Exposure to Hazardous Agents--Recommendations for the Protection of Military Troops.

For almost a decade, U.S. military veterans have expressed concerns about the potential long-term health effects of chemical warfare agents and other hazardous materials that might have been used during the 1991 Gulf War. As a result, the Department of Defense (DOD) has asked the National Academies for advice on a long-term strategy to protect the health of military personnel. The project is being undertaken in two stages: Technical analyses will be followed by a comprehensive policy guidance.

On November 30, 1999, the National Research Council (NRC) and the Institutes of Medicine (both of the National Academies), issued three new reports in their series, Strategies to Protect the Health of Deployed U.S. Forces:

* "Analytical Framework for Assessing Risks";

* "Force Protection and Decontamination"; and

* "Medical Surveillance, Record Keeping, and Risk Reduction."

A synthesis study will use these reports, along with a fourth one on methods of detecting and tracking exposures, to craft a unified, long-term strategy. A final report is expected by the end of 2000.

The First Report: Assessing Risks

The NRC report "Analytical Framework for Assessing Risks" offers a structure military leaders can use in assessing threats that U.S. forces may face from biological and chemical warfare, as well as from nonbattle hazards such as infectious diseases. The framework sets out three major phases of risk assessment:

1. Ongoing baseline preparation. Military planners should strive systematically to anticipate threats; distinguish which threats are greater; determine the risk of exposure; and incorporate risk estimates into operating procedures and training.

2. Activities during deployment. To document potential hazards and changes in concentrations of hazardous agents, a variety of information should be collected routinely: Troop activities and positions should be recorded, and samples should be collected from soil, water, and air. Use of environmental monitors and other remote detection devices may be helpful. Data collection also should take into account novel and unanticipated threats, such as local pathogens and long-term, low-level exposures that could lead to health problems.

3. Activities after deployments Veterans should be monitored for effects that may appear later, and it should be ascertained whether those effects are associated with exposure to potentially harmful agents during deployment. Uncertain outcomes should be investigated through reconstruction of exposure scenarios and through population studies. Much of the information obtained during deployment can be used to refine ongoing baseline risk analyses by providing a deeper understanding of known threats and by identifying threats not previously considered.

Unlike more traditional risk assessment models, this framework organizes threats around possible military activities--such as deployment near an industrial facility that houses toxic chemicals--rather than specific agents. Emphasizing deployment scenarios encourages thinking beyond a standard list of recognized hazards, the report says. In particular, attention should be given to the possibility that delayed effects might result from exposures to chemical or biological agents. The possibility of latent effects has been poorly examined, but the lack of data does not mean that no effects exist.

DOD should consider developing an explicit framework for risk-management decision making. That framework should include a clear list of objectives for keeping deployed forces safe, try to identify previously unrecognized hazards, and make exposure guidelines and deployment-specific data readily available for quick decision making by field commanders.

The Second Report: Protection and Decontamination

While the United States has discontinued its offensive biological and chemical research programs, such programs have proliferated in other countries, along with advances in biomolecular engineering. These events have prompted the U.S. military to substantially step up its defensive program to mitigate the potential consequences of such agents. The NRC report "Force Protection and Decontamination" offers guidance in guarding against exposure and harm from chemical and biological agents.

Threat projections and risk perceptions should be re-evaluated continually DOD should use its findings to revise materiel requirements, training protocols, and operational doctrine. Commander training must be improved, especially in the area of determining when and how much protective gear troops should put on and take off. Also, commander training must be developed to help leaders make appropriate risk-based decisions when missions might involve chemical or biological contamination.

The human respiratory system is extremely vulnerable to chemical and biological agents. Research and development of respirators is needed--including respirator seals, fit, and sealants--as well as more emphasis on testing the adequacy of respiratory protection from hazardous agents. Current protective garments cannot be used effectively with other systems, such as night vision goggles. These garments also are still vulnerable to leaks; suits or other technologies must be developed that minimize this vulnerability especially at seals and closures.

Techniques and training for decontaminating personnel and equipment must continue to improve, and better methods for assessing the effectiveness of decontamination are needed, DOD should give high priority to research on systems that can decontaminate both personnel and equipment--without using large volumes of water or complicated equipment.

The Third Report: Medical Surveillance

DOD has put great effort into improving the medical surveillance of deployed forces and record keeping since the Gulf War. It has launched or planned a variety of initiatives to address acknowledged shortcomings in these areas. But these efforts lack the comprehensive planning required to use systems and resources efficiently, says the Institute of Medicine report "Medical Surveillance, Record Keeping, and Risk Reduction."

DOD should develop an improved strategy to address medically unexplained symptoms, the report says. This strategy should include a continuing-education program for the military's primary care providers to improve their ability to diagnose, treat, and communicate with patients who have unexplained symptoms. In addition, a pilot program should identify service members in the early stages of such illnesses through the use of routinely self-administered questionnaires and through informed primary care providers. A research program also should be developed to assess the role of factors that lead to or perpetuate such symptoms.

Another aspect of this strategy should be a plan to collect baseline health data from all recruits, and to update this information annually for both active duty and reserve personnel. Health surveillance systems developed for deployment purposes should be integrated with the existing patient care system and should automatically report information to a central medical command for timely analysis. After major deployments, a sample of veterans should be monitored, along with those who remain on active duty or in the reserves. As soon as possible, DOD should develop the means to ensure that important environmental and other exposures are included in an individual's medical records. Research also should be conducted into the needs of service members and their families during deployments and after the return home. The findings of such research should be used to re-evaluate reintegration programs.

An integrated approach to information systems--that spans all military services--will require leadership and accountability. Standard policies and procedures should be obtained across the three branches. Ongoing advice from an external advisory board would help ensure the successful development of computer-based patient records for the military.

Also vital are risk communication efforts aimed at military personnel and their families. DOD should designate a group that will have primary responsibility for developing and implementing a risk communication plan.