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Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2022. Reassessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry. Washington, DC: The National Academies Press. doi: 10.17226/26729.
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Summary

More than 3.7 million U.S. service members have participated in the Southwest Asia theater of military operations1 beginning with the 1990–1991 Gulf War, through the response to the September 11, 2001, terrorist attacks (i.e., post-9/11 conflicts), and to the present.2 Deployments to Southwest Asia have exposed service members to a number of airborne hazards, including oil-well fire smoke, emissions from open burn pits, airborne dust and sand, diesel exhaust, and poor-quality ambient air. Many military personnel, particularly those who served in Iraq and Afghanistan post-9/11, have reported health problems that they attribute to their exposure to emissions from open-air burn pits on military installations or operations in those countries and elsewhere. The U.S. military routinely used burn pits to dispose of all types of waste, although at some of the larger bases incinerators were eventually installed. More than 270 burn pits are known to have been in operation in Southwest Asia.

In response to service members’ and veterans’ concerns and the growing number of adverse health effects they reported as well as the lack of studies on the relationships between these exposures and health outcomes, Congress directed the Department of Veterans Affairs (VA), through public law (PL) 112-260, to establish and maintain the Airborne Hazards and Open Burn Pit (AH&OBP) Registry. The law required an initial independent assessment of the registry and a reassessment 5 years later. This reassessment report responds to that mandate and follows the initial assessment by the National Academies of Sciences, Engineering, and Medicine in 2017.

COMMITTEE’S APPROACH AND OVERALL RECOMMENDATIONS

The reassessment committee’s Statement of Task was very different from that of the initial assessment committee—less focused on data characterization and analyses and more focused on determining whether the registry is accomplishing its intended purposes (see Box S-1). PL 112-260 states that the AH&OBP Registry is to “ascertain

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1 The Department of Veterans Affairs defines the Southwest Asia theater of military operations as comprising Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Gulf of Aden, Gulf of Oman, Oman, Qatar, the United Arab Emirates, and the waters of the Persian Gulf, the Arabian Sea, and the Red Sea. As deployments to other countries in this region, including Afghanistan, Syria, Uzbekistan, Djibouti, Egypt, and others may be added to the eligibility criteria for different VA programs or policy decisions, for the sake of brevity, this report follows previous National Academies reports on the topic and refers to this region as the “Southwest Asia theater” or simply the “theater.”

2 These operations include Operation Desert Shield (August 7, 1990–January 17, 1991); Operation Desert Storm (January 17, 1991–Febru-ary 28, 1991); Operation Enduring Freedom (October 7, 2001–December 28, 2014); Operation Iraqi Freedom (March 19, 2003–August 31, 2010); Operation New Dawn (September 1, 2010–December 15, 2011); Combined Joint Task Force–Operation Inherent Resolve (October 17, 2014–present [as of September 2022]); and Operation Freedom’s Sentinel (January 1, 2015–August 31, 2021).

Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2022. Reassessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry. Washington, DC: The National Academies Press. doi: 10.17226/26729.
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and monitor the health effects of the exposure of members of the Armed Forces to toxic airborne chemicals and fumes caused by open burn pits” and to have a public information campaign about the registry to include information updates. VA added other purposes, so that the AH&OBP Registry currently has five purposes:

  • Etiologic (causal relationships) research on health effects associated with deployment exposures to airborne hazards;
  • Population health surveillance to monitor the health of veterans exposed to airborne hazards while deployed;
  • Improving clinical care for veterans who have health concerns related to their deployment exposures;
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2022. Reassessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry. Washington, DC: The National Academies Press. doi: 10.17226/26729.
×
  • Supporting VA policies and processes, including benefits claims, and VA programs to help veterans with deployment exposure concerns; and
  • Communications and outreach from VA to veterans, health care providers, and other stakeholders.

The committee considered whether—after nearly 7 years of operation—the AH&OBP Registry does or could perform these functions, all of which are fully deserving of attention and appropriate action. If not, the committee considered whether improvements could be made or if alternatives, such as the Individual Longitudinal Exposure Record (ILER) or the Millennium Cohort Study, might better address a purpose. At VA’s urging, the committee did not limit its assessment to only burn pit exposures, but considered deployment-associated airborne hazards more broadly.

The committee spent nearly 2 years reviewing and deliberating the evidence as to whether the AH&OBP Registry is able to fulfill its five purposes. The evidence included extensive original analyses of AH&OBP Registry data; multiple information requests; presentations from VA, the Department of Defense (DoD), and other representatives; targeted literature searches; and examination of related exposure registries, epidemiologic cohorts, and military data sources. Its review leads the committee to conclude that

The stated registry purposes of “research about potential health effects of airborne hazards exposures”3 and conducting population health surveillance are unattainable, that data collection to meet these purposes is not helpful, and that efforts to address these important functions could be pursued in other, more effective ways.

Therefore, the committee offers recommendations to optimize the registry’s use by refining its operation to concentrate on attainable goals. The health problems experienced by the many veterans who deployed to Southwest Asia need to be addressed, but the AH&OBP Registry is not the right mechanism to do so. Congress and VA both need to consider how to balance the needs of their constituencies with the limited capabilities of the AH&OBP Registry and to identify other, more effective ways of meeting those needs.

Given the significant costs of maintaining the current registry and a participant burden with few benefits, as detailed in this report, the goals and functions of the registry need to be modified so that they are attainable and provide value to this veteran population in an efficient manner. The effort and resources currently devoted to the registry would be better directed toward alternative, more effective mechanisms for etiologic research and population health surveillance, with sufficient resources to support a greatly streamlined registry for generating and maintaining a roster of individuals who are interested in or concerned about the health effects of airborne hazards exposures. AH&OBP Registry resources could then be focused on the two meaningful areas to which it can contribute: health care—especially for those enrolled in VA health care, which is conducted by the Veterans Health Administration (VHA)—and communications. AH&OBP Registry information could also be used to inform VA policies or procedures. Implementing this new phase will require thoughtful and deliberate efforts and careful alignment of the narrowed functions with the data collection process to ensure the latter is efficient and effective in meeting the revised registry’s goals.

The committee recommends that the AH&OBP Registry be ended in its current form as its stated purposes have largely been to support research and population health surveillance, neither of which it can do. Therefore, the committee recommends that VA initiate a new phase for the AH&OBP Registry. This new phase would build on key information from the first 7 years of registry operations and would be developed and implemented to optimize the registry to be a user-friendly, efficient, and effective resource to provide two-way communication between participants and VA. Implementing this new phase will require thoughtful and deliberate efforts and careful alignment of the narrowed functions with the data collection process. Additionally, VA should ensure that this new phase provides information to enhance health care access and quality.

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3https://www.publichealth.va.gov/exposures/burnpits/registry.asp (accessed May 24, 2022).

Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2022. Reassessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry. Washington, DC: The National Academies Press. doi: 10.17226/26729.
×

As of July 1, 2022, more than 317,000 participants had completed the registry questionnaire, while over 130,000 individuals had begun but not completed it. Approximately 30,000 of registry participants had received the optional health evaluation. These many veterans have invested considerable time and effort to participate in the AH&OBP registry and constitute a unique and valuable roster of concerned individuals. Their contribution will not be lost with the registry’s enhanced focus on communications and a one-time standardized health evaluation platform for current and future participants. The health evaluation will continue to be an opportunity for participants to talk with knowledgeable clinicians about their deployment-related health concerns. It can also give VA health care providers information about the range and frequency of health conditions reported by registry participants, advise them on health risks, and recommend medical screening and follow-up activities, regardless of VHA enrollment status. The AH&OBP Registry can evolve into an important forum that is unique as the collective voice of hundreds of thousands of concerned veterans and be a conduit for that voice to be heard by VA and Congress, documenting and justifying the efforts of those who have chosen to participate. The need for bidirectional communication is clear—not only for veterans to “speak” to VA about their deployment exposures and health concerns, but also to enhance VA efforts to inform these concerned veterans about new information on the diagnosis or treatment of specific conditions or about new research results, as well as provide guidance on obtaining VA health care.

Therefore, the committee recommends that the current self-assessment questionnaire be replaced with one that is shorter, more efficient, user friendly, and limited in scope to collect only information that can be used to support communication or health care.

The committee further recommends that the information generated by the AH&OBP Registry be presented in a manner that is helpful for informing the general public, Congress, and the media about participants’ collective concerns.

The new phase of the AH&OBP Registry would have only a few brief questions that each serve a well-defined purpose, have free text fields to capture additional concerns, be pilot tested before implementation, and would allow participants to indicate whether they want to receive a health evaluation with proactive follow-up.

In the following sections, the committee details its process and methods for assessing each purpose of the AH&OBP Registry. The current registry was assessed for its ability to fulfill each purpose using objective measures when possible.

AH&OBP REGISTRY QUESTIONNAIRE AND DATA ANALYSIS

The reassessment committee concurs with the 2017 assessment that while any voluntary registry that relies on self-reported information has certain limitations, in the case of the AH&OBP Registry these limitations are exacerbated by flaws in the registry’s structure and operation, and in the questions that are asked, their order, and their phrasing. The AH&OBP Registry questionnaire contains approximately 140 questions, with the exact number depending on the number of eligible deployment segments a participant has and some skip patterns.4 The questionnaire asks about 21 health conditions (median reported was 4) and 10 exposures (median reported was 5). Two exposures—having been near a burn pit and having spent time outside or in an open tent or shelter—were reported by over 90% of participants. Questions with the highest nonresponse rates were exposure-related, so that the most critical questions for an exposure registry are the least likely to be answered.

Although the initial assessment committee offered nine recommendations to enhance the AH&OBP Registry or the data collected by it, in the 5 years since those recommendations were issued, few changes have been made, and those changes that were made have had little impact on the larger structural issues of the registry. Those changes include several minor alternations to questions and an opportunity for participants to add new eligible

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4 Skip patterns are a question or series of questions that are associated with a conditional response. For example, if a respondent answers that they have “never smoked,” questions pertaining to duration or frequency of smoking would not be applicable to them and would be skipped.

Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2022. Reassessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry. Washington, DC: The National Academies Press. doi: 10.17226/26729.
×

deployments with deployment-related exposure information after submitting the questionnaire. The changes were not pilot tested and did not involve external survey experts; it is unclear how they benefit the registry. A legislative change expanded the locations of eligible deployments; this change increased the size of the potential registry population but it did not improve the representativeness and the generalizability of findings from participants to the entire population.

The 2017 report detailed a number of quality issues with the registry’s information, so the reassessment committee determined that it was unnecessary to repeat several of the initial analyses, particularly the multivariable analyses. However, many descriptive analyses were repeated and updated, including population characteristics, comparisons with the eligible population, question-by-question responses, time for questionnaire completion, and nonresponse factors. Registry participants in the 2017 analysis (early) were compared with those who have participated since then (late) in order to assess the implications of continued enrollment. VA health care use was also examined to understand whether any participant characteristics are connected to the participants’ use of VA health care.

As a percentage of the entire eligible population (see footnote 1), the questionnaire completion rate at the time of this report is only 3.9% for 1990–1991 Gulf War era and 11.0% for post-9/11 era. Registry participants are still not representative of the total eligible population or of the population of a particular era of service. The committee’s registry dataset included 278,645 participants and 1,190,888 deployment segments.5

The time required to complete the questionnaire was directly related to the number of an individual’s deployment segments (on average, 4.3 deployments). About 75% of participants completed the questionnaire in less than 60 minutes, with an average completion time of 52 minutes, which did not include the additional time required by participants to verify and correct deployment information. A very conservative estimate is that participants invested at least 200,000 person-hours in completing AH&OBP Registry questions outside of their deployment history.

USE FOR ETIOLOGIC RESEARCH

To assess the registry’s ability to support etiologic research on the association between deployment exposures to airborne hazards and burn pits and health outcomes, the committee identified six characteristics that any exposure registry to be used for etiologic research should have and then applied them to the AH&OBP Registry:

  • a sufficient sample size for precise estimation of causal effects;
  • a representative sample of the population of interest;
  • identification of an appropriate comparison population;
  • an exposure assessment of adequate quality;
  • a health outcome assessment of adequate quality; and
  • identification of other contributing factors that might impact the association.

These characteristics correspond to the standard methodologic concerns in observational epidemiologic studies, namely random error (i.e., chance variation), selection bias, exposure and health outcome measurement error, and confounding. These characteristics have also been used in prior National Academies’ reports that reviewed epidemiologic studies of exposures and health outcomes in service member and veteran populations.

The AH&OBP Registry does not exhibit several of these characteristics, and therefore the committee concludes that AH&OBP Registry data are not appropriate for etiologic research of airborne hazards exposures and health outcomes. The registry has major design and data quality issues that cannot be overcome. Even

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5 A deployment—defined as any movement from a service member’s home station to somewhere outside of the continental United States and its territories until the service member returns to his or her home station—may include several segments. For example, an individual whose military unit is based in the United States and who is deployed to Kuwait for several days or weeks, then enters Iraq for several months, and returns to Kuwait before returning to the United States would have three deployment segments that would be eligible to include in the AH&OBP Registry.

Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2022. Reassessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry. Washington, DC: The National Academies Press. doi: 10.17226/26729.
×

substantial changes to the questionnaire would be insufficient to make the AH&OBP Registry appropriate for etiologic research.

Other sources were considered that might fulfill this research function, including ILER, the Millennium Cohort Study, the Gulf War Registry, and targeted epidemiologic studies. Each of the alternatives has potential value for etiologic research, but at present, none is ideal because they do not cover the same entire population or do not replicate all of the exposures and health outcomes collected by the registry.

Successfully using ILER data will depend on the extent to which ILER ultimately attains the etiologic research characteristics the committee identified. Currently, there are many unknowns about the quality of the data compiled by ILER that affect its usefulness for etiologic research, including missing values, incomplete data, the sampling measures or methods used for exposure assessments, single point-in-time measurements, the lack of validation or reconciliation of disparate sources (and their continued accessibility), and the extent of data systems interoperability. Its location data do not include deployments prior to 2000, which excludes individuals who served in the 1990–1991 Gulf War and the Peacetime period. Most exposure data are only available for 2006 onward, and ILER has a limited capability to determine individual-level exposures. DoD and VA electronic health record information is only available after 2012 and 2000, respectively; there is no health information for individuals who receive care outside of these systems.

The committee finds that Millennium Cohort Study fulfills the six characteristics for etiologic research on the general deployment-related health effects of post-9/11 service members and veterans—its intended purpose. The committee also finds that, with some modifications to the number and type of exposure questions the Millennium Cohort Study asks, it could capture the airborne hazards in the AH&OBP Registry questionnaire, and it could be an improved resource for etiologic research on airborne hazards exposures for post-9/11 veterans and service members.

Recent epidemiologic studies on burn pit exposures vary with respect to both methods and quality but they illustrate that studies of burn pit exposures and associated health outcomes continue to be undertaken. New epidemiologic studies or modification of existing ones such as the Millennium Cohort Study could easily address the most salient exposures and collect more granular data on the participants, thus providing a better data source for etiologic research.

The committee recommends that VA support the conduct of epidemiologic studies to examine the associations between exposures to airborne hazards and open burn pits and health outcomes. The studies should be designed specifically to fulfill the characteristics needed for etiologic research—a sufficient sample size for precise estimates, a sample that is representative of the eligible population, identification of an appropriate comparison group, an exposure assessment of adequate quality, a health outcome assessment of adequate quality, and identification of other relevant and contributing factors.

USE FOR POPULATION HEALTH SURVEILLANCE

Although neither PL 112-260 nor VA’s stated goals for the registry use the term “surveillance,” the committee believes that this function is implied by the requirement that VA “monitor” veterans’ health. A population health surveillance system should: 1. have overarching goals to address the prevalence or incidence of a potentially harmful exposure or occurrence of a disease in a defined population; 2. have regular data collection, analysis, and interpretation to look for predefined signals; 3. disseminate results and information to key audiences; and 4. use the collected information to improve health.

Although the AH&OBP Registry has an overarching goal to monitor veterans’ health, it does not do so because participation in the registry is a one-time self-assessment and no subsequent data are collected that might signal changes in an individual’s health status. Further, VA does not analyze or interpret the data on all registry participants; it only summarizes their responses to the questionnaire. VA shares deidentified data summaries by posting

Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2022. Reassessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry. Washington, DC: The National Academies Press. doi: 10.17226/26729.
×

them on the registry’s website, but they do not appear to be regularly distributed to key audiences. The Airborne Hazards and Burn Pits Center of Excellence may eventually improve clinical guidance for diagnosing and treating veterans with deployment-related health effects, but VA currently does not use the registry data to improve veterans’ health at the population level.

The committee finds that the AH&OBP Registry does not satisfy all four of the criteria necessary to conduct population health surveillance for service members and veterans potentially exposed to burn pits or other airborne hazards in the Southwest Asia theater.

Furthermore, given its fundamental design, the committee concludes that refinements or improvements will not allow the AH&OBP Registry to serve as a population health surveillance system.

The committee considered whether the registry could be used for simply monitoring participants’ health, which it defined as activities used to gather data without intended action or intervention or to determine the prevalence of a health outcome in the selected population. VA does not use the registry to monitor participants’ health, as this would require longitudinal data on participants; participants can add new eligible deployment segments and associated exposures, but they cannot update their health information. VA has no plans to establish a monitoring system and has stated that there are no immediate plans to follow-up with all registry participants.

Therefore, the inability of the AH&OBP Registry to perform population health surveillance or to simply monitor health patterns over time leads the committee to conclude that it should not be promoted as being able to conduct either of these functions.

The committee found that ILER was the only realistic candidate for a population health surveillance system for airborne hazards. However ILER is not fully functional at this time and it does not fulfill the committee’s four surveillance system criteria. It may be a component of a future population health surveillance or monitoring system, but its already-identified limitations will prevent it from fulfilling that function for the AH&OBP Registry population, particularly those who were exposed prior to 2006.

USE TO IMPROVE CLINICAL CARE

Veterans are eligible to enroll in VHA for health care by qualifying for one of eight priority groups. AH&OBP Registry participation does not influence that eligibility even if the veteran has a health condition that may be related to his or her exposure to airborne hazards or burn pits.

After submitting the registry questionnaire, a participant may request an optional, registry-associated health evaluation at a VA medical facility. The registry, particularly the health evaluation aspect, may encourage eligible veterans to enroll in VHA or serve as a mechanism for connecting them with other VA services. The health evaluation is an opportunity for participants, regardless of eligibility for VHA enrollment, to receive a standardized physical examination and to discuss their deployment-related health concerns with a VA health care provider trained to understand their exposures. The current template for the health evaluation allows the documentation of many aspects of the veteran’s medical, family, and behavioral history, but it does not include military and deployment exposures.

Registry participants can save and print their questionnaire responses, and they receive a summary of the health evaluation results if they have one. These materials can be shared with the veteran’s health care providers, both within and outside VA, to discuss the veteran’s health care needs. Health evaluation information is not used to confirm or correct participants’ responses to the questionnaire. Participating in the registry—and receiving the evaluation—might increase subsequent VHA use.

The committee concludes that the AH&OBP Registry health evaluation may enhance a veteran’s knowledge of his or her health status, but it does not improve a veteran’s access to or continuity of health care.

Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2022. Reassessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry. Washington, DC: The National Academies Press. doi: 10.17226/26729.
×

The health evaluation may facilitate entry to VHA for those registry participants who are eligible to access it, but not all participants are eligible.

Veterans are entirely responsible for scheduling their health evaluations with the VA environmental health coordinator and for scheduling any follow-up referrals they receive. Of the approximately 50% of registry participants who have requested a health evaluation, only about 10% have received one. VA has found it challenging to encourage registry participation and to maintain the capacity to perform all the requested evaluations. To improve clinical care, the committee recommends the following:

VA should expedite the receipt of the optional health evaluation for those registry participants who request one.

VA should simplify the scheduling of the registry’s optional health evaluation by having the VA environmental health coordinator proactively reach out to a veteran when notified of his or her interest via completion of the AH&OBP Registry questionnaire.

The Airborne Hazards and Open Burn Pit Registry Clinical Template for registry health evaluations and the accompanying clinical guidance should be modified to ensure that the VA clinician conducting the evaluation discusses the registry participant’s military deployment and exposure history with them and documents the information in the participant’s electronic health record.

At the end of the health evaluation, VA should proactively schedule any necessary referrals with the appropriate VA providers for veterans enrolled in VHA to ensure that they receive the appropriate diagnoses and treatments. The committee recognizes that this proactive scheduling will not be possible for veterans who receive health care outside of VA.

VA states that registry participation can help veterans monitor their health, but it is unclear about how the registry serves this end, as registry information cannot be updated or corrected. No information is available on whether the in-depth health evaluations for the small, select number of participants evaluated by the VA Airborne Hazards and Burn Pits Center of Excellence have improved clinical care for veterans or resulted in better clinical guidance.

INFORMING VA POLICIES AND PROCESSES

VA does not use the AH&OBP Registry for internal policy decisions beyond the standardization of registry procedures in VHA Directive 1307,6 which directs administrative and clinical procedures and processes for the registry health evaluation, although how the registry informed the directive is unclear. VA could use AH&OBP Registry data to inform program development and budgeting processes related to the registry, for example, by identifying bottlenecks in clinical care, such as long wait times for the health evaluation or increasing clinical capacity to perform the evaluations by recruiting new staff. Registry data could also be used to identify health concerns among veterans, making those concerns a research priority. A research agenda to address pressing knowledge gaps, such as increased reporting of a rare outcome, could also be formulated on the basis of registry input. However—to the committee’s knowledge—none of these activities have been undertaken.

Although improving the benefits claims process is one of VA’s goals for the AH&OBP Registry, the Veterans Benefits Administration’s claims review process is completely separate from a veteran’s registry participation. Veterans may use the questionnaire responses and results of the health evaluation to support a disability claim, but the registry health evaluation does not replace the disability rating examination.

VA notified registry participants that their information helped support the presumptive service connection between deployment exposures to fine particulate matter and asthma, rhinitis, and sinusitis, but these connections

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6 VHA Directive 1307 was rescinded and replaced with VHA Directive 1308 on March 25, 2022.

Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2022. Reassessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry. Washington, DC: The National Academies Press. doi: 10.17226/26729.
×

appear to be based on published literature and internal analysis of claims data, as rhinitis and sinusitis are not among the health outcomes in the registry questionnaire.

SUPPORTING COMMUNICATIONS AND OUTREACH

VA is required to “develop a public information campaign to inform eligible individuals about the open burn pit registry . . . and periodically notify eligible individuals of significant developments in the study and treatment of conditions associated with exposure to toxic airborne chemicals and fumes caused by open burn pits.” VA has made some efforts to meet the mandate of informing eligible individuals about the registry, but it has not been consistently proactive about informing them about research developments, the treatment of conditions related to airborne hazards, or about new programs and benefits designed for them.

VA communication activities include the dissemination of information and educational materials to registry participants, other stakeholders, and health care providers using a variety of communication channels. The value of these materials to registry participants is unclear, and there is no mechanism for participants to inform VA about their concerns outside of responses to the questionnaire.

VA’s communication strategy for the AH&OBP Registry focuses on promoting awareness of and participation in the registry, and it continues to evaluate the effectiveness of its strategy by the number of new participants. There is little communication to registry participants about how their information is being used to benefit themselves or their fellow veterans. VA posts on its website a variety of information on deployment exposures, including airborne hazards and burn pits, but it is unclear whether the registry sends electronic or printed materials directly to participants on a regular basis. VA did email participants to inform them about the new presumptive service connections for three respiratory conditions (but not the new presumption for nine rare respiratory cancers). Passive electronic messaging may not be sufficient to reach all interested participants. Participants cannot select more than one communication method or change it once the questionnaire is submitted.

The committee concludes that notifications about deployment exposures and health outcomes could be one of the primary benefits of registry participation.

The committee concludes that both VA and DoD have made good efforts to reach and educate their health care providers on the AH&OBP Registry, how to talk with their patients about joining the registry, and how to conduct health evaluations. Many of these materials are publicly available on either VA or DoD websites and thus are accessible to community health care providers.

The committee recommends that VA periodically assess whether its communications and outreach materials and activities provide value to registry participants and health care providers. This assessment may result in the expansion of the Health Outcomes Military Exposures communication strategy7 to capture feedback from potential or existing registry participants regarding their concerns or questions about the registry, their exposures to airborne hazards, and their health outcomes. A bidirectional communication strategy should include both written and verbal communications among VA experts, participants, and other interested stakeholders. Communication channels other than the questionnaire that might be used include hardcopy mailed materials, virtual meetings, webinars, workshops, town halls, and a comment field on the registry’s website.

The reassessment committee concurs with the initial assessment committee’s finding that the AH&OBP Registry is primarily useful as a mechanism to create a roster of concerned individuals and to provide bidirectional communications with registry participants. Requiring participants to complete a lengthy questionnaire to avail themselves of this mechanism is neither necessary nor advisable.

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7 The Health Outcomes Military Exposures communication strategy may be found in the annex to Chapter 9.

Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2022. Reassessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry. Washington, DC: The National Academies Press. doi: 10.17226/26729.
×

The committee recommends that the AH&OBP Registry serve as a roster of interested service members and veterans to provide a vehicle for them to express their concerns regarding exposure to burn pits and other airborne hazards and potential health outcomes.

CLOSING OBSERVATIONS

The Statement of Task specified that the committee make recommendations in several areas based on its assessment of the evidence. The committee considered whether the information collected by the AH&OBP Registry is scientifically up-to-date, and found that it is not.

The committee was also tasked with assessing “the most effective and prudent means of using the AH&OBP Registry or another system of records to provide information that translates into learning more about the conditions that are likely to result from exposure to open burn pits.” To accomplish this task, the committee recommends that VA support epidemiologic studies that satisfy the six characteristics for etiologic research, such as those described in the 2011 Institute of Medicine report Long-Term Health Consequences of Exposure to Burn Pits in Iraq and Afghanistan. The committee expects that such studies would be cost-effective in terms of discovering associations between airborne hazards and burn pit exposures and health outcomes. The 2020 National Academies report, Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations, identified gaps in the research, diagnosis, and treatment of the possible respiratory health effects stemming from exposure to airborne hazards and burn pits during deployment. That report may also inform the development and conduct of an epidemiologic study for etiologic research.

The AH&OBP Registry can be a unique and valuable resource for communications between veterans and VA and, indirectly, with health care providers, Congress, and other stakeholders. None of the other mechanisms considered in this report allow for the self-identification of interests and concerns that are captured by the AH&OBP Registry, and, therefore, the registry provides a function that needs to be preserved and enhanced by a new, more efficient, and impactful phase of the registry.

Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2022. Reassessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry. Washington, DC: The National Academies Press. doi: 10.17226/26729.
×
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Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2022. Reassessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry. Washington, DC: The National Academies Press. doi: 10.17226/26729.
×
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Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2022. Reassessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry. Washington, DC: The National Academies Press. doi: 10.17226/26729.
×
Page 3
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2022. Reassessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry. Washington, DC: The National Academies Press. doi: 10.17226/26729.
×
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Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2022. Reassessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry. Washington, DC: The National Academies Press. doi: 10.17226/26729.
×
Page 5
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2022. Reassessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry. Washington, DC: The National Academies Press. doi: 10.17226/26729.
×
Page 6
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2022. Reassessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry. Washington, DC: The National Academies Press. doi: 10.17226/26729.
×
Page 7
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2022. Reassessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry. Washington, DC: The National Academies Press. doi: 10.17226/26729.
×
Page 8
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2022. Reassessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry. Washington, DC: The National Academies Press. doi: 10.17226/26729.
×
Page 9
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2022. Reassessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry. Washington, DC: The National Academies Press. doi: 10.17226/26729.
×
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Beginning with the 1990–1991 Gulf War, more than 3.7 million U.S. service members have been deployed to Southwest Asia, where they have been exposed to a number of airborne hazards, including oil-well fire smoke, emissions from open burn pits, dust and sand, diesel exhaust, and poor-quality ambient air. Many service members, particularly those who served in Iraq and Afghanistan, have reported health problems they attribute to their exposure to emissions from open-air burn pits on military installations.

In 2013, Congress directed the Department of Veterans Affairs (VA) to establish and maintain the Airborne Hazards and Open Burn Pit (AH&OBP) Registry to "ascertain and monitor" the health effects of such exposures. This report serves as a follow-up to an initial assessment of the AH&OBP Registry completed by an independent committee of the National Academies in 2017. This reassessment does not include any strength-of-the-evidence assessments of potential relationships between exposures to burn pits or airborne hazards and health effects. Rather, this report assesses the ability of the registry to fulfill the intended purposes that Congress and VA have specified for it.

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