Antonsen, Erik

Kerstman, Eric

Masterova, Kseniya

Reyes, David

English

NASA Technical Reports Server

Probabilistic Assessment of 
Sex-Dependent Medical Risk 
During Spaceflight
David Reyes 1, Kseniya Masterova 2, Eric Kerstman 1, Erik Antonsen 3
1. Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
2. School of Medicine and Graduate School of Biomedical Sciences, University of Texas Medical Galveston, Texas
3. Department of Emergency Medicine and the Center for Space Medicine, Baylor College of Medicine, Houston Texas, and Johnson Space 
Center, NASA, Houston, Texas 
National Aeronautics and Space Administration
www.nasa.gov 
Aerospace Medical Association, 90th Annual Scientific Meeting, Las Vegas, Nevada
https://ntrs.nasa.gov/search.jsp?R=20200001661 2020-03-28T19:12:05+00:00Z
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Disclosure Information
Aerospace Medical Association, 90th Annual Scientific Meeting, Las Vegas, Nevada
We have no financial relationships to disclose.
We will not discuss off-label use and/or investigational use in this presentation 
Modelling Sex-Dependent Medical Risk - IMM S-20170724-387 
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Quantifying Risk
• Differences between males and females create different medical risks
• These differences may effect medical outcomes and mission success
• The Integrated Medical Model (IMM) was used to quantify these risks
Modelling Sex-Dependent Medical Risk - IMM S-20170724-387 
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Sex Differences Examples
System Male Female
Cardiovascular Predisposition to cardiovascular 
events (e.g. stroke6, MI12) 
Higher rates of orthostatic 
intolerance post flight3
Genitourinary Prostatitis2,17 Urinary tract conditions7,17
Musculoskeletal Higher rates of musculoskeletal 
injury on ISS19
Osteoarthritis, joint issues15
Behavioral Higher responses with anger, 
noncooperation, and conflict in 
psychosocial isolation7
Higher rates of depression and 
anxiety3
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Study Objective
 Assess medical risk differences between men and women in a space flight environment
 Assess impact of those differences on mission outcomes
 Determine effect of those risks on different mission types/lengths
 Identify ways to mitigate risks
Modelling Sex-Dependent Medical Risk - IMM S-20170724-387 
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What is the Integrated Medical Model?
• Probabilistic Risk Assessment (PRA) using Monte Carlo methodology
• Used to assess mission risk due to in-flight medical events
• Considers relevant preexisting medical conditions
• User defined Design Reference Missions (DRM) (e.g. crew, duration, EVA, etc.)
• Considers outcomes for 100 medical conditions that have or may occur in-flight
Incidence data from spaceflight medical events, and analog and general populations
20 of 100 conditions have sex-dependent outcomes
Modelling Sex-Dependent Medical Risk - IMM S-20170724-387 
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IMM Sex-Dependent Medical Conditions
Male Predominant Female Predominant
Acute Prostatitis (male only) Abnormal Uterine Bleeding (female only)
Acute Compartment Syndrome Urinary Incontinence (female only)
Angina/MI Vaginal Yeast Infection (female only)
Atrial Fibrillation/Flutter Acute Arthritis
Cardiogenic Shock Secondary to MI Acute Cholecystitis
Hip/Proximal Femur Fracture Acute Glaucoma
Lumbar Spine Fracture Anxiety
Retinal Detachment Depression
Cerebral Vascular Accident Lower Extremity Stress Fracture
Urinary Retention
Urinary Tract Infection
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Model Outputs
 Total Medical Events (TME)
 Crew Health Index (CHI) – 0 to100%, complete impairment to normal function
 Probability of Evacuation (pEVAC) occurs if…
 Risk for LOCL (needs advanced care to survive)
 Risk for significant permanent impairment
 Risk of intractable pain
 Probability for Loss of Crew Life (LOCL) – clinical scenario resulted in death
 Influential Conditions, those that had significant contribution to outcomes
 Medical Resources used
Modelling Sex-Dependent Medical Risk - IMM S-20170724-387 
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IMM Methodology
Modelling Sex-Dependent Medical Risk - IMM S-20170724-387 
Best-case 
resources 
available?
Worst-case 
resources 
available?
Treated case: 
Decrement medical 
resources
Untreated Case
Treated case: 
Decrement medical 
resources
Untreated        
Worst- Case
Calculate End States:
• pEVAC
• pLOCL
• QTL
• Resource Utilization 
• Type and number of 
medical events
Best-case Scenario
Worst-case Scenario
Yes
Yes
No
No
Medical Event
Weighted for  Partial 
Treatment
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Study Design Reference Missions (DRM)
 4 crew members in each DRM
 Three different crews  mixed sex, all female, all male, 
 Three different mission lengths
 Lunar sortie (42 days)
 International Space Station (ISS) mission (182 days)
 Mars mission (913 days)
 9 total studies performed
 Inventory of medical supplies from the ISS med kit with and without the possibility of resupply
Modelling Sex-Dependent Medical Risk - IMM S-20170724-387 
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CHI - No resupply
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pLOCL - No resupply
Modelling Sex-Dependent Medical Risk - IMM S-20170724-387 
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pEVAC - No Resupply
Modelling Sex-Dependent Medical Risk - IMM S-20170724-387 
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pEVAC Medical - No Resupply
Modelling Sex-Dependent Medical Risk - IMM S-20170724-387 
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pEVAC (No Resupply): Female Influential Conditions
All Female
Rank Case Treated Condition Events
Contribution 
(%)
Cumulative 
(%)
1 BEST PARTIAL EYE CHEMICAL BURN 11702 28.45 28.45
2 WORST PARTIAL URINARY TRACT INFECTION 7710 18.74 47.19
3 WORST PARTIAL BACK SPRAIN/STRAIN 2088 5.08 52.27
4 WORST PARTIAL EYE CHEMICAL BURN 1877 4.56 56.83
5 BEST PARTIAL FINGER DISLOCATION 1527 3.71 60.54
6 WORST PARTIAL NEPHROLITHIASIS 1124 2.73 63.28
7 WORST TREATED SANS 1026 2.49 65.77
8 WORST TREATED SMOKE INHALATION 668 1.62 67.39
9 WORST PARTIAL EYE INFECTION 617 1.50 68.89
10 WORST PARTIAL LE STRESS FRACTURE 534 1.30 70.19
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pEVAC (No Resupply): Male Influential Conditions
Modelling Sex-Dependent Medical Risk - IMM S-20170724-387 
All Male
Rank Case Treated Condition Events Contribution (%) Cumulative (%)
1 BEST PARTIAL EYE CHEMICAL BURN 4072 16.08 16.08
2 WORST PARTIAL BACK SPRAIN/STRAIN 2033 8.03 24.10
3 BEST PARTIAL FINGER DISLOCATION 1603 6.33 30.43
4 WORST TREATED SANS 1022 4.03 34.47
5 WORST PARTIAL EYE CHEMICAL BURN 925 3.65 38.12
6 WORST PARTIAL NEPHROLITHIASIS 811 3.20 41.32
7 WORST TREATED NEPHROLITHIASIS 689 2.72 44.04
8 WORST TREATED SMOKE INHALATION 674 2.66 46.70
9 WORST PARTIAL EYE INFECTION 659 2.60 49.30
10 WORST PARTIAL DENTAL ABSCESS 482 1.90 51.21
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But…
Modelling Sex-Dependent Medical Risk - IMM S-20170724-387 
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pEVAC - With Resupply
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pEVAC Medical – With Resupply
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pEVAC Trauma – With Resupply
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pEVAC (With Resupply): Female Influential Conditions
Modelling Sex-Dependent Medical Risk - IMM S-20170724-387 
All Female
Rank Scenario Treated Condition Events
Contribution 
(%)
Cumulative 
(%)
1 WORST TREATED NEPHROLITHIASIS 1490 12.95 12.95
2 WORST TREATED SANS 1074 9.33 22.28
3 WORST TREATED DENTAL ABSCESS 924 8.03 30.31
4 WORST TREATED SEPSIS 770 6.69 37.00
5 WORST TREATED SMOKE INHALATION 726 6.31 43.31
6 BEST TREATED SMALL BOWEL OBSTRUCTION 519 4.51 47.82
7 WORST TREATED WRIST FRACTURE 441 3.83 51.66
8 WORST TREATED BACK SPRAIN/STRAIN 336 2.92 54.58
9 WORST TREATED URINARY TRACT INFECTION 305 2.65 57.23
10 WORST TREATED HEAD INJURY 249 2.16 59.39
11 BEST TREATED CEREBROVASCULAR ACCIDENT 245 2.13 61.52
12 WORST TREATED TRAUMATIC HYPOVOLEMIC SHOCK 236 2.05 63.57
13 BEST TREATED SEIZURES 236 2.05 65.62
14 WORST TREATED CEREBROVASCULAR ACCIDENT 221 1.92 67.54
15 BEST TREATED ANGINA /MYOCARDIAL INFARCTION 190 1.65 69.19
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pEVAC (With Resupply): Male Influential Conditions
Modelling Sex-Dependent Medical Risk - IMM S-20170724-387 
All Male
Rank Scenario Treated Condition Events
Contribution 
(%)
Cumulative 
(%)
1 WORST TREATED NEPHROLITHIASIS 1507 12.45 12.45
2 WORST TREATED SANS 1058 8.74 21.18
3 WORST TREATED DENTAL ABSCESS 803 6.63 27.82
4 WORST TREATED SEPSIS 794 6.56 34.37
5 WORST TREATED SMOKE INHALATION 734 6.06 40.44
6 BEST TREATED SMALL BOWEL OBSTRUCTION 497 4.10 44.54
7 WORST TREATED WRIST FRACTURE 463 3.82 48.36
8 WORST TREATED HIP/PROXIMAL FEMUR FRACTURE 383 3.16 51.53
9 WORST TREATED CEREBROVASCULAR ACCIDENT 340 2.81 54.34
10 WORST TREATED BACK SPRAIN/STRAIN 326 2.69 57.03
11 BEST TREATED CEREBROVASCULAR ACCIDENT 323 2.67 59.70
12 BEST TREATED ANGINA/MYOCARDIAL INFARCTION 290 2.40 62.09
13 WORST TREATED TRAUMATIC HYPOVOLEMIC SHOCK 264 2.18 64.27
14 BEST TREATED ATRIAL FIBRILLATION/  FLUTTER 263 2.17 66.44
15 BEST TREATED SEIZURES 240 1.98 68.43
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Discussion
 No differences in CHI or LOCL between sexes
 Partially-treated UTI drives higher female EVAC using the base ISS med kit
 Coronary and trauma risks for males are important for long missions
 Appropriate med kit design and prevention can mitigate sex-dependent risks
 Other conditions have sex-dependent risks which are not represented
 PRA is a useful tool to ask “what if…”!
Modelling Sex-Dependent Medical Risk - IMM S-20170724-387 
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Disclaimer
These results are subject to the biases inherent in the model 
and should only be used by subject matter experts as one 
point of information among many.
Thank you!
“All models are wrong. Some are useful.”
- George Box (1919 – 2013)
Modelling Sex-Dependent Medical Risk - IMM S-20170724-387 
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Back Up
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Other Considerations: Landing/Postflight
• Orthostatic intolerance
• Landing impact trauma
• Neurosensory
• Men: higher incidence of post-flight motion sickness
• Women: higher incidence of post-flight vestibular instability symptoms
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Other Considerations: Landing/Postflight
• Orthostatic intolerance
• Landing impact trauma
• Neurosensory16
• Men: higher incidence of post-flight motion sickness
• Women: higher incidence of post-flight vestibular instability symptoms
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Other Considerations: Behavioral/Social
• Response to stress due to psychosocial isolation7
• Women: more likely to be interpersonally supportive 
• Men: more often respond with anger, noncooperation and conflict
• Inconclusive studies in spaceflight and Antarctic groups as to ideal 
crew composition7,8,10,28
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Other Considerations: Malignancy
• Women have increased susceptibility to radiation induced cancer 9
• Antarctic winter-overs as analogue: multiple instances of cancer 
• Large induction period for many cancers, but still possible for cancer to surface
• Breast, lung, testicular carcinoma1,2
• Evacuation unlikely
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References
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Space Environ Med 2007; 78:A26-37. 
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3. Buckey JC. Space physiology. Oxford ; New York: Oxford University Press; 2006.
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US adult population. Results from the Third National Health and Nutrition Examination Survey, 1988-
1991. Hypertens Dallas Tex 1979 1995; 25:305–13. 
5. Drudi L, Grenon SM. Women’s Health in Spaceflight. Aviat Space Environ Med 2014; 85:645–52. 
6. Gilkey K, McRae M, Griffin E, Kalluri A, Myers J. Bayesian Analysis For Risk Assessment of Selected 
Medical Events in Support of the Integrated Medical Model Effort. Cleveland, OH: National Aeronautics 
and Space Administration, Glenn Research Center; 2012. Technical Paper No: NASA/TP-2012-217120.
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Optimization of an Exploration Medical Kit
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References
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National Aeronautics and Space Administration
References
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Gender on Adaptation to Space: Neurosensory Systems. J Womens Health 2014; 23:959–62. 
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Probabilistic Assessment of Sex-Dependent Medical Risk During Spaceflight

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