Disclosures Respiratory Hazards of Military Restricted research - - PDF document

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Respiratory Hazards of Military Service

Mehrdad Arjomandi, MD University of California San Francisco San Francisco Veterans Affairs Medical Center

Disclosures

• Restricted research grants through

Department of Veterans Affairs research foundation from:

– Five Prime Therapeutics – GlaxoSmithKline – MagArray Inc.

• Nothing to disclose in regards to this talk

Learning Objectives

• Recognize military service as an occupation

with both common and unique exposures

• Describe the occupational respiratory

hazards in modern era wars

• Describe the various physical, chemical, and

psychological hazards encountered in military service that can augment respiratory morbidities

Occupational & Environmental Medicine

• Devoted to:

– Prevention & management of

• ccupational &

environmental injury, illness & disability – Promotion

• f health & productivity
• f workers, their

families & communities

• Assists employers in:

– Identifying hazards – Detecting exposures – Protecting the workforce – Educating people regarding workplace hazards

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Why should we care about military service specific occupational exposure?

• Many exposure are similar to those

experienced in non‐military occupations

• Many health conditions associated with

exposures encountered during military service are recognized after its conclusion

• Most veterans obtain their care outside the

Veterans Affairs Healthcare System

– Total # of Veteran Population in 2014= 21,619,731 – # of Veterans using VA in 2014= 5,908,042 – % Veterans not using VA in 2014= 73%

Congressional Research Service Report #7‐5700. R43579. www.crs.gov

Military Service as an Occupation

• The most serious health hazards from military

service are due to trauma:

– Penetrating wounds (GSW & sharp injuries) – Blunt trauma – Blast injury – Burns

• However, the most common health hazards

that service members encounter are due to

• ther occupational & environmental conditions

that they are obliged to work in

Routes of exposure

Damalas C, et al. Toxics 2016, 4(1)

Contact Ingestion Inhalation

& Injection

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Deployment‐Related Exposures:

Every Conflict Has Its Own Characteristics Exposure

Agent Orange Nerve Agent Solvents Anti‐ Malarial Dust & Sand Fuels Pesticides Radiation Depleted Uranium Vaccines Oil Well Fires Burn Pits

Slide courtesy of Michael Falvo, PhD; New Jersey War‐related Injury & Illness Study Center

Inhalational Hazards Encountered during Military Service

• Natural air pollution:

– Sandstorms – Forest fires

• Anthropogenic (human‐made) air pollution:

– Fossil fuel‐related:

• Fuel‐burning vehicles and aircrafts
• Factories
• Oil‐well fires

– Military‐specific:

• Open air burn pits
• Herbicides & pesticides
• Depleted uranium
• Chemical weapons

Dust and Sand Storms

• Southwest Asia is known to have some of

the highest levels of particulate matter (PM) in the world

• Reports from Middle East have documented

frequent dust or sand events:

– 1 event every 3 days – PM 10 >200 μg/m3 & PM 2.5 >60 μg/m3 – Associated with increase hospital admissions due to respiratory conditions

Thalib & Al‐Taiar 2012

Concentrations

• f PM 10 & 2.5 in

the Middle East

• National Ambient

Air Quality Standards (NAAQS):

– Not to be exceeded PM 10 = 150 μg/m3

• nce a year

– Annual average PM 2.5= 12 ‐ 35 μg/m3

Engelbrecht et al. 2008

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Open Air Burn Pits

• Military operations generate large quantities of

waste that need to be disposed of:

• 8‐10 lbs waste/day/person
• Example: Joint Base Balad burn pit

– >15,000 personnel – ~200 tons waste/day – A range of possible pollutants including:

• Combustion by‐products
• Volatile organic compounds
• PM
• Generate incomplete combustion

GAO 2010; IOM 2011

Open Air Burn Pits

• Alternatives to open‐air burn pits are solid

waste incinerators

– Capacity: 30 tons waste/day – More complete burn – Increased use over time:

• # installed in Iraq grew from 2 to 39
• # of installed in Afghanistan from 1 to 20

GAO 2010; IOM 2011

Institute of Medicine Report on Burn Pits

• “…service in Iraq or

Afghanistan – might be associated with long‐ term health effects, in highly exposed…or susceptible populations”

• Public Law 112‐260
• On‐line self‐assessment questionnaire (SAQ)
• Optional in‐person clinical evaluation

http://www.publichealth.va.gov/exposures/burnpits/registry.asp

Airborne Hazards & Burn Pit Registry

Slide 16 OOY1

Osinubi, Omowunmi Y., 9/23/2014

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Airborne Hazards & Burn Pit Registry

• Eligible veterans & service

members 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

• perations on or after

August 2, 1990

• No cost to participate
• Not a disability

compensation questionnaire or required for other VA benefits

• Enrollment in VA’s health

care system not necessary

• In total, 99,713 veterans &

service members completed and submitted the registry between 2014 & 2017

http://www.publichealth.va.gov/exposures/burnpits/registry.asp

Vulnerability & Susceptibility Factors Affecting the Respiratory Health in Military Personnel

Falvo et al., Epidemiologic Rev, 2015

Stress & Violence

• Animal studies:

– Respiratory effects of particulate matter exposure in rats worsens with stress

• Human Studies:

– Animal studies show worse respiratory

• utcome in response to

exposure to

Clougherty et al., Environ Health Persp, 2010; Niles et al., Chest, 2011

Military Living Condition

• Dry climate promotes

generation of aerosolized PM pollution

• Exercising in hotter

climate increases susceptibility to pollutant‐induced respiratory symptoms

Garcia‐Chevesich et al., Environ Poll, 2014; Gordon et al., Compr Physiol, 2014

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Increased Ventilation with Exertion

• Military service is an

active job which requires:

– Staying in good physical condition by exercise – Severe exertion

• Even carrying a heavy

load – like a military assault load – can increase ventilation

• Exertion:

– Increases ventilation – Promotes mouth breathing

Rundell , Br J Sports Med 2012

Tobacco Use in Military

• Smoking rates are high

in all branches of the military

– 40% higher in Veterans

• vs. general population

– 50% higher in deployed

• vs. non‐deployed

– Higher level of smoking

• Risk Factors

– Combat exposure – Non‐combat war zone stressors – Alcohol consumption – PTSD

Beckham et al. Mil Med. 2008

Any Smoking Heavy Smoking All 31.7% 10.6% Army 38.1% 15.6% Navy 32.3% 9.6% Marine 30.8% 9.5% Air Force 25.5% 7.7%

ABPM SLIDE‐ Question 1: Which one of the following statements is incorrect?

• A. All veterans obtain their health through VA

Healthcare System

• B. Many exposures encountered in military

service are similar to those of non‐military

• ccupations
• C. Many health conditions associated with

military service exposures are recognized after the end of veterans’ service

• D. Exposure to stress & violence potentially

augments the respiratory effects of airborne hazards

ABPM SLIDE‐ Question 2: Which one of the following occupational hazards were NOT encountered during military service in Iraq & Afghanistan?

• A. Tobacco smoke
• B. Extreme temperatures
• C. Naturally occurring air pollution
• D. Herbicide such as agent orange

3/1/2017 7 ABPM SLIDE‐ Question 3: Which answer is NOT correct about the VA Airborne Hazards & Burn Pit Registry?

• A. It is a volunteer‐based registry
• B. Its purpose is to understand the health

effects of respiratory exposures from Iraq and Afghanistan wars

• C. Requires completing an online

questionnaire

• D. Requires an MD visit at either VA or DOD