U.S. DEPARTMENT OF VETERANS AFFAIRS

CLINICIAN'S GUIDE TO 

AIRBORNE HAZARDS

EXPOSURE CONCERNS

Many Veterans and service members are 

concerned their health was adversely affected by 

environmental exposures to airborne hazards. 

After deployment to locations with open burn 

pits and other air pollution sources in Iraq and 

Afghanistan, some Veterans have returned with a 

range of mild to serious respiratory illnesses. 

The use of burn pits was a common waste 

disposal practice at military sites overseas, 

exposing thousands of service members to 

potentially harmful substances, including 

elevated levels of particulate matter (PM). Poor 

air quality (pollution) was measured at many 

overseas locations.

ENCOURAGE VETERANS TO PARTICIPATE IN THE 

REGISTRY

The Airborne Hazards and Open Burn Pit Registry 

(AHOBPR) is a tool to help Veterans and service members 

become more aware of their own health issues and 

to help the Department of Veterans Affairs (VA) 

identify health conditions possibly related to burn pit 

exposure during military service. Participation in the registry 

is voluntary. Veterans and service members can participate in 

the registry by completing a web-based health questionnaire 

about their exposures and health. Information reported by 

participants is maintained in a secure database, and may be 

used in future research studies. Participants may schedule an 

optional in-person clinical evaluation by a VA provider.

• Visit the registry at: https://

veteran.mobilehealth.va.gov/AHBurnPitRegistry.

• Find steps to completing the registry at https://

www.publichealth.va.gov/docs/exposures/RegistrySteps.pdf.

THE ROLE OFTHE MEDICAL SUPPORT STAFF

Medical Support Assistants (MSAs) and Environmental 

Health Coordinators (EHCs) have a very important role 

in VA’s support to Veterans with military-related health 

concerns. Unlike other registries, the AHOBPR does not 

require a Veteran or service member to have an exam.

However, an optional registry-related in-person 

examination is available and valuable for those who 

have health care concerns. This foundational service 

can only be done at a VA facility. Here are some 

guidelines you should know related to the in-person 

examination:

• Any eligible Veteran or service member who wishes

to participate in the registry may receive an optional,

no cost in-person evaluation.

• Veterans and inactive reserve and Guard members

may be seen for the in-person evaluation at their

nearby VA medical center. Service members and

active Reserve and Guard members should make an

appointment with their Department of Defense

healthcare provider to discuss any exposure related

concerns.

• The eligible participant is not required to enroll in

Veterans Health Administration (VHA) health care

to receive their examination. Veterans not enrolled

who wish to receive an examination may request one

through their local VA medical center’s EHC.

• In-person examinations scheduled specifically under

the AHOBPR program are not to be billed.

• Before scheduling the in-person appointment, the

MSAs should first verify that the self-assessment

questionnaire was completed by using the Provider

Portal (https://vaww.ahobpr.registries.aac.va.gov/

RegistrantSearch.aspx). The access credentials are

identical to your VistA log in credentials. The Veteran

should be directed to complete the online portion

before scheduling the exam.

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A CLINICIAN'S GUIDE

THE ROLE OFTHE CLINICIAN

CONDUCT AN INITIAL EVALUATION

First, assess the intensity and specific focus of concern of 

the individual. Patients seeking medical attention may 

have a variety of symptoms and exposure concerns. 

There are no biomarkers specific to the environmental 

exposure-related health concerns of Veterans who 

deployed to Southwest Asia, Afghanistan, or Djibouti at 

this time. Clinicians must rely on their own evidence 

based knowledge, expertise, and skills to guide a patient 

centered evaluation and management. For example, for 

an individual with chronic lower respiratory symptoms, 

such as wheezing, chronic cough, or dyspnea with 

exertion, the following may be appropriate:

• A complete blood count—to rule out anemia.

• Posteroanterior and lateral chest radiographs—to rule

out significant structural abnormalities

• Pulse oximetry—to assess for hypoxia.

• Spirometry with bronchodilator—to assess pulmonary

function and reversibility of bronchoconstriction. Other

symptoms should be evaluated according to best

clinical practices, as well.

DECIDE IF A SPECIALTY CONSULTATION IS WARRANTED

The decision to conduct specialty evaluations should be 

made in the context of the individual patient’s concerns 

and symptoms, findings on initial evaluation, and the 

comfort level of the primary care team. The indicated 

specialty evaluations are considered part of the exposure 

evaluation and should be made available to the 

individual by VHA at no cost to the Veteran. Appropriate 

specialties may include pulmonary; ear, nose, and throat; 

and allergy/immunology.

Consultations may result in additional assessments, such 

as high-resolution chest computerized tomography (CT) 

scan, full pulmonary function tests, assessment of vocal 

cord function, cardiopulmonary exercise tests, or lung 

biopsy.

After local evaluation is completed, some patients may 

still have complex, difficult-to-diagnose or medically 

unexplained health concerns related to airborne hazards 

or other deployment-related exposures. For these 

patients, consultation with the War Related Illness and 

Injury Study Center (WRIISC) might be appropriate. 

WRIISC information can be found at 

www.warrelatedillness.va.gov.

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AIRBORNE HAZARDS & OPEN BURN PITS

TALKING TO VETERANS

ABOUT EXPOSURE CONCERNS

LISTEN TO AND RESPECT VETERANS' 

HEALTH CONCERNS. 

Airborne hazards exposure and possibly 

associated health risks are complex issues 

with many uncertainties.

TAKE TIME TO ESTABLISH TRUST 

AND RAPPORT. 

Help Veterans make informed decisions 

about possible next steps and management 

of health concerns. Identifying areas of 

agreement and focusing on risk reduction 

and optimization of health and function 

may provide a constructive way forward.

REFER VETERANS WITH SERVICECONNECTED DISABILITY BENEFITS 

QUESTIONS TO VETERANS BENEFITS 

ADMINISTRATION. 

Visit www.benefits.va.gov for more 

information. Claims related to burn 

pit exposures are handled on a caseby-case basis by the Veterans Benefits 

Administration.

VETERAN'S SELF-ASSESSMENT

View a Veteran’s self-assessment at https://

vaww.virp.registries.aac.va.gov/. Document an 

evaluation using the National Note Airborne 

Hazards and Burn Pit Initial Evaluation Clinical 

Template.

RESEARCH ON HEALTH EFFECTS OF 

AIRBORNE HAZARD EXPOSURES

At this time, there is conflicting and insufficient research to 

show that long-term health problems have resulted from 

airborne hazards and burn pits exposure. Some research 

shows higher rates of self-reported pulmonary symptoms, 

asthma, and unexpected conditions (e.g., eosinophilic

pneumonia and constrictive bronchiolitis) among service

members who deployed to Southwest Asia. Other research 

reports no elevation in disease or symptom reporting. It is 

unclear what problems deployed individuals may develop 

and how widespread these problems are.

In 2011, the Institute of Medicine (IOM) reviewed the 

scientific literature related to the possibility of adverse 

long-term health effects of open burn pits. The report 

noted U.S. Department of Defense air quality monitoring 

data measured levels of PM higher than generally 

considered safe by U.S. regulatory agencies. It also cited 

research linking high PM levels to cardiopulmonary effects, 

particularly in individuals at increased risk due to preexisting conditions such as asthma and emphysema. The 

IOM concluded there is only limited evidence suggestive

“of an association between exposure to combustion 

products and reduced pulmonary function in these 

populations,”suggesting that the high level of fine dust 

and pollution common in Iraq and Afghanistan may pose a

greater danger for respiratory illnesses than exposure to

burn pits. 

For a summary of research related to airborne hazards 

and burn pits exposure, go to:

https://www.ncbi.nlm.nih.gov/pubmed/31368802. 

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DEPARTMENT OF VETERANS AFFAIRS’ ENVIRONMENTAL HEALTH PROGRAMS

VHA has a designated EHC and Clinician at each VA medical center. Some of these 

clinicians may be able to provide additional information about exposure concerns or 

deployment-related health issues. See a listing of EHCs by facility at:

www.publichealth. va.gov/exposures/coordinators.asp.

AIRBONE HAZARDS AND BURN PITS CENTER OF EXCELLENCE (AHBPCE)

The AHBPCE was formally established in May 2019. It conducts clinical and translational research 

and disseminates educational products and best practices related to airborne hazards and burn 

pits. The AHBPCE focuses on a range of health concerns including respiratory symptoms and 

unexplained shortness of breath (dyspnea), among other health outcomes. Learn more at: 

https://www.warrelatedillness.va.gov/WARRELATEDILLNESS/AHBPCE/index.asp.

LITERATURE SUMMARY

• Abraham JH, Baird CP. A Case-Crossover Study of Ambient Particulate

Matter and Cardiovascular and Respiratory Medical Encounters Among

US Military Personnel Deployed to Southwest Asia. J Occup Environ Med

54:733-739, 2012.

• Baird CP, Harkins DK, editors. Airborne hazards related to deployment.

Falls Church, Virginia: Borden Institute; 2015

• IOM (Institute of Medicine). 2011. Long-term health consequences of

exposure to burn pits in Iraq and Afghanistan. Washington, DC: The

National Academies Press.

• King MS, Eisenberg R, Newman JH, Tolle JJ, Harrell FE, et al. Constrictive

Bronchiolitis in Soldiers Returning from Iraq and Afghanistan. N Engl J

Med 365:222-230, 2011.

• Kreiss K. Occupational causes of constrictive bronchiolitis. Curr Opin

Allergy Clin Immunol. 2013 Apr; 13 (2):167-72.

• Morris MJ, Lucero PF, Zanders TB, Zacher LL. Diagnosis and management

of chronic lung disease in deployed military personnel. Ther Adv Respir

Dis. 2013 Aug; 7 (4):235-45.

• Rose C, Abraham J, Harkins D, Miller R, Morris M, et al. Overview and

Recommendations for Medical Screening and Diagnostic Evaluation for

Postdeployment Lung Disease in Returning US Warfighters. J

OccupEnviron Med 54:746-751, 2012.

• Santos SL, Helmer D, Teichman R. Risk communication in deploymentrelated exposure concerns. J Occup Environ Med. 2012 Jun; 54 (6):752-9.

• Shorr AF, Scoville SL, Cersovsky SB, Shanks GD, Ockenhouse CF,

SmoakBL, Carr WW, Petruccelli BP. Acute eosinophilic pneumonia among

US Military personnel deployed in or near Iraq. JAMA. 2004 Dec 22; 292

(24):2997-3005.

• Smith B, Wong CA, Smith TC, Boyko EJ, Gackstetter GD, Ryan MAK. Newly

Reported Respiratory Symptoms and Conditions Among Military

Personnel Deployed to Iraq and Afghanistan: A Prospective Populationbased Study. Am J of Epidemiol 170:1433-1442, 2009.

• Szema AM, Peters MC, Weissinger KM, Gagliano CA, Chen JJ. New-onset

Asthma Among Soldiers Serving in Iraq and Afghanistan. Allergy Asthma

Proceedings 31:e67-e71, 2010.

• U.S. EPA. Integrated Science Assessment for Particulate Matter

(Final Report). U.S. Environmental Protection Agency, Washington,

DC,EPA/600/R-08/139F, 2009.

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