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Pulmonary Disease

As burn pit registry grows, VA expands research into related lung disease

by Annette Boyle

July 15, 2018
Master Sgt. Darryl Sterling, 332nd Expeditionary Logistics Readiness Squadron equipment manager, tosses unserviceable uniform items into a burn pit in Balad, Iraq, in 2008. (Photo by Senior Airman Julianne Showalter)

WASHINGTON, DC — The potential cost to the VA for lung disease associated with deployment to Iraq or Afghanistan shot up this year when an administrative law judge with the U.S. Department of Labor ruled that exposure to open-air burn pits caused a veteran’s lung disease.

Almost 150,000 veterans have signed onto the VA’s Airborne Hazards and Open Burn Pit Registry to document their concerns about exposure to damaging particulates during deployment.

The recent case involved Veronica Landry, a civilian contractor who worked as a morale, welfare and recreation specialist at two forward operating bases in Mosul, Iraq, between March 2004 and February 2005. During her time in Iraq, a contractor for the Department of Defense operated open-air burn pits to dispose of trash, hardware, tires and, for some of the period, hazardous waste. Landry subsequently developed bronchiolitis, which her physician attributed to exposures that occurred during her deployment based on a lung biopsy.

The court’s decision does not directly affect the VA, which had no comment on the case. “VA benefits decisions are generally made on a case-by-case basis,” said Patricia R. Hastings, DO, MPH, deputy chief consultant, VA Post-Deployment Health Services. “Our adjudicators take into consideration all relevant facts and evidence, including medical evidence, when making these decisions.”

While making claims based on burn pit and other exposures has not become easier since the ruling, participating in the Airborne Hazards and Open Burn Pit Registry and research related to lung disease has.

Veterans deployed to the Southwest Asia theater of operations since Aug. 2, 1990, can join the registry, which, while often called the “burn pit registry,” tracks exposure to a wide range of environmental factors. Many pre-9/11 veterans had waited months for manual verification of deployment histories before they were able to join the registry, but recent improvements have eliminated most of the delays by linking the registry to more-complete deployment records, according to the VA. As of June 15, 144,000 veterans had registered, with the number climbing by several thousand a month.

“Once veterans have submitted their questionnaire, they can immediately schedule a medical evaluation for the registry,” said Martaineous Allen, a staff assistant in the VA’s Post-Deployment Health Services who help veterans join the registry. The exam is free.

The registry also “provides a venue for providers to discuss health concerns and any possible findings with the veteran,” Hastings told U.S. Medicine. In addition, the VA and DoD have a number of studies in process to determine the effect of airborne hazards on deployed personnel.

“A major contributor to ambient particulate matter (PM) in Southwest Asia was re-suspension of dust and soil from the desert floor. During Desert Shield/Desert Storm, Operation Enduring Freedom (OEF), Operation New Dawn (OND), and OIF, open-air burn pits were used. Burn pit emissions contributed to the total burden of air pollutants, including gases and PM, to which deployed personnel were exposed. It would be difficult to separate environmental and burn pit exposures,” Hastings said.

Future servicemembers may not need to worry about the hazards of burn pits. According to Hastings, DoD has “replaced burn pits with incinerators in the deployed environment.”

Multiple studies have found increasing rates of chronic respiratory conditions in veterans of the Iraq and Afghanistan conflicts, though the association with deployment has varied. The prevalence of asthma tripled in this veteran group between 2003 and 2011 and the prevalence of chronic obstructive pulmonary disease and interstitial lung disease or pulmonary fibrosis doubled, leading the authors to conclude that the findings may “suggest a link between deployment exposures and increased diagnoses of chronic lung disease” in this cohort.1

A recent study sought to define the characteristics of veterans with interstitial lung disease. The researchers used the VA’s Corporate Data Warehouse to analyze records of 2,642 veterans who received care for interstitial lung disease in the Mid-Atlantic region (VISN 6) between January 2008 and 2013. A preliminary analysis published in the American Journal of Respiratory and Critical Care Medicine found that 44% of veterans diagnosed with ILD were on oxygen therapy and 24% took immunosuppressive medication.2

Common comorbidities included diabetes mellitus (37%), chronic obstructive pulmonary disease (33%), coronary artery disease (30%) and gastroesophageal reflux disease (29%). Two-thirds of patients were white and 95% were male, with an average age of 71.

A type of interstitial lung disease, idiopathic pulmonary fibrosis leads to scarring of the lungs and is associated with high morbidity and mortality. To date, the disease has had few effective therapies. Researchers led by Elizabeth Frances Redente of the VA Eastern Colorado Health Care System are optimistic that they have found a way to enhance resolution of pulmonary fibrosis by using tumor necrosis factor-alpha (TNF-alpha), which could benefit many veterans.

Dust exposure and smoking, both common in veterans, increase the risk of developing idiopathic pulmonary fibrosis. “In addition, recently deployed military persons exposed to burn pits and pollutants may also have an increased risk of IPF as they age. Thus, patients in the VA health care system are expected to have a higher rate of IPF than the general population, establishing a major potential health issue facing U.S. veterans,” according to the researchers.3

An earlier study by the same team indicated that administration of TNF-alpha at the height of a bleomycin-induced fibrotic response in mice accelerated resolution of lung scarring and, on the flip side, also found that TNF-alpha deficiency impaired fibrosis resolution. The researchers are now investigating several hypotheses related to these findings, including whether TNF-alpha induces a change in macrophage programming that stimulates tissue remodeling and restoration of normal lung architecture. They hope to translate the work next to humanized mouse models of fibrosis using IPF-derived myofibroblasts.

Beyond these studies that are specifically focused on pulmonary fibrosis, “VA and DoD are working together and in partnership with various private institutions on studies regarding possible adverse health effects related to exposure to open-air burn pits,” Hastings said.

The studies include:

  • The National Health Study for a New Generation of U.S. Veterans, an epidemiological study of 22,000 Operation Iraqi Freedom and Operation Enduring Freedom veterans that will compare health and behavioral issues in deployed and non-deployed veterans;
  • The Pulmonary Health and Deployment to Iraq and Afghanistan Objective, which is funded through 2022, to evaluate the association between deployment and potential exposure to airborne hazards on current measure of respiratory health, Hastings said;
  • Next year’s Comparative Health Assessment Interview launch of an analysis of data gathered during interviews with veterans of Iraq and Afghanistan, veterans who served in other theaters, and a civilian control group to assess any environmental or deployment-related exposures and their impact on health outcomes;
  • The Millennium Cohort Study, the largest prospective study in U.S. military history, which began in 2000 and currently has more than 200,000 enrolled participants, of whom more than 70% are now veterans, according to Hastings; and
  • The Million Veterans Program, now the largest genomic database in the world, with demographic, medical and genetic data on more than 650,000 veterans who receive their care through VA. The program aims to enroll one million veterans by 2025. “This study will be invaluable in evaluating the genetic components of respiratory disease risk,” Hastings said.

1Pugh MJ, Jaramillo CA, Leung KW, Faverio P, Fleming N, Mortensen E, Amuan ME, Wang CP, Eapen B, Restrepo M, Morris MJ. Increasing Prevalence of Chronic Lung Disease in Veterans of the Wars in Iraq and Afghanistan. Mil Med. 2016 May;181(5):476-81. 2Bedoya AD, Pleasants R, Boggan J, Seaman D, Howard L, Reihman A, Welty-Wolf K, Tighe RM. Characteristics of Interstitial Lung Disease in the Mid-Atlantic Veterans Affairs Regional Network. Am J Respir Crit Care Med. 2017;195:A1134.

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