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pdf Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
Deployment and Environmental Health Surveillance Investigation of
1/24 BN SBCT Mosul, Iraq 2004–2005
December 2014
Prepared by
Army Institute of Public Health
Distribution authorized to U.S. Government Agencies only. December 2014.
Requests for this document must be referred to the Director, Army Institute of
Public Health, 5158 Blackhawk Road, Aberdeen Proving Ground, MD 210105403
General Medical: 500A, Public Health Survey
Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
ACKNOWLEDGEMENTS
PREPARED BY:
Farhana Schickedanz
Data Assessment Team Chief
Deployment Environmental Surveillance
Program
Tim Schickedanz
Health Risk Communication Specialist
Health Risk Communication Program
Katie Riley, MPH, CPH, MCHES
Health Risk Communication Specialist
Health Risk Communication Program
Nathan Cook
Physical Scientist
Deployment Environmental Surveillance
Program
Coleen P. Baird, MD, MPH, FACOEM
Program Manager,
Environmental Medicine Program
Charles McCannon, MD MPH, MBA, FACPM
Environmental Medicine Program
Ronald Teichman MD MPH, FACP, FACOEM
Environmental Medicine Program
Amy Jenness
Meteorologist
Deployment Environmental Surveillance
Program
Denise Robinson
Environmental Engineer
Deployment Environmental Surveillance
Program
REVIEWED BY:
Jeffrey S. Kirkpatrick
Portfolio Director, Health Risk Management
William A. Rice
COL, MC
Portfolio Director, Occupational and Environmental Medicine
APPROVED BY:
John J. Resta
Director, Army Institute of Public Health
Use of trademarked name(s) does not imply endorsement by the U.S. Army
but is intended only to assist in identification of a specific product.
Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
Table of Contents
Page
Executive Summary
1
1
2
Summary
1.1 Purpose..........................................................................................................2
1.2 Background ....................................................................................................2
1.3 Methodology...................................................................................................2
1.4 Findings .........................................................................................................3
1.4.1 Potential Exposures ....................................................................................3
1.4.2 Reported Health Concerns and the Potential Exposures ............................4
1.4.3 Cluster Assessment ....................................................................................5
1.4.4 Rationale for Conducting Cancer Studies ...................................................5
1.5 Recommendations .........................................................................................5
1.5.1 1/24 BN SBCT Personnel............................................................................5
1.5.2 Department of the Army ..............................................................................7
1.6 Point of Contact..............................................................................................8
2
References
8
3
Appendices
8
4
Introduction
8
4.1 Background ....................................................................................................8
5
Site Description
9
5.1 Mosul .............................................................................................................9
5.1.1 Major Routes.............................................................................................10
5.2 Forward Operating Base Marez ...................................................................11
5.3 Camp Courage.............................................................................................11
6
Interviews 1/24 BN SBCT Personnel
11
6.1 Overview of Interview Findings ....................................................................12
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
7
Occupational Environmental Health Surveillance Data Gathering
13
7.1 Open Sources ..............................................................................................13
7.2 Databases....................................................................................................14
7.2.1 DOEHRS...................................................................................................14
7.2.2 MESL ........................................................................................................15
7.2.3 Modernized Integrated Database ..............................................................16
7.2.4 Troop Unit/Personnel Tracking..................................................................16
7.3 Geographic Information Systems .................................................................17
8
Evaluating a Suspected Disease Cluster
18
8.1 Background ...................................................................................................18
9
Identified Environmental Exposures
20
9.1 IED/VBIEDs/SBIEDs/Fougasse ...................................................................21
9.1.1 Weapon Caches .......................................................................................22
9.2 Open burning/Burn Pits........................................................................ .…..22
9.3 Equipment Graveyards and Depleted Uranium ..........................................23
9.4 Burning Stryker Vehicles and Halon Fire Suppression System ..................25
9.5 Non-Ionizing Radiation (Microwave/High Frequency Jammers)..................26
9.6 Air Quality ...................................................................................................27
9.7 Human Remains ........................................................................................27
9.8 Raw Sewage ..............................................................................................28
9.9 The “Ice Factory” ........................................................................................29
9.10 Industrial Facilities………………………………………………………………..29
10
Reported Health Concerns
30
10.1 Follicular Lymphoma ..................................................................................30
10.2 Acute Lymphoblastic Leukemia..................................................................31
10.3 Biliary Carcinoma or Bile Duct Cancer ......................................................31
10.4 Pulmonary Nodules...................................................................................31
10.5 Asthma ......................................................................................................32
10.6 Post-Traumatic Stress Disorder .................................................................32
10.7 Mild Traumatic Brain Injury.........................................................................33
10.8 Panic Disorder............................................................................................33
10.9 Kidney Stones ...........................................................................................34
10.10 Crohn’s Disease.......................................................................................34
10.11 Gastrointestinal Symptoms .......................................................................35
10.12 Hearing Loss .............................................................................................35
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
10.13 Miscellaneous Conditions.........................................................................35
11
Findings
36
11.1 Potential Exposures ...................................................................................36
11.2 Reported Health Concerns and the Potential Exposures ...........................37
11.3 Cluster Assessment ...................................................................................38
11.4 Rationale for Conducting Cancer Studies ..................................................38
12
Recommendations
38
12.1 1/24 BN SBCT Personnel ...........................................................................38
12.2 Department of the Army ..............................................................................40
13
Point of Contact
41
Appendices
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
References..........................................................................................................42
Acronym List .......................................................................................................49
Approach to Disease Cluster Assessment ..........................................................55
Meteorological Data and Wind Direction for Mosul……………………………… ..63
POEMS Factsheet/Requesting a POEMS ..........................................................67
Post Deployment Health Assessment and Reassessment Form Review ...........71
Health Effects Associated with Chlorine and Chlorine IEDs and
......76
Preventive Medicine Actions Fact Sheet
Health Effects Associated with Burn Pits and Burn Pit Factsheets ....................81
OTSG MEDOCM Policy 14-021 (Medical Management of Army Personnel ...84
Exposed to DU)
Additional Information on DU ............................................................................113
Particulate Matter Factsheet .............................................................................123
Handling of Human Remains Fact Sheet…………………………………………. 126
Infectious Diseases Presumptively Associated with Deployment......................129
Health Effects Associated with Ammonia Exposure………………………….. ....134
Assessment of Health Outcomes......................................................................137
Statement of Evidence Associating Deployment with Respiratory Conditions ..147
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
EXECUTIVE SUMMARY
Deployment and Environmental Health Surveillance Investigation
1/24 BN SBCT Mosul, Iraq 2004–2005
December 2014
In December 2013, a Request for Information from the Chief of Staff of the Army was provided to The
Surgeon General regarding the deployment exposure concerns of a group of Soldiers from the 1/24
Battalion (BN) Stryker Brigade Combat Team (SBCT) who served in the vicinity of Mosul/Task Force
Olympia, Iraq in 2004-2005. Health conditions identified in the request included liver cancer, liver
disease, lymphoma, adverse reproductive and birth outcomes, and Crohn’s disease. The U.S. Army
Public Health Command, Army Institute of Public Health, conducted a Deployment and Environmental
Health Surveillance Investigation to examine and address health and environmental exposure concerns
expressed by the 1/24 BN SBCT during their 2004-2005 deployment to Mosul, Iraq.
The goals of the investigation were to: (1) identify potential environmental exposures to 1/24 BN SBCT
personnel; (2) determine if historical data were available to characterize the frequency, magnitude, and
duration of environmental exposures with a completed exposure pathway; and (3) determine if adverse
health effects associated with such exposure were likely based on the available information.
The findings suggested that the health effects reported by Unit members did not have definitive
associations with potential exposures identified by the Unit or to other known exposures. Although the
available data were limited, long-term health effects were not expected based on the available
information. Also, a cluster (pattern) of a specific disease or condition was not evident.
Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
Deployment and Environmental Health Surveillance Investigation
1/24 BN SBCT Mosul, Iraq 2004–2005
December 2014
1
Summary
1.1 Purpose
The U.S. Army Public Health Command (USAPHC), Army Institute of Public Health (AIPH)
conducted a Deployment and Environmental Health Surveillance Investigation to examine and
address health and environmental exposure concerns expressed by a group of Soldiers from the
1/24 Battalion (BN) Stryker Brigade Combat Team (SBCT) during their deployment to Iraq in 20042005. The main goals were: (1) identify potential environmental exposures to 1/24 BN SBCT
personnel, (2) determine if historical data were available to characterize the frequency, magnitude,
and duration of environmental exposures with a completed exposure pathway, and (3) determine if
adverse health effects were likely based on available information.
1.2 Background
In early December 2013, the USAPHC was made aware that multiple members of the 1/24 BN
SBCT Headquarters and Headquarters Command (HHC) reported a variety of health conditions to
include liver cancer, lymphoma, Crohn’s disease, and undiagnosed symptoms and health concerns.
Affected individuals served in the vicinity of Mosul/Task Force (TF) Olympia, Iraq in 2004-2005 as
part of Operation Iraqi Freedom (OIF). Their major concern was whether or not the observed
health outcomes represented an excess of disease in the unit. The Deployment Environmental
Surveillance Program (DESP), Health Risk Communication Program (HRCP), and Environmental
Medicine Program (EMP) engaged in fact finding in the areas of exposure and potential health
implications as well as risk communication to assess health concerns and perceptions. All of these
efforts are described in this report.
1.3 Methodology
The investigating team’s objective was to identify exposures and potential exposures to members of
the 1/24 BN SBCT deployed to Mosul, Iraq area in 2004-2005. Occupational and environmental
health surveillance (OEHS) data were collected from environmental sampling, descriptive
documents regarding incidents or releases, and historical operational/personnel data.
Next, the likelihood that an individual was actually exposed (also known as a “completed exposure
pathway”) was evaluated, which considered the source from which the harmful stressor could be
emitted, whether or not there was a release mechanism and whether it involved air, water, or soil.
If so, the method of contact with the exposure was identified: ingestion, inhalation (breathing) or
contact with skin (dermal).
The team also conducted 16 personal interviews with former Soldiers, spouses, and leaders of the
1/24 BN SBCT to determine deployment exposure concerns, health status, health concerns, and
current perceptions and beliefs. All individuals interviewed were asked about their deployment
history, experiences during the deployment, major incidents of concern, environmental exposures,
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
in-theater injuries and illnesses, medical care, and health status before, during, and after their
deployment to Mosul, Iraq 2004-2005.
Health conditions, symptoms, and health concerns identified from the interviews were utilized and
medical records were reviewed. In addition, medical encounter data in the Department of Defense
(DoD) electronic health record—Armed Forces Health Longitudinal Technology Application
(AHLTA)—and the Department of Veterans Affairs’ electronic health record were reviewed when
personnel data were available. The goal was to identify health conditions that might be present in
excess of their existence in the general population and to create case definitions for those
conditions. The case definition described what was required for a person’s injury or illness to be
counted as a case in subsequent analyses. Next, a preliminary assessment determined whether
an excess amount of cases had occurred (see Appendix C for Approach to Disease Clusters). If a
cluster of cases was confirmed, the identified potential exposures were assessed for a biologically
plausible relationship with this outcome. Finally, a decision was made as to whether an
epidemiological study was feasible and warranted (references 1, 2, and 3).
1.4 Findings
Minimal objective information was available regarding potential exposures incurred by Unit
members. The 1/24 BN SBCT was deployed to Mosul during a time of heavy insurgent activity and
engaged in numerous dangerous missions. There was limited environmental monitoring conducted
during this period of high operational tempo. Unit members were potentially exposed to products of
combustion and incomplete combustion and an unknown mix of other potential hazards when
detonating unexploded ordinance, during frequent improvised explosive device attacks, and when
responding to burning Stryker vehicles.
In general, the health effects reported by Unit members did not have definitive associations with
potential exposures identified by the Unit or to other known exposures. Although the available data
were limited, long-term health effects were not expected based on the information available.
Finally, a disease cluster (pattern) was not evident.
1.4.1 Reported Potential Exposures
An extremely limited amount of specific, quantitative, and applicable exposure information was
identified in the review of available data sources. Ambient air quality was considered poor by many
Soldiers. Exposure to ambient particulate matter (PM) and vehicle exhaust was highly likely. This
is based on environmental monitoring conducted after 2005. Soldiers and the Unit surgeon were
concerned about emissions from a burn pit. A burn pit used for waste control was determined to
have been appropriately sited with respect to prevailing wind patterns. However, atypical events
(such as atmospheric temperature inversions) may have occurred. These events have the
potential to cause prolonged lingering of burn pit smoke near the ground. Exposure to other
products of combustion from burning vehicles and uncharacterized burn pit emissions occurred at
an unknown frequency, duration, and intensity.
While it is plausible that toxic industrial chemicals may have been present, there were no
documented chemical releases or industrial accidents apart from a single ruptured canister incident
at the “Ice Factory” discussed in the interviews. The impression of those interviewed for this
investigation was that industrial facilities located in and around Mosul were generally not
operational.
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
Soldiers were concerned about exposure to Halon discharged from the fire suppression systems,
installed in Stryker vehicles. However, Halon was not the fire suppressing agent used in these
vehicles. A burning Stryker would be expected to generate a variety of potentially hazardous
combustion products. Magnitude and duration of hazardous exposures from burning vehicles were
not known.
Unit members reported being near destroyed or disabled vehicles that may have been hit with
depleted uranium (DU) rounds. Contact with vehicles hit by DU rounds may have resulted in
limited incidental DU exposures (considered “Level III” exposures). Such exposures are not
associated with significant health risks.
Individuals reported sporadic or potential exposure to sewage and human remains. The extent of
barrier protection was variable between individuals. One individual reported an episode of what he
considered “dysentery” from drinking water that was bottled; therefore, ingestion of contaminated
water was not likely to have occurred. The lack of other reported acute episodes of infectious
disease were evidence of a low level of risk for future health consequences of exposure to
untreated sewage and human remains. The long-term risk of infectious disease risk was minimal.
Based on events as described by Unit members, some individuals likely incurred short-term
exposures to irritants from Improvised Explosive Device (IEDs)/ Vehicle Borne Improvised
Explosive Device (VBIEDs)/ Suicide Bomber Improvised Explosive Device (SBIEDs) and possibly
at the “Ice Factory” or elsewhere. In no instance were these exposures quantified. Typically,
however, acute health effects would have been apparent if exposures were of sufficient magnitude
to be of long-term concern. Other hazards (such as propellants and accelerants) were mentioned
by those interviewed, but it was not clear to what extent the exposure pathways were completed
(i.e., item was inhaled, ingested or substantially absorbed through the skin). Some exposure
concerns (such as the microwave “jammers”) do not pose a health hazard under normal operating
conditions.
The evaluation of the frequency, duration, and magnitude of specific exposures which could
potentially result in long-term health effects did not provide evidence of a singular source of risk.
However, there is substantial uncertainty about the risk posed by combinations of hazards and
about exact exposures experienced at the individual level.
1.4.2 Reported Health Concerns and the Potential Exposures
Regarding health conditions and potential associations with deployment-related exposures, it could
be stated with a high degree of certainty that self-reported post-traumatic stress disorder (PTSD),
traumatic brain injury (TBI) and mild TBI (MTBI) were likely to have resulted from Unit activities
during their deployment. The Unit operated for prolonged periods at high intensity with little “down
time”, and was exposed to deaths of Unit members, other human remains, and high-stress combat
conditions. Likewise, hearing loss and combat injuries resulted from deployment activities. There
were few complaints of respiratory disease from the interviewees—asthma, shortness of breath,
and pulmonary nodules were reported—although inhalation exposures were likely. The association
between respiratory symptoms and deployment to OIF has been noted, and asthma following
deployment has been demonstrated in some published studies. Other non-cancer conditions (such
as kidney stones, Crohn’s disease, and non-infectious gastrointestinal disease and symptoms) do
not have a clear relationship with potential exposures incurred during the Unit’s deployment.
Biliary carcinoma is not associated with a specific environmental exposure. Two of the reported
malignancies, follicular lymphoma and acute lymphoblastic leukemia (ALL), are associated with
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
ionizing radiation. Follicular lymphoma had also been associated with solvent exposure, although
evidence for this relationship is considered limited/suggestive. While there are no quantitative
measurements, exposure to incidental ionizing radiation is unlikely to result in development of
either cancer. Cancer related to solvent exposure is limited to particular solvents and typically
occurs in working populations with regular, recurring, long-term exposure. See Appendix P for
details on the published literature regarding these opinions.
1.4.3 Disease Cluster Assessment
Overall, there is not a predominant and specific health condition of concern. No unifying case
definition could be delineated. The presence of different cancer types in this small group was not
evidence of a disease cluster, given that a cluster involves one specific type of disease. Likewise,
singular occurrences of a specific disease type cannot be assessed as occurring in excess to what
would be expected (references 1, 2, and 3). The age of onset for the noted cancers are somewhat
atypical, but not wholly uncommon.
Since a unifying case definition cannot be established and because no known completed exposure
pathway for a biologically plausible exposure can be identified, a formal epidemiological
investigation would not be useful and is unfounded.
1.4.4 Rationale for Conducting Cancer Studies
The AIPH is planning to conduct a set of epidemiologic studies to evaluate whether a history of
deployment in support of OIF/OEF was associated with subsequent incidence of primary cancer
(from 2004–2013) among Active Duty Service Members and U.S. Veterans. Cases of primary
melanoma, brain cancer, leukemia, lymphoma, thyroid cancer, testicular cancer, and breast cancer
will be identified using DoD and VA medical records and cancer registry databases. Many of these
cancers will have peak incidence during the young adult years and will have known or suspected
environmental or occupational risk factors.
In responding to the concerns of the 1/24 BN SBCT Soldiers, Service Members and Veterans, a
necessary first step is to evaluate whether the incidence of cancer among deployed personnel is
greater than what would be expected. Thus, the objective of this study is to systematically identify
cases of cancer among Active Duty Service Members and Veterans, evaluate their deployment
experience in comparison to the deployment experience of a representative set of control subjects,
and estimate the excess risk of cancer among deployed personnel. An understanding of the
presence and magnitude of an excess risk of cancer among formerly deployed individuals – or the
lack thereof – can be used to substantiate or alleviate concerns, support the public health and
medical communities that care for formerly-deployed personnel and Veterans, and inform DoD and
VA policy makers regarding the long-term effects of deployment-associated exposures.
1.5 Recommendations
1.5.1 The 1/24 BN SBCT Personnel
Encourage all individuals to seek medical evaluation for unexplained, persistent, or
concerning health conditions. Individuals should speak with their healthcare provider
regarding potential exposures of concern. Providers with questions regarding deploymentrelated exposures and potential associations with health conditions may contact the AIPH
Environmental Medicine Clinical Consult Service (usarmy.apg.medcom-
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
[email protected]). Questions and contact information may be emailed to this
address and a provider will contact the requestor, typically within 48 hours.
Foster a positive climate for seeking care for both physical and behavioral health injuries
and concerns. A stigma against seeking care is still pervasive in some units. Given the
nature of the missions and experiences of the 1/24th, they are at risk for PTSD. If still on
Active Duty, they may seek assistance through their primary care manager or evaluate
resources on the Defense Center of Excellence at: www.dcoe.mil Web page which also
provides information, 24/7 access and other assistance. The PTSD may affect close
relationships, particularly those with the Family. The Family may play an important role in
encouraging individuals to seek help. The Family can access resources at: www.dcoe.mil.
The VA Web site at: www.ptsd.va.gov provides resources for Family members, self-help
online tools for those with PTSD, and information and telephone numbers for use when in
crisis and how to seek help and get assessed in the VA system.
Ensure Active Duty Soldiers from the 2004-2005 1/24 BN SBCT deployment contact their
primary care manager for any TBI health concerns related to exposures from IEDs,
VBIEDs, and SBIEDs. All individuals with a history of such trauma, particularly if they are
exhibiting symptoms such as headaches, dizziness, memory loss and other cognitive
difficulties, irritability, mood disorder or impact to their daily functioning should be
evaluated. Some of these symptoms may be contributing to, overlapping with, or
exacerbating other behavioral health issues such as PTSD. The DoD Defense Centers of
Excellence for Psychological Health and Traumatic Brain Injury offers a 24/7 Outreach
Center Web site at: www.dcoe.mil with access to phone center, live chat and email, as well
as resources for the individual and the Family. The VA now has Polytrauma Care Facilities
which have expertise in addressing all of the effects and symptoms of TBI in multiple organ
systems. Resources and contact information may be found at:
(http://www.polytrauma.va.gov/understanding-tbi/). In addition, any combat Veteran may
bring their DD214 to a Veterans (VET) Center to speak to a counselor or therapist without
an appointment and regardless of enrollment status with the VA. Information, Web links,
and contact information on these programs, to take a self-assessment online, and other
topics can be found at http://www.maketheconnection.net/resources
Encourage all individuals with concerns regarding inhalational exposures or open burning
of trash to register for the VA Airborne Hazards and Open Burn Pit Registry. The VA, in
coordination with DoD, has established an Airborne Hazards and Open Burn Pit Registry to
allow Military personnel and Veterans previously deployed in Afghanistan, Iraq, or 19901991 Gulf War with concerns regarding their exposure to various sources of air pollution
(such as smoke from burn pits, oil-well fires, or pollution) during their deployment to provide
detailed information regarding their exposure situation and health concerns. In addition,
the registry offers an optional medical assessment, though it is not required to be in the
registry. The VA Airborne Hazards and Open Burn Pit Registry can be accessed through
the Web site below:
https://veteran.mobilehealth.va.gov/AHBurnPitRegistry
Inform former members of the 1/24 BN SBCT about the updated U.S. Army Medical
Command (MEDCOM) Office of The Surgeon General (OTSG) Policy 14-021. The
updated policy provides former and current Soldiers specific guidance and classification, for
Soldiers who have or may have been exposed to DU during a deployment. The policy also
provides specific information to request a DU urine bioassay through their primary care
provider if warranted.
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
1.5.2 Department of the Army
Coordinate with higher headquarters personnel from the Army, U.S. Central Command
(CENTCOM), and DoD to establish the steps needed to review all sensitive data/information
from this investigation and the OEF/OIF/Operation New Dawn (OND) campaigns for applicable
declassification/redaction steps to allow inclusion in future investigative reports. This is
particularly important with respect to exposure incidents and other information potentially
relevant to health outcomes. The DoD VA Data Transfer Agreement requires DoD to provide
such information to the VA for their use.
Improve documentation of personnel locations for all Army military and Civilian personnel. At
minimum, daily locations for each Soldier and Civilian should be captured and maintained. In
the absence of individual monitoring and in order to appropriately associate a fixed potential
hazard to potentially exposed personnel, their location in association with the hazard must be
known. Although personnel locations are mission sensitive, these data should be made
available to public health professionals in a timely manner.
Ensure OEHS requirements identified in Army Regulation (AR) 11-35 (Deployment Occupational
and Environmental Health Risk Management) are implemented and executed.
Ensure prompt reporting of all exposure incidents in the Defense Occupational Environmental
Health Readiness System (DOEHRS) Incident Module. This reporting allows for the reporting of
descriptive information related to exposure incidents such as fires, releases, spills or other
events even in the absence of sampling information. Additionally, rosters of the potentially
exposed population are associated with this information, which is searchable by the individuals
SSN, location or other key terms.
Ensure all Soldiers properly complete the Post-Deployment Health Assessment (PDHA) and
Post Deployment Health Assessment and Reassessment (PDHRA) and that they receive proper
guidance and education on the importance of these assessments. Individuals should be
encouraged to document on these forms exposures that are of concern as well reporting specific
symptoms or health effects experienced in theatre in relation to such exposures.
Ensure providers have access to current information on relevant potential hazards with an
understanding of when a referral is warranted and when reassurance is appropriate. Risk
communication is required at the time of the PDHA and PDHRA for exposure concerns if the
Service member is not referred. Factual, understandable, and updated assessments of potential
health risks associated with deployment exposures should be available to DoD providers, as well
as VA providers, particularly those associated with the VA War-Related Illness and Injury Study
Centers (WRIISCs).
Ensure that the Army is prepared to handle additional future stakeholder groups coming forward
with health outcomes perceived to be associated with deployment related activities from the
OEF/OIF/OND campaigns. It is critical that investigating agencies have comprehensive,
accessible, interpretable, relevant and useable data that affords subject matter experts and
healthcare providers the information needed to better assess, care for, and educate Soldiers and
Veterans.
Ensure that the Army enhances environmental, occupational, and medical surveillance activities
via state of the art technologies to realize comprehensive health surveillance.
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
1.6 Point of Contact
Ms. Farhana Schickedanz, DESP, MCHB-IP-RDE, DSN 312.584.6096, COM 410.436.6096,
[email protected] and [email protected].
2
References
See Appendix A for a complete listing of references used in this report.
3
Appendices
The following are a list of appendices:
4
Appendix B for Acronym List
Appendix C for Approach to Disease Cluster Assessment
Appendix D for Meteorological Data and Wind Patterns for Mosul
Appendix E for the POEMS Factsheet and How to Request a POEMS
Appendix F for Post Deployment Health Assessment and Reassessment Forms
Appendix G for Health Effects associated with Chlorine and Chlorine IED’s and Preventive
Medicine Actions Fact Sheet
Appendix H for Health Effects associated with Burn Pits and Burn Pits Fact Sheet
Appendix I OTSG MEDOCM Policy 14-021 (Medical Management of Army Personnel Exposed to
DU),
Appendix J for additional information on DU
Appendix K for Particulate Matter Factsheet
Appendix L for handling of Human Remains Fact Sheet
Appendix M for Infectious Diseases Presumptively Associated with Deployment
Appendix N for Health Effects Associated with Ammonia Exposure
Appendix O for Assessment of Health Outcomes
Appendix P for Summary of Evidence Regarding Deployment and Respiratory Conditions
Introduction
4.1 Background
The 1st Battalion, 24th Infantry Regiment was assigned to the 1st Brigade, 25th Infantry Division
st
th
"Lightning" (a Stryker brigade). The 1 Battalion, 24 Infantry (1/24 BN SBCT) equipped with
Stryker wheeled armored vehicles were deployed to Mosul, Iraq from October 2004–September
2005. The 1/24 BN SBCT was responsible for the western half of Mosul where they faced constant
insurgent attacks (reference 4).
The 1/24 BN SBCT organization consisted of HHC (referred to as Hatchet) and three infantry (or
line) companies A (Apache), B (Bulldog), and C (Cobra). Each of the companies was assigned an
Area of Operation (AOR) sector (reference 4).
The arrival of the 1/24 BN SBCT coincided with the upcoming Iraqi election in January 2005 and
the offensive operations to eradicate the insurgents. The 1/24 BN SBCT played a major part in the
Battle of Mosul in November 2004 where the insurgents were conducting coordinated attacks and
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
ambushes in an attempt to take over the city including the police stations. The Units from the 1/24
BN SBCT frequently fought against the insurgents in the vicinity of the Yarmuk traffic circle. The
Iraqi Security forces and Iraqi National Police (now called the Iraqi Federal Police) were in a state
of flux, and the 1/24 BN SBCT patrolled with and trained them (reference 4).
The Battalion personnel earned 5 Silver Stars, 31 Bronze Stars, and 181 Purple Hearts. The Unit
was also awarded the Valorous Unit Award as being part of the 1st Brigade, 25th Infantry Division
(SBCT).
The Unit reflagged as the 3rd Squadron, 2nd Stryker Cavalry Regiment and moved to Vilseck,
Germany. The 1st Battalion, 24th Infantry Regiment replaced the 2nd Battalion, 1st Infantry
Regiment of the now decommissioned 172nd Stryker Brigade Combat Team as of 14 December
2006 (reference 5).
Figure 1. Map of Iraq (reference 6)
5
Site Description
5.1 Mosul
Mosul is a city in northern Iraq and the capital of the Nineveh Province, some 400 kilometers (km)
(250 mi) northwest of Baghdad (Figure 1). The 1/24 BN SBCT was responsible for half of the city
west of the Tigris River, which was heavily industrialized and consisted of the oldest section of
Mosul. Mosul is northern Iraq’s major center for trade, industry, and communications. The Tigris
River bisects the city, and the area is primarily agricultural, with most of the local infrastructure and
industry supporting agricultural activities. The Yarmuk Traffic circle (Figure 2) and surrounding
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
neighborhoods were the center of most insurgent and counterinsurgent activities during the time
the 1/24 BN SBCT was in Mosul (references 4, 7 and 8). See Appendix D for a discussion on air
dispersion and meteorology for Mosul.
Figure 2. Map of Western Mosul
5.1.1 Major Routes
The majority of key roads intersect at the Yarmuk Traffic circle which is northwest of the old city.
Iraqi national Route 1 known to U.S. Forces as Military Supply Route (MSR) Tampa runs northsouth through western Mosul and intersects Yarmuk Traffic circle. Iraqi national Route 2 known to
U.S. Forces as MSR Santa Fe proceeds west northwest from the Yarmuk Circle towards the Syrian
border and to the city of Tal Afar (reference 4).
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
5.2 Forward Operating Base Marez
Forward Operating Base (FOB) Marez (aka Glory) was located along side of MSR Tampa (Figure
2). The 1/24 BN SBCT living quarters were located in the southern portion of FOB Marez. The
FOB Marez also housed the U.S. military airfield, Mosul Airport (aka LSA Diamondback), on the
east. The Combat Support Hospital (CSH) was located on LSA Diamondback. On 21 December
2004, 14 U.S. Soldiers, 4 American employees of Halliburton, and 4 Iraqi Soldiers were killed in a
suicide attack on a dining hall at FOB Marez (references 4 and 5).
5.3 Camp Courage
st
th
The parent brigade of the 1/24 BN SBCT IN, the 1 Brigade, 25 Infantry Division, was
headquartered at the former Saddam Hussein palace complex, also referred to as Camp Courage
or Camp Freedom. Camp Courage was located in northern Mosul, east of the Tigris River.
6
Interviews 1/24 BN SBCT Personnel
The HRCP, in collaboration with the EMP and the DESP, conducted interviews with prior members
of the 1/24 BN SBCT (Mosul, Iraq 2004-2005) to determine current perceptions, beliefs, health
status, health concerns, and deployment exposure concerns. The primary purpose of interviewing
various stakeholders of the 1/24 BN SBCT was to meet the critical need for human “on the ground”
intelligence and information to support known data sources. In some situations, the interview
became the only source of information for a specific incident or concern. The characterization of
the actual health risk and risk communication efforts were more successful due to the interview
process. The interviews became a road map for the DESP to be able to focus resources on
investigating specific environmental exposure incidents and concerns. Interviewees also provided
hard copy information (such as maps and photos), which were significant in proceeding with the
investigation. In addition to the above purpose which supported the evaluation of available
exposure information, an additional purpose was to assess the health conditions of concern and to
assess whether or not there was a cluster or irregularity of a disease present.
The team conducted 16 fact finding interviews with former Soldiers, spouses, and leaders of the
1/24 BN SBCT from 06 January 2014 to 01 April 2014. Interview participants were identified by a
spouse of a former 1/24 BN SBCT Soldier, who provided a list of members of the 1/24 BN SBCT
they personally knew and believed may be interested in sharing their experiences with the
investigation team. A former member of the 1/24 BN SBCT also communicated about the
®
investigation on the Deuce 4, “1/24th BN SBCT” Facebook Web site and collected names and
®
contact information of individuals who were interested in being interviewed. (Facebook is a
registered trademark of Facebook, Inc.)
The HRCP contacted persons of interest to set up interviews with varying degrees of success.
When contacted at scheduled interview times, a few individuals or their family members indicated
they were no longer interested or able to participate in the interviews. Many interviewees kept a
journal during the deployment. However, several former members of the 1/24 BN SBCT indicated
that the memories were still too painful to go back and read and were not able to provide additional
information.
The interview phase of the investigation officially ended on 01 April 2014, but interviews were still
completed up until July 2014 as additional persons of interest came forward to volunteer
information. Each interview was recorded (upon their approval) and a written summary was
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
created. All recordings and interview documents were secured in a locked container to protect the
interviewee’s privacy. Interview summaries were provided to EMP and DESP. The DESP used the
information identified in the interviews to conduct more targeted database searches.
6.1 Overview of Interview Findings
The following health concerns were identified by members of the 1/24 BN SCBT during interviews.
More detailed information can be found in section 10, Health Concerns.
Follicular Lymphoma
Acute Lymphoblastic Leukemia
Biliary Carcinoma or Bile Duct Cancer
Pulmonary Nodules
Asthma
Traumatic Brain Injury (and associated symptoms)
Post-Traumatic Stress Disorder
Panic Disorder
Kidney Stones
Crohn’s disease
Gastrointestinal Symptoms
Hearing Loss
Pilonidal Cyst
Restless Leg Syndrome
Rashes
The overall findings of environmental exposure concerns from interviews can be categorized into
the following groups. More detailed information can be found in Section 9, Identified Environmental
Exposures.
IED/VBIED/Weapon Caches
Equipment graveyards (potential DU)
Burn Pit Exposures
Burning Stryker Vehicles/“Halon” Fire Suppression System
Air Quality (Dust storms/vehicle exhaust)
Non-ionizing (microwave, radio frequency) Radiation
Raw Sewage
Human Remains
One time unknown acute exposure from pierced tank known as the “Ice Factory” incident
Industrial Facilities
Many of those interviewed also reported exposure to numerous blasts in firefights and from IED
attacks. Many former members of the 1/24 BN SBCT reported having concussions that were not
medically evaluated or documented in their medical records due to OPTEMPO. In addition, most
personnel indicated they routinely did not seek medical attention for acute events. The 1/24 BN
SBCT patrolled the city for long hours seven days a week. Members of the 1/24 BN SBCT
interviewed indicated there was limited downtime and that they felt that they would be leaving their
teams understaffed and at risk if they sought medical care which resulted in being put on quarters
or temporary medical profile. Medical providers interviewed indicated it was common for Soldiers
to continue to perform their duties without seeking care, or to have a quick evaluation by field
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
medics. When Soldiers did seek care, expedient field medical assessments were typically not
documented. Limited documentation of deployment related illnesses, injuries, and potential
exposures were one limiting factor of the investigation. A detailed explanation of the exposures
identified by members of the 1/24 BN SBCT can be found in section 9, Identified Environmental
Exposures. More detailed information about the health conditions and concerns of members of the
1/24 BN SBCT can be found in in section 10.
7
Occupational Environmental Health Surveillance Data Gathering
All relevant OEHS data were gathered from databases, open sources, email archives, and archived
public folders. The OEH related information collected during interviews with prior 1/24 BN SBCT
personnel were also researched. The sections below discuss the methods used to gather
information needed to characterize environmental exposures.
7.1 Open Sources
The DESP evaluated historical archives and conducted open source searches on the Secret
Internet Protocol Router Network (SIPRNET) and Non-Classified Internet Protocol Router Network
(NIPRNET) specific to Mosul in the 2004-2005 timeframe. Specifically, email archives and DESP
public folders were queried for any information about the 1/24 BN SBCT, Mosul, FOB Marez, LSA
Diamondback, and the 2004-2005 timeframe.
All the open source searches were conducted on the SIPRNET and NIPRNET for any information
about the “1/24 BN SBCT”, “Mosul”, “ FOB Marez”, “LSA Diamondback”, “Camp Courage”, and the
“2004-2005 timeframe”. The team also looked for any exposure incidents (e.g., “Ice Factory”) that
had been reported to better assess possible environmental exposures. Operational intelligence
products generated on the SIPRNET, Significant Activities (SIGACTS), and Situation Report
(SITREPS) were also reviewed for pertinent information that could identify any possible
environmental exposure events. A separate classified report (available on the SIPRNET by
request) provides information on the classified open sources that were used to conduct the
SIPRNET searches.
All the information found was reviewed by DESP. The only relevant SIGACTS found contained
information on IEDs attacks and finding weapon caches. The 1/24 BN SBCT interviewed personnel
also stated coming in contact with IEDs/VBIEDS and weapon caches on routine basis. An
intelligence product was found on the SIPRNET that discussed finding the biggest weapon caches
in Mosul around the deployment timeframe of 1/24 BN SBCT. The report just provided the facts on
what transpired, but no environmental exposures were discussed. From the OEHS data searches,
no information was found on insurgents using chlorine IEDs in Mosul during the 1/24BN SBCT
deployment timeframe. The use of Chlorine IEDs by insurgents was confirmed and documented by
DoD from 2006 onwards.
The majority of the SITREPS found were Medical SITREPS that discussed medical distribution of
medical assets. There was no information found on the SIPRNET about the “Ice Factory” incident.
There was an intelligence report on fire at an oil storage tank in western Mosul and research
facilities. The team could not find any other incident reports from open sources that could be linked
to a specific environmental exposure.
One of interviewees had alluded to a Container Express (CONEX) which contained information on
1/24 BN SBCT Operations (paperwork/disks/cds) was transported to Germany (upon return from
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
their deployment, the 1/24 BN SBCT was reflagged to the 3/2 Stryker Cavalry Regiment in Vilsek,
Germany). The regiment has been contacted through USAPHC Region Europe and they were not
able to find this CONEX.
7.2 Databases
All relevant databases were researched to identify any information on Mosul, 1/24BN SBCT, and
the deployment timeframe. The goal of the team was to identify any historical operational/
personnel data that can be used to characterize potential environmental exposures. The databases
used are discussed below.
7.2.1 Defense Occupational and Environmental Health Readiness SystemIndustrial Hygiene (DOEHRS)
The team searched the DOEHRS for environmental samples related to locations LSA
Diamondback, Camp Courage, FOB Marez, and Tall Afar, Iraq and collected between 2004-2005
timeframe. The DOEHRS is a Military Health System (MHS) managed by Defense Health Services
Systems (DHSS) for entering, assessing, managing and reporting occupational and environmental
exposures. The DOEHRS consists of multiple business areas; industrial hygiene (IH),
environmental health (EH), radiation health (RH), and incident reporting. It is used for both garrison
and deployed operations, is mandated by various DoD policies and public laws and is the exposure
system for the DoD longitudinal health record. The DESP search of the DOEHRS database found
that 10 environmental samples were collected at the aforementioned locations either during or
close to the associated timeframe.
There were three Reverse Osmosis Water Purification Unit (ROWPU)-treated water samples, two
well water samples, and two soil samples collected at Mosul area camps and analyzed by the U.S.
Center for Health Promotion and Preventive Medicine (CHPPM) (now USAPHC) Main laboratory in
2004 and 2005. Treated water samples were analyzed for approximately 195 parameters while
untreated water samples were analyzed for approximately 322 parameters. These parameters
included herbicides, insecticides, metals, polycyclic aromatic hydrocarbon (PAH), polychlorinated
biphenyl (PCB), semivolatile organic compounds (SVOC), volatile organic compounds (VOC) and
characteristics such as color, conductivity, pH, total dissolves solids, and turbidity. Soil samples
were analyzed for approximately 193 parameter that included fungicides, herbicides, insecticides,
metals, PAH, PCB, SVOC and VOC. The sample results did not exceed military exposure
guidelines (MEGs) in reference to USAPHC Technical Guide (TG) 230, Chemical Exposure
Guidelines for Deployed Military Personnel, Version 1.3, May 2003; and the January 2004
addendum, which were standard at the time samples were taken. In addition, sample results were
also screened in reference to USAPHC TG 230 “Environmental Health Risk Assessment and
Chemical Exposure Guidelines for Deployed Military Personnel, 2013 Revision.” It was determined
the sample results also did not exceed current MEGs, which were more stringent in comparison.
[The MEGs are concentrations of chemicals in air, water, and soil that are designed as decision
aids for health risk assessors to evaluate the significance of field exposures to chemical hazards
during deployments.]
The reevaluated OEHS sample data using the updated MEGs were sent to the AIPH Health
Physics Program to review the radionuclide results from deployment soil and water samples
collected from the Mosul area. The Health Physics Program reviewed the results for these samples
in February 2014 and determined the risk for exposure to the sampled waters is low and the soil
sample results are indicative of natural background levels of radionuclides.
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
There was one canal water sample, two well water samples, and one ROWPU-treated water
sample collected at Mosul area camps and analyzed by the CHPPM-Europe laboratory in 2004 and
2005. The well water samples were not analyzed for radionuclides due to visible solids that would
interfere with analysis. The CHPPM Europe DESP reported the risk for exposure to the canal
water and ROWPU-treated water was low.
7.2.2 Military Exposure Surveillance Library (MESL)
The MESL was searched for all documents related to location Diamondback (LSA for Mosul, Mosul
Airfield), Camp Courage, FOB Marez, and Tall Afar, Iraq for 2004-2005. The MESL provided
preventive medicine personnel with the ability to submit, search, view and download OEHS-related
documents and data to include:
Pre-deployment Site Surveys
Basecamp Assessments
Preventive Medicine Unit Reports
Preventive Medicine Situational Reports
Environmental Sampling Reports
Raw Environmental Sampling Data
Analytical Summaries
OEHS Exposure Incident Reports
After Action Reports
Chemical, Biological, Radiological, Nuclear (CBRN) Incident Lesson Learned Reports
Preventive Medicine Reports
Photographs
Entomology Surveillance/Control
Rodent Surveillance/Control
Sanitation Inspections (Public, Food, Housing, etc.)
Industrial Hygiene Assessments
Briefings (Medical Threat, OPD/NCOPD, etc.)
Water Distribution Point Surveillance
Periodic Occupational and Environmental Monitoring Summary (POEMS)
Documents found consisted of monthly pest management reports, reports for water samples,
reports for soils samples, one PM air report, pesticide usage reports, an asbestos air sampling
study, a 3ACR barber/beauty shop inspection and a basecamp assessment checklist. The pest
management reports or barber/beauty shop inspection reports were not reviewed.
The location of the burn pit and summary of the burn pit were found in the POEMS report. A
POEMS is an official, provider-focused, DoD technical document that describes OEH exposure and
their associated health implications for a deployment location during a specific time. More
background information on POEMS and information on how Military personnel/ personal healthcare
provider can request POEMS for a deployments location can be found in Appendix E.
The open air burn pit on Camp Marez was used to dispose of solid waste/refuse. The burn pit was
about 3 km southwest of the center of the airfield and about 1.5 km southeast of the equipment
graveyard (see Figure 3). No source air samples specifically associated with the burn pit were
taken. The open burn pit at FOB Marez was closed on 31 December 2010. See Section 8.3 for
more information on burn pit exposure (reference 9).
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
Additionally, the POEMS described the environmental health surveillance data for ambient
Particulate Matter (PM). Data for PM less than 10 micrometers in diameter (PM10) was available for
2003, 2007, 2009, and 2010. PM less than 2.5 micrometers in aerodynamic diameter (PM2.5)
sampling occurred only in 2010. Both data sets were limited to samples collected by U.S. Forces.
For both PM10 and PM2.5, levels were fairly consistent with those found through Iraq during the
entire conflict. These values are, in many cases, higher than those observed anywhere within the
United States. At the PM10 levels observed, specific subgroups of the deployed forces (e.g., those
with pre-existing asthma or cardiopulmonary conditions) were at greatest risk of developing health
effects. These were typical of dusty environments and probably included eye or respiratory
irritation, increased mucous production or cough. For PM2.5 levels, the development of chronic
health conditions such as reduced lung function or exacerbated chronic bronchitis, chronic
obstructive pulmonary disease, asthma, atherosclerosis, or other cardiopulmonary diseases is
plausible in generally healthy troops. Personnel with a history of these conditions would be more
likely to develop such chronic health conditions.
The MESL documents contained the air, water, and soil sample results that related to the samples
results found in DOEHRS (mentioned previously). Concentrations of detected chemicals were
below the MEGs and no other relevant or significant environmental exposures were identified from
the documents reviewed.
7.2.3 Modernized Integrated Database
The Defense Intelligence Agency's (DIA) Modernized Integrated Database (MIDB) was used to
identify all the industrial facilities in and around Mosul. The MIDB is a primary repository for data
production and dissemination of military intelligence involving worldwide orders of battle, facilities,
command and control networks, targeting, battle damage assessments, and other related
information required for strategic assessments and national policy decision making (reference 10).
7.2.4 Troop Unit/Personnel Tracking
Since Operation Desert Storm, a major challenge of conducting OEHS has been determining the
individual geographic locations of Service Members to then associate exposure data for assessing
health risk and medical outcomes. During OIF and OEF, the USAPHC has obtained access to
several software and data applications to obtain data for identifying individuals and/or Units and
their recorded locations for the purpose of assessing and studying potential environmental
exposures. The major data source was the CENTCOM SIPRNET based Command & Control
Personal Computer (C2PC), which was a client application that provided unit names and near realtime geographic location data. Although C2PC was a tool designed for tracking tactical Units, it
had limited capabilities in identifying individual personnel locations and command elements below
the company level. No personnel social security number (SSN) records were available in C2PC.
To help develop a working personnel roster in relation the recorded C2PC Unit locations, the
USAPHC related the Unit Identification Code (UIC) from the C2PC to the deployment roster data
from the DoD Defense Manpower Data Center (DMDC).
Daily data pulls of C2PC data were archived by the DESP from 12 March 2003 to 30 December
®
®
2005 in a Microsoft Access database. The DESP queried the access database to identify troop
Unit location of the 1/24 BN SBCT UICs. The DESP expected to find the 1/24 BN SBCT UIC
geographical coordinates (e.g., MGRS; latitude/longitude), dates, and possible individuals
associated with leadership positions during the deployment timeframe. The DESP planned on
16
Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
using these coordinates and dates to identify specific locations of 1/24 BN SBCT personnel and
compare to any exposure incidents that have been reported to better assess possible health risks.
Unfortunately, significant data gaps in C2PC data output existed. The DESP only found records on
1/24 BN SBCT personnel for three months of the deployment timeframe on random days and it was
limited to key basecamp/leadership positions. The DESP based their analysis on the required
assumption that all personnel will be accounted for by association with the documented key
leadership positions recorded in the database. Graphics depicting the recorded C2PC based UIC
locations for the 1/24 BN SBCT via Geographic Information Systems (GIS) technology are available
®
®
in the supplementary classified report on SIPRNET (available by request). [Microsoft and Access
are registered trademarks of Microsoft Corporation].
The DoD DMDC is the central repository for current and historic human resource information
serving as the authoritative source of information on over 42 million people now and previously
connected to DoD (reference 9). Its mission is to collect, provide and utilize this information for the
benefit of members of the DoD and to support DoD decision makers and other government
agencies. An application of the DMDC is the Contingency Tracking System (CTS), which is a
SIPRNET-based system to track deployments of Active, Guard & Reserve members to OEF and
OIF. The CTS is designed to track individuals as they move from assigned basecamp to assigned
basecamp and redeploy. The CTS does not track daily movements related to the individual’s
mission responsibility (e.g., daily patrol assignments). The CTS is the primary data source for
individuals demographic and location data for health surveillance programs during and after
deployments (reference 10).
The C2PC UIC was used in CTS to obtain the deployment roster (including the SSN). The DESP
received 625 records of individual’s information on the SIPRNET: the SSN, name of individuals,
deployment begin and end dates, assigned and attached UIC, service of branch, and location base
name. After the data review, DESP had identified some of the fields were empty and that not all
the 1/24 BN SBCT members were represented. This was due to limitations in the data that
included; UIC assignment documentation and overall incompleteness of CTS data, especially in the
early years of OIF/OEF. Due to the noted data gaps in the C2PC and some data gaps from the
DMDC/CTS roster, the DESP were only able to locate approximately 50 percent of the 1/24 BN
SBCT that were interviewed. These data/information were provided to AIPH physicians to review
patient records in the AHLTA.
7.3 Geographic Information Systems (GIS)
®
Maps were created using the GIS software ArcGIS 10.2. The unclassified map (Figure 3) provides
pertinent information or locations and facilities identified by the interviewed 1/24 BN SBCT
personnel, unclassified historical queries and information derived from unclassified imagery. The
prevailing wind direction was determined by the creation of a wind rose for the site based on
®
meteorological data. See Appendix D for the Wind Rose information. [ArcGIS is a registered
trademark of VMware, Inc].
The classified GIS maps that were created on the SIPRNET have pertinent operational information
(e.g., location of IED/VBEID attacks and weapon cache), C2PC data output, locations identified by
the interviewed 1/24 BN SBCT personnel, and classified historical queries. Classified imagery was
used to identify the boundary of FOB Marez, LSA Diamondback, and Camp Courage. Pertinent
operational information has not been declassified and the imagery itself is classified; as a result,
information must remain on the SIPRNET. A separate supplementary classified report (available
on the SIPRNET by request) provides all the classified GIS maps.
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
Figure 3. Western Mosul Area of Operations
8
Evaluation of a Suspected Disease Cluster
8.1 Background
In the evaluation of any chronic disease or medical condition, there is rarely a one cause/one effect
relationship. Health outcomes are a result of the complex interplay of a chain and/or web of
individual or host factors (the “who”), disease agent factors (the “what”), and environmental factors
over a person’s lifetime (the “where”). This is known as the epidemiological triad. Individual
factors, or the “who,” include a person's biological adaptation and physiological responses, general
health status, nutrition status and body mass index, immune responses, genetics, microbiota,
personal behaviors, habits and activities, and other unique susceptibilities. This complex
constellation of conditions comprising the “who” can change daily, hourly, or even by the minute.
Agent factors, or the “what,” can be divided into biological agents such as food, viruses, bacteria,
parasites, chemicals, physical and natural ambient agents, as well as social and psychological
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
stressors. Environmental factors, or the “where,” influence the probability and circumstances of the
interaction between individual and agent (completed exposure pathway) such as breathing in or
ingesting the agent as well as having direct contact with the agent via the skin. No matter what the
hazard, without a completed exposure pathway, there is no risk of associated disease. Other
factors that characterize an exposure are the duration, frequency, and/or the concentration/
magnitude of the exposure. These equate to how much of an exposure occurs. Additionally,
exposure to a substance does not equate to internalized dose, which may be dependent upon a
variety of host or substance factors. For example, if an agent has contact with the skin or is
inhaled, but is not absorbed into the body, the only health effects possible would be localized
effects and not systemic effects, which might occur elsewhere in the body. It is important to recall
that for any exposure to have a health effect, it must interact with the body, not simply occupy the
same space or even just come in contact with the body. To further complicate matters, any one
factor or combination of factors can cancel (attenuate) or augment the effects of another factor or
combination of factors. Also, effects may be summative or synergistic, desirable or undesirable,
intended or unintended, etc.
When health conditions appear to occur more commonly than expected within any social,
employment, or military Unit, or group, it is normal for members of that group to ask questions
and/or request assistance to determine if this perceived “cluster” of health effects is actually
occurring in excess of what is expected and whether there is a common cause. Gastrointestinal
disease as a result of food poisoning in individuals who ate food contaminated with bacteria or
viruses often appears as an outbreak or cluster. Epidemiologic investigation can often identify the
common food and then the source of that food, therefore preventing further cases of the poisoning
from occurring. This same process also applies to cancers which occur in work groups. In the
1960s, a cluster of a rare type of lung cancer, called mesothelioma, was identified in asbestosexposed shipyard workers, further investigation revealed asbestos’ causative relationship with
mesothelioma. Cancer clusters may be suspected when people notice several individuals with
cancer in a group, be it family, neighbors, or coworkers. Typically to be labeled a true cluster, the
cases should all have the same, or very similar, type of condition, such as red blotchy rash on
exposed skin. Some cases of red blotchy rash on exposed skin, some male pattern baldness,
some eczema, and some acne is not likely to be indicative of a true cluster (references 1, 2, and 3).
Suspected clusters of cancer or other specific diseases are often investigated by public health
physicians and epidemiologists who study the frequency, distribution, causes and control of disease
in populations. These specialists have identified circumstances that may lead them to suspect a
cancer cluster and to look for a potential common source or cause. Clusters are suspected when
there are a large number of cancers of one type (rather than several different types), the cancers
are of a rare type, or there are an increased number of cases of a certain type of cancer in an age
group that is typically not affected by that type of cancer. Epidemiologists will try to establish
whether the suspected exposure (if there is one) is plausibly associated with the cancer of concern.
If such a cluster is suspected, a case definition, or a description of the criteria necessary for a case
to be counted, is then formulated. The time period of concern for exposure as well as the
population at risk is also considered. Different types of cancers have differing latencies, meaning
they occur at different times following an exposure. Generally speaking, cancers of the blood and
lymph systems develop more quickly after a possible cancer-causing exposure than solid tumors,
such as lung cancer. Therefore, the relationship between the exposure of interest and the time of
onset of the cancer is evaluated. The population at risk (or sometimes called population of interest)
includes all of those who were at risk of exposure. For example, in the evaluation of a workplace
cluster, non-workers would not be included. If the exposure was limited to individuals in a certain
location or doing a specific job, everyone in that location or doing that job should ideally be
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
included, while workers in other areas and doing others jobs might be excluded from the population
at risk (references 1, and 2).
When a cluster investigation is conducted, the expected rate of the specific condition in a reference
population is calculated. This could be the U.S. population in the appropriate age range, or a rate
from a more local population may be used, if one is available. The reference population is selected
to be as representative of the population at risk as possible in terms of age, gender and other
demographics. For example, a general U.S. population of both sexes and all ages (including the
elderly and children) would not be an appropriate comparison population for a military population.
The expected cases (based on the reference population) are then compared to the observed cases
(in the population at risk). Statistical tests are performed to determine if the number of cancers that
have occurred in the population at risk is significantly greater than would be expected, indicating a
true cluster (reference 11).
At the onset of this investigation, the population at risk was unclear and the case definition (the
disease of interest and its characteristics), was uncertain. The initial population identified was an
approximate 25-member reconnaissance platoon. In this instance, a review of health conditions
was conducted to determine if there was a disease cluster. Such an evaluation was performed with
respect to those individuals in the 1/24 SBCT who reported health concerns, about half of the
platoon. We did not have contact information to interview the entire platoon, and not all those who
were contacted completed a telephone interview. Interviews were utilized to identify the case
definition and the population at risk, with the assumption that the “exposure” was the Mosul
deployment in 2004, or a more specific aspect of that deployment. A descriptive analysis based on
those who were interested and available for interview follows. This analysis served as the basis for
consideration of whether or not to conduct an epidemiologic study of a potential disease cluster.
Details regarding considerations relevant to the decision of whether to conduct an epidemiological
analysis may be found at Appendix C, “Approach to Disease Cluster Assessment”.
9
Identified Environmental Exposures
The exposure evaluation included OEH data searches for evidence of hazards and their sources,
whether or not there was a release, and if and under what circumstances contact or a completed
exposure pathway may have occurred. The potentially exposed population and the route of
exposure were evaluated. In addition, data quality and representativeness was assessed.
Frequency, magnitude and duration of exposure were estimated to the extent possible. This
process identifies hazards that should be further evaluated. In the absence of quantitative objective
information, interviews were reviewed to determine exposures of concern and exposure
circumstances. These included improvised explosive devices, weapon caches, open burning of
trash, equipment graveyards and DU, burning Stryker vehicles/halon fire suppression system
(actually was heptafluoropropane), high frequency jammers and other non-ionizing radiation, raw
sewage, human remains, an incident at the “Ice Factory”; industrial facilities and air quality. The
PDHAs for the individuals assigned to the UIC where reviewed. This represented approximately
600 individuals who were identified as part of the 1/24 BN SBCT deployed during the period of
interest. The reported exposures were similar to those exposures reported in interviews, with the
exception of the report of exposure to oil well fires. This finding was not reported by any of the
individuals who were interviewed and so was not further assessed. See discussion at Appendix F.
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
9.1 IEDs/VBIEDs/SBVIEDs
Iraqi insurgent attacks on this Unit utilized Improvised explosive devices, roadside bombs, and
suicide car bombs. The interviewees cited this exposure most frequently. The 1/24 BN SBCT
routinely came into contact with explosive devices. Many Unit members suffered associated
concussion, blast, shrapnel and other injuries and reported multiple exposures. SITREPS
documented the increased use of this form of warfare. From the interviews, the 1/24 BN SBCT
identified IEDs containing chemicals such as fertilizer, chlorine or visible white powder (possibly
propellant), which were irritating or made it hard for Soldiers to breath. It was generally noted that
individuals did not seek care after these incidents, and that TBI screening after IED/VBIED attacks
was not consistent. Some individuals mentioned the term “Fougasse” during the interviews. This is
a World War II term to refer to combinations of gases/mixtures that are not clearly identifiable, but
can include accelerants, propellants, explosives, and/or other combustibles.
An IED is characterized as a low-technology exploding mine, usually "homemade”, that is hidden
beside a roadway and set off using a variety of trigger mechanisms. Methods of detonation
included simple pull-wires and mechanical detonators, cell-phones, garage-door openers, cable,
radio control, children’s remote-control toys, and infrared lasers among others. In addition to
attacking the Stryker vehicles, the vehicle-borne IEDs (VBIEDs) and car bombs are also used to
strike police stations, markets, and mosques, with the intent to kill local citizens as well as U.S.
troops and coalition troops. These IEDs convert several types of potential energy into forces that
cause a high rate of complex injuries to the body, particularly to the head and extremities, which are
regions of the body less protected by body armor.
An explosion from an IED/VBIED might cause blunt-force trauma, blast effects, concussions, TBI,
and injury from projectiles, heat, and fire, or a combination of these effects. For example, one
member of the Unit sustained a tibia fracture and burns to several parts of his body following an
IED explosion as documented in his medical record. An IED/VBIED explosion could also result in
an unquantifiable, complex combination of the following:
• Non-combusted and partially combusted explosives, propellants, accelerants and their respective
combustion products;
• Carbon monoxide (CO), carbon dioxide (CO2), nitric oxide (NO) and nitrogen dioxide (NO2) which
are produced by the explosion;
• Burning and/or dispersion of hydraulic fluids, fuel, and other combustible material within the
Stryker; and
• Burning and/or dispersal of engine oil, brake fluid, transmission fluid, and other combustible
material from the vehicle (VBIEDs)
Some of these components might be very irritating to the skin, eyes, and respiratory system, even
to the point of partial or total incapacitation. Occupants of the Stryker could be exposed to any or
all of these substances if the vehicle is breached during a catastrophic VBIED event. Because of
these complex combinations of hazards, with differing degrees of effect, concentration, duration of
exposure, and individual breathing response, it is difficult to determine, with any degree of certainty,
the short- or long-term health effects of this type of event. If there are any long-term health effects,
it is difficult, if not impossible, to determine which exposure or combination of exposures may have
caused or contributed to these effects.
The addition of chlorine and other substances to IEDs was identified by an interviewed member of
1/24 BN SBCT. From the OEHS data searches, no information was found on insurgents using
chlorine IEDs in Mosul during the 1/24BN SBCT deployment timeframe. The use of chlorine in
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
IEDs by insurgents was confirmed and documented by DoD from 2006 onwards. While most of
these additions pose acute effects, it was not possible to completely identify all potential additions
and subsequent health effects. Even though chlorine IEDs were not documented during the 1/24
BN SBCT deployment timeframe, it was identified by an interviewee. See Appendix G, Health
Effects Associated with Chlorine, as well as a Fact Sheet on Chlorine Improvised Explosive
Devices and Preventive Medicine Actions.
9.1.1. Weapons Caches
The 1/24 BN SBCT aggressively sought out weapons caches which included ammunition and
unexploded live ordnance. Due to the high OPTEMPO, the Explosive Ordnance Disposal (EOD)
team was often unable to keep up with the platoon’s discoveries to destroy them. Eventually, EOD
personnel conducted informal training with several Soldiers in the platoon so that they could
disarm/destroy ordnance and weapons on their own. Depending on OPTEMPO and the quantity of
weapons found, they were either destroyed onsite or brought back to FOB Marez where EOD
would destroy them. Figure 3 shows the potential area used by EOD as the detonation area.
Prevailing winds should have taken any smoke or combustion products from detonation away from
the camp and the living areas. There is no information, classified or other, to suggest that these
caches included chemical agents, as well as no information regarding other potential exposures
from weapons caches. One location was reported to have a very large quantity of white powder in
storage, which was characterized as “possibly propellant”. There was no information regarding the
nature, magnitude and frequency of exposure to this substance and; thus, there was no
assessment of potential health effects offered.
9.2 Open Burning of Trash/Burn pits
About two thirds of the Unit reported exposure concerns related to burning trash. In addition, the
Unit surgeon at the time pointed to the burn pit as the most concerning environmental exposure
since it burned “24/7/365”. Interviewed personnel described the smoke from the burn pit as a
constant fog over FOB Marez. The interviewees also stated that it was located 1,000-1,500 feet
from the sleeping quarters. Review of a 2006 site assessment by preventive medicine personnel
included a recommendation to move the burn pit further south due to concerns of smoke near the
living quarters, particularly in the morning when inversion conditions where present.
During the OEH data gathering, DESP found information on the FOB Marez burn pit in the POEMS
for FOB Marez. [The POEMS are unclassified summaries of the site description, available
environmental sampling results, potential vectors and infectious disease risks, results of radiation
surveys, and so forth for the location for a specified period of time.] See Appendix E for the
background information on POEMS and the process for requesting a POEMS. Potential health risk
from open burning could be associated with burning plastics, petroleum products, non-medical
waste, metal, and other chemicals (paints, solvents, and so forth). There was no documentation of
the degree of waste segregation or of the waste stream for the burn pit at FOB Marez in 2004.
Burn pit workers or tower guards (if any) or other personnel that work at or in proximity to the burn
pits would have a higher risk of exposure to contaminants emitted from the burn pits than the
general population at Mosul Airfield (and the associated camps) (reference 7).
The wind rose for FOB Marez indicated that the predominant wind direction emanates from the
North/Northwest. Since the burn pit was located in the southeast of the camp (see Figure 3), the
predominant wind direction should have taken the smoke away from the living areas and the camp,
although under certain conditions, such as an atmospheric inversion, the smoke might linger over
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
the area. Per interviews, inversions occurred. Also, as noted, a 2006 site assessment
recommended moving the burn pit further south due to morning inversions.
During OIF, onsite open burning was used as an available and expedient means to dispose of solid
waste to improve the overall sanitary conditions of the camp by eliminating potential food and
harborage for rodents and potential vectors of infectious disease. In addition, burning onsite
minimized contact of Service Members to hostile action when hauling the waste outside of the
secured perimeter. At many locations, smoke emissions from open burning were a visible
contributor to air quality and have often been noted as a primary concern among Service members.
Other air pollution sources including flight operations, vehicular emissions, generators, blown sand,
and off-site sources were present and likely contributing to the pollutant levels. See Appendix H for
a discussion of the assessment of health effects associated with open burning.
The DoD recognizes that acute, mild to more serious short-term health effects due to smoke
exposure may occur (e.g., eye, nose or throat and lung irritation, including reddened eyes, irritated
respiratory passages, and cough that may persist for some time). For inhalational exposure to high
levels of dust, PM10 and PM2.5, such as exposure to burn pit smoke and during high winds or dust
storms, the DoD considers it plausible that some otherwise healthy personnel who were exposed
for a long-term period to dust and PM could develop certain long-term health conditions (e.g.,
reduced lung function, cardiopulmonary disease, to include asthma), possibly due to combined
exposures (such as sand/dust, industrial pollutants smoke, and other compounds) associated with
deployment to Southwest Asia. In addition, individual susceptibilities (such as preexisting health
conditions or genetic factors) may play a role. For example, personnel with a history of asthma or
cardiopulmonary disease could potentially be more likely to develop chronic health conditions.
According to the Institute of Medicine’s review of the Long-term Health Consequences of Burn Pit
Exposure, they consider there to be limited/suggestive evidence that such exposure might be
associated with a reduction in pulmonary function. Thus far, there has not been sufficient evidence
of associations with other conditions (such as neurological, liver toxicity, cancers, respiratory
toxicity, kidney toxicity, blood effects, cardiovascular toxicity or reproductive or developmental
effects). However, there are limited studies of these endpoints in similarly exposed populations.
(See Appendix H regarding this review).
9.3 Equipment Graveyards and Depleted Uranium
The 1/24 BN SBCT interviewees expressed concern regarding possible DU exposure from the
vehicle graveyard and the tank graveyard (two areas with old Iraq and U.S. armored vehicles in
varying degrees of deterioration and disrepair) and that this exposure may have caused or
contributed to their medical conditions and/or the medical conditions of other Unit members. This
area was confirmed and is identified on the map in Figure 3. Some of these vehicles might have
been destroyed or disabled by DU armor-piercing munitions (such as 30 millimeter (mm) rounds or
a penetrator from an armor-piercing munition). Even though command instructed Soldiers to stay
away from the equipment graveyards due to potential DU exposure, it was identified through the
interviews that individuals took pictures and walked through graveyards and most drove on a road
that was near or passed through the graveyard. Some Soldiers reported that they entered or
climbed on or in vehicles possibly damaged by DU munitions on an infrequent basis. This possible
DU exposure concern was unknown by officers who we interviewed who may have not been aware
that troops were in the area looking around, taking pictures and just generally exploring the
“graveyards.” This type of reported potential exposure to DU would be characterized as a Level III
“incidental” exposure. An example of a Level III incidental DU exposure would be individuals who
have driven through smoke from a fire involving DU munitions or who have entered or climbed on
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
or in a battle damaged vehicle on an infrequent basis (not as a first responder and not as a job
requirement) or Soldiers that may have been exposed to buried DU.
Uranium is a weakly radioactive element and is found in soil, water, and mineral deposits. It
contains U238 (99%), U235, and U234 isotopes. The DU is made from natural uranium that has
had most of the radioactive isotope removed by the uranium enrichment process. It has the same
chemical properties as natural uranium and has about 60 percent of the radioactivity of natural
uranium.
The MEDCOM has an established policy that provides guidance for the medical management of
Army personnel exposed to DU. This policy is reviewed and updated approximately every 2 years.
A copy of the latest policy can be found in Appendix I. All personnel with actual or potential
exposure to DU should be identified and assigned a potential exposure Level (I, II, III). A urine
bioassay test is available to help with the initial assessment of a person who has been exposed to
DU or has a suspected exposure to DU. This test is based on the analysis of a urine sample
collected over a 24-hour period and is not part of a routine urinalysis. The sample is obtained as
soon as practical after a DU exposure and may be repeated at follow-up assessments if the initial
urine uranium level is significantly above normal. It is not required for personnel with Level III
exposures, though a physician may choose to preform one based on medical indications or at the
potentially exposed individual’s request. As of this report, elevated urine uranium levels which have
been identified as DU have been found only in Service Members with embedded fragments, or
those who were in a vehicle during a friendly fire incident (personal communication with VA DU
Follow-up Program).
Service Members who have the most extensive exposure to DU are characterized as a Level I
exposure (i.e., those who were in or on a vehicle when it was hit by DU munitions and/or have
imbedded DU fragment(s)). Service Members with Level I exposure have been closely monitored
for over 20 years in a formal research protocol, the DU Follow-up Program at the Baltimore VA
Hospital, and to date have not experienced any long-term adverse health effects related to DU
exposure. Thus, long-term adverse health effects would not be expected from a Level III exposure
to DU.
According to the Agency for Toxic Substances and Disease Registry (ATSDR), “No health effects,
other than kidney damage, have been consistently found in humans after inhaling or ingesting
uranium compounds or in Soldiers with uranium metal fragments in their bodies”. No renal
abnormalities have been consistently seen in the DU exposure cohort enrolled in the DU Follow-up
Program at the Baltimore VA, who have had retained DU metal fragments for many years. There is
no definitive evidence regarding genotoxicity, mutagenicity, or reproductive effects. However,
based on questionnaire data, there have been no birth defects noted in over 80 children born to
Gulf War veterans in DU Follow-up Program (including those with retained fragments).
Without an ongoing exposure to DU (such as an embedded fragment or inhaled particles),
detectable increases in uranium levels in the urine resulting from a DU exposure would be
indistinguishable from the normal urine uranium levels after several days or weeks from that
exposure. Some Soldiers with injuries or retained fragments have had symptoms related to those
injuries and the physical presence of a fragment. However, in the absence of more significant
contact with a source of DU exposure, the members of the brigade would not likely to have had any
adverse health consequences from DU. Those that have separated and still have concerns are
eligible for a 24-test for urine uranium test, which may be requested from their VA primary care
provider. Appendix J contains more information about the DU Follow-up Program.
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
9.4 Burning Stryker Vehicles/Halon Fire Suppression System
Some Soldiers mentioned exposure to “halon” when the Stryker vehicle that they were in was hit by
a VBIED. While halon and the halon FSS is used in the Abrams Main Battle Tank and the Bradley
Fighting Vehicle, the FSS in the Stryker vehicles uses 1,1,1,2,3,3,3-Heptafluoropropane (CAS: 43189-0) (also known as heptafluoropropane, HFC-227ea, FM 200®, FE-227™). The chemical in the
Stryker vehicle FSS is not halon, even though the Soldiers referred to the agent as halon and the
system as the halon FSS. If the FSS in the Stryker stays intact and is working properly, long-term
adverse health effects would not be expected from an exposure to the discharged HFC-227 as
described by these Soldiers. If conditions are such that exposure to high levels of HFC -227 were
to occur, individuals likely experienced a cold sensation which may have actually progressed to
frostbite. Other acute effects include dizziness, headache, and confusion with the potential for
cardiac arrhythmias and loss of consciousness. These effects are similar to those of anesthetic
agents and will reverse upon cessation of exposure.
The HFC-227 is a non-flammable, non-explosive, and non-oxidizing gas. It is colorless and
odorless, but may have a slight ether-like odor. In addition to its use as a fire suppressant, HFC227 is also used as a refrigerant (alone or in combination with other similar substances) and as a
Food and Drug Administration (FDA) approved propellant in medical use metered dose inhalers
used in the treatment of asthma and chronic obstruction pulmonary disease (COPD). The HFC-227
can be rapidly absorbed by the body when inhaled and is rapidly cleared from the body once the
HFC-227 is removed or the individual moves to areas of fresh air.
The HFC-227 has been used in Army vehicles since 2001. The HFC-227 is used as a fire
suppressant and replaced halon-1301 for use as a fire extinguishing agent in crew occupied spaces
of military ground vehicles. The HFC-227 is effective against Class A, B, & C fire hazards and was
determined to be a suitable substitute for halon-1301 and has zero Ozone Depleting Potential
(zero-ODP). The fire suppression agent in the Stryker vehicle’s Automatic Fire Extinguishing
Systems (AFES) is HFC-227BC, a blend of HFC-227ea (heptafluoropropane) and sodiumbicarbonate-based dry chemical, and has essentially the same environmental and safety properties
as the HFC-227ea. The sodium-bicarbonate-based dry chemical reduces thermal decomposition
products generated during a fire suppression event. The HFC-227BC is also used for fire
suppression in the Mine Resistant Ambush Protected (MRAP) and other military ground vehicles.
The HFC-227BC and AFES have met certain performance criteria that allow for improved
survivability, expeditious egress from a damaged vehicle, and should not significantly contribute to
incapacitation or injuries that vehicle occupants may receive during an attack or fire. In addition to
fragment injuries produced by projectiles formed when an armored vehicle in penetrated by
munitions and VBIEDs, crew may experience non-fragment hazards from blast overpressure, toxic
gases, burns, etc. The HFC-227 performance criteria and exposure limits have been adopted from
the National Fire Protections Association and include not exceeding the lowest-observed adverse
effect level (LOAEL) while still achieving the minimum HFC-227 concentration to effectively
suppress a fire, as well as minimizing overpressure, minimizing acid/toxic gases (combustion
products of HFC-227 - hydrofluoric acid, hydrobromic acid, carbonyl fluoride), and maintaining
acceptable oxygen levels for five minutes when the AFES is properly functioning, is intact, and not
overmatched by the fire. The HFC-227 performance criteria also require suppression of a fire in
less than 250 milliseconds to maintain acceptable levels of oxygen, decrease the risk of burns to
occupants, and decrease the production of combustion products, carbon monoxide (CO), carbon
dioxide (CO2), and smoke. There is no available information to determine whether or not systems
were operating optimally. While exposure to HFC-227 usually does not cause skin, eye, or
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
respiratory system irritation; exposure to its combustion products, hydrofluoric acid, hydrobromic
acid, and carbonyl fluoride, even in small amounts, will result in eye and respiratory irritation if not
wearing protective equipment.
In animal studies, inhalation of high concentration of HFC-227 can result in death and may result in
the heart becoming temporarily sensitized to adrenaline (epinephrine) leading to cardiac arrest.
However, this is based on animal studies at very high doses creating blood levels of epinephrine
ten times greater than would be seen in humans under normal conditions or periods of physical and
emotional stress. In surviving animals long-term health effects, including genetic and reproductive
effects, were not observed.
9.5 Non-Ionizing Radiation (High Frequency Jammers, Microwaves, Radar)
During the interviews with the 1/24 BN SBCT, some Soldiers mentioned exposure to radio
frequency (RF) jammers. Additionally, some members of the Unit gave positive responses about
exposure or concerns about exposure to non-ionizing radiation on their PDHAs and PDHRAs. No
adverse health effects would be expected from typical operational exposures to non-ionizing
radiation generated by RF jammers.
The RF radiation, microwaves, visible light, and infrared radiation are all examples of non-ionizing
electromagnetic radiation. In addition to RF jammers, mobile/cell/cordless phones, radios, radars,
lasers, and spotlights are sources of non-ionizing radiation. Overexposure to non-ionizing radiation
could result in the heating of body tissues to the point of discomfort, pain, or body tissue damage
(such as burns). For this reason, all sources of non-ionizing radiation (including RF jammers) are
assessed for potential health hazards and Soldiers are trained to follow the standing operating
procedures associated with each source.
Ionizing radiation (alpha particles, beta particles, gamma rays, and neutrons) can ionize atoms,
resulting in severe damage to tissue and DNA. Any exposure to ionizing radiation can damage
tissue. Radioactive materials are a primary source of ionizing radiation. The term “radioactivity”
describes the emission of ionizing radiation and does not apply to non-ionizing radiation sources.
Potential adverse health effects commonly associated with high doses of ionizing radiation include
radiation sickness, certain cancers, and birth defects. These health effects are not caused by
exposure to non-ionizing radiation, because non-ionizing radiation cannot ionize atoms.
Soldiers are protected from adverse health effects associated with non-ionizing radiation emitted by
RF jammers by following procedures and maintaining their systems. All RF jammers were
assessed by healthcare professionals to ensure that Service Members were protected from RF
radiation exposure above the maximum permissible exposure (MPE) limits. These MPE limits were
established by the Institute of Electrical and Electronics Engineers, Inc. (IEEE) and incorporated a
margin of safety to ensure that no-adverse health effects would result from exposure to the RF
jammers. Use of the IEEE MPE limits is directed by DoDI 6055.11 (2009), Protecting Personnel
from Electromagnetic Fields. A copy of the IEEE radiofrequency standards can be downloaded at:
http://standards.ieee.org/getieee/C95/download/C95.1-2005.pdf.
Additionally, DoDI 6055.11 (1995), Protection of DoD Personnel from Exposure to Radiofrequency
Radiation and Military Exempt Lasers, which was in effect in 2004–2005, directed that no practice
will be adopted or operation conducted involving planned exposure of personnel to radiofrequency
levels in excess of the applicable permissible exposure limit (PEL). No-adverse health effects
would be expected to occur with RF exposures within PEL, even with repeated or long-term
exposures. The radio frequency PELs in 2004–2005 were derived from the recommended
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
®
®
exposure levels in American National Standards Institute (ANSI )/IEEE C95.1-1992. (ANSI is a
registered trademark of the American National Standards Institute, Inc.)
9.6 Air Quality
Service Members deployed to the CENTCOM AOR (e.g., Iraq, Afghanistan, Kuwait) were exposed
to sand and dust storms, pollutant emissions from vehicles, and other airborne hazards. [The PM is
the term for particles found in the air, including dust, dirt, soot, smoke, and liquid droplets. Particles
can be suspended in the air for long periods of time. Some particles are large or dark enough to be
seen as soot or smoke. Others are so small that they can be detected individually only with
specialized microscopes. Small PM that is less than 10-micrometers in diameter can be breathed
in (inhaled) into the lungs. A 10-micrometer particle is roughly one-sixth the width of a human hair.
This is called the PM10 size range. A 2.5 micrometer in diameter particle is called PM2.5. In some
areas, PM can be very heavy because of high levels of industrial activity or natural environmental
conditions (e.g., dry, dusty climates)].
The POEMS report identified PM10 sampling results from 2003, 2007, 2009, and 2010. The range
of 24-hour PM10 concentrations in 33 samples collected from May 2003 to March 2010 was 65 to
1768 µg/m3 (where the average was 374 µg/m3). The comparison 24-hour guideline value is
250µg/m3. Since the average PM concentration exceeded the 24-hour level, on those days
irritation and cough were likely. However, the PM levels varied, and so typical exposures ranged
from low in 2003 to moderate risk in 2010. During the period of Shamal winds, the PM10 levels may
be extremely high and skew the average which is why the range in levels is large. Dust storms may
result in high levels of ambient PM for short periods. This could irritate the eyes and respiratory
passages. Overall, the risk was low on 96 percent of the days with sampling results, and high on 4
percent of the days sampled. The risk was indeterminate for all other years due to insufficient data.
The POEMS report also identified sampling for PM2.5 in 2010. PM2.5 is smaller and more easily
inhaled deeply into the lungs. [It is also the fraction of PM that is linked to long-term health effects.
The range of 24-hour PM2.5 concentrations in the 25 samples collected in 2010 was 70 to 113
µg/m3 (with an average of 101 µg/m3). The comparison 24-hour guideline level is 65 µg/m3. This
indicates that on average, the PM2.5 levels were higher and exposed individuals may have
experienced cough, or other symptoms. The long-term risk is based on a comparison of the
average sample concentration to the long-term guideline level of 15 µg/m3 resulting in what would
be categorized as a moderate risk. Chronic exposure to elevated levels of PM2.5 is associated with
some long-term respiratory conditions such as chronic obstructive pulmonary disease and
cardiovascular health consequences.]
Exposure to high levels of PM might cause or exacerbate chronic lung conditions including chronic
bronchitis and asthma, with effects dependent on the size of the PM, the degree and duration of
exposure, as well as characteristics of the population being exposed (healthy, young individuals
versus older individuals or those with pre-existing medical conditions. Appendix K includes a PM
fact sheet created by the USAPHC.
9.7 Human Remains
Five interviewees reported exposure to Iraqi and U.S. Soldier corpses, and in some instances, this
contact was without the benefit of gloves. Hepatitis B and HIV may be transmitted by direct contact
with human blood and body fluid. Service Members are immunized before deployment against the
first of these two viruses and have annual blood tests to evaluate for the presence of HIV. In the
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
absence of any symptoms of an acute infection or the development of any serum indicator of such
an infection after the deployment, it I would be extremely unlikely that any members of the brigade
had a health impacting exposure to human remains or human blood or body fluids. Observation of
or contact with human remains would be a traumatic event, and the individual response to such an
event would be variable. Such events might contribute to the development of PTSD. Appendix L is
a fact sheet addressing Handling of Human Remains.
9.8 Raw Sewage
Four individuals reported a stream mixed with raw sewage. In some instances, it was reported that
the stream of raw sewage splashed onto individuals. There was a report of a young specialist
falling into the sewage and one of the interviewees sat near him for several hours in the Stryker.
Two primary areas of health concern related to exposure to raw sewage were chemical hazards
and bio-hazards. Without knowing any specifics of what was in the sewage in regards to specific
toxic chemicals, it would not be possible to comment directly about their potential toxicities.
However, most common urban and rural sewage would contain mostly non-toxic substances.
When hazardous materials might be injected into the waste stream, they are usually sufficiently
diluted that they become innocuous.
The larger health concern involved with being exposed to waste streams and to human waste and
body fluids would be the risk of transmission of infectious agents and/or infectious disease. Raw
sewage might carry bacteria, viruses, protozoa (parasitic organisms), helminthes (intestinal worms),
and borroughs (inhaled molds and fungi). The diseases they might cause range in severity from
mild to moderate gastroenteritis (causing stomach cramps and diarrhea) to life-threatening ailments
(such as cholera, dysentery, infectious hepatitis, and severe gastroenteritis). The majority of the
bacteria that might be transmitted from person to person or waste stream to person would likely
cause infection right away, within hours to days. Viruses (such as rotaviruses, adenoviruses,
Norwalk virus and others) also could cause an acute illness, characterized by watery diarrhea,
vomiting, headache, fever, and abdominal cramps. These would tend to have an onset within 48
hours of exposure and run their course in 1 to 10 days. The parasites, intestinal worms, and mold
and fungi might take a little longer to begin causing symptoms, but generally if they are going to
cause infections, the symptoms will present within days to weeks. Many of these infections could
result in dermatologic or gastrointestinal illness, a significant number of which could be self-limited.
The VA has determined that nine infectious diseases, including three gastrointestinal conditions,
are considered presumptively associated with military deployment under certain conditions. These
three conditions are salmonella, shigella and campylobacter jejuni infections. See Appendix M for a
discussion of these conditions and the eligibility criteria.
The other primary virus of concern with sewage exposure is Hepatitis A. Hepatitis A vaccination is
a requirement for deployment to the CENTCOM area of operations. Hepatitis A is a liver disease
caused by the Hepatitis A virus (HAV) which is transmitted mainly via the fecal-oral route by person
to person contact or ingestion of contaminated food or water. Symptoms generally begin 28 days
following infection and include fever, tiredness, nausea, abdominal discomfort, dark urine, and
jaundice (skin and whites of eyes turn yellow in color). Most people recover within 2 months of the
onset of symptoms, although about 10 percent might have prolonged symptoms or a severe case.
Interestingly, when infection occurs in those less than 6 years of age, there will typically be no
symptoms.
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9.9 “Ice Factory”
Five Soldiers described being present at a one-time acute exposure at the “Ice Factory”, and
several others recalled the incident. They explained that buildings were given nicknames that did
not necessarily match the buildings’ function. Thus, the actual use of the building and the materials
which might be on hand were not known. It was stated that on a rainy day in the western Mosul
industrial area, there was heavy gunfire and firefight inside a building. A container was pierced and
released an unknown gas/substance inside the building. The canisters were reported to be 6-8 feet
tall. Approximately 10 Soldiers were involved. One individual stated that they had to egress
because they could not breathe. Another stated that there was a strong smell, possibly ammonia
mixed with something decaying, and they left the building due to the smell. Others reported no
smell and no breathing difficulty. One Soldier described a white gas cloud after a sound like a “tea
kettle going off” and the odor of Freon or a refrigerant. He also described the smell as possibly
eggs or ammonia. The Unit surgeon did not specifically recall an event that resulted in an acute
exposure that came to medical attention. Interviewees agreed that the building was off MSR
Tampa close to Yarmuk traffic circle. No information was provided or found regarding what
substances were in the canisters. Therefore, it was not possible to comment about the potential
toxicities. No SITREPS or other documentation of the incident were found in open sources or in
classified reports. As noted earlier, an assessment of potential chemicals that may have been
stored in the Mosul area based on industry type was conducted, but the contents of the canister
remained unknown. There was no information that suggests any specific chemicals were released
at any other time, or any other exposures.
Since some individuals reported an ammonia smell associated with the “Ice Factory”, the health
effects of exposure to ammonia are discussed in Appendix N.
9.10 Industrial Facilities
The 1/24 BN SBCT interviewed personnel identified Mosul as being a highly industrialized area.
The DESP used the SIPRNET based MIDB to identify all the facilities around the Mosul, Iraq during
the 2004–2005 timeframe. An industrial hazard assessment (IHA) was performed by extracting
non-industrial facilities from the list and grouping the remaining facilities into industry categories
(e.g., research facilities, petroleum product storage, food production facilities, thermal power plants,
water treatment plants, etc.) and identifying the chemicals associated with them. The MIDB
database does not identify if the facility is still operational and nor describe their manufacturing
process. For the IHA, it was assumed that the manufacturing process in Iraq would be the same as
in the United States when the chemical list was extracted. See the separate supplementary
classified report (available on the SIPRNET by request) for a listing of industries in the Mosul area.
However, as stated previously, there were no specific exposure incidents reported with the
exception of the “Ice Factory” incident.
There were no specific concerns in the interviews regarding industrial facilities, except one
interviewee described a strong odor from a fertilizer plant that caused him to experience nausea
and vomiting. As stated, there were industries in the area, but it was not known if they were
operational. One Soldier described guarding a factory that stored tanks of chlorine to keep
insurgents from the tanks, but he did not recall any incidents. Interviewees stated that there was a
food production facility and cement factory close to FOB Marez. There was no information to
suggest any accidental or intentional acute releases or exposures from any other facilities apart
from the “Ice Factory”.
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10
Reported Health Concerns
As noted earlier, members of the 1/24 BN SBCT became concerned when two cases of cancer
developed among individuals in the Unit. Through communications with other members, other
health conditions were identified, and the question of the relationship with potential deployment
exposures and these outcomes was raised. One response to these concerns was to evaluate
potential exposures related to the deployment and to assess the potential for adverse health effects
resulting from these potential or known exposures. Health effects associated with identified levels
of exposure were identified if sufficient information exists.
Apart from the assessment of the health implications of known or suspected exposures, reported
health concerns were reviewed to look for a cluster of disease in response to the concern about a
potential cluster. Initially, this was done by interview. The health concerns, diagnoses, and
symptoms identified by interviewees were varied and included malignancies and conditions in the
musculoskeletal system, the respiratory system, the gastrointestinal system, the skin, the
neurological system, the genito-urinary system as well as some behavioral and mental health
complaints. This information was obtained from individuals who came forward to be interviewed, as
well as two spouses who served as proxy. In one of these two cases, the actual Soldier was then
also interviewed. Individuals self-reported symptoms, conditions and concerns. The specific
diagnoses reported were follicular lymphoma, acute lymphoblastic leukemia, biliary carcinoma or
bile duct cancer, skin cancer, Crohn’s disease, kidney stones, asthma, pulmonary nodules, PTSD,
TBI or MTBI, anxiety attacks and hearing loss. There were a few additional ill-defined or nonspecific complaints. The number of clinical issues raised per Soldier ranged from one (4
individuals) to four (1 individual). Medical records for all individuals with cancer were provided and
reviewed and confirmed the diagnoses. An additional medical board was provided for review and
confirmed two diagnoses. For the 10 remaining individuals, 8 were no longer on Active Duty, but
the DoD and Veteran’s administration electronic health record system was queried. Available
medical records tended to confirm the self-reported conditions, although not all symptoms were
represented in the records with a diagnosis. While there was obviously incomplete capture of
objective medical outcomes, these were reviewed to determine if a cluster of a specific disease was
present, and to identify which, if any, might be associated with known, or potential environmental
exposures sustained during the 1/24 BN SBCTs deployment to the Mosul area from 2004–2005.
These conditions and assessments are discussed briefly below and in Appendix O.
10.1 Follicular Lymphoma
There was one reported case of follicular lymphoma (FL), which was a common form of nonHodgkin’s lymphoma (NHL). Lymphoma and leukemia are cancers of the blood system. Leukemia
is a disease of circulating blood cells while lymphoma can include tumors or solid masses. FL is
rare in young individuals and the average age at diagnosis is 60. Just over 14,000 cases of FL are
anticipated to be diagnosed in the U.S. in 2014 (reference 12). Approximately 1 in 50 Americans
will develop NHL during their lifetime and about 20 percent of these are FL; thus, the risk of
developing FL is about 1 in 250 people. The major risk factors for NHL (and FL) include increasing
age, male sex and Caucasian race. Ionizing radiation exposure was linked to NHL, and some
studies suggest that exposure to benzene and certain herbicides and pesticides might be linked to
NHL (reference 13). See Appendix O, Section 10.1 for further discussion of the etiology of FL.
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10.2 Acute Lymphoblastic Leukemia (ALL)
Leukemia is a cancer of the white blood cells. There are several different types of white blood cells,
and therefore, there are several different types of leukemia. Acute Lymphoblastic Leukemia (ALL),
also referred to as Acute Lymphocytic Leukemia, is a cancer that originates in the lymphocytes,
®
usually arising in the bone marrow. The American Cancer Society reports that only approximately
one third of cases of ALL occur in adults. Children under the age of 5 are at the highest risk of
developing ALL. The risk then declines until the third decade of life, stays fairly stable, and then
slowly increases after the age of 50. The lifetime risk of developing ALL is about 1 in 750 people
®
(reference 14). (American Cancer Society is a registered trademark of the American Cancer
Society, Inc.)
Known and suspected risk factors for ALL include exposure to high levels of ionizing radiation.
Survivors of exposure to the Atomic Bomb in Hiroshima and Nagasaki developed ALL (among other
cancers) 6–8 years following the exposure at higher rates than non-exposed persons. Exposure to
chemicals (such as benzene) has not been associated with an increased risk of ALL (references
15, 16, and 17). Several viral infections and certain inherited conditions have been associated with
an increased risk of ALL, as is male gender, being Caucasian, and having a twin with ALL
(reference 14). See Appendix O, Section 10.2 for further discussion of the etiology of ALL.
10.3 Biliary Carcinoma or Bile Duct Cancer
Biliary Carcinoma or Bile Duct Cancer (BDC) includes cancer of the bile ducts within the liver and
outside the liver. The American Cancer Society estimates that about 2,000-3,000 people will be
diagnosed with BDC in 2014, making it relatively rare. The average age at diagnosis is in the
seventies. Almost 65 percent of people are over the age of 65 when diagnosed (reference 18).
Regarding the case in the 1/24 BN SBCT, during his evaluation, a geneticist found no evidence of a
genetic predisposition and considered the etiology “environmental”. One provider considered a
potential role of DU or oil well fires.
Known and suspected risk factors include increasing age, increased weight, and certain conditions
which result in inflammation of the liver or bile duct. Exposure to a radioactive contrast substance
used for X-rays up to the 1950s has some association to bile duct cancer. However, at this time
there are no strong associations between common environmental exposures and bile duct cancer
(references 19 and 20), except for heavy alcohol consumption (reference 18). See Appendix O,
Section 10.3 for further of the etiology of BDC.
10.4 Pulmonary Nodules
Pulmonary nodules are small round or oval-shaped growths in the lung that are generally less than
3 centimeters (cm) in diameter. They may also be referred to as spots on the lung. Growths that
are larger than 3 cm are usually referred to as pulmonary masses; these are more likely to be
malignant than nodules (reference 21). Estimates are that between 0.09 percent and 0.20 percent
of all chest X-rays reveal a solitary pulmonary nodule and that 150,000 of these nodules are
identified each year (reference 22). Pulmonary nodules may be caused by a wide variety of clinical
situations and conditions. Often blood vessels viewed 'on end' may appear on a routine chest Xray as nodules. Prior infections (such as anything from community acquired pneumonia to
tuberculosis to several different fungal infections) may leave small scars in the lungs which appear
as pulmonary nodules. Accumulations of inflammatory cells, called granulomas (such as are seen
in conditions like sarcoidosis or reactions to infections) may appear as pulmonary nodules. Some
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infections, including tuberculosis, non-malignant conditions and malignant cancer, whether primary
pulmonary or metastatic from elsewhere, may also present as pulmonary nodules.
Pulmonary nodules may present as solitary lesions or multiple spots on the lungs, they may be
unilateral or bilateral, they may be uni-lobular or multi-lobular, they may be round or irregularly
shaped and they may have smooth contours or they may have spikey surfaces. Given the
frequency of pulmonary nodules on chest X-rays in the general population, the wide range of
possible etiologies, and the variability at presentation it is not possible to make any definitive
statement regarding the cause of pulmonary nodule(s) in any given Service member, without
having much more information.
10.5 Asthma
Asthma is a chronic lung disease characterized by inflammation and narrowing of the airways, and
by intermittent spasms of the airways. Asthma can affect people of all ages, but most often begins
in childhood. More than 25 million people in the United States have asthma, and more than a
quarter of these are children (reference 23). When the airways are inflamed, they are swollen and
tend to be extremely sensitive to a variety of inhaled substances which can then trigger spasms of
the muscles surrounding the airways, called bronchospasm.
Scientists are not sure what causes asthma, but most believe that it involves an interaction between
genetic and environmental factors. These factors may include: an inherited tendency to develop
allergies; a family history of asthma; certain respiratory infections during childhood; and contact with
some airborne allergens or exposure to some viral infections in infancy or in early childhood, when
the immune system was still immature (reference 23). Individuals with a predisposition to develop
asthma are often more sensitive to non-specific airborne irritants. Some workplace exposures were
associated with the development of asthma.
Various researchers have studied the relationship between deployment and respiratory symptoms
and respiratory conditions to include asthma. These studies as a group appear to show an
increase in asthma symptoms associated with deployment to Iraq or Afghanistan. See Appendix O,
Section 10.5, for further discussion of the etiology of asthma, including in relationship to military
deployment.
10.6 Post-Traumatic Stress Disorder (PTSD)
The PTSD is a frequent result of being in combat, with estimates for OEF/OIF Veterans running
from 5-30 percent (references 24, 25, 26, and 27). PTSD is a mental health condition that may be
caused by a terrifying or traumatic event. Symptoms may include flashbacks, nightmares and
severe anxiety, as well as uncontrollable thoughts about the event. Symptoms typically start within
a few months of the trauma but sometimes do not appear until years after the event. Symptoms
may cause problems in social or work settings and in relationships. Other symptoms include guilt
and shame, irritability, self-destructive behavior, trouble concentrating, sleeping and hyper arousal.
All of these PTSD symptoms may vary over time and may be worse when an individual is stressed
or reminded of the event. Some of the symptoms overlap with mood disorders. PTSD is also a risk
factor for suicide.
It is believed that fear of hazardous consequences of an environmental exposure may result in
PTSD, much the same way that fear of hostile activity, even without actually being in combat may
do so. There are no known links between environmental chemical exposure and the development
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of PTSD, other than from the fear and anxiety of being exposed. Anyone with symptoms of PTSD
that interfere with any aspect of his/her life, should seek help. The VA has many programs for
Veterans with PTSD, including a Veterans Crisis Hotline at 1-800-273-8255. Anyone with thoughts
of harming themselves should seek help immediately (reference 28).
10.7 Traumatic Brain Injury (TBI)
Traumatic Brain Injury (TBI) as the name implies is an injury to the brain due to a bump, blow or jolt
to the brain or a penetrating head injury, which disrupts the normal brain function. Much has been
learned about mild TBI (m-MTBI) and TBI in the years since the beginning of OEF/OIF. Research
has shown that there are several mechanisms of potential brain injury including penetrating trauma,
direct non-penetrating trauma, acceleration/deceleration injury, and blast or concussive waves.
Injury can range from mild to severe, with the majority of cases being concussions or mTBI.
Symptoms of brain injury include headaches, dizziness, cognitive impairment, fatigue, irritability,
vision changes, balance problems, mood changes, and sleep difficulty. With mTBI or concussion,
these symptoms may resolve in minutes to days. Most individuals with concussions recover fully
within weeks, but others may develop chronic symptoms. There are no known links between
environmental chemical exposure and the development of TBI.
Many of the interviewees reported concussions, head trauma, and blasts severe enough that they
were thrown in the air. One individual suffered bilateral rupture of his eardrums and a concussion.
These were not universally evaluated screened due to OPTEMPO. Some interviewees complained
of memory difficulties which interfere with ability to hold a job and other functioning. Mood changes
and sleep difficulty were also common. As noted, some of these symptoms overlap with PTSD,
and this Unit was at high risk for both. Soldiers are encouraged to seek care as approaches to
these conditions change regularly and may have significant impact on improving the quality of life
for these individuals.
10.8 Panic Disorder
Anxiety attacks, also known as panic attacks, are part of a condition called Panic Disorder, which
affects approximately one out of every 75 people (reference 29). Anxiety attacks often first occur
during the teens or early adulthood. Frequently there is a connection with major stressful life
experiences. There is also some evidence for a genetic predisposition. The symptoms of anxiety
attacks are well known and may include any of these, among others: tachycardia, palpitations, air
hunger, paralyzing terror, dizziness, lightheadedness, sweating, shaking, chest pain, tingling in
fingers or toes, and fear of imminent death. The primary difference between panic attacks and
appropriate response to a stimulus (such as an enemy attack) is that the former occur suddenly in
seemingly harmless situations and can even occur while sleeping. Anxiety attacks typically pass
within a few minutes but can recur repeatedly for hours (reference 29).
In a study of almost 10,000 individuals in the United States, anxiety disorder was the most
prevalent DSM-IV mental diagnosis, with a prevalence rate of 18.1 percent (reference 30). This
was almost double the rate of the next most common diagnosis, mood disorder, which was found in
9.5 percent of the sample. The National Institute of Mental Health estimates that panic disorder
affects about 6 million American adults and is twice as common in women as men (reference 31).
Anxiety is also one of the potential manifestations associated of both TBI and PTSD. See Appendix
O, Section 10.8 for further discussion of the etiology of panic disorder, including in relationship to
environmental exposures.
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10.9 Kidney Stones
Among the interviewees, there was one report of kidney stones. Kidney stones are pieces of solid
matter that form in the kidney when there are high levels of certain substances, normally found in
the urine at lower concentrations. One or more stones may form at the same time and these may
stay where they formed in a particular part of kidney, or they may travel further down the urinary
tract. Kidney stones vary in size; small stones may pass out of the body on their own, while larger
ones may get stuck along the urinary tract.
According to data from National Health and Nutrition Examination Survey 2007–2010 (NHANES) in
the United States the prevalence of kidney stones was 8.8% (95% confidence interval [CI], 8.1-9.5)
(reference 32). This represents 27,995,035 individuals (reference 33). Obesity and diabetes were
strongly associated with a history of kidney stones in multivariable models. There seems to be a
correlation between stone occurrence and weight gain, body mass index (BMI) and diabetes
mellitus (references 34 and 35). After milk products in China were tainted with melamine, there
was a significant increase in the number of babies and children diagnosed with kidney stones,
leading to belief that melamine, known to be able to cause kidney stones in rats can also do so,
under the correct conditions, in humans (reference 36). It has been known for decades that there is
an increased risk of kidney stone is workers occupationally exposed to Cadmium (references 37,
38, 39, and 40). Despite extensive review of the medical and scientific literature, no occupational or
environmental exposures were identified that were strongly associated with an increased risk of
kidney stones.
10.10 Crohn’s disease
One individual had Crohn’s Disease (CD) which was diagnosed in theatre; CD is a form of
Inflammatory Bowel Disease (IBD), which can affect any part of the gastrointestinal track. CD is a
chronic disease, which involves inflammation of the gut, most commonly at the end of the small
bowel and the beginning of the colon. According to the Crohn’s and Colitis Foundation of America,
700,000 Americans may have CD (reference 41), with an equal risk in men and women. The onset
is usually between the age of 15 and 35; however, it may occur at any age.
The causes of CD are unknown, although some research suggests hereditary, genetics, infections,
smoking, and/or environmental factors may contribute to the development of CD. Individuals living
in urban or industrial areas and people in northern climates are at higher risk of developing CD than
those in rural communities, less developed countries or more southern climates (references 41 and
42). Most research indicates that the body’s immune system plays a major role in the development
of CD (references 42 and 43). Diet and stress may aggravate CD, but do not cause it. The CD
runs in families and is more common in people of Eastern European descent, although four out of
five patients do not have a close relative with CD and it is found in people of other backgrounds
(references 41 and 42).
The Institute of Medicine conducted an extensive review of the literature that looked at solvent and
pesticide exposure and a variety of clinical outcomes (reference 44). This review failed to identify a
single study that found an increased incidence of CD with solvent or pesticide exposure. There is
some evidence that some solvent exposures may be linked to immune system effects (reference
45), however, based on a review of the literature, there are no currently published studies indicating
an increase in CD related to any known chemical exposure.
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10.11 Gastrointestinal Symptoms
Gastrointestinal (GI) symptoms were reported in three individuals excluding the case of CD. These
complaints included rectal bleeding in two individuals (one who reports it for approximately two
years), “stomach issues”, and sporadic bowl movements. One individual was diagnosed with
gastritis which was service-connected. The descriptions of some of these symptoms sound as if
they may represent Irritable Bowel Syndrome (IBS). This is a completely different clinical condition
than CD, which is an IBD. Without further information, the diagnosis of IBS is obviously
speculative. IBS is a problem with the motility of the intestines for which no cause has yet been
found, but there are treatments that are highly effective. In order to be diagnosed with IBS, all other
causes for the symptoms must be excluded from possibility. That includes various tests that can be
ordered or performed by most primary care providers and/or by a gastroenterologist. Rectal
bleeding may indicate anything from hemorrhoids to colon cancer, and certainly warrants evaluation
by primary care physician if not done already. Without a specific diagnosis, it is difficult to consider
environmental exposures, although some GI symptoms are related to stress. As noted earlier,
there are three infectious gastrointestinal conditions which are presumptively related to deployment
by the VA, and these are discussed in Appendix O.
10.12 Hearing Loss
Three interviewees reported hearing loss; it was bilateral in two cases and one individual uses
hearing aids. Military service has been associated with hearing loss, and this Unit was exposed to
continuous noise as well as sudden explosions with associated noise and blast overpressure.
10.13 Miscellaneous Conditions
There were a variety of conditions identified where the cause is obvious or well-established (such
as burns, fractures, sprains, strains, torn ligaments, low back pain, shrapnel wounds and other
injuries). The following are some other reported medical conditions or symptoms with a brief
discussion of each. These conditions are found in military and Civilian populations.
Headaches were reported by a few Unit members. Headaches are associated with a variety of
conditions and have a variety of causes. Persistent headaches; frequently re-occurring
headaches; or headaches that have increased in duration, frequency, and intensity; as well as
having “the worst headache of my life,” should be assessed by a healthcare professional.
Pilonidal Cyst: At least one individual developed a symptomatic pilonidal cyst (a cyst that
usually occurs in the buttock area near the “tailbone”) requiring treatment. This pilonidal cyst
became symptomatic several years after the 2004-2005 deployment. Individuals can have an
asymptomatic pilonidal cyst for many years, but it can become more noticeable, painful,
inflamed and/or infected (becomes an abscess) with prolonged pressure or irritation in the area
of the cyst, such as sitting for long periods of time. A pilonidal cyst is not a result of an
environmental exposure. Soldiers with any cysts or abscesses should see their healthcare
provider for assessment and possible treatment.
Frequent Urination: At least one individual reported that he began to experience frequent
urination after deployment. A persistent increase in urinary frequency, and well as other
persistent or chronic changes in urination habits such as urinary urgency, urinary hesitancy,
painful urination, and so forth, are usually a symptom of another medical condition but can be
just a normal variation in urination. Urinary frequency is not associated with any known
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
environmental exposure. Soldiers should see their healthcare provider if they are having these
types of urinary symptoms or other unexplained changes in their urination habits.
11
Restless Leg Syndrome: At least one individual reported that he had restless leg syndrome
(RLS). RLS usually involves an urge to move your legs and the voluntary movement of the legs
at rest or while trying to sleep. Involuntary movement and jerking of the legs while sleeping is
called periodic leg movements of sleep (PLMS). These conditions may be difficult to
distinguish and some movement of the arms and legs is normal. Each condition may occur by
itself or can be associated with other sleep disturbances and/or other medical conditions.
However, there is not any known environmental exposure associated with RLS. Soldiers
should see their healthcare provider for persistent bothersome symptoms, if the symptoms
interfere with getting a good night’s sleep, or for other health related concerns.
Rashes: A few Soldiers reported rashes or other skin conditions but did not have a specific
diagnosis. Without a specific diagnosis, it is difficult to determine whether a particular exposure
or suspected exposure might have caused or contributed to the rash. Likewise, without a
specific exposure, it is difficult to determine a specific cause of the rash. Soldiers should see
their healthcare provider for persistent skin rashes or other skin conditions.
Findings
Minimal objective information was available regarding potential exposures incurred by Unit
members. The 1/24 BN SBCT was deployed to Mosul during a time of heavy insurgent activity and
engaged in numerous dangerous missions. There was limited environmental monitoring conducted
during this period of high operational tempo. Unit members were potentially exposed to products of
combustion and incomplete combustion and an unknown mix of other potential hazards when
detonating unexploded ordinance, during frequent improvised explosive device attacks, and when
responding to burning Stryker vehicles.
In general, the health effects reported by Unit members did not have definitive associations with
potential exposures identified by the Unit or to other known exposures. Although the available data
were limited, long-term health effects were not expected based on the information available. Finally,
a disease cluster (pattern) was not evident.
11.1 Reported Potential Exposures
An extremely limited amount of specific, quantitative, and applicable exposure information was
identified in the review of available data sources. Ambient air quality was considered poor by many
Soldiers. Exposure to ambient particulate matter (PM) and vehicle exhaust was highly likely. This
is based on environmental monitoring conducted after 2005. Soldiers and the Unit surgeon were
concerned about emissions from a burn pit. A burn pit used for waste control was determined to
have been appropriately sited with respect to prevailing wind patterns. However, atypical events
(such as atmospheric temperature inversions) may have occurred. These events have the potential
to cause prolonged lingering of burn pit smoke near the ground. Exposure to other products of
combustion from burning vehicles and uncharacterized burn pit emissions occurred at an unknown
frequency, duration, and intensity.
While it is plausible that toxic industrial chemicals may have been present, there were no
documented chemical releases or industrial accidents apart from a single ruptured canister incident
at the “ice factory” discussed in the interviews. The impression of those interviewed for this
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investigation was that industrial facilities located in and around Mosul were generally not
operational.
Soldiers were concerned about exposure to Halon discharged from the fire suppression systems,
installed in Stryker vehicles. However, Halon was not the fire suppressing agent used in these
vehicles. A burning Stryker would be expected to generate a variety of potentially hazardous
combustion products. Magnitude and duration of hazardous exposures from burning vehicles were
not known.
Unit members reported being near destroyed or disabled vehicles that may have been hit with
depleted uranium (DU) rounds. Contact with vehicles hit by DU rounds may have resulted in limited
incidental DU exposures (considered “Level III” exposures). Such exposures are not associated
with significant health risks.
Individuals reported sporadic or potential exposure to sewage and human remains. The extent of
barrier protection was variable. One individual reported an episode of what he considered
“dysentery” from drinking water that was bottled; therefore, ingestion of contaminated water was not
likely to have occurred. The lack of other reported acute episodes of infectious disease were
evidence of a low level of risk for future health consequences of exposure to untreated sewage and
human remains. The long-term risk of infectious disease risk was minimal.
Based on events as described by Unit members, some individuals likely incurred short-term
exposures to irritants from IEDs/VBIEDs/SBIEDs and possibly at the “ice factory” or elsewhere. In
no instance were these exposures quantified. Typically, however, acute health effects would have
been apparent if exposures were of sufficient magnitude to be of long-term concern. Other hazards
(such as propellants and accelerants) were mentioned by those interviewed, but it was not clear to
what extent the exposure pathways were completed (i.e., item was inhaled, ingested or
substantially absorbed through the skin). Some exposure concerns (such as the microwave
“jammers”) do not pose a health hazard under normal operating conditions.
The evaluation of the frequency, duration, and magnitude of specific exposures which could
potentially result in long-term health effects did not provide evidence of a singular source of risk.
However, there is substantial uncertainty about the risk posed by combinations of hazards and
about exact exposures experienced at the individual level.
11.2 Reported Health Concerns and the Potential Exposures
Regarding health conditions and potential associations with deployment-related exposures, it could
be stated with a high degree of certainty that self-reported PTSD, TBI and MTBI were likely to have
resulted from Unit activities during their deployment. The Unit operated for prolonged periods at
high intensity with little “down time”, and was exposed to deaths of Unit members, other human
remains, and high-stress combat conditions. Likewise, hearing loss and combat injuries resulted
from deployment activities. There were few complaints of respiratory disease from the
interviewees—asthma, shortness of breath, and pulmonary nodules were reported—although
inhalation exposures were likely. The association between respiratory symptoms and deployment
to OIF has been noted, and asthma following deployment has been demonstrated in some
published studies. Other non-cancer conditions (such as kidney stones, Crohn’s disease, and noninfectious gastrointestinal disease and symptoms) do not have a clear relationship with potential
exposures incurred during the Unit’s deployment.
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Biliary carcinoma is not associated with a specific environmental exposure. Two of the reported
malignancies, follicular lymphoma and ALL, are associated with ionizing radiation. Follicular
lymphoma had also been associated with solvent exposure, although evidence for this relationship
is considered limited/suggestive. While there are no quantitative measurements, exposure to
incidental ionizing radiation is unlikely to result in development of either cancer. Cancer related to
solvent exposure is limited to particular solvents and typically occurs in working populations with
regular, recurring, long-term exposure. See Appendix P for details on the published literature
regarding these opinions.
11.3 Disease Cluster Assessment
Overall, there is not a predominant and specific health condition of concern. No unifying case
definition could be delineated. The presence of different cancer types in this small group was not
evidence of a disease cluster, given that a cluster involves one specific type of disease. Likewise,
singular occurrences of a specific disease type cannot be assessed as occurring in excess to what
would be expected (references 1, 2, and 3). The age of onset for the noted cancers are somewhat
atypical, but not wholly uncommon.
Since a unifying case definition cannot be established and because no known completed exposure
pathway for a biologically plausible exposure can be identified, a formal epidemiological
investigation would not be useful and is unfounded.
11.4 Rationale for Conducting Cancer Studies
The AIPH is planning to conduct a set of epidemiologic studies to evaluate whether a history of
deployment in support of OIF/OEF was associated with subsequent incidence of primary cancer
(from 2004–2013) among Active Duty Service Members and U.S. Veterans. Cases of primary
melanoma, brain cancer, leukemia, lymphoma, thyroid cancer, testicular cancer, and breast cancer
will be identified using DoD and VA medical records and cancer registry databases. Many of these
cancers will have peak incidence during the young adult years and will have known or suspected
environmental or occupational risk factors.
In responding to the concerns of the 1/24 BN SBCT Soldiers, Service Members and Veterans, a
necessary first step is to evaluate whether the incidence of cancer among deployed personnel is
greater than what would be expected. Thus, the objective of this study is to systematically identify
cases of cancer among Active Duty Service Members and Veterans, evaluate their deployment
experience in comparison to the deployment experience of a representative set of control subjects,
and estimate the excess risk of cancer among deployed personnel. An understanding of the
presence and magnitude of an excess risk of cancer among formerly deployed individuals – or the
lack thereof – can be used to substantiate or alleviate concerns, support the public health and
medical communities that care for formerly-deployed personnel and Veterans, and inform DoD and
VA policy makers regarding the long-term effects of deployment-associated exposures.
12
Recommendations
12.1 1/24 BN SBCT Personnel
Encourage all individuals to seek medical evaluation for unexplained, persistent, or
concerning health conditions. Individuals should speak with their healthcare provider
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regarding potential exposures of concern. Providers with questions regarding deploymentrelated exposures and potential associations with health conditions may contact the AIPH
Environmental Medicine Clinical Consult Service ([email protected]). Questions and contact information may be emailed to this address
and a provider will contact the requestor, typically within 48 hours.
Foster a positive climate for seeking care for both physical and behavioral health injuries and
concerns. A stigma against seeking care is still pervasive in some units. Given the nature of
the missions and experiences of the 1/24th, they are at risk for PTSD. If still on Active Duty,
they may seek assistance through their primary care manager or evaluate resources on the
Defense Center of Excellence at: www.dcoe.mil Web page which also provides information,
24/7 access and other assistance. The PTSD may affect close relationships, particularly
those with the Family. The Family may play an important role in encouraging individuals to
seek help. The Family can access resources at: www.dcoe.mil. The VA Web site at:
www.ptsd.va.gov provides resources for Family members, self-help online tools for those with
PTSD, and information and telephone numbers for use when in crisis and how to seek help
and get assessed in the VA system.
Ensure Active Duty Soldiers from the 2004-2005 1/24 BN SBCT deployment contact their
primary care manager for any TBI health concerns related to exposures from IEDs, VBIEDs,
and SBIEDs. All individuals with a history of such trauma, particularly if they are exhibiting
symptoms such as headaches, dizziness, memory loss and other cognitive difficulties,
irritability, mood disorder or impact to their daily functioning should be evaluated. Some of
these symptoms may be contributing to, overlapping with, or exacerbating other behavioral
health issues such as PTSD. The DoD Defense Centers of Excellence for Psychological
Health and Traumatic Brain Injury offers a 24/7 Outreach Center Web site at: www.dcoe.mil
with access to phone center, live chat and email, as well as resources for the individual and
the Family. The VA now has Polytrauma Care Facilities which have expertise in addressing
all of the effects and symptoms of TBI in multiple organ systems. Resources and contact
information may be found at: (http://www.polytrauma.va.gov/understanding-tbi/). In addition,
any combat Veteran may bring their DD214 to a VET Center to speak to a counselor or
therapist without an appointment and regardless of enrollment status with the VA.
Information, Web links, and contact information on these programs, to take a self-assessment
online, and other topics can be found at http://www.maketheconnection.net/resources
Encourage all individuals with concerns regarding inhalational exposures or open burning of
trash to register for the VA Airborne Hazards and Open Burn Pit Registry. The VA, in
coordination with DoD, has established an Airborne Hazards and Open Burn Pit Registry to
allow Military personnel and Veterans previously deployed in Afghanistan, Iraq, or 1990-1991
Gulf War with concerns regarding their exposure to various sources of air pollution (such as
smoke from burn pits, oil-well fires, or pollution) during their deployment to provide detailed
information regarding their exposure situation and health concerns. In addition, the registry
offers an optional medical assessment, though it is not required to be in the registry. The VA
Airborne Hazards and Open Burn Pit Registry can be accessed through the Web site below:
https://veteran.mobilehealth.va.gov/AHBurnPitRegistry
Inform former members of the 1/24 BN SBCT about the updated MEDCOM OTSG Policy 14021. The updated policy provides former and current Soldiers specific guidance and
classification, for Soldiers who have or may have been exposed to DU during a deployment.
The policy also provides specific information to request a DU urine bioassay through their
primary care provider if warranted.
39
Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
12.2 Department of the Army (DA)
Coordinate with higher headquarters personnel from the Army, CENTCOM, and DoD to
establish the steps needed to review all sensitive data/information from this investigation and
the OEF/OIF/OND campaigns for applicable declassification/redaction steps to allow
inclusion in future investigative reports. This is particularly important with respect to exposure
incidents and other information potentially relevant to health outcome. The DoD VA Data
Transfer Agreement requires DoD to provide such information to the VA for their use.
Improve documentation of personnel locations for all Army military and Civilian personnel. At
minimum, daily locations for each Soldier and Civilian should be captured and maintained. In
the absence of individual monitoring, in order to appropriately associate a fixed potential
hazard to potentially exposed personnel, their location in association with the hazard must be
known. Although personnel locations are mission sensitive, these data should be made
available to public health professionals in a timely manner.
Ensure OEHS requirements identified in AR 11-35 (Deployment Occupational and
Environmental Health Risk Management) are implemented and executed.
Ensure prompt reporting of all exposure incidents in the DOEHRS Incident Module. This
reporting allows for the reporting of descriptive information related to exposure incidents such
as fires, releases, spills or other events even in the absence of sampling information.
Additionally rosters of the potentially exposed population are archived with this information,
which is searchable by the individuals SSN, location, or other key terms.
Ensure all Soldiers properly complete the PDHA and PDHRAs and that they receive proper
guidance and education on the importance of these assessments. Individuals should be
encouraged to document on these forms exposures that are of concern as well reporting
specific symptoms or health effects experienced in theatre in relation to such exposures.
Ensure providers have access to current information on relevant potential hazards with an
understanding of when a referral is warranted and when reassurance is appropriate. Risk
communication is required at the time of the PDHA and PDHRA for exposure concerns if the
Service member is not referred. Factual, understandable and updated assessments of
potential health risks associated with deployment exposures should be available to DoD
providers, as well as VA providers, particularly those associated with the VA WRIISCs.
Ensure that the Army is prepared to handle additional future stakeholder groups coming
forward with health outcomes perceived to be associated with deployment related activities
from the OEF/OIF/OND campaigns. It is critical that investigating agencies have
comprehensive, accessible, interpretable, relevant and useable data that affords subject
matter experts and healthcare providers the information needed to better assess, care for
and educate Soldiers and Veterans.
Ensure that the Army enhances environmental, occupational, and medical surveillance
activities via state of the art technologies to realize comprehensive health surveillance.
40
Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
13
Point of Contact
Ms. Farhana Schickedanz, DESP, MCHB-IP-RDE, DSN 312.584.6096, COM 410.436.6096,
[email protected] and [email protected].
41
Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
Appendix A
References
42
Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
References
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workers. Br J Ind Med 1993;50:598-602
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44. The Committee on Gulf War and Health of the Institutes of Medicine. National Research Council. Gulf
War and Health: Volume 2. Insecticides and Solvents. Washington, DC. The National Academies Press,
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45. Cooper GS, Makris SL, Nietert PJ, Jinot J. Evidence of Autoimmune-Related Effects of
Trichloroethylene Exposure from Studies in Mice and Humans. Env Hlth Perspectives May 2009.
117;(5):696-702
Related References
Abhyankar A, Bhambure N, Kamath NN, et al. Six month follow up of 14 victims with short term exposure
to chlorine gas. J Soc Occup 1989; Med 39:131–132.
Abraham JH, DeBakey SF, Reid L, et al. Does Deployment to Iraq and Afghanistan Affect Respiratory
Health of US Military Personnel? JOEM 2012 June; 54(6):740-745
Agabitia N, Anconaa C, Forastierea F, et al. Short term respiratory effects of acute exposure to chlorine
due to a swimming pool accident. Occup Environ Med 2001;58:399-404
Michigan Department of Community Health. Chlorine – Public Fact Sheet. Accessed at:
http://www.michigan.gov/documents/Chlorine_factsheet_82357_7.pdf
Agency for Toxic Substances and Disease Registry (ATSDR). 2004. Toxicological profile for Ammonia.
Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service.
A I Smith B, Wong CA, Boyko EJ, et al. The Effects Of Exposure To Documented Open-Air Burn Pits On
Respiratory Health Among Deployers Of The Millennium Cohort Study. JOEM 2012 June; 54(6):708Ammonia Solution (UN 3318); Ammonia Anhydrous (UN 1005) : Lung Damaging Agent. Accessed at
http://www.cdc.gov/niosh/ershdb/EmergencyResponseCard_29750013.html:
Albatanony MA, El-Shafie MK. Work-related health effects among wastewater treatment plants workers.
Int J Occup Environ Med. 2011 Oct;2(4):237-44.
August 28, 1995 correspondence from Ruth E. McCully, Director, Office of Health Enforcement, OSHA, to
David L. Trimble, President, Milieu Systems Corporation. Accessed at:
https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=21904
Centers for Disease Control and Prevention. Emergency Preparedness and Response. Facts about
Chlorine. Accessed at: http://www.bt.cdc.gov/agent/chlorine/basics/facts.asp
Das R1, Blanc PD. Chlorine gas exposure and the lung: a review. Toxicol Ind Health. 1993 May-Jun;
9(3):439-55.
Deployment Health and Family Readiness Library. Chlorine gas exposure for Service Members.
Accessed at: http://deploymenthealthlibrary.fhp.osd.mil/Product/RetrieveFile?prodId=300
Emmen HH, et al. Human safety and pharmacokinetics of the CFC alternative propellants. HFC 134a
(1,1,1,2-tetrafluoroethane) and HFC 227 (1,1,1,2,3,3, 3-heptafluoropropane) following whole-body
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
exposure. Regul Toxicol Pharmacol. 2000 Aug;32(1):22-35.
(http://www.epa.gov/rpdweb00/docs/cleanup/402-r-06-011.pdf
General information about IEDs may be found at: http://www.history.navy.mil/library/online/ied.htm
Hasan FM, Gehshan A, Fuleihan FJ. Resolution of pulmonary dysfunction following acute chlorine
exposure. Arch Environ Health 1983; 38:76–80.
Hines SE, et al. Pulmonary Health Effects in Gulf War I Service Members Exposed to Depleted Uranium.
J Occup Environ Med. Volume 55, Number 8, August 2013, 937-944
Hodges SE, McCormick SJ. 2010. Fire extinguishing agents for protection of occupied spaces in military
ground vehicles. NFPA SUPDET 2010
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xtinguishing_agents_for_protection_of_occupied_spaces_.pdf)
Kidde Fire Systems, Material Safety Data Sheet (MSDS), FM-200 (Fire Extinguishing Agent). Revision:
February 9, 2012.
Indiana State Department of Health. Diseases Involving Sewage. Accessed at:
http://www.in.gov/isdh/22963.htm
Institute of Medicine 2011. Long-Term Health Consequences of Exposure to Burn Pits in Iraq and
Afghanistan Washington, DC: The National Academies Press. Access online at:
http://books.nap.edu/openbook.php?record_id=13209&page=R2
or
http://www.iom.edu/Reports/2011/Long-Term-Health-Consequences-of-Exposure-to-Burn-Pits-in-Iraqand-Afghanistan.aspx
Leroyer C, Malo JL, Infante-Rivard C, et al. Changes in airway function and bronchial responsiveness
after acute occupational exposure to chlorine leading to treatment in a first aid unit. Occup Environ Med
1998; 55:356–359.
McDiarmid, MA, Gaitens, JM, Hines, S, et al. “The Gulf War Depleted Uranium Cohort at 20 Years:
Bioassay Results and Novel Approaches to OTSG/MEDCOM Policy Memo 14-021, Medical Management
of Army Personnel Exposed to Depleted Uranium
More Information on DU exposures can be accessed at:
Force Health Protection & Readiness (FHP&R), http://fhp.osd.mil/du/;
Deployment Health Clinical Center, http://www.pdhealth.mil/du.asp;
Veterans Administration,
http://www.warrelatedillness.va.gov/warrelatedillness/education/exposures/depleted-uranium.asp,
Morris MJ, Zacher LL, Jackson DA: Investigating the Respiratory Health of Deployed Military Personnel.
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postdeployment medical encounters for respiratory conditions." Mil Med 179(5): 540-6.
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National Pollutant Discharge Elimination System (NPDES), U.S. Department of Environmental Protection.
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http://cfpub.epa.gov/npdes/faqs.cfm?program_id=4#72
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https://www.health.ny.gov/environmental/emergency/chemical_terrorism/ammonia Tech.htm
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Szema AM, Salihi W, Savary K, et al. Respiratory Symptoms Necessitating Spirometry Among Soldiers
With Iraq/Afghanistan War Lung Injury. JOEM 2011 September; 53(9): 960-965
Schneidermann A, Walters T. Letter to the Editor: Respiratory Symptoms Necessitating Spirometry
Among Soldiers With Iraq/Afghanistan War Lung Injury JOEM 2011 December; 53(12): 1356-1357
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Statement: Uranium. Atlanta GA, February 2013. (http://www.atsdr.cdc.gov/ToxProfiles/tp150-c1-b.pdf
U.S. EPA, Office of Solid Waste and Emergency Response. Depleted Uranium Technical Brief, EPA 402R-06-011. Washington, DC, December 2006. (http://www.epa.gov/rpdweb00/docs/cleanup/402-r-06011.pdf)
White CW, Martin JG. Chlorine Gas Inhalation: Human clinical evidence of toxicity and experience in
animal models. Proc Am Thor Soc 2010; July 1; 7(4):257-263
48
Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
Appendix B
Acronym List
49
Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
Acronyms
A – Apache
ADS – Ambulatory Data System
AFES - Automatic Fire Extinguishing Systems
AHLTA – Armed Forces Health Longitudinal Technology Application
AIDS – Acquired Immunodeficiency Syndrome
AIPH – Army Institute of Public Health
ALL - Acute Lymphoblastic Leukemia
ANSI - American National Standards Institute
AOR – Area of Operation
AR - Army Regulation
ASD (HA) – Assistant Secretary of Defense, Health Affairs
ATSDR - Agency for Toxic Substances and Disease Registry
B – Bulldog
BDC - Bile Duct Cancer
BN – Battalion
BUN – Blood Urea Nitrogen
C – Cobra
C2PC - Command & Control Personal Computer
CBRN - Chemical, Biological, Radiological, Nuclear
CD – Crohn’s Disease
CDC – Center for Disease Control and Prevention
CENTCOM - U.S. Central Command
CHPPM - Center for Health Promotion and Preventive Medicine
CO – Carbon Monoxide
CO2 – Carbon Dioxide
50
Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
COCOM – Combatant Command
COPD - chronic obstruction pulmonary disease
CSH - Combat Support Hospital
CTS - Contingency Tracking System
DESP - Deployment Environmental Surveillance Program
DHSS - Defense Health Services Systems
DIA - Defense Intelligence Agency
DMDC – Defense Manpower Data Center
DoD - Department of Defense
DOEHRS - Defense Occupational and Environmental Health Readiness System
DU - Depleted Uranium
EH – Environmental Health
EMP - Environmental Medicine Program
EOD - Explosive Ordnance Disposal
ESIP – Environmental Surveillance Integration Program
FDA – Food and Drug Administration
FHP&R - Force Health Protection & Readiness
FL – Follicular Lymphoma
FOB - Forward Operating Base
FSS – Fire Suppression System
GI – Gastrointestinal
GIS - Geographic Information Systems
HAV - Hepatitis A Virus
HHC - Headquarter and Headquarters Command
HIV – Human Immunodeficiency Virus
HRCP - Health Risk Communication Program
51
Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
IBD – Inflammatory Bowel Disease
IBS – Irritable Bowel Syndrome
IED - Improvised Explosive Device
IEEE - Institute of Electrical and Electronics Engineers
IH – Industrial Hygiene
IHA – Industrial Hazard Assessment
JBB – Joint Base Balad
JTTR – Joint Theater Trauma Registry
KE – Kinetic Energy
LOAEL - Lowest-Observed Adverse Effect Level
MEDCOM - U.S. Army Medical Command
MEGs - Military Exposure Guidelines
MESL – Military Exposure Surveillance Library
MHS - Military Health System
MIDB - Modernized Integrated Database
MPE – Maximum Permissible Exposure
MRAP - the Mine Resistant Ambush Protected
MSDS - Material Safety Data Sheet
MSR – Military Supply Route
MTBI - Mild Traumatic Brain Injury
MTF – Medical Treatment Facilities
NCI – National Cancer Institute
NDDIC - National Digestive Diseases Information Clearinghouse
NHL – Non-Hodgkin’s Lymphoma
NIDDK – National Institute of Diabetes and Digestive and Kidney Diseases
NIH – National Institutes of Health
52
Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
NIPRNET - Non-classified Internet Protocol Router Network
NO – Nitrogen Oxide
NO2 – Nitrogen Dioxide
NPDES - National Pollutant Discharge Elimination System
OEF - Operation Enduring Freedom
OEHS - Occupational and Environmental Health Surveillance
OEHSA – Occupational and Environmental Health Site Assessment
OEM - occupational and environmental medicine
OIF - Operation Iraqi Freedom
OND - Operation New Dawn
OPTEMPO - Operational Tempo
OTSG - Office of The Surgeon General
PAH - Polycyclic Aromatic Hydrocarbon
PCB - Polychlorinated Biphenyl
PDHA - Post-Deployment Health Assessment
PDHRA - Post Deployment Health Assessment and Reassessment
PEL – Permissible Exposure Limit
PLMS – Periodic Leg Movements of Sleep
PM - Particulate Matter
POEMS - Periodic Occupational and Environmental Monitoring Summary
PTSD - Post-Traumatic Stress Disorder
RF – Radio Frequency
RH – Radiation Health
RLS- Restless Leg Syndrome
ROWPU - Reverse Osmosis Water Purification Unit
RTD – Return To Duty
53
Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
SARS – Severe Acute Respiratory Syndrome
SBCT – Stryker Brigade Combat Team
SBIED - Suicide Bomber Improvised Explosive Device
SIGACTS - Significant Activities
SIPRNET - Secret Internet Protocol Router Network
SITREPS - Situation Report
SSN – Social Security Number
SVOC - Semivolatile Organic Compounds
TBI - Traumatic Brain Injury
TF - Task Force
TG - Technical Guide
UIC – Unit Identification Code
USAPHC – United States Army Public Health Command
VA - Veteran’s Administration
VBIED - Vehicle Borne Improvised Explosive Device
VET – Veteran
VOC – Volatile Organic Compounds
WRIISCs - War-Related Illness and Injury Study Centers
Zero-ODP - zero Ozone Depleting Potential
54
Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
(U) Appendix C
Approach to Disease Cluster Assessment
55
Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
Disease Clusters – USAPHC Environmental Medicine Program
This document was created for use by the USAPHC Environmental Medicine Program based on the
CDCs “Guidelines for Investigating Clusters of Health Effects”
NO
1. Initial Contact and Response: Does initial info
suggest further evaluation (e.g., rare disease,
plausible exposure, plausible clustering)?
YES
2. Assessment
Prepare Summary
Report and Close out of
Case
Preliminary Evaluation: Is there an
apparent cluster? OR if there is no
excess, does the data suggest an
occurrence of biological and public
health importance?
NO
YES
Case Evaluation: Are all cases
verified and an excess confirmed?
NO
YES
NO
Occurrence Evaluation: Is there an
epidemiological and biologic
plausibility relationship between
exposure and disease?
YES
NO
3. Major Feasibility Study: Does the
major feasibility study suggest that an
etiologic investigation is warranted?
YES
4. Etiologic Investigation
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
Introduction.
Army populations living on military installations and/or working in Army workplaces may perceive and be
concerned about excess disease, such as cancer, in the population. They may also feel that the excess
is likely due to some occupational or environmental exposure(s) related to past or present Army activities.
Many times, they will bring their concerns up to leadership, management or other responsible parties.
Local and/or regional installation and/or medical assets (such as safety, IH, PM, OEM) may or may not be
engaged and respond, or attempt a response. At some point, if the concerned population is not satisfied
with the response, or local assets are recognized as limited in personnel and/or expertise, USAPHC may
be requested to investigate and respond to these concerns.
What are disease clusters?
A disease cluster “is the occurrence of a greater than expected number of cases of a particular cancer or
disease within a group of people, a geographic area, or a period of time” (National Cancer Institute,
2006). For example, recent disease clusters have included: pneumonia among homosexual men in the
1980s, which led to the discovery of human immunodeficiency virus (HIV) and acquired
immunodeficiency syndrome (AIDS); the 2003 outbreak of severe acute respiratory syndrome (SARS);
and a 1960s cancer cluster linking asbestos exposure to mesothelioma (National Cancer Institute, 2006).
To determine if a disease outbreak is indeed a disease cluster, health officials must follow a methodology
that distinguishes a statistically significant excess from the natural variability of disease occurrence. A
methodology based on the CDC’s “Guidelines for Investigating Clusters of Health Effects 1990” is
presented below. When following these guidelines, however, the analysis of statistical significance will
vary based on available data. If a disease outbreak is confirmed to be a statistically significant disease
cluster, it may be appropriate to carry out etiologic and epidemiological studies to determine if there is a
possible occupational/environmental exposure causing the disease.
A disease cluster may not always be the consequence of an environmental or occupational exposure.
“The occurrence of a disease may be random, but the distribution may not be uniform, and clusters of
disease may arise by chance alone” (NIOSH, 2009).
Why are disease clusters important?
Scientifically, true clusters are important because they contribute to the scientific wealth of knowledge
necessary to understand and prevent disease. Many epidemiological studies have successfully shown a
connection between an exposure and a disease or adverse health outcome in a population. For public
health reasons, true clusters are important because when a true cluster is present and recognized,
intervention may be possible to interdict the exposure or cause, or secondarily prevent disease.
Perceptions of clusters are also important to the people who perceive them and must be addressed for
this reason. Populations become alarmed when they either perceive an excess of an exposure, or an
excess of disease. In the former, they fear the consequences of the exposure, and in the latter, they want
to know the cause.
Cancer Clusters
Cancer is many diseases with a variety of causes and, in general, is common. What first appears to be a
cancer cluster may not; a review of the situation may show that the number of new cancer cases is in the
expected range for the population and therefore that the cases do not represent a cancer cluster. Cases
are more likely to represent a cancer cluster if they involve: 1) one type of a cancer, 2) a rare type of
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
cancer, or 3) a type of cancer in a group not usually affected by that cancer, such as cancer in children
that is normally seen in adults (CDC, 1990).
People who “converge” for part of their lives into a particular neighborhood or workplace may not
necessarily develop cancer while at the neighborhood or workplace because of something in that
neighborhood or workplace. There are many risk factors associated with the development of cancer that
have nothing to do with occupational/environmental exposures, such as age, gender, race, family
genetics/history, and lifestyle decisions (e.g., tobacco/alcohol use, nutrition, physical inactivity, obesity),
or exposures that occurred at some past point in their lives.
The primary public health purpose of investigating reports of excess cancer in workplaces is to identify
and control the cause. Objectives of an investigation should be to answer the following questions: Is
there an actual excess of cases? Are cases occurring independently or are they related? Are there any
occupational factors that might be part of the causal pathway?
Epidemiologists must also determine if the cancer cases could have occurred by chance. They often test
for “statistical significance,” which is a mathematical measure of the difference between groups. The
difference is said to be statistically significant if it is greater than what would be expected to happen by
chance alone. In common practice, a statistically significant finding means that the probability that the
observed number of cases could have happened by chance alone is 5% or less. For instance, if one
examines the number of cancer cases in 100 neighborhoods, and cancer cases are occurring by chance
alone, one should expect to find about 5 neighborhoods with a statistically significant elevation in the
number of cancer cases. In other words, some amount of clustering within the same family or
neighborhood may occur simply by chance. (NCI, 2006)
What are the difficulties in determining whether or not a disease cluster exists?
Accurately defining the group of people who should be considered at risk is important when investigating
a possible cancer cluster. One of the greatest problems in defining clusters is the tendency to expand the
geographic borders of the cluster to include additional cases of the suspected disease as they are
discovered. The tendency to define the borders of a cluster on the basis of where known cases are
located, rather than to first define the population and geographic area and then determine if the number of
cancers is excessive, creates ‘clusters’ that are not real. (NCI, 2006)
Among the pitfalls epidemiologists face in determining whether a cluster exists, is defining the numerator
and denominator when determining the rate in the population of concern; migration in and out of the area
over time; ascertainment differences; and determining comparable background rates. The numerator
cases counted will ultimately depend on the “case definition” of the disease(s) of concern which must be
clear and consistent.
Determining the denominator can be much more problematic. Denominators should truly be determined
by a commonality of exposure, but more often are defined by a geographic area where the cases are
located. There should be a biological, as opposed to statistical definition of a cluster, as “a geographically
and/or temporally bounded group of occurrences related to each other through some social or biological
mechanism, or having a common relationship with some other event or circumstance.” However, this is
rarely the case at the small population (e.g., neighborhood) level, where, when examining a single cluster,
the boundaries are often ill-defined, and the dimension (geographic, occupational) is rarely obvious. A
major pitfall for epidemiologists is defining a denominator for a perceived cluster by what has already
been recognized. Suspicion of a cluster often begins with the identification of a group of cases, and only
after is the underlying population from which the cases arose defined.
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
This pre-selection bias can shape the outcome of the investigation. There is an inherent danger of
overestimating the disease rate through “boundary shrinkage” of the population from which the cases are
assumed to have arisen or to extend the geographic borders of the cluster to include additional cases of
the suspected disease as they are discovered. There is also a tendency to include all the years in which
cases were reported, thereby maximizing and magnifying any effect which may be present. “Perceived
cluster” analyses end up being done “post hoc”, and not as a result of a prior hypothesis. It is difficult to
apply statistical procedures without a clear hypothesis in advance. The tendency to define the borders of
a cluster on the basis of where known cases are located, rather than to first define the population and
then determine if the number of cancers is excessive, creates many “clusters” which are not genuine.
Further issues are those of migration, latency, differential ascertainment, and comparison rates. Migration
into or out of the area over time – both of the well and the ill - can affect case finding for numerator cases
or determining the denominator in a particular neighborhood or workplace. Examples are change of
residences, discharge from the military, or leaving work due to illness. This can lead to data collection
problems such as having difficulty identifying other previous exposures; and difficulty in finding the
records on alleged cases of cancer/disease
Differential ascertainment of data can lead to difficulties comparing an “exposed” population rate with a
background or control rate. Ideally, ascertainment of data should be the same between the concerned
population and the comparison population. Pitfalls such as this which are classic issues with
epidemiological investigations in general, can be much more problematic in a cluster investigation for a
small population. For example, if interviews are conducted with the concerned population, information
must be ascertained from a control population by interview and not medical record review.
Variance and large confidence intervals in small populations
A major issue in applying statistical tests to small populations in cluster investigations is that of variance
and large confidence intervals. In small populations, a rate of disease can vary greatly and each case
can swing the rate widely. A high rate at any particular point in time may be due purely to this local
variation in a small population. As another side of this issue, a calculated rate will be accompanied by
large confidence intervals which may well overlap those of the comparison population. Therefore, it can
be very difficult to show, and have confidence in, a statistical excess rate in a small population. Over the
course of time, and with increasing data points, this wide variation in rate, especially if there appears to
be an excess at a particular point in time, would be expected to regress back to the true rate and become
less variable. This is one reason why health departments, and others investigating a cluster, may opt to
continue surveillance in the population for a time, rather that judge the existence of a cluster, when the
results are too uncertain.
When Results of the Investigation are Positive: Randomness and Clustering, and Chance
When a “cluster” is determined statistically by an investigation, even if well done, there is still the likely
explanation that it was a chance occurrence and not a true cluster. Because of this and the likelihood of
many of the pitfalls discussed above, the results of cluster investigations are often not fruitful. NCI and
CDC state that confirmation of a cluster doesn’t necessarily mean that there is any single, external cause
or hazard that can be addressed. It may be the results of chance, miscalculation of the expected number
of cases (e.g., not considering a risk factor within the population at risk), or differences in the case
definition between observed cases and expected cases, known risk factors for cancer (e.g., smoking), or
unknown risk factors for cancer.
The NIOSH website observes that the cases of cancer in a cluster may have a common etiology or may
be the coincidental occurrence of unrelated causes. Although the occurrence of a disease may be
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
random, the distribution of that disease may not be uniform, and clusters of disease may arise by chance
alone. Disease or tumor rates are very variable in small populations and rarely match the overall rate for
a larger area such as the State, so that for any given time period some populations have rates above the
overall rate and others have rates below. Even when there is an excess, this may be completely
consistent with the expected random variability. Statistical significance states that there is a 5% or less
chance that the observed number of cases could have happened by chance. However, ATSDR notes
that: “unusual events such as clusters occur all the time, especially in large populations…When first
noticed, such clusters are often regarded as resulting from some specific predictable process, rather than
as events with independent causes that happen to have occurred by chance in one particular place (such
as a coin toss).”
Thun and Sinks believe that despite the value of statistical testing, chance remains the most plausible
explanation for many confirmed cancer clusters, especially that involve common types of cancer or all
cancers combined. Spatial clustering of cancer is inevitable. The fact that boundaries of a suspected
cluster are defined based on when and where the cases actually occurred increases the likelihood that
random variation will appear to give rise to clusters.
Investigating Disease Clusters
This section outlines a four stage approach for managing and reporting a cluster; from original contact to
final disposition. The section does not speak directly to the particular outcome of concern (e.g., cancer or
birth defects), to the types of data available (e.g., mortality, hospital, discharge, or disease registries), or
to the specific analytic techniques (see section 4 and appendix). Usually these particulars will be
determined by local resources and circumstances. The four stages may be viewed as a series of filters
that provide appropriate responses to the reported problem. An assessment of feasibility should be made
before the actual study is begun, and the issue of increased frequency of occurrence should be separated
from the issue of potential etiologies. (MMWR 1990)
Once the decision has been made to proceed with an assessment, an important step is to separate two
concurrent issues: whether an excess has actually occurred and whether that excess can be linked
etiologically to some exposure. The first issue usually has precedence and it may or may not lead to the
second. (MMWR 1990)
A methodology for investigating disease clusters was put forth by the CDC (Guidelines for investigating
Clusters of Health Effects, 1990). This guidance presents a four step process: 1) an initial response, 2) an
assessment, 3) a major feasibility study, and 4) an etiologic investigation. Initial contact and response
includes getting the initial information from the concerned people and other knowledgeable sources.
Assessment includes analyzing the initial information to determine if there are indications to move on to
more extensive study. A major feasibility study is a formal scientific process for design of an
epidemiologic investigation to address the community concerns. An etiologic investigation is a scientific
investigation of the causes of a disease cluster, using epidemiological methods. For a study of any
perceived disease cluster, there is an additional set of technical criteria for determining when detailed
epidemiological investigation beyond the initial response and assessment phase is indicated
The CDC states that in many instances, the health agency will not be able to demonstrate an excess of
the condition in question or establish an etiologic linkage to an exposure. Nevertheless, a systematic,
integrated approach is needed for responding to reports of clusters. Besides the purely epidemiologic
and statistical expertise needed, there are social dimensions. The protocol involves four stages and each
provides opportunities for collecting data and making decisions. This is a systematic plan with points at
which the decision may be made to either terminate or continue the investigation. (See flow chart)
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
These stages are a series of filters that provide appropriate responses to the reported problem. An
assessment of feasibility should be made before the actual study begins and the issue of finding if there is
an increased frequency of occurrence (of the health event) should be separated from the issue of if there
are potential etiologies (e.g. exposures).
1. Initial Contact and Response. This is the best educational opportunity for communication with the
caller about the nature of clusters. Collect identifying information from the persons or groups first
reporting a perceived cluster: name, address, telephone #, organization affiliation, if any. Follow-up with
data on the potential cluster: the suspected health event(s), the suspected exposure(s), the number of
cases, the geographic area of concern, the time period of concern, how the caller learned about the
cluster. It is important to collect identifying information on the persons affected (that the informant is
aware of – they should not be sent out to find new cases): name, sex, age (or birthdate, age at
diagnosis), occupation, race, the disease outcome or diagnosis for each case being reported [if cancer,
which site(s)] , vital status of the cases, date of diagnosis, date of death, address (or approximate
geographic location), telephone #, length of time in residence at the site, contact person (family, friend)
and method for contact. If the initial contact suggests further evaluation is needed (for example, a single
and rare disease entity, plausible exposure, plausible clustering), proceed to stage 2.
2. Assessment. Again, the issue of an excess of a health event should be separate from whether it can
be linked etiologically with an exposure.
a. Preliminary evaluation – assess quickly from available data whether an excess may have
occurred, assuming all the cases reported are real. Look at the observed vs expected rate (reference
population and denominator issues), geographic area, time and latency periods. Outcome: if there is a
possible excess, go to 2b. If not, make a judgment whether to stop here or not (depending on if the data
suggest biological and public health importance). Respond to the stakeholder (s) with findings if not
proceeding.
b. Case evaluation –Assure that a biological basis exists for further work, and verify the diagnosis
(contact the cases or family, HCP, pathology reports, registries, etc.). Outcome: if the cases are verified
and there appears to be an excess, go to 2c. If excess is not substantiated, make a judgment to stop
here or not (depending on if there is biological plausibility and if the data is suggestive). Respond to the
stakeholder with findings, if not proceeding.
c. Occurrence evaluation – Determine if an excess has occurred and to describe the epidemiological
characteristics. Determine the “boundaries” and consider applying statistical and epidemiological
procedures for analysis. It is also a time, if needed, to review the scientific literature. Assess the
likelihood that an event-exposure relationship may be established. Assess stakeholder perceptions,
reactions and needs. Outcome: if an excess of a health event is confirmed and it appears
epidemiologically and biologically plausible (“compelling”), proceed. If the excess is confirmed but there
is no link to an exposure, terminate the investigation and explain to the stakeholder(s). If there is no
excess, terminate and report findings to the stakeholders.
3. Major Feasibility Study: Determine the feasibility of performing an epidemiological study linking the
health event and a putative exposure. Outcome: if warranted, go to stage 4; if little is to be gained by
etiologic investigation, summarize and report to concerned parties.
4. Etiologic investigation: attempt to establish a potential disease- (or injury-) exposure relationship.
Investigate the epidemiological and public health issues that the cluster generated (as opposed to the
specific cluster). This is should be a standard epidemiological study. Develop a protocol and implement
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
the study. The outcome is expected to contribute to epidemiological and public health knowledge that an
association does or does not exist, or confirmation of previous findings.
(NCI - National Cancer Institute, 2006): http://www.cancer.gov/cancertopics/factsheet/Risk/clusters
(NIOSH, 2009): http://www.cdc.gov/niosh/topics/cancer/
(CDC): http://www.cdc.gov/nceh/clusters/about.htm
(MMWR 1990): Guidelines for Investigating Clusters of Health Events, MMWR, 39 (RR-11); 1-16
07/27/1990; http://wonder.cdc.gov/wonder/prevguid/m0001797/m0001797.asp
STAT APPENDIX TO MMWR 1990: Guidelines for Investigation Clusters of Health Events – APPENDIX.
Summary of Methods for Statistically Assessing Clusters of Health Events;
http://www.cdc.gov/mmwr/preview/mmwrhtml/00001798.htm
Michigan Department of Community Health: Chemical Illness Response- Guidelines for Public
Health Investigations of Acute Onset Illness Clusters for Chemical Etiology. September 28, 2007.
http://www.michigan.gov/documents/mdch/Chemical_Illness_Response_final_210418_7
Sharkey JM, Hauschild VD. Addressing Cancer Clusters in the US Army. Army
Med Dept J. April-June 2013:31-34.
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
(U) Appendix D
Meteorological Data and Wind Patterns for Mosul
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
Meteorological Data and Wind Patterns for Mosul
Atmospheric conditions, governed by meteorological factors, have a crucial influence on the dispersion of
air pollutants released from industrial operations. Dispersion is predominately affected by three main
factors; the topography and characteristics of the land surface, atmospheric stability and inversions, and
wind speed and direction.
Mosul, Iraq is a city on the banks of the Tigris River about 148 km northwest of Kirkuk, and 350 km
northwest of Baghdad. Mosul is situated between the Taurus Mountain Range to its north and the Zagreb
Mountain Range to its east. These mountains generally dampen the overall wind flow in the area
resulting in calm conditions most of the year. When prevailing winds are evident they are generally from
the north northwest year round. These winds are often referred to as Shamals. Shamals result from
strong northwest winds that are funneled into the Persian Gulf by the mountains of Turkey and Iraq to the
northeast and the high plains of Saudi Arabia to the southwest. The winds are generally strongest in the
spring and summer. During the summer months the polar jet stream to the north moves southward and
becomes close to the subtropical jet to the south. The proximity of these two jet streams promotes the
formation of strong fronts which help create the Shamal. Shamals normally last about three to five days
at a time. The result of this strong wind in the desert like region of Mosul is severe dust or sandstorms.
Therefore, contaminants in the sand can become airborne and may result in an inhalation exposure.
To assist with the understanding of wind direction with respect to living areas on the basecamp/forward
operating locations and industrial facilities, burn pits, etc., historical meteorological data that includes
wind speed and wind direction are used to generate a wind rose. The wind rose is a graphical tool that
can be used to provide a succinct view of how wind speed and direction are typically distributed for an
identified timeframe for a particular location. The length of each spoke around the circle is related to the
frequency the wind emanates (i.e., blows from) a particular direction. The color coded spokes show the
wind speed ranges with each color corresponding to an average wind speed range. There is a
meteorological station at the airfield in Mosul (Station # ORBM). Figure D-1 depicts the annual wind rose
for the Mosul Airfield. Mosul has a predominant north northwest wind direction year round based on the
historical data. See Table 1 for meteorological information for Mosul in tabular form (reference 1).
Meteorological data from January 1973 through August 2011 was used in developing the wind rose and
data from January 2004 through July 2012 was used in developing this Table. Since industrial facilities
are scattered throughout Mosul and the airfield is on the southeastern side of Mosul, any release to the
northwest of basecamps/forward operations could result in higher concentrations of contaminants (or
would result in potential exposure to the base camp of the emissions).
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
Table D-1. Monthly Climatological Averages for Mosul, Iraq (reference D-1)
Month
Average
High Degree
Fahrenheit
(°F)
Average
Low (°F)
Average
Precipitation
inches (in)
Prevailing
Wind
Direction
Mean Wind
Speed (KTS)
UNCLASSIFIED
Apr May Jun
Jul
Jan
Feb
Mar
Aug
Sep
Oct
Nov
Dec
55
59
69
79
NA
104
110
109
100
87
69
60
37
41
47
55
NA
77
82
81
72
62
47
39
2.5
2.7
2.4
2.1
0.8
Trace
Trace
Trace
Trace
0.4
1.7
2.4
NN
W
NN
W
NN
W
NN
W
NN
W
NN
W
NN
W
NN
W
NN
W
NN
W
NN
W
NN
W
3.1
3.3
3.7
4.5
5.1
5.6
5.2
5.2
3.9
3.1
2.5
2.5
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
Figure D-1. Annual Wind Rose for Mosul, Iraq (reference 1)
References:
th
D-1. (U) Climate Services, 14 Weather Squadron, Mosul, Iraq,
https://notus2.afccc.af.mil/SCIS/prodloc.asp (accessed 24 March 2014)
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
Appendix E
Poems Factsheet and How to Request a Poems
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
Figure E-1. POEMS Information
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
Figure E-1. POEMS Information
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
Figure E-2. How to Request POEMS
POEMS documents are available by contacting the applicable Service Surveillance Center for most
pertinent documentation [U.S. Army Public Health Command (USAPHC) (800) 222-9698; Navy and
Marine Corps Public Health Center (NMCPHC) Phone: (757)953-0700; U.S. Air Force School of
Aerospace Medicine (USAFSAM) Phone: (888) 232-3764].
ACCESS/AVAILABILITY:
Personnel with deployment-related exposure concerns and their health care providers can request a
POEMS from USAPHC. Service Members can submit a request at the "Request USAPHC
Services" web link at https://usaphcapps.amedd.army.mil/MSRV/ServiceRequest.aspx. Select
"POEMS" from the category list. Providers who are not in the DoD or VA health care systems
should also use this process to request a POEMS. Service Members, Veterans, and DoD and VA
medical staff may get direct access to all of the available POEMS at the Military Exposure
Surveillance Library at https://mesl.apgea.army.mil/mesl/. POEMS are available as they are
produced and currently available for many of the large troop locations in Iraq and Afghanistan. More
recent time periods may not be available but are in the production process.
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
Appendix F
Discussion on Post Deployment Health
Assessment and Reassessment forms
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
Post Deployment Health
Assessment and Reassessment
Reported exposure concerns and potential exposures were identified following a review of all classified
and unclassified information, telephone interviews and review of the Post Deployment Health Assessment
(PDHA) and Reassessment (PDHRA) forms. The PDHA was instituted in April 2003. The PDHRA was
mandated in March 2005. DoD Instruction 6490.03 and Health Affairs Policy 05-011 describe these postdeployment health activities.
One of the purposes for the Post Deployment Health Assessment is to identify occupational and
environmental exposures and to provide a forum for discussion of deployment-related health concerns
with medical providers. The questionnaire could be completed during in-theater medical out-processing
or within 30 days after redeployment. Designed to identify health concerns that emerged over time since
the end of deployment or to capture and address persistent health concerns that Service Members were
reluctant to report immediately following redeployment, the PDHRA should be completed by all Service
Members 90-180 days after deployment.
For the PDHA and PDHRA, we obtained a roster of those individuals associated with the UIC for the 1/24
BN SBCT as described in Section 7.2.4. There were 593 individuals with SSNs on this roster. As noted,
the rosters were not complete and some of the individuals who came forward to be interviewed were not
on the roster of personnel associated with the UIC. Social security numbers for medical data collection
were available only for those who were listed on the roster. However, as a hypothesis generating step, in
addition to interviews, we reviewed the Post-Deployment Health Assessments (PDHA; DD Form 2796)
and the Post-Deployment Health Reassessments (PDHRA, DD Form 2900) of those associated with the
UIC to identify exposure concerns identified when unit members redeployed in 2005 from the deployment
of interest. This was done with the awareness that although the interviewees came from the larger UIC,
they may not be representative of the larger UIC and findings from the UIC may not align with the smaller
group of those interviewed. As stated, there were 593 individuals assigned to this UIC as compared to an
approximate 25 in the platoon, and fourteen individuals interviewed regarding their health and exposure
concerns. This includes two Soldiers’ spouses who were interviewed as proxy although one Soldier was
subsequently interviewed directly and this was combined with his wife’s interview to count as one. The
fifteenth contact was the unit surgeon at the time but he was not queried regarding personal health
issues.
Post-Deployment Health Assessments (PDHAs)
A total of 593 social security numbers were assigned to the UIC. Post-Deployment Health Assessments
(PDHA; DD Form 2796) were obtained from the Armed Forces Health Surveillance Center and reviewed.
For the deployment of interest, Service Members identified the following exposures during deployment as
occurring “sometimes” or “often”:
Table G-1 lists the self-reported exposures in the order found on the questionnaire. The percentage of
individuals who answered “sometimes” or “often” combined, in rank order follows. As might be expected,
the most frequently reported exposure was sand/dust, which is ubiquitous in theatre (89%), followed by
smoke from burning trash or feces (83.5%), loud noises (83.3%), vehicle or truck exhaust fumes (79.1%),
JP-8 or other fuels (69.6%), industrial pollution (39%), excessive vibration (38.9%), smoke from oil fire
(34.5%), radar/microwaves and lasers (16.7%), tent heater smoke (15.4%), paints (14.8%), solvents
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Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
(14.7%), environmental pesticides (14.5%), fog oil (8.3%), “other exposures” (1.3%), ionizing radiation
(1%), and depleted uranium (0.8%)
More than half (313/593, 52.8%) of the questionnaires reviewed had a positive response to the following
item: “Were you in or did you enter or closely inspect any destroyed military vehicles?” When asked, “Do
you think you were exposed to any chemical, biological, or radiological warfare agents during this
deployment?” one Service member (0.2%) responded yes, while 139 (23.4%) responded don’t know.
During the healthcare provider interview section of the PDHA, 18% (104/592) of Service Members said
they had concerns about possible exposures or events during this deployment that they felt may affect
their health.
Table F-1. Identified Post Deployment Health Assessments
Sometimes
Often
n=593
Concern
Count Percent Count Percent
environmental pesticides
69 11.6% 17
2.9%
smoke from oil fire
158 26.6% 47
7.9%
smoke from burning trash or feces 231 39.0% 264 44.5%
vehicle or truck exhaust fumes
182 30.7% 287 48.4%
tent heater smoke
73 12.3% 20
3.4%
JP8 or other fuels
194 32.7% 219 36.9%
fog oils
39
6.6%
10
1.7%
solvents
61 10.3% 26
4.4%
paints
79 13.3%
9
1.5%
ionizing radiation
5
0.8%
1
0.2%
radar/microwaves
70 11.8% 34
5.7%
lasers
70 11.8% 34
5.7%
loud noises
185 31.2% 303 51.1%
excessive vibration
100 16.9% 167 28.2%
industrial pollution
109 18.4% 122 20.6%
sand/dust
53
8.9% 482 81.3%
depleted uranium
5
0.8%
0
0.0%
other exposures
373 0.5%
5
0.8%
Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
Based on the original 593 PDHA’s, a total of 534 (90.1%) Service Members had subsequent PostDeployment Health Reassessments (PDHRA; DD Form 2900). With two missing observations, 77/532 or
15% of individuals replied affirmatively to the question “Do you have any persistent major concerns
regarding the health effects of something you believe you may have been exposed to or encountered
while deployed?” The following specific concerns were identified by Service Members in rank order:
smoke from burning trash or feces (61/534, 11.4%), loud noises (60/534, 11.2%), sand/dust (58/534,
10.9%),vehicle or truck exhaust fumes (49/534, 9.2%), JP8 or other fuels (42/534, 7.9%), smoke from oil
fire (39/534, 7.3%), industrial pollution (39/534, 7.3%), excessive vibration (36/534, 6.7%), solvents
(20/534, 3.7%), lasers (19/534, 3.6%), other (18/534, 3.4%), depleted uranium (13/534,
2.4%),radar/microwaves (14/534, 2.6%), paints (12/534, 2.2%), environmental pesticides (9/534, 1.7%),
tent heater smoke (8/534, 1.5%)fog oils (6/534, 1.1%), and radiation (3/534, 0.6%).After the interview with
the Service member and review of the PDHRA form, healthcare providers indicated a need for further
evaluation and follow-up for identified exposure concerns for 7.8% of the 40/516 who reported persistent
concerns. Twenty-nine Service Members (5.4%) were considered to have a minor concern and 11
Service Members (2.1%) with a major exposure concern. Of the original 77/534 (15%) with persistent
major concerns by self-report, 38 were identified by the provider as having concerns requiring further
evaluation whereas 36 were not; the information was missing on three individuals.
Table F-2. Identified Post Deployment Health Reassessments Exposures
N=593
Concern
Post Deployment Health Reassessments
Count
534
Percent
90.1%
N=534
Positive response
Environmental pesticides
Smoke from oil fire
Smoke from burning trash or feces
Vehicle or truck exhaust fumes
Tent heater smoke
JP8 or other fuels
Fog oils
Solvents
Paints
Ionizing radiation
Radar/microwaves
Lasers
Loud noises
Excessive vibration
Industrial pollution
Sand/dust
Depleted uranium
Other exposures
Minor concern
Major concern
77
9
39
61
49
8
42
6
20
12
3
14
19
60
36
39
58
13
18
29
11
74
15%
1.7%
7.3%
11.4%
9.2%
1.5%
7.9%
1.1%
3.7%
2.2%
0.6%
2.6%
3.6%
11.2%
6.7%
7.3%
10.9%
2.4%
3.4%
5.4%
2.1%
Deployment and Environmental Health Surveillance Investigation of 1/24 BN SBCT Mosul, Iraq 20042005, December 2014
The PDHA was modelled after exposure concerns from the first Gulf War (for example, oil well fire
exposure and pesticides/repellents such as DEET and permethrin) and so some of the exposure
concerns are less relevant to OIF/OEF/OND. Questionnaire responses in this population indicate that
while the percentage of some self-reported exposure concerns increased (DU and other exposures); the
relative rank orders did not change substantially. Concerns regarding most exposures decreased or
remained stable over time (environmental pesticides, smoke from oil fire, smoke from burning trash or
feces, vehicle or truck exhaust fumes, tent heater smoke, JP8 or other fuels, fog oils, solvents, paints,
radiation, radar/microwaves, lasers, loud noises, excessive vibration, industrial pollution, and sand/dust).
Responses indicate that the percentage of Service Members with exposure concerns also decreased
slightly between the completion of the PDHA and the completion of the PDHRA in this population (17.5%
on PDHA versus 14.5% on PDHRA respectively). The observed decrease in exposure concerns is not
typical of what has been previously reported.
Burning oil wells were a visible hazard during the first Gulf War; however, there has been little discussion
of burning oil wells in this conflict. Nearly a third of re-deployers in this unit reported this exposure on the
PDHA which was reduced to about 7% at the time of the PDHRA, although the relative rank of this
concern did not change. Interestingly, although not mentioned in the interviews, there was a report of an
oil storage tank which caught on fire in 2004 47 km southwest of FOB Marez, which might have been
mistakenly reported. There is no other information about duration of fire or potentially exposed population,
if any. There has not been much indication of the use of fog oil, yet it is cited as a concern initially by
8.3% which had decreased to 1.1% by the PDHRA. Additionally, some exposures became common in the
latter conflicts, such as the use of IEDs/VBIEDs/SBIEDs which are not listed on the PDHAs.
The forms changed in 2012 so that individuals no longer check from a “pick list” of exposures as above.
At present, the form asks if the individual has an exposure of concern, if they think that they were
exposed to a chemical, biological or radiological during the deployment, and if they think that they had an
exposure to DU. The provider follows up during the interview and checks off the “pick list” which is
essentially the same as the one individuals completed on the earlier version. Chlorine gas is added, as
are chemical, biological and radiation exposures. There is a section marked “other toxic chemicals that
the provider must fill in that lists ammonia and nitric acid as the example. At the end of this exposure
section, with respect to whatever exposures have been checked, the provider must indicate the need for
referral. If “no” is marked, the provider is instructed to provide risk communication, and choose the
reason for non-referral. These include already under care, already has referral, no significant impairment,
and other, which must be explained. The DU portion requires the provider to assess the need for referral
for urinalysis.
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(U) Appendix G
Health Effects Associated with Chlorine Exposure
and
Chlorine IEDS and Preventive Medicine Actions
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Health Effects Associated with Exposure to Chlorine Gas
While no quantitative measurements are available regarding chlorine, potential exposure to chlorine has
been reported in association with IEDs. From the OEHS data searches, no information was found on
insurgents using chlorine IED’s in Mosul during the 1/24BN SBCT deployment timeframe. The use of
Chlorine IED’s by insurgents was confirmed and documented by DoD from 2006 onwards. It may have
been used prior to 2006, but not confirmed and documented. One interviewee remembers many IEDs
having chemicals such as fertilizers or chlorine that made it hard for the Soldiers to breath.
According to the Centers for Disease Control and Prevention (CDC) chlorine is one of the most common
chemicals manufactured in the United States (reference G-1). Chlorine gas can be pressurized and
cooled to change it into a liquid so that it can be shipped and stored. When liquid chlorine is released, it
quickly turns into a gas and because of its density it stays close to the ground and can spread rapidly. It
can be recognized by its pungent, irritating odor, which is like the odor of bleach. Chlorine can react
explosively or form explosive compounds with chemicals such as turpentine and ammonia. Chlorine is
used in a variety of everyday products and processes, including paper manufacturing, swimming pool
treatments, household/industrial/healthcare cleaning operations and pesticide manufacturing.
Chlorine gas can be detected by humans at airborne concentration below those believed to be toxic. The
detection limit for chlorine gas odor ranges from 0.1-0.3 ppm. At 1-3 ppm there is mild mucous
membrane irritation which can usually be tolerated for about an hour. Moderate mucous membrane
irritation occurs at 5-15 ppm. Exposure to levels of 30 ppm and above will cause immediate substernal
chest pain, shortness of breath and cough. Exposures to 40-60 ppm are associated with the development
of toxic pneumonitis and/or pulmonary edema (reference G-2). Thus, individuals with an exposure of a
magnitude to cause long term health effects are likely to be aware of the exposure at the time of its
occurrence.
People can be exposed via inhalation of chlorine gas, ingestion of food contaminated with chlorine liquid
and dermal/mucous membrane exposure to chlorine gas, liquid chlorine or water containing chlorine.
When chlorine gas comes into contact with moist tissues such as the eyes, throat, and lungs, an acid is
produced that can damage these tissues (reference G-1).
Signs and symptoms of exposure to dangerous levels of chlorine include the immediate development of:
blurred vision; burning pain, redness, and blisters on the skin if exposed to gas; burning sensation in the
nose, throat, and eyes; cough; chest tightness; nausea and vomiting; watery eyes; and wheezing.
Difficulty breathing, shortness of breath and pulmonary edema (fluid accumulation in the lungs) may
appear immediately with high levels of exposure or they may be delayed several hours if the exposure
level is lower. The vast majority of exposures to chlorine, both gas and liquid, do not cause any adverse
health effects. Long term complications are much more likely to occur if there are significant immediate
symptoms, such as pulmonary edema (reference G-1).
Many studies have shown that pulmonary effects after an acute exposure to chlorine disappear after a
few weeks; however there are reports that have documented longer term effects, such as asthmatic
reactions, bronchial hyper-responsiveness, and reduced lung function (references G-2-8). Those longterm, persistent effects may be obstructive or restrictive pulmonary deficits or increased nonspecific
airway reactivity (references G-3,5). There is also some evidence that longer term hyper-responsiveness
is more common in older individuals, smokers and those with pre-existing lung problems (references G2,5). No reports were located of long-term sequelae in individuals that had asymptomatic or minimally
symptomatic exposures, and many authors acknowledge the unlikelihood of this occurring (references G-
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2-9). Therefore, in the absence of any members of the 1/24BN SBCT reporting acute chlorine exposure
symptoms, they should anticipate no problems from this exposure nine years or more after leaving Mosul.
References:
G-1. Centers for Disease Control and Prevention. Emergency Preparedness and Response. Facts about
Chlorine. Accessed at: http://www.bt.cdc.gov/agent/chlorine/basics/facts.asp
G-2. White CW, Martin JG. Chlorine Gas Inhalation: Human clinical evidence of toxicity and experience
in animal models. Proc Am Thor Soc 2010; July 1; 7(4):257-263
G-3. Deployment Health and Family Readiness Library. Chlorine gas exposure for Service Members.
http://deploymenthealthlibrary.fhp.osd.mil/Product/RetrieveFile?prodId=300
G-4. Hasan FM, Gehshan A, Fuleihan FJ. Resolution of pulmonary dysfunction following acute chlorine
exposure. Arch Environ Health 1983; 38:76–80.
G-5. .Das R1, Blanc PD. Chlorine gas exposure and the lung: a review. Toxicol Ind Health. 1993 MayJun;9(3):439-55.
G-6. Abhyankar A, Bhambure N, Kamath NN, et al. Six month follow up of 14 victims with short term
exposure to chlorine gas. J Soc Occup 1989; Med 39:131–132.
G-7. Leroyer C, Malo JL, Infante-Rivard C, et al. Changes in airway function and bronchial
responsiveness after acute occupational exposure to chlorine leading to treatment in a first aid unit.
Occup Environ Med 1998; 55:356–359.
G-8. Agabitia N, Anconaa C, Forastierea F, et al. Short term respiratory effects of acute exposure to
chlorine due to a swimming pool accident. Occup Environ Med 2001;58:399-404
G-9. Michigan Department of Community Health. Chlorine – Public Fact Sheet. Accessed at:
http://www.michigan.gov/documents/Chlorine_factsheet_82357_7.pdf
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Figure G-1. Chlorine IEDs and Preventive Medicine Actions Fact Sheet
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Figure G-1. Chlorine IEDs and Preventive Medicine Actions Fact Sheet (2007)
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Appendix H
Burn Pit Fact Sheets
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Figure H-1. Frequently Asked Questions, Burn Pit Exposure
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Figure H-1. Frequently Asked Questions, Burn Pit Exposure
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Appendix I
OTSG MEDOCM Policy 14-021
Medical Management of Army Personnel Exposed to DU
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Appendix J
Additional information on DU
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Figure J-1. ATSDR Natural and Depleted Uranium
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Figure J-1. ATSDR Natural and Depleted Uranium
115
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Figure J-2. Urine Testing Depleted Uranium
116
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Figure J-2. Urine Testing Depleted Uranium
117
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Figure J-3. Depleted Uranium-Individual
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Figure J-3. Depleted Uranium-Individual
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Figure J-4. Depleted Uranium-Medical
120
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Figure J-4. Depleted Uranium-Medical
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Long-Term Health Effects Associated in Service Members with
Level I DU Exposure
Health effects of depleted uranium are typically related to chemical (heavy metal) toxicity rather than
any radiological effects. Most information about the known health effects of DU exposures are
derived from studies of natural uranium exposure on miners and millers who have chronic
exposures, more intense exposures; longer duration of exposures; and have additional exposures to
radon & other potentially toxic substances.
Exposure to depleted uranium can occur by external exposure or internal (inhalation, ingestion, and
breaks in the skin) exposure. External exposures are usually not a significant risk, because DU is an
alpha particle emitter. Alpha particles travel a short distance in air (a few centimeters) and have poor
penetration into any nearby materials. Clothing and intact skin, even a sheet of paper, provide
adequate protection from DU and any residual DU can be washed off.
Inhalation of any DU dust and fumes can cause irritation to the lungs, but long term health effects are
not expected from an acute exposure. Most inhaled or ingested uranium in not absorbed
systemically and is cleared from the body. There can be some systemic absorption of DU from an
acute exposure. However, there is no evidence of any health effects from this type of internal
exposure, including effects on the kidneys (the organ most sensitive to DU), which tends to be the
target organ for heavy metals. DU may also be found in the liver and the bones. According to the
Agency for Toxic Substances and Disease Registry, “No health effects, other than kidney damage,
have been consistently found in humans after inhaling or ingesting uranium compounds or in soldiers
with uranium metal fragments in their bodies.” Some human and animal studies of cancer effects of
uranium (which is more radioactive) have demonstrated increases in lung cancer. The human
studies involved uranium miners whose long-term exposures differ substantially from military
exposure to depleted uranium, and in addition, these studies have some methodological problems.
These studies have not found increases in kidney or bone cancer.
The Depleted Uranium Follow-Up Program is an ongoing clinical surveillance program started in1993
at the Baltimore VA Medical Center. It began with 33 Soldiers with retained DU who were involved in
DU friendly fire incidents. As of 2009, 79 cases have been evaluated from Gulf War I and 4 cases
have been evaluated from Operation Iraqi Freedom. In 1998, the urine uranium testing portion was
added. As expected, Soldiers with retained DU fragments have higher urine uranium levels than
average. Some Soldiers with injuries or retained fragments have symptoms related to those injuries
and the physical presence of a fragment. These Veterans have been being followed for 18 years
with thorough medical evaluations every two years. Otherwise, there is no difference in health
measures when compared to non-exposed GW Veterans.
Out of an additional 3246 Veterans who had a 24 urine collection tested for uranium under the DU
screening program, four were identified as having an elevated amount of urine Uranium and all four
were involved in friendly fire incidents and/or have DU shrapnel. These are the two groups
considered to have had a high level of exposure, i.e., level I, and thus far, there are no specific
adverse health effects reported in these Veterans. No renal abnormalities have been consistently
seen; no evidence indicating that DU is genotoxic, mutagenic, or that it has reproductive effects.
Additionally, based on questionnaire data, there have been no birth defects noted in over 80 children
born to Gulf War veterans in DU Follow-up Program (including those with retained fragments).
The article discussing long-term follow-up may be found at:
(http://www.publichealth.va.gov/exposures/depleted_uranium/followup_program.asp
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Appendix K
Particulate Matter
Fact Sheet
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Figure K-1. PM Air Pollution Exposure During Military Deployment
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Figure K-1. PM Air Pollution Exposure During Military Deployment
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Appendix L
Handling of Human Remains Fact Sheet
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Figure L-1. Handling of Human Remains from Natural Disasters
127
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Figure L-1. Handling of Human Remains from Natural Disasters
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Appendix M
Infectious Diseases Presumptively Associated with Deployment
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Figure M-1. Presumptive Disability for Nine Infectious Diseases Related to
Military Service in Southwest Asia
130
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Figure M-1. Presumptive Disability for Nine Infectious Diseases Related to
Military Service in Southwest Asia
131
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Figure M-2. Presumptive Disability for Nine Infectious Diseases Related to
Military Service in Southwest Asia
132
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Figure M-2. Presumptive Disability for Nine Infectious Diseases Related to
Military Service in Southwest Asia
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Appendix N
Health Effects Associated with Exposure to Ammonia
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Health Effects Associated with Exposure to Ammonia
Ammonia, either as a gas or as a liquid, when concentrated (usually greater than 50%), can be
immediately corrosive to tissues upon contact. High enough levels of exposure to ammonia in sufficient
quantities can be fatal. Ammonia is another of the most common chemicals manufactured in the U.S.
Concentrated ammonia is used in manufacturing, refrigeration, and agriculture (as a fertilizer).
Household ammonia is much less concentrated (approximately 5-10% or less); it rarely causes burns, but
it does cause irritation. The lowest level at which humans can detect the odor of ammonia (odor
threshold) generally provides sufficient warning of exposure; however, persons with prolonged exposure
to ammonia will lose their ability to detect the odor (olfactory fatigue) (reference N-1,2).
Ammonia exists naturally in humans and in the environment. It is essential for many biological processes
and serves as a precursor for amino acid and nucleotide synthesis. In the environment, ammonia is part
of the nitrogen cycle and is produced in soil from bacterial processes. Ammonia is also produced
naturally from decomposition of organic matter, including plants, animals and animal wastes. Ammonia is
used in industry and commerce, as well as many household uses (references N-1,2).
Human exposure to ammonia is usually via inhalation of gas or vapor or dermal/mucous membrane
exposure. The distinctive odor and taste of ammonia renders ingestion an uncommon route of exposure.
It is irritating to the eyes and causes severe caustic injuries and spasmodic blinking, thus absorption
through the eyes is very limited. Ammonia can be introduced into the air, indoor or outdoor, as a liquid
spray (aerosol) or as a vapor. It can contaminate water and as a liquid has the potential to contaminate
agricultural products.
Unlike chlorine gas, ammonia gas is lighter than air and therefore when released it will dissipate quickly.
However, when released into humid air the anhydrous ammonia will form ammonia vapor which is heavier
and will settle and spread along the ground and into low lying areas (reference N-2).
When ammonia comes into contact with moisture in the skin and mucous membranes it immediately
reacts and forms the very caustic ammonium hydroxide. Ammonium hydroxide causes the necrosis of
tissues through disruption of cell membrane lipids leading to cell death. As cells break down, an
inflammatory response is initiated that causes further damage. Due to this immediate reaction, exposure
to high concentrations of ammonia in air causes immediate burning of the nose, throat and respiratory
tract, which may result in bronchiolar and alveolar edema, and airway destruction, further resulting in
respiratory distress or failure. Cough and nose, mouth and throat irritation may result from inhalation of
lower concentrations. Exposure to low concentrations of ammonia in air or solution may produce rapid
skin or eye irritation. Higher concentrations of ammonia may cause severe injury and burns. Contact
with concentrated ammonia solutions such as industrial cleaners may cause corrosive injury including
skin burns, permanent eye damage or blindness, with the full extent of eye injuries sometimes not
apparent for up to a week after the exposure. Swallowing high concentrations of ammonia solution does
not generally cause systemic poisoning, but will result in corrosive damage to the upper GI track
(reference N-2).
In an inhalation scenario, most of the ammonia inhaled will be exhaled unchanged. The ammonia that is
retained from inhalation, as well as most ammonia that is ingested, forms non-toxic substances, such as
ammonium compounds, which are then carried throughout the body in seconds. The rest of the ingested
ammonia leaves the body in urine within a couple of days. Ammonia causes its effect on the body
surfaces that it directly contacts, and is not known to cause remote effects (reference N-3). Long term
damage may be seen after initial corrosive injury. No reports were identified in the literature that
described long term effects in the absence of initial immediate corrosive damage. Therefore, in the
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absence of any members of the 1/24BN SBCT reporting acute ammonia exposure symptoms, they
should anticipate no problems from this exposure nine years or more after leaving Mosul.
References
N-1. Ammonia Solution (UN 3318); Ammonia Anhydrous (UN 1005): Lung Damaging Agent. Accessed at
http://www.cdc.gov/niosh/ershdb/EmergencyResponseCard_29750013.html:
N-2. New York State Department of Health. The Facts About Ammonia. Technical Information. Accessed
at: https://www.health.ny.gov/environmental/emergency/chemical_terrorism/ammonia Tech.htm
N-3. Agency for Toxic Substances and Disease Registry (ATSDR). 2004. Toxicological profile for
Ammonia. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service.
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Appendix O
Assessment of Health Outcomes
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This appendix discusses, in greater detail, some of the health conditions and concerns discussed
in Section 10, regarding relationship between known environmental exposures and specific health
conditions, including specific malignancies.
Follicular Lymphoma
There was one reported case of follicular lymphoma (FL), which is a common form of nonHodgkin’s lymphoma (NHL). The American Cancer Society reports that approximately 20% of NHL
cases are FL (reference O-1). It is rare in young individuals and the average age at diagnosis is 60.
About one third of cases of FL turn into fast growing diffuse B-Cell lymphomas. NHL accounts for
about 4% of all cancer cases diagnosed in the US. Just over 14,000 cases of FL are anticipated to
be diagnosed in the US in 2014. Approximately 1 in 50 Americans will develop NHL during their
lifetime, thus the risk of developing FL is about 1 in 250 people.
Known and suspected risk factors for NHL include age, gender, and race among others. The risk
for most types of NHL increases with increasing age. NHL occurs more commonly in males than in
females, more often in Caucasians and there are higher rates in developed countries, with the US
and Europe having the highest rates. There is an association with prior treatment for cancer, yet it
is still not clear if the development of NHL in survivors of Hodgkin’s lymphoma is because of the
treatment or a function of the Hodgkin’s lymphoma itself. Other risk factors include radiation
exposure, immune deficiency (whether disease induced, e.g., AIDS and genetic immune system
disorders, or treatment induced, e.g., immuno-suppression post organ transplant) and autoimmune
disease such as rheumatoid arthritis and systemic lupus erythematosis. Additional risk factors
include certain infections, elevated body mass index, and diet, with some studies showing a link
between high fat and high red meat diets (references O-1, 2).
Much has been studied and written about whether there is a relationship between exposure to
various solvents and/or pesticides and an increased risk of NHL or FL. The medical and scientific
literature is still highly unclear about this question with conflicting studies. The US Environmental
Protection Agency reports a likely relationship between Trichloroethylene (TCE) and NHL and
Perchloroethylene (PERC) and NHL, but not with Benzene (BZ) and NHL (references O-3,4,5). A
2002 study, (reference O-6), demonstrated an increased risk of leukemia and multiple myeloma in
BZ exposed workers, but not an increase in NHL. A study published in 2007(reference P-7) found a
barely statistically significant (95% CI of 1.0-4.8) relationship between high level of exposure to
TCE and NHL. These researchers also did not find a relationship between BZ and NHL.
Many authors speak of increased risk of NHL in immunosuppressed individuals (references O-8,9)
and of the increased incidence of NHL in the US over the past several decades (references O9,10). Despite a large number of studies looking into this increase and its causes, few consistent
relationships with exposures have been identified. Bassig and his colleagues at the National
Cancer Institute state “Specifically, positive associations with NHL have been reported for the use
of hair dye before 1980, diets high in fat and some dairy products, higher BMI, smoking for FL, as
well as exposure to certain solvents and chemicals. However, the inconsistency in some of these
associations across studies precludes their consideration as established NHL risk factors, and the
associated risk estimates have generally been only marginally elevated”(reference O-9). A recent
large study (reference O-11) found no increased risk of NHL after either any exposure or
substantial exposure to either of two chemical families or any of six chlorinated solvents.
A study in Italy (reference O-12), found that subjects with a medium or high level of exposure to
benzene, toluene and xylene, either individually or combined, had statistically significant increased
risks of developing NHL. Cocco, et al, (reference O-13) found that three independent metrics of
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exposure to benzene, toluene and xylene combined and to styrene alone increased the risk of FL.
An Australian study (reference O-14) found a statistically significant increased risk of FL in subjects
with substantial exposure to any pesticide, organophosphate pesticides, and other (non-Phenoxy)
herbicides, but not in subjects exposed to organochlorine pesticides, phenoxy herbicides or other
pesticides. A study in Sweden (reference O-15) found no statistically increased risk of FL in
subjects exposed to a variety of herbicides, either alone or excluding some, no increased risk of FL
in subjects exposed to any of several fungicides and rodenticides, but did find increases in those
exposed to DDT or mercurial seed dressings.
Therefore it is not clear whether and which solvents can cause or increase the risk of developing
NHL and/or FL. What does seem clear is that if there is such a relationship it is only after significant
exposure to the solvent over a prolonged period of time and not causal, infrequent, short time, or
minimal exposure. The existence of a relationship between pesticide exposure and the risk of
developing NHL or FL, is also still unclear, with studies available that identify such a link and
studies that fail to find a positive relationship. As best as can be determined, the members of the
1/24 BN SBCT were not subject to any exposures in Iraq that would increase their risk of
developing FL.
Acute Lymphoblastic Leukemia
Leukemia is a cancer of the white blood cells. There are several different types of white blood cells
and therefore there are several different types of leukemia. In all types the cells look abnormal and
behave abnormally. When cancer develops in lymphocytes it is called lymphocytic leukemia and
when it develops in monocytes or granulocytes it is called myelocytic or myelogenous leukemia.
Leukemias are also classified by whether they are acute, in which the immature, abnormal cells,
called blasts, remain not fully developed and their number increases rapidly and the acute leukemia
progresses rapidly. In chronic leukemias most of the cells develop further and can perform some of
the function of normal cells. While there are still some blasts present, the overall number of cells
increases much more slowly and as a result the disease progresses less rapidly.
Based on the type of white blood cell seen under the microscope leukemias are classified into four
main categories: acute lymphocytic leukemia (ALL); acute myelogenous leukemia (AML); chronic
lymphocytic leukemia (CLL) and chronic myelogenous leukemia (CML). Each of these types has
different epidemiologic and etiologic profiles and they each require very different treatment
regimens. Although they are all leukemia they are very clearly not the same disease.
Acute Lymphoblastic Leukemia (ALL), also referred to as Acute Lymphocytic Leukemia, is a cancer
that originates in the lymphocytes, usually arising in the bone marrow. The American Cancer
Society reports that only approximately about one third of cases of ALL occur in adults, but three
quarters of the deaths from ALL are in adults (reference O-16). Children under the age of 5 are at
the highest risk of developing ALL. The risk then declines until the third decade of life, stays fairly
stable, and then slowly increases after the age of 50. The lifetime risk of developing ALL is about 1
in 750 people.
Known and suspected risk factors for ALL include: Radiation exposure; certain viral infections, e.g.
human T-cell lymphoma virus -Type 1 (HTLV-1) and Epstein-Barr Virus (EBV); certain inherited
conditions, e.g., Down syndrome, Klinefelter syndrome, Neurofibromatosis, and others;
race/ethnicity - ALL is more common in Caucasians than in African Americans; gender - ALL is
slightly more common in males than in females; and having an identical twin with ALL - if one twin
develops ALL within the first year of life the other twin is at increased risk of developing the disease
as well.
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While there are some studies that have shown a link between exposure to benzene and both nonHodgkins lymphoma and multiple myeloma, those that have specifically looked at ALL and benzene
exposure have failed to find a correlation (references O-17,18,19). The medical and scientific
literature supports a positive relationship between trichloroethylene (TCE) and perchloroethylene
(PERC) with the development of non-Hodgkin’s lymphoma, but once again, neither of these has
been shown to be associated with an increased risk of ALL.
Therefore, as best as can be determined, the 1/24 BN SBCT were not subject to any exposures in
Iraq that would increase their risk of developing ALL.
Biliary Carcinoma or Bile Duct Cancer
Biliary Carcinoma or Bile Duct Cancer (BDC) includes cancer of the bile ducts within the liver
(approximately 10%) and outside the liver (reference 7). The American Cancer Society estimates
that about 2,000-3,000 people will be diagnosed with BDC in 2014. The average age at diagnosis is
in the seventies. Almost 65% of people are over the age of 65 when diagnosed (reference O-20).
Known and suspected risk factors for BDC include:
Certain diseases of the liver or bile ducts - people with chronic inflammation of the bile duct
have an increased risk of developing BDC, examples include primary sclerosing cholangitis,
bile duct stones, liver fluke infections, cirrhosis, and others;
Inflammatory bowel disease - including both ulcerative colitis and Crohn’s disease;
Age - the risk of being diagnosed with BDC goes up with age;
Obesity - the risk of developing BDC (and gallbladder cancer) is elevated in overweight and
obese individuals;
Exposure to Thorotrast - this is a radioactive substance that was used as a contrast agent for xrays until the 1950s;
Family history;
Diabetes;
Viral hepatitis - both hepatitis B virus and hepatitis C virus infections increase the risk of intrahepatic BDC; and
Alcohol - heavy drinkers are at increased risk of developing intra-hepatic BDC (reference O-20).
A study in Japan found that individuals with bile duct cancer had a history of exposure to
dichloropropane (for 7-17 years) and dichloromethane (for 1-13 years) 7-20 years prior to being
diagnosed, while working in a printing company (reference O-21). There were many more cases of
cholangiocarcinoma than expected in the workforce as a whole. However, the Institute of Medicine
conducted an extensive review of the literature which looked at insecticide and solvent exposure
and an increased risk of cancer (reference O-22). This review committee was unable to locate a
single study that identified a statistically significant link between insecticide exposure and an
increased risk of developing BDC or between solvent exposure and an increased risk of developing
BDC. Therefore, as best as can be determined, the 1/24 BN SBCT were not subject to any
exposures in Iraq that would increase their risk of developing biliary cancer or bile duct cancer.
Asthma
Asthma is a chronic lung disease characterized by inflammation and narrowing of the airways, and
by intermittent spasms of the airways. Asthma can affect people of all ages, but most often begins
in childhood. More than 25 million people in the United States have asthma, more than a quarter of
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these are children (reference O-23). When the airways are inflamed they are swollen and tend to
be extremely sensitive to a variety of inhaled substances which can then trigger spasms of the
muscles surrounding the airways, called bronchospasm.
Scientists are not sure what causes asthma, but most believe that it involves an interaction between
genetic and environmental factors. These factors may include: an inherited tendency to develop
allergies; a family history of asthma; certain respiratory infections during childhood; and contact with
some airborne allergens or exposure to some viral infections in infancy or in early childhood, when
the immune system was still immature (reference O-24). Individuals with a predisposition to
develop asthma are often more sensitive to non-specific airborne irritants.
Many things can serve as triggers which can initiate an episode (attack) of bronchospasm and
inflammation. Some common triggers include:
•
•
•
•
•
•
Allergens from dust, animal fur, cockroaches, mold, and pollens from trees, grasses, and
flowers;
Irritants such as cigarette smoke, air pollution, chemicals or dust in the workplace,
compounds in home décor products, and sprays (such as hairspray);
Medicines such as aspirin or other nonsteroidal anti-inflammatory drugs and nonselective
beta-blockers;
Sulfites in foods and drinks;
Viral upper respiratory infections, such as colds;
Physical activity, including exercise (reference O-24)
Occupational asthma (OA) is asthma caused by inhalation exposure to certain gases, fumes, dusts,
and other substances while at work. Hydrochloric acid, sulfur dioxide and ammonia are three
examples of irritants which may be found in the workplace and which are known to cause OA when
people are exposed to high doses (reference O-25). There are other substances, such as
isocyanates, which are known to cause OA in people after even extremely low level of exposures.
OA may occur in individuals with no previous history of asthma. If workplace irritants worsen
already existing asthma it is referred to as work-exacerbated asthma. Symptoms of OA are
frequently worse during work and get better between shifts, on weekends and during vacations. As
many as 11% of spray painters exposed to diisocyanate-based paints have bronchial hyperreactivity. Approximately 5% of workers in the lumber industry exposed to western red cedar dust
developed asthma. As many as 2.5% of all workers exposed to natural rubber latex and up to 20%
of bakers or warehouse workers exposed to flour have been reported to have occupational asthma.
In addition, farmers, painters, and cleaners have been reported to have the greatest risk for
developing occupational asthma (reference O-25). The U.S. Occupational Safety and Health
Administration (OSHA) estimates that 11 million workers in the United States are occupationally
exposed to at least one substance known to be associated with OA (reference O-26). OSHA
further estimates that up to 15 percent of cases of disabling asthma in the US are associated with
occupational factors.
Various researchers have studied the relationship between deployment and respiratory symptoms
and respiratory conditions. In 2009, Smith, et al, reported that deployers had a higher rate of newly
reported respiratory symptoms, relative to non-deployers (14% vs. 10%), while observing similar
rates of diagnosed chronic bronchitis or emphysema (1% vs. 1%) and asthma (1% vs. 1%)
(reference O-27). In their survey-based study of Millennium Cohort Study participants, the authors
found that deployment length was significantly associated with increased respiratory symptom
reporting among Army personnel.
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In October 2010, Szema and his colleagues reported on an increased incidence rate of new onset
asthma in US Service Members deployed to Iraq versus those not deployed (6.6% versus 4.3%;
with a crude odds ratio, 1.58; 95% CI, 1.18, 2.11) (reference O-28). They go on to state that
"Deployment to Iraq and Afghanistan is associated with new-onset asthma." In September 2011,
Szema, et al. reported that Veterans at their VA Medical Center, on Long Island, NY, that had
deployed in support of OEF and/or OIF had higher rates of pulmonary symptoms and of spirometry
testing than Service Members deployed elsewhere (reference O-29). When tested, the ratio of
forced expired volume in 1 second/forced vital capacity was similar in both groups of Veterans. The
authors introduce the term “Iraq/Afghanistan war lung injury (IAW-LI) to describe pulmonary
complaints related to exposures which occurred in South West Asia during the current and recent
wars.
A Letter to the Editor regarding the latter article raised some interesting and valid points about the
paper's findings, not the least of which is, that Veterans Administration hospital clinicians, being
sensitized to the fact that Veterans returning from deployment to OEF and OIF were having
increased respiratory complaints and were therefore likely to have a lower threshold to request
additional tests, including spirometry (reference O-30).
A paper published in October 2011, reviewed the extant studies conducted by the US military and
the planned research efforts of the military to investigate the possibility of deployment related
pulmonary disease (reference O-31). The authors conclude that there is an increase in respiratory
symptoms post deployment, but not clinical diagnoses and that although there is some evidence of
a higher rate of new-onset asthma in deployed versus non-deployed military personnel there is no
data that deployment is a definitive cause of new-onset asthma.
In the June 2012 issue of the Journal of Occupational and Environmental Medicine (JOEM), an
issue dedicated to Health Effects of Deployment to Afghanistan and Iraq, Smith and her colleagues
reported on respiratory symptoms and respiratory illness among Millennium Cohort participants
who deployed to Iraq or Afghanistan (reference O-32). The authors looked at newly reported
chronic bronchitis or emphysema, newly reported asthma, and self-reported respiratory symptoms
and possible burn pit exposure within 2, 3, or 5 miles, among Army and Air Force deployers
surveyed in 2004 to 2006 and 2007 to 2008 (n = 22,844). Burn pit exposure within 3 or 5 miles was
not associated with respiratory outcomes after statistical adjustment. Increased symptom reporting
was observed among Air Force deployers located within 2 miles of Joint Base Balad; however, this
finding was marginally significant with no evidence of trend. In general, these findings do not
support an elevated risk for respiratory outcomes among personnel deployed within proximity of
documented burn pits in Iraq.
In the same issue of JOEM, Abraham and his colleagues reported on an assessment of pre- and
post-deployment rates of medical encounters for obstructive pulmonary disease among a group of
Active Duty military personnel who had been deployed to OEF/OIF (reference O-33). Overall, the
rate of respiratory system encounters decreased after deployment, a finding driven largely by a
statistically significant drop in acute respiratory infections. The vast majority of obstructive
pulmonary disease encounters were either for asthma (46%) or bronchitis (50%). They reported
statistically significant increases in the encounter rates for obstructive respiratory diseases from the
pre- to post-deployment periods for single deployers, but not multiple deployers. The same group
published a study demonstrating that respiratory symptoms and new-onset asthma are increased in
those who deployed versus those who were deployment eligible but had not yet deployed
(reference O-34). This finding was demonstrated in cohorts at all four locations studied- two with
and two without burn pits.
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In summary, there has been a documented increase in symptoms of obstructive pulmonary disease
post deployment, and this disease category includes asthma, following deployment to Iraq and/or
Afghanistan.
Panic Disorder
Anxiety attacks, also known as panic attacks, are part of a condition called Panic Disorder, which
affects approximately one out of every 75 people (reference O-35). Anxiety attacks often first occur
during the teens or early adulthood. Frequently there is a connection with major stressful life
experiences. There is also some evidence for a genetic predisposition. The primary difference
between panic attacks and appropriate response to a stimulus, such as an enemy attack, is that
the former occur suddenly in seemingly harmless situations and can even occur while sleeping
(reference O-35).
A purported relationship between chemical exposure and panic disorder was prevalent in various
groups in the late 1980's and early 1990's, often as part of the multiple chemical sensitivities (MCS)
episode. One such group was a cohort 53 aircraft manufacturing facility composite-materials
workers who had filed claims for illness labeled by the media as the "aerospace syndrome'
(reference O-36). The investigators acknowledged that they could not "absolutely exclude" that the
outbreak of anxiety in these workers was due to some as yet unknown neurotoxic effect of mixed
chemicals at very low levels of exposure, they nevertheless felt that this explanation "seems
unlikely." Idiopathic Environmental Intolerance (IEI), another term for MCS was claimed to be a
cause of panic disorder, however Binkley, et al, showed in their small sample that there was a
neurogenetic commonality between the two indicating that IEI was not causative (reference O-37)
However, most investigators came to the conclusion that MCS was not causative for panic
disorder.
There was a published report in 1987 of three workers who had idiosyncratic panic attack reactions
to solvent exposures (reference O-38). However, no additional such reports were located in the
published literature and all three had their initial attack during exposure. Therefore, in the absence
of a member of the 1/24 BN SCBT who had a panic attack during exposure to solvent while
deployed, and whose attacks have continued ever since, it is unlikely that solvent induced panic
attacks will occur to members of the brigade. Panic attacks precipitated by memories or fears of
occurrences from Iraq are beyond the scope of this discussion.
References
O-1. American Cancer Society. Non-Hodgkin Lymphoma. What is non-Hodgkin lymphoma?
Topics. http://www.cancer.org/cancer/non-hodgkin lymphoma/detailedguide/non-hodgkinlymphoma-types-of-non-hodgkin-lymphoma
O-2. Ambinder AJ, Shenoy JP, Malik N, et al. Review Article - Exploring Risk Factors for
Follicular Lymphoma. Advances in Hematology 2012, Volume 2012, Article ID 626035, 13 pages
O-3. US Environmental Protection Agency Integrated Risk Information System Tetrachloroethylene (Perchloroethylene) - http://www.epa.gov/IRIS/subst/0106.htm
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O-4. US Environmental Protection Agency Integrated Risk Information System Trichloroethylene - http://www.epa.gov/iris/subst/0199.htm
O-5. US Environmental Protection Agency Integrated Risk Information System - Benzene http://www.epa.gov/iris/subst/0276.htm
O-6. Rinsky RA, Hornung RW, Silver SR, et al. Benzene exposure and hematopoietic mortality:
A long-term epidemiologic risk assessment. Am J Ind Med 2002. 42(6):474-480.
O-7. Seidler A, Matthias Möhner1, Jürgen Berger, et al. Solvent exposure and malignant
lymphoma: a population-based case-control study in Germany. Journal of Occupational Medicine
and Toxicology 2007, 2:2
O-8. Müller AMS, Ihorst G, Mertelsmann R. Epidemiology of non-Hodgkin’s lymphoma (NHL):
trends, geographic distribution, and etiology. Annals of Hematology. January 2005; 84(1):1-12
O-9. Bassig BA, Lan Q, Rothman N, et al. Current Understanding of Lifestyle and Environmental
Factors and Risk of Non-Hodgkin Lymphoma: An Epidemiological Update. J Cancer Epidemiol.
2012; 2012: 978930. Published online 2012 September 12.
O-10. Clarke CA, Glaser SL. Changing incidence of non-Hodgkin lymphomas in the United
States. Cancer. 2002; 94(7);2015–2023.
O-11. Christensen KY, Vizcaya D, Richardson H, et al. Risk of selected cancers due to
occupational exposure to chlorinated solvents in a case-control study in Montreal. J Occup
Environ Med. 2013 Feb;55(2):198-208.
O-12. Miligi L, Costantini AS, Benvenuti A. Occupational Exposure to Solvents and the Risk of
Lymphomas. Epidemiology. 2006 Sep; 17(5):552-561.
O-13. Cocco P, t'Mannetje A, Fadda D. Occupational exposure to solvents and risk of lymphoma
subtypes: results from the Epilymph case-control study. Occup Environ Med. 2010
May;67(5):341-7
O-14. Fritschi L, Benke G, Hughes AM, et al. Occupational Exposure to Pesticides and Risk of
Non-Hodgkin’s Lymphoma. Am. J. Epidemiol. 2005 Nov; 162(9):849-857.
O-15. Eriksson M, Hardell L, Carlberg M and Åkerman M. Pesticide exposure as risk factor for
non-Hodgkin lymphoma including histopathological subgroup analysis. Int. J. Cancer 2008;
123:1657–1663.
O-16. American Cancer Society. Leukemia - Acute Lymphocytic. What is leukemia - Acute
Lymphocytic Leukemia (ALL) in adults? Topics. http://www.cancer.org/cancer/leukemiaacutelymphocyticallinadults/detailedguide/leukemia-acute-lymphocytic-what-is-all
O-17. Raabe GK, Wong O. Leukemia mortality by cell type in petroleum workers with potential
exposure to benzene. Environ Health Perspect. 1996 Dec;104 Suppl 6:1381-92.
O-18. Rushton L, Romaniuk H. A case-control study to investigate the risk of leukaemia
associated with exposure to benzene in petroleum marketing and distribution workers in the
United Kingdom. Occup Environ Med. 1997 Mar;54(3):152-66.
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O-19. Schnatter AR, Rosamilia K, Wojcik NC. Review of the literature on benzene exposure and
leukemia subtypes. Chem Biol Interact. 2005 May 30;153-154:9-21.
O-20. American Cancer Society - Bile Duct (Cholangiocarcinoma) Cancer. What is Bile Duct
Cancer? Topics.http://www.cancer.org/cancer/bileductcancer/detailedguide/bile-duct-cancerwhat-is-bile-duct-cancer
O-21. Kumagai S, Kurumatani N, Arimoto A, Ichihara G. Short report - Cholangiocarcinoma
among offset colour proof-printing workers exposed to 1,2-dichloropropane and/or
dichloromethane. Occup Environ Med 2013;70:508-510
O-22. The Committee on Gulf War and Health of the Institutes of Medicine. National Research
Council. Gulf War and Health: Volume 2. Insecticides and Solvents. Washington, DC. The
National Academies Press, 2003 Also cited twice above (BDC-3 and CD-4)
O-23. National Heart, Lung, Blood Institute at the National Institutes of Health. What is Asthma?
http://www.nhlbi.nih.gov/health/health-topics/topics/asthma/
O-24. American Academy of Allergy, Asthma and Immunology. Occupational Asthma. Accessed
at: http://www.aaaai.org/conditions-and-treatments/conditions-a-to-z-search/occupationalasthma.aspx
O-25. Cowl CT. Occupational asthma: review of assessment, treatment, and compensation.
Chest. 2011;139:674-681
O-26. Occupational Safety and Health Administration, U.S. Department of Labor. Safety and
Health Topics- Occupational Asthma. https://www.osha.gov/SLTC/occupationalasthma/
O-27. Smith B, Wong CA, Smith TC, et al. 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.
O-28. Szema AM, Peters MC, Weissinger KM, et al. New-onset asthma among soldiers serving
in Iraq and Afghanistan. Allergy and Asthma Proceedings 2010 Sep;31(5):67-71
O-29. Szema AM, Salihi W, Savary K, et al. Respiratory Symptoms Necessitating Spirometry
Among Soldiers With Iraq/Afghanistan War Lung Injury. JOEM 2011 September; 53(9): 960-965
O-30. Peterson MR, Schneidermann A, Walters T. Letter to the Editor: Respiratory Symptoms
Necessitating Spirometry Among Soldiers With Iraq/Afghanistan War Lung Injury JOEM 2011
December; 53(12): 1356-1357
O-31. Morris MJ, Zacher LL, Jackson DA: Investigating the Respiratory Health of Deployed
Military Personnel. Military Medicine, 2011 October; 176 (10) 1157-1168
O-32. Smith B, Wong CA, Boyko EJ, et al. The Effects Of Exposure To Documented Open-Air
Burn Pits On Respiratory Health Among Deployers Of The Millennium Cohort Study. JOEM 2012
June; 54(6):708-716
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O-33. Abraham JH, DeBakey SF, Reid L, et al. Does Deployment to Iraq and Afghanistan Affect
Respiratory Health of US Military Personnel? JOEM 2012 June; 54(6):740-745
O-34. Abraham, J. H., Eick-Cost, A. et al. (2014). A retrospective cohort study of military
deployment and postdeployment medical encounters for respiratory conditions. Mil Med 179(5):
540-6.
O-35. American Psychological Association. Answers to Your Questions about Panic Disorders.
http://www.apa.org/topics/anxiety/panic-disorder.aspx
O-36. Sparks PJ, Simon GE, Katon WJ, et al: An outbreak of illness among aerospace workers.
West J Med 1990 Jul; 153:28-33
O-37. Binkley K, King N, Poonai N, et al. Idiopathic environmental intolerance: Increased
prevalence of panic disorder–associated cholecystokinin B receptor allele 7. J Allergy and Clin
Immunology. May 2001; 107(5):763-764
O-38. Dager SR, Holland JP, Cowley DS, et al. Panic disorder precipitated by exposure to
organic solvents in the workplace. Am J Psychiatry. 1987; 144:1056-1058
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Appendix P
Summary of Evidence Regarding Deployment
and Respiratory Conditions
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EPIDEMIOLOGIC EVIDENCE SUMMARY STATEMENT
Military Deployment and Chronic Respiratory Conditions
PURPOSE: This document is intended to provide technical audiences with a summary of the
current scientific evidence regarding potential associations between deployment-related exposures
and post-deployment chronic respiratory conditions. This information may be used by healthcare
professionals to brief leaders and assist in counseling individual Service Members and their family
members.
WHY is this information needed? The health and well-being of personnel is a top priority of
the Department of Defense (DoD). Some military personnel are returning from Iraq and Afghanistan
with persistent respiratory symptoms, and are concerned that exposures sustained during
deployment have made them sick. The DoD shares this concern. Evaluations of associations
between deployment and incidence of persistent post-deployment respiratory symptoms and specific
chronic lung conditions are being performed. The DoD is continually evaluating the strengths and
limitations of the available science. This communication represents what the US Army Public Health
Command (USAPHC) considers to be factually supported statements that reflect the most current
scientific information.
WHO is the population of concern? U.S. personnel deployed to the Central Command
(CENTCOM) Area of Operation (AOR) (i.e., Southwest Asia –Iraq, Afghanistan, and Kuwait), from
2002 to present.
WHAT do we know?
Personnel deployed to the CENTCOM AOR are exposed to dust and
ambient particulate matter, often in conjunction with airborne emissions from vehicles, waste
burning, and local industry. For years, DoD has conducted environmental sampling to characterize
these exposures, focusing on particulate matter (PM). The data demonstrate variable conditions
including occasions where pollutant levels exceed health guidelines (Engelbrecht, McDonald et al.
2009). When these conditions occur, high levels of ambient particulate matter and other air
pollutants can irritate the eyes and respiratory passages. Acute exposure can also exacerbate preexisting respiratory conditions like asthma and COPD. More persistent health effects of air pollutant
exposures are dependent on the type of pollutant(s), the duration of exposure, and characteristics of
the population being exposed (Pope and Dockery 2006). With respect to particulate matter air
pollution, persons with underlying disease, the elderly, and the very young are most likely to be
susceptible to short-term exposures to elevated PM. There may be more broad susceptibility to
long-term PM exposure, although significant effects of cumulative exposure are most likely to be
observed in older age groups with repeated exposures and higher baseline risks of health events.
(Pope 2000) Susceptibility to exposures of intermediate length typical among deployed personnel is
not well characterized.
Medical surveillance data for the U.S. Service member population indicate that the overall rates of
chronic respiratory diseases after deployment have been either stable or slightly decreasing over the
last 10 years (Baird, ATS 2011; Abraham, Clark et al. 2014) However, the rate of diagnoses of
“bronchitis, not specified as acute or chronic,” increased between 2001 and 2009, before reversing
course, and decreasing since 2009. Interpretation of this information is complicated because the
rates are based on medical encounter diagnosis codes and selected diagnostic codes may be too
general or may not correspond to a clinical definition of a disease, limiting their validity.
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The scientific studies evaluating the association between deployment and respiratory health that
have been completed indicate a range of different findings. These include: (a) no evidence of an
association between deployment and chronic respiratory conditions (AFHSC 2010; Abraham and
Baird 2012); (b) an association between specific respiratory diseases and deployment (Szema et al.
2010; Barth et al. 2014; Abraham et al. 2014) ; and (c) evidence of increased respiratory symptoms
but not a specific diagnosed disease (Roop et al. 2007; Smith et al. 2009; Szema et al. 2011;
Abraham et al. 2012). Additional conditions (i.e. acute eosinophilic pneumonia (Shorr et al. 2004)
and constrictive bronchiolitis (King et al. 2011) are described in case series from which
epidemiologic associations cannot be directly estimated. Although all of these studies have
methodological limitations that constrain the strength of the conclusions being drawn, their findings
warrant continued investigation.
In conclusion, the evidence to date does not clearly support the inference of a specific association
between deployment and chronic respiratory conditions among deployed personnel, or the absence
of such an association. Chronic respiratory conditions and other severe effects of air pollution are
generally not expected in a relatively young and healthy adult population. However, susceptibility to
health effects of intermediate duration exposure remains a substantial gap in current knowledge.
Some previously deployed Service Members may experience persistent effects due to their
combined deployment exposures in conjunction with unique experiences, smoking habits, and/or
individual susceptibilities associated with existing health conditions or genetics.
WHY is it so difficult to get a clear answer? Arriving at weight of the evidence-based
conclusions regarding associations between deployment environmental exposures and long-term
respiratory health of military personnel is challenging for several reasons. Key complicating factors
include:
This is a relatively new area of scientific investigation. A small but growing number of
assessments evaluating the association between military deployment to Southwest Asia and
chronic respiratory conditions have been published in the peer-reviewed scientific literature. This
current body of evidence shows a range of observations that are not consistent. Multiple, wellconducted studies with consistent results are typically needed to support a strong conclusion
regarding an exposure-disease relationship. Current work is ongoing to fill this need.
The data used to represent both exposure and medical outcomes are surrogates for
actual conditions.
Though the relationship between deployment-related environmental
exposures and chronic respiratory disease is the concern, the “exposure” is often defined only as
deployment status (e.g., number, timeframe, and location of deployment(s)), rather than by
quantified environmental exposure data. Similarly, medical outcomes are often identified using
diagnostic codes that may, or may not, reflect properly diagnosed disease.
No single study presents a definitive answer. The significance of a study’s contribution to the
overall body of evidence should be based on a consideration of both its strengths and limitations.
Findings should be balanced against limitations regarding study design to include adequacy of
comparison groups, exposure assumptions, how outcomes are assessed, latency periods,
confounding and other epidemiological biases, and low statistical power.
Reports of individual cases may be newsworthy but can also easily distort or distract
from the interpretation of available scientific evidence. Such cases are often compelling and
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deserving of the public’s attention, and may serve as clues to the scientific community for their
hypothesis generating potential. However, individual case-reports alone do not provide strong
scientific evidence of an association between deployment-related exposures and the condition.
Further studies are needed to explore any potential relationships.
WHAT are we looking at more closely? The DoD has established a Pulmonary Research
Working Group with members from the VA, academia, and other Civilian research organizations to
help determine prioritized areas of focus. New research has been submitted for publication while
other work is ongoing and in the planning stages. In addition to exposure risk assessments,
epidemiologic studies are evaluating chronic respiratory diseases and dypsnea on exertion.
Summary: The evidence to date is inconclusive regarding increased risk of chronic respiratory
conditions associated with military deployment to the CENTCOM AOR. However, some previously
deployed personnel may experience persistent symptoms or develop chronic respiratory conditions
which may be due to their combined deployment exposures, unique experiences, and/or individual
susceptibilities. DOD acknowledges the concern regarding potential respiratory health effects
associated with deployment, and is collaborating with the VA and independent researchers to further
evaluate and quantify potential long-term health risks related to deployment exposures.
Service members with medical concerns should consult with their healthcare providers. Providers may consult
with the USAPHC Environmental Medicine Program.
[email protected] Tel: 410-436-2714
References Cited:
Abraham, J. H., Clark L.L., et al. (2014). "Trends in rates of chronic obstructive conditions among U.S. military
personnel, 2001-2013." Mil Med. Accepted for Publication.
Abraham, J. H. and C. P. Baird (2012). "A case-crossover study of ambient particulate matter and cardiovascular and
respiratory medical encounters among US military personnel deployed to southwest Asia." J Occup Environ Med
54(6): 733-9.
Abraham, J. H., DeBakey S. F., et al. (2012). "Does deployment to Iraq and Afghanistan affect respiratory health of
US military personnel?" J Occup Environ Med 54(6): 740-5.
Abraham, J. H., Eick-Cost A., et al. (2014). "A retrospective cohort study of military deployment and post-deployment
medical encounters for respiratory conditions." Mil Med. Accepted for Publication.
AFHSC (2010). Epidemiological Studies of Health Outcomes among Troops Deployed to Burn Pit Sites. Silver
Spring, MD, Armed Forces Health Surveillance Center.
Barth S.K., Dursa E.K, et al. (2014) Prevalence of respiratory diseases among veterans of operation enduring
freedom and operation iraqi freedom: results from the national health study for a new generation of U.S. Veterans. Mil
Med. 179(3): 241-245.
Engelbrecht, J. P., E. V. McDonald, et al. (2009). "Characterizing mineral dusts and other aerosols from the Middle
East--Part 1: ambient sampling." Inhal Toxicol 21(4): 297-326.
King, M. S., R. Eisenberg, et al. (2011). "Constrictive bronchiolitis in soldiers returning from Iraq and Afghanistan." N
Engl J Med 365(3): 222-30.
Pope, C. A., 3rd (2000). "Epidemiology of fine particulate air pollution and human health: biologic mechanisms and
who's at risk?" Environ Health Perspect 108 Suppl 4: 713-23.
Pope, C. A., 3rd and D. W. Dockery (2006). "Health effects of fine particulate air pollution: lines that connect." J Air
Waste Manag Assoc 56(6): 709-42.
Roop, S. A., A. S. Niven, et al. (2007). "The prevalence and impact of respiratory symptoms in asthmatics and
nonasthmatics during deployment." Mil Med 172(12): 1264-9.
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Shorr, A. F., S. L. Scoville, et al. (2004). "Acute eosinophilic pneumonia among US Military personnel deployed in or
near Iraq." JAMA 292(24): 2997-3005.
Smith, B., C. A. Wong, et al. (2009). "Newly reported respiratory symptoms and conditions among military personnel
deployed to Iraq and Afghanistan: a prospective population-based study." Am J Epidemiol 170(11): 1433-42.
Szema, A. M., M. C. Peters, et al. (2010). "New-onset asthma among soldiers serving in Iraq and Afghanistan."
Allergy Asthma Proc 31(5): 67-71.
Szema, A. M., W. Salihi, et al. (2011). "Respiratory symptoms necessitating spirometry among soldiers with
Iraq/Afghanistan war lung injury." J Occup Environ Med 53(9): 961-5.
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| File Type | application/pdf |
| File Title | Microsoft Word - 1_24 SBCT deployment health surveillanceinvestigation report Final_CG_final |
| Author | farhana.schickedanz |
| File Modified | 2016-10-18 |
| File Created | 2014-12-31 |