THE

VETERAN

ATOMIATOMICC

History, Principles and History, Principles and ProcessProcess

Victoria Anne Cassano, MD, MPHVictoria Anne Cassano, MD, MPHCaptain, MC, USN (RET)Captain, MC, USN (RET)

Director, Radiation and Physical ExposuresDirector, Radiation and Physical ExposuresDEPARTMENT OF VETERANS AFFAIRSDEPARTMENT OF VETERANS AFFAIRS

OFFICE OF PUBLIC HEALTH AND OFFICE OF PUBLIC HEALTH AND ENVIRONMENTAL HAZARDSENVIRONMENTAL HAZARDS

““Atomic Veteran”Atomic Veteran”

Applies to:Applies to:

• Occupation Personnel in Hiroshima or Occupation Personnel in Hiroshima or NagasakiNagasaki

• Former POWs held within 75 miles of Former POWs held within 75 miles of either Cityeither City

• Participants in Atomic Nuclear Participants in Atomic Nuclear TestingTesting

DEFENCE NUCLEAR AGENCY DEFENCE NUCLEAR AGENCY Report 6030FReport 6030FAugust 1982August 1982

From 1945 to 1962, the U.S. Government, through theManhattan Engineer District and its successor agency, the Atomic Energy Commission (AEC), conducted 235 atmospheric nuclear weapons tests in the United States and in the Pacific and Atlantic Oceans.

In all, an estimated 220,000 Department of Defense (DOD) participants, both military and civilian, were present at the tests.

Of these, approximately 90,000 participated in the atmospheric nuclear weapons tests conducted at the Nevada Test Site (NTS), northwest of Las Vegas, Nevada.

In 1977, 15 years after the last above-ground nuclear weapons test, the Center for Disease Control noted a possible leukemia cluster among a small group of soldiers present at Shot SMOKY, a test of Operation PLUMBBOB, the series of atmospheric nuclear weapons tests conducted in 1957.

FROM DNA Report 6030FFROM DNA Report 6030FAugust 1982August 1982

FROM DNA Report 6030FFROM DNA Report 6030FAugust 1982August 1982

Since that initial report by the Center for Disease Control, the Veterans Administration has received a number of claims for medical benefits from former military personnel who believe their health may have been affected by their participation in the weapons testing program.

FROM DNA Report 6030FFROM DNA Report 6030FAugust 1982August 1982

In late 1977, the DOD began a study to provide data to both the Center for Disease Control and the Veterans Administration on potential exposures to ionizing radiation among the military and civilian participants in the atmospheric nuclear tests.

FROM DNA Report 6030FFROM DNA Report 6030FAugust 1982August 1982

The DOD organized an effort to:– Identify DOD participants in the

atmospheric nuclear weapons tests– Determine the extent of the

participants' exposure to ionizing radiation

– Provide public disclosure of information concerning participation by DOD personnel in the atmospheric nuclear weapons tests.

TITLETITLE DATESDATES LOCATIONLOCATION• Operation Trinity Operation Trinity 1945 – 1946 1945 – 1946 New Mexico New Mexico • Operation Crossroads Operation Crossroads 1946 1946 Pacific Pacific• Operation Sandstone Operation Sandstone 1948 1948 PacificPacific• Operations Ranger Operations Ranger 19511951 NTSNTS• Operation Greenhouse Operation Greenhouse 19511951 PacificPacific• Operation Buster-Jangle Operation Buster-Jangle 19511951 NTSNTS• Operation Tumbler-Snapper Operation Tumbler-Snapper 1952 1952 NTSNTS• Operation Ivy Operation Ivy 1952 1952 PacificPacific• Operation Upshot-Knothole Operation Upshot-Knothole 1953 1953 NTSNTS• Operation CastleOperation Castle 19541954 PacificPacific• Operation Teapot Operation Teapot 19551955 NTSNTS• Operation WigwamOperation Wigwam 19551955 PacificPacific• Operation Redwing Operation Redwing 1956 1956 PacificPacific• Operation Plumbbob Operation Plumbbob 19571957 PacificPacific• Operation Hardtack I Operation Hardtack I 1958 1958 PacificPacific• Operation ArgusOperation Argus 19581958 South AtlanticSouth Atlantic• Operation Hardtack IIOperation Hardtack II 1958 1958 NTSNTS• Operation Dominic I Operation Dominic I 1962 1962 PacificPacific• Operation Dominic II, Operation Dominic II, 1962 1962 NTSNTS• Project Gnome and Sedan 1962Project Gnome and Sedan 1962 NTSNTS• The Plowshare ProgramThe Plowshare Program1961 – 19731961 – 1973 NTS, New Mexico, CONTS, New Mexico, CO

Defense Nuclear AgencyDefense Nuclear AgencyNuclear Weapons Testing Nuclear Weapons Testing

OperationsOperations

PRINCIPLESPRINCIPLESLEGISLATIVE BACKGROUND LEGISLATIVE BACKGROUND

• Pub. L. 98-542 - Veterans’ Dioxin and Pub. L. 98-542 - Veterans’ Dioxin and Radiation Exposure Compensation Radiation Exposure Compensation Standards Act (Oct. 24, 1984)Standards Act (Oct. 24, 1984)

• 38 C.F.R. § 3.31138 C.F.R. § 3.311

• Pub. L. 100-321 - Radiation-Exposed Pub. L. 100-321 - Radiation-Exposed Veterans Compensation Act of 1988 (May Veterans Compensation Act of 1988 (May 20, 1988)20, 1988)

• 38 C.F.R. § 3.309 38 C.F.R. § 3.309

• Established presumption of service Established presumption of service connectionconnection

• Defined “radiation-risk activity”Defined “radiation-risk activity”

• Periodic reports submitted to Senate and Periodic reports submitted to Senate and House Veterans’ Affairs CommitteesHouse Veterans’ Affairs Committees

• 38 CFR 3.309(d)38 CFR 3.309(d)

• Established presumption of service Established presumption of service connectionconnection

• Defined “radiation-risk activity”Defined “radiation-risk activity”

• Periodic reports submitted to Senate and Periodic reports submitted to Senate and House Veterans’ Affairs CommitteesHouse Veterans’ Affairs Committees

• 38 CFR 3.309(d)38 CFR 3.309(d)

PRINCIPLESPublic Law 100-321

5/20/88

PRINCIPLESPublic Law 100-321

5/20/88

PRINCIPLESPRINCIPLESEligibilityEligibility

• Onsite participation in a test involving the Onsite participation in a test involving the atmospheric testing of a nuclear deviceatmospheric testing of a nuclear device

• Six month post operational period duties on Six month post operational period duties on related projects or decontaminationrelated projects or decontamination

• Present during a total of 250 days before Present during a total of 250 days before February 1992 on the grounds of a February 1992 on the grounds of a gaseous diffusion plant gaseous diffusion plant – Paducah, KentuckyPaducah, Kentucky– Portsmouth, OhioPortsmouth, Ohio– K25K25– Amchitka Island, Alaska before January 1 1974Amchitka Island, Alaska before January 1 1974

PRINCIPLESPRINCIPLESEligibilityEligibility

• Participation in the Occupation of Participation in the Occupation of Nagasaki or Hiroshima, Japan Nagasaki or Hiroshima, Japan – Between August 6 1945 and July 1 1946.Between August 6 1945 and July 1 1946.– Occupation within 10 mile limitOccupation within 10 mile limit

• Internment as a prisoner of war in JapanInternment as a prisoner of war in Japan– Within 75 miles of HiroshimaWithin 75 miles of Hiroshima– Within 50 miles of NagasakiWithin 50 miles of Nagasaki

• Repatriation through Hiroshima/ Repatriation through Hiroshima/ NagasakiNagasaki

PRINCIPLESPRINCIPLESPresumptive DiagnosesPresumptive Diagnoses

• Leukemia and LymphomasLeukemia and Lymphomas– Excludes CLLExcludes CLL– Excludes Hodgkin's DiseaseExcludes Hodgkin's Disease– Includes Multiple MyelomaIncludes Multiple Myeloma

• Solid TumorsSolid Tumors– ThyroidThyroid– BreastBreast– PharynxPharynx– EsophagusEsophagus– Stomach and small intestineStomach and small intestine– Pancreas and Gall bladder including bile ductPancreas and Gall bladder including bile duct– Liver cancer (except if cirrhosis or hepatitis B or C)Liver cancer (except if cirrhosis or hepatitis B or C)– Salivary glandsSalivary glands– Urinary tract (excludes genitalia)Urinary tract (excludes genitalia)

• 3/26/02: 5 additional cancers added 3/26/02: 5 additional cancers added – Brain, Bone, Lung, Colon, & OvaryBrain, Bone, Lung, Colon, & Ovary

PRINCIPLESPRINCIPLESPublic Law 98-542 10/24/84Public Law 98-542 10/24/84

PRINCIPLESPRINCIPLESPublic Law 98-542 10/24/84Public Law 98-542 10/24/84

•Establish guidelines for resolving Establish guidelines for resolving claimsclaims

•Establish Veterans’ Advisory Establish Veterans’ Advisory Committee on Environmental Committee on Environmental HazardsHazards

•Secretary of Defense to prescribe Secretary of Defense to prescribe guidelines for preparation of guidelines for preparation of radiation dose estimatesradiation dose estimates

•Establish process for independent Establish process for independent dose estimatedose estimate

•38 CFR 3.31138 CFR 3.311

•Establish guidelines for resolving Establish guidelines for resolving claimsclaims

•Establish Veterans’ Advisory Establish Veterans’ Advisory Committee on Environmental Committee on Environmental HazardsHazards

•Secretary of Defense to prescribe Secretary of Defense to prescribe guidelines for preparation of guidelines for preparation of radiation dose estimatesradiation dose estimates

•Establish process for independent Establish process for independent dose estimatedose estimate

•38 CFR 3.31138 CFR 3.311

PROCESSPROCESS

• Presumptive DiagnosisPresumptive Diagnosis– Establish participationEstablish participation

– Medical Evidence of diagnosisMedical Evidence of diagnosis

– Handled at local VAROHandled at local VARO

• Non-PresumptiveNon-Presumptive– 38 CFR 3.31138 CFR 3.311

– All cancers includedAll cancers included

– Some non-cancerous conditions includedSome non-cancerous conditions included

– Any disability or disease may be considered if supported Any disability or disease may be considered if supported by medical or scientific evidenceby medical or scientific evidence

Veteran files claim with the VA Regional Office (VARO) of the

Veterans Benefits Administration (VBA) serving

his/her areaAll non-presumptive claims are

sent through Jackson, MS VARO

Veteran files claim with the VA Regional Office (VARO) of the

Veterans Benefits Administration (VBA) serving

his/her areaAll non-presumptive claims are

sent through Jackson, MS VARO

VARO

Jackson requests documentation of

participation and dose from DTRA

Jackson requests documentation of

participation and dose from DTRA

DTRA researches case and responds by letter to Jackson MS VARO with a copy to the veteran when his/her mailing

address is known

DTRA researches case and responds by letter to Jackson MS VARO with a copy to the veteran when his/her mailing

address is known

VARO

If DTRA confirms participation and provides a positive dose estimate,

VARO submits case to Compensation and Pension (C&P) Service of the VBA in VA Central

Office (VACO), Washington, DC for an advisory opinion

If DTRA confirms participation and provides a positive dose estimate,

VARO submits case to Compensation and Pension (C&P) Service of the VBA in VA Central

Office (VACO), Washington, DC for an advisory opinion

DTRA

OPHEH returns case with a medical opinion to the

C&P Service

OPHEH returns case with a medical opinion to the

C&P Service

C&P Service refers the case to the Office of Public Health and

Environmental Hazards (OPHEH) of the Veterans Health

Administration (VHA) in VACO for a medical opinion on the likelihood

that radiation was responsible

C&P Service refers the case to the Office of Public Health and

Environmental Hazards (OPHEH) of the Veterans Health

Administration (VHA) in VACO for a medical opinion on the likelihood

that radiation was responsible

C & P

OPHEH

VARO makes compensation decision and

informs veteran

VARO makes compensation decision and

informs veteran

C&P Service reviews the medical opinion and

returns case to the VARO with an advisory opinion

C&P Service reviews the medical opinion and

returns case to the VARO with an advisory opinion C & P

VARO

PROCESSPROCESS

• VARO should not refer claims to VACO with a VARO should not refer claims to VACO with a radiation dose estimate prepared by DTRA on radiation dose estimate prepared by DTRA on or before MAY 8, 2003or before MAY 8, 2003

• DTRA will no longer automatically return DTRA will no longer automatically return improper requests for dose reconstruction.improper requests for dose reconstruction.

• DTRA will contact VACO when additional DTRA will contact VACO when additional information or assistance is needed. information or assistance is needed.

• Because…Because…

PROCESSPROCESS

• Senate hearings in 1998 Senate hearings in 1998 • GAO was asked to review the Dose GAO was asked to review the Dose

Reconstruction processReconstruction process• Reconstruction process was validReconstruction process was valid• No Independent Review ProcessNo Independent Review Process• National Research Council (NRC) National Research Council (NRC)

reviewed the process in 2000reviewed the process in 2000• Report out in 2003Report out in 2003

PROCESSPROCESS

• Average doses are validAverage doses are valid• Individual doses highly uncertainIndividual doses highly uncertain• Upper bounds of doses to external exposure to Upper bounds of doses to external exposure to

gamma radiation underestimatedgamma radiation underestimated• Skin and eye doses from Beta particles do not Skin and eye doses from Beta particles do not

seem to have credible upper boundsseem to have credible upper bounds• Skin doses from radioactive particles on skin not Skin doses from radioactive particles on skin not

taken into accounttaken into account• 70% of dose reconstructions were in response to 70% of dose reconstructions were in response to

Veterans’ claims, but most of these are now in Veterans’ claims, but most of these are now in the presumptive category the presumptive category

PROCESSPROCESSMedical OpinionMedical Opinion

• VHACO Office of Public Health and VHACO Office of Public Health and Environmental HazardsEnvironmental Hazards– Director Radiation and Physical ExposuresDirector Radiation and Physical Exposures– Health PhysicistHealth Physicist

• NIOSH IREP Computer ProgramNIOSH IREP Computer Program– 99% Confidence Interval that it is as likely as not99% Confidence Interval that it is as likely as not– Used for Cancers onlyUsed for Cancers only– https://www.niosh-irep.com/irep_niosh/https://www.niosh-irep.com/irep_niosh/

• Non-cancers or those not considered Non-cancers or those not considered radiogenicradiogenic

• No dose estimate availableNo dose estimate available

PROCESSPROCESS

• Skin cancersSkin cancers – need specific site(s) – need specific site(s)

• Throat cancerThroat cancer – need specific organ – need specific organ

• Cataracts Cataracts – only one specific type is on the – only one specific type is on the radiogenic list—any other kind requires existence radiogenic list—any other kind requires existence of medical evidence of medical evidence

• TumorsTumors – need specific site and evidence of – need specific site and evidence of malignancy or radiogenicity (except for brain and malignancy or radiogenicity (except for brain and central nervous system)central nervous system)

• CancersCancers – need target organ if not obvious from – need target organ if not obvious from disease type and classificationdisease type and classification

PROCESSPROCESS Determining Radiation ExposureDetermining Radiation Exposure

PROCESSPROCESS Determining Radiation ExposureDetermining Radiation Exposure

• DD1141 formsDD1141 forms

• Veteran’s service medical recordsVeteran’s service medical records

• Dosimetry officesDosimetry offices

• Department of EnergyDepartment of Energy

• Individual nuclear weapons facilitiesIndividual nuclear weapons facilities

• Projects - HanfordProjects - Hanford

• Air Force: Technical Applications CenterAir Force: Technical Applications Center

• DD1141 formsDD1141 forms

• Veteran’s service medical recordsVeteran’s service medical records

• Dosimetry officesDosimetry offices

• Department of EnergyDepartment of Energy

• Individual nuclear weapons facilitiesIndividual nuclear weapons facilities

• Projects - HanfordProjects - Hanford

• Air Force: Technical Applications CenterAir Force: Technical Applications Center

PROCESSPROCESSDetermining Actual DiagnosisDetermining Actual Diagnosis

• Hospital discharge summariesHospital discharge summaries

• Operative reportsOperative reports

• Sub-specialty consultationsSub-specialty consultations

• Pathology reportsPathology reports

• Death CertificateDeath Certificate

ResourcesResources

• Victoria Cassano, MD, MPHVictoria Cassano, MD, MPH– Victoria.Cassano@va.govVictoria.Cassano@va.gov– 202-461-7221202-461-7221

• Ionizing radiation registryIonizing radiation registry– Helen.Malaskiewicz@va.govHelen.Malaskiewicz@va.gov– 202-461-7226202-461-7226

• Our Website is being upgradedOur Website is being upgraded– http://www.publichealth.va.gov/exposures/radiation/indehttp://www.publichealth.va.gov/exposures/radiation/inde

x.aspx.asp

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