Exposures of Veterans: Agent Orange and Beyond What Have We Learned? Exposure Concerns of Veterans

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Exposures of VeteransAgent Orange and
BeyondWhat 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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Environmental Exposures of VeteransAgent
Orange and Beyond What Have We Learned?
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Not much
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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?

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Which one?

• Korean War (1950-1953)
• Vietnam (1961-1975)
• Grenada (1983)
• Panama (1989)
• First Gulf War/Desert Storm (1990-91)

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Maybe one of these?

• Somalia (1993)
• Bosnia (1993-95)
• Kosovo (1998-99)
• Operation Enduring Freedom/OEF (2001-present)
• Operation Iraqi Freedom/OIF (2003-present)

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Vietnam Conflict

• Signature environmental exposure??

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Vietnam Conflict

• Signature environmental exposure??
• Correct Agent Orange!

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Vietnam Conflict

• Signature environmental exposure??
• Correct Agent Orange!
• Other exposures?

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Vietnam Conflict

• Signature environmental exposure??
• Correct Agent Orange!
• Other exposures?
• Napalm
• Malaria, insects, insecticides
• Burning trash
• Poor hygiene and sanitary conditions

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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

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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!

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Vietnam Agent OrangePresumptively Service
Connected Conditions

• Acute and Sub-acute Peripheral Neuropathy
• AL Amyloid
• Chloracne
• Chronic Lymphocytic Leukemia
• Hodgkins Disease
• Multiple Myeloma
• Non-Hodgkin's Lymphoma
• Porphyria Cutanea Tarda
• Soft tissue Sarcoma
• Prostate Cancer
• Respiratory Track Cancer

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Vietnam Agent OrangePresumptively Service
Connected Conditions

• Diabetes Mellitus-Type II
• B Cell Leukemias
• Ischemic Heart Disease
• Parkinsons Disease
• Next HTN?
• All sequelae thereof!

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Presumptions

• Why?

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Prevalence () of exposures common to Vietnam,
Persian Gulf and Bosnia-Kosovo
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Top ten environmental exposures of concern Gulf
War

• Protective gear/alarms (82.5)
• Diesel, kerosene, other petrochems (80.6)
• Oil well fire smoke (66.9)
• Local food (64.5)
• Insect bites (63.7)
• Harsh weather (62.5)
• Smoke from burning trash or feces (61.4)
• Within 1 mile of missile warfare (59.9)
• Repellants and pesticides (47.5)
• Paint, solvents (36.5)
• From Schneiderman, Lincoln, Wargo, et. al., APHA,
  12-14-05

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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.

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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

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Percentage of OEF/OIF service members who
endorsed Exposure Concerns on PDHA and PDHRA
(9/07-10/08)

• Active component
• Pre-Deployment n245,378 0.0
• Post-Deployment n224,511 16.2
• Reassessment n189,933 21.2
• Reserve component
• Pre-Deployment n85,843 0.0
• Post-Deployment n75,174 24.9
• Reassessment n96,886 34.8
• Frequency of exposure concerns rise after 3-6
  months
• MSMR Vol. 15 / No. 7 Sept. 2008

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Top five Concerns of Veterans from Afghanistan
and Iraq

• Sand
• Noise
• Smoke from trash
• Vehicle exhaust
• JP8 or other fuel
• MSMR Vol. 12 / No. 8 Nov. 2006

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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/OIF

• Smoke from burning trash or feces (44.6)-7
• Sand and dust storms (41.5)-6
• Gasoline, Jet Fuel, Diesel Fuel (21.1)-2
• Depleted Uranium (19.0)
• Paint, solvents, other petrochems (15.2)-10
• Oil well fire smoke (14.9)-3
• Contaminated food and water (14.4)-4
• Anthrax Vaccine (14.2)
• Multiple Vaccinations (13.9) 89gt3
• Vehicular Exhaust (10.3)
• Seen at NJ WRIISC, n612. 1889 concerns, range
  0-15

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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?

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But wait!
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Maybe theres hope!
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Maybe theres hope!

• The last decade has seen change happening at an
  increasing rate
• Brand new initiatives
• Entirely new programs
• New ways of doing what weve always done

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Didnt you say theres hope?

• Integrated Care Initiatives
• Exposure monitoring and tracking
• Better communications
• Medical surveillance
• Long term research program
• Making information available

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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

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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.

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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.

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WRIISC Services

• Clinical
• Education/Risk Communication
• Research

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WRIISC

• Unlike most VA programs, we were designed to be
  flexible to address the needs of post-deployment
  Veterans
• The VA was positively prescient!

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WRIISC

• We are able to focus on
• The Past
• The Present and
• The Future

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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!

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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

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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

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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.

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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

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PDICI

• Mission/Goals
• To 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

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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

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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.
  

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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

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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

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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.

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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

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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

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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

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POEMS

• Periodic Occupational Environmental Monitoring
  Summaries
• CHPPM/PHC
• Not service member specific, but site specific
  for a base camp

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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

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POEMS

• Only a few available at present
• Plan is to prepare many more
• Plan is to provide access to health care
  providers
• deanna.harkins_at_apg.amedd.army.mil 

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What have we learned?

• There is a huge universe of things we dont 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)

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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

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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

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What have we learned?

• Veterans do not come home from war
• They come home with war.

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• 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.

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• Thank you