This Tab describes the history of the expanded medical follow-up program and provides copies of the notification letter and fact sheet describing how to arrange follow-up medical monitoring for veterans potentially exposed to depleted uranium (DU) during or after the Gulf War.

On July 8, 1998, the Departments of Defense (DoD) and Veterans Affairs (VA) expanded the DU medical follow-up program to include all veterans who were potentially exposed to the highest levels of DU during the Gulf War. These highest, Level I, exposures occurred in friendly-fire incidents when US combat vehicles were struck by DU munitions fired from US M1A1 tanks. Soldiers riding in or on these vehicles were potentially exposed to DU through fragments embedded in their bodies, inhaling or ingesting DU particles created on impact or penetration, and wound contamination. As a result, some soldiers still retain DU in their bodies. Other Level I soldiers entered a struck vehicle immediately after impact and could have inhaled or ingested the fine DU particles still suspended in the vehicle's interior. Scientists believe personnel classified as Level II received smaller exposures to DU oxides, residues, and fragments while working in or on US vehicles contaminated with DU. DoD and the VA believed these Level II personnel also warranted evaluation.

The Office of the Special Assistant for Gulf War Illnesses (OSAGWI) contacted Level I and II personnel for two purposes: first, OSAGWI informed the veterans about the DoD and VA depleted uranium medical evaluation programs and encouraged the veterans to enroll in the program for which they were eligible, with a follow-up letter to arrive within a week. Second, OSAGWI asked the veterans about their experiences in the friendly-fire incidents or other possible exposures to reconstruct the veterans' possible DU exposure levels. OSAGWI used the data to identify additional personnel potentially exposed to DU.

The DU medical follow-up program was aimed at ensuring Gulf War veterans with higher-than-normal amounts of uranium in their bodies were identified and appropriately monitored and evaluated. The program requires collecting urine over 24 hours and a detailed medical history, in addition to obtaining the examination Gulf War veterans receive through the Comprehensive Clinical Evaluation Program or the Department of Veterans Affairs Gulf War Registry.

The follow-up was executed in phases.

Initially, the Office of the Special Assistant for Gulf War Illnesses recontacted the friendly-fire victims it contacted in October 1997, informed them of their eligibility for the expanded DU medical follow-up program, and urged them to obtain a medical follow-up. The Office of the Special Assistant sent these veterans a notification letter and DU Fact Sheet (included below).

Then on July 15, 1998, OSAGWI started contacting veterans not previously contacted but believed to have been in or on vehicles when they were struck by DU munitions and senior leadership from each unit that incurred DU-related friendly-fire losses. These veterans required a more detailed, flexible notification interview, since some of them were not personally exposed but may have had information about soldiers who were. The interview questions were designed to estimate exposures and identify other soldiers who may have been exposed to DU.

Finally on July 29, 1998, OSAGWI began contacting other Gulf War veterans possibly exposed to DU, including those who entered DU-contaminated vehicles while serving in these organizations or performing these functions: 144^th Services and Supply Company, battle damage assessment teams, logistics assistance representatives, radiation control teams, and unit maintenance personnel. While the DU medical follow-up protocols and procedures remained the same for this Phase, the information-gathering portion of the notification script was tailored to the specific functions the contacted veterans performed. By analyzing the data from the expanded DU medical follow-up program, the head of the Baltimore VA DU medical follow-up program will determine the need to extend DU medical evaluations to veterans with even lower DU exposures.

Some Gulf War veterans expressed concerns about much smaller potential DU exposures than the Level I or Level II veterans experienced. For example, some veterans are concerned about potential exposures incurred in climbing on damaged Iraqi vehicles or from their presence in the South Compound during the fire at Doha, Kuwait in July 1991. While they were at much lower risk than the veterans in the friendly-fire incidents, some of these veterans had questions for their physicians. Though OSAGWI did not identify or contact veterans in lower exposure categories, these veterans were able to refer themselves to the DoD or VA for medical advice. If they and/or their physicians believed it was warranted, they received a DU medical evaluation.

The next two pages reprint the fact sheet which OSAGWI mailed to all veterans notified for follow-up.

Uranium is a weakly radioactive element that occurs naturally in the environment. Each of us ingests and inhales natural uranium every day from the natural uranium in our air, water, and soil. The amount varies depending upon the natural levels found in the area you live and the levels found in the areas where the food you eat and the water you drink are produced. Consequently, each of us has some level of uranium in our body, which is eliminated in the urine. In areas where the natural uranium level in the soil or water is high, these levels can be substantially higher.

Enriched uranium (uranium that is more radioactive than natural uranium) is used in nuclear power reactors and very highly enriched uranium is used in some nuclear weapons.

Depleted uranium (sometimes known as DU) is uranium that is 40 percent less radioactive than natural uranium, while retaining identical chemical properties.

The United States Armed Forces used depleted uranium munitions and armor in combat for the first time during the Gulf War. Depleted uranium's ability to protect our soldiers' lives was clearly demonstrated. Depleted uranium is the most effective material for these uses because of its high density and the metallic properties that allow it to "self-sharpen" as it penetrates armor. In contrast, antitank munitions made from other materials (tungsten compounds) tend to mushroom and become blunt as they penetrate. Armor containing depleted uranium is very effective at blunting antitank weapons.

The major health concerns about DU relate to its chemical properties as a heavy metal rather than to its radioactivity, which is very low. As with all chemicals, the hazard depends mainly upon the amount taken into the body, its route of entry, and its solubility. It has been recognized that natural uranium at high doses has caused kidney damage. The greatest potential for medically significant DU exposure occurred with those veterans who were in or on tanks and other armored vehicles when the vehicles were hit by DU munitions and in veterans who worked in or on US vehicles or sites contaminated with DU.

Since 1993, the Department of Veterans Affairs has been monitoring 33 veterans who were seriously injured in friendly-fire incidents involving depleted uranium. These veterans are being monitored at the Baltimore VA Medical Center. Many of these veterans continue to have medical problems, especially problems relating to the physical injuries they received during friendly-fire incidents. About half of this group still have depleted uranium metal fragments in their bodies. Those with higher than normal levels of uranium in their urine since monitoring began in 1993 have embedded DU fragments. These veterans are being followed very carefully and a number of different medical tests are being done to determine if the depleted uranium fragments are causing any health problems.

The veterans being followed who were in friendly-fire incidents but who do not have retained depleted uranium fragments, generally speaking, have not shown higher than normal levels of uranium in their urine.

For the 33 veterans in the program, tests for kidney function have all been normal. In addition, the reproductive health of this group appears to be normal in that all babies fathered by these veterans between 1991 and 1997 had no birth defects.

As part of follow-up efforts to ensure that Gulf War veterans who may have had the highest DU exposures receive appropriate evaluation and follow-up, DoD and VA have instituted a new program to identify, contact, and evaluate these individuals. This would include veterans who were riding in or on a vehicle that was struck by DU munitions or veterans who entered a struck vehicle immediately after it was hit by DU munitions. Also included are personnel who worked in or on US vehicles contaminated with DU.

If you are on active duty and not enrolled in the Comprehensive Clinical Evaluation Program (CCEP) or if your CCEP examination is over 1 year old, you will receive the standard CCEP evaluation. If your CCEP evaluation is less than 1 year old, your physician will decide what evaluations are clinically required.

All participants will be asked to fill out a brief questionnaire relating to possible exposure to depleted uranium during the Gulf War. In addition, all participants will be asked to provide a 24-hour urine sample -- you will be provided a container in which you will collect all of your urine for one day. This urine sample will be analyzed for the presence of uranium.

If you are no longer on active duty, you may enroll in the Gulf War Registry Examination Program at any VA Medical Center. You will be asked to fill out a brief DU questionnaire and provide a 24-hour urine sample for uranium and get a medical examination if you have not already had one or wish to be re-examined.

It is good news. It means that the level of uranium in your body now is no higher than would be expected from normal intake from natural sources (food, water, and air). It does not mean you were never exposed to DU. It simply means that you have a normal level of uranium in your body now.

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