more accustomed to the rigors and lack of amenities incurred during deployment than are Reserve members; therefore, they may be less likely to raise a concern about something that they simply consider a routine part of the job. This may, in part, account for the difference in the frequency with which Active versus Reserve component Service members endorse concerns about exposures. Once they return home, regardless of whether they are Active component or Reserve component, Service members have freer access to both people and media outlets, which may raise issues of exposures that the Service member may have encountered during their deployment. This may get them thinking, remembering, or worrying about additional possible exposures that incurred in service. This may be one of the reasons that the frequency of exposure concerns being endorsed on the PDHRA is consistently higher than that on the PDHA.
EXPOSURES OF CONCERN TO SERVICE MEMBERS AND VETERANS RETURNING FROM THE CURRENT AND RECENT WARS IN AFGHANISTAN AND IRAQ
There are very few other reports on the frequency of a wide range of exposure concerns during OEF/OIF. One of these articles concerns reported exposure concerns among Veterans seeking treatment at a tertiary VA clinic, the War Related Illness and Injury Study Center located at the VA Medical Center (VAMC) in East Orange, New Jersey (NJ WRIISC). The NJ WRIISC established a program in 2004 whereby comprehensive clinical evaluations were conducted on recently returned Veterans from OEF and OIF. All Veterans seen at the NJ WRIISC complete a structured intake packet with questions regarding their health, symptoms, exposures, and exposure concerns (Fig. 3).
The author has previously published on the exposure concerns of the first 56 of these Veterans, beginning with June 2004.3 Forty-nine or 87.5% of these Veterans indicated that they were concerned about one or more exposure sustained during their deployment. The most frequently mentioned exposures of concern, in decreasing frequency, were poor air quality from burning trash and feces; depleted uranium; multiple vaccinations (tied for second place); smoke from oil well fires; poor air quality from sand and dust; petrochemicals (tied for fifth place); anthrax vaccine; with biological or chemical weapons, contaminated water or food, mefloquine (an antimalarial medicine used as a once weekly prophylactic agent), pesticides, and body fluids all tied for eighth place.
A modified exposure measure was added to the intake packet in 2006, and since then 469 OEF/OIF Veterans have completed this measure. This exposure measure is a 16-item self-report exposure questionnaire created by this author. The measure asked participants whether they had been exposed to specific hazards during their deployment or military career; with response options of yes, don't know, and no. The potential exposures are listed in Table 2. Veterans who indicated that they were exposed to a hazard were then asked to indicate their level of concern for each hazard. Veterans indicated their level of concern on a five-point Likert scale (0 = not at all, 1 = somewhat, 2 = moderately, 3 = very, 4 = extremely). The 10 most frequently mentioned exposures, in decreasing frequency, were air pollution–general (eg, sandstorm); air pollution–specific (eg, burn pit); vaccines; anthrax vaccine; petrochemicals; insect bites; dead bodies/combat injury; insect repellant; chemicals used on job; and preventive medicine.
It is clear that Veterans returning from the current and recent conflicts in Afghanistan and Iraq frequently return with concerns about one or more substances that they may have been exposed to in preparation for and/or during deployment.
REVIEW OF RECENTLY PUBLISHED LITERATURE ON EXPOSURES OF CONCERN TO OEF/OIF VETERANS
Although there is little research on the prevalence of a wide number of exposures for OEF/OIF, there is much greater literature examining specific exposures of concern. Some of the recent articles on this subject are reviewed here.
In October 2010, Szema et al16 published on an increased rate of new-onset asthma that they identified in OEF/OIF Veterans at the VAMC in Northport, New York (Long Island). They performed a retrospective review of the computerized medical records for Veterans discharged from active duty and seen at the VAMC between March 1, 2004, and May 1, 2007, who had a diagnosis of asthma. Those who had deployed to Iraq or Afghanistan had a higher rate of new-onset asthma than those who remained in the United States.
A supplement to Military Medicine was published in July 2011, with the proceedings of a 3-day symposium and workshop titled “Assessing Potentially Hazardous Environmental Exposures Among Military Populations” held on May 19 to 21, 2010, in Bethesda, Maryland.18 The supplement contained four introductory or summary essays, such as “Military Occupational and Environmental Health: Challenges for the 21st Century.”46 There were 11 articles on the main symposium topics, such as “The Kuwaiti Oil Fire Health Risk Assessment Biological Surveillance Initiative”47 and “Exposure Science for Terrorist Attacks and Theaters of Military Conflict: Minimizing Contact With Toxicants.”48 Many presentations addressed exposures to Service members in past conflicts and what was done, both correctly and otherwise, in terms of monitoring the health of those military personnel and what should be done going forward. There was significant discussion in several presentations about a report by the Institute of Medicine Committee on strategies to protect the health of deployed US forces. That report, “Protecting Those We Serve: Strategies to Protect the Health of Deployed U.S. Forces,”49 was published in 2000 and laid out specific strategies, based on lessons learned from past deployments, which should be applied to subsequent conflicts. These articles concluded that the DOD has made progress in preventing and protecting troops from environmental hazards and in measuring exposure data, but that a lot more needs to be done. There were also five break-out panel reports. This monograph provides an excellent primer on what the DOD has done and plans to do to protect troops from potentially hazardous exposures during deployment.
The New England Journal of Medicine published an article by King et al19 from Vanderbilt University, in the July 21, 2011, issue, which reported for the first time on a group of soldiers who underwent open lung biopsy for evaluation of their postdeployment shortness of breath. Of 80 Service members referred from Fort. Campbell to Vanderbilt University Medical Center for unexplained dyspnea on exertion, 49 underwent thoracoscopic lung biopsy. All 49 had abnormal biopsy samples and 38 of these had pathology that was read as diagnostic for constrictive bronchiolitis. Constrictive bronchiolitis is a rare condition, previously unreported in a population of Service members. The article raised many questions, many of which are still unanswered.
In the September 2011 issue of the Journal of Occupational and Environmental Medicine, Szema et al39 report on their finding that Veterans at their VAMC that had deployed in support of OEF and/or OIF had higher rates of pulmonary symptoms and of spirometry testing than Service members deployed elsewhere. The ratio of forced expired volume in 1 second/forced vital capacity was similar in both groups of Veterans. The authors introduce the term “Iraq/Afghanistan War Lung Injury (IAW-LI)” to describe pulmonary complaints related to exposures that occurred in South West Asia during the current and recent wars. A Letter to the Editor regarding this article raised some interesting and valid points about the findings.40
In October 2011, Morris et al21 published an article that reviewed the extant studies conducted by the US military and the planned research efforts of the military to investigate the possibility of deployment-related pulmonary disease. The authors begin by acknowledging what is now well known and accepted, that Service members deployed to OEF and OIF are exposed to high levels of airborne particulate matter (PM) that exceed environmental, occupational, and military exposure guidelines. The pathogenicity and toxicity of the PM were also studied in several rat exposure studies and showed no evidence of long-term health effects; however, no long-term exposure testing was conducted. The authors conclude that there is an increase in respiratory symptoms postdeployment, but not clinical diagnoses, and that the symptoms may be related to cigarette use during deployment, that although there is some evidence of a higher rate of new-onset asthma in deployed versus non-deployed military personnel, there are no data that deployment is a definitive cause of new-onset asthma, and that in the 45 diagnosed cases of acute eosinophilic pneumonia, an infectious cause was not found but that most patients reported exposure to fine airborne dust and 100% of the first 18 Service members diagnosed all used tobacco, with 78% reporting new-onset smoking. The authors concluded that there are not adequate data to find that any specific inhalation exposures during deployment in support of OEF and OIF were causally related to health effects. Nevertheless, the DOD has and is continuing to evaluate the possibility of deployment-related pulmonary disease in OEF/OIF Veterans.
Late in October 2011, the Institute of Medicine published a report on the “Long-Term Health Consequences of Exposure to Burn Pits in Iraq and Afghanistan.”24 The committee concluded that the exposure of greatest concern may be the high particulate count in the ambient environment in the desert, which includes a variety of chemicals from ambient sources, both regional background and local, in addition to the burn pits. They felt that there was limited evidence to suggest that this high PM reduced pulmonary function. Nevertheless, they did not feel that there was enough evidence to conclude that exposure to combustion products from burn pits caused cancer, respiratory disease, circulatory disease, neurologic disease, and adverse reproductive and developmental outcomes. The committee recommended that additional studies be conducted.24
In the February 23, 2012, issue of the New England Journal of Medicine, Dr Chretien reported that between October 2001 and September 2010 there were more than 62,000 medical evacuations of US military personnel from Afghanistan and Iraq, of which 81% were for disease or non-battle injuries.50 The author speaks of the importance of collaborative responsibilities of military medical officers and military commanders. He briefly describes the four tracks that comprise the US military's preventive health strategy. Dr Chretien goes on to emphasize that the planning, procedures, preventive measures, and investigations are not sufficient or effective without command support.
As we learn more about the levels of exposure to our Service members during their deployments and more about which of these exposures present health hazards, the mission planning, which includes assessing medical threats, the preventive measures, the medical and environmental surveillance, and the investigations, and development of countermeasures will become not only more complex but also more critical. Preventing adverse health consequences is more effective and less expensive, with less impact on force readiness, than playing catch-up once large numbers of Service members are either ill or concerned about becoming ill from exposures that could have been prevented or mitigated much earlier.
NEW PROGRAM FOR VETERANS AT THE VA
In 2001, the Department of Veterans Affairs (VA) established two specialty centers for addressing the issues of Veterans with postdeployment health problems and concerns and Veterans with Medically Unexplained Symptoms, initially with a specific focus on Gulf War Veterans. These are the War Related Illness and Injury Study Centers, and they are located at the VAMCs in Washington, DC (DC WRIISC), and East Orange, New Jersey (NJ WRIISC). In 2007, another WRIISC was created at the VAMC in Palo Alto, California (PA WRIISC). Further discussion of the WRIISC program has already been published.2,51
Many Veterans returning from the Gulf War reported a wide variety of sometimes debilitating multisymptom illnesses. Many believe that these symptoms are related to one or more of a myriad list of deployment-related environmental exposures. As a result, the WRIISC developed into a program with recognized expertise in exposure concerns of Veterans. This expertise and recognition were further advanced as it became obvious that Veterans returning from OEF and OIF had significant exposure concerns as well.
As this collection of articles is going to press, the VA has begun implementing a three-tiered plan to bring exposure expertise to Veterans at all VAMCs. All primary care providers will be given a rudimentary training in exposures of concern and how to begin the discussion with their patients. Each VAMC will have a staff clinician with special training in occupational and environmental health to have much fuller discussions regarding exposure issues with Veterans, and the three WRIISC centers will remain available to support these clinicians, and to assist with issues of new exposures, new exposure concerns, etc.
As Col DeFraites and CPT Richards close their article in the Military Medicine supplement,19 “We must take action to bring about change in the way we deal with environmental hazards. We must use the experiences of the past to improve current and future situations.”52 It seems that the DOD and the VA are doing just that.