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THE RADIATION EXPOSURE SCREENING AND EDUCATION

PROGRAM (RESEP)

Cecile Rose, MD, MPHProfessor of Medicine, National Jewish Health

Uranium Training: Coconino Center for the Arts, Museum of Northern AZ, Northern AZ

UniversityOctober 2016

Overview

¨ History¨ Exposures¨ Health effects¨ Legislation and

restitution¨ RESEP today

Brief Uranium History

¨ 1789 – Martin Klaproth discovers new element, uranium, extracted from pitchblende in Bohemia

¨ 1895 – Wilhelm Roentgen discovers x-rays¨ 1896 – Henri Becquerel discovers radioactive

properties of uranium¨ 1896 – Marie Curie experiments with radium¨ 1898 – John Wetherill recognizes significance of yellow

mineral carnotite formations on the Colorado Plateau.¨ 1914 – WWI – Radium used for luminous paint for

nighttime warfare machinery.

Brief recent uranium history

¨ 1939 – Otto Hahn discovers fission

¨ 1940 – Rapid increase in mining operations, many on Navajo lands.

¨ 1942 – Manhattan Project -Los Alamos, Oak Ridge

¨ 1945 – Nuclear weapons used at Hiroshima and Nagasaki

¨ 1950s – Cold War and nuclear power

How many were exposed?

¨ Estimated 1 million in the West and former Soviet Union

¨ Thousands worked in the Colorado Plateau region

¨ Peak of 5000 underground miners in Grants uranium belt

Contaminants in uranium operations

Present in uranium ores, mine wastes, mill tailings:

¨ Radioactive elements – uranium (U), radium (Ra), radon (Rn), polonium (Po), lead (Pb)

¨ Heavy metals – arsenic (As), lead (Pb), selenium (Se), uranium (U)

¨ Organic compounds, strong acids and bases – used in ore milling, end up in tailings

¨ Dusts that cause lung scarring – in mines, mills, ore transport

Uranium industry respiratory exposures

¨ Irritants/asphyxiantsn Diesel exhaust

particulatesn Nitrogen oxides and

other combustion products from blasting

n Adhesives

¨ Respirable silica¨ Ionizing radiation:

radon and progeny

Non-malignant occupational health effects of uranium industry work

¨ Kidney disease: interstitial nephritis¨ Musculoskeletal injury: repetitive motion

injury, trauma¨ Noise-induced hearing loss¨ Lung disease

Nonmalignant lung disease from uranium mining and milling

¤ Silicosis¤ Lung fibrosis¤COPD/emphysema¤Mycobacterial lung

infection

Non-malignant respiratory disease in White uranium miners

¨ Colorado Plateau Uranium Miner Cohort (>3000 White male miners)¨ 5-fold excess of deaths from:

¤ Silicosis (9% prevalence in uranium miners, Samet 1984)¤ Emphysema¤ Pulmonary fibrosis

¨ Study limitation: relative contributions of cigarette smoking, silica and radon progeny were not quantified.

Archer VE et al, 1976. Respiratory Disease Mortality Among Uranium Miners. Ann NY Acad Sci. 271:280

Waxweiler, RJ et al, 1981. Mortality Follow-up Through 1977 of the White Underground Uranium Miners Cohort Examined by US Public Health Service. Radiation Hazards in Mining

Non-malignant respiratory disease in Native American uranium miners

¤Higher prevalence of radiographic pneumoconiosis than Hispanics and non-Hispanic Whites.

¤Strong association between uranium mining and obstructive lung disease.

¤Much less contribution from smoking than other ethnic groups.

D Mapel et al. Am J Public Health. 87(5):833, 1997

Lung infection in uranium miners

¤Tuberculosis and NTM¤Relative risk 1.5-10¤ Increased risk without x-

ray evidence of silicosis¤Can be treated with 12-

18 months of antibiotics¤High index of suspicion

Uranium milling hazards

¨ Uranium oxides (yellow cake)

¨ Vanadium dusts¨ Solvents¨ Respirable silica¨ Noise¨ Musculoskeletal

trauma

Uranium mill workers mortality study

¨ Retrospective mortality study¨ >2000 uranium millers employed for at least 1

year from 1940 to 1971¨ 7 uranium mills on the Colorado Plateau

[RJ Waxweiler et al. Mortality Patterns Among A Retrospective Cohort of Uranium Mill Workers. Epidem Appl Health Phys, 1983]

Uranium mill workers mortality study

Observed Expected SMR 95%CI

Nonmalignant respiratory disease

55 33.7 163 123-212

Other respiratory disease 39 15.6 250 178-342

Chronic & nonspecific nephritis and renal sclerosis

6 3.6 167 60-353

Acute nephritis 0 .04 0 16-482

Nephritis with edema including nephrosis

0 0.2 0

Radon exposure and lung cancer

¨ First described in metal ore mines in Central European region of Schneeberg. ¤ Fatal lung disease among miners in Erz Mountains described

by Agricola in 1500s¤ Recognized as primary lung cancer in late 1800’s

¨ Similar lung cancer problems documented for underground miners at Joachimsthal, Czechoslovakia in 1929.

¨ Common denominator in mines was high levels of radon.

Radon exposure and lung cancer

¨ USPHS Study: Colorado Plateau uranium miners (late 1940s – late 1950s) had excess rates of lung cancer.

¨ Confirmed in studies of underground miners in other countries:¤ Canadian uranium miners¤ Swedish and French iron ore (hematite) miners¤ Norwegian niobium miners¤ British tin miners¤ Newfoundland fluorspar miners

Radon-caused lung cancerBasic Mechanism

Uranium

Radon gas decay species

Alpha particles damage

respiratory cell DNA Lung cancer

Lung cancer

Lung cancer mortality: non-smoking uranium miners (Gilliland, Health Physics, 2000)

WLM Odds Ratio 95% CI

0-79 1.0 -

80-274 1.9 0.3, 11.7

275-699 5.3 1.0, 29.6

700-1449 24.7 4.4, 138.3

+1450 29.2 5.1, 1672

Malignant lung disease in uranium miners

¨ 3.5 average relative risk of lung cancer from underground uranium mining.

¨ Inverse dose effect: For the same cumulative radon dose, miners exposed longer at lower levels have higher lung cancer risk than those exposed over shorter period.

J. Samet, Occupational Medicine, 2nd edition, 1998R. Hornung, Environ Health Perspect 103(Supppl 3):49, 1995

Basis for 1990 RECA -- Radiation Exposure Compensation Act

Congressional Findings“Radiation released in underground uranium mines that were providing uranium for the primary use and benefit of the nuclear weapons program of the United States Government exposed miners to large doses of radiation and other airborne hazards in the mine environment that together are presumed to have produced an increased incidence of lung cancer and respiratory diseases among these miners.”

§42U.S.C. 2210(2)(a)

Intent of RECA Legislation

¨ Partial restitution to individuals exposed to radiation for the burdens those individuals bore for the Nation as a whole.

¨ Apologize on behalf of the U.S. to individuals and families for the hardships they endured.

¨ Establish a trust fund to make restitution payments to individuals.

1990 RECA Coverage

¨ Underground uranium miners

¨ Downwinders¨ On site

participants at atmospheric nuclear test sites

1990 RECA: Underground uranium miners

¨ Mined uranium in Colorado, New Mexico, Arizona, Wyoming or Utah between 1947 and 1971.

¨ Contracted lung cancer or nonmalignant respiratory disease

¨ Smoker: >300 working level months (WLM) exposure if onset before age 45; > 500 WLMs if cancer after age 45. Nonsmoker: >200 WLM if cancer onset at any age.

¨ $100,000 compensation

RECA Coverage: Downwinders

¨ Persons present in listed counties in Utah, Nevada, and Arizona during specified period in the 1950s and 1960s.

¨ Covered diseases include leukemia, multiple myeloma, lymphoma, and primary cancer of the thyroid, female breast, esophagus, stomach, pharynx, small intestine, pancreas, bile ducts, gall bladder or liver.

¨ $50,000 compensation

RECA Coverage: On Site Participants

¨ Present at atmospheric detonation of nuclear device

¨ Same specified diseases as for Downwinders

¨ $75,000

2000 RECA Amendments

¨ Congressional Findings¤Regulations implementing RECA provision

were overly burdensome and prevented some deserving individuals from receiving compensation.

¤Scientific data supports expanding the list of compensable radiogenic pathologies.

Year 2000 RECA Amendments

¨ Expanded persons covered to also include¤ Above ground uranium miners¤ Mill workers¤ Ore transporters

¨ Relaxed eligibility requirements¨ Medical documentation specifics updated¨ Eliminated distinctions between smokers and

nonsmokers

RECA 2000 expanded eligibility for uranium miners, millers, ore transporters¨ Employment documentation relaxed.¨ Employed between January 1, 1942 and December

31, 1971¨ Miners need only show >40 WLM or one (1) year of

exposure, regardless of smoking status.¨ Mill workers and ore transporters need only prove

one year of employment.¨ Allows use of affidavits to prove employment for

miners. ¨ Includes mines in additional states: Idaho, Oregon,

Texas, Washington, South and North Dakota.

Expanded Eligibility for Downwindersand Onsite Participants¨ Additional diseases compensable: primary cancers of

lung, male breast, salivary gland, urinary gland, brain, colon, and ovary.

¨ On site participants: Above or within boundaries of the Nevada, Pacific, Trinity or South Atlantic Test Sites

¨ Downwinders:¤ Lived or worked downwind of Nevada Test Site during

atmospheric nuclear testing¤ Certain counties in UT, NV, AZ¤ For at least two years during January 21, 1951 – October

31, 1958 or between June 30, 1962 – July 31, 1962

Where did RESEP come from?

¨ Radiation Exposure Compensation Act (RECA) Amendments of 2000.

¨ Section 417C: Grants for Education, Prevention, and Early Detection of Radiogenic Cancers and Diseases: the Radiation Exposure Screening and Education Program.

¨ “To aid thousands of individuals adversely affected by the mining, transport and processing of uranium and the testing of nuclear weapons for the Nation’s weapons arsenal.”

RESEP Purposes

¨ 8 RESEP grantees (AZ, CO, WY, NM, UT) supported by funds from HRSA

¨ Develop education programs and disseminate information on radiogenic diseases and the importance of early detection.

¨ Screen eligible individuals for cancer, lung disease, and other radiogenic diseases.

¨ Provide appropriate referrals for medical treatment.

¨ Facilitate documentation of RECA claims.

RESEP Clinics

¨ North Country HealthCare, Flagstaff, AZ¨ University of New Mexico Health Sciences Center,

Albuquerque, NM¨ Northern Navajo Medical Center, Shiprock, NM¨ University of Nevada School of Medicine, Las Vegas,

NV¨ Dixie Regional Medical Center, St. George, UT¨ Utah Navajo Health Systems, Montezuma Creek, UT¨ San Juan Health Service District, Monticello, UT¨ National Jewish Health, Denver, CO

RESEP clinical services

¤ Medical & occupational questionnaire¤ Physical exam¤ Spirometry¤ Chest x-ray with B-reading¤ Oximetry & blood pressure measurements¤ Urinalysis¤ Fecal occult blood sample¤ Arterial blood gas¤ Health education & benefits counseling¤ Results letter & referral¤ Case management & follow-up

RESEP activities

¨ Outreach to locate and assist eligible participants

¨ Medical screening and referral

¨ Education (annual meetings; shared materials)

¨ Benefits counseling (RECA and EEOICPA)

¨ Legislative strategies for expanding eligibility

Acknowledgements: RESEP team

¨ NJH: ¤ Bibi Gottschall, MD, MPSH¤ Wendy Vonhof,

coordinator¤ Catie Stroup, spirometry

and outreach¤ Jenny Smith, PA-C¤ Dymond Ruybal, scheduler

¨ HRSA and other grantees(Thanks, Shannon!)

QUESTIONS?

Persons Eligible for RECA Benefits

¨ Individual who meets criteria.¨ Surviving spouse if married to individual during last

year of individual’s life.¨ If no surviving spouse, then living children of individual

in equal shares (includes natural children, stepchildren who lived with individual in a regular parent-child relationship, and adopted children).

¨ If no surviving spouse or children, then living parents of individual in equal shares.

¨ If no surviving spouse, children or parents, then living grandchildren of individual in equal shares.

¨ If no surviving spouse, children, parents or grandchildren, then living grandparents in equal shares.