1. Exposures of Veterans: Agent Orange and Beyond What 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

2. Environmental Exposures of Veterans: Agent Orange and Beyond What Have We Learned?

3. Not much…

4.  Burning trash  Harsh Weather Conditions  Poor Sanitary Conditions  Pesticides and Insects  Hazardous Weapons Systems  Occupational Chemical Hazards Which war am I talking about?

5. Which one?  Korean War (1950- 1953)  Vietnam (1961-1975)  Grenada (1983)  Panama (1989)  First Gulf War/Desert Storm (1990-91)

6. Maybe one of these?  Somalia (1993)  Bosnia (1993-95)  Kosovo (1998-99)  Operation Enduring Freedom/OEF (2001- present)  Operation Iraqi Freedom/OIF (2003- present)

7. Vietnam Conflict  Signature environmental exposure??

8. Vietnam Conflict  Signature environmental exposure??  Correct – Agent Orange!

9. Vietnam Conflict  Signature environmental exposure??  Correct – Agent Orange!  Other exposures?

10. Vietnam Conflict  Signature environmental exposure??  Correct – Agent Orange!  Other exposures?  Napalm  Malaria, insects, insecticides  Burning trash  Poor hygiene and sanitary conditions

11. 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

12. 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!

13. 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  Prostate Cancer  Respiratory Track Cancer

14. Vietnam – Agent Orange Presumptively Service Connected Conditions  Diabetes Mellitus-Type II  B Cell Leukemias  Ischemic Heart Disease  Parkinson’s Disease  Next – HTN?  All sequelae thereof!

15. Presumptions Why?

16. Prevalence (%) of exposures common to Vietnam, Persian Gulf and Bosnia-Kosovo

17. Top ten environmental exposures of concern: Gulf War 1.Protective gear/alarms (82.5%) 2.Diesel, kerosene, other petrochems (80.6%) 3.Oil well fire smoke (66.9%) 4.Local food (64.5%) 5.Insect bites (63.7%) 6.Harsh weather (62.5%) 7.Smoke from burning trash or feces (61.4%) 8.Within 1 mile of missile warfare (59.9%) 9.Repellants and pesticides (47.5%) 10.Paint, solvents (36.5%) From Schneiderman, Lincoln, Wargo, et. al., APHA, 12-14-05

18. 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.

19. 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

20. 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

21. Top five Concerns of Veterans from Afghanistan and Iraq 1.Sand 2.Noise 3.Smoke from trash 4.Vehicle exhaust 5.JP8 or other fuel MSMR Vol. 12 / No. 8 – Nov. 2006

22. Frequency of OEF/OIF service member exposure concern reported on the PDHRA (9/05-8/06) MSMR Vol. 12 / No. 8 – Nov. 2006 Sand Noise Smoke from trash Vehicle exhaust JP8 or Fuel Smoke from oil fire Excessive vibration Industrial pollution Pesticide treated uniform DEET on skin Blast / Vehicle accident Solvents 30.0 25.0 20.0 15.0 10.0 5.0 0.0 Percent Reserve Active Sand Noise Smoke from trash Vehicle exhaust JP8 or Fuel Smoke from oil fire Excessive vibration Industrial pollution Pesticide treated uniform DEET on skin Blast / Vehicle accident Solvents 30.0 25.0 20.0 15.0 10.0 5.0 0.0 Percent Reserve Active

23. Top ten environmental exposures of concern: OEF/OIF 1.Smoke from burning trash or feces (44.6%)-7 2.Sand and 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

24. 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?

25. But wait!

26. Maybe there’s hope!

27.  The last decade has seen change happening at an increasing rate  Brand new initiatives  Entirely new programs  New ways of doing what we’ve always done

28. Didn’t you say there’s hope?  Integrated Care Initiatives  Exposure monitoring and tracking  Better communications  Medical surveillance  Long term research program  Making information available

29. 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

30. 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.

31. 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.

32. WRIISC Services  Clinical  Education/Risk Communication  Research

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

34. WRIISC We are able to focus on:  The Past  The Present and  The Future

35. 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!

36. 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

37. 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

38. 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.

39. 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

40. 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

41. 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

42. 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.

43. 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

44. 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

45. Developing A Medical Surveillance Program - What happened at Qarmat Ali 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.

46. 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

47. 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

48. 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

49. POEMS  Periodic Occupational Environmental Monitoring Summaries  CHPPM/PHC  Not service member specific, but site specific for a base camp

50. 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

51. POEMS  Only a few available at present  Plan is to prepare many more  Plan is to provide access to health care providers  deanna.harkins@apg.amedd.army.mil

52. What have we learned?  There is a huge universe of things we don’t 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)

53. 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

54. 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

55. What have we learned?  Veterans do not come home from war…  They come home with war.

56. 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.

57. Thank you