1. 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

2. Objectives Define Environmental Exposures
Define Presumptive Conditions
Registry Examinations

3. 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:

4. 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).

5. 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

6. 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

7. 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

8. Agent Orange Exposure – Ship List
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

9. 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

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

11. 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.

12. 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.

13. 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.

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

15. 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. )

16. 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.

17. 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.

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

19. 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

20. 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

21. 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.

22. 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.

23. 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

24. 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
Phone: ,
8am - 4pm, Mon.- Fri.

26. 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

27. 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
McMurdo Station, Antarctica Nuclear power plant
Nose or throat radiation treatment ’s to prevent ear damage from pressure changes
Radiation therapy- to treat cancer

28. 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

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

30. 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.

31. 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

32. 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

33. 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

34. 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

35. 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:
WHAT

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

37. 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.

38. 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

39. 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

40. 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

41. . .

42. Registry Eligibility .

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

44. 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

45. 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

46. 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.

47. VA Compensation & Pension Benefits
Contact VA for the application by calling:
eBenefits –
See local county VSC or VSO
Apply online at