+---------------+---------------------------+-------------------------+
| ![](media/im  | NASA TECHNICAL STANDARD   | NASA-STD-3001           |
| age1.jpeg){wi |                           |                         |
| dth="1.165972 |                           |                         |
| 2222222222in" |                           |                         |
| heig          |                           |                         |
| ht="0.8840277 |                           |                         |
| 777777777in"} |                           |                         |
+---------------+---------------------------+-------------------------+
| National      |                           | Approved: 03-05-2007    |
| Aeronautics   |                           |                         |
| and Space     |                           |                         |
| A             |                           |                         |
| dministration |                           |                         |
+---------------+---------------------------+-------------------------+
| Washington,   |                           | Expiration Date:        |
| D.C.          |                           | 03-05-2012              |
| 20546-0001    |                           |                         |
+---------------+---------------------------+-------------------------+
|               |                           | Superseding             |
|               |                           | NASA-STD-3000, Vol. 1,  |
|               |                           | Chapter 7 and JSC       |
|               |                           | 26882, Space Flight     |
|               |                           | Health Requirements     |
|               |                           | Document                |
+---------------+---------------------------+-------------------------+
| **NASA SPACE  |                           |                         |
| FLIGHT HUMAN  |                           |                         |
| SYSTEM        |                           |                         |
| STANDARD**    |                           |                         |
|               |                           |                         |
| **VOLUME 1:   |                           |                         |
| CREW HEALTH** |                           |                         |
+---------------+---------------------------+-------------------------+
| Measurement   |                           |                         |
| System        |                           |                         |
| Id            |                           |                         |
| entification: |                           |                         |
|               |                           |                         |
| NONE          |                           |                         |
+---------------+---------------------------+-------------------------+

DOCUMENT HISTORY LOG

  ---------- -------------- ---------------- -----------------------------
  Status     Document       Approval Date    Description
             Revision                        

  Baseline                  03-05-2007       Initial Release
  ---------- -------------- ---------------- -----------------------------

FOREWORD

This standard is published by the National Aeronautics and Space
Administration (NASA) to establish standards for providing a healthy and
safe environment for crewmembers, and to provide health and medical
programs for crewmembers during all phases of space flight. Standards
are established to optimize crew health and performance, thus
contributing to overall mission success, and to prevent negative
long-term health consequences due to space flight.

In this document, the Office of the Chief Health and Medical Officer
establishes NASA's space flight crew health standards for the
pre-flight, in-flight, and post-flight phases of human space flight.
These standards apply to all NASA human space flight programs and are
not developed for any specific program. However, while some of the
existing programs, such as the Space Shuttle and International Space
Station programs, meet the intent and purpose of these standards
currently, these standards may have implications for longer duration
missions and missions with architectures and objectives outside of low
Earth orbit. Although the standards are applicable to the in-flight
phase of all space missions, it is anticipated that they will be most
relevant during long-duration lunar outpost and Mars exploration
missions, since the combined ill effects of exposure to the space
environment will be of most concern in those mission scenarios.

This standard is approved for use by NASA Headquarters and NASA Centers,
including Component Facilities.

Requests for information, corrections, or additions to this standard
should be submitted via "Feedback" in the NASA Technical Standards
System at [**http://standards.nasa.gov**](http://standards.nasa.gov/).

*Original Signed By*

5 March 2007

Richard S. Williams, M.D. Approval Date

NASA Chief Health and Medical Officer

NASA Headquarters

+------+----+-------------------------------------------------+-------+
| [\   |    | TABLE OF CONTENTS                               | [\    |
| SECT |    |                                                 | PAGE\ |
| ION] |    |                                                 | \     |
| {.un |    |                                                 | ]{.   |
| derl |    |                                                 | under |
| ine} |    |                                                 | line} |
+------+----+-------------------------------------------------+-------+
| DOCU |    |                                                 | 2     |
| MENT |    |                                                 |       |
| HIS  |    |                                                 |       |
| TORY |    |                                                 |       |
| LOG  |    |                                                 |       |
+------+----+-------------------------------------------------+-------+
| FORE |    |                                                 | 3     |
| WORD |    |                                                 |       |
+------+----+-------------------------------------------------+-------+
| T    |    |                                                 | 5     |
| ABLE |    |                                                 |       |
| OF   |    |                                                 |       |
| CONT |    |                                                 |       |
| ENTS |    |                                                 |       |
+------+----+-------------------------------------------------+-------+
| LIST |    |                                                 | 7     |
| OF   |    |                                                 |       |
| FIG  |    |                                                 |       |
| URES |    |                                                 |       |
+------+----+-------------------------------------------------+-------+
| LIST |    |                                                 | 7     |
| OF   |    |                                                 |       |
| TA   |    |                                                 |       |
| BLES |    |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 1\.  | S  |                                                 | 8     |
|      | CO |                                                 |       |
|      | PE |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 1.1  | P  |                                                 | 8     |
|      | ur |                                                 |       |
|      | po |                                                 |       |
|      | se |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 1.2  | A  |                                                 | 9     |
|      | pp |                                                 |       |
|      | li |                                                 |       |
|      | ca |                                                 |       |
|      | bi |                                                 |       |
|      | li |                                                 |       |
|      | ty |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 1.3  | Ov |                                                 | 10    |
|      | er |                                                 |       |
|      | vi |                                                 |       |
|      | ew |                                                 |       |
+------+----+-------------------------------------------------+-------+
|      |    |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 2\.  | AP |                                                 | 10    |
|      | PL |                                                 |       |
|      | IC |                                                 |       |
|      | AB |                                                 |       |
|      | LE |                                                 |       |
|      | D  |                                                 |       |
|      | OC |                                                 |       |
|      | UM |                                                 |       |
|      | EN |                                                 |       |
|      | TS |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 2.1  | G  |                                                 | 10    |
|      | en |                                                 |       |
|      | er |                                                 |       |
|      | al |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 2.2  | Go |                                                 | 11    |
|      | ve |                                                 |       |
|      | rn |                                                 |       |
|      | me |                                                 |       |
|      | nt |                                                 |       |
|      | D  |                                                 |       |
|      | oc |                                                 |       |
|      | um |                                                 |       |
|      | en |                                                 |       |
|      | ts |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 2.3  | No |                                                 | 11    |
|      | n- |                                                 |       |
|      | Go |                                                 |       |
|      | ve |                                                 |       |
|      | rn |                                                 |       |
|      | me |                                                 |       |
|      | nt |                                                 |       |
|      | D  |                                                 |       |
|      | oc |                                                 |       |
|      | um |                                                 |       |
|      | en |                                                 |       |
|      | ts |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 2.4  | O  |                                                 | 11    |
|      | rd |                                                 |       |
|      | er |                                                 |       |
|      | of |                                                 |       |
|      | Pr |                                                 |       |
|      | ec |                                                 |       |
|      | ed |                                                 |       |
|      | en |                                                 |       |
|      | ce |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 3\.  | AC |                                                 | 11    |
|      | RO |                                                 |       |
|      | NY |                                                 |       |
|      | MS |                                                 |       |
|      | A  |                                                 |       |
|      | ND |                                                 |       |
|      | D  |                                                 |       |
|      | EF |                                                 |       |
|      | IN |                                                 |       |
|      | IT |                                                 |       |
|      | IO |                                                 |       |
|      | NS |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 3.1  | Ac |                                                 | 11    |
|      | ro |                                                 |       |
|      | ny |                                                 |       |
|      | ms |                                                 |       |
|      | a  |                                                 |       |
|      | nd |                                                 |       |
|      | A  |                                                 |       |
|      | bb |                                                 |       |
|      | re |                                                 |       |
|      | vi |                                                 |       |
|      | at |                                                 |       |
|      | io |                                                 |       |
|      | ns |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 3.2  | D  |                                                 | 13    |
|      | ef |                                                 |       |
|      | in |                                                 |       |
|      | it |                                                 |       |
|      | io |                                                 |       |
|      | ns |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 4\.  | RE |                                                 | 13    |
|      | QU |                                                 |       |
|      | IR |                                                 |       |
|      | EM |                                                 |       |
|      | EN |                                                 |       |
|      | TS |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 4.1  | Le |                                                 | 13    |
|      | ve |                                                 |       |
|      | ls |                                                 |       |
|      | of |                                                 |       |
|      | M  |                                                 |       |
|      | ed |                                                 |       |
|      | ic |                                                 |       |
|      | al |                                                 |       |
|      | Ca |                                                 |       |
|      | re |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 4    | Le |                                                 | 14    |
| .1.1 | ve |                                                 |       |
|      | ls |                                                 |       |
|      | of |                                                 |       |
|      | Ca |                                                 |       |
|      | re |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 4.2  | S  |                                                 | 16    |
|      | ta |                                                 |       |
|      | nd |                                                 |       |
|      | ar |                                                 |       |
|      | ds |                                                 |       |
|      | f  |                                                 |       |
|      | or |                                                 |       |
|      | H  |                                                 |       |
|      | um |                                                 |       |
|      | an |                                                 |       |
|      | P  |                                                 |       |
|      | er |                                                 |       |
|      | fo |                                                 |       |
|      | rm |                                                 |       |
|      | an |                                                 |       |
|      | ce |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 4    | Ov |                                                 | 16    |
| .2.1 | er |                                                 |       |
|      | vi |                                                 |       |
|      | ew |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 4    | T  |                                                 | 17    |
| .2.2 | yp |                                                 |       |
|      | es |                                                 |       |
|      | of |                                                 |       |
|      | S  |                                                 |       |
|      | ta |                                                 |       |
|      | nd |                                                 |       |
|      | ar |                                                 |       |
|      | ds |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 4    | Fi |                                                 | 17    |
| .2.3 | tn |                                                 |       |
|      | es |                                                 |       |
|      | s- |                                                 |       |
|      | fo |                                                 |       |
|      | r- |                                                 |       |
|      | Du |                                                 |       |
|      | ty |                                                 |       |
|      | A  |                                                 |       |
|      | er |                                                 |       |
|      | ob |                                                 |       |
|      | ic |                                                 |       |
|      | Ca |                                                 |       |
|      | pa |                                                 |       |
|      | ci |                                                 |       |
|      | ty |                                                 |       |
|      | St |                                                 |       |
|      | an |                                                 |       |
|      | da |                                                 |       |
|      | rd |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 4    | Fi |                                                 | 18    |
| .2.4 | tn |                                                 |       |
|      | es |                                                 |       |
|      | s- |                                                 |       |
|      | fo |                                                 |       |
|      | r- |                                                 |       |
|      | Du |                                                 |       |
|      | ty |                                                 |       |
|      | Se |                                                 |       |
|      | ns |                                                 |       |
|      | or |                                                 |       |
|      | im |                                                 |       |
|      | ot |                                                 |       |
|      | or |                                                 |       |
|      | St |                                                 |       |
|      | an |                                                 |       |
|      | da |                                                 |       |
|      | rd |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 4    | Fi |                                                 | 18    |
| .2.5 | tn |                                                 |       |
|      | es |                                                 |       |
|      | s- |                                                 |       |
|      | fo |                                                 |       |
|      | r- |                                                 |       |
|      | Du |                                                 |       |
|      | ty |                                                 |       |
|      | Be |                                                 |       |
|      | ha |                                                 |       |
|      | vi |                                                 |       |
|      | or |                                                 |       |
|      | al |                                                 |       |
|      | He |                                                 |       |
|      | al |                                                 |       |
|      | th |                                                 |       |
|      | a  |                                                 |       |
|      | nd |                                                 |       |
|      | C  |                                                 |       |
|      | og |                                                 |       |
|      | ni |                                                 |       |
|      | ti |                                                 |       |
|      | on |                                                 |       |
|      | St |                                                 |       |
|      | an |                                                 |       |
|      | da |                                                 |       |
|      | rd |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 4    | Fi |                                                 | 19    |
| .2.6 | tn |                                                 |       |
|      | es |                                                 |       |
|      | s- |                                                 |       |
|      | fo |                                                 |       |
|      | r- |                                                 |       |
|      | Du |                                                 |       |
|      | ty |                                                 |       |
|      | He |                                                 |       |
|      | ma |                                                 |       |
|      | to |                                                 |       |
|      | lo |                                                 |       |
|      | gy |                                                 |       |
|      | a  |                                                 |       |
|      | nd |                                                 |       |
|      | Im |                                                 |       |
|      | mu |                                                 |       |
|      | no |                                                 |       |
|      | lo |                                                 |       |
|      | gy |                                                 |       |
|      | St |                                                 |       |
|      | an |                                                 |       |
|      | da |                                                 |       |
|      | rd |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 4    | P  |                                                 | 19    |
| .2.7 | er |                                                 |       |
|      | mi |                                                 |       |
|      | ss |                                                 |       |
|      | ib |                                                 |       |
|      | le |                                                 |       |
|      | O  |                                                 |       |
|      | ut |                                                 |       |
|      | co |                                                 |       |
|      | me |                                                 |       |
|      | L  |                                                 |       |
|      | im |                                                 |       |
|      | it |                                                 |       |
|      | f  |                                                 |       |
|      | or |                                                 |       |
|      | N  |                                                 |       |
|      | ut |                                                 |       |
|      | ri |                                                 |       |
|      | ti |                                                 |       |
|      | on |                                                 |       |
|      | St |                                                 |       |
|      | an |                                                 |       |
|      | da |                                                 |       |
|      | rd |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 4    | P  |                                                 | 19    |
| .2.8 | er |                                                 |       |
|      | mi |                                                 |       |
|      | ss |                                                 |       |
|      | ib |                                                 |       |
|      | le |                                                 |       |
|      | O  |                                                 |       |
|      | ut |                                                 |       |
|      | co |                                                 |       |
|      | me |                                                 |       |
|      | L  |                                                 |       |
|      | im |                                                 |       |
|      | it |                                                 |       |
|      | f  |                                                 |       |
|      | or |                                                 |       |
|      | Mu |                                                 |       |
|      | sc |                                                 |       |
|      | le |                                                 |       |
|      | St |                                                 |       |
|      | re |                                                 |       |
|      | ng |                                                 |       |
|      | th |                                                 |       |
|      | St |                                                 |       |
|      | an |                                                 |       |
|      | da |                                                 |       |
|      | rd |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 4    | P  |                                                 | 20    |
| .2.9 | er |                                                 |       |
|      | mi |                                                 |       |
|      | ss |                                                 |       |
|      | ib |                                                 |       |
|      | le |                                                 |       |
|      | O  |                                                 |       |
|      | ut |                                                 |       |
|      | co |                                                 |       |
|      | me |                                                 |       |
|      | L  |                                                 |       |
|      | im |                                                 |       |
|      | it |                                                 |       |
|      | f  |                                                 |       |
|      | or |                                                 |       |
|      | Mi |                                                 |       |
|      | cr |                                                 |       |
|      | og |                                                 |       |
|      | ra |                                                 |       |
|      | vi |                                                 |       |
|      | ty |                                                 |       |
|      | -I |                                                 |       |
|      | nd |                                                 |       |
|      | uc |                                                 |       |
|      | ed |                                                 |       |
|      | Bo |                                                 |       |
|      | ne |                                                 |       |
|      | M  |                                                 |       |
|      | in |                                                 |       |
|      | er |                                                 |       |
|      | al |                                                 |       |
|      | Lo |                                                 |       |
|      | ss |                                                 |       |
|      | P  |                                                 |       |
|      | er |                                                 |       |
|      | fo |                                                 |       |
|      | rm |                                                 |       |
|      | an |                                                 |       |
|      | ce |                                                 |       |
|      | St |                                                 |       |
|      | an |                                                 |       |
|      | da |                                                 |       |
|      | rd |                                                 |       |
|      | (  |                                                 |       |
|      | Ba |                                                 |       |
|      | se |                                                 |       |
|      | li |                                                 |       |
|      | ne |                                                 |       |
|      | wi |                                                 |       |
|      | th |                                                 |       |
|      | Me |                                                 |       |
|      | as |                                                 |       |
|      | ur |                                                 |       |
|      | ed |                                                 |       |
|      | T- |                                                 |       |
|      | sc |                                                 |       |
|      | or |                                                 |       |
|      | e) |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 4.   | S  |                                                 | 20    |
| 2.10 | pa |                                                 |       |
|      | ce |                                                 |       |
|      | P  |                                                 |       |
|      | er |                                                 |       |
|      | mi |                                                 |       |
|      | ss |                                                 |       |
|      | ib |                                                 |       |
|      | le |                                                 |       |
|      | Ex |                                                 |       |
|      | po |                                                 |       |
|      | su |                                                 |       |
|      | re |                                                 |       |
|      | L  |                                                 |       |
|      | im |                                                 |       |
|      | it |                                                 |       |
|      | f  |                                                 |       |
|      | or |                                                 |       |
|      | S  |                                                 |       |
|      | pa |                                                 |       |
|      | ce |                                                 |       |
|      | Fl |                                                 |       |
|      | ig |                                                 |       |
|      | ht |                                                 |       |
|      | R  |                                                 |       |
|      | ad |                                                 |       |
|      | ia |                                                 |       |
|      | ti |                                                 |       |
|      | on |                                                 |       |
|      | Ex |                                                 |       |
|      | po |                                                 |       |
|      | su |                                                 |       |
|      | re |                                                 |       |
|      | St |                                                 |       |
|      | an |                                                 |       |
|      | da |                                                 |       |
|      | rd |                                                 |       |
+------+----+-------------------------------------------------+-------+
| T    |    |                                                 |       |
| ABLE |    |                                                 |       |
| OF   |    |                                                 |       |
| C    |    |                                                 |       |
| ONTE |    |                                                 |       |
| NTS, |    |                                                 |       |
| c    |    |                                                 |       |
| onti |    |                                                 |       |
| nued |    |                                                 |       |
|      |    |                                                 |       |
| [    |    |                                                 |       |
| SECT |    |                                                 |       |
| ION] |    |                                                 |       |
| {.un |    |                                                 |       |
| derl |    |                                                 |       |
| ine} |    |                                                 |       |
| [P   |    |                                                 |       |
| AGE\ |    |                                                 |       |
| ]    |    |                                                 |       |
| {.un |    |                                                 |       |
| derl |    |                                                 |       |
| ine} |    |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 4.3  | He |                                                 | 20    |
|      | al |                                                 |       |
|      | th |                                                 |       |
|      | a  |                                                 |       |
|      | nd |                                                 |       |
|      | M  |                                                 |       |
|      | ed |                                                 |       |
|      | ic |                                                 |       |
|      | al |                                                 |       |
|      | Sc |                                                 |       |
|      | re |                                                 |       |
|      | en |                                                 |       |
|      | in |                                                 |       |
|      | g, |                                                 |       |
|      | E  |                                                 |       |
|      | va |                                                 |       |
|      | lu |                                                 |       |
|      | at |                                                 |       |
|      | io |                                                 |       |
|      | n, |                                                 |       |
|      | a  |                                                 |       |
|      | nd |                                                 |       |
|      | C  |                                                 |       |
|      | er |                                                 |       |
|      | ti |                                                 |       |
|      | fi |                                                 |       |
|      | ca |                                                 |       |
|      | ti |                                                 |       |
|      | on |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 4    | I  |                                                 | 21    |
| .3.1 | ni |                                                 |       |
|      | ti |                                                 |       |
|      | al |                                                 |       |
|      | S  |                                                 |       |
|      | el |                                                 |       |
|      | ec |                                                 |       |
|      | ti |                                                 |       |
|      | on |                                                 |       |
|      | Re |                                                 |       |
|      | qu |                                                 |       |
|      | ir |                                                 |       |
|      | em |                                                 |       |
|      | en |                                                 |       |
|      | ts |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 4    | M  |                                                 | 21    |
| .3.2 | ed |                                                 |       |
|      | ic |                                                 |       |
|      | al |                                                 |       |
|      | C  |                                                 |       |
|      | er |                                                 |       |
|      | ti |                                                 |       |
|      | fi |                                                 |       |
|      | ca |                                                 |       |
|      | ti |                                                 |       |
|      | on |                                                 |       |
|      | a  |                                                 |       |
|      | nd |                                                 |       |
|      | Ev |                                                 |       |
|      | al |                                                 |       |
|      | ua |                                                 |       |
|      | ti |                                                 |       |
|      | on |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 4.4  | M  |                                                 | 21    |
|      | ed |                                                 |       |
|      | ic |                                                 |       |
|      | al |                                                 |       |
|      | Di |                                                 |       |
|      | ag |                                                 |       |
|      | no |                                                 |       |
|      | si |                                                 |       |
|      | s, |                                                 |       |
|      | I  |                                                 |       |
|      | nt |                                                 |       |
|      | er |                                                 |       |
|      | ve |                                                 |       |
|      | nt |                                                 |       |
|      | io |                                                 |       |
|      | n, |                                                 |       |
|      | Tr |                                                 |       |
|      | ea |                                                 |       |
|      | tm |                                                 |       |
|      | en |                                                 |       |
|      | t, |                                                 |       |
|      | a  |                                                 |       |
|      | nd |                                                 |       |
|      | Ca |                                                 |       |
|      | re |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 4    | Tr |                                                 | 22    |
| .4.1 | ai |                                                 |       |
|      | ni |                                                 |       |
|      | ng |                                                 |       |
|      | S  |                                                 |       |
|      | ec |                                                 |       |
|      | ti |                                                 |       |
|      | on |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 4    | Pr |                                                 | 24    |
| .4.2 | e- |                                                 |       |
|      | fl |                                                 |       |
|      | ig |                                                 |       |
|      | ht |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 4    | I  |                                                 | 26    |
| .4.3 | n- |                                                 |       |
|      | fl |                                                 |       |
|      | ig |                                                 |       |
|      | ht |                                                 |       |
+------+----+-------------------------------------------------+-------+
| 4    | P  |                                                 | 29    |
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+------+----+-------------------------------------------------+-------+
| 5\.  | GU |                                                 | 31    |
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+------+----+-------------------------------------------------+-------+
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+------+----+-------------------------------------------------+-------+
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| 48   |    |                                                 |       |
+------+----+-------------------------------------------------+-------+
|      |    |                                                 |       |
+------+----+-------------------------------------------------+-------+

  ---------------------- ----------------------------------------------------- --------------------
  LIST OF FIGURES                                                              

  [FIGURE]{.underline}                                                         [PAGE]{.underline}

  1                      Risk of Hip Fracture in Males Using Standardized      63
                         Total Hip BMD                                         
  ---------------------- ----------------------------------------------------- --------------------

  --------------------- ----------------------------------------------------- --------------------
  LIST OF TABLES                                                              

  [TABLE]{.underline}                                                         [PAGE]{.underline}

  1                     50^th^ Percentile Values for Maximal Aerobic Power    18

  2                     CEV Functional Strength Requirements                  60

  3                     Example career effective dose limits                  66

  4                     Dose limits for short-term or career non-cancer       67
                        effects                                               
  --------------------- ----------------------------------------------------- --------------------

**NASA Space Flight Human System Standard**

**Volume 1: Crew Health**

1\. SCOPE

1.1 Purpose

NASA policy for establishing standards to protect the health and safety
of crew, and for providing health and medical programs for crewmembers
during all phases of space flight, is authorized by NPD 1000.3, The NASA
Organization, and NPD 8900.5, NASA Health and Medical Policy for Human
Space Exploration. NPD 8900.1, Medical Operations Responsibilities in
Support of Human Space Flight Programs and NPD 8900.3, Astronaut Medical
and Dental Observation Study and Care Program, authorize the specific
provision of health and medical programs for crewmembers. NASA\'s policy
is to establish standards for providing a healthy and safe environment
for crewmembers, and to provide health and medical programs for
crewmembers during all phases of space flight. Standards are established
to optimize crew health and performance, thus contributing to overall
mission success, and to prevent negative long-term health consequences
due to space flight. In this document, the Office of the Chief Health
and Medical Officer establishes NASA's space flight Crew Health
standards for the pre-flight, in-flight, and post-flight phases of human
space flight.

Human system standards are established to guide and focus the
development of the crew health requirements as a means of protecting
space-faring crews. The standards presented in this document, NASA Space
Flight Human System Standards, Volume I: Crew Health, are intended to
complement the overall set of human standards for space flight, which
also includes NASA Space Flight Human Systems Standards, Volume II:
Habitability and Environmental Health; NASA Medical Standard for
Crewmembers; and current medical standards of clinical practice.
Combined, these standards provide Agency technical requirements for an
appropriate environment for human habitation, certification of human
participants, the necessary level of medical care, and risk-mitigation
strategies against the deleterious effects of space flight. The
standards described in this document include levels of care, permissible
exposure limits, fitness-for-duty criteria, and permissible outcome
limits as a means of defining successful operating criteria for the
human system. These standards help ensure mission completion, limit
morbidity, and reduce the risk of mortality during space flight
missions. See Appendix A for an overview document map.

All standards are based on the best available scientific and clinical
evidence, as well as operational experience from Apollo, Skylab,
Shuttle, Shuttle/MIR (United Soviet Socialists Republic (USSR) Space
Station), and International Space Station (ISS) missions. Standards are
periodically and regularly reviewed, especially as the concept of
operations and mission parameters for a program become defined, and may
be updated as new evidence emerges.

A Crew Health Concept of Operations document is developed by the Space
Medicine Division at the Johnson Space Center (JSC) for each space
flight program and coordinated with the appropriate Program Manager for
concurrence. See Appendix B for an example Crew Health Concept of
Operations outline.

Following the development of the Crew Health Concept of Operations, a
Medical Operations Requirements Document (MORD) is developed by the JSC
Space Medicine Division for each program. The MORD details the medical
requirements for the program, and is consistent with the overall medical
concept outlined in the Crew Health Concept document. See Appendix C for
an example outline of a MORD.

1.2 Applicability

These standards apply to all NASA human space flight programs and are
not developed for any specific program. However, while some of the
existing programs, such as the Space Shuttle and ISS Programs, meet the
intent and purpose of these standards currently, these standards may
have implications for longer duration missions and missions with
architectures and objectives outside of low Earth orbit (LEO). Although
the standards are applicable to the in-flight phase of all space
missions, it is anticipated that they are most relevant during
long-duration lunar outpost and Mars exploration missions, since the
combined ill effects of exposure to the space environment is of most
concern in those mission scenarios. The standards and technical
requirements specified in this volume shall

a\. Apply to all space exploration programs and activities involving
crewmembers.

b\. Apply to internationally provided space systems as documented in
distinct separate agreements such as joint or multilateral agreements.

c\. Be made applicable to contractors only through contract clauses,
specifications, or statements of work in conformance with the NASA
Federal Acquisition Regulation (FAR) supplement and not as direct
instructions to contractors.

d\. Supersede any conflicting crew health requirements imposed by other
NASA standards.

This standard may be cited in contract, program, and other Agency
documents as a technical requirement. Mandatory requirements are
indicated by the word "shall," statement of fact and descriptive
material by "is," and permission by "may" or "can." Tailoring of,
deviation from, or waivers to this standard for application to a
specific program or project shall be approved by the NASA Chief Health
and Medical Officer.

1.3 Overview

The Space Flight Human System Standard, Volume I: Crew Health considers
human physiologic parameters as a system, much as one views the
engineering and design of a mechanical device. Doing so allows the human
system to be viewed as an integral part of the overall vehicle design
process, as well as the mission reference design, treating the human
system as one system along with the many other systems that work in
concert to allow the nominal operation of a vehicle and successful
completion of a mission.

Volume 1, Crew Health covers the main physiologic parameters associated
with the health and successful operation of the human system. It is not
all encompassing, but does address those areas where the human system
has shown particular vulnerability in response to adaptation or exposure
to microgravity. The standards set forth in this volume serve as a
guideline to develop requirements for maintaining the human system
within normal operating parameters. To achieve this aim, the standards
of the human system should be considered in vehicle design, mission
architecture, countermeasures, and future directed research. Many of the
standards are not in their mature forms and are not fully identified for
all areas, perhaps because of a lack of knowledge as to the human system
physiology for that length and scale of mission, or other reasons. In
such cases, top-level functional standards for these are cited, and
further work is/may be required to define the standard more accurately.

A cascading effect is often seen with system failures in engineering,
and so it is with the human system as well.

2\. APPLICABLE DOCUMENTS

2.1 General

The documents listed in this section contain provisions that constitute
requirements of this standard as cited in the text of section 4. The
latest issuances of cited documents shall be used unless otherwise
approved by NASA Chief Health and Medical Officer. The applicable
documents are accessible via the NASA Technical Standards System at
[**http://standards.nasa.gov**](http://standards.nasa.gov/), directly
from the Standards Developing Organizations, or from other document
distributors.

2.2 Government Documents

[National Aeronautics and Space Administration]{.underline}

NASA Crewmember Medical Standards, Volume I

JSC 25396 NASA Astronaut Medical Standards Selection and Annual

Medical Certification Payload Specialist Class III

JSC 27384 Procedure Manual for the NASA Psychological Services Group

2.3 Non-Government Documents

None.

2.4 Order of Precedence

When this standard is applied as a requirement or imposed by contract on
a program or project, the technical requirements of this standard take
precedence, in the case of conflict, over the technical requirements
cited in applicable documents or referenced guidance documents.

3\. ACRONYMS AND DEFINITIONS

3.1 Acronyms and Abbreviations

ACLS Advanced Cardiac Life Support

ACSM American College of Sports Medicine

AED Automated External Defibrillator

ALARA As Low as Reasonably Achievable

AMB Aerospace Medical Board

ART Assisted Reproductive Technology

ATLS Advanced Trauma Life Support

BFO Blood Forming Organism

BMD Bone Mineral Density

CBA clinical blood analyzer

CDR Commander

CEV Crew Exploration Vehicle

CMO Crew Medical Officer

CNS Central Nervous System

CPR Cardiopulmonary Resuscitation

CS Crew Surgeon

DEXA T Dual Energy X-ray Absorptiometry

DMCF Designated Medical Care Facility

DSS Destination Service Segment

EMS Emergency Medical Services

EVA Extravehicular Activity

FAR Federal Acquisition Regulation

FCOD Flight Crew Operations Directorate

FFD Fitness for Duty

FMC Flight Medicine Clinic

FS Flight Surgeon

g Gravity

GCR Galactic Comic Rays

HQ Headquarters

HSP Health Stabilization Program

ISS International Space Station

JSC Johnson Space Center

LEO Low Earth Orbit

LET Low Linear-Energy Transfer

LMS Life and Microgravity Spacelab

kg Kilograms

m Meters

~max\ (Subscript)~ Maximum

MCC Mission Control Center

MIR USSR Space Station

min minute

ml milliliter

MOD Mission Operations Directorate

MORD Medical Operations Requirements Document

MOSIPs Medical Operations Support Implementation Plans

MPB Medical Policy Board

NASA National Aeronautics and Space Administration

NCRP National Council on Radiation Protection

NPD NASA Policy Directive

NPR NASA Procedural Requirements

Ops Operations

PAWS Performance Assessment Workstation

PFCs Private Family Conferences

PMC Private Medical Communication/Conference

POL Permissible Outcome Limits

PRD Program Requirements Document

RBE Relative Biological Effectiveness

REID Risk of Exposure-Induced Death

SD Standard Deviation

SMS Space Motion Sickness

SPE Solar Particle Event

SPEL Space Permissible Exposure Limits

STD Standard

U.S. United States

USSR United Soviet Socialists Republic

VO Volume of oxygen

WHO World Health Organization

3.2 Definitions

None.

4\. REQUIREMENTS

4.1 Levels of Medical Care

Medicine typically uses two phrases to discuss care: (1) the Level of
Care that one can provide and (2) the Standards of Care. These are not
interchangeable terms. "Level of Care" refers to the amount and type of
care rendered based on perceived need and the ability of the provider,
whereas "Standard of Care" is the benchmark and current clinical
practice by which that care is provided. See Appendix D for additional
rationale on levels of care.

The Level of Care that can be provided during any particular space
mission is dependent on several factors:

a\. The level of training of the medical provider.

b\. The technology and advances in medicine that allow such care to be
rendered in austere environments.

c\. The distance from the platform to more definitive care.

d\. The duration of the mission.

e\. The health and performance of the crew upon embarking on the
mission.

f\. The type of mission, to include vehicle, mass, length of stay,
extravehicular activities (EVAs), and mission objectives.

g\. Mission/Programmatic philosophy of accepted medical risk (Crew
Health Concept of Operations and MORD).

h\. Medical risk of illness or injury.

i\. Time required to return to Earth or other fallback location for more
definitive medical treatment.

j\. Terrestrial medical standards.

In addition to human space flight, the training environment for space
flight missions also carries some inherent risk. Vacuum chambers, diving
operations, flying operations, suited flight profiles, survival
training, and other types of training may have similar risks and
concerns; and thus training environments may also be discussed within
the Levels of Care.

4.1.1 Levels of Care

4.1.1.1 Level of Care Zero

No perceived threat to health or life exists, and there is no planned
medical support to mitigate any risks. There are currently no space
vehicles or missions in human space flight with this level of care;
however, there are training situations that fall into this category.
Level of Care Zero does not require any special medical support.
Examples for Level of Care Zero are non-hazardous training activities. A
T-38 flight, although hazardous in respect to aviation, does not have an
overwhelming medical threat or risk. Thus, it has a survival kit but
does not have medical kits as part of perceived medical risk mitigation.

4.1.1.2 Level of Care One

Little perceived threat to health or life exists during training or that
portion of the mission where medical intervention would be allowed, and
the relatively short time and distance to definitive care allows for
first-aid implementation without more advanced care. Level of Care One
requires a minimum of (basic life support) first-aid capability and
implementation plans for follow-on medical support. Level of Care One
shall be provided for survival training and transfer missions to
vehicles in LEO (e.g., Shuttle or Crew Exploration Vehicle (CEV) to ISS)
or for sub-orbital flights.

4.1.1.3 Level of Care Two

4.1.1.3.1 A moderate level of risk exists that personnel may experience
medical problems during training or that portion of the mission.
Preventive strategies shall be used to reduce the risk.

4.1.1.3.2 Intervention strategies shall be used to reduce the risk to an
acceptable level with return to Earth available for more serious
illness/injuries.

4.1.1.3.3 Level of Care Two shall be provided for crews in LEO for less
than 30 days (e.g., stand alone Space Shuttle missions).

4.1.1.4 Level of Care Three

4.1.1.4.1 A moderate to high level of risk exists that personnel may
experience medical problems during training or that portion of the
mission. Preventive strategies shall be used to a greater degree to
reduce the overall risk.

4.1.1.4.2 Intervention strategies shall be used to reduce the risk to an
acceptable level and shall include an increased level of advanced care
in the form of medications or equipment.

4.1.1.4.3 Plans shall be available for transport to Definitive Medical
Care Facilities (DMFC) upon return to Earth.

4.1.1.4.4 Return to Earth capability shall be available for more serious
illness/injuries on orbit, when feasible. It is also expected that all
rescue crews, whether they be NASA sponsored or DoD sponsored, that
support launch and landing contingencies can provide this Level of Care.

4.1.1.4.5 Level of Care Three shall be provided for space flight crews
that are engaged in missions outside of LEO, but of a short duration
(e.g., lunar/planetary/missions equal to or less than 30 days).

4.1.1.5 Level of Care Four

4.1.1.5.1 A moderate to high level of potential risk exists that
personnel may experience medical problems on orbit. Risk to the mission
is greater for medical issues beyond routine ambulatory medicine.
Preventive strategies shall be used to a greater degree to reduce the
overall risk.

4.1.1.5.2 The ability to support chronic illness is limited.
Intervention strategies shall be used to reduce the risk to an
acceptable level and shall include increasing levels of advanced care in
the form of medications, equipment, training, or consumables over and
above previous levels.

4.1.1.5.3 The scope of medical care available shall be limited or
triaged due to availability of supplies, consumables, or mission risk.
Return to Earth is not readily available and takes days, not hours, for
more serious illness/injuries. Impact to overall mission is greater.

4.1.1.5.4 Level of Care Four shall be provided for lunar/planetary
(destination surface segment) missions greater than 30 days, but equal
to or less than 210 days, as well as missions in LEO greater than 30
days (e.g., ISS).

4.1.1.6 Level of Care Five

4.1.1.6.1 A high level of potential risk exists that personnel may
experience medical problems on orbit at some time during the mission.
Preventive strategies shall be used to a greater degree to reduce the
overall risk.

4.1.1.6.2 The ability to support chronic illness is limited.
Intervention strategies shall be used to reduce the risk to an
acceptable level and shall include increasing levels of advanced care in
the form of medications, equipment, training, or consumables over and
above those for previous levels.

4.1.1.6.3 The training and caliber of the caregiver shall be at the
physician level, due to the exclusively autonomous nature of the
mission.

4.1.1.6.4 The scope of medical care available shall be limited or
triaged due to availability of supplies, consumables, or mission risk.
Return to Earth is not a viable option for more serious
illness/injuries. Impact to overall mission is greater.

4.1.1.6.5 Level of Care Five shall be provided for lunar/planetary
missions greater than 210 days.

4.1.1.7 Termination of Care

4.1.1.7.1 NASA shall have a policy and procedures for termination of
care, in the event the crewmember cannot be saved, or if continued
treatment causes undue risk or peril to the remaining crew.

4.1.1.7.2 Topics such as disposition of the deceased shall be included
in this plan.

4.2 Standards for Human Performance

4.2.1 Overview

In order to support the Exploration Vision and to guide and focus
efforts to protect the health of space-faring crews, Space Flight Health
Standards for Human Performance has been developed. These standards
provide a declaration of acceptable medical risk from the deleterious
health and performance effects of space flight, and help target and
prioritize biomedical research and technology development efforts,
providing target parameters for products and deliverables that support
the health maintenance of crews during space missions. They also promote
operational and vehicle design requirements, and aid in medical decision
making during space missions.

The standards are based on the best available scientific and clinical
evidence. Research findings, lessons learned from previous space
missions and in analogue environments, current standards of medical
practice, risk management data, and expert recommendations were all
considered in the process of setting the standards. The process used for
setting the standards was modeled on that used by the United States
Occupational Safety and Health Administration, but were tailored to meet
the unique needs and characteristics associated with the human health
aspects of space exploration and the NASA mission.

These standards shall be periodically and regularly reviewed, and may be
updated as new evidence emerges. Additional standards may be developed
as the need arises or is identified.

Appendix F, Rationale for Space Flight Health Standards for Human
Performance,, provides additional information on the content of the
standards and supporting information that can help guide actions to
address them.

4.2.2 Types of Standards

4.2.2.1 [Fitness for Duty]{.underline} (FFD) - Minimum measurable
capability or capacity for a given physiological or behavioral parameter
that allows successful performance of all required duties. Functional
capacity measured.

4.2.2.2 [Space Permissible Exposure Limits (SPEL)]{.underline} -
Quantifiable limit of exposure to a space flight factor over a given
length of time (e.g., lifetime radiation exposure). Physical/chemical
agent measured.

4.2.2.3 [Permissible Outcome Limits (POL)]{.underline} - Acceptable
maximum decrement or change in a physiological or behavioral parameter,
during or after a space flight mission, as the result of exposure to the
space environment. Biological/clinical parameter measured (e.g., bone
density).

4.2.3 Fitness-for-Duty Aerobic Capacity Standard

4.2.3.1 Crewmembers shall have a pre-flight maximum aerobic capacity
(VO~2max~) at or above the mean for their age and sex (see American
College of Sports Medicine Guidelines (ACSM)), in table 1 below).

Table 1---50^th^ Percentile Values for Maximal Aerobic Power (ml kg^-1^
min^-1^)

  ----------------------- --------------------- -------------------------
  Age                     Men                   Women

  20-29                   43.5                  35.2

  30-39                   41.0                  33.8

  40-49                   38.1                  30.9

  50-59                   35.2                  28.2

  60+                     31.8                  25.8
  ----------------------- --------------------- -------------------------

4.2.3.2 The in-flight aerobic fitness shall be maintained, either
through countermeasures or work performance, at or above 75 percent of
the pre-flight value, as determined by either direct or indirect
measures.

4.2.3.3 The post-flight rehabilitation shall be aimed at achieving a
VO~2max~ at or above the mean for age and sex (see ACSM's Guidelines in
table 1).

4.2.4 Fitness-for-Duty Sensorimotor Standard

4.2.4.1 Pre-flight sensorimotor functioning shall be within normal
values for age and sex of the astronaut population.

4.2.4.2 In-flight Fitness-for-Duty standards shall be guided by the
nature of mission-associated high-risk activities, and shall be assessed
using metrics that are task specific.

4.2.4.3 Sensorimotor performance limits for each metric shall be
operationally defined.

4.2.4.4 Countermeasures shall maintain function within performance
limits.

4.2.4.5 Post-flight rehabilitation shall be aimed at returning to
baseline sensorimotor function.

4.2.5 Fitness-for-Duty Behavioral Health and Cognition Standard

4.2.5.1 Pre-flight-, in-flight, and post-flight crew behavioral health
and crewmember cognitive state shall be within clinically accepted
values as judged by clinical psychological evaluation.

4.2.5.2 End-of-mission rehabilitation for crewmember cognitive state
shall be aimed at transitioning the crewmember back to pre-flight
values.

4.2.5.3 End-of-mission rehabilitation for behavioral health of the
crewmember shall be aimed at transitioning the crewmember back into
terrestrial work, family, and society.

4.2.5.4 The planned number of hours for completion of critical tasks and
events, workday, and planned sleep period shall have established limits
to assure continued crew health and safety.

4.2.6 Fitness-for-Duty Hematology and Immunology Standard

4.2.6.1 Pre-launch hematological/immunological function shall be within
normative ranges established for the healthy general population.

4.2.6.2 In-flight countermeasures shall be in place to sustain
hematological/immunological parameters within the normal range as
determined by direct or indirect means.

4.2.6.3 Countermeasures and monitoring shall be developed to ensure
immune and hematology values remain outside the "critical values" (i.e.,
that level which represents a significant failure of the
hematological/immunological system and is associated with specific
clinical morbidity) defined for specific parameters.

4.2.6.4 Post-flight rehabilitation shall be aimed at returning to
pre-flight baseline.

4.2.7 Permissible Outcome Limit for Nutrition Standard

4.2.7.1 Pre-flight nutritional status shall be assessed and any
deficiencies mitigated prior to launch.

4.2.7.2 In-flight nutrient intake shall be no less than 90 percent of
the calculated nutrient requirements, based on an individual's age, sex,
body mass (kg), height (m), and an activity factor of 1.25.

4.2.7.3 Nutrition planning shall be aimed at maintaining a body mass and
composition greater than 90 percent of pre-flight values.

4.2.7.4 Post-flight nutritional assessment and rehabilitation shall be
aimed at returning to baseline.

4.2.8 Permissible Outcome Limit for Muscle Strength Standard

**4.2.8.1** Pre-flight muscle strength and function shall be within
normal values for age and sex of the astronaut population.

**4.2.8.2** Countermeasures shall maintain in-flight skeletal muscle
strength at or above 80 percent of baseline values.

**4.2.8.3** Post-flight rehabilitation shall be aimed at returning to
baseline muscle strength.

**4.2.9 Permissible Outcome Limit for Microgravity-Induced Bone Mineral
Loss**

## **Performance Standard (Baseline with Measured T-score)**

4.2.9.1 Crewmembers\' pre-flight bone mass Dual Energy X-ray
Absorptiometry (DEXA T) score shall not exceed -1.0 (-1.0 Standard
Deviation (SD) below the mean Bone Mineral Density).

4.2.9.2 Countermeasures shall be aimed at maintaining bone mass
in-flight consistent with outcome limits.

4.2.9.3 The post-flight (end of mission) bone mass DEXA T score shall
not exceed -2.0 (-2.0 SD below the mean Bone Mineral Density).

4.2.9.4 Post-flight rehabilitation shall be aimed at returning bone mass
to pre-flight baseline.

4.2.10 Space Permissible Exposure Limit for Space Flight Radiation
Exposure Standard

4.2.10.1 Planned career exposure for radiation shall not exceed 3
percent risk of exposure-induced death (REID) for fatal cancer.

4.2.10.2 NASA shall assure that this risk limit is not exceeded at a 95
percent confidence level using a statistical assessment of the
uncertainties in the risk projection calculations to limit the
cumulative effective dose (in units of Sievert) received by an astronaut
throughout his or her career.

4.2.10.3 Exploration Class Mission radiation exposure limits shall be
defined by NASA based on National Council on Radiation Protection (NCRP)
recommendations.

4.2.10.4 Planned radiation dose shall not exceed short-term limits as
defined in table 4 in Appendix F supporting material for the radiation
standard.

4.2.10.5 In-flight radiation exposures shall be maintained using the "as
low as reasonably achievable (ALARA) principle.

4.3 Health and Medical Screening, Evaluation, and Certification

a\. A program of comprehensive health care shall be provided that
minimizes undesirable health consequences and enables a healthy and
productive crew to accomplish mission goals.

b\. Requirements for the health, medical safety, and well-being of the
crewmembers for each space flight program shall be established by the
Space Medicine Division at JSC.

4.3.1 Initial Selection Requirements

a\. The NASA Medical Standards for Crewmembers includes initial
selection criteria approved by the Chair, Medical Policy Board (MPB).
The initial medical screening, testing, and certification required for
astronaut selection shall be conducted by the JSC Flight Medicine Clinic
(FMC) and Aerospace Medical Board (AMB), as outlined in the NASA
Crewmember Medical Standards, Volume I and JSC 27384, Procedure Manual
for the NASA Psychological Services Group.

b\. Medical standards and procedures for this process shall be
maintained and updated on a periodic basis through formal review
involving the JSC AMB and NASA MPB. Selection and waiver criteria differ
for the different types of missions (long duration versus short).

4.3.2 Medical Certification and Evaluation

4.3.2.1 Annual Evaluations

a\. Crewmember certification medical examinations shall be performed
annually by the JSC FMC.

b\. These evaluations shall be performed in accordance with NASA
Crewmember Medical Standards, Volume I.

c\. Payload specialists shall have a current certification according to
JSC 25396, NASA Astronaut Medical Standards Selection and Annual Medical
Certification Payload Specialist Class III.

d\. Waivers shall be approved through the JSC AMB. Waivers in excess of
6 months and permanent medical disqualifications shall be reviewed for
approval by the MPB Chair.

4.3.2.2 Selection for a Mission

During the selection process for crewmember assignment, the JSC Space
Medicine Division shall be consulted to ensure that the individual meets
the medical standards for that particular mission.

4.4 Medical Diagnosis, Intervention, Treatment, and Care

a\. Medical diagnosis, intervention, treatment, and care for illness and
injury shall be available to all crewmembers.

b\. Care on Earth shall be in accordance with current U.S. medical
standards and managed by the FMC.

c\. Medical intervention and care for assigned crews shall be managed by
the assigned flight surgeons beginning at a time designated by the Space
Medicine Division.

d\. In-flight medical intervention and care shall be available to all
crewmembers and shall be provided as close to current U.S. medical
standards as the program and mission allow.

e\. The level of in-flight medical intervention and care to be provided
for assigned crews shall be as described under the levels of care in
section 4.1 of this document.

4.4.1 Training Section

a\. A comprehensive medical training program shall be provided to
support crew health during space flight.

b\. Medical training to astronaut candidates, assigned crewmembers,
flight surgeons, mission control support staff, and other appropriate
ground support personnel (e.g., flight directors, consultants) shall be
provided by the JSC Space Medicine Division.

4.4.1.1 Astronaut Training

a\. Beginning with the astronaut candidate year, general medical
training shall be provided to the astronaut corps.

b\. Issues like first aid, cardiopulmonary resuscitation (CPR), altitude
physiological training, carbon dioxide exposure training,
familiarization with medical issues, procedures of space flight, and
psychological training shall be addressed.

c\. Supervised physical conditioning training shall be available.

4.4.1.1.1 Crewmember Medical Training

a\. Crewmembers who have received a mission assignment shall be provided
with more detailed and specific medical training.

b\. Health issues, space physiology, medical procedures, medical
equipment, toxicology, and countermeasures shall be included during this
training.

c\. This shall be documented in specific crew training documents for the
program.

4.4.1.1.2 Crew Medical Officer Training

a\. Each assigned flight crew shall have a minimum of two crewmembers
designated as crew medical officers (CMOs).

b\. The CMOs shall receive specific training to function as the
in-flight medical staff, which focuses on communications during a
private medical communication (PMC, diagnostics procedures, therapeutics
procedures, medical equipment, use of the medical checklist, and
anticipated medical contingencies.

4.4.1.2 Crew Surgeon Training

NASA and/or contractor flight surgeon(s) (FS) assigned to support the
subject space program shall receive training and certification as
defined in the Program, Medical Operations Flight Support Training and
Certification Plan. For the subject program, this training includes
courses such as mission controller certification, ACLS/ATLS, flight
medicine procedures, aerospace physiology, space medicine, hyperbaric
medicine, and emergency mishap response.

4.4.1.3 Medical Operations Flight Controller Training

All Medical Operations personnel staffing the Mission Control Center
(MCC) are required to complete the training and certification
requirements outlined in the Program, Medical Operations Flight Support
Training and Certification Plan. All medical operations MCC personnel
shall be trained in the following:

a\. MCC systems

b\. Biomedical monitoring equipment

c\. Vehicle life support systems

d\. Flight operations

e\. In-flight experiments

f\. Extravehicular activities

g\. Payloads

h\. EMS

i\. Crew Rescue

4.4.1.4 Other Support Personnel Training

Supervised training programs shall be implemented for individuals who
require knowledge of space medicine or flight medical procedures, such
as flight directors, medical consultants, and/or personnel deemed
appropriate by JSC Space Medicine Division.

4.4.1.5 Emergency Medical Services

a\. Requirements shall be provided by JSC Space Medicine Division in the
Program MORD or similar document and in a program requirements document
(PRD) or similar document to task outside agencies for EMS support and
ensure its implementation.

b\. Training shall be certified by the JSC Space Medicine Division for
EMS personnel who work launch operations, and that Division shall concur
on training plans for organizations that have a specific EMS training
plan in support of a NASA space flight program.

4.4.2 Pre-flight

a\. Pre-flight medical intervention and care shall be available to all
crewmembers, to include Assisted Reproductive Technology (ART) through
the JSC FMC if desired by the crewmember.

b\. Flight crewmember training and testing in situations that can be
hazardous to flight crewmember health shall be monitored by the crew
surgeon (CS) or designee.

c\. Specific pre-flight standards outlined in section 4.2 shall be
addressed in the Program MORD.

4.4.2.1 Crew Selection and Assignment

When operationally feasible, crew selection and assignment may consider
the application of validated information concerning personality and its
effect on crew composition.

4.4.2.2 Pre-flight Exercise

a\. A supervised physical conditioning program shall be available to all
crewmembers to assist in mission preparation.

b\. Specific exercise testing/training activities shall be offered to
crewmembers with mission-unique needs involving endurance, strength,
and/or flexibility.

4.4.2.3 Psychological Mission Training

Specific pre-flight briefings and/or training shall be provided as
appropriate to the commander (CDR), CMOs, crewmembers, key ground
personnel (e.g., Flight Director and Astronaut Support Person), and crew
families concerning the significant psychological and social phenomena
that may arise during and after a mission. This may include the
following:

a\. Provision of recommendations and guidelines for family support
activities

b\. Training and support for effective individual adaptation, crew
integration, and team dynamics

c\. Recommendations to Flight Crew Operations Directorate (FCOD), as
requested, to assist in crew assignment and composition

d\. Training for medical and other ground support personnel as indicated
in support of behavior and performance issues

e\. Cross-cultural training support as indicated for international
missions.

4.4.2.4 Physiological Adaptive Mission Training

Proven countermeasures designed to assist crewmembers with physiological
training and pre-flight adaptation in preparation for space flight shall
be provided.

4.4.2.5 Health Stabilization Program

a\. A Health Stabilization Program (HSP) that includes screening and
monitoring shall be in place during the preparatory stages of the
mission.

b\. The HSP shall reduce the likelihood of contracting an infectious
disease in the week prior to launch by limiting exposures.

c\. Pre-flight immunization against infectious diseases shall be
employed.

4.4.2.6 Circadian Shifting Operations

Support of crew schedule planning and operations shall be provided by
the JSC Space Medicine Division to include circadian entrainment,
work/rest schedule assessment, task loading assessment, and input to
special activity schedules.

4.4.2.7 Pre-flight Medical Evaluations

a\. To evaluate and certify medical fitness for flight, pre-flight
medical evaluations of all crewmembers shall be conducted before launch.

b\. These evaluations shall be performed at adjusted time intervals
according to the specific program requirements.

4.4.3 In-flight

Specific in-flight standards outlined in section 4.2 shall be addressed
in the Program MORD.

### 4.4.3.1 Risk Management and Data Integration

Crew health shall be monitored and medical data collected to accomplish
the following purposes:

a\. Real-time assessment of crewmember health

b\. Establishment of baseline health norms for space flight

c\. Health trend analysis of individual crewmembers, and identification
of health risks

### 4.4.3.2 Level of Medical Care

a\. The medical capability on a mission shall primarily be prepared to
handle those illnesses and injuries that will heal more rapidly with
treatment or will become serious without treatment.

b\. The levels of care described in section 4.1 shall be used to develop
the requirements for a space flight program or vehicle.

4.4.3.3 Private Medical Communication (PMC)

a\. A PMC shall be scheduled on a routine basis at a frequency dictated
for short- or long-duration missions and detailed in the Program MORD.

b\. Medical information that is sent to the ground via spacecraft
telemetry shall be supplemented through the use of the PMC. The PMC
deals directly with medical problems and preventive medicine.

c\. Two-way private voice and video communication shall be planned for
PMCs.

4.4.3.4 Periodic Health and Fitness Evaluation

a\. For long-duration space flight, a periodic health status evaluation
shall be conducted to monitor the crewmember's health.

b\. The timeline and details of the periodic health status shall be
documented in the Program MORD.

4.4.3.5 Countermeasures

a\. The capability to implement, monitor, and validate operational
in-flight countermeasures shall be provided to mitigate undesirable
physical, physiological, and psychological effects of space flight upon
crewmembers.

b\. The requirements shall be documented in the Program MORD.

4.4.3.5.1 Physiologic

The ability to define and monitor acceptable in-flight
physical/physiological parameters and provide pharmacologic and
therapeutic countermeasures to maintain these parameters shall be
provided.

4.4.3.5.2 General Health and Well Being

Countermeasures shall be provided to address issues of human factors and
general crew health and well being including considerations for hygiene,
privacy, nutrition, crew schedule, workload, Earth observation, and
leisure activities.

**4.4.3.5.3 Behavioral Health and Performance**

a\. Provisions shall be made to implement appropriate psychological
support programs for the crew, key ground personnel (e.g., Flight
Director and Astronaut Support Person), and crew families throughout the
mission.

b\. These shall be detailed in the Program MORD and may include the
following:

\(1\) Capability to monitor and assess psychological status

\(2\) Private Family Conferences (PFCs) with two-way video and/or voice
communication scheduled at least weekly for each crewmember

\(3\) Crisis intervention as needed

\(4\) Capabilities for crew relaxation, recreation, entertainment, news
services, and social communication

4.4.3.6 Extravehicular Activity (EVA)

All EVA shall be preceded by an assessment of medical fitness requiring
concurrence by ground medical support personnel.

4.4.3.6.1 Extravehicular Suit Monitoring

The extravehicular suit shall provide monitoring of suit parameters,
physiological variables, and external environmental variables.

4.4.3.6.2 Biomedical Data Availability

a\. EVA biomedical data shall be available to the MCC medical ground
support personnel.

b\. Biomedical monitoring parameters shall be documented in the Program
MORD.

4.4.3.6.3 Hyperbaric Oxygen Treatment

Hyperbaric treatment (stand alone, increase suit pressure, or
equivalent) shall be included as a part of medical intervention and care
when EVAs are considered part of the mission architecture.

4.4.3.7 Toxic Exposure Protection, Prevention, and Treatment

Personal protection and treatment of crewmembers subject to potential
toxic exposure shall be included as part of in-flight medical
intervention and care during all space missions.

4.4.3.8 Stabilization and Transport

a\. Medical intervention and care shall include the capability to
stabilize and transport an ill or injured crewmember. Transportation
time begins when the crewmember is medically stable for transport and
ends at delivery to a Definitive Medical Care Facility (DMCF).

b\. Stabilization and transport shall be addressed in the Program Crew
Health Concept of Operations and MORD.

c\. For those situations where stabilization and transport are not
possible or no longer required, procedures shall be incorporated into
the Crew Health Concept of Operations and MORD to address a crewmember
fatality.

4.4.3.9 Medical and Survival Kits

Requirements for vehicle medical kits (routine and survival) shall be
documented in the Program MORD and be consistent with the capabilities
described in the Program Health Care Concept of Operations.

4.4.3.10 Medical Operations Ground Support

4.4.3.10.1 Crew Health Monitoring

a\. Crew health surveillance shall be performed during missions by JSC
Space Medicine Division personnel.

b\. Personnel shall monitor critical flight activities, respond to
contingencies, and take corrective medical action as necessary.

c\. In addition to the program of routine crew health assessment, crew
health monitoring shall be performed by JSC Space Medicine Division
personnel during intense exercise, medical tests, EVAs, and hazardous
flight operations where real-time decisions and action may be required.

4.4.3.10.2 Record Keeping

a\. The results of all crew health monitoring shall be kept in a
permanent and easily retrievable format for trend analysis.

b\. There shall be a simple and rapid way to communicate the data to the
records.

c\. The method for handling, storing, and transmission of crewmembers'
medical health records shall be secured.

## **4.4.4 Post-flight**

a\. The post-landing timeline for crewmember activities shall be
controlled by a program document.

b\. Signature by the JSC Space Medicine Division shall be on the program
document.

c\. The medical safety of the crew during the post-flight phase shall be
ensured by the JSC Space Medicine Division.

d\. Specific post-flight standards outlined in section 4.2 shall be
addressed in the MORD.

e\. This post-flight health care shall be provided to support
rehabilitation and to minimize the chance of illness or injury to the
crewmember due to his or her deconditioned state.

4.4.4.1 Post-flight Medical Evaluations

a\. Medical evaluation and monitoring of crews shall be conducted by
NASA FSs or contractor FSs immediately post-flight periodically until
crew status is stable.

b\. Criteria for the immediate post-flight medical evaluation at the
landing site shall be provided in the Program MORD.

4.4.4.2 Emergency Medical Services

a\. Requirements shall be provided by JSC Space Medicine Division in the
Program MORD or similar document and in a PRD or similar document to
task outside agencies for EMS support and ensure its implementation.

b\. Training shall be certified by the JSC Space Medicine Division for
EMS personnel who work launch and landing operations.

c\. Concurrence on training plans for organizations that have a specific
EMS training plan in support of a NASA space flight program shall be
obtained from the JSC Space Medicine Division.

4.4.4.3 Rehabilitation

a\. A post-flight crew rehabilitation program shall be planned,
coordinated, and implemented by the JSC Space Medicine Division, in
cooperation with the FCOD and Mission Operations Directorate (MOD). The
post-flight rehabilitation starts with crew egress at landing, and
includes a guided, phased reconditioning protocol.

b\. The individualized rehabilitation program shall be specific to
crewmember and mission type and duration. The goals of the
rehabilitation program are as follows:

\(1\) Ensure the health and safety of the returning crew

\(2\) Actively assist the crew\'s return to full functional abilities
and return-to-flight status

\(3\) Actively assist in the crew's return to pre-flight fitness

4.4.4.4 Psychological Function

Provisions shall be made to implement appropriate psychological support
programs as needed for the crew, key ground personnel (e.g., Flight
Director and Astronaut Support Person), and the crew families following
space flight.

4.4.4.5 Post-flight Testing

a\. Post-flight medical intervention and care shall be available to all
flight crewmembers of space missions and shall include the following:

\(1\) Physical examinations

\(2\) Clinical laboratory tests

\(3\) Physical and psychosocial re-adaptation

\(4\) Treatment as required

\(5\) Scheduled days off and rest periods

\(6\) Circadian rhythm retraining

\(7\) Nutrition assessment and support

b\. The FS or designee shall monitor flight crewmember testing in
situations that can be hazardous to the health of the flight crew.

5\. GUIDANCE

5.1 Reference Documents

> ACSM's *Guidelines for Exercise Testing and Prescription*, 6^th^
>
> Edition. 2000. Franklin BA, Whaley MH, Howley ET (eds). Philadelphia.
> Lippincott, Williams & Wilkins. 77p.

NASA-STD-3001 NASA Space Flight Human Systems Standards, Volume 2:

Habitability and Environmental Health

NPD 1000.3 The NASA Organization

NPD 8900.1 Medical Operations Responsibilities in Support of Human Space

Flight Programs

NPD 8900.3 Astronaut Medical and Dental Observation Study and Care

Program

NPD 8900.5 NASA Health and Medical Policy for Human Space Exploration

APPENDIX A

DOCUMENT MAP

APPENDIX B

EXAMPLE OUTLINE OF A CONCEPT OF OPERATIONS

[Crew Health Concept of Operations for Constellation
Missions](#__RefHeading___Toc130724561)

[Section I - Introduction](#__RefHeading___Toc130724562)

[General/Overview](#__RefHeading___Toc130724563)

[Purpose](#__RefHeading___Toc130724564)

[Scope](#__RefHeading___Toc130724565)

[Authority](#__RefHeading___Toc130724566)

[NASA Medical Authority Structure](#__RefHeading___Toc130724567)

[Risk](#__RefHeading___Toc130724568)

[Assumptions](#__RefHeading___Toc130724569)

[General Assumptions](#__RefHeading___Toc130724570)

[Crew Health Assumptions](#__RefHeading___Toc130724571)

[Countermeasure Assumptions](#__RefHeading___Toc130724572)

[Environmental Assumptions](#__RefHeading___Toc130724573)

[Section II - Pre-flight](#__RefHeading___Toc130724574)

[Crew Health](#__RefHeading___Toc130724575)

[Health Stabilization Program](#__RefHeading___Toc130724576)

[Countermeasures](#__RefHeading___Toc130724577)

[Physical Conditioning](#__RefHeading___Toc130724578)

[Environmental](#__RefHeading___Toc130724579)

[Air Quality/Toxicology](#__RefHeading___Toc130724580)

[Acoustics](#__RefHeading___Toc130724581)

[Microbiology](#__RefHeading___Toc130724582)

[Water Chemistry](#__RefHeading___Toc130724583)

[Radiation](#__RefHeading___Toc130724584)

[Section III - Launch](#__RefHeading___Toc130724585)

[Medical Support](#__RefHeading___Toc130724586)

[Countermeasures](#__RefHeading___Toc130724587)

[Environmental](#__RefHeading___Toc130724588)

[Section IV - In-flight/On-orbit](#__RefHeading___Toc130724589)

[General/Overview](#__RefHeading___Toc130724590)

[Medical/Physiological Considerations of Exploration Class
Missions](#__RefHeading___Toc130724591)

[Space Motion Sickness](#__RefHeading___Toc130724592)

[Behavior and Performance Evaluation](#__RefHeading___Toc130724593)

[Decompression Illness](#__RefHeading___Toc130724594)

[Neurovestibular](#__RefHeading___Toc130724595)

[Cardiovascular](#__RefHeading___Toc130724596)

[Bone](#__RefHeading___Toc130724597)

[Immune Response](#__RefHeading___Toc130724598)

[Muscle Alterations and Atrophy](#__RefHeading___Toc130724599)

[Nutrition](#__RefHeading___Toc130724600)

[Environmental Health Considerations of Exploration Class
Missions](#__RefHeading___Toc130724601)

[Radiation](#__RefHeading___Toc130724602)

[Crew Exploration Vehicle (CEV) Transfer Missions (ISS, Lunar, and To Be
Determined\
Mars Transfer Vehicle)](#__RefHeading___Toc130724603)

[General/Overview](#__RefHeading___Toc130724604)

[Risks](#__RefHeading___Toc130724605)

[Matrix Overview](#__RefHeading___Toc130724606)

[CEV](#__RefHeading___Toc130724607)

[Medical Intervention and Care](#__RefHeading___Toc130724608)

[Minimum Levels of Medical Care for Transfer
Missions](#__RefHeading___Toc130724609)

[First Aid/Ambulatory/Basic Life Support](#__RefHeading___Toc130724610)

[Private Conferences](#__RefHeading___Toc130724611)

[Electronic Mail](#__RefHeading___Toc130724612)

[Countermeasures](#__RefHeading___Toc130724613)

[Environmental](#__RefHeading___Toc130724614)

[Air Quality/Toxicology](#__RefHeading___Toc130724615)

[Acoustics](#__RefHeading___Toc130724616)

[Microbiology](#__RefHeading___Toc130724617)

[Water Chemistry](#__RefHeading___Toc130724618)

[Radiation Ops](#__RefHeading___Toc130724619)

[EVA](#__RefHeading___Toc130724620)

[Lunar Sortie Mission](#__RefHeading___Toc130724621)

[General/Overview](#__RefHeading___Toc130724622)

[Risk](#__RefHeading___Toc130724623)

[Medical Intervention and Care](#__RefHeading___Toc130724624)

[Minimum Levels of Medical Care](#__RefHeading___Toc130724625)

[First Aid/Ambulatory/Basic Life Support](#__RefHeading___Toc130724626)

[Private Conferences](#__RefHeading___Toc130724627)

[Electronic Mail](#__RefHeading___Toc130724628)

[Countermeasures](#__RefHeading___Toc130724629)

[Environmental](#__RefHeading___Toc130724630)

[Air Quality/Toxicology](#__RefHeading___Toc130724631)

[Acoustics](#__RefHeading___Toc130724632)

[Microbiology](#__RefHeading___Toc130724633)

[Water Chemistry](#__RefHeading___Toc130724634)

[Radiation Ops](#__RefHeading___Toc130724635)

Extravehicular Activity ([EVA) Operations](#__RefHeading___Toc130724636)

[Lunar Mission with Destination Surface
Segment](#__RefHeading___Toc130724637)

[General/Overview](#__RefHeading___Toc130724638)

[Risk](#__RefHeading___Toc130724639)

[Medical Intervention and Care](#__RefHeading___Toc130724640)

[Minimum Level of Medical Care](#__RefHeading___Toc130724641)

[First Aid/Ambulatory/Basic Life Support](#__RefHeading___Toc130724642)

[Chronic Care](#__RefHeading___Toc130724643)

[Periodic Health and Fitness Evaluations](#__RefHeading___Toc130724644)

[Private Conferences](#__RefHeading___Toc130724645)

[Electronic Mail](#__RefHeading___Toc130724646)

[EVA Operations](#__RefHeading___Toc130724647)

[Countermeasures](#__RefHeading___Toc130724648)

[Environmental](#__RefHeading___Toc130724649)

[Air Quality/Toxicology](#__RefHeading___Toc130724650)

[Acoustics](#__RefHeading___Toc130724651)

[Microbiology](#__RefHeading___Toc130724652)

[Water Chemistry](#__RefHeading___Toc130724653)

[Radiation Ops](#__RefHeading___Toc130724654)

[Mars Missions](#__RefHeading___Toc130724655)

[Section V - Return](#__RefHeading___Toc130724656)

[Medical Intervention and Care](#__RefHeading___Toc130724657)

[Countermeasures](#__RefHeading___Toc130724658)

[Environmental](#__RefHeading___Toc130724659)

[Section VI - Landing and Crew Recovery](#__RefHeading___Toc130724660)

[Ground Support Operations - Medical
Support](#__RefHeading___Toc130724661)

[General/Overview](#__RefHeading___Toc130724662)

[Nominal Landing Medical Support](#__RefHeading___Toc130724663)

[Section VII - Post-landing](#__RefHeading___Toc130724664)

[Medical Intervention and Care](#__RefHeading___Toc130724665)

[Return to Johnson Space Center](#__RefHeading___Toc130724666)

[Medical Assessment](#__RefHeading___Toc130724667)

[Rehab/Countermeasures/ Physical
Conditioning](#__RefHeading___Toc130724668)

[Countermeasures](#__RefHeading___Toc130724669)

[Environmental](#__RefHeading___Toc130724670)

[Section VIII - Medical Selection, Certification, and
Training](#__RefHeading___Toc130724671)

[Medical Selection and Certification](#__RefHeading___Toc130724672)

[Medical Exams](#__RefHeading___Toc130724673)

[Additional Medical Exams](#__RefHeading___Toc130724674)

[Behavioral Health](#__RefHeading___Toc130724675)

[Pre-flight Training](#__RefHeading___Toc130724676)

[Crewmember Training](#__RefHeading___Toc130724677)

[Hazardous Training](#__RefHeading___Toc130724678)

[EVA Training](#__RefHeading___Toc130724679)

[Crew Medical Training](#__RefHeading___Toc130724680)

[CEV Missions](#__RefHeading___Toc130724681)

[Lunar Sortie Mission](#__RefHeading___Toc130724682)

[Lunar Mission with Destination Surface
Segment](#__RefHeading___Toc130724683)

[Countermeasures Training](#__RefHeading___Toc130724684)

[Pre-flight](#__RefHeading___Toc130724685)

[CEV Missions](#__RefHeading___Toc130724686)

[Lunar Sortie Mission](#__RefHeading___Toc130724687)

[Lunar Mission with Destination Surface
Segment](#__RefHeading___Toc130724688)

[Environmental Training](#__RefHeading___Toc130724689)

[Medical Flight Control Team Training](#__RefHeading___Toc130724690)

[Mars Missions](#__RefHeading___Toc130724691)

[Section IX - Off-Nominal Situations](#__RefHeading___Toc130724692)

[Launch](#__RefHeading___Toc130724693)

[Abort Medical Support](#__RefHeading___Toc130724694)

[Pad](#__RefHeading___Toc130724695)

[Coastal Waters](#__RefHeading___Toc130724696)

[Open Ocean](#__RefHeading___Toc130724697)

[Countermeasures](#__RefHeading___Toc130724698)

[Environmental](#__RefHeading___Toc130724699)

[In-flight/On-orbit](#__RefHeading___Toc130724700)

[CEV](#__RefHeading___Toc130724701)

[Medical Intervention and Care](#__RefHeading___Toc130724702)

[Chronic Care](#__RefHeading___Toc130724703)

[Advanced Life Support](#__RefHeading___Toc130724704)

[Countermeasures](#__RefHeading___Toc130724705)

[Environmental](#__RefHeading___Toc130724706)

[Air Quality/Toxicology](#__RefHeading___Toc130724707)

[Acoustics](#__RefHeading___Toc130724708)

[Microbiology](#__RefHeading___Toc130724709)

[Water Chemistry](#__RefHeading___Toc130724710)

[Radiation Ops](#__RefHeading___Toc130724711)

[EVA](#__RefHeading___Toc130724712)

[Lunar Missions](#__RefHeading___Toc130724713)

[Lunar Sortie Mission](#__RefHeading___Toc130724714)

[Medical Intervention and Care](#__RefHeading___Toc130724715)

[Chronic Care](#__RefHeading___Toc130724716)

[Advanced Life Support](#__RefHeading___Toc130724717)

[Stabilization and Transport](#__RefHeading___Toc130724718)

[Countermeasures](#__RefHeading___Toc130724719)

[Environmental](#__RefHeading___Toc130724720)

[Air Quality/Toxicology](#__RefHeading___Toc130724721)

[Acoustics](#__RefHeading___Toc130724722)

[Microbiology](#__RefHeading___Toc130724723)

[Radiation Ops](#__RefHeading___Toc130724724)

[EVA](#__RefHeading___Toc130724725)

[Lunar Mission with DSS](#__RefHeading___Toc130724726)

[Medical Intervention and Care](#__RefHeading___Toc130724727)

[Advanced Life Support](#__RefHeading___Toc130724728)

[Stabilization and Transport](#__RefHeading___Toc130724729)

[Countermeasures](#__RefHeading___Toc130724730)

[Environmental](#__RefHeading___Toc130724731)

[Air Quality/Toxicology](#__RefHeading___Toc130724732)

[Acoustics](#__RefHeading___Toc130724733)

[Microbiology](#__RefHeading___Toc130724734)

[Water Chemistry](#__RefHeading___Toc130724735)

[Radiation Ops](#__RefHeading___Toc130724736)

[EVA](#__RefHeading___Toc130724737)

[Mars](#__RefHeading___Toc130724738)

[Return](#__RefHeading___Toc130724739)

[Medical Intervention and Care](#__RefHeading___Toc130724740)

[Ill/Injured Crewmember Return](#__RefHeading___Toc130724741)

[Environmental](#__RefHeading___Toc130724742)

[Countermeasures](#__RefHeading___Toc130724743)

[EVA](#__RefHeading___Toc130724744)

[Landing and Crew Recovery](#__RefHeading___Toc130724745)

[Medical Intervention and Care](#__RefHeading___Toc130724746)

[Land](#__RefHeading___Toc130724747)

[Coastal Waters](#__RefHeading___Toc130724748)

[Open Ocean](#__RefHeading___Toc130724749)

APPENDIX C

# **EXAMPLE OUTLINE OF A MEDICAL OPERATIONS**

# **REQUIREMENTS DOCUMENT**

Title Page

Signature Page

Table of Contents

Section I - Introduction

1.1. General

1.2 Purpose

1.3 Scope

1.4 Authority

1.5 Applicability

1.6 Medical Authority Structure

1.6.1 U.S. Medical Authority Structure

1.6.1.1 HQ

1.6.1.2 AMB

1.6.2 U.S. Crew Care

1.6.2.1 Before Mission Selection

1.6.2.1.1 Flight Medicine Clinic

1.6.2.2 Following Mission Selection

1.6.2.2.1 Crew Surgeon Responsibility

1.6.2.2.1.1 Pre-flight

1.6.2.2.1.2 In-flight

1.6.2.2.1.3 Post-flight

1.6.3 International Medical Authority Structure (if applicable)

1.7 Privacy of Medical Information

1.7.1 Handling and Release of Medical Data

1.8 Risk Management and Data Integration

1.8.1 Risk Management

1.8.2 Data Integration

1.9 Medical Strategies for Space Flight Missions (See Appendix E in this
document)

1.10 Levels of Care (Define the levels of care for the mission. See
definitions in NASA

Space Flight Human System Standard, Volume 1, Section 4.1)

1.11 Mission Duration

1.11.1 Pre-flight Medical Evaluations

1.11.2 In-flight Medical Evaluations

1.11.2.1 Private Medical Communications

1.11.2.2 Nominal Health and Fitness Evaluation

1.11.2.3 Extravehicular Activity Medical Requirements

1.11.2.3.1 Extravehicular Mobility Unit Monitoring

1.11.3 Post-flight Medical Evaluations

Section II - Operations

2.1 Medical Intervention and Care

2.1.1 Pre-flight

2.1.1.1 Hazardous Training and/or Testing

2.1.2 In-flight

2.1.2.1 Minimum Level of Medical Care

2.1.2.1.1 First Aid/Ambulatory

2.1.2.1.2 Basic Life Support

2.1.2.1.3 Advanced Life Support (if required)

2.1.2.1.4 Stabilization and Transport

2.1.2.1.5 Chronic Care (if required)

2.1.2.1.6 Hyperbaric Oxygen Treatment (if required)

2.1.2.1.7 Toxic Exposure Protection, Prevention, and Treatment

2.1.2.1.8 Private Medical Conference

2.1.2.1.9 Periodic Health Status

2.1.2.1.10 Medical Operations Ground Support

2.1.2.1.10.1 Crew Health Monitoring

2.1.3 Post-flight

2.1.3.1 Rehabilitation

2.1.3.2 Testing

2.2 Environmental Health

2.2.1 Pre-flight

2.2.1.1 Water Quality

2.2.1.1.1 Water Quality Specifications

2.2.1.1.2 Water Monitoring Requirements

2.2.1.1.3 Water Decontamination Requirements

2.2.1.2 Air Quality

2.2.1.2.1 Off-gas Testing

2.2.1.2.2 Air Quality Specification

2.2.1.2.3 Air Monitoring Requirements

2.2.1.2.4 Air Decontamination Requirements

2.2.1.3 Microbiology

2.2.1.3.1 Microbiology Specifications

2.2.1.3.2 Microbiology Monitoring Requirements

2.2.1.3.3 Microbiology Decontamination Requirements

2.2.1.4 Radiation

2.2.1.4.1 Ionizing Radiation

2.2.1.4.1.1 Radiation Prediction, Monitoring, and Warning

2.2.1.4.1.2 Radiation Dose and Quality Monitoring

2.2.1.4.1.3 Crew Health Risk Assessment and Exposure Records

2.2.1.4.2 Non-Ionizing Radiation

2.2.2 In-flight

2.2.2.1 Water Quality

2.2.2.1.1 Water Quality Specifications

2.2.2.1.2 Water Monitoring Requirements

2.2.2.1.3 Water Decontamination Requirements

2.2.2.2 Air Quality

2.2.2.2.1 Air Quality Specifications

2.2.2.2.2 Air Monitoring Requirements

2.2.2.2.3 Air Decontamination Requirements

2.2.2.3 Microbiology

2.2.2.3.1 Microbiology Specifications

2.2.2.3.2 Microbiology Monitoring Requirements

2.2.2.3.3 Microbiology Decontamination Requirements

2.2.2.4 Radiation

2.2.2.4.1 Ionizing Radiation

2.2.2.4.1.1 Radiation Prediction, Monitoring, and Warning

2.2.2.4.1.2 Radiation Dose and Quality Monitoring

2.2.2.4.1.3 Crew Health Risk Assessment and Exposure Records

2.2.2.4.2 Non-Ionizing Radiation

2.2.3 Post-flight

2.2.2.1 Water Quality

2.2.2.2 Air Quality

2.2.2.3 Microbiology

2.2.2.3.1 Microbiology Monitoring Requirements

2.2.2.3.2 Microbiology Decontamination Requirements

2.2.2.4 Radiation

2.3 Countermeasures System

2.3.1 Pre-flight

2.3.1.1 Crew Selection and Assignment

2.3.1.2 Psychological Training

2.3.1.3 Pre-flight Exercise

2.3.1.4 Physiological Adaptive Training

2.3.1.5 Health Stabilization Program

2.3.1.6 Crew Schedule Support Operations

2.3.1.6.1 Circadian Shifting Operations

2.3.2 In-flight

2.3.2.1 Physical/Physiological

2.3.2.2 General Health and Well-being

2.3.2.3 Behavioral Health and Performance

2.3.3 Post-flight

2.3.3.1 Re-adaptation

2.3.3.2 Physiological Function

2.3.3.3 Behavioral Health and Performance

2.4 Human Factors

2.4.1 Pre-flight

2.4.1.1 Acceleration Requirements

2.4.1.2 Lighting Level Requirements

2.4.1.3 Maximum Noise Level Requirements

2.4.2 In-flight

2.4.2.1 Acceleration/Impact Requirements

2.4.2.2 Lighting

2.4.2.3 Noise Exposure Monitoring

2.4.3 Post-flight

2.5 Ground Support

2.5.1 Pre-flight

2.5.1.1 Normal Operations

2.5.1.1.1 Flight Control Team Exams

2.5.1.1.2 Hazardous Duty and Toxic Material Handling Certification

2.5.1.1.3 Personnel Reliability Program

2.5.1.1.4 Medical Consultants

2.5.1.1.5 Ground Occupational Medical Services

2.5.1.1.6 Medical Support of Hazardous Activities

2.5.1.1.6.1 Test Sites and Facilities

2.5.1.1.6.2 Medical Supervision of Pre-flight Experiments on Crewmembers

2.5.2 In-flight

2.5.2.1 Launch Phase Staffing

2.5.2.2 In-flight Phase Staffing

2.5.2.3 Landing Phase Staffing

2.5.2.3.1 Recumbent Seats (if required)

2.5.3 Post-flight

2.5.3.1 Emergency Medical Services

2.5.3.1.1 General

2.5.3.1.2 Emergency Medical Services Plan

3.0 Training Section

3.1 Astronaut Training

3.1.1 Crewmember Medical Training

3.1.2 Crew Medical Officer (CMO) Training

3.2 Crew Surgeon Training

3.2.1 Medical Operations Flight Surgeon Controller Training

3.2.2 Emergency Medical Services

3.3 Other Support Personnel Training

3.3.1 Medical Operations Flight Controller Training

3.3.2 Emergency Medical Services

Appendix A Acronyms

Appendix B Reference Documents

APPENDIX D

Rationale for Levels of Care

### D.1 Standard of Care and Level of Care

Medicine uses two phrases to describe care: (1) the Level of Care that
one can provide and (2) the Standards of Care. These are not
interchangeable terms. "Level of Care" refers to the amount and type of
care to be rendered based on perceived need and the ability of the
provider. "Standard of Care" is the benchmark and current clinical
practices by which that care is provided.

For example, a first-aid station, the neighborhood ambulance, and the
surgical hospital provide different levels of care. One does not go to
the first-aid station or the firehouse to have an appendectomy, nor does
one go to the surgical hospital for a simple bandage. Yet, each of these
entities is held to a standard of care that is expected among similar
platforms that provide the same level of care. For instance, an
ambulance on the east side of town is held to the same standard as one
on the west side.

### D.2 Level of Care Zero

Rationale --- The expectations of need for medical care is low (for
example, accidentally cutting oneself on a sharp edge while flying in
the T-38). This is an unplanned and unforeseen injury, such that
opportunistic treatment (using a handkerchief, glove, napkin, or
available resource within the vehicle) is employed to stop the bleeding
until further care is sought. The injury was not planned for, and the
experience of flying the aircraft hundreds of times did not allow the
foresight into the occurrence of this problem. Although this level of
care is acceptable for the scenario given, human space flight has a
history of certain medical maladies that are expected, with obvious
risks that have to be mitigated.

### D.3 Level of Care One

Rationale --- In this category, the risk of medical maladies has been
mitigated almost exclusively by preventive medicine. Routine first aid
including bandages, anti-emetics, etc. is appropriate for a suborbital
space flight. Vehicle up-mass constraints, training, and vehicle size
may eliminate the possibilities of a more extensive system.

### D.4 Level of Care Two 

Rationale --- In this category, the care may be delivered by a CMO, and
most major illnesses are mitigated by preventive medicine (e.g.,
screening). The medical care, however, becomes more robust and includes
the ability to support an increased level of care in the form of
medications or equipment. In addition to routine ambulatory care,
medications or equipment can be used to support contingency emergencies
such as anaphylaxis or toxic exposure, and routine diagnoses such as
urinary retention, space motion sickness, ocular foreign bodies, etc.
The relatively short mission duration eliminates the need for medical
hardware to evaluate long-term changes due to microgravity. For example,
ultrasound, Holter monitoring, and surgical capability are not necessary
components of this medical suite.

### D.5 Level of Care Three

Rationale --- Preventive medicine is still employed as a risk mitigation
strategy, but illness, injury, or deconditioning may still occur. More
robust medications and equipment are added to the previous foundation of
care. Although immediate life-saving care is available in the form of
airway management and limited advanced life support, the ability to
sustain a critically ill or injured patient for any length of time is
limited by consumables, training, and vehicle constraints.

### D.6 Level of Care Four

Rationale --- Preventive medicine is the paramount risk mitigation
strategy. However, advanced and ambulatory care is necessary. The
additional risk has increased to ensure the survival of the remaining
crewmembers (intubating a crewmember on the moon can use up the oxygen
supply for the remaining crewmembers, or increase the fire risk on ISS)
so that triage is then necessary. Small portable diagnostic devices,
such as a portable ultrasound or portable clinical blood analyzer (PCA)
may be carried. Although immediate life-saving measures are still to be
available, such as an Automated External Debrillator (AED) for
ventricular defibrillation, the critical care needed after such an event
is not guaranteed, but rather is dependent on many variables such as
consumables, risk to the other crew, and patient condition. For
instance, a crewmember can be defibrillated within 3 minutes and saved.
Conversely, after multiple defibrillations, intubation, and oxygenation,
the patient may deteriorate and may thus exceed the ability to sustain
or save the patient. The patient's care is thus triaged as required.
Triage becomes much more important on long-duration Exploration Class
missions.

### D.7 Conversion from Ground-reliant to Autonomous Care

In autonomous medical care concepts, the astronaut caregiver is
self-sufficient in the immediate care phase and relies on Mission
Control for consultation. Also, more than likely, an increase in the
amount of ambulatory medications is needed to accommodate the longer
duration. The ability to sustain a critically ill or injured patient for
any length of time is limited by consumables, training, and vehicle
constraints. The medical care system is also dependent on the means of
return or availability of return (Soyuz, Shuttle, CEV, or other
vehicle).

### D.8 Level of Care Five

Rationale --- The training and caliber of the care giver is at the
physician level, due to the autonomous nature of the mission. Advanced
and ambulatory care is provided, but expanded. Additional portable
diagnostic devices and surgical equipment may be used to augment the
advanced and ambulatory support packs but are limited by up-and
down-mass, the vehicle, and the ability to pre-deploy such items.
Despite the addition of a physician care giver, consumables and survival
of the remaining crewmembers dictate what resources can be expended on
critical care for the ill or injured crewmember.

APPENDIX E

MEDICAL STRATEGIES FOR SPACE FLIGHT MISSIONS

## **E.1 Definitions**

E.1.1 Primary Prevention Strategies

Primary prevention management strategies seek to prevent the occurrence
of an injury or illness through pre-flight screening, training,
administrative controls, and control of the environment.

E.1.2 Secondary Prevention Strategies

Secondary prevention management strategies seek to prevent illness and
injury, or reduce the severity of injury through measures such as
countermeasures, safety aids, and acute care.

E.1.3 Tertiary Prevention Strategies

Tertiary prevention management strategies seek to minimize complications
of and disability from injury or illness through measures such as
advanced medical care, medical treatments, and rehabilitation.

E.2 Implementation Strategies

E.2.1 Primary Strategies

Primary prevention during astronaut selection is implemented by the
Space Medicine Division. Once selected, the astronaut is to be medically
qualified to fly one of the NASA missions (short duration, long duration
in LEO, or long duration beyond LEO).

E.2.2 Secondary Strategies

After astronauts have been selected for a program flight, secondary
strategies are implemented for continuation of certifications for flight
(long or short) and training certifications. The selection standards are
broken down into the categories of short duration (less than 30 days in
orbit), long duration (over 30 days in orbit), and space flight
participant. For long duration, the standards may be further clarified
such that few or no waivers are allowed for exploration missions; or a
subset of the standards (Program Medical Standards Supplement), which
are more restrictive, may be developed for certain programs. The
requirement/notice for this is defined in the program-specific MORD. If
further details are required, review the details in other appropriate
documents (waiver guides) or program medical standard supplements. The
MORD and/or waiver guide for each space flight program details the
secondary medical strategies and requirements for that program.
Implementation is explained in the Medical Concept.

E.2.3 Tertiary Strategies

Program requirements and plans to support the astronauts during
pre-flight, including training events as well as during in-flight and
post-flight, are implemented by the Space Medicine Division at JSC
through Medical Operations. This includes, but is not limited to,
providing an ACLS/ATLS-certified FS to accompany the astronauts during
hazardous training events and be available during launch and landing.
The MORD for each space flight program details the tertiary medical
strategies and requirements for that program's in-flight mission.
Implementation is explained in the Medical Operations Support
Implementation Plans (MOSIPs).

E.2.4 Emergency Medical Services (EMS)

Requirements during launch and landing are documented in the MORD and
MOSIP. On orbit, astronauts are provided with the capability to provide
care as defined in the levels of care described in this document.
Medical support at all primary landing sites are sufficiently uniform,
without disparity between standards of care. If there is no Definitive
Medical Care Facility that satisfies the level of care for emergency
treatment, mobile or fixed medical suites are provided or engaged to
raise the level of care to sufficient levels to protect crew health and
afford the capability of resuscitation.

APPENDIX F

RATIONALE FOR SPACE FLIGHT HEALTH STANDARDS FOR HUMAN PERFORMANCE

## **F.1 Fitness-for-Duty Aerobic Capacity Standard**

Human space flight and the consequent exposure to microgravity result in
a well-documented reduction of aerobic capacity (VO~2max~). In the
experience of the international space community, including the United
States and Russian space programs, aerobic capacity degrades 15-30
percent during initial exposure to microgravity (1-3 weeks), often
followed by an in-flight training effect. Testing has revealed that
aerobic capacity is decreased again upon return to the 1g environment.
The current countermeasure strategy, both for the microgravity
environment and for reconditioning upon return, is cardiovascular
exercise.

Studies have shown that individuals with significantly reduced aerobic
capacity have difficulty performing or are unable to perform specific
job-related tasks such as load carrying and emergency egress. The
inability of an individual to perform assigned tasks can lead to
dependence on other crewmembers. Fit crewmembers may have to compensate
for the individual with compromised capabilities and have the added
responsibility of caring for the impaired crewmember, which may further
compromise mission objectives.

In-flight decreases in aerobic capacity may result from variable causes
such as physiological adaptation to microgravity (this is especially
true in the first 4 weeks of space flight), problems with the
functioning of exercise equipment, decreased intensity and/or duration
of exercise, and inaccurate/unreliable VO~2max~ measurement capabilities
in-flight. In order to assess the risk adequately, VO~2max~
measurements, either actual or derived, may be required at regular
intervals to assess aerobic fitness during early, middle, and late
mission phases, as well as to assess for fitness to complete critical
mission tasks.

References

1.  Extended Duration Orbiter Medical Project: Final Report 1989-1995.
    Sawin, S.F., Taylor, G.R., Smith, W.L. (eds). National Aeronautics
    and Space Administration, Lyndon B. Johnson Space Center, Houston,
    TX. NASA/SP 1999-534.

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1.  Biomedical Results from Skylab. Johnston, R.S., Dietlein, L.F. 1977
    (eds). National Aeronautics and Space Administration, Washington,
    D.C., NASA/SP-377.

2.  Longitudinal Study of Astronaut Health, unpublished results. NASA
    JSC.

3.  ACSM's *Guidelines for Exercise Testing and Prescription*, 7^th^
    Edition. Whaley, M.H., Brubaker, P.H., Otto, R.M. (eds).
    Philadelphia, Lippincott Williams & Wilkins. 79p.

4.  Bilzon, J.L., Allsopp, A.J., Tipton, M.J. 2001. Assessment of
    physical fitness for occupations encompassing load-carrying tasks.
    *Occup. Med.,* 51(5):357-361.

5.  Bishop, P.A., Lee, S.M., Conza, N.E., et al. July 1999. Carbon
    dioxide accumulation, walking performance, and metabolic cost in the
    NASA launch and entry suit. *Aviat Space and Environ Med.,*
    70(7):656-665.

6.  Space Flight Health Standards Review: Cardiovascular Panel Report.
    July 25, 2005. NASA Headquarters, Office of the Chief Health and
    Medical Officer.

## **F.2 Fitness-for-Duty Sensorimotor Standard**

During space flight missions, sensorimotor impairments may occur.
Impairments may present as sudden performance decrements or failures. An
individual sensorimotor baseline can be obtained on all exploration
astronauts upon initial selection and repeated as clinically indicated
and prior to space flight. Crews start missions in optimal condition.
The nature of the requirements of duties (e.g., EVA, piloting and
navigating tasks, and habitat tasks (experiment operations,
human/computer interface tasks, and repair and maintenance tasks)) and
their criticality need to be considered when assessing crew condition.
In addition, the operational environments to be encountered (e.g.,
microgravity (in-flight) and reduced gravity (planetary surface)) also
need to be considered. Application of the standards depends on the
nature and duration of the mission and associated high-risk activities.

There are four different measures that can be used to examine the
complex integration of sensory stimuli and motor responses. It is highly
likely that data collection along one dimension/ modality may affect or
interact with data collection along another dimension/modality.
Information on the four different measures is shown below.

1\. General Sensory Motor status can be broken down as follows:
significant health issues, or transient or resolving events, that
interfere with activities; diminished vision, hearing, language ability,
strength, or sensory function; impaired executive function; inability to
see, speak, hear, ambulate, or move; and unconsciousness or diminished
consciousness, or intractable pain.

2\. Motion sickness can be broken down as follows: transient motion
sickness with Graybiel Motion Sickness Severity Level of M IIa (\< 7
points); exacerbated or repetitive symptoms of motion sickness that are
mission-impacting that exceed the Graybiel Motion Sickness Severity
Level of M IIa (\> 7 points); and unresolved/incapacitating motion
sickness.

3\. Perception can be broken down as follows: transient illusions; any
repetitive or persistent illusions with operational impact; and
persistent illusions that significantly impair the crewmember's ability
to perform or that pose a danger to the mission or crew.

4\. Gaze Control Performance can be broken down as follows: gaze battery
test score (value greater than 10^th^ percentile relative to baseline
score); gaze battery test score (value less than 10^th^ percentile but
greater than 5^th^ percentile relative to baseline score); and gaze
battery test score (value less than 5^th^ percentile relative to
baseline score).

The most common sensorimotor difficulties encountered in space flight
are space motion sickness (SMS) and post-flight neurovestibular
symptoms. SMS is routinely controlled with pharmacological
countermeasures. The functional neurologic assessments listed above
allow motor and sensory performance ratings to be applied such that the
crewmember's inability to complete complex mission critical tasks can be
determined, based on neurologic decrement.

References

1.  Graybiel, A., Miller, E.F., Homick, J.L. 1976. Experiment M131.
    Human Vestibular Function, In Michel, E.L., Johnston, R.J.,
    Dietlein, L.F. (eds). Biomedical Results of Skylab, NASA SP-377,
    NASA, Washington, D.C.

2.  Lackner, J.R., Graybiel, A. Jan. 1984. Influence of gravitoinertial
    force level on apparent magnitude of Coriolis cross-coupled angular
    accelerations and motion sickness. NATO-AGARD Aerospace Medicine
    Panel Symposium on Motion Sickness: mechanisms, prediction,
    prevention and treatment. AGARD-CP372, 22.

3.  Lackner, J.R., Graybiel, A. 1984. Elicitation of motion sickness by
    head movements in the microgravity phase of parabolic flight
    maneuvers. *Aviat. Space Environ. Med.*, 55, 513-520.

4.  Reschke, M.F., Kornilova, L.N., Harm, D.L., Bloomberg, J.J.,
    Paloski, W.H. 1997. Chapter 7, Neurosensory and Sensory-Motor
    Function. Genin, A.M., Huntoon, C.L. (eds). Space Biology and
    Medicine, Vol.: *Humans in Spaceflight, Book 1: Effects of
    Microgravity, American Institute of Aeronautics and Astronautics*
    (AIAA), Washington, D.C.

5.  Roll, R., Gilhodes, J.C., Roll, J.P., Popov, K., Charade, O.,
    Gurfinkel, V. 1998. Proprioceptive information processing in
    weightlessness. *Exp. Brain Res*. 122, 393-402.

6.  Watt, D.G.D. 1997. Pointing at memorized targets during prolonged
    microgravity. *Aviat Space Environ. Med.,* 68, 99-103.

## **F.3 Fitness for Duty Behavioral Health and Cognition Standard** 

Factors that impact behavioral health and cognition during space flight
include microgravity, isolation and confinement, radiation, workload,
sleep and circadian rhythm disturbances, and psychological adaptation.
In the experience of the international space community, including United
States and Russian space programs, behavioral health issues have
resulted in early termination of missions, depressive states, degraded
performance, and interpersonal friction. Efforts to mitigate loss of
behavioral health have included pharmacologic and physical
countermeasures and training.

Behavioral health encompasses behavior, mood, cognition, sleep-circadian
cycles, work-rest, and psychological adaptations that suppress disease
or disorders and sustain safe and effective performance.

The development of baselines established from behavioral health and
cognitive assessment tools are critical to the development of operating
(performance) and morbidity (medical) ranges. Fitness for duty
examinations may employ behavioral health and cognitive assessment tools
during exploration missions to measure the crewmember's capability and
ability to operate and perform in the nominal ranges.

An individual Earth baseline may be developed for each astronaut and
then monthly monitoring testing maintained. In case of a clinical insult
(head trauma, decompression sickness involving the central nervous
system, exposure to toxins, cognitive side effects to medication, etc.),
then additional testing can be obtained to assist with medical treatment
and disposition.

It may be necessary to carry out a task-specific performance readiness
assessment before a critical task (e.g., docking, EVA, robotic arm
operations) is begun on long-duration missions. The performance on an
assessment determines the readiness of the individual to initiate that
task. These performance ranges require re-evaluation and update.

The normal uninterrupted sleep period for humans is 7-8 hours. An Earth
sleep baseline may be obtained for each individual astronaut. An
individual confidence level is developed for each individual astronaut
for sleep-related fatigue. These clinical ranges require regular
re-evaluation and update.

The Circadian Clinical Range is maintained as the individual astronaut
or crew maintains a 24-hour cycle set to one time zone. When an
individual or crew cycle is shifted [\>]{.underline} 2 hours for 4 or
more days, then adaptation has to occur at the rate of 1 day per hour.
Shifting causes changes in physiology and directly affects sleep,
physiological fatigue, and performance. The clinical range requires
continued re-evaluation and update.

The planned nominal number of work hours is 6.5 hours per day. It is
recommended not to exceed a 48-hour total workweek. Maintaining the
nominal work hours and workload is even more important during critical
operations. A critical overload workload is defined as 10-hour work days
\> 3 days in a week or \> 60 hours in a workweek. This performance range
requires continued re-evaluation and update.

References

1.  Ball, J.R., Evans, C.H. 2001. *Safe passage: Astronaut care for
    exploration missions*. Institute of Medicine. National Academy
    Press, Washington, D.C.

2.  Dinges, D., Van Dongen, H. 1999. Countermeasures to neurobehavioral
    deficits from cumulative partial sleep deprivation during space
    flight. In *Proceedings of the first Biennial Investigator's
    workshop.* January 11-13. Houston: National Aeronautics and Space
    Administration.

3.  Dinges, D., Pack, F., Williams, K., Gillen, K.A., Powell, J.W., Ott,
    G.E., Aptowicz, C., and Pack, A.I. 1997. Cumulative sleepiness, mood
    disturbance, and psychomotor vigilance performance decrements during
    a week of sleep restricted to 4-5 hours per night. *Sleep,*
    20(4):267-277.

4.  Kanas, N., Manzey, D. 2003. *Space psychology and psychiatry.*
    Microcosm Press, El Segundo, CA.

5.  Kane, R.L. 2003. Spaceflight Cognitive Assessment Tool for Windows:
    Development and Validation. Paper presented at New Directions in
    Behavioral Health: Integrating Research and Application,
    December 23. Davis, CA.

6.  Manzey, D., Lorenz, B. 1998. Mental performance during short-term
    and long-duration space flight. *Brain Research Reviews,* 27:
    215-221.

7.  Manzey, D., Lorenz, B., Poljakov, V. 1998. Mental performance in
    extreme environments: results from a performance monitoring study
    during a 438-day space flight. *Ergonomics,* 41(4):537-59.

8.  Monk T. et al. 1998. Human sleep, circadian rhythms and performance
    in space. In Life and Microgravity Spacelab (LMS) Final Report,
    NASA/CP-1998-206960.

9.  Newberg, A.B. 1994. Changes in the central nervous system and their
    clinical correlates during long-term space flight. *Aviation, Space,
    and Environmental Medicine,* 65:562-572.

10. Schiflett, S., Eddy, D., Schlegel, R.E., French, J.,
    Shehab, R. 1995. *Performance Assessment Workstation (PAWS).*
    Unpublished Final Science report to NASA.

11. Shayler, D.J. 2000. Disaster and accidents in manned space flights.
    Praxis Publishing, UK.

## **F.4 Fitness-for-Duty Hematology and Immunology Standard**

During space flight, immune system changes occur which potentially
decrease the body's ability to fight infections and control dormant
viruses. Space flight factors that can alter immune response include
exposure to microgravity; increased radiation exposure; exposure to
hazardous chemicals; exposure to toxins, molds, and bacteria; and
increased stress. These changes may result in increased health risks for
crewmembers during long-duration space flight.

The standard establishes the boundaries of the clinical range that
exposes the crewmembers to acceptable risk of immune and hematologic
disorders. The "critical value" is defined as that level which
represents a significant failure of the hematopoietic system and is
associated with specific clinical morbidity. Evaluation and action by
the appropriate health care team are indicated when values reach this
level.

Actions that can be taken to facilitate good immunological/hematological
status include implementing a quarantine period prior to launch;
assuring immunizations are current, in accordance with the NASA
Crewmember Medical Standards; employing environmental measures to reduce
exposure and subsequent sensitization to allergens and particulate
matter; and determining whether crewmembers were sensitized to new
environmental agents during flight using pre- and post-flight
hypersensitivity panels.

During the mission, hematological/immunological values are to remain
within normative values established for the general population. Target
parameters have to remain outside the "critical values," defined as
those levels of the target parameters which are associated with specific
clinical morbidities.

References

> 1\. Crucian, B.E., Stowe, R.P., Pierson, D.L., Sams, C.F. 2001.
> Routine detection of Epstein-Barr virus specific T-cells in the
> peripheral blood by flow cytometry. *J.Immunol.Methods,* 247:35-47.
>
> 2\. Mehta, S.K., Pierson, D.L., Cooley, H., Dubow, R., Lugg, D. 2000.
> Epstein-Barr virus reactivation associated with diminished
> cell-mediated immunity in Antarctic expeditioners. *J.Med.Virol.,*
> 61:235-240.
>
> 3\. Mehta, S.K., Stowe, R.P., Feiveson, A.H., Tyring, S.K., Pierson,
> D.L. 2000. Reactivation and shedding of cytomegalovirus in astronauts
> during spaceflight. *J.Infect.Dis.,* 182:1761-1764.
>
> 4\. Payne, D.A., Mehta, S.K., Tyring, S.K., Stowe, R.P., Pierson, D.L.
> 1999. Incidence of Epstein-Barr virus in astronaut saliva during
> spaceflight. *Aviat.Space Environ.Med.,* 70:1211-1213.
>
> 5\. Stowe, R.P., Pierson, D.L., Feeback, D.L., Barrett, A.D. 2000.
> Stress-induced reactivation of Epstein-Barr virus in astronauts.
> *Neuroimmunomodulation,* 8:51-58.
>
> 6\. Brockett, R.M., Ferguson, J.K., Henney, M.R. 1978. Prevalence of
> fungi during Skylab missions. *Appl.Environ.Microbiol.,* 36:243-246.
>
> 7\. Henney, M.R., Raylor, G.R., Molina, T.C. 1978. Mycological profile
> of crew during 56-day simulated orbital flight. *Mycopathologia,*
> 63:131-144.
>
> 8\. Pierson, D.L., Mehta, S.K., Magee, B.B., Mishra, S.K. 1995.
> Person-to-person transfer of Candida albicans in the spacecraft
> environment. *J.Med.Vet.Mycol.,* 33:145-150.
>
> 9\. Brancaccio, R.R., Alvarez, M.S. 2004. Contact allergy to food.
> *Dermatol.Ther.,* 17:302-313.
>
> 10\. Garner, L.A. 2004. Contact dermatitis to metals.
> *Dermatol.Ther.,* 17:321-327.
>
> 11\. Sasseville, D. 2004. Hypersensitivity to preservatives.
> *Dermatol.Ther.,* 17:251-263.
>
> 12\. Fahey, J.L. 1998. Cytokines, plasma immune activation markers,
> and clinically relevant surrogate markers in human immunodeficiency
> virus infection. *Clin.Diagn.Lab Immunol.,* 5:597-603.
>
> 13\. Hengel, R.L., Kovacs, J.A. 2003. Surrogate markers of immune
> function in human immunodeficiency virus-infected patients: what are
> they surrogates for? *J.Infect.Dis.,* 188:1791-1793.
>
> 14\. Lum, G. 1998. Critical limits (alert values) for physician
> notification: universal or medical center specific limits?
> *Ann.Clin.Lab Sci.,* 28:261-271.
>
> 15\. McLellan, S.A., McClelland, D.B., Walsh, T.S. 2003. Anaemia and
> red blood cell transfusion in the critically ill patient. *Blood
> Rev.,* 17:195-208.
>
> 16\. Rempher, K.J. Little, J. 2004. Assessment of red blood cell and
> coagulation laboratory data. *AACN.Clin.Issues,* 15:622-637.
>
> 17\. Simmons, E.M., Himmelfarb, J., Sezer, M.T., Chertow, G.M., Mehta,
> R.L., Paganini, E.P., Soroko, S., Freedman, S., Becker, K., Spratt, D.
> et al. 2004. Plasma cytokine levels predict mortality in patients with
> acute renal failure. *Kidney Int.,* 65:1357-1365.
>
> 18\. Singbartl, K., Innerhofer, P., Radvan, J., Westphalen, B., Fries,
> D., Stogbauer, R., Van Aken, H. 2003. Hemostasis and hemodilution: a
> quantitative mathematical guide for clinical practice.
> *Anesth.Analg.,* 96:929-35, table.

## **F.5 Permissible Outcome Limit for Nutrition Standard** 

Nutrition has been critical in every phase of exploration to date, from
the scurvy that plagued earlier seafarers to polar explorers who died
from under-nutrition or, in some cases, nutrient toxicities. In this
regard, the role of nutrition in space exploration is no different, with
the exception that during space exploration, there is no opportunity to
obtain food from the environment.

Nutritional assessments of MIR and ISS crews have documented a range of
issues including inadequate caloric intake, weight loss, and decrements
in status of individual nutrients (even in cases where intake was
adequate). For some nutrients, status appears to be declining, while in
others, excess is a concern (e.g., protein, sodium, iron).

Key areas of clinical concern for long-duration space flight and
exploration-class missions include loss of body mass, bone and muscle
loss, increased radiation exposure, and general inadequate food intake.

In developing this standard, the following factors were considered:
nutritional/biochemical data from 3- to 6-month space flight, known
terrestrial dietary reference intakes and clinically significant
blood/urine marker levels, target range necessary for full function to
carry out mission tasks, standard deviations from target range that are
acceptable on Earth, and margin of safety needed to maintain the
standard above the clinically significant range.

Nutrient deficiency (or excess) due to inadequate supply, inadequate
stability, or increased metabolism and excretion can lead to illness
and/or performance decrements. Nutritional status has to be adequate
prior to flight to ensure healthy crews at the start of the mission.

In the general sense, the primary nutrition risk is having a viable and
stable food system, and further, one that the crew is willing and able
to consume. Having food is important, but having the right nutrient mix
can be more critical than having food alone. The risk factors for
nutrition fall into a tiered approach, as described below.

First, the risks to the food system are based on the development of a
food system that contains the required amounts of all nutrients. The
stability of these nutrients over an extended period of time is a risk,
but even more critical is the impact of the spacecraft environment,
especially radiation, on these foods and nutrients. Degradation of
nutrients with ground-based radiation (e.g., for preservation) is
damaging to certain vitamins.

Second, adequate consumption of food by the crew is a critical risk.
Many crewmembers on long-duration station missions have not consumed
adequate amounts of food. On exploration-class missions, food
"freshness," menu fatigue, stress, and other factors play a significant
role in crew food consumption, health, and performance.

Last, even if the food system contains all required nutrients, and the
crew consumes it, the risk is high for altered metabolism (e.g.,
absorption, storage, utilization, excretion) to factor into nutritional
requirements.

References

> 1\. Smith, S.M., Davis-Street, J.E., Rice, B.L., Nillen, J.L.,
> Gillman, P.L., Block G. 2001. Nutritional status assessment in
> semiclosed environments: ground-based and space flight studies in
> humans. *J Nutr.,* 131:2053-61.
>
> 2\. Smith, S.M., Zwart, S.R., Block, G, Rice, B.L., Davis-Street, J.E.
> 2005. Nutritional status assessment of International Space Station
> crewmembers. *J Nutr.,* 135:437-443.
>
> 3\. Zwart, S.R., Davis-Street, J.E., Paddon-Jones, D., Ferrando, A.A.,
> Wolfe, R.R., Smith, S.M. 2005. Amino acid supplementation alters bone
> metabolism during simulated weightlessness. *J Appl Physiology.*
>
> 4\. Zwart, S.R., Hargens, A.R., Smith, S.M. 2004. The ratio of animal
> protein intake to potassium intake is a predictor of bone resorption
> in space flight analogues and in ambulatory subjects. *Am J Clin
> Nutr.,* 80:1058-65.
>
> 5\. Heer, M., Baisch, F., Drummer, C., Gerzer, R. 1995. Long-term
> elevations of dietary sodium produce parallel increases in the renal
> excretion of urodilatin and sodium. In: Sahm, P.R., Keller, M.H.,
> Schiewe, B. (eds). *Proceedings of the Norderney Symposium on
> Scientific Results of the German Spacelab Mission D-2.*
> Wissenschaftliche Projectführung D-2, Norderney, Germany, pp 708-714.
>
> 6\. Smith, S.M. 2002. Red blood cell and iron metabolism during space
> flight. *Nutrition,* 18:864-866.
>
> 7\. Holick, M.F.. 1998. Perspective on the impact of weightlessness on
> calcium and bone metabolism. *Bone 22,* (5 Suppl):105S-111S.
>
> 8\. Holick, M.F. 2000. Microgravity-induced bone loss - will it limit
> human space exploration? *Lancet,* 355:1569-70.
>
> 9\. Smith, S.M., Heer, M. 2002. Calcium and bone metabolism during
> space flight. *Nutrition,* 18:849-52.
>
> 10\. Smith, S.M., Lane, H.W. 1999. Nutritional biochemistry of space
> flight. Life Support and Biosphere Science: *International Journal of
> Earth Space,* 6:5-8.
>
> 11\. Smith, S.M., Wastney, M.E., Morukov, B.V., et al. 1999. Calcium
> metabolism before, during, and after a 3-mo spaceflight: kinetic and
> biochemical changes. *American Journal of Physiology,* 277 (1 Pt
> 2):R1-10.
>
> 12\. Smith, S.M., Wastney, M.E., O\'Brien, K.O., et al. 2005. Bone
> markers, calcium metabolism, and calcium kinetics during
> extended-duration space flight on the MIR space station. *J Bone Miner
> Res.,* 20:208-18.
>
> 13\. Scheld, K., Zittermann, A, Heer, M., et al. 2001. Nitrogen
> metabolism and bone metabolism markers in healthy adults during 16
> weeks of bed rest. *Clin Chem.,* 47:1688-95
>
> 14\. Ferrando, A.A., Lane, H.W., Stuart, C.A., Davis-Street, J.,
> Wolfe, R.R. 1996. Prolonged bed rest decreases skeletal muscle and
> whole body protein synthesis. *Am J Physio., l* 270:E627-33.
>
> 15\. Ferrando, A.A., Paddon-Jones, D., Wolfe, R.R. 2002. Alterations
> in protein metabolism during space flight and inactivity. *Nutrition,*
> 18:837-841.
>
> 16\. Fritsch-Yelle, J.M., Charles, J.B., Jones, M.M., Wood, M.L. 1996.
> Microgravity decreases heart rate and arterial pressure in humans. *J
> Appl Physiol.,* 80:910-4.
>
> 17\. Pamnani, M.B., Mo, Z., Chen, S., Bryant, H.J., White, R.J.,
> Haddy, F.J. 1996. Effects of head down tilt on hemodynamics, fluid
> volumes, and plasma Na-K pump inhibitor in rats. *Aviat Space Environ
> Med.,* 67:928-34.
>
> 18\. Appel, L.J., Moore, T.J., Obarzanek, E., et al. 1997. A clinical
> trial of the effects of dietary patterns on blood pressure. DASH
> Collaborative Research Group. *N Engl J Med.,* 336:1117-24.
>
> 19\. Gramenzi, A., Gentile, A., Fasoli, M., Negri, E., Parazzini, F.,
> La Vecchia, C. 1990. Association between certain foods and risk of
> acute myocardial infarction in women. *BMJ*, 300:771-3.
>
> 20\. Mensink, R.P., Katan, M.B. 1990. Effect of dietary trans fatty
> acids on high-density and low-density lipoprotein cholesterol levels
> in healthy subjects. *N Engl J Med.,* 323:439-45.
>
> 21\. Ascherio, A., Rimm, E.B., Hernan, M.A., et al. 1998 Intake of
> potassium, magnesium, calcium, and fiber and risk of stroke among US
> men. *Circulation,* 98:1198-204.
>
> 22\. Ascherio, A., Rimm, E.B., Stampfer M.J., Giovannucci, E.L,,
> Willett, W.C. 1995. Dietary intake of marine n-3 fatty acids, fish
> intake, and the risk of coronary disease among men. *N Engl J Med.,*
> 332:977-82.
>
> 23\. Jacobs, D.R., Jr., Meyer, K.A., Kushi, L.H., Folsom, A.R. 1998.
> Whole-grain intake may reduce the risk of ischemic heart disease death
> in postmenopausal women: the Iowa Women\'s Health Study. *Am J Clin
> Nutr.,* 68:248-57.
>
> 24\. Key, T.J., Thorogood, M., Appleby, P.N., Burr, M.L. 1996. Dietary
> habits and mortality in 11,000 vegetarians and health conscious
> people: results of a 17 year follow up. *BMJ,* 313:775-9.
>
> 25\. Sonnenfeld, G., Shearer, W.T. 2002. Immune function during space
> flight. *Nutrition,* 18:899-903.
>
> 26\. Turner, N.D., Braby, L.A., Ford, J., Lupton, J.R. 2002.
> Opportunities for nutritional amelioration of radiation-induced
> cellular damage. *Nutrition,* 18:904-12.
>
> 27\. Steinmetz, K.A., Potter, J.D. 1991. Vegetables, fruit, and
> cancer. II. Mechanisms. *Cancer Causes Control,* 2:427-42.
>
> 28\. Stein, T.P. 2002. Space flight and oxidative stress. *Nutrition,*
> 18:867-71.
>
> 29\. Stein, T.P., Leskiw, M.J. 2000. Oxidant damage during and after
> spaceflight. American *Journal of Physiology. Endocrinology and
> Metabolism,* 278:E375-82.
>
> 30\. Alfrey, C.P., Rice, L., Smith, S.M. 2000. Iron metabolism and the
> changes in red blood cell metabolism. In: Lane, H.W., Schoeller, D.A.
> (eds). *Nutrition in spaceflight and weightlessness models*. CRC
> Press, Boca Raton, FL, pp 203-11.
>
> 31\. Alfrey, C.P., Udden, M.M., Huntoon, C.L., Driscoll, T. 1996.
> Destruction of newly released red blood cells in space flight.
> *Medicine and Science in Sports and Exercise,* 28(10 Suppl):S42-4.
>
> 32\. Alfrey, C.P., Udden, M.M., Leach-Huntoon, C., Driscoll, T.,
> Pickett, M.H. 1996. Control of red blood cell mass in spaceflight.
> *Journal of Applied Physiology,* 81:98-104.
>
> 33\. Rice, L., Alfrey, C.P. 2000. Modulation of red cell mass by
> neocytolysis in space and on Earth. Pflugers Archiv: *European Journal
> of Physiology,* 441(2-3 Suppl):R91-4.
>
> 34\. Lakritz, L., Fox, J.B., Thayer, D.W. 1998. Thiamin, riboflavin,
> and alpha-tocopherol content of exotic meats and loss due to gamma
> radiation. *J Food Prot.,* 61:1681-3.
>
> 35\. Van Calenberg, S., Philips, B., Mondelaers, W. Van Cleemput, O.,
> Huyghebaert, A. 1999. Effect of irradiation, packaging, and
> postirradiation cooking on the thiamin content of chicken meat. *J
> Food Prot.,* 62:1303-7.
>
> 36\. Stein, T.P., Leskiw, M.J., Schluter, M.D., et al. 1999. Energy
> expenditure and balance during spaceflight on the space shuttle.
> *American Journal of Physiology,* 276:R1739-R1748.
>
> 37\. Vodovotz, Y., Smith, S.M., Lane, H.W. 2000. Food and nutrition in
> space: application to human health. *Nutrition,* 16:534-7.
>
> 38\. NASA JSC. 1993. Nutritional requirements for Extended Duration
> Orbiter missions (30-90 d) and Space Station Freedom (30-120 d).
> National Aeronautics and Space Administration Lyndon B. Johnson Space
> Center, Houston, TX.
>
> 39\. NASA JSC. 1996. Nutritional requirements for International Space
> Station (ISS) missions up to 360 days. National Aeronautics and Space
> Administration Lyndon B. Johnson Space Center, Houston, TX.
>
> 40\. Herbert, V. 1999. Folic Acid. In: Shils, M.E., Olson, J.A.,
> Shike, M., Ross, A.C. (eds). *Modern Nutrition in Health and Disease*.
> Baltimore, MD: Lippincott Williams & Wilkins.

## **F.6 Permissible Outcome Limit for Muscle Strength Standard**

The impact to muscle performance as a result of the physiologic changes
from human space flight and microgravity is well documented. Efforts to
mitigate loss of strength and endurance have included exercise
countermeasures. In spite of current on-orbit exercise regimens that
include resistive and aerobic exercise 6 days per week, deconditioning
still occurs.

Health issues related to skeletal muscle deconditioning include
musculoskeletal injury. Retrospective epidemiological studies indicate
musculoskeletal injury rates among Shuttle astronauts more than double
during the mission period. The mission period includes pre-flight
training and testing, in-flight activities, and post-flight testing.
Crewmembers tend to have a higher incidence of musculoskeletal injury in
the back during the post-flight phase, which may be related to the large
losses shown in the postural muscles. Men had a higher incidence of
injury than women in all sites and types. The highest incidence of
injuries was in the ankle and back, pre- and post-flight, respectively.

The operational concern regarding reductions in skeletal muscle strength
is that these health outcomes may result in performance decrements
required for completing mission tasks and can have an unacceptable, and
possibly catastrophic, impact to exploration mission objectives. The
skeletal muscle deconditioning effects of space flight are considered
environmentally adaptive, reversible, and without sequelae affecting
quality of life. However, in the absence of occupational task
specifications, clinical guidelines were used to define the threshold
for acceptable muscle loss contained in the current standard. This
threshold, POL, is an alternative until task analyses can be completed.
Therefore, consider this standard a placeholder until actual exploration
tasks, suits, vehicles, and mission scenarios are defined. The
preliminary POL for skeletal muscle strength is relative to the
crewmember's pre-flight baseline levels, as it is assumed that assigned
astronauts have the capacity to complete all mission objectives at the
time of launch.

Knowledge gaps have been identified to define the current rationale for
not having definitive standards for missions, tasks, vehicles, and suits
not yet characterized. Table 2 below is the initial assessment but
requires quantitative measures by task.

> Table 2--- CEV Functional Strength Requirements

  ------------------ ----------------------------------------------------
  Strength           Functional Basis

  Pinch/Finger       Fasten and release seatbelt, operate controls
  Strength           

  Grip Strength      Handling knife, sky genie, pry bar

  Push Strength      Open side hatch, push escape slide

  Pull Strength      D-ring, quick disconnects, pull escape slide

  Shoulder Strength  Lifting from sit, swing out of hatch opening onto
                     slide

  Arm Strength       Lifting from sit, pry bar

  Dynamic Strength   Lifting from sit

  Wrist Strength     Handling knife

  Torque             Turn wheel on side hatch, pry bar

  Lifting Strength   Lift escape slide, lift out of escape hatch

  Hand Strength      Pry bar, sky genie

  Leg Strength       Operate rudder, brakes, foot restraints
  ------------------ ----------------------------------------------------

In summary, these guidelines are considered preliminary and by default
are conservative. This standard may be refined as specific information
becomes available.

References

1.  Adams, G.R., Caiozzo, V.J., Baldwin, K.M. 2003. Skeletal muscle
    unweighting: spaceflight and ground-based models. *Journal of
    Applied Physiology,* 95: 2185-2201.

2.  Alkner, B.A., Tesch, P.A. 2004. Efficacy of a gravity-independent
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    345-357.

3.  Alkner, B.A., Tesch, P.A. 2004. Knee extensor and plantar flexor
    muscle size and function following 90 days of bed rest with or
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4.  Bioastronautics Roadmap: A risk reduction strategy of human space
    exploration. February 2005. NASA/SP-2004-6113.
    [**http://bioastroroadmap.nasa.gov/index.jsp**](http://bioastroroadmap.nasa.gov/index.jsp).

5.  Biomedical Results from Skylab. 1977. Johnston, R.S., Dietlein, L.F.
    (eds). National Aeronautics and Space Administration, Washington,
    D.C. NASA/SP-377.

6.  [Chekirda,
    I.F](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Chekirda+IF"%5BAuthor%5D).,
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    Dynamics of cyclic and acyclic locomotion by the crew of
    \"Soyuz-18\" after a 63-day space flight. *Kosm Biol Aviakosm Med*.,
    Juy-Aug; 11(4):9-13.

7.  Colledge, A.L., Johns, R.E., Thomas, M.H. 1999. Functional
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8.  Colwell, S.A., Stocks, J.M., Evans, D.G., Simonson, S.R., Greenleaf,
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9.  Convertino, V.A., Sandler, H. 1995. Exercise countermeasures for
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10. Draft NASA-STD-3000, human-systems integration standards. Crew
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11. Extended Duration Orbiter Medical Project: Final Report 1989-1995.
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    and Space Administration, Lyndon B. Johnson Space Center, Houston,
    TX. NASA/SP 1999-534.

12. Gonzalez, Maida, Miles, Rajulu, Pandya. 2002. Work and Fatigue
    Characteristics of unsuited humans during isolated isokinetic joint
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13. Isokinetics Explained. <http://www.isokinetics.net/index2.htm>.

14. [Kozlovskaya, I.B., Grigoriev,
    A.I.](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15806738&query_hl=5) 2004.
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    Space Station (ISS): the first results. *Acta Astronaut*., Aug-Nov;
    55(3-9):233-7.

15. Kozlovskaya, I.B. 2002. Countermeasures for long-term space flights,
    lessons learned from the Russian space program. *J Gravit Physiol*.,
    Jul; 9(1):P313-7.

16. [Kozlovskaya, I.B., Barmin, V.A., Stepantsov, V.I., Kharitonov,
    N.M.](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=2371310&query_hl=5) 1990.
    Results of studies of motor functions in long-term space flights.
    *Physiologist,* Feb; 33(1 Suppl):S1-3.

17. [Kozlovskaya, I.B., Kreidich, YuV, Oganov, V.S., Koserenko,
    O.P.](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11543096&query_hl=5) 1981.
    Pathophysiology of motor functions in prolonged manned space
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18. LeBlanc, A., Lin, C., Shackelford, L., Sinitsyn, V., Evans, H.,
    Belichenko, O., Schenkman, B., Kozlovskaya, I., Oganov, V., Bakulin,
    A., Hedrick, T., Feeback, D. 2000. Muscle volume, MRI relaxation
    times (T2), and body composition after spaceflight. *Journal of
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19. LeBlanc, A.D., Rowe, R., Schneider, V., Evans, H., Hedrick T. 1995.
    Regional muscle loss after short duration spaceflight. *Aviation,
    Space, and Environmental Medicine,* 66: 1151-1154, 1995.

20. LeBlanc, A.D., Schneider, V.S., Evans, H.J., Pientok, C., Rowe, R.,
    Spector, E. 1992. Regional changes in muscle mass following 17 weeks
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21. Longitudinal Study of Astronaut Health, unpublished results. NASA
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25. Widrick, J.J., Knuth, S.T., Norenberg, K.M., Romatowski, J.G., Bain,
    J.L.W., Riley, D.A., Karhanek, M., Trappe, S.W., Trappe, T.A.,
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    contractile properties of human soleus muscle fibres. *Journal of
    Physiology,* 516: 915-930.

## **F.7 Permissible Outcome Limit for Microgravity Induced Bone Mineral** 

## **Loss Performance Standard**

Bone loss is a consistent finding of space flight and, for a 6-month
mission, averages 1 percent loss per month at the lower spine and hip
locations. Bone loss does show great variability among individual
astronauts and between various bone locations. Countermeasures to
prevent or mitigate bone loss include exercise, pharmacological agents,
and nutrition. It is expected that partial gravity missions will have
bone loss rates less or equal to those seen on ISS flights.

The World Health Organization (WHO) defines normal bone mineral density
(BMD) as a T-score \> -1, osteopenia as a T-score of -1 to -2.5,
osteoporosis as a T-score below -2.5, and severe osteoporosis as a
T-score below -2.5 in combination with previous fragility fracture.

![](media/image2.png){width="6.444444444444445in"
height="5.305555555555555in"}

Figure 1---Risk of Hip Fracture in Males Using Standardized Total Hip
BMD

+-----------------------------------------------------------------------+
| World Health Organization Definitions of Osteoporosis Based on Bone   |
| Density Levels                                                        |
|                                                                       |
| Normal.\                                                              |
| Bone Density is within 1 SD (+1 or -1) of the young adult mean.       |
|                                                                       |
| Low Bone Mass.\                                                       |
| Bone density is 1 to 2.5 SD below the young adult mean (-1 to -2.5    |
| SD).                                                                  |
|                                                                       |
| Osteoporosis.\                                                        |
| Bone density is 2.5 SD or more below the young adult mean (\> -2.5    |
| SD).                                                                  |
|                                                                       |
| Severe (established) osteoporosis.\                                   |
| Bone density is more than 2.5 SD below the young adult mean and there |
| has been one or more osteoporotic fractures.                          |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+

From National Osteoporosis Foundation Website

<http://www.nof.org/osteoporosis/bmdtest.htm>

References

1.  Bioastronautics Roadmap: A Risk Reduction Strategy for Human Space
    Exploration. February 2005. NASA/SP-2004-6113.

2.  Marshall, D., Johnell, O., Wedel, H. 1996. Meta-analysis of how well
    measures of bone mineral density predict occurrence of osteoporotic
    fractures. *Br Med J,* 312:1254-9.

3.  Medical Evaluation Documents (MED) Volume A: Medical Standards for
    ISS Crewmembers (AMERD 2A). SSP 50667. Version, March 2004 draft.

4.  Medical Evaluations Document (MED) Volume B (AMERD 2B): Pre-flight,
    In-flight, and Postflight Medical Evaluation Requirements for
    Increment Assigned ISS Crewmembers. SSP 50667. Version March 2004
    MSHE WG Draft 1.0.

5.  Shapiro, J.R., Schneider, V. J. 2000. Countermeasure development:
    future research targets. *Gravit Physiol*., 7:1-4.

6.  Vico, L., Collet, P., Guignandon, A. et al. 2000. Effects of
    long-term microgravity exposure on cancellous and cortical
    weight-bearing bones of cosmonauts. *Lancet,* 355:1607-11.

7.  WHO study group. 1994. Assessment of fracture risk and its
    application to screening for postmenopausal osteoporosis. Geneva,
    WHO. WHO Technical Report series.

## 

## **F.8 Space-Permissible Exposure Limit (SPEL) for Space Flight Radiation Exposure Standard** 

Radiation sources in space consist of the galactic cosmic rays (GCR),
trapped radiation, and solar particle events (SPEs). As missions
progress to outside LEO and away from the protection of Earth's magnetic
shielding, the nature of the radiation exposures that astronauts
encounter change to include higher GCR and possible SPE exposures.

SPEL for radiation have the primary functions of preventing in-flight
risks that jeopardize mission success and limiting chronic risks to
acceptable levels based on legal, ethical or moral, and financial
considerations. Both short-term and career exposure limits are applied
using assessments of the uncertainties in projection models and a
reasonable "worst-case" space environment to be encountered on specific
missions. Uncertainties are due to gaps in knowledge of biological
effects of GCR, heavy ions, and the nature of SPEs. Although specific
exposure limits are identified based on mortality risk, in all cases
decisions concerning vehicle, habitat, and mission design are made such
that resulting crew radiation exposures are ALARA. As an operating
practice, ALARA is a recognized NASA requirement. However, at the
current time the large uncertainties in GCR risk projections prevent an
effective ALARA strategy for shielding approaches to be developed. For
SPEs, uncertainties are smaller, acute risks are a concern, and ALARA is
possible.

F.8.1 Risk Factors

Risk varies with the age and sex of the astronaut. Prior radiation
exposures do not modify chronic risks for a specific mission, but can
reduce the available margin of individuals for specific missions.
Possible risk factors related to genetic sensitivity are not included in
current risk assessments. Mission risks vary over the approximately
11-year solar cycle with higher GCR doses at solar minimum and higher
likelihood of SPEs near solar maximum. Risks from an SPE are highest
during EVA. Shielding can substantially reduce SPE doses and provide
modest reductions for GCR.

F.8.2 Career Cancer Risk Limits

Career exposure to radiation is limited to not exceed 3 percent REID for
fatal cancer. NASA assures that this risk limit is not exceeded at a 95
percent confidence level using a statistical assessment of the
uncertainties in the risk projection calculations to limit the
cumulative effective dose (in units of Sievert) received by an astronaut
throughout his or her career.

F.8.3 Cancer Risk-to-Dose Relationship

The relationship between radiation exposure and risk is age and sex
specific due to latency effects and differences in tissue types,
sensitivities, and life-spans between sexes. Table 3 lists examples of
career effective dose (E) limits for a REID = 3 percent for missions of
1-year

duration or less. Limits for other career or mission lengths vary and
can be calculated using the appropriate life-table formalism. Tissue
contributions to effective doses are defined in table 3. Estimates of
average life-loss based on low linear-energy transfer (LET) radiation
are also listed in table 3; however, higher values may be expected for
high LET exposures such as GCR.

F.8.4 Dose Limits for Non-Cancer Effects

Short-term dose limits are imposed to prevent clinically significant
non-cancer health effects including performance degradation, sickness,
or death in-flight. For risks that occur above a threshold dose, a
probability of \< 10^-3^ is a practical limit if more accurate methods
than dose limit values are to be implemented. Lifetime limits for
cataracts, heart disease, and damage to the central nervous system are
imposed to limit or prevent risks of degenerative tissue diseases (e.g.,
stroke, coronary heart disease, striatum aging, etc.). Career limits for
the heart are intended to limit the REID for heart disease to be below
approximately 3 to 5 percent, and are expected to be largely age and sex
independent. Average lifeloss from gamma-ray-induced heart disease death
is approximately 9 years. Dose limits for non-cancer effects (units of
milli-Gray Equivalent (mGy-Eq)) are listed in table 4.

Table 3---Example Career Effective Dose Limits in Units of Sievert (mSv)

For 1-year Missions and Average Life-loss for an Exposure-induced

Death for Rradiation Carcinogenesis (1 mSv= 0.1 rem)

Table 4---Dose limits for short-term or career non-cancer effects (in
mGy-Eq. or mGy) Note RBE's for specific risks are distinct as described
below.

  ------------------- ---------------- ---------------- ------------------
  *Organ*             *30 day limit*   *1 Year Limit*   *Career*

  Lens\*              1000 mGy-Eq      2000 mGy-Eq      4000 mGy-Eq

  Skin                1500             3000             4000

  BFO                 250              500              Not applicable

  Heart\*\*           250              500              1000

  CNS\*\*\*           500              1000             1500

  CNS\*\*\* (Z≥10)    \-               100 mGy          250 mGy
  ------------------- ---------------- ---------------- ------------------

> \*Lens limits are intended to prevent early (\< 5 yr) severe cataracts
> (e.g., from a solar particle event). An additional cataract risk
> exists at lower doses from cosmic rays for sub-clinical cataracts,
> which may progress to severe types after long latency (\> 5 yr) and
> are not preventable by existing mitigation measures; however, they are
> deemed an acceptable risk to the program.
>
> \*\*Heart doses calculated as average over heart muscle and adjacent
> arteries.
>
> \*\*\*CNS limits should be calculated at the hippocampus.

F.8.5 The Principle of As Low as Reasonably Achievable (ALARA)

The ALARA principle is a legal requirement intended to ensure astronaut
safety. An important function of ALARA is to ensure that astronauts do
not approach radiation limits and that such limits are not considered as
"tolerance values." ALARA is especially important for space missions in
view of the large uncertainties in cancer and other risk projection
models. Mission programs and terrestrial occupational procedures
resulting in radiation exposures to astronauts are required to find
cost-effective approaches to implement ALARA.

References

1.  Billings, M.P., Yucker, W.R., Heckman, B.R. 1973. Body
    Self-Shielding Data Analysis, McDonald Douglas Astronautics Company
    West, MDC-G4131.

2.  Cucinotta, F.A., Schimmerling, W., Wilson, J.W., Peterson, L.E.,
    Saganti, P., Badhwar, G.D., Dicello, J.F. 2001. Space Radiation
    Cancer Risks and Uncertainties for Mars Missions. *Radiat. Res*.,
    156, 682--688.

3.  Cucinotta, F.A., Kim, M.Y., Ren, L. Managing Lunar and Mars Mission
    Radiation Risks Part I: Cancer Risks, Uncertainties, and Shielding
    Effectiveness. NASA-TP-2005-213164.

4.  National Academy of Sciences National Research Council, Radiation
    Protection Guides and Constraints for Space-Mission and
    Vehicle-Design Studies Involving Nuclear System. 1970. Washington,
    D.C.

5.  National Academy of Sciences, NAS. 1996. National Academy of
    Sciences Space Science Board, Report of the Task Group on the
    Biological Effects of Space Radiation. Radiation Hazards to Crews on
    Interplanetary Mission National Academy of Sciences, Washington,
    D.C.

6.  National Council on Radiation Protection and Measurements,
    NCRP. 1989. Guidance on Radiation Received in Space Activities. NCRP
    Report 98, NCRP, Bethesda, MD.

7.  National Council on Radiation Protection and Measurements,
    NCRP. 1997. Uncertainties in Fatal Cancer Risk Estimates Used in
    Radiation Protection, NCRP Report 126, Bethesda, MD.

8.  National Council on Radiation Protection and Measurements. 2000.
    Recommendations of Dose Limits for Low Earth Orbit. NCRP Report 132,
    Bethesda MD.

9.  Preston, D.L., Shimizu, Y., Pierce, D.A., Suyumac, A.,
    Mabuchi, K. 2003. Studies of Mortality of Atomic Bomb Survivors.
    Report 13: Solid Cancer and Non-cancer Disease Mortality:
    1950--1997. *Radiat. Res.,* 160, 381--407.

10. Wilson, J.W., et al*.* 1995. Variations in Astronaut Radiation
    Exposure Due to Anisotropic Shield Distribution. *Health Phys.,* 69,
    34-45.