Agent Orange Review Vol. 15, N0. 2 Information for Veterans Who Served in Vietnam August 1999 West Seeks Benefits for Women of Vietnam service on male veterans. Women veterans Vietnam Veterans' Children with Birth were routinely excluded from many studies due to their Defects, Asks for Special IOM Review small numbers. The studies of birth defects among male of Diabetes Vietnam veterans have been mostly negative. These studies have shown that Vietnam service was not associated with an increase in the risk of birth defects, On July 23, 1999, Secretary of Veterans Affairs Togo D. spontaneous abortions, stillbirths, or neonatal deaths. West Jr., announced that the Department of Veterans Affairs would seek the legal authority to provide benefits The VA Environmental Epidemiology Service (EES) for children with birth defects who were born to women recently completed an investigation of reproductive Vietnam veterans. Secretary West also indicated that he outcomes among women Vietnam veterans. This study has asked the National Academy of Sciences (NAS) was not finalized before the completion of the 1998 IOM Institute of Medicine (IOM) for a special review of the report, and consequently it was not reviewed by IOM. evidence regarding diabetes mellitus. This was in response (There is a lengthy article about this study and its findings to a recent study by the National Institute for Occupational in the March 1999 issue of the "Agent Orange Review.") Safety and Health (NIOSH) that suggested a possible link. The Secretary asked that the IOM complete this special The EES study identified a statistically significant review "as soon as possible." increase in the risk of birth defects in women Vietnam veterans. EES investigators also found an increase in the Secretary West said, "To have a child with birth defects risk of severe birth defects. The risk of having a child can be devastating for any family. I am pleased that VA with birth defects was significantly elevated even after can reach out to women veterans of the Vietnam War and adjustment for age, demographic variable, military help them and their children." characteristics, smoking and alcohol consumption of the mothers. Similarly, the risk of having a child with a Secretary West's actions were based, in large measure, severe birth defect was significantly elevated among on the findings and recommendations of the 1999 Agent women Vietnam veterans. Orange Task Force that he established to advise him regarding appropriate action on the IOM report, entitled Based on these findings, the Task Force recommended Veterans and Agent Orange: Update 1998, and other that the Secretary seek statutory authority (from available information. (A lengthy article regarding the Congress) to provide benefits for children with birth IOM report was included in the March 1999 issue of the defects born to women Vietnam veterans. "Agent Orange Review".) Following release of the 1996 IOM report, which Other Information Drove the Decisions, IOM indicated that there is "limited/suggestive" evidence of an Report Secondary association between herbicide exposure and the birth defect spina bifida in the children of Vietnam veterans, The Secretary's actions to seek benefits for certain VA successful sought authority to provide certain benefits children with birth defects and a special IOM review of and services for Vietnam veterans' children with this birth diabetes did not come only from the IOM report. Task defect. Force members had available to them important recent information not available to IOM. The IOM cut-off date Diabetes for the literature reviewed was December 1997, before the NIOSH report was available. A recently published NIOSH morbidity study of two U.S. plants with TCDD-exposed production workers Birth Defects in Offspring of Women Vietnam suggested a possible association between high levels of Veterans TCDD exposure and diabetes. (TCDD is the dioxin contaminant produced during the manufacture of one of Most epidemiologic studies regarding Vietnam the ingredients of Agent Orange.) veterans provide information on the health consequences Department of Veterans Affairs In addition to associations described in occupational category of association for any disease compared with the studies, research investigations examining the association previous report, issued in 1996. Urinary bladder cancer between TCDD exposure and the risk of diabetes in was changed from the category "limited/suggestive veterans have been positive. A recent report of Ranch evidence of no association" to "inadequate/insufficient Hand personnel revealed a modest but statistically evidence to determine whether an association exists" significant increase in prevalence of diabetes in the because studies (including but not limited to new studies) highest-exposure category compared to a well-matched showed non-significant risks, weakening previous comparison group. evidence of no association. A recent study of Australian Vietnam veterans also The IOM, a non-governmental organization under found an increased risk for diabetes among these contract with VA, evaluated the body of scientific veterans, and the Australian government recently evidence to determine what health outcomes may be recognized diabetes for service connection in Australian associated with exposure to Agent Orange and other troops who served in Vietnam. herbicides used in Vietnam. Prior to the publication of the NIOSH study, the 1998 In the 1998 report, the IOM reviewers indicated that IOM update concluded that there is "inadequate/ they found additional support for some previously- insufficient evidence to determine whether an association identified associations, specifically lung cancer, prostate exists" between herbicide/dioxin exposure and an cancer, and spina bifida. The IOM report made several increased risk of diabetes. Under the standards set forth recommendations on research regarding herbicide in Public Law 102-4, the Secretary is to presumptively exposure and diabetes risk. It recommends that a then recognize as service connected only those conditions unpublished NIOSH study of diabetes in dioxin-exposed where the evidence is indicative of a "positive workers in chemical plants be documented more association" between herbicide exposure and the completely and published in a peer-reviewed journal. condition. The IOM also recommends further analyses of the In light of the NIOSH study, Secretary West asked for Ranch Hand data and suggests that consideration be an expedited opinion from the IOM based on the NIOSH given to a combined analysis of the Ranch Hand and data in conjunction with earlier findings. The IOM is NIOSH studies to further examine the possibility that expected to complete the diabetes review by late January herbicide exposure leads to an increased risk of diabetes. 2000. The Ranch Hand Study is an Air Force research effort designed to assess the long-term health consequences of "I requested quick turnaround to determine the herbicide exposure on individuals who served in the unit significance of a recent study of the incidence of diabetes responsible for most of the aerial spraying of herbicides in among certain dioxin-exposed employees" said Secretary Vietnam. West. "We amended our contractual agreement with NAS so veterans do not have to wait two years until the next Although finding that available evidence is insufficient scheduled NAS report for a decision on whether or not a to determine whether an association exists between presumption for diabetes should be established based on herbicide exposure and any forms of skin cancer, the IOM this new evidence." encourages further study of basal and squamous forms of skin cancer incidence among exposed workers and Task Force Personnel Vietnam veterans' populations. The IOM suggested that in any future studies, careful attention should be paid to Kenneth W. Kizer, M.D., M.P.H., then Under Secretary exposure assessment, as well as to controlling for for Health, chaired the 1999 Task Force, appointed by ultraviolet (UV) exposures. The Task Force and the Secretary West. The other Task Force members were the Secretary agreed. VA's Under Secretary for Benefits, General Counsel, and Chief Consultant, Occupational and Environmental Researchers categorize chrondrosarcomas of the skull, Health Strategic Healthcare Group. A Working Group of a type of malignant tumor, with bone cancers even though VA headquarters staff and subject matter experts assisted they resemble soft tissue sarcomas in some respects. Soft the Task Force. tissue sarcomas are recognized by VA for service connection while bone cancers are not. The IOM advises Secretary West asked the Task Force to review the VA that the epidemiologic classification of skull IOM report and make recommendations to him regarding chondrosarcomas should not be used as a substitute for possible VA actions on the findings. The IOM report, released February 11, 1999, contains no major change in 2 the expert judgment of pathologists in individual cases. Veterans and Agent Orange: Update 1996, ISBN 0­ 309-05487-7; 1996, 384 pages, 6 x 9, $49.00, can also be Action Required by Public Law 102-4 purchased from the National Academy Press, at the above address. The Executive Summary of this report is Under Public Law 102-4, the Agent Orange Act of available on-line at http://www, nap.edu/readingroom/ 1991, the Secretary of Veterans Affairs must determine books/veterans/. whether a presumption of service connection is warranted for each disease covered by the report. If