IGWC MESSAGE BOARD - Compensation, Treatment, and Research Resources

CFIDS(Chronic Fatigue and Immune Dysfunction Syndrome)

usafang1967 — Thur, 11 Jun 2009 01:19:44 GMT

Hello all,
Does anyone belong to CFIDS(http://www.cfids.org/default.asp)?
They have a lot of info on those who has CFS/GWI.

Forum: Compensation, Treatment, and Research Resources

Understanding Post-Mycoplasma

ryan_khoo — Sun, 14 Sep 2008 18:00:03 GMT

My 9 year old boy was down with fever and I took him to visit a GP. The sequence of event are as follows:

Day 1: Cough and Fever developed and appeared for the first time at night.

Day 2: Highest recorded fever is 41 degree Centrigade. Took him to a GP. Doctor said that the throat was red and there was wheezing sound in the chest. Was prescribed some antibiotic and paracetemol to control the fever.

Day 5: Fever still did not go away although the fever fluctuates between 38 to 40. So took him to the same GP and was prescribed the same antibiotic as the doctor said that the throat was no more red and lungs was "cleared"

Day 8: As the cough and fever remains, the GP advised to go to hospital for a checukp. At the hospital, after some blood test and x-ray was taken, the doctor changed the antibiotic to Augmentin.

Day 11: No signs of improvement, so took my boy to the Hospital again. Xray was taken again and this time the doctor susptected it is mycoplasma and prescribed Azithromycin for 5 doses (ie 1 dose each day). Took 1st dose of Azithromycin

Day 12: Took 2nd dose of Azithromycin. Fever down to normal but fever appeared again after 22 hours of no fever. But the fever fluctuates from normal to 38.

Day 13: Fever and cough cured. But still took 3rd doage.

Day 14: Took 4th dose despite being cured. But boy showed sign diziness, tiredness and sign of imbalance (he cannot stand still with both eyes closed and remain unsteady). Took him to Hospital but doctor said he needed a rest. Doctor suspected the dowsiness was due to sign effects of promithezane. Similarly no fever and cough.

Day 15: No fever but notice insignificant on-off cough. Sign of imbalance deteriorates. Loss of appetite, vomitted and face look pale. So took him to Hospital again. The boy was examined and was asked to perform many tasks. This time was warded to due suspicion of meningitis.

Blood test was done on an emergency basis. result of blood test is negative. MRI scan was done and results of MRI is negative so tumour was ruled out. Fluid was extracted from his spine and result was negative so meningitis was ruled out.

Doctor at the hospital then concluded that the imbalance was due to post-mycoplama. The doctor explained that no medicine will be prescribed for post-mycoplsma and will leave it for the body will fight itself. The doctor explained that post-mycoplsma is the body's reaction to mycoplasma by attacking its own brain. So with time, as the attack ceased, the boy will turn back to normal.

My questions are as follows:

1) If post-mycoplasma is the body's reaction to attack its own brain. Why in some (or most) cases of mycoplasma, the body did not attack the brain ?

2) How does the body decides when to attack the brain and when not to attack the brain ?

3) How does the body knows when to stop attacking the brain ?

4) What will happen if the body continue and did not stop attacking the brain ?

5) How do we ensure that the body will stop attacking the brain ?

6) Is this phenomena of of body's reaction to attack its own brain due to side effect of azithromycin or due to the anti-body produced by the body to fight the mycoplasma ?

Your opinion is gratly appreciated.

Thank you.

Forum: Compensation, Treatment, and Research Resources

Annual Report to Congress, Research on GWI 2007

IGWCADMIN — Sat, 06 Sep 2008 05:58:37 GMT

http://www.research.va.gov/resources/pubs/GulfWarRpt07.cfm

ANNUAL REPORT TO CONGRESS
Federally Sponsored Research on
Gulf War Veterans Illnesses for 2007
July 2008
Deployment Health Working Group Research Subcommittee

i
Federally Sponsored Research on
Gulf War Veterans Illnesses for 2007
DEPLOYMENT HEALTH WORKING GROUP
RESEARCH SUBCOMMITTEE MEMBERS
Department of Veterans Affairs:
William J. Goldberg, PhD (VA Co-Chair)
K. Craig Hyams, MD, MPH
Richard Johnston, MD, Captain, Royal Navy, British Liaison Officer
(ex officio)
Department of Defense:
Bart Kuhn (DoD Co-Chair)
Kelley Ann Brix, MD, MPH
Salvatore M. Cirone, DVM, MPVM
Janet R. Harris, PhD, RN, Colonel, US Army Nurse Corps
Carl A. Castro, PhD, Colonel, Medical Service Corps, US Army
Department of Health and Human Services:
Drue H Barrett, PhD, Captain, USPHS
G. Bryan Jones, PhD, Captain, USPHS
Annual Report to
Congress V 2007
ii
iii
TABLE OF CONTENTS
EXECUTIVE SUMMARY ............................................................................................... 1
I. INTRODUCTION.........................................................................................................................1
II. RESEARCH PRIORITIES ...........................................................................................................1
III. RESEARCH RESULTS, CALENDAR YEAR 2007...................................................................1
IV. RESEARCH FUNDING TRENDS, FISCAL YEARS 1998 V 2007...........................................1
V. NEW RESEARCH PROJECTS AND INITIATIVES................................................................1
I. INTRODUCTION.......................................................................................................... 2
II. RESEARCH PRIORITIES.......................................................................................... 2
A. Nineteen Research Topics..............................................................................................................2
B. Research Portfolio Descriptors .....................................................................................................3
C. Portfolio Criteria ............................................................................................................................4
III. RESEARCH RESULTS AND STATUS OF THE FIELD IN 2007 ....................... 6
A. Brain and Nervous System Function ............................................................................................6
B. Environmental Toxicology.............................................................................................................7
C. Immune Function and Infectious Diseases ..................................................................................9
D. Reproductive Health ......................................................................................................................9
E. Symptoms and General Health ...................................................................................................10
F. Abstracts from Published Research............................................................................................12
IV. RESEARCH FUNDING TRENDS, FISCAL YEARS 1998 - 2007 ...................... 46
V. NEW RESEARCH PROJECTS AND INITIATIVES ............................................ 49
A. New Initiatives ..............................................................................................................................49
B. Portfolio Review ...........................................................................................................................49
C. New Projects ................................................................................................................................49
VI. REFERENCES .......................................................................................................... 52
APPENDICES, FEDERALLY FUNDED RESEARCH PROJECTS ........................ 61
Appendix A: Project Index by Department .......................................................................................62
Appendix B: Project List by Research Focus Areas .........................................................................80
Appendix C: Project Funding, Fiscal Years 1998 - 2007................................................................103
1
EXECUTIVE SUMMARY
I. INTRODUCTION
Section 707 of Public Law 102-585, as amended by section 104 of Public Law 105-368, requires that an annual report
be submitted to the Senate and House Veterans Affairs Committees on the results, status, and priorities of research
activities related to the health consequences of military service in the Gulf War (Operations Desert Shield and Desert
Storm; August 2, 1990 V July 31, 1991). The Research Subcommittee of the interagency Deployment Health Working
Group (DHWG) prepared this 2007 Annual Report to Congress, which is the fourteenth report on Federal research and
research activities. The DHWG tracks all federally funded research projects related to Gulf War veterans illnesses
(GWVI).
As in previous Annual Reports to Congress, the material presented is divided into 5 sections. Section I is an
introduction; Section II summarizes the research priorities and organization of the Federal Gulf War (GW) research
portfolio; Section III highlights and summarizes research progress published since the last Annual Report; Section IV
summarizes Federal funding trends for GW research during the 10-year period from fiscal year (FY) 1998 through FY
2007; and Section V highlights new research projects and initiatives.
II. RESEARCH PRIORITIES
The research priorities remain unchanged from last year. The 19 Research Topics (2 were eliminated in last years
report) are grouped into five major Research Focus Areas. These Research Focus Areas are used to organize Sections
III and V, as well as Appendix B (Project Listing by Research Focus Area). In November 2005, at the request of the
Secretary of Veterans Affairs (VA), the VA Office of Research and Development (ORD) developed a set of criteria for
inclusion of VA-funded projects in the GW research portfolio and then evaluated the entire VA research portfolio for
projects meeting those criteria. The criteria used as the basis for the review are presented in Section II.
III. RESEARCH RESULTS AND STATUS OF THE FIELD IN 2007
Section III provides brief summaries of research on the health problems of GW veterans which was published in
English during calendar year 2007. Research results are grouped according to the five Research Focus Areas used to
organize the 19 Research Topics (see Section II): Brain and Nervous System Function, Environmental Toxicology,
Immune Function, Reproductive Health, and Symptoms and General Health Status. In this section, published research
results are described followed by specific study abstracts taken from PubMed.
IV. RESEARCH FUNDING TRENDS
From FY 1992 through FY 2007 the Departments of Veterans Affairs (VA), Defense (DoD), and Health and Human
Services (HHS) funded 345 distinct projects related to health problems affecting GW veterans. The scope of the
Federal research portfolio is broad, from small pilot studies to large-scale epidemiology studies involving large
populations and major center-based research programs. Federal funding for research on GWVI totaled $267 million for
the period from FY 1998 through FY 2007. As of September 30, 2007, 272 projects (79 percent of the 345 projects)
were completed, and 73 projects (21 percent) were new or ongoing.
V. NEW RESEARCH PROJECTS AND INITIATIVES
Nine projects were funded through the FY06 Gulf War Veterans' Illnesses Research Program (GWVIRP) and three
were funded through the Peer Reviewed Medical Research Program (PRMRP), both managed by the Congressionally
Directed Medical Research Program (CDMRP) at DoD. These projects focused on Brain and Nervous System Function
(2), Environmental Toxicology (3), and Symptoms and General Health (7). Although funded from the FY06
appropriation, these projects did not actually begin until FY 2007. The two key priority areas for the FY06 GWVIRP
were Identification and evaluation of currently available treatments and Identification of objective indicators of
pathology that distinguish ill from healthy veterans.
VA funded 2 new projects in FY 2007; one focused on Environmental Toxicology and the other on Symptoms and
General Health.
2
I. INTRODUCTION
The Secretary of Veterans Affairs (VA) is required by section 707 of Public Law 102-585, as amended by section 104
of Public Law 105-368, to submit an annual report on the results, status, and priorities of research activities related to
the health consequences of military service in the GW to the Senate and House Committees on Veterans Affairs. The
Research Subcommittee of the interagency Deployment Health Working Group (DHWG) prepared this Annual Report
to Congress for 2007, which is the fourteenth report on research and research activities (DHWG, 2004; DHWG, 2005;
DHWG, 2006a; DHWG, 2006b; DHWG, 2007; MVHCB, 2001; MVHCB, 2002; PGVCB, 1995; PGVCB, 1996b;
PGVCB, 1997; PGVCB, 1998; PGVCB, 1999; PGVCB, 2001). The DHWG tracks all federally funded research
projects related to GWVI.
As in previous Annual Reports to Congress, the material presented is divided into five sections. Section I is an
introduction. Section II summarizes the research priorities and organization of the Federal GW research portfolio.
Section III highlights and summarizes published research progress since the last Annual Report. Section IV summarizes
Federal funding trends for GW research during the 10-year period from FY 1998 through FY 2007. Section V
highlights new research projects and initiatives since the last Annual Report.
II. RESEARCH PRIORITIES
A. Nineteen Research Topics
The Persian Gulf Veterans Coordinating Board (PGVCB) was created in 1994 to coordinate research from VA, DoD,
and HHS on GWVI. In 1995, the PGVCB devised a contextual framework for the results of completed and ongoing
studies and also to develop an approach for the interpretation of research results. To that end, the PGVCB identified 19
major research questions and subsequently added two additional questions in 1996 (PGVCB, 1996a), to bring the total
to 21. The comprehensive GW research portfolio has addressed each of these 21 questions, and relevant results have
been published on each one. The Military and Veterans Health Coordinating Board (MVHCB), the successor
organization to the PGVCB, conducted a comprehensive assessment of the progress made on each of these 21 questions
in the Annual Report to Congress for 2000. The Research Subcommittee of the DHWG, which was established to
address a broader range of deployment health issues, reviewed the 21 questions and replaced them with a corresponding
list of 21 Research Topics for the Annual Report to Congress for 2004 (DHWG, 2006a).
The original list of 21 questions has been reduced to 19. Based on the Institute of Medicine of the National Academies
(IOM) review of the scientific literature on infectious diseases (Institute of Medicine, 2006b) and the state of our current
scientific knowledge, the conclusion was reached in last years Annual Report that there is no rationale to continue
inclusion of infectious diseases as an area of research that will provide answers to the causes or cure for these
symptoms. Questions 2 and 19 have, therefore, been removed from the original list of 21 Questions and the third
Research Focus Area has been refocused from Immune Function and Infectious Diseases to just Immune Function.
Projects originally identified as Gulf War research under these two questions will continue to be listed in Appendices
A and B, but no funding amounts will be shown for FY 2007 or beyond.
Similarly, PTSD-related projects that were originally included in the Federal Gulf War research portfolio will be closed
as of FY2007 (i.e., no funds listed in Appendix C) if they do not directly study a population of ill Gulf War veterans or
are not investigating treatments that may prove beneficial for ill Gulf War veterans.
The IOM report reviewing the available literature on Amyotrophic Lateral Sclerosis (ALS) in veterans (Institute of
Medicine, 2006a) concluded there is limited and suggestive evidence of an association between military service and
later development of ALS. This strengthens the decision to include ALS as a relevant topic in the Federal portfolio of
Gulf War research (DHWG, 2006b). ALS projects included in the GW portfolio are primarily focused on
epidemiologic studies in GW veterans and the development of new methodologies to identify and/or treat ALS.
The organization of the 19 Research Topics into five major categories is described in Section B below.
3
B. Research Portfolio Descriptors
VA maintains a research database of federally sponsored research on GWVI. This includes research conducted by
Federal scientists, as well as that by non-Federal scientists supported by Federal research funds through grants,
contracts, and cooperative agreements. It is not possible to accurately track research efforts that fall within the private
sector or otherwise outside of the purview of the Federal government.
Nonetheless, the Research Subcommittee of the DHWG attempts to stay abreast of all research relevant to GWVI. This
is accomplished by monitoring peer-reviewed published scientific literature, attending scientific meetings, and even
using newspaper reports and personal accounts of researchers.
Appendix A lists the projects that VA, DoD, and HHS have funded to date. Research projects are grouped according to
the department that is responsible for funding. Dual-funded projects are listed under both departments.
Appendix B lists all federally funded GW research projects, regardless of the agency providing the funding. Three
descriptors are used to categorize each funded project.
The first descriptor is the primary Research Focus Area of the project. The five Research Focus Areas are also used to
organize the 19 Research Topics (see Section A, above).
h Brain and Nervous System Function (e.g., studies on neurological or psychological deficits and/or alterations)
h Organic neuropsychological and neurological deficits (original Question 16)
h Psychological symptoms and/or diagnoses (original Question 18)
h Environmental Toxicology (e.g., studies focused on specific environmental exposures such as pesticides, oil well
fires, jet fuel, vaccines, medical prophylactic agents, etc.)
h Petroleum products and combustion products (original Question 3)
h Occupational/environmental hazards (original Question 4)
h Organophosphorus nerve agent and/or sulfur mustard from bombing at Muhammadiyat or weapons bunker at
Khamisiyah (original Question 5)
h Chemical agents, other than at Khamisiyah (original Question 6)
h Pyridostigmine bromide (PB) and other medical prophylaxes (e.g., vaccines and anti-malarials) (original
Question 7)
h Psychophysiological stressors (original Question 8)
h Short term, low level exposures to pyridostigmine bromide, N,N-diethyl-m-toluamide (DEET), or permethrin,
alone or in combination as a cause of short-term and/or long-term neurological effects (original Question 17)
h Immune Function (e.g., studies on alterations in immune function or host defenses)
h Altered immune function or host defense (original Question 10)
h Reproductive Health (e.g., studies on sexual and/or reproductive dysfunction)
h Birth defects in offspring (original Question 11)
h Lower reproductive success (original Question 12)
h Sexual dysfunction (original Question 13)
h Symptoms and General Health (e.g., studies on mortality, pulmonary disease, cancer, chronic multisymptom
illnesses, etc.)
h Increased prevalence or severity of symptoms and/or illnesses (original Question 1)
h Nonspecific symptoms and symptom complexes (e.g., chronic multisymptom illnesses) (original Question 9)
h Changes in lung function or airway reactivity (original Question 14)
h Smaller baseline lung function or greater degree of nonspecific airway reactivity (original Question 15)
h Development of cancers of any type (original Question 20)
h Mortality rates (original Question 21)
4
Secondary and/or tertiary Research Focus Areas from the above list may also be assigned. Two additional Research
Focus Areas may be used for secondary and tertiary assignments. This permits accounting for projects that cover
multiple focus areas.
h Chemical weapons (e.g., sarin, sulfur mustard, etc.)
h Pyridostigmine bromide and other medical prophylaxes (e.g., vaccines, pyridostigmine bromide, antimalarials, etc)
The second descriptor is the Project Focus, categorized as follows:
h Diagnosis: studies that will improve the ability to diagnose previously unexplained conditions, or to better refine
diagnoses with new tools
h Exposure: studies that examine individual exposures and/or interactions of exposures (chemical, biological,
pharmacological, physiological, etc.)
h Interactions: interactions of combined exposures (chemical, biological, pharmacological, physiological, etc.)
h Prevention: studies that will produce knowledge that could lead to disease prevention strategies
h Symptoms: prevalence and risk factors for symptoms and alterations in general health status
h Treatment: development or testing of new therapies
Each project is assigned up to three Project Focus areas as categorical descriptors. This allows accounting for projects
that cover multiple focus areas. For example, a project on the neurophysiological effects of exposure to sarin in animals
would have a focus on the brain and nervous system, and a focus on chemical weapons. The number of focus areas
(between one and three) assigned to a project depends on the project itself.
The third descriptor for each project is Research Type. Each research project on GWVI uses a method of approach to
test a specific research hypothesis. Although precise categorization of research types can be difficult because of
overlapping methodologies, research projects can be divided into the following general types:
MECHANISTIC: Research into underlying mechanisms of diseases and illnesses using in vitro and in vivo models.
CLINICAL: Application of an intervention, such as in a controlled drug trial, or use of methodologies such as casecontrol
studies to define risk factors for disease.
EPIDEMIOLOGY: Study of the distribution and determinants of disease in human populations. It includes populationbased
studies focused on outcomes such as mortality, symptoms, hospitalizations, etc., using devices such as postal
surveys, telephone interviews, and reviews of medical records.
In addition to tracking research on GWVI, the DHWG also tracks development activities. In general, development is
the systematic use of the knowledge or understanding gained from research directed toward the production of materials;
devices; systems; or methods, including design, development, and improvement of prototypes and new processes.
Within the context of GWVI, the DHWG categorizes activities as development as follows:
DEVELOPMENT: An activity that satisfies the general definition of development described above, and is directed
toward new biologically based prevention, intervention, and treatment measures.
The research database on GWVI catalogs only research and development activities that either directly involve GW
veterans or answer specific questions about risk factors. An example of the latter is a research project using animal
models to determine health effects of low-level chemical warfare agents. The database does not account for the vast
accumulated knowledge derived from the Nations investment in more generalized biomedical research over the past 50
years.

Forum: Compensation, Treatment, and Research Resources

Sleep Disorders Nexus

IGWCADMIN — Sat, 30 Aug 2008 05:22:55 GMT

Posted in behalf of Robert White: Robert F. White

You need to get a nexus opinion letter. You can cite this study below if you have a SC disability that deals with Sinusitis, Rhinitis or some type of nasal obstruction. If you want to know more about the nexus letter contact Gale and she can forward your email to me.

Nasal obstruction as a risk factor for sleep-disordered breathing. The University of Wisconsin Sleep and Respiratory Research Group.

Young T, Finn L, Kim H.

Department of Preventive Medicine, University of Wisconsin, Madison 53705, USA.

Nasal obstruction frequently has been associated with sleep-disordered breathing as a potential etiologic factor. Nasal obstruction results in pathologic changes in airflow velocity and resistance. Experimentally produced nasal obstruction increases resistance and leads to sleep-disordered breathing events, including apnea, hypopnea, and snoring. Clinical research examining the correlation between nasal obstruction and sleep-disordered breathing is limited, especially in regard to patients with conditions that increase nasal resistance, such as rhinitis and sinusitis. To further identify risk factors for sleep-disordered breathing, the role of chronic and acute nasal congestion was investigated in a population-based sample. Data on nasal congestion history and sleep problems were obtained by questionnaire (n = 4927) and by objective inlaboratory measurement (n = 911). Participants who often or almost always experienced nighttime symptoms of rhinitis (5 or more nights a month) were significantly (p < 0.0001) more likely to report habitual snoring (3 to 7 nights a week), chronic excessive daytime sleepiness, or chronic nonrestorative sleep than were those who rarely or never had symptoms. Habitual snorers had significantly (p < 0.02) lower air flow than nonsnorers, although a linear relation between decreased airflow and sleep-disordered breathing severity did not exist. Participants who reported nasal congestion due to allergy were 1.8 times more likely to have moderate to severe sleep-disordered breathing than were those without nasal congestion due to allergy. Men and women with nasal obstruction, especially chronic nighttime symptoms of rhinitis, are significantly more likely to be habitual snorers, and a proportion also may have frequent episodes of apnea and hypopnea, indicative of severe sleep-disordered breathing. Because allergic rhinitis is a common cause of nasal obstruction and it is a modifiable risk factor, further study of this association is warranted.

Forum: Compensation, Treatment, and Research Resources

Mycoplasma and Gulf War Syndrome - 24Apr08

IGWCADMIN — Fri, 25 Apr 2008 11:38:44 GMT

http://weeksmd.com/?p=697

Mycoplasma and Gulf War Syndrome

Antibiotics Recommended When Indicated for

Treatment of Gulf War Illness/CFIDS/FMS

By Prof. Garth L. Nicolson

The Institute for Molecular Medicine

15162 Triton Lane, Huntington Beach,

California 92649-1041

Tel: (714) 903-2900 Fax: (714) 379-2082

e-mail: gnicimm@ix.netcom.com

Doxycycline

(AKA Vibramycin, Monodox, Doxychel, Doxy-D, Doryx)

Doxycycline is a broad spectrum tetracycline with good lipid solubility and ability to penetrate the blood-brain-barrier. This antibiotic acts by inhibiting microorganism protein synthesis, it is readily absorbed by the (normal) gut, and peak blood concentrations are maintained between 2-18 hours (half-life 18-22 hours) after an oral dose of drug. Food, calcium, magnesium and antacids reduce absorption, and alcohol, phenytoin or barbiturates reduce blood half-life.

For Gulf War Illness/Chronic Fatigue Syndrome/Fibromyaligia Syndrome (GWI/CFIDS/FMS) use, the recommended dose is 200-300 mg/day (oral, 2-3100 mg capsules) for each 6 week cycle of therapy. Initially, doxycycline initially exacerbates symptoms (Herxheimer reactions or adverse antibiotic responses, such as transient fever, skin, gut discomfort, etc.) but these are usually gone within 2 weeks or so. Patients usually start feeling better with alleviation of most major signs and symptoms within 2-6 weeks, but in some patients major symptoms are not alleviated until the second 6-week course. Severe reactions or prior damage to the gastrointestinal system may require I.V. administration of 100-150 mg/day (rapid I.V. administration is to be avoided) for 2-3 weeks, then the remainder of the 6 week course should be on oral antibiotic (to avoid thrombophlebitis complications which can occur with prolonged I.V. therapy). Some react to the starch filler in the capsules and must use Doryx, a granular form of doxycycline.

Virtually all patients relapse (show the same major signs and symptoms) after the end of the first and second 6-week course of therapy, and these can be run together without a pause. In a pilot study, >85% relapsed after 2 cycles, and after 5 and 6 cycles, 27% and 11%, respectively, still relapsed after discontinuing antibiotic therapy.

In some cases doxycycline has been used successfully with other antibiotics in situations where either antibiotic alone appeared to have minimal effect (for example, doxycycline in combination with Ciprofloxacin). Doxycycline is primarily bacteriostatic and effective against the following organisms: gram-negative bacteria (N. gonorrhoeae, Haemophilus influenzae, Shigella species, Yersinia pestis, Brucella species, Vibrio cholera); gram-positive bacteria (Streptococcus pneumoniae, Streptococcus pyogenes); myco plasmas (Mycoplasma pneumoniae, Mycoplasma fermentans , Mycoplasma penetrans); others (Bacillus anthracis , Clostridium species, Chlamydia species, Actinomyces species, Entamoeba species, Treponema pallidum , Plasmodium falciparum and Borelia species).

Precautions: Avoid direct sunlight and drink fluids liberally. Doxycycline therapy may result in overgrowth of fungi or yeast and nonsensitive microorganisms (see Other Considerations). Patients on anticoagulants may require lower anticoagulant doses. Last half of pregnancy, infancy and children under 8 years are not recommended, in the latter case due to tooth discoloration, but lower doses of doxycycline have proven to be very effective in children under 8 with GWI/CFIDS (if weight 100 lbs. or less, 1-2 mg/lb. divided into two doses; if is weight over 100 lbs. use adult doses). Patients with impaired kidney function should not take doxycycline, and the following drugs should not be taken with doxycycline: methoxyflurane , carbamazepine , digoxin or diuretics.

In case of complicating bacterial infections, a 2 week course of Augmentin (3 X 500 mg/day) should be taken between courses of doxycycline or other antibiotics. For fungal and yeast complications, please see the instructions under. Other Considerations at the end of this handout.

Adverse Reactions: In a few patients doxycycline causes gastrointestinal irritation, anorexia, vomiting, nausea, diarrhea, rashes, mouth dryness, hoarseness and in rare cases hypersensitivity reactions, hemolytic anemia, skin hypersensitivity and reduced white blood cell counts. In general, doxycycline is considered a safe drug, in that there are few adverse reactions reported in the literature.

Ciprofloxacin

(AKA Cipro, Cifox, Cifran, Ciloxan, Ciplox)

Ciprofloxacin is a broad spectrum synthetic fluoroquinolone antibiotic with good absorption characteristics. This drug acts on bacterial DNA gyrase to inhibit bacterial DNA synthesis. Ciprofloxacin is secreted rapidly in the urine and has a half-life in the blood of about 4 hours. Food delays the absorption of antibiotic (by ~2 hours) but not the total absorption; antacids containing magnesium, aluminum or other salts reduce absorption and should not be taken at the same time of day.

For GWI/CFIDS/FMS use, the recommended dose is 1500 mg/day (for oral use, 3500 mg capsules) for each 6 week cycle of therapy. Ciprofloxacin may or may not be taken with meals. Initially, Ciprofloxacin may exacerbate some symptoms (Herxheimer reactions or adverse antibiotic responses) but these are usually gone within a week or so, and some patients report that doses of 1000 mg/day or lower are not effective in alleviating GWI/CFIDS/FMS symptoms. Patients usually start feeling better with alleviation of most major signs and symptoms within 1-4 weeks, but in some patients major symptoms are not alleviated until the second 6-week course. Ciprofloxacin has been used in patients in which doxycycline cannot be tolerated or in some patients that no longer respond to doxycycline. In a few cases Ciprofloxacin has been used simultaneously with doxycycline, but the usual course is one type of antibiotic alone.

Herxheimer reaction, if present, usually passes within a few days to 2 weeks or so; prior damage to the gastrointestinal system may require I.V. administration of 400 mg/day (over one hour per each infusion, rapid I.V. administration is to be avoided) for 2-4 weeks, then the remainder of the 6-week course should be on oral antibiotic (oral doses). Virtually all patients relapse (show the same major signs and symptoms) after the end of the first or second 6-week course of therapy. Additional cycles of antibiotic result in milder relapses after drug is discontinued. Subsequent cycles of antibiotics may require the use of doxycycline or other antibiotics instead of Ciprofloxacin.

Ciprofloxacin is effective against the following organisms: gram-negative bacteria (Shigella species, Citrobacter diversus, Citrobacter freundii, Escherichia coli, Klebsiella pneumoniae, Haemophilus influenzae, Enterobacter species, Proteus vulgaris, Psuedomonas aeruginosa, Yersinia pestis, Vibrio cholera); gram-positive bacteria (Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus hominis, Staphylococcus saprophytieus); mycoplasmas, moderately active (Mycoplasma species); others (Clostridium species, Chlamydia species, Mycobacterium tuberculosis).

Precautions: Direct sunlight is to be avoided, and patients should not take Ciprofloxacin and theophyline concurrently. Ciprofloxacin therapy may result in drug crystals in the urine in rare cases, and patients should be well hydrated to prevent concentration of urine. Pregnant women and children should not use this drug due to reduction in bone and cartilage development.

Adverse Reactions: Adverse antibiotic responses resulted in discontinuing drug in ~3.5% of patients, and such reactions included nausea (5%), diarrhea (2%), vomiting (2%) abdominal pain (1.7%), headache (1.2%) and rash (1.1%). In rare cases Ciprofloxacin may cause cardiovascular problems (<1%) and central nervous system (dizziness, insomnia, tremor, confusion, convulsions and other reactions (<1%). Small numbers of patients have experienced hypersensitivity (anaphylactic) reactions which have required immediate emergency treatment.

Azithromycin

(AKA Zithromax)

Azithromycin is an azalide (macrolide) antibiotic with good absorption and a serum half-life of 68 hours. This class of drug acts by binding to the 50S ribosomal subunit of susceptible organisms where it interferes with protein synthesis. Food decreases absorption rate, but absorption is unaffected by antacids containing magnesium, aluminum or other salts. For GWI/CFIDS/FMS use, the recommended dose is 500 mg/day (for oral use, 2250 mg capsules) for each 6-week cycle of therapy. Azithromycin should not be taken with meals (1 hour before or 1 hour after). Initially, azithromycin may exacerbate some symptoms but these are usually gone within a week or so. Patients usually start feeling better with alleviation of most major signs and symptoms within 1-2 weeks, but in some patients major symptoms are not alleviated until the second 6 week course. Azithromycin has been used in patients in which doxycycline cannot be tolerated or in some patients that no longer respond to doxycycline. Herxheimer reactions are rare and usually pass within a few days to a week or so. Virtually all patients relapse (show the same major signs and symptoms) after the end of the first or second 6-week course of therapy. Additional cycles of antibiotic result in milder relapses after drug is discontinued. Azithromycin has been shown to be safe for pediatric use (10 mg/kg/day is recom mended for children under 14).

Azithromycin is effective against the following organisms: gram-negative bacteria (Bordetella pertussis, Shigella species, Haemophilus influenzae, Chlamydia species, Yersinia pestis, Brucella species, Vibrio cholera); gram-positive bacteria (Streptococci group C, F, G); mycoplasmas (Mycoplasma species); others (Clostridium species, Treponema pallidum , and Borelia sp.).

Precautions: Azithromycin is principally absorbed by the liver, and caution should be exercised with patients with impaired liver function. Antacids containing magnesium, aluminum or other salts should not be taken at the same time of day with azithromycin. Macrolides and terfenadine (Seldane) or astemizole (Hismaral) may dangerously elevate plasma antihistamine and cause arrhythmias and increase serum theophyline levels in some patients, particularly those receiving methylated xanthine causing nausea, vomiting, seizures. Plasma levels of carbamazepine (Tegretol) can also be elevated, leading to carbamazepine toxicity and nausea, vomiting, drowsiness and ataxia.

Adverse Reactions: Adverse antibiotic responses were mild to moderate in clinical trials and included diarrhea (5%), nausea (3%), abdominal pain (3%). In rare cases (<1%) azithromycin may cause cardiovascular problems (palpitations, tachycardia, chest pain) and central nervous system (dizziness, headache, vertigo), allergic (rash, photosensitivity, angioderma), fatigue and other reactions (<1%). In pediatric patients >80% of the adverse responses were gastrointestinal.

Clarithromycin

(AKA Biaxin)

Clarithromycin is a broad spectrum macrolide antibiotic with good absorption and serum half-life. This class of drug acts by binding to the 50S ribosomal subunit of susceptible organisms and interfering with protein synthesis. The drug is mostly bacteriostatic but high concentrations can be bactericidal. Food decreases absorption rate, but absorption is unaffected by antacids containing magnesium, aluminum or other salts.

The recommended dose is 500-750 mg/day (for oral use, 2-3250 mg capsules) for each 6-week cycle of therapy. Clarithromycin should not be taken with meals (1 hour before or 1 hour after). Initially, Clarithromycin may exacerbate some symptoms due to Herxheimer reaction and bacterial death but these are usually gone within a week or so.

Patients usually start feeling better with alleviation of most major signs and symptoms within 1-2 weeks, but in some patients major symptoms are not alleviated until the second 6-week course. Clarithromycin has been used in patients that do not respond to doxycycline or in patients that cannot tolerate doxycycline. Herxheimer reactions usually pass within a few days to over a week or so. Virtually all patients relapse (show the same major signs and symptoms) after the end of the first or second 6-week course of therapy. Additional cycles of antibiotic result in milder relapses after drug is discontinued.

Clarithromycin is effective against the following organisms: gram-negative bacteria (Neisseria gonorrhoeae, N. meningitides, Moraxella catarrhalis, Campylobacter jejuni, Eikenella corrodens, Haemophilus ducreyi, Bordetella pertussis, Shigella species, Salmonella species, Haemophilus influenzae, Chlamydia species, Yersinia pestis, Brucella species, Vibrio cholera, Aeromonos species, E. coli, gram-positive bacteria (Streptococcus pyogenes, S. pneumeniae, anerobic Streptococci, Enterococcus faccalis, Staphlococcus aureus, S. epidermidis, Bacillus anthracis, Corynebacterium diptheriae, C. minutissimum, Listeria monocytogenes, Actinomyces israelii); mycoplasmas (Mycoplasma species, M. pneumoniae, Ureaplasma urealyticum); others (Clostridium species, Treponema pallidum , Legionella pneumophilia, L. micdadei, Mycobacterium avium, M. chelonae, M. chelonae absessus, M. fortuitim, Rickettsia species and Borrelia species). Yeasts, fungi and viruses are resistant.

Precautions: Clarithromycin is principally absorbed by the liver, and caution should be exercised with patients with impaired liver function. Antacids containing magnesium, aluminum or other salts should not be taken at the same of day as azithromycin. Macrolides and terfenadine (Seldane) or astemizole (Hismaral) may dangerously elevate plasma antihistamine and cause arrhythmias and increase serum theophyline levels in some patients, particularly those receiving methylated xanthine causing nausea, vomiting, seizures. Plasma levels of carbamazepine (Tegretol) can also be elevated, leading to carbamazepine toxicity and nausea, vomiting, drowsiness and ataxia. Macrolides should not be used with cyclosporin (Sandimmune).

Adverse Reactions: Adverse antibiotic responses were mild to moderate in clinical trials and included diarrhea, nausea, and abdominal pain. In rare cases (<1%) azithromycin may cause cardiovascular problems (palpitations, tachycardia, chest pain) and central nervous system (dizziness, headache, vertigo), allergic (rash, photosensitivity, angioderma) and fatigue.

Other Information

(see Additional Considerations)

GWI/CFIDS/FMS patients are often low in vitamins (B, C and E) and minerals. Sublingual (under the tongue) natural B-complex vitamins (Total B, Real Life Research, Norwalk, CA) can be ordered from Vitamin Park (Irvine, CA). General vitamins plus extra C and E and general mineral supplements are also useful, but not at the same time of day that antibiotics are taken because minerals can affect the absorption of the antibiotics. Selenium and magnesium are two of the minerals that are low in GWI/CFIDS/FMS patients. Some have recommend 300-500 mg/day sodium selenite for a few days, followed by lower maintenance doses. Some zinc supplementation is recommended. L- cysteine supplementation has been proposed but should not be taken at the same time as minerals.

Antibiotics can result in yeast overgrowth, especially in female patients. Gynecologists recommend Nizoral, Diflucan, Mycelex, or anti-yeast creams for women on antibiotics. In some cases, simultaneous use of metronidazole (Flagyl, Prostat) have been used to prevent fungal and parasite overgrowth or antifungals (Nystatin, Amphotericin B, Fluconazole) have been administered for fungal infections that can occur while on antibiotics. To replace bacteria in the gastrointestinal system yogurt, Lactobacillus acidophillus tablets are recommended. In some patients organic food has been beneficial. Caffeine should be avoided. On page 1 are instructions for suppressing bacterial overgrowth (if necessary) in between cycles of antibiotics with a 2 week course of Augmentin (3 X 500 mg/day). Augmentin can be taken concurrently with the other antibiotics, if necessary.

A number of natural remedies, such as ginseng root, whole lemon/olive oil drink or an extract of olive leaves with antioxidants (Eden or Immunoscreen of Covina, CA), and a mixture of herbals and vitamins (Nu-Life Formula, Sophista-Care of Indian Wells, CA) have been used to boost immune systems. Although these products appear to help CFIDS/FM patients, their effectiveness in GWI/CFIDS/FM patients has not been examined. They appear to be useful after antibiotic therapy.

Finally, GWI/CFIDS/FMS patients should not smoke and not drink alcohol, caffeinated products or eat refined sugar, and they should avoid pollutant exposure, especially those who are chemically sensitive. Flying, excessive exercise and lack of sleep can make signs/symptoms worse; some exercise (dont over do it!) and dry saunas help rid the system of contaminating chemicals.

_____________

Additional Considerations when Undergoing

Treatment for Gulf War Illness/CFS/FMS

By Prof. Garth L. Nicolson

The Institute for Molecular Medicine

15162 Triton Lane, Huntington Beach,

California 92649-1041 Tel: (714) 903-2900

Fax: (714) 379-2082

e-mail: gnicimm@ix.netcom.com

There are a number of considerations that should be taken into account when undergoing therapy for Gulf War Illness/Chronic Fatigue Syndrome/Fibromyaligia . A few are mentioned below, and some product examples are given. The Institute for Molecular Medicine is a nonprofit institution and does not endorse commercial products. The products mentioned below are only examples of the types of substances that could be beneficial to patients. Consult with your physician.

Antibiotic Therapy for Associated Chronic Infections

Please consult Antibiotics Recommended When Indicated for Treatment of Gulf War Illness/CFS/ FMS for general information. We are finding that subsets of GWI (~45%) and FMS/CFS (~60%) patients have chronic mycoplasmal infections, and probably other chronic infections as well. We usually recommend to physicians that antibiotics (doxycycline, ciprofloxacin, Biaxin, minocycline, azithromycin) be given for several 6 week cycles with 2 week cycles of Augmentin in between or concurrently, if needed. To overcome Herxheimer reactions or die-off that cause chills, low grade fever, night sweats, muscle aches, joint pain, short term memory loss and fatigue) or adverse responses, IV antibiotics have been used, and a whole lemon/olive drink is useful (1 blended whole lemon, 1 cup fruit juice, 1 TBS olive oilstrain and drink liquid). This period usually passes within 1-2 weeks. During recovery, which is often slow and can take over a year with ups and downs in your condition, a number of additional nutritional and immune problems must be considered.

General Nutritional Considerations

GWI/CFS /FMS patients are often immunosuppressed and could be susceptible to a variety of opportunistic infections, so proper nutrition and exercise are important. GWI/CFS/FMS patients should not smoke or drink alcohol or caffeinated products. Drink as much fresh fluids as you can, lots of fruit juices or pure water are best. Try to avoid high sugar and fat foods, such as military (MRE) or other fast foods and acid-forming, allergen-prone and stressing foods or junk foods. Increase your intake of fresh vegetables, fruits and grains, and decrease your intake of fats and eliminate simple or refined sugars that can suppress your immune system. To build up your immune system cruciferous vegetables, soluble fiber foods, such as prunes and bran, wheat germ, yogurt, fish and whole grains are useful. In some patients exclusive use of organic foods have been beneficial.

Vitamins and Minerals

GWI/CFS/FM patients are often depleted in vitamins (especially B, C and E) and certain minerals. Unfortunately, illnesses like GWI result in poor absorption. Therefore, high doses of some vitamins must be used, and the gut (oral capsules) cannot easily absorb others, such as vitamin B complex. Sublingual (under the tongue) natural B-complex vitamins in small capsules or liquids (such as Total B, Real Life Research, Norwalk, CA, 310-926-5522) should be used instead of oral capsules that are swallowed. General vitamins plus extra C, E, CoQ-10, beta-carotene, folic acid, bioflavoids and biotin are best. L-cysteine, L-tyrosine, L-carnitine and malic acid are reported by some to be useful. Certain minerals are also often depleted in GWI/CFS/FMS patients, such as zinc, magnesium, chromium and selenium. Some recommend doses as high as 300-mg/day-sodium selenite for a few days, followed by lower maintenance doses. Minerals should not be taken at the same time of day that antibiotics are taken because the minerals can affect the absorption of certain antibiotics.

Replacement of Natural Gut Flora

GWI/CFS/FMS patients are often undergoing treatment with antibiotics and other substances that can destroy the normal gut flora. Antibiotic use that depletes normal gut bacteria and can result in over-growth of less desirable bacteria. To supplement bacteria in the gastrointestinal system yogurt and especially Lactobacillus acidophillus tablets are recommended. One product is a mixture of Lactobacillus acidophillus, Lactobacillus bifidus and FOS (fructoologosaccharides) to promote growth of these friendly bacteria in the gut (example, DDS-Plusor Multi-Flora ABF, UAS Labs of Minnetonka, MN, 800-422-3371). L. acidophillus should be taken daily to restore gut flora. A human bowel culture, Replete (Interplex) has proven useful to restore natural gut flora.

Natural Immunoenhancers or Immunomodulators

A number of natural remedies, such as ginseng root, herbal teas, whole lemon/olive extract drink or an extract of olive leaves with antioxidants are available and are potentially useful, especially during or after antibiotic therapy has been completed. Some examples are botanical mixtures, such as Eden, Echinacea-C (NF Formulas, 800-547-4891), Super-Immunotone (Phyto Pharmica, 800-553-2370), olive leaf extract (Immunoscreen of Covina, CA, 818-966-1610), NSC-100 (Nutritional Supply, Carson City, NV, 888-246-7224), a mixture of herbals and vitamins (Nu-Life Formula, Sophista-Care, Indian Wells, CA, 760-837-1908) or Super Defense Plus (BioDefense Nutritionals, Grand Terrace, CA, 800-669-9205). These have been used to boost immune systems. Although these products appear to help some CFS/FMS patients, their clinical effectiveness in GWI/CFS/FMS patients has not been evaluated. They appear to be useful during therapy to boost the immune system or after antibiotic therapy in a maintenance program to prevent relapse of illness.

Yeast/Fungal or Bacterial Overgrowth

Yeast overgrowth can occur, especially in female patients (vaginal infections). Gynecologists recommend Nizoral, Diflucan, Mycelex, or anti-yeast creams for women on antibiotics. In some cases, use of metronidazole (Flagyl, Prostat) have been used to prevent fungal or parasite overgrowth or other antifungals (Nystatin, Amphotericin B, Fluconazole, Diflucan) have been administered for fungal infections that can occur while on antibiotics. As described above, L. acidophillus should be taken daily to restore gut flora. Bacterial overgrowth can also occur, for example, in between cycles of antibiotics or after antibiotics have been stopped. This can be controlled with 2-week courses of Augmentin (3 X 500 mg/day) in between cycles or concurrent with other antibiotics.

Flying and Exercise

Flying, especially in unpressurized aircraft, excessive exercise and lack of sleep can make GWI/CFS/FMS signs/symptoms worse. Some exercise (Please dont over do it! A common problem when recovering from this illness is over-exertion followed by relapse!) is useful and even necessary for recovery. The main problem here is to adjust your exercise level to help the recovery process without causing a relapse. Dry saunas help rid the system of contaminating chemicals, and saunas should be taken at least 3-5X per weekmoderate exercise, followed by 15-20 min of dry sauna and tepid shower. The sauna can be repeated, by not more than two per day. The idea is to raise body temperature enough to work up a good sweat, eliminating chemicals without placing too much stress on your system. During exercise GWI/CFS/FMS patients should always try to avoid pollutant and allergen exposures. For recovery after exercise and to decrease muscle soreness, some use a Jacuzzi or hot tub, but only after a sufficient cool-down period. Dont get overheated in the process.

Forum: Compensation, Treatment, and Research Resources

Current Clinical Trials and Research

IGWCADMIN — Fri, 05 Oct 2007 01:59:23 GMT

Email forwarded by DSNurse. --Gale

Sleep Disordered Breathing in Gulf War Syndrome Veterans and the Effect of Continuous Positive Airway Pressure (CPAP) Treatment

This study is currently recruiting participants.
Verified by Department of Veterans Affairs May 2007

Sponsored by:	Department of Veterans Affairs
Information provided by:	Department of Veterans Affairs
ClinicalTrials.gov Identifier:	NCT00252629

Purpose

The purpose of this study is to determine any sleep disordered breathing in veterans with Gulf War Syndrome (GWS) and compare it to healthy normal asymptomatic Gulf War veterans. This study will also determine the effect of treatment with continuous positive airway pressure on veterans with Gulf War Syndrome.

The investigators hypothesize that sleep complaints (insomnia, un-refreshing sleep and daytime fatigue) among GWS patients are related to increased sleep fragmentation in GWS patients.
The investigators hypothesize that increased collapsibility of the upper airway during sleep with the development of inspiratory flow limitation (IFL) causes the increased sleep fragmentation in GWS patients.
The investigators hypothesize that correction of IFL in GWS patients will result in an improvement of their sleep quality resulting in an improvement of their sleep complaints and other functional symptoms.

Condition	Intervention
Chronic Fatigue Syndrome Apnea, Sleep	Procedure: CPAP treatment

Study Type: Interventional
Study Design: Treatment, Randomized, Double-Blind, Placebo Control, Factorial Assignment, Efficacy Study

Official Title: Inspiratory Flow Dynamics During Sleep in Gulf War Syndrome (GWS) and the Effect of Continuous Positive Airway Pressure (CPAP)

Further study details as provided by Department of Veterans Affairs:

Primary Outcome Measures:

Objective 1: The arousal indices and sleep stage shifts (mean + standard deviation ) reported for GWS patients and GW normals
Objective 2: The prevalence of flow limited breaths during sleep in GWS patients
Objective 3: The assumption that the investigators will observe a 50% decrease in fatigue and sleep problems and a 45% decrease in pain in patients with GWS (from their preliminary GWS patients pilot study)
the postulated placebo response is a 10% decrease.

Total Enrollment: 44

Expected completion: October 2008

Hypothesis 1: To demonstrate that compared to Gulf War Veterans without GWS, GWS patients have decreased total sleep and increased sleep fragmentation

In order to accomplish this goal and subsequent goals, we will assemble two samples of Gulf War veterans. The first will be a sample of male GWS patients and the second will be a sample of male Gulf War veterans without GWS (Gulf War veteran control group). All of the GWS patients will be registered in the Gulf War Veterans Registry. To avoid referral bias favoring the presence of IFL during sleep, we will enroll GWS patients by contacting them from the Registry and inviting them to participate. Gulf War veteran controls will be recruited in the same way and by advertisement. Prospective study participants will be screened on several self-report instruments to determine eligibility and assignment to the GWS group or to the Gulf War veteran control group. Criteria for assignment to the GWS group are scores above the designated clinical cutpoint on each of three instruments measuring cognitive difficulties, pain, and fatigue. Conversely, criteria for assignment to the GW Veteran control group will require scores in the non-clinical range on each of those instruments. Every subject will have a full night polysomnogram.

Hypothesis 2: To demonstrate that the presence of IFL during sleep among GWS patients distinguishes them from Gulf War veterans without GWS

A second sleep study will be used to accomplish this second objective. Using precise methods, we will quantify the prevalence of IFL during sleep in GWS patients and in Gulf War veteran controls. Following completion, each study will be staged using Rechtschaffen and Kales criteria. From each study, 3 three minute periods of continuous NREM sleep (a total of approximately 120 breaths) will be randomly selected and analyzed for the prevalence of flow limited breaths. During the three minute periods, all of the breaths will be analyzed whether they occur during sleep or during brief (< 15 second) arousals.

Hypothesis 3: To demonstrate that relief of IFL during sleep will result in improvement of the functional symptoms of GWS patients

We will accomplish this utilizing a double blind, placebo-controlled trial of nasal continuous positive airway pressure (CPAP) in GWS patients. Functional symptoms will be assessed using validated, self-report questionnaires and daily ratings of symptoms with an electronic diary.

Eligibility

Ages Eligible for Study: 32 Years - 52 Years, Genders Eligible for Study: Male

Criteria

Inclusion Criteria:

First Gulf War veterans with and without the syndrome
Males
Between 32 and 52 years of age
No history of current alcoholism nor opiate use
No history of current active depression nor post-traumatic stress disorder (PTSD)

Exclusion Criteria:

Females
History of active alcoholism or opiate drug use
History of active depression and PTSD

Location and Contact Information

Please refer to this study by ClinicalTrials.gov identifier NCT00252629

Mohammad Amin, MD 631-261-4400 Ext. 2469 mohammad.amin2@med.va.gov
Pamela Jannello 631-261-4400 Ext. 2475 pamela.jannello@med.va.gov

United States, New York
VAMC - Northport, NY, Northport, New York, 11768, United States; Recruiting

Anne Whelton, BA 631-261-4400 Ext. 2865 anne.whelton@med.va.gov
Dorothy Baker, BA 631-261-4400 Ext. 2850 dorothy.baker@med.va.gov
Mohammad Amin, MD, Principal Investigator

Study chairs or principal investigators

Mohammad Amin, MD, Principal Investigator, VAMC - Northport, NY

More Information

Publications

Self-reported illness and health status among Gulf War veterans. A population-based study. The Iowa Persian Gulf Study Group. JAMA. 1997 Jan 15;277(3):238-45.

Barrett DH, Gray GC, Doebbeling BN, Clauw DJ, Reeves WC. Prevalence of symptoms and symptom-based conditions among Gulf War veterans: current status of research findings. Epidemiol Rev. 2002;24(2):218-27. Review. No abstract available.

Study ID Numbers: RCD-001-05S
Last Updated: May 15, 2007
Record first received: November 9, 2005
ClinicalTrials.gov Identifier: NCT00252629
Health Authority: United States: Federal Government
ClinicalTrials.gov processed this record on October 04, 2007

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Forum: Compensation, Treatment, and Research Resources

VA/M-10 Policy Manual for Gulf War Vets (no longer in publication)

IGWCADMIN — Sat, 25 Aug 2007 20:30:35 GMT

The VA has pulled the M-10 Policy Manual regarding Gulf War Veterans from its publications and replaced it with a 38 page Handbook 1303.2 (much more brief in its evaluations). A copy of the old M-10 Policy Manual can be seen here: http://www.gulfwarcouncil.com/vam10_manual_for_gulf_war_vete.htm

Suggest you keep a copy of it for referring to when we need to insist on its revision to include more detailed evaluations and demand it be brought back into publication. The M-10 for Agent Orange still seems to be in place (for now).

Forum: Compensation, Treatment, and Research Resources

March 7, 2005 VHA HANDBOOK 1303.2 - UNIFORM CASE ASSESSMENT PROTOCOL (UCAP)

IGWCADMIN — Tue, 23 Jan 2007 16:39:09 GMT

This is excerpted from the VHA Gulf War Handbook. These are the tests (from the VA healthcare protocol) which are authorized for veterans with the related conditions. Providing you are eligible for VA care and treatment, you should review this to make sure you have been adequately evaluated for your condition(s).

March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX F
F-1
UNIFORM CASE ASSESSMENT PROTOCOL (UCAP)
1. Phase I-Level Laboratory Evaluations
a. Complete Blood Count (CBC),
b. Urinalysis, and
c. Blood Chemistry - SMA-6. (SMA is a Manufacturers Trademark for a Chemistry
Analyzer)
2. Phase II-Level Evaluation Protocol. Phase II-Level Evaluations are recommended for those
veterans after complete clinically-indicated evaluations are conducted and the clinician
determines that the patient has an unexplained illness. Individuals who, after completing Phase I
or registry evaluations, have a disability and do not have a clearly defined diagnosis which
explains their symptoms, must receive the following supplemental baseline laboratory tests and
consultations.
a. Supplemental Baseline Laboratory Tests
(1) CBC,
(2) Sedimentation Rate Erythrocyte Sedimentation Rate (ESR),
(3) C-Reactive Protein,
(4) Rheumatoid Factor,
(5) Anti-Nuclear Antibody (ANA),
(6) Liver Function,
(7) Creatine Phosphokinase (CPK),
(8) Hepatitis Serology,
(9) Human Immunodeficiency (HIV),
(10) Venereal Disease Research Laboratory (VDRL),
(11) B-12 and Folate,
(12) Thyroid Function Test,
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX F
F-2
(13) Urinalysis, and
(14) Tuberculosis (TB) skin test Purified Protein Derivative (PPD).
b. Consultations, to include:
(1) Dental, but only if participants annual screening is not done.
(2) Infectious Disease.
(3) Psychiatry, but only with physician-administered instruments.
(a) Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental
Disorders, Third Edition, Revised (DSM III-R). NOTE: Delete modules for mania and
psychosis.
(b) Clinician Administered Post-traumatic Stress Disorder (PTSD) Scale (CAPS).
(4) Neuropsychological Testing, but only as indicated by a psychiatry consult.
c. Symptom-specific Examination. Individuals who have the following symptoms need to
have the listed minimum work-up.
(1) Diarrhea, to include:
(a) Gastrointestinal (GI) consult,
(b) Stool for Ova and Parasites (O&P),
(c) Stool Leukocytes,
(d) Stool culture,
(e) Stool volume,
(f) Colonoscopy with biopsies, and
(g) Esophagastroduodenoscopy (EGD) with biopsies and aspiration.
(2) Abdominal pain to include:
(a) GI consult,
(b) EGD with biopsy and aspiration,
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX F
F-3
(c) Colonoscopy with biopsy,
(d) Abdominal Ultrasound,
(e) Upper Gastrointestinal (UGI) series with small bowel follow-through, and
(f) Abdominal Computed Tomography (CT) Scan.
(3) Headache
(a) Magnetic Resonance Imaging (MRI) of the head, and
(b) Lumbar Puncture (LP) to include:
1. Glucose,
2. Protein,
3. Cell Count,
4. VDRL,
5. Oligoclonal (lgG),
6. Myelin basic protein,
7. Opening pressure, and
8. Neurology.
(4) Muscle Aches and/or Numbness
(a) Electromyogram (EMG), and
(b) Nerve Conduction Velocity (NCV).
(5) Memory Loss, only if verified by neuropsychological testing, to include:
(a) Magnetic Resonance Imaging (MRI),
(b) LP, NOTE: See tests on headache evaluation.
(c) Neurology consult,
(d) Neuro-psychological testing,
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX F
F-4
(6) Vertigo and/or Tinnitus, to include:
(a) Audiogram,
(b) Electronystamogram (ENG), and
(c) Brainstem Auditory Evoked Response (BAER).
(7) Chronic Fatigue, to include:
(a) Polysomnography, and
(b) Multiple Sleep Latency Test (MSLT).
(8) Chronic Cough and/or Shortness of Breath, to include:
(a) Pulmonary Consult,
(b) Pulmonary Function Test (PFT) with exercise and Arterial Blood Gases (ABG),
(c) If routine PFTs are negative, perform Methacholine challenge test, and
(d) Bronchoscopy with biopsy and/or lavage which is to be considered if PFTs are normal.
(9) Chest Pain and/or Palpitations, to include:
(a) Electrocardiogram (ECG),
(b) Exercise Stress Test, and
(c) Holter monitor.
(10) Skin Rash, to include:
(a) Dermatology consult, and
(b) Consider a biopsy.
(11) Reproductive Concerns, to include for:
(a) Males, an urology consult; and
(b) Females, a gynecology (GYN) consult.
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX F
F-5
(c) Additional elements recommended for the evaluation of Gulf War veterans with
complaints of Reproductive Health Problems (RHP):
1. Detailed genitourinary history and/or problems, e.g.,:
a. Sexual,
b. Genitourinary symptoms,
c. Menstrual,
d. Contraceptive practices,
e. Pregnancy-related,
f. Conception,
g. Birth defects,
h. Congenital disorders,
i. Menopause,
j. Prior infections,
k Prior surgery, and
l. Exposures to toxic agents, etc.
2. Detailed genital and/or pelvic examination.
3. Laboratory and ancillary testing, e.g.;
a. Pap tests; and
b. Tests for genitourinary infections.
4. Urologist consultation for male veterans who have RHP that cannot be diagnosed or
managed successfully by primary care practitioners.
5. Gynecology consultation for female veterans who have RHP that cannot be diagnosed or
managed successfully by primary care practitioners.
(d) Additional elements for evaluation of Gulf War veterans with complaints of infertility.
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX F
F-6
1. Detailed menstrual and reproductive history (such as the Infertility Questionnaire utilized
by Walter Reed Army Medical Center).
2. Semen analysis, e.g.:
a. Volume,
b. pH,
c. Liquefaction,
d. Sperm concentration,
e. Motility,
f. Progressive motility,
g. Sperm viability,
h. Leukocytes, and
i. Morphology.
3. Referral to an infertility specialist or program.
(e) Additional elements for evaluation of GW veterans with complaints related to birth
defects or genetic disorders in offspring conceived during or after GW service.
1. Detailed history of congenital or genetic disorders (such as the Patient Genetic Screen
Questionnaire utilized by Walter Reed Army Medical Center).
2. Detailed occupational exposures questionnaire (such as Worker and Supervisor
Questionnaires utilized by National Naval Medical Center).
3. Referral to a genetic disease specialist or program.
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX G
G-1
INSTRUCTIONS FOR COMPLETING GULF WAR
UNIFORM CASE ASSESSMENT PROTOCOL (UCAP), PHASE II, PART III
1. General Instructions for Completing Department of Veterans Affairs (VA) Gulf War
Registry Examination, Uniform Case Assessment Protocol (UCAP), Phase II.
a. The Phase II examination needs to be offered to all eligible Gulf War (including Operation
Iraqi Freedom) veterans with unexplained illnesses. The Phase II examination needs to be
performed after the completion of the Phase I registry examination and a thorough clinicallybased
evaluation of the veterans symptoms as deemed necessary by the examining physician.
b. Phase II needs to be performed at the local VA medical facility or if the medical expertise
is unavailable, local referral must be made to the nearest regional tertiary care center or War
Related Illness and Injury Study Center (WRIISC). NOTE: Refer to VHA Handbook 1303.5 or
website http://www.va.gov/environagents and video entitled War and Health: Treating War-Related
Illnesses at VAs WRIISCs.
2. Instructions for Completing Part III, Phase II
a. Tests and Consultations. Only those entries which are related to the veterans symptoms
and deemed necessary by the examining physicians need to be completed; leave test and consult
questions that are not applicable blank Select either (Y)es or (N)o from the pull-down menu.
NOTE: Refer to website http://vaww.registries.aac.va.gov for instructions.
(1) Item 1. Were the following tests performed? Enter one of the following codes from the
pull-down menu:
(2) Item 2. Blood Tests
(a) Complete Blood Count (CBC)?
(b) Skin Erethyma Dose (SED) Rate?
(c) C-Reactive Protein?
(d) Rheumatoid Factor?
(e) Fluorescent Anti-Nuclear Antibody (ANA)?
(f) SGOT (AST) (Glutamic Oxaloacetic Transaminase)?
(g) SGPT (ALT) (Transaminase Glutamic Pyruvate)?
(h) Lactic Acid Hydrogenase (LDH)?
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX G
G-2
(i) Alkaline Phosphatase?
(j) Creatine Phosphokinase (CPK)?
(k) Hepatitis B Surface Antibody?
(l) Hepatitis B Core Antigen?
(m) Venereal Disease Research Laboratory (VDRL)?
(n) Vitamin B-12?
(o) Folate?
(p) Human Immuno-deficiency (HIV)?
(q) Thyroxine Total Serum (T4)?
(r) Thyroid Stimulating Hormone (TSH)?
(3) Item 3. Urinalysis?
(4) Item 4. Tuberculosis (TB) Skin Test Purified Protein Derivative (PPD)?
(5) Item 5. Chest X-ray?
(6) Item 6. Psychiatric Consultation?
(a) Item 6A. Structured Clinical Interview for Diagnosis (SCID) for Diagnostic and
Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R). Was the SCID
interview given?
(b) Item 6B. Clinical Administered Post-traumatic Stress Disorder (PTSD) Scale (CAPS).
Was the CAPS performed?
(c) Item 7. List of Diagnoses. Designated physician staff or clinical staff are to provide
narrative description of diagnoses. If none, leave blank. NOTE: Coders: Enter International
Classification of Diseases, Clinical Modification, 9th Edition (ICD-9) codes as required.
b. SYMPTOM-SPECIFIC EXAMINATIONS, PHASE II NOTE: Complete only those
questions which are appropriate to the veterans symptoms; otherwise leave these blank.
(1) Item 8. Psychology-Neuropsychological Test.
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX G
G-3
(a) Was this test performed?
(b) List of Diagnoses and ICD-9 codes.
(2) Item 9. Infectious Disease-Screening Examination.
(a) Was this examination performed?
(b) List of Diagnoses and ICD-9 codes.
(3) Item 10. Dental Examination.
(a) If there was a medical indication, was this examination performed?
(b) List of Diagnoses and ICD-9 codes.
(4) Item 11. Diarrhea and/or Abdominal Pain.
(a) Did patient receive a GI (Gastroenterology) consult?
(b) List Diagnoses and ICD-9 codes.
(5) Item 12. Headache and/or Memory Loss.
(a) Did patient receive neurology consult?
(b) List Diagnoses and ICD-9 codes
(6) Item 13. Muscle Aches or Numbness.
(a) Did patient receive a neurology consult?
(b) List Diagnoses and ICD-9 codes.
(7) Item 14. Chronic Fatigue.
(a) Did patient receive consult(s) relating to chronic fatigue?
(b) List Diagnoses and ICD-9 codes.
(8) Item 15. Joint Pain.
(a) Rheumatology Consult. Did patient receive rheumatology consult?
(b). List Diagnoses and ICD-9 codes.
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX G
G-4
(9) Item 16. Chronic Cough and/or Shortness of Breath.
(a) Pulmonary Consult. Did patient receive pulmonary consult?
(b) List Diagnoses and ICD-9 codes.
(10) Item 17. Skin Rash.
(a) Dermatology Consult. Did patient receive a dermatology consult?
(b) List Diagnoses and ICD-9 codes.
(11) Item 18. Vertigo and/or Tinnitus.
(a) Audiology consult? Did patient receive an audiology consult?
(b) List Diagnoses and ICD-9 codes.
(12) Item 19. Chest Pain and/or Palpitations.
(a) Cardiology Consult. Did patient receive a cardiology consult?
(b) List Diagnoses and ICD-9 codes.
(13) Item 20. Reproductive Concerns.
(a) Did male patient receive a urology consult?
(b) Did female patient receive a gynecology consult?
(c) List Diagnoses and ICD-9 codes.
(14) Item 21. Final Diagnoses. List up to ten major definite medical diagnoses, with the
primary diagnosis listed on line 21A with ICD-9 codes. If no diagnosis is made, leave these
lines blank as well as the ICD-9 codes.
(15) Item 22. After completing the Uniform Case Assessment Protocol (UCAP), Phase II,
Part III, does the physician feel that the veteran has an unexplained illness? Enter either Y(es) or
N(o) from the pull-down menu.

Forum: Compensation, Treatment, and Research Resources

ENVIRONMENTAL HEALTH (EH) COORDINATORS - 2006

IGWCADMIN — Mon, 22 Jan 2007 10:26:42 GMT

http://www1.va.gov/environagents/docs/EH_Coord_Dir_List_August_2006.pdf

DISCLAIMER: THIS LIST CONTAINS THE LATEST INFORMATION RECEIVED

FROM VA FACILITIES. IF YOU HAVE ANY QUESTIONS OR CONCERNS ABOUT

THIS LIST, PLEASE CALL VACO (202) 273-8463 OR 8465 OR SEND AN

E-MAIL MESSAGE TO VHACO13Bsha@va.gov

AUGUST 2006 TELEPHONE/ADDRESS DIRECTORY

Department of Veterans Affairs

Veterans Health Administration

Environmental Agents Service (131)

Washington, D.C. 20420

ENVIRONMENTAL HEALTH (EH)COORDINATORS

(AGENT ORANGE, IONIZING RADIATION, GULF WAR/IRAQI FREEDOM, SHAD, ETC.)

__________________________________________________ _____________________

FACILITY TELEPHONE/FAX NUMBERS EH COORDINATOR

ADDRESS & E-MAIL______________________________

VA HEALTH CARE NETWORK UPSTATE NEW YORK:

113 Holland Ave.

ALBANY, NY COM: (5l8) 626-6717 Robert Pecker

12208 e-mail: Robert.Pecker@va.gov (136E1)

FAX: (518) 626-6720

ALBUQUERQUE, NM (SEE NEW MEXICO VA HEALTH CARE SYSTEM))

87108

P. O. Box 69004

ALEXANDRIA, LA COM: (3l8) 473-00l0x2292 Linda Cross

71301-9004 e-mail: Linda.Cross@va.gov

FAX: (318) 483-5072

ALLEN PARK, MI (SEE DETROIT MI VAMC)

2907 Pleasant Valley Blvd.

ALTOONA, PA COM: (814) 943-8164x7484 James Russell

16602 e-mail: James.Russell@va.gov (15P)

FAX: (814) 940-7898

COM: (814) 943-8164x7083 Carol A.Davis,Alt. Clerk

AMARILLO VA HEALTH CARE SYSTEM;

6010 Amarillo Blvd, West

AMARILLO, TX COM: (806) 355-9700x7825 Cynthia Ward

e-mail: Cynthia.Ward@va.gov

FAX: (806) 354-7876

COM: (806) 355-9700X7287 David E.Crabtree,Supv

e-mail: Crabtee.David@va.gov

6104 Ave Q South Drive

(LUBBOCK OPC) COM: (806) 472-3400x3540 Larry Morris

79412 e-mail: Larry.Morris3@va.gov

FAX: (806) 472-3482

ANCHORAGE HCS & REGIONAL OFFICE:

2925 DeBarr Rd.,Rm 2391 COM: (907) 257-4711 Kathy A. Johnson

ANCHORAGE, AK (OPC-463) e-mail: Kathy.Johnson@va.gov

99508 FAX: (907) 257-6990

VA ANN ARBOR HEALTH CARE SYSTEM:

2215 Fuller Rd.

ANN ARBOR, MI COM: (734) 769-7100x5286 Phyllis Russell

48105 e-mail: Phyllis.Russell@va.gov (11A)

FAX: (734) 769-7091

3333 Glendale St.

(TOLEDO OPC) COM: (419) 259-2000x3028Perry Campbell

43614 e-mail: None

FAX: (419) 259-2008

1100 Tunnel Rd. COM: (828) 298-7911x15234 Joseph M. Svatos

ASHEVILLE, NC e-mail: Joseph.Svatos@va.gov

28805-2087 FAX: (828) 299-5961

1670 Clairmont Rd.

ATLANTA/DECATUR, GA COM: (404) 321-6111x7523 Michelle Nelson, LCSW

30033 e-mail: Michelle.Nelson@va.gov

FAX: (404) 235-2237

COM: (404) 321-6111x2108 Amanda Jackson (Alt)

e-mail: Amanda.Jackson@va.gov (111SWS)

FAX: (404) 235-3011,3097 or(404) 417-1544

COM: (404) 321-6111x6908 Leatrice McGrew

e-mail: Leatrice.McGrew@va.gov

1 Freedom Way

AUGUSTA, GA COM: (706) 823-3999 William Kingsberry

30904 e-mail: William.Kingsberry@va.gov (116)

FAX: (706) 823-3989 or 3935

BALTIMORE, MD 211201 (SEE VA MARYLAND HEALTH CARE SYSTEM)

Ft. Howard, Md. (CONTACT EH COORDINATOR AT THE BALTIMORE VAMC)

(BANDON,OR CBC) 97411 (SEE VA ROSEBURG HEALTH CARE SYSTEM)

BATAVIA, NY 14020 (SEE VA WESTERN NEW YORK HEALTH CARE SYSTEM)

14020

76 Veterans Ave.

BATH, NY COM: (607) 664-4841 or 4898 Lois Peck

14810 e-mail: Lois.Peck2@va.gov

FAX: (607) 664-4915

5500 Armstrong Rd.

BATTLE CREEK, MI COM: (269) 966-5600x3862 Bridgett Griffore

49015-1099 e-mail: Bridgett.Griffore@va.gov GW/IR

FAX: (269) 660-6079

COM: (269) 966-5600x3834 Shela Hill

e-mail: Shela.Hill@va.gov AG

COM: (269) 966-5600x3853

COM: (616) 966-5600x3853 Jean Drayton

e-mail: Jean.Drayton@va.gov

FAX: (269) 660-6082

COM: (269) 966-5600x3834 Angela Kay Dice

e-mail: Angela.Dice@va.gov

FAX: (269) 660-5021

7968 Essen Park Avenue

(BATON ROUGE, LA OPC) COM: (225) 761-6753 JoAnn Brown

70809 e-mail: Joann.Brown@va.gov

COM: (225) 761-6716 Tatiana Bates

e-mail: Tatiana.bates@va.gov

FAX: (225) 761-6760

P. O. Box 5005

(or 1000 Bay Pines Blvd.

St. Petersburg, FL 33700)

BAY PINES, FL COM: (727) 398-6661 x5415 Robert Bauer

33744 e-mail: Robert.Bauer@va.gov (136D)

COM: (727) 398-6661 X4560 Stacy Chatman

e-mail: Stacy.Chatman@va.gov

COM: (727) 398-6661 x4225 Nydia Maymi

e-mail: Nydia.Maymi@va.gov

FAX: (727)319-1017

3033 Winkler Ext.

(FT. MYERS OPC,FL) COM: (239)-939-3939x6215 Ivette Santiago

33916 e-mail: Ivette.Santiago2@va.gov (136FM)

FAX: (239) 939-7641

(1-888-513-0045 x6215)

(BEAUMONT TX OPC 77707) (SEE HOUSTON TX VAMC)

200 Veterans Ave.

BECKLEY, WV COM: (304) 255-2121 x4241 Wendy Garcia

25801 e-mail: Wendy.Garcia@va.gov

FAX: (304) 255-2431

200 Springs Rd.

BEDFORD, MA COM: (781) 687-2408 Kendra Kiley

01730 e-mail:None AGO

FAX: (781) 687-2565 GW referred to Boston

VAMC/Jamaica Plains

BIG SPRING, TX (SEE WEST TEXAS VA HEALTH CARE SYSTEM)

79720

BILOXI, MS 39531 (SEE GULF COAST VETERANS HEALTH CARE SYSTEM)

(PENSACOLA OPC

32503)

(MOBILE OPC

36604)

700 S. 19THth St.

BIRMINGHAM, AL COM: (205) 933-8l0l x6849/6793 Susan L. Davis, NP

35233 e-mail: susan.davis4@va.gov (11F)

FAX: (205) 558-4809

VA BLACK HILLS HEALTH CARE SYSTEM:

113 Comanche Rd. (CONTACT EH COORDINATOR AT HOT SPRINGS SD)

FORT MEADE, SD

57741

500 North 5th St. COM: (800) 764-5370X2519/2365 L. Kay Stewart

HOT SPRINGS, SD 57747 and Kelly Simunek

e-mail: kay.KAY.Stewart@va.gov (Pri-HS)

e-mail: Kelly.simunek@va.gov

FAX: (605) 745-2816

500 W. Fort St.

BOISE, ID COM: (208) 422-1254 Marj Doescher

83702-4598 e-mail: Marjaneal.Doescher@va.gov (136CP)

FAX: (208) 422-1386

BONHAM, TX 75418 (SEE VA NORTH TEXAS HEALTH CARE SYSTEM)

VA BOSTON HEALTH CARE SYSTEM:

150 South Huntington Ave.

(Jamaica Plains,MA 02130) COM: (617) 232-9500x45267 Cathleen Stephens

e-mail: Cathleen.Stephens@va.gov (136)

FAX: (857) 364-4410

251 Causeway St.

(BOSTON, MAS OPC 02114) COM: (617) 248-1213 Paul Segien

e-mail: Paul.Segien@va.gov

FAX: (617) 248-1282

940 Belmont St.

(BROCKTON, MA 02301) COM: (508) 583-4500 x62686 Nancy Shooshan

e-mail: Nancy.Shooshan@va.gov (136F)

FAX: (774) 826-2493

1400 VFW Parkway

WEST ROXBURY,MA DIV 02132) COM: (617)323-7700x35471 Anne Clasby

- e-mail: Anne.Clasby@va.gov

FAX: (857) 203-5646

605 Lincoln St. Veterans are referred to the West Roxbury VAMC

(WORCHESTER MAS OPC 01605) for registry exams.

130 West Kingsbridge Rd/6th Floor

BRONX, NY COM: (718) 584-9000x5278/3777 Erica Stewart (6C)

10468 e-mail: Erica.Stewart@va.gov

COM: (718)-584-9000x5870 Sonia Cortes

e-mail: Sonia.Cortes@va.gov (AgentOrange Exams)

(AnitaCarney,Staff Asst.)

FAX: (718) 741-4571

COM: (718) 584-9000x5872 Blanca Faber

e-mail: Blanca.Faber@va.gov (OEF/OIF Coordinator)

BROOKINGS, OR CBC 97415 (SEE VA ROSEBURG HEALTH CARE SYSTEM)

BROOKLYN, NY 11209 (SEE NEW YORK HARBOR HEALTH CARE SYSTEM)

(NEW YORK, NY) 10010 (SEE NEW YORK HARBOR HEALTH CARE SYSTEM)

BUFFALO, NY 14215 (SEE WESTERN NEW YORK HEALTH CARE SYSTEM)

(BATAVIA, NY ) 14020 (SEE WESTERN NEW YORK HEALTH CARE SYSTEM)

325 New Castle Road

BUTLER, PA COM: (724) 285-2206 Nancy L. Bowser

16001-2480 e-mail: Nancy.Bowser@va.gov (529/71)

FAX: (724) 477-5071

(CAMP HILL PA OPC 17011) (SEE LEBANON PA VAMC)

400 Ft. Hill Avenue

CANANDAIGUA, NY COM: (585) 393-7125 Brenda Bryant

14424 e-mail: Brenda.Bryant2@va.gov

FAX: (585) 393-7345

COM: (585) 393-7344 MaryAnn Hartranft

e-mail: MaryAnn.Hartranft@va.gov

465 Westfall Road

(ROCHESTER, NY OPC) COM: (585) 463-2688 Sandy Cobo, Suprv.

14620 e-mail: Sandy.Cobo@va.gov (528GE/VSC)

COM: (585) 463-2685 Deidra Brooks

e-mail: Deidra.Brooks@va.gov

FAX: 585-463-2746

CASTLE POINT, NY 12511 (SEE VA HUDSON VALLEY HEALTH CARE SYSTEM)

VA CENTRAL ALABAMA HEALTH CARE SYSTEM:

215 Perry Hill Rd.(CONTACT EH COORDINATOR AT THE TUSKEGEE, AL VAMC)

MONTGOMERY, AL

(West Campus) 36109

2400 Hospital Road

TUSKEGEE, AL COM: COM: (334) 727-0550x5117 Avis Tidwell

(East Campus) 36083 e-mail: Avis.Tidwell3@va.gov

FAX: (334) 724-6891 (112)

VA CENTRAL ARKANSAS VETERANS HEALTH CARE SYSTEM:

4300 West 7th

LITTLE ROCK, AR COM: (501) 257-5651 Anthony Hatchett

72205 e-mail: Anthony.Hatchett@va.gov (11C)

FAX: (501)257-5071

VA CENTRAL CALIFORNIA HEALTH CARE SYSTEM:

2615 E. Clinton Avenue (MAS Trailer)

FRESNO, CA COM: (559)225-6l00x5437 Tomlinson-Zanovich,Donna

93703-2223 e-mail:Donna.Tomlinson-Zanovich@va.gov(GW/IR)

COM: (559) 225-6100x6340 Andrea Willis(reports)

e-mail: Andrea.Willis@va.gov

COM: (559) 225-6100 x5408 Betsy Keeler (Alt)

e-mail: Betsy.Keeler@va.gov

COM: (559) 225-6100 x5372 Tom Quevedo (AGO)

e-mail: Thomas.Quevedo@va.gov

FAX: (559) 228-6990

VA CENTRAL IOWA HEALTH CARE SYSTEM:

3600 30th St.

DES MOINES, IA COM: (515) 699-5999 x4181 Lila Albrecht

50310 e-mail: Lila.Albrecht@va.gov (136)

FAX: (515) 699-5563

KNOXVILLE, IA (CONTACT EH COORDINATOR AT THE DES MOINES IA VAMC)

50138

VA CENTRAL TEXAS HEALTH CARE SYSTEM:

Olin E. Teague Veterans Center

1901 Veterans Memorial Drive

TEMPLE, TX COM: (254) 743-0745/2949 Melissa Poursmaeili

76504 e-mail: Melissa.Poursmaeili@va.gov

FAX: (254)-743-0132

MARLIN, TX (CONTACT EH COORDINATOR AT TEMPLE, TX VAMC)

76661

WACO, TX COM: (254) 297-3088 Dianna Castillo

76711 e-mail: Diana.Castillo@va.gov (GW exams/at Temple TX)

FAX: (254)-297-3111

Ralph H. Johnson VAMC

109 Bee Street

CHARLESTON, SC COM: (843) 789-7300 Donna Nash

29401 e-mail: Donna.Nash@va.gov (11C)

e-mail: None Anita Stiechen

FAX: (843) 805-5968

150 Debra Road, Suite 5200 (SEE VA TENNESSEE VALLEY HEALTHCARE SYSTEM)

(CHATTANOOGA, TN OPC )

37411

2360 East Pershing Boulevard

CHEYENNE, WY COM: (307) 778-7580 Rita Negrette

82001 e-mail: Rita.Negrette@va.gov

FAX: (307) 778-7318 (136B)

VA CHICAGO HEALTH CARE SYSTEM:

Jesse Brown VAMC #537

820 South Damen Avenue (formerly WS)

CHICAGO, IL (LS) COM: (312) 569-8387x57273 (Dr. James Cummings)

60612 e-mail: None (llC)

FAX: (312) 569-8040

COM: (312) 569-7698 Thomas Beatty

e-mail: Thomas.Beatty@va.gov

FAX: (312) 569-8113

COM: (312) 569-6260 Lewis Coulson,M.D.

e-mail: Lewis.Coulson@va.gov

FAX: (312) 569-6536

17273 State Route 104

CHILLICOTHE, OH COM: (740) 773-1141x7787 Kathryn L. Keeney

45601 e-mail: Kathy.Keeney@va.gov (161F3)

FAX: (740) 772-7175

3200 Vine Street

CINCINNATI, OH COM: (513) 475-6316 Tina Cole

45220 e-mail: Tina.Cole@va.gov (136A)

COM: (513) 475-6973 Evette Hunter

e-mail: Evette.Hunter@va.gov

COM: (513) 861-3100x4166 Valery Patterson

e-mail: Valery.Patterson@va.gov

FAX: (513) 487-6037

Please route all pamphlets, etc. to MDP 136A2/VAMC/Cincinnati

1 Medical Center Drive

CLARKSBURG, WV COM: (304) 623-3461x3343 Russell Harding (GW)

26301 e-mail: Russell.harding@va.gov (017)

FAX: (304) 626-7022 Performance Improvement

COM: (304)623-3461x3797 Mary Shaffer (AO/IR/GW)

e-mail: Mary.Shaffer2@va.gov

FAX: (304) 623-7014

Louis Stokes VAMC

10701 East Boulevard

CLEVELAND, OH (Wade Prk) COM: (216) 791-3800x3055 Danita Thornton

44106-3800 e-mail: Danita.Thornton@va.gov (136W)

FAX: (216) 421-3080

COM: (216) 791-3800x5348 Annette Baskin, Suprv

FAX: (216) 231-3410

COM: (216) 791-3800X5316 Kim L. Robinson, Asst.

55 West Waterloo Rd. COM: (330) 724-7715x1161 Mary Szollosi

(AKRON, OH OPC 44319) e-mail: MaryEllen.Szollosi@va.gov

FAX: (330) 724-4598

10000 Brecksville Rd.

(BRECKSVILLE,OH OPC)

44141) COM: (440) 526-3030x6817 Margaret Markee

e-mail: Maragret.Markee@va.gov

FAX: (440) 546-2769

733 Market Ave., South

(CANTON OPC) COM: (330)-489-4600x1652 Clinton Becker

44702 e-mail: Clinton.Becker@va.gov

FAX: (330) 489-4659

2031 Belmont Avenue

(YOUNGSTOWN OPC) COM: (330) 740-9202 Mark Bell

44505 or (330) 740-9200x1502

e-mail: Mark.Bell@va.gov

FAX: (330) 740-9249

1400 Black Horse Hill Road

COATESVILLE, PA COM: (610) 384-7711x6205 Donna Regener

19320 e-mail: Donna.Regener@va.gov (111E)

FAX: (610) 383-0275

Harry S. Truman Memorial Veterans Hospital

800 Hospital Drive

COLUMBIA, MO COM: (573) 814-6433 Juanita Robinson

65201 e-mail: Juanita.robinson@va.gov (Bus/Adm)

FAX: (573) 814-6431

William Jennings Bryan Dorn VAMC

6439 Garners Ferry Road

COLUMBIA, SC COM: (803) 776-4000x6179 Cora Stegall

29201-1639 e-mail: Cora.Stegall@va.gov (136A)

COM: (803) 776-4000x6182 Earnest Bridge

e-mail: Earnest.Bridges@va.gov

FAX: (803) 695-6709

(GREENVILLE OPC) COM: (864) 299-1600 Mary E Graves

3510 Augusta Road e-mail: May.E.Graves@va.gov (181R)

Greenville, SC 29605 FAX: (864) 422-2623

Chalmers P. Wylie OPC COM: (614) 257-5626 Shelley Leister,A (RHIA)

543 Taylor Ave e-mail: Shelley.Leister@va.gov

COLUMBUS, OH 43203-1278 FAX: (614) 257-5637

Chf/HIMS/PrivacyOfficer(136)

COM: (614) 257-5634 Shelley Lenavitt(Alt)

e-mail: Shelley.lenavitt@va.gov

FAX: (614) 257-5439

VA CONNECTICUT HEALTH CARE SYSTEM:

West Haven Campus Refer to Deborah Gordneer at the Newington VAMC

West Haven, CT 06516

Newington Division

555 Willard Ave.

Newington, CT COM: (860) 667-6717 Deborah Gordneer

06111 e-mail: Deborah.Gordneer@va.gov

FAX: (860) 594-6381

DALLAS, TX (SEE VA NORTH TEXAS HEALTH CARE SYSTEM)

75216

FT. WORTH,TX (SEE VA NORTH TEXAS HEALTH CARE SYSTEM)

76104

BONHAM, TX (SEE VA NORTH TEXAS HEALTH CARE SYSTEM)

75418

1900 E. Main St.

DANVILLE, IL

61832 COM: (217) 554-3000x5132 Brooke Heckerson

COM: (217) 554-5132

e-mail: brooke.heckerson@va.gov

COM: (217) 554-3000 Janet Fender

e-mail: Janet.Fender@va.gov

FAX: (217) 554-4856

411 Martin Luther King Jr. Drive

(PEORIA OPC) Refer veterans to Danville, IL VAMC

61605 for registry exams.

4100 West Third Street

DAYTON, OH 45428 COM: (937) 268-6511x1073 Sheryl Yarbrough

e-mail: Sheryl.Yarbrough@va.gov (136A)

FAX: (937) 267-5331

Daytona Beach, FL 32117 (SEE VA NORTH FLORIDA/SOUTH GEORGIA HEALTH CARE

SYSTEM)

DENVER, CO. 80220 (SEE VA EASTERN COLORADO HEALTH CARE SYSTEM)

DES MOINES, IA (SEE VA CENTRAL IOWA HEALTH CARE SYSTEM)

50310

John D. Dingell VAMC

4646 John R

DETROIT, MI COM: (313) 576-1000x63489 Cheryl Best

48201 e-mail: Cheryl.Best@va.gov (001B-HBA)

(formerly Allen Park) FAX: (313) 576-1094

Carl Vinson VAMC

1826 Veterans Boulevard

DUBLIN, GA COM: (478) 272-1210x3086 Donna R. Krumwiede

31021 e-mail: Donna.Krumwiede@va.gov (557/136)

FAX: (478) 277-2871

508 Fulton Street

DURHAM, NC COM: (919) 286-0411x6006 Cindy Force

27705 e-mail: Cindy.Force@va.gov (11C)

FAX: (919) 416-5927

EAST ORANGE, NJ (SEE VA NEW JERSEY HEALTH CARE SYSTEM)

07019

(BRICK OPC ) (SEE VA NEW JERSEY HEALTH CARE SYSTEM

08724

(LYONS OPC ) (SEE VA NEW JERSEY HEALTH CARE SYSTEM

07939

VA EASTERN COLORADO HEALTH CARE SYSTEM:

1055 Clermont Street

DENVER, CO COM: (303) 393-2807 Nancy Ahrens

80220 or 1-888-336-8262x2807

e-mail: Nancy.Ahrens@va.gov (136Alb)

FAX: (303) 393-5064

VA EASTERN KANSAS HEALTH CARE SYSTEM:

Dwight D. Eisenhower VAMC

4101 South 4th Street Trafficway

LEAVENWORTH, KS COM: (913) 682-2000x52756 Carolyn B. Hart

66048 e-mail: Carolyn.Hart@va.gov

FAX: (913) 758-4233

COM: (913) 682-2000X2423 Sherrie Mailen

e-mail: Sherrie.Mailen@va.gov `

Colmery-ONeil VAMC

2200 SW Gage Boulevard

TOPEKA, KS (Bldg #1) COM: (785) 350-4621 Sherrie Mailen

66622 e-mail: Sherrie.Mailen@va.gov

FAX: (785) 350-4622

COM: (913) 682-2000x52756 Carolyn B. Hart

e-mail: Carolyn.Hart@va.gov

FAX: (913) 758-4233

VA EASTERN MONTANA HEALTH CARE SYSTEM:

VAMC/ROC

William St.Highway 12

FORT HARRISON, MT COM: (406) 447-7966 Sharon Fiske

59636 e-mail: Sharon.Fiske@va.gov (11E)

FAX: (406) 447-7360

(MILES CITY, MT) 59301 (CONTACT EH COORDINATOR AT FORT HARRISON, MT VAMC)

EL PASO VA HEALTH CARE SYSTEM;

5001 North Piedras Street

EL PASO, TX COM: (915) 564-6133 Yolie Villegas

79930 e-mail: Yolanda.Villegas@va.gov (11E)

FAX: (915) 564-7877

ERIE VA HEALTH CARE SYSTEM

135 East 38th St.

ERIE, PA COM: (814) 860-2526 Carla Amendola

16504 e-mail: Carla.Amendola@va.gov (174E1)

FAX: (814) 868-6245

(500 EAST WALNUT) (CONTACT EH COORDINATOR AT THE MARION, IL VAMC)

EVANSVILLE, IL 47713

EUGENE, OR CBC) 97415 (SEE VA ROSEBURG HEALTH CARE SYSTEM)

VAM/ROC:

2101 North Elm St.

FARGO, ND COM: (70l) 239-3700x2982 Cindi K. Nordick

58102 e-mail: Cindi.Nordick@va.gov

FAX: (701) 239-3729

1100 North College Avenue

FAYETTEVILLE, AR COM: (479) 443-4301x5059 Melanie Wood

72703 e-mail: Melanie.Wood@va.gov

COM: (479) 443-4301X5620 Luanna Oxford,Suprv.

e-mail: Luanna.Oxford@va.gov

FAX: (479) 587-5997

COM: (479) 587-5839 Gary M. Eagle (IR)

e-mail: Gary.Eagle@va.gov (114)

FAX: (479) 444-5055

2300 Ramsey Street

FAYETTEVILLE, NC COM: (910) 822-7941 George Grimes

28301 e-mail: george.grimes@va.gov (136)AC&P,HAS

FAX: (910) 482-5217

COM: (910)488-2120X7569 Erma Robertson,

1-800-771-6106 Pt. Svc. Asst.

e-mail: Erma.Robertson@va.gov

FAX: (910) 482-5050

FORT HARRISON, MT (SEE VA EASTERN MONTANA HEALTH CARE SYSTEM)

59636

FORT HOWARD, MD (SEE VA MARYLAND HEALTH CARE SYSTEM)

21052

FORT MEADE, SD (SEE VA BLACK HILLS HEALTH CARE SYSTEM)

57741

FORT MYERS, FL 33901 (SEE BAY PINES FL VAMC)

F.WAYNE/MARION, IN (SEE VA NORTHERN INDIANA HEALTH CARE SYSTEM)

46805

FORT WORTH, TX (SEE VA NORTH TEXAS HEALTH CARE SYSTEM)

76104

FRESNO, CA 93703-2223 (SEE VA CENTRAL CALIFORNIA HEALTH CARE SYSTEM)

GAINESVILLE, FL (SEE VA NORTH FLORIDA/SOUTH GEORGIA HEALTH CARE

SYSTEM) 32608-1197

GRAND ISLAND, NE (SEE VA NEBRASKA WESTERN IOWA HEALTH CARE SYSTEM)

68803

GRAND JUNCTION VA MEDICAL CENTER

2121 North Avenue

GRAND JUNCTION, CO COM: (970) 242-0731x2127 Pat Crooks

TOLL FREE: 1-866-206-6415

81501 e-mail: patricia.crooks@va.gov (118D)

FAX: (970) 244-1331

VA GREATER LOS ANGELES HEALTH CARE SYSTEM:

VA Los Angeles Healthcare Center

11301 Wilshire Boulevard

LOS ANGELES WEST, CA COM: (310) 478-3711x40339 Yolanda Quezada

e-mail: Yolanda.Quezada@va.gov

COM: (310) 478-3711X83747 Nelson Mejia

e-mail: Nelson.Mejia@va.gov

FAX: (310) 268-4723

VA Sepulveda Ambulatory Care Center & Nursing Home

16111 Plummer Street

SEPULVEDA, CA COM: (818) 895-9528 Robin Shannon

91343 e-mail: Robin.Shannon@va.gov (C&P)

FAX: (818) 895-5877

GULF COAST VETERANS HEALTH CARE SYSTEM:

400 Veterans Avenue

BILOXI, MS COM: (228) 523-5074 Johnny Bills

39531 e-mail: Johnny.Bills@va.gov (136A12)

FAX: (228) 523-4378

312 Kenmore Road

(PENSACOLA OPC, FL)

32503 COM: (850) 471-7544 Patrice Rayford

e-mail: Patrice.Rayford@va.gov

FAX: (850) 471-7566

(MOBILE OPC, AL) (CONTACT EH COORDINATOR AT BILOXI, MS VAMC)

36604

100 Emancipation Drive

HAMPTON, VA COM: (757) 722-9961x2644 Kay Reid,N.P.

23667 e-mail: Kay.Reid@va.gov

COM: (757) 722-9961x2644 Kadedra Brown (Alt)

e-mail: Kadedra.Brown@va.gov

FAX: (757) 728-3110

Edward Hines, Jr. VA Hospital

5th Avenue & Roosevelt Road, Bldg.1,Rm D255 (for boxes)

P. O. Box 5000

HINES, IL COM: (708) 202-8387x22076 Ivy Bryant (GW)

60141-5000 e-mail: Ivy.Bryant@va.gov (122/for mail)

FAX. (708) 202-2087

COM: (708) 202-8387x27957or4365 Cris Mabrito (AO)

e-mail: Cris.mabrito@va.gov (11CS)

FAX: (708) 202-2386

COM: (708) 202-8387X27957or4365 Alexis Turner

e-mail: Alexis.Turner@va.gov

Direct Line (708) 202-7957

Pacific Islands Health Care System

Spark M. Matsunaga Medical Center:

459 Patterson Road

HONOLULU, HI COM: (808) 433-7712 Elaine Lum

96819-1522 e-mail: Elaine.Lum@va.gov (136D)

FAX: (808) 433-7739/0396

HOT SPRINGS, SD (SEE VA BLACK HILLS HEALTH CARE SYSTEM&CONTACT

57747 EH COORDINATOR AT FT. MEADE, SD))

2002 Holcombe Boulevard

HOUSTON, TX COM: (713) 794-7543 Ron Ratliff (GW)

77030 e-mail: Ratliff.Ronniee@va.gov (111MCL)

FAX: (713) 794-7377

COM: (713) 794-7091 Doris Richardson (AO/IR

e-mail: Doris.Richardson2@va.gov (BOSL\04PAC4)

FAX: (713) 794-7182

COM: (713-791-1414 X3801 Harvey Irwin (AO)

e-mail: none

COM: (713)794-7094 Fern A. Taylor (OIF)

e-mail: Fern.Taylor@va.gov

3420 Veteran Circle

(BEAUMONT OPC, TX ) COM: (409) 981-8550 x6113 Byrd-Ross,Karen

(AO/GW) 77707 e-mail: Byrd-Ross.Karena@va.gov (BOPC)

FAX: (409) 981-8563 or 8589

1301 West Frank Avenue

(LUFKIN OPC, TX ) COM: (936) 633-2710 Catherine Tucker

75904 e-mail: Catherine.tucker@va.gov (LOPC)

FAX: (936) 633-2747

Forum: Compensation, Treatment, and Research Resources

Dr Rokke - SW Asia Presentation November2006.ppt

IGWCADMIN — Tue, 16 Jan 2007 15:48:47 GMT

Forwarded from Dr Rokke.

Analysis of VA Health Care Utilization Among US Southwest Asian War Veterans Operation Iraqi Freedom Operation Enduring Freedom VHA Office of Public Health and Environmental Hazards November 2006
Current DoD Roster of Recent War Veterans
Evolving roster development by DoD Defense Manpower Data Center (DMDC)

In September 2003, DMDC developed initial file of separated Iraqi and Afghan troops using proxy files: Active Duty and Reserve Pay files, Combat Zone Tax Exclusion, and Imminent Danger Pay data.

In September 2004, DMDC revised procedures for creating periodic updates of the roster and now mainly utilizes direct reports from service branches of deployed OIF (Operation Iraqi Freedom) and OEF (Operation Enduring Freedom) troops.

DMDC is actively addressing the limitations of the current roster to improve the accuracy and completeness of future rosters

Current DoD Roster of Recent War Veterans

Latest Update of roster

Provided to Dr. Kang, Veterans Health Administration (VHA) Environmental Epidemiology Service, on September 29, 2006

Qualifications for OIF/OEF deployment roster

Contains list of veterans who have left active duty and does not include currently serving active duty personnel
Does not distinguish OIF from OEF veterans
Roster only includes separations through August 31, 2006
2,693 veterans who died in-theater are not included

Updated Roster of SW Asian War Veterans Who Have Left Active Duty
631,174 OIF and OEF veterans who have left active duty and become eligible for VA health care since FY 2002

46% (292,295) Former Active Duty troops
54% (338,879) Reserve and National Guard

Use of DoD List of War Veterans Who Have Left Active Duty
This roster is used to check the VAs electronic inpatient and outpatient health records, in which the standard ICD-9 diagnostic codes are used to classify health problems, to determine which OIF/OEF veterans have accessed VA health care as of September 30, 2006.

The data available for this analysis are mainly administrative information and are not based on a careful review of each patient record or a confirmation of each diagnosis. However, every clinical evaluation is captured in VHAs computerized patient record.

These administrative data have to be interpreted with caution because they only apply to OIF/OEF veterans who have accessed VHA health care due to a current health question. These data therefore do not represent all 631,174 OIF/OEF veterans who have become eligible for VA healthcare since FY 2002 or the approximately 1.4 million troops who have served in the two theaters of operation since the beginning of the conflicts in Iraq and Afghanistan.

Use of DoD List of War Veterans Who Have Left Active Duty (2)

Because VA health data are not representative of the veterans who have not accessed VA health care, formal epidemiological studies will be required to answer specific questions about the overall health of recent war veterans.

Analyses based on this updated roster are not directly comparable to prior reports because the denominator (number of OIF/OEF veterans eligible for VA health care) and numerator (number of veterans enrolling for VA health care) change with each update.

This report presents data from VHAs health care facilities and does not include Vet Center data or DoD health care data.

The following data are cumulative totals since FY 2002 and do not represent data from any single year.

The numbers provided in this report should not be added together or subtracted to provide new data without checking on the accuracy of these statistical manipulations with VHAs Office of Public Health and Environmental Hazards.

VA Health Care Utilization from FY 2002 to 2006 (4th QT) Among SW Asian War Veterans
Among all 631,174 separated OIF/OEF Veterans

32% (205,097) of total separated veterans have sought VA health care since FY 2002

97% (198,379) of 205,097 evaluated OIF/OEF patients have been seen as outpatients only by VA and not hospitalized
3% (6,718) of 205,097 evaluated OIF/OEF patients have been hospitalized at least once in a VA health care facility

VA Health Care Utilization for FY 2002-2006 (4th QT) by Service Component

292,295 Former Active Duty Troops

35% (101,260) have sought VA health care since FY 2002

338,879 Reserve/National Guard Members

31% (103,837) have sought VA health care since FY 2002

Comparison of VA Health Care Requirements
The 205,097 OIF/OEF veterans evaluated by VA over approximately 4 years from FY 2002 to FY 2006 (4th QT) represents about 4% of the 5.3 million individual veterans who received VHA health care in any one year (2005 data)

Frequency Distribution of SW Asian War Veterans According to the VISN Providing the Treatment
OIF-OEF Veterans
Treated at a VA Facility*
Treatment Site Frequency %

VISN 1 VA New England Healthcare System 9,790 4.77
VISN 2 VA Healthcare Network Upstate New York 6,088 2.97
VISN 3 VA New York/New Jersey Healthcare System 8,351 4.07
VISN 4 VA Stars & Stripes Healthcare System 9,279 4.52
VISN 5 VA Capital Health Care System 4,975 2.43
VISN 6 VA Mid-Atlantic Healthcare System 10,504 5.12
VISN 7 VA Atlanta Network 14,721 7.18
VISN 8 VA Sunshine Healthcare Network 17,479 8.52
VISN 9 VA Mid-South Healthcare Network 12,481 6.09
VISN 10 VA Healthcare System of Ohio 5,621 2.74
VISN 11 Veterans in Partnership Healthcare Network 7,246 3.53
VISN 12 VA Great Lakes Health Care System 13,069 6.37
VISN 15 VA Heartland Network 6,697 3.27
VISN 16 South Central VA Health Care Network 17,943 8.75
VISN 17 VA Heart of Texas Health Care Network 12,337 6.02
VISN 18 VA Southwest Healthcare Network 10,540 5.14
VISN 19 VA Rocky Mountain Network 8,304 4.05
VISN 20 VA Northwest Network 12,164 5.93
VISN 21 VA Sierra Pacific Network 8,650 4.22
VISN 22 VA Desert pacific Healthcare Network 16,429 8.01
VISN 23 VA Midwest Health Care Network 11,483 5.60

* Veterans can be treated in multiple VISNs. A veteran was counted only once in any single VISN but can be counted in multiple VISN categories. The total number of OIF-OEF veterans who received treatment (n = 205,097) was used to calculate the percentage treated in any one VISN.
Demographic Characteristics of Iraqi and Afghan Veterans Utilizing VA Health Care
% SW Asian Veterans
(n = 205,097)
Sex
Male 87 %
Female 13
Age Group
<20 3
20-29 53
30-39 23
40 21
Branch
Air Force 12
Army 67
Marine 11
Navy 10
Unit Type
Active 49
Reserve/Guard 51
Rank
Enlisted 92
Officer 8
Diagnoses
Veterans of recent military conflicts have presented to VHA with a wide range of possible medical and psychological conditions.

Health problems have encompassed more than 7,700 discrete ICD-9 diagnostic codes.

The three most common possible health problems of war veterans were musculoskeletal ailments (principally joint and back disorders), mental disorders, and Symptoms, Signs and Ill-Defined Conditions.

As in other outpatient populations, the ICD-9 diagnostic category, Symptoms, Signs and Ill-Defined Conditions, was commonly reported. It is important to understand that this is not a diagnosis of a mystery syndrome or unusual illness. This ICD-9 code includes symptoms and clinical finding that are not coded elsewhere in the ICD-9. It is a diverse, catch-all category that is commonly used for the diagnosis of outpatient populations. It encompasses more than 160 sub-categories and primarily consists of common symptoms that do not have an immediately obvious cause during a clinic visit or isolated laboratory abnormalities that do not point to a particular disease process and may be transient.
Frequency of Possible Diagnoses Among Recent Iraq and Afghan Veterans
Diagnosis (n = 205,097)
(Broad ICD-9 Categories) Frequency * %

Infectious and Parasitic Diseases (001-139) 21,362 10.4
Malignant Neoplasms (140-208) 1,584 0.8
Benign Neoplasms (210-239) 6,571 3.2
Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279) 36,409 17.8
Diseases of Blood and Blood Forming Organs (280-289) 3,591 1.8
Mental Disorders (290-319) 73,157 35.7
Diseases of Nervous System/ Sense Organs (320-389) 61,524 30.0
Diseases of Circulatory System (390-459) 29,249 14.3
Disease of Respiratory System (460-519) 36,190 17.6
Disease of Digestive System (520-579) 63,002 30.7
Diseases of Genitourinary System (580-629) 18,886 9.2
Diseases of Skin (680-709) 29,010 14.1
Diseases of Musculoskeletal System/Connective System (710-739) 87,590 42.7
Symptoms, Signs and Ill Defined Conditions (780-799) 67,743 33.0
Injury/Poisonings (800-999) 35,765 17.4

*Hospitalizations and outpatient visits as of 9/30/2006; veterans can have multiple diagnoses with each healthcare encounter. A veteran is counted only once in any single diagnostic category but can be counted in multiple categories, so the above numbers add up to greater than 205,097.
Frequency of Possible Mental Disorders Among OIF/OEF Veterans since 2002*

Disease Category (ICD 290-319 code) Number of SW Asian
War Veterans**

PTSD (ICD-9CM 309.81)+ 33,754
Nondependent Abuse of Drugs (ICD 305) 28,732
Depressive Disorders (311) 23,462
Neurotic Disorders (300) 18,294
Affective Psychoses (296) 12,386
Alcohol Dependence Syndrome (303) 5,413
Sexual Deviations and Disorders (302) 3,239
Special Symptoms, Not Elsewhere Classified (307) 3,178
Drug Dependence (304) 2,387
Acute Reaction to Stress (308) 2,273

Note ICD diagnoses used in these analyses are obtained from computerized administrative data. Although diagnoses are made by trained
healthcare providers, up to one-third of coded diagnoses may not be confirmed when initially coded because the diagnosis is rule-out or
provisional, pending further evaluation.
** A total of 73,157 unique patients received a diagnosis of a possible mental disorder. A veteran may have more than one mental disorder
diagnosis and each diagnosis is entered separately in this table; therefore, the total number above will be higher than 73,157.
+ This row of data does not include information on PTSD from VAs Vet Centers and does not include veterans not enrolled for VHA health care.
Also, this row of data does not include veterans who did not have a diagnosis of PTSD (ICD 309.81) but had a diagnosis of adjustment
reaction (ICD-9 309).

Summary
Recent Iraq and Afghan veterans are presenting to VA with a wide range of possible medical and psychological conditions.

Recommendations cannot be provided for particular testing or evaluation veterans should be assessed individually to identify all outstanding health problems.

32% of separated OIF/OEF veterans have enrolled for VA health care since 2002 compared to 31% in the last quarterly report three months ago. As in other cohorts of military veterans, the percentage of OIF/OEF veterans receiving health care from the VA and the percentage with any type of diagnosis will tend to increase over time as these veterans continue to enroll for VA health care and to develop new health problems.

Summary (2)
Because the 205,097 Iraqi and Afghan veterans who have accessed VA health care were not randomly selected and represent just 15% of the approximately 1.4 million recent US war veterans, they do not constitute a representative sample of all OIF/OEF veterans.

Reported diagnostic data are only applicable to the 205,097 VA patients a population actively seeking health care -- and not to all OIF/OEF veterans.
For example, the fact that 36% of VHA patients encounters were coded as related to a possible mental disorder does not indicate that 1/3 of all recent war veterans are suffering from a mental health problem. Only well-designed epidemiological studies can evaluate the overall health of Iraqi and Afghan war veterans.
Summary (3)

High rates of VA health care utilization by recent Iraqi and Afghan veterans reflect the fact that these veterans have ready access to VA health care, which is free of charge for two years following separation for any health problem possibly related to wartime service.

Also, a massive outreach effort has been developed by VA to inform these veterans of their benefits, including the mailing of a personal letter from the VA Secretary to each war veteran identified by DoD when they separate from active duty and become eligible for VA benefits.

When a combat veteran's two-year health care eligibility passes, the veteran will be moved to their correct priority group and charged all co-payments as applicable. If their financial circumstances place them in Priority Group 8, their enrollment in VA will be continued, regardless of the date of their original VA application.

Follow-Up

VA will continue to monitor the health status of recent Iraq and Afghan veterans using updated deployment lists provided by DoD to ensure that VA tailors its health care and disability programs to meet the needs of this newest generation of war veterans.

Created with pptHtml

Forum: Compensation, Treatment, and Research Resources

[NVIC] HIV (AIDS) Vaccine for Newborns

IGWCADMIN — Mon, 15 Jan 2007 03:01:31 GMT

January 12, 2007

National Vaccine Information Center

e-news

"Last week, Prof Francis Mmiro, the lead investigator, said the baby vaccine trial has been successful so far, adding that he hoped the vaccine will be added to the many given to babies at birth and thereafter like polio, tetanus, hepatitis B and measles. Preliminary results are expected by mid 2007 in the two-and-and-half-year study."- Esther Nakkazi, Nationmedia.com, The East African

Barbara Loe Fisher Commentary:

There are different HIV (AIDS) vaccines in various stages of clinical trials in the U.S. and other countries. In the past, evaluations of the toxicity of experimental HIV (AIDS) vaccines were conducted in adults at high risk for HIV infection, such as IV drug abusers and those with multiple sexual partners. However, children have now become the preferred testing ground for experimental HIV (AIDS) vaccines and will be the eventual target for routine vaccination.

Newborn infants in Africa are now being enrolled in clinical trials. In the U.S., future HIV vaccine trials will involve pre-adolescents and babies.

A worldwide mass vaccination infrastructure is being created by governments in partnership with multinational pharmaceutical companies, the World Health Organization and private donors such as Bill Gates and the Catholic Church. During the next decade, an international campaign to vaccinate every man, woman and child with HIV (AIDS) vaccine will begin and societal sanctions, including denial of an education and health care, may well be levied against citizens in America and other developed countries who refuse the HIV (AIDS) vaccine.

What many people do not realize is that the financing of world vaccination campaigns are dependent upon forcing the citizens of wealthy nations to purchase and use vaccines in order to finance the supply of those same vaccines to underdeveloped countries at a reduced rate. For example, hepatitis B disease is prevalent in Asia and Africa but has never been in the U.S.; and HPV associated cervical cancer occurs at a high rate in underdeveloped countries without routine pap smear screening but cervical cancer is at an all time low in the U.S.. Still, American children are forced to get hepatitis B vaccine or be denied an education and the CDC has told told doctors that pre-adolescent American girls must get HPV vaccine.

In 1996, HIV vaccine developer Stanley Plotkin, M.D., of Pasteur Merieux Pharmaceuticals (who is a co-patent holder on rubella and rotavirus vaccines) explained why mandatory vaccination in rich countries like the U.S. help deliver vaccines to Third World markets:

"The keystone of the system is that the research costs are recouped in North America and Europe and the vaccines are sold in the developing world at much, much lower margins...the relatively high rate of childhood vaccination seen lately in most parts of the world is the result of that system," explained Plotkin.

One-size-fits-all forced vaccination policies target the genetically vulnerable for injury and death and violate the human right to informed consent to medical risk-taking. The casualties of mass vaccination policies are never acknowledged or counted in the cost benefit analyses drug companies and public health officials publish. This will be especially true when the CDC announces every child in America must be injected with just a little bit of the HIV (AIDS) virus.

No forced vaccination. Not in America.

Uganda launches HIV vaccine trials for babies

AllAfrica.com
The East African (Nairobi)

Click here for the URL:

December 26, 2006
By ESTHER NAKKAZI
Special correspondent

Uganda has screened and vaccinated at least a quarter of the 50 babies needed for vaccine trial focused on prevention of HIV transmission from mother to child during breastfeeding.

The first baby in the vaccine trials was enrolled in October and by last week 14 of them had received either the vaccine or placebo saline solution (for control) while 16 have been screened to participate.

The study is in its phase I, randomised double blind - where the researchers will not know which babies receive the vaccine or the placebo solution, while 40 babies will randomly receive the vaccine and 10 the placebo.

In this first phase of the trial, the researchers are testing whether the vaccine, formally known as Alvac-HIV, is safe for use in children, following which they will study whether it can stop mother-to-child transmission of the Aids-causing virus during breastfeeding.

Last week, Prof Francis Mmiro, the lead investigator, said the baby vaccine trial has been successful so far, adding that he hoped the vaccine will be added to the many given to babies at birth and thereafter like polio, tetanus, hepatitis B and measles.

Preliminary results are expected by mid 2007 in the-two -and a half-year study.

The Alvac-HIV vaccine is being given to children less than or equal to three days of age, who weigh at least 2kg, have normal blood levels and are born to HIV positive mothers.

The babies enrolled are also not participating in other trials, have not received blood transfusions, do not have serious illnesses, and can be monitored for 24 months. Their families should, therefore, be living around Mulago referral hospital in Kampala.

The study primarily aims at evaluating the safety and immunogenicity of the vaccine in infants born to HIV-infected women.

If successful, the vaccine could prevent at least 25,000 infections in newborns in East Africa alone. The trial is being carried out by the Uganda in collaboration with US Aids researchers.

Many children, especially in the developing world, are infected by their HIV positive mothers who cannot afford to buy milk based formulas and are forced to breastfeed them.

In Uganda, at least 8,000 babies were infected last year. At least 22,000 infections are registered in children each year.

So far, 535 women have been referred to Makerere University John Hopkins Collaboration at Mulago Hospital.

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

National Vaccine Information Center

email: news@nvic.org

voice: 703-938-dpt3

web: http://www.nvic.org

NVIC E-News is a free service of the National Vaccine Information Center and is supported through membership donations.

NVIC is funded through the financial support of its members and does not receive any government subsidies. Barbara Loe Fisher, President and Co- founder.

Learn more about vaccines, diseases and how to protect your informed consent rights at http://www.nvic.org

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Forum: Compensation, Treatment, and Research Resources

Pregnancy outcomes among U.S. Gulf War veterans: a population-based survey of 30,000 veterans.

IGWCADMIN — Thur, 11 Jan 2007 15:46:48 GMT

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11557183&dopt=Abstract

1: Ann Epidemiol. 2001 Oct;11(7):504-11. Links

Pregnancy outcomes among U.S. Gulf War veterans: a population-based survey of 30,000 veterans.

Environmental Epidemiology Service, Department of Veterans Affairs, 1120 20th Street NW, Washington, DC 20036, USA.

PURPOSE: We evaluated an association between veterans' Gulf War service and reported adverse pregnancy outcomes. METHODS: We conducted a health survey in which selected reproductive outcomes of a population-based sample of 15,000 Gulf War veterans representing four military branches and three unit components (active, reserve, and National Guard) were compared to those of 15,000 non-Gulf veteran controls. RESULTS: Male Gulf veterans, compared with their non-Gulf veteran controls, reported a significantly higher rate of miscarriage (odds ratio = 1.62; 95% confidence interval = 1.32-1.99). Female Gulf veterans also reported more miscarriages than their respective controls, although their excess was not statistically significant (OR= 1.35; CI = 0.97-1.89). Both men and women deployed to the Gulf theater reported significant excesses of birth defects among their liveborn infants. These excess rates also extended to the subset of "moderate to severe" birth defects . No statistically significant differences by deployment status were found among men or women for stillbirths, pre-term deliveries or infant mortality. CONCLUSION: The risk of veterans reporting birth defects among their children was significantly associated with veteran's military service in the Gulf War. This observation needs to be confirmed by a review of medical records to rule out possible reporting bias.

PMID: 11557183

VHA PROGRAM GUIDE 1103.3 - MENTAL HEALTH PROGRAM GUIDELINES FOR THE NEW VETERANS HEALTH ADMINISTRATION

IGWCADMIN — Wed, 03 Jan 2007 05:42:34 GMT

http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1094

June 3, 1999 VHA PROGRAM GUIDE 1103.3

Department of

Veterans Affairs

VHA PROGRAM GUIDE 1103.3

MENTAL HEALTH PROGRAM GUIDELINES

FOR THE NEW VETERANS HEALTH ADMINISTRATION

Office of Patient Care Services

Mental Health Strategic Healthcare Group (116)

Veterans Health Administration

Washington, DC 20420

VHA PROGRAM GUIDE 1103.3 June 3, 1999

ii

FOREWORD

Guidelines as set forth in this document are published to improve the care for a large and often

complex group of veteran patients. These Guidelines reflect what the Veterans Health

Administration (VHA) is capable of doing now and suggest directions for future program

development, particularly in response to the revolutionary changes accompanying the Journey of

Change. The Department of Veterans Affairs (VA) operates a large, diverse healthcare system

that must adapt, create, lead, and innovate, or it will not meet the needs of veterans of future

decades. VA strongly encourages the creation of new, evidence-based, innovative programs,

organizations of clinical services, and alliances with, and input from, community organizations,

as it moves from a predominately hospital-based system to one based in, and serving the entire

veteran community.

This organization of mental health services, based on the concept of an integrated continuum

of care should be incorporated into the regular VA planning process at all levels. If additional

resources are required to provide necessary services, requests should be incorporated into the

planning process at the Veterans Integrated Services Network (VISN) level.

These are guidelines. None of the programs listed are mandated at this time. It is strongly

encouraged to use the enclosed definitions, Decision Support System (DSS) Identifiers, Treating

Specialty Codes, and Consolidated Distribution Report (CDR) Accounts at all sites so that we

can share meaningful information among medical centers and across Veteran Integrated Service

Networks (VISNs).

Thomas V. Holohan, M.D., FACP

Chief, Patient Care Services Officer

Distribution: RPC: 0005

Printing Date: 6/99

June 3, 1999 VHA PROGRAM GUIDE 1103.3

iii

CONTENTS

MENTAL HEALTH PROGRAM GUIDELINES

FOR THE NEW VETERANS HEALTH ADMINISTRATION

PARAGRAPH PAGE

1. Introduction and Overview ....................................................................................................... 1

a. Authorization ........................................................................................................................ 1

b. Purpose .. 1

2. Guidelines for Providing Mental Health Services .................................................................... 2

a. Principles for Organizing Mental Health Care ..................................................................... 2

b. Principles for Program Planning .......................................................................................... 3

(1) Definition of Program and Program Elements .................................................................. 3

(2) Organizational Structure ................................................................................................... 3

c. Principles for Providing Quality Mental Health Care .......................................................... 4

(1) Mental Health Providers ................................................................................................... 4

(2) The Continuum of Care .................................................................................................... 4

(3) Mental Health and Primary Care ...................................................................................... 5

(4) Case (Care) Management .................................................................................................. 7

(5) Psychosocial Rehabilitation ............................................................................................ 11

d. Principles for Individual Patient Treatment Planning ........................................................ 12

(1) Designing a Treatment Plan ............................................................................................ 12

(2) Intensity of Therapeutic Interventions ............................................................................ 13

(3) Level of Therapeutic Supervision or Structure ............................................................... 14

(4) Principles Regarding Planning Patients Living Arrangements ..................................... 15

(5) Principles when Families are Involved in Living Arrangements .................................... 15

3. Special Populations ................................................................................................................. 16

a. The Eligibility Reform Act of 1996..................................................................................... 16

(1) Public Law 104-262 ........................................................................................................ 16

(2) Definition of Disabled Veterans with a Mental Illness ................................................... 16

(3) Subgroups ....................................................................................................................... 16

(4) Comorbidities ................................................................................................................. 17

(5) Specialized Programs ...................................................................................................... 17

(6) Capacity ........................................................................................................................... 17

(7) Special Emphasis Programs ............................................................................................ 17

(8) Resulting Mandate .......................................................................................................... 17

(9) References .......................................................................................................................18

VHA PROGRAM GUIDE 1103.3 June 3, 1999

iv

PARAGRAPH PAGE

b. Veterans Diagnosed with a Serious Mental Illness ................................................................. 18

(1) Background ..................................................................................................................... 18

(2) Principles for Providing Quality Treatment .................................................................... 18

(3) Treatment Guidelines ...................................................................................................... 19

(4) The Continuum of Care for SMI Veterans ..................................................................... 19

(5) Alternates to Long-term Psychiatric Hospitalization ...................................................... 19

(6) References ....................................................................................................................... 21

c. Veterans Diagnosed with a Substance Use Disorder .......................................................... 23

(1) Background ......................................................................................................................23

(2) Principles of Treatment and Rehabilitation of Veterans

with a Substance Use Disorder .................................................................................. 23

(3) The Substance Abuse Disorder Continuum of Care ....................................................... 23

(4) References ....................................................................................................................... 25

d. Veterans Diagnosed with Post Traumatic Stress Disorder (PTSD) ................................... 26

(1) Background ..................................................................................................................... 26

(2) Principles of Treatment and Rehabilitation of Veterans Suffering from PTSD ............. 27

(3) The PTSD Continuum of Care ....................................................................................... 27

(4) Outcome Monitoring ....................................................................................................... 29

(5) References ....................................................................................................................... 29

e. Homeless Mentally Ill Veterans .......................................................................................... 30

(1) Background and Definition ............................................................................................. 30

(2) Principles of Treating Homeless Veterans Disabled by Mental Illness .......................... 33

(3) Continuum of Care for HMI ........................................................................................... 33

(4) References ....................................................................................................................... 35

f. Elderly Veterans with Psychogeriatric Problems ................................................................ 35

(1) Definitions ...................................................................................................................... 35

(2) Interdisciplinary Approach ............................................................................................. 36

(3) Special Issues .................................................................................................................. 36

(4) Staffing Considerations ................................................................................................... 37

(5) The Psychogeriatric Continuum of Care ......................................................................... 37

(6) References ....................................................................................................................... 38

g. Providing Services to Veterans Living in Rural Areas ...................................................... 38

(1) General Principles to Consider ....................................................................................... 38

(2) Guidelines for Using Tele-Mental Health Technology ................................................... 39

(3) References ....................................................................................................................... 40

h. Special Issues For Women and Other Minority Veterans .................................................. 41

(1) Women Veterans ............................................................................................................. 41

(2) African-American Veterans ............................................................................................ 41

(3) Latino Veterans ............................................................................................................... 41

(4) Native American Veterans .............................................................................................. 42

(5) Reference ........................................................................................................................ 42

4. Program Elements and Settings .............................................................................................. 42

a. Overview ............................................................................................................................. 42

(1) Journey of Change .......................................................................................................... 42

June 3, 1999 VHA PROGRAM GUIDE 1103.3

v

PARAGRAPH PAGE

(2) Admission to Mental Health Care .................................................................................. 42

b. General Mental Health (Seriously Mentally Ill Veterans) .................................................. 43

(1) Mental Health Primary Care Teams ............................................................................... 43

(2) Community-based Clinics ............................................................................................... 44

(3) Mental Health Clinics (MHCs)........................................................................................ 45

(4) Standard Case Management ............................................................................................ 46

(5) Intensive Community Case Management (ICCM) ......................................................... 47

(6) Day Treatment Centers (DTCs) ...................................................................................... 48

(7) Day Hospital Programs ................................................................................................... 49

(8) Community Residential Care (CRC) .............................................................................. 50

(9) Community-based Residential Treatment Settings ........................................................ 51

(10) Psychosocial Residential Rehabilitation Treatment Programs (PRRTPs) .................... 51

(11) Mental Health Services Within VA Domiciliaries ....................................................... 53

(12) General Compensated Work Therapy-Transitional Residences (CWT-TR) ................. 53

(13) Nursing Home Care ...................................................................................................... 54

(14) Medical -Psychiatric Sustained Treatment and Rehabilitation Units ........................... 54

(15) Community Reentry STAR Program ............................................................................ 55

(16) Skilled Psychiatric Nursing STAR Unit ....................................................................... 55

(17) General Psychiatry Subacute, and/or Rehabilitation Setting ........................................ 56

(18) Continued Extensive Psychiatric Care (CEPC) ............................................................ 57

(19) General Psychiatric Hospital Unit ................................................................................ 57

(20) Psychiatric Intensive Care Units (PICUs) ..................................................................... 58

(21) Summary of Reporting Codes for SMI Programs.......................................................... 59

c. Substance Use Disorder Services, Program Elements, Settings ......................................... 59

(1) Substance Use Disorder Treatment Clinics .................................................................... 59

(2) Intensive Outpatient Substance Use Disorder Treatment ............................................... 60

(3) Substance Use Disorder Residential Programs ............................................................... 60

(4) Substance Use Disorder Subacute Rehabilitation Settings ............................................. 61

(5) Inpatient Substance Use Disorder Settings ..................................................................... 61

(6) Summary of Reporting Codes for Substance Use Programs ............................................61

d. PTSD Services, Program Elements, Settings ...................................................................... 61

(1) Vet Centers ..................................................................................................................... 61

(2) Subclinics for PTSD ....................................................................................................... 62

(3) Sexual Trauma Counseling ............................................................................................. 62

(4) PTSD Clinical Teams (PCTs) ......................................................................................... 62

(5) Women Veteran Stress Disorder Treatment Teams ........................................................ 63

(6) Substance Use PTSD Treatment Programs (SUPTs) ......................................................63

(7) Day Hospitals for PTSD ................................................................................................. 63

(8) Day Treatment Centers for PTSD ................................................................................... 63

(9) PTSD Residential Rehabilitation Programs (PRRPs)...................................................... 63

(10) Domiciliary-based PTSD Treatment Programs ............................................................ 64

(11) PTSD CWT/TR ............................................................................................................ 64

(12) Specialized Inpatient PTSD Units (SIPUs) ................................................................... 64

(13) Evaluation and Brief Treatment PTSD Unit (EBTPU) ................................................. 64

VHA PROGRAM GUIDE 1103.3 June 3, 1999

vi

PARAGRAPH PAGE

(14) Summary of Reporting Codes for PTSD Programs ......................................................65

e. Health Care For Homeless Veterans (HCHV) Programs......................................................65

(1) Homeless Chronically Mentally Ill (HCMI) Programs.....................................................65

(2) VA Supported Housing (VASH) Programs .................................................................... 66

(3) SSA-VA Joint Outreach Initiative .................................................................................. 66

(4) HCMI CWT/TR .............................................................................................................. 66

(5) Domiciliary Care Programs ............................................................................................ 66

(6) Summary of Reporting Codes for Homeless Programs ...................................................67

f. Services, Program Elements for Elderly Veterans with Psychogeriatric Problems ............ 67

(1) Concept of Clinical Teams ............................................................................................. 67

(2) Psychogeriatric Integrated Care Teams (PICTs) ............................................................. 67

(3) Collaboration with Pertinent Geriatrics and Extended Care Programs .......................... 68

(4) Family and Caregiver Support ........................................................................................ 69

(5) Psychogeriatric Primary Care Clinics ............................................................................. 69

(6) Psychogeriatric Day Programs ........................................................................................ 70

(7) VHA Domiciliaries ..........................................................................................................70

(8) Psychogeriatric Sections Within VA Nursing Home Care Units ................................... 71

(9) Medical - Psychogeriatric Sustained Treatment and Rehabilitation Units ......................71

(10) Skilled Psychogeriatric STAR Nursing Units ................................................................72

(11) High Intensity (Brief Stay) Psychogeriatric Evaluation Settings. ...................................72

(12) Summary of Reporting Codes for Psychogeriatric Programs .........................................73

g. Psychosocial Rehabilitation Program Elements ................................................................. 73

(1) Psychosocial Rehabilitation .............................................................................................73

(2) The Psychosocial Rehabilitation Continuum of Care ......................................................73

(3) Integration of Work Programs .........................................................................................75

(4) Summary of Reporting Codes for Psychosocial Rehabilitation Programs .......................76

APPENDIXES

A Common Acronyms Used in these Guidelines .................................................................... A-1

B Mental Health Directives and Clinical Practice Guidelines for Mental Health

Practitioners .................................................................................................................... B-1

C Comparative Definitions of "Levels Of Care" for Mental Health Services .......................... C-1

D Current DSS Identifiers (Stop Codes) and CDR Accounts for Mental Health Programs ... D-1

E Index ...... E-1

June 3, 1999 VHA PROGRAM GUIDE 1103.3

1

MENTAL HEALTH PROGRAM GUIDELINES

FOR THE NEW VETERANS HEALTH ADMINISTRATION

1. INTRODUCTION AND OVERVIEW

a. Authorization

(1) "The mission of the veterans healthcare system is to serve the needs of Americas

veterans by providing primary care, specialized care, and related medical and social

support services. To accomplish this mission, the Veterans Health Administration (VHA)

needs to be a comprehensive, integrated healthcare system that provides excellence in

healthcare value, excellence in service as defined by its customers, and excellence in

education and research, and needs to be an organization characterized by exceptional

accountability and by being an employer of choice." (Kizer, Journey of Change, 1997)

(2) "Each eligible (enrolled) veteran will have access to a comprehensive, integrated,

continuum of high quality effective mental health services by the year 2002." (Mental Health

Strategic Healthcare Group (MHSHG), 1997.)

(3) Within the context of the dramatic transformation of VHA as anticipated in Dr. Kizers

Vision for Change, and authorized by Public Law 104-262, the Eligibility Reform Act of 1996,

this document reflects:

(a) A new integrated continuum of mental health services providing continuity of care.

(b) A major shift from an inpatient focus to that of residential treatment and communitybased

services.

uncoupling patient treatment and rehabilitation modalities from the settings with which they are

traditionally associated.

(d) A framework for integrating the specialized knowledge of mental health into primary care.

(e) Healthcare decision-making at the facility and Veterans Integrated Service Network

(VISN) level.

(f) Accountability through providing national workload definitions, methods for data capture,

and measures of costs and outcomes.

b. Purpose. The purpose of this program guide is to:

(1) Provide current program guidelines for mental health professionals, planners, and

administrators.

VHA PROGRAM GUIDE 1103.3 June 3, 1999

2

(2) Reflect changes involving current best practice in mental health care as VHA moves into

the next century.

(3) Define levels of care.

(4) Stimulate innovative and evidence-based approaches for clinical care.

(5) Reflect requirements regarding "capacity" contained within the Veterans Healthcare

Eligibility Reform Act of 1996.

(6) Provide a template for individual patient treatment planning.

(7) Provide definitions and a crossover to VHAs new Decision Support System (DSS)

methodology.

2. GUIDELINES FOR PROVIDING MENTAL HEALTH SERVICES

a. Principles for Organizing Mental Health Care. Quality primary and specialty mental

health care can be provided to veterans under a variety of organizational structures, including the

traditional professional services model, a product and/or service line (Charns et al, 1998) model,

or a combination of these and other models. In developing an efficient structure for the delivery

and monitoring of quality mental health care in VHA, organizational structures need to:

(1) Promote inter-professional collaboration in leadership, planning, and the monitoring of

mental health program performance.

(2) Provide for a cost-effective, seamless continuum of mental health treatment programs.

(3) Support a continuity of care to meet both the primary care and specialty mental health care

needs of patients while mindful of the patients involvement in treatment decisions.

(4) Acknowledge the need for discipline specific involvement in the recruitment and

evaluation of the practice of mental health professionals, including the oversight of training and

research activities.

(5) Include contributions from patients and patient advocate groups in planning and

evaluating mental health care delivery.

(6) Reference. Charns MP, Parker V, Wubbenhorst W. Clinical Service Lines In Integrated

Healthcare Delivery Systems, for Industry Advisory Board, Center for Health Management

Research, 1998.

June 3, 1999 VHA PROGRAM GUIDE 1103.3

3

b. Principles for Program Planning

(1) Definition of Program and Program Elements. In the context of reorganization of

clinical programs to focus on patients needs, a useful definition of a program is "an integrated,

comprehensive and cost effective continuum of care for veterans provided under a single

administrative structure." Program elements make up the total program. Under this definition,

all program elements at a single Department of Veterans Affairs (VA) medical center, for

instance, would be considered as a single program if administered as a single program. If

program administration were at a consolidated VA Healthcare System or a VISN level, then the

larger unit would be considered a "program." The word, "program," is also used for some

program elements organized under a single administrative structure and for some settings where

an integrated treatment regimen is indistinguishable from the setting (e.g., day treatment center).

NOTE: In the past programs tended to be defined, at least in part, by funding sources. If there

were separate sources of funding for inpatient and outpatient program elements at the same

facility, these might be listed as two programs whereas if these program elements had the same

funding source, they would be seen as a single program.

(2) Organizational Structures. Organizational structures involved in planning mental health

services, whether at the facility or VISN level, need to:

(a) Identify programs and program elements in a manner consistent with local organizational

structures as well as national priorities;

(b) Create plans based on veteran populations rather than existing programs or facilities;

(d) Partner with other service providers in planning;

(e) Involve patients and patient representatives in the process;

(f) Consult clinical practice guidelines where they are available;

(g) Include, or provide access to, the often multiple sources of expertise required to treat

patients with comorbidities; and

(h) Encourage the evaluation of programs and outcome measurements of delivery systems.

NOTE: Comorbidities in veteran populations pose a problem for program planning. Terms

such as "dual diagnosis" and "Mentally Ill Chemical Abusers (MICA)," that have surfaced

nationally over the last decade reflect the growing realization that not only veterans, but many

VHA PROGRAM GUIDE 1103.3 June 3, 1999

4

other individuals with a mental disorder have, in addition, one or more other disorders that

complicate not only individual treatment planning but organization of programs. Special

funding by diagnosis or circumstance (e.g., substance abuse or elderly) in the past has

compounded the problem by putting artificial barriers to clinicians faced with real patients

presenting simultaneously with, for instance, a substance use disorder, post-traumatic stress

disorder (PTSD), and depression. Under new funding and allocation systems, VHA now has the

opportunity to remedy that situation.

c. Principles for Providing Quality Mental Health Care

(1) Mental Health Providers. Mental health providers should strive to:

(a) Maximize each patients functional independence;

(b) Make ongoing quality mental health care available in the most appropriate location based

on the patients medical and functional condition;

(d) Advocate for the needs of patients;

(e) Involve patients, their families, and other caregivers in shared decision-making;

(f) provide continuity of care and a knowledgeable treatment team through case management

(or care management) and primary care approaches; and

(g) Use evidence-based treatment guidelines where available and appropriate (see App. B).

(2) The Continuum of Care. VHA is committed to providing an integrated, comprehensive

and cost effective continuum of care for veterans with mental disorders.

(a) Program elements along a continuum of care should be driven by needs of the patients and

their families rather than by traditional bed levels or funding sources.

(b) Patients should move among the components of the continuum as is clinically appropriate,

with minimal disruption in treatment, and in a manner which facilitates positive treatment

outcomes.

continuum.

(d) Treatment of all patients with mental health problems should be provided by appropriately

trained, credentialed, and privileged clinicians and should be managed to assure continuity of

care.

June 3, 1999 VHA PROGRAM GUIDE 1103.3

5

(e) Treatment provided by VA should reflect state-of-the-art care as documented in the

empirical literature and clinical treatment guidelines and should be provided in a cost-effective

manner.

(f) Treatment outcomes should be monitored and serve as a basis for improving care.

(g) Evaluations of VAs mental health service delivery and outcomes should benchmark

results with comparable non-VA healthcare systems.

(h) During reorganizations of clinical services, primary emphasis should be placed on the

development of an accessible continuum of care for all patients with mental disorders.

(i) When developing admission and readmission policies care should be taken to distinguish

between the intensity of services necessary to address the clinical problem and the setting (i.e.,

ambulatory, residential, partial hospital, inpatient, etc.) most appropriate for the patient.

(j) Case (care) management is an effective tool and should be utilized to assure that patients

receive all necessary services throughout the continuum in a timely and coordinated manner.

(3) Mental Health and Primary Care. Mental Health Primary Care should be made

available to veterans with significant mental disorders.

(a) Definition of Primary Care. Primary Care is the coordinated, interdisciplinary provision

of comprehensive healthcare including intake, initial assessment, health promotion, disease

prevention, emergency services, management of acute and chronic biopsychosocial conditions,

referrals for specialty, rehabilitation, and other levels of care, follow-up, overall care

management, and patient and caregiver education.

(b) Rationale. As described in The Prescription for Change, VA has adopted primary care as

a fundamental emphasis for the delivery of healthcare to veterans (Kizer, 1995). Mental health

care is the primary focus of healthcare for a substantial proportion of patients in the public and

private healthcare system (Regier, et al, 1978). For many other healthcare patients with

undetected psychiatric problems, mental health services, although often overlooked, can also

reduce the risk and intensity of medical illness and the extent and cost of medical care services

(Friedman, et al, 1995).

a tenet of primary care that there be continuity of care across service delivery sites and across

episodes of care, ensuring that there is coordination of care, and that patients do not "fall through

the cracks" as can happen in a fragmented care system. Four models are evolving for the

provision of mental health primary care, each of which can be adapted to fit specific sites,

resources, and goals (see VHA Program Guide 1103.2).

Forum: Compensation, Treatment, and Research Resources

AGENT ORANGE HEALTH REGISTRY (AOR) PROGRAM PROCEDURES TO INCLUDE ALL VETERANS EXPOSED TO AGENT ORANGE AND SPECIAL HEALTH CARE BENEFITS FOR VIETNAM...

IGWCADMIN — Wed, 03 Jan 2007 05:23:14 GMT

http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1474

T-1

Department of Veterans Affairs VHA HANDBOOK 1302.01

Veterans Health Administration Transmittal Sheet

Washington, DC 20420 September 5, 2006

AGENT ORANGE HEALTH REGISTRY (AOR) PROGRAM PROCEDURES

TO INCLUDE ALL VETERANS EXPOSED TO AGENT ORANGE

AND SPECIAL HEALTH CARE BENEFITS FOR VIETNAM VETERANS CHILDREN

1. REASON FOR ISSUE. This Veterans Health Administration (VHA) Handbook

establishes new reporting procedures for the Department of Veterans Affairs (VA), VHA,

and the Environmental Agents Service (EAS) Agent Orange Health Registry Program.

2. SUMMARY OF MAJOR CHANGES. The principal changes to VHA Handbook

1302.01 are to:

a. Provide new Registry data entry procedures required to access the reconstructed

EAS Web site http://vaww.registries.aac.va.gov, allowing Environmental Health (EH)

Clinicians and Coordinators to search for and access exam information by veterans name or

social security number, and giving them the ability to retrieve all exam information,

historical and current, regardless of point of entry, and

b. Provide new subscription instructions for the EAS publication "Agent Orange

Review."

3. RELATED ISSUES: VHA Directive 1302.

4. RESPONSIBLE OFFICIALS: The Director, EAS (131), is responsible for the

contents of this VHA Handbook. Questions may be referred to that individual at 202-273-

8579. NOTE: Questions relating to eligibility for VA care, including enrollment, are to be

directed to the eligibility staff at each facility and on the Intranet at http://www.va.gov/elig/.

5. RESCISSIONS: Handbook 1302.1, dated October 5, 2004, is rescinded.

6. RECERTIFICATION: This VHA Handbook is scheduled for recertification on or

before the last working day of September 2011.

S/ Louise Van Diepen for

Michael J. Kussman, MD, MS, MACP

Acting Under Secretary for Health

DISTRIBUTION: CO: E-mailed 9/7/06

FLD: VISN, MA, DO, OC, OCRO, and 200 E-mailed 9/7/06

September 5, 2006 VHA HANDBOOK 1302.01

i

CONTENTS

AGENT ORANGE HEALTH REGISTRY (AOR) PROGRAM PROCEDURES

TO INCLUDE ALL VETERANS EXPOSED TO AGENT ORANGE

AND SPECIAL HEALTH CARE BENEFITS FOR VIETNAM VETERANS CHILDREN

PARAGRAPH PAGE

1. Purpose ...... 1

2. Authority ... 1

3. Vietnam Veterans Eligibility for AOR Examinations .............................................................. 1

4. Health Registry Examinations .................................................................................................. 2

5. Further Evaluation and Treatment ............................................................................................ 2

6. Health Registry Participation Does Not Constitute a Formal Claim for Compensation .......... 2

7. Special Health Care Benefits for Vietnam Veterans Children Born with Spina Bifida

(except Spina Bifida Occulta) ............................................................................................... 3

8. Special Benefits for Women Vietnam Veterans Children with Birth Defects ........................ 3

9. Program Management ............................................................................................................... 3

10. Environmental Health (EH) Clinician Responsibilities .......................................................... 4

11. EH Coordinator Responsibilities ............................................................................................ 7

12. Active Duty Military Personnel .............................................................................................. 9

13. Incarcerated Veterans ........................................................................................................... 10

14. Veterans with Other than Honorable Discharges ................................................................. 11

15. Conducting the Physical Examination .................................................................................. 11

16. Reporting Requirements ....................................................................................................... 14

17. Education and Training ......................................................................................................... 14

VHA HANDBOOK 1302.01 September 5, 2006

ii

APPENDIX PAGE

APPENDICES

A Sample Agent Orange Follow-up Letter (Medical Problems

Indicated for Vietnam Veterans) ..................................................................................... A-1

B Sample Agent Orange Follow-up Letter (Medical Problems Indicated for Veterans

Who Are Not Eligible for VA Health Care) .................................................................... B-1

C Sample Agent Orange Follow-up Letter (No Medical Problems for

All Veterans Exposed to Agent Orange or Other Herbicides) .......................................... C-1

D Definitions and Acronyms ................................................................................................... D-1

E Instructions for Completing and Accessing VA AOR Worksheets ...................................... E-1

September 5, 2006 VHA HANDBOOK 1302.01

1

AGENT ORANGE HEALTH REGISTRY (AOR) PROGRAM PROCEDURES

TO INCLUDE ALL VETERANS EXPOSED TO AGENT ORANGE

AND SPECIAL HEALTH CARE BENEFITS FOR VIETNAM VETERANS CHILDREN

1. PURPOSE

This Veterans Health Administration (VHA) Handbook sets forth clinical and administrative

procedures related to the maintenance of the VHA Agent Orange Health Registry (AOR)

program of physical examinations for eligible, concerned, Vietnam veterans who served in the

Republic of Vietnam between 1962 and 1975, veterans who served in Korea during 1968 or

1969, and any United States (U.S.) veterans who may have been exposed to dioxin, or other

toxic substance in an herbicide or defoliant, during the conduct of, or as a result of, the testing,

transporting, or spraying of herbicides for military purposes.

2. AUTHORITY

a. Under Public Law (Pub. L.) 102-585 Section 703, the Secretary of Veterans Affairs may

provide, upon request, a health examination, consultation, and counseling to a veteran who is

eligible for listing or inclusion in any health-related registry administered by the Secretary of

Veterans Affairs. Under this authority, the Department of Veterans Affairs (VA) must provide

registry examinations to veterans who served in Korea in 1968 or 1969, and/or any other U. S.

veteran who may have been exposed to dioxin, or other toxic substance in an herbicide or

defoliant, during the conduct of military operations, or as a result of, the testing, transporting, or

spraying of herbicides for military purposes, and who requests an AOR examination. The results

of such an examination are to be included in the AOR.

b. Pub. L. 100-687, the Veterans Judicial Review Act of 1988, requires the Secretary of

Veterans Affairs to organize and update the information contained in the VA AOR, enabling VA

to notify Vietnam era veterans who served in the Republic of Vietnam of any increased health

risks resulting from exposure to dioxin or other toxic agents. NOTE: VA must continue to meet

this mandate and extend it to include all other veterans who qualify for inclusion and

participation in the AOR.

3. VETERANS ELIGIBILITY FOR AO HEALTH REGISTRY EXAMINATIONS

Health registry examinations must be provided to:

a. Any U.S. male or female Vietnam era veteran who served in the Republic of Vietnam

between 1962 and 1975, regardless of length of service (i.e., 1 hour, 1 day, 1 month, 1 year, etc.).

Verification of service during the Vietnam era is required. NOTE: Inasmuch VA presumes that

a veteran was exposed to phenoxy herbicides during any service in Vietnam, a verified claim of

such in-country service constitutes the required contention of exposure and establishes eligibility

for registry examinations within these provisions.

VHA HANDBOOK 1302.01 September 5, 2006

2
NOTE: Congress gave VA the authority to presumptively service-connect certain diseases

associated with exposure to herbicides used in the Vietnam War (see subpar. (10(c) for the

conditions that are currently presumptively recognized as service connected) and to presume

that Vietnam veterans were exposed to such herbicides. Veterans from other conflicts (Korea,

etc.) may take advantage of these "presumptions of service connection" if the veterans are

diagnosed with one of the presumed illnesses. But unlike Vietnam veterans, they are required to

prove they were exposed to Agent Orange or other herbicides during their military service; they

do not have the benefit of a presumption of exposure like Vietnam veterans.

b. Any U.S. veteran who served in Korea during 1968 or 1969.

c. Any U.S. veteran who may have been exposed to dioxin, or other toxic substance in an

herbicide or defoliant, during the conduct of military operation, or as a result of, the testing,

transporting, or spraying of herbicides for military purposes. NOTE: See Web site

http://www1.va.gov/agentorange/ for a Department of Defense (DOD) list (75 percent complete)

of locations and dates where dioxin (Agent Orange and other agents) was used. For those sites

that are not listed, the veteran needs to provide some proof of exposure to be able to obtain a

registry examination.

4. HEALTH REGISTRY EXAMINATIONS

The health registry examination protocol for veterans exposed to dioxin or other toxic

substance in an herbicide or defoliant is described in paragraph 15. NOTE: Veterans eligible

for inclusion in the AOR do not need to be enrolled in VA health care to receive the health

registry examinations.

5. FURTHER EVALUATION AND TREATMENT

Where the findings of the health registry examination reveal a condition requiring treatment,

the veteran is to be referred to a VA primary care clinician to obtain the necessary medical

assessment and appropriate treatment, if enrolled or otherwise eligible for VA health care. If the

veteran is not enrolled or otherwise eligible, the veteran must be encouraged to enroll or seek

non-VA care.

6. HEALTH REGISTRY PARTICIPATION DOES NOT CONSTITUTE A FORMAL

CLAIM FOR COMPENSATION

Veterans must be advised that participation in the AOR examination program does not

constitute a formal claim for compensation. Although the results of such an AOR examination

may be used to support a compensation claim, the examination must not, in most cases, be

considered such a claim. Veterans may be advised of the routine procedure to file a claim

through the Veterans Benefits Representative (VBR) at the nearest VA facility, medical center,

or regional office.

September 5, 2006 VHA HANDBOOK 1302.01

3

7. SPECIAL HEALTH CARE BENEFITS FOR VIETNAM VETERANS CHILDREN

BORN WITH SPINA BIFIDA (EXCEPT SPINA BIFIDA OCCULTA)

a. Spina bifida (except spina bifida occulta) is presumptively recognized in the offspring of

Vietnam veterans as due to herbicide exposure.

b. Title 38 United States Code (U.S.C.) Section 1803 states that VA must provide health

care benefits for children of Vietnam veterans who are born with spina bifida or any disability

that is associated with such condition. The term "child," with respect to a Vietnam veteran,

means a natural child of the Vietnam veteran, regardless of age or marital status, who was

conceived after the date on which the veteran first entered the Republic of Vietnam during the

Vietnam era between January 9, 1962 and May 7, 1975, inclusive. NOTE: The term "Vietnam

veteran" means a veteran who performed active military, naval, or air service in the Republic of

Vietnam during the Vietnam era. The Veterans Benefits Act of 2003 extended these benefits to

the natural children of veterans who served in Korea between September 1, 1967, and August 31,

1971, and who were exposed to certain herbicides during such service in or near the Korean

Demilitarized Zone (DMZ). The spina bifida conditions covered apply with respect to all forms

and manifestations of spina bifida except spina bifida occulta. NOTE: For information about

this program, access Web site http://www.vba.va.gov/bln/21/benefits/Herbicide/index.htm#bm03,

or contact the VA spina bifida-birth defects Hotline at 1-888-820-1756.

8. SPECIAL HEALTH CARE BENEFITS FOR WOMEN VIETNAM VETERANS

CHILDREN WITH BIRTH DEFECTS

a. In accordance with the mandate in 38 U.S.C. 1813, VA has identified the birth defects of

children of women Vietnam veterans that:

(1) Are associated with Vietnam service; and

(2) Result in permanent physical or mental disability.

b. A list of those diseases is available at

http://www.vba.va.gov/bln/21/Topics/Women/Birth.htm. For further

details concerning these benefits, contact the VA spina bifida /birth defects hotline at 1-888-820-

1756.

9. PROGRAM MANAGEMENT
NOTE: The Environmental Health (EH) Clinicians, Coordinators, and health administration

staff of each VA facility are often the first points of contact for veterans requesting health

registry examinations. They play a significant role in determining the perception veterans have

concerning the quality of VA health care services and of their individual treatment by VA health

care providers. These individuals need to be well informed of the policies and procedures of this

Agent Orange Program to provide good management and quality health registry examinations

for this veteran population.

VHA HANDBOOK 1302.01 September 5, 2006

4

a. Environmental Health (EH) Clinician. An EH Clinician, or designee, must be assigned

by the Chief of Staff (COS) and approved by the Director at each facility.

b. EH Coordinator. An EH Coordinator and alternate(s) must be designated by

administrative staff assigned by the facility Director. Final approval rests with the facility

Directors office.

c. Updating EH Clinician and EH Coordinator Appointments

(1) Separate listings of the EH Clinicians and EH Coordinators are maintained within

Environmental Agents Service (EAS) and published on internet and intranet Web sites

http://www.va.gov/EnvironAgents/ and http://vaww.va.gov/EnvironAgents.

(2) In an effort to keep these listings current, facilities are mandated to notify EAS of

changes as they occur in status of EH Clinicians and Coordinators at their respective facilities

and/or satellite clinics.

(3) As changes in appointments occur, submit the name, title, mail routing symbol,

telephone and FAX numbers including area code, to the Environmental Health Coordinator, EAS

(131), Department of Veterans Affairs, 810 Vermont Avenue, NW, Washington, DC 20420.

NOTE: In order to provide current Agent Orange Program information to concerned VA

Registry Staff, it is important that any changes in appointments of EH Clinicians and

Coordinators at VA facilities be provided to VA Central Office (131) as they occur.

10. EH CLINICIAN RESPONSIBILITIES

The EH Clinician is responsible for clinical management and serves in an advisory capacity

for the administrative management of the program. Major responsibilities include:

a. Counseling. The EH Clinician advises the veteran that the examination cannot detect the

presence of dioxin in the body nor determine whether adverse health effects or potential health

problems are related to Agent Orange.

b. Documenting the Physical Examination. NOTE: If a compensation examination is

performed for a veteran and the veteran requests inclusion in the AOR, it is not necessary to

perform an additional health registry examination as long as the demographic and medical

information is sufficient to adequately complete the AOR worksheet on the Web site

http://vaww.registries.aac.va.gov for transmission to the Austin Automation Center (AAC). The

EH Clinician must:

(1) Conduct and document the physical examination in the veterans health record at the

time of the visit.

(a) Perform a complete medical history to include information about:

1. Family;

September 5, 2006 VHA HANDBOOK 1302.01

5

2. Occupation;

3. Social history noting tobacco, alcohol, and drug use;

4. Civilian exposure to possible toxic agents; and

5. Psychosocial history.

(b) If a non-VA doctor diagnoses a veteran with a significant health problem, the veteran is

to be encouraged to contact a VA medical center to include the diagnosis in the veterans health

record.

1. This diagnosis must be submitted over a non-VA physician's signature and on official

letterhead.

2. The private physicians health registry examination data needs to be reported to the

AAC via Web site http://vaww.registries.aac.va.gov.

(2) Review and complete, if necessary, the health registry examination worksheets at Web

site http://vaww.registries.aac.va.gov.

(3) Review the records of every veteran examined to ensure that a complete physical

examination was performed and documented.

(4) Personally discuss with each veteran the:

(a) Findings of the physical examination and completed diagnostic studies. NOTE: The

interview is to be conducted in such a way as to encourage the veteran to discuss health

concerns, as well as those of family members, as they relate to herbicide exposure. This

information must be documented in the veteran's health record.

(b) Need for follow-up examination (not a consultation, but an additional registry

examination) either recommended by the EH Clinician or requested by the veteran. NOTE: A

follow-up registry examination does not need to be provided routinely; it needs to be based on

new symptoms or health problems experienced by the veteran.

1. Preparing and Signing Follow-up Letter. The EH Clinician must ensure that an

appropriate personalized follow-up letter, explaining the results of the examination and

laboratory studies, has been signed and mailed to the veteran (see Apps. A, B, and C). NOTE:

It is essential that this letter be written in language that can be easily understood by the veteran.

Inappropriate wording could unduly alarm or confuse the veteran. A great deal of sensitivity

and care must be exercised in the preparation of this correspondence.

a. Follow-up letters must be mailed to the veteran within 2 weeks of the initial

examination appointment. The only exception to this timeframe is when a consultation at a

specialty clinic is requested as part of the initial examination process. This exception suspends,

VHA HANDBOOK 1302.01 September 5, 2006

6

but does not remove, the requirement for the follow-up letter. The follow-up letter must be sent

within 2 weeks after the consultation.

b. A dated copy of the follow-up letter must be filed in the veteran's administrative record

or scanned to an appropriately titled progress note in Computerized Patient Record System

(CPRS).

c. The follow-up letter must explain that:

(1) If the veteran examined has no detectable medical problems, the follow-up letter needs

to so indicate and suggest that the veteran contact the nearest VA health care facility if health

problems appear later.

(2) If it is determined upon examination that the veteran does have medical problems, it is

not necessary to specify the problems in the letter. The veteran needs to be advised in the letter

that the recent examination indicated a health condition and/or problem, which may require

further examination and/or treatment. NOTE: Depending on the seriousness of the condition

identified, the EH Clinician needs to phone the veteran to discuss the examination findings.

Clinical judgment needs to be exercised. If the veteran is eligible for VA medical treatment, the

letter needs to so state and provide the name of a contact person, including telephone number,

within the facility.

(3) If the veteran is not eligible for VA treatment, the letter needs to recommend that the

veteran contact the EH Coordinators office or a VBR at the VA facility or Regional Office for

further information. NOTE: Another point of contact is the local Enrollment Coordinator or

Health Benefits Service Center at 1-877-222-VETS (8387) for those found not eligible for VA

treatment. Rejected applicants are to be provided their appeal rights as part of the normal

notification of the denial of health benefits.

(4) If the problem(s) is (are) not necessarily related to possible Agent Orange exposure,

the letter needs to explain that there is considerable research underway to learn more about the

possible long-term health effects of Agent Orange exposure.

c. Health Conditions Presumptively Recognized to Date

Currently, the following conditions have been presumptively recognized as service

connected (SC) for the treatment of veterans who were exposed to herbicide agents during

service, so long as the condition has manifested to a degree of 10 percent or more:

(1) Chloracne or other acne form disease consistent with chloracne (must manifest to a

degree of 10 percent or more within 1 year after the last date of exposure to Agent Orange);

(2) Non-Hodgkin's lymphoma;

(3) Soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposis sarcoma, or

mesothelioma);

September 5, 2006 VHA HANDBOOK 1302.01

7

(4) Hodgkin's disease;

(5) Porphyria Cutanea Tarda (PCT) (must manifest to a degree of 10 percent or more within

1 year after the last date of exposure to Agent Orange);

(6) Respiratory cancers (cancers of the lung, larynx, trachea, and bronchus);

(7) Multiple myeloma;

(8) Prostate cancer;

(9) Peripheral neuropathy, transient acute and sub-acute (i.e., transient peripheral neuropathy

that appears within weeks or months of exposure and resolves within 2 years of date of onset)

(must manifest to a degree of 10 percent or more within 1 year after the last date of exposure to

Agent Orange).

(10) Type 2 diabetes; and

(11) Chronic lymphocytic leukemia.

NOTE: Other conditions may be recognized in the future.

d. Reviewing Records. The EH Clinician reviews records of every veteran receiving an

AOR examination to ensure that a complete physical examination was performed and

documented and that the veteran has been appropriately notified of the examination results.

11. EH COORDINATOR RESPONSIBILITIES

The EH Coordinator is responsible for the administrative management of the program,

including:

a. Scheduling of Appointments. Every effort needs to be made to give each veteran an

AOR examination within 30 days of the request date. If numerous consultations are required,

whenever possible, all of these need to be scheduled on the same day, so that the veteran is not

unduly inconvenienced. When it is not possible to provide all consultations on the same day, the

EH Coordinator, or the scheduler, needs to work with the veteran to minimize the number of

disruptions in the veterans life. If a medical center fails to meet the time standard of 30

calendar days from date of request, the medical center Director, or designee, must explore all

alternatives; i.e., referrals to other VA facilities, additional staff hours to perform these

examinations, and the possibility of using fee-basis or contractual sources to furnish these

examinations, to bring the medical center in line with the time standard. If, after these

alternative measures have been explored and the time standard still cannot be met, an exemption

needs to be requested by contacting EAS, VA Central Office, at (202) 273-8463 or (202) 273-

8465.

VHA HANDBOOK 1302.01 September 5, 2006

8

b. Monitoring Timeframe Compliance

(1) Follow-up Letters. Mail to veteran within 2 weeks of initial registry examination.

(2) Health Registry Examination Appointment. Schedule within 30 days of request date.

(3) VA Staff (EH Clinician and Coordinator) Changes. Advise EAS, VA Central Office

(131), as staff changes occur.

(4) Health Registry Worksheets for Initial and Follow-up Examinations. Enter

worksheet data via EAS Web site http://vaww.registries.aac.va.gov.

c. Reviewing Records for Accuracy and Completion. All required records, follow-up

letters, and health registry examination worksheet data of veteran participants, are to be

completed, reviewed for accuracy, and filed and/or scanned into the veterans health or

administrative record.

d. Collecting Data for Reporting Purposes. Required registry worksheet data needs to be

obtained from the veteran or family and entered into AAC database via Web site

http://vaww.registries.aac.va.gov. The AAC provides the AOR data reports to VA Central

Office based on VA facility input.

e. Disseminating Information. It is important that each veteran be fully advised of the

AOR examination program.

(1) The facility staff are to fully communicate all aspects of the AOR examination program

by an appropriate means, including advising the veteran to enroll with the VA on the initial visit.

(2) The EH Coordinator is required to provide veterans reporting to the Outpatient and/or

admission area with a copy of the VA publication the Agent Orange Review, and upon request,

or in response to questions, the Agent Orange Briefs, Agent Orange General Information, and

posting the Agent Orange Posters, inserting your name and phone extension as the individual

responsible for the AOR Program. NOTE: These publications and other informational

materials are to be visible and accessible in prominent areas (outpatient clinics, admission

areas, etc.) to ensure availability to Vietnam veterans, Korea veterans, and other interested

individuals. The Agent Orange Review includes information relating to use of the herbicide

Agent Orange used by the Republic of Korea troops along the Korean DMZ in 1968 and 1969

and during the conduct of, or the result of, the testing, transporting, or spraying of herbicides for

military purposes.

(a) The Agent Orange Review is a VA EAS publication, published periodically, to provide

information on Agent Orange and related matters to veterans, their families, and others with

concerns about herbicides used during the conduct of, or the result of, the testing, transporting,

or spraying of herbicides for military purposes. NOTE: The Agent Orange Review needs to be

included as a supplement to an application for examination.

September 5, 2006 VHA HANDBOOK 1302.01

9

(b) The Agent Orange Briefs consist of a series of fact sheets prepared and distributed

periodically to VA facilities by EAS, VA Central Office, Washington, DC. The fact sheets are

designed to answer questions relating to the purpose of the examination, its limitations (i.e.,

explains that the examination cannot detect the presence of dioxin in the body nor determine

whether adverse health effects or potential health problems are related to exposure, etc.) and a

variety of related matters.

(3) The EH Coordinator receives all Agent Orange-related inquiries and informs each

veteran of the toll-free helpline (1-800-749-8387) for Agent Orange concerns.

(4) The EH Coordinator provides copies of the VA Agent Orange Briefs and the Agent

Orange Review (prepared and provided to VA facilities by EAS, VA Central Office,

Washington, DC) to all telephone callers, local Veteran Service Organizations (VSOs) and

public libraries. NOTE: All past, current, and future issues of the Agent Orange Review have

been, or are to be, posted on the internet at http://www.va.gov/agentorange. Many veterans may

wish to obtain and/or read this publication via the Internet rather than receive it through the

postal service.

(5) The EH Coordinator posts and communicates the names, locations, and office telephone

numbers of the EH Clinicians and Coordinators to concerned VA facility staff. NOTE: An

appropriate method of communicating is through the use of: (a) medical center memoranda

providing registry policy and procedures which identify the staff who are responsible for

carrying out these policies, and (b) the medical center patient handbook (both inpatient and

outpatient, if available).

f. Records and Record Retention. The EH Coordinator must establish a health record for

the veteran, if one does not already exist. All health records of health registry examinations must

be maintained within CPRS.

(1) A posting for herbicides must be generated in CPRS and if appropriate, VA Form 10-

1079, Emergency Medical Identification, is to be affixed to the front of the paper health record.

(2) AOR worksheets and dated follow-up letters must be scanned, or made electronic, and

attached to an appropriately titled CPRS progress note. Documents that are considered strictly

administrative need to be linked to the patient in Veterans Health Information Systems and

Technology Architecture (VistA) Imaging only.

(3) Laboratory results are to be maintained within the electronic laboratory package unless

results are only available on paper, i.e., outside laboratory results; in which case, those results

are to be scanned into VistA Imaging.

(4) AOR examination documents that become part of the patients health record must be

retained for 75 years in accordance with VA Records Control Schedule (RCS) 10-1.

VHA HANDBOOK 1302.01 September 5, 2006

10

12. ACTIVE DUTY MILITARY PERSONNEL

a. When active duty members of the uniformed services apply to VA facilities for an Agent

Orange examination, the DOD must provide VA with appropriate authorization, i.e., DOD Form

1161, Referral for Civilian Care.

NOTE: The requirements of M-1, Part I, Chapter 15, regarding the authorization and billing

from the appropriate branch of service apply.

(1) The procedures for processing the examination are the same as those for a veteran

participating in this program.

(2) A military facility may perform the Agent Orange examination according to VA

instructions.

(3) Military facilities may obtain the pertinent information and samples of appropriate forms

from the nearest VA facility. Military facilities must complete the health registry worksheets

with the exception of the following coding identifiers which are to be filled in by VA coding

clerks:

(a) Facility number and/or suffix,

(b) County and state, and

veterans symptom and/or complaint.

(4) The completed health registry worksheets, copies of the physical examination, laboratory

tests, etc., are to be forwarded to the EH Coordinator at the nearest VA medical center or

outpatient clinic.

b. After the documents reach the EH Coordinator, the EH Coordinator must:

(1) Complete the health registry worksheet with identifier codes;

(2) Transmit the health registry worksheet data to the AAC via Web site:

http://vaww.registries.aac.va.gov, in accordance with instructions; and

(3) Maintain the medical documents and original registry worksheets in the veterans health

record, which is to be available if, or when, the individual is discharged from the service and

reports for treatment as a veteran.

Forum: Compensation, Treatment, and Research Resources

THE ROLE OF VHA POINTS OF CONTACT AND CASE MANAGERS TO COORDINATE CARE FOR RETURNING COMBAT SERVICE MEMBERS AND VETERANS

IGWCADMIN — Wed, 03 Jan 2007 05:19:01 GMT

http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1402

Department of Veterans Affairs VHA DIRECTIVE 2006-017 Veterans Health Administration Washington, DC 20420 April 3, 2006

THE ROLE OF VHA POINTS OF CONTACT AND CASE MANAGERS TO COORDINATE CARE FOR RETURNING COMBAT SERVICE MEMBERS AND VETERANS

1. PURPOSE: This Veterans Health Administration (VHA) Directive establishes policy regarding the Department of Veterans Affairs (VA) collaboration with Department of Defense (DOD) to seamlessly transition the health care of injured and ill returning combat active duty service members and veterans from DOD to the VA health care system. NOTE: This includes active duty service members and veterans directly referred from Military Treatment Facilities (MTFs), as well as outpatient active duty service members and veterans who present to VA medical centers seeking health care.

2. BACKGROUND

a. VA is collaborating with DOD and their MTFs to seamlessly transition the health care of injured or ill returning combat active duty service members and veterans from the MTF to a VHA facility. VHA has assigned part-time and full-time social workers to major MTFs to serve as VHA liaisons between the MTF and VHA facilities (see Att. A for list of sites). Each VHA facility has selected a Point of Contact (POC) who works closely with the VA-DOD Social Work Liaisons detailed to MTFs and the Veterans Benefits Administration (VBA) representatives to ensure a seamless transition and transfer of care. While this initiative pertains primarily to military personnel returning from Iraq and Afghanistan having served in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), it also includes active duty military personnel returning from other combat theater assignments. It does not include active duty military personnel who are serving in non-combat theaters of operation.

b. Veterans who have served on active duty in a theater of combat operations (as determined by the Secretary of Veterans Affairs in consultation with DOD) during a period of war after the Persian Gulf War, or in combat against a hostile force during periods of hostility after November 11, 1998, are eligible for hospital care and medical service for any illness potentially related to their service in the combat theater for a 2-year period following separation from military service. During this 2-year post-discharge period, they are not subject to medical care and medication copayments when their physical or mental condition is determined by their health care provider to be potentially related to their exposure or military experience, regardless of income (known as enhanced combat veteran benefits). Those veterans who did not serve in a combat theater are subject to the same eligibility requirements as all other veterans. NOTE: Reference VHA Directive 2005-020, Determining Combat Veteran Eligibility, for further details.

c. Members of the Reserve Component (National Guard and Reserve) are eligible for VA health care if they were called or ordered to active duty by a Federal declaration, served the period to which they were called and have separated from active military service under other

THIS VHA DIRECTIVE EXPIRES SEPTEMBER 30, 2007

VHA DIRECTIVE 2006-017 April 3, 2006

than dishonorable conditions. National Guard and Reserve members who were mobilized to active duty, served in a combat theater, and separated from active duty receive a DD 214, Certificate of Release or Discharge from Active Duty; they are eligible for VA health care and benefits including the enhanced combat veteran benefits.

3. POLICY: It is VHA policy that each VHA facility must have at least one seamless transition facility POC, an alternate POC, and a facility OIF-OEF Case Manager to assist in the transition of returning combat veterans.

4. ACTION

a. Veterans Integrated Services Network (VISN) Director. Each VISN Director is responsible for designating a POC within the VISN to provide guidance to facility POCs and Case Managers.

b. VISN POC. Each VISN POC oversees the seamless transition of care and ensures that each facility in the VISN has selected a primary and alternate facility POC. Other responsibilities include:

(1) Ensuring that each facility in the VISN has made arrangements to assign an OIF-OEF Case Manager to each OIF and/or OEF service member or veteran being treated.

(2) Providing guidance and support to Facility POCs and OIF-OEF Case Managers, including ensuring they have adequate resources

(3) Notifying the VA Office of Seamless Transition (10AT), as soon as possible, of any changes in VISN POCs, facility POCs, OIF-OEF Case Managers, or VA-DOD Social Work Liaison. Maintaining an accurate POC Case Manager list is essential; the master list is updated weekly by the VA Office of Seamless Transition

(4) Serving as the clearinghouse for questions and problems related to the transfer of care and the provision of care to returning combat veterans and active duty personnel who have served in combat theaters in support of OIF and OEF.

(5) Having regular communication with facility POCs to troubleshoot barriers to services, to identify areas for improvement, and to identify best practices. NOTE: Conference calls and e-mail groups are ideal for this communication.

c. Facility Director. The facility Director is responsible for ensuring:

(1) Active duty service members needing urgent or emergent medical care receive the necessary care. Authorization and administrative issues need to be addressed, however without causing delay in care. NOTE: The service members MTF needs to be contacted as soon as possible to notify them of the care provided.

2

VHA DIRECTIVE 2006-017 April 3, 2006

(a) When being requested by an active duty service member to provide other than urgent or emergent treatment, authorization from the MTF, the service point of contact (SPOC), or the regional TRICARE contractor must be obtained prior to treatment. If the active duty service member lacks an authorization for routine care, appropriate staff must contact the appropriate MTF, the regional TRICARE Contractor or the SPOC to assist in obtaining the authorization. If the MTF, or TRICARE Contractor declines to provide an authorization, VA is unable to provide treatment. Staff must inform the active duty service member of the MTF or TRICARE Contractor determination and provide information to assist the service member in seeking treatment at the appropriate site of care (see VHA Directive 2005-045, Treatment of Active Duty Service Members in VA Health Care Facilities, for further details). NOTE: Fee Basis is not to be used. Active duty service members can receive care outside the VA via TRICARE or authorization from their MTF. Care provided outside VA is to be coordinated with local MTF or TRICARE Service Center.

(b) Active duty service members are the responsibility of the military. At any time, the military may request that VA transfer an active duty service member to a military hospital. VAs role is to be supportive to the military. The request to transfer a patient needs to be honored as soon as the patient is medically stable for transfer. If there is medical information that needs to be conveyed to the staff at the military facility, the facility clinicians or the facility POCs are to contact the staff at the receiving facility to communicate the necessary information. In addition, copies of the medical record need to be sent with the patient.

(2) That the facility POC is contacted immediately if an OIF and or OEF service member on convalescent leave seeks care from a VHA facility without being referred by an MTF or TRICARE. If the service member is seeking care for an emergent or urgent health care need, VHA will provide this care. If the service member is seeking care for a routine health care need, the Facility POC must obtain DOD or TRICARE authorization.

(3) A seamless transition facility POC and an alternate facility POC are designated. The role of these POCs is critical to the successful transfer of care from the MTF to VHA. VHA has standardized many of the functions of the facility POCs to ensure that the care of all returning combat veterans is transferred seamlessly from and to VHA. Facility POCs are responsible for coordinating all transfer arrangements at the receiving facility for all patient care referrals received from MTFs.

(4) Each returning combat veteran seeking treatment at a VA facility is assigned a facility OIF-OEF Case Manager, who must be either a social worker or nurse. This includes both inpatients and outpatients.

(5) Dedicated staff are assigned to the facility POC and facility OIF-OEF Case Manager roles. The responsibilities of these positions have grown since the inception of the seamless transition program precipitating the need to ensure that dedicated staff are assigned to the roles rather than having current staff perform the functions as a collateral duty.

(a) An adequate number of facility POCs and facility OIF-OEF Case Managers are to be designated based on the workload. Although there is not a prescribed ratio of facility POCs or

3 VHA DIRECTIVE 2006-017 April 3, 2006

OIF-OEF Case Managers to patients, the number of OIF and OEF service members returning to that facilitys catchment area and the number seeking health care at the facility need to be reviewed in order to ensure that adequate personnel are assigned to perform the duties. NOTE:

Case Managers at the Polytrauma Centers need to be assigned no more than six OIF and or OEF patients at any given time.

(6) Facilities located close to MTFs, who have assigned social workers to serve as VA-DOD Social Work Liaisons for seamless transition, need to be closely monitored. If the workload warrants more than one full-time Liaison, a second Liaison needs to be assigned.

d. VA-DOD Social Work Liaison. The primary role of the VA-DOD Social Work Liaison is to ensure the transfer of health care, both inpatient and outpatient, from the MTF to the appropriate VHA facility. The VA-DOD Social Work Liaisons are stationed at the following eight MTFs: Walter Reed Army Medical Center, National Naval Medical Center, Brooke Army Medical Center, Eisenhower Army Medical Center, Evans Army Medical Center, Madigan Army Medical Center, Darnell Army Medical Center, and Naval Hospital Camp Pendleton. The responsibilities of the VA-DOD Social Work Liaison include:

(1) Working closely with the MTF treatment team to provide ongoing consultation regarding complex discharge planning issues, VHA health care benefits, resources, and facilities.

(2) Developing relationships and collaborating with the MTF social workers, case managers, managed care staff, and discharge planners to identify patients ready for discharge to VHA, and to obtain clear referral information and authorization for VHA to treat those still on active duty. This referral needs to:

(a) Including the MTF Medical Records, VA Referral Form, Admission Sheet, and Clinical Orders, or other authorization for VHA to provide services and bill TRICARE or other appropriate entity such as through a VA-DOD Sharing Agreement.

(b) Clearly identifying the patients health care and psychosocial needs and requests for VHA health care services to ensure that Clinical Orders, or authorizations, specifying which services are authorized for VHA to provide are completed prior to the transfer of any patients to VHA facilities.

(3) Meeting with the service member and/or family to provide education and an overview of VHA health benefits and resources to address current medical issues identified as part of the service member's treatment plan. In collaboration with the MTF treatment team, the liaison must assess the patient and or family's psychosocial situation, their ability to comprehend and comply with VA treatment plan, and any special needs of the patient and/or family that may impact reaching optimal psychosocial functioning. NOTE: Regular onsite collaboration and coordination is crucial to provide effective consultative services with the referral, linkage, education, and assessment functions. The provision of direct services may be necessary to enhance the communication and relationship with service members and their families.

4

VHA DIRECTIVE 2006-017 April 3, 2006

(4) Coordinating with the liaisons home facility enrollment coordinator to initially register active duty OIF-OEF service members or enroll OIF-OEF veterans at their facility utilizing the referral information. Getting the service members registered and in the computer system eases transfer of care to the VHA treatment facility.

(5) Collaborating with MTF social workers and case managers in identifying the VHA facility where care will be transferred and an accepting physician at that facility. To ensure ease of registration or enrollment procedures, information must be transmitted via PDX or Network Health Exchange (NHE) from the liaisons facility to the identified receiving VHA facility.

(6) Identifying and communicating with the facility POC at the receiving VHA facility and initiating referrals and linkages for transfers of care.

(7) Documenting all liaison activity in the Computerized Patient Record System (CPRS).

(8) Maintaining contact with the VHA facility POC and with MTF staff, coordinating the transfer of care upon discharge from the MTF; and assisting in identifying and obtaining additional information needed from the MTF staff to optimize the transfer of care.

(9) Providing patient level referral and outcome information on all transfers of care from the MTF to the VHA Social Work Program Manager to VA Central Office, Office of Seamless Transition, on a monthly basis through use of a spreadsheet (see Att. B), and inputting summary information into an automated intranet workload report on a weekly basis.

e. VHA Facility POC. The principal role of the VHA facility POC is to receive and expedite referrals and transfers of care from the VHA Social Work Liaison and to ensure that the appropriate linkage is made for the requested clinical follow-up services. NOTE: Given the importance of this patient population, significant efforts must be made to expedite the transfer of care and provision of the VHA health care services identified. Responsibilities of the facility POC are:

(1) Confirming that OIF-OEF service members are registered and OIF-OEF veterans are enrolled at the treating VHA facility and arranging for assignment to the appropriate health care provider, based on the Clinical Orders or authorization received from the MTF.

(2) Coordinating initial transfer of care activities (i.e., arranging for an inpatient bed; ensuring that outpatient appointments have been made, etc.) and ensuring the continuing provision of necessary Durable Medical Equipment, prosthetic devices, supplies, etc.

(3) Documenting all activity in CPRS.

(4) Ensuring the receipt of copies of the military medical record from the referring MTF and coordinating the completion of all necessary paperwork for the transfer of care, including application for VHA medical benefits.

5 VHA DIRECTIVE 2006-017 April 3, 2006

(5) Serving as the primary facility liaison with the referring VA-DOD Social Work Liaison on all information and coordination of activities. Serving as the initial POC to the active duty members, veterans, and their families during the initial entry into the VHA health care facility (i.e., meeting patients and families on first visit)

(6) Alerting the facility OIF-OEF Case Manager of the impending transfer of care of all OIF-OEF service members and veterans.

(7) Immediately alerting the appropriate VBA Case Manager of the service members transfer.

(8) Working with local military units, VBA Regional Offices, and Vet Centers staff in providing outreach to service members returning from Iraq and Afghanistan.

f. VHA Facility OIF-OEF Case Manager

(1) The principal role of the facility OIF-OEF Case Manager is to provide ongoing case management services to returning OIF and OEF service members, veterans, and their families over the course of time VHA health care services are being provided. NOTE: While this Directive pertains primarily to the patients transferred from an MTF, Case Management services need to be provided to OIF and/or OEF veterans who are enrolled and receiving VA health care services. This includes veterans who may not have been transferred through the Seamless Transition process from an MTF to a VA facility and are seeking healthcare on an outpatient basis following discharge from the Military. Though these patients may not require intensive case management, each OIF and/or OEF patient must have an initial assessment by a case manager to identify and assist with immediate needs. A facility OIF-OEF Case Manager must also be accessible to the patient should additional needs arise in the future.

(2) Other responsibilities include:

(a) Making initial contact with the OIF and/or OEF service member prior to transfer of health care from the MTF to provide the facility OIF-OEF Case Managers name and phone number and to explain the role of a facility OIF-OEF Case Manager.

(b) Making initial contact with the OIF or OEF service members immediate family to determine whether any family members will accompany the service member to the VHA facility. If family members accompany the service member, or visit during an inpatient stay, the facility OIF-OEF Case Manager assists in arranging lodging in a VHA Fisher House or in the local community. The facility OIF-OEF Case Manager determines whether the family members require air transportation, and if so, assists them in applying for free airline ticket vouchers through Operation Hero Miles.

(c) Serving as the ongoing contact person for the family and for the MTF staff. This involves regular communication with the family.

6

VHA DIRECTIVE 2006-017 April 3, 2006

(d) Working closely with the service members interdisciplinary treatment (IDT) team to ensure good communication and treatment planning.

(e) Facilitating, when indicated, communications between the VHA provider and the service member at the MTF to discuss transfer of medical care. The facility OIF-OEF Case Manager serves as the point of contact when MTF providers wish to speak to the VHA provider regarding the care being provided.

(f) Communicating and collaborating closely with the VBA Case Manager and assisting VBA in making contact with the service member.

(g) Contacting the referring MTF to obtain new clinical orders or authorization for additional care or services if additional health services beyond those specified in the original referral from the MTF are required for active duty service members.

(h) Contacting the provider at the referring MTF, if the service member requires care or services not provided by the VHA facility, to obtain authorization for referral to another VHA facility or to a community agency. Once authorization is provided, the facility OIF-OEF Case Manager makes referrals to community agencies for services not provided by VA, and, in conjunction with TRICARE or the MTF, coordinates all care and services provided to the service member by VA and non-VA agencies from the initial point of contact until the service member no longer requires services.

(i) Continuing to follow veterans who are transferred for treatment at contracted health care facilities nearby. Follow-up includes, but is not be limited to:

1. Communicating and or collaborating, on a regular basis, with the staff and or treatment teams at the contracted facility, VA (both VHA and VBA), and the home MTF.

2. Ongoing communication and coordination of VHA services with the veteran and the veterans family regarding VA benefits, health care coordination, and education.

(j) Identifying mental health treatment needs and readjustment counseling needs. If such needs are identified, the facility OIF-OEF Case Manager contacts the referring MTF to obtain new Clinical Orders, or authorization, for the additional care or services. Once authorization is provided, the case manager makes referrals, as appropriate, to the VHA facility Mental Health Program and/or to the local Vet Center.

(k) Communicating regularly with the MTF provider and case manager or social worker who referred the service member. If the service member has started the military disability process in order to obtain a medical discharge or medical retirement from active duty, the facility OIF-OEF Case Manager is responsible for:

1. Providing information about the VHA treatment services being provided to the MTF Physical Evaluation Board (PEB) staff on a regular basis, and

7 VHA DIRECTIVE 2006-017 April 3, 2006

2. Ensuring coordination with the VBA Case Manager.

(l) Actively participating in discharge planning, if the service member is receiving inpatient care at the VHA facility, involving the service member and family and keeping the MTF updated.

(m) Documenting all activity in CPRS.

5. REFERENCES

a. VHA Directive 2005-020, Determining Combat Veteran Eligibility.

http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1270

b. VHA Directive 2003-061, Combat Veteran Intake Processing And Software Implementation. http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=289

c. VHA Directive 2002-049, Combat Veterans Are Eligible For Medical Services For 2Years After Separation From Military Service Notwithstanding Lack Of Evidence For Service Connection. http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=197

d. VHA Directive 2005-045, Treatment of Active Duty Service Members in VA Health Care Facilities. http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1325

6. FOLLOW-UP RESPONSIBILITY: The Director, Seamless Transition (10AT) is responsible for the contents of this Directive. Questions are to be referred to (904) 287-2082.

7. RESCISSION: None. This VHA Directive expires September 30, 2007.

Jonathan B. Perlin, MD, PhD, MSHA, FACP Under Secretary for Health

DISTRIBUTION: CO: E-mailed 4/5/06 FLD: VISN, MA, DO, OC, OCRO, and 200 E-mailed 4/5/06

8

VHA DIRECTIVE 2006-017 April 3, 2006

ATTACHMENT A

MILITARY TREATMENT FACILITIES WITH DEPARTMENT OF VETERANS AFFAIRS (VA) - DEPARTMENT OF DEFENSE (DOD) SOCIAL WORK LIAISONS STATIONED ON-SITE

1. Walter Reed Army Medical Center, Washington, DC.

2. National Naval Medical Center, Bethesda, MD.

3. Brooke Army Medical Center, San Antonio, TX.

4. Darnell Army Community Hospital, Ft. Hood, TX.

5. Madigan Army Medical Center, Tacoma, WA.

6. Eisenhower Army Medical Center, Augusta, GA.

7. Evans Army Medical Center, Ft. Carson, CO.

8. Naval Hospital, Camp Pendleton, CA.

NOTE: The Social Work Program Manager for the Office of Seamless Transition serves as the Veterans Health Administration (VHA) Liaison for the remaining MTFs.

A-1

VHA DIRECTIVE 2006-017 April 3, 2006

ATTACHMENT B

SAMPLE OF DEPARTMENT OF VETERANS AFFAIRS (VA) - DEPARTMENT OF DEFENSE (DOD) SOCIAL WORK LIAISON REFERRAL TRACKING SPREADSHEET

Sample VA-DOD Liaisons Workload Cap

B-1

Name of MTF

Rank at Time of Referral (Rank or Unknown)

Last Name

First Name

Middle NameSuffixFull

OEF/ Non

Date of Birth

Gender (M/F)

Home Phone

Cell Phone

SSNOIF/

Branch of Service (Army/Marines/Navy/ AF/CG)

Status - AD/NG/ RES

VA Employee (Yes / No)

Military Class of Injury - Battle Injury (BI) Non-Battle Injury (NBI) or Disease (Dis)

Veteran ServiceRep VBA Referral/ Involvement (Yes/No)

Date Referral toVHA/DoD Liaison Received

Date of First Pt/Fam Contact w/Liaison

Name of VHA Facility Referred To

Inpatient or Outpatient Transfer (I or O)

Enrollment Status (Yes/No)

VHA OIF/OEF POC Communication (Yes/No)

Name of VHA Point of Contact

Type of Care Coordinated (TBI/SCI/VIST/ Amputee/MH/PC/Other)

Status of Referral (Pending or Date Referral Closed)

VHA Comments

Forum: Compensation, Treatment, and Research Resources

IGWC MESSAGE BOARD - Compensation, Treatment, and Research Resources

CFIDS(Chronic Fatigue and Immune Dysfunction Syndrome)

Understanding Post-Mycoplasma

Annual Report to Congress, Research on GWI 2007

Sleep Disorders Nexus

Mycoplasma and Gulf War Syndrome - 24Apr08

Current Clinical Trials and Research

VA/M-10 Policy Manual for Gulf War Vets (no longer in publication)

March 7, 2005 VHA HANDBOOK 1303.2 - UNIFORM CASE ASSESSMENT PROTOCOL (UCAP)

ENVIRONMENTAL HEALTH (EH) COORDINATORS - 2006

Dr Rokke - SW Asia Presentation November2006.ppt

[NVIC] HIV (AIDS) Vaccine for Newborns

Pregnancy outcomes among U.S. Gulf War veterans: a population-based survey of 30,000 veterans.

Pregnancy outcomes among U.S. Gulf War veterans: a population-based survey of 30,000 veterans.

Related Links

VHA PROGRAM GUIDE 1103.3 - MENTAL HEALTH PROGRAM GUIDELINES FOR THE NEW VETERANS HEALTH ADMINISTRATION

AGENT ORANGE HEALTH REGISTRY (AOR) PROGRAM PROCEDURES TO INCLUDE ALL VETERANS EXPOSED TO AGENT ORANGE AND SPECIAL HEALTH CARE BENEFITS FOR VIETNAM...

THE ROLE OF VHA POINTS OF CONTACT AND CASE MANAGERS TO COORDINATE CARE FOR RETURNING COMBAT SERVICE MEMBERS AND VETERANS