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6 Health Effects Associated with Combustion Products This chapter examines the epidemiologic studies on the relationship between adverse long-term health out - comes and exposure to combustion products thought by the committee to be comparable to those emitted from the military burn pits in Iraq and Afghanistan. The media has described disheartening stories of returning Iraq and Afghanistan veterans with unusual and often multiple medical problems, anecdotally associated with expo - sure to smoke from burn pits. Stories published in the New York Times and Washington Post (both on August 6, 2010) describe individuals with disabling respiratory diseases, reports of constrictive bronchiolitis (an unusual lung disease), leukemia, and other cancers, and a claim of increased rates of asthma, all suggested to be linked to exposures to burn pits (Glod 2010; Risen 2010). However, such anecdotal reports do not demonstrate causality or even association; the committee looked instead to the epidemiologic literature on the exposed populations, and on populations similarly exposed. This chapter describes the committee’s approach to reviewing the literature, the main uncertainties and limitations associated with the studies, summarizes the Department of Defense’s (DoD’s) report of several epidemiologic studies particular to health effects and burn pit exposure, summarizes the available literature by health outcome, and presents the committee’s conclusions. APPROACH TO THE EPIDEMIOLOGIC LITERATURE Chapters 4 and 5 identified specific contaminants present at Joint Base Balad (JBB) and outlined their potential human health effects. These health effects are, in many cases, based on animal studies, and usually only pertain to exposure to a single chemical, not mixtures of chemicals from burning materials. Thus, the committee thought it necessary to evaluate human health effects to the complex mixture of chemicals resulting from combustion. The committee began by reviewing health studies on military personnel exposed to burn pits in Iraq and Afghani - stan. As discussed in Chapter 3, however, there are few such studies available. Thus, the committee decided to approach its review of the health effects stemming from exposure to burn pits by identifying populations that were considered to be the most similar to military personnel with regard to exposures to burn pits or other sources of combustion products. The committee then conducted an extensive literature search for epidemiologic studies on long-term health outcomes seen in those populations. Pertinent studies were reviewed and classified as “key” or “supporting” based on their quality and relevance to the task. These key and supporting studies formed the basis of the committee’s weight-of-the-evidence approach and its conclusions on the degree of association demonstrated between exposure to combustion products and long-term health outcomes. In the following sections, the com - 63

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64 HEALTH CONSEQUENCES OF EXPOSURE TO BURN PITS mittee discusses the selection and characteristics of the surrogate populations, the methods used for the literature searches, the criteria to distinguish key and supporting studies, and the categories of association on which the committee’s conclusions were based. Populations of Interest The committee reviewed and evaluated the epidemiologic literature for studies on populations with inhalation exposure to chemical mixtures that were considered to be similar to burn pit emissions, that is, mixtures formed by combustion of a variety of materials and waste in occupational and environmental exposure settings. Two occupational groups were identified as most likely to have comparable exposures: firefighters, including those with exposures to wildland and chemical fires, and incinerator workers. Firefighters are exposed to highly complex chemical mixtures (McGregor 2005; IARC 2010). The short intermittent spikes in exposure for firefighters are likely to differ from the long-term, chronic exposures to burn pit emissions on military bases; nevertheless, stud - ies on firefighters are useful as the best available representation of exposures to mixtures of combustion products. The waste disposed in burn pits is described by the DoD as municipal waste (Taylor et al. 2008). Therefore, occupational exposures to emissions from municipal incinerators were considered to be another surrogate for exposure of military personnel to burn pit emissions. Furthermore, because military personnel at JBB and other burn pit locations not only work on the base but also live there, the committee considered the literature on the health effects seen in residents living near municipal incinerators to be of interest. The committee acknowledges that exposures to emissions from municipal waste incinerators likely differ from exposures to burn pit emissions, and the value of these studies in understanding the health effects of burn pit exposures is limited. Studies of military personnel exposed to smoke from oil-well fires in Kuwait during the 1990–1991 Gulf War were also considered. Assessments of health effects among Gulf War veterans are particularly useful because of the common background exposures (for example, dusty environment, vehicle exhaust, munitions) and personnel characteristics (for example, underlying health, exposure to stressors, general demographics) shared by those deployed to Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF) in Iraq. The committee acknowledges that its ability to compare exposures among the populations of interest is restricted by the unknown degree to which exposures of varying intensity, duration (short-term, intermittent exposure to combustion products for firefighters; chronic exposures for incinerator workers and those living near incinerators; short-term exposure to oil-well–fire smoke in Kuwait), and composition can be extrapolated to the burn pit exposure of military personnel at JBB and elsewhere. Military personnel at JBB might have been exposed for a few days or up to 12 months as they lived and worked on the base whereas firefighters and incinerator work - ers might experience occupational exposure for many years, and residents near incinerators might be subject to a lifetime of exposure to pollutants. The committee recognized that JBB personnel may have had days of high exposures when smoke and emissions from the burn pits spread across the camp, but on other days there may have been less smoke, and the overall level of emissions was unknown. Exposure to burn pit emissions via ingestion and dermal contact is an even greater unknown as no sampling of surfaces and soil was conducted. Exposure to combustion products among all groups is likely affected by time-dependent changes in engineering or other con - trols. For example, some firefighter studies cited in this chapter were conducted before the use of self-contained breathing apparatus and other protective gear was common, while other studies assessed firefighters using protec - tive gear that minimized exposure. The same is true for occupational and environment exposure to incinerator emissions; engineering controls to minimize hazardous emissions have been implemented over time. At JBB, the composition and volume of the burn pit changed as practices to separate waste and the use of incinerators were implemented. Since the composition of combustion products varies greatly depending on burn characteristics and fuel, and little is known about specific exposures to the burn pits at JBB and elsewhere, the committee was unable to directly compare constituents and concentrations of the pollutants that military personnel at JBB and the sur- rogate populations were exposed to, nor was it able to compare the duration and frequency of these exposures. Furthermore, all the groups considered in this chapter experience a variety of additional exposures independent of their exposure to combustion products from burn pits, fires, or municipal incinerator emissions. These additional exposures include emissions from diesel engines (aircraft, vehicular, and machinery), kerosene heaters, and other

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65 HEALTH EFFECTS ASSOCIATED WITH COMBUSTION PRODUCTS environmental stressors such as combat exposure, job-related stress, and other environmental pollutants such as dust storms. The committee focused on health effects related to combustion products as related to burn pits and did not attempt to assess health effects from these other exposures. The committee did not consider studies of health effects reported for first responders to the World Trade Center attacks in 2001 because the composition of the smoke and emissions from this event are substantially different from combustion emissions, particularly those expected from burn pits. Methods Extensive searches of the scientific literature published after 1980 were conducted using two major biomedi - cal databases: MEDLINE and EMBASE. The literature search for long-term health effects among firefighters retrieved over 400 studies, including studies of structural fires, wildland or forest fires, and chemical fires. The titles and abstracts of those studies were reviewed and studies that did not appear to be immediately relevant were deleted from the database. Deleted studies included those not linked to inhalation exposure (such as studies of job-related stress); studies that had fewer than 10 participants; studies of acute or short-term health effects only (unless considered relevant to long-term effects); studies of exposures to uranium and other types of radiation; studies reporting behavioral or psychiatric outcomes; or studies that assessed DNA or other cellular damage. The literature search for incineration workers and residents of nearby communities also returned over 400 studies. In this case, rejected studies included those that were not linked to inhalation exposures; studies that reported acute or short-term health effects only; studies that were modeling studies of emissions or that focused on children, genet - ics, or DNA damage; and studies of ambient air pollution. Studies that characterized emissions from incinerators but not their health effects, or that focused on waste management, were also rejected. The committee adopted a policy of using only published papers that had undergone peer review as the basis of its conclusions. An exception was made for the epidemiologic studies conducted by the DoD to assess health effects in military personnel exposed to burn pits; theses studies are summarized below and discussed after the peer reviewed epidemiologic studies for each health outcome. Since epidemiologic studies of Gulf War veterans have been described previously by other Institute of Medicine (IOM) committees, most recently in Volume 8 of the Gulf War and Health series (IOM 2010), this committee relied on those assessments supplemented with a review of more recent publications. Key and Supporting Studies After the removal of the extraneous studies, the full text of the remaining articles and reports were retrieved. For each health outcome, committee members reviewed the studies most closely related to their area of expertise, to determine whether the criteria for a key or supporting study were met. Consistent with previous IOM reports (IOM 2010), to be designated as key, a study had to be published in a peer-reviewed journal, present information about the putative exposure and specific health outcomes, demonstrate rigorous methods, include methodological details adequate to allow a thorough assessment, and use an appropriate control or reference group. A supporting study typically had methodological limitations, such as lack of a rigorous or well-defined diagnostic method or a lack of an appropriate control group. The committee as a group reviewed the key and supporting studies identified by the committee members responsible for each health outcome. The strengths and limitations of each study and its categorization as key or supporting were discussed in plenary session and a consensus reached on its contribu - tion to the evidence base for each category of association for each health outcome. After having reviewed all the studies in detail, the committee based its conclusions primarily on key studies. Supporting studies are included as part of the committee’s analysis because they provide information that might modify confidence in the con - clusions based on key studies, but they carry less weight than key studies. The committee considered the DoD epidemiologic studies as supporting literature when making conclusions about associations between exposure to combustion products and health outcomes.

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66 HEALTH CONSEQUENCES OF EXPOSURE TO BURN PITS Categories of Association For its conclusions, the committee agreed to use the categories of association that have been established and used by previous IOM committees, such as those that prepared the Veterans and Agent Orange reports and the Gulf War and Health series. These categories of association have been accepted for more than a decade by Congress, the Department of Veterans Affairs (VA) and the DoD, researchers, and veterans’ groups. The five categories describe different levels of association;1 the validity of an association is likely to vary to the extent to which common sources of spurious associations could be ruled out as the reason for the observed association. Accordingly, the criteria for each category express a degree of confidence based on the extent to which sources of error and bias were reduced. The committee discussed the evidence and reached consensus on the cat - egorization of the evidence for each health outcome in this chapter. The committee used the following categories: • ufficient Evidence of a Causal Relationship: Evidence is sufficient to conclude that a causal relationship S exists between exposure to combustion products and a health outcome in humans. The evidence fulfills the criteria for sufficient evidence of a causal association and satisfies several of the criteria used to assess causality: strength of association, dose–response relationship, consistency of association, temporal relation- ship, specificity of association, and biologic plausibility. • ufficient Evidence of an Association: Evidence is sufficient to conclude that there is a positive association. S That is, a positive association has been observed between exposure to combustion products and a health outcome in human studies in which bias and confounding could be ruled out with reasonable confidence. • imited/Suggestive Evidence of an Association: Evidence is suggestive of an association between expo- L sure to combustion products and a health outcome in humans, but this is limited because chance, bias, and confounding could not be ruled out with confidence. • nadequate/Insufficient Evidence to Determine Whether an Association Does or Does Not Exist: The avail- I able studies are of insufficient quality, consistency, or statistical power to permit a conclusion regarding the presence or absence of an association between exposure to combustion products and a health outcome in humans. • imited/Suggestive Evidence of No Association: There are several adequate studies, covering the full range L of levels of exposure that humans are known to encounter, that are mutually consistent in not showing a positive association between exposure to combustion products and a health outcome. A conclusion of no association is inevitably limited to the conditions, levels of exposure, and length of observation covered by the available studies. In addition, the possibility of a very small increase in risk at the levels of exposure studied can never be excluded. UNCERTAINTY AND LIMITATIONS OF THE STUDIES The studies cited in this chapter have limitations and uncertainties, some common to epidemiologic studies in general, and some specific to studies of occupational populations. These limitations and uncertainties include • ealthy worker effect—Studies of firefighters are likely to be biased downward when the comparison H group is the general population, that is, risk estimates might reflect a lower risk than really exists because firefighters must meet physical health standards for employment, and must remain healthy to continue working. Thus, firefighters might have a better health status than members of the general population of the same sex and age. • xposure misclassification—None of the studies cited in this chapter have actual measures of inhalation to E combustion products. Without measured individual exposure information, an individual might be assigned the wrong level of exposure thus masking the association between effect and exposure. Most studies use employment as a firefighter (yes/no) as the only measure of exposure, although a few studies used additional 1 The following categories of association are excerpted from Gulf War and Health: Volume 1 (IOM 2000).

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67 HEALTH EFFECTS ASSOCIATED WITH COMBUSTION PRODUCTS measures to better define exposures, such as the number of years employed or number of fires attended. Studies of communities in the vicinity of an incinerator rely on distance from the incinerator as the best surrogate of residential exposure, using either classification into concentric rings around the site or mod - eled exposure estimates. Ecological study designs are limited to using information on residential history, which can lead to exposure misclassification. Not all studies report the type of waste being burned, the age or technological practices of the incinerator, or adherence to government regulations, all of which affect the amount and constituents of the emissions. Furthermore, communities might be affected by other pol - lution sources, such as local industry, so that exposure to an environmental contaminant cannot be wholly attributed to the incinerator. • L ack of information on confounders—Most of the studies do not adjust for potential confounders such as tobacco smoking and alcohol consumption. The use of tobacco products, particularly cigarettes, has been causally associated with long-term adverse health effects (U.S. Surgeon General 1964). Military person - nel have a greater prevalence of tobacco use than civilians, particularly when deployed where smoking rates might be as high as 50% (IOM 2009). Tobacco smoke contains many environmental contaminants, including particulate matter (PM), acrolein, polyaromatic hydrocarbons (PAHs), benzene, and metals. The 2004 U.S. Surgeon General’s report associated tobacco smoke with cancer, cardiovascular disease (CVD), pulmonary disease, gastrointestinal disease, and reproductive effects (U.S. Surgeon General 2004). Even exposure to secondhand smoke can result in long-term health effects, in particular, an increased risk for lung cancer (IARC 2004) and CVD (IOM 2010). • L imited statistical power—Small sample size in many of the studies prevents the detection of associations for the less common health outcomes such as rare cancers. • D isease misclassification—Many of the studies in this chapter investigate mortality based on the cause of death listed on death certificates. The validity of these mortality studies is dependent on the accuracy of the reported cause of death. • P ublication bias—It is likely that the evidence base for some health outcomes is affected by publication bias, that is, results that are positive or statistically significant are more likely to be published than null results. The variability of the studies’ results and methods makes comparison across them difficult. Variables include different criteria for reference populations, lack of adjustment for confounding factors, and different statistical methods. In addition, there is uncertainty regarding the degree of similarity between the exposures to combustion products in the studies and exposure to the emissions from the burn pits. Despite these limitations, the studies reviewed in this chapter provide useful evidence on the potential health effects that might be associated with exposure to burn pits. They also highlight the many challenges inherent in the conduct of any epidemiologic study of exposure to complex mixtures. HEALTH OUTCOMES Health outcomes were investigated by organ system. The committee drew conclusions for the following health outcomes: respiratory, circulatory, neurologic, reproductive and developmental effects, and cancer. In addi - tion, the committee examined the literature on other outcomes such as the autoimmune disorders systemic lupus erythematosus and rheumatoid arthritis, and on chronic multisymptom illness because these health outcomes were evaluated in the DoD epidemiologic studies of OEF/OIF military personnel deployed to sites with burn pits (AFHSC et al. 2010). Results from the epidemiologic literature are reported here for each health outcome and organized by popu - lation (firefighters, incinerator workers and surrounding communities, and Gulf War veterans exposed to smoke from oil-well fires). Little information is available on health effects linked directly to burn pit exposure; however, two epidemiologic studies conducted by the Armed Forces Surveillance Center, Naval Health Research Center (NHRC), and U.S. Army Public Health Command (AFHSC et al. 2010) on health outcomes among OEF/OIF troops deployed to bases with burn pits are considered. A brief discussion of the key and supporting studies and a

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68 HEALTH CONSEQUENCES OF EXPOSURE TO BURN PITS conclusion are provided for each health outcome. The committee assigns a category of association for each health outcome after a summary of the results. For readers interested in more details for the key and supporting studies, descriptions of the study design, population, exposures, outcomes measured, adjustments, and limitations are given in tabular format in Appendix C in alphabetical order by study author rather than by health outcome to avoid duplication of studies reporting on multiple outcomes. DoD Epidemiologic Investigations In May 2010, the Armed Forces Health Surveillance Center (AFHSC), the Naval Health Research Center (NHRC), and the U.S. Army Public Health Command (APHC) released a report on five epidemiologic studies of military personnel deployed to burn pit sites in Iraq (AFHSC et al. 2010). In the studies, exposure was defined as deployment to a site with an active burn pit as individual exposure data were not available. The AFHSC retro - spective cohort study compared the incidence rates of various diseases, among deployed (two locations with burn pits, two locations without burn pits, and Korea) and never deployed cohorts. The cohorts consisted of Army and Air Force personnel deployed between January 1, 2005, and June 30, 2007, to one of four U.S. Central Command (CENTCOM) bases or to the Republic of Korea. CENTCOM bases were Joint Base Balad (JBB) and Camp Taji in Iraq, both of which had burn pits, and Camp Buehring and Camp Arifan in Kuwait which did not have burn pits. Active-duty personnel who were located within a 3-mile radius of a burn pit were included in the exposed groups. There were 15,908 personnel who served at JBB; 2,522 personnel at Taji; and 51,299 personnel at bases without burn pits. Military personnel were included in the study if they served at least 31 days at a base by the end of their deployment in order to capture any health effects resulting from being at the base. Camps in the Republic of Korea had no burn pits but were subject to urban air pollution and PM from the surrounding desert. The compari - son group consisted of 237,714 active-duty personnel stationed in the United States and not previously deployed. All individuals were followed from their return from deployment, or April 15, 2006, and censored at the earliest occurrence of a diagnosis of interest, separation from active service, start of subsequent deployment or change of station, or the end of the 36-month follow-up period. The analysis adjusted for age, race, grade, and service. The report included several different investigations: (1) incidence rates of respiratory conditions, circulatory disease, CVD, sleep apnea, and ill-defined conditions for deployed personnel versus nondeployed personnel; (2) responses to post-deployment health surveys were compared between deployed personnel at sites with or without active burn pits; and (3) medical encounters for respiratory outcomes were compared for deployed personnel at sites with or without burn pits. The investigation of medical encounters while deployed is not discussed in this chapter because such encounters were considered to relate to acute, rather than long-term, health effects (AFHSC et al. 2010). This AFHSC study looked only at health effects occurring within 36 months after return from a site with an active burn pit. Follow-up was not long enough to detect diseases with long latency, such as cancer. There was no adjustment for confounders such as smoking. This study had a large population and was able to capture individuals’ health status using electronic medical records. The DoD concluded that, based on in-theater reports of respiratory problems and the high proportion of Air Force personnel reporting exposure to burn pits at JBB, acute respiratory effects are of concern, and possible long-term health effects are not discussed in the report (AFHSC et al. 2010). The DoD report also contains four NHRC studies that looked at the personnel stationed at the same bases as for the AFHSC study but the NHRC also included a third base in Iraq with a burn pit, Camp Speicher. Exposure was based on being located within a 5-mile radius of a documented burn pit. The first study assessed birth outcomes in infants of military personnel exposed before or during pregnancy to burn pits and is discussed in the section of this chapter on reproductive and developmental outcomes. The second study looked at respiratory health of military personnel who had been exposed to burn pits and were participants in the Millennium Cohort Study; this study is discussed in the section of this chapter on respiratory outcomes. The third and fourth studies, also of participants of the Millennium Cohort Study, focused on service members who had been exposed to burn pits and their risk of having chronic multisymptom illness (CMI), or of having physician-diagnosed lupus or rheumatoid arthritis, respectively. The Millennium Cohort examined by NHRC consisted of more than 27,000 personnel deployed in support of OEF/OIF and included over 3,000 participants considered exposed, with at least one deployment

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69 HEALTH EFFECTS ASSOCIATED WITH COMBUSTION PRODUCTS within a 5-mile radius of a documented burn pit. Exposed participants were compared with participants who were deployed to locations without burn pits. The Millennium Cohort is considered to represent U.S. military personnel, with reliable self-reported information obtained prior to enrollment and unaffected by subsequent health status. CMI was defined by the reporting of at least two symptoms from the following categories: general fatigue, mood and cognition, and musculoskeletal. CMI was not significantly associated (p = 0.16) with being deployed within a 5-mile radius of a burn pit, cumulative exposure to a burn pit overall, or being deployed to JBB or Camps Taji or Speicher, when adjusted for sex, birth year, education, service component, service branch, pay grade, smoking status, alcohol-related problems, mental health symptoms, and baseline CMI status. However, cumula - tive exposure to a burn pit for more than 210 days showed a slight increase in risk for CMI (OR 1.22, 95% CI 1.04–1.44) after adjustment. There was no association between a new diagnosis of lupus and being within 5 miles of a burn pit, cumula - tive exposure, or being deployed to Camp Taji or Camp Speicher. There was, however, a significant increase in the likelihood of a lupus diagnosis for those deployed to JBB (OR 3.52, 95% CI 1.59–7.79) compared with those deployed to locations without burn pits. For rheumatoid arthritis, there was no association with deployment to a burn pit location, cumulative days exposed, or camp site. One exception was an increase in rheumatoid arthritis diagnoses for those exposed to burn pits for 132–211 days (OR 2.03, 95% CI 1.18–3.49), although exposure for more than 211 days was not significant. Electronic medical records were used to confirm 33% of self-reported lupus cases and 17% of self-reported rheumatoid arthritis cases among active-duty personnel diagnosed while in the military. Among verified cases, no association between lupus or rheumatoid arthritis and exposure to burn pits was found (AFHSC et al. 2010). There are several limitations to using the Millennium Cohort data. Confirmation of self-reported medical issues is difficult for participants who are not active-duty allowing for disease misclassification. The rare occurrences of bronchitis, emphysema, lupus, and rheumatoid arthritis and short average follow-up (2.8 years) compromise the precision of the risk estimates (AFHSC et al. 2010). Exposure misclassification is also possible as individual exposure information was not available. The committee categorized these DoD studies as supporting due to the short period of follow-up (36 months), ecologic nature, lack of information on other hazardous environmental exposures common in the context of desert and war (for example, smoking, diesel exhaust, kerosene heaters, PM, local and regional pollution). However, as the only studies of health effects and burn pit exposure, they are uniquely valuable to the current assessment and provide the first indications of adverse health effects resulting from exposure to burn pits. The lack of additional studies and further followup to corroborate or refute the DoD’s reported findings prevent the committee from being able to make decisions about the strength of an association between burn pits and the reported health outcomes. DISEASES OF THE RESPIRATORY SYSTEM Environmental conditions experienced by military personnel in Iraq and Afghanistan might cause respiratory effects from exposure to windblown dust, local combustion sources, and volatile evaporative emissions. The local combustion sources include burn pits or other waste incinerators, compression ignition vehicles, aircraft engines, diesel electric generators, and local industry and households. Although local contributions of wood smoke might be minimal (there is mention in the sampling field notes of a local brush fire causing smoky conditions), exposure to wood smoke from burn pits would have been likely (burning of materials such as shipping pallets). Asthma, bronchitis, chronic obstructive pulmonary disease (COPD), and respiratory symptoms have been reported to occur more frequently than expected among Gulf War veterans (IOM 2010). A retrospective case-control study found a higher risk of new-onset asthma (OR 1.58, 95% CI 1.18–2.11) among military personnel who served in OEF/OIF, compared with age- and sex-matched personnel deployed in the United States (Szema 2010). Personnel exposed to combustion products from burn pits might be at increased risk of respiratory diseases as some chemicals released by the burning of waste (as described in Chapters 4 and 5), such as acrolein and PM, are known to cause respira - tory effects (see Chapter 5). This section focuses on long-term, nonmalignant adverse respiratory conditions resulting from exposures to combustion products that are considered to be similar to burn pit emissions. First, respiratory outcomes (assess -

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70 HEALTH CONSEQUENCES OF EXPOSURE TO BURN PITS ments of respiratory disease and pulmonary function indicative of potential disease) related to occupational expo - sures of firefighters (including firefighters involved in structural, wildland, and chemical fires) are considered. Next, respiratory outcomes from exposure to incinerators, both for workers and surrounding communities are discussed. Lastly, respiratory outcomes for veterans exposed to oil-well fires in the 1990–1991 Gulf War and the preliminary data available for veterans from OEF/OIF will be examined. Details of the studies presented in this section are found in Appendix C. Respiratory Disease in Firefighters The committee recognizes that firefighter exposures may be very different depending on the type of fire. Struc- tural firefighters primarily work to extinguish fires on anthropogenic objects—for example, buildings, furniture, manufactured items—whereas wildland firefighters are exposed to combustion products from the burning of the natural environment, that is, forests and grasslands. Firefighters working to extinguish chemical fires might be exposed to a wide variety of combustion products as well as the unburned chemical(s) itself. Key Studies No key studies of respiratory diseases in firefighters were identified by the committee. Supporting Studies Fifteen studies were considered to be supportive. Of the 13 studies reporting on mortality, all reported no significant increase and even reductions in mortality from respiratory causes (Eliopulos et al. 1984; Feuer and Rosenman 1986; Vena and Fiedler 1987; Heyer et al. 1990; Rosenstock et al. 1990; Beaumont et al. 1991; Grimes et al. 1991; Demers et al. 1992a, 1995; Guidotti 1993; Aronson et al. 1994; Baris et al. 2001; Ma et al. 2005). In the largest study, Ma et al. (2005), found firefighters to have significantly lower mortality rates for all respiratory causes, and for pneumonia specifically, compared with the general Florida population. However, the 13 studies had one or more limitations that precluded their categorization as key studies including too few deaths for meaningful statistical analyses, exposure assessments that were dichotomous (employed as a firefighter, Y/N) or absent, and failure to consider tobacco smoking or the healthy worker effect. There is concern that environmental exposures could contribute to respiratory diseases of unknown cause such as sarcoidosis. Sarcoidosis is a systemic disease characterized by granulomatous inflammation, most often involving lymph nodes and the lung, but also involving the eyes, skin, liver, heart, and central nervous system. Prezant et al. (1999) studied the annual incidence and point prevalence of biopsy-proven sarcoidosis in New York City firefighters and emergency medical personnel between 1985 and 1988. The average annual incidence among firefighters was 12.9 cases per 100,000 firefighters and the point prevalence in 1998 was 222 cases per 100,000 firefighters. The majority of those with sarcoidosis (23 of 25) had minimal impairment as assessed by radiograph (x-ray and CT scan) and pulmonary function testing. These data suggest an association between firefighting and sarcoidosis, but confirmatory studies are lacking and causation was not demonstrated. There are few studies on the health consequences of fighting chemical fires. One longitudinal follow-up study of firefighters exposed to a 1985 fire burning polyvinyl chloride found that exposed firefighters had significantly more respiratory symptoms (cough, wheeze, shortness of breath, chest pains) at both 5–6 weeks and 22 months postexposure than unexposed firefighters with the exception of wheezing at 22 months (Markowitz 1989). Among exposed firefighters, the incidence of respiratory symptoms showed a decreasing trend over time and respiratory scores between the two time points were well correlated. The findings were similar among current, past, and never smokers. After 22 months, 12 of 64 (18%) of exposed firefighters had been diagnosed with asthma or bronchitis by a physician whereas none of the 22 controls had these diagnoses. This study is limited to a single heavy exposure to a specific set of chemicals.

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71 HEALTH EFFECTS ASSOCIATED WITH COMBUSTION PRODUCTS Pulmonary Function in Firefighters Pulmonary function tests are frequently used to diagnose respiratory diseases such as asthma, bronchitis, emphysema, or fibrosis. Measurements include spirometry (the flow rate and volume of air that is inhaled or exhaled), diffusion capacity (how well oxygen moves from the lungs into the blood), and lung volumes (the total amount of air in the lungs). Testing might be used to evaluate shortness of breath, diagnose disease, and track disease progression or effects of treatments/medicines (Medline Plus 2011). Pulmonary function effects can be observed even in the absence of clinical symptoms or disease. Key Studies Sparrow et al. (1982) conducted a longitudinal study of pulmonary function in 168 male firefighters who were participants in the larger Normative Aging Study of 2,280 male military veterans that began in 1963 in Boston. Spirometric measurements, as well as a survey of smoking habits and respiratory symptoms, were collected at 5-year intervals. The control group was a non-firefighting population from the same study. The authors found a significantly greater loss of forced vital capacity (FVC) and forced expiratory volume in one second (FEV 1) in the firefighters even after adjusting for smoking, age, height, and initial pulmonary function level (p < 0.05). Few respiratory symptoms and diseases were reported during follow-up, with no differences between firefighters and controls. Peters et al. (1974) studied pulmonary function in 1,430 Boston firefighters. Repeat pulmonary function tests and questionnaires collecting self-reported respiratory symptoms and smoking habits were completed from 1970 to 1972. Pulmonary function declined in the entire cohort (FVC annual loss of 77 mL, FEV1 of 68 mL) and was significantly associated with frequency of exposure to fires (p < 0.01). Decreases could not be explained by the effects of age, smoking, or race. Additional follow-up of 1,146 firefighters through 1974 showed that decreased pulmonary function and association with numbers of fires fought was maintained (Musk et al. 1978). However, a further follow-up of this cohort for a total of 6 years through 1976, found smaller declines in FVC and FEV1, no correlation with exposure, and no significant difference from healthy nonsmoking non-firefighters (Musk et al. 1982). This change was attributed to increased use of protective respiratory equipment. Supporting Studies Supporting studies of pulmonary function show mixed results. Several studies report no decrease in pulmonary function for firefighters while other studies indicate increases in respiratory symptoms. Decreased pulmonary function was reported for structural firefighters (Unger et al. 1980; Tepper et al. 1991) and for forest firefighters (Liu et al. 1992; Serra et al. 1996; Betchley et al. 1997). An examination of respiratory function among 128 firefighters and 88 controls in Zagreb, Croatia, found significantly higher rates (p < 0.01) of respiratory symptoms (dyspnea, nasal catarrh, sinusitis, and hoarseness) and decreased pulmonary function in firefighters compared to controls (Mustajbegovic et al. 2001). The authors found these chronic respiratory symptoms and decreases in pulmonary function to be associated with duration of employment and smoking. Young et al. (1980) conducted a cross-sectional study of respiratory disease and pulmonary function among 193 firefighters in New South Wales, Australia. The authors found no increased respi - ratory problems attributable to fire exposure and concluded that “the major combustion products responsible for respiratory damage were self-administered, arising from burning tobacco rather than from burning buildings.” Miedinger et al. (2007) examined respiratory symptoms, atopy, and bronchial hyperreactivity in 101 professional firefighters compared with 735 local men in Basel, Switzerland. Firefighters had better FEV 1, FVC (significant), and FEV1/FVC values than controls, although they also had elevated rates of respiratory symptoms, atopy, and bronchial hyperreactivity (OR 2.24, 95% CI 1.12–4.48). Douglas et al. (1985) examined the effect of firefighting on the pulmonary function of 1,006 London firefighters over 1 year. Lower than expected pulmonary function was not associated with exposure, based on years of employment and self-reported exposure to severe smoke

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72 HEALTH CONSEQUENCES OF EXPOSURE TO BURN PITS events, except for a nonsignificant decrease among firemen who had worked for more than 20 years. This analysis adjusted for smoking. Horsfield et al. (1988a,b) conducted two longitudinal studies of respiratory health in 96 West Sussex firefighters and 69 local nonsmoking men assessed every six months for 2 years and annually thereafter over the course of 4 years. Respiratory symptoms increased at a faster rate for firemen, regardless of smoking status, compared with the nonsmoking controls, leading the authors to conclude “these results suggest that being affected by smoke and fumes at work may be a cause of long-term symptoms in firemen” (Horsfield et al. 1988b). However, the control group had a greater decrease in pulmonary function and spirometric measurements than the firemen, leading the authors to further conclude that “these results show no evidence of chronic lung damage in West Sussex firemen” (Horsfield et al. 1988a). They attributed these findings not only to a healthy-worker selection bias but to the increasing use of protective breathing apparatus by these firemen. Unger (1980) investigated the acute and chronic effects of a severe smoke exposure event on the pulmonary function of 30 firefighters sent to a Houston-area hospital after a single fire. Spirometric data and a survey of self- reported symptoms were collected immediately, after 6 weeks, and again after 18 months. Significant decreases in FVC (p < 0.01) and FEV1 (p < 0.05) were observed compared to matched controls. Tepper et al. (1991) evaluated pulmonary function changes after 6 to 10 years in male Baltimore firefighters (n = 632) in a longitudinal cohort study that adjusted for age, smoking, blood type, and weight. Firefighters who did not wear respirators and those who were exposed to ammonia were both found to have 1.7 times the rate of decrease in FEV 1 of unexposed con- trols. Active firefighting was associated with 2.5 times (p < 0.05) the rate of decrease compared with individuals no longer working as firefighters. Three studies investigated forest firefighters. Two examined cross-season differences in respiratory function. Liu et al. (1992) conducted a longitudinal study of 63 seasonal and full-time wildland firefighters in Northern California and Montana, pre- and post firefighting season in 1989. The authors found a postseasonal loss in lung function (0.15 L FEV1) and an increase in airway responsiveness (significant mean declines in FVC, FEV 11, and FEF25–75) compared with preseason values after controlling for smoking. Betchley et al. (1997) observed signifi - cant decreases (p < 0.05) in cross-season spirometry values for 53 forest firefighters based on questionnaires and testing before and after the 1992 firefighting season. Mean individual decreases were 0.033 L for FVC 1, 0.104 L for FEV1, and 0.275 L/sec for FEF25–75. The authors also reported significant decreases in pulmonary function across shifts for the 72 individuals assessed for cross-shift differences. Results were not affected by smoking, recent colds, lung conditions, allergies, or other potential confounders with the exception of those relying on wood to heat their homes. The third study of forest firefighters by Serra et al. (1996), examined pulmonary function in 92 Sardinian forest firefighters compared with 51 local police officers. The firefighters had significant decreases in FEV1, FVC, FEF75, FEV1/FVC, FEF50, FEF25, but the decreases were not correlated with length of service or number of fires extinguished after adjusting for age, height, smoking status, and pack-years. No difference in permeability of alveolar-capillary barrier was observed. Respiratory Disease in Incinerator Workers No studies of occupational respiratory disease among incinerator workers were identified by the committee. Pulmonary Function in Incinerator Workers Key Studies No key studies of pulmonary function in incinerator workers were identified.

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73 HEALTH EFFECTS ASSOCIATED WITH COMBUSTION PRODUCTS Supporting Studies Three supporting studies of pulmonary function in incinerator workers were considered by the committee. Bresnitz et al. (1992) conducted a cross-sectional study of 89 male incinerator workers in Philadelphia, Pennsyl - vania. The study included environmental monitoring, physical examinations of all study participants, analysis of biological samples, and pulmonary function tests. The prevalence of pulmonary function patterns were similar in high and low exposed groups, after adjusting for smoking status. The OR for small airway obstruction in the high versus low exposed group was 1.19 (95% CI = 0.45–3.16). Changes in pulmonary function were related only to smoking status. Conversely, two other studies report decreased pulmonary function among incinerator workers after adjusting for smoking. Charbotel et al. (2005) noted significantly reduced pulmonary function from predicted values in the third year of monitoring—FEF50 (p = 0.04), FEF25–75 (p = 0.02) and FEF25–75/FVC (p = 0.01)—among 83 workers exposed to incinerator emissions compared with 76 unexposed workers, indicating possible obstructive disorders for the exposed workers. After adjusting for history of allergy or lung disease, smoking, and location of examination, the reduction of FEF75 in the first year and FEF25–75/FVC in the third year were linked to exposure in incinerator plants. Charbotel et al. (2005) noted that daily variation in lung function may not have been captured. A study of 102 male workers at three French urban incinerators by job type was conducted by Hours et al. (2003). Symptoms were self-reported on a survey and a physical exam was performed with blood testing and respiratory function assessment. Workers were compared with 84 water-meter assemblers, security guards, or woolen-mill workers. Daily coughing was reported more often by incinerator furnace men (OR = 6.58, 95% CI 2.18–19.85) and decreased respiratory performance was found in incinerator maintenance and effluent treatment workers (p < 0.01) after adjusting for smoking, age, and work location. Respiratory Disease in Communities Near Incinerators No studies assessing respiratory disease incidence or mortality in populations exposed to incinerator emissins were identified by the committee. Pulmonary Function in Communities Near Incinerators Key Studies No key studies of pulmonary function in populations exposed to incinerator emissions were identified by the committee. Supporting Studies Four studies, conducted as part of the Health and Clean Air Study (Shy et al. 1995), assessed health outcomes in communities living near incinerators. Exposure was based on distance from an incinerator. No significant dif - ferences were noted between respiratory symptoms or pulmonary function and community exposure to incinera - tor emissions (Shy et al. 1995; Lee and Shy 1999; Hu et al. 2001; Hazucha et al. 2002). Using the Health and Clean Air Study (Shy et al. 1995) and one additional community near a commercial hazardous waste incinerator, Mohan et al. (2000) compared respiratory symptoms with four control communities matched by socioeconomic characteristics and population size. The authors found a higher prevalence of all respiratory symptoms in the one community near a hazardous waste incinerator compared with the control community (p < 0.05) even after con - trolling for perceptions of air quality.

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98 HEALTH CONSEQUENCES OF EXPOSURE TO BURN PITS TABLE 6-2 Continued Study Study Type Population Risk Estimate (95% CI) Tornling et al. 1994 K Firefighters SMR 0.90 (0.53–1.42) Bates et al. 2001 S Firefighters SIR 1.14 (0.7–1.8) Burnett et al. 1994 S Firefighters PMR 1.02 (0.94–1.11) 6.8 (1.3–37.4) Elci et al. 2003 S Firefighters OR Firth et al. 1996 S Firefighters SIR 1.65 (0.60–3.62) Heyer et al. 1990 S Firefighters SMR 0.97 (0.65–1.39) 0.65 (0.54–0.78) Ma et al. 2006 S Firefighters SIR Biggeri et al. 1996 S Incinerator communities Excess 1.48 (p = 0.0937) risk 1.08 (1.07–1.09) Elliott et al. 1996 S Incinerator communities SMR Michelozzi et al. 1998 S Incinerator communities SMR 0.95 (0.48–1.69) Gustavsson et al. 1989 S Incinerator workers SMR 1.97 (0.90–3.74) Bullman et al. 2005 Gulf War RR 0.72 (0.47–1.10) Bone Ma et al. 2006 S Firefighters SIR 1.02 (0.27–2.61) Soft Tissue Sarcoma Kang et al. 2008 K Firefighters SMOR 1.05 (0.46–2.37) Ma et al. 2006 S Firefighters SIR 1 (0.55–1.69) Elliott et al. 1996 S Incinerator communities SMR 1.03 (0.94–1.13) 1.44 (p = 0.004) Viel et al. 2000 S Incinerator communities SIR 31.4 (5.6–176.1) Comba et al. 2003 S Incinerator workers OR 3.30 (1.24–8.76) Zambon et al. 2007 S Incinerator workers OR Skin Aronson et al. 1994 K Firefighters SMR 0.73 (0.09–2.63) Baris et al. 2001 K Firefighters SMR 1.18 (0.64–2.20) 1.50 (1.33–1.70) Bates et al. 2007 K Firefighters OR Beaumont et al. 1991 K Firefighters SMR 1.69 (0.68–3.49) Demers et al. 1994 K Firefighters IDR 1.0 (0.4–1.8) Demers et al. 1994 K Firefighters SIR 1.2 (0.6–2.3) Guidotti 1993 K Firefighters SMR 0.0 (0.0–3.31) Kang et al. 2008 K Firefighters SMOR 0.65 (0.44–0.97) Bates et al. 2001 S Firefighters SIR 1.26 (0.8–1.9) 1.63 (1.15–2.23) Burnett et al. 1994 S Firefighters PMR Ma et al. 2006 S Firefighters SIR 1.17 (0.95–1.42) Breast Demers et al. 1994 K Firefighters SIR 2.4 (0.1–13.3) Kang et al. 2008 K Firefighters SMOR 0.25 (0.03–2.31) Ma et al. 2006 S Firefighters SIR 0.51 (0.06–1.84) Genito–urinary Deschamps et al. 1995 S Firefighters SMR 3.29 (0.40–11.88) Prostate Aronson et al. 1994 K Firefighters SMR 1.32 (0.76–2.15) Baris et al. 2001 K Firefighters SMR 0.96 (0.68–1.37) 1.22 (1.12–1.33) Bates et al. 2007 K Firefighters OR 0.38 (0.16–0.75) Beaumont et al. 1991 K Firefighters SMR 1.4 (1.1–1.7) Demers et al. 1994 K Firefighters SIR Demers et al. 1994 K Firefighters IDR 1.1 (0.7–1.8) Guidotti 1993 K Firefighters SMR 1.46 (0.63–2.88) Kang et al. 2008 K Firefighters SMOR 0.98 (0.78–1.23) Tornling et al. 1994 K Firefighters SMR 1.21 (0.66–2.02) Vena and Fiedler 1987 K Firefighters SMR 0.71 (0.23–1.65) Bates et al. 2001 S Firefighters SIR 1.08 (0.5–1.9)

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99 HEALTH EFFECTS ASSOCIATED WITH COMBUSTION PRODUCTS TABLE 6-2 Continued Study Study Type Population Risk Estimate (95% CI) Ma et al. 2006 S Firefighters SIR 1.1 (0.95–1.42) Testes Aronson et al. 1994 K Firefighters SMR 2.52 (0.52–7.37) 1.54 (1.18–2.02) Bates et al. 2007 K Firefighters OR 0.40 (0.18–0.77) Beaumont et al. 1991 K Firefighters SMR Kang et al. 2008 K Firefighters SMOR 1.53 (0.75–3.14) Bates et al. 2001 S Firefighters SIR 1.55 (0.8–2.8) 1.6 (1.20–2.09) Ma et al. 2006 S Firefighters SIR Bladder Aronson et al. 1994 K Firefighters SMR 1.28 (0.51–2.63) Baris et al. 2001 K Firefighters SMR 1.25 (0.77–2.00) 0.85 (0.72–1.00) Bates et al. 2007 K Firefighters OR Beaumont et al. 1991 K Firefighters SMR 0.57 (0.19–1.35) Beaumont et al. 1991 K Firefighters SMR 0.61 (0.28–1.17) Demers et al. 1994 K Firefighters SIR 1.2 (0.7–1.9) Demers et al. 1994 K Firefighters IDR 1.7 (0.7–4.3) Guidotti 1993 K Firefighters SMR 3.16 (0.86–8.08) Kang et al. 2008 K Firefighters SMOR 1.22 (0.89–1.69) 2.86 (1.30–5.40) Vena and Fiedler 1987 K Firefighters SMR Bates et al. 2001 S Firefighters SIR 1.14 (0.4–2.7) Burnett et al. 1994 S Firefighters PMR 0.99 (0.70–1.37) 1.29 (1.01–1.62) Ma et al. 2006 S Firefighters SIR Elliott et al. 1996 S Incinerator communities SMR 1.01 (0.98–1.04) Gustavsson et al. 1989 S Incinerator workers SMR 1.39 (0.03–7.77) Kidney Aronson et al. 1994 K Firefighters SMR 0.43 (0.05–1.56) Baris et al. 2001 K Firefighters SMR 1.07 (0.61–1.88) Bates et al. 2007 K Firefighters OR 1.07 (0.87–1.31) Beaumont et al. 1991 K Firefighters SMR 0.68 (0.19–1.74) Demers et al. 1994 K Firefighters SIR 0.5 (0.1–1.6) Demers et al. 1994 K Firefighters IDR 0.4 (0.1–2.1) 4.14 (1.66–8.53) Guidotti 1993 K Firefighters SMR Kang et al. 2008 K Firefighters SMOR 1.34 (0.90–2.01) Tornling et al. 1994 K Firefighters SMR 1.10 (0.30–2.81) Vena and Fiedler 1987 K Firefighters SMR 1.30 (0.26–3.80) Bates et al. 2001 S Firefighters SIR 0.57 (0.1–2.1) 1.44 (1.08–1.89) Burnett et al. 1994 S Firefighters PMR Ma et al. 2006 S Firefighters SIR 0.78 (0.52–1.14) Michelozzi et al. 1998 S Incinerator communities SMR 2.76 (0.31–9.34) Brain and Nervous System 2.01 (1.10–3.37) Aronson et al. 1994 K Firefighters SMR Beaumont et al. 1991 K Firefighters SMR 0.81 (0.26–1.90) Vena and Fiedler 1987 K Firefighters SMR 2.36 (0.86–5.13) Burnett et al. 1994 S Firefighters PMR 1.03 (0.73–1.41) Heyer et al. 1990 S Firefighters SMR 0.95 (0.26–7.89) 0.58 (0.31–0.97) Ma et al. 2006 S Firefighters SIR Eye Demers et al. 1994 K Firefighters SIR 5.2 (0.6–18.8) Ma et al. 2006 S Firefighters SIR 1.54 (0.42–3.95) continued

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100 HEALTH CONSEQUENCES OF EXPOSURE TO BURN PITS TABLE 6-2 Continued Study Study Type Population Risk Estimate (95% CI) Brain Baris et al. 2001 K Firefighters SMR 0.61 (0.31–1.22) 1.35 (1.06–1.72) Bates et al. 2007 K Firefighters OR Demers et al. 1994 K Firefighters SIR 1.1 (0.3–2.9) Demers et al. 1994 K Firefighters IDR 1.4 (0.2–11) Guidotti 1993 K Firefighters SMR 1.47 (0.30–4.29) 1.90 (1.10–3.26) Kang et al. 2008 K Firefighters SMOR Tornling et al. 1994 K Firefighters SMR 2.79 (0.91–6.51) Bates et al. 2001 S Firefighters SIR 1.27 (0.4–3.0) Gustavsson et al. 1989 S Incinerator workers SMR 2.44 (0.06–13.59) Barth et al. 2009 Gulf War RR 0.90 (0.73–1.11) 1.94 (1.12–3.34) Bullman et al. 2005 Gulf War RR Glioma Carrozza et al. 2000 S Firefighters OR 2.7 (0.3–26.1) Krishnan et al. 2003 S Firefighters OR 5.88 (0.70–49.01) Thyroid Bates et al. 2007 K Firefighters OR 1.17 (0.82–1.67) Demers et al. 1994 K Firefighters SIR 0.8 (0.2–4.2) Kang et al. 2008 K Firefighters SMOR 0.71 (0.30–1.70) 1.77 (1.08–2.73) Ma et al. 2006 S Firefighters SIR Lymphatic and Hematopoietic Aronson et al. 1994 K Firefighters SMR 0.98 (0.58–1.56) Beaumont et al. 1991 K Firefighters SMR 0.65 (0.35–1.09) Beaumont et al. 1991 K Firefighters SMR 0.89 (0.24–2.29) Guidotti 1993 K Firefighters SMR 1.27 (0.61–2.33) Tornling et al. 1994 K Firefighters SMR 0.44 (0.09–1.27) Vena and Fiedler 1987 K Firefighters SMR 0.55 (0.18–1.29) 1.30 (1.11–1.51) Burnett et al. 1994 S Firefighters PMR Heyer et al. 1990 S Firefighters SMR 1.26 (0.65–2.22) 0.68 (0.54–0.85) Ma et al. 2006 S Firefighters SIR Elliott et al. 1996 S Incinerator communities SMR 1.01 (0.99–1.03) Michelozzi et al. 1998 S Incinerator communities SMR 1.20 (0.24–3.37) Gustavsson et al. 1989 S Incinerator workers SMR 1.30 (0.16–4.71) Hodgkin’s Disease Aronson et al. 1994 K Firefighters SMR 2.04 (0.42–5.96) Demers et al. 1994 K Firefighters SIR 0.7 (0.0–4.1) Kang et al. 2008 K Firefighters SMOR 1.81 (0.72–4.53) Ma et al. 2006 S Firefighters SIR 0.77 (0.38–1.38) Non-Hodgkin’s Lymphoma Baris et al. 2001 K Firefighters SMR 1.41 (0.91–2.19) Bates et al. 2007 K Firefighters OR 1.07 (0.90–1.26) Demers et al. 1994 K Firefighters IDR 1.8 (0.4–13) Demers et al. 1994 K Firefighters SIR 0.9 (0.4–1.9) Kang et al. 2008 K Firefighters SMOR 0.77 (0.31–1.92) 1.32 (1.02–1.67) Burnett et al. 1994 S Firefighters PMR Ma et al. 2006 S Firefighters SIR 1.09 (0.61–1.80) 1.03 (1.00–1.07) Elliott et al. 1996 S Incinerator communities SMR 2.3 (1.4–3.8) Floret et al. 2003 S Incinerator communities OR Michelozzi et al. 1998 S Incinerator communities SMR 2.51 (0.29–8.51) 1.12 (1.002–1.251) Viel et al. 2008 S Incinerator communities RR 1.27 (p = 0.00003) Viel et. al. 2000 S Incinerator communities SIR Multiple Myeloma Aronson et al. 1994 K Firefighters SMR 0.47 (0.01–2.59)

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101 HEALTH EFFECTS ASSOCIATED WITH COMBUSTION PRODUCTS TABLE 6-2 Continued Study Study Type Population Risk Estimate (95% CI) Baris et al. 2001 K Firefighters SMR 1.68 (0.90–3.11) Bates et al. 2007 K Firefighters OR 1.03 (0.75–1.43) Demers et al. 1994 K Firefighters SIR 0.7 (0.1–2.6) Kang et al. 2008 K Firefighters SMOR 0.76 (0.39–1.48) 1.48 (1.02–2.07) Burnett et al. 1994 S Firefighters PMR Leukemia Aronson et al. 1994 K Firefighters SMR 1.20 (0.33–3.09) Aronson et al. 1994 K Firefighters SMR 1.90 (0.52–4.88) Baris et al. 2001 K Firefighters SMR 0.83 (0.50–1.37) Bates et al. 2007 K Firefighters OR 1.22 (0.99–1.49) Beaumont et al. 1991 K Firefighters SMR 0.61 (0.22–1.33) Demers et al. 1994 K Firefighters SIR 1.0 (0.4–2.1) Demers et al. 1994 K Firefighters IDR 0.8 (0.2–3.5) Kang et al. 2008 K Firefighters SMOR 0.72 (0.43–1.20) Bates et al. 2001 S Firefighters SIR 1.81 (0.5–4.6) Burnett et al. 1994 S Firefighters PMR 1.19 (0.91–1.53) Heyer et al. 1990 S Firefighters SMR 1.73 (0.70–3.58) Ma et al. 2006 S Firefighters SIR 0.77 (0.47–1.19) Michelozzi et al. 1998 S Incinerator communities SMR 0.82 (0.03–4.09) Other Aronson et al. 1994 K Firefighters SMR 1.20 (0.33–3.09) Beaumont et al. 1991 K Firefighters SMR 1.11 (0.76–1.58) Deschamps et al. 1995 S Firefighters SMR 1.18 (0.14–4.27) NOTE: Risk estimates in bold italics denote significant differences in risk. K = key study; S = supporting study. aThe risk estimates included in Table 6-2 reflect the cause-specific mortality or diagnosis for the study population as a whole. Many of these studies also include risk estimates by work duration, time since first exposure, or latency, but those data are not included here. For more detailed results, see chapter text or Appendix C. better exposure assessment, the committee concluded there is no evidence for any one cancer site that rises above the level of inadequate/insufficient. Studies of Gulf War veterans exposed to oil-well–fire smoke also showed no cancer sites of concern, including brain cancer. Based on a review of the epidemiologic literature, the committee concludes that there is inadequate/ insufficient evidence of an association between long-term exposure to combustion products and cancer in the populations studied. ALL-CAUSE MORTALITY Cohort mortality studies often present SMRs for all causes of death combined as well as for specific causes of death. The all-cause SMR is an indication of how healthy the study population is in comparison to the population chosen to represent the background rates of disease. An all-cause SMR serves as a measure of the comparability of the study group with the reference population and can highlight potential biases in the study design and analysis. All-Cause Mortality in Firefighters Occupational cohort mortality studies comparing an employed group with the general population typically report SMRs for all causes of death combined as less than 1.0, indicating that fewer cohort members died than expected after adjusting for age, race, gender, and calendar year. One explanation for the commonly observed deficit is the healthy worker effect, a form of selection bias reflected in the better health status of workers relative to the general population (Fox and Collier 1976). The SMR for all causes of death combined can be interpreted

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102 HEALTH CONSEQUENCES OF EXPOSURE TO BURN PITS TABLE 6-3 All-Cause Mortality Among Firefighters Study SMR (95% CI) Aronson et al. 1994 0.95 (0.88–1.02) 0.96 (0.92–0.99)a Baris et al. 2001 0.90 (0.85–0.95)a Beaumont et al. 1991 0.81 (0.77–0.86)a Demers et al. 1992a 0.52 (0.35–0.75)a Deschamps et al. 1995 0.80 (0.67–0.96)a Eliopulos et al. 1984 Guidotti 1993 0.96 (0.87–1.07) Hansen 1990 0.99 (0.75–1.29) 0.76 (0.69–0.85)a Heyer et al. 1990 0.57 (0.54–0.60)a Ma et al. 2005 0.82 (0.73–0.91)a Tornling et al. 1994 Vena and Fiedler 1987 0.95 (0.87–1.04) aSMR values in bold italics indicate a significant difference. as a measure of the extent of the bias in a particular study (Monson 1986). There is some evidence that health worker effect bias affects chronic disease mortality such as cardiovascular, lung, and digestive diseases more than cancer (Blair et al. 1986). Several of the studies reviewed earlier in this chapter report results for all-cause mortality. In particular, Vena and Fiedler (1987), Hansen (1990), Guidotti et al. (1993), and Aronson et al. (1994), reported SMRs of less than 1.0 with wide confidence intervals that included the null. Eight studies, Eliopulos et al. (1984), Heyer et al. (1990), Beaumont et al. (1991), Demers et al. (1992a), Tornling et al. (1994), Deschamps et al. (1995), Baris et al. (2001), and Ma et al. (2005), and found that overall mortality in firefighters was significantly lower than the reference groups. See Table 6-3 for the all-cause mortality SMRs for firefighters. All-Cause Mortality Among Incinerator Workers and Communities Near Incinerators One study (Gustavsson 1989) reported elevated all-cause mortality for incinerator workers compared to National Swedish mortality rates and to local rates for the greater Stockholm area (SMR 1.13, 95% CI 0.9–1.14, and SMR 0.99, 95% CI 0.79–1.22, respectively). Conclusion The committee concludes that there is insufficient/inadequate evidence to determine whether an association exists between all-cause mortality and exposure to combustion products in the populations studied. SUMMARY The committee studied the epidemiologic literature on exposure to combustion products from sources believed to be relevant to the burn pit exposures at JBB and other bases with burn pits in Iraq and Afghanistan. From that epidemiologic literature, the committee concludes that further study of health effects specifically among OEF/ OIF veterans is necessary. The 2010 joint services report describing several health outcomes in military personnel at bases with and without operating burn pits is a first step in addressing some of these issues but the period of follow-up is too short to detect long-term health effects in this population (AFHSC et al. 2010). Further follow-up of these populations is warranted. The research considered in this chapter is a best attempt to use currently available information on occupational and residential exposures to combustion products to extrapolate to exposures of military personnel stationed at JBB. However, because of differences in exposure parameters, population characteristics, access to medical care, and monitoring of health, the results for firefighters, incineration workers, and people living near incinerators might not be generalizable to military personnel exposed to burn pit emissions. Furthermore, although the dif -

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103 HEALTH EFFECTS ASSOCIATED WITH COMBUSTION PRODUCTS ficulties in determining exposure to burn pits are apparent (see Chapter 4) such assessments are critical if adverse health outcomes that might result from such exposures are to be distinguished from those that might result from deployment per se and desert environments. The committee recognizes that the risks associated with being a fire - fighter, incinerator worker, or living near and incinerator might not provide a comprehensive picture of the risks posed to military personnel from burn pit emissions. Nevertheless, given the lack of information on the health effects associated with such exposures, the committee believes that studies of these surrogate populations provide a reasonable approach for evaluating the long-term consequences of exposure to combustion products similar to burn pit emissions. Based on a review of the epidemiologic literature presented in this chapter, the committee concludes that there is limited/suggestive evidence of an association between exposure to combustion products and reduced pulmonary function in the populations studied. However, there is inadequate/insufficient evidence of an association between exposure to combustion products and cancer, respiratory disease, circulatory dis - ease, neurologic disease, and adverse reproductive and developmental outcomes in the populations studied. REFERENCES AFHSC (U.S. Armed Forces Health Surveillance Center), the Naval Health Research Center, and the U.S. Army Public Health Command. 2010. Epidemiological Studies of Health Outcomes among Troops Deployed to Burn Pit Sites. Silver Spring, MD: Defense Technical Information Center. May. Aronson, K. J., L. A. Dodds, L. Marrett, and C. Wall. 1996. Congenital anomalies among the offspring of fire fighters. American Journal of Industrial Medicine 30(1):83-86. Aronson, K. J., G. A. Tomlinson, and L. Smith. 1994. Mortality among fire fighters in metropolitan Toronto. American Journal of Industrial Medicine 26(1):89-101. Bandaranayke, D., D. Read, and Clare. Salmond. 1993. Health consequences of a chemical fire. Internatinal Journal of Envi- ronmental Health Research 3:104-114. Baris, D., T. J. Garrity, J. L. Telles, E. F. Heineman, A. Olshan, and S. H. Zahm. 2001. Cohort mortality study of Philadelphia firefighters. American Journal of Industrial Medicine 39(5):463-476. Barth, Shannon K., Han K. Kang, Tim A. Bullman, and Mitchell T. Wallin. 2009. Neurological mortality among U.S. veterans of the Persian Gulf War: 13-year follow-up. American Journal of Industrial Medicine 52(9):663-670. Bartoo, Carole. 2010. Soldiers’ mysterious lung disease identified. The Reporter: Vanderbilt University Medical Center’s Weekly Newspaper, February 12. Bates, J. T. 1987. Coronary artery disease deaths in the Toronto Fire Department. Journal of Occupational Medicine 29(2):132-135. Bates, M. N. 2007. Registry-based case-control study of cancer in California firefighters. American Journal of Industrial Medicine 50(5):339-344. Bates, M. N., J. Fawcett, N. Garrett, R. Arnold, N. Pearce, and A. Woodward. 2001. Is testicular cancer an occupational disease of fire fighters? American Journal of Industrial Medicine 40(3):263-270. Beaumont, J. J., G. S. Chu, J. R. Jones, M. B. Schenker, J. A. Singleton, L. G. Piantanida, and M. Reiterman. 1991. An epi - demiologic study of cancer and other causes of mortality in San Francisco firefighters. American Journal of Industrial Medicine 19(3):357-372. Betchley, C., J. Q. Koenig, G. van Belle, H. Checkoway, and T. Reinhardt. 1997. Pulmonary function and respiratory symptoms in forest firefighters. American Journal of Industrial Medicine 31(5):503-509. Biggeri, A., F. Barbone, C. Lagazio, M. Bovenzi, and G. Stanta. 1996. Air pollution and lung cancer in Trieste, Italy: Spatial analysis of risk as a function of distance from sources. Environmental Health Perspectives 104(7):750-754. Blair, A., P. Stewart, M. O’Berg, W. Gaffey, J. Walrath, J. Ward, R. Bales, S. Kaplan, and D. Cubit. 1986. Mortality among industrial workers exposed to formaldehyde. Journal of National Cancer Institute 76(6):1071-1084. Bresnitz, E. A., J. Roseman, D. Becker, and E. Gracely. 1992. Morbidity among municipal waste incinerator workers. American Journal of Industrial Medicine 22(3):363-378. Bullman, T. A., C. M. Mahan, H. K. Kang, and W. F. Page. 2005. Mortality in US Army Gulf War veterans exposed to 1991 Khamisiyah chemical munitions destruction. American Journal of Public Health 95(8):1382-1388. Burnett, C. A., W. E. Halperin, N. R. Lalich, and J. P. Sestito. 1994. Mortality among fire fighters: A 27 state survey. American Journal of Industrial Medicine 26(6):831-833. Calvert, G. M., J. W. Merling, and C. A. Burnett. 1999. Ischemic heart disease mortality and occupation among 16- to 60-year- old males. Journal of Occupational Environmental Medicine 41(11):960-966.

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