Office of Public Health Environmental Hazards Environmental Exposure

Office of Public Health & Environmental Hazards Environmental Exposure Concerns of Veterans: Agent Orange and Beyond What 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 (19501953) § 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 Orange Presumptively 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 Orange Presumptively 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 From Schneiderman, Lincoln, Wargo, et. al. , APHA, 12 -14 -05

Top ten environmental exposures of concern: Gulf War 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 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

Multi-System, Medically Unexplained Symptoms NOT GULF WAR SYNDROME § GW 1 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 Headache Memory problems Joint pains Muscle aches Rash SOB Chest pain Diarrhea Abdominal pain Cough Fatigue Parasthesia Sleep disorder 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.

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

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 months MSMR Vol. 15 / No. 7 – Sept. 2008

Top five Concerns of Veterans from Afghanistan and Iraq 1. 2. 3. 4. 5. Sand Noise Smoke from trash Vehicle exhaust JP 8 or other fuel MSMR Vol. 12 / No. 8 – Nov. 2006

MSMR Vol. 12 / No. 8 – Nov. 2006 Reserve 25. 0 Active Solvents 30. 0 Blast/ /Vehicleaccident Blast DEET on on skin Pesticidetreateduniform Pesticide Industrial pollution Excessive vibration Smoke from oil fire JP 8 or or Fuel Vehicle exhaust Smoke from trash Noise Sand Percent Frequency of OEF/OIF service member exposure concern reported on the PDHRA (9/05 -8/06) 20. 0 15. 0 10. 0 5. 0 0. 0

Top ten environmental exposures of concern: OEF/OIF 1. Smoke from burning trash or feces (44. 6%)-7 2. Sand dust storms (41. 5%)-6 3. Gasoline, Jet Fuel, Diesel Fuel (21. 1%)-2 4. Depleted Uranium (19. 0%) 5. Paint, solvents, other petrochems (15. 2%)-10 6. Oil well fire smoke (14. 9%)-3 7. Contaminated food and water (14. 4%)-4 8. 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.