The First 75 Years Timeline of United States Army Preventive, Occupational and Environmental Medicine, and Public Health History.

In 2017, the US Army Public Health Center (USAPHC) at Aberdeen Proving Ground, Maryland, celebrated its 75th Anniversary. The organization began in 1942 at The Johns Hopkins University School of Hygiene and Public Health in Baltimore, Maryland, as the US Army Industrial Hygiene Laboratory to provide Occupational Medicine, Industrial Hygiene and other Occupational Health services in support of the World War II military industrial base. In 1945, the organization moved to the Edgewood Area of Aberdeen Proving Ground and underwent organizational changes, mission changes and name changes. In 1960 it was renamed the US Army Environmental Hygiene Agency or AEHA, and under that name was widely recognized for significant accomplishments in Occupational and Environmental Health. In 1994, it became the US Army Center for Health Promotion and Preventive Medicine (USACHPPM) and took on an expanded role in Public Health. A later reorganization brought in Veterinary services. In 2015, it became the USAPHC. This publication provides a timeline of important accomplishments, mission modifications, administrative changes, challenges and threats in the organization's first 75 years. To help readers put these events in perspective, abbreviated timelines of significant events in military and civilian Preventive, Occupational and Environmental Medicine and Public Health history, legal and regulatory actions related to Public Health and US military history are also included.

Chemical Weapons Exposures in Iraq: Challenges of a Public Health Response a Decade Later.

An October 14, 2014 article in The New York Times reported that the US Department of Defense (DoD) concealed, for nearly a decade, circumstances surrounding service members' exposure to chemical warfare agents (CWA) while deployed to Iraq in support of Operations Iraqi Freedom and New Dawn from March 13, 2003, to December 31, 2011, and alleged failure of the DoD to provide expedient and adequate medical care. This report prompted the DoD to devise a public health investigation, with the Army Public Health Center (Provisional) as the lead agency to identify, evaluate, document, and track CWA casualties of the Iraq war. Further, the DoD revisited and revised clinical guidelines and health policies concerning CWA exposure based on current evidence-based guidelines and best practices.

Environmental Air Sampling Near Burn Pit and Incinerator Operations at Bagram Airfield, Afghanistan.

OBJECTIVE: This study presents environmental air samples collected at a US military installation with a solid waste disposal facility (SWDF) containing a burn pit from 2005 through 2012 and compared these results with occupational (breathing zone) samples. METHODS: Particulate matter (PM) environmental samples were collected as part of the installation monitoring program. Service Members in four security positions were monitored for PM and acrolein occupational exposures. RESULTS: The highest recorded PM2.5 concentration occurred at the SWDF. A highly populated sampling site, the Bazaar site, had the highest mean PM10, with the SWDF following in second. Acrolein and respirable PM were considerably higher in the breathing zone samples than environmental samples. CONCLUSIONS: The diversity of results support the concept of a complex environment with multiple polluting sources and changing meteorological and operational conditions.

Oil well fires of Operation Desert Storm--defining troop exposures and determining health risks.

During Operation Desert Storm, in February 1991, Iraqi troops began burning Kuwaiti oil wells. Almost immediately there was concern about possible adverse health effects in U.S. personnel exposed to crude oil combustion products. Combustions products were predicted from the known composition of Kuwaiti crude oil. Monitoring sites were established in Saudi Arabia and Kuwait; about 5,000 environmental samples were studied. Data collected were used to develop health risk assessments for the geographic areas sampled. This initial approach to assessing risk had to be greatly expanded when Congress passed Public Law 102-190, requiring development of means to calculate environmental exposures for individual U.S. service members. To estimate daily exposure levels for the entire area over 10 months for all U.S. troops, air dispersion modeling was used in conjunction with satellite imagery and geographic information system technology. This methodology made it possible to separate the risk caused by oil fire smoke from the total risk from all sources for each service member. The U.S. military responses to health concerns related to the oil well fires and to Public Law 102-190 were reviewed. Consideration was given to changes in technology, practices, and policies over the last two decades that might impact a similar contemporary response.

Effectiveness, suitability, and performance testing of the SKC Deployable Particulate Sampler (DPS) as compared to the currently deployed Airmetrics MiniVol portable air sampler.

Epidemiological studies have linked particulate matter (PM) exposure to morbidity and mortality from cardiovascular and respiratory disease. In order to monitor and assess the potential PM health risk to deployed military personnel, the U.S. Army must field a portable sampler that can accurately sample particles with an aerodynamic diameter less than or equal to a nominal 2.5 mm (PM2.5). In the study described in this article, the SKC Deployable Particulate Sampler (DPS) was compared to the currently deployed Airmetrics MiniVol portable air sampler in the hot, dry environment of Yuma Proving Grounds, Arizona, and the cold, wet environment of Fort Drum, New York. For all measurements taken and averaged, the DPS and the MiniVol did not differ significantly for mean concentration collected; however, the DPS collected 4.0 times more mass than the MiniVol (p < .05). The DPS was shown to be an improvement over the MiniVol when evaluated for measures of effectiveness, suitability, and performance.

Fatal motor vehicle crashes among veterans of the 1991 Gulf War and exposure to munitions demolitions at Khamisiyah: a nested case-control study.

BACKGROUND: A proposed explanation for the observed higher risk of fatal motor vehicle crashes (MVC) among 1991 Gulf War-deployed veterans is neurocognitive deficits resulting from nerve agent exposure at Khamisiyah, Iraq. Our objective was to assess any association between postwar fatal MVC and possible nerve agent exposure based on 2000 modeled plume data. METHODS: Cases were defined as MVC deaths with a record in the Department of Transportation Fatality Analysis Reporting System through 1995. Cases (n = 282) and controls (n = 3,131) were derived from a larger nested case-control study of Gulf War-era veterans and limited to Army, male, deployed personnel. Exposure and cumulative dose by case-control status were analyzed using multivariate techniques. RESULTS: Exposure status was not associated with fatal MVC (OR 0.96, 95% CI 0.72-1.26), nor were tertiles of cumulative dose. CONCLUSIONS: Findings do not support an association between possible exposures at Khamisiyah and postwar fatal MVC among Gulf War veterans.

Military deployment human exposure assessment: urine total and isotopic uranium sampling results.

Currently the Department of Defense (DoD) does not use exposure biomarkers to measure service members' exposure to environmental chemicals. Blood and urine exposure biomarkers for volatile organic compounds (VOC), selected heavy metals, depleted uranium (DU), and chemical warfare agents are currently available but have not been field tested or validated by the DoD in military deployments as a tool to document exposures. The Military Deployment Human Exposure Assessment Study, a prospective cohort of 46 soldiers deployed to Bosnia, was designed to field test blood and urine exposure biomarkers as a mechanism to document exposures to these chemicals during military deployments. Blood and urine were collected before, during, and after deployment. Standard questionnaire, environmental, and occupational monitoring data collection methods were conducted for comparison to the exposure biomarker results. This article compares and reports the pre-, during, and postdeployment urine total and isotopic uranium measurements and compares them to perceived exposures captured on questionnaire, to environmental data collected by the United Nations Environmental Program in Bosnia, and to standard U.S. urine uranium reference levels (CDC, 2003). Additionally, the questionnaire and environmental and occupational measurements are reported. The results of the study indicate that exposure biomarkers may be a valuable tool to the DoD in exposure and risk assessment with regard to environmental and occupational exposures to uranium.

In-theater hospitalizations of US and allied personnel during the 1991 Gulf War.

The postwar morbidity of Gulf War veterans has been closely examined. However, data have not been available to evaluate morbidity suffered during the 1991 Gulf War. In this report, the authors examine archived records of hospitalizations in US military facilities in the Kuwaiti theater of operations or those medically evacuated to facilities in Europe. Using multivariable logistic regression modeling, the authors determined that service personnel at greatest odds for "in-theater" hospitalization were enlisted, female, White, Reservist, Army, and health care workers. No increase in odds was observed for oil well fire smoke exposure or possible exposure to the nerve agent hazard areas. Although these data may be incomplete, they represent the best-known data reflecting in-theater hospitalizations during the Gulf War of 1991 and show remarkable similarities in risk factors to those for postwar hospitalization.

The postwar hospitalization experience of Gulf War veterans participating in U.S. health registries.

In response to concerns that Gulf War veterans were experiencing increased morbidity resulting from wartime exposures in the Gulf War, the Department of Veterans Affairs and the Department of Defense (DoD) initiated clinical registries to provide systematic health evaluations for self-referred Gulf War veterans. The authors used Cox's proportional hazard modeling with data from all DoD hospitals to estimate the probability of hospitalization resulting from any cause, resulting from diagnosis in a major diagnostic category, and resulting from a specific diagnosis of interest. After adjusting for other risk factors, registry participants were 1.43 times more likely to have a postwar hospitalization than registry nonparticipants (95% confidence interval, 1.40-1.46). These findings support the hypothesis that registry participants were more likely to experience postwar morbidity than veterans who chose not to enroll in the health registries.

Anthrax vaccination and self-reported symptoms, functional status, and medical conditions in the National Health Survey of Gulf War Era Veterans and Their Families.

PURPOSE: To evaluate the health status of Gulf War veterans who reported receipt of anthrax vaccination and a small group of Gulf War veterans for whom documentation of anthrax vaccination exists. METHODS: Among the 11,441 Gulf War veterans who completed a health survey, 4601 reported receiving the anthrax vaccine during the war; 2979 veterans reported not receiving it; 3861 were uncertain. Also, 352 of these respondents were documented by the Department of Defense as having received anthrax vaccination. We compared the medical history of these groups of veterans using multivariate analyses. Finally, we analyzed perception of exposure and its relation to reporting bias. RESULTS: There were statistically significant differences in prevalence for almost all outcomes studied between those who reported having received anthrax vaccination and those who did not so report. However, when we compared the veterans for whom vaccination records exist to the group who self-reported that they had not received the vaccine, the significant differences in prevalence for almost all of the outcomes disappeared. CONCLUSIONS: The extent of a reporting bias should be carefully considered when one evaluates the health consequences of anthrax vaccination based on self-reported data.

Gulf War veterans and Iraqi nerve agents at Khamisiyah: postwar hospitalization data revisited.

Chemical warfare agents were demolished by US soldiers at Khamisiyah, Iraq, in March 1991. The authors investigated postwar morbidity for Gulf War veterans, contrasting those who may have been exposed to low gaseous levels of nerve agents and those unlikely to have been exposed. Cox regression modeling was performed for hospitalizations from all causes and hospitalizations from diagnoses within 15 categories during the period March 10, 1991, through December 31, 2000, for the duration of active-duty status. After adjustment for all variables in the model, only two of 37 models suggested that personnel possibly exposed to subclinical doses of nerve agents might be at increased risk for hospitalization from circulatory diseases, specifically cardiac dysrhythmias. Of the 724 hospitalizations for cardiac dysrhythmias, 203 were in the potentially exposed group, slightly higher than expected (risk ratio = 1.23, 95% confidence interval: 1.04, 1.44). The increase was small in comparison with potential observational variability, but the findings are provocative and warrant further evaluation. Veterans possibly exposed to nerve agents released by the Khamisiyah demolition were not found to be at increased risk for hospitalizations from any other chronic diseases nearly 10 years after the Gulf War.

Exposures to the Kuwait oil fires and their association with asthma and bronchitis among gulf war veterans.

Military personnel deployed to the Persian Gulf War have reported a variety of symptoms attributed to their exposures. We examined relationships between symptoms of respiratory illness present 5 years after the war and both self-reported and modeled exposures to oil-fire smoke that occurred during deployment. Exposure and symptom information was obtained by structured telephone interview in a population-based sample of 1,560 veterans who served in the Gulf War. Modeled exposures were exhaustively developed using a geographic information system to integrate spatial and temporal records of smoke concentrations with troop movements ascertained from global positioning systems records. For the oil-fire period, there were 600,000 modeled data points with solar absorbance used to represent smoke concentrations to a 15-km resolution. Outcomes included respiratory symptoms (asthma, bronchitis) and control outcomes (major depression, injury). Approximately 94% of the study cohort were still in the gulf theater during the time of the oil-well fires, and 21% remained there more than 100 days during the fires. There was modest correlation between self-reported and modeled exposures (r = 0.48, p < 0.05). Odds ratios for asthma, bronchitis, and major depression increased with increasing self-reported exposure. In contrast, there was no association between the modeled exposure and any of the outcomes. These findings do not support speculation that exposures to oil-fire smoke caused respiratory symptoms among veterans.

A case-control study of asthma among U.S. Army Gulf War veterans and modeled exposure to oil well fire smoke.

OBJECTIVE: Thousands of American troops were exposed to oil well fire smoke during the Persian Gulf War, but the actual impact of this on their health is unknown. To assess the potential association between physician-diagnosed asthma and objective estimates of oil fire smoke, we conducted a case-control study of Army Gulf War veterans. METHODS: Subjects were participants in the Comprehensive Clinical Evaluation Program. Cases had physician-diagnosed asthma; controls were selected from the population of noncases. The two estimates of exposure were cumulative exposure and number of days at high levels. RESULTS: A total of 873 cases and 2,464 controls were included. Significant associations were observed between asthma and both estimates of exposure, with an adjusted odds ratio of 1.4 (95% confidence interval = 1.11.8) for both the highest levels of cumulative exposure and days exposed to high levels. A dose response was observed for both exposure measures. CONCLUSIONS: We found significant associations between asthma and oil fire smoke exposure. Because much of the medical history was not available, an etiological association cannot be determined from this study, and additional research is needed.

Ten years and 100,000 participants later: occupational and other factors influencing participation in US Gulf War health registries.

For more than a decade after the Gulf War, there has been concern that wartime exposures have resulted in significant morbidity among Gulf War veterans. After the end of the war, the Department of Veterans Affairs (VA) and the Department of Defense (DoD) initiated health registries to provide systematic clinical evaluations of Gulf War veterans who chose to participate. By September 1999, there were 32,876 participants in the DoD Comprehensive Clinical Evaluation Program and 70,385 participants in the VA Gulf War Registry Health Examination Program. We identified demographic and military service factors, as well as potential war-related exposures associated with subsequent registry participation after 10 years of observation. Veterans potentially exposed to oil well fire smoke, those near Khamisiyah, Reserve and National Guard, Army veterans, and veterans in the theater of operations during intense combat periods were most likely to elect to participate in a registry. These findings support the hypothesis that certain occupational factors and wartime exposures may influence subsequent health care-seeking behavior.

Are Gulf War veterans experiencing illness due to exposure to smoke from Kuwaiti oil well fires? Examination of Department of Defense hospitalization data.

There has been much concern among the public and veterans that specific environmental exposures incurred during the Gulf War were the cause of subsequent illness among Gulf War veterans. In this historical cohort study, the authors compared the postwar morbidity of US military personnel exposed to smoke from the 1991 Kuwaiti oil well fires with that of unexposed personnel. Complete exposure and demographic data were available for 405,142 active-duty Gulf War veterans who did not remain in the region after the war. The authors used data from all Department of Defense hospitals for the period August 1, 1991-July 31, 1999 to estimate rates of hospitalization due to any cause, hospitalization due to a diagnosis in one of 15 major categories, and hospitalization due to one of nine diagnoses likely to be manifestations of smoke exposure. Exposures to particulate matter from oil-well-fire smoke were based on the integration of meteorologic data, diffusion modeling, and troop location data. The authors constructed seven exposure groups combining duration and amount of exposure. In Cox modeling, three of the 25 models showed an increased adjusted risk of hospitalization. However, there was no evidence of a dose-response relation. Despite some limitations, these data do not support the hypothesis that Gulf War veterans have an increased risk of postwar morbidity from exposure to Kuwaiti oil-well-fire smoke.