Chronic respiratory symptoms following deployment-related occupational and environmental exposures among US veterans.

OBJECTIVES: Characterise inhalational exposures during deployment to Afghanistan and Southwest Asia and associations with postdeployment respiratory symptoms. METHODS: Participants (n=1960) in this cross-sectional study of US Veterans (Veterans Affairs Cooperative Study 'Service and Health Among Deployed Veterans') completed an interviewer-administered questionnaire regarding 32 deployment exposures, grouped a priori into six categories: burn pit smoke; other combustion sources; engine exhaust; mechanical and desert dusts; toxicants; and military job-related vapours gas, dusts or fumes (VGDF). Responses were scored ordinally (0, 1, 2) according to exposure frequency. Factor analysis supported item reduction and category consolidation yielding 28 exposure items in 5 categories. Generalised linear models with a logit link tested associations with symptoms (by respiratory health questionnaire) adjusting for other covariates. OR were scaled per 20-point score increment (normalised maximum=100). RESULTS: The cohort mean age was 40.7 years with a median deployment duration of 11.7 months. Heavy exposures to multiple inhalational exposures were commonly reported, including burn pit smoke (72.7%) and VGDF (72.0%). The prevalence of dyspnoea, chronic bronchitis and wheeze in the past 12 months was 7.3%, 8.2% and 15.6%, respectively. Burn pit smoke exposure was associated with dyspnoea (OR 1.22; 95% CI 1.06 to 1.47) and chronic bronchitis (OR 1.22; 95% CI 1.13 to 1.44). Exposure to VGDF was associated with dyspnoea (OR 1.29; 95% CI 1.14 to 1.58) and wheeze (OR 1.18; 95% CI 1.02 to 1.35). CONCLUSION: Exposures to burn pit smoke and military occupational VGDF during deployment were associated with an increased odds of chronic respiratory symptoms among US Veterans.

Deployment-related Cigarette Smoking Behaviors and Pulmonary Function Among U.S. Veterans.

INTRODUCTION: The effects of smoking on lung function among post-9/11 Veterans deployed to environments with high levels of ambient particulate matter are incompletely understood. MATERIALS AND METHODS: We analyzed interim data (04/2018-03/2020) from the Veterans Affairs (VA) Cooperative Studies Program #595, "Service and Health Among Deployed Veterans". Veterans with ≥1 land-based deployments enrolled at 1 of 6 regional Veterans Affairs sites completed questionnaires and spirometry. Multivariable linear regression models assessed associations between cigarette smoking (cumulative, deployment-related and non-deployment-related) with pulmonary function. RESULTS: Among 1,836 participants (mean age 40.7 ± 9.6, 88.6% male), 44.8% (n = 822) were ever-smokers (mean age 39.5 ± 9.5; 91.2% male). Among ever-smokers, 86% (n = 710) initiated smoking before deployment, while 11% (n = 90) initiated smoking during deployment(s). Smoking intensity was 50% greater during deployment than other periods (0.75 versus 0.50 packs-per-day; P < .05), and those with multiple deployments (40.4%) were more likely to smoke during deployment relative to those with single deployments (82% versus 74%). Total cumulative pack-years (median [IQR] = 3.8 [1, 10]) was inversely associated with post-bronchodilator FEV1%-predicted (-0.82; [95% CI] = [-1.25, -0.50] %-predicted per 4 pack-years) and FEV1/FVC%-predicted (-0.54; [95% CI] = [-0.78, -0.43] %-predicted per 4 pack-years). Deployment-related pack-years demonstrated similar point estimates of associations with FEV1%-predicted (-0.61; [95% CI] = [-2.28, 1.09]) and FEV1/FVC%-predicted (-1.09; [95% CI] = [-2.52, 0.50]) as non-deployment-related pack-years (-0.83; [95% CI] = [-1.26, -0.50] for FEV1%-predicted; -0.52; [95% CI] = [-0.73, -0.36] for FEV1/FVC%-predicted). CONCLUSIONS: Although cumulative pack-years smoking was modest in this cohort, an inverse association with pulmonary function was detectable. Deployment-related pack-years had a similar association with pulmonary function compared to non-deployment-related pack-years.

Respiratory Health after Military Service in Southwest Asia and Afghanistan. An Official American Thoracic Society Workshop Report.

Since 2001, more than 2.7 million U.S. military personnel have been deployed in support of operations in Southwest Asia and Afghanistan. Land-based personnel experienced elevated exposures to particulate matter and other inhalational exposures from multiple sources, including desert dust, burn pit combustion, and other industrial, mobile, or military sources. A workshop conducted at the 2018 American Thoracic Society International Conference had the goals of: 1) identifying key studies assessing postdeployment respiratory health, 2) describing emerging research, and 3) highlighting knowledge gaps. The workshop reviewed epidemiologic studies that demonstrated more frequent encounters for respiratory symptoms postdeployment compared with nondeployers and for airway disease, predominantly asthma, as well as case series describing postdeployment dyspnea, asthma, and a range of other respiratory tract findings. On the basis of particulate matter effects in other populations, it also is possible that deployers experienced reductions in pulmonary function as a result of such exposure. The workshop also gave particular attention to constrictive bronchiolitis, which has been reported in lung biopsies of selected deployers. Workshop participants had heterogeneous views regarding the definition and frequency of constrictive bronchiolitis and other small airway pathologic findings in deployed populations. The workshop concluded that the relationship of airway disease, including constrictive bronchiolitis, to exposures experienced during deployment remains to be better defined. Future clinical and epidemiologic research efforts should address better characterization of deployment exposures; carry out longitudinal assessment of potentially related adverse health conditions, including lung function and other physiologic changes; and use rigorous histologic, exposure, and clinical characterization of patients with respiratory tract abnormalities.

Respiratory disease in Army recruits: surveillance program overview, 1995-2006.

BACKGROUND: Since 1966, the U.S. Army has had in place a comprehensive surveillance system for acute respiratory disease (ARD) because of its continued high incidence in the recruit population. A retrospective review of the program from 1995 to 2006, a continuation of an earlier analysis from 1985-1994, was performed to describe the program and to summarize group A streptococcal (GAS) outbreaks identified through this program. METHODS: Weekly incidence data and daily sentinel case data collected as part of the ARD surveillance program were analyzed in 2007 to report rates of ARD and GAS outbreaks over this 12-year period (1995-2006) for five participating Army sites. RESULTS: Average ARD rates were consistently higher from 2000 to 2006 than from 1995 to 1999. Rate ratios of winter rates to summer rates were greater than 1.0 prior to 2000, but from 2000 to 2006, ratios were consistently near 1.0. Rheumatogenic M types were available for three of five outbreaks. CONCLUSIONS: Continuing high incidence of ARD in the military, re-emerging rheumatogenic M types, and a highly mobile military underscore the need for continued surveillance efforts. The continued employment of interventions with demonstrated effectiveness, such as chemoprophylaxis and basic preventive measures, is essential to reducing the burden of ARD.

Malaria in U.S. military forces: a description of deployment exposures from 2003 through 2005.

U.S. service members are often deployed to regions endemic for malaria. Preventive measures play an important role in mitigating the risk of disease and adverse effects on mission performance. Currently, a large contingent of U.S. forces is deployed in malarious regions in southeast and southwest Asia. The purpose of this study was to describe malaria cases reported by the tri-service reportable medical events system in terms of exposure (deployment history) and latency of infection. We conducted a retrospective analysis of population health data routinely collected for disease surveillance. All malaria reports received into the Defense Medical Surveillance System by January 3, 2006 with a date of onset between January 1, 2000 and December 31, 2005 in which the individual diagnosed is a member of the active or reserve military components linked to personnel and deployment data were analyzed to determine assignment and deployment history. The main outcome measure was the ICD9-CM diagnosis of malaria (Plasmodium vivax, P. falciparum, P. ovale, P. malaria, and unspecified malaria) by date of onset and days from exposure. A total of 423 cases of malaria were reported during the study period. The Army (n = 325) and the Marine Corps (n = 46) had the highest number of reported cases. Plasmodium vivax (n = 242) and P. falciparum (n = 92) caused nearly four-fifths of all reported cases. During the period from 2003 through 2005, 34% of deployed cases were exposed to more than one malaria-endemic region. Seventy-four cases had been assigned in the Republic of Korea, and all were present in Korea during the high risk transmission period. Seventy-eight cases had documented service in Afghanistan; only 4 had off-season exposure and no other documented exposures. Sixty cases had documented exposure during Operation Iraqi Freedom (OIF). Only six seasonally exposed and six off seasonally exposed OIF cases had no other documented exposure. Fifty percent of Korean cases were diagnosed during an exposure season, and only 3% of Afghan cases were diagnosed during an exposure season. Soldiers in today's military can be exposed to more than one malaria-endemic region prior to diagnosis. This presents new complexities for disease monitoring and prevention policy development.

Findings From the Department of Veterans Affairs Qarmat Ali Medical Surveillance Program.

OBJECTIVE: To review the Veterans Affairs (VA) medical surveillance program for Veterans with potential hexavalent chromium (CrVI) exposure that occurred during 2003. METHODS: Retrospective review of medical records of the 124 Veterans that participated in standardized, in-person clinical evaluations for possible CrVI exposure during the incident in question. The evaluations were reviewed to define population level effects. In addition, a mortality analysis was conducted for the 808 unique personal identifiers available to Veterans Health Administration. RESULTS: Mean reported number of days exposed was 21 (median 10). A history of respiratory (n = 78) and skin (n = 38) symptoms were reported during the period of exposure. No abnormalities that were specific to chromium exposure (e.g., nasal septum perforation) were found. Eight deaths occurred between 2005 and 2012. CONCLUSIONS: The lack of severe nasal abnormalities in the VA evaluations supports a time-limited peak exposure. However, the overall low participation rate (15%) severely compromises any ability to generalize to the entire potentially exposed population. Regardless, since the actual level of exposure to CrVI will never be known with certainty, the VA will continue to monitor these Veterans with periodic evaluations to identify and manage any pathologic findings that might be associated with past CrVI exposure.

Burn Pit Emissions Exposure and Respiratory and Cardiovascular Conditions Among Airborne Hazards and Open Burn Pit Registry Participants.

OBJECTIVE: The aim of this study was to determine how burn pit emissions exposure is associated with the incidence of respiratory and cardiovascular conditions. METHODS: We examined the associations between assumed geographic and self-reported burn pit emissions exposure and respiratory and cardiovascular outcomes in participants of the Airborne Hazards and Open Burn Pit Registry. RESULTS: We found significant dose-response associations for higher risk of self-reported emphysema, chronic bronchitis, or chronic obstructive pulmonary disease with increased days of deployment within 2 miles of selected burn pits (P-trend = 0.01) and self-reported burn pit smoke exposure (P-trend = 0.0005). CONCLUSIONS: We found associations between burn pit emissions exposure and higher incidence of post-deployment self-reported respiratory and cardiovascular conditions, but these findings should be interpreted with caution because the surrogate measurements of burn pit emissions exposure in this analysis may not reflect individual exposure levels.

A severe case of Angiostrongylus eosinophilic meningitis with encephalitis and neurologic sequelae in Hawa'i.

Angiostrongylus eosinophilic meningitis is caused by infection with larvae of the rat lungworm, Angiostrongylus cantonensis. We report the case of an adult who ingested a raw, giant African snail (Achatina fulica) on the island of O'ahu in Hawa'i and developed an eosinophilic meningoencephalitis with severe headache, confusion, sixth cranial nerve palsy, ataxia, limb weakness, and paresthesia. He was treated with lumbar punctures to relieve pressure, high dose corticosteroids, and 14 days of albendazole. He had a prolonged convalescence, requiring 3 months of prednisone, and still had evidence of motor nerve weakness 4 months after exposure. A field investigation at the site of exposure yielded 5 of 9 Achatina fulica snails with evidence of A. cantonensis DNA by PCR. Cerebrospinal fluid samples from the patient were negative acutely but positive on day 15 of symptoms, using an investigational, real-time PCR assay. We discuss clinical management of this case in light of the current medical literature.