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

1. OEF/OIF/OND Airborne Hazards and Respiratory Health: An Update Michael J. Falvo, PhD Research Physiologist, VA NJ WRIISC Assistant Professor, New Jersey Medical School

2. Disclaimer • The views expressed in this presentation are my own and do not necessarily represent the views of the Department of Veterans Affairs

3. Acknowledgements • OEF/OIF/OND Veterans • NJ WRIISC Team • VANJHCS Pulmonary and Critical Care • Office of Public Health • Drew Helmer, MD, MS • Susan Santos, PhD, MS • Florence Chua, MS • Employee Education Services • VA RRD 1I21RX001079-01

4. Learning Objectives • Airborne Hazards and Potential Health Effects • Research Studies on Respiratory Health • Experience of the NJ WRIISC • Clinical Algorithm and Referral • VA Efforts and Resources

5. Learning Objectives • Airborne Hazards and Potential Health Effects • Research Studies on Respiratory Health • Experience of the NJ WRIISC • Clinical Algorithm and Referral • VA Efforts and Resources

7. Burning Waste in Open-Air “Burn Pits” • 273 burn pits in operation in OEF/OIF/OND (8/2010) GAO 2010; IOM 2011

8. Burn Pit Emissions • Low-temperature burning/smoldering • Incomplete combustion by-products • Pollutants from burn pits: • Particulate matter; polycyclic aromatic hydrocarbons; volatile organic compounds; carbon monoxide; hexacholorobenzene; dioxins; lead; mercury; furans

9. 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…”

10. High PM in Southwest Asia

11. DoD PM Surveillance Program Engelbrecht et al. 2009 InhalToxicol

12. Virus RBC Hair Bacteria Pollen Molecules Pin .01μm 0.1μm 1μm 10μm 100μm Coarse PM: PM₁₀ Fine PM: PM2.5 Ultrafine PM Stapleton et al. 2012 Microcirculation

14. Why PM ‘Matters’ For Military Daigle et al. 2003; Muza et al. 1989

15. PTSD and Respiratory Health • Probable PTSD associated with WTC cough syndrome (Niles et al. 2011 Chest) Spitzer et al. 2011 EurResp J

16. Tobacco Use in the Military >50% of active duty in Iraq smoke (Beckham et al. 2008)

18. Possible Pathways & Health Effects

19. Learning Objectives • Airborne Hazards and Potential Health Effects • Research Studies on Respiratory Health • Experience of the NJ WRIISC • Clinical Algorithm and Referral • VA Efforts and Resources

20. VA/DoD Research Efforts

21. Self-Reported Respiratory Symptoms

22. New-Onset Asthma • Northport VAMC • Asthma diagnoses • Deployed (04-07) • 290 new-onset cases • 6.6% deployed (61 of 920) • 4.3% stateside (229 of 5313) Szema et al. 2010 Allergy Asthma Proc

23. Proximity to Burn Pit • 22,844 Army and AF • Exposure within 3 or 5 miles not associated with respiratory outcomes • ↑ symptom reporting in AF personnel within 2 miles Smith et al. 2012 JOEM

24. Is Deployment an Exposure? • Post-deployment • ↑ symptoms • ↑encounters • No association with: • Deployment duration • Number of deployments • Cases (ICD-9: 490-496) • 50% bronchitis • 46% asthma • 3% chronic bronchitis Abraham et al. 2012 JOEM

25. Summary of Findings • Respiratory infections are commonly reported during deployment • Specific 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 codes

26. Clinical Case Series

27. Acute Eosinophilic Pneumonia • 18 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 JAMA

28. AEP - Update • 44 cases from 2003 – 2010 (Sine et al. 2011) • Abstract presented in Oct 2011 • Excluded a number of patients by Shorr et al. that did not have BAL data • Smoking/smoking variations common • Unpublished

29. Constrictive Bronchiolitis 80 Soldiers from Ft. Campbell with exercise intolerance King et al. 2011 NEJM

30. Clinical Characteristics King et al. 2011 NEJM

31. Summary of Findings • Acute Eosinophilic Pneumonia • Concerns over case definitions • No 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 sample

32. Learning Objectives • Airborne Hazards and Potential Health Effects • Research Studies on Respiratory Health • Experience of the NJ WRIISC • Clinical Algorithm and Referral • VA Efforts and Resources

33. Research Clinical Evaluations Education & Outreach

34. Research Clinical Evaluations Education & Outreach

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

36. Clinical Suspicion

37. Pulmonary Function Testing • Lung volumes • Spirometry before and after bronchodilator • Lung diffusing capacity

38. Reversibility Testing • Bronchodilator or Reversibility Testing • Most important  magnitude of response • ↑ risk of accelerated lung function loss • Development of fixed airflow obstruction (Ulrik et al. 1999)

39. Spirometry Flow-Volume Curve PEF FEF25-75 Hegewald & Crapo 2010

40. Positive BD Response ATS/ERS Task Force: +12% and 200 mL in FEV1 or FVC Hegewald & Crapo 2010

42. *p < 0.05; Abnormal < Normal †p < 0.05; Normal (+BD) < Norm (No BD)

43. Respiratory Symptoms Normal (No BD) Normal (+BD) Abnormal

44. Summary of Findings • 67% of OEF/OIF/OND Veterans evaluated at the NJ WRIISC have normal spirometry • Approximately1 in 5 (19%) of these Veterans exhibit a +BD response • Average post-BD FEV1 or FVC = 14.9±0.01%

45. Limitations • Reversibility 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 sample

46. Research Clinical Evaluations Education & Outreach

47. Exercise Challenge • Exercise-Induced Bronchospasm (EIB) ≥ 10% decrease in post-exercise FEV₁ 6-8 min 80-90% max HR 10 min post Baseline ATS 2000; Amer J RespCrit Care Med

48. Research Sample

49. Exercise-Induced Bronchospasm (EIB) • EIB = ≥ 10% decrease in post-exercise FEV₁ Sonna et al. 2001; Seear et al. 2005; Ali et al. 2012

50. Post-Exercise Spirometry > 6 months < 6 months