The MPHP 439 Online Text Book
Public Health Management of
Radiation Emergencies
By
David E. Bell
Introduction:
A radiation emergency may be
loosely defined as any event in which exposure to radiation has the potential
for widespread harm. If causing a
medical disaster, radiation emergencies may be characterized by a rapid ability
to overwhelm medical resources, or for impacting societies to an extent that
normal functioning is significantly altered.
Given their medical consequences, radiation emergencies may challenge
the very structure of healthcare as well as strongly underscore the need for
public health management.
The
Context for Radiation Emergencies:
Whether from atomic bomb
tests, nuclear reactor accidents, or released industrial or radiotherapy
material, the impacts of radiation emergencies may be prolonged and pervasive. The world of the 21st century, a
world characterized by globalization, urbanization, and technological
interchange, is a time in which human populations have never been at greater
risk for radiation disaster. Public
health systems for managing and responding to radiation emergencies have become
increasingly important for long-term global health stability. This chapter aims to disclose basic
principles of radiation exposure, aspects of public health intervention, and
general approaches to public health management in a radiation emergency.
Understanding
Concepts of Risk:
In the short period of its recognized
existence, the threat of radiation emergency has greatly escalated. The rise of this threat can be explained in a
manner at least two fold; not only have a higher number of people become placed
at greater risk for the likelihood of radiation emergency, but the potential
damage associated with these emergencies has increased. Factors of modern society that contribute to
escalated risk include technology growth, urbanization, resource concentration,
aging populations, and globalization.
While technology growth has
helped monitor and contain radioactivity, potentials for damage have also co-evolved
with potentials for control. The past
decades have seen an increase in the number of operational nuclear power
plants, industrial practices involving radioactivity, and nuclear warfare
programs being developed or maintained worldwide. Increased prevalence of radioactive
facilities will increase elements of emergency risk. Currently, there are 103 active nuclear
reactors in 66 power plants in 31 states of the
It is currently estimated
that close to half of the world population resides in urban areas, and that
this percentage is rapidly increasing.
Up to 90% of anticipated population growth in developing countries is
projected to be urban (IFRC, 2004). With
human population numbers still accelerating at an exponential rate, and a
greater proportion of these numbers becoming more and more concentrated in
major metropolitan centers around the world, exposure to industrial sources of
radiation and targets of warfare or terrorism all constitute major factors for
increases in risk. If a population is of
higher density, a higher number of people are placed at greater risk of
exposure in one area. High proportions
of elderly or disabled individuals and limited or concentrated resources also
affect disaster risk, both impacting societal resistance to emergency
conditions.
Finally, frequency of legal
and illegal marketing combined with increased capacity for international travel
may encourage an increase in trade or exchange of radioactive materials. The exchange of material may be for purposes
as diverse as weapons production, economic gain, belief that a source is of
precious nature, or a source becoming unknowingly lost. Regardless of its origin, timely and
effective public heath management of a radioactive emergency or incident should
be sensitive to the nature of a threat as well as the underlying factors contributing
to the threat.
Chapter Table
of Contents:
The
FOUR-POINT-PLAN for CBRN (chemical, biological, radiation, nuclear) emergency
management
1. Prevention
A) Threat Awareness
B) Education
C) Removal or Restriction of Hazard
D) Surveillance
2. Preparedness
A) Risk Address
B) Established Communication Network
C) Plan of Action
D) Training
3. Response
A) Recognition
B) Assessment and Cooperation
C) Containment and Intervention
D) Facility Triage
4. Recovery
A) Information Share
B) Medical and Mental Healthcare
C) Professional Service Integration
D) Follow Up
Radiation
Specific Management:
PREVENTION
Threat Awareness:
Consideration and awareness of possible threats, both in
magnitude and in likelihood, should occur not only for public health officials,
first responders, and healthcare professionals, but also for the public which
is being served. The very first of
responders to an incident in a public arena are likely to come from the public
sector. A public that is aware of its
threats may become less prone to panic, and in a critical situation where a
disaster can be averted by quick action or sound thinking, this difference can
be of crucial importance.
In order to avert or reduce the likelihood of an
emergency situation with radiation, it is important to first establish,
identify, and understand the potential threats of this hazard. The fist step of prevention resides in simple
recognition that there may be a hazard. Many
health incidents have occurred as a result of poor or misguided threat awareness
(Turai et al, 2004).
Education:
Once a viable threat to
radiation has been acknowledged, timely and effective educational programming
is of high priority. Radiation is an
intangible hazard, invisible to the eye and undetectable to other primary
senses. Enough exposure can result in rapid
vomiting, severe burns, and death.
Although not every exposure results in observable injury, educational
programming should not be insensitive to the fears associated with radiation
along with the underlying logic for grounding these fears. Education has the potential to break down
excessive fear, as well as prevent the formation of unnecessary stigma for
persons who have been exposed. Potential
health benefits of therapeutic radiation, diagnostic X rays, and nuclear
medicine should be remembered.
If educational programming
can illustrate the nature of radiation harm, it is also likely to be successful
in lowering preventable injury. An
improved public response may be anticipated if a public body understands why
particular actions may be necessary in an emergency scenario.
Different response approaches
should be encouraged respective to different types of ionizing radiation. The five known types of ionizing radiation
are alpha and beta particles, X and gamma rays, and neutrons. Although alpha particles may cause
significant damage where they come in contact with human tissue, the particles
can be shielded off by a piece of paper.
Beta particles may be stopped in a thick layer of clothing, while gamma
rays may take a solid foot of concrete (HPS, CDC online). While removal of outer clothing may be
important with particulate radiation contamination, shelter in secure buildings
would be more important for non-massive radiation.
Another aspect of radiation
that may affect management decisions is the fact that radioactivity decreases
with time. Some radionuclides are
relatively short lived, while others have half-lives of many years. The differences in decay rate may alter decisions
regarding the decontamination of affected areas.
Removal or Restriction of
Hazard:
The mere existence of nuclear facilities, concentrated
radioactive sources, and nuclear weaponry ensures a sustained potential for
radiation emergency. The likelihood of
these emergencies may be reduced, however, with increased security and
regulatory practices, as well as the elimination of loosely guarded sources.
Unlike chemical or biological
emergencies, incidents with radiation may not be readily isolated or contained. Difficulties in identification,
decontamination, and environmental restriction all promote prevention as a
favorable approach to hazard mitigation.
For these reasons, organizations such as the Nuclear Non-Proliferation
Treaty and the Comprehensive Test Ban Treaty play important roles in present
existence of radiological hazards (IAEA, 2004).
Surveillance:
Active surveillance of radiological threat and threat
development is a cornerstone for prevention.
Successful surveillance must be both highly sensitive and specific;
sensitivity ensures accurate detection of true cases, while specificity
prevents inclusion or misclassification of false cases that may appear as
radiation incidents. Medical
unfamiliarity with radiation injury increases the likelihood of these injuries
being misdiagnosed. Examining the
possibility for exposure along with symptom formation and any patterns in
symptom occurrence can help distinguish a radiation exposure outbreak from
other types of outbreaks.
While various laws and
regulations may be enacted for the protection of a public’s health, these
actions should be mindful of a population’s human and civil rights. The violation of civil liberty and democratic
principal by a democratic government to prevent a terrorist act may elicit
elements of terrorism in and of itself (Gofin, 2005).
PREPAREDNESS
Risk Address:
Between the years of 1944 and 2002, there have been at
least 420 reported “incidents,” in which elements of radiation emergency have
been employed, worldwide (Turia et al, 2004).
In terms of average incident counts, the world is now observing a rate of
roughly seven and quarter per year.
Archive lists of radiation incidents demonstrate a persistent and
evolving history for the management of radiation incidents (
One underlying consideration for assessing radiation risk
is the fact that not all people, and not even all human tissue, have equal
susceptibility to radiation damage. Standard
units of exposure for an absorbed dose include the “rad” and the international “gray”
(100 rad). One rad is approximately observed
in a typical X-ray or nuclear medicine diagnosis (Bross et al, 1979). Separate units, however, are designated for
an effective dose of an exposure, since one rad may have different effects when
applied to different parts of the body.
Both the “rem” and the international “sievert” (100 rem) reflect the
biological effects of a radiation dose.
Under most conditions, one rem is about equal to one rad. Tissues of particularly high susceptibility
to radiation include tissues in which cells are rapidly dividing with low
differentiation, such as in the reproductive system.
Children in general are much more susceptible to
radiation injury than adults. Children
have disproportionately higher ventilation rates, which allows for greater
internal contamination with radioactive gases.
Having the majority of a lifespan and physical growth ahead of them,
children are at much higher risk for future developments of cancer. Finally, psychological injury has been
observed to be of greater concern for children than adults (CEH, 2003). Both children and elderly persons should be
considered more vulnerable as a result of reduced capacity for mobility and
self-protection, and susceptibility to post-traumatic infection (Gofin, 2005). Increased vulnerabilities should be given
high priority in any disaster planning risk assessment.
Established Communication
Network:
Whether accidental or intentional, the CDC is the
Routes of communication should
be established within state and local health departments to ensure cooperation
between the various sectors of service professionals that are likely to be
involved. Routes of communication should
also enable quick and effective transmission of information, allowing a “chain
response” where communication does not significantly delay a response process.
Communication networks should
address command and control issues, aspects of organizational responsibility,
levels of notification criteria, and public broadcast announcements. They should address the type and quantity of
resources that might be needed for various scenarios, and should be geared for affective
administration of action such as evacuation implementation. Maximum protection should be given to people,
animals, food and water supplies from radioactive contamination in the
structure of emergency communication (Mettler et al, 2002).
Plan of Action:
It is estimated that humans are exposed to approximately
one mrem (one thousandth of a rem) of radiation per day from background sources
of cosmic radiation, radon, cigarette smoke, medical devices, pharmaceutical
agents, and home appliances such and smoke detectors (CEH, 2003). Current recommendations for public exposure
are not to exceed 5 rem per year.
Guidelines for the Environmental Protection Agency stipulate a dose
limit for healthcare workers to be 5 rem per event, but up to 25 rem per event
for “lifesaving” activities, where entrance into exposed area may save a human
life (Mettler et al, 2002). The Nuclear Council
on Radiation Protection and Measurements suggests 50 rem as a “life-saving”
dose limit, while the North Atlantic Treaty Organization allows up to 150 rem for
the same scenario (Mettler et al, 2002), (HPS, CDC online).
Regardless of the limits set for health provider
exposure, it is important for a healthcare provider to always place his or her
own safety and well-being before the patient, so that another patient is not
created. Different healthcare providers
will naturally have different levels of comfort regarding radiation, resistance
to injury, and propensity for risk taking.
The underlying consideration guiding radiation emergency action planning
should be sustaining normal function of service. Mundane healthcare or service delivery should
not be neglected in considerations of radiological threat.
An important resource to utilize in the preparation of an
emergency plan includes all persons who deal with radiation on an occupational
basis. Hospital workers, university
researchers, military specialists, and anyone else working for a laboratory,
industry, or agency involving radiation are potentially valuable volunteers. Additionally, the availability of Geiger
counters or dose-rate meters from their respective institutions should not be overlooked.
Training:
Training can be broken into training applicable to
emergency responders and training applicable to a general public. In both cases, training should be pragmatic,
integrative, and repeatable. Drill based
training is of high preference, as it combines physical and working memory with
cognitive memory and rationale. Training
should be maintained on a comprehensive level that corresponds with likely
involvement; people living in close vicinity to a nuclear power plant or
individuals on special response teams should be trained in a manner of
respectively increased comprehension and updated quality.
RESPONSE
Recognition:
Nausea, vomiting, diarrhea, headache, weakness, and
lymphocyopenia are all symptoms that may be attributed to a wide range of
causes. Given a potential for radiation
exposure, however, these symptoms may be important indications of Acute
Radiation Syndrome.
In general, the higher a
received radiation dose to the whole body, the faster and more severe the
reduction of blood cell counts. Ionizing
radiation can have both acute as well as delayed medical effects. Early recognition can be of substantial
impact in improving the clinical outcomes of many delayed symptoms (Turai et
al, 2004).
Clinical signs for typical
radiation injury of the skin include erythema, depilation, dry and moist
desquamation, blistering, ulceration, and necrosis. Local injury and skin burns often result from
unrecognized source exposure, such as placing a source inside a clothing
pocket. The quicker a source of
radiation injury can be recognized, the more patient formation may be reduced.
If a terrorist action were to
contaminate drinking water supplies or stocks of food, symptoms of illness are
likely to occur in highly identifiable geographical patterns. A public health response should utilize epidemiologic
methodology and give considerations for statistical probabilities.
Assessment and Cooperation:
Assessment of a radiation incident must be made quickly,
but not in haste. It is important for
assessments to be made accurately and on a continual basis. Initial assessments by first responders are
likely to gauge the efficiency of subsequent responder arrival. Professional or expert assessment of
radiation contamination is always desirable, but should not be a cause for
significant delay. A successful
assessment process triggers the involvement of appropriate institutions in a
timely manner.
As more institutions become involved in the response of a
radiation emergency, cooperation becomes increasingly pivotal. Cooperation in a radiation incident is a
multi-sectorial affair. The ability of
different legal, technical, and health organizations to work collaboratively
for a mutually beneficial outcome is essential to the well being of all persons
involved, both as responders and patients.
Containment and Intervention:
A major goal for a public health response to a radiation
emergency would be to monitor and control a contaminated area (Mettler et al,
2002). It should be noted that a
contaminated area may range from several feet surrounding a radioactive source
to hundreds of miles from radioactive fallout.
Radioactive contamination of clothing and skin usually
does not constitute a medical emergency.
With particulate radiation, removal of clothing can easily eliminate up
to 90% of contamination (Mettler et al, 2002).
Removal of clothing and showering with soap and water generally
constitute the essence of decontamination.
Consideration should be given to containment and disposal of
contaminated materials, given the scenario and ability to do so.
In addition to decontamination procedures, radioactive
intervention includes controlling access to contaminated sites, appropriately
directing people to either stay indoors or to efficiently evacuate, providing
respiratory protection, administering potassium iodide, restricting certain
foods, or decontaminating property all where it is necessary to do so. If a patient has sustained significant
physical trauma in addition to radiation injury, ordinary stabilization should
always be the primary objective, with decontamination following after (Mettler
et al, 2002).
Early blood counts, nostril or oral cavity swabs, and
urine or feces samples can all be collected to assess the severity of patient
exposure. In this way, exposure
assessments can determine both extent and route of exposure (Turai et al,
2004).
Facility Triage:
It is estimated that a 12.5 kiloton nuclear explosion at
ground level in a port equal to
Regardless of the severity of an incident, medical triage
is an integral aspect of the management response. Triage is also a continuing process; changes
in a patient’s status may occur and more developments of exposure could
unfold. The initial phase of triage
management entails on-scene decisions with the transport of patients to
emergency rooms. Various allotments of
space should be designated to differing groups of patients, all depending on
the nature of an incident.
For large scale incidents, significant
amounts of space may be necessary for treating patients of relatively minor
medical symptoms, or symptoms of psychological etiology. Ideally, known community centers may be
utilized under these circumstances. In
the case of hospitals not being able to cope with the scale of a large
disaster, facilities such as airports may become useful for treatment purposes.
RECOVERY
Information Share:
A public will want to be informed of a radiation incident
promptly and accurately. Significant
psychological trauma may be naturally and unavoidably occurring in the process
of a radiation emergency. This trauma
should not be complimented with intentionally misleading or false information.
The disclosure and sharing of information should be
prompt, but more importantly it should be timely. Being fast is important, but not the only time
consideration. A spokesperson should not
be overly rushed; as in any emergency, it is important for persons in position
of lead to take the time they need to gather their thoughts and think
rationally and clearly. A timely
correspondence does not rush to conclude what is yet to be ascertained and will
attempt to reduce sensations of panic where possible.
Healthcare:
A hierarchical approach to
healthcare treatment should not be dogmatic in placing medical care apart and
above mental health care; both medical and mental health care are simultaneous
processes of an emergency that are initiated and cared out from the very first
interactions between patient and healthcare provider.
Visible symptoms of Acute Radiation Syndrome are likely
to begin in the range of 100 rem.
Exposure symptoms and fatality rates may vary up to 1000 rem, where 100%
fatality is probable even with supportive care (HPS, CDC online). Treatment of Acute Radiation Syndrome may
include treatment for such conditions as hypotension, cerebral edema, sepsis,
electrolyte imbalance, and gastrointestinal de-epitheliation.
Symptoms associated with Acute Radiation Syndrome such as
nausea, vomiting, fatigue, and disorientation may become difficult to detect if
severe psychological symptoms mimic those of the radiation exposure. It is estimated that the detonation of a
nuclear device could result in 75 percent of affected survivors having
observable psychological symptoms (Mettler et al, 2002), (Walker et al, 1989).
Professional Service
Integration:
The interplay of medical and
mental healthcare is one of but many provider overlaps that occur in radiation
emergency responses. The success of a
response may be largely contingent upon successful integration of all relevant
professional services and needs.
Treatment needs often follow
phases in an emergency, ranging from acute, late, and post phases
respectively. In the first phase, crude
mortality rates and case-fatality ratios are accumulating. This is a time of very basic healthcare
interventions, delivery of basic needs, and establishing control over the
destructive process. The second phase is
one in which death rate has declined, and stabilization, security, and
utilization of resources take precedence.
The final stage has a focus of long term health stabilization, and
supports efforts in caretaking that are sensitive to a patient’s
self-sufficiency and personal recovery.
Each stage must necessarily integrate different healthcare services and
resource providers.
Follow Up:
Radiation incidents can result in medical and mental
effects that are both profound and long lasting. Periods of dramatic change or damage often
require very long periods of recovery.
Post-incident phases should include a continued availability of
healthcare services, considerations for material or economic support, and
informational exchange.
One potential resource for
questions about radiation exposure and injury includes the U.S. Department of
Energy, available for contact on a 24 hours a day basis at the
Radiation
Emergency Case Histories and Responses:
The following events
represent a sample of radiation incidents and emergencies in which the
International Atomic Energy Agency (IAEA) has published specific reports to
summarize and assess individual emergency responses. In all of these instances, it is important to
understand not only what happened but also how the responses may be improved in
future scenarios. Each report entails an
in depth review and analysis, and links to each full text should be
provided.
Of note is that each of these
events has occurred in the post 1986
1.
A teletherapy source that had been improperly disposed of
was found and spread as a result of an admired bight and pretty color.
http://www-pub.iaea.org/MTCD/publications/PDF/Pub815_web.pdf
2.
An irradiation room was entered at an electron
accelerator facility, allowing significant X ray exposure.
http://www-pub.iaea.org/MTCD/publications/PDF/Pub1008_web.pdf
3.
Contamination occurred when an accident blew the concrete
off of a reaction vessel in a plutonium extraction facility.
http://www-pub.iaea.org/MTCD/publications/PDF/Pub1060_web.pdf
4.
A radioactive waste site was entered by local
individuals, and a radioactive source was removed.
http://www-pub.iaea.org/MTCD/publications/PDF/Pub1053_web.pdf
5.
Sealed industrial radiation sources were abandoned by a
previous owner and left to later expose surrounding individuals.
http://www-pub.iaea.org/MTCD/publications/PDF/Pub1097_web.pdf
6.
A teletherapy source was broken down and sold as scrap
metal. http://www-pub.iaea.org/MTCD/publications/PDF/Pub1102_web.pdf
7.
A welder picked up an industrial radiography source and
placed it in a pant’s pocket for several hours.
http://www-pub.iaea.org/MTCD/publications/PDF/Pub1101_web.pdf
8.
A teletherapy head was dismantled, and parts were left in
an insecure storage location. Parts were
later sold as scrap metal.
http://www-pub.iaea.org/MTCD/publications/PDF/Pub1124_web.pdf
9.
Accidental overexposure occurred as the resulted of
improperly calibrated radiotherapy.
http://www-pub.iaea.org/MTCD/publications/PDF/Pub1180_web.pdf
10.
An industrial source was transported by way of a fully
loaded passenger bus for an eight hour trip from
http://www-pub.iaea.org/MTCD/publications/PDF/Pub1199_web.pdf
Overview
of Radiation Emergencies and Nuclear Concerns:
While many incidents and emergencies have been observed
in recent decades, the field of radiation preparedness is still incipient,
evolving, and largely untested. Although
evidence of improved measures may exist since cases such as the scare of
nuclear meltdown in
In terms of large scale
radiation events, nuclear war and terrorism generally hold a spot light
compared to nuclear power plant or reactor meltdown. Many simulation and preparedness models
utilize a bomb of comparable size to the weapon dropped on
Weapons held today by either the
Final
Conclusion:
A large scale radiation
emergency or a nuclear disaster would be likely to reflect fundamental features
of society and culture, including interpersonal communication, relationships,
and core values through the intensity of impact and stress of recovery (Oliver-Smith,
2002). The ability to cope, recognize
vulnerability, and assist recovery in emergencies of radioactive nature may be
tools of invaluable importance for the management of public health in the
modern world. Both response and
prevention are concepts that should be molded to the features of a society most
germane to its fundamental well being and continued self-sufficiency.
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http://www.who.int/ionizing_radiation/a_e/en
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