Gästinlägg av Magnus Simonsson
Specialistläkare i klinisk fysiologi och kardiologi och
medlem i Socialstyrelsens RN-medicinska expertgrupp
Det var en bra konferens med korta och tydliga föredrag. Av sekretesskäl var det förbjudet att ta bilder. Det märktes att CBRN är en aktuell fråga. Man har börjat räkna på smutsiga bomber och mindre, taktiska kärnvapen som en klart aktuell möjlighet, även i Europa. Här är några länkar:
Det fullständiga materialet: https://radiation-medicine.de/fileadmin/user_upload/ConRad-Program-2017-04-26.pdf
Hemsida för RITN Radiation Injury Treatment Network: https://ritn.net/default.aspx
Deras övningar: https://ritn.net/exercises/
Nedan följer ett urval av intressanta föredrag och även postrar. Enstaka kommentarer av undertecknad.
Först en aptitretare. Hjälper vitlök mot strålskador?
Evaluation on the Supplementation of Bawang Lanang (fermented garlic) extract in protecting human lymphocytes in vitro from the genotoxic activity of gamma rays. Syaifudin et al., Natl. Nucl. Energy Agency, Jakarta, Indonesia
We concluded that aqueous garlic extract did not possesses antigenotoxic properties toward ionizing radiation.
CBRN event: pre-hospital victims management at the Paris Fire Brigade
D Riccobono et al., Armed Forces Biomedical Research Inst., Brétigny, France
Due to the current international context, emergency medical services have to be prepared for CBRN events. In Paris, emergency response requires coordination between many components: the fire brigade composed of military firemen, nurses and physicians, civilian emergency services with nurses and physicians, policemen, hospital etc. To optimize efficiency, victim management is governed by a specific text called Yellow Plan. This plan is inspired by military CBRN victim management on operational theatre. The Yellow plan is based on extraction, decontamination, triage and treatment, CBRN agent identification and training. It is also supported by specific CBRN dotation. Pre-hospital victim management will be described in this communication as well as French CBRN supplies. However is important to remember that the complexity of the NRBC context subjects this response plan to a constant evolution.
Man lagrar DTPA i civila lager och man har även färdiga dekontaminationskit till civilbefolkningen med tunn overall, munskydd och värmefilt.
Predicting the Public Health Consequences of Nuclear Terrorist Attacks T Jorgensen, Radiat. Medic., Georgetown Univ., DC, USA
In addition to prevention, we need to prepare for the aftermath of an improvised nuclear device (IND) attack by nuclear terrorists. Since such an attack has yet to occur, we have no direct experience from which to draw insight. But we do know that a ground level detonation of an IND will simultaneously produce both blast and fallout radiation casualties — a combined public health threat that we have not encountered before. With regard to blast casualties, the Hiroshima bombing provides a good public health preparedness model, since an IND would likely be of similar size. But the Hiroshima bombing produced little fallout (because of its detonation at altitude), so it provides no insight into fallout casualties. In contrast, nuclear power plant accidents produce fallout similar to the detonation of a uranium fission bomb, but there are no blast radiation casualties involved. So we need to draw inferences from both types of events, in order to best predict and prepare for the public health consequences of an IND attack. Models of blast and fallout dose distributions coupled with census data allow for fairly precise estimates of types of radiation effects that will be seen and the numbers of people experiencing those effects. Current medical countermeasures for radiation exposures will likely have little impact on the casualty statistics because very few victims will experience doses within the windows where countermeasures are medically effective, and poor individual dosimetry data will make it difficult to identify the victims where medical treatment would be beneficial. When to evacuate attack victims will be a problem. But also, exactly when people can safely return to radioactively contaminated areas will also be a major recovery issue that needs to be addressed. Public education about radiation risks should ideally begin prior to potential attacks, not after, because elevated fear and misunderstanding about radiation further plays to terrorist interests. Föredragshållaren ansåg att LD50 inte var 5 Sv utan närmare 8 Sv med hematopoetisk behandling. Detta ifrågasattes i frågestunden. Med full modern behandling skulle bara 5% av offren i Hiroshima kunnat räddas eftersom de flesta dog av brand och explosionsskador. Bäst effekt av behandlingen har man mellan 4-8 Sv.
Triage and medical management of high-volume mass casualties after a nuclear detonation: Hiroshima revisited Flynn DF REAC/TS USA
Today, nuclear terrorism is a greater threat than nuclear war. The U.S. Department of Homeland Security, issued a number of different major threat scenarios. National Planning Scenario #1 (NPS1) is a 10-kiloton ground-level nuclear detonation in a densely populated area. This would result in a surge of overwhelming casualties. The death toll, particularly during the first few days, would be very high; however there still would be the potential to save many seriously injured people by implementing appropriate triage, treatment, and evacuation strategies. Casualties within a five kilometer blast zone radius will sustain various combinations of physical trauma, thermal burns, and radiation injuries. In addition, because of the ground-level detonation in NPS1, there will be a downwind radioactive fallout plume that extends well beyond the blast zone. Here there will not be physical trauma or burns but there will be delayed radiation-alone casualties including some fatalities.
The Hiroshima nuclear 15-20 kiloton detonation was at low altitude so that fallout was not considered an issue. Of the estimated 136,000 casualties, at four months following the detonation, there were 64,000 fatalities including 45,000 on day one and 19,000 between day two and four months. More than half of the fatalities were attributed to the thermal injuries alone, physical trauma alone, or combined. Other fatalities were attributed to radiation-alone or combined injuries with thermal and/or trauma. Of those who survived the first 20 days, some developed alopecia, purpura, and painful oropharyngeal lesions. These symptoms were attributed to serious, sometimes fatal, exposures in the hematopoietic syndrome range. Recognizing these three delayed radiation manifestations would be important in NPS1 ground level detonation fallout zone.
The U.S.military triage system for mass casualties originally adopted for trauma (physical injuries and burns) consists of four categories: IMMEDIATE(highest priority) – requires immediate treatment to save a life; DELAYED – requires treatment that can be delayed as less urgent than IMMEDIATE category; MINIMAL – requires minor treatment which can be administered as an outpatient if necessary (“walking wounded”); and EXPECTANT – requires extensive treatment and resources but has a poor prognosis even with treatment. It is expected that within 12-48 hours post-detonation, that clinical (time-to-emesis) and laboratory (such as lymphocyte depression) data will be available to modify conventional triage. However laboratory results may be delayed with high-volume mass casualties and damaged area infrastructure including communication. In that event, for unshielded casualties, rough radiation dose assessment may be made by the degree of thermal burn or the visible blast injuries. This assessment should provide the likely distance from ground zero and subsequent expected radiation dose. This has the potential, in addition to time- to-emesis, to speed up combined injury triage.
En smutsig bomb kommer sannolikt inte att kunna ge mer än 1 Sv/person. Men den kommer att orsaka radioaktivt nedfall eftersom den sprängs på marken. Jämfört med Hiroshima där det var en luftdetonation dvs mycket ringa radioaktivt nedfall. Ska man evakuera området? 20 mSv/år ger ett mer cancerfall på 1000 invånare vilket läggs till de 250 cancerfallen/1000 invånare i normalfallet.
Enhancing National Preparedness through Biodosimetry Wathen L et al., Biomedical Advanced Research and Development Authority
In all potential radiation disasters, the population is likely to encounter a number of complex radiation exposure scenarios, including different dose ranges and dose rates. Therefore, performing triage and definitive radiation biodosimetry will require multiple tests to measure absorbed dose. Qualitative point-of-care tests are being designed to be administered quickly to determine whether an individual has absorbed a minimum threshold radiation dose and needs further medical care. Quantitative high-throughput laboratory-based tests that estimate the actual absorbed dose a person has received to enable more accurate clinical management. Five promising biodosimetry tests are currently funded by BARDA to identify the most relevant proteomic, genomic and cytologic radiation biomarkers and validate their utility using animal models and humans. Algorithms integrate multiple individual biomarker results into a single test result. The two point of care tests in development use immune-capture technology. One uses multiple test lines on a nitrocellulose lateral flow device with upconverting phosphor signal output, and the other uses a spotted array in a cartridge with an electrochemiluminescent reporter. Both technologies use capillary (finger stick) blood samples to detect host protein biomarker levels that increase (or decrease) following gamma or x-ray exposure. Of the three high-throughput tests under development, two use changes in gene expression patterns to determine the extent of radiation damage, and the third measures chromosomal damage and micronucleus generation to predict absorbed dose. ASPR’s BARDA working with federal and industry partners will enable the development, regulatory review by the United States Food and Drug Administration, and acquisition of radiation biodosimeters. The Biodosimetry Program’s continued success will help the United States prepare for and respond more effectively to a nuclear incident.
Lesson learned from Chernobyl and Fukushima: http://www.crealradiation.com/index.php/shamisen-home
Clinical triage of radiation victims – the hematological module of the Bundeswehr InstRadBioBw applied during the recent NATO exercise on clinical signs & symptoms Port M, Bundeswehr Institute of Radiobiology, Munich, Germany
Rapid clinical triage of radiation injury patients within the first days after a radio nuclear attack or accident is mandatory to guide therapeutic interventions. We developed an early prediction model for the acute hematological syndrome (H-ARS) using complete blood counts (CBC), based on real radiation-accident data. This tool (H-module) enables the first responder to differentiate between worried well and patients that develop different severity degrees of H-ARS. It also provides information on the medical management such as hospitalization required and treatment decisions. The ”H-module”, was tested during an international NATO exercise, again using real patient data. In this exercise the “H-module” together with clinical signs and symptoms proved to predict the later developing ARS in more than 90% of the cases correctly within the first 3 days after exposure. Also, clinical decisions regarding hospitalization were made correctly in more than 90% of the cases. Encouraged by the promising results of the NATO exercise we developed a short training course for students of the Munich mastercourse of radiobiology and again were able to reproduce prior results. Surprisingly, these students (with background e.g. in biology or pharmacology) performed as well as the best performer of the NATO exercise. This experience underlines the requirement of medical training courses which are planned to be conducted in near future under the umbrella of the NATO.
Epidemiology of Late Health Effects in Chornobyl Cleanup Workers Bazyka D, National Research Centre for Radiation Medicine, Kyiv, Ukraine
Studies of health effects in exposed with acute radiation syndrome included clinical follow-up, haematopoietic system and immune function. Number of persons under follow-up in RCRM varied from 179 in 1986-1991 to 105 in 2011-2015. The main causes of late deaths (52) included cancers and leukemia (18), cardiovascular diseases (20).
On stochastic effects the main findings after the 2008 UNSCEAR report demonstrated increased radiation risks of leukemia comparable with hibakusha data (ERR/Gy for 20 years – 2.38; 95% CI 0.49; 5.87), the excess of chronic lymphocytic leukemia for 26 years after the exposure (SIR 1.44 (95% CI: 1.21; 1.68), new evidence on the association of radiation dose and younger age at exposure with shorter survival and gene expression.
A significant excess was registered in incidence of multiple myeloma (SIR 1.61, 95% CI 1.01; 2.21), thyroid cancer (TC) (SIR 3.50, 95% CI 3.04; 4.03) and all solid cancers (SIR 1.08; 95% CI 1.05; 1.11). High prevalence was demonstrated for cardio- and cerebrovascular diseases, mental health changes. However the mechanisms have to be further investigated. Last studies have demonstrated an involvement of genes regulating the basic cell response to exposure and disease.
Conclusions and future direction. Expected effects for the next period include increased rates of thyroid, breast and lung cancers; multiple myeloma, reduction of radiation risks of leukemia to population levels, increased morbidity and mortality of cleanup workers from cardio- and cerebrovascular pathology. Analytical cohort and case-control studies are in need on circulation pathology, late high dose effects, specific types of radiogenic cancers using molecular epidemiology approach.
New insights into thyroid cancer epidemiology: Chernobyl, Fukushima and beyond Kesminiene A, International Agency for Research on Cancer, Lyon, France
Worldwide, thyroid cancer occupies place outside the ten most frequent malignancies. However, the increase in thyroid cancer incidence observed in many countries over the last three decades initiated concerns about the causes of such rise.
Ionising radiation, as a risk factor for thyroid cancer, was established following studies of atomic bomb survivors of Hiroshima and Nagasaki, exposed instantaneously to external radiation, as well as of patients treated with radiotherapy.
Initially, the increase in thyroid cancer in young residents of the areas of Belarus, Ukraine and Russia, contaminated after the Chernobyl accident, was met with scepticism based on the “evidence of non-carcinogenicity” of iodine-131 from the previous studies of medically exposed populations with underlying thyroid diseases and limited data on childhood exposure. Chernobyl produced a new evidence of the radiosensitivity of paediatric thyroid gland following exposure to internally incorporated radioactive iodine.
A role of various modifying factors, such as age at exposure (including exposure in utero and in adulthood), attained age, sex and iodine deficiency present in the areas affected by the accident has been hypothesised but remains to be established, as well as the pattern of the risk in the longer term.
Although contribution of screening in the increase of thyroid cancer observed after Chernobyl was questioned, it is obvious that an important fraction of these thyroid cancers is attributable to radioiodine intake in 1986. Long-term increases are difficult to quantify in the population which is aging and in which spontaneous thyroid cancer risk is also increasing. Finally, after several decades of data accumulation, the dominating hypothesis for explaining the worldwide increase in thyroid cancer shifted to improved surveillance and diagnostics. In this context, the findings of the large-scale thyroid screening survey in Fukushima prefecture should be interpreted with caution.
Radiation-epidemiological study of the incidence of complexes of disease of the circulatory system and comorbidities disease among Chernobyl recovery operation workers Karpenko S, A. Tsyb Medical Radiological Research Center, Russian Federation
Author presents retrospective cohort study of the incidence of complexes of disease of the circulatory system and comorbidities among liquidators of the Chernobyl accident, for the follow-up period 1986-2012. Cohort selected for analysis consists of more than 100 thousands Russian liquidators registered in National Radiation and Epidemiology Registry (NRER) who worked in the Chernobyl zone. External radiation whole-body dose varied from 0.0001 Gy to 1.41 Gy with average dose of 0.113 Gy. Evaluation of radiation risks obtained in terms of the excess relative risk (ERR) and relative risk (RR). Maximizing the likelihood function for ERR, RR and calculation of 95% confidence intervals were performed using Epicure software. In our previous studies, we provided estimates of ERR for cerebrovascular disease (CeVD), taking into account comorbidities. (ERR / Gy = 1.29 – CeVD with diabetes mellitus (E10-E14) and ERR / Gy = 0.35 – CeVD without diabetes mellitus). In this study we estimated ERR for some complexes of the following diseases: hypertension (I10-I15), cerebrovascular disease (I60-I69), ischemic heart disease (IHD) (I20-I25), diabetes mellitus (E10-E14), overweight and obesity (E66). The time at risk calculated as the difference between the date of entry into the Chernobyl zone and the last (maximum) date of three cases diagnosed first time.
The result is statistically significant estimates for the following complexes of diseases:
- Hypertension (I10-I15), CeVD (I60-I69), diabetes mellitus (E10-E14): ERR/Gy = 1.88; p < 0.001
- Hypertension (I10-I15), IHD (I20-I25), diabetes mellitus (E10-E14): ERR/Gy = 1.32; p = 0.002
- Hypertension (I10-I15), IHD (I20-I25), CeVD (I60-I69): ERR/Gy = 0.69; p < 0.001
These estimates obtained for the liquidators, who entered in the Chernobyl zone in the period of 26.04.1986 to 26.04.1987 and worked there less than 6 weeks.
Early, rapid dose magnitude estimation and monitoring for internal decontamination following accidental exposure to an actinide Dainiak N et al., REAC/TS, Oak Ridge, TN, USA
Prompt assessment of the magnitude of ionizing radiation (IR) dose involved in a radiological/nuclear incident is essential to inform medical management, including the use of medical countermeasures. Reliable activity measurements are needed to compare potential intakes to the Clinical Decision Guide (CDG) for a particular radionuclide (ICRP Report No. 161). In the case of exceeding regulatory limits for cutaneous wounds, the derived reference level (DRL) is used for early dose assessment. These tools provide comparisons of dose magnitude that is in a general range of absorbed doses rather than a precise estimate of absorbed dose. Radiation dose magnitudes should be communicated to first responders and receivers, clinicians and other healthcare providers in terms of the risk posed to the exposed individual(s). In contrast to absorbed radiation doses that are measured at the time of external exposure, radiation doses are calculated for internal exposures. Regulations in the US require that internal doses be reported as a committed dose based on a protracted exposure over 50 years. Internalization of radionuclides occurs not only by inhalation, ingestion, parenteral injection (i.e, the administration of a radioactive material for a medical purpose) and direct transdermal absorption, but also by absorption through open wounds. A case will be discussed of a puncture wound that resulted in a plutonium (Pu-238) intake requiring prolonged decorporation therapy with diethylenetriaminepentaacetic acid (DTPA). Although the initial count rate measured at the wound site was minimal and would not have predicted a serious medical threat (particularly as alpha-emitting particles penetrate poorly through barriers such as intact skin), subsequent detection of associated x-rays with a high purity germanium (HPGe) detector and Pu-238 in the urine, augured a more significant medical condition. Monitoring of the effectiveness of DTPA therapy in this individual will be discussed in the context of the averted committed effective dose (CED).
New paradigms of the treatment of acute radiation syndrome Drouet M, Armed Forces Biomed. Research Inst., Brétigny sur Orge, France
Acute Radiation Syndrome (ARS) represents the pathophysiological consequences of total body or large partial body exposure to high doses of ionizing radiation (accident or terrorist attack). In such cases the hematopoietic syndrome (HS, is frequently the first therapeutic challenge in clinic. Importantly the bone marrow damages appear heterogeneous in most accidental cases. Therefore intermediate damages (H3 Metrepol scoring) may benefit of cytokine treatment. Thus the current gold standard consists in administering Growth Stimulating Factor (G-CSF) to counteract neutropenia, albeit mitigating the crucial thrombopenia parameter remains a target for future optimization.
Following the FDA statement in 2015, accidental radiation-induced bone marrow aplasia represents now a full indication for G-CSF treatment. In addition, preclinical models (especially monkey) have clearly established the benefit of the early injection of G-CSF towards delayed administration. This is the reason why NATO is now recommending a rapid injection schedule within the first 24 hours after the diagnosis, even if the classical cytogenetic dosimetry is not available. This pointed out the importance of clinical dosimetry to be ideally completed with blood cell counts to discard the worried well and prevents the sparing of available G-CSF. It is now obvious that thus a recommendation may imply huge logistic constraints and necessitate adequate stockpiling based on ad-hoc realistic attack/accident scenarii to be selected.
Development of the Toll-Like Receptor-5 Agonist, Entolimod, as a Medical Radiation Countermeasure Miller LL et al., Cleveland BioLabs, Inc., USA
Radiation injury caused by a hostile nuclear attack or an accident could cause thousands of deaths. Medical radiation countermeasures (MRC) are needed to improve survival among victims of a radiation disaster.
Entolimod is a recombinant Toll-like receptor-5 (TLR5) agonist in advanced development as an MRC to reduce the risk of death following a radiation disaster. Entolimod binding to TLR5 induces production of granulocyte colony-stimulating factor (G-CSF) and interleukin-6 (IL-6), and mobilizes neutrophils. These effects promote multiorgan tissue protection and regeneration. Because humans cannot be lethally irradiated to test drug activity, entolimod is being developed based on efficacy data in animals and safety data in humans.
Efficacy studies in nonhuman primates (NHP) show that a single intramuscular (IM) injection of entolimod within 48 hr after lethal irradiation decreases radiation-related myelosuppression and gastrointestinal injury resulting, in highly significant survival benefits, even in animals that receive minimal supportive care.
Studies of single IM injections in healthy male and female humans have confirmed dose-dependent increases in G-CSF, IL-6, and neutrophils consistent with effects in NHP. The human safety profile has been well characterized, comprising transient flu-like symptoms, hemodynamic changes, and asymptomatic laboratory findings that resolve spontaneously. A formal dose-conversion paradigm has established a human dose based on cross-species comparisons of changes in the 3 circulating biomarkers of drug effect (G-CSF, IL-6, and neutrophils).
Entolimod meets military and civilian requirements for an MRC that can be administered after radiation exposure as a single-injection solution for deployment during field operations or in a mass-causality situation to enhance the survival of military and civilian victims of a radiation catastrophe.
United States Department of Health and Human Services Radiological/Nuclear Medical Countermeasures Programs Homer M, Biomedical Advanced Research and Developm. Authority, DC, USA
The United States Department of Health and Human Services (HHS) is fully committed to the development of medical countermeasures (MCM) to address national security threats from chemical, biological, radiological, and nuclear (CBRN) agents. Through the Public Health Emergency Medical Countermeasures Enterprise, HHS has launched and managed a multi-agency, comprehensive effort to develop and operationalize medical countermeasures. Within HHS, development of MCMs includes the National Institutes of Health (NIH) (the MCM effort is led by the National Institute of Allergy and Infectious Diseases (NIAID)), the Office of the Assistant Secretary of Preparedness and Response (ASPR)/Biomedical Advanced Research and Development Authority (BARDA) and the Division of Medical Countermeasure Strategy and Requirements, the Centers for Disease Control and Prevention (CDC), and the Food and Drug Administration (FDA) as primary partners in this endeavor. The presentation describes the BARDA portfolio and strategy as well as the coordinating efforts of BARDA and NIH for the development of countermeasures for radiological and nuclear threats. Establishment of product development tools, strategies for biomarker and target identification, and strategies for reducing product development costs will be briefly discussed in the context of BARDA portfolio management.
Protecting the population depending on the differentiation of populations Freitinger-Skalicka Z, Inst. of Radiology, Toxicology and Civil Protection, Univ. of South Bohemia, Czech Republic
Within the project VG 20132015122 “Protecting the population depending on the differentiation of populations“ the realisation team conducted an analysis of the current status of the evacuation planning from the emergency zone planning and suggest new methods of evacuation planning with the disruption of ethical issues. The safety of the nuclear power plant´s is achieved by the design safety and the power plant’s operational culture level, which includes qualified personnel, quality documentation, use of operating experience, technical control, protection against radiation, fire safety, etc. To facilitate a preplanner strategy for protective actions during an emergency, there are two emergency planning zones (Temelin Nuclear Power Plant) or three emergency planning zones (Dukovany Nuclear Power Plant) around each nuclear power plant. Emergency evacuation from is the immediate and urgent movement of people away from the threat or actual occurrence of a hazard. In these often emotionally stressful situations, it is also necessary to ensure effective communication with the evacuated population. Evacuation must be well managed, not only on the technical side, but also on the biopsychosocial side. This plane, which is viewed from the evacuated population is important, it is often neglected.