VA Presumptions - Fine Particulate Matter
On August 5, 2021, the U.S. Department of Veterans Affairs (VA) established presumptive service connection for asthma, rhinitis, and sinusitis for presumed exposure to fine particulate matter during the Gulf War and post-9/11 Southwest Asia theater of operations, a significant development in recognizing and addressing health concerns related to military service. This was followed up by an April 26, 2022 amendment to add presumptions for nine rare respiratory cancers.
What is Fine Particulate Matter?
Environmental Protection Agency (2023). Particulate Matter Basics.
Fine particulate matter (PM2.5) refers to tiny particles suspended in the air, each measuring 2.5 micrometers or smaller in diameter. These microscopic particles are a diverse mix of solid particles and liquid droplets, originating from various sources such as vehicle emissions, industrial processes, waste burning, and natural sources such as geologic dusts and regional pollutants. The small size of PM2.5 allows them to penetrate deep into the respiratory system when inhaled. The health effects of fine particulate matter are a growing concern, as scientific studies have linked exposure to PM2.5 with a range of adverse health outcomes. These may include respiratory and cardiovascular issues, exacerbation of pre-existing conditions such as asthma and heart disease, and even associations with long-term health problems such as decreased lung function and increased mortality.
The ability of PM2.5 to bypass the body's natural defenses and reach the deeper parts of the lungs and bloodstream underscores the potential risks it poses to human health. Veterans that served in the Southwest Asia theater of operations were likely exposed to dust, sandstorms, military burn pits, and other environmental hazards containing fine particulate matter that exceeded healthy levels. The EPA maintains National Ambient Air Quality Standards (NAAQS) which currently define a healthy exposure to PM2.5 of up to 35 ug/m3 for a 24-hour exposure and up to 9 ug/m3 for a chronic 1-year exposure.
Presumptive Conditions
Particulate matter presumptions by the VA refer to the acknowledgment that certain health conditions are presumed to be service-connected for veterans exposed to fine particulate matter at a specific location and time frame during their military service. The VA has identified specific health conditions associated with exposure to fine particulate matter, granting presumptive service connection for affected veterans.
Chronic Diseases (at any time following separation from a qualifying period of military service)
Asthma
Rhinitis
Sinusitis, to include rhinosinusitis
Cancers (at any time following separation from a qualifying period of military service)
Squamous cell carcinoma of the larynx
Squamous cell carcinoma of the trachea
Adenocarcinoma of the trachea
Salivary gland-type tumors of the trachea
Adenosquamous carcinoma of the lung
Large cell carcinoma of the lung
Salivary gland-type tumors of the lung
Sarcomatoid carcinoma of the lung
Typical and atypical carcinoid of the lung
While this list includes presumed conditions, it is important to bear in mind that there are likely other health conditions associated with respiration of fine particulate matter. Veterans with illnesses resulting from particulate matter exposure that are not yet considered presumptive by VA can still establish service connection on a direct basis.
Eligibility Criteria
To be eligible for the particulate matter presumptions, veterans must have had a qualifying period of service - any period of active military, naval, or air service in:
The Southwest Asia theater of operations on or after August 2, 1990
Iraq
Kuwait
Saudi Arabia
The neutral zone between Iraq and Saudi Arabia
Bahrain
Qatar
The United Arab Emirates
Oman
Gulf of Aden
Gulf of Oman
Persian Gulf
Arabian Sea
Red Sea
The airspace above all these locations
Afghanistan, Syria, Djibouti, or Uzbekistan on or after September 19, 2001
What about other populations exposed to PM2.5?
PM2.5 Concentrations from 15 military bases featured in the DoD’s Enhanced Particulate Matter Surveillance Program (2010)
The decision to focus on a select few cohorts for particulate matter presumptions is a complex one, influenced by factors such as scientific evidence, available data, legislative mandates, VSO influence, available resources, and VA discretion.
Many exposures, especially older ones, lack comprehensive sampling data. The VA has more PM2.5 environmental sampling data from post-9/11 deployments due to the DoD’s Enhanced particulate Matter Surveillance Program (EPMSP), a one year sampling program of 15 military sites in the Southwest Asia theater of operations which measured in-theater concentrations of PM2.5. The sampling program found that exposures in the region consistently exceeded military and national PM2.5 health protective regulations at deployment locations even though particulate matter composition varied considerably over space and time. Furthermore, most of the VAs current epidemiological data is focused on veterans that served in the Persian Gulf and post-9/11 Southwest Asia theater of operations through the VA Airborne Hazards and Burn Pits Center of Excellence(AHBPCE) and Airborne Hazards and Open Burn Pit Registry, which was mandated by Congress in 2013. This data allows more meaningful analysis to be performed than what may be available for other military exposure populations.
In the interim final rule for rare respiratory cancers presumably related to fine particulate matter, one commenter noted that particulate matter and burn pits have affected many other Veterans prior to 1990 - as well as in other locations - and questioned why these presumptions would not apply for all veterans exposed to particulate matter. In response the VA wrote:
“VA’s rulemaking establishes presumptive service connection for nine rare respiratory cancers in association with presumed exposure to fine particulate matter; it does not address the locations or periods of service that qualify for the presumption of exposure to fine particulate matter. Thus, these comments are outside the scope of the present rulemaking. Additionally, we note that the Secretary has made the decision to limit these presumptive conditions to a timeframe and locations during which VA has evidence of relevant levels of fine particulate matter in the air. “
VFEA’s Take
While the VA has made progress in recognizing the health impact of particulate matter exposure, these PM2.5 presumptions do in fact neglect other military exposures that have known and documented exceedances of the EPA NAAQS health protective guidelines for PM2.5, including the NAF Atsugi, Japan cohort. Consistently high PM2.5 levels were recorded in a one-year sampling study at NAF Atsugi, which was a chronic exposure caused by a neighboring incinerator complex that operated over a 21-year time span (1980-2001), affecting veterans, accompanied dependents, and civilians that lived, worked, or went to school on base.
When considering rare respiratory cancers, epidemiological studies have limited use due to low incidence rates, therefore the evaluator must look to the scientific literature -if available- and examine the biological plausibility of any health associations. Given the fact that the VA could not rely on epidemiological data in making the decision to implement rare respiratory cancer presumptions and that the evaluative process could only consider concentration of the fine particulate matter fraction, and not the chemical constituents due to a paucity of PM compositional data which “varied considerably over space and time”, it is unclear why other known exposure populations with documented NAAQS PM2.5 exceedances could not also be extended these presumptions.
Based on the methodology used to decide these presumptions, VFEA finds it sensible for eligibility to be expanded to other service locations with known NAAQS PM2.5 exceedances. This will serve to increase equity within the presumptive process by considering all veterans that have been exposed to PM2.5 or another hazardous pollutant(s) under examination by the VA, with exposure through a similar pathway.
The introduction of particulate matter presumptions by the VA in 2021 is a positive step toward acknowledging and addressing the health concerns of veterans exposed to specific environmental hazards during their service. As new research emerges, more evidence becomes available, and pressure mounts to consider other veteran populations, the VA may expand the presumptive conditions and cohorts covered under these regulations. Veterans and advocacy groups play a crucial role in influencing policy changes and expanding presumptions to cover additional cohorts. By raising awareness, advocating for comprehensive coverage, and pushing for continuous research, the veteran community can contribute to shaping future developments in the VA's approach to toxic exposures.
The New Presumptive Process
With the implementation of the PACT Act in August of 2022, the VA was tasked to form a toxic exposure working group. This new working group, known as the Military Environmental Exposure Sub-Council (MEESC), consists of Veterans Health Administration (VHA) and Veterans Benefits Administration (VBA) personnel that will jointly assess cases of toxic exposures affecting veterans, and their dependents, that occurred during active military, naval, air, or space service. In response to each recommendation made by the working group, the VA Secretary will establish a process to conduct a formal evaluation.
The first conditions proposed for study through the new process were announced on July 26, 2023 when the VA published a notice for plans to assess the possibility of a relationship between acute leukemias, chronic leukemias and multiple myeloma, and exposure to fine particulate matter from airborne hazards and open burn pits for service members who were deployed in the Southwest Asia theater of operations. (READ MORE)