Assessment of the
Department of Veterans Affairs
Airborne Hazards and
Open Burn Pit Registry
David A. Savitz, Anne N. Styka, and David A. Butler, Editors
Committee on the Assessment of the Department of Veterans Affairs
Airborne Hazards and Open Burn Pit Registry
Board on the Health of Select Populations
Board on Population Health and Public Health Practice
Health and Medicine Division
A Report of
THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu
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This study was supported by Contract No. VA241-P-2024 between the National Academy of Sciences and the Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-45117-8
International Standard Book Number-10: 0-309-45117-5
Digital Object Identifier: 10.17226/23677
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Cover photo by E. B. Boyd. Used with permission.
Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2017. Assessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry. Washington, DC: The National Academies Press. doi: 10.17226/23677.
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COMMITTEE ON THE ASSESSMENT OF THE DEPARTMENT OF VETERANS AFFAIRS AIRBORNE HAZARDS AND OPEN BURN PIT REGISTRY
DAVID A. SAVITZ (Chair), Vice President for Research, Professor of Epidemiology, and Professor of Obstetrics and Gynecology, Brown University, Providence, RI
VINÍCIUS C. ANTÃO, Director of Patient Registries, Healthcare Research Institute, Hospital for Special Surgery, New York, NY
JANE E. CLOUGHERTY, Associate Professor and Director of Exposure Science, University of Pittsburgh, PA
MONTSERRAT FUENTES, Dean of College of Humanities and Sciences, Virginia Commonwealth University, Richmond, VA
RICHARD A. KULKA, Consultant, Richard A. Kulka Consulting, Raleigh, NC
FRANCES MURPHY, President and CEO of Sigma Health Consulting, LLC, Silver Spring, MD
CECILE S. ROSE, Professor of Medicine in the Division of Environmental and Occupational Health Sciences, National Jewish Health, Denver, CO
ARMISTEAD G. RUSSELL, Howard T. Tellepsen Chair and Regents’ Professor, Georgia Institute of Technology, Atlanta, GA
DAVID H. TRUMP, Chief Deputy Commissioner for Public Health and Preparedness, Virginia Department of Health (retired), Richmond, VA
JOYCE S. TSUJI, Principal Scientist, Exponent, Bellevue, WA
MARK J. UTELL, Professor of Medicine and Environmental Medicine, Director of Occupational and Environmental Medicine, University of Rochester Medical Center, Rochester, NY
Study Staff
DAVID A. BUTLER, Study Director. Scholar and Director, Office of Military and Veterans Health
ANNE N. STYKA, Program Officer
CARY HAVER, Program Officer (from July 2016)
PAMELA RAMEY-McCRAY, Administrative Assistant (from October 2016)
SULVIA DOJA, Research Associate (through August 2016)
NICOLE FREID, Senior Program Assistant (August 2015–September 2016)
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Reviewers
This report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose 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 manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
Ronald Blanck, Martin, Blanck & Associates
Babette Brumback, University of Florida
Don A. Dillman, Washington State University
Herman Gibb, Gibb Epidemiology Consulting, LLC
Grace LeMasters, University of Cincinnati
Shari Beth Libicki, Ramboll Environ
Dylan Small, University of Pennsylvania
Tyler C. Smith, National University School of Health and Human Services
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Frank E. Speizer, Harvard Medical School; Ellen Wright Clayton, Vanderbilt University; and Chris Whipple, Environ (retired). They were 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
Women and men who were deployed to Iraq, Afghanistan, and other locations in Southwest Asia were subjected to an extensive array of health threats beyond those directly resulting from combat. Environmental exposures, in particular, have been of great concern to many of those who served, and understandably so, and there is perhaps no more worrisome issue in this area than the potential health consequences from exposure to emissions from open burn pits. Undoubtedly, for some period of time, the disposal of all waste materials through uncontrolled incineration led to the exposure of large numbers of service personnel to particulate matter and other health hazards, which in turn created a high probability of both acute and chronic health consequences in these individuals. Congress mandated that the Department of Veterans Affairs (VA) create a registry that would acquire exposure and health information on service members and veterans exposed to burn pits and other airborne hazards. Despite a number of daunting challenges in doing so in a short time frame, VA was fully responsive and developed an ambitious program to enroll volunteer participants. With a substantial volume of information now in hand, our committee was asked to evaluate the effectiveness of this program along a number of dimensions. As the report indicates, we have a number of major concerns and suggestions for improvement, but we acknowledge that we are addressing these issues with the luxury of hindsight, sufficient time to examine and evaluate the work, and the range of expertise needed to make such an assessment. VA faced a much more daunting task and deserves the gratitude of the Congress, service members, and veterans for its efforts, which we applaud. We also want to be clear that as we critically examine the nature of the registry and the data VA has produced, we fully appreciate and support the need to be responsive to the concerns of those who served, and we acknowledge that some of those who were exposed to burn pits and airborne hazards undoubtedly have suffered and continue to suffer adverse health consequences. Our assessment is focused on the registry itself as a means of answering questions about the health consequences of that exposure in a scientifically informative and constructive manner.
The committee wishes to acknowledge the VA staff who responded to our many requests for information related to the registry: Drs. Paul Ciminera, Nicholas G. Lezama, and Michael A. Montopoli; and Mr. Vincent Mitchell. The data analyses contained in this report were performed by the research corporation Westat under the direction of the committee. The committee greatly benefited from the work performed by Dr. Joseph Gasper, Mr. Jason Liu, and Ms. Jennifer Kawata and very much appreciates their rigor, their willing and able response to repeated requests, and the clarity of their presentation. The committee is grateful to the many veterans and experts who attended and provided input or materials during and after the committee’s May 2015 workshop. Finally, we need to give a great deal of credit to the Health and Medicine Division staff who contributed profoundly to the
committee’s report. Dr. David Butler, Ms. Anne Styka, and Ms. Cary Haver provided a critical understanding of the past work on other reports related to burn pits as well as evincing a nuanced ability to inform and guide the committee’s work without constraining its conclusions. We also thank Ms. Sulvia Doja, Ms. Pam McCray, and Ms. Nicole Fried for generously and capably providing logistical support to the committee. A thank you is also extended to Mr. Daniel Bearss, who conducted database and literature searches, and Ms. Ellen Kimmel, who assisted the committee with fact checking the report.
David A. Savitz, Chair
Committee on the Assessment of the Department of Veterans Affairs
Airborne Hazards and Open Burn Pit Registry
Contents
THE COMMITTEE’S CHARGE AND APPROACH TO ITS TASK
Prior National Academies Reports Regarding Burn Pit Exposures and Health Outcomes
Registry Data Analysis Efforts
Summary of the Committee’s Workshop
Recent Epidemiologic Studies of Military Personnel Exposed to Burn Pits
2 USE OF REGISTRIES IN ENVIRONMENTAL HEALTH RESEARCH
USE OF REGISTRIES IN HEALTH RESEARCH
VA AND DOD ENVIRONMENTAL HEALTH REGISTRIES
VA Environmental Health Registries
DoD Environmental Health Registries
Selective Participation and Bias
IDENTIFICATION OF AN APPROPRIATE COMPARISON GROUP
3 THE AIRBORNE HAZARDS AND OPEN BURN PIT QUESTIONNAIRE AND REGISTRY
SCIENTIFIC BASIS AND CONGRESSIONAL DIRECTIVE
Open Comment Period and Pilot Testing
Registry Questionnaire Basic Characteristics
LINKING OTHER DATA TO REGISTRY DATA
4 ANALYSIS METHODS AND DESCRIPTIVE STATISTICS
DATA ON AH&OBP REGISTRY PARTICIPANTS
Assuring Quality Control of Analyses
Demographic and Military Characteristics Comparisons
Comparisons of Differences Between Respondents and Total Eligible Population
OVERVIEW OF QUESTIONNAIRE RESULTS
Questions with Limited Variability in Responses
Questions with High Rates of Nonresponse
5 ANALYSIS AND INTERPRETATION OF EXPOSURES DATA
Sources and Nature of Exposures
Limitations of Exposure Information
EXPOSURE INFORMATION COLLECTED BY THE AH&OBP REGISTRY
Location-Specific Deployment Exposures
General Military Occupational Exposures
Environmental Exposures and Regional Air Pollution
Limitations of AH&OBP Registry Questionnaire Exposure Information
Committee-Created Exposure Variables
EXPOSURE METRICS FOR MULTIVARIATE ANALYSES
Changes in Burn Pit Exposure Over Time
6 ANALYSIS AND INTERPRETATION OF REGISTRY HEALTH OUTCOME DATA
HEALTH OUTCOMES COLLECTED BY THE QUESTIONNAIRE
Strategies for Assessing Self-Reported Health Information
HEALTH CONDITIONS USED IN ANALYSES
Descriptive Statistics for Health Outcomes
ANALYSES OF EXPOSURES AND HEALTH OUTCOMES
Unexpected Patterns of Association
OVERALL INTERPRETATION OF REGISTRY DATA ANAYSIS
7 FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS
THE AIRBORNE HAZARDS AND OPEN BURN PIT REGISTRY QUESTIONNAIRE
ANALYSIS METHODS AND DESCRIPTIVE STATISTICS FOR THE REGISTRY DATA
ANALYSIS METHODS AND INTERPRETATION OF REGISTRY EXPOSURE DATA
ANALYSIS METHODS AND INTERPRETATION OF REGISTRY HEALTH OUTCOMES DATA
OTHER FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS
C Airborne Hazards and Open Burn Pit Registry Self-Assessment Questionnaire
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Acronyms and Abbreviations
AFHSC | Armed Forces Health Surveillance Center |
AFIOH | Air Force Institute for Occupational Health |
AH&OBP | Airborne Hazards and Open Burn Pit |
AOR | adjusted odds ratio |
BMI |
body mass index |
CAD |
coronary artery disease |
CHPPM | Center for Health Promotion and Preventive Medicine |
CI | confidence interval |
CMI | chronic multisymptom illness |
COPD | chronic obstructive pulmonary disease |
CTS | Contingency Tracking System |
DEERS |
Defense Enrollment Eligibility Reporting System |
DMDC | Defense Manpower and Data Center |
DoD | Department of Defense |
DOEHRS | Defense Occupational Environmental Health Readiness System |
EPMSP |
Enhanced Particulate Matter Surveillance Program |
GAO |
Government Accountability Office |
ICD-9 |
International Classification of Diseases, Ninth Revision |
IED | improvised explosive device |
IOM | Institute of Medicine |
IRR | incidence rate ratio |
MI |
myocardial infarction |
NHIS | National Health Interview Survey |
OEF |
Operation Enduring Freedom |
OIF | Operation Iraqi Freedom |
OMB | Office of Management and Budget |
OND | Operation New Dawn |
OR | odds ratio |
PAH |
polycyclic aromatic hydrocarbons |
PCDD/F | polychlorinated dibenzo-p-dioxins and dibenzo-p-furans |
PM | particulate matter |
SSC |
Sergeant Thomas Joseph Sullivan Center |
VA |
Department of Veterans Affairs |
VHA | Veterans Health Administration |
VOC | volatile organic compound |