Alright, welcome to the session on Military Environmental Exposures. We're actually going to be followed by another session related to it by Dr. Stephen Hunt and Dr. Ortiz. I'm Dr. Peter Ohm. I'm a Director of Policy in Military Environmental Exposures at the VA in what's called Health Outcomes and Military Exposures. Last year at AECOM we had a nine hour symposium on this topic, more than 70 people attended. This year at ACPM we had one that over 80 people attended. So there's a lot of interest in this topic. So today in an hour we really can't give it justice, or even in the following thing, but we just had a discussion and Dr. Bregi will be speaking, will be the Chair of the Environmental Health Section here in AECOM about trying to get an expanded session next year in Austin on this topic. So what I'm going to do today is I'm going to, a little about my background, I've been in state health, I've been in the military, I've been at the FDA, I've been in academia, and now I'm at the VA. And the VA is probably the most enjoyable job I've ever had because we're working with veterans and we're working with a lot of people doing a lot of things and I'm going to give an overview of our office and the challenges we face and then talk about the most revolutionary legislation that came along called the PAC Act. I'll show the clear slides from the department and I believe Dr. Ortiz and others are going to take this a step further in a later session. So with that, we'll get into this and again, just trying to give kind of a staunt on the importance of this topic and how we go forward. There's nothing to disclose, Dr. McDermott both works at the VA and the University of Maryland. Dr. Bianchi and myself are employees just of the VA. We have no financial, Brangy, I'm sorry, it should be Brangy, that's a mistake, opinions of those of the speakers and not necessarily that of the VA or the University of Maryland. Since the 2002 PAC Act, Dr. Stephen Hunters in the audience is the primary lead on this, has screened over 6 million veterans for toxic military exposures and 42% believe they have had a toxic exposure in the service. That's important to recognize. Now whether or not that risk actually leads to health issues and stuff is in some cases a matter of debate, but we try to align the best science we can and policy to come up with the fairest way to treat veterans. I'll talk more about the PAC Act and how that's revolutionized some of that, but the bottom line is we have a lot of exposures we face. We've had tactile herbicides such as Agent Orange. We've had nerve agents, more evidence potentially as a risk for possible Gulf War illness and other things in the Gulf War. Solvents, we have studies going on right now on fuels and things going on. Antimalarial, the concern has been brought up about whether or not that can be linked to psychiatric and long-term depressive outcomes even though the science is not kind of equivocal on that one. We've had dust and sand. We'll talk later about particulate matter in particular, fuels, pesticides, radiation, a lot of interest recently in radiation, particularly in the White House. We have a study going on with Manhattan Project right now and the PAC Act expanding the eligibility for certain things for veterans with radiation. Depleted uranium, you'll hear about that from Dr. McDermott who's a world expert in that topic. Vaccines, particularly anthrax comes up all the time as being possible concerns of veterans. We have oil well fires and burn pits. We have Dr. Shuping who I'll bring up at the, Dr. Shuping raise your hand there. He's our head of our operations and I'm going to let him give a few minutes at the end here to talk about some revolutionary things going on with our registries and what we're doing you know with burn pits. So we've got an office in what's called patient care services specifically directed at these health outcomes and military exposures. We now also have a, I won't talk about it much in the talk, we have a new office in our benefits called the military environmental team that is actually looking at claims and benefits for veterans with military exposures. We prefer the term military environmental rather than toxic. Toxic is a term used by Congress. We serve veterans, we're a trusted team. We've got a policy section in operations that Dr. Shuping and I lead. Radiation dose evaluations, we've got the only person in the VA who does assessments of basically risk to veterans for health on radiation exposures named Danny McClellan. We've got environmental field, we've got a military exposure section and we have a huge new thing that's come along the past year which is kind of keep your eye open because occasionally job analysis go on it. We have virtual jobs doing basically registry exams and health assessments of veterans. It's just getting going. This year it's called Vet Home, it's based in Denver. And right now it's 44 providers that will be doing those. We have two epidemiology sections. One is epidemiology and the other one is called SME which basically is more of a surveillance military environmental exposures. They're more intertwined in the policy part that deals with trying to figure out what we might make next to cover for benefits in healthcare for veterans. The epidemiology does more classic surveillance led by a doctor named Dr. Schneiderman. And then we have three unique centers in the country called the War Related Illness Injury Studies that is in California, D.C. and New Jersey and they each have sub-centers of excellence on women's health, airborne hazards and CETSI which I'm sure Dr. Oteze will talk about emerging threats like Havana syndrome and things like that. So we have a lot going on dealing with this. We have last year we have what's called a tracker that tracks things that come into our office. Had over 8,000 things come into our office last year. At least 500 of those were fairly high I would say time sensitive requests for information from the media, Congress, internal agencies and so forth. So we work with DOD, ATSDR and particularly very closely but we work with other agencies, other parts of CDC. We just had a talk from FDA on a medical device, part of my background in the past, EPA, NIH, particularly the war on cancer. Our office has several of us that are working on the war, the national war on cancer. So we have, I'll let Dr. Schuping talk quickly again at the end a little bit more about the registries but we have six congressionally mandated registries. One's on Agent Orange, one's on Gulf War, one's on ionizing radiation, one airborne hazards and open burn pits. Probably the most important one right now because it's actually going with the revolution of how they're doing things. And it's also the population from the first Gulf War and all the conflicts post 9-11 and it's growing by far the fastest growing registry. And then we have the depleted uranium program and the toxin-benefiting which Dr. McDermott will talk about which are world, they actually advise the World Health Organization and the FDA on medical toxicity and other agencies come up. So we do a lot of original research, looking at surveillance for looking at cohorts deployed but the real thing that's changed over the last year is we're also looking at garrison type exposures for our bases. We have the Camp Lejeune program but we have concerns about places like Fort Ord, we have a study going on with Fort McClellan, we have other things that are raised with PFAS and other things. So we have a lot going on looking outside the classic deployed military cohorts. And so we changed our name, we used to be called Deployment Health Services to Health Outcomes and Military Exposures, we wanted to capture the idea that we're not just about you know battle conditions and war. We have a huge endeavor at the very bottom going on right now which is to create a website that tracks all federal research going on in toxic military exposures. We've hired a team of librarians, a webmaster, and we're getting that going. That's part of the PAC Act, we'll talk more about that later. Before this PAC Act I'll talk about war, we've actually created 12 what's called presumptions. What's presumption? A presumption means if you were in that theater, you're presumed exposed to something. In the case of the more recent conflicts, we assume it's primarily been particulate matter, particulate PM 2.5, and we actually had our center of excellence in New Jersey came up with aspirinitis and cyanitis and I worked on getting nine rare cancers were approved as presumptions before the PAC Act. And then we have this again this large registry that's had a lot of interest and innovatively Dr. Hastings, our chief consultant, Dr. Shooping and others have worked to bring that along and further improve that. I'll let him talk a little about that in a minute. The PAC Act, we have a huge thing called ILR which Dr. Shooping also is involved with. It's been transcended out of our office as a primary control but we're still giving a lot of input to it. This is the idea that going back in time for a number of decades, they're tracking all kinds of databases and merging them between the military and VA to get basically a report on a veteran when they go in for disabilities, whatever, to give a record of possible exposures that could be linked to possible health conditions called ILR. I'm going to go through the PAC Act. It's this huge thing passed in 2022. I'll go over it more in a minute with some slides directly from the department. But our office has about 40% of that off the thing. And the most important one is probably not the, well, one of the most important ones is section 202 that deals with all these things dealing with how we innovatively get benefits and health conditions brought on based on science and policy to expand the benefits in healthcare for veterans. We've got a, had a National Academy report on that. They agreed with our, basically agreed with our program and were further modifications to it. We're looking right now at leukemias in the Gulf War, and we're also looking at multiple myeloma. And next year, we'll probably be looking at, we'll have internal discussions where we put it out there to others that I can share. We're probably going to be looking at the PFAS report from ATSDR and other sources and considering adding potential PFAS-linked conditions to veterans. So we have listening sessions. We have federal registry notices. Dr. Hunt may talk on section 405. This is kind of a tough one where the idea of taking the symptoms for Gulf War illness and getting them into something that could be linked potentially to benefits as healthcare. We have section 302 is another tough one where we attract to come up with chemicals that could cause, be linked to possible future presumptions. Right now, the only one we've adapted theater-wide is PM 2.5, and we're actually turning it, have turned that into a working group with the idea that's been the most pervasive thing in the theater. We can link to that along with that particular matter we know. And we have a lot of event-driven issues. There's one going on, I have a call tomorrow with, in Hawaii, there's a water contamination kind of like Camp Lejeune situation going on with the military, and it's called Red Hill. They're going to create a registry, and they're doing a lot of public communication stuff to try and address that as it goes along. We have nuclear cleanup things. There were accidents at Palmeneras where bombs fell off. They didn't explode, but they fell in Spain, and to WIAC where there's underwater nuclear testing and others. So we, and then the last one's really important. We get a lot, I'm, by background, I'm probably the only pediatrician in the VA that I know about. And we get a lot of intergenerational concerns of veterans that go to war, and they come back, and their kid gets a birth defect, and so forth. At least in the Agent Orange literature, despite other literature internationally, but at least in our veterans, there's not been evidence of linked birth defects in Agent Orange. Although for a while spina bifida was put across, but then later National Academy reports reversed that, and said there was insufficient, inadequate evidence of association, so. But we've had, this came up in the Gulf War, and we continue to look at that. We have a linked office called the Office of Research and Development, kind of leads the charge on it. There are, those in the home, two of us serve on what's called the Toxic Environmental Research Group, which is looking with a bunch of federal agencies trying to figure out topics. And intergenerational affairs is one of the things that's ongoing concern. I mentioned the presumption process. We've gone through a revamping of that, we've got a, now a much more formal process with a dedicated part of our office to lead that. They do, there's both an informal and a formal review of the literature. There's a, it goes through a three-step process. We have what's called the Military Environmental Exposure Subcouncil, which Dr. Hastings co-chairs with the VBA lead. And they make, they take a recommendation from the, our office, and make a decision whether to bring it forward to the Governance Project, which is two levels, and then ultimately the Secretary. And again, we're looking right now at leukemias, and we're looking at myeloma, we have other, we have a long list of things we're potentially going to look at in the future. It's a really hot area, and it takes a lot of our time trying to figure out what we're going to, we have regular meetings with stakeholders, veteran service organizations, Congress, and others give input. So there's a, there's a workflow where we do surveillance, we select the conditions, we do a scientific review, then it goes through a bunch of offices, and then it's decided whether or not to make a presumption. We do a lot of education. Every single provider in the VA has had at least one hour of military environmental exposures now. And more importantly, which I'll, I think I have a slide on in a minute, we have a thing which we, honestly, they came forward first, otherwise we'd probably be done with this college. We have a free certificate in military environmental exposures with the American College of Preventive Medicine. Level one has trained about almost 1,000 people in level one, and we've got over 250 trained in level two. It's free online, you can see me, particularly for residents and those, it's a great thing to get. We have a, we have a website, we have a screening app called Toxic Exposure Screening App that we bring up called Exposure Ed that basically puts our entire website in an app, which is a nice thing to have on your phone if you're a provider doing, kind of working with veterans. I talked about the certificate in military environmental exposures. It's free, it gets you credit, there's a, there is an exam, the exam is not that difficult. If you take the, take the modules and you, and you get your, you get your certificate. So real quick, we've talked about this, this is just because Dr. Hunt and Dr. Ortiz and others and the other speakers will allude to it. These are the official department slides on the PAC Act, and they're geared mainly at veterans, so maybe a little bit basic, but it's important to kind of get an idea. This is probably the most important policy thing that's happened in the VA, at least in decades. It's actually called the Sergeant First Class Heath Robertson thing. It was bipartisan, got great support, endorsed by the White House, and signed into law in late 22. It expands eligibility for healthcare. There's a thing called TERRA, Toxic Exposure, I think, Resource Act, that basically allows any veteran who feels he's been exposed to a toxin to actually go through benefits and the healthcare eligibility to get at least, to get healthcare in the VA. So we've, we've rapidly expanded our, our healthcare to the veterans. And the VA will improve its decision process, require scientific studies, I've talked some of those, got them going on in mortality, for McClellan, mental health and exposures, the Manhattan Project, and all kinds of things. It expands the eligibility of certain countries in the Gulf War, and so forth, won't go into too much of that. It expands some of these potential radiation exposures, cohorts, to get healthcare if they have a radiation condition. But more importantly, it adds about 25 conditions, including many, almost, about 70% of all cancers were added to the Gulf War. There's some exceptions, that's why we're working on leukemia. We have a new, we also are proposing looking at bladder cancer and other genital urinary cancers right now. And so forth. Glioblastoma is on the list, that's the one that President Biden's son, son died of. Now again, this does not mean we definitely have evidence one way or another on the use of science, but they were congressionally mandated, and they've been implemented throughout this. And the healthcare eligibility has expanded, particularly for some of the locations where Agent Orange was at least contested by veterans. Probably the most important of that is Guam. There's no evidence it was in Guam, but Congress added it. This toxic exposure screening is very important, and Dr. Hunt may talk on that more, but bottom line, millions of veterans are being exposed, get at least a basic exposure for toxic exposures. There's claims, they're really pushing, they've hired many people in the claims section. They're pushing getting claims in. And the bottom line is they're really pushing getting benefits and claims in for the veterans. So the bottom line is, if you're a veteran out there, you take care of veterans, and they were denied a claim like five, ten years ago, haven't put it back in, they may be eligible for something. So I will turn this over to Dr. McDermott, thank you. I'm going to give an overview of the Depleted Uranium and Embedded Fragment Program that's located at the Baltimore VA. So we'll just start at the very beginning. Depleted uranium is a heavy metal and it's a byproduct of the uranium enrichment process through which U-235 is extracted from natural uranium for nuclear fuel. And what's left over is a product that is depleted, air quotes, of some U-235, hence the name. And therefore depleted uranium is approximately only 40% less radioactive than natural uranium. That's important a lot of times in the conversations we have with our patients. So the military uses are several tank armor for increased resistance to enemy projectiles and it was used as a munition because of its excellent penetrating power. Although depleted uranium was around for several decades prior to the first Gulf War, it was used primarily in the first Gulf War at a larger level. And so that's where there were enough people to have had an opportunity for exposure to depleted uranium. So I'm going to make a little timeline here of how the depleted uranium program came into being and what our missions have done and how they've evolved over the 30 years that we've been working. As I mentioned, this story begins in 1991, but the group at Baltimore received a phone call in 1993. And I'd like to make this point that occupational medicine was who was called by Dr. Susan Mather, who was then in charge of environmental health at VACO. And she recognized this always as an occupational medicine problem, a military occupational exposure problem. And she called my predecessor, Dr. Jim Keogh, to take a look at about 30 veterans of Gulf War I. As a number of you know, there were a series of unrelated friendly fire events in the desert during Gulf War I, and our military groups were mistakenly fired upon by their comrades. And the fire was depleted uranium. So this is where the original DU cohort arose from, and Baltimore was asked to begin surveillance on this group. You see there's a gap because this was 93 when the phone call came, so people were not seen immediately, but there was a concern to try to get our arms around this group. And although they were seen individually, cohort data were collected and started to be expressed, you know, at the population level. So the first visit for these veterans was in 1993. And I joined in 97, and we started to organize things a little differently than by seeing groups of people instead of individuals one at a time. We started seeing six people at a time in a three-day inpatient surveillance kind of marathon, as you might imagine. And this just displays the visit year and the display of patients that we saw. In 97, we started to, for one time, we included a comparison population because I didn't want people saying it's not from depleted uranium if we were seeing signals. And so we included, the only time, a non-exposed but still Gulf War-deployed group of volunteers who had the same surveillance battery that the depleted uranium-exposed folks did. And you can see we made the determination that they needed to be followed serially and followed forward, and we began biennial visits. We've now seen 81 people altogether. All but four were Gulf War I. There were four unique cases related to OIF. They were our only Air Force members, and it was air-to-ground friendly fire. So one of the summary bright lines is that if you had a depleted uranium signature so far, it's all been friendly fire. So that's reassuring to a lot of patients who want to know or just want their uranium checked and, you know, what's the likelihood of, or I was there, or this sort of thing. And so for 30 years, we haven't gotten an isotopic signature but from friendly fire. We just finished, as you can see, the most recent visit in 2023. We are still seeing about half the cohort. Everybody's invited every two years, and because of primarily personal conflicts or work conflicts, only about half come for the event. However, the average number of times someone has come for surveillance is nine, so I feel pretty good. Nine times over 30 years, I feel like we have a pretty good handle on folks, and so I don't think we're missing anything dramatic, which is reassuring to me. So here's the surveillance protocol. Again, these are conducted during a three-day visit, detailed history, physical exam, exposure assessment, and we're able to use urine uraniums to parse our population. I'll show you a picture of that in a minute. Very extensive laboratory studies that you can see listed here, both the common ones, and we've included surveillance of target organs that are either targets of specifically uranium or early on when we didn't have a textbook of exactly how to do surveillance for these folks 30 years ago, we looked at other related metals and what their target organs were to make sure we didn't miss anything. Also special imaging to survey for local effects because we're not only worried about the systemic insult from uranium leaching from these foci of fragments, but we're also worried about foreign body carcinogenesis, especially with an alpha agent coming out right locally. So those are the two things we're kind of balancing in this surveillance effort, and of course, NeuroCOG is very important because we know uranium crosses the blood-brain barrier, and we know that neurocognitive and central nervous system targets are shared by a lot of different metals. On the right, I can show you what we used to include and what have been since sunsetted because basically we didn't find any abnormalities, but for a long time we did semen quality analyses, we looked for hypersensitivity with skin patch testing with our colleagues from dermatology. Early on, we weren't sure the best way to measure uranium, and the RAD Health people were telling us we had to do whole body radiation counting, and that turned out not to be right because it was less sensitive than urine biomonitoring, and so we stopped doing that. We looked for gene tox for a very long time because it's for obvious reasons, right? Metal toxicity as well as, again, this alpha agent sitting long residence time in soft tissue, et cetera. Already a lot of the gene tox, I mean all of the gene tox studies that we've done over time have not shown a difference between low and high exposed uranium groups. We did focus groups with colleagues from psychology to make sure we weren't missing any of the concerns that our patient cohort had in terms of health information, how they wanted us to run the inpatient visits, et cetera, and lots of lung function testing because at time zero, of course, there was an inhalation exposure as well, right? So one of our colleagues was a pulmonologist as well as an op doc, and we were including that. So the most complicated thing I'm going to show you is this. This is ... I'm trying to see what's going on with that slide. It must be the version. I'm really apologizing about this. So pretend this is an X and Y axis that you're seeing, and the distribution on the X axis is from low to high of the urine uraniums in 81 DU patients. And the concentrations of the uranium measures in urine are on the Y axis. And as you can see, there's a whole lot of blue symbols at the bottom with a few orange ones. And then at the extreme top, there are yellow symbols. And if you could read the legend at the bottom, the people at the very top, the far right, have a DU isotopic signature, and they have a fragment. So early on, we had to interpret this as the guys with DU were leaching uranium into their urine. And we've sort of seen this regularly since inception. And so we know that's the case now, and it turns out a famous, actually, radiation biologist person who was at the Boston VA, believe it or not, where there was, did you know the VA has a counting chamber? I bet it's kind of hard to believe what resources VA has, but we do. We have a counting chamber, should anybody ever need one. Pre-World War II steel lining, that's exactly what you want, because then that can filter out all of the radiation post-dropping the bomb. And so they could actually discern whole body counting from DU. Anyway, long story short, he told me, Dr. McDermott, we all know uranium rusts. And so they mobilize and leach uranium ions from their frags, and that is what we're picking up in their urine. But it enabled us to parse the population kind of tidally, as you can see here. There are a couple of folks who have orange symbols, which means they have a frag, but they have a lesser concentration of uranium. And there's a couple of cut points here that help parse the population, and our patients actually asked us to show them the group results every time we have a visit. We don't, obviously, they don't see anybody's result but their own, and theirs is circled, but they kind of wanted to know where they stood in this distribution. But in order to help them interpret this, we found some other values, like at the time, this was about, I don't know, 15 years ago, the NHANES results for the upper 95th percentile was 0.043 micrograms or 43 nanograms. We had chosen 100 nanograms as a cut point to do low, high urine uranium in our cohort, because when we started doing this almost 30 years ago, NHANES was not measuring uranium, and it was really hard to find normal values for normal populations in the medical literature. So we had, we found two sources, and we picked 100, and it's close to correct. Also, just to help everybody understand, including our patients, there are places in the U.S. that have this dietary limit that would be 365 nanograms per liter of uranium. That's pretty high. And so it helps kind of orient people who might be thinking, holy cow, look at how high my uranium is. But that's, there are places, as I say, in the U.S. that are that high. And the messed up thing at the top, unfortunately, is a currently allowed urine uranium concentration for DOE workers. So our highest folks are only approaching an allowable concentration for uranium workers now. So that's something to hold on to as I show you outcomes. Just want to say quickly, if anybody's noticing, some of these data are expressed per gram creatinine and some are per liter, and they're roughly equivalent with somebody who has normal kidney function. So just saying. Because we had to go with what the documents showed in the units that were originally used were primarily by volume, but of course we're standardizing everything by gram creatinine now to account for hydration status. Okay. So clinical findings in this friendly fire cohort, we can see and still do 30 years later sustained elevated urine uraniums in those who have fragments. And evidence demonstrated decreased bone mineral density, which is about the only uranium driven finding that we can show, even after I showed you that big pull down menu of all the things we were looking for. This makes sense because we know uranium is stored in bone. We are still following that, but we've seen that for the last three visits. So I think it's probably a for real finding. We've seen no other clinically significant differences detected in this long list. Mostly these are the things that I showed you that we've sundowned. But some of them we still continue to do anyway, like basic labs, urine chemistries, hematologic, such like. And we're still doing neuroendocrine measures as well. So that's reassuring, right? All right. So I'm back to my timeline. And besides the DU cohort, we were asked, this is the friendly fire cohort, we were asked to also accommodate all the other veterans who have concerns about maybe I was exposed or my wife wants me to get tested and this sort of thing. So we were charged with setting up biomonitoring by mail, which was a big deal methodologically because you can't use a regular urine containing cup. We had to figure out what kind of plastic. We had to figure out what kind of pictures and how to instruct someone in collecting these and what the collaboration would be with the local VA's provider and the patient and all this kind of stuff. Anyway, we set that up. The results of these are, we call these the mail, this is the mail-in cohort. We've done 9,000 of these now, about half from Gulf War I, about half from OIF-OEF. And the punchline is, as I said before on the left, we found only one DU isotopic signature from the Gulf War I that we hadn't known about and it was a friendly fire person. I will also call attention to the fact that early on, this group here, we worked extensively to do methods development because people didn't know how to, even DOE was not proficient in measuring isotopic analysis in very low total uranium concentrations and so we had to collaborate with a couple different labs and they had to actually develop methods to do isotopic analysis at total urine uraniums below 50 nanograms. So that was kind of a big deal. So we had to, the book wasn't yet written, so we had to get collaborators to help us with that, which was great. I'm out of time here, but I'm going to try to just tell you the punchlines. OIF-OEF, again, the four isotopic signature folks we found were those Air Force air to ground friendly fire. So I think there's high confidence that we don't think we're missing friendly fire or other reasons for somebody to have an isotopic signature. There's a real long questionnaire that goes in the kit for all the mail-ins and so we are able to interpret the results. So I feel fairly confident about that. So because of the mail-in story, there were a couple of other DOD events that took place in 2007. There was a decision made that any frag that comes out in surgery is supposed to be sent for content ID. We all know that's not happening, but, because I can see looks on some people's faces, but we can also tell that because we aren't receiving them, but that was thought to be important in order to determine content ID so that that would help know what else might be remaining in the body for folks that have more than one fragment. And we were also asked by VA central office to start a program for victims of IED injuries or RPG injuries who've got frags that aren't DU. And we kind of just enlarged the playbook of how to manage a patient with an embedded fragment longitudinally. And so that's been done and we had to determine what metals would be of concern, which I'll tell you in a minute, but if anybody's wondering why we're not taking the frags out, this is why we aren't taking the frags out. Okay? So the surgeons don't want to do this because there's not going to be anything left because of the surgical morbidity. So we have to manage folks medically. So we've done about 29,000 people have been asked in their medical history at VA if they think they have a fragment or have a fragment and about this group in red down here think that they do. And so we try to chase these folks. So of the more than million that have been screened and asked that question, about 70% might have a fragment. So we're following those folks, those folks, primary care doc from the VA of origin get an email from one of our nurses that says, please have the patient send us a urine. So that's what I'm going to show you now. And we also tell the local folks who are caring for these patients to get imaging because we want to do surveillance on the evolution of the frag. So here's the list of metals that we include now in the urine uranium, excuse me, the embedded fragment portfolio. These are metals of concern, metals that have been found and killed in injury reviews that have been done at Fort Detrick. And also we included the group on IARC carcinogen metals. So here's a example of a result from our colleague, Dr. Gatenson, about 2000 metals. And this is a summary of those that are abnormal. And of course, the questionnaire that we include helps us chase down and interpret an arsenic, for example, folks that have metal implants, cobalts and chromiums are going to be elevated sometimes. If someone's urine lead is elevated, we chase after that and we get a blood lead because the epi is easier to sort with a blood lead than a urine lead. And a lot of people have elevated zincs because zinc is everywhere. So we think with less concern about that. But this just gives you an idea of what we have to manage. And we return a individualized patient letter and an individualized provider letter to help the local provider chase down some of these metal elevations. How frequently they need to be repeated is a function of how high they were. Here's the additional, the list of homework for the primary care provider whose patient they've helped submit the urine. And in an interest of time, I know you guys have that. The key findings are we've looked at now 2300 of these veterans. The majority of the urines fall within established reference ranges. And the results serve as a baseline so we can follow people forward. Thanks for your attention. All right. Let's see. All righty. Are you guys awake? I know I got the post-lunch crowd, so sorry if I woke you up. So I'm the closer for today, so I'm going to try to be brief. I definitely want to make sure we have time for questions. So I'm Manny Berenji. I'm the rookie of this stellar team. Thank you, Dr. Ruhm and Dr. McDermott for really sending this great discussion today about military exposures. I'm just really going to provide some updates on Camp Lejeune as well as AFFF. So I don't have any disclosures, so let's go ahead and jump right to it. Many of you know about Camp Lejeune. I'm not going to belabor the point, but essentially starting in the early 80s, there was known contamination of trichloroethylene at multiple sites across Camp Lejeune. And really, over the last 40 years or so, there's been a strong effort by DOD as well as the VA to identify these individuals and make sure that we're getting them routed to the right resources. So for those of you that may not be familiar, I'm going to try to see if I can work this laser pointer. Let's see here. I just want to make sure I got the right spots here. So hopefully I'm pointing it the right direction. So there are two essential locations within the Camp Lejeune base that were areas of concern for the trichloroethylene. That includes Tarawa Terrace, as well as Hadnot Point. I'm going to try to see if I can point. There we go. So these are the two locations that were deemed to be contaminated sites. The EPA actually came in in the 1980s, and they determined that the concentrations of TCE were 70 to 100 times the maximum concentration levels by EPA. So the National Academy of Medicine, formerly known as the Institute of Medicine, has come out with a lot of thought leadership and papers looking at the contamination and the degree of contamination at these particular well sites at these two locations within Camp Lejeune. And I think many of you already know, a lot of these individuals were exposed to the well water. The TCE concentrations, again, were super elevated. And really over the last 40 years, there's been a strong concerted effort by multiple federal agencies to really try to identify these individuals. And speaking as the VA rookie, over the last two and a half years, I've actually seen a couple of folks who have come to my VA. I'm at the Long Beach VA in Long Beach, California, and have really relayed some of their concerns about their experiences at Camp Lejeune. I'm looking forward to continuing the conversations with them and making sure that we get them routed to the right resources. So I am not a policy expert by any means, but I did want to provide some education about legislation that's come out in the last 10 years or so. As you can read here on the slide, the Congress passed and President signed the Honoring America's Veterans and Caring for Camp Lejeune Families Act in 2012. And really what you need to know is that there were 15 health outcomes that were identified that were essentially associated with the TCE, PCE and a combination of solvent mixtures. I won't read all 15, you can read them there. I'm just gonna highlight a few studies. I know we don't have a lot of time to discuss, but I did want to mention this particular paper that came out about five, or I'm sorry, about 10 years ago. This was a study that came out by Bove et al. And they wanted to kind of look at mortality among Marines and Navy personnel who were exposed to TCE and PCE at Camp Lejeune. And they conducted this retrospective cohort study. So I actually just summarized it here in two bullets. You can go ahead and read that there. So essentially what they did was that they conducted a retrospective cohort mortality study of Marine and Naval personnel, essentially during a 10 year period in between 1975 and 1985. And essentially they had two specific cohorts. They looked at folks who were based at Camp Lejeune and essentially they had a control at Camp Pendleton. They actually did studies and they found that there was no evidence of any TCE or PCE exposures. So that was essentially their control. So just to summarize what they found, they did find that the folks who were at Camp Lejeune had elevated mortality hazard ratios for all cancers, kidney cancer, liver cancer, esophageal cancer, Hodgkin lymphoma, and multiple myeloma. Fast forwarding to 2017, there was more legislation coming. This is really just highlighting kind of the presumptions. And I know Dr. Rum gave a great overview of what presumptions are, but essentially this legislative action in 2017 was focused on active duty reserve and natural guard members who served at Camp Lejeune for a 30 day period between August 1st of 1953 and December 31st of 1987. And any of these individuals who had these respective cancer diagnoses and Parkinson's is also included, essentially were able to file a claim and essentially get service connected. So over the years, the Institute of Medicine, now the National Academy of Medicine, has provided the VA with additional subject matter expertise and guidance, really trying to make sure that they are following the most current evidence-based guidelines when it comes to monitoring these individuals who are exposed to TCE and PCE during their respective tenures at Camp Lejeune. And I highly recommend that you all take a look at this. I really don't have time to get into it. Fast forward again to 2022, Dr. Rum did a great overview of the PACT Act. And at least with respect to Camp Lejeune, I just wanted to bring the second bullet to your attention, Camp Lejeune Justice Act of 2022. And essentially all that you need to know about that is that it allowed individuals, including veterans, who were previously exposed to contaminated water at Camp Lejeune, they had the ability to file a new claim with the Department of the Navy. So I thought this third bullet was kind of interesting. Essentially individuals could also seek relief in federal court for a claim that was denied, or if there was no decision made after six months after a claim was filed. I just wanted to briefly highlight TCE and Parkinson's. So this is a paper that came out in the last few years in JAMA Neurology. This was a paper by Goldman et al. And they wanted to look at the risk of Parkinson disease among service members at Camp Lejeune. So I just summarized this here for your reference. So essentially it was a population cohort study. They wanted to compare the risk of Parkinson's among veterans who were at Camp Lejeune, again, from 1975 to 1985. And they kind of used the same study kind of methodology as with both et al. Essentially they used the Navy personnel at Camp Pendleton as their control. And essentially what they found was that there was a higher prevalence rate of Parkinson disease in the Camp Lejeune cohort compared to the folks at Camp Pendleton. And this just came out in the last year or so. The VA came out with this announcement stating that they were going to cover Parkinson's care for family members of veterans who served at Camp Lejeune. I think that's a good thing. So now I'm going to switch gears and talk about PFAS and specifically going to talk about AFFF. Do you all know what AFFF is? Raise your hands. Okay, so I'll try to do my best to at least do the subject justice, but feel free to come up to me later and I'm happy to share more material with you. So just to provide some background, PFASs are a family of more than 4,000 plus highly fluorinated aliphatic compounds. And when we're talking about AFFF or aqueous film foaming foams, PFAS is actually a significant component of that. And this particular compound was utilized by various different military operations, primarily in firefighting, but also in other military training activities. I love graphics. So I just wanted to kind of use this graphic to illustrate some points. We think of PFAS and there's various different routes of exposure. What I really wanted to highlight here was where active duty personnel would be exposed to AFFF. So if you can focus on that AFFF icon right there and look at the routes of exposure, clearly individuals who are utilizing this compound in their military activities, firefighting activities, they were exposed to it via inhalation. And as a result, this material was essentially leached out into the environment, as well as within the waste infrastructure. I thought this was a really great illustration of how AFFF has started to kind of be identified in various different facilities across the United States. This is a paper by Sunderland et al, and this came out a few years ago. And really what you need to know is you need to look at the big blue bubbles. I mean, if you look at the progression from 1999 through 2017, the number of military installations that had identified PFAS related compounds, including AFFF, really started to multiply. So I think this is really educational for a lot of us who work at the VA as well as DOD, kind of understanding the prevalence of AFFF and a lot of these PFAS related compounds and military personnel who were exposed to these compounds as a result. This is just some more background on AFFF. Essentially consists of fluorosurfactants, hydrocarbons, surfactants, solvents, and organic salts. And just based on the chemical structure, I don't have time to really get into all the chemistry, but essentially there's a low surface tension and that allows it to really disseminate widely. That's why it was a chemical of choice, especially for firefighters, if they wanted to get something extinguished really quickly, they chose this particular compound for that. So I just wanted to illustrate what this stuff looks like. Clearly it is, I mean, in the past, it was the go-to for firefighting activities. Clearly we've learned a lot in the last decade or so about the potential environmental and toxicological impacts of AFFF on military personnel and the long-term consequences of those exposures. I wanted to highlight a couple of areas where AFFF has been found. So just to kind of highlight what's on this slide, some military bases did use what are called fire training ponds or FTPs for firefighting training activities. And AFFF was a compound that was utilized during these trainings. I'm sure many of you in the audience may know more about this than I do, but I was doing some research on this and these particular ponds had super high concentrations of AFFF. So, you know, there's ongoing studies about the extent of these exposures. I just thought this was something interesting to highlight. So I know many of you in the audience work for DOD. I just wanted to make sure that we could provide some education for the rest of our audience about some of the highlights with respect to the PFAS task force. This was started a couple of years ago and essentially it consists of five pillars as you can see here, managing or sorry, mitigating and eliminating the use of AFFF and then fulfilling the cleanup responsibilities, understanding the impacts of PFAS and then really looking at public outreach to veterans and other members of the general community and then really focusing on research. So DOD does perform annual occupational exams, really trying to make sure that they're evaluating these individuals and there's also some efforts between DOD and NIOSH and this is just highlighting some additional information about DOD's efforts with respect to AFFF and ensuring that there's a plan to essentially transition out of utilizing AFFF products for firefighting and other types of training activities. So I think that's progress. Let's see here. So yeah, this is just a continuation of looking at some of the programs that the DOD has recently implemented, really looking at ways to essentially not utilize AFFF for any type of firefighting or other type of activity on military installations and this is an announcement that came out a few months ago. I thought it would be good to highlight here. The DOD is really active in trying to identify these locations that do have PFAS contamination and making sure that there are cleanup actions taking place. Again, very good progress and I think that's all I had. So thank you. I know we're short on time. I want to give Dr. Eric Schuping, who's here in the audience, a chance, because we're doing some revolutionary things with operational registry exams and assessments. I'll give him like one or two minutes. Dr. Schuping, do you want to help? Are you sure? Yeah. I've got three minutes left. Come on. Okay. Is there a break before the next session, Steve, or should we go right into it? Is there a break? All right. So, we might go. Just two minutes. Two minutes. Okay. Bill Shepard's crook. Sorry about that. Yeah. Shepard's crook. I'm about to go too long. Yeah. I wrote down some notes here, and I want to talk about our registry programs. Dr. McDermott talked about, too, so I'll skip them, but one common theme is when they started. So, let's talk about how long they've been going on and who we're there for. The first is the Ionizing Radiation Registry, started in 1986, and this is dedicated to what we call atomic veterans, people who were prisoners of war, Hiroshima, Nagasaki in Japan, people who served shortly thereafter near the atomic bombs, and people who were part of the surface detonations that the U.S. did and underground detonations, too. So, really, this cohort ended in the 1960s. Moving on to Vietnam veterans, we know about the Vietnam War. It's enrolled 822,000 people so far, so it's got really good penetrance, and we're still enrolling people, too, but this registry actually started by the VA in 1978, but Congress kind of codified the law in 88, too, so another very longstanding registry. That brings the Gulf War Registry, and that was designed for, really, Gulf War illness, which is still being worked on. Started in 1992, and it's really kind of morphed to a combination with the Burn Pit Registry. Pretty much everyone in the Gulf War is eligible for the Burn Pit, but not the reverse, too, but they're about 80% overlap. So, these four registries, or three registries, have been going on for a really long time, and that brings us to the Burn Pit Registry. Ten years now. The next month is going to be a 10-year anniversary of it, and enrolled about a half a million people, so a lot of people have joined. However, the whole population is 3.7 million people, actually, a higher estimate, 4.7 million, so we're about one-sixth of the group, and one of the goals of these registries is to do surveillance, to look at the entire population, and we only really got a fraction of that, too. So, we're in the process of changing this to an opt-out system, where we auto-enroll everyone. If you don't want to be in it, let us know. We'll take you out. So, it'll be really totally different right now, and some of you may have tried to join the Burn Pit Registry. Alternatively, it takes an hour to start. You have to struggle with a secure log-in, you know, take all that time, and answer a lot of questions, 140-plus questions, too, so if a person's had multiple deployments, it can take up to three hours to do that, so a lot of people just stop. It's like, I don't want to do this. I don't have the time or interest, so that's part of the reason why, you know, it's only a half a million people doing so. This opt-out system will be absolutely zero effort for the veteran, you know, moving forward. They'll be in it, and we'll have that data for surveillance, so, you know, what I'm telling you is this is kind of a general trend with the VA. Back in, really, up to 22, the registries were like the thing, but as Dr. Ruhm illustrated, PACT Act, all this enhanced surveillance, all these different things, we're really changing things around, you know, what we're doing with the VA, and instead of these fairly expensive, you know, multi-person registries, we're going to move to a different system, and Dr. Steve Hopp will talk about that, exposure-informed care, which will be a primary care initiative where exposure is just more mentioned, talked about, acknowledged at the primary care, but as we all know, primary care is very busy. They have more things to do than time allowed, and if you really want to do, like, an exposure assessment, it takes time. You know, give yourself an hour, maybe longer, and you need the expertise, too, which is what this conference is about, you know, learning that expertise, so, you know, we're setting up a system, which is kind of a pop-off valve for primary care, if the needs of the veteran exceeds the time and knowledge, they have somewhere to go, you know, to, so one more thing to really mention is ILR, Individual Longitudinal Exposure Record Program, is a database of people, people who served, and their exposures, to a certain degree. It's got a lot of work to do before it's really ready for primary care use, however, one of the biggest utilities of it, and, you know, we talked about Camp Lejeune, PFOS, not a day or week doesn't go by, we're asked to start a registry, you know, last week was Chernobyl, you know, from the 1980s, and we just can't possibly start a registry like we're doing for everyone, but this ILR system, you know, let's fast forward 20 years from now, there's going to be another compound, don't know what it's going to be called, that's going to make the news, and people are going to be concerned about it, too, and people are going to know, hey, what about our health, you know, this ILR program, if done well, we could pull a cohort, you know, pick a base, pick a time, and start studying the VA health records of the people, so that's kind of the wave of the future, and I think my two minutes are way over, and listen to Dr. Hunt's lecture, it's going to be good this afternoon. All right, does anybody have any questions for Dr. Berenji, or Dr. McDermott, or myself? So, I had a question about just the ILR system, first, I'd just like to thank you for all the work you've done, incorporating the activities of the PACT Act, and really coming forward as a preventive medicine physician, and the chief of public health at Fort Campbell, I have a lot of soldiers that come to me, and asking me, hey, this is what I've done, this is what I do, I grind on CARC pain all the time, I heard that I'm going to get cancer from Hexchrome, and it's down to me to be that person to go, hey, we're kind of tracking all this stuff, but when you look in the ILR, like, it's doing a fantastic job at that environmental exposure for wastewater, or PFAS, but it doesn't get down to that granularity of, okay, you are an airframe mechanic that does airframe mechanic stuff, and these are the exposures that we understand are appropriate to that MOS. Is there a plan to get to that point at some time, or is this something that we're hoping to go retroactive with, to really be able to define for that individual soldier what your exposures were, to gratify whether that's a work-related issue in the future? Yeah, ILR, a work in progress, you know, for sure, you've seen it, you'd probably agree with that, and there's good things, too, but it's kind of limited right now, and first and foremost is just the people in there, getting to the DOD personnel system. I'm retired Army, so I know the system, too, and we collaborate really daily on ILR. Kind of one of the best things that has happened to ILR recently is getting into VA government bureaucracies, you know, how large organizations work, and this ILR work was really about five years down to, you know, senior people, and that's changing. It's going to be run by two SESs, one DOD and one VA SES. It's called the ILR Business Line, and I hope they'll have the muscle power to talk to DOD about the changes it needs, because really, everything that's sampled, put in there, it happens on the DOD side, right? Once they're veterans, we clean it up, right? But yeah, I think some good, honest conversations need to have with DOD to have that data be as good as possible, and I think we've got the firepower to get there now. And that's behind you, is doing the evaluations to demonstrate what they're experiencing in their workplaces at that location. It's just not transferring over this muscle machine of ILR that we've created. Yeah. Hey, Jess. Hi. Good afternoon. Thank you, everybody, for an excellent series of talks. So the answer to the garrison question is DOORS IH, that feeds into ILR, and I'm going to put my colleague on the spot, John O'Neill. Hey, John, can you talk about what the Air Force does with ASIMS? Air Force has a program called ASIMS that's not a government program, where the industrial hygienics and DEs put in the same exposures into the ASIMS model with a supervisor. Air Force has a program where the industrial hygiene data gets put into the exposure for the ASIMS OH module. The supervisor then says who works at that point, and then the OCMED provider can see that by the shop. So that actually matches the real-time exposure data in together with the medical data. The other services, the Army does it sometimes, the Navy does it sometimes, but that data is put in DOORS OH, which does not talk to any of the other medical records. And the big problem is matching the actual exposure records with the patient's or the worker's or their service member's real exposure. And Genesys is not set up to do any type of this analysis. So one of the capability gaps that we have in active-duty military is really getting the exposure data we know to match it in the OCMED records together. And that's a major problem we have and needs to be addressed. I'm going to make a suggestion that those with the ILR come up and talk to Dr. Shookley afterward. And then next year at ACOB, we get an hour session on ILR, because there seems to be a lot of interest in ILR. He'll look for some co-speakers, because we are hoping to expand this next year again. We had nine hours a year ago. We only had an hour this time. But ILR is critical. And again, it's going to have that high visibility and executive leadership, at least in the VA and DOD, to really push it to the next level. So my email is peter.rumm at va.gov. But I know Dr. Shookley would also give out his. Anybody has any ideas, come up and talk to us afterward. Is there any other question other than ILR? I want to make sure we don't... Anyway, all right. Well, thank you for a great attendance. Thank you. Thank you. You got your talk for next year.

Dr. Peter Ohm

military environmental exposures

PAC Act

Ionizing Radiation Registry

Vietnam Veterans Registry

Gulf War Registry

Burn Pit Registry

Camp Lejeune Justice Act

PFAS contamination

Individual Longitudinal Exposure Record Program (ILR)