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Federal Register / Vol. 86, No. 148 / Thursday, August 5, 2021 / Rules and Regulations approximately one year at 15 military sitesincluding Djibouti, Afghanistan Bagram, Khowst, Qatar, United Arab Emirates, Iraq Balad, Baghdad, Tallil, Tikrit, Taji, Al Asad, and Kuwait Northern, Central, Coastal, and Southern regions. The Enhanced Particulate Matter Surveillance Program Report found that exposures in the region may have exceeded military/
national exposure guidelines, including EPAs 24-hr NAAQS for PM2.5 see p.4
and p. 8, Figure 41.
The National Research Council NRC
of NASEM independently reviewed DODs final report in Review of the Department of Defense Enhanced Particulate Matter Surveillance Program Report in 2010.4 The NRC committee highlighted that the EPMSP was one of the first large-scale efforts to characterize PM exposure in deployed military personnel. Despite the practical challenges of conducting this effort in an austere deployment environment, the NRC Report found the results of the EMPSP can be viewed as providing sufficient evidence that deployed military personnel endured occupational exposure to a potential hazard to justify implementation of a comprehensive medical-surveillance program to assess PM-related health effects in military personnel deployed in the Middle East Theater.
The NRC committee noted the EPMSPs approach and methodological techniques preclude comparison to existing literature on air sampling and limit a full understanding of PM
chemical composition. The study also describes the challenges associated with conducting exposure-assessment/health surveillance studies, including related to: The need to have co-deployed medical/public health experts to conduct sampling; limitations in monitoring technologies in harsh environments for which they have not been validated and where they may overestimate concentrations due to bounce-off problems, limitations in DODs health effects studies, difficulties in characterization of exposure of troops to multiple sources dust storms, vehicle emissions, and emissions from burn pits, and potential confounding factors such as smoking. This along with the infrequency of sampling as well as the lack of consideration of other ambient pollutants in the deployment environment make it challenging to fully ascertain the relationship between exposure data and health effects.
4 National Research Council, Review of the Department of Defense Enhanced Particulate Matter Surveillance Program Report 2010, https doi.org/
10.17226/12911.

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Further complicating this interpretation are the paucity of exposure data from earlier conflicts, such as the first Gulf War, that limit understanding of potential chronic health effects.
Despite these limitations, the NRC
committee found that the EPMSP results clearly documented that deployed Service Members deployed in the Middle East are exposed to high concentrations of PM and that the particle composition varies considerably over time and space. Further, the NRC
Report committee concluded that it is indeed plausible that exposure to ambient pollution in the Middle East theater is associated with adverse health outcomes. The health outcomes noted may occur both during service acute as well as manifest years after exposure chronic.
b. 2011 NASEM Report, Long-Term Consequences of Exposure to Burn Pits in Iraq and Afghanistan To further address and investigate this service member exposures, VA
requested that NASEMexamine the long-term health consequences of service members exposure to open burn pits while serving in Iraq and Afghanistan. In NASEMs report, LongTerm Consequences of Exposure to Burn Pits in Iraq and Afghanistan, published in 2011, NASEM concluded that particulate matter from regional sources was of potential importance.5 The report also recommended that VA expand its research studies beyond burn pits to explore the role of a broader range of possible airborne hazards.
c. 2020 NASEM Report Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations In September 2018, the VA Post Deployment Health Services PDHS
requested NASEM to study the respiratory health effects of airborne hazards exposures in Southwest Asia.
Specifically, VA requested NASEM to evaluate the extent to which the existing knowledge base informs the understanding of the potential adverse effects of in-theater military service on respiratory health; identify gaps in research that could feasibly be addressed for outstanding questions;
Review newly emerging technologies that could aid in these efforts, and identify organizations that VA might partner with to accomplish this work.
A NASEM committee was formed to undertake this review, which completed 5 NASEM,
Long-Term Health Consequences of Exposure to Burn Pits in Iraq and Afghanistan 2011, https doi.org/10.17226/13209.

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its work in early summer 2020. On September 11, 2020, NASEM published its findings and recommendations in the report, Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations.6 The NASEM committee focused on hazards associated with burn pit exposures; Excess mortality, cancer, bronchial asthma, chronic bronchitis, sinusitis, constrictive bronchiolitis, and other respiratory health outcomes that are of great concern to veterans; and emerging evidence on respiratory health outcomes in service members from research such as the Millennium Cohort Study, Study of Active Duty Military for Pulmonary Disease Related to Environmental Deployment Exposures STAMPEDE, National Health Study for a New Generation of U.S. Veterans, Comparative Health Assessment Interview CHAI Study, Pulmonary Health and Deployment to Iraq and Afghanistan Objective Study, Effects of Deployment Exposures on Cardiopulmonary and Autonomic Function Study, and research being conducted by the Department of Veterans Affairs VA War Related Illness and Injury Study Center WRIISC Airborne Hazards Center of Excellence AHCE in New Jersey.
The NASEM committee formulated a list of 27 respiratory health outcomes it deemed to be of concern to veterans in its review: Rhinitis, sinusitis, sleep apnea, vocal cord dysfunction, asthma, chronic bronchitis, chronic obstructive pulmonary disease, constrictive bronchiolitis, emphysema, acute eosinophilic pneumonia, hypersensitivity pneumonitis, idiopathic interstitial pneumonia, idiopathic pulmonary fibrosis, pulmonary alveolar proteinosis, sarcoidosis, acute bronchitis, pneumonia, tuberculosis, chronic persistent cough, shortness of breath dyspnea, wheeze, esophageal cancer, laryngeal cancer, lung cancer, oral/
nasal/pharyngeal cancers, as well as changes in pulmonary function and mortality due to diseases of the respiratory system.
The NASEM committee also considered different types and sources of exposure in its review: Exposures associated with military operations in the Southwest Asia theater such as open burn pits, emissions from the 2003 AlMishraq sulfur plant fire, fuels, oil-well fires, nerve agents, and depleted 6 NASEM, Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations 2020, https doi.org/
10.17226/25837.

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