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Characterizing Exposure of Veterans to
Agent Orange and Other Herbicides
Used in Vietnam
Final Report
Committee on the Assessment of Wartime
Exposure to Herbicides in Vietnam
Board on Health Promotion and Disease Prevention
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu
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THE NATIONAL ACADEMIES PRESS
500 Fifth Street, N.W.
Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board of the
National Research Council, whose members are drawn from the councils of the National Academy of
Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the
committee responsible for the report were chosen for their special competences and with regard for
appropriate balance.
Support for this project was provided by the US Department of Veterans Affairs. The project was
supported by Cooperative Agreement V101~93)P-1637 between the National Academy of Sciences and
the US Department of Veterans Affairs. The views presented in this report are those of the Institute of
Medicine Committee on the Assessment of Wartime Exposure to Herbicides in Vietnam and are not
necessarily those of the funding agencies.
Copies of this report are available at: www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.
Copyright 2003 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America.
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and
religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of
Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.
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"knowing is not enough; we must apply.
wining is not enough; we must do "
Goetl~e
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
Shaping the Future for Health
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THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medirine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in
scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general
welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to
advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of
Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a
parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing
with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of
Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and
recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent
members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts
under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal
government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is
president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community
of science and technology with the Academy's purposes of furthering knowledge and advising the federal government.
Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating
agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the
government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies
and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National
Research Council.
www.national-academies.org
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COMMITTEE ON THE ASSESSMENT OF WARTIME EXPOSURE TO HERBICIDES
IN VIETNAM
DAVID G. HOED (Chairs' Distinguished University Professor, Department of Biometry and
Epidemiology, Medical University of South Carolina, Charleston, South Carolina
S. KATHARINE HAMMOND, Professor of Environmental Health Sciences and Director, Industrial
Hygiene Program, School of Public Health, University of California, Berkeley, California
LOREN D. KOLLER, Consultant, Environmental Health and Toxicology, Corvallis, Oregon
DANA P. LOOMIS, Associate Professor, Department of Epidemiology, School of Public Health,
University of North Carolina at Chapel Hill, North Carolina
THOMAS ,1. SMITH, Professor of Industrial Hygiene and Director, Industrial Hygiene Program,
Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts
DAVID it. TOLLERUD, Clinical Professor and Chair, Department of Environmental Health and
Occupational Health Sciences, School of Public Health and Information Sciences, University of
Louisville, Louisville, Kentucky
LAUREN ZEISE, Chief, Reproductive and Cancer Hazard Assessment Section, Office of Environmental
Health and Hazard Assessment, California Environmental Protection Agency, Berkeley, California
Stay
David A. Butler, Senior Program Officer
'Jennifer A. Cohen, Research Associate
Lames A. Bowers, Project Assistant /Research Assistant (through July 2000)
Anna B. Staton, Research Assistant (through November 2002)
Elizabeth ,l. Albrigo, Project Assistant
Joe A. Esparza, Project Assistant
Rose Marie Martinez, Director, Board on Health Promotion and Disease Prevention
Kathleen Stratton, Acting Director (1997-1999), Board on Health Promotion and Disease Prevention
Rita Gaskins, Administrative Board Assistant
Donna D. Thompson, Administrative Board Assistant (through May 2000)
Melissa French, Financial Associate (through June 2002)
Jim Banihashemi, Financial Associate
Norman Grossblatt, Senior Editor
Kathi E. Hanna, Consultant
*Member, Institute of Medicine.
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REVIEWERS
This report has been reviewed in draft form by persons chosen for their diverse perspectives and
technical expertise, in accordance with procedures approved by the National Research Council's Report
Review Committee. The purpose of this independent review is to provide candid and critical comments
that will assist the institution in making its published report as sound as possible and to ensure that the
report meets institutional standards of objectivity, evidence, and responsiveness to the study charge. The
review comments and draft manuscript remain confidential to protect the integrity of the deliberative
process. We wish to thank the following for their review of this report:
Howard M. Kipen, University of Medicine and Dentistry of New Jersey Robert Wood Johnson
Medical School; Rutgers University
David A. Spritz, University of North Carolina School of Public Health
Kirk R. Smith, University of California, Berkeley
David F. Utterback, National Institute for Occupational Safety and Health
Although the reviewers listed above have provided many constructive comments and suggestions,
they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the
report before its release. The review of this report was overseen by Jonathan M. Samet, Johns Hopkins
University. Appointed by the National Research Council and Institute of Medicine, he was responsible
for making certain that an independent examination of this report was carried out in accordance with
institutional procedures and that all review comments were carefully considered. Responsibility for the
final content of this report rests entirely with the author committee and the institution.
. .
V11
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PREFACE
In response to the concerns voiced by Vietnam veterans and their families, Congress called on the
National Academy of Sciences (NASJ to review the scientific evidence on the possible health effects of
exposure to Agent Orange and other herbicides (Public Law 102-4, enacted on February 6, 19914. The
creation, in 1992, of the Institute of Medicine (IOM) committee tasked to conduct the review underscored
the critical importance of approaching the question from a nonpartisan scientific standpoint. The study
reported here is an outgrowth of that work, focusing on the assessment of wartime exposure to herbicides.
The 1994 IOM report Veterans and Agent Orange noted that "exposure assessment has been a weak
aspect of most epidemiologic studies of Vietnam veterans" (page 18) and recommended that an effort be
undertaken to develop exposure reconstruction models. The US Department of Veterans Affairs asked
IOM to organize the effort, which led to the formation of the Committee on the Assessment of Wartime
Exposure to Herbicides in Vietnam.
As noted in the interim report released in April 2003 (IOM, 2003), the committee commends the
work of the team of investigators from the Columbia University Mailman School of Public Health
(Jeanne Mager Stellman, PhD, principal investigator) who carried out the exposure-assessment research.
Their dogged pursuit of historical records has led to a substantial improvement in the quality and
completeness of the information on wartime spraying and the people who may have been exposed to it.
The geographic information system they developed is innovative and serves as an exemplar of how this
technology can be exploited in exposure-characterization studies. And finally, the spirit of cooperation
and collaboration shown by the Columbia University researchers greatly facilitated the committee's job of
oversight and made its task enjoyable and intellectually engaging.
David Butler served as the study director for this project. The committee would like to acknowledge the
excellent work of IOM staff members Jennifer Cohen, Anna Staton, Elizabeth Albrigo, Joe Esparza, and
James Bowers. Kathi Hanna, a consultant to the committee, provided valuable assistance by composing a
summary of the Columbia University research effort that served as a foundation for the report text.
Thanks are also extended to Melissa French and Jim Banihashemi, who handled the finances for the project;
Linda Kilroy' Joan Rodda, Donald Holmes and Robin Cohen, who were responsible for contracting issues;
Norman Grossblatt, who edited the manuscript; William McLeod, who conducted database searches;
Jennifer Bitticks, who supervised the production of the report; and Rita Gaskins, who provided
administrative support to the project.
The committee greatly benefited from the input of scientists, researchers, government employees,
veterans service organizations, and other interested persons who generously lent their time and expertise
to help give committee members insight on particular issues, provide copies of newly released research,
or answer queries concerning their work or experience. We thank them for their contributions.
David G. Hoel, Chair
1X
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Contents
INTRODUCTION AND BACKGROUND
CONTRACT SUMMARY
PROJECT 1: MILITARY UNIT AND HERBICIDE SPRAYING DATABASES,
AND EXPOSURE ASSESSMENT MODEL DEVELOPMENT
PROJECT 2: COVARIATES, CONFOUNDERS, AND CONSISTENCY:
CHARACTERIZING THE VIETNAM VETERAN FOR EPIDEMIOLOGIC
STUDIES
PROJECT 3: EVALUATION AND STANDARDIZATION OF MILITARY
RECORDS FOR USE IN EPIDEMIOLOGIC STUDIES
PROJECT 4: BIOMARKERS OF TCDD (DIOXIN) EXPOSURE IN VIETNAM
VETERANS
PROJECT 5: ANALYSIS OF IARC TISSUE SAMPLES OF SELECTED
VIETNAMESE FOR DIOXIN AND DIBENZOFURAN LEVELS IN ARCHIVED
ADIPOSE TISSUE
FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS
REFERENCES
APPENDIXES
A MATERIALS FROM CONTRACTOR
B COMMITTEE AND STAFF BIOGRAPHIES
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1
7
11
26
31
33
34
36
38
A-1
B-1
