Using a public health registry to conduct medical surveillance: the case of toxic embedded fragments in U.S. military veterans

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Joanna M. Gaintes
Carrie D. Dorsey
Melissa A. McDiarmind


embedded fragment, medical surveillance, registry, injury, biological monitoring


Aim: Beyond inflicting acute traumatic injury, contact with improvised explosive devices, the leading cause of injury for soldiers serving in Iraq and Afghanistan, may result in wound contamination with embedded fragments permitting chronic exposure to toxic materials. Because health effects associated with embedded fragments are not well-delineated, the U.S. Department of Veterans Affairs (VA) is establishing an exposure registry and surveillance center to identify, track and monitor the health of veterans who have embedded fragments. Methods: U.S. Veterans wounded with embedded fragments are identified when making contact for healthcare using a screening process incorporated into the Veterans Administration’s national electronic medical record system. A data review results in recommended follow-up which may include fragment analysis, urine biological monitoring, and/or clinical consultation. The registry will link to the individual’s electronic medical record and other data sources to capture injury and exposure data, urine biological monitoring data, health outcomes, and fragment content results, when available. Results: Preliminary data suggest that approximately 3% of veterans have embedded fragments and are eligible for inclusion in the registry. Most fragments are metallic; therefore, a suite of 13 metals frequently found in fragments will be included in the biological monitoring protocol. Conclusions: Using a public health exposure registry, the surveillance center team will employ population level surveillance to better characterize exposure and identify potential health outcomes associated with retained fragments. The registry also provides an avenue for ongoing contact with exposed veterans as knowledge evolves affecting medical and surgical management guidelines for veterans with embedded fragments.


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