Veterans and Agent Orange Update 2006 (2007) / Chapter Skim
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9 Other Health Effects
9 Other Health Effects
Pages 599-698
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From page 599... ...
For each type of health outcome, background information is followed by a brief summary of the findings described in earlier reports by the Institute of Medicine Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides. In the discussion of the most recent scientific literature, studies are grouped by exposure type (occupational, environmental, or Vietnam veteran)
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From page 600... ...
Although it is resistant to acne treatments, it usually regresses over time. Therefore, new cases of chloracne in Vietnam veterans would not be the result of exposure during Vietnam and are not of concern for this report.
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From page 601... ...
The patient has had several surgical interventions for the deep inflammation and cysts. An exposed colleague of the patient also had high serum TCDD but had only mild symptoms, which resolved after treatment.
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From page 602... ...
implicates additional inflammation-related mechanisms by which TCDD exposure may lead to chloracne (Tauchi et al., 2005)
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From page 603... ...
Conclusion On the basis of its evaluation of the evidence reviewed here and in previous VAO reports, the committee concludes that there is limited or suggestive evidence of an association between exposure to at least one compound of interest and PCT.
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From page 604... ...
Because Vietnam veterans received health screenings before entering military service, few severe hereditary chronic lung disorders are expected in that population. The major risk factor for many nonmalignant respiratory disorders is cigarettesmoking.
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From page 605... ...
Additional information available to the committees responsible for Update 1996 and Update 1998 did not change that finding. Update 2000 drew attention to findings from the Seveso cohort that suggested a higher mortality from nonmalignant respiratory disorders among study subjects, particularly men, who were more heavily exposed to TCDD.
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From page 606... ...
* of sodium trichlorophenol and of 2,4,5-T ester contaminated with TCDD, chronic bronchitis and COPD 2 -- Studies Reviewed in Update 1998 Kogevinas Mortality of male and female international et al., 1997 workers producing or applying phenoxy herbicides, nonmalignant respiratory mortality (ICD-9 460–519)
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From page 607... ...
Studies Reviewed in Update 1996 Zober et al., German workers exposed to trichlorophenol 1994* contaminated with TCDD from an accident at a BASF plant, 1953–1989; 175 of 247 cohort members compared to unexposed workers for prevalence of nonmalignant respiratory conditions Illness episodes per 100 person-years (cohort/reference)
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From page 608... ...
COPD -- 1.2 (0.5–2.8) Coggon et al., Production of phenoxy herbicides and 1991 chlorophenols in four British plants, mortality from nonmalignant respiratory diseases, 1963–1985 8 0.7 (0.3–1.3)
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From page 609... ...
Children -- –3.8 (p 0.05) Studies Reviewed in Update 2000 Bertazzi et al., Follow-up of 1976 accident in Seveso, Italy, 2001 who were exposed to pure TCDD in an industrial accident, 1976–1996 Nonmalignant respiratory diseases (ICD-9 460–519)
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From page 610... ...
8 1.0 (0.5–2.2) VIETNAM VETERANS New Studies Kang et al., US Army Chemical Corps personnel 2006 Self-reported, nonmalignant respiratory problems diagnosed by a doctor Deployed vs non-deployed 129 1.4 (1.1–1.8)
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From page 611... ...
20 0.8 (0.5–1.5) Studies Reviewed in Update 1998 Crane et al., Mortality of male Australian Vietnam veterans 1997a compared to the general Australian population Nonmalignant respiratory mortality (ICD-9 460–519)
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From page 612... ...
Watanabe Mortality of US Vietnam veterans who and Kang, died during 1965–1988, PMR analysis of 1996; Watanabe nonmalignant respiratory mortality (ICD-8 et al., 1991 460–519) (results from Army 648 0.81 (p 0.05)
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From page 613... ...
Vietnam veterans compared to Wisconsin 32 0.3 (0.2–0.5) Vietnam veterans compared to other veterans 32 0.5 (0.4–0.7)
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From page 614... ...
published findings from 20 years of follow-up for mortality in the US Air Force Health Study (AFHS) that compared Ranch Hands with referent subjects.
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From page 615... ...
, which involved 19,240 Vietnam veterans and 24,729 nondeployed veterans, there was no excess risk of death from nonmalignant respiratory diseases among those deployed to Vietnam compared with non-deployed veterans (RR 1.12, 95% CI 0.56–2.23) and no excess risk of death from COPD (RR 1.00, 95% CI 0.34–2.80)
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From page 616... ...
that found no association of exposure with episodes of COPD, the NIOSH cross-sectional study of production workers exposed to 2,4,5-T ester contaminated with TCDD (Calvert et al., 1991) that found no increase in COPD associated with serum TCDD concentration, a cross-sectional study in Saskatchewan (Senthilselvan et al., 1992)
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From page 617... ...
Immune Suppression Suppression of immune responses can result in reduced resistance to infectious disease and increased risk of cancer. Infection with HIV is a well-recognized example of an acquired immune deficiency in which a specific type of lymphocyte (CD4 T cells)
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From page 618... ...
The immune system attacks the body's own cells and tissues as though they are foreign. For example, the autoimmune reaction in multiple sclerosis is directed against the myelin sheath of the nervous system; in Crohn's disease, the gut is the target of attack; in type 1 diabetes mellitus, the insulin-producing cells of the pancreas are destroyed by the immune response.
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From page 619... ...
(2004) compared post-service mortality in male US Army Vietnam veterans with that in non-Vietnam veterans and found no significant difference in death due to "endocrine, nutritional and metabolic diseases, and immunity disorders" (ICD-9 240–279)
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From page 620... ...
However, several studies of various measures of human immune function have failed to reveal consistent correlations with TCDD exposure, and no detectable pattern of increased infectious disease has been documented in veterans exposed to TCDD or other herbicides used in Vietnam. Although suppression of the immune response by TCDD could increase the risk of some cancers in Vietnam veterans, there is no evidence to support that connection.
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From page 621... ...
Onset can occur before the age of 30 years, and incidence increases steadily with age thereafter. The main risk factors are age, obesity, central fat deposition, a history of gestational diabetes (in women)
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From page 622... ...
ICD-9 Range Diseases of the Circulatory System Men Women Men Women 250 Diabetes -- -- 35,000 37,800 Physician diagnosed 7.4a 7.9a -- -- Undiagnosed 2.9a 2.1a -- -- Prediabetes 33.8a 22.2a -- -- Lipid disorders Total cholesterol 200 mg/dL 47.8 55.2 -- -- Total cholesterol 240 mg/dL 16.2 17.1 -- -- LDL cholesterol 130 mg/dL 32.2 32.4 -- -- HDL cholesterol 40 mg/dL 25.1 9.1 -- -- 390–459 All circulatory disorders 37.5 36.6 410,400 461,200 390–398 Rheumatic fever and rheumatic heart -- -- 1,022 2,226 disease 401–404b Hypertensive disease 22,800 31,400 401 Essential hypertension -- -- -- -- 402 Hypertensive heart disease -- -- -- -- 403 Hypertensive renal disease -- -- -- -- 404 Hypertensive heart and renal disease -- -- -- -- 410–414, 429.2 Ischemic or coronary heart disease 8.9 6.1 233,300 219,100 410, 412 Acute or old myocardial infarction 5.1 2.5 83,100 74,500 411 Other acute and subacute forms of -- -- -- -- ischemic heart disease 413 Angina pectoris 4.4 3.9 -- -- 414 Other forms of chronic ischemic -- -- -- -- heart disease 429.2 Cardiovascular disease, unspecified 8.9 6.1 233,300 219,100 415–417b Diseases of pulmonary circulation -- -- -- -- 420-429 Other forms of heart disease (e.g., -- -- -- -- pericarditis, endocarditis, myocarditis, cardiomyopathy) 426–427 Arrhythmias -- -- -- -- 428 Heart failure 2.8 2.2 22,500 35,200 430–438b Cerebrovascular disease (e.g., 2.6 2.8 58,700 91,500 hemorrhage, occlusion, transient cerebral ischemia; includes mention of hypertension in 401)
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From page 623... ...
in epidemiologic studies. Conclusions from VAO and Updates The committee responsible for VAO concluded that there was inadequate or insufficient information to determine whether an association between exposure to the compounds of interest and diabetes mellitus exists.
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From page 624... ...
18 0.6 (0.4–1.0) Studies Reviewed in Update 2002 Steenland et al., Ranch Hand veterans and workers exposed to 2001 TCDD-contaminated products compared to unexposed comparison cohorts Ranch Hands 147 1.2 (0.9–1.5)
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From page 625... ...
Vejlupkova et al., 1981 ENVIRONMENTAL New Studies Chen HL et al., Residents around 12 municipal-waste 2006 incinerators in Taiwan -- prevalence of physician diagnosed diabetes Serum TCDD/TCDF (international TEQs) in logistic model adjusted for age, sex, smoking, BMI 29 2.4 (0.2–31.9)
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From page 626... ...
Michalek et al., Air Force Ranch Hand Veterans (n 343) 92 NS 2003 Studies Reviewed in Update 2000 AFHS, 2000b Air Force Heath Study -- 1997 exam cycle (Numerous analyses Ranch Hand veterans and comparisons discussed in the text of Herbicide/Dioxin Exposure and Type 2 Diabetes)
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From page 627... ...
O'Toole et al., Australian Vietnam veterans 12 1.6 (0.4–2.7) e 1996 Studies Reviewed in VAO AFHS, 1991a Air Force Heath Study -- 1987 exam cycle p 0.001, Ranch Hand veterans and comparisons 85 p 0.028 AFHS, 1984 Air Force Heath Study -- 1982 exam cycle Ranch Hand veterans and comparisons 158 p 0.234 ABBREVIATIONS: 2,4,5-T, 2,4,5-trichlorophenoxyacetic acid; ADVA, Australian Department of Veterans Affairs; AFHS, Air Force Health Study; AIHW, Australian Institute of Health and Welfare; CDC, Centers for Disease Control and Prevention; CI, confidence interval; EOI, exposure opportunity index; HDL, high-density lipoprotein; N/A, not applicable; NIOSH, National Institute for Occupational Safety and Health; NS, not significant; SS, statistically significant; TCP, trichlorophenol.
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From page 628... ...
Serum dioxin concentrations measured in a subgroup of 897 of the participants confirmed the reliability of selfreports of herbicide spraying as a surrogate for TCDD exposure. With respect to diabetes risk, the OR for Vietnam veterans relative to non-Vietnam veterans was 1.16 (95% CI 0.91–1.49)
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From page 629... ...
and consisted of a Ranch Hand veteran with serum TCDD over 10 ppt and a comparison veteran with serum TCDD under 10 ppt. A total of 29 matched pairs from the 1997 examination and 71 matched pairs from the 2002 examination were studied.
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From page 630... ...
Chronic active inflammation, acinar cytoplasmic vacuolization, and acinar atropy were found in the pancreata of rats exposed to TCDD for two years without lesions in the insulin-secreting islet beta cells. Nonetheless, several recent in vitro studies provide evidence that TCDD exposure could contribute to the development of type 2 diabetes.
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From page 631... ...
Moreover, the study investigated a group of Vietnam veterans with documented herbicide exposure, and individual selfreports of herbicide spraying were effectively validated by measurements of serum TCDD in a subsample. The study's reliance on self-reported data for disease classification was mitigated by fairly complete verification with medical records only for diabetes.
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From page 632... ...
The crosssectional analyses of Ranch Hand and comparison subjects took account of BMI, but not changes in weight (AFHS, 2005)
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From page 633... ...
Diabetes mellitus and metabolic syndrome are associated with increased triglycerides and decreased HDL. Other diseases (thyroid and renal disorders)
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From page 634... ...
in which the highest level of the parameter was measured and serum 2,3,7,8-TCDD level in 1966 Cholesterol r 0.78; p 0.01 Triglycerides r 0.66; p 0.02 Studies Reviewed in Update 2002 Kitamura Workers exposed to PCDDs -- hyperlipidemia 8 6.1, p 0.02 et al., 2000 Studies Reviewed in Update 1998 Calvert Workers exposed to 2,4,5-T derivatives vs et al., 1996 matched referents OR Abnormal total cholesterol Overall 95 1.1 (0.8–1.6)
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From page 635... ...
b Triglycerides [no significant effect] b VIETNAM VETERANS New Studies AFHS, Air Force Ranch Hand veterans (2002 exam 762 2005 data)
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From page 636... ...
Studies Reviewed in VAO AFHS, Air Force Ranch Hand veterans -- serum 283–304f 1991a dioxin analysis (1987 exam data) Cholesterol p 0.175e Triglycerides p 0.001e,g HDL cholesterol p 0.001e AFHS, Air Force Ranch Hand veterans -- Original 8–142f 1990h exposure group analysis (1987 exam data)
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From page 637... ...
. Finally, a weak but significant positive association between the percentage of Ranch Hand veterans with abnormally high serum triglycerides and their 1987 serum TCDD (adjusted RR 1.20, 95% CI 1.03–1.40, p 0.02)
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From page 638... ...
The recent report on Ranch Hand veterans (AFHS, 2005) shows that serum TCDD concentrations are positively associated with serum triglycerides; however, even in Ranch Hand veterans with the highest TCDD exposure, the mean serum triglyceride concentration (130 mg/dL)
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From page 639... ...
. Thus, an increasing number of Vietnam veterans may be exhibiting at least three of the diagnostic criteria for metabolic syndrome: hypertriglyceridemia, diabetes mellitus, and hypertension.
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From page 640... ...
The relative sensitivity and specificity of those enzymes for diagnosing liver disease vary, and several tests can be required for diagnosis. The only regularly reported abnormality in liver function associated with TCDD exposure in humans is an increase in GGT.
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From page 641... ...
A report on the Ranch Hand study (AFHS, 2000) found a significantly higher percentage of other liver disorders among veterans in the high-dioxin category than among comparisons.
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From page 642... ...
No increased mortality from diseases of the digestive system were found (ICD-9 530–579) in production workers (SMR 1.3, 95% CI 0.4–3.3)
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From page 643... ...
The percentage of Ranch Hand veterans with abnormal triglyceride concentrations increased significantly as the 1987 dioxin concentration increased. The only regularly reported abnormality in liver function associated with TCDD exposure in humans, increased GGT, was not increased in any of the comparisons made in the report.
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From page 644... ...
, heart enlargement, and heart attacks. Chest radiography can be used to assess the consequences of ischemic heart disease and hypertension, such as the enlargement of the heart seen with heart failure.
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From page 645... ...
cohort of workers exposed to phenoxy herbicides. There was a non-significant increase in mortality from circulatory diseases overall (SMR 1.16, 95% CI 0.91–1.46)
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From page 646... ...
c Heart disease diagnosed by MD 1.45 (1.13–1.86) c Thomas and Kang, US Army Chemical Corps vs US male population -- Mortality 6 0.55 Not adjusted for known 1990 Circulatory diseases (390–458)
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From page 647... ...
344 1.08 (0.85–1.38) a increase in serum TCDD 411 Myocardial infarction 42 1.31 (0.97–1.77)
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From page 648... ...
a increase in serum TCDD AFHS, 1995 Operation Ranch Hand -- Results of 1992 exam [largely superseded Hypertension -- medical record review by AFHS, 2005] Model 3: RH high TCDD vs background 1.20 (0.88–1.63)
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From page 649... ...
a AFHS, 1984 Operation Ranch Hand -- Results of 1982 baseline exam [largely superseded Model 1: before analyses on serum TCDD levels by AFHS, 2005] All verified by medical record review Heart disease 147 p 0.982 Myocardial infarction 7 p 0.432 649 continued
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From page 650... ...
risk factors Bullman and Kang, US wounded Vietnam veterans vs US men -- Mortality (through 1996 1981, focus on suicide) Circulatory disease 246 0.72 (0.55–0.91)
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From page 651... ...
e Partition at 1970 arbitrary Discharged after 1970 NR 1.43 (1.02–1.99) e Ischemic heart diseases 125 0–15 years since discharge 8 0.77 (0.31–1.55)
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From page 652... ...
effect for later time? Studies of Austrian Vietnam Veterans ADVA, 2005b Australian Vietnam Veterans vs General Male Population -- Mortality Circulatory disease 1,767 0.88 (0.84–0.92)
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From page 653... ...
Crane et al., 1997a Australian Vietnam Veterans -- Mortality (1980–1994) [largely superseded Circulatory disease 0.96 (0.88–1.05)
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From page 654... ...
Valvular heart disease 8 p 0.0019 Concerns of selection Congestive heart failure 5 p 0.5018 bias, quality of diagnosis, Ischemic heart disease 34 p 0.0045 low participation, gross Hypertension 383 p 0.0143 pooling of blood samples Adjusted for risk factors 2.29 (1.33–3.95) g made TCDD levels useless Occupational Studies McLean et al., IARC Cohort of pulp and paper workers -- Circulatory 2006 disease -- Mortality Never exposed to nonvolatile organochlorines 2,727 0.92 (0.89–0.96)
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From page 655... ...
619 0.5 (0.5–0.6) f 't Mannetje et al., New Zealand phenoxy herbicide workers -- Mortality Not adjusted for known 2005 risk factors Producers (1969–2000)
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From page 656... ...
Only adjusted for age and Ischemic heart disease 775 1.67 (1.23–2.26) timing of exposure Cerebrovascular disease 161 1.54 (0.83–2.88)
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From page 657... ...
545.1–4361.9 1.70 (1.02–2.85) p-trend 0.04 Ischemic heart disease (410–414)
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From page 658... ...
545.1–4361.9 2.06 (1.23–3.45) p-trend 0.01 Ischemic heart disease (410–414)
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From page 659... ...
for I Hamburg Circulatory diseases (390–458)
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From page 660... ...
-- Mortality 1996 (1940–1989) Circulatory diseases (390–458)
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From page 661... ...
TCDD effect vs unexposed in logistic model Self-reported and verified conditions combined Myocardial infarction Serum TCDD 238 pg/g lipid NR 1.14 (0.29–4.49) i Serum TCDD 238 pg/g lipid NR 1.09 (0.23–5.06)
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From page 662... ...
i Serum TCDD 238 pg/g lipid NR 0.97 (0.51–1.87) i Suskind and Monsanto workers at Nitro, WV -- Morbidity Hertzberg, 1984 Workers exposed to 2,4,5-T production (n 204)
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From page 663... ...
Alavanja et al., US forest and soil conservationists -- Mortality PMRs Not adjusted for known 1989 risk factors Ischemic heart disease (410–414)
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From page 664... ...
al., 1989a,b, 1998] Ischemic heart diseases (410–414)
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From page 665... ...
i Adjusted for age, sex, BMI, smoking, drinking, diabetes, triglycerides, total cholesterol, HDL, family history of heart disease, and which plant. j Adjusted for age, sex, BMI, and smoking.
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From page 666... ...
Mortality from circulatory diseases was lower, but not significantly, among Vietnam veterans in the first 15 years after discharge (RR 0.56, 95% CI 0.28–1.15) and was more comparable with that among the non-deployed men in the 15- to 30-year follow-up period (RR 1.06, 95% CI 0.85–1.32)
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From page 667... ...
than in Vietnam-era Air Force veterans who did not spray herbicides. However, in analyses that were restricted to enlisted ground crew, Ranch Hand veterans had increased mortality from circulatory diseases (RR 1.7, 95% CI 1.2–2.4)
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From page 668... ...
Covariates used in the adjusted analyses of the cardiovascular assessment included age, race, military occupation, smoking history, alcohol-consumption history, uric acid, BMI, waist-to-hip ratio, cholesterol, HDL, cholesterol-to-HDL ratio, family history of heart disease, diabetes mellitus, and use of blood-pressure medication. The analyses revealed a significant positive association between essential hypertension and 1987 serum dioxin concentration for all Ranch Hand veterans (unadjusted RR 1.18, 95% CI 1.08–1.29)
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From page 669... ...
Although the prevalence of heart disease or hypertension was greater in diabetic veterans than in non-diabetic veterans, herbicide spraying increased the prevalence equally in the two groups. Those results imply that the increases in the risk of heart disease and hypertension in Vietnam veterans who sprayed herbicides are associated with spraying herbicides, regardless of diabetes status.
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From page 670... ...
However, additional studies are needed to confirm the relationships and to determine their relevance to humans. Specifically, future research studies are needed to establish animal models of TCDD-induced cardiovascular disease to increase understanding of the physiologic and pathologic mechanisms that mediate the increased morbidity and mortality from circulatory diseases, including hypertension and ischemic heart disease, that have been suggested to be associated with herbicide and TCDD exposure in epidemiologic studies.
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From page 671... ...
Exposure to TCDD was directly measured in a subset of the study population and linked to the entire sample by establishing correlations of high values with self-reported spraying. It also had the merit of controlling for established risk factors for hypertension.
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From page 672... ...
(2006) are consistent with those of other studies of Vietnam veterans, including the other most highly exposed cohort composed of Vietnam veterans who served in Operation Ranch Hand (AFHS, 1995, 2000, 2005)
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From page 673... ...
The major quantifiable risk factors for circulatory diseases are similar to those for hypertension and include age, race, smoking, serum cholesterol, BMI or percentage of body fat, and diabetes. Reported results of new morbidity and mortality studies of the most highly exposed Vietnam-veteran cohorts (ACC and Operation Ranch Hand)
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From page 674... ...
The primary reason approximately half the committee could not agree to a conclusion of limited or suggestive evidence for an association for ischemic heart disease was that uncontrolled confounders might be distorting the results, while the remainder was not concerned that this was likely to be a major problem in occupational cohort studies. Conclusion Following extensive deliberations regarding the strengths and weaknesses of the new evidence and evidence from studies reviewed in previous VAO reports, the present committee deemed that the strengths of the evidence related to hypertension outweighed the weaknesses and concluded that there is limited or suggestive evidence of an association between exposure to the compounds of interest and hypertension (ICD-9 401–405)
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From page 675... ...
AL amyloidosis has been considered by the committees responsible for Update 2000, Update 2002, and Update 2004. Those committees concluded that there was inadequate or insufficient evidence to determine whether there is an association between exposure to the compounds of interest and AL amyloidosis.
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From page 676... ...
Overnight fasting serum concentrations of PCDDs, PCDFs, and PCBs, expressed as TEQs, were compared among three groups of women: 25 with peritoneal endometriosis and 25 with deep endometriosis -- both those groups were recruited from a hospital -- and 21 healthy controls recruited concurrently from the consultations of the same gynecologists who referred the deep-endometriosis cases. The controls were of similar age as the other two groups and showed no clinical signs of peritoneal or deep endometriosis or clinical evidence of another gynecologic abnormality.
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From page 677... ...
2002 of age in 1976; compared Serum TCDD 100 ppt: incidence of endometriosis 9 exposed cases; OR 2.1 (90% CI, 0.5–8.0) across serum TCDD concentrations continued
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From page 678... ...
et al., being evaluated for 1997 infertility; compared number of women with elevated TCDD concentrations in diagnosed with endometriosis (n 44) with subjects not diagnosed with endometriosis (n 35)
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From page 679... ...
. Although those studies do not establish the degree to which TCDD may cause or promote endometriosis, they do provide evidence that supports the biologic plausibility of a link between TCDD exposure and endometriosis.
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From page 680... ...
The studies reviewed previously in Updates 2002 and 2004 were limited primarily by their small study sizes, which did not produce statistically significant associations between the compounds of interest and endometriosis. However, they showed positive associations that can be considered consistent with the results of the two studies reviewed above.
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From page 681... ...
. The prevalence of thyroid dysfunction among adults in the general population ranges from 1 to 10%, depending on the group, the testing setting, sex, age, method of assessment, and the presence of conditions that might affect thyroid function.
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From page 682... ...
Update of the Scientific Literature Occupational Studies No new occupational studies concerning the compounds of interest and thyroid homeostasis were published since Update 2004. Environmental Studies The one environmental study published since Update 2002 involved anglers chronically exposed to dioxin-like compounds in the diet (Bloom et al., 2006)
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From page 683... ...
Vietnam-Veteran Studies No new publications examining thyroid function in the AFHS cohort or in other Vietnam veterans since Update 2004 were identified (IOM, 2005)
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From page 684... ...
examined mortality in the Ranch Hand and comparison veteran groups. There were 3 deaths from endocrine diseases in the Ranch Hand group and 31 in the comparison group (RR 1.4, 95% CI 0.4–4.7)
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From page 685... ...
. In a repeatedmeasures linear regression adjusted for age, race, and military occupation, the low-exposure and high-exposure Ranch Hand veterans had TSH significantly higher than the comparison population, and the trend test showed a significant linear increase over the comparison and background-, low-, and high-exposure groups (p 0.002)
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From page 686... ...
Despite extensive consideration of the full evidentiary databases, the committee could not reach consensus as to whether ischemic heart disease satisfied the criteria for inclusion in the category of limited or suggestive evidence of an association or should be retained in the category of inadequate or insufficient evidence. Health Outcomes with Sufficient Evidence of an Association For diseases in this category, a positive association between exposure and outcome must be observed in studies in which chance, bias, and confounding can be ruled out with reasonable confidence.
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From page 687... ...
; endometriosis; and disorders of thyroid homeostasis. The committee was unable to reach consensus as to whether another cardiovascular endpoint, ischemic heart disease, belonged in this category or in the classification above, "limited or suggestive evidence of an association." Health Outcomes with Limited or Suggestive Evidence of No Association To classify outcomes in this category, several adequate studies covering the full range of known human exposure must be consistent in not showing a positive association between exposure and outcome at any magnitude of exposure.
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From page 688... ...
2005b. The Third Australian Vietnam Veterans Mortality Study 2005.
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From page 689... ...
1996. The risk of suicide among wounded Vietnam veterans.
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From page 690... ...
1997b. Mortality of National Service Vietnam Veterans: A Report of the 1996 Retrospective Cohort Study of Australian Vietnam Veterans.
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From page 691... ...
2001. Dioxin exposure is an environmental risk factor for ischemic heart disease.
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From page 692... ...
1997. Serum dioxin and diabetes mellitus in veterans of Operation Ranch Hand.
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From page 693... ...
2006. Health status of Army Chemical Corps Vietnam veterans who sprayed defoliant in Vietnam.
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From page 694... ...
2000. Serum dioxin level in relation to diabetes mellitus among Air Force veterans with background levels of exposure.
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From page 695... ...
2003. Diabetes mellitus and 2,3,7,8-tetrachlorodibenzo-p dioxin elimination in veterans of Operation Ranch Hand.
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From page 696... ...
1996. The Australian Vietnam Veterans Health Study: II.
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From page 697... ...
2001. Dioxin and diabetes mellitus: an analy sis of combined NIOSH and Ranch Hand data.
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From page 698... ...
1990. Mortality and morbidity among Army Chemical Corps Vietnam veterans: A preliminary report.
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