Medical Preparedness and Response to a Radiation Emergency

Transcription

1 Medical Preparedness and Response to a Radiation Emergency The Radiological Accident in Goiânia, Brazil Lecture 31 International Atomic Energy Agency

2 Content History of the accident Nature of the accident Different impacts Medical response Use of cytokines and Prussian Blue Lessons: the accident as a model for possible impact of radiation malicious acts 2

3 History of the Accident (1) On 13 September 1987, two scavengers entered the abandoned premises of a radiotherapy clinic in Goiânia and removed the rotating assembly of a 137 Cs radiotherapy device. At the house of one of them, they managed to break open the shutter of the collimator orifice and were exposed to radiation. 3

4 History of the Accident (2) Five days later, the violated equipment was sold to a junkyard. During the next days, fragments of 137 Cs were given to many persons and pieces of the equipment were sold to two other junkyards. Some people put fragments of 137 Cs in pockets or rubbed them on their skin. 4

5 History of the Accident (3) Over the next few days, people developed prodromal manifestations of ARS and local radiation injuries (CRS). Manifestations were not recognized by local physicians as radiation induced ones. Courtesy: Dr.Valverde, N. 5

6 Identification of the Accident On September 28, 1987, the wife of the owner of the junkyard suspected the manifestations people were presenting were caused by exposure to the object She and another individual took it to the Secretary of Sanitary Surveillance of Goiânia 6

7 Identification of the Accident as a Serious Problem Initial exposures: 13 September 1987 Initial manifestations: 3 to 4 hours after initial exposures Identification of the accident s nature: 29 September

8 Immediate Medical Impact Hospitalization ARS CRS Death 20 (ARS/CRS/Contamination/ Association) Screened people ~15% of the Goiânia population 8 Courtesy: Dr.Valverde, N.

9 Misdiagnoses: Insect Bites, Phemphigus, Allergic Reactions Example of alopecia (not from Goiânia) Radionecrosis of thigh From: The Radiological Accident in Goiânia,, Vienna (1988) 9

10 Screening for Contamination Local school 10 From: CNEN (Brazilian Nuclear Commission)

11 Past and Present: Influences on the Psychological Consequences The magnitude of the accident The myth of radiation as an evil force Severe medical manifestations and deaths The low cultural and social background of victims and patients Misinformation and lack of information 11

12 Environmental Impact: Waste Generation of 3500 m boxes; 4223 drums; 10 sea containers; 8 concrete drums; 7 houses demolished Photo: 12 From: The Radiological Accident in Goiânia,, Vienna (1988)

13 Seven Houses were Demolished From: The Radiological Accident in Goiânia,, Vienna (1988) 13

14 Socio-economic Impact Discrimination against victims, relatives, friends, neighbours... Vehicles with Goiás plates not allowed into other States of Brazil. Prejudice against Goiás citizens in airports, interstate bus stations... State of Goiás was not allowed to be present in a traditional Catholic charity fair in Rio de Janeiro Police force had to be used during burials The GDP of the State of Goiás dropped 30% within four months after the accident 14

15 Structure of Medical Response Site of the accident Olympic Stadium Triage station Primary care Medico-social character ARS Severe CRS Massive internal contamination GGH HNMD Secondary care Tertiary care International cooperation 15

16 Clinical Aspects: First Experience with GM- CSF in Radiation Accidents Patient Age (a) Sex Estimated dose (Gy) Estimated intake (Bq) Outcome LNF 6/F 4.4 1x10 9 died MGF 38/F 3.9 2x10 7 died AAS 18/M 3.7 1x10 8 died IBS 22/M x10 7 died MGA 57/F 2.8 1x10 7 survived EDF 42/M x10 7 survived WMP 19/M 1.8 5x10 7 survived GGS 21/M 1.9 1x10 8 survived severe CRS massive internal burden 16

17 Clinical Aspects: Apparent Response to GM- CSF leukocytes x 10 9 /L GM-CSF day PE 17

18 Use of Prussian Blue (1) The efficacy of Prussian Blue to reducing 137 Cs burden was followed by about 4000 urine and faeces bio-assays The average reduction of 137 Cs biological T1/2 with Prussian Blue was the same either with a daily dose of 3, 6 or 10 g: * In adults 69% * In adolescents 46% * In children 43%

19 Use of Prussian Blue (2) Activity in excreta 10 4 Bq X urine 14.8 x x. faeces 11.1 x 7.4 x x 3.7 x x x x x Time (days) 19

20 Side Effects of Prussian Blue Hypokalemia (possible values 2.5 to 2.9 meq/l) [The effect of Prussian Blue in decorporating Cs>Rb>K>Na] Intestinal constipation in 10 individuals Dyspepsia (6 months later, in 11 individuals that also had other reasons for this manifestation) 29

21 Special Case Patient LNF, 6 years old Initial calculated Cs intake: 1677 MBq (279.5 ALI) Prussian Blue: 6 g/d Blood activity on day 10: MBq/L Blood activity on day 24: MBq/L 21

22 Goiânia Accident: Necropsies Case age, sex Death (days after initial exposure) Cause of death LNF 6 y, F 29 Diffuse haemorrhage of multiple organs; sepsis IBS, 22 y, M 34 APE and bilateral bronchopneumonia; sepsis MGF, 38 y, F 34 Diffuse haemorrhage of multiple organs; sepsis AAS, 18 y, M 35 Lungs collapse and lobar pneumonia; sepsis Cs burden (MBq) Estimated dose by CA, Gy

23 Goiânia Accident: Radiation Protection for Necropsies (1) To protect personnel from unnecessary exposure and to avoid contamination To protect necropsy rooms To protect equipment All procedures were performed under radiation protection guidance and supervision 23

24 Goiânia Accident: Radiation Protection for Necropsies (2) Pathologists, coroners, morgue technicians, radiation medicine doctors and radiation protection personnel discussed and planned necropsies It was established that personnel would rotate every ten minutes during necropsies and outer gloves would be changed frequently 24 Photo credits: Dr.Valverde, N.

25 Goiânia Accident: Radiation Protection for Necropsies (3) Room preparation Photo credits: Dr. Valverde, N. 25

26 Goiânia Accident: Radiation Protection for Necropsies (4) RP officers monitored all the necropsies Each necropsy took about two hours The team of pathologists, coroners and technicians consisted of 13 persons All cavity fluids were carefully collected in special containers Personnel, equipment and necropsy rooms were thoroughly screened for contamination after each procedure Photo credit: Dr. Valverde, N. 26

27 Goiânia Accident: Radiation Protection for Necropsies (5) Personnel, equipment and necropsy rooms were thoroughly screened for contamination after each procedure Graves were checked for exposure rates 27

28 Long-Term Follow-up Group I: 56 persons (32 M / 24 F) ARS and/or CRS WBD 0.20 Gy Body burden ½ ALI ( 50 µci) Group II: 46 persons (22 M / 24 F) Exposures or body burdens below the limits for Group I Group III: 517 persons (258 M / 259 F) Social victims People living close to the main foci of contamination 28

29 Medical Follow-up: Deaths between 1987 and 2007 (1) Condition Sex M F ARS 2 2 Traffic accident (GR III) 4 Assassination (GR III) 1 1 CPOD (GR I, GR III) 3 Brain aneurism (GR III) 1 AMI (GR I, GR II, GR III) 4 Arrhythmia (GR III) 1 Stroke (GR III) 2 Hypertensive encephalopathy (GR I) 1 source: SULEIDE - JF Silva, MD 29

30 Medical Follow-up: Deaths between 1987 and 2007 (2) Condition Sex M F Liver cirrhosis (GR I) 1 Heart failure (GR III) 1 Brain edema (GR III) 1 Acute lung edema (GR III) 1 Septicemia (GR I, GR II, GR III) 1 2 Cardiogenic shock (GR III) 1 Traumatic brain injury (GR III) 1 Unknown (GR III) 7 1 source: SULEIDE - JF Silva, MD 39

31 Medical Follow-up: Deaths by Cancer between 1987 and 2007 Site Sex M F Tonsils ( GRIII) 1 Bladder (GRI) 1 Breast (GRIII) 2 Pharynx (GRIII) 2 Uterus (GRIII) 2 Tongue (GRIII) 1 Not specified (GRIII) 1 Sarcoma of mandible (GRIII) 1 Melanoma (GRIII) 1 TOTAL : source: SULEIDE - JF Silva, MD 31

32 For Further Information: Epidemiological Study on Morbi-mortality by Cancer in Goiânia (Koifman S. et al., 2007) 32

33 Conclusions (1) The Goiânia accident was characterized by protracted exposure of individuals of the public to ionizing radiation The violation of the caesium source took place on 13 September 1987 and the accident s nature became known16 days later This fact was mainly caused because local health personnel were not able to identify the clinical manifestations of the victims as radiation induced ones 33

34 Conclusions (2) A radiation exposure device (RED) source could also determine protracted exposures of individuals of the public One lesson from Goiânia is that health personnel must be aware of the clinical manifestations of whole body and local radiation exposures ( acute radiation and cutaneous radiation syndromes) 34

35 Conclusions (3) Besides conventional injuries, the detonation of a radiation dispersal device (RDD) could also cause both external irradiation and also contamination (like in Goiânia) Caesium-137 could be used in an RDD because of its chemical and radiological properties! 35

36 Thank you for your kind attention! This activity is conducted by the, with funding by the European Union, among others. The views expressed in this presentation do not necessarily reflect the views of the European Union. International Atomic Energy Agency