Training information and guidance on the 2003 sulfur fire at Mishraq State Sulfur Mine near Mosul, Iraq, was provided by the Department of Veterans Affairs to all VA Regional Offices in 2010.
- To inform regional office employees on specific environmental hazard incidents that present potential health risks to service members and veterans
- To provide guidance on handling claims for disabilities potentially resulting from exposure to environmental hazards while on active duty
- To provide “fact sheets” that may serve as valuable resources for VA examiners when they conduct Compensation and Pension (C&P) examinations associated with these exposures.
It’s important for veterans who were affected by the sulfur fire at Mishraq State Sulfur Mine during active duty service to know how the VA is guiding its employees to handle the associated claims.
Sulfur Fire at Mishraq State Sulfur Mine Near Mosul, Iraq
General Information: On June 24, 2003, a fire ignited at the Mishraq State Sulfur Mine Plant in northern Iraq. The Mishraq Sulfur Mine is the largest sulfur mine in the world. It burned for approximately 3 weeks and caused the release of roughly 42 million pounds of sulfur dioxide (SO2) per day; hydrogen sulfide (H2S) was also released.
Satellite imagery showed the smoke plume direction, length, and opacity varied throughout the timeframe. Field sampling data collected by a preventive medicine detachment and anecdotal reports of odors and irritation suggest levels of SO2/H2S were not solely located in the immediate vicinity of the fire. Levels were found at the Qayyarah Airfield West (Camp Q West), which is 25km to the south and is a major military supply airstrip and the primary area of deployment for the 101st Airborne Division. Satellite imagery also showed northerly movement of the smoke plume reaching approximately 50 km to the north up to the Mosul Airfield area. DoD estimates that several thousand troops were within the 50km radius from the sulfur fire to the Mosul airfield.
A roster of firefighters and support elements that participated in controlling the fire was prepared. It identifies individuals primarily from the 101st Airborne Division – 52nd Engineer Battalion, 326th Engineer Battalion, and 887th Engineer Battalion. C&P Service is in the process of requesting this roster and other reports, risk assessments, etc., from DoD. USACHPPM has stated that it does not have the means to identify specific exposures; and that all exposed persons are not definitely known.
Both sulfur dioxide and hydrogen sulfide are gases that can produce irritation and reddening of the nose and throat, eye irritation/pain, and coughing. At high levels, sulfur dioxide can burn the skin and can cause severe airway obstruction, hypoxemia, pulmonary edema, and even death. Service members involved with suppressing this fire experienced irritation, minor burns, and effects such as blood-tinged nasal mucous. Some have been found to have long-term respiratory conditions such as “constrictive bronchiolitis.”
In early 2007, USACHPPM medical personnel visited Ft. Campbell, Kentucky, which is the U.S. base for the 101st Airborne Division, and learned that from late 2004 through February 2007, 41 soldiers citing exposures to the sulfur fire and reporting unexplained shortness of breath on exertion, had been referred by the Blanchfield Medical Center to a pulmonary specialist at the Vanderbilt Medical Center. As of February 2007, nineteen (19) personnel had an open lung biopsy, and were all diagnosed with constrictive bronchiolitis. Constrictive bronchiolitis is an inflammatory and fibrotic lesion of the terminal bronchioles of the lungs. This diagnosis is very uncommon and has been associated with inhalation exposures, organ transplantation, certain drugs, and collagen vascular disorders. Individuals with this finding typically have shortness of breath on exertion, but may have normal chest X-rays and inconclusive findings on pulmonary function testing. Due to some similarities, symptoms of constrictive bronchiolitis may be wrongly attributed to asthma or chronic obstructive pulmonary disease (COPD).
Regional office personnel may have a difficult time rating disabilities in this population. In most cases, the affected soldiers are comfortable at rest and are able to perform the activities of daily living. They have normal or near normal pulmonary function tests, but, at the same time, become short of breath on slight physical exertion, cannot meet physical training requirements, and are considered unfit for deployment. This unique circumstance challenges those who must determine a disability rating. Pulmonary function testing is the usual standard for rating respiratory disabilities. Therefore, rating authorities should utilize an appropriate analogous code (such as 6600-6604) since the condition does not have its own diagnostic code, and consider extra-scheduler ratings in such cases when there is evidence that a Veteran’s employment is affected.
While individual exposure levels cannot be accurately determined, USACHPPM currently considers constrictive bronchiolitis (initially diagnosed as “bronchiolitis obliterans”) to be plausibly associated with exposure to the 2003 Mishraq State sulfur fire event. This health effect has been scientifically associated with high exposures to SO2 . While personnel exposures varied considerably, individual risk factors or susceptibility may play a role. Due to limitations in the military deployment tracking databases used in 2003-2004, the actual cohort of all exposed persons is not definitively known.
The Veteran’s lay statement of exposure to the sulfur fire is sufficient if his or her service records shows service in Iraq at Mosul Airfield or Qayyarah Airfield West (Camp Q West) at any time during the 4-week period starting from June 24, 2003. Otherwise, verification of exposure should be made on a case-by-case basis with careful consideration given to the period of deployment together with duty locations. Contacting a military unit the Veteran served in at the time of Iraq deployment may be necessary to confirm the required location. C&P Service will notify regional offices if and when it receives the DOD list of personnel involved in this incident. In the meantime, a careful review of service treatment records, personnel records and other alternative evidence such as lay statements should be conducted in efforts to verify exposure. If the claim is for a respiratory condition possibly related to the sulfur fire exposure, consider requesting tests for “bronchiolitis” to be conducted in addition to other respiratory testing, while noting that many standard test results may be normal.
Claims Processing Policies and Procedures
A. Priority of Processing
Because of the potential of receiving claims due to exposure to environmental hazards from Veterans who served in Iraq and Afghanistan, employees should review VBA Letter 20-07-19 dated February 6, 2009, to determine if “priority processing” procedures apply.
B. End Product Control and Tracking
Upon receipt of service connection claims for disabilities due to exposure to environmental hazards or toxic agents, establish a standard end product, (e.g., 110, 010, 020). A special end product to control these issues is not necessary.
Employees involved in the development of these claims must choose the appropriate Special Issue identifier on the MAP-D Contentions screen. Currently, the only identifier pertaining to exposure claims is “Environmental Hazard in Gulf War,” which is only appropriate for exposure within Southwest Asia. As C&P Service updates corporate applications, (i.e., MAP-D, RBA 2000, etc.) to better track and identify these types of claims, we will notify the field accordingly. Therefore, so as not to dilute future data on hazardous exposure claims regarding Southwest Asia service, do not use the “Environmental Hazard in Gulf War” identifier for claims regarding Atsugi or Camp Lejeune service.
By taking the following steps in the development process, raters will be well-equipped to make fair and equitable decisions on service-connection claims as a result of exposures to environmental hazards.
• If Veteran alleges exposure to environmental hazards during service, but does not claim service connection for a specific disability, inform the veteran that he/she must at least identify a symptom or cluster of symptoms since exposure in and of itself is not a disability.
• Ensure the claimant provides at least some general information about the exposure event. A follow-up letter or phone call to the Veteran may be required if the Veteran fails to provide sufficient information regarding exposure and/or disability claimed because of such exposure.
o Notwithstanding the foregoing instructions, regional office personnel must actively review cases for potential exposure. While many service members who served in Iraq and/or Afghanistan may have been exposed, for example to burn pits and particulate matter, not all Veterans will be aware of such exposure or will associate such exposure with specific disabilities.
o Therefore, regional office personnel must be vigilant in reviewing claims from Veterans with Southwest Asia service, especially when the claim is for service connection for disabilities such as respiratory, skin, autoimmune, neurological (except where clearly caused by injury), gastrointestinal disorders, etc. Many Veterans will simply be unaware of the possible link between such disabilities and the exposures discussed in this training letter. In these cases, it may be necessary to invite or solicit a specific claim from the Veteran and undertake the development procedures explained in this training letter.
• Develop for service treatment records and any VA and/or private medical records that are noted by the claimant.
• Verify dates of military service and obtain military personnel records as per normal procedures.
Verifying Exposure to Environmental Hazards
Verifying and/or conceding exposure is one of the key elements in the adjudication process. VA is actively working with DoD to identify individuals who were exposed to specific environmental hazards while serving in the military. In most cases, it will not be possible to refer to a list of service members present at a specific location. It is critical that VA employees rely upon all available sources of evidence when verifying and/or conceding exposure.
Currently, C&P Service has only acquired a list for those who served at the Qarmat Ali Water Treatment Plant in Basrah, Iraq. For other incidents, if exposure cannot be verified through an official list provided by DoD, then personnel records should be reviewed for evidence that corroborates the Veteran’s statement of exposure.
IMPORTANT: Service Treatment Records, to include the Post-Deployment Health Assessment (PDHA) and Discharge Examination, should be carefully reviewed for exposure information. The PDHA includes specific questions relating to exposure incidents.
Because military service records will not verify all incidents, if any, of exposure, alternative evidence such as personal statements, buddy statements, unit histories, news articles, or other lay evidence shall be considered in establishing whether the Veteran participated in or was affected by an in-service exposure incident. Exposure may be verified or conceded, if the statements provided by the Veteran and/or others are consistent with the facts, places, and circumstances of the Veteran’s service. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a).
Because of the widespread nature of the burn pits, and the inability of military personnel records to identify all duty locations, the Veteran’s lay statement of burn pit exposure generally will be sufficient to establish the occurrence of such exposure if the Veteran served in Iraq, Afghanistan, or Djibouti. For example, a Veteran who performed guard duty at a burn pit in Iraq would have been subject to potentially higher levels of toxic exposure than someone who did not perform such duty. The Veteran’s service records will generally not provide that level of detail necessary to show that he/she performed that particular duty. Thus, if the statements provided by the Veteran and/or others are consistent with the facts, places, and circumstances of his or her service, then concede them as a fact of record. See Id. (Do not confuse this section with the provisions found at 1154(b)—applicability of 1154(a) does not require evidence of combat).
Further, in applying section 1154(a) to concede a Veteran’s exposure to burn pits and PM specifically, it is important to remember the information contained in section 1.A. and 1.B. of this Training Letter. Essentially, that VA is aware, primarily through cooperation with DoD, of the extent of potentially hazardous exposures (i.e., elevated PM levels throughout Iraq, Afghanistan, and Djibouti; as well as burn pits located at all military FOBs in these same regions). Therefore, VA is aware of the “facts, places, and circumstances” of a Veteran’s service in those regions. Going beyond section 1154(a) by requiring proof of exposure, such as by service personnel or unit records, could arguably violate section 1154(a). The resulting interplay between VA’s knowledge of exposure and section 1154(a), results in easily conceding exposure without an actual “presumption” of exposure.
Note: Because Veterans generally will not possess the type of exposure information contained in this training letter, regional office personnel should be aware of the environmental hazards that may apply for Veteran claimants who served in Iraq, Afghanistan, or Djibouti, even if the claimants did not allege such exposure, (e.g., Particulate Matter exposure). Be aware also that more than one environmental hazard may apply when Veterans are alleging exposure to a specific event. For example, if a Veteran claims a disability due to exposure at the Qarmat Ali Water Treatment Plant, each pertinent Fact Sheet should be provided to VA examiners, as explained below, since the Veteran served in Iraq and could have been exposed to burn pit emissions and the same high levels of particulate matter as others in the Southwest Asia theater of operations.
VA Examinations and Medical Opinions
In claims for disability compensation, VA has the responsibility to assist the claimant by obtaining a medical opinion and/or examination when the opinion and/or examination is necessary to make a decision on the claim. 38 CFR 3.159(c)(4)
Reminder: Generally, VA examinations are ordered for all claims received within one year of separation from the military, unless the evidence is sufficient for deciding the claim. This includes a general medical examination and any specialty examinations deemed necessary.
In claims received more than one year after separation from service, a VA examination should be ordered for environmental-hazard claims when the evidence of record contains the following three elements:
• Element 1: Evidence of a current diagnosed disability or persistent or recurrent symptoms of disability.
• A claimant ordinarily lacks the medical training and experience to diagnose his/her own medical condition or offer a medical opinion. However, a claimant is competent to describe symptoms of disability that he/she is experiencing, (e.g., shortness of breath, coughing, fatigue, skin rash, etc.). Therefore, medical evidence of the claimed disability is not necessary to trigger the VA examination request as long as the claimant describes persistent or recurrent symptoms of the claimed disability.
• Element 2: Evidence that the veteran was exposed to an in-service exposure event or incident, including a Veteran’s lay evidence. For the purposes of this element, exposure to certain environmental hazards can be conceded, on a case-by-case basis, as previously discussed.
• See section on Verifying Exposure to Environmental Hazards
• Element 3: Evidence that the claimed disability or symptoms may be associated with the in-service exposure event.
• In determining whether a claimed condition may be associated with an in-service exposure incident and therefore warrants a VA examination or opinion request, you must consider the information herein to determine if the Veteran’s symptoms may be representative of an illness or disease linked to a specific exposure. Because the scientific studies to identify health effects of exposures are in the preliminary stages, C&P Service is providing general guidelines as to what type of symptoms trigger a VA examination or opinion. If in doubt, regional office personnel should err on the side of the Veteran when determining if a VA examination or opinion is needed. If that doubt exists in any degree, then evidence of a current disability (or symptoms of a disability) is sufficient to request a medical examination and medical nexus opinion if the proper service is verified and no evidence exists of subsequent cause for the disability.
• Regional office personnel should carefully review lay statements that may provide evidence that shows continuity of symptoms from service to the present. In cases where evidence showing continuity of symptoms is strong, medical examinations/opinions may not be necessary. In others, it may serve as evidence that a claimed condition may be associated with an in-service exposure event(s). Ultimately, VA employees should remember that the threshold bar for requesting an examination/opinion is very low, but if existing evidence is satisfactory to decide the claim, then a VA examination is not necessary.
What to Include in a VA Examination or Medical Opinion Request
When requesting medical examinations, inform the examiner of the Veteran’s service along with the location and nature of the environmental hazard in which the Veteran was exposed. When requesting examinations/opinions, always forward the claims file to the medical examiner (or appropriate material to the contract examiner) and direct him or her to review the medical and other evidence in the claims folder and provide a rationale for his or her opinion. Fact Sheets explaining the various environmental hazards are attached to this training letter. The pertinent Fact Sheets must be made available to the VA medical examiner for review. The examiner should state whether it is more likely, less likely, or as likely as not that a Veteran’s claimed condition is related to the hazardous environmental exposure. The fact sheet(s) must subsequently remain in the record.
Note: The Fact Sheets are not meant to influence examiners rendering opinions concerning the etiology of any particular disability, but rather to ensure that such opinions are fully informed based on all known objective facts. It is imperative that examiners utilize this information objectively and together with other evidence, (e.g., lay statements) in the Veteran’s record.
In some cases, an opinion based on record review only may be sufficient. In other cases, a current examination may be required. When an opinion only is initially requested, the examiner should be informed that an examination will be scheduled if the examiner believes it is necessary in order to render the requested medical opinion.
When the opinion is completed and returned to the regional office, rating personnel should ensure that the examiner has identified the specific evidence reviewed and considered when forming the opinion, provided a rationale for the opinion, and stated his/her conclusions using one of the legally recognized phrases.
When rating a disability due to an in-service exposure event, it is imperative that raters adhere to the principles relating to service connection set forth in 38 CFR § 3.303. Because scientific studies regarding health effects from exposures are in the preliminary stages, raters should carefully review the nature, dates, and locations of the Veteran’s military service, and apply the law under a broad and liberal manner, consistent with all available facts and circumstances. Claims should be evaluated on a case-by-case basis with evidentiary weight given to medical examinations and opinions from both private and VA physicians. In all cases, the benefit of the doubt shall be given to the Veteran. 38 CFR § 3.102.
Claims based on Southwest Asia Service (38 CFR § 3.317)
Regulations governing claims based on undiagnosed illnesses, and medically unexplained chronic multisymptom illnesses that were promulgated following the initial 1990-1991 Gulf War continue to be in effect for any Veteran with Southwest Asia service. Regional office personnel are reminded that the provisions of 38 CFR § 3.317 should be applied when rating claims for disabilities due to environmental hazards in the Southwest Asia theater, if the following applies:
• The Veteran claims a disability due to an environmental hazard while serving on active military, naval, or air service in the Southwest Asia theater of operations from August 2, 1990, through a date yet to be finally determined;
• The medical evidence reveals an undiagnosed illness, or a diagnosed condition without conclusive etiology; and
• The medical evidence does not provide a sufficient link to Veteran’s military service.
If the above scenario is presented, the claim should be developed under the Gulf War and Southwest Asia service procedures outlined in Training Letter 10-01, released February 4, 2010. (See “What to Include in a VA Examination or Medical Opinion Request”, above).
Independent Medical Opinions (§3.328)
If there are complex or controversial medical issues involved in the rating of disabilities claimed as a result of environmental exposures, an advisory opinion can be obtained from non-VA medical experts. Requests for this type of opinion are initiated by the regional office and submitted through the Veterans Service Center Manager to C&P Service for approval. The request must detail the reasons why the opinion is necessary.
Note: These are special requests and not the same as requesting a VA physician to express an opinion on a VA examination.
About the Fact Sheet
The VA notes that the Fact Sheet is not meant to “influence examiners rendering opinions concerning the etiology of any particular disability, but rather to ensure that such opinions are fully informed based on all known objective facts.” The VA asks the examiner to utilize the Fact Sheet along with other evidence in the Veteran’s record.
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