# Presentation: 631316

## Air Force Interaction with IOM

- Karen Fox, Col, USAF, MC
- Principal Investigator
- Brooks City-Base TX

## Air Force Interactions with IOM

**February 2005, briefing by Dr Michalek**
**May 2005, visit to Brooks City-Base**
**Responded to questions**
**Scanned and provided data upon request**
**Documented all laboratory test across all 6 cycles**

## Slide 3

| TEST DESCRIPTION                                  CYCLE: | 1 | 2 | 3 | 4 | 5 | 6 |
| --- | --- | --- | --- | --- | --- | --- |
| HEMATOLOGY                                   |  |  |  |  |  |  |
|    CELL COUNT/INDICIES | X | X | X | X | X | X |
|       WBC | X | X | X | X | X | X |
|       RBC | X | X | X | X | X | X |
|       RDW | X | X | X | X |  |  |
|       Hgb | X | X | X | X | X | X |
|       Hct (%) | X | X | X | X | X | X |
|       MCV (Cu microns) | X | X | X | X | X | X |
|       MCH  (ug) | X | X | X | X | X | X |
|       MCHC (gm/dl) | X | X | X | X | X | X |
|       Plt (Thou/cumm) | X | X | X | X | X | X |
|    DIFFERENTIAL | X | X | X | X | X | X |
|       NEUTROPHILS | X | X | X | X | X | X |
|       LYMPH | X | X | X | X | X | X |
|       MONO | X | X | X | X | X | X |
|       EOS | X | X | X | X | X | X |
|       BANDS | X | X | X | X | X | X |
|       BASO | X |  X | X | X | X | X |
|       BLAST | X | X | X | X | X | X |

## Slide 4

| CHEMISTRY MISCELLANEOUS                 | 1 | 2 | 3 | 4 | 5 | 6 |
| --- | --- | --- | --- | --- | --- | --- |
|    FSH | X | X | X | X | X | X |
|    LH | X | X | X | X | X | X |
|    TESTOSTERONE, FREE |  |  |  | X | X | X |
|    TESTOSTERONE, TOTAL | X | X | X | X | X | X |
|    SEX HORMONE BINDING GLOBULIN |  |  |  | X |  |  |
|    ESTRADIOL |  |  |  | X | X | X |
|    T4, FREE |  |  |  |  |  | X |
|    T4, RIA | X | X | X | X | X |  |
|    T3, FREE |  |  |  |  |  | X |
|    T3,UPTAKE | X | X | X |  |  |  |
|    TSH | X | X | X | X | X | X |
|    FTI | X |  |  |  |  |  |
|    PSA |  |  |  | X | X | X |
|    INSULIN,FASTING |  |  |  |  |  | X |

## AFHS Viability Study

**SpecPro Inc.**
**San Antonio, TX, USA**
**    ****	****	****	****	****	**

**Dr. Marian Pavuk**

## AFHS Viability Study

**Purpose: **To examine the viability of AFHS archived biological specimen
- Over 70,000 samples stored
- Some stored for over 20 years

## Viability Study Objectives

**We want to assess whether:**
- The MAP technologies can be applied to assay biochemical parameters in AFHS frozen specimens
- AFHS frozen samples are viable for use in future studies by other investigators

## Viability StudyMethods

- We randomly selected five AFHS veterans who participated at the 1982, 1985, 1987, 1992, and 1997 physical examinations and had multiple serum samples stored
- One sample per examination per participant was selected
- Total of 25 serum samples to be analyzed

## Viability StudyTechnology

- Multi-Analyte Profile (MAP) testing by the Rules Based Medicine laboratory (Austin, TX) to analysis samples
- MAPs are high-density, quantitative immunoassays panels that allow identification of biomarker patterns
- MAPs provide a comprehensive evaluation of protein expression patterns indicative of response to disease, drugs, or environment

## AFHS Viability Study

- Each serum specimen to be analyzed for 78 specific serum antigens, 43 autoimmune serologies and 56 infection disease serologies for a total of 177 analytes
- One complex analytical procedure
- Serum requirements: 100 μl

## Rules-Based Medicine  Technology

- Rules-Based Medicine's MAP technology employs bioassays, dyed microspheres, high speed fluidics, and digital signal processing
- Specific dyes permeate the polystyrene microspheres

## Rules-Based Medicine  Technology

- Each microsphere set is covered with capture antibodies that react with the target protein
- After the assay is complete, the microspheres pass single file past two lasers

## Viability StudyCurrent Status

- Samples selected and ready to ship to laboratory
- Awaiting completion of contract activities

## Slide 14

## Air Force Health StudyClosure Activities

- RIF of civil servants
- Hard copy and electronic materials
- Specimens

## Slide 16

## Air Force Health Study 

**AFHS history**
- White House letter
- Participant selection, location
- Dioxin testing

**Notes:**
AFHS History: Written in a similar style to the Buckingham book Operation Ranch Hand.  Plan to talk with key personnel associated with the study since its inception.  
- The White House letter was from Stuart Eizenstat, Assistant to the President for Domestic Affairs and Policy, to the secretary of defense.  In it he concurred with the Interagency Work Group’s recommendation that the AF should be instructed to carry out the Ranch Hand study.  It closed by saying “The Interagency Work Group and the White House are prepared to offer any assistance that the Air Force may require in discharging its responsibility to conduct a high quality scientific investigation.”

Compliance Study:  The analysis shall be accomplished through the use of standard statistical procedures that assess the significance of trends and contrasts between groups and strata.  Reasons for noncompliance may include factors such as health, logistics, passive refusals, hostility, and other reasons.
3.8.3.2 Subgroups of participants shall be categorized by exposure group status (Ranch Hand, Comparison), age, military occupation, race, and dioxin exposure category (Comparison and background, low, and high Ranch Hands).

## Air Force Health Study 

**Comprehensive study**
- Formerly called the longitudinal or summary study
- Purpose: To document significant AFHS findings
-  Physical examination reports
-  Air Force technical reports
-  Publications
- Open to RHAC comments

## Slide 19

## Program Management Update

- Mr. Richard OgershokHSG/PSPBrooks City-Base TX

## Air Force Health Study

**6 Oct 05, House & Senate Veterans Affairs Committee**
- 2002 Follow-up Examination Results
- Publications
- Presentations at scientific meetings
- Ranch Hand Advisory Committee meetings
- Interactions with the Institute of Medicine
- Planned research activities
**8 Oct 05, Ranch Hand Reunion**

## Air Force Health Study 2002 Follow-up Physical Examination Report

- Released 8 Jul 2005
- Responded to numerous email inquiries
- Available on AFHS website:
- http://www.brooks.af.mil/AFRL/HED/hedb/default.html

## Air Force Health StudyFY06 Activities Overview

- Air Force history
- Comprehensive study
- Collaborations
- Compliance study
- Relational database
- Publication support
- In-house Research
- Dioxin congeners with CDC

## Air Force Health Study FY06 Activities

**External Collaborations**
- New guidelines for collaborations: past and present
- CDC and dioxin congeners
- UC Davis
- Texas Tech University Health Science Center
- Metabolic syndrome and dioxin
- Insomnia and dioxin
- Metabolic syndrome/chronic sleep loss: nested case-control study

## Air Force Health StudyFY06 Activities

**Compliance study**
- Factors that impacted study subjects participation in the six follow-up physical examinations

## Air Force Health Study FY06 Activities

**Relational database**
**Publication Support**
- Nerve velocity conduction
- Dioxin and memory
- Dioxin and hepatic function

**Notes:**
3.8.4.1 Dioxin Exposure and Hepatic Function  An analysis of hepatic parameters that includes liver disease through the 2002 follow-up examination, as determined from a medical records review, and participant levels of alanine aminotransferase, aspartate aminotransferase, gamma glutamyltransferase, lactate dehydrogenase, alkaline phosphatase, and total bilirubin in 2002.
3.8.4.2 Dioxin Exposure and Memory  A comparison of results from the Wechsler Memory Scale that was administered to AFHS participants at the 1982 baseline examination and the 2002 follow-up examination.
3.8.4.3 Nerve Conduction Studies  Follow-up analysis to an article on serum dioxin and peripheral neuropathy published in 2001.  The analysis shall include a review of NCS evaluations of 60 AFHS participants at the 2002 follow-up examination performed at Scripps Clinic.

## Air Force Health Study FY06 Activities

**In-house research**
-  Mortality
-  Collaborations
-  Viability study

## Dioxins, Dibenzofurans, and Polychlorinated Biphenyls in 106 Participants of 2002 AFHS Physical Examination

**Dr. Marian Pavuk**
**SpecPro Inc.**
**San Antonio, TX, USA**
**    ****	****	****	****	****	**

**Notes:**
Dear colleagues, I have a pleasure and the privilege to be here at the Dioxin Symposium to present results from the Air Force Health Study.

This presentation will focus for the first time on dioxin, dibenzofuran and polychlorinated biphenyls congeners in addition to TCDD that have not been measured previously.  These are a preliminary results from a smaller sample of US Air Force veterans, further analysis is ongoing at the CDC.

## Organochlorines Study Goal

- To measure levels of dibenzo-p-dioxins (PCDDs), dibenzofurans (PCDFs), mono-ortho and non-ortho substituted polychlorinated biphenyls (PCBs) in participants of the 2002 physical examination who did not have a previous valid TCDD measurement

**Notes:**
For the first time other dioxin congeners, only TCDD was measured in the AFHS previously, were measured in the smaller sample of veterans without previous TCDD measurement who attended 2002 physical examination. 
 Only TCDD was measured as only known contaminant of Agent Orange at 1987 and following examinations.  As other dioxin-like compounds have similar toxicological properties, measuring of TCDD only may not provide the best approximation of their exposure.  Measuring the battery of seven 2,3,7,8-substituted dioxin  and ten dibenzofuran congeners, together with 3 or 4 non-ortho dioxin-like PCB congeners became the standard of human exposure assessment to organochlorine compounds and we performed these measurements in this study.

We will present result of dioxin, dibenzofuran, and non-ortho or coplanar PCB congeners in 94 comparison veterans and additionally in smaller sample of 12 Ranch Hands.

## Methods

- 94 Comparison veterans who participated at 2002 examination did not have a TCDD measurement
**	****	****- **61 did not attend any previous physical examination
- 		- 33 did not have a valid previous measurement
- 12 Ranch Hand veterans without TCDD measurement also included in the study

**Notes:**
94 Comparison veterans who participated at 2002 examination did not have a TCDD measurement 
61 did not attend any previous physical examination
33 did not have a valid previous measurement
12 Ranch Hand veterans also included in the study
In 2002, for the first time, dioxin congeners other than TCDD measured by CDC dioxin laboratory

## Methods

- High-resolution gas chromatography high-resolution mass spectrometry used to analyze dioxin-like compounds
- CDC dioxin laboratory performed the analyses
- Lipid adjusted measurements presented in pg/g of lipid  or parts per trillion (ppt) for all congeners except mono-ortho PCBs in ng/g of lipid or parts per billion (ppb)
- WHO TEF used to calculated PCDDs, PCDFs, and PCBs TEQs, and total (sum) TEQ in pg/g of lipid or ppt

**Notes:**
High-resolution gas chromatography, high-resolution mass spectrometry used to analyze dioxin like compounds
Lipid adjusted measurements presented in parts per trillion (pg/g of lipid) for dioxins and dibenzofurans, and non ortho PCBs
Dept. of Dioxins and Organic Pollutants, Dr. Wyman Turner, chief, performed analyses in 2004.

WHO TEF used to calculated dioxin, dibenzofuran and PCB TEQs, and sum (total) TEQ

## Demographic Characteristics of US Air Force Veterans

|  | Comparison
(N=96) | Ranch Hand 
(N=12) |
| --- | --- | --- |
| 
Age at qual. tour (yr), Mean (SD)
Year at birth, Mean (SD)
2002 BMI, Mean (SD)
2002 Alcohol (drink-yrs) 
2002 Pack years of smoking

Officer (%)
Enlisted Flyer (%)
Enlisted Ground (%)
 | 
            31  (7.4)
        1939  (7.6)
            28.9  (4.3)
            46 (107)    
            16.4 (21.5)

    33 (35.1)
    20 (21.3)
    41 (43.6) |  
       30.2 (8.7)
1938 (7.6)
       28.7 (4.7)
   68 (83)
         13.8 (23.2)

     6 (50) 
        2 (16.7)
        4 (33.3) |

**Notes:**
Comparison veterans were matched to Ranch Hand veterans based on age, race, and military occupation, but this was not a random selection for this particular study, only veterans without previous TCDD measurement were analyzed here.

## PCDDs in Comparisons and Ranch Hands (ppt)

| 
 |  | 
% Dt.
 | Comp
Mean | 
Min- Max | 
% Dt.
 | RH
Mean | 
Min- Max |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- |
| 
2,3,7,8-TCDD |  | 
36 | 
1.74 | 
0.42-11.7 | 
42 | 
5.46 | 
0.42-34 |  |
| 1,2,3,7,8-PnCDD
1,2,3,4,7,8-HxCDD 
1,2,3,6,7,8-HxCDD
1,2,3,7,8,9-HxCDD 
1,2,3,4,6,7,8-HpCDD
OCDD
 |  | 60
43
99
19
100
99 | 4.97
3.61
48.2
2.64
47
369 | 0.49-21.7
0.64-14.3
1.62-107
0.64-13
5.7-129
43-900 | 75
50
83
75
100
92
 | 5.27
3.87
37.9
4.73
39.8
261 | 0.42-11.3
0.78-8.4
1.41-67.2
0.85-11.1
6.8-74.9
52.8-529 |  |

**% Dt. - % above the limit of detection**

**Notes:**
We see similar numbers for detection of congeners above the limit of detection for both Ranch Hands and Comparison. Except TCDD, there are no substantial differences in levels of other dioxin congeners, as would be expected, since we do not presume major differences in exposure to organochlorines after return from Southeast Asia. 

TCDD was the only congener previously measured in the AFHS

## PCDFs in Comparisons and Ranch Hands (ppt)

| 
 |  | 
% Dt.
 | Comp
Mean | 
Min- Max | 
% Dt.
 | RH
Mean | 
Min- Max |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- |
| 
2,3,7,8-TCDF
1,2,3,7,8-PnCDF
2,3,4,7,8-PnCDF
1,2,3,4,7,8-HxCDF 
1,2,3,6,7,8-HxCDF
2,3,4,6,7,8-HxCDF 
1,2,3,7,8,9-HxCDF 
1,2,3,4,6,7,8-HpCDF
1,2,3,4,7,8,9-HpCDF 
OCDF
 |  | 
2.1
1.0
88
97
95
0 
50 
100
0
--
 | 
0.73
0.77
7.54
5.56
5.46
0.79
1.54
12.6
0.9
 -- | 
0.42-1.91
0.42-2.26
0.57-23.2
0.49-14.5
0.84-15.7
0.42-2.19
0.57-4.7
3.7-36.5
0.42-2.33
      -- | 
0
0
83
100
75
0
8.3
92
0
-- | 
0.88
0.91
6.49
5.33
4.04
1
1.42
8.91
1.08
-- | 
0.28-4.74    
0.35-4.53
0.71-18.4
1.9-10.8
0.49-8
0.42-5.02
0.49-4.88
4.74-16.7
0.49-4.74
-- |  |

**Notes:**
Very similar levels for dibenzofuran congeners, consistent with background general population level exposures.

## Non-ortho PCBs in Comparisons and Ranch Hands  (ppt)

| 
 |  | 
% Dt.
 | Comp
Mean | 
Min- Max | 
% Dt.
 | RH
Mean | 
Min- Max |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- |
| 
TeCB 77
TeCB 81
PnCB 126
HxCB 169  |  | 
--
32
96
100
 | 
  --
4.3
48.3
33.3 | 
   --
0.1-23.5
1.2-1570
9.7-346 | 
--
0
92
100 | 
--
1.4
19
33.1 | 
      --    
0.3-2.5
8.1-35.9
16.6-63.4 |  |

**% Dt. - % above the limit of detection**

**Notes:**
Slightly higher levels of non-ortho PCBs in Comparison veterans, we should note again that the Ranch Hand sample is much smaller, only 12 veterans so we have to expect some variation. Larger sample is being analyzed which will provide more appropriate comparison of PCB levels.

## Mono-ortho PCBs in Comparisons and Ranch Hands  (ppb)

| 
 |  | 
% Dt.
 | Comp
Mean | 
Min- Max | 
% Dt.
 | RH
Mean | 
Min- Max |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- |
| 
TeCB 118
PnCB 105
PnCB 167
HxCB 156
HxCB 157  |  | 
91.5
21.3
6.4
90.4
4.3
 | 
22
3.9
3.2
10.6
2.6 | 
2.3-395
0.2-82.5
0.6-34.4
2-50
0.5-13.8 | 
91.7
8.3
0
0
8.3 | 
14.4
2.9
2.7
12
2.6 | 
3.6-67.7    
0.7-16.1
1.4-5.4
5-24.3
1-5.4 |  |

**% Dt. - % above the limit of detection**

**Notes:**
Slightly higher levels of non-ortho PCBs in Comparison veterans, we should note again that the Ranch Hand sample is much smaller, only 12 veterans so we have to expect some variation. Larger sample is being analyzed which will provide more appropriate comparison of PCB levels.

## Sums of PCDDs, PCDFs, and non-ortho PCBs 

**ppt**

**Comparisons**

**Ranch Hand**

**Notes:**
Here we present sums of measured levels for dioxins, dibenzofurans and coplanar PCBs for comparisons veterans. Medians and ranges here do not suggest any major occupational exposure. ∑ 

## PCDDs, PCDFs, non-ortho and mono-ortho PCBs TEQs

**ppt**

******* ∑** **PCDDs includes values for TCDD**

**Notes:**
While total Dioxin TEQ mean is slightly higher in Ranch Hands, total mean TEQ is similar in both groups, suggesting little difference in dioxin like compounds body burden 30 to 45 years after the end of exposure in Vietnam and covering environmental exposures back in US.
We may note a higher proportion of TCDD on sum of Dioxin TEQ (35.5 vs 13.5%) and total TEQ  (24.7 vs 7.3%) in Ranch Hands, a pattern suggesting exposure to TCDD contaminated herbicides.

Medians: RH TCDD 2.2; PCDD TEQ 10.8; PCDF TEQ 3.6; PCB TEQ 2.3 , TOTAL TEQ 21
          COMP TCDD 0.95; PCDD TEQ 10.8; PCDF TEQ 4.9; PCB TEQ 3 , TOTAL TEQ 19.5

## 1987 and 2002 TCDD Levels

**ppt**

**Notes:**
TCDD levels decreased in both Comparison and Ranch Hand veterans between 1987 and 2002. We should note that the levels are not from the same veterans, 2002 levels were measured in veterans without a previous TCDD measurement.

Changes in medians: 3.8 to 1 in Comparisons, 11.6 to 2.2 in RH.

## TEQ Levels in US and International General Population

**ppt**

**N.A.**

**Notes:**
International comparisons, data from the general population of different industrialized countries, much lower levels in Australia, higher dibenzofurans and PCBs in Europe (Germany), very similar levels for Dallas Texas, United States.  Levels observed in Comparison veterans are consistent with general population background levels. 

## TEQs in US Vietnam War Veterans  

**ppt**

**Notes:**
Group of 50 Michigan Vietnam veterans who reported they were exposed to Agent Orange in Vietnam was examined and donated blood for organochlorine analysis in 1993.  We would expect their dioxin, dibenzofuran and co-PCB congeners to be higher in 1993, as dioxin-like compounds decreased over time.  Half lives range from 0.3 to over 30 years for different dioxin/dibenzofuran congeners, and as shown in some recent studies metabolism is faster closer to exposure and at higher levels of exposure.

TCDD for 44 veterans, other congeners 50 Michigan veterans, without 6 veterans with elevated TCDD range 22.9-131 ppt measured in 1991-2.
Mono ortho 50 in michinga; 
Mono-ortho Comp: Mean 9.2 – 7.6 med, 10-90% 3.8-12.7
                  RH :9.2 – 6.9 med, 10-90% 5.4-15.7
Data not shown, CDC in bigger sample mono-orhto + di-ortho + pesticides.

## Preliminary Results: PCDDs, PCDFs, non-ortho and mono-ortho PCBs TEQs 

**ppt**

******* ∑** **PCDDs includes values for TCDD**

**Notes:**
New preliminary data for 600 randomly selected Ranch Hand and Comparisons attending 2002 physical examination.

While total Dioxin TEQ mean is slightly higher in Ranch Hands, total mean TEQ is similar in both groups, suggesting little difference in dioxin like compounds body burden 30 to 45 years after the end of exposure in Vietnam and covering environmental exposures back in US.
We may note a higher proportion of TCDD on sum of Dioxin TEQ (35.5 vs 13.5%) and total TEQ  (24.7 vs 7.3%) in Ranch Hands, a pattern suggesting exposure to TCDD contaminated herbicides.

Medians: RH TCDD 2.2; PCDD TEQ 10.8; PCDF TEQ 3.6; PCB TEQ 2.3 , TOTAL TEQ 21
          COMP TCDD 0.95; PCDD TEQ 10.8; PCDF TEQ 4.9; PCB TEQ 3 , TOTAL TEQ 19.5

## Conclusions

- Background organochlorines levels observed in the general population were found in both Ranch Hands and Comparisons in this study
- Mean TCDD levels decreased two to five times relative to the 1987 levels, consistent with decreases observed in the general population

**Notes:**
Background dioxins levels observed in the general population were found in  both Ranch Hand and Comparisons in this study

Although these are not the same subjects as those tested in previous examinations, TCDD levels decreased to about half of the 1987 levels

## Conclusions

- The mean 2002 TCDD level in Ranch Hands was about three times higher than in Comparison veterans (5.5 versus 1.7 ppt)
- Total TEQs were similar, 32.4 ppt and 31.4 ppt (10%-90%: Ranch Hands 15.1-48.4 ppt, Comparisons 15.9-45.7 ppt)
- Ranch Hands sample size was too small to make any definitive inferences about the total TEQs

**Notes:**
While the TCDD levels were  2-times higher in Ranch Hands veterans, total TEQs were similar, 23.1 and 22.3.

10%-90% sum TEQ: Comparison 12.1-33.5; RH 9.1-36.7.

Ranch Hands sample size was too small to make any definitive inferences about the total TEQs

## Conclusions

- Additional 600 samples were analyzed by CDC for PCDDs, PCDFs, PCBs, and organochlorine pesticides
- Statistical analysis of these data by the Air Force and CDC is ongoing

**Notes:**
600 additional samples are being analyzed by CDC for dioxins, dibenzofurans, PCBs, and organochlorine pesticides.
Random sample of the study participants.