Agent Orange Bracelets

Ordering information, three different kinds will be available, personalized
ones for living and deceased victims and a bracelet honoring Agent Orange
Victims in general

The bracelets are of light weight iodized aircraft aluminum and are $9.45
each including postage.
Colors available are gold , silver or black. Please state which color you
desire.The words Agent Orange will appear on all of the bracelets

For personalized bracelets:

For the Deceased Victims please include birth date, death date and full name
of victim

For the Living Victims please include birthdate and full name of victim

The personalized bracelets can say widow, wife, friend etc. of the victim
Please state which you desire

General bracelets will say "In honor of Agent Orange Victims"

Checks and money order accepted , no credit cards please.

Include the name and address to which the bracelet will be mailed.

All proceeds will go towards to the Quilts of Tears Project, which honors
Agent Orange Victims, as it travels across the country to Vietnam Veterans
Reunions and other Vietnam Veterans events.

Send order to:
Jennie R. Le Fevre
The Quilts of Tears Project
6400 W.Shady Side Rd
Shady Side,MD 20764

June 14, 2001

Director (00/21) In Reply Refer To: 211A

All VA Regional Offices and Centers Fast Letter 01-51

SUBJ: Final Regulatory Amendment: Disease Associated With Exposure to Certain Herbicide Agents: Type 2 Diabetes, 38 CFR §3.309

A final regulatory amendment to 38 CFR §3.309(e), adding Type 2 diabetes to VA's list of diseases for which VA allows presumptive service-connection based on herbicide exposure (including Agent Orange), was published in the Federal Register pages 23166-23169, on May 8, 2001.

Medical Records and Exams

We are projecting receipt of approximately 100,000 herbicide exposure diabetes claims over the next 18 months. Obtaining valuable medical information from veterans’ treating physicians should significantly reduce the number of VA C&P examinations needed for rating purposes. This will reduce the time needed to adjudicate claims and save VA resources as well.

Service Centers in Baltimore, Cleveland and St. Petersburg recently reviewed medical treatment records of claimants who are being followed by VHA in its Diabetes Clinics. These reviews showed that in many Agent Orange/diabetes claims it may not be necessary for Service Centers to order C&P exams. Specifically, the reviews revealed the following information:

· Treatment records are sufficient to establish a diagnosis of diabetes

· Obtaining these treatment records will allow rating of approximately 15-20% of the claims without a C&P examination

· Most of the treatment records demonstrated the existence of secondary cardiovascular, peripheral neuropathy, erectile dysfunction, depression and other possible related conditions

· Reviewing treatment records will better focus the C&P examination request by including noted secondary conditions.

Attached to this letter is a sample of the kinds of records that are available in the diabetes clinic. Records sufficient to rate on secondary conditions may exist in other services of the medical center. You are encouraged to work with your medical centers to obtain existing records prior to ordering an examination.

Your cooperation is required to obtain relevant treatment records and avoid unnecessary exams. Please do not automatically schedule VA examinations to evaluate diabetes claims. Instead it is requested that you do the following:

· Obtain and review VA treatment records concerning diabetes before scheduling an exam.

· Work with your local VA Medical Centers to determine the most effective way to obtain pertinent evidence quickly and easily. Stress that cooperation on their part may reduce their examination workload.

· Obtain and review private treatment records concerning diabetes before scheduling an exam.

· If the evidence of record is adequate for rating purposes except for one or more related conditions (such as vision or cardiovascular problems), only schedule examinations for the conditions where additional information is required.

· Schedule a VA examination to evaluate diabetes or any related complication when the existing evidence of record is inadequate for rating purposes. To help ensure complete examinations specify in the examination request any secondary condition noted in the record review.

Please note the attachment that provides an example of a letter to a doctor requesting information for a diabetes claim. The request incorporates information required for rating purposes. This letter would have to be slightly modified if the request was being submitted to a hospital or clinic versus a doctor, or if the veteran was claiming other conditions in addition to the diabetes.

Effective Dates

The effective date of this regulation is July 9, 2001, and on that date, you should begin processing all pending claims using that effective date. For certain claims received prior to July 9, the future results of the ongoing litigation in Nehmer v. U.S. Veterans' Admin., C.A. No. C-86-6160 (TEH) (N.D. Cal.) may impact the effective date. Therefore, DMO is maintaining records of the cleared EP 685's, that will facilitate readjudication of the effective dates for these claims, if this becomes necessary.

End Product Issues

Current Project SHAD cases using pending EP 685 are to be PCHG'd to EP 683 prior to 7/1/01. Any currently pending EP 683's must be changed or cleared prior to 7/1/01 (there are only ten EP 683's). Do not use EP 683 for any purpose other than control of SHAD claims.

Herbicide Exposure Diabetes Claims Currently Under End Product (EP) 685 Diary Control

Allow the currently existing EP 685 diaries to mature and convert to a pending EP 685 with a date of claim of July 1, 2001. Establish either EP 010/110 or 020, as appropriate, to control the adjudication and to record proper work measurement of these claims. Use the effective date of the regulation (July 9, 2001) as the date of claim for the 010/110 or 020 EP. When the diabetes issue is completed, PCLR the EP 685 at the same time the 010/110 or 020 is cleared by the award or disallowance action.

Herbicide Exposure Diabetes Claims Not Currently Under EP 685 Diary Control

Continue to establish future diaries for claims received after receipt of this letter (with maturing date of 7/9/01). For claims received on or after 7/9/01, use the actual date the claim is received as the date of claim and establish an EP 685 and an 010/110 or 020, as appropriate. When the diabetes issue is completed, PCLR the EP 685 at the same time the 010/110 or 020 is cleared by the award or disallowance action.

We will exclude pending EPs 685 from the MMWR to avoid temporarily overstating the total pending work. By using the companion EP 685, we will be able to track herbicide exposure diabetes claims, while accurately reflecting claims processing timeliness and recording appropriate work measurement credit.

Annotating ratings for diabetes claims due to herbicide exposure

VBA's Data Management Office (DMO) will collect data from all rating decisions that involve diabetes claims due to herbicide exposure. In order to capture this data accurately, it is imperative that you annotate all rating decisions that involve diabetes claims due to herbicide exposure. Only through strict compliance with this directive will there be credible data. By using the standard phraseology (i.e. "Service connection for diabetes [or _______ secondary to diabetes] associated with herbicide exposure”) in these ratings the field stations will not be asked to subsequently prepare time-consuming data collection reports on this issue. Uniform phraseology is required in the "decision" and “coded” portions of these ratings. These annotations are required, whether ratings are done using “old” RBA or RBA 2000. (NOTE: These entries are for statistical purposes only; they are not subject to STAR review)

¨ For grants of SC, including secondary conditions: "Service connection for diabetes [or _______ secondary to diabetes] associated with herbicide exposure is granted with a __% evaluation effective Month Day, Year."

¨ For denials: "Service connection for diabetes associated with herbicide exposure is denied because (state the reason for the denial)." For example, if service connection is denied because the veteran did not service in country your denial would look like this:

Decision:

“Service connection for diabetes associated with herbicide exposure is denied because the veteran did not serve in the Republic of Vietnam during the Vietnam Era.”

NOTE: Whether using “old” RBA or RBA 2000 you need to put this phraseology in the “decision” portion of the rating.

¨ When using “old” RBA and RBA 2000 insert "(herbicide)" in the coded conclusion after the diagnosis. For example:

7913 Diabetes mellitus (herbicide)

40% from 07-09-01

IMPORTANT REMINDER: When using “old” RBA, make sure that you include the proper phraseology in the “decision” and the “(herbicide)” annotation in the coded conclusion. Both of these annotations should be done while in the front end of RBA. Make sure that you upload the rating into the Oracle database. Annotations made in the word document will not allow DMO to collect data accurately.

Similarly, when using RBA 2000 make sure that the proper annotations are made before sending the rating to the corporate database. That means you should attach the annotations described above next to the claimed condition in both the “subject” box and “diagnosis” box of the issue management screens. All annotations must be made before you are in the word document.

As mentioned above, there must be strict compliance with this directive in order to prevent the need for additional time-consuming data collection attempts in the future.

Questions

If you have questions concerning this regulation or this letter please note the Calendar Pages for this date on our Intranet Site at:

http://vbaw.vba.va.gov/bl/21/calendar/index.htm.

Rescission Date

This letter is rescinded effective June 1, 2002.

/s/

John F. McCourt, Acting Director

Compensation & Pension Service

Attachments

REGULATORY AMENDMENT

3-01-4

Regulation affected: 38 CFR §3.309

Effective Date of Regulation: July 9, 2001

Date Secretary Approved Regulation: April 19, 2001

Federal Register Citation: 66 FR 23166

The purpose of the following information on this new VA regulation is to inform all concerned why it is being promulgated. This information is not regulatory.

The Department of Veterans Affairs (VA) has amended its adjudication regulations concerning presumptive service connection for certain diseases for which there is no record during service. This amendment is necessary to implement a decision of the Secretary of Veterans Affairs under the authority granted by 38 U.S.C. 1116 that there is a positive association between exposure to herbicides used in the Republic of Vietnam during the Vietnam era and the subsequent development of Type 2 diabetes. The intended effect of this amendment is to establish presumptive service connection for that condition based on herbicide exposure.

Approved: April 19, 2001.

Anthony J. Principi,

Secretary of Veterans Affairs.

For the reasons set forth in the preamble, 38 CFR part 3 is amended as follows:

PART 3--ADJUDICATION

Subpart A--Pension, Compensation, and Dependency and Indemnity Compensation

1. The authority citation for part 3, subpart A continues to read as follows:

Authority: 38 U.S.C. 501(a), unless otherwise noted.

2. In Sec. 3.309, paragraph (e), the listing of diseases is amended by adding ``Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes)'' between ``Chloracne or other acneform disease consistent with chloracne'' and ``Hodgkin's disease'' to read as follows:

Sec. 3.309 Diseases subject to presumptive service connection.

* * * * *

(e) * * *

Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes)

* * * * *

(Authority: 38 U.S.C. 501(a) and 1116).

Dear Dr. Example:

John Smith (fill-in veteran's name), date of birth, (fill-in veteran's date of birth) has applied for disability benefits related to his diabetes. He reported receiving care from you for his diabetes from (fill-in date range). VA needs the information requested in this letter to make an informed decision on the veteran's claim.

What Are We Requesting?

As a service to the veteran, we would appreciate your furnishing without charge:

· Copies of treatment reports and diagnostic test results related to the diabetes and any associated complications for the date range noted above

· Specific information about the level of impairment caused by the diabetes and any related condition

What Specific Information Do We Need?

We need specific information about the veteran's diabetes, including:

· How the diabetes is managed (by restricted diet, oral hypoglycemic agent, insulin, and/or restriction of activities)

· The required frequency of insulin injections (if applicable)

· The frequency of visits to a diabetic care provider

· The frequency of ketoacidosis episodes or hypoglycemic reactions requiring hospitalization

· Whether or not the veteran suffers from progressive loss of weight and

strength

· The severity of any related complications (such as cardiovascular,

visual, neurologic, nephrologic or foot disorders)

Will Your Patient's Privacy Be Protected?

VA will protect your patient's privacy. On the enclosed authorization form, Mr. Smith (fill-in veteran's name) has consented to your giving us information concerning this treatment and has waived any privilege which renders such information confidential. Collection of this information by VA is authorized by law (38 CFR Sec. 3.326). This information may only be disclosed by VA as allowed by law (38 CFR Sec. 1.526-1.584).

Conclusion

We are sending this letter in duplicate so that you may retain a copy. We have also sent a copy of this letter to the veteran. A pre-addressed postage-paid envelope is enclosed for your convenience. VA cannot pay for copies of medical records (38 CFR Sec. 3.159). If you have any questions about this letter, please call (provide appropriate phone number).

Thank you for your time and consideration. Your assistance in this matter is greatly appreciated.

Sincerely Yours,

I. M. Yorfrend

Veterans Service Center Manager

Enclosures: Return Envelope

Duplicate Letter

Authorization for Release of Information

05/03/2001 11:21

CONFIDENTIAL AD HOC SUMMARY pg. 2 *

DOB:

----------- CP Comp.-& Pen. Exams (max 10 occurrences or year) ----------(continued)

DD: 02/16/2001 DT: 02/17/2001 INFOPRO

END CONFIDENTIAL AD HOC SUMMARY pg. 2

Date: MAY 3,2001 Compensation and Pension Exam Report Page: 1

** REPRINT OF FINAL

Processinq time: 13

For DIABETES-MELLITUS Exam

Name: SSN:

C-Number:

DOB:

Address:

Res Phone:

Bus Phone:Unknown

Entered active service: XXX XX,1966 Last rating exam date:

Released active service: XXX XX,1968

Priority of exam: Increase

Examining provider:

Examined on: FEB 16,2001

======= ----------------

Examination results:

Read note on General Medical

This exam has been reviewed and approved by the examining physician.

VA Form 2507

Date: MAY 3,2001 Compensation and Pension Exam Report Page: 1

REPRINT OF FINAL

Processing time: 13

For GENERAL MEDICRL EXAMINATION Exam

Name: SSN:

C-Number:

DOB:

Address:

Entered active service: XXX XX,1966 Last rating exam date:

Released active service: XXX XX, 1968

Priority of exam: Increase

Examining provider:

Examined on: FEB 16,2001

Examination results:

NAME OF PATIENT:

SOCIAL SECURITY

DATE OF EXAMINATION:

C NUMBER:

TYPE OF EXAMINATION: GENERAL MEDICAL EXAMINATION.

PLACE OF EXAMINATION: XXXXXXXX VA.

The C-file was available and reviewed.

HISTORY: is a 56-year-old and his general remarks states that

the veteran is claimaing service connection for diabetes and that the service records be reviewed to find out whether the diabetes it is onset in the service or within one year of discharge. tells me that he was diagnosed with diabetes about two years ago. He is currently on insulin, 30 units of insulin NPH in the morning and he says that he gets about one to two hypoglycemic reactions a week. He is on a diabetic diet. He denies any history of hypertension or heart disease. H does have diabetic retinopathy and has had laser treatment. He had an amputation of the right biq toe about two to three months aqo, was hospitalized at the XXXXX VA Hospital in XXXXXXX. He also has a Proteinuria and he has numbness, tinqling, and decreased feeling in both feet. His other medical problem is significant for hypothyroidism,for which he takes Tevothyroxine-0.025 mg per day.

MEDICATIONS: His other medications include,

1 Ibuprofen 600 mq.

2: Lisinopril 10 m§ per day.

3. Celexa 40 mg per day.

Continued on next page

VA Form 2507

C&P Reprint of Final Report Page: 2

Name:

For GENERAL MEDICAL EXAMINATION Exam

Exam Results Continued

OCCUPATION: Unemployed.

PHYSICAL EXAMINATION: He is 6 feet tall and weighs 190 pounds. Blood Pressure is 130/60 mmHg. He is right handed. Lungs are clear bilaterally. Neck, no JVD. Heart; regular rate and rhythm with no gallops or murmurs. Abdomen, soft and nontender. Feet, amputated right big toe, callus on the left big toe, normal pedalis pedis pulses, decreased sensation to touch.

LABORATORIES: Done 01/2001, urinalysis revealed 1+ proteinuria, in 10/2000 BUN was 11 and creatinine 0.8.

DIAGNOSES: Insulin-dependent-diabetes mellitus with a diabetic retinopathy, neuropathy, and nephropathy.

Review of his records fails to show that he had diabetes while he was in the service. In fact in 05/09/1968, a urinalysis did not show any glycosuria and a fasting blood sugar was normal.

DD: 02 16 2001

DT: 02 17 2001

INFOPRO@/JO

This exam has been reviewed and approved by the examining physician.

VA Form 2507

FORM 10-1338 WORK COPV

MD CLINICAL LABORATORY REPORT

05403@2001 12:53 pm

SC SEX: M AGE: 56

LOC:

Provider-I

Specimen: URINE

AcceBSiOh [UID]: BUR 0105 58 -

- 01/05 2001 13:05

Test name - Result units Ref. range

URINE COLOR YELL

WORK COPY - DO NOT FILE - 05/03/2001 12:53 pm

FORM 10-1338 WORK COPY-

CLINICAL LABORATORY REPORT

05603@2001 12:53 pm

SSN: SEX: M AGE: 56 LOC: B RO

CONTINUATION OF BUR 0105 58

APPEARANCE CLEAR

SPECIFIC GRAVITY 1.020 1.005 1.035

URINE PH 5.50 5 - 8

UROBILINOGEN 0.2 .2 - 1

URINE BILIRUBIN NEGATIVE - ne7

URINE PROTEIN 1+ neg - 1

URINE BLOOD 1+ H - neg

URINE GLUCOSE 3+ H - neg

URINE KETONES NEGATIVE - neg

URINE NITRITE NEGATIVE - neg

LEUKOCYTE.ESTERASE NEGATIVE - neg

URINE WBC/HPF NoneObs hpf 0 -

URINE RBCYHPF 1-4 h f 0 -3 lp

URINE CASTS/LPF NoneObs pf

URINE CRYSTALS NoneObs riax=4+

URINE YEAST NoneObs max=4+

URINE BACTERIA NoneObs max=4+ noneobs - 1+

URINE MUCUS NoneObs max=4+

SQUAMOUS EPITHELIAL 1-3 #/hpf

TRICHOMONAS NoneObs noneobs

KEY: "L"=Abnormal low, "H"=Abnormal high, "*"=Critical value

Department of Diagnostic Radiology and Nuclear Medicine - VAMC

Pat *UROGRAM INTRAVENOUS Phy

SSN Date-. 7,2001 08:50 Service:

AGE:56 case Inst: MD

DOB: Reported: Jan. 17,2001

Ward/Clinic:BT UROLOGY Radiographer:

Date Transcribed:JAN 17,2001 19:18

OLD STUDY DATE:

(Case 30342 COMPLETE)UROGRAM INTRAVENOUS (RAD Detailed) CPT:74400

Proc Modifiers CONTRAST MEDIA USED CPT Modifiers None

Clinical Historv:

56 yobm with microscopic hematuria. R/O mas vs stones

Report:

see impression.

impression:

Survey films of the abdomen show a cluster of calcifications to the right of Ll compatible with pancreatic calcifications suggesting previous pancreatitis. Non-ionic aqueous contrast was infused intravenously without reaction. Renal size and contour are within normal limit. The calyces, pelves, and ureters are unremarkable. The bladder size and contour are within normal limits. There is a small post void residual.

IMPRESSION: No diagnostic abnormality.

mts/ka

Primary Interpreting Staff

/DMP

PT NAME Ss verifier

LOC:BT xAuiuLuGY Ward/Clinic:BT UROLOGY-

RADIOLOGY REPORT Page 1

VAF 10-9034 VICE SF 519B RADIOLOGY/NUCLEAR MEDICINE REPORT

CONFIDIENTIAL AD HOC SUMMARY pg. 1 ******* * ** *

------------- PN - Progress Notes (max 10 occurrences or 1 year) -----------03/30/2001 10:04

TRIAGE NOTE

Title: ECS 10/10

1. MAJOR COMPLAINT: LOW BACK PAIN X2 WKS. NOT RELIEVED WITH REST, HEAT

MOTRIN. DENIES TRAUMA

2. Was visit today as a result of injury? []YES [X]NO

3. ALLERGIES: Patient has answered NKA

4. VITAL SIGNS:

TEMPERATURE: 97.5 F (3/30/2001 10:03)

PULSE: 87

RESPIRATIONS: 20

BLOOD PRESSURE: 146/70

PULSE OX:

WT: 194.5 lb [88.4 kg]

[]PAIN Level(1-10): 9 (03/30/2001 10:03)

5. ORTHOSTATIC VITALS:

LYING:

SITTING:

STANDING:

6. AGE: 56 7. SEX: MALE

8. CURRENT MEDS: Active Outpatient Medications (including Supplies):

Active Outpatient Medications Status

-----------------

1) ALCOHOL PREP PAD (EACH) USE AS DIRECTED BEFORE ACTIVE

MEALS

2) CITALOPRAM 40MG TAB (CELEXA) TAKE 1 TABLET(S) ACTIVE

EVERY DAY

3) IBUPROFEN 600MG TAB TAKE ONE TABLET THREE TIMES A DAY ACTIVE

WITH FOOD WHEN NEEDED FOR PAIN

4) INSULIN NPH (HUMAN) INJ (NOVO) INJECT 30 units UNDER ACTIVE

THE SKIN EVERY DAY

5) INSULIN SYRINGE U100 lml (EACH) USE AS DIRECTED FOR ACTIVE

INSULIN INJECTION

6) LANCET EACH) USE AS DIRECTED BEFORE MEALS ACTIVE

7) LIFES ONE'TOUCH BLD GLUC TEST (STRIP) USE AS ACTIVE

DIRECTED BEFORE MEALS

8) LISINOPRIL 10MG TAB TAKE ONE TABLET EVERY DAY ACTIVE

9) RANITIDINE 150MG TAB TAKE 1 TABLET TWICE A DAY ACTIVE

9. PROBLEMS: Dental Caries

10. ON ARRIVAL PATIENT WAS: [X]AMBULATORY []STRETCHER []W/C

11. DIAGNOSTIC TESTS: [ ] X-ray:

[ ]URINALYSIS

[ ]Finger Stick Results:

12. DISPOSITION: []ACUTE [X]NON-ACUTE

CONFIDENTIAL AD HOC SUMMARY pg. 2 ******* * ***

------------- PN - Progress Notes max 10 occurrence or 1 year)

[ ] Referred to Pharmacv Refill

[ ]Referred to Medical-Manaqement

[ ] Referred to PrimarV Care-Intake

[ ]Referred to SATU -

[ ]Referred for PSYCH Evaluation

MEDICATIONS: Title: PHARMACY: MEDICATION MANAGEMENT/PCC

1) NPH INSULIN 30 UNITS DAILY BEFORE BREAKFAST NSULIN STARTED IN 10/00 AT FORD HOWARD, PRIOR TO THIS ON ORAL AGENTS

2) IBUPROFEN 600MO THREE TIMES DAILY WITH FOOD LENEVER NECESSARY FOR

3) LISINOPRIL 10 MGO?D

4) LEVOTHYROXINE 0. 5 MG QD

5) CELEXA 40 MG QD

PMH:1)OSTEOMYELITIS OF THE RIGHT FOOT WITH CELLULITIS (MRSA 4 MONTH HOSPITALIZATION FROM 10/00 12/00: AMPUTED ON BIG TOE ON RIGHT FOOT

2)DIABETIS MELLITUS WITH POLYNEUROPATHY (DX 3 YEARS AGO)

3)HYPERTENSION

4)DEPRESSION

SUBJECTIVE: IS A 56 YEAR OLD MAN HERE FOR THE FIRST TIME TO MEDICATION MANAGMENT FOR MEDICATION REFILLS PRIOR TO BEING SEEN BY PCP IN 7/00. HE WAS RECENTLY DISCHARGED FROM HOSPITAL IN 12/00, AFTER A 4 MONTH STAY FOR OSTEOMYELITIS OF THE RIGHT FOOT WITH CELLTJLITIS (MRSA%-PATIENT STATES THAT HE IS 100% COMPLIANT WITH HIS MEDICATIONS AND SEEMS TO BE TOLERATING HIS MEDICATIONS WELL. PATIENT DENIES ANY RECENT EPISODES OF HYPOGLYEMIA (IE.SWEATING SHAKES AND SWEATS SINCE STARTED ON NPH. HE ALSO DENIES ANY POLYPHAGIA POLYDIPSIA AND POYPHAGIA. HE HAS NOCTURIA ONCE A NIGHT (WHICH IS STABLE), BUT DENIES ANY DYSURIA, HESITANCY UPON BLADDER EMPTYING OR POSTVOIDAL'DRIBBLING. HE STATES HE HAS TINGLING AND PAIN WHICH HE DESCRIBES AS PIN AND NEEDLES IN BOTH FEET (RL) THAT IS RELIEVED WITH IBUPROFEN. CURRENTLY, HE ONLY TAKES IBUROFEN'ONCE A DAY. PATIENT STATES HE DOES NOT EAT CONCENTRATED SWEETS UT DOES ADMIT TO EATING ALOT OF SALT IN HIS DIET. RECENTLY SAW IN EYE CLI,NIC ON 2/1/01 WHERE HE WAS DX WITH VERY SEVERE OU. HE WAS STARTED ON NPH BACK IN 10/00 RE NPDR OU. PATIENT STATES THAT SINCE HE WAS STARTED ON NPH BACK IN 10/00 HE HAS GAINED ABOUT 10 POUNDS. HE ALSO C/O OF INCREASED GAS/BLOATING WITH PAIN IN HIS BACK. HE TAKES MYLANTA WHICH ONLY TEMPORARY [sic] RELIEVES THE PAIN. HIS SYMPTOMS HAVE BEEN GOING ON FOR LAST FEW WEEKS. HE DOES NOT CORRELATE THIS INDEGETION PAIN WITH SPECIFIC FOODS (IE. SPICY FOODS), DESCRIBES THIS AS A HEARTBURN, AND STATES THAT THE PAIN IS

USUALLY WORSE WHEN LYING DOWN.

PATIENT STATES THAT HE WAS DX WITH HYPOTHYROIDISM WHILE HE WAS HOSPITALIZED FOR OSTEOMYEOLITIS. HE CURRENTLY IS ON LEVOTHYROXINE 0.025 MG QD. PATIENT STATES THAT HE IS COMPLIANT WITH HIS LEVOTHYROXINE, BUT DENIES AMV T.T) INTOLERANCE, BUT DOES HAVE INCREASED LETHARGY, BUT DENIES ANY SOB CP, DOE, ORTHOPNEA, PND. PATIENT STATES THAT THE-CELEXA SEEMS TO BE CONTKOLLING HIS MOODS. HE APPEARS TO BE VERY JOVIAL TODAY. HE TAKES THE CELEXA ONCE A DAY IN THE AM IN ORDER TO AVOID
CONFIDENTIAL AD HOC SUMMARY pg- 3 *

------------- PN - Progress Notes max 10 occurrences or year)

INSOMNIA HOWEVER, HIS SEXUAL DISTURBANCES MAY BE RELATED TO HIS CELEXA. WILL BE F/U IN IMPOTENCE CLINIC.

OBJECTIVE:

BLOOD PRESSURE RA SITTING:128/76 PULSE=84

BLOOD PRESSURE LA SITTING:130778 PULSE=82

9/l7/00: HGAIC=10.6%

9 18 00: TSH=0.211 (Prior to starting levothyroxine)

10/31/00:

HGb=14.1

HCT=42.8

MCV=90.4

GLUCOSE=223

BUN=ll

SCR=0.8

K=4.4

1/3/01

S R'--O.9 u

PSA=0.87 PROTEIN 1+

BLOOD 1+

GLUCOSE 3+

HOME BLOOD GLUCOSE READINGS:

FBS (BEFORE BREAKFAST): 110-130 MG/DL

ASSESSMENT:

1) DIABETES: ALTHOUGH HOME FBS (BEFORE BREAKFAST) SEEMS TO BE WELLCONTROLLED, CAN NOT ACCURATETY ASSESS GLYCEMIC CONTROL SINCE PATIENT ONLY SPORADICALLY REPORTS FBS BEFORE BREAKFAST. LAST HBAIC ON 9/17/00 WAS 10.6%. DENIES ANY S/S OF HYPO/HYPERGLYCEMIC EPISOD. PATIENT WITH PERIPHERAL NEUROPATHY ADEQUEATLY CONTROLLED ON IBUPROFEN. TAKING QD. WILL NEED TO REDRAW HBAIC PRIOR TO NEXT CLINIC VISIT AND HAVE PATIENT RECORD FBS BEFORE EVERY MEAL BEFORE ANY MED CHANGES ARE MADE TO HIS DIABETEIC REGIMEN.

2) HYPOTHRYOIDISM: ONLY DOCUMENTED TSH=0.211 PRIOR TO STARTING TX WITH LEVOTHYROXINE. WILL DISCONTINUE LEVOTHYROXINE 0.025 MG QD AND HAVE TSH DRAWN BEFORE NEXT CLINIC VISIT, TO REASSES NEED FOR REINITIATION.

3) DEPRESSSION: WELL-CONTROLLED ON CELEXA. WILL CONT. TX AT THIS TIME. CELEXA MAY BE CONTRIBUTING TO SEXUAL PROBLEMS PATIENT IS EXPERIENCING. (C/0 OF ERECTILE DYSFUNCTION WITH SOME DIFFICUTLY WITH EJACULATION) PATIENT REFERRED TO IMPOTENCE CLINIC BY UROLOGY.

4) POSSIBLE GERD/GASTROPARESIS RELATED TO DIABETES ?: PATIENT EXPERIENCING HEARTBURN, ACIDIDTY STOMACH AND FEELING OF FULLNESS/BLOATING W/O ANY AGGREVATIRG FACTORS. DESCRIBES THIS PAIN DAILY, WHICH IS WORSE'UPON LYING DOWN. WILL BEGIN WITH H2ANT: RANITIDINE'150 MG BID AND REASSESS. MAY NEED TO BE SWITCHED TO PPI IN FUTURE, IF RANITIDINE IS NOT CONTROLLING HIS SYMPTOMS.

5) HTN: GOOD CONTROL ON LISINOPRIL 10 MG QD. ALSO RENOPROTECTIVE SINCE

----------- CP - Comp. & Pen. Exams (max 10 occurrence or 1 year) --------02/16/2001 DIABETES MELLITUS

C NUMBER: TYPE OF EXAMINATION: GENERAL MEDICAL EXAMINATION. PLACE OF EXAMINATION: The C-file was available and reviewed.

medical problem is significant for hypothyroidism, for which he takes levothyroxine 0.02 mg per day.

Neck, no JVD. Heart, regular rate and rhythm with no qallops or murmurs. Abdomen, soft and nontender. Feet, amputated right big toe, callus on the

------------- PN - Progress Notes max 10 occurrence or 1 year) ------------@continued)

5) PATIENT EDUCATION: PATIENT TOLD TO DO FASTING HBGM PRIOR TO EVERY MEAL. DIETARY RESTRICTION AND.EXCERCISE WAS ENCOURAGED

------------- PN Progress.Notes max 10 occurrences or 1 year) ------------continued)

------------- PN - Progress Notes max 10 occurrences or 1 year) ------------@continued)

o&a: after inquiry with patient he stated that he didn't feel kt was necessary at this time. 1 encouraged him to resume kt. his reply was "not now"

o:pt attended kt sporadically for a restorative rx program of ace's to all e's and and training in paralell bars. Pt was instructed to stay off right foot due to toe amputation and diabetes. pt stopped kt in December after having surgery.

a. strenqth & rom in ue's was good.. le's exhibited fair strength with good rom pt Has ind in transfers and w/c mobility was ind. pt was able to amb with crutches at time of discharge. pt was ind in all her activities. p: pt was discharged from kt 12/y5@ no fullow up at this time.

------------- PN Progress Notes max 10 occurrences or 1 year) ------------@continued)

History of Illness: s a 56-vear-old black gentleman with a past medical history or insulin-dependent diabetes. The patient has been a diabetic for approximately two years but only recently started on insulin. The patient presents today complaining of erectile dysfunction, times one year with partial erection and also some difficulty with ejaculation. The patient denies voiding complaints.

Laboratory Data: PSA is 0.87, creatinine is 0.9, UA, trace blood, 10-13 RBCS, and WBCs 4-5.

1 The patient will be scheduled into the Impotency Aid Clinic for his erectile dysfunction.

12/27/2000 16:11 Title: KINESIOTHERAPY CONSULT PATIEIIT WAS SCHEDULED FOR KT AT 10AM AND TO BE SEEN MY

was discharged homelyesterdav, December 22nd. He remained at the hospital for diabetes, cellulitis and right toe amputation. Pt.

demonstrated good progress in his recreational therapy program. He participated in socialization community outings, leisure education special entertainment and cogitative stimulation activities with patient to enhance leisure lifestyle. He seemed very appreciative of the

------------- PN Progress Notes max 10 occurrences or 1 year) ------------@continued)

will hopefully apply the learned recreational activities within the community. There is no additional recreational therapy service needed for at this time; therefore I am discontinuing his recreational therapy services.

DISCHARGE NOTE: PATIENT ALERT AND ORIENTED. RECEIVED MORNING MEDICATIONS AND WAS DISCWARGED AMBULATORY WITH PERSONAL BELONGINGS, MEDICATIONS, AND DISCHARGE INSTRUCTIONS. VS97.6,90,20,145/69.

------------- PN - Progress Notes max 10 occurrences or 1 year) ------------@continued)

******************************************************************* from: http://www.nvlsp.org/nvlsp/spina.htm

Exposure to Agent Orange Outside of Vietnam

Until recently, the VA would grant compensation to veterans exposed to
Agent
Orange (AO) outside of Vietnam only if the claimant proved exposure to
AO
and provided a medical connection between the current disease and that
exposure.

In an apparent effort to equalize the treatment of all veterans exposed
to
AO, the VA recently announced that if exposure outside of Vietnam were
proven, and the veteran had one of the ten diseases presumed by law to
be
related to exposure to AO, the medical connection would be presumed and
the
claim granted unless there were other disqualifying factors. See
comments
on
the final rule adding diabetes to the list of "AO diseases" in 38 C.F.R.
§
3.309(e), at 66 Federal Register, page 23, 166 (May 8, 2001).

In addition, any veteran concerned about exposure to AO during use,
manufacture, testing or transport outside of Vietnam, may be given an AO
physical by the VA and added to the Agent Orange Registry (VHA Directive
2000-027).

The only real issue is proving exposure (all persons who served in
Vietnam
are presumed to have been exposed.) The VA is determining whether
Department
of Defense information is sufficient to add some non-Vietnam units to
the
presumptive exposure list, but none have been added as of June 2001. The
following areas outside of Vietnam have been confirmed as places where
AO
was used:

1. The Korean demilitarized zone in 1968 and 1969 (extensive spraying).

2. Fort Drum, NY in 1959 (testing).

Other areas where veterans allege AO to have been sprayed include:

1. Guam from 1955 through 1960s (spraying).

2. Johnston Atoll (1972-1978) was used for unused AO storage.

3. Panama Canal Zone from 1960s to early 1970s (spraying).
*********************************************************

The Health Benefits Service Center (HBSC) provides veterans, staff, and other stakeholders with consistent, accurate and complete information concerning details of the Veterans Health Care Eligibility Reform Act of 1996 and The Millennium Health Care and Benefits Care Act of 1999.

Live HBSC call agents, using state of the art call center technology, provide real time scripted responses concerning eligibility for medical treatment and services. Agents also answer questions concerning:

The HBSC also transfers calls to VA Medical Centers and other VA entities when appropriate.

The VA Secretary most likely has an email, but it is not public. You can
write or fax him at:
VA Secretary Anthony Principi, Department of Veterans Affairs, 810
Vermont Avenue, Washington, DC 20420.
Fax: 1-202-275-5947

At the VA website you can contact VA, and ask that they forward a message
to Principi. They may or may not?

    Office of Public Affairs
    Media Relations   Washington, DC 20420
   (202) 273-5700
    www.va.govDepartment of
Veterans AffairsNews Release
FOR IMMEDIATE RELEASE
May 8, 2001

Rules Published for VA's Diabetes-Agent Orange Benefits
WASHINGTON - Vietnam veterans with "Type 2" diabetes came closer today to receiving disability compensation from the Department of Veterans Affairs (VA) with the formal publication of the rules that will allow VA to provide benefits to those veterans.

"The hazards of the battlefield include more than bullets and shells," said Secretary of Veterans Affairs Anthony J. Principi. "As our understanding of the health risks faced by our military personnel increases, VA will adjust its programs and benefits to fit the needs of veterans."

Principi's announcement came as the Federal Register today published VA's final rules for benefits for Vietnam veterans with "Type 2" diabetes. Under federal law, those rules don't take effect for 60 days. However, VA offices are already accepting claims from eligible Vietnam veterans.

Veterans affected by the new rules will receive a priority for VA health care, and, depending upon the severity of their illnesses, disability compensation that ranges from $101 to $2,107 monthly.

Today's announcement follows a report in November by the National Academy of Sciences' prestigious Institute of Medicine (IOM) that found "limited / suggestive" evidence of a link between adult-onset, or Type 2, diabetes, and Agent Orange and other herbicides used in Vietnam.

VA estimates that about 9 percent of the 2.3 million Vietnam veterans still alive have Type 2 diabetes. The illness is characterized by high blood sugar levels caused by the body's inability to process the hormone insulin. Approximately 16 percent of veterans currently receiving care in VA medical facilities have been diagnosed with diabetes.

The number of diseases recognized by VA as associated with Agent Orange has steadily increased since the early 1990s. The following conditions are now considered service-connected for veterans who served in Vietnam: chloracne (a skin disorder); porphyria cutanea tarda (a liver disorder); acute or subacute peripheral neuropathy (a nerve disorder); and certain cancers, including non-Hodgkin's lymphoma, soft tissue sarcoma, Hodgkin's disease, multiple myeloma, prostate cancer and respiratory cancers (including cancers of the lung, larynx, trachea and bronchus).

Starting from this date March 28, 2001-all updates will appear first--please read on for past info and websites..Webmaster

1. What veterans will be afected when this condition is added as a presumptive condition for those exposed to herbicides/dioxins?
Honorably discharged veterans who served in the Republic of Vietnam during the period January 9, 1962 through May 7, 1975 and have "adult onset diabetes mellitus." This does not include veterans who served in the Republic of Vietnam druing the period February 28, 1961, to January 9, 1962.

2. What does "presumptive condition" mean?
Normally, the claimant must show proof of relationship between service and the condition being claimed. Under presumption of servic connection, VA presumes the service-connected relationship exists based on the other qualifying criteria, such as dates and location of service and that the condition being claimed, in this case, is associaated with the exposure to Agent Orange.

3. Must I have served "in-country" Vietnam to be eligible?
To have presumptive service connection granted for diabetes mellitus based on Vietnam servic, the claimant must hav served in-country.

4. What does "in-country" mean? What if I served in support of operations in Vietnam, for example, on board a ship in the Gulf of Tonkin?
During the period 1/9/62 through 5/7/75, you must have physically served or visited in the Republic of Vietnam (RVN), including service in the waters offshore if the conditions of service involved duty or visitation in Vietnam. This means the ship must have come to por in the RVN and you disembarked.

5. Will private medical records be accepted as proof of my diabetes? Will I be required to undergo a VA examination?
If private medical records are sufficient, VA can make a determination and grant based on those records. If not, a va examination will be required. Thes records should:

7. My husband died from diabetes and was an in-country Vietnam veteran. Do I now qualify for service connected death benefits (DIC)?
If you believe the cause of death was related to diabetes and the veteran had in-country service, you should contact the local VA office to determine your eligibility.

8. When will my benefits begin if I am granted service-connection for diabetes?
Va must publish regulations to implement this decision. Benefit payments cannot begin prior to the date VA publishes the final regulation concerning this issue. We expect the process to be completed by late Spring 2001.

9. Will I receive retroactive benefits based on a grant of service-connection due to presumptive service in Vietnam?
Generally, no. the regulations will not have a provision for retroactive payment prior to the date the final regulation is published. We note, however that there is pending litigation before a United States distraic court in the case of Nehmer v.U.S. Department of Veterans Affairs, which, depending on the outcome of that case, could result in entitlement to retraoctive benefits for certain individuals who have previously been denied service-connection for their disability.

10. If I am alrady service connected for diabetes, will I get an increase based on this change?
You will not receive any additional benefits as a result of this change. However, if your diabetic conditon has increased in severity since you were last rated by VA, you should contact your local VA office. you can file a claim for a reevaluation and the local VA office can provide assistance with that claim.

11. Will I be eligible for medical treatment?
Even if you decide not to file a claim based on exposure to herbicide, you can still get a free physical examination at the nearest VA Medical Center. You may also be entitled to free ongoing medical treatment at a VA medical facility. You should contact the nearest VA medical facility or you can obtain information and an application for health beefits at the Veterans Health Administration web site at http://www.va.gov.vbs/health/index.htm or by calling 1-877-222-8387.

12. Where can I get a copy of the National Academy of Sciences Study on Herbicide/Dioxin Expousre and Type 2 Diabetes?
You can download a copy of the study from the NAS web site at http://www.nap.edu/html/diabetes .

Vietnam veterans now have a national toll-free helpline to answer their
questions about Agent Orange exposure, healthcare and benefits.
The new helpline, which can be reached at 1-800-749-8387, is part of the
continuing efforts of the Department of Veterans Affairs (VA) to reach America's
2.3 million Vietnam veterans.
Callers to the helpline can speak directly to VA representatives Monday through
Friday from 8 a.m. to 4 p.m. Central Standard Time or they may access the 24
hour automated system 1-800-827-1000. They can also leave voice mail messages to
have information sent to them or listen to recordings about exposure to Agent
Orange, VA benefits, health care and disability compensation.
For more information on VA benefits and programs visit the VA's Web Site
www.va.gov

-------------------------------------------------------------------------------------------

Veterans who are disabled by injury or disease incurred or aggravated during active service in the line of duty during wartime or peacetime service and discharged or separated under other than dishonorable conditions are eligible for monthly payments from the Department of Veterans Affairs (VA).

The amount of these payments, called disability compensation, is based on the degree of disability. For example, a veteran with a 30 percent service-connected disability would receive more money than a veteran with a 10 or 20 percent disability. A veteran who is totally disabled would receive substantially more than a veteran with a lesser disability.

Does exposure to Agent Orange alone qualify Vietnam veterans for disability compensation? No. Mere exposure to Agent Orange and other chemicals used in military service does not automatically qualify Vietnam veterans for compensation.

As mentioned above, payments are based on disabilities. Many Vietnam veterans who were exposed to Agent Orange have no serious medical problems. Some Vietnam veterans have disabilities clearly unrelated to their military service. For example, a Vietnam veteran may have been in an automobile accident l0 or 15 years after leaving military service.

Under the law, disability compensation can only be approved for conditions incurred in or aggravated during military service.

The number of diseases that VA has recognized as associated with, but not necessarily caused by, Agent Orange exposure has expanded considerably during the 1990's. The following conditions are now recognized as service-connected for Vietnam veterans based on exposure to Agent Orange or other herbicides: chloracne (a skin disorder), porphyria cutanea tarda, acute or subacute peripheral neuropathy (a nerve disorder), and numerous cancers [non-Hodgkin's lymphoma, soft tissue sarcoma, Hodgkin's disease, multiple myeloma, prostate cancer, and respiratory cancers (including cancers of the lung, larynx, trachea, and bronchus)].

If a veteran has a disability that he or she believes was caused by Agent Orange exposure or some other aspect of military service, what should he or she do? To receive disability compensation, the veteran must file an application for such benefits. For information or assistance in applying, the veteran can write, call, or visit a Veterans Benefits Counselor at the nearest VA regional office or VA medical center, or a local veterans service organization representative.

What should a veteran do if his or her claim for disability compensation is denied by VA? While VA provides billions of dollars to veterans and their survivors in disability compensation each year, VA does not approve every claim. When a claim is denied, VA provides the applicant with the reason for this action as well as detailed information-regarding appeal rights.

There was a great deal of publicity in May 1989 about a court decision and VA's response regarding VA Agent Orange disability compensation regulations. What was that all about? In early May 1989, the U.S. District Court for the Northern District of California in Nehmer, et al. v. U.S. Veterans Administration, et. al. invalidated a portion of VA regulations concerning the handling of Agent Orange disability compensation claims.

The Court concluded that in the process of deciding which diseases would be recognized as being caused by Agent Orange, VA used a too demanding standard. Rather than using the cause-and-effect standard, the Court indicated that VA should have recognized any disease for which the scientific evidence shows there is a "significant statistical association" with exposure to dioxin.

The Court also ruled that, in determining whether particular diseases should be recognized, VA should have applied the "reasonable doubt" standard used when weighing evidence in individual claims. This long standing VA rule of claims adjudication provides that if the weight of evidence tending to support a claim is in approximate balance with that tending to oppose it, the benefit of doubt goes to the claimant (that is, the veteran or dependent).

Shortly after the Court ruling was issued, Secretary of Veterans Affairs Derwinski announced that VA would not seek appeal of the decision and ordered a prompt revision of the regulations. This involved establishing criteria for determining when a significant statistical association exists and review of scientific and medical studies using the new criteria.

The proposed regulation changes establishing criteria were published in the Federal Register for public comment. (See 54 Fed. Reg. 30099, July l8, 1989). The proposed changes were modified in response to comments received. In October 1989, the final regulation changes were published in the Federal Register. (See 54 Fed. Reg. 40389, October 2, 1989). Proposed and final changes concerning determinations as to particular diseases will also be published.

What should individuals who have filed a claim do in response to this decision? If a veteran or his or her survivor filed a claim with VA for disability compensation or dependency and indemnity compensation (DIC) based on Agent Orange or dioxin exposure and VA has not yet made a decision, no action is required by the person who filed the claim. It will be evaluated based on new VA regulations. If an Agent Orange/dioxin claim, filed after September 25, 1985, was denied by VA, no action is required. It will be re-evaluated based on the new VA regulations.

In either situation, claimants may submit additional supportive evidence. VA is not required to reopen claims filed before September 26, 1985. Individuals who filed claims prior to that date may wish to file new claims. The earlier a claim is filed, the more money the claimant will receive if the claim is approved.

In 1990, Secretary Derwinski made two important announcements regarding disability compensation and Vietnam veterans. Please explain. On March 29, 1990, Secretary Derwinski announced that VA would recognize non-Hodgkin's lymphoma for service connection based on service in Vietnam. On May 18, 1990, Secretary Derwinski announced that VA would recognize soft tissue sarcoma for service connection based on exposure to dioxin-containing herbicides.

The non-Hodgkin's lymphoma decision followed release of results of the Centers for Disease Control Selected Cancers Study which suggested that Vietnam veterans are at increased risk of developing non-Hodgkin's lymphoma. For additional information regarding non-Hodgkin's lymphoma, see Agent Orange Brief, D3. For additional information regarding the Selected Cancers Study, see Agent Orange Brief, C3.

The decision about soft tissue sarcoma was made after the Veterans' Advisory Committee on Environmental Hazards (a group established by law to provide advice to the Secretary of Veterans Affairs) concluded that it is as likely as not that there is a significant statistical association between exposure to a dioxin-containing herbicide and the development of soft tissue sarcoma. For additional information regarding soft tissue sarcomas, see Agent Orange Brief, D4.

In June 1990, the proposed regulations regarding the non-Hodgkin's lymphoma decision were published in the Federal Register for public comment. (See 55 Fed. Reg. 25339, June 21, 1990). In October 1990, the final implementing regulations were published in the Federal Register. (See 55 Fed. Reg. 43123, October 26, 1990).

In February 1991, proposed regulations regarding the soft tissue sarcoma decision were published in the Federal Register for public comment. (See 56 Fed. Reg. 7632, February 25, 1991). In October 1991, the final regulations were published in the Federal Register. (See 56 Fed. Reg. 51651, October 15, 1991).

Were there additional compensation policy changes announced in 1991? Yes. In March 1991, VA published in the Federal Register proposed regulations to extend, from three to nine months, the period during which chloracne must appear following exposure to a dioxin-containing herbicide to establish service-connection. For information regarding chloracne, see Agent Orange Brief, D2. The same proposal declared that there is no significant statistical association between exposure to a dioxin-containing herbicide and porphyria cutanea tarda. (See 56 Fed. Reg.11536, March 19, 1991).

This proposal was based on a recommendation of the Veterans' Advisory Committee on Environmental Hazards. In October 1991, these regulations were finalized and published in the Federal Register. (See 56 Fed. Reg. 52473, October 21, 1991).

On July 1, 1991, Secretary Derwinski announced that VA would propose rules granting service- connection disability status to certain Vietnam veterans with peripheral neuropathy, a nervous system condition that causes numbness and tingling.

How did the Agent Orange Act of 1991 affect disability compensation? Among its key features, Public Law 102-4, the Agent Orange Act of 1991, codified (established in law), with minor modification, the presumptions of service connection for certain diseases associated with herbicide exposure or military service in Vietnam that VA had recently developed. Specifically, a Vietnam veteran disabled by non-Hodgkin's lymphomas, soft tissue sarcomas (with some exceptions), or chloracne (within one year of leaving Vietnam) is presumed to have incurred the disease while on active duty.

In July 1992, a proposed rule implementing the presumptions established by this statute was published in the Federal Register for public comment. (See 57 Fed. Reg. 30707, July 10, 1992). In May 1993, the rule was finalized and published in the Federal Register. (See 58 Fed. Reg. 29107, May 19, 1993).

Public Law 102-4 also established a mechanism to add conditions to those considered to be service connected. The legislation was signed by President Bush on February 6, 1991.

What else happened in 1992 with regard to disability compensation? In January 1992, proposed regulations regarding the peripheral neuropathy decision, based on a recommendation of the Advisory Committee, were published in the Federal Register for public comment. (See 57 Fed. Reg. 2236, January 21, 1992). These regulations were not finalized because of the findings of the National Academy of Sciences. (See below). For additional information regarding peripheral neuropathy, see Agent Orange Brief, D5. In 1993, the National Academy of Sciences released the initial findings of its review of scientific evidence of the health effects of herbicides used in Vietnam. What was the impact on VA compensation policy? On July 27, 1993 (the day the NAS report, Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam, was released), Secretary Brown announced that VA would recognize Hodgkin's disease and porphyria cutarnea tarda for service connection. On September 27, 1993, after further review of the NAS report, Secretary Brown announced that multiple myeloma and respiratory cancers would also be added to the list of conditions presumed to be service connected based on exposure to herbicides which contained dioxin. Peripheral neuropathy was not recognized as service connected because Secretary Brown concluded that a presumption is not warranted based on existing scientific evidence. In making this determination, he gave great weight to the NAS report that indicated that there was inadequate or insufficient evidence to make a determination about the association between herbicides used in Vietnam and the development of this condition. In view of the earlier decision on peripheral neuropathy, Secretary Brown asked the NAS to take a close look at the evidence on this matter during its next review.

The regulations regarding Hodgkin's disease and porphyria cutanea tarda (PCT) were published in the Federal Register as proposed rules in September 1993 and in final form in February 1994. (See 58 Fed. Reg. 50528, September 28, 1993, and 59 Fed. Reg. 5106, February 3, 1994). For additional information regarding Hodgkin's disease, see Agent Orange Brief, D6. For additional information regarding porphyria cutanea tarda, see Agent Orange Brief, D7.

The regulations regarding multiple myeloma and respiratory cancers were published in the Federal Register as proposed rules in February 1994 and in final in June 1994. (See 59 Fed. Reg. 5161, February 3, 1994, and 59 Fed. Reg. 29723, June 9, 1994). For additional information regarding multiple myeloma, see Agent Orange Brief, D8. For additional information regarding respiratory cancers, see Agent Orange Brief, D9.

In January 1994, VA published a notice in the Federal Register that Secretary Brown has determined that a presumption of service connection based on exposure to herbicides used in Vietnam is not warranted for the following conditions: prostate cancer, peripheral neuropathy, hepatobiliary cancers, bone cancers, female reproductive cancers, renal cancers, testicular cancer, leukemia, abnormal sperm parameters and infertility, cognitive and neuropsychiatric disorders, motor/coordination dysfunction, metabolic and digestive disorders, immune system disorders, circulatory disorders, respiratory disorders (other than lung cancer), nasal/nasopharyngeal cancer, skin cancer, gastrointestinal tumors, bladder cancer, brain tumors, and any other condition for which the Secretary has not specifically determined a presumption of service connection is warranted. (See 59 Fed. Reg. 341, January 4, 1994).

How did the Veterans' Benefits Improvements Act of 1994 affect the VA disability compensation program for Vietnam veterans exposed to Agent Orange? Like Public Law 102-4, the Agent Orange Act of 1991, Public Law 103-446, the Veterans' Benefits Improvements Act of 1994; codified (established in law) presumptions of service connection for certain diseases associated with herbicide exposure in Vietnam that VA had recognized administratively. Specifically, Public Law 103-446 codified presumptive service connection for a Vietnam veteran disabled by (1) Hodgkin's disease manifested to a degree of disability of 10 percent or more; (2) PCT manifested to a degree of 10 percent or more within a year of military service in Vietnam; (3) respiratory cancers manifested to a degree of 10 percent or more within 30 years of military in Vietnam; and (4) multiple myeloma manifested to a degree of 10 percent or more.

What happened in 1996 as a result of the second NAS report? How were compensation regulations affected? After careful review of the NAS report, Veterans and Agent Orange: Update 1996, released March 14, 1996, Secretary Brown concluded that acute and subacute transient peripheral neuropathy (if manifested within one year of exposure to an herbicide in Vietnam and resolved within two years of onset) and prostate cancer should be added to the list of conditions presumed to be service connected based on exposure to herbicides which contained dioxin. He also concluded that an appropriate legislation remedy should be enacted on behalf of Vietnam veterans' children who have spina bifida. On May 28, 1996, President Clinton and Secretary Brown announced these decisions at the White House.

The regulations regarding acute and subacute peripheral neuropathy and prostate cancer were published in the Federal Register as proposed rules in August 1996 and in final in November 1996. (See 61 Fed. Reg. 41368, August 8, 1996, and 61 Fed. Reg. 57587, November 7, 1996). For additional information regarding peripheral neuropathy, see Agent Orange Brief, D5. For additional information regarding prostate cancer, see Agent Orange Brief, D10.

In August 1996, VA published a notice in the Federal Register that Secretary Brown has determined that a presumption of service connection based on exposure to herbicides used in Vietnam is not warranted for the following conditions: hepatobiliary cancers, nasal/nasopharyngeal cancer, bone cancer, female reproductive cancers, breast cancer, renal cancer, testicular cancer, leukemia, abnormal sperm parameters and infertility, cognitive and neuropsychiatric disorders, motor/coordination dysfunction, chronic peripheral nervous system disorders, metabolic and digestive disorders, immune system disorders, circulatory disorders, respiratory disorders (other than certain respiratory cancers), skin cancer, gastrointestinal tumors, bladder cancer, brain tumors, and any other condition for which the Secretary has not specifically determined a presumption of service connection is warranted. (See 61 Fed. Reg. 41442, August 8, 1996).

On July 25, 1996, Secretary Brown sent draft legislation to Congress that would provide for health care, vocational training, and a monthly allowance (similar to disability compensation) for Vietnam veterans' children who have spina bifida, a neural tube birth defect. The legislation was introduced in the Senate and House of Representatives on July 31, 1996. In September, Congress approved a similar version of the spina bifida legislation with an effective date of October l, 1997, as part of the VA FY1997 appropriations bill. It became Public Law 104-204 on September 26, 1996, when it was signed by President Clinton.

If a Vietnam veteran receives an Agent Orange Registry examination, does that automatically make him or her eligible for disability compensation? No. Veterans who wish to be considered for disability compensation must file a claim for that benefit. Necessary forms and relevant information about the claims' process can be obtained from a Veterans Benefits Counselor at the nearest VA regional office or medical center. Many Agent Orange Registry participants have no medical problems whatsoever and never file for compensation.

What is the relationship between the VA disability compensation program and the Agent Orange Veteran Payment Program? There is no connection. The Agent Orange Veteran Payment Program was established as a result of settlement of a class action lawsuit brought by Vietnam veterans and their families against the manufacturers of Agent Orange. The application forms, claims processing, eligibility criteria, etc., of these two programs are completely different. For additional information about the class action lawsuit and benefits from its settlement, see Agent Orange Brief, A2, call toll-free 1-800-225-4712, and/or write to the Agent Orange Veteran Payment Program, P.O. Box 110, Hartford, Connecticut 06104.

Where can a veteran get additional information about the VA disability compensation program? Additional information regarding this program is available from Veterans Benefits Counselors at VA regional offices and medical centers throughout the Nation. The telephone numbers can be found in local telephone directories under the "U.S. Government" listings. In most areas, callers can use the following toll-free number: 1-800-827-1000. Veterans service organization representatives also have considerable information on this subject.

Department of Veterans Affairs Agent Orange Brief Prepared by the Environmental Agents Service January D4 VA Central Office, Washington, DC 1997

Soft tissue sarcomas are a group of different types of malignant tumors which arise from body tissues such as muscle, fat, blood and lymph vessels and connective tissues (that is, distinct from hard tissue such as bone or cartilage). These tumors are relatively rare.

In regulations, VA has defined the term "soft tissue sarcoma" to include adult fibrosarcoma; dermatofibrosarcoma protuberans, malignant fibrous histiocytoma, liposarcoma; leiomyosarcoma; epithelioid leiomyosarcoma (malignant leiomyoblastoma); rhabdomyosarcoma; ectomesenchymoma; angiosarcoma (hemangiosarcoma and lymphangiosarcoma); proliferating (systemic) angioendotheliomatosis; malignant glomus tumor; malignant hemangiopericytoma; synovial sarcoma (malignant synovioma); malignant giant cell tumor of tendon sheath; malignant schwannoma, including malignant schwannoma with rhabdomyoblastic differentiation (malignant Triton tumor), glandular and epithelioid malignant schwannomas; malignant mesenchymoma; malignant granular cell tumor; alveolar soft part sarcoma; epithelioid sarcoma; and clear cell sarcoma of tendons and aponeuroses. (See 56 Fed. Reg. 51651, October 15, 1991).

Why are Vietnam veterans concerned about soft tissue sarcomas? The possibility that exposure to phenoxy herbicides, such as Agent Orange, may have caused rare forms of cancer in humans such as soft tissue sarcomas was suggested in 1979 and 1981 by small scale studies conducted in Sweden. These studies showed that persons reporting occupational exposure to phenoxy herbicides may have a 5 to 6 fold higher risk of developing soft tissue sarcomas as compared to persons without such exposure.

Have more recent research results supported or conflicted with the Swedish studies finding regarding soft tissue sarcomas? A number of scientific studies of soft tissue sarcomas among people who may have been exposed to herbicides and/or dioxins have been published in the past few years. Some studies suggested a possible association between these exposures and an increased risk of some cancers, but none showed an increased risk of soft tissue sarcomas of the magnitude cited by the Swedish researchers, and the majority of these investigations showed no association at all.

Mortality studies conducted by Massachusetts and West Virginia indicated that there might be a link between service in Vietnam and soft tissue sarcomas. However, the small number of deaths in the West Virginia study makes it possible that these findings were the results of chance rather than real association.

A New York State study showed that fewer Vietnam veterans died of soft tissue sarcomas than Vietnam-era veterans who did not serve in Vietnam. A study in New Zealand of soft tissue sarcomas and exposure to phenoxy herbicides and chlorophenols, a National Cancer Institute study of agricultural herbicide use and risk of lymphomas and soft tissue sarcomas in Kansas, a western Washington State study, the Department of Veterans Affairs (VA) Vietnam veterans mortality study, two VA studies of the relationship between soft tissue sarcomas and military service in Vietnam, and the Centers for Disease Control Selected Cancers Study have not supported the findings of the Swedish researchers. The VA studies were published in the Journal of Occupational Medicine in December 1986, and the Journal of the National Cancer Institute in October 1987. Very few cases of soft tissue sarcomas are appearing in the Agent Orange Registry. Research on soft tissue sarcomas and other cancers is continuing.

What did the Veterans' Advisory Committee on Environmental Hazards conclude about the relationship between herbicides and soft tissue sarcomas? This VA committee, established by law, met on May 16-17, 1990, to review scientific literature relating to whether there is a significant statistical association between exposure to a dioxin-containing herbicide and subsequent development of soft tissue sarcoma. After considering more than eighty articles, the Advisory Committee concluded that it was as least as likely as not that such an association existed.

Committee members noted that work done in Sweden was strongly compelling for an association while studies done elsewhere not showing an association were also very strong. Members observed that "positive" studies tended to be confined to one geographic area of the world whereas studies involving Vietnam veterans did not find such an association. Several Committee members noted they did not believe that the scientific evidence demonstrated a causal association.

How did VA respond to the Advisory Committee's finding? The day after the meeting, Secretary Derwinski announced that VA would recognize, as service- connected, soft tissue sarcomas based on exposure to dioxin-containing herbicides.

Final rule implementing the Secretary's decision was published in the Federal Register in October 1991. (See 56 Fed. Reg. 51651, October 15, 1991).

What did Public Law 102-4 due for Vietnam veterans who suffer with soft tissue sarcomas? To a large extent, Public Law 102-4, the Agent Orange Act of 1991, enacted February 6, 1991, codified (established in law) the Secretary's decision. However, since there are significant differences in the eligibility requirements for service connection under the rule and the presumptions of service connection established under Public Law 102-4, the rule implementing the new statute was published separately in the Federal Register. (For proposed rule, see 57 Fed. Reg. 30707, July 10, 1992; for final rule see 58 Fed. Reg. 29107, May 19, 1993).

What did the National Academy of Sciences (NAS) conclude about soft tissue sarcomas (STS) in its 1993 report, entitled Veterans and Agent Orange Health Effects of Herbicides Used in Vietnam? The 832-page NAS report contained the following statements: The strongest evidence for an association between STS and exposure to phenoxy herbicides come from a series of case-control studies involving a total of 506 cases conducted by Hardell and colleagues in Sweden that show an association between STS and exposure to phenoxy herbicides, chloropenols, or both. Although these studies have been criticized, the committee feels that there is insufficient justification to discount the consistent pattern of elevated risks, and the clearly described and sound methods employed. These findings are supported by a significantly increased risk in the NIOSH study for the production workers most highly exposed to TCDD , and a similar increased risk in the IARC cohort for deaths that occurred between 10 and 19 years after the first exposure These are the two largest, as well as the most highly exposed occupational cohorts. Some studies in other occupational, environmental, and veterans group showed an increased risk for STS, but the results were commonly non-significant possibly because of small sample sizes related to the relative rarity of STS in the population, except for males in Zone R of Seveso. The risk of this group was significantly elevated and is consistent with the findings supporting an association Evidence is sufficient to conclude that there is a positive association between exposure to herbicides (2,4-D; 2,4,5-T and its contaminant TCDD; cacodylic acid; and picloram) and soft tissue sarcoma. What did the NAS conclude regarding soft tissues sarcomas in its 1996 update? In the 1996 update, the NAS commented that reports issued since the publication of Veterans and Agent Orange provide "additional evidence for an association" between exposure to herbicides and soft tissue sarcomas.

Where can a veteran get additional information on this subject? Information on soft tissue sarcomas and related matters can be obtained at VA medical center libraries, from the Registry Physicians at every VA medical center, or from the Environmental Agents Service (131), Department of Veterans Affairs, 810 Vermont Avenue, N.W., Washington

Department of Veterans Affairs Agent Orange Brief Prepared by the Environmental Agents Service January D3 VA Central Office, Washington, DC 1997

The term "non-Hodgkin's lymphoma" is used to describe a group of malignant tumors that affect the lymph glands and other lymphatic tissue. These tumors are relatively rare (about 3% of all cancers that occur among the U.S. general population), and although survival has improved during the past 20 years, these diseases tend to be fatal.

What prompted initial concerns among Vietnam veterans about non-Hodgkin's lymphomas? The possibility that exposure to phenoxy herbicides such as Agent Orange may have caused rare forms of cancer in humans was suggested in Swedish studies published in 1979 and 1981. Investigations in Sweden reported a six-fold increased risk of malignant lymphomas (Hodgkin's disease and non-Hodgkin's lymphomas combined) among persons occupationally exposed to phenoxy herbicides or chlorophenols compared to persons without exposure.

Have more recent results supported or conflicted with these Swedish studies? An analysis using the New Zealand Cancer registry indicated an elevated risk of malignant lymphomas (including non-Hodgkin's lymphomas, Hodgkin's disease, and multiple myeloma) linked with agricultural occupations; however, further analyses restricted to interviews of non-Hodgkin's lymphoma and control subjects found no significant differences between non-Hodgkin's lymphoma cases and controls regarding their potential exposure to phenoxy herbicides or chlorophenols.

A population-based study in Kansas found a 6-fold excess risk of non-Hodgkin's lymphomas among farmers exposed to herbicides more than 20 days per year (regardless of the number of years of herbicide use) compared to non-farmers. Excess risk of non-Hodgkin's lymphomas in Kansas were associated primarily with long-term use of the herbicide 2,4-D, one of the ingredients of Agent Orange. (This was not the ingredient of Agent Orange which contained TCDD or dioxin which has caused a variety of illnesses in laboratory animals.) Hodgkin's disease was not associated with herbicide use in Kansas.

A study in Washington State demonstrated small but significantly increased risks of developing non-Hodgkin's lymphomas in association with some occupational activities where phenoxy herbicides have been used in combination with other types of chemicals, particularly for long periods. The study results did not demonstrate an association between increased cancer risks and exposure to any specific phenoxy herbicide product alone.

A 1987 study of Swedish pesticide appliers, 72% of whom were exposed also to phenoxy herbicides, found no excess risk of non-Hodgkin's lymphomas or Hodgkin's Disease.

Conflicting results have also been seen in studies of Vietnam veterans. No significant excess mortality from non-Hodgkin's lymphomas was reported among New York State Vietnam veterans, Australian Vietnam veterans, U.S. Vietnam veterans in the Centers for Disease Control (CDC) Vietnam Experience Study or among Air Force "Ranch Hands" who handled and sprayed herbicides in Vietnam. West Virginia Vietnam veterans had an excess of deaths from Hodgkin's disease compared to non-Vietnam veterans. In a mortality study of U.S. Army and Marine Corps veterans, a significantly higher than expected proportion of non-Hodgkin's lymphomas occurred among U.S. Marine Vietnam veterans, compared to Marines who did not serve in Vietnam. When Marine Vietnam veterans were compared with all non-Vietnam veterans combined (Army and Marine), there was no excess of non-Hodgkin's lymphoma deaths. Non-Hodgkin's lymphomas were not elevated among Army Vietnam veterans included in the same study. Army veterans who served in the same geographical area (I Corps) as the Marines experienced no excess of deaths due to non-Hodgkin's lymphomas.

The CDC Selected Cancers Study suggested that Vietnam veterans are at increased risk of developing this disease, but the excess was confined to men who served in the "blue-water" Navy. A VA study published in the Journal of Occupational Medicine in July 1991 indicated that military service in Vietnam did not increase the risk of developing non-Hodgkin's lymphomas.

Does VA recognize non-Hodgkin's lymphomas as service-connected for Vietnam veterans? Yes. On March 29, 1990, Secretary Derwinski announced that VA would service-connect non- Hodgkin's lymphomas based on service in Vietnam. This announcement was prompted by release of results of the CDC Selected Cancers Study which indicated that Vietnam veterans are at increased risk of developing non-Hodgkin's lymphomas. CDC found no evidence that the increased risk was due to Agent Orange. Final regulations implementing Secretary Derwinski's decision were published in the Federal Register in October 1990. (See 55 Fed. Reg. 43123, October 26, 1990).

What did Public Law 102-4, the Agent Orange Act of 1991, do for Vietnam veterans with non-Hodgkin's lymphoma? Section 2, Public Law 102-4, enacted February 6, 1991, established by statute the presumption of service connection for certain diseases including non-Hodgkin's lymphoma manifested to a degree of 10 percent or more -- associated with exposure to certain herbicide agents.

In July 1992, a proposed rule implementing the presumptions established by this law was published in the Federal Register for public comment. (See 57 Fed. Reg. 30707, July 10, 1992). In May 1993, the rule was finalized and published in the Federal Register. (See 58 Fed. Reg. 29107, May 19, 1993).

What did the National Academy of Sciences (NAS) conclude about non-Hodgkin's lymphomas (NHL) in its 1993 report, entitled Veterans and Agent Orange - Health Effects of Herbicides Used in Vietnam? The 832-page NAS report contained the following statements: The production studies suggest an increased risk of NHL from exposure to TCDD-contaminated chemicals, but not of a degree that would allow a definitive statement to be made Thus, taken as a group, the studies of agricultural and forestry workers suggest that there is an association between exposure to herbicides (including 2,4-D) and NHL Although no single (veterans) study shows definite associations between NHL and exposure to herbicides since individual exposures were not determined except for Ranch Hands, none rules out the possibility that an herbicide-related risk of NHL existed for some military personnel during service in Vietnam Thus, unlike most of the other cancers studied by the committee for which the data do not distinguish between the effects of herbicides and TCDD, the available epidemiologic data suggest that the phenoxy herbicides, including 2,4-D; rather than TCDD may be associated with non-Hodgkin's lymphomas Evidence is sufficient to conclude that there is a positive association between exposure to herbicides (2,4-D; 2,4,5-T and its contaminant TCDD; cacodylic acid; and picloram) and non-Hodgkin's lymphoma What did the NAS conclude about non-Hodgkin's lymphomas in its 1996 update? The NAS indicated that "recent scientific literature continues to support the conclusion that there is a positive association between exposure to herbicides and non-Hodgkin's lymphoma."

Where can a veteran get additional information regarding non-Hodgkin's lymphomas? Information on non-Hodgkin's lymphomas and related matters can be obtained at VA medical center libraries, from the Registry Physician at VA medical centers, or from the Environmental Agents Service (131), Department of Veterans Affairs, 810 Vermont Avenue, N.W., Washington, DC 20420.

Department of Veterans Affairs Agent Orange Brief Prepared by the Environmental Agents Service January C3 VA Central Office, Washington, DC 1997

CDC Epidemiologic Study (Epidemiologic Studies of the Health of Vietnam Veterans Mandated by Public Law 97-72 and Public Law 96-151) - This project was actually three studies: the Vietnam Experience Study, designed to evaluate the overall impact of military service in Vietnam on those who served there; the Agent Orange Exposure Study, intended to assess the possible adverse health effects on Vietnam veterans of exposure to the herbicide; and the Selected Cancers Study, designed to determine the risks of developing specific types of cancer among Vietnam veterans. The Department of Veterans Affairs (VA) provided full funding to the Centers for Disease Control (CDC) for this research.

Vietnam Experience Study There were two components of this study: mortality (death) and morbidity (disease).

The mortality effort (Postservice Mortality Among Vietnam veterans) revealed that total mortality in Vietnam veterans was 17% higher than for other veterans. The excess mortality occurred mainly in the first five years after discharge from active duty and involved motor vehicle accidents, suicide, homicide, and accidental poisonings. Thereafter, mortality among Vietnam veterans was similar to that of other Vietnam-era veterans, except for drug-related deaths, which continued to be elevated. An unexpected finding was a deficit in deaths from diseases of the circulatory system among Vietnam veterans.

The excess in postservice mortality due to external causes among Vietnam veterans was similar to that found among men returning from combat areas after world War II and the Korean War. The results of this study component were published in the Journal of the American Medical Association in February 1987. At the same time, CDC published a comprehensive report on this project.

The morbidity component of the Vietnam Experience Study (Health Status of Vietnam Veterans) indicated that the Vietnam and non-Vietnam veterans studied were similar in terms of level of education, employment, income, marital status, and satisfaction with personal relationships. Certain psychological problems, however, were significantly more common among Vietnam veterans than among non-Vietnam veterans. These included depression, anxiety, and alcohol abuse or dependence. About 15% of Vietnam veterans suffered from combat-related post-traumatic stress disorder at some time during or after military service, and 2.2% had the disorder during the month before the examination. During the telephone interview, Vietnam veterans reported current and past health problems more often than did non-Vietnam veterans, although results of medical examinations showed few current differences in physical health. Vietnam veterans had more hearing loss.

Among a subsample of participants who had semen samples evaluated, Vietnam veterans had lower sperm concentrations and lower average proportions of "normal" sperm cells. Despite differences in sperm characteristics, Vietnam and non-Vietnam veterans fathered similar numbers of children.

Children of Vietnam veterans were not more likely to have birth defects recorded on hospital birth records than were children of non-Vietnam veterans. The rates of total, major, minor, and suspected defects were similar among children of Vietnam and non-Vietnam veterans.

The results of the morbidity component were published in the Journal of the American Medical Association in May 1988. CDC published a report (five volumes plus three supplements) on this study component in January 1989.

Agent Orange Exposure Study This study was designed to evaluate the health effects, if any, of possible exposure to herbicides (primarily Agent Orange), utilizing information contained in military records. This component was put on hold in January 1986 because of problems related to the exposure assessment of veterans who served in Vietnam. More specifically, it was determined that a study based solely on military records was not possible because of the considerable potential for misclassification of exposure status.

Subsequently, the Centers for Disease Control conducted a TCDD validation study to compare military records-based estimates with current serum dioxin levels. The results of this study led the Domestic Policy Council's Agent Orange Working Group and the Congressional Office of Technology Assessment to conclude that the Agent Orange Exposure Study cannot be conducted. Consequently, this study was canceled.

The results of the validation study were published in the Journal of the American Medical Association in September 1988. The final report was published by CDC in September 1989.

Selected Cancers Study This study was designed to determine if Vietnam veterans are at increased risk of contracting any of six specific cancers: soft tissue and other sarcomas, non-Hodgkin's lymphomas, Hodgkin's disease, nasal cancer, nasopharyngeal cancer, and liver cancer.

Data collection for this study component began in January 1985. Selected Cancers Study findings, released in March 1990, indicated that Vietnam veterans are at increased relative risk of developing non-Hodgkin's lymphomas. CDC reported that for "men aged 35-59, the age of most Vietnam veterans, the annual risk of developing non-Hodgkin's lymphoma is 1 in 10,000. For Vietnam veterans, the risk appears to be about one and one-half per 10,000."

The higher non-Hodgkin's lymphoma ratio was due to excessive non-Hodgkin's lymphomas among men who served on ships offshore Vietnam. According to the investigators, there was no similar increased risk among veterans who served in locations other than Vietnam. CDC found that Vietnam veterans were not at increased risk for developing any of the other five types of cancers studied.

Because of the difficulty in estimating Agent Orange exposure in individual veterans (see Agent Orange Exposure Study entry above), CDC only indirectly evaluated the effects of such exposure for the Selected Cancers Study. The study did not find any evidence that the increased risk of non-Hodgkin's lymphomas might be due to Agent Orange exposure. In fact, the pattern of risk among subgroups of Vietnam veterans seems to be the opposite of the use of Agent Orange in Vietnam.

CDC published a "Final Report" on this study in September 1990. The study results were also published in the Archives of Internal Medicine in December 1990.

As a result of the findings of the Selected Cancers Study, Secretary Derwinski announced that VA would recognize non-Hodgkin's lymphomas as service-connected for Vietnam veterans. For additional information about this decision, see Agent Orange Brief, B3.

Questions concerning the conduct of the studies described above should be referred to the Centers for Disease Control and Prevention, Atlanta, Georgia 30333.

Air Force Health Study (An Epidemiologic Investigation of Health Effects in Air Force Personnel Following Exposure to Herbicides) In 1979, the Air Force began this epidemiologic study to determine whether long-term adverse health effects exist following contact with herbicides and whether these medical problems can be attributed to occupational exposure to Agent Orange.

The 20-year study consists of mortality and morbidity components with associated follow-up efforts plus reproductive outcome assessments. The investigation focuses on the Air Force personnel attached to Operation Ranch Hand, who were responsible for the great majority of herbicide spraying missions. Members of the Ranch Hand unit had frequent and repeated exposure to Agent Orange. Individuals in the comparison group served in numerous flying organizations that transported cargo to, from, and within Vietnam but were not involved in the aerial Agent Orange spray operations.

Air Force investigators have issued a series of reports, beginning in 1983, describing the study results. The mortality analyses have not shown any differences between the observed and expected number of Ranch Hand deaths from all causes. There were significantly increased Ranch Hand deaths due to digestive diseases. The 1991 mortality report revealed an increased number of deaths due to circulatory system diseases among the non-flying enlisted personnel. This new finding is being investigated further.

Because of the "healthy veteran effect," (that is, only healthy people are allowed to serve in our Armed Forces) both groups are surviving significantly longer than similarly aged civilians.

The initial morbidity assessments showed only minor differences between the Ranch Hands and the comparisons, and these differences were not considered to be indicators of dioxin-related disease. The 1995 update indicated a possible association between dioxin and diabetes and a relationship between dioxin exposure and heart disease.

A report on reproductive outcomes released in 1992 suggested that there is no adverse relationship between dioxin levels and reproductive outcomes. Investigators also reported no relationship between dioxin levels and sperm count or percentage of abnormal sperm.

Mortality reports were published in 1983, 1984, 1985, 1986, 1989, and 1991. Morbidity assessments were released in 1984, 1987, 1990, and 1995. Additional follow-up examinations are scheduled for 1997 and 2002. An evaluation of the relationship between paternal serum dioxin in Ranch Hand veterans and reproductive outcomes was published in 1995.

For additional information regarding the Air Force Health Study, contact the Office of the Surgeon, Bolling Air Force Base, Washington, DC 20332-7050.

CDC Birth Defects Study (Vietnam Veterans' Risks for Fathering Babies with Birth Defects) This study, conducted by the Centers for Disease Control with funding from VA, Department of Defense, and the Department of Health and Human Services, assessed Vietnam veterans' risks for fathering babies with major structural birth defects. Information regarding military service in Vietnam was obtained from interviews with mothers and fathers of babies in case and control groups and from review of military records.

Vietnam veterans did not have an increased risk of fathering babies with defects. Vietnam veterans who had greater estimated opportunities for Agent Orange exposure were not at greater risk for fathering babies with all types of defects combined. The study results were published in the Journal of the American Medical Association in August 1984. CDC published a comprehensive report of the study findings in August 1984.

Agricultural Herbicide Use and Risk of Lymphoma and Soft-Tissue Sarcoma This population-based case-control study of soft-tissue sarcoma, Hodgkin's disease, and non-Hodgkin's lymphomas in Kansas found farm herbicide use to be associated with non-Hodgkin's lymphomas.

This National Cancer Institute study indicated that the relative risk of non-Hodgkin's lymphomas increased significantly with number of days of herbicide exposure per year and latency. Men exposed to herbicides more than 20 days per year (regardless of the number of years of herbicide use) had a 6-fold increased risk of non-Hodgkin's lymphomas relative to non-farmers. Excess risk was associated primarily with long-term use of the herbicide 2,4-D, one of the ingredients of Agent Orange. (This ingredient did not contain the contaminant of Agent Orange known as TCDD or dioxin which has caused a variety of illnesses in laboratory animals.) Soft tissue sarcomas were not associated with herbicide exposure. This study supports findings from Sweden and the U.S. that suggest non-Hodgkin's lymphomas are associated with farm herbicide use.

The results of the study were published in the Journal of the American Medical Association in September 1986.

Soft Tissue Sarcoma and Non-Hodgkin's Lymphoma in Relation to Phenoxyherbicide and Chlorinated Phenol Exposure in Western Washington This National Cancer Institute-funded population-based case-control study was conducted in western Washington State to evaluate the relationship between occupational exposure of men aged 20-79 to certain herbicides and other chemicals and the risks of developing soft tissue sarcomas and non-Hodgkin's lymphomas. Occupational histories and other information were obtained by personal interviews for 128 soft tissue sarcoma cases and 576 non-Hodgkin's lymphoma cases, diagnosed between 1981 and 1984, for 694 randomly selected controls without cancer.

The results demonstrated small but significantly increased risks of developing non-Hodgkin's lymphomas in association with some occupational activities where certain herbicides have been used in combination with other types of chemicals, particularly for prolonged periods. They do not demonstrate a positive association between increased cancer risks and exposure to any specific herbicide alone. Moreover, these findings provide no evidence of increased risks of developing non-Hodgkin's lymphomas associated with chlorinated phenol exposure or of developing soft tissue sarcomas associated with exposure to either class of chemical.

The results were published in the Journal of the National Cancer Institute in May 1987.

In addition to the scientific investigations described above, the Department of Agriculture, Environmental Protection Agency, Armed Forces Institute of Pathology, National Cancer Institute, National Institute for Occupational Safety and Health, and several other Federal agencies are doing or have completed research to discover more about the possible adverse health effects of exposure to Agent Orange and other herbicides used in Vietnam.

According to the final report issued by the Domestic Policy Council's Agent Orange Working Group in 1994, there are 38 ongoing projects and 189 completed projects. The report indicates that over $127 million has been spent on the completed projects and an additional $86 has been spent on the ongoing projects. The report added that an additional $70 million will be required to complete ongoing projects.

A number of States have also conducted research on Agent Orange and Vietnam veterans. Mortality studies of Vietnam veterans were completed in New York, Wisconsin, West Virginia, and Massachusetts. Studies and/or surveys have also been done in Iowa, New Jersey, and several other States. The American Legion also did a study. That veterans group, in concert with two other organizations, sponsored a review of herbicide literature in 1990.

The Department of Veterans Affairs also is closely monitoring research being conducted in other countries as well as studies being done throughout the United States.

NAS Report (Veterans and Agent Orange - Health Effects of Herbicides Used in Vietnam) In 1992, the National Academy of Sciences (NAS), a non-governmental organization, agreed to conduct a multi-year review of all relevant scientific research and provide advice to the Secretary of Veterans Affairs on a wide range of issues relative to herbicides and dioxin. The NAS review is being undertaken in accordance with Public Law 102-4, the Agent Orange Act of 1991, signed by the President on February 6, 1991. The initial NAS report was released in July 1993. The NAS found "sufficient evidence" to conclude that there is a positive association between herbicides and (1) soft tissues sarcoma, (2) non-Hodgkin's lymphoma, (3) Hodgkin's disease, (4) chloracne, and (5) porphyria cutanea tarda (in genetically susceptible individuals).

The NAS also found "limited/suggestive evidence" of an association between exposure to herbicides used in Vietnam and three other types of cancer: respiratory cancers (including lung, larynx, and trachea), prostate cancer, and multiple myeloma.

For most conditions reviewed, the NAS concluded that there was "inadequate/insufficient evidence" to determine whether an association exists. The NAS Committee included the following diseases and disorders in this third category: hepatobiliary cancers, nasal/nasopharyngeal cancer, bone cancer, female reproductive cancers (breast, cervical, uterine, ovarian), renal cancer, testicular cancer, leukemia, spontaneous abortion, birth defects, neonatal/infant death and stillbirths, low birthweight, childhood cancer in offspring, abnormal sperm parameters and infertility, cognitive and neuropsychiatric disorders, motor/coordination dysfunction, peripheral nervous system disorders, metabolic and digestive disorders (diabetes, changes in liver enzymes, lipid abnormalities, ulcers), immune system disorders (immune modulation and autoimmunity), circulatory disorders, and respiratory disorders.

For a small group of cancers, the NAS found "limited/suggested evidence" that there is "no association" with herbicides used in Vietnam. This category included skin cancer, gastrointestinal tumors (stomach cancer, pancreatic cancer, colon cancer, rectal cancer), bladder cancer, and brain tumors. The Committee report noted, however, that even for these conditions "the possibility of a very small elevation in risk at the levels of exposure studied can never be excluded."

The greatest problem encountered in the review was a severe lack of information about the exposure of individual Vietnam veterans to herbicides. Except for particular groups, such as the individuals directly involved in spraying operations, information on the extent of herbicide exposure among veterans is practically nonexistent. Consequently, most studies evaluated by the NAS did not involve Vietnam veterans. Rather, the NAS focused on studies of people who were exposed to herbicides as a result of their jobs or as a result of contact in the environment.

These types of exposures often were at high levels and for long periods of time. Assessing health risks for Vietnam veterans is complicated by the fact that the levels of exposure were extremely wide ranging. While most Vietnam veterans probably had lower exposure levels, some may have experienced levels as high as that of occupational or agricultural exposures. What is uncertain is how many veterans may have been exposed to those higher levels and who those individuals are.

The NAS concluded that a series of epidemiologic studies of veterans could yield valuable information if a new, valid exposure reconstruction model could be developed. The NAS urged the continuation of the Air Force Health Study of Ranch Hand personnel and the expansion of that investigation to include Army Chemical Corps veterans.

The NAS's research recommendations emphasized epidemiologic studies of Vietnam veterans, rather than general toxicologic or epidemiologic studies of occupationally or environmentally exposed populations. A substantial amount of research on the toxicology of herbicides and herbicide components is already under way in the United States and abroad. Many of the studies on which the NAS's conclusions are based have been published since 1991. Although not targeted specifically to Vietnam veterans, it is likely that this ongoing research will also contribute to the knowledge of potential health effects in this population.

The NAS made the following specific recommendations regarding epidemiologic studies of Vietnam veterans:

Recommendation 1. The NAS endorses continued follow-up of the Air Force Ranch Hand cohort and its comparison group, and recommends that members of the Army Chemical Corps and an appropriate comparison group be followed in a similar study. An independent, nongovernmental scientific panel should be established to review and approve a new, expanded research protocol for both study populations, and to commission and direct a common analysis of the results.

Recommendation 2. The Department of Defense and the Department of Veterans Affairs should identify Vietnam service in the computerized index of their records.

Recommendation 3. Biomarkers for herbicide exposure should be developed further.

Recommendation 4. A nongovernmental organization with appropriate experience in historical exposure reconstruction should be commissioned to develop and test models of herbicide exposure for use in studies of Vietnam veterans.

Recommendation 5. The exposure reconstruction models developed according to Recommendation 4 should be evaluated by an independent, nongovernmental scientific panel established for this purpose.

Recommendation 6. If the scientific panel proposed in Recommendation 5 determines that a valid exposure reconstruction model is feasible, the Department of Veterans Affairs and other government agencies should facilitate additional epidemiologic studies of veterans.

The NAS also recommended that priority be given to additional research on reproductive effects that would help clarify the possible effects of herbicides. In particular, the NAS concluded that extensive reanalysis of the Ranch Hand reproductive data could shed additional light on these questions.

The NAS report noted that although there is sufficient evidence of an association between occupational or environmental exposures to herbicides and several conditions, the existing information on dose-response relationships is incomplete, especially with regard to Vietnam veterans. If a valid exposure reconstruction method can be developed, it might be applied to the exposure data available from existing case-control studies to provide additional dose-response evaluations. Additional refinement of the clinical and pathological definitions of soft tissue sarcomas in epidemiologic studies would also help to determine which of the specific cancers in this class are associated with herbicides or TCDD.

The NAS observed that its recommendations for development of a historical exposure reconstruction model and its use in epidemiologic studies might seem at variance with the Centers for Disease Control, White House Agent Orange Working Group, and Congressional Office of Technology Assessment conclusions made in 1986 regarding the congressionally mandated Agent Orange Study. The NAS offered four reasons for the different conclusion:

(1) the 1986 conclusions were based in large part on serum TCDD measurements, which the NAS thinks are insufficient for validating exposure to herbicides used in Vietnam;

(2) the arguments underlying the earlier conclusion that individuals in combat units were widely dispersed and that troop movement data are incomplete imply that exposure measurements may be imprecise, not that they are invalid. However, these arguments do suggest that historical reconstruction of exposure will have nondifferential misclassification errors that will lead to underestimates of the relative risk of health outcomes if an association is in fact present;

(3) the NAS is proposing the use of more, but less formal, information on exposure than was considered in 1986. This includes the development and use of informal information on perimeter spraying, which might account for more meaningful herbicide exposure than the aerial spraying documented on the HERBS tapes; and

(4) the NAS does not know whether the approach it proposes will prove valid or whether new methods will identify a sufficient number of highly exposed Vietnam veterans for an epidemiologic study. In the NAS's judgment, however, the likelihood that this approach will be successful is sufficient for it to be recommended.

The law that mandated the NAS review (Public Law 102-4, the Agent Orange Act of 1991), required that NAS include in the initial NAS report an evaluation of the feasibility and cost-effectiveness of four specific programs that might be implemented by VA. The NAS conclusions are described below.

Section 6 of that legislation requires VA to compile and analyze, on a continuing basis, all clinical data that (1) are obtained in connection with VA examinations and treatment of Vietnam veterans, and (2) are likely to be scientifically useful in determining the association between disabilities experienced by these veterans and exposure to dioxin or herbicides. The NAS report indicated that such a system, called the Agent Orange Registry, currently exists.

Section 7 concerned the establishment of a system for the collection and storage of voluntarily contributed samples of blood and tissue of veterans who served in Vietnam. Balancing the strengths and weaknesses stored biological samples and clinical data for research purposes, the Committee concluded that systems of this sort have scientific value, but only to the extent that they are components of specific, well-designed studies. In the absence of a clear study design to guide such activities, and without resolution of important design, quality control, and ethical issues regarding tissue banks, the NAS did not recommend the establishment at this time of the clinical data (Section 6) and tissue archiving (Section 7) systems described in the law.

Section 8 related to the feasibility of conducting additional scientific research on health hazards resulting from exposure to dioxin and herbicides used in Vietnam. As stated above, the NAS concluded that a series of epidemiologic studies of veterans could yield valuable information if a new, valid exposure reconstruction model can be constructed.

Section 9 would require VA to test for dioxin (TCDD) in any blood sample voluntarily provided by Vietnam veterans who seek VA health care under priority eligibility based on exposure to Agent Orange. The NAS report noted that the purpose of this idea was not stated in the legislation and is unclear. If research purposes are contemplated, the NAS's conclusions about tissue archiving are applicable, and the NAS would not recommend such a program at this time. The NAS realized that such a program might be intended to provide information on individual exposure to dioxins or herbicides to aid in individual compensation decisions. The NAS cannot make recommendations for VA policy but noted that individual TCDD serum levels in Vietnam veterans are usually not meaningful because of common backgrounds exposures to TCDD, poorly understood variations in TCDD metabolism, relatively large measurement errors, and exposure to herbicides that did not contain TCDD.

Follow-up reports by the NAS are planned for once every two years for ten years following the initial report (to the extent appropriations are available).

NAS Report (Veterans and Agent Orange: Update 1996) The first NAS update was considerably shorter than the initial publication (384 pages compared to 832 pages). Unlike the 1992 report, it did not include research recommendations. The same four categories were used to classify health outcomes according to the likelihood of a positive association with herbicide exposure, based on all available research data.

In its initial report, the NAS included the following conditions in category one (sufficient evidence of an association): soft-tissue sarcoma, non-Hodgkin's lymphoma, Hodgkin's disease, chloracne, and porphyria cutanea tarda (PCT), in genetically susceptible individuals. The 1996 update dropped PCT to category two (limited/suggestive evidence of an association). The other four conditions remained in category one, and no additional health outcomes were included in this category.

In the initial report, the NAS included only three health outcomes in category two: prostate cancer, multiple myeloma, and respiratory cancers. Six outcomes were placed in this category in the update. In addition to these three cancers and PCT, the NAS included the following in category two: acute and subacute peripheral neuropathy in Vietnam veterans and spina bifida in the children of Vietnam veterans.

The first report included peripheral neuropathy among "peripheral nervous system disorders," finding that there is inadequate/insufficient evidence to determine whether an association exists (category three). Similarly, spina bifida was grouped with all other birth defects, and the NAS declared that there is inadequate/insufficient evidence to determine whether an association exists.

In the update, the NAS concluded that birth defects (except spina bifida) as well as chronic peripheral nervous systems disorders should remain in category three. Most conditions evaluated in 1996 report (as well as in the 1993 effort) were listed in category three. In the 1996 report the following outcomes were listed in this NAS category: hepatobiliary cancers, nasal/nasopharyngeal cancer, bone cancer, female reproductive cancers (cervical, uterine, ovarian), breast cancer, renal cancer, testicular cancer, leukemia, spontaneous abortion, birth defects (other than spina bifida), neonatal/infant death and stillbirths, low birthweight, childhood cancer in offspring, abnormal sperm parameters and infertility, cognitive and neuropsychiatric disorders, motor/coordination dysfunction, chronic peripheral nervous system disorders, metabolic and digestive disorders (diabetes, changes in liver enzymes, lipid abnormalities, immune systems disorders (immune suppression and autoimmunity), ulcers), circulatory disorders, respiratory disorders, and skin cancer.

The 1996 list for category three is very similar to the list in the 1993 report. The changes are the two noted above (that is, peripheral nervous system disorders and birth defects) plus an elevation of skin cancer from category four.

Few health outcomes were included in category four (limited/suggestive evidence of no association). The 1996 report included gastrointestinal tumors (stomach cancer, pancreatic cancer, colon cancer, rectal cancer), bladder cancer, and brain tumors. The only change from the earlier NAS report in this category was the elevation of skin cancer to category three.

In two years, as required by the Agent Orange Act of 1991, the NAS will re-evaluate current scientific evidence in conjunction with an assessment of new information regarding the possible long-term health consequences of herbicide exposure.

Single copies of the NAS books were distributed to all VA medical center libraries: Organizations or individuals interested in purchasing these documents can contact the publisher: National Academy Press, 2101 Constitution Avenue, N.W. Box 285, Washington, DC 20055. The telephone numbers are 1-800-624-6242 and 202-334-3313. The NAS is a private, nonprofit society of distinguished scholars engaged in scientific and engineering research. Established in 1863, the NAS is dedicated to the furtherance of science and technology and to their use for the promotion of general public welfare.

Where can a veteran get more information about Agent Orange research and studies on related matters?

Information on these subjects can be obtained at the VA medical center libraries, from the Registry Physician or Agent Orange Coordinator at every VA medical center, or from the Environmental Agents Service, (131), Department of Veterans Affairs, 810 Vermont Avenue, N.W., Washington, DC 20420.

Department of Veterans Affairs Agent Orange Brief Prepared by the Environmental Agents Service January D2 VA Central Office, Washington, DC 1997

Chloracne is a skin condition that looks like common forms of acne that affect teenagers. At present, chloracne is the only well established long-term effect of exposure to TCDD or dioxin, the contaminant found in one of the ingredients of Agent Orange.

It is important to note that skin disorders are among the most common health problems experienced by combat forces. Because of the environment and living conditions in Vietnam, veterans developed a variety of skin problems, ranging from bacterial and fungal infections to a condition known as "tropical acne." However, the only skin disorder consistently reported to be associated with Agent Orange and other herbicides is chloracne.

What does chloracne look like and where does it appear? The first sign of chloracne may be excessive oiliness of the skin. This is accompanied or followed by the appearance of numerous blackheads. In mild cases the blackheads may be limited to the area around the eyes extending along the temples to the ears. In more severe cases blackheads may appear in many places on the body, especially over the malar (or cheek bone) area, other facial areas, behind the ears, and along the arms. The blackheads are usually accompanied by fluid-filled cysts and by an increased or darker growth of body hair. The skin may become thicker and flake or peel. In severe cases, the acne may result in open sores and permanent scars. The condition fades slowly after exposure. Minor cases may disappear altogether, but more severe cases may persist for years after the exposure.

Physicians, even dermatologists, sometimes have difficulty in distinguishing chloracne from other more common skin disorders. While chloracne may be a sensitive indicator of exposure to dioxins in some people, it may not be in other individuals who had equal or greater exposure to dioxins.

The absence of chloracne is not necessarily a reliable basis for concluding that a person has not been exposed to a chemical which is known to cause chloracne.

Has chloracne been a problem for a large number of Vietnam veterans? No, it has not. Of course, many veterans have complained of skin problems. Skin ailments are the most common medical problem in veteran and non-veteran populations. After traumatic injuries, skin disorders are among the most common health problems encountered in combat.

What did Public Law 102-4, the Agent Orange Act of 1991, do for Vietnam veterans with chloracne? Section 2, Public Law 102-4, enacted February 6, 1991, established by statute the presumption of service connection for certain diseases including chloracne or another acneform disease consistent with chloracne manifested to a degree of disability of 10 percent or more within a year after military service in Vietnam -- associated with exposure to certain herbicide agents.

In July 1992, a proposed rule implementing the presumptions established by this law was published in the Federal Register for public comment. (See 57 Fed. Reg. 30707, July 10, 1992). In May 1993, the ru1e was finalized and published in the Federal Register. (See 58 Fed. Reg. 29107, May 19, 1993).

VA had recognized chloracne as service connected for Vietnam veterans based on exposure to Agent Orange for many years prior to the enactment of this legislation.

What did the National Academy of Sciences conclude about chloracne in its 1993 report, entitled Veterans and Agent Orange - Health Effects of Herbicides Used in Vietnam?

The 832-page report included the following statements: In summary, chloracne has been linked to TCDD exposure in numerous epidemiologic studies of occupationally and environmentally exposed populations. The data on Vietnam veterans potentially exposed to Agent Orange and other herbicides are less convincing Evidence is sufficient to conclude that there is a positive association between exposure to herbicides (2,4-D; 2,4,5-T and its contaminant TCDD; cacodylic acid; and picloram) and chloracne Because TCDD-associated chloracne becomes evident shortly after exposure, there is no risk of new cases occurring long after service in Vietnam.

What did the NAS conclude about chloracne in its 1996 update? The NAS reviewers essentially reached the same conclusion in 1996 they had in the earlier report.

What should a Vietnam veteran do if he or she thinks his or her skin condition may be chloracne? Contact the nearest VA medical center for a medical examination and possible treatment and file a claim for disability compensation at the nearest VA medical center or regional office. For many years, VA has recognized chloracne as a service-connected disability based on the results of scientific research that links this condition with exposure to dioxin. For information about the VA examination and treatment programs, see Agent Orange Brief, B1 and B2. For information regarding disability compensation, see Agent Orange Brief, B3.

**Bottom of Page Department of Veterans Affairs Agent Orange Brief Prepared by the Environmental Agents Service January B4 VA Central Office, Washington, DC 1997

Review of literature on Herbicides, Including Phenoxy Herbicides and Associated Dioxins This multi-volume document was primarily designed for use by researchers, physicians, scientists, and others with similar backgrounds. The initial review was mandated by Public Law 96-151 in December 1979. The first two volumes were released in 1981. Updates (in two volume sets) were issued in 1984 and each year thereafter through 1994. The review has been prepared by independent contractors. Because the National Academy of Sciences is reviewing the scientific literature on the effects of herbicides and reporting biannually to the Secretary of Veterans Affairs, this project was discontinued.

Volume I Analysis of Literature $9.00 GPO Stock No. 051-000-00154-1 October 1981

Volume II Annotated Bibliography $9.50 GPO Stock No. 051-000-00155-9 October 1981

Volumes VII Analysis of Literature and Annotated Bibliography $7.50 and VIII GPO Stock No. 051-000-00186-9 (combined document) October 1986

Volumes IX Analysis of Literature and Annotated Bibliography and X Not available from GPO (combined document) July 1987

Volumes XI Analysis of Literature and Annotated Bibliography and XII Not available from GPO (combined document) July 1988

Volumes XIII Analysis of Literature and Annotated Bibliography and XIV Not available from GPO (combined document) June 1989

Volumes XV Analysis of Literature and Annotated Bibliography and XVI Not available from GPO (combined document) May 1990

Volumes XVII Analysis of Literature and Annotated Bibliography and XVIII Not available from GPO (combined document) August 1991

Volumes XIX Analysis of Literature and Annotated Bibliography and XX Not available from GPO (combined document) June 1992

Volumes XXI Analysis of Literature and Annotated Bibliography and XXII Not available from GPO (combined document) June 1993

Volumes XXIII Analysis of Literature and Annotated Bibliography and XXIV Not available from GPO (combined document) June 1994

Synopsis of Scientific Literature on Phenoxy Herbicides and Associated Dioxins These documents summarize in non-technical language the literature reviews cited above. Number 1 in the synopsis series corresponds with Volumes I - IV of the literature review; Number 2 with Volumes V - VI; Number 3 with Volumes VII - VIII; Number 4 with Volumes IX - X; Number 5 with Volumes XI - XII; Number 6 with Volumes XIII - XIV; Number 7 with Volumes XV - XVI; Number 8 with Volumes XVII - XVIII; Number 9 with Volumes XIX - XX; Number 10 with Volumes XXI - XXII; and Number 11 with Volumes XXIII -- XXIV.

Monographs The VA's Agent Orange Projects Office (now known as the Environmental Agents Service) published several technical documents of interest to individuals concerned about the use of herbicides in Vietnam:

Cacodylic Acid: Agricultural Uses, Biologic Effects, and Environmental Fate by Ronald D. Hood, Ph.D. - GPO Stock No. 051-000-00177-0 - $6.00 December 1985

Human Exposure to Phenoxy Herbicides by Terry L. Lavy, Ph.D. - NTIS Accession No. PB- $19.95 May 1987

To purchase items with GPO stock numbers, write to the Superintendent of Documents, United States Government Printing Office, Washington, DC 20402. Please note that some of the GPO documents may be out of stock.

To purchase the monograph with the NTIS accession number, write to the U.S. Department of Commerce, National Technical Information Service, Springfield, VA 22161. The Environmental Agents Service (131), Department of Veterans Affairs, 810 Vermont Avenue, N.W., Washington, DC 20420, has a limited supply of many of these documents. These items are also maintained in all VA medical center libraries.

Agent Orange Review From 1982 to 1989, this newsletter was prepared by the VA's Office of Public Affairs in Washington, DC, with the assistance of the VA's Environmental Agents Service. In 1989, the Environmental Agents Service -- then called the Environmental Medicine Office -- assumed primary responsibility for this publication. The "Review" is published periodically to provide information on Agent Orange to concerned veterans and their families. The newsletter provides updated information about Federal government studies and activities related to Agent Orange and the Vietnam experience. Anyone interested in getting a copy of the "Review" should contact the Agent Orange Coordinator at the nearest VA medical center or the Environmental Agents Service (131), Department of Veterans Affairs, 810 Vermont Avenue, N.W., Washington, DC 20420.

Agent Orange Videotapes The Regional Learning Resources Service at the VA Medical Center in St. Louis, Missouri, has produced several Agent Orange videotape programs with the assistance of the Environmental Agents Service. These programs explain what Agent Orange was, where, when, and how it was used, why concerns arose among those exposed to it, and what VA and other departments and agencies are doing in response to these concerns. The videotapes are maintained at many VA medical centers.

Agent Orange Brief The paper you are now reading is one of a series of two-to-ten page fact sheets, prepared by the Environmental Agents Service, to help answer questions about Agent Orange and related matters. The series is updated on a regular basis. The Agent Orange Coordinator at all VA medical centers should have copies of all Agent Orange Briefs. Questions or ideas concerning these fact sheets should be directed to the Environmental Agents Service (131), Department of Veterans Affairs, 810 Vermont Avenue, N.W., Washington, DC 20420.

VA Field Staff Each VA medical center has a Registry Physician and an Agent Orange Coordinator. Registry Physicians are responsible for the clinical management of the Agent Orange program at the VA facility where they work. These doctors meet with concerned veterans, conduct examinations, document medical programs, and answer health-related questions from Vietnam veterans and their families. Agent Orange Coordinators handle Agent Orange program administrative matters at VA health care facilities. They schedule appointments, review records for accuracy and completeness, and collect data for reporting purposes.

Veterans Benefit Counselors (VBC) located in VA regional offices and many medical centers possess a wealth of information about the wide range of VA benefits. These counselors have all the forms necessary to apply for VA benefits, including disability compensation and dependency and indemnity compensation. VBC's also assist veterans and their survivors in completing these forms, if necessary.

VA vet center personnel also are very helpful to Vietnam veterans experiencing difficulties readjusting to civilian life. There are more than 200 vet centers nationwide. Vet centers offer individual, group, and family counseling.

VA National Headquarters The Environmental Agents Service in Washington, DC, is an excellent source of information about Agent Orange. The office was organized more than sixteen years ago. While the staff is quite small, many veterans have found the personnel to be very helpful. Comments, suggestions, and criticisms about VA's Agent Orange program are always welcome. The mailing address is Environmental Agents Service (131), 810 Vermont Avenue, N.W., Washington, DC 20420. The telephone number is 202-273-8580.

Non-VA sources Veterans service organizations (such as The American Legion, veterans of Foreign Wars of the United States, Disabled American Veterans, Vietnam Veterans of America, VietNow) and State government entities (such as Agent Orange Commissions, Departments or Divisions of Veterans Affairs, Departments of Health) have also assisted many veterans.

National Academy of Sciences (NAS) Under a contract with VA, the Institute of Medicine, a component of the NAS, prepared an 832-page report, entitled Veterans and Agent Orange: Health Effects of Herbicides Used in Vietnam. The report, released in July 1993 and available in hardbound form with a 1994 copyright, provides a historical review of the issue, examines studies of populations environmentally and occupationally exposed to herbicides and dioxin, and discusses problems in study methodology. The core of the book presents what is known about the toxicology of dioxin and the herbicides used in greatest quantities in Vietnam, what is known about assessing exposure to herbicides and dioxin, what can be determined from the wide range of epidemiological studies conducted by different authorities, and what is known about the relationship between exposure to herbicides and dioxin, and cancer, reproductive effects, neurobehavioral disorders, and other health effects.

In March 1996, the NAS released a 384-page report, entitled Veterans and Agent Orange: Update 1996. This book updates and evaluates available scientific evidence regarding statistical associations between disease and exposure to dioxin and other chemical compounds in herbicides used in Vietnam, focusing on new scientific studies and literature published since the completion of the initial NAS report. The update gives special attention to the relationship between exposure to herbicides and the development of birth defects and transient peripheral neuropathy, as well as the subsequent development of prostate, hepatobiliary, nasopharyngeal, and other cancers. It explores the relationship between the length of time since first exposure and the possible risk of cancer development. The publication reviews and summarizes the strength of scientific evidence concerning the association between herbicide use in Vietnam and each disease suspected to be associated with such exposure.

Single copies of the NAS books were distributed to all VA medical center libraries. Organizations or individuals interested in purchasing these documents can contact the publisher: National Academy Press, 2101 Constitution Avenue, N.W. Box 285, Washington, DC 20055. The telephone numbers are 1-800-624-6242 and 202-334-3313. The NAS is a private, nonprofit society of distinguished scholars engaged in scientific and engineering research. Established in 1863, the NAS is dedicated to the furtherance of science and technology and to their use for the promotion of general public welfare.

Congressional committees, especially the House Committee on Veterans' Affairs and the Senate Committee on Veterans' Affairs, have collected a great deal of information regarding the possible long-term health consequences of exposure to Agent Orange.

Department of Veterans Affairs Agent Orange Brief Prepared by the Environmental Agents Service January D5 VA Central Office, Washington, DC 1997

Peripheral neuropathy is a nervous system condition that causes numbness, tingling, and muscle weakness by involvement of the nerves, that is, neural conducting tissue outside the brain and spinal cord.

Why are Vietnam veterans concerned about peripheral neuropathy? Is it caused by Agent Orange/dioxin? Some Vietnam veterans have been diagnosed with peripheral neuropathy and others have expressed concern about developing this condition. Some scientific literature has linked peripheral neuropathy to exposure to dioxin, which was contained in Agent Orange.

On May 23, 1991, the Veterans' Advisory Committee on Environmental Hazards considered the relationship between exposure to dioxin and the development of this condition. The Committee concluded that there is a "significant statistical association" between peripheral neuropathy and exposure to dioxin. The Committee qualified this opinion, stating that the association could be said to exist in the absence of exposure to chemical substances known to cause this disorder. Committee members indicated that other risk factors that must be considered are age and whether the individual suffers from other known causes of peripheral neuropathy such as diabetes, alcoholism, or Guillain-Barre syndrome. The Committee also advised that the disorder must become manifest within ten years of the last known dioxin exposure.

What did the Department of Veterans Affairs (VA) do in response to the Advisory Committee's finding and the subsequent report released by the National Academy of Sciences in July 1993? On July l, 1991, Secretary of Veterans Affairs Derwinski announced that VA will propose rules granting service-connected disability status to certain veterans with peripheral neuropathy. Proposed rule implementing the Secretary's decision was published for public comment in the Federal Register in January 1992. (See 57 Fed. Reg. 2236, January 21, 1992). It was anticipated that the final rule would be published in 1993.

However, in July 1993, when the National Academy of Sciences (NAS) released its comprehensive report, entitled veterans and Agent Orange - Health Effects of Herbicides Used in Vietnam, peripheral neuropathy was not included in the category "sufficient evidence of an association" or "limited/suggestive evidence of an association." Rather, the NAS reviewers concluded that there is "inadequate or insufficient evidence to determine whether an association exists between exposure to herbicides (2,4-D; 2,4,5-T and its contaminant TCDD; cacodylic acid; and picloram) and disorders of the peripheral nervous system." The NAS report added, "Although many case reports suggest that an acute or subacute peripheral neuropathy can develop with exposure to TCDD and related chemicals, reports with comparison groups do not offer clear evidence that TCDD exposure is associated with chronic peripheral neuropathy. The most rigorously conducted studies argue against a relationship between TCDD or herbicides and chronic neuropathy."

VA asked the NAS, in its follow-up report, to consider the relationship between exposure to herbicides and the subsequent development of the acute and subacute effects of peripheral neuropathy (as compared to the chronic effects which were focused on in the initial report).

In January 1994, VA published a notice in the Federal Register that Secretary Brown has determined that a presumption of service connection based on exposure to herbicides used in Vietnam is not warranted for a long list of conditions identified in the NAS report. Peripheral neuropathy was included in this list. (See 59 Fed. Reg. 341, January 4, 1994).

What did the NAS 1996 update conclude about peripheral neuropathy? When the NAS reviewers separated chronic persistent peripheral neuropathy from acute and subacute transient peripheral neuropathy, they found that there was still inadequate or insufficient evidence of an association between exposure to herbicides and chronic persistent peripheral neuropathy. On the other hand, they reported that there is some evidence to suggest that "neuropathy of acute or subacute onset may be associated with herbicide exposure." They included acute and subacute transient peripheral neuropathy among those conditions they placed in their second category "limited/suggestive evidence of an association." (Chronic persistent peripheral neuropathy remained in category three, "inadequate/insufficient evidence to determine whether an association exists.")

What was VA's response to the NAS 1996 finding about acute and subacute transient peripheral neuropathy? After careful review of the report, Secretary Brown decided that VA should add acute and subacute peripheral neuropathy (when manifested one year of exposure) to the list of conditions recognized for presumption of service connection for Vietnam veterans based on exposure to herbicides. President Clinton announced this, along with other, decisions, at the White House, on May 28, 1996. The proposed rule was published for public comment in the Federal Register in August 1996. (See 61 Fed. Reg. 41368, August 8, 1996). The final rule was published in the Federal Register in November 1996. (See 61 Fed. Reg. 57587, November 7, 1996).

Where can a veteran get additional information about peripheral neuropathy? Information regarding peripheral neuropathy and related matters can be obtained at VA medical center libraries, from the Registry Physicians at every VA medical center, or from the Environmental Agents Service (131), Department of Veterans Affairs, 810 Vermont Avenue, N.W., Washington, DC 20420.

Department of Veterans Affairs Agent Orange Brief Prepared by the Environmental Agents Service January D6 VA Central Office, Washington, DC 1997

Hodgkin's disease is a malignant lymphoma characterized by progressive enlargement of the lymph nodes, liver, and spleen, and by progressive anemia.

Why are Vietnam veterans concerned about Hodgkin's disease? Is it caused by Agent Orange? Some Vietnam veterans have been diagnosed with Hodgkin's disease and others have expressed concern about developing this cancer. Some research has suggested that Hodgkin's disease may be associated with exposure to herbicides, but there is no conclusive scientific evidence that Agent Orange or other herbicides cause this condition.

A Department of Veterans Affairs (VA) study, published in the Annals of Epidemiology in September 1995, concluded that service in Vietnam was not associated with any significant increase risk of Hodgkin's disease. Furthermore, surrogate measures of potential measures of potential Agent Orange exposure, such as service in a specific military branch, in a certain region within Vietnam, in a combat role, or extended Vietnam time, were not associated with any significant increased risk of Hodgkin's disease.

What did the National Academy of Sciences (NAS) conclude about Hodgkin's disease in its 1993 report, entitled Veterans and Agent Orange - Health Effects of Herbicides Used in Vietnam? The NAS reviewers reported that nearly all of the case-control and agricultural worker studies the evaluated show increased risk for this disease. Although only a few of these results are statistically significant, those that are show a positive association. Those that are not statistically significant generally indicate increased risk of Hodgkin's disease, and the pattern of the results is notably consistent.

Hodgkin's disease has a number of clinical features that typically differ from other lymphomas. While there were fewer studies for Hodgkin's disease than for non-Hodgkin's lymphoma, the NAS noted that the pattern of results was consistent with the findings for non-Hodgkin's lymphoma and concluded that there was sufficient evidence for a positive association between exposure to the herbicides used in Vietnam and the development of Hodgkin's disease.

What was VA response to the NAS finding? After reviewing the NAS report and noting (l) the difficulty in distinguishing between Hodgkin's disease and non-Hodgkin's lymphoma, (2) the occasional development of both diseases in the same patient, and (3) the biologic relationship between the two diseases in terms of origin, Secretary Brown determined that there is an association between exposure to herbicides used in Vietnam and the subsequent development of Hodgkin's disease which manifests itself to a degree of ten percent at any time after exposure.

The proposed rule on Hodgkin's disease was published for public comment in the Federal Register in September 1993. (See 58 Fed. Reg. 50524, September 28, 1993). The final rule implementing the Secretary's determination was published in the Federal Register in February 1994. (See 59 Fed. Reg. 5106, February 3, 1994).

What did Public Law 103-446 do for Vietnam veterans with Hodgkin's disease? Section 505, Public Law 103-446, Veterans' Benefits Improvements Act of 1994, enacted November 2, 1994, codified (established in law) presumptions of service connection for Vietnam veterans for certain diseases including Hodgkin's disease manifested to a degree of disability of 10 percent or more -- associated with exposure to certain herbicide agents.

What did the NAS conclude about Hodgkin's disease in the 1996 update? The 1996 report declared the "recent evidence continues to support the conclusions of a positive association between exposure to herbicides and Hodgkin's disease."

Where can a veteran get additional information on this subject? Information on Hodgkin's disease and related matters can be obtained at VA medical center libraries, from the Registry Physicians at every VA medical center, or from the Environmental Agents Service (131), Department of Veterans Affairs, 810 Vermont Avenue, N.W., Washington, DC 20420.

Department of Veterans Affairs Agent Orange Brief Prepared by the Environmental Agents Service January D7 VA Central Office, Washington, DC 1997

PCT is a disorder characterized by thinning and blistering of the skin in sun-exposed areas.

Why are Vietnam veterans concerned about PCT? Is it caused by Agent Orange? Some Vietnam veterans have been diagnosed with PCT and others have expressed concern about developing this disorder. Some research has suggested that PCT may be associated with exposure to herbicides, but there is no conclusive scientific evidence that Agent Orange or other herbicides cause this condition.

What did the Veterans' Advisory Committee on Environmental Hazards conclude with regard to PCT? During its August 22-23, 1990 meeting, the Veterans' Advisory Committee on Environmental Hazards, a VA-managed statutorily established group of independent medical and scientific authorities, found that there was no significant statistical association between exposure to a herbicide containing dioxin and the subsequent development of PCT. A majority of Advisory Committee members felt that while scientific literature, particularly that dealing with an industrial accident in Seveso, Italy, left open the possibility of an association, the existing requirement of a "significant statistical association" was not met.

What was VA's response to the Advisory Committee's finding? Secretary Derwinski concurred. In October 1991, "final" regulations were published in the Federal Register to that effect. (See 56 Fed. Reg. 52473, October 21, 1991).

What did the National Academy of Sciences (NAS) conclude about PCT in its 1993 report, entitled Veterans and Agent Orange - Health Effects of Herbicides Used in Vietnam? The NAS indicated that case studies and animal studies provide sufficient evidence to conclude that there is a positive association between exposure to herbicides used in Vietnam and the subsequent development of PCT in genetically susceptible individuals.

What was VA's response to the NAS l993 finding regarding PCT? After reviewing the NAS report and reconsidering the Advisory Committee's conclusions, Secretary Brown found that the "credible evidence for an association outweighs the credible evidence against an association." A proposed rule soliciting public comment was published in the Federal Register in September 1993. (See 58 Fed. Reg. 50528, September 28, 1993). The final rule was published in the Federal Register in February 1994. (See 59 Fed. Reg. 5106, February 3, 1994). In view of the clinical evidence that PCT onset occurs soon after exposure and consistent with manifestation periods established for many other presumptive conditions, VA established a one-year manifestation period for PCT (that is, the symptoms must have appeared within one year of last day of exposure).

What did Public Law 103-446 do for Vietnam veterans with PCT? Section 505, Public Law 103-446, the Veterans' Benefits Improvements Act of 1994, enacted November 2, 1994, codified (establish in law) presumptions of service connection for certain diseases -- including PCT manifested to a degree of disability of 10 percent or more within a year of military service in Vietnam -- associated with exposure to certain herbicide agents.

What did the NAS conclude about PCT in its 1996 update? The NAS reviewers concluded that new data (not available during the 1993 review) combined with the studies reviewed in Veterans and Agent Orange justify moving PCT from NAS category one (sufficient evidence of an association) to category two (limited/suggestive evidence of an association).

How does this change impact VA policy regarding PCT? There is no change in VA policy regarding PCT.

Where can a veteran get additional information on this subject? Information on PCT and related matters can be obtained at VA medical center libraries, from the Registry Physicians at every VA medical center, or from the Environmental Agents Service (l31), Department of Veterans Affairs, 810 Vermont Avenue, N.W., Washington, DC 20420.

Department of Veterans Affairs Agent Orange Brief Prepared by the Environmental Agents Service January D8 VA Central Office, Washington, DC 1997

Multiple myeloma is cancer of specific bone marrow cells, the plasma cell, characterized by plasma cell tumors in various bones of the body.

Why are Vietnam veterans concerned about multiple myeloma? Is it caused by Agent Orange? Some Vietnam veterans have been diagnosed with multiple myeloma and others have expressed concern about developing this cancer. Some research has suggested that multiple myeloma may be associated with exposure to herbicides, but there is no conclusive scientific evidence that Agent Orange or other herbicides cause this condition.

What did the National Academy of Sciences (NAS) conclude about multiple myeloma in its 1993 report, entitled Veterans and Agent Orange - Health Effects of Herbicides Used in Vietnam? The NAS reviewers found "limited/suggestive evidence" of an association between herbicide exposure and the subsequent development of multiple myeloma.

What was VA's reaction to this NAS finding? VA found the evidence concerning multiple myeloma convincing. Most of the studies reviewed by the NAS showed an increased risk, although in most cases it was not a statistically significant increase. Multiple myeloma is closely related biologically to B-cell non-Hodgkin's lymphoma; consequently, the epidemiological evidence concerning non-Hodgkin's lymphoma gives added weight to the association between herbicide exposure and multiple myeloma.

Based on this clinical consideration and the weight of the epidemiological evidence, Secretary Brown concluded that there is a positive association between herbicide exposure and multiple myeloma that manifests itself to a degree of ten percent at any time after exposure.

The proposed rule regarding multiple myeloma was published for public comment in the Federal Register in February 1994. (See 59 Fed. Reg. 5161, February 3, 1994). The final rule was published in the Federal Register in June 1994. (See 59 Fed. Reg. 29723, June 9, 1994).

What did Public Law 103-446 do for Vietnam veterans with multiple myeloma? Section 505, Public Law 103-446, the Veterans' Benefits Improvements Act of 1994, enacted November 2, 1994, codified (established in law) presumptions of service connection for certain diseases -- including multiple myeloma manifested to a degree of disability of 10 percent or more -- associated with exposure to certain herbicide agents.

What did the NAS 1996 update conclude about multiple myeloma? New data analyzed for 1996 did not change the NAS view that there is a "limited/suggestive association between exposure to herbicides and multiple myeloma."

Where can a veteran get additional information on this subject? Information on multiple myeloma and related matters can be obtained at VA medical center libraries from the Registry Physicians at every VA medical center, or from the Environmental Agents Service (131), Department of Veterans Affairs, 810 Vermont Avenue, N.W., Washington, DC 20420.

Department of Veterans Affairs Agent Orange Brief Prepared by the Environmental Agents Service January D9 VA Central Office, Washington, DC 1997

Why are Vietnam veterans concerned about respiratory cancers? Are they caused by Agent Orange? Many Vietnam veterans have been diagnosed with a respiratory cancer and others have expressed concern about developing such a cancer. Respiratory cancers are now the leading causes of cancer death in the United States. Some research has suggested that respiratory cancers may be associated with exposure to herbicides, but there is no conclusive scientific evidence that Agent Orange or other herbicides cause these conditions.

What did the Veterans' Advisory Committee on Environmental Hazards conclude with regard to respiratory cancers? In May 1991, the Advisory Committee considered approximately forty studies dealing with lung cancer. The Committee observed that most of the studies failed to adequately consider exposure documentation and potential confounding factors, particularly smoking. The only study, considered by the Advisory Committee, to address the factor of smoking was negative with regard to lung cancer. The Advisory Committee concluded that, on the basis of available epidemiological data, there is no evidence of a significant statistical association between exposure to herbicides containing dioxin and lung cancer.

What was VA's response to the Advisory Committee's finding? On June 27, 1991, Secretary Derwinski found that sound medical and scientific evidence does not establish the required association. On January 21, 1992, the Federal Register published a proposed rule that would have added lung cancer to the list of "diseases not associated with exposure to herbicides containing dioxin." The January 21 proposal was never finalized. (See 57 Fed. Reg. 2236, January 21, 1992).

What did the National Academy of Sciences (NAS) conclude about respiratory cancers in its 1993 report entitled Veterans and Agent Orange - Health Effects of Herbicides Used in Vietnam? The NAS found "limited/suggestive evidence" -- a category it defined as meaning that evidence suggests an association between herbicide exposure and a specific disease, but that chance, bias, and confounding factors cannot be ruled out with confidence -- of association between herbicide exposure and the subsequent development of respiratory cancers (including cancers of the lung, larynx trachea, and bronchus).

What was VA's response to the NAS finding? In reviewing the NAS report, which noted that not all studies had fully controlled for or evaluated smoking as a confounding factor, VA gave weight to the fact that the studies found relatively high risks for respiratory cancers in production workers. VA also noted that despite the failure of some to control for smoking, it is unlikely that there were major differences in smoking patterns between the study and control groups.

Considering all the evidence, Secretary Brown determined that the credible evidence for an association outweighs the credible evidence against an association between exposure to herbicides used in Vietnam and the subsequent development of respiratory cancers. Based on existing scientific evidence, a thirty-year manifestation period was established.

The proposed rule regarding respiratory cancers was published for public comment in the Federal Register in February 1994. (See 59 Fed. Reg. 5161, February 3, 1994). The final rule was published in the Federal Register in June 1994. (See 59 Fed. Reg. 29723, June 9, 1994).

What did Public Law 103-446 do for Vietnam veterans with respiratory cancers? Section 505, Public Law 103-446, the Veterans' Benefits Improvement Act of 1994, enacted November 3, 1994, codified (established in law) presumptions of service connection for certain diseases -- including respiratory cancers (cancer of the lung, bronchus, larynx, or trachea) manifest to a degree of 10 percent or more within 30 years of military service in Vietnam.

What did the NAS conclude about respiratory cancers in the 1996 update? The NAS noted that among the many epidemiologic studies of respiratory cancers reviewed, positive associations were found consistently only when TCDD (dioxin) or herbicide exposures where probably high and prolonged. This was "especially true in the largest, most heavily exposed cohorts of chemical production workers exposed to TCDD." The NAS commented that studies of farmers tended to show a decreased risk of respiratory cancers (perhaps due to lower smoking rates), and studies of Vietnam veterans were inconclusive. The report concluded that the evidence for this association was limited/suggestive rather than sufficient, because of the "inconsistent pattern of positive findings across populations with various degrees and types of exposure" and because the most important risk factor -- cigarette smoking -- was not fully controlled for or evaluated in all studies.

Where can a veteran get additional information on this subject? Information on respiratory cancers and related matters can be obtained at VA medical center libraries, from the Registry Physicians at every VA medical center, or from the Environmental Agents Service (131), Department of Veterans Affairs, 810 Vermont Avenue, N.W., Washington, DC 20420.

Department of Veterans Affairs Agent Orange Brief Prepared by the Environmental Agents Service January D10 VA Central Office, Washington, DC 1997

In the United States there are about 28 million men 50 years of age or older. There are approximately 8.6 million male veterans aged 50-70. Autopsy studies have shown that nearly 30 percent of these men have prostate cancer. Thus, an estimated 2.5 million veterans may now have or will develop prostate cancer over a lifetime.

Some Vietnam veterans have already joined this age group (when prostate cancer is typically detected), while others are fast approaching the half century mark. Since prostate cancer is a slow-growing tumor, many in this population will die with the disease but from other causes. Prostate cancer is the most common non-skin cancer diagnosis in men, representing about 32 percent of all cancer cases. Prostate cancer is the second leading cause of death in men. It is estimate that more than 200,000 cases of prostate cancer (including about 10,000 veterans) will be diagnosed annually with an approximately 40,000 death. A problem with prostate cancer is that about 40 percent of the tumors have spread beyond the prostate before it is diagnosed.

How is prostate cancer detected? There are currently three methods of screening: (1) digital rectal examination, (2) transrectal ultrasound, and (3) prostate specific antigen (a blood test to measure a protein found only in prostate tissue). Unfortunately, there are significant problems with each of these screening techniques. For each cancer detected, there are many false positives that may incorrectly diagnose a patient as having prostate cancer.

What treatments are available? Since prostate cancer is a relatively slow-growing tumor compared to other cancers, the paradox in managing it is the need to intervene early to stop the disease and also being cautious about using the major treatment, radical prostatectomy. This is a serious procedure with significant complications. From 25 to 75 percent of patients will be impotent and 2 to 6 percent severely incontinent after the surgery.

In addition to surgery, current treatments for prostate cancer include radiation therapy, which has some unpleasant side effects, and male hormone (androgen) deprivation. Chemical or surgical deprivation or administration of estrogen is effective in relieving pain, reducing urinary obstruction, and improving general well-being. Endocrine therapy delays disease progression, but has not been shown to prolong survival.

A relatively new approach to treatment is known as "expectant management," which means following the patient and giving hormonal or surgical treatment as necessary. This approach is reasonable because the progression of the tumor for each patient is uncertain, the treatment effectiveness is uncertain, and many patients with prostate can die of cause other than prostate cancer.

What did the National Academy of Sciences (NAS) conclude about the relationship between exposure to herbicides and the development of prostate cancer in its 1993 report, entitled Veterans and Agent Orange - Health Effects of Herbicides Used in Vietnam? The NAS reviewers observed that most of the agricultural studies they examined indicate "some elevated risk" of prostate cancer. Furthermore, one large well-done study in farmers showed an increased risk, and subanalyses in this study indicate that the increased risk specifically associated with herbicide exposure. The three major production worker studies reviewed by the NAS all show a small, but not statistically significant, elevation in risk. The NAS report noted that most of the associations seen in the studies reviewed are "relatively weak." The NAS added that Vietnam veterans have "not yet reached the age when this cancer tends to appear." In the report released in July 1993, the NAS concluded that there is "limited/suggestive evidence" of an association between exposure to herbicides used in Vietnam and prostate cancer.

What was VA's reaction to this NAS finding? In its July 1993 report, the NAS placed three health outcomes in its category two (limited/suggestive evidence of an association): multiple myeloma, respiratory cancers, and prostate cancer. After careful review, Secretary Brown concluded that while the credible scientific evidence for an association is equal to or outweighs the evidence against an association between exposure to herbicides used in Vietnam and the development of multiple myeloma and of respiratory cancers, the evidence for an association between these herbicides and prostate cancers failed to reach that standard.

In January 1994, VA published a notice in the Federal Register that Secretary Brown has determined that a presumption of service connection based on exposure to herbicides used in Vietnam is not warranted for a long list of conditions identified in the NAS report. Prostate cancer was included in this list. (See 59 Fed. Reg. 341, January 4, 1994).

VA asked the NAS, in its follow-up report, to further consider the relationship between exposure to herbicides and the subsequent development of prostate cancer.

What did the 1996 NAS update conclude about prostate cancer? Citing additional studies, the NAS report concluded that there is "limited/suggestive evidence" of an association between exposure to herbicides used in Vietnam and prostate cancer.

What was VA's response to the NAS 1996 finding regarding prostate cancer? Secretary Brown found that the credible evidence for an association equals or outweighs the evidence against an association between exposure to herbicides used in Vietnam and prostate cancer. He concluded that prostate cancer should be added to the list of conditions recognized for presumption of service connection for Vietnam veterans based on exposure to herbicides. President Clinton announced this, along with other decisions, on May 28, 1996. The proposed rule to implement this decision was published for public comment in the Federal Register in August 1996. (See 61 Fed. Reg. 41368, August 8, 1996). The final rule was published in the Federal Register in November 1996. (See 61 Fed. Reg. 57587, November 7, 1996).

Where can a veteran get additional information about prostate cancer? Information regarding prostate cancer and related matters can be obtained at VA medical center libraries, from the Registry Physicians at every VA medical center, or from the Environmental Agents Service (131), Department of Veterans Affairs, 810 Vermont Avenue, N.W., Washington, DC 20420.

To obtain additional information or a copy of some or all of the fact sheets, contact: Agent Orange Briefs Environmental Agents Service (131) VA Central Office 810 Vermont Avenue, NW Washington, D.C. 20420

Department of Veterans Affairs Agent Orange Brief Prepared by the Environmental Agents Service January D11 VA Central Office, Washington, DC 1997

Spina bifida is the most frequently occurring permanently disabling birth defect. It affects approximately one of every 1,000 newborns in the United States. Neural tube defects (NTD) are birth defects that involve incomplete development of the brain, spinal cord, and/or protective coverings for these organs. Spina bifida, the most common NTD, results from the failure of the spine to close properly during the first month of pregnancy. (Anencephaly and encephalocele are less common types of NTDs). In severe cases, the spinal cord protrudes through the back of and may be covered by skin or a thin membrane.

Some Vietnam veterans have children with spina bifida. While Vietnam veterans and their mates are now moving out of the age category usually associated with childbirth, it is anticipated that some future births will occur and that some of these children may have birth defects, including spina bifida. Some research efforts have suggested that there may be a relationship between exposure by Vietnam veterans to Agent Orange and/or other herbicides used in Vietnam and the subsequent development of spina bifida in some of their children.

What can be done for children with spina bifida? Surgery to close the infant's back is generally performed within 24 hours after birth to minimize the risk of infection and to preserve existing function in the spinal cord. Because of the paralysis resulting from the damage to the spinal cord, people born with spina bifida may need surgeries and other extensive medical care. Spina bifida is also associated with bowel and bladder complications.

Many individuals with spina bifida also suffer with hydrocephalus, fluid in the brain. Hydrocephalus is controlled by a surgical procedure which relieves the fluid build up by redirecting it to the abdominal area.

Because of medical advances, most children born with spina bifida live well into adulthood.

What did the National Academy of Sciences (NAS) conclude about the relationship between exposure to herbicides and the development of spina bifida in its 1993 report, entitled Veterans and Agent Orange - Health Effects of Herbicides Used in Vietnam? While there were several references to spina bifida in this 832-page report, the condition was grouped with all other birth defects. The NAS reviewers concluded that there is "inadequate or insufficient evidence" to determine whether an association exists between exposure to herbicides use in Vietnam and birth defects among offspring.

What did the 1996 NAS update conclude about spina bifida? In 1996, the NAS commented that published results of the analysis of birth defects among the offspring of the Operation Ranch Hand (the Air Force unit responsible for most of the Agent Orange spraying) personnel "suggest the possibility of an association between dioxin exposure and risk of neural tube defects."

The NAS reviewers noted that a number of studies of veterans "appear to show an elevated relative risk for either service in Vietnam or estimated exposure to herbicides or dioxin and neural tube defects (anencephaly and/or spina bifida) in their offspring."

NAS noted that while the Centers for Disease Control (CDC) Birth Defects Study revealed no association between "overall Vietnam veteran status" and the risk of spina bifida or anencephaly, the CDC herbicide "exposure opportunity index," based on interview data, indicated an increased risk of spina bifida in the children of Vietnam veterans who had high index ratings. There was no similar pattern of association for anencephaly.

The CDC Vietnam Experience Study indicated that more Vietnam veterans reported that their children had a central nervous system disorder (including spina bifida) than did non-Vietnam veterans who participated in the study.

The NAS observed that all three of these epidemiologic studies (which are of the "highest overall quality") suggest an association between herbicide exposure and an increased risk of spina bifida in offspring. While the NAS took note of the weaknesses in each of these studies, the NAS report concluded that there is "limited/suggestive evidence" of an association between exposure to herbicides used in Vietnam and spina bifida. On the other hand, the NAS found "inadequate or insufficient evidence to determine whether an association exists" between exposure to the herbicides and "all other birth defects."

What was VA's response to the NAS finding regarding spina bifida? While Secretary Brown could easily add peripheral neuropathy and prostate cancer (two other "limited/suggestive evidence" conditions cited in the 1996 update) to the list of conditions recognized by VA for presumption of service connection for Vietnam veterans based on exposure to herbicides, VA lacked the authority to provide benefits to non-veterans based on the possible relationship between those individuals' disabilities and a veteran's service.

On May 28, 1996, President Clinton announced that VA would send to Congress proposed legislation that would provide an "appropriate remedy" for Vietnam veterans' children who suffer from spina bifida. On July 25, 1996, Secretary Brown sent to Congress a draft bill that would provide for the special needs of these children through the provision of comprehensive medical care, vocational training, and monetary benefits (monthly allowance). On July 28, 1996, the legislation was introduced in the Senate and House of Representatives. In September, Congress approved a similar version of the spina bifida legislation with an effective date of October l, 1997, as part of the VA FY1997 appropriations bill. It became Public Law 104-204 on September 26, 1996, when it was signed by President Clinton.

On May 24, 1996, VA announced a "solicitation for applicant to establish a research center for epidemiological, clinical, and basic science studies of environmental hazards and their effects on reproductive and developmental outcomes." On November 14, 1996, VA announced that the Louisville VA Medical Center was selected as the site of this center.

Where can a veteran get additional information about spina bifida? Some information regarding spina bifida and related matters can be obtained at VA medical center libraries in other medical libraries, from the Registry Physicians at every VA medical center, or from the Environmental Agents Service (131), Department of Veterans Affairs, 810 Vermont Avenue, N.W., Washington, DC 20420. Non-government organizations, such as the Spina Bifida Association of America (SBAA), Easter Seal Society, and the March of Dimes, also have a great deal of information. The SBAA is located at 4590 MacArthur Blvd., Suite 250, Washington, DC 20007-4226. The toll-free telephone number for SBAA is (800) 621-3141. The e-mail address is spinabifda@aol.com.

THE VIETNAM CONFLICT An estimated 3.1 million veterans served in the Southeast Asia Theater (Vietnam, Laos, Cambodia, flight crews based in Thailand, and sailors in the South China Sea). An estimated 2.6 million personnel served within the borders of South Vietnam and in adjacent waters.

Date: Thursday, August 24, 2000 2:37 AM
Subject: [VeteranIssues] VETERANS STILL BATTLING VA OVER AGENT ORANGE
ILLNESS

Less than 10% of claims are approved
*******
From: MilitaryReport

VETERANS STILL BATTLING VA OVER AGENT ORANGE ILLNESS

Fox News reports that many Vietnam veterans are still
trying to get compensation from the Veterans Administration for medical
conditions resulting from exposure to Agent Orange.

From 1962 to 1971, the U.S. military sprayed more
than 18 million gallons of the defoliant over Vietnam. The
VA accepts as policy that all 3.1 million veterans who
served in Southeast Asia during the Vietnam conflict were
exposed to Agent Orange. Under the Agent Orange Act of 1991, the VA
compensates victims and their families for conditions that, according to
scientific evidence, are at least as likely as not to result from exposure
to Agent
Orange. Yet of the 99,226 Agent Orange-related disability or survivorship
claims submitted to the Veterans
Administration, only 7,520 have been granted.

********************************************************

• An estimated 2.6 million personnel served within the borders of South Vietnam and in adjacent waters.

Agent Orange was a herbicide used in Vietnam to defoliate trees and remove cover for the enemy. Agent Orange spraying missions were flown in Vietnam between January 1965 and April 1970. Shipped in orange-striped barrels, it was a reddish-brown liquid containing four chemicals: 2,4,5-trichlorophenoxyacetic acid (2,4,5-T), 2,4-dichlorophenoxyacetic acid (2,4-D), cacodylic acid and picloram. The 2,4,5-T was contaminated in the manufacturing process with dioxin. Several herbicides were sprayed in Vietnam at different times -- during different years as well as during different seasons because of the variety of vegetation and environmental conditions.

The history of herbicides for military use dates to World War II. During the early part of the war, interest arose in chemicals that could be used for crop destruction. Two chemicals were developed as a result of those early efforts -- 2,4-D and 2,4,5-T. Although neither chemical was used in World War II, the value of their use in weed and brush programs was recognized, and both chemicals have been used widely throughout the world since the 1940s by farmers, foresters and homeowners.

Free Medical Care: VA has offered special access to health services and studies since 1978, when it initiated a medical surveillance program for Vietnam veterans with health concerns. By 1981, VA offered priority medical care to Vietnam veterans with any health problems which may have resulted from Agent Orange exposure. That program continues today.

Special Compensation for 10 Diseases: As with other veterans, Vietnam veterans with disabilities incurred or aggravated by military service may receive monthly VA compensation. As knowledge has grown from studies of Agent Orange, some diseases that may not have become evident in service have been recognized as service-connected. Based on clinical research, the following diseases are now on VA's Agent Orange list: chloracne, Hodgkin's disease, multiple myeloma, non-Hodgkin's lymphoma, porphyria cutanea tarda, respiratory cancers (lung, bronchus, larynx and trachea), soft-tissue sarcoma, acute and subacute peripheral neuropathy and prostate cancer. In addition, monetary benefits, health care and vocational rehabilitation services are provided to Vietnam veterans' offspring with spina bifida, a congenital birth defect of the spine. VA presumes that all military personnel who served in Vietnam and who have one of the listed diseases were exposed to Agent Orange.

• VA developed the Agent Orange Registry Examination Program in 1978 to identify Vietnam veterans concerned about Agent Orange exposure. Nearly 300,000 Vietnam veterans have been provided examinations under the Registry program as of December 1999. VA maintains a computerized registry of data from these examinations. Registrants receive periodic updates on Agent Orange studies and VA policy.

• VA's Advisory Committee on Health-Related Effects of Herbicides was established in 1979 to examine issues surrounding the possible health effects of herbicides on Vietnam veterans. VA also established the Veterans' Advisory Committee on Environmental Hazards, consisting of non-VA experts in dioxin and radiation exposure as well as several lay members, to advise the Secretary on the results of Agent Orange-related research, and regulatory, administrative and legislative initiatives. Since passage of a 1991 law (PL102-4), which directs VA to request that the National Academy of Sciences (NAS) review diseases associated with herbicide exposure, the committee's work has been superseded by the NAS review.

• The NAS reviews and evaluates scientific literature about Agent Orange. NAS reviewed more than 6,000 abstracts of scientific or medical articles and analyzed 230 epidemiological studies before its initial July 1993 report, which led to the inclusion of additional diseases on the list for presumptive service-connection. The NAS review has been continuing, with acute and subacute peripheral neuropathy and prostate cancer added to VA's presumptive list after the NAS issued an updated report in March 1996. Also based on that report's findings of new "limited or suggestive evidence" of an association between herbicides and spina bifida in the children of Vietnam veterans, VA proposed legislation to aid children of Vietnam veterans who suffer from that disorder, and established a reproductive outcomes research center to investigate potential environmental hazards of military service. An NAS update, released in February 1999, contained no major changes in its classifications of diseases.

In April 2000, VA asked IOM to broaden an ongoing study to include the results of the military’s latest report on Agent Orange, which found a high rate of adult-onset diabetes among Vietnam veterans who participated in spraying operations.

In October 2000, NAS issued a report that found “limited / suggestive evidence” of a link between adult-onset (Type 2) diabetes and herbicides used in Vietnam, including Agent Orange. The IOM report concluded that other traditional risk factors for diabetes – heredity, weight and sedentary lifestyle – far outweigh the risks of Agent Orange.

Still, based upon that IOM report, Acting VA Secretary Hershel Gober announced on Nov. 9, 2000, that he was directing the addition of Type 2 diabetes to the list of presumptive conditions associated with herbicide exposure. VA officials estimate that more than 178,000 veterans might qualify for disability compensation under the new rules within five years.

VA Sponsors New Program for End-of-Life Care
WASHINGTON - Dying is never easy - not for an individual, not for a family, not for the medical staff who administer the care. But the Department of Veterans Affairs (VA) is taking new steps to ease the process for everyone.

An initiative, called "VA Interprofessional Fellowship Program in Palliative Care," will develop health-care professionals with vision, knowledge and compassion to lead end-of-life care into the 21st century. Although aimed at improving care for veterans, the program will affect how this care - known as "palliative care" in medical circles -- is provided throughout the country.

"As VA serves an increasingly higher percentage of older and chronically ill veterans, the need for end-of-life care similarly increases," said Dr. Stephanie H. Pincus, VA chief officer for Academic Affiliations, a program that educates more than 90,000 physicians, medical students, and associated health professionals each year. "This interdisciplinary fellowship will jump-start palliative care as an important field in health care. It will change the way physicians, social workers, nurses and other caregivers approach patients at an extremely difficult time in their lives."

Historically, VA has taken a leadership role in the promotion and development of hospice care and, more recently, in a national pain management initiative. In 1998, VA's Office of Academic Affiliations addressed the need for clinicians trained in end-of-life care and was awarded a $985,000 grant by the Robert Wood Johnson Foundation to support further education. On March 1, 2001, the palliative care fellowship program was announced and will involve up to six sites, with four one-year fellowships provided at each site.

"The training changes the focus of health-care providers who are treating the terminally ill," said Pincus. "In the past, doctors saw death as a failure, so they consequently focused on medical cures and preventing death at any cost. We are training medical care staff now to concentrate on symptom management rather than disease management."

Pincus further explained that the new fellowship program has a large educational component. Trained clinicians are expected to serve as leaders promoting development and research. Selected training sites will be required to develop and implement an "Education Dissemination Project" to spread information beyond the training site through conferences, curricula for training programs, patient education materials and clinical demonstration projects.

And, of course, as resident doctors go out into the community, they take their training with them. More than 130 VA facilities have affiliations with 107 medical schools and 1,200 other schools across the country. More than half the physicians practicing in the United States have received part of their professional education in the VA health care system.

"This is an important step for health-care providers. But what does this mean to the chronically ill veteran?" said Pincus. "It means that he will be more comfortable. It means he might not have to die in ICU but instead be able to remain in the secure surroundings of his home. It means he will be treated by a caring, trained partnership of doctors, nurses, chaplains and social workers. It means his family will be included in decision-making and care giving.

"There comes a time when all the modern medicine in the world can't cure the illness. That's when treating the pain, communicating with compassion and providing support and counseling become paramount. And that's what these fellowships are all about," said Pincus.

Issue
Secretary of Veterans Affairs Anthony J. Principi announced April 19 that he will seek legal authority from Congress to provide benefits for the children of Vietnam veterans who have contracted a rare, deadly form of leukemia.

Background
The secretary made the decision to seek VA benefits hours after reviewing a report by the Institute of Medicine (IOM) that found "limited or suggestive" medical evidence of a link between a deadly form of leukemia in children and a parent's service in Vietnam during the war.

The leukemia, acute myelogenous leukemia (AML), strikes about 550 people under the age of 21 every year. It is considered one of the most difficult leukemias to treat and is almost always fatal. Rough estimates suggest from 500 to 1,000 children of veterans are affected.

The presumed culprit is Agent Orange, a herbicide used to unmask enemy hiding places during the Vietnam War. VA already recognizes a number of medical conditions - chloracne, porphyria cutanea tarda, soft-tissue sarcoma, Holdgkin's disease, multiple myeloma, respiratory cancers, prostate cancer, non-Hodgkin's lymphoma, type II diabetes and spina bifida - as being associated with Agent Orange exposure during the war.

The IOM conclusion was based upon three studies - one involving veterans who served in Vietnam or Cambodia; the children of Australia's Vietnam veterans, who had a four-fold greater incidence of the disease; and the children of fathers exposed to pesticides and weed-killers like Agent Orange, who had a nearly three-fold greater incidence.

IOM conducted its study under a 1991 federal law (P.L. 102-4) that requires the institute to review scientific literature on the health effects of Agent Orange and issue reports periodically. The recently released report, "Veterans and Agent Orange: Update 2000," was the fifth in the series (1994, 1996, 1998 and a special review of diabetes in 2000).

In response to the study April 19, Secretary Principi obtained White House approval to seek legislation that would give VA the legal authority to provide health care, financial payments and other benefits to these children. Details are being developed. VA officials are examining the range of benefits, the application process and the numbers of people likely to be eligible.

Talking Points
VA is committed to help veterans and their families deal with the effects of military service. Hours after receiving the latest IOM report, VA began preparations to provide benefits to affected veterans and their families.

As scientific studies increase our understanding of the health risks of Agent Orange, VA will continue to expand the services and benefits available to Vietnam veterans.

VA has a new, free telephone hotline for Vietnam veterans to obtain information about Agent Orange. It is 1-800-749-8387.

Public affairs officers should be prepared to speak about services available to Vietnam veterans in their communities, including the free health examination program for those who may be concerned about Agent Orange exposure, enrollment in the VA health system for ongoing medical needs and the availability of compensation for certain diseases and injuries.

Media interested in issues that go beyond the limits of this guidance, or media who want help developing stories about VA's response to Agent Orange, should be referred to the Office of Public Affairs (202-273-6000).

    Media Relations   Washington, DC 20420
   (202) 273-5700
    www.va.govDepartment of
Veterans AffairsNews Release

VA To Create Benefits for Some Childhood Leukemia Victims
WASHINGTON - Hours after receiving a study that linked Agent Orange to a deadly form of childhood leukemia, Secretary of Veterans Affairs Anthony J. Principi ordered the Department of Veterans Affairs (VA) to begin setting up benefits for these children.

"The medical evidence is clear and persuasive that these illnesses are associated with the service of our men and women during the Vietnam War," said Principi. "Equally clear is VA's responsibility to provide benefits and programs that meet the needs of these veterans and their families."

Principi's decision affects the children of Vietnam veterans with acute myelogenous leukemia, a rare, deadly form of the childhood disease. The Institute of Medicine (IOM) released a report April 19 that cited "limited or suggestive" evidence that a parent's exposure to Agent Orange during the Vietnam War may lead to a child contracting the disease. About 500 to 1,000 children of Vietnam veterans are believed to have the disease.

Since VA has no legal authority to provide benefits for these children, Principi said he has obtained White House approval to ask Congress for legislation to create special benefits. VA officials are determining what those benefits should be.

In 1997, VA set up a program for the children of Vietnam veterans with spina bifida. That program provides health-care benefits, vocational training and a monthly allowance based upon the severity of the illness. About 940 people with spina bifida are now receiving these VA benefits.

(PERSONAL NOTE) I spoke to my childrens doctor about this--this is a very rare form of leukemia--only a few hundred cases are known****

##### START #####
News from Congressman Lane Evans-IL Ranking Democratic Member, House
Veterans Affairs Committee March 30, 2001

Evans Commends Secretary Principi For Expanding Agent Orange Registry And
Assisting Veterans Who Were Exposed to Agent Orange at Fort Drum Common
Sense Approach Will Help Affected Veterans Washington, DC - Congressman
Lane Evans of Illinois, the Ranking Democrat on the House Veterans'
Affairs
Committee, today reported that Secretary of Veterans Affairs Anthony
Principi has agreed to expand the Agent Orange Registry to include
veterans
who believe that they were exposed to Agent Orange at Fort Drum, New
York,
and in other areas where veterans were exposed during its manufacture,
testing or transport. Last year, the Registry was expanded to include
veterans who had served in Korea during 1968 and 1969, when Agent Orange
was used near the Demilitarized Zone.

Evans request to include the Fort Drum veterans followed an admission by
the Department of the Army that testing of the herbicide was conducted
there during 1959. At Evans urging, the Department of Veterans Affairs
(VA)
has provided its regional offices with information supplied by the Army
regarding the testing at Fort Drum so that those facts will not need to be
proved by each veteran who served there. Evans called this a time-saving
common sense approach to aid veterans in establishing their claims.
"Veterans who served in areas outside Southeast Asia where Agent Orange
was
used have experienced greater difficulty obtaining service-connected
compensation from the VA for disabilities linked to Agent Orange than
veterans with the same disabilities who served in Vietnam," said
Evans.Secretary Principi also affirmed VA's practice of not requiring
proof
of a link or "nexus" between exposure to Agent Orange and certain diseases
which VA recognizes as being associated with exposure. Affected veterans
still must prove actual exposure to Agent Orange or other related
herbicides, if the veteran did not serve in an area where Agent Orange
exposure has been confirmed by the military. Evans noted that this issue
is
of particular interest to him because of his long-standing concerns about
the health effects of exposure to Agent Orange and other herbicides during
military service. "I am very pleased that Secretary Principi has taken
these actions to assist veterans who were exposed to Agent Orange during
military service," Evans said. Evans applauded Secretary Principi for
both
the positive decisions he has made regarding veterans exposed to Agent
Orange at Fort Drum and for Principi's quick response to Evans request.The
illnesses that VA regulations currently associate with exposure to Agent
Orange and its contaminant dioxin are chlorachne, Hodgkin's disease,
multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral
neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers
and soft-tissue sarcoma.

Additionally, VA has announced its intention to add adult-onset diabetes
to
the list. "The actions taken by Secretary Principi to address the concern
of veterans exposed to Agent Orange demonstrate his strong commitment to
our Nation's veterans," Evans said.

##### END #####

Agent Orange Bracelets

Ordering information, three different kinds will be available, personalized
ones for living and deceased victims and a bracelet honoring Agent Orange
Victims in general

The bracelets are of light weight iodized aircraft aluminum and are $9.45
each including postage.
Colors available are gold , silver or black. Please state which color you
desire.The words Agent Orange will appear on all of the bracelets

For personalized bracelets:

For the Deceased Victims please include birth date, death date and full name
of victim

For the Living Victims please include birthdate and full name of victim

The personalized bracelets can say widow, wife, friend etc. of the victim
Please state which you desire

General bracelets will say "In honor of Agent Orange Victims"

Checks and money order accepted , no credit cards please.

Include the name and address to which the bracelet will be mailed.

All proceeds will go towards to the Quilts of Tears Project, which honors
Agent Orange Victims, as it travels across the country to Vietnam Veterans
Reunions and other Vietnam Veterans events.

Send order to:
Jennie R. Le Fevre
The Quilts of Tears Project
6400 W.Shady Side Rd
Shady Side,MD 20764

DISEASES RECOGNIZED BY THE VA AS CONNECTED TO AGENT ORANGE EXPOSURE	LENGTH OF TIME REQUIREMENTS: (WHEN SYMPTOMS OF THE DISEASE HAVE TO APPEAR AND RESULT IN A DISABILITY AT LEAST 10 PERCENT DISABLING IN ORDER TO QUALIFY FOR BENEFITS.)
TYPES OF CANCER
Cancer of the Bronchus	Within 30 years of the last day the veteran served in Viet Nam
Cancer of the Larnyx	Within 30 years of the last day the veteran served in Viet Nam
Lung Cancer	Within 30 years of the last day the veteran served in Viet Nam
Cancer of the Trachea	No time requirement (veteran qualifies no matter when the disease first appears.)
Prostate Cancer	Within 30 years of the last day the veteran served in Viet Nam
Hodgkin's Disease	No time requirement (veteran qualifies no matter when the disease first appears.)
Multiple Myeloma	No time requirement (veteran qualifies no matter when the disease first appears.)
Non-Hodgkin's Lymphoma	No time requirement (veteran qualifies no matter when the disease first appears.)

DISEASES OTHER THAN CANCER	TIME REQUIREMENT
Peripheral Neuropathy (acute or subacute) Just added as of April 1, 2000 Diabetes.....	Within months of exposure to agent orange in Vietnam and cured within 2 years after symptoms first appear (Note: this time requirement is written so narrowly it appears to be impossible for any Vietnam veteran to qualify)
Chloracne	Within one year of the last day the veteran served in Vietnam.
Porphyria Cutanea Tarda	Within one year of the last day the veteran served in Vietnam.

DISABILITIES IN CHILDREN OF VIETNAM VETERANS	TIME REQUIREMENT
Spina Bifida	Child must have been conceived after veteran first arrived in Vietnam.

DISEASES RECOGNIZED BY THE VA AS CONNECTED TO AGENT ORANGE EXPOSURE	LENGTH OF TIME REQUIREMENTS: (WHEN SYMPTOMS OF THE DISEASE HAVE TO APPEAR AND RESULT IN A DISABILITY AT LEAST 10 PERCENT DISABLING IN ORDER TO QUALIFY FOR BENEFITS.)
TYPES OF CANCER
Cancer of the Bronchus	Within 30 years of the last day the veteran served in Viet Nam
Cancer of the Larnyx	Within 30 years of the last day the veteran served in Viet Nam
Lung Cancer	Within 30 years of the last day the veteran served in Viet Nam
Cancer of the Trachea	No time requirement (veteran qualifies no matter when the disease first appears.)
Prostate Cancer	Within 30 years of the last day the veteran served in Viet Nam
Hodgkin's Disease	No time requirement (veteran qualifies no matter when the disease first appears.)
Multiple Myeloma	No time requirement (veteran qualifies no matter when the disease first appears.)
Non-Hodgkin's Lymphoma	No time requirement (veteran qualifies no matter when the disease first appears.)

DISEASES OTHER THAN CANCER	TIME REQUIREMENT
Peripheral Neuropathy (acute or subacute) Just added as of April 1, 2000 Diabetes.....	Within months of exposure to agent orange in Vietnam and cured within 2 years after symptoms first appear (Note: this time requirement is written so narrowly it appears to be impossible for any Vietnam veteran to qualify)
Chloracne	Within one year of the last day the veteran served in Vietnam.
Porphyria Cutanea Tarda	Within one year of the last day the veteran served in Vietnam.

Effective Dates

Herbicide Exposure Diabetes Claims Currently Under End Product (EP) 685 Diary Control

Herbicide Exposure Diabetes Claims Not Currently Under EP 685 Diary Control

Annotating ratings for diabetes claims due to herbicide exposure

7913 Diabetes mellitus (herbicide)

Application for the Order of Silver Rose Award

AGENT ORANGE AND VA DISABILITY COMPENSATION

New Jersey Agent Orange Commission Homepage . . .
Additional Resources:

Links to other Agent Orange/Dioxin related documents and sites.

Please bookmark this page and check back often. As new documents are located and reviewed, they will be added to this archive.

Effective Dates

Herbicide Exposure Diabetes Claims Currently Under End Product (EP) 685 Diary Control

Herbicide Exposure Diabetes Claims Not Currently Under EP 685 Diary Control

Annotating ratings for diabetes claims due to herbicide exposure

7913 Diabetes mellitus (herbicide)

Application for the Order of Silver Rose Award

AGENT ORANGE AND VA DISABILITY COMPENSATION

New Jersey Agent Orange Commission Homepage . . . Additional Resources:

Links to other Agent Orange/Dioxin related documents and sites.

Please bookmark this page and check back often. As new documents are located and reviewed, they will be added to this archive.

New Jersey Agent Orange Commission Homepage . . .
Additional Resources: