environmental exposure surveillance in a combat theatre
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Environmental Exposure Surveillance in a Combat Theatre. Coleen Baird , MD, MPH US Army Center for Health Promotion and Preventive Medicine I have no disclosures to make. Range of Exposures in Deployed Settings. Occupational/Personal Sampling- Individual Exposures

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environmental exposure surveillance in a combat theatre

Environmental Exposure Surveillance in a Combat Theatre

Coleen Baird , MD, MPH

US Army Center for Health Promotion and Preventive Medicine

I have no disclosures to make

range of exposures in deployed settings
Range of Exposures in Deployed Settings
  • Occupational/Personal Sampling- Individual Exposures
    • Actionable for surveillance or other
    • Archive for general information, document “negative exposure”
  • Ambient Sampling: Exposure Not Clearly Linked to an Individual
    • Epidemiological formation of cohort
    • Population level risks
  • Potential Exposures- based on defined “reasonable probability”
    • May be actionable
    • May lack sampling information
air exposure concentration continuum
Air Exposure Concentration ‘Continuum’

multiple low-level

exposures, continuous,

long-term

Terrorist attack;

accidental release

industrial operations;

accidental releases

Single

exposure

Lifetime

exposure

past practices;

uncontrolled emissions

mg/m3

ug/m3

EPA:

IDLH

TLVs

ambient air standards

severe

significant

minimal

refined exposure assessments
Refined Exposure Assessments
  • Exposures identifiable to an individual or Similarly Exposed Groups (SEGs)
    • Exposed by nature of location or occupation such as asbestos, lead, burning trash
    • Requires an exposure assessment and identification of group/SEG constituents
    • Relatively easy to put into medical records
    • May require individual surveillance
ambient or routine exposures
Ambient or Routine Exposures
  • Greater likelihood of being “low”
  • Lower likelihood of health effects
  • Cohorts more readily “defined” thru available data sources
  • Exposures to those in defined cohort more variable
ambient environmental monitoring
Ambient Environmental Monitoring
  • Air: PM/metals/volatile organics in the ambient environment of the sampler
    • PM levels high, but variable
    • Most other findings rare
  • Large population at risk/Base camp level
  • Exposures not uniform
    • Movement
    • Distance from sampler
    • Indoors
    • Convoys/Trash
ambient environmental monitoring1
Ambient Environmental Monitoring

Challenges linking location data (population at risk) to health data

Outcomes may be diluted due to misclassification of exposure, non-specific outcomes

Data not readily interpretable by most providers

incident or unplanned events
Incident or Unplanned Events
  • Greater likelihood of being “high”
  • Greater likelihood of health effects
  • Lower likelihood of actual measurement
  • Typically involve fixed but hard to define cohort
principles of medical surveillance under the nrp
Principles of Medical Surveillance Under the NRP
  • Maintain the physical and mental health of responders/Identify new clinical entities/Assess adequacy of PPE
  • Participation should be confidential and voluntary
  • There should be a centralized mechanism to capture data related to individual and collective exposures
principles of medical surveillance under the nrp1
Principles of Medical Surveillance Under the NRP
  • Creation of a registry of workers at the site
  • Exposure assessment strategies should be developed and implemented to protect workers and guide interventions
  • Each individual should receive detailed and interpreted biomedical and exposure data
  • Risk communication needs to be an integral part
2003 sulfur fire
2003 Sulfur Fire
  • Multiple samples taken over weeks at various locations*
  • Health care provided on site by a special team*
  • Documented in medical record*
  • Exit physical standardized for firefighters
  • Roster of firefighters obtained and archived*
  • Health outcome analysis*
long term follow up
Long Term Follow-up
  • Defined cohort
    • Small numbers
  • Poorly defined cohort
    • Exposures variable
    • Weak exposure/ weak inclusion
      • Misclassification bias
      • Rare outcomes/unusual coding
lessons learned
Lessons Learned
  • Traditional IH surveillance possible in deployed setting if equipment/skill sets available
  • Ambient sampling has proven difficult to integrate into routine medical care
  • “Incident driven” events pose a challenge for data collection, and potentially for long-term follow-up
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