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Federal Register / Vol. 86, No. 148 / Thursday, August 5, 2021 / Rules and Regulations
uranium; regional environmental exposures such as air pollution, particulate matter, biologic agents and allergens, the toxicity of sand and dust;
and occupational exposures such as vapors, gases, dust, and fumes.
The summarized findings of the 2020
NASEM report found that: 1 Of the 27
different respiratory systems and diseases, three respiratory symptoms, i.e., chronic persistent cough, shortness of breath dyspnea, and wheezing, met the criteria for limited or suggestive evidence of an association with service in Southwest Asia whereas the remaining 24 conditions had inadequate or insufficient evidence to determine an association; 2 deployment to the 1990
1991 Gulf War and changes in lung function were determined to have limited or suggestive evidence of no association; and 3 many of the studies that report on these conditions were weakened by bias due to self-selection of the participants and self-reported outcomes and exposures and/or lack of control for confounders such as cigarette smoking.
The 2020 NASEM report stated that, while there was inadequate or insufficient evidence to determine an association between respiratory health outcomes and deployment to Southwest Asia, the existing studies included were limited in the available data in exposure estimation; the availability of pertinent health, physiologic, behavioral, and biomarker data, especially data collected both pre-and post-deployment;
the amount of time that passed since exposure; and use of additional or alternate sources of data that might enrich analyses. The NASEM committee recommended that a new approach was needed to allow researchers to better examine and respond to whether specific respiratory outcomes are associated with deployment.

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d. VAs Review and Analysis of the 2020
NASEM Report: Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations VA adheres to established internal procedure requiring it to review and respond to the recommendations in NASEM reports as outlined in VA
Directive 0215, Management of Reports Issued by the National Academies of Sciences, Engineering, and Medicine.

This VA Directive establishes the process for developing responses to all NASEM studies, whether legally mandated or not. VA is not obligated by statute to provide Congress with VAs response to the 2020 NASEM report.
Pursuant to the VA Directive process, VA convened a workgroup of VA
subject matter experts SMEs in disability compensation, health care, infectious diseases, occupational and environmental medicine, public health, epidemiology, toxicology, and research.
The workgroup convened in early spring of 2021 and was composed of subject matter experts from the Veterans Health Administration and the Veterans Benefits Administration. This workgroup was charged with analyzing the information presented by NASEM
and informing the VA Secretary of its findings. The VA workgroup used the same management, coordination, and collaboration process in responding to NASEM reports that are undertaken and submitted because of legal mandates.
Upon review of the findings and recommendations of the 2020 NASEM
report, the VA workgroup noted that NASEM focused its review on airborne hazards encountered during service in Southwest Asia Theater of Military Operations and Afghanistan but did not opine on the relevance of the literature regarding the potential impact of long-term general population or occupational exposure to ambient levels of particulate matter pollution in nor the mechanistic, animal and toxicologic studies. Other Federal agencies i.e., the Environmental Protection Agency, Occupational Safety and Health Administration, and the National Institutes for Health have explored those relationships in detail. In addition, VA conducted its own review of epidemiological studies of population exposures related to cough, wheeze, and shortness of breath dyspnea. The practice per VA Directive 0215 is that the VA workgroup on NASEM reports reviews pertinent literature that has been published during the time following the NASEM literature review and writing/publication of the report.
VA identified the narrowed focus of the NASEM literature that omitted areas of inquiry that were felt to be relevant to a complete understanding of the hazards associated with respiratory outcomes.

While the 2020 NASEM report concluded there was inadequate or insufficient evidence of an association between airborne hazards exposures in the Southwest Asia theater and subsequent development of rhinitis, sinusitis, and asthma, the report did conclude that certain respiratory symptoms such as chronic persistent cough, shortness of breath dyspnea, and wheeze did have limited or suggestive evidence of an association.
Understanding the immediate needs and concerns of the Gulf War cohort and airborne exposures in service, VA
reviewed the most commonly claimed chronic conditions related to airborne hazards for disability compensation benefits as described further below and found that asthma, sinusitis, and rhinitis were the most commonly claimed and granted respiratory conditions, and these conditions also most closely represented the symptomatology of chronic persistent cough, shortness of breath dyspnea, and wheeze. Sleep apnea was noted as the top claimed and granted respiratory condition. However, VA has not identified literature to support inclusion of sleep apnea as a presumption at this time. VA is currently reviewing the other disabilities reviewed by NASEM
in the 2020 report for consideration for potential presumptive service connection. VA will utilize a phased approach in reviewing these disabilities to explore additional studies and data.
e. VAs Review of Internal Claims Data In response to the 2020 NASEM
report, VA analyzed respiratory claims data for veterans who were deployed to Southwest Asia theater of operations and other locations and compared this data to a similar cohort of veterans who served during the same period but who had never deployed. Based on a review of aggregate claims data see table below, VA observed that the claims rates for rhinitis, sinusitis, and asthma in the combined Gulf War I and GWOT
deployed cohorts were higher than the claims rates of similar non-deployed cohorts. In addition, the serviceconnection prevalence rates, i.e., percentage of cohort population for which VA finds service connection were higher for the deployed cohorts than the non-deployed cohorts.

TABLE 1AGGREGATE DISABILITY CLAIMS DATA BY COHORT
GW 1
deployed Population Size

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GW 1-era nondeployed
750,205

PO 00000

Frm 00046

GWOT
deployed
2,615,287

Fmt 4700

Sfmt 4700

2,450,344

GWOT-era non-deployed 2,599,446

E:FRFM05AUR1.SGM

05AUR1

K2 cohort subset 15,670

Totals across cohorts 8.4 M