Lessons learned from Fukushima Daiichi Nuclear Power Plant Accident From clinical perspective

1. Lessons learned from Fukushima Daiichi Nuclear Power Plant Accident From clinical perspective Koichi Tanigawa Department of Emergency and Critical Care Medicine*1 Radiation Emergency Medicine Promoting Center*2 Hiroshima University

2. Key Concepts • Exposed (irradiated) persons are not “radioactive” • Radiation is not responsible for immediate death • Trauma or heart attack, stroke, or exacerbation of underlying medical problems during evacuation or emergency care are more dangerous • Simple protective gears such as caps, cloths, gloves and masks alleviate risk of contamination • Sheltering (in-house evacuation) is very effective to avoid exposure from radioactive plume • Radiation can be easily measured

3. Irradiation Radiation Exposure Types Internal Contamination External Contamination * * * * * * * * * * * * * *

4. thick lead thin lead γray γray external irradiation aluminum foil βray R R αray Neutron (nuclear fission) internal contamination paper : radioactive materials

5. Contamination with radioactive dusts following nuclear power plant accidents • External contamination: Radioactive dusts may attach clothes or skin surface. However, irradiation by those dusts does not pose any significant health risk • Internal contamination : Incorporation of radioactive materials may poses hazard because of continuous irradiation; Example; I-131(β-ray) caused thyroid cancer in Chernobyl accident

6. Is there any health risk to medical personnel treating a person internally contaminated with radioactive dusts in a nuclear accident? No, it does not pose any significant health risk for families or care takers!

7. Criteria for discharge from controlled areas of hospital in patients with I-131 treatment for thyroid cancer, hyperthyroidism • Residual dose of I-131 in body, 500MBq (500,000,000Bq) • → • Exposure to care takers < 1 mSv/yr • → • Clear for discharge! • Health and Labor ministry, 1998/06/30 Permitted dose for occupational personnel by law 100mSv/5yrs, 50mSv/yr （for pregnant:2mSv/yr）

8. 1 1 0 m 0 S v S Level time（hour） / h v 4 　～　　1 3 　～　　10 2 c m 2 　～　　100 1 　～　　1000 0 unlimited Estimated time to limit external irradiation to medical staff less than 1 mSv 100kcpmby GM survey meter 1 0 0 0 1 1 0 0 μ μ . μ contaminated area 1 S S v v μ / / / h 0 0 h S h v / h L e v e l L e v e l L e v e l L e v e l L e v e l 2 4 3 1 0 1 0 1 2 4 6 8 1 0 1 0 1 0 1 0 6 0 2 C o B q / c m radiological density Permitted dose for personnel by law 100mSv/5yrs, 50mSv/yr （for pregnant:2mSv/yr）

9. Treat life-threating injuries first! • Safety for medical personnel • No significant heath risk • α-ray, β-ray：no concern regarding external irradiation • However, be careful on internal contamination • γ-ray: γ-ray from surface contamination is negligible • Simple protective maneuvers are effective as personnel protection • For Patients • Immediate deaths are caused by injuries or medical problems • No reports of immediate deathdue to irradiation itself

10. Setting up the decontamination area in hospital • Management of radioactive materials • ambient dose rate > 100 μSv/h at 1m • →isolate the substances （IAEArecommendation） • Secure routes for ambulance and patient with contamination • Sufficient space • Re-route the traffic and other patients • Cover the area floor with vinyl sheet and tape the covering • Designate the controlled (contaminated) area for decontamination • Establish a control line to the decon area • Prepare and check survey meters for use • Security

11. Example of a decon area and treatment zone (Emergency room in the Fukushima Daiichi NPP)

12. Set up a controlled (contaminated) area • Cover the floor, stretchers and medical equipment with plastic sheet • Remove unnecessary items from the controlled area • Demark the area with tapes or cones to prevent unauthorized entry • Necessary items for decontamination • Hot water and soap • Normal saline for wound decon • Absorbable pads • Surgical drapes • Plastic bags for specimens • Plastic containers for contaminated wastes • General surgical items, i.e., gauzes, forceps

13. Survey meters • GMsurvey meter • NaIscintillation survey meter • Ionizing Chamber Survey meter

14. Personnel protective equipment • Water resistant gowns • Double gloves • Surgical masks and caps • Eye protection • Shoe cover • Personnel dosimeter (γ-ray) • Needs to wear gloves doubly which allow you to replace outer gloves if contaminated • No need to wear a lead apron because γ-ray easily penetrate it

15. Achieve medical stabilization first! If necessary for life saving, bypass the decontamination room. Remove the patient's clothing and wrap the patient in a sheet to limit contamination of the treatment area.

16. Radiological surface survey • wound　→　 • orifice (eyes, mouse, nostrils) →　whole body • Take specimens using nasal swabs • 90% of decontamination can be achieved by simply removing cloths • Take blood samples for HLA typing if high levels irradiation suspected

17. Decontamination should be started from the wound → extended to other surface areas with higher contamination • Use normal saline to decontaminate wounds • Use tap water for contaminated skin with no injuries • Repeat this procedure until radiation levels go down to trough levels • Wrap up the contaminated areas with water resistant cover • *Note: radiological substances scale off along with the dermal metabolism

18. Chronological order of events in Fukushima

19. Fukushima Pref. Gov. Fukushima Medical Univeｒsity (FMU) 8 Hospitals, 1240patients 17nursing facilities, 983patients Off site center (Command center) Fukushima Pref. Radiation emergency Hospital NHK Hiroshima

20. In the Fukushima Daiichi Nuclear Power Plant accident, what we have seen, • difficulties in reallocating patients forced them to stay in the confined space of the transporting vehicles for long hours. • patients died during or soon after evacuation. • On the other hand, • no significant contamination was found in the evacuated patients from the 20-km area despite the fact that 48 hours had already passed since the first explosion. These facts suggest the effectiveness of indoor sheltering for protection from radioactive plumes.

21. Therefore, we conclude that, • In contrast to physical injuries caused by collapse of buildings or tsunami, radiation itself does not create any immediate life-threatening conditions. Rather, ill-prepared evacuation may increase the health risk of hospitalized patients or the elderly. • In the case of nuclear disasters, therefore, evacuation for these vulnerable people should be carefully performed with medical arrangements.

22. Medical responses for patients who suffered injuries following the explosion of No. 3 reactor on March 14th Fukushima city Fukushima Daiichi (No.1) Nuclear PP １Ｆ Fukushima Medical Univeｒsity (FMU) H Fukushima Daini (No.2) Nuclear PP 2Ｆ H H March 14th H １Ｆ FMU, NIRS, etc Ｏ Nuclear Disaster Management Center H 2Ｆ Ｊ March 15th J-village FMU Nuclear Disaster Management Center Ｏ March 16th Fukushima Daini (No.2) Nuclear PP H closed radiation emergency Hp H H partially functioned radiation emergency Hp Iwaki city H available radiation emergency Hp

23. As for emergency medical systems, • difficulties in finding hospitals to provide care for injured workers with contamination were observed. Fortunately, non of them suffered life-threatening injuries. However, collapse of radiation emergency hospitals may have resulted in preventable death for those with severe trauma. • Therefore, • more hospitals are required to provide emergency care for patients with radiological contamination, considering combined disasters such as earthquakes and nuclear accidents.

24. 9:00, March 15 21:00, March 15 Fukushima Iwaki Simulated radiation levels at 9:00 and 21:00 on March 15th, when massive radioactive materials were released from the No. 2 reactor of the Fukushima Daiichi Nuclear Power Plant. South-west spread of radioactives was observed at 9:00 (left). In the evening, however, the distribution shifted toward the north-west area due to changes in the wind direction (right). The bottom bars indicate radiation levels (μSv/h).

25. μSv/hr Serial changes of radiation levels at 7 sites in Fukushima prefecture from March 12th through 23rd. This graph was depicted using the data reported by the Fukushima Prefectural government on March 24th .

26. Report of the national government and the Energy Ministry of USA, May 6th. Estimated accumulation doses of Cs-134 and 137 (Bq/m2) Date Soma Fukushima Iitate Kawamata Minamisoma Nihonmatsu Namie Katsuraomura Motomiya Futaba Tamura Okuma Kohriyama Tomioka Kawauchimura Naraha Hirono Iwaki Chernobyl 1,480,000Bq/m2<: Closed Zone 555,000Bq/m2<: Permanent Control Zone

27. The medical teams were exposed to radiation risk, • due to lack of information on radiation. • We should understand the patterns of spread of nuclear plumes. Nuclear plume does not spread in a concentric fashion. It spreads discontinuously and changed its direction quickly by wind direction, geographic, and weather. • Therefore, we need • more monitoring devices and posts in place. Information on radiation should be readily available for all personnel involved.

28. Fukushima Pref. Fukushima Pref. Gov. No death from irradiation No death from explosions However, evacuation was accompanied by loss of life!! Off site center (Command center) Fukushima Pref. NHK Hiroshima

29. Shimane Pref. Fukushima Pref. Gov. Off site center (Command center) 30hospitals, 3800patients 83nursing facilities, 3144patients NHK広島

30. Summary There was no death resulting from irradiation or explosions. However, the evacuation from 20 km zone was accompanied by loss of life. Because irradiation itself does not pose any immediate life-threatening conditions, well planned evacuation should be considered. Significant difficulties were encountered to reallocate evacuated patients to hospitals. Admitting facilities should be designated in advance. Education for medical personnel and students should be emphasized and radiation emergency medical system needs to be refined. Proper knowledge on radiation mitigates health risks, overcomes misunderstandings and prejudice for the victims.