National Aeronautics and Space Administration THE LIFETIME SURVEILLANCE OF ASTRONAUT HEALTH Newsletter Volume 25, Issue 1 Editor’s Note: We hope you are all doing well during this unprecedented time in our history. This edition of the LSAH Newsletter looks at the most recent updates to the TREAT Astronauts Act, as well as how to make a behavior- al telehealth appointment with the JSC Clinic during the COVID-19 pandemic. We dive into the history of LSAH in the last three decades, and peer into the future of the Artemis program while remembering the great strides taken from the Apollo era. A Message from the JSC Clinic! As a reminder, your routine medical evaluation now includes a dedicated behavioral health session with our Clinical Neuropsychologist, Dr. Carmen Pulido. The initial session will take approximately 1.5 hours, and will include a review of your devel- opmental, occupational, and medical history. In response to COVID-19 and the current limitations Nov. 15, 2019 - NASA astronaut Andrew Morgan waves as on travel, we have this service available virtually! he is photographed during the first spacewalk to repair the For a behavioral telehealth appointment with Dr. Alpha Magnetic Spectrometer, a cosmic particle detector on Pulido, please contact the JSC Flight Medicine the International Space Station. Clinic at 281-483- 7999 during normal business hours. Making a behavioral telehealth appointment LSAH: Looking Back, Moving Forward will not affect your ability to visit the JSC Clinic Mary Wear, Ph.D. and Jacqueline Charvat, Ph.D. for your routine physical and other health appoint- The National Aeronautics and Space Act of 1958 ments. Please note, we do not currently have multi- established NASA and included a mandate to disciplinary telehealth services available with other monitor the effects of exposure to the space envi- Clinic staff. If you already met with Dr. Pulido as ronment on astronaut health.1 The first NASA as- part of your annual visit, you can meet with her tronauts were selected in 1959; as of 2018, NASA again if desired. had selected 350 individuals to serve in the Astro- naut Corps. Members of this group are chosen We hope that you and your family are healthy and based on stringent health, skills, and educational safe, and we look forward to hearing from you. requirements.2 Astronauts face unique occupation- al exposures; spaceflight poses known and un- Sincerely, known risks to human health. Health risks for as- Ronak V. Shah, DO, MBA, MPH Medical Direc- tronauts may have short-term and long-term physi- tor of Clinical Services cal and psychological consequences. To under- stand the effects of spaceflight on the long-term Carmen Pulido, Ph.D., Clinical Neuropsychologist health of the Astronaut Corps, NASA developed Mobile 832-284-5125, [email protected] longitudinal research and occupational surveil- lance programs, including the Longitudinal Study For past newsletters, please visit the LSAH website Page 2 Continued from page 1 LSAH: Looking Back, Moving Forward continued Astronaut Edwin E. Aldrin Jr., lunar module pilot, stands beside the deployed United States flag during Apollo 11 EVA on the lunar surface. The Lunar Module "Eagle" is on the left. The footprints of the astronauts are visible in the soil of the moon. of Astronaut Health and Lifetime Surveillance of miologists and statisticians to evaluate Phase I. Astronaut Health. Since the 1980’s these programs The panel identified a number of limitations in- have been continuously reevaluated and improved cluding a biased selection of comparisons and une- in several distinct phases to meet higher standards ven data collection between the two groups. The of efficiency, internal validity, and ultimately, pro- panel recommended that the study design be tection of the Astronaut Corps. strengthened to mitigate these limitations and the first phase of the longitudinal study ended in 1991.4 Phase I The Longitudinal Study of Astronaut Health, Phase I, was established to examine the incidence of Phase II acute and chronic morbidity and mortality of astro- NASA began Phase II of the longitudinal research nauts and was conducted during the 1980s. Phase I study in 1992. Phase II included a 3:1 ratio of JSC described the health risks associated with astronaut civil service employees to serve as a comparison occupational exposures, and compared them to the population to astronauts. The JSC civil service risks for a group of civil service employees of comparison population was considered a healthy Johnson Space Center (JSC). The comparison worker cohort that was matched by selection year, group was individually matched to the first 178 age, sex, and BMI. The retrospective match was astronauts at a 5:1 ratio. The matching criteria in- performed for the entire astronaut population, in- cluded sex, age, body mass index (BMI), smoking cluding deceased and retired astronauts. A detailed habits, length of service at JSC, and exercise habits description of the retrospective matching process (if this information was available).3 is provided elsewhere.5 From 1992 to 2000, a pro- spective match of comparison subjects to astro- nauts was made as each astronaut selection class In 1989, NASA enlisted an external panel of epide- was announced. For past newsletters, please visit the LSAH website Page 3 Continued from page 2 LSAH: Looking Back, Moving Forward The IOM panels recommended that NASA estab- continued lish an occupational surveillance program and pro- vide long-term healthcare. The IOM cited other government-sponsored occupational surveillance The Phase II study had a number of strengths. The programs such as the Department of Energy, Veter- data collected were unique among longitudinal an’s Administration, and Department of Defense as studies, collecting a substantial volume of medical models to follow. The Phase II research study offi- data based on standardized testing at regular inter- cially ended in May 2010. vals over a period of up to 50 years. This database was used to populate the JSC Electronic Medical Record when it was first implemented in 1999. Re- The Lifetime Surveillance of Astronaut Health tired astronauts returned for annual follow-up ex- (LSAH) Occupational Health Program aminations at a rate of 65-70% while the compari- son subjects had a 62-65% return rate. The Phase II In accordance with the IOM recommendations, study generated an annual cancer incidence report NASA transitioned the Longitudinal Study of As- and a number of other internal reports and analyses tronaut Health into an occupational health pro- to inform NASA’s space medicine program. Phase gram, the Lifetime Surveillance of Astronaut II study results also informed internal NASA poli- Health (LSAH). This program treats the Astronaut cy and decision making, and supported several oth- Corps as a worker population with unique occupa- er contributions to the greater science community.6 tional exposures. The JSC Flight Medicine Clinic collects the medical data and LSAH conducts anal- ysis of the data. Given the small number of astro- It is difficult to design a perfect case-control study nauts who have flown in space, every possible and the Phase II study had some challenges. The piece of data is necessary to understand the unique most critical challenge was that the limited match- health implications of spaceflight on the human ing criteria resulted in significant differences be- body. However over 70% of health data is in narra- tween the astronaut and comparison populations. tive text format, making preparation and analysis Differences between the populations include dis- of these data labor intensive. In 2019, LSAH epide- similar health status at selection. For instance, the miologists began using clinical text extraction members of the comparison population were not (CTE) software to reduce the time to process and excluded based on pre-existing medical conditions extract critical information from text data. These such as diabetes, whereas rigorous medical screen- data help medical staff, epidemiologists and re- ing performed during astronaut selection would searchers better understand the association between have excluded astronauts with these conditions. In medical events, medication use, symptoms report- addition, different exam intervals between groups ed, and the association to spaceflight. (bi-annually for the comparison population; annu- ally for astronauts), and differences in laboratory testing performed (astronauts received a wider bat- TREAT Astronauts Act tery of tests on a more frequent schedule) created On March 21, 2017, President Trump signed the disparities in the population data. National Aeronautics and Space Administration 8 Transition Authorization Act of 2017 with biparti- san support. Included was a new initiative: To Re- Noting the challenges in Phase II, NASA sought search, Evaluate, Assess, and Treat (TREAT) As- external advice and commissioned the Institute of tronauts Act. The TREAT Astronauts Act, some- Medicine (IOM) to consider approaches to space times referred to as simply TREAT, significantly medicine in preparation for long duration space expands NASA's authority. For NASA astronauts travel and to evaluate the Phase II program. The and payload specialists who have spaceflight expe- IOM panels issued two reports, “Committee on rience, NASA will provide monitoring, diagnosis Creating a Vision for Space Medicine During and treatment for spaceflight-associated conditions. 7 Travel Beyond Earth Orbit” , and “A Review of NASA will, as a secondary payer, cover any medi- 4 NASA’s Longitudinal Study of Astronaut Health” cal costs associated with the monitoring, diagnosis For past newsletters, please visit the LSAH website Page 4 Continued from page 3 LSAH: Looking Back, Moving Forward continued and treatment of a spaceflight-associated condi- by a panel of aerospace physicians, and 2) Identify tion. This includes deductibles, coinsurance, co- latent medical and psychological conditions asso- payments, and similar charges, but excludes insur- ciated with hazards of the astronaut occupation at ance premiums. Former U.S. astronauts and pay- a population level.