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IAEAInternational Atomic Energy Agency

International work in radiation protection of patients at the IAEA:

Therapeutic, diagnostic and interventional procedures

Ola Holmberg, Ph.D.Head, Radiation Protection of Patients Unit

Radiation Safety and Monitoring SectionDivision of Radiation, Transport and Waste Safety

International Atomic Energy AgencyVienna, Austria

Nationellt möte om sjukhusfysik13-14 nov 2013, Varberg

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Outline

• Context• Radiation in medicine – the upside

• Radiation in medicine – the downside

• IAEA – Why and How are we involved?• International Action Plan for Radiation Protection of Patients

• Actions taken for radiation protection of patients

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• Symbol for the International Conference on Radiation Protection in Medicine in Bonn, December 2012: “The rod of Asclepius” with wave package overlaid

• “Pharmakon” meant both "medicine" and "poison" in the ancient Greek language

• Two sides to the snakes venom (venom and basis for antivenom)

• Two sides to radiation

• (Not the staff of Hermes (on which the caduceus is based))

Context

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Context

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• X-rays were discovered by Wilhelm Conrad Röntgen 8 Nov 1895

Context

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• The first medical use of x-rays was reported on 23 Jan 1896

(only 76 days later)

when x-rays were used to locate the piece of a knife in the backbone of a drunken sailor, who was paralyzed until the fragment was removed.*

* Radiobiology for the Radiologist (6th ed.) – E.J. Hall, A.J. Giaccia

Context

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• The first unnecessary exposure took place several weeks earlier

Context

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• The first unnecessary exposure took place several weeks earlier

- soon followed by many more

Context

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The use of radiation in medicine has brought tremendous benefits to the global population

• An estimated 5.1 million courses of radiotherapy treatment were administered annually between 1997 and 2007 (up from an estimated 4.3 million in 1988)*

• 50-60% of cancer patients could benefit from radiation therapy

• The fraction of cancer patients treated is increasing, where RT is available

* UNSCEAR 2008 Report

Radiation in medicine – the upside

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The use of radiation in medicine has brought tremendous benefits to the global population

• An estimated 33 million diagnostic nuclear medicine procedures annually in the world*

• An estimated 3.6 billion diagnostic radiology procedures annually in the world*

* UNSCEAR 2008 Report

Radiation in medicine – the upside

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• It is essential to remain focussed on protecting the patients, e.g.:

• Reports of radiation injuries in interventional radiology

Radiation in medicine – the downside

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• It is essential to remain focussed on protecting the patients, e.g.:

• Reports of accidents in radiotherapy, leading to injuries and death• Sometimes errors repeated in more clinics

Radiation in medicine – the downside

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Radiation in medicine – the downside

UNSCEAR 2008 Report, Volume II, Annex C

• Radiation accidents involving medical uses:• Over the last three decades, at least 3000 patients have been affected by

radiotherapy incidents and accidents

• Radiation accidents involving medical uses have accounted for more acute radiation deaths than any other source, including Chernobyl

• These accidents do not only affect patients directly (e.g. harm and death), but might also undermine the public’s confidence in the treatment

• Preventable medical errors overall also cost countries billions of dollars each year

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• Medical exposure is overwhelmingly the most significant manmade source of exposure to the population from ionizing radiation

• Issues around the optimization of medical exposure (e.g. wide variation in doses reported for the same type of CT-scan)

• Issues around the justification of medical exposure (a substantial fraction of radiological examinations may be inappropriate)

Radiation in medicine – the downside

Advertisement for radiological screening gift certificates

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The increasing medical exposure

UNSCEAR 1993

Global annual per caput effective dose

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UNSCEAR 1993

Global annual per caput effective dose

The increasing medical exposure

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UNSCEAR 2000

Global annual per caput effective dose

The increasing medical exposure

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UNSCEAR 2008

Global annual per caput effective dose

The increasing medical exposure

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NCRP160 2009

U.S. annual per caput effective dose

The increasing medical exposure

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Fundamental issues to consider when attempting to improve the radiation protection of patients and make a lasting impact:

• Medical use if ionizing radiation is a massive global activity (>10M exposures per day) – Overall benefits huge; Balanced message; Individual risks vary greatly

• Medical use of ionizing radiation is an inhomogeneous and rapidly developing activity – Access and issues vary around the world; New medical technology is implemented rapidly

• Reaching stakeholders and making efforts effective and lasting is complex – Many groups of stakeholders; One of many issues to consider by health professionals; Language barriers; IT environment changing fast; To ensure lasting impact: capacity building and infrastructure need to be addressed

• Underlying reasons for medical radiation protection issues are many, e.g. – Human errors, which will continue to occur at a steady rate; Lack of knowledge or experience; Lack of resources, support or safety culture; Self-motivated economical interest or defence against litigation; Pressure and expectations from patients

• Dose limits don’t apply to medical exposures

Fundamental issues to consider

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Statute of the International Atomic Energy Agency:

1. Came into force on 29 July 1957

2. “The Agency shall seek to accelerate and enlarge the contribution of atomic energy to peace, health and prosperity throughout the world.”

3. “To establish or adopt … standards of safety for protection of health and minimization of danger to life… and to provide for the application of these standards”

IAEA – Why and How?

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International Atomic Energy Agency:

• Member of the United Nations family

• Set up as the world´s "Atoms for Peace" organization in 1957

• The world´s centre of cooperation in the nuclear field

• Headquarters in Vienna, Austria

• 2200 staff from > 90 countries

• Winner of Nobel Peace Prize in 2005

IAEA – Why and How?

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IAEA – Why and How?

Department of Nuclear Safety and Security

Department of Nuclear Sciences and Applications

Department of Safeguards

Department of Nuclear Energy

Department of Management

Department of Technical

Cooperation

Director General

Division of Radiation,

Transport and Waste Safety

Division of

Human Health

Radiation Safety and Monitoring

Section

Radiation Protection of Patients Unit

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IAEA – Why and How?

Radiation Protection of Patients Unit

• 2 P-staff

• 2 G-staff

• 2 Consultants on shorter contracts

• 1 Junior P-staff

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The International Action Plan (2002)

was born in the Málaga Conference (2001) requested by the General Conference (1999)

International Action Plan

International Action Plan for the

Radiation Protection of Patients

• Education and training

• Guidance

• Information exchange

• …

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A Steering Panel was set up to review the implementation of the International Action Plan for the Radiation Protection of Patients:

• Providing guidance on the overall approach to the implementation of the Action Plan and harmonizing activities between organizations (Meetings 2004, 2006, 2008, 2010, Int’l Conf. 2012, Next 2014)

International Action Plan

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Steering Panel members:

• Coordinated by IAEA and involving:

• WHO (World Health Organization)

• PAHO (Pan American Health Organization)

• UNSCEAR (United Nations Scientific Committee on the Effect of Atomic Radiation)

• EC (European Commission)

• ESTRO (European Society for Therapeutic Radiology and Oncology)

• ICRP (International Commission on Radiological Protection)

• ICRU (International Commission on Radiation Units and Measurements)

• IEC (International Electrotechnical Commission)

• IOMP (International Organization for Medical Physics)

• IRPA (International Radiation Protection Association)

• ISRRT (International Society of Radiographers and Radiological Technologists)

• ISR (International Society of Radiology)

• ISO (International Organization for Standardization)

• WFNMB (World Federation of Nuclear Medicine and Biology)

International Action Plan

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Professional bodies, regulatory networks and other international organizations:

• AAPM (American Association of Physicists in Medicine)

• AFOMP (Asia-Oceania Federation of Organization for Medical Physics)

• ALFIM (Latin American Association of Medical Physics)

• ARAN (Asia Region ALARA Network)

• EAN (European ALARA Network)

• EMAN (European Medical ALARA Network)

• HERCA (Heads … Working Group Medical Applications)

• FORO (Foro Iberoamericano de Organismos Reguladores Radiológicos..)

• ILO (International Labour Organisation)

• Image Gently (Society for Radiation Safety in Pediatric Imaging)

• OECD-NEA (Nuclear Energy Agency of the OECD)

• SCAI (Society of Cardiovascular Angiography and Interventions)

• SNM (Society of Nuclear Medicine)

• WGO (World Gastroenterologists Organization)

Interactions with other bodies

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Actions taken for the radiation protection of patients:

Providing guidanceProviding training

Providing standards

Giving technical assistance

Facilitating knowledge exchange

Building awareness

Safety Reports

Technical documents

Public website

Meetings

Workshops

Reporting systems

Press campaigns

Information campaigns

Safety Standards

Scientific publications

Missions

Direct advice

Providing tools

Training material

Training courses

Assessments

Fellowships

Scientific visits

Involve in projects

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IAEA Safety Standards relating to medical exposures and occupational exposures of medical workers:

Safety Fundamentals

Safety Requirements

Safety Guides

Basic objectives, concepts and principles of safety and protection

Requirements that must be met to ensure safety, expressed as “shall” statements

Recommends actions, conditions or procedures for meeting safety requirements, expressed as “should” statements

1. Providing standards

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2. Providing guidance

Dedicated website on radiation protection of patients (rpop)• Reaching a broad audience: >1 million hits per month on rpop.iaea.org• Also information for patients and public, not only health professionals;

and in many languages

Safety Reports and TECDOC’s• Always available as free pdf’s

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3. Facilitating knowledge exchange

Reporting and learning systems for safety in radiological procedures (SAFRAD) and radiotherapy (SAFRON)

• SAFRAD is web-based system for collecting, analyzing and disseminating information on circumstances around higher exposure of patients in interventional procedures; certain trigger-criteria are used

• SAFRON is web-based safety reporting system for radiotherapy - for reporting and learning from incidents and near-incidents; integrating with existing systems, complementing national and mandatory systems, also integrating other documents and links

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4. Building awareness

Building awareness through the press and information campaigns

• Input to the global press, e.g. Reuters, CNN and New York Times• International campaign on Awareness, Appropriateness and Audit (AAA)

for strengthening justification in diagnostic imaging

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5. Giving technical assistance

Direct assistance to Member States by technical assistance• High number of countries participating in technical cooperation projects

on radiation protection of patients• Seven main tasks in projects, in all major areas of patient protection• Expert missions, direct advice and provision of tools

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6. Providing training

Providing training courses and training material• Regional training courses organized and National training courses

supported• Main target audience: Health professionals in hospitals; but also radiation

protection professionals

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• Some numbers:• 5000 emails (received) in preparation

• 536 participants and observers in attendance

• 77 Member States and 16 organizations represented

• 88 presentations in the main programme (1-track)

• 2 breakout sessions (EC and UNSCEAR)

• 214 contributed papers, summarized by rapporteurs

• 68 postersdisplayed

• 1 Call-for-Action issued

Bonn Conference

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Bonn Call-for-Action

• The Bonn Call-for-Action highlights ten main actions, and related sub-actions, that were identified as being essential for the strengthening of radiation protection in medicine over the next decade.

• The actions are not listed in order of importance. Action by all stakeholders is encouraged.

• Member States have requested (GC 2013) that the IAEA takes the Bonn Call-for-Action into consideration in the International Action Plan

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Conclusion

• Medical exposure is overwhelmingly the most significant manmade source of exposure to the global population from ionizing radiation

• Underlying reasons for medical radiation protection issues are many; and reaching stakeholders and making efforts effective and lasting is complex

• The IAEA addresses these issues globally, in co-operation, through the International Action Plan, in a variety of actions

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