Environmental Exposures and Risk Communication (Mobile Accessible)

1. Environmental Exposures and Risk Communication (Mobile Accessible) Presented by: Lucile Burgo, M.D Stephen C. Hunt, M.D

2. Module Topics • Post-Deployment Care • Understanding Military Culture • Environmental Exposure Concerns in Veterans • Compensation & Pension / Benefits

3. Toxic/Environmental Exposures in Veterans

4. Purpose • Acquaint health care providers with common military related environmental agent exposures and the resources and benefits available to Veterans related to these exposures • Provide training on assessment and discussion of these concerns

5. Learning Objectives • Develop the skills to assess for significant in-service environmental exposure • Identify, document and discuss these concerns • Direct Veterans to appropriate programs, services and benefits • Be aware of signature exposures from different conflicts and their possible health effects • Understand how to discuss basic principles of toxicology and exposure assessment

6. Military service and deployment often involve exposures to hazardous environmental agents…

7. Toxic/Environmental Exposures in OEF/OIF Veterans The most common exposures in OEF/OIF Veterans: WRIISC, n = 612 • Smoke from burning trash/feces 44% • Sand and dust storms 41% • Gas/fuel exposure 21% • Depleted uranium 19% • Others

8. Jack asks: “Did asbestos exposure cause my lung problems?”

9. Larry: “Did Agent Orange cause my diabetes?”

10. Sam tells you: “My health has been terrible ever since I was in the Gulf. I think it’s because of all the stuff I was exposed to…especially the oil well fires and depleted uranium…”

11. Maria tells you: “I have a lot of pain and shortness of breath and fatigue. Is it because of something I was exposed to in Iraq?”

12. Environmental Agent Exposures • Environmental • Dust/sand, cold/heat, air pollution, infectious agents, herbicides, insecticides • Weaponry related • Radiation, depleted uranium, chemical/biological agents, prophylaxis • Disease prophylaxis and treatment agents • Immunizations, prophylactic medications, pesticides • Job related • Paints, fuels, solvents, vehicle exhaust

13. Discussing Exposure Concerns with Veterans (1 of 4) Step 1 • Display empathy for the Veteran to establish trust and credibility. • Explain what you do and don't know, be honest • Listen actively and patiently.

14. Discussing Exposure Concerns with Veterans (2 of 4) Step 2 Route of exposure Temporal relationship between exposure and effect The amount of exposure usually determines the degree of effect. Basic Principles of Toxicology

15. Discussing Exposure Concerns with Veterans (3 of 4) Step 3 Time, duration and location of potential exposures Symptoms the Veteran or other individuals have at the time of potential exposure Interval or current symptoms Brief Exposure History

16. Discussing Exposure Concerns with Veterans (4 of 4) Step 4 Repeat back to the Veteran those exposure concerns that you heard raised Ranking the degree of concern Ask about anything you may have missed Provide information and support that addresses those concerns Specific exposure concerns: risk communication

17. Jack’s Concerns • Smoker • COPD • Asbestos • Benefits

18. Health Impacts of Asbestos • Benign pleural plaques • Asbestosis • Lung cancer • Mesothelioma • Colon CA

19. Military Occupations with Potential Asbestos Exposure • Pipe fitter or insulation work • Milling • Shipyard work • Carpentry/construction/demolition of old buildings • Servicing of clutch facings/brake linings • Installation of products, such as roofing and flooring (Federal regulation of asbestos began in mid-1970’s)

20. Larry’s Concerns •  Diabetes • Agent Orange • Benefits

21. Agent Orange • Type 2 diabetes mellitus • Ischemic heart disease • Chloracne • Porphyria cutanea tarda • Soft-tissue sarcoma, Hodgkin's disease, non-Hodgkin’s lymphoma • Multiple myeloma • Respiratory cancers • Prostate cancer • Peripheral neuropathy • Chronic lymphocytic leukemia • Spina bifida in children • Parkinson’s disease

22. Sam’s Concerns • Depleted uranium shells that did and didn’t explode • Chemical alarms, MOPP gear, Khamasiyah • Oil well fires and plume • Damaged tanks • Dead bodies and prisoners • Low back pain • Diarrhea and constipation • Rash • Memory problems

23. Depleted Uranium • 40% less radioactive than naturally occurring uranium which is found everywhere • As a heavy metal may have effect on kidneys • Group of GW Veterans followed for 19 years and thus far no significant health effects • Routes of Exposure • Trans-dermal as embedded shrapnel • Inhaled particles too large to reach lungs cleared by coughing and sneezing • Ingested dust not absorbed and excreted in feces • Testing thru Baltimore VA – 24hr urine collection

24. Gulf War Presumptive Conditions • Included are medically unexplained chronic multi-symptom illnesses defined by a cluster of signs or symptoms that have existed for six months or more, such as: • Chronic fatigue syndrome • Fibromyalgia • Irritable bowel syndrome • Any diagnosed or undiagnosed illness that the Secretary of Veterans Affairs determines warrants a presumption of service connection. • Signs or symptoms of an undiagnosed illness include: • Fatigue • sleep disturbance • skin symptoms • Headaches • neurological symptoms • muscle and joint pain • respiratory symptoms • GI symptoms • cardiovascular symptoms • weight loss • menstrual disorders

25. Maria’s Concerns • Depleted uranium shells that did and didn’t explode • Chemical alarms, MOPP gear, Khamasiyah • Oil well fires and plume • Damaged tanks • Dead bodies and prisoners • Low back pain • Diarrhea and constipation • Rash • Memory problems

26. Summary: Exposure Assessment It is important that VA providers are able to recognize and discuss: • Basic principles of toxicology and exposure assessment as they relate to military toxic agent exposure • Any number of potential military environmental agent exposures: • known health effects; • confirmatory testing (if available); • methods to identify and measure the health effects; • appropriate recommended treatment and management strategies.

27. Surveillance/Remediation Exposure to smoke and fumes from burn pits Samples collected from January to April 2007 showed that chemicals of potential concern found in smoke from open pit burning of solid waste including metals, volatile organic compounds, dioxins, furans, and polycyclic aromatic compounds, were within acceptable standards (Military Exposure Guidelines or MEGs). Only one substance, particulate matter (PM), was found at levels above its MEG.

28. Surveillance Protocols Toxic Embedded Fragments (TEF) • Bio-monitoring/toxicological screening • Surgically removed fragments • Biomarkers of effect • Local fragment effects

29. Surveillance Protocols (cont’d) • OPHEH Office of Public Health and Environmental Hazards • WRIISC War Related Illness and Injury Study Centers • Environmental Agent Clinicians

30. Summary: risk assessment/risk communication and management of exposure concerns It is important that VA providers are: • Knowledgeable about the common military related exposures of concern to Veterans • Able to assess, discuss and document military related environmental agent exposures with Veterans • Able to direct Veterans to information, resources and benefits related to such exposures • Cognizant of the ways that these exposure concerns fit into the overall health care needs of Veterans and are addressed in a way that is effectively integrated into the overall Veteran centered, team based, coordinated approach to the Veteran’s health care

31. Summary Keys to successful management of exposure concerns in Veterans: • Listen to the Veteran • Document concerns • Assess and discuss risk • Insure that the Veteran has the information and access to resources and benefits to assist him/her with any health concerns related to exposures

32. Reference/Resources http://www.warrelatedillness.va.gov/ http://www.publichealth.va.gov/exposures/index.asp • Agent Orange • Gulf War Veterans' Illnesses • Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Hazardous Exposures • Radiation • Toxic Embedded Fragments • Cold and Heat Injuries (Thermal Injuries) • Project 112/Project SHAD • Depleted Uranium • Mustard Gas • Noise, Vibration & Other Physical Exposures • Occupational & Environmental Exposures

33. Environmental Exposures in Veterans and Risk Communication for Frontline Providers Conclusion We acknowledge the risks and the sacrifices your service involved We appreciate your service !