Anthony Szema, B.S.E, M.D. 1,2,3,4,5 Matthew Burns, B.S.E., M.Phil. 3 Guadalupe Jimenez, B.S. 3,6 Brittany Dukes, B.S. 3,7

ANALYSIS OF VA BURN PITS REGISTRY: TESTIMONY TO NATIONAL ACADEMY OF SCIENCES INSTITUTE OF MEDICINE WORKSHOP MAY 1, 2015 Clinical Assistant Professor, Department of Occupational Medicine, Epidemiology and Prevention, Hofstra North Shore-LIJ School of Medicine at Hofstra University 1 Adjunct Professor, Department of Technology and Society, College of Engineering and Applied Science, Stony Brook University 2 Three Village Allergy & Asthma, PLLC, South Setauket, NY 3 John T. Mather Memorial Hospital Internal Medicine Residency Program Faculty 4 World Trade Center Monitoring Program Consultant, Stony Brook University 5 Marine Corps/Navy Medic in Iraq and Afghanistan 6 St. Louis University Medical Student, 19 7 Anthony Szema, B.S.E, M.D. 1,2,3,4,5 Matthew Burns, B.S.E., M.Phil. 3 Guadalupe Jimenez, B.S. 3,6 Brittany Dukes, B.S. 3,7

ANALYSIS OF VA BURN PITS REGISTRY: TESTIMONY TO NATIONAL ACADEMY OF SCIENCES INSTITUTE OF MEDICINE Missing questions Question limitations WORKSHOP VA burn pit registry missing questions in comparison to Burnpits360.org Limitations Summary 2

VA BURN PIT REGISTRY MISSING QUESTIONS VA Burn Pits Registry does not ask about: 1. Impulse Oscillometry (measure of small airways narrowing and airway hyper-responsiveness) 2. Allergy skin testing 3. Patch testing for contact dermatitis to metals and chemicals 4

VA BURN PIT REGISTRY MISSING QUESTIONS 4. Exhaled breath condensate Nitric Oxide level for eosinophilic airway inflammation. 5. VA Burn Bits Registry does not ask about open lung biopsies or whether lung biopsies were checked for crystals, titanium, iron 5

VA BURN PIT REGISTRY MISSING QUESTIONS 6. Burn pits registry leaves out triad analogous to World Trade Center Related Illness: Sinusitis Gastro-Esophageal Reflux Disease (GERD) Late changes in spirometry 5 years out with airway hyper-responsiveness (methacholine challenge) 6

VA BURN PIT REGISTRY MISSING QUESTIONS 7. Does not ask about dust in Containerized Housing Units (CHU) 8. Does not ask about new-onset post deployment symptoms to dust mite antigens on return to US, which would suggest sensitization to dust-mite allergens in Iraq 7

VA BURN PIT REGISTRY MISSING QUESTIONS 9. 1.3 page 3 None of the questions on page asks if vehicles were powered with JP-8 jet fuel, which with exposure leads to inhalation of high concentrations of particulate matter containing benzene 8

VA BURN PIT REGISTRY MISSING QUESTIONS 10.Branch of service, rank, job, and what specifically did you burn (metals, plastics, electronics, etc.) and with what accelerant (JP-8) 11.Exposure to grinding metals, lathes 12.Exposure to asbestos in buildings/palaces 9

VA BURN PIT REGISTRY MISSING QUESTIONS 13. If lung biopsy was performed after exposure and if constrictive bronchiolitis was diagnosed 14. If soldiers requested evaluation at VA WRIIC 10

VA BURN PIT REGISTRY MISSING QUESTIONS 15. Spirometry or impulse oscillometry 16. 2.1 page 4 11

VA BURN PIT REGISTRY MISSING QUESTIONS 17. Asks only about current functional limitations not whether they were: Asymptomatic pre-deployment What was their pre and post deployment physical fitness run time Spirometry beforehand and whether there was no history of any allergies or asthma prior 12

VA BURN PIT REGISTRY LIMITATION 1. 1.2A. page 1 Were you exposed to soot, ash, smoke or fumes from the Gulf Oil well fires? 2. Question is asked before burn pit question 14

VA BURN PIT REGISTRY LIMITATION 3. 1.2D page 2 Were you near a burn pit during these dates (on the base or close enough to the base for your to see the smoke)? 4. Question ignores soldiers burning smaller burn pit fires in theater in forward operating bases 15

VA BURN PIT REGISTRY LIMITATION 5. 1.2B. Page 1 Where did you spend most of your time during these dates? 6. Question ignores fact even large bases had classified longitude and latitude location and many soldiers cannot spell or pronounce or write names of cities and towns they were deployed to. 16

VA BURN PIT REGISTRY LIMITATION 7. All soldiers early in war passed through Balad Air Base as Camp Anaconda with 10 acre 24h a day 365 day a year burn pit 2003-Nov 2009 8. 1.3 page 3 Were you ever close enough to feel the blast form an IED? 17

VA BURN PIT REGISTRY LIMITATION 9. Questions ignores blast from mortar fired rounds Omitted diagnoses of traumatic brain injury, which can result in lung injury from blast overpressure and shock waves Omitted diagnoses of PTSD, which is associated with cytokine release and asthma in civilian populations even among monozygotic twins 18

VA BURN PIT REGISTRY LIMITATION 10. Length of entire questionnaire is too long and will deter veterans from completing this after the first visit. 11. No incentive or rewards are associated with participation so this may lead to an overall low participation rate. 19

VA BURN PIT REGISTRY LIMITATION 12.1.3B page 3 Question: How many days heavy smoke from weapon, signal smoke, mortars or other combat items? 13.Many soldiers have had multiple deployments and the number of times a week one was exposed may vary depending on the dates and location of deployment. 20

VA BURN PIT REGISTRY LIMITATION 14. 1.4 B page 4 Wore a mask? 15. Does not specify if mask was N95 or respirator with oxygen. Even a firefighter s tank only last 10 minutes. 16.Some troops wore neck gaiters over nose Not a mask 21

VA BURN PIT REGISTRY LIMITATION 17. Same page does not ask about daily or weekly sandstorm exposure during deployment dates. If available one could link NASA satellite imagery of storms moving from Africa to Iraq and correlate weather with self reported exposure and symptoms. 22

VA BURN PIT REGISTRY MISSING QUESTIONS IN COMPARISON TO BURNPITS360.org Burnspit360.org has DD214 forms anonymouslycoded and de-identified and linked to clinical data asks specific questions regarding veterans post deployment symptoms (N=48): 56 % reported general lung related symptoms (i.e. shortness of breath, chronic cough, asthma) 48% reported shortness of breath post-minimal activity 24

VA BURN PIT REGISTRY MISSING QUESTIONS IN COMPARISON TO BURNPITS360.org 16.67% reported post-deployment cancer diagnosis 27.08% reported chronic cough issues 12.5% reported asthma related symptoms 25

VA BURN PIT REGISTRY MISSING QUESTIONS IN COMPARISON TO BURNPITS360.org In Burnpits360.org database Whether or not veterans received post deployment testing : 8.33% received a lung biopsy 12.5% had PFTs performed Whether or not post deployment services were also offered was also recorded 26

VA BURN PIT REGISTRY MISSING QUESTIONS/LIMITATIONS SUMMARY 1. VA Burn Pits Registry does not ask about key exposures: What were they exposure to what type of trash was burned, and with which fuels--jp-8 or other accelerants? Were they exposed to vehicles running on JP-8? 28

VA BURN PIT REGISTRY MISSING QUESTIONS/LIMITATIONS SUMMARY 2. Where were they located if bases are classified? 3. Why were they not asked about personal burning in forward operating bases even in absence of large burn pits? 4. Sandstorm and IED questions are too limited ignoring traumatic brain injury and post-traumatic stress leading to Iraq Afghanistan War Lung Injury (IAW-LI) and asthma. 29