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VAgent
eterans
and
Orange
Update 2010
Committee to Review the Health Effects in
Vietnam Veterans of Exposure to Herbicides
(Eighth Biennial Update)
Board on the Health of Select Populations
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing
Board of the National Research Council, whose members are drawn from the councils of
the National Academy of Sciences, the National Academy of Engineering, and the Institute
of Medicine. The members of the committee responsible for the report were chosen for
their special competences and with regard for appropriate balance.
This study was supported by Contract No. V101 (93) P-2136, Task Order #20 between
the National Academy of Sciences and US Department of Veterans Affairs. Any opinions,
findings, conclusions, or recommendations expressed in this publication are those of the
author(s) and do not necessarily reflect the view of the organizations or agencies that
provided support for this project.
International Standard Book Number-13: 978-0-309-21447-6
International Standard Book Number-10: 0-309-21447-5
Additional copies of this report are available from the National Academies Press, 500 Fifth
Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313
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For more information about the Institute of Medicine, visit the IOM home page at: www.
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Copyright 2012 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
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cultures and religions since the beginning of recorded history. The serpent adopted as a
logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by
the Staatliche Museen in Berlin.
Suggested citation: IOM (Institute of Medicine). 2012. Veterans and Agent Orange: Up-
date 2010. Washington, DC: The National Academies Press.
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“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
— Goethe
Advising the Nation. Improving Health.
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www.national-academies.org
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COMMITTEE TO REVIEW THE HEALTH EFFECTS
IN VIETNAM VETERANS OF EXPOSURE TO
HERBICIDES (EIGHTH BIENNIAL UPDATE)
MARY K. WALKER (Chair), Professor, Department of Pharmaceutical
Sciences, University of New Mexico, Albuquerque, New Mexico
ERIN BELL, Associate Professor, Department of Epidemiology and
Biostatistics, University of Albany, SUNY, Rensselaer, New York
SCOTT W. BURCHIEL, Professor and Associate Dean, Research College of
Pharmacy, University of New Mexico, Albuquerque, New Mexico
RODNEY R. DIETERT, Professor, Department of Microbiology and
Immunology, Cornell University, Ithaca, New York
NAIHUA DUAN, Professor, Department of Biostatistics, Columbia University,
New York, New York
RUSS B. HAUSER, Professor, Environmental Health, Harvard School of Public
Health, Boston, Massachusetts
KARL KELSEY, Professor, Community Health and Pathology and Laboratory
Medicine, Brown University, Providence, Rhode Island
NANCY I. KERKVLIET, Professor, Department of Environmental and
Molecular Toxicology, Oregon State University, Corvallis, Oregon
STEPHEN B. KRITCHEVSKY, Director, J. Paul Sticht Center on Aging,
Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
PETER S.J. LEES, Professor, Department of Environmental Health Sciences,
Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
LINDA A. McCAULEY, Dean and Professor, Nell Hodgson Woodruff School
of Nursing, Emory University, Atlanta, Georgia
JAMES R. OLSON, Professor, Department of Pharmacology and Toxicology,
School of Medicine and Biomedical Sciences, University at Buffalo,
Buffalo, New York
JEREMY M. SHEFNER, Professor and Chair, Department of Neurology,
Upstate Medical University, Syracuse, New York
MICHAEL SKINNER, Professor, Center for Reproductive Biology, School of
Molecular Biosciences, Washington State University, Pullman, Washington
LUOPING ZHANG, Associate Adjunct Professor, School of Public Health,
University of Califorina, Berkeley, California
Study Staff
MARY BURR PAXTON, Study Director
JENNIFER A. COHEN, Program Officer
TIA S. CARTER, Senior Program Assistant
ANDREA COHEN, Financial Associate
NORMAN GROSSBLATT, Senior Editor
FREDERICK (RICK) ERDTMANN, Director, Board on the Health of Select
Populations
v
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Reviewers
This report has been reviewed in draft form by individuals chosen for their
diverse perspectives and technical expertise, in accordance with procedures ap -
proved by the National Research Council’s Report Review Committee. The pur-
pose of this independent review is to provide candid and critical comments that
will assist the institution in making its published report as sound as possible and
to ensure that the report meets institutional standards for objectivity, evidence,
and responsiveness to the study charge. The review comments and draft manu -
script remain confidential to protect the integrity of the deliberative process. We
wish to thank the following individuals for their review of this report:
Linda S. Birnbaum, US Environmental Protection Agency
Norman Breslow, University of Washington
James (Jay) Brophy, McGill University
Brenda Eskenazi, University of California
Warren G. Foster, McMaster University
Chris Gennings, Virginia Commonwealth University
David G. Hoel, Medical University of South Carolina
Steve Holladay, University of Georgia
Robert G. Holloway, University of Rochester
Elaine S. Jaffe, National Institutes of Health
Mitzi Nagarkatti, University of South Carolina
Robert D. Sparks, California Medical Association Foundation
Hollie I. Swanson, University of Kentucky
Hugh H. Tilson, University of North Carolina
Mary H. Ward, National Institutes of Health
vii
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viii REVIEWERS
Although the reviewers listed above have provided many constructive com-
ments and suggestions, they were not asked to endorse the conclusions or recom -
mendations nor did they see the final draft of the report before its release. The
review of this report was overseen by Kristine M. Gebbie, Adjunct Professor,
Flinders University School of Nursing and Midwifery, Adelaide, South Australia.
Appointed by the National Research Council and Institute of Medicine, she was
responsible for making certain that an independent examination of this report
was carried out in accordance with institutional procedures and that all review
comments were carefully considered. Responsibility for the final content of this
report rests entirely with the authoring committee and the institution.
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Preface
In 1991, Congress passed Public Law (PL) 102-4, the Agent Orange Act of
1991, to address the uncertainty about the long-term health effects on Vietnam
veterans who during their service in Vietnam were exposed to herbicides—mix -
tures of 2,4-dichlorophenoxyacetic acid (2,4-D), 2,4,5-trichlorophenoxyacetic
acid (2,4,5-T), and its contaminant 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD),
picloram, and cacodylic acid. That legislation directed the Secretary of Veterans
Affairs to ask the National Academy of Sciences (NAS) to perform a comprehen-
sive evaluation of scientific and medical information regarding the health effects
of exposure to Agent Orange, other herbicides used in Vietnam, and the various
chemical components of those herbicides, including TCDD. The resulting com -
mittee report, Veterans and Agent Orange: Health Effects of Herbicides Used
in Vietnam (VAO), was published by the Institute of Medicine (IOM) in 1994.
That report evaluated and integrated the scientific evidence regarding statistical
associations between health outcomes and exposure to the herbicides and TCDD
on the basis of published material that had accumulated by 1994.
As required by PL 102-4, the Secretary also asked that NAS conduct updates
at least every 2 years for 10 years from the date of the first report to review newly
available literature and draw conclusions from the overall evidence. The first of
the updates, Veterans and Agent Orange: Update 1996 (Update 1996), was pub-
lished in March 1996. It was followed by Veterans and Agent Orange: Update
1998 (Update 1998) in 1999, Veterans and Agent Orange: Update 2000 (Update
2000) in 2001, Veterans and Agent Orange: Update 2002 (Update 2002) in 2003,
and Veterans and Agent Orange: Update 2004 (Update 2004) in 2005.
PL 107-103, the Veterans Education and Benefits Expansion Act of 2001, ex-
tended the period for biennial updates to 2014. The first update after the new leg -
ix
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x PREFACE
islation was Veterans and Agent Orange: Update 2006 (Update 2006), published
in 2007, followed by Veterans and Agent Orange: Update 2008 (Update 2008) in
2009. The present report is the third of this second 10-year period of evaluation.
The present update focuses on the relevant scientific studies published from
October 1, 2008, through September 30, 2010, that is, after the literature consid -
ered in Update 2008. To accomplish the review, IOM established a committee of
15 members representing a wide array of expertise to evaluate the newest scien-
tific evidence and to consider it in light of the studies reviewed in VAO, Update
1996, Update 1998, Update 2000, Update 2002, Update 2004, Update 2006, and
Update 2008. A link to the experience and expertise of previous committees was
provided by recruiting eight members from committees responsible for earlier
updates. All committee members were selected because they are experts in their
fields, have no conflicts of interest with regard to the matter under study, and have
taken no public positions concerning the potential health effects of herbicides in
Vietnam veterans or related aspects of herbicide or TCDD exposure. Biographic
sketches of committee members and staff appear in Appendix D.
In this second decade of evaluation, the committee sought the most accurate
information and advice from the widest possible array of knowledgeable sources
for consideration. To be consistent with NAS procedures, the committee met in
a series of closed sessions in which members could freely examine, character-
ize, and weigh the strengths and limitations of the evidence. The committee also
convened four open meetings in September, November, and December 2010 and
in February 2011 to provide an opportunity for veterans and veterans service
organizations, researchers, policy-makers, and other interested parties to present
their concerns, review their research, and exchange information directly with
committee members. The oral presentations and written statements submitted to
the committee are listed in Appendix A. The committee thanks the persons who
provided valuable insights into the health problems experienced by Vietnam
veterans.
The committee is grateful to Mary Paxton, who skillfully served as study
director for this project. The committee also acknowledges the excellent work of
IOM staff members Jennifer Cohen, Tia Carter, and Frederick (Rick) Erdtmann.
Thanks are also extended to Andrea Cohen, who handled the finances for the
project; Norman Grossblatt, who provided editorial skills; and William McLeod,
who conducted database searches.
The committee benefited from the assistance of several scientists and re -
searchers who generously lent their time and expertise to give committee mem-
bers insight into particular issues, provide copies of newly released research,
or answer queries about their work. Arnold Schecter, a professor at the Univer-
sity of Texas School of Public Health, discussed research activities concerning
herbicide contamination in Vietnam and health of the Vietnamese population.
Vaughan Turekian, Chief International Officer of the American Association for
the Advancement of Science and its representative to the US–Vietnam Dialogue
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xi
PREFACE
Group on Agent Orange–Dioxin, also discussed activities involving the Vietnam-
ese population. Paul Enright, a professor at the Mel and Enid Zuckerman College
of Public Health at the University of Arizona, was helpful in answering questions
concerning Agent Orange and chronic obstructive pulmonary disease. Yasmin
Cypel and Han Kang, Environmental Epidemiology Service of the Department
of Veterans Affairs, responded to questions regarding their recent publication
concerning the Army Chemical Corps.
Mary K. Walker, Chair
Committee to Review the Health Effects
in Vietnam Veterans of Exposure to
Herbicides (Eighth Biennial Update)
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xx TABLES AND FIGURES
7-39 Average Annual Incidence (per 100,000) of Hodgkin Disease in United
States, 457
7-40 Selected Epidemiologic Studies— Hodgkin Lymphoma, 458
7-41 Average Annual Incidence (per 100,000) of Non-Hodgkin Lymphoma in
United States, 467
7-42 Selected Epidemiologic Studies—Non-Hodgkin Lymphoma, 468
7-43 Selected Epidemiologic Studies—Chronic Lymphocytic Leukemia, 481
7-44 Average Annual Incidence (per 100,000) of Multiple Myeloma in United
States, 489
7-45 Selected Epidemiologic Studies—Multiple Myeloma, 491
7-46 Average Annual Incidence (per 100,000) of Leukemias in United
States, 500
7-47 Selected Epidemiologic Studies—Leukemia, 502
8-1 Selected Epidemiologic Studies—Endometriosis, 544
8-2 Selected Epidemiologic Studies—Male Fertility (Altered Hormone
Concentrations, Decreased Sperm Counts or Quality, Subfertility, or
Infertility), 550
8-3 Selected Epidemiologic Studies—Female Fertility (Altered Hormone
Concentrations, Subfertility, or Infertility), 554
8-4 Selected Epidemiologic Studies—Sex Ratio, 560
8-5 Selected Epidemiologic Studies—Spontaneous Abortion, 566
8-6 Selected Epidemiologic Studies—Birth Defects in Offspring of
Subjects, 575
8-7 Selected Epidemiologic Studies—Neural-Tube Defects in Offspring of
Subjects, 581
8-8 Selected Epidemiologic Studies—Childhood Cancers, 587
9-1 Epidemiologic Studies of Herbicide Exposure and Parkinson
Disease, 619
9-2 Epidemiologic Studies of Pesticide Exposure and Amyotrophic Lateral
Sclerosis, 629
10-1 Prevalence of Mortality from Diabetes, Lipid Disorders, and Circulatory
Disorders in United States, 2006, 648
10-2 Selected Epidemiologic Studies—Diabetes and Related Health
Outcomes, 651
10-3 Selected Epidemiologic Studies—Circulatory Disorders, 667
11-1 Selected Epidemiologic Studies—Noncancerous Respiratory Disease, 712
11-2 Selected Epidemiologic Studies—Thyroid Homeostasis, 739
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xxi
TABLES AND FIGURES
12-1 Summary from Eighth Biennial Update of Findings in Occupational,
Environmental, and Veterans Studies Regarding the Association Between
Specific Health Outcomes and Exposure to Herbicides, 761
12-2 Research Needs, 770
C-1 Mapping of Groupings of Malignant Neoplasms That Are the Subjects
of Conclusions in the Veterans and Agent Orange Series with ICD-9
Codes, 791
C-2 Surveillance, Epidemiology, and End Results (SEER) Program Malignant
Neoplasm Site Groupings for ICD-9 and ICD-10, 797
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Abbreviations and Acronyms
2,4-D 2,4-dichlorophenoxyacetic acid
2,4,5-T 2,4,5-trichlorophenoxyacetic acid
2,4,5-TCP 2,4,5-trichlorophenol
2,4,5-TP 2-(2,4,5-trichlorophenoxy) propionic acid or Silvex
8-hydroxy-2′-deoxyguanosine
8-OHdG
ACC Army Chemical Corps
ACS American Cancer Society
AD Alzheimer disease
AFHS Air Force Health Study (also referred to as the “Ranch Hand
Study”)
AHR aryl hydrocarbon receptor
AHRE AHR-responsive element of the canonical DNA recognition
motif of the AHR/ARNT complex, also referred to as
the dioxin-responsive element (DRE) or the xenobiotic-
responsive element (XRE)
AHS Agricultural Health Study
AIHW Australian Institute for Health and Welfare
AL acute leukemia
AL amyloidosis amyloid light chain form of amyloidosis in which the
amyloid in deposits in various organs and tissues
consists of antibody light chains
ALL acute lymphocytic leukemia
ALS amyotrophic lateral sclerosis (or Lou Gehrig’s disease)
xxiii
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xxiv ABBREVIATIONS AND ACRONYMS
AML acute myeloid leukemia [previously called “acute
myelogenous leukemia”]
ARNT aryl hydrocarbon nuclear translocator
BIRLS VA’s Beneficiary Identification Record Locator Subsystem
Blimp1 B lymphocyte maturation protein 1
BMD bone mineral density
BMI body-mass index
BWIS Baltimore–Washington Infant Study
CALUX chemical-activated luciferase gene expression bioassay, a
test for determination of dioxin-like activity in tissue
samples
CAS No. CAS Number is generated by the Chemical Abstracts Service
and serves as unique identifier for every chemical
CCR9 chemokine C receptor 9
CD4/CD8 ratio percentage of T-lymphocytes expressing CD4 antigen (T4
or helper T-cells) to percentage of T-lymphocytes
expressing CD8 antigen (T8 or suppressor T-cells), also
called T4/T8 ratio
CDC Centers for Disease Control and Prevention
CHD coronary heart disease
CI confidence interval, as defined by lower (LCL) and upper
confidence limits (UCL)
CLL chronic lymphocytic leukemia (which is now regarded as
being the same disease as small lymphocytic leukemia
[SLL] and designated by some as CLL/SLL)
CNS central nervous system
COIs chemicals of interest to VAO series (i.e., TCDD, 2,4,5-T, 2,4-
D, picloram, and cacodylic acid)
Con A concanavalin A
COPD chronic obstructive pulmonary disease
CSF cerebrospinal fluid
CT computed tomography
CVD cardiovascular disease
CYP--- cytochrome P450 (specific members of this family of
metabolizing enzymes are indicted by a number-letter-
number suffix)
DDE p,p´-diphenyldichloroethene, an environmentally persistent
metabolite of the insecticide DDT
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xxv
ABBREVIATIONS AND ACRONYMS
dicamba 2-methoxy-3,6-dichlororbenzoic acid, benzoate herbicide
with chemical structure related to phenoxy herbicides
dl dioxin-like
DLC dioxin-like compound (or chemical)
DMA dimethyl arsenic acid
DMAIII dimethyl arsenic acid of valency 3
DMAV dimethyl arsenic acid of valency 5; form of arsenic found in
cacodylic acid
DNA deoxyribonucleic acid
DOD US Department of Defense
DRE dioxin-responsive element, which is the recognition motif of
the AHR/ARNT complex (also called AHRE or XRE)
DTH delayed-type hypersensitivity, a cell-mediated immune
response
ECG electrocardiography
EOI Exposure Opportunity Index, metric of possible Agent
Orange exposure of ground troops generated by the
Stellman model
EPA US Environmental Protection Agency
FEF25–75 forced midexpiratory flow
FEV1 forced expiratory volume in 1 second
femtogram (10–15 gram)
fg
FSH follicle-stimulating hormone
FVC forced vital capacity
g gram
GBDS Birth Defects Study
GC/MS gas chromatography/mass spectrometry
GCT germ-cell tumor
GERD gastroesophageal reflux disease
g-glutamyltransferase
GGT
GI gastrointestinal
GIS geographic information system
HbA1c hemoglobin A1c
HCL hairy-cell leukemia
HDL high-density lipoprotein
HepG2 human hepatocarcinoma cell line
HIV human immunodeficiency virus
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xxvi ABBREVIATIONS AND ACRONYMS
HL Hodgkin lymphoma (previously referred to as Hodgkin’s
disease [HD] in VAO series)
HpCDD heptachlorodibenzo-p-dioxin, a dioxin congener with seven
chlorines
HpCDF heptachlorodibenzofuran, a furan congener with seven
chlorines
HPV human papilloma virus
HR hazard ratio
hsp heat shock protein
HT hypertension
HxCDD hexachlorodibenzo-p-dioxin, a dioxin congener with six
chlorines
HxCDF hexachlorodibenzofuran, a furan congener with six chlorines
IARC International Agency for Research on Cancer
ICAM-1 inter-cellular adhesion molecule 1
ICD-# International Classification of Diseases, Revision #
(# = version current for records being abstracted)
ICD-#-CM International Classification of Diseases, Revision #, Clinical
Modification
ICDO-II International Classification of Diseases for Oncology, 2nd
Edition
IFN-g interferon-gamma
IHD ischemic heart disease
IgE immunoglobulin E
interleukin-6 (also called β2-interferon)
IL-6
IOM Institute of Medicine
IQR inter-quartile range
IU international unit
IUGR intrauterine growth retardation
JEM job–exposure matrix
kg kilogram
L liter
LDL low-density lipoprotein
LH luteinizing hormone
LHCs lymphohematopoietic cancers
LOD limit of detection
LPS lipopolysaccharide
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xxvii
ABBREVIATIONS AND ACRONYMS
M molar (concentration in a solution, molecules per volume)
MCF-7 human breast cancer cell line
MCPA 2-methyl-4-chlorophenoxyacetic acid
MCPP 2-(2-methyl-4-chlorophenoxy) propionic acid or Mecoprop
MDS myelodysplastic syndrome
mg milligram
MGUS monoclonal gammopathy of undetermined significance
MI myocardial infarction
MIH molar incisor hypomineralization
MIP macrophage-inflammatory protein
ml milliliter
MLR mixed lymphocyte response
MM multiple myeloma
MMA monomethyl arsonic acid
MMAIII monomethyl arsonic acid of valency 3
mmHG millimeters mercury, for blood pressure measurements
MMP matrix metalloproteinase
MPTP 1-methyl-4-phenyl-1,2,4,6-tetrahydropyridine
MTD maximum tolerated dose
MRI magnetic resonance imaging
n number of study participants
na not applicable
NAS National Academy of Sciences
NCI National Cancer Institute
ndl not dioxin-like
nanogram (10–9 gram)
ng
NHANES National Health and Nutrition Examination Survey
NHL non-Hodgkin lymphoma
NIOSH National Institute for Occupational Safety and Health
NK T-cell natural killer T-cell
NLS nuclear-localization signal
NOEL no-observed-effect level
nr not reported
NRC National Research Council
not statistically significant (usually refers to p < 0.05)
ns
NTP National Toxicology Program
NVVRS National Vietnam Veterans Readjustment Study
OCDD octachlorodibenzo-p-dioxin (1,2,3,4,6,7,8,9-OCDD is the
only dioxin congener with eight chlorines)
OFFHS Ontario Farm Family Health Study
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xxviii ABBREVIATIONS AND ACRONYMS
OR odds ratio
p p-value, probability of the observed result or one more
extreme under null hypothesis
p23 prostaglandin E synthase
PAH polycyclic aromatic hydrocarbons
PBDD polybrominated dibenzo-p-dioxin
PBDF polybrominated dibenzofuran
PBPK model physiologically based pharmacokinetic model
PCB polychlorinated biphenyl
PCDD polychlorinated dibenzo-p-dioxin
PCDD/Fs polychlorinated dioxins and furans combined
PCDF polychlorinated dibenzofuran
PCP pentachlorophenol
PCT porphyria cutanea tarda
PD Parkinson disease
PE peritoneal endometriosis
PeCDD pentachlorodibenzodioxin, a dioxin congener with five
chlorines
PeCDF pentachlorodibenzofuran, a furan congener with five
chlorines
picogram (10–12 gram)
pg
PGE2 prostaglandin E2
PHA polyhydroxyalkanoate
picloram 4-amino-3,5,6-trichloropicolinic acid
PL Public Law
PM proportionate mortality
PMR proportional mortality ratio
PNS peripheral nervous system
POP persistent organic pollutant
ppb parts per billion = ng/g
ppm parts per million = µg/g = mg/kg
ppt parts per trillion = pg/g
PSA prostate-specific antigen
PSP Progressive Supranuclear Palsy
PTD preterm delivery, premature birth at less than 259 days (37
weeks gestation)
PTSD post-traumatic stress disorder
RA rheumatoid arthritis
regulated on activation, normal T-cell–expressed, and
RANTES
secreted
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xxix
ABBREVIATIONS AND ACRONYMS
RAST radioallergosorbent
RDD random-digit dialing
RFP request for proposals
RH Ranch Hand, member of Air Force unit primarily responsible
for spraying herbicides in Vietnam
RNA ribonucleic acid
RP relative prevalence
RR relative risk (also called “risk ratio”)
SCE sister chromatid exchange
SE standard error
SEA Southeast Asia
SEER NCI’s Surveillance, Epidemiology, and End Results
SES socioeconomic status
SIR standardized incidence ratio
SLE systemic lupus erythematosus
SLL small lymphocytic lymphoma, which is now recognized as a
different stage of CLL, rather than a separate disease
SMR standardized mortality ratio
STS soft-tissue sarcoma
SWHS Seveso Women’s Health Study
T3 triiodothyronine
T4 thyroxine
TCDD 2,3,7,8-tetrachlorodibenzo-p-dioxin
TCDF tetrachlorodibenzofuran, a furan congener with four chlorines
TCP trichlorophenol
TECK thymus-expressed chemokine
TEF toxicity equivalency factor, potency of a dioxin-like
compound (DLC) relative to TCDD
TEQ (total) toxic equivalent, or by older usage “toxicity
equivalent quotient”, i.e., cumulative toxic potency, sum
of TEFs for a mixture of PCDDs, PCDFs, and PCBs
tetraCDD tetrachlorodibenzo-p-dioxin, any of the 22 dioxin congeners
with four chlorines, including TCDD as defined above
TGF transforming growth factor
TNF tumor necrosis factor
Treg regulatory T cell
TRH thyrotropin-releasing hormone
TSH thyroid-stimulating hormone
TTP time to pregnancy
TWA time-weighted average
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xxx ABBREVIATIONS AND ACRONYMS
UFW United Farm Workers of America
UGT UDP-glucuronosyltranserfase
US United States
VA US Department of Veterans Affairs; previously, Veterans
Administration
VAO Veterans and Agent Orange (refers to series of IOM
committees and reports; italicized VAO, refers to the first
comprehensive review published in 1994)
VCAM-1 vascular cell adhesion molecule 1
VES Vietnam Experience Study
VLDL very-low-density lipoprotein
VOC volatile organic compound
WBC white blood cell
WHO World Health Organization
XRE xenobiotic-responsive element, which is the recognition
motif of the AHR/ARNT complex (also called DRE or
AHRE)
