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1
Introduction
BACKGROUND
Deploying military personnel in hostile or unfamiliar environments is
inherently risky. Unlike garrison environments, which are reasonably well-
protected, well-known, and well-controlled, deployment environments are
imposed by the military mission. Deployment can present a novel array of
military and nonmilitary threats, and mission objectives often dictate that
those threats be addressed. Many deployment activities are not routine.
Tasks must be accomplished with limited means, despite the potential dan-
gers of the setting. In the deployment environment, time, materiel, and
attention are at a premium, and excessive precautions can engender their
own risks or jeopardize the military mission.
In the past, health-based risk-assessment and risk-management strate-
gies for deployment situations focused primarily on warfare-related mission
impacts. However, recent wars and conflicts, such as operations Desert
Shield and Desert Storm, have highlighted the need for the U.S. military to
protect its forces from health threats that do not directly impact the mission,
are indirectly related to battle, or could appear after the deployment has
ended. Thus, the U.S. Department of Defense (DOD) has developed a force
health protection plan that is a “unified and comprehensive strategy that
aggressively promotes a healthy and fit force and provides full protection
from all potential health hazards throughout the deployment process. Its
major ingredients include healthy and fit force promotion, casualty and
injury prevention, and casualty care and management” (U.S. Department of
16
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INTRODUCTION 17
the Army 2001). “Deployment” is defined as a troop movement to a land-
based location outside the continental United States that does not have a
permanent medical treatment facility (i.e., funded by the Defense Health
Program). Deployment is the result of a Joint Chiefs of Staff/Unified Com-
mand deployment order and lasts for 30 or more consecutive days (U.S.
Department of the Army 2001).
The role of U.S. military forces has changed and expanded. Increas-
ingly, U.S. troops are deployed for operations other than war, including
peacekeeping, humanitarian, and nation-building missions of varying scope
and duration. (See Figure 1-1 for an illustration of potential conflicts and
likelihood of occurrence.) Deployments differ in the degree and nature of
tactical risks (i.e., risk due to the presence of an enemy or adversary). How-
ever, with or without tactical threats, there are risks of accident, disease, and
illness inherent in deployment. Those might arise from contaminated local
environments, from the intensive activities of the deployed forces, from
exposure to hazards associated with mission tasks, from intentional expo-
sures to pesticides and prophylactic agents, and from the rigors of exposure
to climatic extremes.
In deployment situations, commanders must balance the effects of
multiple risks. Effects can include casualties, impacts on civilians, damage
to the environment, loss of equipment, and levels of public reaction against
the value of the mission objectives. The Army’s Field Manual 100-14 (U.S.
Department of the Army 1998) outlines the principles, procedures, and
responsibilities of applying an operational risk-management (ORM) process
to conserve combat power and resources. The manual defines risk manage-
ment as “the process of identifying, assessing, and controlling risks arising
from operational factors and making decisions that balance risk costs with
mission benefits . . . . It applies to all missions and environments across the
wide range of Army operations.” The ORM process is a cycle of (1) identi-
fying hazards, (2) assessing the risk associated with those hazards, (3) de-
veloping controls and making risk decisions, (4) implementing the controls,
and (5) supervising and evaluating the effectiveness of the controls. The
process is depicted in Figure 1-2. The basic principles for implementing the
process include the following:
• Integrating risk management into mission planning, prepara-
tion, and execution. Leaders and staff continuously identify hazards and
assess both accidental and tactical risks. They then develop and coordinate
control measures. They determine the level of residual risk for accidental
hazards in order to evaluate courses of action, and they integrate control
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18
Presence
HIGH
Disaster Relief
Humanitarian Assistance
Surveillance / Peacekeeping
Counter Narcotics
Freedom of Navigation
Regional Crisis
Show of Force
LIKELIHOOD
OF Punitive Strike
OCCURENCE Global Global
Armed Intervention/ Regional Conflict Conventional Nuclear
Peace Enforcement War War
Regional
Regional
Chemical War
Nuclear War
LOW
Peace Conflict Regional Conflict Global War
LEVEL OF CONFLICT
FIGURE 1-1 Spectrum of potential conflict. Source: Ciesla 2002.
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INTRODUCTION 19
STEP 1. IDENTIFY HAZARDS
Apply METT-T
MISSIONS
STEP 2. ASSESS HAZARDS
Estimate Probability
STEP 5. SUPERVISE AND EVALUATE
Estimate Severity
New
Controls Determine Risk Level for Each
Hazard and Determine Overall
Mission Risk
STEP 4. IMPLEMENT CONTROLS
STEP 3. DEVELOP CONTROLS AND
MAKE RISK DECISIONS
Develop Controls
Determine Residual Risk Level for Each
Hazard and Overall Residual Mission
Risk
Make Decision
FIGURE 1-2 Continuous application of risk management. Source: Modified from U.S.
Department of the Army 1998.
measures into staff estimates, operational plans (OPLANs), operation orders
(OPORDs), and missions. Commanders assess the areas in which they
might take tactical risks. They approve control measures that will reduce
risks. Leaders ensure that all soldiers understand and properly execute risk
controls. They continuously assess variable hazards and implement new
risk controls.
• Making risk decisions at the appropriate level in the chain of
command. The commander should address risks in his guidance. He
should base his risk guidance on established Army and other appropriate
policies and on his higher commander’s direction. He then gives guidance
on how much risk he is willing to accept and delegate. Subordinates seek
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20 TECHNICAL GUIDES ON ASSESSING AND MANAGING CHEMICAL HAZARDS
the commander’s approval to accept risks that might imperil the next higher
commander’s intent.
• Accepting no unnecessary risk. Commanders compare and bal-
ance risks against mission expectations and accept risks only if the benefits
outweigh the potential costs or losses. Commanders alone decide whether
to accept the residual risk to accomplish the mission.
As part of the DOD’s force health protection program, the U.S. Army
is developing strategies and methods for assessing the broad range of poten-
tial occupational and environmental health (OEH) threats that might occur
as a result of deployment. Those threats include chemical, radiological,
biological, entomological, and endemic-disease hazards. In the past, Army
policies addressed health threats under only two deployment condi-
tions—garrison peacetime deployment and wartime deployment. No guid-
ance was available for the range of deployments that fall between those
mission extremes. Recognizing this need for guidance, the Army developed
an OEH policy intended to address the broad spectrum of possible military
operations, activities, and scenarios (U.S. Department of the Army 2001).
The goal of the policy is to allow commanders to make informed decisions
about OEH hazards and there by minimize the total risk to soldiers and
civilian personnel executing a range of military operations. To help com-
manders consider chemical OEH threats in their strategic decision-making
process, the Army has developed two technical guides (Technical Guide
230 and Technical Guide 248) and one reference guide (Reference Docu-
ment 230) that propose methods for assessing and managing chemical risks
to deployed personnel. This NRC report reviews those documents for their
scientific validity and their conformance with current understanding of risk-
assessment practices.
The technical guides and reference document were informed by the
efforts of several task forces and committees that have spent years evaluat-
ing the health of veterans; ensuring appropriate evaluation and care of veter-
ans’ health concerns; determining connections between service in the Per-
sian Gulf, specific exposures, and veterans’ health status; and developing
guidance to help prevent and reduce unanticipated illnesses in future de-
ployments. Reports from these groups include Presidential Review Direc-
tive 5 (NSTC 1998), Potential Radiation Exposure in Military Operations
(IOM 1999a), DOD Strategy to Address Low-Level Exposures to Chemical
Warfare Agents (DOD 1999), and Protecting Those Who Serve (IOM 2000)
and its supporting reports, Strategies to Protect the Health of Deployed U.S.
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INTRODUCTION 21
Forces (IOM 1999b; NRC 1999; 2000a,b). The following considerations
from those reports were instrumental in shaping the Army guidance:
• Full range of deployment scenarios (as illustrated in Figure 1-1).
• Broad range of chemical types, including those that are unique to
the military (e.g., chemical warfare agents, depleted uranium, smokes, and
obscurants) and those that might be present at the deployment site (e.g.,
pesticides, toxic industrial chemicals).
• Low-level exposures. The military has focused on exposures to
high concentrations of chemicals because those exposures are the most
likely to have direct negative consequences on the success of missions.
However, more attention is being given to possible health effects from
exposures to low concentrations of chemicals, particularly exposures that
occur over an extended period of time.
• Personnel assumptions. In the past, deployed military populations
were assumed to consist of healthy, physically fit men and nonpregnant
women. Although personnel must meet certain health and fitness require-
ments, the military now recognizes that deployed populations (active duty,
reserve, and National Guard personnel) can include individuals with health
factors that might make them more susceptible to certain chemicals.
• Broad range of health effects. Historically, the military primarily
was concerned with health threats that would affect deployed personnel
immediately, because those might have the potential to affect the success
of the mission. Operational planning now includes more emphasis on con-
sidering the risk of health effects that could occur months or even years
after exposure.
GUIDANCE DOCUMENTS
Technical Guide 248 (TG-248) (USACHPPM 2001) proposes processes
and tools to be used by preventive-medicine personnel for evaluating and
communicating the occupational and environmental health (OEH) and
endemic disease (ED) risks of deployment to commanders in accordance
with the Army’s ORM process. The process it proposes is intended to (1)
document OEH/ED hazards and exposures to soldiers and the force, (2)
characterize the risk of OEH/ED hazards during all phases of deployment,
(3) communicate risks in understandable terms to commanders and opera-
tional planners, (4) allow the commanders’ staffs to develop courses of
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22 TECHNICAL GUIDES ON ASSESSING AND MANAGING CHEMICAL HAZARDS
action that consider and/or minimize OEH/ ED risks to the force, and (5)
provide data to assist in post-deployment health assessments and evalua-
tions of OEH/ED operational risk-management processes. The overall goal
of TG-248 is to characterize OEH/ED risks in such a way that they can be
placed in a similar ranking scale with each other and with other operational
hazards. This report focuses on the usefulness of TG-248 for evaluating
chemical hazards only, and not radiological, biological, entomological, or
endemic disease hazards.
Technical Guide 230 (TG-230) (USACHPPM 2002a) presents proposed
military exposure guidelines (MEGs) for chemicals in air, water, and soil.
A MEG is an estimated chemical concentration above which certain types
of adverse health effects might begin to occur in individuals within the
exposed population after a continuous, single exposure of specified dura-
tion. MEGs are used for deployment purposes only and are different from
occupational standards for garrison situations. MEGs are used to assess the
significance of field exposures to chemical hazards during deployment.
They are designed to address a variety of exposure conditions not covered
by occupational or other standards used in garrisons, such as a single cata-
strophic release of large amounts of a chemical, temporary exposures last-
ing hours or days, continuous ambient environmental conditions (e.g., re-
gional pollution), use of a contaminated water supply, or persistent soil
contamination.
MEGs were developed for chemicals for which information was readily
available and for chemicals that were otherwise identified by the Army as
key hazards of concern, including chemical warfare agents and toxic indus-
trial chemicals. For air contaminants, the Army developed MEGs for expo-
sure durations of 1 hour, 8 hours, 24 hours, 14 days, and 1 year. For water
contaminants, MEGs were developed for exposure durations of 5 days, 14
days, and 1 year. For soil contaminants, only 1-year MEGs were devel-
oped, because short-term exposure guidelines were deemed unnecessary.
The Army does not anticipate that soil contamination will be an immediate
or severe hazard. Severely contaminated soils are often easily detected
because of odors, dead or discolored vegetation, or free chemical product.
TG-230 proposes a standardized process for using MEGs to character-
ize the levels of health and mission risk associated with chemical exposures
in accordance with the military’s ORM paradigm. The guidance is intended
for use by preventive-medicine personnel, environmental staff officers,
industrial hygienists, health risk assessors, and other medically trained
personnel. An important element of the assessment process outlined in TG-
230 involves the distinction between a “health threat” and a “medical
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INTRODUCTION 23
threat.” A health threat would affect an individual soldier’s health, whereas
a medical threat refers to a subset of health threats that have the potential to
degrade a unit’s combat (or mission) effectiveness.
TG-230 is supported by Reference Document 230 (RD-230) (USACH-
PPM 2002b), which provides details of the scientific rationale and assump-
tions that were used to derive the MEGs. The general approach for deriving
MEGs was to select the most relevant existing exposure guidelines or peer-
reviewed toxicological estimates developed for workers and the general
population by government agencies or other organizations and to accept or
adjust those values for deployment scenarios. The Army selected that ap-
proach because it was the most expedient and least costly way to develop
exposure guidance for a large number of chemicals.
STATEMENT OF TASK
The National Research Council (NRC) was asked to independently
review TG-248, TG-230, and RD-230 for their scientific validity, complete-
ness, and conformance to current risk-assessment practices. The subcom-
mittee was asked to review the Army’s documents, identify deficiencies,
and make recommendations for improvements. The subcommittee was
asked to focus specifically on the following issues:
1. The Army’s risk assessment, hazard-ranking, and risk-management
processes described in TG-230 and its supporting documents.
2. The use of pre-existing exposure guidelines developed by the NRC
and other agencies and organizations and the hierarchical scheme used by
the Army in selecting from those various guidelines.
3. The Army’s approaches to deriving MEGs for criteria pollutants,
lead, soil contaminants, and other chemical contaminants.
4. Technical aspects of the Army’s risk-management framework (as
presented in TG-248) regarding competing health risks from different
chemicals.
5. The assumption that the military population includes susceptible
subpopulations (e.g., personnel with unknown health conditions, asthma,
undetected pregnancies in the first trimester) and the use of uncertainty
factors in the derivation of MEGs.
6. The adjustments of exposure guideline values to account for differ-
ences in exposure durations in the derivation of MEGs.
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24 TECHNICAL GUIDES ON ASSESSING AND MANAGING CHEMICAL HAZARDS
7. The exposure assumptions and mathematic models used for the
derivation of MEGs for air, water, and soil contaminants.
8. Technical aspects of the Army’s acceptable cancer risk level of 1
in 10,000.
9. The balance of emphasis between health effects that are produced
immediately or soon after exposure and possible delayed effects (e.g., can-
cer) in the derivation of MEGs for chemical warfare agents and toxic indus-
trial chemicals.
10. The use of a single risk-assessment methodology for assessing the
toxicological risk from exposures to chemical warfare agents and toxic
industrial chemicals rather than separate risk-assessment methodologies.
11. The assumption that the toxicity of a mixture of chemicals that have
similar modes of action will be equal to the sum of the toxicities of individ-
ual chemicals in the mixture.
12. The utility of TG-248, TG-230, and RD-230 for decision makers
(who might not be knowledgeable about toxicology or the science behind
the health risk-assessment process) who will be using MEGs in the field.
THE SUBCOMMITTEE’S APPROACH
To accomplish its task, the subcommittee held four meetings between
October 2002 and August 2003. The first two meetings involved data-
gathering sessions that were open to the public. The subcommittee heard
presentations from DOD, on its force health protection program, and from
the U.S. Army Center for Health Promotion and Preventive Medicine, the
service organization responsible developing TG-230, RD-230, and TG-248.
The subcommittee critically evaluated TG-230, RD-230, and TG-248 as
well as other supporting documentation from the Army. The documents
were evaluated for their technical soundness, conformance with current
risk-assessment practice, and utility for the intended user.
This report is organized into four chapters. Chapter 2 reviews the
framework provided in TG-248 and TG-230 for assessing and managing
mission and health risks from chemical exposures. Chapter 3 reviews the
key concepts, assumptions, and decisions made in developing TG-248, TG-
230, and RD-230. Chapter 4 outlines the subcommittee’s recommended
approach to characterizing mission risks, and Chapter 5 presents how MEGs
should be improved to support health risk assessment and determine health
risk management options. Table 1-1 presents a list of tasks and the corre-
sponding chapters and relevant pages.
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INTRODUCTION 25
TABLE 1-1 Chapters That Address the Specific Task Issues
Task Location
1. The Army’s risk-assessment, hazard- Chapter 2
ranking, and risk-management processes
2. Use of existing exposure guidelines Chapter 2, general overview
and the hierarchy for their selection Chapter 5, medium-specific guidelines
and hierarchies reviewed
3. Criteria pollutants, lead, and soil Chapter 3, lead
contaminants Chapter 5, criteria pollutants, lead, and
soil
4. Competing health risks from other Chapter 2
hazards and between chemicals
5. Assumptions about the military Chapter 3
population and the use of uncertainty fac-
tors
6. Adjustments for exposure durations Chapter 5, medium-specific adjustments
reviewed
7. Exposure assumptions and calcula- Chapter 3, general overview
tions used to develop MEGs Chapter 5, medium-specific assumptions
and calculations reviewed
8. Acceptable cancer risk of 1 in 10,000 Chapter 3
Appendix B
9. Balance between immediate and Chapter 3
delayed or chronic health effects
10. Use of a common risk-assessment Chapter 3
methodology for chemical warfare agents
and toxic industrial chemicals
11. Chemical mixtures Chapters 3 and 4
Chapter 5, possible approaches for MEGs
Appendix E, possible approaches for
CCEGs
12. Utility for decision makers Chapter 3
REFERENCES
Ciesla, J.J. 2002. Military Operational Deployments. An Information Brief for the Na-
tional Research Council. Presentation at the First Meeting on Toxicological Risk to
Deployed Military Personal, October 2, 2002, Washington, DC.
DOD (U.S. Department of Defense). 1999. DOD Strategy to Address Low-Level Expo-
sures to Chemical Warfare Agents (CWAs). May 1999. [Online]. Available: http://
chppm-www.apgea.army.mil/chemicalagent/caw/lowlevestrategy.PDF [accessed Nov-
ember 25, 2003]
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26 TECHNICAL GUIDES ON ASSESSING AND MANAGING CHEMICAL HAZARDS
IOM (Institute of Medicine). 1999a. Potential Radiation Exposure in Military Operations:
Protecting the Soldier Before, During, and After. Washington, DC: National Academy
Press.
IOM (Institute of Medicine). 1999b. Strategies to Protect the Health of Deployed U.S.
Forces: Medical Surveillance, Record Keeping, and Risk Reduction. Washington, DC:
National Academy Press.
IOM (Institute of Medicine). 2000. Protecting Those Who Serve: Strategies to Protect the
Health of Deployed U.S. Forces. Washington, DC: National Academy Press.
NRC (National Research Council). 1999. Strategies to Protect the Health of Deployed U.S.
Forces: Force Protection and Decontamination. Washington, DC: National Academy
Press.
NRC (National Research Council). 2000a. Strategies to Protect the Health of Deployed
U.S. Forces: Analytical Framework for Assessing Risks. Washington, DC: National
Academy Press.
NRC (National Research Council). 2000b. Strategies to Protect the Health of Deployed
U.S. Forces: Detecting, Characterizing, and Documenting Exposures. Washington,
DC: National Academy Press.
NSTC (National Science and Technology Council). 1998. A National Obligation Planning
for Health Preparedness for and Readjustment of the Military, Veterans, and Their
Families after Future Deployments. Presidential Review Directive 5, Executive Office
of the President, Office of Science and Technology Policy, Washington, DC.
USACHPPM (U.S. Army Center for Health Promotion and Preventive Medicine). 2001.
Guide for Deployed Preventive Medicine Personnel on Health Risk Management.
Technical Guide 248. U.S. Army Center for Health Promotion and Preventive Medi-
cine. August 2001. [Online]. Available: http://chppm-www.apgea.army.mil/deploy-
ment/ [accessed November 25, 2003].
USACHPPM (U.S. Army Center for Health Promotion and Preventive Medicine). 2002a.
Chemical Exposure Guidelines for Deployed Military Personnel. Technical Guide 230.
U.S. Army Center for Health Promotion and Preventive Medicine. January 2002.
[Online]. Available: http://chppm-www.apgea.army.mil/deployment/ [accessed No-
vember 25, 2003].
USACHPPM (U.S. Army Center for Health Promotion and Preventive Medicine). 2002b.
Chemical Exposure Guidelines for Deployed Military Personnel. A Companion Docu-
ment to USACHPPM Technical Guide (TG) 230 Chemical Exposure Guidelines for
Deployed Military Personnel. Reference Document (RD) 230. U.S. Army Center for
Health Promotion and Preventive Medicine January 2002. [Online]. Available:
http://chppm-www.apgea.army.mil/deployment/ [accessed November 25, 2003].
U.S. Department of the Army. 1998. Risk Management, Field Manual No. 100-14. U.S.
Department of the Army, Washington, DC. April 23, 1998.
U.S. Department of the Army. 2001. Force Health Protection (FHP): Occupational and
Environmental Health (OEH) Threats. HQDA Ltr 1-0-1. U.S. Department of the
Army, Washington, DC. June 27, 2001.
Representative terms from entire chapter:
chemical warfare