1. This letter calls attention to a concern that some veterans, who served as deck grinders on aircraft carriers in the Navy during the 1970s through the 1990s, may have unrecognized, misdiagnosed occupational lung disease. Reevaluation of a Navy veteran who had been involved in grinding antiskid materials on aircraft carrier decks resulted in a change of diagnosis from sarcoidosis to pneumoconiosis. This case led to a study by staff of the National Institute of Occupational Safety and Health (NIOSH) which found an increased risk for diagnosis of sarcoidosis, especially for African-Americans, associated with service on aircraft carriers. Conversely, another paper reported a decreased risk for a diagnosis of sarcoidoisis in Navy veterans who had served only on "clean ships."

2. Navy veterans who are concerned about possible misdiagnosis of pneumoconiosis as pulmonary sarcoidosis or who have other pulmonary problems possibly related to hazardous exposures in service are being invited to enroll to receive Department of Veterans Affairs (VA) health care. It is recommended that VA facilities provide the following services to veterans who may have occupational lung disease:

a. Performance of a Detailed Occupational History. This should include a list of all occupations during Navy service and the duration of each. Any shipboard service and type of ship, such as aircraft carrier, should be identified. Any potentially hazardous exposures should be described. Periods of service performing deck grinding should be specifically noted. All other occupations prior to and after service with the duration of each also should be listed.

b. Performance of a Detailed Medical History

(1) This should include special attention to respiratory symptoms, diagnosis of respiratory diseases and/or sarcoidosis, and treatment for respiratory conditions during the following 4 time periods:

(a) Before service,

(b) In service prior to the start of any deck grinding or other potentially hazardous exposure,

(c) In service following the start of any deck grinding or other potentially hazardous exposure, and

(d) After service.

(2) Attention also should be given to smoking, current respiratory symptoms (e.g., cough, sputum, hemoptypsis, wheezing, dyspnea on exertion, fever, night sweats, weight gain or loss, anorexia, asthmatic attacks), current treatment including medications, need for supplemental oxygen and indication, periods of incapacitation, pulmonary malignancy, and review of previous chest X-rays, biopsy findings and special studies such as Computerized Tomography (CT) and Magnetic Resonance Imaging (MRI).

c. Performance of a Detailed Physical Examination. Special attention should be given to findings of cor pulmonale, right ventricular hypertrophy, pulmonary hypertension, congestive heart failure, respiratory failure, and pulmonary and/or extrapulmonary sarcoidosis.

d. Performance of Diagnostic and Clinical Tests. Tests could include pulmonary function tests before and after bronchodilation (unless performed within 6 months previously), chest X-ray (unless performed within 1 year previously) (NOTE: Chest X-rays may be sent to be re-read by a certified B-reader, if desired; if a B-reader is not available locally, you may contact the VA Office of Public Health and Environmental Hazards for assistance in identifying one), baseline screening tests (e.g., complete blood count, blood chemistries including calcium) and angiotensin converting enzyme (ACE) levels. Subspecialty consultations and other tests should be obtained if clinically indicated (e.g., referral to a pulmonary specialist, biopsies, CT and MRI studies). NOTE: If there are questions about biopsy findings, review by the Armed Forces Institute of Pathology may be helpful.

3. Veterans should be advised to contact a VA Benefits Counselor or the appropriate VA Regional Office (telephone 1-800-827-1000) if they have questions about or wish to file a compensation claim.

4. This information letter needs to be distributed to all Ambulatory Care physicians.

5. Questions may be directed to the Office of Public Health and Environmental Hazards at 202-273-8575, or if assistance is needed to identify a B-reader. NOTE: Consultations with the VA Program Director for Pulmonary Diseases or occupational health specialists may be arranged if necessary.

6. References

a. "Sarcoidosis Among U.S. Navy Enlisted Men, 1965-1993," Mortality and Morbidity Weekly Report (MMWR), Vol. 46, Number 23, June 13, 1997, pp 539-543.

b. Jajosky, P., "Sarcoidosis Diagnoses Among U.S. Military Personnel: Trends and Ship Assignment Associations," American Journal of Preventive Medicine, Volume 14, Number 3, 1998, pp. 176-183.

S/ by Thomas Garthwaite, M.D. for

Kenneth W. Kizer, M.D., M.P.H.

Under Secretary for Health

DISTRIBUTION: CO: E-mailed 3/5/99

FLD: VISN, MA, DO, OC, OCRO, and 200 – FAX 3/5/99

EX: Boxes 104, 88, 63, 60, 54, 52, 47, and 44 – FAX 3/5/99