More Than Burn Pits: Caring for Military Members and Veterans With Hazardous and Toxic Exposures

BY ELAINE BRUNER, MSN, RN, CMGT-BC, FCM

In 2025, there were approximately 17.6 million veterans in the United States and 1.3 million active-duty service members. Their healthcare needs are different from those of civilians due to toxic fumes from burn pits, environmental hazards, biologics, and endemic country diseases, which are examples of hazardous exposures that impact service members’ and veterans’ well-being. Professional case managers are uniquely positioned to assess these warriors, create a care plan that offers military and Veterans Affairs (VA) resources, and provide support to these individuals and their families. The topic of hazardous and toxic exposures during military service has gained public attention after the PACT Act in August 2022; however, hazardous exposures have been known for decades, particularly during the multiple wars and conflicts, beginning in the 20th century. It’s beyond the scope of this article to offer a comprehensive discussion. What follows is a summary of this topic, with resources and references to stimulate additional exploration and discussion.

Introduction

Service members, veterans, and their families may have been exposed to toxic and hazardous substances while living on military installations and while deployed. Examples of exposures may include:

• Airborne hazards and air pollution, including burn pits
• Asbestos
• Herbicides, insecticides, and defoliants such as Agent Orange
• Chemical and biologic contaminants
• Warfare agents such as gases and nerve agents
• Radiation, microwave, and laser
• Contaminated water
• Infectious diseases such as malaria, rabies, hepatitis, and Dengue fever
• Noise, shock, and vibration
• Extreme hot and/or cold conditions
• Petroleum products
• Dust, sand, and other particulate matter
• Shrapnel and embedded fragments

In the 2021 Annual Warrior Survey, 98% of the warriors reported experiencing hazardous and toxic exposures. 75% reported that they were exposed to burn pits. During the Global War on Terror (GWOT), burn pits were the signature exposure. Everything and anything was thrown into these pits; trash, medical and surgical waste, electronics, and plenty of unidentified items. Burning the pit contents produced toxic fumes, which were inhaled by service members. In June 2014, Congress directed the establishment of the Airborne and Open Burn Pit Registry (AOBPR) by the U.S. Department of Veterans Affairs. Participation is voluntary and highly encouraged. The AOBPR advances research in health-related conditions and informs decisions related to presumptive conditions. There are over twenty diseases related to airborne and burn pit exposures, including respiratory diseases and cancers. These diagnoses are presumed to be service-connected for those who served on or after September 11, 2001, in Iraq and Afghanistan. Disability benefits may be awarded for these presumptive conditions. Before the PACT Act (Honoring Our Promise to Address Comprehensive Toxics Act) in 2022, the burden of proof was on the veteran to prove that their military service caused a medical condition or disease.

Impact of the PACT Act

This legislation was a major advancement for veterans and military members seeking disability benefits and VA health care due to Agent Orange, burn pits, and other airborne toxins. The PACT Act expands eligibility for those who served in the Vietnam War, Gulf War, and post-911/GWOT veterans. Professional case managers can identify eligible individuals by asking, “Have you served?” or, “What concerns do you have about service-related hazardous exposures?” The American Academy of Nursing created the Have You Ever Served campaign to increase awareness and the impact on veteran health. Many veterans may not report hazardous or toxic exposures as part of their health history. They may not realize a connection between an exposure and a current health concern. Injuries and diseases related to these exposures are often invisible and develop over time. Please refer to this article’s reference list for additional information.

Assessment for Exposure-Related Symptoms and Conditions

During my tenure as the case manager with the Navy, I encountered many warriors with chronic cough, sinusitis, and other respiratory ailments. One warrior stated, “I coughed up black boogers the entire deployment.” That comment will get the attention of a case manager! Asking the right questions to assess hazardous toxic exposures can be tricky, as the warrior or veteran may be reluctant to share details. Active-duty members don’t want any health conditions to “take them out of the fight.” Resources such as the Environmental Exposure Hub and the VA Pocket Card for Health Professionals offer guidelines on addressing exposure concerns, documentation, and resources on VA benefits and presumptive conditions.

Below is an excerpt of the VA Pocket Card:

Ask all Veterans: I’d like to learn more about your military experience. Please share:
When and where did you serve and in what branch?
What type of work did you do while in the service?
Would it be okay if we talked about environmental exposures you experienced in the military? To the best of your knowledge, did you encounter any of the following? [refer to the list below] What precautions were taken? (avoidance, personal protective equipment, treatment)
How were you exposed? (inhaled, on skin, swallowed, etc.)
Where were you exposed? When were you exposed? Who else may have been affected? Unit name, etc.

Possible Exposures to Ask About

• Airborne hazards (oil well fires, burn pit smoke, sand and dust storms, etc.)
• Biological hazards (infectious diseases, animal bites, weapons, etc.)
• Chemical hazards (pollution, solvents, fuels, DU, weapons, etc.)
• Prophylactic measures (anthrax vaccine, mefloquine, pyridostigmine bromide pills, etc.)
• Psychological trauma or abuse
• Blast or explosion
• Excessive noise
• Physical injury (heat/cold injuries, shell fragment, etc.)

Included in the PACT Act, veterans enrolled in VA healthcare have access to toxic exposure screening. It’s a brief assessment identifying any exposures, followed by appropriate referrals and resources. The VA offers a fact sheet: Toxic Exposure Screening Information, https://www.va.gov/files/2023-04/ToxicExposureScreeningEnglish.pdf.

Based on my experience, once one or two warriors or veterans share their exposure experience, they alert their colleagues, family members, and battle buddies. Military and veteran case managers must be knowledgeable in this area. Many veterans seek healthcare in the civilian network, so all case managers need to be aware of resources on hazardous and toxic exposures.

Documentation

Exposure documentation may vary between service branches. For example, the Navy form is the OP-NAV 5100. However, as medical records are transitioning to electronic, the best document is the Individual Longitudinal Exposure Record (ILER). The ILER is a joint effort between the VA and the Department of Defense to manage exposure data, enhance VA disability claim processes, increase transparency among stakeholders, and integrate other environmental health registries, including the Agent Orange Registry and the Gulf War Registry. Ideally, the ILER begins at boot camp or entry into military service and is then updated annually or after each deployment. Additional ILER information is available at ILER: https://health.mil/Military-Health-Topics/Environmental-Exposures-Hub/Environmental-Exposures-Topics/ILER.

Documentation may also include a case manager encounter note via an electronic template or freehand. Your organization may be using Z codes to record social drivers of health, and the Z code for military toxic exposure is Z65.5. In addition, military service is a social driver of health with Z code: Z91.85. Military service encompasses the five domains of the social drivers of health in a unique way that civilian life may not include.

CREATING A CARE PLAN AND MOVING FORWARD

An appropriate care plan is based on a thorough assessment. Often, a discussion regarding hazardous and toxic exposures occurs when the service member transitions out of the military. As noted above, an annual exposure review or after each deployment is ideal. A post-deployment assessment, covering multiple areas including hazardous and toxic exposures, is available. However, service members will deny exposures because a positive response may delay leave or interfere with their career. Judicious questioning, alerting them to future healthcare needs, can encourage participation.

Based on symptoms or active disease, appropriate referrals are necessary. Collaborating with a cross-disciplinary team is essential to support the individual and their family.

Incidental diagnostic findings may reveal exposure-related conditions, such as a lumbar spine film revealing a renal tumor or a CT scan for unrelenting headaches showing a brain mass. Case managers must familiarize themselves with the PACT Act presumptive conditions, appropriate screening, and resources. Many of the exposure-related conditions are life-changing diagnoses requiring medical and surgical treatment. As appropriate, coordinate and facilitate eligibility for VA services. The VA Special Issue Hotline (800-749-8387) is available for more information on hazardous and toxic exposures; see the Resources table.

“So What?”—Awareness and Advocacy

Any case manager may encounter a veteran or military member in their practice setting. Identifying those who have served and conducting an exposure assessment has implications for long-term health. Warriors are aware of those with similar symptoms and deployment history, so they want answers and action.

There continues to be evolving research, and as the veteran community increases, there will be a need for well-informed case managers. What actions can you take?

• Assess for military service.
• Educate yourself on hazardous and toxic exposures associated with military service.
• Be familiar with the VA and Department of Defense resources.
• Advocate for exposure screenings.

Neurologic diseases, cancers, and chronic diseases are associated with hazardous and toxic exposures. Your awareness and knowledge impact the journey to optimal health and wellness for our nation’s heroes. We owe these men and women our best case manager knowledge, skills, and talent.

Elaine Bruner, MSN, RN, CMGT-BC, FCM, is an experienced nurse, case manager, and educator. Elaine was awarded the CMSA Award of Service Excellence in 2008. She embraces her educator role, authoring manuscripts, offering national and regional continuing education presentations, and coaching case managers to certification success. She is on the editorial board of CMSAToday. and Co-Chair with the CMSA Military/Veteran/DoD Planning Committee. In 2025, Elaine joined the CMSA Board of Directors and was honored to be inducted as a CMSA Fellow in Case Management.