Postdeployment Respiratory Health Care Encounters Following Deployment to Kabul, Afghanistan: A Retrospective Cohort Study

Longitudinal changes in lung function following post-9/11 military deployment in symptomatic veterans

RATIONALE

Exposure to burn pit smoke, desert and combat dust, and diesel exhaust during military deployment to Southwest Asia and Afghanistan (SWA) can cause deployment-related respiratory diseases (DRRDs) and may confer risk for worsening lung function after return.

METHODS

Study subjects were SWA-deployed veterans who underwent occupational lung disease evaluation (n = 219). We assessed differences in lung function by deployment exposures and DRRD diagnoses. We used linear mixed models to assess changes in lung function over time.

RESULTS

Most symptomatic veterans reported high intensity deployment exposure to diesel exhaust and burn pit particulates but had normal post-deployment spirometry. The most common DRRDs were deployment-related distal lung disease involving small airways (DDLD, 41%), deployment-related asthma (DRA, 13%), or both DRA/DDLD (24%). Those with both DDLD/DRA had the lowest estimated mean spirometry measurements five years following first deployment. Among those with DDLD alone, spirometry measurements declined annually, adjusting for age, sex, height, weight, family history of lung disease, and smoking. In this group, the forced expiratory volume in the first second/forced vital capacity (FEV1/FVC) ratio declined 0.2% per year. Those with more intense inhalational exposure had more abnormal lung function. We found significantly lower estimated FVC and total lung capacity five years following deployment among active duty participants (n = 173) compared to those in the reserves (n = 26).

CONCLUSIONS

More intense inhalational exposures were linked with lower post-deployment lung function. Those with distal lung disease (DDLD) experienced significant longitudinal decline in FEV1/FVC ratio, but other DRRD diagnosis groups did not.

Burn Pit Smoke Condensate-Mediated Toxicity in Human Airway Epithelial Cells

Burn pits are a method of open-air waste management that was common during military operations in Iraq, Afghanistan, and other regions in Southwest Asia. Veterans returning from deployment have reported respiratory symptoms, potentially from exposure to burn pit smoke, yet comprehensive assessment of such exposure on pulmonary health is lacking. We have previously shown that exposure to condensates from burn pit smoke emissions causes inflammation and cytotoxicity in mice. In this study, we explored the effects of burn pit smoke condensates on human airway epithelial cells (HAECs) to understand their impact on cellular targets in the human lung. HAECs were cultured at the air-liquid interface (ALI) and exposed to burn pit waste smoke condensates (plywood, cardboard, plastic, mixed, and mixed with diesel) generated under smoldering and flaming conditions. Cytotoxicity was evaluated by measuring transepithelial electrical resistance (TEER) and lactate dehydrogenase (LDH) release; toxicity scores (TSs) were quantified for each exposure. Pro-inflammatory cytokine release and modulation of gene expression were examined for cardboard and plastic condensate exposures. Burn pit smoke condensates generated under flaming conditions affected cell viability, with flaming mixed waste and plywood exhibiting the highest toxicity scores. Cardboard and plastic smoke condensates modulated cytokine secretion, with GM-CSF and IL-1β altered in more than one exposure group. Gene expression of detoxifying enzymes (ALDH1A3, ALDH3A1, CYP1A1, CYP1B1, NQO1, etc.), mucins (MUC5AC, MUC5B), and cytokines was affected by several smoke condensates. Particularly, expression of IL6 was elevated following exposure to all burn pit smoke condensates, and polycyclic aromatic hydrocarbon acenaphthene was positively associated with the IL-6 level in the basolateral media of HAECs. These observations demonstrate that exposure to smoke condensates of materials present in burn pits adversely affects HAECs and that aberrant cytokine secretion and altered gene expression profiles following burn pit material smoke exposure could contribute to the development of airway disease.

Chronic respiratory symptoms following deployment-related occupational and environmental exposures among US veterans

OBJECTIVES

Characterise inhalational exposures during deployment to Afghanistan and Southwest Asia and associations with postdeployment respiratory symptoms.

METHODS

Participants (n=1960) in this cross-sectional study of US Veterans (Veterans Affairs Cooperative Study 'Service and Health Among Deployed Veterans') completed an interviewer-administered questionnaire regarding 32 deployment exposures, grouped a priori into six categories: burn pit smoke; other combustion sources; engine exhaust; mechanical and desert dusts; toxicants; and military job-related vapours gas, dusts or fumes (VGDF). Responses were scored ordinally (0, 1, 2) according to exposure frequency. Factor analysis supported item reduction and category consolidation yielding 28 exposure items in 5 categories. Generalised linear models with a logit link tested associations with symptoms (by respiratory health questionnaire) adjusting for other covariates. OR were scaled per 20-point score increment (normalised maximum=100).

RESULTS

The cohort mean age was 40.7 years with a median deployment duration of 11.7 months. Heavy exposures to multiple inhalational exposures were commonly reported, including burn pit smoke (72.7%) and VGDF (72.0%). The prevalence of dyspnoea, chronic bronchitis and wheeze in the past 12 months was 7.3%, 8.2% and 15.6%, respectively. Burn pit smoke exposure was associated with dyspnoea (OR 1.22; 95% CI 1.06 to 1.47) and chronic bronchitis (OR 1.22; 95% CI 1.13 to 1.44). Exposure to VGDF was associated with dyspnoea (OR 1.29; 95% CI 1.14 to 1.58) and wheeze (OR 1.18; 95% CI 1.02 to 1.35).

CONCLUSION

Exposures to burn pit smoke and military occupational VGDF during deployment were associated with an increased odds of chronic respiratory symptoms among US Veterans.

Gross Hematuria and Lower Urinary Tract Symptoms Associated With Military Burn Pits Exposures in US Veterans Deployed to Iraq and Afghanistan

OBJECTIVE

The aim of the study is to describe rates of hematuria and other lower urinary tract symptoms, including self-reported cancer rates, among veterans postburn pits emissions exposure during deployment to Iraq and Afghanistan.

METHODS

US post-9/11 veterans with burn pits emissions exposure confirmed via DD214 forms in the Burn Pits360.org Registry were sent a modified survey. Data were deidentified and anonymously coded.

RESULTS

Twenty-nine percent of the 155 respondents exposed to burn pits self-reported seeing blood in their urine. The average index score of our modified American Urological Association Symptom Index Survey was 12.25 (SD, 7.48). High rates of urinary frequency (84%) and urgency (76%) were self-reported. Bladder, kidney, or lung cancers were self-reported in 3.87%.

CONCLUSIONS

US veterans exposed to burn pits are self-reporting hematuria and other lower urinary tract symptoms.

Impact of poor air quality while deployed on respiratory health: a systematic review

INTRODUCTION

British military personnel deploy internationally to areas with high levels of ambient air pollution. Air pollution can cause acute respiratory symptoms which lead to concern about potential long-lasting health effects. There is a requirement for evidence-based policy on chronic respiratory disease associated with military deployments to areas with poor air quality (AQ). This literature review examines the published evidence relating to the development of chronic respiratory disease in military personnel after exposure to poor AQ while deployed.

METHODS

A literature search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Embase, MEDLINE and Global health databases were searched for English language studies published since 2014 examining the respiratory health of military personnel deployed to Southwest Asia since 2001. A quality appraisal of selected articles was conducted using the Critical Appraisals Skills Programme checklist and a descriptive review completed.

RESULTS

Eleven studies were found, eight of which had objective outcome measures. Two prospective cohort studies were included; the remainder of the data were retrospective.

CONCLUSION

High rates of respiratory symptoms are reported by personnel who deploy to areas of poor AQ, giving rise to high levels of concern. Spirometry testing has found mild deficits, mostly of an obstructive nature, in a third of those with ongoing symptoms post deployment. These have not been consistently linked with deployment length. An increased risk of asthma appears to be multi-factorial in aetiology and there is no evidence for an increased risk of chronic obstructive pulmonary disease or histological pathology post deployment. At present, there is no definitive evidence of chronic respiratory disease due to exposure to poor AQ while deployed. Further objective longitudinal studies are required to continue to investigate the association, diagnosis and management of those with ongoing symptoms.

Deployment-Related Respiratory Disease: Where Are We?

Military personnel and veterans who have deployed to Afghanistan, Iraq, and parts of Southwest Asia (SWA) since 1990 are at risk of developing a host of respiratory symptoms and deployment-related respiratory diseases (DRRDs). This review aims to summarize our current understanding of DRRD and inform pulmonary practitioners of recent updates to DRRD screening, diagnosis, evaluation, and management. The most common respiratory diseases in these patients include asthma, chronic sinonasal disease, laryngeal disease/dysfunction, and distal lung disease. Pulmonary function testing and chest imaging are the most commonly used diagnostic tools, but techniques such as lung clearance index testing via multiple breath washout, forced oscillation testing/impulse oscillometry, and quantitative chest computed tomography (CT) assessment appear promising as noninvasive modalities to aid in lung disease detection in this population. We also summarize guidance on conducting an occupational and deployment exposure history as well as recommendations for testing. Finally, we discuss the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act) that includes a list of health conditions that are "presumptively" considered to be related to SWA military deployment toxic exposures, and provide resources for clinicians who evaluate and treat patients with DRRD.

Military deployment-related respiratory problems: an update

PURPOSE OF REVIEW

Military personnel deployed to Southwest Asia and Afghanistan were potentially exposed to high levels of fine particulate matter and other pollutants from multiple sources, including dust storms, burn pit emissions from open-air waste burning, local ambient air pollution, and a range of military service-related activities that can generate airborne exposures. These exposures, individually or in combination, can have adverse respiratory health effects. We review exposures and potential health impacts, providing a framework for evaluation.

RECENT FINDINGS

Particulate matter exposures during deployment exceeded U.S. National Ambient Air Quality Standards. Epidemiologic studies and case series suggest that in postdeployment Veterans with respiratory symptoms, asthma is the most commonly diagnosed illness. Small airway abnormalities, most notably particularly constrictive bronchiolitis, have been reported in a small number of deployers, but many are left without an established diagnosis for their respiratory symptoms. The Promise to Address Comprehensive Toxics Act was enacted to provide care for conditions presumed to be related to deployment exposures. Rigorous study of long-term postdeployment health has been limited.

SUMMARY

Veterans postdeployment to Southwest Asia and Afghanistan with respiratory symptoms should undergo an exposure assessment and comprehensive medical evaluation. If required, more advanced diagnostic considerations should be utilized in a setting that can provide multidisciplinary expertise and long-term follow-up.

A Clinician's Guide to Occupational Exposures in the Military

PURPOSE OF REVIEW

Adverse occupational and environmental exposures are common causes of respiratory disease and health consequences requiring medical care. Understanding how these various exposures affect patients and how to elicit an adequate history is critical for any clinician. Military personnel are often overlooked when discussing groups at risk for environmental exposure-associated airway disease. There are close to 20 million active duty and veterans in the USA, and nearly all clinicians will at some point care for a patient that has served in the military.

RECENT FINDINGS

Exposures related to military work include burn pits, chemicals/toxins, sandstorms, and living conditions. Burn pits and military waste are increasingly recognized as potential hazards attributed to the ongoing conflicts in the Middle East. The link between these various military exposures and acute or chronic airway diseases remains difficult. Epidemiological studies are emerging to demonstrate correlations with chronic lung disease and prolonged burn pit exposure. This review provides an overview of potential occupational and environmental exposures that may affect current and/or former military service men and women.

A perspective on persistent toxicants in veterans and amyotrophic lateral sclerosis: identifying exposures determining higher ALS risk

Multiple studies indicate that United States veterans have an increased risk of developing amyotrophic lateral sclerosis (ALS) compared to civilians. However, the responsible etiological factors are unknown. In the general population, specific occupational (e.g. truck drivers, airline pilots) and environmental exposures (e.g. metals, pesticides) are associated with an increased ALS risk. As such, the increased prevalence of ALS in veterans strongly suggests that there are exposures experienced by military personnel that are disproportionate to civilians. During service, veterans may encounter numerous neurotoxic exposures (e.g. burn pits, engine exhaust, firing ranges). So far, however, there is a paucity of studies investigating environmental factors contributing to ALS in veterans and even fewer assessing their exposure using biomarkers. Herein, we discuss ALS pathogenesis in relation to a series of persistent neurotoxicants (often emitted as mixtures) including: chemical elements, nanoparticles and lipophilic toxicants such as dioxins, polycyclic aromatic hydrocarbons and polychlorinated biphenyls. We propose these toxicants should be directly measured in veteran central nervous system tissue, where they may have accumulated for decades. Specific toxicants (or mixtures thereof) may accelerate ALS development following a multistep hypothesis or act synergistically with other service-linked exposures (e.g. head trauma/concussions). Such possibilities could explain the lower age of onset observed in veterans compared to civilians. Identifying high-risk exposures within vulnerable populations is key to understanding ALS etiopathogenesis and is urgently needed to act upon modifiable risk factors for military personnel who deserve enhanced protection during their years of service, not only for their short-term, but also long-term health.

Evaluation of an Injectable, Solid-State, Oxygen-Delivering Compound (Ox66) in a Rodent Model of Pulmonary Dysfunction-Induced Hypoxia

INTRODUCTION

Pulmonary dysfunction (PD) and its associated hypoxia present a complication to the care of many service members and can arise intrinsically via comorbidities or extrinsically by infection or combat-related trauma (burn, smoke inhalation, and traumatic acute lung injury). Current supportive treatments (e.g., ventilation and supplemental oxygen) relieve hypoxia but carry a significant risk of further lung injury that drives mortality. Ox66 is a novel, solid-state oxygenating compound capable of delivering oxygen via intravenous infusion.

MATERIALS AND METHODS

Male Sprague Dawley rats (N = 21; 250-300 g) were surgically prepared for cardiovascular monitoring, fluid infusion, mechanical ventilation, and intravital and phosphorescence quenching microscopy (interstitial oxygen tension; PISFO2) of the spinotrapezius muscle. Baselines (BL) were collected under anesthesia and spontaneous respiration. PD was simulated via hypoventilation (50% tidal volume reduction) and was maintained for 3 hours. Groups were randomized to receive Ox66, normal saline (NS; vehicle control), or Sham (no treatment) and were treated immediately following PD onset. Arterial blood samples (65 µL) and intravital images were taken hourly to assess blood gases and chemistry and changes in arteriolar diameter, respectively. Significance was taken at P < .05.

RESULTS

PD reduced PISFO2 for all groups; however, by 75 minutes, both NS and Sham were significantly lower than Ox66 and remained so until the end of PD. Serum lactate levels were lowest in the Ox66 group-even decreasing relative to BL-but only significant versus Sham. Furthermore, all Ox66 animals survived the full PD challenge, while one NS and two Sham animals died. No significant vasoconstrictive or vasodilative effect was noted within or between experimental groups.

CONCLUSION

Treatment with intravenous Ox66 improved interstitial oxygenation in the spinotrapezius muscle-a recognized bellwether for systemic capillary function-suggesting an improvement in oxygen delivery. Ox66 offers a novel approach to supplemental oxygenation that bypasses lung injury and dysfunction.

Chemistry, lung toxicity and mutagenicity of burn pit smoke-related particulate matter

BACKGROUND

Open burning of anthropogenic sources can release hazardous emissions and has been associated with increased prevalence of cardiopulmonary health outcomes. Exposure to smoke emitted from burn pits in military bases has been linked with respiratory illness among military and civilian personnel returning from war zones. Although the composition of the materials being burned is well studied, the resulting chemistry and potential toxicity of the emissions are not.

METHODS

Smoke emission condensates from either flaming or smoldering combustion of five different types of burn pit-related waste: cardboard; plywood; plastic; mixture; and mixture/diesel, were obtained from a laboratory-scale furnace coupled to a multistage cryotrap system. The primary emissions and smoke condensates were analyzed for a standardized suite of chemical species, and the condensates were studied for pulmonary toxicity in female CD-1 mice and mutagenic activity in Salmonella (Ames) mutagenicity assay using the frameshift strain TA98 and the base-substitution strain TA100 with and without metabolic activation (S9 from rat liver).

RESULTS

Most of the particles in the smoke emitted from flaming and smoldering combustion were less than 2.5 µm in diameter. Burning of plastic containing wastes (plastic, mixture, or mixture/diesel) emitted larger amounts of particulate matter (PM) compared to other types of waste. On an equal mass basis, the smoke PM from flaming combustion of plastic containing wastes caused more inflammation and lung injury and was more mutagenic than other samples, and the biological responses were associated with elevated polycyclic aromatic hydrocarbon levels.

CONCLUSIONS

This study suggests that adverse health effects of burn pit smoke exposure vary depending on waste type and combustion temperature; however, burning plastic at high temperature was the most significant contributor to the toxicity outcomes. These findings will provide a better understanding of the complex chemical and combustion temperature factors that determine toxicity of burn pit smoke and its potential health risks at military bases.

The Impact of Deployment and Combat Exposure on Physical Health Among Military Personnel: A Systematic Review of Incidence, Prevalence, and Risks

OBJECTIVES

The impact of deployment and combat on mental health of military personnel is well described. Less evidence is available to demonstrate and summarize the incidence, prevalence, and risks of these exposures on physical health. This study aims to (1) systematically review the available literature to determine the incidence and prevalence of physical health conditions among military personnel during and after deployment and (2) investigate the risks of deployment and combat exposure on physical health.

METHODS

A systematic review using the PubMed and EMBASE databases was performed. The literature search was limited to articles written in English, published from 2000 through 2019. The quality of studies was assessed with the Joanna Briggs Institute Appraisal Checklist. The results were grouped per system or condition of physical health and presented by forest plots without a combined effect size estimate.

RESULTS

Thirty-two studies were found eligible for this review. We identified a wide variety of incidence and prevalence rates of numerous physical health conditions and a high heterogeneity across the included studies. Acute respiratory symptoms, diarrhea, musculoskeletal injuries, pain, and tinnitus were found to be the most incident or prevalent conditions. Except for hearing loss, no associations with deployment and physical health problems were observed. An increased risk for asthma, headache, hearing loss, and pain was reported in relation to the combat exposure.

CONCLUSION

Given the characteristics of included studies and extracted data, the magnitude of the found differences in incidence and prevalence rates is most likely to be due to methodological heterogeneity. The specific exposures (e.g., infrastructure, environmental conditions, and activities during deployment) are suggested to be the determinants of (post) deployment physical health problems and need to be addressed to decrease the impact of deployment. Findings from this systematic review highlight which conditions should be addressed in response to service members' health and wellness needs in the (post)deployment phase and may be used by clinicians, researchers, and policy-makers. However, knowledge gaps regarding the potential risk factors during deployment and combat still exist. Studies using consistent methods to define and measure the physical health conditions and specific exposures are needed.

Estimation of ambient PM2.5 in Iraq and Kuwait from 2001 to 2018 using machine learning and remote sensing

Iraq and Kuwait are in a region of the world known to be impacted by high levels of fine particulate matter (PM2.5) attributable to sources that include desert dust and ambient pollution, but historically have had limited pollution monitoring networks. The inability to assess PM2.5 concentrations have limited the assessment of the health impact of these exposures, both in the native populations and previously deployed military personnel. As part of a Department of Veterans Affairs Cooperative Studies Program health study of land-based U.S. military personnel who were previously deployed to these countries, we developed a novel approach to estimate spatially and temporarily resolved daily PM2.5 exposures 2001-2018. Since visibility is proportional to ground-level particulate matter concentrations, we were able to take advantage of extensive airport visibility data that became available as a result of regional military operations over this time period. First, we combined a random forest machine learning and a generalized additive mixed model to estimate daily high resolution (1 km × 1 km) visibility over the region using satellite-based aerosol optical depth (AOD) and airport visibility data. The spatially and temporarily resolved visibility data were then used to estimate PM2.5 concentrations from 2001 to 2018 by converting visibility to PM2.5 using empirical relationships derived from available regional PM2.5 monitoring stations. We adjusted for spatially resolved meteorological parameters, land use variables, including the Normalized Difference Vegetation Index, and satellite-derived estimates of surface dust as a measure of sandstorm activity. Cross validation indicated good model predictive ability (R2 = 0.71), and there were considerable spatial and temporal differences in PM2.5 across the region. Annual average PM2.5 predictions for Iraq and Kuwait were 37 and 41 μg/m3, respectively, which are greater than current U.S. and WHO standards. PM2.5 concentrations in many U.S. bases and large cities (e.g. Bagdad, Balad, Kuwait city, Karbala, Najaf, and Diwaniya) had annual average PM2.5 concentrations above 45 μg/m3 with weekly averages as high as 150 μg/m3 depending on calendar year. The highest annual PM2.5 concentration for both Kuwait and Iraq were observed in 2008, followed by 2009, which was associated with extreme drought in these years. The lowest PM2.5 values were observed in 2014. On average, July had the highest concentrations, and November had the lowest values, consistent with seasonal patterns of air pollution in this region. This is the first study that estimates long-term PM2.5 exposures in Iraq and Kuwait at a high resolution based on measurements data that will allow the study of health effects and contribute to the development of regional environmental policies. The novel approach demonstrated may be used in other parts of the world with limited monitoring networks.

Respiratory Health after Military Service in Southwest Asia and Afghanistan. An Official American Thoracic Society Workshop Report

Since 2001, more than 2.7 million U.S. military personnel have been deployed in support of operations in Southwest Asia and Afghanistan. Land-based personnel experienced elevated exposures to particulate matter and other inhalational exposures from multiple sources, including desert dust, burn pit combustion, and other industrial, mobile, or military sources. A workshop conducted at the 2018 American Thoracic Society International Conference had the goals of: 1) identifying key studies assessing postdeployment respiratory health, 2) describing emerging research, and 3) highlighting knowledge gaps. The workshop reviewed epidemiologic studies that demonstrated more frequent encounters for respiratory symptoms postdeployment compared with nondeployers and for airway disease, predominantly asthma, as well as case series describing postdeployment dyspnea, asthma, and a range of other respiratory tract findings. On the basis of particulate matter effects in other populations, it also is possible that deployers experienced reductions in pulmonary function as a result of such exposure. The workshop also gave particular attention to constrictive bronchiolitis, which has been reported in lung biopsies of selected deployers. Workshop participants had heterogeneous views regarding the definition and frequency of constrictive bronchiolitis and other small airway pathologic findings in deployed populations. The workshop concluded that the relationship of airway disease, including constrictive bronchiolitis, to exposures experienced during deployment remains to be better defined. Future clinical and epidemiologic research efforts should address better characterization of deployment exposures; carry out longitudinal assessment of potentially related adverse health conditions, including lung function and other physiologic changes; and use rigorous histologic, exposure, and clinical characterization of patients with respiratory tract abnormalities.

Use of Biomarkers to Assess Environmental Exposures and Health Outcomes in Deployed Troops

OBJECTIVE

This paper provides an overview of our Military Biomarkers Research Study (MBRS) designed to assess whether biomarkers can be used to retrospectively assess deployment exposures and health impacts related to deployment environmental exposures.

METHODS

The MBRS consists of four phases. Phase I was a feasibility study of stored sera. Phase II looks at associations between exposures and biomarkers. Phase III examines relationships of biomarkers and health outcomes, and Phase IV investigates in vitro biomarker changes associated with exposures to chemicals of interest. This paper briefly summarizes work already published and introduces the new reports contained in this supplement.

RESULTS

Novel biomarkers were identified. These were associated with deployment exposures.

CONCLUSIONS

Significant associations were noted between deployment exposures, microRNA biomarkers and metabolomic biomarkers, and deployment health outcomes.

Clinical Evaluation of Deployed Military Personnel With Chronic Respiratory Symptoms: Study of Active Duty Military for Pulmonary Disease Related to Environmental Deployment Exposures (STAMPEDE) III

BACKGROUND

Chronic respiratory symptoms are frequently reported after Southwest Asia deployment in support of combat operations. The full spectrum of clinical lung diseases related to these deployments is not well characterized.

METHODS

Military personnel with chronic symptoms, primarily exertional dyspnea, underwent a standardized cardiopulmonary evaluation at two tertiary medical centers. Pulmonary function testing consisted of spirometry, lung volume, diffusing capacity, impulse oscillometry, and bronchodilator testing. Further testing included methacholine challenge, exercise laryngoscopy, high-resolution CT scan, ECG, and transthoracic echocardiography.

RESULTS

A total of 380 participants with a mean age of 38.5 ± 8.4 years completed testing. Asthma was the most common diagnosis in 87 patients (22.9%) based on obstructive spirometry/impulse oscillometry and evidence of airway hyperreactivity, whereas another 57 patients (15.0%) had reactivity with normal spirometry. Airway disorders included 25 (6.6%) with laryngeal disorders and 16 (4.2%) with excessive dynamic airway collapse. Interstitial lung disease was identified in six patients (1.6%), whereas 11 patients (2.9%) had fixed obstructive lung disorders. Forty patients (10.5%) had isolated pulmonary function abnormalities and 16 (4.2%) had miscellaneous disorders. The remaining 122 patients (32.1%) with normal studies were classified as undiagnosed exertional dyspnea. Significant comorbidities identified included elevated BMI > 30 kg/m² (34.2%), smoking (36.4%), positive allergy testing (43.7%), sleep apnea (38.5%), and esophageal reflux (13.6%). Mental health disorders and posttraumatic stress disorder were likewise common.

CONCLUSIONS

Postdeployment pulmonary evaluation should focus on common diseases, such as asthma and airway hyperreactivity, and include testing for upper airway disorders. Diffuse lung diseases were rarely diagnosed, whereas numerous comorbidities were common.

Fumes and faeces in Kabul

Soldiers deploy worldwide, often in hostile and remote locations. Considerable effort is made to ensure British soldiers deploy to locations with the correct force health protection, such as vaccinations and antimalarial chemoprophylaxis. British soldiers are currently serving, among other places, in Kabul, Afghanistan. The poor air quality in this area is something that cannot be easily mitigated, other than advising to minimise time spent outdoors. This article reviews the data from a self-reported questionnaire about the respiratory symptoms soldiers experienced while serving in Kabul. It appears that during their deployment up to 90% of soldiers experienced nasal congestion, among other things. A detailed air quality study in the capital of Afghanistan may help us to better understand the reported symptoms and, if attributed to the air quality, to help provide better advice to those soldiers in the future.

Afghanistan and Iraq War Veterans: Mental Health Diagnoses are Associated with Respiratory Disease Diagnoses

Introduction

Many veterans of the wars in Afghanistan and Iraq have concomitant respiratory conditions and mental health conditions. We wanted to evaluate the association of mental health diagnoses with respiratory disease diagnoses among post-deployment veterans.

Methods

We conducted a retrospective cohort study of all Afghanistan and Iraq War veterans who were discharged from the military or otherwise became eligible to receive Veterans Health Administration services. The primary exposure was receipt of a mental health diagnosis and the primary outcome was receipt of a respiratory diagnosis as recorded in the electronic health record. We used multivariable adjusted logistic regression to measure the associations of mental health diagnoses with respiratory diagnoses and conducted several analyses exploring the timing of the diagnoses.

Results

Among 182,338 post-deployment veterans, 14% were diagnosed with a respiratory condition, 77% of whom had a concomitant mental health diagnosis. The incidence rates were 5,363/100,000 person-years (p-y), 587/100,000 p-y, 1,450/100,000 p-y, and 233/100,000 p-y for any respiratory disease diagnosis, bronchitis, asthma, and chronic obstructive lung disease diagnoses, respectively, after the date of first Veterans Health Administration utilization. Any mental health diagnosis was associated with increased odds for any respiratory diagnosis (adjusted odds ratio 1.41, 95% confidence interval 1.37-1.46). The association of mental health diagnoses and subsequent respiratory disease diagnoses was stronger and more consistent than the converse.

Conclusion

Many Afghanistan and Iraq War veterans are diagnosed with both respiratory and mental illnesses. Comprehensive plans that include care coordination with mental health professionals and treatments for mental illnesses may be important for many veterans with respiratory diseases.

Small airways disease in an Operation Desert Storm Deployer: Case report and review of the literature on respiratory health and inhalational exposures from Gulf War I

Constrictive Bronchiolitis (CB) has been reported in US Operation Iraqi Freedom/Enduring Freedom (OIF/OEF) deployers but not in those from prior US conflicts. A 62-year old presented with progressive dyspnea 13 years after deployment to the Persian Gulf in 1991-1992, where he was exposed to burning oil well fire emissions, dust storms, and other potential airborne hazards. In 2014, after a chest computed tomography (CT) scan demonstrated diffuse mosaic attenuation, he underwent surgical lung biopsy, which revealed CB. Deployers from both GWI and OIF/OEF share many exposures. As respiratory symptoms are a feature associated with Gulf War medically unexplained illness, there may be a role for renewed interest in evaluating GWI Veterans with unexplained respiratory symptoms for conditions such as CB, which may result from exposures relevant to deployers from both conflicts.

Combat zone exposure and respiratory tract disease

BACKGROUND

The impact of deployment to combat zones on the respiratory and sinonasal health of U.S. soldiers is an emerging public health concern. Retrospective studies have shown a correlation between deployment and development of post-deployment pathology, particularly of the aerodigestive system. Respiratory disease, including sinusitis, allergic rhinitis, and asthma, are commonly reported in soldiers deployed to the Middle East and Southwest Asia.

METHODS

Current literature pertaining to combat zone exposure and development of respiratory disease was retrieved using PubMed, Embase, Web of Science, and Google Scholar.

RESULTS

Several types of combat zone exposures exist that may play an influential role in the development of upper and lower respiratory tract diseases. Exposures including foreign dusts, harsh environments, particulate size, and close living quarters may play a causative role. The effect of combat zone exposures has been better examined for lower respiratory tract diseases; however, with the theory of the unified airway, the upper respiratory tract may also be involved. There is evidence that the upper respiratory tract is susceptible, with an increased risk for development of sinusitis and sinonasal disease; however, the quality of evidence of the present literature is generally low.

CONCLUSION

More research is necessary to determine a pathophysiologic mechanism between combat zone exposure and the development of sinonasal disease. Practicing otolaryngologists should be aware of the possibility of combat zone exposures that could contribute to rhinologic symptomatology.

Introduction to Department of Defense Research on Burn Pits, Biomarkers, and Health Outcomes Related to Deployment in Iraq and Afghanistan

OBJECTIVE

This paper provides an overview of our study that was designed to assess the health impact of environmental exposures to open pit burning in deployed troops.

METHODS

The rationale for the study and the structure of the research plan was laid out. An overview of each article in the supplement was provided. The cohort of deployed Service members was assessed for airborne exposure, relevant biomarkers, and health outcomes following deployment to Balad, Iraq, and/or Bagram, Afghanistan.

RESULTS

Polycyclic aromatic hydrocarbon (PAH) exposures were elevated, and serum biomarkers were statistically different postdeployment. Associations were noted between PAHs and dioxins and microRNAs. Some health outcomes were evident in deployers compared with nondeployers.

CONCLUSIONS

Future research will examine the associations between demographic variables, smoking status, biomarker levels, and related health outcomes.

Assessing Health Outcomes After Environmental Exposures Associated With Open Pit Burning in Deployed US Service Members

OBJECTIVE

This study assessed the long-term health impact of environmental exposures associated with open pit burning in deployed US service members.

METHODS

Two hundred individuals deployed to Balad, Iraq, and Bagram, Afghanistan, with known exposure to open pits, were matched to 200 non-deployed service members. Both cohorts were observed for adverse health outcomes after returning from deployment.

RESULTS

Slight increased risks were observed for respiratory diseases in the Bagram cohort (adj RR: 1.259), and for cardiovascular disease in the Balad cohort (adj RR: 1.072), but the findings were not significant. The combined deployed cohort showed lower risks for adverse health outcomes, suggesting a healthy deployer effect.

CONCLUSIONS

In conclusion, this study did not find significantly increased risks for selected health outcomes after burn pit exposure during deployment among two deployed cohorts compared with a non-deployed cohort.