War Related Illness and Injury Study Center

Airborne Hazards & Open Burn Pit Registry

Introduction to Airborne Hazards for Providers

What is the Airborne Hazards & Open Burn Pit Registry?

In January 2013, Public Law 112-260¹, the “Dignified Burial and Other Veterans’ Benefits Improvement Act of 2012,” was enacted. Section 201 of the law requires VA to establish a burn pit registry to monitor the health of Veterans who may have been exposed to airborne hazards (e.g., air pollution), inform Veterans about the registry, and periodically notify Veterans of significant developments related to the study and treatment of conditions associated with exposures. In response, VA’s Office of Public Health established a registry for individuals deployed to Southwest Asia on or after August 2, 1990, or Djibouti, Africa or Afghanistan after September 11, 2001. The registry consists of a web-based self-assessment to be completed by the eligible individual. Participants may also schedule an optional in-person clinical evaluation by a VA provider.² Up-to-date information about the registry and related resources are available at the Office of Public Health.

What is the concern about airborne hazards and open burn pits?

Burn pits were used in Operation Enduring Freedom and Operation Iraqi Freedom to dispose of all sorts of solid wastes. Material may have included human and medical waste, as well as substances known to generate carcinogens and other harmful substances produced in the combustion process. In addition, elevated levels of particulate matter from industrial activities, burning oil wells (particularly during and after Operation Desert Shield/Storm), and other man-made and natural sources contributed to poor air quality in many locations. Many deployed individuals wonder if these exposures affected their health.

In 2011, the Institute of Medicine (IOM) reviewed the scientific literature related to the possibility of adverse long-term health effects of open burn pits. The report noted that the U.S. Department of Defense monitored air quality and measured levels of particulate matter (PM) that were higher than generally considered safe by U.S. regulatory agencies.³ It also cited work linking high PM levels to cardiopulmonary effects, particularly in individuals at increased risk due to pre-existing conditions such as asthma and emphysema. However, the IOM concluded there is only limited evidence suggestive “of an association between exposure to combustion products and reduced pulmonary function in these populations”⁴.

What are the clinical concerns?

There are published reports of higher rates of self-reported pulmonary symptoms⁵, higher rates of asthma⁶, and rare, unexpected conditions (e.g., eosinophilic pneumonia and constrictive bronchiolitis)^7,8 among Service members deployed to Southwest Asia. However, there are also publications that report finding no elevation in disease or symptom-reporting rates.⁹ Given the different methods and conclusions of these studies, it is still unclear exactly what problems deployed individuals may develop or how widespread these problems are. However, current evidence does warrant heightened clinical attention to exposed individuals reporting cardiopulmonary symptoms.¹⁰

Talking About Health and Exposure Concerns

It is essential to listen to and respect the Veteran’s concerns about the exposure and possible health effects. Airborne hazards exposure and possibly associated health risks are complex issues with many uncertainties. Other risk factors may be present, such as past or current cigarette smoking, civilian occupational exposures, or other inhalation exposures, which can complicate causal attribution. The complex interplay can result in disagreement about the relative contribution of various risk factors to the current health status of a patient. It is often impossible to definitively ascertain the contribution of a particular risk factor for an individual.

By taking the time to listen to the Veteran’s concerns, a provider can establish trust and rapport and assess gaps in knowledge and differences of opinion. This information can be critical for making informed decisions about possible next steps or management of health concerns. Identifying areas of agreement and focusing on risk reduction and optimization of health and function may provide a constructive way forward. Health risk communication is emphasizes the importance of building trust through active listening and empathy and recognizing the relevance of perceptions of possible harm. It also acknowledges the uncertainties related to extent of exposure, relationship between exposures and possible health effects, diagnostic precision, management options, and prognosis.¹¹

What initial evaluation is appropriate?

The clinician should first assess the intensity and specific focus of concern of the individual using the health risk communication approach discussed above. Patients seeking medical attention may have a variety of symptoms and exposure concerns.

At this time, there are no biomarkers specific to the environmental exposure-related health concerns of U.S. Service members deployed to Southwest Asia, Afghanistan, or Djibouti. Clinicians must rely on their own evidence-based knowledge, expertise, and skills to guide a patient-centered evaluation and management. For example, for an individual with chronic lower respiratory symptoms, such as wheezing, chronic cough, or dyspnea with exertion, the following might be appropriate initially:

• a complete blood count— to rule out anemia
• postero-anterior and lateral chest radiographs— to rule out significant structural abnormalities
• pulse oximetry— to assess for hypoxia
• spirometry with bronchodilator— to assess pulmonary function and reversibility of bronchoconstriction

Other symptoms should be evaluated according to best clinical practices, as well.

What specialty consultations are warranted?

The decision to conduct specialty evaluations should be made in the context of the individual patient’s concerns and symptoms, findings on initial evaluation, and the comfort level of the primary care team. The indicated specialty evaluations are considered part of the registry evaluation and should be made available to the individual by VHA at no cost to the Veteran. Some specialties of particular relevance include:

• pulmonary (PULM)
• ear, nose and throat (ENT)
• allergy/immunology (ALL/IMM)

Consultations might result in additional assessments, such as high-resolution chest computerized tomography (CT) scan, full pulmonary function tests, assessment of vocal cord function, cardiopulmonary exercise tests, or lung biopsy^12,13.

The Veterans Health Administration maintains the Environmental Health Program with a designated Environmental Health Coordinator and Clinician at each VA medical center. Some of these clinicians may be able to provide additional information about deployment-related exposure or health concerns (see a listing of Environmental Health Coordinators by state and facility). This describes how a Veteran can apply and includes information about local benefits offices if he or she wishes to initiate the process in person.

After local evaluation is completed, some patients may still have complex, difficult-to-diagnose or medically unexplained health concerns related to airborne hazards concerns or other deployment-related exposures. For these patients, consultation with the War Related Illness and Injury Study Center (WRIISC) might be appropriate.

Service Connected Disability

In addition, Veterans may have questions about service-connected disability benefits. The clinician should acknowledge these and can refer the Veteran to the Veterans Benefits Administration for more information.

References

1. Public Law 112-260. *
2. Department of Veterans Affairs Notice: Initial Research on the long-Term Health Consequences of Exposure to Burn Pits in Iraq and Afghanistan, Federal Register, Vol 78. No 23, Monday February 4, 2013. *
3. EPA/600/R-08/139F Integrated Science Assessment for Particulate Matter. National Center for Environmental Assessment – RTP Division, ORD, US EPA, December 2009. *
4. IOM, “Long-term health consequences of exposure to burn pits in Iraq and Afghanistan” 2001, Washington, DC: The National Academies Press. *
5. Smith B, Wong CA, Smith TC, Boyko EJ, Gackstetter GD, Ryan MAK. Newly Reported Respiratory Symptoms and Conditions Among Military Personnel Deployed to Iraq and Afghanistan: A Prospective Population-based Study. Am J of Epidemiol 170:1433-1442, 2009. *
6. Szema AM, Peters MC, Weissinger KM, Gagliano CA, Chen JJ. New-onset Asthma Among Soldiers Serving in Iraq and Afghanistan. Allergy Asthma Proceedings 31:e67-e71, 2010.)
7. Shorr AF, Scoville SL, Cersovsky SB, Shanks GD, Ockenhouse CF, Smoak BL, Carr WW, Petruccelli BP. Acute eosinophilic pneumonia among US Military personnel deployed in or near Iraq. JAMA. 2004 Dec 22;292(24):2997-3005. *
8. King MS, Eisenberg R, Newman JH, Tolle JJ, Harrell FE, et al. Constrictive Bronchiolitis in Soldiers Returning from Iraq and Afghanistan. N Engl J Med 365:222-230, 2011.*
9. Abraham JH, Baird CP. A Case-Crossover Study of Ambient Particulate Matter and Cardiovascular and Respiratory Medical Encounters Among US Military Personnel Deployed to Southwest Asia. J Occup Environ Med 54:733-739, 2012. *
10. Kreiss K. Occupational causes of constrictive bronchiolitis. Curr Opin Allergy Clin Immunol. 2013 Apr;13(2):167-72. *
11. Santos SL, Helmer D, Teichman R. Risk communication in deployment-related exposure concerns. J Occup Environ Med. 2012 Jun;54(6):752-9.
12. Rose C, Abraham J, Harkins D, Miller R, Morris M, et al. Overview and Recommendations for Medical Screening and Diagnostic Evaluation for Postdeployment Lung Disease in Returning US Warfighters. J Occup Environ Med 54:746-751, 2012. *
13. Morris MJ, Lucero PF, Zanders TB, Zacher LL. Diagnosis and management of chronic lung disease in deployed military personnel. Ther Adv Respir Dis. 2013 Aug;7(4):235-45.

Disclaimer

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