his presentation will introduce a comprehensive framework that describes individual health risks for military members based on genetic factors and occupational, lifestyle, and environmental exposure factors, medical disposition, protective factors, and others variables that affect their exposure health risk (known as Individual Exposure Health Risk Profiles, or IEHRP).

1. Revolutionizing Precision Health with Big Data –
The Individual Exposure Health Risk Profile
(IEHRP)
06 Nov 2017
American Public Health Association
Annual Meeting 2017
Richard Hartman, PhD
United State Air Force Medical Service
1Cleared for Public Release, SAF/PA Case Number:2016-0444

2. Disclosure
Richard Hartman, PhD
∎ No Relationships to Disclose
Cleared for Public Release, SAF/PA Case Number:2016-044411/4/2017 2

3. Healthcare is Changing…
Healthcare in Changing – Focus on the Individual
11/4/2017 3Cleared for Public Release, SAF/PA Case Number:2016-0444
Policy, technology, marketplace
& consumer expectations are
disrupting healthcare & we can
position ourselves to better
support
“Personalized Healthcare”

4. Total Exposure Health
Description: Solution to capture workplace, environment & lifestyle
exposures to the individual (i.e., N=1, genome) using advances in science,
technology & informatics to prevent disease; improve health and well-being:
Healthiest Performing Population by 2025
E
H
Increase use of
genomic research
and knowledge
Improve
exposure
monitoring
through sensors
and wearables
Better understanding of
monitored exposure to
performance and
individual health
outcomes
Advance operational
decisions using
advancements in science,
medicine, technology, and
informatics with digital
biodata bank, Big Data
analytics, and expert
systems
4Cleared for Public Release, SAF/PA Case Number:2016-0444

5. Total Exposure Health- Visualized
EFFECT
DOSE
11/4/2017
When we account for
genetic variance we
find we are all unique!
But we can also use
this information to
protect health and
enhance performance
“Sensitive”
Individual
“Resilient”
Individual
“Average”
Individual
Chemical
Allergen
Radiation
Cleared for Public Release, SAF/PA Case Number:2016-0444

6. Reimagining Healthcare w/TEH
6Cleared for Public Release, SAF/PA Case Number:2016-0444

7. Total Exposure Health - Big Picture
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8. TEH – Helping to Solve Military Hearing Loss
∎ Common exposure
 We all experience noise exposure in workplace, lifestyle and environment
 Untreatable hearing loss can negatively affect one’s quality of life
∎ Costly Exposure
 $1.5-3B DoD/VA annual bill (Benefits and Medical)
 Hearing loss and tinnitus are among the top medical complaints, and most
widespread injuries,
 Linked to chronic disease, dementia, depression, and anxiety.
∎ Affects the mission
 Mission effectiveness directly proportional good communication
 Good hearing is prerequisite for peak performance
Cleared for Public Release, SAF/PA Case Number:2016-044411/4/2017 8

9. Noise Demonstration Project
• Noise demonstration project will:
• Demonstrate the ability to collect, store, and utilize
unstructured “noise” exposure data to identify the unique
health risk associated noise and manage NIHL
• Data to include: sensor, survey, clinical, and genetics
• Create intervention strategies to protect beneficiaries
(training, medical interventions such as functional hearing
tests and customized protection)
• Identify future research questions and research needs
Exposure
Big Data
Analytics
Cleared for Public Release, SAF/PA Case Number:2016-0444 9
Turn Data into
Insight

10. Personnel Exposure Monitor (PEM)
11/4/2017 10
∎ Initial NEDP device senses
noise exposure but is
actually a general
wearable sensor platform
 Air (VOCs, CO, T, RH)
Toxins
Radiation
∎ Anything an individual is
exposed to: on-duty and
off-duty
∎ Transmits data to cloud
(via phone or sensor node) On duty Off duty
Cleared for Public Release, SAF/PA Case Number:2016-0444

11. ∎ 10 published studies
Small to modest sample sizes
Multiple genetic variants in multiple genes associated with
NIHL or related phenotypes
 Grondin et al 2015. “Genetic Polymorphisms Associated
with Hearing Threshold Shift in Subjects during First
Encounter with Occupational Impulse Noise.” PLoS ONE 10
(6): e0130827.
Effect sizes are surprisingly large
 Odds Ratios range from 5.2 to 22.36
Several associated genotypes are already typed in the
available genechips
Genetics - Noise Induced Hearing Loss
11/4/2017 11Cleared for Public Release, SAF/PA Case Number:2016-0444

12. Identified Gene variants associated w/NIHL
Cleared for Public Release, SAF/PA Case Number:2016-0444 1211/4/2017

13. Our Clinical Disposition
Individual Exposure Health Risk Profile (IEHRP)
13
Our Unique Genetic Proclivity
IEHRP:
Individual
Exposure Indices
Our Exposures
11/4/2017 Cleared for Public Release, SAF/PA Case Number:2016-0444

14. Basic linear equation for Noise:
Individual Exposure Risk Index (Noise Induced Hearing Loss) = (CF) Personal Monitored
Exposure(Noise) + (CF) Medical/Clinical Disposition(Noise) + (CF) Genetic Proclivity(Noise) + n…+n
IEHRP Example – “Noise”
11/4/2017 14
Adding Chemical Exposure the equation changes to:
Individual Exposure Risk Index (Noise Induced Hearing Loss) = (CF) Personal Monitored
Exposure(Noise) + (CF) Medical/Clinical Disposition (Noise) + (CF) Genetic Proclivity (Noise) + (CF)
Ototoxins + n…+n
The Individual Exposure Risk Profile becomes more refined as we identify confounding
factors that affect the risk of NIHL
Individual Exposure Risk Index (Noise Induced Hearing Loss) = (CF) Personal Monitored
Exposure (Noise) + (CF) Medical/Clinical Disposition (Noise) + (CF) Genetic Proclivity (Noise) + (CF)
Ototoxins + n…+n – Protective factors – Protective Interventions
Cleared for Public Release, SAF/PA Case Number:2016-0444

15. Genetics
Diagnostics
Sensors and
Mobile Data
Lifestyle
Occupation
Medical History
Environment
Faimly History
Exposure Index can have many variables
11/4/2017 15Cleared for Public Release, SAF/PA Case Number:2016-0444

16. IEHRP Exposure Index Data Sources
11/4/2017 16Cleared for Public Release, SAF/PA Case Number:2016-0444

17. Repsentencing IEHRP Mathematically…
11/4/2017 17
h Exposure
measurements
Clinical
measurements
Genetic propensity
……
Exposure element 1 Index(1,1) Index(1,2) Index(1,3)
Exposure element 2 Index(2,1) Index(2,2) Index(2,3)
Exposure element 3 Index(3,1) Index(3,2) Index(3,3)
Exposure element 4 Index(4,1) Index(4,2) Index(4,3)
:
.
Cleared for Public Release, SAF/PA Case Number:2016-0444

18. NOISE
TYPICAL
EXPOSURE
CURVE
Rethinking Exposure….
EFFECT
DOSE
11/4/2017
When we layer these
exposures we find
we are all unique
BENZENELEADRADIATIONGLUTEN
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TOTAL
EXPOSURE
Cleared for Public Release, SAF/PA Case Number:2016-0444

19. Visualizing the IEHRP – Individual
11/4/2017
IEHRP will aid in
visualizing an individual’s
unique exposure
susceptibilities
Kirk
NOISE BENZENELEAD RADIATION GLUTEN
SUSCEPTABILITY
HIGH
LOW
Cleared for Public Release, SAF/PA Case Number:2016-0444

20. Visualizing the IEHRP – Population
11/4/2017
Yr 1 Baseline IEHRP
Intervention/Changes
Y2 IEHRP
See Unique PatternsAnn
Al
Lily
Kirk
Rich
YEAR 1
BENZENE
LEAD
RADIATION
GLUTEN
NOISE
YEAR 2
Cleared for Public Release, SAF/PA Case Number:2016-0444

21. 11/4/2017
How will
Similar Exposure Groups
(SEGs) be determined?
By Exposure?
or
By Profile?
Ann
Al
Lily
Kirk
Rich
By Exposure?
BENZENE
LEAD
RADIATION
GLUTEN
NOISE
Rethinking the Similar Exposure Group (SEG)
By Profile?
Cleared for Public Release, SAF/PA Case Number:2016-0444

22. Rethinking Exposure Limits
INCREASINGEFFECT
INCREASING DOSE
11/4/2017
Exposure limits Pop Based
Protects based on Economic
Feasibility
We’re all Respond Differently
Super humans?
EXPOSURE
CURVE
OSHA PEL
“SUPER”
Rich
Lily
Kirk
Al
“No-Effect”
Range
Maximum Effect
Range
Increasing Effect with
Increasing Dose
Ann
Cleared for Public Release, SAF/PA Case Number:2016-0444

23. TEH Full Implementation
SADA
&
(IEHRP)
Sensor Data
PHA Surveys
Genomic /
Biodata bank
DOEHRS
Other databases
MHS Genesis
ILER
VBA
Vet
Benefits
DOD
Provider
analytics
ingest
sharing
T
E
H
Clinical
Decision
Support
System
T
E
H
VHA/EHR
Provider
DoD/VA
Researchers
Cleared for Public Release, SAF/PA Case Number:2016-0444 23

24. THE/IEHRP Brings these things together:
24
∎ Area sensors, Personnel/Physiological Sensors, …
∎ Integrated with all genetics, previous exposures, DBs, …
∎ All information integrated about an individual
∎ Advanced analytics and decision support
∎ Situational awareness tools for real-time monitoring/use
∎ Predictive capability for optimized readiness and performance
∎ Open, integrated, advanced system for force health protection,
improved care, and operational use
∎ Technologies are real, available, and ready for application/use
Cleared for Public Release, SAF/PA Case Number:2016-0444

25. 11/4/2017 25
Questions
Cleared for Public Release, SAF/PA Case Number:2016-0444