Reassessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry (2022) / Chapter Skim
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2 Methods and Approach
2 Methods and Approach
Pages 21-64
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From page 21... ...
Eligibility to participate in the AH&OBP Registry is based on the locations of deployment and timeframes as defined in Chapter 1, footnotes 1 and 2. INTERPRETATION OF THE STATEMENT OF TASK The legislative language that directed the establishment and assessments of the AH&OBP Registry specifically focused on "health effects of exposure to toxic airborne chemicals and fumes caused by open burn pits."1 Although burn pit emissions are one of the most visible and recognized exposures of military operations in the Southwest Asia theater, several other airborne hazards (e.g., desert dust, diesel exhaust, construction emissions, local industrial pollutants)
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. The reassessment committee looked to related exposure registries, epidemiologic cohorts, and military data sources for best practices and for "effective and prudent" approaches to learning about health conditions likely to result from exposure to airborne hazards and open burn pits.
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; • Long-Term Health Consequences of Exposure to Burn Pits in Iraq and Afghanistan (IOM, 2011) ; • Gulf War and Health, Volume 10: Update of Health Effects of Serving in the Gulf War (NASEM, 2016)
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Studies reviewed by the initial assessment committee or in the recent National Academies' report, Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations (NASEM, 2020) , were excluded.
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Preliminary findings from such studies would need to be replicated. The epidemiologic studies available on airborne hazards -- and on burn pits specifically -- vary with regard to both their methods and their quality.
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, validation of self-reported exposure to burn pits (Gasper and Kawata, 2015) , deployment segments (Ciminera, 2015a)
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Impact of open burn pit exposure on respiratory and cardiovascular health among military veterans Lead PI: David Savitz Awardee organization: Brown University Year: 2018 Topic area: Measurement of exposure to burn pits CONSIDERATIONS OF EXPOSURE REGISTRY DATA Well-designed epidemiologic studies are one of the best means of measuring the strength of associations between exposures and health outcomes, but large epidemiologic cohort studies are expensive and may take years to design, conduct, and assess. Therefore, epidemiologists may use other methods to conduct observational or experimental research studies.
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. As noted in the 2017 initial assessment, there are inherent limitations in using registries to draw inferences on the strength of an association between an exposure and a health outcome.
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These are: a main dataset that contains responses to all of the exposure and health condition questions (SAQ Main/Questionnaire Dataset) and a data file that contains information on all deployment segments,5 both verified and added deployments (SAQ Deployment Segment Data/Deployment Dataset)
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Some inconsistencies were observed among the annotated questionnaire, the data dictionary, and the data. For example, the response options or values for a given variable in the dataset were sometimes different than those indicated in the annotated questionnaire BOX 2-3 Registry Dataset Variables Imported from Other Sources Age Date of death Gender Marital status Ethnicity Race Service branch Service status Date of military separation Flag: Gulf War veteran Flag: deceased AH&OBP Registry specific evaluation date AH&OBP Registry Evaluation STA3N (station code, AH&OBP Registry Evaluation VISN indicates facility in which the encounter took place)
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9 extract provided by DMDC and the Gulf War Oil Well Fire Smoke Registry File. The following data were requested: • For all eligible service members: sex, month and year of birth, race, ethnicity, education, marital status, service branch, component, number of eligible deployment segments, separation status, separation date, fact of death, and date of death.
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One limitation of reusing the Gulf War Oil Well Fire Smoke Registry file information as presented in the initial assessment is that the inclusion and exclusion factors cannot be revised.10 As such, the 545,383 individuals who constituted the eligible population for 1990–1991 Gulf War veterans as included in the Gulf War Oil Well Fire Smoke Registry in 2015 were used as the eligible comparison for the current update.11 VA Electronic Health Records To examine self-reported and diagnosed health conditions, VA electronic health record data were requested for both the entire eligible population and the participants of the AH&OBP Registry who use VA health care. On December 2, 2021, VA provided a data file of 243,331 registry participants (using registry participants from the June 3, 2021, extract)
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Analyses Not Repeated The initial assessment committee analyzed health outcomes with latencies of more than 6 months and less than 10 years after exposure. Health outcomes were limited to those associated with the respiratory and the cardiovascular systems because these are the most plausible and well-documented health effects associated with airborne hazards and are emphasized in the registry.
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That committee further stated that the registry analyses are not generalizable and can only describe what exposures and conditions the registry participants are reporting; the registry data cannot be used to determine cause or estimate disease prevalence in the total eligible population of service members or veterans. The reassessment committee determined that there was no value in recreating or updating the multivariable analyses in the initial assessment because of (1)
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Participants were separated into mutually exclusive eras based on their eligible deployment segments: • 1990–1991 Gulf War: deployment that started on or before April 6, 1991; • Peacetime: deployment between April 7, 1991, and October 6, 2001; • Operation Enduring Freedom (OEF) /Operation Iraqi Freedom (OIF)
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Although Syria, Uzbekistan, and Egypt have become eligible deployment locations, they were not reflected in the AH&OBP Registry data as of February 1, 2022.
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-- 5.3 898 (0.3%) -- 0.3 Unit component Active Duty 9,077 (48.4%)
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Finally, they had a notably different distribution of eligible deployment segments, with 55.7% having a single deployment compared with 38.4% of the entire eligible population. Comparisons of post-9/11 participants to the eligible population of that era found that registry participants were less likely to be women and 50 years of age or older.
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To determine why so many deployment segments had inaccurate information for registry participants, the committee conducted several analyses that examined whether certain military- or deployment related characteristics were more likely to be associated with either verified or user-entered deployments. The analyses might indicate whether system-level changes are necessary to more accurately identify or code deployment segments as eligible.
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0.2 0.3 0.2 -0.1 Other (includes Public Health Service, missing and unknown service 0.0 1.1 0.8 1.2 0.4 branches) Unit component Active Duty 76.8 50.8 46.5 51.9 5.4 Reserves*
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* Last deployment Before 1992 -- 5.1 7.6 4.6 -3.0 Before 2001 -- 1.1 0.4 1.2 0.8 Before 2015 -- 74.5 86.6 72.0 -14.6 2015 or later -- 19.3 5.4 22.1 16.8 Deployment era Gulf War only -- 1.5 2.2 1.4 -0.8 Peace Time only -- 1.2 0.5 1.3 0.8 OEF/OIF/OND only -- 69.4 79.8 67.3 -12.5 OIR/OFS only -- 6.8 <0.1 8.1 8.1 Multiple Eras -- 21.1 17.5 21.9 4.4 Gulf War + Peacetime -- 3.5 5.3 3.1 -2.2 Gulf War + OEF/OIF/OND -- 0.7 0.9 0.6 -0.3 Peacetime + OEF/OIF/OND -- 2.7 3.0 2.6 -0.3 Gulf War + Peacetime + OEF/OIF/ - 1.8 2.9 1.6 -1.4 OND Gulf War + OIR/OFS -- <0.1 <0.1 <0.1 0.0 Peacetime + OIR/OFS -- <0.1 0.0 <0.1 0.0 Gulf War + Peacetime + OIR/OFS -- <0.1 <0.1 <0.1 0.0 OEF/OIF/OND + OIR/OFS -- 11.9 5.0 13.3 8.2 Gulf War + OEF/OIF/OND + OIR/ - <0.1 <0.1 0.1 0.1 OFS Peacetime + OEF/OIF/OND + OIR/ - 0.4 0.2 0.5 0.3 OFS Gulf War + Peacetime + OEF/OIF/ - 0.1 0.1 0.1 0.0 OND + OIR/OFS Number of deployments 1 44.7 26.2 22.4 26.9 4.5 2 29.0 17.2 14.3 17.8 3.5 3 15.0 12.7 11.6 12.9 1.3 4 5.9 9.5 9.6 9.5 -0.1 5 2.5 7.8 8.6 7.6 -1.0 6 1.1 6.1 7.3 5.8 -1.5 7 0.6 4.6 5.6 4.4 -1.2 8 0.4 3.5 4.3 3.3 -1.1 9 0.2 2.7 3.4 2.5 -0.9 10 or more 0.5 9.8 12.9 9.2 -3.6 continued
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era of service, with pre-2001 deployments much more likely to be user-entered. In particular, of the 40,963 eligible 1990–1991 Gulf War and Peacetime deployment segments, 92.1% were user-entered, whereas 20.2% of all eligible post-9/11 segments (n = 1,149,925)
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(n = 1,149,925) Country of Deployment % User-entered % User-entered Afghanistan 100.0 26.3 Arabian Sea 100.0 12.1 Bahrain 93.3 22.8 Djibouti 100.0 36.3 Gulf of Aden 100.0 47.0 Gulf of Oman 100.0 59.0 Iraq 80.4 26.7 Kuwait 96.0 8.9 Oman 96.6 32.5 Persian Gulf 100.0 30.4 Qatar 98.0 17.9 Red Sea 100.0 15.5 Saudi Arabia 91.6 28.7 United Arab Emirates 95.5 28.1 TOTAL 92.1 20.2 NOTE: Deployments that started before September 11, 2001, include the 1990–1991 Gulf War and Peacetime deployments.
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, were more likely to be from the post-9/11 era than the 1990–1991 Gulf War era (99.7% vs 96.0%) , and were more likely to have had a deployment segment to Kuwait than not (65.2% vs 30.7%)
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(n = 261,423) No User-Entered At Least 1 User- No User-Entered At Least 1 User Deployments Entered Deployment Deployments Entered Deployment Characteristic (n = 2,942)
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(%) Last deployment Before 1992 98.8 79.4 0.0 0.0 Before 2001 1.0 20.2 0.1 0.1 Before 2015 0.2 0.4 86.4 70.3 2015 or later 0.0 <0.1 13.5 29.7 Deployment era Gulf War 28.0 24.1 0.0 0.0 Peacetime 2.0 22.1 <0.1 <0.1 OEF/OIF/OND 0.0 0.0 85.7 58.9 OIR/OFS 0.0 0.0 5.0 10.0 Multiple eras 70.0 53.8 9.3 31.0 Number of deployments 1 99.8 80.4 24.0 20.3 2 0.1 12.8 15.6 20.3 3 0.1 4.0 11.3 15.9 4 0.0 1.6 9.1 11.3 5 0.0 0.7 8.4 8.1 6 0.0 0.2 6.8 6.1 7 0.0 0.1 5.3 4.3 8 0.0 0.1 4.0 3.3 9 0.0 0.1 3.2 2.4 10 or more 0.0 0.1 12.4 8.1 Duration of deployments <3 months 11.9 13.2 6.4 2.0 3–6 months 43.9 41.4 13.4 8.2 6–9 months 41.4 31.3 20.4 14.5 9–12 months 2.5 6.2 18.4 15.2 1–2 years 0.3 5.2 28.9 37.1 Longer than 2 years <0.1 2.7 12.6 23.0 TABLE 2-8 Frequency and Item Nonresponse of Short-Duration Deployments All Registry Deployments (n = 1,071,085)
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From page 47... ...
Indeed, during the 2021 live demonstration of the questionnaire to the reassessment committee, the website was slow to load, often took multiple reviews to identify questions that had not been answered, or would load followup items in the same section only after the screen had been saved. The initial assessment committee found that the time required to complete the AH&OBP Registry questionnaire was directly related to the number of deployment segments for an individual (NASEM, 2017)
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The detailed review of verified versus user-entered deployment segments presented in the previous section highlights the difficulty of completing the self-assessment questionnaire for some participants, as the first section of the questionnaire requires a great deal of manual review and entry, which is likely a reason for noncompletion. VA Health Care Users According to the VA-provided data on 228,696 AH&OBP Registry participants matched to VA health care data between 2001 and 2021, 170,122 (74.4%)
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Health Conditions The AH&OBP Registry questionnaire asks about a wide range of symptoms and health conditions, but the questions and the response options do not have the specificity necessary to allow them to be used to draw conclusions about the presence or absence of specific diagnoses among the registry participants. This section describes the health status of registry participants: overall, by early and late time of participation, and by VA enrollment status.
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(%) Sex Male 87.3 80.7 Female 11.2 8.9 Missing 1.5 10.5 Age at questionnaire completion <30 11.1 12.5 30–39 41.2 40.3 40–49 31.4 25.9 50–59 13.7 5.8 60 or older 1.9 0.5 Missing 0.5 15.0 Race White 67.2 72.9 Black 13.0 8.6 Hispanic 11.2 10.0 Other 5.9 5.0 Unknown 1.4 3.3 Missing 1.4 0.2 Service status Retiree 35.1 12.5 National Guard/Reserves 22.5 21.1 Active duty 3.6 57.1 Separated 37.9 8.1 Unknown 0.5 0.9 Missing 0.4 0.2 Branch Air Force 19.0 36.8 Army 62.4 45.9 Marine 11.6 7.8 Navy 6.7 8.7 Coast Guard 0.2 0.4 Public Health Service <0.1 <0.1 Unknown <0.1 <0.1 Missing 0.1 0.5 Unit component Active duty 47.4 62.8 Reserves 32.5 22.5 National Guard 19.2 11.2 Unknown 0.2 2.7 Missing 0.7 0.8
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METHODS AND APPROACH 51 TABLE 2-12 Continued Used VA Care at Least Once, Never Used VA Care, 2001–2021 2001–2021 Characteristic (n = 170,122)
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Participants Total Reported Early Late (Yes) Participants Participants Percent Question Number and Text Eligible n (%)
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, the most common being skin cancers and melanoma, followed by prostate cancer. Exposures The reassessment committee updated and augmented specific exposure analyses presented in the initial assessment.
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54 REASSESSMENT OF THE VA AH&OBP REGISTRY TABLE 2-14 Types of Cancer Diagnoses Reported Cancer Type Frequency Skin (non-melanoma) 4,433 Skin (don't know what kind)
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. VA Health Care Users Using the VA data file of registry participants who used VA health care between 2001 and 2021, Table 2-16 shows unadjusted responses to the exposure-related questions.
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56 REASSESSMENT OF THE VA AH&OBP REGISTRY TABLE 2-16 Number and Percent of Responses to Exposure Questions of AH&OBP Registry Participants Who Used VA Health Care, 2001–2021 Used VA Care at Least Once, Never Used VA Care, Total Number of 2001–2021 2001–2021 Exposure Responses (n = 170,122)
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METHODS AND APPROACH 57 TABLE 2-16 Continued Used VA Care at Least Once, Never Used VA Care, Total Number of 2001–2021 2001–2021 Exposure Responses (n = 170,122)
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Yes 196,548 87.7 80.9 No 9,983 3.3 7.5 Do not wish to answer 624 0.2 0.4 Don't know 18,199 7.2 10.1 Missing 3,342 1.5 1.2 1.4.E – Respiratory symptoms due to air quality (days per month) 1–4 days 20,632 8.0 11.9 5–9 days 29,453 12.2 14.8 10–14 days 27,731 12.1 12.3 15–19 days 25,677 11.7 9.8 20–24 days 19,531 9.1 6.9 25–31 days 43,510 21.1 13.1 Never 156 0.1 0.1 Not applicable/Not asked 32,148 12.3 19.1 Do not wish to answer 849 0.4 0.4 Don't know 28,996 13.1 11.5 Missing 13 <0.1 0.0 Some indication of Gulf War smoke exposure on 6,115 3.2 1.0 at least one deployment No exposure/no data 222,581 96.8 99.0 Some indication of exposure to burn pits on at 210,198 92.7 89.7 least one deployment No exposure/no data 18,498 7.3 10.3 Some burn pit duties on at least one deployment 129,404 59.7 47.5 No exposure/no data 99,292 40.3 52.5 Some deployment hours outside on at least one 221,142 96.7 96.6 deployment No exposure/no data 7,554 3.3 3.4 Some indication of exposure to sewage on at 165,415 59.7 47.5 least one deployment No exposure/no data 63,281 40.3 52.5 NOTE: Column 3 lists the percentage of individuals (n = 170,112)
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From page 59... ...
As described in Chapter 1, the information regarding the locations and dates of operation -- let alone contents -- of burn pits is incomplete and there is no gold standard with which to compare self-report of these exposures. In the second method used to examine the concordance of self-reported burn pit exposure, deployment segments were used to compare three locations (Joint Base Balad, Camp Taji, and Contingency Operating Base Speicher in Iraq)
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Before 36,224 32.4 53.1 13.8 0.2 0.5 During 20,521 29.6 54.0 15.6 0.3 0.6 After 7,492 22.7 55.4 20.9 0.3 0.7 NOTE: "Before" indicates deployment between January 2003 and June 2007, before the incinerator installation; "during" indicates deployment between July 2007 and October 2009, while incinerators were being installed; and "after" indicates deployment from November 2009 through February 2022, after incinerator installation and when the AH&OBP Registry data were extracted. Table 2-18 shows the responses to the three deployment exposure questions by location; shaded locations denote where burn pits were known to be operating.
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Balad 64,237 30.4 53.6 15.2 0.2 0.5 Speicher 19,159 24.1 56.8 18.2 0.3 0.6 Taji 24,236 25.6 56.6 16.8 0.3 0.7 Arifjan 21,478 20.5 55.8 22.4 0.4 0.9 Buehring 23,617 22.8 53.8 22.3 0.4 0.7 NOTE: Shading denotes locations with known burn pits. This chapter described the committee's approach to responding to its Statement of Task, gathering information to address its charge, considering exposure registries in general, and, finally, offering a descriptive review of the AH&OBP Registry data.
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From page 62... ...
2016. Burn pit emissions exposure and respiratory and cardiovascular conditions among Airborne Hazards and Open Burn Pit Registry participants.
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2020. Respiratory health effects of airborne hazards exposures in the Southwest Asia Theater of Military Operations.
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