Environmental Exposures in the Military 2017 Hidden Wounds of War Conference West Michigan Veterans Coalition Grand Rapids, MI May 11, 2017 Deborah S. Heaney, MD, MPH VA Ann Arbor Healthcare System

Objectives Define Environmental Exposures Define Presumptive Conditions Registry Examinations

Types of Environmental Exposures Veterans may have been exposed to a range of environmental hazards during military service such as: Chemicals (Agent Orange, contaminated water…) Radiation (nuclear weapons, x-rays…) Air Pollutants (burn pit smoke, dust…) Occupational Hazards (asbestos, lead…) Warfare Agents (chemical and biological weapons) See more at: http://www.publichealth.va.gov/exposures

Presumptive Conditions VA assumes that certain diseases can be related to a Veteran's qualifying military service. Don’t have to prove an association between illness and military service. Link is presumed (assumed).

ALS Presumptive VA presumes ALS-amyotrophic lateral sclerosis (Lou Gehrig's Disease) diagnosed in all Veterans who had 90 days or more continuous active military service is related to their service (not any particular exposure). Rare incurable

Agent Orange Exposure Herbicide- sprayed 1962-1971 Named for the Orange identifying stripe used on the 55-gallon drums in which it was stored. Used for combat operations Heavy sprayed areas included: forests near the DMZ (demarcation zone), forests at the junction of the borders of Cambodia, Laos, and South Vietnam, and mangroves on the southernmost peninsula of Vietnam and along shipping channels southeast of Saigon. Dioxin TCDD unwanted byproduct of herbicide Inside and Outside Vietnam

Agent Orange Exposure Those the VA considers exposed include: Exposure to Agent Orange in Vietnam-on land or inland waterways (Brown Water Navy) Airmen who worked on C-123 Aircraft- Agent Orange residue Korean DMZ Thailand Military Bases- exposure at or near airbase perimeter Blue Water Navy- large ocean-going ships, certain ships

Agent Orange Exposure – Ship List http://www.benefits.va.gov/compensation/claims-postservice-agent_orange.asp Ships operating primarily or exclusively on Vietnam’s inland waterways Ships operating temporarily on Vietnam’s inland waterways Ships that docked to shore or pier in Vietnam Ships operating on Vietnam’s close coastal waters for extended periods with evidence that crew members went ashore Ships operating on Vietnam’s close coastal waters for extended periods with evidence that smaller craft from the ship regularly delivered supplies or troops ashore

Agent Orange Presumptives Amyloidosis Chloracne Diabetes Mellitus Type II Ischemic Heart Disease Parkinson’s Disease Peripheral Neuropathy-Early Onset Porphyria Cutanea Tarda CANCERS Chronic B-cell Leukemias Hodgkin’s Disease Multiple Myeloma Non-Hodgkin’s Lymphoma Prostate cancer Lung and other respiratory cancers Soft Tissue Sarcomas

Veterans and Agent Orange: Update 2014 . Veterans and Agent Orange: Update 2014 National Academies of Sciences, Engineering, and Medicine. 2016. Veterans and Agent Orange: Update 2014. Washington, DC: The National Academies Press.

Agent Orange Exposure Birth Defects Spina Bifida is the only condition related for compensation. Incomplete closing of the vertebrae around the spinal cord. Most common birth defect in the United States.

Agent Orange Exposure Birth Defects Veterans and Agent Orange: Update 2014 Committee: Effects on Veterans' Descendants Did not find any new significant associations between the relevant exposures and adverse outcomes in future generations. Changed the previous categorization for spina bifida to inadequate or insufficient.

Gulf - Definition Veterans who served on active duty in the Southwest Asia theater of military operations any time from August 2, 1990 to present. Iraq, Kuwait ,Saudi Arabia, Bahrain, Qatar, The United Arab Emirates (U.A.E.), Oman, Gulf of Aden, Gulf of Oman Waters of the Persian Gulf, the Arabian Sea, and the Red Sea The airspace above these locations.

Gulf - Definition Operation Desert Shield Operation Desert Storm Operation Iraqi Freedom (OIF) Operation New Dawn NOT Operation Enduring Freedom (OEF )- Afghanistan

Gulf War Potential Exposures Vaccinations (including anthrax) Oil Well Fires Chemical and Biological Weapons (demolished storage depots) Depleted uranium (used in tank armor and some bullets) Noise CARC paint (vehicles) Pyridostigmine Bromide-PB (tablet to prevent against nerve agent) Pesticides Sand, dust, and particulates Toxic Embedded Fragments (shrapnel and other metal) Infectious disease (9 specific) Heat Injury Other occupational hazards (machinery, chemicals, paint, etc. )

Gulf War Veterans’ Medically Unexplained Illnesses Cluster of medically unexplained chronic symptoms that can include fatigue, headaches, joint pain, indigestion, insomnia, dizziness, respiratory disorders, and memory problems. VA refers to these illnesses as "chronic multisymptom illness" and "undiagnosed illnesses." VA presumes certain chronic, unexplained symptoms existing for 6 months or more are related to Gulf War service without regard to cause. The "presumptive" illness must have first appeared during active duty in the Southwest Asia theater of military operations or by December 31, 2021. and be at least 10 percent disabling.

Gulf War Veterans’ Medically Unexplained Illnesses VA does not uses the term “Gulf War Syndrome” because symptoms vary widely. Syndrome= a group of symptoms that consistently occur together or a condition characterized by a set of associated symptoms.

Gulf War Presumptives Diagnosable Chronic Fatigue Syndrome Diagnosable Fibromyalgia Diagnosable Functional Gastrointestinal disorders (IBS, etc.) Undiagnosed illness

Gulf War & Afghanistan Presumptive Infectious Diseases Brucellosis- from animals Campylobacter jejuni- foodborne illness Coxiella burnetii (Q fever)- infected animals Malaria – mosquito Mycobacterium tuberculosis (TB) Nontyphoid Salmonella- foodborne illness Shigella- foodborne illness Visceral leishmaniosis- parasite West Nile Virus- mosquito

Research Updates No association with “chronic multisystem illnesses” Pyridostigmine Bromide (PB) anti-nerve agent pill Pesticides CARC paint Particulate matter (PM) Vaccinations- Insufficient/inadequate evidence at this time. Oil well fires

Health Effects Respiratory CARC paint- Dry paint is no problem. Inhaling during painting (especially spray painting) can be harmful to lungs. Particulate matter (PM)- Respiratory and cardiopulmonary health effects in specific, susceptible groups such as young children, the elderly, and people with existing asthma or cardiopulmonary disease. Oil well fires- No long-term health problems. Particles from oil well fires may cause skin irritation, runny nose, cough, shortness of breath; eye, nose, and throat irritation; and aggravation of sinus and asthma conditions. Most of the irritation is temporary and resolves once the exposure is gone.

Airborne Hazards -Burn Pits Way to get rid of waste in Iraq and Afghanistan Toxins in burn pit smoke may affect the skin, eyes, respiratory and cardiovascular systems, gastrointestinal tract and internal organs. Veterans who were closer to burn pit smoke or exposed for longer periods may be at greater risk. Most of the irritation is temporary and resolves once the exposure is gone. This includes eye irritation and burning, coughing and throat irritation, breathing difficulties, and skin itching and rashes. Sand, Dust and Particulates (fine particles) may pose greater risk No presumptives At this time, research does not show evidence of long-term health problems from exposure to burn pits. VA continues to study.

War Related Illness & Injury Study Center Clinical program providing Environmental Exposure Assessments For Veterans with “chronic, medically unexplained symptoms and/or and difficult to diagnose symptoms that they believe are related to their deployment.” Provides post-deployment health education to Veterans and families Research Program

War Related Illness & Injury Study Center East Orange, NJ Mailing Address: War Related Illness and Injury Study Center Department of Veterans Affairs New Jersey Health Care System 385 Tremont Ave, Mail Stop 129 East Orange, New Jersey 07018-1023 Email: wriisc.nj@va.gov Phone: 1-800-248-8005, 8am - 4pm, Mon.- Fri.

Ionizing Radiation Two types of radiation, non-ionizing and ionizing. Ionizing radiation sends out extremely high energy, which may pose a health risk: Heat or light from the sun, x-rays, and gamma rays from radioactive elements. Non-ionizing is electromagnetic radiation without enough Energy to cause damage: radio, microwave

Ionizing Radiation Radiation-Risk Activity Fukushima nuclear accident-Japan 2011 Radiation-risk activity- nuclear weapons testing and Hiroshima & Nagasaki (Atomic Veterans) Military occupational Exposure- nuclear weapons and dental techs Depleted Uranium-During an explosion, pieces used in tank armor and some bullets can scatter and embed in muscle and soft tissue. LORAN radiation-long range navigation Coast Guard 1942-2010 McMurdo Station, Antarctica Nuclear power plant 1964-1973 Nose or throat radiation treatment- 1940-1960’s to prevent ear damage from pressure changes Radiation therapy- to treat cancer

Ionizing Radiation Presumptives- Cancers bile ducts bone brain breast colon esophagus gall bladder liver(not w/ cirrhosis or hepatitis) lung pancreas pharynx ovary salivary gland small intestine stomach thyroid urinary tract (kidney, bladder) leukemia (except CLL) Non-Hodgkin’s lymphoma multiple myeloma

Ionizing Radiation- Possible Causation All cancers Non-malignant thyroid nodular disease Parathyroid adenoma Posterior subcapsular cataracts Tumors of the brain and central nervous system

Depleted Uranium The process of manufacturing enriched uranium from natural uranium used in nuclear reactors or weapons leaves "depleted" uranium. DU has 40 percent less radioactivity, but the same chemical toxicity as natural uranium. U.S. military uses DU: tank armor and some bullets made with depleted uranium (DU) penetrate enemy armored vehicles began using DU on a large scale during the Gulf War.

Depleted Uranium When projectile made with DU penetrates a vehicle, small pieces of DU can scatter and become embedded in muscle and soft tissue; If service member is exposed in a struck vehicle, may inhale or swallow small airborne DU particles Potential health hazard it embedded, inhalation or ingestion The DU Follow-Up Program is especially geared to Veterans who were on, in or near vehicles hit with "friendly fire"; rescuers entering burning vehicles, and those near burning vehicles; salvaging damaged vehicles; or near fires involving DU munitions. Gulf War, Bosnia, OEF, OIF, Operation New Dawn

Depleted Uranium Exposures May have been exposed: on, in or near vehicles hit with friendly fire; entering or near burning vehicles; near fires involving DU munitions; or salvaging damaged vehicles Simply riding in a vehicle with DU weapons or DU shielding will not expose to significant amounts of DU or external radiation So far no health problems have been found associated with DU exposures No presumptives Depleted Uranium Follow-Up Program- questionnaire & 24-hr urine Toxic Embedded Fragment program

Camp Lejeune- History From the 1950s through the 1980s, people living /working at the U.S. Marine Corps Base Camp Lejeune, NC, were potentially exposed to drinking water contaminated with volatile organic compounds (VOCs)- TCE,PERC/PCE, VC and benzene. In 1980 began doing testing, no EPA til 1970 Specific ones identified in 1982 WHERE

Sources of Contamination Off-base dry cleaning firm ABC cleaners Leaking underground storage tanks Waste disposal sites First detected in 1982, contaminated wells were shut down by February 1985, and the system was shut down in March, 1987 VC break-down product TT and HP are region of CL – treatment plants

Primary Chemicals Tetrachloroethylene or Perchloroethylene (PCE or “Perc”)  - dry cleaning solvent Trichloroethylene (TCE) - metal degreasing solvent Benzene -a fuel component Vinyl chloride - which can form when TCE/PCE break down For more information, visit: http://www.atsdr.cdc.gov/sites/lejeune/chapterA_factsheet.html WHAT

CLCW Presumptive Conditions In effect as of March 14, 2017- 30 days on base Kidney Cancer Liver Cancer Non-Hodgkin Lymphoma Adult Leukemia Multiple Myeloma Parkinson's Disease Aplastic Anemia / Myelodysplastic Syndromes Bladder Cancer

Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012 Among those standing with the President at the Aug 6 signing were Jerry Ensminger, a Marine Corps veteran who has been an advocate for affected families, and Mike Partain, who was born at Camp Lejeune and later developed male breast cancer. The bill the President signed was named after Janey Ensminger, the Master Sergeant's daughter who passed away from leukemia at age nine.

Healthcare Law Provides hospital care and medical services to Veterans and Family Members who were stationed or resided at CL for > 30 days between Aug. 1,1953 to Dec. 31, 1987: Veterans on active-duty status assigned to Camp Lejeune Family Members* who were residents on Camp Lejeune or in-utero 15 covered conditions *VA is the payer of last resort for family members

The 15 Conditions in the Health Care Law Esophageal cancer Lung cancer Breast cancer Bladder cancer Kidney cancer Leukemia Multiple myeloma Myelodysplastic syndromes 9. Renal toxicity 10. Hepatic steatosis 11. Female infertility 12. Miscarriage 13. Scleroderma 14. Neurobehavioral effects 15. Non-Hodgkin’s lymphoma

Environmental Health Registries Free, voluntary medial assessment for Veterans who may have been exposed to certain environmental hazards during military service. Agent Orange Airborne Hazards and Open Burn Pit Gulf War Ionizing Radiation Depleted Uranium In 1980 began doing testing, no EPA til 1970 Specific ones identified in 1982 WHERE

. https://www.publichealth.va.gov/docs/exposures/registry-evaluation-brochure.pdf .

Registry Eligibility .

Environmental Health Registries No testing for chemicals (except Depleted uranium) No test for specific exposures like vaccines, PB tabs, etc. No test for radiation

Environmental Health Registries Data Gathering To document exposure and health concerns Not related to compensation system Not required for claims Questionnaire- exposures and medical diagnoses & symptoms are entered Exam and Lab testing offered No ongoing treatment Primary Care evaluation suggested Contact VA to schedule

Airborne Hazards/ Burn Pit Registry Eligible Veterans and Servicemembers include those who served in: Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Djibouti, Africa on or after September 11, 2001 Operations Desert Shield or Desert Storm Southwest Asia theater of operations on or after August 2, 1990 Online only- can opt to have an examination https://veteran.mobilehealth.va.gov/AHBurnPitRegistry/#page/home

Chemical Warfare Agents Chemical and Biological weapons Mustard gas- 1940’s Nerve agents (Sarin) Military warfare tests in 60’s-70’s **Process for evaluation and surveillance being developed.

VA Compensation & Pension Benefits Contact VA for the application by calling: 1-800-827-1000 eBenefits – www.ebenefits.va.gov See local county VSC or VSO Apply online at www.va.gov