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

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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


Environmental exposure surveillance in a combat theatre

Enhanced exposure analyses

UNCLASSIFIED


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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