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Proportionate-mortality ratios were calculated for three referent groups: A third followup proportionate-mortality study Watanabe and Kang, used the veterans from Breslin et al. The final study included 70, veterans—33, who served in Vietnam and 36, who never served in SEA—and the analyses were performed with the same referent groups described previously Watanabe et al.

The AOR was set up in to monitor Vietnam veterans' health complaints or problems that could be related to Agent Orange exposure during military service in Vietnam. The examinations consist of an exposure history, a medical history, laboratory tests, and an examination of body systems most commonly affected by toxic chemicals. As of June 1,the registry contained information fromexaminations Agent Orange Review, Using early data from the registry, Bullman et al.

The final analyses include PTSD cases and controls whose military records were used to verify Vietnam service, Military Occupational Specialty Codes MOSCsprimary duties, military branch, dates of Vietnam service, medals, awards, and disciplinary actions for each veteran.

Similarly, Bullman et al. The final analyses in that study included 97 testicular-cancer cases and controls. A surrogate metric for Agent Orange exposure was developed by using branch of service, combat MOSCs, geographic area of service in Vietnam, location of military units in relation to herbicide-spraying missions, and the length of time between spray missions and military operations in sprayed areas.

Watanabe and Kang compared postservice mortality in Vietnam veterans in the Marine Corps with that in Vietnam-era marines who did not serve in Vietnam. All study participants were on active duty during — and were followed from their discharge date or from the date of the US military withdrawal from Vietnam until their date of death or December 31,whichever came first.

The final study population included 10, Vietnam and 9, non-Vietnam veteran marines. All tissue samples were archived specimens from the US Environmental Protection Agency National Human Adipose Tissue Survey and had been collected by hospitals and medical examiners from men who died from external causes or surgical procedures.

Military service—branch of service, MOSC, and geographic service location in Vietnam, if applicable—was researched and verified with military records. Study participants were identified via inpatient discharge records from VA medical centers for fiscal years — Cases were identified as having a malignant lymphoma and a birth date during — Controls were identified from VA medical-center discharge records and were matched by hospital, discharge date, and birth date.

The location and dates of each veteran's military service were verified by using military records. A surrogate Agent Orange exposure opportunity was also developed for each Vietnam veteran according to branch of service, combat experience, and geographic location of the military unit assignment.

The final analysis included cases and controls. Another study by Dalager et al. It used the same method as the Dalager et al. VA has evaluated specific health outcomes, including case-control studies of soft-tissue sarcoma STS Kang et al.

It also has conducted a study of self-reported physical health Eisen et al. VA has examined other outcomes in Vietnam veterans: PTSD Bullman et al. The studies have been included for completeness, but the outcomes that they address are outside the purview of this committee.

Several attempts have been made to estimate exposure of Vietnam veterans who were not part of the Ranch Hand or ACC groups. That involved determining the proximity of troops to Agent Orange spraying by using military records to track troop movement and the HERBS tapes to locate herbicide-spraying patterns.

Vietnam veterans were selected for the study on the basis of the number of Agent Orange hits that they were thought to have experienced given the number of days on which their company was within 2 km and 6 days of a recorded Agent Orange spraying event. The median serum TCDD in Vietnam veterans in was 4 parts per trillion ppt range, under 1 to 45 ppt.

Only two veterans had concentrations above 20 ppt.

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The distribution of TCDD measurements was nearly identical with that in the control group of 97 non-Vietnam veterans. In addition, neither record-derived estimates of exposure nor self-reported exposure to herbicides could predict Vietnam veterans with currently high serum TCDD CDC, aa.

The report concluded that it was unlikely that military records alone could be used to identify a large number of veterans who might have been heavily exposed to TCDD in Vietnam. The study was divided into three parts: Another study O'Brien et al. To evaluate whether self-reported assessment of exposure to herbicides influences the reporting of adverse health outcomes, CDC designed a study of VES participants Decoufle et al.

The serum TCDD measurements in Vietnam veterans also suggested that exposure to TCDD in Vietnam was substantially lower, on the average, than that of persons exposed as a result of the industrial explosion in Seveso or that of the heavily exposed occupational workers who have been the focus of many of the studies evaluated by the present committee.

The assessment of average exposure does not preclude heavy exposure of subgroups of Vietnam veterans. To date the only resulting publication Currier and Holland, on a sample from the NVVRS addressed psychologic outcomes in association with combat trauma and bereavement. Studies examined physical health and reproductive outcomes, social—behavioral consequences, and PTSD in veterans who had served in SEA and elsewhere Snow et al. No additional studies have been published on the cohort. State Studies Several states have conducted studies of Vietnam veterans, most of them unpublished in the scientific literature.

No additional state studies have been published. Additional studies have examined health outcomes that included spontaneous abortion Aschengrau and Monson, and adverse outcomes late in pregnancy in spouses of Vietnam veterans Aschengrau and Monson, After a published study indicated a potential association between testicular cancer in dogs and their service in Vietnam Hayes et al.

VAO summarized those studies, and no additional studies have been published on these study populations. Australian Vietnam-Veteran Studies Over many years the Australian government has commissioned studies to follow health outcomes in two sets of Australian veterans who served in Vietnam. Association of Vietnam service with cancer incidence ADVA, b was sought by comparing diagnoses from — among male Vietnam veterans with those in the general population of Australia.

Additional case-control studies of the incidence of adrenal gland cancers, leukemia, and NHL were conducted in this population AIHW, A related report ADVA, a considered the causes of death of men in all branches of service through The numbers of deaths were 4, in the Army, 1, in the Navy, and in the Air Force. The mortality experience of military personnel serving in Vietnam was compared with that of the general population of Australia and reported by branch of service.

The findings of this study supersede those in the report on mortality from to CDVA, a. There had been several earlier studies of mortality among Austalian Vietnam veterans CIH, abc ; Crane et al.

Those government-sponsored studies of Australian Vietnam veterans did not characterize the veterans' exposure to the herbicides sprayed in Vietnam beyond the fact that they served on land or in Vietnamese waters during May 23, —July 1, It is the convention of VAO committees to regard Vietnam veterans in general as being more likely to have received higher exposures to the COIs than the general public, but it would have been informative to validate that assumption by gathering biomarkers of exposure, such as serum measurements, in a sample of Australian Vietnam veterans.

Update had moved the occurrence of acute myeloid leukemia in offspring of Vietnam veterans to the limited or suggestive category of association primarily on the basis of findings reported by the Australian Institute of Health and Welfare AIHW, but rescinded in a revised report AIHW, The reversal of the conclusion on this matter by the committee for Update is discussed in Veterans and Agent Orange: In wave 1, conducted in —, members of the sample were located and interviewed.

In wave 2, conducted in —, O'Toole et al. The veterans' self-reported health status was compared with that of the general male Australian population gathered during the government's administration of the same survey in — and —; it is not clear that this instrument was administered to the two groups under comparable conditions. The low response rates make the findings vulnerable to nonresponse bias, and the use of self-report measures of health conditions might be of low validity and subject to recall bias.

The committee for Update was skeptical about the reliability of the nearly uniform findings of statistically increased prevalence of nearly 50 health conditions. It is of interest, however, that they found that Case-Control Study of Birth Defects in Australian Infants The Australian government sponsored a case-control study of 8, infants with congenital anomalies born in — at 34 hospitals in New South Wales, Victoria, and the Australian Capital Territory matched by period of birth, mother's age, hospital, and means of hospital payment to live-born infants without diagnosed birth defects Donovan et al.

The fathers of both groups were identified and their names compared to the roster of men who had served in the Australian Army in —; additional means of verification were used to determine whether the child's father had been in the Army during this interval cases and controls and also whether he had been deployed to Vietnam cases and controls.

Adjusting for maternal age, infant sex, multiple births, and father's place of birth, conditional logistic regression was used to compare the Vietnam veterans National Service or regular Army to other era veterans and to all other fathers for all birth anomalies and for seven diagnostic groups.

Kim JS et al. The study involved veterans who served in Vietnam and 25 veterans who did not. The exposure index was based on Agent Orange spraying patterns in military regions in which Korean personnel served, time—location data on the military units stationed in Vietnam, and an exposure score derived from self-reported activities during service.

A total of 13 pooled samples were submitted to CDC for serum dioxin analysis. One analytic sample was prepared from the pooled blood of the 25 veterans who did not serve in Vietnam.

The remaining 12 samples were intended to correspond to 12 exposure categories; each was created by pooling blood samples from 60 veterans. The 12 exposure categories ultimately were reduced to four exposure groups, each representing a quartile of Vietnam veterans but characterized by only three serum TCDD measurements. The paper by Kim JS et al. The statistical analyses apparently were based on the assignment of the pooled serum dioxin value to each person in the exposure group and thereby inflated the true sample size.

The multiple regression analysis evaluated such variables as age, BMI, and consumption of tobacco or alcohol. In a later report on the same exposure groups and serum dioxin data, the authors corrected their analysis Kim JS et al. A correlation was observed between serum dioxin concentrations and ordinal exposure categories, but the correlation was not statistically significant.

The authors attributed the lack of statistical significance to the small sample, and they noted that the data exhibited a distinct monotonic upward trend; average serum dioxin concentrations, 0. The decision to pool blood samples from a large number of persons in each exposure set Kim JS et al. Instead of samples in each of the final exposure categories, the pooled analysis produced only three samples in each category.

The lipid-adjusted serum TCDD concentrations in the 12 pooled samples from Vietnam veterans ranged from 0. The narrow range of results makes the biologic relevance of any differences questionable. Thus, it appears that there was not a clear separation between Korean Vietnam veterans and non-Vietnam veterans.

The relatively low serum dioxin concentrations observed in the s in those people are the residual of substantially higher initial concentrations, as has been seen in other Vietnam-veteran groups. However, the concentrations reported in the Korean-veterans study are significantly lower than are those reported in American Vietnam veterans in the CDC AOVS, which was nonetheless unable to distinguish Vietnam veterans from non-Vietnam veterans on the basis of serum dioxin CDC, a.

The Korean authors were able to construct plausible exposure categories based on military records and self-reporting, but they were unable to validate the categories with serum dioxin measurements.

The age range was limited to 50—70 years to reflect the current age of Korean veterans of the Vietnam War. There were patients: Medical records were reviewed to determine a variety of cardiovascular recovery outcomes. T tests, chi-square tests, and logistic regression were used to determine whether measures of recovery differed between the acute coronary patients who had served in Vietnam and those who had not.

The study findings are not informative about associations between TCDD and acute coronary syndrome itself, as the researchers allege. Exposure characterization varies widely in the metric used, the extent of detail, confounding by other exposures, and whether individual, surrogate, or group ecologic measures are used. Some studies use job titles as broad surrogates of exposure; others rely on disease-registry data. The committee reviewed many epidemiologic studies of occupationally exposed groups for evidence of an association between exposure to TCDD or to the herbicides used in Vietnam—primarily the phenoxy herbicides 2,4-dichlorophenoxyacetic acid 2,4-D and 2,4,5-trichlorophenoxyacetic acid 2,4,5-T —and health risks.

In reviewing the studies, the committee considered two types of exposure separately: That separation is necessary because some health effects could be associated with exposure to 2,4-D or 2,4,5-T in the absence of substantial TCDD exposure.

After recognition of the problem of dioxin contamination in phenoxy herbicides, production conditions were modified to minimize contamination, but use of the products most subject to containing specifically TCDD 2,4,5-T and Silvex was banned. As a result, study participants exposed to phenoxy herbicides only after the late s would not be assumed to have been at risk for exposure to TCDD.

The distinction is particularly important for workers in agriculture and forestry, including farmers and herbicide appliers, whose exposure is primarily the result of mixing, loading, and applying herbicides.

In addition to those occupational groups, the committee considered studies of occupational exposure to dioxins, focusing on workers in chemical plants that produced phenoxy herbicides or chlorophenols, which tend to be contaminated with polychlorinated dibenzo-p-dioxins PCDDs.

Waste-incineration workers were also included in the occupation category because they can come into contact with dioxin-like compounds while handling byproducts of incineration. Other occupationally exposed groups included were pulp and paper workers exposed to dioxins through bleaching processes that use chlorinated compounds, and sawmill workers exposed to chlorinated dioxins that can be contaminants of chlorophenates used as wood preservatives.

Twenty cohorts were combined for the analysis: There were 12, production workers and 5, sprayers in the full cohort. Questionnaires were constructed for workers who were manufacturing chlorophenoxy herbicides or chlorinated phenols and for herbicide sprayers; the questionnaires were completed with the assistance of industrial hygienists. Information from production records and job histories was examined when available.

Workers were classified as exposed, probably exposed, with unknown exposure, or nonexposed. The exposed-workers group 13, consisted of all those known to have sprayed chlorophenoxy herbicides and all who worked in particular aspects of chemical production. Two subcohorts totaling had no job titles available but worked in chemical-production facilities that were likely to produce TCDD exposure, so they were deemed probably exposed. Workers with no exposure information were classified as of unknown exposure.

Nonexposed workers 3, were those who had never been employed in parts of factories that produced chlorophenoxy herbicides or chlorinated phenols and had never sprayed chlorophenoxy herbicides. An expanded and updated analysis of the IARC cohort with an emphasis on cancer mortality was published in Kogevinas et al. The 21, male and female workers exposed to phenoxy herbicides or chlorophenols were classified in three categories of exposure to TCDD or higher-chlorinated dioxins: Several exposure metrics were constructed for the cohort—years since first exposure, duration of exposure in yearsyear of first exposure, and job title—but detailed methods were not described.

The overall results were for mortality in —, but for some of the subcohorts, followup had begun as late asand at the time of publication, mortality in some had been tracked only through For nonneoplastic causes of death, Vena et al. International Agency for Research on Cancer Subcohorts In addition to the NIOSH cohort and its component subcohorts discussed belowseveral of the subcohorts that make up the IARC cohort have generated independent reports that have been evaluated separately by VAO committees to garner additional insights, such as results associated with TCDD concentrations measured in some subjects: Several of the component cohorts have not been the subject of any separate publications: Australian herbicide sprayers, Canadian herbicide sprayers, Finnish production workers, two cohorts of Italian production workers, and Swedish production workers.

The international production-worker cohorts are discussed below in alphabetical order, followed by the NIOSH cohort and its subcohorts. The section on studies of herbicide-using workers, which follows discussion of all production-worker studies, includes consideration of the separate reports on the New Zealand herbicide sprayers.

Dutch production workers The two Dutch subcohorts of the IARC cohort consist of 2, male workers employed in two manufacturing factories producing and formulating chlorophenoxy herbicides: Accordingly, members of both subcohorts had potential exposure to phenoxy herbicides, but only those in factory A could have been exposed to TCDD.

The study populations were defined as all workers who worked in factory A during — or factory B during — On the basis of an assumption of first-order TCDD elimination with an estimated half-life of 7.

A regression model was then used to estimate, for each cohort member, the effect on estimated maximum TCDD exposure attributable to exposure as a result of the accident, duration of employment in the main production department, and time of first exposure before or after Both cohorts were followed throughaccumulating 65, person-years, with deaths observed. Death certificates obtained by linkage to Statistics Netherlands were used to ascertain cause-specific mortality, including various cancers, endocrine or blood diseases, nervous system, ischemic heart disease, other heart disease, cerebrovascular diseases, respiratory diseases, digestive diseases, and genitourinary diseases.

Exposure to chlorophenoxy herbicides was determined on the basis of the type of work experience such as production vs office and involvement in the accident of in factory A factory A: TCDD measures taken in support that exposure classification; the highest mean TCDD concentrations were found in workers involved in the accident 1, Cox proportional-hazards models with attained age as the time scale were used to assess hazard ratios for exposed vs nonexposed workers.

Exposure to phenoxy herbicides and dioxins was expected to be different between factory A and factory B, and the factories were therefore analyzed separately. Further nested case-control studies were conducted for the factory A cohort by using all cancer cases and three controls per case matched on age and employment period; analysis used conditional logistic regression.

Since Updateseveral new studies based on this cohort have been published. From May to Septemberblood was drawn for the determination of plasma TCDD concentrations in a systematically selected subsample of workers in factory A, 86 in factory B.

The combination of linear regression on the log-transformed serum results and work-history details was used to derive a model to predict current TCDD in the entire cohort, from which back-extrapolation predicted each person's concentration when he left employment in factory A or B.

A Cox proportional-hazards model was used to assess exposure—outcome relationships on the basis of the predicted exposures as a time-varying covariate. To allow for latency, a 1-year lag was used for noncancer endpoints and a year lag for cancer outcomes.

The log-linear TCDD model was applied to the workers in factory A only and to the entire cohort, including workers from factory B, who had been exposed only to phenoxy herbicides as confirmed by the serum samples from the 86 factory B subjects who had only background concentrations of TCDD. Saberi Hosnijeh et al. TCDD exposure was characterized by using exposure status exposed vs nonexposedcurrent serum concentration, and back-extrapolated serum concentration at the time of last exposure.

Logarithmic transformation was used for TCDD and immune-marker concentrations. Statistical analyses were conducted with t tests, chi-square tests, and linear regression. These scholarships recognize individuals furthering their education who have volunteered their time in making the many programs of the Believe in Books Literacy Foundation successful, and who have truly captured the giving spirit. These scholarships are intended to aid in the oncoming academic year and are used as reimbursements in the purchase of educational tools such as books, supplies, and software.

The Believe in Books Literacy Foundation awards scholarships annually to further their contribution to the community and also to promote their literacy programs. The scholarship program is one of many that the Believe in Books Literacy Foundation has created to engage those seeking to further their education in their community, involving them in the goals of exercising the mind and body of children with education and engagement of healthy habits.

For more information about the program call or visit www. Performances will be every Friday at Children ages 3 and under are FREE. Goldilocks and the Three Bears July 3: The Pied Piper of Hamelin July Puss in Boots July Arabian Nights July The Three Little Pigs July The Emperor's New Clothes Aug 7: Snow White and the Seven Dwarves Aug Pinocchio This program is one of many that the Believe in Books Literacy Foundation has created to reach the goals of exercising the mind and body of youngsters through education and healthy habits.

They were also winners of Song, Album and Producer of the Year for The concert is a fundraiser for the Believe in Books Literacy Foundation. The Adam Ezra Group continues to pile up accolades for their music and live performances. It was an honor to tour with them.

The races will take place on the first Sunday of every month from June — October. Registration will begin at 9am, the kids race will start at 9: There will be three levels of races; expert, sport, and beginner.

This will be a great opportunity for family fun outdoors on the Trails in the Wood with music, prizes, food, and drinks to follow. For more information about this event please visit www. The Believe in Books Literacy Foundation is happy to host this event, as it meets their goals of exercising the mind and body of youngsters with education and engagement of healthy habits.

This event is one of many that the Believe in Books Literacy Foundation has created to match the goals of exercising the mind and body of youngsters with education and engagement of healthy habits.

The 5K trail run starts at 9: The Kids Fun Runs begin at 9: Runners and walkers may register for the runs at www. This event is presented by the Medical Staff of the Memorial Hospital with the following sponsors joining them: For more information on the Literacy Foundation please call or visit www.

Entrants were required to write about what Dr. Seuss' story The Lorax means to them. Children were prompted to make up a story, relate a true experience, or write a poem of words or less. Inventive spelling was encouraged and accepted in honor of Dr. Entries must have had at least one original, clear and colorful illustration as part of the story and were judged on originality, creativity, storytelling, and imagination.

This program is one of many that the Believe in Books Literacy Foundation has created to reach the goals of exercising the mind and body of youngsters through education and healthy habits. The contest begins on Monday, March 23rd and ends on April 10, Entrants are required to write about what Dr. Children may make up a story, relate a true experience or write a poem. Only single author stories qualify; please no co-authored stories or parents.

Inventive spelling is encouraged and accepted in honor of Dr. Each story must not exceed words. Text must be printed or written legibly. Story must have at least one original, clear and colorful illustration as part of the story.

Entries will be judged on originality, creativity, storytelling, imagination and integration of artwork. More information is available at www. The entries will be judged as follows: Kindergarten and first grade. Winners will be announced on Monday, April 13th.

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A presentation honoring the winners will be held as part of the Earth Day Celebration with Dr. This program is one of many that the Believe in Books Literacy Foundation has created to match the goals of exercising the mind and body of youngsters with education and engagement of healthy habits.

The Foundation is encouraging families to participate in the tapping and collecting of sap on their own property, which will then be exchanged for Acre Wood Maple Syrup at the end of the season. The on-site Sugar Shack will have all the supplies needed to tap and collect the sap and will be open on weekends from 11am — 4pm to provide families with tapping supplies and advice. They will also offer a guided wagon ride through the woods once a day on the weekends where you can learn about the history of sugaring, how to identify maple trees, tap for sap, collection and sample tasting.