Soldiers walk through a dust storm in Iraq in March 2011. (Photo by Elliott Plack via Flickr)
Training information and guidance on exposure to particulate matter “in Iraq, Afghanistan, and Djibouti” 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 particulate matter during active duty service to know how the VA is guiding its employees to handle the associated claims.
Particulate Matter In Iraq, Afghanistan, and Dijibouti
General Information: “Particulate matter” (PM) is a complex mixture of extremely small particles and liquid droplets. PM is made up of a number of components, including acids (such as nitrates and sulfates), organic chemicals, metals, and soil or dust particles. Although PM emissions from natural and manmade sources are generally found worldwide, the PM levels in Southwest Asia are naturally higher and may present a health risk to service members.
There are generally two size ranges of particles in the air that are a health concern. These include particles with a diameter less than or equal to 10 microns (PM10) and those with a diameter of 2.5 microns (PM2.5) and smaller. The size of particles is directly linked to their potential for causing health problems, with the smaller particles being considered more harmful. Particles that are 10 micrometers in diameter or smaller are the particles that generally pass through the throat and nose and enter the lungs. Once inhaled, these powder-like particles can affect the heart and lungs and cause serious health effects.
Primary sources of PM in Southwest Asia include dust storms and emissions from local industries. The DoD conducted a year-long sampling survey to characterize the chemistry and mineralogy of the PM at 15 sites in OIF and OEF. These results were published by the Desert Research Institute in 2008 and are being reviewed by the National Academy of Sciences Committee on Toxicology. The widespread existence of burn pits only exacerbates the high concentrations of PM in Iraq and Afghanistan. DoD stated in their 2008 Balad assessment, that emission from burns pits, among other things, “may increase localized concentration of 2.5 micrometer PM and other potentially toxic air pollutants.”
Most studies relate PM exposure data to respiratory and cardiopulmonary health effects in specific susceptible general population subgroups to include young children, the elderly, and especially those with existing asthma or cardiopulmonary disease. Many variables influence the nature and probability of health outcomes. The key variables are the size-fraction and chemical make up of the PM, the concentration levels, the duration of exposures, and various human factors to include age, health status, existing medical conditions, and genetics. These variables combined with scientific data gaps limit the medical community’s ability to estimate health impacts to relatively healthy troops. Another key factor is that most studies have been on older or less healthy groups. Several studies to determine potential health effects/outcomes are currently underway.
DoD collected approximately 60 air samples at Balad from January to April 2007 and assessed for PM. The samples were taken from five different locations around Balad. The heaviest measured concentration of PM was taken in April 2007—the concentration level was 299 ug/m3 of PM10 sized particles. In total, 50 of the 60 samples registered above the military exposure guidelines.
Although a Veteran who is claiming a disability may not specify the source of exposure as PM, employees handling such claims should be aware of PM exposure and its potential health effects. In certain cases, a statement of exposure may be appropriate to include in VA examination/opinion requests. In all cases involving PM exposure and potentially related disabilities, regional office personnel should ensure that the attached fact sheet is included with C&P examination/opinion requests. As C&P Service becomes more aware of the concentration levels of and health outcomes from PM exposure in Iraq and Afghanistan, we will notify regional office personnel accordingly.
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.
Rating Principles
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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