Where There’s Smoke: DoD Investigates Causes of Deployment-Related Pulmonary Symptoms Reported by Troops

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The media headlines are almost as incendiary as the dramatic pictures of burn pits splashed across the front page. Blamed for generally harmful and even potentially toxic exposure, burn pits have become a focus of speculation in media outlets from Army Times to The New York Times and CNN. Concerns for the health and well-being of deployed U.S. servicemembers make attention-grabbing headlines: “Burn pit at Balad raises health concerns,” “Military: Burn pits could cause long-term damage to troops,” “Lung disease of soldier linked to burn pits,” and “Veterans sound alarm over burn pit exposure.”1-4

Many of these media reports assume or imply that the U.S. military has not investigated the issue or is not acknowledging the widespread disease. But clinical determinations of the cause of pulmonary disease or injury—or the diagnosis of disease itself—can’t be made from anecdotal reports. Neither published data nor reports to Congress, have fully clarified the situation.

To further complicate the issue, pulmonary disease and/or injury can be difficult to properly attribute without testing. Many reports of “asthma-like symptoms” may actually indicate other illnesses or temporary reactions to inflammation or exposure. Researchers at Brooke Army Medical Center in Texas are actively pursuing studies to help to clarify the scope of pulmonary disease, and, specifically, adult-onset asthma in deployed U.S. service personnel.

Research Background

The U.S. Army Medical Department and other DoD agencies have initiated a number of investigations into deployment-related lung disease and exposures. Clinicians and researchers are working to define the severity and prevalence of pulmonary disease in these servicemembers. Despite media suppositions, these problems have not gone unnoticed by military officials.

In 2005, the Joint Particulate Matter Working Group was created by the Assistant Secretary of Defense for Health Affairs to investigate issues related to exposure to particulate matter in theaters of operation in southwest Asia, especially Iraq and Afghanistan. The Public Health Command, then known as U.S. Army Center for Health Promotion and Preventive Medicine, initiated the Enhanced Particulate Matter Surveillance Program to identify and characterize the involved substances. This data helped them to determine what materials were being released and to what level servicemembers were exposed.

Army researchers have previously recognized increases in general respiratory symptoms, including cough and dyspnea, during deployment. In studies on the health effects of U.S. troops’ exposure to oil fires in Kuwait during the first Gulf War, reports of increased pulmonary symptoms, upper respiratory tract irritation, shortness of breath and cough, among servicemembers in the area of the fires. However, these symptoms resolved after leaving Kuwait.5 Retrospective reviews of DoD hospitalization data also did not find increased hospital admissions related to respiratory disease or exposure to oil fires.6,7

Based on a survey of 15,000 military personnel who had deployed to Iraq and Afghanistan, investigators from the U.S. Naval Medical Research Center found that 69.1% of respondents reported that they experienced respiratory illnesses.8 The Millennium Cohort Study from the Naval Health Research Center reported an increased rate of new-onset respiratory symptoms in deployed personnel and than non-deployed personnel (14% versus 10%), but similar rates of chronic bronchitis/emphysema (1% versus 1%) and asthma (1% versus 1%).9

“In the Millennium Cohort, rates of self-reported, newly reported respiratory symptoms were higher in deployed versus non-deployed individuals, however there were no increased rates of physician-diagnosed conditions,” noted Lisa L. Zacher, COL, MC , USA, Chief of the Department of Medicine at Brooke Army Medical Center at Fort Sam Houston.  “The authors suggested that specific exposures, rather than deployment, may be a determinant of post-deployment respiratory illness.”

With so many questions unanswered, in 2010, researchers and clinicians from the DoD, the VA and academic medical centers met at National Jewish Center in Denver, CO, to discuss available data on deployment-related respiratory disease and new directions in research. The results of these discussions, and their recommendations, will be published in 2011. This discussion clearly identified the need for additional research, especially given the disparity of published studies.

“We have identified research priorities in four specific focus areas: clinical research, animal models of toxicity, biomarkers, and exposure assessment and epidemiology,” said Michael J. Morris, COL (Ret), MC, USA, Pulmonary/Critical Care and Associate Program Director, Internal Medicine, San Antonio Uniformed Services Health Education Consortium, San Antonio. “We also identified four major data gaps: the prevalence and severity of deployment-related disease, methods for diagnosis and screening, intervention and treatment, and toxicity and pathogenicity of particulate matter in Southwest Asia theaters of operation.”

Deployment-Related Asthma

Little data has yet been established that specifically addresses the effects of deployment on asthma. For the most part, a potential service recruit is excluded from service with established diagnosis of asthma after the age of 12. Yet active-duty military members are diagnosed with asthma.

From a clinical testing study of active-duty patients with exertional dyspnea, Morris and his colleagues reported that nearly half the study group had either asthma or exercise-induced bronchospasm.10 If this asthma incidence exists in deployed personnel, the environmental and particulate exposure in Iraq and Afghanistan could lead to exacerbations of existing asthma. A survey of Army personnel deploying to Southwest Asia revealed that 5% of troops reported a previous diagnosis of asthma.11 But both study groups––those with and without asthma––reported increased respiratory symptoms during deployment as compared with their symptoms prior to deployment. A retrospective assessment of ICD-9 diagnostic codes gathered from more than 6,000 VA medical records reported an increased rate of new-onset asthma in deployed U.S. military personnel from 2004 to 2007 when compared with nondeployed military service members who were stationed in the United States. (6.6% versus 4.3%).12

“Investigators do not have good objective data pre- and post-deployment to either support or refute deployment as a ‘definitive’ cause of asthma,” Zacher pointed out. “I strongly believe that we need to conduct a prospective study that measures pre-deployment symptoms and physiologic/radiographic data with post-deployment measurements. Specific exposures, length of exposure, genetic predisposition, and concomitant tobacco use might also be important factors.”

“I firmly believe this is an important topic that needs to be further studied in a broad, scientific manner rather than with record review that is not standardized,” she added.

Morris concurred. “As clinicians, we are not seeing an overwhelming number of patients with unexplained lung disease after deployment, despite media reports that imply that there are lots of people with undiscovered disease. We’re not seeing high numbers of people who suddenly report breathing issues after deployment.”

Physicians are concerned, however, that the issue of lung disease is not better understood. “We are looking at the data in detail to be sure we determine the true prevalence of disease among our military population,” noted Morris. “We want to define what the clinical issues really are and not rely on survey studies.”

Ongoing Research

In order to systematically gather relevant data to assess the effect of deployment on pulmonary disease in military troops, physicians at Brooke Army Medical Center have undertaken a number of clinical studies. These include:

A Database Registry of Military Personnel Diagnosed with Post-Deployment Chronic Pulmonary Disease: a retrospective database study of all active-duty military who have a diagnosis of chronic pulmonary disease, including asthma, emphysema, chronic bronchitis, chronic obstructive pulmonary disease, bronchiectasis, sarcoidosis, pulmonary fibrosis, constrictive bronchiolitis, and other pulmonary interstitial/infiltrative disorders. This preliminary study will investigate the effect of deployment on the development of chronic pulmonary disease.

Pre- and Post-Deployment Spirometry to Detect Airways Disease Related to Environmental Dust Exposure: A prospective study of deploying soldiers from Fort Hood, Texas that will compare baseline (pre-deployment) screening tests with tests repeated following deployment. This study will provide measurable data on the extent and incidence of pulmonary changes in returning military personnel.

Study of Active Duty Military for Pulmonary Disease related to Environmental Dust Exposure (STAMPEDE): A prospective study of active-duty servicemembers who report new symptoms of dyspnea following deployment. Subjects will undergo chest radiograph, high-resolution computed tomography of the chest, full pulmonary function testing, impulse oscillometry, methacholine challenge testing, and bronchoscopy with bronchoalveolar lavage. This extensive evaluation will identify any chronic inflammatory findings in the lung.

Pre- and Post-Deployment Evaluation of Military Personnel for Pulmonary Disease Related to Environmental Dust Exposure (STAMPEDE II): This study will provide a prospective health evaluation of service members before and after their deployment to determine if acute or chronic lung disease can be attributed to dust exposure.

The STAMPEDE Registry of Deployment Related Lung Disease: A database registry that will expand to all DoD military treatment facilities to enroll military personnel who are diagnosed with chronic lung disease related to their deployment. This database will include 10 years of follow-up data to better understand the short-term and long-term effects of deployment on the lungs.

Perspectives

A problem with the Millennium Cohort studies, according to Morris, is “they are based on survey results, which rely on people reporting respiratory symptoms accurately. They didn’t find more chronic respiratory disease; they found symptoms.”

He also noted the difference between reported symptoms and clinical diagnoses. “Reports of respiratory disease can include symptoms of colds and upper respiratory injections, especially in theater where it is harder to self-treat. But we have not seen that these reports are translated to chronic, long-term respiratory symptoms or a higher level of disease in post-deployment soldiers.”

While the BAMC studies have not yet found increased pulmonary disease intrinsically related to Southwest Asia deployment, Zacher emphasized that these ongoing studies reflect the concern to find additional information.

“The potential effects of exposure to dust, burn pits, and other inhalational toxins is concerning to our military physicians and researchers,” she noted. “I believe our research to date shows that the vast majority of deployed service members do not have significant pulmonary findings post-deployment, but we need to remain open-minded and continue to explore both potential short term and long term pulmonary conditions.”

References

  1. Kennedy K. Balad burn pit harmed troops living 1 mile away. Army Times. Posted: 23 Jan 2010. http://www.armytimes.com/news/2010/01/military_burn_pit_011810w/. Accessed March 24, 2011.
  2. Kennedy K. Lung disease of soldier linked to burn pits. Army Times. Posted: 2 Jul 2009. http://www.armytimes.com/news/2009/06/military_burnpits_lungs_063009w/. Accessed March 24, 2011.
  3. Risen J. Veterans sound alarm over burn pit exposure. New York Times. Aug 6, 2010. http://www.nytimes.com/ 2010/08/07/us/07burn.html. Accessed March 24, 2011.
  4. Shane L. Study: Respiratory illnesses higher near infamous Balad burn pit. Stars and Stripes. 1 July 2010. http://www.stripes.com/news/middle-east/iraq/study-respiratory-illnesses-higher-near-infamous-balad-burn-pit-1.109538. Accessed March 24, 2011.
  5. Petruccelli BP, Goldenbaum M, Scott B, Lachiver R, Kanjarpane D, Elliott E, et al. Health effects of the 1991 Kuwait oil fires: A survey of US army troops. J Occup Environ Med. 1999;41:433–439.
  6. Smith TC, Heller JM, Hooper TI, Gackstetter GD, Gray GC. Are Gulf War veterans experiencing illness due to exposure to smoke from Kuwaiti oil well fires? Examination of Department of Defense hospitalization data. Am J Epidemiol. 2002;155:908–917.
  7. Smith TC, Corbell TE, Ryan MAK, Heller JM, Gray GC. In-theater hospitalizations of U.S. and allied personnel during the 1991 Gulf War. Am J Epidemiol. 2004; 159:1064-1076.
  8. Sanders JW, Putnam SD, Frankart C, Frenck RW, Monteville MR, Riddle MS, et al. Impact of illness and non-combat injury during Operations Iraqi Freedom and Enduring Freedom (Afghanistan). Am J Trop Med Hyg. 2005;73:713-719.
  9. Smith B, Wong CA, Smith TC, Boyko EJ, Gacksetter GS, Ryan MAK. Newly reported respiratory symptoms and conditions among military personnel deployed to Iraq and Afghanistan: A prospective population-based study. Am J Epidemiol. 2009;170:1433-1442.
  10. Morris MJ, Grbach VX, Deal LE, Boyd SY, Johnson JE, Morgan JA. Evaluation of exertional dyspnea in the active duty patient: The diagnostic approach and the utility of clinical testing. Mil Med. 2002;167:281-288.
  11. Roop SA, Niven AS, Calvin BE, Bader J, Zacher LL. The prevalence and impact of respiratory symptoms in asthmatics and nonasthmatics during deployment. Mil Med. 2007;172:1264–1269.
  12. Szema AM, Peters MC, Weissinger KM, Gagliano CA, Chen JJ. Increased rates of asthma among U.S. military personnel after deployment to the Persian Gulf. Presented at the American Thoracic Society meeting, May 2008, Toronto, Canada.

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