Follow-up of Persons Exposed to Radiation and Radioactivity Niel Wald, M.D. and Michael Kuniak, D.O....

Follow-up of Persons Exposed to Radiation and Radioactivity

Niel Wald, M.D. and Michael Kuniak, D.O.

Dept. of Environmental & Occupational Health

University of Pittsburgh,

Graduate School of Public Health

Pittsburgh, PA 15261

Presentation Outline1. Definitions: Prompt vs. Long-term Follow-up

2. Examples of Prompt Early Health Follow-up :Airline Shipment Accident

Goiania Stolen Source AccidentChernobyl Reactor Accident

3. a. Examples of Prompt Preparations for

Long-term Health Follow-up:

ABCC databaseTMI database Chernobyl database

b. Long-term Psychological Stress Reduction

192Iridium Shipping Incident

H.P. Participants included:K.Z. Morgan, Oak Ridge National LaboratoryR. Zimmerman, Phoenix Technology Corp.B.J. Porter, Louisiana Bureau of Radiation Control

M.D. Participants included:N. Wald, University of PittsburghC. Huguley, Emory UniversityW. Jensen, George Washington UniversityC.A. Paulsen, University of Washington

Normal Source Position in C 10 Cask

69lb 192Iridium Source ExchangerSource Position on Return to Vendor

14R/Hr

Source Position at Ryan Airportfor about 56 hours

Magnitude of the AccidentExposure Locations:

Sender and Receiver Sites: 2 Airline Freight Depots: 3 Aircraft: 2 Passengers: 157

Med. exam and CBC: 154Worst Case Dose: 7 rads

Airline and freight employees: 48Med. Exam and CBC: 48Chromosome studies: 11Sperm Counts: 53 ___

Total persons: 205

Lesson Learned In a population exposure event, M.D. must initiate triage independent of firm H.P. information to assess possible injury and to meet psychological needs, but the latter is of great value as soon as available.








454-2

Location of Goiania, Brazil

451-1

Goiania Accident Source

137Cs teletherapy source capsule:

Physical form: CsCl hygroscopic powder with blue fluorescence as it absorbed moisture.

Radioactivity: 50.9 TBq (1375Ci)

Dose rate @1 m: 4.56 Gy/hr (456 rad/hr)

451-3

Goiania Medical Disposition

580-9

Goiania Casualty Burial

412-3

Goiania Local Injury

454-5

Goiania Contaminated Areas

451-2

Goiania Population Screening

55-3

Goiania Accident MagnitudePeople monitored: 112,000

Chromosome analyses: 110

Roads monitored: 2,000 Km

Remediation workers: 755Above DL: 38 (Highest: 10 mSv CDE)

Homes contaminated: 85Demolished: 7

Vehicles contaminated:50

Radwaste created: 3,800 200L drums

Lessons Learned

Lack of awareness of the detrimental health effects of radiation exposure can impede its recognition on the part of patients and medical practitioners until much damage is done.

The alert M.D. who faces an unusual public health problem must find a collaborating H.P. to evaluate its possible radiogenic origin and if confirmed, to help deal with it.

Presentation Outline1. Definitions: Early vs. Long-term Follow-up

2. Examples of Early Health Follow-up :Airline Shipment Accident


3. a. Examples of Early Preparations for




Chernobyl: Healthcare Resources Used

• Local medical facilities

• 400 special medical brigades

–M.D., H.P., etc.

• 15,000 health workers

–2,000 M.D.’s, 4,000 nurses, med students, etc

• 213 mobile laboratories

• Special hospitals (Kiev, Moscow)

Chernobyl: Healthcare Procedures

Medical Examinations

1,000,000 persons

Dosimetric & lab tests

700,000 (216,000 children)

Inpatient care 32,000 persons (12,000 children)

Iodine prophylaxis 5,400,000 persons (1,700,000 children)

Lessons Learned

• In the USSR highly organized Civil Defense, Health system, Military and other government resources were quickly mobilized.

• In the US less centralized resources might currently have more difficulties, although the maturation of the Homeland Security Agency should facilitate such a response.











3. a. Examples of EarlyPreparations for




Nuclear Weapons Test, Nevada

91-B

91-C

Estimated Civilian Casualties within 2000 Meters of the Hypocenter, by City

92-B

METERS NUMBER NUMBER PERCENTAGE OF THOSE EXPOSED

Hiroshima:

0 - 499

500 - 999

1000 - 1499

1500 - 1999

TOTAL

6,230

24,950

45,270

67,900

144,350

220

4,240

21,910

53,030

79,400

3.5

17.0

48.4

78.1

55.0

Nagasaki:

0 - 999

1000 - 1499

1500 - 1999

TOTAL

30,900

14,320

6,500

51,770

3,580

6,950

4,690

15,220

11.6

48.5

71.6

29.4

Types and Magnitude of Injury Among Survivors

Causing Factor

Type of Injury

Injured Survivors (%)*

Injury Reported to Distance of:

BlastTrauma,Mechanical

70 4000 meters

Heat Burns 65 4000 meters

Ionizing Radiation

Radiation injury

30 1500 meters

* Total exceeds 100%, since many had multiple injuries.

98-A

Atomic Bomb Casualty Commission

91-J

ABCC Medical Program• Purpose:

– Compilation of Medical data about Hiroshima and Nagasaki A-bomb survivors to quantitate radiation effects.

– Statistical analysis of medical data.

• Scope:– Clinical data collection by:

• Adult medical project• Pediatric medical project• Ophthalmology project• Hematology project• Pathology project• Clinical laboratory project

– Biostatistical analysis 93-F

ABCC Pediatric Study Patient

93-H

ABCC Leukemia Study Patient (Hiroshima Red Cross Hospital)

96-E

A-Bomb Survivors by Age and Sex

98-B

1950 City Residents

Proximal

Distal

Non-exposed

2,000 - 10,000 meters

0 - 2,000 meters

Nonexposed

Master Sample (Proper Part)

Master Sample (Proper + Reserve) 92-F

ABCC Shielding Program• Purpose:

– Compilation of sufficient historical data about Hiroshima and Nagasaki A-bomb survivors to permit calculation of individual radiation dosages when dosimetry is available.

• Scope:– Location of exposed individuals.– Description of shielding structures.– Preparation of three-dimensional maps of

cities.– Collection of bomb detonation conditions,

height of burst, weather, etc.– Shielding measurements using sources. 93-A

ABCC Shielding Study

93-B

ABCC Shielding Study

E39

Early DOSE/DISTANCE curves used for ABCC Patient Exposure Estimation

HiroshimaRads Nagasaki

Distance from hypocenter (meters)94-F

ABCC/ORNL Ichiban Dosimetry Project• Purpose:

– Compilation of experimental dosimetry data which when used with ABCC shielding information, will permit calculation of individual radiation dosages of A-bomb survivors.

• Scope:– Determination of angular distribution of radiations.– Radiation shielding by Japanese houses

• Plane slab experiments• Parametric study of houses

– Determination of air dose.– Calculation of doses for ABCC cases and

documentation of IBM cards.

92-E

Correlation Program• Purpose:

– Correlation of dose and medical effects data.– Preparation of interim and final reports.

• Scope:– Dose-effect correlations including:

• Acute radiation death• Premature aging• Shortened life-span• Epilation• Cataracts• Acute hematological changes• Leukemia• Carcinogenesis• Genetic effects

95-F

Lesson LearnedEffect of Delayed Database Startup

Resident in Same City

(1960)

Migrated from City (1950 - 1960)

No. of people in city

at time of bomb

92-D

Died of acute effects

of bomb (1945)

Survived acute effects

of bomb (to 1946) Died and migrated

from city (1946-1950)1950 city residents

Died (1950-1960)

Radiation Risk Estimation Using A-bomb Survivor Data

• In the 1950’s, survivors of the A-bombings were interviewed and gave detailed reports of their location at the time of bombing and their experience afterward.

• The Atomic Bomb Casualty Commission (ABCC), now the Radiation Effects Research Foundation (RERF), made very detailed engineering drawings of the survivor location.

• These drawings are used to determine the ground range and the shielding to assign organ doses from the dosimetry system.

• Members of Life Span Study (LSS) are followed for cancer incidence and mortality.

• A cohort of LSS, the Adult Health Study (AHS) undergo biennial clinical examinations for health effects studies.

• Statistical analysis of dose-dependent frequency is used to estimate radiation risk.

576-4















TMI Health-Related Research

1. TMI Census/Population Registry

2. Mother/Child Registry

3. Radiation Dose Assessment Study

4. Epidemiologic Surveillance System

Epidemiologic Data Base Development

364-7

TMI Health-Related Research Epidemiological Data Base Development

PROJECT PURPOSE RESULTS

TMI Census/

Population Registry

June 1979-30+ years (PA Dept. of Health, US Census Bureau, US PHS/CDC)

To develop population profile and registry

Interview data from 35,930 persons living within 5 miles of TMI

Mother/Child Registry

1979 - 30+ years

(PA Dept. of Health)

To develop a retrospective cohort of 4,000 Mother/child pairs

Maternal radiation dose estimates, stress measures, child perinatal findings documented for long-term epidemiologic study

398-1

The TMI Cohort and Its Dataset

• 35,946 residents in the Three-Mile Island

5 mile area.

• US Census Bureau, CDC and PA Dept. of Health did a door to door survey of everyone in cohort

• 257 variables, including age, smoking status, etc. are included in the dataset

Population Database Dosimetry364-12

Population Database Dosimetry364-11

Cohort in 5 Mile Radius

Epidemiological Data Base Development (continued)


Radiation Dose Assessment

(1979-1984, University of Pittsburgh)

Individual dose assessment in 5 mile population over 10 day accident, pregnant women in 10 miles+ thyroid and skin doses

Max. possible 5 mi. dose = 175 mrem, Avg. max. = 25 mrem, Max. likely 80 mrem, Avg. likely = 9 mrem

64% evacuated, more young, female, better educated, having pre-school children

Epidemiologic Surveillance in PA

(1981 - present, PA Dept. of Health)

Baseline health information system for populations within 20 miles of the 6 PA nuclear power plants

Natality, mortality and morbidity data base developing to assess impact of any health-threatening events

398-2


1. Pregnancy Outcome

2. Congenital/Neonatal Hypothyroidism

3. Infant Mortality

4. Health Updates of TMI Population and Mother/Child Registries

Bio-Medical Studies

364-16

Low Level Radiation and the Long-Term Follow-up of the Residents of the Three

Mile Island Accident Area:

1979-l998 Evelyn Talbott, Dr. P.H.

Jeanne Zborowski, Ph.D.

Ada O.Youk, Ph.D.

Departments of Epidemiology and Biostatistics

Graduate School of Public Health

April 8, 2003

Distribution of TMI Cohort by Vital Status and Gender: l998

Methods (Relative Risk Regression cont.)

• The outcomes of interest were:

All malignant neoplasms Cancer of the Bronchus, Trachea and Lung Cancer of the Breast (females) Cancer of the Lymphatic and Hematopoietic Tissue (excluding

Chronic lymphocytic leukemia and Hodgkin’s Disease) Cancer of the Central Nervous System All Heart Disease

• Exposure variables were natural background radiation, maximum and likely ( radiation

• Potential confounders included smoking and education

Conclusions of Talbott et al. • This ~ 20-year follow-up within the TMI cohort

provided no consistent evidence that radioactivity released during the nuclear accident has had any significant impact on the overall mortality experience of the residents

• Overall cancer mortality in the TMI cohort was similar to the surrounding three county area

• However, several elevations persist and certain potential dose-response relationships (lympho-hematopoietic tissues, breast cancer) cannot be definitively excluded

Lessons Learned

• Negative results can be of great value in allaying public distress and associated stress symptoms

• Prompt initiation of the impacted population census facilitates and adds credibility to the long-term follow-up








Chernobyl: All-Union Register

• Contaminated area: residents, transients, mitigation workers

• Children & grandchildren of above

• Evacuees from contaminated area

Total: now about 600,000 persons


• Name, date & place of birth, sex residence• Location where radiation exposed and duration• State of health (by history)• Pregnancy status before and/or after exposure

onset• Pregnancy outcome and child data• Cause of death (adult, child, newborn)• Therapy received (iodine prophylaxis,

hospitalization)

Registration Card Data


• Radiation exposure features of locale

• Individual’s exposure and contamination extent

• Thyroid radioiodine burden

• Personal dosimetry (bioassays, whole body counter and/or other measurements)

Dosimetry Card Data


• Registration and dosimetry cards compiled by local authorities. Maintained at clinic.

• Copies to Republic’s Ministry of Public Health and to USSR Ministry of Public Health.

• Exam frequency based on 1st exam results and dose assessment. Protective and mitigating measures considered also.

Chernobyl All-Union Register• “ Long-term programmes for the medical and

biological monitoring of the population are being established….The measures taken….include the establishment of a register of all those exposed to radiation.”

• “The prepared programmes take account of the experience of other countries (the Three Mile Island programme; the IAEA meeting in Yugoslavia and so on).”

Part II, Annex 7. 2. USSR State Committee on the Utilization of Atomic Energy: The Accident at the Chernobyl’ Nuclear Power Plant and its Consequences. IAEA Experts’ Meeting, 25-29

August 1986, Vienna, pp. 67-70.

Lesson Learned








28 March 1979

• Initial Condition - TMI at 97% Power• The Accident

– Secondary plant malfunction causes turbine trip and reactor scram– After pressure transient, PORV (relief valve) fails to close– Based on incorrect diagnosis, operators interrupt high pressure

injection– Loss of coolant continues for 2 1/2 hours– Core uncovery and severe overheating result

• The Consequences– Massive fuel damage– Release of much radioactive water and gas to plant structures– Hydrogen burn in containment– Damage to plant instrumentation and control equipment– Minor off-site releases of radioactivity– Widespread public confusion and fear

TMI Dose AssessmentReleases:

Noble gases: 2.4x106 - 13x106CiRadioiodine: 14 - 15Ci

Doses: Individual:

Maximally exposed: ~100mremAverage dose within 50 miles: 1.5mrem

Population:Within 50 miles: 1600 - 5300person-rem

Estimated Potential Health Impact of TMI Radiation Release on 50 mile Population

(2.2 Million People, 3,300 person-rem)

Natural Radiation Incidence

AttributableCANCERFatal 325,000 0.7 (0.15-2.4)Non-fatal 216,000 0.7 (0.15-2.4)

GENETIC1st Generation 78,000 (0.01-0.64)All Generations 0.7 (0.05- 4.8)

Post-TMI Accident Self-evacuation

364-14

Media Views

266-1

Media Views

266-3

Media Views

266-6

Media Views

172-31

Media Views

266-7


Psycho-Behavioral StudiesPROJECT PURPOSE RESULTS

Health Behavioral (Stress) Studies

(July 1979 - 1981, PA Dept of Health)

Analysis of local residents’ TMI crisis reactions and 3, 9 and 18 month restudies

2,100 person telephone survey showed major impact in early few weeks, some persistence over following year. Most in younger, more educated, married females living within 15 miles of TMI

Mental Health Study of High Risk Groups

(1979 - 1980, University of Pittsburgh)

Measurement of mental health impact on TMI workers, area mothers with small children and mental health clinic patients

TMI mothers had higher incidence of depression lasting over a year. No difference from controls in other two groups

398-5

TMI Psycho-Behavioral Studies (continued)


Residential Mobility Study

(1979 - 1982, PA Dept. of Health)

Analysis of local residents’ TMI crisis reactions and 3, 9, and 18 month restudies

15% of high mobility people moved because of TMI. Replaced by demographically similar people with significantly more positive attitudes toward TMI

Health Economics Study

(1979 - 1982, Pennsylvania State University and NRC)

Measurement of economic costs related to physical and mental health impact of TMI on 5 mi. population

Estimated costs of about $200,000 incurred through workdays lost, physician visits and increased cigarette, alcohol and tranquilizers in 10 months after the TMI accident 398-6

Sources of Response Decisions and Public Information

NRC GPU PA NRR TMI Governor

DOE Off. Admin.NEST HEW PEMABNL FDA Env.Res.ORNL CDC HealthLRL NIH PoliceBAPL EPA Nat. Guard FEMA Audit. Gen.

Media View

266-5

Early Psychological Stress Reducers

–One responsible decision maker

–One public communicator

–Realistic appraisal and clear communication of problem

–Credible action plan and adequate resources to accomplish it

–Pre-emergency education

NRC’s TMI Advisory Committee I. History

Origin Charge

II. Some Major Issues Addressed Funding for Decontamination TMI-1 Restart Worker Radiation Exposure Health Studies III. Effectiveness View of NRC View of GPU View of Public

Origin of the TMI Panel

510-4

TMI Panel Charter

510-5

TMI Panel Charter

510-7

The proposed bill stipulated that the panel consist of twelve members selected

by the Commission as follows:

1. Three members shall be appointed from among persons representing agencies of the State of Pennsylvania;

2. Three members shall be appointed from among persons representing local government authorities in the vicinity of Three Mile Island nuclear reactor;

3. Three members shall be appointed from among persons representing the scientific community; and

4. Three members shall be appointed from among persons having their principal place of residence in the vicinity of the Three Mile Island nuclear reactor.

510-6

A TMI Advisory Panel Meeting

510-8

NRC’s TMI Advisory Committee I. History Origin Charge

II. Major Issues Addressed Funding for Decontamination TMI-1 Restart Worker Radiation Exposure Health Studies

III. Effectiveness View of NRC View of GPU View of Public

UNITED STATES NUCLEAR REGULATORY COMMISSIONCharter for Advisory Panel for the

Decontamination of Three Mile Island, Unit 2

• Official Designation– Advisory panel for the decontamination of Three

Mile Island, Unit 2

• Objectives and Scope of Activities and Duties– The panel consults with and provides advice to the

Commission on major activities required to decontaminate and safely clean-up the TMI-2 facility

• Time Period– The Committee will be utilized during the period

public views on clean-up issues at Three Mile Island are required.

510-7

Cleanup Cost Issues

364-24

Cleanup Cost Issues

510-12

Cleanup Cost Issues

510-10

Cleanup Cost IssuesIn conclusion, given the long-term serious hazards posed by TMI-2, the lack of funding from any source to undertake a serious and expeditious clean-up effort, and the lack of an effective commitment on the part of the NRC, we are forced to conclude that the failure to make sufficient and timely progress toward decontamination constitute threats to the public health and safety. The commission’s action, or lack of action, in permitting this condition to exist and to continue constitutes a violation of the fundamental requirement of the Atomic Energy Act - protection of the public health and safety. We believe the Commission has both a moral and a legal duty to act immediately to insure that the clean-up of TMI-2 proceeds expeditiously in order to eliminate this threat to the public.

510-11

Issues: Operational Challenges

510-20


510-25


510-26

Issues: Operational Reality

510-27

TMI-2 Cleanup Doses

• Clean-Up Estimate: 13,000 - 46,000 Person-REM

• Actual Collective Dose: 2742 Person-REM

(through 1986)

364-30

TMI-2 Worker Clean-Up DosesYear Person-rem Maximum Worker Dose

(rem)

1979

1980

1981

1982

1983

1984

1985

418

193

138

384

373

514

722

4.5

2.1

2.0

3.0

2.7

3.7

3.5

Total: 2742 (Clean-Up Estimate: 13,000-46,000 Person-rem)

364-29

Panel Challenges Lost

510-17

Panel Challenges Lost

510-18

Amended Charter For Advisory Panel for the Decontamination of Three Mile Island, Unit-2

• Official Designation– Advisory Panel for the Decontamination of Three Mile

Island Unit 2.• Objectives and Scope of Activities and Duties

– The panel consults with and provides advice to the Commission on major activities required to decontaminate and safely cleanup the TMI-2 facility. The Panel also consults with and provides advice to the Commission on the public’s reactions to plans and the results of studies and review deriving from Federal, State and TMI Public Health Fund efforts regarding the TMI-2 accident. (This activity is to be carried out under the attached criteria.)

• Time Period– The committee will be utilized during the period public

views on cleanup issues at Three Mile Island are required.

510-21








NRC’s TMI Advisory Committee I. History

Origin Charge

II. Major Issues Addressed Funding for Decontamination TMI-1 Restart Worker Radiation Exposure Health Studies

III. Effectiveness View of NRC View of GPU View of Public

TMI Advisory Committee Assessment: GPUThe NRC Advisory Committee on the Cleanup of TMI-2 gave GPU Nuclear the opportunity to explain its activities during the cleanup and plans for TMI-2 in a public forum available to open debate and scrutiny. As the cleanup comes to an end, GPU Nuclear would benefit from continuing these discussions with the community. Decline in newsworthiness and public attention concerning the cleanup a decade after the accident makes the NRC Advisory Committee forum a less effective method and tends to link GPU Nuclear with the events of the accident. However, GPU Nuclear should consider establishing its own mechanisms for regular cooperative interactions with citizen groups including those that have been highly critical of its activities. It should also continue to maintain a multidimensional communications program.

The Board believes that the public reaction to the 1979 accident and its aftermath should alert the entire electric power industry to the need for open discourse between the operators of nuclear power plants and the residents of adjacent communities. There is no single approach which will alleviate all fears of risks to health and safety. However, availability of information should improve the knowledge base within the community and serve to build confidence in the management and staff of the utility.

510-35

TMI Advisory Committee Assessment:Member of Environmental Action Group

And you, as the panel, are there in place. You’re there for the company, you’re there for the NRC, and you’re there for the community, and you’re there for the public officials, too. I mean, we’re in touch with public officials, both of the city, the county levels. And that networking, that vehicle of the panel in place and that review process is not just today, tonight. That’s a process that is in place that serves a real purpose.

And I was one of those people almost ten years ago -- well, over ten years ago who was looking for what kind of a vehicle could be put in place. And I’ve appreciated what the panel has done. I know that you’re serving without pay, and it’s a lot of time and effort.

But I would ask, and I ask on behalf of the citizens at large and the people that call our office, that you stay in place at least for another year and look at this again next year at this time and see where we are with PDMS, what’s going on with evaporation and what’s going on with the funding. 510-37

TMI Advisory Committee Assessment:Member of Public

I think that another thing that this panel provides is a historical memory. The people -- Not all of you have been on this panel all the time. But enough people have been on

for a long period of time that you have a historical memory that if there are problems along the way, you can determine whether they are significant or whether they are

something which is not significant. And that’s important, I think, to the public, because the public doesn’t have that kind of background generally to make those kind of judgments. So I think it’s important that we keep a panel.

510-39

TMI Advisory Committee Assessment:Member of Public

I would just like to speak briefly in behalf of the panel continuing its activities, because I think over this past ten years, this forum has been the only one in which the media and the public of this area really have gotten a sense of what really is going on in the cleanup. And we come and we ask sometimes dumb questions, and sometimes we ask smart questions. And with the intercession of this body, I think we’ve gotten a lot more information than we ever would have gotten about the accident itself in some cases and about the real problems and the real activities going on in cleanup. I think we know ten times as much about the situation because of your existence, and I hope it continues. Thank you.

510-36

In dealing with the aftermath of any radiation event, the early creation of a mechanism for frequent honest communication and feedback between the “authorities” and the concerned public can help alleviate the prolonged mistrust and anxiety that are integral parts of such an occurrence.

Lesson Learned








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Follow-up of Persons Exposed to Radiation and Radioactivity Niel Wald, M.D. and Michael Kuniak, D.O....

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