1. 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

2.  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

3. 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

4. Environmental Exposure Concerns of Veterans –  Are exposure concerns of Veterans new?  What combat and military exposures are Veterans concerned about?

5. 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?

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

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

8. Vietnam Conflict  Signature environmental exposure??

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

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

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

12. 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

13. 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!

14. Presumptions Why?

15.  Okay, so exposures are not new.  Are exposure concerns new?

16. Prevalence (%) of exposure concerns common to Vietnam, Persian Gulf and Bosnia-Kosovo From Schneiderman, Lincoln, Wargo, et. al., APHA, 12-14-05

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 NOT GULF WAR SYNDROME Multi-System, Medically Unexplained Symptoms NOT GULF WAR SYNDROME  GW1 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: ConfusionRashCough HeadacheSOBFatigue Memory problemsChest painParasthesia Joint painsDiarrheaSleep disorder Muscle achesAbdominal painIrritability

19. 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.

20. 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 Through 3 rd Quarter FY 2010

21. 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

22. 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

23. 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

24. 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

25. 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?

26.  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.