Depleted Uranium Exposure Myths Facts and What You

Depleted Uranium Exposure Myths, Facts, and What You Need to Know to Talk to Your Patients. Omowunmi (‘Wunmi) Osinubi, MD, M. Sc. , MBA, FRCA. Adjunct Assistant Professor Department of Occupational and Environmental Health UMDNJ-School of Public Health & Robert Wood Johnson Medical School Occupational Health Physician War Related Illness and Injury Study Center

Depleted Uranium - Clinical Case § Mr. Just Strong is a 39 yr old OIF Veteran § Recently diagnosed with Hodgkin’s lymphoma § His new born baby that was conceived post-deployment has down syndrome § Deployments § As Samawah, Iraq from 2/2003 to 8/2003 § Al Asad, Iraq from 8/2004 to 4/2005 § Exposure Concerns § § § Smoke from burn pit Sand dust storms Spider bites Multiple immunizations including small pox & anthrax Depleted uranium

Veteran’s Perspective § As Samawah base was reportedly contaminated with gamma radiation & DU. § 550, 000 metric tons of yellow cake uranium was reportedly transported through Baghdad which had to be transported by rail. The only major rail line was through As Samawah. § Locals looted containers of uranium from the Tuwaitha nuclear complex, § Used the large plastic containers as drinking pots, building materials, e. t. c. § Area littered with remnants/residues DU munitions & damaged vehicles § Area was found to have radiation levels that were 300 X the background rate. § His colleagues had non-specific rashes, joint aches, lethargy and malaise, but he had no symptoms at the time. § He was situated in close proximity to the 442 nd US Military Police Brigade and members of this unit reportedly have had a number of health problems. http: //www. msnbc. msn. com/id/25546334/

Public Perception - Toxic Effects of DU

Doctor: Did depleted uranium cause my health problems/concerns?

“The term depleted uranium is linguistically radioactive. Simply uttering the words can prompt a reaction akin to preaching atheism at tent revival. Heads shake, eyes roll, opinions are yelled from all sides” - Deborah Hastings http: //www. neilrogers. com/news/articles/2006081401. html

Natural Uranium § Heaviest naturally occurring element § Density: § 19 X that of water § 1. 65 X that of lead § Soil, rocks, surface & underground water, air, plants & animals § Average concentration § 0. 0003% of earth crust § 3. 0 µg/L in sea water § Trace amounts in food & water § 1 -2 µg daily intake in food § 1. 5 µg/L of water consumed § Human body content § Average 90 µg § 69 µg in skeleton § 7 µg in kidneys Appearance: silvery gray metallic Corrodes to a spalling black oxide coat in air

Civilian Uses of Natural Uranium § Primarily used as fuel for nuclear power plants § Smaller amounts used in manufacturing § § § Ceramic & pottery glazes Yellow glass Light bulbs & filaments Photographic chemicals Dentures Leather & wood stains/dyes

Radioactive Properties of Natural Uranium § Weakly radioactive element with 3 isotopes § 238 U (99. 2745%) § highest abundance; lowest radioactivity § T ½ = 4. 46 billion years § 235 U (0. 7200%) § T ½ = 704 million years § 234 U (0. 0055%) § lowest abundance; contributes half of radioactivity of natural uranium § T ½ = 245, 000 years § Uranium isotopes primarily emit alpha particles § § α particles are large & heavy with little penetrating power Range is 4 cm in air Travels only 25 -80 µm in tissues Poses radiation hazard only if it is in the body

§ Uranium isotopes decay to other radioactive elements which eventually decay to stable isotopes of lead § Decay process emits beta particles & gamma rays § Beta high energy electron range § 15 m in air § 1 cm in solids § Gamma rays § Highly penetrating ionizing radiation § Radiation hazard even when outside the body. An induced nuclear fission event involving uranium-235

What is Depleted Uranium? § DU is a byproduct of a process that converts natural uranium to enriched uranium for use in nuclear weapons and reactors Ø What is left is “depleted” uranium § DU is partially depleted of 235 U & 234 U Ø Ratio of 238 U to 235 U § Natural uranium = 137. 88 § Depleted uranium = 314. 95 § DU is about 60% as radioactive as natural uranium

Physical Properties of DU § Extremely dense heavy metal § 1. 67 times as dense as lead § Only slightly less dense than tungsten and gold § 84% as dense as Osmium or iridium (densest known substances) § High melting point § 2070 o. F or 1132 o. C § High tensile strength § Comparable with that of most steel § Abundant and inexpensive

DU Commercial Uses § § § Radiation shielding in medical equipment Aircraft counterweights Rotors Flywheels Ship ballasts Gyroscopes

Military Uses of DU § The M 2/3 Bradley fighting vehicles, M 1 -series tanks, and some US military aircrafts fire DU munitions § 25 mm & 30 mm DU rounds fired by the Air Force’s A 10 aircraft & Marine Corps’ AV-8 B Harriers § 105 mm & 120 mm kinetic energy penetrators anti-armor rounds fired by the Abrams tanks § US Navy’s Phalanx CIWS's M 61 Vulcan Gatling gun used 20 mm armor-piercing penetrator rounds § The M 1 A 1/A 2 Abrams heavy armor tanks use steel-encased DU for increased armor protection.

DU and Military Applications § Exceptionally valuable for use in weaponry for offense Ø Armor-piercing DU penetrating munitions § For a given mass of DU, it has a smaller diameter than an equivalent lead projectile § Less aerodynamic drag § Deeper penetration due to a higher pressure at impact

DU – Effective for Offence § Highly pyrophoric § DU rounds burst into flames when they hit their targets § Frequently causes explosions and fires especially when the target’s fuel tank or munitions are ignited

DU – Effective for Defense § High density DU is sandwiched between sheets of steel armor plate § M 1 A 1 HA & M 1 A 2 Abrams tanks built after 1998 have DU reinforcement in armor plating in the front of the hull and the turret. Location of DU armor

Use of Depleted Uranium in War § US Army began researching the use of DU for military applications in the early 1970 s § Desert Shield/Desert Storm (1990 -1991) was the first time that US military used DU munitions & armor protection extensively during conflict § Estimated 320 tons of DU was used in PGW § US military fired an estimated 860, 000 DU rounds, many in training & practice Ø Thousands of Iraqi tanks were destroyed by DU munitions Ø None of the American DU armored tanks were penetrated by Iraqi fire

Use of DU in Other US Conflicts § Bosnia-Herzegovina (1994 -5) § 10, 800 DU rounds were fired § Kosovo (1999) § 30, 000 DU rounds were fired § Operation Iraqi Freedom & Operation Enduring Freedom (2003 to Present) § Estimated amount of DU? ? ?

DU Exposures of Military Personnel § Iraqi forces did not have DU weaponry § US military personnel were exposed to DU as a result of: § § Friendly-fire incidents Clean-up and salvage operations Close proximity to burning DU armored tanks Occupants of Army combat vehicles struck by DU projectiles

Camp Doha, Kuwait fire PGW - July 1991 § A defective heater in an M 992 ammunition carrier loaded with 155 mm artillery shells caught on fire and exploded § Fire spread to other stored munitions and other vehicles loaded with ammunition § Chaotic series of explosions and fires, with vehicles & shells exploding for over 6 hours & fire burning for 24 hours § Fire destroyed $15 million in ammunition, over 100 vehicles and more than 20 buildings § Troops at the scene & clean-up personnel may have been exposed to DU residue § 4, 000 people in the area § 600 directly involved in cleanup & decontamination § Others were likely exposed through contact with vehicles or inhalation of DU dusts

Camp Doha Fire

DU Exposure Assessment Routes of exposure § DU penetrator strikes on military tanks/vehicles generate inhalable aerosols with high concentrations of DU § DU fragments can cause deep penetrating shrapnel wounds that may be retained in tissues § Ingestion of DU particles in contaminated vehicle and/or dusts is possible, but unlikely to be an important exposure route

DU Exposure Assessment (contd. ) § Exposure to DU aerosols affected by: § Characteristic of struck vehicle and impact conditions § Soft target (e. g. , lightly armored vehicle) § Little conversion to DU oxides § Hard target (e. g. , Abrams tank), much of penetrator mass is converted to DU oxides ØSubstantial DU aerosols generated § Residence time of personnel in contaminated vehicle

Levels of exposure to DU (DOD office of the Special Assistant for Gulf War Illness) § Level I – highest exposures § Occupants in or near combat vehicles when they were struck by DU rounds § Occupants of DU armored vehicles struck by non-DU munitions § Soldiers entered the struck vehicle soon after impact § Persons with DU fragments in shrapnel wounds Ø Inhalation of DU aerosols, ingestion of DU dusts and or contamination of open wounds with DU particles § Approximately 164 individuals experienced Level I exposures from friendly fire incidents in PGW § Approximately 75 soldiers with level I exposure are in a DU health effects cohort study.

Levels of Exposure to DU § Level II – Intermediate exposures § Soldiers & civilian employees worked on DU contaminated vehicles § Clean-up efforts from Camp Doha fire Ø Estimated 700 people § Level III – Lowest exposures § Troops downwind of burning DU ammunition or vehicles, or Camp Doha fire § Personnel entered DU contaminated Iraqi tanks Ø Estimated number of people is unknown

Chemical Toxicity of DU § Enriched, natural and depleted uranium have identical chemical properties & tissue toxicity § Kidney toxicity is primary effect of soluble uranium compounds § Studies of Uranium miners have documented impaired kidney function § None have found excess mortality from renal disease § Lung injury potentially caused by ionizing radiation from uranium decay isotopes § Insoluble uranium compounds remain in pulmonary tissues especially lymph nodes for a long time and constitute localized radiologic hazard

Radiological Toxicity § Radiological effects of natural uranium exceed those of DU § Studies of uranium miners & mill workers § High levels of uranium exposures over long periods § Prior research suggested elevated rates of lung & laryngeal cancer, leukemia & other cancers § Recent reviews & government reports have concluded that the apparent increased rates of cancers in uranium workers is questionable § Increased lung cancer attributable to confounding factors such as radon exposure in uranium mines, except at very high levels of U exposure.

Health Effects of DU Evidence-based Perspective Report Key Findings RAND, 1999 Little concern related to radiological effects and cancer or other health outcomes. Evidence does not suggest long-term excess morbidity or mortality from hematological or renal changes. IOM, 2000 & 2008 Inadequate evidence is to determine whethere is an association between uranium exposure and lung cancer or other cancers. Insufficient evidence to determine whether uranium exposure is associated with nonmalignant renal diseases, respiratory disease, or reproductive effects. USACHPPM 2000 In the Gulf War, Level I exposures may have exceeded radiation and chemical standards, warranting medical follow-up of individuals in friendly fire incidents; Levels II and III exposures are not likely to cause health effects.

Health Effects of DU Evidence-based Perspective Report Key Findings World Health Organization 2001 DU may produce transient dose-related effects on renal function; Insoluble inhaled particles may cause radiological damage in lung tissues, dermal effects are unlikely. British Royal Society 2002 Excess risk associated with radiation, primarily for lung cancer, is extremely small. Chemical toxicity may cause acute kidney effects in relation to very high exposure. Capstone Report 2004 Modeled health risks from DU inhalation, based on simulated friendly fire exposures, indicate that health effects from radiation are generally unlikely for personnel in, or near vehicles hit by DU munitions. Minimal increase in cancer risk and short-term kidney effects possible for personnel in unventilated Abrams tanks. Individuals working in DU contaminated vehicles for long periods may also exceed occupational exposure standards.

Cohort Study of PGW Veterans with Level I DU Exposure § Ongoing studies of Veterans who have embedded DU shrapnel compared to Veterans who had no exposure to DU. § After almost 14 years of follow up, the DU shrapnel group has not had any health problems that can be linked to the DU, including cancer, birth defects and kidney problems, even though their measures of uranium on a urine test are elevated, as expected. § Minor elevations in renal function tests did occur for the DU shrapnel Veterans but the overall mean values remained within normal clinical ranges. § Future research is needed to investigate if these minor changes would impact kidney function later on in life. § Current cohort has insufficient duration of follow-up and/or number of subjects to address cancer and or reproductive endpoints Ø Squibb et al. 2008, 2009; Squibb & Mc. Diarmid, 2006; Mc. Diarmid et al, 2004, 2001

Key Questions to ask to determine Veterans’ Probable DU Burden Question (s) about Possible Exposure (s) Exposure Body Burden of DU Did you have contact with intact DU? Handling intact DU munitions or sitting inside or near a vehicle with intact DU armor. The likelihood of exposure is extremely low and would approximate to Zero Did you fire DU munitions? Loading and firing weapons that fire armor piercing ammunition made of DU. Some smoke/fumes may be present, especially in closed spaces (e. g. , tanks). Slight/mild exposure Quite unlikely that there will be significant body burden of DU

Key Questions to ask to determine Veterans’ Probable DU Burden (Contd. ) Question (s) about Possible Exposure (s) Exposure Body Burden of DU Were you in close proximity to burning or exploded DU? Being in the smoke cloud of exploded DU munitions or burning DU armor, such as on an Abrams battle tank or a Bradley fighting vehicle. Mild to moderate chance of inhalation and/or ingestion of DU particles. Do you have retained DU shrapnel in your body? Metal fragments from DU armor or DU munitions remain in the body after an attack or accident. High chance of significant DU in the body. These Veterans may need to be evaluated further for DU exposure.

Discuss Risks of DU Exposure with Veteran § Engage in meaningful dialogue with the vet about his/her DU exposure concerns § Allow the Veteran to completely state what his or her concerns are before attempting to provide the factual information. Ø Listen and Empathize Ø Acknowledge and Normalize § Be honest and open with the Veteran about what you do and do not know Ø Builds trust and credibility § Provide factual information about DU § Address any residual DU exposure concerns § Offer test for DU if indicated Ø Probable moderate to high exposures Ø Any level of exposure if Veteran remains concerned about DU

What is the ‘Test’ for DU and What does it Show? Baltimore VA Medical Center (800 -815 -7533). § 24 -hour urine collection test measures the total uranium excretion rate (Gold standard). If the level of urine uranium is high, additional testing of the same urine sample will examine how much of the total uranium is DU. § Compares individual’s level of urinary DU to the normal range of DU excretion in the general population. § § § Results communicated directly to the Veteran by letter. A copy is sent to the referring VA provider. If urinary DU is high, the Veteran may be enrolled in an ongoing program to follow the uranium excretion rate over time. This determination will be made based on discussions among the Veteran, the Veteran’s VA primary care provider and the staff at the Baltimore DU Follow-up Program. Ø 24 hour DU excretion test does NOT measure any impact on kidney function or any health effect of the DU. Ø Annual measures of kidney function (BUN, creatinine, and urinalysis) as indicators of a possible health effect, would be prudent (as indicated) and likely reassuring to the Veteran,

Summary § Extensive amounts of DU weaponry has been used in US conflicts since 1991 Operation Desert Shield/ Desert Storm. § Levels of DU exposure are highly variable among deployed troops § Newspaper articles and conference reports have reported dramatic increases in cancer and birth defects in Iraqi locals in areas heavily contaminated with DU (Basrah) § Limitations in data make interpretation impossible § No formal studies have been conducted to clarify this issue § Evidence-based reviews of available scientific data have concluded: Ø It is biologically plausible that very high exposures to natural uranium for prolonged periods may cause cancer Ø This is not proven in epidemiological research Ø DU is less radioactive than naturally occurring uranium Ø DU potentially poses a chemical hazard at very high levels, but Gulf War exposure levels are unlikely to produce long-term excess morbidity or mortality from kidney, hematological, reproductive or malignant diseases

References Institute of Medicine. Gulf War and Health: Volume 1 - Depleted Uranium, Pyridostigmine Bromide, Sarin, Vaccines. Washington, DC: National Academy Press; 2000. Institute of Medicine. Gulf War and Health: Updated Literature Review of Depleted Uranium. Washington, D. C. : National Academy Press; 2008. Mc. Diarmid, MA, Engelhardt, SM, Dorsey, CD, et al. “Surveillance results of depleted uranium-exposed Gulf War I Veterans: sixteen years of follow-up. ” J Toxicol Environ Health A. 2009; 72(1): 14 -2989 Mc. Diarmid, MA, Engelhardt, SM, Oliver, M, et al. “Health surveillance of Gulf War I Veterans exposed to depleted uranium: Updating the cohort. ” The Radiation Safety Journal. 2008; 93(1): 60 -73. Mc. Diarmid MA, Engelhardt S, Oliver M, et al. “Health effects of depleted uranium on exposed Gulf War Veterans: A 10 year follow-up. ” J Tox Environ Health 2004; 67: 277 -96. Mc. Diarmid MA, Engelhardt SM, Oliver M. “Urinary uranium concentrations in an enlarged Gulf War Veteran cohort. ” Health Phys 80; 270 -273: 2001. Mc. Diarmid MA, Squibb K, Engelhardt, et al. “Surveillance of depleted uranium exposed Gulf War Veterans: Health effects observed in an enlarged ‘friendly fire’ cohort. ” JOEM 2001; 43(12): 991 -1000. Mc. Diarmid MA, Squibb K, Engelhardt, et al. “Biological Monitioring for Urinary Uranium in Gulf War 1 Veterans. ” Health Phys 2004; 87(1): 51 -56.

References Contd. Parkhurst MA, Daxon EG, Lodde GM, et al. Uranium Aerosol Doses and Risks: Summary of U. S. Assessments (Capstone Report). Richland, WA: Pacific Northwest National Laboratory; Oct, 2004. Research Advisory Committee on Gulf War Veterans’ Illnesses Gulf War Illness and the Health of Gulf War Veterans: Scientific Findings and Recommendations Washington, D. C. : U. S. Government Printing Office, November 2008 Royal Society. The health hazards of depleted uranium munitions - Part 1. London. May, 2001. Royal Society. The health hazards of depleted uranium munitions - Part 2. London. March, 2002. Squibb K & Mc. Diarmid MA. “Depleted uranium exposure and health effects in Gulf War Veterans. ” Phil Trans R Soc 2006; 361: 639 -48. U. S. Army Center for Health Promotion and Preventive Medicine http: //chppm-www. apgea. army. mil/documents/FACT/65 -0503. pdf U. S. Department of Defense, Office of the Special Assistant for Gulf War Illnesses. Environmental Exposure Report: Depleted Uranium in the Gulf (II). Washington, D. C. Dec 13, 2000. VHA Handbook 1303. 1 “Evaluation Protocol for Gulf War and Iraqi Freedom Veterans with Potential Exposure to Depleted Uranium (DU)” (September 2, 2004). http: //www 1. va. gov/vhapublications/View. Publication. asp? pub_ID=1158 World Health Organization. Depleted Uranium: Sources, Exposures and Health Effects. Geneva, Switzerland. Apr, 2001. WHO/SDE/PHE/01. 1.