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Chemical weapons exposures in Iraq: challenges of a public health response a decade later.

On October 14, 2014, The New York Times published the first part of an in-depth expose, "The Secret Casualties of Iraq's Abandoned Chemical Weapons," (1) initiating a landslide reaction and innovative response by the Department of Defense (DoD). The article alleged that:
   From 2004 to 2011, American and American-trained
   Iraqi troops repeatedly encountered, and on at least six
   occasions were wounded by, chemical weapons remaining
   from years earlier in Saddam Hussein's rule. (1)


The investigation contained eyewitness accounts by 17 service members and 7 Iraqi police officers claiming exposure to aging chemical weapons abandoned years earlier, pointing out that the weapons were not part of an active arsenal during the Iraq war; they were remnants from Iraq's arms program in the 1980s during the IranIraq war. The New York Times also asserted the US government, specifically the DoD, kept secret the fact that these troops were being injured as they stumbled across aged chemical weapons that Saddam Hussein had built for his war with Iran, stating that the "[American government] ... failed to prepare its troops and medical corps for the aged weapons it did find." Further:
   The American government withheld word about its discoveries
   even from troops it sent into harm's way and
   from military doctors. The government's secrecy, victims
   and participants said, prevented troops in some of
   the war's most dangerous jobs from receiving proper
   medical care and official recognition of their wounds.


Perhaps most disappointing was the article's allegation that "[n]one of the veterans were enrolled in long-term health monitoring."

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A March 25, 2015 New York Times article, "Veterans Hurt by Chemical Weapons in Iraq Get Apology," reported an apology Under Secretary of the Army Brad Carson offered for the DoD mishandling of past cases. (2) As described in the article, the DoD acknowledged that the military had not followed its own policies for caring for troops exposed to old and abandoned chemical munitions, and that the Pentagon had failed to follow-up thoroughly. The DoD Uniformed Services also agreed to consider awarding Purple Heart medals, which may be awarded for injuries requiring medical treatment that are a result of enemy action, (3) to those exposed to makeshift bombs made from chemical weapons. Mr Carson further stated, "My ambition, and what I am committed to, is to make sure that any person who was exposed to a weaponized chemical or a chemical weapon is addressed through this process." He explained that, under the new guidelines, Veterans identified as possibly having suffered exposure to a chemical weapon will be contacted by their respective military service branch, evaluated in a structured interview, and in some cases, invited for a full medical examination. The Veterans will also be provided with documentation of their exposure and have their medical records updated accordingly. This information, Mr Carson promised, will also be shared with the Department of Veterans Affairs (VA) to help Veterans receive follow-up care and/or submit claims. (2) Following the October 2014 New York Times article, DoD leadership formed a working group, under the direction of Under Secretary Carson, and developed an investigation centered on 4 objectives:

1. identify, contact, and evaluate service members and Veterans for possible exposure to chemical warfare agents (CWA);

2. offer and provide service members and Veterans with likely or confirmed CWA exposure a medical exam, if appropriate;

3. document these efforts in the Defense Occupational and Environmental Health Readiness System (DOEHRS) and individual service treatment records and ensure the VA is informed of these findings, and;

4. consider appropriate recognition for service members and Veterans with injuries resulting from likely or confirmed CWA exposure. (4)

The working group designated the Army Public Health Center (Provisional) (APHC(P)) as the DoD lead agency for the identification of service members potentially exposed to weaponized chemical agents through the concept of a public health investigation.

Further, the working group adopted a definition for CWAs derived from the Chemical Weapons Convention. As such, chemical exposures of concern included any toxic chemical listed on Schedule 1 or any toxic chemical when applied as a method of warfare (eg, incorporated into a munition or device specifically designed to cause death or other harm through the release of the toxic chemical during the employment of the munition or device). (5) Principally, this included, among other substances, nerve agents, mustard agents, and chlorine.

CLINICAL EFFECTS OF MUSTARD

Sulfur mustard is a blister agent. Signs and symptoms of sulfur mustard exposure normally do not occur immediately thereafter. (6(pp204-212)7,8) Instead, they manifest 2 to 48 hours following exposure. The areas of involvement include exposed skin, eyes, and the respiratory tract, usually when it has vaporized due to temperature. Tender (or thin) skin, mucous membranes, and perspiration-covered skin are more sensitive to its effects. More severe exposure may involve the gastrointestinal tract, the central nervous system (CNS), and the hematologic system. (7) The extent of physiologic damage depends on the route and intensity of exposure. Effects from liquid mustard manifest sooner than effects from mustard gas. In mild to moderate cases, blisters occur 2 hours and up to 18 hours after the appearance of skin redness or erythema, which typically occurs 4 to 8 hours following exposure, but can occur one to 24 hours after exposure. The erythema may be accompanied by an itchy sensation (pruritis) and painful burning. The vesicles do not contain sulfur mustard and will not cause secondary contamination. In severe cases, vesication is more severe, followed by areas of necrosis. Systemic health effects include fever, malaise, prostration, and emesis. With ocular exposure, the onset of lacrimation, irritation, pruritis, burning, blepharospasm, and possible miosis occurs within 4 to 12 hours. With higher levels of exposures to the eye, onset of symptoms occurs within 3 to 6 hours. In addition to the above, there is increased erythema, eyelid edema, and moderate pain. With severe exposures, usually due to liquid mustard, the onset occurs within one to 2 hours. In addition to the above, increased eyelid edema, painful photophobia, cornea ulceration, severe pain, and blindness may occur.

Mild inhalation (respiratory) exposures will manifest within 2 to 24 hours with rhinorrhea, sneezing, epistaxis, hoarseness progressing to "toneless" voice, barking cough, anosmia, wheezing, and dyspnea in smokers and asthmatics, and, sometimes, nasal or sinus pain. (6(pp204-212)) More severe exposures manifest within 2 to 6 hours. In addition to the above, there is acute inflammation of the upper and lower airways, necrosis of the respiratory epithelium, possible obstruction of the upper and/ or lower airways secondary to pseudomembranous formation, airway occlusion from inflamed and necrotic cells, and death secondary to pneumonia. Other organ systems may be affected by other routes or increased severity of exposure. (7) The symptoms of ingestion exposure include nausea, emesis, abdominal pain, diarrhea, possible chemical burns of the gastrointestinal tract, and prostration. Acute CNS effects, such as CNS excitation and seizures, occur only following very severe exposure. (6(pp204-212)) In addition to being a vesicant, sulfur mustard is also an alkylating agent. Absorption into the body can injure the bone marrow, lymph nodes, and spleen, resulting in leukopenia and immunosuppression.

CLINICAL EFFECTS OF SARIN

Signs and symptoms of sarin exposure usually occur within seconds to hours following a mild or moderate dose. Symptoms manifest within seconds to minutes after exposure to sarin gas while the onset of symptoms following exposure to liquid sarin may take up to 18 hours. (6(pp142-154)) An exposed individual can experience one or more of the following: rhinorrhea, blurred vision, lacrimation, miosis, eye pain, blurred vision, excessive salivation, cough, chest tightness, tachypnea, diarrhea, abdominal pain, nausea and/or emesis, polyuria, confusion, drowsiness, weakness, headache, bradycardia, tachycardia, muscle twitching, hyperhidrosis, hypotension, or hypertension. (6(pp142-154)7) Exposure to a large sarin dose may result in more deleterious health effects including loss of consciousness, paralysis, seizures, and respiratory failure, which may lead to death. (6(pp142-154)7,8)

ELEMENTS OF THE CWA INVESTIGATION

Current and former service members were assigned to one of 4 cohorts, depending on the methodology which led to their identification as having been exposed to CWAs. (4,9) The first cohort included those 26 service members and Veterans identified in the October 2014 New York Times article. (1) Seventeen Soldiers, 6 Marines, and 3 Navy personnel were identified as exposed through contact with old munitions. As APHC(P) gathered contact information and contacted these individuals, it was determined that efforts should be made to identify the units of service members and Veterans specifically identified in media reports, and assess whether other unit members were potentially exposed; the identified 244 potentially exposed personnel formed Cohort 2. Further, service members and Veterans identified upon review of Post-Deployment Health Assessments (PDHA) or Post-Deployment Health Re-Assessments (PDHRA) as having been exposed or potentially exposed to CWAs in Iraq during Operations Iraqi Freedom and New Dawn at any time after March 19, 2003, through December 31, 2011, were included as Cohort 3. (4,9,10) The PDHA/ PDHRA forms are completed when service members redeploy and answer a series of questions about current health, changes in health, and deployment-related exposure concerns. The form has a question regarding potential exposure to chemical, biological, or nuclear agents as well as radiation. If this multipronged question is answered in the affirmative, the service member is supposed to elaborate, and the healthcare provider reviewing the form should discuss this with the service member. Unfortunately, details of the exposure or the discussion are not evident on the forms, so the forms for all redeployed service members during the time period were searched for key words and assessed for inclusion in Cohort 3. This cohort was expanded to include service members and Veterans identified in operational reports as having been exposed to weaponized toxic industrial chemicals (also considered CWA) at any time from March 19, 2003 through December 31, 2011. (9) Operational records regarding exposure incidents during this period remained classified and so use of this information for unclassified purposes required coordination between APHC(P) and US Central Command intelligence. The last cohort, Cohort 4, included service members and Veterans who self-reported exposure or potential exposure to CWAs while deployed to Iraq in support of Operations Iraqi Freedom and New Dawn at any time from March 19, 2003 through December 31, 2011. (4,9) Two weeks following the first New York Times article, (1) the DoD made a hotline available to individuals who wished to report CWA exposure. This was the Office of the Deputy Assistant Secretary of Defense for Force Health Protection and Readiness hotline (1-800497-6261). Although this hotline existed prior to this investigation and receives calls on a number of topics, it was specifically publicized to Veterans and service members starting on October 31, 2014, to report CWA exposures.

The review process varied somewhat for the respective cohort populations as shown in the Figure. Once a service member or Veteran entered a cohort, the service treatment record was reviewed to determine if there was any documentation of symptomatic CWA exposure and/ or treatment as well as sequelae or subsequent medical follow-up. A "positive" finding was a clinical encounter record entry for a CWA exposure or any indication of a personal CWA or possible personal CWA exposure, including the service member or Veteran endorsing or mentioning a personal CWA exposure in the absence of an AHLTA * clinical encounter record entry for a CWA exposure. (11) The service member or Veteran may have endorsed a history of personal CWA exposure in a follow-up visit, which may or may not have been related to a CWA exposure; yet, it is possible that there was not an associated initial clinical encounter for CWA exposure due to a lack of in-theater electronic health records early in the conflict. In this investigation, a review of a service member's or Veteran's AHLTA electronic health record is completed and documented in DOEHRS, a Military Health System (MHS) resource for entering, assessing, managing, and reporting occupational and environmental exposures. (10,12) Paper treatment records, including paper medical records from the deployment, were not available centrally and were not reviewed as part of this investigation.

* AHLTA is the DoD electronic health record system.

It is recognized that the electronic medical record might not contain all encounters, particularly those from early in the conflict before deployment use of electronic systems was in place.

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STRUCTURED INTERVIEW

If the medical record screen contained evidence of a symptomatic exposure to a CWA, or for all hotline callers, the service member or Veteran was offered a structured interview (SI). (11) The voluntary SI is a tool used to confirm the service member's or Veteran's inclusion based on location, time, and possible exposure to CWA. Based on the results of the SI, the service member or Veteran may be offered a clinical assessment (CA) at a military treatment facility. Service members and Veterans may decline the SI and/or CA without any effect on their eligibility for military or Veteran's benefits.

The SI is a healthcare provider-conducted, telephonic interview that occurs after the medical records screening to formally evaluate a potential CWA exposure. (9,11) This interview does not establish a physician-patient relationship, but serves as a fact-finding effort to determine the probability of a confirmed or likely CWA exposure based on the service member's or Veteran's history of exposure, symptoms and the time until onset, and any available CWA testing results. A service member or Veteran was offered a medical examination if the interviewing provider determined that sufficient evidence existed to support a likely or confirmed CWA exposure. A service member or Veteran progressed to the end-point determination of "no evidence of symptomatic exposure" if the interviewing provider determined there was not a preponderance of evidence to support CWA exposure (eg, the likelihood of CWA exposure for the service member or Veteran was determined to be less than 50%). Pertinent service member or Veteran information from the SI was documented in DOEHRS and uploaded. If the interviewing provider determined that the service member or Veteran had no evidence of symptomatic CWA exposure, the necessary CWA exposure information was documented in DOEHRS. Clinical assessments were offered to any service member or Veteran who was determined to have a confirmed or likely exposure. Additionally, service members or Veterans who were considered to have no evidence of a symptomatic exposure may request and be granted an examination. (9)

CLINICAL ASSESSMENTS

The CAs were conducted at the Walter Reed National Military Medical Center (WRNMMC). In order for Veterans who were no longer DoD beneficiaries to be seen at WRNMMC, Secretarial Designee status was obtained. This status allowed invitational travel orders to be created for the Veteran to travel to WRNMMC and undergo a one-time examination to assess whether the Veteran had current signs or symptoms of known health effects associated with CWA, including any referrals which the examining provider considered indicated, at no cost. (11) Lodging and per diem were included. The designee status did not include treatment or ongoing follow-up in the MHS. For this effort, APHC(P) provided administrative support to schedule SIs and CAs in coordination with WRNMMC, created invitational travel orders, and assisted service members and Veterans with travel arrangements and vouchers associated with the assessment. The WRNMMC Preventive Medicine Department, through the Occupational Medicine clinic providers, conducted the CAs and coordinated with other specialties as needed, documented the visit in the medical record, and provided health risk communication.

DOCUMENTING THE INVESTIGATION

As mentioned earlier, DOEHRS is an MHS resource for entering, assessing, managing, and reporting occupational and environmental exposures. (12) The Solution Delivery Division of Health Information Technology at the Defense Health Agency manages DOEHRS, which consists of multiple business areas: industrial hygiene, environmental health, radiation health, incident reporting, and registries. Useful for both garrison and deployed operations, it is mandated by various DoD policies and public laws and is an exposure system for AHLTA. (10,12) The existing incident reporting module was modified to meet the needs of the CWA initiative by allowing the creation of a record for each individual, attaching the medical record, the SI, the CA, and allowing the recording of status and key information throughout the process. This system also contains a mailbox function so that records can be forwarded to the appropriate individual when certain steps are completed, allowing traceability throughout the process. In addition, this system is a permanent archival system which can be accessed by the VA directly or through future DoD-VA information sharing platforms. Although the AHLTA record for each individual who undergoes a CA contains the information regarding the visit and the disposition, DOEHRS serves as a searchable system to retrieve CWA process information on all participants who have entered the process, regardless of the disposition, including demographic information, medical record screening results, the SI outcome, and the CA outcome.

RECOGNITION

The initial New York Times article (1) identified 14 Soldiers who, it was claimed, suffered from CWA exposure and were not appropriately recognized for their injuries. Information was gathered to determine whether or not these individuals were eligible for the Purple Heart award. (3) As part of this effort, individuals who were identified as having a confirmed or likely exposure to CWA were contacted to discuss possible concerns regarding awards. Such scenarios included exposure to CWA from the enemy use of an improvised explosive device. Exposure through digging up ordnance or contact with old leaking munitions is generally not considered to be enemy activity. The Army assisted Soldiers or Veterans who believe themselves to possibly be eligible for the Purple Heart award to identify and submit the appropriate documentation to support their request for consideration. (9)

COMMUNICATION: KEEPING THE INDIVIDUAL AND DOD LEADERSHIP INFORMED

High-level interest in this process necessitated keeping leadership informed of the recommended approach, progress, and roadblocks. In the early phase of the process, daily briefings were conducted between APHC(P) and the Office of the Surgeon General to communicate changing cohort sizes, progress in identifying and contacting the individuals, as well as the status of draft correspondence to the cohort members, fact sheets, and the implementation plan. (9) Although APHC(P) was the lead agency on this effort and had the majority of the participants, the other military services also had potential exposures. Coordination between representatives from their respective Surgeons General and Manpower and Reserve Affairs was conducted in weekly briefings to Under Secretary Carson. During and between these briefings, recommendations and issues were discussed. The briefings occurred for months until the overall process, including the CA, was established, although the cohorts, particularly Cohort 4, might still grow. The first CAs occurred in February 2015, less than 4 months after the process was initiated.

CONDUCTING INTERVIEWS

The SI was a provider-service member or Veteran conversation designed to gather information from the service member or Veteran about their potential exposure to CWA. There were a variety of responses as providers spoke to these service members and Veterans. While some service members or Veterans were happy that the program was in place, some were angry that they had been told not to talk about the event, and others stated that medical personnel did not always recognize the exposure and proceed accordingly. For some, talking about the event and the deployment was traumatic and difficult; for others, it was cathartic and a relief to get it out in the open. Many expressed the opinion that the interview was worthwhile, as well as gratitude that "someone cares" and "someone believes them." It was necessary to provide the service member or Veteran with the time he/she needed to discuss their exposure scenario and concerns in their own way. In some cases, individuals had not previously shared this information with a provider and did not know if they should be concerned about long-term health effects. To successfully conduct these interviews, it was essential to practice not only good and compassionate listening to establish trust and a connection to the service member or Veteran, but to allow them to express the variety of their feelings surrounding their exposure experiences.

LONG-TERM FOLLOW-UP

A key concern of the author of the initial New York Times article (1) was the lack of medical follow-up for affected service members; prior Army policy espoused lifetime monitoring. Although it was alleged that these exposures were kept "secret" and that medical providers were not made aware of the possibility of exposure, in 2004, the Army Medical Command (MEDCOM) published and widely disseminated guidance documents (13,14) prompted by 2 chemical agent exposure events. The first incident involved 2 service members exposed to a leaking munition containing nerve agent. The second incident involved the exposure of a US Air Force explosive ordnance technician to sulfur mustard in response to dredging a leaking World War I round from the bottom of the Atlantic Ocean. Each of these exposures was the subject of a medical case report. (15,16) The 2004 MEDCOM documents included guidance for the acute medical treatment of CWA exposure casualties (with focus on moderate to severe exposures), clinical and chain of command notification procedures, and exposure-related evaluation and follow-up plan. (13,14) Further, the guidance contained a broad follow-up protocol, which included surveillance of casualties extending beyond full clinical recovery due to the relative rarity of casualties suffering symptomatic CWA exposures. In light of casualty interviews and inconclusive or nonexistent medical documentation, the 26 service members initially identified by The New York Times were presumed to have not been clinically managed in accordance with the 2004 Army MEDCOM guidance for nerve agents and sulfur mustard. It should be noted that MEDCOM guidance is not theatre medical policy in a combatant command's area of responsibility, and at the time of exposure, the reporting of such casualties was classified and not easily accessible by typical MEDCOM queries. Service members with symptomatic CWA exposure in theatre may have been treated appropriately and followed-up on redeployment, but no centralized documentation was available.

The APHC(P) collaborated with representatives from the Army, Navy, Marine Corps, Air Force, Defense Health Agency, and VA, as well as academic experts and other nongovernmental personnel to review the scientific basis for the recommended long-term management of CWA casualties. The collaborative team specifically focused efforts on sarin and sulfur mustard by incorporating a review of published literature, best clinical practices, and information gleaned from exposure-based interviews and clinical examinations of CWA casualties. The literature review of military, medical, and scientific articles was conducted to research information and focused on information about the persistent health effects and the delayed-onset of signs and symptoms following exposure to chemical agents. (17-23) The review identified articles describing the use of CWAs during World War I, where the types of weapons employed ranged from tear gas and mustard gas to phosgene and chlorine. Also found during the review was the act of domestic terrorism perpetrated by members of Aum Shinrikyo in Matsumoto, Japan, who released sarin gas from several sites in the Kaichi Heights area during the evening of June 27 and morning of June 28, 1994. This event, known as the Matsumoto incident, resulted in the deaths of 8 people and injuries to over 200 others. It occurred about 9 months before the better known Subway Sarin Attack on March 20, 1995, an act of domestic terrorism perpetrated in Tokyo, Japan, by members of the same religious group who released sarin gas simultaneously from 5 containers on 3 different Tokyo subway lines. Information was also available relating to exposures during the Iran-Iraq War in which Iraq used large quantities of chemical weapons, reportedly mostly sarin and sulfur mustard, against both civilian and military populations in Iran.

The focus on the long-term medical management presupposed that the service member or Veteran underwent a clinical evaluation which determined that all acute and subacute health effects of the CWA exposure had resolved. The review report does not address those with high-level exposures, as these individuals often have life-long health issues and may need to remain under the care of specialists throughout their lives. To our knowledge, none of the exposures associated with the investigation fit that description. While the report presents some background and information about longterm health effects, its main purpose is to provide guidance on long-term follow-up of exposed individuals. Specific follow-up recommendations resulting from clinical evaluations should be discussed with the individual using principles of shared decision-making and should be documented in his/her medical record. All individuals who undergo evaluation for symptomatic CWA exposure(s) should be provided with educational materials. For this initiative, due to limitations in the ability to predict long-term health outcomes, individuals with confirmed symptomatic exposure(s) to CWAs will be sent a follow-up letter or health status questionnaire from APHC(P) on a periodic basis. The purpose of this periodic contact is threefold: (1) to provide patient education and updates when new information becomes available; (2) to help ensure optimal treatment of identified health conditions; and (3) to reassure the patient and demonstrate continued commitment. The DoD will communicate with the VA as needed.

FOLLOW-UP FOR MUSTARD EXPOSURES

All individuals with ocular exposure to sulfur mustard should be educated about the importance of good eye hygiene and eye care (eg, avoiding putting anything in the eyes that was not designed specifically for that use, seeing an eye care professional regularly). If an individual required eight weeks or more of medical care at the time of exposure, they should also be educated about the possibility of recurrent keratopathy and should be encouraged to see an eye care professional immediately for any unexplained eye pain or visual changes.

All individuals with ocular exposure to sulfur mustard should be counseled to notify their eye care professional and other healthcare providers about their exposure history. Late-onset or late-occurring ocular effects (these are effects which were not present acutely or subacutely after the exposure) of sulfur mustard exposure are impossible to predict and are unlikely to be identified in a periodic evaluation. Fortunately, late-onset ocular effects are unlikely to occur based on the currently known level of exposure to US military personnel; therefore, no formal DoD or VA medical surveillance is recommended.

Individuals exposed to sulfur mustard by inhalation should be educated about the possibility of long-term pulmonary effects and the importance of avoiding pulmonary toxins, including tobacco smoke, second-hand smoke, etc. These individuals should be educated about the importance of establishing and maintaining a close ongoing relationship with a primary care provider, so that changes in their clinical status are more likely to be detected. All individuals with symptomatic inhalation exposure to sulfur mustard should be encouraged to report all cases of pulmonary symptoms and/or pulmonary diagnoses to their provider. Each encounter for pulmonary evaluation should be used as an opportunity to emphasize the importance of avoiding pulmonary toxins--most notably, tobacco smoke. Fortunately, there have been no documented cases of high-level exposures to sulfur mustard involving US service members in a combat zone since World War II.

All individuals with symptomatic dermal exposure to sulfur mustard should be educated about the possibility of long-term dermal effects and the importance of avoiding dermal injuries, including sun- and tanning booth-induced injuries to the affected skin. Individuals with symptomatic dermal exposure to sulfur mustard with residual scarring at the site(s) of exposure-related dermal burns should be educated about the possibility of cicatricial malignancies and the importance of seeing a skin care professional if the scar(s) begin(s) to change color, shape, texture, etc. All individuals with asymptomatic dermal exposure to sulfur mustard should be reassured regarding the absence of evidence of longterm effects in the absence of acute effects. They should also be educated about the importance of avoiding dermal trauma, including sun exposure and tanning booth injuries.

There is no clear scientific or medical evidence concerning any risk of late-onset skin effects. If such effects exist, they are likely to be uncommon. They are also unlikely to be identified in a regular periodic evaluation; therefore, no formal DoD or VA medical surveillance is recommended.

Based on the levels of exposure during exposure incidents involving US service members while deployed to combat zones since WWII, systemic effects of sulfur mustard exposures are unlikely to occur. Therefore, no formal DoD or VA medical surveillance is recommended.

FOLLOW-UP OF NERVE AGENT EXPOSURE

Signs and symptoms of nerve agent exposure can range from frank effects of cholinergic poisoning with highlevel exposure (convulsions, near lethality, or requiring intervention to prevent death), to the presence of threshold cholinergic effects (miosis, rhinorrhea, measurable depression of cholinesterase) with intermediate exposures, to an absence of immediate clinical signs and symptoms with minimal exposure. If the eyes are exposed to vapor only, miosis may be the only sign. Currently, the literature does not support the development of late-onset symptoms in a nerve agent-exposed person after the acute effects of nerve agent exposure have resolved.

Although there have been no documented cases of highlevel exposures to nerve agents involving US service members since development of these agents in the 1930s, individuals with high-level exposure to nerve agents should undergo comprehensive neurological evaluation (with consideration of neuropsychological, vestibular, and ophthalmologic testing and/or referrals) to determine if there are any residual effects from their exposures. This also applies to highly exposed individuals who are asymptomatic from the abnormalities identified at the time of their initial referral for specialty evaluation. This/these evaluation(s) should attempt to isolate any residual nerve agent exposure effect from effects due to posttraumatic stress disorder (PTSD) and/or traumatic brain injury (TBI), which can be difficult. If this evaluation and concurrent testing are normal, or, if abnormal, explained by other factors such as PTSD or TBI, no further follow-up is recommended. If the above tests are abnormal and cannot be explained by a non-nerve agent-related condition or situation, it is recommended that the individual be referred to a neurologist, neuropsychologist, otolaryngologist, or ophthalmologist for further evaluation and follow-up as appropriate. Once these tests normalize, another cause for the abnormalities is identified, or the individual becomes asymptomatic with residual test abnormalities, no further followup is recommended.

All individuals with intermediate-level exposure to nerve agents (documented exposure that required treatment at the time) should undergo comprehensive neurologic evaluation (with consideration of neuropsychological and vestibular testing) to determine if there are any residual effects from their exposures. This applies whether or not they are symptomatic at the time of their initial referral for specialty evaluation. This evaluation should attempt to isolate any residual nerve agent exposure effects from effects due to PTSD and/or TBI. If this evaluation and concurrent testing are normal, or, if abnormal, explained by other factors, no further followup is recommended. If the above tests are abnormal and cannot be explained by a non-nerve agent-related condition or situation, it is recommended that the individual be referred to a neurologist, neuropsychologist, or otolaryngologist for further evaluation and follow-up as appropriate. Once these tests normalize, another cause for the abnormalities is identified, or the individual becomes asymptomatic with residual test abnormalities, no further follow-up is recommended.

All individuals with mild or low-level exposure to nerve agents should be educated regarding what is known about late-onset effects of nerve agent exposure, especially in cases of mild or no symptoms at the time of the exposure. Individuals with a history of possible exposure to nerve agent vapor only (with no possibility of liquid exposure) who had no signs of exposure within 15 minutes of the potential exposure can be considered nonexposed (because these effects occur within seconds to minutes after exposure). No follow-up is recommended.

CONCLUSION

Since the onset of the public health investigation in October 2014 until the time of this writing (March 2015), over 7,504 service members and Veterans have been evaluated in this process. Cohort 1 ultimately contained 48, while Cohort 2 had 226, and 5,777 were identified via the PDHA forms plus an additional 103 identified in operational records brought Cohort 3 to a total of 5,880. There were 1,350 hotline callers comprising Cohort 4. A total of 7,474 medical record reviews were completed, and 1,152 SIs conducted. At the end of the process, 6,439 individuals were identified as having no evidence of a symptomatic exposure. Two hundred sixty-six individuals were categorized as confirmed or likely to have had a symptomatic exposure. Of these, 111 have completed the CA and 52 have declined it. An additional 52 individuals had no evidence of symptomatic exposure but requested an examination anyway. At the onset of the effort in October 2014, APHC(P) worked to identify the individuals in Cohort 1 and called them to discuss their exposures, signs, and symptoms at the time; the medical care that they had received; and their current health status. A decision was made that all members of Cohort 1 would be seen at WRNMMC. While this strategy incurred travel costs, the purpose of having all individuals evaluated at one location was to promote standardization. A previous surveillance program established for individuals who were exposed to a hazard at the Qarmat Ali Water Treatment Plant in Iraq (23) employed a limited number of medical treatment facilities to conduct the evaluations. This was to ensure the needed level of specialty care was available, and to limit providers to a few who understood the objectives of the examination and were comfortable with the risk communication aspects of the program. This had been successful and was the model of choice for the effort. The CA was designed after a review of the literature regarding acute as well as chronic exposures, but it was designed without knowledge of the actual level of exposure of those who would be evaluated.

As described earlier, the 4 goals of the process were to:

1. identify, contact, and evaluate service members and Veterans for potential CWA exposure;

2. offer and provide service members and Veterans with likely or confirmed CWA exposure a medical exam, if appropriate;

3. document these efforts in DOEHRS and individual service treatment records and ensure the VA is informed of these findings; and

4. consider appropriate recognition for service members and Veterans with injuries resulting from likely or confirmed CWA exposure (these were met (to date)).

Coordination with the VA to provide identifying information on participants has already occurred. A tremendous amount of effort was expended to process the 7,504 potentially exposed individuals to date, and the ratio of confirmed or likely to potentially exposed was small at 226/7,504, or 3.5%. In almost every case, the service member or Veteran had a usual source of care, and many of them were already being followed, for example, for their respiratory complaints. The assessment conducted was not a compensation examination for the VA, but served to document an exposure (although most often with no true measure of dose). In the future, should an individual develop a condition that they attribute to their past exposure, in the absence of a presumption, another examining physician will assess the probability of an association. These efforts to identify service members and Veterans who had likely or confirmed exposures to CWA while in theatre might have been avoided if there was a central registry of service members who had been determined through medical channels to have had such an exposure. This serves to illustrate the importance of field recognition, care, and reporting of symptomatic exposures, and of making this information available in an unclassified format. In most instances when signs and symptoms were typical, contact with the medical community ultimately occurred and these exposures were known outside of classified channels. (15,16) At present, DOEHRS has an incident-reporting module for this purpose. While some individuals may not have sought medical care, had there been a centralized, unclassified location to report these exposures, or had the postdeployment health assessments clearly identified them, it would have been possible to conduct active or passive surveillance. The question on the PDHA that addresses chemical exposures is rolled in with other exposures, making it difficult to search the forms for likely exposures. To the degree that reporting remains classified, there remain substantial barriers to identifying and following such exposures. Ideally, after being promptly recognized and treated in the field with concurrent electronic medical record documentation, personnel symptomatically exposed to CWA would redeploy and receive appropriate follow-up care from their next healthcare provider. Even then, however, there would be no ability to easily identify these individuals, should the need arise, apart from the use of a very specific reporting code. To prevent future difficulties, unique symptomatic exposures should be reported through unclassified channels in accordance with deployment policy and tracked when appropriate. (10)

REFERENCES

(1.) Chivers CJ. The secret casualties of Iraq's abandoned chemical weapons. New York Times [archives]. October 14, 2014. Available at: http://www. nytimes.com/interactive/2014/10/14/world/mid dleeast/us-casualties-of-iraq-chemical-weapons. html. Accessed July 6, 2016.

(2.) Chivers CJ. Army apologizes for handling of chemical weapon exposure cases. New York Times [archives]. March 25, 2015. Available at: http:// www.nytimes.com/2015/03/26/world/middleeast/ army-apologizes-for-handling-of-chemical-weap on-exposure-cases.html. Accessed July 6, 2016.

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Coleen Baird, MD, MPH

MAJ Raul Mirza, MC, USA

Jessica Sharkey, MPH

Ron Teichman, MD, MPH

MAJ Romarius Longmire, MC, USA

Deanna Harkins, MD, MPH

LTC Joseph Llanos, MC, USA

Joseph Abraham, ScD

Charles McCannon, MD, MPH

Jack Heller, PhD

Carole Tinklepaugh, MD, MPH

COL William Rice, MC, USA

AUTHORS

Dr Baird is Chief, Environmental Medicine Division, US Army Public Health Center, Aberdeen Proving Ground, Maryland.

MAJ Mirza is the Occupational Medicine Division Chief, US Army Public Health Center, Aberdeen Proving Ground, Maryland.

Ms Sharkey is an Epidemiologist, Environmental Medicine Division, US Army Public Health Center, Aberdeen Proving Ground, Maryland.

Dr Teichman is a Physician, Environmental Medicine Division, US Army Public Health Center, Aberdeen Proving Ground, Maryland.

MAJ Longmire is a Physician, Environmental Medicine Division, US Army Public Health Center, Aberdeen Proving Ground, Maryland.

Dr Harkins is a Physician, Environmental Medicine Division, US Army Public Health Center, Aberdeen Proving Ground, Maryland.

LTC Llanos is a Physician, Environmental Medicine Division, US Army Public Health Center, Aberdeen Proving Ground, Maryland.

Dr Abraham is an Epidemiologist, Environmental Medicine Division, US Army Public Health Center, Aberdeen Proving Ground, Maryland.

Dr McCannon is a Physician, Environmental Medicine Division, US Army Public Health Center, Aberdeen Proving Ground, Maryland.

Dr Tinklepaugh is a Physician, Environmental Medicine Division, US Army Public Health Center, Aberdeen Proving Ground, Maryland.

Dr Heller is a Health Risk Assessor, Environmental Medicine Division, US Army Public Health Center, Aberdeen Proving Ground, High-level

COL Rice is Portfolio Director and Consultant to The Surgeon General for Occupational and Environmental Medicine, US Army Public Health Center, Aberdeen Proving Ground, Maryland.
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Author:Baird, Coleen; Mirza, Raul; Sharkey, Jessica; Teichman, Ron; Longmire, Romarius; Harkins, Deanna; Ll
Publication:U.S. Army Medical Department Journal
Geographic Code:7IRAQ
Date:Oct 1, 2016
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