Consensus Study Report

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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2026. Clinical Follow-Up and Care for Those Impacted by the JP-5 Releases at Red Hill. Washington, DC: National Academies Press. https://doi.org/10.17226/29404.

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COMMITTEE ON THE CLINICAL FOLLOW-UP AND CARE FOR THOSE IMPACTED BY THE JP-5 RELEASES AT RED HILL

GRACE M. LEE (Chair), Stanford University; Stanford Medicine Children’s Health

ALBERTO J. CABAN-MARTINEZ, University of Miami

THERESA A. CULLEN, Pima County Department of Health

RICARDO CUSTODIO, University of Hawai‘i–West O‘ahu

NATALIE EXUM, Johns Hopkins Bloomberg School of Public Health

MAIDA P. GALVEZ, Icahn School of Medicine at Mount Sinai

O’NEIL W. GUTHRIE, Northern Arizona University

JERRIS R. HEDGES, John A. Burns School of Medicine, University of Hawai‘i at Mānoa

MARCUS KĀWIKA IWANE, ‘Ahahui o nā Kauka; John A. Burns School of Medicine, University of Hawai‘i at Mānoa; Hawai‘i Permanente Medical Group

JOSEPH KEAWE‘AIMOKU KAHOLOKULA, John A. Burns School of Medicine, University of Hawai‘i at Mānoa

KURUNTHACHALAM KANNAN, New York State Department of Health; University at Albany

ANDREW F. OLSHAN, The University of North Carolina at Chapel Hill

MELISSA J. PERRY, George Mason University

PAUL M. WAX, American College of Medical Toxicology

ANDREW J. WHELTON, Purdue University

MATTHEW K. WYNIA, University of Colorado

Study Staff

ELIZABETH BARKSDALE BOYLE, Study Director

KATHRYN GUYTON, Senior Program Officer

ANNE STYKA, Senior Program Officer

ANTHONY DEPINTO, Program Officer

MATTHEW MASIELLO, Associate Program Officer (through March 2025)

ALEXANDRA MCKAY, Research Associate

EMMA FLETCHER, Research Associate

SHALINI SINGARAVELU, Program Officer

MIA SALTRELLI, Senior Program Assistant (through July 2025)

MAGGIE ANDERSON, Research Assistant (from September 2025)

Y. CRYSTI PARK, Program Coordinator (through September 2025)

ROSE MARIE MARTINEZ, Senior Board Director (through November 2025)

CLARE STROUD, Senior Program Director (from November 2025)

Reviewers

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their review of this report:

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft before its release. The review of this report was overseen by DAVID L. EATON, University of Washington, and BRUCE N. CALONGE, University of Colorado School of Medicine. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.

Acknowledgments

The successful completion of this report and fulfillment of the committee’s charge would not have been possible without the support of numerous individuals. The committee’s deliberations were enriched by diverse perspectives shared through presentations and discussions at the public meetings. The following speakers contributed their expertise, experience, and insights: Roger Brewer, Veronia Carvajal, Eva Davis, Sorina Eftim, Diana Felton, Patricia Hastings, Cary Haver, Aimee Malia Grace, Shonali Palacios, Catherine Pirkle, William Rice, Wayne Tanaka, Terra Vincent-Hall, and Rosana “Sanie” Weldon. The committee is grateful to the Red Hill Registry team at the University of Hawai‘i for their outreach support, including promoting public meetings and recommending potential nominees and speakers. This report would also not have been possible without the dedication of Colonel John Oh from the Defense Health Agency. Colonel Oh was instrumental in working with Red Hill communities to launch research projects to inform their health and recovery.

The committee also benefited from hearing the experiences and contributions from many individuals exposed to or affected by the JP-5 releases at Red Hill. These discussions helped ground our work, and we are extremely grateful for their courage in sharing those experiences in a public forum.

The committee sincerely thanks our community liaison group, whose shared experiences, perspectives, and contributions were essential to the development of this report. This engagement ensured that our public meetings would include relevant perspectives that allowed us to learn about the social, environmental, public health, and medical challenges central to our charge. In addition, the committee found the information and perspectives

provided by the presentations and discussions at our public meetings immensely helpful in informing our deliberations, and is grateful to the following individuals for their time and insight:

Finally, the committee would like to express its sincere appreciation to the National Academies of Sciences, Engineering, and Medicine staff who contributed to producing this report: Elizabeth Boyle, Anthony DePinto, Alexandra McKay, Emma Fletcher, Shalini Singaravelu, Mia Saltrelli, Maggie Anderson, Kathryn Guyton, Anne Styka, Matthew Masiello, Y. Crysti Park, Clare Stroud, and Rose Marie Martinez. Thanks as well go to other staff who provided additional support, including Sam Gerard and Amber McLaughlin (Office of Communications), Megan Lowry (Office of News and Public Information), Thanh Nguyen and Wahidullah Nazari (Office of Financial Administration), and Christopher Lao-Scott and Anne Marie Houppert (National Academies Research Center). Finally, a thank you is extended to Rona Briere and Allison Boman, who assisted the committee with editing the report.

Contents

PREFACE

ACRONYMS AND ABBREVIATIONS

SUMMARY

1 INTRODUCTION

Statement of Task

Background: Red Hill, the 2021 Releases, Response, and Recovery

Study Approach and Committee’s Interpretation of Its Charge

Organization of the Report

References

2 HISTORICAL AND SOCIOCULTURAL CONTEXT OF RED HILL AND COMMUNITY EXPERIENCES OF THE 2021 FUEL RELEASES

History of Red Hill

History of Water Governance and Environmental Stewardship

Community Experiences of the 2021 Red Hill Fuel Releases, Incident Response, Remediation, and Recovery

Conclusions

References

3 EXPOSURE ASSESSMENTS AND MODELS

Chemical Composition of Jet Fuel

Biomonitoring: Utility and Constraints in the Red Hill Context

Key Components of Exposure Models

Characteristics of Joint Base Pearl Harbor–Hickam and Āliamanu Military Reservation Public Water Systems

Fate And Transport of Jet Fuel Constituents

Data Quality and Availability

Review of Existing Exposure Information for 2021 Fuel Releases

Conclusions

Annex 3-1: Biomarkers of JP-5 Constituents

References

4 HEALTH EFFECTS OF JET PROPELLANT 5 EXPOSURE

Approach to Evidence Review and Synthesis

Strength-of-Evidence Conclusions, by Health Symptoms and Conditions

Evidence Gaps and Conclusions

References

5 EVALUATING CLINICAL AND COMMUNITY HEALTH GUIDANCE FOR THE RED HILL EXPOSURES

Chemical Exposures and Psychological Stress in Impacted Populations

Standards for the Development of Trustworthy Guidance for Clinical Assessment and Care

Review of Potentially Applicable Guidance

Challenges with Developing Trustworthy Guidance Specific to the Red Hill JP-5 Exposures

Benefits and Harms of Increased Clinical Follow-Up for Individuals and Communities

Conclusions

References

6 ENHANCING CARE AND PUBLIC HEALTH CAPACITY POST–RED HILL

Assurance: Delivering and Sustaining Services that Protect Public Health

Policy Development: Coordinating Guidance, Governance, and Community Trust

Assessment: Understanding Exposure and Its Consequences

Closing Reflections

References

Appendixes

A Committee and Staff Biosketches

B Community Liaison Biosketches

C Summary of Virtual Listening Sessions and Community Meetings

D Evidence Review: Methods and Approach

E Timeline of Known Spills at Red Hill

F Example Clinical Guidance for Red Hill Patients

Boxes, Figures, and Tables

BOXES

S-1 Red Hill Bulk Fuel Storage Facility: Timeline of Release Events and Response

S-2 Specific Elements the Committee Recommends Be Incorporated in the Red Hill Clinical Guidance

S-3 Ongoing and Planned Public Health Assurance Activities for Communities Surrounding the Decommissioned Red Hill Bulk Fuel Storage Facility

S-4 Essential Actions of Joint Communication Plans and Emergency Response Standard Operating Procedures

1-1 Statement of Task

1-2 Drinking-Water Access Shafts Impacted by the 2021 Red Hill Releases

2-1 Significance of Wai in Toponyms and the Hawaiian Lexicon

2-2 Examples of Contemporary U.S. Military Actions and Implications for Environmental and Cultural Stewardship in Hawai‘i

3-1 Potential Exposure Pathways for Children

3-2 How Contamination Moves through Water Distribution Systems and Building Plumbing

3-3 Limitations of Using Odor to Infer Drinking-Water Contamination and Health Risk

3-4 Problems with Total Petroleum Hydrocarbon Analysis

5-1 Standards of Trustworthy Clinical Practice Guidance for Both Community and Individual Health

6-1 Specific Elements the Committee Recommends Be Incorporated in the Red Hill Clinical Guidance

6-2 Ongoing and Planned Public Health Assurance Activities for Communities Surrounding the Decommissioned Red Hill Bulk Fuel Storage Facility

6-3 Essential Actions of Joint Communication Plans and Emergency Response Standard Operating Procedures

6-4 Ongoing Assessment Activities

6-5 Research Priorities Identified by the Committee

D-1 ROBIS Critical Domains and Overall Confidence in Results

D-2 IRIS Evaluation for Epidemiological Studies

D-3 Bradford Hill Considerations

FIGURES

S-1 Red Hill Bulk Fuel Storage Facility in relationship to wells or shafts that access water from O‘ahu’s sole source aquifer

S-2 Vertical profile of the Red Hill Bulk Fuel Storage System and groundwater interface

S-3 The committee’s approach to its charge

S-4 The committee’s framework for developing its recommendations

S-5 Categories of association used in this report

1-1 Red Hill Bulk Fuel Storage Facility in relationship to wells or shafts that access water from the Southern O‘ahu Basal Aquifer

1-2 Size and scale of each fuel tank and relationship with the aquifer

1-3 Diagram of how groundwater is taken from the aquifer through a system of shafts, wells, and tunnels

1-4 Heatmap of drinking-water consumer complaints

1-5 Water system flushing zone map

1-6 The committee’s approach to its charge

1-7 The 10 essential public health services and their relationship to the core public health functions of assurance, policy development, and assessment

1-8 The committee’s framework for developing its recommendations

2-1 Excerpt adapted from “Oahu, Hawaiian Islands” Map of 1881 Hawaiian Government Survey, noting location of Red Hill ridge (upper-right quadrant of map in blue square) in relation to Hālawa and Moanalua geographic subdivisions (center of map)

2-2 Island of O‘ahu hydrologic units

2-3 National and state-level institutions, agencies, and organizations with responsibilities for access to safe water in Hawai‘i

2-4 Location of housing complexes served by the Joint Base Pearl Harbor–Hickham water system

3-1 Conceptual model of exposures to jet propellant 5 (JP-5) among residents receiving their drinking water from the Joint Base Pearl Harbor–Hickam (JBPHH) and Āliamanu Military Reservation (ĀMR) water systems

3-2 Joint Base Pearl Harbor–Hickam (JBPHH) and Āliamanu Military Reservation (ĀMR) water system flushing zones

3-3 Joint Base Pearl Harbor–Hickam water system

3-4 Residential building domestic plumbing designs: trunk-and-branch design (top diagram) and manifold design (bottom diagram)

3-5 Free fuel product and emulsions, as well as dissolved volatile organic compounds (VOCs) and semivolatile organic compounds (SVOCs), would interact with biofilm, scales, and metal and plastic infrastructure materials

4-1 Risk-of-bias assessment for studies of the Red Hill population

4-2 Categories of association used in this report

4-3 Risk-of-bias assessment for respiratory studies

4-4 Risk-of-bias assessment for cardiovascular studies

4-5 Risk-of-bias assessment for gastrointestinal studies

4-6 Risk-of-bias assessment for hematological studies

4-7 Risk-of-bias assessment for hepatic studies

4-8 Risk-of-bias assessment for renal and urologic studies

4-9 Risk-of-bias assessment for dermal studies

4-10 Risk-of-bias assessment for immune studies

4-11 Risk-of-bias assessment for neurological studies

4-12 Risk-of-bias assessment for mental health studies

4-13 Risk-of-bias assessment for reproductive studies

4-14 Risk-of-bias assessment for cancer studies

5-1 Conceptual model of the association of environmental hazards with mental health outcomes at the individual and community levels (not unique to the Red Hill Bulk Fuel Storage Facility release events)

D-1 Categories of association used in this report

TABLES

1-1 Annex Table: Chronology of Public Health Advisories and Communications Following the Red Hill Fuel Releases (November 2021–April 2025)

3-1 Relative Percent Composition of Neat JP-5 as Reported by Hawai‘i State Department of Health

3-2 Summary of Assessment of Exposure of JBPHH Residents to Contaminants in Tap Water Immediately Following the November 20, 2021, Release of JP-5 into the Base Drinking-Water System

3-3 Estimated Exposure Dose for JP-5 Constituents

D-1 Authoritative Reviews Assessed in Analysis

D-2 Literature Search #1 Inclusion and Exclusion Criteria

D-3 Medline Search Filters (Search #1)

D-4 Literature Search #2 Inclusion and Exclusion Criteria

D-5 Embase Search Filters (Search #1)

D-6 IEEE Filters (Search #1)

D-7 American Chemical Society Filters (Search #1)

D-8 Scopus Filters (Search #1)

D-9 Scopus Filters (Search #2)

D-10 MEDLINE Filters (Search #2)

D-11 Embase Filters (Search #2)

D-12 IEEE Filters (Search #2)

D-13 American Chemical Society Filters (Search #2)

Preface

Communities served by the Joint Base Pearl Harbor–Hickam water distribution system were directly impacted following two major releases of jet propellant 5 (JP-5) aviation fuel from the Red Hill Bulk Fuel Storage Facility in May 2021 and November 2021. While human error initially contributed to these incidents, the responses to these leaks could also be seen as a sequence of potentially avoidable errors that led to ongoing confusion and mistrust about the safety of the water supply and the impact on the health of communities affected by the fuel leaks. An ad hoc committee of the National Academies of Sciences, Engineering, and Medicine was convened to recommend further guidance on clinical actions to monitor the long-term health of community members exposed to JP-5 aviation fuel releases.

In 1999, the Institute of Medicine published a landmark report: To Err Is Human: Building a Safer Health System. While the report highlighted that preventable medical errors were a major cause of serious patient harm, it shifted the focus away from blaming individuals for harm to redesigning systems and processes to make health care safer. The committee approached this report similarly, taking a system-level perspective to address recommendations for clinical care of exposed individuals and communities, including mitigating risks for future exposure that might compound harm.

The committee’s work was also guided by engaging with individuals exposed during the Red Hill fuel release, through a panel of community liaisons and multiple listening sessions, including in-person community

meetings. “Nothing about us without us” is a common phrase used in health care to remind us of the critical role of patients in health care decision making, to ensure we remain “respectful of and responsive to individual patient preferences, needs, and values and ensure that patient values guide all clinical decisions.”¹ As such, active learning from patients and communities impacted by the Red Hill fuel leaks was essential in our formulation of these clinical recommendations. While the experiences of individuals were unique, we heard common themes with clinical implications, including the desire for acknowledgment and the need for ongoing communication, assurance of water safety, and support.

Our initial approach to understanding the health risks associated with exposure to JP-5 focused on understanding the evidence base for specific conditions or health outcomes by body system following exposure to jet fuels. We faced two key uncertainties that made this assessment challenging. First, despite an extensive review of available data, understanding the degree and duration of exposure for individuals was not possible based on the sampling and analytic approaches used. Second, the current evidence regarding the long-term health effects of JP-5 exposure remains limited, underscoring the necessity for ongoing research into the impacts of jet fuel exposure on long-term health outcomes.

Finally, the committee had the opportunity to see firsthand the Red Hill fuel storage tanks and the Waihe‘e Tunnel during our visit to O‘ahu. The juxtaposition of the need for military readiness with the critical infrastructure necessary to protect the island’s water supply enriched our view of the complexity and challenges. The influence of the culture and history of Hawai‘i on how this spill was experienced also became apparent during our visit, giving us a greater connection to the past and present, and showing us opportunities for a better future. The committee integrated these insights into two complementary ethical lenses: (1) public health and clinical ethics principles drawn from existing National Academies reports, and (2) traditional Native Hawaiian cultural values.

We hope this report will be received in the spirit of compassion and understanding for individuals who have been impacted by the Red Hill fuel leaks seeking to move toward recovery and healing, as well as the agencies responsible for ensuring the safety of the water, the health of military personnel and their families, and the health of communities. Medical professionals have learned that building and rebuilding trust following an error requires humility, honesty, a willingness to improve systems and processes, and ongoing presence in the community. These

___________________

¹ Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press, page 6.

recommendations are thus intended to serve as a road map for recovery and a path for prevention.

Grace M. Lee, Chair
Committee on Clinical Follow-Up and Care for Those Impacted by the JP-5 Releases at Red Hill
March 2025

Dark tunnel’s water

Purified from above-

Wai Ola whispers

—Andrew Olshan, Member, Committee on Clinical Follow-Up and Care for Those Impacted by the JP-5 Releases at Red Hill

Acronyms and Abbreviations