Prevalence of Renal Dysfunction among Evacuees and Non-evacuees after the Great East Earthquake: Results from the Fukushima Health Management Survey

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1 ORIGINAL ARTICLE Prevalence of Renal Dysfunction among Evacuees and Non-evacuees after the Great East Earthquake: Results from the Fukushima Health Management Survey Hiroaki Satoh 1,2, Tetsuya Ohira 2,3, Masato Nagai 2,3, Mitsuaki Hosoya 2,4, Akira Sakai 2,5, Tsuyoshi Watanabe 1,2, Akira Ohtsuru 2,6, Yukihiko Kawasaki 2,4, Hitoshi Suzuki 2,7, Atsushi Takahashi 2,8, Gen Kobashi 9, Kotaro Ozasa 10, Seiji Yasumura 2,11, Shunichi Yamashita 2,12, Kenji Kamiya 2,13 and Masafumi Abe 2 Abstract Objective We conducted the present study to evaluate the prevalence of chronic kidney disease (CKD) and CKD complications among evacuees and non-evacuees after the Great East Japan Earthquake and Fukushima Daiichi nuclear disaster. Methods Twenty-seven thousand and eighty-eight subjects who were living near the Fukushima Daiichi Nuclear Power Plant in Fukushima Prefecture in Japan, aged 40 years by the Heath Care Insures, were included in the analyses. Metabolic factors were compared between the evacuees and non-evacuees stratified by the egfr and proteinuria grades. Results The prevalence of CKD with a low egfr (<60 ml/min/1.73 m 2 ) and proteinuria were 21.59% and 1.85%, respectively. The risk of CKD complications was classified into four grades according to the egfr and proteinuria grades. The prevalence of diabetes, hypertension, and dyslipidemia were significantly higher in the very high risk group than in the low risk group. The prevalence of diabetes and dyslipidemia were significantly higher in evacuees than in non-evacuees in only the low risk group. However, a multivariate logistic regression analysis showed that evacuation was not significantly associated with the risk of a low egfr or proteinuria. Conclusion This study did not reach the definitive conclusion that evacuation elevated the risk of CKD complication, although evacuation might lead to increased CKD complications in the future. We believe that this information is important for follow-up and lifestyle change recommendations for evacuees. Key words: chronic kidney disease, Great East Earthquake, Fukushima Daiichi Nuclear Power Plant accident, Fukushima Health Management Survey (Intern Med 55: , 2016) () Department of Diabetology, Endocrinology, and Metabolism, Fukushima Medical University, Japan, Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima Medical University, Japan, Department of Epidemiology, Fukushima Medical University, Japan, Department of Pediatrics, Fukushima Medical University, Japan, Department of Radiation Life Sciences, Fukushima Medical University, Japan, Department of Radiation Health Management, Fukushima Medical University, Japan, Department of Cardiology and Hematology, Fukushima Medical University, Japan, Department of Gastroenterology and Rheumatology, Fukushima Medical University, Japan, Department of Public Health, Dokkyo Medical University, Japan, Department of Epidemiology, Radiation Effects Research Foundation, Japan, Department of Public Health, Fukushima Medical University, Japan, Japan and Atomic Bomb Disease Institute, Nagasaki University, Japan and Research Institute for Radiation Biology and Medicine, Hiroshima University, Japan Received for publication December 22, 2015; Accepted for publication January 20, 2016 Correspondence to Dr. Hiroaki Satoh, hiroaki@fmu.ac.jp 2563

2 Introduction Materials and Methods The Great East Japan Earthquake occurred on March 11th, After this earthquake, a tsunami hit the Tokyo Electric Power company s Fukushima Daiichi Nuclear Power Plant, resulting in a radiation hazard in Fukushima Prefecture. The Fukushima Daiichi nuclear disaster forced the evacuation of a number of towns, causing lifestyle changes and anxiety about radiation in the evacuees. After the disaster, Fukushima Prefecture launched the Fukushima Health Management Survey (FHMS) to investigate the effect of long-term low-dose radiation exposure caused by the disaster (1). This survey comprises a basic survey to estimate individual radiation exposure of the residents and four detailed surveys that include a comprehensive health check (CHC), thyroid ultrasonography, mental health and lifestyle survey, and survey on pregnant women and nursing mothers (1). The comprehensive health check was implemented to aid the early detection and treatment of disease, as well as the prevention of lifestyle-related diseases including chronic kidney disease (CKD), diabetes, hypertension, dyslipidemia, obesity, and cardiovascular diseases (CVD). CKD is a major independent risk factor for CVD (2). Therefore, the early detection and initiation of treatment for CKD are important in order to prevent the progression to kidney failure as well as cardiovascular complications. Recently, the Kidney Disease: Improving Global Outcomes (KDIGO) group recommended that patients with CKD should be assigned to stage and composite relative risk groups according to criteria of the glomerular filtration rate (GFR) (G) and proteinuria (A) (3). In Japan, the CKD Clinical Practice Guide was revised by the Japanese Society of Nephrology, and stage composite relative risk groups were described according to the GFR and proteinuria criteria. Proteinuria is a dependent risk factor for death, myocardial infarction and progression to kidney failure at a given level of the estimated GFR (egfr) (4, 5). The primary purposes of the Fukushima Health Management Survey are to monitor the long-term health of residents, promote their future well-being, and determine whether long-term low-dose radiation exposure has health effects. Evacuees from the government-designated evacuation zone were forced to change their lifestyle, diet, exercise, and other personal habits. The comprehensive heath check attempts to review the residents health information while assessing the incidence of various diseases and improving their health status. In this study, we investigated the prevalence of CKD and the degree of CKD stages among evacuees and non-evacuees after the disaster by using the data obtained from the FHMS. Study population and design The subjects and methods of the CHC of the FHMS have been described elsewhere (1). Briefly, the CHC performed health examinations for individuals of all ages living in the evacuation zone designated by the government who were officially registered residents at the time of the earthquake. The subjects of the present study were residents living in the evacuation zone aged 40 years or older in the Fukushima Prefecture, including Tamura City, Minamisoma City, Kawamata-machi, Hirono-machi, Naraha-machi, Tomiokamachi, Kawauchi-mura, Okuma-machi, Futaba-machi, Namie-machi, Katsurao-mura, Iitate-mura, and Date City. In 2010, the census populations of these communities were 42,085, 71,661, 16,065, 5,495, 7,927, 15,854, 3,074, 11,553, 7,171, 21,551, 1,582, 6,584, and 67,684 (total: 278,276), respectively. A total of 45,278 residents aged 20 to 99 years (18,953 men and 26,325 women; mean age 56 years) in the communities participated in the CHC from June 1st, 2011 to March, We excluded residents aged 39 years or younger, those aged 91 years or older, those without data of creatinine, and those on dialysis due to renal impairment. The remaining data on 27,088 subjects, aged years (12,249 men and 14,839 women, mean age of 67 years), were used for the analyses. This study obtained informed consent from the participants to conduct an epidemiological study according to the guidelines of the Council for International Organizations of Medical Science. The Ethics Committee of Fukushima Medical University approved this study (#1916). Measurements Each patient s height in stocking feet and weight in light clothing were measured, and the body mass index (BMI) was calculated as weight (kg)/height (m) 2. A urinalysis using the dipstick method was performed on a single spot urine specimen collected in the early morning after overnight fasting. The results of the urinalysis were recorded as negative, trace, (1+), (2+) or (3+). Positivity for proteinuria was defined as (1+) or greater. Serum creatinine was measured using an enzymatic method, and the GFR was calculated as the egfr from serum creatinine, age, and sex using the Japanese equation as follows: egfr (ml/min/1.73 m 2 ) =194 serum creatinine ag e (if female) (6). We defined subjects with the presence of proteinuria and/or renal insufficiency (egfr 60 ml/min/1.73 m 2 ) as having CKD. The CKD stage was determined at baseline according to the modified classification for Japanese people based on the KDIGO Consensus Conference (3); GFR stages G1-5 were defined as G1+G2, GFR 60 ml/min/1.73 m 2 ; G3a, ml/min/1.73 m 2 ; G3b, ml/min/1.73 m 2 ; G4, ml/min/1.73 m 2 ; and G5, <15 ml/min/1.73 m 2. Proteinuria stages A1-3 were defined as A1, negative; A2, 1+; and 2564

3 Table 1. Distribution of egfr and Proteinuria after the Great East Japan Earthquake. egfr (ml/min/1.73 m 2 ) 60 < 60 Urinary Protein Negative or trace 1+ or more Total Subjects 77.46% (20,983) 0.95% (257) 78.41% (21,240) Men 78.41% (9,604) 1.57% (192) 79.97% (9,796) Women 76.68% (11,379) 0.44% (65) 77.12% (11,444) Subjects 20.68% (5,603) 0.90% (245) 21.59% (5,848) Men 18.70% (2,290) 1.33% (163) 20.03% (2,453) Women 22.33% (3,313) 0.55% (82) 22.88% (3,395) Subjects 98.15% (26,586) 1.85% (502) % (27,088) Total Men 97.10% (11,894) 2.90% (355) % (12,249) Women 99.01% (14,692) 0.99% (147) % (14,839) Data are presented as percentage (number). A3, 2+. Other examinations included aspartate aminotransferase (AST), alanine aminotransferase (ALT), γ-glutamyl transpeptidase (γ-gt), triglyceride (TG), HDL-C, lowdensity lipoprotein cholesterol (LDL-C), hemoglobin A1c (HbA1c), and fasting plasma glucose. The value for HbA1c was estimated using a Notional Glycohemoglobin Standardization Program equivalent value calculated using the equation HbA1c (%) =1.019 HbA1c (JDS) (%) +0.30% (7). Diabetes was defined in accordance with the Japan Diabetes Society (JDS) guidelines (7): a fasting plasma glucose level 126 mg/dl (7.0 mmol/l), HbA1c level 6.5%, or selfreported use of antihyperglycemic drugs. Hypertension was defined as systolic blood pressure 140 mmhg, diastolic blood pressure 90 mmhg, or self-reported use of blood pressure-lowering drugs. Dyslipidemia was defined as LDL- Clevels 140 mg/dl, TG level 150 mg/dl, HDL-C level 40 mg/dl, or self-reported use of cholesterol-lowering drugs. Statistical analysis Data are presented as the means ± standard deviation (S.D.). The participants were divided into two groups: evacuees (n=9,407) and non-evacuees (n=17,681). Student s t-test or the chi-square test was used to examine differences in variables or proportions between the evacuees and nonevacuees, stratified by the CKD stages (low, moderate, high, and very high). A logistic regression analysis tested for associations between evacuation and other potential confounders among subjects with renal dysfunction. Potential confounders included age, gender, BMI, diabetes, dyslipidemia, hypertension and current smoking. The SAS version 9.3 software program (SAS Institute, Cary, USA) was used for all analyses. All probability values for statistical tests were two-tailed, with p values <0.05 considered to be statistically significant. Results Prevalence of CKD after the Great East Japan Earthquake There were 27,088 participants (12,249 men and 14,839 women; average age 67.7 years) who were officially registered residents at the time of the earthquake and underwent the follow-up examination after the Great East Japan Earthquake. The prevalence of CKD with a low egfr (egfr <60 ml/min/1.73 m 2 ) and proteinuria were 21.59% (men: 20.03% and women: 22.88%) and 1.85% (men: 2.90% and women: 0.99%), respectively (Table 1). Subjects with CKD with both a low egfr and proteinuria comprised 0.90% of the total cohort (men: 1.33% and women: 0.55%). Distribution of a low egfr and proteinuria between non-evacuees and evacuees after the disaster Table 2 displays the CKD risk stratification table according to the egfr and proteinuria categories. The egfr and proteinuria grades are stratified from G1 to G5 and from A1 to A3, respectively. The prevalence of CKD in all grades did not significantly differ between the evacuees and nonevacuees (Table 2). The risk of end-stage kidney disease (ESKD) requiring dialysis, or transplantation, and risks for CVDs such as stroke, myocardial infarction, and heart failure were coded with colors ranging from green (low risk), yellow (moderately increased risk), orange (high risk), and red (very high risk). Clinical characteristics and prevalence of diabetes, hypertension, and dyslipidemia between evacuees and non-evacuees stratified by CKD stage after the disaster In the low risk group (7,253 evacuees and 13,730 nonevacuees), the BMI (p<0.0001), FPG (p<0.0001), HbA1c (p<0.0001), triglyceride (p<0.0001), LDL-C (p<0.0001), AST (p<0.0001), ALT (p<0.0001), and γ-gt (p<0.0001) were significantly higher in the evacuees than in non- 2565

4 Table 2. Distribution of egfr and Proteinuria between Non-evacuees and Evacuees after the Great East Japan Earthquake. Urinary Protein Negative or trace or more egfr (ml/min/1.73 m 2 ) Total 77.46% (20,983) 0.69% (188) 0.25% (69) 60 Evacuees 77.10% (7,253) 0.65% (61) 0.24% (23) Non-evacuees 77.65% (13,730) 0.72% (127) 0.26% (46) Total 18.12% (4,908) 0.34% (93) 0.17% (45) Evacuees 18.24% (1,716) 0.31% (29) 0.22% (21) Non-evacuees 18.05% (3,192) 0.36% (64) 0.14% (24) Total 2.29% (620) 0.14% (37) 0.11% (29) Evacuees 2.53% (238) 0.16% (15) 0.11% (10) Non-evacuees 2.16% (382) 0.12% (22) 0.11% (19) Total 0.26% (71) 0.06% (12) 0.06% (14) Evacuees 0.27% (25) 0.02% (2) 0.07% (7) Non-evacuees 0.26% (46) 0.06% (10) 0.04% (7) Total 0.00% (4) 0.01% (7) 0.03% (8) < 15 Evacuees 0.03% (3) 0.02% (2) 0.03% (2) Non-evacuees 0.01% (1) 0.03% (5) 0.03% (6) Data are presented as percentage (number). Risks of ESKD requiring dialysis, or transplantation, and risks for cardiovascular diseases such as stroke, myocardial infarction, and heart failure are coded with colors ranging from green (low risk), yellow (moderately increased risk), orange (high risk), and red (very high risk). evacuees, whereas HDL-C (p<0.0001) was significantly lower in the evacuees than in non-evacuees (Table 3). In the moderately increased risk group (1,777 evacuees and 3,319 non-evacuees), the BMI (p<0.0001), DBP (p=0.012), FPG (p =0.005), LDL-C (p=0.009), ALT (p=0.006), and ALT (p< ) were significantly higher in the evacuees than in non-evacuees (Table 3). In the high risk group (290 evacuees and 492 non-evacuees), the BMI (p=0.007), SBP (p= 0.037), and γ-gt (p=0.021) were significantly higher in the evacuees than in non-evacuees (Table 3). In the very high risk group (87 evacuees and 140 non-evacuees), only AST (p=0.043) was significantly higher in the evacuees than in non-evacuees, and other metabolic factors such as the BMI, glucose metabolism, lipid metabolism, and blood pressure did not significantly differ between the evacuees and nonevacuees (Table 3). Furthermore, the prevalence of diabetes, hypertension, and dyslipidemia were significantly higher in the very high risk group than in the low risk group (Table 3). Interestingly, in the low risk group, the prevalence of diabetes (p=0.001) and dyslipidemia (p<0.0001) were significantly higher in the evacuees (10.9% and 54.1%, respectively) than in non-evacuees (9.4% and 47.6%, respectively) (Table 3). In the moderately increased risk group, the prevalence of dyslipidemia (p=0.011) was significantly higher in the evacuees (59.4%) than in non-evacuees (55.7%) (Table 3). However, in the high risk and very high risk groups, the prevalence of diabetes, hypertension, and dyslipidemia did not significantly differ between the evacuees and nonevacuees (Table 3). Risk factors for CKD after the disaster Both a reduction in the egfr and the grade of proteinuria influenced the prognosis and had a synergistic effect. Therefore, a multivariate logistic regression analysis was performed to identify independent associations with the prevalence of a low egfr (egfr <60 ml/min/1.73 m 2 ) and the prevalence of proteinuria after the disaster (Table 4). Age, sex, obesity, dyslipidemia, hypertension, and current smoking were significantly associated with the prevalence of a low egfr (OR 1.097, p<0.0001; OR 1.276, p<0.0001; OR 1.254, p<0.0001; OR 1.325, p<0.0001; OR 1.313, p<0.0001; and OR 0.827, p=0.0020; respectively). However, evacuation and diabetes were not significantly associated with the prevalence of a low egfr. On the other hand, age, sex, diabetes, hypertension, and current smoking were significantly associated with the prevalence of proteinuria (OR 1.022, p= ; OR 0.401, p<0.0001; OR 3.357, p<0.0001; OR 2.469, p<0.0001; and OR 1.528, p=0.0007; respectively). However, evacuation and dyslipidemia were not significantly associated with the prevalence of proteinuria (Table 4). Discussion The present study demonstrated that metabolic factors, such as the BMI, glucose and lipid metabolism, and liver function, were worse in the evacuees than in non-evacuees in the low risk group for CKD complications. Additionally, hypertension and diabetes were strongly associated with the risk of a low egfr and proteinuria. In addition, in the low risk group, the prevalence of diabetes and dyslipidemia were significantly higher in the evacuees than in non-evacuees. CKD is classified according to the GFR and proteinuria categories and the etiology. Many studies have demonstrated associations between a GFR <60 ml/min/1.73 m 2 and the risk of overall mortality, cardiovascular mortality, CKD progression, ESKD, and acute renal failure (8-12). Variables 2566

5 Table 3. Clinical Characteristics and Prevalence of Diabetes, Hypertension, and Dyslipidemia between Non-evacuees and Evacuees in the Severity CKD Stages after the Great East Japan Earthquake. Low risk Moderately increased risk High risk Very high risk Evacuees Non-evacuees p Evacuees Non-evacuees p Evacuees Non-evacuees p Evacuees Non-evacuees p Number (%) 7,253 (77.1) 13,730 (77.7) 1,777 (18.9) 3,319 (18.8) 290 (3.1) 492 (2.8) 87 (0.9) 140 (0.8) Sex (men/women) 3,230/4,023 6,374/7, /1,036 1,379/1, / /232 54/33 80/60 Age (years) 66.1 ± ± ± ± 7.7 < ± ± ± ± Body weight (kg) 58.8 ± ± 10.4 < ± ± ± ± ± ± BMI (kg/m 2 ) 24.1 ± ± 3.3 < ± ± 3.3 < ± ± ± ± SBP (mmhg) ± ± ± ± ± ± ± ± DBP (mmhg) 78.5 ± ± ± ± ± ± ± ± FPG (mg/dl) ± ± 20.2 < ± ± ± ± ± ± HbA1c (%) 5.55 ± ± 0.65 < ± ± ± ± ± ± Triglyceride (mg/dl) ± ± 74.5 < ± ± ± ± ± ± HDL-C (mg/dl) 58.4 ± ± 14.8 < ± ± ± ± ± ± LDL-C (mg/dl) ± ± 30.2 < ± ± ± ± ± ± Creatinine (mg/dl) 0.70 ± ± ± ± ± ± ± ± egfr (ml/min/1.73 m 2 ) 75.2 ± ± ± ± ± ± ± ± AST (IU/L) 26.2 ± ± 11.5 < ± ± ± ± ± ± ALT (IU/L) 24.2 ± ± 14.2 < ± ± 11.2 < ± ± ± ± GT (IU/L) 37.5 ± ± 50.8 < ± ± ± ± ± ± Hypertension (%) Diabetes (%) Dyslipidemia (%) < Data are presented as percentage or means ± S.D. Risks of ESKD requiring dialysis, or transplantation, and risks for cardiovascular diseases such as stroke, myocardial infarction, and heart failure are coded with colors ranging from green (low risk), yellow (moderately increased risk), orange (high risk), and red (very high risk). Diabetes was defined as a fasting plasma glucose level 126 mg/dl (7.0 mmol/l), HbA1c level 6.5%, or self-reported use of glucose-lowering drugs. Hypertension was defined as systolic blood pressure 140 mmhg, diastolic blood pressure 90 mmhg or self-reported use of blood pressure-lowering drugs. Dyslipidemia was defined as low-density cholesterol (LDL-C) level 140 mg/dl, triglyceride level 150 mg/dl, high-density cholesterol (HDL-C) level < 40 mg/dl, or self-reported use cholesterol-lowering drugs. p: p value comparing the evacuee group to the non-evacuee group after the earthquake. BMI: body mass index, SBP: systolic blood pressure, DBP: diastolic blood pressure, FPG: fasting plasma glucose, HbA1c: hemoglobin A1c, HDL-C: high density lipoprotein cholesterol, LDL-C: low density lipoprotein cholesterol, AST: aspartate aminotransferase, ALT: alanine aminotransferase, -GT: -glutamyl transpeptidase that determine the risk of CKD complications include many factors, such as the GFR grade, proteinuria grade and other risk factors and comorbidities. A decline in the GFR is correlated with the risk of CVD, coronary disease, myocardial function, heart failure, stroke, mortality from CVD and total death. CKD patients, particularly those with grades 3a to 5, 2567

6 Table 4. Multivariate Logistic Regression Analysis of Factors Influencing the Prevalence of Renal Dysfunction after the Great East Japan Earthquake. Model egfr < 60 ml/min/1.73m 2 Proteinuria OR (95% CI) p value OR (95% CI) p value Evacuation ( ) ( ) Age (years) ( ) < ( ) Sex (0, men; 1, women) ( ) < ( ) < BMI < 18.5 kg/m ( ) ( ) BMI 25 kg/ m ( ) < ( ) Diabetes ( ) ( ) < Dyslipidemia ( ) < ( ) Hypertension ( ) < ( ) < Current smoking (0, no; 1, yes) ( ) ( ) Data are presented as odds ratio (95% confidence interval). OR: odds, CI: confidence interval, BMI: body mass index Diabetes was defined as a fasting plasma glucose level 126 mg/dl (7.0 mmol/l), HbA1c level 6.5%, or self-reported use of glucose-lowering drugs. Hypertension was defined as systolic blood pressure 140 mmhg, diastolic blood pressure 90 mmhg or self-reported use of blood pressure-lowering drugs. Dyslipidemia was defined as low-density cholesterol (LDL-C) level 140 mg/dl, triglyceride level 150 mg/dl, high-density cholesterol (HDL-C) level < 40 mg/dl, or self-reported use cholesterol-lowering drugs. have an increased CVD risk that corresponds to the accumulation of many factors, such as hypertension or diabetes. Elevated proteinuria can increase the risk independently of a decline in the GFR (13). Furthermore, both a reduction in the egfr and the grade of proteinuria influence the prognosis and has a synergistic effect. Our data showed that the negative effects on metabolic factors were greater in the evacuees than in non-evacuees. These differences might be related to lifestyle changes, such as dietary life, physical activity, and life environment before and after the evacuation. A life as an evacuee in unfavorable conditions increases stress due to many factors, such as privacy, food availability, duty assignments, income jobs and health (14). Natural disasters have been shown to have a negative impact on metabolic factors (15). After the Great Hansin-Awaji earthquake, glycemic control was aggravated in diabetic patients, and an association between chronic lifethreatening stress and worsened metabolic control has been suggested (14). Similar effects have been reported with hypertension, with ambulatory blood pressure revealing that sympathetic activation is an important component of rising blood pressure after life-threatening events and may trigger myocardial infarction (16). The comprehensive management of cardiorenal risk patients forms the basis of CKD progression prevention. Although different nuances may be established between CKD progression prevention measures and cardiovascular prevention measures, the bases for overall prevention are dietary and lifestyle changes, high blood pressure control, reninangiotensin system blockade and metabolic (mainly, glucose and lipid metabolism) control. Lifestyle and dietary advice on obesity prevention, smoking cessation, and a sodiumrestricted diet, and treatment for metabolic disorders, hypertension, and dyslipidemia are effective to prevent the progression of CKD. Therefore, these findings suggests that chronic metabolic health problems such as CKD, obesity, type 2 diabetes, hypertension and dyslipidemia should be carefully monitored and treated after the disaster, especially in evacuees. In conclusion, this study did not reach the definitive conclusion that evacuation elevated the risk of CKD complication, although evacuation might lead to increased CKD complications such as End Stage Renal Disease, myocardial infarction, heart failure, and all death in the future. We believe that this information is important for follow-up and lifestyle change recommendations for evacuees. The authors state that they have no Conflict of Interest (COI). The Fukushima Health Management Survey Group Hitoshi Ohto, Masafumi Abe, Shunichi Yamashita, Kenji Kamiya, Seiji Yasumura, Mitsuaki Hosoya, Akira Ohtsuru, Akira Sakai, Shinichi Suzuki, Hiroaki Yabe, Masasharu Maeda, Shirou Matsui, Keiya Fujimori, Tetsuo Ishikawa, Tetsuya Ohira, Tsuyoshi Watanabe, Hiroaki Satoh, Hitoshi Suzuki, Yukihiko Kawasaki, Atsushi Takahashi, Kotaro Ozato, Gen Kobayashi, Shigeatsu Hashimoto, Satoru Suzuki, Toshihiko Fukushima, Sanae Midorikawa, Hiromi Shimura, Hirofumi Mashiko, Aya Goto, Kenneth Eric Nollet, Shinichi Niwa, Hideto Takahashi, and Yoshisada Shibata. Financial Support This survey was supported by the National Health Fund for Children and Adults Affected by the Nuclear Incident. The findings and conclusions of this article are solely the responsibility of the authors and do not represent the official views of the Fukushima Prefecture government. References 1. Yasumura S, Hosoya M, Yamashita S, et al. Study protocol for the Fukushima Health Management Survey. J Epidemiol 22: , Keith DS, Nichols GA, Gullion CM, Brown JB, Smith DH. Longitudinal follow-up and outcomes among a population with 2568

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