Disclosures Respiratory Hazards of Military Restricted research - PDF document

3/1/2017 Disclosures Respiratory Hazards of Military • Restricted research grants through Service Department of Veterans Affairs research foundation from: – Five Prime Therapeutics – GlaxoSmithKline Mehrdad Arjomandi, MD – MagArray Inc. University of California San Francisco • Nothing to disclose in regards to this talk San Francisco Veterans Affairs Medical Center Occupational & Environmental Learning Objectives Medicine • Recognize military service as an occupation • Devoted to: • Assists employers in: with both common and unique exposures – Prevention & – Identifying hazards • Describe the occupational respiratory management of – Detecting exposures occupational & hazards in modern era wars – Protecting the environmental injury, workforce • Describe the various physical, chemical, and illness & disability – Educating people – Promotion psychological hazards encountered in regarding workplace of health & productivity hazards military service that can augment respiratory of workers, their morbidities families & communities 1

3/1/2017 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 Routes of exposure 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 Contact Ingestion Inhalation other occupational & environmental conditions that they are obliged to work in & Injection Damalas C, et al. Toxics 2016, 4(1) 2

3/1/2017 Inhalational Hazards Encountered Deployment ‐ Related Exposures: during Military Service Every Conflict Has Its Own Characteristics Exposure • Natural air pollution: – Sandstorms – Forest fires Agent Nerve Anti ‐ Solvents Orange Agent Malarial • Anthropogenic (human ‐ made) air pollution: – Fossil fuel ‐ related: • Fuel ‐ burning vehicles and aircrafts Dust & • Factories Fuels Pesticides Radiation Sand • Oil ‐ well fires – Military ‐ specific: • Open air burn pits • Herbicides & pesticides Depleted Oil Well Vaccines Burn Pits Uranium Fires • Depleted uranium • Chemical weapons Slide courtesy of Michael Falvo, PhD; New Jersey War ‐ related Injury & Illness Study Center Concentrations Dust and Sand Storms of PM 10 & 2.5 in the Middle East • Southwest Asia is known to have some of the highest levels of particulate matter (PM) • National Ambient in the world Air Quality Standards • Reports from Middle East have documented (NAAQS): frequent dust or sand events: – Not to be exceeded PM 10 = 150 μ g/m 3 – 1 event every 3 days once a year – PM 10 >200 μ g/m 3 & PM 2.5 >60 μ g/m 3 – Annual average PM 2.5= 12 ‐ 35 μ g/m 3 – Associated with increase hospital admissions due to respiratory conditions Thalib & Al ‐ Taiar 2012 Engelbrecht et al. 2008 3

3/1/2017 Open Air Burn Pits Open Air Burn Pits • Military operations generate large quantities of • Alternatives to open ‐ air burn pits are solid waste that need to be disposed of: waste incinerators • 8 ‐ 10 lbs waste/day/person – Capacity: 30 tons waste/day • Example: Joint Base Balad burn pit – >15,000 personnel – More complete burn – ~200 tons waste/day – Increased use over time: – A range of possible pollutants including: • # installed in Iraq grew from 2 to 39 • Combustion by ‐ products • # of installed in Afghanistan from 1 to 20 • Volatile organic compounds • PM • Generate incomplete combustion GAO 2010; IOM 2011 GAO 2010; IOM 2011 Airborne Hazards & Burn Pit Registry Institute of Medicine Report on Burn Pits • Public Law 112 ‐ 260 • On ‐ line self ‐ assessment questionnaire (SAQ) • Optional in ‐ person clinical evaluation • “…service in Iraq or Afghanistan – might be associated with long ‐ term health effects, in highly exposed…or susceptible populations” http://www.publichealth.va.gov/exposures/burnpits/registry.asp 4

Slide 16 OOY1 Osinubi, Omowunmi Y., 9/23/2014

3/1/2017 Vulnerability & Susceptibility Factors Affecting the Airborne Hazards & Burn Pit Registry Respiratory Health in Military Personnel • Eligible veterans & service • No cost to participate members include those • Not a disability who served in: compensation – Operation Enduring questionnaire or required Freedom/Operation Iraqi for other VA benefits Freedom/Operation New • Enrollment in VA’s health Dawn care system not necessary – Djibouti, Africa on or after September 11, 2001 – Operations Desert Shield or • In total, 99,713 veterans & Desert Storm service members – Southwest Asia theater of completed and submitted operations on or after the registry between 2014 August 2, 1990 & 2017 Falvo et al., http://www.publichealth.va.gov/exposures/burnpits/registry.asp Epidemiologic Rev, 2015 Military Living Condition Stress & Violence • Animal studies: • Dry climate promotes – Respiratory effects of generation of particulate matter aerosolized PM exposure in rats pollution worsens with stress • Exercising in hotter • Human Studies: climate increases – Animal studies show susceptibility to worse respiratory pollutant ‐ induced outcome in response to exposure to respiratory symptoms Clougherty et al., Environ Health Persp , 2010; Niles et al., Chest , 2011 Garcia ‐ Chevesich et al., Environ Poll, 2014; Gordon et al., Compr Physiol, 2014 5

3/1/2017 Increased Ventilation with Exertion Tobacco Use in Military • Military service is an • Smoking rates are high active job which in all branches of the requires: military Any Heavy – Staying in good physical – 40% higher in Veterans condition by exercise Smoking Smoking vs. general population – Severe exertion All 31.7% 10.6% – 50% higher in deployed • Even carrying a heavy vs. non ‐ deployed Army 38.1% 15.6% load – like a military – Higher level of smoking Navy 32.3% 9.6% assault load – can • Risk Factors increase ventilation Marine 30.8% 9.5% – Combat exposure • Exertion: Air Force 25.5% 7.7% – Non ‐ combat war zone – Increases ventilation stressors – Promotes mouth – Alcohol consumption breathing – PTSD Rundell , Br J Sports Med 2012 Beckham et al. Mil Med. 2008 ABPM SLIDE ‐ Question 1: ABPM SLIDE ‐ Question 2: Which one of the following statements is Which one of the following occupational incorrect? hazards were NOT encountered during military service in Iraq & Afghanistan? A. All veterans obtain their health through VA Healthcare System B. Many exposures encountered in military A. Tobacco smoke service are similar to those of non ‐ military occupations B. Extreme temperatures C. Many health conditions associated with C. Naturally occurring air pollution military service exposures are recognized after D. Herbicide such as agent orange the end of veterans’ service D. Exposure to stress & violence potentially augments the respiratory effects of airborne hazards 6

3/1/2017 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 7