Environmental Health Perspectives • volume 117 | number 6 | June 2009
Responding to veterans’ concerns and as part
of an ongoing medical surveillance program
for U.S. military veterans exposed to depleted
uranium (DU), biological monitoring of urine
uranium (U) concentrations has been carried
out by the Department of Veterans Affairs
(VA) since the early 1990s. Since the first
Gulf War in 1991, DU has been used both in
armor-piercing projectiles and as armor itself,
because of its high density, availability, and
relative low cost [Army Environmental Policy
Institute (AEPI) 1995].
A by-product of the U enrichment process,
DU is the material remaining after the more
radioactive U234 and U235 isotopes are removed
from natural uranium (Unat) (AEPI 1995). DU
thus possesses only about 60% of the radioac-
tivity of Unat but retains the elemental, chemi-
cal characteristics of this heavy metal.
Although DU was first deployed in the
Gulf War in 1991 and was also used in the
Bosnian conflicts, it has played less of a role
in the present military campaigns in Iraq and
Afghanistan. Despite this, health concerns
persist about potential exposure risks, so sur-
veillance efforts have been expanded to offer
biomonitoring to any veteran requesting a
test for DU exposure.
Veterans access the biomonitoring pro-
gram through any VA clinic or hospital.
The U.S. Navy and Air Force also use the
VA’s DU biomonitoring program for their
active-duty service members. The assessment
includes a self-completed questionnaire and
submission of a 24-hr urine sample, which
is analyzed for total U concentration and for
the presence of DU. With accompanying
interpretation, results are returned to the vet-
eran and his or her health care provider. The
questionnaire addresses specific DU exposure
scenarios of concern to veterans. Examples
of potential exposure opportunities include
inhalation of smoke containing DU particles
(e.g., during a fire involving DU weapons at
Doha depot, Qatar), entering or salvaging
vehicles or bunkers hit by DU projectiles, and
reporting close contact with DU munitions
in tanks and other vehicles.
Results of surveillance completed between
August 1998 and December 1999 and
between January 2000 and December 2002
have been previously reported (McDiarmid
et al. 2001a, 2004a). Both studies concluded
that a veteran without a history of traumatic
injury involving DU munitions would be
unlikely to have an elevated urine U value.
In the 5 years since the last report of these
surveillance results, 1,769 additional urine
samples have been measured. In addition, we
can now accurately perform determinations of
U isotopic signatures at very low total U con-
centrations, enabling accurate identification
of DU as opposed to Unat. This capability has
significantly enhanced our ability to assess
DU exposure. We report here an update of
Materials and Methods
Program enrollment. From January 2003
through June 2008, 1,769 veterans and active-
duty service members from the U.S. Navy
and Air Force who served in the 1991 Gulf
War and/or who have served since the end of
the Gulf War (referred to as post-Gulf War
veterans) provided 24-hr urine samples for
U testing. The latter group includes veterans
of the military conflicts in Iraq, Afghanistan,
and the Balkans. The veterans’ local VA or the
service members’ medical treatment facility
contacted the DU program at the Baltimore
VA Medical Center (BVAMC) to request
a test kit and coordinated collection of the
urine sample. As previously reported, the kit
contained a demographic and exposure ques-
tionnaire, instructions for the collection and
handling of the 24-hr urine specimen, and
urine collection containers (McDiarmid et al.
2001a, 2004a). The collected specimen was
returned to the BVAMC for processing. This
protocol has been reviewed and approved
by the University of Maryland School of
Medicine Institutional Review Board and
the Research and Development Office at the
BVAMC. Personnel at the local VA hospital,
clinic, or medical treatment facility obtained
consent for medical evaluation. Informed
consent requirements for the purposes of
population surveillance were waived after
review by the University of Maryland School
of Medicine Institutional Review Board.
Urine U analytic methods. Measurements
of total volume and creatinine in the 24-hr
urine samples were made at the BVAMC
clinical labs. Before July 2003, U concen-
trations for Gulf War veterans were mea-
sured by STL Richland (formerly Quanterra,
Inc., and International Technology Analytic
Services; Richland, WA) using kinetic phos-
phorescence analysis (KPA). When urine U
concentrations were > 0.05 µg U/g creati-
nine, patients were asked to submit a second
Address correspondence to K. S. Squibb, 405 W.
Redwood St., 2nd Floor, Baltimore, MD 21201
USA. Telephone: (410) 706-7464. Fax: (410) 706-
4078. E-mail: email@example.com
We thank the Depleted Uranium Follow-up
Program administrative staff and the Baltimore
Veterans Administration Clinical Labs for their
This program is funded through the U.S.
Department of Veterans Affairs.
The authors declare they have no competing
Received 20 November 2008; accepted 25 February
Biological Monitoring for Depleted Uranium Exposure in U.S. Veterans
Carrie D. Dorsey,1,2 Susan M. Engelhardt,2 Katherine S. Squibb,2,3 and Melissa A. McDiarmid1,2
1Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA; 2Veterans Affairs Medical Center,
Baltimore, Maryland, USA; 3Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine,
Baltimore, Maryland, USA
Background: As part of an ongoing medical surveillance program for U.S. veterans exposed to
depleted uranium (DU), biological monitoring of urine uranium (U) concentrations is offered to
any veteran of the Gulf War and those serving in more recent conflicts (post-Gulf War veterans).
oBjectives: Since a previous report of surveillance findings in 2004, an improved methodology
for determination of the isotopic ratio of U in urine (235U:238U) has been developed and allows for
more definitive evaluation of DU exposure. This report updates previous findings.
Methods: Veterans provide a 24-hr urine specimen and complete a DU exposure questionnaire.
Specimens are sent to the Baltimore Veterans Affairs Medical Center for processing. Uranium
concentration and isotopic ratio are measured using ICP-MS at the Armed Forces Institute of
results: Between January 2003 and June 2008, we received 1,769 urine specimens for U analysis.
The mean urine U measure was 0.009 µg U/g creatinine. Mean urine U concentrations for Gulf
War and post-Gulf War veterans were 0.008 and 0.009 µg U/g creatinine, respectively. Only 3 of
the 1,700 (0.01%) specimens for which we completed isotopic determination showed evidence of
DU. Exposure histories confirmed that these three individuals had been involved in “friendly fire”
incidents involving DU munitions or armored vehicles.
conclusions: No urine U measure with a “depleted” isotopic signature has been detected in U.S.
veterans without a history of retained DU embedded fragments from previous injury. These find-
ings suggest that future DU-related health harm is unlikely in veterans without DU fragments.
key words: bioassay, biomonitoring, depleted uranium, exposure, isotopic analysis. Environ
Health Perspect 117:953–956 (2009). doi:10.1289/ehp.0800413 available via http://dx.doi.org/
[Online 25 February 2009]
Dorsey et al.
volume 117 | number 6 | June 2009 • Environmental Health Perspectives
sample for confirmation of the U concentra-
tion. Additionally, the presence of DU versus
Unat in the samples was determined by isoto-
pic analysis at the Armed Forces Institute of
Pathology (AFIP) in Washington, DC, using
inductively coupled plasma mass spectrometry
(ICP-MS) as described by Ejnik et al. (2005).
Since July 2003, all urine samples, including
those from Gulf War veterans, have under-
gone U quantification and isotopic analysis
Urine U distribution. We dichotomized
urine U values into high U (≥ 0.05 µg U/g
creatinine) and low U (< 0.05 µg U/g creati-
nine) for statistical analysis. The 0.05 µg U/g
creatinine cut-point has been used in prior
publications related to this surveillance popu-
lation (McDiarmid et al. 2001a, 2004a). We
chose the value of 0.05 µg U/g creatinine
because it was the approximate upper limit of
the urine U distribution for nonoccupation-
ally exposed, geographically divergent popula-
tions available when this project began in the
mid-1990s (Dang et al. 1992; Medley et al.
1994). Although levels for the general popula-
tion are now available through the National
Health and Nutrition Examination Survey
(NHANES) database [Centers for Disease
Control and Prevention (CDC) 2005], the
cut-point of 0.05 µg U/g creatinine has been
retained to allow comparison with prior stud-
ies. Also, the cut-point is near the NHANES
95th percentile level (0.043 µg/g creatinine)
for the general U.S. population ≥ 20 years of
age (CDC 2005).
DU exposure history assessment. As
described previously (McDiarmid et al. 2001a),
a team of VA and Department of Defense
occupational health experts, health physicists,
and field experts crafted a DU exposure ques-
tionnaire for use by military personnel. In the
past, relationships between urine U concen-
tration and exposure history were evaluated
for the entire surveillance population. These
analyses revealed that the presence of a retained
DU fragment from a traumatic injury was the
only predictor of an elevated urine U concen-
tration. For this study, we analyzed exposure
from questionnaire responses for only the sub-
set of samples with a urine U concentration
≥ 0.05 µg U/g creatinine or isotopic analysis
consistent with DU (n = 30).
Between January 2003 and June 2008, we
received 1,769 urine specimens for U analy-
sis: 404 specimens from veterans of the Gulf
War and 1,365 from post-Gulf War veterans.
Figure 1 provides a summary of the urine
U biomonitoring activity and the isotopic
Urine U measures. Table 1 summarizes the
mean and median urine U measures. The mean
urine U concentration for the entire population
of 1,769 individuals was 0.009 µg U/g creati-
nine. Mean urine U concentrations for Gulf
War and post-Gulf War veterans were 0.008
and 0.009 µg U/g creatinine, respectively, and
did not differ statistically (p = 0.869). The
median urine U measures were 0.004 (total
group), 0.005 (Gulf War), and 0.004 (post-Gulf
War) µg U/g creatinine.
Isotopic analysis was performed on 1,700
of the 1,769 (96%) specimens. The pres-
ence or absence of DU is determined by the
235U:238U ratio. A ratio between 0.0020 and
0.0030 defines a sample that is primarily DU.
A ratio between 0.006 and 0.009 defines Unat.
A ratio between these two ranges describes a
sample that is a mixture of DU and Unat. Only
3 of the 1,700 (0.01%) specimens had an iso-
topic signature consistent with DU (ratios =
0.0029, 0.0029, and 0.0030). Mean urine U
levels are higher in the individuals with DU
compared with those with no DU detected
in the urine (0.036 vs. 0.008 µg U/g creati-
nine). These individuals had been involved
in friendly fire incidents and had retained
DU fragments. As previous work has demon-
strated, veterans with retained DU fragments
continue to have elevated urine U levels com-
pared with those without embedded fragments
(McDiarmid et al. 2000, 2001b, 2004b, 2006,
2007, 2009). The remaining 1,697 specimens
contained Unat at levels that would be expected
in the general U.S. population.
Figure 2 shows the distribution of urine
U values ranked from low to high urine U (µg
U/g creatinine) for both the Gulf War and
post-Gulf War veterans. The urine U values
ranged from < 0.001 to 0.105 µg U/g crea-
tinine for the Gulf War specimens and from
< 0.001 to 1.686 µg U/g creatinine for post-
Gulf War specimens. The three specimens
isotopically identified as having DU are indi-
cated in Figure 2. Stratifying results into low
(< 0.05 µg U/g creatinine) and high (≥ 0.05
µg U/g creatinine) urine U groups resulted
in only 2.2% of Gulf War samples and 1.5%
of specimens from post-Gulf War veterans
being in the “high” range. Horizontal lines are
shown for comparing the urine U concentra-
tions obtained from the mail-in biomonitor-
ing program with urine U concentrations that
occur from environmental and occupational
Ninety-seven percent (97%) of Gulf War
and 98% of post-Gulf War veterans had urine
U values below the 95th percentile value of
0.043 µg U/g creatinine for the general U.S.
population ≥ 20 years of age (CDC 2005). In
addition, as shown in Figure 2, most sample
concentrations fell below the mean urine U
values found in two populations exposed to
high Unat concentrations in drinking water
supplies: 0.65 µg U/g creatinine (Kurttio et al.
2002) and 0.397 µg U/g creatinine (Orloff
et al. 2004). Nearly all urine U measurements
were at least an order of magnitude below
occupational exposures reported for U fabri-
cation workers in 1980 (Thun et al. 1985).
Exposure scenarios predictive of DU pres-
ence in urine. Thirty urine samples had a
U concentration ≥ 0.05 µg U/g creatinine
Figure 1. Summary of urine U surveillance activities from January 2003 through June 2008. The number of
samples analyzed is stratified into Gulf War and post-Gulf War veterans. The results of isotopic analyses,
which define the presence of DU are presented. “Unknown” indicates samples obtained before July 2003,
when routine isotopic analysis on samples was initiated. The three samples with an isotopic signature
consistent with DU were from individuals identified to have been injured as a result of friendly fire.
Samples analyzed between
January 2003 and June 2008
n = 1,769
Gulf War I
n = 404
Post Gulf War
n = 1,365
n = 0
n = 335
n = 69
n = 3
n = 1,362
Table 1. Mean and median urine U values (µg U/g creatinine) in U.S. veterans.
McDiarmid et al. (2001a)
McDiarmid et al. (2004)
Samples from Gulf War veterans since January 2003
Samples from post-Gulf War veteransb since January 2003
All samples since January 2003
Mean ± SE
0.020 ± 0.003
0.023 ± 0.006
0.008 ± 0.001
0.009 ± 0.001
0.009 ± 0.001
aIncludes 169 samples from McDiarmid et al. (2001a). bVeterans who have served since the first Gulf War, including those
serving in Iraq, Afghanistan, and the Balkans.
Depleted uranium exposure monitoring in U.S. veterans
Environmental Health Perspectives • volume 117 | number 6 | June 2009
and/or were isotopically consistent with DU.
Review of the questionnaires submitted by
these veterans revealed that only the pres-
ence of a retained fragment and involvement
in an incident known to involve DU muni-
tions or DU armored vehicles predicted the
presence of DU in the urine. This observa-
tion is consistent with previous findings from
mailed-in specimens sent before January 2003
(McDiarmid et al. 2001a, 2004a).
The overwhelming majority (97%) of the
1,769 urine specimens submitted by Gulf
War and post-Gulf War veterans had urine
U levels in the range of those found in the
general U.S. population, that is, ≤ 95th per-
centile of NHANES results collected between
2001 and 2002 (CDC 2005). More impor-
tantly, only 3 of the 1,700 urine specimens
that underwent isotopic analysis had a DU
isotopic signature. These three came from
individuals reporting embedded fragments
from DU friendly fire–related injury.
Only a small percentage of samples (2.2%
Gulf War and 1.5% post-Gulf War) had urine
U concentrations above the DU surveillance
program’s cut-point of 0.05 µg U/g creati-
nine. The vast majority of these samples were
Unat. The source of exposure for these individ-
uals was most likely drinking water. The con-
centration of U in drinking water varies across
the United States and the world, depending
on the composition of the local bedrock. For
example, unusually high concentrations of
Unat in drinking water have been found in
areas of Finland (Kurttio et al. 2002), Canada
(Zamora et al. 1998), and the United States
(Orloff et al. 2004). Another potential source
of Unat exposure may be related to residence
near a uranium mine or mill.
The findings of this study are generally
consistent with those reported previously for
surveillance of Gulf War personnel performed
between August 1998 and December 1999
(McDiarmid 2001a) and from January 2000
through December 2002 (McDiarmid 2004a)
(see Table 1). We found no statistical differ-
ence in the means of the urine U between
the 169 samples received from 1998 through
1999 and the 277 samples received between
2000 and 2002 (the earlier reports of mail-in
surveillance results cited above). However,
when we compared mean urine U measures
for these two cohorts (0.020 and 0.023 µg
U/g creatinine) with the mean of the 1,769
samples reported here (0.009 µg U/g creati-
nine), we observed a statistically significant
difference (p = 0.001). This difference can
be explained by the change in the methodol-
ogy used to measure the urine U concentra-
tion value. As noted above, starting in July
2003 samples were analyzed by ICP-MS. This
methodology is more sensitive at lower urine
U concentrations than is the KPA method
formerly used to measure urine U concen-
trations. For samples collected and analyzed
before 2003, we used the detection limit value
for the KPA method in the calculation of the
creatinine-standardized urine U concentra-
tions for samples with U concentrations at or
below the detection limit. This small overes-
timate of urine U concentrations is likely the
basis for the higher group averages calculated
for the earlier two cohorts.
As mentioned above, isotopic analysis of
the samples examined for this study detected
only three individuals who are excreting DU in
their urine. Levels of urine U are higher in this
group of three compared with the isotopically
Unat group (0.037 vs. 0.009 µg U/g creatinine).
When we consider the entire surveillance popu-
lation, dating back to 1998 (n = 2,246), only
a total of four individuals have been identi-
fied as excreting DU in their urine. Exposure
history confirms that these four individuals
were injured as a result of friendly fire and have
retained embedded fragments.
The results reported here are also consis-
tent with those of another Department of
Veterans Affairs–sponsored DU surveillance
program, which has been following for 15
years a dynamic cohort of 77 Gulf War veter-
ans with known exposure to DU from docu-
mented friendly fire incidents during the 1991
Gulf War. Among this group, only those
with retained DU fragments from traumatic
injury continue to excrete higher concentra-
tions of U in their urine (McDiarmid et al.
2000, 2001b, 2004b, 2006, 2007, 2009).
Urine U levels in those without retained
DU fragments, but who sustained a histori-
cally documented inhalation exposure dur-
ing the friendly fire incidents, are similar to
general population levels and are isotopically
consistent with Unat.
The persistent elevation of urine U
observed in those with retained fragments is
supported by animal studies in which DU
pellets implanted into the animals (Hahn
et al. 2002; Pellmar et al. 1999) oxidized
in situ, thus serving as a metal depot for
ongoing systemic exposure. As the metal ions
are released to the circulation, they are fil-
tered by the kidney and excreted in urine,
resulting in higher U concentrations.
The data reported here on this expanded
surveillance cohort of both Gulf War and
more recently deployed soldiers and veterans
confirm previous findings that, in the absence
of retained DU fragments, it is highly unlikely
that an individual will have chronically ele-
vated urine U.
Historically, concern has been raised about
the long lag time between exposure during
deployment and subsequent biomonitoring
Figure 2. Distribution of urine U results from mail-in specimens from January 2003 through June 2008 plot-
ted as two separate groups: Gulf War (GWI) versus post-Gulf War (PGW) veterans. Samples are ranked
from low to high urine U concentration. The different symbols within each group denote whether DU was
identified in each of the urine samples. Only three specimens were isotopically consistent with DU in the
PGW group. Reference lines are provided on this graph for comparison purposes: Mean total urine U found
in a subcohort of U fabrication workers in 1980 (Thun et al. 1985); Means from two populations with known
high levels of environmental exposure to Unat (Kurttio et al. 2002; Orloff et al. 2004); Cut-point established by
the Depleted Uranium Follow-up Program to identify high versus low urine U concentrations (McDiarmid
et al. 2001a); 95th percentile for urine U from the NHANES 2000–2001 population study for adults ≥ 20 years
of age (CDC 2005); mean from the current cohort of 1,769 reported in the present study.
0 200400 600 8001,000 1,200
U (µg/g creatinine)
Samples ranks (µg U/g creatinine)
9.1 µg U/L (Thun et al. 1985)
0.65 µg U/g creatinine (Kurttio et al. 2002)
0.397 µg U/g creatinine (Orloff et al. 2004)
DU cut point, 0.05 µg U/g creatinine
NHANES 2000–2001 95th percentile, 0.043 µg U/g creatinine
Mean urine U, 0.009 µg U/g creatinine
GWI, No DU (n = 335)
GWI, DU unknown (n = 69)
PGW, No DU (n = 1,362)
PGW, DU (n = 3)
Dorsey et al.
volume 117 | number 6 | June 2009 • Environmental Health Perspectives
performed years later. A transient U elevation
from a one-time inhalation exposure could
be missed if sampling occurred too long after
U exposure, whereas measurements taken at
the time of a potential exposure incident may
indicate that an exposure to DU has occurred.
Estimates reported by the Royal Society of
London (2002) suggest that a DU oxide inha-
lation dose sufficiently high to cause signifi-
cant health effects would still be detectable
10 years after exposure, using analytical tech-
niques currently available.
The rate of elimination of an inhaled dose
of DU depends on many parameters, includ-
ing the chemical and physical form of the
DU oxide particles inhaled and the exposure
dose. Data collected as part of a U.S. Army
DU aerosol characterization and risk assess-
ment study, which characterized DU aerosols
created by the perforation of an Abrams tank
and a Bradley Fighting Vehicle with a large-
caliber DU penetrator, indicate that soldiers
in friendly fire incidents inhaled DU that
was a mixture of soluble and insoluble DU
oxides (Parkhurst et al. 2005). Soluble oxides
would have been rapidly absorbed through
the lungs and cleared by the kidney. Insoluble
oxides would have been phagocytized by lung
macrophages and cleared from alveolar areas
either through the mucocilliary system to
the mouth or by transport to lung-associated
We also address the concern regarding the
lag time between exposure and biomonitor-
ing by including veterans from recent mili-
tary conflicts in our surveillance program. We
achieved a shortened time interval between
potential initial exposure and assessment of
urine U with this group, because we obtained
many of these specimens within several weeks
of the veterans’ return from deployment.
Closing this gap between potential exposure
opportunity and sample collection and the
fact that we are still observing normal urine U
results gives some reassurance that large num-
bers of soldiers from previous conflicts likely
did not incur urine U elevations that were
missed because of the delay in sampling.
Even if participants in the Gulf War
conflicts had transient exposure to DU, it
is highly unlikely that this would result in
significant, subsequent health effects for sev-
eral reasons. The clearance of U from the
body is relatively rapid (nearly two-thirds of
an acute dose is cleared through the kidney
in 24 hr; Agency for Toxic Substances and
Disease Registry 1999). Acute effects of U on
the kidney (the primary target organ for solu-
ble U compounds) do not persist after short
exposures, and only under chronic exposure
conditions does accumulation of U in the
kidney cause long-term effects (Royal Society
of London 2002). In addition, the absence of
expected effects is supported by findings from
the DU Surveillance Program for friendly fire
victims. In 15 years of follow-up, no clinically
significant U-related health effects have been
observed in the cohort, including those with
retained DU fragments (McDiarmid et al.
2000, 2001b, 2004b, 2006, 2007, 2009),
except for subtle changes in renal proximal
tubule markers in veterans with retained frag-
ments (McDiarmid et al. 2009).
To summarize, the U biomonitoring
results obtained over three reporting peri-
ods—the present study and two previous
reports (McDiarmid et al. 2001a; 2004a)—
have shown that > 95% of the 2,246 total
urine specimens collected since 1998 had
urine U concentrations similar to those found
in the general U.S. population (CDC 2005),
and all but one sample, which has a Unat iso-
topic signature, had U concentrations < the
occupational decision level (0.8 µg/L) used
by the Fernald Environmental Management
Project for U-exposed workers (Fernauld
Environmental Management Project 1997).
In addition, review of exposure histories con-
firms previous findings that the presence of a
retained DU fragment and history of friendly
fire exposure are the best predictors of an ele-
vated urine U concentration.
This indicates that for most veterans who
are concerned about exposure to DU as a result
of their deployment, urine U concentrations
outside the normal range are a rare occurrence
and DU isotopic signatures are even more
uncommon. No persistent urine U elevations
have been detected in potentially exposed
veterans without a history of DU-embedded
fragments. This further suggests that future
DU-related health harm is unlikely.
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