**Environmental Agents Service Conference Call -- August 2, 2005,
1:00-1:50 Eastern Time, Room 864 VACO**

**Opening Remarks/Welcome/Introductions DRosenblum**

Greetings from VA Central Office, Washington, DC

Welcome to Environmental Agents Service (131) Conference Call,

I am Donald J. Rosenblum, Deputy Director, Environmental Agents Service
or EAS.

With me today are John Kraemer, Helen Malaskiewicz, Michelle Foster, and
our extraordinary intern Tiffany Anzalone all from the EAS, and Clare
Mahan from the Environmental Epidemiology Service (EES). Clare is here
due to recent retirement of Nancy Dalager of that office, she will
report on her services' recent activities. Absent today is Dr. Brown,
our Director. Dr. Otchin will also be joining us today in our conference
call, Dr. Otchin is Clinical Director in the Office of Public Health
Environmental Hazards.

I understand that several people from the business policy office have
called in or will call in to respond to eligibility questions you may
have.

Our most recent quarterly conference call was held on May 3, 2005. The
last call for this year, is planned for Tuesday, November 1 at 1:00 p.m.
eastern time.

As usual, we have a series of VACO and other presentations followed by
an opportunity for listeners to ask questions, make comments, etc.

Once again, we request that you hold any questions/comments until that
part of the call. Please mute or turn off the telephone speaker until
you are asking a question or making a comment. Thank you for your
cooperation.

**Conference Call Contest MBrown DRosenblum**

As you may recall, the contest question for our previous EAS conference
call was, "how should VA's Environmental Health Clinicians and
Coordinators respond to OIF/OEF veterans requesting a Gulf War registry
examination?"

Ok, it probably wasn't really a great question \-- even though I know
you all know the answer!

Unfortunately, we had no Winner for May 3, 2005 EAS Conference Call
Contest!

That is why Dr. Brown, as the default winner when nobody enters, is
lucky enough to be on an all expenses paid vacation in Florida right now
in the interest of full disclosure, he is (using his own money, of
course).

The answer we were hoping for was that OIF veterans are just as eligible
as Desert Shield/Desert Storm veterans for a Gulf War registry
examination.

That means, any OIF veteran who requests one should be provided the Gulf
War registry exam.

Furthermore, you may have noticed that the Gulf War registry examination
code sheet has space on it to indicate date of service and other
relevant information that will allow us to distinguish from veterans who
served in the 1991 Gulf War.

OEF veterans (those who served in Afghanistan) are not considered to be
Gulf War veterans, even though they are fighting in the same overall
conflict in the same part of the world. OEF veterans who request a
registry examination should be told to make an appointment with their VA
primary care provider instead.

For today's EAS conference call contest (get out your pencils and
paper), the question is:

"Name at least one important environmental hazard for Operation Iraqi
Freedom or Operation Enduring Freedom that you can find information
about at our web site www.va.gov/EnvironAgents."

And, if you think that you know the answer to this EAS conference call
contest question, send it to me at <rosdon@hq.med.va.gov>. We'll
announce the winner on our next conference call.

Please have your entries here within one week, and immediate past
winners not eligible, which would include Dr. Brown!

And as always, we welcome your question and comments -- we realize that
you may be hearing about new concerns among new OIF and OEF veterans
before anyone else and we'd very much like to hear from you about these
issues!

Also, if you have any suggestions for future topics that we can cover in
future conference calls, please email them to Dr. Brown at
<mbrown1@hq.med.va.gov>, or to me.

We have a lot of topics to cover today.

**Announcements and Commentary MBrown**

**Now I will turn the microphone over to Tiffany Anzalone who will make
some announcements on behalf of our Director, Dr. Mark Brown.**

On July 19^th^ we participated in a Congressional Hearing for
Congressman' Chris Shay's Subcommittee on National Security, Emerging
Threats and International Relations, of the Committee on Government
Reform.

As you may recall, Congressman Shays has had many hearings over the
years on Gulf War veterans' health issues, and has generally been
outspokenly critical of VA and DoD efforts to help veterans from that
conflict.

The title of the hearing was "Occupational and Environmental Health
Surveillance of Deployed Forces: Tracking Toxic Casualties."

Dr. Susan Mather accompanied by Dr. Mark Brown testified for VHA.

Several veterans from the current conflicts in Iraq and Afghanistan
testified first.

These recent veterans spoke of a wide range of environmental health
concerns including the generally poor living conditions encountered by
U.S. troops living in that area, and concerns about long-term health
consequences from exposure to depleted uranium, vaccines and other
materials.

One veteran, Mr. Raymond Ramos, retired staff sergeant of the 442^nd^
Military police company, of the New York National Guard, spoke very
movingly of his frustration in getting answers to his questions and
concerns about possible health effects from Depleted Uranium.

He strongly believed that he and others in his unit had been exposed to
DU, and that it had had led to a lot of health problems among them. This
included some accounts of reproductive health problems among members of
his unit.

Apparently, DoD had been unable or unwilling to address his concerns,
which as we have seen before with veterans from Vietnam and from the
1991 Gulf War, only served to strengthen his health concerns.

I can tell you that listening to his testimony, we really sympathized
with this veteran's situation. Not getting good information about his
health concerns had clearly made his situation worse.

I think this story shows how VHA's Environmental Health Clinicians and
Coordinators can help veterans by providing credible answers to
questions about environmental health concerns.

When veterans come to VA with questions such as "how could DU affect my
health and how can I get tested," we should be prepared to either give
good answers, or know how to direct a veteran to those answers.

We here in Central Office see a big part of our job as making credible,
scientifically based information available to folks in the field who
will come across environmental health questions from veterans seeking
our care.

As I'm sure you all know, we maintain a lot of current information on
environmental health issues on our web site at
[www.va.gov/EnvironAgents](http://www.va.gov/EnvironAgents).

For example we have a number of products available on line specifically
to answer heatlh questions from veterans and others concerned about DU.
Examples include:

1.  The Independent Study Guide, which is part of the Veterans Health
    Initiative or "VHI, called "A Guide to Gulf War Veterans Health."

2.  The VHI Independent Study Guide called "Health Effects from
    Chemical, Biological and Radiological Weapons."

3.  Our "Ionizing Radiation Brief: Depleted Uranium (DU)" came out in
    December 2004, and provides basic information for health care
    providers, veterans, their families and others with concerns about
    long-term health effects from exposure to DU.

4.  Finally, we posted a "Frequently Asked Questions" brochure on DU,
    and also reprints from back issues of the Gulf War Review that
    covered DU health effects.

All of these materials are available at [www.va.gov/EnvironAgents and
www.va.gov/GulfWar](http://www.va.gov/EnvironAgents and www.va.gov/GulfWar).

So if you haven't checked these web sites out yet, now would be a good
time!

**Next, I'd like to turn to a publication that came out this week that
reported an increased risk of brain cancer deaths among 1991 Gulf War
veterans, possibly related to sarin exposure.**

Many of you have asked us this week about a scientific publication that
came out this week that reported US Army 1991 Gulf War veterans possibly
exposed to low levels of nerve agents during March 1991 weapons
demolitions at Khamisiyah, Iraq, have an increased risk for brain
cancer.

Congressman Lane Evans has already issued a press release asking that
Secretary Nicholson presumptively service connect brain cancer among
1991 Gulf War veterans.

The title of the article is "Mortality in US Army Gulf War Veterans
Exposed to 1991 Khamisiyah Chemical Munitions Destruction," and it
appeared in the August 2005 issue of the *American Journal of Public
Health*.

DoD requested the National Academy of Sciences Institute of Medicine
(IOM) to conduct the study, which also involved VA researchers.

As many of you will remember, health problems from low-level sarin
exposure became an issue for 1991 Gulf War veterans following
revelations that some Iraqi munitions destroyed by US forces at
Khamisiyah contained this agent.

DoD-sponsored exposure modeling concluded that Gulf War veterans were
exposed at most only to sub-clinical sarin levels (less than that
causing any immediate or obvious poisoning).

A 2000 IOM review and 2004 update for VA concluded that a substantial
scientific literature, including reports based on Khamisiyah modeling,
does not suggest any long-term health effects from sub-clinical sarin
exposure.

In the new study, using the DoD exposure model, researchers compared
causes of death among 100,487 sarin-exposed to 224,980 non-exposed Army
Gulf War veterans.

They reported no difference in overall death rates or cancer death
rates. However, exposed veterans were about twice as likely to have died
from brain cancer compared to unexposed veterans -- about 12 excess
brain cancer deaths among the 100,487 exposed veterans over a 9-year
period (this is a rare cancer). 

Consistent with earlier studies, overall mortality for these veterans
was less than half that of the US population.

There are several significant limitations with the new study.

First, DoD Khamisiyah exposure modeling has been soundly criticized as
unreliable by both the U.S. Congressional Government Accounting Office
(GAO) and the IOM. The IOM concluded, "Because of the uncertainty in the
\[Khamisiyah\] exposure assessment models . . . studies \[based on that
model\] do not provide strong evidence for or against the presence of
neurologic effects."

Second, the report's authors also point out that since sarin is not a
known carcinogen, it may be that the demolitions at Khamisiyah released
other hazardous agents that could have caused the apparent increased
risk of brain cancer death.

Finally, the multiple statistical comparisons used in this study could
have lead to a spurious statistically significant association.

The authors conclude that additional research is needed to confirm
findings of a higher brain cancer death risk for some Gulf War
veterans. 

We'll keep you informed about what happens next with this research!

**Radiation Report -- Dr. Otchin**

Dr. Neil Otchin: Radiation Activities: I just want to mention a few
things I think I missed the previous conference call in May, so it may
have been already mentioned for radiation compensation claims the VA is
no longer using screening doses that was developed in 1988 but now is
using software that was developed jointly by HHS and the VA to estimate
the likelihood that radiation caused the claimed disease. So we're no
longer using the screening doses but we are using a new software. Also
we want to announce that a updated version of the Veterans Health
Initiative Education Program Veterans and Radiation that was published
in November 2004 is now available on the internet in addition to the
intranet and the internet address is
<http://www1.va.gov/VHI/docs/Radiationfinal.pdf> and I want to mention
that this also includes a section on depleted uranium. While intended
primarily for VA staff the module is also available to veterans and
others if requested. If there are any questions please feel free to call
or email me after this call.

.

**Status of EES Studies' Updated Clare Mahan**

I shall spend a few minutes summarizing the mortality study of 1991 Gulf
War Army veterans who may have been exposed to nerve agent sarin by the
weapons demolitions at Khamisiyah, Iraq in March 1991. The mortality
study examining cause-specific mortality risk of Gulf War veterans
potentially exposed to chemical warfare agents at Khamisiyah Iraq has
been published in the August 2005 issue of the American Journal of
Public Health. Last week, certain aspects of the finding of excess
deaths due to brain cancer in the possibly exposed Army veterans were
printed in USA Today.

This study was a collaborative effort between EES and the Institute of
Medicine. Likelihood of exposure was based on the plume model developed
jointly by Department of Defense and Central Intelligence Agency
personnel. This model developed in 2000, is considered a refinement of
the exposure model created in 1997. The study compared the
cause-specific mortality of Gulf War veterans potentially exposed to
nerve agents released at Khamisiyah to Gulf War veterans not believed to
have been exposed. Looking at overall mortality as well as
cause-specific mortality, the only cause of death for which there was a
statistically significant increased risk was deaths due to brain cancer.
Compared to unexposed, exposed veterans had an almost 2-fold increased
risk (RR: 1.94; 95%, C.I., 1.12-3.34) of deaths due to brain cancer. Of
the particular interest was the dose-response relationship observed
between length of exposure and risk of brain cancer deaths. As length of
exposure increased from 1 to 3 days, so did risk of brain cancer. Brain
cancer death rates per 100,000 persons increased steadily as number of
days exposed increased limiting the risk analysis to only those deaths
due to primary brain tumors did not change the association between
potential for exposure and risk of brain cancer deaths. Additional
analyses that addressed; 1) effects of exposure to oil well fire; 2)
exposure misclassification; and 3) diagnostic misclassification also did
not alter the original finding between potential of exposure and
increased risk of brain cancer deaths. It is important to note that
sarin is not a known carcinogen and that there was no indication of
acute sarin exposure among troops at Khamisiyah at the time of the
demolitions. However, this study suggests that these potentially exposed
veterans should be monitored into the future. Tim Bullman is the lead
author and statistician of this manuscript.

Longitudinal Health Study of Gulf War Era Veterans

The data collection period of the Longitudinal Health Study of Gulf War
Veterans has been completed and final files are being reviewed in
preparation for data analysis. A total of n=9388 veterans responded to
the 16 page survey questionnaire by mail. A sample of non respondents to
the paper survey were offered a Computer Assisted Telephone Interview
(CATI) and a total of n=496 veterans completed the interview. These
interviews provide data to assess selection bias among the veterans who
chose to participate early in the data collection period compared with
those who did not respond until telephoned.

A major effort on confirmation of self- reported reasons/conditions for
doctor visits or hospitalizations, as reported by the veteran
respondents during the paper survey or telephone interview, forms part
of Phase 2. After request from a sample of veterans for permission to
contact his/her provider, and follow-up for receipt of signed
authorization forms, a total of 549 sets of medical records have been
received from providers. During the next month, the medical records will
be compared with the conditions or reasons for visit/hospitalization as
reported by the veteran. The results of the comparisons will be assessed
in the validation study.

Since the last conference call, several manuscripts in which EES has
been involved have been published or accepted for publication in peer
reviewed journals. The Prisoner of War paper entitled, "Risk of Selected
Cardiovascular Diseases and Posttraumatic Stress Disorder among Former
World War II Prisoners of War", is in press in Annals of Epidemiology.
This study provides at least partial scientific basis for providing
compensation to WWII POWs with Cardiovascular Diseases.

In June 2005 issue of Annals of Internal Medicine, the results of
combined efforts of Investigators at 16 Veterans Affairs Medical Centers
were published in a paper entitled, "Gulf War Veterans' Health: Medical
Evaluation of a US Cohort." The veterans in this study are a subset of
deployed and nondeployed veterans who had participated in the National
Health Survey of Gulf War Era Veterans and Their Families in 1995/97.
The 2005 manuscript presents the results of the direct medical
evaluations designed to assess and compare long-term prevalence of
selected medical conditions.

In collaboration with colleagues from George Washington University,
Department of Epidemiology and Biostatistics, EES has collaborated in
the publication in Military Medicine entitled, "Is Testicular Cancer
Related to Gulf War Deployment? Evidence from a Pilot Population-Based
Study of Gulf War Era Veterans and Cancer Registries." Our data from
this pilot study and those of investigators studying Vietnam veterans
suggest that testicular cancer may be related to military deployment.

There are three papers which give results of the collaborative effort
between the Medical Follow-Up Agency of the Institute of Medicine and
the VA Environmental Epidemiology Service on effects of possible
exposure to chemical warfare agents at Khamisiyah in 1991. The first
paper was described earlier, "Mortality in US Army Gulf War Veterans
Exposed to 1991 Khamisiyah Chemical Munitions Destruction," published in
August 2005, American Journal of Public Health. Two companion papers,
accepted by Military Medicine, are entitled, "Health effects in Army
Gulf War veterans possibly exposed to chemical munitions destruction at
Khamisiyah, Iraq I. Morbidity associated with potential exposure," and
"Health effects in Army Gulf War veterans possibly exposed to chemical
munitions destruction at Khamisiyah, Iraq. II. Morbidity associated with
notification of potential exposure."

This completes my report for today. Thank you.

**Registry Updates and Related Administrative Issues HMalaskiewicz**
**and MFoster**

To evaluate whether VHA standard policies and procedures issued for our
Environmental Health programs are being followed, we e-mailed a survey
to all EH coordinators. Out of the 172 EH coordinators who received this
survey form, 161 responded.

11 VA facilities have failed to respond. Since we do not want to
embarrass anyone, we will not give you the names of these facilities but
they are located at: Alexandria, LA; Battle Creek, MI; Big Spring, TX;
Butler, PA; Detroit, MI; Kerrville, TX; Prescott, AZ; Sheridan, WY;
Syracuse, NY; Tucson, AZ, and Walla Walla, WA.

In summary, of the 161 coordinators that responded, close to 70%
answered positively to our inquiries indicating that they are following
the policies and procedures issued by the Under Secretary for Health. A
breakdown of these responses will appear in the minutes of our
conference.

Here's the Survey Breakdown prepared by Tiffany Anzalone (summer intern)

**Summary of Environmental Health Coordinators Survey**

To evaluate whether VHA standard policies and procedures issued for our
Environmental Health programs are being followed, in June EAS e-mailed a
survey to all EH coordinators. Out of the 172 EH coordinators who
received this survey form, we received 161 responses.

8 VA facilities have failed to respond. These facilities are located in:
Tucson, AZ; Walla Walla, WA, Battle Creek, MI, Prescott, AZ; Alexandria,
LA; Sheridan, WY; Detroit, MI; and Butler, PA.

The following summarizes these responses:

**At the time of summarization, there were 159 responses:**

-   59.74% Have every publication available for reference purposes in
    hard copy and website

-   66.8% said they are scheduling all registry exams within 30 days of
    the request date

-   22.6% said they are not scheduling the Agent Orange Registry Exams
    within 30 days

-   23.27% said they are not scheduling the GW/OIF Registry Exams within
    30 days

-   19.49% said they are not scheduling the IR Registry Exams within 30
    days

-   Those that are not scheduling exams w/in 30 days are scheduling them
    at a range of 45 days to at the most 7 months.

-   98.1% enter registry data in AAC website

-   62.26% enter data within 10 days following the completion of the
    examination

-   On average, if they are not entering the registry data, there are 33
    code/work sheets waiting for data entry

-   69.18% attend the EAS quarterly telephone conferences

-   72.95% disseminate all posting information (registry posters,
    newsletters and other publication, memos)

-   73.58% mail follow-up letters to veterans regarding the results of
    their registry examinations w/in 2 weeks of their completed registry
    examination (117)

-   If No, these letters are mailed out to the veterans on average, 1 to
    2 months after the exams.

-   Less than 1% said no letters were initiated by EH clinicians

-   88.67% advise VACO of any staff changes that occur

Facility directors will be receiving letters from our office regarding
failure to comply with scheduling, mailing follow-up letters and
entering registry data in the AAC website.

This survey will be repeated next year with revisions to include areas
for explanatory notes. We appreciate your time and effort on this
important issue.

However, for those EH coordinators that stated non-compliance with VHA
legislative and administrative policies and procedures issued by VA
Under Secretary for Health in Handbooks and Directives (located on our
website
[[http://vaww.va.gov/environagents/]{.underline}](http://vaww.va.gov/environagents/),)
facility directors will be receiving letters from our office requesting
correction of these deficiencies. In addition, we will be sending
letters to those facilities that have not responded to our survey.

This survey will be repeated next year with revisions to include areas
for explanatory notes. We appreciate your time and effort in completing
these surveys.

A revised VHA Handbook on the War Related Illness and Injury Study
Centers located at East Orange, NJ and Washington, DC will be
transmitted tomorrow (8/3/05) to all VA facilities This updates the July
15, 2004 issue. Just a reminder - this evaluation program is offered to
any combat veteran with disabling, unexplained illness. The protocol
calls for an evaluation at a VA facility and referral by a Primary Care
clinician. The veteran must be in a stable condition to travel with no
drug or alcohol abuse. There are two forms that require completion - one
WRIISC assessment to be completed in CPRS Clinical Notes and the other a
one page pre screen form to be faxed to me. Travel costs for one leg of
the journey to the WRIISC is absorbed by the local VA facility of
referral and the return trip by the WRIISC. No registry involved.

Now with relation to our new website for data entry
[\<[http://vaww.registries.aac.va.gov](http://vaww.registries.aac.va.gov/)\>]{.underline}
, the AAC staff from Austin are available to address any questions that
you might have on this new entry system. Please go ahead and call in
with your questions now.

**Helen**: There was a question posed to Roscoe Butler, the Business
Office

in Central Office from Elaine Lum in Hawaii, it concerns veterans
exposed to Agent Orange outside of Vietnam. Roscoe can you address that
question?

**Roscoe Butler** Yes, I can. The CBO recently emailed the following
guidance to the field. DoD has published a list of instances where
service members could have been exposed to Agent Orange and related
herbicides outside of Vietnam. It includes many military facilities both
in the U.S. and abroad. Therefore, if VA can establish that a veteran
was in any location designated as a documented testing area for AO, or
was involved in the transportation or spraying of the herbicides for
military purpose, VA would determine them to be eligible for the
registry exam. However, if VA is unable to verify this information, the
veteran may be required to provide proof of his/her assertion.

A copy of the list of sites where testing occurred outside of Vietnam
will be included as an attachment to these conference call minutes.

**Education/Outreach Initiatives** **DRosenblum**

I have some information about Outreach, I'm happy to report that a
number of outreach initiatives have been completed or are moving forward
since our last call.

The Agent Orange Revised April 2005 is being printed and distributed, we
had some distribution problems that have been resolved, work is on the
way on a new Newsletter tentatively planned for October 2005. The Gulf
War Review dated May 2005 was put on the internet but is not being
mailed out due to budgetary considerations.

We anticipate publication of the Ionizing Radiation Review and the
OIF/OEF Review Newsletters this month. In addition we're working on
revisions of three information bulletins that's IB10-41, IB 10-42,
IB10-49, that is, the Gulf War Veterans Illness Questions and Answers
Brochure, the Gulf War Research Report to Veterans, and the Agent Orange
General Information Brochure.

Soon there will be more Agent Orange Briefs and Ionizing Radiation
Briefs have been revised and will be mailed to you this month. We're
also making progress on completion of a similar fact sheet series for
Gulf War veterans named the Gulf War Briefs, we hope to have them
completed in October 2005**.** Much of these advances were possible by
the good work of our 2005 summer intern Tiffany in relation to her hard
work on these publications she has written a soon to be published
article in Vanguard about our four national newsletters, co-hosted VA
News this week, and has been a big help to Helen on the all station
survey discussed earlier in this call. We have a surplus of the most
recent issue of the OIF/OEF review and Gulf War review newsletters, if
any station need a copy of these publications please contact me.

Questions and Comments from Field Stations Field

**Next conference call -- Tuesday, November 2, 2005, 1:00-1:50 p.m.,
Eastern Time**