Deepwater Horizon Disaster Response Long Term Studies & Coast Guard Worker Roster Dr. Erica G. Schwartz, MD, MPH

Disclosure Statement I have no financial interests or other relationship with manufacturers of commercial products, suppliers of commercial services, or commercial supporters. Our presentation will not include any discussion of the unlabeled use of a product or a product under investigational use.

Outline Coast Guard responder population Responder missions Responder medical readiness C.G. occupational surveillance Medical surveillance of C.G. responders Long term follow-up studies of responders Coast Guard Responder Cohort NIH GuLF Study

Coast Guard Response 34 response locations ~7,500 Coast Guard responders ~ 40 Coast Guard medical, safety and work-life specialists

Coast Guard Response Administrative Air – Overflight Beach / Marsh Cleaning Booming Operations Controlled Burn Group Distribution Center Federal On-Scene Coordinator Law Enforcement Medical & Dental Pollution Investigator Rescue Swimmer Safety Shoreline Cleanup Assessment Search & Rescue Skimming Ops SMART Group Spill Clean Up & Decontamination Staging Subsea Containment Group Work-Life Wildlife Rehabilitation

Medical Readiness All CG military members are required to have an annual Periodic Health Assessment (PHA) Face to face visit with a medical provider to assess member’s health status and medical readiness

Occupational Surveillance Occupational Medical Surveillance & Evaluation Program (OMSEP): Identification of work related diseases or conditions Use of baseline and periodic examinations Use of quantitative work-site sampling

Occupational Surveillance Resident inspectors Pollution investigators Marine safety (general) Port safety (general) Vessel inspectors Marine investigators Firefighters

Occupational Surveillance Pesticides Respiratory sensitizers Solvents Tuberculosis Bloodborne Pathogens Radiation Asbestos Benzene Chromium Hazardous Waste Lead Noise Coast Guard Medical Surveillance Action Level: The medical surveillance action level (MSAL) is the level of worker exposure, determined by workplace sampling, at or above which occupational medical surveillance examinations will be performed. The Coast Guard MSAL will be 50% of the most stringent of the current OSHA permissible exposure limit (PEL), or the most current American Conference of Governmental Industrial Hygienists (ACGIH) Threshold Limit Value (TLV). *Enrollment based upon the Medical Surveillance Action Level

Medical Surveillance Coast Guard direct care + purchased care captured by CHCS, which feeds: M2 database ICD-9 codes Query of diagnoses via ICD-9 codes Electronic Health Records (EHRs)

Deepwater Horizon Inventory All CG responders required to complete survey (“Inventory Tool”) upon demobilization Demographics, period of deployment Site, mission, self reported exposures, self reported injuries & symptoms, PPE use Mobilization Readiness Tracking Tool (MRTT) Provides denominator (approximate) Some groups not covered (cutters, aviators, local shore units) Enumerating total responder population by merging MRTT with other databases

Enumeration of Responder Cohort Mobilization Readiness Tracking Tool (MRTT) Provides denominator (approximate) Some groups not covered (cutters, aviators, local shore units) Enumerating total responder population by merging MRTT with other databases National Pollution Funds Center (NPFC)

Follow-up of DWH responders Follow-up by Coast Guard physicians for all “positive” responses in Inventory Tool Epidemiology analysis of Inventory (existing survey) data Surveillance based on inpatient/outpatient encounters (ICD-9 coding) pre- and post-DWH rates for responder cohort Comparison of responders to other CG members Linkage with Electronic Health Record For pre- and post-DWH health effects

Follow-up Study of Coast Guard DWH Responder Cohort Rationale Crude oil, burning oil, dispersants contain known and suspected toxins Heat and stress may also have adverse long-term health effects Clean-up workers’ exposures range from negligible to potentially significant Little is known about health effects from oil spills on response workers, despite the frequency of these events worldwide However, prediction of adverse health effects is not possible because the long-term human health consequences of oil spills are largely unknown

Follow-up Study of Coast Guard DWH Responder Cohort Human studies of oil spill exposures Very few, mainly in the wake of: Exxon Valdez (1989), Braer (1993), Sea Empress (1996), Nakhodka (1997), Erika (1999), Prestige (2002), & Tasman Spirit (2003) Crude methods of exposure assessment (exposed vs. non-exposed) Predominantly cross-sectional Provide some evidence of relationship between exposure to spilled oils and a range of acute adverse health effects, such as: Respiratory, acute physical symptoms, neurologic, psychological, genotoxic, and endocrine effects in the exposed population Long term effects? Exposure to Corexit 9500 and 9527A?

Follow-up Study of Coast Guard DWH Responder Cohort Overall objective: Identify potential short- and long-term health effects from oil spill response work exposures In a cohort of Coast Guard DWH responders NIH RO-1 application Collaborative effort: Uniformed Services University U.S. Coast Guard Study Design: Prospective Cohort

Questions ?

Back-up Slides

Follow-up Study of Coast Guard DWH Responder Cohort Specific Objectives Identify health outcomes associated with the CG responders’ DWH response activities, including: Respiratory, cardio-vascular, heat stress-related, hematologic, dermatologic, neurologic, immunologic, hepatic, renal, & mental health conditions Identify health conditions newly diagnosed or that changed in severity since the oil spill by making pre- and post-spill comparisons Further elucidate high interest associations identified in specific aims 1 & 2 by: Focusing on an OMSEP subset Accounting for genetic polymorphisms in genes related to the metabolism of benzene in a subset of highest exposed and group of controls CYP2E1, GSTM1, GSTT1, EPHX, MPO, NQO1

Follow-up Study of Coast Guard DWH Responder Cohort Key sources of data: Exit survey (inventory) completed by responders Self reported oil spill-related exposures & acute health effects Personal monitoring data for subset of responders Objective clinical data: EHRs, ICD-9 codes Will enable validation of self reported health data, account for pre-existing health conditions, and allow for pre- and post-spill comparisons Department of Defense Serum Repository

Follow-up Study of Coast Guard DWH Responder Cohort Exposure Assessment Exit survey (inventory): Exposed missions vs. non-exposed missions Comparisons of: groups of missions individual missions individual exposures geographic location of response PPE use Duration of response Quantitative monitoring data + exit survey

Strengths & Limitations Ability to compare objective health data, post-spill to pre-spill Large population with exposure data already collected Similar access to medical care Limitations Potential for few people with very high exposures Buoy Tender cutters (booming and skimming operations) Decontamination operations Can only follow-up responders (under these mechanisms) while they remain in C.G. Population may incur other responder exposures from other disaster responses