OEF/OIF/OND Airborne Hazards and Respiratory Health: - PowerPoint Presentation

Slide1

OEF/OIF/OND Airborne Hazards and Respiratory Health: An Update

Michael J. Falvo, PhD

Research Physiologist, VA NJ WRIISC

Assistant Professor, New Jersey Medical SchoolSlide2

DisclaimerThe views expressed in this presentation are my own and do not necessarily represent the views of the Department of Veterans AffairsSlide3

AcknowledgementsOEF/OIF/OND VeteransNJ WRIISC TeamVANJHCS Pulmonary and Critical CareOffice of Public HealthDrew Helmer, MD, MS

Susan Santos, PhD, MS

Florence Chua, MS

Employee Education Services

VA RRD 1I21RX001079-01Slide4

Learning ObjectivesAirborne Hazards and Potential Health EffectsResearch Studies on Respiratory HealthExperience of the NJ WRIISCClinical Algorithm and Referral

VA Efforts and ResourcesSlide5

Learning ObjectivesAirborne Hazards and Potential Health EffectsResearch Studies on Respiratory Health

Experience of the NJ WRIISC

Clinical Algorithm and Referral

VA Efforts and ResourcesSlide6
Slide7

Burning Waste in Open-Air “Burn Pits”273 burn pits in operation in OEF/OIF/OND (8/2010)

GAO 2010; IOM 2011Slide8

Burn Pit EmissionsLow-temperature burning/smolderingIncomplete combustion by-productsPollutants from burn pits:Particulate matter; polycyclic aromatic hydrocarbons; volatile organic compounds; carbon monoxide;

hexacholorobenzene

; dioxins; lead; mercury; furansSlide9

IOM Report 2011“…service in Iraq or Afghanistan – that is, a broader consideration of air pollution than exposure only to

burn pit emissions – might be

associated with long-term health

effects, particularly in highly

exposed populations or susceptible

populations, mainly because of the high ambient concentrations of PM…”Slide10

High PM in Southwest AsiaSlide11

DoD

PM Surveillance Program

Engelbrecht

et al. 2009

Inhal

ToxicolSlide12

Hair

Pin

Pollen

RBC

Bacteria

Virus

Molecules

100

μ

m

10

μ

m

1

μ

m

0.1

μ

m

.01

μ

m

Coarse PM: PM₁₀

Fine PM: PM

2.5

Ultrafine PM

Stapleton et al. 2012

MicrocirculationSlide13
Slide14

Why PM ‘Matters’ For Military

Daigle et al. 2003;

Muza

et al. 1989Slide15

PTSD and Respiratory HealthProbable PTSD associated with WTC cough syndrome (Niles et al. 2011 Chest)

No

trauma

(n = 857)

Trauma

(n = 887)

PTSD

(n = 28)

FEV

1

 L

3.45±0.88

3.17±0.88

2.84±0.90

FVC

 L

4.04±1.03

3.76±1.01

3.38±0.95

FEV

1

/FVC

 %

85.4±6.0

84.4±6.5

83.2±9.3

Airflow

Limitation

 FEV

1

/FVC ≤70%

1.4

2.7

10.7

 NHANES III

0.9

1.6

7.1

Spitzer et al. 2011

Eur

Resp

JSlide16

Tobacco Use in the Military

Any Smoking

Heavy Smoking

All Branches

31.7%

10.6%

Army

38.1%

15.6%

Navy

32.3%

9.6%

Marine Corps

30.8%

9.5%

Air Force

25.5%

7.7%

>50% of active duty in Iraq smoke

(Beckham et al. 2008)Slide17
Slide18

Possible Pathways & Health EffectsSlide19

Learning ObjectivesAirborne Hazards and Potential Health EffectsResearch Studies on Respiratory HealthExperience of the NJ WRIISC

Clinical Algorithm and Referral

VA Efforts and ResourcesSlide20

VA/DoD Research EffortsSlide21

Self-Reported Respiratory SymptomsSlide22

New-Onset AsthmaNorthport VAMCAsthma diagnosesDeployed (04-07)290 new-onset cases

6.6% deployed

(61 of 920)

4.3% stateside

(229 of 5313)

Szema et al. 2010 Allergy Asthma

ProcSlide23

Proximity to Burn Pit22,844 Army and AFExposure within 3 or 5 miles not associated with respiratory outcomes↑ symptom reporting in AF personnel within 2 miles

Smith et al. 2012 JOEMSlide24

Is Deployment an Exposure?Cases (ICD-9: 490-496)50% bronchitis46% asthma

3% chronic bronchitis

Post-deployment

↑ symptoms

↑

encounters

No association

with:

Deployment duration

Number of deployments

Abraham et al. 2012 JOEMSlide25

Summary of FindingsRespiratory infections are commonly reported during deploymentSpecific environmental exposures, rather than deployment, may be factors in post-deployment respiratory illness Limitations of these studies are reliance on survey data and ICD-9 codesSlide26

Clinical Case SeriesSlide27

Acute Eosinophilic Pneumonia18 cases from 2003 – 2004 All smokers, 78% new-onset 2/3rd

required mechanical ventilation

2 soldiers died; 16 responded to corticosteroids and/or supportive care

Only 7 cases met criteria for definitive AEP

Shorr

et al. 2004

JAMASlide28

AEP - Update44 cases from 2003 – 2010 (Sine et al. 2011)Abstract presented in Oct 2011Excluded a number of patients by Shorr

et al. that did not have BAL data

Smoking/smoking variations common

UnpublishedSlide29

Constrictive Bronchiolitis

King et al. 2011 NEJM

80 Soldiers from Ft. Campbell with exercise intoleranceSlide30

Clinical CharacteristicsKing et al. 2011 NEJMSlide31

Summary of Findings Acute Eosinophilic PneumoniaConcerns over case definitionsNo regional/geographic clustering

Role of new-onset smoking (78%)

Constrictive

Bronchiolitis

74% had sulfur dioxide exposure

Methacholine

challenge testing was performed on only 32% of sampleSlide32

Learning ObjectivesAirborne Hazards and Potential Health EffectsResearch Studies on Respiratory Health

Experience of the NJ WRIISC

Clinical Algorithm and Referral

VA Efforts and ResourcesSlide33

Clinical Evaluations

Education & Outreach

ResearchSlide34

Clinical Evaluations

Education & Outreach

ResearchSlide35

NJ WRIISC Clinical DataVeterans are concerned about their exposures and these concerns are associated with their somatic symptom burden (Helmer et al. 2007; McAndrew et al. 2012)

n

= 469

Exposure

Concern about Exposure

Self-Reported

‘General’ Air Pollution

94%

90%

Self-Reported

‘Specific’ Air Pollution

87%

93%Slide36

Clinical SuspicionSlide37

Pulmonary Function Testing Lung volumesSpirometry before and after bronchodilatorLung diffusing capacitySlide38

Reversibility TestingBronchodilator or Reversibility Testing

Most important

 magnitude of response

↑ risk of accelerated lung function loss

Development of fixed airflow obstruction

(

Ulrik

et al. 1999)Slide39

Hegewald

& Crapo 2010

Spirometry Flow-Volume Curve

PEF

FEF

25-75Slide40

Positive BD

Response

ATS/ERS Task Force:

+12% and 200 mL

in FEV1 or FVC

Hegewald

& Crapo 2010Slide41
Slide42

Abn

ormal

n = 16

Normal

(+BD)

n

= 6

Normal

(No BD)

n = 26

FVC

4.56±1.1

(84.9%)

4.01±0.6

(87.1%)

4.75±0.7

(96.7%)

FEV₁*†

3.31±0.7

(76.8%)

3.11±0.5

(85.9%)

3.80±0.6

(95.8%)

FEV₁/FVC*

74.1±9.4

(92.0%)

77.5±3.8

(98.3%)

80.0±4.1

(99.2%)

FEF₂₅₋₇₅*†

2.77±0.9

(67.1%)

2.92±0.9

(89.4%)

3.83±1.6

(99.6%)

PEF

7.81±1.9

(77.8%)

8.02

±1.1

(87.8%)

8.15

±2.9

(85.3%)

*

p < 0.05; Abnormal < Normal †p

< 0.05; Normal (+BD) < Norm (No BD)Slide43

Respiratory Symptoms

Normal (No BD)

Normal (+BD)

AbnormalSlide44

Summary of Findings67% of OEF/OIF/OND Veterans evaluated at the NJ WRIISC have normal spirometryApproximately

1 in 5

(19%) of these Veterans exhibit a +BD response

Average post-BD

FEV

1

or FVC

=

14.9±0.01%Slide45

LimitationsReversibility may not be evident by spirometry alone (Smith et al. 1992)Volume-related or

non-effort dependent

evaluations

Several spirometric evaluations over several days may be necessary

(

Anthonsien

and Wright 1987)

Selection biases and small sampleSlide46

Clinical Evaluations

Education & Outreach

ResearchSlide47

Exercise ChallengeExercise-Induced Bronchospasm (EIB) ≥ 10% decrease in post-exercise FEV₁

6-8 min

80-90% max HR

Baseline

10 min post

ATS 2000;

Amer

J

Resp

Crit

Care MedSlide48

Research Sample

Deployed

< 6 months

Deployed

> 6 months

Sample

N

=

6

N = 14

Age

34.6 ± 8.7

35.4 ± 7.7

Smoking Status

0/6

1/14

Pre-Deployment

Respiratory

Hx

1/6

0/14

Deployment Length

3.8 ± 1.9 mo

10.9 ± 2.8 mo

Current Exercise

125 min/wk

166 min/wkSlide49

Exercise-Induced Bronchospasm (EIB)EIB = ≥ 10% decrease in post-exercise FEV₁

Sonna

et al. 2001;

Seear

et al. 2005;

Ali et al. 2012

%

Meeting EIB Criteria

Deployed

< 6 Months

0%

Deployed > 6 Months

31%

Military Recruits

7%

Civilian

Population

4-20%

Elite Athletes

11-50%Slide50

Post-Exercise Spirometry

< 6 months

>

6 monthsSlide51

Preliminary Research FindingsOEF/OIF Veterans with self-report exposures to airborne hazards AND who were deployed for > 6 months

31% exercise-induced

bronchospasm

Small sample size

Additional measures other than EIBSlide52

Learning ObjectivesAirborne Hazards and Potential Health Effects

Research Studies on Respiratory Health

Experience of the NJ WRIISC

Clinical Algorithm and Referral

VA Efforts and ResourcesSlide53

Causes of Chronic DyspneaRedrawn from: Pratter et al. 1989

Arch Intern MedSlide54

Factors for Diagnostic Referral Persistent unexplained cough, shortness of breath, wheezing/chest tightnessSpirometry values below normal rangeObserved declines in spirometry (FEV₁) of 15% more (pre vs. post-deployment) even if within normal range

New-onset symptoms and 10%+ decline in spirometry

Excessive decline in Physical Readiness Test

Rose et al. 2012 JOEMSlide55

Rose et al. 2012 JOEMPost-deployment Diagnostic ApproachSlide56

Post-Deployment Diagnostic Algorithm

Morris et al. 2013

Ther

Adv

Respir

DisSlide57

Stepped CareSlide58

Clinical EvaluationsSlide59

WRIISC Service Area Map

www.warrelatedillness.va.gov

Slide60

Learning ObjectivesAirborne Hazards and Potential Health Effects

Research Studies on Respiratory Health

Experience of the NJ WRIISC

Clinical Algorithm and Referral

VA Efforts and ResourcesSlide61

Initial EffortsStandardized Post-Deployment Evaluation ProtocolsExposure Assessment Instruments

Integrated DoD/VA Clinical Informatics System

Design Appropriate Studies

Conduct a Long-Term Cohort Study

Federal Register 78(23):7860, 2013Slide62

Open Burn Pit RegistryEstablish and maintain an open burn pit registryAscertain and monitor the health effects of service membersDevelop outreach effortsPeriodically notify registrants of new information

VA’s Action Plan: Burn Pits and Airborne Hazards

:

http://www.publichealth.va.gov/exposures/burnpits/action-plan.aspSlide63

How Can I Stay Updated?www.publichealth.va.gov Slide64

ReferencesDaigle et al. 2003 Inhal Toxicol 15:539

Rose et al. 2012 JOEM 54:3

Thomas et al. 2000

DoD

Engelbrecht

et al. 2000

Inhal

Toxicol

21:297

DoD

Survey of Health Related Behaviors Among Active Duty Personnel (2006)

de

Nijs

et al. 2013

Eur

Resp Rev 127:44Ulrik and Lange 1994 Am J Respir

Crit

Care Med 150:629

Toren

et al. 2006 J

Clin

Epidemiol

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de Marco et al. 2001 J Allergy

Clin

Immunol

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et al.

Clin

Exp

Allergy 2012 42:769

ten

Brinke et al. Am J Respir Crit

Care Med 164:744Naval Research Advisory Committee Report (NRAC) September 2007, “Lightening the Load”Iowa Persian Gulf Study Group 1997 JAMA 277:238Kang et al. 2000 JOEM 42:491Unwin et al. 1999 Lancet 353:169Lee et al. 2002 J R Soc Med 95:491Hyams et al. 1995

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Eur Respir J 26:720-35Pellegrino et al. 2005; Eur Respir J 26:948-58Dykewicz et al. 2009 J Allergy Clin Immunol 123:519

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