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Dengue

Questions and answers about Dengue

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Dengue
Q1:

What is dengue?

A:

Dengue (pronounced den' gee) is a disease caused by any one of four closely related dengue viruses (DENV 1, DENV 2, DENV 3, or DENV 4). 

Q2:

How is dengue transmitted?

A:

The dengue viruses are transmitted to humans by the bite of an infected mosquito. In the Western Hemisphere, the Aedes aegypti mosquito is the most important transmitter of dengue viruses, although a 2001 outbreak in Hawaii was transmitted by Aedes albopictus

Q3:

What are symptoms of dengue fever?

A:

The principal symptoms of dengue are a high fever that lasts 2-7 days and at least two of the following:

  • Severe headache
  • Severe eye pain (behind eyes)
  • Joint pain
  • Muscle and/or bone pain
  • Rash
  • Mild bleeding manifestation (e.g., nose or gum bleed, petechiae, or easy bruising)
  • Low white cell count

Go IMMEDIATELY to an emergency room or the closest health care provider if any of the following warning signs appear:

  • Severe abdominal pain or persistent vomiting
  • Red spots or patches on the skin
  • Bleeding from nose or gums
  • Vomiting blood
  • Black, tarry stools (feces, excrement)
  • Drowsiness or irritability
  • Pale, cold, or clammy skin
  • Difficulty breathing
Q4:

Where are people contracting dengue virus?

A:

Outbreaks of dengue occur primarily in areas where Aedes aegypti (sometimes also Aedes albopictus) mosquitoes live. This includes most tropical urban areas of the world. Dengue viruses may be introduced into areas by travelers who become infected while visiting other areas of the tropics where dengue commonly exists.

Q5:

Who is at risk of being infected?

A:

Anyone who is living in or traveling to an area where the virus is found is at risk for infection.

Q6:

What is the treatment for dengue?

A:

There is no specific medication for treatment of a dengue infection. Persons who think they have dengue should use analgesics (pain relievers) with acetaminophen and avoid those containing aspirin. They should also rest, drink plenty of fluids, and consult a physician. If they feel worse (e.g., develop vomiting and severe abdominal pain) in the first 24 hours after the fever declines, they should go immediately to the hospital for evaluation.

Q7:

What is the treatment for dengue hemorrhagic fever (DHF)?

A:

As with dengue fever, there is no specific medication for DHF. It can however be effectively treated by fluid replacement therapy if an early clinical diagnosis is made. DHF management frequently requires hospitalization. 

Q8:

What can I do to prevent dengue infection?

A:

There is no vaccine available against dengue, and there are no specific medications to treat a dengue infection. This makes prevention the most important step, and prevention means avoiding mosquito bites if you live in or travel to an endemic area. 

Q9:

Should we be concerned with dengue in the United States?

A:

Dengue rarely occurs in the continental United States, but it is endemic in Puerto Rico and in many popular tourist destinations in Latin America, Southeast Asia and the Pacific islands.

Depleted Uranium

The Department of Defese (DoD) began testing depeted uranium (DU) about 40 years ago, and first used it in a military operation in 1991. It has fewer risks than natural uranium because it is less radioactive. DoD and many other organizations have studied, and continue to study, the health, chemical, radiological and environmental effects and exposures of DU.

Recommended Content:

GulfLINK | Depleted Uranium
Q1:

What is depleted uranium (DU)?

A:

Depleted uranium is what is left over when most of the highly radioactive types (isotopes) of uranium are removed for use as nuclear fuel or nuclear weapons. The depleted uranium used in armor-piercing munitions and in enhanced armor protection for some Abrams tanks is also used in civilian industry, primarily for radiation shielding and aircraft balance control.

Q2:

What makes DU a potential hazard?

A:

Depleted uranium (DU) is a heavy metal that is also slightly radioactive. Heavy metals (uranium, lead, tungsten, etc.) have chemical toxicity properties that, in high doses, can cause adverse health effects. DU that remains outside the body can not harm you.

A common misconception is that radiation is DU's primary hazard. This is not the case under most battlefield exposure scenarios. DU is approximately 40% less radioactive than natural uranium. DU emits alpha and beta particles, and gamma rays. Alpha particles, the primary radiation type produced by DU, are blocked by skin, while beta particles are blocked by the boots and battle dress utility uniform (BDUs) typically worn by Service members. While gamma rays are a form of highly-penetrating energy, the amount of gamma radiation emitted by DU is very low. Thus, DU does not significantly add to the background radiation that we encounter every day. 

When fired, or after "cooking off" in fires or explosions, the exposed DU rod poses an extremely low radiological threat as long as it remains outside the body. Taken into the body via metal fragments or dust-like particles, DU may pose a long-term health hazard to personnel if the amount is large. However, the amount which remains in the body depends on a number of factors, including the amount inhaled or ingested, the particle size and the ability of the particles to dissolve in body fluids.

Q3:

Why does the DoD use DU?

A:

DoD uses DU tank armor and some DU munitions (bullets) to penetrate enemy armored vehicles. The use of DU has saved the lives of many Service members in combat. The Agency for Toxic Substances and Disease Registry has stated there is no evidence that natural or depleted uranium exposure has caused cancer in people.

Q4:

Were any studies conducted on the health effects of DU before the Gulf War?

A:

The health effects of uranium have been studied extensively for more than 50 years. This is relevant because chemically, depleted uranium (DU) has the same properties as natural uranium, while being 40% less radioactive. While natural and depleted uranium are considered chemically toxic, they are not considered a radiation hazard. In May 1989 the Department of Health and Human Services' Agency for Toxic Substances and Disease Registry published a Toxicological Profile for Uranium reviewing and summarizing the key uranium health effects literature. This document was updated in September 1999. 

The Department of Defense has comprehensively studied the environmental fate of depleted uranium both before and after the Gulf War. Burn tests and other evaluations performed under simulated battlefield conditions indicated that the health risks associated with the battlefield use of depleted uranium were minimal and could be reduced even more by simple, field-expedient measures, especially avoidance of depleted uranium-contaminated vehicles and sites. 

Q5:

Are DU penetrators hazardous to individuals?

A:

Depleted uranium (DU) penetrators are only one of many possible hazards on the battlefield. Civilians and soldiers are strongly discouraged from recovering souvenirs, particularly spent ammunition, from the battlefield. 

Fortunately, DU is only mildly radioactive emitting alpha and beta particles, and gamma rays. Alpha particles, the primary radiation type produced by DU, are blocked by skin, while beta particles are blocked by clothing and shoes. While gamma rays are a form of highly-penetrating energy, the amount of gamma radiation emitted by DU is very low. The risk of chemical toxicity is also minimal because there is little likelihood that sufficient quantities of DU could be inhaled or ingested to cause a heavy metal concern. 

Q6:

Were any DU health effects studies conducted after the Gulf War?

A:

The main areas that were not adequately addressed before the Gulf War were the medical implications of embedded depleted uranium (DU) fragments in people and inhalation exposure estimates for friendly fire incidents, recovery activities, and incidental contact scenarios. 

These are recognized weaknesses that are being addressed. The December 19, 2000 Environmental Exposure Report, DU in the Gulf (II) includes the Army's latest health risk exposure estimates for various Gulf War exposure scenarios. Health risk estimates for DU-contaminated vehicle recovery and incidental contact scenarios indicate that these exposures were well within safety standards. Because of gaps in data pertaining to uranium oxide dust levels inside DU-struck vehicles, exposure estimates for personnel inside DU-struck vehicles at the time of impact, or immediately afterwards, were based on conservative assumptions. These estimates for this highest exposed group indicated that medical follow-up was warranted. DoD is currently in the process of conducting additional live-fire testing in order to further refine the exposure estimates for those troops in or around vehicles when they were hit by DU munitions. It is important to note that over 60 friendly-fire victims have been evaluated by the voluntary VA DU Medical Follow-up Program. Aside from the problems associated with their traumatic injuries, to date, this follow-up program has attributed no illness or other harmful effects in the evaluated veterans to DU. 

The voluntary Veterans Affairs DU Medical Follow-up Program began in 1993-1994 with the medical evaluations of 33 friendly-fire DU-exposed veterans, many with embedded DU fragments. An additional 29 of the friendly-fire victims were added to the surveillance program in 1999. In 1998, the program was expanded to include Gulf War veterans who may have been exposed to DU through close contact with DU munitions, inhalation of smoke containing DU particulate during a fire at the Doha depot or while entering or salvaging vehicles that were hit with DU projectiles. The published results of these medical evaluations indicate that the presence of embedded DU fragments is the only scenario predictive of a high urine uranium value, and those with embedded DU fragments continue to have elevated urine uranium levels ten years after the incident. It is unlikely that an individual without embedded DU fragments would have an elevated urine uranium level, and consequently any uranium-related health effects. Those individuals with normal urine uranium levels now are unlikely to develop any uranium-related toxicity in the future, regardless of what their DU exposure may have been in the Gulf War. Those individuals with elevated levels of urine uranium ten years after the Gulf War have not developed kidney abnormalities, leukemia, bone or lung cancer, or any other uranium-related adverse outcome. The DU Medical Follow-up Program will continue to monitor those individuals with elevated urine uranium levels to enable early detection of any adverse health effects due to their continued exposure to DU.

Q7:

Can exposure to DU be the cause of some cases of leukemia?

A:

It is highly unlikely that exposure to depleted uranium (DU) ammunition would cause leukemia. The Agency for Toxic Substances and Disease Registry of the U.S. Department of Health and Human Services stated in its Toxicological Profile for Uranium," no human cancer of any type has ever been seen as a result of exposure to natural or depleted uranium." A 1999 RAND study concluded, "there are no peer-reviewed published reports of detectable increases of cancer or other negative health effects from radiation exposure to inhaled or ingested natural uranium at levels far exceeding those likely in the Gulf." Exposures in the Balkans should be no more than those in the Gulf.

After the media reports in early 2001, nations who had deployed peacekeepers to the Balkans have begun medical monitoring and epidemiological studies. The objective of the studies is to determine whether there is an increase in medical problems in troops who served in the region when compared to troops who did not. To date, none of these studies have found a connection between DU exposure and leukemia or any other pathology. The United Nations and other international organizations also have conducted environmental surveys in Bosnia-Herzegovina and Kosovo. These surveys consistently have reported no widespread DU contamination and no current impact on the health of the general population or deployed personnel. 

Leukemias following high doses of radiation peak in frequency five to seven years after exposure. Media accounts of leukemia cases and deaths within months of return from the Balkans are not consistent with current scientific understanding of the time course of radiation-induced leukemia. 

Q8:

What is DoD doing to protect future service members from accidental exposure to DU?

A:

The DoD is fully aware of its responsibility for the safe use of DU. Since the Gulf War, the DoD has dramatically stepped up its emphasis on increasing soldier and leader awareness of the hazards associated with the battlefield use of depleted uranium. The Deputy Secretary of Defense has ordered the Service Chiefs to ensure that DU awareness training is incorporated into their general military training programs. The U.S. Army's Training and Doctrine Command published Training Support Packages for general DU awareness training and certain specialty training in July 1999. The Marine Corps also uses a three-level DU training program. Both the Marines and Navy use a service-specific variant of the Army's DU Awareness Training video. The Air Force program calls for all personnel on mobility status to receive DU awareness training and has incorporated DU awareness guidance in the Nuclear, Biological, and Chemical handbook carried by all deploying personnel. Complete implementation of the various training programs is underway. The Office of the Special Assistant will continue to monitor the status of the Services' DU training efforts.

Q9:

How did traces of plutonium and other containments get into DU?

A:

Yes, trace levels of transuranics have been found in depleted uranium (DU). The Department of Energy (DOE) operated three gaseous diffusion plants (Paducah, Kentucky; Portsmouth, Ohio; and Oak Ridge, Tennessee) where they enriched uranium for nuclear weapons and power plants; creating depleted uranium as a by-product. Some or all of these plants received recycled uranium extracted from spent nuclear fuels in the '50s, '60s, '70s, and '80s. Uranium extracted from spent nuclear fuels included low levels of transuranics, including americium, neptunium, and plutonium, technetium-99, and uranium-236. The gaseous diffusion process concentrates these contaminants in the enriched uranium and decreases the levels in the depleted uranium so that only trace quantities remain. The radioactive contaminants increase the radiation dose from the DU itself by less than 1%, which is considered insignificant.

In March 2001, DOE reported the results of a two-year recycled uranium study that concluded the transuranic content in depleted uranium was very low. The DOE data are consistent with U.S. Army testing of the DU used in armor plate for the Abrams Heavy Tank, which concludes the radioactive contaminants contribute less than a one percent increase in the radioactivity from DU itself. Various NATO countries and the United Nations Environment Programme (UNEP) recently recovered penetrators in the Balkans and tested them for the level of contaminants. Their findings are consistent with DOE/DoD findings. The UNEP concluded that the transuranics have no significant impact on the overall radioactivity or the health risk. These contaminant levels are in the parts per billion range. A part per billion is approximately equivalent to one second in 31.7 years. 

Q10:

What are health effects of contact with unfired DU munitions or unperforated armor?

A:

No adverse health effects are expected from such contact. Unfired depleted uranium munitions are encased in thin metal jackets that seal in alpha and beta particles. The amount of gamma emissions from depleted uranium (DU) is very low and falls well below regulatory health and safety limits. Similarly, depleted uranium panels used in tank armor pose no health risk because the depleted uranium is sealed inside several inches of regular steel armor. Alpha radiation, which is the major concern for internalized depleted uranium, is not an external concern because alpha radiation does not penetrate the outer layers of skin. The second source of radiation is from the depleted uranium rounds stored on board the tank. While soldiers are exposed to an increased level of radiation from the stored munitions, the cumulative exposure levels for tank crewmembers are within applicable guidelines. Since depleted uranium munitions are only used in combat, only forward-deployed vehicles are routinely uploaded with depleted uranium munitions. 

While it is impossible to evaluate all potential exposure scenarios, each of the major weapon systems have been fully evaluated and all of the routine exposures are well within exposure guidelines. In fact, radiation levels measured inside the turret of an Abrams Heavy Armor Tank are below background levels measured outside the turret because armor shields the tank occupants from cosmic and terrestrial radiation sources. Crewmembers have their overall radiation exposure reduced by working inside the tank. 

The most frequently cited example of radiation exposure is holding a bare penetrator rod. The penetrator rods in the 120mm, 105mm and 30mm rounds are shielded which prevents direct contact with the actual penetrator rod of intact rounds. But even when holding a bare penetrator rod, an individual could hold the rod for 250 hours before reaching the extremity or skin limit of 50 rem. 

Q11:

How is the DoD monitoring possible exposures to DU?

A:

As DU munitions penetrate armor or when DU burns, DU oxide dust is created. DU exposure may occur from inhalation or ingestion of DU dust, contamination of wounds with DU dust, or from embedded DU munitions or armor fragments in the body. To address these risks, DoD has formal policies in place to monitor its Service members for potential DU exposure, and refers exposed Service members to a medical follow-up program. DoD also has training programs for personnel who could be exposed to the metal. The 2003 Health Affairs' Policy, Operation Iraqi Freedom DU Medical Management, offers every Service member the opportunity to confirm possible exposure to DU. This was supplemented in 2004 by the DoD Deployment Biomonitoring Policy. Exposure evaluation of personnel who served in the Gulf War or Operation Iraqi Freedom is initiated based upon participation in an event (such as a friendly fire incident) or with a unit that would place the individual at risk of DU exposure, or positive patient responses to the Post-Deployment Health Assessment, DD Form 2796.

Potentially exposed Service members complete a DU Exposure Questionnaire, which is reviewed to assess the risk level. Those at greatest risk undergo urine testing for uranium. Personnel at lower risk may also undergo testing based on concerns of either the patient or the medical provider. Service members with confirmed positive results are offered a referral to the VA's DU Follow-Up Program.

Q12:

What is DoD doing to track service members exposed to DU duing Gulf War?

A:

We have categorized the depleted uranium (DU) exposure scenarios into three levels based on their relative exposures, and have conducted testing to estimate the maximum exposure that could be associated with those scenarios. The levels of possible exposure are described more fully on the Medical Follow-Up page of this website, which also contains links to DoD policy on management of exposures. Level I is the highest exposure group, soldiers who were in, on, or near combat vehicles at the time they were struck by depleted uranium rounds, and soldiers who entered these vehicles immediately afterwards to perform combat rescue. This exposure level also includes personnel who have been struck by DU fragments. Depleted uranium metal fragments have struck a number of US soldiers, and some of these still have embedded DU fragments. Others are believed to have inhaled or ingested DU particles, or had DU dust contaminate their wounds.

The voluntary Veterans Affairs (VA) DU Medical Follow-up program in Baltimore remains the most important source for identifying potential adverse health effects in those friendly-fire victims who have embedded DU fragments, or who may have inhaled significant quantities of DU particles. About one fourth of the Level I exposed individuals who have been evaluated by the VA still carry DU fragments in their bodies, and some of those with embedded fragments have elevated levels of urine uranium more than ten years after the Gulf War. None of the individuals with DU fragments have developed kidney problems, leukemia, bone or lung cancers, or any other uranium-related adverse outcomes. No birth defects have been reported in their children. As a result, there is no reason to believe that other exposed Service members have any elevated risk to their health due to their DU exposures. However, to be cautious, the DoD and the VA continue to medically follow veterans with high-level DU exposures to ensure there are no long-term health effects associated with these ongoing DU exposures. References to some of the research articles reporting follow-up results on these Service members and veterans can be found through Research Projects and Publications in this website, and going to "DeployMed ResearchLink" for Medical Research Publications: Environmental & Occupational Health\DU. 

Level II exposures comprise soldiers who worked in and around combat vehicles (mainly US vehicles that were struck by friendly fire munitions) and as many as 600 personnel who took part in the clean up after the fire at Camp Doha, where DU munitions were burned in a fire. These exposures resulted in significantly lower estimated intakes of DU than the Level I exposures. The radiation estimates were less than the 0.1 rem per year guideline for members of the general public and much less than the 5 rem per year limit for radiation workers. The chemical exposure estimates were also well below the chemical toxicity guidelines. 

Level III is an "all others" category for personnel whose incidental exposure to DU particles were very brief and are highly unlikely to have resulted in any medically significant exposure taking place. This group includes curious personnel who entered Iraqi equipment or personnel down wind from vehicles that burned after being struck by depleted uranium rounds. This group's estimated exposures were minimal. 

A multidisciplinary team from the US Army Aberdeen Test Center, US Army Armament Research, Development, and Engineering Center, USACHPPM, Batelle Memoral Institute, Pacific Northwest National Laboratory, Los Alamos National Laboratory, and the Lovelace Respiratory Research Institute conducted a study of the anticipated exposures under various scenarios, as well as the possible health effects or risks resulting from these exposures. The results were reported in the Capstone DU Project, comprised of two phases, the Capstone DU Aerosols Study, and the Capstone DU Human Health Risk Assessment. The Capstone DU Project realistically assessed possible exposures and risks for personnel in Levels I, II, and III. Both a summary fact sheet and the original study document are available. The Capstone DU Aerosols Study confirmed the value of ventilation in reducing possible exposures to DU aerosols inside vehicles struck by DU munitions, and clearly showed that simply getting out of DU-struck vehicles provided a way to significantly reduce exposures. The Capstone Depleted Uranium Human Health Risk Assessment determined there would be little or no impact on the health of service members who breathe in depleted uranium (DU) dust particles while inside tanks or other vehicles hit by DU munitions. 

More information on combat exposures is also available at Tab O of "Environmental Exposure Report", Depleted Uranium in the Gulf (II), or "Depleted Uranium-Human Exposure Assessment and Health Risk Characterization in Support of the Environmental Exposure Report 'Depleted Uranium in the Gulf' of the Office of the Special Assistant to the Secretary of Defense for Gulf War Illnesses, Medical Readiness and Military Deployments (OSAGWI)". 

Q13:

With medical and environmental concerns over DU why has DoD not found a substitute?

A:

Each weapon system that uses DU has undergone extensive developmental testing and evaluation. As part of that process, DoD evaluates possible alternative metal alloys considering operational requirements and medical/environmental impacts. As improvements have been made in the "hardness" of armored vehicles, tests have demonstrated that depleted uranium (DU) offers superior performance to all other alloys. 

DoD must also evaluate the environmental and medical consequences of exposure to any new alloy. Uranium has an advantage in this arena over several candidate materials because of the extensive database on radiological and chemical properties of uranium. While some candidate replacement alloys may not be radioactive, they are not necessarily less toxic to humans.

Depleted Uranium: Chemical Effects

Questions and answers about the chemical effects of DU

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Chemical Effects of DU
Q1:

How does uranium enter the body?

A:

Uranium can enter the body through many routes, including by inhalation, through the mouth, or through the skin. However, regardless of the route, only a very small amount of uranium, whether natural or depleted, enters the body. On the battlefield, a Service member could be exposed to uranium in the air from the use of munitions containing DU. As these munitions penetrate armor or when DU burns, DU oxide dust is created. The Capstone Depleted Uranium Aerosols Study looked at this issue. The Capstone Depleted Uranium Aerosols study looked at the concentration of DU to which a Service member might actually be exposed in such a situation, including when the Service member is inside an armored tank that is struck. The Human Health Risk Assessment of the Capstone Depleted Uranium Aerosols study determined that there would be little or no impact on the health of those breathing DU dust particles inside a tank hit by DU projectiles. In addition to inhalation, DU exposure may also occur through ingestion of DU dust, contamination of wounds with DU dust, or from embedded DU munitions or armor fragments in the body. Although DU exposure is possible through direct contact of fired DU munitions or contaminated equipment or with the skin, this is easily avoided by wearing gloves or proper clothing.

Q2:

What happens to uranium that contacts the skin?

A:

Absorption of uranium through the skin has not been well studied. In animals, it appears that only those forms of uranium that are soluble in body fluids can be absorbed through the skin. Some absorption can also occur through the conjunctiva of the eye. Thus, some forms of uranium could be absorbed if placed in direct contact with unprotected skin, such as with picking up objects containing uranium. This type of exposure could be easily avoided with simple precautions, such as not picking up fired DU munitions without wearing protective gloves.

Q3:

What happens to uranium that is inhaled?

A:

Most DU dust that is inhaled is rapidly eliminated from the body. Larger particles do not stay in the lungs, and are either coughed out or swallowed in mucus. Swallowed particles are generally passed through the gastrointestinal tract as with the oral route of exposure. One study showed that almost all inhaled uranium dust left the body by this route, without ever being absorbed.

Only smaller particles may stay in the lungs, and then will enter the circulation only if soluble. Some of these small particles may stay in the lungs for longer periods of time, and may gradually dissolve enough to be absorbed and enter the circulation. Those that are not soluble and remain in the lungs and surrounding tissues will not cause chemical toxicity, but may be associated with other concerns, such as local effects in the lungs, or radiation exposure. Depending on those factors, only about 1% to 5% of inhaled uranium dust will be absorbed into the body and enter the circulation. Most of this small amount of uranium eventually will be filtered through the kidneys for elimination from the body. Where large amounts of inhaled uranium dust have been associated with local inflammatory changes in the lungs, those effects have been difficult to separate from the effects of ordinary inhaled dust.

Q4:

What happens to uranium that is taken in by mouth?

A:

Experiments have shown that less than 5% of uranium that is taken in by mouth is absorbed into the body to reach the circulation. In fact, for soluble uranium compounds, the percent absorption may be as low as 2%, and for those that are not soluble, the percentage absorption may only be 2/10 of a percent. The remainder continues on through the intestinal tract and is eliminated from the body. Because 95-99% of inhaled uranium particles are coughed up and are also swallowed, in addition to most of the uranium taken in directly by mouth, practically all uranium that an individual takes in passes out through the gastro intestinal tract.

Q5:

What happens to uranium in the circulation?

A:

Forms of the metal that are more soluble are more likely to be associated with toxic chemical effects, because if taken into the body, they can more readily enter the circulation. After absorption, soluble uranium goes mostly to the bones and kidneys. The kidneys filter chemicals from the body, and are susceptible to damage from uranium, as well as many other more common metals. Because the kidney is recognized as the organ most sensitive to uranium exposure and toxicity, exposure standards are generally designed to protect the kidneys from chemical effects, although standards have been set at even higher exposures based on radiation effects. However, at the same time, the kidneys effectively dispose of this soluble uranium in the urine. This helps to rid the body of the chemical. Within a day, about two-thirds of the uranium in the circulation passes through the kidneys and into the urine. This is why if DU or natural uranium exposure is suspected, a urine uranium test is obtained. This is where uranium exposure is easiest to detect. The amount of uranium in the urine can be compared to the amount that is commonly seen in unexposed people to determine if further investigation is indicated.

The uranium that is not in the circulation or being filtered by the kidneys is mainly found in the bones. However, as the kidneys remove uranium from the circulation for elimination from the body, the uranium in the bones slowly re-enters the circulation, where it, in turn, is filtered by the kidney and excreted in the urine. Although the process of uranium leaving the bone occurs more slowly, about half of the uranium in the bone will enter the circulation every week and a half, and from there will reach the kidneys and urine. This means that the body tends to naturally rid itself of uranium over time.

Q6:

How much uranium is usually found in the urine?

A:

Everyone has some uranium in their urine, although the amount varies greatly depending on where they live, and the type of work they perform. The National Center for Environmental Health of the U.S. Centers for Disease Control and Prevention (CDC) published data in 2005 on the amount of uranium found in the urine of men, women, and children from throughout the United States in the Third National Report on Human Exposure to Environmental Chemicals. However, people who work in uranium mines or mills may have higher levels in their urine, reflecting greater amounts of uranium in their bodies. The Occupational Safety and Health Administration has established a maximum safe level for those workers that is about 100 times higher than the average level found in the study by the CDC.

Depleted Uranium: Radiation Effects

Questions and answers about the radiation effects of depleted uranium

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Radiation Effects of DU
Q1:

What types of radiation are associated with DU?

A:

As they decay, uranium atoms, whether natural or depleted, give off small amounts of radiation, like sources of natural background radiation in the environment. DU and its decay products give off radiation that could potentially cause exposure inside the body as well as externally. While DU gives off alpha particles, the decay products give off beta and gamma particles as they decay even more. However, the alpha radiation does not penetrate the outer, dead layer of skin, and so uranium must be first taken into the body for alpha particles to be a concern. Beta radiation is screened out by normal military clothing, but could be a concern if uranium were first taken into the body, or protective clothing (such as gloves) was not worn. Gamma radiation, which is penetrating, must be considered even without internal exposure to uranium, but the doses of it from DU are small. Research indicates that exposures to alpha and beta particles would be below occupational guidelines.

Q2:

Can exposure to DU cause cancer?

A:

There is no solid evidence from human studies that internal uranium exposure is associated with an increased cancer risk. Although cancer is a well known effect of ionizing radiation exposure, it has never been associated with exposure to uranium. A small fraction of the uranium taken into the body becomes deposited in the skeleton, but scientific observations have not shown any increase in bone cancer in persons exposed to uranium, including enriched uranium, which is about 100 times as radioactive as DU.

People are constantly bombarded by radiation from many sources. Radiation comes from space, from radioactive materials in the soil, including natural uranium, and also radioactive isotopes of other more common metals, such as potassium. There is radiation in the air, and the food that we eat. In addition, people receive radiation from routine x-rays to diagnose disease, or with radiation therapy to treat disease. In some areas of the world, people are exposed to levels of background radiation that is three times higher than in the U.S. These people, exposed only to high levels of background radiation, have some alterations in chromosomes due to the higher radiation exposures, but do not show any increase in rates of cancer or other diseases that may be linked to radiation exposure.

Q3:

Has radiation risk in DU-armored vehicles been evaluated?

A:

There is no solid evidence from human studies that internal uranium exposure is associated with an increased cancer risk. Although cancer is a well known effect of ionizing radiation exposure, it has never been associated with exposure to uranium. A small fraction of the uranium taken into the body becomes deposited in the skeleton, but scientific observations have not shown any increase in bone cancer in persons exposed to uranium, including enriched uranium, which is about 100 times as radioactive as DU.

People are constantly bombarded by radiation from many sources. Radiation comes from space, from radioactive materials in the soil, including natural uranium, and also radioactive isotopes of other more common metals, such as potassium. There is radiation in the air, and the food that we eat. In addition, people receive radiation from routine x-rays to diagnose disease, or with radiation therapy to treat disease. In some areas of the world, people are exposed to levels of background radiation that is three times higher than in the U.S. These people, exposed only to high levels of background radiation, have some alterations in chromosomes due to the higher radiation exposures, but do not show any increase in rates of cancer or other diseases that may be linked to radiation exposure.

Q4:

How significant is the radiation risk to civilians residing in areas of former conflict?

A:

Similar mathematical models to those used in the Capstone Study were used by other governments and organizations, including the World Health Organization and the United Nations Environmental Program, to conclude that DU remaining in former areas of conflict did not create a current environmental hazard to the occupants of those areas. Those researchers examined the risk created by DU particles in the soil that could be resuspended in the air through the action of the wind or human activities. Many of these reports may be accessed directly through the section on Environmental Effects and Exposures.

Drug Take Back Program

Questions and answers about the MHS Drug Take Back Program

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Drug Take Back Program
Q1:

Why is drug take back important?

A:

Prescription pain drugs are the second-most commonly abused category of drugs in the U.S.

  • When used as directed, prescription drugs are safe and effective.
  • When abused, prescription drugs can be dangerous, addictive and deadly.

The availability of unwanted, unused, and expired prescription drugs are a major contributor to prescription drug abuse. According to the Office of National Drug Control Policy, more than 70% of prescription pain drug abuse involved drugs obtained from a friend or relative, and nearly one third of suicide attempts among veterans involve prescription medication. Our beneficiaries can reduce these risks by safely disposing their drugs through the MHS Drug Take Back program. 

Q2:

What kind of drugs can we accept through the MHS Drug Take Back program?

A:
  • Both prescription and over-the-counter drugs
  • Pills, tablets, capsules
  • Ointments
  • Creams
  • Lotions
  • Powders
  • Liquid medicines (no more than 4 oz.)
Q3:

Are there any drugs we can't accept at our facility through the MHS Drug Take Back program?

A:

You can’t accept any of the following items at your facility. Please direct patients to the U.S. Environmental Protection Agency Website for details about disposing of these and other hazardous materials.

  • Illegal drugs
  • Aerosol spray cans
  • Alcohol or hydrogen peroxide
  • Needles, syringes or sharps containers
  • More than 4 oz. of liquid
  • Trash
  • Mercury thermometers
  • Batteries
  • Chemicals
  • Home-based care or durable medical equipment supplies
Q4:

We already participate in other drug take back events. Are we still allowed to participate in these throughout the year?

A:

Yes. In addition to these MHS Drug Take Back activities, you can participate in law enforcement-sponsored drug take back events that occur throughout the year.

Q5:

Can a pharmacy staff member accept unused, unwanted, or expired drugs from patients to dispose?

A:

No. Per DEA rules, pharmacists and other pharmacy staff cannot accept drugs from a patient to dispose of. They must physically put the drugs in the collection bin or envelope.

Dugway Proving Ground

Questions and answers about biological and chemical agents tested at Dugway Proving Ground.

Recommended Content:

Biological Surveillance Tools | Dugway Proving Ground
Q1:

What biological agents were tested at Dugway Proving Ground?

A:

The following are the principal biological agents that were used in testing:

a. Bacillus anthracis
b. Brucella melitensis
c. Brucella suis
d. Clostridium botulinum toxin
e. Coccidioides
f. Coccidioides uranine
g. Coxiella burnettii
h. Pasteurella pestis (Yersinia pestis)
i. Pasteurella tularensis (Francisella tularensis)
j. Psittacosis virus

Q2:

What chemical agents were tested at Dugway Proving Ground?

A:

The following are the principal chemical agents that were used in testing

a. Nerve agents (GA (tabun), GB (sarin), GD (soman) and VX)
b. Binary nerve agent precursors
c. Mustard/Lewisite agents
d. Tear agents
e. Cynanides (e.g., CK (cyanogen chloride))
f. Phosgene
g. Hallucinogens (e.g., BZ)

Q3:

What biological simulants were tested at Dugway Proving Ground?

A:

The following are the principal simulants that were used in testing:

a. Bacillus globigii (Bacillus subtilis var niger) - BG
b. Serratia marcescens - SM
c. Aspergillus fumigatus - AF
d. Fluorescent particles – FP

Q4:

I think that I may have been involved in a test. How can I confirm it or get more information?

A:

If you need help verifying your possible participation in any of the tests or have information about the testing, call the Department of Defense's contact managers at 1-800-497-6261, Monday through Friday, 7:30 a.m. to 4 p.m. EST.

Alternatively, you may write to us at:

Force Health Protection and Readiness
ATTN: CB Exposures Manager
7700 Arlington Blvd.
Falls Church, VA 22042

If you'd like to speak with a Veterans Affairs representative, call the Special Issues Helpline at 1-800-749-8387. Many states offer services and benefits to veterans. >>Learn more about a particular state

Ebola

View questions and answers about the DoD response to Ebola

Recommended Content:

Ebola | Pandemic Diseases | Ebola FAQs
Q1:

What are you doing to protect DoD personnel from contracting Ebola?

A:

We are making every effort to ensure that U.S. personnel on the ground are working in an environment where their personal safety and security are protected. Deployed U.S. personnel contracting Ebola would be treated in the most effective manner possible, including evacuation to the U.S.  We are confident that this is a risk we can manage through protective measures in the field as well as screening measures both overseas and here at home.

Q2:

Will DoD personnel be going into hot zones and at risk for contracting Ebola? Will they be in contact with infected individuals?

A:

The Africa Command Surgeon's Office is closely monitoring the situation, which includes reviewing procedures and providing command members information on Ebola.  We are not planning for U.S. military personnel to provide direct patient care.  In the event there is a requirement for U.S. military personnel to work in areas where there is a risk of contracting Ebola, U.S. military personnel will follow the protection guidelines issued by the CDC, and will be issued appropriate personal protective equipment. As a general matter, Ebola virus is spread through direct contact with the blood or body fluids of a person who is sick with Ebola. It is not spread through the air or by water or, in general, by food.

Q3:

What type of pre-deployment medical care are DoD personnel receiving? What type of instruction are they getting to prevent vector-borne infections?

A:

All DoD personnel receive region-specific training before deploying. Personnel are receiving training on Ebola prevention, malaria prevention, other medical threats, and medical readiness requirements. The following is the prescribed list of required immunizations for a deployment to the Africa region:

  • Chickenpox
  • Hepatitis A/Hepatitis B
  • Influenza, Meningococcal
  • Measles
  • Mumps
  • Polio
  • Pneumococcal (for any specific health issues for anyone older than 65 years of age)
  • Rabies (for veterinary and certain other personnel)
  • Rubella (MMR)
  • Tetanus
  • Typhoid
  • Yellow Fever
Q4:

Has the Department issued official health guidance to the Services for their units deploying to the affected outbreak areas?

A:

Yes, we have issued pre-deployment, deployment and post-deployment training, screening and monitoring guidance for DoD personnel deployed or deploying to West Africa.   The policy guidance outlines required medical protocols, including medical threat briefings, deployment ebola monitoring and screening procedures to minimize exposure, risk evaluation, and personnel protective equipment use. 

Q5:

What is considered a risk of exposure? What makes something a high risk versus a moderate risk?

A:

DoD policy defines high exposure risk as a:

  • Needle stick or mucus membrane (e.g., eyes, mouth, etc) exposure to Ebola-infected blood or bodily fluids
  • Direct contact with blood or body fluids of a confirmed Ebola patient without appropriate protect equipment
  • Direct contact with a dead body in a country where an Ebola outbreak is occurring  

DoD policy defines some risk of exposure as:

  • Household-type contact with an Ebola patient
  • Other close contact with an Ebola patient in healthcare facilities or community settings
  • Contact with Ebola patients while not wearing proper protective equipment
  • Direct brief contact with an Ebola patient (e.g., shaking hands)
Q6:

Will service members be screened and quarantined if symtomatic?

A:

Once deployed, all personnel will be evaluated by their unit twice each day for temperature and their exposure to risks. We will have a tiered model for risks based on both symptoms and / or risk exposures. Anyone who is identified as having symptoms will be quickly evaluated by medical personnel.  Medical authorities will make the decision based on a structured set of criteria as to whether the service member can return to duty or should be medically evacuated back to the U.S. Personnel, if determined to have an exposure that represents more than a minimal risk, will be evacuated back to the United States for observation and treatment if required. If someone at risk is moved back to the U.S., they will be quarantined for 21 days at a DoD designated facility to monitor for signs and symptoms of the disease.

Q7:

How will the Department monitor individuals coming back from deployment?

A:

All DoD military personnel will undergo 21 days of controlled monitoring at a specified DoD facility following their return from deployment in support of Operation United Assistance. This monitoring will include twice daily face-to-face interviews to review for symptoms and perform temperature checks. 

Once the 21 days of controlled monitoring are completed, personnel showing no symptoms or signs of infection will be allowed to leave the military facility and return to their duty station.

DoD civilian personnel will have the option to either undergo controlled monitoring at a specified military facility or return home and attend twice-daily in person interviews and temperature checks for the 21 day period following their deployment.

Q8:

Where will returning military members be monitored?

A:

Controlled monitoring areas will be located at the following military installations within the United States and at two locations in Europe.

  • Fort Bliss, El Paso TX
  • Joint Base Langley-Eustis, Hampton, VA
  • Fort Hood, Killeen, TX
  • Fort Bragg, Fayetteville, NC
  • Joint Base Lewis-McChord, WA
  • U.S. Army Garrison Baumholder, Germany
  • U.S. Army Garrison Caserma Del Din, Vicenza, Italy
Q9:

Why were these facilities selected as controlled monitoring locations?

A:

Selection criteria included proximity to medical facilities capable of treating Ebola; facility resources to isolate a significant number of returning service members and control movement / access; and the personnel resources to conduct twice daily temperature checks, medical screenings.

Q10:

Can my deployed service member interact with family when he or she returns home?

A:

Service members will undergo controlled monitoring for 21 days following their deployment and will not be allowed to leave the designated facility during that period. Following the 21 day period, the Service member is considered to have no risk for carrying the Ebola virus, and will be able return to his or her regular duty station and home. Service members will be free to interact with family members, colleagues, and friends.

Q11:

Can I speak with my service member during the 21-day period?

A:

Absolutely. Service members undergoing controlled monitoring will have access to telephone and internet services and will be able to communicate with family members.

Q12:

What precautions do I need to take if my service member has the disease and recovers?

A:

In the unlikely event that your service member were to contract Ebola, they would be taken to a designated treatment facility for treatment until they fully recover from the virus. Upon full recovery, the service member would have no risk of spreading the disease through physical interaction with family or friends.

Q13:

If my service member is diagnosed with Ebola, will he or she be treated at the controlled monitoring locations?

A:

In the unlikely event that your service member were to contract Ebola, they would be hospitalized immediately.  DoD would make arrangements to transfer the individual to one of the three designated civilian medical facilities for treating Ebola cases:  National Institutes of Health in Bethesda, MD; Emory University Hospital, Atlanta, GA; or the University of Nebraska Medical Center in Omaha, NE, or to one of the approved DoD hospitals that have prepared extensively to manage an Ebola patient.

Q14:

What is DoD doing to ensure my family and I won't be stigmatized in our workplaces, schools, or communities because my service member recently returned from West Africa?

A:

The Department's first priority is to ensure the safety of service members and their families. We are communicating throughout DoD and with our local civilian communities about the low risk that Ebola poses to the American public. DoD installations that have service members deploying in support of Operation United Assistance will be conducting extensive outreach and education campaigns of:

  • the work being undertaken in West Africa,
  • precautions being taken to protect deploying and returning service members,
  • the science regarding how Ebola is transmitted,
  • and the subsequent minimal risk related to deployment.

The MHS has made available educational materials online and will continue to disseminate and update information to local installations and MTFs.

Q15:

There is a lot of information about Ebola on the internet. Where do I go for information I can trust?

A:

As with any important subject, especially medical or scientific matters, you should only get your information from reputable sources. For Ebola, these include:

Electronic Prescribing

Questions and Answers about the Electronic Prescribing (eRx) Initiative

Recommended Content:

Electronic Prescribing FAQs | Electronic Prescribing
Q1:

How are non-formulary medications handled by the eRx software?

A:

The eRx software is capable of receiving electronic prescriptions for non-formulary medications. If CHCS determines that an electronic prescription is for a non-formulary drug (which is determined by the formulary status in the CHCS Formulary Management (FRM) file), that prescription will be placed in the CHCS holding queue for pharmacy intervention. Commercially, civilian providers are able to select and transmit any medications within their Electronic Health Record (EHR).

Q2:

How do I print a copy of the eRx?

A:

Within the electronic prescribing holding queue, the user selects one or more eRx's then selects inquiry from the action bar. At the device prompt, the appropriate printer name is entered. If more than one eRx's has been selected, each eRx will be printed on a separate page. Please see training slides or the User Guide for additional information.

Q3:

Why is the auto-match rate of eRx patient to CHCS patient low?

A:

MTF pharmacies may initially have a low auto-match rate of eRx patient to CHCS patient because civilian providers sending eRx's may not be including the specific information required for auto-population in CHCS (e.g. Patient SSN, DOD ID, etc.) Please see training slides or the User Guide for additional information on the patient matching criteria.

Q4:

How can the auto-match rate between the eRx/CHCS patient, the eRx/CHCS medication, and the eRx/CHCS provider be increased?

A:

The auto-match rate of the electronic prescribing solution can be increased through MTF and civilian provider collaboration regarding specific information required for a successful auto-match to occur.

Q5:

When should I clear the holding/error queue?

A:

The eRx software is programmed to automatically remove electronic prescriptions from the holding queue after 365 days. MTFs may choose to manage the holding queue based on local business practices. Removal of an eRx from the holding queue is irreversible and will require a new prescription to be sent from the civilian provider. Please see training slides or the User Guide for additional information on the holding queue capabilities.

Q6:

Can I validate prescriptions in the error queue?

A:

Yes, the electronic prescribing solution allows validation of eRx’s in the error queue. The electronic prescribing solution notifies the user of identified errors. Please see training slides or the User Guide for additional information on the error queue capabilities.

Q7:

What information will I receive in an electronic prescription?

A:

The electronic prescription must contain all legally required information for a valid prescription (e.g. Patient Name, Medication Name, Directions, Quantity, Refills, Provider, etc.)

Q8:

What is the compatibility of the civilian software (Electronic Health Records/Electronic Prescribing) with the MHS electronic prescribing software (CHCS)?

A:

MHS utilizes commercial electronic prescribing industry standards (i.e. NCPDP) to ensure compatibility with electronic health records and commercial ePrescribing networks.

Q9:

Does the electronic prescribing network support controlled substances?

A:

Yes, the electronic prescribing networks supports controlled substances. However, the electronic prescribing solution in CHCS is not certified to receive and process electronic prescriptions for controlled substances.

Q10:

When will I be able to receive controlled substances?

A:

Currently there are no plans to enhance the electronic prescribing solution in CHCS to support receipt and processing of controlled substances via electronic prescribing. The future MHS Electronic Health Record may be able to support the receipt and processing of controlled substances.

Q11:

How do I process controlled substances?

A:

The electronic prescribing solution in CHCS is not certified to receive and process electronic prescriptions for controlled substances. The MTFs will be required to have the proper documentation (i.e., hard copy prescription or faxed prescription) as required by the DEA prior to dispensing a controlled substance. >>View the DEA requirements for a valid prescription

Q12:

Will I see a "script image" in the automation (PharmAssist, ScriptPro, Parta, etc.)?

A:

An eRx is received as text, not in a computerized image format. The MTF may print the eRx and scan the printed copy into the automation based on MTF workflow and/or business rules.

Q13:

How long does an electronic prescription stay in the holding and error queues?

A:

The eRx software is programmed to automatically remove electronic prescriptions from the holding/error queue after 365 days.

Q14:

How is a new provider added to CHCS when validating an electronic prescription?

A:

New providers identified through the electronic prescribing solution are added to CHCS using existing functionality and business processes. Users with the Provider Add/Edit security key should follow current CHCS business rules and local MTF policy for adding providers during the eRx provider validation process.

Q15:

How do I view the original electronic prescription and the resulting CHCS prescription?

A:

The original eRx and resulting CHCS prescription can be viewed using the Prescription Inquiry (PRI) capabilities. Please see training slides or the User Guide for additional information on the updated PRI functionality.

Q16:

What is the guidance on defining electronic prescribing pharmacies in CHCS?

A:

Information regarding guidance for defining electronic prescribing pharmacies in CHCS may be found in the Implementation Guidance document.

Q17:

How does electronic prescribing data affect current CHCS workload reports (e.g. HVR, VSR, etc.)?

A:

Electronic prescriptions processed (i.e. Validated) from the holding/error queue are integrated into current CHCS workload reports (e.g. HVR, VSR, etc.)

Q18:

Will prescriptions in the DRX screen, received through electronic prescribing, fall off after xx days?

A:

Electronic prescriptions processed (i.e. Validated) from the holding/error queue are treated like prescriptions received through CPOE/Pharmacy Order Entry.

Q19:

Will electronic prescribing increase the patient wait times?

A:

The electronic prescribing solution provides the MTF prescription information before the patient arrives at the pharmacy and affords the MTF the option to fill prescriptions before the patient arrives; thereby reducing wait times and delays. Wait times, however, are dependent upon a number of factors including the MTF’s current business processes, procedures (batch vs teller), as well as workload.

Q20:

Is Validating an electronic prescription faster than typing a prescription (hand written, faxed, printed, etc.)?

A:

Validating an electronic prescription in many cases is faster than typing a prescription because the electronic prescribing solution incorporates the look and feel of existing CHCS functionality. Efficiencies are achieved through familiarity, the intuitive user interface, and auto-matching capabilities. One of the benefits of ePrescribing is improving accuracy by eliminating translation and transcription errors.

Q21:

How do I ensure that the quantity the provider intended is the quantity dispensed for medications that could be ordered in variable units (each, bottle, gm, ml, tab, pack, etc.)?

A:

The ordered quantity will be similar to that of a hard-copy prescription. Electronic prescriptions may be received with additional qualifiers (e.g. metric quantity, metric units, etc.). The pharmacy staff should apply clinical judgment regarding quantities ordered.

Q22:

How can I prevent the selection of unused/utdated CHCS medication entries?

A:

Current MTF practices for drug file maintenance of unused/outdated entries are automatically applied to the medication selection list within the CHCS electronic prescribing module.

Q23:

What steps should I take when standing up a pharmacy to receive electronic prescriptions or when assigned a new DEA or NPI?

A:

MTFs should follow local policy for the creation or modification of electronic prescribing pharmacies within CHCS. The MTF electronic prescribing POCs will need to contact the PASS at least 45 days prior to implementing or changing a CHCS ePrescribing pharmacy site to ensure updates are communicated with the electronic prescribing network.

Q24:

Should I accept faxes from prescribers who electronically prescribe?

A:

Fax numbers provided by the MTFs will be used for backup in the event any portion of the electronic prescribing process/network is down.

Q25:

Do I auto-batch eRx's or wait for the patient to check in to start the fill process?

A:

Electronic prescriptions within the holding queue are segregated from the rest of CHCS functionality (e.g. auto-batching) until processed (i.e. Validated). The fulfillment of electronic prescriptions may be incorporated into existing MTF workflow (e.g. fill-ahead, bank teller).

Q26:

How is formulary status determined?

A:

The electronic prescribing solution utilizes the "non-formulary" and "IP/OP" indicators associated with the pharmacy site's formulary group within the CHCS Formulary Management (FRM) option. Please see training slides or the User Guide for additional information on Drug Matching capabilities.

Q27:

Does "removed" mean deleted from the system?

A:

The status of electronic prescriptions processed with the Remove function are changed from "pending" or "error" to "removed". Electronic prescriptions that are removed from the holding queue are permanently deleted from CHCS after 15 months.

Q28:

Can a provider on base ePrescribe to another base?

A:

The electronic prescribing solution in CHCS does not allow for outbound ePrescribing (e.g. MTF Provider to MTF, Mail, or Retail pharmacies). MTF providers can continue to use AHLTA/CHCS to prescribe medications to MTF pharmacies connected to the same CHCS host.

Q29:

What is the next step once the electronic prescribing software is installed on CHCS?

A:

Implementation and activation is a multi-step process, which needs to be coordinated with the Pharmacy Analytics Support Section (PASS). Detailed information regarding the necessary activities can be located in the Implementation Guide.

Q30:

Does the MTF pharmacy have to contact doctors in their local area to tell them to use ePrescribing?

A:

Provider outreach allows MTF pharmacies to manage the transition from paper to electronic prescriptions. A recommended outreach approach and customizable pamphlets are included with the Implementation guidance.

Q31:

How can I best train my staff on e-prescribing?

A:

The following documents are available: training slides, user guide, implementation guide, and CHCS release notes. Provider outreach to facilitate receipt of electronic prescriptions, as part of the "soft" opening allows MTF staff to become familiar with the electronic prescribing solution prior to full go-live. Please see the Implementation Guide for additional information on Provider Outreach and Go-Live activities.

Q32:

Can I process prescriptions in the pending/error queues prior to the patient arriving at the pharmacy?

A:

Yes, the processing of electronic prescriptions may be incorporated into various existing MTF workflows (e.g. fill-ahead, bank teller).

Q33:

Can out-of-town, city, state civilian providers send an electronic prescription to my pharmacy?

A:

Yes, any provider connected to a commercial electronic prescribing network may send an electronic prescription to any pharmacy on the ePrescribing network.

Q34:

My pharmacy receives an electronic prescription; however, the patient decides to have the prescription filled at a civilian pharmacy. Can I forward the electronic prescription to receiving pharmacy?

A:

The electronic prescription may be transferred verbally based on local, state and federal rules, regulations and laws. Once the prescription is transferred the user would use the Remove function from the eRx holding/error queue and select Transfer as the Removal Reason. The user would document the receiving pharmacy's information (name, phone, etc.), receiving staff member's name, etc. The electronic prescribing solution currently does not support electronic prescription transfers.

Q35:

Will the electronic prescribing solution be available for the three Services (Air Force, Army and Navy)?

A:

The CHCS ePrescribing software will be available to all MTFs in the United States, as well as Guam and Puerto Rico.

Q36:

How do I obtain a report of civilian prescribers and volume of prescriptions to help me determine which providers I should reach out to regarding electronic prescribing?

A:

A MTF specific civilian prescribers-volume report can be obtained from the Pharmacy Analytics Support Section (PASS) by calling 1-866-275-4732 Option 1.

Q37:

Will my pharmacy continue to receive faxed prescriptions from civilian providers once my pharmacy starts receiving electronic prescriptions?

A:

It depends. A provider's EHR may have been configured to send the electronic prescription directly to your fax machine or your pharmacy may have been previously registered as a fax enabled pharmacy with the electronic prescribing network. Reaching out to the provider of a faxed prescription will allow for provider education on the availability and published name (DoD "pharmacy name" ePhcy) of your pharmacy to facilitate the transition. Please see the Implementation Guide, and provider and patient flyers for additional information on Provider Outreach.

Q38:

Can I receive an electronic prescription for a patient not picking-up medications from my pharmacy?

A:

Yes, there is a chance that your pharmacy may receive electronic prescriptions for patients that will not pick-up a medication. The electronic prescribing network allows connected providers to send an electronic prescription to any connected pharmacy. The MHS ePrescribing solution attempts to reduce the occurrence of erroneous eRx's from reaching your pharmacy through the standardization of the published pharmacy names (i.e. DoD "pharmacy name" ePhcy).

Q39:

When a SSN is received as part of an electronic prescription, will it be the patient's or the sponsor's?

A:

Industry best practices support the transmission of the patient's SSN. The use of FMP/SSN is unique to the DoD/MHS.

Q40:

Will an eRx be placed in the error queue, when the received medication matches multiple CHCS drug entries?

A:

No, when the required information is received in the eRx and the medication matches multiple CHCS drug entries based on the Drug matching business rules, the Drug auto-match will occur on the latest drug files entry (i.e. the highest IEN). Please see the CHCS Release notes, user guide, and training slides for additional information on Drug auto-match business rules.

Q41:

When an eRx is received and the patient has an active prescription for the same medication with a different formulation (e.g. eRx = Metformin XR and current medication = Metformin), is the eRx automatically placed in the holding queue?

A:

After validation occurs, the clinical warning screen is presented for resolution to users with the appropriate security keys (i.e. PSGRPH = CCS menu option), or the prescription is placed in warning status. Please see the CHCS Release notes, user guide and training slides for additional information on prescription auto-creation and clinical screening business rules.

Q42:

What actions (e.g. print a label, PRI, forward, etc.) are available once an eRx has been validated?

A:

When an eRx has been Validated or auto-created, the result is an actionable prescription and may be processed in the same manner as prescriptions received from AHLTA or entered by the pharmacy staff.

Q43:

Does the MHS electronic prescribing solution affect MTF providers' prescribing processes (i.e. AHLTA or CHCS)?

A:

No, in-house MTF providers will continue to prescribe medications using the current processes (i.e. AHLTA or CHCS).

Q44:

Which electronic prescribing network subscription directory (i.e. electronic or fax) will my pharmacy be published to?

A:

MHS pharmacies will be published to the electronic directory. MTF's are encouraged to provide a fax number to the PASS as backup in case the ePrescribing network is unable to deliver the prescription electronically.

Q45:

Do electronic prescriptions that successfully auto-create display in the holding/error queues?

A:

The prescription auto-creation process from an eRx was disabled on February 3, 2015.

Q46:

Am I required to process (Validate, Remove, etc.) the electronic prescriptions from the holding queue in a certain time frame?

A:

No, the electronic prescribing holding/error queue was designed to receive, store and process eRx's. Business rules have been built in the holding/error queue to assist with maintenance. When an electronic prescription reaches 366 days old from the date written, the eRx status changes to Expired and no longer viewable from the holding/error queue. Expired prescriptions older than 15 months are deleted from the underlying database. Processed (Validated) eRx's are associated/linked with the resultant's CHCS prescription and are not deleted. Please see the CHCS Release notes, user guide and training slides for additional information on Validation, Removal and other business rules.

Q47:

What is the procedure for the electronic prescribing solution when my CHCS host has downtime (scheduled or unscheduled)?

A:

The DoD electronic prescribing intermediary (PDTS) will hold the electronic prescription and will retry to send the eRx to the MTF. When the retry attempts are unsuccessful, the eRx will be sent to the MTF as a fax, if configured, or returned to the civilian provider as undeliverable.

Q48:

Will civilian prescribers receive the same PDTS notifications that in-house prescribers receive and must clear? (Exact duplicate, DEA class overlap, interactions, etc.)?

A:

No, clinical screening (if available) on the civilian provider's electronic health record would occur prior to sending the electronic prescription to the ePrescribing network.

Q49:

Will CHCS workload be generated by the "eRx pharmacy" or only when the eRx is moved into processing pharmacy?

A:

CHCS workload will be generated after the electronic prescription results in an actionable CHCS prescription (e.g. print labels, dispense, refill, etc.); this will follow standard CHCS business rules.

Q50:

I processed (Validated or auto-created) an electronic prescription, the resultant CHCS prescription expired after three days and the patient has arrived five days later to pick-up the medication; what recourse is available?

A:

Guidance is to follow your MTF policies. The example presented would be similar to when an AHLTA or pharmacy entered prescriptions expires.

Q51:

When a separate pharmacy is not designated as the "ePhcy", how will I know that the medication I am filling/checking originated as an eRx?

A:

Any CHCS prescription may be viewed using the Prescription Inquiry (PRI) option. An indicator to the right of the order number identifies the prescription source. A prescription received as an eRx is identified with indicators of "(eRx SYS - Entered)" or "(eRx PHR - Entered)."

Electronic prescriptions may be printed via the holding/error queue Inquiry function prior to processing (Validated). The use of a specific printer that can be defined in the Outpatient Site parameters; different colored paper and scanning the printed eRx may be logical extensions depending on your pharmacy's policies, processes and workflow. Please see the CHCS Release notes, user guide, and training slides for additional information on PRI screen enhancements, holding queue actions, and other related functionality.

Q52:

Will I receive information (name, address, phone, etc.) about the civilian provider on an electronic prescription?

A:

Provider information required for a legal prescription based on local, state and Federal rules, regulations and laws will be received. Generally, the civilian provider's EHR is configured to send the practice name, provider name, street address, city, state, zip code and phone number, as well as the provider's National Provider Identification (NPI) and/or Drug Enforcement Agency (DEA) number(s).

Q53:

Our CHCS supports multiple Divisions, how do I retrieve an eRx sent to another pharmacy's holding queue?

A:

Retrieval of electronic prescriptions from a different holding queue may be dependent on current policies and practices for accessing pharmacy sites outside your MTF, Division, and Service.

Q54:

Am I able to see electronic prescriptions residing in the holding queue and error queue simultaneously?

A:

No, the electronic prescribing solution utilizes a single queue that displays electronic prescriptions based on the selected status (i.e. Pending or Error).

Q55:

When an electronic prescription is received for a non-formulary medication, what indicators are available to alert me?

A:

The electronic prescribing solution contains business rules to alert users when a non-formulary or inpatient use only medication is selected. The CHCS Drug portion of the Validate screen displays a "NON-FORMULARY" or "INPATIENT ONLY" indicator. The business rules do not take into account a populated Inactive Date. The identification and maintenance of non-formulary medications listings in CHCS facilitate increased auto-creation and accurate alerts. Please see the CHCS Release notes, user guide, and training slides for additional information on drug auto-matching, holding queue actions and other related functionality.

Q56:

Are there any plans to educate patient and providers from an Enterprise level in addition to MTF outreach?

A:

Yes, the DHA Pharmacy Operations Division and Beneficiary Education and Support Division are working through the plans to notify and educate patients and providers when the electronic prescribing solution has been successfully activated by all MTFs in the United States.

Q57:

How can I share my formulary information with the civilian providers?

A:

An Enterprise formulary tool is available for use by the MTF pharmacies at no additional cost. The tool is currently provided through the Electronic Clinical Reference contract (LexiComp® is the current vendor).

Q58:

How many epharmacy sites do I need in CHCS?

A:

For MTF pharmacies that current accept prescriptions from civilian providers, the minimum number is one, while the maximum is scalable to accommodate the business practices of each MTF. As with faxed prescriptions, ePrescribing enables the prescription to reach the pharmacy prior to the patient arriving; therefore allowing greater flexibility with how, when, and where to process.

Q59:

How does the program search for the identifiers for the patient (DoD ID #, SSN, Street address)?

A:

The eRx business rules for patients are First/Last names, DOB, and gender. All these must match along with the one of the following identifiers; DoD ID, SSN, or street address. Once a patient is found, an indicator of "Match Found" will be displayed in the "Validate eRx Patient" screen. Please refer to the eRx User Guide for more information.

Q60:

Can I forward e-prescriptions after validation?

A:

When an eRx has been Validated, the result is an actionable prescription and may be processed in the same manner as prescriptions received from AHLTA or entered by the pharmacy staff.

Q61:

How can I view the provider information without using the validate function?

A:

Within the electronic prescribing holding queue, the user selects one or more eRx's then selects inquiry from the action bar. At the device prompt, the appropriate printer name may be entered. If more than one eRx's has been selected, each eRx will be printed on a separate page when a device is specified. The eRx information will be displayed on the screen when a device was not specified. Please see training slides or the User Guide for additional information.

Q62:

If the doctor ordering on the medication has a different profile (NPI, for example) than the one showing but with the same name, what do we need to do?

A:

Users should follow local MTF policy for selecting the appropriate provider during the eRx provider validation process.

Q63:

If an MD ordered a non-formulary, do we just remove the prescription and the provider will see the comment section? What is the best solution if we have orders on hold for validation like this?

A:

The eRx software is capable of receiving electronic prescriptions for non- formulary medications. If CHCS determines that an electronic prescription is for a non-formulary drug (which is determined by the formulary status in the CHCS Formulary Management [FRM] file), that prescription will be placed in the CHCS holding queue for pharmacy intervention. Commercially, civilian providers are able to select and transmit any medications within their Electronic Health Record (EHR). Please refer to your local MTF policies for processing non-formulary prescriptions.

Q64:

We keep getting fax prescription even if CHCS is up. What can we do?

A:

A provider's EHR may have been configured to send the electronic prescription directly to your fax machine or your pharmacy may have been previously registered as a fax enabled pharmacy with the electronic prescribing network. Reaching out to the provider of a faxed prescription will allow for provider education on the availability and published name (DoD "pharmacy name" ePhcy) of your pharmacy to facilitate the transition. Please see the Implementation Guide, and provider and patient flyers for additional information on Provider Outreach.

Q65:

The provider sent the eRx but can't be found in the system, what do we do?

A:

All eRx will be in the holding queue; the user can look up a patient using different methods (please see the "search function" in the training materials. If the eRx does not appear in the holding queue, try checking the error queue. There are several reasons why an eRx maybe sent in this queue (please refer to the error queue section of the training material).

Q67:

Is there a way to unvalidate an eRx that has been accidentally validated?

A:

CHCS does not currently have the capability to unvalidate a validated electronic prescription.  The validation process associates the electronic prescription to the actionable prescription and may be processed (edited, transferred, cancelled, etc.) in the same manner as prescriptions received from AHLTA or entered by the pharmacy staff.

Q68:

Is there a limit on the number of prescriptions that the holding queue or error queue can store?

A:

No. There is not a limit on how many e-prescriptions can be received/stored in the holding queue. However, the holding queue will only display an e-prescription for up to 365 days from the date it was received. Once the e-prescription has passed the 1 year term, it will be automatically removed from the queue with its status updated to EXPIRED.

Q69:

How do I request a change to the published eRx pharmacy demographic information?

A:

Changes may be requested by completing the MTF e-Pharmacy Demographic Change Request Form. For assistance completing this form or any other related information, e-mail the DHA PASS general mailbox or call the DHA PASS at 1-866-275-4732 / (210) 536-6650, press option 1.

Enhanced Multi-Service Markets

Questions and answers about eMSMs

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Multi-Service Markets
Q1:

What are eMSMs?

A:

Enhanced Multi-Service Markets (eMSMs) are Multi-Service Markets identified by the Deputy Secretary of Defense in his March 2013 memorandum. These markets are provided with “enhanced” authorities that include the authority to manage the allocation of the budget for the market, direct the adoption of common clinical and business functions for the market, optimize readiness to deploy medically ready forces and ready medical forces, and direct the movement of workload and workforce between or among the medical treatment facilities. These authorities are effective October 1, 2013.

There are two distinguishing features of the enhanced Multi-Service Market: 

  • a single market manager, and 
  • a unified business performance plan.  

Within each eMSM, an appointed market manager has the authority to: 

  • Manage the allocation of the budget for the market 
  • Direct common clinical and business functions for the market 
  • Direct the movement of workload and workforce among the medical treatment facilities 
  • Develop, execute and monitor the business performance plan 

Within each eMSM, Market-based business performance plans will be:

  • Fully-integrated across the entire market and will replace current MTF based business plans. 
  • Based on a 5-year planning cycle. 
  • Aligned with budget execution process.
Q2:

How were these Markets selected for enhanced authorities?

A:

The markets were selected based on careful review of a number of different characteristics by the MHS Governance Implementation Planning Team. All of these markets share several important factors, including readiness support, market complexity, large TRICARE eligible population, multi-Service provider footprint, recapture potential and GME programs.

Q3:

What is the strategy for eMSMs to recapture care from the private sector?

A:

Each market is creating a five-year Market-focused business performance plan that will outline the strategies each particular market will implement to improve performance, improve outcomes, and recapture care. There are a variety of strategies that the markets will employ – and will feature both internal process reengineering to improve utilization of existing resources, as well as externally facing efforts to attract and retain beneficiaries to use our services. The eMSM Offices will monitor workload, appointing, and referrals across MTFs in the market. The eMSM Offices will analyze and direct the movement of personnel to most effectively and efficiently meet the market workload needs and reduce unnecessary referrals to the direct care system.

Q4:

Are eMSMs collaborating with the VA and other federal health partners?

A:

The five-year market based business performance plans crafted by each market will take into account federal partners within their respective market areas, particularly to include the visbility and utilization of VA medical capabilities. The level of coordination will necessarily vary from market to market based on a number of variables.

Field Testing of Hallucinogenic Agents

Questions and answers about Field Testing of Hallucinogenic Agents

Q1:

What are the effects of exposure to hallucinogenic compounds such as LSD?

A:

The current medical literature indicates that such exposure may have some long-lasting effects among some individuals, such as "flashbacks" (visual hallucinations without new drug exposure).

Fraud and Abuse

View questions and answers about health care fraud and abuse.

Recommended Content:

Program Integrity
Q1:

What does the term "TRICARE" stand for?

A:

TRICARE is the health care program for service members (active duty, Guard/Reserve, retired) and their families around the world. TRICARE is a major part of the Military Health System. >>Learn More about TRICARE

Q2:

What's wrong with a provider waiving the beneficiary's cost-share?

A:

The beneficiary's cost-share is established by law. It protects both the beneficiary and the government. When a beneficiary is responsible for paying part of the cost of the care, we have found there is more attention paid to the accuracy of the Explanation of Benefits. If the charge is inaccurate, the beneficiary is likely to report the discrepancy. Many fraud cases are initiated as a result of such reportings. The cost-share also helps protect the beneficiary. When a beneficiary is responsible for paying 20-25 percent of a $10,000 procedure, he/she is likely to get a second medical opinion to ensure the services are medically necessary and appropriate. Providers cannot waive cost-shares. It is an obligation imposed by Congress for valid reasons. Waiver of the cost-share under the new fraud amendments is treated as a fraudulent act with separate dollar penalties.

Q3:

What is a mutually-exclusive edit?

A:

This is billing for two procedures that are either physically impossible to perform at the same time (such as an abdominal hysterectomy and a vaginal hysterectomy) or are really duplicative. In laboratory billings, a mutually-exclusive billing might be laboratory tests that are billed at the same time when it is necessary to wait for the results of the first before the second test is requested. In U.S. vs. Pickett, an ultrasound for a complete fetal and maternal evaluation was billed in addition to a fetal biophysical profile, basically the same procedure.

Q4:

What is meant by the term "upcoding"?

A:

Upcoding is the practice of billing the services at a higher level than what was actually provided to obtain reimbursement at a higher rate.

Q5:

Is upcoding fraudulent?

A:

Upcoding is considered fraudulent in that it is a misrepresentation of the services provided.

Q6:

What are some examples of upcoding?

A:

One example is billing for a 30 minute session of individual psychotherapy (90843) as if 45-50 minutes were provided (90844). Another is providing group psychotherapy but billing for it as if it were individual psychotherapy. Since a group psychotherapy session generally involves 4-10 patients, and individual psychotherapy reimburses at the rate of approximately $100 per hour, misrepresenting the services could give the provider a financial windfall of $400-$1000 per hour. Other types of upcoding exist, such as providing a unilateral mammography but billing for it as if it were a bilateral mammography.

Q7:

Can upcoding exist with office and hospital visits?

A:

Upcoding can exist in the selection of the Evaluation and Management codes (99000 series) which are used for office and hospital visits. In 1992, the Physicians Current Procedural Terminology (CPT) was revised to include specific time elements for each level of visit, specific clinical examples and a definition of what the patient's condition should be if a higher level code is selected. There are 5 levels of office visits, for both new patients and established patients. The level of office visit is determined by the number of diagnoses, the complexity of the case, the risk of complications or morbidity and the complexity of the decision making—straight-forward, low, moderate or high.

Q8:

Doesn't the new fraud legislation address upcoding?

A:

Yes. It provides for a $10,000 fine per incidence of upcoding, and with the clarification in the CPT as of 1992, clear-cut parameters exist as to what level is the appropriate one to bill.

Q9:

Is "unbundling" or "code gaming" considered fraudulent?

A:

"Unbundling," "fragmenting" or "code gaming" in order to manipulate the CPT codes as a means of increasing reimbursement is considered a misrepresentation of the services rendered. Such a practice is considered fraudulent and abusive. In U.S. vs Pickett, a radiologist was convicted in a criminal trial for billing for a consultation in addition to the diagnostic imaging procedure which included performing the test and its interpretation. This is a form of unbundling or double billing.

Gulf War Illness

Questions and answers about the Persian Gulf War from 1990-1991 and its health effects.

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Gulf War Frequently Asked Questions
Q1:

How many veterans are registered in the Comprehensive Clinical Evaluation Program?

A:

As of December 31, 2000, 56,845 1990-1991 Gulf War veterans were enrolled by self-referral into the program. Of this number, 16,129 declined evaluation.

Q2:

Were 1990-1991 Gulf War veterans exposed to biological agents?

A:

We have no evidence that biological weapons were used during the 1990-1991 Gulf War. In addition we have not found any reports of verified biological agent detections nor are we aware of anyone, soldier or civilian, who has reported experiencing symptoms consistent with exposure to a biological agent.

To date, there is also no evidence that any warfare agents were released as a result of coalition bombings during the air war campaign, January 17, 1991 through February 23, 1991.

Q3:

What were the U.S. capabilities for detecting biological agents?

A:

During the 1990-1991 Gulf War we deployed 17 research and development systems to the Gulf region to monitor the air for suspected Iraqi biological warfare (BW) agents. Twelve of the 17 systems were mobile, and consisted of the Army's XM-2 high volume air samplers and Sensitive Membrane Antigen Rapid Test (SMART) identification tickets. The mobile systems moved across northeast Saudi Arabia to monitor for Iraqi BW agent attacks. The remaining five systems were employed in a static mode at critical logistics facilities and consisted of a modified commercial aerosol sampler with SMART tickets. The mobile units were mounted on HUMVEES and on Isuzu Troopers. These XM-2 air samplers had inherent limitations. They were too big and heavy, had low reliability and an unacceptable false alarm rate. Units that deployed with these systems included personnel from the Edgewood Research Development Engineering Center in mid-January 1991 and elements of the 9th CM Co, an active component unit from Fort Lewis, arrived a few weeks later. This unit was deactivated in February 1994.

Detections from these systems included the following:

Two thousand anthrax and botulinum SMART tickets were used during the 1990-1991 Gulf War. Less than 1% of these gave a positive reading at the respective sampling points. Confirmatory tests of the samples at the Navy's Forward Deployed Medical Diagnostic Lab indicated that all samples were free of suspected BW agent.

Since the 1990-1991 Gulf War we have pursued an aggressive program to field a robust detection system that will protect our forces against a wide spectrum of BW threats. We have fielded two new systems and are developing a third.

In December 1996, the Joint Program Office for Biological Defense (JPO-BD) awarded a contract for the engineering and manufacturing development of the Joint Biological Point Detection System (JBPDS); the next generation system with an enhanced, common biological detection suite that will be employed on all four services' platforms (i.e., Army and Marine Corps HUMVEESs, Navy ships and AF bases).

In June 1995 the Army had one platoon of the 11th Chemical Company at Fort McClellan, Alabama, equipped with the Biological Integrated Detection System (BIDS). On 16 September 1996, the Army activated its first biological detection company, the 310th Chemical Company (Reserve Component) at Fort McClellan. This company is equipped with 38 HMMWV-mounted BIDS and three Long Range Biological Standoff Detection Systems (LR-BSDS). These are enough systems to provide Corps-size coverage.

In September 1994 we fielded the Navy's Interim Biological Agent Detector (IBAD) aboard the USS LaSalle. Nine more IBADS have been deployed with the fleet since then. The Navy will have a total of 25 systems deployed by the end of September 1997.

Q4:

What is a case narrative?

A:

A case narrative is a report of what we know today about specific events that took place during the Gulf War of 1990 and 1991. A case narrative focuses on a particular incident and can include personnel interviews, reviews of official documents from various commands and agencies, collection of scientific data, and original research. From a broader perspective, a case narrative is part of our overall effort to inform the public about the progress being made to solve the many mysteries of 1990-1991 Gulf War illnesses.

Q5:

How do the case narratives effect previously announced initiatives and actions?

A:

These announcements are another step in the investigative process. The case narratives are not final reports. These narratives are intended to generate additional dialogue with 1990-1991 Gulf War veterans who may have more information that will help us accurately understand what occurred with respect to each case under investigation. We encourage veterans with additional information to call the Gulf War Incident Hotline at 1-800-472-6719 or DSN 878-3261.

Q6:

What methodology did you use in developing the narratives?

A:

To investigate these incidents and to determine if chemical weapons were used, the DoD developed a methodology for investigation and validation based on work done by the United Nations and the international community where the criteria include:

  1. A detailed written record of the conditions at the site;
  2. Physical evidence from the site, such as weapons fragments, soil, water, vegetation or human/animal tissue samples;
  3. A record of the chain of custody during the transportation of the evidence;
  4. Testimony of eyewitnesses;
  5. Multiple analyses; and
  6. Review of the evidence by experts.

Our method is designed to provide a thorough, investigative process to define the circumstances of each incident and determine what happened. Alarms alone are not considered to be certain evidence of chemical agent presence, nor is a single individual's observation sufficient to validate a chemical agent presence, without corroboration. By following our methodology, gathering evidence, interviewing eyewitnesses and key personnel, and analyzing the results, the investigator assesses the validity of the presence of chemical warfare agents on the battlefield. Because information from various sources may be contradictory, we have developed the following assessment scale, ranging from "Definitely" to "Definitely Not." This assessment is tentative, based on facts available as of the date of the report publication; each case is reassessed over based on new information and feedback.

The standard for making the assessment is based on the following: do the available facts lead a reasonable person to conclude that chemical warfare agents were or were not present? When insufficient information is available, the assessment is "Indeterminate" until more evidence can be found.

Q7:

What DoD hotlines are available for Gulf War Illness?

A:
  • DoD Incident Reporting Line: 1-800-497-6261
  • DoD Gulf War Medical Registry (CCEP): 1-800-796-9699
  • Veterans’ Affairs Registry: 1-800-749-8387 (PGW-VETS)
Q8:

What is the nature of the illnesses suffered by Gulf War veterans?

A:

Our best information on this question comes from the Comprehensive Clinical Evaluation Program (CCEP) which provides thorough medical evaluations of 1990-1991 Gulf War veterans in DoD health care facilities. Through June 1998, approximately 32,392 veterans have completed CCEP evaluations. Seventy five percent of all 32,392 CCEP participants have as their primary (main) diagnosis one of the following 42 most common diagnoses (ICD-9 Codes are shown in parentheses):

Musculoskeletal Disorders

Number of Participants 5224 / Percent of All Participants 16.2%

  • Pain in Joint (719.4) 1776
  • Osteoarthrosis (715) 1148
  • Back Pain and Other Back Disorders (724) 901
  • Disorders of Tendons, Muscle Attachments (726) 497
  • Other Disorders of Soft Tissue (729) 464
  • Vertebral Disc Disorders (722) 294
  • Knee Derangements (717) 144

Symptoms which the CCEP Evaluation was unable to establish an explanatory diagnosis

Number of Participants 4397 / Percent of All Participants 13.6 %

  • Malaise and/or fatigue (780.7) 1381
  • Sleep Disturbances (780.5) 1067
  • General Symptoms and Hyperhidrosis (780.8-780.9) 625
  • Symptoms of Respiratory System and Chest (786) 530
  • Symptoms Involving the Skin (782) 334
  • Alterations of Consciousness, Awareness (780-780.4) 197
  • Abdominal Pain in Various Locations (789.0) 136
  • Symptoms of Digestive System (787) 127

Psychological Disorders

Number of Participants 3989 / Percent of All Participants 12.3 %

  • Depressive Disorder (311) 942
  • Neuroses (300) 897
  • Prolonged PTSD (309.81) 850
  • Affective Disorders (296) 563
  • Adjustment Reactions (309) 387
  • Sleep Disorders (307.4) 179
  • Organic Brain Syndromes (293-4) 171

Healthy

Number of Participants 2904 / Percent of All Participants 9.0 %

  • Feared Complaint, No Diagnosis (V65.5) 2586
  • Routine General Medical Examination (V70) 318

Headaches

Number of Participants 2757 / Percent of All Participants 8.5 %

  • Tension headache (307.81) 1016
  • Migraine (346) 950
  • Headache (784.0) 791

Respiratory Conditions

Number of Participants 1681 / Percent of All Participants 5.2 %

  • Asthma (493) 719
  • Allergic Rhinitis (477) 501
  • Chronic Upper Respiratory Inflammation (472-476) 461

Skin Disorders

Number of Participants 1387 / Percent of All Participants 4.3%

  • Alopecia, hirsutism, and other diseases of hair and hair follicles (704) 407
  • Fungus Infections (110-111) 406
  • Contact dermatitis and other Eczema (692) 399
  • Urticaria, various types (708) 175

Gastrointestinal Disorders

Number of Participants 1262 / Percent of All Participants 3.9%

  • Irritable Colon (564.1) 496
  • Esophageal Reflux (530.81) 429
  • Enteritis and Colitis (558) 214
  • Gastritis and Duodenitis (535) 123

Hypertension

Essential(401), Number of Participants 393 / Percent of All Participants 1.2%

Endocrine and Metabolic Disorders

Number of Participants 292 / Percent of All Participants 0.9 %

  • Lipoid Metabolism Disord. (272) 168
  • Hypothyroidism (243-244) 124

Hearing Loss 

(388.02-388.2, 389), Number of Participants 130 / Percent of All Participants 0.4 %

Q9:

Are 1990-1991 Gulf War veterans’ illnesses contagious?

A:

A few veterans' illnesses are known to be contagious, but there is little reason to believe that most veterans' illnesses can be spread to other persons. Of all the veterans (33,542) who have completed the detailed medical evaluations at the DoD clinics and hospitals, about 3% were found to have an infection as their main diagnosis. A small number of these veterans had infections well known to medical science which could be passed on to other persons (viral hepatitis, herpes simplex infections, HIV infection, and tuberculosis). Otherwise, the vast majority of the infections were either brief, one-time illnesses, easily treated and cured illnesses, or infections that are not contagious from person to person. Other than the specific infections of malaria and leishmaniasis (which are not spread from person to person), none of the veterans' infections can be specifically linked to service in the Persian Gulf. The infectious diseases among veterans resemble the range of illnesses common in the population at large. Despite the above, however, DoD and the VA continue to pursue research studies of the questions of contagion and of previously unrecognized causes of infection.

Q10:

What are mycoplasmas?

A:

Mycroplasmas are the smallest, free-living infectious agents. They are distinct from viruses because of their ability to grow in cell-free media and from bacteria because they lack a cell wall and the ability to synthesize cell wall precursors. A variety of plant and animal diseases are caused by the mycoplasmas. However, only certain types have been clearly shown to cause disease in humans.

Q11:

What is an environmental exposure report?

A:

The Environmental and Occupational Exposures Division is looking at experiences in the 1990-1991 Gulf War from a more universal approach than previous investigations in general. An Environmental Exposures Report looks to describe any of a variety of exposure opportunities in the 1990-1991 Gulf War that would have occurred more universally, and that may have had an impact on the health of 1990-1991 Gulf War participants.

Q12:

How do environmental exposure reports differ from the case narratives that have been published?

A:

While previous case narratives mostly focused on discrete events or specifically identifiable occurrences, the Environmental Exposures Reports address events or exposures that had the potential to be experienced by anyone participating in the 1990-1991 Gulf War. The approach comes from a more universal perspective and includes personnel who share, or may share, common exposure potentials as relates to their environment.

Q13:

What is the significance of environmental exposure reports?

A:

Consistent with one of the charters of OSAGWI to “leave no stone unturned,” Environmental Exposure Reports will further describe events experienced by personnel in the 1990-1991 Gulf War that may have had a long-term effect on their health. These reports will add to the completeness of the story and better enable veterans, politicians, medical personnel, media, and other interested parties to understand the significance of 1990-1991 Gulf War events as they relate to illnesses experienced by the veterans.

Q14:

What methodology was used in developing the environmental exposure reports?

A:

We have adopted an assessment methodology patterned on that used by the U.S. Environmental Protection Agency. This process estimates the health risk from contaminant concentrations, site exposure, and contaminant toxicity characteristics. It consists of four steps: Hazard Identification, Toxicity Assessment, Dose Assessment, and Risk Characterization, defined below:

  • Hazard Identification - who was exposed, and how? Which incidents warrant a full investigation?
  • Toxicity Assessment - what are the known medical effects of human exposure? At what levels of exposure do these effects occur? How can the effects be mitigated?
  • Dose Assessment - how much of the contaminant were the troops exposed to? What chemical or radiological doses do these intakes represent?
  • Risk Characterization - using validated toxicity and dose information, what medical effects can be anticipated? How serious are those effects? How can the effects be communicated to those affected?

The former Office of the Special Assistant for Gulf War Illnesses (now Force Health Protection & Readiness Policy & Programs) has focused its investigation on determining what happened, what exposures may have occurred, and who may have been exposed. Exposures have been subdivided into levels and scenarios so they can be related to toxicity and dose information.

Q15:

How many 1990-1991 Gulf War veterans have died since they returned from the Gulf?

A:

As of May 1998, approximately 5,425 veterans (0.78%) out of 697,000 participants in the 1990-1991 Gulf War had died. The Defense Manpower Data Center (DMDC) obtained this number by comparing lists of all 1990-1991 Gulf War veterans with files of deaths recorded by the Social Security Administration. A similar comparison disclosed that, of the 2,372,327 members of the active duty force and the selective reserve who did not deploy to the Gulf, 19,475 (0.82%) had died. No information on cause of death was available from this data search.

Previous studies by the Department of Veterans Affairs had compared deaths among GW veterans to those among a random sample (about half) of all other veterans. The overall death rates were about the same in the two comparison groups. GW veterans had higher rates of death due to external causes, particularly due to motor vehicle accidents. GW veterans had lower rates of death from natural causes.

Q16:

Why were troops given Pyridostigmine Bromide (PB) during the 1990-1991 Gulf War?

A:

During Operation Desert Storm, the threat of use of nerve agents by Iraq was very high. After careful deliberation by a specially constituted human-use review committee of the Food and Drug Administration, it was determined that the pretreatment could help save the lives of many Service members if nerve agents were used. Approval for the use of pyridostigmine bromide was based on extensive scientific information that supported the safety and effectiveness of pyridostigmine bromide as a preventive treatment.

Pyridostigmine bromide is not an exotic or experimental drug. The Food and Drug Administration approved it in 1955 for use in treating myasthenia gravis, a neuromuscular disease that causes muscle weakness and fatigue. However, when approved for use in the Gulf, the approval was as an investigational new drug. This classification means that pyridostigmine bromide had not been formally approved for general commercial marketing as a nerve gas antidote.

There was no effort to withhold information from the troops or the public. In fact, pyridostigmine bromide use was widely reported by the news media at the time. The Department of Defense believes that most individuals knew they were taking an oral drug to counter the effects of a possible attack with nerve agents. However, troops did not receive enough information about the possible side effects of pyridostigmine bromide. Information was prepared for distribution in the field, but it did not arrive before hostilities began.

The Defense Department estimates that approximately 250,000 personnel took at least some pyridostigmine bromide during the 1990-1991 Gulf War. During the 1990-1991 Gulf War, all U.S. troops were to have received packets containing pyridostigmine bromide pills.

Actual administration of the pre-treatment was decentralized in nuclear, biological chemical (NBC) and not medical channels. It was intended to be self-administered upon a unit commander's order. We know that in some units, pyridostigmine bromide administration was carefully monitored, while in others, it was not. However, accurate assessments of actual pyridostigmine bromide use are difficult because no specific records were kept of self-administered medications.

To date, the Food and Drug Administration has recalled none of the drugs or vaccines administered by the military. If you would like more information on pyridostigmine bromide you may contact the Defense Personnel Support Center at (215) 737-5768.

Health IT Innovation and Research

Questions and Answers about Health IT Innovation and Research

Recommended Content:

Architecture, Advanced Concepts, and Engineering (AACE)
Q1:

What does AACE stand for?

A:

Architecture, Advanced Concepts and Engineering (The AACE Division replaces the former Innovation and Advanced Technology Development Division)

Q2:

How is the DHA/AACE working to increase transparency of HIT research initiatives across the enterprise?

A:

The AACE Division is committed to ensuring a consistent and centrally managed approach of HIT research initiatives. AACE has developed a process to identify, research, develop, test and evaluate innovative solutions that benefit the MHS enterprise. This streamlined evaluation process will increase transparency into HIT research initiatives and reduce parallel efforts underway. Be sure to view the latest snapshot of HIT R&D projects by checking out our HIT R&D Directory.

Q3:

How can I have my ideas heard by the DHA/ACCE?

A:

To have your ideas heard by us, visit our Health IT Research and Innovation page to explore your options or email us.

Frequently Asked Questions for Transactions

View questions and answers about the nationwide standards for HIPAA compliant electronic administrative health care transactions.

Recommended Content:

Transactions | Table of HIPAA Adopted Transactions Used by MHS
Q1:

Has the MHS provided Companion Guides for HIPAA Transactions?

A:

The TRICARE Managed Care Support Contractors (MCSCs) have provided companion guides for some of the HIPAA transactions they perform. Please contact the MCSC point of contact for your region to obtain the latest information.

Q2:

What is the General Inquiry for Defense Enrollment Eligibility Reporting System (DEERS) (GIQD), and who is able to access this system?

A:

The GIQD is a web-based, direct data entry system which allows authorized users to make eligibility inquiries. The GIQD has been updated to include HIPAA-compliant data elements and can be used in lieu of a direct Electronic Data Interchange (EDI) with DEERS.

Q3:

Is the Defense Online Enrollment System (DOES) enrollment application HIPAA compliant?

A:

The DOES application is a web-based, direct data entry system which can be utilized by Managed Care Support Contractors (MCSCs) to enroll TRICARE beneficiaries into TRICARE programs in the Defense Enrollment Eligibility Reporting System (DEERS). DOES has been updated to include HIPAA-compliant data elements. The system includes upgraded security features and was deployed to all users as of May 2003. All TRICARE enrollments are performed using the HIPAA-compliant DOES application.

Q4:

When will the Claims/Clinical Attachments Final Rule be published?

A:

The Centers for Medicare and Medicaid Services (CMS) published a Claims Attachments Notice of Proposed Rulemaking (NPRM) (CMS-005-0-F) in the Federal Register in September 2005. However, that NPRM was withdrawn in 2010 because of technology and business need changes. The Patient Protection and Affordable Care Act of 2010 (also known as ACA) requires the Department of Health and Human Services (HHS) to publish a Final Rule to adopt a Claims Attachment Standard and Operating Rules by January 2014 with an effective date not later than January 2016. Please note, while originally called "Claims Attachments" the health care industry has shifted toward the phrase "Clinical Attachments" to reflect the broader usage of the standard for purposes including but not limited to claims, referrals, and requests for pre-authorization. On 5 July 2016, National Committee on Vital and Health Services (NCVHS), the statutory advisory committee responsible for providing recommendations on health information policy and standards to HHS, recommended HHS publish a Final Rule to adopt a Clinical Attachment standard. As of January 2017, a Final Rule to adopt a Clinical Attachments Standard and Operating Rules had not been published.

Q5:

When was the industry required to use ASC X12 Version 5010 of the X12 HIPAA Electronic Data Interchange (EDI) standards?

A:

In a Final Rule published by the Department of Health and Human Services (HHS) in January 2009, covered entities were mandated to be in full compliance with Version 5010 and NCPDP Version D.0 by January 1, 2012. The Military Health System (MHS) successfully implemented the EDI standards and is in compliance with the Final Rule.

Frequently Asked Questions for Code Sets

View questions and answers about the nationwide standards for code sets used in the HIPAA compliant electronic health care transactions.

Recommended Content:

Code Sets
Q1:

How do I know how to correctly code my claim?

A:
Q2:

What organization developed the ICD-10 code set?

A:

The World Health Organization (WHO), a specialized agency of the United Nations, owns and publishes the ICD code sets (including ICD-10).

Q4:

Why are code sets used in nationwide electronic health care transactions?

A:

By using standardized code sets, providers across the nation can easily and efficiently communicate with one another in order to serve patients and conduct administrative transactions.  In other words, the use of standardized code sets improves the interoperability of health care payers and providers by normalizing the “language” that is used.

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