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Clinical Follow-Up and Care for Those Impacted by the JP-5 Releases at Red Hill

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In 2021, Navy personnel accidentally caused two fuel leaks at the Red Hill Bulk Fuel Storage Facility—a Navy-operated site on the island of O‘ahu. As a result, approximately 93,000 people, most affiliated with the Department of Defense, were potentially exposed to contaminated drinking water through their residence, workplace, or both. While engaging with affected community members, our expert committee will review the health risks associated with JP-5 exposure and make recommendations to the Department of Defense and the Department of Veterans Affairs regarding clinical follow-up for those exposed.

Clinicians Should Focus on Symptom Evaluation and Continuity of Care Following Jet Fuel Releases in Oahu, Says New Report Examining Health Risks from Potential Exposures Mar 19, 2026 News Release

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Introduction

In 2021, U.S. Navy personnel accidentally caused two releases of kerosene-based aviation fuel (jet propellant 5, or JP-5) from the Red Hill Bulk Fuel Storage Facility on O‘ahu, Hawai‘i, contaminating the drinking water supply for Joint Base Pearl Harbor-Hickam (JBPHH) and the Āliamanu Military Reservation (ĀMR). This exposure impacted up to 93,000 individuals, disrupting their lives and, for many, resulting in acute and ongoing health concerns.

In response, the National Academies of Sciences, Engineering, and Medicine convened an expert committee to assess the scientific evidence for the potential health effects of JP-5, engage with affected communities to gain understand their experiences, and provide guidance to the Department of Veterans Affairs and the Defense Health Agency on clinical care and follow-up for those who were exposed.

Key takeaways

Exposure was Complex and Exposure Concentrations are Uncertain

The Red Hill releases resulted in the contamination of a public drinking water system with a complex fuel mixture that could expose people through ingestion, inhalation, and skin contact. Limitations in environmental sampling and the absence of validated biomarkers make it impossible to precisely quantify individual exposure levels. Experimental evidence suggests contamination levels were plausibly high enough to exceed safety factors for the chemical components of jet fuel.

Evidence for Health Effects Is Limited

There is limited or suggestive evidence linking jet fuel exposure to acute respiratory, gastrointestinal, skin, and mental health symptoms. However, evidence is inadequate or insufficient for most long-term outcomes. Insufficient or inadequate evidence indicates available data cannot determine whether an association exists; it does not indicate that there was no effect.

Symptoms Were Widespread in Affected Communities

Community surveys found that a large majority of respondents reported new or worsening symptoms, often affecting multiple systems and sometimes persisting years after the exposure had ended.

No Established Clinical Guidance Exists

No existing clinical guidance fully meets the standards for evidence-based care specific to JP-5 exposure.

Trust and Communication Are Central to Health

Breakdowns in communication contributed to the loss of trust between officials and the local communities. Rebuilding trust is essential to recovery.

Mental Health and Community Trauma Are Key Impacts

The fuel releases were experienced as collective trauma with lasting psychological effects.

Data Gaps Limit Decision Making

Critical gaps in available data constrain the committee’s ability to assess risk, guide care, and inform policy.

Key Recommendations

- Clinicians should prioritize symptom-based evaluation and continuity of primary care following the U.S. Preventive Services Task Force Guidelines as of November 2025 for adults based on age, sex, and other established risk factors or the Bright Futures Periodicity Schedule for children.
- Clinicians should not implement additional surveillance or testing. This is because exposure levels cannot be precisely reconstructed, and evidence linking JP-5 exposure to specific long-term diseases is insufficient. Instead, clinicians should carefully evaluate and document symptoms, ensure continuity of primary care, follow established preventive screening guidelines.
- Guidance for care should be periodically updated with input from affected individuals and clinicians caring for exposed patients.
- Key partners such as the Department of Defense (DoD), HDOH, Honolulu Board of Water Supply, Hawai‘i Commission on Water Resource Management, Environmental Protection Agency (EPA), Agency for Toxic Substances and Disease Registry, and Office of Hawaiian Affairs should
  Continue efforts to mitigate exposure and reassure the public about the safety of their drinking water,
  Collaboratively and transparently continue drinking water monitoring and improve compound-specific chemical analysis,
  Follow through recommendations from prior oversight and accountability reviews, and
  Jointly identify and apply lessons learned to strengthen preparedness for future events.
- Develop and Validate Biomarkers: The Centers for Disease Control and Prevention (CDC), National Institutes of Health, DoD, and Department of Veterans Affairs (VA) should support research to develop and validate biomarkers of petroleum associated with jet fuel exposure.
- Standardize Environmental Sampling: EPA and CDC should support the development of standardized environmental sampling and chemical analysis methods for petroleum-contaminated drinking water.
- Characterize Fate and Transport: Federal environmental agencies should support research to characterize how petroleum constituents move from drinking-water sources to points of use, which includes evaluation of reactions with disinfectants and behavior in plumbing systems to improve exposure estimates when fuel contaminates drinking water systems.
- Federal and state partners should support longitudinal, community-engaged research on the health impacts of exposure to petroleum hydrocarbons associated with jet fuels. The research should include high-quality epidemiologic studies, toxicologic studies reflecting real-world exposure, and effective use of existing health data systems.
  High-quality epidemiologic studies should include careful assessment of mixed exposures relevant to Red Hill, measurement of both physical and mental health outcomes, use of valid comparison groups, and rigorous control of confounding factors.
  Toxicologic studies reflecting real-world exposure should include multi-route exposure (e.g., ingestion, inhalation, dermal) and chemical mixtures consistent with contaminated drinking water.
  Effective use of existing health data systems should include linking electronic health records, claims data, and registries; development electronic cohorts with cross-mapped exposure documentation; and application of rigorous statistical methods to assess short- and long-term outcomes.
- The Defense Occupational and Environmental Health Readiness System (DOEHRS) Registry, which documents occupational and environmental exposures for service members and eligible beneficiaries should be maintained and expanded. DOEHRS exposure records are linked to the Individual Longitudinal Exposure Record (ILER), supporting continuity between the military health system and VA medical records.
- The DOEHRS Eligibility should be expanded to include all individuals who lived or worked at JBPHH or ĀMR from May 6, 2021, to March 18, 2022.

Background, Engagement, and Framework

Study Background

The Red Hill fuel releases resulted in the first large-scale contamination of a public drinking water system with JP-5—a complex fuel whose components can evaporate into the air—meaning exposures could be occur not only by drinking the water but also by breathing in vapors or through skin contact with the contaminated water.

Access to clean, safe drinking water is recognized by the United Nations as a fundamental human right, essential to the realization of all other rights. In the United States, this expectation is reinforced by the Safe Drinking Water Act, which requires the U.S. EPA to set enforceable standards for water quality. On U.S. military installations, service members and their families are promised stability and safety; Department of Defense[1] (DoD) policy and federal law require housing that is safe, habitable, and protective of health. In Hawai‘i, these expectations take on added significance because wai—fresh water—is central to both physical survival and spiritual well-being. For Native Hawaiians, water represents not just a source of life but a sacred trust; protecting it is a moral and ecological duty.

Constructed into the basalt ridge of Kapūkakī (Red Hill), the Red Hill Bulk Fuel Storage Facility has presented environmental and public health risks since its construction in 1943. The facility, consisting of 20 underground 12.5-million-gallon fuel storage tanks, is located 100 feet above O‘ahu’s Sole Source Aquifer (Figures 1 and 2). Over its operating history, the conditions of the facility have deteriorated because of corrosion and inadequate maintenance,[2] collectively releasing hundreds of thousands of gallons of fuel over its operating history.

[1] The committee recognizes that the Department of Defense now uses its original name, Department of War, as outlined in Executive Order 14347, Restoring the United States Department of War (September 5, 2025). The committee has chosen to use the term Department of Defense throughout this report for clarity and consistency, as that was the department’s official name at the time of the events described and when this study was initiated.

[2] The committee did not review the maintenance activities of the Red Hill Bulk Fuel Storage Facility, but an Office of Inspector General report determined that DoD officials did not effectively manage and oversee its operations, maintenance, and safety.

Map showing the Red Hill Bulk Fuel Storage Facility and nearby wells and shafts that draw water from the Southern O‘ahu Basal Aquifer. The figure illustrates the facility’s proximity to drinking-water sources that serve communities on O‘ahu.

Illustration showing the size and scale of the Red Hill fuel storage tanks and their location above the aquifer. The figure emphasizes the large fuel storage capacity and the relatively short distance between the tanks and groundwater.

Committee Approach

The committee approached its charge with the understanding that effective clinical care in the wake of an error requires rebuilding trust and preventing future harm. The committee’s engagement with communities impacted by the Red Hill exposure provided critical knowledge and accounts of real-life experiences as well as essential context for the committee’s development of effective recommendations for patient-centered care.

For Native Hawaiians, Kapūkakī (Red Hill) is a wahi pana—a sacred place—and water (wai) represents life and responsibility. Contamination of the primary drinking water source for most of Oʻahu reduced trust in local and government institutions and confirmed, for many, enduring concerns about military activities and their environmental and cultural impact.

The committee formed a group of community liaisons and created in-person and virtual opportunities for public input. Fifteen liaisons—including active-duty service members, military families, civilians, Native Hawaiians, and other O‘ahu residents—informed staff of community perspectives throughout the study process. The committee held three public virtual listening sessions and two in-person public sessions at the O‘ahu Veterans Center; they also accepted written comments throughout the study process.

The committee developed a framework (Figure 3) supplemented by Native Hawaiian values such as kuleana (delegated authority and corresponding responsibility) and mālama ‘āina (care for the land).

FIGURE 3 The committee’s framework for developing its recommendations, and approach to its charge. The committee used two complementary ethical lenses to develop evidence-based, equitable, culturally grounded, and responsive recommendations.

Timeline of Release Events and Response

May 6, 2021 During a fuel transfer, 19,377 gallons of JP-5 were spilled and then diverted into an overhead fire suppression system pipeline.
Summer and fall of 2021 Total petroleum hydrocarbons in the oil range were detected in the Red Hill drinking-water shaft; two samples exceeded the action level.
November 20, 2021 A vehicle struck the overhead fire suppression system, which caused the release the residual fuel from the May 6 spill.
November 22, 2021 A Navy media release stated the Navy had stopped the release of “a water and fuel mixture” at Red Hill.
November 27, 2021 The Navy received an initial complaint of a chemical smell in drinking water on JBPHH.
November 28, 2021 The Red Hill drinking water shaft was shut down. Thousands of residents subsequently reported a chemical or fuel smell in the drinking water.
November 29, 2021 A Navy media release told residents, “If chemical or petroleum odors are present, recommend avoiding ingestion as a cautionary measure.” A Hawai`i State Department of Health (HDOH) press release told Navy water system users to avoid using the water for drinking, cooking, or oral hygiene—and additionally bathing, dishwashing, and laundry if users detected a fuel odor. The Navy began flushing fire hydrants, which released the contaminated water to sidewalks and streets.
December 2, 2021 The Army began offering relocation to residents in affected areas. Honolulu Board of Water Supply voluntarily shut down the Hālawa drinking-water shaft.
December 3, 2021 The Navy’s ‘Aiea-Hālawa drinking-water shaft was shut down, leaving only one shaft operating for the JBPHH and ĀMR water systems. The Navy offered relocation to some residents in affected areas.
Mid-December 2021 Cleanup and remediation activities began.
March 7, 2022 The U.S. Secretary of Defense directed the permanent defueling and closure of the Red Hill Bulk Fuel Storage Facility.
March 18, 2022 All zones met clearance criteria, and the HDOH lifted the drinking-water advisory.
June 30, 2022 The Navy acknowledged the violation of the Public Notification Rule under the Safe Drinking Water Act, which required a public notice issuance within 24 hours after the Navy became aware that the JBPHH water system was contaminated with JP-5.
March 2024 All bulk fuel was removed from the 20 underground tanks; the Navy Closure Task Force–Red Hill began closure of the facility.
Ongoing The U.S. Environmental Protection Agency (EPA) and HDOH continue to supervise environmental remediation and site decommissioning at the former Red Hill Bulk Fuel Storage Facility, and the Navy continues to monitor the safety of the drinking water.

Conclusions

The Red Hill Fuel releases were a defining environmental health event for both Hawai‘i and the nation as a whole. The event demonstrated how water safety, public trust, and institutional integrity are intertwined. Recovery requires transparency, coordination, and sustained investment that is guided by aloha, pono, kuleana, and mālama ʻāina. This report provides an opportunity to strengthen emergency preparedness and stewardship of Hawaiʻi’s wai and to support the recovery of communities impacted by the releases at Red Hill.

For Native Hawaiians, water represents not just a source of life but a sacred trust; protecting it is a moral and ecological duty.

Clinical Follow-up and Care for Those Impacted by the JP-5 Releases at Red Hill (2026)

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