UNSCEAR 2008 Report Vol.I

Transcript

1 This publication contains: VOLUME I: SOURCES SOURCES AND EFFECTS Report of the United Nations Scientific Committee on the Effects of Atomic Radiation to the General Assembly OF IONIZING RADIATION Scientific Annexes Annex A. Medical radiation exposures Annex B. Exposures of the public and workers from various sources of radiation United Nations Scientific Committee on the Effects of Atomic Radiation UNSCEAR 2008 Report Volume I: SOURCES Report to the General Assembly Scientific Annexes A and B SOURCES AND EFFECTS OF IONIZING RADIATION — UNSCEAR 2008 REPORT — VOLUME I: SOURCES United Nations publication USD 80 Printed in Austria ISBN 978-92-1-142274-0 Sales No. E.10.XI.3 *0986753* V.09-86753—July 2010—1,450

2

3 SOURCES AND EFFECTS OF IONIZING RADIATION United Nations Scientific Committee on the Effects of Atomic Radiation UNSCEAR 2008 Report to the General Assembly with Scientific Annexes VOLUME I UNITED NATIONS New York, 2010

4 NOTE Official Records of the General The report of the Committee without its annexes appears as Assembly , Sixty-third Session, Supplement No. 46. The designations employed and the presentation of material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the United Nations concerning the legal status of any country, territory, city or area, or of its authorities, or concerning the delimitation of its frontiers or boundaries. The country names used in this document are, in most cases, those that were in use at the time the data were collected or the text prepared. In other cases, however, the names have been updated, where this was possible and appropriate, to reflect political changes. UNITED NATIONS PUBLICATION Sales No. E.10.XI.3 ISBN 978-92-1-142274-0

5 Corrigendum to Sales No. E.10.XI.3 May 2016 18 Sources and Effects of Ionizing Radiation: United Nations Scientific Committee on the Effects of Atomic Radiation 2008 Report Vo l u m e I Report of the United Nations Scientific Committee on the Effects of Atomic Radiation to the General Assembly Corrigendum Page 8, figure 1. III For the for level I (diagnostic medical), entry 1308 read 1332 for For the entry for Global (diagnostic medical), for 482 read 488 figure IV 9, 2. Page entry For the I, for 1.88 read 1.92 for level For the entry for Global, for 0.61 read 0.62 3. Page 11, table 4, column headed “Sources of exposure”, subcolumn headed Sv)” medicine examinations (man “Nuclear a After the entry 82 insert reading Insert at the foot of the table a footnote a Refers to health-care levels III-IV. Page headed 6, column 4. “1990-1994” 14, table For the value for the weighted average, for 0.8 read 1.3 5. Page 15, par agraph 63 In f the ourth line, for 38 read 35 read In f the ifth line, for 26 24 In the sixth line, for 38 read 35 31 34 read In the seventh line, for V. 16-02682 (E) *1602682*

6 Corrigendum to Sales No. E.10.XI.3 29 32 for read In the tenth line, In the eleventh line, read 61 for 68 15, paragraph 64 Page 6. In the fourth line, 85 read 80 for In the sixth for Twenty-five read Nine line, line, for 164 read 120 In the seventh 7. Page 15, paragraph 65 In the third line, for 29 read 34 42 In ifth line, for 33 read the f 8. Page 15, paragraph 66 In t he fourth line, for 29 read 32 In f the ifth line, for 45 read 46 for 613 623 read In f the ifth line, 2 2 V.16-0268

7 CONTENTS Page VOLUME I: SOURCES Report of the United Nations Scientific Committee on the Effects of Atomic Radiation to the General Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Scientific Annexes . Medical radiation exposures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Annex A 21 Annex B . Exposures of the public and workers from various sources of radiation . . . . . . . . . . . . . . . . . . . . . . . . . . 221 VOL UME II: EFFECTS Annex C . Radiation exposures in accidents Annex D . Health effects due to radiation from the Chernobyl accident Effects of ionizing radiation on non-human biota Annex E . iii

8

9 Report of the United Nations Scientific Committee on the Effects of Atomic Radiation to the General Assembly Contents Page 1 Introduction I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Deliberations of the United Nations Scientific Committee on the Effects of Atomic Radiation at II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 its fifty-sixth session Strategic plan and programme of work of the Committee 2 III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Scientific report Sources of radiation exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 A . B . Chernobyl accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 C . 18 Effects on non-human biota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendices Members of national delegations attending the fiftieth to fifty-sixth sessions of the I . United Nations Scientific Committee on the Effects of Atomic Radiation, at which . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 the 2008 scientific report was elaborated Scientific staff and consultants cooperating with the United Nations Scientific II . Committee on the Effects of Atomic Radiation in the preparation of the 2008 scientific report of the Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 v

10

11 INTROdUCTION I. 1. Exposure to radiation has origins such as medical diag- - in Japan. The Committee also reviews advances in the under nostic and therapeutic procedures; nuclear weapons pro- standing of the biological mechanisms by which radiation- duction and testing; natural background radiation; nuclear induced effects on health or on the environment can occur. electricity generation; accidents such as the one at Cherno- Those assessments provide the scientific foundation used, inter alia, by the relevant agencies of the United Nations byl in 1986; and occupations that entail increased exposure to artificial or naturally occurring sources of radiation. system in formulating international standards for protec- 1 tion of the public and of workers against ionizing radiation; 2. those standards, in turn, are linked to important legal and Since the establishment of the United Nations Scientific regulatory instruments. Committee on the Effects of Atomic Radiation by General Assembly resolution 913 (X) of 3 December 1955, the man- date of the Committee has been to undertake broad reviews 1 of the sources of ionizing radiation and of the effects of that The international basic safety standards for protection against ionizing radiation and for the safety of radiation sources are currently co-sponsored - radiation on human health and the environment. In pur by the International Labour Organization, the Food and Agriculture Organi- suit of its mandate, the Committee thoroughly reviews and zation of the United Nations (FAO), the World Health Organization (WHO), evaluates global and regional exposures to radiation; and the International Atomic Energy Agency (IAEA), the Nuclear Energy it evaluates evidence of radiation-induced health effects in Agency of the Organization for Economic Cooperation and Development exposed groups, including survivors of the atomic bombings and the Pan American Health Organization. II. dELIbERATIONS OF ThE UNITEd NATIONS SCIENTIFIC COMMITTEE ON ThE EFFECTS OF A TOMIC RAdIATION AT ITS FIFTy- SIxTh SESSION volume I had not been published until July 2008 and that 3. The Committee held its fifty-sixth session in Vienna from 2 volume II would likely not be published before December Norman Gentner (Canada), Wolfgang 10 to 18 July 2008. 2008, bearing in mind that Member States and some organi- Weiss (Germany) and Mohamed A. Gomaa (Egypt) served 6 zations relied on the information contained in that report, to as Chairman, Vice-Chairman and Rapporteur, respectively. which the Committee members had contributed invaluable The Committee scrutinized and approved for publication five expertise. It was observed that the delays were traceable in scientific annexes that had last been considered at its fifty- part to inadequate staffing and to a lack of sufficient, assured fifth session (21-25 May 2007), as reported to the General 3 and predictable funding. As Assembly in the report of the Committee on that session. 4 the Committee had originally planned previously reported, 5. The Committee noted that the General Assembly, in that those documents would be published by 2005. its resolution 62/100 of 17 December 2007, had appealed to the Secretary-General to take appropriate administrative 4. With regard to the report with scientific annexes that it 5 measures so that the secretariat could adequately service the had approved in 2006, the Committee was disappointed that Committee in a predictable and sustainable manner; and had 2 The fifty-sixth session of the Committee was attended by members of the Committee and by the official contact points of Belarus, the Russian Feder - 6 At its fifty-first regular session, the IAEA General Conference, in its reso- ation and Ukraine, for matters related to the Chernobyl accident; observers for Belarus, Finland, Pakistan, the Republic of Korea, Spain and Ukraine; lution GC(51)/RES/11, entitled “Measures to strengthen international coop- and observers for the United Nations Environment Programme (UNEP), eration in nuclear, radiation and transport safety and waste management”, noted that the IAEA Secretariat had commenced revision of the Interna- WHO, IAEA, the International Agency for Research on Cancer, the Euro- pean Commission, the International Commission on Radiological Protec- tional Basic Safety Standards for Protection against Ionizing Radiation and the Safety of Radiation Sources with the participation of co-sponsors; tion, the International Commission on Radiation Units and Measurements, the International Organization for Standardization and the International noted the report of the United Nations Scientific Committee on the Effects Union of Radioecology. Official Records of the of Atomic Radiation on its fifty-fourth session ( 3 Official Records of the General Assembly, Sixty-second Session, Supple- (A/61/46)); and General Assembly, Sixty-first Session, Supplement No. 46 urged the IAEA Secretariat to consider carefully and to justify any potential ment No. 46 (A/62/46), para. 3. 4 Ibid., changes to the Basic Safety Standards, ensuring consistency with, inter alia, (A/56/46), para. 10. Fifty-sixth Session, Supplement No. 46 5 Ibid., Sixty-first Session, Supplement No. 46 (A/61/46), para. 2. the Committee’s report. 1

12 2 UNSCEAR 2008 REPORT: VOLUME I requested the Secretary-General to provide a comprehensive assured and predictable funding. The secretariat was requested to facilitate the inclusion in the Secretary-General’s report of and consolidated report to the Assembly at its sixty-third session, to be prepared in consultation with the Committee the views of the Committee on those matters. as appropriate, addressing the financial and administrative 6. The Committee decided to hold its fifty-seventh session implications of increased Committee membership, staffing of the professional secretariat and methods to ensure sufficient, in Vienna from 25 to 29 May 2009. STRATEGIC pLAN ANd pROGRAMME OF wORk OF ThE COMMITTEE III. 7 The Committee had developed a strategic plan to pro- 7. coordination with other stakeholders to develop areas of syn- vide vision and direction for all its activities during the ergy and avoid inconsistencies; and (d) raising awareness and period 2009-2013, to facilitate result-based programming improving outreach by enhancing the website of the Com- by the secretariat, to help foster management of sufficient, mittee and disseminating findings in readily understandable assured and predictable resources and to improve planning formats to decision makers and the public. and coordination among the various parties involved. 11. It was assumed that, in order to implement the strategic plan, intersessional work by the Committee would increase 8. The Committee considered that its strategic objective and action would have to be taken to address both the concern for the period was to increase awareness and deepen under - of the Committee that reliance on a single Professional-level standing among authorities, the scientific community and post in its secretariat had left the Committee seriously vul- civil society with regard to levels of ionizing radiation and nerable and had hampered the efficient implementation of the related health and environmental effects as a sound basis its approved programme of work, and methods to ensure for informed decision-making on radiation-related issues. sufficient, assured and predictable funding, as requested in General Assembly resolution 62/100. 9. It was established that the thematic priorities for the period would be medical exposures of patients, radiation levels and For its future programme of work, the Committee 12. effects of energy production, exposure to natural sources of decided to initiate work immediately on assessments of radiation and improved understanding of the effects from levels of radiation from energy production and the effects low-dose-rate radiation exposure. on human health and the environment; uncertainty in radia- tion risk estimation; attributability of health effects due to Several strategic shifts were envisaged in order to better 10. radiation exposure (in response to paragraph 6 of General stream (a) meet the needs of Member States, including: lining Assembly resolution 62/100); updating its methodology for the Committee’s scientific evaluation process by preparing estimating exposures due to discharges from nuclear instal- years on short yet wide-ranging summary reports every 4-5 lations; a summary of radiation effects; and improving data the levels and effects of radiation exposure and preparing spe- collection, analysis and dissemination. Depending on the cial reports that respond to emerging issues as the need arises; availability of resources, other work might be undertaken and establishing standing expert groups to maintain surveil- on the biological effects of key internal emitters, medical lance on emerging issues and networks of centres of excel- exposures of patients, enhanced exposures to natural sources (b) lence to help implement the strategic plan; enhancing of radiation due to human activities, public information and mechanisms for data collection, analysis and dissemination; development of a knowledge base on radiation levels and improving result-based planning, including improving (c) effects. The Committee authorized the secretariat to take appropriate action to implement the strategic plan and future 7 programme of work. Available on request from the Secretary of the Committee.

13 SCIENTIFIC REpORT IV. 13. The scientific report and its annexes were elaborated from the fiftieth to the fifty-sixth sessions of the Committee on the basis of documents submitted by the secretariat. Serving as Chairman, Vice-Chairman and Rapporteur at those sessions were: Vice-Chairman Rapporteur Session Chairman Fiftieth J. Lipsztein (Brazil) Y. Sasaki (Japan) R. Chatterjee (Canada) R. Chatterjee (Canada) Fifty-first J. Lipsztein (Brazil) Y. Sasaki (Japan) P. Burns (Australia) R. Chatterjee (Canada) Y. Sasaki (Japan) Fifty-second Fifty-third Y. Sasaki (Japan) P. Burns (Australia) N. Gentner (Canada) N. Gentner (Canada) C. Streffer (Germany) Fifty-fourth P. Burns (Australia) N. Gentner (Canada) W. Weiss (Germany) P. Burns (Australia) Fifty-fifth W. Weiss (Germany) M. Gomaa (Egypt) N. Gentner (Canada) Fifty-sixth 14. The names of the members of national delegations The main natural sources of exposure are cosmic radia- 17. who attended those sessions are listed in appendix I. The tion and natural radionuclides found in the soil and in rocks. Committee wishes to acknowledge the contribution of Cosmic radiation is significantly higher at the cruising alti- the representatives of specialized agencies of the United tudes of jet aircraft than on the Earth’s surface. External Nations system and other organizations to the discussion. exposure rates due to natural radionuclides vary considerably The Committee also wishes to recognize a small group of from place to place, and can range up to 100 times the aver - consultants who helped prepare the material (see appendix age. An important radionuclide is radon, a gas that is formed II). They were responsible for the preliminary assessment of during the decay of natural uranium in the soil and that seeps the relevant technical information, on which rested the final into homes. Exposures due to inhalation of radon by people deliberations of the Committee. living and working indoors vary dramatically depending on the local geology, building construction and household life- In conducting its work, the Committee applied scien- 15. styles; this mode of exposure accounts for about half of the tific judgement to the material it reviewed and took care to average human exposure to natural sources. assume an independent and neutral position in reaching its 18. The Committee evaluated the additional radiation expo- conclusions. Following established practice, the findings are sures introduced by military and peaceful activities. Nuclear presented in the present report. The supporting scientific test explosions in the atmosphere had been conducted at annexes are aimed at the scientific community and will be a number of sites, mostly in the northern hemisphere, the issued separately as a United Nations sales publication. most active testing being in the periods 1952–1958 and 1961–1962. The radioactive fallout from those tests rep- resents a source of continuing exposure even today, albeit Overview at very low levels. There is concern regarding the return of residents to nuclear test areas, because radioactive residue For as long as they have been on the planet, humans 16. levels are considerable at some sites. People living near sites have been exposed to ionizing radiation from natural where nuclear materials and weapons had been produced are sources, although exposure may be modified by human also exposed to radiation. Military use of depleted uranium, activity. In addition, new, artificial sources of exposure have especially in armour-piercing munitions, has raised concerns developed over the past century or so. The Committee last about residual contamination; however, radiation exposures made estimates of radiation exposure levels and trends in its 8 are generally negligible. 2000 report. The present report updates and extends those estimates; table 1 summarizes the updated values for average 9 19. With regard to the peaceful uses of radiation, medical annual doses and ranges of exposure from all sources. exposures were by far the dominant form. Medical exposure is almost always voluntary and provides a direct benefit to the exposed individual. Irrespective of the level of health care in a 8 Official Records of the General Assembly, Fifty-fifth Session, Supplement country, the medical uses of radiation continue to increase as No. 46 (A/55/46). 9 techniques develop and become more widely disseminated; See paragraph 26 below for a discussion of the concept of radiation dose. 3

14 4 UNSCEAR 2008 REPORT: VOLUME I care, exposure from medical uses is on average now equal to about 3.6 billion radiological examinations are conducted levels of health about 80 per cent of that from natural sources. worldwide every year. In countries with high Table 1. Annual average doses and ranges of individual doses of ionizing radiation by source a ) (Millisieverts Annual average Source or mode Typical range of Comments dose (worldwide) individual doses Natural sources of exposure Inhalation (radon gas) The dose is much higher in some dwellings . 0 .2–10 1 .26 External terrestrial 0 .3–1 The dose is higher in some locations . 0 .48 Ingestion 0 .29 0 .2–1 Cosmic radiation 0 .39 0 .3–1 The dose increases with altitude . 2.4 Total natural Sizeable population groups receive 10-20 millisieverts 1–13 (mSv). Artificial sources of exposure Medical diagnosis (not therapy) 0 .6 0-several tens The averages for different levels of health care range from 0 .03 to 2 .0 mSv; averages for some countries are higher than that due to natural sources; individual doses depend on specific examinations . The average has fallen from a peak of 0 .11 mSv in 1963 . Atmospheric nuclear testing 0 .005 Some higher doses around test sites still occur . Occupational exposure ~0–20 . Most of the The average dose to all workers is 0 .7 mSv 0 .005 average dose and most high exposures are due to natural radiation (specifically radon in mines) . b In 1986, the average dose to 0 .002 Chernobyl accident The average in the northern hemisphere has decreased from more than 300,000 recovery a maximum of 0 .04 mSv in 1986 . . Thyroid doses were much higher workers was nearly 150 mSv; and more than 350,000 other individuals received doses greater than 10 mSv . b 0 .000 2 Nuclear fuel cycle (public exposure) Doses are up to 0 .02 mSv for critical groups at 1 km from some nuclear reactor sites . Total artificial - Individual doses depend primarily on medical treat From essentially zero to 0.6 several tens ment, occupational exposure and proximity to test or accident sites. a Unit of measurement of effective dose . b Globally dispersed radionuclides . The value for the nuclear fuel cycle represents the maximum per caput annual dose to the public in the future, assuming the practice continues for 100 years, and derives mainly from globally dispersed, long-lived radionuclides released during reprocessing of nuclear fuel and nuclear power plant operation . In the area of occupational exposure, attention had tra- 20. The generation of electrical energy by nuclear power 21. ditionally focused on artificial sources of radiation; however, plants has grown steadily since 1956. The nuclear fuel cycle includes the mining and milling of uranium ore; fuel fabri- it is now recognized that a very large number of workers are exposed to natural sources. Occupational exposures at com- cation; production of energy in the nuclear reactor; storage mercial nuclear power plants have been falling steadily over or reprocessing of irradiated fuel; and the storage and dis- posal of radioactive wastes. The doses to which the public is the past three decades, albeit with significant differences between reactor types. Estimates for exposure related to exposed vary widely from one type of installation to another, but they are generally small and they decrease markedly the the nuclear fuel cycle are generally more robust and com- further the distance from the facility. Doses from nuclear prehensive than for other uses of radiation. By contrast, the monitoring and reporting of occupational exposures in the power reactors to local and regional populations decrease over time because of lower discharge levels. medical and industrial sectors is less comprehensive. While

15 5 REPORT TO THE GENERAL ASSEMBLY Sources of radiation exposure A. the average dose to workers in all occupational groups has dropped substantially over the past two decades, occupational All matter is made up of atoms. Some atoms are 25. exposures from natural radiation sources have changed little. naturally stable, others are unstable. Radioactivity is a natural phenomenon that occurs when an atom with an A small number of accidents have occurred in asso- 22. un stable nucleus spontaneously transforms, releasing ciation with the nuclear fuel cycle and have attracted wide- energy in the form of ionizing radiation. These unstable spread publicity. However, more than 100 accidents have elements are known as radionuclides and they are radio- occurred with industrial and medical sources, especially in - active. The released radiation may take the form of par settings termed “orphaned” (i.e. outside regulatory control), ticles (including electrons, neutrons and alpha particles) and those accidents have caused injury to workers and the or of electromagnetic gamma radiation or X -rays, all public. Accidents can also occur during medical uses of radi- with different amounts of energy. Radiation can also be ation, usually involving human or machine error in radio- generated artificially by machines. therapy. While it is known that accidents involving orphan sources and medical uses of radiation have become more When ionizing radiation passes through matter, includ- 26. frequent, the current figures are likely to be underestimates, ing living tissue, it deposits energy that ultimately produces and possibly significantly so, because of underreporting. ionization and excitation in the matter. The amount of energy deposited divided by the mass of tissue exposed is called 23. The accident at the Chernobyl nuclear power plant in the absorbed dose and is usually measured in units known 1986 was the most severe such accident in the history of as milligrays. The biological damage caused by radiation civilian nuclear power. Two workers died in the immediate is related to the amount of energy deposited. However, to aftermath, and 134 plant staff and emergency personnel suf- estimate the potential biological effect, allowance is made fered acute radiation syndrome, which proved fatal for 28 of for the fact that different kinds of radiation have different them. Several hundred thousand workers were subsequently biological effects for the same amount of energy deposited involved in recovery operations. Among the persons exposed and the fact that tissues also react differently. A weighted to the highest radiation doses in 1986 and 1987, there are quantity called the effective dose is used in radiation pro- some reports of increased incidence of leukaemia and of tection, and is the most commonly used indicator of the racts; there is no other consistent evidence to date of cata potential biological effects associated with exposure to ion- other radiation-related health effects. The radioactive cloud izing radiation in humans. The effective dose (here simply created by the accident deposited substantial amounts of “dose”) is usually expressed in millisieverts (mSv). The total radioactive material over large areas of the former Soviet exposure of a group of people to radiation is called the col- Union and other parts of Europe, contaminating land, water lective dose and is expressed in man-sieverts (man Sv). As and biota and causing particularly serious social and eco- a reference for subsequent comparisons, the annual global nomic disruption to large segments of the population in the average per caput dose from natural background radiation is countries known today as Belarus, the Russian Federation 2.4 mSv, while the corresponding annual collective dose to and Ukraine. Among the people who were children or ado- global population from natural background radiation is the lescents in 1986 in affected areas of the former Soviet Union, about 16 million man Sv. more than 6,000 cases of thyroid cancer have been reported (to date only a small number of them fatal), of which a sub- stantial portion could be attributed to drinking milk contami- 1. Natural sources nated with the short-lived radionuclide iodine-131. In the longer term, the general population too was exposed to radi- 27. For most individuals, exposure to natural background ation (of the low-level chronic type) but there has been no radiation is the largest component of their total radiation consistent evidence yet of any other radiation-related health exposure. Although the sources of radiation are natural, effects in the general population. exposures are affected by human activity, of which the sim- plest example is living in a house. Building materials pro- 24. In its 1996 scientific report, the Committee evaluated vide shielding against radiation from the ground but may the rates of exposure below which effects on populations themselves contain radionuclides that increase exposure. of species other than humans were unlikely. The Commit- In addition, buildings may trap radon gas and thus increase tee has since reviewed the approaches to evaluating radi- exposures vis-à-vis those occurring in the open air. ation doses to species other than humans, together with new scientific information on the radiobiological effects Cosmic radiation (i.e. radiation originating in outer 28. on plants and animals (in particular information from the space) is significantly attenuated by the Earth’s atmosphere. continuing follow-up of the environmental consequences At sea level it contributes about 15 per cent of the total dose of the Chernobyl accident). That review has revealed no from natural radiation sources; however, at higher altitudes evidence to support changing the conclusions of the 1996 and especially in outer space, it is the dominant radiation report according to which no effects are expected at chronic source. At cruising altitudes of commercial aircraft, the dose rates below 0.1 milligrays per hour or at acute doses average dose rates are 0.003–0.008 mSv per hour, some two below 1 gray to the most highly exposed individuals in the orders of magnitude higher than at sea level. exposed population.

16 6 UNSCEAR 2008 REPORT: VOLUME I Everything in and on the Earth contains radionuclides. 29. location to another. Some specific locations have such high concentrations of these radionuclides that the dose rates may The so-called primordial radionuclides found in the ground be 100 times the global average value. These radionuclides (potassium-40, uranium-238 and thorium-232), together and some formed by the interaction of cosmic rays with the with the radionuclides into which they decay, emit radiation. 10 Earth’s atmosphere are also present in food and drink and vary considerably from one Estimates of external exposure so become incorporated into the body. Environmental con- centrations of natural radionuclides are highly variable (see 10 External exposure is exposure to radiation that originates from outside 10 is figure I). Most of the dose from such internal exposure the body, whereas internal exposure is exposure to radiation that originates due to potassium-40. from radioactive material inside the body. Figure I. Variability of natural uranium concentrations observed in drinking water 1 000 000 80 000 NATURAL URANIUM CONCENTRATION 100 000 8 000 TION (micrograms per litre) 10 000 800 1 000 80 ONCENTRA 8 100 0.8 10 1 0.08 (millibecquerels per litre) URANIUM�238 C 0.1 0.008 0.01 0.000 8 Italy India Spain Brazil China France Greece Finland Hungary Romania Morocco Germany Argentina Czech Rep. Switzerland United States : The vertical lines express the range of values observed in the country Note . Note that the scales on the vertical axes increase by factors of 10 . 2. Artificial sources 30. One radionuclide produced from the uranium-238 decay series is radon-222 (or simply “radon”). This gas is (a) Exposures from military activities a normal constituent of soil gas and seeps into buildings. When radon is inhaled, some of its short-lived decay prod- Nuclear test explosions in the atmosphere were con- 32. ucts are retained in the lungs and irradiate cells in the respi- ducted at a number of sites, mostly in the northern hemi- ratory tract. Radon levels vary dramatically depending on sphere, between 1945 and 1980, the most active testing the underlying local geology and other factors such as the being in the periods 1952–1958 and 1961–1962. In all, permeability of the soil, construction of the building, climate 502 tests were conducted, with a total yield of 434 mega- and household lifestyles. Very extensive measurement pro- tons of trinitrotoluene (TNT) equivalent. The estimated grammes have been conducted and have formed the basis for annual per caput effective dose of ionizing radiation due implementing measures to reduce indoor radon concentra- to global fallout from atmospheric nuclear weapons test- tions. Radon accounts for about half of the average exposure ing was highest in 1963, at 0.11 mSv, and subsequently to natural sources of radiation. fell to its present level of about 0.005 mSv (see figure II). This source of exposure will decline only very slowly in 31. The estimates of annual average and individual doses the future as most of it is now due to the long-lived radio- of ionizing radiation from exposure to all natural radiation nuclide carbon-14. sources are shown above in table 1.

17 REPORT TO THE GENERAL ASSEMBLY 7 Estimated annual per caput effective dose of ionizing radiation worldwide from atomic bomb tests, 1945–2005 Figure II. 0.12 0.1 0.08 0.06 0.04 ANNUAL EFFECTIVE DOSE �mSv� 0.02 0 1985 1995 2005 1945 1965 1955 1975 YEAR chemical toxicity is its most hazardous property. Except 33. People living near test sites were also exposed to local for a few specific scenarios (such as long-term handling), fallout. Because the sites and the characteristics of the tests radiation exposures should be negligible. differed substantially, doses can only be estimated separately after very detailed studies at each site. Many of those studies were carried out in the late 1990s and the early years of the (b) Exposures from peaceful activities present decade and are still continuing. It is clear that some people living near the sites at the time of testing received Radiation exposures of patients (i) very large doses. Presently there is concern regarding the return to use of nuclear test areas, since radioactive residue 37. The exposure of patients to ionizing radiation relates in some environments may be considerable. to diagnostic radiology, nuclear medicine and radiotherapy. The Committee conducted a survey of medical exposures 34. From 1962 to 1990, following the signature of the for the period 1997–2007. There are some limitations on 1963 Treaty Banning Nuclear Weapon Tests in the Atmos- 11 the survey data, with the majority of the responses being phere, in Outer Space and under Water, typically up to 50 received from relatively more developed countries. Explicit or more explosions were conducted underground annually; a comparison of doses resulting from medical exposures with few tests were also conducted after that. Most underground those from other sources is inappropriate, as patients receive tests had a much lower yield than atmospheric tests, and any a direct benefit from their exposure and, moreover, they may radioactive debris was usually contained unless gases were be sick or older than the general population. In fact, increas- vented or leaked into the atmosphere. The tests generated a ing medical exposure is likely associated with increased very large quantity of radioactive residue, but that residue is health benefits to the population. not expected to expose the public to radiation because it is located deep underground and essentially is fused with the host rock. Diagnostic medical exposures 35. In addition to the weapons tests themselves, the 38. Since the previous survey (covering the period 1991– installations where nuclear materials were produced and 1996), the total number of diagnostic medical examinations nuclear weapons were manufactured were another source (both medical and dental) is estimated to have risen from of radionuclide releases leading to radiation exposure of 2.4 billion to 3.6 billion—an increase of approximately local populations. per cent. As in previous reports of the Committee, data 50 -care level (I, are grouped according to a country’s health A by-product of uranium enrichment is depleted ura- 36. II, III or IV—I being the highest, IV the lowest—based nium, which is less radioactive than natural uranium. Its on the number of physicians per population). Figure III 11 shows, for the period 1997-2007, the annual frequency of Treaty Series United Nations, , vol. 480, No. 6964.

18 8 UNSCEAR 2008 REPORT: VOLUME I medical X-ray examinations by health -care level. As can IV countries (which account for 27 per cent of the global be seen from the figure, such examinations were over 65 population). The wide imbalance in health-care provision is also reflected in the availability of X-ray equipment and times more frequent in level I countries (which account for 24 per cent of the global population) than in level III and of physicians. Average annual frequency of diagnostic medical and dental x-ray examinations, by health-care level, 1997–2007 Figure III. 1 400 1 332 1 200 1 000 800 600 488 FREQUENCY 400 332 275 �per 1 000 population� 200 74 20 16 3 0 Global I III and IV II HEALTH�CARE LEVEL Diagnostic medical Dental X-ray Table 2 shows the trend in the use of diagnostic radiology and the associated exposures. 39. T rend in radiation exposure from diagnostic radiology Table 2. Year of Committee report in which Number of examinations (millions) Collective effective dose (man Sv) Annual per caput dose (mSv) survey data were analysed 1988 1 380 1 800 000 0 .35 1 600 000 0 .3 1 600 1993 1 910 2 300 000 0 .4 2000 3 100 4 000 000 0 .6 2008 As part of that trend, new, high-dose X-ray technology 40. ey analysed by the Committee, Since the last surv 41. (particularly computed tomograph y scanning) is causing the total collective effective dose from medical diagnostic extremely rapid growth in the annual number of procedures examinations is estimated to have increased by 1.7 million Sv, rising from about 2.3 million to about 4 million performed in many countries and, by extension, a marked man increase in collective doses. For several countries, this has man Sv, an increase of approximately 70 per cent. Figure IV resulted, for the first time in history, in a situation where the shows, for the period 1997–2007, the annual average per annual collective and per caput doses of ionizing radiation caput effective dose of radiation by health-care level and for the global population due to diagnostic medical and dental due to diagnostic radiology have exceeded those from the previously largest source (natural background radiation). X-ray examinations.

19 O THE GENERAL ASSEMBLY REPORT T 9 Annual average per caput effective dose of ionizing radiation due to diagnostic medical and dental x-ray Figure IV. examinations, by health-care level, 1997–2007 2.0 1.92 1.5 1.0 0.62 PER CAPUT DOSE �mSv� 0.5 0.32 0.03 0.0 III and IV Global II I HEALTH�CARE LEVEL Nuclear medicine to nuclear medicine examinations rose from 150,000 to 202,000 man Sv, representing an increase of 52,000 man Sv cent. People living in health-care level I coun- or about 35 per 42. million diagnostic nuclear medicine An estimated 32.7 tries account for about 90 per cent of all nuclear medicine examinations are presently performed annually worldwide, examinations. Figure V presents, for the period 1997–2007, which represents an increase of 0.2 million examinations a summary of the annual frequency of diagnostic nuclear per year or under 1 per cent since the 1991–1996 survey. medicine examinations by health-care level. Over that same period, the collective effective dose due Figure V. Annual frequency of diagnostic nuclear medicine examinations, by health-care level, 1997–2007 20 19 15 10 FREQUENCY 5.1 �per 1 000 population� 5 1.1 0.02 0 Global III and IV II I HEALTH�CARE LEVEL

20 10 UNSCEAR 2008 REPORT: VOLUME I 43. three survey periods (1985–1990, 1991–1996 and 1997– The estimated number of diagnostic nuclear medicine examinations conducted annually has grown over the past 2007), as shown in figure VI. Figure VI. Estimated number of diagnostic nuclear medicine examinations conducted annually, 1985–1990, 1991–1996 and 1997-2007 40 32.7 32.5 30 24 20 TIONS �millions� EXAMINA 10 0 1985–1990 1991–19961 997–2007 SURVEY PERIOD cent of all radiotherapy treatments. An estimated per 70 Radiation therapy 5.1 million courses of radiotherapy treatment were administered annually between 1997 and 2007, up from Estimated annual data on the most common types 44. an estimated 4.3 million in 1988. About 4.7 million of of radiotherapy treatment during the period 1997-2007 those treatments involved teletherapy and 0.4 million are shown for each health-care level in table 3. As brachytherapy. can be seen, the level I countries accounted for about a worldwide, 1997–2007 Estimated annual data on radiotherapy treatments Table 3. b Teletherapy Health-care level Brachytherapy Population All radiotherapy treatments (millions) Treatments Treatments Treatments Treatments Treatments Treatments administered administered per administered administered administered per administered per 1 000 population 1 000 population each year each year each year 1 000 population (millions) (millions) (millions) 3 .5 2 .2 I 0 .12 3 .6 2 .4 1 540 0 .18 3 153 1 .2 0 .4 0 .20 0 .06 1 .4 0 .4 II c c 0 .06 (<0 .05) 1 009 (<0 .01) 0 .06 0 .1 0 .06 III c c c c c c (<0 .01) (0 .03) (<0 .005) IV (0 .03) (<0 .01) (0 .01) 744 d World 6 446 4 .7 0 .73 0 .4 0 .07 5 .1 0 .8 Source : Committee survey on medical radiation usage and exposures, 1997–2007 . a Complete courses of treatment . b Excluding treatments with radiopharmaceuticals . c Assumed value in the absence of data . d Global data include several countries not represented by levels I-IV .

21 REPORT TO THE GENERAL ASSEMBLY 11 Summary for the period 1997–2007. Almost 75 per cent of the world- wide collective effective dose due to medical exposures is 45. Table 4 summarizes the estimated annual collectiv e accounted for by health-care level I countries (those that are effective dose of ionizing radiation due to medical exposures relatively more developed). Estimated annual collective effective dose of ionizing radiation due to medical exposures, 1997–2007 Table 4. (Totals may not add precisely because of rounding) Population Total Health-care level Source of exposure (millions) (man Sv) Diagnostic medical Dental X-ray Nuclear medicine examinations (man Sv) examinations (man Sv) examinations (man Sv) I 2 900 000 9 900 186 000 3 100 000 1 540 3 153 1 300 16 000 1 000 000 II 1 000 000 a 33 000 51 III 1 009 33 000 82 IV 744 24 000 38 . . 24 000 World 6 446 4 000 000 11 000 202 000 4 200 000 a Refers to health-care levels III-IV. gest artificial 46. Medical exposure remains by far the lar 2.5 billion in the previous survey period; that is an increase of cent, in the last source of exposure to ionizing radiation and continues to 1.1 billion procedures, or over 40 per decade. The total annual collective effective dose due to medical grow at a remarkable rate. Medical exposures account for 98 cent of the contribution from all artificial sources and exposures (excluding radiotherapy) stood at approximately per 4.2 million man Sv, an increase of 1.7 million man Sv (or are now the second largest contributor to the population dose per cent) over the previous period. The distribu- just over 65 per cent of the worldwide, representing approximately 20 total. About 3.6 billion medical radiation procedures were tion of medical procedures and of doses is markedly uneven performed annually during the survey period, compared with among country groups (see figure VII). Total annual collective effective dose of radiation due to medical exposures (excluding radiotherapy) Figure VII. 5 000 000 4 224 622 4 000 000 3 141 138 3 000 000 2 000 000 COLLECTIVE EFFECTIVE DOSE �man Sv� 1 000 000 1 000 000 33 000 24 000 0 II III IV I Global HEALTH�CARE LEVEL

22 12 UNSCEAR 2008 REPORT: VOLUME I adiation exposures of the general public R (ii) of uranium ore and its conversion to nuclear fuel; fabri- cation of fuel elements; production of energy in a nuclear he generation of electrical energy by nuclear T 47. power plant; storage or reprocessing of irradiated fuel; power plants has grown steadily since the industry began transport between the various stages; and the storage and in 1956. Despite the increase in the decommissioning of disposal of radioactive wastes. The doses of ionizing older reactors, electrical energy production from nuclear radiation to exposed individuals vary widely from one sources continues to grow (see figure VIII). The nuclear type of facility to another, between different locations fuel cycle has the following stages: mining and milling and over time. Figure VIII. Installed nuclear electricity-generating capacity worldwide, 1970–2005 400 300 200 �gigawatts electrical� INSTALLED CAPACITY 100 0 1995 2000 2005 1970 1975 1980 1985 1990 YEAR 51. mining and milling produces substantial The low-level and some of the intermediate-level waste 48. Uranium from fuel cycle operations is currently disposed of in near- quantities of residues in the form of tailings. Until 2003, the tonnes surface facilities, although waste was sometimes dumped at total world production of uranium was about 2 million tonnes. while the resultant tailings totalled over 2 billion sea in the past. Both the high-level waste from reprocessing and the spent fuel (if not reprocessed) are stored but will Current tailing piles are well maintained, but many old, eventually need to be disposed of. The public is expected to abandoned sites exist and only a few have been remedi- ated. The Committee estimates the current annual collective be exposed to radiation from disposed waste only in the dis- dose of ionizing radiation to local and regional population tant future, if at all, so assessment of the radiological impact has to rely on mathematical modelling. Overall, an annual groups around mine and mill sites and tailing piles at about collective dose of about 200 man Sv is estimated for all oper- 50–60 man Sv, similar to its previous estimates. ations related to electrical energy production. The dominant Most component of those operations is mining. The annual per power reactors are of the light-water moderated 49. caput dose to representative local and regional populations and cooled type, although other designs are used in some countries. The average annual collective dose of ionizing around nuclear power plants is less than 0.0001 mSv (about equivalent to the dose received from cosmic radiation in a radiation to local and regional population groups (combined) due to environmental releases from reactors is now estimated few minutes of air travel). to be 75 man Sv. This is lower than previous estimates. here are several types of facility around the world that, T 52. while unrelated to the use of nuclear energy, may all the same the nuclear fuel cycle, spent fuel is reprocessed to In 50. recover uranium and plutonium for reuse in reactors. Most expose the public to radiation because of enhanced concen- trations of naturally occurring radionuclides in their industrial spent fuel is retained in interim storage but about one third products, by-products and waste. The most important such of that so far produced has been reprocessed. The estimate facilities involve mining and minerals processing. Besides of the annual collective dose of ionizing radiation due to reprocessing is still in the range of 20–30 man Sv. these, naturally occurring radioactive material can expose

23 REPOR T TO THE GENERAL ASSEMBLY 13 people to ionizing radiation as a result of various normal million, of whom about 13 million are exposed about 22.8 human practices, such as the agricultural use of sludge from to natural sources of radiation and about 9.8 million to artificial sources. Medical workers comprise the largest water treatment or the use of residue as landfill or building per proportion (75 cent) of workers exposed to artificial material. Although doses to the public are low, on the order of sources of radiation. less than a few thousandths of a millisievert, some especially mSv. vulnerable groups could receive doses approaching 1 Radiation A major effort is under way, at both the national and interna- exposure of workers involved in military 54. activities occurs during the production and testing of weap- tional levels, to assess exposure to naturally occurring radio- vessels ons, the operation of reactors for propulsion of naval active material and to develop strategies to address situations and other uses similar to those in the civilian sector. The that give rise to increased radiation exposure. Committee estimates that the worldwide average annual collective dose of ionizing radiation from such sources was about 50–150 man Sv and the average annual worker dose adiation exposures of workers (iii) R was about 0.1–0.2 mSv. However, there is a large degree of U 53. ntil the 1990s, attention in the area of occupational uncertainty in this estimate. exposure—apart from the practices related to the nuclear extraction and processing of radioactive ores that The 55. fuel cycle—focused on artificial sources of radiation. Now, however, it is realized that a very large number of may contain significant levels of natural radionuclides is a widespread activity. The mining sector accounts for the vast workers are exposed occupationally to natural sources of majority of occupationally exposed workers, and radon is radiation as well, and the current estimate of the result- ing collective dose is about three times that indicated in the main source of radiation exposure in underground mines of all types. Table 5 summarizes the exposure to radon in the the Committee’s 2000 report. The total number of workers exposed to ionizing radiation is currently estimated to be workplace. Table 5. Exposure to radon in the workplace Workplace Number of workers (millions) Collective dose (man Sv) Average effective dose (mSv) Coal mines 6 2 .4 .9 16 560 a 4 13 800 3 .0 .6 Other mines Other workplaces 1 4 .8 .25 6 000 2 .9 Weighted average a Excluding uranium mines . The annual collective dose of ionizing radiation to air- 56. energy produced has also fallen steadily over the past three line flight crews is about 900 man Sv. The estimated annual decades (see figure IX). average effective dose is 2–3 mSv. Dose measurements have also been made available for a number of space missions. 1975 and 1989 the annual collective effec- Between 58. The reported doses for short space missions were in the tive dose averaged over five-year periods for all operations range of 1.9–27 mSv. in the nuclear fuel cycle varied little from the average value of 2,500 man Sv despite the three- to four-fold increase in The annual collective dose of ionizing radiation to 57. electrical energy generated by nuclear means. The energy workers involved in the nuclear fuel cycle is estimated to generated has continued to increase, but the average annual be about 800 man Sv. For the fuel cycle overall, the aver- collective effective dose has fallen by almost half, from age annual effective dose is about 1.0 mSv. The average 1,400 man Sv in the period 1990–1994 to 800 man Sv in the annual dose to monitored workers in the nuclear fuel cycle period 2000–2002. has gradually declined since 1975, from 4.4 mSv to 1.0 mSv at present. Much of this decline is because of the significant T he annual collective dose to workers involved in the 59. reduction in uranium mining coupled with more advanced medical use of radiation is estimated to be about 3,540 man Sv; mining techniques; concurrently, the total occupational the average annual effective dose is about 0.5 mSv. The aver - exposure at commercial nuclear power plants divided by the age annual dose to monitored workers involved in medical

24 14 UNSCEAR 2008 REPORT: VOLUME I uses of radiation increased by a factor of 1.7 from 1994 to has increased significantly, the number of workers involved 2002. However, workers involved in interventional procedures in the medical use of radiation increased by a factor of seven have high effective doses; and extremity doses can reach the in the period from 1975 to 2002, and the estimated number regulatory limits. As the number of interventional procedures was about 7.4 million for 2002. . Annual occupational collective dose of ionizing radiation at reactors, normalized to unit electrical energy produced, Figure Ix 1975– 2002 14 12 10 8 6 4 ELECTRICAL ENERGY PRODUCED �man Sv per gigawatt-year electrical� 2 COLLECTIVE EFFECTIVE DOSE PER UNIT 0 1975–1979 1980–1984 1985–1989 1990–1994 1995–1999 2000–2002 SURVEY PERIOD e dose to workers involved in The annual collectiv 60. The trends in average annual occupational effective doses 61. man industrial uses of radiation is estimated to be about 289 are shown in table 6 for the periods 1980– of ionizing radiation Sv, and the average annual effective dose is about 0.3 mSv. 1984, 1990–1994 and 2000–2002. A decrease in the average This represents a decrease from the level of 1.6 mSv in effective dose can be seen for all categories of exposure to arti- 1975. The number of workers involved in industrial uses ficial sources; the sharp decrease in dose for the nuclear fuel of radiation increased by a factor of 1.6 in the period from cycle was due mainly to changes in uranium mining. However, 1975 to 2002; the estimated number was about 0.9 million the overall weighted average effective dose increased because for 2002. of the increased exposure to natural sources of radiation. Table 6. Trends in average annual occupational effective doses of ionizing radiation, 1980–1984, 1990–1994 and 2000–2002 (Millisieverts) Source of exposure 1980–1984 1990–1994 2000–2002 Natural sources . . 1 .8 2 .9 Military activities 0 .7 0 .2 0 .1 Nuclear fuel cycle 1 .8 1 .0 3 .7 Medical uses 0 .6 0 .3 0 .5 Industrial uses 1 .4 0 .5 0 .3 Miscellaneous 0 .3 0 .1 0 .1 1 . 3 weighted average 1.3 1.8

25 REPORT TO THE GENERAL ASSEMBLY 15 (c) Exposures in accidents collective dose from all other accidents causing exposures to the general population. 62. Early acute effects of radiation exposure occur only as the result of accidents (or malicious acts). Some serious acci- 68. The trends in these accidents vary considerably . Criti- cality accidents were more common during the early peri- dents have led to significant population exposures owing to dispersion of radioactive material in the environment. Radia- ods of nuclear weapons programmes. Operational events related to the nuclear fuel cycle are sporadic. Accidents in tion exposures from accidents have been discussed in several industry and in academic or research establishments appear past reports of the Committee, including specific evaluations to have peaked in the late 1970s, falling off to only a few of the Chernobyl accident. The Committee has categorized and summarized reported radiation accidents that resulted isolated occurrences in industry since 2000. The extensive early acute health effects, deaths or major environmental in and worldwide transport of radioactive materials for non- contamination over the past 60 years. military purposes over the past many years has not resulted in any radiation-related injuries at all. Accidents with orphan Accidents associated with the nuclear fuel cycle 63. sources and those related to medical uses of radiation have included a small number of serious accidents that received suffer shown an increase over recent periods but the data may extensive publicity and whose consequences were reported from underreporting. 5 in detail. Between 1945 and 2007, 3 serious radiation acci- dents occurred in nuclear facilities, 2 4 of them in facilities 5 acci- 3 related to nuclear weapons programmes. Of those Comparison of exposures (d) dents, caused resulted in employee deaths or injury and 7 1 3 off-site releases of radioactive materials and significant pop- Although it is clear from the data presented that doses 69. ulation exposures. Excluding the 1986 accident at Chernobyl vary substantially by location, group, health-care level and below), deaths (includ- 32 (which is discussed in section B so on, it is nonetheless helpful and customary to summa- cases of radiation- ing 4 deaths caused by trauma) and 6 1 rize the findings on a global basis (see table 1 above). Expo- related injuries requiring medical care are known to have sure to natural radiation does not change significantly over occurred as a result of accidents associated with the nuclear time, although individual exposures, particularly to radon, fuel cycle. can vary significantly. One of the most striking changes over the past decade or so has been the sharp increase in medi- Large radiation sources are in widespread use in indus- 64. cal exposures, owing for example to the rapid expansion in facilities try (industrial irradiation have or accelerators) and the use of computed tomography scanning. In several coun- attribut- been involved in a number of accidents, usually tries, this has meant that medical exposure has displaced 0 error. All of the 8 in accidents covered able to operator the exposure due to natural sources of radiation as the largest present cause involved sufficient levels of exposure to report overall component. The residual doses from atmospheric radiation-related injuries to workers. Nine deaths and testing and from the Chernobyl accident continue to decline 1 20 those worker injuries were reported in connection with slowly. Although occupational exposure shows a low value accidents. when averaged across the whole population, the estimated level has increased substantially owing to the recognition Orphan sources are radioactive sources that were origi- 65. of exposure to natural radionuclides in mining. Doses from nally subject to regulatory control but were then abandoned, the nuclear fuel cycle continue to be very small despite the lost or stolen. The 34 reported serious accidents involving gradual expansion of that sector. orphan sources caused radiation-related injuries to the pub- people, including a number of children, lic; altogether, 42 died in those accidents. In the accident in Goiânia, Brazil, in Chernobyl accident b. 1987, several hundred people were contaminated. wer The 1986 accident at the Chernobyl nuclear po 70. In radiation medicine, accidents generally involve 66. plant in the former Soviet Union was the most severe such errors in the delivery of radiotherapy that are often detected accident in the history of civilian nuclear power. Two work- only after many patients have been overexposed. The Com- ers died in the immediate aftermath, and 134 plant staff and reported accidents—involving 32 reviewed only mittee has emergency personnel suffered acute radiation syndrome, 6 4 3 injuries—since 1967. It is likely that some deaths and 6 2 which proved fatal for 28 of them. Several hundred thousand deaths and many injuries in the medical use of radiation have workers were subsequently involved in recovery operations. not been reported. Nevertheless, the reported accidents alone appear to have injured more people than accidents in any active 71. The accident caused the largest uncontrolled radio other category. release into the environment ever recorded for any civilian operation; large quantities of radioactive substances were 67. Of the accidents that caused exposures of ionizing radi- released into the atmosphere for about 10 days. The radio- ation to the general population, the 1986 Chernobyl accident active cloud created by the accident dispersed over the entire was by far the most serious one. The collective dose from northern hemisphere and deposited substantial amounts of accident was many times greater than the combined that radioactive material over large areas of the former Soviet

26 16 UNSCEAR 2008 REPORT: VOLUME I The 74. Union and other parts of Europe, contaminating land, water Committee first considered the initial radiologi- 13 cal consequences of the accident in its 1988 report. In its and biota and causing particularly serious social and eco- 2000 report, the Committee provided a detailed account of nomic disruption to large segments of the population in the the situation as it was known at that time. Subsequent to the countries known today as Belarus, the Russian Federation publication of that report, eight organizations and bodies of and Ukraine. Two radionuclides, the short-lived iodine-131 14 (including the Committee) and the United Nations system (with a half-life of 8 days) and the long-lived caesium-137 (with a half-life of 30 years), were particularly significant the three affected States launched the Chernobyl Forum, because of the radiation dose they delivered to the public. which was to generate authoritative consensual statements on the environmental and health consequences attribut- However, the doses delivered were quite different for the two able to radiation exposure and to provide advice on issues radionuclides: the thyroid doses from iodine-131 ranged up such as environmental remediation, special health-care pro- to several grays within a few weeks after the accident, while grammes and research activities. The work of the Chernobyl the whole-body doses from caesium-137 ranged up to a few hundred millisieverts over the following few years. Forum was appraised at an international conference on the theme “Chernobyl: looking back to go forwards; towards a The contamination of fresh milk with iodine-131 and 72. United Nations consensus on the effects of the accident and the lack of prompt countermeasures led to high thyroid doses, the future”, which was held in Vienna on 6 and 7 Septem- particularly among children, in the former Soviet Union. In ber 2005. At that conference, all the previous assessments of the scale and character of the radiation-related health the longer term, mainly due to radiocaesium, the general population was also exposed to radiation, both externally consequences of the accident were essentially reconfirmed. from radioactive deposits and internally from consuming contaminated foodstuffs. However, the resulting long-term The objective of the Committee in the present evalua- 75. radiation doses were relatively low (the average additional tion is to provide an authoritative and definitive review of the 12 dose over the period 1986–2005 in “contaminated areas” health effects observed to date that are attributable to radiation exposure due to the accident and a clarification of the projec- Belarus, the Russian Federation and Ukraine was 9 mSv, of tion of potential effects, taking into account the levels, trends approximately equivalent to that from a medical computed and patterns of radiation dose to the exposed populations. tomography scan), and should not lead to substantial health To that end the Committee evaluated relevant information effects in the general population that could be attributed to that became available since its 2000 report and ascertained radiation. The foregoing notwithstanding, the severe dis- that observations were not inconsistent with assumptions ruption caused by the accident resulted in a major social used previously to assess radiological consequences. It also and economic impact and great distress for the affected recognized that some outstanding details merited further populations. scrutiny and that its work to provide the scientific basis for a better understanding of the radiation-related health and 73. Since the accident, the international community has environmental effects of the accident needed to continue. made unprecedented efforts to assess the magnitude and characteristics of its radiation-related health effects. Many a considerable volume of new research data 76. Although initiatives, including those by the United Nations Educa- has become available, the major conclusions regarding the tional, Scientific and Cultural Organization (UNESCO), the scale and nature of the health consequences of the Cherno- World Health Organization (WHO), the International Atomic byl accident are essentially consistent with the Committee’s Energy Agency (IAEA) and the European Commission, 1988 and 2000 reports. Those conclusions are as follows: were launched to better understand the consequences of the accident and assist in their mitigation. The results of those total of 134 plant staff and emergency work- A (a) initiatives were synthesized at an international conference ers received high doses of radiation that resulted in acute on the theme “One decade after Chernobyl: summing up the radiation syndrome (ARS), many of them also incurring skin consequences of the accident”, which was held in Vienna injuries due to beta irradiation; from 8 to 12 April 1996. The conference was co-sponsored (b) The high radiation doses proved fatal for 28 of by WHO, IAEA and the European Commission in coopera- those people in the first few months following the accident; tion with the United Nations, the United Nations Scientific Committee on the Effects of Atomic Radiation, the Food and 19 ARS survivors had died by 2006, Although (c) Agriculture Organization of the United Nations, UNESCO those deaths had different causes that usually were not and the Nuclear Energy Agency of the Organisation for Eco- associated with radiation exposure; nomic Co-operation and Development. In the international Skin (d) injuries and radiation-related cataracts were scientific assessments, broadly similar conclusions were among the main sequelae of ARS survivors; reached on the extent and character of the consequences of the accident. 13 Official Records of the General Assembly, Forty-third Session, Supple- ment No. 45 (A/43/45). 14 UNEP, Office for the Coordination of Humanitarian Affairs of the Sec- 12 retariat, the United Nations Development Programme, the United Nations The “contaminated areas” were defined arbitrarily by the former Soviet Scientific Committee on the Effects of Atomic Radiation, FAO, WHO, the Union as areas where the soil levels of caesium-137 were greater than 37 kilobecquerels per square metre. World Bank and IAEA.

27 REPOR 17 T TO THE GENERAL ASSEMBLY Ukraine and four of the more affected regions of the Russian A side from the emergency workers, several (e) Federation. For the period 1991–2005, more than 6,000 cases hundred thousand people were involved in recovery were reported, of which a substantial portion could be attrib- operations but, apart from indications of an increase in uted to drinking milk in 1986 contaminated with iodine-131. incidence of leukaemia and of cataracts among those who Although thyroid cancer incidence continues to increase for received higher doses, there is to date no consistent evi- this group (see figure X for the trend in Belarus), up to 2005 dence of health effects that can be attributed to radiation only 15 cases had proved fatal; exposure; (g) Among the general public, to date there has been A (f) substantial increase in thyroid cancer incidence no consistent evidence of any other health effect that can be among persons exposed to the accident-related radiation as attributed to radiation exposure. children or adolescents in 1986 has been observed in Belarus, Figure x. Thyroid cancer incidence among people in belarus who were children or adolescents at the time of the Chernobyl accident, 1986–1990, 1991–1995, 1996–2000 and 2001–2005 15 10 5 �per 100 000 population� CRUDE ANNUAL INCIDENCE 0 001–2005 1986–1990 1991–1995 1996–20002 PERIOD Males Females residents were exposed to low-level radiation comparable to 77. model-based predictions have been pub- Although or a few times higher than the annual natural background lished about possible increases in solid cancer incidence radiation levels and need not live in fear of serious health among the general population, for all the population groups consequences. considered the doses are relatively small and are compar - able to doses resulting from exposure to natural background 79. Committee considers its most recent evalua- The radiation. The Committee has decided not to use models to tion an important point of reference for the United Nations project absolute numbers of effects in populations exposed Coordinator of International Cooperation on Chernobyl in to low doses because of unacceptable uncertainties in the predictions. However, the Committee considers that it is responding to the request by the General Assembly pursu- appropriate to continue surveillance. ant to paragraph 16 of its resolution 62/9 of 20 November 2007, that the Coordinator continue his work in organ- izing, in collaboration with the Governments of Belarus, 78. on 20 years of studies, it is possible to recon- Based Russian Federation and Ukraine, a further study of the firm the conclusions of the Committee’s 2000 report. Essen- the tially, persons who were exposed as children to radioiodine health, environmental and socio-economic consequences of from the Chernobyl accident and the emergency and recov- the Chernobyl disaster, consistent with the recommenda- ery operation workers who received high doses of radiation tions of the Chernobyl Forum, and to improve the provision are at increased risk of radiation-induced effects. Most area of information to local populations.

28 18 UNSCEAR 2008 REPORT: VOLUME I Effects on non-human biota C. non-human biota. There is a considerable range of end points and corresponding effect levels presented in the lit- 80. species present on the Earth have existed and All erature and also considerable variation in how different evolved in environments where they have been exposed researchers evaluate those data. Table 7 provides a brief to ionizing radiation from the natural background. More summary of the relevant data for aggregated categories of recently, however, organisms are also being exposed to organisms. artificial sources of radiation, such as global fallout from atmospheric nuclear weapons tests and, in certain locations, he Committee concluded that, overall, there was no T 83. controlled discharges of radionuclides or accidental releases evidence to support changing the conclusions of its 1996 of radioactive material. report according to which chronic dose rates of less than milligrays per hour to the most highly exposed individ- 0.1 15 the Committee evaluated those 81. In its 1996 report, uals would be unlikely to have significant effects on most doses and dose rates of ionizing radiation below which terrestrial communities and chronic dose rates of less than effects on populations of non-human biota were unlikely. It 0.4 milligrays per hour to any individual in aquatic popu- considered that the individual responses to radiation expo- lations of organisms would be unlikely to have any detri- sure that were likely to be significant at the population level mental effect at the population level. For acute exposures, were in the areas of mortality, fertility, fecundity and the studies of the Chernobyl accident experience had confirmed induction of mutations. The Committee also considered non-human biota that significant effects on populations of that reproductive changes were a more sensitive indicator of were unlikely at doses below about 1 gray. radiation effects than mortality, and that mammals were the most sensitive of all animal organisms. On that basis, the Since the time of the Committee’s 1996 report, a great 84. Committee derived the dose rates to the most highly exposed deal of work has been done to investigate and improve data individuals that would be unlikely to have significant effects and methods for evaluating pathways through which biota on most populations. are exposed to radiation in their environment; there have also been many improvements in assessing doses to biota. then, new data on the effects of ionizing radia- 82. Since It is important to note that many opportunities remain for tion have been obtained from follow-up observations of improving current understanding and methods in those areas. non-human biota in the area around the Chernobyl site. Vari- An improved understanding of such aspects will improve ous organizations have carried out comprehensive reviews the overall understanding of the relationship between levels of the scientific literature and, in some cases, have devel- of radiation and radioactivity in the environment and the oped new approaches for assessing the potential effects on potential effects on biota. Some effects of ionizing radiation on selected categories of non-human biota Table 7. Chronic dose rate Category Effect End point (milligrays per hour) 0 .1-1 Plants Death of pine needles: reduced numbers of herbaceous plants Mortality, morbidity Reproductive damage Fish Reduction in sperm production, delayed spawning Mammals About 0 .1 Morbidity, mortality, reproductive damage No detrimental end points described 15 Official Records of the General Assembly, Fifty-first Session, Supplement No. 46 (A/51/46).

29 AppENdIx I MEMbERS OF NATIONAL dELEGATIONS ATTENdING ThE FIFTIETh TO FIFTy- SIxTh SESSIONS OF ThE UNITEd NATIONS SCIENTIFIC COMMITTEE ON ThE EFFECTS OF AS ELAbORATEd ATOMIC RAdIATION, AT whICh ThE 2008 SCIENTIFIC REpORT w A. J. González (Representative), D. Beninson (Representative), P. Gisone (Representative), Argentina M. del Rosario Pérez Australia P. A. Burns (Representative), S. Solomon, P. Thomas Belgium H. Vanmarcke (Representative), H. Bosmans, A. Debauche, H. Engels, J. Lembrechts, J. R. Maisin Wambersie, H. Bijwaard, R. O. Blaauboer, (Representative), P. Smeesters, J. M. Van Dam, A. M. J. Brugmans Brazil O. Dias Gonçalves (Representative), J. L. Lipsztein (Representative), M. C. Lourenço, M. Nogueira Martins, D. R. Melo (Representative), E. R. Rochedo N. E. Gentner (Representative), R. P. Bradley, K. Bundy, D. B. Chambers, R. M. Chatterjee Canada (Representative), R. Whillans J. Cornett, R. Lane, C. Lavoie, S. Vlahovich (Representative), D. Pan Z. (Representative), He Q., Hou P., Jia J., Li K., Li J., Liu S., Liu Q., Lu J., Pan S., Shang B., China Y., Yang G., Yang H., Yang X., Yu J., Zhang J., Zhu M. Shi J., Su X., Sun J., Sun Q., Wang F., Xiu B., Xuan Egypt M.A.M. Gomaa (Representative), A. M. el-Naggar (Representative) A. Flüry-Hérard (Representative), E. Ansoborlo, A. Aurengo, D. Averbeck, M. Benderitter, France M. Bourguignon, C. Forestier, J. F. Lacronique (Representative), J. Lallemand, J. J. Leguay, C. Luccioni, R. Maximilien, A. Rannou, M. Tirmarche Germany W. Weiss (Representative), A. Friedl, P. Jacob, A. Kellerer, J. Kiefer, G. Kirchner, W. Köhnlein, R. Michel, W. U. Müller, C. Streffer (Representative) India K. B. Sainis (Representative) Indonesia Z. Alatas (Representative), K. Wiharto (Representative) Japan O. Niwa (Representative), Y. Yonekura (Representative), T. Asano, M. Doi, Y. Ishikuro, A. Iwama, K. Kodama, H. Kuniyoshi, T. Maeyama, M. Nakano, Y. Nakayama, S. Saigusa, K. Sakai, M. Sasaki, Sasaki (Representative), K. Sato, G. Suzuki, H. Tatsuzaki, S. Yoshinaga, M. Yoshizawa Y. Mexico H. Maldonado (Representative) L. V. Pinillos Ashton (Representative) Peru Poland W M. aligórski (Representative), L. Dobrzy ń ski, M. Janiak, Z. Jaworowski (Representative) Russian Federation M. Kiselev (Representative), A. Akleev, R. M. Alexakhin, T. Azizova, N. P. Garnyk, A. K. Guskova (Representative), L. A. Ilyin (Representative), V. K. Ivanov, K. Kotenko, I. I. Kryshev, B. K. Lobach, Y. Mokrov, O. A. Pavlovsky, T. S. Povetnikova, S. Romanov, M. N. Savkin, V. A. Shevchenko, S. Shinkarev Slovakia E. Bédi (Representative), P. Gaál, V. Klener, P. Ragan, L. Tomášek, D. Viktory (Representative), Zachariášová I. A. Elgaylani (Representative), K.E.H. Mohamed (Representative) Sudan M. Larsson (Representative), A. Almén, L. E. Holm (Representative), L. Moberg C. Sweden United Kingdom of R. Cox (Representative), S. Bouffler, R. H. Clarke (Representative), J. Cooper, S. Ebdon-Jackson, Great Britain and G. M. Kendall, T. McMillan, C. Muirhead, R. Paynter, P. Shrimpton, J. W. Stather Northern Ireland United States of F. A. Mettler Jr. (Representative), L. R. Anspaugh, B. G. Bennett, J. D. Boice Jr., N. H. Harley, V. Holahan Jr., C. B. Meinhold, R. J. Preston, H. Royal, P. B. Selby, A. G. Sowder, A. Upton America E. 19

30 20 UNSCEAR 2008 REPORT: VOLUME I ationS Scientific committee Secretary of the United n on the effectS of atomic radiation N. E. Gentner (fiftieth to fifty-second sessions) M. J. Crick (fifty-third to fifty-sixth sessions) AppENdIx II SCIENTIFIC STAFF ANd CONSULTANTS COOpERATING wITh ThE UNITEd NATIONS SCIENTIFIC COMMITTEE ON ThE EFFECTS OF A TOMIC RAdIATION IN ThE pREp ARATION OF ThE 2008 SCIENTIFIC REpORT OF ThE COMMITTEE M. Balonov D. B. Chambers K. Faulkner G. Howe G. Ibbott G. Kirchner D. Melo R. Ricks E. Rochedo M. Stabin G.A.M. Webb D. Woodhead

31 Corrigendum to Sales No. E.10.XI.3 May 2011 d Effects o f Ionizing Ra diation: U nited Na Sources an tions Scientific Committee on t he Effects of Atomi c Radiation cientific 2008 Report to the Genera l Assembl y, with S Annexes— Volume I Co rrigendum 1. Annex A (“Medical radiation exposures”), page 172, figure D-II The title should read Representative isodose distributions: Intensity-modulated radiation therapy plan f r, showing superior conformation of the 50 Gy isodose line to or a prostate tumou the planning target volume Annex B (“Exposures of the public and workers fr om various sources of 2. radiation”), para graph 155 The paragraph should read 155. . Mining operations have been carried out in open Effluents and solid waste p its, in underground mines and by in situ leaching. Uranium mill tailings are ore extracted, and they generally retain generated at about one tonne per tonne of 5–10% of the uranium and 85% of the total activity [V4]. The estimated amounts of 9 t. Besides tailings worldwide are shown in figure XVII; they total about 2.35 × 10 ecome a source of public exposure. For the tailings, waste rock piles may also b open-pit mining, the amount of debris produced is from 3 to 30 tonnes per tonne of extracted ore. For underground mining, a bout ten times less debris is produced. rgentina [R13], On the basis of information provided for 13 mining sites in A 29], the amount of waste rock varies Canada [M28], Germany [F2] and Spain [S from 40 to 6,000 times the amount of tailings, with an average value of about 1,600 tonnes of waste rock per tonne of tailings [I38]. V. 11-80527 (E) *1180527*

32

33 ANNEx A MEDICAl RADIATION ExPOSURES CONTENTS Page 23 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MEDICAl ExPOSURE TO IONIZING RADIATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 I . INTRODUCTION 23 II . SCOPE AND BASIS FOR THE ANAlySIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MEDICAl RADIATION ExPOSURE III . OG y AND SOURCES OF DATA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 IV . METHODOl ASSESSMENT OF Gl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 V . OBAl PRACTICE Diagnostic radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 A . B . Nuclear medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 C . 30 Radiation therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 IMPlICATIONS FOR THE FUTURE ANAlySIS OF MEDICAl ExPOSURES VI . SUMMARy AND CONCl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 VII . USIONS OG y FOR ESTIMATING WORlDWIDE MEDICAl ExPOSURES . . . . . . . . . . . . . . . . . . . . . . . 37 APPENDIx A: METHODOl INTRODUCTION 37 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . M ETHODOl OG y FOR ANAlySIS OF DOSIMETRy IN DIAGNOSTIC AND INTERVENTIONAl RADIOl OG y . . . . . . . 38 II . A . Projection radiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 B . Fluoroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Mammography D . CT dosimetry 44 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Dental panoral tomography F . Dual-energy absorptiometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 III . OG y FOR ANAlySIS OF DOSIMETRy IN NUClEAR MEDICINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 METHODOl A . Dosimetric approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 IV . METHODOl OG y FOR ANAlySIS OF DOSIMETRy IN RADIATION THERAPy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 APPENDIx B: lEVElS AND TRENDS OF ExPOSURE IN DIAGNOSTIC RADIOl OG 49 y . . . . . . . . . . . . . . . . . . . . . . . . . . . . SUMMARy FROM UNSCEAR 2000 REPORT 49 I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II . y PROCEDURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 DOSES FOR SPECIFIC x-RA A . Diagnostic radiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 B . Mammography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 C . Fluoroscopy and angiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 D . Interventional radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 53 E . Interventional cardiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

34 Page Computed tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 F . G . Dental radiology 55 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bone mineral densitometry and dual-energy x-ray absorptiometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 H . 56 DOSES FOR SPECIFIC POPUlATIONS III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paediatric patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 A . B . Foetal dosimetry 57 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 TRENDS IV . A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Trends in practice B . Trends in patient doses 62 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Survey results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 C . SUMMARy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 V . 139 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . APPENDIx C: lEVElS AND TRENDS OF ExPOSURE IN NUClEAR MEDICINE INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 I . ANAlySIS OF PRACTICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 II . DOSES FOR SPECIFIC NUClEAR MEDICINE PROCEDURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 III . A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 Diagnostic uses B . Therapeutic uses 143 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV . DOSES FOR SPECIFIC POPUlATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 A . Paediatric patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Foetal dosimetry C . The breast-feeding infant 144 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SURVEy 145 V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VI . SUMMARy 145 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 APPENDIx D: lEVElS AND TRENDS IN THE USE OF RADIATION THERAPy INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 I . II . TECHNIqUES 170 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SUMMARy FROM THE UNSCEAR 2000 REPORT 175 III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DOSIMETRIC APPROACHES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 IV . V . 177 ANAlySIS OF PRACTICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A . Frequency of treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 B . Exposed populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 Doses from treatments D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Assessment of global practice TRENDS IN RADIATION THERAPy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VI . 180 A . Teletherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 B . Brachytherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Other modalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 C . VII . ACCIDENTS IN RADIATION THERAPy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 184 . SUMMARy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VIII References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 22

35 MEdICAL ExpOSURE TO IONIZING RAdIATION I. INTROdUCTION of the UNSCEAR 2006 Report [U1]) and accidental expo- The objective of the past reports of the Scientific Com- 1. C, “Radiation exposures in accidents”, of the sure (annex mittee [U3, U4, U6, U7, U9, U10] with respect to medical UNSCEAR 2008 Report). exposures has been to establish the annual frequency of medical examinations and procedures involving the use of Exposure of the public resulting from contact with 3. radiation, as well as their associated doses. Reviews have patients undergoing either treatment or a diagnostic proce- been performed of practice in diagnostic radiology, in the dure that uses sealed or unsealed radionuclides is considered use of nuclear medicine and in radiation therapy. Data have in annex B, “Exposures of the public and workers from vari- been analysed to deduce temporal trends, to evaluate the ous sources of radiation”, of the UNSCEAR 2008 Report. collective population dose due to medical exposure, and to That annex also addresses exposures of the public arising identify procedures for which the doses are major contribu- from the disposal of radioactive waste from hospitals and the tors to the total collective dose. In earlier UNSCEAR reports production of radionuclides for medicine. on doses from medical irradiation [U10, U11], the annual frequency of medical exposures was estimated on the basis 4. Occupational exposure resulting from work involving of a very limited series of surveys, mainly but not exclu- the medical use of radiation occurs for persons administer- sively performed in developed countries. Initially informa- ing the radiation to the patient or in some circumstances for tion was obtained under broad headings such as diagnostic B also examines such occupational persons nearby. Annex radiography or diagnostic fluoroscopy [U11]. exposure in detail. The purpose of this annex is to assess the magnitude 2. This annex presents a comprehensive up-to-date review 5. of use of medical exposures around the globe in the period of medical exposures to ionizing radiation. This review is 1997–2007, to determine the relative contribution to dose based in part on an analysis of the responses to the UNSCEAR from various modalities and procedures, and to assess trends. Global Survey of Medical Radiation Usage and Exposures It is not within the mandate of the Committee to assess and a critical assessment of the published literature on medi- potential benefits from medical exposure. Documented detri- cal exposures. The purpose of this annex is to estimate the mental effects resulting from medical exposures have been annual frequency (number of examinations per fixed number covered in other reports of the Committee and their associ- of people) of diagnostic and therapeutic medical procedures ated scientific annexes, for example those on carcinogenesis and the doses associated with them. A, “Epidemiological studies of radiation and cancer”, (annex SCOpE ANd bASIS FOR ThE ANAL ySIS II. 8. Medical exposures typically involve only a portion of the 6. Medical exposures include [I3]: (a) the exposure of body, whereas many other exposures involve the whole body. patients as part of their medical diagnosis or treatment; In addition, many persons who are exposed are not typical of the exposure of individuals as part of health screening (b) the general population. Their average age is usually somewhat (c) the exposure of healthy individuals or programmes; higher and they have medical conditions that may significantly patients voluntarily participating in medical, biomedical, affect the trade-off between the benefits and the risks of using diagnostic or therapeutic research programmes. radiation. In contrast, the introduction of new imaging techno- logies has in some instances resulted in increased use of paedi- There are substantial and distinct differences between 7. atric radiology, influencing the age profile for the examinations medical exposure to radiation and most other exposures to performed. As a result of the above considerations, while the radiation. Medical exposure is almost always voluntary and magnitude of medical exposures can be examined, it is very dif- is generally accepted to bring more benefits than risks. In ficult or impossible to estimate the risks of adverse effects due many developing countries, increasing the availability of estimates to medical uses, still less to defensibly compare such appropriate medical procedures that use ionizing radiation with those for other sources of exposure to radiation. results in a net health benefit. 23

36 24 UNSCEAR 2008 REPORT: VOLUME I III. MEdICAL RAdIATION ExpOSURE Nuclear medicine refers to the introduction of unsealed 11. 9. There are three general categories of medical practice radioactive materials into the body, most commonly to involving exposure to ionizing radiation: diagnostic radio- obtain images that provide information on either struc- logy (and image-guided interventional procedures), nuclear ture or organ function. The radioactive material is usually medicine and radiation therapy. given intravenously, orally or by inhalation. A radionuclide is usually modified to form a radiopharmaceutical that will Diagnostic radiology generally refers to the analysis of 10. be distributed in the body according to physical or chemi- images obtained using X-rays. These include plain radiographs cal characteristics (for example, a radionuclide modified as (e.g. chest X-rays), images of the breast (i.e. mammo graphy), a phosphate will localize in the bone, making a bone scan images obtained using fluoroscopy (e.g. with a barium meal possible). Radiation emitted from the body is analysed to or barium enema) and images obtained by devices using produce diagnostic images. Less commonly, unsealed radio- computerized reconstruction techniques such as computed nuclides are administered to treat certain diseases (most fre- tomography (CT). In addition to their use for diagnosis, quently hyperthyroidism and thyroid cancer). There is a clear interventional or invasive procedures are also performed in trend towards increased therapeutic applications in modern vessel to obtain hospitals (e.g. placing a catheter in a blood nuclear medicine. images). For the purposes of this annex, such uses are con- sidered to be diagnostic exposures. Some of the procedures Radiation therapy refers to the use of ionizing radia- 12. mentioned above are not always performed by diagnostic tion to treat various diseases (usually cancer). Sometimes including others, radiologists but may also be performed by radiation therapy is referred to as radiation oncology; general medical physicians, cardiologists and orthopaedic however, benign diseases also may be treated. External surgeons, whose training in radiation protection may not be radiotherapy refers to treatment of the patient using a as thorough as that of diagnostic radiologists. Physicians also radiation source that is outside the patient. This may be use imaging technologies that do not employ ionizing radia- a machine containing a highly radioactive source (usually imaging tion, such as ultrasound and magnetic resonance cobalt-60) or a high-voltage machine that produces radia- (MRI). Dental radiology has been included in the analysis tion (e.g. a linear accelerator). Treatment can also be per - conducted here of diagnostic radiology practice; however the formed by placing metallic or sealed radioactive sources terms “diagnostic dental radiology” and “diagnostic medical within the patient (brachytherapy). These may be placed distinguish dental radiology” (mutatis mutandi) are used to either temporarily or permanently. exposures from other diagnostic exposures. METhOdOLOG ATA IV. y ANd SOURCES OF d data in previous reports had been based upon surveys in a 13. Evaluation of medical exposures consists of assessing limited number of countries. Data from five continents were the annual frequency and types of procedure being under- presented in the UNSCEAR 1982 Report [U9], which was taken, as well as an evaluation of the radiation doses for also the first UNSCEAR survey to include an assessment of each type of procedure. Annual frequency and dose data are exposures from CT. derived from three main sources: the peer-reviewed scien- tific literature, official reports provided by member States, The four-level health-care model for the analysis of 15. and the Surveys of Medical Radiation Usage and Exposures medical exposures was introduced in the UNSCEAR 1988 conducted by the secretariat on behalf of the Committee. As Report [U7] and has been used in the Committee’s subse- in previous reports, annual frequency data on procedures are quent reports. In this model, countries were stratified accord- stratified by health-care level (level I, II, III or IV), which are ing to the number of physicians per head of population. based on the number of physicians per head of population. I countries were defined as those in which there was Level The number of physicians per head of population has been at least one physician for every 1,000 people in the general shown to correlate well with the number of medical exami- II countries there was one physician population; in level nations performed using ionizing radiation [M39, M40]. III countries there for every 1,000–2,999 people; in level This allows extrapolation to those countries for which the was one physician for every 3,000–10,000 people; and in Committee has limited or no data. IV countries there was less than one physician for every level 10,000 people [U7]. The UNSCEAR 1982 Report [U9] was the first to use a 14. survey, developed by WHO in cooperation with UNSCEAR, 16. The Committee also explored other approaches to the to obtain information on the availability of diagnostic radio- classification of health-care levels, for example by health- logy equipment and the annual frequency of diagnostic X-ray care expenditure or number of hospital beds. However, it examinations in various countries. Examination frequency

37 25 ANNEX A: MEDICAL RADIATION EXPOSURES responses have been received from countries defined by the was found that there was a poor correlation between values I countries, which represent Committee as health-care level for these parameters and the number of medical radiation procedures. Subsequent reports have therefore continued to under a quarter of the world’s population. use the four-level health-care model based upon the number of physicians per head of population [U3, U6]. Over the As annual frequency data were only available from 18. years this model has proved to be robust in estimating those countries that undertake surveys of practice, the analysis of medical exposures has necessarily been based on extrapo- medical radiation exposures. One of the main advantages of the model is that it provides a consistent basis for the lating data from the fraction of countries where data were reported to all other countries in a given health-care level. extrapolation of practice in a small sample of countries to Data on doses were also collected by survey and compared the entire world. It also facilitates the comparison of trends with those in the published literature. For each procedure, the in medical exposures over time [U7]. Consequently this health-care model has been used in the present analysis of number of procedures per head of population is multiplied by worldwide exposure. the effective dose per procedure and the relevant population size (i.e. population size for the respective health-care level). The collective effective dose (or population dose) for the 17. In order to evaluate the level of medical exposures worldwide, the UNSCEAR secretariat conducted a Survey global population is then deduced by performing the above of Medical Radiation Usage and Exposures by circulating calculation for all procedures across all health-care levels and summing the result for all procedures. The Committee also a questionnaire to all Member States of the United Nations. examines trends over time for various procedures, as well as The Committee bases its estimation of medical exposures upon an analysis of the questionnaire returns. Most of the trends over time in the global collective effective dose. V. ASSESSMENT OF GLObAL pRACTICE A. diagnostic radiology there has been a gradual increase in its use. New types of tal imaging device are being introduced to the market- digi 19. The medical use of ionizing radiation remains a rap- place. These systems utilize a large-area direct digital detec- idly changing field. This is in part because of the high level tor for imaging and offer many advantages, one of which of innovation by equipment supply companies [W1] and the in principle is a lower dose per image compared with other introduction of new imaging techniques such as multislice devices. Thus there could be another era of rapidly chang- CT and digital imaging. ing practice in diagnostic radiology over the course of the next UNSCEAR Global Survey of Medical Radiation 20. In the UNSCEAR 2000 Report [U3] it was noted that Usage and Exposures. This will initially influence popula- 34% of the collective dose due to medical exposures arose I countries for radiographic tion doses in health-care level from CT examinations. As a consequence, the increasing and fluoroscopic examinations before the practice widely trend in annual CT examination frequency and the signifi- influences population doses in countries at other health-care cant dose per examination have an important impact on levels. Population doses due to digital radiology will prob- the overall population dose due to medical exposures. The ably increase as a result of an increasing frequency of digital contribution of CT examinations to the population dose has imaging examinations and procedures. continued to increase rapidly ever since the practice was introduced in the 1970s. In the area of CT examinations, the According to the current analysis, there are approxi- 22. introduction of helical and multislice scanning has reduced billion diagnostic radiology X-ray examinations mately 3.6 scan times [I28]. As a consequence, it is now possible to per- (including diagnostic medical and dental examinations) form more examinations in a given time, to extend the scope undertaken annually in the world. Figure I presents trends of some examinations, and to introduce new techniques in the annual frequency of diagnostic medical and dental and examinations. The ease of acquisition of images could radiological examinations for each health-care level. result in unnecessary exposures of patients to radiation. This, combined with the increase in the number of machines, has The 24% of the population living in health-care level 23. I a significant impact on population doses, particularly for countries receive approximately two thirds of these exami- I. An accurate countries with health-care systems at level nations. The annual frequency of diagnostic medical exami- assessment of medical exposures due to CT scanning is nations alone (defined here as excluding dental radiology) in therefore particularly important. health-care level I countries is estimated to have increased from 820 per 1,000 population in 1970–1979 to 1,332 per Digital imaging is another area of diagnostic radiology 21. 1,000 population in this survey. Comparative values for that has seen striking changes [I8]. Digital imaging using health-care level II countries exhibit an even greater relative photostimulable storage phosphor devices was introduced increase, from 26 per 1,000 in 1970–1979 to 332 per 1,000 in into clinical practice in the 1980s. Since its introduction, 1997–2007. Most of the increase for level I and II countries

38 26 UNSCEAR 2008 REPORT: VOLUME I occurred in the period 1997–2007. The estimated annual this period, although since there were limited data for these countries, there is considerable uncertainty associated with frequency of diagnostic medical examinations in health- care level III/IV countries has remained fairly constant over this estimate. Figure I. Trends in the annual frequency of diagnostic medical and dental radiological examinations for each health-care level 1 800 1 600 1 400 1 200 1 000 800 600 PER 1 000 POPULATION NUMBER OF EXAMINATIONS 400 200 0 III I II IV HEALTH�CARE LEVEL 1985–1990 1991–1996 1997–2007 1970–1979 1980–1984 are over 66 times more frequent in health-care level I countries 24. CT scanning accounts for 7.9% of the total number of (where 24% of the global population live) than in health-care I coun- diagnostic medical examinations in health-care level level III and IV countries (where 27% of the global population II countries and just tries, just over 2.0% in health-care level live). The change in annual frequency of diagnostic medical under 14% in health-care level III/IV countries. However, the examinations reflects changes in population demographics, as contribution of CT scanning to the total collective effective most medical exposures are performed on older individuals. dose due to diagnostic medical examinations is approximately Globally, on average there are just over 488 diagnostic medical 47% in health-care level I countries, and 15% and 65% in examinations and 74 dental examinations per 1,000 population. health-care level II and III/IV countries, respectively (there is The wide imbalance in health-care provision is also reflected in great uncertainty in the doses and frequencies for health-care the availability of X-ray equipment and of physicians. Global level III/IV countries). According to this UNSCEAR Survey of Medical Radiation Usage and Exposures, CT scan- collective effective dose ning accounts for 43% of the total Figure II. Variation in the annual frequency of diagnostic due to diagnostic medical radiology. medical and dental radiological examinations for the respective health-care levels and the global average (1997–2007) For diagnostic dental examinations, the annual fre- 25. 1 400 quency has remained fairly constant for health-care level I 1 332 countries, being 275 per 1,000 population in this survey, com- 1 200 pared with 320 per 1,000 population in the 1970–1979 survey. 1 000 Over this period, there has been a substantial increase in the annual frequency of diagnostic dental examinations in health- 800 II countries, rising from 0.8 per 1,000 population in care level 600 1980–1984 to 16 per 1,000 population in the current survey. 488 400 332 275 Figure II summarizes the variation in annual frequency 26. PER 1 000 POPULATION 200 74 NUMBER OF EXAMINATIONS of diagnostic medical and dental radiological examinations 20 16 3 0 for each health-care level, as found in the current UNSCEAR Global I II III–IV Global Survey of Medical Radiation Usage and Exposures. Also shown in figure II are the global averages. There are wide HEALTH�CARE LEVEL variations in the frequency of diagnostic medical and dental Dental Medical examinations. For example, diagnostic medical examinations

39 ANNEX A: MEDICAL RADIATION EXPOSURES 27 Variation in the annual per caput effective dose Figure IV. The variation in the annual collective effective dose 27. from diagnostic medical and dental radiological examinations between health-care levels for diagnostic medical and dental for the respective health-care levels and the global average radiological examinations is summarized in figure III. Den- (1997–2007) tal exposures account for less than 1% of the collective dose. On average, over 70% of the total collective effective dose is billion individuals living in health-care received by the 1.54 2.00 1.92 I countries. The annual collective effective dose to the level 1.80 population of health-care level I countries from diagnostic 1.60 Sv, medical examinations is estimated to be 2,900,000 man 1.40 Sv to the population of health-care with 1,000,000 man 1.20 level Sv to the population of health- II countries, 33,000 man 1.00 Sv to the population care level III countries and 24,000 man 0.80 0.62 of health-care level IV countries. The total annual collec- 0.60 tive effective dose to the global population from diagnostic 0.40 0.32 PER CAPUT DOSE �mSv� medical exposures is estimated to be 4,000,000 man Sv. 0.20 0.03 0.00 Variation in the annual collective effective dose from Figure III. Global II I III–IV diagnostic medical and dental radiological examinations for the HEALTH�CARE LEVEL respective health-care levels and the global total (1997–2007) 4 500 000 28. Figure IV shows the annual per caput effective dose 4 000 000 for the various health-care levels and the average value 3 500 000 mSv) from diagnostic across the global population (0.62 3 000 000 medical and dental radiological examinations. Temporal 2 500 000 trends in the annual frequency of diagnostic dental radi- 2 000 000 �man Sv� ological examinations have been obtained and are shown 1 500 000 mil- V. Worldwide there are an estimated 480 in figure 1 000 000 lion diagnostic dental examinations performed annually. 500 000 COLLECTIVE EFFECTIVE DOSE I countries. Almost all of these are undertaken in level 0 The contribution of dental examinations to annual per II I III–IV Global caput or collective effective dose is very small (much less than 1%). However, the number of dental examinations HEALTH�CARE LEVEL under-reported and the availability of equipment may be Medical Dental in many countries. Figure V. Trends in the annual frequency of dental radiological examinations for each health-care level 450 400 350 300 250 200 150 100 PER 1 000 POPULATION NUMBER OF EXAMINATIONS 50 0 IV II I III HEALTH�CARE LEVEL 1997–2007 1991–1996 1980–1984 1970–1979 1985–1990

40 28 UNSCEAR 2008 REPORT: VOLUME I For diagnostic dental radiology the collective effective (see table 1). Since the previous survey [U3], there has been 29. dose to the population of health-care level a rise of approximately 1,700,000 I countries is esti- man Sv. This increase mated to be 9,900 Sv, with 1,300 Sv, 51 man man man Sv results in part from an increase in the annual frequency of diagnostic medical and dental radiological examinations man and 38 Sv being received by the populations of health- (from 1,230 per 1,000 population to 1,607 per 1,000 popu- care level II, III and IV countries, respectively. The total lation in health-care level I countries; from 168 per 1,000 annual collective effective dose to the global population II population to 348 per 1,000 population in health-care level from diagnostic dental radiology is 11,000 man Sv. countries; and from 20 per 1,000 population to 23 per 1,000 population in health-care level In the period 1997–2007 covered by the 2008 UNSCEAR III/IV countries), an increase 30. Report, the estimated annual collective effective dose to the in the per caput effective dose per examination (from 0.4 to world population from diagnostic medical and dental radio- 0.62 mSv) and an increase in the global population (from Sv logical examinations is estimated to be 4,000,000 5,800 million to 6,446 million). man Estimated annual per caput dose and annual effective dose to the world population from diagnostic medical and Table 1. dental radiological examinations (1997–2007) Population (millions) Annual collective effective dose (man Sv) Health-care level Annual per caput dose (mSv) Medical Dental Medical Dental 1 540 1 .91 I 2 900 000 9 900 0 .006 4 II 3 153 0 .32 0 .000 4 1 000 000 1 300 III 1 009 0 .03 0 .000 051 33 000 51 IV 744 0 .000 051 24 000 38 0 .03 6 446 0 .002 4 000 000 11 000 0 .62 Global 31. Trends in dose for selected diagnostic medical exami- relatively high-dose procedure, has decreased only slightly 2. It is clear that doses for two nations are shown in table since the previous survey. However, the nature of CT scan- typical radiological examinations (chest radiography and ning has changed over the years. In the 1970–1974 survey, mammography) have been decreasing significantly. On the only head scans were included; now most CT examinations other hand, the dose from a CT examination, which is a are of other parts of the body. Trends in average effective doses resulting from selected diagnostic medical examinations in countries of Table 2. health-care level I Average effective dose per examination (mSv) Examination 1970–1979 1980–1990 1991–1996 1997–2007 Chest radiography 0 .25 0 .14 0 .14 0 .07 Abdomen x-ray 1 .9 0 .53 0 .82 1 .1 1 .8 1 Mammography 0 .26 0 .51 CT scan 1 .3 4 .4 8 .8 7 .4 Angiography 9 .2 6 .8 12 9 .3 Nuclear medicine b. receive about 90% of all nuclear medicine examinations. The annual frequency of diagnostic nuclear medicine exami- There are approximately 33 million diagnostic nuclear 32. nations in health-care level I countries is estimated to have medicine examinations performed annually worldwide. increased from 11 per 1,000 population in 1970–1979 to 19 I countries The 24% of the global population living in level per 1,000 in this survey. Comparative values for health-care

41 29 ANNEX A: MEDICAL RADIATION EXPOSURES level II countries also exhibit an increase, from 0.9 per 1,000 33. In the period covered by the 2008 UNSCEAR Report, population in 1970–1979 to 1.1 per 1,000 in 1997–2007. the annual collective effective dose to the world popula- For therapeutic nuclear medicine procedures, according to tion due to diagnostic nuclear medicine examinations is Sv. The trend in the annual estimated to be 202,000 man the global model, the annual frequency of nuclear medicine collective effective dose from diagnostic nuclear medicine I countries has increased from treatments in health-care level examinations over the last three surveys is summarized in 0.17 per 1,000 population in 1991–1996 to 0.47 per 1,000 in this survey, consistent with the trend towards more therapeu- VIII. There has been an increase in collective dose figure II of nearly 50,000 man Sv, a rise of just over a third since tic applications. Comparative values for health-care level countries exhibit an increase from 0.036 per 1,000 popula- the last report. The increase in the global collective effec- tion in 1991–1996 to 0.043 per 1,000 in 1997–2007. Fig- tive dose from diagnostic nuclear medicine examinations results from three factors: an increase of nearly a third in the VI and VII present summaries of the annual frequencies ures of nuclear medicine examinations for the respective health- mSv in the average effective dose per procedure (from 4.6 UNSCEAR 2000 Report to the present estimate of 6.0 care levels and average annual numbers of examinations for mSv) and an increase in the annual number of diagnostic nuclear each time period considered, respectively. medicine examinations to the world population. The annual collective effective dose for the respective health-care levels is shown in figure IX. Annual frequency of diagnostic nuclear medicine Figure VI. examinations for the respective health-care levels and the global average (1997–2007) Trend in the annual collective effective dose Figure VIII. from diagnostic nuclear medicine examinations 20 19 18 250 000 16 14 202 000 200 000 12 160 000 10 150 000 150 000 8 6 5.1 100 000 4 PER 1 000 POPULATION NUMBER OF EXAMINATIONS 2 1.1 0.02 50 000 0 COLLECTIVE DOSE �man Sv� Global III–IV II I 0 HEALTH�CARE LEVEL 1985–1990 1991–1996 1997–2007 Annual collective effective dose from diagnostic Figure IX. Annual number of diagnostic nuclear medicine Figure VII. nuclear medicine examinations for the respective health- examinations care levels and the global total (1997–2007) 35 32.7 32.5 250 000 30 202 000 200 000 24 186 000 25 20 150 000 15 �millions� 100 000 10 50 000 NUMBER OF EXAMINATIONS 5 16 000 82 0 0 COLLECTIVE EFFECTIVE DOSE �man Sv� 1985–1990 1991–1996 1997–2007 II I III–IV Global UNSCEAR SURVEY HEALTH�CARE LEVEL

42 30 UNSCEAR 2008 REPORT: VOLUME I C. Radiation therapy of various types of treatment for each health-care level is shown in table 3. The 24% of the world population in the Worldwide in 1991–1995, approximately equal num- 34. level I countries received approximately three-quarters of all bers of radiation therapy patients were treated using X-ray radiation therapy treatments. machines, radionuclide units and linear accelerators [U3]. Insufficient data were received for the period 1997–2007 35. In the period 1997–2007, the global use of radiation to estimate the numbers of patients treated with each type therapy increased to 5.1 million treatments, from 4.7 million of treatment device. The availability of linear accelerators treatments in 1991–1996. About 4.7 million patients were machines per million population. worldwide was about 1.6 treated with external beam radiation therapy, while 0.4 mil- The availability of X-ray machines and of cobalt units was lion were treated with brachytherapy. The number of lin- I countries, about equal, 0.4 per million population. In level ear accelerator treatment units increased to about 10,000 however, the availability of treatment equipment was con- worldwide, from about 5,000 in the previous period. A siderably greater than the world average (for example, there large increase was seen in level I countries. Level II coun- were 5.4 linear accelerators per million population). The tries appeared to show a decrease, but this is likely to be an total number of treatment machines also varied from one artefact of the limited data received from the survey. At the health-care level to another. The numbers of patients treated same time, the number of brachytherapy treatments and the in different countries varied in approximate proportion to number of afterloading brachytherapy units appeared to have the availability of treatment equipment. The annual number changed very little. a Table 3. Estimated annual number of radiation therapy treatments in the world (1997–2007) Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Population Annual number of all radiotherapy Annual number of teletherapy Health-care level Annual number of brachytherapy b treatments treatments treatments (millions) Per 1 000 Millions Millions Per 1 000 000 Millions Per 1 population population population 1 540 3.5 I 0.18 0.12 3.6 2.4 2.2 II 3 153 1.2 0.4 0.20 0.06 1.4 0.4 c c III (<0.05) 1 009 (<0.01) 0.06 0.1 0.06 0.06 c c c c c c (<0.01) (<0.005) 744 (0.03) IV (0.01) (<0.01) (0.03) d 6 446 4.7 0.73 0.4 0.07 5.1 0.8 World a Complete courses of treatment. b Excluding treatments with radiopharmaceuticals. c Assumed value in the absence of data. d Global data include several countries not represented by levels I–IV. VI. ImplICATIons FoR ThE FuTuRE AnAlysIs oF mEdICAl EXposuREs questionnaire, taking into account feedback from those col- 36. Because of the introduction of new techniques and lecting, analysing or using the data. Comprehensive data equipment and the ever-increasing use of radiation in medi- from less industrialized countries are difficult to obtain, cine, it is important to continue to assess the doses result- but given the large populations of these areas, the Com- ing from medical exposure to radiation [O2]. At present it mittee would encourage those countries to develop their appears that the world is entering another period of major programmes to assess medical uses and exposures. technological changes, where the impact of these changes on the population dose worldwide in the future will be very Just under half of the collective effective dose due 38. difficult to predict. The introduction of the new technologies to diagnostic radiology arises from three procedures: CT, may also affect the age profile of the exposed population. angiographic examinations and interventional radiology. Therefore accurate comprehensive data on these proce- The present questionnaire that the Committee has used 37. dures would improve the estimation of population dose. For to collect information is quite detailed and asks for much diagnostic nuclear medicine, the main contributions to the more information than most countries routinely collect, 99m 201 collective effective dose arise from Tc bone scans, Tl and this may have discouraged some responses. For future cardiovascular studies and iodine thyroid scans. surveys it would probably be useful to design a simpler

43 ANNEX A: MEDICAL RADIATION EXPOSURES 31 VII. summARy And ConClusIons remained fairly constant for health-care levels I and II, but 39. Medical exposure remains by far the largest human- has substantially increased for health-care levels III and made source of exposure to ionizing radiation and con- IV. In addition, the trend for increasing urbanization of the tinues to grow at a substantial rate. There are now about world population, together with a gradual improvement 3.6 billion medical radiation procedures performed annu- in living standards, inevitably means that more individu- ally. There is a markedly uneven distribution of medical als can access health-care systems. As a consequence, the radiation procedures (including both diagnostic medical population dose due to medical exposures has continuously and dental procedures) among countries, with about two- increased across all health-care levels. thirds of these procedures being received by the 24% of I coun- the world’s population living in health-care level Table 4 and figure X summarize the annual collective 40. tries. For level I and II countries, where 75% of the world’s effective dose from diagnostic exposures (including those popu lation resides, medical uses of radiation have increased due to diagnostic medical and dental radiology, and due from year to year as the benefits of the procedures become to diagnostic nuclear medicine procedures) for the period more widely known. While there are limited data on the 1997–2007. Most of the worldwide collective effective dose annual frequency of examinations in countries with health- arises from diagnostic examinations in health-care level I care levels III and IV, the annual frequency of diagnostic countries. The total annual collective effective dose from all medical examinations has remained fairly constant. For diagnostic exposures is approximately 4,200,000 man Sv. diagnostic dental examinations the annual frequency has Table 4. Annual collective effective dose from all diagnostic exposures (including those due to diagnostic medical and dental radiology, and due to diagnostic nuclear medicine procedures) Health-care level Population (millions) Annual collective effective dose (man Sv) Medical Dental Nuclear medicine Total I 1 540 2 900 000 9 900 186 000 3 100 000 II 3 153 1 300 16 000 1 000 000 1 000 000 33 000 1 009 51 III 33 000 a 82 744 24 000 IV 24 000 38 World 6 446 4 000 000 11 000 202 000 4 200 000 a Refers to health-care levels III-IV. Annual collective effective dose from all diagnostic exposures for each health-care level and the global totals Figure X. (1997–2007) 4 500 000 4 000 000 3 500 000 3 000 000 2 500 000 2 000 000 1 500 000 1 000 000 500 000 COLLECTIVE EFFECTIVE DOSE �man Sv� 0 IV Global II I III HEALTH�CARE LEVEL Nuclear medicine Diagnostic Total Dental

44 32 UNSCEAR 2008 REPORT: VOLUME I The annual per caput effective dose to the global popu- 41. to the global population. The total annual collective effective million dose to the global population is estimated to be 19.2 lation due to all sources of ionizing radiation is summarized man 5 and figure 6), most of which arises from natural back- Sv (see table XI. Natural background radiation rep- in table ground radiation. Diagnostic exposures account for approxi- resents just less than 80% of the total per caput effective dose of about 3 mSv. Diagnostic examinations result in a per Sv. Annually there are approximately mately 4.2 million man caput effective dose of 0.66 billion diagnostic medical radiological examinations and mSv. Medical exposures now 3.1 contribute around 20% of the average annual per caput dose 0.48 billion diagnostic dental radiological examinations. Table 5. Global annual per caput effective dose Annual per caput effective dose (mSv) Contribution (%) Source 2.4 Natural background 79 0.62 20 Diagnostic medical radiology <0.1 Diagnostic dental radiology 0.001 8 Nuclear medicine 0.031 1.1 Fallout 0.005 <0.2 3.1 Total 100 Table 6. Global annual total collective effective dose Annual collective effective dose (man Sv) Contribution (%) Source Natural background 79 16 000 000 Diagnostic medical radiology 4 000 000 20 Diagnostic dental radiology 11 000 <0.1 Nuclear medicine 1.0 202 000 <0.1 Fallout 32 000 20 200 000 100 Total Figure XI. Annual per caput effective dose (msv) 1997–2007 42. New medical X-ray technologies and techniques (par- ticularly with respect to CT scanning) are proving increas- ingly useful clinically, resulting in rapid growth in the 3 number of procedures in many countries and hence in a marked increase in collective dose. In at least one country, 2.4 2.5 this has given rise to a situation where medical exposures have resulted in population and per caput doses equal to or greater than those from the previously largest source (i.e. 2 natural background radiation); other countries will follow. 1.5 Diagnostic nuclear medicine has increased worldwide 43. million examinations annually in 1988 from about 23.5 1 to an estimated 32.7 million annually during the period PER CAPUT DOSE �mSv� 1997–2007, and this has resulted in an annual per caput 0.62 mSv. The estimated annual collective dose of about 0.031 0.5 Sv in 1980 to dose has increased from about 74,000 man 0.031 an annual collective dose of about 202,000 Sv by the man 0.001 8 0.005 0 end of the period 1997–2007. About half of the dose results SOURCE vascular applications. The distribution of nuclear from cardio medicine procedures among countries is quite uneven, with Medical Natural background Dental 90% of examinations occurring in level I health-care coun- Nuclear medicine Fallout tries, which represent about 24% of the world’s population.

45 ANNEX A: MEDICAL RADIATION EXPOSURES 33 million patients treated therapeutically mSv to 6.2 mSv, making medical exposure comparable 3.0 There were about 0.9 with the exposure due to natural background radiation [N26]. each year with unsealed radionuclides. million patients treated annu- There were an estimated 5.1 44. 46. Table 7 summarizes the trends in diagnostic radio- ally with radiation therapy during the period 1997–2007, up logy practice since 1988. Over the period shown, the annual number of diagnostic radiological examinations has increased million in 1988. About 4.7 million were from an estimated 4.3 treated with teletherapy and 0.4 by a factor of 2.25 (see figure million with brachytherapy. XIV). This increase has arisen in part because of the increase in the global population and I coun- The 24% of the population living in health-care level tries received 71% of the total radiation therapy treatments. because of the increase in the annual frequency of diagnostic XV). radiological examinations by a factor of 1.7 (see figure Over the same period the annual collective effective dose to 45. Medical exposure has grown very rapidly over the last Sv the world population has increased from 1,800,000 man three decades in some industrialized countries. As an exam- XVI). There has Sv (see figure in 1988 to 4,000,000 man ple, figures XII and XIII show that increases in medical uses also been an upward trend in the annual per caput effective in the United States in the period 1980–2006 resulted in an increase in the total annual per caput effective dose from dose, as may be seen in figure XVII. Annual per caput effective dose (mSv) for the xII. Figure xIII. Annual per caput effective dose (mSv) for the Figure United States population in 1980 [M37] United States population in 2006 [N26] All other 0.14 All other 0.05 Interventional Natural backgroun d radiology 0.4 3.1 Medical 0.53 Diagnostic radiography 0.3 Nuclear medicine 0.8 CT scans 1.5 d Natural backgroun 2.4 Trends in the global use of radiation for diagnosis: diagnostic medical radiological examinations Table 7. From UNSCEAR Global Surveys of Medical Radiation Usage and Exposures Survey Annual number of Annual frequency Annual collective Annual per caput dose examinations (per 1 000 population) effective dose (mSv) (millions) (1 000 man Sv) 1988 [U7] 280 1 800 0 .35 1 380 1993 [U6] 1 600 300 1 600 0 .3 2000 [U3] 1 910 330 2 300 0 .4 2008 3 143 488 4 000 0 .62

46 34 UNSCEAR 2008 REPORT: VOLUME I Trend in the annual number of diagnostic Figure xVI. Trend in the annual collective effective dose xIV. Figure medical radiological examinations from diagnostic medical radiological examinations 3 500 5 000 3 143 3 000 4 000 4 000 2 500 1 910 3 000 2 000 2 300 1 600 1 380 1 800 1 500 2 000 1 600 �millions� 1 000 man Sv 1 000 1 000 500 NUMBER OF EXAMINATIONS COLLECTIVE EFFECTIVE DOSE 0 0 1993 [U6] 1988 [U7] 2008 2000 [U3] 1988 [U7] 1993 [U6] 2000 [U3] 2008 UNSCEAR SURVEY UNSCEAR SURVEY Figure Trend in the annual per caput effective dose xVII. Trend in the annual frequency of diagnostic xV. Figure from diagnostic medical radiological examinations medical radiological examinations 0.7 600 0.62 0.6 488 500 0.5 400 0.4 0.4 330 0.35 300 280 300 0.3 mSv 0.3 200 0.2 100 0.1 PER 1 000 POPULATION PER CAPUT EFFECTIVE DOSE NUMBER OF EXAMINATIONS 0 0 1988 [U7] 2008 1993 [U6] 2000 [U3] 1993 [U6] 2008 1988 [U7] 2000 [U3] UNSCEAR SURVEY UNSCEAR SURVEY Trends in the global use of dental radiology are given in 47. XX). Given effective dose has decreased since 1988 (figure 8. The number of dental radiological examinations has table that the number of examinations has increased, this decrease XVIII). This is mainly because increased since 1988 (figure results from the reduction in the dose per examination associ- of the increase in the world’s population; the annual frequency ated with the introduction of improved films and film–screen of dental radiological examinations has remained fairly con- systems. Similarly, there has been a substantial decrease in XIX). The annual collective stant over this period (figure the per caput dose due to dental radiology (figure XXI). Table 8. Trends in the global use of radiation for diagnosis: dental radiology Data from UNSCEAR Global Surveys of Medical Radiation Usage and Exposures Survey Annual number of Annual per caput dose Annual collective Annual frequency per 1 000 population examinations (mSv) effective dose (1 000 man Sv) (millions) 340 70 17 0 .003 1988 [U7] 1993 [U6] 18 0 .003 2000 [U3] 520 90 14 0 .002 2008 480 74 11 0 .002

47 35 ANNEX A: MEDICAL RADIATION EXPOSURES xVIII. Trend in the annual number of dental Trend in the annual collective effective dose . Figure xx Figure radiological examinations from dental radiological examinations No data were obtained in the 1993 survey 20 600 18 520 17 480 500 15 14 400 11 340 10 300 millions 200 �1 000 man Sv� 5 100 NUMBER OF EXAMINATIONS COLLECTIVE EFFECTIVE DOSE 0 0 1988 [U7] 1993 [U6] 2000 [U3] 2008 1993 [U6] 2008 2000 [U3] 1988 [U7] UNSCEAR SURVEY UNSCEAR SURVEY xxI. Figure Figure xIx. Trend in the annual frequency of dental Trend in the annual per caput effective dose from dental radiology radiological examinations No data were obtained in the 1993 survey 0.003 5 100 90 0.003 0.003 0.003 0 74 80 70 0.002 5 0.002 60 0.002 0 0.002 0.001 5 �mSv� 40 0.001 0 20 0.000 5 PER 1 000 POPULATION PER CAPUT EFFECTIVE DOSE NUMBER OF EXAMINATIONS 0 0 1988 [U7] 1993 [U6] 2000 [U3] 2008 1993 [U6] 1988 [U7] 2000 [U3] 2008 UNSCEAR SURVEY UNSCEAR SURVEY Trends in diagnostic nuclear medicine procedures are 48. the collective effective dose due to diagnostic nuclear medi- XXIV). This is because of 9. Since 1988 there has been a modest cine procedures has tripled (figure summarized in table the introduction of high-dose cardiac studies and a reduction increase in the number of examinations, comparable with the increase in the global population (figure XXII). The annual in the frequency of other types of procedure. The annual per caput dose has remained constant since 1993 (after having frequency of diagnostic nuclear medicine procedures has remained fairly constant since 1988 (figure doubled between 1988 and 1993) (figure XXV). XXIII). However, Table 9. Trends in the global use of radiation for diagnosis: nuclear medicine Data from UNSCEAR Global Surveys of Medical Radiation Usage and Exposures Survey Annual number of Annual per caput dose Annual collective Annual frequency (per 1 000 population) effective dose (mSv) examinations (1 000 man Sv) (millions) 23 .5 4 .7 74 0 .015 1988 [U7] 1993 [U6] 24 4 .5 160 0 .03 2000 [U3] 32 .5 5 .6 150 0 .03 2008 32 .7 5 .1 202 0 .031

48 36 UNSCEAR 2008 REPORT: VOLUME I xxII. Trend in the annual number of diagnostic Figure Trend in the annual collective effective dose Figure xxIV. nuclear medicine procedures from diagnostic nuclear medicine procedures 250 35 32.7 32.5 202 30 200 24 23.5 25 160 150 150 20 15 100 �millions� 74 �1 000 man Sv� 10 50 5 NUMBER OF EXAMINATIONS COLLECTIVE EFFECTIVE DOSE 0 0 1988 [U7] 1993 [U6] 2000 [U3] 2008 1993 [U6] 2008 1988 [U7] 2000 [U3] UNSCEAR SURVEY UNSCEAR SURVEY Trend in the annual frequency of diagnostic Figure xxIII. Figure Trend in the per caput effective dose from xxV. nuclear medicine procedures diagnostic nuclear medicine procedures 6 0.035 5.6 0.031 0.03 0.03 5.1 0.030 4.7 5 4.5 0.025 4 0.020 0.015 3 mSv 0.015 2 0.010 0.005 1 PER 1 000 POPULATION PER CAPUT EFFECTIVE DOSE NUMBER OF EXAMINATIONS 0 0 1993 [U6] 2008 2000 [U3] 1988 [U7] 1993 [U6] 2000 [U3] 2008 1988 [U7] UNSCEAR SURV EY UNSCEAR SURVEY

49 AppENdIx A . y FOR ESTIMATING wORLdwIdE MEdICAL ExpOSURES METhOdOLOG I. INTROdUCTION of medical radiation exposures, but which were found not A1. As early as 1962 the Committee [U15] provided to be helpful, included the percentage of gross domestic tables of information on medical exposures. Data were product spent on health care, the number of hospital beds supplied by approximately 20 countries. The data indicated per 1,000 population, and the number of examinations or the total population and total annual frequency of exami- procedures per X-ray, nuclear medicine or radiation therapy nations (expressed as annual number of examinations per machine. Mettler et al. developed an analytical model to 1,000 population in the general population). Emphasis was estimate the availability and frequency of medical uses of predominantly on gonadal dose and genetically significant radiation worldwide [M39]. Because frequency and equip- dose, since at that time hereditary effects were felt to be ment data are un available for many countries, Mettler et al. very important. By 1972 the Committee [U11] had added investigated data sources that were available and that cor - estimation of marrow dose as well, but again only report- related reasonably well with examination frequency. In their ing the total annual frequency of examinations. In 1977 original paper they found that there was a good correlation the Committee [U10] began to include data on the annual between the number of people in the population divided by frequency of specific examination types for at least one the number of physicians and the annual frequency of diag- country (Sweden). In the 1982 UNSCEAR Report [U9], nostic radiological examinations. This subsequently led to data on the annual frequency of specific examinations the four-level health-care model, which has been used in were presented for 16 countries, and estimates of effective recent UNSCEAR reports [M39, U3, U7, U9]. The model dose equivalent for various examinations were reported for diagnostic has also been used in performing analyses of two countries (Japan and Poland). Absorbed doses to some examinations [M40]. X-ray organs were also estimated. Genetically significant dose and marrow dose were no longer used at that time, having A4. The model used to analyse population exposure equivalent as a quantity been replaced by effective dose assigned countries to four health-care levels as follows: of interest. I with at least one physician for every – Level A2. In the 1988 UNSCEAR Report [U7] the Committee 1,000 people; greatly expanded its presentation on medical exposures and attempted to estimate global exposure rather than simply II with one physician for every 1,000–2,999 Level – presenting country-specific data. This was possible as data people; from large countries, such as China and countries in Latin – Level III with one physician for every 3,000–10,000 America, became available. In addition, the Committee people; decided to prepare and distribute a survey questionnaire to Member States aimed at acquiring data on medical expo- IV with less than one physician for – Level sures in addition to those that appeared in the published every 10,000 people. literature. This survey methodology has continued to the present day. The changes in the population distribution across the A5. four health-care levels between 1970 and 2007 is shown A3. The Committee recognized that estimation of the popu- in figure A-I. About half of the world’s population live in lation dose due to medical exposures had significant weak- countries that have 1,000–2,999 people per physician, and nesses [U3, U9]. In spite of the efforts of the UNSCEAR this percentage has stayed relatively constant for the last secretariat, data were still available for only about a quarter 25 years. There has been a gradual decline in the percent- of the world’s population. Most of the data on frequency age of the world’s population living in level I countries. and types of radiological examination were mainly avail- able from developed countries [M39]. A method was sought A6. While the distribution of population by health-care to extrapolate the existing data to other countries where no level has not changed significantly, the world’s population data were available. Members of the UNSCEAR secretariat billion in has increased substantially, rising from just over 4 examined possible correlations that might be helpful. Some billion in 2006, an increase of over 60% 1977 to about 6.5 correlations that were examined in relation to frequency (figure A-II). 37

50 38 UNSCEAR 2008 REPORT: VOLUME I Figure A-II. Change in the global population over the period By analysing the available data using these health- A7. covered by the various UNSCEAR Global Surveys of Medical care level criteria and data on the annual frequency of Radiation Usage and Exposures selected examinations from various countries, it was possi- ble to obtain an average annual frequency for these exami- 7 000 nations for a given health-care level and apply this value to 6 446 5 800 6 000 the other countries of the same health-care level for which 5 290 5 000 the Committee had no specific data. This allowed a global 5 000 4 200 estimate of the number and type of examinations or proce- 4 000 dures to be presented in the UNSCEAR 1988 Report [U7] 3 000 as well as in all subsequent reports of the Committee [U3, 2 000 U4, U6]. 1 000 POPULATION �millions� 0 1970–1977 1980–1984 1985–1990 1991–1996 1997–2007 Figure A-I. p opulation distribution across the four health- care levels (1970–2007) UNSCEAR SURVEY 60 The UNSCEAR 1988 Report also presented the first A8. estimate of collective effective dose equivalent to patients 50 from diagnostic radiology and diagnostic nuclear medicine [U7]. This estimate was made by multiplying the total number 40 of specific examinations by the effective dose equivalent per examination. The data collected on the calculated effective dose equivalent for various examinations were presented. 30 In more recent reports of the Committee, effective dose has been used rather than effective dose equivalent [U3]. The 20 specific dosimetric methodologies are presented below. CONTRIBUTION �%� A9. The questionnaire used in the most recent UNSCEAR 10 Global Survey of Medical Radiation Usage and Exposures comprises five parts. The first part requests general infor- 0 mation and data on the number of practitioners for various III II IV I groups in a country. Form 1 requests information on diag- HEALTH�CARE LEVEL nostic and therapeutic equipment. Forms 2, 3 and 4 cover diagnostic radiological examinations, nuclear medicine 1980–1984 1970–1977 1985–1990 procedures (both diagnostic and therapeutic) and radiation 1991–1996 1997–2007 therapy treatments, respectively. II. METhOdOLOG y FOR ANAL ySIS OF dOSIMETRy IN dIAGNOSTIC ANd INTERVENTIONAL RAdIOLOG y A10. This section comprises a review of the various a . This incident on a sphere with a cross-sectional area d approaches to patient dosimetry and is based upon the quantity specifies the energy carried by the photons in an approach described by the International Commission on X-ray beam: Radiation Units and Measurements (ICRU) in ICRU Report -2 R Units: J m = d Y a /d 74, “Patient dosimetry for X-rays used in medical imaging” [I46]. Further details on patient dosimetry may be found K Kerma, A13. , is defined at a point and is given by: elsewhere [F1, F3, H34, I17, I32, J2, M22, N1, S17, S18, S19, U3, W16]. -1 /d m = d or Gy K E Units: J kg er A11. Over the years, a number of patient dosimetric quan- E where d is the sum of the initial kinetic energies of all the er tities have been developed. These dosimetric quantities will m charged particles liberated by photons in a mass d [I30]. be described in subsequent paragraphs. , is commonly used. Air K For medical exposures, air kerma, a kerma for photons of a single energy is given by: The ICRU [I47] has defined energy fluence, , as Y A12. -1 ) r or Gy Units: J kg / (μ = Y K is the radiant energy R the quotient of d R by d a , where d a tr a

51 ANNEX A: MEDICAL RADIATION EXPOSURES 39 A18. For measurements of dose from medical exposures r where (μ ) / is the mass energy transfer coefficient for a tr it is important that both the quantity and the measurement air. For medical exposures, the photon beam is usually not point must be specified. This is particularly important when monoenergetic; in these circumstances the mass energy specifying ESD. When making measurements close to the transfer coefficient must be weighted according to the energy entrance surface of the patient or phantom, it is critical distribution of the energy fluence. whether the quantity being measured is incident air kerma • that ignores backscatter or ESAK that includes backscat- , is given by: A14. Air kerma rate, K a ter. Thus the distance from the measurement point to the • -1 -1 -1 entrance surface of the patient or phantom should be speci- K Units: J kg t /d or Gy s s = d K a a fied. Air kerma area product is deduced from the field size in a particular plane perpendicular to the central axis of the is the increment of air kerma in a time /d t where d K a X-ray beam and the air kerma for the central axis in this . interval d t plane (see figure A-III). The deposition of energy due to ionizing radiation A15. The International Commission on Radiological A19. [I47]. D in a material is quantified by the absorbed dose, Protection (ICRP) has recommended that average absorbed Absorbed dose is defined as: dose in a tissue or organ be the basic quantity for assessing -1 e stochastic risks [I48]. The ICRU [I2] has defined the aver- D = d /d Units: J kg m or Gy as T in a specified organ or tissue D age absorbed dose, , T e , divided by the the total energy imparted to the tissue, e where d is the mean energy imparted by the radiation T : mass, m . Absorbed dose, D t , to a material to matter of mass d is m t T related to the energy fluence, Y by the mass energy absorp- , e /m D = / r tion coefficient in that material, (μ , under conditions of ) t T T en t charged particle equilibrium. For photons of a single energy, D is given by: t A20. The risk of a stochastic effect is dependent on the type and energy of the radiation as well as on the absorbed -1 / = Y (μ r D Units: J kg ) or Gy t en t dose. As a consequence, the ICRP [I3] has recommended that the organ dose be weighted by a radiation weighting In medical images where polychromatic X-ray photons are factor. ) r / weighted according to the (μ , usual, the mean value of t en energy distribution of the energy fluence, is used. If brems- For stochastic risk assessment, the ICRP [I3] has A21. strahlung is negligible, . The equivalent H introduced the quantity equivalent dose, T dose in a tissue T is given by: / ) = K D hence ) r = (μ (μ r / t en t t tr t • Absorbed dose rate, A16. , is defined as [I30]: D = H w D ∑ T , R RT R • -1 -1 -1 Units: J kg t /d D = d s or Gy s D T D from is the average absorbed dose to tissue where T,R is the radiation weighting factor ( w w , R radiation = 1 and Incident dose is the dose on the central axis of the X-ray beam R R for X-rays). For medical exposures, gauging the risks of sto- at the point where the X-ray beam enters the patient; it does chastic effects is complicated because almost invariably more not include backscatter. Entrance surface air kerma (ESAK) than one organ is irradiated. The ICRP introduced the unique is the air kerma on the central X-ray beam axis at the point effective dose equivalent quantity ( ) in its Publica- EDE or H where the X-ray beam enters the patient or phantom [I17, e tion 30 [I36], and then redefined and renamed the quantity I46]; it includes the effect of backscatter (see figure A-II). effective dose ( E ) in ICRP Publication 60 [I3], for expressing ESAK is recommended by the ICRU for dosimetry in medi- stochastic risk to radiation workers and to the whole popula- cal imaging. However, many of the publications reviewed in tion [I3]. To evaluate effective dose, the equivalent dose to this report use entrance surface dose (ESD), which does not , H a tissue or organ, is weighted by a dimensionless tissue include the effect of backscatter. For consistency, ESD has T . Multiplying the equivalent dose ( H weighting factor w ) of been used in this report. T T ) an organ or tissue by its assigned tissue weighting factor ( w T gives a “weighted equivalent dose”. The sum of weighted A17. is defined by the ICRU , X The quantity “exposure”, equivalent doses for a given exposure to radiation is the [I47] as: effective dose. Thus: -1 Units: C kg Q /d m = d X where d Q is the absolute value of the total charge of the ions of one sign produced in air when all the electrons and posi- are trons liberated or created by photons in air of mass d m completely stopped in air.

52 40 UNSCEAR 2008 REPORT: VOLUME I A1 summarizes the various tissue weighting Table A22. dose resulting from a non-uniform irradiation is intended to be ) as prescribed by the ICRP over the years. Tissue w factors ( that equivalent dose which, if received uniformly by the whole T weighting factors represent a judgement by the ICRP of the body, would result in the same total risk. (Whole-body doses relative contribution of organs or tissues to the total detriment are usually meaningless for assessing the risk of medical expo- associated with stochastic effects [I46]. The sum of the tissue sures, because non-uniform and localized energy deposition is weighting factors is unity. Thus the numerical value of effective averaged over the mass of the entire body.) Figure A-III. Simple exposure arrangement for radiography illustrating some of the dosimetric and geometric quantities recommended for determination of patient dose [I17] X- ray tube cal spot Fo position r Collimato Air kerma–area product P meter KA Focal spot- Focal spot- -surface to to -image receptor distance distance d d FSD FID (no backscatter) - Incident air kerma K a,i - Entrance surface air kerma K a,e (including backscatter) D Organ dose t Table Image receptor Absorbed dose to tissue at a point D in the patient t Summary of tissue weighting factors [I3, I6, I36] Table A1. Organ Tissue weighting factors, w T ICRP 30 [I36] 1979 ICRP 60 [I3] 1991 ICRP 103 [I6] 2008 Gonads 0 .25 0 .20 0 .08 Red bone marrow 0 .12 0 .12 0 .12 Colon 0 .12 0 .12 0 .12 lungs 0 .12 0 .12 Stomach 0 .12 0 .12 Bladder 0 .05 0 .04 Breasts 0 .15 0 .12 0 .05 0 .05 0 .04 liver Oesophagus 0 .04 0 .05 Thyroid 0 .03 0 .05 0 .04 Skin 0 .01 0 .01 Bone surfaces 0 .01 0 .01 0 .03 Salivary glands 0 .01 Brain 0 .01 Remainder 0 .30 0 .05 0 .12

53 41 ANNEX A: MEDICAL RADIATION EXPOSURES A23. The tissue weighting factors are judged to be inde- In most radiology procedures, the primary X-ray A28. beam will directly irradiate only part of the patient. Effec- pendent of the type and energy of radiation incident on the tive dose is a risk-related quantity, which takes into account body. The nominal stochastic risk coefficients for effective which organs are irradiated and by how much. It is a derived dose to workers and members of the public are based on the quantity and its evaluation provides a numerical value for the notional risk of radiation-induced cancer and severe heredi- uniform whole-body exposure that would result in the same tary disorders averaged over these populations. Moreover, to overall radiation risk as the respective partial-body exposure. assess the risks from exposures at low doses and dose rates, the ICRP has introduced a dose and dose-rate effective- In diagnostic radiology it is common practice to A29. ness factor (DDREF) of 2, which is included in the nominal measure a radiation dose quantity that is then converted stochastic risk coefficients. into organ doses and effective dose by means of conversion Both the radiation and tissue weighting factors are A24. coefficients. These coefficients are defined as the ratio of the derived from the observed rates of expression of these effects dose to a specified tissue or effective dose divided by the nor- in various populations exposed to radiation and from radio- malization quantity. Incident dose, air kerma, ESAK, ESD or kerma–area product (KAP) can be used as biological studies. As more research evidence has become normalization quantities [I46]. available, the ICRP has prescribed different values for these weighting factors [I6] (see table A1). Thus the reported effec- Estimating effective dose from values of organ doses A30. tive dose equivalents are not strictly comparable with the reported values of effective dose for a particular examination, is particularly difficult in radiology, because usually only part of the body is directly irradiated owing to the collimation of since their derivations involve different weighting factors. Another limitation of the use of effective dose in the assess- the X-ray beam to the area of clinical interest. In addition, - ment of medical exposures is that it may be difficult to per often only part of an organ is included in the primary beam, form a coherent trend analysis in the future. This may affect the remainder being exposed to scattered radiation. comparisons of the results between UNSCEAR reports. Irrespective of which approach is adopted to estimate A31. There are other issues regarding the use of effec- doses and risks resulting from diagnostic X-ray examina- A25. tions, there are weaknesses. For example, there are consid- tive dose to gauge the risk of potential effects from medi- cal exposures. The most significant relates to differences in erable uncertainties on estimates or measurements of organ age, sex and health status of the medically exposed popula- dose in many circumstances. There are also differences in the size and position of radiosensitive organs within the bod- tions compared with the population characteristics used by ies of individuals and even within phantoms. Inspection of the ICRP [I3, I6, I36] to derive its nominal risk coefficients normalized organ dose data reveals some variability in this [I46]. For example, the age distribution and life expectancy respect. There is a large difference in the organ dose depend- of patients having percutaneous transluminal coronary angio- plasty (PTCA) procedures is different to that of the general ing on whether or not the organ is in the primary beam [I26, J1, K23, L21, P15, R19, R21, R22, S39, Z9, Z10, Z11, Z12, population or a population of radiation workers [B25]. Con- Z13]. All of these factors lead to uncertainty in organ dose sequently the ICRU suggests that effective dose should not be used for the assessment of risk from medical exposures estimation. [I46]. A32. These problems exist even if a well-defined part of The ICRP suggests that estimating stochastic risks A26. the body is irradiated. For example, in head CT or dental for a specific population is sometimes better achieved using radiology, the value for effective dose will be dependent upon whether the thyroid/oesophagus is assumed to be in absorbed dose and specific data relating to the relative bio- logical effectiveness of the radiation and risk coefficients, the primary beam. Assumptions have also to be made about taking into account health status and/or life expectancy [I3, the amount and location of red bone marrow and about bone I6, I36, I46]. surfaces in the skull [L5, L6]. A27. There are three main approaches to the assessment of A33. The ICRU recommends that stochastic and determin- (a) direct dose measure- patient doses in diagnostic radiology: istic risks associated with medical exposures be assessed dose measurements in physical phan- from a detailed knowledge of organ doses, absorbed dose (b) ments on a patient; distribution, age and sex [I46]. Effective dose is not con- Monte Carlo radiation transport calculations. (c) toms; and The most common approach is the combination of an easily sidered suitable for this purpose by the ICRU. However, measurable quantity such as KAP with the respective con- many authors in the literature survey of reports on doses version coefficients derived from Monte Carlo calculations. from medical examinations and in references cited in the present report have used effective dose, despite its limita- Direct measurement of patient dose is limited to relatively few tions, as a surrogate quantity to assess patient exposures, superficial organs, such as the eye, skin, thyroid or testes. in part because it is convenient to use. Effective dose has therefore been used in this report for purposes of compari- A34. A general problem faced in clinical practice is the son with previous publications despite its weaknesses for difficulty associated with making measurements on groups gauging risks as noted above. of patients whose size and build differ markedly from the

54 42 UNSCEAR 2008 REPORT: VOLUME I norm [F9]. In these circumstances one accepted approach A41. Physical phantoms that simulate patient anatomy can is to perform the measurements on all patients undergoing be used for dosimetry [C1, M2]. Some phantoms have a fair this procedure during a measurement period and then take degree of anatomical accuracy and are a reasonably accurate the average of the dose values as the outcome for a standard representation of human anatomy, both in terms of the size kg. This will give a reasonable esti- sized patient, 70 and position of the organs and with respect to the attenu- kg ± 10 ation properties. A problem with some anthropomorphic mate of that dose provided that the number of patients is not too small, perhaps a minimum of ten patients [E5]. phantoms is that they are not tissue equivalent, which leads to inaccurate dosimetry for diagnostic radiology [S38]. The An alternative approach is to apply a height and A35. ICRU has described the requirements for physical dosimetry phantoms [I30]. weight conversion factor to allow for deviation in size and composition from that of reference man [L4]. Correcting for There are limitations regarding measurements in a A42. patient size was first proposed by Lindskoug [L4] and has physical dosimetry phantom. These relate to the need to use been further developed by Chapple et al. [C1]. It enables ref- erence values to be obtained from large-scale patient dose a large number of dosimeters to estimate the dose to physi- cally large organs, the non-uniform distribution of radiation surveys by correcting each individual dose quantity to what it would have been had the individual corresponded to the within the phantom and the effect of small uncertainties in size and composition of reference man. the position of the radiation field. As a consequence, this method of patient dosimetry as well as the other methods The collective effective dose to the population is the A36. (measuring ESD with TLDs) are not suitable for routine sum, over all types of examinations, of the mean effective patient dose assessments. dose, , for a specific examination type multiplied by the E e . The number of examina- n Monte Carlo computational techniques are also used number of these examinations, A43. e to estimate organ or tissue doses. These are computer-based tions may be deduced from the annual frequency (expressed methods that employ computational models to simulate as number of examimations per 1,000 population) and the the physical processes associated with the interaction of an estimated population for that country or health-care level. X-ray beam with the human body. There are two types of A37. computational model: mathematical and voxel phantoms. The per caput effective dose is also used to quantify Monte Carlo calculations are used to deduce energy deposi- exposures that result from diagnostic radiology. It is the col- tion of X-ray photons in computational models of human lective effective dose averaged over the population of both exposed and non-exposed individuals. The weakness of the anatomy [I30]. Normally, patient dose is assessed by apply- per caput dose approach is that medical exposures tend to ing suitable Monte Carlo calculated conversion coefficients to a routinely measured quantity such as KAP or ESD. be performed on a subset of the population whose members Mathematical phantoms are a three-dimensional representa- are ill. tion of a patient. The organs and the whole body are defined as geometric bodies (such as cylinders and ellipsoids). The rojection radiography A. p various phantoms used have been of increasing anatomical accuracy and complexity [C21, I26, J1, K23, S39]. A38. In projection radiography, the assessment of air kerma Voxel phantoms are based on either CT or MR images A44. or dose (with or without backscatter) at the entrance surface of the patient is a common approach to patient dosimetry. of actual patients. Organ sizes and positions are deduced from the volume elements determined from the imaging data. As This may be achieved by measurement of tube radiation out- put in mGy/mAs at a given point (without a patient) using a consequence these phantoms are physically more accurate, the only limitation being the size of the voxels used. Vari- an ionization chamber, followed by calculation of the ESD from recorded exposure and geometric data, as well as the ous voxel phantoms have been described in references [P15, V13, Z9, Z10]. use of an appropriate backscatter factor. ESD or ESAK may be measured using thermoluminescent dosimetry (TLD). A45. As mentioned above, there are uncertainties in the estimation of organ doses. For example, relatively small dif- A common method for measuring patient doses is to A39. ferences in patient build can result in large differences in use TLDs. The dosimeters are packaged in plastic sleeves that organ doses depending on whether the organs lie within or are sterilizable, and are attached to the patient’s skin using surgical tape. Correction factors for the energy dependence outside the primary beam [G21, S40]. In chest radiology the uncertainty in dose to the lower large intestines can be as of the dosimeters and their sensitivity are applied to the raw large as 48% [I46]. Other uncertainties in Monte Carlo cal- TLD data. A background correction is also applied. culations arise from uncertainties in attenuation coefficients, In addition to TLDs, glass dosimeters are widely used the patient phantom and the model of the X-ray source. A40. in Japan to assess medical exposures owing to their superior technical characteristics. Glass dosimeters have been used A46. If the dose or air kerma at a specified point is known, it to assess ESD in intraoral radiography and for endovascular is possible to use normalized organ dose data to deduce organ treatments [K31, N14]. doses for a typical patient, effective dose being calculated

55 ANNEX A: MEDICAL RADIATION EXPOSURES 43 DAP or KAP readings is approximately 6% for an overcouch from the organ doses. Normalized organ dose data are avail- able for many examination types, including CT. They are gen- X-ray tube geometry [L25] and up to 20% for an undercouch erally based upon Monte Carlo simulations of examinations X-ray tube geometry, depending on how well the DAP meter has been calibrated [C24]. [D3, D4, D6, H13, J1, J3, R2]. The structure of transmission ionization chambers scatter Numerous publications have tabulated back A47. A52. factors for X-rays [B22, C22, G3, G4, G22, H28, H29, I23, often includes high-atomic-number elements [I46], which means that their calibration is dependent on the radiation K24, K25, M29, P16, S41], which may be required in esti- mating entrance skin dose. Various handbooks of dose con- beam energy [B25, L25]. Instrument calibration is therefore particularly important for fluoroscopy equipment on which version coefficients have been published [D6, H13, H30, additional copper filtration is used. H31, H32, J1, J3, K23, R19, R20, R21, R22, S42, S43, V13, Z9, Z11, Z12, Z13]. There is increasing concern about skin dose levels in A53. A computer-based Monte Carlo program for calculat- A48. cardiology and interventional radiology [I1]. This is because of the discovery of deterministic injuries in patients who ing patient doses resulting from medical radiological exami- have undergone long procedures using suboptimal equip- nations has been developed by Tapiovaara et al. [T17]. This computer program uses hermaphrodite phantoms for six ages ment and performed by individuals inadequately trained in radiation protection. Assessment of maximum ESD is partic- ranging from newborn to adult. There is good agreement ularly difficult, as the projection direction and irradiated area between this program and other software [H30, H32, J1] change during interventional procedures. Various measure- when used to calculate organ dose conversion coefficients. ment techniques have been proposed, including slow films [G11], real time software [F12], DAP [V18] and calculation b. Fluoroscopy [M12]. A49. Organ doses resulting from fluoroscopy procedures A54. Approaches to patient dosimetry are different for may also be assessed using TLDs loaded into a physical procedures that involve the use of fluoroscopy equipment phantom. Dosimeters may be placed in the phantom at posi- [B1]. During these examinations an automatic exposure con- tions corresponding to the organs of interest, and a typical trol is used to adjust the generator settings to compensate for fluoroscopy procedure is simulated on the phantom using the changes in attenuation in the X-ray beam. Consequently the appropriate X-ray equipment [C1]. The TLDs are read out tube potential and tube current change continuously as the and the organ doses deduced. Surface doses during fluoros- projection direction changes because of changes in attenu- ation through the patient. Furthermore, the anatomical area copy have also been assessed using glass dosimeters [N14]. of the patient irradiated by the primary beam varies, and dif- Measurement of either air KAP or DAP is probably A55. ferent tissues have different attenuation coefficients. This the method of choice for assessing the doses and effective means that it is difficult to monitor maximum ESD directly, as the anatomical position where this occurs may not be dose, and hence the potential risks, resulting from inter- known in advance [W4]. In addition, dosimeters placed on ventional procedures. DAP correlates reasonably well with the patient’s skin may not be in the primary beam for all radiation risk by means of conversion factors [H13]. These conversion factors are examination-specific and may be projection directions used in some procedures (e.g. interven- deduced from Monte Carlo organ dose calculations made for tional cardiology). In these circumstances, dose–area prod- simulated interventional procedures. This approach has been uct (DAP) or air KAP may be assessed, depending upon the calibration of the measurement instrument. These are quan- used in reporting many of the patient dose data in response tities that have the advantages of being easy to measure and to the surveys (sections III and IV of this appendix). to correlate with risk. Additionally they are independent of the distance from the X-ray tube [A13, B21, C23, M31]. A56. At present there are no established technical approaches that provide a direct indication of maximum ESDs. However, there are four technical approaches that are A50. In fluoroscopy, large-area transmission ionization chambers are commonly used to assess patient doses [C10]. calculation of entrance dose from the (a) being developed: 2 2 generator settings, assuming a given focus–skin distance; ) These instruments measure KAP (Gy cm ) or DAP (Gy cm directly determining entrance dose from either the air (b) [I46], depending on the calibration of the instrument [I46, W26]. These quantities can be used to deduce the total KAP or the DAP and collimator settings, also assuming a energy imparted to the body or effective dose. It is also pos- use of special solid-state detec- (c) given focus–skin distance; tors placed on the skin surface of the patient; and sible to derive other dose quantities from the KAP or DAP use of a (d) reading (e.g. ESD and mean organ doses) [I46, W26]. large-area field-sensing ionization chamber, which measures DAP and entrance dose at a given focus distance simultane- (a) , Transmission ionization chambers must be calibrated A51. ously [T2]. Methods require an assumption (b) and (d) in situ, because for geometry involving an undercouch X-ray about backscatter radiation, whereas the detector in (c) will automatically include it. The use of detectors placed on the tube and overcouch detector the attenuation of the patient couch must be taken into account [C24]. The uncertainty on skin is a potential problem, in that with different angulations

56 44 UNSCEAR 2008 REPORT: VOLUME I Many authors have published conversion coefficients of the X-ray tube, the dosimeter may not be placed at the A63. for assessing doses in mammography [A14, D4, D12, J11, position where the maximum skin dose occurs (as this may not be known beforehand). The dosimeters may also be visi- R23, S43, W27, W28, Z14]. Conversion coefficients are ble on the displayed image. The other approaches inevitably tabulated as a function of half-value layer and compressed yield an overestimate of maximum ESD. breast thickness [D4]. There are variations of up to approxi- mately 15% between different conversion coefficients [I46]. In addition, breast composition also varies with compressed A57. One design of ionization chamber incorporates an ultrasonic distance ruler at the chamber [T2]. This instru- breast thickness [G15, K26, Y11, Y12]. ment can therefore deduce ESD. The computer linked to the chamber applies an inverse square law correction based on A64. Since this earlier work, a number of authors have the measurement of the chamber-to-patient distance made used Monte Carlo techniques to model the interaction of using the ultrasonic ruler. Consequently this instrument low-energy X-ray beams within breast tissue [D3, D4, R2]. design can provide an on-line display of ESD, but if differ- ent angulations of the X-ray tube are used, this method will also overestimate the maximum ESD. CT dosimetry d. P A65. Air kerma–length product, , is recommended by KL Mammography C. the ICRU for CT dosimetry [I46]. The air kerma–length product is the integral of the air kerma free in air along a line Dosimetry in mammography is particularly difficult, A58. of length parallel to the axis of rotation of the CT scanner as low-energy X-rays are used to image the breast [N4]. and is given by: This places particular demands on the instruments used to measure breast dose, as they need to be energy independent (L) K ∫ = P (Gy cm) L d KL L a keV or an appropriate calibration factor should down to 15 be applied. This quantity may also be assessed inside a phantom, P KL,CT. Moreover, while simple measurement of ESD on top A59. , has also CTDI A66. The CT air kerma index free in air, air of an appropriate phantom has been considered as a suit- been defined by the ICRU [I46] for dosimetry of fan beam able quantity, this does not take into account the attenua- scanners. It is the integral of the CT axial air kerma pro- tion properties of breast tissue, which vary according to both , along the axis of rotation of the CT scanner for a file, (z) K a breast composition and X-ray radiation quality. Depth-dose T single rotation divided by the nominal beam collimation, . data are critically dependent upon breast composition and the X-ray spectrum [D3, D4, D12]. K d (z) = 1/ z T CTDI air a A60. It is widely acknowledged that within the breast it is the glandular tissue that is most radiosensitive, rather than /T = P (Gy) KL fat or connective tissue. Mean glandular dose or average absorbed dose in glandular tissue has been recommended by For a multislice CT scanner with A67. slices of collima- N the ICRP as the relevant dosimetric quantity for mammo- T tion graphy [D6, I5, I46, N4]. While the quantity mean glandular dose correlates reasonably well with the associated radiation = P CTDI (Gy) /(NT) KL air risk, it cannot be measured directly and therefore has to be inferred from other measurements. For phantom measurements on CT scanners, a CT air A68. , can also be defined [I46]. C kerma index, K,PMMA A61. Hammerstein et al. [H9] proposed a model for a standard breast comprising 50% adipose and 50% glandu- lar tissue. The composition of this breast was deduced from z d (z) C K = a,PMMA K,PMMA the elemental composition of a relatively small number of autopsy sections. Hammerstein et al. also proposed using a conversion factor to be applied to the measured ESD [H9]. = /T (Gy) P KL,PMMA A62. , can also be derived from D Mean glandular dose, Other specialized dosimetric techniques have been A69. G incident air kerma, K , to a standard breast phantom; this used to assess patient radiation dose in CT, as it is difficult to a,i has a superficial layer of either 0.4 cm of glandular tissue or directly determine organ doses [S17, S18]. These techniques 0.5 cm of adipose tissue with a varying thickness of 50:50 adi- have been described in a series of publications [F3, I32, J2, pose and glandular tissue between the two superficial layers M22, S18, S19, U3, W16]. These dosimetric approaches are [I46]: [D4]. A conversion coefficient is used to deduce D based upon the use of three quantities dedicated to CT dosi- G ), volume-weighted metry: weighted CT dose index ( CTDI W D K = c (Gy) a,i G G CT dose index ( CTDI ) and dose–length product ( DLP ). vol

57 45 ANNEX A: MEDICAL RADIATION EXPOSURES Dedicated CT dosimetry phantoms are recom- A70. A75. CTDI may be normalized to the tube current–time w may also be given for a stand- mended by the ICRU [I30]. The phantom is placed on the CTDI product. Normalized w mm [S19]. For CT scanner couch so that the scanner’s axis of rotation ardized nominal beam collimation of 10 specific models of CT scanner, relative conversion coef- coincides with the longitudinal axis of the phantom [I46]. settings. The centre of the CT scanner slice or multiple slices is ficients are provided for a range of collimation In CT scanners that operate in automatic exposure control aligned to the centre of the phantom. Measurements are mode where the tube current is automatically modulated, phery of the CT dosimetry made at the centre and peri manufactured from polymethylmeth- phantom, which is average tube current or current–time product is used to acrylate (PMMA). take account of the effect of this modulation [K11, K12, L17]. CT dosimetry is based upon the use of PMMA phan- A71. in mGy cm) is given by the follow- A76. DLP (expressed cm to represent an toms with diameters of 16 cm and 32 ing equation: adult head and body, respectively. Measurements are made, mm length, usually with a pencil ionization chamber of 100 NT DLP = CTDI w n at the centre of the phantom and 1 cm below the surface at four equally spaced locations. in centi- N where is the number of slices of collimation T rotation and n is the total number of rotations. metres per The weighted A72. in either phantom is given by: CTDI w Alternatively, may be calculated using: DLP =1/3 CTDI + 2/3 CTDI CTDI 100,p 100,c w DLP = CTDI L vol is the average of the four where CTDI measure- CTDI 100,p where L is the scan length, determined by the outer margin ments (see above) made at the periphery of the phantom. of the volume irradiated in the CT scan [M22, S19]. CTDI is the measurement made at the centre of the phan- 100,c CTDI is measured for a range of technique factors (i.e. tom. w A77. The International Electrotechnical Commission (IEC) tube current, tube voltage, slice collimation) typical of those has recognized the need for a dose display on CT scanners used clinically. CTDI and has recommended that be used [I32]. On some vol machines, DLP is also displayed. These equipment displays CTDI A73. (expressed in mGy) is defined as the integral mean that patient dosimetry in CT is made easier by using 100 (z) over 100 mm along a line parallel to the axis of rotation recently manufactured machines. The IEC has also consid- D(z) of the dose profile for a single rotation, at a fixed tube ered developing a standard for the recording of dosimetry potential, divided by the nominal collimation of the X-ray data in the DICOM header. beam used by the CT scanner [S18]: A78. One of the problems associated with performing 50mm CTDI ∫ z d = 1/NT D(z) patient dosimetry measurements using CTDI on CT scan- 100 –50mm ners with a large number of rows of detectors is the required where, for a single rotation, the number of CT slices is , N integration length. For a nominal beam width of 128 mm, an the nominal thickness of each slice is (expressed NT , and T integration length of 300 mm is required if scattered radia- in cm) is the total detector acquisition width and is equiva- tion is to be appropriately assessed [M36]. Conversion fac- is usu- CTDI lent to the nominal beam collimation [S18]. tors have been developed to allow a standard CTDI phantom 100 mm ally measured using a pencil ionization chamber of 100 and a 100-mm-long ionization chamber to assess on CTDI length. multislice CT scanners [M36]. (expressed in mGy) is given by the following CTDI A74. E may be inferred from the DLP using A79. Effective dose vol equation: ). Conversion E appropriate conversion coefficients (( ) regime DLP coefficients have been calculated for different regions of CTDI = CTDI /P the body at a range of standard ages [J2, J3, K13, S18, S19, vol w S20, S21]. These conversion coefficients are derived from P where given by: is the CT pitch factor mathematical phantoms [K13] using Monte Carlo model- ling. Measured conversion coefficients have been published ∆ d/NT P = by Chapple et al. [C13] for paediatric patients. These con- version coefficients were deduced from a series of measure- where is the distance (expressed in cm) moved by the d ∆ ments made using anthropomorphic phantoms that simulate patient table in the direction, between serial scans or per z a range of ages from 0 to 15 years, into which TLDs had rotation in helical scanning [I32, S19]. been placed.

58 46 UNSCEAR 2008 REPORT: VOLUME I E. dental panoral tomography F. dual-energy absorptiometry ESD is commonly measured in intraoral dental In dual-energy absorptiometry it is common to A82. A80. use approaches to patient dosimetry that are similar to radiology. those employed for projection radiography (i.e. measure- In dental panoral tomography (and also in CT), air A81. ment of ESD or effective dose using anthropomorphic kerma–length product is used for dosimetry. Air kerma– phantoms). , is the integral of the air kerma over a P length product, KL [I17]. L length P ∫ = K(z)dz L KL III. METhOdOLOG y FOR ANAL ySIS OF dOSIMETRy IN NUCLEAR MEdICINE A. dosimetric approaches and all other terms must be amalgamated h in a source region , which becomes: S into the factor A83. The MIRD (medical internal radiation dose) system was developed primarily for use in estimating radiation doses received by patients from administered radio pharmaceuticals. The simplest form of the dose equation is: A84. A85. The ICRP has developed a system for calculating internal doses to radiation workers who inhale or ingest radionuclides. The technical basis is identical to that shown is the number of disintegrations that occur in a where N above, but different symbols are used for many of the quan- source organ and DF is given by: tities. Moreover, values of permissible intakes and air con- centrations for many radionuclides are derived from dose limits established for workers. The details are not given here, because this report focuses on dosimetry for the purposes of nuclear medicine. n = number of particles with energy E where emitted per i i nuclear transition; However, the ICRP has also published extensive A86. compendia of dose estimates for radiopharmaceuticals in its E = energy of particle emitted (MeV); i Publications 53 [I34] and 80 [I25]. In these documents, the f = fraction of energy emitted that is absorbed in the target; available literature supporting the design of a kinetic model i for each of the (over 100) radiopharmaceuticals is reviewed m = mass of target region (kg); and a kinetic model is given, as well as dose estimates for k = the proportionality constant used to resolve the units adult and 15-, 10-, 5- and 1-year-old subjects. –1 (Gy kg·(MBq s MeV) ). As discussed above, the ICRP has defined the quantity A87. The equation for absorbed dose in the MIRD system is effective dose [I3] for the purpose of gauging stochastic risks [T18]: from radiation exposure. The discussion above concerning the limitations of the use of effective dose for assessing the exposures due to medical radiology also apply to its use for assessing exposures due to nuclear medicine. Thus, although represents In this equation, r represents a target region and r the quantity has limitations, it is used here as a surrogate to k h à a source region. The term is the number of disintegrations assess patient exposures because of its convenience. h

59 47 ANNEX A: MEDICAL RADIATION EXPOSURES ySIS OF dOSIMETRy IN RAdIATION ThERApy IV. y FOR ANAL METhOdOLOG of grays. The concept of effective dose strictly applies only Data for analysis of trends and annual frequency of A88. to lower dose levels (in the region where only stochastic procedures in radiation therapy are derived from published effects occur), and therefore neither effective dose nor col- literature, supplied by professional organizations and govern- lective effective dose may legitimately be used for the high ments, and/or from the survey forms. The data are typically dose levels of radiation therapy. As a result, no contribution more difficult to obtain than those for diagnostic radio logy has been calculated for radiation oncology or included in the or nuclear medicine. There are some inherent difficulties estimates of worldwide annual per caput effective dose or with the definition and comparison of the reported values. collective effective dose from medical exposures. Some surveys report the number of patients treated, others report the number of treatment regimens (each of which may There are risks of stochastic and deterministic effects A90. have up to 30 treatments) and still others report treatments. for patients who undergo radiation therapy resulting from For this analysis it has proven valuable to supplement these radiation exposure of tissues outside the target radiation estimates by considering data on the number and type of field. The risk of a second cancer is particularly important installed machines. for those radiation oncology patients who survive treatment for malignant disease or receive radiation therapy for benign The UNSCEAR reports have often presented the A89. disease. However, the Committee has been unable to obtain intended absorbed or equivalent organ doses for various sufficient data to adequately quantify these risks. treatments. However, these are typically of the order of tens

60

61 AppENdIx b. y LEVELS ANd TRENdS OF ExpOSURE IN dIAGNOSTIC RAdIOLOG SUMMARy FROM UNSCEAR 2000 REpORT [U3] I. 14,000 man Sv, equating to about 0.002 mSv per caput. These B1. The utilization of X-rays for diagnosis in medicine values were less than the corresponding estimates for 1985– varied significantly between countries. Information on 1990 of 18,000 man mSv per caput. However, Sv and 0.003 national practices that had been provided to the Committee the uncertainties in all these estimates were considerable and by a sample of countries was extrapolated to allow a broad this apparent trend may not be real. Approximately 68% of assessment of global practice, although inevitably there were the global collective dose due to dental radiology arises from significant uncertainties in many of the calculated results. I, with contributions of about countries in health-care level On the basis of a global model in which countries were 31% and less than 1% from countries in health-care level II stratified into four levels of health care depending on the and level III/IV, respectively. number of physicians relative to the size of population, the world annual total number of medical radiological examina- B3. The numbers of X-ray generators (excluding dental mil- tions for 1991–1996 was estimated to be about 1,900 units) available for diagnostic radiology varied considerably lion, corresponding to an annual frequency of 330 per 1,000 between countries and between the health-care levels of the world population (table B1). Estimates of these quantities global model, with estimated averages of 0.5, 0.2 and 0.02 million and 300 per 1,000 popu- for 1985–1990 were 1,600 per million population for levels I, II and III/IV, respectively lation, respectively. The global total of examinations was B1). The estimated average annual number of medical (table distributed according to the model among countries with radiological examinations per medical X-ray generator was different health-care levels as follows: 74% in countries of lower for countries of health-care levels III and IV (1,100) I (at a mean rate of 920 per 1,000 population; 25% level than for those of level II (2,300) and level I (2,700). The esti- in countries of level II (150 per 1,000 population); and 1% mated average values of annual collective dose per medical in countries of health-care levels III and IV (20 per 1,000 X-ray generator followed a similar global pattern: 1.2 Sv man population). In addition to such medical radiological exam- Sv per unit man per unit in health-care levels III and IV; 2.0 inations, there was also an estimated global total of about Sv per unit in level in level II; and 3.6 I. However, there man 520 million dental radiological examinations annually, cor- may be an under-reporting of medical and dental equipment responding to an annual frequency of 90 per 1,000 world in some countries. population. The assumed distribution between health-care I and less than 0.1% levels is: more than 90% occur in level in levels III and IV. Notwithstanding the estimated mean fre- B4. The estimated global annual per caput effective dose quencies of examination for each health-care level quoted per medical radiological examination for 1991–1996 was above, there were also significant variations in the national mSv esti- 1.2 mSv, which is comparable to the value of 1.0 frequencies between countries in the same health-care level. mated for 1985–1990. However, the levels of dose to individ- ual patients varied significantly among the different types of B2. Estimated doses to the world population resulting examination and also among countries. The contributions to from diagnostic medical and dental radiological examina- collective dose provided by the different categories of exam- B2. For 1991–1996, the global tions are summarized in table B3 according to health-care ination are summarized in table annual collective effective dose due to medical radiological level. On a global scale, population exposure due to medical examinations was estimated to be about 2,330,000 man Sv, radiology was dominated by the use of CT (which accounted corresponding to an average annual per caput dose of for 34% of the annual collective dose) rather than examina- 0.4 mSv; estimates of these quantities for 1985–1990 were tions of the upper gastrointestinal (GI) tract (12%), which mSv, respectively. The distribu- 1,600,000 man Sv and 0.3 had been estimated to be the most important procedure for tion of the collective dose among the different health-care the period 1985–1990. This new pattern applied principally levels of the global model was as follows: 80% in countries I, where the mean contribu- for countries of health-care level of level I (giving a mean annual per caput dose of 1.2 mSv); tion from the use of CT was 41%. However, the dominant mSv per II (corresponding to 0.14 18% in countries of level practice in health-care level II countries was chest fluoros- caput); and 2% in countries of health-care levels III and IV copy (50% of collective dose), and in countries of levels (corresponding to 0.02 mSv per caput). Diagnostic dental III and IV it was examination of the lower GI tract (34%), radiological examinations were estimated to provide a fur- with CT use providing contributions of only 5% and 2%, ther annual collective dose to the world population of about respectively. 49

62 50 UNSCEAR 2008 REPORT: VOLUME I II. dOSES FOR SpECIFIC x-RA y pROCEdURES A. diagnostic radiography a randomized controlled trial that ESDs were higher in the computed radiography group. B5. In the United Kingdom of Great Britain and Northern Ireland, the former National Radiological Protection Board B12. Vañó et al. [V14] performed a retrospective analy- (NRPB) (now the Radiation Protection Division of the Health sis of patient dose levels in projection radiography using a Protection Agency) performed surveys of patient doses for computed radiography system. They found that immediately common radiological examinations [S7]. A national data- following the introduction of computed radiography, doses base is used to collect data on patient doses from routine increased by between 44% and 103% for lumbar spine and examinations according to a national protocol [N1]. chest examinations when compared with the film–screen combination. Since this initial period, patient doses have The NRPB has published data for common radiological B6. been reduced. This analysis is based upon relatively large examinations in terms of ESD and DAP [H34]. sample sizes of between 1,800 and 23,000. Table B4 is a summary of patient dose data for con- B7. B13. Radiation doses for standard radiographic examina- ventional diagnostic radiological examinations (adapted from tions in an accident and emergency department were stud- reference [H33]). It has been revised with additional patient ied by an Italian group [C28]. They concluded that effective dosimetry data. Effective dose estimates are given in the doses for direct digital radiography were typically 29% and table. These have been calculated by the authors of the NRPB 43% lower than for film–screen or computed radiography. report, by the authors of the cited document or by apply- ing a conversion factor used by the NRPB to the additional Since the previous report, digital imaging has been B14. dosimetry data assessed in the cited patient dose survey. introduced into many centres worldwide. In summary, the impact of the introduction of digital imaging on patient dose levels in diagnostic radiography is unclear. B8. Various authors have compared flat panel direct digi- tal detectors with computed radiography (CR) systems [B12, Z4]. For the same image quality, radiation doses were Mammography b. halved using direct digital radiography (DDR) during excre- tory urography [Z4]. Doses for chest imaging were 2.7 times lower for a direct digital detector compared with film–screen Mammography has also undergone many technologi- B15. radiography and 1.7 times lower compared with a computed cal changes. Originally it was performed with conventional radiography system. X-ray tubes using industrial direct exposure X-ray film to have good image quality. The introduction of dedicated B9. In another study, Ludwig et al. used monkeys as surro- mammography equipment, having a specialized tube with gates for paediatric patients in order to deduce the dose a molybdenum target/molybdenum filtration, combined saving from the introduction of flat panel detectors for lum- with the introduction of film–screen cassettes with a rear bar spine radiography [L11]. Dose savings of 75% without phosphor screen, substantially reduced radiation doses. loss in image quality were predicted. B16. This reduction in dose facilitated consideration of the B10. Vañó et al. [V8] have developed a computerized sys- introduction of mass screening programmes. Given the pub- tem for dose monitoring in radiology. Technical details for lic health benefits of breast cancer screening, many countries a series of examinations performed on a CT system were I have introduced mass screening pro- in health-care level deduced from the DICOM header. A computer workstation, grammes. As a consequence, there has been a large increase linked to the hospital PACS network, calculates ESD and in the frequency of use of mammography. DAP from the technical parameters. The dose monitoring system calculates a running average for ESD and DAP for B17. The introduction of film–screen mammography cou- the most recent ten patients. It then compares this running pled with molybdenum target tubes with molybdenum filters average with reference levels. A warning signal is given if the has reduced ESD to about 0.01 Gy [G8]. However, a number running average is higher than the preset reference value. of individuals have advocated increasing film optical density so that the target optical density coincides with the point on the film–screen characteristic curve with maximum slope There is some evidence that the use of “technique B11. and hence contrast amplification [F2]. This has been shown factors” suggested by manufacturers can lead to higher to improve cancer detection rates [Y3]. Brennan doses in projection radiography [P17]. Peters and [P17] were able to reduce patient doses by optimizing Compressed breast thickness was analysed by B18. technique factors. Weatherburn et al. [W20] investigated Ogasawara and Date for Japanese women [O5]. The typical patient dose levels associated with bedside chest radio- compressed breast thickness for Japanese women was under graphy following the replacement of a film–screen system 3.8 cm, comparable to that in the Republic of Korea [O3]. with a computed radiography system. They discovered in

63 51 ANNEX A: MEDICAL RADIATION EXPOSURES fluoroscopy [I11]. However, direct or non-intensified fluor- Mean glandular doses are likely to be similar. Typical glan- mGy in studies in Japan dular doses were reported as 1.5 oscopy is still performed in some countries. The number of dose surveys on non-intensified fluoroscopy systems is and in Taiwan Province of China [D8, T6]. While the com- pressed breast thickness reported in a German study [H22] somewhat limited. Dosimetry on these systems is important, was 5.57 cm, the mean glandular dose was comparable to not least from a historical perspective. that in surveys of Asian women (1.51 mGy). A similar value In a study in Brazil, doses for barium enema were B26. (1.5 mGy) was reported in a Canadian study [F10]. 2 2 Gy reported as 63 . A , with a range of 85–316 cm cm Gy 2 2 Gy Young [Y2] surveyed radiation doses in the United , mean dose of 107 cm Gy , with a range of 25–118 B19. cm hysterosalpingograms [C2]. Most of the was reported for Kingdom trial of breast screening in women aged 40–48 DAP arose from direct fluoroscopy and not from radio- years. Doses for 2,296 women were estimated. The average 2 cm graphic images. Mean DAP for seriography was 167 dose was 2.0 mGy for a craniocaudal film and 2.5 mGy for an Gy 2 ) [C2]. oblique view. Doses in younger women were approximately (range 25–118 Gy cm 7% higher than in older women (those aged over 50 years). B27. Marshall et al. performed a study of chest examina- tions using non-intensified fluoroscopy in Albania [M3]. B20. The Food and Drug Administration in the United States They investigated seven direct chest fluoroscopy systems. approved the first full-field digital mammography unit in 2000 2 , with effective doses DAP ranged from 0.34 to 3.64 Gy [C25]. The introduction of digital mammography in the United cm in the range 0.06–0.42 mGy States has been relatively slow, with digital units compris- mSv. The ESD was typically 17 ing 6.4% of the accredited mammography units [L26, M32]. for a PA chest fluoroscopy, which is nearly 100 times higher than the reference dose for the equivalent examination per- tal mammography offers potential benefits in the imaging Digi of young women and women with dense breasts [P22, P24]. formed using a film–screen system in the United Kingdom However, the high cost of digital mammography represents a [H34]. limitation on its acquisition by screening programmes [T5]. Image intensified fluoroscopy Kingdom, B28. . In the United Doses to over 5,000 women were examined on a Gen- the NRPB published data on DAP received by patients for B21. eral Electric 2000D full-field digital mammography system common examinations involving fluoroscopy [H33]. This in a two-year period [M6]. Dose information was obtained survey was undertaken in a limited number of centres and may not be representative of national practice. from the DICOM header. Mean glandular doses for both craniocaudal and mediolateral oblique projections were B29. mGy and 1.95 mGy, respectively. Fischmann et al. also Average DAP for endoscopic retrograde cholan- 1.8 giopancreatography (ERCP) in Greece was studied by found that doses for full-field digital mammography were 2 Gy Tsalafoutas et al. [T8]. The average DAP was 13.7 cm comparable to those for film–screen systems [F4]. 2 for a diagnostic procedure and 41.8 for a therapeutic cm Gy B22. Gennaro et al. [G15] calculated the ESAK for a sam- one. ple of 800 craniocaudal full-field digital mammograms. Mean glandular doses were in the range 1.27–1.37 B30. mGy and 1.37– Patient doses for barium meal examinations were 1.49 mGy for 50% and 30% glandularity, respectively. These measured in three hospitals in Serbia and Montenegro by Ciraj et al. [C14]. A total of 74 patients were monitored in dose levels are lower than for film–screen mammography. three hospitals with a minimum of 19 in each. All patients The Digital Mammographic Imaging Screening Trial kg of 70 B23. weighed within 10 kg. Median values of KAP var - 2 ied by a factor of 3, from 7.2 to 22.1 Gy cm . The authors (DMIST) included 49,528 women from 33 participating academic and community practices in the United States and also calculated effective doses. These ranged from 1.7 to Canada (25.5 months of enrolment from 2001 to 2003). All 4.8 mSv [C14], which illustrates the variation between women in the trial underwent both film–screen and digital hospitals. mammography. Mean glandular doses were between 1.7 and mGy for the digital systems and between 1.5 and 2 mGy B31. In summary, there are wide variations in dose levels 2.5 for the film–screen mammography units [P25]. for fluoroscopy procedures, reflecting differences in local practice, equipment and staff. The impact of digital imaging B24. As may be deduced from table B4, the variation on dose levels is also unclear. in dose is relatively small for mammography. The small range in doses is consistent with the practice of optimized d. mammography subject to quality control. Interventional radiology B32. Interventional radiology procedures have experienced C. Fluoroscopy and angiography a dramatic increase in frequency in recent years, principally because of the numerous significant benefits. Specifically, it is now possible to perform in a radiology department on B25. Direct fluoroscopy . Most regulatory systems interna- tionally have prohibited the use of direct or non-intensified an outpatient basis procedures that previously would have

64 52 UNSCEAR 2008 REPORT: VOLUME I The effect of the choice of puncture site on radiation necessitated surgical treatment in hospital. This results in B39. considerably reduced trauma for the patient, and the hospi- doses in intrainguinal angioplasty has been studied [N9]. 2 tal gains because more patients can be treated as outpatients for a retrograde puncture cm Gy The mean DAP was 7.95 2 site and 1.07 cm mGy for antegrade punctures, which illus- at a lower cost. Consequently, both hospitals and the public trates the effect of examination protocol on patient doses. demand access to more interventional radiology. This inevi- tably leads to an increase in the frequency of interventional B40. radiology procedures. Doses from cerebral embolization studies were reported by Theodorakou and Horrocks [T9]. The aver - 2 for a posterior–anterior plane and This growth in demand has implications for popula- B33. age DAP was 48 Gy cm 2 tion doses [C11, N10, W10]. Specifically, some interven- 58 Gy cm mGy for a lateral plane. Typical doses were 60 tional procedures are very complicated, and often involve to the patient’s right eye and 24 mGy to the thyroid gland. extended fluoroscopy times and the operation of fluoroscopy B41. equipment in high-dose-rate mode. This leads to high patient Ropolo et al. have deduced a factor to convert DAP 2 )) [R7] for abdominal doses. In some patients the procedures are repeated owing to cm mSv/(Gy to effective dose (0.15 restenosis. and vascular interventional radiology procedures. They con- cluded that there was a good correlation between DAP and Table B5 is a summary of various sources of patient B34. fluoroscopy time, as well as DAP and number of images. dose data for interventional radiology procedures; it has been A large United States study has been reported by B42. adapted from a table produced by Hart and Wall [H33]. The Miller et al. [M13]. The Society of Interventional Radiology original table has been revised with the inclusion of addi- tional patient dose survey results in interventional radiology. was asked by the Food and Drug Administration to undertake Effective dose has been included for comparative purposes. a survey of dose levels in interventional radiology. Twenty- Effective dose was calculated by either the NRPB or the one interventional procedures were studied over a three-year period. Dose data from 2,142 cases were reported. Dosime- original authors of the cited reports. In those instances where try data were obtained in terms of DAP and cumulative dose the authors of the survey did not deduce the effective dose, (i.e. total air kerma at the interventional reference point). the NRPB conversion factor has been applied to the DAP to B6 (adapted from reference [M13]) summarizes the Table derive the value quoted. mean, 95% confidence intervals, minimum and maximum 2 DAP (cGy cm B35. Data on various fluoroscopy and interventional pro- ), and cumulative dose (mGy). cedures have been analysed by the NRPB in the United Vetter et al. [V5] estimated the effective dose result- B43. Kingdom [H33, H34]. However, as the NRPB indicates, ing from uterine artery embolization of leiomyomata. They many of the data were obtained from too small a number of mSv for observed that the estimated effective dose of 34 hospitals or X-ray rooms to be indicative of national practice in the United Kingdom. uterine artery embolization (deduced from the DAP) was twice that for an abdominal CT scan. B36. Results from a large-scale survey of patient doses in interventional radiology have been published by Marshall B44. Bor et al. [B20] performed a series of measurements et al. [M1]. Forty fluoroscopy rooms were monitored using in Turkey for a range of interventional radiology proce- calibrated DAP meters linked to laptop computers. Size- dures. DAP and entrance doses were assessed for a series of 162 adult patients. Conversion factors were used to deduce corrected DAP values for seven groups of interventional effective dose. Table B7 is a summary of effective doses procedures were published. Size correction was performed measured in this study compared with previously published using previously published approaches [C1, L4]. data [C12, H1, M2, M4, M14, S26, T12, Z5]. The effec- It is clear from the data presented in these tables B37. tive dose levels assessed in Turkey are comparable to those reported in previous surveys. that considerable variations in patient dose exist between centres. Doses are dependent upon factors related to both Struelens studied patient doses for interventional B45. equipment and procedure, as well as on the skill of the - procedures in seven different hospitals in Belgium [S25]. Aver interventionalist and the clinical protocol adopted in a spe- cific centre. In addition, some centres perform more com- age DAPs for angiography of the lower limbs, carotid arter - 2 cm , Gy ies and cerebral embolizations were 68, 36 and 230 plex procedures, and hence dose levels tend to be higher [P6]. The data presented in these tables should therefore respectively. Average skin doses were 77, mGy and 262 mGy, be regarded as indicative of radiation dose levels received respectively, for the same three procedures [S25]. by patients. B46. Bridcut et al. investigated patient doses resulting Lavoie and Rasuli have assessed ESDs for angi- from 3-D rotational neurovascular studies [B7]. Three- B38. ographic procedures in Canada [L2]. The mean ESD was dimensional rotational angiography is a recently introduced technique in which the X-ray tube and detector rotate around Gy for a transluminal aortogram, rising to 2.1 0.16 Gy for a the patient during an interventional X-ray procedure. Recon- liver tumour embolization. Uterine embolization had a mean ESD of 1.3 Gy [L2]. struction techniques are used to present the radiologist with

65 ANNEX A: MEDICAL RADIATION EXPOSURES 53 the United Kingdom in 1990, 20% of the annual collective 3-D volume data. This technique is particularly useful in dose due to all radiological examinations resulted from CT the treatment of cerebral aneurysms. The average DAP was 2 cm examinations, even though there were a relatively small Gy for conventional digital subtraction angiography 48 2 and 2 Gy cm number of scanners [S1, S2]. Recent publications have con- for 3-D rotational angiograph. firmed the upward trend in the contribution of CT to the total collective dose from medical examinations [N16, N17]. In 1998 Shrimpton and Edyvean estimated the contribution to E. Interventional cardiology have risen to 40% [S17]. This had increased to 50% in 2003 Coronary angiography is used in the diagnosis of cor- [H24]. The number of CT scanners had almost doubled in B47. onary artery disease [P19]. In these examinations, contrast the six years since the original survey, [S3]. However, the medium is introduced into the bloodstream using a cath- number of CT scanners per caput is over 50% higher in the eter to provide images of the heart. Coronary angiography European Union as a whole and over 400% higher in the is used in the diagnosis of obstructive coronary artery dis- United States than in the United Kingdom [B3]. The col- ease to determine whether an angioplasty or coronary artery lective effective dose to the citizens of countries that have a higher number of CT scanners per caput is likely to be even bypass surgery is appropriate [F6]. Coronary angiography is the most common angiographic procedure and tends to be higher than that in the United Kingdom. undertaken in those aged 45 years or over. Angiography may B54. also be performed in other areas of the body, for example to The NRPB performed a survey of CT practice in the United Kingdom between 2002 and 2003, surveying 126 of diagnose obstructive disease in the extremities or the head. the estimated 471 CT scanners in the country. In the period A literature search has been performed to deduce typ- since the previous survey in 1991, all the CT scanners had B48. ical dose levels for cardiac interventional procedures. Dose been replaced and were capable of scanning in the helical B8. The mode. Over a third of the CT scanners surveyed were capable data for coronary angiograms are presented in table of multislice scanning (2–16 slices). A questionnaire was sent reviews of PTCA patient dosimetry studies are summarized B9 and data for stent procedures are presented in in table to each centre to obtain information on scanning protocols B11 is a review of the patient dosimetry B10. Table table and sequences. Typical doses from CT scanning in the United Kingdom are summarized in tables B12 and B13 [S19]. studies for pacemaker insertions. It may be deduced from 2 cm for this literature review that the typical DAP was 32 Gy 2 2 Gy for B55. cm Huda and Mergo [H5] have investigated the impact of for a PTCA, 46 a coronary angiogram, 44 Gy cm 2 the introduction of multislice or helical CT. Table for a pacemaker insertion. a stent procedure and 18 Gy cm B14 pro- vides a comparison of effective doses for three regions of the B49. body. It is interesting to compare doses with time from these Conversion factors may be used to deduce the effective various surveys of CT practice [H4, J2, S1]. The European dose from DAP or KAP readings and have been published by data for head CT scanning are comparable to the reported various authors for cardiac interventional procedures [B14, mean effective doses, being in the range 1.6–1.8 mSv. This M14, M35, R19]. The average conversion factor is 0.17 mSv/ 2 (Gy cm ). is particularly remarkable, given that the first paper [S1] preceded the last by nearly a decade [H4]. The introduction Larrazet et al. studied the effect of various factors B50. of spiral/axial multislice CT has resulted in an increase in on DAP during percutaneous coronary angioplasty [L14]. effective dose by a factor of over 2.5 for chest CT and of over 2 2 for abdomen CT (table B14). cm Gy for a radial technique compared with DAP was 175 2 138 cm for a femoral technique. Predilation, direct Gy B56. A survey of patient doses from CT examinations has stenting significantly reduced the DAP. been undertaken in Hungary [P1]. The authors estimated B51. In common with other interventional procedures, dose an annual total of 623,000 CT examinations in 1999 on levels in interventional cardiology are influenced by staff and 54 operational machines. This equates to 62.3 examinations the clinical protocol used, as well as the type of equipment. per 1,000 individuals. B57. A comparison of the performance of CT scanners in Computed tomography F. Nordic countries has been undertaken by Torp et al. [T1]. Results for brain, chest and lumbar spine scans are given in B52. A review of the published literature has been under- tables B15, B16 and B17, respectively. Effective dose was taken. Data on DLP and effective dose for head, body, calculated using the method developed by the NRPB [J3]. spine, angiography and other types of CT scans on adults are given in tables B12, B13, B14, B15 and B16, respec- B58. In two editorials in the American Journal of Roentgeno- B17 summarizes patient doses for CT scanning tively. Table logy, Rogers [R13, R14] raised awareness of the need for dose in paediatric patients. reduction in CT, especially the need to adjust CT exposure fac- tors for paediatric patients [D7, P11]. As a consequence, opti- B53. mization of CT examinations has become an important topic The annual frequency of CT examinations has exhib- ited a dramatic increase since CT’s introduction [H3]. In with a high level of public interest [M26, P12, R15].

66 54 UNSCEAR 2008 REPORT: VOLUME I In the United States, a nationwide survey of patient mSv for single-slice, 5.5 mSv for dual-slice and B59. was 7.4 mSv for quad-slice CT scanners. The increase in dose 8.1 doses from CT was undertaken during 2000–2001 as part for quad-slice CT scanners was not as great as reported by of the series of NEXT surveys of X-ray trends [S24]. Infor- mation on patient workload and CT scanning technique Giacomuzzi et al. [G14], probably owing to the optimization factors was obtained from 263 facilities in 39 states. X-ray of procedures. The authors predicted that improved clinical output measurements were performed both free in air and in efficacy and new applications will lead to rising examination a standard head phantom manufactured from PMMA. From frequencies [G14]. these measurements, CTDI and mean effective dose were Zammit-Maempel et al. studied the radiation dose to deduced. B66. the lens of the eye during scanning of the paranasal sinuses [Z1]. TLDs were attached to the patient to measure eye and The NEXT survey estimated that there were 7,800 CT B60. facilities in the United States. The estimated number of CT thyroid doses in the axial and coronal planes on a Siemens CT scanner using 140 mAs and 1 examinations and procedures (both adult and paediatric) was mm collimation. kV, 100 Eye doses of 35.1 mGy for the coronal plane and 24.5 mGy 58,000,000. The survey revealed that 30% of CT scanners for the axial plane were measured. Thyroid doses were performed axial scanning only. Helical scanners comprised mGy and 1.4 2.9 69% of CT scanners. Of the machines surveyed, 29% were mGy, respectively. The use of a low-dose scanning technique resulted in an eye dose of 9.2 capable of multiple slices. Just 1% of the machines were mGy and a thyroid dose of 0.4 mGy. electron beam CT scanners [S24]. B61. The use of CT in the diagnosis of renal colic has been The estimated effective doses for CT scanning in the B67. investigated [K4]. The effective mean dose from low-dose United States are summarized in table B18. mSv for female patients. Low- helical scanning was 1.35 dose helical CT was considered to be the method of choice. B62. A nationwide survey of CT examinations was under- taken in 2000 in Japan [N13]. This survey indicated that there Multidetector CT (MDCT) has enabled angio- were 87.8 CT scanners per million population. The distribu- B68. tion of examinations according to age was 100,000 in chil- graphic examinations to be performed on CT scanners. As million for persons aged dren aged up to 14 years, and 3.54 a consequence, MDCT is being explored as an alternative to conventional angiographic examinations. In another 15 years and older (i.e. 290 examinations per 1,000 popula- tion). The most common examination was head scanning, study [K5], doses from conventional and CT angiography of the renal arteries were compared. For conventional renal which comprised 80% of the examinations in children and 40% of those in adults. A breakdown of the annual number angiography, effective dose was deduced from the DAP. Two dose reduction strategies in conventional renal angio- of CT examinations in Japan is given in table B19. graphy were compared with the default factory settings. B63. The effective dose per examination assessed in this mSv to 11 Effective dose was reduced from 22 mSv if half Japanese survey was 2.4, 9.1, 12.9 and 10.5 mSv for head, the number of digital subtraction angiography images were mSv if the beam filtration was increased. chest, abdomen and pelvis scans, respectively. The trend taken and to 9.1 in the number of CT scanners, examination frequencies, The effective dose from CT angiography was 5.2 mSv, number of CT scans, collective effective dose and effective lower than any of the low-dose conventional angiography procedures. dose per person in Japan is summarized in table B20 [N13]. Nickoloff and Alderson measured radiation doses B69. A survey of radiation exposure for multislice CT B64. was conducted by Brix et al. [B18] in Germany in 2001. from a 64-slice cardiac CT scanner [N25]. Effective doses for mSv, com- 64-slice CT angiography were in the range 8–25 The facilities for each of the 207 multislice CT scanners in mSv for a routine chest CT and 14–26 mSv pared with 3–6 Germany were contacted, of which 113 replied. The response rate was slightly higher for public hospitals (60%) for diagnostic coronary angiography with fluoroscopy [N25]. than for private practice (43%). All facilities were asked to The main cause for concern was the high equivalent dose to the breast of 30–100 mSv. provide data on scan parameters and annual frequency for 14 standard examinations. Standard CT dosimetry quanti- Radiation doses from CT and cone beam CT in B70. ties were deduced using formulae that had been experi- mentally verified. The results of the survey for multislice dentistry were studied by Ludlow et al. [L12]. As might B21. The results of CT scanners are summarized in table be expected, the effective dose varied depending upon the previous survey are summarized in table B22 [G13] whether the salivary gland was included in the calculation. for comparison. (An examination may comprise more than The effective dose for a cone beam CT mandibular/max- μSv if the salivary glands one series.) illiary scan was 36 μSv, or 78 were included in the calculation. For a maxillary scan only, B65. Comparison of the results of the two surveys indicated μSv, respectively. For the effective doses were 19 and 42 that the scanner annual workload is considerably higher for a mandibular scan, the respective effective doses were 35 multislice CT (5,500) than for single-slice CT (3,500), a dif- and 75 μSv. These doses are less than the effective dose for ference of 63%. Average effective dose for CT examinations conventional CT.

67 ANNEX A: MEDICAL RADIATION EXPOSURES 55 Mori et al. compared patient doses for 256-slice CT radiographs weekly, compared with 32.5 for film– of 42.8 B71. with those for 16-slice CT [M24]. A prototype 256-slice CT screen users and 48.4 for centres with solid-state detec- scanner was developed to take dynamic 3-D images of mov- tors. The study concluded that, despite the increase in the ing organs such as the heart. The estimated effective doses frequency of use, the introduction of digital imaging would reduce effective doses by about 25%, as digital intraoral for chest, abdomen and pelvis examinations were 2.2, 2.6 and 3.3 radiography requires 50–80% lower doses. mSv, respectively. Dose profile integrals were between 11% and 47% lower for 256-slice CT than for 16-slice CT A Chinese study looked at eye doses in full-mouth B79. [M24]. dental radiography [Z2]. The dose to the lens of the eye μGy. The dose to the thyroid was 125 Van der Molen et al. [V9] have investigated the B72. was 250 μGy, to the pituitary 110 μGy, to the parotid 150 μGy and to the breast reductions in effective dose achievable on 16-slice CT scan- 12 μGy. ners compared with 4-slice CT, once the scanning protocol was optimized. Dose reduction was greatest for abdomen In panoral tomography, the X-ray tube and film rotate and pulmonary CT angiography, the magnitude of the dose B80. around the patient’s head to obtain an image of the entire reduction depending on the examination. Effective doses for dentition and jawbones. X-ray manufacturers have intro- optimized 16-slice CT ranged from 1.9 mSv for head scans to 7.2 mSv for abdomen scans. duced panoramic equipment that allows the operator to select the part of the jaw or dentition to be imaged. Effective doses for one machine have been reported as being in the range Mettler et al. [M41] have reviewed the published B73. 6–19 μSv, depending upon which anatomical programme literature on radiation doses from CT scanning. These data has been selected [L6]. are presented in table B23. Doses for dental implant imaging were assessed by B81. B74. Effective doses for CT colonography are in the range 1–18 mSv, with a typical effective dose of 8 mSv [I19]. Lecomber et al. [L10]. Conventional radiography, cepha- lometry, linear cross-sectional tomography and CT were In summary, patient dose levels for CT examinations compared. Doses were measured using thermolumines- B75. are higher than for many other types of diagnostic medical cent dosimeters in an anthropomorphic phantom. Salivary exposure. The introduction of multislice CT scanning has gland doses were 0.004 mSv for dental panoral tomography shortened examination times and has enabled more exami- and 0.002 mSv for both cephalometric imaging and cross- nations to be performed on a single scanner. The increase sectional tomography. CT doses were substantially higher, at 0.31 mSv. in workload associated with multislice CT scanning will impact on population doses. Doses in dental radiology have recently been B82. assessed by Helmrot and Alm Carlsson [H2]. ESAK and DAP for four common intraoral dental examinations in G. dental radiology mGy mGy ESAK for an incisor to 2.5 Sweden varied from 1 ESAK for a molar/upper jaw examination. DAP values for 2 Dental radiological examinations are among the B76. for Gy cm panoral tomography were in the range 0.06–0.1 2 most common medical exposures [H12]. There are two for paediatric cm Gy adult examinations and 0.03–0.04 basic techniques: intraoral and dental panoral tomography examinations. [G10, H2]. The former involves placing a film inside the mouth and the use of a dedicated dental X-ray tube. In den- Manufacturers have developed dedicated CT scan- B83. tal panoral tomography both the tube and the film move ners for dental radiology. These devices use cone beams around the head. and software specific to maxillodental CT scanning [S12]. They are used for the diagnosis of a wide variety of max- B77. Geist and Katz [G9] surveyed 65 dental schools in the illofacial diseases in addition to dental implant imaging United States and Canada. They found that 86% use E-speed [H38]. film. Direct digital imaging is used by just over half (58%) for intraoral radiography and by 11% for extraoral. The B84. Digital volume tomography (DVT) is a recently intro- use of dose reduction techniques was quite high, with 88% duced technique in dental radiology [C5]. It is intended to be using long focus–skin distances, 47% rectangular collima- a low-dose alternative to CT and panoramic tomography. A tion and 100% rare-earth film–screen systems for intraoral study has been performed by Cohnen et al. [C5] to assess radiography. DVT. Two types of DVT were compared with CT scan- ning. Radiation doses were measured using TLDs placed The use of digital imaging for intraoral radiography B78. in an Alderson–Rando phantom. The results are given in by general dental practitioners in the Netherlands was inves- B24. DVT acquires an image optimized for the display table tigated [B10]. The study indicated that centres using digi- of bony structures and other high-contrast objects, at the tal imaging devices took more radiographs. Centres using expense of soft-tissue imaging. It operates at a lower dose photostimulable storage phosphor plates took an average than either dental CT or sinus CT.

68 UNSCEAR 2008 REPORT: VOLUME I 56 Low bone density is associated with a higher fracture Doyle et al. [D13] assessed dose–width product B85. B89. risk. Though it affects a small but significant fraction of the (DWP) and DAP for 20 panoral tomography dental units and male population, low bone mass is a particular problem in compared their findings with a series of earlier studies [I33, post-menopausal women. As a consequence, most bone min- N15, O6, P13, T13, W17] (table B25). eral densitometry scans are performed on post-menopausal B86. Iwai et al. [I24] have estimated the effective dose for women. dental cone beam X-ray CT examinations. Effective doses B90. were 7.4 μSv for the maxillary incisor, 6.3 μSv for the maxil- Effective doses for pencil beam and for array modes of operation (dual-energy X-ray absorptiometry (DEXA) lary first molar, 12 μSv for the mandibular first molar, 9 μSv B26 [N5]. There is a clear examinations) are given in table for the temporomandibular joint (TMJ) and 14 μSv for the middle ear when assessed using 3-dimensional X-ray multi- trend towards more frequent and shorter examinations [L3]. image micro-CT. For an ortho-CT machine the effective doses for the mandible, maxilla and TMJ were 13, 22 and The effective dose for an anterior–posterior (AP) lum- B91. bar spine scan was 59 μSv on a Lunar Expert-XL fan beam 23 μSv, respectively. DEXA scanner [S13]. The effective dose was 56 μSv for an μSv for lateral spine morphometry Dose levels from dental radiology are, in the main, B87. AP femoral neck scan, 71 and 75 μSv for a whole-body scan. low compared with other types of diagnostic medical exposure. The impact of dental CT will have to be closely monitored. Effective doses to children from DEXA have been B92. assessed by Njeh et al. [N8]. Patient doses were assessed using lithium borate TLDs in anthropomorphic child phan- toms. Effective doses for posterior–anterior (PA) spine pro- cedures were 0.28 μSv for a 5-year-old and 0.20 μSv for a h. bone mineral densitometry and 10-year-old. The effective dose for a whole-body scan was dual-energy x-ray absorptiometry 0.03 μSv to a 5-year-old and 0.02 μSv for a 10-year-old. Bone mineral densitometry is a rapidly growing spe- B88. B93. In summary, dose levels to patients having DEXA cialized radiological technique. It is used to deduce bone transmission examinations are small compared with those for most other mass and bone density from X-ray or gamma ray diagnostic medical examinations. measurements. III. dOSES FOR SpECIFIC pOpULATIONS aediatric patients A. p B97. Patient doses from paediatric radiology have been assessed in a large Spanish hospital [V10]. Dose values were B94. Data on paediatric doses are very difficult to analyse, obtained for four common projection radiography exami- because the height and weight of children is very dependent nations performed using a photostimulable storage phos- on age [H11]. In addition, it is inappropriate to use effective phor computed radiography system. The DICOM header dose to quantify patient dose levels for paediatric and neo- was interrogated to provide information on the examina- natal radiology. In order to compare centres, an agreement tion, patient and technique factors. ESD was deduced using was reached within the European Union to collect data for knowledge of the measured tube output. Over 3,500 patient five standard ages, i.e. for newborn, 1-year-old, 5-year-old, dose values were obtained. A summary of the results of this 10-year-old and 15-year-old children. survey is given in table B29. B95. Some data are available in the United Kingdom for B98. A multicentre study of patient doses from CT scan- paediatric patients [H34]. These data are summarized in ning in children has been undertaken in Belgium [P7]. Val- B27 for five common radiographic examinations in table mSv, 1.1– ues of effective dose were in the ranges 0.4–2.3 B28 for three fluoroscopic exam- terms of ESD, and in table mSv for head, thorax and abdomen 6.6 mSv and 2.3–19.9 inations (DAP). As these data were obtained from a small scans, respectively. sample of centres, these values may not be representative of practice nationally. B99. ESDs in micturating cystourethrography (MCU) examinations in children have been monitored by Fotakis et Compagnone et al. [C15] assessed ESDs and deduced B96. al. [F11]. Despite its limitations noted earlier, effective dose effective doses for various paediatric examinations. Effec- was evaluated for comparative purposes using the factors mSv for mSv for chest PA and 0.10 tive doses were 0.005 published by the ICRP [I3]. The mean effective dose was abdomen AP examinations. 0.86 mSv for male patients and 0.76 mSv for female patients.

69 ANNEX A: MEDICAL RADIATION EXPOSURES 57 B107. Skin doses during paediatric cardiac catheterization Osei and Faulkner studied the foetal dose received B100. by a series of 50 pregnant women in the north of England examinations have been assessed [L13]. The average ESD to [O1]. These women had asked their physicians about the infants and children was 870 mGy. risks of ionizing radiation to the foetus. Virtually all the The effective dose during the percutaneous treat- dose estimations were performed retrospectively, as most B101. mSv [P9]. This of the women were unaware that they were pregnant at the ment of varicocele in adolescents was 18 compared with the doses from abdominal X-rays (1.31 B31 is a summary of the time of the examination. Table mSv) and for urography (4.6 mSv). estimated mean of foetal absorbed dose per examination for this group of women. Also given in table B31 are reported typical means from the published literature. Most of the foe- B102. In another study, Ono et al. [O9] investigated the tal doses in this table are based upon a United Kingdom - annual frequency and type of X-ray examinations per formed on neonates as a function of birthweight in a neo- survey made in the mid 1980s and may not be representative of current practice. natal intensive care unit. The radiology records of over 2,400 neonates were investigated. On average, neonates weighing less than 720 g birth weight had 26 films. While Most of the foetuses (68%) had a gestational age B108. the number of ESDs per neonate was dependent on birth of less than 8 weeks; a further 26% had a gestational age weight, the maximum dose was not. For chest exami- between 8 and 25 weeks. Five of the foetuses (10%) received mGy, nations the dose varied between 0.02 and 0.17 a total dose of over 10 mGy. The majority (58%) received depending on birth weight. doses of below 5 mGy. Estimated doses to the women tended to be higher than would be deduced from average doses for B103. Kiljunen et al. have collected a series of patient the examination. In addition, the women tended to be older doses for thorax examinations on paediatric patients in six than the norm. hospitals in Finland in the years 1994–2001 and in two hos- pitals in 2004 [K31]. Patient doses correlated exponentially Wagner et al. [W6] have produced a guide to the B109. with projection thickness. As a consequence, diagnostic medical management of pregnant patients and diagnostic reference levels were specified in terms of both ESD and irradiation. In their book, a series of case studies are pre- DAP as a function of patient projection thickness rather sented. While the majority were diagnostic radiological than by age band. examinations, some nuclear medicine procedures were per- mGy. These formed. Most doses were in the range 20–40 Onnasch et al. [O10] evaluated DAP for three differ- B104. doses are higher than those reported by Osei and Faulkner ent types of angiocardiography system over a period of eight [O1], mainly because many patients in the series reported by years. Data on 2,859 patients were acquired. Mean effective Wagner et al. had CT scans [W6]. doses for seven paediatric cardiac interventions are given in table B30 [O10]. Onnasch et al. also investigated the total B110. The estimated foetal dose while patients underwent effective dose for patients with different types of congeni- ERCP procedures was 3.1 mSv in a study in the United tal heart disease who underwent multiple examinations over States [T7]. Foetal doses were reviewed in a study of the use years [O10]. On average a paediatric patient would have 12 of double pigtail stents in the treatment of hydronephrosis four examinations. The mean total effective dose for a child [H20]. The mean uterus/foetal dose was 0.40 mGy (range with congenital heart disease who had multiple examinations 0.03–0.79 mGy). was 19 mSv (range 0.64–184 mSv). CT can be used for the detection of pulmonary B111. embolism in pregnant patients [R8]. Doses from helical CT were calculated [W12]. Foetal doses varied with gestational Foetal dosimetry b. mGy in the first trimester age, being in the range 3.3–20.2 mGy in the third. Mean foetal doses and rising to 51.3–130.8 B105. The risks to the foetus of radiation exposure are well with helical CT were reported as being lower than with the established. Consequently, most X-ray and nuclear medi- scintigraphy technique. cine departments have mechanisms for avoiding unintended irradiation of the foetus. There are relatively few studies of B112. TLDs were used to estimate foetal dose from CT radiation doses to the foetus, reflecting the effectiveness of in late pregnancy using anthropomorphic phantoms [D10]. these mechanisms. The measured foetal dose for abdomen examinations was mGy in the second trimester and in the range 30.0–43.6 B106. A retrospective study performed in the Islamic 29.1–42 mGy in the third trimester. Republic of Iran [A1] involved over 1,300 patients referred to a medical physicist for dose estimation. The B113. Transjugular intrahepatic portosystemic shunts average age of the foetus was 31 days and the mean foetal (TIPS) are used in the treatment of recurrent bleeding in liver - mGy. Most examinations were per absorbed dose was 6–8 cirrhosis [W13]. The foetal dose was estimated as below formed for non-malignant gastrointestinal or urological 10 mSv in a German study [W13]. problems.

70 58 UNSCEAR 2008 REPORT: VOLUME I TRENdS IV. A. Trends in practice be performed in a given period, inevitably leading to more efficient use of equipment and more examinations being performed. In addition, the introduction of colonoscopy will Most radiological examinations are performed on a B114. have an impact on the number of barium studies conducted. subgroup of the population who are ill. Patients who are ill tend to be either young or older than the average age of the Digital imaging has also proved useful to interven- general population. It is for this reason that the data collec- B119. tion forms ask for the age distribution for the examinations tional radiologists and cardiologists. The availability of last image hold or road mapping facilities has made it much performed. For example, the average age of cancer patients is generally higher than the average age of the general popu- easier for the interventionalist to orientate the displayed lation. Some of these patients are likely to have multiple CT image with patient anatomy. The planning of procedures has examinations to diagnose and stage their disease. They are become easier. also likely to be subject to multiple follow-up CT examina- The acquisition of images in a digital format per- B120. tions to check that there is no recurrence of the disease. Con- mits the use of computer techniques to enhance the images. sequently their total dose will likely be somewhat higher than the average. In addition to this effect, there is a trend for the Thus it is easier to see guidewires, catheters, stents, etc. This facilitates the introduction of more complex interventional increasing use of CT examinations for the early diagnosis of procedures. Almost all interventional radiology is performed diseases and the screening of asymptomatic individuals (for lung cancer, colorectal cancer, whole-body screening, and with digital imaging equipment where it is available, even in countries with health-care levels II to IV. calcium scoring). The introduction of MRI has had an impact on While digital radiography was originally intro- B115. B121. the frequency of diagnostic radiological examinations. For duced two decades ago, it is only recently that these sys- tems have started to become widely available in health-care example, in the period 1992–2001 in Canada, the number of level I countries. With these systems, dose becomes a user- MRI spine scans increased by 450%, whereas in the same period the number of CT spine scans increased by 51% and selectable variable. It is therefore important to select a dose the number of radiographic examinations of the lumbar spine sufficient to obtain the image quality required for the clinical objective of the examinations. decreased by 11% [C25]. B122. B116. Dotter and Judkins described the first percutaneous In the main, radiology is performed more frequently treatment of arteriosclerotic vascular obliterations in 1964 on elderly individuals than on the general population. An [D1]. Since then the range of interventional procedures has exception is dental radiology, which tends to be performed more on younger individuals, whose teeth and dentition are dramatically increased. This has been accompanied by sig- nificant developments in equipment, such as the introduction still developing. With improvements in dental hygiene, how- ever, individuals are likely to retain their teeth for longer; thus of digital imaging and more recently direct digital imaging. the age distribution of individuals having dental radiology will change with time. B123. In recent years there has been a dramatic increase in the frequency of both diagnostic cardiological examinations (coronary angiograms) and X-ray-guided coronary treatment The past four decades have witnessed immense tech- B117. nological advances in radiology. The introduction of image procedures, such as PTCA and the insertion of coronary stents and pacemakers. This increase has been motivated by intensification has led to the development of diagnostic pro- the many benefits of X-ray-guided cardiological procedures. cedures such as angiography and interventional radiology. These cardiological procedures, which would previously The improvement in image quality associated with the intro- have required open-heart surgery, can be undertaken on an duction of image intensification and subsequent technical outpatient basis. The patient benefits from a reduction of the developments such as image digitization have made possi- ble the expanded use of fluoroscopic examinations. Angio- trauma associated with the procedure. graphic examinations have become more common and in B124. The aspirations of interventionalists to perform some instances more complicated. more complex procedures have been matched by the desire of manufacturers to design and market systems that meet Digital imaging has had the greatest impact on the B118. these perceived requirements [W1]. Initially, interventional- conduct of barium studies. Almost overnight, conventional ists used equipment intended for diagnostic studies such as fluoroscopy equipment ceased to represent the state of the barium studies or to use a mobile image intensifier system art. Digital imaging meant that barium studies could be performed in a shorter period of time, and spot (still) digi- in a sterile theatre. However, manufacturers nowadays sell tal images were instantaneously available. This meant that equipment with highly differentiated designs. Thus interven- fewer technologists were required to assist the radiologist tional equipment designed specifically for neuroradiology or performing the examination. Also, more examinations could cardiology has been developed. The design and operation are

71 ANNEX A: MEDICAL RADIATION EXPOSURES 59 in 2006 by separately performing a regression analysis on thus optimized for a narrow group of procedures. For exam- each country’s data and then extrapolating to 2006 using the ple, the imaging requirements for embolization in interven- average annual rate of increase. For illustration purposes, tional neuroradiology is different from the requirements for barium studies. the data for the Netherlands are shown in figure B-I. Also shown is the linear regression line fitted to these data. For The frequency of interventional cardiological proce- B125. each country the fitting of a regression line to the PTCA dures has been investigated by Faulkner and Werduch [F19]. annual frequency data was reasonably good, the worst fit -value of 0.047 and an p R -value of On its website [H27] the British Heart Foundation publishes being for Greece with a 0.76. The Finnish data fitted best to a regression analysis for statistical information on the rates of coronary angiograms, PTCA and stents per million population for various European data after 1999, when there appears to be a change in the rate countries for the period 1990–2003. The data are incom- of increase in the annual number of procedures. This general approach was used to analyse the coronary angiography and plete, the most complete data being for PTCA procedures. stent data for those countries where the data were available. It is possible to deduce the frequency of PTCA procedures -I. Figure b Frequency of pTCA procedures in the Netherlands for the period 1990–2003 p < 0 .001; R = 0 .995) A regression line has been fitted to the data ( 1 400 y = 53.478x – 105 860 1 200 1 000 800 600 400 PER MILLION POPULATION NUMBER OF PTCA PROCEDURES 200 0 1990 1998 1996 2001 1995 2002 1994 2003 1993 2004 1997 1992 1991 2000 1999 YEAR 2006 for various European countries. In the table, data esti- B126. For some countries, frequency data on the number mated from the annual frequency of PTCAs using the ratio of coronary angiograms and stents per million population method are given in italics. Data on the population for Euro- were not available on the website. In order to estimate the pean countries were obtained from the Central Intelligence number of coronary angiograms and stents, the ratio of the Agency website [C26]. The total number of procedures for annual frequency of coronary angiograms to PTCAs and the each country was deduced by multiplying the annual fre- ratio of the annual frequency of stents to PTCAs were cal- quency (expressed as number per million population) by the culated for each country using the data available. The aver- size of the country’s population (in millions). For Bulgaria age ratio of coronary angiograms to PTCAs was 3.6, and the and Ireland, limited data were available on the British Heart average ratio of stents to PTCAs was 0.72. These ratios were Foundation website, which gave only the number of PTCA gram and stent used to estimate the number of coronary angio procedures for years around 2000 and no data for other years. procedures for cases where data were not available. The average annual rate of increase across Europe was used B127. There were limited data available for the number of to deduce the number of PTCA procedures in 2006. The pacemaker insertions performed for each country where data ratio method was then used to deduce the estimated number were available. The ratio of pacemaker insertions to PTCAs of coronary angiograms per million population and of stents for the country in 2000 was used to deduce the number of per million population for Bulgaria and Ireland. pacemaker insertions in 2006 from the estimated number of PTCA procedures. If this ratio was not available for a given B129. It may be deduced from table B32 that in the country, the average ratio across those countries where data 29 European countries studied, the estimated average number were available was used. of coronary angiogram is 5,045 (range 670–11,646) per mil- lion population (population-weighted average). The average B128. Table B32 gives the estimated number of procedures number of PTCA procedures in Europe is 1,510 (range 186 per million population and the total number of procedures in

72 60 UNSCEAR 2008 REPORT: VOLUME I eligible population, and to 3,704) per million population. The corresponding figures depends on the health-care level, the the screening interval and uptake. for stent procedures are 836 (range 134 to 2,667) per million and 926 (range 53–2,481) per million for pacemaker inser- B132. CT scanners were introduced into clinical use in tions. On average there are 3.6 coronary angiogram exami- 1972 by EMI in the United Kingdom [H3]. The clinical nations for every stent procedure. This ratio varies between benefits of these procedures were realized immediately. The countries and will reflect the local practice regarding the use of computers in medical imaging has subsequently revo- classification of combined coronary angiogram and PTCA lutionized radiology, with the introduction of digital radio- procedures and stent procedures. Data for recent years will graphy and the digitization of images produced by image be affected by the rate of introduction of drug-eluting stents, intensifier television systems. as these have an impact on the restenosis rate. In Canada, the number of CT scanners increased by B133. B130. López-Palop et al. [L18] have surveyed interven- 82% in the period 1990–2005 [C25]. There was a variation of tional cardiology practice in Spain in 2003. Data were almost a factor of 4 in the number of CT scanners per million acquired from 112 centres (104 adult, 8 paediatric), repre- population in different states, yet the variation in the number senting nearly all centres in Spain. Over 40,000 percutane- of angiography suites per million population was less than a ous coronary interventions were performed; an increase of factor of 3, and the variation in the number of catheterization 14.4% in a year; 92.5% of interventions involved the use laboratories per caput was only a factor of 2. Typically there of stents. The number of mitral valvuloplasty procedures were 2.1 CT scanners for every MRI machine. increased by 23% in 2003 to 433. The Organisation for Economic Co-operation and B134. B131. The annual frequency of screening mammography Development (OECD) has reported wider variations in the varies between countries. For example, the Canadian Cancer number of items of medical imaging equipment. Figure B-II Society recommends that women aged 50 years to 69 years have summarizes the number of CT scanners per million population. a screening mammogram on a biennial basis [C25], whereas in Japan has the largest number of CT scanners per population, the United Kingdom’s National Health Service Breast Screen- approximately 60 times more than Mexico. The median number ing Programme, women aged 50 to 69 are offered mammogra- of CT scanners in the countries studied in the OECD survey phy on a triennial basis [L27]. The number of screening mam- [C25] was 14 per million population. However, the data may not mography examinations performed in a specific country be representative of the number of CT scanners in Germany. Number of CT scanners per million population in OECd countries [C25] Figure b -II. Sources: OECD Health Data 2007, OECD, for all countries except Sweden and Canada; Belgian Health Care Knowledge Centre, HTA of Diagnostic , KCE report vol . 37C, 2006, for Sweden; National Survey of Selected Medical Imaging Equipment, Canadian Institute for Resonance Imaging Health Information, for Canada . Reproduced with permission from the Canadian Institute for Health Information 92.6 Japan (2002*) 45.3 Australia (2004*) 32.2 United States (2004*) 32.2 a Republic of Kore 31.6 Belgium (2004*) 29.4 Austri a Lu xembourg 28.6 Italy 27.7 26.2 rtugal Po 25.8 Greece 23.7 Iceland Switzerland 18.2 17.8 Sweden (2006) 15.4 German y Finland 14.7 14.7 Median 13.8 Denmar k 13.5 Spain Cz ech Republic 12.3 12.1 aland (2004*) New Ze 12.1 Canada (2006**) 11.3 kia Slova 10.7 Ireland France 9.8 7.9 land Po United Kingdom 7.5 7.3 rkey (2003*) Tu 7.1 Hungary 5.8 Netherlands 3.4 o Mexic 07 0506 04 0203 01 100 0 0809 NUMBER OF CT s PER MILLION POPULATION *latest year for which data are available . **As of January 1, 2006 .

73 ANNEX A: MEDICAL RADIATION EXPOSURES 61 B136. Temporal changes in the number of CT scanners Mettler et al. [M37] investigated CT practice B135. for three European countries and Canada over the period in the United States. The authors concluded that in the 1990–2005 are summarized in figure B-III. The largest period 1993–2006 the annual growth in the number of CT increase occurred in Italy, where the number of CT scanners procedures was over 10% (figure B-IV). The rate of increase increased by a factor of over 3. There was a 68% increase in has been steeper since 1998 (just under 17%), which is the number of CT scanners between 1998 and 2002 [C25]. probably associated with the introduction of helical and multislice CT scanning. In the period 1991–2005 the number of CT scanners in Canada increased from 200 to 361 [C25]. b-III. Figure Number of CT scanners per million population in selected G8 countries for which time series were available, 1990–2005 [C25] Sources: OECD Health Data 2007; National Survey of Selected Medical Imaging Equipment (2003, 2004 and 2005) . Reproduced with permission from the Canadian Institute for Health Information 35 30 25 20 15 10 PER MILLION POPULATION NUMBER OF CT SCANNERS 5 0 02 1990 91 04 2005 01 03 92 93 94 95 96 97 98 99 00 YEAR United States France German Italy Canada y -IV. Figure b Number of CT procedures annually in the United States [M37] 70 60 50 40 30 20 10 NUMBER OF PROCEDURES (MILLIONS) 0 1993 1994 1995 2006 1997 1998 1999 2005 2000 2001 2002 2003 2004 1996 YEAR

74 UNSCEAR 2008 REPORT: VOLUME I 62 B143. With the advent of helical and multislice scanning Manufacturers are developing new detectors with B137. higher detective quantum efficiency (DQE) [D2]. The intro- together with the associated use of slip ring technology, CT duction of detectors based on amorphous selenium could has undergone a renaissance. The shortening of scan times, reduce patient doses. These detectors have higher DQEs coupled with the rapid reconstruction of CT images made than conventional film–screen combinations or computed possible by modern computer processing power, has resulted radiography systems and require a lower dose to form an in an increased demand for CT scanners. Given the relatively high doses associated with these machines, it is likely that image containing an equivalent level of noise. CT examinations will make the largest contribution to popu- The detection efficiency of amorphous selenium B144. lation dose from man-made exposures in many countries. depends on the thickness of the material and the X-ray energy. The DQE of amorphous selenium is approximately B138. The development of multimodality CT scanners twice that of the thallium-doped caesium iodide typi- will inevitably lead to an increase in the number and annual cally used in image intensifiers [Y1]. Terbium-activated frequency of CT scans. These machines allow the acquisi- gadolinium oxysulphate, used as a fluorescent screen for tion of nuclear medicine scans and CT scans using the same radiographic imaging, has a DQE comparable to that of machine. They are described in greater detail in appendix C on nuclear medicine. amorphous selenium [Y1]. In the United Kingdom, the Royal College of Radi- B145. Trends in patient doses b. ologists published a handbook on referral criteria designed to fit in the coat pocket of junior doctors and consultants International organizations, regulatory bodies and B139. [R1]. The European Commission has adopted an amended standards organizations have promoted dose reduction for version of this document [E3]. The original handbook has medical exposures [L8]. Equipment manufacturers have also been subsequently revised and replaced [R26]. These responded to this with a series of technological developments publications are based upon research evidence and a consen- and advances to reduce patient doses. Thus doses for a single sus approach. They provide advice to the referring physician examination have tended to decrease because of continuing when a particular radiological examination is recommended improvements in equipment design and performance. Doses for the assessment of a specific clinical condition; their use for diagnostic examinations can be reduced by giving careful is intended to avoid inappropriate or unnecessary radiation consideration to the use of X-ray equipment, its design and exposure. how the procedure is performed. Methods of dose reduction in diagnostic radiology have been reviewed elsewhere [F2]. C. Survey results Film–screen systems are used in conjunction with B140. manual film processing in many centres worldwide, whereas B146. Table B33 is a summary of the world population in centres of health-care level I countries, automatic process- distribution according to the four health-care levels as used ing is almost invariably used. The number of repeat films in previous UNSCEAR assessments of medical exposures. made necessary because of problems with manual process- Countries were allocated to a health-care level according to ing may be as high as 50%, whereas for automatic proces- the number of physicians per caput. Data on the population sors this can drop to 6% [R3]. of each country and the number of physicians per caput were obtained from the WHO website [W2]. B141. Image intensifiers have replaced direct fluoroscopy systems, because the former have enabled the examinations B147. Table B34 is a summary of the number of physicians to be performed in low ambient light rather than under con- and health-care professionals recorded in the UNSCEAR ditions of dark adaptation. In addition, patient and staff doses survey. The data have been stratified according to the four with the non-intensified equipment were unacceptably high. health-care levels described above. Data on the number of B142. Increasing the gain of an image intensifier insert radiology technicians, medical physicists and other phy- means that less radiation is required to be incident upon the sicians performing radiology have been solicited in this input surface of the insert to produce the same light output. survey. High-gain systems can reduce patient doses [B2]. Inappro- B148. priately adjusted control systems may result in unnecessar- The numbers of physicians and other health-care professionals per million population are summarized in ily high patient doses. Checking image intensifier input dose rates under automatic control usually forms part of a quality table B35. The weighted average is obtained from the number assurance programme. Automatic systems can compensate of physicians in a country weighted according to its popula- I countries the weighted average tion. For health-care level for a loss in image intensifier gain without the operator being number of physicians per million population was 3,530, aware of the problem. This has led to one overexposure inci- which represents an increase of just over 600 per million dent in the United Kingdom [G1]. A significant proportion population, or of just under 20%, since the previous survey of the population dose from the overexposure arose from the use of automatic control systems with image intensifiers that [U3]. For health-care level II countries the number of physi- cians per caput has nearly doubled since the previous survey. suffered a rapid loss in gain.

75 ANNEX A: MEDICAL RADIATION EXPOSURES 63 conventional diagnostic X-ray generators, bone mineral den- There is some uncertainty in the data presented in this table as there are no internationally agreed definitions for some B37 summarizing the sitometers and CT scanners, with table of the professions. The number of physicians per caput in data received on digital diagnostic equipment. Zimbabwe has decreased over the period of this report; III Zimbabwe’s inclusion in the health-care level category B150. The data given in tables B36 and B37 have been analysed according to the number of items of equipment, may need to be reviewed in the future. normalized to the size of the population of each country B149. supplying data. This analysis is presented in tables B38 for Information on the number of items of diagnostic radiology equipment in each country has been obtained as conventional generators, bone mineral densitometers and CT part of the UNSCEAR survey of practice. Data on digi- scanners, and in table B39 for digital equipment. Figure B-V tal imaging systems were also requested in this survey. summarizes the number of items of radiological equipment B36 summarizes the data returns for various types of per million population across the four health-care levels. Table -V. Numbers of items of radiological equipment per million population across the four health-care levels Figure b 1: general; 2: mammography; 3: dental; 4: interventional; 5: general fluoroscopy; 6: angiography, 7: bone densitometry, 8: CT 700 Health-care level I 600 Health-care level II 500 Health-care level III 400 V Health-care level I 300 200 100 0 78 56 34 12 NUMBER PER MILLION POPULATION Y EQUIPMENT TY RA PE OF X- I countries the number of con- B151. For health-care level mammography units per caput. Similarly, the number of CT ventional medical X-ray generators has increased to 370 per scanners per caput has increased by a third since the previous million population from 293 per million population in the UNSCEAR survey of practice [U3]. previous survey [U3]. The number of digital mammogra- phy units constitutes just over 25% of the total, whereas for B153. Table B40 contains an analysis of the temporal conventional X-ray generators the proportion of digital units trends in the average provision for medical radiology. I countries. The is considerably lower for health-care level number of CT scanners has nearly doubled to 32 scanners B154. Temporal trends in the number of conventional per million population in health-care level I countries. X-ray generators, dental X-ray units and CT scanners over the period covered by the various UNSCEAR surveys are B152. Trend analysis for health-care level II countries is summarized in figures B-VI, B-VII and B-VIII, respectively. less robust, owing to the limited number of survey returns. The estimated number of conventional X-ray generators in However, it is apparent from the survey that there has I countries decreased until 1991–1996 and health-care level been an increase of nearly a factor of 2 in the number of then increased again with this survey. -VI. Figure b Temporal trends in the provision of conventional x-ray generators 500 Health-care level I 400 Health-care level II Health-care level III 300 V Health-care level I 200 100 0 1991–1996 1970–1974 1980–1984 1997–2007 1985–1990 NUMBER PER MILLION POPULATION UNSCEAR SURVEY

76 64 UNSCEAR 2008 REPORT: VOLUME I Temporal trends in the provision of dental x-ray generators Figure b -VII. 700 Health-care level I 600 Health-care level II 500 Health-care level III 400 V Health-care level I 300 200 100 0 1997–2007 1980–1984 1985–1990 1991–1996 1970–1974 NUMBER PER MILLION POPULATION UNSCEAR SURVEY -VIII. Figure b Temporal trends in the provision of CT scanners 35 Health-care level I 30 Health-care level II 25 Health-care level III 20 V Health-care level I 15 10 5 0 1997–2007 1991–1996 NUMBER PER MILLION POPULATION UNSCEAR SURVEY The UNSCEAR survey also requested information dental examinations per 1,000 population in total in health- B155. care level I countries. For health-care level on the annual number of medical radiological examinations. II countries there These data are summarized in tables B41(a–d). dental exami- were on average just over 410 medical and 15 nations per 1,000 population. The total number of medical The total number of diagnostic medical and dental B156. and dental examinations was just under 430 per thousand population for health-care level II countries. examinations performed in various countries obtained from B42. The the UNSCEAR survey is summarized in table B158. survey data in tables B41(a–d) have been analysed according Tables B45(a–d) summarize the mean patient dose and variation on the mean for all diagnostic medical and to the number of medical and dental radiological examina- dental radiological examinations included in the UNSCEAR tions per thousand population performed annually, and this survey. Data in italics are for ESAK. Data in bold are for information is presented in tables B43(a–d). The weighted DAP, whereas CTDI values are underlined. In mammogra- average has been obtained from the number of examinations phy, mean glandular dose has been used as the dosimetric per caput, weighted according to the size of the country’s population. In general, for health-care level quantity. II countries the number of examinations has increased for virtually all Mean effective doses and variation on the mean B159. examination types. There is a large imbalance in the number value are summarized in tables B46(a–d). Weighted average of procedures per caput across the four health-care levels. effective dose has been estimated using the effective dose values given in the UNSCEAR survey of practice for each B157. Table B44 is a summary of the total annual number of diagnostic medical and dental examinations performed country, weighted according to population size of that IV I and level per thousand population obtained from the UNSCEAR sur- country. Data were available only for level vey. The weighted average total number of diagnostic exam- countries. The values of effective doses per examination inations is approximately 1,180 per thousand population were comparable in these two health-care levels. Mean and approximately 350 dental radiological examinations per effective doses for various examinations are given in figures medical and thousand population, equating to about 1,530 B-IX, B-X and B-XI.

77 ANNEX A: MEDICAL RADIATION EXPOSURES 65 . b-Ix Mean effective doses for various interventional Figure Table B47 is a summary of the distribution by age B160. procedures in health-care level I countries and sex of patients undergoing medical and dental radiologi- 1: PTCA cardiac; 2: cerebral; 3: vascular; 4: other; 5: non-cardiac cal examinations. The weighted average has been calculated. angiography; 6: cardiac angiography Most medical examinations are performed on individu- als aged over 40 years. There is a fairly even split between medical examinations performed on men and on women; the 14 exceptions are mammography, which is mainly performed 11.9 11.2 12 on women, and pelvimetry, which is performed only on 9.3 10 9.0 women, usually aged between 15 and 40 years. 7.9 8 5.7 B161. In dental radiology, most examinations are per- 6 formed on individuals aged between 16 and 40 years. There 4 is an almost equal split of examinations between the two 2 sexes. In general the age and sex distribution of individuals 0 undergoing medical and dental exposures is comparable to MEAN EFFECTIVE DOSE (mSv) 12 56 34 that of the previous survey [U3]. PROCEDURE The annual collective dose due to diagnostic radio- B162. logy was estimated by multiplying the number of examina- tions per thousand population for a health-care level country by the effective dose for that examination and the total popu- lation of that country obtained using the health-care model B33. Using the data in table B48, the summarized in table Figure b-x. Mean effective doses for various CT examinations average effective per caput dose from medical exposures in health-care level I countries mSv for health-care levels I, II and was 1.91, 0.32 and 0.03 1: head; 2: thorax; 3: abdomen; 4: spine; 5: pelvis; 6: other III–IV, respectively. B163. For dental examinations, the total collective dose to 14 12.4 Sv for health-care the population was estimated as 9,900 man 12 Sv for health-care level level I countries, 1,300 II coun- man 9.4 10 Sv for health-care level tries and 89 man III–IV countries. 7.8 8 The total collective dose to the world population from dental 6 exposures estimated on the basis of the survey returns and 5.0 3.8 using the UNSCEAR health-care model is 11,000 man Sv. 4 2.4 2 The total collective dose from all medical and dental B164. 0 exposures is estimated as 2,900,000 man Sv for health-care MEAN EFFECTIVE DOSE (mSv) 56 34 12 I countries, 1,000,000 man level II Sv for health-care level SCAN PE OF CT TY countries and 57,000 man Sv for health-care level III–IV countries. The contribution made by dental exposures to the total is approximately 0.25% for health-care level I coun- tries, 0.03% for level II countries and 0.002% for countries of level III–IV. B165. The total collective dose to the global population Figure Mean effective doses for various dental b-xI. from medical exposures is estimated to be 4,000,000 man Sv examinations in health-care level I countries man Sv. About 73% of the and from dental exposures 11,000 1: intraoral; 2: panoral tomography collective dose to the global population due to medical and dental radiological examinations is received by individuals 0.07 living in health-care level I countries. The populations of 0.06 0.06 III– II receive about 25%, while the populations of level level 0.05 IV countries receive only about 1%. This essentially reflects the variation in the frequency of medical and dental radio- 0.04 logical examinations between health-care levels. 0.03 0.02 0.02 B166. Vanmarcke et al. [V1] have estimated the col- 0.01 lective dose to the population of Belgium in 2001. In this 0.00 study they used the same approach as was used in the previ- MEAN EFFECTIVE DOSE (mSv) 12 ous UNSCEAR report [U3] and which has been employed here. The estimated annual per caput dose from diagnostic EXAMINATION

78 66 UNSCEAR 2008 REPORT: VOLUME I radiological examinations was 1.8 mSv from mSv, with 0.2 in table B52. For health-care level I countries the number of diagnostic medical radiological examinations has increased nuclear medicine. Approximately half of the dose (0.9 mSv) from 820 to 1,332 per 1,000 population over the period arose from CT examinations. covered by the UNSCEAR surveys, mainly because of the steep increase noted in the current survey. Over the same B167. The estimated annual per caput dose to the Belgian period, the increase in the annual frequency of diagnostic population was higher than the average effective per caput II countries dose estimated here for medical and dental procedures in radiological examinations in health-care level level I countries [V1]. This is consistent with Belgium hav- has increased by a factor of over 12. For health-care level ing a higher annual frequency of medical examinations per III and IV countries the number of diagnostic radiologi- I countries (i.e. 1,255 per cal examinations per caput has remained approximately caput than the average for level 1,000 population annually). constant. Scanff et al. [S44] have investigated the dose to the B168. B173. Table B53 summarizes the temporal trends in the French population from diagnostic medical procedures. Data annual frequency of diagnostic dental radiological examina- on the frequency of examinations in 2002 were obtained. tions since the first UNSCEAR survey in 1970–1979, though The estimated annual number of medical examinations was the approach to estimating the annual frequency has changed in the range 672–1,001 per 1,000 population, slightly lower over this period. The annual frequency of diagnostic den- than the average for level I countries estimated here. The tal examinations has remained fairly constant in health-care estimated annual per caput effective dose was in the range I countries, while in level II countries it has increased level mSv, with CT examinations contributing 39% of 0.66–0.83 by a factor of 20. The annual frequency of diagnostic dental the collective dose. The per caput effective dose is less than procedures in health-care level III and IV countries has also that estimated here. This is consistent with CT examinations dramatically increased. making a smaller contribution to the population dose than in other level I countries in this study. B174. Table B54 illustrates the temporal trends in the aver- age effective dose for some diagnostic medical radiological In the United Kingdom, the Health Protection B169. examinations in health-care level I countries over the period Agency has estimated the dose to the United Kingdom covered by the various UNSCEAR surveys of medical prac- population from medical exposures [H33]. Hart and Wall tice. In general, average effective doses for radiography estimated that there were 700 medical examinations per examinations have decreased in this period (e.g. chest and 1,000 population annually, giving rise to an annual per caput head). dose of 0.33 mSv, considerably lower than those for France, Belgium and other level I countries estimated in this annex [H33, S44, V1]. The lower per caput dose was attributed to Effective doses for upper and lower GI examinations B175. the lower doses per examination and fewer examinations per that involve the use of fluoroscopy were constant for the first person in the United Kingdom [H33]. two surveys. Then there was a major decrease to less than half for the third survey period, and those lower doses have B170. The National Council on Radiation Protection and been maintained for the present survey. This could reflect the Measurements (NCRP) [N26] has estimated the dose to the introduction of digital fluoroscopy systems for barium stud- population of the United States due to diagnostic radiology ies and/or the impact of optimization studies in the period and nuclear medicine (table B49). The annual collective 1991–1996. effective dose to the population of the United States was esti- mated to be 900,000 man Sv, with an annual per caput effec- B176. In the first survey period, the only CT scans were mSv, somewhat higher than that estimated for tive dose of 3 examinations of the head. In the next survey, body scan- health-care level I countries here. ning was introduced. The change in practice impacts on the average effective doses because the dose for a B171. Table B50 summarizes the contribution made by head CT examination is less than that for a typical body the various types of radiological examination to the total scan. number of procedures, stratified according to the UNSCEAR health-care level model. Just over 87% of radiological exam- B177. The estimated dose to the world’s population inations worldwide are diagnostic, with 13% being dental. from diagnostic medical and dental radiological examina- Worldwide, CT scanning accounts for just under 6% of all tions in the period 1997–2007, stratified according to the examinations.The percentage contribution to the collective UNSCEAR health-care level model, is given in table B55. dose for various types of medical and dental examination is The total annual collective dose due to all diagnostic medi- B51 summarized in table B51. It may be deduced from table cal radiological examinations estimated using the approach that just under 43% of the total dose to the world population of previous UNSCEAR reports was 4,000,000 man Sv, and arises from CT scanning. Sv due to diagnostic dental examinations. The 11,000 man B172. Temporal trends in the annual frequency of diag- total annual collective effective dose due to all diagnostic nostic medical radiological examinations are summarized radiology was 4,011,000 man Sv.

79 ANNEX A: MEDICAL RADIATION EXPOSURES 67 b-xIV. Figure Variation in collective effective dose from Figure B-XII illustrates the variation in per caput B178. diagnostic medical radiological examinations effective dose for diagnostic medical exposures with health- care level. The per caput effective dose to individuals living 3 500 000 I countries is approximately six times in health-care level 308 2 887 II countries. that received by individuals in health-care level 3 000 000 By comparison, the per caput effective dose for individuals 2 500 000 living in health-care level III and IV countries is less than 2 000 000 one-tenth of that in health-care level II countries. 1 500 000 1 008 460 1 000 000 DOSE (man Sv) 500 000 Variation in per caput effective dose for b-xII. Figure 33 023 24 348 COLLECTIVE EFFECTIVE 0 diagnostic medical radiological exposures with health-care II I IV III level HEALTH�CARE LEVEL 2.0 1.91 1.5 Figure B-XV illustrates the variation in collective B180. effective dose due to diagnostic dental radiological exami- 1.0 nations. Once again the majority of the collective effective dose is received by individuals living in health-care level I 0.5 countries. 0.32 PER CAPUT DOSE (mSv) 0.03 0.03 0.0 IV III I II Figure b-xV. Variation in collective effective dose from HEALTH�CARE LEVEL diagnostic dental radiological examinations 12 000 9 691 10 000 B-XIII illustrates the variation in per caput effective Figure 8 000 dose with health-care level for diagnostic dental radiological examinations. 6 000 1 282 4 000 DOSE (man Sv) 2 000 51 38 COLLECTIVE EFFECTIVE b-xIII. Variation in per caput effective dose for Figure 0 IV II III I diagnostic dental radiological exposures with health-care level HEALTH�CARE LEVEL 0.007 0.006 4 0.006 B181. As with previous estimates of the annual collective 0.005 effective dose to the world’s population from diagnostic 0.004 medical examinations, there are considerable uncertainties in 0.003 this estimate. This uncertainty arises in part from data limi- 0.002 tations in the survey returns at all health-care levels, but par- 0.000 4 ticularly for health-care levels II, III and IV. Survey returns 0.001 PER CAPUT DOSE (mSv) 0.000 1 0.000 1 submitted by countries in health-care level I represented just 0.000 I II IV III under half of the total population in this category. This rep- resents a reasonable level of response. For health-care lev- HEALTH�CARE LEVEL els II, III and IV, the survey returns submitted represented only about 1% of the total population in each category. As a consequence there are major uncertainties in the estimates for the annual frequency of each radiological examination, particularly for health-care levels II, III and IV. This is com- B179. The variation in collective effective dose due to pounded by uncertainties in population estimates and in the diagnostic medical radiological examinations is given in fig- effective dose received for specific radiological examina- B-XIV. Most of the collective effective dose is received ure tions. Thus the value for the annual collective effective dose by individuals living in health-care level I countries, where given here should be regarded as a reasonable estimate, but this value is more than twice that for health-care level II one on which there is some considerable uncertainty. countries.

80 68 UNSCEAR 2008 REPORT: VOLUME I V. SUMMARy II countries exhibit an even values for health-care level B182. A survey of practice in medical and dental radio- greater increase, from 26 per 1,000 population in 1970– logy has been undertaken. Responses from various countries 1979 to 332 per 1,000 in 1997–2007. Between the periods have been received. These data have been supplemented by 1970–1979 and 1997–2007, level III and IV countries have information on medical and dental radiological examina- shown a slight decrease in the annual frequency of diagnos- tions obtained from a review of the published literature. tic medical examinations: from 23 per 1,000 population to III countries and from 27 20 per 1,000 population for level B183. A global model, as used in earlier UNSCEAR per 1,000 population to 20 per 1,000 population for level IV reports, has been used. In this model, countries are strati- countries. fied into four health-care levels, depending on the number of physicians per 1,000 members of the population. As with Temporal trends in the annual frequency of diagnos- B186. previous UNSCEAR surveys of global exposure, there are tic dental examinations have been obtained. For health-care considerable uncertainties on the results estimated using this level I countries, the annual frequency has slightly decreased, global model. from 320 per 1,000 population to 275 per 1,000 between the periods 1970–1979 and 1997–2007, whereas for the coun- B184. The uncertainty arises from a number of sources, tries of other health-care levels, the number of diagnostic but primarily in extrapolating from the limited survey data dental radiological examinations has increased. obtained. In addition, patient dose surveys sample the patient dose distribution, which can have a wide range (i.e. the doses B187. In the period covered by this UNSCEAR report, received by some individuals may be 100 to 1,000 times the estimated annual collective effective dose to the world those received by others). In addition, the small sample size population due to diagnostic medical and dental radiologi- in the UNSCEAR survey could mean that the annual fre- Sv. This cal examinations is estimated to be 4,000,000 man quency data are distorted. There is also an uncertainty on the represents an increase in collective dose of approximately population estimates for the global population, although this 1,700,000 man Sv, or of just over 70% from the previous uncertainty is much smaller than the others. evaluation. This increase in collective dose has occurred because of two main factors. Firstly, the per caput effective According to this global model, the annual fre- B185. mSv, mainly as dose has increased from 0.4 mSv to 0.62 quency of diagnostic medical examinations in health-care a result of the increased annual frequency of CT scanning. I countries has increased from 820 per 1,000 population level Secondly, the world population itself has increased. in 1970–1979 to 1,332 per 1,000 in this survey. Comparative Global use of medical radiology (1991–1996) [U3] Table b1. Estimates derived from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures pART A: NORMALIZEd VALUES a Quantity Number per million population at health-care level I II III IV Globally Physicians All physicians 210 45 1 100 2 800 700 80 70 0 .1 110 Physicians conducting radiological procedures 5 X-ray imaging Medical Equipment 60 40 4 110 290 440 60 10 0 .1 150 Dental 24 0 .2 0 .1 7 0 .5 Mammography 17 2 0 .4 0 .1 6 CT b Annual number of Medical 920 000 150 000 20 000 330 000 examinations c Dental 14 000 200 90 000 310 000 Radionuclide imaging Equipment 7 .2 0 .3 0 .1 0 .03 2 .1 Gamma cameras Rectilinear scanners 0 .9 0 .3 0 .1 0 .01 0 .4 PET scanners 0 .002 0 0 0 .05 0 .2 d 5 600 19 000 1 100 280 17 Annual number of examinations

81 ANNEX A: MEDICAL RADIATION EXPOSURES 69 a Number per million population Quantity at health-care level III I IV II Globally Radionuclide therapy e 170 20 0 .4 65 Annual number of patients 40 Teletherapy 0 .2 0 .03 0 .02 0 .9 x-ray Equipment 2 .8 0 .5 0 .2 Radionuclide 0 .7 1 .6 0 .1 3 .0 0 .06 0 0 .9 linac 0 .3 f 1 500 470 50 820 Annual number of patients 690 Brachytherapy Afterloading units 0 .4 0 .1 0 .1 0 .7 1 .7 g h 17 200 (15) Annual number of patients 70 15 a Extrapolated, with rounding, from limited samples of data . b Based on following population sample sizes for global model: 67% for level I, 50% for level II, 9% for levels III and IV, and 46% overall . c Based on following population sample sizes for global model: 39% for level I, 49% for level II, 4% for levels III and IV, and 37% overall . d Based on following population sample sizes for global model: 68% for level I, 18% for level II, 11% for level III, 16% for level IV and 30% overall . e Based on following population sample sizes in relation to global model: 44% for level I, 16% for level II, 8% for level III, 16% for level IV and 22% overall . f Based on following population sample sizes in relation to global model: 56% for level I, 19% for level II, 17% for level III, 5% for level IV and 27% overall . g Based on following population sample sizes in relation to global model: 38% for level I, 11% for level II, 9% for level III, 0% for level IV and 17% overall . h Assumed value in the absence of survey data . pART b: AbSOLUTE NUMbERS a Quantity Total number (millions) at health-care level II III IV I Globally Physicians 4 .3 0 .13 0 .03 6 .6 All physicians 2 .1 0 .16 0 .23 0 .003 0 .000 1 Physicians conducting radiological procedures 0 .4 X-ray imaging Equipment Medical 0 .45 0 .2 0 .02 0 .002 0 .7 Dental 0 .67 0 .2 0 .01 <0 .000 1 0 .9 Mammography 0 .04 0 .000 1 0 .000 1 0 .04 0 .001 0 .027 0 .007 0 .000 1 0 .034 CT 0 .000 3 b Medical 1 410 470 24 1 910 Annual number of examinations c 475 42 Dental 520 0 .24 Radionuclide imaging Equipment 0 .011 0 .001 0 .000 1 0 .000 02 0 .012 Gamma cameras 0 .001 0 .000 1 Rectilinear scanners 0 .000 01 0 .002 0 .001 PET scanners 0 .000 01 0 0 0 .000 31 0 .000 3 d 32 .5 29 3 .5 0 .2 0 .01 Annual number of examinations Radionuclide therapy e 0 .3 0 .1 0 .01 0 .000 2 0 .4 Annual number of patients Teletherapy Equipment 0 .004 0 .001 0 .000 02 0 .000 01 0 .005 x-ray 0 .002 0 .002 0 .000 1 0 .000 04 0 .004 Radionuclide linac 0 .005 0 .001 0 .000 04 0 0 .005 f Annual number of patients 2 .3 2 .1 0 .3 0 .03 4 .7 Brachytherapy Afterloading units 0 .003 0 .001 0 .000 1 0 . 000 04 0 .004 g h Annual number of patients 0 .3 0 .05 0 .01 (0 .01) 0 .4

82 70 UNSCEAR 2008 REPORT: VOLUME I a Total number (millions) at health-care level Quantity III IV II I Globally Population 3 070 565 1 530 5 800 Total population 640 a Extrapolated, with rounding, from limited samples of data . b Based on following population sample sizes for global model: 67% for level I, 50% for level II, 9% for levels III and IV, and 46% overall . c Based on following population sample sizes for global model: 39% for level I, 49% for level II, 4% for levels III and IV, and 37% overall . d Based on following population sample sizes for global model: 68% for level I, 18% for level II, 11% for level III, 16% for level IV and 30% overall . e Based on following population sample sizes in relation to global model: 44% for level I, 16% for level II, 8% for level III, 16% for level IV and 22% overall . f Based on following population sample sizes in relation to global model: 56% for level I, 19% for level II, 17% for level III, 5% for level IV and 27% overall . g Based on following population sample sizes in relation to global model: 38% for level I, 11% for level II, 9% for level III, 0% for level IV and 17% overall . h Assumed value in the absence of survey data . a Estimated doses to the world population from diagnostic medical and dental radiological examinations Table b2. (1991–1996) [U3] Population Annual collective effective dose (man Sv) Annual per caput effective dose (mSv) Health-care level (millions) Medical Medical Dental Dental 1 530 9 500 I 1 .2 1 875 000 0 .01 II 3 070 0 .14 4 300 0 .001 425 000 0 .02 14 000 III 640 13 <0 .000 1 0 .02 565 IV <0 .000 1 11 13 000 World 5 800 0 .002 2 330 000 14 000 0 .4 a As was discussed in appendix A, because many of these exposures are received by patients nearing the end of their lives and the doses are not distributed evenly among the population, these dose estimates should not be used for the assessment of detriment . Table b3. Contributions to frequency and to collective dose from the various types of diagnostic medical (excluding dental) radiological examination assumed for global model (1991–1996) [U3] Examination Contribution (%) Level I Level II World Levels III and IV Contribution to total annual frequency Chest radiography 19 27 31 16 0 .1 <0 .1 4 Chest photofluorography 3 Chest fluoroscopy 1 42 <0 .1 11 18 13 limbs and joints 17 24 lumbar spine 3 5 5 5 1 0 .8 Thoracic spine 1 2 Cervical spine 4 2 3 3 Pelvis and hip 4 2 7 3 Head 6 14 6 4 4 7 5 Abdomen 8 5 2 Upper GI tract 4 4 lower GI tract 0 .9 1 6 1 Cholecystography 0 .3 0 .1 0 .4 0 .3 Urography 0 .6 3 1 1 Mammography 3 0 .4 <0 .1 2 CT 6 1 .0 0 .4 5

83 ANNEX A: MEDICAL RADIATION EXPOSURES 71 Contribution (%) Examination Levels III and IV World Level I Level II 0 .1 <0 .1 Angiography 0 .8 0 .6 <0 .1 0 .3 0 .1 0 .3 Interventional procedures 4 4 4 4 Other 100 100 100 All 100 Contribution to total annual collective dose Chest radiography 3 3 3 2 <0 .1 2 2 <0 .1 Chest photofluorography 50 <0 .1 Chest fluoroscopy 1 10 0 .8 0 .8 2 0 .8 limbs and joints 7 6 8 7 lumbar spine 1 Thoracic spine 3 1 1 0 .7 0 .6 0 .7 Cervical spine 0 .9 2 2 2 7 Pelvis and hip 0 .4 2 Head 0 .5 0 .5 2 5 6 2 Abdomen 12 9 Upper GI tract 12 15 lower GI tract 8 34 5 5 0 .5 0 .6 0 .5 Cholecystography 0 .3 4 3 Urography 3 11 Mammography 1 0 .2 <0 .1 0 .9 CT 41 5 2 34 Angiography 7 0 .4 6 0 .8 5 4 0 .6 1 Interventional procedures Other 4 4 4 4 100 100 100 All 100 Summary of patient dose data for diagnostic medical radiological examinations Table b4. Examination ESD DAP Effective dose Patients Reference 2 (mSv) (mGy) (Gy cm ) Skull and facial bones [H33] Nasal bones 0 .01 1 0 .01 Facial bones [H33] 3 Mastoids 0 .06 [H33] Skull (PA + lAT + 0 .75AP) 1 .4–2 .5 0 .06 2 580 [G2, H33] Skull PA 2 .7 0 .027 [Z6] 2 .1 0 .021 [Z6] Skull lAT 0 .027 Skull [C28] Skull 0 .1 [M41] Skull (CR) 0 .029 [C28] Skull (DDR) 0 .022 [C28] Cephalometry 40 000 [N23, S43] 0 .01 Mandible 0 .014 2 [H33] 1 .35 TMJ 0 .012 [H33] Sinuses and antra 2 .2 0 .022 50 [H33]

84 72 UNSCEAR 2008 REPORT: VOLUME I ESD Effective dose Patients Reference Examination DAP 2 (mGy) ) (Gy cm (mSv) Head, soft tissue 1 [H33] 1 .8 Dacryocystography 0 .05 0 .06 [H33] Pharyngography 0 .002 20 [H33] Post-nasal space 0 .2 [H33] Salivary glands 0 .056 2 24 [H33] 0 .056 Sialography 0 .025 Eyes 2 .5 [H33] 1 .94 0 .019 [V8] Head Teeth Intraoral 0 .005 [l5, N23] Intraoral [M41] 0 .005 [N23] Panoramic 0 .01 [M41] 0 .01 Panoramic Cerebral angiography 48 .5 4 90 [M2] Carotid/cerebral 28 0 .78 55 [H33] Carotid/cerebral Carotid/cerebral 57 [K30] 42 Myelography 2 .46 68 [H33] Myelography 12 .3 1 .3 75 Discography [M34] lumbar radiculography 3 .5 106 [M34] Neck, soft tissue Soft tissues of neck 0 .1 0 .003 1 [H33] larynx [H33] 0 .07 [H33] laryngography 0 .07 Cervical spine 0 .3, 1 .7 0 .07 83 [H33] Cervical spine 0 .49 Cervical spine 104 [H33] 0 .064 0 .2 [M41] Cervical spine Thoracic spine 0 .7 [W7] Thoracic spine 3 .9, 10 .8 1 277 [H33] Thoracic spine 0 .64 4 .2 0 .8 38 Thoracic spine [H33] Thoracic spine 1 .0 [M41] Thoracic spine AP 6 .5 0 .6 [Z6] Thoracic spine lAT 15 0 .39 [Z6] Lumbar spine lumbar spine AP, lAT 1 9 892 [H33] 6, 14 .5 592 1 .2 lumbar spine [H33] 5 .7 1 .5 lumbar spine [M41] lumbar spine AP 10 1 .1 [Z6] l umbar spine lAT 26 0 .65 [Z6] lumbar spine AP/PA 0 .44 [V8] 4 .08 lumbar spine lAT 17 .5 0 .44 [V8] lumbar spine AP + lAT 0 .309 [C28] lumbar spine AP + lAT (CR) 0 .476 [C28] [C28] 0 .179 lumbar spine AP + lAT (DDR)

85 ANNEX A: MEDICAL RADIATION EXPOSURES 73 ESD Effective dose Patients Reference Examination DAP 2 (mGy) ) (Gy cm (mSv) Lumbosacral joint [W7] lumbosacral joint 0 .3 0 .34 2 210 [H33] 28 .1 lumbosacral joint [N2] lumbosacral joint 2 .2 0 .17 [H33] Sacroilliac 0 .06 1 [H33] Sacroilliac 5 .4 0 .17 6 [H33] Sacrum and coccyx 13 .9 Whole spine/scoliosis Whole spine/scoliosis 0 .1 [H33] 0 .53, 0 .63 0 .07 Whole spine/scoliosis [H33] 78 Whole spine/scoliosis 0 .12 7 [H12] 61 [C29] Whole spine/scoliosis 0 .14 [P21] 283 0 .08 Whole spine/scoliosis Shoulder girdle Shoulder 0 .3 0 .011 21 [H33] 0 .01 [M41] Shoulder 0 .19 0 .001 3 [H33] Shoulder AP 0 .31, 0 .98 4 [H37] Shoulder AP/lAT 0 .009 0 .01 [H33] Acrominoclavicular joints Clavicle/collar bone 0 .01 [H33] Scapula 0 .01 [H33] Sternoclavicular joint 0 .01 [H33] Sternum 0 .01 [H33] Upper arm Upper arm 0 .000 8 4 [H37] 0 .15 Elbow 0 .1 53 Elbow [H33] 0 .001 Forearm, wrist and hand Fingers 0 .000 5 [H33] 0 .1 0 .000 5 Hand [H33] 6 Hand 0 .4 0 .000 4 1 [H33] [H33] 0 .001 Radius and ulna/forearm 0 .001 Extremities [M41] Thumb 0 .000 5 [H33] Wrist/scaphoid 0 .1 0 .000 5 197 [H33] Pelvis 0 .7 [W7] Pelvis 4 .2 4 281 0 .67 Pelvis [H37] Pelvis 0 .75 285 [H33] 2 .6 Pelvis 0 .6 [M41] Pelvis AP 2 .2 0 .64 [N2] Pelvis/hip 2 .18 0 .35 [V8] Pelvis AP 0 .295 [C28] 1 .81 Pelvis AP (CR) 1 .83 0 .326 [C28] Pelvis AP (DDR) 1 .02 0 .168 [C28]

86 74 UNSCEAR 2008 REPORT: VOLUME I ESD Effective dose Patients Reference Examination DAP 2 (mGy) ) (Gy cm (mSv) Hip [H33] Hip 0 .35 0 .18 189 [H33] 2 .7, 3 .7 Hip 3 .1 0 .54 10 [H33] Hip 0 .27 14 [H37] Hip 3 .8 [Z6] 7 .2 Hip 0 .43 [M41] Hip 0 .7 2 .6 0 .7 55 [C30] Orthopaedic pinning Femur 0 .5 Femur 18 [H37] 0 .002 5 Femur 0 .001 4 5 [H33] 0 .13, 0 .14 Leg length leg length [R24] 0 .184 13 Knee, lower leg, ankle, foot 0 .42 0 .002 103 Ankle [H33] 0 .1 0 .001 12 [H33] Ankle 0 .06 0 .000 6 116 Foot [H33] Foot 0 .000 5 1 [H33] 0 .1 0 .49 [H33] 0 .002 5 404 Knee Knee 0 .001 5 52 [H33] 0 .15 Knee 0 .005 [M41] Calcanaeum/heel 0 .09 0 .000 9 5 [H33] Patella 0 .002 5 [H33] [H33] Tibia and fibula 0 .002 [H33] 33 0 .1 Tibia and fibula 0 .000 5 0 .000 6 [H33] Toes Skeletal survey 18 1 .8 2 [H33] Skeletal survey Chest Chest/ribs 0 .02 [W7] 0 .16 0 .016 10 361 [H33] Chest/ribs 0 .5 0 .05 [Z6] Chest PA 0 .02 [M41] Chest PA Chest PA 0 .17 0 .017 61 988 [V8] Chest lAT 0 .94 0 .094 61 988 [V8] 0 .29 [C28] Chest PA + lAT 0 .1 Chest PA + lAT [M41] 0 .041 Chest PA + lAT (CR) [C28] Chest PA + lAT (DDR) 0 .23 [C28] Thoracic inlet 0 .02 [H33] Bronchography 1 .74 0 .21 1 [H33] Mammography Craniocaudal 1 .77 [O3] lateral 1 .88 [O3] Craniocaudal [J5] 1 .54 lateral 1 .82 [J5] 1 .5 [T6] 1 .5 [D6]

87 ANNEX A: MEDICAL RADIATION EXPOSURES 75 ESD Effective dose Patients Reference Examination DAP 2 (mGy) ) (Gy cm (mSv) [H22] 1 .51 Craniocaudal [y2] 2 2 .5 lateral [y2] 1 .5 [F10] [G15] Craniocaudal 1 .27–1 .37 [G15] 1 .37–1 .49 lateral [M11] 1 .8 Craniocaudal [M11] 1 .95 lateral [y12] 0 .37 Symptomatic 0 .33 Symptomatic [B15, P21] Symptomatic 0 .4 [M41] Screening (two views) 0 .37 3 035 [y12] 3 .7 Screening (two views) 0 .33 4 633 [B15] 3 .3 0 .23 50 000 Assessment [N23] Abdomen 0 .7 [W7] Abdomen 5 .4 0 .76 5 500 [H33] Abdomen 3 .1 0 .81 224 Abdomen 7 .5 Abdomen AP [Z6] 1 .05 2 .65 22 374 [V8] Abdomen 0 .37 0 .7 Abdomen [M41] Abdomen AP 1 .88 0 .28 [C28] Abdomen AP (CR) 2 .4 0 .358 [C28] Abdomen AP (DDR) 1 .64 [C28] 0 .223 Kidney and ureter Kidneys exposed 2 .5 [H33] 0 .6 8 [H33] 3 .5 Antegrade pyelography 9 1 .6 57 [H33] Nephrostogram, post-operative 13 2 .3 27 [H33] Retrograde pyelogram Urinary tract AP 2 .18 [C28] 0 .168 2 .51 [C28] Urinary tract AP (CR) 0 .193 Urinary tract AP (DDR) 0 .223 [C28] Intravenous urography IVU 1 141 [H33] 2 .4 IVU 3 .0 [M41] Bladder and urethra Cystourethrography 1 .5 [H33] Cystometrography 7 70 [H33] 1 .3 10 197 [H33] Cystography 1 .8 6 .4 1 .2 995 Excretion urography/MCU [H33] Urethrography 6 1 .1 19 [H33] Gynaecology Pelvimetry 5 .1 0 .8 28 [H33] Pelvimetry 0 .41 1 [H33] 1 .4 Hysterosalpingogram 4 1 .2 201 [H33] Lymphangiogram lymphangiogram 0 .3 0 .06 1 [H33]

88 76 UNSCEAR 2008 REPORT: VOLUME I ESD Effective dose Patients Reference Examination DAP 2 (mGy) ) (Gy cm (mSv) Tomography 3 [R15] Tomography 0 .15 Bone mineral densitometry Bone mineral densitometry 0 .000 5–0 .035 [A7] [N5] Bone mineral densitometry 0 .000 2–0 .01 [M41] Bone mineral densitometry 0 .001 Arthrography 0 .17 [H33] 1 .7 Arthrography 82 Pulmonary angiography 5 .6 5 [H33] Pulmonary arteriography 47 5 [M41] Pulmonary angiogram 7 Arterial pressures [H33] 2 .5 [H33] Superior venacavography 2 .5 [H33] Venacavogram 22 21 Abdominal angiography Inferior venacavography 2 .5 22 .1 338 [H33] 85 Mesenteric angiography 112 Mesenteric angiography [K30] 108 Renal and visceral 23 .9 56 [K30] 92 91 29 Renal and visceral [R10] 12 .7 Aortography 34 .5 4 .1 287 [H33] Thoracic Abdominal 98 25 .5 41 [W14] Abdominal 14 [l16] 19 12 [M41] Abdominal Peripheral angiography 27 .2 7 .1 759 Arteriography [H33] Arteriography 64 571 [K30] 26 .3 4 25 [T12] Arteriography Phlebography 3 .7 158 [H33] 0 .37 23 [W14] Phlebography 26 Barium swallow 1 .5 4 258 Barium swallow [W7] Barium meal Barium meal 2 .6 9 718 [H33] Barium follow-through Barium follow-through 3 [W7] 886 Small bowel enema Small bowel enema 7 .8 176 [H33] 30 Barium enema Barium enema [M41] 8 Barium enema 7 .2 22 586 [H33] Abdominal investigations Endoscopy 0 .3 Fistulogram 1 .7 18 [H33] 6 .4 Herniography 14 3 .6 8 [H33] loopogram 5 1 .3 4 [H33] Peritoneogram 12 3 .1 26 [H33]

89 ANNEX A: MEDICAL RADIATION EXPOSURES 77 ESD Effective dose Patients Reference Examination DAP 2 (mGy) ) (Gy cm (mSv) 3 .9 7 Ileoanal pouchogram 15 [H33] 4 .2 [H33] 16 Sinography 71 Biliary system [H33] Preliminary cholecystogram 2 [H33] Operative cholangiography 3 9 [H33] Infusion cholangiography 8 .8 25 [H33] Intravenous cholangiography 34 3 .1 10 [H33] 12 Oral cholecystography 15 3 .9 525 ERCP [H33] ERCP 3 .8 1 736 [M1] 14 .5 4 .0 [M41] ERCP 8 .1 [H33] Percutaneous transhepatic cholangiography 48 31 2 .6 T-tube choleangiogram [H33] 10 149 Summary of patient dose data for interventional radiology procedures Table b5. 2 ) Procedure Effective dose (mSv) Patients DAP (Gy cm Reference Biopsy 1 .6 Pathological specimen [H33] Biopsy 6 1 .6 32 [H33] Small bowel biopsy 0 .26 15 [H33] 1 Venous sampling 0 .4 [H33] Biliary and urinary systems Bile duct drainage 38 9 .9 8 [H33] Bile duct drainage 43 86 [R10] 11 .2 69 17 .9 [V2] Bile duct drainage 10 38 [R9] 150 18 Bile duct drainage 18 .4 123 Bile duct drainage 70 .6 [M13] 86 .7 22 .5 9 [R10] Bile duct drainage 43 11 .2 Bile duct drainage [R10] 14 Bile duct dilatation/stenting 14 15 [H33] 54 51 74 [W14] Bile duct dilatation/stenting 13 .3 43 11 .2 Bile duct dilatation/stenting [M14] 30 Biliary intervention 54 14 153 [M1] Bile duct stone extraction 27 7 29 [H33] lithotripsy 5 40 [H33] 1 .3 13 68 [H33] Nephrostomy 3 .4 34 .3 8 .9 Nephrostomy [M13] 143 Nephrostomy 22 .7 5 .9 14 [R10] Nephrostomy 43 11 .2 35 [M14] Nephrostomy 2 .1 21 [V6] 8 Nephrostomy 56 14 .6 54 [R9] Ureteric stenting 18 4 .7 15 [H33] Kidney stent insertion 49 12 .7 5 [H33]

90 78 UNSCEAR 2008 REPORT: VOLUME I 2 DAP (Gy cm Effective dose (mSv) Patients Reference Procedure ) Cardiovascular 75 [H33] 19 .5 Embolization 12 27 [W14] 27 .3 105 Embolization 114 29 .6 128 [M1] Embolization 6 .4 41 [C31] Management of varicocele 51 25 .7 106 [R10] Management of varicocele 10 38 [H33] 131 1 Management of varicocele 17 20 Management of varicocele 75 [R9] 50 .8 13 .2 14 [M13] Management of varicocele 202 Neuroembolization 1 [H33] 5 .7 Neuroembolization 10 .6 8 [M2] 122 .2 116 1 .7 [B13] Neuroembolization 8 10 .5 5 105 Neuroembolization [M14] Neuroembolization 320 .1 9 382 [M13] 129 3 .6 21 [J4] Neuroembolization Neuroembolization 81 35 [J4] 2 .3 13 .5 5 [H33] Thrombolysis 3 .5 206 53 .6 TIPS [H33] 10 TIPS 182 47 .3 56 [W14] TIPS 161 18 .7 23 [Z3] TIPS 524 4 [M14] 84 335 .4 87 .2` [M13] TIPS 135 58 .8 [Z3] 226 13 TIPS 20 TIPS [Z3] 77 10 70 [M41] TIPS 162 29 .3 Valvuloplasty [B14] 40 Vascular stenting 10 .4 14 [H33] 40 42 [O8] 44 Vascular stenting 5 .8 60 Pelvic vein embolization [M41] Insertion of caval filters 48 12 .5 4 [H33] Removal of foreign bodies 7 [H33] Uterine fibroid embolization Uterine fibroid embolization 77 .5 90 [M13] 298 .2 30 .6 18 [A4] Uterine fibroid embolization 8 211 .4 55 16 Uterine fibroid embolization [A4] Gastrointestinal Feeding tube 13 3 .4 16 [H33] Gastrostomy 13 3 .4 15 [H33] Dilation/stenting oesophagus 1 .5 96 [H33] 15 Dilation pyloric stenosis 27 7 4 [H33] Colonic stent 7 [H33] Nerve injection 1 .7 0 .2 22 [C30]

91 ANNEX A: MEDICAL RADIATION EXPOSURES 79 Statistics on a variety of interventional radiology and interventional neuroradiology procedures [M13] Table b6. 2 DAP (cGy cm Procedure description ) Cumulative dose (mGy) Total cases 95% CI Mean 95% CI Min Max Min Mean Max 29 071, 37 999 104 136 443 2 039 1 760, 2 317 33 535 7 160 TIPS 135 1 427 7 064 302 38 631 907 730, 1 083 21 4 831 123 Biliary drainage 5 848, 8 281 2 555 1 805, 3 305 41 21 225 257 Nephrostomy, obstruction 3 2 169 79 185, 328 64 2 859, 6 170 47 41 850 611 364, 857 10 6 178 Nephrostomy, stone access 4 514 7 731 342 957 41 416 106 300, 384 34 1 479 Pulmonary angiogram, no IVC filter 6 520, 8 942 17 8 072, 13 580 2 596 26 514 465 356, 575 76 987 Pulmonary angiogram, with IVC filter 10 826 279 4 451 4 079, 4 822 170 20 327 166 152, 181 9 680 IVC filter placement only Renal/visceral angioplasty, no stent 53 11 633, 19 866 2 619 104 075 1 183 892, 1 474 157 5 482 15 749 103 19 004 983 72 420 1 605 1 375, 1 834 104 7 160 Renal/visceral angioplasty, with stent 16 654, 21 355 16 356 729, 1 041 2 060 30 099 885 24 189 1 562 Iliac angioplasty, no stent 13 119, 19 592 93 18 215, 24 350 1 148 88 650 1 335 1 141, 1 530 211 4 567 Iliac angioplasty, with stent 21 282 12 10 089 4 880, 15 298 585 27 695 573 331, 815 34 Central venous reconstruction, SVC 1 209 Central venous reconstruction, IVC 19 549 11 243 35 375 1 247 610 2 316 3 2 21 403 25 312 1 178 937 1 419 Aortic fenestration 23 358 27 13 943 10 119, 17 767 2 821 39 289 1 123 Bronchial artery embolization 248 2 764 840, 1 406 90 415 6 198 61 1 216, 1 596 712 1 406 126 1 25 241, 31 224 28 232 Hepatic chemoembolization Pelvic arterial embolization, trauma 18 31 629 23 046, 40 213 9 291 62 358 1 705 1 237, 2 173 455 4 797 Pelvic arterial embolization, tumour 19 21 128, 39 441 11 002 83 811 1 846 1 338, 2 355 493 4 133 30 284 90 29 822 416 81 575 2 460 2 141, 2 779 15 6 990 Pelvic arterial embolization, fibroids 25 830, 33 815 48 425 2 818 21 842 98 028 12 1 766, 3 871 1 071 6 149 Pelvic arterial embolization, AVM 34 103, 62 748 22 385 16 497 27 900 2 599 808 3 885 Pelvic arterial embolization, aneurysm 4 6 41 355 12 217 102 605 2 838 1 628 5 406 Pelvic vein embolization, ovarian vein 14 1 753, 8 410 Pelvic vein embolization, varicocele 742 19 058 344 168, 520 41 1 007 5 082 91 23 004, 31 970 1 668 152 005 1 579 1 298, 1 860 24 7 986 Other tumour embolization 27 487 17 11 911 2 493, 21 329 330 54 129 Peripheral AVM embolization 245, 1 735 16 4 606 990 GI haemorrhage, diagnosis/therapy 34 757 30 599, 38 915 2 713 94 2 367 2 037, 2 697 105 7 160 129 465 Neuroembolization, head, AVM 177 33 976 30 313, 37 640 398 135 111 3 791 3 407, 4 175 43 13 410 Neuroembolization, head, tumour 56 30 498, 41 054 4 587 95 590 3 865 3 317, 4 414 598 10 907 35 776 149 26 Neuroembolization, head, aneurysm 28 269 6 788 82 515 3 767 3 517, 4 018 1 284 9 809 113, 30 426 2 080 10 28 089, 83 989 8 079 103 399 6 288 4 219, 8 356 Neuroembolization, spine, AVM 10 526 56 039 Neuroembolization, spine, aneurysm 1 54 014 4 214 Neuroembolization, spine, tumour 13 47 062 29 222, 64 902 17 559 126 411 4 935 3 877, 5 993 2 380 7 504 Stroke therapy 19 824 11 333, 28 315 7 924 46 171 2 369 1 430, 3 309 992 4 991 9 Carotid stent 18 16 785 10 762, 22 807 3 193 51 544 1 382 846, 1 917 326 4 405 33 533 Vertebroplasty 7 813 6 578, 9 048 642 98 1 253 1 075, 1 431 146 3 993 Note: IVC = inferior vena cava; SVC = superior vena cava; AVM = arteriovenous malformation .

92 80 UNSCEAR 2008 REPORT: VOLUME I Comparison of effective dose (mSv) for various interventional procedures [b20] Table b7. Procedure Reference b a [M2] [C12] [H1] [M4] [K14] [Z5] [M14] [S26] [T12] [B20] 21 .7 23 8 .6/10 .5 Hepatic 6 .4–13 .6 16 13 .6 25 6 Renal 11 .7/13 .7 11 .9 Thoracic 3 .2 6 16 .3 0 .3 Upper extremity 0 .54/0 .9 3 .5 d c e 4 3 .1 9 7 .4 /2 .8 3 .5/4 .5 lower extremity 4 Carotid 4 .9 2 .5/4 .9 f 7 .4 Cerebral 4 4 .4 3 .6 3 .0/3 .0 a Diagnostic/therapeutic . b Effective dose equivalent . c Femoral angiography . d Digital . e Analogue . f Therapeutic . Table b8. Summary of patient dose data for coronary angiography examinations 2 ) Effective dose (mSv) DAP (Gy cm Reference Patients 57 .8 2 174 [B19] 9 .4 4 .6 [B19] 23 .4 126 288 66 .5 [V2] 111 .03 6 [V16] 147 .43 3 [V16] 40 .72 [V16] 4 13 60 .21 [V16] 27 [D9] 84 .9 45 [D9] 76 .6 14 [V17] 46 62 [V18] 60 .64 110 .1 [V18] 15 4 .6–15 .8 [N11] 23–79 198 76 [P18] 55 .9 27 19 215 [A15] 9 .2 55 6 .6 4 [H33] 26 3 .1 187 [H33] 26 .4 [H34] 231 [H34] 30 .4 8 000 3 .1 90 [l16] 13 .97 63 65 [F18] 30 .4 5 .6 29 [B11] 18 167 [P20] 42 [H7] 29 5 20 [E6] 23 .6 509 [K27] 12 .7 473 [K27] 12 .8 278 [K28]

93 ANNEX A: MEDICAL RADIATION EXPOSURES 81 2 ) Patients Reference DAP (Gy cm Effective dose (mSv) 47 [K28] 13 .2 [T18] 47 .3 195 57 600 [N11] 20 [H35] 49 2 .5 [K29] 2 .1 [K29] 3 079 [B15] 44 .25 39 [Z15] 55 .9 30 [W15] 72 .63 Summary of patient dose data for pTCA examinations Table b9. 2 ) Patients Reference DAP (Gy cm Effective dose (mSv) 214 14 .2 [B19] 77 .9 11 [B19] 51 .6 10 .2 45 [V2] 87 .5 113 .21 [V16] 7 125 .5 33 [D9] [D9] 59 .8 37 14 82 .5 [V17] 115 .23 13 [V18] 27–205 5 .4–41 122 [N22] 101 .9 [P18] 54 223 145 [B9] 17 [W11] 46 90 [M33] 93 89 [P20] 51 6 .9 12 37 .6 [F18] 50 .6 6 [F18] 9 .3 [H7] 42 14 20 [E6] 75 22 .2 [K27] 233 14 .4 269 [K27] 68 97 [T18] 63 .4 334 [H34] 600 94 [N11] 40 10 [H35] 401 [B16] 62 .6 50 .8 [B16] 180 69 .5 183 [B16] 130 .5 58 [B16] 50 .8 14 .2 98 [B16] 128 .3 121 [B16] 10 .2 151 .05 30 [W15] 33 11 9 692 [A15] 11 .8 115 [K28] 15 30 [K28]

94 82 UNSCEAR 2008 REPORT: VOLUME I Summary of patient dose data for stent procedures Table b10. 2 ) Reference Effective dose (mSv) DAP (Gy cm Patients [V18] 10 7 165 .95 9 14 [B11] 49 .2 70 .7 [B11] 13 7 [P20] 41 479 [P20] 58 58 Table b11. Summary of patient dose data for pacemaker insertions 2 DAP (Gy cm ) Patients Reference Effective dose (mSv) [B19] 8 .46 101 17 627 [H34] 3 197 [A15] 19 Summary of patient dose data for head CT examinations Table b12. Effective dose (mSv) Reference DLP (mGy cm) [P4] 2 .1 739–2 2 .8 [A8] 130 544 1 .2 [T23] 2 .2 [N2] 610–1 684 [N3] 332 1 .7 238–1 [O4] 1 .8 [O4] 400 250–1 262 6 .1–7 .9 [M25] 125–1 173 183–2 [T20] 1 .6 1 .6–2 .8 [M43] 1 .5 [H10] 660 36–1 1 .7 [y4] 180 2 .2 [B18] 430–758 1 .4 [T19] 1 .9 [V9] [H14] 1 .5 [H15] 1 .3 [H36] 0 .9 1 .5 [S19] 930 2 .8 (neck) [C16] 1 .4 [T22] 694 [S6] 1 .5 1 .7 [C17] 2 .4 [E1] 740 0 .9 (spiral) [H5] 1 .2 (multislice) [H5] 1 .7 [T1]

95 ANNEX A: MEDICAL RADIATION EXPOSURES 83 Summary of patient dose data for body CT examinations Table b13. Reference DLP (mGy cm) Effective dose (mSv) Abdomen [P4] 7 .4 [M43] 7 .7–13 .3 12 .4–16 .1 [C16] 717–1 428 [N3] 3 .1 [H14] 4 .9–13 .2 [M25] 537 105–2 15 .3 [N2] 470 5 .3 [S19] 5 .3 [S6] 352 10 .1 920 [A8] [V9] 7 .2 [T22] 9 .9 (abscess) 14 .5 (liver metastases) [T22] 58–1 898 7 .4 [T20] [O4] 7 .8 7 .9 [O4] [H10] 2 .4 3 .6 (contrast) [H10] 549 [T23] 8 .2 250–440 7 .0 [y4] 278–582 7 .1 [T19] 880 14 .9 [I4] [W3] 3 .9 9 .7 [B18] [E1] 11 .7 3 .5 (axial) [H5] [H5] 7 .7 (multislice) Chest 3 .9 (spiral) [H5] 10 .5 (multislice) [H5] 420 [T1] 7 .1 [P4] 7 .3 348–807 [T19] 10 .9 224–1 530 9 .3 [A8] 580 5 .8 [S19] 402 5 .8 [S6] [B18] 5 .5 50–2 157 [T20] 8 .9 3 .8 [V9] 7 .5–12 .9 [C16] 2 .3 [T22] 4 .9–7 .8 [M43] 195 4 .0 [H10] 70–270 3 .5 [y4] 35–240 2 .2 (high resolution) [y4] 496–992 [N3]

96 84 UNSCEAR 2008 REPORT: VOLUME I Effective dose (mSv) Reference DLP (mGy cm) 8 .0 [O4] 7 .9 [O4] 215–766 5 .5–9 .7 [M25] 348 5 .9 [T23] 12 .2 [N2] [I4] 6 .8 399 650 11 .1 [E1] Pelvis 10 .3 [P4] 526–1 [N3] 302 205–910 [A8] 9 6–15 .7 286–895 [M25] 67–1 984 7 .7 [T20] [O4] 8 .9 8 .8 [O4] 306–592 9 .3 [T19] 13 .4 [N2] 478 8 .1 [I4] 570 10 .8 [E1] Chest–abdomen–pelvis 320–750 [y4] 10 .9 9 .9 668 [S6] Table b14. Summary of patient dose data for spine CT examinations DLP (mGy cm) Effective dose (mSv) Reference Lumbar spine [P4] 7 .1 7 .2 [H10] 455 220–570 6 .4 [y4] 200–382 [N2] 5 .4 [N3] 166–870 4 .9–8 .1 [M25] 4 .5 [T22] 4 .5 [O4] 47–495 49–500 [O4] 4 .6 411 6 .2 [I4] 800 [E1] 420 [T1] 7 .9 Thoracic spine 13 .1 [P4] Cervical spine 3 .4 [P4] 66–708 1 .5 [O4]

97 ANNEX A: MEDICAL RADIATION EXPOSURES 85 Summary of patient dose data for CT angiography examinations Table B15. Reference DLP (mGy cm) Effective dose (mSv) Coronary angiography [S22] 7.8–8.8 [E4] 9–29 [H10] 305 5–7 (aortic) [E8] 9.5 [E8] 11.7 (calcium scoring) 22.8 (16 slices) [M44] 27.8 (64 slices) [M44] [M44] 14.1 (256 slices) [C20] 14.7 [H39] 3.0 [H35] 6.7–10.9 (male) 8.1–13 (female) [H35] 20.6 [N24] [T21] 8.1 (female) [T21] 10.9 (male) 6.4 (16 slices) [H40] 11.0 (64 slices) [H40] 9.8 [D5] Pulmonary angiography 165 3.4 [H10] 737 19.9 [H41] [H21] 14.4 [T22] 4.1 3.0 [V9] 4.2 [K6] [C27] 21.5 (4 slices) [C27] 18.2–19.5 (16 slices) 5.2 [B18] Table B16. Summary of patient dose data for various other CT examinations DLP (mGy cm) Effective dose (mSv) Reference Appendix 13.3 [H21] Renal 4.5 [H21] 4.6 [H10] Liver–spleen–pancreas 97–2 876 13 [T20] 10.2 [V9] 900 [E1] Kidneys 47–2 157 11 [T20] 800 [E1]

98 86 UNSCEAR 2008 REPORT: VOLUME I Summary of patient dose data for paediatric CT examinations Table b17. Reference DLP (mGy cm) Effective dose (mSv) Head [S21] 300 (<1 year) [S21] 600 (5 years) 750 (10 years) [S21] 1 .3–2 .3 (8 weeks) [M43] 1 .5–2 .0 (5–7 years) [M43] 7 .6 [H15] 6 .0 (newborn) [H14] 4 .9 (1 year) [H14] 4 .0 (5 years) [H14] 2 .8 (10 years) [H14] 1 .7 (15 years) [H14] 230 (1 year) [S6] 2 .5 (1 year) 1 .5 (5 years) 383 (5 years) [S6] 508 (10 years) 1 .6 (10 years) [S6] 3 .6 (<1 year) [H36] [B5] 4 Chest 200 (<1 year) [S21] [S21] 400 (5 years) 600 (10 years) [S21] 1 .9–5 .1 (8 weeks) [M43] 3 .1–7 .9 (5–7 years) [M43] 50 (newborn) 1 .7 (newborn) [H19] 100 (1 year) 1 .8 (1 year) [H19] 2 .1 (5 years) 140 (5 years) [H19] 270 (10 years) 3 .0 (10 years) [H19] 430 (15 years) 4 .1 (15 years) [H19] 5 .4 (18 years) [H19] 780 (18 years) [M45] 6 .4 (8 weeks) 6 .8 (7 years) [M45] 159 (<1 year) 6 .3 (<1 year) [S6] 198 (5 years) 3 .6 (5 years) [S6] 303 (10 years) 3 .9 (10 years) [S6] 3 [B5] Abdomen 330 (<1 year) [S21] 360 (5 years) [S21] 800 (10 years) [S21] 6 .1 (<10 years) [W3] 4 .4 (11–18 years) [W3] 4 .4–9 .3 (8 weeks) [M43] 9 .2–14 .1 (5–7 years) [M43] 5 .3 (newborn) [H14] 4 .2 (1 year) [H14] 3 .7 (5 year) [H14] 3 .7 (10 year) [H14]

99 ANNEX A: MEDICAL RADIATION EXPOSURES 87 Effective dose (mSv) Reference DLP (mGy cm) 3 .6 (15 year) [H14] [B5] 5 560 [H10] 11 Table b18. Effective dose from routine CT examinations in the United States according to the 2000–2001 NExT Survey [S24] a Percentage Examination Percentage Percentage Axial scanning Helical scanning axial helical Mean SD Number Mean SD Number (mSv) (mSv) 27 12 2 1 45 1 1 4 Head (brain) 88 21 Abdomen–pelvis 65 17 6 16 12 7 21 35 Chest 34 66 9 4 14 6 4 22 11 10 6 70 8 4 11 Abdomen 4 19 30 5 21 Simple sinus 79 5 34 66 Chest–abdomen–pelvis 11 10 15 10 18 28 Pelvis 5 31 69 7 4 11 6 4 15 Skull 5 17 83 4 66 Spine 34 24 76 2 Kidneys 1 27 73 liver 1 30 70 Pancreas Other 1 60 40 a The distribution of adult examinations is based on 56 facilities reporting an average of 3,165 axial and 2,680 helical examinations . Annual number of CT examinations in Japan [N13] Table b19. Male Female Scan region Total Head 8 247 000 7 763 000 16 010 000 Head–chest 203 000 162 000 365 000 Head–abdomen 98 000 167 000 69 000 40 000 71 000 Head–pelvis 31 000 2 889 000 2 115 000 5 004 000 Chest Chest–abdomen 2 072 000 4 487 000 2 415 000 Chest–pelvis 741 000 569 000 1 310 000 Abdomen 2 963 000 2 184 000 5 147 000 Abdomen–pelvis 1 493 000 3 244 000 17 511 000 Pelvis 262 000 290 000 552 000 Other 99 000 96 000 195 000 Total 19 708 000 16 844 000 36 552 000

100 88 UNSCEAR 2008 REPORT: VOLUME I CT practice in Japan: comparison of surveys [N13] Table b20. Annual number of examinations Annual number of scans Collective effective dose Survey year Per caput effective dose Number of CT scanners (mSv) (man Sv) 1979 [N16] 1 454 000 14 850 000 712 11 904 000 243 700 000 99 000 0 .8 1989 [N17] 5 382 11 050 36 550 000 295 000 2 .3 2000 [N13] 906 000 000 Summary of measurements undertaken on multislice CT scanners in Germany in 2002 Table b21. Data provided from 113 CT scanners [B18] Relative frequency (%) Number of centres providing data Effective dose/series (mSv) Effective dose/examination (mSv) Examination 27 .1 104 2 .2 2 .8 Brain 4 .4 Face and sinuses 0 .8 0 .8 102 3 .6 99 2 Face and neck 1 .9 108 5 .5 15 .7 Chest 5 .7 Abdomen–pelvis 17 .6 106 9 .7 14 .4 2 .6 94 Pelvis 7 .2 6 .3 liver–kidney 103 5 .5 11 .5 5 .9 4 .1 76 Whole trunk 17 .8 14 .5 Aorta thoracic 1 .4 90 6 .1 6 .7 Aorta abdomen 1 .8 91 9 10 .3 Pulmonary vessels 1 .8 5 .2 5 .4 91 1 .5 88 8 .2 Pelvis skeleton 8 .2 103 2 .9 3 .2 Cervical spine 2 .9 lumbar spine 5 .9 107 8 .1 8 .1 Summary of measurements undertaken on single-slice spiral CT scanners in Germany Table b22. Data provided from 398 CT scanners installed between January 1996 and June 1999 [B18] Examination Effective dose/series (mSv) Effective dose/examination (mSv) Number of centres providing data 387 2 .8 Brain 1 .9 379 1 Face and sinuses 1 .1 Face and neck 365 1 .7 2 Chest 385 5 .2 6 .2 Abdomen–pelvis 377 17 .2 10 .3 367 8 .8 Pelvis 6 .9 375 4 .6 8 .7 liver–kidney Whole trunk 14 .9 20 .5 139 Aorta thoracic 193 5 5 .8 Aorta abdomen 203 6 .3 7 .6 Pulmonary vessels 3 .3 3 .6 180 Pelvis skeleton 328 8 .6 8 .8 Cervical spine 331 2 .1 2 .1 lumbar spine 384 2 .7 2 .7

101 ANNEX A: MEDICAL RADIATION EXPOSURES 89 Representative adult effective dose for various CT procedures [M41] Table b23. Reported range (mSv) Examination Effective dose (mSv) 0 .9–4 .0 2 Head 3 Neck Chest 7 4 .0–18 .0 13–40 Pulmonary embolism 15 8 3 .5–25 Abdomen 3 .3–10 Pelvis 6 liver (3-phase) 15 5 .0–25 Spine 6 1 .5–10 16 Coronary angiogram 5 .0–32 Calcium scoring 1 .0–12 3 10 Virtual colonoscopy 4 .0–13 .2 Dental 0 .2 Table b24. Comparison of effective dose from various types of dental x-ray equipment [C5] DVT old, Sinus CT DVT new, Dental Equipment Dental Dental Dental Orthophos CT 94 mA CT 60 mA CT CT 43 mA soft tissue multislice CT soft tissue 94 mA Effective dose 1 .27 0 .1 0 .11 0 .01 0 .61 0 .36 0 .15 0 .74 (mSv) Table b25. s for panoramic dental radiography examinations [d13] Comparison of mean dwp 2 Sample size Mean DAP (mGy cm ) Study Mean DWP (mGy mm) [D13] 20 65 89 387 57 [N15] 5 [I33] 74 6 [P13] 113 [W17] 16 65 113 [O6] 26 69 [T13] (male) 62 101 62 85 [T13] (female) Table b26. Effective dose for pencil and fan beam dExA (premenopausal women) [N5] Type of machine Scan type Effective dose (mSv) Total body 4 .6 0 .5 AP spine (l1–l4) Pencil beam 0 .6 lateral spine (l2–l4) Proximal femur 1 .4 0 .4–2 .9 PA spine (l1–l4) lateral spine (l2–l4) 1 .2–2 .5 Fan beam Proximal femur 3 .0–5 .9 Total body 3 .6

102 90 UNSCEAR 2008 REPORT: VOLUME I Table b27. Mean ESd per radiograph for paediatric patients [N2] Age (years) Examination Mean ESD (mGy) 110 0 1 340 Abdomen AP 5 590 10 860 15 2 010 60 0 1 80 Chest AP/PA 110 5 10 70 110 15 0 170 350 1 Pelvis AP 5 510 650 10 15 1 300 1 600 Skull AP 5 1 250 1 340 Skull lAT 580 5 Ap for common paediatric fluoroscopic examinations [N2] Table b28. d 2 Age (years) Normalized DAP per examination (mGy cm Examination ) 430 0 810 1 5 940 MCU 1 640 10 15 3 410 0 760 1 1 610 5 1 620 Barium meal 3 190 10 5 670 15 0 560 1 150 1 Barium swallow 1 010 5 10 2 400 15 3 170 Table b29. p atient dose survey of paediatric radiology in a Madrid hospital [V10] Age (years) Sample size Median ESD (mGy) Examination 0–1 1 180 41 1–5 309 34 Chest (no bucky) 6–10 143 54 10–15 92 10

103 ANNEX A: MEDICAL RADIATION EXPOSURES 91 Age (years) Sample size Examination Median ESD (mGy) 181 1–5 87 6–10 255 105 Chest (with bucky) 11–15 363 170 93 91 0–1 30 225 1–5 Abdomen 6–10 69 600 150 1 508 11–15 0–1 48 254 1–5 128 314 Pelvis 122 6–10 702 11–15 137 1 595 Effective dose for seven selected paediatric cardiac interventions [O10] Table b30. Number Procedure Effective dose (mSv) 259 3 .88 ASD occlusion PDA occlusion 3 .21 165 Balloon dilation 122 4 .4 Coil embolization 33 4 .58 VSD occlusion 32 12 .1 25 Atrial septostomy 3 .62 PFO occlusion 21 2 .16 ASD = atrial septal defect; PDA = patent ductus; VSD = ventricular septal defect; PFO = patent foramen ovale . Table b31. Comparison of mean and reported typical mean foetal doses per examination [O1] Mean (from [O1]) (mGy) Reported typical mean from literature (mGy) Examination Abdomen AP 2 .9 1 .9 [S7] 1 .3 0 .53 [S7] Abdomen PA Abdomen 2 .5 [W6] 2 .6 Chest AP <0 .01 <0 .01 [S7] Chest PA <0 .01 <0 .01 [S7] Chest <0 .01 0 .01 [W6] 7 .5 1 .9 [S7] lumbar spine AP lumbar spine lAT 0 .41 [S7] 0 .91 lumbar spine 4 .2 4 .0 [W6] lumbosacral joint lAT 1 .1 0 .56 [S7] Pelvis AP 2 .0 [W6] 3 .4 Thoracic spine AP <0 .01 <0 .01 [S7] Thoracic spine PA <0 .01 <0 .01 [S7] Thoracic spine <0 .01 <0 .1 [W6]

104 92 UNSCEAR 2008 REPORT: VOLUME I b32. Estimated number of procedures per million population and total number of procedures in 2006 for various Table European countries [F19] Number of procedures/million population Population Country Total number of procedures Pacemaker PTCA Stent Pacemaker Stent CA CA PTCA 1 561 1 413 8 192 880 61 246 17 287 12 792 Austria 7 476 2 110 11 577 2 190 1 222 10 379 067 71 017 22 729 1 328 12 683 Belgium 6 842 13 779 a 990 134 124 7 385 367 4 948 1 373 Bulgaria 916 670 186 1 060 Croatia 710 4 494 749 17 150 4 764 3 430 3 191 3 816 763 1 483 1 041 10 235 455 47 512 15 175 10 568 10 655 4 642 1 033 Czech Republic 1 791 1 290 1 199 5 450 661 35 143 Denmark 7 029 6 535 6 448 9 762 2 906 449 692 1 324 333 738 978 595 916 Estonia 3 849 7 997 1 926 Finland 1 143 5 231 372 41 834 10 074 6 059 5 979 1 158 France 2 318 2 230 1 185 60 876 136 362 540 141 084 135 772 72 138 5 955 11 646 3 235 2 167 82 422 299 959 987 266 663 191 962 178 609 Germany 2 329 674 7 205 781 10 688 058 31 325 2 931 6 077 8 347 Greece 569 580 3 772 559 9 981 334 25 305 290 2 893 5 2 535 Hungary 378 6 522 2 658 1 975 827 299 388 Iceland 796 591 248 1 952 a 792 Ireland 570 530 4 062 235 11 581 3 217 2 315 2 153 2 851 7 353 6 352 117 2 667 2 481 Israel 46 704 23 528 16 940 15 760 3 704 Italy 1 540 1 109 1 032 58 133 509 264 854 89 548 64 475 59 994 4 556 latvia 2 550 830 591 576 2 274 735 5 802 1 888 1 345 1 310 lithuania 3 182 249 488 3 585 906 11 410 3 684 893 1 750 1 027 5 098 1 416 948 16 491 461 84 092 23 359 16 818 15 634 Netherlands 1 020 1 012 38 992 688 38 536 869 112 499 2 919 22 027 26 513 Poland 572 3 157 703 599 10 605 870 33 487 8 749 7 459 6 353 Portugal 825 1 421 207 200 142 22 303 552 31 698 Romania 4 455 3 167 4 617 San Marino 1 135 1 135 760 29 251 95 33 33 22 3 243 2 662 107 543 726 601 40 397 842 Spain 37 950 29 317 24 279 939 13 214 5 278 1 056 982 9 016 596 47 570 Sweden 9 514 8 854 1 466 Switzerland 6 241 2 169 1 583 713 7 523 934 46 958 16 319 11 913 5 365 Turkey 3 026 336 53 70 413 958 213 101 39 257 23 640 3 732 558 2 876 ugoslav 601 559 116 2 050 554 1 402 1 232 1 146 238 The former y Republic of Macedonia 3 096 860 722 497 United Kingdom 187 646 52 124 43 785 30 123 60 609 153 Total 2 871 726 859 373 648 612 522 621 569 348 641 Note: Data in italics estimated using average ratio of coronary angiograms to PTCAs (3 .6), stents to PTCAs (0 .72) and pacemakers to PTCAs (0 .67) as appropriate . a Estimated from 2000 data using an average rate . Table b33. p opulation distribution over the four health-care levels as used in global assessments of medical exposures Year Percentage of population by health-care level Global population Reference (millions) I III IV II 29 4 200 23 13 1977 [U9] 35 1984 50 15 8 5 000 [U7] 27 1990 25 50 16 9 5 290 [U6] 1996 53 11 10 5 800 [U3] 26 Present 24 49 16 11 6 446 2007

105 ANNEX A: MEDICAL RADIATION EXPOSURES 93 Table b34. physicians and health-care professionals Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Country/area Number Population (thousands) Physicians All Radiology- Medical- Interventional Other Dentists technicians cardiologists physicians physicians conducting physicists performing radiological radiology procedures Health-care level I 160 120 6 6 Albania 3 200 1 201 392 8 800 59 023 20 406 Australia 37 000 1 030 2 200 70 200 800 4 500 Austria 8 200 42 978 10 300 155 888 8 450 Belgium 1 690 27 526 6 778 8 149 Bulgaria 815 12 830 485 947 22 28 97 3 445 Croatia 4 437 10 290 35 960 3 257 199 434 522 6 429 Czech Republic 1 299 1 370 192 371 20 14 44 1 200 Estonia 4 300 5 250 Finland 770 3 892 88 90 6 113 14 661 France 205 000 7 590 23 380 347 500 13 600 41 250 61 700 82 501 306 435 31 000 635 19 000 65 000 Germany 6 314 55 000 2 500 350 2 400 12 000 11 000 1 800 Greece 36 907 1 171 3 000 60 Hungary 500 5 156 9 981 65 294 1 120 35 170 10 15 25 350 Iceland 127 435 262 687 4 710 41 549 Japan 92 874 117 Korea, Rep . 127 158 2 434 14 291 56 294 24 021 22 366 48 497 2 295 277 7 236 393 21 1 415 latvia 8 956 3 491 14 034 394 1 228 lithuania 36 209 2 446 9 luxembourg 452 1 422 54 165 5 12 183 312 Malta 400 1 407 26 164 3 5 16 195 Netherlands 15 638 730 110 6 344 46 000 737 215 1 600 32 74 200 1 591 8 615 New Zealand 3 18 404 2 350 75 52 756 4 140 4 640 476 Norway 607 000 14 860 26 880 Russian Federation 320 42 200 146 700 150 2 003 4 671 300 457 15 50 1 233 Slovenia 44 109 194 668 3 655 Spain 579 347 3 371 21 055 6 093 Sweden 32 000 1 300 3 000 200 11 000 8 861 7 461 517 5 100 60 205 4 500 4 500 Switzerland 28 251 ugoslav Republic of Macedonia 2 033 5 131 113 The former y 13 24 74 1 602 287 United Kingdom 59 500 100 000 2 750 19 000 1 100 21 000 Venezuela (Bolivarian Rep . of ) 27 031 1 072 208 Health-care level II Azerbaijan 4 3 7 962 186 771 299 56 995 Brazil 466 111 15 116 15 195 700 Chile 8 748 10 China 1 248 100 1 999 521 126 173 Colombia 41 468 13 471 5 544 20 328 Costa Rica 4 326 103 386 5 63 2 696 6 812 El Salvador 7 000 60 600 10 8 30 5 000 6 500 Malaysia 26 909 14 986 275 1 799 47 35 54 3 989 Mauritius 18 115 3 12 106 1 200 262 2 018 3 248 40 334 3 2 Oman

106 94 UNSCEAR 2008 REPORT: VOLUME I Population Country/area Number (thousands) Dentists Physicians Other Radiology- Interventional Medical- All physicists cardiologists conducting physicians physicians technicians radiological performing radiology procedures 329 3 885 Thailand 110 860 3 414 60 607 16 569 98 2 667 5 125 5 7 187 Trinidad and Tobago 1 262 295 9 650 178 3 000 15 10 1 180 Tunisia 8 000 81 988 16 000 130 67 800 14 226 Turkey 3 500 Health-care level III 15 180 4 Zimbabwe 200 12 000 13 Health-care level IV 300 18 3 23 0 1 0 Maldives 10 Table b35. physicians and health-care professionals per million population Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Country/area Number per million population Population (thousands) Dentists All Physicians Radiology- Medical- Interventional Other physicists physicians cardiologists technicians physicians conducting performing radiological radiology procedures Health-care level I 3 200 2 2 Albania 38 Australia 59 19 431 20 406 2 892 8 200 4 512 Austria 268 9 24 98 549 126 Belgium 4 173 164 15 86 820 10 300 8 149 100 832 Bulgaria 3 378 4 437 2 892 109 213 5 6 Croatia 776 22 Czech Republic 10 290 3 495 126 317 19 42 51 625 Estonia 1 370 3 139 140 271 15 10 32 876 Finland 5 250 147 741 17 17 1 164 2 793 61 700 3 323 379 6 8 669 France 123 3 714 230 376 8 82 501 788 Germany 77 11 000 164 227 32 218 1 091 Greece 5 000 9 981 3 698 117 301 6 7 50 517 Hungary 294 Iceland 119 578 34 51 85 1 190 3 810 127 435 37 326 1 729 Japan 2 061 48 497 2 622 50 295 Korea, Rep . 461 1 latvia 2 295 3 902 121 171 (3 153) 9 617 lithuania 3 491 4 020 113 352 3 10 60 701 luxembourg 452 119 365 11 27 405 690 3 146 400 488 65 410 8 13 40 Malta 3 518 15 638 7 47 Netherlands 406 2 942 3 737 New Zealand 58 428 9 20 54 426 2 305 Norway 4 640 3 966 103 506 16 11 163 892 Russian Federation 4 138 101 183 1 2 288 146 700 Slovenia 2 003 2 332 150 228 7 25 616 Spain 44 109 4 413 83 138 13 8 76 477

107 ANNEX A: MEDICAL RADIATION EXPOSURES 95 Population Country/area Number per million population (thousands) Physicians All Dentists Radiology- Other Medical- Interventional physicists technicians physicians physicians conducting cardiologists radiological performing radiology procedures 3 611 147 34 23 Sweden 8 861 1 241 7 461 69 684 8 27 603 603 Switzerland 3 786 ugoslav Republic of Macedonia 2 524 56 141 6 12 36 788 The former y 2 033 59 500 1 681 46 United Kingdom 18 353 319 Venezuela (Bolivarian Republic of) 40 8 27 031 3 530 77 7 40 92 540 Weighted average 370 Health-care level II 7 962 Azerbaijan 0 1 Brazil 186 771 2 496 2 305 15 116 1 005 46 Chile 579 1 China 1 602 101 1 248 100 41 468 490 134 42 0 Colombia 325 Costa Rica 1 575 24 89 1 15 623 4 326 El Salvador 6 500 1 077 9 92 2 1 5 769 Malaysia 26 909 10 67 2 1 2 148 557 1 200 96 3 10 88 Mauritius 15 2 018 1 610 20 166 1 1 130 Oman 60 607 273 5 64 2 2 14 56 Thailand Trinidad and Tobago 2 113 4 99 4 6 148 234 1 262 Tunisia 9 650 829 18 311 2 1 122 Turkey 67 800 52 236 2 210 1 209 1 600 2 100 1 Weighted average 12 280 45 Health-care level III 12 000 1 .1 1 .3 15 .0 0 .3 16 .7 Zimbabwe Weighted average 1 .1 1 .3 15 0 .3 17 Health-care level IV 33 .3 300 60 10 76 .7 0 3 .3 0 Maldives Weighted average 60 10 77 0 3 .3 0 33 Note: Value for latvia excluded from the calculation of the population-weighted mean .

108 96 UNSCEAR 2008 REPORT: VOLUME I Number of items of diagnostic x-ray equipment in various countries Table b36. Bone Country CT scanners X-ray generators densitometry Mammo Dental Interventional General - Angiography Medical graphy fluoroscopy Health-care level I Albania 1 11 1 17 9 10 100 10 100 500 400 3 938 Australia 420 10 000 13 000 150 120 250 Austria 2 230 283 2 241 24 185 204 Belgium 3 914 79 11 5 32 1 498 455 Bulgaria 137 593 17 3 27 Croatia 65 552 45 1 981 137 4 670 323 63 52 126 Czech Republic 80 6 588 17 29 5 5 Estonia 10 Finland 198 5 200 28 86 80 1 079 13 061 2 538 608 France 33 245 3 100 7 000 1 900 2 800 23 000 72 600 Germany 433 10 000 180 200 80 Greece 286 1 373 396 1 800 100 2 600 35 300 50 53 60 Hungary 46 5 360 Iceland 3 6 7 Japan 2 905 131 300 3 223 9 381 11 803 88 000 15 599 1 491 24 592 119 5 939 166 1 734 Korea, Rep . 1 493 41 370 latvia 6 20 3 8 34 610 lithuania 797 26 578 23 luxembourg 61 10 426 6 40 6 1 12 Malta 57 149 3 10 3 6 10 13 665 96 23 43 45 New Zealand 2 228 87 124 75 200 830 Norway 6 400 114 1 305 5 901 24 25 107 Romania 634 18 564 1 167 5 835 480 11 000 243 30 378 Russian Federation Slovakia 650 750 8 350 40 40 94 102 257 376 13 8 34 20 Slovenia 34 12 438 1 093 18 486 Spain 1 253 382 566 32 Sweden 1 200 180 12 000 30 40 130 Switzerland 5 134 239 9 846 1 337 1 300 37 135 214 The former y ugoslav Republic of Macedonia 15 136 66 61 5 2 13 140 400 United Kingdom 506 90 217 60 10 31 64 Venezuela (Bolivarian Republic of) Health-care level II Azerbaijan 2 - 6 18 229 Brazil 20 610 1 402 535 932 2 043 3 057 Chile 1 424 279 815 16 69 42 78 161 China 59 000 2 450 3 712 750 Colombia 98 2 526 5 106 1 833 Costa Rica 284 46 648 12 29 29 13 12 4 El Salvador 38 500 5 53 5 113 17 Mauritius 47 2 60 11 2

109 ANNEX A: MEDICAL RADIATION EXPOSURES 97 X-ray generators Bone CT scanners Country densitometry Mammo Dental Interventional General Angiography - Medical graphy fluoroscopy 4 33 2 1 6 Oman 159 100 Thailand 1 700 261 2 866 1 678 24 50 5 15 4 8 Trinidad and Tobago 90 1 128 77 763 21 7 Tunisia 88 Turkey 433 1 100 181 251 685 3 915 Health-care level III Zimbabwe 2 200 2 30 15 8 250 Health-care level IV 16 1 .0 2 .0 0 .0 1 .0 0 .0 Maldives 1 .0 1 .0 Note: For some countries, the number of items of conventional equipment also includes the number of digital machines . Number of items of digital diagnostic equipment in various countries Table b37. Digital systems Country Mammography Dental General General Angiography Interventional fluoroscopy Health-care level I Albania 92 3 1 50 1 Australia 31 28 1 8 Bulgaria 17 36 Czech Republic Estonia 26 10 1 6 Finland 81 15 3 15 Hungary 3 Iceland 6 30 2 082 Japan 2 649 7 2 latvia luxembourg 0 2 3 New Zealand 0 3 Romania 59 0 0 2 2 Russian Federation 221 528 2 548 1 180 273 1 110 Spain 400 400 Sweden 200 20 2 Venezuela (Bolivarian Rep . of) 43 Health-care level II Costa Rica El Salvador 15 Mauritius 0 0 0 0 0 0 Oman 2 Trinidad and Tobago 20 3 4 Tunisia 10 Note: For some countries, the number of items of conventional equipment also includes the number of digital machines .

110 98 UNSCEAR 2008 REPORT: VOLUME I Number of items of diagnostic x-ray equipment in various countries per million population Table b38. Bone Country CT scanners X-ray generators densitometry Mammography General Dental Angiography Medical Interventional fluoroscopy Health-care level I 0 .3 3 .4 31 .3 5 .3 Albania 3 .1 2 .8 0 .3 495 .0 Australia 24 .5 193 .0 19 .6 51 1 220 159 18 15 31 272 Austria 27 .5 380 .0 Belgium 18 .0 19 .8 217 .6 2 .3 183 .8 55 .8 1 .3 0 .6 3 .9 Bulgaria 9 .7 30 .9 3 .8 0 .7 6 .1 10 .1 14 .6 124 .4 133 .6 Croatia 13 .3 453 .8 31 .4 6 .1 Czech Republic 12 .2 192 .5 5 .1 58 .4 4 .4 429 .2 12 .4 21 .2 3 .6 3 .6 7 .3 Estonia 205 .5 37 .7 990 .5 5 .3 16 .4 Finland 15 .2 France 41 .1 538 .8 9 .9 211 .7 278 .8 37 .6 84 .8 23 .0 33 .9 Germany 880 .0 39 .4 16 .4 18 .2 7 .3 36 .0 26 .0 124 .8 909 .1 Greece 10 .0 260 .5 3 .5 30 .1 5 .0 Hungary 6 .0 180 .3 5 .3 156 .5 1 224 .5 23 .8 17 .0 Iceland 10 .2 20 .4 690 .5 22 .8 1 030 .3 Japan 25 .3 73 .6 92 .6 Korea, Rep . 30 .8 507 .1 2 .5 122 .5 3 .4 35 .8 30 .7 321 .6 161 .2 265 .8 2 .6 8 .7 1 .3 3 .5 17 .9 latvia 14 .8 228 .3 7 .4 165 .6 lithuania 6 .6 luxembourg 135 .0 22 .1 942 .5 13 .3 88 .5 13 .3 2 .2 26 .5 Malta 142 .5 32 .5 372 .5 7 .5 25 .0 7 .5 15 .0 25 .0 Netherlands 179 .1 178 .0 New Zealand 11 .5 12 .0 25 .7 596 .2 6 .2 18 .8 16 .2 43 .1 26 .7 178 .9 Norway 1 379 .3 8 .0 39 .8 3 .3 75 .0 1 .7 0 .2 2 .6 Russian Federation 126 .5 119 .5 Slovakia 0 17 .0 187 .7 6 .5 4 .0 Slovenia 10 . 128 .3 17 .0 Spain 24 .8 419 .1 0 .7 28 .4 8 .7 12 .8 282 .0 135 .4 1 354 .2 3 .4 4 .5 14 .7 Sweden 20 .3 688 .1 32 .0 1 319 .7 179 .2 174 .2 5 .0 Switzerland 28 .7 18 .1 The former y 68 .9 7 .4 66 .9 32 .5 ugoslav Republic of Macedonia 2 .5 1 .0 6 .4 30 .0 United Kingdom 6 .7 Venezuela (Bolivarian Republic of) 18 .7 3 .3 8 .0 2 .2 1 .1 2 .4 Weighted average 370 660 8 .5 96 15 27 32 28 Health-care level II Azerbaijan 0 .3 0 .0 0 .0 0 .8 97 .6 16 .4 110 .3 7 .5 2 .9 5 .0 10 .9 Brazil 94 .2 Chile 53 .9 1 .1 4 .6 2 .8 5 .2 10 .7 18 .5 China 0 .6 2 .0 3 .0 47 .3 Colombia 44 .2 2 .4 60 .9 0 .1 2 .6 Costa Rica 65 .6 149 .8 2 .8 6 .7 6 .7 3 .0 2 .8 10 .6 El Salvador 5 .8 76 .9 0 .8 8 .2 0 .8 0 .6 2 .6 17 .4 Mauritius 39 .2 1 .7 9 .2 1 .7 50 .0 Oman 3 .0 2 .0 16 .4 1 .0 0 .5 78 .8

111 ANNEX A: MEDICAL RADIATION EXPOSURES 99 X-ray generators Bone CT scanners Country densitometry Mammography General Dental Angiography Medical Interventional fluoroscopy 1 .6 28 .0 47 .3 4 .3 Thailand 27 .7 71 .3 4 .0 11 .9 3 .2 6 .3 39 .6 Trinidad and Tobago 19 .0 8 .0 Tunisia 2 .2 0 .7 9 .1 116 .9 79 .1 57 .7 16 .2 2 .7 3 .7 Turkey 6 .4 47 4 .4 0 .6 1 .2 0 .5 0 .7 3 .1 Weighted average 0 .9 Health-care level III 20 .8 0 .2 16 .7 0 .2 2 .5 Zimbabwe 0 .7 1 .3 Average 0 .2 17 0 .2 2 .5 1 .3 0 .7 21 Health-care level IV Maldives 6 .7 0 .0 3 .3 0 .0 3 .3 3 .3 53 .3 3 .3 3 .3 53 0 .0 3 .3 0 .0 6 .7 3 .3 Average 3 .3 Number of items of digital diagnostic equipment in various countries per million population Table b39. Digital systems Country Mammography General Interventional General Dental Angiography fluoroscopy Health-care level I 28 .8 0 .9 0 .3 15 .6 0 .3 Albania 1 .5 Australia Bulgaria 3 .4 0 .1 2 .1 1 .0 Czech Republic 3 .5 Estonia 19 .0 4 .4 7 .3 0 .7 0 .0 15 .4 Finland 1 .5 0 .3 1 .5 0 .3 Hungary 102 .0 20 .4 Iceland 16 .3 20 .8 Japan latvia 3 .1 0 .9 6 .6 4 .4 luxembourg 0 .0 0 .0 0 .8 New Zealand Romania 2 .7 0 .0 0 .0 0 .1 0 .1 Russian Federation 1 .5 3 .6 Spain 57 .8 26 .8 6 .2 25 .2 9 .1 45 .1 22 .6 2 .3 Sweden 0 .2 0 .0 0 .0 1 .6 Venezuela (Bolivarian Republic of) Weighted average 14 4 .5 7 .6 3 .2 20 2 .2 Health-care level II El Salvador 2 .3 Mauritius 0 .0 0 0 .0 0 .0 0 .0 .0 0 .0 Trinidad and Tobago 15 .8 2 .4 3 .2 Tunisia 1 .0 Weighted average 1 .4 0 .0 8 .1 0 .0 1 .2 1 .6

112 100 UNSCEAR 2008 REPORT: VOLUME I Table b40. Trends in average provision of medical radiology per million population Data from the UNSCEAR Global Surveys of Medical Radiation Usage and Exposures Resource Years Number per million population at health-care level I III IV II 550 180 1985–1990 2 600 53 2 780 695 210 45 1991–1996 Physicians 1 580 1997–2007 60 3 530 1 .1 1970–1974 23 62 76 4 1980–1984 64 Physicians conducting radiological procedures 41 6 1985–1990 72 0 .3 106 76 5 0 .1 1991–1996 77 45 1 10 1997–2007 1991–1996 49 3 530 87 Dentists 280 33 540 1997–2007 17 1997–2007 1 .5 0 .3 0 Medical physicists 7 1997–2007 370 100 15 77 Radiology technicians 1997–2007 45 1 .3 10 77 Diagnostic radiology physicians 1997–2007 40 2 .2 3 .3 Interventional cardiologists 1970–1974 450 14 0 .6 10 1980–1984 380 71 16 1985–1990 86 18 4 350 Medical x-ray generators, conventional 290 60 4 1991–1996 40 47 53 370 21 1997–2007 24 0 .5 0 .2 0 .1 1991–1996 Mammography x-ray generators, conventional 28 0 .9 0 .2 3 .3 1997–2007 1970–1974 12 0 .04 440 1980–1984 460 77 5 1985–1990 380 86 3 0 .4 Dental x-ray generators, conventional 1991–1996 440 56 11 0 .1 1997–2007 660 4 17 6 .7 Interventional radiology systems, conventional 1997–2007 0 .6 0 .2 0 .0 8 .5 1991–1996 2 .4 17 0 .4 0 .1 CT scanners 32 3 .1 0 .7 3 .3 1997–2007 General x-ray generators, digital 1997–2007 14 1 .4 Mammography, digital 4 .5 0 .0 1997–2007 Dental, digital 1997–2007 7 .6 8 .1 Interventional radiology, digital 1997–2007 3 .2 0 .0 Bone mineral densitometry 1997–2007 27 0 .7 3 .3

113 ANNEX A: MEDICAL RADIATION EXPOSURES 101 000 LAT 1 656 90 700 56 165 Cervical 195 000 628 466 151 000 143 028 143 114 287 350 200 325 000 1 940 000 2 083 825 92 562 859 000 4 491 500 AP 1 666 3 540 90 700 76 736 13 000 30 242 12 812 Cervical 195 000 145 000 214 543 112 621 350 200 332 000 523 200 1 988 509 2 360 000 2 101 582 6 609 000 LAT 732 8 414 82 000 76 000 51 000 63 058 602 227 759 000 144 964 244 000 875 428 195 700 207 000 Thoracic Spine 40 018 281 000 7 900 000 2 055 100 AP 732 5 760 2 503 7 915 82 000 76 000 51 000 71 400 31 310 13 000 16 100 15 746 869 715 873 330 195 700 222 000 455 900 Thoracic 2 230 000 2 488 000 1 545 721 LAT 2 962 Lumbar 279 000 170 000 787 090 125 000 341 123 442 000 200 112 107 056 391 400 392 000 1 700 000 2 727 445 825 000 161 058 3 940 700 10 060 000 2 962 6 017 AP/PA 14 000 45 880 25 138 Lumbar 279 000 170 000 117 000 183 739 156 261 268 128 800 000 391 400 822 100 400 000 1 066 753 2 770 000 3 542 052 joints 23 603 55 062 452 000 886 887 635 511 109 353 734 261 Limbs and 7 700 000 1 940 000 1 338 000 1 919 608 2 940 000 1 740 362 1 102 625 2 161 000 1 572 134 1 500 000 1 414 331 2 811 900 3 256 400 1 718 000 21 195 500 14 000 000 20 817 000 0 0 3 200 33 745 32 381 43 489 550 000 170 753 397 000 2 600 000 1 962 670 Fluoroscopy - 0 0 412 Photo- 51 000 94 126 301 000 320 196 1 385 085 1 142 015 59 700 000 fluorography Chest 17 134 400 000 - LAT 574 Chest 58 102 21 419 350 000 841 000 121 545 050 314 207 243 937 463 000 378 674 6 460 927 8 540 000 2 125 281 1 637 700 1 464 300 1 200 000 4 320 464 404 2 600 000 5 600 000 3 400 000 83 271 000 PA Chest 47 992 33 053 53 412 841 000 388 000 997 265 185 256 569 187 676 834 440 451 8 300 000 1 400 000 1 173 914 4 794 000 1 060 106 2 533 800 2 208 100 1 977 000 14 391 203 10 500 000 18 408 379 Country ugoslav Republic of Macedonia Annual number of medical radiological examinations United Kingdom Switzerland The former y Sweden Spain Slovenia Russian Federation Norway Romania Netherlands France Germany Finland Hungary Czech Republic Croatia Malta Greece Iceland Bulgaria latvia Japan Korea, Rep . lithuana luxembourg Belgium Australia Austria I level Health-care Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Table b41a.

114 102 UNSCEAR 2008 REPORT: VOLUME I LAT 781 3 516 15 000 17 100 500 Cervical 40 244 93 117 Clinical 844 000 195 000 947 600 410 000 248 602 337 000 250 962 diagnosis 1 506 000 24 514 5 150 300 5 600 000 AP 716 Mammography 3 516 15 000 17 100 Cervical 85 944 85 915 14 872 72 100 57 066 253 000 630 000 197 712 800 000 Screening LAT 269 8 000 5 700 3 500 77 169 Thoracic Spine 2 146 7 037 13 048 38 760 90 888 44 977 47 000 66 703 97 850 31 572 66 464 52 200 131 000 1 442 000 1 208 300 Urography AP 270 8 000 5 700 3 500 Thoracic 754 1 600 7 210 3 521 4 321 1 363 2 790 95 000 20 000 10 954 553 000 LAT 1 551 7 020 10 000 34 200 Cholecystography Lumbar 27 363 9 044 1 437 22 000 81 370 59 267 52 867 13 625 28 271 571 800 149 000 1 550 7 020 Lower GI AP/PA 10 000 34 200 2 270 000 Lumbar joints 8 456 3 500 34 088 216 475 189 800 163 600 1 161 5 361 Limbs and 24 969 99 000 91 670 34 553 85 611 264 046 170 000 302 400 113 000 105 328 Upper GI 2 500 000 15 000 000 0 0 6 386 Fluoroscopy 3 996 81 449 55 159 68 188 277 873 471 000 494 400 156 953 242 000 156 000 Abdomen 4 323 800 2 570 000 16 210 000 0 0 Photo- 10 000 fluorography Chest Head 6 297 633 000 430 000 319 300 157 725 396 993 385 500 417 220 338 000 4 314 452 8 461 000 3 751 100 2 300 000 LAT 237 Chest 4 000 3 200 17 764 45 897 455 800 2 517 589 000 533 000 320 000 123 631 906 400 180 644 317 354 498 000 953 300 Pelvis/hip 2 249 892 3 6 975 000 4 300 000 PA 494 Chest 65 764 20 000 64 500 60 629 163 677 1 823 400 Country Country lithuania latvia Korea, Rep . Japan Hungary Greece Iceland Bulgaria Belgium Germany Finland Croatia Czech Republic Austria Australia France Annual number of medical radiological examinations Trinidad and Tobago Zimbabwe Maldives Oman Mauritius El Salvador Costa Rica I II III IV level Health-care Health-care level Table b41b. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures

115 ANNEX A: MEDICAL RADIATION EXPOSURES 103 7 000 19 570 31 500 Cardiac 253 5 250 1 604 10 000 68 000 60 000 90 388 11 271 Clinical 390 000 260 000 265 000 871 000 250 000 diagnosis 1 473 994 2 005 303 Angiography 2 196 1 206 8 640 Non- 1 601 11 978 67 400 73 000 cardiac 133 900 Mammography 0 5 250 5 059 10 000 12 252 158 680 520 000 239 000 700 000 Screening 1 334 000 1 368 981 1 485 263 Others 23 000 19 760 736 5 488 9 270 16 000 1 758 3 817 1 728 1 632 6 921 Vascular 10 000 42 000 75 000 24 628 142 500 258 000 272 681 248 250 804 000 Urography 5 400 3 000 Cerebral Interventional procedures 0 0 193 251 158 6 000 68 000 38 858 19 658 142 500 162 000 Cholecystography PTCA 14 800 30 000 19 570 52 5 000 1 317 1 629 1 622 1 095 Other 16 000 70 000 28 245 400 000 114 000 359 087 252 805 855 000 Lower GI 112 000 2 880 Inter- ventional 56 891 5 000 4 761 1 990 2 320 1 850 2 396 13 000 63 600 10 733 222 000 171 000 446 020 749 516 Upper GI 1 710 000 Pelvis 44 000 105 521 326 1 333 8 473 8 880 20 000 47 044 24 380 20 900 61 940 92 000 10 70 604 40 000 63 000 45 808 933 446 808 000 Abdomen Spine 1 217 000 24 247 40 000 CT 96 000 669 500 Abdomen Head 1 688 3 713 9 582 30 000 14 015 64 589 49 800 61 940 11 456 73 000 31 300 160 000 628 316 182 000 601 641 1 118 000 6 060 000 Thorax 669 500 101 000 586 5 267 1 238 25 000 19 064 16 673 28 500 29 612 312 000 420 000 274 433 981 484 219 000 340 969 Pelvis/hip 1 773 000 2 420 000 Head 89 444 218 000 432 600 Country ugoslav Republic of Macedonia Country Maldives Zimbabwe Trinidad and Tobago Oman Mauritius Costa Rica United Kingdom Switzerland The former y El Salvador Slovenia Spain Romania Sweden Norway Russian Federation Netherlands Malta luxembourg Annual number of medical radiological examinations Croatia Australia Austria Bulgaria Belgium I II III IV I level Health-care level Health-care Table b41c. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures

116 104 UNSCEAR 2008 REPORT: VOLUME I 0 280 2 051 2 121 6 107 1 545 1 800 1 363 92 196 35 000 17 032 16 556 35 000 19 358 56 330 20 000 37 988 Cardiac 163 000 1 280 300 1 102 000 Angiography 772 0 0 370 793 183 125 Non- 4 424 3 913 3 163 28 732 35 000 12 432 34 162 82 000 75 158 22 000 cardiac 130 000 130 000 721 158 000 1 047 500 0 0 290 241 235 120 231 1 203 3 500 Others 14 416 40 000 97 000 420 000 132 484 1 728 0 0 75 77 124 634 193 7 276 3 200 9 500 10 930 50 000 67 442 65 000 354 000 Vascular 7 633 0 0 0 32 436 357 142 650 462 4 512 7 419 2 000 19 000 12 183 60 100 137 400 Cerebral Interventional procedures 0 0 578 698 580 770 PTCA 9 854 2 517 2 798 8 030 3 600 7 800 15 942 80 000 28 757 26 000 105 553 189 700 636 226 721 Other 6 378 1 475 3 677 8 000 36 000 17 107 10 457 90 800 55 000 20 000 24 000 11 424 195 000 350 000 132 227 0 0 40 Inter- 2 091 1 100 1 000 65 404 ventional 76 231 590 Pelvis 1 036 1 177 1 441 4 000 9 520 51 991 44 741 54 000 25 000 372 200 200 000 149 713 120 000 3 796 000 58 220 581 Spine 3 229 6 000 2 176 1 180 16 807 76 871 85 000 29 271 58 200 58 000 14 158 30 000 12 000 80 000 219 030 CT 1 588 500 1 300 000 11 520 104 650 0 110 2 707 6 024 8 000 1 778 1 770 11 879 81 279 28 800 78 114 62 948 30 000 20 400 305 000 278 096 930 000 200 000 225 000 204 000 645 489 128 000 166 000 297 000 Abdomen 2 269 300 12 878 000 0 98 786 6 035 1 351 2 936 8 000 1 875 7 480 Thorax 49 631 19 984 44 753 33 078 30 000 84 000 97 000 14 625 210 000 188 804 620 000 225 355 199 000 180 000 102 000 247 082 193 000 1 488 600 11 167 000 0 992 Head 5 673 4 143 8 868 19 795 62 497 30 000 10 718 10 000 17 000 300 000 183 922 881 008 187 427 136 512 235 723 276 000 210 000 714 000 719 523 618 000 324 000 196 000 3 267 700 1 900 000 16 613 000 Country ugoslav Republic of Macedonia uxembourg Netherlands Japan Korea, Rep . Norway Malta Czech Republic latvia Hungary Greece lithuania Germany Romania Finland l Russian Federation Iceland Slovakia France Spain Maldives Trinidad and Tobago Zimbabwe United Kingdom Mauritius Switzerland Sweden Oman The former y El Salvador Costa Rica I II III IV level Health-care

117 ANNEX A: MEDICAL RADIATION EXPOSURES 105 Annual number of various medical and dental radiological examinations Table b41d. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Panoramic Health-care level Total medical Intraoral Other Dental CT Total dental Country Pelvimetry medical 8 770 000 5 500 000 1 350 000 400 6 850 000 Austria 6 180 Belgium 14 887 002 1 050 600 272 574 11 808 3 014 561 Bulgaria 12 265 136 808 260 309 Croatia 314 843 68 944 383 787 Czech Republic 5 773 618 2 094 778 367 660 2 462 438 Finland 1 860 3 583 517 1 656 000 300 000 1 956 000 25 872 47 000 000 2 300 000 France 18 000 000 15 700 000 Germany 87 046 500 47 925 500 5 873 400 Greece 22 000 Iceland 198 6 561 182 719 Japan 19 524 000 237 346 000 61 443 000 11 975 000 73 418 000 60 000 Korea, Rep . 44 994 733 I latvia 100 054 320 215 2 540 216 114 960 lithuania 356 199 luxembourg 1 2 702 397 239 108 158 21 444 175 767 Malta 0 108 158 42 321 1 146 0 43 467 0 8 400 000 8 200 000 Netherlands Norway 3 377 606 1 790 000 56 500 1 865 500 342 943 110 61 742 10 555 115 327 406 15 537 9 Romania 16 000 45 700 000 157 800 000 13 300 000 2 100 000 14 100 000 Russian Federation Slovenia 375 000 Spain 245 346 56 356 38 055 077 3 753 836 1 181 763 449 4 936 048 Switzerland 43 600 6 400 000 3 800 000 231 000 4 031 000 The former yugoslav Republic of Macedonia 36 576 6 000 29 000 000 9 500 000 United Kingdom 12 500 000 3 000 000 Costa Rica 0 223 778 5 000 119 300 El Salvador 5 698 4 367 444 83 300 36 000 II 0 0 383 100 320 Mauritius Oman 19 508 5 965 25 473 III Zimbabwe 0 30 000 1 000 IV Maldives 77 580

118 106 UNSCEAR 2008 REPORT: VOLUME I Total annual number of diagnostic medical and dental radiological examinations Table b42. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Country Health-care level Diagnostic examinations Medical Dental 8 770 000 6 850 000 Austria 14 887 002 14 887 002 Belgium Bulgaria 3 014 561 272 574 Croatia 383 787 Czech Republic 5 773 618 2 462 438 3 583 517 1 956 000 Finland France 47 000 000 18 400 000 Germany 87 046 500 47 925 500 Iceland 182 719 Japan 237 346 000 73 418 000 Korea, Rep . 44 994 733 latvia 2 540 216 114 960 I lithuana 356 199 luxembourg 397 239 175 767 108 158 Malta 43 467 Netherlands 9 900 000 4 920 000 Romania 10 555 115 342 943 Russian Federation 14 100 000 157 800 000 Slovenia 375 000 Spain 38 055 077 4 936 048 Sweden 5 120 000 Switzerland 6 400 000 4 031 000 The former y 36 576 ugoslav Republic of Macedonia United Kingdom 29 000 000 12 500 000 Costa Rica 223 778 119 300 El Salvador 4 367 444 II Mauritius 383 100 320 Oman 25 473 IV Maldives 77 580

119 107 ANNEX A: MEDICAL RADIATION EXPOSURES 19 LAT 6 .89 4 .14 6 .59 39 .63 34 .00 28 .75 13 .91 44 .33 13 .22 75 .39 14 .25 10 .24 26 .14 Cervical 54 .44 19 .95 14 .44 32 AP 3 .71 1 .30 4 .17 9 .88 40 .49 25 .64 34 .00 10 .94 44 .71 51 .86 12 .04 14 .62 28 .35 16 .09 72 .39 45 .08 10 .24 26 .14 Cervical 9 .8 LAT 7 .74 0 .82 1 .83 6 .68 5 .17 8 .58 25 .24 19 .00 18 .62 24 .45 25 .46 13 .65 10 .99 Thoracic 8 .62 4 .72 Spine 24 .91 128 .04 3 . 16 AP 1 .93 1 .56 8 .51 5 .96 1 .30 1 .83 8 .58 2 .83 27 .07 22 .34 19 .00 18 .58 19 .52 17 .51 15 .20 25 .46 19 .72 10 .99 348 .37 Thoracic 23 LAT 8 .51 1 .30 7 .41 47 .80 38 .00 13 .14 58 .02 19 .45 15 .71 11 .59 62 .41 17 .84 37 .39 19 .19 Lumbar 78 .94 47 .77 34 .71 13 .87 31 5 .63 1 .40 7 .41 8 .46 40 .29 48 .78 38 .00 75 .35 26 .06 20 .47 72 .73 29 .76 55 .62 18 .88 58 .41 24 .18 37 .39 19 .19 AP/PA Lumbar 151 140 joints 77 .99 59 .01 20 .04 80 .16 43 .52 159 .58 209 .51 271 .00 163 .36 226 .90 256 .91 216 .51 152 .78 136 .36 210 .02 187 .29 405 .14 241 .93 319 .94 191 .14 225 .66 260 .02 129 .41 Limbs and 17 3 .12 7 .30 4 .23 4 .14 0 .43 55 .10 48 .91 17 .72 90 .40 Fluoroscopy 287 0 .04 0 .00 6 .84 30 .16 11 .55 63 .80 Photo- 139 .52 327 .13 406 .95 fluorography Chest 207 .69 70 LAT 5 .65 1 .44 Chest 71 .76 45 .21 85 .34 46 .39 29 .93 47 .39 14 .47 60 .41 58 .21 46 .91 94 .91 146 .34 159 .00 117 .47 146 .48 .12 2 90 .76 653 .44 309 .09 202 .35 166 .26 PA 168 Chest 241 .1 69 .85 82 .63 45 .93 39 .93 71 .57 94 .91 108 .21 246 .00 391 .60 103 .02 152 .54 163 .24 480 .31 223 .60 118 .17 126 .17 193 .71 326 .26 187 .64 139 .50 Country yugoslav Republic of Macedonia Annual number of various medical examinations per 1,000 population atvia Australia Austria Belgium Korea, Rep . France Japan Germany Czech Republic Bulgaria Croatia l Iceland Hungary Greece Finland Malta luxembourg lithuania Netherlands Romania Norway Russian Federation Slovenia Spain Sweden Switzerland Weighted average The former United Kingdom I level Health-care Table b43a. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures

120 108 UNSCEAR 2008 REPORT: VOLUME I 1 .9 1 .3 1 .3 LAT 0 .81 2 .63 0 .07 0 .07 Cervical 4 .94 16 .51 50 .00 92 .00 56 .56 24 .16 Clinical diagnosis 0 .00 19 .42 06 AP 1 .9 1 .3 1 .3 0 .88 0 .81 0 .06 0 . Mammography Cervical 7 .00 7 .00 39 .20 76 .83 Screening 6 .7 LAT 0 .88 0 .81 0 .67 0 .67 0 .02 0 .02 38 .24 Thoracic 0 .00 Spine 32 .30 10 .34 2 .56 9 .50 3 .87 6 .48 15 .98 14 .98 Urography AP 0 .88 0 .81 0 .85 0 .67 0 .67 0 .02 0 .02 Thoracic 0 .14 2 .44 0 .70 0 .43 0 .31 1 .06 3 .8 LAT 1 .62 5 .26 0 .83 0 .83 0 .13 0 .13 Lumbar Cholecystography 0 .01 21 .68 3 .8 5 .26 1 .62 0 .13 0 .13 7 .90 7 .27 6 .37 5 .14 AP/PA 18 .17 Lumbar Lower GI 27 0 .09 7 .88 0 .29 0 .29 0 .70 0 .70 joints 29 .20 136 .33 107 .27 Limbs and 8 .90 3 .36 13 .78 12 .93 19 .29 Upper GI 0 .00 0 .06 0 .03 0 .00 0 .00 Fluoroscopy 9 .99 11 .86 19 .02 48 .00 15 .37 15 .25 Abdomen 0 .01 0 .01 0 .83 0 .83 Photo- fluorography Chest Head 18 .89 41 .22 31 .00 19 .36 40 .55 39 LAT 2 .67 0 .33 0 .33 0 .02 0 .02 Chest 10 .61 70 .12 14 .08 0 .48 PA 1 .7 1 .7 0 .00 140 0 .04 0 .04 46 .72 60 .73 88 .00 15 .17 30 .84 Chest 14 .02 53 .75 81 .11 52 .11 280 .52 Pelvis/hip Country Country Annual number of various medical examinations per 1,000 population Azerbaijan Costa Rica Mauritius El Salvador Oman Trinidad and Tobago Weighted average Zimbabwe Average Maldives Average Australia Austria Belgium Bulgaria Croatia Czech Republic II III IV I level level Health-care Health-care Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Table b43b.

121 109 ANNEX A: MEDICAL RADIATION EXPOSURES 20 6 .1 6 .62 1 .70 4 .01 4 .16 5 .94 6 .55 1 .21 0 .21 0 .83 0 .83 17 .74 17 .73 24 .94 15 .99 29 .96 33 .42 29 .34 35 .52 10 .46 150 .89 432 .18 Clinical diagnosis 0 .60 1 .74 90 .76 62 .43 Mammography 23 14 1 .63 1 .21 0 .00 0 .83 0 .83 37 .66 25 .35 50 .59 37 .44 24 .62 27 .11 12 .65 44 .76 31 .04 58 .68 22 .42 24 .41 320 .10 Screening 8 .5 9 .8 1 .34 4 .71 7 .30 4 .08 5 .31 5 .48 6 .18 8 .46 5 .63 0 .85 4 .34 0 .63 1 .89 1 .39 0 .83 0 .83 0 .06 0 .06 14 .65 11 .32 19 .60 26 .03 15 .31 11 .43 21 .92 Urography 00 .92 11 1 .7 0 .82 1 .15 0 .16 4 .34 0 .33 0 .35 0 . 0 .91 1 .10 0 .88 0 .80 1 .14 0 .10 21 Cholecystography 9 .3 9 .7 2 .60 6 .93 2 .20 4 .89 3 .94 2 .42 4 .06 6 .09 5 .83 8 .14 7 .90 2 .14 6 .72 1 .04 0 .17 0 .17 17 .81 11 .64 17 .54 Lower GI 34 12 1 .02 3 .67 9 .92 3 .95 5 .30 4 .63 2 .31 7 .18 1 .74 3 .73 1 .93 2 .36 1 .58 0 .52 0 .52 40 .52 15 .45 10 .88 34 .52 11 .66 10 .11 26 .31 117 .71 Upper GI 45 11 1 .7 4 .4 9 .87 5 .51 3 .25 7 .11 2 .39 9 .53 1 .67 4 .44 10 .51 31 .15 47 .19 13 .59 91 .98 19 .65 21 .18 19 .97 21 .16 12 .33 20 .45 17 .42 23 .31 19 .32 127 .20 121 .08 Abdomen 44 13 2 .5 5 .6 9 .28 6 .75 8 .24 2 .65 9 .53 2 .50 5 .63 Head 75 .62 37 .28 45 .47 39 .09 63 .42 21 .42 91 .78 66 .40 21 .20 41 .31 27 .71 90 .86 14 .24 21 .44 18 .79 41 .50 32 .01 11 .11 40 4 .9 2 .1 1 .9 8 .56 3 .10 1 .22 4 .38 2 .08 9 .45 1 .95 34 .41 69 .69 84 .54 29 .09 53 .40 28 .16 47 .86 65 .51 73 .48 12 .64 16 .50 22 .25 47 .40 41 .82 29 .80 13 .21 109 .34 Pelvis/hip Country ugoslav Republic of Macedonia Finland France Germany Greece Hungary Iceland Japan Korea, Rep . lithuania latvia luxembourg Netherlands Malta Norway Romania Russian Federation Slovenia Spain Sweden Switzerland United Kingdom The former y Weighted average Costa Rica El Salvador Mauritius Zimbabwe Trinidad and Tobago Oman Weighted average Average Maldives Average I II III IV level Health-care

122 110 UNSCEAR 2008 REPORT: VOLUME I 1 .5 1 .54 3 .15 3 .42 0 .85 8 .96 7 .21 1 .90 5 .13 3 .18 3 .67 0 .89 0 .24 1 .28 0 .90 2 .68 2 .74 15 .52 Cardiac 8 .65 Angiography 2 .6 3 .30 2 .70 2 .37 7 .00 0 .43 8 .90 2 .70 0 .20 0 .93 5 .12 3 .18 6 .19 1 .57 0 .89 1 .70 2 .95 2 .66 12 .70 13 .00 Non-cardiac 41 1 .1 2 .75 0 .52 2 .80 0 .12 0 . 0 .73 6 .81 0 .27 3 .00 0 .47 1 .63 Others 1 .6 1 .39 1 .40 1 .95 0 .31 0 .66 0 .90 0 .67 0 .19 5 .74 2 .36 0 .34 1 .53 1 .27 1 .09 1 .67 Vascular 2 .19 0 .08 0 .07 0 .44 0 .37 0 .66 0 .00 0 .20 1 .21 0 .08 0 .41 0 .17 0 .09 0 .03 0 .31 Cerebral Interventional procedures 1 .88 1 .54 0 .78 3 .66 3 .34 1 .97 1 .45 1 .71 1 .90 2 .30 0 .54 0 .73 0 .55 1 .80 0 .65 1 .05 0 .44 0 .92 PTCA 2 .8 3 .26 1 .60 5 .02 1 .59 5 .67 1 .53 5 .51 3 .27 1 .10 2 .25 3 .00 2 .71 2 .68 0 .13 Other 14 .11 13 .66 0 .40 0 .00 0 .10 0 .11 0 .00 1 .48 0 .97 Interventional 19 0 .22 4 .35 5 .37 0 .79 2 .59 5 .41 4 .51 3 .39 2 .82 Pelvis 23 .78 29 .79 18 .18 11 .20 16 .08 CT 97 11 29 .98 2 .70 4 .88 5 .66 0 .55 5 .46 5 .81 7 .73 4 . 1 .35 Spine 37 .18 12 .75 10 .98 21 .07 16 .57 19 .25 14 .98 10 .72 30 7 .59 6 .77 5 .92 0 .00 1 .39 4 .99 26 .28 12 .55 11 .99 11 .71 20 .49 15 .07 65 .00 19 .50 22 .54 17 .52 27 .51 18 .18 14 .98 14 .63 14 .45 22 .25 101 .06 Abdomen 24 4 .35 3 .38 8 .71 4 .02 6 .30 0 .00 9 .99 0 .70 5 .60 3 .24 13 .35 12 .32 87 .63 10 .05 65 .00 13 .43 19 .94 10 .70 18 .04 16 .36 10 .38 14 .98 10 .95 11 .26 Thorax 40 4 .87 Head 43 .79 18 .21 26 .59 14 .18 18 .74 27 .23 26 .00 30 .79 42 .00 20 .16 39 .64 27 .65 36 .46 19 .18 39 .61 19 .09 10 .86 14 .98 16 .31 36 .56 26 .27 10 .39 130 .36 Country luxembourg lithuania Australia Austria Czech Republic Malta Korea, Rep . latvia Japan France Finland Belgium Croatia Bulgaria Norway Iceland Hungary Netherlands Germany Greece Romania Russian Federation Slovenia Spain Sweden Switzerland United Kingdom Weighted average Annual number of various medical examinations per 1,000 population I Health-care level Table b43c. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures

123 111 ANNEX A: MEDICAL RADIATION EXPOSURES 5 .0 5 .84 0 .23 0 .00 0 .00 Cardiac Angiography 0 .03 0 .00 0 .02 0 .00 0 .00 (111 .04) Non-cardiac 0 .04 0 .00 0 .03 0 .00 0 .00 Others 0 .01 0 .00 0 .01 0 .00 0 .00 Vascular 0 .07 0 .00 0 .06 0 .00 0 .00 Cerebral Interventional procedures 0 .12 0 .00 0 .10 0 .00 0 .00 PTCA 1 .0 0 .17 1 .76 0 .18 Other . 0 .08 0 .08 Interventional 0 .14 1 .46 0 .96 1 .14 0 .33 0 .33 0 .25 0 .25 Pelvis CT 0 .27 0 .33 0 .33 0 .46 0 .50 0 .50 0 .19 0 .19 Spine 1 .8 0 .41 3 .14 0 .00 0 .67 1 .41 0 .67 0 .37 0 .37 Abdomen 0 .18 1 .15 0 .00 7 .25 0 .67 0 .76 1 .49 0 .67 0 .33 0 .33 Thorax 3 .3 2 . 3 2 .05 2 .62 0 .00 3 .28 0 .83 0 .83 3 .31 Head Country verage Costa Rica El Salvador Mauritius Oman Zimbabwe Trinidad and Tobago Weighted average Average Maldives A II III IV Health-care level Note: Data for El Salvador in parentheses were excluded from the calculation of the weighted average for non-cardiac angiography

124 112 UNSCEAR 2008 REPORT: VOLUME I Annual number of various medical and dental radiological examinations per 1,000 population Table b43d. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Country Other medical Total medical Intraoral Panoramic Dental CT Total dental Pelvimetry Health-care level 1 069 .51 670 .73 164 .63 0 .05 835 .37 Austria 0 .60 Belgium 1 445 .34 102 .00 Bulgaria 16 .79 369 .93 31 .94 1 .51 33 .45 1 .45 Croatia 15 .54 86 .50 70 .96 Czech Republic 561 .09 203 .57 35 .73 239 .30 Finland 0 .35 4 .93 682 .57 315 .43 57 .14 372 .57 France 761 .75 37 .28 291 .73 254 .46 71 .19 580 .91 Germany 1 055 .1 Greece 2 .00 0 .67 22 .32 Iceland 621 .49 Japan 0 .47 153 .21 1 862 .49 482 .07 93 .97 576 .12 Korea, Rep . 957 .17 latvia 139 .53 1 106 .85 50 .09 43 .60 I 102 .03 lithuania 0 .00 5 .98 878 .85 239 .29 47 .44 388 .87 luxembourg 0 .00 0 .00 270 .40 105 .80 2 .87 0 .00 108 .67 Malta Netherlands 633 .07 306 .94 7 .67 314 .62 Norway 727 .93 12 .18 402 .05 385 .78 0 .42 15 .08 0 .72 15 .80 486 .16 2 .84 Romania 311 .52 1 075 .66 90 .66 14 .31 96 .11 Russian Federation 0 .11 187 .22 Slovenia 01 111 .91 Spain 85 .10 26 .79 0 . 5 .56 1 .28 862 .75 Switzerland 857 .79 509 .32 30 .96 540 .28 5 .84 0 .10 487 .39 159 .66 50 .42 210 .08 United Kingdom Weighted average 1 .1 159 1 176 230 49 0 .02 316 Costa Rica 51 .73 1 .16 0 .00 El Salvador 0 .88 671 .91 12 .82 5 .54 18 .35 Mauritius 0 .00 0 .00 319 .25 0 .27 II Oman 9 .67 2 .96 12 .62 Weighted average 0 .47 0 .00 410 12 3 .6 15 0 .00 2 .50 0 .08 Zimbabwe III Average 0 .00 2 .5 0 .08 Maldives 258 .60 IV Average 260

125 ANNEX A: MEDICAL RADIATION EXPOSURES 113 Total annual numbers of medical and dental radiological examinations per 1,000 population Table b44. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Country Total dental Total diagnostic Health-care level Total medical Austria 1 069 .51 835 .37 1 904 .88 1 445 .34 Belgium 1 445 .34 Bulgaria 33 .45 403 .38 369 .93 Croatia 86 .50 Czech Republic 561 .09 239 .30 800 .39 Finland 682 .57 372 .57 1 055 .15 France 291 .73 1 053 .48 761 .75 Germany 580 .91 1 636 .01 1 055 .1 Iceland 621 .49 Japan 1 862 .49 576 .12 2 438 .61 Korea, Rep . 957 .17 latvia 1 106 .85 50 .09 1 156 .94 I 102 .03 lithuania luxembourg 878 .85 388 .87 1 267 .71 Malta 270 .40 108 .67 379 .06 Netherlands 537 .15 851 .77 314 .62 727 .93 1 129 .98 Norway 402 .05 Romania 486 .16 15 .80 501 .96 1 075 .66 96 .11 1 171 .78 Russian Federation Slovenia 187 .22 862 .75 111 .91 974 .66 Spain Sweden 566 Switzerland 857 .79 540 .28 1 398 .07 United Kingdom 487 .39 210 .08 697 .48 Weighted average 351 .62 1 492 .80 1 176 .38 Costa Rica 51 .73 El Salvador 671 .91 18 .35 690 .27 319 .52 Mauritius 319 .25 0 .27 II 12 .62 Oman Weighted average 410 15 430 Maldives 258 .60 IV Average 260

126 UNSCEAR 2008 REPORT: VOLUME I 114 7 .20 0 .20 0 .55 1 .45 1 .00 0 .22 0 .30 7 .10 1 .40 1 .40 1 .80 Cervical LAT 1.49 6 .90 0 .39 1 .30 0 .71 0 .45 1 .48 1 .40 0 .25 1 .70 5 .90 1 .50 1 .40 1 .60 0 .08 0.90 Cervical AP 1 .64 7 .80 3 .80 6 .05 9 .00 5 .80 6 .43 1 .96 11 .00 11 .20 11 .00 26 .90 14 .00 Thoracic LAT 3.79 Spine AP 10; lAT 30 3 .10 7 .00 1 .46 2 .37 4 .14 3 .30 2 .50 3 .10 5 .75 2 .85 0 .70 4 .00 3 .00 4.20 15 .50 Thoracic AP 6.5 4 .76 5 .80 30 .00 15 .00 10 .50 13 .10 15 .89 12 .40 27 .00 10 .80 37 .40 15 .52 17 .60 15 .90 14 .00 17 .00 Lumbar LAT 4.20 40 6.5 2 .31 6 .10 4 .60 2 .70 5 .86 9 .20 5 .07 1 .30 4 .40 6 .06 4 .35 6 .30 6 .00 4 . 9.60 10 .00 11 .10 17 .40 16 .59 Lumbar AP/PA 0 .33 4 .50 0 .01 0 .13 0 .10 1 .00 joints Limbs and 5.40 22 .00 11.00 Fluoroscopy . 2 4 .18 4 .40 7 .20 0 .40 Photo- fluorography Chest 0 .46 1 .20 0 .91 1 .23 0 .73 1 .60 0 .44 0 .45 3 .50 0 .20 1 .50 0 .70 0 .49 0 .96 1 .68 0 .20 0.82 0.40 11 .00 Chest LAT 0 .40 0 .52 0 .50 0 .15 0 .16 0 .44 0 .33 0 .20 0 .04 1 .30 0 .20 0 .44 0 .40 0 .20 0 .17 0 .29 0 .38 0 .20 0 .16 0 .10 0 .20 0.13 0.57 0.64 0.40 Chest PA for various medical and dental radiological examinations a Country Czech Republic Germany Greece Hungary Belgium Australia lithuania Iceland Japan Malta Norway Netherlands Romania Maldives Oman Mauritius Chile Sweden Spain Slovenia Turkey Thailand United Kingdom Switzerland Tunisia Mean patient dose I II IV Health-care level Values in regular type are for entrance air kerma in mGy; values in bold type are for DAP in Gy cm Table b45a. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures a

127 115 ANNEX A: MEDICAL RADIATION EXPOSURES b 2 .7 2 .00 6 .7 5 .00 2 .00 7 .00 7 .80 4 .17 1 .65 1 .27 10 .00 44 .80 Clinical diagnosis Mammography (mean glandular dose) b 6 2 .1 2 .00 1.54 3 .04 Screening 2 .50 10 .00 24 .00 51 .60 11.00 19.40 10.00 15.00 33.20 Urography 2 .84 1.41 10 .00 33 .00 32 .10 12.00 15.00 Cholecystography 2 .03 2 .90 7 .00 20 .00 57.43 19.00 89.00 20.00 30.00 36.80 29.00 38.00 Lower GI . 1 .87 2 .90 3 .00 9.00 10 .20 20 .00 23.53 31.90 21.50 21.00 19.00 Upper GI ; values in italic type are for ESD 2 8.25 9 .30 3 .36 2 .20 7 .50 2 .65 2 .37 0 .70 5 .00 7 .60 4 .43 3 .30 5 .40 2.64 7.80 10 .00 16 .70 Abdomen 3 .00 5 .10 2 .27 2 .40 0 .67 2 .37 0 .07 2 .00 5 .00 4 .00 4 .30 1 .98 3 .30 2 .70 0.44 1.20 Head 17 .50 16 .30 9 .90 4 .78 6 .10 2 .65 3 .16 0 .70 3 .10 4 .00 4 .00 3 .95 7 .00 1.96 2.40 5.17 1.60 10 .00 15 .60 10 .00 Pelvis/hip for various medical and dental radiological examinations a Country . Mean patient dose Australia Germany Greece Belgium Czech Republic Iceland Hungary Oman Thailand Malta lithuania Japan Maldives Chile United Kingdom Mauritius Turkey Tunisia Netherlands Norway Slovenia Romania Sweden Switzerland Spain I II IV level Health-care ESD in mammography Values in regular type are for entrance air kerma in mGy; values in bold type are for DAP in Gy cm b Table b45b. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures a

128 116 UNSCEAR 2008 REPORT: VOLUME I 44 36 .00 26.50 30.30 85.00 68.00 Cardiac 298.00 Angiography Dental CT 2 .72 58.10 47.30 85.00 38.00 77.46 29.00 Non-cardiac 10.00 63.60 70.00 Others 1 .6 3 .90 0.10 0.09 6.00 29.00 Panoramic 113.40 170.00 Vascular ` 52.00 77.40 50.00 Cerebral Interventional procedures 3 .00 3 .10 7 .90 2 .50 2 .17 PTCA 80 .00 57.20 67.80 85.00 78.10 120.00 Intraoral Other 170 .00 85 .70 Interventional 0 .20 19 .40 Other medical 6 .00 Pelvis 39 .00 23 .50 70 .00 201 .56 451 .00 . ; values underlined are for CTDI in mGy cm; values underlined and in bold type are for DlP in mGy cm . 2 2 CT 510 248 8 .00 Spine 36 .00 90 .00 372 .00 170 .57 3 .98 36 .20 Pelvimetry 670 28 .00 10 .00 25 .60 72 .00 27 .00 1 239 290 .00 410 .00 700 .90 800 .00 Abdomen 508 390 8 .00 22 .00 18 .80 65 .00 22 .00 Thorax 400 .00 349 .50 238 .00 256 .40 Country for various medical and dental radiological examinations for various medical and dental radiological examinations a a 980 2 .00 Head 39 .00 71 .00 90 .00 145 .00 348 .40 560 .00 1 036 .53 1 200 .00 1 000.00 Switzerland Spain Romania Finland Malta Japan Country Mean patient dose Mean patient dose I Czech Republic Switzerland Netherlands Greece Sweden Maldives Chile Spain Iceland Malta Japan Romania Slovenia Germany Health-care level I II IV level Health-care Values in regular type are for entrance air kerma in mGy; values in bold type are for DAP in Gy cm Values in regular type are for entrance air kerma in mGy; values in bold type are for DAP in Gy cm a Table b45d. Table b45c. a Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures

129 117 ANNEX A: MEDICAL RADIATION EXPOSURES 0 .01 0 .02 0 .30 0 .04 0 .07 0 .31 0 .00 0 .01 0 .10 0 .13 0 .02 0 .02 0 .00 0 .05–0 .1 Cervical LAT 0 .18 0 .02 0 .07 0 .01–0 .02 0 .04 0 .02 0 .40 0 .11 0 .25 0 .06 0 .14 0 .07 0 .40 0 .20 0 .13 0 .08 0 .16 0 .08 0 .03 0 .03 0 .04–0 .7 0 .05–0 .15 Cervical AP 60 0 .20 0 .22 0 .90 0 .81 0 .20 0 .47 0 .18 0 .35 2 .90 0 . 0 .53 0 .26 0 .08 0 .5–0 .7 0 .1–0 .4 Thoracic LAT 0 .72 0 .20 0 .70 Spine 0 .07–0 .3 0 .29 0 .18 0 .80 0 .40 0 .37 1 .43 0 .18 0 .69 0 .80 0 .51 0 .60 0 .70 0 .80 0 .70 0 .38 0 .08 0 .3–0 .7 0 .2–0 .5 Thoracic AP 1 .4 1 .0 0 .31 0 .36 1 .00 0 .28 1 .23 0 .60 0 .40 1 .40 3 .30 0 .90 1 .80 0 .53 1 .80 0 .30 0 .18 0 .16 0 .4–1 0 .3–1 .3 Lumbar LAT 1 .73 0 .40 1 .00 0 .12–0 .73 1 .4 1 .2 0 .43 0 .32 1 .70 0 .69 2 .10 0 .60 1 .92 0 .27 1 .60 0 .75 1 .20 1 .30 1 .18 1 .30 0 .40 0 .13 0 .34 0 .3–1 0 .5–1 .3 Lumbar AP/PA 0 .10 0 .04 0 .05 0 .02 0 .10 0 .02 0 .02 0 .00 0 .12 0 .05 0 .00 0 .01 0 .03 0 .01 0 .10 0 .003 <0 .001 0 .01–0 .1 0 .001–0 .1 Limbs and joints Mean effective dose (mSv) 2 .1 0 .76 0 .91 2 .60 3 .60 0 .40 Fluoroscopy Standard deviation or range of mean effective dose (mSv) 41 0 .84 0 .80 0 .78 0 .11 0 . Chest Photofluorography 0 .07 0 .07 0 .09 0 .05 0 .12 0 .08 0 .28 0 .37 0 .15 0 .13 0 .14 0 .05 0 .20 0 .07 0 .02 0 .11 0 .10 0 .02 0 .13 0 .09 0 .12 0 .04–0 .1 Chest LAT 0 .05–0 .26 0 .042–0 .055 0 .03 0 .06 0 .06 0 .02 0 .03 0 .05 0 .03 0 .14 0 .09 0 .12 0 .02 0 .11 0 .03 0 .02 0 .09 0 .07 0 .07 0 .04 0 .02 0 .02 0 .02 0 .04 0 .01 0 .02 0 .09 Chest PA 0 .03–0 .2 0 .02–0 .05 0 .012–0 .026 0 .005–0 .137 Country Mean effective dose and variation on the mean for various medical and dental radiological examinations Australia Austria Belgium Bulgaria Czech Republic Germany France Romania Japan Korea, Rep . Russian Federation Norway Spain Netherlands Malta Sweden Weighted average Switzerland Maldives United Kingdom Average Australia Spain Bulgaria Belgium Korea, Rep . Germany Netherlands Romania I I IV level Health-care Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Table b46a.

130 118 UNSCEAR 2008 REPORT: VOLUME I 0 .05 0 .39 0 .30 0 .14 0 .40 0 .30 0 .52 0 .13 0 .40 0 .50 1 .20 0 .35 Cervical LAT Clinical diagnosis 0 .10 0 .01 Mammography Cervical AP 0 .1 0 .26 0 .20 0 .70 0 .15 0 .13 0 .21 0 .35 0 .40 Screening 2 .00 Thoracic LAT 2 .6 2 .7 4 .8 Spine 2 .00 5 .30 0 .60 7 .00 3 .81 2 .90 3 .97 Urography 0 .50 0 .02 Thoracic AP 00 2 .0 4 . 1 .00 2 .86 0 .15 2 .90 1 .32 12 .00 14 .85 2 .00 0 .02 0 .27–4 .4 Cholecystography Lumbar LAT 7 .4 8 .4 1 .00 0 .01 7 .00 7 .80 8 .50 5 .00 0 .40 3 .50 5 .35 14 .00 10 .30 12 .57 0 .27–4 .4 Lower GI Lumbar AP/PA 0 .02 0 .00 3 .4 2 .00 7 .80 3 .80 4 .32 5 .17 7 .00 0 .31 6 .00 1 .90 4 .10 13 .00 Upper GI Limbs and joints Mean effective dose (mSv) 2 .00 Fluoroscopy 0 .82 0 .70 2 .10 0 .80 0 .90 2 .39 3 .62 0 .39 0 .25 0 .58 0 .60 1 .10 0 .99 0 .31 1 .00 Abdomen 0 .05 0 .08 0 .06 0 .40 0 .07 0 .14 0 .17 0 .03 0 .01 0 .02 0 .04 0 .07 0 .04 0 .20 0 .02 0 .03 Head Chest Photofluorography 0 .05 0 .01 Chest LAT 0 .02–0 .27 1 .2 0 .50 1 .60 0 .46 0 .80 2 .68 0 .60 0 .20 0 .45 0 .28 0 .77 0 .50 0 .60 1 .40 0 .52 0 .58 Pelvis/hip 2 .23/1 .47 0 .03 0 .01 Chest PA 0 .02–0 .27 Country Weighted average United Kingdom Switzerland Sweden Spain Russian Federation Romania Norway Netherlands Malta Korea, Rep . Japan Germany France Belgium Czech Republic Austria Australia Country Mean effective dose and variation on the mean for various medical and dental radiological examinations Sweden Switzerland Maldives I I IV level Health-care level Health-care Table b46b. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures

131 119 ANNEX A: MEDICAL RADIATION EXPOSURES 0 .18 0 .2–0 .8 0 .05–0 .3 Clinical diagnosis Mammography Screening 0 .03–0 .16 0 .50 2 .00 4 .80 3 .57 2 .50 2 .50 0 .7–8 .5 Urography 2 .00 1 .25 1 .19 Cholecystography 0 .30 5 .00 4 .00 7 .00 7 .00 3 .0–8 7–16 .7 1 .9–20 Lower GI 0 .10 5 .00 2 .14 3 .00 3 .00 3–12 .7 3 .0–19 2 .0–12 Upper GI 0 .02 1 .00 1 .35 0 .10 1 .56 1 .50 0 .70 0 .70 0 .5–1 0 .5–1 Abdomen Standard deviation or range of mean effective dose (mSv) 0 .00 0 .20 0 .11 0 .01 0 .03 0 .07 0 .07 Head 0 .02–0 .06 0 .01 1 .00 1 .68 0 .12 0 .60 0 .70 0 .70 0 .4–1 .0 0 .06–2 .3 0 .1–0 .32 Pelvis/hip Country Maldives Switzerland Spain Sweden Romania Netherlands Korea, Rep . Belgium Germany Australia Average Maldives I IV IV Health-care level

132 120 UNSCEAR 2008 REPORT: VOLUME I 7 5 8 5 17 7 .9 3 .4 9 .3 5 .5 2 .7–20 Cardiac Angiography 5 3 8 10 15 9 .3 0 .12 0 .32 5 .38 10 .0–20 .0 Non-cardiac 5 9 11 18 21 .44 Others 7 4 9 15 9 .0 13 .8 15 .85 Vascular 6 5 2 5 .7 5 .7 3 .31 Cerebral Interventional procedures .8 5 9 12 15 19 7 10 .8 14 .3 5 .67 PTCA 3 .8 2 .88 4 .95 Other 0 .0 Interventional Mean effective dose (mSv) 9 .4 7 .2 8 .5 9 .29 10 .5 6 .98 8 .02 Pelvis 4 .4–10 Standard deviation or range of mean effective dose (mSv) CT 5 4 5 .0 8 .5 2 .7 8 .1 4 .32 4 .99 Spine 2 .0-5 .0 2 .2–21 5 7 12 10 14 10 16 7 .8 3 .5 8 .5 6 .6 6 .7 8 .9 12 .7 12 .9 3 .73 21 .4 14 .7 4–21 11 .30 20 .00 7 .0–26 6 .5–10 10 .0–25 Abdomen 8 4 5 10 10 10 3 .5 7 .8 7 .4 6 .6 9 .1 6 .6 7 .2 7 .7 8 .8 1 .21 6 .64 4 .14 1 .72 11 .50 2 .6–8 Thorax 6 .0–10 4 .0–19 2 .1–19 5 2 3 1 2 2 0 .6 2 .4 2 .2 2 .4 1 .8 7 .8 2 .7 2 .1 1 .83 0 .81 0 .83 2 .22 Head 1 .0–5 2 .0–4 .0 1 .1–2 .3 1 .0–4 .0 Country Mean effective dose and variation on the mean for various medical and dental radiological examinations Belgium Germany Greece Iceland Netherlands Weighted average Romania Spain Sweden Switzerland United Kingdom Korea, Rep . Netherlands Norway Switzerland Romania Iceland Spain Japan Sweden Hungary Greece Germany France Czech Republic Belgium Austria Australia I I level Health-care Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Table b46c.

133 ANNEX A: MEDICAL RADIATION EXPOSURES 121 0 .01 0 .01 0 .00 0 .03 0 .03 0 .01 0 .01 0 .02 0 .02 0 .01 0 .001–1 Total dental 0 .32 0 .32 Dental CT 0 .01 0 .01 0 .01 0 .15 0 .01 0 .05 0 .01 0 .01 0 .06 0 .02 0 .026 Panoramic 0 .10 0 .01 0 .01 0 .01 0 .02 0 .00 0 .03 0 .02 0 .01 0 .01 0 .02 0 .02 0 .01 Intraoral 1 .0 0 .97 1 .75 0 .87 1 .47 1 .25 0 .86 1 .30 0 .70 0 .65 0 .20 Total medical Mean effective dose (mSv) Standard deviation or range of mean effective dose 3 .3 3 .33 2 .10 0 .00 Other medical 1 .4 0 .83 6 .20 0 .80 2 .40 Pelvimetry Country Czech Republic France Germany Austria Netherlands Japan Norway Romania Russian Federation Switzerland Weighted average United Kingdom Romania Average Maldives Germany Switzerland Mean effective dose and variation on the mean for various medical and dental radiological examinations I I IV Health-care level Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Table b46d.

134 122 UNSCEAR 2008 REPORT: VOLUME I b47. distribution by age and sex of patients undergoing various types of diagnostic radiological examination Table (1997–2007) Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Country Age distribution (%) Sex distribution (%) Health-care level Male >40 years 16–40 years 0–15 years Female Chest PA 20 73 50 50 Australia 7 19 34 51 49 Bulgaria 46 7 76 50 50 Czech Republic 17 12 Iceland 78 53 47 10 Japan 18 86 55 45 6 20 46 54 47 Korea, Rep . 34 I 14 80 luxembourg 46 6 54 22 24 54 56 44 Romania 7 49 44 Russian Federation 52 48 Spain 10 80 51 49 10 5 15 53 47 Switzerland 80 30 51 49 Weighted average 9 .0 64 23 28 49 Trinidad and Tobago 41 59 Tunisia 7 35 58 44 56 II 2 14 84 Turkey 55 45 Weighted average 17 80 45 55 3 Zimbabwe 40 10 50 50 50 III 50 40 10 Average 50 50 Maldives 9 38 54 50 50 IV Average 9 38 54 50 50 Chest LAT Australia 20 73 50 50 7 19 46 51 49 Bulgaria 34 12 10 78 53 47 Iceland Japan 6 76 55 45 18 Korea, Rep . 29 55 56 44 17 I 2 luxembourg 82 52 48 16 22 54 56 44 Romania 24 10 11 80 55 45 Spain Switzerland 5 80 53 47 15 Weighted average 20 71 55 46 10 45 Trinidad and Tobago 12 34 54 55 II Tunisia 0 100 100 0 0 1 95 95 5 Weighted average 4 Zimbabwe 0 100 50 50 0 III Average 0 100 0 50 50 29 Maldives 3 43 55 71 IV Average 43 55 71 29 3 Chest photofluorography 14 46 42 31 69 Bulgaria 48 Romania 4 55 41 52 I 48 0 41 59 52 Russian Federation Weighted average 1 43 56 51 49

135 ANNEX A: MEDICAL RADIATION EXPOSURES 123 Country Health-care level Age distribution (%) Sex distribution (%) >40 years Male 16–40 years 0–15 years Female 100 50 50 0 0 Zimbabwe III 0 50 50 Average 0 100 Chest fluoroscopy 5 46 49 44 56 Bulgaria 0 29 71 Czech Republic 50 50 Japan 17 72 63 37 11 I 7 58 50 50 Romania 35 28 71 56 Russian Federation 1 44 6 25 70 58 43 Weighted average Limbs and joints Australia 14 32 54 46 54 Bulgaria 21 46 49 51 32 19 51 50 50 Czech Republic 30 32 18 51 Iceland 53 47 Japan 14 23 63 43 57 I 11 58 49 51 luxembourg 31 20 33 47 55 45 Romania 15 55 39 61 Russian Federation 30 14 22 64 44 56 Spain 16 50 54 Switzerland 50 30 15 43 58 Weighted average 57 27 43 29 28 51 49 Zimbabwe III Average 43 29 28 51 49 Maldives 29 49 48 52 22 IV 22 Average 48 52 49 29 Lumbar spine AP/PA Australia 29 69 42 58 2 6 32 62 50 50 Czech Republic Iceland 7 15 78 41 59 Japan 79 18 3 43 57 Korea, Rep . 36 54 51 49 10 I 5 31 64 44 56 luxembourg 6 Romania 62 49 51 33 Russian Federation 36 53 58 42 11 Spain 6 13 91 42 58 Switzerland 2 69 47 53 29 7 67 49 51 28 Weighted average Trinidad and Tobago 6 47 47 50 50 Tunisia 18 82 18 82 0 II 3 17 80 45 55 Turkey Weighted average 3 18 80 42 58 50 50 60 40 0 Zimbabwe III 0 50 50 60 40 Average Maldives 5 25 70 57 43 IV Average 5 25 70 57 43

136 124 UNSCEAR 2008 REPORT: VOLUME I Country Health-care level Age distribution (%) Sex distribution (%) >40 years Male 16–40 years 0–15 years Female Lumbar spine LAT 2 69 42 58 Australia 29 15 78 Iceland 59 7 41 3 18 79 43 57 Japan 9 53 38 66 34 Korea, Rep . I Romania 53 49 51 6 33 13 42 58 2 Spain 85 29 69 47 53 Switzerland 2 4 26 47 53 Weighted average 70 Trinidad and Tobago 47 47 50 50 6 Tunisia 0 18 82 18 82 II Turkey 17 80 45 55 3 3 18 42 58 Weighted average 80 0 50 60 40 Zimbabwe 50 III 50 50 60 Average 0 40 Maldives 5 25 70 57 43 IV 5 25 70 57 43 Average Thoracic spine AP Australia 21 74 31 69 4 0 14 86 50 50 Czech Republic Iceland 11 15 74 44 56 Japan 23 68 56 44 9 Korea, Rep . 14 34 52 51 49 I luxembourg 4 34 62 43 57 Romania 12 51 49 51 37 13 Russian Federation 60 40 37 50 23 44 56 10 68 Spain 36 58 42 Switzerland 6 58 12 32 57 53 47 Weighted average Trinidad and Tobago 15 47 38 47 53 Turkey 3 17 80 45 55 II 4 75 45 55 21 Weighted average Zimbabwe 0 50 50 50 50 III Average 50 50 50 50 0 4 25 71 54 46 Maldives IV Average 4 25 71 54 46 Thoracic spine LAT Australia 21 74 31 69 4 11 15 74 44 56 Iceland Korea, Rep . 12 33 54 50 50 I Romania 12 37 51 49 51 Spain 13 21 65 44 56 Switzerland 6 58 42 58 36 Weighted average 30 58 47 53 12 53 Trinidad and Tobago 15 47 38 47 55 II 3 17 80 45 Turkey Weighted average 4 21 75 45 55

137 ANNEX A: MEDICAL RADIATION EXPOSURES 125 Country Age distribution (%) Health-care level Sex distribution (%) >40 years Male 0–15 years 16–40 years Female 50 Zimbabwe 50 50 0 50 III 50 50 50 0 Average 50 25 71 54 46 Maldives 4 IV 25 71 54 46 4 Average Cervical spine AP 3 Australia 66 44 56 31 7 63 50 50 Czech Republic 31 15 20 65 42 58 Iceland Japan 4 70 47 53 26 Korea, Rep . 39 48 55 45 12 I 2 35 63 43 luxembourg 57 Romania 27 69 53 47 4 15 Russian Federation 47 53 32 53 18 39 61 7 75 Spain 32 64 42 Switzerland 4 58 9 29 62 47 53 Weighted average Trinidad and Tobago 6 51 43 35 65 Turkey 3 17 80 45 55 II 3 76 44 56 21 Weighted average Zimbabwe 0 53 47 50 50 III Average 53 47 50 50 0 6 45 49 51 49 Maldives IV Average 6 45 49 51 49 Cervical spine LAT Australia 31 66 44 56 3 15 65 Iceland 42 58 20 Korea, Rep . 40 48 54 46 12 I 4 27 53 47 Romania 69 13 72 41 59 Spain 15 4 32 64 42 58 Switzerland 11 50 54 Weighted average 50 33 Trinidad and Tobago 51 43 35 65 6 II 3 17 Turkey 45 55 80 Weighted average 3 21 76 44 56 50 Zimbabwe 0 53 47 50 III Average 53 47 50 50 0 Maldives 45 49 51 49 6 IV 6 45 49 51 49 Average Pelvis/hip Australia 22 71 44 56 7 18 29 53 42 58 Bulgaria 50 Czech Republic 14 12 74 50 Iceland 12 83 39 61 5 I 6 19 75 44 56 Japan Korea, Rep . 10 21 69 55 46 luxembourg 15 81 38 62 4 48 23 24 53 52 Romania

138 126 UNSCEAR 2008 REPORT: VOLUME I Country Age distribution (%) Health-care level Sex distribution (%) >40 years Male 16–40 years 0–15 years Female 17 Russian Federation 56 53 16 44 9 41 59 9 Spain 82 I 79 44 56 5 Switzerland 16 19 73 45 55 9 Weighted average 14 Trinidad and Tobago 46 49 51 40 Turkey 17 80 45 55 II 3 20 46 55 Weighted average 4 76 0 50 50 Zimbabwe 52 48 III Average 0 50 50 48 52 Maldives 8 27 65 50 50 IV 8 27 50 50 Average 65 Head 24 43 45 55 Bulgaria 33 36 38 50 50 Czech Republic 27 24 33 42 58 Iceland 43 17 53 51 49 Japan 29 Korea, Rep . 24 35 42 58 41 I 23 36 50 50 luxembourg 41 21 42 57 43 Romania 37 16 44 40 Russian Federation 48 52 Spain 20 60 46 54 20 21 40 39 54 46 Switzerland Weighted average 19 35 46 52 48 Trinidad and Tobago 39 42 50 50 19 Turkey 3 17 80 45 55 II 5 Weighted average 46 54 20 76 33 50 34 Zimbabwe 50 33 III Average 33 34 50 50 33 Maldives 10 35 55 48 52 IV Average 35 55 48 52 10 Abdomen Australia 24 58 46 54 18 11 31 58 36 64 Bulgaria 4 Czech Republic 79 50 50 17 Iceland 12 70 47 53 19 43 Japan 6 14 80 57 Korea, Rep . 31 47 52 48 23 I 10 67 48 52 luxembourg 23 13 25 63 51 49 Romania Russian Federation 19 60 43 57 21 Spain 13 80 51 49 7 Switzerland 7 22 71 47 53 Weighted average 13 67 50 51 20 Trinidad and Tobago 29 50 51 49 21 25 Tunisia 6 25 69 75 II 55 3 17 80 45 Turkey Weighted average 4 18 78 49 51

139 ANNEX A: MEDICAL RADIATION EXPOSURES 127 Country Age distribution (%) Health-care level Sex distribution (%) >40 years Male 0–15 years 16–40 years Female 50 Zimbabwe 50 25 25 50 III 50 50 50 25 Average 25 36 34 52 48 Maldives 30 IV 36 34 52 48 30 Average Upper gastrointestinal tract 9 Bulgaria 60 35 66 31 3 75 50 50 Czech Republic 23 20 20 60 43 57 Iceland Japan 0 83 65 35 17 luxembourg 25 73 42 58 3 I 8 32 61 50 Romania 50 Russian Federation 29 68 42 58 3 9 19 43 57 Spain 82 12 43 57 4 84 Switzerland 23 75 51 Weighted average 3 50 7 39 54 53 47 Trinidad and Tobago Turkey 1 22 77 47 53 II Weighted average 2 74 48 52 24 Zimbabwe 29 71 50 50 0 III 0 29 71 50 50 Average Maldives 27 55 52 48 18 IV 18 27 55 52 48 Average Lower gastrointestinal tract Bulgaria 7 64 34 65 30 3 82 50 50 Czech Republic 15 4 10 86 43 57 Iceland Japan 2 88 61 39 11 luxembourg 10 88 39 61 2 I 10 73 Romania 49 51 17 3 31 40 60 Russian Federation 66 1 83 40 61 Spain 16 2 13 85 Switzerland 58 42 Weighted average 20 77 48 52 3 5 32 63 49 51 Trinidad and Tobago II Tunisia 1 22 77 47 53 Weighted average 2 75 47 53 23 Zimbabwe 29 71 50 50 0 III 0 29 71 50 50 Average Maldives 29 51 54 46 20 IV Average 29 51 54 46 20 Cholecystography 69 Bulgaria 6 27 68 31 Czech Republic 12 82 50 50 6 Japan 0 6 94 64 36 I luxembourg 1 15 84 35 65 Romania 23 76 62 38 0 56 3 20 77 44 Russian Federation

140 128 UNSCEAR 2008 REPORT: VOLUME I Country Age distribution (%) Health-care level Sex distribution (%) >40 years Male 16–40 years 0–15 years Female 9 54 46 0 90 Spain 13 87 37 63 Switzerland I 0 85 53 47 14 2 Weighted average Urography 14 30 54 40 60 Bulgaria Czech Republic 8 74 50 50 18 4 79 59 41 Iceland 27 3 18 80 62 39 Japan luxembourg 7 69 54 46 24 I Romania 25 67 59 41 9 9 31 60 46 54 Russian Federation 6 Spain 77 49 51 18 16 25 51 49 Switzerland 59 24 53 48 Weighted average 7 70 5 47 48 Trinidad and Tobago 48 52 Turkey 3 28 69 50 50 II 3 30 67 50 50 Weighted average Maldives 5 35 60 48 52 IV Average 35 60 48 52 5 Mammography screening Australia 0 0 100 0 100 3 43 54 7 93 Bulgaria luxembourg 0 0 100 0 100 I Russian Federation 0 30 70 0 100 Spain 0 100 27 0 100 Weighted average 0 73 0 8 92 0 100 Trinidad and Tobago Turkey 0 50 0 100 II 50 45 55 0 100 Weighted Average 0 Maldives 0 10 90 0 100 IV Average 10 90 0 100 0 Mammography clinical diagnosis Australia 0 30 70 0 100 Bulgaria 45 55 0 100 0 0 2 98 Czech Republic 100 Japan 0 13 88 0 I luxembourg 15 85 1 99 0 5 55 21 79 Romania 40 0 20 80 0 100 Russian Federation Spain 0 72 1 99 28 Weighted average 20 80 2 99 0 100 Turkey 0 50 50 0 II Average 50 50 0 100 0 CT head 5 32 63 42 58 Australia 47 Bulgaria 10 37 53 53 I 50 5 18 77 50 Czech Republic Iceland 15 13 73 46 54

141 ANNEX A: MEDICAL RADIATION EXPOSURES 129 Country Age distribution (%) Health-care level Sex distribution (%) >40 years 0–15 years Male 16–40 years Female 94 Japan 52 6 48 33 52 48 17 Korea, Rep . 50 27 luxembourg 46 54 4 70 12 25 63 53 47 Romania I Russian Federation 70 52 48 5 25 8 74 49 51 Spain 18 23 51 49 4 73 Switzerland 26 66 51 Weighted average 8 49 23 33 44 51 49 Trinidad and Tobago Turkey 7 29 64 49 51 II 9 Weighted average 62 49 51 30 Zimbabwe 10 60 53 47 30 III 10 60 53 47 Average 30 8 40 52 Maldives 52 48 IV Average 8 40 52 48 52 CT abdomen Australia 0 19 81 54 46 Bulgaria 41 55 49 51 5 5 15 80 50 50 Czech Republic Iceland 3 12 85 47 53 Japan 99 55 45 1 I Korea, Rep . 23 69 58 42 8 luxembourg 1 17 83 49 52 Russian Federation 3 72 52 48 25 5 10 57 43 Spain 85 17 55 46 1 82 Switzerland 22 74 54 Weighted average 4 46 4 38 58 48 52 Trinidad and Tobago Turkey 7 29 64 49 51 II 7 30 63 49 51 Weighted average Zimbabwe 63 12 44 56 25 III 25 63 12 44 56 Average Maldives 25 70 54 46 5 IV Average 25 70 54 46 5 CT thorax 45 Australia 0 13 87 55 Bulgaria 11 49 49 51 41 Czech Republic 16 81 50 50 3 Iceland 4 13 84 53 47 Japan 99 56 44 1 Korea, Rep . 11 27 62 61 39 I luxembourg 1 13 86 58 42 Romania 11 68 57 43 21 Russian Federation 25 72 52 48 3 Spain 5 11 84 62 38 Switzerland 20 78 51 49 2 45 5 22 73 55 Weighted average

142 130 UNSCEAR 2008 REPORT: VOLUME I Country Health-care level Age distribution (%) Sex distribution (%) >40 years Male 16–40 years 0–15 years Female 39 56 44 2 59 Trinidad and Tobago 29 64 49 Turkey II 7 51 30 63 50 50 6 Weighted average 12 76 12 65 Zimbabwe 35 III 76 12 65 35 Average 12 5 75 52 48 Maldives 20 IV 20 75 52 Average 5 48 CT spine Bulgaria 5 41 55 49 51 Czech Republic 1 21 78 50 50 0 27 73 48 52 luxembourg I 3 22 54 46 Spain 75 24 50 50 0 76 Switzerland 24 73 52 Weighted average 3 48 Trinidad and Tobago 8 53 39 66 34 II 8 53 39 66 Average 34 17 66 17 66 34 Zimbabwe III 17 17 66 34 Average 66 Maldives 4 35 61 50 50 IV Average 4 35 61 50 50 CT pelvis 51 Bulgaria 5 41 55 49 Czech Republic 2 78 50 50 20 1 99 53 47 Japan I 6 Spain 55 45 12 82 32 53 47 4 Switzerland 64 5 78 53 47 Weighted average 18 Trinidad and Tobago 6 34 60 46 54 II Average 34 60 46 54 6 Zimbabwe 50 50 75 25 0 III 0 50 50 75 25 Average Maldives 23 74 57 43 3 IV 3 23 74 57 43 Average CT interventional Bulgaria 41 55 49 51 5 Spain 0 6 94 70 30 I 1 66 88 Weighted average 34 11 Zimbabwe 50 100 0 0 50 III Average 100 0 50 50 0 CT other 51 Bulgaria 5 41 55 49 Iceland 13 82 49 51 5 Japan 5 95 51 49 I luxembourg 2 26 72 53 47 Spain 18 81 59 41 2 47 2 21 77 53 Weighted average

143 ANNEX A: MEDICAL RADIATION EXPOSURES 131 Country Age distribution (%) Health-care level Sex distribution (%) >40 years 0–15 years Male 16–40 years Female Non-cardiac angiography 1 88 50 50 Czech Republic 11 0 100 60 40 Japan 0 0 9 53 47 luxembourg 91 3 75 69 31 Romania 22 I Russian Federation 85 56 44 4 11 0 93 62 38 Spain 7 26 50 50 2 72 Switzerland 8 91 59 Weighted average 2 41 Cardiac angiography Czech Republic 1 8 92 50 50 Iceland 0 2 99 32 69 luxembourg 3 97 65 35 0 4 11 85 63 37 Romania I 6 5 56 44 Russian Federation 89 6 56 44 0 Spain 94 1 88 62 38 Switzerland 11 4 6 90 54 46 Weighted average Cardiac PTCA 96 4 Czech Republic 50 50 0 0 1 99 79 21 Iceland luxembourg 0 3 97 73 28 I Romania 28 71 44 56 0 0 6 94 44 56 Spain Switzerland 0 3 97 79 21 Weighted average 0 89 48 52 11 Cerebral angiography Czech Republic 81 50 50 1 18 0 100 66 34 luxembourg 0 2 18 80 67 33 Spain I 4 38 58 50 50 Switzerland 2 20 78 62 38 Weighted average Vascular angiography (non-cardiac) Czech Republic 13 69 50 50 19 0 2 98 69 31 luxembourg Spain 0 7 93 62 39 I Switzerland 10 86 50 50 4 4 8 88 56 42 Weighted average Other interventional luxembourg 0 92 46 54 8 Spain 11 89 56 44 0 I 4 50 86 Switzerland 50 10 1 55 89 Weighted average 45 11 Pelvimetry 7 40 54 0 100 Bulgaria 100 Iceland 3 97 0 0 Japan 98 2 0 100 0 I 0 100 0 0 100 luxembourg Romania 14 20 66 0 100 Spain 60 40 0 100 0 100 2 79 19 0 Weighted average

144 132 UNSCEAR 2008 REPORT: VOLUME I Country Age distribution (%) Health-care level Sex distribution (%) >40 years Male 16–40 years 0–15 years Female Other diagnostic 7 55 0 Bulgaria 100 38 24 61 51 49 Japan 15 0 3 97 12 luxembourg 88 I 41 58 56 44 Romania 1 11 28 10 72 Spain 80 12 65 44 56 Weighted average 23 Intraoral dental Bulgaria 10 50 40 46 54 Czech Republic 22 42 50 50 37 9 45 63 Japan 56 28 luxembourg 48 47 47 53 5 I 15 43 Romania 46 54 43 20 41 51 49 Spain 40 5 38 57 Switzerland 55 45 Weighted average 12 32 55 46 54 50 Zimbabwe 7 73 20 50 III Average 73 20 50 50 77 .0 Panoramic dental radiology Bulgaria 45 35 49 51 20 22 37 42 50 50 Czech Republic 6 Japan 58 45 55 36 luxembourg 36 37 28 47 53 I Romania 34 37 50 50 28 16 51 33 62 38 Spain Switzerland 21 39 40 44 56 Weighted average 12 49 49 51 39 Zimbabwe 6 14 80 50 50 III 80 14 6 50 50 Average 80 Maldives 15 50 35 20 IV 15 50 35 20 80 Average Dental CT 59 luxembourg 3 38 59 42 I Average 3 38 59 42 59

145 ANNEX A: MEDICAL RADIATION EXPOSURES 133 7 500 5 000 9 600 World 48 000 47 000 53 000 14 000 73 000 50 000 15 000 13 000 91 000 86 000 76 000 22 000 20 000 340 000 310 000 340 000 120 000 170 000 310 000 650 000 57 11 0 .0 5 .3 0 .0 300 800 400 170 290 320 380 560 1 100 2 600 2 500 2 100 2 700 2 100 3 600 3 800 9 000 14 000 Levels III–IV 000 19 210 810 800 4 100 1 400 7 400 3 500 7 400 Level II 30 000 25 000 15 000 12 000 18 000 28 000 71 000 80 000 13 000 17 000 19 000 70 130 000 230 000 Annual collective dose (man Sv) 5 200 6 600 3 900 5 700 5 400 9 100 Level I 17 000 22 000 53 000 10 000 58 000 35 000 13 000 70 000 56 000 34 000 12 000 340 000 180 000 110 000 150 000 290 000 570 000 0 .2 0 .8 2 .1 1 .2 1 .2 0 .6 0 .3 0 .1 0 .1 1 .0 0 .1 0 .8 3 .3 7 .3 2 .0 2 .6 0 .3 0 .4 2 .4 7 .8 0 .05 0 .04 12 .4 World 0 .8 2.1 1 .3 1 .8 0 .7 0.3 0 .1 0.1 0 .7 0 .1 0 .7 3 .0 7 .0 2.0 2 .5 0.3 0.4 2.4 7.8 0 .02 0 .02 0.01 12.4 Levels III–IV 0.1 0.2 0.8 2.1 0.0 1.2 1.0 0.5 0.3 0.1 0.1 1.1 0.1 0.8 3.4 7.4 2.0 2.6 0.3 0.4 2.4 7.8 12.4 Level II Effective dose per examination (mSv) 0 .1 0 .2 0 .8 2 .1 0 .0 1 .2 1 .0 0 .5 0 .3 0 .1 0 .1 1 .1 0 .1 0 .8 3 .4 7 .4 2 .0 2 .6 0 .3 0 .4 2 .4 7 .8 12 .4 Level I 36 69 47 13 18 17 14 12 11 4 .0 9 .2 7 .6 4 .5 5 .8 8 .9 5 .9 7 .0 5 .9 7 .1 8 .0 6 .3 8 .2 110 World 1 0 .3 1 .6 0 .8 0 .0 0 .3 0 .1 0 .8 0 .7 0 .7 1 .2 1 .2 2 . 2 .6 1 .7 0 .5 0 .2 0 .0 0 .8 0 .8 0 .8 0 .9 0 .7 0 .7 Levels III–IV 39 28 13 11 12 11 14 0 .0 0 .0 3 .8 3 .8 0 .8 6 .7 1 .9 1 .9 4 .9 9 .7 9 .8 6 .1 2 .3 0 .8 1 .8 142 Level II Number of examinations per 1 000 population 70 17 31 23 16 32 19 40 44 45 34 23 20 40 24 30 9 .8 9 .3 1 .7 8 .5 168 287 140 Level I Frequencies, population-weighted average effective doses and collective doses assumed in the global model for diagnostic practice with medical and dental Examinations b48. Chest PA Chest lAT Chest photofluorography Chest fluoroscopy limbs and joints lumbar spine AP/PA lumbar spine lAT Thoracic spine AP/PA Thoracic spine lAT Cervical spine AP/PA Cervical spine lAT Pelvis/hip Head Abdomen Upper GI tract lower GI tract Cholecystography Urography Mammography screening diagnosis Mammography clinical CT head CT thorax CT abdomen radiological examinations (1997–2007) Table

146 134 UNSCEAR 2008 REPORT: VOLUME I 1 .28 0 .00 0 .62 0 .024 6 200 3 800 4 300 World 6 200 5 100 96 000 29 000 38 000 21 000 23 000 20 000 11 000 0 .001 8 310 000 200 000 390 000 4 000 000 –5 0 0 0 0 0 88 89 0 .0 0 .0 0 .0 0 .0 1 .5 530 1 .60 0 .00 0 .03 0 .020 4 300 5 400 57 000 5 .1 × 10 Levels III–IV 100 0 .0 0 .0 660 280 600 690 0 .96 0 .00 0 .32 0 .026 5 100 3 800 1 100 1 100 2 0 .004 1 300 Level II 28 000 12 000 180 000 1 000 000 Annual collective dose (man Sv) 1 .44 0 .00 1 .91 0 .023 5 700 2 700 2 300 5 500 4 500 9 900 Level I 87 000 16 000 38 000 26 000 17 000 23 000 19 000 0 .006 4 270 000 390 000 2 900 000 5 .0 9 .4 3 .8 3 .8 9 .3 5 .7 9 .0 1 .4 1 .6 11 .2 11 .9 11 .2 0 .02 0 .05 0 .00 World 5.0 9.4 3.8 3.8 9.3 5.7 9.0 1.4 1.6 11.2 11.9 11.2 0.02 0 .01 Levels III–IV 5.0 9.4 3.8 3.8 9.3 5.7 9.0 1.4 1.6 11.2 11.9 11.2 0.02 0.06 Level II Effective dose per examination (mSv) 5 .0 9 .4 3 .8 3 .8 9 .3 5 .7 9 .0 1 .4 1 .6 11 .2 11 .9 11 .2 0 .02 0 .06 Level I . 38 61 13 74 3 .0 5 .1 0 .3 1 .2 0 .6 2 .8 0 .3 0 .1 0 .4 0 .3 0 .5 488 0 .00 World 3 20 0 .5 0 .3 0 .1 0 .0 0 .0 0 .0 0 .0 0 .0 0 .0 0 .0 0 .0 2 .5 0 .08 Levels III–IV 12 16 0 .3 1 .0 0 .0 1 .0 0 .0 5 .0 0 .1 0 .1 0 .0 0 .0 0 .5 0 .0 3 .7 332 0 .00 Level II Number of examinations per 1 000 population 11 19 49 1 .0 2 .8 2 .6 1 .5 0 .9 0 .3 1 .6 1 .1 1 .1 159 227 275 0 .02 1 332 Level I Examinations CT spine Average effective dose per medical radiological examination (mSv) Average effective dose per dental radiological examination (mSv) CT pelvis CT interventional CT other Non-cardiac angiography Cardiac angiography Cardiac PTCA Cerebral angiography Vascular angiography (non- cardiac) Other interventional Pelvimetry Other diagnostic Total diagnostic Intraoral dental Panoramic dental Dental CT Total dental Average effective dose per caput from dental radiological examinations (mSv) Average effective dose per caput from medical radiological examinations (mSv) Note: Values in italics have been estimated in the absence of data from the UNSCEAR survey

147 ANNEX A: MEDICAL RADIATION EXPOSURES 135 b49. Estimated global number of procedures, collective effective dose and per caput effective dose for various Table categories of radiographic (excluding dental) nuclear medicine procedures using ionizing radiation in the United States [N26] Number of procedures (millions) Collective effective dose (man Sv) Type of procedure Per caput effective dose (mSv) 100 000 293 0 .3 Conventional radiography and fluoroscopy Interventional 17 128 000 0 .4 1 .5 67 CT 440 000 231 000 0 .8 18 Nuclear medicine 899 000 3 .0 Total 395 Table b50. Contribution to the frequency of various types of diagnostic medical and dental radiological examination Examinations Contribution (%) Levels III–IV Level II World Level I Chest PA 10 41 7 .1 20 Chest lAT 1 .4 6 .4 4 .3 11 18 0 .00 3 .6 12 Chest photofluorography 1 .0 Chest fluoroscopy 0 .00 0 .71 0 .01 limbs and joints 7 .9 1 .3 8 .4 8 .7 1 .9 1 .1 1 .6 lumbar spine AP/PA 0 .56 1 .1 1 .4 1 .4 3 .5 lumbar spine lAT 0 .24 2 .8 Thoracic spine AP/PA 1 .0 0 .79 0 .6 1 .9 2 .8 1 .0 Thoracic spine lAT 2 .0 0 .55 Cervical spine AP/PA 1 .6 5 .3 Cervical spine lAT 0 .55 5 .3 1 .0 1 .2 2 .5 9 .0 2 .2 Pelvis/hip 1 .4 2 .7 3 .8 Head 3 .2 11 Abdomen 2 .8 3 .1 7 .6 3 .0 Upper GI tract 2 .1 3 .4 2 .3 2 .5 lower GI tract 0 .6 0 .74 1 .3 2 .8 0 .1 3 .2 1 .0 Cholecystography 0 .00 2 .8 1 .3 0 .5 3 .5 Urography 3 .9 3 .6 Mammography screening 1 .4 2 .2 1 .2 1 .8 3 .6 1 .4 Mammography clinical diagnosis 2 .5 0 .65 3 .9 CT head 2 .0 CT thorax 0 .22 2 .9 1 .1 1 .5 1 .8 2 .9 1 .5 CT abdomen 0 .52 0 .7 0 .09 2 .2 CT spine 0 .53 4 0 .91 CT pelvis 1 .2 0 .27 1 . CT interventional 0 .1 0 .00 0 .35 0 .05 CT other 0 .2 0 .00 0 .21 0 .29 0 .1 0 .00 0 .1 Non-cardiac angiography 0 .1 0 .1 1 .4 0 .00 0 .5 Cardiac angiography Cardiac PTCA 0 .03 0 .00 0 .05 0 .1 Cerebral 0 .0 0 .02 0 .00 0 .02 Vascular angiography (non-cardiac) 0 .1 0 .00 0 .00 0 .07 Other interventional 0 .01 0 .00 0 .05 0 .1 Pelvimetry 0 .1 0 .14 0 .00 0 .09 Other medical 9 .9 0 .00 0 .00 6 .8 Total medical 83 96 89 87

148 136 UNSCEAR 2008 REPORT: VOLUME I Contribution (%) Examinations Levels III–IV World Level I Level II 3 .5 Intraoral dental 11 14 11 0 .36 1 .1 2 .4 Panoramic dental 3 .0 0 .00 0 .00 Dental CT 0 .00 0 .00 11 13 4 .5 17 Total dental 100 .00 100 .00 Total diagnostic examinations 100 .00 100 .00 b51. Table Contribution to the collective effective dose of various types of diagnostic medical and dental radiological examination Contribution (%) Examinations Level II Levels III–IV World Level I 3 .0 Chest PA 0 .93 0 .59 0 .10 0 .74 2 .5 0 .02 0 .98 Chest lAT 12 0 .00 Chest photofluorography 9 .9 2 .0 Chest fluoroscopy 0 .02 0 .00 1 .5 1 .8 0 .35 0 .41 0 .35 limbs and joints 0 .01 1 .5 1 .9 2 .0 0 .52 lumbar spine AP/PA 1 .2 4 .5 lumbar spine lAT 1 .2 1 .3 0 .43 0 .14 1 .4 0 .40 Thoracic spine AP/PA 0 .18 0 .73 Thoracic spine lAT 0 .26 0 .69 Cervical spine AP/PA 0 .08 0 .30 0 .20 0 .22 0 .13 0 .50 0 .13 Cervical spine lAT 0 .08 2 .4 1 .8 Pelvis/hip 2 .3 4 .4 Head 0 .20 0 .35 0 .55 0 .22 Abdomen 1 .9 2 .7 3 .7 2 .1 Upper GI tract 6 .0 4 .8 7 .0 13 3 .6 22 6 .3 lower GI tract 3 .6 7 .1 1 .2 0 .18 0 .00 Cholecystography 7 .9 6 .2 Urography 1 .2 2 .2 0 .31 1 .3 0 .66 0 .45 Mammography screening 0 .40 0 .74 0 .98 0 .46 Mammography clinical diagnosis CT head 5 .0 6 .6 4 .6 1 .7 9 .7 16 8 .7 CT thorax 1 .9 19 7 .0 25 18 CT abdomen CT spine 2 .9 7 .5 2 .7 0 .51 CT pelvis 2 .8 9 . 9 .3 4 8 .4 CT interventional 0 .19 0 .00 0 .93 0 .18 CT other 0 .55 0 .00 0 .64 1 .2 1 .28 0 .00 1 .1 Non-cardiac angiography 0 .07 0 .87 17 0 .00 3 .2 Cardiac angiography Cardiac PTCA 0 .37 0 .00 0 .53 0 .57 Cerebral 0 .09 0 .11 0 .00 0 .09 Vascular angiography (non-cardiac) 0 .77 0 .03 0 .00 0 .65 Other interventional 0 .00 0 .56 0 .10 0 .69 0 .08 0 .20 0 .00 0 .09 Pelvimetry a Other medical 13 0 .00 0 .00 11 Total medical 100 .00 100 .00 100 .00 100 .00

149 ANNEX A: MEDICAL RADIATION EXPOSURES 137 Contribution (%) Examinations Levels III–IV World Level I Level II 47 Intraoral dental 98 60 59 2 41 53 40 Panoramic dental 0 .00 0 .00 0 .00 0 .00 Dental CT 100 .00 Total dental 100 .00 100 .00 100 .00 a As there was only one return giving an effective dose for “other medical” examinations, a value of 1 .6 mSv has been used, which is an average across all examinations when the data for “other medical” are included . This represents an estimate of the typical effective dose for “other diagnostic” examinations . b52. Trends in the annual frequency of diagnostic medical radiological examinations expressed as number per 1,000 Table population Level 1985–1990 1991–1996 1997–2007 1970–1979 1980–1984 820 810 890 I 1 332 920 II 140 120 154 332 26 23 75 17 20 III 67 8 .8 27 20 IV 29 Table b53. Trends in the annual frequency of diagnostic dental radiological examinations expressed as number per 1,000 population 1970–1979 1980–1984 1985–1990 1991–1996 1997–2007 Level 320 310 350 I 275 390 II 0 .8 2 .5 14 16 III 0 .8 1 .7 0 .3 2 .6 IV 0 .1 2 .6 b54. Trends in average effective dose from diagnostic medical radiological examinations for countries in health-care Table level I Average effective dose per examination (mSv) Examination 1991–1996 1997–2007 1980–1990 1970–1979 0 .14 0 .14 0 .07 Chest radiography 0 .25 0 .52 0 .52 Chest photofluoroscopy 0 .78 0 .65 Chest fluoroscopy 0 .98 1 .1 2 .1 0 .72 0 .02 0 .06 limbs and joints 0 .05 0 .06 Pelvis and hip 2 .2 1 .7 1 .8 1 .1 Head 2 .1 1 .2 0 .83 0 .08 Abdomen 1 .9 0 .53 0 .82 1 .1 8 .9 3 .6 3 .4 Upper GI 7 .2 9 .8 4 .1 lower GI 7 .4 6 .4 Cholecystography 1 .9 1 .5 2 .3 2 .0 Urography 3 3 .1 3 .7 2 .6 Mammography 1 0 .51 0 .26 1 .8 CT 1 .3 4 .4 8 .8 7 .4 PTCA 22 11 .9

150 138 UNSCEAR 2008 REPORT: VOLUME I Estimated doses to the world population from medical and dental radiological examinations 1997–2007 Table b55. Population (millions) Per caput effective dose (mSv) Collective effective dose (man Sv) Health-care level Dental Medical Medical Dental I 1 540 1 .91 0 .006 4 2 900 000 9 900 II 3 153 0 .32 0 .000 4 1 000 000 1 300 III 0 .03 0 .000 051 33 000 51 1 009 IV 744 0 .03 0 .000 051 24 000 38 World 6 446 0 .62 0 .002 4 000 000 11 000

151 AppENdIx C: LEVELS ANd TRENdS OF ExpOSURE IN NUCLEAR MEdICINE I. INTROdUCTION A radiopharmaceutical is a compound whose molecu- The reliable delivery of high-quality radionuclides directly C1. specific lar structure causes it to concentrate primarily in a to nuclear medicine centres, or more commonly, to radio- region of the body and which also contains a radio active pharmacies that produce radiopharmaceuticals and deliver external imaging of the body species that allows: them to nuclear medicine centres, is essential to the routine (a) (diagnosis) to evaluate the structure and/or function of the practice of nuclear medicine. Many hospitals and clinics are delivery of a large radiation dose (therapy) to region, or (b) very busy, and depend on an uninterrupted supply of high- quality radiopharmaceuticals to function. The amount of a the region to control a specific disease. Most medical imag- radiopharmaceutical product administered, in terms of mass, ing or therapy procedures rely on external sources of ioniz- ing or non-ionizing radiation to achieve their aims; nuclear is generally quite small, as the specific activity (amount of activity per unit mass, e.g. Bq/g) is kept high. This allows medicine studies employ the unique approach of introduc- labelled substance into the body of the subject, the compound to act as a tracer within the system without ing a radio perturbing the normal system kinetics or introducing toxi- with devices external to the body being able to detect, and in some cases quantify, the activity in different regions city concerns. of the subject. This thus permits not only the study of the configuration of internal structures, but the evaluation of The creation and dissemination of the labelled drug C4. products (radiopharmaceuticals or radiotracers) is the next internal physiological processes. In the case of therapy, the concentration of the material in the target tissue of interest essential step to successful nuclear medicine practice. allows the delivery of lethal doses of radiation to the unde- The large majority of radiopharmaceutical pro- − sirable tissues, with the aim of maintaining lower concen- 99m ducts are labelled with Tc, which has a half-life tissues so as to minimize unwanted trations in other body of approximately 6 hours and is supported in a deleterious effects. 99 generator system by its parent T Mo ( = 66 h). 1/2 − Another large general class of radiopharmaceu- In most nuclear medicine imaging procedures, the goal C2. ticals is that of the radioiodinated compounds— for the physician is diagnosis of disease or improper organ 123 131 125 I and possibly other I, tracers labelled with I, function via study of the distribution of radioactivity inside isotopes of iodine. specific structures within the body. Many imaging procedures evaluate organ structure, size and shape, or may evaluate − The other significant class of radiolabelled products the presence of cancerous or otherwise deleterious lesions. are those designed for use with positron emission Dynamic studies are also widely used to provide informa- tomography (PET) systems. The principal radio- 11 13 15 11 18 18 tion on organ or system function through the measurement N. The C F and nuclides are O and F, C, of the rate of accumulation and subsequent removal of the labels are bound to a number of tracers of interest radiopharmaceutical by an organ of interest. Two examples for the study of myocardial or cerebral function, of dynamic imaging include the study of dynamic cardiac cancer detection and other processes. The isotope 15 function and of renal clearance of radiolabelled substances O is used in a number of O as labelled O or H 2 2 13 [M27]. is used for myocardial N as NH applications; 3 imaging. Nuclear medicine practice depends firstly on the avail- C3. C5. ability of radioactive substances (radionuclides). Radionu- The equipment for imaging nuclear medicine studies clides are generally produced from [W18]: is quite specialized and highly technical. These imaging systems and their associated electronic and computer com- Nuclear reactors; − ponents have evolved over the past five decades or so. The Particle accelerators; or − gamma camera is the main device used for imaging radionu- clides. The main detecting medium is a large sodium iodide − Radionuclide generator systems (devices that (NaI (Tl)) crystal, usually in a circular or square configura- contain a longer-lived “parent” radionuclide that tion. Radiation absorbed by the detector crystal is converted continuously produces a shorter-lived “progeny” that can be readily separated from the system for into light, which is detected by a large array of photomulti- delivery to patients). plier tubes (PMTs). Electronic circuits analyse the PMT 139

152 140 UNSCEAR 2008 REPORT: VOLUME I signals to ensure that the energy of the pulses is within a function, a radiopharmaceutical that is preferen- tially taken up by the kidney is administered to the preset tolerance for the nuclide’s principal decay energy, to patient, usually intravenously. The movement of determine the position of the gamma ray interaction and to pharmaceutical through the body, its accu- the radio record acceptable events in a two-dimensional projection mulation in the kidney and its subsequent excre- field. This information is then displayed and possibly ana- tion are imaged. Kidney function is assessed on the lysed further using computer software provided with the imaging system. Regions of interest may be drawn over dif- basis of the time it takes for the radiopharmaceu- tical to reach peak concentration and how long it ferent portions of the image and the numbers of counts in takes for this activity to be cleared from the body. different regions determined at various times. Nuclear medi- cine cameras employ a range of different types of collimator Many dynamic studies of cardiac function are also routinely performed. for nuclides of different energies and for particular types of study. Typically, cameras employ low-, medium- and high- Tomographic data may be taken (SPECT) in a pro- − energy collimators for large-area viewing, and pinhole or cedure whereby the camera is rotated around the other specialized collimators may be used for particular stud- subject and data are gathered from many different ies. The majority of commercial cameras today contain more angles, with the collected data subsequently ana- than one head (i.e. imaging system comprised of a NaI (Tl) lysed to develop three-dimensional images of the crystal, PMTs and electronic circuitry). Dual-headed systems radionuclide distribution in the patient. Static or are the most common (these permit simultaneous acquisition dynamic gamma camera images provide a two- of data on two sides of the subject, typically anterior and dimensional projection image of the activity within posterior, as well as rapid acquisition of tomographic data the body. A dual-headed camera provides two pro- in single-photon-emission computed tomography (SPECT)), ° jection images, typically 180 apart from each other, but some triple-headed systems have also been developed. although the camera heads can be manipulated to provide other configurations. With correction for C6. Some simpler imaging systems are also routinely used, scatter and attenuation, these two-dimensional pro- e.g. small NaI (Tl) crystals for studies of thyroid uptake and jections can yield quantitative information about function. Simple gamma probes may be used to assist sur- the radionuclide content of an identified region. If a geons in identifying and resecting lymph nodes that take three-dimensional representation is obtained using 99m up Tc-labelled colloids. Some other studies using in tomography, one may obtain images and quantita- vitro analysis of patient tissue or fluid samples may also be tive estimates of activity constructed from millions performed; for example, vitamin B12 absorption from the of “voxels” (volume elements, corresponding to the gastrointestinal tract may be evaluated by measuring the “pixels”, or picture elements, that constitute a two- fraction of orally administered vitamin B12 labelled with dimensional electronic image). This allows a more 57 58 Co and/or Co) that is excreted in urine. radioactive cobalt ( detailed evaluation of the radionuclide distribution Other non-imaging uses of radiopharmaceuticals involve the within the body. The procedures for correcting all in vitro studies of thyroid function [P8] and labelled blood of the many projection images taken around the cells [S5], and radioimmunoassay [Y13]. body for attenuation, scatter and other effects are quite involved. Most camera systems provide some The nuclear medicine camera may be used in a number C7. standard software for performing these evaluations; of different data acquisition modes: the science of these analyses, however, continues to be an area of active investigation and constant − A static image may be obtained by simply plac- improvement. ing the camera near the region of the patient to be imaged and leaving it in place during data acquisi- C8. Properties of many radionuclides commonly used for tion. The camera may be placed, for example, over C1. Many different radio- in vivo imaging are shown in table the abdomen, near the chest (for cardiac imaging) nuclides have been employed for imaging, but the most pop- or over the head (for cerebral imaging). In addition, 99m ular for most studies (except for PET) is Tc. This radionu- the camera may be used to obtain images of the clide has a short half-life (6 hours). It emits a gamma ray at whole body of the subject for bone imaging, quan- keV with about 89% abundance, which is ideally suited 140 titative studies and other purposes. This requires for typical gamma cameras. In addition, as noted above, it is the use of special collimators or large subject-to- readily available from commercially available molybdenum– camera distances. Multiple static images of parts technetium generator systems. Table C2 provides a summary of the body may also be pieced together to create of many important radiopharmaceuticals used in nuclear whole-body images. medicine [K15]. The radiopharmaceuticals in use change Dynamic imaging studies may be performed in − periodically, of course, as new agents are added or others which the gamma camera is positioned over the fall out of use. Particularly in radiation therapy with internal organ to be imaged and images are acquired in a emitters, new radionuclides and agents are continually being time series possibly before, and certainly after, the proposed and tested. In addition, studies that are popular in injection of the radiopharmaceutical. For exam- some parts of the world are not popular, or approved for use, ple, in a renogram, which is used to assess kidney in others, so practice varies widely.

153 ANNEX A: MEDICAL RADIATION EXPOSURES 141 Improved spatial resolution in tomographic nuclear as well as muscle damage in the heart. This infor- C9. mation is particularly important in patients who medicine studies can be achieved with PET. Radionuclides have had a myocardial infarction and who are being that emit a positron provide the unique advantage that after the positron interacts with an electron in the environment considered for a revascularization procedure. MeV and both are annihilated, two photons of energy 0.511 PET studies may be used in neurological studies to − are emitted simultaneously at a 180º orientation to each diagnose Alzheimer’s disease, Parkinson’s disease, other. A PET imaging device exploits this fact and detects epilepsy and other neurological conditions. pairs of photons in spatially opposed detectors, thereby per- − Cancer cells tend to have a higher metabolic rate mitting identification of the location at which the positron 18 than normal cells. As a consequence, F FDG accu- C3 lists some common PET annihilation occurred. Table mulates preferentially in cancer cells, which appear nuclides and studies [L19]. radio as an area of higher activity on a PET scan. C10. PET offers another advantage in that small quantities PET is considered to be particularly effective for C13. of radiopharmaceutical can be used to measure metabolic imaging a number of common cancers, such as lung cancer, function rates, receptor densities, blood flow and changes colorectal cancer, lymphoma, melanoma and breast cancer. in function. The main disadvantage of PET scanning is The nuclear medicine physician is able to identify whether 13 11 15 N, C, that positron-emitting radionuclides (e.g. O and cancer is present or if it has spread. PET is particularly use- 18 F) have relatively short half-lives. As a consequence, PET ful in assessing response to treatment and to confirm whether scanners need to be located within short travelling times of a patient is cancer-free after treatment. PET is also used for the facility that produces the radiopharmaceuticals. cancer staging and for assessing the effectiveness of different kinds of therapy (e.g. chemotherapy). Some advantages of PET studies are that: C11. The sensitivity and resolution of PET scanners are − PET imaging studies have been of high interest to C14. better than those of SPECT systems. The attenua- the nuclear medicine community for many years. Interest tion correction algorithms are more accurate. grew steadily, as did the general use of radiopharmaceuti- cals. In 1953, Gordon Brownell and H.H. Sweet built a posi- Many unique radiopharmaceuticals have been − tron detector based on the detection of annihilation photons developed to image particular biological or physi- by means of coincidence counting. Clinical use has been ological processes, such as general cardiac uptake, increasing in the last decade owing to increases in the avail- tumour imaging and neuroreceptor imaging. ability of equipment and health-care reimbursement for PET The use of short-half-life radionuclides may result − procedures. Patient doses for PET studies are on the high in lower patient doses. end for diagnostic nuclear medicine procedures, as will be shown in detail below, and the 511 keV photon from the In PET scanning, a number of radiopharmaceuti- C12. annihilation radiation contributes to staff radiation doses. cals are used for various diagnostic studies. One example 18 18 is FDG), which is a F F-labelled fluorodeoxyglucose ( C15. Combined SPECT–CT and PET–CT scanners are in labelled sugar compound administered to the patient. FDG is widespread use in many countries. In these devices, images thus a marker for sugar metabolism and is used for a number from the two modalities may be obtained from a patient with- of useful studies. out the patient moving between scans. This enables images obtained from the two imaging approaches to be easily co- In cardiology, PET measures both blood flow (per- − registered and combined to provide a three-dimensional activ- fusion) and metabolic rate within the heart. PET ity map that is tied directly to the subject’s anatomical map. imaging can identify areas of decreased blood flow II. ANAL ySIS OF pRACTICE 201 99m Tl. These examina- examinations using either Tc or C16. A wide variety of radiopharmaceuticals are admin- tions have markedly different values for the average dose per istered diagnostically to patients to study tissue physiology mSv, respectively). However, other procedure (8.0 and 41 and organ function. The practice of diagnostic nuclear medi- cine varies significantly between countries; broad estimates countries that probably used both nuclides simply reported of worldwide practice have been made from the available a “total” number of cardiac studies, without differentiating 99m 201 Tl. Only the data from the countries that national survey data using a global model, although the Tc and between uncertainties in this approach are likely to be significant. reported these examinations separately were used to develop III and There was particularly poor reporting from level average numbers of procedures and values for dose per pro- IV countries in this period, and some discrepancies in level cedure. Also, none of the countries of levels II, III and IV reporting caused difficulties in the data analysis. For exam- reported values for dose per procedure. The values reported ple, many countries reported individual results for cardiac by level I countries were considered to be reliable, and the

154 142 UNSCEAR 2008 REPORT: VOLUME I Overall, the use of diagnostic practices with radio- C18. population-weighted average values were assumed to apply to the other levels and were used in the dosimetric analysis. pharmaceuticals remains small in comparison with the use of X-rays. The annual numbers of nuclear medicine proce- The worldwide total number of procedures for 1997–2007 is dures and their associated collective doses are only 0.9% and million annually, corresponding to estimated to be about 32.7 an annual frequency of 5.1 per 1,000 population. Estimates 5.1%, respectively, of the corresponding values for medical of the worldwide total number of procedures for 1985–1990 X-rays. However, the mean dose per (diagnostic) procedure is larger for nuclear medicine (6.0 and 1991–1996 were 24 and 32.5 million, respectively, cor- mSv) than for medical X-rays (1.3 mSv). responding to frequencies of 4.5 and 5.6 per 1,000 popu- lation. The present global total of procedures is distributed among the health-care levels of the model as follows: 89% Radiopharmaceuticals are administered systemically C19. I (at a mean rate of 19 per 1,000 popula- or regionally to patients in order to deliver therapeutic in countries of level radiation absorbed doses to particular target tissues, in II (1.1 per 1,000 population); tion); 10% in countries of level and <1% collectively in countries of health-care levels III particular the thyroid, for the treatment of benign disease and cancer. The utilization of such therapy varies signifi- and IV (<0.05 per 1,000 population). Notwithstanding the estimated mean frequencies of examination for each health- C6). Global annual num- cantly between countries (table bers of radiopharmaceutical therapeutic treatments have care level quoted above, there are also significant variations in the national frequencies between countries in the same - been broadly estimated from the limited national sur health-care level (table C4). The overall decrease in the aver- vey data available using a global model, and the results I countries is likely to be due to under- age value for level C7. The uncertainties in these are summarized in table data are likely to be significant. The worldwide total reporting during this survey period. Several cases are seen of number of treatments for 1997–2007 is estimated to be clear increases in the numbers of studies in individual coun- tries, and some countries (e.g. the United States and Canada) million annually, corresponding to an average about 0.87 annual frequency of 0.14 treatment per 1,000 population. that previously reported high values did not report during Estimates of the total number of treatments annually for this survey. million and 0.2 mil- 1991–1996 and 1985–1990 were 0.4 - lion, respectively, and for the same two periods the aver The estimated doses to the world population from C17. diagnostic nuclear medicine procedures are summarized age annual frequency of treatments per 1,000 population in table C5. The global annual collective effective dose for was 0.065 and 0.04, respectively. However, this is surely an underestimate, because no level II, III or IV countries Sv, which 1997–2007 is estimated to be about 202,000 man reported a frequency for therapy studies, when surely equates with an average per caput dose of 0.031 mSv. These estimates are comparable to the figures for 1991–1996 many occurred. The present global total of treatments is distributed among the health-care levels of the model as (150,000 man Sv and 0.03 mSv) and 1985–1990 (160,000 man I (at a mean rate of 0.47 follows: 83% in countries of level mSv). The distribution of collective dose Sv and 0.03 among the health-care levels of the global model is currently per 1,000 population), 16% in countries of level II (0.043 III/IV per 1,000 population), 0.9% in countries of level I (giving a mean per as follows: 92% in countries of level mSv), 8% in countries of level caput dose of 0.12 (0.004 per 1,000 population). In comparison with the II (cor- practices assessed for the other modes of radiotherapy, responding to <0.01 mSv per caput) and <1% in countries 05 III (0.000 of level - mSv per caput). Globally, practice is radionuclide therapy is much less common than telether million treatments), but is apy (annual global total of 4.7 dominated by bone scans, cardiovascular studies and thyroid studies, with the last being particularly important in countries similar in number of treatments to brachytherapy (total of of health-care levels III and IV. 0.43 million). III. dOSES FOR SpECIFIC NUCLEAR MEdICINE pROCEdURES A. diagnostic uses The most commonly performed procedure was − bone scintigraphy (35%), followed by myocardial C20. A nationwide survey of nuclear medicine practice in perfusion (24%) and brain perfusion (12%) studies. Japan in 2002 had the following findings [K16]: The annual frequency of all of these types of study has increased steadily over the past 20 years. − A total of 1,697 gamma cameras were installed in Tumour imaging studies, however, fell from − 1,160 facilities; 50% of these were dual-headed third to fourth place in terms of annual procedure cameras. frequency. − The estimated total annual number of examinations million, similar to that of an performed was 1.60 The most commonly used radiopharmaceuticals − earlier survey in 1997. 201 99m were Tc HMDP for bone studies, Tl chloride 67 The annual frequency of SPECT studies increased − for myocardial studies, Ga citrate for tumour 123 to 40%, from 30% in the earlier survey. I IMP for brain studies. imaging and

155 143 ANNEX A: MEDICAL RADIATION EXPOSURES − A total of 29,376 PET studies were performed in and the assumed values of effective dose per unit activity 18 2002. The use of F FDG increased by a factor of administered. Data supplied by the respondents were taken 3.7 over previously reported results. as reported, without checking which source may have been 131 used to estimate these doses. I therapies for − thyroid There were 1,647 and 3,347 cancer and hyperthyroidism, respectively. C23. At the time of writing, a significant change is under − million in vitro radioassays were A total of 31.35 way in the frequency of use of PET procedures, as well as reported; the number of in vitro radioassays has in the use of combined PET–CT and SPECT–CT imaging been decreasing continuously since 1992. systems. One study of four university hospitals in Germany [B4] revealed an average effective dose per PET–CT proce- A nationwide survey of nuclear medicine practice in C21. dure of 25 mSv, with the majority coming from the CT scans. the United Kingdom in 2003–2004 [H25] had the following Ideas for reducing patient dose per procedure have been dis- findings: cussed by a number of authors [B4, C6, C19, T16, W3]. A study based in the United States [F7] concluded that data − A total of 380 gamma cameras were installed in 240 for CT-based attenuation corrections can be obtained with facilities; an average of approximately 1,580 proce- very-low-dose CT scans, and that for CT scans of diagnostic dures are performed annually on these cameras. Donnelly et al. quality, the dose reduction ideas proposed by The total number of procedures performed annu- − D7] and Huda et al. [H6] can be helpful. [ ally increased by 36% over the last ten years. An estimated 670,000 procedures were performed, approximately 11 procedures per 1,000 population, Therapeutic uses b. which is up from 6.8 per 1,000 in 1982 and 7.6 per 1,000 in 1989. C24. Therapeutic procedures using radiopharmaceuticals − Planar imaging constitutes 73% of all nuclear medi- are considerably less frequent than diagnostic procedures. cine studies; SPECT and PET constitute 16% and Many therapeutic procedures are for the treatment of thyroid 2% of all studies, respectively. 131 I, which is particularly useful in the treatment disease using − Non-imaging diagnostic procedures represent 7% of differentiated thyroid carcinoma and hyperthyroidism. of all nuclear medicine studies, and therapy proce- dures account for the remaining 2% of studies. C25. Routine therapeutic applications of radiopharma- ceuticals also include the use of a number of radiolabelled The most frequently performed procedures are − biological agents against various forms of cancer. Two bone scans, which constitute 29% of all proce- monoclonal antibody products were recently approved in dures, followed by lung perfusion scans (14%) and 131 90 Y Ibritumomab I Tositumomab and the United States ( myocardial perfusion studies (14%). tiuxetan) for the treatment of non-Hodgkin’s lymphoma The most frequently performed therapeutic scan is − 90 Y Ibritumomab tiuxetan is also approved in (The use of 131 the use of I for thyrotoxicosis, which accounts for the European Union.). A number of other compounds and 75% of all therapy procedures. nuclides are of current interest in radioimmunotherapy − The annual collective effective dose in the United [G16] (tables C9 and C10). Kingdom from diagnostic nuclear medicine is man Sv (corresponding to an annual around 1,600 The general concept of “molecular targeting” has C26. mSv). Bone per caput effective dose of about 0.03 been used for both imaging and diagnosis in nuclear medi- scans are the largest contributor to collective dose. cine therapy. It may be defined as “the specific concentration Planar imaging comprises 61% of the total collec- − of a diagnostic tracer or therapeutic agent by virtue of its tive effective dose due to diagnostic nuclear medi- interaction with a molecular species that is distinctly present cine studies in the United Kingdom; SPECT, PET or absent in a disease state” [B23]. Specific molecular targets and non-imaging studies account for 33%, 6% and have been attacked with antisense molecules, aptamers, anti- 0.3%, respectively. bodies and antibody fragments. Other cellular physiologi- cal activities, including metabolism, hypoxia, proliferation, Effective doses for many typical radiopharmaceu- C22. apoptosis, angiogenesis, response to infection and multiple tical procedures for adults are shown in table C8. Most of drug resistance, have also been studied by means of molecu- these data are taken directly from the dose estimates given lar targeting [B23]. 201 in ICRP Publication 80 [I25]. Doses for Tl chloride and 99m [S27]. Tc Neurolite were taken from NUREG/CR-6345 C27. A number of radionuclides are used in the palliation 99m 153 Sm and The doses for Tc Apcitide and Depreotide came of bone pain [L20]. The characteristics and treatment modes from the Radiation Internal Dose Information Center in Oak are shown in tables C11 and C12. Ridge, Tennessee, United States [R5]. The survey form used for submitting data for this report asked the countries to C28. Another form of radiopharmaceutical therapy report mean patient effective doses per examination. These involves administration of compounds directly into intracav- doses will depend on the amount of activity administered itary spaces to treat diffuse tumours or arthritis and synovitis.

156 144 UNSCEAR 2008 REPORT: VOLUME I Direct injection of sodium or chromic phosphate labelled highly vascularized tumours that may not be amenable to 32 198 131 90 I- or P or Y-labelled antibodies with Au colloids or of surgery or chemotherapy. These radiolabelled compounds is made into confined anatomical spaces such as the pleu- are injected and lodge in the arterioles and capillaries of the ral space or the peritoneal cavity. Treatment of arthritis and tumour, providing a highly localized radiation dose. 90 synovitis has also been performed using Y ferric hydroxide 165 169 macroaggregate (FHMA), Er colloid into Dy FHMA or joint spaces. There are significant advantages in combining PET C31. and CT images for radiation treatment planning [T18]. This technology provides the ability to acquire accurately Polycythemia vera is a relatively rare disease that C29. aligned anatomical and functional images for subjects in a is characterized by overproduction of red and white blood 32 single imaging session. This aids in accurate identification cells by the bone marrow. P phosphate given intravenously will localize in bone, and the radiation dose delivered results of pathology and accurate localization of abnormal foci. This technology is currently undergoing rapid growth. Some in mild bone marrow suppression and management of this disease. PET–CT design features in 2004 are shown in table C13. The radionuclides and techniques employed here are not 131 90 C30. I-labelled oil contrast and used directly in the therapeutic procedures, but are used to Y glass or resin micro- diagnose and stage disease. spheres have been used to perform intra-arterial therapy for IV. dOSES FOR SpECIFIC pOpULATIONS aediatric patients A. p C34. The processes involved in transfer from maternal to foetal blood through the placenta include simple diffusion, When paediatric patients undergo nuclear medi- C32. facilitated transport and active transport, movement through cine procedures, it is accepted practice that lower activities pores and channels, and pinocytosis [I37]. A radioisotopes fol- of radionuclide are administered. In general, administered lows the same pathways of uptake to maternal blood as the activities of radionuclide are adjusted to body surface area stable element. If data on a particular element are unavailable, or body weight. If the second approach is adopted, then then radionuclides will have similar pathways to elements that the effective dose to paediatric patients will be compara- are chemically similar. For many elements, the rate of trans- ble to that of an adult. Effective doses to paediatric patients fer depends on the chemical affinity for the different transport from diagnostic nuclear medicine procedures are given in systems in various tissues and the placenta [I37]. table C14 [H16, I25, I34, S27]. The references are the same as those for the adult procedures described above. A comprehensive treatment of radiation doses C35. for radiopharmaceuticals has been given in a document of the American National Standards Institute/Health Physics Society [S23]; the values are shown in table C15. b. Foetal dosimetry An area of particular concern in foetal dosimetry is C36. Doses to the embryo and foetus arise from the C33. the dose to the foetal thyroid, principally from administra- uptake of radionuclides by the mother and the transfer of tion of radioiodines. Radiation doses to the foetal thyroid at radionuclides across the placenta, and depend on the types various stages of gestation were estimated by Watson [W19] and distribution of radionuclides in foetal tissue. Radia- and are shown in table C16. tion doses to the embryo and foetus resulting from intakes of radionuclides by the mother also depend on a number of other factors: The breast-feeding infant C. − Their transfer through maternal blood and placenta after deposition in the tissues of the mother; C37. Another population of concern in nuclear medicine is that of infants who ingest radioactive material excreted Their distribution and retention in foetal tissues; − in the breast milk of lactating women who undergo nuclear − Growth of the embryo/foetus; medicine examinations. Several review articles on the sub- ject have been produced, with varying recommendations − Irradiation from deposits in the placenta and mater- about cessation times for breastfeeding after administration nal tissue; of various radiopharmaceuticals. Data on such exposures Direct transfer to the embryo and foetus from − to the population are sparse, as reporting of these events is maternal blood. irregular [M46, M47, R25, S4].

157 ANNEX A: MEDICAL RADIATION EXPOSURES 145 V. SURVEy The results of the UNSCEAR survey of practice in C40. The nuclear medicine questionnaires are given C38. therapeutic nuclear medicine are given in tables C22, C23 in Form 3 of the UNSCEAR Global Survey of Medical and C24. The number of procedures, the number of proce- Radiation Usage and Exposures. dures per million population, and the mean and variance Tables C17 and C18 summarize the current status C39. on effective dose are recorded in these tables. of diagnostic nuclear medicine equipment in each coun- try, according to health-care level, obtained from the latest UNSCEAR survey. The number of examinations, number of C41. Numbers of diagnostic examinations per 1,000 pop- examinations per million population and effective dose for ulation, effective dose per examination and annual collective various diagnostic nuclear medicine procedures are given in dose for diagnostic nuclear medicine examinations are given tables C19 (a–b), C20 (a-b) and C21 (a–b). in table C25. VI. SUMMARy A survey of practice in nuclear medicine has been 11 in 1970–1979 to 19 in the present survey. Compara- C42. undertaken. Responses from various countries have been II countries also exhibit an tive values for health-care level increase, from 0.9 per 1,000 in 1970–1979 to 1.1 per 1,000 received. These data have been supplemented by informa- tion on nuclear medicine procedures and treatments obtained in 1997–2007. from a review of the published literature. C46. By comparison, for therapeutic nuclear medicine A global model, as used in earlier UNSCEAR C43. procedures, according to this global model, the annual reports, has been used. In this model, countries are strati- frequency of nuclear medicine treatments in health-care fied into four health-care levels, depending on the number level I countries has increased from 0.17 per 1,000 popu- of physicians per 1,000 members of the population. As with lation in 1991–1996 to 0.47 per 1,000 population in this previous UNSCEAR surveys of global exposure, there are II coun- survey. Comparative values for health-care level considerable uncertainties on the results estimated using this tries exhibit an even greater increase, from 0.036 per 1,000 global model. population in 1991–1996 to 0.043 per 1,000 population in 1997–2007. In the period covered by this UNSCEAR The uncertainty arises from a number of sources, C44. report, the estimated dose to the world population due to but primarily in extrapolating from the limited survey diagnostic nuclear medicine procedures is estimated to be data obtained. For example, the small sample size in the Sv. This represents an increase in collective 202,000 man UNSCEAR survey could mean that the annual frequency Sv, a rise of just over a third. This rise man dose of 52,000 data are distorted. There is also an uncertainty on the popu- in collective dose occurs because of two factors. Firstly, the lation estimates for the global population. average effective dose per procedure has increased from 4.6 mSv to 6.0 mSv. Secondly, there has been an increase According to this global model, the annual frequency C45. in the annual number of diagnostic nuclear medicine of diagnostic nuclear medicine examinations per 1,000 pop- examinations to the world population. I countries has increased from ulation in health-care level roperties of some radionuclides used for in vivo imaging Table C1. p Half-life Principal emissions Examples of uses Radionuclide 11 C Positrons + 511 keV photons Cerebral perfusion studies 20 min 13 10 min Positrons + 511 keV photons N Myocardial perfusion studies 15 O 2 min Positrons + 511 keV photons Oxygen or water flow studies 18 F 110 min Positrons + 511 keV photons Glucose metabolism 67 Ga 92 keV, 182 keV photons Detection of soft tissue malignancies, infection 78 h 99m Tc 140 keV photons Many 6 h 111 2 .8 d In Blood element imaging 173 keV, 247 keV photons 123 I 13 h 160 keV photons Thyroid imaging 125 I 25–35 keV x-rays and photons Blood volume determination 60 d 131 I 8 d 365 keV photons Thyroid imaging, therapy of cancer and hyperthyroidism 133 xe 5 .3 d 81 keV photons lung ventilation studies 201 Tl 73 h 80 keV x-rays Myocardial perfusion studies

158 146 UNSCEAR 2008 REPORT: VOLUME I Radiopharmaceuticals used in nuclear medicine [k15] Table C2. Use Typical administered activity (adult subjects) (MBq) Route Radionuclide Form 11 Carbon monoxide Inhalation Cardiac, blood volume C 2 200–3 700 11 Brain, benzodiazepine receptor IV Flumazenil injection 740–1 110 C 11 370–740 IV C Methionine injection Neoplastic brain disease 11 Dopamine receptor 370–555 IV Raclopride injection C 11 Cardiac 444–1 480 IV C Sodium acetate 14 C 0 .037 PO Urea Helicobacter pylori diagnosis 51 Sodium chromate 0 .37–2 .96 IV Cr Red blood cells 57 Pernicious anaemia 0 .019 PO Co Cyanoalbain capsules 18 F 370–555 IV Fludeoxyglucose injection Glucose utilization 18 F Dopamine neuronal 148–220 IV Fluorodopa 18 Sodium fluoride injection F 370 IV Bone imaging 67 Gallium citrate Hodgkin’s lymphoma IV Ga 296–370 67 Gallium citrate 185 IV Ga Acute inflammatory lesions 111 Metastases 185 IV In Capromab pendetide injection 111 Indium chloride solution In Radiolabelling 111 Indium oxide solution In 18 .5 IV labelling autologous leucocytes 111 Pentetate injection Cisternography 18 .5 Intrathecal In 111 In Neuroendocrine tumours 111 IV Pentetreotide 111 In Neuroendocrine tumours (SPECT) 220 IV Pentetreotide 111 Ibritumomab tiuxetan Biodistribution 185 IV In 123 I Pheochromocytoma 5 .18/kg (child) IV Iobenguane injection 123 Sodium iodide Thyroid imaging 14 .8–22 PO I 123 I Sodium iodide Thyroid metastases 74 PO 125 I Plasma volume 0 .19–0 .37 IV Albumin injection 125 I 1 .11 IV Iothalamate sodium injection Glomerular filtration rate 2 131 Iobenguane injection 18 .5/1 .7 m IV I Pheochromocytoma 131 Thyroid function 0 .19–0 .37 I Sodium iodide PO 131 I Sodium iodide Thyroid imaging 1 .9–3 .7 PO 131 Sodium iodide Thyroid imaging (substernal) 3 .7 PO I 131 I Thyroid metastases 74 PO Sodium iodide 131 I Hyperthyroidism 185–1 221 PO Sodium iodide 131 Sodium iodide Carcinoma 5 550–7 400 PO I 131 I Recoverable renal function 2 .775–7 .4 IV Iodohippurate sodium 131 I Treatment of non-Hodgkin’s <0 .75 Gy IV Tositumomab lymphoma 13 N Ammonia injection Myocardial perfusion 370–740 IV 15 O Cardiac perfusion 1 .11–3 .7 IV Water injection 32 P Peritoneal and pleural effusions 370–740 Intraperitoneal Chromic phosphate 32 Sodium phosphate Polycythemia 37–296 IV P 82 Rb Myocardial perfusion 1 .11–2 .22 IV Rubidium chloride 153 lexidronam Bone palliation 37/kg IV Sm 89 Sr Strontium chloride Bone palliation 148 IV 99m Tc Heart blood pool 740 IV Albumin injection 99m Albumin aggregated lung perfusion 111 IV Tc 99m Tc Bicisate Stroke 740 IV 99m Disofenin Hepatobiliary 185 IV Tc 99m Tc Exametazime Cerebral perfusion 370–740 IV

159 ANNEX A: MEDICAL RADIATION EXPOSURES 147 Form Use Route Radionuclide Typical administered activity (adult subjects) (MBq) 99m Gluceptate IV Brain Tc 740 99m Renal perfusion IV Gluceptate Tc 370 99m 185 IV Mebrofenin Tc Hepatobiliary 99m Bone 740–1 110 IV Tc Medronate 99m Tc 185 IV Mertiatide Kidney imaging 99m Mertiatide 37–111 IV Tc Renogram, renal transplant 99m Renogram 37–111 Tc Mertiatide IV 99m Tc Oxidronate Bone 740–1 110 IV 99m Tc Pentetate injection 111 IV Glomerular filtration rate (quantitative) 99m Tc 111 IV Pentetate injection Renogram 99m Pentetate injection 370 Tc IV Renal perfusion 99m Tc Infarct-avid 555 IV Pyrophosphate 99m Red blood cells Gastrointestinal bleeding 555 IV Tc 99m Tc Myocardial perfusion 296–1 480 IV Sestamibi 99m Tc Brain 740 IV Sodium pertechnetate 99m Sodium pertechnetate Thyroid imaging Tc IV 370 99m Tc Sodium pertechnetate Ventriculogram 740 IV 99m Tc Sodium pertechnetate Cystography 37 Urethral 99m Tc Dacrocystography 3 .7 Eye drops Sodium pertechnetate 99m Tc 185 IV Sodium pertechnetate Meckel’s diverticulum 99m Succimer 185 Tc IV Renal scan, renal function 99m Tc Renal scan, cortical anatomy 185 IV Succimer 99m Sulphur colloid liver–spleen 185 IV Tc 99m Tc lymphoscintigraphy, breast 14 .8–22 Interstitial Sulphur colloid 99m Tc lymphoscintigraphy, melanoma 18 .5–29 .6 Intradermal Sulphur colloid 99m Sulphur colloid Gastric emptying Tc PO 37 99m Tc Sulphur colloid Gastrointestinal bleeding 370 IV 99m Tc Sulphur colloid lung aspiration 185 PO 99m Tc Gastroesophageal reflux 7 .4 PO Sulphur colloid 99m Tc Myocardial perfusion 296–1 480 IV Tetrofosomin 201 Thallium chloride Myocardial perfusion Tl IV 111–148 133 xe xenon lung ventilation 370–740 Inhalation 90 y Ibritumomab tiuxetan Treatment of non-Hodgkin’s IV 11 .1–14 .8/kg lymphoma Table C3. Radiopharmaceuticals used for clinical pET studies (adapted from reference [L19]) Types of study performed Radionuclide and compound 15 O Carbon dioxide Cerebral blood flow Oxygen quantification of myocardial oxygen consumption and oxygen extraction fraction, measurement of tumour necrosis Water quantification of myocardial oxygen consumption and oxygen extraction fraction, tracer for myocardial blood perfusion 13 N Ammonia Myocardial blood flow 11 C Acetate Oxidative metabolism Carfentanil Opiate receptors in the brain

160 148 UNSCEAR 2008 REPORT: VOLUME I Types of study performed Radionuclide and compound Cocaine Identification and characterization of drug binding sites in the brain Deprenyl Distribution of monoamine oxidase (MAO) type B, the isoenzyme that catabolizes dopamine Amino acid uptake and protein synthesis, providing an indicator of tumour viability leucine Methionine Amino acid uptake and protein synthesis, providing an indicator of tumour viability Neurochemical effects of various substances on dopaminergic function N-methylspiperone Raclopride Function of dopaminergic synapses 18 F Haloperidol Binding sites of haloperidol, a widely used antipsychotic and anxiety-reducing drug Fluorine ion Clinical bone scanning Fluorodeoxyglucose (FDG) Neurology, cardiology and oncology to study glucose metabolism Fluorodopa Metabolism, neurotransmission and cell processes Metabolism, neurotransmission and cell processes Fluoroethylspiperone Fluorouracil Delivery of chemotherapeutic agents in the treatment of cancer 82 Rb 82 Rb Myocardial perfusion Table C4. Trends in annual number of diagnostic nuclear medicine procedures per 1,000 population [U3] Data from the UNSCEAR Global Surveys of Medical Radiation Usage and Exposures 1970–1979 1985–1990 1991–1996 1997–2007 Country/area 1980–1984 Health-care level I Argentina 11 .5 11 .1 3 .8 8 .9 8 .3 12 .0 19 .0 Australia 18 .0 Austria 41 .9 0 .5 Belarus 0 .4 36 .8 52 .8 Belgium Bulgaria 3 .3 13 .0 Canada 12 .6 64 .6 Cayman Islands 0 China - Taiwan 6 .6 2 .4 8 .6 Croatia a (0 .8) Cuba Cyprus 6 .6 b 13 .6 18 .3 22 .9 Czechoslovakia 28 .3 Czech Republic 12 .6 Denmark 14 .2 13 .4 15 .2 14 .0 a Ecuador (0 .8) 0 .8 (0 .5) Estonia 8 .0 2 .0 Finland 12 .6 17 .7 10 .0 7 .7 France 9 .0 14 .0 6 .9 c 31 .1 Germany 39 .8 34 .1 46 .7 39 .7 Greece 16 .7 Hungary 15 .3 17 .9 Iceland 14 .1 Ireland 6 .1 Italy 6 .0 7 .3 11 .0 Japan 8 .3 11 .7 10 .2 Kuwait 13 .1 12 .7

161 ANNEX A: MEDICAL RADIATION EXPOSURES 149 1970–1979 1980–1984 1991–1996 1997–2007 Country/area 1985–1990 latvia 6 .8 10 .6 lithuania 34 .5 luxembourg 52 .2 23 .5 Netherlands 15 .7 24 .3 11 .6 7 .3 7 .5 New Zealand 6 .7 5 .6 8 .3 3 .9 10 .9 Norway 9 .3 3 .4 Panama 3 .0 Poland Portugal 4 .0 4 .7 qatar 3 .0 Romania 3 .0 2 .8 3 .5 d (9) (15) 12 .6 Russian Federation (11) d 9 .4 Slovakia (4 .9) Slovenia 11 .2 10 .4 16 .9 Spain 9 .8 Sweden 13 .6 10 .8 12 .6 ugoslav Republic of Macedonia 4 .0 The former y 44 .9 9 .5 11 .7 Switzerland Ukraine 5 .0 United Arab Emirates 7 .2 United Kingdom 6 .8 8 .2 25 .7 31 .5 United States yugoslavia 6 .1 22 .1 16 Average 11 6 .9 19 Health-care level II Antigua and Barbuda 0 1 .0 Barbados Brazil 1 .7 1 .1 0 .6 China 1 .73 Costa Rica Dominica 0 El Salvador 0 .61 Grenada 0 India 0 .1 0 .2 Iran (Islamic Rep . of) 1 .9 Iraq 1 .2 1 .6 Jordan 1 .1 Mexico Oman 0 .6 0 .6 Pakistan 0 .2 0 .6 Peru Saint Kitts and Nevis 0 Saint lucia 0 Saint Vincent and the Grenadines 0 0 Trinidad and Tobago 0 .17 Tunisia 1 .0 0 .8 Turkey 2 .5 2 .1 Average 0 .9 0 .1 0 .5 1 .1 1 .0

162 150 UNSCEAR 2008 REPORT: VOLUME I 1970–1979 1980–1984 1991–1996 1997–2007 Country/area 1985–1990 Health-care level III 0 .07 0 .21 Egypt 0 .48 Ghana 0 .05 0 .01 Indonesia a (2 .8) (2 .0) Jamaica 0 .62 Morocco 0 .11 0 .06 0 .36 0 .54 Myanmar 0 .28 Sudan 0 .09 0 .12 0 .28 0 .25 0 .26 Thailand 0 .18 0 .02 Zimbabwe Average 0 .30 0 .28 0 .02 0 .25 0 .25 Health-care level IV 0 .014 0 .10 0 .014 Ethiopia United Rep . of Tanzania 0 .024 Average 0 .02 a Categorized in health-care level II in previous analyses . b Historical data . c Historical data for 1970-1979, 1980-1984 and 1985-1990 refer to Federal Republic of Germany . d Historical data were not included in previous analyses . Table C5. Estimated dose to the world population from diagnostic nuclear medicine procedures (1997–2007) [U3] Health-care level Annual collective effective dose (man Sv) Population (millions) Annual per caput effective dose (mSv) 1 540 186 000 0 .12 I II 16 000 0 .005 1 3 153 1 752 0 .000 047 82 III-IV 6 446 202 000 World 0 .031 Table C6. Annual number of therapeutic treatments with radiopharmaceuticals per million population (1997–2007) Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures [U3] 90 Hyperthyroidism Country/area Bone metastases Synovitis Other, e.g. Thyroid malignancy YCl Total Polycythemia vera Health-care level I Austria 134 415 1 .2 12 .2 183 .2 17 .1 763 Croatia 81 .8 0 .0 1 .4 0 .7 0 .0 287 203 27 .7 117 77 .6 50 .5 272 Czech Republic 0 .0 117 3 .6 36 .5 3 .6 1 .5 414 Estonia 252 106 242 70 .9 10 .7 Finland 1 .5 440 8 .8 Greece 16 .8 120 103 45 .1 12 .0 11 .5 Hungary 329 260 91 .8 252 3 .4 347 Iceland Japan 17 .3 17 .3 34 .5 luxembourg 102 2 .2 108 4 .4 100 25 .0 185 Malta 60 .0 59 .3 Norway 0 .9 5 .0 1 .9 3 .9 209 138 Poland 41 .5 272 15 .6 5 .2 1 .3 336 Slovenia 559 1 .5 3 .0 15 .0 684 105 Spain 611 1 267 21 .8 72 .3 63 .3 5 .6 2 040 Sweden 11 .7 259 .2 32 .8 38 .4 1 .6 1 .1 345

163 ANNEX A: MEDICAL RADIATION EXPOSURES 151 90 Hyperthyroidism Synovitis Other, e.g. Thyroid malignancy YCl Total Polycythemia vera Country/area Bone metastases 70 .1 309 Switzerland 201 .0 37 .9 Republic of Macedonia 34 .4 164 yugoslav The former 130 193 .3 11 .9 9 .1 6 .7 3 .4 244 United Kingdom 19 .3 279 Average 21 .1 27 .2 10 .9 401 106 16 .8 Health-care level II 23 .1 57 .8 Costa Rica 34 .7 13 .2 32 .9 El Salvador 19 .7 21 .4 45 .4 Average 24 .0 Health-care levels III and IV Indonesia 0 .5 0 .7 0 .06 1 .3 1 .6 18 .6 20 .2 Myanmar 1 .7 Zimbabwe 0 .0 2 .5 0 .8 0 .0 6 .7 0 .0 0 .0 8 .0 1 .3 Average 0 .06 Table C7. Estimated annual number of therapeutic treatments with radiopharmaceuticals in the world (1997–2007) [U3] Annual number of treatments Health-care level Population (millions) Millions Per 1 000 population I 1 540 0 .73 0 .47 II 3 153 0 .14 0 .043 1 752 0 .007 5 0 .004 3 III–IV 6 446 World 0 .87 0 .14 Effective dose (adult subjects) from typical nuclear medicine procedures [h29, I25, I34, S27] Table C8. Procedure mSv/MBq mSv MBq 14 –2 –3 C urea (normal) 1 .15 × 10 3 .10 × 10 0 .037 14 –2 –3 C urea (Heliobacter positive) 8 .10 × 10 0 .037 3 .00 × 10 57 0 –1 1 .63 × 10 0 .037 Co cyanocobalamin (IV, no carrier) 4 .40 × 10 57 –1 –2 0 .037 1 .7 × 10 Co cyanocobalamin (IV, with carrier) 4 .60 × 10 57 –1 0 Co cyanocobalamin (oral, no flushing) 3 .1 × 10 1 .15 × 10 0 .037 57 –2 0 2 .1 × 10 0 .037 7 .77 × 10 Co-7 cyanocobalamin (oral, with flushing) 51 –1 –1 5 .6 9 .5 × 10 1 .7 × 10 Cr sodium chromate RBCs 18 –2 0 370 1 .90 × 10 F FDG 7 .0 × 10 67 1 –1 1 .00 × 10 185 1 .85 × 10 Ga citrate 123 –2 –1 I hippuran 1 .20 × 10 14 .8 1 .78 × 10 123 –2 –1 I MIBG 1 .30 × 10 14 .8 1 .92 × 10 123 –1 –2 1 .10 × 10 14 .8 I sodium iodide (0% uptake) 1 .63 × 10 123 –1 0 I sodium iodide (35% uptake) 14 .8 3 .26 × 10 2 .20 × 10 125 –1 –1 0 .74 2 .20 × 10 I albumin 1 .63 × 10 131 –2 –2 0 .74 I hippuran 5 .20 × 10 3 .85 × 10 131 –1 –1 I MIBG 0 .74 1 .0 × 10 1 .40 × 10 131 –2 I sodium iodide (0% uptake) 3 700 n .a . 6 .10 × 10 2 131 2 .40 × 10 3 700 n .a . I sodium iodide (35% uptake) 111 –2 1 1 .20 × 10 222 In pentetreotide, also known as Octreoscan 5 .40 × 10 111 –1 0 3 .6 × 10 18 .5 6 .66 × 10 In white blood cells 81m –5 –3 Kr krypton gas 2 .70 × 10 370 9 .99 × 10

164 152 UNSCEAR 2008 REPORT: VOLUME I MBq Procedure mSv mSv/MBq –4 –1 15 370 O water 9 .30 × 10 3 .44 × 10 32 0 2 3 .55 × 10 2 .40 × 10 P phosphate 148 153 –1 n .a . Sm lexidronam, also known as quadramet 1 .97 × 10 2 590 0 89 148 3 .10 × 10 Sr chloride, also known as Metastron n .a . 99m –3 0 6 .88 × 10 Tc apcitide, also known as AcuTect 740 9 .30 × 10 99m –2 1 1 .70 × 10 Tc depreotide, also known as NeoTect 740 2 .30 × 10 99m 0 –2 3 .15 × 10 Tc disofenin, also known as HIDA (iminodiacetic acid) 1 .70 × 10 185 99m 0 –3 8 .80 × 10 Tc DMSA (dimercaptosuccinic acid), also known as Succimer 185 1 .63 × 10 99m –3 0 740 Tc exametazime, also known as Ceretec and HMPAO 9 .30 × 10 6 .88 × 10 99m 0 –2 1 .63 × 10 Tc macroaggregated albumin (MAA) 1 .10 × 10 148 99m 0 –3 5 .70 × 10 740 4 .22 × 10 Tc medronate, also known as Tc-99m Methyenedi-phosphonate (MDP) 0 –3 99m Tc mertiatide, also known as MAG3 (normal renal function) 7 .00 × 10 5 .18 × 10 740 99m 0 –3 4 .51 × 10 6 .10 × 10 740 Tc mertiatide, also known as MAG3 (abnormal renal function) 99m –2 0 Tc mertiatide, also known as MAG3 (acute unilateral renal 1 .00 × 10 740 7 .40 × 10 blockage) –2 0 99m Tc Neurolite, also known as ECD and Bicisate 740 8 .14 × 10 1 .10 × 10 99m 0 –3 370 4 .90 × 10 1 .81 × 10 Tc pentetate, also known as Tc-99m DTPA 99m –3 0 Tc pyrophosphate 3 .16 × 10 5 .70 × 10 555 99m –3 0 5 .18 × 10 740 Tc red blood cells 7 .00 × 10 99m –3 0 740 6 .66 × 10 Tc sestamibi, also known as Cardiolite (rest) 9 .00 × 10 99m 0 –3 Tc sestamibi, also known as Cardiolite (stress) 7 .90 × 10 740 5 .85 × 10 99m 0 –2 1 .30 × 10 370 4 .81 × 10 Tc sodium pertechnetate 99m 0 –3 9 .40 × 10 296 2 .78 × 10 Tc sulphur colloid 99m –2 1 Tc Technegas 1 .11 × 10 1 .50 × 10 740 99m –3 0 740 5 .62 × 10 Tc tetrofosmin, also known as Myoview (rest) 7 .60 × 10 99m –3 0 Tc tetrofosmin, also known as Myoview (stress) 740 5 .18 × 10 7 .00 × 10 201 –1 1 1 .60 × 10 1 .18 × 10 Tl thallous chloride (with contaminants) 74 133 –4 –1 xe xenon gas (rebreathing for 5 minutes) 8 .00 × 10 555 4 .44 × 10 Note : n .a . = not applicable . Table C9. Radionuclides of current interest in radioimmunotherapy [G16] t Emission (for therapy) Maximum energy (keV) Maximum particle range (mm) Isotope (h) ½ 131 193 b 610 2 .0 I 90 64 y 2 280 12 .0 b 177 lu b 496 1 .5 161 67 Cu 62 b 577 1 .8 186 Re b 1 080 5 .0 91 188 17 b 2 120 11 .0 Re 212 Bi 1 a 8 780 0 .09 213 0 .77 a >6 000 <0 .1 Bi 211 At 7 .2 a 7 450 0 .08

165 ANNEX A: MEDICAL RADIATION EXPOSURES 153 Recent clinical studies of radioimmunotherapy in haematological tumours [G16] Table C10. Antibody Radiolabels Tumour type Target antigen 131 I B1 Non-Hodgkin’s lymphoma CD20 90 y y2B8 CD20 131 90 I, y CD22 hll2 131 67 I, Cu lym-1 HlA-DR 131 90 I, y Hodgkin’s disease Ferritin Rabbit 213 131 I, Bi CD33 Myelocytic leukemia HuM195 188 Re NCA95 BW250/183 Table C11. physical characteristics of therapeutic radionuclides for bone pain palliation [L20] Half-life Maximum energy (MeV) Radionuclide Maximum range Mean energy (MeV) g emission (keV) 32 1 .7 (ß) 0 .695 (ß) 8 .5 mm None P 14 .3 d 89 Sr 1 .4 (ß) 0 .583 (ß) 7 mm None 50 .5 d 186 3 .7 d 1 .07 (ß) 0 .362 (ß) 5 mm 137 Re 188 Re 2 .1 (ß) 0 .764 (ß) 10 mm 155 16 .9 h 153 Sm 0 .81 (ß) 0 .229 (ß) 4 mm 103 1 .9 d 117m 13 .6 d 0 .13 and 0 .16 conversion electrons <1 μm 159 Sn 223 Ra 11 .4 d 5 .78 ( a ) (average) <10 μm 154 Table C12. Administered activity, typical response time and duration, and re-treatment interval for bone-seeking radionuclides [L20] Usual administered activity Typical response duration (weeks) Re-treatment interval (months) Radiopharmaceutical Typical response time (days) 32 14 10 >3 P 444 MBq (fractionated) 89 148 MBq 14–28 12–26 >3 SrCl 2 186 1 .3 GBq 2–7 8–10 >2 Re-HEDP 188 Re-HEDP 8 n .e . 1 .3–4 .4 GBq 2–7 153 Sm-EDTMP 2–7 8 >2 37 MBq/kg 117m 2–10 MBq/kg 5–19 12–16 >2 Sn-DTPA 223 RaCl 50–200 kBq/kg <10 n .e . n .e . 2 Note: n .e . = not established . Table C13. CT and pET parameters in pET–CT designs (2004) [L20] PET parameters CT parameters Ceramic Scintillator BGO, GSO, lSO Detectors 1, 2, 4, 8, 16 Detector size 4 × 4 mm, 6 × 6 mm Slices 0 .4–2 .0 s Axial FOV 15–18 cm Rotation speed Tube current 80–280 mA Septa 2-D/3-D, 3-D only Heat capacity 3 .5–6 .5 MHU Attenuation Rod, point, CT only Transaxial FOV Transaxial FOV 55–60 cm 45–50 cm Time/100 cm 13–90 s Time/bed 1–5 min Slice width 0 .6–10 mm Resolution 4–6 mm Patient port 70 cm Patient port 60–70 cm Note : BGO = bismuth germanate; GSO = gadolinium oxyorthosilicate; lSO = lutetium oxyorthosilicate; FOV = field of view; MHU = mega Hounsfield units .

166 154 UNSCEAR 2008 REPORT: VOLUME I Radiation dose (paediatric subjects) from typical nuclear medicine procedures [h16, I34, I35, S27] Table C14. Procedure 10-year-old 15-year-old 5-year-old 1-year-old (mSv/MBq) (mSv/MBq) (mSv/MBq) (mSv/MBq) 18 0 .036 F FDG 0 .050 0 .025 0 .095 67 0 .200 0 .640 0 .130 Ga citrate 0 .330 123 0 .037 0 .037 0 .016 I sodium iodide (0% uptake) 0 .024 123 0 .053 0 .080 0 .150 0 .290 I sodium iodide (5% uptake) 123 0 .110 0 .170 0 .650 I sodium iodide (15% uptake) 0 .350 123 0 .170 1 .000 0 .260 I sodium iodide (25% uptake) 0 .540 123 0 .230 0 .740 1 .400 I sodium iodide (35% uptake) 0 .350 123 0 .440 0 .290 1 .800 I sodium iodide (45% uptake) 0 .940 123 0 .350 I sodium iodide (55% uptake) 1 .100 2 .100 0 .530 111 In pentatreotide, also known as Octreoscan 0 .100 0 .160 0 .280 0 .071 111 0 .836 1 .240 3 .380 In white blood cells 1 .910 99m 0 .021 0 .100 0 .029 Tc disofenin, also known as HIDA (iminodiacetic acid) 0 .045 99m 0 .011 0 .021 0 .037 Tc DMSA (dimercaptosuccinic acid), also known as Succimer 0 .015 99m 0 .017 0 .011 0 .049 Tc exametazime, also known as Ceretec and HMPAO 0 .027 99m 0 .016 Tc macroaggregated albumin (MAA) 0 .034 0 .063 0 .023 99m Tc medronate, also known as Tc-99m methylene diphosphonate (MDP) 0 .011 0 .014 0 .027 0 .007 99m 0 .009 0 .012 0 .022 Tc mertiatide, also known as MAG3 0 .012 99m 0 .014 Tc Bicisate, also known as ECD and Neurolite 0 .032 0 .060 0 .021 99m Tc pentetate, also known as Tc-99m DTPA 0 .008 0 .009 0 .016 0 .006 99m Tc pyrophosphate 0 .007 0 .011 0 .014 0 .027 99m Tc red blood cells 0 .009 0 .014 0 .021 0 .039 99m Tc sestamibi, also known as Cardiolite (rest) 0 .018 0 .028 0 .053 0 .012 99m Tc sestamibi, also known as Cardiolite (stress) 0 .023 0 .045 0 .010 0 .016 99m 0 .017 0 .042 0 .079 Tc sodium pertechnetate 0 .026 99m 0 .018 0 . 028 Tc sulphur colloid 0 .012 0 .050 99m Tc tetrofosmin, also known as Myoview (rest) 0 .010 0 .013 0 .022 0 .043 99m 0 .008 0 .012 0 .018 0 .035 Tc tetrofosmin, also known as Myoview (stress) 201 Tl thallous chloride 1 .160 1 .500 2 .280 0 .293 Estimated foetal dose from various nuclear medicine procedures [S23] Table C15. (shading indicates maternal and foetal self-dose contributions) Radiopharmaceutical Activity administered Dose to foetus at different ages (MBq) 3 months (mGy) 6 months (mGy) 9 months (mGy) Early (mGy) 57 Co vitamin B12 –2 –2 –2 –2 2 .7 × 10 3 .4 × 10 3 .5 × 10 0 .04 4 .0 × 10 Normal, flushing –2 –2 –2 –2 4 .0 × 10 6 .0 × 10 0 .04 5 .2 × 10 Normal, no flushing 4 .8 × 10 –3 –3 –3 –3 6 .8 × 10 6 .8 × 10 6 .0 × 10 0 .04 Pernicious anaemia, flushing 8 .4 × 10 –2 –3 –3 –3 1 .1 × 10 8 .8 × 10 Pernicious anaemia, no flushing 8 .0 × 10 0 .04 8 .4 × 10 58 Co vitamin B12 –2 –2 –2 –2 5 .7 × 10 6 .3 × 10 6 .3 × 10 7 .5 × 10 0 .03 Normal, flushing –1 –2 –2 –2 0 .03 1 .1 × 10 Normal, no flushing 9 .3 × 10 9 .3 × 10 8 .4 × 10 –2 –2 –2 –2 2 .2 × 10 1 .9 × 10 0 .03 1 .4 × 10 Pernicious anaemia, flushing 2 .5 × 10 –2 –2 –2 –2 2 .6 × 10 0 .03 2 .3 × 10 Pernicious anaemia, no flushing 1 .8 × 10 2 .9 × 10

167 ANNEX A: MEDICAL RADIATION EXPOSURES 155 Activity administered Radiopharmaceutical Dose to foetus at different ages (MBq) 6 months (mGy) 9 months (mGy) 3 months (mGy) Early (mGy) 0 0 0 18 0 6 .3 × 10 8 .1 × 10 8 .1 × 10 370 F FDG 6 .3 × 10 67 1 1 1 1 3 .4 × 10 3 .8 × 10 1 .8 × 10 Ga citrate 190 2 .5 × 10 197 –2 –2 –2 –2 2 .7 × 10 2 .8 × 10 4 .4 × 10 Hg chlormerodrin 4 3 .0 × 10 123 0 0 –1 –1 1 .8 × 10 6 .3 × 10 5 .9 × 10 75 I hippuran 2 .3 × 10 123 0 0 0 0 3 .8 × 10 1 .2 × 10 1 .4 × 10 I IMP 200 2 .2 × 10 123 I MIBG 0 0 0 0 4 .2 × 10 2 .2 × 10 2 .4 × 10 6 .3 × 10 Phaeochromocytoma 350 0 –1 –1 –1 5 .4 × 10 1 .4 × 10 5 .0 × 10 9 .6 × 10 Cecholamine tumour 80 123 I sodium iodide –1 –1 –1 –1 2 .9 × 10 4 .2 × 10 3 .3 × 10 6 .0 × 10 Thyroid uptake study 30 –1 –1 –1 –2 Thyroid imaging 1 .7 × 10 15 1 .4 × 10 2 .1 × 10 3 .0 × 10 125 –1 –1 –2 –2 2 5 .2 × 10 7 .6 × 10 I HSA 5 .0 × 10 1 .6 × 10 125 –2 –3 –3 –3 9 .5 × 10 1 1 .8 × 10 3 .5 × 10 I NaI 2 .3 × 10 131 I hippuran –2 –2 –2 –2 2 .5 × 10 2 .3 × 10 6 .5 × 10 8 .3 × 10 Renal function 1 .3 –2 –2 –2 –2 1 .3 8 .3 × 10 2 .3 × 10 2 .5 × 10 6 .5 × 10 Renal imaging 131 –1 –2 –2 –2 2 .6 × 10 8 .0 × 10 I HSA 6 .5 × 10 9 .0 × 10 0 .5 131 0 0 0 0 2 .2 × 10 2 .3 × 10 2 .3 × 10 55 3 .7 × 10 I MAA 131 –1 0 0 –1 1 .1 × 10 7 .6 × 10 20 7 .0 × 10 I MIBG 2 .2 × 10 131 I NaI (diagnostic) –1 –2 –2 –1 1 .3 × 10 3 .7 × 10 1 .5 × 10 Thyroid uptake 0 .55 4 .0 × 10 0 –1 –1 –1 2 .7 × 10 2 .9 × 10 4 1 .1 × 10 Scintiscanning 9 .2 × 10 0 0 0 1 40 2 .7 × 10 9 .2 × 10 1 .1 × 10 localization of extra- 2 .9 × 10 thyroid metastases 131 I NaI (therapeutic) 1 1 1 1 2 .3 × 10 8 .1 × 10 9 .5 × 10 Hyperthyroidism 2 .5 × 10 350 2 2 2 2 Ablation of normal 1 .4 × 10 1 900 5 .1 × 10 1 .3 × 10 4 .4 × 10 thyroid tissue 131 –3 –3 –3 –3 I rose bengal 8 .8 × 10 3 .6 × 10 8 .8 × 10 0 .04 6 .4 × 10 111 –1 –1 0 –1 9 .6 × 10 1 .3 × 10 20 3 . 6 × 10 In DTPA 4 .0 × 10 111 In pentetreotide 0 0 0 0 6 .6 × 10 3 .4 × 10 3 .8 × 10 9 .0 × 10 110 Planar imaging 0 0 1 1 SPECT imaging 1 .4 × 10 7 .0 × 10 230 8 .0 × 10 1 .9 × 10 111 0 0 –1 –1 10 9 .9 × 10 1 .7 × 10 In platelets 1 × 10 8 .9 × 10 111 0 0 0 0 20 2 .6 × 10 1 .9 × 10 In white blood cells 1 .9 × 10 1 .9 × 10 81m –4 –4 –4 –4 Kr gas 1 .0 × 10 2 .0 × 10 1 .1 × 10 600 1 .6 × 10 99m 0 0 0 0 4 .2 × 10 Tc disofenin 2 .3 × 10 5 .2 × 10 350 6 .0 × 10 99m –1 –1 0 0 1 .0 × 10 1 .1 × 10 7 .5 × 10 220 Tc DMSA 8 .8 × 10 99m Tc DTPA 0 0 0 0 6 .5 × 10 3 .1 × 10 3 .5 × 10 750 9 .0 × 10 Kidney imaging and glomular filtration 0 0 0 0 6 .5 × 10 Brain imaging and renal perfusion 3 .1 × 10 750 9 .0 × 10 3 .5 × 10 0 0 0 0 First pass 1 .4 × 10 3 .0 × 10 1 .6 × 10 350 4 .2 × 10 –1 –2 –2 –2 Gastric reflux 1 .2 × 10 8 .7 × 10 4 .1 × 10 4 .7 × 10 10 0 0 0 0 7 .0 × 10 3 .3 × 10 800 3 .8 × 10 Hypertension 9 .6 × 10 0 0 0 0 3 .0 × 10 1 .4 × 10 350 1 .6 × 10 Residual urine determination 4 .2 × 10 –2 –1 –1 –1 99m 2 .3 × 10 1 .7 × 10 Tc DTPA aerosol 9 .2 × 10 1 .2 × 10 40

168 156 UNSCEAR 2008 REPORT: VOLUME I Radiopharmaceutical Dose to foetus at different ages Activity administered (MBq) 3 months (mGy) 6 months (mGy) Early (mGy) 9 months (mGy) 99m Tc glucoheptonate 0 0 0 0 3 .4 × 10 8 .2 × 10 4 .0 × 10 750 9 .0 × 10 Renal imaging 0 0 0 0 4 .0 × 10 3 .4 × 10 9 .0 × 10 Brain imaging 750 8 .2 × 10 0 0 0 0 99m 750 1 .9 × 10 3 .9 × 10 Tc HDP 2 .3 × 10 4 .10 × 10 0 0 0 0 99m 5 .0 × 10 750 2 .7 × 10 Tc HMPAO 3 .6 × 10 6 .5 × 10 -1 -1 0 -1 99m 4 .4 × 10 200 5 .2 × 10 1 .0 × 10 6 .0 × 10 Tc HSA 99m Tc MAA –1 –1 –1 –1 7 .5 × 10 6 .0 × 10 6 .0 × 10 4 .2 × 10 150 Hepatic artery perfusion –1 –1 0 –1 1 .0 × 10 lung imaging 8 .0 × 10 5 .6 × 10 200 8 .0 × 10 –1 –1 0 –1 6 .2 × 10 220 1 .1 × 10 8 .0 × 10 Isotopic venography 8 .8 × 10 –1 –1 –1 –1 4 .4 × 10 leVeen shunt patency 4 .4 × 10 110 5 .5 × 10 3 .1 × 10 1 0 0 1 99m 750 3 .9 × 10 1 .4 × 10 Tc MAG3 4 .1 × 10 1 .0 × 10 0 0 0 0 99m 4 .0 × 10 1 .8 × 10 750 Tc MDP 2 .0 × 10 4 .6 × 10 0 1 1 0 99m 1 .3 × 10 1 100 5 .9 × 10 Tc MIBI, rest 1 .7 × 10 9 .2 × 10 0 1 1 0 99m 7 .6 × 10 Tc MIBI, stress 4 .8 × 10 1 .0 × 10 1 100 1 .3 × 10 99m Tc pertechnetate 1 1 1 1 2 .4 × 10 1 .5 × 10 1 .0 × 10 1 .2 × 10 Brain imaging 1 100 0 0 0 0 400 8 .8 × 10 3 .7 × 10 4 .4 × 10 Thyroid imaging 5 .6 × 10 0 0 0 0 200 4 .4 × 10 2 .8 × 10 1 .9 × 10 Salivary gland imaging 2 .2 × 10 0 0 0 0 2 .4 × 10 1 .1 × 10 1 .0 × 10 110 Placental localization 1 .5 × 10 1 1 1 1 2 .4 × 10 1 .4 × 10 1 .1 × 10 1 .0 × 10 1 100 Blood pool imaging 0 1 0 0 1 .2 × 10 550 7 .7 × 10 6 .0 × 10 5 .1 × 10 Cardiovascular shunt detection 1 0 0 0 First pass 1 .2 × 10 5 .1 × 10 550 6 .0 × 10 7 .7 × 10 99m Tc PyP 0 0 0 0 3 .6 × 10 2 .0 × 10 1 .6 × 10 Skeletal imaging 3 .3 × 10 550 0 0 0 0 700 4 .2 × 10 2 .0 × 10 2 .5 × 10 4 .6 × 10 Cardiac imaging 0 0 0 0 99m 930 2 × 10 4 .4 × 10 2 .6 × 10 Tc red blood cell in vitro labelling 6 .3 × 10 3 . 99m Tc red blood cell in vivo labelling 0 0 0 0 2 .4 × 10 1 .8 × 10 1 .5 × 10 3 .5 × 10 Rest 550 0 0 0 0 930 4 .0 × 10 3 .1 × 10 2 .5 × 10 Exercise 6 .0 × 10 0 0 0 0 lower GI bleeding 4 .0 × 10 2 .5 × 10 930 3 .1 × 10 6 .0 × 10 99m Tc sulphur colloid, normal 0 –1 –1 –1 6 .3 × 10 9 .6 × 10 1 .1 × 10 5 .4 × 10 300 liver–spleen imaging –1 –1 0 0 9 .5 × 10 Bone marrow imaging 1 .4 × 10 450 8 .1 × 10 1 .7 × 10 –2 –2 –2 –2 Pulmonary aspiration 4 .2 × 10 7 .4 × 10 3 .6 × 10 20 6 .4 × 10 –1 –1 –1 –1 110 2 .3 × 10 3 .5 × 10 4 .1 × 10 leVeen shunt patency 2 .0 × 10 –1 –1 –1 –1 99m 5 .6 × 10 5 .8 × 10 200 5 .6 × 10 Tc white blood cells 7 .6 × 10 201 Tl chloride 0 0 1 0 8 .7 × 10 7 .0 × 10 4 .0 × 10 1 .5 × 10 150 Planar imaging 1 0 0 0 SPECT imaging 110 5 .2 × 10 1 .1 × 10 3 .0 × 10 6 .4 × 10 0 0 0 0 Myocardial perfusion 2 .6 × 10 3 .2 × 10 1 .5 × 10 55 5 .3 × 10 0 0 0 0 3 .8 × 10 7 .8 × 10 4 .6 × 10 2 .2 × 10 Thyroid imaging 80 133 xe, injection –5 –5 –5 –5 2 .0 × 10 2 .8 × 10 3 .2 × 10 Muscle blood flow 9 .8 × 10 20 –3 –3 –3 –3 1 .1 × 10 5 .4 × 10 1 .5 × 10 1 100 1 .8 × 10 Pulmonary function with imaging

169 ANNEX A: MEDICAL RADIATION EXPOSURES 157 Absorbed dose to the foetal thyroid per unit activity administered to the mother (mGy/Mbq) [w19] Table C16. 124 123 125 131 I I I I Gestational age (months) 3 2 .7 290 230 24 4 260 2 .6 27 240 76 580 5 6 .4 280 210 550 6 .4 6 100 96 160 390 7 4 .1 110 4 .0 8 150 350 120 99 2 .9 9 270 Table C17. Number of items of nuclear medicine equipment and of sites, physicians and examinations Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Number of sites, physicians and examinations Country Number of items of equipment Therapeutic PET or SPECT Planar Rectilinear Static Sites Physicians Diagnostic scanner treatments gamma examinations PET–CT gamma gamma detector scanner camera camera Health-care level I Albania 2 1 1 145 118 212 Argentina 1 145 504 000 Australia 4 53 23 90 170 343 000 6 250 Austria 70 13 Belarus 1 500 48 3 838 9 Belgium 153 570 900 18 1 274 13 2 6 9 Croatia 38 102 15 67 Czech Republic 51 61 3 19 159 Estonia 2 1 1 3 5 2 708 567 Finland 14 4 5 45 45 693 2 026 42 550 10 France 220 904 60 3 831 000 Germany 120 1 6 Greece 155 210 183 239 1 315 20 20 3 106 143 500 3 285 Hungary 1 2 Iceland 4 <10 4 133 102 4 1 570 4 400 56 1 265 1 560 000 Japan 1 252 79 66 Korea, Rep . 205 1 3 latvia 14 714 4 lithuania 4 11 luxembourg 3 5 1 5 7 17 246 49 Malta 0 0 0 0 2 1 2 305 74 2 180 4 60 247 000 5 000 Netherlands New Zealand 20 2 14 8 26 895 1 Norway 15 36 2 0 4 25 44 50 438 971 12 950 Poland 2 24 50 150 114 000 22 60 Romania 51 25 71 650 Russian Federation 2 106 Slovakia 22 14 4 0 20 11 Slovenia 14 3 1 7 30 22 830 1 360

170 158 UNSCEAR 2008 REPORT: VOLUME I Number of items of equipment Number of sites, physicians and examinations Country Sites SPECT Planar Rectilinear Therapeutic Static Diagnostic Physicians PET or gamma gamma examinations scanner treatments PET–CT gamma camera scanner camera detector 181 21 2 176 356 810 000 90 000 Spain 89 30 Sweden 0 30 200 110 000 3 496 70 10 20 57 67 80 97 827 2 306 Switzerland 16 ugoslav Republic of Macedonia 2 2 15 7 937 334 The former y 2 1 200 650 000 United Kingdom 14 500 Venezuela (Bolivarian Republic of) 4 21 Health-care level II Brazil 9 314 95 342 30 Chile China 13 170 840 725 088 74 880 230 100 6 1 4 5 7 500 250 Costa Rica 1 1 2 3 El Salvador 3 977 214 5 Iraq 10 7 1 2 1 130 Trinidad and Tobago 4 Health-care level III 17 15 17 28 Indonesia 310 3 522 Myanmar 3 2 4 5 9 2 796 956 Zimbabwe 2 2 3 1 206 30 Health-care level IV Maldives 0 0 0 0 0 0 0 0 0 Number of items of nuclear medicine equipment and of physicians per million population Table C18. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Number of items of equipment Country Planar gamma Rectilinear PET or PET–CT Number of SPECT gamma Static gamma camera detector scanner physicians camera scanner Health-care level I 0 .31 0 .31 Albania 5 .88 Argentina 0 .03 3 .28 4 .02 7 .11 Australia 0 .20 8 .55 6 .47 2 .81 Austria 21 Belarus 1 .26 0 .87 0 .00 4 .7 Belgium 1 .75 15 Croatia 2 .93 0 .45 1 .35 15 3 .38 4 .96 0 .29 15 Czech Republic 5 .93 1 .46 0 .73 0 .73 Estonia 3 .7 Finland 2 .67 8 .00 0 .76 0 .95 8 .6 France 8 .91 0 .16 Germany 11 0 .73 1 .82 Greece 0 .09 0 .55 1 .82 19 10 .9 Hungary 0 .30 11 6 .80 Iceland 13 .61 3 .40 Japan 12 .32 9 .82 0 .44

171 ANNEX A: MEDICAL RADIATION EXPOSURES 159 Number of items of equipment Country SPECT gamma Planar gamma PET or PET–CT Number of Rectilinear Static gamma scanner detector physicians camera camera scanner 4 .36 1 .68 Korea, Rep . 1 .40 1 .31 latvia 0 .44 1 .15 lithuania 3 .15 11 .1 15 6 .64 2 .21 luxembourg Malta 0 .00 0 .00 0 .00 2 .5 0 .00 5 .00 11 .5 0 .26 3 .8 Netherlands 0 .27 New Zealand 0 .54 2 .1 5 .35 3 .23 7 .76 0 .00 0 .86 9 .5 Norway 0 .43 0 .57 0 .62 1 .56 1 .30 3 .9 0 .05 Poland 2 .29 Romania Russian Federation 14 Slovakia 2 .57 0 .74 0 .00 3 .68 4 .04 6 .99 0 .50 Slovenia 15 1 .50 Spain 4 .10 0 .48 0 .05 8 .1 2 .02 Sweden 7 .90 3 .39 1 .13 3 .39 23 Switzerland 10 .7 2 .14 7 .6 2 .68 ugoslav Republic of Macedonia 0 .98 7 .4 The former y 0 .98 United Kingdom 20 0 .78 0 .15 Venezuela (Bolivarian Rep . of) Health-care level II Brazil 1 .83 0 .05 1 .7 0 .51 Chile 14 0 .67 0 .080 China 0 .01 0 . 0 .18 Costa Rica 0 .23 1 .39 0 .23 1 .2 El Salvador 0 .15 0 .77 0 .31 0 .26 Iraq 0 .37 Trinidad and Tobago 3 .17 0 .79 Health-care level III Indonesia 0 .069 0 .061 0 .11 Myanmar 0 .042 0 .084 0 .19 0 .063 Zimbabwe 0 .17 0 .17 0 .08 Health-care level IV Maldives 0 0 0 0 0 0

172 UNSCEAR 2008 REPORT: VOLUME I 160 4 252 290 255 550 Total 2 901 5 930 5 600 3 750 1 675 2 900 2 793 4 893 4 603 7 223 49 020 43 782 89 432 13 423 35 000 87 000 58 000 30 000 12 238 26 200 101 000 100 631 200 000 1 435 000 I 123 I/ 250 290 103 2 901 5 037 1 740 131 18 137 22 432 Thyroid scan Tc 4 252 152 550 99m 5 930 3 500 1 675 8 386 3 860 2 793 4 893 4 603 7 223 30 883 21 350 89 432 87 000 58 000 30 000 12 238 26 200 100 631 200 000 0 0 4 51 46 51 80 700 958 144 255 403 128 Total 1 757 2 480 5 608 1 344 2 700 1 900 2 847 4 740 54 933 14 000 33 000 20 752 10 000 26 600 294 000 127 000 Xe 144 133 1 200 Rb Lung ventilation 81m Tc 4 51 46 51 80 700 958 255 144 403 128 99m 5 464 1 757 1 280 1 344 2 700 1 900 2 847 4 740 54 933 33 000 20 752 10 000 26 600 Tc) 50 52 81 27 347 261 144 370 414 120 99m Lung 1 300 4 200 8 808 1 094 2 758 4 800 1 344 7 400 4 389 1 687 ( 66 664 34 000 33 000 10 500 29 143 29 377 14 000 26 800 perfusion 64 84 38 120 384 830 481 400 Total 1 555 3 200 4 579 2 518 1 832 6 188 2 822 4 191 12 540 12 890 11 148 22 200 18 500 55 000 99 619 40 000 76 900 101 976 125 000 396 000 212 000 499 000 Tl 450 979 201 2 851 5 500 55 000 40 000 38 000 Cardiovascular Tc 64 84 38 120 830 481 384 400 99m 2 750 1 555 4 579 2 518 1 832 5 209 2 822 10 039 12 540 11 148 16 700 18 500 99 619 38 900 101 976 396 000 Tc) 945 660 523 830 850 99m Bone 9 225 1 530 2 544 5 575 4 251 2 631 2 485 ( 10 607 28 650 24 740 17 375 39 500 13 57 000 17 190 73 000 49 685 11 992 52 000 341 376 122 000 471 000 423 000 954 000 251 874 196 200 Country ugoslav Republic of Macedonia Annual number of various nuclear medicine examinations Slovenia Romania Trinidad and Tobago Sweden Poland Spain Norway Netherlands Switzerland The former y Costa Rica El Salvador New Zealand Malta luxembourg latvia Japan Iceland Hungary France Finland Greece Germany Estonia Czech Republic Croatia Belgium Belarus Austria Australia I II level Health-care Table C19a. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures

173 161 ANNEX A: MEDICAL RADIATION EXPOSURES 15 Total 2 010 1 528 Total I 123 I/ 131 Ga scan Thyroid scan 114 67 2 500 6 016 Other Tc 15 99m 2 010 1 528 9 297 emptying 0 0 17 Total Other gastric Xe 0 0 133 37 239 3 518 2 600 2 500 1 039 1 000 14 546 PET–CT combined Rb Lung ventilation 81m 0 40 31 84 PET 318 1 817 1 300 1 930 2 265 21 000 12 000 10 000 230 000 Tc 17 99m Tc) Liver 9 200 17 10 99m Lung ( perfusion 0 160 240 Total 57 41 60 350 428 252 4 34 Brain 2 600 2 352 5 200 5 200 1 633 5 862 5 000 2 900 21 579 57 000 14 151 199 000 Tl 201 Cardiovascular 87 30 13 229 160 166 266 232 136 423 911 1 000 5 800 5 600 7 800 1 200 3 200 14 327 67 000 11 214 Tc 240 160 99m Gastroenterology Tc) 374 490 150 99m Bone ( 336 307 346 550 Renal 2 900 5 116 6 750 2 558 2 148 5 690 6 437 1 271 16 600 40 929 16 000 65 000 15 000 14 500 16 820 11 000 12 349 20 400 295 000 Country Country New Zealand Poland Romania Norway Slovenia Spain Iceland Netherlands latvia Malta luxembourg Japan Hungary Germany Greece Estonia Finland Czech Republic Croatia Belarus Austria Belgium Australia Annual number of various nuclear medicine examinations Indonesia Myanmar Zimbabwe I III level Health-care level Health-care Table C19b. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures

174 162 UNSCEAR 2008 REPORT: VOLUME I 49 0 .4 683 986 402 702 Total 2 006 5 811 1 637 2 727 2 758 1 284 9 770 10 825 17 489 24 420 Total 650 000 I 123 I/ 20 986 .4 131 Ga scan Thyroid scan 50 67 Other Tc 29 0 .4 683 702 402 99m 2 006 5 811 2 727 2 758 9 770 1 284 10 825 24 420 439 emptying 0 .4 892 259 586 174 270 173 542 461 58 .4 28 .8 Total Other gastric 2 058 3 583 1 221 1 304 2 015 Xe 133 0 PET–CT combined Rb Lung ventilation 81m 0 PET 1 545 7 970 Tc 0 .4 586 892 259 174 271 173 542 461 58 .4 28 .8 99m 1 221 1 304 2 015 Tc) 846 144 Liver 2 .6 916 586 259 276 673 836 380 87 .6 99m Lung 1 052 2 832 1 709 1 313 2 852 ( perfusion 3 .7 798 286 292 274 945 Total 5 571 3 108 1 854 5 000 6 082 3 436 1 179 4 884 3 768 9 672 0 8 58 27 470 240 Brain 7 831 Tl 186 201 5 000 4 884 1 862 Cardiovascular 6 41 52 50 267 180 Tc 2 041 3 .7 798 286 292 992 274 99m 5 571 3 108 1 854 9 672 1 906 Gastroenterology Tc) 620 241 99m Bone 18 52 3 696 8 949 57 11 6 636 6 656 3 274 4 828 6 349 2 703 9 615 ( 12 334 11 627 24 454 25 521 821 170 178 Renal 4 220 2 085 1 000 13 781 ugoslav Republic Country Country Zimbabwe Myanmar Switzerland Sweden Indonesia The former y United Kingdom of Macedonia El Salvador Trinidad and Tobago Costa Rica Number of various diagnostic nuclear medicine examinations per million population luxembourg latvia Iceland Japan Hungary Germany Greece Finland Estonia France Czech Republic Belgium Austria Belarus Croatia Australia I II III I level Health-care level Health-care Table C20a. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures

175 163 ANNEX A: MEDICAL RADIATION EXPOSURES 8 .2 1 .3 448 750 630 446 670 32 .2 Total 1 272 1 278 1 963 2 028 1 374 1 872 1 515 2 238 Total I 123 I/ 471 125 568 233 446 1 006 131 Thyroid scan Ga scan 67 584 Tc Other 8 .2 1 .3 801 448 957 517 946 630 32 .2 99m 1 278 1 747 2 028 1 374 903 emptying 0 .0 0 .0 7 .8 0 .1 0 .0 0 .0 378 256 125 633 115 332 895 18 .2 33 .3 Total 1 245 Other gastric Xe 16 .3 133 160 .8 122 27 .0 PET–CT combined Rb Lung ventilation 81m PET 220 368 22 .6 18 .9 1 221 2 803 Tc 7 .8 0 .1 379 617 256 125 172 18 .2 33 .3 99m 1 245 115 .0 451 Liver Tc) 8 .0 0 .1 0 .8 109 594 649 994 293 182 643 652 15 .6 33 .3 39 .6 99m Lung 1 511 2 174 ( perfusion 570 611 142 311 695 97 .8 43 .8 Brain 1 374 9 .8 1 .0 0 .0 3 .4 325 408 69 .7 88 .8 95 .1 Total 2 403 1 598 1 455 2 312 7 993 1 225 2 976 1 202 Tl 225 322 737 201 81 1 .3 157 205 817 21 .9 Cardiovascular 1 090 Gastroenterology Tc 9 .8 1 .0 3 .4 325 408 69 .7 88 .8 95 .1 99m 1 373 1 133 2 403 2 312 2 238 1 225 1 202 402 123 Renal 1 635 1 343 1 000 1 451 1 199 3 595 1 084 Tc) 80 1 .5 642 476 753 588 523 12 .5 10 .3 99m Bone 4 606 3 745 3 233 7 739 5 294 3 732 7 802 2 075 ( Country Country ugoslav Republic of Macedonia Number of various diagnostic nuclear medicine examinations per million population Belarus Estonia Czech Republic Austria Australia Croatia Belgium Germany Finland Romania Poland Slovenia Norway Sweden Costa Rica Spain New Zealand Netherlands Switzerland The former y Trinidad and Tobago El Salvador Malta Indonesia Zimbabwe Myanmar I I II III level level Health-care Health-care Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Table C20b.

176 164 UNSCEAR 2008 REPORT: VOLUME I Total 10 924 Ga scan 6 67 5 .1 160 Other 50 emptying Other gastric 0 250 758 330 21 .7 67 .5 2 299 PET–CT combined 0 PET 130 94 .2 68 .5 20 .0 41 .2 1 343 174 .4 1 068 95 33 .3 Liver 63 4 .2 1 .2 521 558 103 333 507 884 489 15 .3 67 .5 55 .5 Brain 1 456 1 562 174 .7 0 .2 0 .9 0 .5 109 789 781 301 218 371 131 230 325 43 .9 61 .3 35 .8 25 .9 27 .7 39 .6 11 .9 79 .9 Gastroenterology 3 .3 2 .1 510 936 765 768 685 431 303 135 231 928 566 27 .4 11 .0 Renal 1 318 1 143 1 503 1 023 1 103 1 448 1 026 1 555 Country ugoslav Republic of Macedonia Greece Hungary Iceland Japan latvia luxembourg Malta Norway New Zealand Poland Netherlands El Salvador Slovenia Trinidad and Tobago Romania Indonesia Costa Rica Spain Myanmar Zimbabwe The former y Switzerland United Kingdom Sweden I II III level Health-care

177 ANNEX A: MEDICAL RADIATION EXPOSURES 165 Mean patient effective dose (mSv) for various nuclear medicine diagnostic examinations Table C21a. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Country Cardiovascular Lung Bone Lung ventilation Thyroid scan 99m ( perfusion Tc) 201 99m 81m 133 99m 131 123 99m Tc Rb Total Xe Total Tl Tc Total I/ I Tc 99m Tc) ( Health-care level I 14 .1 2 .3 0 .7 2 .8 5 .6 21 .3 Australia 23 1 .2 2 .4 1 .0 Austria 4 .0 5 Belarus 18 9 38 4 .1 2 .1 1 .8 Belgium 8 .4 4 .7 7 .9 1 .8 0 .84 Croatia Czech Republic 9 .9 2 .3 0 .6 1 .8 4 4 .8 7 .5 1 .2 1 .1 Estonia 1 .2 7 .5 0 .6 1 .4 3 .6 1 .6 Finland 22 .8 7 .4 1 .2 1 .2 0 .7 Germany 3 .5 5 .1 46 .1 4 4 3 .5 Japan 4 .0 5 .1 1 .2 1 .3 2 .6 Malta 3 .1 1 .1 0 .1 3 .2 Netherlands 6 .8 3 .9 4 .7 2 .1 2 .9 2 Norway Poland 4 .9 7 .2 Romania 1 .8 2 .4 32 .4 8 .6 Spain 5 .1 9 .9 2 .4 2 .9 2 .8 Sweden 2 .9 15 1 .2 1 .5 1 .3 8 8 .5 4 .2 5 .8 2 .1 0 .28 0 .068 1 .7 25 Switzerland 20 Health-care level III Myanmar 5 .3 0 .36 3 Table C21b. Mean patient effective dose (mSv) for various nuclear medicine diagnostic examinations Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures 67 Country Renal Gastro- Ga Brain Liver PET PET-CT Health-care Total Other Other gastric emptying enterology scan level combined 2 7 .5 4 .1 Australia 2 .4 0 .9 6 .5 10 .8 10 .8 Austria 0 .02 1 .4 Belarus Belgium 1 .4 7 .5 1 14 .5 Croatia 1 .1 4 .6 3 .5 6 .3 Czech Republic 1 .2 4 .2 6 .9 0 .9 2 .2 Estonia 4 .4 6 6 7 I 1 .5 5 .6 Germany 5 .6 2 .7 4 .5 2 .5 6 .8 Japan 6 .4 5 .7 1 .0 3 .4 6 Malta Netherlands 0 .6 5 .7 7 .4 6 .8 Norway 1 2 6 .4 0 .1 Romania 2 .6 4 .9 2 3 .8 Spain 1 .8 1 5 .8 7 .4 Switzerland 6 .4 6 .0 0 .4 Myanmar 0 .6 1 .1 2 .5 III

178 166 UNSCEAR 2008 REPORT: VOLUME I Number of various therapeutic nuclear medicine examinations Table C22. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Country Total Thyroid Hyper - Health-care Polycythemia Other, Bone Synovitis 90 metastases e.g. YCl thyroidism malignancy vera level 3 400 10 100 1 500 Austria 6 250 1 100 140 363 902 0 6 3 0 1 274 Croatia Czech Republic 285 1 200 0 799 2 804 520 Estonia 345 5 50 5 2 567 160 2 311 556 372 56 46 8 Finland 1 273 Greece 1 130 185 1 315 Hungary 450 2 600 115 120 3 285 Iceland 74 1 102 27 Japan 2 200 2 200 4 400 luxembourg 46 2 1 49 I Malta 40 24 10 74 Netherlands 6 000 275 642 23 9 18 971 Norway 4 10 500 600 200 50 12 950 Poland 1 600 210 1 120 3 6 Slovenia 1 369 30 Spain 55 863 960 3 191 2 790 245 90 000 26 951 104 2 297 291 340 14 10 3 056 Sweden Switzerland 1 500 283 523 2 306 The former y ugoslav Republic of Macedonia 70 334 264 14 500 1 150 710 540 United Kingdom 200 11 500 400 Costa Rica 100 150 250 II El Salvador 128 86 214 132 163 15 310 Indonesia 77 Myanmar III 879 956 Zimbabwe 20 10 0 0 0 0 30

179 ANNEX A: MEDICAL RADIATION EXPOSURES 167 Number of various therapeutic nuclear medicine examinations per million population Table C23. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Synovitis Health-care Hyper- Country Polycythemia Total Bone Other, Thyroid 90 metastases e.g. YCl vera thyroidism malignancy level 134 415 Austria 12 .2 183 17 .1 763 1 .2 Croatia 203 0 .0 1 .4 0 .7 287 81 .8 27 .7 117 0 .0 77 .6 50 .5 272 Czech Republic Estonia 117 252 3 .6 36 .5 3 .6 1 .5 414 Finland 242 70 .9 10 .7 8 .8 1 .5 440 106 103 120 Greece 16 .8 45 .1 261 11 .5 Hungary 329 12 .0 Iceland 91 .8 252 3 .4 347 Japan 17 .3 17 .3 34 .5 luxembourg 4 .4 2 .2 108 102 I 100 25 .0 185 Malta 60 .0 384 Netherlands Norway 138 0 .9 5 .0 1 .9 3 .9 209 59 .3 Poland 41 .5 272 15 .6 5 .2 1 .3 336 Slovenia 105 1 .5 3 .0 15 .0 683 559 611 1 266 72 .3 63 .3 5 .6 2 040 Spain 21 .8 11 .7 32 .8 38 .4 1 .6 1 .1 345 Sweden 259 201 37 .9 70 .1 309 Switzerland The former y ugoslav Republic of Macedonia 34 .4 164 130 19 .3 244 11 .9 9 .1 6 .7 3 .4 United Kingdom 193 23 .1 34 .7 57 .8 Costa Rica II El Salvador 19 .7 13 .2 32 .9 1 .3 Indonesia 0 .5 0 .7 0 .1 III Myanmar 18 .6 20 .2 1 .6 1 .7 0 .8 Zimbabwe 0 .0 0 .0 2 .5 0 .0 Table C24. Reported mean patient dose (mSv) for various nuclear medicine therapeutic examinations Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Health-care level Country Thyroid Other, Hyperthyroidism Polycythemia vera Bone metastases Synovitis 90 malignancy YCl e.g. Austria 380 435 Estonia 400 I Spain 9 356 7 511 615 130 2 220 III Myanmar 390 000 98 000

180 168 UNSCEAR 2008 REPORT: VOLUME I 5 .6 0 .0 508 7 418 1 633 1 104 5 135 2 622 1 544 1 259 5 612 1 411 2 753 World 30 741 17 861 30 937 91 892 0 .031 4 202 437 82 0 .0 0 .0 8 .5 0 .0 1 .3 0 .0 0 .4 1 .3 0 .2 0 .0 0 .0 0 .0 0 .0 0 .0 43 .7 15 .8 10 .9 0 .000 047 Levels III–IV 0 .0 0 .0 0 .0 0 .0 0 .0 0 .0 0 .0 0 .0 150 136 210 118 375 47 .9 71 .7 1 461 Level II 16 000 13 632 0 .005 1 Annual collective dose (man Sv) 5 .6 0 .0 508 1 104 1 632 7 374 0 .121 4 984 2 403 1 407 2 681 1 363 1 140 5 612 Level I 91 892 29 263 17 304 17 476 186 000 5 1 .0 8 .0 3 .8 7 .3 7 .9 0 .0 4 .10 6 .09 1 .89 3 .97 30 . 3 .52 4 .74 0 .07 2 .66 6 .42 40 .7 World 6 .09 1 .89 4 .10 7 .26 7 .97 1 .00 0 .07 2 .66 6 .42 3 .97 40 .7 30 .5 4 .74 7 .88 3 .75 3 .52 Levels III–IV 6 .09 4 .10 1 .89 3 .52 0 .07 7 .97 3 .97 1 .00 7 .88 3 .75 4 .74 6 .42 40 .7 2 .66 7 .26 30 .5 Level II Effective dose per examination (mSv) 6 .09 4 .10 1 .89 3 .75 30 .5 2 .66 1 .00 4 .74 7 .97 3 .97 7 .26 0 .07 3 .52 7 .88 40 .7 6 .42 Level I 0 0 –1 –2 –3 –2 –1 –2 –1 –2 –1 –1 –2 –1 –2 –3 –1 –2 –1 –3 –1 –1 –3 World 1 .6 × 10 3 .5 × 10 1 .3 × 10 5 .0 × 10 6 .9 × 10 8 .3 × 10 2 .1 × 10 3 .9 × 10 1 .9 × 10 1 .2 × 10 1 .6 × 10 5 .4 × 10 5 .5 × 10 2 .0 × 10 3 .6 × 10 8 .0 × 10 9 .9 × 10 6 .9 × 10 2 .1 × 10 3 .6 × 10 3 .7 × 10 4 .8 × 10 5 .07 × 10 –3 –4 –4 –2 –2 –3 –5 –3 –3 –3 –4 Levels III–IV 3 .45 × 10 4 .48 × 10 2 .17 × 10 3 .25 × 10 2 .15 × 10 1 .05 × 10 1 .37 × 10 3 .45 × 10 3 .33 × 10 6 .93 × 10 1 .17 × 10 0 –1 –2 –2 –2 –2 –1 –2 –2 –2 –1 –2 –2 Level II 1 .09 × 10 2 .47 × 10 2 .04 × 10 2 .96 × 10 3 .08 × 10 1 .12 × 10 4 .70 × 10 1 .68 × 10 4 .46 × 10 3 .33 × 10 2 .18 × 10 1 .80 × 10 2 .11 × 10 0 0 0 0 0 –1 –3 –1 –1 –1 –1 –1 –1 –1 –2 –1 –2 –1 –1 –2 –1 –2 1 Number of examinations per 1 000 population Level I 61 × 10 1 .9 × 10 2 .26 × 10 1 .97 × 10 2 .19 × 10 6 .17 × 10 1 .27 × 10 5 .08 × 10 1 .09 × 10 7 .61 × 10 8 .23 × 10 3 .43 × 10 2 .87 × 10 8 .74 × 10 1 . 2 .85 × 10 2 .88 × 10 2 .88 × 10 5 .67 × 10 8 .19 × 10 2 .07 × 10 5 .12 × 10 6 .65 × 10 1 .52 × 10 I Rb Tc xe Tc Tc Tl 123 Frequency, population-weighted average effective dose and collective dose for nuclear medicine diagnostic examinations (1997–2007) 81m 133 99m Tc I/ 99m 201 99m 131 99m yCl 90 . Tc Examination Ga scan 67 99m Thyroid scan Other gastric emptying Thyroid malignancy PET liver Gastroenterology Polycythemia vera Hyperthyroidism Total diagnostic Synovitis PET Other, e .g Bone metastases lung ventilation lung ventilation Brain PET–CT combined Cardiovascular Average effective dose per caput from diagnostic nuclear medicine examinations (mSv) Cardiovascular lung perfusion Thyroid scan Other Renal lung ventilation Bone Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Table C25.

181 AppENdIx d LEVELS ANd TRENdS IN ThE USE OF RAdIATION ThERApy : INTROdUCTION I. Radiation therapy, often referred to as “radiotherapy”, D1. in which radioactive sources are placed in a body cavity or placed directly in the tissue. For some tumours, such as can- is the collection of treatment options available in the medi- cers of the uterine cervix and the prostate, teletherapy and cal specialty known as clinical radiation oncology. Nowa- brachytherapy often are used sequentially or even concomi- days radiation therapy is used for the treatment of many types of cancer [C18, P14, U3, U4]. The goal of radiation tantly, as is described in more detail below. Unsealed sources therapy is to achieve cytotoxic levels of irradiation to a of radiation are sometimes used for treatment of metastatic well-defined target volume (the volume of tissue that must or widespread disease. Such therapy with unsealed sources be treated to assure that the tumour receives the prescribed (radiopharmaceuticals) or with monoclonal antibodies (radi- dose) of the patient, while as far as possible avoiding the oimmunotherapy) is discussed in appendix C. Beams of radiation for therapeutic purposes are produced by machines exposure of surrounding healthy tissues. Treatments gen- that fall into four general types: X-ray machines are quite erally involve multiple exposures (fractions) spaced over a period of time for maximum therapeutic effect. Radiation commonly used for therapy, and produce beams of radia- tion generated between about 50 and 300 therapy is an important treatment modality for malignant kVp. Cobalt tel- 60 etherapy units contain large sources of radioactive disease, and is most often delivered in combination with Co, surgery or chemotherapy, or both [C18, M28, S10, S11, with a mechanism that moves the source from a shielded W22]. The utilization of radiation treatment in oncology location to a position that permits the gamma rays to pass varies significantly among the different sites of disease and through an opening of adjustable size, called a collimator. also between countries. In the United States, for example, In one type of cobalt unit, multiple sources are arranged in 37% of women diagnosed with early stage breast cancer a spherical shield, into which a patient’s head is positioned in 2002 received radiation treatment [N7]. In contrast, the for treatment. Caesium-137 sources have been used in the radiation therapy utilization rate for breast cancer patients in past, but these have largely been replaced by more modern the Russian Federation in 1995 was 2% [U3]. Less commonly, machines. Megavoltage X-rays can be produced by electron radiation is also used in the treatment of benign disease [O7]. linear accelerators, which are now commonly used through- In 2000, external beam radiation therapy utilization varied out the developed world and are becoming more widely used considerably among countries. In level I countries, Hungary in developing countries. A small number of radiation therapy and the Czech Republic reported 3.5 or more patients treated centres operate cyclotrons or synchrotrons that accelerate per 1,000 population, while the United States and the United beams of protons or heavier charged particles that are used Kingdom reported approximately 2.0 to 2.5 patients per for treatment. At present, 31 centres operate such machines, 1,000 population, and Ecuador, Kuwait and the United Arab most of them in Europe, Japan and the United States. Another Emirates reported fewer than 0.3 patient per 1,000 popula- six are under construction and at least eight more have been tion. In level II countries, 0.7 patient per 1,000 population proposed [F14, P23]. received radiation therapy, and in level III countries, only 0.5 patient per 1,000 population received treatment [U3]. The clinical goal in radiation therapy is either the eradication of Radiation therapy involves the use of intense radiation D3. cancer (curative treatment) or the relief of symptoms associ- beams and high-activity sources. Treatments are often com- ated with the disease (palliative treatment) [C18]. In level I plex, requiring the delivery of conformally shaped beams and II countries, the majority of treatments are considered from multiple directions, or the use of sophisticated beam curative. In level III and IV countries, where tumours are modifiers. Properly trained staff are required, and they must less likely to be diagnosed early and where equipment and follow carefully developed procedures. The equipment must techniques are generally less advanced than in level I and II be properly maintained. Failure to adhere to recommended countries, a larger proportion of treatments are palliative. quality assurance procedures and the use of inadequately prepared staff can contribute to a significant potential for D2. Radiation therapy is delivered by one of two meth- accidents. Such events have resulted in serious consequences ods: teletherapy, in which a beam of radiation is directed to for the health of both patients and staff; such incidents are the target tissue from outside the body; or brachytherapy, discussed further in section VII of this appendix. 169

182 170 UNSCEAR 2008 REPORT: VOLUME I II. TEChNIqUES D4. as megavoltage radiation. The activity of the source must be The objectives of radiation protection in radiation cm. This means that high enough to allow an SSD of 80–100 therapy are to minimize the radiation dose to the patient out- isocentric treatments are possible. As the source size is rela- side the target volume, and to maintain the doses to staff and members of the public as low as reasonably achievable [P14]. tively large, there is a wide penumbra associated with these radiation sources [H17]. Satellite collimators, or “penum- Radiation therapy is becoming increasingly sophisticated in bra trimmers”, were introduced to reduce the width of the the pursuit of these objectives. Achieving the first objective requires that the extent of the tumour be established pre- penumbra, but in comparison with linear accelerator beams, the penumbra of a cobalt beam is still large [H17, J10]. cisely and that nearby sensitive structures be identified. This requires the use of state-of-the-art diagnostic techniques to D8. Megavoltage radiation therapy may also be delivered distinguish tissues involved with tumours from healthy tis- using medical accelerators, usually electron linear accelera- sues. The use of CT and MRI for radiation therapy treatment tors (linacs). These machines use radiofrequency radiation to planning is becoming more common. Treatment planning MeV. accelerate electrons to energies of between 4 and 25 involves the use of a computer to calculate the radiation dose The accelerated narrow electron beam can be passed through distribution within the body. With advances in computing a scattering foil to produce a broad uniform electron beam and the availability of inexpensive fast computer processors, that is directed towards the patient and is defined by a cone it has become practical to plan radiation therapy treatments cm of the or applicator that typically extends to within 5 in three dimensions (3-D), thereby more closely matching or patient surface. Electrons lose energy at the rate of about to the tumour. Optimized “conforming” the treated volume 2 MeV/cm in tissue and are useful for treating superficial tis- treatments may require multiple beam angles, different beam sues quite uniformly while sparing deeper-seated structures. weights, complex field shapes, wedge filters or other modi- When using sterile intraoperative techniques, electrons can fiers, or the use of intensity-modulated techniques. The sec- be used to treat a tumour or the tumour bed once it has been ond goal is addressed through improvements in the design exposed through surgery. and operation of equipment and facilities to provide greater protection for staff and members of the public. D9. Alternatively, the accelerated electron beam can be steered into a metal target, producing bremsstrahlung and External beam radiation therapy (also called tele- D5. characteristic X-rays whose energies fall in a spectrum with a therapy) can be delivered with several classes of treatment maximum energy equal to the energy of the accelerated elec- (a) kilovoltage X-ray machines. These can be grouped as: trons. Similar to kilovoltage X-rays, accelerator-produced radionuclide teletherapy units, mega- (b) generators, (c) megavoltage photon beams are commonly described by a voltage X-ray machines such as linear accelerators, and potential corresponding to the maximum electron energy, proton and heavy particle accelerators. (d) MV to 25 e.g. 4 MV. A collimator consisting of several parts limits and shapes the X-ray beam. A primary collimator is placed near the target and limits the beam to some maximum Kilovoltage X-ray machines can be of three main D6. cm diameter at the normal treatment dis- size, generally 56 types: (1) Contact therapy machines, though rare today, tance. A secondary collimator consists of two pairs of heavy produce X-rays at energies of 25 to 40 kVp. (2) Superficial moveable jaws that can shape the beam to any rectangle up kVp, therapy machines produce X-rays in the range 40–120 to the maximum size. Some accelerators are equipped with with a typical source–skin distance (SSD) of 30 cm or less, multileaf collimators (MLCs) that can produce an irregular- and are used to treat small epithelial lesions. The beam qual- shaped beam. The MLC either replaces one pair of collima- ity of superficial X-ray therapy is usually specified in terms of tor jaws or is mounted below the jaws. High-energy photon mm aluminium its half-value layer and lies in the range 0.5–8 beams are more penetrating than superficial or orthovoltage [H17, I21]. Lesions of the skin and of the oral, vaginal or rec- X-rays and have a skin-sparing effect. Consequently, these tal mucosa are sometimes treated with this technique [L23]. beams are very useful for treating deep-seated tumours, as (3) Orthovoltage therapy machines generate X-ray beams in well as shallower structures such as the breast, for which the range 150–300 kVp. Orthovoltage units have been used beams can be directed tangentially. to treat skin lesions and bone metastases. The beam size is limited by either an applicator or a diaphragm. SSDs in the Worldwide in 1991–1996, approximately equal D10. cm are used. Orthovoltage therapy units have range 30–60 numbers of radiation therapy patients were treated using half-value layers in the range 0.2–5 mm copper [I21]. X-ray machines, radionuclide units and linear accelera- tors (table B1 in appendix B) [U3]. Insufficient data were Many centres worldwide use radiation therapy units D7. received in 1997–2007 to estimate numbers of patients 60 Co). containing a high-activity source of radioactive cobalt ( treated with each type of treatment device. However, the 60 60 Ni, Co decays with a half-life of 5.26 years to The isotope relative availability of linear accelerators worldwide was MeV and 1.33 producing two gamma rays of 1.17 MeV. about 1.6 machines per million population. X-ray machines Consequently, the radiation from this source is referred to and cobalt units were each found at a frequency of 0.4 per

183 171 ANNEX A: MEDICAL RADIATION EXPOSURES million population. In level I countries, however, the avail- The characteristics of a radiation beam are often D11. ability of treatment equipment was considerably greater, and described through the use of isodose curves. These curves represent a map of the radiation dose distribution, in which linear accelerators were reported at a frequency of 5.4 per each curve corresponds to the locus of points at which the D1). The total number of treatment million population (table machines also varied from one health-care level to another Gy, or a relative value, dose is a selected value, such as 20 D2). The numbers of patients treated in different coun- (table such as 70% of the dose at a reference point. Patient dose tries varied in relation to the availability of treatment equip- distributions are generally displayed by superimposing iso- I countries, the number of courses of treatment ment. In level dose curves on a CT image or other representation of the patient. Several examples of isodose distributions are shown given was 2.4 per 1,000 population, while smaller numbers were reported by level II and III countries (table D3). in figures D-I, D-II, D-III and D-IV. Figure d-I. Representative isodose distributions: A 3-dimensional conformal treatment plan for the prostate, showing significant dose to the rectum Isodose levels (in Gy) are shown by solid lines, while structures are contoured in dashed lines . Red dashed line – prostate; purple dashed line – prostate PTV (see paragraphs D28-D31); pink dashed line – rectum 50 60 70 76

184 172 UNSCEAR 2008 REPORT: VOLUME I Representative isodose distributions: Intensity-modulated radiation therapy plan for a tumour, Figure d-II. prostate showing superior conformation of the 50 Gy isodose line to the planning target volume levels (in Isodose lines . Blue gray) are shown by solid lines, while structures are contoured in dashed dashed line – prostate; dark red dashed line – prostate PTV (see paragraphs D28-D31); yellow dashed line – bladder; pink dashed line – rectum 50 45 40 30 d-III. Representative isodose distributions: Treatment plan showing the use of stereotactic body radiation therapy for Figure a lung tumour Isodose levels (in gray) are shown by solid lines, while structures are contoured in dashed lines . Red dashed line – lung tumour CTV (see paragraphs D28-D31); purple dashed line – PTV; yellow dashed line – spinal cord 20 50 70 76

185 ANNEX A: MEDICAL RADIATION EXPOSURES 173 Figure d-IV. Representative isodose distributions: dose– 2-cm-long field, which can be blocked by an MLC consist- volume histograms for a clinical target volume (CTV) and an cm wide cm width. Regions 1 ing of 40 pairs of leaves of 1 organ at risk (OAR) cm long can be effectively switched on and off, as the by 2 gantry is rotated continuously, delivering an IMRT treatment to a 2-cm-thick transverse section of the patient. Following 100 each gantry arc, the patient support couch must be moved 90 precisely 2 cm and the process repeated as necessary to treat CTV helical tomothe- the entire length of the target volume; (d) 80 R OA rapy is a similar process, but rather than delivering an IMRT 70 treatment to a single transverse slice of the patient, the patient couch is moved continuously as the gantry rotates, in exactly 60 the same manner that helical CT is performed. A dedicated treatment machine has been developed for this type of treat- 50 (e) intensity-modulated arc therapy (IMAT) is ment [M5]; 40 VOLUME (%) delivered by adjusting the MLC to a specific shape, then rotating the accelerator gantry through a range of angles with 30 the beam on. The arc is then repeated, but with the MLC set 20 to a different shape, to increase the dose only to selected regions of the target volume. This process may be repeated 10 several times [Y9]. 0 0 70 20 60 10 50 40 30 Radiation therapy is generally delivered to specific, D14. well-defined volumes of tissue, although large-field tech- DOSE (Gy) niques are also used: whole-body photon beam irradiation in conjunction with bone marrow transplantation for the treat- ment of leukaemia, hemibody irradiation for the palliation of D12. The fluence distribution of a teletherapy beam can painful bone metastases, mantle irradiation in the treatment be adjusted by several means. A simple method of modu- of lymphomas, and irradiation of the entire central nervous lating the beam is through the use of a metal wedge filter, system in the treatment of medulloblastoma [S28, W22]. which differentially attenuates the beam, producing a slop- Total-skin electron therapy is used for the treatment of wide- ing intensity profile. The angle through which the isodose spread skin diseases such as cutaneous T-cell lymphoma, or curves are tilted is termed the wedge angle. Modern treat- Kaposi’s sarcoma [B27]. ment machines use programmable wedges, meaning that one jaw is moved across the field while the beam is on, to differ- Stereotactic radiosurgery (SRS) refers to the use D15. entially modulate the beam and produce wedge-shaped dose of narrow, well-defined beams of ionizing radiation for the distributions. precise ablation of a well-defined intracranial or extracranial target volume at the focus of a stereotactic guiding device, MLCs can be used to shape the field to the projec- D13. without significant damage to adjacent (healthy) tissues. tion of the target volume and to protect normal tissue. This SRS is typically given through a single fraction of radiation, obviates the need for heavy metal alloy shielding blocks and with the intention of obliterating the target [C4, F13, G5]. can result in reduced set-up time for treatment. MLCs also can be programmed to modulate the intensity of the treat- A related treatment called stereotactic radiation D16. ment beam to create highly conformal dose distributions. therapy (SRT) refers to the use of stereotactic techniques for This procedure is known as intensity-modulated radiation multifraction radiation therapy. When delivered to extracra- therapy (IMRT) [B26]. IMRT can be delivered in several nial targets, this technique is often referred to as stereotac- ways: (a) in step-and-shoot IMRT, at each of several gantry tic body radiation therapy (SBRT) [K9]. An example of an angles the MLC is programmed to several different shapes. D-III. SBRT treatment to a lung tumour is shown in figure A selected number of monitor units is delivered through Since the introduction of the technique in 1951, clinical stud- each MLC setting, creating a non-uniform intensity distribu- ies have been undertaken with high-energy photons from lin- tion. When combined with the non-uniform intensity distri- 60 ear accelerators [F13, G12, K3, K9] and Co sources, with butions produced at the other gantry angles, a dose distribu- protons and with heavy particles. tion is produced that conforms to the target volume; (b) in sliding window IMRT, a non-uniform intensity distribution D17. Brachytherapy involves the placement of an encap- is created by moving pairs of leaves across the field while sulated source or a group of such sources on or in the patient the beam is on. The width of the field created by each pair by application to a surface, within a cavity or directly into the of leaves is changed, resulting in an increased or decreased tissue to deliver gamma or beta radiation at a distance of up to dose at each location. Again, this is done for each of several a few centimetres [D22]. Radium-226 sources, on the basis serial tomotherapy is delivered through (c) gantry angles; of which many brachytherapy techniques were developed, the use of a “binary MLC” [C3]. This device, first marketed have a number of undesirable characteristics, including the in the 1990s as the Peacock system, uses a 40-cm-wide by

186 174 UNSCEAR 2008 REPORT: VOLUME I risk of contamination through leakage or breaking, and have the United States Food and Drug Administration reported been replaced almost completely by a variety of artificial that the small increased risk of stent thrombosis with drug- 137 192 eluting stents was not associated with an increased risk of Ir and specially designed Cs, radionuclides, principally 60 death or myocardial infarction compared bare metal stents small Co sources [T4]. [F8]. Consequently, intravascular brachytherapy has been abandoned at most centres. A novel electronic brachytherapy source has been D18. described recently [R16]. The device consists of a miniature mm X-ray tube having outer dimensions of approximately 3 D23. Brachytherapy can be used alone but is more often used in combination with external beam therapy [W22]. kVp and is by 3 mm. The tube operates at either 40 or 50 For example, in the management of cancer of the cervix, designed to emit X-rays essentially isotropically. Prelimi- nary data indicate that the device can be used quite success- teletherapy is used to treat the entire target volume, includ- 192 ing the parametrial and pelvic lymph nodes. Intracavitary Ir brachytherapy source [R27]. Dose fully to simulate an brachytherapy is used to deliver an additional dose to the rates of as much as 1 Gy/min at 1 cm can be delivered. primary tumour volume, thus sparing normal tissues and organs at risk from doses above tolerance levels. Tumours of the tongue and breast are often given preliminary treat- D19. When brachytherapy is practical, it offers several ment by teletherapy, with brachytherapy providing a boost advantages over other types of radiation therapy: the radia- in the dose to the primary tumour. Prostate tumours are often tion source can be placed within or adjacent to the target treated with external beam therapy followed by a brachythe- tissue; the radiation usually does not have to traverse healthy rapy boost, although it is also common to use brachytherapy tissue to reach the target tissue; and in the case of low-dose- rate (LDR) brachytherapy, the low dose rate and continuous alone (monotherapy). irradiation offer radiobiological advantages. 137 Conventional LDR brachytherapy using Cs D24. D20. Permanent interstitial brachytherapy implants are sources involves dose rates at the prescribed point or surface in the range 0.4–2.0 generally used for deep-seated tumours and today are princi- Gy/h, with most treatments given over pally used for treatment of the prostate [S29]. The most com- a period of several days in one fraction, or more often two; 103 137 125 Pd, either as individual I and higher-activity monly used sources are Cs sources can provide medium dose rates miniature sources (seeds) or loaded in dissolvable sutures. (MDR) of up to 12 Gy/h. High-dose-rate (HDR) brachythe- 192 Temporary interstitial implants also are used for superficial Ir sources to provide even higher dose rates, rapy utilizes Gy/min, with treatment times reduced to min- and easily accessible tumours such as those of the breast, generally 2–5 utes or less and the treatment generally delivered through head and neck, and base of the tongue. several fractions [P10, T11]. Sources having a nominal GBq (10 Ci) are generally used, and are activity of 3,700 The intracavitary implant technique consists of the driven through coupling tubes into the implanted applicator D21. by a machine called a remote afterloader [S29]. The source placement of an applicator containing radioactive sources is programmed to stop (“dwell”) at selected locations within into a natural body cavity to irradiate an adjacent tumour. the applicator, most often in a pattern that simulates the It is routinely used in the treatment of carcinomas of the source placement used in conventional LDR brachytherapy. cervix, vagina and endometrium. Intraluminal implants, 60 using a special applicator or catheter, are used in the treat- In some countries, sources of Co are increasingly being ment of carcinomas of the oesophagus, bronchus and bile used for HDR brachytherapy; worldwide in 2006, the use ducts [S30]. Ophthalmic applicators are used for treating of 103 such devices was reported, with most in the Russian Federation and China. Pulsed-dose-rate (PDR) brachythe- malignant melanoma of the uvea and other malignant and benign tumours of the eye [H26]; medium-sized and large rapy has recently become popular and allows pulses of HDR 103 125 I plaques, and radiation to be delivered over a time period comparable to tumours are usually treated with Pd or 106 small tumours with beta ray applicators incorporating that used for LDR brachytherapy. This method uses a high- Ru 90 Ci) and a remote Sr. GBq or 1 or activity source (typically 370 afterloading machine to deliver the radiation in fractions of a few minutes; these are repeated at intervals of 1 or 1.5 h. Remote afterloading offers significant radiation protection D22. A number of multicentre studies were completed to benefits, in that the source is returned to the shielded storage investigate the efficacy of endovascular brachytherapy treat- container periodically to allow other persons to be present, ment for the inhibition of restenosis after angioplasty [W21]. for example to give the patinet medical attention. The source These have shown that, while brachytherapy is successful can be retracted at any time in the event of an emergency. in delaying restenosis, newer drug-eluting stents provide equivalent results. Initial concerns about increases in the rate From a radiological protection point of view, remote after- of stent thrombosis leading to increases in the risk of death loading is essential, for HDR, PDR and MDR techniques. and myocardial infarction following the use of drug-eluting Other developments in radiation therapy are discussed in stents have recently been retracted. In a revised statement, section VI.A in relation to trends in the practice.

187 175 ANNEX A: MEDICAL RADIATION EXPOSURES III. SUMMARy FROM ThE UNSCEAR 2000 REpORT estimated from the scarce national survey data available, D25. Radiation therapy involves the delivery to patients supplemented using a global model, although the uncertain- of high absorbed doses to target volumes for the treatment of malignant or benign conditions. Resources for radiation ties in this approach are likely to be significant. The world annual total number of treatments for 1991–1996 was esti- therapy were distributed unevenly around the world, with significant variations in radiation therapy practice both mated to be about 5.1 million, with teletherapy accounting among and often within individual countries. Many can- for over 90% of the treatments. The corresponding average annual frequency of 0.9 treatment per 1,000 population was cer patients had little or no access to radiation therapy ser - vices. Global annual numbers of complete treatments by the similar to the level quoted for 1985–1990 [U6] on the basis of an estimated total number of 4.0 million treatments. two main modalities, teletherapy and brachytherapy, were IV. dOSIMETRIC AppROAChES N19, P5, U17]. However, the publication of results of clini- D26. Successful treatment of cancer with radiation is dependent upon the accurate and consistent delivery of high cal trials, both from single-institution practice and from doses of radiation to specified volumes of the patient, while co operative cancer study groups, has helped to bring a cer- minimizing the irradiation of healthy tissues. Detailed assess- tain degree of conformity to treatment practice among cancer centres. [I16, K19, M23, S32, V11]. ment of the dose for individual patients is critical to this aim, and techniques for dosimetry and treatment planning are well-documented; see, for example, publications from the D28. The ICRU has promoted a uniform approach to ICRU [I9, I10, I13, I14, I15], the IAEA [I12, I42, I43, I44, the specification and reporting of dose distributions. ICRU I45] and others [A12, B28, B29], as well as various codes of Reports 50 and 62 [I9, I31] have updated Report 29 [I10] practice (e.g. [A2, I45, K10, M29, N18, N21, R17]). Special and introduce several clinical volumes: gross tumour volume (GTV); clinical target volume (CTV); planning target vol- treatment and dosimetry techniques are required for preg- nant patients to minimize potential risks to the foetus from ume (PTV); organ at risk (OAR); planning organ-at-risk vol- ume (PRV); treated volume (TV); and irradiated volume (IV) exposure in utero [A3, M20, M21, S31]. Approximately [I9, I10, I31]. The failure to accurately define the tumour, its 4,000 pregnant patients required treatment for malignancy spread into adjacent tissue and its movement relative to land- in the United States in 1995. The radiofrequency radiation marks during a course of treatment can result in inadequate from radiation therapy treatment machines can cause per- dose being delivered to part or all of the tumour. The con- manently implanted cardiac pacemakers to malfunction, and special techniques have been recommended for the planning sequence of such inadequate treatment can be a recurrence of the tumour. Consequently, the systematic identification of and administration of treatment to such patients [L21, M30]. the volumes described above can aid in achieving the goal of Quality assurance measures and dosimetry intercomparisons designing and delivering a successful treatment. are widely recommended to ensure continuing performance to accepted standards [D14, D21, I7, K17, K18, N12, N19, D29. W9]. The GTV defines the extent of a demonstrable tumour. This is determined from clinical examination, surgi- The delivery of clinical radiation therapy requires cal resection or findings from imaging. D27. assessment of the extent of the disease (staging); identifica- tion of the appropriate treatment modality; specification of D30. The CTV extends beyond the GTV by a certain mar- a prescription defining the treatment volume (encompass- gin to take into account the possible microscopic spread of the tumour [S9]. The CTV also can be defined to include ing the tumour volume and tissues at risk for microscopic spread), intended tumour doses, consideration of critical local lymph nodes, and sometimes encompasses several GTVs. For gynaecological brachytherapy, MRI is most use- normal tissues, number of treatment fractions, dose per frac- ful to demonstrate the anatomy, although its use is largely tion, frequency of treatment and overall treatment period; I countries. A recent publica- limited to a few centres in level preparation of a treatment plan to provide an optimal dose tion suggests that the tumour identified at the time of diagno- distribution; and delivery of treatment and follow-up. Radio- logical imaging, frequently involving CT but also including sis be termed the intermediate-risk CTV and be prescribed a moderate dose, say 15 Gy, following 45 radiography, MRI and PET when appropriate, is widely used Gy of external throughout this process; applications include the assessment beam radiation. The volume at risk visible on MRI at the of extent of disease, preparation of the treatment plan, veri- time of brachytherapy plus a margin is considered the high- fying the location of brachytherapy sources and confirming risk CTV and is prescribed a higher dose, typically 35 Gy, correct patient set-up for external beam therapy. Because following external beam radiation [P3]. radiation therapy practice is largely empirical, significant With very few exceptions (such as possibly tumours D31. variations are apparent in the dose/time schedules used in the treatment of specific clinical problems [D11, D19, G17, of the brain), there will inevitably be movement of the CTV

188 176 UNSCEAR 2008 REPORT: VOLUME I In many treatment centres today, radiation ther- D36. relative to external landmarks during a course of treatment involving a number of fractions. To accommodate this inter- apy considers the location and shape of the CTV in three fraction motion, as well as the uncertainty in reproducing dimensions, and the treatment planning process attempts to conform the dose distribution to the PTV and to avoid the patient position from one fraction to the next, the ICRU PRVs. Such 3-D conformal radiation therapy (3-D CRT) specifies an additional margin to the CTV to create the PTV. custom-designed beam blocking or MLCs to shape the uses The PTV is equivalent to the previous concept of target vol- field to the projection of the PTV, and allows the display ume [I10, S9]. Dose planning, specification and reporting are based upon the PTV, although reporting of doses to the of patient anatomy and dose distributions using 3-D tech- niques. Modern treatment planning systems also perform CTV is appropriate under some circumstances [S9]. dose calculations that consider the effects of tissue densities in three dimensions. Healthy tissues that are sensitive to radiation are D32. defined as organs at risk (OAR) and are spared as much D37. The 3-D CRT technique is capable of shaping dose as possible during radiation therapy. To accommodate any distributions only to relatively simple convex shapes (fig- movement of an OAR during a course of therapy and to take ure D-I). In a number of common treatment situations, the into account the uncertainty of delineating an OAR, a margin can be drawn around the OAR to produce a planning organ- PTV exhibits concavities or invaginations produced by the presence or pressure of another structure. A common exam- at-risk volume (PRV), which is analogous to the PTV drawn around a CTV. ple is the prostate, which frequently partially wraps around the rectum. Tumours of the posterior nasopharynx can wrap partly around the spinal cord. It is possible with IMRT to D33. The doses to healthy tissues from radiation therapy generate dose distributions that conform to complex and can be estimated from isodose distributions such as those convoluted PTVs, with the primary goal of minimizing the shown in figures D-I, D-II, D-III and D-IV. For example, dose to nearby PRVs, to allow the delivery of high doses to figure D-I indicates that the dose to the rectum from this the PTV [B26]. The IMRT technique can achieve uniform Gy to more prostate treatment plan varies from below 50 dose delivery to the PTV, but generally uniformity of dose Gy. However, it is clear that the distribution shown than 76 is considered of secondary importance to the sparing of in figure D-I represents the dose only in a single transverse D-II provides an example of the use of organs at risk. Figure plane. To understand the dose to the entire rectal volume (or IMRT. that of another organ), multiple transverse planes must be examined. Alternatively, a dose–volume histogram (DVH) D38. metry A principal objective of radiation therapy dosi can be valuable to indicate the dose to an organ. A DVH is to measure or predict the absorbed dose in various tis- is a graph of the fractional volume of an organ or structure sues [H17, I15]. Radiation therapy dosimetry is typically receiving a selected dose or greater. Figure D-IV shows typi- conducted in two stages. cal DVHs for a target organ (CTV) and an OAR. The figure Gy, shows that about 95% of the CTV is receiving at least 60 while 30% of the OAR is receiving about 37 Gy or more. D39. Firstly, the radiation beam from the treatment unit must be fully characterized in a manner that allows a treat- ment planning computer to reproduce the dose distribu- D34. Brachytherapy treatments for carcinoma of the uter- ine cervix have evolved little from the early Stockholm and tion under a range of clinical circumstances. This is done Paris techniques developed in the 1920s and 1930s [H23, through measurements made in a uniform tissue-simulating P10, R11]. For example, the Manchester system was evolved medium. Water is most often used, as it is very nearly tissue- equivalent and is easily obtained. It has the further impor- from the Paris technique and is still used in a number of cen- tant advantage of allowing an ionization chamber or another tres. Similar treatment applicators are used. In the Manches- ter system, doses are specified at point A and point B. Point radiation detector to be moved to positions within and near A is defined as being 2 the radiation beam to determine the dose distribution. These cm lateral to the centre of the uterine cm from the mucous membrane of the lateral canal and 2 depth-dose data describe the variation of dose with depth, cm from the fornix in the plane of the uterus. Point B is 5 field size and shape, and distance from the source. midline of the uterus. In addition to the depth-dose measurements, it is D40. D35. important to know how radiation output at a reference point In the past several years, significant efforts have been made to develop protocols for image-guided brachy- changes with various important parameters, including the therapy [N19, P3]. The ICRU terminology for defining field size and shape and the distance from the source, and the target volumes has been adapted for brachytherapy, with attenuation of field-shaping and field-modulating devices. It is impractical to measure all conceivable variations, so a modifications that make it possible to distinguish between the masses of tumour present before and after surgery. Such sufficient number of representative measurements must be protocols allow the treatment to be tailored to the patient’s made to allow accurate estimations for clinical treatment situations [H17, I15]. For example, wedge factors are meas- precise condition, rather than relying on simplistic prescrip- ured to deduce the impact of the wedge on patient field sizes tions based on surrogate non-anatomical reference markers A. such as point and depth doses.

189 ANNEX A: MEDICAL RADIATION EXPOSURES 177 In many situations, ionization chambers or similar Quality assurance of IMRT treatments requires the D45. D41. measurement of dose and dose distribution in a phantom detectors used in water phantoms are inadequate to describe the dose distribution in regions of steep dose gradient, as to ensure that the patient will be treated correctly [B26]. is found near brachytherapy sources or in very small fields This is most often done by simulating a simple water or water-equivalent phantom (generally rectangular or such as are used for SRS. Radiochromic film can be used cylindrical) with the treatment planning computer and for quantitative planar dosimetry to map dose distribu- imposing on it the fluence distributions determined for tions under these circumstances as well as for proton beam therapy, and beta ray ophthalmic plaque therapy [N6, V12, patient treatment [L15, L22, T14, W24]. The shape of the Z7]. Radiochromic film offers advantages over radiographic hybrid phantom, as it is often called, will distort the dose film: it does not require processing, and as it has no high- distribution from that intended for the patient, but it allows the placement of ion chambers and film or other detectors atomic-number components, it shows very little energy to compare the calculated distribution with measurements. dependence. Agreement in the hybrid phantom provides assurance that The data obtained to characterize the beam are D42. the intended dose and dose distribution will be delivered to either stored in the treatment planning system or are used to the patient [L1]. create a mathematical model to simulate dose distributions. Data characterizing the patient are also entered, and the dose distribution is calculated taking into account the beam Independent quality audits of radiation therapy D46. arrangement, the location of the tumour and the anatomy of facilities are conducted to help provide assurance that patient the patient. treatments are delivered consistently from one facility to another. Several groups, including the IAEA, the European Radiation therapy equipment is calibrated to deter- D43. Society for Therapeutic Radiology and Oncology (ESTRO) mine the relationship between the dose delivered at a refer- Quality Assurance Programme (EQUAL) and the Radiologi- ence point and time (in the case of isotope units) and the cal Physics Center (RPC), among others, perform periodic signal from a monitor chamber (in a linear accelerator). audits of megavoltage treatment machine calibration using Various protocols exist that explicitly describe each stage of mailed TLDs [F5, H8, I20, I29, K32]. These programmes the calibration process [A2, I45]. A quality assurance pro- identify, at relatively low cost, errors in treatment machine gramme is necessary to ensure that the treatment unit per- calibration, often resulting from misinterpretation of a cali- forms consistently from one treatment fraction to the next bration protocol, incorrect use of the dosimetry equipment and from one patient to the next. Recommendations for qual- or the failure of a component of the treatment machine itself. ity assurance programmes have been published [F15, K17]. Audits also have been conducted of complex treatment D44. In vivo dosimetry is conducted to monitor the actual procedures through the use of anthropomorphic phantoms [I35, I40, M42]. These audits permit evaluation of the entire dose received by the patient during treatment to check the accuracy of delivery and as a means of determining the dose radiation therapy process, from imaging, through treatment planning and quality assurance, to treatment delivery. The to critical organs, such as the lens of the eye and the spinal cord [E7, M15]. TLDs [D18, K20, K21] and several types of experience of the RPC indicates that, in an evaluation of solid-state detector [A9, B30, C7, S8, V7, W23] are used. In IMRT, roughly one third of the institutions surveyed failed to deliver the intended dose distribution to within 7% and vivo dosimetry is particularly useful during 3-D conformal radiation therapy [L24]. 4 mm distance to agreement [I35]. V. ANAL ySIS OF pRACTICE the relative value is over 30 per million residents. Excluding Frequency of treatments A. Monaco, the United States and Japan have the highest values, with 9.2 and 5.7 centres per million population, respectively. Differences in the resources available for radiation D47. II countries, the average falls to 0.56 centre per mil- In level therapy lead to wide variations in national practice, with lion population, with a range of from 0.1 (for example for having many smaller countries or less developed countries Algeria, Pakistan and Uganda) to more than 6 (for example no treatment facilities, or only a few. Even in countries with for Barbados and the Bahamas, both countries with small treatment facilities, the type of equipment available varies III countries, there were fewer than populations). In level considerably, and this affects the numbers of patients treated IV, there 0.2 centre per million population, while in level as well as the types of treatment given. The number of treat- were fewer than 0.1 centre per million. Annual numbers of ment centres available to residents, by country, is shown in treatments reported by different countries from 2000 to I countries table D4. The data demonstrate an average in level 2006 are summarized in tables D5(a–c) and D6(a–b) for of 3.4 radiation therapy centres per million population. The teletherapy procedures and in table D7 for brachytherapy I. Monaco has only number of centres also varies within level procedures. one radiation therapy centre, but with its small population,

190 178 UNSCEAR 2008 REPORT: VOLUME I Patterns of practice vary significantly from country D48. 40% of teletherapy is used for benign disease. Temporal to country, even within a single health-care level. For com- trends in the annual frequency of examinations are discussed I reported 5.41 linear parison, countries in health-care level elsewhere. accelerators per million population (table D4). The number dropped to 0.34 per million population for level II countries, Exposed populations to 0.06 per million for level III countries and to 0.53 per mil- b. IV country reporting these lion for Botswana, the only level D52. The distributions reported by different countries of data. These numbers show a significant increase for level the age and sex of patients undergoing teletherapy treatments II and III countries over data from 1991–1996. In contrast, D8. the number of cobalt units reported by health-care level was for selected diseases in 1997–2007 are presented in table As was done for previous analyses of exposed populations, 0.78 per million population for level I, 0.43 per million for II, 0.19 per million for level level three ranges of patient age have been used, and the countries III and 0.05 per million for level IV. These numbers have increased for all levels except are listed by health-care level. As might be expected, since radiation therapy is primarily employed in the treatment of I, the number of accelerators varied from level I. Within level less than 0.1 per million population in countries such as the cancer, therapeutic exposures are largely conducted on older patients (>40 years old), with the skew in ages being even Republic of Korea and Ukraine to 9 per million in Denmark more pronounced than for the populations of patients under- and 16 per million in the United States. Annual frequencies of teletherapy treatments differed by a factor of over 6 within going diagnostic examinations with X-rays or radiopharma- ceuticals. Countries in the lower health-care levels exhibit I, where the the sample of 18 countries in health-care level average was 2.4 courses of treatment per 1,000 population a shift towards the younger age ranges for most treatments, (see tables D3, D5 (a–c) and D6 (a–b)). Disregarding coun- relative to level I countries, probably as a result of underly- ing differences in national population age structures [U3]. tries reporting zero practice, similarly large variations existed in level II countries, where the average was 0.4 course per For certain teletherapy and brachytherapy proce- 1,000 population. Insufficient data were available from level D53. dures, for example the treatment of breast and gynaecologi- III and IV countries. cal tumours in females and of prostate tumours in males, there are obvious links to patient sex. However, there are D49. Brachytherapy practice was difficult to ascertain for several reasons. Firstly, limited data were obtained through some surprising exceptions in the reported data. For exam- the UNSCEAR surveys. Secondly, the surveys did not dis- ple, Hungary reported that, of the patients treated with tinguish clearly between remote and manual afterloading external beam therapy for head and neck cancer, 84% were procedures. Consequently, the analyses discussed here are female. For other treatments, there is a general bias towards males in the populations of patients. In a few cases, the based on limited data from a small number of countries. bias towards females appears extreme; for example, several Additional data were obtained from a survey of brachythe- countries report the use of brachytherapy almost exclusively rapy use in European installations [G7]. in females, evidently for gynaecological disease. D50. The average annual frequency of brachytherapy treatments in level I countries (0.12 treatment per 1,000 II, population) is about 1/18 of that for teletherapy. In level C. doses from treatments practice in brachytherapy is lower by a factor of about 2 D54. compared with level I. The doses received by patients from radiation ther- apy are summarized in tables D9 (a–c) and D10 (a–c) in Regardless of the differences between the individual D51. terms of the prescribed doses to target volumes for complete countries, some broad patterns of practice in radiation ther- courses of treatment, as discussed previously. The average doses for each type of treatment and health-care level are apy are apparent from the average frequencies of use for the weighted by the numbers of treatments in each country. Pre- different health-care levels. In general, teletherapy is widely used in the treatment of breast and gynaecological tumours, Gy for most scribed doses are typically in the range 40–60 treatments, with somewhat lower doses being used in radia- although there is also significant use for treatments of the tion therapy for leukaemia, testis tumours, benign disease prostate and lung/thorax in countries of level I, and for treat- II. Brachytherapy practice and some paediatric tumours. Other variations in the reported ments of the head/neck in level is universally dominated by treatments of gynaecological apparent, although these might have resulted from data are tumours. Some interesting variations among countries are misinterpretation of the data requested by the survey forms. evident from tables D5 (a–c) and D6 (a–b). Luxembourg D55. reports that a large fraction of teletherapy treatments are used In teletherapy with photon beams, the doses to tis- for breast cancer, while more than 50% of teletherapy treat- sues at large distances from the target volume arise from sev- radiation scattered in the patient; (2) ments in El Salvador are for gynaecological disease. Japan eral sources: (1) leak- reports a high annual treatment frequency for head and neck age through the treatment head of the machine; (3) scatter radiation from the collimator and its accessories; and (4) cancer as well as for digestive tumours other than colorec- scattered from the floor, walls or ceiling [N20, V4]. The first tal. Both Hungary and Norway use teletherapy frequently for palliative treatments, but the Czech Republic reports that and fourth contributions depend on field size, distance and

191 179 ANNEX A: MEDICAL RADIATION EXPOSURES photon energy, and can be measured and applied generally. modified by a factor to account for scatter and absorption in The second and third contributions are machine-specific and tissue, and experimental data have been reported to allow the 137 60 Co, Cs in principle require measurement for individual machines. cm from estimation of dose in the range 10–60 192 Collimator scatter varies according to specific design, and Ir sources [V4]. although levels of leakage radiation are rather similar for all modern equipment, corresponding to an average value of D59. ± 0.01% (relative to the central axis dose maximum) 0.03 The skin-sparing advantage and clinical efficacy of high-energy photon beams can be compromised by elec- cm from the beam in the patient plane at a distance of 50 axis [K22, S34]. When evaluating the deleterious effects of tron contamination arising from the treatment head of the out-of-field doses, the gonads are generally considered the machine and the intervening air volume, and comprehensive consideration limiting organ, although organs such as the thyroid and the dosimetric assessment requires taking into breasts of young women must also be considered. When the the effect of this component on the depth-dose distribu- tion [H18, S35, Z8]. Electrons and photons with energies distance between the organ being considered (for example MeV can produce neutrons through interactions of above 8 the gonads) and the primary beam is large (around 40 cm, with various materials in the target, the flattening filter and for example, in the treatment of breast cancer), gonad dose the collimation system of the linear accelerator, as well as in is primarily determined by the leakage radiation. Collimator Gy to the tar- the patient [K7]. For a typical treatment of 50 scatter can be influenced by the presence of accessories, in get volume using a four-field box irradiation technique with particular wedge filters, which increase the out-of-field dose significantly [F16]. Specific data have also been reported in MV X-rays, the additional average dose over the irradi- 25 ated volume from such photoneutrons is estimated to be less relation to the peripheral dose during therapy using a lin- mGy and is quite negligible in comparison with the than 2 ear accelerator equipped with multileaf collimation [S34]. Leakage radiation might not be insignificant during high- therapeutic dose delivered by the photons [A10]. The average photoneutron dose outside the target volume would be about energy electron treatments, although the associated risks to 0.5 mGy under the same circumstances, and for peripheral patients should be judged in the context of the therapy and doses this component could be similar in magnitude to the the patient’s age and medical condition [M16]. contribution from photons [V4]. High-energy X-ray beams will also undergo photonuclear reactions in tissue to produce Measurements in a patient population have demon- D56. protons and alpha particles [S36], with total charged parti- strated a broad range of gonad doses from photon telethe- cle emissions exceeding neutron emissions above 11 MeV rapy treatments for some specific treatment sites [V4]. The [A11]. However, these charged particles have a short range, minimum and maximum values are determined not only by so any additional dose to the patient will mostly be imparted the range of tumour doses considered but also by the range within the treatment volume and will be insignificant. of field sizes and distances encountered in clinical practice, with due account taken of the variation between men and women in the distance to the gonads. For treatments in the d. Assessment of global practice pelvic region, gonad doses can range from tens of milligrays to several grays, depending on the exact distance from the pro- D3 for the period 1997–2007 D60. The data in table centre of the treatment volume to the gonads. These data are vide estimates of the annual total numbers of teletherapy also relevant for estimating the dose to a foetus carried by a and brachytherapy patients per 1,000 population within each pregnant woman. health-care level. The frequencies of teletherapy in levels II and III may have been overestimated as it appears that The risk to patients of a second malignancy as a D57. some of the national data used refer to numbers of treatments result of out-of-field radiation has been estimated [S31]. rather than cancer patients, although these sources of uncer- With IMRT, these risk estimates are increased. An IMRT tainty are reduced when considering global practice. Data treatment requires that the MLC be adjusted to create small broken down by disease category and by patient age were field segments for much of the treatment, while different provided by too few countries for 1997–2007 to permit an regions of the target volume are irradiated to different doses. in-depth evaluation. Consequently, the mean values shown This makes IMRT delivery considerably less efficient than in table D8 for the individual types of treatment within each 3-D conformal therapy. It is not unusual for the number of health-care level were averaged over different populations monitor units used for IMRT to be from four to ten times because of the lack of comprehensive information for all as great as for 3-D conformal therapy. As a result, the leak- countries listed and so do not represent a self-consistent age radiation emitted by the accelerator head during IMRT set of data. Analyses are presented separately for both tele- is proportionally greater [K22]. therapy and brachytherapy. The estimates of world practice have been calculated using the global model of population In brachytherapy, where radiation sources are D58. described above. The uncertainties inherent in the estimates inserted directly into the body, the dose to peripheral organs of mean frequencies provided by the global model are dif- ficult to quantify but will be significant, particularly when is determined primarily by their distance from the target vol- ume. The decrease in dose with distance from a brachythe- extrapolations have been made on the basis of small samples rapy point source can be described by the inverse square law, of data.

192 180 UNSCEAR 2008 REPORT: VOLUME I the treatment of gynaecological and genitourinary tumours, According to the model developed, the global annual D61. although some differences are apparent between the mean frequencies assessed for radiation therapy treatments during frequencies for the different health-care levels. The global 1997–2007 are dominated by the national practices in health- I countries, which provide contributions of about average annual frequency assessed for brachytherapy treat- care level 73% and 42% to the total numbers of teletherapy and brach- ments (0.07 per 1,000 population) is about one-tenth that for teletherapy treatments (0.7 per 1,000 population) (see . D2) ytherapy treatments, respectively, in the world (table table D3). Figure D-V shows the estimated annual number The most important uses of teletherapy are for treatments of all radiotherapy (both teletherapy and brachytherapy) of breast, lung, genitourinary and gynaecological tumours, treatments (in millions) for the four health-care levels. while practice in brachytherapy is principally concerned with Estimated total annual number of radiotherapy treatments (both teletherapy and brachytherapy) Figure d-V. 6 5 4 3 (millions) 2 1 NUMBER OF TREATMENTS 0 III Total I II IV HEALTH�CARE LEVEL D62. While radiation therapy is most often used for today. However, as shown in tables D5 and D6, the use treatment of malignant diseases, a significant number of of radiation for treatment of benign conditions, such as neuralgias trigeminal patients are treated with radiation for benign conditions. The arteriovenous malformations, use of radiation to treat conditions such as bursitis and acne, and acoustic neuromas, today is quite common in some while common in the 1950s, has essentially disappeared countries [C4]. TRENdS IN RAdIATION ThERApy VI. A. Teletherapy Developments in diagnostic imaging, such as CT and D65. MRI, have benefited the assessment of disease and also the Over the last 50 years, there have been continuing D63. planning and delivery of therapy [C8, R18]. Treatment plans advances in engineering, the planning and delivery of are calculated using sophisticated computer algorithms to pro- treatment, and clinical radiation therapy practice, all with the vide 3-D dose distributions, including so-called beam’s-eye aim of improving performance [B31]. In developed coun- views. Monte Carlo simulation techniques are beginning to be tries, at least, there has been growing use of high-energy used in selected cases for comparison [M17, S37]. Computer linear accelerators for the effective treatment of deep-seated control of the linear accelerator has facilitated the develop- tumours. It has been suggested that the energy ranges ment of new treatment techniques. MLCs can not only replace MeV for electrons are those MV for photons and 4–20 4–15 the use of individual shielding blocks in routine treatments optimally suited to the treatment of cancer in humans [D23]. with static fields as a tool for sparing healthy tissues, but can 60 Units with Co sources remain important for developing also allow the achievement of computer-controlled conformal countries in view of their lower initial and maintenance radiation therapy [G20]. This type of therapy seeks to provide costs and their simpler dosimetry in comparison with linear optimal shaping of the dose distribution in three dimensions so accelerators. as to fit the target volume [D16, F17]. Developments include: tomotherapy, which uses slit beams provided by dynamic con- D64. Chemotherapy has been used in combination with trol of MLCs coupled with movement of the gantry during radiation therapy for many years. The delivery of certain treatment [Y7]; IMAT, which combines spatial and temporal chemotherapeutic agents in close temporal proximity to intensity modulation [Y9]; and adaptive radiation therapy, in radiation therapy can enhance the effectiveness of the radia- which treatment plans for individual patients are automati- tion against cancer cells. The synergistic effects of com- cally reoptimized during the course of therapy on the basis of bined therapy will continue to be pursued as new drugs are systematic monitoring of treatment variations [Y5]. The suc- developed. cess of such therapies is compromised by intrafraction organ

193 181 ANNEX A: MEDICAL RADIATION EXPOSURES 137 motion [Y6], and synchronous gating or tracking of the radia- Cs. The largely been replaced throughout the world by remote afterloading technique is standard practice in most tion beam with respiration is being evaluated in a number of countries for the treatment of carcinoma of the cervix and centres [K8]. is increasingly being used for interstitial implants in rela- tion to the bronchus, breast and prostate [S29]. HDR brachy- D66. Tumours of the lung, breast and liver can move as therapy offers advantages over the manual LDR technique, a result of normal respiration. Such intrafraction motion is for example in terms of improved geometrical stability dur- difficult to estimate, much less accommodate in treatment planning without sophisticated imaging procedures. Four- ing the shorter treatment times and reduced staff exposures. However, the relative loss of therapeutic ratio requires modi- dimensional computed tomography (4-DCT) is being evalu- ated at a number of centres to demonstrate the respiratory fied treatment schedules to avoid late normal tissue dam- motion of some tumours. The 4-DCT technique requires the age and so allow cost-effective therapy [J6, J7, T11]. PDR use of a fast multidetector helical CT scanner, and either gat- brachytherapy has been developed in the hope of combining the advantages of the two techniques, while avoiding their ing of imaging with respiratory motion, or continuous imag- disadvantages [B32, M18]. In essence, a continuous LDR ing during free breathing, with subsequent binning of the interstitial treatment lasting several days is replaced with images according to the stage of the respiratory cycle at the a series of short HDR irradiations, each about 10 minutes time of each scan. From 4-DCT images, an internal target long, for example, and given on an hourly basis, so as to volume can be drawn that contains the full range of motion of the CTV. deliver the same average dose. Each pulse involves the step- ping of a single high-activity source through all catheters of an implant, with computer-controlled dwell times in each D67. The use of a novel 3-D gel dosimeter for evaluating position to reflect the required dose distribution. IMRT dose distributions has been described recently [G19, I22, I38, I39]. The dosimeter, composed of acrylic mono- D72. mers stabilized in a gelatin matrix, responds to irradiation Endovascular brachytherapy treatments to inhibit restenosis after angioplasty enjoyed a brief popularity during by polymerizing. The distribution of polymer microparti- the 1990s and early 2000s, but they have now largely been cles is proportional to the absorbed dose, and a map of the replaced by the use of drug-eluting stents. Patients who are distribution can be obtained either by MRI or by optical CT not candidates for these stents are occasionally treated with scanning [I39]. intravenous brachytherapy using catheters for the temporary 90 90 192 implantation of radioactive seeds and wires ( Y) Ir or Sr/ D68. Portal films and digital imaging devices visualiz- ing exit fields are used to verify the positional accuracy of and also for the permanent implantation of radioactive stents 32 ( external beams during treatment, and increasingly to pro- P) [C9, J8, T3]. vide quantitative dosimetric information [A5, S33, T10]. Some treatment machines are equipped with on-board X-ray imaging devices, and use is beginning to be made of these Other modalities C. systems to image patients on the treatment table, so that A continuing obstacle to definitive radiation ther- adjustments to patient position can be made immediately D73. apy is the difficulty of delivering lethal doses to tumours before treatment [G18]. while minimizing the doses to adjacent critical organs. Vari- A technique called volumetric modulated arc therapy ous special techniques have been developed to overcome D69. (VMAT) has been described recently [T15]. This technique this limitation, although such modalities are less common practice than the techniques discussed above. Intraopera- combines sliding-window MLC control simultaneously with gantry rotation to eliminate the requirement for couch move- tive radiation therapy (IORT) involves surgery to expose the tumour or tumour bed for subsequent irradiation, usu- ment. Commercialization of this technique began at the end MeV, of 2007. ally with a beam of electrons in the energy range 6–17 while normal organs are shifted from the field [D15, M19]. Patients undergoing radiation therapy should have The entire dose is delivered as a single fraction in a com- D70. plex configuration, which makes dose control and measure- available to them the necessary facilities and staff to provide ment particularly critical [B24]. A total of approximately safe and effective treatment. Many radiation therapy centres 3,000 patients are estimated to have been treated with IORT in level II, III and IV countries do not have sufficient num- bers of linear accelerators, simulators or remote afterloading worldwide by 1989, mostly in Japan and the United States. brachytherapy units, and the level of availability significantly A recent development for the treatment of primary bone compromises their ability to deliver radiation therapy [B6]. sarcomas is extracorporeal radiation therapy, in which the afflicted bone is temporarily excised surgically so that it can undergo high-level irradiation in isolation before immedi- b. brachytherapy ate reimplanting [W25]. Studies have also been made of the potential enhancement of dose to the target volume using the technique of photon activation, in which increased pho- Intracavitary brachytherapy for gynaecological can- D71. 226 Ra) was one of the first radiotherapeu- cer using radium ( toelectric absorption is achieved by loading the tissue with tic techniques to be developed. This radionuclide has now an appropriate element prior to irradiation. Modelling has

194 182 UNSCEAR 2008 REPORT: VOLUME I 53,000 patient treatments worldwide with protons and heav- been reported for therapeutic applications of iodine contrast ier ions. The largest numbers of patients have been treated in agents in association with a CT scanner modified for rotation the United States. There are currently 31 facilities actively X-ray therapy [M7, S14] and for a silver metalloporphyrin 125 for use in interstitial brachytherapy with I seeds [Y8]. engaged in proton or ion therapy. Another 20 facilities are in various stages of planning and construction in several Euro- There were at least 451 dedicated stereotactic pean countries, the United States, Africa and Asia [M10, D74. N21, P23, S15, S16]. devices in use worldwide in 2008, of which 247 were in the United States. Of the 451 devices worldwide, at least 247 60 Light ions (e.g. helium or carbon) are attractive D77. were units containing multiple Co sources called a Leksell Gammaknife (LGK). Data from the manufacturer indicate owing to their favourable physical and radiobiological charac- a total of 46 gamma knives in Japan and 16 in China; addi- teristics, such as high relative biological effectiveness, small tional information is given in table D11 [E2]. Data from oxygen effect and small cell-cycle dependence [K1, P23]. In 1996, only two heavy-ion facilities were operational in the the 2000 UNSCEAR Global Survey of Medical Radiation world: HIMAC in Japan and GSI in Germany. A third facil- Usage and Exposures indicated a total of 20 gamma knives ity opened in 2002 at the HIBMC facility in Japan. However, in Japan and 36 in China. The reason for the difference in developments for the establishment of ion therapy centres in numbers in Japan is not known. The difference in numbers Europe have gained momentum and at present are in a very in China may reflect the use of a similar device sold by a dynamic phase. In Heidelberg, Germany, a new facility has Chinese manufacturer. The Leksell Society reported that just initiated patient treatments. In Pavia, Italy, and in Wiener 350,000 treatments had been delivered with the LGK world- Neustadt, Austria, similar facilities are scheduled to become [L7]. Doses to extracranial sites wide up to the end of 2005 - operational before 2009. The ENLIGHT cooperation, coor during LGK treatments have been reported to be relatively dinated by ESTRO and supported by the European Commis- low, with the eyes receiving about 0.7% of the maximum sion, has been instrumental in networking all these projects target dose and doses to other sites decreasing exponentially with increasing distance from the isocentre of the LGK unit and in creating for them a common platform for research and a concerted clinical approach between European radia- [G5]. A frameless robotic radiosurgery system has been tion oncologists. More than 2,800 patients with various types developed in which real-time X-ray imaging of the patient of tumour located in various organs have been treated with a locates and tracks the treatment site during exposure and so provides automatic targeting of a 6 carbon beam at the HIMAC facility alone since 1994 [K2]. MV photon beam [M8, M9]. Data from the manufacturer indicate that there were 98 As of early 2007, more than 3,300 patients had been treated worldwide. In addition, about 1,100 patients were treated with of these devices in use worldwide in 2006, of which 62 were negative pi mesons between 1974 and 1994, although with no in the United States and 17 were in Japan [A6]. At least 72 conventional linear accelerators were used for SRS in 2006; active facilities since 1996, this is not a significant modality. these were modified by adding a micro-MLC. Trials are also Fast neutron radiation therapy was first used as a in progress with a novel miniature X-ray source for stereo- D78. tactic interstitial radiosurgery, in which a needle-like probe cancer treatment tool in 1938 in the United States, but it was is used to deliver relatively low-energy photons directly into not successful, because the radiobiology was not fully under - a lesion. The intensity and peak energy are adjustable for stood [G6]. Later, in the 1960s. studies in the United Kingdom optimal tumour dose while minimizing damage to surround- with appropriate fractionation paved the way for clinical trials at various centres around the world. In particular, a 20-year ing healthy tissue [B9, B25, D17, Y10]. multi phase project was begun in the United States in 1971; the project has involved ten separate neutron facilities and several D75. There are potential advantages in conducting radia- tion therapy with high-energy, heavy charged particles such thousand patients to establish the efficacy of neutron therapy. as protons and heavier charged particles [W5]. Such beams Clinical experience over two decades with neutron therapy for of charged particles can provide superior localization of dose pancreatic cancer has demonstrated high complication rates at depth within target volumes [L9, M10, N21]. Furthermore, and overall survival rates that are no better than those achieved with conventional radiation therapy [D20, R6, R12]. Neutron ions with high-linear-energy-transfer (LET) components 252 can damage cells in locally advanced radioresistant tumours Cf sources is being carried out at one brachytherapy using medical centre in the United States [M11]. Boron neutron more effectively than low-LET radiations such as photons capture therapy is currently being evaluated at a few reactor and electrons [B17]. During proton therapy, secondary neu- facilities. This technique is predicated on the supposition that trons and photons make small contributions to the patient pharmaceuticals containing boron can be designed that will dose [A10]. However, the dose received by non-target tis- sues is low, and is considered comparable to the neutron dose be deposited preferentially in a tumour. If a patient whose received during treatments with high-energy photon beams. tumour contained an adequate concentration of boron were irradiated with a beam of neutrons from a reactor, the tumour D76. would receive a significantly higher dose than the surround- Proton beams have been used therapeutically ing tissue. The technique is proposed for treatment of brain since 1955 and represent the treatment of choice for ocular tumours, specifically glioblastoma multiforme. However, to melanoma [B17, I41]. Protons are currently also being used to treat deep-seated tumours, including those of the prostate, date, the results have been disappointing owing to the lack of brain and lung. As of early 2007, there had been more than selectivity of the boron carriers [V3].

195 ANNEX A: MEDICAL RADIATION EXPOSURES 183 ACCIdENTS IN RAdIATION ThERApy VII. The practice of radiation therapy involves the use D79. involved in several accidents resulting in patient injury. In of large doses of radiation, which if applied incorrectly can one case, 23 patients received doses that were 7% to 34% greater than prescribed. The error was due to a misinterpre- cause serious harm or death to the irradiated individual. The tation of treatment planning software in which the operators delivery of radiation doses that exceed the tolerance of nor- confused dynamic wedge treatments with the use of mechan- mal tissues can result in unintended adverse effects, referred ical (metal) wedge filters. Information displayed by the soft- to as complications of treatment. It should be emphasized that such complications are distinct from radiation therapy ware was in English rather than the operators’ native lan- accidents; the risk of complications is well known and guage, apparently contributing to the confusion. The result understood, and most radiation therapy treatments are pre- was that, on some occasions, the monitor unit setting for the accelerator was calculated as if a mechanical wedge filter scribed with the full knowledge of an attendant small risk of was to be used, when in fact a programmable wedge distri- significant complications. bution was created by moving one collimator jaw across the field to modulate the intensity [P2]. D80. While radiation therapy accidents are rare, a number of serious mistakes have resulted in unfortunate conse- quences for patients and members of the public. A summary D85. Accidents involving IMRT have been reported, of nearly 100 radiation therapy accidents has been published including several in which patients received lethal doses of by the IAEA [I18] and a similar number have been reported radiation. In at least one case, a treatment plan was corrupted in the process of transferring it from the treatment-planning by the ICRP [I27]. These accidents have been examined in detail and categorized to indicate their educational value computer to the treatment machine. Reportedly, the treat- C to the present report, “Radiation to practitioners. Annex ment staff overlooked or ignored a warning message indicat- ing that the treatment plan had not been transferred correctly. exposures in accidents”, also discusses radiation therapy accidents in the context of other radiation accidents. As a result, the treatment was delivered through open fields, rather than with the MLC modulating the beam intensity. The IAEA grouped the accidents into the following The patient was believed to have received approximately D81. seven times the intended dose [V15]. categories: radiation measurement systems; external beam therapy machine commissioning and calibration; external Accidents involving brachytherapy also have been D86. beam therapy treatment planning, patient set-up and treat- reported. One in which a patient received an extremely large ment; decommissioning of teletherapy equipment; mechani- dose, causing her death, was reported in November 1992 in cal and electrical malfunctions; LDR brachytherapy sources Indiana, Pennsylvania. The accident involved a female patient and applicators; HDR brachytherapy; and unsealed sources. scheduled for an HDR brachytherapy procedure using a 192 159 D82. The accidents include events such as the failure to GBq Ir source. The treatment was to be given in three correctly interpret the treatment time setting during calibra- Gy each. Part-way through the first fraction, fractions of 6 tion, resulting in overdoses of 50% to patients. Other acci- the source broke off the guidewire and remained inside one dents have resulted in doses significantly below what was of the catheters that had been surgically implanted into the needed; when such accidents occur under circumstances from patient’s tumour. The patient was returned to a local nursing which recovery is not possible, they can result in progression home without a radiological survey being performed. The of the patient’s tumour. Accidents caused by misinterpreta- catheter containing the source became dislodged four days tion of the physician’s prescription are also reported. later and was discarded in the biohazard waste. It was dis- covered soon afterwards when a waste truck passed through Accidents involving SRS have been reported, includ- D83. a radiation detector installed at an incinerator facility. The ing errors caused by misinterpretation of the coordinates of cm in tissue was 16,000 Gy. Ninety- estimated dose at 1 the target volume [N22]. In one reported case, a patient was four additional individuals, including staff, visitors, family positioned in a CT scanner feet-first rather than the more members and other nursing home residents were exposed, common head-first position. This change was not recognized although the doses were not medically significant [M38]. by the treatment staff, who mistakenly irradiated the wrong side of the patient’s head. Calibration errors have also been D87. A website has been established by a group called the reported, including one in which a linear accelerator used Radiation Oncology Safety Information System (ROSIS), to for SRS was calibrated in error by 50% [J9]. According to which individuals can post a description of radiation therapy news reports, 77 patients were treated before the error was errors or accidents, with the goal of providing education to discovered and received 50% greater doses than had been others [R4]. The website lists over 700 such events, ranging prescribed. from typographical errors in a verification system discov- ered at the time of the first treatment, to the failure to use a D84. The use of modern technology, including dynamic wedge filter for an entire course of treatment, resulting in a MLCs and programmable wedge distributions, has been dose delivery error approaching a factor of 2.

196 184 UNSCEAR 2008 REPORT: VOLUME I SUMMARy VIII. appeared to show a decrease, but this is likely to be an arte- Cancer is likely to be an increasingly important dis- D88. fact of the limited data received from the survey. At the ease in populations with increasing lifespan, and this will same time, the number of brachytherapy treatments and the probably cause radiation therapy practice to grow in most countries. WHO estimates that, worldwide, by the year 2015 number of afterloading brachytherapy units appeared to have the annual number of new cancer cases will have risen to changed very little. million in 1995, with about two million, from 9 about 15 thirds of these cases occurring in developing countries [W8]. D90. Radiation therapy involves the delivery of high doses to patients and accordingly there is an attendant potential for If half of these cases are treated with radiation, at least 10,000 accidents with serious consequences for the health of patients external beam therapy machines will be required at that time (arising from over- or under-exposure relative to prescription) in developing countries, in addition to a large number of and also of staff. Quality assurance programmes help ensure brachytherapy units. high and consistent standards of practice so as to minimize D89. In the period 1997–2007, the global use of radiation the risks of such accidents. Effective programmes compre- million treatments, from 4.7 million hensively address all aspects of radiation therapy, including, therapy increased to 5.1 million patients were inter alia: the evaluation of patients during and after treat- treatments in 1991–1996. About 4.7 mil- ment; the education and training of physicians, technologists treated with external beam radiation therapy, while 0.4 and physicists; the commissioning, calibration and mainte- lion were treated with brachytherapy. The number of lin- ear accelerator treatment units increased to about 10,000 nance of equipment; independent audits for dosimetry and worldwide, from about 5,000 in the previous period. A large treatment planning; and protocols for treatment procedures II countries and the supervision of delivery [D14, D21, K17]. increase was seen in level I countries. Level Global use of radiotherapy (1997–2007): normalized values Table d1. Data from United Nations Survey of Nations and IAEA/WHO Directory (DIRAC) Quantity Number per million population at health-care level II III IV Globally I Teletherapy a a 0 .4 — 1 .3 — 0 .2 x-ray Radionuclide 0 .8 0 .4 0 .2 0 .0 0 .4 Equipment linac 5 .4 0 .3 0 .1 0 .5 1 .6 a Annual number of patients — 2 241 .1 729 .7 370 .0 55 .4 Brachytherapy 1 .4 Afterloading units 0 .07 0 .02 0 .5 0 .2 a a — — Annual number of patients 115 .7 67 .2 61 .9 a No data submitted . Global use of radiotherapy (1997–2007): total values Table d2. Data from United Nations Survey of Nations and IAEA/WHO Directory (DIRAC) Quantity Total number (millions) at health-care level II III IV Globally I Teletherapy a a 0 .002 0 .000 6 — — 0 .002 x-ray Equipment Radionuclide 0 .001 0 .000 19 0 .000 04 0 .003 0 .001 a linac 0 .001 0 .000 06 — 0 .009 0 .008 b 3 .45 1 .17 0 .06 (0 .03) 4 .7 Annual number of patients brachytherapy 0 .002 0 .001 0 .000 1 0 .000 0 0 .003 Afterloading units b b 0 .20 (0 .05) Annual number of patients (0 .01) 0 .18 0 .43 a No data submitted . b Assumed value in the absence of data .

197 ANNEX A: MEDICAL RADIATION EXPOSURES 185 a Estimated annual number of radiotherapy treatments Table d3. in the world (1997–2007) Data from United Nations Survey of Nations and United Nations World Population Database b Annual number of brachytherapy treatments Population Annual number of all radiotherapy treatments Health-care level Annual number of teletherapy treatments (millions) Millions Millions Per 1 000 population Per 1 000 population Per 1 000 population Millions I 0 .18 0 .12 3 .6 2 .4 1 540 3 .5 2 .2 1 .2 0 .4 0 .20 0 .06 1 .4 II 3 153 0 .4 c c (<0 .05) 1 009 (<0 .01) 0 .1 0 .1 0 .06 III 0 .1 c c c c c c (<0 .005) 744 (0 .03) (<0 .01) (0 .01) (<0 .01) IV (0 .03) 6 446 4 .7 0 .73 0 .43 World 5 .1 0 .8 0 .067 a Complete courses of treatment . b Excluding treatments with radiopharmaceuticals . c Assumed value in the absence of data . Table d4. Number of radiotherapy centres and of items of radiotherapy equipment per million population (1997–2007) Data from IAEA/WHO Directory (DIRAC), United Nations Survey of Nations, United Nations World Population Database and Radiological Physics Center Radiotherapy centres Teletherapy units Country/area Brachytherapy afterloading units X-ray Radionuclide Linear accelerator Health-care level I 0 .3 Albania 0 .63 2 .3 2 .25 1 .29 0 .10 Argentina Armenia 1 .00 0 .33 0 .33 0 .7 Australia 0 .96 5 .40 1 .30 1 .6 1 .6 4 .66 1 .83 Austria 0 .36 0 .2 Azerbaijan Belarus 1 .3 2 .17 0 .52 0 .72 Belgium 2 .4 1 .91 0 .38 4 .11 0 .86 Bulgaria 1 .7 1 .57 0 .26 0 .13 1 .0 3 .19 0 .82 Canada 1 .06 2 .91 0 .14 1 .2 0 .28 China - Hong Kong SAR China - Taiwan 0 .4 1 .5 0 .88 1 .54 1 .54 1 .76 Croatia 0 .8 Cuba 0 .18 0 .44 0 .89 Cyprus 2 .34 2 .34 1 .17 2 .3 3 .7 2 .75 1 .57 2 .06 Czech Republic 2 .26 0 .0 0 .04 Democratic People’s Republic of Korea 0 .04 Denmark 1 .1 0 .18 8 .82 0 .74 Ecuador 0 .6 0 .52 0 .37 0 .30 Estonia 1 .5 0 .75 1 .50 3 .00 1 .9 5 .69 2 .08 Finland 0 .38 France 3 . 1 .65 5 .43 0 .41 4 Georgia 0 .9 0 .91 Germany 1 .03 0 .24 4 .72 2 .49 3 .0 Greece 2 .2 0 .27 1 .26 2 .96 0 .99 Hungary 1 .2 0 .90 2 .29 2 .29 2 .09 Iceland 3 .32 6 .64 3 .32 3 .3 Ireland 1 .9 0 .93 2 .09 0 .23 Israel 2 .0 1 .15 3 .61 0 .43

198 186 UNSCEAR 2008 REPORT: VOLUME I Radiotherapy centres Teletherapy units Country/area Brachytherapy afterloading units Linear accelerator X-ray Radionuclide 1 .56 Italy 4 .48 2 .6 0 .46 0 .33 2 .70 5 .7 Japan 5 .81 Kazakhstan 0 .13 0 .84 1 .2 1 .95 0 .70 0 .35 0 .7 Kuwait 0 .38 0 .19 Kyrgyzstan 0 .2 0 .44 latvia 3 .07 0 .88 1 .8 0 .88 2 .20 1 .5 lebanon 0 .98 4 .13 5 .31 0 .59 2 .06 lithuania 1 .5 2 .1 4 .28 2 .14 luxembourg 2 .5 2 .46 2 .46 Malta 2 .46 30 .3 Monaco Netherlands 0 .06 4 .39 2 .74 1 .3 1 .4 1 .68 4 .55 0 .48 New Zealand 0 .24 2 .55 7 .02 1 .06 1 .9 Norway 0 .60 1 .20 Panama 0 .9 0 .6 0 .11 0 .37 1 .68 1 .10 Poland 1 .5 0 .66 2 .45 0 .85 Portugal qatar 2 .4 1 .1 0 .12 1 .43 0 .64 Republic of Korea 0 .53 1 .05 0 .3 Republic of Moldova 2 .1 1 .63 0 .79 0 .23 0 .19 Romania 0 .9 1 .43 0 .26 0 .47 Russian Federation Singapore 0 .7 0 .23 2 .25 0 .68 Slovakia 3 .0 3 .53 2 .60 5 .01 0 .37 0 .5 1 .00 3 .00 Slovenia 1 .00 0 .54 0 .16 0 .4 South Africa 0 .43 0 .54 1 .08 4 .00 1 .56 Spain 2 .6 0 .2 0 .10 Sri lanka 0 .36 2 .1 0 .11 6 .58 2 .41 Sweden 5 .04 3 .5 6 .41 0 .27 Switzerland 4 .41 6 .28 The former y 0 .5 0 .49 0 .98 1 .47 ugoslav Republic of Macedonia 1 .0 1 .93 0 .04 0 .13 Ukraine 0 .5 0 .46 0 .91 0 .46 United Arab Emirates United Kingdom 1 .0 0 .35 3 .11 0 .31 United States 0 .32 15 .50 2 .49 9 .2 Uruguay 4 .2 2 .69 1 .50 Uzbekistan 0 .5 0 .55 1 .7 0 .51 0 .58 0 .14 Venezuela (Bolivarian Rep . of) a 3 .4 1 .26 0 .78 Average 1 . 5 .41 37 Health-care level II 0 .1 0 .27 0 .18 Algeria Bahamas 3 .02 6 .0 Barbados 6 .8 6 .80 3 .40 Bolivia 0 .6 0 .52 0 .10 Bosnia and Herzegovina 0 .25 0 .51 0 .25 0 .3 Brazil 0 .8 0 .31 0 .58 0 .82 0 .26 Chile 0 .90 0 .96 0 .12 1 .3 0 .30 0 .6 0 .16 0 .41 0 .32 China

199 ANNEX A: MEDICAL RADIATION EXPOSURES 187 Radiotherapy centres Teletherapy units Country/area Brachytherapy afterloading units Linear accelerator X-ray Radionuclide 0 .84 Colombia 0 .37 0 .8 0 .02 0 .67 0 .45 0 .22 0 .7 Costa Rica 0 .67 Dominican Republic 0 .10 0 .20 0 .3 0 .31 0 .44 0 .15 0 .73 0 .4 El Salvador 0 .37 0 .01 Iran 0 .3 Jordan 1 .01 0 .17 0 .7 0 .68 0 .97 1 .1 0 .32 libyan Arab Jamahiriya Malaysia 1 .2 0 .26 0 .49 0 .04 Mauritius 0 .79 0 .8 1 .58 0 .7 0 .77 0 .19 0 .04 Mexico 0 .4 1 .14 0 .38 Mongolia 1 .7 Montenegro 1 .67 0 .2 Nicaragua 0 .18 0 .04 0 .02 0 .1 0 .10 Pakistan 0 .33 0 .65 Paraguay 0 .5 0 .4 0 .32 0 .29 Peru 0 .3 0 .28 0 .18 0 .07 Philippines Puerto Rico 1 .5 0 .75 2 .00 0 .7 0 .20 1 .52 0 .30 Serbia 0 .1 0 .20 0 .05 Syrian Arab Republic Tajikistan 0 .30 0 .1 Thailand .4 0 .38 0 .25 0 .19 0 Trinidad and Tobago 0 .8 0 .75 1 .50 Tunisia 0 .6 0 .68 0 .19 0 .39 0 .8 0 .61 0 .15 Turkey 0 .67 0 .1 0 .03 Uganda a Average 0 .43 0 .34 0 .18 0 .56 0 .23 Health-care level III Congo, Rep . 0 .1 0 .4 0 .26 0 .28 0 .03 Egypt 0 .8 Gabon 0 .75 0 .1 0 .09 0 .09 Ghana 0 .4 0 .45 0 .15 Guatemala Haiti 0 .1 0 .10 Honduras 0 .99 0 .14 0 .6 India 0 .2 0 .22 0 .03 0 .07 Iraq 0 .1 0 .07 1 .1 0 .74 0 .37 Jamaica 0 .1 0 .05 Madagascar Morocco 0 .2 0 .16 0 .13 0 .51 Namibia 0 .48 0 .5 Nigeria 0 .0 0 .02 0 .01 0 .01 0 .08 0 .73 0 .08 3 Saudi Arabia 0 . 0 .1 0 .08 0 .05 0 .03 Sudan Viet Nam 0 .1 0 .13 0 .01 0 .03 Zimbabwe 0 .22 0 .15 0 .1 a 0 .07 0 .16 0 .19 0 .06 Average

200 188 UNSCEAR 2008 REPORT: VOLUME I Radiotherapy centres Teletherapy units Country/area Brachytherapy afterloading units Linear accelerator X-ray Radionuclide Health-care level IV 0 .1 Angola 0 .1 Bangladesh 0 .06 0 .53 0 .5 Botswana 0 .1 Cambodia 0 .11 0 .05 Cameroon 0 .1 Ethiopia 0 .01 0 .0 0 .01 0 .0 Indonesia 0 .02 0 .08 0 .03 Kenya 0 .1 0 .1 Myanmar 0 .16 0 .0 0 .04 Nepal Papua New Guinea 0 .16 0 .2 Senegal 0 .08 0 .1 0 .0 United Rep . of Tanzania 0 .05 0 .0 0 .04 yemen Zambia 0 .1 a 0 .06 0 .05 0 .53 0 .02 Average a Averages are based on data submitted by surveyed countries, weighted by the population sizes of those countries . Table d5a. Number of patients treated annually with various teletherapy procedures (2000–2006) Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Leukaemia Breast Lung/thorax Gynaecological Head/neck Brain Country Lymphoma tumour tumour tumour tumour tumour Hodgkin’s Non- Hodgkin’s Health-care level I 8 27 40 Croatia 1 062 570 582 354 1 556 Czech Republic 249 451 596 4 927 2 989 2 856 1 774 653 Hungary 22 88 851 494 318 438 80 34 1 590 570 36 450 49 660 14 830 35 860 14 420 Japan 10 080 1 23 616 139 503 9 39 latvia 12 5 82 61 1 035 608 1 074 533 159 lithuania luxembourg 1 10 263 56 50 52 28 6 20 21 306 Malta 42 61 4 9 Netherlands 9 000 7 000 Norway 8 255 1 875 253 251 363 59 Poland 420 420 5 460 5 040 2 940 2 940 2 100 420 10 325 163 1 099 Slovenia 212 526 86 26 South Africa 9 19 340 200 693 369 34 16 Spain 394 1 076 1 506 17 170 8 268 5 393 7 146 4 369 Switzerland 154 329 3 512 1 111 674 851 544 269 The former y ugoslav Republic of Macedonia 15 10 403 285 345 189 57 Total 2 933 2 891 13 621 84 863 77 510 30 751 51 693 22 986

201 ANNEX A: MEDICAL RADIATION EXPOSURES 189 Leukaemia Lymphoma Country Lung/thorax Breast Gynaecological Brain Head/neck tumour tumour tumour tumour tumour Non- Hodgkin’s Hodgkin’s Health-care level II 11 79 Costa Rica 40 28 42 15 15 2 11 19 139 21 564 100 19 El Salvador 6 189 33 165 61 Trinidad and Tobago 26 189 407 56 769 21 61 Total 30 Health-care level III Zimbabwe 75 104 13 295 19 19 22 22 75 Total 13 295 19 0 19 104 Table d5b. Number of patients treated annually with various teletherapy procedures (2000–2006) Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Other digestive Bladder Country Prostate Tumour of Testis Other urological Skin tumours colon and tumour tumour tumours tumour rectum Health-care level I Croatia 104 305 30 35 406 134 85 792 337 1 298 Czech Republic 471 2 120 618 224 Hungary 48 145 13 29 299 100 182 2 410 500 6 070 Japan 1 850 7 070 25 840 4 040 latvia 89 171 144 91 176 78 462 lithuania 682 188 234 14 76 384 176 luxembourg 15 50 9 3 48 20 3 436 33 63 Malta 96 Netherlands 4 000 337 802 56 5 320 41 Norway 54 420 420 1 680 420 Poland 1 680 420 420 Slovenia 11 128 3 26 245 128 309 156 4 53 South Africa 6 67 316 21 Spain 1 093 11 255 628 186 4 812 2 031 1 998 Switzerland 353 106 1 695 146 152 665 400 The former y ugoslav Republic of Macedonia 55 18 23 8 161 2 8 639 3 358 28 000 2 214 Total 18 516 30 302 6 602 Health-care level II 12 145 23 11 20 Costa Rica El Salvador 4 11 13 8 20 10 Trinidad and Tobago 9 60 2 8 52 2 11 Total 22 218 25 16 83 32 25 Health-care level III Zimbabwe 22 37 33 12 49 12 49 22 37 0 0 33 Total

202 190 UNSCEAR 2008 REPORT: VOLUME I Number of patients treated annually with various teletherapy procedures (2000–2006) Table d5c. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Bone and soft tissue Benign Other Total of all patients Palliative Country treated sarcomas diseases treatments Health-care level I 1 659 98 7 249 9 Croatia 128 21 845 894 51 399 230 Czech Republic 7 965 Finland 12 803 240 000 Germany 2 310 545 4 310 42 582 Hungary 1 190 7 800 Japan 20 310 242 510 18 104 14 16 2 705 latvia 165 506 lithuania 295 6 626 333 luxembourg 112 10 40 787 9 1 091 Malta 38 000 Netherlands 62 192 453 8 984 Norway 3 598 420 13 020 420 420 42 000 Poland Slovenia 51 26 47 4 990 1 569 63 722 37 4 186 South Africa 1 000 1 211 11 325 1 570 Spain 81 756 285 Switzerland 306 3 648 937 1 264 14 881 The former y ugoslav Republic of Macedonia 3 22 1 596 a United States 840 000 23 018 46 816 12 194 1 605 873 Total 27 872 Health-care level II China 494 208 30 50 551 Costa Rica 11 19 6 11 981 El Salvador Trinidad and Tobago 77 705 36 30 6 138 496 445 Total 66 Health-care level III 10 Zimbabwe 739 Total 10 0 0 0 739 a Estimate from the Radiological Physics Center, United States . Table d6a. Number of paediatric patients treated annually with teletherapy (2000–2006) Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Country Lymphoma Neuroblastoma Rhabdomyosarcoma Wilm’s tumour Other tumour Brain Health-care level I 22 5 Croatia 4 2 21 3 Czech Republic 33 14 8 8 9 38 Hungary 17 5 3 3 8 Japan 80 60 1 150 700 lithuania 15 1 luxembourg 1 1 Poland 420 420 420 420 420 420

203 ANNEX A: MEDICAL RADIATION EXPOSURES 191 Brain Lymphoma Rhabdomyosarcoma Wilm’s tumour Other tumour Country Neuroblastoma 2 Slovenia 4 11 4 8 1 South Africa 34 14 21 42 77 56 Spain 42 4 3 9 4 Switzerland 7 7 1 316 479 536 488 1 730 Total 532 Health-care level II 6 2 Costa Rica 8 1 11 6 0 2 1 8 Total 11 Health-care level III Zimbabwe 5 2 22 Total 0 0 5 2 22 0 Number of patients treated annually with special teletherapy procedures (2000–2006) Table d6b. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Whole-body irradiation Stereotactic irradiation Country Intraoperative radiotherapy Total lymphoid irradiation Intracranial Extracranial Health-care level I 4 Croatia 30 5 823 Czech Republic Hungary 170 16 200 70 Netherlands 7 6 Norway 208 Poland 150 50 20 765 110 Slovenia 15 Spain 113 1 1 099 296 211 7 Switzerland 127 108 437 470 3 262 406 Total 36 Table d7. Number of patients treated annually with brachytherapy (2000–2006) Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Head/neck Intravascular Breast Other Gynaecological Country Prostate Total tumour brachytherapy tumour tumour tumour Health-care level I Croatia 369 138 508 1 71 345 1 160 Czech Republic 681 2 257 Finland 774 Hungary 14 13 230 47 89 393 Japan 3 940 7 850 1 560 13 350 660 660 latvia 431 447 lithuania 16 luxembourg 31 31 Malta 5 5 Netherlands 2 000 Norway 148 21 19 188 Poland 120 130 5 850 240 110 1 950 8 400

204 192 UNSCEAR 2008 REPORT: VOLUME I Head/neck Country Gynaecological Breast Prostate Total Intravascular Other brachytherapy tumour tumour tumour tumour 212 28 242 Slovenia 2 600 250 856 6 South Africa 1 655 4 017 986 90 7 165 Spain 417 1 900 Sweden 12 238 113 97 12 498 Switzerland 2 185 4 189 ugoslav Republic of Macedonia The former y a United States 0 Total 2 155 21 986 1 386 228 4 837 37 963 4 573 Health-care level II China 0 244 244 Costa Rica 400 400 El Salvador Trinidad and Tobago 80 60 140 0 0 724 60 Total 0 784 0 Health-care level III 0 Zimbabwe Total 0 0 0 0 0 0 0 a Data from the Radiological Physics Center, United States . Table d8. distribution by age and sex of patients undergoing teletherapy for a range of conditions (1997–2007) Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Age distribution (%) Health-care level Country Sex distribution (%) 0–15 years 16–40 years >40 years Male Female Head and neck tumour 0 Croatia 95 86 14 5 Czech Republic 0 1 99 82 18 Hungary 0 4 97 16 84 Japan 0 97 73 27 3 lithuania 5 95 87 13 0 luxembourg 0 0 100 84 16 I Malta 9 91 66 34 0 0 9 91 78 22 Poland Slovenia 0 2 98 81 19 South Africa 0 91 82 18 9 0 100 45 55 Spain 0 0 3 97 73 27 Switzerland Average 0 96 71 29 4 Costa Rica 11 71 79 21 18 II El Salvador 0 6 94 51 49 Average 8 83 65 35 9 Breast tumour 99 Croatia 0 7 93 1 100 I 0 4 96 0 Czech Republic Hungary 0 5 95 3 97

205 ANNEX A: MEDICAL RADIATION EXPOSURES 193 Country Age distribution (%) Health-care level Sex distribution (%) >40 years Male 0–15 years 16–40 years Female 10 1 99 0 Japan 90 7 93 0 100 latvia 0 0 12 0 100 lithuania 88 0 93 0 100 luxembourg 7 0 Malta 99 2 98 1 I 8 92 2 98 Poland 0 7 0 100 0 93 Slovenia 20 80 6 South Africa 0 94 0 11 89 1 99 Spain 0 7 93 1 99 Switzerland 0 Average 92 1 99 8 Costa Rica 86 0 100 0 14 0 13 87 1 99 II El Salvador 0 13 0 100 87 Average Gynaecological tumour 0 11 89 0 100 Croatia Czech Republic 0 3 97 0 100 Hungary 9 91 0 100 0 0 7 93 0 100 Japan latvia 0 5 95 0 100 lithuania 11 89 0 100 0 luxembourg 0 0 100 0 100 I Malta 0 0 100 0 100 Poland 0 90 0 100 10 0 12 0 100 Slovenia 88 6 0 100 0 94 South Africa 8 92 0 Spain 0 100 0 6 94 0 100 Switzerland 0 7 93 0 100 Average Costa Rica 0 25 75 0 100 El Salvador 17 83 0 100 II 0 0 21 79 0 100 Average Prostate tumour Croatia 1 99 100 0 0 0 0 100 100 0 Czech Republic 0 Hungary 0 0 100 100 Japan 0 100 100 0 0 latvia 0 100 100 0 0 lithuania 0 1 99 100 0 luxembourg 0 100 100 0 0 I 0 0 100 100 0 Malta Poland 0 2 98 100 0 Slovenia 0 100 100 0 0 South Africa 0 100 100 0 0 Spain 0 0 100 100 0 Switzerland 0 100 100 0 0 0 0 0 100 100 Average

206 194 UNSCEAR 2008 REPORT: VOLUME I Country Age distribution (%) Health-care level Sex distribution (%) >40 years Male 16–40 years 0–15 years Female 2 100 0 0 98 Costa Rica 0 100 100 0 El Salvador II 0 99 100 0 1 0 Average Brachytherapy treatments 0 6 94 40 60 Czech Republic Hungary 0 99 38 62 1 0 95 11 89 Japan 5 0 6 94 2 98 latvia lithuania 0 93 0 100 7 luxembourg 0 100 0 100 0 I 0 Malta 100 0 100 0 Poland 10 90 24 76 0 0 Slovenia 92 9 91 8 2 33 67 0 Switzerland 98 5 95 16 84 Average 0 Typical patient teletherapy doses (Gy) Table d9a. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Lymphoma Breast Country Lung/ thorax Gynaecological Leukaemia Head/neck Brain tumour tumour tumour tumour tumour Hodgkin’s Non- Hodgkin’s Health-care level I 45 42 40 50 42 50 64 60 Croatia 24 35 40 60 64 70 64 Czech Republic Hungary 12 36 66 50 46 66 60 Japan 12 40 50 60 50 50 30 6 36 60 50 28 68 60 latvia 40 26 37 45 50 45 60 50 lithuania 35 20 36 36 60 60 50 .4 70 60 luxembourg Norway 30 30 50 60 50 70 60 20 60 40 50 Poland 50 60 60 40 Slovenia 30 .6 30 45 50 .6 50 .4 60 56 12 South Africa 36 60 45 50 60 54 45 Spain 12 40 50 60 45 60 55 30 25 60 35 60 60 50 65 Switzerland 30 ugoslav Republic of Macedonia 60 50 The former y 50 16 33 Average 51 60 51 61 53 40 Health-care level II Costa Rica 27 36 40 50 .4 45 45 70 54 El Salvador 40 40 100 40 45 20 Trinidad and Tobago 50 45 60 Average 27 38 40 67 40 45 63 43

207 ANNEX A: MEDICAL RADIATION EXPOSURES 195 Typical patient teletherapy doses (Gy) Table d9b. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Skin Prostate Testis Other urological Tumour of colon Other digestive Bladder Country and rectum tumour tumours tumour tumours tumour Health-care level I 60 74 35 50 50 45 50 Croatia 74 24 45 45 Czech Republic 65 45 50 60 25 .2 50 50 .4 45 Hungary 60 50 30 30 50 50 50 Japan 60 51 70 36 50 50 64 latvia 60 60 54 57 45 53 lithuania 50 40 luxembourg 60 74 26 60 50 .4 60 60 60 60 25 60 50 50 Norway 70 50 50 30 60 50 50 Poland 64 40 48 72 16 .2 46 .8 50 .4 45 Slovenia 30 30 South Africa 30 30 45 54 66 60 50 76 25 50 50 Spain 60 55 50 Switzerland 30 45 50 60 75 The former y ugoslav Republic of Macedonia 66 .8 25 .2 50 .4 Average 54 55 67 30 39 49 50 Health-care level II Costa Rica 76 25 45 45 46 45 El Salvador 65 50 Trinidad and Tobago 46 45 73 25 49 45 Average Table d9c. Typical patient teletherapy doses (Gy) Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Country Palliative treatments Benign diseases Other Bone and soft tissue sarcomas Health-care level I 10 24 12 60 Croatia 30 10 5 Czech Republic Hungary 60 30 8 Japan 40 35 latvia 60 50 40 30 55 3 43 lithuania 30 luxembourg 66 30 30 Norway 12 Poland 20 20 50 60 50 .4 20 20 48 Slovenia South Africa 40 15 Spain 30 30 60 Switzerland 55 30 10 55 Average 42 23 8 52 Health-care level II 50 66 30 Costa Rica Average 66 30 50

208 196 UNSCEAR 2008 REPORT: VOLUME I Typical paediatric teletherapy doses (Gy) Table d10a. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Lymphomas Brain Wilm’s tumour Neuroblastoma Country Rhabdomyosarcoma Health-care level I 55 30 45 20 Croatia 30 Czech Republic 50 30 30 Hungary 26 30 10 40 Japan 20 lithuania 50 luxembourg 20 54 Norway 50 21 50 30 Poland 20 18 12 Slovenia South Africa Spain 20 45 20 54 Sweden Switzerland 65 50 25 30 39 21 49 29 20 Average Table d10b. Typical patient teletherapy special procedure doses (Gy) Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Intraoperative RT Total body Total lymphoid Country Stereotactic irradiation irradiation irradiation Extracranial Intracranial Health-care level I Croatia 42 12 30 Czech Republic Hungary 12 18 Norway 25 20 36 Poland 10 Slovenia 14 Spain 15 12 Switzerland 10 18 10 18 11 37 27 Average

209 ANNEX A: MEDICAL RADIATION EXPOSURES 197 Typical patient brachytherapy doses (Gy) Table d10c. Data from the UNSCEAR Global Survey of Medical Radiation Usage and Exposures Head/neck Gynaecological Prostate Intravascular Other Breast Country brachytherapy tumour tumour tumour tumour Health-care level I 30 32 Croatia 10 Czech Republic 30 4 6 10 10 Hungary 4 .3 35 latvia lithuania 48 14 luxembourg Norway 27 20 10 30 Poland 35 20 30 19 Slovenia 30 10 30 Spain 19 17 20 100 14 50 Switzerland ugoslav Republic of Macedonia 21 The former y Average 10 26 47 17 28 29 Health-care level II Trinidad and Tobago 40 145 Average 40 145 Number of dedicated stereotactic installations by country Table d11. CyberKnife installations [A6] Novalis installations [B8] Country/area GammaKnife installations [E2] 1 Argentina Austria 3 1 1 Belgium 1 Brazil 3 Canada 2 15 1 China 4 6 4 2 China, Taiwan Croatia 1 Czech Republic 1 Democratic People’s Republic of Korea 2 Denmark 1 2 Egypt Finland 1 2 3 France 2 Germany 4 1 3 Greece 1 1 Hong Kong 1 1 India 3 2 Iran, Islamic Rep . Italy 4 3 Japan 46 19 6 Jordan 1 Malaysia 1

210 198 UNSCEAR 2008 REPORT: VOLUME I GammaKnife installations [E2] CyberKnife installations [A6] Country/area Novalis installations [B8] 2 2 Mexico 1 3 Netherlands 1 1 Norway Philippines 1 Republic of Korea 5 1 11 1 Romania Russian Federation 1 2 Singapore 1 Spain 1 1 1 2 Sweden 1 Switzerland Thailand 1 1 Turkey 3 2 United Kingdom 3 United States 116 87 44 Viet Nam 1 Total 244 134 73

211 ANNEX A: MEDICAL RADIATION EXPOSURES 199 REFERENCES pART A Responses to the UNSCEAR Global Survey on Medical Radiation Usage and Exposures Respondent Country Ida Pashko . Radiation Protection Office, Tirana Albania Argentina Adriana Curti . Nuclear Regulatory Authority, Buenos Aires Australia Julian Thomson and Peter Thomas . Australian Radiation Protection and Nuclear Safety Agency, y allambie, Victoria Manfred Ditto . Federal Ministry of Health, Family and y outh, Vienna Austria Azerbaijan National Centre of Oncology, Baku V . Butkevich, G . Chizh, l . Furmanchuk, I . Minailo, R . Smoliakova, I . Tarutin . Ministry of Health, Minsk Belarus Jan Van Dam and Harry Mol . Catholic University leuven, Health Physics, leuven Belgium lodewijk Van Bladel . Federal Agency for Nuclear Control, Brussels Brazil Simone Kodlulovich Dias and Marcello Gomes Goncalves . Instituto de Radioproteção e Dosimetria, Rio de Janeiro Bulgaria G . Vassilev . National Centre of Radiobiology and Radiation Protection, Ministry of Health, Sofia Canada R .P . Bradley and N . Martel . Health Canada, Ottawa Fernando leyton, Otto Delgado, Alfonso Espinoza, Niurka Pérez and Sandra Pobrete . National Health Institute, Marathon Chile Jun Zheng Zheng . laboratory of Industrial Hygiene, Ministry of Health, Beijing China Colombia Blanca Elvira Cajigas de Acosta . Ministerio de la Protección Social, Bogota Aquilino Forero lovera and Juan Vicente Conde Sierra . Ministerio de Salud, Bogota Costa Rica Patricia Mora . Dosimetry Section, Nuclear Physics laboratory, University of Costa Rica, Atomic and Nuclear Sciences Research Center Daisy Benítez Rodríguez . Ministerio de Salud, San José Croatia Nikša Sviličić. State Office for Radiation Protection, Zagreb Czech Republic State Office for Nuclear Safety, Prague . Hana Podškubková and Karla Petrova El Salvador Ronald Enrique Torres Gómez . Unidad Reguladora de Radiaciones Ionizantes (UNRA), San Salvador Mare Varipuu and Irina Filippova . Estonian Radiation Protection Centre, Tallinn Estonia Ethiopia Solomon Demena and Tariku Wordofa . Nuclear Medicine Unit, Department of Internal Medicine, Faculty of Medicine, Addis Ababa Finland Ritva Parkkinen, Ritva Havukainen, Ritva Bly, Helinä Korpela, Petri Sipilä, Petra Tenkanen-Rautakoski, Antti Servomaa . Radiation and Nuclear Safety Authority – STUK, Helsinki France Bernard Aubert . Institut de Radioprotection et de Sûreté Nucléaire (IRSN), Fontenay-aux-Roses Germany E . Nekolla, B . Bauer, J . Griebel, D . Nosske, A . Stamm-Meyer and R . Veit . Federal Office for Radiation Protection, Depart- ment SG “Radiation Protection and Health”, Neuherberg C .J . Hourdakis, Panagiotis Dimitriou, V . Kamenopoulou and Stavroula Vogiatzi . Greek Atomic Energy Commission, Athens Greece Hungary Ivan Földes, Jozsef lovey and Sándor Pellet . National Research Institute for Radiobiology and Radiohygiene, Budapest Iceland Gudlaugur Einarsson . Icelandic Radiation Protection Institute, Reykjavik Indonesia Fadil Nazir and Heru Prasetio . Indonesia Radiation Oncologist Association, Center for Technology of Radiation Safety and Metrology, National Nuclear Energy Agency, Jakarta Japan Japan Expert Panel for UNSCEAR . Regulatory Sciences Research Group, National Institute of Radiological Sciences, Chiba Masahiro Doi, y oshiharu y onekura, Shinji y oshinaga and Kanae Nishizawa . National Institute of Radiological Sciences, Chiba

212 200 UNSCEAR 2008 REPORT: VOLUME I Responses to the UNSCEAR Global Survey on Medical Radiation Usage and Exposures Country Respondent latvia ē ņ a . Health Statistics and Medical Technologies State Agency, Riga Anta V rdi ė , G . Mork nas and J. Žiliukas. Radiation Protection Centre, Vilnius ū B . Gricien lithuania luxembourg Ferid Shannoun . Department of Radiation Protection, Ministry of Health Malaysia lee Peter . Radiation Safety and Health Branch, Ministry of Health Sheena Moosa and Ibrahim y Maldives . Ministry of Health, Male’ asir Malta Paul Brejza and Tilluck Bhikha . Radiation Protection Board, Pieta Reza Pooloo . Physics Section, Ministry of Health, Victoria Hospital, quatre Bornes Mauritius Daw War War Myo Aung, Daw Mi cho cho, lwin lwin Wai . Radiation Protection Department, Department of Atomic Myanmar Energy, Ministry of Science and Technology, y angon H . Bijwaard, E . Meeuwsen and M . Brugmans . National Institute for Public Health and the Environment, BA Bilthoven Netherlands New Zealand John le Heron, Vere Smyth, Glenn Stirling and Tony Cotterill . National Radiation laboratory, Christchurch Norway Berit Sundby Avset, Hans Bjerke, Dag Clement Johannessen, lars Klæboe, Sverre levernes, Gunnar Saxebøl, Eva Bjørklund, Hilde M . Olerud and Jan Frede Unhjem . Norwegian Radiation Protection Authority, Østerås Oman l .S . Arun Kumar and David Wood . Ministry of Health, Muscat Poland Barbara Gwiazdowska, Jerzy Jankowski, Dariusz Kluszczynski, leszek Krolicki, Julian liniecki and Michal Waligorski . National Centre for Radiation Protection in Medicine, lodz Republic of Korea Ministry of Science and Technology, Government Complex Gwacheon Dae-Hyung Cho . Korea Food and Drug Administration Romania Cornelia Diaconescu, Constantin Milu and Olga Iacob . Institute of Public Health, Radiation Hygiene laboratory, Iasi Gabriel Stanescu . National Commission for Nuclear Activities Control, Bucharest Russian Federation S .A . Kalnitsky and V .y . Golikov . State Institute of Radiation Hygiene, Saint-Petersburg Emil Bédi . Public Health Authority of the Slovak Republic, Bratislava Slovakia Nina Jug . Slovenian Radiation Protection Administration, ljubljana Slovenia Primož Strojan. Institute of Oncology, Ljubljana South Africa Petro van der Westhuizen . Wilgers Radiation Oncology Centre, Pretoria Bernard Donde . Johannesburg Hospital Spain Mercedes Bezares and Eliseo Vañó . Department of Public Health, Madrid Sweden Wolfram leitz . Swedish Radiation Protection Institute, Karolinska Hospital, Stockholm Switzerland Philipp Trueb and Gloria Perewusnyk . Swiss Federal Office of Public Health, Radiation Protection Division, Bern Thailand Danai leelasomsiri . Division of Radiation and Medical Devices, Department of Medical Sciences, Nonthaburi The former y ugoslav Republic of Macedonia lidija Nikolovska and Rumen Stamenov . Radiation Safety Directorate, Skopje Trinidad and Tobago Sue Jaan Mejias . Ministry of Health, Port of Spain Tunisia Sadok Mtimet . Centre National de Radioprotection, Tunis Turkey A. Gönül Buyan, Güngör Arslan, Neşe Güven and Ibrahim Uslu. Turkish Atomic Energy Authority, Ankara United Kingdom David Hart, Steve Ebdon-Jackson, Paul Shrimpton and Barry Wall . Health Protection Agency, Chilton, Didcot Venezuela (Bolivarian Republic of) Dirección General de Salud Ambiental, Coordinación de Radiofísica Sanitaria, Urbanización Andrés Bello, Av . las Delicias, Maracay Zimbabwe Godfrey Mukwada, E .D . Maphosa, Naomi Myedziwa . Parirenyatwa Group of Hospitals, Harare

213 ANNEX A: MEDICAL RADIA TION EXPOSURES 201 pART b Arbabi, A. Ten years investigation on radiological A1 Institut Universitaire de Radiophysique Appliquée, exposures to the embryo and fetus in pregnant women Lausanne, 2000 www.hospvd.ch/public/instituts/ira. of Iran. p. 491-494 in: Radiological Protection of B1 British Institute of Radiology. Radiation Protection Patients in Diagnostic and Interventional Radiology, In Interventional Radiology (K. Faulkner and D. Nuclear Medicine and Radiotherapy. Contributed Teunen, eds.). British Institute of Radiology, London, Papers. IAEA, Vienna (2001). 1995. B2 Broadhead, D.A., C.L. Chapple and K. Faulkner. A2 Almond, P.R., P.J. Biggs, B. Coursey et al. AAPM’s The impact of digital imaging on patient doses dur- TG-51 protocol for clinical reference dosimetry of ing barium studies. Br. J. Radiol. 68(813): 992-996 high-energy photon and electron beams. Med. Phys. (1995). 26(9): 1847-1870 (1999). B3 Bahador, B. Trends in Diagnostic Imaging to 2000. Antolak, J.A. and E.A. Strom. Fetal dose estimates A3 Strategies for Success. FT Pharmaceuticals and for electron-beam treatment to the chest wall of a Healthcare Publishing, London, 1996. pregnant patient. Med. Phys. 25(12): 2388-2391 Brix, G., U. Lechel, G. Glatting et al. Radiation expo- B4 (1998). sure of patients undergoing whole-body dual-modal- A4 Andrews, R.T. and P.H. Brown. Uterine arterial ity 18F-FDG PET/CT examinations. J. Nucl. Med. embolization: factors influencing patient radiation 46(4): 608-613 (2005). exposure. Radiology 217(3): 713-722 (2000). Brody, A.S., D.P. Frush, W. Huda et al. Radiation risk B5 A5 Althof, V.G.M., J.C.J. de Boer, H. Huizenga et al. to children from computed tomography. Pediatrics Physical characteristics of a commercial electronic 120(3): 677-682 (2007). portal imaging device. Med. Phys. 23(11): 1845- B6 Barton, M.B., M. Frommer and J. Shafiq. Role of 1855 (1996). radiotherapy in cancer control in low-income and Accuray Incorporated. List of CyberKnife Installa- A6 middle-income countries. Lancet Oncol. 7(7): 584- tions. www.accuray.com/CyberKnifeCenters/index. 595 (2006). aspx. Website accessed 13 May 2008. B7 Bridcut, R.R., E. Murphy, A. Workman et al. Patient Angelucci, M., R. Borio, S. Chiocchini et al. Patient A7 dose from 3D rotational neuro-vascular studies. Br. J. doses and risk evaluation in bone mineral densitom- Radiol. 80(953): 362-366 (2007). etry. Radiat. Prot. Dosim. 86(3): 191-195 (1999). B8 BrainLab AG. www.shapedbeamsurgery.com A8 Aldrich, J.E., A.M. Bilawich and J.R. Mayo. Radia- Accessed 13 May 2008. tion doses to patients receiving computed tomogra- B9 Biggs, D.S. and E.S. Thomson. Radiation properties phy examinations in British Columbia. Can. Assoc. of a miniature X-ray device for radiosurgery. Br. J. Radiol. J. 57(2): 79-85 (2006). Radiol. 69(822): 544-547 (1996). Alecu, R. and M. Alecu. In-vivo rectal dose meas- A9 Berkhout, W.E., G.L. Sanderink and P.F. van der B10 urements with diodes to avoid misadministrations Stelt. Does digital radiography increase the number during intracavitary high dose rate brachytherapy for of intraoral radiographs? A questionnaire study of carcinoma of the cervix. Med. Phys. 26(5): 768-770 Dutch general practice. Dento-Maxillo-Facial Radiol. (1999). 32(2): 124-127 (2003). A10 Agosteo, S., A.F. Para, F. Gerardi et al. Photoneutron B11 Betsou, S., E.P. Efstathopoulos, D. Katritsis et al. dose in soft tissue phantoms irradiated by 25 MV Patient radiation doses during cardiac catheterization x-rays. Phys. Med. Biol. 38(10): 1509-1528 (1993). procedures. Br. J. Radiol. 71(846): 634-639 (1998). A11 Allen, P.D. and M.A. Chaudhri. Charged photopar- B12 Bacher, K., P. Smeets, K. Bonnarens et al. Dose ticle production in tissue during radiotherapy. Med. reduction in patients undergoing chest imaging: Phys. 24(6): 837-839 (1997). digital amorphous silicon flat-panel detector radiog- Aird, E.G.A., J.E. Burns, M.J. Day et al. Central A12 raphy versus conventional film-screen radiography axis depth dose data for use in radiotherapy: 1996. and phosphor-based computed radiography. Am. J. Report of a BIR/IPSM Working Party. Br. J. Radiol. Roentgenol. 181(4): 923-929 (2003). 25 (Suppl.): (1996). Bergeron, P., R. Carrier, D. Roy et al. Radiation doses B13 A13 Arnal, M.L. and H. Pychlau. Die Strahlenbelastung to patients in neuro-interventional procedures. Am. J. des Patienten bei röntgendiagnostischen Untersu- Neuroradiol. 15(10): 1809-1812 (1994). chungen. Fortschr. Geb. Röntgenstr. 95: 323-325 B14 Broadhead, D.A., C.-L. Chapple, K. Faulkner et al. (1961). The impact of cardiology on the collective effective Alm Carlsson, G. and D.R. Dance. Breast absorbed A14 dose in the North of England. Br. J. Radiol. 70(833): doses in mammography: evaluation of experimen- 492-497 (1997). tal and theoretical approaches. Radiat. Prot. Dosim. B15 Burch, A. and D.A. Goodman. A pilot survey of 43(1): 197-200 (1992). radiation doses received in the United Kingdom A15 Aroua, A., J.-P. Vader and J.-F. Valley. A survey on Breast Screening Programme. Br. J. Radiol. 71(845): exposure by radiodiagnostics in Switzerland in 1998. 517-527 (1998).

214 202 UNSCEAR 2008 REPORT: VOLUME I B16 Balter, S., G. Bernardi, E. Cotelo et al. Potential assurance in radiotherapy. Radiography 3(2): 131- 142 (1997). Radiation Guidance Levels for Invasive Cardiology. Brady, L.W. Jr. and S.H. Levitt. The American B31 American Association of Physicists in Medicine 48th Radium Society. Radiation oncology in the 3rd mil- Annual Meeting, Orlando, USA, 1 August 2006. lennium. Radiology 209(3): 593-596 (1998). Bonnett, D.E. Current developments in proton ther- B17 B32 Bruggmoser, G. and R.F. Mould. Brachytherapy apy: a review. Phys. Med. Biol. 38(10): 1371-1392 Review. Freiburg Oncology Series, Monograph No. (1993). Brix, G., H.D. Nagel, G. Stamm et al. Radiation B18 1. Albert-Ludwigs-University, Freiburg, 1994. C1 Chapple, C.L., D.A. Broadhead and K. Faulkner. A exposure in multi-slice versus single-slice spiral CT: phantom based method for deriving typical patient results of a nationwide survey. Eur. Radiol. 13(8): 1979-1991 (2003). doses from measurements of dose-area product on Broadhead, D.A., C.-L. Chapple, K. Faulkner et al. B19 populations of patients. Br. J. Radiol. 68(814): 1083- Local reference doses during cardiology procedures. 1086 (1995). Radiat. Prot. Dosim. 80(1): 149-150 (1998). C2 Canevaro, L.V. and G. Drexler. Fluoroscopy without image intensifier. p. 121-125 in: Radiological Pro- Bor, D., T. Sancak, T. Olgar et al. Comparison of B20 tection of Patients in Diagnostic and Interventional effective doses obtained from dose-area product and Radiology, Nuclear Medicine and Radiotherapy. air kerma measurements in interventional radiology. Contributed Papers. IAEA, Vienna (2001). Br. J. Radiol. 77(916): 315-322 (2004). Carol, M.P., H. Targovnik, D. Smith et al. 3D plan- C3 B21 Bednarek, D.R. and S. Rudin. Comparison of two ning and delivery system for optimized conformal dose-area-product ionization chambers with different conductive surface coating for over-table and under- therapy. Int. J. Radiat. Oncol. Biol. Phys. 24: 159 (1992). table tube configurations. Health Phys. 78(3): 316- C4 321 (2000). Chang, S.D., I.C. Gibbs, G.T. Sakamoto et al. Staged B22 stereotactic irradiation for acoustic neuroma. Neuro- British Journal of Radiology. Central axis depth dose surgery 56(6): 1254-1261 (2005). data for use in radiotherapy. A survey of depth doses C5 Cohnen, M., J. Kemper, O. Möbes et al. Radiation and related data measured in water or equivalent dose in dental radiology. Eur. Radiol. 12(3): 634-637 media. Br. J. Radiol. (Suppl. 17): 1-147 (1983). Britz-Cunningham, S.H. and S. James Adelstein. B23 (2002). Molecular targeting with radionuclides: State of the Cohnen, M., H. Fischer, J. Hamacher et al. CT of the C6 Science. J. Nucl. Med. 44(12): 1945-1961 (2003). head by use of reduced current and kilovoltage: Rela- tionship between image quality and dose reduction. B24 Beteille, D., R. Setzkorn, H. Prévost et al. Laser heat- Am. J. Neuroradiol. 21(9): 1654-1660 (2000). ing of thermoluminescent plates: application to intra- C7 Cozzi, L. and A. Fogliata-Cozzi. Quality assurance in operative radiotherapy. Med. Phys. 23(8): 1421-1424 (1996). radiation oncology: A study of feasibility and impact Brenner, D.J., C.S. Leu, J.F. Beatty et al. Clinical on action levels of an in vivo dosimetry program dur- B25 relative biological effectiveness of low-energy x-rays ing breast cancer irradiation. Radiother. Oncol. 47(1): emitted by miniature x-ray devices. Phys. Med. Biol. 29-36 (1998). 44(2): 323-333 (1999). Cho, P.S., K.L. Lindsley, J.G. Douglas et al. Digi- C8 B26 Burman, C., C.-S. Chui, G. Kutcher et al. Planning, tal radiotherapy simulator. Comput. Med. Imaging Graph. 22(1): 1-7 (1998). delivery, and quality assurance of intensity-modu- lated radiotherapy using dynamic multileaf collima- Carswell, H. Interventionalists fight restenosis with C9 tor: a strategy for large-scale implementation for the radiation. Diagn. Imag. Int. 13(3): 37-50 (1997). treatment of carcinoma of the prostate. Int. J. Radiat. Carroll, E.M. and P.C. Brennan. Investigation into C10 Oncol. Biol. Phys. 39(4): 863-873 (1997). patient doses for intravenous urography and proposed Ballo, M.T., G.K. Zagars, J.N. Cormier et al. Inter- Irish diagnostic reference levels. Eur. Radiol. 13(7): B27 val between surgery and radiotherapy: effect on local 1529-1533 (2003). control of soft tissue sarcoma. Int. J. Radiat. Oncol. Chu, R.Y.L., C. Parry, W. Thompson III et al. Patient C11 Biol. Phys. 58(5): 1461-1467 (2004). doses in abdominal aortogram and aorta femoral runoff examinations. Health Phys. 75(5): 487-491 B28 Bentel, G.C., C.E. Nelson and K.T. Noell. Treatment (1998). Planning and Dose Calculation in Radiation Oncol- ogy, fourth edition. Pergamon Press, New York, Clarke, S.E., D.G. Clarke and N. Prescod. Radionu- C12 clide therapy in the United Kingdom in 1995. Nucl. 1989. B29 Med. Commun. 20(8): 711-717 (1999). British Institute of Radiology. Recommendations for Chapple, C.-L., S. Willis and J. Frame. Effective dose C13 brachytherapy dosimetry. Report of a Joint Working Party of the BIR and the Institute of Physical Sci- in paediatric computed tomography. Phys. Med. Biol. 47(1): 107-115 (2002). ences in Medicine. British Institute of Radiology, C14 London, 1993. Ciraj, O., S. Markovi ć and D. Košuti ć . Patient B30 doses for barium meal examination in Serbia and Blyth, C.M., A.S. McLeod and D.I. Thwaites. A pilot study of the use of in vivo diode dosimetry for quality Montenegro and potentials for dose reduction through

215 203 ANNEX A: MEDICAL RADIATION EXPOSURES changes in equipment settings. Radiat. Prot. Dosim. Crawley, M.T. and A.T. Rogers. Dose-area product C30 114 (1-3): 158-163 (2005). measurements in a range of common orthopaedic procedures and their possible use in establishing local Compagnone, G., L. Pagan and C. Bergamini. Effec- C15 diagnostic reference levels. Br. J. Radiol. 73(871): tive dose calculations in conventional diagnostic 740-744 (2000). X-ray examinations for adult and paediatric patients Chalmers, N., A.P. Hufton, R.W. Jackson et al. Radia- C31 in a large Italian hospital. Radiat. Prot. Dosim. 114(1- tion risk estimation in varicocele embolization. Br. J. 3): 164-167 (2005). Radiol. 73(867): 293-297 (2000). Cohnen, M., L.J. Poll, C. Puettmann et al. Effective C16 D1 Dotter, C.T. and M.P. Judkins. Transluminal treat- doses in standard protocols for multi-slice CT scan- ment of arteriosclerotic obstruction. Description of a ning. Eur. Radiol. 13(5): 1148-1153 (2003). new technic and a preliminary report of its applica- Cohnen, M., H.J. Wittsack, S. Assadi et al. Radia- C17 tion. Circulation 30(5): 654-670 (1964). tion exposure of patients in comprehensive computed Dainty, J.C. and R. Shaw. Image Science. Academic D2 tomography of the head in acute stroke. Am. J. Neu- Press, London, 1974. roradiol. 27(8): 1741-1745 (2006). Dance, D.R. The Monte Carlo calculation of integral D3 C18 Cox, J.D. and K.K. Ang. Radiation Oncology: Ration- radiation dose in xeromammography. Phys. Med. ale, Technique, Results, eighth edition. Mosby, St. Biol. 25(1): 25-37 (1980). Louis, 2003. D4 Dance, D.R. Monte-Carlo calculation of conversion Crawley, M.T., A. Booth and A. Wainwright. A prac- C19 factors for the estimation of mean glandular breast tical approach to the first iteration in the optimization dose. Phys. Med. Biol. 35(9): 1211-1220 (1990). of radiation dose and image quality in CT: estimates D5 Dill, T., A. Deetjen, O. Ekinci et al. Radiation dose of the collective dose savings achieved. Br. J. Radiol. exposure in multislice computed tomography of the 74(883): 607-614 (2001). coronaries in comparison with conventional coronary Coles, D.R., M.A. Smail, I.S. Negus et al. Com- C20 angiography. Int. J. Cardiol. 124(3): 307-311 (2008). parison of radiation doses from multislice computed Drexler, G., W. Panzer, L. Widenmann et al. The D6 tomography coronary angiography and conventional calculation of dose from external photon exposures diagnostic angiography. J. Am. Coll. Cardiol. 47(9): using reference human phantoms and Monte Carlo 1840-1845 (2006). methods. Part III: Organ doses in X-ray diagnosis. C21 Cristy, M. Active bone marrow distribution as a func- GSF-Bericht 11/90 (S-1026) (1990). tion of age in humans. Phys. Med. Biol. 26(3): 389- Donnelly, L.F., K.H. Emery, A.S. Brody et al. Mini- D7 400 (1981). mizing radiation dose for pediatric body applications C22 Chan, H.P. and K. Doi. Monte Carlo simulation stud- of single-detector helical CT: strategies at a large ies of backscatter factors in mammography. Radiol- Children’s Hospital. Am. J. Roentgenol. 176(2): 303- ogy 139(1): 195-199 (1981). 306 (2001). Cameron, J.R. A proposed unit for patient radiation C23 Dong, S.L., T.C. Chu, J.S. Lee et al. Estimation of D8 exposure from diagnostic X-rays. Health Phys. 21(6): mean-glandular dose from monitoring breast entrance 879-880 (1971). skin air kerma using a high sensitivity metal oxide Carlsson, C.A. and G. Alm Carlsson. Dosimetry in C24 semiconductor field effect transistor (MOSFET) diagnostic radiology and computed tomography. p. dosimeter system in mammography. Appl. Radiat. 163-257 in: The Dosimetry of Ionizing Radiation, Isot. 57(6): 791-799 (2002). Vol. III (K.R. Kase, B.E. Bjärngard and F.H. Attix, Delichas, M., K. Psarrakos, E. Molyvda-Athanasso- D9 eds.). Academic Press, Orlando, 1990. poulou et al. Radiation exposure to cardiologists per- Canadian Institute for Health Information. Medical C25 forming interventional cardiology procedures. Eur. J. Imaging in Canada 2007. CIHI, Ottawa, 2008. Radiol. 48(3): 268-273 (2003). C26 Central Intelligence Agency. www.cia.org cited 11 D10 Damilakis, J., K. Perisinakis, A. Voloudaki et al. Esti- September 2006. mation of fetal radiation dose from computed tom- C27 Coche, E., S. Vynckier and M. Octave-Prignot. Pul- ography scanning in late pregnancy: depth-dose data monary embolism: radiation dose with multi-detector from routine examinations. Invest. Radiol. 35(9): row CT and digital angiography for diagnosis. Radi- 527-533 (2000). ology 240(3): 690-697 (2006). D11 Duncan, G., W. Duncan and E.J. Maher. Patterns of Compagnone, G., M. Casadio Baleni, L. Pagan et al. C28 palliative radiotherapy in Canada. Clin. Oncol. (R. Comparison of radiation doses to patients undergo- Coll. Radiol.) 5(2): 92-97 (1993). ing standard radiographic examinations with con- D12 Dance, D.R., C.L. Skinner, K.C. Young et al. Addi- ventional screen-film radiography, computed radi- tional factors for the estimation of mean glandular ography and direct digital radiography. Br. J. Radiol. breast dose using the UK mammography dosim- 79(947): 899-904 (2006). etry protocol. Phys. Med. Biol. 45(11): 3225-3240 (2000). Chamberlain, C.C., W. Huda, L.S. Hojnowski et al. C29 Doyle, P., C.J. Martin and J. Robertson. Techniques D13 Radiation doses to patients undergoing scoliosis radi- for measurement of dose width product in panoramic ography. Br. J. Radiol. 73(872): 847-853 (2000).

216 UNSCEAR 2008 REPORT: VOLUME I 204 dental radiography. Br. J. Radiol. 79(938): 142-147 E8 Einstein, A.J., J. Sanz, S. Dellegrottaglie et al. Radia- (2006). tion dose and cancer risk estimates in 16-slice com- puted tomography coronary angiography. J. Nucl. Department of Health, United Kingdom. Quality D14 Cardiol. 15(2): 232-240 (2008). Assurance in Radiotherapy: A Quality Management Faulkner, K., D.A. Broadhead and R.M. Harrison. F1 System for Radiotherapy. Department of Health, Patient dosimetry measurement methods. Appl. London, 1994. Radiat. Isot. 50(1): 113-123 (1999). Dobelbower, R.R. Jr. and M. Abe. Intra-operative D15 Faulkner, K. The potential for reducing exposure in F2 Radiation Therapy. CRC Press, Florida, 1989. diagnostic radiology. p. 445-462 in: The Expand- D16 Dearnaley, D.P., V.S. Khoo, A.R. Norman et al. Com- ing Role of Medical Physics in Diagnostic Imaging. parison of radiation side-effects of conformal and American Association of Physicists in Medicine, conventional radiotherapy in prostate cancer: a ran- Washington, 1997. domised trial. Lancet 353(9149): 267-272 (1999). Faulkner, K. and B.M. Moores. Radiation dose F3 Dinsmore, M., K.J. Harte, A.P. Sliski et al. A new D17 and somatic risk from computed tomography. Acta miniature x-ray source for interstitial radiosurgery: Radiol. 28(4): 483-488 (1987). device description. Med. Phys. 23(1): 45-52 (1996). Fischmann, A., K.C. Siegmann, A. Wersebe et al. F4 D18 Duch, M.A., M. Ginjaume, H. Chakkor et al. Thermo- Comparison of full-field digital mammography and luminescence dosimetry applied to in vivo dose film-screen mammography: image quality and lesion measurements for total body irradiation techniques. detection. Br. J. Radiol. 78(928): 312-315 (2005). Radiother. Oncol. 47(3): 319-324 (1998). Ferreira, I.H., A. Dutreix, A. Bridier et al. The F5 Das, I.J., C.W. Cheng, D.A. Fein et al. Patterns of D19 ESTRO-QUALity assurance network (EQUAL). dose variability in radiation prescription of breast Radiother. Oncol. 55(3): 273-284 (2000). cancer. Radiother. Oncol. 44(1): 83-89 (1997). F6 Faulkner, K., H.G. Love, J.K. Sweeney et al. Radia- Donahue, B.R. and A.D. Steinfeld. Neutron therapy D20 tion doses and somatic risk to patients during cardiac for pancreatic cancer: thirty years of unrealized radiological procedures. Br. J. Radiol. 59(700): 359- promise. Radiology 200(3): 608-609 (1996). 363 (1986). D21 Derreumaux, S., J. Chavaudra, A. Bridier et al. A F7 Fahey, F.H., M.R. Palmer, K.J. Strauss et al. Dosim- European quality assurance network for radiother- etry and adequacy of CT-based attenuation correction apy: dose measurement procedure. Phys. Med. Biol. for pediatric PET: Phantom study. Radiology 243(1): 40(7): 1191-1208 (1995). 96-104 (2007). D22 Dutreix, J., M. Tubiana and B. Pierquin. The hazy Food and Drug Administration (FDA). Update to F8 dawn of brachytherapy. Radiother. Oncol. 49(3): FDA Statement on Coronary Drug-Eluting Stents, 223-232 (1998). 4 January 2007. www.fda.gov/cdrh/news/010407. Das, I.J. and K.R. Kase. Higher energy: is it neces- D23 html. Accessed 4 November 2007. sary, is it worth the cost for radiation oncology? Med. Faulkner, K. Appropriate methodology for reference F9 Phys. 19(4): 917-925 (1992). levels in examinations involving fluoroscopy. p. 171- E1 European Commission. European guidelines on qual- 176 in: ERPET Course “Establishment of Reference ity criteria for computed tomography. EUR 16262 Doses in Diagnostic Radiology”. CEC, Brussels, EN (1999). 2000. Elekta AB. www.elekta.com/healthcare_international_ E2 F10 Ford, N.L. and M.J. Yaffe. Comparison of image gamma_knife_surgery.php. website accessed 13 May quality indicators among mammo-graphy facilities 2008. in Ontario. Can. Assoc. Radiol. J. 52(6): 369-372 European Commission. Referral guidelines for imag- E3 (2001). ing. Radiation Protection 118 (2000). F11 Fotakis, M., E. Molyvda Athanasopoulou, K. Psarra- Einstein, A.J., M.J. Henzlova and S. Rajagopalan. E4 kos et al. Radiation doses to paediatric patients up to Estimating risk of cancer associated with radiation 5 years of age undergoing micturating cystourethrog- exposure from 64-slice computed tomography coro- raphy examinations and its dependence on patient nary angiography. J. Am. Med. Assoc. 298(3): 317- age: a Monte Carlo study. Br. J. Radiol. 76(911): 323 (2007). 812-817 (2003). E5 European Commission. Guidance on diagnostic ref- F12 Fletcher, D.W., D.L. Miller, S. Balter et al. Compari- erence levels for medical exposure. Radiation Protec- son of four techniques to estimate radiation dose to tion 109 (1999). skin during angiographic and interventional radiol- E6 Efstathopoulos, E.P., S.S. Makrygiannis, S. Kottou et ogy procedures. J. Vasc. Interv. Radiol. 13(4): 391- al. Medical personnel and patient dosimetry during 397 (2002). coronary angiography and intervention. Phys. Med. F13 Friedman, W.A., J.M. Buatti, F.J. Bova et al. Linac Biol. 48(18): 3059-3068 (2003). Radiosurgery: A Practical Guide. Springer-Verlag, Edwards, C.R., M.H. Grieveson, P.J. Mountford et al. E7 New York, 1998. A survey of current in vivo radiotherapy dosimetry F14 Farr, J. Proton Therapy and Dosimetry. Council on practice. Br. J. Radiol. 70(831): 299-302 (1997). Ionizing Radiation and Measurements, 2005.

217 205 ANNEX A: MEDICAL RADIATION EXPOSURES Therapy (B.D. Kavanagh and R.D. Timmerman, Fraass, B., K. Doppke, M. Hunt et al. American Asso- F15 ciation of Physicists in Medicine Radiation Therapy eds.). Lippincott Williams & Wilkins, 2005. G13 Galanski, M., H.D. Nagel and G. Stamm. CT- Committee Task Group 53: Quality assurance for expositionspraxis in der Bundesrepublik Deutsch- clinical radiotherapy treatment planning. Med. Phys. land. Fortschr. Röntgenstr. 173(10): R1-R66 (2001). 25(10): 1773-1829 (1998). Fraass, B.A. and J. van de Geijn. Peripheral dose Giacomuzzi, S.M., P. Torbica, M. Rieger et al. Evalu- G14 F16 ation of radiation exposure with singleslice- and from megavolt beams. Med. Phys. 10(6): 809-818 a multislice-spiral CT system (a phantom study). (1983). F17 Fortschr. Röntgenstr. 173(7): 643-649 (2001). Fraass, B.A. The development of conformal radiation G15 Gennaro, G., P. Baldelli, A. Taibi et al. Patient dose therapy. Med. Phys. 22(11): 1911-1921 (1995). in full-field digital mammography: an Italian survey. Fransson, S.G. and J. Persliden. Patient radiation F18 Eur. Radiol. 14(4): 645-652 (2004). exposure during coronary angiography and interven- G16 Goldenberg, D.M. Targeted therapy of cancer with tion. Acta Radiol. 41(2): 142-144 (2000). Faulkner, K. and A. Werduch. Analysis of the fre- radiolabeled antibodies. J. Nucl. Med. 43(5): 693- F19 713 (2002). quency of interventional cardiology in various Euro- pean countries. Radiat. Prot. Dosim. 129(1-3): 74-76 G17 Gaze, M.N., C.G. Kelly, G.R. Kerr et al. Pain relief (2008). and quality of life following radiotherapy for bone G1 Gill, J.R. Overexposure of patients due to malfunc- metastases: a randomised trial of two fractionation tions or defects in radiation equipment. Radiat. Prot. schedules. Radiother. Oncol. 45(2): 109-116 (1997). Dosim. 43(1): 257-260 (1992). Groh, B.A., J.H. Siewerdsen, D.G. Drake et al. A per- G18 Gallagher, D. Current practices in accident and emer- formance comparison of flat-panel imager-based MV G2 and kV cone-beam CT. Med. Phys. 29(6): 967-975 gency skull radiography. Radiogr. Today 59(673): 21-24 (1993). (2002). Grosswendt, B. Dependence of the photon backscat- G19 Gustavsson, H., A. Karlsson, S.A.J. Bäck et al. G3 ter factor for water on source-to-phantom distance MAGIC-type polymer gel for three-dimensional dosimetry: Intensity-modulated radiation therapy and irradiation field size. Phys. Med. Biol. 35(9): verification. Med. Phys. 30(6): 1264-1271 (2003). 1233-1245 (1990). G4 G20 Georg, D., F. Julia, E. Briot et al. Dosimetric com- Grosswendt, B. Dependence of the photon back- parison of an integrated multileaf-collimator versus scatter factor for water on irradiation field size and source-to-phantom distances between 1.5 and 10 cm. a conventional collimator. Phys. Med. Biol. 42(11): Phys. Med. Biol. 38(2): 305-310 (1993). 2285-2303 (1997). G5 Gosch, D. and S. Gursky. Describing the radiation Ganz, J.C. Gamma Knife Surgery, second edition. G21 Springer, Vienna, 1997. exposure of patients in diagnostic radiology on the G6 basis of absorbed energy. Radiat. Prot. Dosim. 43(1): Griffin, T.W. Fast neutron radiation therapy. Crit. Rev. Oncol./Hematol. 13(1): 17-31 (1992). 115-117 (1992). Grosswendt, B. Backscatter factors for x-rays gener- G22 G7 Guedea, F., T. Ellison, G. Heeren et al. Preliminary analysis of the resources in brachytherapy in Europe ated at voltages between 10 and 100 kV. Phys. Med. and its variability of use. Clin. Transl. Oncol. 8(7): Biol. 29(5): 579-591 (1984). Hoskins, P.R., I. Gillespie and H.M. Ireland. Patient 491-499 (2006). H1 G8 Gray, J.E. Radiological protection issues in mam- dose measurements from femoral angiography. Br. J. mography and computed tomography. p. 183-189 Radiol. 69(828): 1159-1164 (1996). in: Radiological Protection of Patients in Diagnostic Helmrot, E. and G. Alm Carlsson. Measurement H2 of radiation dose in dental radiology. Radiat. Prot. and Interventional Radiology, Nuclear Medicine and Dosim. 114(1-3): 168-171 (2005). Radiotherapy. Contributed Papers. IAEA, Vienna Hounsfield, G.N. Computerized transverse axial (2001). H3 Geist, J.R. and J.O. Katz. Radiation dose-reduction G9 scanning (tomography). 1. Description of system. Br. techniques in North American dental schools. Oral. J. Radiol. 46(552): 1016-1022 (1973). Surg., Oral Med., Oral Pathol., Oral Radiol. Endoc. H4 Hiles, P.A., S.A. Scott, S.E. Brennan et al. All Wales 93(4): 496-505 (2002). CT dose and technique survey. Report by the Medi- cal Imaging Sub-Committee of the Welsh Scientific G10 González, L., E. Vañó and R. Fernández. Refer- ence doses in dental radiodiagnostic facilities. Br. J. Committee, Welsh Office (1996). Radiol. 74(878): 153-156 (2001). H5 Huda, W. and P.J. Mergo. How will the introduction G11 of multi-slice CT affect patient doses? p. 202-205 Guibelalde, E., E. Vañó, L. González et al. Practical in: Radiological Protection of Patients in Diagnos- aspects for the evaluation of skin doses in interven- tic and Interventional Radiology, Nuclear Medicine tional cardiology using a new slow film. Br. J. Radiol. 76(905): 332-336 (2003). and Radiotherapy. Contributed Papers. IAEA, Vienna (2001). G12 Galvin, J.M. and G.S. Ibbott. Commissioning and Huda, W., E.M. Scalzetti and G. Levin. Technique accreditation of a stereotactic body radiation therapy H6 program. p. 85-93 in: Stereotactic Body Radiation factors and image quality as functions of patient

218 206 UNSCEAR 2008 REPORT: VOLUME I Heyman, J. The so-called Stockholm method and the H23 weight at abdominal CT. Radiology 217(2): 430-435 results of treatment of uterine cancer at the Radium- (2000). H7 hemmet. Acta Radiol. 16: 129-148 (1935). Huyskens, C.J. and W.A. Hummel. Data analysis on Hart, D. and B.F. Wall. UK population dose from H24 patient exposures in cardiac angiography. Radiat. medical X-ray examinations. Eur. J. Radiol. 50(3): Prot. Dosim. 57(1): 475-480 (1995). Hanson, W.F., R.J. Shalek and P. Kennedy. Dosim- H8 285-291 (2004). etry quality assurance in the United States from the H25 Hart, D. and B.F. Wall. A survey of nuclear medicine experience of the Radiological Physics Center, IAEA/ in the UK in 2003/4. HPA-RPD-003 (2005). Hokkanen, J., J. Heikkonen and P. Holmberg. Theo- WHO Vienna, Austria. SSDL Newsletter 30 (1991). H26 retical calculations of dose distributions for beta-ray H9 Hammerstein, G.R., D.W. Miller, D.R. White et al. eye applicators. Med. Phys. 24(2): 211-213 (1997). Absorbed radiation dose in mammography. Radio- Heart Foundation. www.heartstat.org. Accessed 24 H27 logy 130(2): 485-491 (1979). Heggie, J.C. Patient doses in multi-slice CT and the H10 February 2006. Harrison, R.M., C. Walker and R.J. Aukett. Measure- importance of optimisation. Australas. Phys. Eng. H28 Sci. Med. 28(2): 86-96 (2005). ment of backscatter factors for low energy radio- Hart, D., B.F. Wall, P.C. Shrimpton et al. Reference H11 therapy (0.1-2.0 mm Al HVL) using thermolumines- doses and patient size in paediatric radiology. NRPB- cence dosimetry. Phys. Med. Biol. 35(9): 1247-1254 (1990). R318 (2000). Harrison, R.M. Backscatter factors for diagnos- H12 Hart, D., M.C. Hillier, B.F. Wall et al. Doses to H29 tic radiology (1-4 mm Al HVL). Phys. Med. Biol. patients from medical x-ray examinations in the UK: 27(12): 1465-1474 (1982). 1995 review. NRPB-R289 (1996). H30 Hart, D., D.G. Jones and B.F. Wall. Normalised H13 Hart, D., D.G. Jones and B.F. Wall. Estimation of effective dose in diagnostic radiology from entrance organ doses for medical x-ray examinations calcu- lated using Monte Carlo techniques. NRPB-SR262 surface dose and dose-area product measurements. NRPB-R262 (1994). (1994). H31 Hart, D., D.G. Jones and B.F. Wall. Coefficients for H14 Huda, W., J.V. Atherton, D.E. Ware et al. An approach estimating effective dose from paediatric x-ray exam- for the estimation of effective radiation dose at CT inations. NRPB-R279 (1996). in pediatric patients. Radiology 203(2): 417-422 H32 Hart, D., D.G. Jones and B.F. Wall. Normalised organ (1997). H15 Huda, W., C.C. Chamberlain, A.E. Rosenbaum et doses for paediatric x-ray examinations calculated al. Radiation doses to infants and adults undergoing using Monte Carlo techniques. NRPB-SR279 (1996). Hart, D. and B.F. Wall. Radiation exposure of the UK H33 head CT examinations. Med. Phys. 28(3): 393-399 (2001). population from medical and dental x-ray examina- tions. NRPB-W4 (2002). H16 Hays, M.T., E.E. Watson, S.R. Thomas et al. MIRD Dose Estimate Report No. 19: Radiation absorbed H34 Hart, D., M.C. Hillier and B.F. Wall. Doses to patients 18 F-FDG. J. Nucl. Med. 43(2): dose estimates from from medical x-ray examinations in the UK: 2000 210-214 (2002). review. NRPB-W14 (2002). Hendee, W.R., G.S. Ibbott and E.G. Hendee. Radia- Hunold, P., F.M. Vogt, A. Schmermund et al. Radia- H17 H35 tion Therapy Physics, third edition. John Wiley and tion exposure during cardiac CT: effective doses at Sons, Hoboken, N.J., 2004. multi-detector row CT and electron-beam CT. Radi- H18 ology 226(1): 145-152 (2003). Hounsell, A.R. and J.M. Wilkinson. Electron contam- ination and build-up doses in conformal radiotherapy H36 Huda, W. and A. Vance. Patient radiation doses from fields. Phys. Med. Biol. 44(1): 43-55 (1999). adult and pediatric CT. Am. J. Roentgenol. 188(2): H19 Huda, W. Radiation doses and risks in chest com- 540-546 (2007). Heggie, J.C. A survey of doses to patients in a large H37 puted tomography examinations. Proc. Am. Thorac. public hospital resulting from common plain film Soc. 4(4): 316-320 (2007). Hellawell, G.O., N.C. Cowen, S.J. Holt et al. A radia- H20 radiographic procedures. Australas. Phys. Eng. Sci. tion perspective for treating loin pain in pregnancy by Med. 13(2): 71-80 (1990). double-pigtail stents. Br. J. Urol. Int. 90(9): 801-808 Honda, K., T.A. Larheim, K. Maruhashi et al. Osseous H38 (2002). abnormalities of the mandibular condyle: diagnostic H21 reliability of cone beam computed tomography com- Hurwitz, L.M., T.T. Yoshizumi, R.E. Reiman et al. Radiation dose to the female breast from 16-MDCT pared with helical computed tomography based on an body protocols. Am. J. Roentgenol. 186(6): 1718- autopsy material. Dentomaxillofacial Radiol. 35(3): 1722 (2006). 152-157 (2006). Horiguchi, J., M. Kiguchi, C. Fujioka et al. Radia- H22 H39 Hermann, K.P., S. Obenauer, K. Marten et al. Average glandular dose with amorphous silicon full-field digi- tion dose, image quality, stenosis measurement, and CT densitometry using ECG-triggered coronary tal mammography—clinical results. Roefo Fortschr. Geb. Roentgenstr. Neuen Bildgebenden Verfahr. 64-MDCT angiography: a phantom study. Am. J. 174(6): 696-699 (2002). Roentgenol. 190(2): 315-320 (2008).

219 207 ANNEX A: MEDICAL RADIATION EXPOSURES Hausleiter, J., T. Meyer, M. Hadamitzky et al. Radia- H40 International Commission on Radiation Units and I14 tion dose estimates from cardiac multislice computed Measurements. Dose and volume specification for tomography in daily practice: impact of different reporting intracavitary therapy in gynaecology. ICRU scanning protocols on effective dose estimates. Cir- Report 38 (1985). culation 113(10): 1305-1310 (2006). International Commission on Radiation Units and I15 Hurwitz, L.M., R.E. Reiman, T.T. Yoshizumi et al. H41 Measurements. Use of computers in external beam Radiation dose from contemporary cardiothoracic radiotherapy procedures with high-energy photons multidetector CT protocols with an anthropomorphic and electrons. ICRU Report 42 (1987). female phantom: implications for cancer induction. I16 Ibbott, G.S., W.F. Hanson, E. O’Meara et al. Dose Radiology 245(3): 742-750 (2007). specification and quality assurance of radiation I1 International Commission on Radiological Protection. therapy oncology group protocol 95-17; a coopera- Avoidance of Radiation Injuries from Medical Inter - tive group study of iridium-192 breast implants as ventional Procedures. ICRP Publication 85. Annals of sole therapy. Int. J. Radiat. Oncol. Biol. Phys. 69(5): the ICRP 30(2). Pergammon Press, Oxford, 2000. 1572-1578 (2007). International Commission on Radiation Units and I2 I17 International Atomic Energy Agency. Dosimetry in Measurements. Quantities and units in radiation pro- diagnostic radiology: An international code of prac- tection dosimetry. ICRU Report 51 (1993). tice. Technical Reports Series No. 457. IAEA, Vienna International Commission on Radiological Protec- I3 (2007). tion. 1990 Recommendations of the International International Atomic Energy Agency. Lessons I18 Commission on Radiological Protection. ICRP Pub- learned from accidental exposures in radiotherapy. lication 60. Annals of the ICRP 21(1-3). Pergamon Safety Reports Series No. 17. IAEA, Vienna (2000). Press, Oxford, 1991. International Atomic Energy Agency. http://rpop. I19 Imhof, H., N. Schibany, A. Ba-Ssalamah et al. Spiral CT I4 iaea.org accessed 21 July 2008. and radiation dose. Eur. J. Radiol. 47(1): 29-37 (2003). Izewska, J. and P. Andreo. The IAEA/WHO TLD I20 I5 International Commission on Radiological Protec- postal programme for radiotherapy hospitals. Radi- tion. Protection of the Patient in Nuclear Medicine. other. Oncol. 34(1): 65-72 (2000). Includes Statement from the 1987 Como Meeting of International Atomic Energy Agency. Training course I21 the ICRP. ICRP Publication 52. Annals of the ICRP on radiation protection in radiotherapy. IAEA, Vienna 17(4). Pergamon Press, Oxford, 1987. (2005). International Commission on Radiological Protection. I6 Ibbott, G.S. Applications of gel dosimetry. J. Phys.: I22 The 2007 Recommendations of the International Com- Conf. Ser. 3: 58-77 (2004). mission on Radiological Protection. ICRP Publication I23 Institute of Physical Sciences in Medicine. Report of the 103. Annals of the ICRP 37(2-4). Elsevier, Oxford, 2008. IPSM working party on low- and medium-energy x-ray I7 Ibbott, G.S., F.H. Attix, T.W. Slowey et al. Uncertainty dosimetry. Phys. Med. Biol. 36(8): 1027-1038 (1991). of calibrations at the accredited dosimetry calibration I24 Iwai, K., Y. Arai, K. Hashimoto et al. Estimation of laboratories. Med. Phys. 24(8): 1249-1254 (1997). effective dose from limited cone beam X-ray CT International Commission on Radiological Protec- I8 examination. Dental Radiol. 40(4): 251-259 (2000). tion. Managing Patient Dose in Digital Radiology. I25 International Commission on Radiological Protec- ICRP Publication 93. Annals of the ICRP 34(1). tion. Radiation Dose to Patients from Radiopharma- Elsevier, Oxford, 2004. ceuticals. ICRP Publication 80. Annals of the ICRP I9 International Commission on Radiation Units and 28(3). Pergamon Press, Oxford, 1998. Measurements. Prescribing, recording and reporting I26 International Commission on Radiological Protec- photon beam therapy. ICRU Report 50 (1993). tion. Reference Man: Anatomical, Physiological International Commission on Radiation Units and I10 and Metabolic Characteristics. ICRP Publication 23. Measurements. Dose specification for reporting Pergamon Press, Oxford, 1975. external beam therapy with photons and electrons. International Commission on Radiological Protec- I27 ICRU Report 29 (1978). tion. Prevention of Accidents to Patients Undergoing I11 International Atomic Energy Agency. International Radiation Therapy. ICRP Publication 86. Annals of basic safety standards for protection against ioniz- the ICRP 30(3). Pergamon Press, Oxford, 2002. ing radiation and for the safety of radiation sources. Safety Series No. 115. IAEA, Vienna (1996). International Commission on Radiological Protec- I28 tion. Managing Patient Dose in Computed Tomogra- International Atomic Energy Agency. Absorbed I12 phy. ICRP Publication 87. Annals of the ICRP 30(4). dose determination in photon and electron beams: Pergamon Press, Oxford, 2002. An international code of practice. Technical Reports Series No. 277. IAEA, Vienna (1987). I29 Izewska, J., D. Georg, P. Bera et al. A methodology I13 International Commission on Radiation Units and Meas- for TLD postal dosimetry audit of high-energy radio- urements. Radiation dosimetry: electron beams with ener - therapy photon beams in non-reference conditions. gies between 1 and 50 MeV. ICRU Report 35 (1984). Radiother. Oncol. 84(1): 67-74 (2007).

220 208 UNSCEAR 2008 REPORT: VOLUME I I30 International Commission on Radiation Units and International Atomic Energy Agency. Dosimetry I44 Measurements. Phantoms and computational models in radiotherapy. Proceedings Series. IAEA, Vienna in therapy, diagnosis and protection. ICRU Report 48 (1988). (1992). International Atomic Energy Agency. Absorbed dose I45 An determination in external beam radiotherapy: International Commission on Radiation Units and I31 international code of practice for dosimetry based Measurements. Prescribing, recording and reporting . Technical on standards of absorbed dose to water photon beam therapy (Supplement to ICRU Report Reports Series No. 398. IAEA, Vienna. (2000). 50). ICRU Report 62 (1999). I46 International Commission on Radiation Units and International Electrotechnical Commission. Medical I32 Measurements. Patient dosimetry for X-rays used in electrical equipment—Part 2-44: Particular require- medical imaging. ICRU Report 74 (2005). ments for the safety of x-ray equipment for computed I47 International Commission on Radiation Units and tomography. IEC Standard 60601-2-44, edition 2.1. Measurements. Fundamental quantities and units for IEC, Geneva (2002). ionizing radiation. ICRU Report 60 (1998). Isoardi, P. and R. Ropolo. Measurement of dose- I33 International Commission on Radiological Protec- I48 width product in panoramic dental radiology. Br. J. tion. The Biological Basis for Dose Limitation in Radiol. 76(902): 129-131 (2003). . ICRP Publication 59. Annals of the ICRP the Skin I34 International Commission on Radiological Protec- 22(2). Pergamon Press, Oxford, 1991. tion. Radiation Dose to Patients from Radiopharma- Jones, D.G. and B.F. Wall. Organ doses from medi- J1 ceuticals. ICRP Publication 53. Annals of the ICRP cal X-ray examinations calculated using Monte Carlo 18(1-4). Pergamon Press, Oxford, 1988. techniques. NRPB-R186 (1985). I35 Ibbott, G.S., D.S. Followill, H.A. Molineu et al. Chal- Jessen, K.A., P.C. Shrimpton, J. Geleijns et al. J2 lenges in credentialing institutions and participants in Dosimetry for optimisation of patient protection in advanced technology multi-institutional clinical tri- computed tomography. Appl. Radiat. Isot. 50(1): als. Int. J. Radiat. Oncol. Biol. Phys. 71(1): S71-S75 165-172 (1999). (2008). Jones, D.G. and P.C. Shrimpton. Survey of CT prac- J3 International Commission on Radiological Protec- I36 tice in the UK. Part 3: Normalised organ doses cal- tion. Limits for Intakes of Radionuclides by Work- culated using Monte Carlo techniques. NRPB-R250 ers. ICRP Publication 30. Annals of the ICRP 19(4). (1991). Pergamon Press, New York, 1979. Johnson, D.R., J. Kyriou, E.J. Morton et al. Radiation J4 protection in interventional radiology. Clin. Radiol. I37 International Commission on Radiological Protec- 56(2): 99-106 (2001). tion. Doses to the Embryo and Fetus from Intakes Jamal, N., K.H. Ng and D. McLean. A study of mean J5 of Radionuclides by the Mother. ICRP Publication glandular dose during diagnostic mammography in 88. Annals of the ICRP 31(1-3). Pergamon Press, Malaysia and some of the factors affecting it. Br. J. Oxford, 2001. Radiol. 76(904): 238-245 (2003). Ibbott, G., M. Beach and M. Maryanski. An anthro- I38 J6 Jones, G., H. Lukka and B. O’Brien. High dose rate pomorphic head phantom with a BANG® polymer versus low dose rate brachytherapy for squamous cell gel insert for the dosimetric evaluation of intensity carcinoma of the cervix: an economic analysis. Br. J. modulated radiation therapy treatment delivery. Vol- Radiol. 67(803): 1113-1120 (1994). ume 2. p. 361-368 in: Standards and Codes of Prac- J7 Jones, B., P.L. Pryce, P.R. Blake et al. High dose rate tice in Medical Radiation Dosimetry. Proceedings brachytherapy practice for the treatment of gynae- Series. IAEA, Vienna (2003). cological cancers in the UK. Br. J. Radiol. 72(856): I39 Ibbott, G.S. The medical physics consult – gel dosim- 371-377 (1999). etry. J. Am. Coll. Radiol. 3(2): 144-146 (2006). Jani, S.K. Physics of vascular brachytherapy. J. Inva- J8 Ibbott, G.S., A. Molineu and D.S. Followill. Inde- I40 sive Cardiol. 11(8): 517-523 (1999). pendent evaluations of IMRT through the use of an J9 Johnson, S.H. Cancer patients got extra radiation. anthropomorphic phantom. Technol. Cancer Res. Tampa Tribune, 2 April 2005. http://news.tbo.com/ Treat. 5(5): 481-487 (2006). news/MGBIKLZB17E.html. Website accessed 4 I41 International Commission on Radiation Units and April 2005. Measurements. Clinical proton dosimetry. Part 1: J10 Johns, H.E., E.R. Epp, D.V. Cormack et al. 1000 curie beam production, beam delivery and measurement of cobalt units for radiation therapy. II. Depth dose data absorbed dose. ICRU Report 59 (1998). and diaphragm design for the Saskatchewan 1000 I42 International Atomic Energy Agency. Cobalt-60 tel- curie cobalt unit. Br. J. Radiol. 25(294): 302-308 etherapy: A compendium of international practice. (1952). IAEA, Vienna (1984). Jansen, J.T.M., J. Dierker and J. Zoetelief. Calcula- J11 tion of air kerma to mean glandular dose conversion International Atomic Energy Agency. Radiotherapy I43 factors for mammography units employing various in developing countries. Proceedings Series. IAEA, target-filter combinations. p. 66-75 in: Proceedings Vienna (1987).

221 ANNEX A: MEDICAL RADIATION EXPOSURES 209 K14 Kemerink, G.J., P.J.H. Kicken, F.W. Schultz et al. of the Xth Scientific Symposium of the Belgian Society of Hospital Physicists (B. Schaeken and J. Patient dosimetry in abdominal arteriography. Phys. Med. Biol. 44(5): 1133-1145 (1999). Vanregemorter, eds.). Belgian Society of Hospital Kowalsky, R.J. and S.W. Falen. Radio-pharmaceu- K15 Physicists, Antwerpen, Belgium, 1994. ticals in Nuclear Pharmacy and Nuclear Medicine. K1 Kanai, T. and E. Takada (eds.). Proceedings of NIRS American Pharmacists Association, Washington, International Seminar on the Application of Heavy 2004. Ion Accelerator to Radiation Therapy of Cancer. K16 Koizumi, K., N. Tamaki, T. Inoue et al. Nuclear NIRS-M-103 (1994). medicine practice in Japan: a report of the 5th nation- K2 Kanai, T., M. Endo, S. Minohara et al. Biophysical wide survey in 2002. Ann. Nucl. Med. 18(1): 73-78 characteristics of HIMAC clinical irradiation system (2004). for heavy-ion radiation therapy. Int. J. Radiat. Oncol. Kutcher, G.J., L. Coia, M. Gillin et al. Comprehen- K17 Biol. Phys. 44(1): 201-210 (1999). sive QA for radiation oncology: report of AAPM K3 Kavanagh, B.D., T.E. Schefter, H.R. Cardenes et al. Radiation Therapy Committee Task Group 40. Med. Biologically potent doses safely achieved in a multi- Phys. 21(4): 581-618 (1994). center trial of stereotactic body radiation therapy for K18 Kubo, H.D., G.P. Glasgow, T.D. Pethel et al. High liver metastases. Int. J. Radiat. Oncol. Biol. Phys. dose-rate brachytherapy treatment delivery: report 60(1) (Suppl.): S412 (2004). of the AAPM Radiation Therapy Committee Task Knöpfle, E., M. Hamm, S. Wartenberg et al. CT in K4 Group No. 59. Med. Phys. 25(4): 375-403 (1998). ureterolithiasis with a radiation dose equal to intrave- Kuske, R.R., K. Winter, D.W. Arthur et al. Phase II K19 nous urography: results in 209 patients. Roefo Fort- trial of brachytherapy alone after lumpectomy for schr. Geb. Roentgenstr. Neuen Bildgebenden Verfahr. select breast cancer: toxicity analysis of RTOG 95-17. 175(12): 1667-1672 (2003). (In German). Int. J. Radiat. Oncol. Biol. Phys. 65(1): 45-51 (2006). K5 Kemerink, G.J., M.W. De Haan, G.B. Vasbinder et al. K20 Kron, T. Applications of thermo-luminescence The effect of equipment set up on patient radiation dosimetry in medicine. Radiat. Prot. Dosim. 85(1): dose in conventional and CT angiography of the renal 333-340 (1999). arteries. Br. J. Radiol. 76(909): 625-630 (2003). Kirby, T.H., W.F. Hanson and D.A. Johnston. Uncer- K21 K6 Kuiper, J.W., J. Geleijns, N.A.A. Matheijssen et tainty analysis of absorbed dose calculations from al. Radiation exposure of multi-row detector spi- thermoluminescence dosimeters. Med. Phys. 19(6): ral computed tomography of the pulmonary arter- 1427-1433 (1992). ies: comparison with digital subtraction pulmonary Kry, S., U. Titt, F. Poenisch et al. SU-CC-J-6C-02: A K22 angiography. Eur. Radiol. 13(7): 1496-1500 (2003). Monte Carlo simulation of out-of-field radiation from Kase, K.R., X.S. Mao, W.R. Nelson et al. Neutron K7 an 18-MV beam. Med. Phys. 32(6): 1889 (2005). fluence and energy spectra around the Varian Clinac Kramer, R., M. Zankl, G. Williams et al. The calcu- K23 2100C/2300C medical accelerator. Health Phys. lation of dose from external photon exposures using 74(1): 38-47 (1998). reference human phantoms and Monte Carlo meth- Kubo, H.D. and B.C. Hill. Respiration gated radio- K8 ods. Part I: the male (ADAM) and female (EVA) therapy treatment: a technical study. Phys. Med. Biol. adult mathematical phantoms. GSF Bericht S-885, 41(1): 83-91 (1996). ISSN 0721-1694 (1982). K9 Kavanagh, B.D. and R.D. Timmerman (eds.). Stere- K24 Klevenhagen, S.C. Experimentally determined otactic Body Radiation Therapy. Lippincott Williams backscatter factors for X-rays generated at voltages & Wilkins, 2005. kV. Phys. Med. Biol. 34(12): between 16 and 140 K10 Klevenhagen, S.C., R.J. Aukett, R.M. Harrison et al. 1871-1882 (1989). The IPEMB code of practice for the determination of K25 Klevenhagen, S.C. The build-up of back-scatter in absorbed dose for x-rays below 300 kV generating the energy range 1 mm Al to 8 mm Al HVT (radio- potential (0.035 mm Al-4 mm Cu HVL; 10-300 kV therapy beams). Phys. Med. Biol. 27(8): 1035-1043 generating potential). Phys. Med. Biol. 41(12): 2605- (1982). 2625 (1996). Klein, R., H. Aichinger, J. Dierker et al. Determina- K26 Kalra, M.K., M.M. Maher, T.L. Toth et al. Techniques K11 tion of average glandular dose with modern mam- and applications of automatic tube current modula- mography units for two large groups of patients. tion for CT. Radiology 233(3): 649-657 (2004). Phys. Med. Biol. 42(4): 651-671 (1997). K12 Kuon, E., C. Glaser and J.B. Dahm. Effective tech- K27 Keat, N. CT scanner automatic exposure control sys- tems. MHRA Evaluation Report 05016. Medicines niques for reduction of radiation dosage to patients and Healthcare Products Regulatory Agency, London undergoing invasive cardiac procedures. Br. J. Radiol. (2005). 76(906): 406-413 (2003). K28 Kuon, E., J.B. Dahm, M. Schmitt et al. Time of day K13 Khursheed, A., M.C. Hillier, P.C. Shrimpton et al. influences patient radiation exposure from percuta- Influence of patient age on normalized effective neous cardiac interventions. Br. J. Radiol. 76(903): doses calculated for CT examinations. Br. J. Radiol. 189-191 (2003). 75(898): 819-830 (2002).

222 UNSCEAR 2008 REPORT: VOLUME I 210 artificial erosive changes: comparison with conven- Karambatsakidou, A., P. Tornvall, N. Saleh et al. K29 tional screen-film and storage-phosphor radiography. Skin dose alarm levels in cardiac angiography proce- Eur. Radiol. 13(6): 1316-1323 (2003). dures: Is a single DAP value sufficient? Br. J. Radiol. 78(933): 803-809 (2005). Ludlow, J.B., L.E. Davies-Ludlow and S.L. Brooks. L12 Dosimetry of two extraoral direct digital imaging Kicken, P.J.H., D. Koster and G.J. Kemerink. Expo- K30 devices: NewTom cone beam CT and orthophos plus sure conditions of patients in vascular radiology. DS panoramic unit. Dento-Maxillo-Facial Radiol. Radiat. Prot. Dosim. 86(2): 129-137 (1999). 32(4): 229-234 (2003). K31 Kiljunen, T., H. Järvinen and S. Savolainen. Diagnos- tic reference levels for thorax X-ray examinations of L13 Li, L.B., M. Kai and T. Kusama. Radiation exposure paediatric patients. Br. J. Radiol. 80(954): 452-459 to patients during paediatric cardiac catheterisation. (2007). Radiat. Prot. Dosim. 94(4): 323-327 (2001). K32 Kirby, T.H., W.F. Hanson, R.J. Gastorf et al. Mailable Larrazet, F., A. Dibie, F. Philippe et al. Factors influ- L14 TLD system for photon and electron therapy beams. encing fluoroscopy time and dose-area product val- Int. J. Radiat. Oncol. Biol. Phys. 12(2): 261-265 ues during ad-hoc one-vessel percutaneous coronary (1986). angioplasty. Br. J. Radiol. 76(907): 473-477 (2003). L1 LoSasso, T., C.S. Chui and C.C. Ling. Comprehen- L15 Lee, K.Y., M.C. Chau et al. Design of an inexpensive sive quality assurance for the delivery of intensity phantom for IMRT verification. Radiother. Oncol. 61 modulated radiotherapy with a multileaf collimator (Suppl. 1): S110 (2001). used in the dynamic mode. Med. Phys. 28(11): 2209- L16 Leung, K.C. and C.J. Martin. Effective doses for cor- 2219 (2001). onary angiography. Br. J. Radiol. 69(821): 426-431 L2 Lavoie, C. and P. Rasuli. Radiation dose during angi- (1996). ographic procedures. p. 259-262 in: Radiological Lewis, M.A. Multislice CT: opportunities and chal- L17 Protection of Patients in Diagnostic and Interven- lenges. Br. J. Radiol. 74(885): 779-781 (2001). tional Radiology, Nuclear Medicine and Radiother- López-Palop, R., J. Morán, F. Fernández-Vázquez L18 apy. Contributed Papers. IAEA, Vienna (2001). et al. Spanish registry of cardiac catheterization and Lewis, M.K., G.M. Blake and I. Fogelman. Patient L3 coronary interventions. Thirteenth official report of dose in dual x-ray absorptiometry. Osteoporosis Int. the working group on cardiac catheterization and 4(1): 11-15 (1994). interventional cardiology of the Spanish Society of L4 Lindskoug, B.A. Reference man in diagnostic radiol- Cardiology (1990-2003). Rev. Esp. Cardiol. 57(11): ogy dosimetry. Radiat. Prot. Dosim. 43(1): 111-114 1076-1089 (2004). (In Spanish.) (1992). Laxmi. http://laxmi.nuc.ucla.edu:8000/lpp/ radioiso- L19 Lecomber, A.R. and K. Faulkner. Organ absorbed L5 topes/tracers.html. doses in intraoral dental radiography. Br. J. Radiol. Lewington, V.J. Bone-seeking radionuclides for ther- L20 66(791): 1035-1041 (1993). apy. J. Nucl. Med. 46(1): 38S-47S (2005). Lecomber, A.R. and K. Faulkner. Dose reduction L6 L21 Last, A. Radiotherapy in patients with cardiac pace- in panoramic radiography. Dento-Maxillo-Facial makers. Br. J. Radiol. 71(841): 4-10 (1998). Radiol. 22(2): 69-73 (1993). Low, D.A., S. Mutic, J.F. Dempsey et al. Quantita- L22 L7 Leksell Gamma Knife Society. Indications treated tive dosimetric verification of an IMRT planning and December 2005. Stockholm, Sweden. www.elekta. delivery system. Radiother. Oncol. 49(3): 305-316 com/healthcare_us_leksell_gamma_knife_society. (1998). php. L23 Li, X.A., C.-M. Ma, D. Salhani et al. Dosimetric Lillicrap, S.C., P. Paras and H. Duschka. Influence L8 evaluation of a widely used kilovoltage x-ray unit for of standardisation in the design and development of endocavitary radiotherapy. Med. Phys. 25(8): 1464- medical radiological equipment for the protection of 1471 (1998). the patient. p. 347-357 in: Radiological Protection of Lanson, J.H., M. Essers, G.J. Meijer et al. In vivo L24 Patients in Diagnostic and Interventional Radiology, dosimetry during conformal radiotherapy: require- Nuclear Medicine and Radio-therapy. Contributed ments for and findings of a routine procedure. Papers. IAEA, Vienna (2001). Radiother. Oncol. 52(1): 51-59 (1999). Lomax, A.J., T. Bohringer, A. Bolsi et al. Treatment L9 Larsson, J.P., J. Persliden, M. Sandborg et al. Trans- L25 planning and verification of proton therapy using mission ionization chambers for measurements of air spot scanning: initial experience. Med. Phys. 31(11): collision kerma integrated over beam area. Factors 3150-3157 (2004). limiting the accuracy of calibration. Phys. Med. Biol. L10 Lecomber, A.R., Y. Yonegama, D.J. Lovelock et al. 41(11): 2381-2398 (1996). Comparison of patient dose from imaging protocols L26 Lewin, J.M., C.J. D’Orsi and R.E. Hendrick. for dental implant planning using conventional radi- Digital mammography. Radiol. Clin. North Am. ography and computed tomography. Dento-Maxillo- 42(5): 871-884 (2004). Facial Radiol. 30(5): 255-259 (2001). L11 Ludwig, K., A. Henschel, T.M. Bernhardt et al. Per- L27 Law, J., K. Faulkner and K.C. Young. Risk factors formance of a flat-panel detector in the detection of for induction of breast cancer by X-rays and their

223 ANNEX A: MEDICAL RADIATION EXPOSURES 211 M18 implications for breast screening. Br. J. Radiol. Mould, R.F., J.J. Battermann, A.A. Martinez et al. (eds.). Brachytherapy from Radium to Optimization. 80(952): 261-266 (2007). Marshall, N.W., C.L. Chapple and C.J. Kotre. Diag- Nucletron International BV, Netherlands, 1994. M1 Meurk, M.L., D.A. Goer, G. Spalek et al. The Mobe- M19 nostic reference levels in interventional radiology. tron: a new concept for IORT. Front. Radiat. Ther. Phys. Med. Biol. 45(12): 3833-3846 (2000). M2 Oncol. 31: 65-70 (1997). Marshall, N.W., J. Noble and K. Faulkner. Patient Mazonakis, M., J. Damilakis, N. Theoharopoulos et and staff dosimetry in neuroradiological procedures. M20 Br. J. Radiol. 68(809): 495-501 (1995). al. Brain radiotherapy during pregnancy: an analysis of conceptus dose using anthropomorphic phantoms. M3 Marshall, N.W., G. Shehu, D. Marsh et al. Effective Br. J. Radiol. 72(855): 274-278 (1999). dose in Albanian direct chest fluoroscopy. Eur. J. M21 Moeckli, R., M. Ozsahin, G. Pache et al. Fetal dose Radiol. 11(4): 705-710 (2001). Mini, R.L., B. Schmid, P. Schneeberger et al. Dose- M4 reduction in head and neck radiotherapy of a preg- area product measurements during angiographic X nant woman. Z. Med. Phys. 14(3): 168-172 (2004). McNitt-Gray, M.F. AAPM/RSNA physics tutorial for M22 ray procedures. Radiat. Prot. Dosim. 80(1): 145-148 residents: topics in CT. Radiation dose in CT. Radio- (1998). graphics 22(6): 1541-1553 (2002). Mackie, T.R., J. Balog, K. Ruchala et al. Tomother- M5 apy. Semin. Radiat. Oncol. 9(1): 108-117 (1999). M23 Michalski, J.M., J.A. Purdy, K. Winter et al. Prelimi- Moran, P., M. Chevalier, J.I. Ten et al. A survey of M6 nary report of toxicity following 3D radiation ther- patient dose and clinical factors in a full-field digital apy for prostate cancer on 3DOG/RTOG 9406. Int. J. mammography system. Radiat. Prot. Dosim. 114(1- Radiat. Oncol. Biol. Phys. 46(2): 391-402 (2000). 3): 375-379 (2005). Mori, S., M. Endo, K. Nishizawa et al. Comparison M24 of patient doses in 256-slice CT and 16-slice CT M7 Mesa, A.V., A. Norman, T.D. Solberg et al. Dose dist- ributions using kilovoltage x-rays and dose enhance- scanners. Br. J. Radiol. 79(937): 56-61 (2006). Muhogora, W.E., A.M. Nyanda, W.M. Ngoye et al. M25 ment from iodine contrast agents. Phys. Med. Biol. Radiation doses to patients during selected CT pro- 44(8): 1955-1968 (1999). cedures at four hospitals in Tanzania. Eur. J. Radiol. Murphy, M.J. and R.S. Cox. The accuracy of dose M8 57(3): 461-467 (2006). localization for an image-guided frameless radiosur- M26 Mayo, J.R., T.E. Hartman, K.S. Lee et al. CT of the gery system. Med. Phys. 23(12): 2043-2049 (1996). M9 Mould, R.F. (ed.). Robotic Radiosurgery, Volume 1. chest: minimal tube current required for good image The Cyberknife Society Press, Sunnyvale, Califor- quality with the least radiation dose. Am. J. Roentge- nol. 164(3): 603-607 (1995). nia, 2005. M27 Miller, D.W. A review of proton beam radiation ther- Maisey, M.N., K.E. Britton, B.D. Collier (eds.). Cli- M10 nical Nuclear Medicine, third edition. Chapman and apy. Med. Phys. 22(11): 1943-1954 (1995). Hall Medical, New York, 1998. Martin, R.C., R.R. Laxson, J.H. Miller et al. Devel- M11 252 M28 opment of high-activity Cf sources for neutron Mitsuhashi, N., K. Hayakawa, M. Yamakawa et al. brachytherapy. Appl. Radiat. Isot. 48(10-12): 1567- Cancer in patients aged 90 years or older: radiation 1570 (1997). therapy. Radiology 211(3): 829-833 (1999). M12 M29 Ma, C.M., C.W. Coffey, L.A. DeWerd et al. AAPM Miralbell, R., P.A. Doriot, P. Nouet et al. X-ray dose protocol for 40-300 kV x-ray beam dosimetry in radi- to the skin in patients undergoing percutaneous trans- luminal coronary angioplasty. Catheter. Cardiovasc. otherapy and radiobiology. Med. Phys. 28(6): 868- Interv. 50(3): 300-306 (2000). 893 (2001). M30 Miller, D.L., S. Balter, P.E. Cole et al. Radiation M13 Marbach, J.R., M.R. Sontag, J. Van Dyk et al. Manage- doses in interventional radiology procedures: The ment of radiation oncology patients with implanted RAD-IR study: Part I: overall measures of dose. J. cardiac pacemakers: Report of AAPM Task Group Vasc. Interv. Radiol. 14(6): 711-727 (2003). No. 34. Med. Phys. 21(1): 85-90 (1994). M14 Morgan, R.H. The measurement of radiant energy M31 McParland, B.J. A study of patient radiation doses in interventional radiological procedures. Br. J. Radiol. levels in diagnostic roentgenology. Radiology 76: 71(842): 175-185 (1998). 867-876 (1961). Morin, R.L. and A.D.A. Maidment. Technology M15 M32 Mayles, W.P.M., S. Heisig and H.M.O. Mayles. Treat- talk—Digital mammography: coming of age. J. Am. ment verification and in vivo dosimetry. Chapter 10 in: Radiotherapy Physics in Practice (J.R. Williams Coll. Radiol. 2(9): 798-801 (2005). and D.I. Thwaites, eds.). OUP, Oxford, 1993. M33 Maccia, C., V. Neofotistou, R. Padovani et al. Patient M16 doses in interventional radiology. p. 39-44 in: Radia- Morgan, H.M., S.C. Lillicrap and A.L. McKenzie. Technical note: leakage radiation in radiotherapy— tion Protection in Interventional Radiology (K. Faul- kner and D. Teunen, eds.). BIR, London, 1995. what is an acceptable level in the electron mode? Br. Martin, C.J. and S. Hunter. Analysis of patient doses M34 J. Radiol. 66(786): 548-551 (1993). Ma, C.M., E. Mok, A. Kapur et al. Clinical imple- for myelogram and discogram examinations and their M17 mentation of a Monte Carlo treatment planning sys- reduction through changes in equipment set-up. Br. J. tem. Med. Phys. 26(10): 2133-2143 (1999). Radiol. 68(809): 508-514 (1995).

224 UNSCEAR 2008 REPORT: VOLUME I 212 McFadden, S.L., R.B. Mooney and P.H. Shepherd. M35 examinations in Tanzania. Radiat. Prot. Dosim. X-ray dose and associated risks from radiofrequency 121(2): 128-135 (2006). catheter ablation procedures. Br. J. Radiol. 75(891): Ngaile, J.E., P. Msaki and R. Kazema. Towards estab- N3 253-265 (2002). lishment of the national reference dose levels from computed tomography examinations in Tanzania. J. Mori, S., K. Nishizawa, M. Ohno et al. Conversion M36 Radiol. Prot. 26(2): 213-225 (2006). factor for CT dosimetry to assess patient dose using a 256-slice CT scanner. Br. J. Radiol. 79(947): 888- N4 National Council on Radiation Protection and Meas- 892 (2006). urements. Mammography—a user’s guide. NCRP Report No. 85 (1986). M37 Mettler, F.A. Jr., B.R. Thomadsen, M. Bhargavan et al. Medical radiation exposure in the U.S. in 2006: Njeh, C.F., T. Fuerst, D. Hans et al. Radiation expo- N5 preliminary results. Health Phys. 95(5): 502-507 sure in bone mineral density assessment. Appl. (2008). Radiat. Isot. 50(1): 215-236 (1999). Mettler, F.A. Jr and P. Ortiz-Lopez. Accidents in radi- M38 Niroomand-Rad, A., C.R. Blackwell, B.M. Coursey N6 ation therapy. p. 291-297 in: Medical Management et al. Radiochromic film dosimetry: recommenda- of Radiation Accidents, second edition (I.A. Gusev, tions of AAPM Radiation Therapy Committee Task A.K. Guskova and F.A. Mettler, eds.). CRC Press, Group 55. Med. Phys. 25(11): 2093-2115 (1998). Boca Raton, 2001. National Cancer Institute. NCI Cancer Facts. www. N7 Mettler, F.A. Jr., M. Davis, C.A. Kelsey et al. M39 cancer.gov/cancertopics/cancer-advances-in-focus/ Analytical modeling of worldwide medical radiation breast. Accessed 26 May 2008. use. Health Phys. 52(2): 133-141 (1987). N8 Njeh, C.F., S.B. Samat, A. Nightingale et al. Radia- Mettler, F.A., T.M. Haygood and A.J. Meholic. Diag- M40 tion dose and in vitro precision in paediatric bone nostic radiology around the world. Radiology 175(2): mineral density measurements using dual energy 577-579 (1990). X-ray absorptiometry. Br. J. Radiol. 70(835): 719- 727 (1997). Mettler, F.A. Jr., W. Huda, T.T. Yoshizumi et al. Effec- M41 tive doses in radiology and diagnostic nuclear medi- Nice, C., G. Timmons, P. Bartholemew et al. Retro- N9 cine: a catalog. Radiology 248(1): 254-263 (2008). grade vs. antegrade puncture for infra-inguinal angio- plasty. Cardiovasc. Interv. Radiol. 26(4): 370-374 Molineu, A., D.S. Followill, P.A. Balter et al. Design M42 (2003). and implementation of an anthropomorphic quality assurance phantom for intensity-modulated radiation Nikolic, B., J.B. Spies, M.J. Lundsten et al. Patient N10 therapy for the Radiation Therapy Oncology Group. radiation dose associated with uterine artery embo- Int. J. Radiat. Oncol. Biol. Phys. 63(2): 577-583 lization. Radiology 214(1): 121-125 (2000). (2005). Neofotistou, V., E. Vañó, R. Padovani et al. Prelimi- N11 M43 Moss, M. and D. McLean. Paediatric and adult com- nary reference levels in interventional cardiology. puted tomography practice and patient dose in Aus- Eur. Radiol. 13(10): 2259-2263 (2003). tralia. Australas. Radiol. 50(1): 33-40 (2006). N12 Nisbet, A., D.I. Thwaites and M.E. Sheridan. A dosi- Mori, S., K. Nishizawa, C. Kondo et al. Effective M44 metric intercomparison of kilovoltage x-rays, mega- doses in subjects undergoing computed tomography voltage photons and electrons in the Republic of Ire- cardiac imaging with the 256-multislice CT scanner. land. Radiother. Oncol. 48(1): 95-101 (1998). Eur. J. Radiol. 65(3): 442-448 (2008). Nishizawa, K., M. Matsumoto, K. Iwai et al. Sur- N13 McLean, D., N. Malitz and S. Lewis. Survey of effec- M45 vey of CT practice in Japan and collective effective tive dose levels from typical paediatric CT protocols. dose estimation. Nippon Acta Radiol. 64(3): 151-158 Australas. Radiol. 47(2): 135-142 (2003). (2004). Mountford, P.J. and A.J. Coakley. A review of the M46 Nishizawa, K., T. Moritake, Y. Matsumaru et al. N14 secretion of radioactivity in human breast milk: data, Dose measurement for patients and physicians using quantitative analysis and recommendations. Nucl. a glass dosemeter during endovascular treatment for Med. Commun. 10(1): 15-27 (1989). brain disease. Radiat. Prot. Dosim. 107(4): 247-252 (2003). M47 Mountford, P.J. and A.J. Coakley. Radiopharmaceu- ticals in breast milk. p. 167-180 in: Fourth Interna- Napier, I.D. Reference doses for dental radiography. N15 tional Radiopharmaceutical Dosimetry Symposium, Br. Dent. J. 186(8): 392-396 (1999). Proceedings of a Conference, Oak Ridge, Tennessee, N16 Nishizawa, K., T. Maruyama, T. Iwata et al. Esti- 5-8 November 1985. CONF-851113 (1986). mation of stochastic risk from computed tomogra- N1 National Radiological Protection Board/Institute of phy examinations in Japan, 1979. 3. Estimation of Physical Sciences in Medicine/College of Radiog- population doses and stochastic risk. Nippon Igaku raphers. National Protocol for Patient Dose Meas- Hoshasen Gakkai Zasshi 41(5): 436-441 (1981). urements in Diagnostic Radiology. NRPB, Didcot, Nishizawa, K., T. Maruyama, M. Takayama et al. N17 1992. Estimation of effective dose from CT examination. Ngaile, J.E., P. Msaki and R. Kazema. Current status N2 Nippon Igaku Hoshasen Gakkai Zasshi 55(11): 763- of patient radiation doses from computed tomography 768 (1995).

225 213 ANNEX A: MEDICAL RADIATION EXPOSURES O9 Ono, K., K. Akahane, T. Aota et al. Neonatal doses Newhauser, W.D., J. Burns and A.R. Smith. Dosim- N18 from X-ray examinations by birth weight in a neona- etry for ocular proton beam therapy at the Harvard tal intensive care unit. Radiat. Prot. Dosim. 103(2): Cyclotron Laboratory based on the ICRU Report 59. 155-162 (2003). Med. Phys. 29(9): 1953-1961 (2002). O10 Onnasch, D.G.W., F.K. Schröder, G. Fischer et al. N19 Norman, A. and A.R. Kagan. Radiation doses in radi- Diagnostic reference levels and effective dose in pae- ation therapy are not safe. Med. Phys. 24(11): 1710- diatric cardiac catheterization. Br. J. Radiol. 80(951): 1713 (1997). 177-185 (2007). N20 National Council on Radiation Protection and Meas- P1 Pellet, S., L. Ballay, A. Motoc et al. Patient doses urements. Structural shielding design and evaluation for computed tomography in Hungary. p. 210-213 from megavoltage X- and gamma-ray radiotherapy in: Radiological Protection of Patients in Diagnos- facilities. NCRP Report No. 151 (2006). tic and Interventional Radiology, Nuclear Medicine Newhauser, W.D. and G.S. Ibbott. Future Trends in N21 and Radiotherapy. Contributed Papers. IAEA, Vienna Proton Therapy; Increased Standardization. CIRMS, (2001). Gaithersburg, 2005. Ploquin, N., P. Dunscombe and T. Sarrazin. The radi- P2 N22 Nuclear Regulatory Commission. Gamma knife treat- ation therapy incident at the Centre Hospitalier Jean ment to wrong side of brain. NRC Event Notification Monet, Épinal, France. AAPM Newsletter (May/ Number 43746 (2007). June): 14-15 (2007). National Radiological Protection Board. Guidelines N23 P3 Pötter, R., E. Van Limbergen, W. Dries et al. Recom- on radiology standards in primary dental care. Doc. mendations of the EVA GEC ESTRO Working Group: NRPB 5(3): 1-57 1994. prescribing, recording, and reporting in endovascular Nawfel, R. and T. Yoshizumi. Update on radiation N24 brachytherapy. Quality assurance, equipment, per- dose in CT. Am. Assoc. Phys. Med. Newsl. 30(2): sonnel and education. Radiother. Oncol. 59(3): 339- 12-13 (2005). 360 (2001). Nickoloff, E.L. and P.O. Alderson. A comparative N25 P4 Papadimitriou, D., A. Perris, A. Manetou et al. A study of thoracic radiation doses from 64-slice car- survey of 14 computed tomography scanners in diac CT. Br. J. Radiol. 80(955): 537-544 (2007). Greece and 32 scanners in Italy. Examination fre- N26 National Council on Radiation Protection and quencies, dose reference values, effective doses and Measurements. Ionizing radiation exposure of the doses to organs. Radiat. Prot. Dosim. 104(1): 47-53 population of the United States. NCRP Report (2003). No. 160 (2009). Priestman, T.J., J.A. Bullimore, T.P. Godden et al. The P5 O1 Osei, E.K. and K. Faulkner. Fetal doses from radio- Royal College of Radiologists’ fractionation survey. logical examinations. Br. J. Radiol. 72(860): 773-780 Clin. Oncol. (R. Coll. Radiol.) 1(1): 39-46 (1989). (1999). P6 Padovani, R. Interventional radiology. p. 203-222 Overbeek, F.J., E.K.J. Pauwels, J.L. Bloem et al. O2 in: Radiological Protection of Patients in Diagnostic Somatic effects in nuclear medicine and radiology. and Interventional Radiology, Nuclear Medicine and Appl. Radiat. Isot. 50(1): 63-72 (1999). Radio-therapy. Contributed Papers. IAEA, Vienna O3 Oh, K.K., J. Hur, E.K. Kim et al. Dosimetric evalua- (2001). tion of the mean glandular dose for mammography in P7 Pages, J., N. Buls and M. Osteaux. CT doses in chil- Korean women: a preliminary report. Yonsei Med. J. dren: a multicentre study. Br. J. Radiol. 76(911): 803- 44(5): 863-868 (2003). 811 (2003). O4 Origgi, D., S. Vigorito, G. Villa et al. Survey of com- Pearson Murphy, B.E. In vitro tests of thyroid func- P8 puted tomography techniques and absorbed dose in tion. Semin. Nucl. Med. 1(3): 301-315 (1971). Italian hospitals: a comparison between two methods Pieri, S., P. Agresti, M. Morucci et al. Analysis of P9 to estimate the dose–length product and the effective radiation doses in the percutaneous treatment of vari- dose and to verify fulfilment of the diagnostic refer- cocele in adolescents. Radiol. Med. (Torino) 105(5- ence levels. Eur. Radiol. 16(1): 227-237 (2006). 6): 500-510 (2003). O5 Ogasawara, K. and H. Date. A numerical model for P10 Pierquin, B. and G. Marinello. A Practical Manual compressed breast of Japanese women in mammo- of Brachytherapy. Translated by F. Wilson, B. Erick- graphy. Igaku Butsuri 21(4): 215-222 (2001). son and J. Cunningham. Medical Physics Publishing, Oduko, J. Optimisation of patient dose and image O6 Madison, Wisconsin, 1997. quality in dental radiology—Over 65 time to retire P11 Paterson, A., D.P. Frush and L.F. Donnelly. Heli- your OPG? IPEM Meeting, York, 2001. cal CT of the body: Are settings adjusted for pedi- Order, S.E. and S.S. Donaldson. Radiation Therapy O7 atric patients? Am. J. Roentgenol. 176(2): 297-301 of Benign Diseases: A Clinical Guide, second edi- (2001). tion. Springer-Verlag, Berlin, 1998. P12 Prasad, S.R., C. Wittram, J.A. Shepard et al. Stand- ard-dose and 50%-reduced-dose chest CT: compar- O8 O’Driscoll, D., E.A. McNeil, J. Ferrando et al. Effec- ing the effect on image quality. Am. J. Roentgenol. tive dose to the patient undergoing superior vena cava stent. Br. J. Radiol. 71(852): 1302-1305 (1998). 179(2): 461-465 (2002).

226 214 UNSCEAR 2008 REPORT: VOLUME I P13 Perisinakis, K., J. Damilakis, J. Neratzoulakis et al. Nuclear Medicine and Radiotherapy. Contributed Papers. IAEA, Vienna (2001). Determination of dose-area product from panoramic Radiation Oncology Safety Information Sys- radiography using a pencil ionization chamber: nor- R4 tem (ROSIS). www.clin.radfys.lu.se/Default.asp. malized data for the estimation of patient effective Accessed 6 April 2006. and organ doses. Med. Phys. 31(4): 708-714 (2004). Radiation Internal Dose Information Center, R5 P14 Pérez, C.A., L.W. Brady, E.C. Halperin et al. Princi- Oak Ridge, United States. Communication to the ples and Practice of Radiation Oncology, fourth edi- UNSCEAR Secretariat (2008). tion. Lippincott Williams & Wilkins, 2004. Petoussi-Henss, N., M. Zankl, U. Fill et al. The GSF P15 R6 Rivard, M.J. Measurements and calculations of ther- family of voxel phantoms. Phys. Med. Biol. 47(1): mal neutron fluence rate and neutron energy spectra 252 89-106 (2002). Cf fast neutrons: resulting from moderation of P16 Petoussi-Henss, N., M. Zankl, G. Drexler et al. Cal- applications for neutron capture therapy. Med. Phys. culation of backscatter factors for diagnostic radiol- 27(8): 1761-1769 (2000). ogy using Monte Carlo methods. Phys. Med. Biol. Ropolo, R., O. Rampado, P. Isoardi et al. Evaluation R7 43(8): 2237-2250 (1998). of patient doses in interventional radiology. Radiol. P17 Peters, S.E. and P.C. Brennan. Digital radiography: Med. 102(5-6): 384-390 (2001). are the manufacturers’ settings too high? Optimisa- Resten, A., F. Mausoleo, M. Valero et al. Compari- R8 tion of the Kodak digital radiography system with aid son of doses for pulmonary embolism detection with of the computed radiography dose index. Eur. Radiol. helical CT and pulmonary angiography. Eur. Radiol. 12(9): 2381-2387 (2002). 13(7): 1515-1521 (2003). P18 Padovani, R., R. Novario and G. Bernardi. Optimisa- R9 Ruiz Cruces, R., J. García-Granados, F.J. Díaz tion in coronary angiography and percutaneous trans- Romero et al. Estimation of effective dose in some luminal coronary angioplasty. Radiat. Prot. Dosim. digital angiographic and interventional procedures. 80(1): 303-306 (1998). Br. J. Radiol. 71(841): 42-47 (1998). Pratt, T.A. and A.J. Shaw. Factors affecting the radia- P19 Ruiz-Cruces, R., M. Pérez-Martínez, A. Martín- R10 Palanca tion dose to the lens of the eye during cardiac cath- et al. Patient dose in radiologically guided interven- eterization procedures. Br. J. Radiol. 66(784): 346- tional vascular procedures: conventional versus digital 350 (1993). systems. Radiology 205(2): 385-393 (1997). Paisley, E.M., J.P. Eatough, P.J. Mountford et al. P20 Regaud, C. Radium therapy of cancer at the Radium R11 Patient radiation doses during invasive cardiac pro- Institute of Paris. Am. J. Roentgenol. Radium Ther. cedures categorised by clinical code. Br. J. Radiol. 21: 1 (1929). 77(924): 1022-1026 (2004). 252 R12 Cf Rivard, M.J. Neutron dosimetry for a general Palmer, S.H., H.C. Starritt and M. Patterson. Radia- P21 brachytherapy source. Med. Phys. 27(12): 2803-2815 tion protection of the ovaries in young scoliosis (2000). patients. Eur. Spine J. 7(4): 278-281 (1998). Rogers, L.F. Dose reduction in CT: How low can we R13 P22 Parkin, G.J. Clinical aspects of direct digital mam- go? Am. J. Roentgenol. 179(2): 299 (2002). mography. J. Digit. Imaging 8 (1 Suppl. 1): 61-66 Rogers, L.F. Low-dose CT: How are we doing? Am. R14 (1995). J. Roentgenol. 180(2): 303 (2003). Proton Therapy Co-Operative Group (PTCOG). P23 Ravenel, J.G., E.M. Scalzetti, W. Huda et al. R15 http://ptcog.web.psi.ch/ptcentres.html. Accessed 26 Radiation exposure and image quality in chest CT May 2008. examinations. Am. J. Roentgenol. 177(2): 279-284 P24 Pisano, E.D., C. Gatsonis, E. Hendrick et al. Diag- (2001). nostic performance of digital versus film mammog- R16 Rusch, T., T. Bohm and M. Rivard. SU-FF-T-293: raphy for breast-cancer screening. N. Engl. J. Med. Monte Carlo modeling of the Xoft AXXENTTM Erratum in 353(17): 1773-1783 (2005). N. Engl. J. x-ray source. Med. Phys. 32(6): 2017-2018 (2005). Med. 355(17): 1840 (2006). R17 Rivard, M.J., B.M. Coursey, L.A. DeWerd et al. P25 Pisano, E.D., C.A. Gatsonis, M.J. Yaffe et al. Ameri- Update of AAPM Task Group No. 43 Report: A can College of Radiology Imaging Network digital revised AAPM protocol for brachytherapy dose cal- mammographic imaging screening trial: objec- culations. Med. Phys. 31(3): 633-674 (2004). tives and methodology. Radiology 236(2): 404-412 Ruchala, K.J., G.H. Olivera, E.A. Schloesser et al. R18 (2005). Megavoltage CT on a tomotherapy system. Phys. R1 Royal College of Radiologists. Making the Best Use Med. Biol. 44(10): 2597-2621 (1999). of a Department of Radiology. RCR, London, 1993. R19 Rosenstein, M. Handbook of selected tissue doses for Rosenstein, M., L.W. Anderson and L.G. Wagner. R2 projections common in diagnostic radiology. HHS Handbook of tissue doses in mammography. FDA Publication FDA 89-8031 (1988). 85-8230 (1985). R20 Rosenstein, M., L.W. Andersen and G.G. Warner. R3 Rehani, M.M. Protection of patients in general radi- Handbook of glandular tissue doses in mammogra- ography. p. 169-178 in: Radiological Protection of phy. HHS Publication FDA 85-8239 (1988). Patients in Diagnostic and Interventional Radiology,

227 215 ANNEX A: MEDICAL RADIATION EXPOSURES S10 Swedish Council on Technology Assessment in Rosenstein, M., O.H. Suleiman, R.L. Burkhart et R21 Health Care. Radiotherapy for cancer—Volume 1. al. Handbook of selected tissue doses for the upper Acta Oncol. 35 (Suppl. 6): (1997). gastrointestinal fluoroscopic examination. HHS Swedish Council on Technology Assessment in S11 Publication FDA 92-8282 (1992). Health Care. Radiotherapy for cancer—Volume 2. R22 Rosenstein, M., T.J. Beck and G.G. Warner. Hand- Acta Oncol. 35 (Suppl. 7): (1997). book of selected organ doses for projections com- Sukovic, P. Cone beam computed tomography in S12 mon in pediatric radiology. HEW Publication FDA craniofacial imaging. Orthod. Craniofac. Res. 6 79-8079 (1979). (Suppl. 1): 31-36 (2003). R23 Rosenstein, M. Handbook of glandular tissue doses Steel, S.A., A.J. Baker and J.R. Saunderson. An S13 in mammography. Presentation at the 29th Meeting assessment of the radiation dose to patients and staff of the Health Physics Society, New Orleans, 1984. from a Lunar Expert-XL fan beam densitometer. R24 Romanowski, C.A.J., A.C. Underwood and A. Sprigg. Physiol. Meas. 19(1): 17-26 (1998). Reduction of radiation doses in leg lengthening pro- S14 Solberg, T.D., K.S. Iwamoto and A. Norman. Calcu- cedures by means of audit and CT scannogram tech- lation of radiation dose enhancement factors for dose niques. Br. J. Radiol. 67(830): 1103-1107 (1994). enhancement therapy of brain tumours. Phys. Med. R25 Rubow, S., J. Klopper, H. Wasserman et al. The Biol. 37(2): 439-443 (1992). excretion of radiopharmaceuticals in human breast S15 Smith, A.R. Rationale for and history of heavy milk: additional data and dosimetry. Eur. J. Nucl. charged particle radiation therapy. Med. Phys. 23(6): Med. 21(2): 144-153 (1994). 1120 (1996). R26 Royal College of Radiologists. Making the Best Use S16 Sisterson, J.M. World wide proton therapy experi- of a Department of Radiology. Guidelines for Doc- ence in 1997. p. 959-962 in: Applications of Accel- tors, fifth edition. RCR, London, 2003. erators in Research and Industry (J.L. Duggan and R27 Rivard, M.J., S.D. Davis, L.A. DeWerd et al. Calcu- I.L. Morgan, eds.). AIP Conference Proceedings 475. lated and measured brachytherapy dosimetry param- AIP. Press, New York, 1999. eters in water for the XSoft Axxent X-ray source: An S17 Shrimpton, P.C. and S. Edyvean. CT scanner dosim- electronic brachytherapy source. Med. Phys. 33(11): etry. Br. J. Radiol. 71(841): 1-3 (1998). 4020-4032 (2006). Shrimpton, P.C. Assessment of patient dose in CT. S18 S1 Shrimpton, P.C., D.G. Jones, M.C. Hillier et al. Sur- NRPB-PE/1/2004 (2004). vey of CT practice in the UK. Part 2: Dosimetric S19 Shrimpton, P.C., M.C. Hillier, M.A. Lewis et al. aspects. NRPB-R249 (1991). Doses from computed tomography (CT) examina- S2 Shrimpton, P.C., D. Hart, M.C. Hillier et al. Survey tions in the UK—2003 review. NRPB-W67 (2005). of CT practice in the UK. Part 1: Aspects of exami- S20 Shrimpton, P.C., K.A. Jessen, J. Geleijns et al. Ref- nation frequency and quality assurance. NRPB-R248 erence doses in computed tomography. Radiat. Prot. (1991). Dosim. 80(1): 55-59 (1998). Shrimpton, P.C., B.F. Wall and D. Hart. Diagnostic S3 Shrimpton, P.C. and B.F. Wall. Reference doses S21 medical exposures in the U.K. Appl. Radiat. Isot. for paediatric computed tomography. Radiat. Prot. 50(1): 261-269 (1999). Dosim. 90(1): 249-252 (2000). S4 Stabin, M.G. and H.B. Breitz. Breast milk excretion S22 Stolzmann, P., H. Scheffel, T. Schertler et al. Radia- of radiopharmaceuticals: mechanisms, findings, and tion dose estimates in dual-source computed tomog- radiation dosimetry. J. Nucl. Med. 41(5): 863-873 raphy coronary angiography. Eur. Radiol. 18(3): 592- (2000). 599 (2008). S5 Srivastava, S.C. and L. Rao Chervu. Radionuclide- Stabin, M.G., R. Blackwell, R.L. Brent et al. Fetal S23 labeled red blood cells: Current status and future Radiation Dose Calculations. ANSI N13.54-2008. prospects. Semin. Nucl. Med. 14(2): 68-82 (1984). American National Standards Institute, Washington, S6 Shrimpton, P.C., M.C. Hillier, M.A. Lewis et al. 2008. National survey of doses from CT in the UK: 2003. S24 Stern, S.H., R.V. Kaczmarek, D.C. Spelic et al. Br. J. Radiol. 79(948): 968-980 (2006). Nationwide evaluation of x-ray trends (NEXT) 2000- Shrimpton, P.C., B.F. Wall, D.G. Jones et al. A S7 01 survey of patient radiation exposure from com- national survey of doses to patients undergoing a puted tomographic (CT) examinations in the United selection of routine x-ray examinations in English States. Presented at the 87th Scientific Assembly and hospitals. NRPB-R200 (1986). Annual Meeting of the Radiological Society of North S8 Shakeshaft, J.T., H.M. Morgan and P.D. Simpson. America, Chicago, 2001. In vivo dosimetry using diodes as a quality control Struelens, L. Optimisation of patient doses, linked S25 tool—experience of 2 years and 2000 patients. Br. J. to image quality in vascular radiology. PhD Thesis Radiol. 72(861): 891-895 (1999). (2004). S9 Shalev, S. On the definition of beam margins in radi- Steele, H.R. and D.H. Temperton. Technical note: S26 ation therapy. p. 57-60 in: Quantitative Imaging in patient doses received during digital subtraction Oncology (K. Faulkner, B. Carey, A. Crellin et al., graphy. Br. J. Radiol. 66(785): 452-456 (1993). angio eds.). British Institute of Radiology, London, 1996.

228 216 UNSCEAR 2008 REPORT: VOLUME I of selected tissue doses for fluoroscopic and cinean- S27 Stabin, M.G., J.B. Stubbs and R.E. Toohey. Radiation dose estimates for radio-pharmaceuticals. NUREG/ giographic examination of the coronary arteries (in SI units). HHS Publication FDA 95-8289 (1995). CR-6345 (1996). Silverman, C.L. and S.L. Goldberg. Total body irra- Stanton, L., T. Villafana, J.L. Day et al. Dosage eval- S43 S28 uation in mammography. Radiology 150(2): 577-584 diation in bone marrow transplantation and advanced lymphomas: a comprehensive overview. Chapter (1984). Scanff, P., J. Donadieu, P. Pirard et al. Population S44 14 in: Current Radiation Oncology, Volume 2 (J.S. exposure to ionizing radiation from medical exami- Tobias and P.R.M. Thomas, eds.). Arnold, London, 1996. nations in France. Br. J. Radiol. 81(963): 204-213 (2008). S29 Syed, A.M.N. and A.A. Puthawala. Current Torp, C.G., H.M. Olerud, G. Einarsson et al. Use T1 brachytherapy techniques. Chapter 4 in: Current of the EC quality criteria as a common method of Radiation Oncology, Volume 2 (J.S. Tobias and P.R.M. Thomas, eds.). Arnold, London, 1996. inspecting CT laboratories—A pilot project by the Nordic radiation protection authorities. p. 223-227 Stout, R. Intraluminal radiotherapy and its use in lung S30 cancer. RAD Mag.: 33-34 (1996). in: Radiological Protection of Patients in Diagnos- tic and Interventional Radiology, Nuclear Medicine S31 Stovall, M., C.R. Blackwell, J. Cundiff et al. Fetal dose from radiotherapy with photon beams: report of and Radiotherapy. Contributed Papers. IAEA, Vienna (2001). AAPM Radiation Therapy Committee Task Group T2 Toivonen, M. Review of dosimetry instrumentation No. 36. Med. Phys. 22(1): 63-82 (1995). Suwinski, R., M. Bankowska-Wozniak, W. Majew- in digital and interventional radiology. Radiat. Prot. S32 ski et al. Randomized clinical trial on continuous Dosim. 94(1): 147-150 (2001). 7-days-a-week postoperative radiotherapy for high- T3 Teirstein, P.S., V. Massullo, S. Jani et al. Catheter- based radiotherapy to inhibit restenosis after coro- risk squamous cell head-and-neck cancer: a report nary stenting. N. Engl. J. Med. 336(24): 1697-1703 on acute normal tissue reactions. Radiother. Oncol. 77(1): 58-64 (2005). (1997). T4 Stasi, M., V. Casanova Borca and C. Fiorino. Meas- Trott, N.G. Radionuclides in brachytherapy: radium S33 60 and after. Br. J. Radiol. 21 (Suppl.): 1-54 (1987). urements of exit dose profiles in Co beams with T5 Taibi, A., S. Fabbri, P. Baldelli et al. Dual energy a conventional portal film system. Br. J. Radiol. imaging in full field digital mammography: a phan- 70(840): 1283-1287 (1997). S34 Stern, R.L. Peripheral dose from a linear accelera- tom study. Phys. Med. Biol. 48(13): 1945-1956 (2003). tor equipped with multileaf collimation. Med. Phys. Terada, H. Mammography—a guidance level and T6 26(4): 559-563 (1999). the present situation of mammographic dose. Igaku Sjögren, R. and M. Karlsson. Electron contamination S35 Butsuri 22(2): 65-73 (2002). in clinical high energy photon beams. Med. Phys. 23(11): 1873-1881 (1996). T7 Tham, T.L., J. Vandervoort, J. Wong et al. Safety of Sotherberg, A. and L. Johansson. Photonuclear pro- S36 ERCP during pregnancy. Am. J. Gastroenterol. 98(2): duction in tissue for different 50 MV bremsstrahlung 308-311 (2003). beams. Med. Phys. 25(5): 683-688 (1998). T8 Tsalafoutas, I.A., K.D. Paraskeva, E.N. Yakoumakis S37 et al. Radiation doses to patients from endoscopic Solberg, T.D., J.J. DeMarco, F.E. Holly et al. Monte Carlo treatment planning for stereotactic radiosur- retrograde cholangio-pancreatography examina- tions and image quality considerations. Radiat. Prot. gery. Radiother. Oncol. 49(1): 73-84 (1998). Shrimpton, P.C., B.F. Wall and E.S. Fisher. The S38 Dosim. 106(3): 241-246 (2003). Theodorakou, C. and J.A. Horrocks. A study on radi- tissue-equivalence of the Alderson Rando anthropo- T9 ation doses and irradiated areas in cerebral embolisa- morphic phantom for X-rays of diagnostic qualities. tion. Br. J. Radiol. 76(908): 546-552 (2003). Phys. Med. Biol. 26(1): 133-139 (1981). T10 Snyder, W.S., H.L. Fisher Jr., M.R. Ford et al. Esti- Thompson, V., M. Bidmead and C. Mubata. Pictorial S39 review: comparison of portal imaging and megavolt- mates of absorbed fraction for monoenergetic photon sources uniformly distributed in various organs of a age verification films for conformal pelvic irradia- tion. Br. J. Radiol. 69(828): 1191-1195 (1996). heterogeneous phantom. MIRD Pamphlet No. 5. J. T11 Nucl. Med. 10 (Suppl. 3): 7-52 (1969). Thomadsen, B. Why HDR? Differences compared to LDR brachytherapy. Med. Phys. 23(6): 1046 (1996). Schultz, F.W., J. Geleijns and J. Zoetelief. Calcula- S40 Thwaites, J.H., M.W. Rafferty, N. Gray et al. A patient tion of dose conversion factors for posterior-anterior T12 dose survey for femoral arteriogram diagnostic radi- chest radiography of adults with a relatively high- energy X-ray spectrum. Br. J. Radiol. 67(800): 775- ographic examinations using a dose-area product 785 (1994). meter. Phys. Med. Biol. 41(5): 899-907 (1996). Tierris, C.E., E.N. Yakoumakis, G.N. Bramis et al. S41 T13 Stanton, L., S.D. Brattelli and J.L. Day. Measure- Dose area product reference levels in dental pano- ments of diagnostic x-ray backscatter by a novel ion chamber method. Med. Phys. 9(1): 121-130 (1982). ramic radiology. Radiat. Prot. Dosim. 111(3): 283- Stern, S.H., M. Rosenstein, L. Renaud et al. Handbook S42 287(2004).

229 ANNEX A: MEDICAL RADIATION EXPOSURES 217 United T14 Nations sales publication E.96.IX.3. United Tsai, J.S., D.E. Wazer, M.N. Ling et al. Dosimet- York, 1996. ric verification of the dynamic intensity-modulated Nations, New United Nations. Sources and Effects of Ionizing U6 radiation therapy of 92 patients. Int. J. Radiat. Oncol. Radiation. United Nations Scientific Committee on Biol. Phys. 40(5): 1213-1230 (1998). the Effects of Atomic Radiation, 1993 Report to the T15 Tang, G., M.A. Earl, S. Luan et al. Converting multi- ple-arc intensity modulated arc therapy into a single General Assembly, with scientific annexes. United arc for efficient delivery. Int. J. Radiat. Oncol. Biol. Nations sales publication E.94.IX.2. United Nations, Phys. 69(3): S673 (2007). New York, 1993. Takahashi, M., W.M. Maguire, M. Ashtari et al. Low- U7 T16 United Nations. Sources, Effects and Risks of Ioniz- ing Radiation. United Nations Scientific Committee dose spiral computed tomography of the thorax: standard-dose comparison with the technique. Invest. on the Effects of Atomic Radiation, 1988 Report to the General Assembly, with annexes. United Nations Radiol. 33(2): 68-73 (1998) . sales publication E.88.IX.7. United Nations, New Tapiovaara, M., M. Lakkisto and A. Servomaa. T17 PCXMC: A PC-based Monte Carlo program for cal- York, 1988. culating patient doses in medical x-ray examinations. U9 United Nations. Ionizing Radiation: Sources and Biolog- STUK-A139 (1997). ical Effects. United Nations Scientific Committee on the Tsapaki, V., S. Kottou, E. Vano et al. Patient dose val- T18 Effects of Atomic Radiation, 1982 Report to the General Assembly, with annexes. United Nations sales publica- ues in a dedicated Greek cardiac centre. Br. J. Radiol. 76(910): 726-730 (2003). tion E.82.IX.8. United Nations, New York, 1982. U10 Tsapaki, V., S. Kottou and D. Papadimitriou. Applica- United Nations. Sources and Effects of Ionizing Radia- T19 tion. United Nations Scientific Committee on the tion of European Commission reference dose levels in CT examinations in Crete, Greece. Br. J. Radiol. Effects of Atomic Radiation, 1977 Report to the Gen- 74(885): 836-840 (2001). eral Assembly, with annexes. United Nations sales pub- Tsai, H.Y., C.J. Tung, C.C. Yu et al. Survey of com- T20 lication E.77.IX.1. United Nations, New York, 1977. U11 puted tomography scanners in Taiwan: dose descrip- United Nations. Ionizing Radiation: Levels and Effects. Volume I: Levels; Volume II: Effects. tors, dose guidance levels, and effective doses. Med. Phys. 34(4): 1234-1243 (2007). United Nations Scientific Committee on the Effects T21 of Atomic Radiation, 1972 Report to the General Trabold, T., M. Buchgeister, A. Küttner et al. Estima- Assembly, with annexes. United Nations sales publi- tion of radiation exposure in 16-detector row com- puted tomography of the heart with retrospective cation E.72.IX.17 and 18. United Nations, New York, 1972. ECG-gating. Roefo 175(8): 1051-1055 (2003). United Nations. Report of the United Nations Scien- T22 U15 Teeuwisse, W., J. Geleijns and W. Veldkamp. An inter-hospital comparison of patient dose based on tific Committee on the Effects of Atomic Radiation. Official Records of the General Assembly, Seven- clinical indications. Eur. Radiol. 17(7): 1795-1805 (2007). teenth Session, Supplement No. 16 (A/5216). New Tsapaki, V., J.E. Aldrich, R. Sharma et al. Dose reduc- T23 York, 1962. Uppelschoten, J.M., S.L. Wanders and J.M. de Jong. U17 tion in CT while maintaining diagnostic confidence: Gy): palliation in painful diagnostic reference levels at routine head, chest, and Single-dose radiotherapy (6 bone metastases. Radiother. Oncol. 36(3): 198-202 abdominal CT: IAEA-coordinated research project. Radiology 240(3): 828-834 (2006). (1995). Vanmarcke, H., H. Mol, J. Paridaens et al. Exposure U1 V1 United Nations. Effects of Ionizing Radiation. Vol- of the Belgian population to ionizing radiation. Paper ume I: Report to the General Assembly, Scientific Annexes A and B; Volume II: Scientific Annexes C, 6d20 in: 11th International Congress of the Inter- national Radiation Protection Association, Madrid, D and E. United Nations Scientific Committee on the Effects of Atomic Radiation, UNSCEAR 2006 23-28 May 2004. Report. United Nations sales publications E.08.IX.6 V2 Vañó, E., L. González, J.M. Fernández et al. Patient (2008) and E.09.IX.5 (2009). United Nations, New dose values in interventional radiology. Br. J. Radiol. York. 68(815): 1215-1220 (1995). Van Rij, C.M., A.J. Wilhelm, W.A. Sauerwein et al. U3 V3 United Nations. Sources and Effects of Ionizing Boron neutron capture therapy for glioblastoma mul- Radiation. Volume I: Sources; Volume II: Effects. tiforme. Pharm. World Sci. 27(2): 92-95 (2005). United Nations Scientific Committee on the Effects van der Giessen, P.H. Dose outside the irradiated V4 of Atomic Radiation, 2000 Report to the General volume in radiotherapy: gonadal or fetal dose and Assembly, with scientific annexes. United Nations sales publications E.00.IX.3 and E.00.IX.4. United its associated risks. Doctoral Thesis, University of Leiden (1997). Nations, New York, 2000. U4 United Nations. Sources and Effects of Ionizing Vetter, S., F.W. Schultz, E.P. Strecker et al. Patient V5 Radiation. United Nations Scientific Committee radiation exposure in uterine artery embolization of on the Effects of Atomic Radiation, 1996 Report effective leiomyomata: calculation of organ doses and to the General Assembly, with scientific annex. dose. Eur. Radiol. 14(5): 842-848 (2004).

230 218 UNSCEAR 2008 REPORT: VOLUME I V6 Vehmas, T., R. Havukainen, M. Tapiovaara et al. Waite, J.C. and M. Fitzgerald. An assessment of W4 methods for monitoring entrance surface dose in Radiation exposure during percutaneous nephros- fluoroscopically guided interventional procedures. tomy. Roefo Fortschr. Geb. Roentgenstr. Neuen Bild- p. 254-258 in: Radiological Protection of Patients gebenden Verfahr. 154(3): 238-241 (1991). in Diagnostic and Interventional Radiology, Nuclear Voordeckers, M., H. Goossens, J. Rutten et al. The V7 Medicine and Radiotherapy. Contributed Papers. implementation of in vivo dosimetry in a small radio- IAEA, Vienna (2001). therapy department. Radiother. Oncol. 47(1): 45-48 (1998). Wambersie, A., P.M. Deluca, P. Andreo et al. “Light” W5 V8 Vañó, E. Communication to the UNSCEAR Secre- or “Heavy” ions: a debate of terminology? Radiother. tariat (2002). Oncol. 73 (Suppl. 2): iii (2004). Van der Molen, A.J., W.J.H. Veldkamp and J. Gelei- V9 W6 Wagner, L.K., R.G. Lester and L.R. Saldane. Expo- jns. 16-slice CT: achievable effective doses of com- sure of the Pregnant Patient in Diagnostic Radiology. mon protocols in comparison with recent CT dose Medical Physics Publishing, Madison, 1997. surveys. Br. J. Radiol. 80(952): 248-255 (2007). W7 Wall, B.F. and D. Hart. Revised radiation doses for V10 Vañó, E., D. Martínez, J.M. Fernández et al. Paediat- typical x-ray examinations. Br. J. Radiol. 70(833): ric entrance doses from exposure index in computed 437-439 (1997). radiography. Phys. Med. Biol. 53(12): 3365-3380 World Health Organization. Quality Assurance in W8 (2008). Nuclear Medicine. WHO, Geneva, 1982. V11 Vicini, F.A., E.M. Horwitz, M.D. Lacerna et al. World Health Organization. Quality Assurance in W9 Long-term outcome with interstitial brachytherapy in Radiotherapy. WHO, Geneva, 1988. the management of patients with early-stage breast W10 World Health Organization. Efficacy and Radiation cancer treated with breast-conserving therapy. Int. J. 2. WHO, Safety in Interventional Radiology. Chapter Radiat. Oncol. Biol. Phys. 37(4): 845-852 (1997). Geneva, 2000. V12 Vatnitsky, S.M., R.W. Schulte, R. Galindo et al. Radi- Warren-Forward, H.M. and L. Duggan. Patient radia- W11 ochromic film dosimetry for verification of dose dis- tion doses from interventional procedures. p. 136 in: tributions delivered with proton-beam radiosurgery. Southport ’99, Proceedings of the 6th SRP Interna- Phys. Med. Biol. 42(10): 1887-1898 (1997). tional Symposium (M.C. Thorne, ed.). SRP, London, Veit, R., M. Zankl, N. Petoussi et al. Tomographic V13 1999. anthropomorphic models. Part 1: Construction tech- W12 Winer-Muram, H.T., J.M. Boone, H.L. Brown et al. nique and description of models of an 8 week old baby Pulmonary embolism in pregnant patients: fetal radi- and a 7 year old child. ISSN 0721-1694. GSF-Bericht ation dose with helical CT. Radiology 224(2): 487- 3/89 (1989). 492 (2002). Vañó, E., J.M. Fernández, J.I. Ten et al. Transition V14 W13 Wildberger, J.E., D. Vorwerk, R. Winograd et al. New from screen-film to digital radiography: Evolution TIPS placement in pregnancy in recurrent esophageal of patient radiation doses at projection radiography. varices hemorrhage—assessment of fetal radiation Radiology 243(2): 461-466 (2007). exposure. Roefo Fortschr. Geb. Roentgenstr. Neuen Varian Medical Systems. [Treatment facility] Inci- V15 Bildgebenden Verfahr. 169(4): 429-431 (1998). (In dent evaluation summary, CP-2005-049 (April 13, German). 2005). Williams, J.R. The interdependence of staff and W14 V16 Vañó, E., L. Gonzalez, J.I. Ten et al. Skin dose and patient doses in interventional radiology. Br. J. dose-area product values for interventional cardiology Radiol. 70(833): 498-503 (1997). procedures. Br. J. Radiol. 74(877): 48-55 (2001). Werduch, A. Dose estimation in interventional car- W15 V17 Vañó, E., J. Goicolea, C. Galvan et al. Skin radia- diology procedures. Master’s Thesis, University of tion injures in patients following repeated coronary Lodz, Poland (2005). angioplasty procedures. Br. J. Radiol. 74(887): 1023- W16 Wall, B.F. Radiation protection dosimetry for diag- 1031 (2001). nostic radiology patients. Radiat. Prot. Dosim. V18 Van de Putte, S., F. Verhaegen, Y. Taeymans et al. 109(4): 409-419 (2004). Correlation of patient skin doses in cardiac interven- Williams, J.R. and A. Montgomery. Measurement W17 tional radiology with dose-area product. Br. J. Radiol. of dose in panoramic dental radiology. Br. J. Radiol. 73(869): 504-513 (2000). 73(873): 1002-1006 (2000). World Health Organization. Efficacy and Radiation W1 W18 Wagner, H.N. Jr., Z.S. Szabo and J.W. Buchanan Safety in Interventional Radiology. Chapter 4. WHO, (eds.). Principles of Nuclear Medicine, second Geneva, 2000. edition. W.B. Saunders Company, Philadelphia, W2 World Health Organization. www.who.int/whosis/ 1995. database/core_select_process.cfm?countries=all&in Watson, E.E. Radiation absorbed dose to the human W19 dicators=health personnel. Accessed 3 March 2007. fetal thyroid. p. 179-187 in: Fifth International Radi- W3 Ware, D.E., W. Huda, P.J. Mergo et al. Radiation Proceedings opharmaceutical Dosimetry Symposium, effective doses to patients undergoing abdominal CT of a Conference, Oak Ridge, 1992. examinations. Radiology 210(3): 645-650 (1999).

231 219 ANNEX A: MEDICAL RADIATION EXPOSURES Weatherburn, G.C., S. Bryan and J.G. Davies. Com- W20 Y9 Yu, C.X. Intensity-modulated arc therapy with parison of doses for bedside examinations of the dynamic multileaf collimation: an alternative to tomotherapy. Phys. Med. Biol. 40(9): 1435-1449 chest with conventional screen-film and computed radiography: results of a randomized controlled trial. (1995). Radiology 217(3): 707-712 (2000). Y10 Yasuda, T., J. Beatty, P.J. Biggs et al. Two-dimen- W21 sional dose distribution of a miniature x-ray device Waksman, R., S.B. King, I.R. Crocker et al. Vas- cular Brachytherapy. Nucletron International BV, for stereotactic radiosurgery. Med. Phys. 25(7): Veenendaal, 1996. 1212-1216 (1998). World Health Organization. Radiotherapy in Cancer Y11 Young, K.C., M.L. Ramsdale and F. Bignell. Review W22 Management—A Practical Manual. Chapman & Hall of dosimetric methods for mammography in the UK Medical, London, 1997. Breast Screening Programme. Radiat. Prot. Dosim. W23 Waligórski, M.P.R. What can solid state detectors 80(1): 183-186 (1998). do for clinical dosimetry in modern radiotherapy? Young, K.C. and A. Burch. Radiation doses received Y12 in the UK Breast Screening Programme in 1997 and Radiat. Prot. Dosim. 85(1): 361-366 (1999). W24 1998. Br. J. Radiol. 73(867): 278-287 (2000). Wang, X., S. Spirou, T. LoSasso et al. Dosimetric Yalow, R.S. and S.A. Berson. Immunoassay of Y13 verification of intensity-modulated fields. Med. Phys. endogenous plasma insulin in man. J. Clin. Invest. 23(3): 317-327 (1996). 39(7): 1157-1175 (1960). W25 Walker, S.J. Extra-corporeal radiotherapy for primary Zammit-Maempel, I., C.L. Chadwick and S.P. Willis. Z1 bone sarcomas. Radiography 2: 223-227 (1996). Wambersie, A., J. Zoetelief, H.G. Menzel et al. The W26 Radiation dose to the lens of eye and thyroid gland in paranasal sinus multislice CT. Br. J. Radiol. 76(906): ICRU (International Commission on Radiation Units and Measurements): its contribution to dosimetry in 418-420 (2003). Zhang, G., O. Yasuhiko and Y. Hidegiko. Absorbed diagnostic and interventional radiology. Radiat. Prot. Z2 Dosim. 117(3): 7-12 (2007). doses to critical organs from full mouth dental radi- Wu, X. Breast dosimetry in screen-film mammog- ography. Chin. J. Stomatology 34(1): 5-8 (1999). (In W27 Chinese). raphy. p. 159-175 in: Screen-Film Mammogra- Z3 Zweers, D., J. Geleijns, N.J.M. Aarts et al. Patient phy: Imaging Considerations and Medical Physics and staff radiation dose in fluoroscopy-guided TIPS Responsibilities (G.T. Barnes and D.M. Tucker, eds.). Medical Physics Publishing, Madison, 1991. procedures and dose reduction using dedicated flu- oroscopy exposure settings. Br. J. Radiol. 71(846): Wu, X., E.L. Gingold, G.T. Barnes et al. Normal- W28 ized average glandular dose in molybdenum target- 672-676 (1998). Zähringer, M., V. Hesselmann, O. Schulte et al. Z4 rhodium filter and rhodium target-rhodium filter Reducing the radiation dose during excretory urog- mammo-graphy. Radiology 193(1): 83-89 (1994). Yaffe, M.J. and J.A. Rowlands. X-ray detectors for dig- Y1 raphy: flat-panel silicon x-ray detector versus com- ital radiography. Phys. Med. Biol. 42(1): 1-39 (1997). puted radiography. Am. J. Roentgenol. 181(4): 931- Y2 937 (2003). Young, K.C. Radiation doses in the UK trial of breast screening in women aged 40-48 years. Br. J. Radiol. Zoetelief, J., J. Geleijns, P.J.H. Kicken et al. Diag- Z5 75(892): 362-370 (2002). nostic reference levels derived from recent surveys on patient dose for various types of radiological Y3 Young, K.C., M.G. Wallis, R.G. Blanks et al. Influ- examination in the Netherlands. Radiat. Prot. Dosim. ence of number of views and mammographic film density on the detection of invasive cancers: results 80(1): 109-114 (1998). Z6 Ziliukas, J. and G. Morkunas. Results of a patient from the NHS Breast Screening Programme. Br. J. Radiol. 70(833): 482-488 (1997). dose survey on diagnostic radiology in Lithuania. Yates, S.J., L.C. Pike and K.E. Goldstone. Effect of Radiat. Prot. Dosim. 114(1-3): 172-175 (2005). Y4 Z7 Zhu, Y., A.S. Kirov, V. Mishra et al. Quantitative multislice scanners on patient dose from routine CT evaluation of radiochromic film response for two- examinations in East Anglia. Br. J. Radiol. 77(918): dimensional dosimetry. Med. Phys. 24(2): 223-231 472-478 (2004). Yan, D., F. Vicini, J. Wong et al. Adaptive radiation Y5 (1997). Zhu, T.C. and J.R. Palta. Electron contamination in 8 Z8 therapy. Phys. Med. Biol. 42(1): 123-132 (1997). and 18 MV photon beams. Med. Phys. 25(1): 12-19 Yu, C.X., D.A. Jaffray and J.W. Wong. The effects Y6 (1998). of intra-fraction organ motion on the delivery of dynamic intensity modulation. Phys. Med. Biol. Z9 Zankl, M., R. Veit, G. Williams et al. The construc- tion of computer tomographic phantoms and their 43(1): 91-104 (1998). application in radiology and radiation protection. Yang, J.N., T.R. Mackie, P. Reckwerdt et al. An inves- Y7 Radiat. Environ. Biophys. 27(2): 153-164 (1998). tigation of tomotherapy beam delivery. Med. Phys. Zankl, M. and A. Wittmann. The adult male voxel 24(3): 425-436 (1997). Z10 125 model “Golem” segmented from whole-body CT Young, L.A., I.J. Kalet, J.S. Rasey et al. Y8 I brachy- therapy k-edge dose enhancement with AgTPPS4. patient data. Radiat. Environ. Biophys. 40(2): 153- Med. Phys. 25(5): 709-718 (1998). 162 (2001).

232 220 UNSCEAR 2008 REPORT: VOLUME I Z11 Zankl, M., N. Petoussi, R. Veit et al. Organ doses Zankl, M., W. Panzer and G. Drexler. Tomographic Z13 anthropomorphic models. Part II: Organ doses from for a child in diagnostic radiology: comparison of a computed tomographic examinations in paediatric radi- realistic and a MIRD-type phantom. p. 196-198 in: ology. ISSN 0721-1694. GSF-Bericht 30/93 (1993). Optimization of Image Quality and Patient Exposure Zoetelief, J. and J.Th.M. Jansen. Calculation of air Z14 in Diagnostic Radiology (B.M. Moores, B.F. Wall, H. Eriskat et al., eds.). BIR Report 20 (1989). kerma to average glandular tissue dose conversion Zankl, M., W. Panzer and G. Drexler. The calculation Z12 factors for mammography. Radiat. Prot. Dosim. of dose from external photon exposures using refer- 57(1): 397-400 (1995). ence human phantoms and Monte Carlo methods. Z15 Zorzetto, M., G. Bernardi, G. Morocutti et al. Radia- Part VI: Organ doses from computed tomographic tion exposure to patients and operators during diag- nostic catheterization and coronary angioplasty. examinations. ISSN 0721-1694. GSF-Bericht 30/91 (1991). Cathet. Cardiovasc. Diagn. 40(4): 348-351 (1997).

233 Corrigendum to Sales No. E.10.XI.3 May 2016 18 Sources and Effects of Ionizing Radiation: United Nations Scientific Committee on the Effects of Atomic Radiation 2008 Report Vo l u m e I workers from various sources of Annex B (Exposures of the public and radiation) Corrigendum 1. 3 Page 328, table In the header, for Collective dose per unit read release (man Sv/PBq) (man Sv/TBq) release Collective dose per unit 2.1 In the first row, 0.0021 for read s e econd row , th fo r 270 read 0.27 In the third row, for 0.0074 read In 0.0000074 In f the our r th ow, fo r 0.044 read 44 0.3 fi ft In h ow, fo r 0.0003 read th e r fo the sixth row, r 0.0074 read 7.4 In 0.0000014 read 0.0014 In th s e eventh row, fo r fo In r h ow, ei ght r 1000 read 1 the the nint r h ow, fo r 4.7 read 0.0047 In In the tenth row, fo r 3.3 read 0.0033 In th e eleventh row fo , r 99 read 0.099 98 In th t e welfth row, fo r read 0.098 2. P age 367, table 72, section headed “1985-1989”, column headed “Monitored workers” read 12 17 In th e row h eaded “Reprocessing fo ”, r V. 16-02700 (E) *1602700*

234 Corrigendum to Sales No. E.10.XI.3 3. Page 378, table 92, last row headed “T otal” For entry for the period 1990-1994, 0.8 for read 1.3 for 0.9 read 1.8 For entry for the period 1995-1999, For entry for the period 2000-2002, 0.8 1.8 read for 2 V.16-02700

235 Corrigendum to Sales No. E.10.XI.3 May 2011 Sources and Effects of Ionizing Radiation: United Nations Scientific Committee on the Effects of c Radiation Atomi 2008 Report Assembly to the General , with Scientific Annexes—V olume I Co rrigendum 1. Annex A (“Medical radiation exposures”), page 172, figure D-II The title should read Representative isodose distributions: Intensity-modulated radiation therapy pl anfor a prostate tumour , showing superior conformation of the 50 Gy isodose line to the planning target volume and workers fr om various sources of 2. Annex B (“Exposures of the public radiation”), paragraph 155 should read The paragraph . Mining operations have been carried out in open Effluents and solid waste 155. pits, in underground mines and by in situ leaching. Uranium mill tailings are generated at about one tonne per tonne of ore extracted, and they generally retain 5–10% of the uranium and 85% of the total activity [V4]. The estimated amounts of 9 the tailings worldwide are shown in figure XVII; they total about 2.35 × 10 t. Besides tailings, waste rock piles may also become a source of public exposure. For open- pit mining, the amount of debris produced is from 3 to 30 tonnes per tonne of extracted ore. For underground mining, about ten times less debris is produced. On the basis of information provided for 13 mining sites in Argentina [R13], Canada [M28], Germany [F2] and Spain [S29], the amount of waste rock varies from 40 to 6,000 times the amount of tailings, with an average value of about 1,600 tonnes of waste rock per tonne of tailings [I38]. V. 11- 80527 (E) *1180527*

236

237 ANNEX B exposures of the public and workers from various sources of radiation N ts t Co EN Page . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . introduction 223 225 ose assessment issues i . d . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225 a . p ublic exposure ccupational exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226 b . o . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228 c . s pecial quantities for radon ii . public exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 atural sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a . n 229 1 osmic radiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 . c 2 . t errestrial radiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233 ummary of the exposures to natural sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 3 . s nhanced sources of naturally occurring radioactive material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 b . e 1 . m etal mining and smelting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 . p hosphate industry 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 . 3 . c oal mining and power production from coal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 . o il and gas drilling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 4 5 . r are earth and titanium oxide industries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 6 . Zirconium and ceramics industries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240 7 . a pplications of radium and thorium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241 . o ther exposure situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241 8 ummary on exposure to enhanced norm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 9 . s se of man-made sources for peaceful purposes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c . u 242 1 uclear power production . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 . n . t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 249 ransport of nuclear and radioactive material . a pplications other than nuclear power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252 3 . . . . . . . . . . . . . . . . . s ummary on exposure due to peaceful uses of man-made sources of radiation 4 . 255 se of man-made sources for military purposes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d . u 255 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . uclear tests . n 1 255 . r esidues in the environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262 2 e . h istorical situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276 f . e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xposure from accidents 277 s ummary on public exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277 . G . iii . o . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ccupational radiation exposure 279 ssessment methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a . a . 280 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ose recording . d 1 . 280 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c haracteristics of dose distributions 2 . 280 . e stimation of worldwide exposures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281 3 221

238 Page atural sources of radiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281 b . n 1 osmic ray exposures of aircrew and space crew . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282 . c 2 xposures in extractive and processing industries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284 . e . Gas and oil extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287 3 4 . r adon exposure in workplaces other than mines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288 . c onclusions on occupational exposure to natural sources of radiation . . . . . . . . . . . . . . . . . . . . . . . . 289 5 c . m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290 an-made sources for peaceful purposes 1 . n uclear power production 290 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 . m edical uses of radiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300 3 . i ndustrial uses of radiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309 . m iscellaneous uses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315 4 d . m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317 an-made sources for military purposes 1 . o ther exposed workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319 e . s ummary on occupational exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319 concl usions on public and worker exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322 t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325 ables f i G ures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379 r eferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439 222

239 IN DUC t I o N t R o e xposure o f h uman b eings t o i onizing r adiation f rom difference of protection the managing for responsibilities in 1. The nescapable o f l ife nd a ontinuing c a s i ources s atural workers and of the public n i that is reflected in the different f eature o t he e arth. F or m ost i ndividuals, t his n e xposure e xceeds t hat interests of users of this annex. T here f rom a ll m an-made s a re t wo m ain ombined. c ources c previous updates and supplements annex 3. This os- c h xposures: e adiation r atural n o t ontributors igh-energy tmosphere a arth’s he t n o ncident i articles p ay r mic UNSCEAR estimates The subject. the on publications of adio- r nd a e primarily based been have exposure radiation n uclides t hat o riginated i n t he e arth’s c rust a nd a re - submis active on the i ncluding t he h uman doses of assessment for databases UNSCEAR the to sions p resent e verywhere i n t he e to nvironment, T reports significant by supplemented workers, and public the b ody i tself. he w orld p opulation i s a lso e xposed t o r adiation does not cover processes the literature. in he The annex r esulting open f rom r eleases t o t e nvironment adioactive r f o o m f rom m an-made s ources, a nd f rom t he u se aterial f f uels o r reference pertinent, whenever detail; in described previously I n m be may information detailed more where sources to aterials made is c ontaining n aturally o ccurring r adionuclides. ide o a separately has Committee the because particular, In found. ddition, t here a re a w v ariety f s ituations i n eople p hich w s a w UNSCEAR a the e of t E i (annex r radon T to due exposures evaluated onizing t ituations hese adiation. o xposed re ork s o m r f h 2006 Report [U1]), to medical uses of radiation (annex A of r a rom aterial, f mall ange andling adioactive mounts g i t s t o r e 2008 the f of C (annex accidents to and Report) 2008 the tudies, xample adiation- racer o enerating n perating or t the 1986 Chernobyl g o e Report), t in w particular i exposures i due o to auging quipment, o orking n r nstallations f he accident e n t (annex D of w the 2008 Report), these aspects are not f c s a a T here uclear uel he ycle. ituations lso xpo- re here Where annex. this in extensively with dealt s i r appropriate, o s n t w o f ources ufficiently atural o s orkers adiation f sure h a r o for here reflected been have evaluations other of summaries a c a t w t m ontrol nd adiation he igh s arrant anagement n o f completeness. e t w A h o r azard. ere ccupational hese xposures egularly ll C t m p r i o t a r n revious eports f he ommittee, he ost ssessed ecent Committee t b 2 R 4. U [ has historically T described the p exposure o 000 eing he f NSCEAR eport urposes he The U3]. different general several g u of t the i members t o a of a to t public the hese re o mprove he f nderstanding lobal ssessments p of radiation. The principal man-made and t e w sources a natural l a t t o ublic xposure, evels nd orker emporal nd rends o f m c presented exposures o public of e analysis the s of e objectives a t t in a p rovide eas- he s valuate o o xposure f omponents t t o a section i i r e ure heir elative mportance, nd o dentify merging II are: f w i t m s a m a nd ore crutiny. arrant hat ssues ay ttention to w le radiation the e which vels − To valuate orldwide human beings are usually exposed; addresses I Section sections. three comprises annex 2. This assess v of usual w e the − ariability To xposure orld- and general public issues for related assessment to dose to different sources; wide and radiation, quanti the occupational exposure to special - radon. to due assessing and Sec measuring for exposure - ties of T identify sources − concern for public e xposure; o of the II and III address exposures to ionizing radiation tions allo compari for benchmarks deri to users - To w ve − the general public and workers, respectively. The distinc of - to and deri purposes, to manage e son xposures ve exposure is public kept between occupational for and tion relationships investigative for work; their main (a) two the reasons: two groups exhibit significant dif - exposed, with to age, the numbers of analyse respect of contrib the in trends temporal people ferences utions − To the relevant exposure pathways, and the methodologies dif for to sources ferent exposure. public overall 1 assessing and radiation a doses; and (b) there is monitoring between differentiate to straightforward is not often 5. It 1 doses to the public are usu - While doses to w orkers are measured, mostly normal exposures and enhanced exposures to natural sources methods, ally measurements using typically performed indirect by assessed between of and radiation, these and man-made exposures to v arious e xpo- vironment en the in or of en vironmental samples, modelling assessment sources. common illustrative the example An is emplo and scenarios sure accurac ying The habits. population data on y background natural the where indoors, exposure radiation of made doses used: methodology the with fers dif usually assessments of radiation exposure is influenced natural by the presence of those for assessed members of for w orkers are normally more accurate than from occupational e xposure relate to a specific the public. Moreo ver, doses are building in leading radioactivity to what some materials, - set of people, usually health y adults. the to doses of assessments Although enhanced exposures. Another example is the treated as times age ferent dif of properties the of account e tak sometimes public or groups process, alter impact to of known the is urbanization which the dose estimates do not usually apply to the v alues specific their habits, of natural laying the (e.g. of background radiation exposure under population the within vidual indi specific y an rather ut b consideration, reduces soil, the in radionuclides from exposure pavement dose people. of groups to average an represent 223

240 224 REPORT: V OLUME I UNSCEAR 2008 n t se o f g ranite a nd c ertain c eramic m aterials i u whereas the w orkforce) he for each of the major practices I n t he c onstruction o f b uildings m ay radiation; nhance e xposure). in volving the use of ionizing e eveloping c ountries, t he e xpansion a ddition, e specially f or d w to doses ve collecti orkers annual the assess To − ith w rea a n a n i nstallation i ining m ew n a e.g. ( ndustries i f o each of the major practices in volving the use of for ay h igh l evels o f b ackground r adiation) m e nhance p ublic u se vides pro radiation. ionizing This a measure of the n s a rea a n a f o vail- h nd a a ecomes b nfrastructure i ew abitation ution made by contrib e xposures to the occupational f t hese n p e xposure. B i hanges c o t eading l able, ecause o ublic o unit per impact the and use that of impact verall d ifficulties, n o a ttempt w ill b e m ade h ere t o d raw a r igorous practice; atu- n o t xposures e nhanced e nd d istinction b etween a ormal n − in trends temporal occupational analyse o xpo- e T xposure ral s ources o f r adiation. S ubsection I I.A, o n p e ublic the to in order e valuate sures ef fects of changes in o f o n atural t s ources o f r adiation, i ncludes c onsideration gulatory standards re or requirements (e.g. changes e xposures t o c osmic a nd t errestrial s adiation. r ources f o dose increased and limits in attention to ensuring achie that doses are as lo w as vable), reasonably radiation exposure of the 6. The general public to resulting ne modified and de technological w velopments as the mining, from industries deemed non-nuclear—such practices; ork w of ores that, apart from the raw mate - milling and processing and/or uranium thorium (Th)—is described contain rial, (U) orkers To − e xposures of w in dif ferent coun - compare of radiation. Expo - in subsection II.B on enhanced sources tries e of vels le orldwide w the estimate to and xpo- resulting from nuclear sures (i.e. those related to industries sure for each significant use of ionizing radiation. and to are radionuclides) artificial cycle fuel nuclear the described subsections two in on man- to exposure public 9. According t o t he I nternational L abour O rganization, t he of describes II.C, subsection these, first The sources. made f ormal d efinition o f o azardous h ny a o t xposure e ccupational exposure to man-made public sources arising from peaceful xposures a i ncludes a ll f o egardless r gent ork, w t e a i ncurred of energy the and generation uses atomic energy (including r or f owever, H I62]. [ ource s n i urposes, p rotection p adiation operation of the associated fuel cycle facilities, the produc - d t ubject s e b hould s hat t o xposures e he t istinguish o t rder o tion radioactive and nuclear of transport the radioisotopes, of f rom t he c xposures ontrol b y t he o perating e m anagement use material, waste management and the of consumer prod - he g eneral r rising a adiation e nvironment i n w hich a ll f rom t presents ucts). second, subsection II.D, The the public expo - m ust l ive, t he t erm “ occupational ften o s i xposure” e adiation r sources to related purposes man-made to sures military ean m w hich c an o t aken t ork t a eceived r xposures e w hose t (including atomic weapons tests and their fallout or radio - t perating he f o esponsibility r he o s a egarded r e b easonably r t active residues, the military use of depleted uranium in war m lso a ormally n re a xposures e uch S 47]. I 16, I I7, [ anagement sites situations and contaminated by waste from previous I7]. s sually u re a xposures e he T [ ontrol c egulatory r o t ubject associated practices, mostly with the development of nuclear a etermined b y i ndividual m onitoring, d nd ssessed a oses d he t exposures the not but technology, weapons including to due r a r ecorded f or adiological p rotection p urposes. nd Hiroshima received doses As bombings). Nagasaki and the been have explosions nuclear to due by the population world 10. The terms “practice” and “intervention” have been described systematically in previous reports of the Commit - widely in radiological protection. used The term “practice” tee and a major overview was presented in the UNSCEAR the has been exposure used increase that activities human for summary 2000 and tests the regarding a only [U3], Report the or or radiation to people of the likelihood of exposure here resulting worldwide exposures has been included the number of people exposed. The International Commission for completeness. had (ICRP) distinguished Protection Radiological on “practices” that increase exposure or between likelihood of its updated has evaluations the III section 7. In Committee and exposure - likeli or exposure reduce that “interventions” U7, work for U10] U9, U6, [U3, exposures of occupational exposure ICRP latest the I47]. However, hood [I7, of in six broad categories of practice: practices involving ele - a use [I60] recommendations to approach situation-based to of levels vated natural exposure sources of radiation; the possible situations where radiation exposure the characterize uses industrial uses radiation; of medical cycle; fuel nuclear “emergency” may as “planned”, - occur and “existing expo and activities; military radiation; of of uses miscellaneous is more The situations. sure” ICRP now believes that it radiation includes educational (which and veterinary uses). of appropriate to limit the use to “intervention” term the while actions protective describe exposure, reduce that the istributions nnual a f o 8. The C ommittee h as e valuated t he d exposure” “existing to or “emergency” terms will be used a e ndividual ffective d oses a nd i nnual c ollective e ffective d oses where such protective actions describe radiological situations he ccupational r adiation e xposures i n t v arious o rom f esulting r reduce to the annex terms this In [I60]. needed are exposure ource. rincipal he ractices r bjec- o arious ypes f ue s p t v p T o t o d o the are to “intervention” “practice” and applied according s f xposures nalysis emain, ccupational he f n tives r e a o i t a o o [I47]. definitions ICRP previous he ollows: f ssessments s he revious ommittee, C t t p a a o f he or − To f nclusion nd xternal ecording 11. The rocedures p f internal t committed r a e i annual o assess and o ractice ve rom iffer orkers xposures ccupational ractice to o e (both d w f the p cumulati t and p doses doses nd ountry, ountry verage o he nfluence ution ay his nd a c within t a c dose a and t the m distrib i of t doses

241 ANNEX B: EXPOSURES OF THE PUBLIC AND W ORKERS FROM V ARIOUS SOURCES OF RADIATION 225 exposed d ifferent w ays. S ome c ountries workers of number significant a are there s respective to ioniz - tatistics i n nd m ay o verestimate t he s ize o f t he e xposed ing radiation w who are not individually monitored. The larg - orkforce, a opula- hereby natural to exposed those are workers these of proportion est t p nd a ndividual i he t f o ssessment a istort d s oreover, M istributions. d ose d tion the Before radiation. r ionizing of of eport implementation ountries c ome sources Safety o International the nly t he d oses o f w orkers i n c ontrolled a reas, w hile o ther Protection for Standards Basic e xposed a nd n on- for and Radiation Ionizing against the c Radiation of ountries Safety r eport t he d oses f rom b oth dequately Sources “International Basic Safety Standards”) [I7], rack t (the a ot n o d ountries c ome S orkers. w exposed ork w ay d ho w orkers, w ontract c o t oses he t few data were recorded in national databases on occupa - ccu- a nd a m Recently, radiation. of sources natural to exposure i n mulate e xposure i n d ifferent i tional p ossibly e ven ndustries, however, exposures to enhanced levels of natural radiation ubsec- s n iscussed d re a ssues i hese T ountries. c ifferent d i focus a become have tion I II.A. T hese d ifferences i n m onitoring a nd r eporting radiation of field the in attention of is devoted to natural sources of III.B Subsection protection. p ractices m ean t hat nterpreting i n i pplied a e b ust m aution c t r eported d he exposure. radiation occupational ata. involved in practices that are - 12. Although expo occupational address III.D and III.C 13. Subsections most workers for and peaceful used radiation of sources regulatory national the by established controls to subject sure to man-made authorities are individually monitored on basis, a routine for military purposes, respectively. A E I. ss E ssm EN t I ss UE s Dos a i a t [ S ( m b y s v) he man nd ccompanied an-sieverts I7] used describe to here quantity basic 14. The radiation i o n i t g W t q wa umber hile ndividuals he his f uantity roup. n s Although artificial dose”. fective “ef the is xposure e this o p t f s d a o o urposes f ptimization f eveloped trictly or he lso protection it strictly quantity veloped is de purposes, as w for t i rotection, p ommittee ela- r he t ssess a o t C he t y b sed u s i purposes assessment. xposure e of The the for here used tive f i mportance o v arious s ources o f r adiation e xposure. the includes dose fective ef committed annual e of sum xter- t c d r b T a g d b y ollective ivided eceived he y ose roup he reported in millisie verts nal and internal doses and is usually g o i i t i t “ p n c he he f n average roup umber ndividuals s er aput (mSv): g d i t n ose” roup. his (1) u I o t S C U nternational nits ommittee ystem he 18. The f ses t a r eport d ata a s v alues t hat c an b e e asily u sed nd r ecalled; o v ne recommended recently ery w has [I60] ICRP The 15. t i m s a s o u pecifically, t ses ultiples nd ubmultiples f he for radiation and v of some the alues tissue weighting f actors d p u s f b t refixes: tandard nits, esignated y he ollowing wever, Ho dose. fective ef valua- of definition the in e the for the here, doses has been made tions fective of assessment ef 15 -15 (P) 10 peta femto (f) 10 definition earlier the of basis the on ICRP in vided pro 12 -12 tera (T) 10 pico (p) 10 60 Publication [I47]. 9 -9 giga nano (n) 10 (G) 10 - 16. In particular , the Committee continues to use in its esti -6 6 micro (μ) 10 mega (M) 10 ( of mations of ef fective dose ) a radiation weighting f actor w R 3 -3 milli (m) 10 kilo (k) 10 1 for all photon and beta emitters, including tritium. A recent - report of an independent Advisory Group on Ionising Radia tion to the Health Protection Agenc y (HP A) in the United P A. ublic exposure Kingdom that recommended the ICRP consider increasing from tritium for alue v to 2 [A3]. The ICRP has consid - 1 this is v ery rare that are public the of members 19. It to doses this recommendation, into ered account recent re views taking assessed are doses these Usually measured. the directly on v of scientific basis for this the alue [L18, L19]. It concluded basis of en vironmental or effluent monitoring data, using that, assessments i.e. approach, broad their for co vered by e to models en simulate xposure scenarios. These vironmental that indi not vidual-specific, are remains a 1 of alue v discussed xtensively e the scenarios and models ha ve been in [C32]. appropriate the UNSCEAR of only and [U3], Report a 2000 summary presented here. relevant aspects will be most o r t c d t f v t adiation ompare o rder 17. In ose rom ari- he otal s i b d g t C ncurred roups, ources ommittee he ifferent ous y 20. The (1) data on depends the Eq. in E of estimation u t q “ d w i d a t s uantity ose”, efined he s hich collective ses he ext main The measurements. en from vailable a vironmental d t e r i i t s o a f oses eceived ll he um ndividual ffective he n to due fields xposure e xternal e characterize to used quantity i e u c i I g u o f nits t n onsideration. nder xpressed roup s

242 OLUME 226 REPORT: V 2008 I UNSCEAR sources is the absorbed dose rate in air , usually ower p uclear n f o peration o he t o t ue d oses d ssess a 23. To natural nd reported onversion c ose d he t cilities, fa ycle c uel f ther o a lants p report authors Some (nGy/h). hour per nanograys in U3] [ eport R 000 2 NSCEAR U he t n e also erma, k air the i nanograys erived d oefficients c in per hour . Under xpressed the f o erms t n i pecified s re a oefficients c hese T sed. u een b ave h assumption that char ged-particle equilibrium e xists he elease absorbed the and erma k air the material, of olume v the within t c ollective e ffective d ose p er u nit r o f a r adionu- nd a eactors r uclear n dose or used actor f The valent. equi be to assumed be may air in clide. T hey a re p resented i n t able 2 f absorbed of to xter- ycle c uel f ther o or F cilities. fa eprocessing r or f 3 able t n i measurements transform to air e in dose nal ef fective dose to adults is 0.7 Sv/Gy , as described in the asis b he t n o stimated e fa cilities, c ollective d oses ave b een h describing When [U3]. Report 2000 UNSCEAR o f t he e lectrical public e nergy g enerated a nd t he s ame d ose c oef- e xternal e xposures are assessed using ef fective e xposure, ficients a s u sed i n [ U3], n amely 0 .2 m an S v/(GW a ) f or ining, 0 .0075 m an S v/(GW a ) f or m ranium hour per verts nanosie either of units in xpressed e rates dose o perational u fields, xposure e instantaneous for (nSv/h) perational t ailings p iles, 0 .00075 m an S v/(GW a ) o for verts millisie or f ) a v/(GW S an m .003 0 iles, p ailings t esidual r rom eleases r per year (mSv/a) for estimating the a verage annual e xposure fa brication fa uel f nd a nrichment e ranium u for - cilities, of indi viduals. The “occupanc y fraction”, related to the frac isposal d he t for , ) a v/(GW S an m .5 0 nd a I indoors, spent time of tion actors” of f “shielding the and nd a ow- l f o in i wa ste. b T he C ommittee h as d ecided n ot ntermediate-level uildings, SF , describing the ratio of the absorbed dose rate he fa r f uture, a s wa s t o e xtend i ts e stimates o f d oses i nto t to used also are outdoors, rate dose absorbed the to indoors l t he v doses: effective annual average estimate ery eports, arge u ncer- d one i n p revious r b ecause o f urrent o hus T ssessments. a uch s c n i nherent i tainty nly (2) t he p ublic a re d escribed oses i n d r eceived b y m embers o f t his a nnex. also be estimated from en viron- 21. External doses may natural in soil, C , mental concentrations of radionuclides 24. For assessment uses of e xposures due to military of the soil actors, DCF as , using appropriate dose con version f also radiation, the main quantity used is the ef fective dose, soil presented in table 1: dose although sometimes the equi valent to specific or gans, such also as the th yroid, ha ve been reported. Both quantities (3) xpressed in e are units of millisie verts, b ut when the term “dose” refers to a specific or gan dose, this is made clear in oses d 22. Internal he t sing u alculated c re a dults a or f estimates te xt. In this section, for doses occurring in the the 5 y ear nter- i ntegrated i he t i.e. ( oses d ffective e ommitted c 0 are future near and present past, doses future The ven. gi are 5 or f ntake); i ollowing f ears y 0 he t ver o eceived r ose d nal e to the to due xposures predicted or possible mainly related o t p c u hildren, t he c ommitted e ffective d oses a re i ntegrated use of contaminated sites. t he a ge o f 7 0 y ears. V ery f ew a ssessments i nclude e stimates ublic o f d oses t o c hildren. I nternal d oses t o m embers o f t he p b re u sually e stimated o n he a asis o f t he s cenarios d escribed t n o ata d sing u U3], [ eport R oncen- 000 2 NSCEAR U he t ccupational exposure n i c o B. f o trations i n t he e nvironment, s uch a s c on- r adionuclides er n ater o r f ood, C , e xpressed i n b ecquerels p w i that indicated [I47], 60 Publication its in centration , 25. The ICRP k nd c on- e undertak to decision the influence l actors f important three itre ( Bq/L) o r b ecquerels p er k ilogram ( Bq/kg), a ubic c er p ecquerels b n i xpressed e , in C ir, a n i centration indi vidual monitoring: the e xpected le vel of dose or intak e air 3 ( etre m in Bq/m relation to the rele vant limits; the lik ely v ariations ): the doses intak es; and the comple xity of the measurement and and interpretation procedures that mak up the monitoring e programme. Where doses are consistently lo w or predicta - are ble, other methods of monitoring sometimes used, as in case the for from calculated whom be can doses w aircre of xity comple measurement of techniques The rosters. flight (4) results irradiation xternal e for monitoring to approach an in resulting intak for that from ferent dif is that and es the dose. committed where j refers to radionuclides, k refers to the type of food or radionuclide, ater, I is the intak e of IR is the inhalation rate w 26. The to needs , E(t) dose, e fective ef the of estimate tak coefficient the is e and , k for f foodstuf of rate ingestion the or the account into internal and xternal e from ution contrib , con e dose, fective ef committed (50) to e intak from version j xposure, be estimated using the e if appropriate. E(t) can for grated fective years inte dose 50 i.e. for ef committed the expression: wing follo fective dose inte - e , (70) and i.e. adults, committed ef the j years for children, separately for grated up to the age of 70 The coefficients and ingestion. inhalation dose con version adults due for intak es of doses for x anne this in used to (5) natural also radionuclides are presented in table 1.

243 EXPOSURES OF THE PUBLIC AND W ORKERS B: FROM V ARIOUS SOURCES OF RADIATION 227 ANNEX o f p artial-body e xposure r emains p roblematic c onditions time during valent equi dose personal the is (d) H where P robably hat t equire r p ould w ccurate a ully e b o t hat t nd a f t mm for pene - 10 period at a depth d in the body (normally m ultiple m e iffer- D one. d ften o ot n s i hich w sed, u b onitors is radiation); e (50) trating the committed ef fective dose j,inh m here- ing t ay m adiology r edical m n i ractices p onitoring acti vity intak e by inhalation of radionuclide j , inte - per unit c d a ffect t he v alidity o f t he ata f or omparison p urposes. fore grated by j radionuclide of e intak the is I years; 50 ver o j,inh r p elation he t o t he l osition o f t ince S t he d ead osimeter i n during inhalation ; t period e time the (50) is the committed j,ing pparent a arge l a ountries, c tandardized mong a s ot n s i pron a e intak vity acti unit of per dose ingestion fective ef radio - by c v lgorithms a nless u esult r ould alues ose d f o uctuation fl of nuclide j , inte grated o ver 50 e intak the years; is I and j,ing he t onvert c o t sed u re a stimates e recise p ore m ield y hat t radionuclide j by ingestion during time period t . Uptak e ose t easured q uantity o e ffective d m [ N9]. V ariations i n t he ounds can circum some the skin and through w - in occur o ay f t he l ead a pron i tself a nd i n i ts t hickness m d r ep- esign F or - pro coefficients dose stances. the e, intak of forms most hese T ncertainty. u f o ources s dditional a resent ncertainties u by the ICRP are for vided intak es by inhalation and ingestion c a nd h ow t hey a re a ddressed b y d osimetry s ervices ould into take not do and account uptake skin. the through a mpact lso h ave a n i o n t he c omparisons m ade h ere. I n t his hat i ave h arameters p hese t ll a b t ssumed a s een t i nnex a - Pro Radiation on Council National States United 27. The c onsidered i n d ose e stimation. p roperly and Measurements (NCRP), tection in collaboration with the and a for model dosimetric ICRP , has de veloped biokinetic version con 30. The radiological in use pro - for coefficients radionuclide-contaminated w ounds. The multicompartment - e ainst tection ag xternal Publi ICRP in ven gi are irradiation describe to biokinetics the first-order uses model linear radon for Except [I56]. of the 74 cation v alues y, progen retention of the on deposited radionuclide a clearance and unit inhalation, for e intak per dose fective ef committed w ound site. Se ven def ault cate gories ha ve to defined been and - Publica ICRP in found are , (50) e (50) , ingestion, e ound contamination retention: relate site w four to describe j,ing j,inh weighting of account es tak which [I50], 68 tion tissue the and materials (weak, soluble moderate, initially strong with lung model w ne the and [I47] 60 Publication in actors f ICRP v- vid), contamination to with relate materials three ha and a data pro - is Publication ICRP in It [I51]. assumed 66 that the ing solid and particle fragment). (colloid, The properties to the Committee ha ve been based vided on these con version ound models coupled ICRP is the model systemic for w to difficulties of number A coefficients. in encountered be may xcretion aecal e patterns, f and as as urinary well predicting determining occupational e xposure. These difficulties may ound-specific wever, Ho for w producing dose coefficients. addressed in v arious w ays, as is e vident in the v ariety be of vailable, are a resulting not and coefficients dose the yet recording dose procedures and adopted monitoring practices x the therefore doses the anne on in were estimated based this in countries throughout the w orld. While some countries inhalation or [G15]. ingestion for coefficients dose Publi ha already adopted the recommendations ve of ICRP - countries are still cation 60 [I47], a significant proportion of actors 28. One garding re the f uncertainty the of of the of quantities the limits dose the using Publication ICRP and w xternal dose concerns ho and where personal e assessment cur- the in analysed period first the for especially [I43], 26 - orn esti to the in best order w dosimeters be should obtain xplaining rent anne x e (1995–1999). This may be a f actor in mate fective valent equi In or dose, dose appropriate. as ef of among dif ferent practice ven gi a for doses in ariation v the general, is is this placed body; dosimeter the on of a front the countries. Quantities for - radiation method the and xposure e actory vided ve ha the satisf been pro designed that dosimeters for xternal and internal dose assessment ha ve been ologies e aprons measure to lead where , radiology medical In . (10) H P and [U3], Report 2000 the in described well UNSCEAR ve been adopted. In some dif approaches ha are used, ferent measured the because described techniques the and quantities orkers the assessment carried is cases, w to doses fective ef of not need remain report that in the unchanged, be issue of means by out the trunk, orn under on the dosimeter a w addressed further here. be higher , for e xample in apron. Where doses are lik ely to tw are dosimeters o , radiology entional interv sometimes material ve radioacti of 31. Intakes assessed normally are orn w second a and apron outside. the under orn w one used, for routinely designated are that areas in yed emplo orkers w dosimeter - the assess to is contri second the of purpose The as controlled (specifically in relation to the control of con - bution to the ef fective dose due to the irradiation of unshielded are tamination) or in which there grounds for e xpecting sig - are lo w and indi vidual parts of the body [N9]. Where doses wever, nificant intak es [I13, I55]. Ho there are difficulties in of estimate upper an ve gi to only intended is monitoring due comparing data on doses to intak es of radionuclides in be w orn outside the e xposure, dosimeters might single the ferent countries because of dif dif ferent approaches used apron. for monitoring inter- veral Se results. the interpreting to and national e xercises for intercomparison internal dose assess - 2 9. Measurements m ade o n eams b -ray X sing u hantoms p ganized, ve gest ar as ment f or the ha w lar which been the so of t w t o e o 7 a 1 k h s nd f hat, 04 stimates Vp f 6 ave hile he hown ercise on European Internal Ex Dose Intercomparison Third o w 2 d e w w a l t ose he ithout pron ere ead ithin f ffective 0% work ganized the in or Assessment, frame of the EULEP/ w w e t t d v e o orn alues, osimeter n xpected ith stimates he he Action important I15]. EURADOS The [D11, most Group t l w u t t w a l t han pron he ead he aist he ere ower nderneath xercises as lesson from these intercomparison e w that there S [ a v e t r s uggest alues M12]. uch esults hat ccurate xpected velop as need dose internal for w a guidelines to de agreed u u o p d e e d osimeters ersonal ffective sing ose nder stimation f

244 OLUME 228 REPORT: V 2008 I UNSCEAR procedures in order to promote the harmonization his T ssessments. a ose d f o an b e a n i mportant s ource o f c evaluation etween of ountries c ifferent d y b eported r oses d he t b ariation v - Signifi countries. and ganizations or between assessments their t f o ost m hen w onsideration, c nder u laboratories among vealed re were ferences dif cant eriod p he t or f in oun- c he rom approaches, CRP I o t I43] [ 6 2 ublication P CRP I f hanged c tries methods and assumptions, and consequently in ecommendations. r I47] [ 0 6 ublication P their results. One major source of di vergence at the time of the e xercise w as due to the particular ICRP models used. Most dosimetry services were using the models from ICRP reasons. Ho w- 30 pecial quantities for radon s C. [I44] for le gal Publications 26 [I43] and of ever, - genera w ne the to ving mo process the in were most tion of ICRP models (Publications 66 56 [I46], 60 [I47], 222 health risk due to e xposure to 34. The Rn (radon) and [I51], 67 [I49], 68 [I50], 69 [I52], 71 [I55] 78 [I54], 72 [I53], 220 the principally comes (thoron) Rn from of inhalation the and 100 [I58]), partly because these are considered to be and ved decay products short-li the resulting alpha particle imminent the of - more implemen realistic and partly because airw radiation dose ays. The bronchial the of irradiation and [I7] Standards Safety Basic International the of tation system, vered to the respiratory deli and the resulting poten - Euratom w ne mod w ne the - on based are which ve, directi the tial health detriment, are a comple function of the radon x I14]. H30, D12, [C29, els aiming projects to Similar D10, product aerosol characteristics and the ph ysiological decay ve dosimetry procedures ha internal been carried harmonize parameters e the of indi vidual. The radon xposed and thoron the auspices of the the under orld w of parts ferent dif in out described dosimetry is II section of summary a x anne this in [M20]. (IAEA) y Agenc Energy Atomic International annex in E of the UNSCEAR 2006 Report [U1]. the [I47], the 60 Publication its 32. Since vised re has ICRP product 35. Radon and thoron decay e xposure rates are used in internal dosimetry , models biokinetic and dosimetric xpressed by the measure of e potential alpha ener gy concen - model the the respiratory tract [I51]; the specifically: for 3 tration with units of joules per cubic metre (J/m AEC), ) (P for [I56]; [I46, models systemic tract model alimentary the equi - for the equilibrium bec valent concentration (EEC) or - I52] I49, ICRP w ne The bioki [I54]. models dosimetric and 3 the w orking le vel (WL: ) (Bq/m metre cubic per querels for changed and dosimetric models ha ve the dose coeffi - netic unit of concentration of radon of metre cubic one in y progen dose the of ratios The . dosimetry internal for used cients –5 that for has the potential alpha ener gy of 2.08 × 10 air J for coefficients - Publi ICRP of models the on based orkers w 222 the combination linear a from of Rn). The P AEC is deri ved on 68 Publication of models the based those to [I50] cation in products decay ved short-li the of vities acti radon each 800 about for calculated radionuclides. been ve ha [I44] 30 decay the series (see paragraph 122, anne x B of UNSCEAR F inhalation, or 40% of the ratios f all in the range 0.7– about linear the in combination The [U3]). Report 2000 constants about 1.5, about 4% of the ratios are greater than 10 and of the fractional contrib utions are each decay product to the are 1.4% ingestion, ratios the of 73% about or F 0.1. than less total potential alpha ener gy from the decay g as. The EEC (in the in all f 10 and than greater are 3.4% about 0.7–1.5, range 3 verted the by AEC P the to con be can ) Bq/m of units than both about 1.3% are less 0.1. The analysis addressed relationships: w the in radionuclides of ingestion inhalation and orkplace 3 222 3 6 - included and Bq/m 1 10 5.56 mJ/m = = 0.27 mWL ( Rn) × - consid 800) (some radionuclides the all almost were considered ered in ICRP Publication 30. and The tissues 3 3 - 5 220 1 3.64 = Rn). mJ/m ( 10 × 7.6 = mWL Bq/m the lungs, stomach w all, colon w all, bone mar- red ace, surf and testes breast, yroid, th ver, li w, ro solubility The muscle. 36. As were those considered in ICRP Publication 30. Dose classes 006 2 NSCEAR U he t f o E nnex a n i iscussed d ose a he d adiation r f o stimates e U1], [ eport R coefficients for the types (T ypes F , M and S) cur- t nd r esulting absorption r f o nhalation i rom f isk r erived d e b for coefficients with compared were ICRP the by used rently an c roducts p ecay d adon Class D, W and Y compounds, respecti vely, as defined in odels. m osimetric d r o tudies s pidemiological e ither e rom f o coefficients dose inhalation The 30. Publication ICRP F or gener- ccupational e xposure t o i nhaled r adon d ecay p roducts, by ated models of ICRP Publication 30 were based on a f o se u he t I48] [ 5 6 ublication P the t he I CRP r ecommended i n onversion recommended (AMAD) m μ 1 of size particle ault def the s ingle c in f actor b ased o n t he r esults o f t he u ranium by models of that publication, and the coefficients generated m iner e pidemiological s tudies, b e quating t he r adiation y def the on based were 68 Publication ICRP oefficient c etriment d etri- d iner m he t ith w ievert) s er p risk ( size particle ault his of μ m recommended in that publication. As an e xample, ( 5 t xposure, e orker w or F xposure). e AEC P er p risk ment - 3 o t rounded ( ) the m h Sv/(J m ,430 1 s i actor f ratio of the dose coefficient from ICRP Publication 68 to Sv/ m ,400 1 3 - of er )), WLM) ( onth m evel l p Sv m .06 orking insoluble w inhalation the for 30 Publication ICRP from that (J h m 5 239 - 3 for w marro bone for 0.07 is compound Pu r o m 5 o t rounded ( rounded ( ) Sv/WLM) m h Sv/(Bq n .95 7 - inhala the and 3 238 - tion o Sv/(Bq EC E )) m h for n 8 t is compound U the insoluble lung. of The onth m evel l orking w he T U1]. 0.13 [ such actors f on and radionuclide the on depend clearly ratios c orresponds t o t he e xposure r esulting f rom t he i nhalation o f he T . h 70 1 P9]. [L6, solubility and body the in retention as c ata d eporting r ountries c a ir or ontaining 1 W L f ften d o n ot s pecify w hich o d osimetric m odel w as u sed t o I CRP m ethodologies f or 33. The a pplication o f d ifferent c alculate t he d ose, a lthough i t i s l ikely t hat t he I CRP o c d r a i t a a w u [ esults nd alculations pproach he ntake as bviously ose sed ffects I7].

245 FROM EXPOSURES OF THE PUBLIC AND W ORKERS V ARIOUS SOURCES OF RADIATION 229 ANNEX B: r esults o f t he d osimetric m odel a gree w ith t he on based were turn in which [I45], the results of an Expert 37. The 2 n to According [N20]. y Agenc gy Ener Nuclear the epend of Group d nd a f o actor f a ithin w onvention c onversion c o [U3], this v alue is intended to include the dose to reference he t v alue urther f ntil U actor. f eighting w adiation r he t or f C larification o f ommittee of transfer the from resulting lungs the than other c gans or t he f actor i s av ailable, t he c on- - 3 212 lungs the from Pb n Sv/(Bq h m ) siders u sed t hat t he e stablished v alue o f 9 principal The gans. or other these to i dosimetric assessments of lung dose due to deposited thoron till s s 7] U 6, U U3, [ alculations c NSCEAR U ast p n i (see use continued the support products a ppropriate f or i ts p urpose o f e valuating av erage e ffective decay the of E x anne oses d of actor f version con a of [U1]) Report 2006 UNSCEAR [ U1]. 3 - m ) 40 EEC. h nSv/(Bq 38. It is not possible to assess the radiation dose due to For epidemiological by products decay thoron of inhalation 39. the present anne x, most countries w ould probably esti - actors f dosimetric ICRP of basis the on doses means, and the dose con version f actor must therefore be ha ve estimated the of A x Anne modelling. dosimetric using mated de veloped after ICRP Publication 60 [I7, I47]. The ICRP is indicated [U3] Report 2000 UNSCEAR version con a that currently re viewing its biokinetic and dosimetric models, on thoron for actor f deri ved the be could products decay which will certainly influence dose estimation for future of the recommendations gi ven in ICRP Publication basis e valuations. 50 PUBLIC EXP os URE II. e xposure has been e valuated by the Committee significant part of their total e xposure most to radiation. 40. Public tw o broad classes: e xposure to natural radiation sources Radon for is usually the lar gest natural source of radiation con - man-made sources. In pre vious reports, and e xposure to tributing to the e xposure of members of the public, some - sources these tw o classes were usually described in separate anne xes. times accounting for half the total e xposure from all types this anne x, e xposures to these In tw o [W6]. of source are con - from sidered together . Exposures to man-made sources uses of nuclear peaceful ener gy are and from military 1. Cosmic radiation separately. described i n t his s ection h ave een d ata 43. Cosmic radiation 41. The can be di vided into u sed dif ferent types he t n i btained o b w ay a s f or p revious U NSCEAR r eports, i .e. f rom t he s density flux the and type, and gy ener origin, its to ame according G lobal S urvey o n P ublic R adiation E xposures, xposure e for important types the only When particles. the of U NSCEAR main m o t istributed d uestionnaires q f o eans m y b em- three are there account, into en tak are humans of c onducted NSCEAR U he radiation, cosmic alactic g radiation: cosmic such of sources t y tates S ber b ub- p he t rom f nd a ecretariat, S solar radiation and radiation from the earth’ s radia - lished cosmic s cientific l iterature. T here a re m any u ncertainties ere, h rovided p nformation i ssociated tion belts (Van Allen belts) [S30]. he t o t wing a o w ith t he analyse ifferent ways in which d countries collect, and man- magnetic s earth’ the by vided pro shielding the 44. Besides age t heir o wn d ata. T hese u ncertainties r eflect d ifferences i n belo II.A.1(c) section in discussed is which field, or s ampling, m easuring, t reating a nd is life w, t he m ethodologies f t of layer air an by radiation this ag shielded r a approxi d a w a d i he ssessment ata, s - ell ainst s ifferences n eporting 2 2 is which ), comparable g/cm (1,000 to kg/m 10,000 a f e t u o d d c pproaches, xample f mately ifferent he or ose se onver- 10 a m thick w ater layer . As a result, at sea le vel the cosmic f T C r t t i a n sion eed s here hat ecognizes ommittee he actors. contrib m utes s e about t u w 10% of radiation the b total dose rate t from e o ethodologies tandard stablish o orldwide sed ways m a c i o been o al ve ha beings human which to radiation natural t i t mprove f he nd n o anipulation omparison rder xposed. Ho wever, at higher altitudes in the m atmosphere or in r r d a t t b a t d e o ore eported herefore e raw nd eliable ble o ata the fields radiation dominant c constitute rays cosmic space, onclusions. [H20]. f osmic c 5. These 4 tmos- a o uclei n he t ith w nteract i ays r Natural sources A. i pheric t o onstituents c p roduce a c ascade o f nteractions a nd eaction 42. roducts hat ontribute econdary o osmic ay has c s t p c sources r t e to natural radiation r Human xposure hese epth ncreasing ith ntensity n ecrease xposures. d w i d i i by bombarded T been al e has al earth e The ways ways xisted. round o ltitudes ircraft rom tmosphere, he nside evel. outer generate space l that high-ener i in t g a originating f a particles a t gy nteractions ay f adio roduce umber lso he osmic p atmosphere. a lo the a in i sho particle r secondary - r o T n c Addi wers wer - adionuclides. os- ctive uclei nown s osmogenic he earth’ the c c a F k T n radionuclides. contains a crust most r or s tionally, 14 adionuclide s xposure ublic mogenic ost elevant o to radiation e e indi the background r is m C. r natural t i p viduals, xposure

246 230 UNSCEAR REPORT: V OLUME I 2008 cosmic (a) Galactic (b) Solar cosmic radiation radiation 46. from sources out - Galactic cosmic 51. Another c omponent o f c osmic r ays i s g enerated arise rays (GCRs) t agnetic the solar system, from deep space. The GCRs incident n ear side he s urface o f t he s un b y m isturbances. d f consist upper atmosphere nucleonic component, lares f olar s rom of riginates o SCR) ( adiation r osmic c olar S a on the - w t he p articles p a re d irected t owards t he hen elec and total, the of 98% for accounts gate aggre in which roduced nucleonic ev trons, f o ostly m omprised c re a ents article p which s hese T arth. e account for the remaining 2%. The olar t component f o ~99% ( rotons p is primarily protons (85.5% of the flux) and alpha elow b enerally g nergies e ith w lux), f he nuclei bove a arely r nly o nd a eV M 00 1 particles (~12%), with the remainder being hea 1 0 G eV. T hese p articles vier s ignificant that of uranium [S30, U3]. up (~1%) c an p roduce to d ose r ates a t h igh a ltitudes, b ut a oses d o t ontribute c nergetic e ost m he t round g t o nly l evel. h s nergy e n a ave 47. These pec- articles p osmic c rimary p 20 8 1 0 trum V. B elow t hat e xtends f rom 1 0 e e V t o m ore t han 15 s an b e r epresented he 0 e V, t he s hape o f t he e nergy 1 pectrum c 52. Solar p article e vents, i n a ddition, c an d isturb t –2.7 , o f t he f orm E lac- b w here E i s i n e lectron- y a p ower f unction e arth’s m agnetic fi eld i n s uch a w ay a s t o c hange t he ga k pectrum volts. A bove t hat p oint, nown a s t he “ knee”, t he s tic p article i ntensity. T hese e vents a re o f s hort d uration, o m easured ew – 3. s teepens t o a p T he h ighest e nergy t ypically a f ower h ours, a nd a re h ighly v ariable i n t heir f 20 hich f ar i s 3 .2 × 1 0 t e V, hus oses d ong-term l n o mpact i egligible n a ave h hey T round g rom f nferred i as w w s trength. m o f t he r esulting c ascade i nteractions i n t he t o easurements t g eneral p opulation. A l ong-term f orecast o f s olar he tmosphere a U3]. fl ares i n t erms o f [ e ither i ntensity o r e nergy s pectrum i s n ot p S olar fl ares a re m ore f requent a t ossible. p eriods o f m axi- f mum ctivity, ith eri- uch olar nd he t argest he a s s o e w t a l p t ut 48. It gy is the that b highest-ener cosmic all rays thought eld nfluences eomagnetic ods. he lso he enetration fi a i t p g T wn alaxy. our reaching o originate The g within earth the arth’s o ower nergies, he CR urface. ecause f f he t s l e e o S B t t o rays and that cosmic mechanisms sources acceleration create nfluence n han uch CR hat his ore n s mportant S i m m i t i o t o t - ut are uncertain, (substantiated by one measure b possibility CRs S30, 3]. [ U G gized ments is that a the particles are from ener spacecraft) vas. aves xpanding from by superno e w The shock particles ignificant 53. The he s ffect olar ong-term ost alactic - m s confined and s continually t deflected by l the i g are mag e netic orrespond- enerates hich ycle, ctivity olar 1-year is and field. s direction a in c isotropic 1 w becomes g flux a c Their adiation otal ing ntensity. [U3]. time in constant airly n osmic istorical ycle olar s c i t f r i H c . hown ariation olar re gure he ycles n n eriodic s i v p T I c fi i s a 15 ind, ctivity olar roduces he n ariation imilar t s v i a s p w a 49. Above 0 e e V, p rotons b egin scape g alactic c on- o t 1 ag- lasma ssociated ith onized hich n ighly s h a i i w p m a a w finement. h r eaves l his T elatively igher p roportions o f trength he netic hose odulates ntensity arying eld v i fi w t s m a bove h eavier n uclei i n t he c omposition o f c osmic r ays olar imes f aximum t adiation. osmic alactic f s o t A r m c g o e his e nergy l evel. P rotons w ith han t reater g f t o nergies 19 he ighest alactic ts nd osmic t ctivity, he s eld i fi t a a i a t g c h 1 nter- i he t y b eflected d ignificantly s e b ot n ould w V e 0 adiation s t ts owest. ntensity n xample f he ffect r l i A e o a t i e i ux fl he t hat t act f o he T eld. fi agnetic m galactic f o rotons p f s ircraft t ate ltitudes ose n odulation olar f a d r a i o a m s o w ith t he a s i nergy e igh h uch s lso i sotropic a nd n ot a ligned gure hown n I. fi i I s lane o f t he g d isc s uggests t hat p t he p rotons a re alactic p robably o f e xtragalactic o rigin. heo- t strophysical a nly O c rigins o he t uggest s an ries ltra-high-energy u hese t f o c r [ ays U3]. osmic (c) Van belts radiation Allen V r ormed v f w s re a a 54. The hrough G t fl an A llen r adiation b elts olar ith aries ate uence CR 50. The ctivity, a he s t w p l b y b lectrons e nd a mainly) ( rotons f o apture o c s T he h t i s ower pectrum f he ctivity hen olar igher. eing w s a w s a ev- G a c e arth’s m agnetic f ield. T he p roton e nergy c an r each s hanges olar olar lso ctiv- ctivity; ith CRs hen i c h t nergy m e o t lectron e e s i he t an eral h undred m egaelectronvolts; aximum pectrum nergy he f s he igher, s ity t p t h e G p s h r each o nly a f ew m egaelectronvolts a nd t he e lectrons’ hifted igher ave CR o o articles nergies. enetrate o t wo a g t t llen e A m fi n b va p enetration i s t herefore l imited. T here a re eomagnetic his, f ecause eld; agnetic arth’s he i i ,000 m 3 m bout c a t t t a c m e k w r adiation b elts, a n i nternal o ne c entred o lose mportant ore he s hich xists, ut-off uch rom t f e m k 2,000 2 bout a t a entred c ne o xternal e n a c nd i a c T p he g t t a he he ut-off s har- oles. eomagnetic t han quator a “ R kin . R igidity i s d efined a s t he n b i e arth’s s urface. T he d aily e quivalent d ose t o t he s rigidity”, y acterized c t he c osmic r ay p article d ivided b y i ts m omentum o f t he i nternal b elt c ould r each s everal t ens o f s ieverts f or articles t his i nfluence, t he n umber o f p c harge. O wing t o p rotons a nd s everal t housands o f s ieverts f or e lectrons. e a tmosphere i s h igher c lose t o t he arth’s p enetrating t he T he i nternal r adiation b elt d escends r ather c lose t o t he o ecause f t his, p oles a nd t heir s pectrum t here i s s ofter. B e arth’s s urface i n t he r egion c alled t he S outh A tlantic s olar a ctivity i s r elatively m ore i mportant t he e ffect o f A nomaly, w hich i s c entred a t a bout 8 00 k m e ast o f P orto S30]. oles p eomagnetic g [ he t o t lose c A legre, B razil [ S30].

247 ANNEX EXPOSURES OF THE PUBLIC AND W ORKERS FROM V ARIOUS SOURCES OF RADIATION 231 B: of (d) Effects and altitude latitude component of the char particle flux at ground le The ged vel. y small are also accompanied by a flux of “collision” electrons the earth’s magnetic field reduces The Latitude ef fects. 55. that their along generated are path. reaching atmosphere. intensity upper the radiation cosmic of magnetic field The such that only par- shape of the earth’ s is second by caused dose of components changing - 59. The ener can penetrate at lo wer ticles geomagnetic gies higher of in ary are cosmic atmosphere illustrated ray the constituents latitudes. fect”, ef latitude “geomagnetic the produces This figure in the is component muon the le ground At . IV vel, intensities and dose rates minimal at the equator with and utor contrib important most dose, while neutrons, elec - to poles. ef near the geomagnetic maximal The latitude fect at the trons, significant are most protons positrons, and photons III. 20 km altitude is shown in figure e the components higher altitudes, At altitudes. aircraft at ven be vy-nuclei also must component hea considered. - a as acts field separa geomagnetic the earth, 56. Near the according to their ener gy tor of the incident cosmic particles relationship (in reality , according to their rigidity). The radiation (e) Exposure to cosmic and rigidity , which defines between particle ener gy the par- threshold belo w which particles are unable to reach a ground Exposures at ground level. At 60. le vel, muons because of location the by shielding fective ef the ticular ener gies mainly of between 1 and 20 GeV) constitute (with field [B23], is: geomagnetic ray y con - field. The cosmic the of component dominant the absorbed tribute about 80% of the arising dose rate in free air 22 ERZeAmm +− = (/) directly from the ionizing radiation; the remainder comes from electrons produced by the muons or present in the elec - is the where rigidity in GeV R , E is the in nucleon per gy ener - cascade. In the early tromagnetic com o tw these literature, the atomic weight and m is GV , Ze is the nuclear char ge, A is ponents the char ged particle of flux were referred to as the in mass nucleon the protons, getic ener highly or F [O1]. GeV component, refer- and the “soft” “hard” respecti vely, with rigidity and gy ener particle the - similar Each . quite geo are the to ence - elec the wer, po penetrating their in ference dif may cut-of a by characterized be latitude magnetic f rigidity , being trons shielding. y an by absorbed readily more much rigidity that particles with less such cannot arri ve at this increases, altitude As important more become electrons R The cut-off rigidity ( latitude. by: ) is given c contrib rate. dose the to utors 4 R = 149 .cos() λ c the component from ionizing rate photon dose 61. The and b latitude, with v to is kno The small. is v the ariation wn ary ut the are latitudes Equatorial is geomagnetic λ latitude. where equator rate is about 10% dose lo at the geomagnetic wer Only re particles with rigidities protected most the gions. Considering than at high latitudes. the population distrib u- than greater than greater of gies ener with protons and GV 15 sea at air free in rate dose verage a an latitude, with tion vel le to [B14]. GeV are able 14 reach the equatorial regions 31 of the This [U3]. Committee by adopted been has nGy/h account tak also figure into solar the to due v the es ariability gy the on incident particles High-ener Altitude effects. 57. c ycle, u- distrib population The 10%. about be to estimated interact with atoms and atmosphere molecules in the air and le vel due to the tion of the ef fective dose rates outdoors at sea a generate comple x set of secondary char ged and unchar ged 4. table in wn sho The is rays cosmic of component ionizing Z particles, including protons, neutrons, pions and lo wer- 9 w considered population orldwide as 4 × 10 w [U3]. persons nucleons nuclei. The secondary in turn generate more - nucle exposure human to contributors main the Because at ground in ons, a nucleonic cascade producing the atmosphere. Neu - le vel are muons, a radiation weighting of f assumed, is 1 actor path, free the mean dominate longer because their of trons, ef fective dose at sea orldwide w a to leading a verage annual component a As altitudes. lo at nucleonic result of the wer about le 0.27 mSv. of vel at interactions, distrib v peaks neutron the ener gy arious ution around at 50 and 500 between MeV A lo ener peak, . wer gy de-e nuclear produced (e 1 MeV is by , xcitation vaporation). ho 62. The component is, ionizing wever, strongly depend - Both components are important for the assessment cosmic of the by a f actor ent same or latitude, F a altitude. v on ariation ray exposures. 4 about of rate dose in absorbed as the in w air free measured in China between sea le vel and 4,000 m altitude in ibet T generated in nuclear interactions are the main 58. Pions [W2]. be in the Dose rates in Switzerland were estimated to the of other components of source cosmic radiation field in nSv/h. range with nSv/h, 64 of alue v an verage a 40–191 pions the high- Neutrally into char decay atmosphere. ged density population with rates Combining the results for dose , in that electrons high-ener produce these photons; ener gy gy verage as caput w per in the rate Switzerland dose estimated a turn photons more and so produce on, resulting in the “elec - [R23]. ray nSv/h rates 46 cosmic to of dose Estimates be at Electrons and or “photon/electron” cascade. tromagnetic” vations ve vel made a abo are procedure using le ele sea particle positrons dominate at the rate char fluence mid ged - [B45]: Bouville Lowder and by published into long whose muons, decay pions Char altitudes. dle ged . . 04528 1649 z . . − − z   EzEe + = 0021079 . e ()(). 1 1 them in atmosphere the mak dominant the mean path free es    

248 232 UNSCEAR REPORT: V OLUME I 2008 occupanc y fraction of 0.8, indoor the w orld a verage annual Ė is the altitude where is the dose rate at sea le vel and z (0) 1 ef dose due to the neutron component of cosmic radia - fective thirds population orld w the of li o tw Some ves kilometres. in The . mSv 0.1 be to estimated is tion population-weighted - in coastal re gions, b ut because dose rates increase with alti hemisphere a annual doses for each verage and for w orld the populations at high tude, altitudes contrib - the dose rates of a of range the erall, Ov 5. table in summarized are verage weighted proportionately more to the ute a verage. F or the annual ef fective , mSv 0.3–2 is population dose w the to orld population- the ionizing directly component, photon and with mSv [U3]. of 0.38 average population-weighted a sea at that times 1.25 is rate dose vel. le verage a weighted Using a shielding f actor of 0.8 and an indoor occupanc y 67. Exposures at aircraft altitudes. Exposure to cosmic dose fective ef annual verage a orldwide w the fraction of 0.8, - increases rapidly with radiation Persons who fly fre altitude. due radiation is component the ionizing of cosmic to of radiation cosmic of vels le vated ele to xposed e are quently to be estimated about 0.28 mSv. and origin solar and alactic g produced radiation secondary to both altitude and latitude component, neutron the 63. For the particle cosmic The etc. in structure, aircraft atmosphere, fluence strongly af fect e xposure rates. A latitude-a veraged The - radia flux depends on solar acti vity and solar eruptions. 1 - –2 s at for latitude 50° N rate has sea le vel of 130 m been tion at aircraft altitudes field consists of neutrons, protons, obtained, rate dose fective ef The ved. deri weight - applying a and neutral and charged Neutrons contribute 40–80% pions. ener gy distrib ution of ing f actor for the fluence neutron the equi valent dose rate, depending on altitude, latitude of 2 gy 0.02 pSv/m The , is 9 nSv/h. shape of the neutron ener in cycle. time and the solar altitudes habitable vely at spectrum relati be to considered is e xpected in to be generally v alid to variant, and therefore it is altitudes 68. Commercial transport aircraft are typically to con vert fluence to ef fective dose a use simple coefficient dose m, where the 6,100–12,200 very e for doubles rate fective ef at On sea dose basis, the annual (isotropic). this vides aircraft 1,830 altitude. fuselage increased of m pro The vel le at 50° latitude due and neutrons is estimated to be to radiation cosmic ainst ag shielding little W5]. Expo - [B43, mSv. 0.08 section III.B.1 sures of aircre w are described in of x. anne this on The dose - recei ved during a particular flight depends alti 64. Neutrons gy of high-ener collisions from arise protons and tude, and flight time. latitude F or altitudes of between 9 the protons atmosphere. that within initiate upper Incoming of 50° (corresponding to flight a from 12 km and a latitude fected strongly neutron af the field by ray the are cosmic America), is rate dose the northern gener- Europe to North - fect s flu the that ef neutron the with field, magnetic earth’ ally Sv/h. 4–8 Dose rates at lo wer latitudes are range the μ in ence gions than equatorial that is in in polar re rate less lo wer; hence a generally dose rate to used be may Sv/h μ 4 of - gions. Ala quoting et re al. Florek the [F11], Los results of for rate dose verage a the represent trans- (e.g. long-haul all mos - code suggest LAHET that the system equa calculation, altitude flights. Atlantic) F or short-haul flights the is flight vel torial polar neutron of le at sea 20% the rate is fluence this lo wer, between 7.5 and 10 km. At generally altitude, the rate 50° at that rate latitude the is fluence 80% fluence of and Sv/h. verage a These dose 3 is μ dose rate rates typically orld ver- fluence w polar rate. population-weighted the a The dose an allo wance for the include recei ved during the climb vel - age fective le ef rate at sea dose due to cosmic ray neu and study in the United King - flight. the of phases descent A trons or [U3]. nSv/h mSv/a 5.5 is The determined 0.048 thus per dose verage of a about caput an 30 estimated μ Sv dom to for ution distrib population outdoors rates dose fective ef the United xposure e the radiation to due Kingdom population at is rays cosmic of component neutron the to due vel le sea xtended alue wever, vel. tra Ho to e during this be v cannot air table in 4. shown also countries, populations the the because e xposure is of all vel, y in strongly which frequenc the tra by air influenced of also there rays, cosmic of component neutron the 65. For is turn on the country’ s depends velopment de and economic and Bouville fect. ef altitude substantial a used [B45] wder Lo le vel [W6]. deri of xpressions e ve to calculations both measurements and habitable the around vations at the ele dependence altitude w orld: radionuclides (f) Cosmogenic . . az 0 EzEbe ()() = N N N with of radiation cosmic present interaction nuclei 69. The . in a atmosphere also produces and elementary the particles ()0 E rate where is the ef fective dose at sea le vel due to N A series comprehensive cosmogenic radionuclides. of of list neutrons: production rates and properties, radionuclides (with their –1 1 a and 1 = b z < 2 km; for km = N tropospheric the in included a w concentrations) verage as –1 UNSCEAR [U3]. Production 2000 is greatest in the Report km 0.7 = a and 2 = b km [U6]. 2 > z for N neutrons upper stratosphere, b some ener cosmic ray getic ut the into survi protons and producing lo atmosphere, wer ve with relationships their altitude–dose these Combining 66. there Production cosmogenic well. is as radionuclides analysis population of with the the w distrib of orld ution only on dependent latitude, not as on also well b as altitude ut altitude, these in deri estimates for the popula ved vestigators - with modulates which the c solar 11-year v ycle, arying dose as neutrons times to 2.5 due rate a tion-weighted verage cosmic field. magnetic earth’s the through penetration ray the an at sea le Using v a shielding f of 0.8 and actor alue vel.

249 EXPOSURES OF THE PUBLIC AND W ORKERS FROM B: V ARIOUS SOURCES OF RADIATION 233 ANNEX 14 22 7 3 H, 70. Except C, Na and for Be, which are isotopes of quantity to contrib ute significantly to population sufficient , cosmo - body the E x anne in described been ve ha radon to Exposures xposure. e human the in roles metabolic with elements and genic Report 2006 UNSCEAR the of radionuclides contrib ute little to radiation doses [U1]. rele vance mainly as tracers of in the atmosphere and, are systems [U3]. Carbon-14 deposition, h after in ydrological interaction exposure radiation external of (a) Sources ( t = 5,730 a) arises from the of cosmic slo w 1/2 14 14 into with N. T ransformed neutrons CO in , it participates 2 14 from comes xposure e ycle. xternal e to ution contrib main 76. The T oday, the specific acti vity of c C is the photosynthetic trace present in amounts in radionuclides amma-emitting g approximately 230 Bq/kg of total carbon, and the content in 232 238 40 the is about 2,700 Bq, resulting in an a verage - Informa amilies. f Th and U body the and the soil, mainly human K Sv. 12 about of dose effective individual annual tion on outdoor e xposure comes μ from direct measurements e dose rate or from of valuations based on measurements of 14 of production 71. The is rela neutrons ray cosmic from C - radionuclide concentrations in soil. The 2004 UNSCEAR annual rate of 1.4 PBq, resulting in a tively also which Exposures, Radiation Public on ey Surv Global constant at an information esti best A [U10]. PBq 140 of ventory in atmospheric sought on the numbers of people e xposed, has global - acti vity of naturally produced (cosmic mate of pro vided information on the the distrib ution of doses according specific 14 to verage C prior to industrialization is 222 Bq/kg of total car- - radio of range and a the on and ranges specified ray) nuclide rates dose absorbed on Data soil. in concentrations and 1950s the from xplosions e test nuclear The [N7]. bon air introduced absorbed as w This EBq. 0.35 estimated an in 1960s for v arious countries, including data for high- and a half-life of about 6 a. The into the marine en vironment with lo w-background areas, are 6. table in given 14 of vity C from weapons residues is currently acti specific on both e xternal dose rates and about 0.05 Bq/kg in the atmosphere. Releases from nuclear 77. Additional information concentrations radionuclide in soil is a vailable in the recent po wer reactors are also v ery small. that suggested been has It 12 there of the CO mapping from the interest xpanded e been has as literature, b urning of fossil fuels w ould in addition 2 14 and C Some produced naturally the dilute data already collected and countrywide e xposures. measurement the that 14 indicator as used be then could ratio C/C to the of complementary an in presented are [U3] reports earlier the of 238 232 carbon table A-1, with a verage and maximum v alues for to U, addition Th the planet on a global scale [S44]. On going 40 and and in ve conclusi not are vailable a data recent measurements V–VII. figures in wn sho soil in concentrations K The 14 current the significantly fect af not do data w ne respect, as current specific acti vity le vels of this C are still orldwide w 238 226 Ra 1950 in observed those than higher slightly a verage v alues of 33 Bq/kg for U, 32 Bq/kg for [R18]. and 232 40 Bq/kg for v Th. The a verage alue for 45 K, 412 is Bq/kg, 72. Tritium also close to the pre vious v alue (420 Bq/kg). Although the ( t of = 12.3 a) results from the interaction 1/2 are soils in radionuclides natural of concentrations verage a tritiated cosmic rays with nitrogen and oxygen nuclei; the in participates produced ater w there w, lo ge a is ariation, with reported le vels of up to - concentra Its ycle. lar c ater w the v 232 3 238 3,200 and Th for Bq/kg 360 U, for Bq/kg 1,000 tion Bq/kg le vel is about 400 Bq/m in continental w ater and 40 3 purposes for for Therefore, the K. - assess dose global 100 Bq/m of in the oceans. On a verage a human ingests Bq/a, these Sv. μ 0.01 of dose annual average resulting a with 500 data corresponding with ed link be to need ment, population distributions. d) 53.6 = a t has concentration of 73. Beryllium-7 ( 1/2 3 con - - pre rates dose outdoor a orldwide w on data 78. The ater, 3 mBq/m thus in air . It reaches the earth in rainw verage of alue v verage a [U3] vious pre the confirm 6 table in sented tributing to an annual commitment for indi viduals of approx - of egetables, v fresh of ingestion the through Bq 1,000 imately ution distrib the on date to 58 nGy/h. The data a vailable an dose absorbed outdoor the vering to Sv. annual μ 0.03 of dose effective respect with population the deli to presented are radiation amma g terrestrial due air in rates 22 nnual ) i s a pprox- 49.7 9 = range t ( Na f o ommitment c d a in table 7. The mean v alue for this distrib ution is in the 74. The 1/2 nnual nGy/h. n a ontributes c his t ut b q, B 0 5 imately 50–59 a f o ose d ffective e han a μ S v, s ignificantly m ore t f or t ritium. .15 0 pproximately f adiation e xposure o - p opulations d ue t o c osmogenic T concentra he r 79. Indoor e xposures depend on radionuclide 14 herefore t he p roduction o f r C adio n ve relati The materials. uclides i s t d ominated b y tions in outdoor soil and in b uilding reater contrib i s s lightly the on dependent g t han 1 2 μ S v/a [ M22]. a nd highly is source each from ution type of house and b uilding material. Information on distrib u- e ved deri xposures from tions of measurements direct indoor is not e xtensive, b ut these can be assessed on the basis of radiation 2. Terrestrial uilding information on soil, shielding and b material, and xposed 75. Naturally ed in then radionuclides of terrestrial origin, to order occurring e people of number the with link ve xposures. arious also are present primordial in termed v radionuclides, estimate population e Extensi information is vironmental vity garding grees orldwide athered re including in all en media, the concentrations human acti de w g being ves . uilding w half-li b those body materials. Only Ne with comparable information, radionuclides complementing in that xist ven verage age in in [U3], e is products, gi to the in reference table of A-2. the In earth, general, and a their decay

250 234 UNSCEAR REPORT: V OLUME I 2008 for the radionuclides are higher in most b uilding short-li ved decay products of radon, which because of values natural E materials of x anne in separately considered were significance than their presenting marble and granite with soils, in 226 a Ra (77 Bq/kg) and with highest the [U1]. Report 2006 UNSCEAR the v alues verage for 232 v alues for Th also presenting granite highest a verage the 40 K (1,200 Bq/kg). 84. The (84 Bq/kg) and of natural radionuclides other than inhalation decay a radon and its products mak es only minor contrib u- 80. present are radionuclides These xposure. e internal to tion Table 6 also confirms the pre vious v alue of 1.4 for the in decay rates. xposure e outdoor to indoor of ratio v alue Therefore The particles. soil of resuspension the of because air the are radon of products in air of rate dose . air in as g radon of because present absorbed indoor verage a orldwide w the for 232 238 3 - con Th of and U 84 and g/m μ 50 loading dust a Assuming nGy/h gi ven in reference [U3] is considered to be still centrations air in concentrations the Bq/kg, 25–50 of soil in v alid. Using from coefficient version con the as Sv/Gy 0.7 3 ould dose rate in air to the ef fective dose recei ved by w be e xpected to be 1–2 μ Bq/m absorbed , and this is generally for 0.8 and adults, ho a - ver- ariability v ge lar a wever, the fraction, y occupanc indoor the what is observ ed. There is, asso natural v- se by fected af be may vels le local as alue, v this with ciated e to due dose fective ef annual age xternal e xposure to mSv 0.41 with , mSv 0.48 is radiation of sources terrestrial eral factors, such as climate, soil class and concentrations in occu 0.07 and y occupanc outdoor indoor to related to - mSv soil. Other f actors af fecting the v ariability of natural radio - countries are mostly in the the pancy. The a verage le vels nuclide concentrations for in air are contrib ution to the dust while 0.3–0.6 range loading of air from b urning fuels, because, mSv. or ganic content is usually deficient in uranium compared with soil, for is (3) 81. Equation useful outdoor verage a calculating fly ash contains much higher In uranium. of concentrations addition, coastal locations, concentrations of uranium in in at concentrations soil global from rates xposure e ray g amma in continental soil error standard and verage a These A-1. table concentra air may be an - order of magnitude lo wer than 238 40 Bq/kg; 4 ± 37 U: Bq/kg; 24 ± and 400 tions are: K: inland. areas industrialized or 232 3 ± 33 Th: coefficients are DCF 1 table The Bq/kg. soil 238 40 UNSCEAR 1993 Report [U6], representati ve 0.0417, 85. In 0.462 and U the K, for Bq/kg, per nGy/h 0.604 and 232 calculated the and vely, respecti Th, alues of the concentrations of terrestrial radionuclides in air terrestrial v outdoor estimated v were selected. Because Using nGy/h. 54 as is rate xposure e ray amma g has little, ery the database changed from coefficient version con the as Sv/Gy 0.7 still most of those v alues are considered v alid. The highest dose absorbed 3 210 air to the ef fective dose recei ved by adults, and 0.2 in concentration, 500 μ Bq/m , is concentrations The Pb. rate for for 3 210 3 occupanc y B μ 1 Po; fraction, or f q/m B μ 0 5 re: a adionuclides r ther o he t f o the a verage annual fective ef the outdoor q/m 238 226 228 228 3 232 Bq/m μ 0.5 Th; due and Ra Ra, to U, for e xternal e xposure to natural terrestrial sources of and Th dose for 230 3 235 Th; μ radiation is 0.066 mSv , in close agreement with the estimated Bq/m for and U. The age-weighted annual 0.05 dose F a verage based on absorbed dose rate measurements. ef fective due to the inhalation of radionuclides from the or indoor en vironments, the estimated dose rate is then uranium and thorium series in air w as estimated to be about can 0.006 mSv [U3]. 0.43 nGy/h. This be tak en as the contrib ution from the material, soil the and alue v this between ference dif the and 40 from 86. Doses are mainly due to ingestion K and to the w orldwide a verage v alue can mainly be attrib uted to the 238 232 and U and foods in present radionuclides series Th contrib ution from building materials to indoor exposure. ingestion w ater. The drinking of natural radionuclides t hows s III V 82. Figure ith w opulation p f o istribution d he depends on the consumption rates of food and w ater and on espect r concentrations. ountries. c 8 3 or f utdoors o ates r ose d xternal e - consump food Reference o t the radionuclide tion F t he l eft-hand fi gure, i t c an b e s een t hat t he l argest Report 2000 UNSCEAR the in ved deri were profiles rom opulation onfirm- ange, r Gy/h n 5 he t n i s i raction f c p [U3] and are summarized in table 8. Although the tab ulated 0–59 t ing assessments, alues v other with agreement reasonable in are utdoors. o ate r ose d xternal e or f stimates e revious p he va- he r ight-hand fi gure, i t c an b e s een t hat a bout t 9 0% o f rom F substantial uncertainties are implicit in their mode of deri h b een p rovided f or t he wo rld opulation f or w hich d ata p ave tion. Moreo ver, there are lar ge de viations from this profile lls w ithin t he ange o f a bout 2 0 t o o ver t his a nnex fa for v arious parts of the w orld because of dif ferences in r n Gy/h. he C ommittee h as d ecided t o r evise t he r ange 1 00 dietary habits (for e xample, milk consumption in Asia and T or f dopted a reviously p egetable alues v The wer). lo are Africa in consumption v leafy Sv/a) m 0.3–0.6 ( ate r ose d xternal e in 0 .3–1.0 m Sv/a. t table 8 o are actual alues; v reference as only seen be to v vary widely. alues exposures due to radionuclides other than radon adionu- r ccurring o aturally n f o oncentrations c 87. The (b) Internal f ecause he n ifferences idely ary oods n clides i f v w b o d i t 83. Internal gricultural he e nd limate he oil, xposures n ackground evels c l i e s arise t from the a intak t of a terrestrial b revail. hat he n ifferences lso re here onditions c t radionuclides p by T inhalation a and a ingestion. d Doses i due t to ncluded uch egeta- n ategories s ypes f ocal ood in dust presence a the from result s inhalation of c t o v l particles f air i i 232 238 nd o ruits bles, elect herefore s t sh. efer- ifficult r s t chains. decay Th and f a U fi the I of i radionuclides t containing d alues ence eported. oncentrations f anges ide he rom t are r dominant components inhalation of c e v f o The due w r to xposure

251 EXPOSURES OF THE PUBLIC AND W ORKERS B: FROM V ARIOUS SOURCES OF RADIATION 235 ANNEX r elevance o f s pecific n uclides t o t he d ose d epends o n n b one f or r adionuclides o f t he u ranium a nd t horium i The r horium t U3]. [ II X gure fi n i resented p re a eries s o t ranium u f o atio he t nd a omposition, c oil s he t t aries f rom p lace o p lace, a s s hown i n fi gure I X, l eading t v o nd ctivity r atios horium t nhalation, i a ngestion i y b ntake i 91. Following b etween t heir d augh- l arge v ariations i n t he a 226 228 s etained r s i t i here w urfaces, one b n o ainly m eposited d s i a ffects t he a ters, e .g. t he Ra/ lso Ra r atio. T he s oil t ype or f o 0% 7 hat t ssume a odels m etabolism M eriods. p ong l f r etention/mobility o f vaila- a heir t nd a oil s n i adionuclides r s i he T F17]. [ lants p o t bility horium t f o ontent i ntakes o f r adionuclides a c ody b he t nnual keleton. s he t n i etained r rom iven ountries c arious v n i eries s horium t nd a ranium u he t f nd a 9 able t n i g oncentrations c eference r he t rom F t asses m one b rabecular t nd a ortical c he t ssuming a a a n h pproximately l og-normal d ave istribution f or e ach e b o k pan a n o rder o f m agnitude. T he h ighest s he t hat t stimated e e b ay m t nd i espectively, r g, 1 adionuclide r 4 k g a nd a 210 210 230 232 ave h hich w Po, a nd a Pb imilar or f re a b ody b urdens re 2 10 m Bq o f s Th a nd 7 0 m Bq o f Th. oncentrations c 230 or Th a nd d istributions. T he l owest c oncentrations a T he d istributions o f u ranium a nd t horium re c oncentrations i n f 226 232 w hich a lso h ave s imilar d istributions, w hile om- Ra a nd c he T ountry. c a ithin w og-normal l b one Th, a re t ypically 238 oncentrations c ntermediate i ave h U U3]. bined v alues [ f or v arious c ountries h ave a n a pproximately agni- l og-normal d istribution a nd e xtend o ver a n o rder o f m intak the for important is ater w drinking 88. Because of e tude, w ith t he v ariability b eing c aused p rimarily b y d iffer- ascer- to necessary is it radionuclides, radium and uranium ences i n i ntake o f he T ter. wa nd a ood f n i adionuclides r he t 238 230 c f or U a in included been has nd istributions Th d oncentrations i n b one a re tain that this source of ingestion intak e l omewhat s imilar; s r re a oncentrations c f or natural in eported contents radionuclide The estimates. e intak dietary ower 232 been emain r hey t imited, l re a o b e c onfirmed mineral and spring viewed; ata d hese t s A Th. t w ater and tap w ater ha ve re r ruly t s a epresentative. w ater ha ve also been of particular interest. Some ne w data and vailable a are are summarized table A-3. W orldwide in v huge a is there s n i 92. Radium b i one, a nd c oncentra- rimarily p etained r - radio natural of concentrations in ariability a nuclides drinking w ater. Figure X sho ws the ranges cited lso in ead L ountries. c any m n i easured m een b ave h tions s i olonium p ontrast, c y B one. b n i ccumulates a by countries for uranium. There is a v ariation of about eight istributed d indi among magnitude of orders ven i irect d f o bsence a he t n i ntake, m ainly i n s oft t issues. The E samples. ater w vidual he consequence of such v ariation is a high v ariability in the v al- ody b t i b oth l ead a nd p olonium w ould s till b e p resent n 226 f o s i ntake i ietary d irect d ut b Ra, ues f o ecay d he t f o ecause b for global per caput doses. Figure XI sho ws the distrib u- 238 where A-3, table in ven gi he t U reatest for alues v verage a of tion t he g i mportance i n e stablishing t he c ontent i n 210 210 among is there a v ariation of three orders oncen- c Po of Pb/ he t howed s easurements m arly E magnitude b ody. l nd .8 0 e b o t atio r tration values. average orldwide w n b one, a 0 .5 i n t he i ungs g enerally 210 ome i n o ther s oft t issues. S nity e nhancement o f u Po i n t he d ave h uthors 89. Several he t mphasized e a isequilibrium l iver a nd k idneys h as a lso b een o bserved. T he f o resence p 210 210 238 234 nd A Po i n t obacco g reatly i ncreases t he i ntake o f s urvey o f l evels i n n atural Pb ater. w n i U nd a U a etween b 210 hese r adionuclides b y s mokers; t he m b ottled w ater f oncen- c t Po I rom n orthern taly h as s hown easured r atios o f 234 238 ung l he t n i tration [ R21]. A f s mokers i o s a bout t hree t o arenchyma 1 .63 U/ p U c oncentrations r anging f rom 0 .99 i atios r howed s iver R uphrates E he t rom f n ater w f o urvey s on-smokers. n f o hat t imes t he t easurements m ncluded i hat t urvey s A .75–3.11. 0 ange r 210 r t ap a nd w ell w ater i n t he U S tates s howed f atios i n issue t uman h n i Po o f o easurements m ublished p 93. The nited 1 ange r he t nd a ummarized a verages he r eported b y F isenne s ere w t as w .5 5 f o alue v a ocation, l ne o t A .16–2.92. nnual o a t a nother l ocation, a r o f 0 .37 w as o bserved bserved; a he t nd a rgans o he t n i oncentration c otal t he T F9]. [ atio III. X gure fi n .5, 1 f o rder i he t f o re a atios r verage A [ ater w pring s or f hown s re a ose d quivalent e rgan o o arious v he T F9]. 234 210 m eans t hat d oses d ue t o w ater i ngestion f or U a hich apan, w m easurements o f Po i n t issue w ere f rom F inland, J re 238 t hey a re b ased o n U m u nderestimated i f t he R ussian F ederation, t he U nited K ingdom a nd t he U nited easurements ere w one b quilibrium. e adioactive r ssuming a lone a n i easurements m ublished p he T tates. S eported r nd c ountries a ame s he t rom f a dditionally f rom F rance, t a oland. P nd ealand Z ew N ermany, G 90. Uranium i he s n i rimarily p ody b he t n i etained r as b een f ound t hat t he s oncentrations i n v ari- t on. kele I t h c annual 94. The ous t ypes o f b one ( vertebrae, r ib a nd f emur) a re a pproxi- dose due to radionuclides from fective ef ifferent con reference the at tissue in series thorium and uranium the - d mong a ariability v arge l a how s ut b imilar s mately sti- n A F9]. [ roups g ge a ifferent d the nd a ountries c in valuated e as w body human the in centrations e arlier e 238 7 0% o f t he b ody c ontent o f aluation Ev . mSv 0.12 as [U3] Report 2000 UNSCEAR of U w as mate i n t he w as t hat 238 from radionuclides of ingestion to due doses internal the n the U f o oncentration c eference r he t ssuming A one. b i e Bq/kg, orrespond o Bq o his as 00 00 viewed one ould b t b 1 m the in re also w series thorium and uranium t w c t 5 m he he keleton nd 10 n he hole ody. n ver- alues Bq the a UNSCEAR s a t i v T using b w [U3] t reference Report i of m 2000 7 orldwide ould e Bq/kg, issues oft n oncentration age verage hen a 3 w and m foods t t in s w i concentrations c consumption b ith igher - or ants, oncentrations easured n he ungs nd id- the a l t i m c k h w rates for inf children and adults. F adults, esti n alues or oncentrations eference o mated issues neys. . re a t annual R dose i is 0.120 c mSv These f tw v results are in 210 main alues n agreement. resented easured is f dose istributions this he to . contributor able T close i The t 9 p d o m v Po.

252 OLUME 236 REPORT: V 2008 I UNSCEAR is more or less uniformly distrib uted in the the lack of specific criteria, such areas are of 99. Despite 95. Potassium body follo wing intak e in foods, and its concentration in interest mainly because the y ha ve been used to illustrate high the cur- is le vels of radiation to which human beings are chronic body - con body the adults, or F control. homeostatic under such e xpo- for and 0.18%, children, about is potassium of tent about rently e xposed and to consider the rele vance of 40 lo w-dose a of 0.0117% for ith K in natu - natural ab W 0.2%. undance sures to epidemiological studies on the ef fects of 8 40 × and 10 listed are areas these of Some xposures. e w-dose-rate lo 2.6 of K Bq/kg for vity acti specific a potassium, ral dose rounded a and of coefficient char- the and xposures e higher the of origins The 10. table in version con 0.003 mSv/a 40 Bq/kg, the annual equi valent doses in tissues from per K in acteristic le vels that define the are ENRA an as area the are 0.165 and 0.185 mSv for adults and children, body included. same appropriate are alues v for The vely. respecti fec- ef the indi - this preliminary literature of The 100. the ven gi doses, tive re view more or less uniform distrib ution of results of - spe be may radiation natural to xposure e public body. the within potassium cate that Ho concern in ENRAs. cial wever, most of the currently 96. The total annual ef fective dose due to inhalation and volved; in persons of number the ve gi to ail f data vailable a vided pro information the be ingestion terrestrial radionuclides is assessed to typically utions” of “dose on distrib 40 only to the e xposure fields and not to population. relates to is mSv 0.17 which of , mSv 0.29 K and 0.12 mSv to due Republic, Czech countries—the three Only and uranium the in radionuclides ved long-li the the thorium Islamic Republic of Iran and Spain—had responded by April 2006 series. on information with their ution; distrib dose population the presented data high-background areas are in table 11. for of radon (c) Inhalation of radiation sources to 3. Summary on exposures 97. Exposure to radon has been the natural E x anne in described UNSCEAR 2006 Report [U1]. Committee has decided The to 101. Although it is recognized that a lar ge ef fort has been for mSv 0.1 and mSv 1.15 of estimates vious pre its eep k to doses made due to natural the a verage annual per caput ef fective the radon, (mainly sources radiation natural map most rele vant the a vailable information can - - repre This [U3]. vely respecti thoron, and radon of sources radionuclide), be not approximately one half of the estimated dose due to sented which for ays pathw xposure e with correlated other data The detail. of gree de a such in presented yet not are data all natural sources of ionizing radiation. Combining the presented Euro most for vailable a already maps radon countrywide in - table 1 of anne x E of the UNSCEAR 2006 pean for Costa Rica [M25, M30] ha ve [D14] countries vailable a information updated recently with [U1] Report and from the European Commission [D14], the distrib ution of been pro vided to UNSCEAR. In addition, distrib utions of dose are for and countries, some for vailable a rates xternal e is countries among indoors concentration radon verage a thorium uranium, of utions distrib the wn sho States, United the in figure XIV . - The and a verage v alues for indi vidual coun 3 are potassium . vailable Bq/m 184 to 9 from ranged tries a currently The w- Kno [U28]. maps countrywide on vailable a ing the cumulati ve e xposure to dif ferent sources on a geo - geometric a with 0.98) = r ( ution distrib fit a data log-normal 3 xposure e current the change could basis graphical mean of assessment Bq/m (similar to the pre vious estimated v alue of 45 3 of 40 Bq/m ) with a geometric and lead to more precise estimates of the distrib ution standard 2.1. of deviation e discussed further be will aspect This orldwide. w xposures in the of w ne The x. anne this section of conclusion II.E does not currently allo w estimates to atural n o t ue d evels l adiation r levated e ith w reas information d) ( a vailable A ources xposures e verage a orldwide w s characterize to made be to more significantly are that radiation natural than accurate o t he w orld a re k nown t o h ave l evels o f f reas a 98. Several those pro vided in pre vious reports. It w as therefore decided i n e xposure d ue t o n atural s ources o f r adiation t hat a re to maintain the same numerical v alues b ut to slightly e xtend xcess o f t hose c onsidered 12). t o b e “ normal b ackground”. e some ranges (see table ate o r o T a ctivity c oncen- here i f n o s pecific v alue o f d ose r s n t he e nvironment t hat d efines w hat c onstitutes a n tration i 102. The v alues in table 12 are to be seen as “a verage” r efer- “ enhanced n atural r adiation a rea” ( ENRA). S ome v alues, b ut it should be k ept in mind that the w orldwide s uch a s a d ose r ate o f g reater t han dis ences c ite c riteria e xposure to each pathw ay usually follo ws a log-normal - 222 o f t he reference 3 00 n Gy/h o r a n i ndoor Rn c oncentration i n a ir tribution. Therefore the y should be seen only as 3 y an to specific as ot n re a hese t owever, H . not q/m B 50 1 f o rder o and a alues v dequate r efer- as act, f In place. particular l the , other each with correlated are ays pathw xposure e some ence evels, b ecause s ituations e xist i n w hich t hose l evels a may ution distrib actual ferent dif among significantly ary v a re c learly n ot a pplicable ( for e xample i n reas w ith h igh places. adiation; r osmic c o t xposure e f o evels l w here t he reas a 226 222 xposure ue t o h igh l evels o f i Ra a nd/or s Rn i n w ater, e d o ften c alled “ dynamic E NRAs”; o r a reas w here t he t otal concen vironmental en in ariability v ge lar the Besides 103. - ose, i h igher xposures, e nternal i nd a xternal e ncluding i s d trations and in population habits throughout the w orld, the he t han r t ange). sual u rate at which dose is accumulated may also v ary as the

253 EXPOSURES OF THE PUBLIC AND W ORKERS B: FROM V ARIOUS SOURCES OF RADIATION 237 ANNEX ages. A study performed in the United Kingdom of en vironmental liabilities (such as w aste rock Descriptions individual aste found aluable v a be can areas) contaminated and basins are w piles, children and ants inf for doses inhalation that that starting of those for an adult, while terrestrial g amma future for within used be can 20% database a for point gi uranium of features The dose. and xposure e of assessments rays ve ef fective doses for inf ants and children that are mining related e xposures are described - respec 15%, and 30% the about by adults for those than ger lar and milling and - the in xposures, e ycle c fuel other with together sec w, belo tively. The v ariation of ingestion doses between indi viduals to that of doses from terrestrial tion on e xposures due to nuclear po wer production, section g amma rays is comparable annex. of this [K8]. III.C.1 xposure during aircraft Regarding 104. e public flights, the 1. Metal although smelting and during passengers by ved recei doses estimated mining be flights vidual indi quite high are lo w, collecti ve doses may the copper addi In orldwide. w flights of number huge - of because , 108. The metals considered include aluminium, gold frequently may The others. and viduals zinc, tin, niobium, lead, steel), (and iron indi specific to doses tion, who fly e to xposure e verall o their to ution contrib appreciable an mak NORM acti vity in feed material for metal smelting is gener- sources. ally lo w, and the natural same is true for most slags and other w aste. in The of radionuclides concentration intermediary products and w ho wever, will depend on the content initially astes, used process of type the on and ore the in present B. Enhanced sources of naturally xtract e to the metal. In the case of thermal processes, a lar ge part of the occurring radioactive material content slags, will be concentrated in metallic radionuclide 105. for example, in those from tin industry [V6]. as, Activities related to the e xtraction and processing of the - can ores to enhanced le vels of naturally lead occurring radio 109. The acti vity le vels in the niobium industry may be astes. w and by-products products, in (NORM) material active of An assessment of Bq/kg 10,000–80,000 containing yrochlore p with high, the situation related to sites with techno - 232 [V4]. In one niobium f acility in Brazil, acti vity le vels enhanced Th logically in performed been has NORM of vels le 228 in barium sul - - cate important Nine [V4]. Union European the of countries w aste ranged to 200,000 Bq/kg of up Ra (in 232 and phate) were identified. This anne x uses a similar approach of Exposure slag). the (in Th of Bq/kg gories 117,000 and cate the within aste w of use or disposal the discusses - the public due to feedstock or the metal products is not gory e are gories cate the of Eight aste. w the generates that xpected. The main pathw ays for public e include xposure mining contamination groundw ater with radium isotopes and of metal milling; and mining uranium here: addressed content (if this is po and mines coal industry; phosphate smelting; and wer e xternal e xposure to slag with high thorium - rare earth and tita as g and oil coal; from drilling; Expo [I22, manner) acceptable an in of disposed generation not - P11]. industries; ceramic and and tin from material resuspended of inhalation to due sures zirconium industries; oxide nium natural radionuclides slag used as landfill have also been cited [V4]. and applications using niobium (typically radium and thorium). The ninth cate gory (disposal of b uild- deep under- 110. In South Africa, the gold deposits from ing material, which is recognized to be of little concern) is considered them. with associated uranium w-grade lo ve ha mines ground not here. 1952, Since by- a as vered reco been ve ha O U of t 170,000 8 3 product epre- mining of tonnes billion 6 Some mining. gold of east f or urope, t he fi rst E t l hree 106. At c ategories r tailings, m ajor c ontaminating i ndustries w ith r espect t o t he sent t kg 200 and uranium of t 500,000 he about containing 226 r rall - depos being are tailings w Ne deposited. been ve ha Ra, of a mount o f w aste p roduced, t hough ove adionuclide 226 c l i n p roducts a nd/or w aste f rom t he s econd t hree evels ate - million tonnes annually . Ele vated Ra ited at a rate of 86 articularly p e b ay m ories g in ed [ observ been ve ha Bq/L, 1.7 to up concentrations, A part f rom u ra- V4]. the levated e dischar atural n sing u pplications a illing, m nd a ining m ges. Annual doses to nearby populations ha ve been nium irconium z ndustries, ecently, r ore m nd, a adionuclides r estimated as up to 0.04 mSv due to the ingestion of w ater i due mSv 0.086 to up Annual fish. of ot n enerally g ave h ategories c ther o he t o t elated r ctivities a ingestion the to and een f ully e valuated f rom t he p erspective o f p ublic ex po- wer, lo much are products food land of ingestion to b due doses sure, o t ccording a hem t haracterize c o t ttempts a hough t ranging up to about 0.002 mSv . Annual doses to the public c ontent o f m aterials h ave b een m ade i n tailings he the from dust of and radon t r adionuclide due to the inhalation of 6]. U3, [ eports r NSCEAR U revious p piles ha ve been U estimated to be about 0.04 and 0.02 mSv , respecti vely [W18]. concern main the industries, past 107. For related the to is left where residues were sites before present standards of industry 2. Phosphate radiological protection were established. Man y of these sites and/or residual and up, cleaned been already ve ha doses contents are kno wn. F or industries currently in radionuclide 111. Phosphate r ock i s u sed e xtensively, fi rstly a s a s ource focus relates to effluents, from operation, the main o f p hosphorous f or f ertilizers a nd s econdly f or m aking releases aste w the of groups xposed e vant population. rele the and p hosphoric a cid a nd g ypsum. O res t ypically c ontain a bout

254 238 REPORT: V OLUME I UNSCEAR 2008 o B u ranium a nd r adium, a lthough s ome p hos- f 1,500 furnace q/kg contain ferrophosphorus and calcium silicate, also 226 o f U Ra O [ P7]. I n phate - concen r ocks c ontain u p t o 2 0,000 B kno wn as slag [I22]. The slag, which contains q/kg 3 8 used as ranging trations g eneral, p hosphate o res o f s edimentary o rigin h ave h igher from 750 to 1,100 Bq/kg, has been construction T amily. in specifically States, United the in material he f ranium u he t o uclides n f o oncentrations c f south-eastern in communities K ola ( Russian m agmatitic m inerals, s uch a s t hose f rom xternal e for eys Surv Idaho. e were conducted in 1,472 residences. It w as esti - xposure ower l resent p frica), A South ( halaborwa P nd a ederation) F h igher residences the of 12% than wer fe that mated c oncentrations o f n uclides o f t he u ranium f amily in Soda Spring a nd oncentrations houses no Hall ort F and Pocatello in while slag, contained c o f n uclides f rom t he t horium f amily, a lthough t i dose vidual indi highest The slag. the found were containing iner- m edimentary s rom f hat t han ower l s t he t otal a ctivity s rate w as estimated vidu- to be 1.3 mSv/a, and only als [ V6]. I n 9 0% o f c ases, t he o re i s t reated w ith ulphuric indi nine T f ertilizers b ecome s omewhat e nriched i n u ranium cid. a he als were identified as recei ving more than 1 mSv/a abo ve 226 public the of ( up t o 1 50% r elative t o t he o re), fraction significant A background. w 0% o f 8 t he hile Ra, w- ho roads, 232 Spring Soda in 23% Pocatello, in 27% slag: contained ever, 3 0% o f t he 5 Th a nd he t n i eft l re a ranium u he t f o % 20% [A13]. p and hosphogypsum. in Fort Hall generate 112. The processing of phosphoric rocks may 226 238 Ra; U and g aseous and particulate emissions that contain 3. Coal mining and power production from coal dischar ged to the en vironment, these nuclides lead to when 232 238 xposure of the population. Local dump sites for in Th verage and U e both of vity acti specific 116. The a radiation and all rainf from protected not usually are Coal phosphogypsum coal is generally around 20 Bq/kg (range 5–300 Bq/kg). to surf ace w aters and shal - - concentra uranium ve ha y, German Freital, in mines which become h ydraulically connected tions - in fertilizers phosphate of use The [V4]. aquifers low agri of 15,000 Bq/kg coal, are an e xception [V4]. During further culture and of gypsum in b uilding materials is a the b urning of coal, the or ganic compounds are con verted possible of e xposure of the public [P7]. Ele vated source into g ases (w ater v apour and carbon dioxide), while the inor- which elements, anic g the significant naturally radon e xposure of the public can further be in sites e xpected include radionuclides, for [V4]. developed being [V6]. ashes the in concentrated occurring are housing general, the radionuclide enhancement In f actor in ash is ash w, and therefore there from Leaching 10. about fly is lo 113. For some what more than half a century , phosphate 226 Ra fe w restrictions on the use of fly ash in landfill and road ores of marine origin processed been ve ha are containing Belgium to produce The construction. calcium phosphate for use in in cattle use of fly ash for b uilding construction, dischar are astewaters w The . fodder wever, ho - direct both irra from xposure e radiation in results v- ri small o tw into ged may of concentrations Enhanced Laak. the is which increase one ers, of diation and radon e xhalation. Dumping fly ash 226 Ra are observ ed along the ri verbank, mostly confined to a vel le radiation the around the dump site. The most signifi - m strip sides along 10 cant e xposure pathw ays are ingestion and of the of the ri ver, including flooding both inhalation 210 210 studies in the Ho of top on uilt b been had dwellings no 1999, of As zones. [V4]. Po wever, and Pb recent isotopes human incor- the that indications earlier confirm Kingdom United these higher -activity areas and no crops for direct to is materials uilding b into ash fuel erized pulv of poration consumption were gro wn there, so no immediate threat ely unlik or gislation le national current either vene contra to the population existed [P6]. Union H18]. [H17, directive European the 1 114. Prior t o 990, F rance d ischarged a bout 3 m illion f of content 117. The onnes Brazil from coal in uranium natural t o p hosphogypsum i nto t he B aie d e l a S eine. After that estimated is It million. per parts 2,000 to 30 from ranges 1 990, wa ste wa s s tored o n l and. I n t he U nited K ingdom, 6 210 e about ges dischar year per coal of t Po 10 × 2.2 of urning b the t he a nnual d ischarge o f xceeded 0 .5 T Bq i n t he 0 [P7]. bout a 993, 1 n I 980–1983. 1 eriod p m illion t onnes o f environment the into equivalent O U of t 270 1 3 8 enerated he t ithin w uropean E g ere w ste wa hosphogypsum p xample a s b uilding U nion, w ith 1 5% b eing ecycled ( for e 1 18. About 5 0 u nderground c oal m ines a re l ocated i n t he r n and o tored s 0% 6 nd a ea s o t ischarged d 5% 2 aterials), m l U pper S ilesian C oal B asin, i n t he s outhern p art o f P oland. he i mport o f p hosphate E16]. o re t o E uropean U nion [ T T he t otal w ater o utflow f rom t hese m ines i s a bout 3 b etween 1 985 c ountries d ecreased b y a bout a fa ctor o f 8 00,000 m 2 /d. W aters w ith h igh r adium c ontent ( up t o 3 eflecting r hos- 992, 1 nd a en- mport i p o t endency t ncreasing i n a 3 90,000 B q/m ) a re f ound m ainly i n t he s outhern a nd c t i tself. T his phoric cid d irectly r ather t han i mport a he o re tral p arts o f t he b asin w here a t hick l ayer o f i mpermeable o f u ranium t o s ea, b ringing a bout a r rom educed t he d isposal c lay o verlies t he c oal s eams. R adium-bearing w aters f 210 Po, b ut l arge d ecrease i n e nvironmental c oncentrations o f c oal m ining a re d ischarged i nto s urface s ettling p onds a nd isposal d ste wa he t ransferring t ack rocess p he t n i b roblem p l ater i nto r ivers. I n s ome c ases, r adium i sotopes a re c o- p a re t he o re- o roducing c ountries s uch a s M orocco [ E13]. t r o onds p hese t n i n o bsorbed p recipitated w ith b arium a b s ediments ottom [ C7, W 19]. high 115. Phosphate rock can be melted in a furnace at 119. Slags produc the for coal and oxide iron sand, with temperature - deri ved from coal mined in the vicinity of the elemental of tion in the solids residual The phosphorus. to wn of T atabánya in Hung ary ha ve ele vated concentrations

255 EXPOSURES OF THE PUBLIC AND W ORKERS FROM V ARIOUS SOURCES OF RADIATION 239 ANNEX B: 226 Bq/kg). (850–2,400 The slag has been used as filling Ra - contri noticeable a e mak may ays pathw Waterborne 124. of persons of xposure e radiation the to bution resident and insulating material for b uilding houses, blocks of on f arm- flats, schools and kinder gartens, and to fill playgrounds and roads land contaminated with residual NORM arising from crude reco [N13]. oil very operations. Persons li ving in such areas w ould and g e incur amma e xposure xternal e xposure from radon 226 inhalation [R2]. e The from dissolution of xposure is Ra increased in drilling gas and Oil 4. cases contaminated soil is located near where [A9]. sea water as, t he o a nd n o traction ex he t 120. During atural g il f re a ormations f nderground u rom n atural r adionuclides f 226 earth and titanium oxide industries b rought t o t he s urface. E levated a ctivities o f 5. Rare Ra a nd 228 ften Ra p resent i n N ORM a re o r eleased b y as g nd a il o i p articularly i n p roduction w aters. D uring ndustries, t he 125. Bastnaesite and monazite are the most important min - c w ith long vity acti an has Bastnaesite a s i adium r rocess, p traction ex o-precipitated erals containing rare earth metals. t b arium a nd s trontium. eposited d s i adium r A p ortion o f the in radionuclides for he Bq/kg 900–1,200 of concentration 238 i t he s cale f ormation p rocess a nd nother p ortion uring s d U decay series and 700–7,000 Bq/kg for radionuclides in a 232 o t he s ea w ith e ffluents. M ean c oncentrations d ischarged the Th decay series. Monazite, on the other hand, has an t 226 228 a a re 2 a nd 2 .3 B q/L f or n Ra w nd astewater Ra, i acti vity concentration of 10,000–50,000 Bq/kg for radio - 238 r adium a re r espectively. A lthough t hese h igh a ctivities o nuclides in the f U series and 5,000–350,000 Bq/kg for 232 w ater f or s ome p latforms, w ater a nd p resent i n p radionuclides in the roduction Th series. In Europe, minimal amounts han 2 50 m f rom s ediments s ampled a t a d istance o f m ore t of waste are produced by these industries [I22, V4]. how- he p roduction s ite h ad t n ormal b ackground l evels, s ifferent. d omewhat s s i xperience e razilian B 26. The 1 n i oncentrations c educe r o t ufficed s ixing m a s A ing t hat w ater he t or f rocessing p onazite m f o onsequence c e he t 6]. V J2, [ nvironment f o roduction p asi- are e arth c hlorides, c arried o ut r f rom 1 949 t o 1 992, b ther d ifferent k inds o f w aste w ere p roduced: ( a) t he t cally 121. The m ost i mportant r adionuclides i n s cales a nd o hree t a recipitates p he i sotopes o f r adium, w ith s pecific re a ctivities q/g) B 70–320 1 oncentration c activity ( raction f ight-mineral l aver- ( I” I cake “ b) ( urification; p hysical p onazite m he t rom f A r anging f rom 1 00 t o 1 ,000 B q/kg. ctivity c oncentrations i n horium hy droxide t a nd 1 % u ranium age c ontent 2 0% s ludges a re t ypically a f actor o f 1 00 l ower. C oncentrations o f 210 210 etween ludge s n i Po nd nd a Pb s cales c an v ary b 2 0 a nd q/g) B ,820 1 oncentration c ctivity a pproximate a droxides, hy a lkaline a onazite m he t rom f 1 ,000 B q/kg [ V4]. T he s ludges o n t he B acia d e C ampos o il esothorium m c) ( nd a igestion; d i n c ctivity a approximate ( ) maximum Ba(Ra)SO ( ake c p latforms oncentration B razil h ave a bout 1 05,000 B q/kg ( 4 4 226 e ,360 3 40,000) o f 4 Ra a nd 7 8,000 B q/kg ( maximum 2 86,000) o f B q/g). I t i s stimated t hat a bout 3 × 1 0 t o f c ake I I 228 5 Ra a nd 1 × 1 0 [ t o f m esothorium c ake w nnually. a ere roduced p M14]. hese w astes a nd r esidues w T d isposed i n s hallow g round ere r o ilos s d r rums, o r w ere b uried i n t renches. A reas ubber n i 122. Activity le vels in scales are of the same order as those andfill l s other t hat u sed t he l ight-mineral f raction e b o t ad h ater l in uranium mill tailings and a materials that are re gu- 222 222 for potential their of because lated release. The Rn Rn L1]. [ econtaminated d pipe scale, ho is generally wever, emanation fraction for typical mill tailings [W10]. The disposal ith w tates, S that nited U he t n i ccurred o for than wer lo 127. Similar s ituations o of and installations industry xtraction e oil from scale of w aste riginating f rom a R are E arths F acility t hat o perated e are r roduce p o t 973 1 ntil u 932 1 - signifi vironmental en of be can NORM containing sludge rom f nd adioactive r a arths sing ranium contamination of land being the major concern. cance, n a with u e lements s uch a s t horium, r adium a nd u eaching f o roduction P rocess. p The l cid a a verage radium concentrations in soils sampled at an ener- g lements e hese t adioactive entucky, K eastern in NORM with contaminated oilfield ated r m ill t ailings t hat c ontained r esidual l evels States, United [R2]. Bq/kg 340 ± 32,560 were o f t horium, r adium a nd u ranium. O ver s everal d ecades, t he u m t ailings w ere a vailable f or ill se a s l andfill m aterial b y w ater sediment 123. Tank battery sites, which separate r esidents a nd c ontractors. W inds a lso m ay h ave s pread s ome and o t ailings t ill m he t f o lean-up C eighbourhoods. n earby n the for used been historically ve ha produced, oil the from p processing of crude oil. The sediment remaining in the pproximately a or f id-1980s m he t n i erformed initial ere w ctions a esidential r I n i rea a hicago C est W he t n i roperties p lli- 20 1 pit is an oily , viscous material often called “sludge”. This NORM is associated with the covering ( roperties p ,170 be 2 han t ore m or f ater l nd a nois, radioacti ve if sludge can 2 on nd a n i ) A m 0,000 1 = a h 1 ( ectares h 00 4 pproximately a matrix. radiological surv ey conducted six viously pre remediated E5]. tank [ battery sites re vealed a verage g amma radia - hicago C est W round a In to 100 μ Gy/h [H19]. 27 from rates xposure e tion ranging 228 the scales, older n i oncentrations c ctivity a roduction, p itanium t 128. For ve ha will Th increased of concentrations 238 particularly sludges, and Scales wth. ingro of because t he o re a re those a bout 3 00–600 B q/kg f or t he U d ecay s eries 232 of ctivities from g as fields, may also contain relati vely high le a nd 3 5–600 B q/kg f or t he vels Th s eries. S pecific a 210 210 Pb Po [E13]. and o f r adium s ulphate p recipitates i n p igments o r s cales m ay

256 240 UNSCEAR REPORT: V OLUME I 2008 228 a h igh a s 4 00,000 B q/kg, a nd be Th l evels m ay b e d ilution o f z ircon w ith o ther c onstituents. I t i s e xpected s t hat a n 6 Sv μ 00 1 f o rder o he t f o ose d ffective e nnual a s t he m aximum nclude i athways p xposure E q/kg. B i 0 1 × 1 han t igher h m igration o f r adionuclides f rom f o esult r a s a ublic p he ex f o ember m a y b eceived r e b ould c hat t ternal i rradiation a nd t F acilities. f andfill l n i aterials m hese t f o isposal d he t he l andfill [ V4]. t or y he t inerals, m irconium z f o usion f b irconia z f o anufacture m he t f o embers m o athways p xposure e ain m t f ormed d uring t itanium d ioxide p igment 129. Scales p roduc- is- d re a ublic p 2 238 oncentrations w floor ( ffluent e iquid l i 10 < rom f anging r c ctivity a eries s U ashings) ave h tion charges o f r adionuclides n 6 232 nd a q/kg B 0 1 × .65 1 o t he t nd a missions, e tack s nd a rom f adionuclides r f o igration oncentrations c ctivity a eries s Th m 6 3 210 alue v aximum m the ( q/kg B r 0 1 × 2 o t f 0 1 × 4 o rom f anging t he l andfill d isposal o f f urnace d ust. C oncentrations o f Pb 228 228 210 igments t ur- f n i q/kg B 00,000 6 o t p u c ould a pply e qually t o f Ra he o p r Th). H u p t o 2 00,000 B q/kg a nd owever, Po o I22]. adioactivity r f o ree f ssentially e re a hemselves nace d usts h ave b een f ound. T he m aximum [ ose r eceived b y t d earby r esident f rom t he r elease n o f r adionuclides i n l iquid a can also lead to public ose 130. The use of the ensuing w e ffluents i s n egligible. T he d aste r eceived a s a r esult o f p lume most dioxide, titanium of production the During xposure. e i nhalation nd e xposure t o m aterial d eposited f rom s tack a occurring naturally the in present originally radionuclides e missions w as e stimated a s as w Sv μ 5 3 ver o hich w f o Sv, μ 7 3 d t o d ust i nhalation. T he d ose r eceived b y a f uture s ite u ser ue ore are precipitated as metallic h ydroxides, e xcept for radium 5 0 t o f f urnace a fter c losure o f a l andfill f c ontaining isotopes (the radium chlorides remain partially soluble and acility ust d ilica s hich or f adon, r ndoor i rom f ose d he t excluding ( are discarded with w astewaters) [V6]. The processing of w monazite r ealistic e stimate w as m ade) w as 4 .5 μ Sv, o f w hich 3 .8 μ Sv n in ginning be xtraction, e earth rare o for France in 232 xposure. amma g xternal e o t ue d as 1976, led to the w input of significant e of Th and quantities 228 authorized within , Bay Rochelle annual La to Ra limits of 74 and GBq 37 acture of zirconium compounds by GBq, 133. For the manuf treatment aste w ved Impro vely. respecti be in 1990 reduced the annual dischar ges to about ginning chemical - poten main the minerals, zirconium of dissolution 228 232 of GBq 6 and e Th of GBq 0.5 pathw ays to members of the public are tial those [E13]. Ra xposure and with the landfill disposal of pipe scales associated silica- scales containing residues. Chemical processing produce can 226 228 and + Ra ( Zirconium radium with residues other and ceramics industries 6. - concentra Ra) tions of up to a fe w thousand kilobecquerels per kilogram. A landfill a on closure after ving li resident future 131. The a verage acti vity concentrations in zircon and zir- into site 232 600 for Th, and Bq/kg 300 and are vely, respecti conia, which 20,000 t of solid residue had been disposed w as esti - 238 Bq/kg for 7,000 and 3,000 mated to recei ve a dose of 750 μSv/a, mostly from e xternal U. Except for bricks, refractory 238 where U acti vity been ve ha Bq/kg 10 of concentrations g amma radiation. - pro the and zircon of chlorination the or F duction of zirconium metal, - the sludge from the zirconium– reported, the acti vity concentrations in the products are com o process, separation hafnium in those to parable radioacti ve ved Long-li material. feed the and content radium its to wing dust v olume, gi ves rise to radiological issues similar to constitutes the main source of radiation e xposure, lar ge which The dust the in thorium to due mainly is [V4]. zirconium - Conse tailings. mine radium-rich with associated those sludge stockpiled in ponds and piles represents a source a quently, be may zirconium of uses industrial the and industry reuse the only xposure; e occupational of potential source of public e xposure through the migration could aste w solid of of xposure e public to lead possibly particularly vironment, en surrounding the into radionuclides amma g from Doses [V6]. else if emitted from lar ge stockpiles of zircon sand are radiation - used being than rather long-term stored is sludge the soil conditioner a as xample e for where, mainly an issue w orkers, b ut in principle, indi viduals out - . Although there are for a as sludge using in benefits this via xposure e ve recei also may plant milling zircon a side vious ob rather conditioner soil than storing if the y are sufficiently close to the f acility. The criti - radiological are there piles, in indefinitely it ay pathw with industrial area - man this in sludge of use the associated implications cal group w ould be indi viduals w orking in the 226 annual ative conserv maximum a with plant, the surrounding ner. If the Ra acti vity concentration in the sludge is of the viduals . μSv 200 about be to estimated dose fective ef Indi order of about 1,000 Bq/kg, this corresponds to a radon flux 226 outside may also recei ve e xposure from material deposited density per unit Ra acti vity concentration similar to that of f and from the inhalation of the plant by storm w ater runof normal rocks and soil. Sludge deposited on agricultural fields rate the in openings and stockpiles from emitted dust airborne dose amma g a to rise ve gi to found been has of 0.1–1 uildings. In studies from se veral countries, applying of density flux radon a to and m 1 of height a at b μSv/h plant –1 –2 ative s m Bq 0.44 conserv . approaches, the maximum annual ef fective esti - acility w as dose recei ved by an indi vidual outside the f such and ater w to ges dischar from μSv 1 than less be to mated 134. Products from the zircon industry , as ceramic vity acti ve ha are, w sanitary nearby In atmosphere. to emissions from μSv 56 population ar f concentrations tiles and normally [I41]. negligible be to found was dose the centres, belo w 1 Bq/g and w ould not be re garded as gi ving rise to e xposures of concern. Ho wever, since these products horium 132. The a ctivity c oncentrations o f u ranium a nd t are essentially b uilding materials, some consideration of aste a re l ikely s eries r adionuclides i n s pent f oundry s ands o r w their radiological impact on members of the public is o rder o he t f o e b o t t f o ecause b ess l r o q/kg B he ,000 1 f w arranted. The potential e xposure pathw ays are through

257 EXPOSURES OF THE PUBLIC AND W ORKERS B: FROM V ARIOUS SOURCES OF RADIATION 241 ANNEX g amma radiation and inhalation of radon released c lose t o t he s ite i s a n a rea t hat h ad p reviously 137. Also external evel l n i ifference d he T urroundings. s ts i han t ower l een b ve ha countries ferent dif in studies veral Se product. the from esi- r epositing d y b 960 1 nd a 955 the to utable attrib doses found 1 etween b emoved r as w glazed tiles in dwell - of use a ings ormerly f uilding b f o ebris d he t roduction, p obalt c f o dues to be in the range 19–113 μSv abo ve background. White imited content zircon higher a ve ha tiles porcelain -white near or adium r f o u sed f or r adium p roduction a nd a l a mount ize s n i ectares h –10 9 s i rea a he T esidues. r xtraction e than therefore ould w and tiles glazed be e xpected to gi ve rise nd a ixed tiles porcelain of use The doses. higher correspondingly to c ontains m r adium a nd c hemical w aste t o a d epth o f 13% gi ve rise to zircon in residences may 3 m . N o d irect p ublic e xposure o ccurred, b ecause a s ecurity about containing to 120 μSv . The zircon content of glazes applied doses of f ence s urrounded t he a rea. M aterial i n t he d ump c ontained up to w w are is similar to that of glazes applied to ceramic sanitary r adium ith c oncentrations o f u p t o 3 4,000,000 B q/kg. a solated i everal s nd a oad r f o tretches s en t tiles, b ut since the surf ace area of sanitary w are glaze in S ome n ine o r w of impact radiological the , smaller ar f is home p oints the ere typical a o t avement p ontaminated c ontain c o t ound f ery v ate r ose d 1,000 1 he t f o % 5 is bout A . m .3 0 bout a f o epth d are w sanitary to applied glazes the zircon used in easurements m erformed h ad v alues o f g reater t han p small compared with that of ceramic tiles. F or refractories, aterial nder 0 .2 μ S v/h. O ne d welling ( with c ontaminated m the only potentially significant source of public e xposure is u h ad a n a verage r adon c oncentration i n disposal a ir o f site. t he v eranda) the b urial of spent refractories at a landfill - Cal 3 3 a eranda v he t n o oom. q/m B 20 7 r iving l he t n i q/m a by ved recei dose fective ef annual the that w sho culations B 70 3 nd member of the public from the disposal of furnace lining wellings; d 46 8 n i erformed p ere w easurements m adon R s nly dose the including landfill, a in nozzles refractory and bricks o hat ix s howed a verage r adon c oncentrations i n a ir t 3 use of V5]. [ ved q/m B 50 1 han t reater recei as a result of future, uncontrolled residential w ere g the be to ely lik is site, more no verts. microsie w fe a than significant public e xposure pathw ays for the for used minerals same the from xtracted e is 138. Thorium There are no xtraction. of use the or F glass. in zirconia of source a as zircon of use rare earth e Specific acti vities of feed material are 3 4 reject of disposal the applications, other in zirconia fused in range 10 –10 the Bq/kg. Thorium has been used ge lar a in at number of products and processes. Le vels in the - products sig y an to lead to ely lik not is material a landfill f acility as than higher typically are tungsten) and glass mantles, (g nificant migration of radionuclides into the surrounding those Discarding [V4]. 100 of actor f a by ore original the in en vironment. The production processes of zircon ceramic may require particular and aste w industrial g as mantles tiles, sanitary w are, ceramic pigments and abrasi ves do not public exposure [V6]. to ays pathw xposure e attention significant of members in order to avoid gi ve rise to an y the public [I41]. exposure 8. Other situations thorium and radium of 7. Applications 1999, where instances 53 there to 1994 139. From were vity radioacti of vidence e by vered disco as w scraps ferrous in 135. Radium has ores. uranium-rich from xtracted e been in companies steel orphan surrounding soil 15 recorded were vels le contamination High volved in These China. aiwan, T in 226 60 in London, with ve Ra le vels of between NORM- 20 rebars, Co-contaminated acility 16 f sources, radioacti a luminizing cases of up wn. unkno as w cause whose spots” 2 and scraps contaminated 0.4 and 400,000 Bq/kg, and with le vels for “hot to possible ve ha may processes industrial e fiv NORM, the or F in found were concentrations Similar Bq/kg. 4,000,000 the vicinity of a w atch f actory at Dieppe, France. Exposures been in volved: oil production and treatment; hea vy mineral mining to the public are mainly due to e xternal e xposure and radon sand processing and rare earth processing; copper [V4]. inhalation and processing; reco very of ammonium chloride by lime absorption in the ammonium–soda process; and uranium se veral C10]. 136. An e xtensive radiological surv ey identified enrichment processes and tailings [C9, former Olen radium contaminated areas in the vicinity of the site w as the f acility in Belgium. The major contaminated 140. At least eight hea vily used streets (approximately whose bed and banks were contaminated Bankloop brook, 3–5% of all ci vic road surf aces in the wntown area of do and radium with m 1,400 of distance a ver o aiwan, T , City ayoyuan T usual un xhibit e to found were China) aste w chemical (hea metals) to a depth of up to 1 m. The contamination radiation. of vels le Crushed rock debris and coarse sands vy wide w one as mainly confined to a narro w strip 5–10 separated from the asphalt pa vement were identified as m the on 238 232 v concentrations vity acti The source. Th and U were of olume total the of 64% About brook. the of sides both or of and 4,000 about to up contaminated range to found soil and sediments, which had an associated - respec Bq/kg, 1,000 road surf ace reached about Sv/h, w as in a residential tively. e xternal dose rate of o ver 0.15 μ The dose rate on the area. of vel le background usual the with compared Sv/h, μ 1.3 of hectares 3 about Bankloop, the of mouth the At found of former (a armland f T on Sv/h [C8]. μ 0.08 - con be to aiwan were flooding) area depth with radium taminated of 1 m (from deep up to a own razil, as w rea a rban u n a B legre, A onte M dose verage a The pasture. for used is area The ploughing). 141. In t he t f o onstructed are about 0.3 μ Sv/h, and the maximum v alue measured c rates u sing s tones t aken f rom a n earby u ranium a nom- as w Sv/h. μ 5.5 aly a s l andfill. T he u rban a rea h as a bout 2 0,000 i nhabitants,

258 OLUME 242 REPORT: V 2008 I UNSCEAR 222 t Rn c oncentrations i n a ir i ndoors a re i n t he r ange he s pread o f s ludge w ill d epend o n t he r adionuclide c on- and 3 3 mall A ludge s he t f o hickness t he t n o nd a ludge s he t n i centration q/m B 5 7 bout a f o verage a n a ith w , s q/m B –310 9 . o r ural ro- p gricultural a or f and l he t f se u he T and. l he t n o ayer l s ettlement o f 3 ,000 p eople c lose t o t he a nomaly s hows 3 ngestion i he t ia v xposure e ublic p o t ise r ive g an c duction , q/m B 5–462 3 ange r he t n i ir a n i oncentrations c adon r ndoor i 3 m ean v alue o f nnual A athway. p w a he t o t ue d ingdom K nited U he t n i oses d 1 16 B q/m ith [ B27, M 21]. t ertilizers f s a reatment ater w rom f ludges s f o se u w ere e sti- m .01–0.3 0 ange r he n i e b o t mated f or Sv s ludges f rom 142. There has been some concern about the e xposure due t treatment. All natural w aters ater w ap t rom f ludges s or f Sv m .02–33 0 nd a ater w ineral m aste w arising to from w ater concentrations contain of naturally occurring radio - certain H23]. [ reatment t nuclides. the w aste (mainly filter These may be in enriched are and disposal of this transport handling, the and 145. There also se veral sites with residues from former sludge), xposure of operating personnel w aste may cause radiation installations around the w orld. Most of these sites are con - e with and of the public. A study performed in taminated Europe radium from former luminizing industries. concluded that, while the e xposure of operating personnel due to direct Some European countries, such as the United Kingdom and and the pub - Canada, g amma radiation and the e xposure of the dri Belgium, as well as the United States ver and ha ve such no during the transport and unloading of w aste are of lic con - contaminated sites. Ho wever, these sites ha ve already been need tw o xposure e be do that ays pathw cern, there are identified and most of them ha ve remediated, been already to so that the current levels of public exposure are very low. considered. The first is the e xposure of operating personnel to radon. The dose due to inhalation will be highly depend - ent radon on both the content in the w ater and the v entilation on exposure to 9. Summary enhanced NORM samples of rooms [H23]. An analysis of ra w w ater Ger- in 222 indicated Bq/L 5.9 of alue v median a with y man Rn, of orldwide w only about 1% of samples ha ving concentrations of greater that are not related 146. Several types of f acility 222 of e to rise ve gi may gy ener nuclear of use actors” the transfer vity “acti The Rn. to f of Bq/L 500 than xposures 3 3 - of members concentrations enhanced from public for the Bq/m 0.1 and Bq/m 50 about are radon for reported of nat rooms, entilated v and ventilated by- for ater w in Bq/L 1 products, industrial in radionuclides occurring urally un a vely. The annual doses products and w astes. A lar ge ef fort is under w ay at both the w orker w orking for respecti 222 areas, to assess e xposure to - concen Rn vel a assuming such in year a in hours 2,000 international the and national le of 500 Bq/L in w ater, w ould be 155 mSv and 0.3 mSv - situa xisting e address to gies strate velop de to and NORM tration to The vely. respecti rooms, entilated v and ventilated un for tions that give rise exposure [E16, I22]. T able 13 presents annual - concen mean geometric the to corresponding doses a summary of the dose estimates for members of the public 222 5.9 the United Kingdom due to the release of NORM from and mSv 2 be ould w ater w in tration of Bq/L of in Rn can NORM these, Besides [W6]. industries typical some 0.004 mSv for un ventilated and v entilated rooms, respec - practices, e xpose also people as a result of se veral common tively. The second pathw ay that may deserv e attention relates w ater treatment, land. arable on fertilizer such as the agricultural use of sludges to the use of w aste sludges as a from or ative approaches, the estimated annual conserv material. uilding b or landfill as residues of use ery v Using the 2 low, of the order of Although depending adults, for mSv to mSv 0.02 from range doses doses to the public are usually microsie the of origin the on w fe a w could groups critical some less, or verts the with sludge, the generating ater deserv ants being about one order of magnitude higher e inf may which range, vert millisie the in doses ve recei dose for Committee The than that for adults encourages the further de velop- [H23]. attention. ment of in ventories and methodologies for assessment dose 143. A similar analysis w as performed in the United King - in order to ha ve a more comprehensi ve vie w in issue the of of context of public exposure. the treatment tap to relating scenarios the Exposure dom. and mineral w aters include the transport, the the and unloading arable land as a fertilizer . F or transport - use of the sludges on treatment C. Use of man-made sources for peaceful purposes ater w mineral of the from resulting sludges ing to a with high measured radon content, the annual dose production power Nuclear 1. member of the public w as conserv atively estimated as –3 The × 10 resulting μ Sv. 8 corresponding v alue for sludges ater w tap from n o ata d ollected c outinely r as h ommittee C 147. The - result dose The gligible. ne also is treatment peration he from a single unloading e vent w as found not to e xceed uclear n f o o ing t o t ue d adionuclides r f o eleases r R U6] [ eport 993 1 NSCEAR U he T nstallations. i ycle c uel f 10 μ Sv for an y type of sludge and for an y e xposure group, r adionuclides f o eleases r nnual a f o verview o n a rovided p ven using [H23]. approaches conservative e very o t or e ach o f t he b asic ypes f f r eactor a nd o ther f uel c ycle t reatment c an b e d irectly u sed 144. Sludges f rom t ap w ater i nstallations s ince t he p ractice o f c ommercial n uclear s a griculture, a n i hile s ludges f rom t he t reat- w ertilizers, f p ower g eneration b egan. D ata f or i ndividual m ines, m ills, ment o f m ineral w ater a re f ed i nto a s ewage p lant, w here r eactors a nd r eprocessing p lants w ere p rovided f or t he U3], [ eport R 000 2 NSCEAR U he t n I ith w iluted d re a hey t s o f ludges o ther o rigin, r educing t he he t y ears 1 985–1989. ata t ue d ontamination c and L oncentration. c adionuclide r nal fi d o f or a n a dditional p eriod, 1 990–1997, w ere a ssessed.

259 ANNEX EXPOSURES OF THE PUBLIC AND WORKERS FROM VARIOUS SOURCES OF RADIATION 243 B: present anne x prov ides addi tional oper ational data for countries have been involved in uranium production. The 37 The and the peri od 1998 –2002 for nucl ear powe r reac cumulative production for up to 2003 is presented in figure XV. tors Canada peri od 1998 –2003 for uran ium mini ng. the and 20% States United the 21%, about produced Germany produced uranium of amount the glo- of 12% total bally 148.The generation of electrical energy by nuclear the in produced amount the for means except 2003, to up started ever steadily grown has former Soviet Union (about 20% since it of total production) and the rela- The 1956. in occurred from 1970 to 1985, an before 1990 [O16, O17, O21]. Annual in production China tively rapid expansion that in energy generation of over production has decreased since increase 1990 but since 2000 has been average 20% per year, XVI). 1990 quite stable (figure slowed to a pace averaging just over 2% per year from 1995. has to Although there been an increase in the decom- missioning and the shutdown of nuclear nuclear reactors, 153. There are a large number of mining areas being growing, energy production is still lower although with rates decommissioned. The countries that have declared mining to of increase in generated energy: about 0.2% from 1996 areas decommissioned or under decommissioning through to 2000 from 0.1% about and 2000 the addition, In 2005. their National Reports to the Joint Convention on Spent Fuel [I27, number of countries using nuclear power has increased and Radioactive Waste Management [I38] are Argentina I28, I31]. [R13], Australia [C26], Bulgaria [R9], Canada [M28], the [C31], Denmark [N5], France [F14], Ger- Czech Republic 149.The nuclear of fuel cycle includes: mining and milling many [F2], Slovenia [R12], Spain [S29] and the United uranium ore and its conversion to nuclear fuel material; fab- States [U24]. Other countries with environmental liabilities the in energy of nuclear production elements; fuel of rication resulting from uranium mining are Brazil [F5], Estonia [R3], with fuel irradiated of disposal reactor; reprocessing, its or Kazakhstan [K12], Romania [B18] and Ukraine [R19]. the of fissile and useful materials recovered; and recycling involve the processing of the ore to and disposal of radioactive waste. storage, treatment Milling operations 154. release, extract the uranium in a partially refined form, known as enrichment of the isotopic content For some types of reactor, 235 yellow cake. In 2003, there were 294 uranium milling instal- fuel an additional step in the fuel the in U of is material includes transport of lations in operation and eight under construction worldwide; cycle fuel nuclear The the cycle. also installations. various the between material 149 installations radioactive had already been decommissioned and 231 were shut down or being decommissioned [I28]. exposures of members of the public result- 150.Radiation Mining operations have 155. Effluents and solid waste. discharges of radioactive ing material installa- from from been carried out in open pits, in underground mines and by of tions previous in assessed were cycle fuel nuclear the in situ leaching. Uranium mill tailings are generated at about reports [U3, U6, U7]. In this annex, the trends in UNSCEAR per tonne of ore extracted, and they generally one tonne the to normalized releases and resultant doses due nuclear retain 5–10% of the uranium and 85% of the total activity 1998– presented for operation are reactor power the years [V4]. The estimated amounts of tailings worldwide are environmental the using estimated are Doses 2002. dosi- and 9 shown in figure XVII; they total about 2.35 × 10 t. Besides annex A, metric models “Dose assessment described in the tailings, waste rock piles may also become a source of the UNSCEAR 2000 Report [U3]. methodologies”, of public exposure. For open-pit mining, the amount of debris produced is from 3 to 30 tonnes per tonne of extracted ore. widely exposed individuals vary to from 151.The doses For underground mining, about ten times less debris is pro- another, between different locations, with one installation to duced. On the basis of information provided for 13 mining time. Generally the habits and indi- with population different sites in Argentina [R13], Canada [M28], Germany [F2] and decrease vidual doses spe- markedly with distance from a Spain [S29], the amount of waste rock varies from 40 to cific source. To evaluate the total impact of radionuclides 6,000 times the amount of tailings, with an average value of at each fuel stage of the released nuclear cycle, the results about 1,600 tonnes of waste rock per tonne of tailings [I38]. collective of terms in effective evaluated are dose per unit energy electrical a). Sv/(GW man as expressed generated, ailings are often confined because of the associated T 156. Only to members of the public are considered in exposures risk. At some locations, exposure to radon may be of consid- Occupational exposures associated nuclear with this section. erable concern, but it is sometimes not addressed. For exam- are section III of addressed this annex, production power in ple, at some tailings locations, exposure to radon may “Occupational radiation exposure”. become important where the site is subsequently used for housing, as has happened in eastern Germany, the Czech Republic and other eastern European countries [V4]. Prob- milling (a) Uranium mining and lems may also arise from exposure via aquatic pathways, since acid drainage can leach uranium from waste piles 152.In the period 1998–2003, a total of t 35,000 about of [A14, F5]. The erosion of covers, structural failure of 24 produced annually in was countries (table 14). uranium embankments, seepage to ground or surface water and this period major producer in The was Canada, with about 21% with Australia, by followed production, world of 30% the total production. Since of beginning of the nuclear era,

260 244 UNSCEAR REPORT: V OLUME I 2008 of are some of the more important of radon dose fective ef vidual indi annual verage a the t/a, 500 emanation ve collecti the that assumes (which Sv μ 25 mechanisms for release of pollutants to the environment. ved recei is dose the population within 100 km of the mine and mill sites) by is 157. Critical Considerable countries. producing major the for alid v still ite-dependent. s e b o t end t athways p xposure e a or f oncern c reatest g f o adionuclides r he T of alues v ve representati the from viations de ath- parameters p tmospheric 222 ways are selected articulates of conditions general more the for possible p irborne a nd a rogeny, p ecay d ts i Rn, re a c ontaining t xample, e for Brazil, in locations are There practice. present horium, r adium a nd l ead. T he m ain c oncern f or 210 230 238 226 high for responsible be may leaching acid where a quatic p athways i s ay m Pb nd a Th - U, concentra lthough a Ra, e e qually i mportant [ V4]. M any a bandoned s ites e xist, b a nd tions in drainage w aters from the mining area [A14, F5]. nly o ith ssociated a roblems P emediated. w r een b ave h ew f a Also, v ery high population densities are reported in areas viously pre cases, some In China. in mills the adon r nclude i p ublic e xposure p r esulting f rom p ast ractices surrounding tailings r w ater ontamination, t he p roximity o f c abandoned elease, may not ha ve been so carefully secured ontamination c o f w astes f or c onstruction, t o h uman s ettlements, t he as the y might ha ve been. Although careful management of r emoval xpected i nventories a nd a ppreciable a erial d ispersion [ V4]. tailings areas w ould be e arge in the future, the e xtremes l in management approaches (from lea the tailings unco v- ving former uranium to 158. Some remediated sites related ered to pro viding secure and co vered impoundment) could or pro ha ve follo w-up monitoring and assessment - increase mines decrease the estimated e xposure by at least an vironment. en the in contamination on grammes Although order of magnitude. are some litera the in vailable a - these of descriptions limited no useful information e xists on e xposures to or little ture, population groups, because (b) Uranium enrichment and most assessments actual were fuel fabrication conserv atively to demonstrate compliance with performed critical hypothetical to doses limiting groups. 162. For light-w ater-moderated and -cooled reactors gulations re adv and WRs) (L for anced g as-cooled, graphite-moderated mills needs to GRs), (A reactors the at uranium the 159. There processed are fe w ne w data on releases of radionuclides 235 2–5% mining and milling operations. Pre vious UNSCEAR be to of Enrichments U. due isotope fissile the in enriched O reports (U oxide uranium the enrichment, Before required. are ha estimated the a verage release of radon for ) ve 8 3 ground under and then to be con verted to uranium tetrafluoride (UF must ) There a). TBq/(GW 75 approximately as mines 4 for no estimates of releases due to open-pit operations. In needed not is Enrichment ). were (UF xafluoride he uranium 6 (GCRs) reactors graphite-moderated a the [U6], Report 1993 UNSCEAR the as-cooled, g normalized verage vy- hea or water-cooled -moderated reactors (HWRs). radon release from mills in Australia and Canada w as and esti - mated from limited data a vailable to be 3 TBq/(GW a) the ere w 163. There [U6]. These v alues are not e xpected to change with current acilities f onversion/recovery c ranium u 9 2 w 003; 2 n i orld he t n i onstruction c nder u 1 nd a peration o n i mining and milling practices. The long-li ved precursors of 222 226 230 a s een b ad h 4 1 a ecommissioned, d een b lready ad h 2 nd Rn, namely Ra (half-life 1,600 a) and hut Th (half-life nrich- e ranium u or F ecommissioned. d eing b ere w r o own d 80,000 a) are present in mill tailings and constitute a long- o onstruc- c nder u 2 acilities, f perating 1 2 ere w here t ment, term source of radon release to the atmosphere. On the basis 5 7 radon normalized the [U3], Report 2000 UNSCEAR the of tion, d ecommissioned a nd s hut d own o r b eing - eavy-water h r o are releases aban and operational for a) TBq/(GW 1 and 3 ro- d ecommissioned. F or f uel f abrication p doned respecti tailings, and these v alues are used here. vely, onstruc- c nder u 5 acilities, f perating o 6 6 ere w here t duction, The ecommissioned little and tailings ace surf no ve ha acilities f leach situ in tion, 2 3 d a nd 2 7 s hut d own o r b eing after emission radon closure. d ecommissioned [ I28]. N ominal c apacities f or u ranium y exafluoride h b abrication f uel f nd a onversion c nrichment, e ith the by w c hile w 5, 1 able t n i resented p re used methodology The Dose estimates. 160. ountry c a - Com ountries mill and mining to re a acilities f roduction p uel f uclear n due dose VIII X gure fi n i hown ve collecti the estimate to mittee s - I35]. ing is described in [ UNSCEAR 1977 and 1982 Reports the on representati ve [U9, estimates Dose U10]. are based and version, from material ve radioacti the ving ha site mill con mine 164. The releases of “model” a from rates release generally are plants therefore are results The sites. xisting e of features typical abrication f fuel and enrichment not small applicable and consist mainly of uranium series F or the to an y particular site without due consideration of isotopes. rather and reflect the o verall fective ef ve collecti normalized the installations, “model” data, site-specific to meant are impact ef ve collecti The acilities. f milling and mining of fec- dose due to these operations w as estimated to be tive to estimated is generated gy ener electrical unit per dose 0.003 man Sv/(GW a). Inhalation is the most important to doses ve collecti The ay. 0.2 be pathw mill, and mine the of operation during a) Sv/(GW man gional re local e xposure and piles than less comprise ges dischar liquid from resulting groups per a) Sv/(GW man 0.0075 and year of release from the a verage milling and mining operational of tailings residual of 10% of the total e xposure. The sites. annual collecti ve estimated dose for the period 1998–2002 is to be 0.8 man Sv . production current the 161. With and t/a 35,000 about of Considering that 18 countries ha ve nuclear fuel enrichment the with than more produce countries 12 that assumption and/or f abrication f acilities, the estimated annual indi vidual

261 EXPOSURES OF THE PUBLIC AND W ORKERS FROM V ARIOUS SOURCES OF RADIATION 245 ANNEX B: doses w ould be about 0.2 μ Sv for local population - radionu of releases verage a ved deri Committee 168. The effective reactors from clides the groups and about 0.1 nSv for regional groups. basis of reported data; these a ver- on ages ha ve been used to estimate a for xposures e the resulting reactor . The geographical reference location , reactor of the of ution the points, release the distrib food (c) Nuclear population, power reactors the and vironmental en the habits, consumption and production ays 165. Reactors for are generation gy ener electrical for pathw - of radionuclides are f actors that influence the cal used radionuclide and vity acti of release same The systems dose. the most part classified according to their coolant culated ve and ferent dif to rise gi can reactors ferent dif from composition moderators: light-w ater-moderated and -cooled pressu - radiation public. xposures e calculated the Thus and WWERs, (PWRs, reactors ater boiling-w or rized- the to doses reactors measure of BWRs,); hea vy-water-cooled and -moderated generalized for a reference reactor pro vide only a - stand as as-cooled, e serv vertheless ne ut b xperience e operating reactor (HWRs); g graphite-moderated reactors (GCRs); for light-w reactors graphite-moderated ater-cooled, and ardized measures analysing longer -term trends from the all are These WGRs). (L which in reactors, “thermal” the practice. is used to slo w do wn the f ast fission neu - moderator material trons thermal ener gies. In f ast-breeder reactors (FBRs), to 169. Effluents. Information on effluents released from induced by f ast by neu - there United is no moderator , and fission is operating nuclear po wer plants ha ve been pro vided Member for States Nations trons; the coolant is a liquid metal. FBRs mak e only a minor ey Surv Global UNSCEAR the contrib reactors of list production. gy ener to ution that on Public Radiation Exposures, and by the International A capaci - operated 1998–2002 in the period and their installed Atomic Ener gy Agenc y (from its DIRA TA database [I30]). Commission European the by published been ve ha Data ties presented in table A-4, and the w orldwide distrib ution is States United the and V2] [E15, N17, [N16, N18, N19]. F or of operational reactors for the same period is sho wn in fig - the ure Republic of Korea, data were obtained from the national arious v these by generated gy ener electrical The XIX. in 1997 presented been has to up reactor of types report to the Joint Con vention on the Safety vious pre Fuel Spent of the Safety sites reactor vidual indi for alues v and reports, UNSCEAR of Radioacti and ve Management W aste Man - on vailable for the period 1998–2002 are gi ven in table A-5 [I31]. A a the of Most R11]. [I38, agement data are related to summary (including PWRs 16. only with HWRs, and BWRs WWERs), table in presented is type reactor each for GRs v limited information for A ery GCRs, L WGRs and FBRs. The radioacti ve material released in airborne and liq - a verage ener gy generated by 166. The nuclear po wer from of awatts gig (net GW(e)/a 278 as w 2002 to electrical 1998 the for operation routine during reactors from effluents uid in reported are 1998–2002 period po wer per year), ranging from 264 GW(e) in 1998 to or F A-12. to A-6 tables of amounts increasing for y tendenc The 2001. in GW(e) 288 airborne effluents, the releases of noble g ases (table A-6), 14 131 (table net The wer po nuclear by generated be to par- and A-9) (table C continues. A-8), (table I A-7), gy tritium ener plants, ticulates (table A-10) are gi ven. F or liquid effluents, the installed electrical ener gy capacity of nuclear po wer number the tritium of releases gi ven in table A-11 and of are other installed net verage a the and reactors operating of increasing orld- table in radionuclides capacity per unit po wer reactor are still A-12. w period wide (figure XX). In the 1998–2002 co vered by this been - traditionally ve ha releases normalized The 170. com anne x, there were 452 operational reactors. Of these, 23 had each for separately piled period, justified is This type. reactor started operating in the had 8 and wn do shut were 14 2005, and 2003 Between period. the in gy ener generated ferent not dif the of because mainly releases, the of composition “dose f ne w reactors started operation and 8 were shut do wn. In to required are actors” 10 ferent dif and ases, g noble for the types. vely relati ith W reactor ferent dif for doses the estimate same period, there were reactors wer po nuclear 22 also 10 countries. uilt By 2007, the number being b uilt estimating for needed is being xtrapolation e little data, complete b in to the and releases, total the from resulting doses ve collecti the increased trend time The [I31]. countries 13 in reactors 30 total ener gy generated by reactor type is sho wn for in normalized v alues are retained by reactor type mainly for XXI. figure con venience. The results are presented in table 17. These v are intended only for alues use in estimating the contrib u- the total 167. PWRs contrib the lar gest fraction of tion of operating nuclear po wer plants to the o verall public ute 67% about orldwide, w generated gy ener between comparison for used be not should and xposure e nuclear the for dif 1998–2002, follo wed by BWRs, with a contrib ution a of choice The purposes. other for types reactor period ferent of e tak must purposes generating for reactor of type specific about 24%. The contrib utions of other reactor type are: veral se account into about 5% for HWRs, 3% for L WGRs and 2% for GCRs. - reac the of safety the as such aspects, tors; aste w including ycle, c fuel complete the of impact the FBRs contrib ute v ery little, only about 0.1% of the total gy ener generated. The a verage contrib ution for each reactor generation; and the industrial infrastructure a vailable in each the period - type can be seen in figure XXII for country—f actors that are not co vered in this anne x. In addi 1998–2002 the period 1970–1997. The (the age vered reactors’ the on dependent are releases co by this anne x and for tion, effluent inter- the reflects GCRs from ution contrib smaller current performance of older reactors is usually dif ferent from that (later resumed) by some ruption in nuclear po wer production of more modern reactors) and also on impro vements in w aste reactors Kingdom. United the in management systems. Also, reactors that ha ve had long

262 OLUME 246 REPORT: V 2008 I UNSCEAR periods for maintenance operations may present estimate v alues for the per caput local and re gional 174. To shutdown it higher to relates dose ve collecti total the that assumed is doses, ges dischar effluent while because, alues v usual than zero. The informa - the plants: wer po nuclear be may all around groups population model po wer generated is enhanced, radius km 50 a within lie to assumed is population tion local the used in this anne x includes the total ener gy generated its and plant wer po nuclear a surrounding density population and the total effluents released in each year , and these figures -2 is to ference dif the of account e tak xplicitly e not do to assumed population gional re the ; km 400 be to en tak is main - due nuclear the from radius km 2,000 lie a within plant wer tenance periods. Only those reactors po that ha ve not generated -2 a during gy ener ha ve been e xcluded from this the whole Using . year km 20 be to en tak is and its population density 444 with [U3], reference in described site model analysis. On the whole, the v alues for the a verage release per operational units pre from results with consistent are generated gy ener unit reactor vi- and an a verage of tw o reactors per site, the general, normalized releases are ous dose reports. In Committee has UNSCEAR that the per caput ef fective estimated time. with due to each site w ould be about 0.1 μ Sv annually for local decreasing (50 km radius) and only a of a nanosie vert groups fraction e ffluents gional 171. The l argest c ontributions t o t he a ctivity o f for the re t groups within a 2,000 km radius surrounding he nd r a re a ssociated w ith t ritium a n oble g ases. F rom eleased site. a i nformation a vailable, t he r elease o f n oble g ases p er u nit t he g i s h igher f or L WGRs t han f or o ther enerated r eactor nergy e 175. The annual doses estimated for critical groups used plants f o mount a he T t ypes. r elease i n b oth a tmospheric a nd ritium for licensing and effluent control of nuclear po wer t are iquid ormal- N eactors. r eavy-water h or f igher h s i eleases the of radius km 3 a within area the to apply to considered l r alues and in most countries are constrained by an annual ized v reactors f or n oble g ases r eleased f rom n uclear p ower 200–300 range the in limit dose doses actual ut b are Sv, μ p lants o ver d ifferent t ime p eriods a re s hown i n fi gure X XIII. L n i ecrease d a how s ypes t eactor r ther o ll a WGRs, or f xcept E usually much lo wer than this. Considering that more than u e nergy g enerated; t his n he t er p eleased r ctivity a as g oble nit 80% of the collecti and effluents, airborne to due is dose ve eflect taking the dif ference rocedures p anagement m aste n i mprovements i r ay m between the v alues for dilution f actors w and source eactors. r odern m f o haracteristics c esign d he t n i nd a ve representati the for - condi verage a long-term Report as defined in anne x tions A of the UNSCEAR 2000 The c oncentrations Local and regional dose estimates. the [U3] for the distance of 1 km for 172. critical group, it can be i n assumed that, for the period 1998–2002, the e xpected maxi - t enerally g re a adionuclides r eleased r f o nvironment e he e xcept c lose t o t he n uclear f acility of km 1 within groups critical to doses fective ef annual mum t oo l ow t o b e m easurable hen T adionuclides. r f o umber n imited l a or f nly o here- t nd a reactor sites wer po nuclear from releases effluent to due ose d fore b nvironmental E ata. mSv. 0.02 of order the of are operation plant d ffluent e n o ased re a stimates e ere a , A nnex n i eviewed r w odels t ransfer a nd d osimetric m f o ethodologies”, m ssessment a Dose “ 176. Some information w as also a vailable for releases from 000 2 NSCEAR U he t A as treated be cannot releases These reactors. wn do shut some R eport [ U3]. gain, b ecause o f t he v ariability i n a nnual “operational” with associated not are y the because releases, r eleases, n ormalized r eleases, i n T Bq/(GW a ), a re a veraged c stimate e o t total the of alues v The gy. the ener nuclear of generation ose d he T oses. d ollective o ver a fi ve-year p eriod releases from some shut do wn reactors are presented in c onversion f actors s a ame s he t ere w oses d stimating e n i sed u nd a U3] [ eport R 000 2 NSCEAR U he t n i sed u hose t table ere reactors these from releases total of comparison A 19. w ummarized s n t able 2 . with those from i operational reactors of a similar type and po wer sho ws that releases from shut - sig are reactors wn do gional nificantly smaller than those from the equi valent operational re and local for estimated doses ve collecti 173. The may reactors, population groups combined are presented in table 18. The found, be xceptions e some mainly although collecti ve down shut low-powered and old to related reactors. dose for 1998–2002 is lo wer than that the for the period 1990–1994 gi in UNSCEAR 2000 Report ven this for reasons main The are noble for alues v wer lo the [U3]. BWRs from releases as g of a contrib ution the reprocessing (d) Fuel absence and the United Kingdom that were not in opera - from GCRs in tion collecti annual verage a The 1998–2002. period the in ve 177. The reprocessing of spent fuel is performed to sepa - dose plutonium and uranium reusable ver reco and out rate from released effluents to due groups gional re and local to from po wer plants in the period 1998–2002 w as esti - in site on retained is reactors from fuel spent Most aste. w nuclear made pending storage, interim decisions mated as about 75 man Sv . (If the estimates were to on ultimate disposal or be storage. the of third one about that estimated is It vable retrie effluent total the considering i.e. approach, simpler a using - spent by vided di type specific a of reactors all from releases repro the to submitted been has produced already the fuel by those reactors, the a verages w ould fuel nuclear the of ycle [I34]. France, Japan stage cessing c total po wer generated be operating countries main the are Kingdom United the and reactors vidual indi of performance the to ve sensiti less more ould w and commercial the of estimate plants. ve representati reprocessing a probably be dose. results of such a calculation The verage a orldwide w Relati about of dose ve collecti annual the for alue v a vide pro ould w 178. Effluents. vely lar ge quantities of radioacti ve 42.6 Sv.) man material are in volved at the fuel reprocessing stage, and the

263 EXPOSURES OF THE PUBLIC AND W ORKERS B: FROM V ARIOUS SOURCES OF RADIATION 247 ANNEX 3 for its release in w aste dischar ges is greater than for planet. The radionuclides of specific interest are whole H, potential 129 85 14 been and 10.7 5,730, 12.26, of ves half-li with I, and Kr ve C, ha releases Routine ycle. c fuel the of stages other 7 × volved in uncertainties ge lar The vely. respecti lar years, 10 gely 1.6 in releases of liquid effluents to the sea. Operating in prolonged to due are periods time ver o doses estimating standards ha ve been considerably impro ved at reprocessing reductions population ays, pathw vironmental en predicting in problems in the substantial plants o ver the years, with distrib uncer- The amounts released. etc. change, climate habits, dietary utions, tainties is gration inte the when increase calculations dose in carried thou or time—hundreds of periods long ery v - for out in plants reprocessing fuel 13 were there 2003, 179. In - of 100-year the Considering . longer ven e or years trun sands operation, 3 under construction, 13 decommissioned and 18 3 0.004 coefficients dose cated for a) Sv/(GW man shut do wn or being decommissioned [I28]. Information on H, of 85 14 releases for a) Sv/(GW man 0.12 C, for a) Sv/(GW man 6.3 and Kr period the for installations these of some from 129 is presented in table A-13 for airborne effluents - continu a and [U7], releases I for a) Sv/(GW 1998–2002 man 0.0008 of origins The effluents. liquid for A-14 table in and ing these practice of about 300 GW a ener gy production per year , rate dose fective ef caput per maximum Global data were countries’ responses to the UNSCEAR ould w the w orldwide Surv on Public Radiation Exposures, the ey DIRA TA be about 0.18 μ Sv/a. IAEA database [I30] and the open literature [E15, V2]. Included are for the reprocessing f acilities at La Hague (France), data (German y), Krasno yarsk and T omsk-7 (Russian (f) Solid waste disposal Karlsruhe Sellafield and Kingdom) (United Federation), Dounreay and okai T 183. Solid w astes arise at v arious stages in (Japan). the nuclear fuel w astes, vel intermediate-le and w- lo include y The c ycle. 180. Collective doses from nuclear fuel reprocessing fuel from aste w vel high-le operation; reactor from mainly can be p er and w- Lo disposal. direct for fuel spent and reprocessing; u nit e nergy g ener- ormalized n he t rom f stimated e r eleases intermediate-le vel w astes are generally disposed of by ated, t he e lectrical e nergy e quivalent o f t he f shal - essed c epro r uel c or concrete-lined structures, b ut more trenches in urial b low a nd t he ollective d ose p er u nit r elease o f r adionuclides [ U6]. sites disposal and aste w vel High-le xist. e also adv P revious anced U NSCEAR r eports u sed d ose f actors he t n o ased b e uel e nergy e quivalent o f t he f r epro c essed. T he s ame spent fuel are currently retained in interim storage tanks lectrical the nformation o n t he disposal for methods adequate of velopment de pending i ecause b ere, h sed u e b annot c ethodology m f o mount a the and hus sites. disposal of selection t ere w oses D vailable. a ot n s i eprocessed r uel f e o n t he b asis o f t he stimated a ctivity r eleased i n t he e ffluents, u sing 184. The r adiological i mpact a ssessment o f a h igh-level t he T . 3 able t n i resented p actors f onversion c ose d he ste wa d ata c ollected a re c urrently n ot c omplete, a nd t his n ecessarily ong-term l he t f o odelling m n o ely r o t as h epository r l i stimates. e esulting r he t nto ncertainties u arge ntroduces i b ehaviour o f t he wa ste a nd t he m igration o f r eleased r adio- a ver o istances d reater g t a nd a ite s he t ear n oth b nuclides U sing o nly t he a vailable r eported d ata, t he a verage a nnual c ol- v S an m 8 bout a ith w v, S an m 0 3 s l eriod ong o f p t ime. T o c arry o ut s uch p erformance a ssess- lective d ose i s e stimated a ncluding eeded, n re a ata d ite-specific s f o umber n a ments, d ue t o i a irborne e ffluents a nd a bout 2 2 m an S v d ue t o l iquid or f alled c hose t stimate ransport t nd a haracterization c ste wa y b e ffluents, a s s hown i n t able 2 0. T he e ol- c otal t he t or f o S or f ainly m erformed, s i eprocessing r f p eginning b he t ince s ose d lective een b ave h ssessments a uch odels. m an v. T he l argest c ontribution t o t he t otal d ose e sti- ypothetical S m ,828 4 u se i n f ormulating d esign c riteria f or t he h 14 associated with the release epositories. of mate C. T he actual val- is still r arger f t he t otal d oses, h owever, a re p robably a l ittle ues l or han t hese e stimates, b ecause s ome d ata a re m issing t hat t 185. Information o n s pent f uel h as b een o btained f rom o e stimate d oses a ccurately. w ould b e n eeded t t he N ational R eports o f c ountries t hat a re p arties t o t he anage- J oint C onvention o n t he S afety o f S pent F uel M 181. The estimate of the annual collecti ve dose is still in ment a nd n t he S afety o f R adioactive W aste M anagement o if Sv; man 20–30 range the local s i ountries c ifferent d mong a omparison c irect d he T I38]. [ single a xposing e were this 6 population (say , 3.1 × 10 d persons within a 50 km n i pecified s re a nventories i ecause b ifficult d ifferent group μ 10 Sv thers o hile w tored, s ass m otal t he t eclare d ome s ays: w about be ould w dose fective ef caput per the radius), of operation. The corresponding v alue for re gional ass. m per HM) ( eavy-metal h he t r o ass m ranium u he t d year eclare resent p ew f a nd a lume, vo he t eport r ountries c ther O groups w ould be about 0.12 μ Sv/a. Considering that fiv e he t s ometimes the dose, ve collecti this to uted contrib ve ha installations a ctivity ( but i t i s n ot c lear i f t he v alue g iven fective ef verage a for Sv μ 2 of order the of be ould w doses r efers t o t he u ranium c omponent o r i f i t i ncludes a ctivity groups population local a y groups. regional for Sv μ 0.024 and f rom b fi ssion p roducts). F rom t he m aterial p rovided f c ountries t hat h ave d eclared ew t heir t otal i nventory o f s t pent f uel b y n uclear p ower p lant a nd a lso d eclare hat radionuclides (e) Globally dispersed t hey d o n ot r eprocess t heir s pent f uel, av erage v alues f or eneration t a nnual s pent f uel g he p er u nit i nstalled e lectri- dispersed easily and ved long-li are that 182. Radionuclides cal c apacity h ave b een e stimated a nd a re p resented i n the in en vironment can gi ve rise to doses to people across the t able 2 1.

264 248 UNSCEAR REPORT: V OLUME I 2008 the of operating years, the type - decommis being are or wn do shut been ve ha installations 186. Considering number acilities, f milling uranium 231 includes list 2003 The sioned. of reactor and the net electrical capacity , a total amount of t uranium con version/recovery plants, 7 enrichment f acili- about 210,000 14 of HM in spent fuel is estimated to ha ve ties, 27 fuel f abrication/heavy-water production f acilities 2002 from nuclear been generated w orldwide up to the end of po plants that were operational in the period 1998–2002. wer commercial 107 Also, plants. reprocessing fuel 18 and material go- were or wn do shut been had plants wer po nuclear already has that been This amount includes the under about to amounts which reprocessed, reactors research 21 also were There decommissioning. orldwide w t 90,000 ing several research units undergoing decommissioning. [I34]. and this figure also includes material reprocessed Because some from reactors already shut do wn, there are at least from nuclear in countries by vided pro information the to 191. According po 120,000 plants t of HM in spent fuel wer 2005 under the arrangements for the Joint Con vention on the storage temporary in currently it of most stored, being Fuel Spent of Safety and conditions. on the Safety of Management acti Radio - decommission gest lar the Management, aste W ve to be which States, United the of that as w 2005 in programme ing final disposal, all such material will ha ve Before 187. which wer po nuclear 16 decommissioning as w manipulated and transported, research 20 reactors, will gi ve rise to both public and occupational e xposures. Public e xposure due to reactors, 66 radioacti ve installations and about 1,186 sites for used formerly of spent fuel is discussed in section II.C.2 of France [U24]. defence transport the to related vities acti x. arious v of material ve radioacti of transport The anne this w as decommissioning 9 nuclear power reactors, 15 research between types and 16 cause may installations ycle c fuel nuclear reactors, 3 small reactors used for defence acti vities to be near the transport wer po nuclear 17 had y German [F14]. installations other members of the public who happen ve radioacti of transport The xposed. e be to and ehicles v reactors and 14 research reactors under going decommission - is addressed as a separate item in this anne x. processes nuclear material ing [F2]. All these of amounts ge lar generate will fuel c ycle, doses nuclear may research both from spent including aste, w ve radioacti F or the be estimated using the fuel and po wer reactors, which will ha ve to be handled, trans - f actor of 0.1 man Sv/(GW a), as in pre vious UNSCEAR W of. disposed and ported the information ith a vailable it is reports [U3, U9, U10]. not and acti vity of the possible estimate to the total amount will nuclear of operation routine 188. The po wer plants gener- highly be waste of amount The of. disposed be to aste w type, size and operational history . ge amounts of long-li ved and high-acti vity radioac - ates lar dependent on the f acility As that estimated has ventories in aste w on information is there an Although aste. w tive orea K of Republic the xample, e 12 3 w fe Bq a only countries, veral se for about of vity acti an with aste w of m 620 some × 1.24 are ventories in these of 10 the of origin specific the to respect with detail in described decommissioning of tw o research will be generated by the 3 of Some countries report the v olume after treatment and reactors, about aste. vity acti an with aste w of w m 380 some and 5 of decommissioning the by Bq conditioning 10 × 6.5 while others report the weight produced; care is version con one The infor- of basis the on vertheless, Ne interpretation. in needed f acility. decommissioning reactors wer po nuclear o tw of a in Canada, at Douglas Point and at Gentilly-1, has left total mation pro vided by Ar gentina [R13], Canada [M28], Hun - vely, respecti gary t, 80 and 300 of and [S29] Spain [R11], orea K of Republic the [R10], The fuel. spent in uranium of Switzerland xpected total v olumes of conditioned w aste from e xisting e [D6] in their National Reports to the Joint Con - ves li their of end the to acilities f Kingdom United are vention on the Safety of Spent Fuel Management and on the 6 3 3 5 m [I38], Management aste W ve Radioacti of Safety 1.5 × 10 2.4 annual of lo w-level w aste, × intermediate- of m the 10 3 3 dif types of by [I38]. waste high-level of m w 10 × 1.5 and waste vel le ve radioacti of amount generated aste ferent capacity these and estimated, as w installed unit per reactor also presented in table 21. lso a re a 92. There 1 c urrently fi ve r eprocessing fa cilities results are a f c apacity o g reater t han 1 t /a u ndergoing d ecommis- w ith nd wo m ore f or w hich d ecommissioning i s Doses due to solid w aste disposal ha ve been estimated sioning t a 189. t - radio of migration ventual e projected the of basis the he on rom f xposures e o t elated r nformation I I34]. [ lanned p o f s uch fa cilities i s s carce a nd r d ecommissioning - esti These ater. groundw into site urial b the through nuclides elates egulatory r he the about assumptions the on critically depend mates t o t ore m ith w ompliance c f o evel l onstraints c a ctual of the solid w aste and the site characteristics, ay m xposure e rker wo hile W xposure. e t han t o containment p ublic - The uncertain. highly generally are accordingly and a rise approxi f rom d ismantling, d emolition a nd wa ste m anagement collecti ve ef fective dose due to lo w- and mate normalized o perations, p ublic e xposure ill d epend o n t he c riteria w a ite s he t t w, lo vely relati wever, ho is, disposal aste w vel intermediate-le a adioactivity r esidual r or f dopted a he t n o nd of order of 0.5 man Sv/(GW a), and is due almost entirely ransport the vail- a nformation i he T ites. s isposal d o t ste wa f o t 14 t ue d ublic p he to f o xposure e he t hat t ndicates i able t C [U6, U9]. The w orldwide a verage annual per caput ecom- d o ill of year per nSv 1 about be ould w rate dose fective ef missioning w b e v ery l ow a nd w ill b e c onstrained i n t he ong cceptable a egarding r egulations r ational n b erm practice. y l t i aterials l evels f or r esidual r adioactivity n r ecycled m a nd i n gi ves rise The decommissioning 190. of nuclear f acilities t he e nvironment. E stimates o f d oses d ue t o wa ste r ock a nd and aste, w ve radioacti to xperience e is decommissioning t ailings w ere, h owever, i ncluded i n t he d oses e stimated f or considerable a orldwide W accumulated. being of number u ranium m ining a nd m illing.

265 EXPOSURES OF THE PUBLIC AND W ORKERS B: FROM V ARIOUS SOURCES OF RADIATION 249 ANNEX the decommissioning of f acilities, man y mate - considered as a subset of the “public” who are gener- often 193. During by in wever, Ho [V23]). rates dose highest the to xposed e ally applied being are criteria ferent Dif ycled. rec be may rials of dif ferent countries, ver whene will, orkers w of group this xposure e x, anne this b ut the information currently a vailable is not of xposure e the from separately considered be possible, sufficient to estimate the contrib ution from rec ycled general I24, I40, L13]. the of members [B13, I19, - passen pedestrians, as such public, materials to public exposure and gers bystanders. 197. The data on numbers of packages are generally well (g) Summary of estimates of doses due to power nuclear production kno ycle operations, b ut for other trans - fuel nuclear for c wn - operations the number can port most cases only be esti in embers o f in countries between ariation m o t oses d stimated e 94. The 1 v ge lar a also is o t ue d ublic p he t There mated. t g eneration o f e lectrical e nergy b y n uclear p ower he a re s um- ve ha countries some the number of packages, because a nd r egional p g roups, suppliers major ve ha some and operations ycle c fuel nuclear opulation marized i n t able 2 2. F or l ocal a n ormalized f actor o f 0 m an S v/(GW a ) h as b een of radionuclides [H29]. The IAEA estimates that 10 million d eter- .27 t he v alue d erived i n t he material mined. T his i s s lightly l ower shipments of radioacti ve t are transported annually . han 000 R eport [ U3], 0 .44 m an S v/(GW a ). F or a ll 2 NSCEAR U Each shipment is made up of either a single package or a a ctivities r elated t o t he p roduction o f e nergy, a n ormalized number of packages [I5]. The v ast majority , some 95%, of e ffective d ose o f 0 .72 m an S v/(GW are a ) w as d eter- c only ycle, c fuel nuclear the to unrelated ollective these shipments G W(e)/a transport cycle fuel to related being 5% mined. U sing t his c oefficient, w ith a n a verage o f 2 78 [W16]. ollec- nnual a n a eriod, p 998–2002 1 c t n i roduced p ear y er p he a bout 2 00 m an S v i s e stimated f or a ll o perations tive d ose o f 198. Road, rail, air and sea transport are all commonly used o ve radioacti of material, ycle c fuel nuclear of transport the for r elated t e nergy p roduction. T he a nnual p er c aput d oses t o in used be to material and research, and industry medicine, r epresentative l ocal a nd r egional p opulations s urrounding ycle c fuel nuclear of is transport Air aste. w of car- material n uclear p ower i nstallations a re l ess t han 1 0 μ S v. T he c ollec- xtent g d ispersed r adionuclides a re d eliv- ried f oses d tive out only to a lobally limited e [W14]. The a vailable data rom p transport of conditions normal under xposures e that indicate maximum” “ ssumed a n ered a o t nd a eriods ong l o ver v ery f the and Kingdom United the for least At w. lo are p opulation o United t he w orld. I f t he p ractice o f n uclear p ower p ro- fuel of transport the States, contrib utes sig - material ycle c duction w ere l imited t o t he resent p he t t a ears y 00 1 ext n t c t he m aximum a nnual p er c aput e ffective d ose t o he apacity, does than orkers w transport of xposure e the to less nificantly v. [I5]. material non-fuel-cycle of transport the g lobal p opulation ould b e l ess w t han 0 .2 μ S numerous vely relati are sources y radiograph 199. Mobile are there radioactive and nuclear of 2. Transport throughout the w orld. F or e xample, about material 850 in France, half one about and of these are transported daily by place their to storage from users nor- “ he t o t elated xposures e escribes d ection s 195. This r dose transport The use. of radiograph y operators due to these sources has not been mal for t ransport” o f r adioactive m aterial. N ormal t ransport distin - t he included in this anne x because of the difficulty in r efers t o o perations t hat o ccur w ithout l oss o r d amage t o between guishing c onveyance. ccident a n a ithout w nd a ackage p i nvolving - radio of transport the from arising doses t t material and doses resulting from the radiograph y E vents i n w hich he s hipment i s n ot active r o ackage p he t imely, ontents ost l re a c he t r o amaged d s i onveyance c [C3, themselves operations estroyed, d H4]. o r a c onsidered t o b e t ransport re a ccidents o r i ncidents [ I20]. ncidents i nd a ccidents A umber n 200. The G n i ransports t uel f f o ermany hown s s i heir t ut b ransport, t uring d ccur o o d gure a re n ormally l imited b y b uilt-in s afety f ea- umber n he T 994–2002. 1 eriod p he t or f XIV X onsequences c fi n i t or uel f on-irradiated n nd a rradiated i f o ransports ncludes i tures o f t he p ackage t ogether w ith t he c ontrols r equired f b aste H28]. [ rocedures p esponse r mergency e ncluding i ransport, t a nd o f w y r ail, r oad, s ea a nd a ir. T he ove rall n umber onsideration his c he T t f o cope s he t utside o s i ccidents a f o o f t ransports d ecreased f rom 1 994, r eaching a m inimum i n “ Radiation e xposures i n a nnex a nd i s d iscussed i n a nnex C , a bout 1 999, a nd s tarted a r elatively s low g rowth u p t o o ccidents”, a 002, 2 n I 002. 2 f o umber n he t o t ontributor c ajor m he t eport. R 008 2 NSCEAR U he t f t on-irradiated n f o ransport t nternational i he as w ransports t o 0% 5 early n or f ccounted a hich w oad, r y b uel f natural or artificial origin are uclear of n ll a f 196. Radioactive materials f o ransport t ea and within transported are s and orld w the around widely used f uel t ransports, w ith t he i nternational A countries. between or f ccounting a uel f on-irradiated n B48]. [ 0% 2 bout a are materials ferent dif of range wide quantities transported, from small of radiopharmaceuticals medical for to purposes fuel nuclear spent ve radioacti highly the nuclear fuel c ycle. The routes and vitrified w aste arising from (a) Transport by land of these radioacti ve materials can handling and transport radiation e xposure of w orkers and of mem - gi ve rise to the 201. Most transport operations include the initial road is often bers of the public. In a lay sense, the term “public” transport from the production site to the rail way station, air- to en tak (i.e. transport w orkers are orkers w transport include port, harbour or collection centre. During this part of the

266 250 UNSCEAR REPORT: V OLUME I 2008 v r may pass through residential or cro wded ailway s tation, a nd t hen b etween t he r ail t erminal a nd t he ehicles journey, t aste w f o ransport lso, A areas and along b usy roads and highw ays. In certain places L a H ague r eprocessing f acility. t he v arious p roducers a nd t he s torage c entre a t high, the unusually be pedestrian density may while in others etween b there may be only people w aiting at b us stops to represent L a H ague i s a ccomplished p rincipally b y artly p nly o r nd a ail ehicles y r oad. T he c ontribution o f w aste the t ransport b t o t he i rradia- potentially e xposed population. P assengers in v emains r ublic p he t a orkers w f o tion v ehicle will also be e xposed. Ov erall, the nd near the deli very embers M ow. l ery v ransport o t p ublic r esiding a long t he ( road a nd r ail) t f be to xpected e is public the of members such of xposure e he t n i torage s f o ites s he t much ear n r o outes r lo wer than of the e xposure of w orkers in volved in eceive r ay m ransit operations. Collecti ve doses will o t ue d oses d t actual transport and car go he t ransport o f r adioactive m aterial. T he e along mainly on the population density the transport stimated depend as w ublic p he t y b eceived r ose d ollective c nnual a ose d he t f o alf h bout a v, S an m .10–0.15 0 bout a ost ve collecti both that appear ould w it Although [V23]. route t o b e a t m doses vidual indi and to the public are lo w [I5], data are H4]. [ orkers w y b eceived r scarce. roups g opulation p or f ssessed a ere w oses d 206. Collective 202. surv ey w as performed in Mumbai, India, re garding i n t he A v icinity o f t he t ransport r outes w ithin G ermany a nd radioacti of carriage packages the A” ype “T in material ve w ere r elated t o t he i ncident-free t ransport o f r adioactive use in medicine, industry and research; such mate - nd [I33] for m aterial a s pent f uel. T he p opulation g roups o utside n f Centre, Research Atomic Bhabha ncluded i ssessment a his t i onsidered c acilities uclear n the by supplied is rial ards, y hunting s n i ersonnel p ailway r of number ge lar a to Mumbai, India. ver o all users he t n i opulations p P ackages go air the to vered deli terminal are ultimately sent to v ari- as- v icinity car o f s hunting y ards a nd r ail r outes, a nd r ailway p o s pent doses to the urban public Radiation country. the f of parts ous stimates e ose d ollective C sengers. ypes t hree t or f are f omparison C 3. 2 able t n i resented be to ely lik material ve radioacti of shipments to due p re a anagement m uel other ain y an in than Mumbai in greater much ow-level l or f stimates e ith w m he t t howed s aste w India. in city hat c ontributor t o t he c ollective d ose f or a ll p opulation g roups the pedestrians and Essentially the passengers tra velling it is w ould b e t he t ransport o f in nearby v ehicles who are e xposed he t o t WRs P rom f aste w ow-level l to radiation during the G radioacti of transport material. The estimated d epository a t ve orleben, w hich e xceeded t he e xposure d ue t o radiation found were xposures e f uel f pent s f o ransport t he t o o rders wo t y b WRs P f rom could doses ve collecti ut b w, lo be to high vely relati the of because ge lar be theoretically T he t ransport o f s pent f uel a ccounts f or m l ess agnitude. - pedes f o % 1 han t trian and passenger density in Mumbai. Measured dose rates, pothetical hy a o t ose d nnual a he T ose. d otal t he t used asses Gy/h μ 55 to 1 from ranged xposure, e public estimate to “ critical g roup” p assenger w ho p e very s hipment o f the deli very v an and for beside ehicles v in passengers for r adioactive m aterial f rom t he r eprocessing f acility t o t he as ho w nhabitants I Sv. m .08 0 e b o t stimated e w epository d pedestrians on side walks. The annual collecti ve dose result - istance d t a ithin w ear y ntire e he he t pend s rom f m k 1 f o ing from the transport of radioacti ve consignments in r t rack w ould ailway eceive r a c onservatively e stimated Mumbai was estimated to be about 0.1 man Sv [V23]. o f 0 .03 m Sv [ a B7]. nnual d ose 203. The collecti ve doses accruing to the general public the former German Demo - 207. A study w as sources spent sealed of transport road incident-free to performed due in - cratic by nuclear application institutes in India were esti - generated trans the of assessment impact an to related Republic - col aste w of port mated for the year 2001 [U43]. The main contrib ution to to the Endlager für radioakti ve Abfälle 192 Morsleben decayed of transport the to due as w dose lective mine salt former a y- Saxon in (ERAM), located sources Ir shutdo dis had been used for industrial radiograph y, brach ytherapy - that restarted ERAM wn, temporary a After Anhalt. transport some 1996, of end the to then both From 1994. in operations posal and nucleonic g auges, with a collecti ve to dose 3 w man 46 about of public the to and orkers w 11,000 m aste, of Sv. primarily lo w-level solid w aste from plants operating nuclear po wer and from decommissioning, for road by shipments period the of 204. Analysis the were deli vered and placed in deep geological formations. mode 1987–2000 by authorized carriers in Italy concluded that as w shipments aste w for transport of The preferred for associated operations transport from arise mainly doses rail, e xcept with a small fraction of the journe y within 40 km of Estimates site. repository the transport the with and ution, distrib and supply radioisotope of members to doses annual non-nuclear radioacti ve w aste. Ne gligible doses arise [S12]. mSv 0.1 than less generally were of public the of transport operations associated from with the nuclear fuel of of are material ve radioacti packages 500,000 208. Some because of the v ery small number of shipments c ycle, The and road by Kingdom United the within annually shipped nuclear material. people to xposures e the of part greater around rail. by annually vements mo ve radioacti of shipment the to due 4,000 material for industrial and of 52,000 About packages purposes, medical for transport from arises uses medical these are shipped to and from hospitals; about 15% with of dose fective ef vidual indi annual maximum estimated an these contain technetium generators. Doses to members of 0.0012 of [C3]. mSv the public due to the transport of radioacti ve material tend to estimated be v ery lo w. The maximum indi vidual doses were f uel i s c arried m ainly b y r ail. R oads 205. In F rance, s pent less than 20 μ Sv/a. The estimated collecti ve dose to the pub - ower p ertain c etween b nly o sed u re a earest n he t nd a lants p lic due to the mo vement of radioisotopes to and from

267 EXPOSURES OF THE PUBLIC AND W ORKERS B: FROM V ARIOUS SOURCES OF RADIATION 251 ANNEX w as 0.013 man Sv , with a further 0.005 man Sv due arbour w orkers, w ith a n a nnual c ollective d ose o f a bout H hospitals - 4 he t eceived r hat t roup g opulation p he t ere w v, S an m 0 1 × 3 to due public the to dose ve collecti estimated The xports. e to fuel flasks the within the United vement S1]. [ oses d ndividual i argest l spent nuclear of mo A w as no more than about 0.001 man Sv [W7]. Kingdom NORM study on the transport of in the United Kingdom (c) Transport by air found that the annual dose to an y member of the public from NORM y of shipment the type of an w ould be much less than producer [H30]. orldwide w for major radionuclides of a microsievert 213. A Kingdom. United the in located is use medical - radionu The then domestic for either road by sent clides are packaged and very deli via ackages P airports. of number sea a xport by (b) Transport for or e containing radioacti ve material arri ve the airport in light at the in ed check and dedi unloaded then are and trucks by transported is Japan from fuel 209. Spent - in sea s carrier’ v arehouses. sea at ving arri Europe, in reprocessing for essels ter- cated w The packages are sorted and grouped according plants and then under going air by transported packages of the majority The destination. to close minals reprocessing to handled are flasks fuel Spent ys. journe road/rail short are by e xcepted or T ype A. Excepted packages ha ve sur- either terminals, with limited access by w orkers. cranes Sv/h. the f ace dose rates of less than 5 μ sea Ho wever, some T ype A at surf - conti from sea by transported ewise lik is fuel spent Some packages containing technetium generators ha ve ace Europe nental to the United Kingdom. The limited transport dose rates approaching 1 mSv/h. Measurements ha ve indi - xample of high-le vel w aste, for to e France in Hague La - techne from containing packages to close rates dose typical cated tium generators of around 40 μ storage f Sv/h, with surf ace dose rates acilities else where in Europe and in Japan, follo ws [W14]. those to similar procedures transport fuel spent [W3]. Sv/h μ 800 to up of for s r ores, as (such material fuel nuclear 210. Non-irradiated 214. An e xtensive urvey o n t he outes, k inds o f a irplane, are vatives) deri chemical and concentrates c argo o perations, c rew fl ight s chedules a nd n umbers o f shipped around arried ingdom c i n 2 001. s wa assengers p K nited U he t n i ut o the w orld in v arious types irradiated while , container of material is generally transported by special ships dedicated tored s ackages p o t xposed e e b ay m assengers p nd a ircrew A umber material ve radioacti containing ackages P purpose. this for n he T ight. fl uring d olds h t n i ransported ackages p f o are carried in containers on board ships or in v ans 25. usually table in shown is 2001 in Kingdom United the in air y b hey t hat t tated s arriers c he t f o umber n A and lorries. The containers are usually loaded with material onsider c ot n id d here- t nd a aterial” m radioactive “ e b o t ackages p excepted” “ for the nuclear fuel c ycle, while the v ehicles usually carry F general industrial assen- p medical for radionuclides of packages fore e xclude t his c ategory f rom p ackage t otals. or or [B11]. use gers, m easured d ose r ates r anged f rom 0 .5 t o 9 μ S v/h i n t he rom m ain c abin a rea, a nd f 4 t o 1 5 μ S v/h i n t he f ront s eats. xposed alf some on carried as w material ve radioacti 1994 211. In H t he p assengers w ere e t han t ess l f o ates r ose d o 3 1 μ S v/h, a nd t he a verage p assenger d ose r ate wa s μ S v/h. 1,100 v oyages to, from or in transit through the United King - a nd r wa egarding nformation i o N rovided p s f requent fl yers dom. Of these v oyages, about 55% were of nuclear fuel c ycle c onsidered t c hat f requent fl yers u sing ouriers, b ut i t wa material (50% non-irradiated and 5% irradiated), and the s h ave a R adioactive T raffic F actor remaining s hort-haul fl ights ( which 45% in for consignments radionuclide volved medical and o general industrial use. The carriage of nuclear f 1 i n 4 75) a re u nlikely t o r eceive a s ignificant d ose o t ue d adioactive c argo [ W3]. ( ships dedicated and essels v freight on material ycle c fuel The R adioactive T raffic F actor r of number small a w, cre the of xposure e possible the to leads o t argo c adioactive r arrying c ights fl f o atio r he t s i RTF) ( and transport of packages con - orkers. dockw passengers t he t otal The n umber o f fl ights.) E stimates o f c ollective d oses K nited U t taining n i ransport t radionuclides in v ehicles on ferries may result in the n i resented p re a ingdom d ue t o a ir he Exposures to passen - 2 able t 6. e xposure of both cre w and passengers. xceed gers are e to ely unlik doses vidual indi annual with w, lo 0.032 mSv [B11]. (d) Summary on the exposure to radioactive material a i n E gypt transport ssessed t he e xposure o f 212. A s tudy p erformed during l iving a longside t he S uez C anal d ue t o p he i nten- t opulations r adioactive m aterial b y s hips p assing t hrough sive t ransport o f 215. In general, doses to members of the public due to the c anal. T he q o f r adioactive m aterial t hat p oten- t he normal transport of radioacti ve material are v erifiably v ery uantities n i resented p re a opulations p c xposed e tially of results Some w. lo oastal - pre are topic this on eys surv initial 4. 2 able t a verage a nnual c ollective d oses t o t he p ublic stimated e he T sented in table 27. More recent surv eys produced similar S f P ort aid, I smailia atively conserv i highest the n t he p eriod 1 986–1992 i n t he t owns o results (table 28). In German y, 8 - 8 - 8 - × re 4 .11 × 1 0 v, a , 3 .01 nd 1 0 S uez and 5 .04 × 1 0 a m an S estimated annual dose to members of the public due to T he t ransport o f l ow- a ctivity m aterial, s uch a s r espectively. nuclear fuel shipments w as typically less than 0.1 mSv . In l argest c ontribution t o t he u ranium ( as U maxi O ), r epresented t he France, these shipments are estimated to gi ve rise to a - 8 3 he t ithin w ublic p he t o t ose d ollective c uez C anal a rea. S mum annual dose of 0.2 mSv , while shipments of w aste at a

268 252 UNSCEAR REPORT: V OLUME I 2008 131 f are estimated to gi ve rise to a maximum 220. With t he g lobal a nnual u sage o f storage I i n t herapeutic acility dose of 0.12 mSv , and shipments by road could lead t reatments annual e stimated a t 6 00 T Bq, a r elease f raction f o - 4 131 an to 0.07 mSv o wing to the v annual I ehicles or f v/TBq S m .03 0 f o oefficient c ose d a nd a dose 0 1 × 5 of to an up “ r i n l iquid e ffluents ( f rom a nnex A , eleased Dose estimated the Netherlands, the In lights. traffic at aiting w taken due to both nuclear and non-nuclear eport R 000 2 NSCEAR U he t f o maximum m ssessment a annual dose ethodologies”, t U3]), [ nly shipments w as 0.02 mSv [I5]. More recent estimates pre - o e b o t stimated e s i ose d ollective c nnual a he annual dicted doses of less than 0.002 mSv for critical groups he t educe r hould s anks 0 .009 m an S v. T he u se o f h old-up t 99m o he t Tc, [E6]. f o elease r In the United Kingdom, 0.02 mSv w as the maximum egligible n o t adionuclide, r ajor m ther estimated passengers, while air and sea for dose annual l evels a s w ell. rail and road to due xposures e annual were less transport than 0.01 mSv [I5]. nclud- i aterial, m adioactive r 221. In t he U nited K ingdom, se ing r adiolabelled m aterials f or u i n m edicine, r esearch nd a i ndustry, i s m anufactured a t t wo s ites: A mersham a nd C than other 3. Applications power nuclear ardiff. A t A mersham, t he t otal a nnual d ose t o c ritical iquid g i n 2 003 d ue t o l roups d ischarges w as a ssessed t o b e radioisotopes umming (a) Production of l ess t han 5 μ S v. S f reshwater fi sh c onsumption a nd ritical e e xposure, d oses t o c xternal g roups w ere e stimated t o edicine he 216. Radioisotopes a re w idely u sed i n i ndustry, m b e o f t he o rder o f 5 μ S v i n 2 003. T he d oses e stimated f or t g v S μ 5 han t ess l lso a ere w ood f errestrial t or f roup ritical c a nd r esearch. R adiation e xposures m ay o ccur o wing t o t race s tages A 003. 2 n i t C ardiff, t he l aboratory p roduces r adiolabelled s ubsequent a mounts b eing r eleased i n p roduction o r a t 14 3 roducts a nd rod- C t o b e u sed i n r esearch a nd p p H c ontaining o f t he u se o r d isposal o f t he r adionuclide-containing 14 o ll a C, s a ost uch s adionuclides, r ery-long-lived v or F e he xposed g roup m edical d iagnostic k its. T he d ose t o m he t f t ucts. F or o f s eafood c onsumers w as 2 4 μ S v i n 2 003, a mount u tilized m ay u ltimately r each t he e nvironment. i ncluding a c on- T e xternal e rom f tribution he hy pothetical c ritical xposure. adiopharmaceuticals, r ost m s a uch s adionuclides, r hort-lived s c omprised nfants n a s i elease r o t rior p ecay d adioactive r e ho ssential c onsidera- g roup f or t errestrial f oodstuffs w i u sotopes i he T tion. o n l and c onditioned b y p elleted edical i ngested f ood p roduced xaminations e m n i idely w ost m sed 131 99m a uclear m edicine p rocedures a re a I a nd n Tc. nd ssessed as w t I orks. w reatment t astewater w he t rom f ludge s n i hat t han t ess l een b ave h ould w ose d ighest h he t 003 2 f oses d ith w v, S μ 6 1 217. Estimates o f d oses r esulting f rom r adioisotope p roduc- ess l eing b athways p on-foodstuff n rom wing a tion t han 1 μ S v [ W6]. nd u se a re u ncertain, o t o t he l imited a vailability o f ata r he t f o roduction p ommercial c he t n o adioisotopes d a nd o t he r elease f ractions d uring p a nd u se. T urvey s 006 2 n a f o esults r he t o t 222. According he m ain c onducted roduction 133 3 14 125 131 H, re a nterest i f o n i perating o yclotrons c 46 2 ere w here t AEA, I he t y b Xe. nd a adionuclides r I I, T C, he adioisotope I hat e stimated a nnual c ollective e ffective d ose d ue t o r t stimated e as 3 9 I AEA M ember S tates. T he AEA h a nd u se i s o f t he o rder o f 1 00 m an S v [ U6]. bout 3 00 c yclotrons c urrently o perat- orldwide w here a re a p roduction t roduc- t hat a re i nvolved i n ing s ome a spect o f r adionuclide p of use important 218. An istribute - diag medical in is radionuclides tion. d hat t nstitutions i yclotron c f o umber n he T 18 e adiopharmaceuticals, a nd i n p articular nostic r xaminations and therapeutic treatments. Medical uoro- F-labelled fl 18 s i DG), F F produced be can radionuclides parent their or radioisotopes ( deoxyglucose I37]. [ rowing g nd a ignificant s 99 131 f (by fission of uranium, e.g. o Mo, reactor I; or by acti - nformation i o N in n p ublic e xposure d ue t o t he a o peration o 59 ound. e.g. reactions, nuclear (by yclotron c a in or vation, f een b as h yclotrons c Fe) e.g. 123 201 Tl). The most important radioisotope, used in I, 80% of 99m 99 man In Mo). (from Tc y is xaminations, e diagnostic all isolation and incorporation of the (b) Research countries the production, reactors - or kits pharmaceu generators, into radioisotopes diagnostic ham - ticals are often carried out in dif ferent f acilities, which 223. Research reactors, gi ven their wide v ariety of designs the range wide their as well as operation, of verall o the from resulting releases modes of quantification pers and uses, of producing Research gy. ener electrical production. reactors from fer dif - nuclear arious v and fuels materi testing for used are reactors 131 Limited als, were cited - bio ysics, ph neutron and nuclear in vestigations in for data on I 219. releases from hospitals [U6]. xcretion e high is There Report 1993 UNSCEAR the in radioisotopes. of production the for and medicine, and logy 131 use of research reactors is globally much more wide of - The I from patients follo wing oral administration, aste w ut b In production. gy ener for reactors of use the than in fective ef are tanks hold-up with systems treatment spread reduc - operated ving ha as listed countries 70 were there 2003 ing the amounts in liquid effluents to a small fraction (e.g. 4 - seems of 10 × 5 the amounts administered to patients. This ) operate research reactors; among the 57 countries that still 131 - - I meas to be confirmed by the v ery lo w concentrations research reactors, there were 274 in operation; and 8 coun of aters w ace veral surf the in ured se of systems wage se and tries had a total of 10 research reactors under construction. not to be countries [U6], although such information seems The number of reactors is presented in figure XXV according collected systematically reported. or to operational status and nominal power [I29].

269 ANNEX EXPOSURES OF THE PUBLIC AND W ORKERS FROM V ARIOUS SOURCES OF RADIATION 253 B: sites 224. Three the United Kingdom—Dounreay , be found on collectors’ mark ets. It w as found that handling in may of vels le w lo ery v to rise ve gi contamination items such ve Harwell and W infrith—house research reactors that ha decommissioned. At the on the skin, and the use of in process are or been this table ware for eating could of being Dounreay , the critical group of [W6]. doses ingestion low very to lead people who consumed food w from the terrestrial vironment as estimated to ha ve en f o embers m 228. Some 2003, in Sv μ 6 ved recei contrib a includes also which ossils, f f o ollections c ave h ublic p ution t he there w as no he from t ingdom K nited U he t f o arts p ome s n I inerals. m r o ocks r weapons test f allout. At Harwell, although n r ocks c ontain s ignificant c oncentrations f u ranium a nd ative assumed an consumed, were ver ri the from fish that vidence e o the dose assess - pecimens s uch s rom f annual d verall o he T roducts. p ecay d ts i consumption rate of 1 kg w as used in ose leading to a dose estimate of 11 μ Sv for 2003. The nder u n ormal c onditions o f h andling a nd d isplay a re o nly a ment, f - to the critical group of local consumers from g aseous dose hoto s mall raction o f t he o verall d ose f rom n atural r adiation. P 232 i hem t o t a Th dischar ges w as estimated to be less than 5 μ Sv. Doses o t dded rder o n g raphic l enses u sed t o h ave t [W6]. magnitude similar of are infrith W for estimated i ncrease he r efractive i ndex. P hotographers c arrying a c amera w ith s uch l enses a round t he n eck f or s everal h ours a d ay o n r m d ays o f t he y ear c ould any eceive a n a nnual e ffective d ose o f products (c) Consumer a f ew h undred m icrosieverts. C urrently t hese l enses a re o ut o f w u se i n U nited K ingdom. A s ummary o f d oses a ssociated ith - con use veryday e for bought products of number 225. A e xposure t o c onsumer p roducts i s p resented i n t able 2 9 [ W6]. these of Some radionuclides. of vels le w lo tain items contain ut b NORM, of vels le w lo majority of the consumer products 229. The United States Nuclear Re gulatory Commission the assessed has ve ve radioacti the had ve ha substances ve radioacti containing (NRC) collecti and vidual indi potential added - chem its of use e mak to - prod selected with associated doses radiation (population) material deliberately order in 2 ical containing “by-product” material [U35]. The dose ucts and radioactive properties. Historically the most signifi- on based general in were assessments assump reasonable - cant radionuclide for use in radioluminous consumer 226 there that noted NRC the cases some in although tions, as products w as w Ra. Ho wever, production of items luminized w the of use actual the on data with decades radium being reliable of absence an ago, products with radium ceased a fe 147 3 viduals where. The esti - or orkplace w are indi radionuclides these because H either in the replaced by else Pm and by mates radiotoxic. F or timepieces containing tritium com - less ver- a the to valent equi dose fective ef for are reported radioacti indi The group. critical the of member age pounds, some leakage of the ve source may occur , and vidual tritium is ritium emits only to restricted are discussed estimates dose ve collecti T v ery mobile. because v ery weak here radiation - prod particular a of ycle c life normal the for estimated doses beta - con it that so skin, the penetrate cannot that to or material, co vering distrib ution and transport, intended tributes the ef fective dose only when the tritium uct has 1 year [W6]. body the entered a o occurring disposal and use, routine xpected e or ver of quantities xpected e or Actual period. time ve radioacti 226. Ionization ve gi to used are detectors e smok chamber used were wn, kno when materials, and products in material arning w equal used as w alue v a otherwise, doses; estimating for early an fire. a contain detectors e smok Modern of to 241 foil the allo wed under the United States le gislation on small maximum of Am with an acti vity of not greater than quantities. detector a from m 2 of distance e xempted 40,000 Bq. The dose rate at a - 5 about 2.4 × 10 is μ Sv/h, assuming that the detector contains estimates 230. The annually incurred doses vidual indi of the maximum amount of acti vity. In the United Kingdom, a of ycle c life normal the during - associ material or product about 80% of homes ha ve a smok e detector fitted. Assuming ated a in material by-product for detector the from m 2 of distance at h/d 8 of xposure e an xemptions e current the with 5 - dose States [W6]. Sv μ 0.07 of annual estimated an in results United the less from than 1 × 10 ranged mSv to summary from fective ef vidual indi of doses A . mSv 0.2 by- products in the United States presented in table 30. The 227. Glass to which uranium is added to produce a yello w is green or called V aseline glass. It w as v ery popular than greater or to equal were doses vidual indi estimated is colour is for used instruments (a) products: o tw for annually mSv 0.1 in the and States United the in produced still the and 1800s Republic. The g amma dose rate close to the Czech surf ace of measuring ionizing radiation that contain by-product mate - as w and w lo ery v is item glass the less as measured rial, with an estimated annual dose of 0.2 mSv recei ved by a than w technician laboratory instrument; bench-top a radiation beta to due rate dose ace surf typical A Sv/h. μ 0.1 with orking 60 as while the beta doses measured a fe w centime - μ Sv/h, 15 w and (b) spark g ap irradiators containing - Co, with an esti maintenance by ved recei mSv from 0.1 the surf ace were ne gligible. Indi vidual doses for of tres a mated annual dose to irradiators. gap 0.5 spark some maintaining and installing orker w collections of uranium glass could be up mSv with a range of annually . Ho wever, for a lar ge collection w magni of order an be ould - dose maximum typical a items, 2 By-product with associated material ve radioacti y an includes here material glaze in used been also on ve ha salts Uranium wer. lo tude the e reactors, nuclear of nuclear for material source the for xcept the operation were y The tiles. and also ware table as such products ceramic fuel and the special nuclear material which constitutes the fuel in a reactor . table ware produced in the used as a colourant in ceramic from Source material is the ra w material which nuclear fuel is made; it no may items These States. United the w in 1940s and 1930s in abundances. uranium or thorium their natural isotopic includes

270 254 UNSCEAR REPORT: V OLUME I 2008 estimates collecti ve dose incurred during the 231. The of treatment (b) for incandescent g as mantles, the users sludge; to 0.1 from ranged products these of ycle c life normal ute of collec the to most - contrib lanterns camping portable s cate - man 40 or tw o Sv for 1 year’ distrib ution of products. F use dose. The mantles as g tive of the wards to trend current doses ve collecti estimated gories products, of the equal were not containing thorium and the use of other lighting de vices dose arising to or greater than 10 man Sv: (a) the collecti ve should significantly reduce this estimate; collecti ve dose 3 timepieces use the H from of containing dials or hands with dose containing ve collecti the thorium, rods welding for (c) 147 man Sv , which w as incurred be to estimated as or 40 Pm w although this is predominantly 300 estimate is man Sv , number the wear who viduals indi of ge lar of because mainly period, year 1 time a ver o welders professional by ved recei dose aris - collecti ve the (b) atches); (wristw timepieces such can xposure; e public to related be it of fraction a only and ing from the use of electron tubes containing by-product dose the are, glassw for (d) - num ge lar of display the to due Sv material estimated to be 10 man o ver the w tubes’ use - as utes contrib museums) and homes (in items of - col the to bers collecti ful lifetime of 10 years. In this case, ve of the most the lenses, optical finished in thorium for (e) dose; lective people ould result because of the lar ge number of w dose doses to users of 35 mm photographic cameras estimated tubes electron from radiation to xposed e home the in and most of the collective dose. contrib ute w Ho wever, indi vidual doses are normally v ery orkplace. lo w, usually less than 0.1 mSv/a. situations 235. There are also tw o where the collecti ve than doses were equal to or greater 10 man Sv b ut less than 232. The of indi vidual estimates doses incurred annually - mix compounds, and metals earth rare for (a) Sv: man 100 - material or product a of ycle c life normal the associ during tures and products, are dose ve collecti to utors contrib the ranged material source for use current the with ated from (industrial bastnaesite cerium concentrates and w orkers), - 5 mSv to 40 mSv . The estimated annual indi - 10 × 1 than less aste on-site resi (future disposal - w and aceplates f vision tele e doses vidual cases o tw wing follo the for mSv 10 xceed esti (b) landfills); at table ware, the for - dents ceramic glazed 30): (a) chemical (table mixtures, compounds, solutions or are doses mated items lar numbers of display ge the of to due weight less containing ys allo 0.05% by than source material; and homes (in museums). (b) and - prod and mixtures compounds, and metals earth rare ucts mate containing not more than 0.25% by weight source - cases high estimates in these rial. result from the lar ge The sources exposure (d) Other of public present v of e xempted material olumes in w orkplaces and the in thorium and uranium of concentrations high material. this oses p otential a nnual d 236. Estimated f rom e xposures a t ould w estimated doses be reduced substantially for These e ducation a nd o ther r esearch h h ospitals, i nstitutions igher o f of case the the workers using respiratory protection. here w aboratories l nited U he t n i sed u s i aterial m adioactive r rom anged ingdom K nnual a ighest h he T v. S μ 3 1 o f r 0 .02 t equal were doses to indi annual estimated 233. The vidual d ose e stimated f or a n i ndustrial s ite w as 1 70 μ S v, b ut t he less or materi three for mSv 10 than - ut b mSv 1 than greater c alculation a ssumed a uthorized d ischarge l evels a s o pposed als: source containing ore unprocessed and unrefined for (a) a o t l ower. uch enerally g re a hich w m evels, l ischarge d ctual dose estimated the material, mSv/a 3 of ver dri to a truck r o embers m f o xposure o t ise f ive g lso a ay m ites s andfill L e of v ge lar the from results olume is that material xempted e roup he p ublic. D oses i n 2 003 t o t he c ritical g t o f p eople high handled and the relati vely in uranium of concentration t he D rigg d isposal f acility i n t he U nited c ive l ho w lose t o as the (b) for incandescent g mantles, the estimated material; ingdom w ere 4 6 μ S v ( including c omponents d ue t o epos- d K annual light for lanterns as g only using person a to dose t its all- f rom he C hernobyl a ccident a nd t o w eapons t ests f 2 mSv and that to indi vidual an who uses portable w ould be m aterial m adioactive r f o evels l f ow L out). o isposed d e b ay ould be 0.1 mSv; (c) w for welding rods lanterns camping a ose d nnual he t hat t stimated e s i t I a t s ome l andfill s ites. of 8 mSv to a containing thorium, the estimated annual dose ater w i y b ncurred i rising a eachate l a ontaining c ngesting 125 represents dedicated grinder an of probably rods welding f hat t andfill l a rom ccepts a I v. S μ 5 e b ould w aste w n i occur construction at only ould w that sites situation unusual h T ritium as a lso b een d etected n ear s ome l andfill s ites. A employed. are welders many where n p d rinking w ater f rom a earby b orehole w ith a bout erson 1 ,000 B q/L w ould r eceive a n a nnual d ose o f l ess t han collecti ve dose incurred during the 234. The estimates of 1 2 μ S v [ W6]. c life normal the with associated material or product a of ycle xemptions source material current e in the States United for use 237. The unsealed an in substances ve radioacti of form 700 - s year’ 1 for Sv man to Sv man 0.001 from ranged distri widespread is yed emplo are substances These medicine. in collecti which for situations dose e fiv are There bution. ve medi- in nuclear medicine and radiotherapy departments for 100 man Sv: (a) estimates are equal to or greater than for cal diagnosis and for treating cancers and other diseases with or allo ys chemical - mixtures, compounds, contain solutions internal irradiation, and also in clinical biology and medical ing the collecti ve less than 0.05% material, by weight source ol- research laboratories. These uses result in significant v to the use of is combination of estimated doses due dose a umes of radioacti ve w aste, only a small part of which is slag for glass, doses due the use of phosphate ophthalmic - transferred to specialist radioacti ve w aste processing cen uilding construction, and doses to future on-site residents b tres, while the major part is stored on the site until the acti v- disposal the from w and slag phosphate ater ash, coal of ity aste vel wing to the w a to le decreased be has treated allo

271 EXPOSURES OF THE PUBLIC AND W ORKERS B: FROM V ARIOUS SOURCES OF RADIATION 255 ANNEX 4. peaceful due exposures to on Summary the lar ge number of normal as w aste. In vie w of hospital radiation of sources man-made of uses in and departments establishments volved and the multiple of managing the w aste, gulatory systems ha ve been re ays w 240. A of xpo- e public to related estimates dose summary in place. Ho wever, chance put incidents, such as the disco v- due sures ionizing of sources man-made of uses peaceful to or radioacti ve w aste in areas normally needles ery of radium vailable Currently 31. table in presented is radiation a infor- of to the public, or accessible quantities of radioacti ve iodine made, be not allo w estimates of global doses to mation does in ver ri w aters, although without consequences for public ery although indi vidual doses are v lo w for sources unrelated have health, alarmed the nevertheless general [E12]. public Although may doses vidual indi to nuclear po wer production. a to be population specific for year per verts millisie w fe up a term utilized by 238. “Orphan radioacti ve source” is some e and practices specific xpo- with connection groups, in are out ve radioacti denote to sources gulators re nuclear - that dose caput per annual verage a orldwide w sure scenarios, the side include: official re gulatory control. Orphan sources is of the of microsieverts. order control; sources sources that were ne ver subject to re gulatory b that subject to re gulatory control ut ha ve since been were lost or misplaced; and sources that were stolen abandoned, D. Use of man-made sources for military purposes without proper authorization. Exactly remo ho w man y or ved there are in the w orld is not kno wn, b ut the orphan sources 1. Nuclear tests in the thousands. The NRC reports thought numbers to be are ha ve lost track of nearly that United States companies (a) Global fallout country since 1996, and within the sources ve radioacti 1,500 ne ver been vered. A European reco more than half ha ve in were atmosphere the car- e test xplosions 241. Nuclear to about year 70 sources up Union study very e that estimated sites, out at a number of ried mostly located in the northern within control gulatory Although re from lost are Union. the hemisphere, between 1945 and 1980. The periods of most w ould not pose the majority of a significant these sources 1952–1958 In 1961–1962. and all, were testing acti ve radiological risk, the risk of accidents is the major concern with 502 atmospheric tests, a total fission and fusion yield of from arising orphan sources. Sealed sources or their contain - 440 of yields and w The conducted. were Mt, number orld- to scrap the for vengers sca attracti ers can be metal trade ve estimated by atmospheric nuclear e xplosions as wide the appear to be made of v aluable metals and may y because are and table in summarized 32 [U3] fig - UNSCEAR not - unsus where Cases label. arning w radiation a display XXVI. After the T ure Banning Nuclear W T reaty ests eapon or people pecting tampered ve ha public the of members ven e in and Under W ater w as Space Outer in Atmosphere, the injury sources cases some in and serious to led ve ha with test on 1963, e Mosco August in nuclear signed 5 w xplosions death. Some of the more notable such accidents are described all of summary A [I9]. were mostly conducted under ground annex C in of the present report. atmospheric and under ground nuclear weapons tests by 33. country is presented in table were there these, Besides 239. Orphan the in phenomenon widespread a are sources abo 39 tests that took place safety ve ground, in which more Union. viet So former the of (NIS) States Independent wly Ne nuclear subjected were de to de fully less or veloped vices gacy le a xample, e or F decline economic sharp gia’s Geor of conditions (i.e. the accident nuclear weapon cores simulated of control of loss a as w Union viet So the after the break-up xplosives, e ventional con of means by yed destro were with o radioacti ve sources used in industry . The collection and ver fission energy) [I12]. no or very small releases of sale of scrap metal from abandoned f actories has pro vided a means of li velihood for some persons, and some orphan 242. The p e t r a t ests tmospheric emain arlier he rincipal the in found been ve ha sources of scrap. shipments Not all s o t ue d rldwide wo xposure e adiation r urrent c f o ource to incidents reflect deliberate attempts steal radioacti ve n uclear w he t f o stimates e rovides p 4 3 able T eapons esting. t of great The sources. majority the trafficking incidents r adionuclides r f o ctivity a g n i ispersed d lobally nd a eleased appear to in volve opportunists detected unsophisticated or a rom f ebris d adioactive R U3]. [ ests t uclear n tmospheric a ll of criminals cases, the some In profit. hope the by vated moti p he t etween b artitioned s i est t uclear n tmospheric a n ocal l a theft sources w as incidental to of the theft of v ehicles. As trato - g round o r wa ter s urface a nd t he t ropospheric a nd s reco been ve ha sources ve radioacti 300 vered as y man in t est, f he l ocation o ype t he t n o epending d egions, r pheric s t these and mid-1990s, the since gia Geor caused ve ha sources ubsequent ebris d he t f o recipitation p s he T ield. y he t nd a least one death and man y injuries to the public. In 2006, at “ o t n o eposit d ts i nd a arth e he t llout” fa local ermed t s i potentially o abandoned and tw dangerous radioacti ve de vices llout” a w hen d eposited l ocally, a nd “ tropospheric fa nd the village of Iri, one in were successfully secured, where w hen d eposited g [ I9]. “ stratospheric fa llout” lobally were vels le radiation background ele vated to 12 times abo ve the village centre, and the other in the village of normal in 137 as the of 50% as much contain can allout f 243. Local total radioisotope The Likhaura. Cs. In as w sources both in produced and tests, ve-ground abo of case the in allout f Moldo va, se veral lar ge de vices containing about 130 TBq 137 particles deposited are that includes aerosol ve radioacti ge lar Ci) of po wdered (3,500 Cs chloride used for agricultural allout f ropospheric T site. test the of km 100 within about purposes in the former So viet Union were found abandoned across carried not are that aerosols the consists of smaller precarious stored in or conditions [G13, I36, W8].

272 256 UNSCEAR REPORT: V OLUME I 2008 95 d the e xplosion and that deposit with mean ecay ts i with ( Zr after adionuclide r hort-lived s 248. The tropopause a 95 roduct p residence time in the atmosphere of up to 30 days. Nb) w as t he m ain c ontributor t o e xternal e xposure During esting. this period the debris becomes dispersed, although not well d uring a ctive t O f t he o t ontributing c adionuclides r 137 band e xposure, o nly e Cs h w- follo and injection initial the of xternal latitude the in ed, mix as a h alf-life o f g reater t han a trajectories go wind ing o t ontributor c mportant i ost m he t ecame b t i hus t ears, y ew f by patterns. From the vie w- verned point he t s i t i resent p At 966. 1 pproximately a fter a oses d nnual a of human e xposure, tropospheric f allout is important fe xternal e ontinuing c o t ontributing c adionuclide r nly o for nuclides with half-li ves of a w days to tw o months, 131 140 89 I, Ba and such Sr. as e xposure f rom d eposited r adionuclides. u p a l arge p art o f 244. Stratospheric f allout, w the hich m akes 249. Several radionuclides contrib ute to e xposure via 131 t f o onsists c allout, f otal t he t arried c radionuclides I, ( re a hat t articles p hose ingestion pathw ay. F or the short-li ved 140 89 l ater r - fol months or weeks within occur tratosphere, xposures e the Sr), nto Ba, i p u g o t ise s he t ive d isperse a nd n w f allout, t he m ajor p art f w hich o ccurs i orldwide t lowing deposition. Further e xposure via ingestion of longer - he o 55 f t he i nitial i njection. S tratospheric f allout comes lived radionuclides h from emisphere Fe and the transuranic o f to f or m ost o f t he w orldwide r esidues o l ong-lived ccounts a elements. Committed doses due the transuranic radionu - umans t o f allout c om- fi ssion p roducts. T he e xposure o f h clides are v ery lo w and the contrib utions to annual doses 137 prises i nternal i rradiation ( inhalation o f - r adioactive m ne gligible. During acti ve testing, aterial Cs w as the most signifi s urface a ir a nd i ngestion o f c ontaminated f oodstuffs) a nd o i n cant component, wing to its more immediate transfer to diet e rom continuing the of Because dose. of very deli subsequent and s xternal i rradiation f r adioactive m aterial p resent i n ur- 90 - ro p tmospheric A I9]. [ round g he t n o eposited d ved long-li the of diet, transfer to Sr as well as the longer face a ir o r 90 became radionuclide this , body the in Sr of retention c esses the elated t o d ispersion a nd d eposition o f n uclear t est r about 1967. most important contrib utor to dose be ginning f allout w ere c omprehensively r eviewed i n t he U NSCEAR in ved [ eport R 000 2 The short-li U3]. radionuclides ha ve been relati vely insignifi - contrib u- Important contrib cant utors to ingestion e xposure. 144 tors transuranic the Ce, were to inhalation e xposure 95 89 91 106 Deposition om global fallout Zr Doses fr (and and thus (i) Y, Ru, radionuclides, Sr. radionuclides - decreased air) in these of concentrations rap for calculations of doses due to f allout the for en Ev 1980. in ceased testing atmospheric after idly 245. The basic input the xposure e inhalation radionuclides, transuranic ved long-li radionuclides has of density deposition measured been 90 deposition Sr. The measured annual hemispheric - for repre became insignificant after 1985. sentative General 35. table in ven gi is sites middle-latitude the to ution contrib further 250. One procedures for deri ving dose estimates from the measured or comes xposure e annual 3 14 globally radionuclides of densities deposition calculated from the dispersed radionuclides H and were C. F or and [U3], reference in detail in described of summary a only both radionuclides, there is no e xternal e xposure component be xposure e inhalation; from xposure e gligible ne only and will reports vious pre from conclusions main the presented almost arises The long-li ved radio - from entirely here ingestion. completeness. for 14 dominant for accounting utor, contrib 70% the is C isotope to the w orld t popula - nnual a otal t he t f o 246. Estimates ue d oses d ffective o of the total ef e fective dose commitment 14 dose C the of 10% only if wever, Ho tion. commitment is n uclear t esting a re r adionuclides p roduced i n a tmospheric s included 3 6, a nd t he are commitments dose if i.e. comparison, the in v ariation w ith t ime o f t he t n i ummarized able truncated approximately to the year 2200 (by which time all a verage p er c aput e ffective d oses f rom n uclear w eapons f i s p resented i n fi gure X XVII. T hese r esults a re allout f or other radionuclides will ha ve deli vered ef fectively all of their 14 he t to 19% only utes contrib C o doses), fective ef truncated the eighted w adionuclides r allout f f eposition d verage a t quar- h emisphere a nd t he w orld p opulation. D oses o a ccording dose commitment to the w orld population. About one a e o btained b y djust- f or s pecific r egions o f t he w orld c an b ter of the collecti ve dose will ha ve been deli vered by the year o f d eposition the ing t hese r esults f or t he l atitudinal d istribution 2200. The global estimates include a contrib ution from 90 d etermined f rom Sr m easurements. doses to people close to the sites used for atmospheric tests. is ution contrib some terms, global in small Although this c aput substantial were doses local [I9]. 247. The e stimated g lobal av erage a nnual p er o t eapons w uclear n tmospheric a esting t ue d ose d ffective e ubsequently s nd a Sv) 0.11 ( 963 1 n i ighest h as w m eclined d t egional exposures han 0 .005 m Sv i n t he 2 000s. E xternal e xposure Local and r (ii) o t l ess d l c ontribution t o a nnual argest oses; he t m enerally g ade d ue t o s hort-lived r adionuclides a nd s ubse- he i nitially i t w 251. Local f allout c an c onstitute a s m uch a s 5 0% o f t as 137 he a nnual d oses a t p resent a re d ue t o Cs. quently T t otal p roduced b y s urface t ests a nd i ncludes l arge r adioactive e xposure ( 53%) a nd i nternal a f lmost e qually t o e xternal a erosol p articles t hat a re d eposited w ithin a bout 1 00 k m o 14 t o i ngestion iffer- ( 47%). T he d ose f rom e C ( 30% xposure d ue t he t est s ite [ I9]. A s ummary o f t he e stimated y ields i n d t he t n ow e xceeds t hat f rom i ngestion o f o ther o f ent a tmospheric l ayers w as s hown i n fi gure X XVI. S ince otal) [ U3]. adionuclides r a tmospheric n uclear w eapons t ests w ere c onducted i n

273 ANNEX EXPOSURES OF THE PUBLIC AND W ORKERS FROM V ARIOUS SOURCES OF RADIATION 257 B: r a reas, t he e xposures o f l ocal p opulations 72% of the total about to amounted Atoll Bikini at tests the relatively emote the o ose d ollective c lobal g he t t ignificantly s Islands. Marshall in sites test two the for yield ontribute c ot n id d ractice. N f i ndividuals rom l iving d ownwind t his p evertheless, the of north-west km 850 located Atoll, 257. Bikini o oses t han a verage. f t he t est s ites r eceived h igher capital d of the Marshall Islands, comprises more than Majuro, site islets. and islands 23 Bikini, 252. Areas within a fe w hundred kilometres of the Eneu, Nam and Enidrik Islands test are the generally designated as “local” and those within a fe w are Eneu and Bikini area. land of 70% account for o ver of atoll the of islands only the ve ha that a had thousand kilometres as “re gional”. - popu permanent A detailed description lation. Before nuclear weapons reference in found - be can tests all of characteristics main the testing started, the popula time of tion that (at Atoll Bikini [U3]. The locations of main test sites are sho wn in vacuated e as w people) 167 the XXVIII. figure and resettled. 253. Ne xpo- The Nevada test site (United States test site). 258. The vada test resulting in the most significant local e thermonuclear the as w sures T est in the United States w as the location for March 1 on vo Site Bra Castle test (NTS) at 86 allout f local vy hea xpectedly Une Atoll. Bikini 1954 atmospheric nuclear tests, carried out from 1951 to 1962. In addition, 38 of the approximately 800 under ground tests unusual and sudden a to wing o atoll occurred east of the small Although material. ve radioacti of releases volved in in change in wind direction, predominantly from the west with releases from the atmospheric tests, the y rather than the east, on the day of the test, and an une xpected comparison increase were Additional [S22]. f-site of detected be to sufficient were in fission yield. High radiation doses recei ved tests cratering by - Rela atmosphere. the into debris injected also the inhabitants of Rongelap Island (67 persons, including three about 210 km from Bikini Atoll, and by some in fected af that releases to led tests ground under utero), tively fe w temporarily residing on Ailinginae Atoll, areas local [U3]. Rongelap islanders in one including persons, utero). (19 way a km 150 about occurred at Rongerik Atoll (28 United east, e xposures 254. Estimates of e xternal e xposures due to atmospheric Further including persons, (167 Utirik and servicemen) States Atoll film and meter ey the surv from ved deri were NTS tests at eight in utero). These indi viduals were e vacuated within a badge measurements for 300 communities in the local areas initial exposures [I9, U3]. w fe days of the (at distances of less than 300 km) around the test site in The in and vada Ne south-western ef fective dose Utah. xceeded 3 mSv in 20% of the population of 180,000. The d oses a s a r esult o f 259. Effective e xternal e xposures, e m v .9 1 rom f anged r adionuclides, r hort-lived s rom f ainly S the mSv; 60–90 range the in were doses fective ef highest o population-weighted a verage w as 2.8 mSv . Exposures n t toll A ilinginae A earby n o v S .1 1 nd a sland I ongelap R n o g amma emitters (with as w ose d ffective e ollective c he T toll. A tirik U n o v S .1 0 resulted primarily from short-li ved e ve collecti The days). 100 than less of ves half-li a bout 1 60 m an S v [ I9]. E quivalent d oses t o t he t hyroid, xternal as w NTS the to closest km 300 the within dose whole-body sotopes c aused b y y b nd a ellurium t nd a odine i f o i everal s a ga mma r adiation, w ere e stimated t o b e 1 2, 2 2 xternal nd about 500 man Gy , and 12,000 man Gy for the area within e o v S 2 5 test area [S22], arising primarily from km 800 about of the o t aximum, m v S 00 2 nd a 2 8 2, 4 nd a verage, a n espec- the n ine-year-old a nd o ne-year-old c hildren, r dults, a populations. large with areas of exposure d ue t o r esidual r adia- tively, o n R ongelap I sland. E xposures tirik testing atmospheric from resulting xposures e 255. Internal tion o n U a nd R ongelap A tolls o f r esidents w ho r eturned NTS the a at 954 1 n i slands i hese t o t he t f o ere w espectively, r 957, 1 nd measurements deposition from estimated were 2 transfer model. Absorbed doses to nd a rradiation i xternal e rom f Sv m 0–30 vironmental en an using o rder o f m were xposure e internal from tissues and gans or 2 0–140 substantially Sv f rom i nternal e xposure o ver t he s ubsequent than those from e xternal e xposure, with the e xception of eriod. less 2 0-year p 131 I the the ingestion of milk contrib - th yroid, to which from to uted relati vely higher doses. Estimates of absorbed doses 260. External e xposure of the servicemen on Rongerik 3,545 locally e xposed indi viduals ranged from the th yroid in Atoll due to the Castle Bra vo test w as 0.8 Sv . The Japanese verage Gy , with an a of 0.098 Gy . Mean th yroid doses 0 to 4.6 fishing v essel Luck y Dragon w as also in this area at the time xternal e Their xposed. e were fishermen to estimated were Arizona and vada Ne Utah, of residents for 23 and test, the of from be 0.17, 0.05 and 0.012 Gy, respectively [U3]. 1.7 ranged deck on deposition allout f from xposures e allout to 6 Sv , mostly recei ved on the first day of ut b the f for 14 days until the continuing ship returned to its port. 256. Bikini and Enewetak Atolls, Marshall Islands (United were fishermen these in to doses yroid Th the 0.2– at estimated States test sites). In 1946, Bikini Atoll w as the first site 131 due wever, ho counting; xternal e of basis the on I used to Gy 1.2 Marshall Islands to be for nuclear weapons testing by iodine ved short-li other since present, also were isotopes the United States. In 1948, atoll, neighbouring a Eniwetok, replaced a Bikini as the test site. In 1954, Bikini w as reacti - ver o inhalation to due yroid th the to doses total of period Gy - weapons nuclear fiv e hours were estimated to have been 0.8–4.5 until used as w and site test a as vated [U3]. test w the in ing as ended in 1958. Bikini Atoll Marshall Islands 261. No conducted were which tests, 66 the of 23 of site the as w o ther t ests s eem t o h ave r esulted i n s ignificant ground at ater, w under yields The ground. ve abo and vel le of e xposures t o t he p opulation i n t he P acific r egion, e ven

274 258 UNSCEAR REPORT: V OLUME I 2008 p though a nd o ther o fficial s pectators d id o bserve t he a nd i ts 1 990 p opulation w as a bout 2 ,500. T here w ere s ix ress ritish o wo C rossroads e xplosions, i n 1 946, f rom r elatively s hort B t n uclear t ests eriod p he t n i sland I hristmas C n eceived icinity v he t n i 962 1 n i ests t est tates S nited U 4 2 nd a 957–1958 1 t d istances. M ilitary nd a p ersonnel p robably r d o t he i sland H7]. s ome e xposure f rom uring f ebris d adioactive r andling h [ c lean-up o perations [ S22]. sland I alden M 267. Nearby oday, t toll a ninhabited u n a s i een b as h nd a 262. In 1968, follo wing radiological surv eys that had been n i ccupation o ritish B he t ince s 1 956. T here o s hree since 1958, resettlement of the Bikinian people out carried w ere t B ritish n uclear t ests n ear M alden I sland. T he nd C he t a sland I alden M t a on acific P he t n the atoll w as appro ved, and in 1969 the atoll w as cleared hristmas t ests i f o xplosions e r o cean o w slands I of debris. Fruit trees, including coconut, breadfruit, panda - he t ver o irbursts a ere ver d s uspended f rom b alloons a t 3 00–450 m o evices l and entually, Ev replanted. were banana, and papaya nus, h ould w allout f ocal L U3]. [ b 139 Bikinians resettled there. Further radiation surv ey and ollowing f inimal m een ave o i xposure e n o vailable a s i nformation o n r ittle L in increase tenfold a 1978, in wed, sho programmes sampling t hese t ests. 137 body content of the Cs for the inhabitants of Bikini Atoll; o f t he p ublic o r o f c ivilian t est p ersonnel a t e ither s ite, mainly as w this of coconut consumption increased to due a lthough F ijian t roops t hat p articipated i n t he t ests a nd a fter- ater. In response lack of adequate supplies of freshw fluid for wards w ere i nvolved i n c lean-up o m ade c laims perations r residents the population, the in caesium of e uptak high the to elated t o t hese e vents [ S22]. were resettlement temporary the During [I9]. relocated ain ag of 268. Monte Bello, Emu and Maralinga, Australia (United whole-body total 1978, to 1971 from Atoll Bikini he estimated were xposures e [U3]. mSv/a 2–3 eapons w uclear n ingdom K nited U T Kingdom test sites). at t p rogramme i ncluded 2 1 a tmospheric esting t ests a t s ites i n A ustralia a nd t he P acific. T welve t ests w ere c onducted 263. Johnston Island (United States test site). T he U nited 952 1 etween b outh- onte M he t ustralia: A n i ites s hree t t a 957 1 nd a S tates u sed J ohnston A toll, l ocated a bout 1 ,330 k m s aralinga M nd t ests E slands, I ello B M a mu aralinga. T he west o f H onolulu, H awaii, a s a l aunch s ite f or 1 2 h igh- a nd h undreds o f m inor t i ncluded ri- s even n uclear e xplosions a ltitude n uclear t ests b eginning i n 1 958. A ll t ests w ere i als f o r adio a ctive xplosions e enerated g hemically c nvolving i ntended a s a irbursts, b ut t hree r esulted i n u nintended n on- o m ed l hat t estruction d nuclear c ontamination o f t he a toll aterial. T ests c onducted a t t he E mu s ite, a bout 2 00 k m n orth t f ve fi nd a xplosions e uclear n wo t ncluded i aralinga M o rimarily p s wa ontamination c he T ebris. d adioactive r ith w o f i t b eing m p continental f o orm f he t n i in tests hese T 1953. in experiments maller-scale s articulate d ebris, m uch etal t he t f o ontamination c adioactive r esidual r o t ed l ustralia A f rom t he r ockets a ccompanied b y c onsiderable a mounts f o wo i ilometres k quare s f o undreds h ome s overing c reas, a fi ssionable p lutonium a nd/or u ranium. otal t n w [ r o t k 0 6 f o ields y ith ests, t urface s ainly m ere w hese T H7]. t he f o rajectories T ess. l 264. The a toll h ad b een a U nited S tates m ilitary i nstalla- r adioactive c loud w ere d etermined c i s a w ildlife s anctu- tion f or s everal d ecades a nd f or e ach o f t hese t ests, urrently a nd l ocal a nd onitoring m ountrywide c o a ir a nd d eposition w ere p erformed. p ative n f o e o n s i here T ary. opulations f e ver h aving vidence l o n t he a toll, a nd ived ertainly n one w ere p resent d uring c ot n ere w xposures e xternal e ocal l f o 269. Estimates t ade t he y ears o f n uclear m esting. H ence t here i s n o e vidence t hat t ere w egion r mmediate i he t ithin w ublic p he t f o embers m he t 957, 1 nd a 956 1 n i ests t he t or f f or he e arlier t ests; Sv. m 1 han t ess l ere w oses d ffective e xternal e he t o t xposed e d adioactive r ebris f rom t he a borted t ests. T he umbers n he T n f o stimates E U3]. [ ndicated i ot n ere w opulations p igh h nd a ields y arge l heir t f o ecause b ests, t ocal uccessful s ine l f or nternal allout, a ltitude o f d etonation, c ontributed m ostly t o g lobal f i ustral- e xposures w ere a lso m ade f or t he o verall A ose d ffective e f o hose t een b ave h ould w slands i opulated p losest c he t s a verage a he Sv, s μ 0 7 T opulation. p ian wa ue ol- [ S22]. awaii H 8 3% o f w hich wa s d t o i nternal e xposures, a nd t he c m or f v S an opu- 00 7 s wa ose p verall o he t lective e ffective d S22]. f three The Amchitka Island (United States test site). 265. lation o f A ustralia [ A n umber o s afety t ests c onducted of 15–16% represent the Alaska, Island, Amchitka on tests a t t he M aralinga a nd E mu s ites i n S outh A ustralia r esulted 239 quare s f o undreds h ome s ver o Pu United total ef fective ener gy released during the i n t he d ispersion o f States testing to 1951 from programme 1992. nuclear ground under k ilometres [ U3]. w Shot Long - Mil 1965, in m 716 of depth a at detonated as 270. as detonated at a depth of 1,220 w m in 1969, and row he T Semipalatinsk, Kazakhstan (Soviet test site). gest United States under ground nuclear test, f o orner c orth-east n he t n i ocated l s i ite s est t emipalatinsk S Cannikin, the lar o orth n m k azakhstan, 00 8 K w as detonated at a depth of 1,790 m in 1971 [D2]. lmaty, A apital c ormer f he t f m k 00 2 bout a 4 00 k m e ast o f t he p resent c apital A stana a nd f egion Christmas Island and Malden Islands, Kiribati 266. r ussian R he t ith w order b he o outh-west s t ltai. A f o 4 (United States and United Kingdom test sites). C hristmas ncluding i onducted, c ere w ests t uclear n 56 ite, s his t t A sland y t he sed u ere w ceania O n i slands I alden M he t nd a b I 8 6 a tmospheric a nd 3 0 s urface t ests. F ive o f t he s urface t or f ingdom K nited U he t nd a tates S nited U esting n uclear t ests w ere n ot s uccessful a nd r esulted i n d ispersion o f p lu- f d evices. B oth i slands a re n ow p art o f t he R epublic o tonium i n t he e nvironment. T he s ite c overs a bout 2 2 f o rea a and l he T iribati. K m k 90 3 bout a s i sland I hristmas C 1 9,000 k m . T he l ocal p opulations m ost a ffected l ived

275 EXPOSURES OF THE PUBLIC AND W ORKERS B: FROM V ARIOUS SOURCES OF RADIATION 259 ANNEX i n t he S emipala t insk r egion o f K azakhstan ( now [S22]. V ery little information is publicly a vailable distances mainly f azakhstan) a nd is It tests. those from resulting doses local the concerning egion r amenogorsk K st- U K he t f o art p o r t vely relati were residents local to doses that wever, ho ely, lik he A ltai egion o f t he R ussian F ederation, e ast a nd n orth- T ite. at xploded e were vices de atmospheric the of most as w, lo races o f r adioactive c ontamination s east o f t he t est w high the touch not did fireballs xpanding e the that so altitude ere a lso f ound i n s outherly a nd s outh-easterly d irections Preliminary ace. surf ground 3]. presented U been has information a fter s ome t ests [ S22, in literature open the concerning e xternal radiation doses at w ests t arliest e 271. The for dose - xternal e verage a The scale. gional re the ere a bove g round ( atmospheric a nd the popula the of o part eastern t the of tion ut i n arried c ere w nd a urface) s t he n orthern echnical - mil . Š rea a (35 Federation Russian T c entre o f t he fi rst ( surface) e xplosion h istorically i s about is 1955–2000 years the in allout f gional re to due lion) he ests w ere nderground u 40 3 he T ero”. Z Ground “ s a o t eferred r 1 mSv [L24]. Concerning ingestion e xposure, it is kno wn t 137 a reas i n t he s outh c onducted i n w idely s eparated that Cs is ab undant in lichen, reindeer and other en viron- t echnical 137 meat ( between 1 961 a nd 1 989) a nd e ast ( from 1 968 t o 1 989). T his mental media. The Cs concentrations in reindeer are otal or i ncludes f our c ratering n uclear e xplosions w here t he much greater than those in milk, fish, geese t ducks, and lik elow round. g e xplosive c harge w as p laced a t a s hallow d epth reindeer herders are internal higher much ve recei to ely b hese t ests. I t r esulted i n a nd a rst fi he t consume who area, the in residents urban the than doses as w hagan C l argest o f t m reindeer only occasionally . The estimated internal dose u l ake a bout 0 .5 k meat i n d iameter a nd 1 00 m d eep, w ith c p liffs 90 137 lesser e xtent to due Sr) for reindeer herd - to Cs A ake”. L Atomic “ he t r o alapan, B ake L alled c igh, h m 00 1 o t (and to a f m s maller l ake w as f ormed b y t he T el’kem-2 t est. O uch t he ers has a veraged about 1 mSv annually since the early 1960s; d r esulted r 3 1 nderground, u eep elease ut o arried c ests t i n t be to estimated are residents urban to doses annual verage a he a o wer by a factor of 100. tmosphere. lo he t o t ases g adioactive r f only 272. The test site dur- 275. Kapustin Yar, Russian Federation–Kazakhstan (Soviet nuclear the within settlements m k the n orth-west o f t he north urchatov, K 40-year test period ing test site). K apustin Y ar i s l ocated 2 50 of wn to the were 957. 1 n i egan b ar Y apustin K t a esting t oviet S ea. S aspian C of technical area Š (b uilt for servicing the test site), and the 0 n apustin K t a lace p ook t ests t uclear tmospheric a 1 northern its along Moldari and Akzhar of settlements small I n a ll, edge. T wo tests led to the most significant e xposures of the Y ar o ver s ix y ears. V ery l ittle i nformation i s p ublicly a vail- of Kazakhstan: the first test, on 29 August 1949, population able a bout e xposures r esulting f rom t he n uclear t ests apustin and These 1953. August 12 on test, thermonuclear ere w ests t ar Y K he t ll A ar. Y apustin K rom f aunched l the first ( xplosions e ltitude a igh- h tests additional o tw and August 24 and 1951 September (24 eneral g n i hich w m), k 10.4–300 [ m ore t o g lobal f allout t han t o l ocal f allout ontribute L25, 1956) are stated to ha ve contrib uted 85% of the total collec - c S 22]. tive ef fective accumulated dose from all tests combined. The districts 0.04– fective doses for se veral ef were in the range 276. 2.4 Reganne and In Ecker, Algeria (French test sites). Sv . The collecti ve ef fective dose for ten districts w as esti - f f our Between 1 960 a nd 1 966, F rance c onducted a s eries o mated to be 3,000–4,000 man Sv verage a ve Representati . doses a se ven villages close to the site (in Kazakhstan) tmospheric a nd 1 3 u nderground n uclear t ests a t R eganne for a o f s he t n i ocated l ites s emote r n-Ecker, I nd A lgeria. xposure e whole-body for mGy 0.2–900 be to estimated were outh th yroid e xposure. dose to the ow- l our f ith w egan Absorbed rogramme p esting t uclear n rench F he T and 0.3–3.8 Gy for b uncertain, quite is radioiodines of 1 ingestion from yroid th yield s urface t ests i n 1 960 a nd ut b 961 a t a s ite n ear R eganne i n a ahara, S lgerian A he t eganne ulak Akb the in children for Gy 8 as high as been ve ha may R f o outh-east s m a ( k 0 5 bout v [I10, S22, U3]. m k settlement 50 1 bout a nd a nhabitants) i housand t ew f a f o illage/oasis i 5 pproximately a ith w ity c a drar, A f o outh s 0,000 nhabitants. f ollow- o Novaya Zemlya, Russian Federation (Soviet test sites). 273. i nformation w as N ound r egarding l ocal e xposures f hese t ing robably p ere w eople ost m he t t a ocated l sland i n a ortherly s i emlya Z Novaya n e dge 5 1 hat t laimed c s i t I ests. t p c w hen r adioactive v apour a nd a erosol e scaped 955. 1 n ontaminated egan b emlya Z ovaya N n o esting t oviet S urope. E f o i hrough t a N ovaya Z emlya w as t he s ite o f t he w orld’s l argest n uclear hat t 962 1 ay M n i est t uring d ock r he t n i ssure fi a t a bout a f o ltitude a n a t a etonation d t M 0 5 est, eapons w w as p erformed u nder a dverse w ind c onditions. N ine s oldiers n n I m. k .5 3 o lace p ook t ests t uclear n tmospheric a 1 9 ll, a r eceived a bout 6 00 m Sv, m ainly d ue t o e xternal i rradiation >90%) ( nd t ests p erformed o n t he i emlya, Z ovaya N a sland a ccount f or ffects e linical c r o adiological r arly e o N 3]. U S22, [ o emains r ontamination c esidual r ome S B12]. [ bserved o ere w a bout o ne h alf o f t he t otal e nergy y ield f a ll n uclear t ests c ar- t e nder- u 3 1 here w n-Ecker, I ite, s earby n a nd a ite s his t oth b t a ried o ut i n he ntire w orld. O nly o ne t est, i n 1 957, on- c as w ere ducted irectly o n t he g round s urface. I n a ddition, t here w d ground t ests w ere c onducted. S mall q uantities o f p lutonium hree t ests nder w ater a t t wo t ests o n t he w ater s urface a nd t w ere d ispersed a t t hese s ites f rom s afety e xperiments, w hich u ented, hat t ests t nderground u 7 1 i n lso a ere w here T ite. s he t v i nvolved c onventional e xplosives o nly. N o i nformation h as nly. m ests ost c ases r esulting i n o n-site t ontamination o b een l ocated o n e stimates o f d oses t o t he p ublic f rom t he c b lgeria A n I32]. i onducted c [ rance F y is way, a 280 and Amderma, village, nearest 274. The km ger population centre of Arkhangelsk is approx - the much lar 277. Mururoa and Fangataufa (French test sites). The intermediate Three way. a km 1,000 imately at lie villages Mururoa and F angataufa Atolls in French Polynesia, situated

276 OLUME 260 REPORT: V 2008 I UNSCEAR the South P acific Ocean, ha ve e volved from e xtinct sub - ufficient f or o nly ~ 20% o f l ocal n eeds, a nd c onsumption i s s in E xposures. e ngestion i imited l hich w ase, c ny a n i sti- ow l igneous ve massi a upon rests each and olcanoes, v marine sedimentary ffective e mated capped substratum basalt olcanic v a carbon - by ndividuals i xposed e aximally m o t oses d f ate n i Sv m –5 1 ange r he t n i ere w ombined c vents e ve fi he t rom coral reef platform hundreds of metres thick and sur- deep. ollowing f ear y he t t he t est. A c ollective e ffective d ose o f rounded by ocean w ater thousands of metres France as and ve abo xperiments e nuclear 193 conducted beneath the est t his t t a xposures e a or f stimated e w v S an m 0 7 ocal l ll and and 1966 July between angataufa F Mururoa of atolls U3]. s ite [ nuclear tests, were 178 these, January Of 1996. which in releases de vices were e xploded with lar ge of fission nuclear Chinese 281. Lop Nor test site (Chinese test site) . The atmos safety trials. F orty-one were - the at out carried as w programme testing weapons nuclear ener gy, and 15 were pheric tests (37 at Mururoa Atoll and 4 at F angataufa Atoll, Lop Nor test site in western China; 22 atmospheric tests and and September 1974), and 137 were conducted between July 12 under ground tests were between 1964 and 1966 under - nuclear tests (127 at Mururoa Atoll and 10 at ground 1988 [S22, U3]. Limited information is a vailable in the lit Atoll, between June 1975 and January 1996). Of F angataufa erature on local deposition follo wing the tests. External which were carried out at Mururoa 400–800 the 15 safety trials, all of e xposures in cities or to wns within km do wnwind Atoll, safety ground under were 10 and atmospheric were 5 of the test site are estimated to a verage about 0.044 mSv , assuming 80% indoor occupanc y trials and a b uilding [I12]. shielding 0.8 of actor f [S22]. were 278. The atmospheric tests mostly carried out nuclear t dult a 282. The detonation a at as w that altitude rom f ange r stimates e ose d hyroid sufficient for the fireball not T to reach sea le vel, thereby minimizing the 0 .06 m Gy i n aiyuan t o 2 .5 m Gy i n L anzhou. T hyroid production of d ave uld wo nfants i f h o b een a oses bout 1 0 t imes h igher. local f allout. There were, ho wever, four atmospheric nuclear tests (three at Mururoa Atoll and one at F angataufa Atoll) in p hinese C he t y b eceived r d hyroid t verage a he T opula- ose or wa s e sti- esult he r a s a tion t t f the in floating ges bar on mounted were vices de the which o ests c onducted a t L op N he lagoon. Most of the residual radioacti ve material presently in mated verage a t hough t ven E Gy. m .14 0 bout a e b o t 90 accessible the d eposition d ensity o f as n i by produced w atolls the of vironment en Sr s eems t o h ave b een l ower these nuclear C hina t han i n t he r est o f t he n orthern h emisphere, i nternal Fi were trials safety atmospheric ve tests. 90 re a Sr rom f oses d conducted on the northern part of Mururoa Atoll. a s a hina C n i igher h e b o t stimated e o he c onsequence o f t he d iet T f t he C hinese p opulation. 90 conducted were tests nuclear under The 279. s wa Sr ground f o ntake i rom f esulting r ose d the in a verage e ffective e basement at depths of between about 500 and 1,100 m e stimated t o b basalt 0 .27 ot n ests t o t ue d his t f o ost m Sv, m C n o onducted c in lagoons. the of rims the beneath ertically v drilled shafts oil. s hinese ve of the residual radioacti material associated with the Much rock under ground nuclear tests w as trapped in molten basalt as solidified (b) Underground were radionuclides some ut b va, la e glass-lik tests that rock the into collapsed that basalt fractured on deposited t 283. There h ave b een 1 ests. ,877 u nderground n uclear ca vity-chimney and remained a vailable for e xchange with S ome ga seous r adionuclides w ere u nintentionally v ented w ater in the ca vity-chimney. The ten under ground safety tri - a nsuf- the beneath ertically v drilled shafts in out carried were als d uring f ew u nderground t ests, b ut a vailable d ata a re i Mururoa Atoll. The three of rim the north-eastern part ficient t o on a llow a n a ccurate a ssessment adiological r he t f o t i T he t otal e xplosive y o f t he u nderground mpact. ests gy ener fission some volved in that trials safety ground under i s ield han t maller s uch m t, M 0 9 xcess e in depths at formations carbonate in place took release e b o t stimated e arlier e he t or f a 280 m [I12]. tmospheric t ests. of T he y ields f or t he t ests p erformed y b emocratic I P akistan a nd t he D P eople’s R epublic o f ndia, 280. The c losest i nhabited a toll w as T ureia ( population ost m lthough A otal. t his t i ncluded i ot n re a DPRK) ( orea K n a t ong- l otential p a s i t i nderground, u emains r ebris d he t f o 1 40) a er- p ,000 5 nly o orth; n he t o m k 20 1 f o istance d t opula- l ived w ithin 1 ,000 k m o f t he t est s ite. A l arger sons p term s ource o f h uman e xposure. T he t otal n umber o f t ests X gure fi n i hown s s i ountry c ach e y b erformed p 974) 1 n i w 184,000 ( tion as l ocated 1 ,200 k m t o t he XIX. re- ormally n hat t onditions c he p nder U ahiti. T t a orth-east, n t ebris d adioactive r ite, s est t he t s t a vail Committee’ the to prior test recent most 284. The report ropo- t nd a ocal l he t f o w f c arried t o t he e ast o ver u ninhabited allout as spheric w as performed by the DPRK, on 9 October 2006. Between 133 r egions o f t he P acific. O n o ne o ccasion, h owever, m 21 and 25 October 2006, ele vated le vels of atmospheric aterial Xe acific b y w esterly w as t ransferred t o t he c entral S outh P were observ ed in Y ellowknife, Canada. The measurements f m oving e ddies w ithin a f ew d ays o t he t ests. F rench s cien- could not be traced back to kno wn nuclear f acilities, and i dentified fi ve t ests w here r egional p opulation tists dispersion h ave the applying atmospheric modelling to backtrack ere m ore d irectly e xposed. A s ingle r ainout e vent g roups sho ws that the amount measured is consistent (to within an w fter a ahiti T n i xposures e aused c magnitude) of order f 1 7 J uly 1 974. for assumed scenarios leak simple with est o t he t E f rom f rradiation i xternal e rom ainly m esulted r xposures a lo w-yield under ground nuclear e xplosion on the K orean d i ahiti T n o roduction p s ilk M adionuclides. r eposited peninsula [S3].

277 ANNEX EXPOSURES OF THE PUBLIC AND W ORKERS FROM V ARIOUS SOURCES OF RADIATION 261 B: weapons production (c) Nuclear Doses decreased irradiation xternal e to due [A7]. mSv 1,400 1956, when residents of the in upper reaches of the ri ver actual addition to 285. weapons tests, the installations In mo the contami highly most were - ved to ne w locations and weapons as f abri- w where nuclear material produced and the - inhab some or F nated enclosed. were plain parts of flood which cated were another source of radionuclide releases to remains itants, a ho contamination ver Ri echa T the wever, e xposed. Some informa - were populations gional re and local day. the to present source of exposure significant on this practice w as presented tion 1993 UNSCEAR the in Report [U6]. Especially in earliest years of weapons pro - the yarsk Krasno The Krasnoyarsk. 289. - pro material nuclear production the and schedules lack meet to pressures duction, duction x is located about 40 km from the city of comple aste dischar ge controls resulted w in higher local of stringent Krasno radiochemical plant for irradiated fuel The yarsk. sites, weapons some e xposures than in later years. Also, at gan reprocessing operation in 1964. be In 1985, a storage are now being dismantled. as for service into put fuel w acility f spent assemblies from reactors There Ukraine. and Russia of republics viet So the in nuclear to plans are fuel from the ci vilian fuel reprocess (i) United States c the Krasnoyarsk site in the future. ycle at lants tates nited U he t n i S p eapons w 86. Nuclear 2 i ncluded: aste w 290. Radioactive rasnoyarsk K he t rom f ischarges d ernald, O hio ( materials F p rocessing); P ortsmouth, O hio, iver. nter e omplex c an c ontamination c race T R enisei Y he t O a P aducah, K entucky ( enrichment); ak R idge, T ennessee nd stuary, e he t o t omplex c he t rom f iver b e f ound a long t he r l p eapon w f o ab- arts, anufacture m eparation, s enrichment, ( a bout 2 ,000 k m a way. A n e stimate f or t he c ollective d ose p oratories); rocess- plutonium ( exico M ew N lamos, A os L the r from Krasnoyarsk esulting from discharges radioactive ( manufacture ing, w ssembly); a R ocky eapons F lats, C olorado c d uring 1 958–1991 w as a bout 1 ,200 m an S v [ U3]. omplex anford, o w eapons p arts); H f W ashington ( plutonium p ro- ose w as fi sh he ost i mportant c ontributor ( 70%) t o t his d m T a duction); plutonium ( arolina C outh S iver, R avannah S nd ue c he t o t ontaminated d xposure e xternal E onsumption. c w hich s uch o per- re a here T roduction). p m any m ore s ites a t he ood he ccounted ose. or lain ollective 7% f fl o t c 1 p d f a T is- tored s ere w ations astes w here w nd a onducted w ere c d r o ain ontributing o he adionuclides nternal ose ue o m i c d d t t r t 24 54 65 32 posed r o f. E stimates o f h istorical r eleases o f adioactive fi sh c onsumption w ere he P, Na, Mn ain m T Zn. nd a p ifferent d uring d aterial m uclear n he t f o peration o f o eriods ontributors mma- ga ere w 0%) 9 over ( t ose d xternal e he t o c 152 137 60 eviewed i n r eference [ i h ave nstallations b een r U3]. Cs, Co r a nd adionuclides, Eu. I ndi- p rimarily emitting a ver o aried v oses d vidual o t .05 0 rom f ange, r ide w p about ( 2 .3 m Sv/a. T he m ajor ose ortion o f t he c ollective d ormer Soviet Union (ii) F m p 8 4%) w as r eceived b y opulations l iving w ithin 3 50 k o f r he s ite o f t t he adioactive d ischarges. are 287. There three main sites where weapons materials were in the produced former So viet Union: Chelyabinsk, 1 291. In 992, t he t he K rasnoyarsk d irect-flow r eactors o f Krasno routine ge lar vely Relati omsk. T releases and yarsk c omplex w ere s hut d own. T his r educed c onsiderably t he early years of operation of these occurred f acili- during the R iver, a nd o f r adioactive mount d ischarges t o t he a Y enisei background le vels In ties. addition, accidents contrib uted to o d as w opulation p he t ecreased t d ollective c nnual a he t ose the to and contamination of radiation e xposure of indi viduals a f actor o f m ore t han y 4 . E b stimates o f a verage a nnual areas. ving li in regional and local the t or f oses d xternal e or f v S μ 0 3 ere w 993–1996 1 eriod p he 0 opulation p ocal l a ith W oses. d nternal i or f v S μ 2 nd a oses d production 288. material Chelyabinsk. nuclear Mayak The nnual o f 2 00,000, t he a c ollective stimated e s i ose d ffective e gion x the comple Chelyabinsk re in is between located the 1 0 m o an S v. b t e yshtym e wns Lak near to the and eastern K shore Kasli of of - for Irtyash. plutonium reactors produc Uranium–graphite Siberian com production material - nuclear The Tomsk. 292. tion gan - 1948. Rela operating be plant reprocessing a and in right bank the on omsk-7, T of wn to the of in plex is located echa ve ges ge tively radioacti dischar the material lar T into of km T - of city the of north Sibe The omsk. the T om Ri ver 15 vailable ver and infor- Ri 1956. The occurred a between 1949 Radionuclides 1953. in in rian comple x w as commissioned xposures as summarized population local the to e on mation w liquid w aste are dischar into the T om Ri ver, which flo ws ged viduals 1993 in The indi most Report the UNSCEAR [U6]. for into to due dose ve collecti the estimate An ver. Ri Ob the echa ver xposed releases e highly as Ri T the into the of result a the ve radioacti from ges Siberian comple x between dischar ver, ver villages ri were residents of the along the ri who used 1,200 and 1958 1996 is man period the During [U3]. Sv ater, atering aterfowl breeding, for w w fishing, drinking w 1990–1992, - three Com of the fiv e reactors of the Siberian ashing. ation ardens, vestock, li irrig g of bathing and w In of amount the considerably reducing wn, do shut were plex vy resulted flood contamination of hea a 1951, in April–May col annual the and ver Ri om T the to ges - dischar radioacti ve vestock for li used grazing plain and flood hay the making. fective ef ve collecti The population. lective dose to the dose xposed ve the from most dose e collecti to population The Sv . utor contrib gest lar The w as estimated to be 200 man vidual , verage as 6,200 indi an with Sv man a w 1956 to 1949 consumption. fish from The main (73%) to this dose w as fective , to dose of about 300 mSv ranging from 36 ef radionuclides contrib uting to the internal dose due to fish

278 262 REPORT: V OLUME 2008 I UNSCEAR 24 32 Sichuan P and consumption Na. About 80% of the collecti ve Pro vince, where lar ger installations were con - were within km of ving x. comple 30 Jiuquan the at assembled were eapons W structed. li populations the by ved recei as w dose e - produc weapons site nuclear to due xposures the of Assessments of the radioactive discharges [U3]. and reported been ve ha China in tion populations to doses been surrounding installations ha ve estimated [U3]. specific (iii) United Kingdom to the military fuel xperience c ycle, since e This relates commercial nuclear po wer programme started only China’ s material abrication f the and nuclear of production The 293. 1990s. the in the gan in weapons 1950s in the United Kingdom. The of be - as such sites at years Spring se for continued as w ork w veral Capenhurst fields (uranium processing fuel and f abrication), 2. Residues in environment the and (enrichment), Sellafield (plutonium production reactors research) Aldermaston (weapons reprocessing), and Harwell sites (a) Nuclear test , w ork related to the commercial (research). Subsequently some wer w as incorporated at programme of po nuclear these atmos - from 297. As described earlier , radioacti ve debris an these installations, sites. of the earliest years of operation In is pheric nuclear weapons test partitioned between the local radionuclide dischar ges were with wholly almost associated - strat and tropospheric ater w or ground surf ace and the the military fuel cycle. ospheric gions, depending on the type of test, the location re The yield. the and of depositing or precipitation subsequent operated 294. Plutonium reactors were production in the - dis locally is it when allout” f “local the debris is termed Sellafield as- graphite-moderated, o (tw at Kingdom United g persed, and “tropospheric f allout” and “stratospheric f allout” reactors as wn kno cooled at later and Piles) indscale W the dispersed. when globally at and site Sellafield the on Hall Calder in Chapelcross Scotland. 298. Exposures earlier described were f global to due allout this anne x. Local f allout in constitute as much as 50% of can for surf ace tests, and includes lar ge radioac - the (iv) F rance production about within deposited particles aerosol tive the of km 100 F w ith 945 1 n i egan b rance n i rogramme p uclear n 295. A utions test allout f total site. to e contrib the tests, some In xpo- t à c reation o f t he C ommissariat he T tomique. a ’énergie l he to people close to the sites ha ve been substan - doses of sure a n r esearch l aboratory uclear t F ontenay-aux-Roses b egan be considered actual potential or tial, and these sites must he a t he f ollowing y T ctivities fi rst e xperimental r eactor ear. subsection This xposure. e public of sources on focuses w ent c ritical i n 1 948 a nd a egan b lant p eprocessing r ilot p potential ef - associ xposures e estimating wards to forts recent eactor xperimental e econd s A 954. 1 r n i peration o on- c s wa ated nuclear former of occupation future and present with 1 o structed a t t he S aclay c entre. F rom 1 956 t 959, t hree sites. test eactors l arger p roduction r b egan o peration a t t he M arcoule c raphite- g omplex o n t he R hône R iver. T hese g as-cooled, 1 oderated r eactors o perated u ntil m 968, 1 980 a nd 1 984, Mar (i) alinga and Emu r espectively. A f ull-scale r eprocessing p lant wa s b uilt a nd t o f rom 1 958, a lso a t perated he M arcoule s ite. T wo m ore ests, t eapons w uclear n he t f o esult r a 299. As esidual r o lants t r eprocess ere w p eactors r ommercial c rom f uel f r adioactive c ontamination i n t he M aralinga a nd E mu a reas t c a om- t L a onstructed H ague i n he n orth o f F rance, b eing c ossible p he T ilometres. k quare s f o undreds h s overs c ome eporting o f r adio- T 990. 1 nd a 966 1 n i pleted he s ystematic r resent o ccupation o uture f nd a f p ith w ssociated a xposures e nuclide d ischarge d ata m ay a lso r eflect t he r eprocessing o f reas a hese t opulations, p boriginal a ocal l f o ainly m e b ould w ommercial r eactor f uel. c t onstitute c o t ikely l re a ho w m ajority o f f he uture i nhabit- igratory ants o t he a reas. T he m l ifestyle o f t he a boriginal f p ssessment a n o f p opulation d oses a akes m reas a he t n i eople (v) China o t oses d or f stimates e est b nly o nd a ncertain, u i ndividuals l een b as h ssessment a he T ere. h iscussed d e b ill w t imited o gy w as created in Ener Atomic of Institute The 296. 1950. s xisting e f o onsequences c he t urface c on- f o onsideration c The first Beijing, in constructed as w reactor xperimental e o a emoval r he t f o onsequences ctivity tamination. T he c f and a uranium enrichment plant w as b uilt at Lanzhou in rom f t n i xist e o t ot n ave h reas a he nown k its p urial b he t vel- de weapons nuclear A Ganzu Pro vince in western China. H7]. onsidered c b een [ opment programme w as in China that led to the first initiated e nuclear in The first nuclear country that 1964. by xplosion exposure are: possible 300. The pathways foreseen an of as w test produc Plutonium vice. de uranium - enriched were reprocessing and tion com Jiuquan the - at conducted − Inhalation o f m aterial r esuspended f rom t he g round, in located also The production reactor Pro plex, vince. Ganzu i ncluding b oth n atural w ind-driven r esuspension a nd in 1968. be gan operation in 1967 and the reprocessing plant r esuspension a rising f rom m echanical d isturbance and Production also occurred in Guangyuan in reprocessing o f b oth s oil a nd fi re a sh;

279 ANNEX EXPOSURES OF THE PUBLIC AND W ORKERS FROM V ARIOUS SOURCES OF RADIATION 263 B: material Ingestion foodstuf fs and associated soil (con - already of ve radioacti residual the to due ve recei − present tamination of foodstuf fs with soil and fire ash) in the accessible en vironment of Mururoa and F an- and and w ingestion; special consideration of deliber- gataufa ater their surrounding w aters. The scenario main also ve ate soil ingestion (a practice material radioacti residual of release called as w addressed “pica”) is the currently under ground at the atolls discussed; into the lagoons or into the surrounding ocean as a result of the normal directly and sores of Contamination − wounds; the residual ve material through radioacti migration of the radioacti ve g External amma irradiation due − to ef modified by the h ydrogeological the geosphere, of fects ground; the on material paid to three radio - articular P attention w as nuclear testing. 239 137 irradiation of potential radiological significance— Pu, Cs the nuclides − Beta due to radioacti ve material on 3 90 to additionally Sr—and useful tracer as which and on and H, a w skin and clothing. ground models. validating for e potential further handling of the ay, pathw xposure 301. A objects contaminated pre vious permanent indige - included 305. There are no records of been not has fragments, and in this assessment. Measurements ha ve been made of these Atolls, angataufa F and Mururoa the of habitation nous although some intermittent habitation from resulting doses and items, contaminated of Mururoa Atoll has prolonged postulated to or handling of considerable. be may items occurred. The study such h ypothetical dwellers on the proximity the on information no wever, ho is, There and and elihood atolls eating lar gely local seafood lik locally gro wn pro - such that doses of bound upper the estimated and duce, be e xposures, and for this reason an assessment of duration might incurred if the atolls were actually to be of dose has also not been attempted. inhabited. It vided ved recei being doses the pro of estimate ative conserv a 302. Doses to calculated are population present by Atoll, the nearest inhab - T ureia of v- ha population aboriginal the the km 130 (about land ited angataufa F and Mururoa the doses that assumed be may It lifestyle. semi-traditional a ing from persons to other groups will be lo wer, with the e xception of Atolls). carrying particular acti vities for such out as souv enir hunting utors contrib important most The 306. contaminated fragments. There is also considerable diffi - - radio verall o the to at nuclide rates were the 12 nuclear tests carried out release culty in estimating indi vidual doses realistically because of terms Mururoa Atoll early in the nuclear test programme. the In great v ariability in the radionuclide le vels in dif ferent areas. In areas contaminated by the atomic e xplosions (the ut b releases, early the dominated tritium vity, acti of with were that concentrations vity acti “major trials”), the significant radionuclides currently are - signifi radiological no of 137 60 152 cance. including radionuclides, other tests, the Since neutron acti vation products, principally Co and Cs Eu, and 90 90 155 and within ground under retained fectively ef been ve ha Sr, f allout radionuclides, principally Sr, and Eu. More sig - basement, basalt the vity acti their decaying of most nificant radionuclide le vels remain as a result of the v arious only and trials”). “minor (the explosions triggered chemically small amounts being released. Plutonium continued to be released o ver long periods of time b rates. ut at v ery lo w The 239+240 137 of concentrations that predicted modelling Pu ferent and Cs 303. The dose assessment for dif contaminated zones, w v- le present xceed e to ely unlik be ould w ater lagoon the in identifying the critical groups and the most rele vant radionu - 3 90 els clides, sho wn in table 37. The calculated doses assume H and Sr of Concentrations future. the in time y an at is residence that and year a of period the ver o area the in 100% could rise mar ginally abo ve current le vels, b ut only during and cook ed locally (for kang aroo, a ve radioacti residual of dispersion The decades. food caught is obtained the ne xt fe w verage a site-independent and ve representati - material concentration the ocean will lead to long-term concen throughout of gree de a therefore is There used). as w meat the for of trations to decrease will - back which radionuclides, some - con vels into the calculations, which is sub - servatism atolls. the from km 100 about ground oceanic le incorporated yond be Thus of range considerable A zones. smaller the for annual stantial be will concentrations predicted the Atoll ureia T at the area of from [I12]. levels background around ef fective dose estimates e xists, 0.5 mSv in 137 of Cs) of detection aerial to limit (at I otem Emu–T the at Inner T aranaki. As e xpected, the highest doses 500 mSv gions Bikini (iii) w ould be incurred from occupanc y in - immedi re the in surrounding the test ately sites. Continuous occupanc y fficial o he t - Con size. small their of because ely unlik ery v is areas such 997, 1 07. In 3 oci- S hysics P ealth H he t f o ournal j H b ut still significant doses w ould be incurred siderably ety, wer ealth Physics , lo d evoted a c omplete i ssue [ H16] t o t he defined by aerial survey. at the outermost contour lines c onsequences o f n uclear w eapons t esting i n t he M arshall i ection s his t n i resented p nformation i he T ainly m s I slands. elated t o t he p revailing r r adiological c ircumstances a nd t heir f Murur (ii) i mplications f or t he oa and Fangataufa uture h abitability o f B ikini A toll. C ur- r rently t he s ignificant r esidual adionuclides f rom n uclear t ests 304. The at situation the of the assessments recent of aim t hat r emain i n t he s oil a nd t he s urroundings o f t he a toll a re 137 90 239+240 241 w as to estimate the radiation Mururoa and F angataufa Cs, Sr, Atolls Pu a nd Am. T hese a re f ound t o v arying ould w acific P South the in ywhere an people that doses d egrees i n b oth t errestrial a nd m arine e nvironments. T he

280 264 UNSCEAR REPORT: V OLUME I 2008 c unique o f c oral s oil, w hich i s p rimarily c alcium dose rate in air measured at 1 m abo ve the ground v aried omposition c o t August in conducted studies in mGy/a 5 to 0.01 about w from vailability a f o attern p a roduces p lay, c o n ith arbonate 137 90 The 1978. Cs a nd o Sr v ery d ifferent f rom t hat f or w hich f p lants about be ould w 1999 to decay-corrected alues v a luminium s ilicate c lay s oils o f t he m ost Other mGy/a. 3 to 0.006 from alues, v 1978 the of 60% d ata ( which r elate t o i.e. urope) a A r eported i n t he l iterature [ R17]. as (such occur could xposure e which by routes potential mericas a nd E re di or swimming in the lagoon) ha ve been analysed. The ving to primary island for habitation at so Island, 308. Bikini contrib utions the dose via these pathw ays were found to be 137 has the highest concentrations of dose Cs per unit Bikini general Atoll, small that the y could be ne glected in the 137 of soil and v egetation in the atoll. The assessment. a verage mass Cs range among the concentration v aries o ver a considerable 137 verage atoll’ Cs concentration in soil and s islands. The a 3 12. Assessments p erformed t o e valuate t he p otential - v egetation on Eneu ive Island, the other main island of resi c ommitted d oses t o t he p opulation t hat m ight i n f uture l 137 The Cs Island. dence, is about 10–13% of that o n B ikini I sland h ave e stimated t he a verage a nnual e ffective Bikini on d ocal soil on Nam Island and Enidrik Island (the concentrations d ose in ue t o e xternal ga mma r adiation, b ased o n t ypical l 999, 1 tw t ecay-corrected d nd a abits h ccupancy o o other islands lar ge enough for possible residence) are Sv. m .4 0 s o a respectively, of that on Bikini Island. b e a bout o t redicted p as w ose d ndividual i nnual a verall o he T about 70% and 15%, a iet d igh-calorie 8 .0 m Sv f or a h l ow-calorie d or F iet. 239+240 c Pu i 309. Concentrations mported radionuclides transuranic of a ssumed t o ( onsist o f b oth erived d ocally l nd a 137 241 nd of concentrations to on- c iet d a or f a stimated, e as w Sv m .0 4 f o alue v a oods, f ratios their and Am), and and Cs 90 a o f o nly l ocally d erived f oodstuffs, t he o verall sisting nnual design Sr, v ary around the atoll, reflecting dif ferences in the de vices esulting oses d ractice, p n I Sv. m 5 1 s a stimated e as w ose d detonated near the v arious islands. In r of the nuclear nlikely general, d iet o f l ocally d erived f oodstuffs a re u a t o b e rom f with rapidly decrease concentrations radionuclide onditions, e a s t he p resent M ar- i ncurred in xceptions are there although column, soil the in depth u nder t he c urrent c The islands. some of parts d iet c ontains ( and w resum- i n t he shallese unit per radionuclides of vities acti n ear f uture p ould o t ontinue c The 38. table in wn sho are Island Bikini on soil of weight dry f o roportion p ubstantial s a ontain) c ably 137 w of concentration Cs in coconut reaches v alues up to i mported f ood, hich i s a ssumed t o b e f ree o f r esidual r adi- 137 such fruits, other Some Bq/kg. 6,000 - pandanus and onuclides. T he u ptake o f as Cs i nto t errestrial f oodstuffs bread 137 f or t he l argest f raction o f t he t otal e stimated ose a fruit, and 4 about of concentrations Cs ccounted verage a ve ha d 90 [ 9) 3 400 table ( Bq/kg, respecti vely. The Sr acti vities are less than 10% B34]. 137 fs. foodstuf vant rele the in the vities acti Cs of ve respecti 241 239+240 The the than wer lo ven e are Am and Pu of vities acti 313. Transuranic radionuclides in the lagoon remain an 90 studies vidence e is There radiation. of source potential resuspension from results The [R17]. vities acti Sr important ery v is soil ace surf of resuspension verage a the that w sho that plutonium is indeed transferred from sediments into the 1 - 11 - 10 - ranging . 10 to m concentrations measurable ut b small in ecosystem aquatic lo w, with resuspension f actors 10 from basis the action of biogeochemical processes. Ho wever, On the through of the measured acti vity concentrations in soil, 239+240 241 the radionuclides through the these of transfer ed observ the concentrations of Pu and Am in air are e xpected w. lo ery v is fs foodstuf human to chain food marine ery The to be v ution contrib xpected e the consequently and w, lo radiation is ays pathw inhalation via xposure e to due doses to actions that indicates further information vailable a vere se of area do years 40 past the ver o insignificant. the in hurricanes and storms judged be to transported ve ha to appear not or the mobilized transuranic 137 90 239+240 significant extent [I9]. 310. The residual radionuclides, any Cs, Sr, radionuclides Pu to and 241 s Am, are present in the atoll’ lagoon, mainly in sediments ater and biota. Caesium-137 is found in v ery b ut also in w and Semipalatinsk, Kazakhstan fish. Cae - (iv) lo w concentrations in lagoon sediment, w ater highly major the and soluble, generally are compounds sium 137 of the Cs in part lagoon has long of the original in ventory 314. Emphasis in this assessment is gi ven to residual radio - w orld’s oceans. since dissolv ed and become mix ed into the activity from nuclear testing. As such, the main tests of inter- (a Strontium-90, which is chemically similar to calcium est are those that resulted in local f allout. These include the e xcavation e tests, ace surf and ground under three carbonate), calcium as soils coral the of component major xperiments competes the v ery lar ge quantities of calcium a vailable with material ve radioacti of enting v unplanned an which in tests is also nuclear the outside areas most In occurred. atmosphere the to for uptak e by and distrib ution in marine species. It acti concentra vity sediment, coral and coral wing gro the - in bound chemically test site, e xternal radiation dose rates and vironment en lagoon gions the in remains and re other in vels le typical to similar are soil in tions and car- the in primarily 90 una vailable to matrix. carried been has testing weapons nuclear bonate no where countries Consequently , Sr is relati vely marine out. The estimated annual life. ef fective dose to persons outside mSv 0.1 is radionuclides residual to due site test nuclear the 239+240 most. best estimate for the total in ventory of 311. The Pu at order Actual e xposures are more lik ely to be of the 241 Am and and TBq 25 ± 103 is sediments Atoll Bikini in of a fe w microsie verts per year , a dose rate v ery close to the 93 absorbed the Island Bikini On vely. respecti TBq, 10 ± global average due to fallout [I10].

281 FROM EXPOSURES OF THE PUBLIC AND W ORKERS B: V ARIOUS SOURCES OF RADIATION 265 ANNEX 90 137 ost o f t he t est s ite t here i s l ittle o r n o r esidual hat t Cs a nd 315. Over Sr c oncentrations w ere n ot s ignificant. T he m t he t o t wing o ater w round g f o ontamination c uture f ossible p ake L he t nd a ero Z round G he owever, H adioactivity. r nd a re h eavily c ontami- e b ust m ests alapan B t nderground u rom f adionuclides r f o eaching l reas a re ex ceptions a a ro- nated. 991– 1 uring d ut o arried c ampling s ir A owever. h onsidered, c T he o nly o n-site i nhabitants d uring t he t esting p b ite s est t he t round a nd a nside i 1992 y t he f ormer S oviet gramme w ere i n t he mall s he t n i nd a rchatov Ku f o own t 137 ettlements o f A kzhar a n ndicated i nion U nd M oldari a long s t he n egligible a irborne l evels o f e Cs a nd dge orthern 239+240 o b as h here t ecently R ite. s he t f o nd a olon D n i Pu een illages. v ther esettlement r imited l f ithin t he a rea, m ostly b y s emi-nomadic armers a nd h erd- w h hey t hat t vidence e ave s s i here T ers. g razed a 320. External r adiation e xposure h as b een a ssessed f rom nimals ome round Z ero a nd t he L ake B alapan a reas. I t i s i n b oth t m easurements o f a bsorbed d ose r ates. I nternal r adiation he G o k nown i f t here a re a ny s ettlements c lose t o t he o ther f n asis b he t ot n o ssessed a een b as h nhalation i e xposure f rom i egarding est t ratering c a ctivity c oncentrations s n s oil a nd a ssumptions r ites. t he l evels o f r esuspended d ust. T he i ngestion p athway h as are soil in the concentrations 316. Activity for vailable a b een m odelled u sing e nvironmental t ransfer f actors ( repre- at most occu - most radiologically important radionuclides senting t ransfer f rom s oil t o t he f ood c hain) a nd a t ypical b ut for fe w locations on site. Outside as pied locations of f-site, l ocal d iet. T he i ngestion o f s oil h a lso b een a ssessed. T he 137 t from measurements Cs a of results the site, test nuclear the e stimated d oses o a dults, ssuming c abitation h ontinuous xposure o t he a rea, a re g iven i n t able 4 1. T he e f o f c hildren IAEA missions in 1993 and 1994 all fell within the range the e een b lso a as h nnual a otal t he t ases c ll a n i nd a stimated, of this end wer lo 5–100 Bq/kg. Most results were at or a dults. The a nnual d ose e sti- a re range, which is d typical of global a verage f allout oses le vels. l ower t han t hose f Results i ite s Bq/ 0.2–7 range the within fell soil in plutonium for s est t he t utside o ettlements s n i iving l ersons p o t mated in measured kg, f 0 .14 m Sv f or D olon. perspecti ve, concentra - (F or 0 .06 m Sv, w ith a h igher v alue o 1992. and 1991 239 as a he t n i ade m ssumptions a onservative c he t a ssess- England south-central in soil ace surf in Pu B of tions f o ecause Bq/kg.) 0.5–1.7 range the in are allout f weapons of result v hese t ment, ore m a verestimates; o e b o t ikely l re a alues An xception e e ealistic r ose he t f o t o a n a verage p erson l iving i d stimate much where Dolon, of village the in is this to n ikely l s i ettlements s he t higher plutonium le vels (by a f actor of up to 100) ha ve been hese t f o enth t ne o bout a e b o t stimates. e recorded. out for considered were scenarios xposure e 321. Two the 317. The absorbed dose rates due to terrestrial sources - first the nuclear test site ha ve been e xtensively measured The side assumes a group of visitors that and nuclear test site. one for areas contaminated highly the at stay represent the , together aken T 40. table in wn sho are v alues day per hour these the results of a surv ey conducted between 1991 and 1994 of from feed their of 10% e tak that animals eep k and approximately 600 locations around the entire nuclear test areas. The v alues in table 41 indicate the le vel of a that dose ved small of frequent visitors might recei ve. The e xter- belie are site perimeter . All nearby centres of population number to test the to visitors outside measured alues v The included. been ve nal e xposure pathw ay dominated the doses ha to almost The these second scenario considered potential future to due rates dose of range the within entirely site are areas. in one is scenario future pessimistic most The reported and countries ferent dif in measured sources natural settlement. UNSCEAR by persons which Zero or Ground the inhabited permanently μGy/h). (0.024–0.160 ved e Balapan areas and deri Lak all their crops and animal 318. Measurements a ctivity rom i nside t he n uclear f o f products from within these areas. The estimated potential permanent to doses future are also ven in vailable a ata d inhabitants he t ith w omparison c n i carce s re a ite s est t gi table xposure e main the be nder- u urvey s erial a ould pectrometry s amma g he T utside. o or f w xposure e External 41. n 1 990 i ndicated t hat t he a bsorbed d ose r ate i ove r taken pathw ay for persons who might in the future permanently r ange - 0 .07–1 μ Gy/h. t he e ntire t est s ite w as w ithin t he inhabit these tw o areas, b ut ingestion w ould also mak e a sig w m eters M easurements m ade a t G round Z ero ith s urvey nificant contrib ution, o wing to the production of food in the w apidly r hanged c ate r ose d he t hat t ndicated i - perma to doses annual estimated The areas. contaminated ncreas- i ith ing he e picentre, s uch t hat v alues c lose t o are t site the on vity radioacti residual to due rom f istance d nent residents mSv 140 [I10]. about n ormal b ackground l evels w ere i ndicated a t d istances o f a i bserved o ere w ariations v n imilar S etres. m h ew f undred round t he L ake B alapan c rater. H igh l evels o f a cti- a nd - a 322. Recent surv eys at the Semipalatinsk test site high re p resent c lose t o G round radiostrontium the in ariability v of nides a nd fi ssion p roducts a lighted the high de gree alapan. ake L nd a ero Z contamination. The highest v alues measured were B associ - in ated with leakage from tunnels the De gelen area, where o f a rtificial r adionuclides i n s oil c oncentrations 239 under ground tests were performed, including one as part 319. Low m ain s ettlements s uggest, h owever, f rom t he v icinity o f t he of the programme on peaceful nuclear e xplosions. It w as 90 o b e a s ignificant p ath- t form mobile hat t he highly l ocal f ood c hain i s u nlikely also suggested that some t Sr may be in a 90 o f e xposure. A l imited f ood-sampling p rogramme s up- ay pathw important vely comparati a is ingestion Sr way that and his ocal rom f aken t amples s ater w rinking D I10]. [ l t ports of e xposure compared with other radionuclide e xposures at ite s est t he t utside o ells w ndicated ite s est t he t nside i i ne o nd a the test site and in the surrounding areas [H25].

282 266 UNSCEAR REPORT: V OLUME I 2008 Streams ephem by e lea e in the area are xcept ves vaporation. - No (v) vaya Zemlya, Russian Federation is v lo in precipitation the re Although during w eral. gion, ery e e flooding precipitation of risk some there is vents xtreme g slands i emlya Z en- ovaya N he t n i ates r ose d 323. Current along around playa lak Throughout the re and arro es. yos gion, .08 t o 0 .12 μ G y/h, w i s s imilar t o erally t he hich v ary f rom 0 springs are the only natural of perennial surf ace sources ot n reas a djacent a i bserved o ange r nd a esting t n f sed u or con the are not w b for human consumption. A used - ut ater, y ackground ssentially l e evels, hich w o n atural orresponds c b t 3 9 , m 10 v × of 2.7 groundw at estimated ater, olume siderable a lthough i n s mall a reas m uch h igher d ose r ates c an b e 137 and NTS the beneath storage verable in held is the reco d etected. T he i nternal d r esser l a o t and ( ate ose o t ue d Cs 90 region. surrounding t o Sr) xtent d ue f or e r eindeer h erders i s e stimated t o h ave r ates t o Sv/a m ince 1 bout a een b t s he e arly 1 960s; d ose the NTS 327. Radioactive at contamination of surf ace areas imes t 00 1 bout a een b ave r o t stimated e ere w u rban esidents h nuclear resulted primarily from atmospheric testing of the [ S22]. ower l 1962. weapons between 1951 and Additionally, safety tests and conducted the surf ace between 1954 at 1963 resulted in soil. contamination of the ve radioacti More than 200 areas (vi) Ne vada, United States are controlled because of radioacti ve contamination that the on mapped and identified been ve ha NTS. the United areas 324. Four under used been ve ha vada Ne in T est States nuclear test programme: the NTS, the T onopah han t 328. More een b ave h ests t uclear n nderground u 00 8 Central The Area. est T vada Ne the and Shoal Project Range, 2 as h esting esulted t nderground U TS. N he t r c onducted a t of the under land jurisdiction km 3,496 encompasses NTS n i u navoidable a dverse i mpacts t o p ortions o f t he l and the The (USDOE). gy Ener of of Department States United t nd a aking m esources, r roundwater g nd a eological g he onopah est as wn T from Range public T use w for withdra t hem adioactive r f o ockets P urposes. p ost m or f sable u n u est onopah 1940s. T use in the military Since 1956, the T ocation. est l s c urround ontamination e ach u nderground t Range has been encompasses managed and by USDOE the 2 nderground n o t he ata d t rom F n u umber a nd d ates o f he km 1,606 of land used for defence and related research, t ests a t t he N TS, t he t otal a ctivity o f r adionuclides design testing as and acti vities. The Project Shoal Area w 19 × .1 1 e b o t stimated e s q. i nderground u emaining r B 0 1 under of purposes for ground use public from wn withdra he t M n i aptured c emains r aterial m adioactive r his t f o uch nuclear nuclear test testing. The Project Shoal under ground avity c riginal o he t nto i each l o t vailable a ot n s i hus t nd a area The 1963. on place took United the by used currently is onducting roundwater. T he i mpacts g ubcritical s c f o States vy for testing and training for Na tactical manoeuvring e u nderground w ould b e xperiments uch l ess t han t hose m and support. Subsequent to an under ground test in 1968, air s f ission c hain o f n uclear t esting, s ince n o s ustaining elf- of wal withdra the lands for the Central Ne vada T est public ess l uch m nd a ccur o eactions r s i aterial m adioactive r and remains area the under unchanged remained has Area d eposited i t he g eological e nvironment. A s i n t he c ase n and grazing Cattle USDOE. the of control the are recreation n aterial adioactive r he t esting, t uclear f o i s c aptured m main uses the of the area around this site. u nderground. isposal d nd a anagement ste wa 325. Radioactive o pera- m in resulted has testing nuclear 329. Underground - the con he t t ow-level, l a a 960s, 1 arly e he t n i TS N egan b tions nd of of groundw ater in tamination immediate vicinity a the nd ave h t ransuranic m ixed a c lassified l ow-level wa stes been has ater groundw number the of quality The tests. of andfills l renches, t its, p elected s n i f o isposed d een b a nd impaired, ut only in these limited areas. No radioacti ve b TS d a s a erves s urrently c is- N b oreholes o n t he N TS. T he to USDOE acti vities has been utable attrib contamination s l ow-level wa ste g enerated b y U SDOE- or posal f ite outside of in monitoring wells detected the NTS. Detection a o l s a s a a a f approved imited nd lso s torage ite or perators ground under to limited is contamination significant testing t o t m wa T a t o opography mount ixed f he ransuranic he f ste. areas on the NTS. T ritium-contaminated groundw ater e xists N b a U h p b a h y ctions, istoric as SDOE ltered articu- een TS subsurf the of testing ground under past of result a in as ace o e u p T n t esting. uclear f he nderground rincipal ffect larly performed weapons nuclear at f- of o tw and NTS the within i c n o Y c t b h t f een umerous ucca as raters n esting he reation Ne Central the and Area Shoal Project the locations, site vada a n F U M a R o P ahute n uclear nd nd ainier esas. lat nderground basis the On of results combined the of T est Area. studies e p t o i i r h t esting nvironment esulted he as hysical n n mpacts performed by v arious authors, the estimated range of peak t o o i d m t g g n eological erms f round otion, isruption f he at tritium concentrations the area of uncontrolled use closest s o c t a s s m ub- he urface ontamination f edia, ubsidence, nd the after years 150 at Bq/L 0.02 from the to aries v NTS d W s s a m g uperficial edia oils. is- eological nd aste surface 5 25–94 in Bq/L of 10 × 1.4 to ginning be migration years. d s i r a h o esulted ave n perations lso urface posal isturbance ater groundw tritium-contaminated of migration The from m o a i l t h p o f lacement n aterial he aving ong-term nd mpacts location test the in result could Area Shoal Project the at s b t i t 4 T e ummarizes able nfor- he nvironment. 2 aseline he 7 4 10 × 1 from ranging concentrations 10 × 2.7 peak to Bq/L t a t r N o r i TS. he t nventory adionuclide esidual he n mation 71 and of the controlled area between at the boundary public w ater well currently e xists years 206 after the test. No considered are NTS the in located areas the of 326. Most location. this at within w Great Basin, an area the from which no surf ater ace

283 EXPOSURES OF THE PUBLIC AND W ORKERS FROM V ARIOUS SOURCES OF RADIATION 267 ANNEX B: ufficient en impacts related to the w aste man - ep- r e b o t vironmental s ot n ere w hat t amples s f o umber n mall s 330. The with those of the f o resentative agement programme are minor t he a rea a nd w hich t herefore c ould n ot b e compared programmes. Under ground nuclear detonations create r o nventory i he t f o valuation e recise p r o other etailed d u sed f or a ve abo rock and soil the which into vities ca ground under s pecific the d istribution o f a ctivity i n t he A drar T ikertine a rea. is a crater on the sur- f o oncentration c ctivity a nthropogenic a ca vity then collapse. The final result N evertheless, t he w aste at the Area ace. 3 Radioacti ve W aste Man - abo- l elow b enerally g as w amples s hose t n i w-level adionuclides r Lo f esidual r he t hat t pected ex s formed craters subsidence in of disposed is Site agement ratory d etection l imits. i T hus i t management past under ground nuclear tests. W aste s urface from c ontamination f rom t he p lutonium d ispersion programme operations in Area 5 are more di verse and ex periments i s u nlikely t o g ive r ise t o d oses t o n omadic include f for hazardous and mix ed-waste management in I32]. [ Sv/a m 1 acilities ceeding ex amilies f heir t r o erders h to lo w-level-waste addition management f acilities. After the USDOE has not disposal operations, 30 years of w aste contamination groundw wells monitoring ater in y an detected (viii) Lop Nor , China completed area. recently this near gion re in 334. Lop Nor , located central Asia in a v ast desert western China, w as the in location for 34 nuclear weapons 1964 ganne and In Ecker, Algeria (vii) tests conducted between Re and 1988; of these, 22 were were atmospheric tests and 12 under ground. Little informa - sealed of f, 331. Though the Re ganne site is at present not tion is publicly a vailable on doses recei ved by the public or to the area of the test sites has been and continues to access by test personnel in China. It is kno wn, ho wever, that the trajectory as w debris ve radioacti carrying cloud the of deter- be restricted by military control. There are practically no The test. a each ery v access making for mined up set Health Public of Ministry roads leading to the Algerian test sites, for en vironmental radio - nuclear the at performed been recently has ey surv A nationwide difficult. monitoring netw ork ne has site test Nor Lop the ut b 1960s, early the ver in vity acti test sites [I32]. External dose rate measurements were made could been opened to W estern scientists and no information at 76 locations. A total of 25 en vironmental samples were of rate number the While collected. dose measurements w as be located on present le vels of contamination and public e the that indicates information vailable a although xposure, considered adequate, the number of samples collected and the for e reserv a made as w site some what Bactrian endangered highly analysed w as small, in vie w of the size of the residual little ve ha sites test the at areas the of Most areas. [S22]. camel material e xcept: (a) the ground zero locations radioacti ve of Gerboise and Blanche Gerboise the tests atmospheric Bleue Re the at ve ele hitka, United States Amc (ix) site, ha that areas the where vated test ganne xternal dose rates are only a e v ery small part of tracts the are confined to distances of a fe w hundred ve radioacti as w there that stating report a 335. Following surv eyed and en and points; zero ground vidual indi four the from metres leakage from the test site to terrestrial and freshw ater vi- T tunnel, E2 the of vicinity the in Afella an T aourirt at (b) ronments, concentrations tritium determined eys surv recent sites in surf ace - w ater in the range 0.41–0.74 Bq/L at the sam where at the opening of one of the partially confined under- at Only sites. leakage reported the included which pled, the ground tests an accidental release of fission products mix ed ve radioacti with of bed ge lar a formed and place took rock molten of leakage where site, test Shot Long the to ases g 3 hardened lava. ace surf occurred in 1965, were higher near H le vels 239 240 1997. Pu alue Pu/ mean The v in ed still Bq/L) (5.8 observ samples for Amchitka alues v with 0.1991, as w the of all 332. Despite t he p reliminary n ature o f t he s nd a ampling 0.2431. to hat 0.1824 ndicate i onclusions c ll a rogramme, p nvestigation i from ranging t a d o n ot j ustify ates r r equirement xposure e resent-day p 239 3 240 s v iew o f t he c urrent resh- tate o f d evelop- f or i ntervention, 336. The m easured H l evels a nd i Pu/ n Pu r atios i n f t t he r egion. H owever, i f he e conomic c onditions ment o f water m oss a nd s ediments a t A mchitka p rovide n o e vidence or t he hange i n t he a rea, t he r equirement f c i ntervention a t o f l eakage o ccurring a t t he s ites. D eviations f rom t he m ean 239 240 E 2 t unnel s ites G erboise B leue, G erboise B lanche a Pu/ nd Pu r atios f or g lobal f allout w ere o bserved i n m arine eganne, v isi- s hould b e r econsidered. A t R f or o ccasional a lgae, s ediment a nd p ooled A mchitka s amples, a nd m ay ue d adiation xternal e o t xposures e ite, s he t o t tors s nother a uggest s r arine m he t o t elease r lutonium p f o ource o t r r adionuclides f rom t he t ests a re l ikely t o b e l ow, esidual nvi- e nd a nalyses a n i ncertainties u owever, h nvironment; e d ay, w hile t he a rea ny a efore b ssessed a ully f e b o t eed n rocesses p ronmental i .e. l ess t han a f ew m icrosieverts p er fella eces- n ot n o d esults r hese T rawn. d e b an c onclusions c rm fi a t T aourirt T an A h as b een p ublic p rom f rotected b y a s ecurity f ence. i sarily m ean ntrusion t hat l eakage f rom t he A mchitka u nderground ccur i nto t he N orth t ests i s n ot o ccurring o r w ill n ot n uclear o acific P t t he a bove-mentioned s ites, a t t he o odel- m ydrogeological H ea. S ering B he t r ddition a 333. In o cean O 3 t lutonium p cker, E n I t a ite, s perimental ex ikertine T drar A ling p redicts hat l eakage o f H f rom t he t est s ites i nto t he fi T n i he rea. a ide w a r ove pread s as w orm f articulate p ne m arine w ater m ight b e s een b eginning 2 0 t o 3 ,000 y ears rom f etermined d as w and s n a i lutonium p f o oncentration c f rom n ow [ D2].

284 268 REPORT: V OLUME I 2008 UNSCEAR contaminated by non-nuclear tests (b) Sites stones may ricochet and be found lying on the surf ace and some distance from [U20]. area targeted the (i) ar sites contaminated with depleted uranium W round the of 70%) (maximum 341. Normally 10–35% e nrichment p rocess u f or n atural ranium, 337. During t he becomes armour aerosol on impact with . Most of the dust 235 t n atural l evel ( 0.72% he U f raction i s i ncreased f rom i ts less particles are than 5 μm in diameter and dispersed be can fter a emains r hat t ranium u he T b y m ass) t o ore. 2 % o r m according wind to direction. spreading vironment, en the in emoved een b as h raction f r on- c educed r as h t he e nriched The amount of dust produced is actually small, because the 235 234 nown his a s T b y-product i s centrations o f U a nd k U. hit or gets tar their miss soft munitions DU of majority ast v 235 U u ranium ( DU). T he d epleted c ontent i n D U i s d epleted DU the of dispersion dust The intact. remain and gets tar bout o ne t hird t o 0 .2–0.3%, o f i ts o riginal n atural f raction a resuspended acti - depo subsequent and air the in vity to leads 234 ince S U17]. [ i s a l ighter i sotope, i ts U c oncentration i s wever, sition on the ground. Ho such radioacti ve material a nd l ower i n D U i igher h uel c f n u ranium orrespondingly should be limited to within about 100 of the tar get. In a m U act f he T ranium. u atural n ith w ompared c h hat as t D main hazard radiological associated the situation, combat 234 235 ower c oncentrations o f l U a nd han U ranium u atural n t inhalation when with DU munitions is of the aerosols created adioactive t han n atural u ra- m lso eans t hat D U a i s l ess r [U20]. DU munitions hit an armoured target 231 234 sotopes i f o races t nly O nium. n i Th nd he a Th t eyond b d ecay p roducts d ecay c hain a re p resent i n D U, a s t he o ther radu- p enetrator f ragments a nd 342. Small D U d ust a re g t ad h ot n ave h ime n i uantities q ignificant s n i p u uild b o t t ally t ransported i nto he u pper s oil l ayer b y w eathering o t otal t he T he t ime s ince t he D U w as riginally p roduced. ind, rocesses. p ainwater o r s urface W w ater fl ow m ay a lso r o f n atural u ranium i s 2 5.4 B q/mg, w hile a pecific s ctivity ust. oil s he t hrough t U D f o obilization M d he t r edistribute T D f o hat t U i s 1 4.2 B q/mg. able 4 3 g ives t he m ain p hysical U D f o igration m t ossible p p he nd a rofile roundwater g nto i sotopes p o f t he t hree i roperties o f u ranium a nd c ompares hemistry epend d ill w o n a n umber o f f actors, s uch a s t he c a t elative a bundance b y m ass r nd a ctivity i n n atural heir s tructure a o f t he s urrounding s oil, r ainfall drology hy nd a nd D U [ U17]. nd u ranium a [ U20]. military and vilian ci both pur- for used been has 338. DU v ery ener getic particles alpha 343. The by emitted DU are vilian poses man y years. The ci applications include uses for - pen barely b can y The tissue. in range limited ery v a ve ha ut counterweights aircraft. in DU is in radiation shielding or as the of layer xternal e the etrate a pose not do hence and skin . is DU of made Armour armour tank vy hea for used also irradiation, xternal e of terms in irradia internal ut b hazard - more resistant to much penetration by anti-armour munitions tion is an important consideration. Uranium is not generally hard Also, plate. armour steel rolled ventional con than o wing fectively ef transferred food chains; therefore, in through of property its , and point melting high density high its to its xposure e path - en vironmental assessments, inhalation is the becoming “sharper” as it is penetrates armour plating, DU such primary attention. Processes usually that way as merits yrophoric; p is impact on DU munitions. anti-tank in used deposition through the soil, migration of resuspended mate - a DU ag its tar get, ainst penetrator will ignite, breaking up transfer to groundw ater may , ho wever, rial on to crops and aerosol into and an forming fragments of particles (“DU in of interest [I24]. the longer term be air in spontaneously ignite can [I24]. dust”) that 344. The may concern of xposure e only xternal e from arise 339. Both with munitions, DU fire can aircraft and tanks to beta radiation the skin if a penetrator is placed in a pock et and mm) 120 and (105 rounds ger-calibre lar firing tanks air- orn is on an a or neck ornament chain. used This w could as and -calibre craft rounds (25 smaller 30 firing mm). T ypically in radiation some localized result doses high after quite - DU the conical round a by has pene aircraft fired A-10 DU of weeks e continuous xposure. Although there will not be trator, in the a 95 mm diameter with length and of base at . y urns, an b skin may occur resulting radiation The erythema ed et. 16 fix inside an aluminium mm, The weight of one jack of insignificant, be will xposure e radiation amma g same the - penetrator penetra When [U20]. approximately g is 300 the at radiation, natural as [U17]. magnitude of order most tor ehicle, the v penetrator armoured continues an through hits outside. remains usually jacket the while armouring the 345. Although it has been suggested that DU from muni - osovo or other K locations in may remaining migrate tions urst 340. A typical by an A-10 aircraft occurs for b of fire ater, the uranium concentration arising from to groundw volves s 120 rounds. ground 195 in the and to hit These 2–3 with ould be undetectable compared naturally w source this apart, the m on 1–3 in line, angle straight of the depending a ater. et occurring Oeh concentrations [O3] in w al. measured gets Penetrators hit approach. that either or tar non-armoured urinary the and samples ater w a in uranium of xcretion e gets uried generally intact will and become tar b miss remain gion yed. osovo where were deplo More K of re DU munitions depends of ground. The depth the on the in angle the peacek 1,300 samples from personnel and than urine eeping get approach, the speed of the plane, the type of tar the and of controls une genders and ages were dif ana ferent - xposed ace. nature In the clay penetrators ground used of soils, surf xposed for 113 measurements une urine The subjects lysed. a of attack aircraft may reach A-10 depth by more than 2 m. of rate e uranium a had stand (geometric ng/d 13.9 - xcretion versely, as hard penetrators rocks such hitting objects Con viation The 2.17). analysis = of (GSD) 1,228 de urine ard

285 ANNEX EXPOSURES OF THE PUBLIC AND W ORKERS FROM V ARIOUS SOURCES OF RADIATION 269 B: from samples peacek eeping personnel resulted in a geo - a gainst a h ard s urface w hile t he p enetrator e nters t he t ar- the get. mean of 12.8 ng/d (GSD = 2.60). No DU could be metric P otential ex posures a rising f rom j ackets a re f ar l ower a lu- ater ade m found in re a ackets j he t w samples, and y there w as no dif ference f t han f an rom p enetrators, b ecause o xposed e potentially persons from samples ow l ry ve nly o ave h and hey t hich w f o U, D han t ather r minium urine between U17]. [ controls. evels l 350. It been confirmed that DU munitions ha ve been has as ay w same the in chemically reacts DU Metallic 346. ve reacti a be to considered is which uranium, metallic used in se veral recent military conflicts, including the Gulf - mate W Studies carried out on penetrators collected in K osovo, 1994 in govina Herze Bosnia in conflicts the 1991, in rial. ar impact caused in used also probably as w It 1999. in osovo K in and Serbia and Montene gro sho wed that the 2003 ground w Iraq This f avours subsequent in cracks fine numerous penetrators. ar. A vailable estimates of the total munitions used in vely 44. corrosion and dissolution [U17]. Corrosion occurs relati each conflict are presented in table when the penetrator remains in the ground and is quickly A penetrator can be completely corroded surrounded by soil. 351. Kuwait. The 1991 Gulf W ar w as the first conflict in products years follo wing impact. The corrosion in the 25–35 which DU munitions were used e xtensively. The total number dissolv e and disperse in w ater. Ho wever, the rate may in turn of rounds expended in the Gulf W ar is estimated to be about If the of corrosion depends on the composition of the soil. 860,600, representing a total weight of DU of about 286 t penetrator is lying on the ground surf ace, the corrosion rate [I24]. Of the 3,700 Iraqi army tanks destro yed during the corroded uranium is is significantly lo wer. Ho wever, t he 500. Gulf W ar, DU munitions accounted for only around loosely attached and easily remo vable. Consequently , if such easily a contaminate penetrator is pick ed up, it the skin 352. A l arge n umber o f D U m unitions w ere s tockpiled o n could nited and clothing of an yone handling it. Buried penetrators t he U S and tates re fi a hen w oha D amp C f o ase b ilitary m b roke o ut o n 1 1 J uly 1 991. A fter t he i mmediate c lean-up jack ets may inadv ertently be brought to the surf ace in the through o construc or val remo soil of part as digging - future corre- ( enetrators p U D 00 3 pproximately a perations, t then be the ork. w tion o f 1 ,500 k g o f D U) w ere f ound a o t sponding t o b e The corresponding e xposures w ould otal ets T he a rea wa s f enced a same as for penetrators and jack issing. m n I estricted. r t i o t ccess a nd currently lying on the onducted. s wa here T 001, c ere w ctions a emediation r 2 vi- e surf ace. f he t f o dence amples, b ut o D U i n e nvironmental s resence p 238 rders reports been ve ha 347. There the DU in munitions con - f o that o wo t han t ore m w U f o oncentrations c he t ere l ower t han t he v alues o bserved i isotopes as such radionuclides, other of amounts small tained n t he s oil p rior m agnitude 236 ay americium and plutonium as well as of U. The presence of d ach e ours h everal s pending s erson p A emediation. r t o S μ .7 7 f o ose d a eceive r ould c ite s he t n o rking wo these man-made radionuclides indicated that some of the he t ver o v rom a y ear, m ainly f f i nhalation o f r esuspended o ourse c DU had been obtained irradiated been had that uranium from ur- in nuclear reactors and subsequently reprocessed, resulted or m aterial. I ndividuals u sing t he a rea f or r ecreational p f uld poses r eceive d oses o f a bout o ne s ixth o wo t his. A ccess from contamination of equipment in the processing plant ctual a nd a estricted, r emains r rea a he t o t the during of spent nuclear fuel [I24]. reprocessing U D o t ue d oses d eople wo rking o r s pending t ime p n earby wo uld b e l ower t o 348. Doses [ U24]. s to members of till the public li ving in areas where be could y the e xposed to DU munitions are v ery lo w [I24]. adjacent to the possible - popula which 353. At ays pathw veral se are There the Military Hospital storage site, through contaminated tanks by emitted radiation to xposed e be may areas in tions area where had been stored, some DU these . layer soil the in present as w cm 5 top highest of inhalation is ay pathw significant most The munitions. DU the wever, Ho 238 that ha ve been resuspended either by the wind four to o tw about only were ed observ U DU particles of concentrations or the DU of Fragments ploughing. as such vities acti human by times v alue e xpected from the natural background le vels to brought the surf ace during the construction of be can across K uwait. A person who w orked on this part of the site of DU lying on the ground surf ace Sv, μ 3.3 of about houses, roads, etc. Lumps could recei ve an annual dose due to DU or penetrator fragments) can material. resuspended of inhalation via entirely almost be (either complete penetrators Annual there , Consequently public. the of members by up ed pick is doses to members of the public using the area for being of possibility a be ould w recreation people of members to Doses Sv. μ 1 than less and beta xternal e to xposed e radiation and to internal radiation if dust from cor- wer lo be ould w acilities f nearby of use making public amma the g radi still roded DU or DU fragments enter the body . The [U24]. - surf ace g from its from radiation amma and beta includes DU ation 234 store to used is aty Kw Al Um of site decay product, 354. The Th. The e xternal dose due to direct contact - thou veral se with [F7, mSv/h 2.3 be to estimated been has fragments DU sand Iraqi military v ehicles destro yed during the w ar, among I24, U20]. U17, them 105 tanks contaminated with DU. It is estimated that a the tanks stored at the site ha ve total of about 1 t of DU t he n on-DU p art 349. As m entioned a bove, t he j acket i s associated with them. The site also contains 366 heaps of w eapon p rojectile t hat e ncases t he D U p enetrator. T he o f a contaminated soil from Al Doha that contain ash from the s acket mpact j he t hat t o s esigned d s i rojectile p i pon u tops fire at Camp Doha, fragments of munitions and other

286 270 UNSCEAR REPORT: V OLUME I 2008 as debris. The debris is estimated to contain about 1.5 t a ound f w ir a n i ontamination c U D ood. f n i actor f ptake u metallic t wo t b of DU. Access to the site is currently restricted [U24]. ad h se u U D here w een c onfirmed. T he c oncentra- ites s nd ery v ere w tions ow, a t he r esulting r adiation d oses w ere l Iraqi of rom f m 00 1 ver o f o istances d t A nsignificant. i nd a inor m voy con a on attack an in used were rounds 355. DU at a i etected d e b ould c U18]. U D o n c ontaminated v ehicles n Al Mutlaa, a major and e xpanding urban area t he a ir [ reas, a population of about 50,000. V ehicles the in yed with destro Kosovo. attack DU 1999, in conflict osovo K the During 360. ha ve been remo ved and the road has been completely egetation or soil either of samples the of None aced. resurf reported been has it aircraft; ATO N from fired v were weapons o concentrations the and DU, of amounts detectable contained that the ver 30,000 rounds of DU were used. Because of 238 in the soil samples were consistent with the alues U of risks posed by mines and une xploded ordnance, the sites v xpected generally in soil in in vestigated by UNEP in Kuwait. 2000 were limited compared with e the total area potentially af fected by the use of DU in K osovo Manageesh sites co ver oilfields a v ery lar ge area south- DU using ed attack and represented some 12% of all 356. The the Gulf W ar the y were sub - conflict Kosovo the during munitions [U20]. west of K uwait City . During raids munitions. DU volving in air repeated to jected The to contain se veral hundred area as a whole is thought still 361. No significant widespread contamination of ground xploded landmines and cluster bombs. K Access to this localized although osovo, une surf aces or soil w as found in restricted. penetrator to close contamination of points concentrated area is also xist. sites or penetrator holes e impact The le vels of DU fragments that xcluded DU e be cannot it 357. Overall, of detected decreased rapidly with distance from impact points, and col - were penetrators or entire munitions might still be found the maximum distance at which levels still measurable 10–50 m. where uwait K in locations at public the of members by on found as w et jack a or penetrator a When lected being nor- surf ace of the ground, the soil belo w the penetrator the DU munitions were used in the 1991 Gulf W ar. Prolonged mally impact the of area The DU. of vels le measurable had skin contact with these DU residues is the only possible 2 normally as w point m ut the rela - , 0.04 than less i.e. small, e xposure pathw ay that could result in e xposures of radio - b areas concentration of DU at such a point could be high. The remains tive logical significance. As long as access to the the lik could public absolute the of members that elihood concentration of DU in soil restricted, v aried from a fe w mil - per DU of g 18 about to soil of kilogram per DU of ligrams is residues pick up or otherwise come into contact with these of kilogram soil, which corresponded to about 6% of the w lo [U24]. penetrator. a of weight t arget Bosnia and Herzegovina. s ites T here a re 1 5 358. onfirmed O reaty T tlantic A orth N he t y b rganization c measur- with points impact beneath soil of depth 362. The nd a osnia B n i NATO) ( the as normally vels le DU able in the range 10–20 w cm, with unitions m U D here w erzegovina H w u sed, o f w hich o ne i s i naccessible b ecause ere o f t he p res- This depth. increasing with decreasing concentration vity acti re a lso s ix N ATO t arget s ites i n t he dissolution the from resulted probably ution distrib ertical v ence o f m ines. T here a the w or f arajevo S f o icinity v and dispersion of DU follo wing initial iss- m till s re a oordinates c he t hich surf ace contami - ites s hese T ing. ould f o hree T nvestigated. i e b ot n herefore t c nation or from the penetrator lying on the surf ace. Ho wever, the amount of DU at the impact points w as v ery w and the t he 1 4 s ites i nvestigated b y t he U nited N ations E nvironment lo ( rogramme insignificant. exposures corresponding P ontamination, c U D howed s learly c UNEP) f onfirming t he e arlier u se o c D U o rdnance. N o D U c ontami- ites s 1 1 ther o ace of penetrators w as probably subject to f o one N 363. The nvestigated. surf i nation w as f ound a t t he t as w material ve radioacti the of part as oxidation, t he easily f o ontamination c idespread w f o igns s howed s ites s hese U D urface s round G urface. s remo round g ved from the oxidized surf ace. Ho wever, the amount as w ontamination c 5 - i.e. ally l imited t o a reas w ithin 1 –2 m o f p enetrators a nd t , penetrator the of mass the of ypi 10 about w, lo ery v as w a c the of case the in As enetrator p y b aused c ontamination c f o oints p ocalized l milligrams. fe w soil the penetrators, beneath 3 00 c ontamination p oints w ere i dentified A mpacts. i lmost a jack et had measurable acti vity to a depth of s nly lightly d uring t he m ission, b ut m ost o f t hem w ere o 15–20 cm. The potential e xposure to radiation arising from r w ere c ontaminated. G iven t hat s everal t housand D U the jack ets is much lo wer than from the penetrators, because ounds t he r slightly only are and DU of made not are eportedly fi red a gainst t he t arget s ites ets i nvestigated, the jack i s l ow. I t i s p ossible t hat t he m ajority o f t he [U20]. contaminated n umber f ound enetrators U18]. round g he t n i eep d uried b re a [ p 364. It is probable that man y penetrators and jack ets remain ground. the in depth metres some at hidden i measurable rinking d he t f o ne o n dentified i learly c e b ould c 359. DU No w A s econd d rinking w ater s ample f rom a w ell amples. s ater le vels of DU were found in houses, v ehicles or other objects. t races o f D U c ontamination, w hich w ere d etectable - s howed Results on the le vels in botanical material were not conclu easurements. D U o nly t hrough t he u se o f m ass s pectrometric sive e xcept for lichen (and possibly bark). No measurable m w as f ound i n l ichen s amples a t t he t s ites m entioned a bove. le vels of DU were found in milk samples tak en from co ws hree easons t o e xpect t he p resence o f a ny D U i n f ood, T here a re n o r grazing in fields that potentially might ha ve ele vated le vels he t o t wing o l he t nd a round g he t n i ate r ispersion d ow ow l of DU [U20].

287 EXPOSURES OF THE PUBLIC AND W ORKERS FROM V ARIOUS SOURCES OF RADIATION 271 ANNEX B: U, s i ontamination c ut b D ith w ontamination c nvironmental e Serbia, significant Serbia and Montenegro. le vels 365. In t nticipated a till s ound, f e b a s m any o f t he d estroyed I raqi o of DU were found at localized points in the immediate vicin - t anks a nd ounds, r U D y b it h ere w arriers c ersonnel p rmoured a ity of penetrators penetrator around and ground the on lying rmoured –7 n ormally t imes p er a 2 v ehicle. T hese v ehicles a re decreased The marks/holes. impact DU detected of vels le ontamination t herefore e xpected t o h ave e xtensive D U c i n t he - with distance from such rapidly points, and be yond a dis U rine nalysis i n orm f f d ust a nd o l arge f ragments [ U19]. a tance of one metre were no longer detectable by field meas - U S tates p ersonnel een nited as w ho s erved i n t he c onflict h b urements. wever, ho samples, soil of analyses Laboratory U o t xposure e egarding r nconclusive i [ M24]. D for traced be to vels le acti enabled further metres veral se vity from the points. More detailed laboratory analyses of soil w lo widespread vealed re samples the of e fiv at of vels le DU (ii) Contaminated sites in the Russian F ederation sites study six [U17]. the former inherited Federation Russian 370. The from can 366. Localized points of at occur vity acti increased - veral se Union viet So thousand square kilometres of radio to has that penetrator a of close sites or impacts penetrator of tens some petabecquerels and land nuclide-contaminated and corrosion. to subject been The ace surf the on remained of gan be contamination vironmental En aste. w ve radioacti ut of DU can be v ery high at these the points, b concentration w as particularly intensi ve in and the early years of the of increased acti vity is v ery limited, normally e xtent the “ Atomic Project” acti vities initiated in the mid-1940s [V10]. radius a , widely aries v amount within total the and m, 1 of Federation, Russian the in present At million 650 about in the range 0.01–10 g of DU per kilogram soil. being metres of liquid and solid radioacti ve w aste with a cubic acti vity le vels are measurable in Beneath these points, the 19 Bq (2 billion curies) 7.4 total 10 × acti vity of approximately wn do soil vity acti the with more, or cm 10–20 of depth a to ve 12,000 approximately addition, t In accumulated. been ha with increasing decreasing depth concentration [U20]. The 20 × of about 3 10 of Bq spent nuclear fuel, with a total acti vity vered in decreased mass had by reco 10–15% penetrators are k ept at the sites of Minatom and other (8.2 billion curies), corrosion. of important This implications because for has [L2]. Federation Russian the in agencies possible well for as future approaches decontamination as ater. y as not present w in migration an groundw into of DU total with contaminated radionuclides area land 371. The groundwater or drinking water samples [U17]. the result as a of about is enterprises Minatom the of vities acti 2 km 480 About total area contaminated with 15% of . the o 367. Airborne at tw detected of were the particles six DU has radionuclides abo ve of rates xposure e radiation amma g ve While particles become these airborne may from sites. ha 2 km , as w 65.7 More [L2]. Gy/h μ 2 than 90% of this land, i.e. - pos highlighted finding the operations, digging on-site the the accident at the Mayak com - contaminated as a result of sibility xposure ays associated of with pathw soil e distur- plex in 1957 [V10]. The main areas contaminated and sites verall xposure o DU decreases e sites. at to The DU bance 2 as w 45. km 0.26 about of area An table in described are xposure airborne with time as the from contamination e via and rehabilitation of restored in the period 1996–1999, ace resuspension the dust ground DU surf of decreases on 2 the km 13.5 period for land planned contaminated of is - other the migra DU of probability the hand, On time. with 2001–2010 [L2]. wing tion soil the in time, DU with to corrosion of o increases v- y to be hea [U17]. Man penetrators penetrators were found ining a nd m illing e nterprises, m ore 372. At o re m u ranium - ven ily similar rate a gi corrosion, and those corroded, pen of arren illion o f s olid w aste ( in t onnes d umps o f b t han 3 00 m ace etrators ve less disappeared surf the on more still ha may or m illion c ubic r ocks a nd u nspecified o res, e tc.) a nd a bout 6 0 vironment objects) from solid within en 10–20 (as years. the etres l iquid w aste ( in t ailings d umps) h ave a ccumulated f m o uried deep What of b case the penetrators in in happens the heir t resent p he t o t p u ime. n adio r o t due ( ctivity a otal t uclides T not yet known. is ground 15 1 × 7 bout a o s i roducts) p ecay d ts i nd a ranium u he T Bq. f 0 2 [ k .871 9 s i umps d he t y b ccupied o rea a otal t m L2]. ormal ere he oncentrations 368. Uranium ithin w n c w t on- or ange ater. n he ranium rinking oncentration T r i w c d u f c and metallur gical 373. Chemical enterprises for nuclear ere f n lso amples centrations ranium ir aried i a s w a u o v ha fuel and material ve accumulated production element ormal hey he ven pper ere ange, hough n ithin he t t i w t u e r n t w 3 than more and aste w ve radioacti liquid of about m 600,000 NEP o f hat ange. he art 000 n ission osovo T o U p m t 2 i r K t radioacti radio containing aste, w ve - solid of tonnes million 5 ioindicator ppears e f hat ichen irborne o ound b o b a a t a l t f with nuclides of uranium, thorium and their decay products U ontamination. c D 14 The acti vity of o ver 1.6 × 10 total Bq (4,200 Ci). area of 2 contaminated with radionuclides is 1.868 km land , includ - t f Iraq. o here ime onclusive 369. he riting, ere A t o w t w n c t 2 xposure e with in km 0.464 ing the rates range 2–10 μ Gy/h U esults ublicly evels vailable rom n ssessments f l o D f a p i r a (200–1000 R/h). μ unitions lso, nvironment n raq. he U f mount he o I t e m D i a t A he nd nknown. re onflict 003 n mpact f ites he sed t t i 2 c s a u o a u i operating were there 1999 50 374. In nuclear research ublic o n onclusions he urrent ituation egarding s c r t o c p N Russian reactors or critical and subcritical assemblies in the relimi- xposure resent. ue o t U n rawn an e raq d c P I i b D t p d e a 53 Federation, suspended been had operation whose acilities f etected ot ave urveys raq n f nary pots” hot “ i o I s h s n d

288 272 REPORT: V OLUME I UNSCEAR 2008 t ere i n t he p rocess o f d ecommissioning, a nd 6 fa cil- preparation fuel to radium, with hat dealing or for nuclear po wer w he defence with associated institutions research to and plants t rom f uel f uclear n pent S onstruction. c nder u ities a t t he f ollowing programmes. fa cilities wa r esearch c oncentrated m ainly s K urchatov I nstitute; t he s ites: t he R ussian R esearch C entre f R he t ngineering; E ower P nd a hysics P esearch o nstitute I 379. The United States En vironmental Protection Agenc y I nstitute o f A tomic R eactors; t he S verdlovsk B ranch o f t he (EP A) coordinates a project aimed at identifying and clean - country a the throughout areas contaminated up ing . It has R esearch nd D evelopment I nstitute o f P ower E ngineering; he t hysics P uclear N f o nstitute I etersburg P t. S f t he 61 these, of radionuclides; with contaminated sites 84 listed o the on currently are Priority R ussian A cademy o f S ciences; a nd t he K arpov P hysical National List. Of these, A’s EP C hemical R esearch I nstitute’s b ranch i n O bninsk. T he - mili nuclear States United with ed link nd directly are sites a 14 a 8 0% ven Brookha sites): re USDOE (i.e. operations programme tary i nterim s torage fa cilities f uel f uclear n pent s or Feed Material [ verage a n o lled fi National Laboratory , Ne w Y ork state; L2]. Produc - tion Center , Ohio; Hanford Areas 100, 200 and 300, W ash- the 375. At were studies Association, Industrial Mayak ington state; Idaho National Engineering Laboratory , Idaho; with soil. carried out on Karachai Lak e, which is being filled La wrence Li vermore National Laboratories, California; 1951, the lak e w as used for the dischar ge of Ohio; Plant, Oak Be ginning in Monticello Mill T ailings, Utah; Mound fusion Dif Gaseous aducah and P medium- ennessee; T ation, Reserv ver Ri high-le liquid radioacti ve w aste. Stage-by- vel in started as w oir reserv ater w the of 1988. stage Plant, K entucky; Rock y Flats Plant, Colorado; Sa vannah remediation result of the remediation actions, the a verage At present, as Ri ver Site, South Carolina; and W eldon Spring, Missouri. a and the 3 ver o of actor f a by reduced been has e Lak Karachai of area F our sites are related to production of radium de vices 2 products, phos mainly NORM, to related are sites eight and - - emana the (to 100,000 m ), which has significantly reduced ace surf ater w the from aerosols ve radioacti of tion vy-metal hea and processing ore phate and About smelting. - shore w aste disposal by wind. This w ork is subsequent their and line ve ha sites 25 transport by contaminated improper been landfill; be to soon are sites these of some completed as aste w of use the by or [L2]. concern main The military inside installations. sites such for contamina - related to the public e xposure due to possible is 376. At the Mining and Chemical Comple x, tw o of the tion the sites, other the or F origin of the ater. groundw of three uranium–graphite production reactors ha ve already radioacti led operation reactor of years y Man wn. do shut been the ve contamination is not clear , e xcept for one site, to result radiopharma of a as contaminated been ve ha to - reported storage and cooling in silts ve radioacti of accumulation the Y enisei Ri ver also programme national and ponds, ge lar A [E5]. acture manuf ceutical contamination of caused - con hazardous of clean-up the gets tar Superfund the called flood plain. Contamination le vels in the Y enisei flood plain when the reactors with once-through cool - at operations very reco conducting is and sites taminated be gan to decline ing do operations remedial them of some for listed; sites the of most were shut wn. Dose rates in the range 0.08–0.4 μ Sv/h completed. already ve ha been ha ve been measured in populated areas along the Y enisei once-through Ri ver. As a these result of the shutdo wn of the radionuclide dischar ges into reactors, Y enisei Ri ver ha ve decreased opean Union (iv) Contaminated sites in the Eur by a f actor of o ver 10, and the present e xposure rate at the w ater surf ace does not e xceed allo wable v alues, orth ounreay D 380. The c oast n he t n o ocated l ite, s uclear n e ven at the discharge point [L2]. o f S cotland, U nited K ingdom, w as r esponsible f or t he r elease and-sized had vy Na Russian the 2000, to 377. Up 184 wn withdra o f a n u nknown q uantity o f a pproximately s f rag- 950s, ments o f i rradiated n uclear f uel d uring t he l ate 1 1 960s nuclear submarines from service. Of these, 108 were in the h ounreay D rst fi he T 1 nd a Murmansk (the country the of part north-west t Archangel and ormally f e b o article p ot 970s. and the F ar East (Primorsk and the Kam - n i oreshore f ounreay D he t rom f ecovered r as w dentified i gions) re were 76 in urther andside S rom f ecovered r as w article p ingle s f A 983. 1 chatka re gion). Spent nuclear fuel w as not unloaded from f he t each B articles nd a etected d een b ave h P ear. y ollowing most of the submarines. A number of the nuclear submarines f emoved r 984 1 ince s egularly r oreshore f ounreay D he and ago, years 10–15 ver o service from wn withdra were t rom 1 defects the v essels’ structures ha ve appeared during this ndi- i ,200 in ver O 997. 1 ince s ediments s ffshore o he t rom f nd a f een b ince s ave h articles p vidual long period afloat. The nuclear submarines with spent inter- ( ittoral l he t n i ound f ounreay, D o icinity v he t n i nvironments e arine m nd a tidal) nuclear radiation potential serious a represent board on fuel o hazard to the environment [L2, V10]. he t ounreay), D f est w m k i ncluding S andside B each ( 1 a each ounreay f oreshore, D unnet B D nd M urkle B each ( both nd a ounreay), D s arine edi- f m n i a pproximately 2 5 k m e ast o n I ite. s Contaminated sites in the United States (iii) he t o t djacent a ments ounreay articles p 6 8 ddition, D a o h ave b een f ound 4 table ( 6). tself i ite s ounreay D he t n the main The 378. United States are contaminated sites in 137 prod other of and uranium of mining the to related - usually are detected in the en vironment by their 381. Particles Cs that ucts phos as - (such ore the with associated uranium ve ha g amma acti vity, b ut the total acti vity is dominated by the 90 90 phate to monazite, industries of processing the to beta emitters rocks), Sr and its associated Y. The particles were

289 EXPOSURES OF THE PUBLIC AND W ORKERS B: FROM V ARIOUS SOURCES OF RADIATION 273 ANNEX during the reprocessing of fuel at Dounreay during lo w-level w aste w as released into the open Barents Liquid produced On histories operating reactor of basis the Seas. Kara and of types main wo T 1970s. and 1960s 1950s, particle, late the calculated spectra, the estimate of the total ast F Dounreay and Reactor est T Materials from and neutron produced aste w ve radioacti vel high-le the of ventory in nuclide at radio Reactor fuel, ha ve been identified. Materials T est Reactor the total reco vered, were up ~80% of the time it w as dumped has been re vised to 37 PBq. The cor- particles, which mak e responding as w sea at dumped aste w vel high-le of ventory in and milling during conditions ault f of result a as produced be milling These reprocessing. to prior operations, cropping to estimated which 86% were fission of 1994, in PBq 4.7 90 137 vation radionuclides Sr and acti vities stopped at Dounreay in (main acti 12% Cs), Reac products 1973. Dounreay F ast - 63 ustion comb during produced ely lik most (main radionuclide actinides Ni) products 2% tor particles were (main and 241 incidents v- Se reprocessing. during ycle c dissolution Pu). radionuclide the in eral such incidents are kno wn to ha ve occurred between 1969 1972. Kara in