EMBARGOED Not for public release before FRIDAY, SEPTEMBER 11, 2020, AT 11:00 A.M. (ET) PREPUBLICATION COPY: UNCORRECTED PROOFS Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations Committee on the Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations Board on Population Health and Public Health Practice Health and Medicine Division A Consensus Study Report of PREPUBLICATION COPY—Uncorrected Proofs THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was supported by Contract Order No. 36C24E18C0068 between the National Academy of Sciences and the Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25837 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2020 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2020. Respiratory health effects of airborne hazards exposures in the Southwest Asia Theater of Military Operations. Washington, DC: The National Academies Press. https://doi.org/10.17226/25837. PREPUBLICATION COPY—Uncorrected Proofs The National Academy of Sciences was established in 1863 by an Act of Congress, signed by Presi- dent Lincoln, as a private, nongovernmental institution to advise the nation on issues related to sci- ence and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medi- cine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encour- age education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www. nationalacademies.org. PREPUBLICATION COPY—Uncorrected Proofs Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on informa- tion gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www. nationalacademies.org/about/whatwedo. PREPUBLICATION COPY—Uncorrected Proofs COMMITTEE ON THE RESPIRATORY HEALTH EFFECTS OF AIRBORNE HAZARDS EXPOSURES IN THE SOUTHWEST ASIA THEATER OF MILITARY OPERATIONS MARK J. UTELL (Chair), Professor of Medicine and Environmental Medicine, Director of Occupational and Environmental Medicine, former Director of Pulmonary and Critical Care Medicine, University of Rochester Medical Center LUNG-CHI CHEN, Professor, Department of Environmental Medicine, New York University Grossman School of Medicine ELLEN A. EISEN, Professor, School of Public Health, University of California, Berkeley MEREDITH FRANKLIN, Associate Professor, Division of Biostatistics, Keck School of Medicine, University of Southern California; Director of MS programs in Biostatistics, Health Data Sciences, and Epidemiology KIRK D. JONES, Clinical Professor, University of California, San Francisco MEREDITH C. MCCORMACK, Associate Professor of Medicine, Johns Hopkins University School of Medicine, Johns Hopkins Bloomberg School of Public Health, Medical Director, Johns Hopkins University Pulmonary Function Laboratory, Vice Chair, American Thoracic Society Committee for Proficiency Standards in Pulmonary Function Testing CECILE S. ROSE, Professor of Medicine, National Jewish Health, Division of Environmental and Occupational Health Sciences, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine FRANK E. SPEIZER, Professor of Environmental Science, Harvard T.H. Chan School of Public Health, Edward H. Kass Distinguished Professor of Medicine, Harvard Medical School ELAINE SYMANSKI, Professor, Center for Precision Environment Health, Department of Medicine, Baylor College of Medicine SVERRE VEDAL, Professor Emeritus, Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington JODY WIREMAN, Environmental Health Advisor, Defense Health Agency Study Staff DAVID A. BUTLER, Scholar and Study Director ELIZABETH BARKSDALE BOYLE, Program Officer CHRISTINA R. SAMUEL, Research Associate REBECCA F. CHEVAT, Senior Program Assistant ANNE N. STYKA, Senior Program Officer KRISTIN E. WHITE, Associate Program Officer ROSE MARIE MARTINEZ, Senior Director, Board on Population Health and Public Health Practice v PREPUBLICATION COPY—Uncorrected Proofs PREPUBLICATION COPY—Uncorrected Proofs Reviewers This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspec- tives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, 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 thank the following individuals for their review of this report: GEORGIANA BROOKE ANDERSON, Colorado State University VICTORIA CASSANO, Performance Medicine Consulting, LLC CAROLYN COMPTON, Arizona State University SARAH C. R. ELGIN, Washington University in St. Louis DIANE GOLD, Harvard University PHILIP I. HARBER, University of Arizona HOWARD KIPEN, Rutgers University School of Public Health PETROS KOUTRAKIS, Harvard University CARRIE A. REDLICH, Yale School of Medicine RICHARD B. SCHLESINGER, Pace University Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft before its release. The review of this report was overseen by SANDRO GALEA, Boston University School of Public Health, and DAVID A. SAVITZ, Brown University. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies. vii PREPUBLICATION COPY—Uncorrected Proofs PREPUBLICATION COPY—Uncorrected Proofs Acknowledgments The committee could not have written this report without the help of a number of people. We wish to par- ticularly thank the presenters and participants in our October 2019 workshop—listed in Appendix A—who shared their expertise and perspectives on respiratory health issues in veterans and the research that might allow a better understanding of them. Drs. R. Loren Erickson and Eric Shuping of the Department of Veterans Affairs also briefed the committee and responded to our follow-up questions. The committee members are very appreciative of the outstanding efforts of the staff of the National Acad- emies of Sciences, Engineering, and Medicine’s Health and Medicine Division, who supported us in our work, David Butler, who served as study director; and Elizabeth Boyle, Christina Samuel, Anne Styka, Kristin White, and Stephanie Hanson, who had a daunting task of identifying and culling the large and complex literature we reviewed and more generally guiding and assisting the committee in its mission.