burn pits and other airborne hazards / stella e. hines…€¦ · burn pits and other airborne...

Burn Pits and Other Airborne Hazards / Stella E. Hines, MD, MSPH!!

Western Occupational Health Conference: September 25 – 28, 2013 / Sheraton Waikiki, Honolulu, Hawaii!

Burn Pits and Other Airborne Hazards: Post-Deployment Lung Complaints in Returning Service

Members

Stella E Hines, MD, MSPH The University of Maryland School of Medicine and

Baltimore VA Medical Center Western Occupational Health Conference

2013

Content Attestation

I, Stella Hines, MD, hereby declare that the content for this activity, including any

presentation of therapeutic options, is well balanced, unbiased, and to the extent possible,

evidence-based.

Conflict of Interest Disclosure

I have no financial relationships with commercial entities producing, marketing, re-selling, or distributing health care

goods or services consumed by, or used on, patients relevant to the content I am planning, developing,

presenting, or evaluating.



Objectives

•  Impact of previous military exposures on current respiratory health

•  Gulf War I, respiratory health and depleted uranium

•  Recent conflicts in Iraq and Afghanistan –  Inhalational hazards – Reported health effects

Respiratory health complaints in returning Veterans not new

•  Vietnam era – Concerns for respiratory cancers associated

with Agent Orange exposure •  Persian Gulf War (Gulf War I)

– Undiagnosed respiratory disorders considered part of the spectrum of Gulf War Veterans’ Illnesses

Respiratory disease in GWI Veterans

•  Increased respiratory symptoms

•  No clear correlations with exposure –  Oil well fire smoke –  Sand storms

•  + Correlations with perceptions of exposure

•  Limited data on functional abnormalities or “disease”

•  No publications since 2004

6

h"p://www.evidence.org.kw/photos.php?page=0002_Oil-‐Well-‐Fire-‐and-‐Black-‐Smoke



Depleted Uranium Inhalation

Fratricide events: all Service members sustained inhalation to DU and other metal oxides

US Army CHPPM Capstone modeled estimates of inhaled Uranium content and radiation exposure (Parkhurst et al,, 2005)

Health risks from inhaled DU

•  Chronic low level α emission from DU particles remaining in lung and intrathoracic lymph nodes.

•  Inhalation of blast particulate à chronic airway & mucus membrane injury due to irritants and particulate matter.

•  Prior human data from Uranium miners, millers, and Uranium hexafluoride occupational accidents

•  Animal data: pulmonary edema, hemorrhage, interstitial inflammation and fibrosis, emphysema

20 Years After Inhalational Exposure

•  Symptoms AND Pulmonary Function Tests –  No significant

differences in high versus low U exposure groups

–  PFTs overall in “normal range”

Overall

Mean PFT Parameter (n=36) mean Spirometry

FVC % pred 90.94

FEV1 % pred 93.86

FEV1/FVC 77.39 Lung Volumes

TLC % pred 103.97

FRC % pred 91.62

RV % pred 111.06 Gas Exchange

DLCO % pred 100.50

Hines et al, JOEM 2013



Visible evidence for inhalation?

•  Low-dose Chest CT –  No significant differences

in high versus low U exposure groups

–  Expected abnormalities in smokers

–  Focal nodules similar to prevalence in screening studies

•  PET-CT Thorax –  Subset with embedded

fragments –  No thoracic lesions

suggestive of malignancy

Overall (n=36)

Chest CT Finding N (%)

Focal nodules 22 61.1 Fissural nodules 9 25 Nodularity 4 11.1 Mosaicism 14 38.9 Bronchiectasis 1 2.8 Large airway thickening 14 38.9 Emphysema 15 41.7 Reticulation 2 5.4 Honeycombing 0 0 Calcified lymph nodes 5 13.9 Esophageal abnormalities 5 13.9

Hines et al, JOEM 2013

Thus, respiratory complaints in Gulf War I Veterans remain causally unanswered…

•  Single large episode of inhalation of DU particulate does not appear to lead to chronic respiratory disease

http://www.publichealth.va.gov/exposures/gulfwar/military-service.asp

•  Patients may still perceive these exposures to be related to their symptoms

OIF/OEF/OND: Recent Conflicts

•  Some old, some new sources of inhalational exposures –  Burn Pits –  Sand Storms –  Sulfur fire @ Mishraq sulfur

mine near Mosul –  Blast Injury –  Tobacco smoke

http://www.wired.com/images_blogs/dangerroom/images/2008/04/24/iraqiexplosion_ied.jpg



Burn Pits

13

Photo credit: R. Teichman, WRIISC conference, Aug 2011

What’s in that Burn Pit Smoke? Good question

•  Depends on what you burn

•  “Typical” Solid Waste Stream (Hardt AFPHC 2011) –  11% Plastics –  6% Wood –  4% Metals –  75% Miscellaneous

combustibles: natural and synthetic fabrics, oils, greases, rubber

–  4% Dunnage –  Accelerant: JP-8 (jet fuel)

•  So you can get: –  PM 10 –  PM 2.5 –  Lead –  Mercury –  Dioxins –  Furans –  Polycyclic aromatic

hydrocarbons –  VOCs –  Irritant gases

•  Inefficient combustion

14

Air Force Ins@tute for Opera@onal Health. Environmental Health Site Assessment, Balad Air Base, Iraq. In: Deployed Environmental Surveillance Branch (RSED), ed; 2005.

Sandstorms, Desert Dust, Shamal Winds

15



Toxicity of Particulate Matter (PM)

•  PM10 – “Natural” –  Sources: Crustal elements, sea spray

•  PM 2.5 – “Anthropogenic” –  Sources: combustion products

•  Numerous associations between PM and –  increased respiratory symptoms:

airway irritation, coughing, difficulty breathing;

–  decreased lung function; –  aggravated asthma; –  development of chronic bronchitis; –  irregular heartbeat; –  nonfatal heart attacks; and –  premature death in people with

heart or lung disease.

16

Figure courtesy R. Teichman, Aug 9 2011

•  Sand in Iraq extremely fine, < 5 micron

hOp://www.epa.gov/oar/par@clepollu@on/health.html

Al Mishraq Sulfur Mine Fire June-July 2003

•  Largest manmade

SO2 release –  “more polluting gas than

most volcanic eruptions” –  Generated 21,000 tons

of SO2/day – half the daily emissions of the US

•  > half of air sampling –  over 13 ppm

•  Highest [SO2]: –  120 ppm

•  US EPA stnd - 0.03 ppm

17

The sulphur dioxide plume can be seen as a white haze on the map. The smog trailed for a further 1000 km through Iran and down to the Persian Gulf. Red squares show the highest sulphur dioxide concentra@ons, blue the lowest. Credit: NASA / University of Maryland Bal@more County

hOp://news.bbc.co.uk/2/hi/science/nature/3955005.stm

Cigarette Smoke

•  Higher tobacco usage in deployed soldiers

18 DiNicola et al, Military Medicine 2010

2006 US

Military before deployment

Military during deployment

Increased use during deployment

M 23.5% 52% 58% 25%

F 18.1% 42% 52% 48%

•  Prompts tobacco cessation counseling



All seem like they could be quite hazardous……

Human Health Effect Data

Reported Respiratory Health Effects

•  Respiratory Symptoms •  Asthma •  Constrictive Bronchiolitis •  Acute Eosinophilic Pneumonia •  Interstitial Lung Disease •  Allergic Rhinitis

20

Millennium Cohort study

•  21-year longitudinal study •  > 46,000 participants (2001 - 2006) •  Deployers: more respiratory sxs than nondeployers

(14% v 10%) •  Deployment length linearly associated with

increased symptoms in Army personnel (p<0.0001) •  More sxs associated with land-based

–  (Army & Marines)

21 Smith Am J Epi 2009, Casano WRIISC 2-‐2011

http://www.millenniumcohort.org



Millennium Cohort Follow-Up

•  Army & Air Force deployers, 2004-06, 2007-08

•  Burn pit exposure within 3 or 5 miles not associated with respiratory outcomes

•  Increased Sxs among Air Force within 2 miles of Balad

22 Smith et al. JOEM 2012 Photo: hOp://[email protected]/news/2008/11/airforce_burnpit_112608/

IMPORTANT in context of current symptoms

“Asthma” (RADS?)

•  Northport VA asthma study – (Szema AJRCCM 2008)

– Persian Gulf deployment vs stateside soldiers asthma risk (2004-2007)

– 6.6% vs. 4.3%, – crude OR 1.58,

[1.18-2.11]

•  Follow-up: all Vets deployed & discharged from service (2004-2010) – (Szema JOEM 2011) –  6.2% Iraq/Afghanistan

dx with asthma compared to 0.7% elsewhere, p<0.001

–  No differences in FEV1/FVC (~78%)

23

*Emphasis on deployment as exposure risk factor

Constrictive Bronchiolitis

•  Fort Campbell soldiers referred to Vanderbilt for evaluation of exertional dyspnea – Unable to complete 2 mile run – Most exposed to Al Mishraq sulfur mine fire – 80 evaluated

•  49 referred for VATS – 38 had constrictive bronchiolitis – Remaining 11: 2 with Respiratory Bronchiolitis,

2 RB-ILD, 2 HP, 2 Sarcoidosis, 2 other

24 King NEJM 2011; Miller, ATS 2011



PFTs & Imaging not that “impressive”

•  PFTs –  Totally normal in 13 –  25 with abnormal gas

exchange (low diffusion capacity (DLCO))

•  FEV1, FVC, FEV1/FVC all

significantly different from controls but still “normal” –  FEV1 % Pred: 86.7 –  FVC % Pred: 90.3 –  FEV1/FVC %: 79.1 –  TLC % Pred: 96.1 But… –  DLCO % Pred: 73.4

•  vs. 90.6% in controls

•  High res chest CTs (n=37) –  25 NORMAL –  6 mild air trapping –  1 single nodule –  2 multiple nodules –  1 basilar scarring –  1 pleural thickening –  1 apical bullae

•  Cardiopulmonary Exercise Tests –  VO2 max & Anaerobic

Thresholds significantly lower than controls

25

King NEJM 2011

Constrictive Bronchiolitis, Arteriopathy, and Peribronchial Pigment Deposition

Subepithelial fibrosis

Smooth muscle hypertrophy

Fibrosis btwn epithelium & muscle

layer

Smooth muscle hypertrophy + intimal fibrosis + PA medial hypertrophy & peribronchiolar pigment

Smooth muscle hypertrophy Polarizable pigment

(from E)

So, clinically this is odd. Was it really constric@ve bronchioli@s?

King NEJM 2011 26

Acute Eosinophilic Pneumonia

•  18 cases AEP in military personnel in/near Iraq

•  2 deaths •  Extensive questionnaire:

–  Tobacco, dust, petroleum products, ammo, solvents, medical waste, burning vehicles/buildings, pesti/fungi/herbicides

27 Shorr JAMA 2004

•  Only unifying & distinct exposure was tobacco smoke, 100% reported exposure •  78% were NEW smokers (14 of 18)



Usual Interstitial Pneumonitis (UIP) in soldier returning from Afghanistan

•  38 yo male c/o 2 mos dry cough •  Deployed to Iraq x 2 since 2005 •  Non-smoker •  Exposures to burn pits, sandstorms, dust •  Chest CT – bilateral diffuse infiltrates, basilar

subpleural fibrosis & honeycombing •  Serology, HP panel, viral studies neg •  Spiro: mild obstruction, gas exchange

impairment •  Surgical lung bx: UIP •  SEM/EDXA: silicates in regions of fibrosis

28 Zembrzuska AJRCCM 2011

Institute of Medicine Report, released 2011

•  VA directed IOM to prepare an evaluation of Burn Pit issues and recommendation back to the VA

•  Conclusions – Mixture of chemicals from regional bkgrd & local

sources that contribute to the high PM – Unable to determine whether long-term health

effects likely due to burn pit emissions; •  BUT service in Iraq or Afghanistan might be associated

with long-term health effects (mainly b/c of PM from natural & anthropogenic sources)

– Needs more study

29

Recent Activity

•  Research – DOD STAMPEDE – NJ/USGS DOD-funded Pathology

Standardization •  Public Law 112-260

– Burn Pit Registry – VA Cooperative Studies Program

•  Clinical Evaluations – WRIISCs, Local VAs & DOD, Other sites (NJH)



Summary

•  Veterans may have experienced inhalational exposures to potential airborne hazards –  High PM concerning

•  Causal associations between burn pit emissions and lung disease not definite

•  A variety of respiratory health effects have been reported which could contribute to current respiratory complaints

burn pits and other airborne hazards / stella e. hines…€¦ · burn pits and other airborne...

Documents