June 25, 2003

EVALUATION PROTOCOL FOR POTENTIAL EXPOSURE TO

DEPLETED URANIUM (DU)

 

1.  PURPOSE

 

 This Veterans Health Administration (VHA) Directive outlines the policy and procedures for evaluating U.S. veterans with possible exposure to depleted uranium (DU).

 

2.  BACKGROUND

 

 a.  DU is natural uranium left over after most of the U-235 isotope has been removed for special purposes, such as for fuel in nuclear power plants. It is about half as radioactive as natural uranium and is a radiation hazard primarily if internalized, such as in shrapnel, contaminated wounds, and inhalation.  In addition to its radioactivity, DU has some chemical toxicity related to being a heavy metal (similar to lead).

 

 b.  During the Gulf War (beginning in 1990), DU was used by the United States military in projectiles and armor for tanks.  Service personnel who may have had potential inhalation exposures to DU include those on, in, or near vehicles hit with "friendly fire," rescuers entering burning vehicles, individuals near fires involving DU munitions, individuals salvaging damaged vehicles, and those near burning vehicles.

 

 c.  The medical effects of DU exposure are continuing to be evaluated.  A group of Gulf War veterans with retained DU fragments or DU-contaminated wounds is being followed at a special DU Program at the Department of Veterans Affairs (VA) Medical Center, Baltimore, MD.  While no clinically significant adverse effects of DU have been evident to date in this group, some abnormalities have been detected on specialized testing.

 

 d.  The Baltimore DU Follow-up Program has determined that for Gulf War friendly-fire victims, a 24-hour urine determination for uranium is a more

sensitive screening test for DU than whole-body counting.   Thus, 24-hour urine uranium concentrations will be used to monitor for DU exposure in soldiers from the OIF conflict.

 

 

NOTE:  For additional background information on DU, see the references in Section 6.

 

3.  SCOPE

 

 Each VHA and MTF facility will use the DU protocol examination to evaluate soldiers identified and referred by the Department of Defense (DOD) or those veterans who self-refer because they are concerned about potential inhalation exposure to DU according to the protocol outlined in Section 5.

 

4.  RESPONSIBILITY

 

 The VHA facility Director is responsible for ensuring that the facility VA Registry programs provide DU protocol examinations to any eligible veterans identified by DOD or any other veterans concerned about possible exposure to DU.

 

 c.  The Baltimore DU program staff is responsible for:

 

 (1)  Arranging for testing of urine samples for uranium.

 

(2) Sending by letter the results of the 24-hour urine for uranium directly to the veteran with a

   copy to the VA or MTF referring clinician.

 

 (3)

 

 (4)  Providing consultative advice to VA and military clinicians regarding DU testing.

 

5.  PROTOCOL

 

 The DU protocol consists of a DU Registry examination, DU exposure questionnaire, and a 24-hour urine collection for creatinine and uranium.

 

 a.  The exposure history contained on VA Form 10-9009D, Depleted Uranium

(DU) Questionnaire (see Att. A) (or the equivalent DOD DU Exposure Questionnaire), must be administered to each veteran who is concerned about possible DU exposure.

 

 b.  Any positive responses to the DU questionnaire are to be followed up with more detailed history-taking by the examining health care provider. The full exposure history must be recorded in the veteran's consolidated health record (CHR) and/or the computerized patient record system (CPRS). All free text on the DU questionnaires must be included in the CHR or CPRS, but not in the Registry dataset at AAC.  Completed DU questionnaires are to be submitted to AAC on completion of protocol examination.

 

 c.  If the veteran was not identified by DOD as possibly DU-exposed, but information provided during the examination of the veteran suggests that the veteran may have had a significant exposure to DU, or if the veteran has a high level of concern that such an exposure occurred despite counseling by the health care provider, a DU protocol examination needs to be completed.

 

 d.  The health care provider must contact the DU Follow-up Program at the Baltimore VA Medical Center (1-800-815-7533) to discuss obtaining a 24-hour urine collection for uranium.  NOTE:  The 24-hour urine collection for uranium must be performed in accordance with instructions in Attachment B. The VA or MTF facility should collect a 24-hour urine collection for uranium following the procedure outlined in Attachment B and samples should sent to the Baltimore VA Medical Center at the address listed in Attachment B.

 

e.

f.  Results of the 24-hour urine for uranium are communicated directly to the veteran by letter from the Baltimore DU Follow-up Program with a copy to the VA or MTF referring physician for the veteran's CHR and/or CPRS..

 

 g.  Follow-up actions for any veteran with an elevated 24-hour urine uranium determination will be individualized based on discussion between the veteran's primary VA or military clinician and the staff at the Baltimore DU Follow-up Program.

 

 h.  Additional diagnostic evaluation of signs or symptoms identified during the examination are to be completed as clinically indicated.  NOTE: Eligible veterans who wish to have VA follow-up care need to be assigned to a primary care team.

 

6.  REFERENCES

 

a) Voelz, George L., Chapter 13 - "Uranium," in Hazardous Material Toxicology, Eds. Sullivan, John B. and Krieger, Gary R.Williams and Wilkins, Baltimore, MD, 1992.

 

b) Health Effects of Depleted Uranium - Fact Sheet, Department of Defense, June 11, 1993.  NOTE:  Copies can be obtained by calling (703) 697-3189.

 

c) "Agency for Toxic Substances and Disease Registry," U.S. Public Health Service, 1990. Toxicologic Profile for Uranium.  PB91-180 471, U.S. Department of Commerce, National Technical Information Service.  NOTE: Customer Service is (703) 487-4660.

 

d) McDiarmid, et al. "Health Effects of Depleted Uranium on Exposed Gulf War Veterans" Environmental Research, Section A, Vol. 82, 2000, pages 168-180.

 

e) McDiarmid, et al. "Urinary Uranium Concentrations in an Enlarged Gulf War Veterans Cohort," Health Physics, Vol. 80, number 3, 2001, pages 270-273.

 

f) McDiarmid, et al. "Surveillance of Depleted Uranium Exposed Gulf War

Veterans:  Health Effects Observed in an Enlarged "Friendly Fire" Cohort, JOEM, Vol. 4, Number 12, December 2001, pages 991-1000.

 

g) VHA website:  www.va.gov/gulfwar

 

 

ATTACHMENT A

 

VA FORM 10-9009D, DEPLETED URANIUM (DU) QUESTIONNAIRE

 

Below is an embedded copy of Department of Veterans Affairs (VA) Form 10-9009D.  This form can also be found on the Veterans Health Administration

(VHA) Forms http://www.va.gov/vaforms or at http://vaww.va.gov/vaforms . This is to be used for local reproduction.  Since this is a low use form, it will not be stocked by the Hines Service and Distribution Center (formerly known as the Forms and Publications Depot).

 

 You should use Adobe Acrobat 5.05 or later to view this form.  To print this form, your printer must be set to "print as image" and "fit to page."