Good afternoon, everybody. I'm Dr. Michael Brunage, and I work at the VA in the Office of Post-Employment Health Services, and today we're going to be speaking about military exposures in veterans. I'm being joined today by Dr. Shauna Smith, Dr. Peter Rum, and Dr. Aaron Block from the Office of Research and Development. As standard for these kinds of presentations, our disclaimer is that we have no conflicts of interest to introduce, and the information or advice given during this presentation is not the official opinion of the Department of Veteran Affairs. Just in a way of background, I'm a fellow of the American College of Physicians, as well as a fellow of the American College of Preventive Medicine, and it's an honor for me to be able to speak once again at ACPM 2021. My background is both, as you probably guessed from my title, internal medicine, preventive medicine, and I'm the Deputy Chief Consultant for the Office of Post-Employment Health Services that deals with the health outcomes of military exposures. So there are, as you can see from this slide, a number of exposure issues that have veterans concerned, and you have probably seen some of these showing up in the news. Those include things like Camp Lejeune, where there was recently a North Carolina protest about Camp Lejeune with exposures through primarily TCE and PCE. PFAS is a big area of interest right now, an area of concern for veterans with contaminated water around multiple bases, but it's ubiquitous. It was the subject of the movie Dark Waters, and many other garrisons have environmental concerns as well. Of course, you've heard of obviously Agent Orange already, and we're interested in airborne hazards in burn pits, which also you have seen in the news, exposures of chemical weapons, and the Gulf War, which there is still no single case definition for Gulf War, and I know that Dr. Momin will speak about that a little bit later on, and there's a whole host of other concerns, one of which is Karshi Khanabad, which makes the news. That's also known as K2, was a base in Uzbekistan, former Soviet air base, where there were a number of potential contaminants. Our office is the lead VA office for environmental exposures concerning veterans, and we oversee secondary prevention and other efforts, and oversee six registries, which I'll talk to you about. We have the pre-911 era environmental programs, which Dr. Momin oversees, post-911 era environmental programs, which includes airborne hazards. We have a large epidemiology program, and we have three war-related illness and injury study centers that are part of our office, one in California, one in the District of Columbia, and the Burn Pit Center of Excellence is in New Jersey, and we give referrals and consults through the risks. We also have the Embedded Fragment Surveillance Center depleted uranium follow-up program located at the Baltimore VA. So there are six registries. You can read them off the slide here, starting with Agent Orange, which Dr. Rum is very familiar with, as well as Gulf War Registry, and you can look down through the list. The Airborne Hazards and Open Burn Pit Registry is right now gaining about 1,000 new veterans every month. Now, there's a lot of reasons that we have these registries. For the most part, our registries are voluntary, and so there is a free and voluntary medical assessment for veterans who may have been exposed to certain environmental hazards during military service, and occasionally, we discover new diagnoses on these free and voluntary medical assessments. Evaluations alert veterans to the possible long-term health problems that may be related to their exposure to specific environmental hazards, and the registry data actually helps us understand the response to these health problems more effectively, can also be used for research purposes. If you want to go on, we have a very robust website that really tells you a lot about these registries and about exposures in general, and you'll see these links throughout the presentation. Of course, registries, especially when they're self-identified, when veterans have to volunteer to join a registry, have potential and actual limitations that we have to consider. So we know, as we discussed before, they can be a valuable tool for surveillance and epidemiology. We can collect information about occupational exposure and diseases in large populations, and it can provide us some overview of disease trends. But also, it's important to remember that these registry examinations are not part of the disability and compensation process, but they do go into the veteran's medical record. But we know also, you might have already guessed, that there are some significant weaknesses, inherent limitations, in the use to draw inferences regarding the presence or strength of association, and some of the issues include the self-reporting of an effect, recall bias, misclassification, and other things that are a hindrance to using registries. I'm just going to go very briefly through some of these registries. The Agent Orange Registry, again, Dr. Rung knows quite a bit about this. These are mandated by law, and it's the largest of all the registries, with almost three quarters of a million veterans signing up for the Agent Orange Registry. The eligibility includes service members who served in Vietnam, some very limited times and areas around the Korean DMZ, and very limited areas of Thai bases and certain occupational series. We know that C-123 crews who are part of Operation Ranch Hand were exposed to Agent Orange, as well as a number of locations. Recently, the Blue Water Navy was added in 2020, if you were within 12 miles of the coast of Vietnam. And there, again, more information is always here on our website. We have almost three, a quarter of a million now, registrants with airborne hazards and open burn pit registry, again, created at the direction of Congress. It has an online questionnaire and allows eligible veterans and service members to document their exposures. And so, the eligibility is very specific, includes Operations Enduring Freedom and Operation Iraqi Freedom. Operation Enduring Freedom, of course, is in Afghanistan. Operation Iraqi Freedom, self-explanatory. Operation New Dawn, also in Iraq. Djibouti, Africa, and other places in Southwest Asia. And it's important to note that Gulf War registrants are eligible veterans as well. Speaking of the Gulf War, there was a registry created under the authority of certain public laws that are listed on the slide, has about 180,000 veterans enrolled right now. And it can be repeated when there's new information or symptoms that are presented. This is primarily to serve veterans who were in the Gulf during Operations Desert Shield and Desert Storm, but it can also include those involved with Operation Iraqi Freedom, Operation New Dawn as well. A much smaller registry is our Ionizing Radiation Registry, with only about 18,000 enrolled veterans. It includes a comprehensive examination that includes an exposure medical history laboratory test and a physical examination. Those include veterans exposed to above or below, some below ground nuclear testing, as well as prisoners of war in Japan who were in the vicinity of Hiroshima and Nagasaki when the bombs were detonated there. Again, a link to our website with more involved history. The Toxic Embedded Fragments Center in Baltimore was established in 2008 to provide medical surveillance for Iraq and Afghan veterans who have embedded fragments which cannot be surgically removed. Those included radiologic tests, urine tests, and fragment analyses, not only for the metals but in looking also for depleted uranium if there was any involved with the explosion that they were involved with. Speaking of depleted uranium, this is also a congressionally mandated registry. It has only about 6,000 registrants, but of all those who have been screened for a depleted uranium from their urine analysis, only five have had a positive DU screen so far. So the vast majority do not have, and it's only those who have embedded fragments who have had a positive DU profile. This biannual inpatient surveillance protocol includes exams, exposure assessments, lab studies, and imaging studies. The eligibility of those veterans who served in the Gulf War, Bosnia, where it was also DU used, as well as OIF, Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn, who may also be eligible. But the future, and what we're really trying to do is get away from these self-identified registries and move to something that's better, and that's called ILR, or the Individual Longitudinal Exposure Record, ILR. This is a joint venture between the Department of Defense and VA, creating a record for each service member. This provides real-time, long-term exposure records that are matched to health status and health history. So the ILR matches a service member to its place, time, location, and event. This is not a separate database, but it mines other databases, such as some of the exposure databases that belong to the Department of Defense and also the defense manpower databases, so we can identify locations. So you can actually build cohorts of veterans, depending on where they were deployed, perhaps what they were exposed to, and follow them long-term. And I think this is a better way to follow these veterans other than with registries. And with that, I will hand it over to Dr. Shauna Smith. Dr. Smith, if you want to unmute, you're up next. Thank you, Dr. Smith. Good afternoon, everyone. As previously mentioned, my name is Dr. Shauna Smith. I am the Program Manager for Post-Appointment Health Services Military Environmental Exposure Registry Program. Okay, so on slide number 15, you can see that I will be taking a few minutes to discuss the structure of our registry program, training for environmental health clinicians, and the resources available that are readily available to environmental health clinicians and other health care providers. So let's begin. Okay, so we have a total of 18 veterans integrated service networks, which I will refer to as VISNs for the remainder of my presentation. You can VISNs, sort of a regional office that governs the VA medical centers. VISN level, we have one environmental health, we have one lead environmental health clinician, as well as one lead environmental health coordinator. Now that lead clinician is responsible for the medical management of the VISN registry program. So, I want to make sure I'm staying on track here for you all. So moving on to the VA medical centers, the actual work begins. So at the VA medical center, the environmental health physician performs medical examinations and is eligible. And the environmental health coordinator, on the other hand, of course, is responsible for veteran eligibility and scheduling. So initiatives do not necessarily have to be passed down eligibility and the scheduling, they can focus more or less on the exam and focusing on the presumptions that we're looking for when a veteran comes in for that exam. So also at each VAMC or VA medical center, we employ at least one environmental health clinician and one environmental health coordinator. Now, what you may find interesting is that many of our environmental health clinicians serve in dual roles. So not only are they environmental health clinicians, it may also be compensation and pension, primary care, occupational, or internal medicine, healthcare providers. And so, in fact, according to the 2019 healthcare analysis and information group report, what we refer to as the Hague report, approximately 60% of our environmental exposure registry programs are located in compensation and pension clinics, and primary care, environmental health services, and the remaining 20% are located in a variety of staffing models. So the one thing I do want to highlight is that although our environmental health clinicians represent a variety of healthcare professionals who specialize in various areas of medicine, environmental health clinicians understand and are equipped with the tools necessary to address veterans military environmental exposure concerns. So what do we do to ensure our environmental health clinicians are equipped with the tools necessary to address veterans military environmental exposure concerns? So we're going to head to our next slide, which is slide 17. Let me make sure it is for you all. So PDAS provides various training options. One option includes our accredited risk models, which are also available to community providers on Triton. We also offer an annual training conference, bi-monthly special presentations, and webinars. And efforts are also underway for a possible certificate program for our environmental health clinicians. So I am so sure many of you are wondering where you can locate these accredited risk models since they are available to community providers. So on our next slide, I will go ahead and advance here. Hopefully, it has. Okay, there we go. So I included a link to the modules. Additionally, I included a link that houses a list of VA Medical Center coordinators alphabetically by state. This slide is very important. So if you want to know more information about these military environmental exposure, please go for the check out on the website that is listed here. And also on the website that is listed here. And also those modules are accredited. And also, you have a better if you yourself have any questions regarding people's environmental exposures. If you really want to identify some of the exposures, or you just want to reach out, please make sure you reach out to that link coordinator. If you want to reach out to me, my name is Shanna Smith. And that email address is shanna.smith.va.gov. Once again, my name is Dr. Shanna Smith. This concludes my part of this presentation. I do believe my colleague Dr. Peter Ruhm is next 3911 exposures. Hello, I'm Dr. Ruhm. I am one. First off, I'm an ACPM fellow. I trained at Madigan in the Army, went on to do epidemiology consultants in Europe, and then went on to academia, state health, I've worked at the FDA, and at the Surgeon General's office, and finally at the VA. And it's a privilege to be here. As Dr. Smith mentioned, we're actually working with the academy and looking at creating a training program for the physicians who do environmental health throughout the thing. And I'll be talking about a number of topics. You can see them on the slides. Mr. Robertson, I'm not actually seeing the slides very well, but I think I can get through them just so you know that. Anyway, we'll go on to the next slide here. Okay, the first topic I'm going to talk about is basically the Vietnam War and Agent Orange and other tactical herbicides and how it affected a lot of things that we do in the field situation. Dr. Brummage talked about our registry. It is our largest registry with about 750,000, which is about one-fourth of those who actually served in the Vietnam War have enrolled. This next slide shows basically some things about Agent Orange. The main point about Agent Orange is it was a combination of things that are basically in commercial herbicides, including TCDD, however, that had a contaminant in it with dioxin and was used heavily. About 20 million, 20 million gallons were sprayed. They were used, and some of these were some of the other agents like Orange and Purple, and basically they were very effective. Agent Orange was used to a limited extent in Laos and Cambodia. It was also, it has been used, tested in a few other places around the nation. VA has a website after a two-year basic investigation by DOD, relooked at some places, and the main point about that is that a lot of veterans think it was in Guam, American Samoa, and other places, and the bottom line, it wasn't. There may have been use of commercial herbicides or other agents, but at least the Agent Orange itself or any of its near relatives was not used in those places. Any veteran who was basically exposed to, potentially exposed, and it's presumed if you're in the country or at one of these places during the right time and location, you can apply for benefits. I'm just going to talk a little bit about the Blue Water Navy. This is something some of you may have heard about, particularly those who are in the Navy. Until a few years ago, Agent Orange benefits and the ability to get in the registry was not allowed for basically the Blue Water Navy. However, based on our court hearing and then a law that has been given to veterans, in fact, just this past few weeks, VA sent out a notice to veterans because there's a thing called NEMR, which actually gives survivor benefits and the ability to actually have claims filed automatically. So the bottom line is this is a little bit controversial still this day because the National Academies looked at this and there was not a lot of evidence scientifically that it actually made it into the water, at least in significant amounts. But these veterans do have benefits today. All right, let me go back. The next slide is on what's called presumptions. This is a term which those who are not in the military or VA may not know what it means. But basically, again, Congress and the secretary both have the right to basically make a law or regulation that basically if a person was in the right time and place, they're considered exposed. And because they're exposed, they have a certain disease, they would get that presumption. This process is fairly complicated in the VA, particularly after we get a National Academy report, which I'll talk about in a minute, where there's a three-step process with a technical work group and a strategic work group, and finally, a task force looks at this to make recommendations to the secretary whether or not to add a condition to be a presumption. Just recently, bladder cancer, hypothyroidism, and Parkinsonism have been added by Congress as Agent Orange presumptions, and there's other ones under potential deliberation. I talked about the National Academies. There's been 11 of these Veterans in Agent Orange reports. They basically use four levels of evidence. And there's only a few conditions that are thought to have a sufficient level of association. And I'll talk about that more in a minute. The bottom line is, again, we look at them intensely and they look at the science. We can track with the academies when we do one of these reports, and again, have an internal work group to look at the reports to give possible recommendations to the secretary. This is the last report, at least, that's scheduled to be done. And the good news about these reports, they're fairly thick, but they're also available free online from the National Academies. So you can download them anytime you want to. And this just shows some of the levels of association that are most important. The one that right now has been looked at the most is this hypertension. As you know, it's a very prevalent condition. The attributable risk due to actually Agent Orange and stuff is very controversial. There was one VA paper by one of, somebody actually works in our office, Dr. Sapel and others, who did find in the Army Chemical Corps higher rates of hypertension than in those who had high sprayers versus low sprayers, as far as Agent Orange. Based on this, National Academies made a recommendation to put it in a sufficient level of association. But again, it remains to be seen whether or not this will be added to be a presumption. The other one that's under, that's brought up by Congress, at least right now, and also by advocacy groups, is MGIS, monoclonal gammonopathy, undetermined significance. And this is, for those of you who don't know this, this is basically a laboratory condition and that can lead to a possibly having an increased risk of multiple myeloma. Multiple myeloma is already a presumption, and VA has looked at this, and at least right now, feels it's more of a laboratory finding, but it remains under potential consideration. The next thing I'm going to talk about is probably the topic I spend the most on right now, which is on Gulf War illness and Gulf War concerns. And we have, we, VA, I think has been, has taken a very, a lot of work in this area, coupled with DOD that does a lot of funding in Gulf War research. The bottom line is about a third of the people that went to the Gulf War have the mysterious illness and some veterans have it fairly severe. And I'll talk more about some of what that means, but the bottom line is it's been an enigma for many years. There's not, at this time, either a known cause or a very good by itself treatment. So it's continued to be explored. And I think that a lot of that comes down to the fact, I'm trying to get the slides to advance. It was kind of a unique war. There was the air war for a while, but the ground invasion was actually very quick and actually an amazing victory of the coalition. But there was smoke, there was oil, there was pyrostigmine and other things I'll talk about in a minute. And there was, you know, at least as I'll talk about after the war, an accidental release of a low dose of sarin and other possible exposures that have been brought up. The invasion itself, again, was an amazing success. General Schwarzkopf and others involved, Colin Powell and others involved in this made a very dramatic thing working with the coalition troops to really bring a quick endgame. To the war and the American casualties were very low in the hundreds as far as deaths with low morbidity. But unfortunately, the long more but lower mortality, but the long morbidity of the Gulf War illness remains. And there were many exposures, and I'm not going to go over the whole slide, but some of them have been brought up. I mean, anthrax we've seen, the chemical things, parsing of bromide as an antidote for possible chemical things. TARC paint, which was used again to protect against chemical weapons, various infectious things. I can say I actually gave a lecture last year to what's called the Gulf War Advisory Committee and looked at the infectious disease things, because this has been brought up a number of times for Gulf War illness, but all the evidence points against an infectious agent being there, particularly the one that had been brought up the most, which is mycoplasma. You know, the background is that, you know, the bottom line is that there's a chronic multi-symptom illness that just involves a number of symptoms, and there's never been a very good definition of that. Past research by the CDC and others showed that, again, about a third were involved, and they came up with really the first definition. The second definition was brought up by the Kansas group, by Dr. Steele, who's an eminent researcher in this field, and they basically had this idea you had to have three or six domains, fatigue, pain, and others, in order to qualify, and again, consistently, between 20 to 40% of veterans had met this thing, depending on whether you use the CDC, because it's broader, tends to be more sensitive, or the Kansas definition tends to be more specific. However, the GAO, Government Accounting Office, and the National Academies and others have tried to define Gulf War Illness, or have it defined, a report by the National Academies really ended up just basically saying, use either the Kansas or CDC, they're not ideal, but VA should work with DOD and others to come up with a definition. So we've taken that on, that challenge, and are in the middle of doing it. Basically, we have two large projects. One is a sophisticated charting thing at our risk, which Dr. Brummage brought up, our research centers, and then, really, the more intensive and things at the University of West Virginia, other academic centers, DOD, and others, is using artificial intelligence and big data to actually use algorithms to try and look at possible symptoms and signs of Gulf War Illness. We expect, within the next six months, to bring this all together. We have a steering committee, and interestingly, I checked, on that steering committee, there's 12 people involved, four are board-certified preventive medicine physicians, so they're actually contributing to the field and putting in their work on trying to get this done to come up with an actual definition. And I talked about the fact there was an accidental release of sarin gas. A bunker was bombed after the war and other demolitions of it, and it was not expected to have extra sarin gas, was actually detected afterward. The DOD actually sent letters to veterans, about 100,000 to 130 were exposed in a series of letters. However, modeling and things have shown the risk was very low, but the only thing that's come out of this is that, again, in our office, a researcher named Shannon Barth is actually working on her doctorate now with another, Dr. Durst and others, looked at brain cancer, and it appeared in the first decade or so after the war, there might have been an increase in brain cancer. However, that's reverted to normal going out, but other studies of this population also showed possible changes in the brain and things by Dr. Chow and others. This remains kind of a controversial area, and whether or not it actually, the exposure was enough to actually cause these things, or whether or not, it remains to have additional study in this area. There are Gulf War presumptions, just like the Agent Orange presumptions, there's not as many, but the VA does not use the term Gulf War illness, but uses basically undefined illness when you look at and rule out other things, particularly their GI or fibromyalgia, other things. And they're also, some of the infectious diseases can also get some benefits, but they have to be diagnosed within the war time period and have some sustaining periods, which is pretty rare, except maybe for like leishmaniasis. But things like TB in particular in these veterans can, if it's a chronic, poorly controlled situation or had some deterioration, can apply for benefits based on that for Gulf War. And one of the final things I'm going to talk about in the printed 11 very quickly is there was an issue of liver flukes. There's a couple of liver flukes in Vietnam and South Korea, but particularly in Vietnam that can cause rarely cholangiocarcinoma, but really cause a lot of other things. A paper came out suggesting there was a small increased risk, it was a small study. However, it turned out the fluke that was used was actually one used in Korea and had issues with serology that the CDC and others criticize. And we actually wrote a letter to the paper, but it remains in an area of interest. The Foreign Service University of Health Sciences is doing a study on this. And we also have a thing called the V Hero study, which is looking at morbidity and another study, mortality in the Vietnam population that's ongoing right now. And they're doing a special study on cholangiocarcinoma. So far, our internal data has not shown an increase in cholangiocarcinoma. I'm going to go quickly through some topics here. Another one is mefloquine, many know this issue, larium. It's thought to cause potentially some neurological psychiatric events. It can actually has a black box warning. It is still a drug of use by the Peace Corps, the CDC, and others, particularly for pregnant women. It remains a viable drug, although its use is not high these days. Veterans and some advocacy groups, in particular, have brought up the idea that there could be persistent or delayed onset, long-term adverse psychiatric effects. The first three studies there, however, have sort of pointed against that, largely the military VA studies. However, Dr. Nevin's study at the bottom looked at adverse effects. And he's one of the proponents of having at least this looked at in more depth. And then, so basically, there was a VA contracted with the National Academies. They did not find insufficient or inadequate evidence, but suggested more research in this area. They did find a drug called tenofoquin, has an unusual thing called vortex keratopathy. We alerted, the VA alerted, the ophthalmologist consultant alerted the VA optometry ophthalmologist, and they did a study on that. And they're not seeing this in the population. But we're continuing to evaluate this topic going forward and whether or not additional studies need to be done. We have one ongoing right now at the Oral Illness Injury Study Center here in DC. It's actually a fairly unique, large case series that had some very good psychometric testing and so forth. And we hope to have that published within the next year. I'm going to go quickly through some other things that Dr. Brummage talked about. The biggest thing is much of our attention in our office these days on airborne hazards and open burn pits, that's congressional interest, has mediated things. And there are, there was a couple National Academy reports, the most recent did not come up with actual conditions, talked about possibly some symptoms, could be related to toxic exposures. But it continues, it has the fastest growing registry. And it's important to recognize that all the Gulf War veterans can get into this airborne hazards, whether they're in the first Gulf War or the second Gulf War. And there's a big push to get more people in the registry and study it. And also Congress and or VA may ultimately decide to do something more for veterans, depending on what the evidence shows. We have an Airborne Center Hazard Excellence, which is in New Jersey at the risk, which is doing some really pioneering and unique research in this area, led by Dr. Falvo and others. So there's a lot of good things being going on in this area. And it's an area of topical interest and expected to continue to be so in the VA. Depleted uranium is really two things about this. There was a lot of concern in the Gulf War, this was the cause of Gulf War illness. Three papers, including a recent paper, have sort of discounted that as being a cause, as did a National Academy Report. And there is a center in Baltimore, as Dr. Brummage talked about. And this kind of ties into those who actually have embedded fragments that could have depleted uranium. And there's been only about five veterans have actually had any kind of potential issues during this. And they continue to go through, those veterans and others go through really rigorous examinations and testing to try and determine the side effects of this. But it remains a topic of interest. It's in the K2 population as well, which we'll talk about in a minute. I just mentioned K2, Dr. Brummage alluded to this, a base in the former Soviet Union had lost the possible toxic explosions. They did have a study by the military, what's now, it was called CHIPM now, called the Army Public Health Command, looked at that and found some possible rates of some cancers, but nothing specific. And the bottom line is, because the population was small and the compensators are wide, this has led to attention and several studies going on between DOD, ASTDR, but VA has sort of taken the lead on it. I come up with a study of its own working with other partners. That's gonna be fairly intensive and well done. And the bottom line is we should have some answers. It is a fairly small population. And so, again, that's something that it's a possibility Congress may act and just act on something before all the evidence is in, but it continues to be in the news. The plebeian reigning was one of the things, but there was smoke, there were fuels, there were asbestos, there were other things in the air. PFAS, if there's one thing that those of you out in the civilian non-military VA should probably know about is PFAS. This is a persistent class of chemicals. It's found in the water, it's found in Teflon, it's found in lots of things. It was used in firefighting foam on military bases, but it was endemic to other things. Tends to be persistent. EPA is in the middle of writing new standards on this. Some states have taken on their own lead of having their own things. The bottom line is that the VA and others and DOD, DOD in particular is doing a study on firefighters and ASTDR is involved with another study. But the bottom line is probably most important take home message is right now, a blood test for PFAS is not recommended because it's not been linked to definitely a specific health hazard and or a specific exposure so in some research studies they're doing blood tests, but it's not considered clinically indicated this time in the normal situation. All right. I'm going to turn this over to Dr. Block and I want to thank you and I'll come back at the end to close up and moderate. There's at least one question in the chat room right now. We'll answer that at the end after Dr. Block speaks. Thank you. Thank you, Dr. Ruhm. My name is Karen Block and I'm from the VA Office of Research and Development. Today I'll be talking to you about military exposure research with an emphasis on the 1990-1991 Gulf War. As noted earlier and as seen here, Gulf War, let's see. I can't see the slides very well. I cannot see the slides. I'm sorry. It looks like, oh, okay. Karen, I think we're seeing a lot of noise. Yeah, that's what I'm afraid of. Can I upload from my side or? Karen, I suggest you cover your first one or two slides, and I'll reach out to Robert right now. Okay. So, as Dr. Rumm was talking about, the reason that the field is so complex and it's difficult to come up with a case definition and known etiologies is because Gulf War service members were exposed to a number of toxic agents, and those were either singly or in combination of unknown quantities. Moreover, there are no reliable measures for exposure assessment, let alone mixtures. And together, these challenges have limited our basic understanding of toxic effects under military exposure. We know that approximately 30% of the 700,000 deployed troops presented with medically unexplained illnesses, and in 1998, Congress authorized a research advisory committee on Gulf War veterans' illnesses to oversee research and understanding the health consequences of serving in the Gulf. This FACA committee is still active today. The Gulf War Research Program resides in the Office of Research and Development in Washington, D.C., and ORD oversees clinical and basic sciences, health sciences, and rehabilitation research conducted at VA medical centers. We have over 100 VA nationwide that has the capacity to do research, and VA partners with our academic universities to enhance our research capabilities. Our VA Research Program is an intramural program, and our Gulf War budget is about $16 million per year. ORD has funded about 205 projects over the last two decades. And the pie chart, which you don't see, shows our current portfolio with approximately equal balance between model systems, biomarker mechanisms, and clinical trials in the Gulf War arena. I'll just talk to you a little bit about a few studies that have shown us potential treatments and targets for Gulf War illness. Chronic multi-symptom illness, it is hypothesized that exposure to the toxic agents can cause damage to the brain or gut barriers, resulting in enhanced systemic inflammation and oxidative stress. The perpetual heightened imbalance of cytokines, chemokines, and other metabolic instabilities contribute to chronic multi-symptom phenotypes of Gulf War illness, including cognitive dysfunction, joint pain, fibromyalgia, irritable bowel syndrome, and migraine headache. Studies examining the microbiome in veterans with Gulf War illness or in animal models of Gulf War illness find perpetration in microbiota compared to control. In part, the anti-inflammatory butyrate producing microbiota is reduced, which is associated with gastrointestinal inflammation, decreased tight junction proteins, leaky gut, and neuroinflammation, suggesting butyrate may be a novel therapy for Gulf War illness. Lipid metabolic pathways are also altered in veterans with Gulf War illness. Studies found that an increase of very long-chain fatty acids, ceramamides, sphenolamides, and phosphatidylcholine lipids associate with increased beta-oxidation and inflammation in the brain. Gulf War veterans with Gulf War illness present with systemic brain and oxidative stress and inflammation, and we also find mitochondrial dysfunction. Cognitive animal models with antioxidant nutraceuticals, such as curcumin, monosodium luminol, CoQ10, improve cognitive and mood function and irritable bowel syndrome in those models. Based on theories of immune deficiencies, neuroimmune changes, mitochondrial changes, and oxidative stress, emerging treatments for Gulf War illness include the nutraceuticals just mentioned, the antioxidants, complementary medicine, such as acupuncture, whole health programs, such as yoga and mindfulness, whole health programs, drugs to control the symptoms, and treat cognitive behavior therapy. The National Academy of Medicine, Engineering, and Science, Engineering, and Medicine produced 11 volumes of Gulf War and health theories, and volume 11 was entitled The Generational Effects of Serving in the Military. The Academy found 27 chemicals of interest associated with military service that could alter reproductive birth or developmental health effects. However, they did not find any evidence that these exposures were linked to the outcomes. To better understand the generational effects, the National Academy recommended a comprehensive health and monitoring research program. The health monitoring research program is being currently considered by a subject matter expert non-DACA work group. More broadly, the VA has determined that one in three veterans report exposures during service. Every military conflict has characteristic exposure-relevant health concerns. However, building that nexus between exposure and health outcomes has been a barrier for veterans to have access to care and benefits. One major gap in the field of military exposures is the lack of exposure assessment at the individual level, and understanding the health outcomes caused by that exposure. The activation of the individual longitudinal exposure record, as mentioned earlier, is one major step towards solving that problem. But additional approaches include standing up a new military exposure research program with the mission to advance military exposure assessments and to understand the effects of military exposures on veterans' health outcomes to inform care and policy. Our office is now going through a planning process to undertake a military exposure research program, and we expect the military exposure research program to launch in fiscal year 2022. Importantly, we understand that standing up a MIRP requires broad partnerships and a whole government approach. We have outlined intra and inter-federal agencies, academic partners, veterans, and other stakeholders to round out the subject matter expertise needed for database, synergy, biospecimen access, technology and infrastructure, and assessment. So I apologize that we may not have had the slides go along with that talk, but I thank you for your attention, and we'll turn it back over to Dr. Rumm. Yeah, Karen, can you advance to the next slide, please? All right, I guess the last slide, please, so we can get there. Okay, let's just, hopefully everybody can hear me. I just want to highlight, Dr. Brummage is part of the college, I am, and want to thank the college. And I just wanted to highlight the fact that preventive medicine doctors do some of this work. At the risk we talked about, Dr. Katz is actually an example. She's also the Surgeon General of the National Guard of California, so she's been really busy during the COVID, and has won several awards from the leadership awards, from AMA and so forth. My colleague, Dr. Schuping, who oversees a lot of the post-9-11, the airborne hazards, the K2 and others, is board certified preventive medicine, he's also occupational medicine and family practice trained, and he's just an example of the type of physicians we have at the VA. And I want to make a pitch that the VA is a good place to work, and we always, there are always potential opportunities for preventive medicine doctors and public health doctors. If anybody has an interest, just send me an email. My email is peter.rum at va.gov. Because not only the military exposure is growing, another preventive medicine doctor, Dr. Kim, Jane Kim, is leading the COVID vaccine efforts across the agency. So there's a lot going on in our agency that preventive medicine and public health doctors, or doctors and other clinicians with preventive medicine and public health background, may find an opportunity. So we'll turn it over now to some possible questions, and I'm going to read, there's two of these, and I'll read these, and whoever wants to answer, if nobody answers, I'll give it a crack. In fact, I think I should probably take the first one, because Dr. Brummage is fairly new, but he may want to add on to what I say. The question is, since around 2000, DOD is collecting data on where and when service members deployed using the post-deployment health assessment to use this data now. We have a thing I think was mentioned earlier called the ILO, the Individual Longitudinal Exposure Record, which is bringing a lot of exposure and databases, and will eventually hopefully replace the registries. We also have a giant effort going on right now with Department of Defense and VA to actually create a standardized separation health assessment that's across all three services. But right now, until this point, a lot of this data was not used and had to be recollected and reassessed to register exams and others, but it's sort of becoming part of the effort to, again, with the ILO and others, to bring this data in. We also have, with the Cerner, which is a $10 billion project to create an electronic health record that matches the DOD's record in VA, have put environmental exposure and assessment questions into there that hopefully will capture some of the same data. Dr. Brummage, do you want to comment on that a little bit more maybe? Yeah. Thanks, Dr. Brummage. I appreciate that. That was an excellent answer, and the short answer is that we do not currently use the post-deployment health assessment or the post-deployment health reassessment data. Those are largely history-driven so that it's the veterans or the service members' own account of what their exposures were. The current ILR system that Dr. Brummage talked about uses objective data that was collected on the ground, either through area monitoring or through many of the services public health assessments that they do on the ground. We have objective data. There's a database called DOORS, the Defense Occupational Environmental Hazards Database that collects this kind of data, and ILR taps into it, mines the data from DOORS as a way to get objective exposure data. All right. The next question I think every one of us should chime in on, and I'll go last. I think I'm going to give Dr. Smith the first chance to respond, then maybe Dr. Brummage and Dr. Block from a research perspective. It's basically, what can healthcare providers do to raise awareness of exposure prevention, such as burn pits and post-exposure monitoring? Dr. Smith, maybe you could talk about this from what you're doing with the environmental and the efforts to maybe train other providers. Oh, that's excellent, Dr. Brummage. Thank you for the question. Well, in PDHS, we get that information out through different avenues of training. I do know that many of our environmental health clinicians and coordinators in the field have been advantageous in getting others to come to our special presentations that we offer. Every other month, webinars and our risk models. So we do have a lot of resources out there on our website, as well as if there are any other questions, I know that we can be contacted. Does anyone else want to chime in? Again, Dr. Brummage, your question, what can healthcare providers do to raise awareness of exposure preventions with things like burn pits and post-exposure monitoring? Well, I think at the point that you're talking about, once a veteran has left the service with a provider, the provider, of course, needs to be aware of these kinds of exposures. And really, military environmental exposures are a very specific kind of occupational exposure. And doing things to avoid further, for example, if a person was exposed to high particulates from their deployment in the Middle East, where we know that there were large suspensions of dusts, there were combustion products, either from automobiles, from generators, from burn pits and others that generate a large number of particulate matter, PM2.5, is to do good care, do regular preventive care. Of course, once you're deployed, you really can't avoid those things that you come into contact with as a part of your job. But as a provider, I think it's important to be able to tell people how to take care of themselves well. It was interesting that Dr. Block talked about some other preventive measures that you can use, like mindfulness and yoga exercise. So these so-called complementary and alternative means of caring for people are also important to be able to generate sort of whole person wellness and talking about that as a way to deal with the soldier, sailor, airman, and Marines who might have had these kinds of exposures in the past. Also becoming educated and knowing where to go to get definitive information. One of those places is the VA's exposure website. And you have a lot of links in the talk that you have. There's also an app called Exposure Ed that you can get it either from the Google or the Apple App Store. You can download it onto your device and you can look up almost any exposure by chemical, by location, by conflict, and be able to advise your patients better. And it just takes a little bit of time, I think, to sit down and go through. Of course, you know, when people get rare diseases, that's what a common problem that's seen among primary care providers is a service member will say, or a veteran will say, you know, I have this disease, a cancer or other kind of chronic illness. Could my exposures have caused this? And I think we all want to, you know, form a therapeutic bond with the patient and say, yes, they are, but we have to be careful about what we're doing. Because once you say yes and it's not true, it's really hard to, you know, spool that back in and correct it. And the service member, the veteran, is left permanently with the impression that it was the exposure that caused their illness. So I think there's a whole lot of layers to that kind of answer. I wish I could speak to the person who had asked the question so I could really kind of bore down a little bit deeper into what they were actually thinking about when they asked the question. Yeah, this is Peter. I think we're, I think I got it, but I think we're at the end of our time. I'm just going to say we got a thank you from a former Merritt College preventive medicine president, Michael Parkinson, former Air Force senior officer who did Gulf War stuff. He, especially I want to thank Dr. Block, some of the research stuff. So, and the stuff we're doing in Gulf War illness. So we'll close there. Thank you, Mark, Mike, for the compliment. So I think we're at the 3.15 time. We got to break off. Anybody has another question, just email me at peter.rum.va.gov and we promise to get you an answer. Thank you. Bye.

military exposures

veterans

environmental concerns

Camp Lejeune

PFAS contamination

Agent Orange

burn pits

Gulf War illness

registries

exposure assessment

healthcare providers