TMT Handbook

TMT TMT TMT
HANDBOOK
Triage, Monitoring and Treatment of people exposed
Chapter A Introduction..........................................................................
Chapter B Handbook structure and how to use it...................................
Chapter C Scenarios............................................................................... 11
1
to ionising radiation following a malevolent act Chapter D Public information and communication strategy.................... 14
Chapter E Immediate actions................................................................. 22
Chapter F Triage and monitoring for the purpose of screening.............. 70
Chapter G Decontamination of people in the field.................................. 150
Chapter H Monitoring for dose assessment purposes............................. 168
Chapter I Handling of contaminated casualties and transport

to hospital............................................................................. 222
Chapter J Medical management at the hospital..................................... 230
Chapter K Public health response........................................................... 320
Chapter L International liaison............................................................... 338
Annex
Annex 1: Required facilities .............................................................................. 380
Annex 2: Equipment required for radiological triage and monitoring purposes . 386
Annex 3: Forms, questionnaires and information leaflets . ................................ 392
Annex 4: Allocation of roles ............................................................................. 428
Annex 5: Interpretation of clinical signs and symptoms . .................................. 434
Annex 6: Specifying a monitoring strategy for internal contamination .............. 438
Annex 7: Later triage and monitoring ............................................................... 441
Annex 8: Monitoring techniques ....................................................................... 444
Annex 9: Biodosimetry ..................................................................................... 466
Annex 10: Action Levels ..................................................................................... 470
Annex 11: Sampling of excreta and blood .......................................................... 491
Annex 12: Management of internal contamination . ............................................ 495
Annex 13: Look-up tables for the assessment of internal doses .......................... 505
Annex 14: Methodology applied by WHO for developing guidance on health
interventions for Chapters J and K of this Handbook . ........................ 553
Carlos Rojas-Palma ¡ Astrid Liland ¡ Ane Næss Jerstad Photos front page, clockwise from top left: NRPA, NRPA, NRPA, REAC/TS, WHO and STUK.
George Etherington ¡ María del Rosario Pérez ¡ Tua Rahola ¡ Karen Smith (Eds.)
At the scene At the hospital
Chapters E to I Chapter J
Incident
Immediate actions ■ Preparing for arrival of victims at the
Chapter E
hospital, section J.1–J.3
Monitoring to Establishing Control of

■ Second triage, section J.4
confirm radiation zones and zone exposure ■ Management of
emergency boundaries
Transport ● Acute radiation syndrome (ARS), section J.5
of victims to ● Combined injuries, section J.6
Scenarios
Chapter C Triage and monitoring for hospital ● Local radiation injuries, section J.7
Chapter I ● Radionuclide contamination, section J.8
screening purposes
Chapter F
■ Dealing with deceased victims,
Public section J.9
Initial Initial
information and triage monitoring ■ Cytogenetic dosimetry, section J.10
communication
Chapter D
Decontamination of people
Chapter G
International
liaison Monitoring for dose
Chapter L assessment purposes
Chapter H
Specifying Dose
Monitoring
monitoring assessment
techniques
strategy methods
Later triage Recording
and and reporting
Public health response and long-term
monitoring results
follow up of exposed people
Handling of contaminated casualties Chapter K

Chapter I
TMT Handbook
Triage, Monitoring and Treatment of people exposed to

ionising radiation following a malevolent act
www.tmthandbook.org
Carlos Rojas-Palma, Astrid Liland, Ane Næss Jerstad, George Etherington, Disclaimer
María del Rosario Pérez, Tua Rahola, Karen Smith (eds.) [2009]
This publication contains the collective views of an international group of
experts and does not necessarily represent the decisions or the stated policy
Copyright
by member organisations of the consortium. Whilst reasonable steps have
been taken to ensure that the information contained within this Handbook
© SCK•CEN [2009]
is correct, you should be aware that the information contained within it
© Norwegian Radiation Protection Authority (NRPA) [2009]
may be incomplete, inaccurate or may have become out of date.
© Health Protection Agency (HPA) [2009]
Accordingly, the authors and the members of the consortium (SCK•CEN,
© Radiation and Nuclear Safety Authority (STUK) [2009]
NRPA, HPA, STUK, WHO, Enviros and CLOR), its agents, contractors
© World Health Organization (WHO) [2009]
and subcontractors make no warranties or representations of any kind as to
© Enviros Consulting Ltd (Enviros) [2009]
the content of this Handbook or its accuracy and accept no liability
© Central Laboratory for Radiological Protection (CLOR) [2009]
whatsoever for the same including, without limit, direct, indirect or
consequential loss, business interruption, loss of profits, production,
All rights reserved. Requests for permission to reproduce whole or parts of
contracts, goodwill or anticipated savings. Any person making use of this
texts contained in this publication should be addressed to:
Handbook does so at own risk and liability.
NRPA
The identification of specific companies or of certain manufacturers’
P.O. BOX 55
products does not imply that they are endorsed or recommended by the
No-1332 Østerås
European Commission or members of the Consortium in preference to
Norway
others of a similar nature that are not mentioned. Therefore, nothing in this
[email protected]
Handbook, including its Annexes, is intended to be or should be interpreted
www.nrpa.no
as an endorsement of, or recommendation for, any supplier, service or
product.
ISBN (printed version): 978-82-90362-27-5
ISBN (pdf version): 978-82-90362-28-2
Print: Lobo Media AS, Norway
b c
Foreword Chapter H George Etherington and Michael J Youngman, HPA;
European national emergency response plans have long been focused on Tua Rahola and Maarit Muikku, STUK; Alicja
accidents at nuclear power plants and other nuclear installations. Recently, Jaworska, NRPA
possible threats by disaffected groups have shifted the focus to being Chapter I María del Rosario Pérez, WHO; Michael J
prepared for malevolent use of ionising radiation aimed at creating Youngman, HPA
disruption and panic in society. Although some countries may have Chapter J María del Rosario Pérez, WHO; Alicja Jaworska,
adequate national plans for response, there is a need for European NRPA
guidelines on how to act in the event of malevolent use of radioactive
Chapter K María del Rosario Pérez, WHO
material.
Chapter L Carlos Rojas-Palma, SCK·CEN; Zhanat Carr, WHO;
This Handbook has been produced by the project TMT Handbook (Triage, Hannele Aaltonen, STUK
monitoring and treatment – handbook for management of the public in the
event of malevolent use of radiation) to address this need. The project has
been partly funded by the European Commission under the 6th Euratom Contribution from consortium members’ organisations
Framework Programme for Research and Technological Development People from consortium members’ organisations who have contributed to
under grant FI6R-036497. The coordinator of the project has been Carlos the work in the project and in producing the Handbook are listed below:
Rojas-Palma from SCK•CEN – Belgian Nuclear Research Centre.
SCK•CEN – Belgian Nuclear Research Centre (Belgium)
More detailed information about the methodology applied for the Carlos Rojas-Palma Project co-ordinator
development of Chapters J and K of this Handbook is provided in Annex Klaas van der Meer Consortium member, Work package leader
14. Robby Nijs Scenario dose calculations
Authors NRPA – Norwegian Radiation Protection Authority (Norway)

The authors of the Handbook have been as follows: Astrid Liland Consortium member, Work package leader
Ane Næss Jerstad Consortium member, main technical editor
Chapters A & B Astrid Liland, NRPA
Alicja Jaworska Consortium member
Chapter C Klaas van der Meer and Carlos Rojas-Palma, Anne Marit Østreng Public information and communication strategy
SCK•CEN Synne M. Egset Technical support in editing
Chapter D Anne Marit Østreng, NRPA Inger Nergaard Technical support in editing
Chapter E Alan Hodgson, Michael J Youngman and George
Etherington, HPA; Tua Rahola and Maarit Muikku, HPA- Health Protection Agency (United Kingdom)
STUK George Etherington Consortium member, Work package leader
Chapter F George Etherington, Alan Hodgson and Peter G D Michael J Youngman Consortium member
Pellow, HPA; Tua Rahola and Maarit Muikku, STUK Alan Hodgson Consortium member
Peter G D Pellow Consortium member
Chapter G Michael J Youngman, HPA
Denise Dorrian Bioassay and internal dose calculations, Annex 10/13
d e
WHO – World Health Organization Makoto Akashi
Zhanat Carr Consortium member, Work package leader Research Center for Radiation Emergency Medicine
María del R Pérez Consortium member National Institute of Radiological Sciences (NIRS), Japan
Eileen McKenna Financial officer
Bernard Dizier External relations officer Robert Nicolas Gent
Clare Creo External relations officer Health Protection Agency (HPA), United Kingdom
Chantal Streijffert Legal officer
Patrick Gourmelon
STUK- Radiation and Nuclear Safety Authority (Finland) Institut de Radioprotection et de Sûreté Nucléaire (IRSN), France
Tua Rahola Consortium member, Work package leader
Maarit Muikku Consortium member Siegfried Joussineau
Hannele Aaltonen International liaison, Chapter L Radiation Medicine Center, Karolinska University Hospital, Sweden
Wendla Paile Scientific advisor
Harri Toivonen Scientific advisor Volker List
Petri Smolander Scientific advisor Head, Medical Department, Forschungszentrum Karlsruhe, Germany
Enviros Consulting Ltd. (United Kingdom) David Lloyd

Karen Smith Consortium member, Technical Secretariat Cytogenetics Group Leader, Health Protection Agency (HPA), United
Phil Kruse Former consortium member, Technical Secretariat Kingdom
Carol Robinson Consortium member
Nelson Valverde
CLOR- Central Laboratory for Radiological Protection (Poland) Laboratory of Radiological Sciences (LCR), Rio State University, Brazil
Genowefa Smagala Former consortium member
Pawel Krajewski Consortium member Albert L. Wiley
Radiation Emergency Assistance Center /Training Site (REAC/TS), United
Acknowledgements States
We would like to thank all the authors and people from consortium
Last, but not least, we would like to thank the European Commission and
members’ organisations for their substantial work necessary to produce this
the Research Council of Norway for their financial support of this project.
Handbook. We would also like to thank all the end-users who took part in
the evaluation process of an advanced draft of the TMT Handbook,
through returning their comments in writing and/or by providing their
input at the TMT Feedback Workshop held at Lillehammer in December
2008.
We are also grateful to the following international experts who attended the
expert meetings and provided technical input specifically on Chapters J and
K:
f g
Contents
Contents Chapter F Triage and monitoring for the purpose of screening ................ 70
1 Objectives of triage ....................................................................................................... 70
2 Initial triage ................................................................................................................... 74
2.1 Trauma triage ........................................................................................................ 74
2.2 Radiological triage ................................................................................................80
Chapter A Introduction ................................................................................. 1
2.2.1 Triage based on information on location ...................................................80
Chapter B Handbook structure and how to use it ........................................ 5 2.2.2 Triage based on clinical signs and symptoms ............................................ 98
3 Initial monitoring ........................................................................................................ 110
Chapter C Scenarios ...................................................................................11
3.1 Preparatory actions for monitoring teams .......................................................... 112
1 Introduction ................................................................................................................... 11 3.2 Environmental monitoring ................................................................................. 116
2 Considered scenarios .................................................................................................... 11 3.3 Monitoring people for external contamination................................................... 124
2.1 Radiological Exposure Device .............................................................................. 12 3.4 Monitoring people for internal contamination ................................................... 134
2.2 Radiological Dispersal Device .............................................................................. 12 3.4.1 In vivo monitoring ..................................................................................... 134
2.3 Attack on transport of radioactive material .......................................................... 13 3.4.2 In vitro monitoring .................................................................................... 142
2.4 Contamination of food and water supplies ........................................................... 13 4 Advice on dealing with psychological issues ............................................................. 146
Chapter D Public information and communication strategy .......................14 Chapter G Decontamination of people in the field ....................................150
1 Introduction ................................................................................................................... 14 1 Preparations for decontamination of people .............................................................. 152
2 Public communication as an emergency response tool ............................................... 14 2 Decontamination procedures ...................................................................................... 156
3 Effective public information – some key elements ...................................................... 16 2.1 Instructions common to all decontamination procedures .................................. 156
4 Plan ahead ..................................................................................................................... 17 2.2 Decontamination using specialist mass decontamination facilities .................. 158
5 Coordination and consistency ...................................................................................... 18 2.3 Decontamination procedure for people in trauma triage group P2 ................... 158
2.4 Decontamination of small numbers of people ................................................... 160
6 Instructions – public communication in the event of malevolent use of radiation...... 18
2.5 Decontamination of larger numbers of people .................................................. 162
Chapter E Immediate actions...................................................................... 22 3 Self-decontamination at home .................................................................................... 164
1 Control of exposure.......................................................................................................22 4 Contamination control ................................................................................................ 166
1.1 First responders .....................................................................................................24
5 Waste considerations .................................................................................................. 166
1.2 Authorised personnel ............................................................................................ 30
1.3 Public ..................................................................................................................... 30 Chapter H Monitoring for dose assessment purposes..............................168
1.4 Dealing with deceased persons ............................................................................ 34 1 Objectives of individual monitoring........................................................................... 168
2 Monitoring to confirm a radiation emergency ............................................................. 36 2 Specifying a monitoring strategy ............................................................................... 170
2.1 Contamination and irradiation incidents ..............................................................40 2.1 Identification of radionuclide(s) .......................................................................... 172
2.2 Contaminated food/water incidents ...................................................................... 50 2.2 Characterisation of source .................................................................................. 172
3 Establishing zones and zone boundaries ......................................................................54 2.3 Selection of individuals for monitoring .............................................................. 174
3.1 Initiate the Red Zone .............................................................................................54 2.4 Locations for individual monitoring ................................................................... 176
3.2 Initiate the Yellow Zone .......................................................................................60 2.5 Individual monitoring methods........................................................................... 176
3.3 Evolution of the Red Zone .................................................................................... 62 3 Monitoring techniques ................................................................................................ 182
3.4 Evolution of the Yellow Zone ...............................................................................64 4 Later triage and monitoring ........................................................................................ 188
3.5 Outside the Yellow Zone ...................................................................................... 68 4.1 Action Levels ....................................................................................................... 188
4.2 Triage after initial external contamination measurements ................................ 190
4.3 Triage after initial internal contamination measurements ................................. 194
i ii
Contents
4.4 Triage after cytogenetic measurements ..............................................................200 Chapter L International liaison................................................................. 338
5 Dose assessment methods ...........................................................................................202 1 Introduction ................................................................................................................. 338
5.1 Internal dose assessment .....................................................................................204 2 International notification arrangements ..................................................................... 338
5.2 Assessment of dose to the skin resulting from external contamination ...........208 2.1 The Early Notification Convention ..................................................................... 339
5.3 Issues for consideration when performing more accurate assessment of 2.2 The European Commission Notification system ................................................ 339
internal dose ....................................................................................................... 210 2.3 World Health Organization ................................................................................340
5.4 Estimation of dose from external irradiation ..................................................... 212 3 Coordination of international assistance ....................................................................340
6 Recording and reporting results ................................................................................. 216
References ............................................................................................... 342
Chapter I Handling of contaminated casualties and
transport to hospital .................................................................................222 Bibliography ............................................................................................. 356
Chapter J Medical management at the hospital ........................................230 Glossary ................................................................................................... 362

1 Receiving notification of the incident ........................................................................ 232 List of abbreviations ................................................................................375
2 Preparing the hospital for patient reception ............................................................... 234
3 Arrival of patients at the hospital ...............................................................................240
Annexes .................................................................................................... 380
4 Performing a second triage at the hospital .................................................................246
Annex 1: Required facilities ..........................................................................................380
5 Management of uncontaminated but possibly irradiated casualties ......................... 250
Annex 2: Equipment required for radiological triage and monitoring purposes .........386
5.1 Therapeutic Principles for ARS patients ........................................................... 268
Annex 3: Forms, questionnaires and information leaflets ............................................392
6 Combined injuries ...................................................................................................... 276
Annex 4: Allocation of roles ..........................................................................................428
7 Local radiation injuries .............................................................................................. 282
Annex 5: Interpretation of clinical signs and symptoms ..............................................434
8 Radionuclide contamination ....................................................................................... 296
Annex 6: Specifying a monitoring strategy for internal contamination .....................438
9 Dealing with deceased persons at the hospital........................................................... 314
Annex 7: Later triage and monitoring ..........................................................................441
10 Cytogenetic dosimetry ................................................................................................ 316
Annex 8: Monitoring techniques .................................................................................. 444
Chapter K Public health response ............................................................ 320 Annex 9: Biodosimetry .................................................................................................466
1 Introduction ................................................................................................................. 320 Annex 10: Action Levels .................................................................................................470
2 The role of the health authorities during the emergency .......................................... 320 Annex 11: Sampling of excreta and blood ......................................................................491
3 Risk communication and communication with health care workers ......................... 321 Annex 12: Management of internal contamination ........................................................495
4 Establishing peripheral health care centres................................................................ 323 Annex 13: Look-up tables for the assessment of internal doses .....................................505
5 Referral hospitals ........................................................................................................ 325 Annex 14: Methodology applied by WHO for developing guidance on
6 Dealing with worried well .......................................................................................... 326 health interventions for Chapters J and K of this Handbook ........................553
7 Outbreak of unusual disease attributable to radiation exposure ............................... 327
8 Prevention and treatment of psychological consequences ......................................... 328
9 Taking decisions about long-term follow up of people involved in a radiation
emergency ................................................................................................................... 331
9.1 Long-term follow up of patients who developed local radiation injuries .......... 332
9.2 Long-term follow up of casualties who developed acute radiation syndrome
(ARS) ................................................................................................................... 334
9.3 Long-term follow up of populations exposed to low doses ................................ 335
iii iv
Contents
List of figures Figure J11. Clinical evolution of LRI.......................................................................................285

Figure B1. Example of the chosen structure in chapters E to J .............................................. 6 Figure J12. “The rule of nines” .............................................................................................. 289
Figure B2. Example of a flowchart .........................................................................................10 Figure J13. Radiation induced epithelitis in hands ................................................................291
Figure E1. Examples of the personal protective equipment ..................................................23 Figure J14. The evolution of tissue necrosis after surgical treatment including
Figure E2a. Basic ionising radiation warning symbol .............................................................37 artificial skin graft ...............................................................................................293
Figure E2b. Supplementary ionising radiation warning symbol ..............................................37 Figure J15. Dosimetry-based surgery as an approach to treatment of LRI ...........................297
Figure E3. Packages and vehicle with potentially dangerous sources symbol ..................... 39 Figure J16. Specific solutions for external decontamination ................................................ 303
Figure E4. Typical radiography camera..................................................................................41 Figure J17. Management of external contamination ............................................................ 304
Figure E5. Very dangerous source from radiography camera................................................43 Figure J18. When to stop external decontamination efforts ................................................ 305
Figure E6. Generic layout of Red Zone ...................................................................................55 Figure J19. Effectiveness of iodine thyroid blocking as a function of time after intake ...... 309
Figure E7. Red Zone Algorithm (Part A)................................................................................. 58 Figure J20. Effectiveness of decorporating agents for treating internal contamination....... 309
Figure E8. Red Zone Algorithm (Part B) ..................................................................................59 Figure J21. Cytogenetic biological dosimetry - dicentric assay ............................................. 317
Figure E9. Generic layout of Yellow Zone ...............................................................................61 Figure K1. Peripheral healthcare centres - role in medical response to a radiation
Figure E10. Yellow Zone algorithm ......................................................................................... 63 emergency ..........................................................................................................323
Figure F1. Flowchart for trauma triage ................................................................................. 79 Figure K2. Referral hospitals offer advice and support to lower level health facilities ........325
Figure F2. Dependence of exposure category on distance and time .....................................93 Figure L1. Framework for inter-agency response to nuclear or radiological mergencies ....341
Figure F3. Flowchart for radiological triage based on information on location .....................97
Figure F4. Relationship between time to onset of vomiting and dose .................................. 99 List of tables
Figure F5. Lymphocyte depletion ........................................................................................101 Table B1. Response teams ................................................................................................ 8
Figure F6. Flowchart for radiological triage based on clinical signs and symptoms ...........102 Table E1. Examples of occupancy times in the areas with elevated dose rates .............. 29
Figure F7. European approach for the medical management of mass radiation Table E2. Emergency worker turn back dose guidance ...................................................31
exposure (EBMT) ................................................................................................. 103 Table E3. Operational intervention levels (OILs) in radiological emergencies ................ 33
Figure F8. An outline of a radiological triage system...........................................................109 Table E4. Recommended avertable doses for undertaking countermeasures ................. 33
Figure F9. Alpha contamination monitoring ....................................................................... 117 Table E5. Guide to transport packages markings ...........................................................41
Figure F10. Monitoring people for external contamination ..................................................129 Table E6. An example of subdivision of the Red Zone .................................................... 69
Figure F11. Entire body scan.................................................................................................. 131 Table F1. Stages in the triage process ............................................................................ 73
Figure F12. Recommended procedures for external contamination monitoring .................. 132 Table F2. Maximum acceptable contamination levels and dose rates at Safety
Figure F13. "Lap geometry" for whole body measurement ..................................................139 Perimeter ......................................................................................................121
Figure F14a. Measurement of 131I in the thyroid. ......................................................................141 Table F3. Actions corresponding to the action levels of Annex 10 ...............................133
Figure F14b. Background measurement to be used for the thyroid measurement .................141 Table G1. Potential surface contamination from a RDD..................................................153
Figure F15. Recommended procedures for internal contamination monitoring ....................145 Table H1. Individual monitoring methods ......................................................................177
Figure G1. Flowchart for decontamination of people. ..........................................................151 Table H2. Comparison of usefulness and limitations of different cytogenetic assays ....187
Figure G2. Example of a specialist mass decontamination unit ..........................................159 Table H3. Action Levels (copy of tables from Annex 10) ................................................191
Figure G3. Mobile decontamination unit .............................................................................161 Table H4. Actions corresponding to the Action Levels of Annex 10 ...............................195
Figure G4. Demonstration of decontamination of people who need assistance. ................163 Table H5. Relative Biological Effectiveness (RBE) for severe deterministic effects ........ 207
Figure G5. Remember to monitor personnel for contamination ...........................................167 Table H6. Generic reference levels on RBE-weighted absorbed dose ............................ 207
Figure H1. The TIARA method. .............................................................................................197 Table H7. Skin beta dose rate conversion factors for material deposited on
Figure H2. Flowchart - radiological triage based on external contamination monitoring ....199 skin or clothing ............................................................................................ 209
Figure H3. Flowchart - radiological triage based on internal contamination monitoring .....201 Table H8. Radiation emissions, absorption types and gastro-intestinal uptake
Figure I1. Transporting the casualties to hospital .............................................................. 229 factors f1 for intake by inhalation ................................................................... 213
Figure J1. How to go through Chapter J ..............................................................................231 Table J1. Radiological triage categories ........................................................................249
Figure J2. Example of a scheme for preparation of the hospital reception area .................243 Table J2. Scoring for the first 48 hours .........................................................................257
Figure J3. Treatment of contaminated patients - staff must wear PPE ................................245 Table J3. Selection of the therapeutic strategy according to clinical status for first 48 h. ... 259
Figure J4. Emergency department staff should assume that the patients are Table J4. METREPOL: Neurovascular system ................................................................ 262
contaminated until confirmed otherwise ...........................................................247 Table J5. METREPOL: Haematopoietic system .............................................................. 262
Figure J5. If contamination is suspected, patient’s clothing and shoes should be Table J6. METREPOL: Cutaneous system ..................................................................... 263
removed as promptly as possible, without compromising life or limbs .............247 Table J7. METREPOL: Gastro-intestinal system ............................................................. 263
Figure J6. How to calculate the respons categories (RC) using METREPOL .........................265 Table J8. Therapeutic strategy according to the METREPOL response categories ........ 266
Figure J7. Overall therapeutic approach for ARS patients according to METREPOL ........... 273 Table J9. Grades of severity of LRI ............................................................................... 287
Figure J8. Blood cell depletion curves (from EBMT).............................................................275 Table J10. Action Levels for treatment of radionuclide contamination........................... 307
Figure J9. Patients with fractures should be stabilised, decontaminated and Table J11. Recommended single dosage of stable iodine according to age group ......... 309
the fracture treated, before ARS management....................................................281 Table K1. Late radiation morbidity score (RTOG) ...........................................................333
Figure J10. Skin structure .....................................................................................................285
vi vii
CHAPTER A
Introduction
Aim
This Handbook has been produced to address the need for practicable tools
to assist those responding to malevolent use of ionising radiation. The
Handbook is intended for the purpose of planning and training by
emergency response organisations, and subsequent use in the field.
Audience
The Handbook is developed for use by emergency response organisations
with specific functions to plan, coordinate and execute mitigating actions
in response to incidents involving the malevolent use of ionising radiation.
It gives guidance both for field operations and for medical treatment at the
hospital, as well as public health response.
Although the Handbook gives specific instructions for actions at the scene
and at the hospital, any user would need to be familiar with the Handbook
content before responding to an actual event. The Handbook is thus not
intended as a quick look-up guide for first responders with no prior
knowledge or training in emergency situations involving ionising radiation.
It can, however, be used for training of response personnel and experts in
radiation protection or medical treatment, and as a tool in emergency
exercises.
Handbook content
The Handbook content focuses on topics specifically related to the
radiological triage, monitoring and treatment necessary to respond to a
malevolent act, while ensuring the appropriate protection of responding
personnel. The content builds on state-of-the-art procedures and
techniques, and on relevant international guidelines. It contains both
general information and detailed proposals for actions to be taken in the
field and in the hospitals by specialised teams in radiation protection,
monitoring and medical treatment. This information can be found in
chapters E to J, which constitute the core content of the Handbook.
Supporting information is given in the other chapters.
1
Chapter A Introduction
Chapter B gives an explanation on the Handbook structure and guidance The annexes include supporting information on:
on how to use it.
• Required facilities and equipment;
It is strongly recommended that users read Chapter B carefully • Example forms, questionnaries and information leaflets;
before proceeding to Chapters E to J. • Allocation of roles;
• Interpretation of clinical signs and symptoms;
Chapter C gives a summary of possible malevolent scenarios.
• Specifying a monitoring strategy for internal contamination;
Chapter D gives general guidelines on public information and • Later triage and monitoring, monitoring teqniques and
communication strategies. biodosimetry;
• Action Levels;
Chapter E describes immediate actions to be taken at the scene, including
• Sampling of excreta and blood;
monitoring to confirm a radiation emergency, establishing zones and
controlling exposures of people responding to the incident and members of • Management of internal contamination; and
the public. • Assessment of internal doses.
Chapter F describes triage and monitoring for screening purposes in the A glossary is included for explanation of relevant terminology used in the
field. Handbook. A list of acronyms and abbreviations used in the text is also
provided.
Chapter G gives information on decontamination procedures in the field
and self-decontamination at home. The Handbook does not contain a general description of radioactivity,
radiation protection nor instrumentation. This information may be found in
Chapter H gives advice on monitoring strategy, monitoring techniques, many books in various languages across Europe. Nor does the Handbook
assessment of doses, and reporting monitoring results. contain descriptions of normal emergency actions in the field or at the
hospital as first responders are already trained for such tasks. The
Chapter I concerns the handling of contaminated casualties and transport Handbook provides instructions on actions specifically required for
of patients to hospital. handling radiation incidents.
Chapter J details actions to be taken at the hospital for proper handling of
Although the focus of the Handbook is response to malevolent acts, the
patients with local radiation injuries, acute radiation syndrome or combined
guidelines could also be used for response to other non-site specific
injuries (conventional and radiation injuries). The management of
incidents involving ionising radiation like orphan sources or accidents
contaminated patients is also addressed, including decorporation
involving transport of radioactive material.
techniques for internal contamination.
Chapter K deals with public health response and long-term follow up of National adaptation
exposed people. It is envisaged that this Handbook could help create a European standard
for response to malevolent acts involving ionising radiation. At the same
Chapter L is dedicated to international cooperation on early warning and time it is acknowledged that the European countries are diverse with
assistance. respect to size, capacities, organisational structure, regulations, climate and
culture. For the implementation of these guidelines, end users should
2 3
Chapter A Introduction
consider national feasibility, availability of resources and capabilities, as CHAPTER B

well as country specific conditions. As a result of this, the guidelines may
be adapted to national conditions and regulations. Nonetheless, it is
anticipated that the Handbook will contribute to harmonisation across
Handbook structure and how to
Europe concerning triage, monitoring and treatment of people exposed to use it
ionising radiation following a malevolent act.
The structure of the Handbook is depicted in the fold-out page of the front
cover. It follows the timing of various actions necessary to address a
malevolent act, starting with defining the emergency zones, then triage,
monitoring and on-scene treatment, followed by medical treatment in
hospitals and long-term follow up of exposed persons. Public information
and communication is expected to take place throughout the response
phase, at various levels. The different chapters have been given a chapter
specific colour coding. The colours are reflected in chapter titles in the
fold-out figure in the front cover to make navigation easy.
The different chapters may be used independently by the reader. Hospital
staff could for instance go directly to chapter J. There are, however, links
between different chapters for consistency. Links to other parts of the
Handbook are given in square brackets. Complementary information is
given in annexes, and these are referenced as appropriate.
Instructions vs Information panels

Chapters E to J have a specific lay-out. On the left hand page, introductory
parts are given in grey boxes followed by instructions on how to act in
various situations. Each instruction has a unique number, starting with the
chapter letter and then consecutive numbering within that chapter, e.g. E.1,
F.11, G.24.
The right hand page gives supporting and additional information related to
the instructions. The information panels have the same number as the
instruction to which it refers. In some cases, the information panel relates
to a whole section. This is then stated explicitly.
In chapters E to J both the sections and the instructions are given in the
order in which the issues would be expected to arise. The necessary actions
are thus listed chronologically and not grouped according to type of
response team or type of incident.
4 5
Chapter B Handbook structure and how to use it
Instructions on Additional information

Main chapter left hand page on right hand page Sub-chapter
Type of Indicates if the

incident incident is of a covert
or overt nature
Link to another
relevant section
Additional information
Unique
relating to Instruction F.11
instruction
numbering
Response
team
Figure B1 (both pages). Example of the chosen structure in chapters E to J.
6 7
Types of incidents hospital. In the heading of each instruction the relevant teams for
The Handbook considers three types of incidents (or a combination of performing the actions are given in brackets. A figure of the different
these): teams necessary at the scene of a radiological incident is given at the fold-
out page of the back cover. The colour coding corresponds to the chapters
• Environmental contamination incident; where the main tasks of these teams are described.
• Food/water contamination incident; and
• External irradiation incident. Further description of the roles and responsibilities of various teams is
given in Annex 4.
In those cases where the instructions are relevant only for specific types of
incidents, this is stated at the beginning of the actual instructions or at the Flowcharts
beginning of the section. If no indication of incident is given, the The Handbook contains various flowcharts for decision support. One
instructions are relevant for all incidents. The incidents could be of a covert example is given in Figure B2.
or overt nature. Covert means e.g. secret/hidden source or unannounced
contamination, while an observable source or an announced contamination The rhombuses indicate that a decision has to be made, while the rectangles
would be of an overt nature. indicate actions to be taken. Rectangles with dotted lines refer to another
flowchart.
Response teams
Various response teams are necessary to perform the different instructions The flowcharts presented are generic ones and might need to be adapted
given in this Handbook. The proposed teams are stated in Table B1. according to the real event. Example of such an adaptation related to a
specific exercise scenario, is given in Information F.38b.
Table B1: Response teams
At the scene At the hospital

Tactical Incident Command (TIC) Security Personnel
First Responders Ambulance Team
Security personnel Emergency Medical Manager
Medical Team Hospital Emergency Team
Environmental Monitoring Team Pathology Department
Radiological Triage Team Radiation Protection Officer
Decontamination Team Health/Medical Physicist
People Monitoring Team
Dose Assessment Team
Records Team
Ambulance Team
The teams given in bold are teams specifically designed to respond to

radiological incidents, while the others are teams normally involved in any
incident/accident where people would need assistance at the scene or at a
8 9
CHAPTER C
Scenarios
1 Introduction
The scenarios described here are used for illustrative purposes only. They
are not meant to indicate the probability or possibility of any such event
actually occurring. Neither should it be assumed that the scenarios
described here are an exhaustive list of the possible incidents that could
occur. Predictions of what might actually happen based on the scenarios
considered in this handbook are at most semi-quantitative, since reality
differs from human imagination. The poisoning of Alexander Litvinenko
with 210Po in 2006 serves as an example of this, since prior to the event
such a scenario was not considered in emergency and response plans.
2 Considered scenarios
(a) 1000 Bq/cm2 beta, gamma or 100 Bq/cm2 alpha
(b) For requirements of emergency services AND access through Security Perimeter can be The aim of malevolent acts with radioactive material is to induce a
controlled effectively
significant economic, political and/or health effect, including psychological
Figure B2. Example of a flowchart
stress. The casualties in such incidents are likely to be members of the
public. According to event, the number of affected people could vary from
a few to mass casualties (i.e. a high number of exposed and/or injured
people). Some scenarios could result in received doses high enough to
cause Acute Radiation Syndrome (ARS). For other scenarios, such
exposures are unlikely. Radiation injuries could also be combined with
conventional injuries. A number of potential scenarios for such events are
possible to identify. Possible scenarios include:
• Radiological Exposure Device;

• Radiological Dispersal Device;
• Attack on transport of radioactive material;
• Contamination of food and water supplies;
• Attack on nuclear installation or installation containing radioactive
material; and
• Improvised Nuclear Device.
10 11
Chapter C Scenarios
The two latter scenarios have not been elaborated further. An attack on a 2.3 Attack on transport of radioactive material
nuclear installation and subsequent release of radioactive material is well Transport of radioactive material may contain a very high amount of
covered by the existing emergency plans. An attack on an installation with radioactivity. An attack may have the purpose to spread the radioactive
radioactive material (e.g. sources in medicine or industry) would be covered material in the immediate neighbourhood of the scene or to transport the
by the description of a Radiological Dispersal Device, while an attack with material to another place where a release of the radioactive material can do
an Improvised Nuclear Device (home made nuclear weapon) is beyond the significant harm to society. The variety of material transported means that
scope of this project. it is difficult to predict the consequences. The material could be used in
RED, RDD or to contaminate food and water supplies.
2.1 Radiological Exposure Device
A Radiological Exposure Device (RED) is a hidden radioactive source that 2.4 Contamination of food and water supplies
will typically irradiate people externally. Internal contamination could The contamination of food or water supplies may have a direct impact on
occur if the source is compromised either deliberately or accidentally. public health. The contamination can be performed in an indirect way via
contamination of a lower part of the food chain, like cattle food or water, or
If the objective is to affect the maximum number of people the RED is more directly via contamination of human food, e.g in the food industry.
likely to be placed where a large number of people would be present, Water can be contaminated in drinking water reservoirs or closer to the tap
congregate or pass by. It could be moved to different locations for this points, e.g. at the distribution points of local neighbourhoods.
purpose. An alternative would be the targeting of specific individuals, or
high-level authorities.
2.2 Radiological Dispersal Device

A Radiological Dispersal Device (RDD) is a device for spreading
radioactive material to contaminate a large area and/or number of people.
The spread of the radioactive material can be performed by an explosive,
also called a “dirty bomb”, but other means may also be used for
dispersion. The event could be of a covert or overt nature.
The effects of radiological contamination dispersed by an explosion are

difficult to predict and depend on diverse factors like environmental
conditions (temperature, time of day, relative humidity, wind conditions,
precipitation), chemical and physical form of the radioisotope (particle size,
etc), type and amount of explosives, local environment, etc. Calculations
serve at their best therefore as a semi-quantitative approximation of the
potential situation and resulting contamination. Reality will in all
probability differ from any modelled simulations.
12 13
Chapter D Public information and communication strategy
CHAPTER D involving the use of 210Po, shows how most people are dependent on
statements made by experts or the information communicated through the
Public information and media. And the media works fast! It is not uncommon, during events or
accidents, to find the media to be the first on the scene. This implies that
communication strategy the public interpretation of the crisis is created at the same time as the
emergency preparedness response efforts unfold.
To an ever increasing degree, the public can monitor how an emergency or

1 Introduction crisis evolves, in real time, on live TV or on the internet. Hence, the
emergency response organisation must realise, and act upon, the fact that
The scenarios described in the previous chapter all present tremendous
the media created impressions of a crisis are as real as the crisis itself. Risk
challenges to public communication efforts. In the following section, some
communication needs to consider the difference between how a risk is
general ideas and recommendations are presented. However, it must be
perceived by the public versus how the risk is actually assessed and
recognised that there exist cultural differences between countries, and
measured by the experts. Effective risk communication may not be able to
therefore similar means and techniques for communication may not be
change strongly held perceptions, but it can improve understanding of, and
effective in all countries. Any approach would need to be tailored to the
compliance with, response measures.
specific situation and location.
For a member of the public, first and foremost it is important to establish
Public communication should be considered a key function in any response
whether or not the risk at hand constitutes a danger to themselves or their
involving the malevolent use of radiation. Without successful public
loved ones. Secondly, they need to be able to make their own informed
communication, authorities cannot achieve their emergency response
decisions on what actions to take. In case of an event involving the
objectives to save human lives and protect the public and the environment.
malevolent use of radiation, both the scenario and the motive will influence
Thus, information strategies constitute an integral part of emergency
on risk perception. A person’s experience, attitudes and knowledge will
preparedness. Authorities, be it on a national, regional or local level, should
also influence on how risk is perceived. The less knowledgeable a person is
prepare to respond to the public information demands that will arise during
about a risk, the more the person is likely to rely on information provided
an event involving the malevolent use of radiation. To be effective, a public
through the media.
information response should be planned in advance of any emergency.
These plans will need to be integrated within the overall planning for
So, if emergency response organisations can provide relevant acurate
managing malevolent acts and should detail the roles and responsibilities to
information on the risk and response measures, in a prompt and timely
be carried out during the response.
fashion, then there is a good chance of meeting the needs of the target
group, and subsequently, providing effective crisis communication.
2 Public communication as an emergency Basically, this means providing information on what has happened, the
response tool consequences thereof, and the response measures (to be) implemented.
Public communication activities can help prevent unnecessary fear or panic. Moreover, information on response measures should also be clearly
In general, the public has little knowledge of radiation. This can be separated from other information being released. If that information is not
attributed to a number of factors. This field of expertise is not readily delivered on time, or clearly phrased, it may result in a lack of trust in the
accessible to the layman. At the same time, however, the effects of, for response organisation. Independent, authorative guidance will be seen as
example, nuclear accidents are well known. The Chernobyl accident in the best source of information.
1986 is still well remembered. The Litvinenko case in London in 2006,
14 15
3 Effective public information – some key this data is managed needs to be considered as part of the communication
elements strategy. It may also be a good idea to have only selected spokespersons
making statements to the media as it will most likely facilitate coordination
For public communication to be credible and trustworthy, the organisation
both within and between different organisations.
providing it must be seen as open and transparent. The need for
transparency may be difficult to comply with since the information
Events involving the malevolent use of radiation will be followed closely in
available is usually incomplete due to the time necessary to fully
neighbouring countries, or even worldwide. Hence, the media pressure may
understand what has happened. However, lack of information may be
become overwhelming. Also, the general public will demand timely and
interpreted as trying to hide something from the public, which in turn will
complete information on the risks and prognosis during such an event.
impact negatively on the emergency response organisation’s credibility.
Advances in information communication technology and the globalisation
Timely information is thus of the essence, and it is important to keep a low
of the news media have increased the demand for real-time information
threshold for handing out information to the media. To wait until there is a
about any incident or emergency. The media is generally considered as the
comprehensive and verified picture of what has taken place before releasing
primary source of information to the public, although the internet is gaining
information to the media (and the public) could result in the media
in importance in providing information and should be utilised to its full extent.
preferring other, less authoritative sources of information. In the first
hour(s), lacking verified information to hand out, the emergency response
By definition, an event involving the malevolent use of radiation is an
organisation can at least inform about what their responsibilities are and
unexpected one and there is very little or no time available before the first
what is being done, until more information is available. Doing so will help
media or public inquiry is received. At this point the ability for the
establish the emergency response organisation as a credible source towards
emergency response organisation to provide clear, if not precise,
the media, and show the public who is in charge. The media is in fact a
information on what is known at the time is a key element.
very well suited platform for disseminating crucial messages, and should
be regarded by the emergency response organisation as an additional
resource. 4 Plan ahead
Some information products can, at least partly, be developed in advance of
A plain language explanation of the radiation risks and any an emergency. These products can be developed for a variety of target
countermeasures being taken is a vital part of an effective risk audiences depending on the potential emergency situation and information
communication process. It not only facilitates public understanding, it needs. By developing information products in advance, they can be rapidly
satisfies their need for information and fosters trust with those who are in distributed or adapted as necessary in the event of an emergency. To
charge. Trust and availability of information become the key elements for develop templates of required products such as press releases; questions
risk communication. To establish this trust, particularly during and answers format information; basic advice on general actions the public
emergencies where the public may be asked to comply with can take; general background information on radioactive materials; contact
countermeasures, information provided to the public must not only satisfy information, will save time when dealing with an actual emergency
their needs, but must also be provided in plain language so that it can be situation. Some example templates are provided in Annex 3.
easily understood and facilitate their decision making.
Other information products will need to be developed in response to the
It is recommended that all updates, news or (monitoring) results are specifics of the situation. This information is produced according to the
published on the internet as soon as they come in, and not withheld from situation and how it develops, what response measures are chosen as well
the media, unless obstructive to the police/intelligence investigations. Care as what protective actions and advice to the public is initiated by the
also needs to be taken when dealing with medical-in-confidence data. How response organisation. Information products (press releases, press
conferences, media statements, website updates, monitoring results, etc.)
16 17
are generated with some degree of uncertainty as to how the situation In crisis communication it is important to:
might evolve. However, it is important to maintain the information effort • Define key messages;
with frequent updates. The media is always very quick to react and to make • Establish target audiences, and tailor the information accordingly;
use of the first information obtained, from any source. Any delay in
• Show empathy with the casualties and their next of kin; and
providing clear (and verified) information to the mass media and the public
creates an atmosphere for spreading rumours and information without • Select appropriate modes of communication.
evidence. These may be very difficult to correct later on since they may be
more emotional than rational. In providing service to the media it is useful to note that:
• Selected personnel should be available to the media at all times; and
5 Coordination and consistency • It will ease off some of the media pressure on the response organisation/
spokespersons if you spend time on:
Proper coordination between governmental and official bodies that are likely
to interact with the public is crucial for effective public communication. Any - Regular press releases;
lack of coordination may result in critical inconsistencies between various - Press conferences – at regular, set intervals, if possible; and
official sources of information, which again would have a negative impact of - Internet. Suggested web content includes:
public trust towards these official bodies. National level plans and procedures • Press releases and public statements
should be in place to coordinate public information activities with regional • Background information, fact sheets
and local authorities. It is vital to the credibility of the response that the • Questions and answers
information itself be consistent. Procedures should identify roles and • Results of monitoring
responsibilities of the different actors in the public information response of • Links to other related sites.
the organisations and should include specific mechanisms for coordination of
information between all levels. Procedures should also be developed for the The following tasks should always be planned ahead:
wide variety of public information activities – media monitoring, media • National, regional and local public information plans/procedures must
relations, public information products, public hot-line for questions – that be in place defining roles and responsibilities, necessary resources and
may be needed during an emergency response. manpower;
• In order to avoid contradictory messages, plans on how to coordinate
6 Instructions – public communication in the public information between different national authorities must be in
event of malevolent use of radiation place;
Public communication must be: • Develop a task list for all personnel – a “what to do” in case of an
emergency;
• Transparent and open;
• Crisis management is exhausting – have a pre-planned roster of staff,
• Prompt, avoid unnecessary delays; including trained spokespersons;
• Frequent; • Templates for press releases, protective directives etc. and their
• Reliable – never lie; dissemination capabilities; and
• Objective; • Plain language conversion of scientific/technical information.
• Understandable to the layman, use plain language;
• Two-ways; and
• Not obstructive to police/intelligence investigations
18 19
The following could also be valuable if resources are available:

• Media monitoring and analysis;
• Draft fact sheets, draft Questions & Answers;
• Toll free number for public calls; and
• Logistics and procedures to establish a dedicated public information
centre.
Last, but not least, it is essential to carry out exercises, preferably including
media professionals. The exercises must be evaluated and the lessons
learned taken forward to improve the information and communication
response.
20 21
Information 1 Control of exposure
CHAPTER E
Immediate actions
Introduction Information E.1
In the initial stages of the response, there will be little time to carry out
detailed planning of the response, and minimal information on which to
base such plans. Chapters E, F and G describe initial actions to be taken
at the scene (mainly during the first 48 hours after notification or
discovery of an incident). These actions may be implemented
automatically without the need to develop plans that are specific to the
incident. Recommendations for developing a detailed plan for monitoring
after the initial (emergency) phase are given in Section H.2.
1 Control of exposure
Introduction
The purpose of this section of the Handbook is to give instructions on
how to control the exposure to ionising radiation at the scene.
Instructions are directed to:
• First responders working at the scene in the first moments after the
incident; Figure E1. Examples of the personal protective equipment. Left: waterproof clothes
and full face respirator. Right: Disposable coveralls and dust mast. Photos: STUK.
• Authorised personnel who are not emergency workers; and
• Tactical Incident Command (TIC) for protection of the public.
22 23
Chapter E Immediate actions Instructions Information 1 Control of exposure
The guidance is given at the levels of dose that will allow completion of Information E.1 (cont.)
tasks and return to the base without exceeding the levels in the
Occupational protection techniques
international guidance (IAEA Safety standards series GS-R-2, 2002,
Managing field exposures
ICRP Publication 96, 2005). Emergency dose guidance levels for The dose rate may vary considerably over short distances. As there is
workers are expressed as integrated external dose. It is assumed that all unlikely to be an experienced radiation protection professional at hand, and
necessary precautions are taken to prevent internal exposure. The dose levels will not usually be clear until later in the event, first responders
need to have a method to assess their individual exposure to external
guidance is for the entire emergency period. National regulations may radiation during the initial stages of the event [Annex 8]. First responders
result in more restrictive dose constraints, which should be followed. should, therefore, be issued alarming detection devices that will indicate
when certain dose rates or total cumulative external doses have been
Instructions given in this section should always be applied when reached. Noting that such devices will not detect non-penetrating radiation
responding to a radiological emergency unless directed otherwise by the or hazardous levels of airborne radioactive material, first responders need
TIC. to be made aware during training of these limitations.
Integrating alarming dosemeters should be provided to the responders,
with appropriate alarms corresponding to the guidance levels in Table E2
1.1 First responders [Information E.5]. For instance, the alarm levels should warn first
responders when their doses approach levels of 5, 50, and 500 mSv.
Alarming dose meters do not measure the dose from inhalation, ingestion
CAUTION: Only first responders wearing waterproof protective or skin contamination. Responders must also follow all the general
clothing and full face respirators should do life saving actions and instructions in Section E.1.1 to limit the dose from these pathways. The dose
evacuation before the radiological assessment at the scene has been meter alarm levels should be reviewed throughout the response and
lowered when appropriate.
made. Female workers who may be pregnant should notify the
appropriate authority and must be excluded from emergency duties. Following the detonation of an RDD or release from RDD, the radiation
fields in the immediate vicinity may be extremely inhomogeneous due to
the presence of highly radioactive fragments – resulting in radiation hot
E.1 Instructions that should always be followed spots. People managing field exposures need to be aware of this possibility,
(FIRST RESPONDERS) especially if the parameter "time" is used as the only variable to manage the
1. Follow standard safety procedures for your professional area. doses to first responders.
2. Wear some form of identification (high visibility uniform, Personal Protective Equipment (PPE)
armbands, jacket etc.) when within the Red Zone. Protective clothing
3. Do not touch/hold suspected radioactive items, including bomb The skin should be protected to reduce potential burns from high levels of
fragments (shrapnel). relatively non-penetrating beta or alpha radiation, and to prevent possible
transfer of radioactive material into the body through the skin and
4. Perform only the following actions within 1 metre of suspected inadvertently through the mouth or nose. The choice of clothing will often be
radioactive materials/source or, within 100 metres of fire or influenced by more immediate hazards such as fire, heat, or chemicals.
explosion: Protection against these other hazards will generally provide protection from
radioactive material. For medical personnel, normal barrier clothing and
• Life saving actions; gloves may provide personal protection against intake of contamination.
• Actions to prevent the development of catastrophic Disposable medical scrub suits, high-density polyethylene or other close-
conditions; and/or weave coveralls, safety helmets and waterproof shoes or boots should be
used if available. Secondary contamination of the medical staff from handling
• Actions to prevent severe health effects or injuries (e.g. patients should not be a cause of great concern. However, to prevent the
evacuation/protection of the public, rescue from potential unnecessary spread of contamination and thereby reduce the need for clean
threats of serious injuries, immediate treatment of serious up, it is prudent to utilise conventional protective clothing. (Continued over
injuries). page)
24 25
5. Minimize time spent within 10 metres of suspected radioactive

materials/source. Information E.1 (cont.)
6. When dispersion of radioactive material (dust/smoke) and Respiratory protection
contamination are suspected or confirmed: In most situations, respiratory protection that is designed to protect
• Use protective clothing and respiratory protection equipment; responders against chemical or biological agents is likely to offer adequate
respiratory protection in a radiological attack. Concerns about the
and
presence of chemical or biological contaminants will influence the
• Keep hands away from mouth, do not smoke, eat or drink selection of respiratory protection. If used properly, simple surgical
and wash hands regularly. facemasks provide reasonably good protection against the inhalation of
particulates, and allow sufficient air transfer for working at high breathing
7. When treating or transporting contaminated persons use rates. If available, high-efficiency particulate air filter masks provide better
normal barrier methods (standard precautions) such as protection [Annex 8].
protective clothing, surgical gloves and masks. Keep hands
away from mouth and wash hands regularly. Personal Protective Equipment (PPE) appropriate to the role of
the responder
8. Take a stable iodine tablet if instructed to do so by your field
In all cases alternative PPE giving a similar level of protection may be used.
controller/supervisor [Instruction J.24]. Record the fact that you
have taken a tablet [Form A3.5, Annex 3]. A. First Responders and emergency workers entering the Red Zone:
• Full face respirator;
E.2 Limiting exposure for emergency workers • Waterproof gloves (must be abrasion resistant)
(TACTICAL INCIDENT COMMAND [TIC]) • Waterproof clothing (all skin and hair must be covered)
• Waterproof shoes or boots;
1. Ensure that the names and occupancy times of the first • Safety helmet;
responders and activities performed by them are recorded when • Alarming personal dosemeter (measuring instantaneous dose rate as
they are within the Red Zone – for possible follow up and dose well as cumulative dose);
• A personal dosemeter (film badge or thermoluminescent dosemeter
reconstruction [Annex 3]. (TLD); and
2. Instruct the first responders to get monitored for radioactive • High visibility clothing is recommended.
contamination after being within Red Zone [Section F.3.3]. If
not immediately possible, advice them to shower and change B. First Responders and emergency workers entering the Yellow Zone and
medical staff handling contaminated casualties:
clothing as soon as possible [Chapter G].
• Surgical gloves, which should be changed frequently;
3. As soon as possible have work areas monitored [Section F.3.2]. • Coveralls;
• Simple respirators/dust masks;
E.3 Instructions if gamma dose rate is known • Plastic shoe covers;
• Hair cover (e.g. surgical cap); and
(FIRST RESPONDERS)
• A personal dosemeter (film badge or thermoluminescent
1. Follow Instruction E.1 above. dosemeter (TLD) is recommended).
2. If ambient dose rate in a particular area is greater than 100
mSv/h perform only the following actions: C. Personnel carrying out decontamination of people
• See B above
• Life saving actions; • Waterproof clothing is recommended.
• Actions to prevent the development of catastrophic
conditions; and
• Actions to prevent severe health effects or injuries (e.g.
evacuation/protection of the public, rescue from potential
26 27
threats of serious injuries, immediate treatment of serious

injuries).
3. Do not proceed into area with an ambient dose rate of greater
than 1000 mSv/h unless directed by TIC for life saving actions.
Workers who undertake actions in the areas where the dose rate
may exceed the limit shall be volunteers and must be clearly
and comprehensively informed in advance of the associated
health risk to allow them to make an informed decision.
E.4 Limiting exposure if gamma dose rate is known

(TIC) Information E.4
1. Follow Instruction E.2 above.
2. Estimate the doses for the first responders using the recorded Table E1. Examples of occupancy times in the areas with elevated dose rates.
occupancy times and dose rates [Annex 3]. Limit their total Dose rate Total time of staying after Total time of staying after
which the dose limit of 50 which the dose limit of 500
time of staying in Red Zone so that the constraint of 50 mSv mSv will be exceeded mSv will be exceeded
will not be exceeded [Table E1 in Information E.4, Table E2 in 0.1 mSv/h 500 hours 5000 hours
Information E.5]. (100 μSv/h)
3. The constraint of 50 mSv can be exceeded, if the first 1 mSv/h 50 hours 500 hours
responders are needed to perform life saving actions or actions 10 mSv/h 5 hours 50 hours
to prevent severe health effects/injuries or the development of 100 mSv/h 30 minutes 5 hours
catastrophic conditions [Table E2]. The workers shall be 1000 mSv/h 3 minutes 30 minutes
volunteers and must be clearly and comprehensively informed,
in advance, of the potential consequences of the exposure to
allow them to make an informed decision.
E.5 Guidelines if self-reading dosemeters are being used

(FIRST RESPONDERS)
CAUTION: Self-reading dosemeters do not measure the dose from
inhalation, ingestion or skin contamination; consequently
responders must also follow all the general instructions in Section
E.1.1 to limit the dose from these pathways.
1. Follow Instruction E.1 and Instruction E.3 above.

2. Make all reasonable efforts not to exceed the dose guidance
from the Table E2 in Information E.5.
28 29
1.2 Authorised personnel

Information E.5
E.6 Mandatory instructions for authorised personnel within the Table E2. Emergency worker turn back dose guidance. Reproduced courtesy of IAEA
Red or Yellow Zones (IAEA EPR-First responders, 2006).
(ALL TEAMS) Do not exceed unless
approved by the
Tasks
incident commander,
CAUTION: Female workers who may be pregnant should notify the Hp (10)
appropriate authority and must be excluded from duties in the Red Life saving actions, such as:
or Yellow Zone. -
-
rescue from immediate threats to life;
provision of first aid for life threatening injuries;
- prevention/mitigation of conditions that could be 1000 mSv1,2, 3, 4
1. Follow standard safety procedures for your professional area. life threatening.
2. Wear some form of identification (high visibility uniform,

Actions to prevent severe health effects or injuries,
armbands, jacket etc.) when within the Red and Yellow Zones. such as:
3. Use self-reading dosemeters given at the scene by radiation - evacuation/protection of the public;
- environmental monitoring of populated areas to
protection personnel. identify where evacuation, sheltering or food
4. Make all reasonable efforts not to exceed the dose guidance of restriction are warranted;
- rescue from potential threats of serious injury;
50 mSv for occupational exposure [Table E2]. - immediate treatment of serious injuries;
5. If working within the Red Zone follow the instructions given in - urgent decontamination of people.
500 mSv1, 3, 4
the Secure Access Control Point [Instruction E.36]. Actions to prevent the development of catastrophic
conditions, such as:
6. When treating or transporting contaminated persons use - prevention or mitigation of fires, etc;
normal barrier methods as directed in Information E.1. Keep - apprehension of terrorist suspects.
hands away from mouth and wash hands regularly. Actions to avert a large collective dose, such as:
- environmental sample collection and analysis for
7. Take a stable iodine tablet if instructed to do so by your field environmental monitoring of populated areas;
50 mSv1
controller/supervisor [Instruction J.24]. Record the fact that you - localized decontamination if required to protect the
public.
have taken a tablet [Forms A3.5 and A3.9, Annex 3]. **
1) This dose guidance is set at the levels that will allow completion of tasks and return to the base
without exceeding the levels in the international guidance (IAEA Safety Standards Series No. GS-R-2,
E.7 Exposure records 2002). Emergency worker dose level guidance values are expressed as integrated external dose and it
is assumed that all necessary precautions are taken to prevent internal exposure. The guidance is for
(ALL TEAM LEADERS) the entire time of the emergency.
2) In principle, no dose restrictions are recommended for life saving if, and ONLY IF, the benefit to
Ensure that the names and occupancy times of the team members others clearly is more important than rescuer’s own risk.
and activities performed by them when they are within the Red or 3) Workers shall be volunteers and be provided with information on the potential health
consequences of exposure to allow them to make an informed decision (IAEA Safety Standards Series
Yellow Zone are recorded – for possible follow up and dose No. GS-R-2, 2002, IAEA Safety Series No. 115, 1996). For example: 3000 mSv exposure could be life
threatening, 500-1000 mSv can result in short term vomiting, reduction in sperm count and an
reconstruction. increase in the chance (risk) of development of fatal cancer from the normal rate of about 25 % to
about 30 %. Exposure to a dose of 100 mSv will not result in any short term effects, but will result in a
small increase (about 0.5 %) for the risk of development of fatal cancer (IAEA TECDOC 1432, 2005,
ICRP Publication 96, 2005).
1.3 Public 4) Every effort should be made to keep doses below this level while performing life saving actions.
E.8 Members of the public within the Red Zone

(TIC)
1. Evacuate as soon as possible [Table E3, Table E4]. Before
30 31
evacuation takes place instruct the public to take best available

shelter (e.g. go to indoor hall, stay away from windows). Information E.6
2. Instruct them not to handle, but to isolate and identify to a Stable iodine
responder, any possible radioactive item. National arrangements for distribution and use of stable iodine for the
3. Instruct them not to smoke, eat, drink or place hands near purpose of blocking uptake of radioiodine to the thyriod should be
mouth. followed. In the absence of national guidelines, the generic criteria for
4. Following evacuation: thyroid blocking recommended in IAEA EPR-Medical, 2005, should be
adopted.
(a) Register evacuated people [Annex 3];
(b) If contamination is a concern (possible presence of
radioactive smoke, liquid or dust):
• Remind evacuees not to smoke, eat, drink or place hands
near mouth Information E.8
• Perform monitoring [Section F.3.3] Table E3. Operational intervention levels (OILs) in radiological emergencies based on
ambient dose rate measurements from gamma-emitting radionuclides.
• If warranted and practical, conduct immediate Table adapted from IAEA TECDOC 1162, 2000.
decontamination [Chapter G]; Major exposure conditions OIL Main actions
(c) Provide them with instructions on where to go for further External radiation from a 100 μSv/h Isolate the area
information and/or medical/radiological assessment; and point source Recommend evacuation of Red Zone
Control access and egress
(d) Instruct them of the need, after leaving the scene, to:
External radiation from 100 μSv/h Isolate the area
• Conduct decontamination at home (if not implemented at ground contamination over Recommend evacuation of Red Zone
the scene) [Section G.3] a small area or in the case Control access and egress
of not very disruptive
• Listen for further instructions on where to get evacuation
information and/or medical/radiological assessment. External radiation from 1 mSv/h Recommend evacuation or
ground contamination over substantial shelter
a wide area or in the case of
E.9 Members of the public who may have left the Red Zone very disruptive evacuation
(TIC) External radiation from air 1 μSv/h Isolate the area (if possible)
Instruct them, if necessary via the media, on the following: contamination with an Recommend evacuation of Red Zone
unknown radionuclide(s) or downwind in case of open area
1. Not to handle any items, but report to the local police any items
they might have picked up at the scene.
Table E4. Recommended avertable doses for undertaking countermeasures.
2. Not to smoke, eat, drink or place hands near the mouth until a Table reproduced with kind permission from ICRP (ICRP Publication 96, 2005).
shower is taken and clothes are changed. Countermeasure Avertable dose (for which the counter-
3. To remove outer wear before entering home. Shower with warm measure is generically optimised)
water and mild soap. Change clothes, seal clothes in plastic bag Sheltering ~ 10 mSv in 2 days (of effective dose)
and store [Section G.3]. Temporary evacuation ~ 50 mSv in 1 week (of effective dose)
4. To continue to listen for and follow official instructions given Iodine prophylaxis (if radioiodine is ~ 100 mSv (of equivalent dose to the
via the media (TV or radio). present) thyroid)
Relocation ~ 1000 mSv or ~ 100 mSv first year (of
effective dose)
32 33
E.10 Members of the public outside the Red Zone

(TIC)
The members of the public outside the Red Zone should stay indoors
and listen for official instructions given via the media (TV or radio).
They should be advised not to go to the scene to volunteer to help.
If there has been an atmospheric release (smoke from fire or bomb)

instruct public, via the media, within about 1 km of the release
point that it would be prudent:
1. To remain inside building during the release (smoke).

2. Not to eat any vegetables grown outside or drink rainwater.
3. Not to play on the ground.
4. To wash hands before eating.
5. To avoid dusty areas or activities that will generate dust.
6. To listen for and follow official instructions given via the media
(TV or radio).
1.4 Dealing with deceased persons
E.11 (CONTAMINATION INCIDENTS) (MEDICAL, AMUBLANCE, FIRST

RESPONDERS AND ENVIRONMENTAL MONITORING TEAMS)
No special procedures need to be followed to handle people after
external irradiation. Instructions below should be followed when
dealing with human remains containing radioactive materials.
1. Apply radiation protection measures for managing deceased
persons with external and/or internal contamination such as:
(a) Use protective clothing and respiratory protection equipment;
and
(b) Place the contaminated corpses with clothing and personal
effects intact in body bags, use appropriate labelling and
visible radiation signs. Wipe the exterior of the bag with a
small piece of absorbent paper and count the smears with a
surface contamination monitor. Surveying the surface of the
bag is not possible because the detector would register the
radiation emanating from the interior of the bag.
2. Move the contaminated corpses to the temporary morgue
established within the Yellow Zone.
For dealing with contaminated corpses at the hospital see Section J.9.
34 35
Chapter E Immediate actions Instructions Information 2 Monitoring to confirm a radiation emergency
2 Monitoring to confirm a radiation

emergency
Introduction
The purposes of this section of the Handbook are:
• To establish whether or not the incident involves the use of
radiation or radioactive material [Figures E2a, E2b and E3];
• To establish whether radioactive material has been dispersed
through the environment; and
• To establish approximately those areas where dose rates or
levels of contamination are highest. (Dispersion may cause a
spread of contamination so that several locations are of major
concern).
Figure E2a. Basic ionising radiation warning symbol. Photo: HPA.
The procedures in this section will facilitate collection of basic
information about the scenario. This information is required for
subsequent decisions about triage and monitoring [Section F.2.2].
Priorities and actions will differ according to the scenario. The
following scenarios are considered:
• External irradiation incident;
• Environmental contamination incident; and
• Contamination of food/water.
These scenarios are associated with RED and RDD incidents in the
following way:
1. RED is primarily an irradiation incident, but would in addition
be classified as an environmental contamination incident if Figure E2b. Supplementary ionising radiation warning symbol. The symbol is
material was released from the irradiation source. intended for IAEA Category 1,2 and 3 sources defined as dangerous sources capable
of death or serious injury. To be placed on the device housing the source, as a
2. RDD is both an irradiation and environmental contamination warning not to dismantle the device or to get any closer.
incident. This symbol taken from ISO 21482:2007, Ionizing-radiation warning – Supplementary
Actions described in this section for an irradiation incident and symbol, is reproduced with the permission of the International Organization for
Standardization, ISO. This standard can be obtained from any ISO member and from
environmental contamination incident are the same because: the ISO Central Secretariat. Web site at the following address: www.iso.org. Copyright
remains with ISO.
• Until monitoring results are available it may be uncertain
whether the incident involves irradiation only or irradiation
combined with environmental contamination; and
36 37
• An irradiation source may be damaged.

For an incident involving deliberate contamination of food or water,
actions are very different and are described separately.
The required actions are described in the order in which they should be
carried out.
Information E.12a
E.12 Hazard Assessment When monitoring to confirm a radiation emergency, remember that
(TIC, FIRST RESPONDERS) accuracy of the measurement is not as critical as verifying that radiation is
First responders must assume there is a radiological hazard, until a present. It is also important to determine the type of radiation present.
radiological assessment has been made. Signs that radiation may be
present are shown in Information E.12b.
Information E.12b
E.13 Establishing the scenario type Signs that radiation may be present:
(TIC, ENVIRONMENTAL MONITORING TEAM) • Spill, fire or explosion;
1. Incidents may not involve environmental contamination; • Alarming personal dosemeter;
however, measurements must be carried out to confirm the • Elevated reading on a dose rate meter;
absence of contamination, even if the incident involves a • Elevated reading on a contamination monitor;
suspected irradiation device. It will not be possible to monitor • Transport accident involving a vehicle with radiation warning
close to an irradiation source until it is removed or shielded. labels;
2. Monitoring for all radiation types (i.e. alpha, beta, gamma and • Presence of packages bearing the radiation symbol;
neutron radiation) must be carried out and shown to be absent • Intelligence information;
• Information from witnesses; and/or
before the incident can be declared not to involve radiation or
• People with symptoms consistent with radiation exposure.
radioactive material.
3. Carrying out the procedures in this section will provide basic
information about the scenario to be collected. This information
is required for subsequent decisions about triage and
monitoring [Section F.2.2].
4. Information on whether radiation or radioactive material has
been used (or may be used) may be provided by means other
than monitoring (for example, as a result of police intelligence
or information from a terrorist organisation). Such information
must be confirmed, by monitoring, and then may be used to
adapt the procedures described in this section.
Figure E3. Packages and vehicle with potentially dangerous sources symbol.
Photos: HPA
38 39
5. If monitoring is carried out which confirms that the incident

does not involve the use of radiation or radioactive material, Table E5. Guide to transport packages markings.
then a statement that radiation is not involved should be passed UN Number Possible other marking Threat
2909, 2908, 2910, 2911 None Not dangerous
immediately to Strategic Command [Annex 4]. Such an incident
2912; 2913, 3321, 3322, Type IP-1, Type IP-2, Low Possibly dangerous if
no longer falls within the scope of this Handbook. 3324; 3325, 3326 Specific Activity (LSA), material is inhaled or
6. Even if a radiation emergency has already been declared, Surface Contaminated ingested
ensure that all of the procedures described below for the Object (SCO)
2915; 2982, 3327, 3332, Type A Possibly dangerous
relevant scenario have been carried out. 3333
2916, 2917, 3328, 3329 Type B (U), Type B (M)
E.14 Establishing the tactical control point 3323, 3330 Type C
(TIC, FIRST RESPONDERS, ENVIRONMENTAL MONITORING
TEAM) Reproduced courtesy of IAEA (IAEA EPR-First responders, 2006; IAEA Safety standards
series TS-G-1.2 (ST-3), 2002).
To manage the incident a "Tactical Control Point" (TCP) will need
to be established [Section E.3.2]. The TCP must be set up as soon as
there is notification of a potential or real emergency. The ‘Tactical
Incident Commander’ (TIC) [Annex 4] has overall responsibility for
the local incident response and will be located at the TCP. The TIC
will need to initiate and direct radiation monitoring, and use the
results to assess the situation.
E.15 Environmental contamination and external irradiation incidents

vs. food/water contamination incidents
(TIC, ENVIRONMENTAL MONITORING TEAM)
For all incidents, with the exception of those involving
contaminated food/water, the procedures in Instruction E.16 - E.22
must be followed. For incidents involving contaminated food/water
Figure E4. Typical radiography camera. Photo: HPA.
the procedures in Instruction E.23 - E.24 should be followed.
2.1 Contamination and irradiation incidents
E.16 Monitoring teams

(TIC)
1. Monitoring teams should be established. These teams are likely
be made up of staff from first responder organisations (e.g. fire
service) or of specialist radiation protection staff [Annex 4]. It is
unlikely that emergency services will have the equipment or
experience to monitor for all types of radiation. Emergency
services staff required to do emergency monitoring must, as a
40 41
minimum, be able to identify elevated gamma dose rates. If

only gamma dose rate monitoring is available then it must be
assumed there is widespread contamination of the environment,
until contamination monitoring has been carried out.
2. If at the early stages of the incident response, only equipment to
measure gamma dose rate is available then equipment for alpha
contamination, beta contamination and neutron dose rate
monitoring must be urgently obtained.
E.17 Safety of monitoring team staff

1. PPE (Personal Protective Equipment) must be worn, as
described in Section E1.1.
Figure E5. Very dangerous source from radiography camera
2. Clear instructions are needed from the TIC about acceptable/ (should never be picked up). Photo: HPA.
unacceptable levels of exposure and permissible occupancy
times [Section E1.1]. A warning must be given not to approach
Information E.18:1
an irradiation source unless monitoring confirms that doses are
within acceptable limits. Alarming personal dosemeters
The dose rate indication of these devices should only be used as a rough
indicator of dose rate, as many have poor sensitivity due to long response
E.18 Equipment times. The primary function is the measure of accumulated dose.
1. The following are essential equipment:
(a) Two (or more) hand held monitors measuring gamma dose Information E.18:1c
rate; Communication
(b) An alarming personal dosemeter (providing a measure of In an emergency situation, the commercial GSM and GPRS-systems may
cumulative dose and an indication of instantaneous dose collapse, as happened in the aftermath of the Tsunami in Thailand 2006, for
example. Therefore it is important to have more than one communication
rate) for each person [Section E1.1]; and channel between the mobile teams and the headquarters. The additional
(c) Reliable 2-way communication with the control centre communication link may be a satellite phone capable of data transfer or a
(Note that mobile phone networks may not be reliable TETRA-based professional mobile radio.
[Information E.18:1c]). In an emergency situation, the data transfer lines will be heavily loaded.
2. The following equipment must be urgently obtained: Automation of data transfer must always respond to the following questions:
(a) Alpha contamination monitors; • What information should be transferred continuously, in real-time?
• What information should be transferred when certain decision
(b) Beta contamination monitors; criteria are met?
(An instrument capable of detecting both alpha and beta • How is additional data transferred?
contamination could be used, but it must be able to The selection of data is crucial, since one cannot count on the normal
distinguish between alpha and beta contamination.) available bandwidth in an emergency situation; therefore, it is wise not to
(c) X-ray and low energy gamma contamination monitor; push the transmission speed near to its extreme capacity.
(Continued over page)
42 43
(d) Hand held monitors for measuring neutron dose rate;

(e) Equipment to take wipe samples; Information E.18:1c (cont.)
(f) GPS equipment; Data transfer should be highly automated. Crucial time is saved, when the
(g) Detailed map of the area; position of the mobile teams is transferred automatically and in real time
(h) Spray paint; and to a mapping system in the headquarters. When something is found, the
location is already seen on the map and the communication between the
(i) Means of recording information. mobile team and the headquarters can focus on what was found.
3. If available use a hand-held radionuclide identifier as means of All functional data transmission pipelines needs well defined formats,
protocols and send/receive procedures. These are defined by the data
determining the radionuclide(s) present. If this equipment is not management of the system.
available, or there is no significant gamma-ray emitting
contamination, then take a wipe sample from a contaminated
surface and arrange for this to taken to a suitably equipped Information E.18:2
laboratory as soon as possible. Inform the laboratory that the
Monitoring instruments
sample has been dispatched and instruct them to identify (but
The following is a comprehensive list of instrument types which may be
not quantify) the radionuclides(s) present as quickly as possible. useful for confirming the presence of specific radiation types or to identify
Instructions for laboratory analysis are beyond the scope of this the radionuclide(s) present:
Handbook. • Alpha contamination monitors;
• Beta dose rate monitors;
E.19 Locating areas with highest dose rate or contamination • Beta contamination monitors;
• X-ray and low energy gamma contamination monitors;
• Gamma dose rate monitor;
1. If present, the irradiation source and areas of highest • Portable gamma-spectrometry equipment; and
contamination must be located. If dose rates are low enough, • Neutron dose rate monitor.
then a single team can achieve this. This is determined by Annex 8 contains more detailed descriptions of these instruments.
estimating the cumulative dose and comparing with emergency
worker turn-back guidance [Section E.1, Table E2]. If dose rates
are higher then it may be necessary to send additional teams Information E.18:2e
into the area from different starting points. It should not be
Surface monitoring using a wipe sample
necessary for all of the teams to enter areas of highest radiation, The sampling location should be flat and smooth. The sample should be
in order to achieve this. If the source of irradiation and/or the taken by wiping an area of approximately 100 cm2. Light pressure should
areas of highest contamination are not located then this must be be used so that the wipe sample is not torn or rolled. Wipes may be taken
a priority for later monitoring. from roads and pavements but only a small fraction of the total activity
2. The TIC must keep records of the monitoring team’s will be removed. Unless the exact fraction of non-fixed contamination by
the wipe is known, a default value of 0.1 should be used. Use a portable
measurement so that it is clear when the irradiation source and/
contamination meter to assess activity on the wipe. The measurement
or the areas of highest contamination have been located. A form must be done away from radiation sources. After monitoring the wipe
for recording measurements is included in Annex 3. sample should be placed in a labelled plastic bag with appropriate
information about the sample, including sample location, date and time.
Samples must be retained for laboratory analysis, this is particularly
important for alpha emitters where self-absorption can lead to a gross
underestimation of activity [Annex 11].
44 45
E.20 Post deployment actions

(TIC, ENVIRONMENTAL MONITORING TEAM, Information E.21
DECONTAMINATION TEAM) Cautions for monitoring
After deployment, monitoring teams need to be monitored for Some instruments can saturate at very high radiation fields and show zero
contamination and, if necessary, decontaminated. or low reading, or show ‘battery low’.
Monitoring teams need to be familiar with the monitoring instrument used

E.21 Detailed monitoring instructions and in particular be aware of requirements for probe to surface distance
(ENVIRONMENTAL MONITORING TEAM) and rate of movement of the probe.
1. Monitoring equipment must be tested before approaching the
site. Monitoring instruments, with the exception of probes for alpha and beta
(a) Check condition of batteries before leaving your base of contamination, should be covered with a plastic bag to facilitate
decontamination.
operations;
(b) Check instrument response with calibration sources; Measurements of X-ray emitting radionuclide contamination and beta
(c) If more than one instrument is available perform cross contamination should be made by taking a surface wipe sample and
checks to ensure a consistent reading; monitoring it away from any other sources of gamma and X-rays.
(d) Measure and record background readings from instruments;
Alpha particles can not be detected with an instrument designed for beta/
(e) After these checks leave all monitors switched on; and
gamma radiation. Alpha emitting radionuclides often produce X-rays and
(f) Note cautionary advice in Information E.21. photons, with a low abundance, which can be detected with beta/gamma
sensitive instruments. The presence of alpha emitting radionuclides must
2. Detailed monitoring procedure to be followed: be confirmed with an alpha sensitive instrument.
(a) Start from TCP [Section E.3];
(b) Approach at walking pace; continuously monitor gamma Alpha measurements can only be made on smooth surfaces which are free
from water, oil, dirt etc. The probe must be held less than 1 cm from the
dose rate with an instrument that can read at least 100 surface being monitored.
mSv/h [Information E.21:2b]. If the dose rate is changing
rapidly move more slowly;
(c) Look for signs of a possible RDD or RED [Information
E.21:2c]; Information E.21:2b
(d) Report results of measurements to TIC frequently (e.g. If gamma dose rate instruments that can read at least 100 mSv/h are not
every 5 minutes); also report whenever gamma dose rate available, then extra care should be taken to ensure the instrument is not
increases by a factor of 10 compared with previously saturated.
reported value;
Beta and X-ray contamination measurements may not be possible in the
(e) If gamma dose rate increases by a factor of 10 compared presence of significantly elevated gamma fields.
with previously reported value and if equipment is available
carry out: Visual identification of a source may be very difficult. Make sure you turn
• Alpha contamination measurements on “hard” upward- the instrument on well before attending the incident location.
facing surfaces
It is expected that the presence of neutron radiation would be a very rare
• Beta contamination measurements on “hard” upward-
situation for a RED incident, as such sources are difficult to obtain.
facing surfaces Neutron radiation would be associated with primitive nuclear devices.
• X-ray/low energy gamma contamination measurements
46 47
• Surface wipe sampling from approximately 100 cm2 from

a horizontal smooth surface [Information E.18:2e] Information E.21:2c
• Neutron dose rate measurements; and Indicators of a possible RDD
(f) If gamma dose rates do not increase by a factor of 10, take • Gamma dose rates > 100 μSv/h at 1 m above the ground;
measurements and samples as detailed in (e) above every 50 • Alpha contamination measurements above background;
metres. (Note that as walking in a straight line may be • Beta contamination measurements above background; and/or
difficult, this can be interpreted as every 50 paces). • X-ray/low energy gamma contamination measurements above
background.
3. (ENVIRONMENTAL MONITORING TEAM, TIC)
Indications of a RED or other dangerous source
If elevated gamma dose rates (and/or neutron dose rate) are found,
• Gamma dose rates > 100 μSv/h at 1 m from an object;
advice is needed from TIC on occupancy times.
• Presence of neutron radiation;
• Medical symptoms of radiation injuries such as vomiting,
4. If a “maximum permissible limit” [Section E.1.1] on gamma dose diarrhoea and unexplained erythema [Section F.2.2.2];
rate (and/or neutron dose rate) is reached (or reading exceeds • A heavy container with the radiation symbol [Figure E3];
instrument full-scale): • Item with radioactive transport labels [Figure E3];
(a) Determine location (e.g. building, street name, distance • Item with transport UN numbers or markings indicating a
from three fixed points or GPS reading); radioactive material [Table E5];
(b) Mark location with spray paint (if available) or other visible • Device used for cancer treatment (teletherapy or brachytherapy);
means; • Radiography cameras or source (e.g. Figure E4 and E5); or
(c) Retreat quickly to a “safe” position (return by the entry • Well logging sources used in drilling operations.
path); and
(d) Report information described below [Instruction E.22].
5. If gamma dose rate remains below 2x background, carry out the

following measurements:
(a) Alpha contamination measurements on “hard” upward-
facing surfaces;
(b) Beta contamination measurements on “hard” upward-facing
surfaces;
(c) X-ray/low energy gamma contamination measurements;
(d) Neutron dose rate measurements; and
(e) Surface wipe samples should also be taken for later
analysis.
6. If position of source is identified [Information E.21:2b], or

because measured quantities reach maximum values, determine
location, mark location, take the following measurements and
samples:
48 49
(a) Peak gamma dose rate;

(b) Peak alpha contamination count rate;
(c) Peak beta contamination count rate;
(d) X-ray/low energy gamma contamination measurements;
and
(e) Neutron dose rate.
Note that if activity has been dispersed there may be several areas
of very high contamination.
7. If elevated gamma dose rate is present and no alpha or beta

contamination is found, then a surface wipe sample should be
monitored with a gamma contamination monitor. This will
determine if radionuclides which only produce gamma rays are
present in the environment [Annex 11].
E.22 Reporting results

(ENVIRONMENTAL MONITORING TEAM)
1. Retreat to a “safe” position along the route of entry, report
information described below.
2. Report the following information to TCP. A form which can be
used is given in Annex 3:
(a) Peak gamma dose rate, instrument used and location;
(b) Peak alpha contamination count rate, instrument used and
location;
(c) Peak beta contamination count rate, instrument used and
location;
(d) Peak gamma/X-ray contamination measurement (if
applicable), instrument used and location;
(e) Peak neutron dose rate, instrument used and location; and
(f) Locations of any surface wipe samples taken.
2.2 Contaminated food/water incidents
E.23 Measurements
(TIC) Information E.23
1. Arrange for monitoring to confirm that the identified food/ Methods of analysis for alpha and beta emitting radionuclicles can be
water source is contaminated. found in IAEA TECDOC 1092, 1999.
50 51
2. As monitoring is likely to be carried out in a laboratory after

collection of samples, identify laboratories with appropriate
expertise and arrange for samples to be collected and
transported to the laboratory [Annex 11].
3. Rapid gamma-spectrometry measurements will be required on
samples of food/water.
4. If a radionuclide is identified, that is an alpha emitter, rapid
alpha spectrometry measurements (or possibly mass
spectrometry for very long-lived radionuclides) are required to
determine activity concentrations. Note that radiochemistry
will be required, which will limit the rate of analysis.
5. If a radionuclide is identified, that is a beta emitter without
significant gamma-ray emissions (e.g. Sr-90), rapid beta
measurements are required to determine activity
concentrations. Note that radiochemistry will be required,
which will limit the rate of analysis.
6. An extensive monitoring programme is required to determine
activity concentrations and the extent of contamination of food/
water.
E.24 Identification of a radiological incident

(PUBLIC HEALTH AUTHORITY)
1. An incident may be discovered by routine monitoring of soil,
air, water or food supply, but this is probably unlikely.
2. Information on possible contamination may be provided by
means other than monitoring, for example, as a result of police
intelligence or credible information from a terrorist
organisation.
3. Contamination may be discovered by epidemiological
surveillance of the population or public health reports leading
to a suspicious pattern of illness [Section K.7].
4. If intelligence reports suggest radioactive contamination, then a
programme of measurements should be considered. The nature
of this programme will depend on the intelligence reports.
5. If the radionuclide concerned is unknown, then efforts should,
at first, be concentrated on radionuclides which are listed in
Table H1 [Information H.13 and H14].
52 53
Chapter E Immediate actions Instructions Information 3 Establishing zones and zone boundaries
3 Establishing zones and zone boundaries
Introduction
Zones are established around the scene of an incident to:
• Identify the affected population;
• Protect and control the public;
• Protect and control members of the emergency services;
• Facilitate the operations of all agencies;
• Guard the scene; and
• Prevent unauthorised interference with evidence or property.
The Red Zone is the potentially hazardous area immediately
surrounding the incident where extreme caution and safety measures are
required. Responsibility for the health and safety of personnel working
within the Red Zone remains with the individual agencies involved. The
cordon surrounding this zone is called the "Safety Perimeter".
The Yellow Zone surrounds the Red Zone and provides a safe and
secure working environment for personnel and members of the public
being processed for clearance from the incident. The cordon
surrounding this zone is called the "Security Perimeter".
The security forces, in consultation with other agencies, will establish
the size and position of each zone. The sizes of each zone will
invariably be a compromise between the emergency services (wanting
as much space as possible to function effectively) and the security
services (wanting to limit the area to minimise resources required to Figure E6. Generic layout of Red Zone.
maintain its integrity).
The two algorithms [Figures E7, E8 and E10] can be used to assist in the
positioning and possible repositioning of the Safety and Security
Perimeters.
3.1 Initiate the Red Zone

See Figure E6, "Generic layout of Red Zone".
54 55
E.25 Establishing the Safety Perimeter

(TIC, SECURITY PERSONNEL) Information E.25
Unless it is safe to locate the Safety Perimeter nearer the incident, For safety reasons, such as the possibility of high dose rates, the threat of
surround and secure the immediate area by establishing a Safety an explosion, or the instability of the area, the Safety Perimeter should
Perimeter at least 400 m radius from the incident. Where possible, initially be established no closer than 400 metres radius from the incident.
use existing natural boundaries such as roads, rivers, buildings etc. Set at a radius of 400 metres, the Safety Perimeter will extend for more
than 2500 metres and enclose an area greater than 500,000 square
E.26 Control of access metres, which in a city, could contain a large number of people.
(SECURITY PERSONNEL) Considerable resources will be required to maintain the integrity of the
Install physical barriers with well defined "gateways" and security Safety Perimeter and to deal with the "potentially" exposed people. Ideally
the area of the Red Zone should be reduced as soon as practicable BUT only
personnel at public thoroughfares, to control the movement of
after receiving confirmation from Tactical Incident Command that it is safe
people by evacuating members of the public and excluding non- to do so.
essential personnel from the Red Zone.
Alternatively, conditions may dictate that the distance between the safety
E.27 Restriction of access perimeter and the incident be increased i.e. the spread of radioactive
(FIRST RESPONDERS, SECURITY PERSONNEL) contamination and/or dose levels, risk of explosion, direction of plume,
unstable structures.
Access to the Red Zone must be restricted to emergency workers
who should be: The Red Zone can be an irregular shape and its size and shape will likely
• Logged in and out of this area; change as more information becomes available.
• Using appropriate PPE [Information E.1]; and
• Minimising their exposure [Section E.1].
E.28 Limits on dose rates and contamination levels at the Safety

Perimeter Information E.28
(FIRST RESPONDERS)
Dose rates at the Safety Perimeter must not exceed 100 μSv/h and All radioactive waste should be properly handled at an early stage and
at each level (scene of the event, evacuation, hospital departments etc). All
contamination levels must not exceed 1000 Bq/cm2 for β/γ emitters, waste must be treated as potential evidence, but waste should be
and 100 Bq/cm2 for α emitters [Table F2]. However, there could be evaluated for its significance as evidence, as waste preservation may pose
debris ("hot spots") present from the original incident/explosion. a greater radiological problem than its disposal. Waste materials that do
These should be identified by marking in some way (e.g. spray not require preservation should be disposed of properly, seeking guidance
paint/cones/tape etc.) and/or removed as soon as possible to a Waste from the appropriate regulatory authority if required.
Store [Instruction E.48] or the Safety Perimeter extended to include
them [Instruction E.29].
E.29 Regular review

(FIRST RESPONDERS, SECURITY PERSONNEL)
Regularly review the position of the Safety Perimeter and, if
approved by the Tactical Incident Command, reposition the Safety
Perimeter using Figures E7 and E8, Red Zone algorithm.
56 57
Chapter E Immediate actions 3 Establishing zones and zone boundaries
Figure E7. Red Zone Algorithm (Part A) Figure E8. Red Zone Algorithm (Part B)
58 59
3.2 Initiate the Yellow Zone

See Figure E9, "Generic layout of Yellow Zone".
E.30 Establishing the TCP

(TIC)
The Tactical Command Point (TCP) should be sited outside the Red
Zone, in a location that provides shelter and is safe, secure,
convenient for directing operations, and to where emergency
services are able to deploy their command and control vehicles.
E.31 Establishing the Security Perimeter

(TIC, SECURITY PERSONNEL)
The Tactical Incident Command, in consultation with the
emergency and security services, should use Figure E10 "Yellow
Zone algorithm" to establish the size and position of the Security
Perimeter.
E.32 Control and restriction of access

(SECURITY PERSONNEL) Figure E9. Generic layout of Yellow Zone.
Use natural boundaries (roads, rivers, buildings etc), where
possible, and install physical barriers with well defined ‘gateways’,
manned by security staff, at public thoroughfares to control the Information E.30
movement of people through the Security Perimeter. Access to the Tactical Command Point (TCP) is the point from which on-scene
Yellow Zone must be restricted to authorised staff. management and co-ordination of the incident takes place. It is also the
point of contact for other agencies with a part to play at the scene.
E.33 Monitoring
Information E.31
Initiate routine monitoring (surface contamination and large
volume air sampling) to confirm the Yellow Zone is not becoming The extent of the Yellow Zone will inevitably be a compromise between
contaminated and that the Red Zone is not expanding. the emergency services, requesting a large area to function efficiently, and
security services, reducing the area according to resources available to
maintain its integrity.
E.34 Limits on dose rate and contamination levels at the Security
Perimeter The larger this area becomes then the more people are needed to control
(ENVIRONMENTAL MONITORING TEAM) it for decontamination, monitoring, evacuating etc.
Dose rates in this area should be below 100 μSv/h, and
The priority is to establish a Security Perimeter to identify the outer
contamination levels below 1000 Bq/cm2 for β/γ emitters and 100
boundary of the Yellow Zone. The Yellow Zone can be an irregular shape
Bq/cm2 for α emitters [Table F2]. However there could be debris and its size and shape may change depending on the activities being
("hot spots") present from the original incident/explosion. These performed in this area.
60 61
should be identified by marking in some way (eg. spray paint/cones/

tape etc) and/or removed as soon as possible to the Waste Store
[Instruction E.48].
E.35 Regular review

Regularly review the area requirements of the Yellow Zone and
the position of the Security Perimeter and, if approved by the
Tactical Incident Command, reposition the Security Perimeter
using Figure E10, "Yellow Zone algorithm".
3.3 Evolution of the Red Zone

See Figure E6, "Generic layout of Red Zone".
E.36 Establishing the Secure Access Control Point (SACP)

As soon as practicable a single ‘gateway’ on the Safety Perimeter
should be developed into a Secure Access Control Point (SACP) to
provide controlled rapid access between the Red and Yellow Zones
(a) 1000 Bq/cm2 beta, gamma or 100 Bq/cm2 alpha
without compromising the safety of those involved. (b) For requirements of emergency services AND access through Security Perimeter can be
controlled effectively
E.37 Purpose of the SACP Figure E10. Yellow Zone algorithm.

(SECURITY PERSONNEL)
All emergency, specialist and voluntary services personnel should
Information E.36
enter and exit the Red Zone through the SACP to ensure that they:
• Can be accounted for (logged in and out of the Red Zone); The correct location of the SACP on the Safety Perimeter is of the utmost
importance as this site will probably be developed into the Operational
• Are briefed on their duties and any associated hazards;
Control Point (OCP).
• Are deployed when appropriate;
• Are using the appropriate PPE [Information E.1] and that it is
functioning before entering the Red Zone; and
• Wearing some form of identification (e.g. high visibility
uniform, armbands, jacket, headgear). Information E.38
E.38 Establishing Operational Control Points (OCPs) The functions of Operational Control Points (OCPs) include securing rapid
gateways for emergency personnel/equipment/transport and the rapid
‘screening’ of minor casualties and first responder personnel (and
Establish Operational Control Points (OCPs) inside the Red Zone, equipment).
on the Safety Perimeter, away from the public processing area
[Section E.1]. Agencies may be located together or separately.
62 63
E.39 Establishing transit routes

(FIRST RESPONDERS)
Develop well defined and identified "safe" transit routes from the
SACP toward the incident, for use by emergency personnel
Information E.43
[Section E.1].
The correct location of the SACP on the Perimeter is important because the
SACP is used to rigorously control the movement of emergency personnel
E.40 "Hot spots" through the Security Perimeter, without compromising the safety of those
(FIRST RESPONDERS) involved, and prevent unauthorised personnel and members of the public
Areas of high contamination or dose rates ("hot" spots) must be entering the Yellow Zone.
identified and labelled (using spray paint/tape/cones etc) or, if
possible, removed to a radioactive waste storage area. Information E.45
The Public Processing Area will comprise a Reception Centre and Radiation
E.41 Monitoring transit routes Monitoring Unit.
Reception Centre
Transit routes should be routinely monitored to confirm they are The Centre should be set up at a location where people not requiring urgent
remaining "safe" and not becoming further contaminated. medical treatment following an emergency can be sent for:
• Shelter;
E.42 Forensic evidence • Triage;
(SECURITY PERSONNEL) • Rest;
• Medical treatment;
A Forensic Evidence Store should be designated within the Red • Collection of information from affected individuals;
Zone for the safe and secure storage of evidence recovered from the • Provision of information to affected individuals; and
scene and for maintenance of the continuity and integrity of • Counselling of affected individuals.
evidence. It is expected that people evacuated from within the Security Perimeter
should be directed to the Public Processing Area. People returning after
having left the scene would be directed to similar facilities set up outside
3.4 Evolution of the Yellow Zone the Security Perimeter.
See Figure E9, "Generic layout of Yellow Zone". Radiation Monitoring Unit
Associated with the Reception Centre a Radiation Monitoring Unit may be
established. This may be located in the same building as the Reception
E.43 Establishing the Secure Access Control Point (SACP)
Centre or located in a separate nearby building. People should be monitored
(SECURITY PERSONNEL) at the Radiation Monitoring Unit and, if necessary, decontaminated, before
As soon as practicable, a single gateway on the Security Perimeter entering the Reception Centre.
should be developed into a Secure Access Control Point (SACP). The Radiation Monitoring Unit should have:
• A segregated area for people waiting for decontamination;
E.44 Purpose of the SACP • An area for external contamination measurements;
• An area for decontamination of people;
(SECURITY PERSONNEL) • An area for internal contamination monitoring (if available);
All emergency, specialist and voluntary services should be directed • Storage for replacement clothing;
to the SACP for logging, briefing, equipment issue and deployment. • Storage for contaminated clothing and other contaminated items;
• An area for recording and reporting information with
communications equipment; and
• An area for counselling concerned individuals.
64 65
E.45 The Public Processing Area

(TIC, ALL TEAMS)
Ideally, this area should be covered with good access to both
SACPs, and be large enough to achieve the following tasks:
• Processing and registering the public evacuated from the Red
Zone [Section H.6, Annex 3];
• Radiological triage, medical treatment and preparation of
patients for transport [Chapter F]; and
• Monitoring and decontamination of the public evacuated from
the Red Zone [Section F.3, Chapter G].
E.46 Monitoring the Public Processing Area Information Section E.3

(ENVIROMENTAL MONITORING TEAM)
Routinely monitor the Public Processing Area to ensure that Additional Information on Establishing Zones and Boundaries
The description of zones and zone boundaries presented in this Handbook
ambient dose and contamination levels remain low (close to natural
is based on the guidance in IAEA (IAEA TECDOC 1162, 2000). Many other
background values) and the area is not becoming unsafe. If the schemes exist for setting zones and zone boundaries and it is not possible
ambient dose rate exceeds 100 μSv/h and/or contamination levels to present them all. However, these all share many of the characteristics of
exceed 1000 Bq/cm2 for β/γ emitters or 100 Bq/cm2 for α emitters, the IAEA scheme.
then the Public Processing Area should be moved to another The "safety perimeter" may be known as the "exclusion perimeter" or
location with lower levels of dose and/or contamination. "inner cordon", and similarly the "security perimeter" may be known as the
"outer cordon". Other perimeters may be created for logistical purposes,
for example a cordon may be created outside of the security perimeter to
E.47 Rest area for emergency response personnel
prevent access to unauthorised vehicles. Several other systems include an
(TIC) area of the "Red Zone" where dose rate exceeds 100 mSv/h and where
Establish a safe, secure and sheltered area, away from the view of access is allowed only for life saving actions and residence time is
the public, where off-shift personnel can rest and receive restricted to avoid large doses to first responders. (Continued over page)
refreshment.
E.48 Storage of radioactive waste

(ENVIROMENTAL MONITORING TEAM, SECURITY
PERSONNEL)
If required, designate a Waste Storage Area away from the Public
Processing Area and preferably in a building to prevent the spread
of contamination, to where radioactively contaminated debris can
be removed and potentially contaminated items (e.g. clothing) can
be stored. Contamination and dose levels in this area should be
monitored regularly to ensure that the accumulation of
contaminated waste does not pose a health threat to those using the
facility.
66 67
Chapter E Instructions Information 3 Establishing zones and zone boundaries
E.49 Temporary Morgue

(FIRST RESPONDERS, MEDICAL TEAM, SECURITY PERSONNEL) Information Section E.3 (cont.)
If required designate a Temporary Morgue, sheltered and away It is probable that some time after the incident, additional zones may be
from the Public Processing Area. Facilities should be provided for created when extensive environmental monitoring data is available; one
scheme is presented below which is based on access restriction.
grieving family members and associates.
3.5 Outside the Yellow Zone Zone Designation Admission Rules
See Figure E9, "Generic layout of Yellow Zone". Red Zone Permission needed to enter
Orange Zone Access only to those who live and work
in this zone
E.50 Establishing a Marshalling Area
Yellow Zone People are advised not to enter
(TIC, ALL TEAMS)
Identify a secure area to act as a Marshalling Area in close
proximity to, or with communication with, the TCP, where Similar schemes subdivide the ‘red zone’ on the basis of dose rates, which
resources and personnel arriving at the scene, being held for further determine the actions that can be taken. An example is illustrated below
use or not immediately required at the scene, can be directed to from the U.S. Conference of Radiation Control Program Directors (www.
standby. crcpd.org).
Table E6. An example of subdivision of the Red Zone.

E.51 Establishing the Public Information Centre
Zone Designation Zone Dose Action Allowed in the zone
(TIC, ALL TEAMS) rates, mSv/hr
Identify a secure area to act as a Public Information Centre in close Extreme Caution ≥ 100 • Activities restricted to saving lives
proximity or communication with the TCP with space and the Radiation Zone • Total accumulated stay time for first
12 hours: minutes to hours
infrastructure to support media briefings.
High Radiation 10 Access restricted to authorized personnel
Zone performing critical tasks:
E.52 Establishing a Public Processing Area outside of the Yellow • Fire fighting
Zone • Medical assistance
• Rescue
(TIC, ALL TEAMS) • Extrication
A Public Processing Area should be established for people who • Other time-sensitive activities
were evacuated from the Yellow Zone without being monitored or Medium Radiation 1 • Access restricted to authorized
Zone personnel entering the "High
decontaminated [Information E.45]. Radiation Zone" to perform critical
tasks such as saving of lives and
property
• Serves as a buffer zone/transition
area between the "High Radiation
Zone" and "Low Radiation Zones"
Low Radiation 0.1 • Access restricted to essential
Zone individuals
• Initial decontamination of first
responders should occur near the
outer boundary of this area
68 69
Information 1 Objectives of triage
CHAPTER F
Triage and monitoring for the

purpose of screening
1 Objectives of triage Information Section F.1a

Triage is the use of simple procedures for rapidly sorting people into Suspected presence of chemical or biological agents
groups based on (a) their degree of physical injury and (b) actual or If chemical or biological contamination is suspected, then procedures for
this type of incident MUST take precedence over those described in this
potential effects on health, and the allocation of care [Information
Handbook.
Section F.1b] to these people in order to expedite treatment and maximise
the effective use of resources.
Information Section F.1b
Triage is a fundamental part of the response to accidents (such as road
Types of “care”
traffic accidents) or natural disasters (floods, earthquakes, etc.). In such The care allocated to the various groups of people identified by the triage
events, triage is designed to allocate medical treatment and resources process, ranges from “high intervention” measures such as urgent
according to the urgency of the patients' need for care. This process is treatment of injuries (trauma triage categories P1 and P2) or treatment of
intended to maximise the number of survivors and can be termed "trauma life-threatening radiation exposures (radiological triage categories II or III),
triage". to “low intervention” measures, such as long-term radiological protection
follow up through a programme of monitoring measurements designed to
Trauma triage may be required following incidents involving the provide information on potential long-term effects on health.
malevolent use of radiation or radioactive material in a public place.
However, the scope of triage is broader for such incidents and includes a Trauma triage categories are defined opposite.
group of actions that can be termed "radiological triage". These actions
are intended to sort people rapidly into groups depending on actual or Radiological triage categories are defined in Section F.2.2.2.
potential effects on their health resulting from radiation exposure.
A widely-used trauma triage system allocates people into one of three
categories:
• Category P1 (Priority 1) is used for severely injured people who
require immediate life-saving intervention;
• Category P2 (Priority 2) is used for people with less severe
injuries who will need hospital care, but whose transfer to a
medical facility may be delayed for 10 – 12 hours; and
70 71
Chapter F Triage and monitoring for the purpose of screening Information 1 Objectives of triage
• Category P3 (Priority 3) is used for injured people who will Information Section F.1c
require medical care but may wait for a number of hours or be
Stages in the triage process
told to go home and return the next day (the “walking
Triage following an incident involving the malevolent use of radiation or
wounded”). radioactive material is a multi-stage process that would be carried out
It is important to be clear about the objectives of the triage process. over an extended period of time. A major problem will be to differentiate
those needing care from the potentially large numbers of people who
These objectives are presented below in order of urgency. Objectives 1, require only information and reassurance (often known as the “worried
2 and 3 constitute the aims of trauma triage; they are to identify: well”). In the early stages, triage decisions will have to be based on limited
1. People who should be assigned to Category P1 (Priority 1). information, and will concentrate on the identification of those with an
2. People who should be assigned to Category P2 (Priority 2). urgent need for treatment. In the later stages, more information (such as
the results of initial monitoring) will be available, and triage will be
3. People who should be assigned to Category P3 (Priority 3). extended to the identification of groups requiring “low intervention” care
Objectives 4, 5 and 6 constitute the aims of radiological triage; they are [Information Section F.1b].
to identify: Table F1. Stages in the triage process.
4. Those people who have been exposed (or are still being Triage Stage Typical time period
when triage deci-
Information available
exposed) to radiation or radioactive material at a level that will sions will be made
definitely have an effect on their health (e.g. as a result of acute Trauma 0-12 h
Severity of physical injuries
radiation syndrome). to individuals
Location, etc., at time of
5. Those people who may have been exposed (or are still being Pre-
2-36 h
incident
exposed) to radiation or radioactive material at lower levels that monitoring Clinical signs and symp-
might nevertheless have an effect on health. In general these 0 h – 6 days
toms, and in the later
would be longer term effects such as cancer. stages, the results of
complete blood counts
6. The potentially large groups of people whose exposures are very Results of initial screening
unlikely to have an effect on health, or who were not exposed at 6-72 h measurements made at
all. Once identified, these groups may be excluded from further incident location
consideration for medical treatment or monitoring. Radiological Results of measurements

made with transportable in
12 h – 6 d
vivo monitoring facilities
Section F.2 describes the process of field triage in the event of an close to incident location
Post
incident involving the malevolent use of radiation or radioactive monitoring Results of laboratory in vivo
24 h – 6 d
material. The term “field triage” is used to describe all those triage monitoring measurements
procedures that are carried out on the affected population outside of a Results of laboratory in vitro
measurements of biological
hospital or other medical facility, either at the site of the incident or at a 72 h – 6 d samples (e.g. radionuclides
distance from it. Its scope includes all of the triage decisions made from in urine, cytogenetic
the commencement of the incident up until the time when all people are measurements of blood, etc.)
correctly categorised for triage purposes (assumed to be about 6 days Notes.

1. The results of radiological monitoring will continue to be received well beyond
following the incident), or up to the admission of a particular individual the end of the period where triage decisions are expected to be made. For some
to a medical facility. The various stages in the field triage process are cases, the same will apply to the results of observations of clinical signs and
symptoms.
described in Information Section F.1c. 2. For some types of incident, not all of these triage stages would arise.
72 73
Chapter F Triage and monitoring for the purpose of screening Instructions Information 2 Initial triage
2 Initial triage
Introduction
Initial stages of triage
The required actions are described in the order of urgency in which the
various stages of triage need to be carried out. However, preparations
for each stage of triage need to be initiated in a timely manner.
Preparations for the next stage of triage cannot await the completion of
the previous stage. The teams required to carry out the various roles are
described in Annex 4.
The initial stages of triage are likely to take place before the results of
radiological monitoring of individuals are available. It is assumed that Information F.1a
first responders (i.e. paramedics or ambulance staff) will have
Trauma triage
commenced trauma triage by the time the actions described in this The first responders dealing with trauma injuries are likely to be the first
section are carried out. These actions are summarised in Figure F1. on the scene.
People with trauma injuries are the first group of people who should be
2.1 Trauma triage identified. If trauma injuries have resulted from an explosion, people in
this group should be assumed to be contaminated, both externally and
internally, by radioactive material.
F.1 Identifying people with trauma injuries
(TACTICAL INCIDENT COMMAND [TIC], FIRST RESPONDERS, Treatment of life-threatening trauma injuries must always take priority
MEDICAL TEAM) over all actions relating to radiation protection, UNLESS radiation exposure
If traumatic injuries have occured, contact should be established is life-threatening to either patient or first responder. An example would
be where the patient is exposed to very high dose rates because of
with first responders dealing with people with such injuries. The
proximity to a radiation source. Here, the highest priority would be to
Incident Commander at the Tactical Control Point should facilitate reduce the dose rate by removing the patient from the immediate
this contact [Section E.3]. Information on identity, location at time environment of the source [Section E.1].
of incident, and triage category should be recorded for patients who
have been processed through the trauma triage system [Annex 3]. Trauma injuries may well be absent if the incident did not involve an
This must not delay or interfere with treatment of trauma injuries. It explosion or aggravated method of attack.
should be possible to carry out this task in the Public Processing
Area of the Yellow Zone [Section E.3].
Information F.1b
If there are no trauma injuries, proceed to Section F.2.2. The trauma triage system described in the Handbook employs three
categories, P1, P2, P3 [Section F.1]. There may be differences between this
system and some national triage systems, but these differences are not
significant.
74 75
F.2 Assessing people with trauma injuries

(ENVIRONMENTAL CONTAMINATION INCIDENTS) (MEDICAL Information F.2
TEAM) It is probable, though not certain, that patients in groups P1, P2 and P3
It should be assumed that patients in trauma triage categories P1, will be among the most heavily contaminated, both externally and
P2 and P3 are both externally and internally contaminated with internally. Furthermore, P1 may be more heavily contaminated than P2,
and P2 more than P3.
radioactive material. In the absence of reliable information on
location, assume that these patients were within the Red Zone at the
time of the incident.
F.3 Transfer of Category P1 patients to hospital

(MEDICAL TEAM) Information F.3
Patients in category P1 must be transferred to hospital immediately, Suspected presence of chemical of biological agents
without carrying out decontamination procedures (unless chemical or If chemical or biological contamination is suspected, then procedures for
biological contamination is suspected). First responders should this type of incident MUST take precedence over those described in this
Handbook.
communicate the fact that no decontamination has been carried out to
those responsible for transferring the patient to hospital, for onward
transmission to hospital staff receiving the patient [Chapter I].
F.4 Decontamination of Category P2 patients

(MEDICAL, DECONTAMINATION TEAMS) Information F.4
Patients in category P2 are likely to have serious injuries, but
Presentation of a large number of contaminated patients to a hospital may
hospital care may be delayed (perhaps for 10 – 12 hours, but result in saturation of its capabilities to provide medical treatment.
determined on a case-by-case basis). Patients in category P2 should
be decontaminated at the site of the incident before transfer to
hospital, if possible [Chapter G]. If this is not possible, facilities for
handling contaminated casualties must be established at the
receiving hospital [Section J.2, Section J.6].
F.5 Decontamination of Category P3 patients

(MEDICAL, DECONTAMINATION TEAMS)
Patients in category P3 (“walking wounded”) should be
decontaminated at the location of the incident, or provided with
instructions on decontamination to be followed when they return
home [Chapter G]. They must not be directed to a hospital for
decontamination. Medical treatment will have a lower priority than
that for P1 and P2 groups. It may be delayed for 24 hours or more,
and could be carried out in an Outpatients Department of a hospital
or other medical facility, where a second triage will be performed
[Section J.4].
76 77
F.6 Initiation of radiological triage

(RADIOLOGICAL TRIAGE TEAM)
All patients assigned to trauma triage categories P2 and P3 should,
as soon as practicable, be subjected to radiological triage based on
clinical signs and symptoms [Section F.2.2.2].
These patients should then be subjected to radiological triage based

on information on location at the time of the incident
[Section F.2.2.1].
F.7 Monitoring of trauma triage patients

(RADIOLOGICAL TRIAGE, MEDICAL, PEOPLE MONITORING
TEAMS)
All patients assigned to trauma triage categories P1, P2 and P3
should undergo initial monitoring (i.e. simple external and internal
contamination measurements) as soon as their medical condition
allows it. The aims of this monitoring are described in Section H.1.
Section F.3 describes the decisions to be made regarding initial
monitoring, and the criteria on which these decisions should be
based. Decisions on when (or whether) monitoring can be initiated
for patients assigned to trauma triage categories P1, P2 and P3, and
the appropriate type of monitoring, must be made on a case-by-case
basis, in consultation with medical staff who are responsible for the
care of the individual.
F.8 Deceased people

(RADIOLOGICAL TRIAGE, MEDICAL TEAMS)
Bodies of deceased people may constitute a radiological hazard.
This issue should referred to the Tactical Incident Command [Annex
4 and Section J.9].
Figure F1. Flowchart for trauma triage.
78 79
2.2 Radiological triage
Introduction
The radiological triage procedures to be followed depend on the
circumstances of the exposure (i.e. whether it was by direct irradiation,
as a result of environmental contamination, or as a result of
contamination of foodstuffs/water).
For most people, information on location will be the prime indicator of
potential exposure in the initial stages of the response to an incident. For
contamination incidents, individual monitoring will provide more reliable
information, but the instruments and facilities to carry out such
monitoring are unlikely to be available during the first few hours of the
response.
Patients assigned to trauma triage categories P2 and P3 are not subjected
to triage based on information on location because it is assumed that they
are potentially the most highly contaminated, both internally and externally.
For all other groups of people (with the exception of those in category
P1), radiological triage based on information on location is the first stage
of triage [Figure F3].
2.2.1 Triage based on information on location

Information F.9a
F.9 Target groups for triage after irradiation incidents People selected according to bullet 1 may be identified by means of police
(EXTERNAL IRRADIATION INCIDENTS) (RADIOLOGICAL intelligence, CCTV cameras, etc. These procedures are however beyond
TRIAGE TEAM) the scope of this Handbook.
The following groups of people (with the exception of those in
category P1, P2 and P3), must be identified and then subjected to
radiological triage based on information on location relative to the Information F.9b
source of irradiation: If information is available that provides strong evidence that the activity of
• People who can be identified as being within a pre-defined the source is relatively small (i.e. less than 1 TBq), then this distance can
distance from the location of the source of irradiation at any time be set at 30 m (but compliance with the dose constraint described in
Instruction E.28 should be confimed urgently by monitoring [Section
during the specified time period [Section E.3.1]; and
F.3.2]). If the source activity is larger, or there is no information on source
• People who believe they may have been within a pre-defined activity, then the distance should be set at 400 m until monitoring is
distance from the location of the source of irradiation at any time carried out that confirms that the distance can be reduced.
during the period of time that people could have been irradiated
[Section E.3.1].
80 81
F.10 Covert external irradiation incidents

(EXTERNAL IRRADIATION INCIDENTS [COVERT]) Information F.10
(RADIOLOGICAL TRIAGE TEAM) Covert scenarios
If the incident was covert (i.e. the location of the source was In the absence of adequate information on source location, greater reliance
unannounced, or was unknown prior to detection), then it will not must be placed on triage based on clinical signs and symptoms [Section
F.2.2.2] and on biological dosimetry [Section J.10] to identify affected
be possible to carry out Instruction F.9 fully until information is
individuals. Effective communications to the public using radio, TV and
obtained on the location of the source during the period that it could newspapers will be needed. It must be accepted that it will not be possible
have resulted in irradiation of members of the public. Such to identify everyone whose health may be affected by the incident.
information must be obtained from intelligence sources. Procedures
for obtaining such information are beyond the scope of this
Handbook.
F.11 Target groups for triage after environmental contamination

incidents Information F.11a
(ENVIRONMENTAL CONTAMINATION INCIDENTS)
(RADIOLOGICAL TRIAGE TEAM) Effect of wind direction
The following groups of people must be identified and then Wind direction should not be used in the selection of people for this stage
subjected to triage based on information on location relative to the of triage. In an urban environment, wind direction is not a good indicator
of potential exposure. Exposures seemingly upwind can be greater than
source: downwind at the same distance from the source because of the complex
• People who are emerging from the Red Zone set up around the airflow patterns around buildings.
source of contamination [Section E 3];
• People who believe they were within the Red Zone at any time
since the incident, before or after the Safety Perimeter was set Information F.11b
up. It will be necessary to define this area on a map so that
Zone boundaries
streets and buildings can be identified; and
As the incident progresses, the position of the Safety Perimeter may
• In the absence of an established Safety Perimeter, people who change. If so, the area inside the Perimeter (i.e. the area of the Red Zone) is
were within 400 m of the source of contamination at any time most likely to decrease, but be aware of the possibility that the Red Zone
since the incident. This includes people in the building or other area could also increase. It is possible therefore that the numbers and
identity of the people to be subjected to this stage of triage may change
enclosed location where the incident occurred at any time since
as the response progresses. Triage must be treated as a dynamic process,
the incident. The area should be delineated on a map so that and the allocation of people to the various categories should be reviewed
streets and buildings can be identified. regularly.
The circumstances of the incident may dictate that other groups of
people should be defined.
82 83
F.12 Covert environmental contamination incident

(ENVIRONMENTAL CONTAMINATION INCIDENTS [COVERT]) Information F.12
(RADIOLOGICAL TRIAGE TEAM) Covert environmental contamination scenarios
If the incident was covert (i.e. the location of the source of This instruction is likely to apply for scenarios involving the covert
contamination was unannounced, or was unknown prior to dispersion of radionuclides, i.e. not involving an explosion or obvious
sabotage of a radioactive source. The site of any explosion may be
detection), then it will not be possible to establish an adequate
assumed to be co-located with the source of contamination unless
Safety Perimeter or to carry out Instruction F.11 fully until the environmental or individual monitoring indicates otherwise.
results of comprehensive environmental contamination monitoring
In the absence of adequate information on source location, greater
are obtained. This monitoring must be carried out with the highest reliance must be placed on triage based on external and internal
priority [Section F.3.2]. Unless such monitoring can be guided by contamination monitoring [Section F.3 and Section H.4] to identify affected
intelligence sources, it is likely to require a significant time, individuals. This is likely to involve a large-scale programme of
particularly if the contamination is by alpha-emitting radionuclides. radiological monitoring for members of the public. Effective
communications to the public using radio, TV and newspapers will be
needed. Triage based on clinical signs and symptoms [Section F.2.2.2]
F.13 Contacting affected people
should also be employed as a supplementary method for identifying the
(EXTERNAL IRRADIATION & ENVIRONMENTAL most exposed individuals. It must be accepted that it may not be possible
CONTAMINATION INCIDENTS) (RADIOLOGICAL TRIAGE TEAM) to identify everyone whose health may be affected by the incident.
People identified according to Instructions F.9 or F.11 should be
contacted using printed leaflets, announcements on radio and TV, Information F.13
by using an internet-based health information service or by
Examples of a printed leaflet that could be handed out at the site of the
telephone using call centres. People still within the Red or Yellow incident, and a media release that could be provided to newspapers, radio
Zones should be invited to present themselves at a Reception and TV stations, are provided in Annex A3. A telephone- or internet-based
Centre established within the Yellow Zone. Otherwise, they should health information service such as NHS Direct in the UK
(http://www.nhsdirect.nhs.uk/) could also be used.
be invited to present themselves at a Reception Centre established
beyond the Yellow Zone.
Information F.14
F.14 Decontamination Many people will very quickly remove themselves from the scene of an
(ENVIRONMENTAL CONTAMINATION INCIDENTS) incident, and they should not be prevented from doing so unless security
personnel decide otherwise. It will not be possible to record personal
(RADIOLOGICAL TRIAGE, DECONTAMINATION TEAMS) information for such people at the scene of the incident. The approach
People identified according to Instruction F.11 who have already should be to make announcements on radio and TV, as soon as possible,
returned home should be provided with advice on decontamination inviting people in “potentially at risk” groups to present themselves at an
appropriate location such as a Reception Centre outside the Yellow Zone.
[Section G.3].
F.15 Symptoms of ARS Information F.15

(EXTERNAL IRRADIATION & ENVIRONMENTAL A caution
CONTAMINATION INCIDENTS) (RADIOLOGICAL TRIAGE, Many people who report these symptoms will not have been exposed to
any significant extent to radiation or radioactive material, but may be
MEDICAL TEAMS) experiencing symptoms because of stress and anxiety.
People identified according to Instructions F.9 or F.11 must be
advised to contact immediately the appropriate authorities if they Nevertheless, it is extremely important that this message is given clearly,
as it could save lives.
are suffering from nausea, vomiting or diarrhoea [Section K.7].
84 85
F.16 Collection of information from potentially affected people,

irradiation incidents
(EXTERNAL IRRADIATION INCIDENTS) (RADIOLOGICAL
TRIAGE, RECORDS TEAMS)
People identified according to Instruction F.9 should be contacted
and more detailed information of the following types should be
collected:
1. Name, date of birth, address, contact telephone number.
2. If direct physical contact took place:
• Length of contact time;
• Date, time of day this contact took place;
• Did the individual move the source? and Information F.16 and F.17
• If so, where from? Any people who are still in the Red Zone should be evacuated from the
3. If no direct contact: area before they are asked to provide this information.
• Length of time the subject was close to source;
• Distance from the location where source was located; and
• Within line of sight? If not, information on what lay between Information F.16, F.17 and F.21
the source and the individual is needed (may be of use for The radiation dose received by an individual close to a radioactive source
shielding calculations). increases in direct proportion to the amount of time spent close to it, but
4. If the incident took place in an enclosed space: decreases rapidly with increasing distance (the inverse square law). The
dose is reduced if other objects occupy the space between the source and
• Whether on same or different floor of building; or the individual, particularly if the objects contain a lot of mass.
• Whether on same or different platform in a station
(similar criteria can be specified for other locations).
5. If the source was mobile, then the same criteria should be
applied to every point on the track of the source during the
period when irradiation of people could have taken place.
An example questionnaire that can be customised is provided in
Annex 3.
F.17 Collection of information from potentially affected people,

environmental contamination incidents
(RADIOLOGICAL TRIAGE, RECORDS TEAMS)
People identified according to Instruction F.11 should be contacted
and more detailed information of the following types should be
collected:
1. Name, date of birth, address, contact telephone number.
86 87
2. General:
• Was there any direct contact with material released as a result
of the incident (hit by debris, breathed fumes, etc.)? If so, and
person has returned home, details of the journey (in case of
transfer of contamination);
• Whether inside or outside;
• Activity at the time of the incident (running towards or away;
driving towards or away; entering or leaving a building; etc.);
and
• The locations between which the person moved at the time of
the incident.
3. If the incident took place in the open:
• Distance from the source of contamination (0 – 400 m; > 400
m); and
• Time of day, and length of time, at this location.
4. If the incident took place in an enclosed space:
• Whether on same or different floor of building as the source of
contamination;
• Whether on same or different platform in a station, etc.; and
• Time of day, and length of time, at this location.
5. If the source was mobile, then the same criteria should be
applied to every point on the track of the source during the
period when releases could have taken place.
An example questionnaire that can be customised is provided in
Annex 3.
F.18 Collection of information from potentially affected people

(EXTERNAL IRRADIATION & ENVIRONMENTAL
CONTAMINATION INCIDENTS) (RADIOLOGICAL TRIAGE TEAM)
Information collected on identity and location at time of incident
must be recorded [Annex 3].
F.19 Selection of people

On the basis of information collected according to Instruction F.17,
88 89
people who meet the following criteria should be selected for

further consideration within the radiological triage process:
• All who came into direct contact with debris, fumes or other
material originating directly from the primary source;
• If incident took place outside, then all those who were within
400 m of the source of contamination (or a smaller distance as
defined in Section E.3) at any time since the incident;
• If incident took place inside, then everyone within the same
enclosed space (e.g. a building) at any time since the incident. If
in doubt, then everyone within 400 m of the source of
contamination at any time since the incident; and
• If the source of contamination was mobile, then the same criteria
should be applied to every point on the track of the source during
the period when releases could have taken place.
F.20 Prioritisation of people, environmental contamination incidents

(ENVIRONMENTAL CONTAMINATION INCIDENTS) Information F.20
(RADIOLOGICAL TRIAGE TEAM) This categorisation scheme is completely separate from the trauma triage
The people selected according to Instruction F.19 should be categorisation scheme (i.e. P1, P2 and P3) [Section F.1] and the radiological
prioritised using the information collected using Instruction F.17, as triage categorisation scheme (i.e. I, II and III) [Section F.2.2.2].
follows. Five categories are used: LOW, LOW – MODERATE,
MODERATE, MODERATE – HIGH, HIGH. The following factors
should be taken into account:
• If person came into contact with material released as a result of
the incident, likelihood of exposure is HIGH;
• If incident was outside and individual was outside within 400 m
of the source of contamination at the time of the incident,
likelihood of exposure is MODERATE;
• If incident was outside and individual was more than 400 m
away at the time of the incident, likelihood of exposure is LOW;
• If incident was outside and individual was inside at the time of
the incident, likelihood of exposure is LOW;
• If incident was inside and individual was outside at the time of
the incident, likelihood of exposure is LOW;
• If incident was inside, and individual was inside close to the site
of the incident (e.g. on the same floor) at the time of the incident,
90 91
likelihood of exposure is MODERATE – HIGH;

Information F.21
• If incident was inside, and individual was inside at the same
This figure illustrates how exposure category depends on time and distance
location (e.g. in the same building) at the time of the incident,
from a source of gamma radiation. It shows exposure relative to the exposure
likelihood of exposure is MODERATE; arising from a residence time of 1 second at a distance of 1 metre from a
• If the individual moved towards the incident, likelihood of radiation source. These calculations are approximate and do not take account
exposure INCREASES by ONE LEVEL; of the effect of shielding by material (e.g. walls of buildings) between the
person and the source.
• If the individual remained close to the incident for more than 5
minutes, likelihood of exposure INCREASES by ONE LEVEL;
and Time (s) Distance (m)
1 2 5 10 20 50 100
• If the individual was at the location, but not until 15 minutes or 1 1.00E+00 2.50E-01 4.00E-02 1.00E-02 2.50E-03 4.00E-04 1.00E-04
2 2.00E+00 5.00E-01 8.00E-02 2.00E-02 5.00E-03 8.00E-04 2.00E-04
more after the incident, likelihood of exposure DECREASES by 5 5.00E+00 1.25E+00 2.00E-01 5.00E-02 1.25E-02 2.00E-03 5.00E-04
ONE LEVEL. 10 1.00E+01 2.50E+00 4.00E-01 1.00E-01 2.50E-02 4.00E-03 1.00E-03
20 2.00E+01 5.00E+00 8.00E-01 2.00E-01 5.00E-02 8.00E-03 2.00E-03
Specific circumstances may require other factors to be taken into 50 5.00E+01 1.25E+01 2.00E+00 5.00E-01 1.25E-01 2.00E-02 5.00E-03
account. 100 1.00E+02 2.50E+01 4.00E+00 1.00E+00 2.50E-01 4.00E-02 1.00E-02
200 2.00E+02 5.00E+01 8.00E+00 2.00E+00 5.00E-01 8.00E-02 2.00E-02
500 5.00E+02 1.25E+02 2.00E+01 5.00E+00 1.25E+00 2.00E-01 5.00E-02
F.21 Prioritisation of people, irradiation incidents 1000 1.00E+03 2.50E+02 4.00E+01 1.00E+01 2.50E+00 4.00E-01 1.00E-01
(EXTERNAL IRRADIATION INCIDENTS) (RADIOLOGICAL 2000 2.00E+03 5.00E+02 8.00E+01 2.00E+01 5.00E+00 8.00E-01 2.00E-01
5000 5.00E+03 1.25E+03 2.00E+02 5.00E+01 1.25E+01 2.00E+00 5.00E-01
TRIAGE TEAM)
The people selected according to Instruction F.9 should be
HIGH exposure category
prioritised using the information collected using Instruction F.16, as MODERATE - HIGH exposure category
follows. Five categories are used: LOW, LOW – MODERATE, MODERATE exposure category
MODERATE - LOW exposure category
MODERATE, MODERATE – HIGH, HIGH. Each person should LOW exposure category
be assigned to one of these categories using information on the
distance of closest approach to the source of irradiation, and their Figure F2. Dependence of exposure category on distance and time.
best estimate of the time they remained at this location. Figure F2
may be used for this purpose. If a person came into direct contact
with the source, the likely magnitude of exposure is HIGH.
F.22 Selection and prioritisation of people

(FOOD/WATER CONTAMINATION INCIDENTS) (RADIOLOGICAL
TRIAGE TEAM)
Affected individuals must be identified on the basis of information Information F.22
on the likelihood of them having consumed contaminated Monitoring of contaminated foodstuffs/water
foodstuffs or water. The location of contaminated food or water This is likely to require a large-scale programme of foodstuffs/water
monitoring. Triage based on clinical signs and symptoms [Section F.2.2.2]
may be identified on the basis of intelligence, and/or on the basis of
should also be employed as a supplementary method for identifying the most
monitoring of foodstuffs/water. Individuals should be prioritised exposed individuals. It must be accepted that it may not be possible to
according to the likelihood of them having consumed contaminated identify everyone whose health may be affected by the incident.
foodstuffs or water.
92 93
F.23 Recommended actions

Instructions F.24 to F.29 should be carried out for each person
selected according to Instructions F.19 or F.9 or F.22, in the order of
priority determined according to Instructions F.20 or F.21 or F.22.
F.24 The next stage of triage

Carry out radiological triage based on clinical signs and symptoms
[Section F.2.2.2].
F.25 Decontamination
(RADIOLOGICAL TRIAGE, DECONTAMINATION TEAMS)
Direct to decontamination facilities if this has not already been
done [Chapter G.2].
F.26 Initial individual contamination monitoring Information F.23 - F.28

(ENVIRONMENTAL CONTAMINATION INCIDENTS) Decontamination should not be delayed in order to carry out monitoring.
(RADIOLOGICAL TRIAGE, PEOPLE MONITORING TEAMS) However, if there is a backlog of people waiting for decontamination facilities
to become available, those waiting may be monitored.
Carry out initial individual monitoring as described in [Section
F.3]. In general, the sequence is: external contamination
monitoring; further decontamination (if monitoring indicates that it
is necessary); and initial internal contamination monitoring.
F.27 Internal contamination monitoring

(FOOD/WATER CONTAMINATION INCIDENTS) (RADIOLOGICAL
TRIAGE, PEOPLE MONITORING TEAMS)
Carry out initial individual monitoring for internal contamination
as described in Section F.3.4.
F.28 Advice on decontamination

(RADIOLOGICAL TRIAGE, DECONTAMINATION TEAMS)
If people selected according to Instruction F.19 are sent home
without decontamination and without monitoring because of
shortage of suitable resources, they should be provided with advice
on decontamination [Section G.3].
94 95
F.29 Symptoms of ARS

People selected according to Instructions F.19, F.9 or F.22 and who
are sent home, must be advised to contact immediately the
appropriate authorities if they are suffering from nausea, vomiting
or diarrhoea [Section K.7]. These individuals should be interviewed
regularly to determine whether they are exhibiting these symptoms
[Section F.2.2.2].
Figure F3. Flowchart for radiological triage based on information on location.
96 97
2.2.2 Triage based on clinical signs and symptoms

Information F.30a
Liaison with medical staff
It is very important that procedures are put in place to ensure effective and
Introduction
timely exchange of information between staff with responsibilities for triage
Radiological triage based on clinical signs and symptoms is aimed at and monitoring and medical staff responsible for the care of patients.
identifying people who may have received radiation doses that are large
enough to cause deterministic effects on health. This section explains Information F.30b
how the observation of prodromal (i.e. early onset) symptoms should be Important information
used to identify these people. In many cases, symptoms will present For uniform whole body irradiation giving doses less than about 1 Gy, the
themselves within a few hours of acute whole body exposure, but this patient will generally not show any symptoms (Goans et al, 2005).
will not always be the case, and some individuals with exposures at People not suffering from any of the symptoms listed in Instruction F.30
deterministic effect levels may not exhibit observable prodromal may still have received doses in excess of 1 Gy. Even at 2 Gy, only about
40 % of patients will suffer from vomiting (Dainiak, 2007). Thus, some
symptoms at all. This stage of triage should be treated as a dynamic, people exposed at levels that will cause deterministic effects will not be
rather than a “once only” process; it will be necessary to review at identified as such by this stage of triage.
regular intervals the outcomes of this part of the triage process for the
individuals of potential concern. This regular review will certainly need
to be carried out during the 6-day period covered by the triage
procedures described in this chapter, but it will also need to be extended
to later phases of the response [Sections J.4 and J.5]. Actions required
for this stage of radiological triage are summarised in Figure F6.
F.30 Target groups for triage

The three groups of people who must be subjected to triage based Figure F4. Relationship between time to onset of vomiting and dose over a range of
on clinical signs and symptoms are: 2-10 Gy. The right hand scale runs from zero to 100 %. Reproduced with kind
permission from Nicholas Dainiak (Dainiak, 2007).
• All patients in trauma triage categories P2 and P3 (P1 patients
would already have been sent to hospital and would be being
dealt with on an individual basis); Information F.30c
• All people who were within the Red Zone during or after the Important information
incident; and The initial (prodromal) phase of acute radiation syndrome usually occurs in
• Any people for whom individual monitoring and dosimetry the first 48 hours, but may not develop until 6 days after exposure
(Waselenko et al, 2004).
indicates that they may receive exposures large enough to cause
deterministic effects.
Information F.30d
These people must be interviewed to determine whether they have A caution
(or are observed to have) the following symptoms: Note that many people who report these symptoms will not have been
exposed to any significant extent to radiation or radioactive contamination,
• Vomiting; but may be experiencing the symptoms because of stress and anxiety.
• Nausea;
98 99
• Diarrhoea; and/or
• Erythema (reddening of the skin).
Information F.32a
F.31 Actions if symptoms of ARS are not observed This categorisation scheme is completely separate from the trauma triage
categorisation scheme (i.e. P1, P2 and P3) [Section F.1].
If the person is not suffering from any of these symptoms, then no
further actions are required in this stage of radiological triage. The Information F.33
person must be instructed that they MUST report to an identified Important information
health care centre if they develop symptoms such as nausea,
vomiting, diarrhoea, skin reddening or blistering. Written For whole body doses exceeding 1 Gy, the
instructions with a contact list for these health centres should be lymphocyte blood cell population decreases with
provided [Section K.4]. increasing dose and increasing time since exposure
(Goans and Waselenko, 2005), so measurements of
F.32 Assignment to a radiological triage category depletion kinetics provide an estimate of dose. This
graph shows the concentration of lymphocytes in
blood (number of lymphocytes in 1 μl of blood)
Information on time to vomiting and on time to onset of nausea and after an acute whole body exposure.
diarrhoea should be collected from all people suffering from any of
the symptoms identified in Instruction F.30. People should be CBC provides estimates of uniform whole body
assigned to Radiological Triage Categories I, II or III on the basis doses in the range 1 – 10 Gy (Blakely et al, 2005).
of the information collected, according to the scoring system given Figure F5. Lymphocyte depletion
in the leaflet “European approach for the medical management of (EBMT, 2007, courtesy of authors).
mass radiation exposure”. The relevant part of the leaflet is Software tools are available to estimate dose from both time to vomiting
reproduced in Information F.32b. Further guidance is given in and from CBC (Blakely, http://www.afrri.usuhs.mil/www/outreach/biodos-
Annex 5, where the complete leaflet is reproduced. tools.htm#software).
All those people subjected to radiological triage and not assigned to Additional blood samples
Categories I, II or III should be assigned to Category 0. CBC is more accurate when two or more samples are taken so that
changes in blood cell counts can be observed directly. It is therefore very
important to obtain at least one further blood sample, whenever possible,
F.33 Blood cell counts and to take the initial blood sample as soon as possible.
(MEDICAL TEAM)
A blood sample should be taken as soon as possible for any persons Further blood samples should be taken after admission to hospital to
enable blood cell depletion to be measured. Different approaches have
in Radiological Triage Categories I, II or III, and a complete blood been proposed in terms of numbers and frequency of sampling (Mettler,
count (CBC) should be carried out urgently. If necessary, call in 2005; Blakely et al, 2005; Daniak et al, 2006). After the first sample, it is
staff with specialist expertise. recommended to take sequential samples several times within the initial
days after exposure in order to calculate the rate of lymphocyte decline.
Guidance on blood sampling after admission to hospital is provided in
Chapter J [Section J.4, Instructions J.6:3 and J.7:7].
100 101
Information F.32b
Figure F6. Flowchart for radiological triage based on clinical signs and symptoms.
Figure F7. European approach for the medical management of mass radiation exposure.
Reproduced from EBMT, 2007, courtesy of authors. The full leaflet is reproduced in Annex 5.
102 103
If the person is to be admitted to hospital immediately, the blood

sample may be taken there, otherwise the blood sample should be
taken at an appropriate location in the field (e.g. at the Public
Processing Area in the Yellow Zone).
If admission to hospital is not possible during the first hours, take

blood samples at 8 hour intervals on the first day, 12 hour intervals
on the second day, and perform blood cell counts. Depending on
the results, two further blood samples should be taken during the
first week after the incident, depending on the number of people for Information F.35
whom a CBC is required and the available capacity [Section J.4 and In the flowchart in Figure F6, actions corresponding to the "Yes" pathway
Instruction J.6:3]. to the right of the decision boxes labelled "CAT I?" and "CAT II or III?" are
actions relating to the individual. Actions corresponding to the "Yes"
pathway to the left of these boxes are actions relating to groups of other
F.34 Review of triage assessments people.
Allocation of individuals to Radiological Triage Categories should Information F.36a
be reviewed as soon as the result of each CBC count is available.
Chromosome aberration analysis is a more accurate dose assessment method
The graph shown in Information F.33 may be used for an initial than CBC and is often described as the ‘‘gold standard’’ for individual
evaluation. Any result other than “Normal” should be referred for biodosimetry (Lloyd et al, 2000). However, results are unlikely to be available
medical assessment [Section J.4]. until 4 to 5 days after the incident [Section J.10].
F.35 Extension of blood sampling Information F.36b

(RADIOLOGICAL TRIAGE, MEDICAL TEAMS) Other techniques will also provide supplementary information (e.g.
If there is any evidence that suggests that doses received by some premature chromosome condensation assay, analysis of molecular
individuals could be high enough to result in deterministic effects, biomarker analysis, etc.) [Section J.10].
then blood samples should be taken for a representative number of
people assigned to the highest potential exposure category on the Information F.37a
basis of information on location [Section F.2.2.1]. There is no urgent need for medical intervention for patients in
Radiological Triage Categories I, II or III within the first 48 h after acute
If CBCs on these samples indicate significant exposures to any exposure. The most important need is for patients to be kept under
observation by a medical team whose members possess the appropriate
individual, blood sampling should be extended to every person expertise [Section J.5].
assigned to the highest potential exposure category on the basis of
information on location, and to randomly selected people in lower
Information F.37b
exposure categories. Decisions on people selected for blood
In the flowchart in Figure F6, two action paths are identified for people
sampling should be reviewed as soon as CBC results are available. referred for outpatient monitoring. The first path refers to actions relating
to general care, which are addressed in Section J.5. The second path refers
F.36 Chromosome aberration analysis specifically to further blood sampling, which may need to take place
within the context of the field response. Clearly, liaison between field and
(RADIOLOGICAL TRIAGE, PEOPLE MONITORING TEAMS) hospital is needed [Information F.30a].
Where CBCs indicate significant exposures, separate blood samples
104 105
should be collected for chromosome aberration analysis. Samples

should be collected approximately 24 hours after exposure Information F.38a
[Section J.10 and Annex 11]. Important information
Erythema (reddening of the skin) is generally seen within a few hours to a
few days after doses to the skin in excess of 2 Gy. Erythema occurring on
F.37 Referral to hospital some part of the skin but not others may be an indicator of high but
(RADIOLOGICAL TRIAGE, MEDICAL TEAMS) non-uniform exposure. Other prodromal symptoms may not be exhibited
Patients should be referred to hospital or other medical facility on under such circumstances. It is important to ensure that patients are not
wrongly excluded on the assumption that the erythema has a different
the basis of their Radiological Triage Category (i.e. I, II or III). The cause (e.g. heat burn, chemical burn, sun burn). On the other hand,
“European approach for the medical management of mass radiation erythema should not be attributed immediately to radiation exposure.
exposure” leaflet [Annex 5] advises on medical treatment [Section
J.5]. Table A5.1 in Annex 5 also presents advice on the level of Information F.38b
medical response needed for people in these categories.
An example of a radiological triage system from a recent
emergency exercise
F.38 Observation of erythema In the event of a real incident, the guidelines on radiological triage given
(RADIOLOGICAL TRIAGE, MEDICAL TEAMS) in Section F.2.2 would need to be adapted to the circumstances of the
If prodromal erythema (reddening of the skin) is observed, this may incident and the extent of information available. As noted in the
Introduction to Section F.2, different stages of triage would need to be
indicate exposures in excess of about 2 Gy. A blood sample should
carried out together rather than sequentially. Figure F8 shows an outline
be collected for CBC. A decision should be made on whether to of a triage system set up as part of an emergency exercise held in the UK
admit the patient to hospital [Section J.7]. in 2008. This triage system took account of information on both location
and observed clinical signs and symptoms. The scenario was the
F.39 Non-uniform exposures, and exposures extended in time discovery of a highly radioactive 137Cs fragment at a railway station on 28
(RADIOLOGICAL TRIAGE, MEDICAL TEAMS) August, following an explosion at another location on 26 August. The
Guidelines given above for the interpretation of information on dose rate close to the fragment was of the order of 100 mGy h-1. The aim
clinical signs and symptoms apply only to acute whole body was to prioritise people for cytogenetic analysis of blood samples; this
technique should provide the capability to detect doses from external
exposures (typically where more than 60 % of the body is irradiation above about 100 mGy.
uniformly irradiated). If exposures are non-uniform or extended in
time the guidelines will not be directly applicable. Reference should Measures had already been put into place for a medical team to carry out
be made to Section J.5 for guidance, and expert advice should be radiological triage assessments for all those who visited the station on or
sought. after 26 August and reported nausea, vomiting and diarrhoea. The top
priority was therefore to find people who could be suffering from
F.40 Internal contaminations and deterministic effects radiation erythema as a result of being in contact with the radioactive
(CONTAMINATION INCIDENTS) (RADIOLOGICAL TRIAGE, fragment. The next priority was to identify people who could have
remained close to the fragment for more than 5 minutes. Given that
MEDICAL TEAMS) exposure could have taken place up to two days previously, it was
Radiation doses resulting from internal contamination are generally presumed that people would not recall how long they remained on the
received over a protracted period of time and can be either platform with any accuracy. Furthermore, the information available
distributed uniformly (e.g. after intake of 137Cs) or very non- indicated that the radioactive fragment could have been anywhere within
uniformly (e.g. after intake of 210Po). Monitoring and assessment of the covered section of the platform during the previous two days.
(Continued over page).
internal dose will provide an important input to triage decisions
[Section H.4].
106 107
F.41 Long-term follow up Information

f F.38b (cont.)
(PEOPLE MONITORING, MEDICAL TEAMS)
People subjected to radiological triage based on clinical signs and
symptoms may be considered for long-term health and radiation
protection follow up [Section K.9].
Figure F8. An outline of a radiological triage system.
108 109
Chapter F Triage and monitoring for the purpose of screening 3 Initial monitoring
3 Initial monitoring
Introduction 4. Monitoring of internal contamination levels in people (required for

any environmental contamination incident and for any incident
In the initial stages of the response, a number of different types of involving contamination of food/water). Monitoring will enable
monitoring are needed: people who could potentially have internal contamination levels high
1. Monitoring of environmental gamma dose rates within the affected enough to cause deterministic effects to be identified quickly and
areas (required for both external irradiation incidents and directed for medical assessment. Results will enable decisions to be
environmental contamination incidents). Results will allow doses made on the need for treatment to reduce internal doses (e.g. with
received from external irradiation to be estimated for individuals Prussian Blue to reduce levels of Cs in the body [Instruction J.24]).
who were within (or remain within) the affected areas. This Taken together with estimates made of external doses to individuals,
monitoring will enable decisions to be made to remove any this monitoring will also help to establish the magnitude of
remaining people from areas with high dose rates and to restrict stochastic risks to health.
access to these areas. It will also help to confirm that zone
boundaries have been correctly located (or will indicate where This section details the procedures necessary for carrying out this
changes to zone boundaries are needed). monitoring, and includes practical advice on monitoring for different
2. Monitoring of environmental contamination levels within the types of radiation.
affected areas (required for any environmental contamination
incident). Monitoring will provide information on the spread of In general, initial monitoring can be carried out using appropriate hand
environmental contamination, and will help in the control of held radiation monitors [Annex 2]. Radiation monitoring is a specialised
exposure to internal contamination. Contamination monitoring task that must be carried out by trained staff [Annex 4]. Emergency
provides another important input to decisions about the placement services personnel who are quickly on the scene may have the skills
of zone boundaries. necessary to carry out the less specialised monitoring tasks (e.g. of
3. Monitoring of external contamination levels on people (required for environmental gamma dose rates), but staff with the skills necessary to
any environmental contamination incident). Results will enable carry out all the required monitoring tasks will take some time to arrive.
decisions to be made on the need for decontamination of people, It is very important that adequate records are kept of the results of
which is usually the simplest and most effective means for reducing monitoring [Section H.6 and Annex 3].
individual doses in the early stages. Monitoring will enable people Guidelines on limiting exposure of monitoring teams are given in
who could potentially have contamination levels high enough to Section E.1.
cause deterministic effects to be identified quickly and directed for
medical assessment. Results would also be used to prioritise people
for internal contamination monitoring. The rapid initial screening
will enable decisions to be made on which type of further
monitoring, if any, would have to be carried out.
110 111
Chapter F Triage and monitoring for the purpose of screening Instructions Information 3 Initial monitoring
3.1 Preparatory actions for monitoring teams
F.42 Despatch to incident location

(TACTICAL INCIDENT COMMAND [TIC], ENVIRONMENTAL
MONITORING TEAM, RECORDS TEAM)
Before leaving for the incident site the monitoring team(s) must be
informed of the location of the Marshalling Area [Section E.3] and
the most direct route to take to get there, avoiding the incident and
associated traffic.
F.43 Equipment
The monitoring team(s) must confirm that all required equipment is Information F.43
in good working order, with fully charged batteries, and calibrated
Dose meters, gamma probes and rate meters can be enclosed in plastic
against a check source. Details of the equipment, check source
film to protect them from becoming contaminated, as can the handles on
results and local background levels should be recorded [Annex 3]. alpha and beta probes. The detection surfaces (Mylar screen) on alpha and
If possible the equipment should be prepared for use in a hostile beta probes must not be covered as this will seriously impair their
environment [Information F.43]. Each team should have cans of performance.
spray paint to physically mark monitored locations, and individual
portable Global Positioning System (GPS) equipment.
F.44 PPE and communications

(ENVIRONMENTAL MONITORING TEAM) Information F.44
Each member of the monitoring team must have appropriate PPE It is assumed that each monitoring team will be prepared to carry out any
comprising of [Section E.1 and Annex 2]: of the monitoring tasks described in the Introduction.
• Gloves;
• Waterproof clothing (all skin and hair must be covered);
• Safety helmet; and
• Alarming dosemeter (measuring instantaneous dose rate as well
as cumulative dose).
Alternative PPE giving a similar level of protection may be used.
Each team member should also have a reliable means of two-way
communication with the control centre (note that mobile phone
networks may not be reliable), for example VHF radios.
112 113
F.45 Initial briefing and instructions on control of exposure

(TIC, ENVIRONMENTAL MONITORING TEAM) Information F.45
On arrival at the incident site, the monitoring team should inform Contamination monitoring equipment display activities as counts per
Tactical Incident Command (TIC) of their arrival. TIC must fully second or cps and not Bq cm-2. Conversion from cps to Bq cm-2 requires
brief the monitoring team on the incident, the type of radiation the response efficiency to be known, and this is instrument-specific
(although similar equipment will have similar efficiencies and so a generic
present and provide clear instructions about acceptable/ value may be applied). The monitoring team may be more familiar with
unacceptable levels of exposure, permissible occupancy times and cps and prefer to use these units. If so, they should convert the values
turn-back limits [Section E.1]. The monitoring team should be (and double check the calculations) before starting monitoring. Reported
familiar with the equipment to be used and its response efficiency results must include the reading, the units in which the result is
[Information F.45]. expressed, the type of instrument and the conversion factor for the
instrument. Record the conversion factor on the instrument with a
waterproof marker pen.
F.46 Monitoring Control responsibilities
(TIC, RECORDS TEAM)
TIC should establish a Monitoring Controller, a Monitoring Control
Team and a Records Team to perform the following functions:
• Select specific locations to be monitored;
• Prioritise monitoring locations;
• Establish a safe route to a location for a monitoring team;
• Deploy monitoring team(s) to the required locations;
• Maintain and regularly update levels of cumulative dose for all
members of the monitoring teams [Section E.1 and Annex 3].
• Maintain records of the monitoring team(s) deployment and
levels of contamination and dose rate found at monitored
locations;
• Maintain contact with the monitoring team(s); and
• Relay results and liaise with TIC.
F.47 Maps, GPS and report forms

(TIC, ENVIRONMENTAL MONITORING TEAM, RECORDS TEAM)
The monitoring team should be provided with adequate maps of the
area, hand-held GPS units if possible, and appropriate report forms
[Annex 3].
F.48 Monitoring instruments

If the type of radiation (e.g. alpha (α), beta (β), gamma (γ) or
neutron) has been identified, then only the equipment required to
114 115
detect that type of radiation need be deployed. Annex 2 and

Annex 8 specify recommended monitoring equipment. Information F.49
Due to the short range of alpha and beta particles in air, when monitoring
F.49 Expertise for this type of radiation the probe should be as close as possible, and no
(ENVIRONMENTAL MONITORING TEAM) further than 1 cm, from the surface being monitored. The contaminated
surface must be dry and should be traversed at a rate of 10 cm per second
If alpha (α) or beta (β) radiation has been identified, then TIC must or slower.
ensure that all monitoring teams are proficient in detecting this
type of radiation [Information F.49]. Particular care is required when monitoring for alpha and/or beta radiation
to avoid puncturing the detection surface (Mylar screen) of the probe and
F.50 Monitoring in the Marshalling Area making the instrument light sensitive. The extent of the damage can result
in readings ranging from enhanced background to full scale deflection.
Damaged probes should be replaced.
Wearing PPE, the monitoring team should switch ON (and leave on)
the monitoring equipment and obtain and record representative
background values at the Marshalling Area. The dose rates or Information F.50
contamination levels should not exceed those for the Security Initially the positioning of the Security Perimeter will be based on criteria
Perimeter [Table F2, Information F.56]. If any of these values are other than monitoring data. This will probably be the first opportunity to
exceeded, then TIC must be informed immediately and a new confirm that the area completely encompasses the Red Zone and is
location considered. radiologically "safe".
3.2 Environmental monitoring
F.51 Establishing monitoring priorities

Priorities should be established from a consideration of the
circumstances of the incident. Monitoring tasks are likely to
include some or all of the following:
• Monitor along the Safety Perimeter to confirm it is safely
positioned;
• Perform a rapid area survey within the Safety Perimeter to
determine whether the area enclosed within it (the Red Zone) can
Figure F9. Alpha contamination monitoring. This photograph illustrates the method,
be reduced; but when responding to an incident, additional measures would need to be employed,
• Perform a rapid area survey within the Red Zone, close to the i.e. the detector would be wrapped in plastic film with the exception of the front
window. Photos: STUK.
incident location to identify any areas of high gamma dose rate
(Sv h-1 or Gy h-1) or contamination (Bq cm-2 or Bq m-2);
• Perform a rapid area survey of the Yellow Zone to confirm that
no ‘hot spots’ are present, doses to emergency services personnel
and other personnel responding to the incident remain with
116 117
acceptable limits, and doses to members of the public

temporarily remaining in the Yellow Zone remain within
acceptable limits;
• Perform a detailed area survey of the Red Zone, when resources
become available; and/or
• Perform a detailed area survey of the Yellow Zone, when
resources become available.
F.52 Specifying tasks for the Monitoring Teams

Each monitoring task should be reduced to a set of simple Example of a “Task Sheet” for monitoring within the Red Zone
instructions to be provided to a monitoring team. This task plan 1. Commence gamma dose rate measurements immediately on
should specify the locations to be monitored and the type of leaving the Marshalling Area, and proceed via the Secure Access
measurements to be performed (e.g. gamma dose rate, Control Point (SACP) to map grid reference SU 4730 8650.
contamination with beta-emitters, contamination with alpha 2. While proceeding along the path at walking pace, record position
emitters, etc). An example of a simple task plan for gamma dose and gamma dose rate (mGy h-1) at 10 m intervals.
3. Proceed 200 m south (compass heading 183o) to map grid
rate monitoring around a boundary is given in Information F.52. reference SU 4730 8630.
For an area survey, the monitoring team should be requested to 4. Then proceed 200 m east (93o) to map grid reference SU 4750
monitor at the intersection points on a suitably spaced grid. 8630.
5. Then proceed 280 m north-west (318o), returning to map grid
F.53 Initiating the monitoring task reference SU 4730 8650.
6. Return and report to the Monitoring Control Team at the TCP.
(ENVIRONMENTAL MONITORING TEAM, TIC)
7. If a dose rate in excess of x mGy h-1 is recorded at any point,
From a previously confirmed ‘safe’ location, the monitoring team report reading immediately to Monitoring Control and then follow
should advise Monitoring Control when they are ready to proceed the instructions issued.
and await instructions. Monitoring Control should then issue a task 8. At all times, comply with the “turn back” guidance provided
plan to the Monitoring Team. TIC must confirm, via Monitoring separately [Information E.5, Table E2].
Control, that it is safe for the monitoring team to proceed.
F.54 Recording and Reporting

Monitored positions and corresponding monitoring data (as
requested in the task plan) should be recorded on an appropriate
report form [Form A3.1, Annex 3], and provided to Monitoring
Control.
118 119
F.55 Control of exposure

While proceeding to a specified location, the monitoring team must
comply with turn-back guidance [Table E2, Information E.5], and
ensure that they do not enter into a high dose or contaminated area.
Rapid measurements, particularly gamma dose rates, must be taken
at regular intervals (for example at 5 to 10 metre intervals). Team
members should report their individual cumultative dose readings
to Monitoring Control at regular intervals.
F.56 Monitoring the Safety Perimeter

(ENVIRONMENTAL MONITORING TEAM, RECORDS TEAM, TIC) Information F.56
A minimum of 8 regularly spaced locations on the Safety Perimeter Table F2. Maximum acceptable contamination levels and dose rates at Safety
Perimeter for α−, β−, and γ −emitters.
must be monitored to confirm that the Safety Perimeter is safely
Perimeter Type of measurement Measured value must not exceed
positioned.
Alpha contamination level 100 Bq cm-2
If the dose rates or contamination levels exceed those for the Safety
Beta contamination level 1000 Bq cm-2
Perimeter [Table F2], then the monitoring team must perform a Red Zone
(Safety) Gamma contamination level 1000 Bq cm-2
more detailed survey to confirm whether the high dose rate or
Gamma dose rate 100 μSv h-1
contamination is widespread or a "hot spot" [Section E.2].
(IAEA EPR-First responders, 2006).
If the high levels are widespread, the monitoring team must
physically mark the location and record results before retreating to
their previous (rapidly monitored) location (5 to 10 metres back).
There they must rapidly confirm that dose rates and contamination
levels are within limits [Table F2] and report their findings to
Monitoring Control. They must then perform a detailed survey of
their present location and report the result, plus the current
cumulative dose for each member of the monitoring team, to
Monitoring Control. Monitoring Control must liaise with TIC who
must consider relocating the Safety Perimeter.
If the high dose rate or contamination is a "hotspot", the monitoring

team must physically mark the location, record the results and
report their findings to Monitoring Control. Information F.57
Initially the Safety Perimeter will be established at a radius of 400 m
F.57 Reducing the size of the Red Zone surrounding the incident. At this distance, the Safety Perimeter extends for
(ENVIRONMENTAL MONITORING TEAM, TIC) more than 2500 metres, enclosing an area greater than 500 000 m2, and
will require considerable resources to maintain. Ideally the area of the Red
If 4 or more monitoring teams are available, then monitoring should Zone should be reduced as soon as practicable.
be undertaken to determine whether the size of the Red Zone can be
120 121
reduced [Information F.57]. On completion of Instruction F.56,

Monitoring Control should deploy each monitoring team to different
points on the Safety Perimeter where ALL the dose rate and
contamination values are less than the Safety Perimeter values [Table
F2]. Then, each monitoring team should move towards the centre of
the Red Zone until they detect a dose rate or a contamination level
equivalent to a Safety Perimeter value [Table F2]. The results should
be reported to Monitoring Control who should relay them to the TIC.
TIC should consider relocation of the Safety Perimeter.
F.58 Rapid area survey within the Red Zone

Monitoring Control should review existing environmental Monitoring Control should divide areas requiring monitoring into sections
monitoring data for the Red Zone, and then specify map references using physical features such as roads, rivers and buildings where possible.
for a grid of points at which area survey monitoring is to be carried
The monitoring team may well decide to further subdivide each section for
out. A higher priority should be given to monitoring areas where monitoring using other physical features such house numbers, trees and
casualties and emergency services personnel are (or were) located drain covers.
[Information F.58].
Team members should ensure they are aware of the guidelines on
control of exposure [Section E.1], and in particular:
• The emergency worker turn-back guidance [Table E2,
Information E.5]; and
• Operational Intervention Levels (OILs) [Table E3, Information
E.8] (which apply when gamma dose rate is known).
F.59 Control of exposure

If the dose rates exceed 100 mSv/h, then the monitoring team must
immediately stop, mark the location, retreat to the previous ‘safe’
location (5 to 10 metres back), and record the result. There they
should confirm that dose rates are below 100 mSv/h and then
inform Monitoring Control, who should record the results of the
monitoring plus the cumulative dose of each member of the team.
Monitoring Control should then provide an alternative route for the
monitoring team.
Monitoring Control must consider withdrawing monitoring teams if
accumulated dose to an individual arising from the incident could
exceed 50 mSv.
122 123
F.60 Rapid area survey within the Yellow Zone

Monitoring Control should review any existing environmental
monitoring data for the Yellow Zone, and then specify map
references for a grid of points at which area survey monitoring is to
be carried out. Priority should be given to areas occupied by
emergency services personnel and other personnel responding to the
incident, and to areas being used to process members of the public.
3.3 Monitoring people for external contamination
F.61 Working with contaminated people

(PEOPLE MONITORING TEAM)
The presence of radioactive material, in any quantity, on people
should not prevent trained personnel wearing PPE from monitoring
them.
F.62 Planning
Monitoring Control should decide the monitoring procedures to be
adopted taking into account the following:
• Severity of any injuries to people requiring monitoring;
• Number of people requiring monitoring;
• Availability of decontamination facilities; and
• Availability of monitoring facilities.
F.63 Transfer of Category P1 patients to hospital

(FIRST RESPONDERS)
Casualties designated as P1 must be dispatched immediately to
hospital and will not be monitored [Section F.2.1]. Personnel
transporting a P1 casualty to hospital must be informed and must
inform hospital staff that the casualty has not been decontaminated
[Chapter I].
F.64 Decontamination and monitoring of category P2 patients

(FIRST RESPONDERS, PEOPLE MONITORING TEAM, RECORDS
TEAM)
Casualties designated as P2 should be decontaminated and if
124 125
possible monitored and the results recorded before going to hospital

[Section F.2.1]. These people may need to be moved to be
monitored. This should be performed by medical personnel.
F.65 Decontamination and monitoring of category P3 patients

(PEOPLE MONITORING TEAM, RECORDS TEAM)
Casualties designated as P3 should be decontaminated, and if
possible monitored, and the results recorded before going to a
medical facility [Section F.2.1]. These people may need to be moved
to be monitored. Some P3 casualties may be advised to return home
after being provided with advice on self-decontamination [Section
G.3], with instructions to return to a medical facility at a later time.
F.66 Monitoring people from the Red and Yellow Zones

Uninjured people who have been in the Red Zone should be
monitored and, if possible, decontaminated.
Uninjured people who have been in the Yellow Zone, but not the
Red Zone, should be monitored if resources allow.
F.67 Monitoring emergency services personnel

All emergency services personnel must be monitored, and
decontaminated if necessary, at the end of their period of duty.
F.68 Monitoring procedures

The monitoring undertaken could take place in the Public
Processing Areas [Section E.3] and will depend on resources
available and the number of people to be monitored. Priority must
be given to those considered to be the most potentially
contaminated. Results and personal information should be recorded
for each person monitored [Annex 3].
Any monitoring procedure adopted should aim to monitor and

identify all potentially contaminated people within 10 hours of the
incident occurring as the last person to be monitored may be the
most contaminated.
126 127
In the event that the number of potentially contaminated people

greatly exceeds the monitoring resource available, then the
monitoring approach must be adapted to screen people and identify
those most contaminated. Faster monitoring times, with
consequential loss in monitoring sensitivity, and the setting of
higher action level values should be considered.
Each monitoring team should consist of a monitoring officer and a

clerk to record results.
F.69 Use of portal monitors

A portal monitor is specialist monitoring equipment, capable of
monitoring more than 150 people per hour, that should be used, if
available, to categorise potentially contaminated people when:
• The contamination includes only beta/gamma emitters (or the
isotope ratios of beta/gamma emitters to alpha emitters or pure
Figure F10. Monitoring people for external
beta emitters is known). Portal monitors will not detect the contamination. Photo: HPA.
presence of pure beta or alpha contamination;
• The number of potentially contaminated people requiring
monitoring greatly exceeds other monitoring resources (either
personnel or equipment); and/or
• High action level values are permissible (portal monitors are of
limited sensitivity particularly at gamma energies below 200 Information F.70
keV).
Screening survey
Holding the survey meter probe about 2-5 cm (for alpha monitoring about
F.70 Screening survey 1 cm) away from the body, slowly move the probe at about 5 cm per
(PEOPLE MONITORING TEAM) second over the areas to be monitored. Do NOT touch any potentially
Using the method described in Information F.70, each monitoring contaminated surfaces. Pause the probe for about five seconds at
team, using hand held instruments, could monitor up to about 20 locations most likely to be contaminated and areas identified as
people per hour. This approach should be considered if: contaminated. The following areas must be monitored:
• Start with the face, top and sides of head (pause at mouth and
• Portal monitors are not available; or nose for approximately five seconds (high readings may indicate
• Alpha contamination is present (this will considerably reduce the internal contamination);
throughput of people). • Front of the neck and shoulders;
• Right hand – palm and back (pause at palm for about five
To attain the 10 hour target for indentifying contaminated people, seconds);
there should be no more than 200 people allocated to each • Left hand – palm and back (pause at palm for about five seconds);
monitoring team. and
• Back of the neck and shoulders.
128 129
F.71 Entire body scan Information F.71

Using the method described in Information F.71, entire body scans Entire body scan (see diagram below)
Holding the survey meter probe about 1 cm away from the body, slowly
require considerable monitoring resources (personnel and hand move the probe at 3-5 cm per second over the areas to be monitored. Do
held instruments). Up to 10 people can be monitored per hour per NOT touch any potentially contaminated surfaces. Pause the probe for
monitoring team. This approach should be considered if: about five seconds at locations most likely to be contaminated and areas
identified as contaminated.
• Portal monitors are not available;
• Alpha contamination is present (this will considerably reduce the
throughput of people to about 5 per hour); and/or
• Lower action levels or more precise monitoring is required.
To attain the 10 hour target there should be no more than 100
people allocated to each monitoring team.
F.72 Recording results

The data recorded should include the type of survey (portal
Figure F11. Entire body scan. Reproduced courtesy of IAEA (IAEA EPR-Medical/T, 2002).
monitor, screen survey, entire body), the average contamination
activity and any high activity values for each type of radiation To begin a body survey, the individual to be monitored should stand with
monitored on the diagram provided on the Contamination Survey their legs spread and arms extended, as shown in the diagram with palms
Sheet [Form A3.4, Annex 3]. facing forward. A consistent procedure should be followed to ensure all
the following areas of the body are monitored (see figure above):
• Top and sides of head, face (pause at mouth and nose for
F.73 Comparing measured levels (M) to Action Levels (AL) approximately five seconds; high readings may indicate internal
(PEOPLE MONITORING, RADIOLOGICAL TRIAGE, contamination);
• Front of the neck and shoulders;
DECONTAMINATION, MEDICAL TEAMS ) • Down front of one arm (pause at palms for about five seconds)
Results of external contamination monitoring should be interpreted and back up the outside;
using the procedures described in Figure F12. Measured levels of • Repeat for other arm;
external contamination should be compared with Action Levels • Across trunk working from shoulders downwards;
• Down front of one leg, over top of foot (pause for about five
given in Annex 10. The procedures are described and explained in seconds) and back up the inside of the foot and leg;
more detail in Section H.4.2. • Repeat for other leg and foot;
• Back of head;
• Back of the neck and shoulders;
F.74 Actions based on measured levels vs. Action Levels • Down back of one arm (pausing at elbow), and back up the inside;
(PEOPLE MONITORING, RADIOLOGICAL TRIAGE, • Side of trunk;
DECONTAMINATION, MEDICAL TEAMS ) • Repeat for other arm and side of trunk;
On the basis of the comparison of measured levels with Action • Across back working from shoulders downwards;
• Down back of one leg, monitor sole of shoe (pause for about five
Levels [Annex 10], the actions specified in Table F3 should be carried seconds) and back up the outside of the foot and leg; and
out. • Repeat for other leg and foot.
NOTE: P2 casualties should only be moved during monitoring by medically

qualified staff.
130 131
Information F.73 Information F.74

Table F3. Actions corresponding to the action levels of Annex 10 (also presented in Table H4
[Section H.4.1] with explanatory text).
Action Measure-
Actions
level on: ment, M
1. Remove contaminated clothing immediately.
2. Carry out urgent decontamination followed by re-
External
monitoring [Section G.2].
contami- M > ALU
3. Commence blood sampling for CBC.
nation
4. Refer individual immediately for medical assessment
[Section J.4].
5. Carry out decontamination procedures on individuals in
ALU > M > ALL
priority order [Section G.2].
6. Include in any programme of long-term follow up
ALU > M > ALL monitoring [Section K.9]. Carry out rapid initial screening
for internal contamination, in priority order.
7. Instruct individuals to return home and carry out simple
M < ALL
decontamination procedures there [Section G.3].
8. Provide information to individual on measured external
All measure-
contamination levels and any associated dose and risk
ment values
assessments1 [Annex 3 and Chapter D].
Internal 9. Carry out measurements with primary monitoring

contamina- method urgently.
tion -rapid M > ALU 10. Refer for medical assessment [Section J.4].
initial 11. Commence blood sampling for CBC and cytogenetic
screening measurements.
12. Carry out measurements with primary monitoring
ALU > M > ALL
method in priority order.
13. Consider for inclusion in any programme of long-term
M < ALL
follow up monitoring [Section K.9].
14. Provide information to individual on measured internal
All measure-
contamination levels and associated dose and risk
ment values
Internal
contamina-
15. Refer for medical assessment [Section J.4].
tion
M > ALU 16. Commence blood sampling for CBC and cytogenetic
-primary
measurements if not already started.
monitoring
method
ALU > M > ALL
monitoring [Section K.9].
M < ALU
All measure-
ment values
Notes.
1. Information provided will depend on the Action Level band in which the measurement value falls.
Figure F12. Recommended procedures for external contamination monitoring (also presented in
Figure H2 [Section H.4.2] with explanatory text).
132 133
3.4 Monitoring people for internal contamination
Information Section 3.4.1

Introduction Body measurements
Rapid measurements of activity in the bodies of people possibly internally
After incidents which result only in external exposure to radiation, no contaminated are needed to separate people not contaminated from those
contamination monitoring of people is needed. In case of suspected contaminated.
internal contamination, screening should be done. The purpose of the
Direct measurements methods for internal contamination that can be
initial screening, with field survey equipment, is to classify people
conducted close to the scene during the first 48 hours are:
according to their levels of internal contamination as a guide to decisions
on further action. The preliminary screening and classification should be • Measurements with dose rate monitors;
performed in an area appropriate to the potential demand, and large • Whole-body measurements with hand-held scintillation probes;
• Thyroid measurements with hand-held scintillation probes;
enough to permit adequate separation of people awaiting initial • Portal monitors; and
monitoring, being monitored, and awaiting transfer for further • Portable or transportable body monitors.
assessment. Space for temporary collection and storage of contaminated
Such monitoring equipment should be efficiency-calibrated in advance to
clothing should also be available. A tented area in the Yellow Zone, or be ready to use in case of emergency. If more than one device is available
public facilities such as sports centres and arenas, are likely to be suitable the devices should be checked against each other. The calibration
if a large group of people has to be handled. For a small group, a efficiency should be checked once a year or according to local quality
basement or cellar close to the incident area can be used. The availability assurance procedures for example for 60Co, 131I and 137Cs [Annex 8].
of showering and/or washing facilities and good exit route for those sent
home would be an advantage. Information F.75
Location of facilities
3.4.1 In vivo monitoring The environmental background is often highly variable and must be taken
(CONTAMINATION INCIDENTS) into account in data analysis. The measurement technique should be quick
and convenient, to ensure cooperation and to avoid anxiety among those
monitored. The monitoring equipment should be sited where the levels of
F.75 Choice of measurement area natural background radiation are not unusually high, and where levels
(PEOPLE MONITORING TEAM) have not been unduly enhanced by contamination from the incident. The
Establish availability of equipment and facilities for monitoring. monitoring facilities needed to carry out the actions illustrated in the
Choose a closed (or tented) area large enough to permit adequate flowchart [Figure F15] do not necessarily have to be located in the same
separation of people awaiting initial monitoring; being monitored; building or perhaps not even in the same area of a town or city [Figure
F12].
awaiting transfer for further assessment; and also large enough to
permit for temporary collection and storage of contaminated A major consideration is to remove external contamination to prevent
clothing and other belongings. further internal contamination of the people being measured and to
reduce errors in assessment of the internal contamination. The equipment
F.76 Extra external screening should be used with due regard to the possibility of errors resulting from
external contamination (IAEA TECDOC 746, 1994, Section 3.2), either of
the subject or of the immediate environment. The background response of
If the external contamination monitoring shows upper body the instrument should be recorded both prior to, and periodically during,
contamination, perform another external screening survey after the daily monitoring programme.
removing outer clothing.
134 135
F.77 First steps in monitoring for internal contamination

(PEOPLE MONITORING TEAM) Information F.77
1. Staff should be dressed in disposable coveralls and gloves. Control of surface contamination
Provide also disposable gloves if there are no facilities for Account must be taken for monitoring procedures, particularly in the
washing hands. initial screening, of the possibility of spurious assessments because
2. People coming for internal contamination monitoring should subjects have imported loose surface contamination, and precautions are
required to ensure ready removal of such contamination if it occurs
have been decontaminated. If this has not been done then they [Information G.2]. The initial screening should take place in an enclosed (or
should at least remove their outer clothing and shoes. Storage at least tented area) with replaceable surfaces, which subjects would enter
facilities for contaminated clothes and shoes should be after removal of shoes. The monitoring probe should be protected from
contamination and staff should wear disposable clothing. The discarded
prepared. clothing should itself be monitored, and if found to be unacceptably
3. Separate from all others those persons with upper body contaminated for further everyday use, it should be put in plastic bags
contamination, particularly the shoulder, head and hair. Assume and held in a separate, designated area pending disposal. Clothing
contaminated at lower levels, may need to be withheld from subjects
that a person is not likely to have received a significant internal referred for more rigorous assessment.
dose from inhalation without presenting gross external
contamination at triage. These persons are the most likely to be Handling of people to be measured
Remember that it is important to handle the persons coming for
internally contaminated. Assume that individuals with measurement calmly and kindly. They are probably more concerned than
contamination only on lower portion of the body crossed the you. Don’t show your worry, don’t talk too much, concentrate on what you
contaminated zone, but were not exposed to the passing plume are doing and explain briefly why. Bear in mind this might be the first
opportunity the subject has had to talk to someone. Make sure the teams
and did not inhale high airborne radioactivity concentrations. are well briefed and are aware of where more information can be found
People with significant upper body contamination may require [Section F.4 and Section K.8] .
evaluation for follow up medical treatment because they may
have inhaled excess amounts of radioactive material (Musolino Keep in mind the risk of contamination; avoid contamination of floors,
seating places, and instruments. Use common sense in the strange
& Harper, 2006). In case of oral intake via contaminated food environment.
or drink the instructions below are also valid.
4. In case of radioiodine contamination thyroid measurements
should be made [Instruction F.80]. Portal monitors as well as
portable or transportable body monitors would be useful for
body counting if accessible [Instruction F.69]. Information on
measurement sensitivities are given in Annex 8, Tables A8.1,
A8.2 and A8.3.
F.78 Monitoring with dose rate instruments

The initial survey can be done with hand-held scintillation probes
or dose rate monitors without any knowledge of the radionuclides
involved. Responders arriving at the scene from elsewhere could be
used as assumed uncontaminated background reference persons.
136 137
Especially with a large group of people, 100 persons or more,

waiting to be measured a standing position or a geometry with the Information F.78
subject sitting in a chair and the monitoring team member doing the Example of dose rate indication and dose
measurement holding the dose rate instrument should be adopted: To illustrate, in the case of 137Cs, level A, corresponding to a committed
effective dose (E50) of 0.5 mSv, would be 4 x 104 Bq. Several days after
1. Choose a suitable area for the monitoring with as low intake, this would give an indication of about 0.05 μGy/h on a survey
background radiation as possible. meter placed 1-2 cm from the body. Under typical conditions, this is
2. Prepare the monitoring equipment. Ensure that the person roughly equivalent to a 50 % increase compared to the background. Level
monitoring is familiar with the instrument. B, corresponding to an E50 of 50 mSv, would be 5 x 106 Bq, resulting in a
dose rate under equivalent conditions of 5 μGy/h. The arbitrarily chosen
3. Register the person to be monitored (example registry form in decision level in this example, A’ = 0.5 mSv, may be unnecessarily
Annex 3). restrictive. Such a conservative approach allows for the large uncertainties
which exist in the actual correspondences between A’ and the estimated
4. Cover the instrument and the chair with uncontaminated plastic
value of A (and between B’ and B). These relationships would depend not
or other material that can be easily changed between each only on factors relating to the measurement, but also on aspects of the
measurement. individual’s metabolism, the circumstances of the intake, and where a
5. Start the measurement, record the result and fill in the registry mixture of radionuclides was present, on its composition. Moreover, there
may be situations in which a given level of internal contamination,
form.
insignificant in itself, implies the possibility of significant external
6. Do a background measurement on a non-contaminated person, irradiation. In practice, the initial choices of decision level A’ and B’, or the
if possible. action levels A and B derived from them, may need to be reviewed
according to the measurement range of available equipment and the
7. Advise the monitored person on suitable follow up actions.
capacity of the more rigorous monitoring arrangements in relation to the
demands made on them (IAEA TECDOC 746, 1994).
F.79 Whole-body measurements of high energy gamma emitters
with simple equipment
Information F.79a
The measurement geometry used could be the so-called lap
geometry if the number of persons to be monitored is limited to less
than 100 people. If there is a large group of people awaiting
measurement, a standing or sitting position should be adopted with
the person doing the measurement holding the detector:
1. Choose a suitable area for the monitoring with as low a level of
background radiation as possible. If this is not possible out-
doors try a building with high shielding factor, a basement or
cellar. The facility should be large enough to make it possible to
arrange separate waiting and monitoring rooms.
2. Arrange the facility for measurement and for handling the
people to be measured. Establish waiting room and monitoring Figure F13. "Lap geometry" for whole body measurement with portable gamma
areas that should be kept free of contamination. Cover chairs spectrometer. This photograph illustrates the method, but when responding to an
with plastic or other material that can easily be changed. incident, additional measures would need to be employed, i.e. the detector would be
wrapped in plastic film, and the subject would wear disposable gloves. Photo: STUK.
138 139
3. Prepare the monitoring equipment. Preferably use NaI or CsI

detector. Ensure staff are familiar with the instruments. Information F.79b
4. Switch on the monitor. Monitoring with hand-held instruments
The minimum detectable amount (MDA) in this type of measurement is
5. Set a suitable time for measurement (100 seconds or the about 1–2 kBq for 137Cs (± 50 %) (Zvonova et al, 1995). The uncertainty
standard for the monitor used). depends partly on the position of the person and partly on the
6. Fill in the name of the person and other data indicated in the background to some degree shielded by the body of the person. Since the
measurements often are performed in environments with enhanced
registry form [Annex 3].
background the actual background in the person measurement might be
7. Cover the detector with a new plastic bag between each difficult to estimate. Comparisons with regular whole body counting
measurement. measurements have shown satisfactory agreement and the method is
useful when remembering the corrections that have to be made and the
8. Start the measurement, record the result and fill in the registry limitations involved.
form.
9. Do a background measurement on a non-contaminated person,
if possible. Record all details in the measurement protocol.
10. Always check that the form is completed correctly.
11. Inform the person monitored about the result and give her/him
the information leaflet "Information for people monitored and/
or decontaminated" [Annex 3].
12. Advise the monitored person on suitable follow up actions.
Information F.80
F.80 Thyroid monitoring with hand-held instruments

1. Choose a suitable area for the monitoring with as low a level of
background radiation as possible. If this is not possible
outdoors, try a building with high shielding factor, a basement
or cellar. The facility should be large enough to make it possible
to arrange separate waiting and monitoring rooms.
2. Arrange facility for measurement and for handling the people
to be measured. Establish waiting room and monitoring area
that should be kept free of contamination. Cover chairs with
plastic or other material that can easily be changed.
3. Prepare the monitoring equipment. Preferably use NaI or CsI Figure F14a. Measurement of 131
I in the Figure F14b. Background measurement to be
detector. Provide instrument manuals. thyroid. used for the thyroid measurement of a
person. This is important for later dose
4. Switch on the monitor. Photos: STUK. assessment.
5. Set measuring time (100 seconds or the standard for the These photographs illustrate the method, but when responding to an incident,
additional measures would need to be employed, i.e. the detector would be wrapped in
instrument used). plastic film, and the subject would wear disposable gloves.
140 141
6. Do an environmental background measurement.

7. Do a reference measurement on a non-contaminated person, if
possible.
8. Register the name of the person to be monitored and other
information indicated in the registry form [Annex 3].
9. Shield the detector with a plastic bag which should be replaced
after each measurement.
10. Keep the detector close to the persons neck when performing
the thyroid measurement [Figure F14a, Information F.80].
11. Perform a background measurement, asking the person to keep
the detector resting on the thigh as shown in Figure F14b in
Information F.80.
12. Record the results and fill in the registry form.
13. Check that the form is completed correctly.
14. Inform the person monitored about the result.
15. Advise the person on suitable follow up actions.
3.4.2 In vitro monitoring Information Section 3.4.2

(CONTAMINATION INCIDENT) Bioassay
Indirect bioassay is the determination of the type, quantity, location and/
or retention of radionuclides in the body by in vitro analysis of material
F.81 Samples excreted or removed from the body. The primary use of bioassay
(TIC, PEOPLE MONITORING TEAM) procedures is to determine whether an individual has been exposed to
Samples that can be used for bioassay are: urine, faeces, nose blow radioactive material in a manner that resulted in internal deposition and, if
or blood, and in special cases, teeth, hair, nails or saliva. Only nose so, to quantify the magnitude of that deposition and its dosimetric
blow/nasal swabs can be taken at the scene of the incident. For consequences (NCRP Report 87, 1987).
other samples, additional expertise is needed. For sampling, contact For a particular sample, the method of analysis depends primarily on the
a health care centre, hospital or other organisation routinely taking emissions available for detection. If only particulate emissions are
and handling excreta and blood samples. For analysis of the available (α or β particles), or the yield or energies of any photon emissions
samples, special laboratories are required. The sampling procedures are very low, these radionuclides may first need to be separated from the
are described in Annex 11. sample matrix to achieve good and reproducible detection. In the case of
urine (or other liquid) samples, however, direct dispersion of a small
volume of the sample into a liquid scintillant may be sufficient.
F.82 Nasal swabs and nose blow samples
(PEOPLE MONITORING TEAM) Radionuclides emitting penetrating photons can, in general, be quantified
For survey of persons at or close to the scene of an incident nasal in bulk samples. Although these radionuclides may also be detectable in
swabs can be taken outside the Red Zone or for example at the the body, by direct counting, detection in excreta may be more practical
Radiation Monitoring Unit if it is already established [Information or the only possibility if direct monitoring is not available.
142 143
E.45]. The activity detected in the swabs can be used to estimate Information F.85
intake by inhalation. Lung contamination is estimated to be about 5
% of total radioactivity measured from swabs of both nasal cavities,
but the estimation is rather uncertain. The swab collection should
be done before nasal decontamination, sneezing etc. If activity is
found only in one nostril the contamination is probably non-
respiratory. Swabs must be dry when surveying for alpha emitters.
During a large contamination event, there will not be time to do
analysis by nasal swabs, but instead nose blow could be used for
screening purposes [Annex 11].
F.83 Urine samples

The method for collection of urine samples depends on the aim of
measurement, e.g. whether it is for confirmation of internal
contamination (spot sample) or for dose assessment purposes (24
hour sample) [Annex 11].
Contact a suitable organisation, health care centre or other

organisation routinely taking and handling excreta samples, and
arrange the procedure for sampling. Contact a laboratory, or if it is
a mass casualty event, more than one laboratory able to analyse the
samples for the radionuclides of concern may be required. A spot
sample is enough for confirmation of internal contamination, but
for dose assessment purposes 24 hour samples should be used
[Instruction J.24].
F.84 Faecal samples

Contact a suitable organisation, health care centre or other
organisation routinely taking and handling excreta samples, and
arrange the procedure for sampling. Contact a laboratory, or if it is
a mass contamination event, more than one laboratory that is able
to analyse the samples for the radionuclides of concern may be
required. The usual faecal sample is a single voiding, but for dose Figure F15. Recommended procedures for internal contamination monitoring (also
presented in Figure H3 [Section H.4.3.3] with explanatory text).
assessment purposes, faeces should be collected for a period of 2-3
or even 5 days. Consult a dose assessment specialist for advice
[Instruction J.24].
144 145
Chapter F Triage and monitoring for the purpose of screening Instructions Information 4 Advice on dealing with psychological issues
F.85 Comparing measured levels (M) to Action Levels (AL)

(PEOPLE MONITORING, RADIOLOGICAL TRIAGE, MEDICAL
TEAMS )
Results of internal contamination monitoring should be interpreted
using the procedures described in Figure F15. Measured levels of
internal contamination should be compared with the Action Levels
given in Annex 10. The procedures are described and explained in
more detail in Section H.4.1.
F.86 Actions based on M vs. AL

(PEOPLE MONITORING, RADIOLOGICAL TRIAGE, MEDICAL
TEAMS)
On the basis of the comparison of measured levels with Action Information F.88a
Levels [Annex 10], the actions specified in Table F3 [Information
Section K.8 summarises the main issues relating to the management of
F.74] should be carried out.
psychological impact in radiation emergencies, but does not provide
prescriptive guidance. Section F.4 presents brief guidelines for teams
working in the field on dealing with psychological impact.
4 Advice on dealing with psychological
issues
Information F.88b
F.87 Staff roles A radiation emergency resulting from a malevolent act is a highly stressful
event. It may act as a powerful and persistent stressor even after the
(MEDICAL TEAM) emergency has been controlled. Psychological reactions following
One or more members of the medical team should be assigned to man-made disasters, such as malevolent acts, are more intense and more
dealing with psychological effects on people affected by the prolonged than psychological reactions following natural disasters. They
incident. Ideally, they should have received training for this role. may include multiple symptoms like fear, grief, anxiety, anger, depression
Other staff working in the field should not be diverted from their and distrust. Psychosomatic symptoms are frequent and differential
diagnosis and treatment of physical and psychological conditions will be
main responsibilities in an attempt to deal with the psychological
essential during the early stage of the event, including the triage of
impact of the event on individuals. Instead, people affected in this people.
way should be referred to the member(s) of the medical team
assigned to this task. Ionising radiation cannot be perceived by the senses and most people are
not familiar with the magnitude of its effects, which could result in
F.88 Initial psychological effects community-wide feelings of helplessness and vulnerability. Disasters with
a high degree of uncertainty regarding the potential of future health
(ALL TEAMS) effects are more psychologically traumatic than situations with more
Staff whose duties bring them into contact with members of the visible, immediate, and predictable outcomes. Moreover, the fact that the
public should be aware that any event dealt with by this Handbook control of the situation is normally in the hands of the government (i.e.
may result in adverse psychological effects in the people they are out of citizens’ hands) increases the degree of feelings of vulnerability in
dealing with. These staff should make themselves familiar with the the population. Emotional reactions may affect both casualties and
responders, and these reactions may be so intense and severe that they
contents of Section K.8. They should be alert to the possible initial
could even affect decision-making and operations.
reactions of people involved in the incident. These could include
146 147
Chapter F Triage and monitoring for the purpose of screening Instructions Information 4 Advice on dealing with psychological issues
disbelief, bewilderment, stupefaction, fatigue, impaired

concentration, emotional numbing and social withdrawal.
F.89 Role of the medical team

(MEDICAL TEAM)
Assigned staff from the medical team should attempt to calm and
reassure individuals who are experiencing adverse psychological
effects. In the longer term, affected people should be advised to
contact their family doctor, who may decide to refer them for
specialist help.
F.90 Dealing with members of the public

Staff whose duties bring them into contact with members of the
public should have good interpersonal skills. They should
communicate with people calmly and openly, but should focus on
their primary duties and not engage in conversation unnecessarily.
They should take care to use language that is understandable by the
layman, and avoid technical jargon. Communication should be
two-way; staff should spend time listening as well as speaking.
They should avoid transmitting any concerns or anxieties they may
have themselves. If asked, they should communicate objective
information about the incident, or about measurements they are
performing on the individual, whenever possible. Information
provided should be accurate; providing inconsistent information
will act to reduce confidence. Information relevant to the health of a
particular individual should not be withheld from that person; such
actions will only act to reduce their confidence in the organisations
responding to the incident. On the other hand, if staff do not have
the information needed to respond to a particular query, they should
say so. Taken together, these measures should have the effect of
reducing the general level of stress and anxiety.
148 149
Information Decontamination of people in the field
CHAPTER G Information G.1
Decontamination of people in the

field
Introduction
Decontamination of people described in this section refers to the
removal of radioactive contamination and not removal of chemical or
biological material.
People who have only been externally irradiated do not require
decontamination.
People involved in an incident where radioactive material is present in
the environment will be prioritised for decontamination using the
procedures detailed in the triage section [Section F.2].
Contamination with radioactive materials is not immediately life
threatening. Decontamination should be carried out as soon as possible,
but does generally not require the same immediacy as chemical or
biological contamination, except in extreme circumstances where the
contamination is sufficient to cause deterministic effects [Section H.4].
Decontamination of injured people will take place either in hospital or
adjacent to the incident, depending on the severity of injuries; details
are given in the section on triage and monitoring [Chapter F].
Figure G1. Flowchart for decontamination of people.
150 151
Chapter G Decontamination of people in the field Instructions Information 1 Preparations for decontamination of people
1 Preparations for decontamination of

Information Chapter G
people
Contamination
Decontamination procedures are straightforward; removing clothing and
(CONTAMINATION INCIDENTS) washing the body with soap and water will eliminate most external con-
tamination. Removal of outer clothing, without washing may reduce con-
G.1 Strategy tamination by 80-90 %.
(TACTICAL INCIDENT COMMAND [TIC], DECONTAMINATION
TEAM) Cross-contamination (spreading of contamination from person to person)
is a secondary concern, especially when the contaminated area or the
1. The decontamination team should work according to the affected population is large.
strategy summarised in Figure G1. The details of the strategy
depend on:
• Severity of injury to people requiring decontamination;
• Number of people requiring decontamination; and
• Availability of decontamination facilities.
The instructions in this section explain how to carry out the

strategy.
2. If necessary, inform Decontamination Team members that

Information G.1
concerns about their own radiation exposure resulting from
cross contamination must not prevent people decontamination The values in the table below can be used to give an upper bound on levels
procedures from taking place. of contamination on surfaces (including survivors).
3. If the wait for decontamination exceeds 2 hours, or is likely to Table G1. Potential surface contamination from a RDD from a large radioactive sourcea.
exceed 2 hours, then additional decontamination facilities Radionuclide

Surface contamination (GBq m-2)
should be introduced, or the method of decontamination 10 kg HEb (9-270 m)c 100 kg HE (19-550 m) 1000 kg HE (40-1200 m)
revised.
60
Co 4.8 - 780 1.6 - 230 0.56 - 170
4. If the number of people requiring decontamination, or the lack

137
Cs 33 - 7400 7.4 - 3300 1.5 – 1700
of decontamination facilities, would mean decontamination

90
Sr/90Y 11 -1900 3.5 - 520 0.81 - 350
would be delayed by more than 2 hours, uninjured people with a

The radioactive sources are of the order of 106 GBq. The intention is to provide a
a low priority for decontamination [Section F.2] can be realistic upper bound for contamination of surfaces from a maximum credible
event.
encouraged to go home and self-decontaminate [Section G.3]. If b
The quantity of high explosive (HE) designated is not the quantity used in the
possible transport should be provided to reduce the spread of C
device, but rather is used to establish the range of probable survivability only.
The range of distances from closest for survivability to safe stand-off.
contamination.
Adapted from Smith et al, 2005.
G.2 Location of decontamintation facilities
(TIC, MEDICAL TEAM, DECONTAMINATION TEAM)
1. If injured people are sent to hospital before being
decontaminated, then the receiving medical facility must be
152 153
Chapter G Decontamination of people in the field Instructions Information 1 Preparations for decontamination of people
informed they will be receiving potentially contaminated

casualties.
(TIC, DECONTAMINATION TEAM)

2. Decontamination of casualties who do not require urgent
medical attention, and of uninjured people who are evacuated
from the Red Zone, should be carried out in the Yellow Zone at
the People Processing Area [Section F.2 and Section E.3].
3. Decontamination of casualties who do not require urgent medical
attention, and of uninjured people who have self evacuated from
the Red Zone to outside the Security Perimeter, should be carried
out in a building in, or near, a Reception Centre [Section F.2],
located outside the Security Perimeter. This Reception Centre must
meet the specification given in Information E.45.

4. Decontamination facilities outside the Security Perimeter
should be monitored, prior to use, to ensure dose rates are close
to natural background levels [Information E.45].
G.3 Requirements before decontamination can take place

(TIC, DECONTAMINATION TEAM)
1. Replacement clothing must be available in sufficient quantities
before decontamination can commence, except where doses
sufficient to produce deterministic effects are possible; under
these circumstances decontamination is urgent. Blankets or
similar should be provided if replacement clothing is not
immediately available.
2. A one-way system should be established so that people in need
of decontamination do not come into contact with those people
who have been decontaminated. Areas for decontamination
must have separate entrance and exit points.
3. Warm water should be used in showers. Cold water can be used
if the air temperature is above 20 °C, or medical advice has been
given that the risk from hypothermia is negligible.
4. While decontamination is taking place it will be necessary to:
• Keep families together;
• Where possible respect cultural and gender differences;
• Assist people with medical problems; and
154 155
Chapter G Decontamination of people in the field Instructions Information 2 Decontamination procedures
• Answer questions relating to radiological protection

[Annex 3].
5. Personnel carrying out decontamination procedures must wear
appropriate PPE [Section E.1].
6. If possible, clothing should not be removed over the head.
However, with the exception of people in triage category P2,
there is no need to remove clothing by cutting.
2 Decontamination procedures
2.1 Instructions common to all decontamination

procedures
G.4 Common instructions for decontamination

(DECONTAMINATION TEAM)
1. People awaiting decontamination should be advised not to eat,
drink or smoke and keep hands away from mouth, until
decontamination procedures are complete.
2. While people are waiting for decontamination, they should be
given moist wipes with instructions for washing the face and
hands. Bags for disposal of used wipes must be provided.
3. Plastic bags for valuables (keys, wallet, prescription medicines
etc.) must be provided for all people, before they are
decontaminated. These should accompany the person
throughout decontamination procedures.
(DECONTAMINATION TEAM, RECORDS TEAM)

4. A registration form for each person must be completed (an
example form that can be customised is provided in Annex 3).
This should include a reference to the clothing bag, perhaps by
using a bar code.
5. People undergoing decontamination procedures must be issued
with information on where to get further information and
instructions when released [Annex 3].
6. If possible, a receipt should be issued for contaminated clothing.
156 157
(PEOPLE MONITORING TEAM, DECONTAMINATION

TEAM)
7. Move potentially contaminated items to a secure store at
regular intervals.
8. The effectiveness of people decontamination must be confirmed
by monitoring [Section F.3]. The number of people monitored to
confirm effectiveness will depend on availability of monitoring
resources. Decontamination should not be slowed down due to
the lack of resources to monitor decontamination effectiveness.
2.2 Decontamination using specialist mass

decontamination facilities Information G.5
Specialist mass decontamination equipment
G.5 Procedures These are usually temporary buildings or enclosures containing shower
(DECONTAMINATION TEAM) facilities; an example is shown in Figure G2. The procedures used for this
Procedures may vary depending on the individual specialist mass type of equipment are similar to that described in [Section G.2.4]. Typically
decontamination facilities available. Procedures to be followed will the units can be erected in minutes and are capable of decontaminating up
be similar to those for "Decontamination of small numbers of to 100 people per hour. The units consist of three sections, an area to
disrobe, a shower area using warm water, and a re-robe area. In some
people" [Section G.2.4]. Assistance for injured people will be
units, non-ambulant casualties can be decontaminated on stretchers, but
required. at a much lower rate (10 casualties per hour).
2.3 Decontamination procedure for people in trauma Ideally, the correct percentages of detergent should be mixed with the
water before these facilities are used, but plain water can also be used.
triage group P2
G.6 Staffing
(MEDICAL TEAM)
1. As people in this category are injured, this procedure must only
be carried out by medically trained personnel.
2. Teams of at least 2 people are required for each patient. Explain
what you are going to do, before you start and as you proceed, as
this will be an unpleasant, frightening procedure for most people.
G.7 Disrobing procedure

(MEDICAL TEAM)
Remove/cut off clothing, do not pull clothing over the head.
1. If clothing is adhering to the skin, soak with water until
clothing can be separated from the underlying tissue to avoid
Figure G2. Example of a specialist mass decontamination unit. Photo: HPA.
damaging the skin.
158 159
2. Fold clothing outside to middle and place in a large labelled

plastic bag.
3. Spectacles should be washed, dried and returned to the patient,
hearing aids should be wiped thoroughly with saline-moistened
gauze and returned to the patient.
G.8 Washing procedure

(MEDICAL TEAM)
1. Step 1: Gently wash affected areas with soap and water (5 ml
per litre), and use saline for open wounds and the surface of the
eyes.
2. Step 2: Wipe affected areas gently but thoroughly with sponge
or soft brush (DO NOT abrade the skin).
3. Step 3: Rinse affected areas.
4. Decontaminate the face first and sites needed for intravenous
access.
5. Next, irrigate any open wounds with saline and cover with a
dressing.
6. Then, working from hair/head to toes, pay special attention to
skin folds and creases, nails, ears and legs, and other areas
Figure G3. Mobile decontamination unit. Photo: Norwegian Civil Defence.
which were not covered by clothing. If possible, roll patient
onto their side to reach their back.
7. Eyes: if contact lenses are present, remove if possible without
harm; use topical anaesthetic if needed; flush eyes copiously
with saline.
8. Dry and clothe patient.
2.4 Decontamination of small numbers of people
G.9 Strategy
1. If the number of people requiring decontamination is less than
around 100, the following procedure should be used, as this is
likely to be more effective than procedures which do not use
showering.
2. The decontamination facility should be established in an area
with showering facilities, ideally with separate areas for males
and females.
160 161
G.10 Procedure
Provide each person with instructions to:
1. Remove all clothing and place it in a plastic bag, which should
then be tagged and sealed.
2. Gently blow nose and wash out eyes and ears.
3. Shower thoroughly with warm (not scalding hot) water and
soap, allowing the water to run away from the face. Wash hair,
but do not use hair conditioner as this would fix the
contamination to the hair.
4. Use the mechanical action of flowing water and/or a cloth,
sponge or soft brush.
5. Avoid causing mechanical, chemical or thermal damage to the
skin.
6. Change into clean clothing. Figure G4. Demonstration of decontamination of people who need assistance. Photos:
HPA.
Wash out shower between people.
2.5 Decontamination of larger numbers of people
G.11 Strategy
These decontamination procedures should be used when the number
of people requiring decontamination exceeds the capabilities of the
procedure for decontamination of small numbers of people [Section
G.2.4].
G.12 Procedure
Provide each person with instructions to:
1. Remove all clothing and place it in a plastic bag, which should
then be tagged and sealed.
2. Gently blow nose.
3. Wash face and hands with water or a damp cloth.
4. Change into clean clothing.
5. Follow procedure for decontamination at home when released
[Section G.3)].
162 163
Chapter G Decontamination of people in the field Instructions Information 3 Self-decontamination at home
3 Self-decontamination at home
G.13 Strategy
(CONTAMINATION INCIDENTS) (TIC)
1. For incidents involving large numbers of people, the uninjured
and people in category P3 can be encouraged to go home and
self-decontaminate providing they are assigned a low priority in
the triage process, and may be monitored at a later date. It is
also likely that some people will self-evacuate and return to
their homes, and these people must also be instructed to follow
this procedure.
2. Guidance must be given to this population through the media
(television, newspapers, teletext, radio, or telephone/internet
based healthcare service e.g. NHS Direct in UK) on what to do
and how to perform their own decontamination. This guidance
should include the following:
• Explain that, like dirt, most contamination washes off with
soap and water. They should be advised to act as if they
were going home in clothes covered with mud and did not
want to spread it into their homes; and
• Provide instructions for them to:
- Undress at the external doorway or in their garage
- Remove clothing and place it in a plastic bag which
should then be sealed and placed in a store, away from the
living areas
- Gently blow nose and wash out eyes and ears
- Shower or bath thoroughly with warm (not scalding hot)
water and soap, allowing the water to run away from the
face. Wash hair but do not use hair conditioner as this will
fix the contamination to the hair
- Use the mechanical action of flowing water and/or a cloth,
sponge or soft brush
- Avoid causing mechanical, chemical or thermal damage
to the skin (e.g. scrubbing to hard)
- Change into clean clothing
- Wash out bath or shower
- Wash car if they drove home from the area of contamination
- Tune in to television or radio for further instructions.
164 165
Chapter G Decontamination of people in the field Instructions Information 4 Contamination control
3. The bagged clothing is not likely to be heavily contaminated,

but it may form a source of irradiation for the public. There may
be a need for later contamination monitoring of the clothes. A
course of action will need to be decided after the radiological
assessment of the incident. It may be possible to return clothing
to use after laundering, but it may also be necessary to treat it
as radioactive waste.
4 Contamination control
G.14 (DECONTAMINATION TEAM, ENVIRONMENTAL MONITORING

TEAM)
Personnel carrying out decontamination procedures must be
monitored for contamination every hour. If contamination is found
on clothing it must be changed. If contamination is found on the
skin, then staff must go through the decontamination procedure.
Decontamination facilities must be monitored every hour for
contamination [Section F.3.3].
5 Waste considerations
G.15 (TIC, DECONTAMINATION TEAM)

Figure G5. Remember to monitor personnel for
1. Equipment used for decontamination, in particular sponges, contamination. Photo: Norwegian Civil Defence.
towels, brushes etc. should be stored for eventual safe disposal.
2. Do not attempt to contain contaminated water. Alert relevant
authority that contaminated water has been discharged.
166 167
Information 1 Objectives of individual monitoring
CHAPTER H
Monitoring for dose assessment

purposes
1 Objectives of individual monitoring Information Section H.1
The term “monitoring”, sometimes also known as “radiological Definitions of radiological monitoring
These definitions are adapted for the specific case of monitoring in the
monitoring”, describes the measurement of radiation dose or
event of an incident involving the malevolent use of radiation or
contamination for reasons related to the assessment or control of exposure radioactive material from the IAEA's safety glossary (IAEA STI/PUB/1290,
to radiation or radioactive material, and the interpretation of the results. 2007).
Individual monitoring is monitoring using measurements of quantities of
radioactive material in or on the body of the individual, or measurements
made by equipment worn by individual workers. It includes the
assessment of radiation doses to the individual from the results of such
measurements. In the present context, the objectives of individual
monitoring are closely associated with the objectives of triage described
in Section F.1. The main objectives are:
1. To quantify absorbed doses to organs and tissues for people
exposed to radiation or radioactive material at a level high enough
to potentially give rise to deterministic health effects.
2. To provide the dosimetric information that would allow urgent
decisions to be made to remove individuals from a source of external
exposure, or to remove or reduce contamination on or in the body.
3. To quantify committed effective doses for people with lower levels
of internal contamination that could result in an elevated risk of
stochastic health effects.
4. To provide dosimetric information that could be used when making
decisions on medical treatment for the groups of people identified in
objectives 1 and 3.
5. To quantify committed effective doses for people whose exposures are
very unlikely to have an effect on health, or who were not exposed at all.
Secondary objectives include the prevention of further exposures, the
provision of information to individuals on their levels of exposure, and
the provision of information to the appropriate authorities on the
radiological consequences of the incident.
168 169
Chapter H Monitoring for dose assessment purposes 2 Specifying a monitoring strategy
2 Specifying a monitoring strategy
This section does not specify the monitoring strategy itself, because this
Introduction
will depend on information that will only become available as the
What is a monitoring strategy? incident progresses. Rather, it details the steps that need to be carried out
to develop the monitoring strategy. The strategy may be implemented by
In the initial stages of the response, there will be little time to carry out making use of the material in Section F.3, Section H.3, Section H.5,
detailed planning of the response, and minimal information on which to Section H.6, Annexes 6-10 and Annex 13. The use of monitoring
base such plans. Anticipating this, Chapters E, F and G describe actions information to make radiological triage decisions, including on the need
that can be implemented automatically without the need to develop for further monitoring, is described in Section H.4.
detailed plans that are specific to the incident.
After these initial actions are under way, perhaps after 24-48 hours have A monitoring strategy is part of the public health response. It does not
passed, there will be time to develop a monitoring strategy. This is a address the monitoring necessary for individuals who may be at risk of
general plan for the radiological measurements and assessments needed to developing deterministic health effects.
provide the necessary information on actual or potential effects on health. Actions should be carried out by the TIC in collaboration with the relevant
The plan will take into account the specific characteristics of the incident, team leaders.
and the information received as a result of the initial stages of triage and
monitoring.
Topics addressed by a monitoring strategy are:
• Identification and characterisation of radionuclide(s);
• The people to be monitored;
• Where individual monitoring should be carried out;
• The individual monitoring methods to be employed;
• When individual monitoring should be carried out;
• Action levels to trigger the various actions to be performed after
individual monitoring;
• Long-term follow up monitoring; and
• Recording and reporting of monitoring results.
170 171
Chapter H Monitoring for dose assessment purposes Instructions Information 2 Specifying a monitoring strategy
H.1 Incident status

Information H.1
(TIC)
If any of the stages described in Information H.1 have not yet Incident response status
commenced, refer to Chapters E, F, G. It is assumed that the following have been established or are well
advanced at the point at which development of the monitoring strategy is
initiated:
2.1 Identification of radionuclide(s) 1. It has been established whether or not the incident has resulted in:
• trauma injuries;
• distribution of radioactive contamination; and/or
H.2 Dispersed radionuclides • exposures that could result in deterministic health effects.
2. Initial zone boundaries have been established.
All contaminant radionuclides dispersed into the environment as a
3. Gamma dose rates and contamination levels (of alpha, beta and gamma
result of the incident must be identified. emitting radionuclides) within the Red and Yellow Zones have been
mapped.
H.3 Irradiation source 4. Trauma triage is complete or well advanced.
(EXTERNAL IRRADIATION INCIDENTS) (TIC) 5. Radiological triage based on information on location is in progress.
The radionuclide(s) present within an irradiation source must be 6. Radiological triage based on clinical signs and symptoms is in progress.
identified. It would probably be a high yield gamma-ray emitter and 7. Initial monitoring of people for external contamination is in progress,
therefore easily identifiable using a portable radionuclide detector. but internal contamination monitoring has not yet commenced.
8. Decontamination of some individuals is under way.
2.2 Characterisation of source
Some elements of the response may be more advanced than described
here. This should not affect the development of the monitoring strategy.
H.4 Temporal variation
(TIC)
Information H.2
Any temporal variation of gamma dose rates and contamination
levels (of alpha, beta and gamma-emitting radionuclides) within the Radionuclide identification must be performed to enable internal doses
to be assessed and to inform decisions on decorporation. Gamma-emitting
Red and Yellow Zones should be quantified. This will require a
radionuclides (e.g. 137Cs, 60Co) may be easily identified using a portable
programme of regular area surveys to be carried out, until the radionuclide detector. Use of such detectors may also assist in identifying
situation has been stabilised. Initial surveys should be carried out alpha-emitting and pure beta-emitting contaminants (by detection of low
frequently (e.g. hourly) until the magnitude of any temporal yield photon emissions, and in the latter case Bremsstrahlung radiation).
variation is established. Samples should be taken at the scene for urgent gamma and alpha
spectrometric analysis at specialist laboratories [Section F.3 and Section
H.4.3]. The identity of alpha-emitting and pure beta-emitting contaminants
H.5 Air sampling must be confirmed on the basis of this sample analysis.
A programme of air sampling, using high volume air samplers, in
areas where people are located should also be established. Samples Information H.4 and H.5
should be collected and measured at regular intervals. Temporal variation will arise if the contaminant material is moving. This
may arise because material in the form of a dust or aerosol is being
resuspended in air. If this is happening, there is a risk of further exposures
by inhalation.
172 173
H.6 Assessment of potential exposures

(TIC)
Predictive assessments should be made of potential exposures to
individuals (particular emergency services workers) present within
the Red Zone on the basis of this air sampling. It should be
confirmed that the relevant dose constraints are not (and will not
be) exceeded [Section E.1].
Information H.7
2.3 Selection of individuals for monitoring
Selection of individuals for monitoring should already be in progress
[Section F.2]. However, the various stages of triage should be regularly
H.7 Individual monitoring reviewed because it is a dynamic process. Further information will become
(TIC) available that will generally be more detailed and more accurate. It should
Individual monitoring should be carried out on people selected and be expected that new individuals will be selected for monitoring.
prioritised according to Instructions F.23, F.26 and F.27. The
various stages of the triage process should be reviewed at regular Information H.9
intervals to confirm that individuals have been correctly selected, Monitoring of people who were not immediately selected for
and to select new individuals as appropriate. monitoring
After individual monitoring has been completed for those groups of
people who were positively selected by the triage process after a
H.8 Representative monitoring
contamination incident, there will almost certainly be demands to extend
(TIC) monitoring to other individuals or groups for reassurance or public
If the numbers of people requiring monitoring exceed the available information purposes. It will in any case be necessary to carry out further
capacity, then priority must be given to people who could individual monitoring on limited groups of people to determine whether
potentially have levels of contamination that could have an effect predictions or expectations regarding spread of contamination are correct;
on physical health. For other groups of people, representative (for a contamination incident, this would involve extending monitoring to
people who were not within the Red Zone during the incident). Analysis of
individuals should be selected. The results for these individuals the results for people already monitored will give an indication of the
may be taken to be typical of other people in the group, providing extent to which the target population for monitoring may need to be
that monitoring results support this assumption. extended.
A large scale programme of public monitoring could well overwhelm
H.9 Reassurance monitoring available resources, so any commitments made should be carefully
considered in advance. Where the aim is reassurance, arrangements for
(TIC)
any monitoring programme should be fully integrated with arrangements
After all those people selected using the procedures described in for dissemination of information to the public. To avoid over commitment
Section F.2 have been monitored, individuals who were not of resources, representative individuals from defined groups could be
immediately selected may be considered for monitoring. The main monitored. Release of information on such monitoring may well act to
purpose is expected to be the provision of reassurance to reassure other members of the group. Where contamination could be
individuals and to the public at large that significant sources and widespread, individuals to be monitored could be selected on the basis of
their place of residence using a geographic grid. Professional people who
pathways of contamination have not been overlooked. work with the community (health visitors, nurses, teachers, police, local
council members, etc.) may well be willing to cooperate in such a
monitoring programme.
174 175
2.4 Locations for individual monitoring

Information H.13 and H.14
Individual monitoring methods
H.10 Re-location
The primary monitoring method should be that which is expected to provide
(CONTAMINATION INCIDENTS) (TIC) the most reliable assessment of internal dose. The measurement is likely to
Potential or current locations for monitoring should be reviewed to be carried out in a laboratory. For most radionuclides, more rapid
ensure they meet (and will continue to meet) the criteria specified measurements can be carried out in the field, although these will, in general,
in Information E.45. be less accurate. Such measurements are of most use for rapid triage
purposes, and are referred to here as rapid screening methods. Descriptions
of these methods are given in Section H.3 and Annex 8. An explanation of the
H.11 Consideration for location principles underlying the choice of monitoring methods is given in Annex 6.
Table H1. Individual monitoring methods.
Initial monitoring locations are likely to have been sited in the
Radionuclide (absorption Radiation Rapid screening Primary monitor-
Yellow Zone because of its proximity to people being evacuated type)1 type emitted method ing method
from the Red Zone. After monitoring has been completed for this Manganese-54 (F) 54
Mn γ (EC) Whole body (rapid) Whole body4
group of people, locations outside of the Yellow Zone should be Cobalt-60 60
Co β, γ Whole body (rapid) Lung5
employed that meet the criteria specified in Information E.45. Strontium-90 90
Sr β Nose blow/nasal swab6 Urine
Selenium-75 75
Se γ (EC) Whole body (rapid) Whole body
Silver-110m 110
Ag β, γ Whole body (rapid) Whole body
2.5 Individual monitoring methods
Cadmium-109 109
Cd γ (EC) Whole body (rapid)
Whole body, urine
Nose blow/nasal swab
H.12 External contamination measurements Iodine-131 131
I β, γ Thyroid (rapid) Thyroid
(CONTAMINATION INCIDENTS) (TIC) Barium-133 133
Ba γ (EC) Whole body (rapid) Whole body
The results of external contamination measurements should be Caesium-137 137

Cs β, γ Whole body (rapid) Whole body
interpreted using the Action Levels given in Annex 10. Depending Europium-152 152
Eu β, γ Whole body (rapid) Whole body
β, γ
on the results of these measurements, the actions described in Table
154
Europium-154 Eu Whole body (rapid) Whole body
Iridium-192 (F) 192
Ir β, γ Whole body (rapid) Whole body4
H4 [Information H.35] should be carried out.
Polonium-210 210
Po α None Urine
Radium-226 226
Ra α Nose blow/nasal swab Lung5, Urine
H.13 Rapid screening
(CONTAMINATION INCIDENTS) (TIC) α
238
Plutonium-238 Pu Nose blow/nasal swab Urine, Faeces2
(Lung3,5)
Wherever possible, rapid measurements of internal contamination Americium-241 241
Am α, γ Nose blow/nasal swab Lung5
should be carried out using the rapid screening method identified in Californium-252 252
Cf α Nose blow/nasal swab Urine, Faeces2
Table H1 [Information H.13], for all people selected for this type of (Lung3,5)
monitoring by the triage process [Section F.2]. The results should α – alpha emitter β – beta emitter γ – gamma emitter EC – electron capture
be interpreted using the Action Levels given in Annex 10. 1. The Absorption Type (F, M or S) to which a chemical compound is assigned [Table H8]
Depending on the results of these measurements, the actions reflects the rate at which it is absorbed from the respiratory tract to body fluids.
2. Faecal monitoring is unlikely to be suitable for large numbers of people.
described in Table H4 [Information H.35] should be carried out. 3. Lung monitoring has very low sensitivity for these radionuclides. Nevertheless, the
sensitivity is adequate for the detection of contamination levels that could result in
deterministic effects.
Measurements made using the rapid screening method should be 4. Different primary monitoring methods are recommended for compounds of manganese
carried out within 24 hours. and iridium other than those allocated to Absorption Type F [Annex 10].
5. Intake by inhalation only. For ingestion, see Table A10.1, Annex 10.
6. Nose blow/nasal swab monitoring is not suitable for soluble compounds of 90Sr [Table H8].
176 177
H.14 Primary monitoring method

More accurate measurements of internal contamination should then
be carried out using the primary monitoring method identified in
Information H.13, for all people selected by the triage process for
this type of monitoring [Section F.2]. The results should be
interpreted using the Action Levels given in Annex 10. Depending
on the results of these measurements, the actions described in Table Information H.17
H4 [Information H.35] should be carried out.
Biological dosimetry requirements and strategy
Biological dosimetry is not the first diagnostic method to be used for
In general, measurements made using the primary monitoring radiation exposed subjects. First dose assessments should be based on
method may be delayed for a number of days, if lack of monitoring symptoms. Except for people with very serious prodromal symptoms who
resources makes this necessary. will be taken immediately to the hospital, the best dose estimations are
achieved if the blood samples are taken 24 hours after exposure.
H.15 Long-term follow up Biodosimetry by cytogenetics is more efficacious for external and
(CONTAMINATION INCIDENTS) (TIC) penetrating radiation.
People selected by the triage process for this type of monitoring
In the case of low penetrating radiations such as beta radiation and low
may be included in any programme of long-term follow up energy x-rays, it is not very useful. For exposures from internal
measurements [Section K.9]. contamination, biological dosemeters could be useful, but usually they do
not work well. Biological dosemeters can be used in such cases to detect
elevated levels of internal contamination but not necessarily for dose
H.16 Blood cell counts reconstruction purposes.
(TIC)
For people selected by the triage process for CBC [Section F. 2.2.2], For exposures resulting from internal contamination, bioassay
a programme of blood sampling should be specified. measurements can be used to assess internal doses with much greater
sensitivity than can be obtained with cytogenetic dosimetry. In the case of
direct measurements (i.e. on whole body or organs), results can be obtained
H.17 Chromosome aberration analysis almost immediately, while indirect measurements (i.e. on excreta) can
(TIC) provide initial results within 48-72 hours, depending on the radionuclide.
For people selected by the triage process for this type of monitoring
The detection limit for the most sensitive biological dosimetry method
[Section F.2.2.2], but who are not being admitted to hospital, a – dicentric assay – is 0.1 Gy.
programme of blood sampling for cytogenetic analysis should be
specified [Section J.10]. In collaboration with medical personnel, In the case of large scale emergencies, with great numbers of casualties, the
biological dosimetry triage approach is a strategy for increasing
prioritisation of samples to be sent/analysed should be made. First throughput. In such situations most laboratories will be able to cope with up
priority: samples from people without symptoms for days or more to 100 patients, but the detection limit will be 1 Gy. An additional strategy to
but with anticipated exposure. If this group is large, there will be a speed-up biodosimetry is the development of interactive networks between
need to prioritise again. Groups of the population likely to be experienced laboratories, along with the assistance of clinical laboratories in
hospitals doing cytogenetics (e.g. karyotyping, micronucleus assay) to
vulnerable to radiation should be prioritised (children, pregnant provide satellite scoring support. Utilising all the formal and informal
women etc.). If the group without symptoms is large, networks (world-wide) it could be possible to deal with several hundreds of
representatives from groups of people with similar anticipated patients in the short term (1-2 weeks). Descriptions of cytogenetic methods
are given in Section J.10 and additional information in Annex 9.
doses may be selected first. Samples from people allocated to lower
178 179
priorities may be sent for biological dosimetry analysis one or more

weeks after accident. Realistic estimates should be made of the Information H.18
time required to provide the results of measurements and associated Dosimetry on personal belongings
dose assessments. In some cases externally irradiated individuals can be monitored indirectly
by measuring personal objects carried during exposure (e.g. tablets, other
objects in the pockets). Two approaches are possible;
H.18 Dosimetry on personal belongings (EPR and OSL)
• EPR spectroscopy that can be applied at higher doses and for
(TIC) small numbers of individuals (usually requested at later stages of
Measurement of doses on the basis of measurements of objects monitoring); and
present in people’s pockets, clothes or other personal belongings • Optical stimulated luminescence (OSL) and thermoluminescence
may be considered (EPR and OSL are described in Information (TL) techniques may be performed on a wide variety of natural
and manufactured materials (e.g. objects usually present in
H.18 and Annex 9). people’s pockets such as chips in credit cards and mobile phones
(Inrig et al, 2008; Barkyoumb and Mathur, 2008)). The method is
Analysis will need to be performed at specialist laboratories suitable for detection of very low doses from the range
10-100 mGy up to 10 Gy and has great potential for population
[Section J.10 and Annex 1]. triage, since measurements can be made rapidly with a semi-
automatic reader, more than several tens per day.
H.19 Time to report results
(PEOPLE MONITORING TEAM, TIC) These methods are still subject of ongoing research.
Realistic estimates should be made of the time required to provide
the results of measurements and associated dose assessments, and
this information should be provided to the TIC and to other teams
awaiting monitoring results.
H.20 Action Levels

Action Levels for making decisions on decontamination, referral
for medical assessment, additional monitoring, provision of
information to individuals, and inclusion in any programme of
long-term follow up monitoring should be set as described in
Section H.4.
180 181
Chapter H Monitoring for dose assessment purposes 3 Monitoring techniques
3 Monitoring techniques If only α or particles are emitted, or the yield or energies of any photon
emissions are very low [Table A13.1] in vitro measurements will need to
be performed. If in vivo monitoring facilities are not available in vitro
Introduction
methods may be employed. Radionuclides may first need to be separated
This section presents information that gives an overview of the possible from the sample matrix to achieve a good and reproducible measurement.
techniques to assess internal and external doses. In vivo and in vitro If complicated radiochemical separation is needed before analysis (e.g.
monitoring for the purpose of dose assessment, as well as biological polonium, plutonium), the results are obtained only after some days - or
dosimetry, should be performed by specialists. Detailed guidelines on even weeks. In the case of urine samples, however, direct dispersion of a
methods and procedures are therefore not given here. small volume of the sample into a liquid scintillant or using ICP-MS
techniques may be sufficient for rapid analysis. Radionuclides emitting
Direct measurements, in vivo, can be used to determine the body content penetrating photons can, in general, be quantified in bulk samples.
and distribution of radionuclides that emit penetrating radiation [Table Although these radionuclides may also be detectable in the body by in
A13.1]. The measurement technique is quick and convenient such that it vivo counting, detection in excreta may be more practical or the only
should be relatively easy to ensure subject cooperation and to avoid anxiety. alternative if in vivo monitoring is not available.
Typical in vivo monitoring lasts from a couple of minutes to an hour and the There are no internationally agreed procedures for the assay of samples
results are available to the monitoring personnel immediately after the obtained for indirect assessment of levels of radionuclides in the body.
measurement. The minimum detectable activities (MDA) vary from some The preference for a given procedure will depend on the equipment
tens of becquerels (Bq) to thousands of becquerels depending on the available, the samples to be analysed, their anticipated levels of activity
radionuclide and measurement technique used as well as the measurement and experience of the staff. Samples that can be used are [Annex 11]:
time. Before measurement, any external contamination needs to be
• Urine;
removed to prevent further internal contamination of the person being
• Faeces;
measured, and to reduce errors in assessment of the internal contamination.
• Blood; and
The environmental background radiation is likely to be highly variable and
• Nasal swab.
must be taken into account in data analysis.
In an accident situation, it is often not possible to reconstruct reasonably
Three types of in vivo measurements may be necessary: the absorbed dose on the basis of physical dosimetry, and biodosimetry is
1. Whole body counting; then the only option for characterising the exposure.
2. Organ or partial body counting; Biological dosimetry, or biodosimetry, is the measurement of radiation
(thyroid, lung, liver, bone); and/or
induced changes in human body for dose assessment. The term biological
3. Wound counting.
dosimetry encompasses cytogenetics, Electron Paramagnetic Resonance
Detectors that could be used include [Annex 8]: (EPR) biodosimetry with tooth enamel and other calcified tissues,
• Scintillation detectors; mutation expression and DNA damage related assays, observation of
• Semiconductor detectors; symptoms and signs (clinical biological dosimetry), and bioassay.
• Gas filled detectors; All of the above methods have limitations related to detection limit, dose
• Liquid scintillation detectors; and range applicable and, type of radiation, persistence of the marker,
• Gamma cameras.
feasibility of measuring a large number of samples due to labour
In vitro monitoring is based on the determination of activity intensity and the need for expertise. Biological dosimetry by cytogenetic
concentrations in biological samples excreted by or taken from the body. assays and EPR assays are discussed in more detail in Annex 9.
182 183
Chapter H Monitoring for dose assessment purposes Instructions Information 3 Monitoring techniques
H.21 Whole body and organ monitoring

(CONTAMINATION INCIDENTS) (TACTICAL INCIDENT Information H.21
COMMAND [TIC])
Wound monitoring
1. Establish contact with the national internal dosimetry Wound monitoring is done at hospitals often in connection with
laboratory, or the laboratory that performs in vivo monitoring decontamination. Gamma contamination is easily detected, but beta
for your country, region or facility. contamination is more difficult. For detection of alpha contamination a
2. Notify the laboratory of the estimated number of subjects for in special probe is required. This Handbook does not give special
instructions for this kind of monitoring. The advice is to contact a
vivo monitoring.
specialist.
3. Arrange transport for the subjects to the laboratory.
4. In consultation with the laboratory, establish:
Information H.23
• The number of measurements per day that can be performed;
Biological dosimetry assays
• The time expected for reporting results; and The choice of assay method depends on the capacity and availability of
• The minimum detectable activity or detection limit for the assays in designated national laboratories, or networks of other
measurements to be performed. laboratories and the usefulness of the technique for a given exposure. In
most European countries, the best standardised method will be the
Individual monitoring methods suitable for typical radionuclides dicentric assay and one can expect that triage dicentric assay will be the
are listed in Information H.13. Monitoring for internal method applied for scenarios with many people in need of biological
contamination with dose rate meters and simple hand-held dosimetry. Countries with a standardised micronucleus assay analysis
instruments is described in Section F.3.4.1. capability, may prefer to use this test, and possibly increase their capacity
by employing other laboratories that use micronucleus assays for other
purposes. In situations where clinical symptoms, like vomiting and white
H.22 In vitro monitoring blood cells, indicate that the doses are in excess of the limit for dicentric
(CONTAMINATION INCIDENTS) (TIC) and micronuclei assays, the premature chromosome condensation method
1. Establish contact with the national bioassay laboratory or (PCC) could be applied. There are few laboratories in Europe capable of
laboratory that performs the in vitro monitoring for your doing this assay and they should be contacted via national or regional
country, region or facility. laboratories/authorities. The same applies to Electron Paramagnetic
Resonance techniques.
2. Notify the laboratory of the estimated number of samples.
3. Follow the instructions of the bioassay laboratory personnel to “Triage” approaches using cytogenetic methods are the biological
dosimetry approch of choise when there are many subjects to test.
arrange collection and transportation of the urine, blood or
faecal samples to the laboratory. The guidance for taking blood samples and transporting them to the
laboratories are the same for all cytogenetic assays. Hospitals and health
4. In consultation with the laboratory, establish:
centres should have available stocks of sampling equipment and lithium
• The number of measurements per day that can be performed; heparin tubes. A large stock of such tubes could be needed for mass
• The time expected for reporting results; and casualty situations.
• The minimum detectable activity or detection limit for the Procedures should be available in advance for contacting the biological
measurements to be performed. dosimetry laboratory, for taking blood samples and for logistic connected
with the transport of blood. Special considerations have to be taken
regarding transport conditions. All available exposure details, and
Examples of minimum detectable activity (MDA) for detection of information regarding blood collection and storage, should accompany the
137
Cs with gamma spectroscopy are about 0.1 Bq/l and for 90Sr blood samples. (Continued over page)
184 185
Chapter H Monitoring for dose assessment purposes Instructions Information 3 Monitoring techniques
0.1 Bq/l after radiochemistry and beta-measurement. Using

radiochemical procedures and alpha spectroscopy the MDA for 238U Information H.23 (cont.)
is about 0.1 mBq/l and for 210Po 1 mBq/l. ICP-MS is a modern and Biological dosimetry by cytogenetics
more sensitive method for detection of long-lived alpha emitting These techniques estimate the frequency of chromosomal aberrations i.e.
radionuclides, but might not always be available. Remember the the characteristic chromosome changes. Assays used are: metaphase
spread dicentric assay, micronucleus assays, premature chromosome
possibility of international assistance.
condensation (PCC) and fluorescent in situ hybridisation (FISH).
H.23 Biological dosimetry Countries with a developed nuclear power industry usually have biological
(TIC) dosimetry laboratories, but there are several countries without such
1. Establish contact with the national biological dosimetry facilities. It takes at least 3-4 days to get the result of counting from the
time the blood sample enters the laboratory. All these methods demand
laboratory or the laboratory that performs the biodosimetry special expertise and calibration curves for different type of radiations. The
service for your country, region or facility (Laboratory table below presents the main characteristics of cytogenetic biodosimetry
preferably meeting the requirements of ISO 19238). methods. Further information is given in the Annex A9.
2. Notify the laboratory of the estimated number of subjects for Table H2. Comparison of usefulness and limitations of different cytogenetic assays
biological dosimetry. In case of a great number of samples, for acute biological dosimetry (based on BiodosEPR-2006 Meeting recommendations,
Alexander et al, 2007).
consider in consultation with this laboratory, whether formal or
ASSAY
informal networks for biological dosimetry by cytogenetics
CRITERION Dicentric assay Micronucleus Premature Fluorescent in
should be activated. Anticipate type of exposure (if possible). assay (MN) chromosome situ
(cytokinesis condensation hybridisation
3. Agree on the number of samples and on the arrangement for the block (PCC) (FISH)
delivery of the samples to the laboratory. micronucleus
assay CBMN)
4. Take and transport the blood samples according to procedures Dose range (Gy) 0.1 - 5 0.3 - 5 1 - 20 0.25 - 3
described in Annex 11. Sensitivity (Gy) 0.1 0.3 1 0.25
Time for taking ≥ 24h ≥ 24h ≥ 24h ≥ 24h
samples after If sign and symptoms of expose occur within
expose hours and other information of exposure indicates
dose of several Gray, then take the sample as soon
as possible (usually hospital patients)
Triage approaches Yes, but Possible Yes, but Not
(mass casualty sensitivity is sensitivity is applicable
situation with 1 Gy several Gy
more than ca. 20
samples during
the first week in
one lab)
How long the Days-weeks Days-weeks Hours- days Retrospective
technique can be
used after
exposure?
(Optimum time)
Standardisation of ISO standard - - -
the assay
Usefulness for Yes No (some No data Yes
partial body indications)
exposure
186 187
Chapter H Monitoring for dose assessment purposes Instructions Information 4 Later triage and monitoring
4 Later triage and monitoring Information H.25

Dose action levels
The upper dose action level for internal contamination, ALU, is a fixed
Introduction value that corresponds to a committed effective dose of 200 mSv. This is
the upper action level proposed by the TIARA project, (Menetrier et al,
This section describes the later stages of radiological triage that would
2005), above which medical treatment to reduce doses (e.g. by
be carried out using information from initial individual monitoring decorporation) should be considered.
[Section F.3]. Triage based on the results of monitoring is likely to take
place after a Monitoring Strategy [Section H.2] as been established. The The upper dose action level for external contamination by beta-gamma
actions to be carried out for these triage groups, including additional emitters, ALU, corresponds to an absorbed dose to the skin of 2 Gy to an
monitoring, are briefly described. They are summarised in Figures H2 area of skin in excess of 600 cm2. In comparison, IAEA recommends a
Generic Reference Level for Medical Action of 10 Gy to an area of skin in
and H3, and Table H4. excess of 600 cm2 (IAEA EPR-Medical, 2005, Table F2, p. 104). In IAEA’s
recommended scheme, exceeding this action level would trigger
H.24 Symptoms of ARS immediate decontamination and immediate medical examination,
consultation and treatment. A lower action level for external
contamination is recommended here because there is evidence that a
If any individual exhibits symptoms of nausea, vomiting or number of symptoms may appear at skin doses below 10 Gy, including
diarrhoea during triage or monitoring, they should be referred initial transitory erythema, later transitory hair loss, secondary erythema
immediately for medical assessment [Section J.4]. and later hyper-pigmentation. It should be noted that exceeding the TMT
Handbook action level would trigger immediate medical assessment, but
is not intended to trigger medical treatment in itself.
4.1 Action Levels
Action Levels on measured quantities
H.25 Action Levels The Action Levels presented in the Tables in Annex 10 are directly related
(TIC, LEADERS FOR RADIOLOGICAL TRIAGE, PEOPLE to these dose action levels but are specified in terms of measured
quantities. Action Levels for external contamination on skin and clothing
MONITORING, AND MEDICAL TEAMS) were determined by direct application of the skin beta dose rate
Action Levels should be specified for decontamination, referral for conversion factors contained in Table H7 [Information H.55]. Action levels
medical assessment, additional monitoring, provision of for elapsed times after the contamination event of 12 hours and 1 day
information to individuals, and for inclusion in any programme of assume that contamination was present at a constant level until that time,
long-term follow up monitoring. Recommended Action Levels are and is then removed completely. These Action Levels may be taken to
apply to contamination of both skin and clothing; no allowance is made
given in the Tables in Annex 10 for the radionuclides listed in Table
for the effect of shielding in the latter case.
H1 [Information H.13 and H.14], for various times after acute
exposure. For intermediate times, the higher value for the two Action Levels for internal contamination were determined by carrying out
adjacent times should be used. These Action Levels are directly bioassay calculations using current ICRP models and the default parameter
related to dose, but are specified in terms of measured quantities so values described in Table 1 of Annex 10. These calculations are not
that direct comparison with the results of measurements can be intended to provide an accurate assessment of the relationship between
bioassay quantities and dose, because the parameter values used in the
made. An upper Action Level is associated with urgent actions, calculation may well differ significantly from values appropriate for a
while a lower Action Level is associated with actions that are less specific incident or exposure scenario. Nevertheless, the calculations
urgent. Depending on the radionuclide, Action Levels are specified should be adequate for the intended purpose; that is, to facilitate decisions
for: about further actions. (Continued over page)
188 189
• External contamination measured on skin or clothing (Bq cm-2);

Information H.25 (cont.)
• Internal contamination measured in whole body, lungs or thyroid
(Bq); and No action levels are provided for nose blow or nasal swab monitoring
because the available techniques do not provide quantitative estimates of
• Measurements of activity in 24-hour urine samples (Bq d-1). internal dose after inhalation. The results of such monitoring may, however,
Information H.25 presents the Action Level tables for inhalation of be used to help to prioritise people for more accurate measurements, such as
90
Sr (Type F), inhalation of 131I and ingestion of 137Cs. those provided by lung monitoring. Detection of relatively high levels of
activity on a nasal sample may be taken to indicate that the individual could
be one of the more highly exposed. Failure to detect activity on a nose blow
H.26 Lower Action Levels sample should never be taken to indicate that no intake has occured.
The ratio of the upper Action Level to lower Action Level Three examples of Action Level tables (for inhalation of 90Sr (Type F),
(ALU/ALL) should initially be set at 10, but should be considered as inhalation of 131I and ingestion of 137Cs) are presented below.
a variable quantity, to allow demand for resources to be matched to Table H3. Action Levels (copy of tables from Annex 10.)
their availability. A value of 10 is a minimum value. It is unlikely to Copy of Table A10.5a. Action Levels for 90Sr, Inhalation, Type F.
exceed 200.
Radio- Action Level Method ALU Initial
nuclide on: value
12 h 1d 3d 7d 14 d
H.27 Recommended actions for ALU
/ALL
(CONTAMINATION INCIDENTS) (TIC) External External 4.8E+04 2.4E+04 - - - 10
Recommended actions corresponding to these Action Levels are contamination scan
given in Table H4 [Information H.35]. Internal

contamination -
Nose
blow
~ ~ ~ ~ ~ 10
rapid initial
Sr-90
screening
H.28 Action Levels for children Type F
Internal Urine - 4.5E+05 1.0E+05 4.2E+04 1.9E+04 10
(CONTAMINATION INCIDENTS) (TIC) contamination -
primary
For children (below 16 years of age), the Action Levels determined monitoring
for adults should be reduced by a factor of 10 to provide an method
adequate degree of conservatism in the initial stages of the

response. These Action Levels may be revised subsequently, on the (Continued over page)
basis of more realistic dosimetric calculations appropriate for
children. Such calculations are beyond the scope of this Handbook,
and should be carried out by experts in internal dosimetry.
4.2 Triage after initial external contamination

measurements
H.29 Recommended actions

(RADIOLOGICAL TRIAGE, DECONTAMINATION, PEOPLE
MONITORING TEAMS)
The following actions should be carried out in the order of priority
indicated by the measured external contamination levels. Unless
190 191
there is unequivocal evidence that an irradiation source has

remained sealed, the actions specified in Instructions H.30-H.34
should be carried out [Figure H2]. Information H.25 (cont.)
131
Copy of Table A10.8a. Action Levels for I, Inhalation, Type F.
H.30 Actions when the measurement (M) > ALU Radio-
nuclide
Action Level
on:
Method ALU Initial
value
(RADIOLOGICAL TRIAGE, MEDICAL, DECONTAMINATION 12 h 1d 3d 7d 14 d for ALU
/ALL
TEAMS)
External External 1.0E+05 5.2E+04 - - - 10
If an individual has contamination levels on skin or clothing above contamination scan
the Upper Action Level, ALU, [Annex 10], then carry out actions 1, Internal Thyroid 1.7E+06 2.3E+06 2.1E+06 1.4E+06 7.3E+05 10
contamination - (rapid)
2, 3, 4 and 8 in Table H4 [Information H.35], take a blood sample I-131
rapid initial
for CBC, and refer the individual immediately for medical Type F
screening
Internal Thyroid 1.7E+06 2.3E+06 2.1E+06 1.4E+06 7.3E+05 10
assessment [Section J.4]. contamination -
primary
monitoring
H.31 Actions when ALU > M > ALL method
(RADIOLOGICAL TRIAGE, DECONTAMINATION, PEOPLE Copy of Table A10.10b. Action Levels for 137
Cs, Ingestion.
MONITORING TEAMS) Radio- Action Level Method ALU Initial
For individuals with contamination levels between the Upper and nuclide on:
12 h 1d 3d 7d 14 d
value
for ALU
Lower Action Levels ALU and ALL [Annex 10], carry out actions 5, /ALL
6 and 8 in Table H4 [Information H.35]. External External 1.0E+05 5.2E+04 - - - 10

contamination scan
Internal Whole 1.5E+07 1.5E+07 1.4E+07 1.3E+07 1.2E+07 10
H.32 Actions when M < ALL contamination - body
rapid initial (rapid)
(RADIOLOGICAL TRIAGE TEAM) Cs-137 screening
For contaminations levels below the Lower Action Level ALL Internal Whole 1.5E+07 1.5E+07 1.4E+07 1.3E+07 1.2E+07 10
contamination - body
[Annex 10], then carry out actions 7 and 8 in Table H4 [Information primary
H.35]. monitoring
method
Notes
H.33 Selection for rapid internal contamination monitoring ALU - Upper Action Level
(RADIOLOGICAL TRIAGE TEAM) ALL - Lower Action Level
- Comparison with Action Level not valid at these times
People with contamination levels above the Lower Action Level Action Levels are expressed in Bq, except for external contamination (Bq cm-2) and urinary excretion
(Bq d-1).
ALL should be selected for initial internal contamination Dose calculations were performed using the same assumptions as specified in Annex 13.
monitoring [Section F.3.4]. These people should be monitored in the
order of priority determined by their measured external
contamination level. Where people have similar measured external Information H.28
contamination levels, those with contamination on the face should Action Levels for children
be assigned a higher priority, as this could indicate that inhalation In some cases, the value of the committed effective dose assessed from a
of contaminated material has taken place. unit measurement value is significantly greater for a child than for an
adult. Action Levels for children should be reduced by a factor of 10 until
dose per unit measurement calculations have been carried out for children
of different ages.
192 193
H.34 Long-term follow up

(RADIOLOGICAL TRIAGE, PEOPLE MONITORING TEAM) Information H.35
People above the Lower Action Level ALL should be included in Table H4. Actions corresponding to the Action Levels of Annex 10.
any programme of long-term follow up monitoring. People below Action level on:
Measure-
ment, M
Actions
the Lower Action Level ALL may be considered for inclusion in any 1. Remove contaminated clothing immediately.
programme of long-term follow up monitoring [Section K.9]. External
2. Carry out urgent decontamination followed by
re-monitoring [Section G.2].
M > ALU
contamination 3. Commence blood sampling for CBC .
4. Refer individual immediately for medical assessment [Section
J.4].
4.3 Triage after initial internal contamination
5. Carry out decontamination procedures on individuals in
measurements ALU > M > ALL
priority order [Section G.2].
6. Include in any programme of long-term follow up monitoring
ALU > M > ALL [Section K.9]. Carry out rapid initial screening for internal
H.35 Recommended actions contamination, in priority order.
(RADIOLOGICAL TRIAGE, MEDICAL AND PEOPLE MONITORING M < ALL
7. Instruct individuals to return home and carry out simple
decontamination procedures there [Section G.3].
TEAMS)
8. Provide information to individual on measured external
The following actions should be carried out in the order of priority All measure-
ment values
contamination levels and any associated dose and risk
determined by the measured internal contamination levels. Unless
there is unequivocal evidence that an irradiation source has Internal
9. Carry out measurements with primary monitoring method
urgently.
remained sealed, the specified actions in Instructions H.36-H.41 contamination
-rapid initial
M > ALU 10. Refer for medical assessment [Section J.4].
11. Commence blood sampling for CBC and cytogenetic
should be carried out (Figure H3). screening
measurements.
12. Carry out measurements with primary monitoring method
ALU > M > ALL
in priority order.
H.36 Actions when M > ALU
(RADIOLOGICAL TRIAGE, MEDICAL AND PEOPLE MONITORING M < ALL
TEAMS) All measure-
If rapid measurements of internal contamination levels indicate that ment values
the upper Action Level, ALU, is exceeded [Annex 10], then carry
Internal
out actions 9, 10, 11 and 14 in Table H4. contamination 15. Refer for medical assessment [Section J.4].
-primary M > ALU 16. Commence blood sampling for CBC and cytogenetic
monitoring measurements if not already started.
H.37 Prioritisation for more accurate internal contamination method
monitoring, M > ALU ALU > M > ALL
monitoring [Section K.9].
(PEOPLE MONITORING TEAM) 18. Consider for inclusion in any programme of long-term
M < ALU
If ALU is exceeded, more accurate internal contamination follow up monitoring [Section K.9].
measurements should be carried out as soon as possible (1ST All measure-
ment values
MONITORING PRIORITY) [Section H.4.1]. assessments1 [Annex 3 and Chapter D].
Notes.
1. Information provided will depend on the Action Level band in which the measurement value falls.
H.38 Prioritisation for more accurate internal contamination
monitoring, ALU < M < ALL
If rapid measurements of internal contamination levels give a result
between the upper and lower Action Levels, ALU and ALL, [Annex
194 195
10], more accurate internal contamination measurements should be

carried out as soon as possible (2ND MONITORING PRIORITY)
and action 14 in Table H4 should be carried out [Section H.4.1].
H.39 Prioritisation for more accurate internal contamination

monitoring, M < ALL
Remaining individuals should be prioritised for more accurate
internal contamination measurements (3RD MONITORING
PRIORITY) and action 14 in Table H4 [Information H.35] should
be carried out [Section H 4.1]. Information H.41
1.E+08
C
H.40 Recommended actions
(RADIOLOGICAL TRIAGE, MEDICAL, PEOPLE MONITORING
Bq (whole body or organ) or Bq d-1 excreted

1.E+07
Degree of uncertainty
TEAMS)
B200
Actions 15, 16, 17, 18 or 19 should be carried out, as required [Table 1.E+06
H4, Information H.35], on the basis of the results of these more
accurate internal contamination measurements.
1.E+05
B20
H.41 The TIARA method
(RADIOLOGICAL TRIAGE, PEOPLE MONITORING TEAMS) 1.E+04
The simple graphical method developed for the TIARA project B1
should be used as an input to decisions on decorporation treatment 1.E+03
based on the results of these more accurate internal contamination A

measurements. The method applies where intakes occurred by 1.E+02
inhalation and is described in Annex 7. Instruction H.42 explains 1 10 100
Days
how to use the method.
Notes
H.42 Using the TIARA method 1. The y-axis shows the measured amount of the radionuclide in whole body or
(RADIOLOGICAL TRIAGE, PEOPLE MONITORING TEAMS) organ of the body, expressed in Bq, or the measured amount of the radionuclide
excreted in urine or faeces per day, expressed in Bq d-1.
Select the appropriate figure for the radionuclide and monitoring 2. The x-axis shows the elapsed time of the measurement or sample after intake.
method from the TIARA booklet “Dose Assessment of Inhaled 3. This example is for whole-body measurements of 137Cs.
Radionuclides in Emergency Situations”. An example figure is Figure H1. The TIARA method (Menetrier et al, 2007b).
shown in Information H.4.1.
Use the measurement value and the elapsed time of the

measurement or sample after intake to determine the colour band
(also labelled A, B1, B20, B200 and C) in which the result lies.
196 197
For results in the red bands (B200 or C), with an estimated

committed effective dose of 200 mSv or greater, treatment should
be considered. However, psychological factors and the potential
efficacy of extended or protracted treatment should also be
considered [Instructions J.24 and J.25].
For results in the yellow band (B20), with an estimated committed

effective dose between 20 and 200 mSv, treatment should be
subject to medical judgement. Although clinical effects are unlikely
to occur, the potential efficacy of initial short-term treatment should
be considered [Instructions J.24 and J.25].
For results in the green band (B1), with an estimated committed

effective dose between 1 and 20 mSv, more accurate dose
assessment is required. Treatment does not need to be considered
[Instructions J.24 and J.25].
For casualties in the green band (A), with an estimated committed

effective dose below 1 mSv, treatment does not need to be
considered. No further dose assessment is required.
H.43 Demand exceeds capacity

(RADIOLOGICAL TRIAGE, PEOPLE MONITORING TEAMS)
If numbers requiring monitoring exceed the immediately available
capacity, then smaller numbers of people who are representative of
the various groups identified in the triage process may be
monitored [Section H.2.3].
H.44 Action Level for stable iodine treatment

No action level is proposed for use of stable iodine for thyroid
blocking. National guidelines for the use of stable iodine should be
followed.
H.45 Action Level for Prussian Blue treatment

If the incident involves exposure to 137Cs, and internal Figure H2. Flowchart for radiological triage based on results of external contamination
contamination monitoring measurements indicate that the projected monitoring.
dose would be greater than 20 mSv, then these individuals should
198 199
be considered for treatment with Prussian Blue [Section J.8]. A

projected dose of 20 mSv should be treated as a guideline value
which may be varied according to circumstances. Any treatment
must always be subject to medical judgement on a case-by-case
basis.
H.46 Action Level for DTPA treatment

If the incident involves exposure to plutonium, americium or
californium, please refer to the TIARA method [Instruction H.41]
for consideration of treatment with DTPA [Section J.8]. Any
treatment must always be subject to medical judgement on a
case-by-case basis.
H.47 Long-term follow up

(RADIOLOGICAL TRIAGE, PEOPLE MONITORING TEAMS)
People above the Lower Action Level ALL should be included in
any programme of long-term follow up monitoring. People below
the Lower Action Level ALL may be considered for inclusion in any
programme of long-term follow up monitoring [Section K.9].
4.4 Triage after cytogenetic measurements
H.48 (PEOPLE MONITORING TEAMS)

Determination of the presence and frequency of chromosome
aberrations provides a more accurate dose assessment method than
that obtained from measurements of blood cell depletion kinetics
based on complete blood counts (CBC) [Section J.10]. However,
results are unlikely to be available until 4 to 5 days after the
incident. The technique is therefore likely be used to confirm or
refine dose estimates obtained from CBC, external contamination
and internal contamination measurements.
Figure H3. Flowchart for radiological triage based on results of internal contamination
monitoring.
200 201
Chapter H Monitoring for dose assessment purposes Information 5 Dose assessment methods
5 Dose assessment methods

Information Section H.5
Topics not covered in this section
Assessment of doses resulting from external irradiation is not addressed
Introduction
in any detail in this section because these doses are measured directly by
This section addresses the retrospective assessment of doses to dose rate monitoring equipment and by biological dosimetry.
individuals. Doses may result from:
The detailed reconstruction of doses based on information on the
• Internal contamination following inhalation or ingestion of movements of individuals at the time of the incident is beyond the scope
radioactive material; of this Handbook.
• External contamination resulting from deposition of radioactive
material on the skin and/or clothing; and/or The assessment of doses based on the results of biological dosimetry
• External irradiation resulting from proximity to a radioactive source. techniques is described in [Section J.10].
Scope
Assessment of doses resulting from internal contamination
Retrospective assessment of internal doses makes use of measurements
of the activities of radionuclides in the body (measured in becquerels,
Bq) or in excreta (measured in Bq d-1). Internal dose assessment is a
complex subject. This section does not attempt to present
comprehensive guidance for the accurate assessment of internal doses,
for which expert guidance must be sought (see, for example, ICRP
Publication 78, 1997). Rather, information is presented that will allow
simple and approximate calculations to be carried out using default
model parameter values.
Results of these calculations will inform decisions on the need for
additional and/or more accurate monitoring and more accurate dose
assessments. In the early stages of the response, the main requirement is
to be able to make such decisions rapidly, and approximate results are
adequate for this purpose. In fact, it is likely to be counter-productive to
attempt to achieve higher levels of accuracy, because this will require a
considerable effort and the expenditure of scarce resources. In many
cases, individual doses are likely to be low enough that an approximate
assessment is all that is required.
202 203
Chapter H Monitoring for dose assessment purposes Instructions Information 5 Dose assessment methods
Once the emergency phase is over, expert advice should be obtained, in

order to improve the accuracy of dose assessments. Furthermore, if
approximate dose assessments indicate that there may be a significant
risk to the health of an individual, then advice should be obtained
immediately from experts in internal dosimetry to improve the accuracy
and reliability of dose estimates.
Assessment of doses resulting from external contamination
In general, it is the dose to the skin that is of most concern when a
person is externally contaminated. Retrospective assessment of skin
dose makes use of measurements of the activities of radionuclides on
the skin (measured in Bq cm-2). Where doses to the skin are very high,
assessment of doses to internal organs may also be required. Information H.50
The default daily urine volumes are those recommended by ICRP in ICRP
Assessment of doses resulting from external irradiation Publication 89, 2003.
Retrospective assessment of doses resulting from external irradiation
presents a significant challenge. Where exposure is high enough to Information H.51 and H.52
cause deterministic effects, doses may be estimated from observations
It is preferable that dose assessments are based on 24 hour urine samples.
of clinical symptoms; however, dose assessment is of secondary concern
This avoids the variability that can arise from the use of single voiding (i.e.
for such cases. Where whole body (WB) exposures are potentially in “spot”) samples, and the uncertainties that are associated with the use of
excess of about 0.5 Gy, complete blood counts (CBC) may provide an any normalisation method. 24 hour sampling is preferable to
estimate of dose. For WB exposures in excess of about 0.1 Gy, normalisation by volume, because of the large inter-subject variation in
biodosimetry techniques [Section J.9 and Annex 9] may allow doses to daily urine volume.
be assessed. However, for potential exposures below 0.1 Gy, no
established techniques exist. Doses can only be estimated, rather than Information H.52
assessed, based on information derived from environmental monitoring ICRP states that “the restrictions on effective dose are sufficient to ensure
results and modelling. Some guidelines are presented in Information the avoidance of deterministic effects on all body tissues and organs,
H.64. except the lens of the eye …, and the skin which may well be subject to
localised exposures” (ICRP Publication 60, 1991). Thus, it can be assumed
that deterministic effects to all organs except to skin and the lens of the
eye will not occur if the occupational dose limit of 20 mSv has not been
5.1 Internal dose assessment exceeded.
H.49 Dose assessment data Information H.52 and H.54

(CONTAMINATION INCIDENTS) (DOSE ASSESSMENTS TEAM) If the committed effective dose exceeds 200 mSv, the individual should
The tables presented in Annex 13 should be used to determine the already have been referred for medical assessment if the guidelines
committed effective dose to age 70 y for all those for whom internal regarding Monitoring Strategy have been followed [Section H.2]. Where the
contamination monitoring has been carried out. This Annex committed effective dose is in excess of 20 mSv the need for medical
contains look-up tables that allow measurements of activity in assessment should have been considered [Section H.2].
204 205
whole body, lungs, thyroid on urine to be converted to dose. Data is

presented for both inhalation and ingestion of all of the
radionuclides in Table H1 [Section H.2.5]. For whole body, lung and
thyroid, the tables contain data for measurements made during the
period 6 hours to 28 days after an acute intake. For urine
measurements, the tables contain data for urine samples taken
during the period 1 – 28 days; it is assumed that 24 hour samples Information H.52 and H.53
would be taken, so no samples would be available for sample times Relative Biological Effectiveness (RBE)
less than 24 hours [Section H.4.3]. The following values have been used in the calculation of RBE-weighted
absorbed dose in Annex 13.
H.50 Normalisation of urine measurements
(CONTAMINATION INCIDENTS) (DOSE ASSESSMENT TEAM) Table H5. Relative Biological Effectiveness (RBE) for severe deterministic effects.
If the urine sample was not collected over a 24 hour period, then Radiation RBE
the measurement should be normalised according to volume by Gamma-radiation & X-radiation 1

Beta particles 1
multiplying the measured value by (V24/(volume of urine sample
Alpha particles irradiating lungs 7
(litres))). V24 is equal to 1.6 litres for men, and 1.2 litres for women.
Alpha particles irradiating red bone marrow 2
The volume of the sample should be measured at the time of receipt
Alpha particles irradiating colon 0
of the sample [Section H.4.3].
Iodine-131 irradiating thyroid 0.2
H.51 Alternative normalisation method (IAEA EPR-Medical, 2005, Table F1).
(CONTAMINATION INCIDENTS) (DOSE ASSESSMENT TEAM)

An alternative is to normalise the measurement by multiplying the
Information H.54
measured value by (24/[time period of sample (h)]). This is
appropriate if the sample was collected for a period that is close to The RBE-weighted absorbed organ dose is used to assess the likelihood
24 hours. Information on the start time and end time of the urine and magnitude of deterministic effects on those organs. If the values in
Table H6 are exceeded, then the person should be referred immediately
sample should have been obtained from the individual providing the for medical assessment and consideration for treatment, decorporation
sample [Section H.4.3]. therapy or prescription of stable iodine as appropriate.
H.52 Assessment of absorbed doses to organs Table H6. Generic reference levels on RBE-weighted absorbed dose.1
(CONTAMINATION INCIDENTS) (DOSE ASSESSMENT TEAM) Organ RBE-weighted absorbed dose (Gy-Eq)2
If the assessed committed effective dose summed for internal and Red marrow (intakes of actinides) 0.2
external exposure is > 20 mSv, then the RBE-weighted absorbed Red marrow (intakes of other 2
radionuclides)
doses to the lungs, red bone marrow and colon should also be
Thyroid3 2
assessed using the tables in Annex 13.
Lung 30
Colon 20
H.53 Assessment of absorbed doses to the thyroid Notes
(CONTAMINATION INCIDENTS) (DOSE ASSESSMENT TEAM) 1. From IAEA EPR-Medical, 2005, Table F2.
2. Integration period = 30 d.
The exception to Instruction H.52 arises when the contaminant 3. For use only when the thyroid is the critical organ.
radionuclide is a radio-iodine isotope. For 131I exposures, the
206 207
RBE-weighted absorbed dose to the thyroid should be assessed

using the tables in Annex 13. Information H.55
Table H7. Skin beta dose rate conversion factors for material deposited on skin or
clothing.
H.54 Provision of dose assessment results to medical staff
Conversion factor Conversion factor
(CONTAMINATION INCIDENTS) (DOSE ASSESSMENT TEAM) Radionuclide
(μSv h-1)/(Bq cm-2)
Radionuclide
(μSv h-1)/(Bq cm-2)
Where the assessed committed effective dose exceeds 200 mSv, Manganese-54 0.062 Europium-152 0.92
then the individual should have been referred immediately for Cobalt-60 0.78 Europium-154 2.1
medical assessment [Section H.4.1]. Full information on the Selenium-75 0.14 Iridium-192 1.9
assessed RBE-weighted absorbed organ dose should be provided to Strontium-90/

Yttrium-90
3.5 Polonium-210 6.9E-7
the relevant medical staff [Instructions J.6, J.24 and J.25]. This Silver-110m 0.68 Radium-226 no value given
information should be regularly updated as additional monitoring Cadmium-109 0.54 Plutonium-238 3.7E-3
data is obtained and improved dose assessments carried out. Iodine-131 1.6 Americium-241 0.019
Barium-133 0.13 Californium-252 3.2E-3
Caesium-137 1.6
5.2 Assessment of dose to the skin resulting from
external contamination Note: The dose rates are to the basal layer of the skin (70 μm in depth) due to beta
rays and electrons. The gamma contribution to the dose rate is generally just a few
per cent. Contamination is supposed to be uniformly spread over the skin (infinite
thin deposit).
H.55 Calculation of dose rate to skin
With the exception of contamination by alpha or neutron emitters, the dose
(CONTAMINATION INCIDENTS) (DOSE ASSESSMENT TEAM) equivalent to the skin expressed in Sv is equal to the absorbed dose expressed in
Dose rates to the skin should be calculated using the conversion Gy. For alpha emitters, the dose to the basal layer of the skin is zero. For neutron
irradiation, expert advice must be sought.
factors in Table H7.
For an initial dose estimate, no correction should be made for the shielding effect of
clothing. Be aware, however, that doses to skin may then be substantially
H.56 Skin dose overestimated.
(CONTAMINATION INCIDENTS) (DOSE ASSESSMENT TEAM) If a mixture of radionuclides is present, gamma spectrometry on wipe samples must
The actual or projected dose to an area of skin should be be employed to determine radionuclide-specific concentrations on the skin.
determined by integrating the assessed dose rate to that area of skin Taken from IAEA TECDOC 1162, 2000, Table E5.
over the period during which the contamination was present, or is Refer to Table E5 in IAEA TECDOC 1162, 2000, if the radionuclide encountered is not
expected to be present. included in the above table.
H.57 Provision of dose assessment results to medical staff

If the assessed dose to an area of skin in excess of 600 cm2 could
exceed 2 Gy, then the individual should have been referred
immediately for medical assessment [Section H.4.1 and Section J.4]
if not already done, and full information on assessed skin and
internal doses should be provided to the relevant medical staff.
Further decontamination is urgently required [Section F.2 and
Section G.2].
208 209
5.3 Issues for consideration when performing more

accurate assessment of internal dose
H.58 Assumed time of exposure

If the exact time of exposure is unknown, or if the exposure could
have been protracted over time, then it should be assumed that the
exposure took place at the earliest possible time, based on specific
information about the incident.
H.59 Inhaled particle size assumptions

It is reasonable to make the initial assumption that, at the time of
the incident, particle sizes close to the site of an incident (e.g.
within the area affected by blast) are characterised by an Activity Information H.61
Median Aerodynamic Diameter (AMAD) of 5 μm and a geometric Assumptions about absorption behaviour (“solubility”)
standard deviation (gsd) of 2.4. Similarly, it can be assumed that It is quite possible that radionuclides that are quite soluble when they are
particle sizes further from the site of the incident are characterised present as a pure chemical compound (e.g. 137Cs, which is usually
by an Activity Median Aerodynamic Diameter (AMAD) of 1 μm encountered as a salt such as caesium chloride) may be much less soluble
with the same gsd. when they are bound to refractory materials as may happen during an
explosion or fire.
H.60 Realistic particle size distributions

(CONTAMINATION INCIDENTS) (DOSE ASSESSMENT TEAM) Information H.62a
However, be aware that that particle size distributions, particularly
Assumptions about particle size distribution
close in to the site of an explosion or fire, may be very broad. The An AMAD of 5 μm is assumed for inhalation exposures close to the site
effect on assessed doses (particularly doses to the respiratory tract) because it is the default for exposures in the workplace, where exposed
of making different assumptions about particle size distribution people are likely to be close to the source of airborne material. An AMAD
should be investigated to give an indication of uncertainties in dose of 1 μm is assumed for inhalation exposures more distant from the site
estimates. More realistic information on the actual particle size because it is the default for environmental exposures. A particle size
distribution characterised by an AMAD of 1 μm is more typical of the
distribution must be used if this becomes available.
ambient aerosol, to which radionuclides may become attached at sites of
exposure far from the original source.
H.61 Absorption assumptions
It is reasonable to make the initial assumption that the absorption Information H.62b
behaviour of the material containing the radionuclide (i.e. its For very soluble materials, the choice of pathway does not have a
“solubility”) can be characterised by the ICRP default absorption significant effect on dose. For less soluble materials, the choice of pathway
type and gastro-intestinal uptake factor (Table H8). However, it may have a significant effect. For example, assuming inhalation rather
than ingestion may result in a significant increase in the assessed lung
cannot necessarily be assumed that the chemical form will be the dose.
210 211
same as that considered in ICRP publications. More realistic Information H.61

assumptions about absorption behaviour may result in more accurate Table H8. Radiation emissions, absorption types and gastro-intestinal uptake factors f1 for
dose assessments. Expert advice should be sought on the chemical intake by inhalation.
Radia- Absorp-
form of the material to which people were exposed. The effect on Radionuclide tion
γ energy1
tion f1
Compounds
(keV)
assessed doses of making different assumptions about absorption type types
behaviour should be investigated, to give an indication of Manganese-54 54

Mn γ (EC)
F
835 (100 %) M
0.1
0.1
Unspecified compounds
Oxides, hydroxides,
uncertainties in dose estimates. halides, nitrates
M 0.1 Unspecified compounds
1332 (100 %)
Cobalt-60 60
Co β, γ S 0.05 Oxides, hydroxides,
1173 (100 %)
H.62 Intake route in the event of explosion, fire or airborne dispersal halides, nitrates
(CONTAMINATION INCIDENTS) (DOSE ASSESSMENT TEAM). Strontium-90 90

Sr β -
F
S
0.3
0.01
Unspecified compounds
strontium titanate
If the incident involved explosion, fire or dispersal of airborne F 0.8 Unspecified inorganic
136 (61 %)
material, then the intake route should be assumed to be inhalation. Selenium-75 75
Se γ (EC) 265 (59 %) M 0.8
compounds
Elemental selenium,
280 (25 %) oxides, hydroxides and
carbides
H.63 Intake route in the event of food and water contamination F 0.05 Unspecified compounds &
658 (95 %)
(CONTAMINATION INCIDENTS) (DOSE ASSESSMENT TEAM). Silver-110m 110m
Ag β, γ 885 (73 %) 0.05
metallic silver
Nitrates and sulphides
M
If the incident involved deliberate contamination of food or water, 937 (34 %)
S 0.05 Oxides and hydroxides
then the intake route should be assumed to be ingestion, except for 88 (3.6 %)
F 0.05 Unspecified compounds
Nitrates, halides,
Cadmium-109 109
Cd γ (EC) M 0.05
people who were close to the original site of contamination, where S 0.05 sulphides
Oxides and hydroxides
inhalation may also have taken place. 365 (81 %)
Iodine-131 131
I β, γ 637 (7 %) F 1 All compounds
284 (6 %)
If the incident does not fall into one of these established categories, 356 (62 %)
and/or if information on exposure conditions is incomplete, then a Barium-133 133
Ba γ (EC) 81 (34 %) F 0.1 All compounds
303 (18 %)
combination of inhalation and ingestion should be assumed, with Caesium-137 137
Cs β, γ 662 (85 %) F 1 All compounds
the proportions reflecting the probability of each pathway. 122 (28 %)
Europium-152 152
Eu β, γ, β+ 344 (27 %) M 5E-4 All compounds
1408 (21 %)
5.4 Estimation of dose from external irradiation 123 (41 %)
Europium-154 154
Eu β, γ 1274 (36 %) M 5E-4 All compounds
723 (20 %)
H.64 Estimation of external dose 317 (83 %) F 0.01 Unspecified compounds
Iridium-192 192
Ir β, γ 468 (48 %) M 0.01 Metal, halides, nitrates
(EXTERNAL IRRADIATION INCIDENTS) (DOSE ASSESSMENT 308 (30 %) S 0.01 Oxides and hydroxides
TEAM). F 0.1 Unspecified compounds
Polonium-210 210
Po α - M 0.1 Oxides, hydroxides,
If projected whole body dose could be in excess of 0.5 Gy, then nitrates
complete blood counts should be initiated and the results used to Radium-226 226
Ra α 186 (3.3 %) M 0.2 All compounds
M 5E-4 Unspecified compounds
provide an estimate of dose [Annex 5]. If projected whole body Plutonium-238 238
Pu α -
S 1E-5 Insoluble compounds
dose could be in excess of 0.1 Gy, then biological dosimetry Americium-241 241
Am α, γ
59.5 (36 %)
M 5E-4 All compounds
procedures [Annex 9] should be considered. To estimate lower 26.3 (2.4 %)
Californium-252 252
Cf α - M 5E-4 All compounds
whole body doses, information from a number of sources will need
1. The three most intense gamma lines with yields > 1 % are listed, in order of intensity
to be collected: (ICRP Publication 38, 1983).
Recommended absorption types and f1 values are taken from ICRP Publication 68, 1995,
Annex F.
212 213
• Information on location of individuals collected for radiological

triage purposes [Section F.2.2.1]; Information H.64
• Results of surveys of dose rate near the source of irradiation In principle, the process of estimation of external dose to affected
individuals requires:
[Section F.3.2];
1. A three-dimensional map of the dose rate as a function of time in
• Information on the location of the source (and its distribution, if the space through which the individual has moved.
material was dispersed); and 2. A description of the path that the individual has taken through
• The identity of the radionuclide and the activity of the source. this space, expressed as a function of time.
Information H.64 provides some proposals on how this information The dose received by the individual could then be determined by
calculating the time-integral of the dose rate along the path taken.
could be used.
However, difficulties are likely to arise because of the limited extent or
accuracy of these two types of information.
Dose rate information may be obtained from direct measurements made

with monitoring instruments, or from calculations based on the activity of
the source and data on the shielding effect of material in the vicinity of the
source. Optically-stimulated luminescence (OSL) measurements on
irradiated materials may also provide useful data on cumulative dose over
a period of time although, at present, this is more a research technique
than a technique for dose reconstruction.
Information on location of individuals taken for radiological triage

purposes will prove to be useful for dose estimation, although it is likely
that more accurate information will eventually be needed. However, it has
to be recognised that the accuracy of such information will always be less
than ideal.
If large numbers of people must be considered, it is possible that dose

estimation may need to be performed for groups of people, rather than
individuals. Furthermore, it may not be possible to identify all potentially
affected individuals. In this case, it may be necessary to estimate doses to
hypothetical individuals and issue statements such as “People who were at
location X for Y minutes may have received a dose up to Z Gy. Such a dose
would result in a risk of long-term health effects equivalent to ……(e.g.
number of chest X-ray procedures)…………….”.
214 215
Chapter H Monitoring for dose assessment purposes Information 6 Recording and reporting results
6 Recording and reporting results
Introduction
The purpose of record keeping is to record, in chronological order,
everything that has been done and everything that has been produced
by the different teams, for later processing. For this, a database should
be prepared in advance so that it is immediately available when needed.
The records should include all the results from monitoring, analyses and
assessments [Instructions F.54 and F.72]. The nature and scope of the
records, and the extent of record keeping systems, depend in part on
national requirements and standards. Examples of forms for recording
and for reporting results are given in Annex 3.
The recording procedure for incidents needs to be prepared in advance.
Details specifying the incident must be added to the appropriate
national templates. For the recording of monitoring and analysis results
for people, the minimum information should include the unambiguous
identification of the person and of samples taken from that person,
documentation of the monitoring procedure, analytical procedures
employed, measured activity for each analysed radionuclide and any
comments on the analyses that might be helpful in the interpretation of
the results. The identity of the analyst should always also be recorded. It
would be useful to emphasise results exceeding specified recording or
investigation levels.
Several different types of reporting are needed. For general reporting
every organisation should have its own procedures. Reporting is needed
within organisations, between different organisations and authorities,
directly to individuals, to the media etc. Some examples of forms and
leaflets are given in Annex 3.
For reporting individual monitoring results, procedures specified by

national bodies and regulatory authorities should be followed. The
information that should be reported to individuals should be clearly
identified and communicated in an understandable way to the lay man.
216 217
Chapter H Monitoring for dose assessment purposes Instructions Information 6 Recording and reporting results
H.65 Collection of information

(RECORDS TEAM) Information H.65
Records should be kept of people who are monitored and/or At various stages during the response, information of various types will
decontaminated. These records will be used to contact people who need to be collected from people affected by the incident. This
require short-term medical follow up, or for purposes of long-term information may be collected as part of the field triage process, or in order
to help interpret the results of individual monitoring, or because it will be
health monitoring. Workers who responded to the incident and who
needed by a receiving medical facility. It is important that the information
were potentially contaminated should be included. collection process is well-organised, avoids duplication, and avoids
collection of unnecessary information. It is also important that an effective
The following information should be collected: system is put in place to organise this information.
• Information required from people involved in the accident;
• Information for medical facilities receiving contaminated
casualities; and
• Information to be collected from contaminated casualities.
H.66 Confidentiality
(RECORDS TEAM) Information H.66
All data and information that identifies individuals (known as
Some guidelines for using PII during an emergency are presented below:
person-identifiable information, PII) should be treated as
confidential. It is recommended that the following principles • Ensure minutes of meetings do not use the names of individuals;
governing the use of PII should be adopted: • Team members keeping their own records should be aware of the
principles governing the use of PII;
• The purpose for which PII is being used should be justified; • Papers containing PII should be stored securely after use;
• PII should not be used unless absolutely necessary; • Databases containing PII must be password-protected;
• PII should be the minimum necessary; • Laptops should have encrypted hard drives;
• Access to PII should be on a strict “need to know” basis; • Take care when giving information over the telephone, especially
when dealing with the press; and
• All those who have access to PII should be aware of their • PII should only be shared with other organisations when this is
responsibilities; and required in order to protect health, but sharing should be
authorised by a senior member of staff.
• All those who have access to PII should understand and comply
(Caldicott report, 1997)
with the relevant laws of their country.
It is recommended that the following principles of data protection
should also be adopted:
• Personal data should be processed fairly and lawfully;
• Personal data should be obtained for one or more specified and
lawful purposes and should not be further processed in a manner
incompatible with those purposes;
• Personal data should be adequate, relevant and not excessive in
relation to those purposes;
218 219
Chapter H Monitoring for dose assessment purposes Instructions Information 6 Recording and reporting results
• Personal data should be accurate and kept up-to-date;

• Personal data should not be kept longer than is necessary for that
purpose;
• Personal data should be processed in accordance with the rights
of the person;
• Appropriate measures should be taken against unauthorised or
unlawful processing of personal data and against accidental loss,
destruction or damage; and
• Personal data shall not be transferred to countries outside the EU
without adequate protection.
220 221
Information Handling of contaminated casualties and transport to hospital
CHAPTER I
Handling of contaminated
casualties and transport to
hospital
Information Chapter I
Handling casualties
Introduction Casualties require different handling depending on the radiation exposure.
This section provides instructions on how to handle contaminated and Physically injured and known not to be contaminated or to have received a
uncontaminated persons and transport them from the site of the incident significant dose from external irradiation
These people do not require special facilities relating to radiation. They
to the hospital.
present no hazard to other people.
I.1 Notifying the radiation emergency department of the hospital Physically injured and contaminated or potentially contaminated
These people may have radioactive material on their skin or clothing or
about the transport of patients
may have inhaled or ingested radioactive material. Transfer of
(AMBULANCE TEAM) contamination may incur a small risk to other people. Precautions should
1. Provide information to the receiving hospital about the event, be taken to reduce the spread of contamination to other people, vehicles
location and type of scenario, risk of radioactive contamination, and treatment facilities. The casualty's clothing, dressings, swabs and
nature of the possible contaminant/s (if known) and the number excreta should be bagged and labelled and retained for analysis [Section
of patients to be transported. H.3]. Radiation monitoring, and possibly decontamination facilities, will be
required [Section F.3.3 and Chapter G].
2. For each patient, notify the receiving hospital of his/her medical
status, actions taken at the scene (e.g. on site treatment/s, Casualty exposed to a high radiation dose, whether physically injured or
sampling), estimated time of arrival, risk of patient not
contamination and need for monitoring of the ambulance and Unless they are also externally contaminated, they present no hazard to
its medical team. other people, and there is no risk of contamination of vehicles or
treatment facilities.
3. All the relevant information should be recorded and travel with
the victim, e.g. name, age, unique person code (if one has been Uninjured but contaminated, or potentially contaminated
assigned), circumstances of the incident (location, time, Radiation monitoring, and possibly decontamination facilities, will be
scenario), most likely pathways for exposure, radionuclide/s required [Section F.3.3 and Chaper G]. It is possible that contamination
potentially involved, conventional injuries, medical problems alone, without physical injury or a significant dose from external radiation
beyond radiation exposure, actions taken on site. would be sufficient to cause deterministic effects in the casualty, but is
unlikely to cause adverse effects on health for other people.
4. Ask for any special instructions the hospital may have.
222 223
Chapter I Handling of contaminated casualties and transport to hospital Instructions Information Handling of contaminated casualties and transport to hospital
I.2 Transporting uncontaminated casualties with conventional

injuries and/or external exposure to the hospital Information I.1
(AMBULANCE TEAM) Essential information must be documented in the medical record of the
Apply the conventional procedures for transport in an ambulance. emergency department to provide the receiving hospital with all the
relevant information, and for possible legal purposes.
I.3 Transporting contaminated casualties with conventional All local hospitals, and other medical facilities, should be informed about
injuries and/or external exposure to the hospital the incident. This is particularly important if there is a possibility that
(RADIOLOGICAL TRIAGE TEAM, MEDICAL TEAM, contaminated casualties will self-present.
AMBULANCE TEAM)
1. If victim transport is needed before decontamination can be In events involving radiation sources, the emergency entrance of the
hospital may be accessed by different people including: health care
completed, enter the contaminated (Red) zone at the scene of
personnel, patients, family members, health authorities and media. The
the accident wearing available protective clothing (always wear ambulance team should ask for any further instructions, since, for
respiratory protection and double gloves). Liaise with TIC, or example, the entrance for the ambulance with a contaminated patient may
other emergency services already at the incident, to ensure that not be the usual emergency entrance.
hazards have been evaluated before proceeding into the Red
Zone. This must include consideration of conventional hazards
i.e. fire, smoke, chemicals etc. as well as radiological hazards. Information I.3
2. Use a personal alarming dosemeter if a significant gamma CAUTION
source is involved, unless well defined "safe" routes have been It is important that emergency services personnel are protected from large
radiation doses.
identified.
3. Do not eat, drink or smoke while in the Red Zone. Emergency services staff must be aware of the following:
4. Prepare the backboard or other device that will be used to • Turn back guidance [Table E2];
remove the patient from the Red Zone by spreading a first • The operation and alarms of their dosemeter;
blanket (or other protective barrier, sheet, etc.) and then a • When responding to a known or suspected malicious act
involving sealed sources, do not approach, handle or otherwise
second blanket or other barrier on top of the first blanket. come in contact with these sources;
5. Place the backboard or other device in the centre of the blanket • Radiation dose is reduced by avoiding close proximity to areas of
and roll up the edges of the blankets and fold blankets over the high dose rate or highly contaminated areas; and
top of the backboard. • Radiation dose is reduced by minimising time in areas of high
dose rate or highly contaminated areas.
6. After receiving confirmation that is acceptable to do so, enter
the Red Zone and place the backboard or other device adjacent Emergency services staff must be trained in advance on how to apply this
to the patient and unroll the protective barriers. Life threatening guidance.
injuries should be corrected immediately.
7. Potentially contaminated casualties should not be given food or
water (unless urgent oral medication is required which should
preferably be preceded by local facial decontamination).
8. Casualties should be advised not to eat, drink, smoke and keep
hands away from the mouth, until decontamination procedures
are complete.
224 225
9. Remove patient’s clothing except if the victim has serious

trauma and needs urgent transport to the hospital. Carefully cut Information Chapter I
the patient’s clothing away from the body, if this can be Measures to prevent the spread of contamination
accomplished without causing harm or unacceptable delay. The purpose of these actions is to protect the staff and prevent cross
Otherwise, the clothing should be removed as promptly as contamination.
possible, without compromising life or limb. Cut clothing on the
The two-blanket method will minimise the spread of contamination. The
centre of all body extremities and the trunk. Carefully lay cut outer-blanket will reduce/eliminate inner blanket contact with
clothing open, exposing the patient’s body. Prevent contaminated surfaces. The inner blanket, when wrapped around the
hypothermia. patient will encapsulate any contamination associated with the patient,
helping to prevent further spreading of the contamination. Blankets are
10. Load the patient onto the backboard, leaving clothing behind,
recommended instead of plastic sheets to avoid heat shock. Most
using standard medical protocols and wrap the inner protective contamination will be reduced by simply removing the patient’s clothing,
barrier around the patient. carefully cutting it away from the body. Hypothermia should be avoided
11. Removed clothing, gloves, and outer blanket should remain in during this procedure, particularly if it is conducted on pediatric patients
(e.g. use of warming blankets).
the Red Zone within a labelled plastic bag. The removed
clothing and gloves should be considered as waste. Other measures which can be taken to prevent the spread of
12. Hand carry the patient to the Safety Perimeter of the Red Zone. contamination are:
A second team of care providers should have an appropriate • Covering the floor of ambulances using rolls of paper or cloth
transportation device waiting at the Safety Perimeter. This sheets. The floor covering should be taped securely to the floor;
device should also be covered with a protective barrier. • Make a path from the ambulance entrance to the hospital
entrance using rolls of paper or cloth sheets. The floor covering
13. At the Safety Perimeter, responders should pass the patient should be taped securely to the floor and be non-slip; and
across the control line to waiting emergency care providers. • Contaminated or potentially contaminated items such as
Care providers within the RED zone should not cross the Safety casualties’ clothes, dressings, equipment, staff clothing etc.
should be bagged and labelled and stored in a secure area.
Perimeter until monitored. If additional responders are not
available, the treating responders should either self monitor for
contamination and/or remove their protective clothing at the
Safety Perimeter and provide transportation of the patient to the
appropriate medical facility.
14. After transferring the patient to the clean area, the emergency
care providers should cover the patient with the protective
barrier that was placed over the transport device.
15. Place floor covering on the ambulance. Load patient into the
ambulance and transport to hospital, ensuring that all the
relevant information travels with the victim [Instruction I.1:3].
16. Emergency care providers inside the ambulance should wear
respiratory protection and other appropriate protective clothing,
and change gloves as necessary. Open the protective barrier
covering the patient only to administer necessary treatment,
226 227
and handle all items used in the treatment of the patient as

potentially contaminated.
17. Assess patients’ vital status during transport and intervene
appropriately. Check status of intravenous lines started on site.
18. Inform the receiving hospital of any change in the patients’
medical status that occurred during transportation and actions
taken during the journey (e.g. venopunctures, administration of
fluids/medication, sampling).
19. Vehicles used to transport contaminated casualties should not
be decontaminated between journeys, but must be monitored
and if necessary decontaminated before return to normal
service.
Figure I1. Take care to limit the spread of radioactive contamination when
transporting the casualties to hospital. Photo: NRPA.
228 229
Information
CHAPTER J
Medical management at the

hospital
Introduction
This chapter of the handbook is directed at doctors, nurses and other
health workers, who are responsible for actions at the first referral level
(hospital response) for the diagnosis, treatment and health care
management of people affected by events involving the malevolent use
of radioactive sources.
It presents up-to-date guidelines for both inpatient and outpatient care.
It was developed to be used in hospitals where basic laboratory facilities
and essential drugs and medicines are available.
The guidelines presented in this chapter are the result of a harmonised
approach across the EU and are consistent with currently existing
international guidance. Actions recommended are evidence-based
statements systematically developed to assist decisions about
appropriate health interventions. In areas where clinical evidence is
limited, recommendations are based on expert experience from recent
radiation incidents.
This chapter includes the management of acute radiation syndrome,
local radiation injuries, radionuclide contamination and combined
injuries.
The hospital’s disaster plan and the general guidance for responding to
conventional emergencies are part of the preparedness of the emergency
health system. Standard procedures for stabilisation of clinical
conditions, protocols for supportive care, treatment of conventional
injuries and management of thermal burns, are out of scope of this
Handbook (they are available at hospitals). Figure J1. How to go through Chapter J.
(Bushberg and Miller, 2004; Bushberg et al, 2007; Dainiak et al, 2006).
230 231
Chapter J Medical management at the hospital Instructions Information 1 Receiving notification of the incident
1 Receiving notification of the incident

Information J.1
Gathering and updating information about the event could be performed
by a non-medical staff member.
Introduction
Collection of relevant information before the arrival of patients is essential
This section provides guidance about the minimum information that for the preparation of the hospital. The person responsible for this task
should be exchanged with the person/s who notify the hospital about the should be informed on the expected role, and the briefing should include
incident. Ideally, a designated member of the hospital staff should be basic concepts about radiation protection (e.g. it is possible to safely
assigned for this task, and should be briefed on her/his role and handle radiation casualties, the difference between exposed vs.
contaminated casualties) to ensure that the hospital staff will not hesitate
responsibilities. to admit casualties of radiation incidents from fear of irradiation or
contamination.
When gathering this information the communication process may involve

J.1 Gathering information from the field different individuals, including:
(HOSPITAL EMERGENCY TEAM) • The Tactical Incident Command (TIC) in the field;
• The ambulance crew;
1. Gather information about the event, location, time, size, type of • Conscious patients arriving by ambulance and those self-presenting;
scenario, risk of radioactive contamination, nature of the and
possible contaminant(s) (if known), possible chemical and/or • Other persons, e.g. relatives, companions, if the casualty arriving in
the ambulance is unconscious.
biological hazards and number of patients to be transported.
It is important to know whether biological or chemical agents were
2. For each patient, request information about identification (e.g. present, as these will take precedence over radioactive agents.
name, age, gender), medical status, conventional injuries,
medical problems unconnected with the radiation exposure, It is also important to have an indication of the size of the event (not only
about the number of patients who will be transported to the hospital, but
actions taken at the scene (e.g. treatment(s), sampling), also about attendees) to get an idea of the numbers of “worried well” who
estimated time of arrival, radioactive contamination suspected may be expected to self present at hospitals.
or proven, and decontamination procedure conducted in the
field.
3. Record the information provided and keep track of updates. Information J.1:2
4. Request and record the names of the persons who provided the Identification of patients, samples and personal belongings should be
carefully planned to maintain anonymity and confidentiality while
information and how they can be contacted. guaranteeing the traceability of the data. Every hospital should have an
5. Ensure that any further relevant information will be transported established system to be performed in an unambiguous way (e.g. unique
bar code label). This system should allow for assigning a unique ID to
with the patients when transferred to the hospital. Request the every casualty upon arrival at the hospital and should be able to be scaled
ambulance team for information about any change in the up for a sudden influx of patients. In the event of mass casualties,
victim’s medical status that occurred during transport and radiation event patients will be transported to, or show up at, various
actions taken during transportation (e.g. treatment(s), hospitals and may be moved on to specialist clinics. Also, most of the
“worried well” will be dealt with in on-scene temporary clearing points or
venopunctures, sampling). Inform them about the location of peripheral health care centres, designed to keep them away from the busy
the ambulance reception area. hospitals (or they will be managed by their own general practitioners).
Since people will have multiple entry points into the health care system, it
will not be feasible to impose a universal scheme for identification.
232 233
Chapter J Medical management at the hospital Instructions Information 2 Preparing the hospital for patient reception
2 Preparing the hospital for patient

Information J.2
reception
Hospital preparation
These instructions should be adapted to local conditions and incorporated
into the framework of the hospital’s general disaster plan. The HOSPITAL
Introduction EMERGENCY TEAM should ideally include a coordinator (“manager”); triage
officer(s); medical doctors in charge of diagnosis & treatment; nurses and
Once the hospital emergency department receives the notification of the technicians; administrative, maintenance and security personnel. Medical/
incident, it should immediately initiate its emergency plan. It is assumed health physicists and other health care workers may be required. One
that such a plan is available at the hospital and the details of its development member of the hospital staff (preferably a medical doctor or senior
administrator) should be nominated to deal with the media (public
and execution are out of scope of this Handbook. It is assumed that health information officer).
care personnel are familiar with conventional emergency management, and
that they will be responsible for making decisions regarding initial care of While casualties of malevolent acts involving sealed sources (e.g. RED1) are
patients, according to standard protocols, until the arrival of external not likely to be contaminated, there exists a risk of radioactive
contamination in scenarios such as RDD2 or open sources. External
specialists or experts. This section provides specific instructions on how to
contamination will be usually managed outside the hospital. However,
prepare the hospital for patient reception, that are applicable to radiation conventional casualties (e.g. injuries due to an explosion) may require
emergencies. These instructions should be added to the requirements quick transportation to the hospital before any decontamination
included in the hospital’s disaster plan. The instructions in this section are procedures. The HOSPITAL EMERGENCY TEAM should respond
globally addressed to the “hospital emergency team”. This team includes bearing in mind that the first priority is to save lives: treatment of
life- or limb-threatening conditions should take precedence over
some sub-groups which, in some cases, may be required to deal with more decontamination. In addition to the equipment and supplies required for
specific tasks e.g. medical doctors, security personnel, administrative the management of conventional emergencies, hopital staff should
personnel, nurses, health physicists and other health workers. These prepare the equipment and supplies likely to be required for the
sub-groups will be explicitly mentioned, to help the end-users of the management of a radiation emergency with potentially contaminated
patients, to protect the staff and prevent cross-contamination.
Handbook to identify their own roles during the emergency. The role of the
emergency medical manager could be performed by the Director of the Radiation protection equipment (e.g. survey instruments) should be
Hospital or the Head of the Emergency Department. calibrated and used by trained personnel, such as a radiation protection
officer or a health physicists. Such equipment may also be available at
some departments of the hospital dealing with radiation e.g. radiology,
J.2 Hospital preparation radiation oncology or nuclear medicine. In any case, according to
(HOSPITAL EMERGENCY TEAM) Instruction J.2:3, the relevant competent authority will be alerted about
Once the hospital is notified that patients will arrive, the following the need for technical support.
tasks should be undertaken. (CDC Interim Guidelines, 2003; Dainiak, 2007; Goans and Waselenko, 2005;
Gusev et al, 2001; Mettler 2005; Ricks et al, 2002; Turai et al, 2004).
(EMERGENCY MEDICAL MANAGER)
1. Activate the hospital disaster plan and notify personnel of the
emergency department. Involve personnel with knowledge of
radiation protection (health/medical physicist, radiation
oncologists, nuclear medicine physicians, radiologists) and alert 1 RED: radiological exposure devices are devices designed to cause external exposure to
ionising radiation.
relevant services such as haematology, surgery, intensive care
2 RDD: radiological dispersal device is any device that causes the purposeful dissemination
unit, paediatrics, diagnostic imaging and laboratory services. of radioactive material without a nuclear detonation.
234 235
2. Identify roles, distribute duties, establish work teams, convene a

briefing session to provide the emergency department team Information J.2:2
with information about the event and define assignments. During this briefing session the emergency medical manager should
provide the emergency department team with basic concepts on radiation
3. If it has not already been done, notify the relevant competent
safety i.e. radiation protection principles, management of contaminated
authority and alert about the eventual need for participation of patients and objects, use of personal protective equipment and radiation
specialised teams e.g. radiation protection, radiation emergency monitors, radioactive waste management, etc. This may be a good
medicine, physical dosimetry, biological dosimetry, internal opportunity to issue dosemeters. They can be provided by a medical
dosimetry, in vivo and in vitro bioassay. These teams are not health physicist, radiation protection officer or requested from other
routinely part of the staff in most hospitals but they can be departments of the hospital dealing with radiation e.g. diagnostic or
interventional radiology, nuclear medicine, radiation oncology.
available at national, regional or international level to provide
on-site or remote assistance.
4. Consider that arriving patients are contaminated until proven
otherwise, and prepare the emergency department to prevent the
spreading of contamination. Exception: if the absence of
radioactive contamination is intrinsically ensured by the scenario
conditions and/or by the results of a radiological survey.
5. Allocate an ambulance parking space, and establish the area for
ambulance reception, close to the entrance of the treatment
area. Identify the path from the ambulance to the emergency Information J.2:7
room. Whenever possible select areas for reception and Health care providers should be protected from radioactive contamination
treatment of casualties near an outside entrance. by using (at least) standard universal precautions. Health care providers
should be advised to follow the same procedures as those used to deal
with human blood or body fluids when handling contaminated patients
(SECURITY PERSONNEL) and objects.
6. Clear the areas for ambulance reception and treatment of
causalties from public and patients. Restrict access and establish A checklist of PPE for health care workers should ideally include: face
a system for control of entrances and exits. Re-distribute hospital masks, coveralls or waterproof gowns, surgical gloves, waterproof shoe
access and circulation of staff, other patients and public, provide covers or boots and surgical caps (eye protection devices are
recommended).
clear signs and erect physical barriers, as necessary.
A checklist for decontamination supplies should include: cotton
(HOSPITAL EMERGENCY TEAM) applicators, plastic bags for collection of clothes and personal items,
7. Remove unnecessary equipment and supplies from areas adhesive tapes and labels, towels or disposable wipes, soft nail brushes,
designated for radiation emergency response, cover treatment tooth brushes, plastic sponges, dressings, gauze, wrapping paper, plastic
tables, surfaces and equipment that cannot be removed with sheets, general cleansing agents (e.g. saline solution, mild soap, liquid
soap, chlorine bleach, shampoo, tooth paste), blankets, and assorted
waterproof sheets, and prepare personal protective equipment replacement clothing for adult and paediatric patients. Radiation warning
(PPE) and other supplies for the control of sterility and signs, rope, assorted pens and notebooks, specimen bottles, emesis
radioactive contamination. Ensure provision of equipment and basins, and record forms should also be available.
supplies necessary for the diagnosis and treatment of patients,
consider requirements for sample collection and storage and (REAC/TS Guidance, http://orise.orau.gov/reacts/guide/care.htm).
236 237
temporary waste disposal, as well as the need for radiation

monitors (staff would need to be familiar with their use)
[Information J.2:7].
8. Prepare containers for solid and liquid radioactive waste
collection, prepare plastic bags of different sizes, labels, radiation
tags, worksheets and special forms [Annex 3]. Cover the path
from the ambulance to the emergency room, and the floor of the
reception and treatment areas, with a non-slippery covering (e.g.
wrapping paper) securely taped at the borders. Protect handling
surfaces, signal the pathways and rope off.
9. Start preparation for triage, diagnosis and treatment. Verify
availability of protocols, procedures, equipment, supplies and
worksheets [Annex 3].
10. Identify the equipment to be used for telecommunications
during the emergency, check their location, availability and Information J.2:10
status e.g. telephones, facsimile machine, computers, internet It should be borne in mind that there is a potential for communication
access. Consider also photocopiers, scanners and photographic equipment to become contaminated. This would generally be a minor
cameras (for medical photographic records). problem, except for telephones which are necessarily close to the
breathing zone during use (risk of internal contamination). Some possible
recommendations to minimise these risks are:
(RADIATION PROTECTION OFFICER, HEALTH/MEDICAL
• Consider using speakerphones;
PHYSICIST, OTHER QUALIFIED PROFESSIONAL)
• Allow only uncontaminated personnel to use this equipment; and
11. Verify availability of radiation protection equipment and
• Monitor communication equipment regulary.
supplies [Information J.2:7], check status of survey instruments,
establish checkpoints for monitoring, e.g. at the ambulance
reception area, and at the entrance and exit of the radiation
emergency response area. Information J.2:12
12. Put on respiratory protection and other PPE [Information J.2:7].
Staff should be instructed to regularly/routinely place their hands over
Cover the scrub suit with a water resistant gown. Always wear a radiation monitors to confirm that their gloves are not becoming
cap and boots or shoe covers. Use two pairs of gloves and tape contaminated. If this is not possible, outer gloves should be changed
the first pair to the gown or plastic suit. The external pair of frequently.
gloves should be changed after handling contaminated items or
between patients. Dosemeters (if available) should be worn Staff will need to dispose of gloves to bin(s) identified for radioactive
waste – and the bins should be regularly monitored or removed/emptied
under protective clothing. Personnel dosemeters should be before they become a significant source of radiation.
issued to person(s) directly involved in the process of removal
and storage of radioactive shrapnel. They can be provided by a If the numbers of personal dosemeters are limited, then consider using a
medical health physicist, radiation protection officer or by other dosemeter to monitor the most active area (e.g. as a sentinel). The results
departments of the hospital dealing with radiation e.g. from the sentinel dosemeter could later be used to provide an estimate of
individual staff doses on the basis of staff occupancy times.
radiology, radiation oncology or nuclear medicine.
238 239
Chapter J Medical management at the hospital Instructions Information 3 Arrival of patients at the hospital
3 Arrival of patients at the hospital
Introduction
This section provides guidance on the transfer of patients from the
ambulance to the emergency room and their admission into the reception
and treatment areas. Unlike the toxicity from chemical agents, radiation
does not usually cause acute life threatening damage. According to the
result of a second trauma triage performed at the hospital, life and limb
threatening conditions must always have treatment priority over radiation Information J.3
injuries. Treatment of injured patients should take place according to
standard guidelines. As a general criterion, the priority order may be Persons who received a radiation dose from an external radioactive source
were “exposed” to radiation but they are not contaminated (and they do
considered as follows: not emit radiation). Thus, standard procedures can be used for
1. First aid and resuscitation. transportation/transfer.
2. Clinical stabilisation.
3. Treatment of serious injuries. Information J.4
4. Management of external contamination. A person is contaminated when radioactive material has been deposited
5. Treatment of internal contamination and minor injuries. on the skin or entered into the body through ingestion, inhalation, wounds
or transdermal absortion. Spread of contamination should be prevented in
such cases.
J.3 Transferring non-contaminated patients with conventional
injuries and/or external exposure to the emergency room These instructions should be adapted to local conditions, resource
(AMBULANCE TEAM, HOSPITAL EMERGENCY TEAM) availability and the magnitude of the incident, bearing in mind the
Apply standard procedures for the transport and transfer of patients principles of scalability and flexibility.
during conventional emergencies. If no information is available, Ideally, the ambulance and its team will be monitored by personnel trained
consider patients to be contaminated until otherwise confirmed, in the use of survey instruments (radiation protection officers, health
and apply Instruction J.4. physicists, exceptionally other staff members with some knowledge of
monitoring such as nuclear medicine personnel, radiology or radiation
J.4 Transferring contaminated patients with conventional injuries oncology staff). The number of ambulances required, and the number of
times an ambulance will be re-used in the field, will depend on the
and/or external exposure to the emergency room
scenario and magnitude of the incident. The response may need to be
(AMBULANCE TEAM, HOSPITAL EMERGENCY TEAM) scaled-up in a mass casualty event (e.g. use of non-medical transports
1. Upon arrival at the hospital, a contamination control zone such as private cars or buses to transport patients).
should be established in and around the ambulance and the
ambulance staff should be met by hospital staff wearing Similar procedures can be performed for helicopter transport. The landing
respiratory protection and other PPE, as appropriate, at the edge zone should be considered to be potentially contaminated and the clean
team transfer can occur at the border of that zone.
of this zone.
2. The ambulance gurney and the hospital cart should be placed (Bland, 2004; IAEA EPR-Medical, 2005).
240 241
side by side at the edge of the zone. Ambulance personnel

should stay on one side, hospital staff remain on the other. The Information J.5
patient should then be transferred to the clean gurney, to be Treatment of life threatening conditions is always the first priority.
admitted for further assessments and treatment. Management of radiation injuries and/or decontamination should neither
impede nor delay stabilisation of any patient.
3. Once the patient has been removed from the ambulance, both
the ambulance and crew should not return to regular service Medical consequences of radiation exposure do not depend on the
(except for life saving transport) until monitored and, if intentional or accidental nature of the event and decision making about
necessary, decontaminated [Information J.4]. medical strategy will be based on the patient’s medical condition and the
4. Submit personal dosemeters to the responsible person or severity of the injuries. It is important for the treatment to determine
whether a conventional injury (trauma, thermal burn) is associated with
organisation for evaluation of personal doses. Confirm that the external radiation exposure and/or radionuclide contamination (external
ambulance crew did not incorporate radioactive material (e.g. or internal) [Figure J3].
through external monitoring, and initiation of bioassay
samples). (Smith et al, 2005)
5. Ensure the proper disposal of all contaminated clothes, supplies
and equipment.
J.5 Receiving patients with conventional injuries and/or external

radiation exposure in the emergency room Information J.5:1
(HOSPITAL EMERGENCY TEAM)
1. Perform a second triage at the entrance of the area designated
for reception of patients in the emergency room [Figure J2].
Second triage should include conventional medical screening of
patients, according to their need for treatment (trauma triage),
to ensure that priority is given to life threatening injuries,
before any evaluation concerning radiation injuries
(radiological triage). Clinical stabilisation of the patients is
always the priority. Uncontaminated patients with conventional
injuries can be treated in a clean (“cold”) area while
contaminated patients should be directed to a “dirty” (“hot”)
area, where decontamination procedures will take place.
2. In the absence of any information (e.g. lack of survey
instruments and/or lack of trained personnel), assume that the
patients are contaminated until confirmed otherwise.
Respiratory protection and other PPE should be worn, as
appropriate [Information E.1]. If the absence of radioactive
contamination can be confirmed (e.g. by scenario description or
monitoring data), revert to the hospital´s standard emergency Figure J2. Example of a scheme for preparation of the hospital reception area. The example in the
figure should be adapted to the local conditions.
procedures for patient reception.
242 243
3. Whenever the clinical condition of the patient requires urgent

treatment, decontamination procedures should be postponed but
staff must wear respiratory protection and other PPE, as appropriate.
4. Depending on the scenario, highly radioactive fragments may
be present in wounds and should be removed as soon as
possible, following radiation safety procedures. Potentially
radioactive metallic fragments should be removed without
touching them directly (even if using gloves), using forceps to
increase the distance (and thus lowering the exposure of the
medical staff). The personnel involved should use PPE. Dose
rate must be monitored during this procedure. The fragment(s)
must be stored in a heavily shielded lead container and
monitored before storage in an appropriate place in the hospital
(e.g. radiation therapy department, nuclear medicine
department). Person(s) directly involved in removal and storage
of radioactive fragments must wear a personnel dosemeter,
Figure J3. Whenever the clinical condition of the patient requires
which can be provided by a radiation protection officer or by urgent treatment, decontamination procedures should be
other hospital departments which routinely deal with radiation postponed but staff must wear respiratory protection and other
PPE as appropriate. Photo: WHO.
e.g. radiology, radiation oncology or nuclear medicine.
Maximum permissible doses for medical staff must be specified
[Table E2, Section E.1.1] and compliance ensured by Information J.5:5
monitoring. It should always be borne in mind that medical stabilisation takes
5. If intravenous or intra-arterial access is required in a precedence over decontamination of the skin. Moreover, the amount of
contaminated patient, swab/clean the area before and, if radioactivity that might be incorporated through a needle puncture is
minimal. Consequently, if any injection is required, it will be sufficient to
possible (i.e. available time and/or equipment) monitor the skin swab/clean the area, without additional monitoring.
and perform the puncture in a clean area, or in the area with a
lower degree of contamination.
Information J.5:6
6. Once treatment has been completed, patients should be passed
to a buffer zone and complete monitoring conducted (preferable Hospital medical physicists will have information about the availability of
medical physicist), before their transfer to a free circulation area monitoring equipment and will possess the necessary radiation protection
knowledge and skills on the management of radioactive contamination.
of the hospital. These members of staff play an essential role in a hospital response to
7. After initial management in the emergency department, patients radiation emergencies. Among other tasks, they are involved in:
may be: • Monitoring patients during second radiological triage;
• Admitted to the hospital (inpatient care) and directed to the • Supervising and monitoring decontamination efforts;
appropriate service; • Providing support for initial dose estimation;
• Transferred to a higher complexity referral hospital (inpatient • Surveying staff involved in the response; and
care); or • Supervising the return of the radiation emergency room to routine
• Released (outpatient care). use.
244 245
Chapter J Medical management at the hospital Instructions Information 4 Performing a second triage at the hospital
8. Patients and staff should be monitored at the last check point

before leaving the contamination control area by radiation
protection personnel.
9. Consider the appropriate safe, short-term storage and eventual
disposal of contaminated materials and wastes (maintenance
personnel, nurses, radiation protection personnel).
10. In the short-term, items should be double-bagged and removed
under the guidance of radiation protection or health physics
staff, to a place where public and staff access is minimised.
Figure J4. In the absence of any Figure J5. If contamination is suspected,

4 Performing a second triage at the hospital information, the emergency
department staff should assume
patient’s clothing and shoes should be removed
as promptly as possible, without compromising
that the patients are contami- life or limbs.
nated until confirmed otherwise,
and wear respiratory protection Photos: WHO.
Introduction and PPE as appropriate.
This section provides guidance on the sequence of steps to sort casualties

of radiation emergencies at the hospital. Two kinds of triage are
considered: Information J.6
Conventional or trauma triage is the medical screening of patients
• Conventional or trauma triage, to sort casualties into groups based on according to their need for treatment and the resources available. Although
their need for immediate medical treatment as compared to their triage systems may differ among countries, the rationale behind the
chance of benefiting from such care; and procedures and the basic criteria are quite similar.
• Radiological triage, based on radiological conditions of the casualties Patients are transported to the hospital after they have been classified in
the field. An initial or “primary” trauma triage is conducted on-site
in order to direct patients to the most appropriate medical services
(pre-hospital level) keeping in mind that the subsequently highest priority
[Section F.2.2]. should be given to life-threatening conventional injuries. Then, a “primary”
Despite the first triage conducted by the field teams, this second triage radiological triage is conducted in the field by emergency and rescue
teams, to identify people who require decontamination and/or emergency
should be done at the hospital, since the conditions of the casualties will admission.
be dynamic and thus may change whilst in transit.
The conditions of the patients are dynamic and they may therefore change
after this first triage (e.g. the clinical condition may worsen during transport
J.6 Second triage due to an ongoing haemorrhage or a person who was asymptomatic may
(HOSPITAL EMERGENCY TEAM) start vomiting after field triage). Thus, a second (trauma and radiological)
1. Perform a second trauma triage based on the medical condition triage should be performed upon the arrival of patients at the hospital.
of the patients, which may have improved or worsened. The second trauma triage is based on medical conditions of the patients
2. This second trauma triage will identify three levels of priority and allows them to be classified according to their clinical status, to ensure
(P): that priority is given to the management of life threatening conditions. The
second radiological triage is based on radiological conditions of the
• P1: need for immediate life-saving medical intervention prior patients and is aimed at directing patients to the most appropriate medical
to any decontamination action. These patients may be placed services.
246 247
Chapter J Medical management at the hospital Instructions Information 4 Performing a second triage at the hospital
into an isolated area of the hospital, where they can receive

urgent treatment, while clean conditions can be maintained
elsewhere. Decontamination may be conducted during
stabilisation of the patients, if it does not interfere with
medical actions. Otherwise, it should be postponed until the
end of the treatment.
• P2: need for medical intervention, but not immediate. If these
patients were not decontaminated at the scene,
decontamination may be performed at an appropriate (pre-
designated) area in the hospital, by staff wearing respiratory
protection and appropriate PPE, prior to further treatment.
• P3: less severe injuries, suitable for outpatient health care
depending on the results of the second radiological triage. Information J.6:2
These patients will normally have been decontaminated at If resources are stretched (e.g. a mass casualty event), it would be
the scene before arrival at the hospital. If it is not the case, appropriate to encourage P3 patients to go home to self-decontaminate
[Section G.3] and then return and present themselves as outpatients. Those
decontamination may be performed at an appropriate
patients may then be referred to a peripheral health care centre to avoid
(pre-designed) area in the hospital, by staff wearing overwhelming hospitals.
respiratory protection and appropriate PPE, before further
treatment of minor injuries.
3. Perform a second radiological triage based on radiological Information J.6:3
conditions of the casualties in order to direct patients to the The second radiological triage will consider the kinetics and severity of signs
most appropriate medical services. In this subsequent triage and symptoms attributable to radiation exposure (e.g. nausea, vomiting,
phase, patients with suspected radiation exposure of unknown diarrhea, erythema). Some individuals do not exhibit clinical signs/symptoms,
even after being exposed to radiation doses which are known to induce acute
severity should be transferred to a hospital medical service radiation syndrome (Dainiak, 2007), and they might not be identified initially
capable of identifying radiation induced effects. This includes: as irradiated people. In addition to the evaluation of clinical parameters, the
• Brief case history (based on the information transferred from second radiological triage should always include the evaluation of
the field and questioning the victim and/or family members); hematological parameters, i.e. sequential complete blood counts (CBC) with
white blood cell (WBC) differential.
• Basic physical examination (organ system-oriented inventory
of health impairments); and
• Blood sampling: blood cell counts (neutrophils, lymphocytes, Information J.6:4
platelets, red blood cells, reticulocytes), blood grouping, Table J1. Radiological triage categories.
chromosomal analysis and biochemical profile. Blood Score Condition
samples should be taken at the earliest stage to establish
0 Bystanders who, most probably, were not exposed to radiation
baseline values. Repeat differential blood cell counts every
Patients that can be followed on an outpatient basis or by a day care
4-8 hours the first day, every 12 hours the second day and I
hospital structure
daily thereafter. II Patients needing maximum medical effort to be rescued
4. As a result of this second radiological triage, three categories of Patients predicted to develop multiple organ failure (MOF), beyond
patients may be identified (I to III), while bystanders may be III
any curative measures
considered as score 0 [Table J1].
248 249
Chapter J Medical management at the hospital Information 5 Management of uncontaminated but possibly irradiated casualties
5 Management of uncontaminated but

possibly irradiated casualties
Introduction
This section provides guidance on the evaluation and treatment of
individuals who have been exposed to radiation (or are suspected of
having been exposed) but are neither contaminated with radioactive
material nor suffering conventional physical injuries. Depending on the
characteristics of the exposure (e.g. dose, dose distribution, radiation
quality) and of the patient (age, pre-existing pathologies), some of these
individuals may develop a clinical condition named Acute Radiation
Syndrome (ARS).
ARS is a set of characteristic signs and symptoms observed after total
or large volume partial body exposure to radiation. Most often ARS
results from exposure to an acute external penetrating irradiation.
However, it could develop after protracted irradiation and also as a
consequence of high dose internal exposure (e.g. ingestion or inhalation
of a radionuclide).
Before making therapeutic decisions it is necessary to confirm the
diagnosis of ARS and assess the prognosis in the shortest time possible.
The objective of the initial assessment of the health status of an ARS
patient is to:
1. Assess quickly whether exposure to ionising radiation has occurred.
2. Produce a first tentative diagnosis and assess the severity of damage.
3. Decide whether or not hospitalisation is required (inpatient or
outpatient?).
4. If the patient is admitted (inpatient), decide what type of health care
facility and sub-specialty consultation will be necessary to ensure
provision of appropriate health interventions.
5. Evaluate patient’s prognosis and the initial therapeutic approach.
250 251
Chapter J Medical management at the hospital Instructions Information 5 Management of uncontaminated but possibly irradiated casualties
J.7 Diagnostic strategies for ARS Information J.7

(HOSPITAL EMERGENCY TEAM) The purpose of the diagnostic phase is to obtain all the relevant data to
1. Obtain a detailed case history (based on the information determine severity of the radiation injuries and to establish prognosis.
transferred from the scene and from questioning the patient Special emphasis is put on the early reacting organ systems i.e.
and/or family/companions). haematological , gastrointestinal, neurological and cutaneous organ
systems. Classical signs and symptoms attributable to radiation exposure
2. Collect information on the accident and on the patient’s should be looked for (e.g. nausea, vomiting, diarrhoea, erythema [Tables J4
conditions of exposure (scenario, time, distance, position, - J7]).
shielding, risk of contamination).
Tenderness, oedema and pain of salivary glands (parotid), with an increase
3. Record current symptoms and signs focused on early radiation in the levels of serum amylase, is an early sign of cephalic exposure.
reacting organ systems such as haematopoietic system (H), Similarly, slowing of the EEG waves is an indicator of high dose exposure.
cutaneous system (C), gastrointestinal system (G) and Conventional trauma combined with ARS, may aggravate the patient’s
prognosis. If, owing to trauma, immediate invasive intervention is necessary,
neurovascular system (N). Concentrate on characteristic
this should be performed as quickly as possible, prior to, or in parallel with
prodromal ARS signs and symptoms such as nausea, vomiting, the diagnostic phase. As there is a risk of pancytopenia, surgical measures
diarrhoea, erythema of skin and/or mucosa, headache, should be definitive. The time window for performing surgery is restricted to
abdominal cramps, and unusual fatigue. Note and record time the first 72 hours, due to the possible onset of the pancytopenia, leading to
of onset, severity and frequency of any symptoms. Initial shock, an increased risk of bleeding and infection. Any further surgical intervention
unconsciousness, coma, ataxia, and lethargy, are suggestive of a should be performed after two months [Section J.6].
particularly poor prognosis (rule out trauma as a cause of Most infections in neutropenic patients come from endogenous microbial
altered neurological function). flora and they increase the risk of mortality. Sometimes, it is very difficult to
detect infections in neutropenic patients (e.g. no fever) and more
4. Look at the first blood cell counts (total and differential white sophisticated laboratory tests are necessary, such as interleukin-8 and
cell counts and absolute lymphocyte counts). A decrease in C-reactive protein.
absolute lymphocyte count or an early granulocytosis are In cases when stem cell transplantation may be required, it is recommended
typical prodromal signs observed in ARS patients. that the search for possible (compatible) stem cell or bone marrow donor(s)
5. Record conventional non-radiation related injuries (e.g. thermal, among the relatives should be initiated urgently. However, stem cell
mechanical). If immediate invasive intervention is necessary, transplantation is a therapeutic alternative to be considered after 14 to 21
days, in the absence of response to cytokine administration. In severely
perform surgery as fast as possible (within the first days after irradiated patients, growth factors/cytokine therapy should be started as
the accident). soon as possible. As a result of these evaluations, an organ specific grading
6. Perform a physical examination of the entire body, including: is applied and the patient may be categorised according to the type of
vital signs, blood pressure, temperature, pulse, and breathing response required.
rate. For symptomatic patients, take vital signs every 2 hours.
Include ophthalmologic, cardiac, pulmonary, abdominal and
neurological examination, and a careful observation of skin and
mucous membranes looking for erythema, oedema, blisters,
epilation, petechiae, conjunctival haemorrhage. Evaluate the
status of salivary glands. Record the patient’s weight.
7. Perform blood cell counts, repeat them on a regular basis (every
4-8 hours during the first day, every 12 hours on the second day
252 253
and every 24 hours thereafter), record the results in tables and

graphics. Information J.8
8. Perform red cell group typing. Acute radiation syndrome (ARS) is not just a single entity but a more
complex clinical condition. The classical concept of ARS is defined as a set
9. Perform qualitative and quantitative assessment of bone of signs and symptoms observed after external whole body or large
marrow smears. volume partial body exposure. ARS is more often associated with overt
exposures, but it may differ if there is a delayed discovery (e.g. covert
10. Perform laboratory tests including: amylase, electrolyte release) and particularly if the patient’s symptoms have been treated
balance, and functional tests for liver and kidney. before radiation is determined to be the cause. ARS becomes more
11. Consider other available haematological/immunological tests complex in terms of prolonged, partial, internal and/or organ specific
exposure. (Waselenko et al, 2004).
(e.g. clonogenic assays, lymphocyte subpopulations, and
proliferation response tests). Clinical changes are the result of damage to early reacting organ systems
12. Consider feasibility of performing laboratory tests for and are mainly manifest within two months after exposure. An early
prodromal phase developed during the first week is followed by a
endocrinology and metabolism.
clinically silent phase, which is shorter after higher doses.
13. Perform the necessary histocompatibility tests (HLA) in
patient/s and potential donors (relatives). The score presented in Table J2 is very useful when applied during the
first 48 hours after the exposure. The symptoms and signs indicated in
14. Store serum and cells or DNA for further analysis. the table are reliable only in cases of whole body or large volume partial
15. Obtain an inventory of the endogenous microbial flora (e.g. body exposures, and when the radiation dose is delivered within a few
intestine, skin). minutes to a few hours. The evaluation of clinical and haematological
parameters is generally considered to be the most reliable and available
16. Obtain additional information from imaging studies: chest and tools to categorise the patients, evaluate the prognosis and decide upon a
abdominal radiographs; skin ultrasound using more than 7.5 MHz; therapeutic strategy. These parameters are generally applicable to uniform
CT scans; MRI sequences; thermography; and bone scintigraphy exposures, but they are less applicable and less reliable for non-uniform
radiation exposure that might not affect substantial volumes of bone
of irradiated territories (as necessary and if available). marrow.
17. Obtain one electroencephalogram (EEG) and one
electrocardiogram (ECG). The more recent approach to the diagnosis of ARS is the METREPOL
SYSTEM, which is focused on an integrative quantification of the radiation-
18. Take sample for biological dosimetry [Instruction J.27]. induced damage in some critical organ systems such as neurovascular (N),
19. If possible, request assistance for dose reconstruction. haemopoietic (H), cutaneous (C) and gastrointestinal (G) to produce a
graded code [Instruction J.10]. After very high doses, the prognosis of ARS
will rely mainly on the extent of damage to organs other than bone
J.8 Primary Scoring of ARS patients (to be used during the first 48 marrow (e.g. lung, gastrointestinal tract, skin), with the risk of multiple
hours) (HOSPITAL EMERGENCY TEAM) organ dysfunction (MOD) and even failure (MOF).
Table J2 shows a simple method for early patient scoring according (Weisdorf et al, 2007; Freisecke et al, 2001; Fliedner et al, 2001; Fliedner et
to the severity and delay of the main clinical findings (symptoms al, 2005; Gorin et al, 2006).
and signs) and lymphocyte kinetics, during the first two days after
exposure. (Continued over page)
254 255
J.9 Quick strategies to be applied after the initial scoring to deal

with great number of casualties Information J.8 (cont.)
(HOSPITAL EMERGENCY TEAM) Table J2. Scoring for the first 48 hours1 (adapted from EBMT, 2007).
This procedure is intended to be applied during the first 48 hours. It Score I Score II Score III
can be particularly useful when there are large numbers of Delay < 12 hours < 5 hours < 30 minutes
casualties to be managed, while undertaking the necessary actions erythema 0 +/- + + + < 3rd hour
to properly evaluate them and make decisions about treatment. asthenia + ++ +++
nausea + +++ (-)
1. Life-threatening trauma, wounds and/or burns should be treated
vomiting (per day) 1 1-10 >10; intractable
first.
diarrhoea (stools per
2-3; bulky 2-9; soft >10; watery
2. Remember that an externally IRRADIATED person does not day)
impose any risk to staff and there is no need to use PPE for abdominal pain minimal intense excruciating
radiation protection (consider personnel protection for other headaches 0 ++
excruciating;
ICHT2
risks, in accordance with standard procedures in hospital
temperature < 38 °C 38-40 °C > 40 °C
emergency departments).
temporary
blood pressure normal Systolic < 80 mm
3. In case of external IRRADIATION associated with decrease
RADIONUCLIDE CONTAMINATION, decontamination loss of consciousness 0 0 temporary / coma
procedures should be performed immediately following patients Lymphocytes at 24h > 1500/μl < 1500/μl < 500/μl
stabilisation. In this case use respiratory protection and Lymphocytes at 48h > 1500/μl < 1500/μl < 100/μl
appropriate PPE [Section J.8]. Outpatient
Hospitalisation
Hospitalisation
Strategy for curative
monitoring (MOF predicted)
4. Perform urgent sampling: treatment3
• Blood cell counts every 4-8 hours during the first day1, and 1 The symptoms and values presented in this table are reliable only in cases where the whole
body or large parts of the body have been externally exposed to a high dose absorbed in a
then every 12-24 hours (include platelets and reticulocytes); short time (minutes to few hours)
2 ICHT: intra-cranial hypertension
• Red cell group typing; 3 Depending on the scale of the event, see if some patients on score 2 could be managed as
outpatients (e.g. mass casualty event).
• Biodosimetry (see procedure for cytogenetic dosimetry in
Instruction J.27);
• Store serum and cells or DNA for further analysis including
HLA typing;
• Standard biochemistry including amylasemia;
Information J.9:4
• In case of neutron exposure: Blood sample (20 ml) to
During exposure to neutrons, the reaction between neutrons and the body
measure 24Na in whole body counting and determination of
sodium gives rise to 24Na, an activated isotope that emits gamma-rays. It is
32
P concentration in hair; and possible to measure these gamma-rays to estimate the specific activity of
• If internal radionuclide contamination is suspected: collect 24
Na (in blood samples or by using whole body counters), which can be used
excreta (urine and faeces). for the retrospective estimation of neutron doses.
The reaction between neutrons and the body phosphorus gives rise to 32P, a
neutron activated isotope that can be measured in hair and clothes (other
neutron activated products can be also measured in personal belongings).
1 The frequency of blood cell counting should be adapted to the number of casualties and existing (Hankins, 1980).
capabilities
256 257
5. Beware of the potential for Multiple Organ Dysfunction (MOD)

/Failure (MOF). The severity of the following prodromal Information J.9:6
clinical features are of major importance to predict MOD/MOF: The information required to consider further dose reconstruction (i.e.
circumstances of the event, type of scenario, source, source-victim geometry,
• Extensive and immediate erythema; duration of the exposure, shielding, heterogeneity of the exposure, etc.) would
have ideally been collected at the scene by the procedures described in section
• Temporary loss of consciousness; H.5, except in the case of a category P1 patient.
• High fever; It is important to collect personal belongings, clothes, hair, nails, and even teeth
• Hypotension; and (if removed for any reason) because those materials could be further used for
dose reconstruction purposes. Electron spin resonance/ESR (also termed
• Immediate diarrhoea. electron paramagnetic resonance/EPR) may be used for retrospective dose
6. Consider and gather information for dose reconstruction: assessment in tooth enamel, nails and personal belongings. (Greenstock and
Trivedi, 1994; Swartz et al 2006, Swartz et al, 2007; Alexander et al, 2007).
• Enquire into the circumstances of the event, type of scenario,
source, source-victim geometry, duration of the exposure,
shielding, homogeneous/heterogenous irradiation; Information J.9:7
Table J3. Selection of the therapeutic strategy according to the clinical status of the patient,
• Collect, label and store personal belongings, clothes, hair, based on the scoring for the first 48 hours proposed in Table J2 (EBMT, 2007).
nails, etc.; and Score Score I Score II Score III
• If a patient’s tooth is removed for any reason, it should be Hospitalisation for
curative treatment.
collected, labelled and kept for analysis by electron spin Depending on the
resonance. Patient
Outpatient
clinical
scale of the event, Hospitalisation. Prediction of
manage- some patients could Multi-Organ Failure (MOF)
This task can be performed by the health/medical physicist of ment
monitoring
be managed as
the hospital (if available), a nurse, auxiliary, other health worker outpatients (e.g. mass
casualty event).
or even administrative personnel (provide instructions).
At least daily Supportive care, blood
External assistance from the local/national competent blood cell component therapy as Palliative/symptomatic
authorities (health authority and/or regulatory body) for further Supportive counts for 6 necessary, treatment. Blood component
care days and symptomatic treatment therapy if considered
processing of the samples should be requested, if necessary. weekly for 2 of GI damage, reverse necessary
months isolation
7. The therapeutic strategy should be selected according to the
Indicated until reassessment
clinical status of the patient, as shown in Table J3. Cytokines/
Early administration
of the score. The re-evaluation
of G-CSF for 14-21
growth no during the first week will be
Biodosimetry and dose reconstruction may contribute to factors
days.
based on laboratory findings
evaluating the heterogeneity of the exposure and the feasibility and clinical symptoms
of spontaneous recovery of bone marrow function. Although Criteria to transplant: severe bone marrow aplasia
persisting 14-21 days under cytokines, no residual
physical and biological dosimetry are required for later Stem Cell haematopoiesis, no irreversible organ damage.
no Type of graft: bone marrow, peripheral HSC, cord
treatment, samples should be taken in the early stages, Transplan-
tation blood.
otherwise data will be lost. Conditioning: fludarabine +/- antilymphocyte globulin.
Don’t use MTX for GVHD prevention
The dose distribution is more important than the dose itself (e.g.
G-CSF: Granulocyte-colony stimulating factor
5 Gy heterogeneous exposure has better prognosis than 4 Gy GI: Gastro-Intestinal
homogeneous exposure). However, dose estimate (population MTX: Methotrexate
GVHD: Graft Vs. Host Disease
dose exposure and distribution) is important in terms of HSC: Haematopoietic Stem Cells
258 259
planning resources required e.g. medical services for the next

two weeks and even for the following several months.
J.10 Organ specific grading and Response Categories (RC) to be

applied beyond the first 48 hours
(HOSPITAL EMERGENCY TEAM) Information J.10
The steps for establishing METREPOL organ specific grading, The manifest illness phase of the ARS becomes clinically evident as a
grading code and the corresponding response categories (RC) are consequence of the impairment of some critical organ systems such as
the following: neurovascular (N), haematopoietic (H), cutaneous (C) and gastro-intestinal
(G). After exposure to ionising radiation these 4 early reacting organ
1. Assess signs and symptoms, rating them with a degree of systems express different signs and symptoms. After very high doses, the
severity between 1 and 4 according to the tables provided for prognosis of ARS depend mainly on the extent of damage to organs other
neurovascular (N), haematopoietic (H), cutaneous (C) and than bone marrow (e.g. lung, gastrointestinal tract, skin), with the risk of
gastrointestinal (G) organ systems. Consider as “zero degree” if multiple organ dysfunction (MOD) and even failure (MOF). The METREPOL
a given sign or symptom is absent. system of categorisation uses a semiquantitative method for describing
signs and symptoms and rating them with a degree of severity between 1
2. Take the maximum of any degree found in a given organ
and 4. Zero is used when a given sign or symptom is absent. The
system (maximum approach) and attach this number as an combination of clinical characteristics and degree of severity is termed
index, to the initial representing that organ system. “grading”. The highest degree of severity, for a given symptom/sign within
3. Proceed in this way for the four organ systems (N, H, C and G). one organ, determines the organ specific grading. The combination of the
4. The grading code will thus be represented by the four letters organ specific grading for N, H, C and G is termed “grading code”. On the
(N, H, C and G) with their corresponding indexes. basis of the integration of the elements of the four systems, the highest
grading code of a given organ determines the Response Category (RC)
5. The highest organ specific severity index will determine the [Figure J6, example of RC calculation]. RC reflects the damage to critical
response category (RC) at a certain time point (days after organs based on indicators of effect and expressed as a function of time
exposure). after exposure. Based on this category of response, the patient might be
6. Repeat steps 1-5 at periodic intervals, according to the discharged from the emergency department, admitted to a routine care
recommendations provided in Instruction J.11. medical/surgical floor, admitted to an intensive care unit of the hospital,
or referred to another hospital that has greater relevant specialist capacity.
On the following pages METREPOL tables for rating signs and (Fliedner et al, 2001; Fliedner et al, 2007; Gourmelon et al, 2005).
symptoms with a degree of severity between 1 and 4 are presented.
Four tables are provided for neurovascular (N), haematopoietic (H),
cutaneous (C) and gastro-intestinal (G) organ systems.
260 261
Chapter J Medical management at the hospital 5 Management of uncontaminated but possibly irradiated casualties
Table J4. METREPOL: Neurovascular system. Table J6. METREPOL: Cutaneous system.
Symptom Degree 1 Degree 2 Degree 3 Degree 4 Symptom Degree 1 Degree 2 Degree 3 Degree 4
N C
Nausea Mild Moderate Intense Excruciating Moderate; Marked, Severe; isolated

isolated isolated patches or
Vomiting Once/day 2-5 times/day 6-10/day > 10/day Minimal and
Erythema patches < 10 patches or confluent; >40%
transient
Decreased Minimal Parenteral nutrition cm2 of body confluent; of BS,
Anorexia Able to eat
intake intake needed surface (BS) 10-40 % of BS erythroderma
Work Assistance Slight and Moderate and
Fatigue Able to work Cannot do ADL Sensation/ Severe and
impaired for ADL Pruritus intermittent persistent pain
Itching persistent pain
> 40 for pain
Temperature (°C) < 38 38-40 > 40 for > 24 hrs.
< 24 hrs. Swelling/ Present; Symptomatic, Secondary Total
Headache Minimal Moderate Intense Excruciating
oedema asymptomatic tension dysfunction dysfunction
Blood pressure Rare, with Rare; with Bullae with Bullae with
Blistering
> 100/70 < 100/70 < 90/60 < 80 sistolic sterile fluid haemorrhage sterile fluid haemorrhage
(mmHg)
Neurologic Barely Easily Desquamation Absent Patchy dry Patchy moist Confluent moist
Prominent Life-threatening LOC
deficits1 detected detected Ulcer/ Muscle/bone
Epidermal only Dermal Subcutaneous
Cognitive Major Complete Necrosis involvement
Minor loss Moderate loss
deficits2 impairment impairment Complete and Complete and
Thining, not
Hair loss Patchy, visible most likely most likely
1 Reflexes (included corneal), papilledema, seizures, ataxia, other motor and sensory striking
reversible irreversible
signs
2 Impaired memory, reasoning or judgement Onycholisis Absent Partial Not defined Complete
ADL: activities of daily living; LOC: loss of consciousness
Table J5. METREPOL: Haematopoietic system.

Table J7. METREPOL: Gastro-intestinal system.
Symptom Degree 1 Degree 2 Degree 3 Degree 4
H Symptom Degree 1 Degree 2 Degree 3 Degree 4
Absolute G
lymphocyte >
_ 1500 1000-1500 500-1000 < 500 Diarrhoea 7-9 stools/
2-3 stools/day 4-6 stools/day >
_ 10 stools/day
count/μL frequency day
Absolute Stool
< 500 or initial Bulky Loose Sloppy Watery
neutrophil >
_ 2000 1000-2000 500-1000 consistency
granulocytosis
count/μL
Intermittent
Persistent with
Platelet 50000 Mucosa loss Intermittent with large Persistent
>
_ 100000 20000-50000 < 20000 large amount
count/μL - 100000 amount
Local, no Local, only Systemic, oral Gross
GI bleeding Occult Intermittent Persistent
antibiotic local antibiotic antibiotic Sepsis, intravenous haemorrhage
Infection
therapy therapy therapy antibiotics necessary Abdominal
required required sufficient cramps or Minimal Tolerable Intense Excruciating
Petechiae; Gross blood Spontaneous pain
Mild blood loss
Blood loss easy loss with bleeding or blood
with < 10 %
bruising; 10-20 % loss with > 20 %
decrease in Hb
normal Hb decrease in Hb decrease in Hb
Normal reference values (degree 0):

Absolute lymphocyte count: 1400 - 3500 cells/microliter (μL)
Absolute neutrophil count: 4000 - 9000 cells/microliter (μL)
Platelet count: 140000 - 400000 cells/microliter (μL)
262 263
J.11 Frequency of examination of METREPOL Response Categories

(RC) Information J.10
These instructions provide guidance on the frequency with which Example of METREPOL RC calculation
the response categories (RC) should be re-evaluated, according to A patient evaluated two days after the exposure presents:
the patient´s condition.
severe haematopoietic damage H3
1. If the patient is categorised as RC1 (mild damage):
(a) Complete system review every 24 hours for 6 days;
(b) Thereafter once weekly; and moderate gastrointestinal damage G2
(c) Final assessment at day 60 post-exposure.
moderate neurovascular damage N2
2. If the patient is categorised as RC2 (moderate damage): 2 days post-
irradiation
(a) If the patient does not present clinical complications such as mild cutaneous damage
bleeding, infections, etc., complete system review every C1
24 hours for 6 days; Maximun
(b) If the patient has clinical complications, complete system degree of
severity in H3 G2 N2 C1 RC= 32d
review every 12 hours until stabilisation of symptoms, the code
thereafter once weekly; and
(c) Final assessment at day 60 post-exposure. Figure J6. How to calculate the response categories (RC) using METREPOL.
3. If the patient is categorised as RC3 (severe damage):

(a) If the patient does not present clinical complications such as
bleeding, infections, unconsciousness, etc., complete system Information J.11
review every 12 hours for about 6 days. Thereafter, once The Response Categories (RC) are intended to be regarded in the daily
daily up to day 30. Only if signs of recovery are seen, can clinical routine as dynamic values which should be re-evaluated
periodically, since the clinical condition of patients is also dynamic and
the intervals be extended (e.g. examination once weekly);
may improve or worsen with time.
(b) If the patient has clinical complications, complete system
review every 6 h until stabilisation of symptoms. Then,
complete system review every 12 hours for about 6 days.
Thereafter, once daily up to day 30. Only if signs of recov-
ery are seen, can the intervals be extended (e.g. examination
once weekly); and
(c) Final assessment at day 60 post-exposure.
4. If the patient is categorised as RC4 (serious damage):

(a) Complete system review every 6 h for about 3 days (in case
of uncertainties or clinical complications, for about 6 days).
Thereafter, examine once daily. Only if signs of recovery
264 265
can be seen, and no additional complications arise, can the

intervals be extended (e.g. examination every 2 or 3 days or
once weekly); and
(b) Final assessment at day 60 post-exposure.
J.12 Strategies according to METREPOL Response Categories (RC)

(HOSPITAL EMERGENCY TEAM) Information J.12
The actions are described in Table J8 below, where the response Each RC represents a level of damage, which in turn can be associated
categories (RC1 to RC4) are correlated with: with a probability of autologous recovery. The requirements for the
• Severity of damage (mild, moderate, severe or serious); and institution where the patients should be hospitalised are highly dependent
on patients’ RCs, which in turn require specific therapeutic interventions.
• Likelihood of autologous recovery.
The complexity of clinical care required for the patients increases at
higher RC.
For each of the four response categories (RC1 to RC4) a strategy is
proposed. This strategy includes: Accidental radiation exposure is generally heterogeneous. Some under-
exposed/protected regions of the bone marrow can provide sufficient
• Institutional levels of care for radiation casualties; and
residual stem cells to enable endogenous (autologous) haematopoietic
• RC-dependent therapy. recovery, during which time possibly intensive clinical support is needed.
Table J8. Therapeutic strategy according to the METREPOL response categories.

Haematopoietic Stem Cell (HSC) transplantation is not an emergency
Response action. In immune compromised patients, blood components treatment
Severity of
Category Strategy
damage (substitution or replacement) may be followed by Graft Versus Host
(RC)
Disease (GVHD). It is crucial to avoid GVHD in order not to compromise a
Mild damage
Outpatient care or general medical wards. possible endogenous (autologous) recovery. In order to reduce leucocyte
Autologous
RC 1 General support of recovery processes. number, all blood products should be irradiated (~25 Gy) prior to
recovery
Usually no specific therapy.
certain administration to a patient with ARS. Only if severe aplasia persists under
Moderate Medical wards with haematological, neurological cytokine treatment for more than 14 days, should HSC transplantation be
damage and dermatological consultation services. considered.
RC 2
Autologous Supportive care.
recovery likely Substitutive therapy with blood components.
(Dainiak et al, 2003; Fliedner et al, 1996; EBMT, 2007).
Haematological-oncological institution/service
Severe
with reverse isolation; intensive care unit;
damage
consultations of all medical specialities.
RC 3 Autologous
Supportive care.
recovery
Substitutive therapy with blood components.
possible
Stimulation therapy (cytokines/growth factors).
Specialised hospital with experience in all areas
Serious of intensive care medicine, particularly
damage allogeneic stem cell transplantation.
RC 4 Autologous Supportive care.
recovery most Substitutive therapy with blood components.
unlikely Stimulation therapy (cytokines/growth factors).
Stem cell transplantation
266 267
5.1 Therapeutic principles for ARS patients

Information Section J.5.1
In accordance with the response categories (RC), the therapeutic measures
should be adapted to the patient’s state of health and to the extent of
J.13 Supportive care for ARS patients damage to different organs and systems. Individual contraindications and
1. Anti-emetic therapy: low effectiveness (e.g. antihistamines) or possible side effects should also be taken into account. Therapeutic
high effectiveness drugs such as 5-HT3-antagonists (e.g. principles for ARS patients are based on supportive care, substitution
(blood component therapy), stimulation (growth factor therapy), stem cell
ondasetron) and dopamine-D2-antagonists (e.g. domperidone). transplantation and surgery (if indicated).
If it is not effective, glucocorticoids combined with neuroleptics
The strategy is based on the principle of allowing spontaneous
may be indicated. (autologous) recovery whenever possible. Biodosimetry and dose
2. Analgesic therapy: follow WHO schemes levels I-III as follows: reconstruction may contribute to indicate the extent of heterogeneity of
the exposure and the feasibility of spontaneous recovery of bone marrow
• Level I: non-steroid anti-inflamatory drugs (NSAID) except function. However, waiting for dosimetry before making decisions on
aspirin; treatment could be detrimental to the patient. The first 24 hours can be
considered as an important therapeutic window and clinical dosimetry
• Level II: low effect opiates; could be sufficient, especially in highly irradiated casualties.
• Level III: high effect opiates; and
Supportive care includes the reverse isolation and movement to an
• If level III is not effective: combine with corticoids and environment protected from potential infectious agents because
neuroleptics. prevention of sepsis is critical in the period of bone marrow aplasia, which
3. Brain oedema therapy: corticosteroids (e.g. dexamethasone), depending on the dose and dose distribution, will not occur until several
days or even weeks after the exposure.
mannitol and diuretics.
4. Adapted nutrition: enteral hypercaloric diet, preventing The criteria for managing ARS patients during the period of bone marrow
infections, glutamine and sucralfate to protect gut mucosa, aplasia are quite similar to those applied for other severely neutropenic
patients. Since the patients will not be producing white blood cells, in the
parenteral nutrition if needed. Consider electrolyte and fluid case of sepsis, they may not show the typical signs of infection. The most
replacement according to laboratory data. reliable sign, and often the only one, will be a fever (in excess of 38 °C).
The presence of any traditional sign or symptom of infection in an ARS
5. Prevention of infections: prophylactic antibiotics directed patient should be carefully followed, e.g.:
against gram-negative bacilli, using extended-spectrum • Respiratory System: cough, bronchial obstruction, crackles, rhonchi,
quinolones or similar agents. Antibiotic therapy specified wheezes;
according to microbiological tests or, if not available, third • Urinary system: burning, dysuria, hematuria, cloudy urine, genital
generation cephalosporin or monotherapy. Suppression of yeast secretions;
colonisation with fluconazole or alternative agents. • Gastro-intestinal: diarrhoea, bloody stools;
Gastrointestinal decontamination with common schemes. • Skin & Mucous Membranes: redness, tenderness, swelling, “fungal”
white patches, blisters; and
Antifungal therapy if febril patients do not respond to
• Indwelling devices: intra-venous lines and urinary catheters
antibiotics. Antiviral therapy (to prevent/treat herpes simplex or symptomatic for infection.
cytomegalovirus infection). Reverse isolation and protected
Platelet substitution prevents bleeding during the bone marrow aplasia
environment. period, but risk of overtransfusion should be prevented. The rationale for
6. A standard protocol for the prevention and management of avoiding surgery during the period of bone marrow aplasia is not to
expose an immunosuppressed patient to surgery, to prevent infection and
infection in neutropenic patients can be applied e.g.: to start bleeding. To cover wounds at least with a temporary technique will reduce
antibiotics if the ARS patient has a neutropenic fever (> 38°C) the risk of infections during the aplastic period. (Fliedner et al, 2001;
with an absolute neutrophil count (ANC) of 500/μL or less or if Fliedner, 2006).
268 269
their ANC is 1000/μL and is likely to fall below 500/μL in the

next 48 hours (e.g. forthcoming nadir) or if there are any signs Additional information concerning ARS
of infection. ARS in children
7. Skin treatment: dermoprotector creams in the prodromal phase; ARS in children may vary depending on age. Children have a number of
later topical or systemic steroids might be considered, vulnerabilities that place them at greater risk of harm after radiation
exposure. Information about ARS after exposure to ionising radiation in
hydrocolloid dressings, local infection prophylaxis & treatment; children and the fetus is very limited. It is confined to historic data from
in a later stage pentoxifylline and alpha-tocopherol might need the atomic bombings of Hiroshima and Nagasaki, and a few cases of
to be applied. accidental over exposure to orphaned sources or unintended medical
8. Others: mental health interventions, physiotherapy, prevention/ exposure (e.g. miscalibration in paediatric radiotherapy). The experience
from therapeutic irradiations and paediatric haematology may also be
treatment of seizures, hypotension. considered, although those situations imply fractionated exposure regimes
and/or partial irradiations often combined with chemotherapy.
J.14 Substitution therapy for ARS patients
Paediatric patients should not be split into many categories during an
1. Blood components should be irradiated (25 Gy) to prevent Graft emergency, since the system needs to operate in a cohesive way and allow
Versus Host Disease (GVHD). responders to treat patients in the time available. Dealing with children in
2. Platelets substitution with threshold as follows: subgroups would slow down the response.
• 10 000 /μL if close monitoring is possible, no bleeding, no
For adults, the medical evaluation starts from symptoms (not from doses),
other complications;
but with children and fetuses, biology and prognoses based on the dose
• 20 000 /μL if close monitoring is not possible, bleeding, no reconstruction are relatively more important.
other complications; and
• 50 000 /μL if additional trauma, surgery, cerebral oedema, After a delayed discovery, the physician may need to reconstruct the dose
10-20 days after exposure; if a patient received symptomatic treatment,
transfusions.
this medical intervention could have modified the clinical picture.
3. Erythrocyte substitution: Indications for transfusion should be
strict and related to the level of haemoglobin (Hb) according Fetus & pregnant women
with the hospital criteria. Patients at higher risk of coronary Fetal doses can be a significant public health issue and a very emotional
disease or stroke may receive transfusions if Hb < 10 g/dl. subject as one of the options to be considered may be pregnancy
termination, depending on gestational age and dose. To provide adequate
support for decision making, the professionals involved must rely on dose
J.15 Stimulation therapy for ARS patients reconstruction. Individual risk perception and the family context are
There are presently several cytokines available for the treatment of critical elements in decision making for pregnant women.
radiation induced bone marrow failure:
The need to identify pregnant women in a population affected by radiation
• Granulocyte Colony-Stimulating Factor (G-CSF), including should be evaluated depending on the scale of the event and availability
pegylated forms; of resources. Although the estimated percentage of total population who
• Granulocyte-Macrophage Colony-Stimulating Factor are pregnant at a given period varies according to the local CBR1, for most
(GM-CSF); European countries it could be around 1 % (EUPHIX Public Information
System).
• Erythropoietin;
• Interleukin 11 (IL-11);
• Thrombopoietin (TPO) and several TPO agonists;
• Keratinocyte Growth Factor (KGF); and
• Stem Cell Factor (SCF). 1 CBR: crude birth rate is the annual number of live births per 1000 persons
270 271
Treatment with cytokines:

1. The use of cytokines is a therapeutic decision that should be
made on a case by case basis. Information J.15
2. The decision will depend on availability of resources and The efficacy of cytokines has been demonstrated even when the treatment
magnitude of the event (number of casualties). started around 3 weeks after exposure in people exposed to whole body
3. There is consensus in the EU that G-CSF (5-10 μg/kg per day) doses below 5 Gy and/or exhibiting under exposed bone marrow
territories. These patients will show a temporary phase of aplasia, but
and KGF should be used. should recover spontaneously. This recovery will take place earlier in case
4. SCF could be of interest, but there is some concern about its of cytokine administration.
clinical tolerance. TPO and IL-11 should not be combined. (CDC Neupogen, 2006; Dainiak et al, 2003; Gorin et al, 2006).
5. It is desirable to start stimulation therapy as quickly as possible,
but blood changes should be observed for at least 24 h
(lymphocyte count is an important factor in decision making).
6. The medical staff of the emergency department can wait 24 h Information Section J.5.1
for expert advice before taking decisions about stimulation
therapy. 1 2 3 4
7. Once started, the treatment should be continued for 14-21 days
(except if, several days after having started the treatment, the
results of the biological dosimetry indicate that it should be Ambulatory
Monitoring
Hospitalization
stopped).
Hematologic Degree
J.16 Stem cell transplantation in ARS patients 2 3 4

1. Haematopoietic Stem Cell (HSC) transplantation may be
considered only if it appears that spontaneous haematopoietic ICU ICU
recovery will not occur. The absence of residual haematopoiesis Blood Blood Blood
should be confirmed. Component
Transfusion
Component
Transfusion
Component
Transfusion
2. HSC transplantation may be indicated if a severe aplasia
Growth Growth
persists for more than 14-21 days under cytokine treatment. Factor Factor
3. HSC transplantation is not indicated in patients exhibiting Therapy Therapy
irreversible organ damage.

Stem Cell
4. Sources of HSC are: bone marrow, peripheral blood and cord Transplantation
blood.
5. Priorities for donors are as follows: Figure J7. Overall therapeutic approach for ARS patients according to the METREPOL
1-4 Response Categories. Note: ICU -intensive care unit. (Reprinted from Experimental
• HLA-identical sibling or 7/8 matched; Hematology, 30, Nicholas Dainiak, Hematologic consequences of exposure to ionizing
• HLA-identical unrelated donor or 9/10 matched; and radiation, 513-528, Copyright (2002), with permission from Elsevier).
• Cord blood < 4/6 matched.
6. Once the patients for whom HSCT might be indicated have
been identified, an oral swab and blood sampling from patients
and immediate siblings should be performed for donor
searching. In case no family donor is available, high resolution,
272 273
allele-level HLA typing for HLA-A, HLA-B, HLA-C and

HLA-DR loci should be performed on the potential recipient to Information Section J.5
facilitate the identification of an allogeneic unrelated SC or cord
blood donor.
7. Although irradiated casualties may be significantly
myelosupressed, they may be incompletely immunosuppressed
and they could require additional immunosuppression if a
HSCT is envisaged, to prevent graft rejection, particularly if
unrelated or partially matched donors are used.
Immunosuppresive treatment includes fludarabine (30 mg/m2
per day for 3 days, alemtuzumab or anti-lymphocyte globulin,
accompanied in some cases by alkylators (e.g.
cyclophosphamide).
8. Graft Versus Host Disease (GVHD) prophylaxis includes Figure J8. Blood cell depletion curves (reproduced from EBMT, 2007, courtesy of
authors).
cyclosporine or tacrolimus, in addition to mycophenolate
mofetil. Methotrexate should not be used to avoid epithelial
toxicity.
9. Doses of cells to be grafted (at least):
• 2 · 106 CD 34 cells (stem cells)/kg;
• 2 · 108 bone marrow nucleated cells/kg; and
• 3 · 107 cord blood nucleated cells/kg.
J.17 Surgery in ARS patients

If surgical interventions are required in a patient with ARS, specific
rules should be followed:
1. Surgical interventions should be carried out as early as possible
(< 72 hrs) or at a time when risk of bleeding or infection can be
controlled (> 2 months after exposure).
2. Non-urgent surgical interventions should be postponed until
patient recovery from pancytopenia.
3. Consider wound closure, even with temporary covering, at an
early phase.
274 275
Chapter J Medical management at the hospital Instructions Information 6 Combined injuries
6 Combined injuries
Introduction
This section provides guidance on the medical management of
combined injuries (e.g. medical conditions where the radiation exposure
is combined with burns, wounds, trauma or infection).
Since radiation does not cause immediate life-threatening risks, any
serious injury will take priority over concerns about irradiation or
contamination.
The prognosis for all combined injuries is worse than for radiation
injury alone. There is not a simple addition of risks but a synergistic
effect. Radiation injury affects the response to trauma and burns and,
on the other hand, trauma and burns modify the responses to radiation Information J.18a
sickness.
Since radiation does not cause immediate life threatening risks, any
serious injury should take priority over concerns about irradiation or
contamination. The patient with multiple injuries should be resuscitated
J.18 Criteria for managing combined injuries and stabilised. Standard preparation for surgery (if necessary) will partly
remove the radioactive contamination on the skin.
1. Evaluate Air-Breathing-Circulation (ABC) and perform Combined injuries shift the treatable range of radiation injuries to the
standard trauma resuscitation and clinical stabilisation. lower radiation doses. Experimental data have demonstrated that, when
Maintain ventilation and perfusion and stop hemorrhages. other injuries are accompanied by sublethal irradiation, infections are
Prevent infection, maintain fluid and electrolyte balance and much more difficult to control and wounds and fractures heal more
slowly. Even potentially survivable burns and trauma can be fatal in
prevent bleeding. During these procedures, assume the patient
persons who have also received sublethal doses of radiation.
is contaminated until confirmed otherwise.
2. Determine if the victim is contaminated with radioactive There is not a simple addition of risks but a synergistic effect. Radiation
material. If suitable personnel and/or survey instruments are injury affects the response to trauma and burns (slower healing, loss of
weight, loss of granulation tissue, increase risk of infection and
not available, assume contamination until proven otherwise
haemorrhage, prolonged hospitalisation, increase morbidity and
[Information J.2]. If it has not already been done, remove mortality). On the other hand, trauma and burns modify the responses
clothing following procedures described [Instruction G.7] to radiation sickness.
provided it does not cause harm or unacceptable delay. Delay
further decontamination until the patient is in a stable Due to the delay in wound healing and the subsequent neutropenia and
condition. Any (potentially contaminated) clothing removed thrombocytopenia, most of the life saving, limb saving and
reconstructive surgical procedures must be performed within 36-72
should be bagged, labelled and removed from the area. hours after exposure. Surgery should then be avoided, if possible, for
3. Staff should wear PPE, particularly respiratory protection, and the next 1-2 months post-exposure.
ideally a personal dosemeter. Alternatively a single dosemeter (Pellmar and Ledney, 2005; Flynn and Goans, 2006).
276 277
could be used as a “sentinel” for the area.

Information J.18b
4. If metallic fragments are visibly embedded in the body (e.g.
tissues, wounds), assume that they are radioactive until proven If the event includes fire or explosions as well as radiation exposure, it is
likely that flame/flash burns will exacerbate with radiation-induced
otherwise and promptly remove them by using long forceps,
erythema (skin redness). From the very beginning, flame and flash burns
without touching them directly (even if using gloves). If they are painful, they involve loss of hair and even tissue loss (depending on
are fragments from a radioactive source they could be the depth of the burn). Although the kinetics of radiation burns (or “local
extremely radioactive. The wounds should then be monitored radiation injuries” or “cutaneous radiation syndrome”) is highly
for gamma activity as soon as possible to determine how staff dependent on the local absorbed dose, they usually exhibit an early
should proceed. (primary) erythema but without neither tissue nor hair loss at the
beginning (however, they may occur by two weeks after exposure). More
5. If the fragments are highly radioactive, or if the wound has not detail provided in Section J.7.
been monitored, then the following procedure should be applied:
• Remove the fragment using two people - one to extract the Trauma or stress can cause initial lymphocytosis followed by
lymphopenia, which may lead to misinterpretations of the blood cell
fragment and the other to assist and quickly remove the counts used to follow ARS patients. If a trauma or burned patient is in
excised fragment to a safe location, without direct physical pain, shock or reacting to a medication, vomiting will be a less reliable
contact; indicator of ARS. On the other hand, serum amylase is not affected by
• The person removing the fragment (and ideally the assistant trauma, unless the parotids are directly involved (e.g. cranial trauma).
as well) must be wearing a dosemeter (capable of providing
instantaneous dose rate and accumulated dose) and ideally
finger dosemeters (e.g. TLDs);
• The most active fragment (if known) should be dealt with
first and each excised fragment should be safely contained,
labelled and removed to an area well away from normal staff
operations (until they are dealt with by experienced
personnel or confirmed non-radioactive) before the next
fragment is removed; and
• The accumulation (or concentration) of radioactive fragments
in staff working areas must be avoided.
6. Staff may need to be changed (or rotated) during this procedure
to minimise the individual dose [Tables E1 and E2].
7. Someone should be assigned responsibility for maintaining
records of staff exposure, and ensuring that members of staff do
not become over exposed.
8. Obtain a medical and exposure history, based on the information
transferred from the scene and from questioning the victim and/
or family members. Information on mechanisms of trauma and
injury, previous pathological conditions, previous medications,
and allergies should also be collected.
278 279
9. Conduct an evaluation of the possible external exposure (Acute

Radiation Syndrome), take biological samples and follow
procedures for ARS described in Section J.5. However, note
that absolute lymphocyte counts may be less reliable, due to the
physiological response to trauma and/or thermal injury.
Hemoconcentration or hemodilution may be seen as a
consequence of the injuries, the therapy, or the use of
transfusions in patients with hemorrhagia.
10. Treat serious injuries according to standard protocols. A patient
with ARS should be subjected to surgery, only if strictly
necessary. Such surgery should be completed as soon as possible
(i.e. within the first 36 to 72 hours of the radiation exposure). Plan
to postpone any additional surgery until hematopoiesis is restored.
11. Decisions on transfer for surgery, burn care or supportive care,
are based on the patient’s injuries, clinical condition, age, the
number of patients, and the availability of resources. Figure J9. If the patient presents a fracture, the patient should be stabilised,
decontamination should be performed (if needed) and the fracture definitely treated.
12. Whenever possible, transfers should be performed during the Then, the procedures for ARS management should be followed. Photos: © Fotosearch.
first 72 hours and necessary surgical procedures completed
within that period.
13. Following initial stabilisation, radiation exposed trauma or burn Additional information to Section J.6
patients may be given palliative/compassionate care. The Guidance on minimum standards in emergency and essential surgical care
presumption of severe ARS will be based on case history and at first referral level health-care facilities is available at http://www.who.
initial score (early vomiting/diarrhoea, fever, extended int/surgery/publications/imeesc/en/index.html (WHO Integrated
erythema, neurological signs/symptoms, early increase in Management of Essential and Emergency Surgical Care e-learning tool kit).
serum amylase, severe lymphopenia, etc.).
14. Patients with ARS and trauma or thermal injury involving more
than 10 % of the body surface [Information J.19:8 on the “rule
of nines”] should be hospitalised, due to the risk of
immunosuppression and pancytopenia. Reverse isolation is
recommended, particularly if neutrophil or platelet counts are
low, if signs of infection are present, if the victim refers to a
pre-existing illness or if the victim belongs to a critical
sub-population (e.g. child, pregnant women, elderly).
15. If an ARS patient presents simple fractures, stabilise, perform
decontamination (if needed), treat the fracture and then, follow
procedures for ARS described in Section J.5. It should be noted
that callous formation, is likely to be delayed during the aplasic
period.
280 281
Chapter J Medical management at the hospital Instructions Information 7 Local radiation injuries
7 Local radiation injuries

Information J.19
Cutaneous radiation syndrome (CRS) is an academic concept, proposed to
describe an inflammatory reaction of the skin with a particular cytokine
Introduction profile, observed after radiation exposure. It has been incorporated into
texts related to radiation emergency medicine. However, the definition of
A range of medical terms have been used to describe the clinical this term (CRS) is not included in most texts related to conventional
condition resulting from the exposure of a localised area of the body to emergencies and it is not well understood by general practitioners (GPs).
high doses of ionising radiation: Moreover, following exposure to high doses it is not only the skin which is
involved, but also the subcutaneous tissue, and even muscles and bones
that are involved (it is more than “cutaneous”).
• Localised irradiation;
Regarding the use of the term “radiation burn”: even though it is more
• Local radiation injuries; understandable for GPs and emergency physicians, radiation injuries are
• Radiation burn; quite different from classical thermal burns. For the purpose of this
handbook, this entity will be termed local radiation injury.
• Radiodermitis; and The skin is the largest human organ (between 1.5 and 2 m2, comprising
• Cutaneous radiation syndrome. about one sixth of total body weight). The skin performs multiple roles in
human physiology. It helps regulate body temperature and metabolism
In the context of this chapter, this condition will be referred to as “local and protects the body from water loss, friction and impact wounds. It
serves as a barrier to the environment and some of its glands have
radiation injuries” (LRI). General practitioners and emergency antiinfective properties. Through its specialised pigment cells
physicians should be able to recognise LRI. Unfortunately, in many (melanocytes) it protects from the UV rays of the sun. Human skin consists
cases, skin lesions have been misinterpreted by the physicians as insect of three functional layers: epidermis, dermis and hypodermis.
bites, mechanical trauma, local infections, allergic reactions and even The majority of cells in the epidermis are keratinocytes, which are
pemphygus. Misdiagnosis unnecessarily delays the appropriate arranged in stratified layers. Epidermis is a hierarchical tissue. The basal
layer of keratinocytes is also called the stratum germinativum, because it
treatment and worsens the prognosis. In scenarios concerning is concerned with cell proliferation. Three types of keratinocytes in the
malevolent use of radiation sources, people might not know that they basal stratum have been defined by kinetic analysis: stem cells, transient-
have been exposed to radiation. If whole body dose is not high enough, amplifying cells and committed cells. Stem cells represent around 10 % of
the basal cell population and generate daughter cells from mitosis, that
prodromal symptoms such as nausea, vomiting or diarrhoea may be are either stem cells themselves or transient-amplifying cells. Transient-
absent or, if present, such symptoms might be attributed to other causes. amplifying cells represent around 40 % of the basal cell population and
The experience from several radiation accidents demonstrates that LRI replicate with much higher frequency than stem cells, but are capable of
are quite often the initial reason why casualties require medical advice. only a few population doublings. Transient-amplifying cells produce
daughter cells that are committed to terminally differentiate.
This section provides guidance on the diagnosis and treatment of LRI. These committed cells detach from the basal membrane, differentiate, and
ultimately cease to proliferate as they migrate towards the skin surface,
where they are sloughed off as dead, cornified cells. This classical
J.19 Identifying the clinical features of local radiation injuries hierarchical organisation of the epidermis explains its typical acute
response following exposure to ionising radiation.
1. Clinical features of acute skin effects can be related to single On the other hand, dermis and hypodermis are flexible tissues that mainly
develop late effects after radiation exposure. The dermis is composed of
radiation exposure as follows : water, and, primarily, collagen. Embedded in this layer are systems and
• 4-5 Gy: Simple and transitory hair loss; structures common to other organs such as: lymphatic and blood vessels,
nerve fibers, and muscle cells. Hair follicles, sebaceous glands, and sweat
• 5-12 Gy : Erythema, followed by hyperpigmentation; glands are unique to the dermis. (Continued over page)
• 12-15 Gy : Dry epithelitis, with erythema and desquamation;
282 283
• 15-25 Gy : Moist epithelitis; and

• 25- 30 Gy : Skin radio-necrosis. Information J.19 (cont.)
The hypodermis or subcutaneous tissue refers to the fat tissue below the
This correlation between skin dose and clinical features has skin. It consists of spongy connective tissue interspersed with adipocytes
been observed after single high dose rate exposures (i.e. high (fat cells). Vascular endothelium is particularly vulnerable to radiation.
Neovascularisation processes as well as endarteritis obliterans may be
doses delivered in a very short time). The influence of the dose observed after moderate to high dose exposure. Radiation fibrosis is a
rate in LRI is not clearly documented and data concerning skin frequent sequel of radiation overexposure of skin and it is related to a
effects after protracted doses (dose delivered over a longer time chronic activation of myofibroblasts within these tissues. (Delanian and
Lefaix, 2007; Meineke, 2005)
period) or chronic exposures are very poor. In such cases, Sweat gland
similar clinical features would probably be seen after higher Hair shaft
pore
doses, due to a longer time available for repair of damage. This

is seen with skin reactions observed in patients undergoing Epidermis
fractionated irradiation in radiotherapy, for which the dose

thresholds are much higher.
2. Radiation induced late effects on skin include: Dermis
Basement
membrane
• Skin atrophy;
• Cutaneous fibrosis; Sweat gland
• Hyper/hypo pigmentation; Subcutaneous
duct
layer Capillary
• Telangiectasia; Touch receptor
• Hyperkeratosis; and Figure J10. Skin structure. Reprinted by permission from Macmillan Publishers Ltd:
Nature (MacNeil, 2007), copyright (2007). www.nature.com/nature.
• Alterations in nails and hair.
3. Radiation-induced late effects on the skin may involve
Information J.19:4
functional impairment, secondary necrosis and even cancer.
One characteristic of local radiation injuries is that, even after
wound healing, a secondary necrosis may re-appear several
years later.
4. Local radiation injuries (LRI) may evolve in different clinical
phases (prodromal phase, illness phase, and late phase) which
can extend from hours to years after radiation exposure [Figure
J11]. These phases can evolve as an acute, sub-acute or chronic
condition. LRI are dynamic, with successive inflammatory
waves (pain, oedema, erythema) alternating with periods of no
or little clinical symptoms.
5. By using the METREPOL categorisation system, it is possible
to define four grades of severity of LRI related to the clinical
symptoms and signs [Table J9]:
• C1: mild damage; Figure J11. Clinical evolution of LRI.
284 285
• C2: moderate damage;

• C3: severe damage; and Information J.19:4 (cont.)
• C4: fatal damage Table J9. Grades of severity of LRI.
6. Changes in the skin pigmentation may also occur, but this Symptom Degree 1 Degree 2 Degree 3 Degree 4
symptom is not included in the METREPOL grading system Moderate; Marked, Severe; isolated
isolated isolated patches or
due to the lack of reference data for depigmentation or Erythema
Minimal and
patches < 10 patches or confluent; >40 %
transient
hyperpigmentation. Nevertheless, it should be recorded cm2 of body confluent; of BS,
surface (BS) 10-40 % of BS erythroderma
systematically.
Slight and
7. Although it is only mentioned as a clinical symptom in the Sensation/
Pruritus intermittent
Moderate and Severe and
Itching persist pain persistent pain
METREPOL table for cutaneous system, pain evolution should pain
be considered and recorded as a separate entity, since it is a Swelling/ Present; Symptomatic, Secondary Total
oedema asymptomatic tension dysfunction dysfunction
very good indicator for the prognosis and prediction of necrosis.
Rare, with Rare; with Bullae with Bullae with
Blistering
8. Information concerning the extent of LRI on surface and in sterile fluid haemorrhage sterile fluid haemorrhage
depth, as well as localisation of the lesions should also be Desquamation Absent Patchy dry Patchy moist Confluent moist
recorded. Like in thermal burns, the extent is very important, Ulcer/Necrosis
Epidermal
Dermal Subcutaneous
Muscle/bone
only involvement
and the prognosis varies according to the site (e.g. thorax is
Complete and Complete and
more critical than buttock) and depth. Standard criteria, similar Hair loss
Thining, not Patchy,
most likely most likely
striking visible
to those applied to thermal burns, may be used to determine the reversible irreversible
extent of LRI, e.g. the “rule of nines” [Figure J12]. Onycholisis Absent Partial Not defined Complete
9. If LRI is suspected, photographs of the affected areas should be

obtained on the first day. If signs of radiation injury evolve
further, additonal photographs should be obtained daily;
otherwise, they should be repeated twice weekly and before/
after any surgical procedure (to monitor clinical evolution and
therapeutic response, and for legal purposes). These
photographs should be labelled (patient ID, date, time) and
included in the medical records of the patient.
10. LRI results in skin lesions quite similar to thermal burns.
However, thermal burns are different from “radiation burns” in
the following respects:
• Radiological burns are dynamic, their temporal and spatial
evolution is unpredictable and even relatively independent of
the initial clinical evolution;
• Patients do not present initial shock;
• Pain is not immediate in LRI (as it is with thermal burns), but
when it later appears it is very severe and resistant to drugs.
It is a prognostic symptom which heralds a new wave of
286 287
clinical recurrence; and

Information J.19:8
• Although the kinetics of radiation burns are highly
dependent on the local absorbed dose, they usually exhibit
an early (primary) erythema without tissue nor hair loss at
the beginning (however, they may occur two weeks after
exposure), while thermal burns involve early hair and tissue
loss (depending on the depth of the burn).
11. Unfortunately, there are no specific clinical features for
identifying LRI at the hospital and the presumption of LRI will
result from a combination of data:
• Potentially attributable clinical features (as those previously
described);
• Dynamics and evolution of the lesion(s);
• Non-explainable burn, unknown cause (no history of
previous exposure to chemical, mechanical or thermal
injury);
• Shape of the lesion(s): circular shape suggests exposure to
ionising radiation (however anthrax lesions are also circular);
and
• Other people presenting similar signs/symptoms (e.g. family
members, neighbours, colleagues).
Figure J12. “The rule of nines” (reproduced from British Medical Journal, Hettiaratchy
and Papini, 329, 101-103, 2004, with permission from BMJ Publishing group Ltd).
J.20 Main diagnostic tools in local radiation injuries
(HOSPITAL EMERGENCY TEAM) The “rule of nines” may be used to determine the total body surface area
1. The diagnosis of LRI during the early phase of an emergency (TBSA) that has been burned on an adult. The body surface area that has
been burned may be estimated by using multiples of 9 as follows:
will be mainly based on clinical findings (interrogation and
• Head = 9 %
observation). Complementary diagnostic tools may be useful to
• Chest and abdomen = 18 %
support the presumption and evaluate the extent and depth of
• Upper/mid/low back and buttocks = 18 %
the injury. The results should be combined and interpreted by
• Each arm = 9 %
focusing on the clinical findings.
• Groin = 1 %
• Each leg = 18 %
• Colour photography is relevant for the documentation of
As an example, if one leg (18 %), the groin (1 %), and the chest and
changes as a function of time. Calibration is mandatory to
abdomen (18 %) were burned, this would involve 37 % of the body.
record the dimensions of the lesion(s); The “rule of nines” cannot be used to determine the TBSA of children and
• Ultrasonography with 7.5 MHz or higher resolution infants because their surface area of the head and neck is larger and the
(7.5 - 20 MHz) should be performed daily in the acute phase, limbs are smaller than for adults. The Lund-Browder chart may be used in
those cases to compensate for the variation in body shape with age and
and weekly in the manifest illness phase, to determine
therefore give a better assessment of burn areas in children.
changes in the thickness and density of the skin. Depending
288 289
on the resolution of the equipment, ultrasonography could

also provide information about the depth of the lesion, but it
cannot be used to plan and guide surgery;
• Thermography can be performed during the first hours and
then once weekly, to detect the development of hypertermic
or hypotermic skin areas (determination of isothermal lines),
in addition to the clinical identification of the erythema.
Blisters may cause problems in the interpretation of the
results. Thermographic findings may be used as a reference Figure J13. Radiation induced epithelitis in hands: it is essential to take photos in
for regular patient follow up; colour to record the clinical evolution. Photo: Figure reproduced courtesy of IAEA
(IAEA, 2002b).
• Blood flow may be evaluated by capillary microscopy (to
evaluate the dermal capillaries) or by doppler ultrasound (to
identify damage to larger vessels); Information J.20
• Magnetic Resonance Imaging (MRI) can be useful in Main diagnostic tools in local radiation injuries
detecting damage in deeper tissues e.g. muscle. Since MRI Colour photography should be performed in addition to a detailed
may demonstrate oedema and inflammatory reactions description of the observed sign. It is important to record the dimensions
of the lesion(s).
extending well beyond the lesion, these signs cannot be used
alone to guide surgery. However, it was recently demonstrated High resolution ultrasonography is a non-invasive method for the
that MRI is the best tool to provide the anatomical references evaluation of skin thickness, skin density, ulcer depth and status of the
subcutaneous tissues. The depth of radiation fibrosis and ulcers can be
for dose reconstruction by the Monte Carlo method, which can
determined by 7.5 MHz scanners, while 20 MHz scanners are suitable for
then guide the surgery; and investigation of epidermis, dermis and subcutaneous fat tissue up to a
• Before ruling out the possibility of LRI, the patient should be depth of 10 mm.
followed for at least 4 weeks, to see whether a second wave Thermography is a non-invasive method for the quantification of skin
of erythema appears. If this secondary erythema does not temperature and heat loss of the body, which are indirect parameters for
appear within the first 4 weeks, it is unlikely that skin lesions skin vascularisation. Techniques such as infrared thermography,
will develop later. microwave thermography and liquid crystal contact thermography are
only available in some countries. Thermography is a valuable tool, since
necrosis is associated with lower local skin temperature and higher skin
J.21 Medical management of local radiation injuries temperature is observed in areas with inflammation.
(HOSPITAL EMERGENCY TEAM) Magnetic Resonance Imaging (MRI) is a non-invasive procedure to evaluate
1. As a general approach, dermoprotector creams may be used in the signal intensity of dermis, subcutaneous fat tissue, muscle and bone,
the prodromal phase; later topical or systemic steroids might be which increases as a result of fluid accumulation (inflammation, oedema,
considered, hydrocolloid dressings, local infection prophylaxis necrosis).
and treatment; later still pentoxifylline and alpha-tocopherol MRI may demonstrate local damage within the first day after exposure
might be applied. and should be used to determe the extent of the lesion, as soon as
possible. It is important to take the decision about the indication for
2. The treatment of mild (C1) and even moderate (C2) degrees of
surgery, but it may be difficult to discriminate between necrosis and
LRI is relatively simple and undemanding and could be inflammation.
undertaken in most countries. The therapeutic strategy for (Peter and Gottlober, 2002).
290 291
severe and fatal (C3 and C4) degrees of LRI requires the
participation of experts and very often, international assistance. Information J.21
3. Outpatient treatment is indicated for C1 LRI. This would The follow up of LRI patients will be discussed later [Section K.9:1] .
However, some consideration of information that maybe of use in the
include anti-inflammatory aqueous lotions/powders, topical
easrly stages are presented here. LRI patients should be followed for at
anti-inflammatory and antiproliferative non-atrophic least 10 years. The risks of deterministic late effects is higher in these
glucocorticoids (for suppression of cytokine expression) as well patients than ARS patients, and even higher than the risks of stochastic
as systemic antihistamines. effects. It is common to see people developing lesions resulting from any
kind of physical trauma on the irradiated area. Scratches, thermal injury
4. Treatment of C2 LRI may be on an outpatient basis. Puncture (extremely high or low temperatures), insect bites, or mechanical trauma
of blisters and non-adherent dressings are usually required. can easily induce necrosis. This should be prevented by clear
Blisters should not be treated with drying powders. Prevention recommendations to the patients. Status of vessels is also relevant e.g.
of infection is important. people of >80 years old, aging process, hypoxic tissues.
5. Hospitalisation is indicated for patients with C3 LRI, with The recommendations to LRI patients during their follow up are more
aspiration of blister fluids, debridement of necrotic tissues, important than in ARS patients. And this also applies to occupational
topical applications of bacteriostatic agents, anti-inflammatory health, a big issue to be considered. LRI can disrupt the occupational life
agents and essential fatty acids, with the use of non-adherent of the patients.
dressings. Systemic treatment will include anti-inflammatory (Schertan et al, 2007).
and antiproliferative glucocorticoids and effective analgesia,
according to standard protocols [Instruction J.13:2].
6. Hospitalisation in an intensive care unit is indicated for patients
with C4 LRI. Instruction J.21:5 may be followed, but these
patients will probably also require early surgery.
7. The classical therapeutic approach for severe LRI (C3 and C4)
is:
• Conservative treatment for superficial lesions;
• Surgery for painful deep ulcerations and necrosis:
- Ulcerectomy
- Necrectomy
- Wound closure by rotation flap
- Amputation; and
• In cases of profound and extensive necrosis, the lesion should
be excised and the wound bed covered with a good quality,
full thickness skin graft.
8. Examples of different options used to cover the lesions after Figure J14. While conservative treatment may be indicated for superficial lesions,
excision are: painful deep ulcerations and necrosis require surgical treatment. These photos show
the evolution of tissue necrosis after surgical treatment including artificial skin graft.
• Rotation flap; Photos: courtesy of Percy Hospital and IRSN. For artificial skin graft photo, permission
also provided by IAEA (IAEA, 2000a).
• Artificial skin graft (INTEGRA®) covered by a silicon sheet.
292 293
Colonisation of the artificial skin by patient’s cells has been

demonstrated. The neoderma covers the artificial skin in a Information J.21:8
couple of weeks. The silicon is then removed and a classical The concept of excision on “apparently healthy tissue” for LRI may imply
skin graft is performed on the neoderma; huge exeresis, well beyond the visible injury. The surgeon should be
aware of this. Sometimes it is very difficult to convince surgeons, who
• Excision on “apparently healthy tissue” followed by a porcine usually deal with thermal burns, that LRI is a totally different “burn” and
xenograft and later artificial skin graft covered by a silicon that they should remove tissues that will evolve towards necrosis even if
sheet. Neoderma develops, allowing the sheet of silicon to be they are apparently intact.
removed and replaced by a meshed autograft; and
• Omentum flap with tunellisation. In one month the omentum
Information J.21:9
is growing and a skin graft can then be performed.
Human Mesenchymal Stem Cells
Very often, despite the fact that these diverse approaches are Bone marrow- derived mesenchymal stem cells (MSC) are multipotent stem
generally successful, necrosis reappears later on and a new cells that can differentiate in vivo or in vitro into a variety of cell types
autograft(s) will need to be performed. such as osteoblasts, myocytes, chondrocytes, adipocytes. Due to these
properties, MSC have been used to repair tissue injuries. Experimental
9. Local administration of human mesenchymal stem cells (MSC) studies demonstrated that ionising radiation increases the homing of
for treating LRI has been used for several casualties of radiation injected MSC to the injured tissues and to other tissues outside the local
accidents and has demonstrated to be very effective. irradiation field.
MSC should be injected into the irradiated area after large Cellular therapy with in vitro expanded MSC was recently used to treat
excision of tissue (e.g. all the volume contained within the 20 severe LRI. In combination with dosimetry-guided surgery, autologous
Gy isodose). Surgery should be performed as soon as possible MSC were locally injected into the lesion. This combined therapy resulted
(in the first month following exposure), the lesion covered by a in a favourable clinical evolution with healing progression. This novel
skin graft and autologous MSC locally injected (70-200 · 106 approach of regenerative medicine opens new prospects in the medical
management of severe LRI. (Lataillade et al 2007).
MSC per injection, in a volume of around 0.5 ml). However,
this new promising approach is still under development. MSC are currently available in few countries for in vitro culture expansion.
One advantage of MSC is that they are not HLA specific (“universal
10. A new approach in LRI treatment is dosimetry-based surgery. donors”, options for banking MSC?). Good control of pain is observed soon
MRI or CT scan should be used to provide the anatomical after MSC administration. However, this technique will not be applicable in
information and a numerical voxel phantom should be used for a mass casualty event. It is not yet evident whether its use could be scaled
isodose reconstruction by the Monte Carlo method, followed by up to 15-20 patients. Ongoing research may make it available to be used in
dosimetry-guided surgery design. larger event.
11. Actions that may be considered for the treatment of C3 and C4

LRI, before arrival of specialist, include: Information J.21:11
• Emergency medication could possibly be required during the In contrast to C1 and C2 LRI, which are relatively simple to manage, C3
early phase e.g. steroids; and C4 LRI impose a real challenge. The classical treatment approach may
fail and the alternatives are still under development. In selected cases
• KGF may be useful for the management of local mucositis; experimental treatments could be used under the supervision of experts.
• Pentoxifillin could be used to improve microcirculation; Even in the case of mass casualty events, there should be time to organise
international cooperation to ensure expert advice to take care of these
• Prevent/treat infection, and inflammation; patients. The key message already learned in a few of these cases is “to
• Hyperbaric oxygen; provide supportive care and to wait until the specialists arrive”.
294 295
Chapter J Medical management at the hospital Instructions Information 8 Radionuclide contamination
• Pain management [Instruction J.13:2];

• Regional sensitive nerve blocking for pain control (different
from sympathetic nerve blocking to improve blood flow); and
• Other pharmacological approaches e.g. tracolimus, linoleic
acid, calcikrin, prednisolone, and retinoic acid.
8 Radionuclide contamination
Figure J15. A new approach in local radiation injuries treatment is
dosimetry-based surgery. Photo: HPA.
Introduction
This section provides guidance for the management of externally
contaminated patients at the hospital emergency department. Some
general criteria concerning the treatment of internal radionuclide
contamination are also described. However, it should be bourne in mind
that decorporating agents are not usually available at general hospitals. Information J.22
If it is not explicitly mentioned in the hospital disaster plan, the relevant Radioactive contamination is defined as unwanted radioactive material
competent authority coordinating the response in a radiation emergency inside the body or on the body (internal or external contamination
respectively). In contrast to external irradiation, contaminated patients are
will provide information on how to obtain the necessary drugs and continually exposed to radiation until the contamination is removed or
specialist advice concerning their use. eleminated.
Isotope/s identification is particularly important if internal contamination

J.22 General management of contaminated patients in the hospital is suspected, to choose the best mechanism for removing the
(HOSPITAL EMERGENCY TEAM) radionuclides from the body, based on their chemical composition. Spread
1. Always give first priority to life support, control of of contamination should be prevented.
haemorrhage and treatment of trauma.
The sooner the decontamination procedures start, the lower the dose will
2. Protect the treatment area and staff with use of isolation, clean be. Contamination levels rarely imply serious hazard to healthcare
transfer techniques, respiratory protection and other appropriate providers for the time required to perform lifesaving measures and
Personal Protective Equipment (PPE). decontamination procedures. One possible exception is where a patient
may have embedded fragments from an explosion of a high activity
3. If possible, remove the patient’s clothing and place in labelled source.
plastic bags. (Smith et al, 2005; Marcus et al, 2005).
296 297
4. Assess the patient’s medical condition, stabilise and treat as

necessary .
5. Survey contamination and document the affected areas along with
their levels of contamination.
6. Take samples from affected areas (e.g. eyes, nose, mouth) for
analysis and planning of definitive treatment.
7. Conserve specimens from wounds or removed tissues for later
analysis. Every sample should be clearly labelled.
8. If possible, identify the isotope/s involved with appropriate
techniques [Section H.2:1].
9. Avoid spread of contamination. Information J.23
10. Document all the procedures and the results of monitoring on External contamination is produced when radioactive material, as dust,
appropriate worksheets [Annex 3]. solid particles, aerosols or liquid, becomes attached to victim’s skin or
clothes. Early skin decontamination is crucial, as it lowers the risk of
internal contamination (particularly important if alpha emitters are
J.23 Management of externally contaminated patients present). Moreover, it decreases the risk of radiation skin burns (e.g. skin
(HOSPITAL EMERGENCY TEAM) contamination with beta emitters) and reduces the chance of cross
1. Staff must wear respiratory protection and other PPE as contamination. Most external contamination (around 90 %) is removed
appropriate. with clothing and the remaining skin contamination is usually easily
removed by washing. Normal saline solution or a mild detergent are
2. Remove patient’s clothing and place in labelled plastic bags. generally sufficient. Mechanical and/or thermal trauma from medical
Consider washing contamination from breathing zone of treatment should be avoided; it is better to use flushing and/or friction of
casualty and avoid removing clothing over the head. It might cloth, sponge or soft brush, starting with a gentle stream of warm water.
be useful to provide the casualty with respiratory protection Hair and nails can be difficult to decontaminate because particles may
become lodged under the nails and become attached to the hair. Protein
(after washing nose/mouth) while removing contaminated
based shampoos with conditioners should be avoided since they may coat
clothing. the hair and fix the contaminants. Natural orifices need special attention
3. Perform monitoring of the patient’s skin to delimit because absorption of radioactive material is more rapid than through
contaminated areas and measure and record the level of intact skin.
contamination; the type of radiation detector should be chosen
depending on the radioisotopes involved and the type of Information J.23:3
emission concerned (alpha, beta or gamma emitters).
It is unlikely that alpha monitors will be readily available in hospitals. Such
4. Wash the skin with normal saline solution or a mild detergent. monitors and expert advice can be obtained from specialist scientific
Perform decontamination with the following priorities: institutes.
breathing zone, site of intravenous access, wounds, mouth,
eyes, high level skin areas and low level skin areas (head down Monitoring procedures for alpha emitters should be rigorous (e.g. the
body to toes). Be careful not to wash radioactive material into monitor must be close to the surface (closer than 1 cm), the area must be
monitored more slowly (compared to gamma), surfaces must be dry), to
the nose, mouth or wounds. prevent under estimation of alpha activity in a wound or on hair etc.
[Annex 6].
298 299
5. Document all the procedures and results of monitoring on

appropriate forms. Information J.23:9
6. Avoid mechanical and/or thermal trauma; do not use harsh Solutions for skin washing may be specific or non-specific
cleansers which may compromise skin integrity. 1. Non-specific solutions:
• Common soap and water;
7. Change gloves and survey hands frequently to prevent the
• Mild detergent solution, low acidity (pH ~5) recommended;
spread of contamination to other sites.
• Non-soap emollient skin cleansers and water;
8. Perform decontamination by single inward movements or • 3 % hydrogen peroxide solution;
circular motion. • 1 % sodium hypochlorite solution (not for facial use);
9. After washing, rinse the area with tepid water and gently dry • Potassium permanganate 5 % aqueous solution. It should be used
using the same motions. After drying, skin should be carefully only when conventional washing is ineffective (not
re-monitored to determine effectiveness of decontamination. recommended for face, natural orifices and genital regions). It should
be followed by application of reducing agents like sodium
Washing may be repeated (3 times). According to the hyposulphite 5 % in freshly prepared aqueous solution and then
radionuclide involved, specific solutions may be used instead of rinsed with water;
non-specific solutions [Information J.23:9]. • Mildly abrasive soap or a mixture of powdered detergent and
cornmeal mixed with water into a paste can be used for calloused
10. Nail clippers can be used to remove most of the residual areas; and
contamination under the nails. • Antiphlogistic topical ointment for fixed contamination, especially
11. Wash the hair with a mild shampoo (avoid protein based useful for contamination of fingers.
shampoos with conditioners). 2. Specific solutions:
• Isotonic 1.4 % bicarbonate solution for removing uranium;
12. For people extensively contaminated, start showering at the
• Lugol solutions for iodine contamination, followed by application of
head and proceed downwards to the feet, keeping materials out reducing agents like sodium hyposulphite (5 %) in freshly prepared
of natural orifices and wounds. aqueous solution and then rinsed with water;
13. Replace shower by bathing for seriously injured patients. • Acetic acid solution (pH 4 to 5) or simply vinegar for phosphorus;
• Solution of EDTA (10 %) acts as a chelating agent for skin or hair
14. Oral cavity: brush teeth with toothpaste, rinse mouth with 3 % contamination with transuranics, rare earth and transition metals;
citric acid. and
15. Pharyngeal region: gargle with 3 % hydrogen peroxide solution. • Ca-DTPA (1 %) in aqueous acid solution (pH ~4) acts as a chelating
agent for washing skin after contamination with transuranics,
16. Nose: rinse with tap water or physiological saline. lanthanides or heavy metals.
17. Eyes: rinse by directing stream of sterile water or physiological
(Continued over page)
isotonic saline solution from inner to outer canthus while
avoiding contamination of naso-lacrimal gland.
18. Ears: rinse externally with water, rinse auditory canal using ear
syringe [Figure J16].
300 301
19. Stop decontamination efforts when:

Information J.23:9 (cont.)
• Evidence that skin integrity is beginning to be compromised
appears (apply antiphlogistic topical ointment);
• No significant further decrease of the contamination level is
achieved (e.g. no more than 10 %); or
• Residual contamination level is less than two times
background radiation.
J.24 Management of internally contaminated patients

1. Internal contamination must be suspected in patients with
external contamination of natural orifices or wounds and in
patients admitted with an airway or endo-tracheal tubes.
2. Although it has been suggested that internal contamination may
constitute a therapeutic urgency, except for radioiodine there is
no clear consensus about empiric treatments for people
internally contaminated with radionuclides other than radio-
iodine. If the radionuclides involved are not known, specific
decorporation cannot be implemented. In the very early phase,
treatment decisions are based on accident history rather than
careful dose estimate.
3. According to the information provided from the scene
(scenario, possible radionuclides involved, route of entry), take Figure J16. Specific solutions for external decontamination.
relevant samples: urine, faeces, sputum, nasal swabs, vomitus,

wound secretions etc. Information J.23:19
4. Perform appropriate bioassay, according to the radionuclide
When to stop external decontamination efforts
involved, to calculate intake, commited effective dose and, The goal of whole body external decontamination is to decrease external
where necessary, absorbed dose to organs [Section H.5]. This contamination to a level of no more than two times the background
can be done based on: radiation level [Figure J18].
• Whole body measurements;
• Urinary excretion (sample collected during 24 hours); However, external decontamination procedures should be stopped after 2
decontamination cycles even when the second survey shows that external
• Faecal excretion2 (serial samples collected during 72 hours); contamination is higher than 2 times background radiation level, if ad-
and ditional external decontamination efforts do not further reduce contami-
• Thyroid measurement (for iodine). nation levels by more than 10%. In any case, external decontamination
efforts should not continue if signs of skin irritation appear. Aggressive
and/or vigorous decontamination procedures should be avoided, since
they damage skin barrier and increase the risk of internal contamination.
2 Not applicable to everybody. The request for faecal samples should be done on a case by case (Continued over page)
analysis, according to the specialist advice.
302 303
Chapter J Medical management at the hospital 8 Radionuclide contamination
Figure J17. Management of external contamination.
Figure J18. When to stop external decontamination efforts.
304 305
5. Radionuclide activity measured in excreta at different times Information J.23:19 (cont.)

after intake may be used to identify ranges of effective dose
It may not be feasible to remove all contamination from the skin. Some
with an acceptable level of uncertainty (dose assessment). These
radioactive material may be trapped in the outermost layer of the
data may also be used to follow up the effect of treatment (this epidermis where it will remain during a normal period of skin cell renewal
approach may be easily applicable to small incidents, but will (i.e. two weeks).
be less applicable in mass casualty events). Residual radiation contamination areas should be covered with waterproof
6. Examples of specific agents potentially useful for radionuclide dressings to limit the spread of contamination.
decorporation can be found in Annex 12. In fact, treatment of If elevated levels of external contamination persist after adequate
decontamination efforts, consider:
radionuclide contamination is only indicated in very few cases.
• Internal contamination;
7. Proposed action levels for treatment of radionuclide • Contamination of wounds or body orifices; and
contamination in adults (intervention criteria) are presented in • Retained radioactive fragments (shrapnel).
Table J10 in terms of assessed committed effective dose. (REMM, 2008).
8. Clinical evidence about the use of decorporating and blocking
agents in adults is limited. Only a few agents have proven to be Information J.24
effective for treating internal radionuclide contamination. e.g. Internal contamination may result from inhalation, ingestion, direct
potassium iodide, DTPA, Prussian Blue. Approval for clinical use absorption through open wounds or intact skin and mucosa. Once the
by national health authorities and availability for purchase differs radionuclide crosses cell membranes, it is said to be incorporated. The rate
among countries. and level of incorporation is related to both the physical and chemical nature
of the contaminant. Incorporation can be rapid, occurring in minutes, or it
9. Thyroid blocking using stable iodine can be used to reduce can take days or months. Thus, time may be critical and prevention of
radiation exposure to the thyroid from radioactive iodine. If uptake is urgent. The following factors determine the extent of the
administered shortly before or at the same time as the exposure contamination hazard: mode of entry; amount of radionuclides incorporated;
to radioactive iodine, it may effectively prevent close to 100 % of energy and type of radiation (nature of the emission); combination of
radioactive iodine from reaching the thyroid. biological and physical half-life (effective half-life); site of deposition (critical
organs); chemical and physical properties of the radionuclides.
Thyroid blocking is often achieved by oral administration of
potassium iodine (KI). Stable iodine can also be administered as Information J.24:7
potassium iodate (KIO3).
Table J10. Action Levels for treatment of radionuclide contamination.
Children and pregnant women are at higher risk, since they are
Assessed committed
more sensitive to radiation exposure. Recommendations on the effective dose
Recommended actions
dosage according to age are presented in Table J11. Appropriate for public reassurance that doses pose a
Unfortunately, the effectiveness of iodine thyroid blocking < 1 mSv minimum risk to health. No treatment
decreases rapidly with time after exposure (e.g. 50 % by 4 hours More accurate dose assessment is required. Treatment
1-20 mSv should not be considered.
and very little effect by 12 hours). Because of this limitation,
More accurate dose assessment is required. Treatment is
thyroid blocking is not expected to be useful in the case of subject to medical judgement. Although clinical effects
malevolent use of radioactive sources. This approach could be 20-200 mSv are unlikely to occur, the potential efficacy of extended
or protracted treatment should be considered.
used if radioiodine is present in the scenario, but only if stable
Treatment should be considered. However, psychological
iodine distribution can be performed immediately or within the factors and potential efficacy of extended or protracted
> 200 mSv
first few hours. In such situations, the protection of the treatment should be considered.
responders should be considered. Adapted from Menetrier et al, 2007b.
306 307
10. Ca-DTPA and Zn-DTPA (diethylentriamene pentaacetate) are

chelating agents for the treatment of internal contamination Information J.24:9
with transuranic metals (e.g. plutonium, americium, curium) It is important to clearly explain to the population that the iodine is only
and other metals. DTPA acts by chelating (binding) the efficient for internal contamination with radioactive iodine, and that it does
radionuclides in the blood stream and thus speeds up their not offer protection for any other radionuclide. It also does not protect
against external exposure to radiation (need to avoid self administration of
excretion from the body through urine. The effectiveness of stable iodine as a generic “anti-radiation pill”).
Ca-DTPA in the first 24 hours after internal contamination is 10
times higher than Zn-DTPA. However, after 24 hours, both
agents are equally effective. Thus the recommendation is to
use: Information J.24:9 and 10
• Ca-DTPA for the first 24 hours after internal contamination;
and
• Zn-DTPA (less toxic) thereafter (weeks or months).
Ca-DTPA or Zn-DTPA should be administered as soon as
possible after internal contamination, since effectiveness
decreases once these elements are incorporated in bones.
The recommended dose of DTPA is 1 g in 250 mL normal saline
solution, or 5 % dextrose solution, in slow IV administration
(control bone marrow and renal function). For pregnant patients,
the less toxic Zn-DTPA should be used (if not available, use
Ca-DTPA and ensure provision of zinc supplement).
Figure J19. Figure J20.
11. Prussian Blue is indicated for decorporation of caesium, Effectiveness of iodine thyroid blocking as a function Clinical evidence about
rubidium and thallium. It binds radioactive caesium or thallium of time after intake (Ilyin, 1972). decorporating agents is limited
to a few agents that have
in the gut and speeds up its excretion from the body through the already proven to be effective
faeces. Its effectiveness was clearly demonstrated during the for treating internal
contamination with
Goiânia accident, where it was administrated to a large radionuclides.
population (including children and pregnant women). It did not Photo: WHO/Olli Häkämies.
demonstrate adverse effects, except occasional constipation.
The recommended dosage is 1-3 g /day (2 to 6 capsules · 0.5 g)
for a minimum of 4 weeks or longer, as required. Doses up to Table J11. Recommended single dosage of stable iodine according to age group.
10-12 g/day for significantly contaminated adults may be used. Age group Mass of iodine Mass of KI (mg) Mass of KIO3 (mg)
(mg)
Adults 100 130 170
3-12 years 50 65 85
1 month to 3 years 25 32 42
Neonate (< 1 12.5 16 21
month)
Adapted from IAEA EPR-Medical, 2005.
308 309
J.25 Actions to be considered according to the route of entry of the

contaminant Information J.25
In internal contamination following inhalation of radionuclides, the fate of
inhaled particles is dependent on their physicochemical characteristics. In
According to the radionuclide involved, different therapeutic general, soluble radionuclides (e.g. tritium, phosphorum, caesium) are
approaches can be proposed to manage internal contamination. absorbed directly into the circulatory system and insoluble radionuclides
Annex 13 shows examples of some possible strategies. In addition (e.g. cobalt oxide, plutonium dioxide) are cleared by the lymphatic system or
to the systemic treatment, particular actions could be also by the mucociliary apparatus above alveolar level. Following inhalation of
radionuclides, part of the respiratory secretions reach the pharynx, are
considered according to the route of entry of the contaminant. swallowed and enter the gastrointestinal system. The contaminant’s particle
size determines the deposition in the respiratory tract (< 5 μm in diameter
1. Actions for internal contamination following inhalation of may reach the alveolar area; > 10 μm are deposited predominantly in the
radionuclides: pulmonary washing (broncho-alveolar lavage) is upper airways).
to be considered only in extreme circumstances after inhalation In internal contamination following ingestion of radionuclides, all swallowed
of very large amounts of insoluble compounds that would be radionuclides enter the digestive tract, but their fate depends on the
solubility of the compound. Some radionuclides, in the form of soluble
likely to result in major pulmonary problems (fibrosis) if not compounds, exhibit high intestinal absorption, (up to 100 %), while for
removed. others it can be as low as 0.001 % [Instruction H.61]. Internal contamination
2. Actions for internal contamination following ingestion of of the gastrointestinal tract may result directly from ingestion of
contaminated food and water or secondarily from the contamination of the
radionuclides: gastric lavage is only effective if done within respiratory tract.
1–2 hours after ingestion and should only be used for large
Internal contamination may be due to incorporation of radionuclides through
single intakes of radioactive material.
wounds. Generally, radionuclides do not cross intact skin, so uptake by this
3. Actions for internal contamination following incorporation of route does not generally occur (exceptions: tritium, iodine, caesium). The
radionuclides through wounds: any wound in an externally radionuclide incorporation rate increases from burns to wounds in the
contaminated patient should be considered contaminated until following order:
• Thermal burns;
proven otherwise. The level of urgency for treatment will be
• Chemical burns;
determined by two factors: (a) the uptake rate of the
• Abrasions and excoriations;
radionuclide from the site, which would determine doses to
• Lacerated wounds;
organs and tissues remote from the wound site; (b) the
• Incised cutaneous-muscular wounds; and
accumulated dose to tissues in the local area around the wound.
• Stab wounds.
The former would be more important for soluble compounds
than to insoluble compounds. Medical measures applied to (NCRP Report 161, 2008).
contaminated wounds should assure prompt removal of the (Continued over page)
radionuclide from the injured area (local treatment) while
increasing their elimination from the body (oral or parenteral
treatment of internal contamination). While abrasions can be
cleaned by washing, lacerations and sometimes punctures, may
require local excision of the contaminated tissue, if washing
alone is not effective. If the wound is contaminated with soluble
compounds, first aid (including washing and possibly
tourniquet) given in the first minutes, will be more effective in
310 311
preventing uptake than excision of tissues, which generally will

be performed later. If the wound is contaminated with slowly Information J.25 (cont.)
absorbable radionuclides, surgical excision even after several The contaminating radionuclide may be in the form of soluble or insoluble
hours can provide effective removal of wound contaminants. compounds, which may condition their biokinetics and hence, the choice
Washing techniques to clean wounds contaminated with non- of the appropriate therapeutic approach. Treatment of internal
contamination may include saturation of the critical organ, dilution
soluble compounds include the use of chelator compounds (e.g. therapy, isotope displacement or use of chelating agents. The sooner the
DTPA, EDTA) which bind the radionuclide into stable, non- treatment is started, the more effective it will be. In practice, initial
dissociable and soluble complexes. Parenteral administration of treatment decisions are based on accident history, rather than careful dose
such compounds to prevent radionuclide incorporation in the estimates. However, health/medical physicists should be involved in dose
body should be done at the earliest possible opportunity. assessment and clinical toxicologists should advise on potential risks and
benefits of decorporation.
Chemical burns may easily disrupt the integrity of the Four major phases of internal contamination may be identified:
epidermis and should be managed in a similar way as • Intake and deposit of the radionuclide in the primary compartment
contaminated wounds. In general, the rate of radionuclide (airway, gastrointestinal tract, wounds or intact skin and mucosa);
resorption in thermal burns (with epidermal integrity) is very • Transfer of the radionuclide from the primary compartment through
similar to that for intact skin. When thermal burns are the blood and/or lymphatic vessels;
associated with scabs, they will act as an almost impenetrable • Uptake of the radionuclide in organs and tissues; and
barrier for resorption. Because of the relatively low rates of • Elimination by excretion organs.
radionuclide resorption from thermal burns, medical care Different therapeutic approaches may be addressed to each of these three
should be focused on prophylaxis of local exposure by phases:
removing the radionuclides from the injured area (local • Prevention of the intake from the entry site;
treatment). However, if the epidermal integrity is altered, e.g. • Binding of the transferred radionuclide into soluble non-dissociable
blistering, special attention is required because rupture of complexes;
blisters will expose underlying layers of epidermis and dermis • Decorporation from organs and tissues; and
and consequently increase radionuclide resorption. In these • Stimulation of radionuclide excretion.
cases, oral or parenteral treatment should be considered for (Berber and Thomas, 1992; CDC DTPA, 2006; CDC KI, 2006; CDC Prussian
internal contamination. Blue, 2006; NCRP Report 161, 2008; Wood et al, 2000).
4. Actions to be considered to deal with contaminated shrapnel:

if metallic fragments are visibly embedded in the body (e.g.
tissues, wounds), assume that they are radioactive until proven
otherwise and promptly remove them by using long forceps,
without touching them directly (even if using gloves) to
increase the distance (and thus lowering the dose rate). The
personnel involved should use PPE and a personal dosemeter
[Instruction J.18.5].
312 313
Chapter J Medical management at the hospital Instructions Information 9 Dealing with deceased persons at the hospital
9 Dealing with deceased persons at the

hospital
Introduction
While no special procedures are needed to deal with deceased persons
after external irradiation, some recommendations should be carried out
to deal with human remains containing radioactive materials. This
section provides some guidance on this issue.
J.26 How to deal with deceased persons at the hospital

(HOSPITAL EMERGENCY TEAM, PATHOLOGY DEPARTMENT) Information J.26
1. Apply conventional procedures to manage corpses for
While deceased persons externally irradiated do not represent a risk for
externally exposed deceased persons, without special health workers, public or other patients, management of contaminated
precautions. corpses requires radiation protection measures to be considered.
2. Apply radiation protection measures for managing deceased
persons with external and/or internal contamination such as use
of PPE for staff, perform basic decontamination if possible,
cover the corpse with a plastic sheet or bag, and use appropriate
warning tag or label and visible radiation signs.
3. Monitor to determine external dose rate close to the body, and
alpha and beta contamination levels on the body.
4. Move the contaminated corpse to the morgue (area should be
restricted from workers and public access). If the family of the
victim request permission to visit the morgue to mourn,
consider the need to move the body to another area,
temporarily.
5. Dose rate measurements should be performed as soon as
possible upon admission at the morgue (if they have not been
done before).
6. Request radiation protection advice before releasing a
contaminated corpse. The measurement of contamination in the
body or in autopsy samples taken from the body will be a
minimum requirement.
7. It is possible that a deceased persons may have radioactive
fragments embedded in the corpse (e.g. due to explosions) and
314 315
Chapter J Medical management at the hospital Instructions Information 10 Cytogenetic dosimetry
such fragments may be highly radioactive [Instruction J.18:5].

8. Consider issues related to the forensic investigation, particularly
if a malevolent act is suspected. If a post mortem examination
is essential (e.g. for forensic reasons), considerable planning of
radiation protection measures may be required and it is quite
possible that the corpse may need to be moved to a more
suitable place than is available in most hospital pathology
departments.
9. Hospital staff dealing with contaminated corpses (e.g. during
the autopsy) should be briefed on basic radiation safety
precautions and advised by personnel trained in radiation
protection (e.g. radiation protection officer, health physicist,
trained personnel from the nuclear medicine department and/or
the radiation oncology department).
10 Cytogenetic dosimetry
Introduction
Dose assessment contributes to, but should not be used alone to dictate,
medical treatment decisions. As described in previous sections,
radiological triage is mainly based on clinical and haematological
parameters (e.g. vomiting, blood cell count). A second line of triage is
based on cytogenetics, which allows identification of false alarms (i.e.
people with symptoms that are not due to radiation exposure: “worried
well” people) and verification of high doses and dose distribution that
may assist in subsequent treatment.
Biological dosimetry can provide information about dose and the
heterogeneity of the exposure, which is crucial for decision making Normal Metaphase, Aberrant Metaphase, Dicentric with
about feasibility of spontaneous bone marrow recovery. It is important 46 chromosomes. accompanying acentric fragment (AF).
to note that it takes at least three days to get results from biological Figure J21. Biodosimetry is mainly based on cytogenetics, which requires a
dosimetry. There are some more rapid techniques, but they are generally specialised, calibrated laboratory. Dicentric assay is the gold standard in cytogenetic
biological dosimetry. Photos: NRPA.
less accurate.
316 317
Chapter J Medical management at the hospital Instructions Information 10 Cytogenetic dosimetry
This section gives advice on the use of current biodosimetric methods Information J.27
that are mainly based on cytogenetics and, in some cases, electron
Cytogenetic dosimetry assay is not available in most hospitals. It requires
paramagnetic resonance.
a specialised, calibrated laboratory of which there are one or two in some
countries, but many countries do not have this resource. There is,
Further information on this subject is provided in Section H.3, Section
nevertheless, within Europe a sufficiently wide geographical spread of
H.4.4 and Annex 9. Detailed guidance on sampling procedure is laboratories that will respond to a major event and analyse samples. Dose
presented in Annex 11. estimates will become available from approximately 72 hours after receipt
of the blood specimens. (Alexander et al, 2007; Blakely et al, 2005; Blakely
et al, 2009).
J.27 Blood sampling procedure for cytogenetic dosimetry
(HOSPITAL EMERGENCY TEAM) Very specialised laboratories (external support at local, national or
1. Establish contact with the national biological dosimetry international level) might be able to measure free radicals generated by
laboratory or the laboratory that performs the biodosimetry ionising radiation in non-aqueous systems, such as teeth, bone, fingernails
service for your country, region or facility (Laboratory and hair by a magnetic resonance technique (EPR) (Romanyukha et al,
2005; Trompier et al, 2007).
preferably meeting the requirements of ISO 19238).
2. Notify the laboratory of the estimated number of subjects for The hospital emergency team may be requested, by the radiation
biological dosimetry. In case of a great number of samples, protection authority or the relevant health authority, to take samples for
consider in consultation with this laboratory, whether formal or cytogenetic analysis. The authorities should facilitate the contact between
the hospital and the national/foreign specialised laboratories, which can
informal networks for biological dosimetry by cytogenetics provide information on the type of EPR technique used (i.e. types of
should be activated. Anticipate type of exposure (if possible). samples like teeth, or fingernail or toenail clippings) and how many
3. Agree on the number of samples and on the arrangement for the samples can be sent. The hospital emergency team should follow the
delivery of the samples to the laboratory. advice from the specialised laboratory regarding sampling and the
logistics of transportation. (Alexander et al, 2007; Dainiak et al, 2007;
4. Take and transport the blood samples according to procedures Chao, 2007).
described in Annex 11.
318 319
CHAPTER K 1. To ensure proper interaction with the relevant competent authority
which coordinates the response to radiation emergencies at local
and national level.
Public health response 2. To coordinate medical and public health information.
3. To ensure the provision of health services including the
establishment of peripheral health care centres.
4. To ensure the provision of safe food and water supplies.
1 Introduction
5. To consider water and sanitation and other environmental health
This chapter provides guidance on public health response and a summary issues.
of the main actions to be taken during the initial phase of the emergency,
6. To help law enforcement agencies with the criminal investigation of
and the expected role of health authorities.
the event.
Although public information is addressed in more detail in Chapter D of 7. To evaluate the requests for deployment of strategic equipment and
this Handbook, some considerations of risk communication related to supplies (including national or international resources).
health care workers are presented here. 8. To convene national experts if necessary.
9. To evaluate the magnitude of the event from a health care
This chapter provides some basic criteria for establishing peripheral health perspective, its potential international concern and the need for
care centres with the objective of bringing people into the health system international notification and/or request for assistance through the
while preventing hospitals from being overwhelmed by the "worried well" appropriate channels.
and by patients seeking primary health care. 10. To assist in the establishment of a national registry of exposed
individuals.
The first evidence of radiation exposure resulting from a covert malevolent
11. To assist in dose reconstruction and long-term follow up of
act may be an outbreak of unusual disease. It is important to raise
populations.
awareness of this possibility among medical doctors and health authorities,
and to help them to identify the types of symptoms that may be attributable
to radiation exposure. This is the primary purpose of this chapter.
3 Risk communication and communication
Finally, guidance for decision making on short-term health surveillance with health care workers
and long-term follow up of casualties is provided. Communication of radiation risks to people involved in emergencies
resulting from a malevolent use of radioactive sources, is of paramount
importance. The language of radiation protection is not readily understood
2 The role of the health authorities during
by non-specialists; radiation dose units, risk nominal probabilities and
the emergency coefficients for stochastic effects are difficult to understand (Picano, 2004).
The role of the health authorities, during a radiation emergency resulting Patients and general public often personalise risks, even when scientists try
from a malevolent act, may differ between countries. Health authorities to depersonalise it. For instance, a "one-in-a-million" comparison to
will, in general, be responsible for coordinating public health aspects express cancer risk might be perceived as low by the scientific community,
related to the event (CDC, 2007; IAEA EPR-Medical, 2005; WHO, 2007a), but patients and public may personalise risk and perceive that the "one"
including: could be themselves or a loved one (EPA, 2007).
320 321
Chapter K Public health response
Risk communication has to address a fundamental dilemma: the risks that personal communication). Education in such unfamiliar types of
kill people and the risks that alarm them are often completely different. emergency is the key to providing the staff with relevant response
There is virtually no correlation between the ranking of hazards according capabilities and to understanding personal safety issues.
to statistics on expected annual mortality and the ranking of the same
hazards by how upsetting they are (Covello and Sandman, 2001). Bearing in mind the infrequency of actual radiological events, on-going
professional training, to maintain the level of staff competence, should be
The people in charge of communicating risk should be skilled in built into the emergency preparedness plan: It is useful to integrate the
interpersonal communication, be able to convey empathy, and be an training with that for other hazards, rather than treating radiation in
effective listener, respectful of people's concerns. They should be isolation. It is important to ensure that hospitals have an integrated incident
knowledgeable about the topic area they are dealing with and be able to management response which is regularly exercised.
answer basic questions about the current as well as possible future risks
(EPA, 2007). They should know when to refer a given question to an
expert. In terms of public health, ideally this role should be played by
known, respected professionals associated with respected institutions or
agencies.
Family doctors will be particularly eligible to play this role when

communicating risks to individual patients. Radiation doses might be
easily be communicated by reporting them as multiples of a chest X ray,
which is rather familiar to both patients and health workers and may serve
as a "dose unit" to help them to perceive the magnitude of the exposure and
the associated risks. Doctors can also communicate risks in a more
understandable way through equivalents of risks associated with ordinary
life activities such as driving a car (Picano, 2004).
Provision of information to health care workers during radiation

emergencies, particularly those associated with malevolent uses of
radiation, is essential. In addition to routine briefing/debriefing sessions, Figure K1. Peripheral healthcare centres will conduct the first evaluation and refer patients
further information could be provided through a password protected to the appropriate medical facilities, as necessary. Photo: WHO/Chris Black.
website, organised by the occupational safety services.
Biological and chemical emergencies pose fewer uncertainties and fears

among the staff than radiological hazards. Experience in radiological 4 Establishing peripheral health care
training courses has demonstrated that staff that initially felt more centres
comfortable in handling biological (80 %) and chemical (60 %) One of the objectives of monitoring is to identify the large groups of people
emergencies compared with radiological (40 %), modified their risk whose exposures are very unlikely to induce a health effect, or who have
perception after being better informed. At the end of the training more than not been exposed at all. Once identified, these groups can be excluded from
90 % of the health workers indicated that they would feel more comfortable further medical treatment or monitoring actions. However, some people
responding to radiation emergencies than to the others (REAC/TS, could develop later signs or symptoms such as nausea, vomiting, diarrhoea,
322 323
skin reddening (erythema) or blistering. Such signs and symptoms, that critical sub-populations (e.g. children, pregnant women, elderly people,
were not detected during the field triage, might be attributed to radiation etc.) and list of contact points for news and further information.
exposure and people should be advised to contact the appropriate
competent authorities, if they develop them.
Outpatient departments, might become congested with patients seeking

primary health care, resulting in long queues of patients, who could be
successfully treated at other facilities. Those people should be brought into
the health care system in a way that prevents hospitals from becoming
overwhelmed, which is particularly important in emergencies with great
number of casualties. This can be achieved by establishing peripheral
centres with the capacity to provide diagnosis and outpatient care (i.e.
primary health care).
Plans to establish peripheral health care services should be made to ensure

sufficient staff (technical and non-technical), on a 24 hour operation basis
for several days or weeks, depending on the magnitude of the event. These
centres will conduct the first evaluation and refer those patients who need
further medical assistance to the appropriate healthcare facilities (e.g.
general hospital or specialised institution).
Figure K2. Referral hospitals offer advice and support to lower level health facilities. Photo:
To scale up the response, in case of a mass casualty event, health care WHO/Olli Häkämies.
standards may have to be modified: the aim should be to keep the health
care system functioning and to deliver an acceptable quality of care to 5 Referral hospitals
preserve as many lives as possible. Referral hospitals offer advice and support to lower level health facilities.
Referral hospitals that operate at the regional/provincial level (secondary)
During the emergency, the competent authorities should provide early will act as referral for the local hospital (primary). Referral hospitals that
warning messages and disseminate their information through press operate at national/ central level (tertiary) provide more complex and
releases, national broadcasting and local radio stations. Written instructions specialised services to patients who have been referred from communities
for the early phase of the emergency (e.g. fact sheets in easy-to-understand where such services are not available.
language), including information about hotline numbers and lists of
peripheral health care centres, should be available to the public at strategic Referral hospitals provide support to other health facilities, either in
distribution points. assisting patients or giving remote advice on the management of patients’
conditions, and whether and when to refer or discharge the patients. In
After providing assistance, as people are released from these peripheral some countries, referral hospitals can provide managerial and
health care centres, they should be given an information leaflet or fact sheet administrative support to other elements of the health system, including
telling them that the health authorities may need to contact them again for managing more complex laboratory services, serving as drug and medical
further monitoring or medical evaluation. These fact sheets should contain supply depots, managing health information systems, central transport
any relevant health recommendation for the general population and for fleets and human resource support.
324 325
Medical research is often undertaken at referral hospitals. New the information and support provided by their local embassies will be of
technologies are therefore being applied, which may be particularly great value. The formation of stakeholder advisory groups can also be a
important when dealing with complex clinical conditions, such as acute valuable mechanism for building trust, helping the casualties to feel that
radiation syndrome and severe local radiation injuries. their views are important and are taken seriously (Becker, 1997).
6 Dealing with worried well 7 Outbreak of unusual disease attributable

During radiation emergencies, health authorities should make provisions to radiation exposure
for dealing with a large number of people who may self report experiencing After an overt release of radioactive material (e.g. a dirty bomb) the
symptoms or even as asymptomatic patients. Those people are concerned emergency departments of the hospitals will probably be aware of the
about possible exposure to radiation, even if it did not occur. presence of radioactive material at the scene of the event. This may not be
the case if the exposure resulted from a covert release in the context of a
The term "worried well" includes people worried about their health from malevolent act (e.g. a radioactive source hidden in a public place).
the potential risks of an accident. In addition to radiological and nuclear
emergencies, they have been also described in biological and chemical An ongoing outbreak of an unusual disease may be the first indication. The
emergencies, as well as natural disasters. suspicion that such an outbreak could be attributable to radiation exposure
may be considered if a large group of people exhibit a characteristic pattern
The "worried well" may develop sub-clinical anxiety and/or chronic of illness including nausea, vomiting, diarrhoea and/or skin damage (e.g
somatic preoccupation. Some of their psychosomatic symptoms may mimic redness, alopecia, unusual “burns”), particularly if it is associated with
those symptoms that can be attributable to radiation exposure, such as typical haematological changes (e.g. lymphocytopenia, granulocytopenia).
nausea and vomiting. Therefore, differential diagnosis is essential and the A more systematic surveillance should be implemented to identify the
health care facilities should identify true symptomatic patients, to avoid cause of the outbreak, and to confirm or reject the hypothesis of a radiation
transferring to hospitals people who do not require medical assistance. incident.
Provision of information is the key for dealing with "worried well". Clear If an unusually large number of patients presenting two or more of those
information about the event should be provided through the media, and the signs/symptoms is detected, the health professional/s should inform the
public health services where people may ask for assistance or counselling. appropriate competent authority to start an investigation (health
In the midst of a community crisis, such a radiation emergency, the impact surveillance). Epidemiological intelligence can be used to alert authorities
of these messages may exert a strong influence. Sometimes casualties may to look for similar cases in their own jurisdiction.
experience frustration and feelings of helplessness related to local or
national governmental authorities. Brief non-sensationalistic press releases, In brief, outbreak management involves several steps:
broadcasting, posters and leaflets may be valuable tools to reassure the
public, including the "worried well". 1. Epidemic detection and alert demands the timely reporting of data
through the public health hierarchy – local, regional, provincial,
In addition to peripheral health care centres, some local institutions such as national or international, as appropriate.
schools, church, social clubs, cultural centers and non-governmental 2. Rapid epidemiological assessment is essential, at the beginning of
organisations may serve as focal points for provision of support to worried an outbreak or epidemic, to define initially the scope of the problem
people (WHO, 2003). Teachers may play a relevant role in providing (clinical pattern, initial number and distribution of cases).
emotional support for children and parents. In the case of foreign citizens
326 327
3. Epidemic investigation to identify whether there is a causal may include multiple symptoms like fear, grief, anxiety, anger, depression
association between radiation and the outbreak of the unusual and distrust. Psychosomatic symptoms are frequent and differential
illness. For radiation incidents, case definition should be diagnosis and treatment of physical and psychological conditions will be
established, to confirm these cases. Their etiology is not so essential during the early stage of the event, including the triage of
straightforward as it is for known infectious agents. This process casualties. (Berger and Sadoff, 2002).
may take some time and it will involve a multidisciplinary
collaboration (e.g. environmental monitoring, scenario Ionising radiation cannot be perceived by the senses and most people are
reconstruction, biological dosimetry). Along with confirming unaware of the magnitude of its effects, which could result in
apparent cases, the outbreak management and investigation team community-wide feelings of helplessness and vulnerability. Those disasters
should identify cases and define the scope of the problem. with a high degree of uncertainty, regarding potential future health effects,
4. Environmental health investigations are based on the preliminary are more psychologically traumatic than situations with more visible,
findings of the epidemiological investigation. For example, if water immediate, and predictable outcomes. The fact that the control of the
is suspected to be the source of the illness, more resources will be situation is out of citizens’ hands increases the feeling of vulnerability in
directed to monitoring the water source. the population.
5. As data accumulate during the outbreak, the public health team
Radiation emergencies resulting from malevolent acts may affect the
should generate descriptive epidemiologic information, and report
mental health of casualties, friends, relatives and responders. Emotional
findings to national competent authorities (which in turn will
reactions in responders may be so intense and severe that they could even
evaluate the need for notifying international bodies). These
affect decision making and operations. These emergencies may also have
outbreaks are often highly visible and are conducted under intense
an impact on people who have seen the event either first hand or through
public, political and media scrutiny. Communication between staff,
the media. Many people will fear possible exposure to radiation (“worried
departments, emergency services and government agencies, and
well”) and could develop psychological symptoms. Casualties with
communication with the media, is the key to preventing panic and
radiation induced illness or injuries are at higher psychological risk than
achieving maximal control.
the worried well. They will often face long-term medical care, repeated
surgery, isolation, rehabilitation, etc. Additional consequences, such as loss
8 Prevention and treatment of psychological of the ability to work, financial problems and loss of self-esteem could
increase the frequency and intensity of psychological reactions (Becker,
consequences 2001).
Psychosocial impact is one of the chief aims of terrorism. It presents
significant challenges to medical community and health authorities and Parents with young children, pregnant women, children, elderly people,
impacts at all levels of society. The health care system may be totally emergency workers, people with pre-existing mental disorders, clean up
overwhelmed by people requesting advice, assessment and care, as a workers and evacuees, are at higher risk. Acute stress reactions typically
consequence. observed include: physical, emotional, cognitive and interpersonal effects.
Although many of them are transient and reversible mild to moderate
A radiation emergency resulting from a malevolent act, is a highly stressful reactions, early management of these symptoms can speed recovery and
event. It may act as a powerful and persistent stressor, even after the avoid long-term consequences (IAEA EPR-Medical, 2005; WHO, 2003).
emergency has been controlled. Psychological reactions following human
made disasters, such as malevolent acts, are more intense and more There are mechanisms that societies have developed for better supporting
prolonged than psychological reactions following natural disasters. They crises. These implicit abilities to withstand the negative effects can be
328 329
partly acquired by previous experience, training, cultural features and The psychosocial effects of radiation accidents may extent far beyond the
individual personality. One of the best intervention strategies is to make area of impact because of the “anticipatory stress”. Long-term
use of those normal mechanisms to promote personal and societal cohesion. consequences may affect not only people exposed to ionising radiation but
Psychiatric and psychologist teams should assist emergency medical staff also those who have not been exposed but are concerned about “probable”
to differentiate persons exhibiting psychosomatic symptoms from those and “imagined” future risks. The size of the population exhibiting chronic
patients with radiation-induced symptoms. The risk of either delay in stress may be quite large and pervasive social stigma in residents of
therapy or administration of unnecessary medications should be avoided. affected areas may exacerbate the problems, resulting in an increased
burden on the health care system.
Wide-scale psychotherapy for the population is to be discouraged as this
runs the risk of creating additional casualties. Instead, people should be National preparation plans made before occurrence of emergencies should
referred to their family doctor (a general practitioner), in order to preserve involve a system of coordination with specification of focal mental health
the normal conditions and use the existing services. Most psychologists do spesialists, detailed plans to prepare for an adequate social and mental
not know about radiation risks or stochastic effects like cancer risks. For a health response, and training of relevant personnel in social and
well established therapy, it is better to refer to a psychologist with psychological interventions (WHO, 2003). Because the psychosocial
experience in dealing with cancer phobia or post-traumatic stress, who is consequences of radiation emergencies can be as important as their
also able to communicate risks. When psychological symptoms appear, biological and ecological impacts, psychosocial issues should be better
they could be managed through conventional strategies i.e. psychotherapy integrated into emergency planning (Becker, 1997).
and even psycho-pharmacotherapy, as routinely employed for anxiety and
depression in other situations.
9 Taking decisions about long-term follow
The psychological impact of traumatic events can last for weeks to months. up of people involved in a radiation
A persistent state of alarm may result in chronic stress reactions involving emergency
behavioural, emotional and physiological consequences. Most people report Medical monitoring programmes addressed at people involved in a
feeling better within three months after a traumatic event. If the problems radiation emergency should consider two different target populations:
become worse or last longer, the person may be suffering from
post-traumatic stress disorder (PTSD), characterised by persistent • Persons who developed clinical conditions requiring medical
symptoms of irritability, anger, increased startle response and frequent assistance during the emergency (e.g. acute radiation syndrome,
re-experiencing of the accidental event. If PTSD develops, two types of local radiation injuries); and
therapies could be efficient: trauma focus therapy and cognitive • Asymptomatic persons known (or presumed) to have been exposed
behavioural therapy. to ionising radiation.
A smaller fraction of the population may develop more serious and Long-term follow up of symptomatic persons is mainly aimed at the
persistent mental health problems such as: anxiety disorders, depression, diagnosis and treatment of long-term complications and prevention and
alcohol or drug abuse and personality disorders. Higher incidences of management of sequelae. The benefits of such medical monitoring
psychosomatic symptoms, psychological distress and psychiatric disorders programmes for symptomatic patients are clearly identifiable and their
have been observed among casualties of radiation accidents. Decrements in practical implementation does not substantially differ from the
performance on speed and accuracy tests and an increase in the prevalence implementation of medical follow up of other medical conditions.
of high blood pressure, cardiovascular diseases, digestive and
neuroendocrine disorders, have been also found.
330 331
On the other hand, proper medical follow up of asymptomatic persons Table K1. Late radiation morbidity score according to the Radiation Therapy Oncology
Group (RTOG) criteria.
involved in a radiation emergency, poses major concerns related to the
ORGAN Grade Grade Grade Grade Grade Grade
ability to identify populations at higher risk and to screen for disease in the TISSUE 0 1 2 3 4 5
population at risk in a manner that produces more benefits than harm. The
goal is to detect disease in people without symptoms so that they can be Slight
atrophy, Patch atrophy;
treated earlier, on the assumption that earlier diagnosis will result in pigmentation moderate
Marked atrophy;
Skin None gross telangi- Ulceration
reduced morbidity and/or mortality. change, telangiectasia,
ectasia
some hair total hair loss
loss
During the emergency, basic relevant information needs to be in place (e.g.
patient data in suitable worksheets) to facilitate epidemiological studies.
Death
Health care workers involved in the emergency should be aware of these Severe directly
Moderate
needs. Specific advice will be requested, about the needs for further Slight
fibrosis but
induration and related
Subcu- induration loss of to
implementation of medical monitoring programmes, and health taneous (fibrosis) and
asymptomatic,
subcutaneous radiation
professionals in charge of managing the emergency should be capable of tissue
None
loss of
slight field
contracture
tissue, field
Necrosis
late
dealing with these requests (IAEA EPR-Medical, 2005; WHO, 2006; IAEA subcutaneous
<10% linear
contracture effects
fat > 10 % linear
TECDOC 1300, 2002). reduction
measurement
9.1 Long-term follow up of patients who developed local Moderate Marked atrophy
Mucous
radiation injuries Slight atrophy atrophy and with complete
membrane None Ulceration
and dryness Telangiectasia, dryness, severe
Patients who suffered local radiation injuries, after moderate to high dose little mucous telangiectasia
exposure, should be periodically monitored for many years. Patients will be
advised to contact their family doctors/general practitioners (GPs) to report The follow up should be tailored case by case. Although there are no
what happened and to plan the follow up programme. Although the follow standard follow up protocols, some generic criteria similar to those applied
up will be conducted by the family doctor, interaction with the relevant to radiotherapy patients could be adapted to local radiation injuries (e.g.
hospital department is recommended. Moreover, family doctors should monthly clinical examination during the first three months, every third
interact with burn specialists, plastic surgeons, mental health professionals month during the first year, every 6-12 months the second year, and once a
or other relevant health professionals, as necessary. year thereafter).
Telangiectasia and fibrosis are some of the characteristic late sequelae of The evolution of skin lesions must be recorded, preferably by colour
local radiation exposure. According to the late radiation morbidity score photographs, making use of imaging diagnosis if necessary (e.g.
(available at www.rtog.org/members/toxicity/late.html), late effects are ultrasound, thermography). Depending on the severity of the damage, the
those that appear 3 months or more after local radiation exposure. This late need for prevention/treatment of fibrosis (e.g. interferon, pentoxifyllin,
radiation morbidity scoring may also be applied to ensure common criteria alpha-tocopherol) should be considered and protocols for pain control
for evaluation and categorisation of late symptoms and signs [Table K1]). implemented.
Mental health support and reproductive health counselling should be

provided if required.
332 333
Periodical (e.g. annual) ophthalmological exams should be performed, during the first year; thereafter, a clinical routine examination may be
particularly recording lens opacities (cataracts). Patients should know that conducted once a year.
they have to request medical advice in case of local infections, wounds or
alarm signs such as erythema, oedema, pain, etc. Even after apparent Mental health support and reproductive health counselling should be
healing, skin lesions may break down and acute inflammatory signs and provided, if required.
symptoms may reappear. Due to the higher vulnerability of irradiated
Periodic (e.g. annual) ophthalmological exams should be performed,
tissues, necrosis may be triggered even after mild mechanical, chemical or
particularly to record lens opacities (cataracts).
physical trauma. Recommendations to prevent additional damage in
irradiated areas should be provided, including advice to avoid chemical Follow up of stochastic effects (i.e. cancer) should not be indiscriminate
exposures, mechanical trauma, sun exposure and exposure to extreme since it may increase psychological morbidity. The peak of onset of
temperatures. leukaemia occurs 5 years after exposure, and most solid tumours appear
Radiation induced damage to the endothelium of blood vessels and well beyond 10 years after exposure. Even with the availability of an
functional disturbances the immunocompetent skin cells may alter accurate test for early detection of cancer, there must be scientific evidence
protection against infections and healing processes. The management of of the benefit of such early detection (availability of effective therapy,
infections in irradiated skin is of great importance. improvement of the clinical outcome). Effective use of specific tests/
screening depends on knowledge of their accuracy, their rate of
Any planned surgical intervention (even minor) on the irradiated tissues or false positive results, the appropriate interval for repeating them, as well as
involving neighboring areas, should be carefully planned and agreed with on their costs, unpleasantness and risks.
the family doctor and relevant specialists.
9.3 Long-term follow up of populations exposed to low
9.2 Long-term follow up of casualties who developed doses
acute radiation syndrome (ARS)
The epidemiological follow up of asymptomatic persons, after a radiation
Persons who developed acute radiation syndrome (ARS) are at higher risk emergency, is implemented with the main purpose of detecting adverse
of developing long-term effects from ionising radiation. These effects effects or diseases potentially related to radiation exposure (e.g. cancer).
include not only late deterministic effects (e.g. cataract, sterility, immune (WHO, 2006).
dysfunction) but also effects of a probabilistic nature, such as cancer.
For such screening to be beneficial:
Patients will be advised to contact their family doctors/GPs to report what
• Disease risk should be identified in the population or population
happened and to plan the follow up programme. Although the follow up
subgroups (e.g. children, pregnant women);
will be conducted by the family doctor, interaction with the relevant
• An accurate practical screening tool must be available;
hospital department is recommended. Moreover, the family doctor should
• Early detection of the disease must improve survival;
interact with hematologists, mental health professionals or any other
• Effective treatment of the disease needs to exist; and
relevant health professionals, as necessary.
• The benefits of the screening must be greater than the harm.
Follow up should be tailored on a case by case basis, according to the
severity of the ARS and individual organ doses (in cooperation with A radio-epidemiological study may be conducted with the following
appropriate specialists). As an example, after recovery of aplasia, clinical purposes:
and haematological examination may be performed every three months
• To identify adverse effects in a group of people known (or
334 335
presumed) to have been exposed to ionising radiation; 1. Determine the availability of an appropriate and clearly defined
• To determine whether the risk of such effects is significantly greater study population.
in this group than for a comparable (e.g. age, gender) unexposed 2. Ensure the correct identity and contact details of persons to be
group of individuals; included in the registry.
• To determine whether the increased risk (if any) is statistically
3. Include relevant medical information in the initial registry
associated with the exposure;
(history of any injury and treatment given during the emergency).
• To determine if there is a relationship between the increased risk
and other factors (e.g. tobacco smoking, exposure to chemicals); 4. Collect information about the magnitude and distribution of
• To derive and refine risk estimates; and exposure (results of dose assessment, including effective dose,
• To plan health interventions, as necessary. organ specific dose, ranges of doses received and projected,
results of surveys for external and/or internal contamination,
Medical monitoring of people exposed to low doses must be carefully physical dose reconstruction, biodosimetry data).
considered, taking into account legal, social, economic and psychological 5. Evaluate the accuracy with which the exposure can be
factors. There is not enough evidence to recommend follow up for determined.
stochastic effects (i.e. cancer), from a medical management perspective. 6. Consider the background rate of the disease to be studied (e.g.
However, in some cases, it is prudent to develop a registry and to conduct cancer) and the expected increase in the incidence/mortality
epidemiological research. among the exposed group, based on current knowledge of
radiation risks.
An epidemiological follow up study starts by identifying two target
7. Determine the size and composition of the study population and
populations (those exposed and those unexposed) to determine whether
control group needed taking into account the previous points;
these two groups experience different health outcomes.
8. Define inclusion and exclusion criteria for the study population
In radiation epidemiology, cancer incidence or mortality are the typical and control group.
outcomes. However, data emerging from the A-bomb survivors’ life span 9. Apply objective criteria for inclusion of persons in the registry
studies indicate that other non-malignant morbidities and causes of based on the potential for an increase in cancer morbidity/
mortality should also be included. Mortality is the most conclusive mortality (e.g. effective dose ≥ 100 mSv to the whole body).
outcome to study for epidemiological purposes because its occurrence is 10. Apply objective criteria for inclusion of exposed pregnant women
clearly definable and relatively complete records are available in most that indicate a potential for an increase of consequences of
countries. However, it is not always the health outcome of interest, since prenatal exposure (e.g. effective dose ≥ 100 mSv to the foetus).
many non-fatal diseases, including cancers, may affect quality of life. 11. Ensure proper disease identification and recording (history of
disease confi rmed by hospital records, cause of death confirmed
The size of the population that needs to be studied, to detect a statistically by death certificates).
significant difference in mortality, increases dramatically (to hundreds of
12. Consider the inclusion of risk factors other than radiation that
thousands or even millions) when the difference becomes small in might affect the outcome.
comparison with the natural incidence of the disease of interest
(UNSCEAR Report, 1993).
Several practical actions are involved in the planning and implementation
of an epidemiological study in order to:
336 337
CHAPTER L 2.1 The Early Notification Convention
The Early Notification Convention was adopted in 1986, following the
International liaison Chernobyl nuclear plant accident, and establishes a notification system for
nuclear accidents which have the potential for international transboundary
release that could be of radiological safety significance for another State
(IAEA Legal series 14, 1987). It requires States to report the time and
1 Introduction location of the accident, associated, radioactive releases, and other data
essential for assessing the situation. Notification is to be made to
Nuclear and radiological accidents, and situations resulting from potentially affected States directly or through the IAEA, and to the IAEA
malevolent acts involving radioactive material, can become a serious threat itself. Reporting is mandatory for any nuclear accident involving facilities
to life, health, the environment and society, over wide geographical areas. and activities listed in Article 1. Pursuant to Article 3, States may notify
Relevant national authorities have the responsibility to decide upon and other emergencies as well. The five nuclear weapon States (China, France,
implement appropriate response actions, and to ensure that relevant Russia, United Kingdom, and United States) have all declared their
resources are available for mitigation. However, the proper handling of intention to also report accidents involving nuclear weapons and nuclear
severe nuclear and radiological emergencies, or situations where prompt weapons tests.
response is warranted in order to mitigate the effects of a perceived hazard,
may require resources that challenge the capabilities of a single country. It On receiving the notification through the Emergency Notification and
is therefore important for countries to cooperate in order to better respond Assistance Convention ENAC web site or by fax the IAEA sends an initial
to such emergencies and situations through the arrangements set up message to all Member States. This is followed by further information as it
through formal mechanisms, such as, for example, the IAEA's Convention becomes available. Information is also sent to all relevant international
on Early Notification of a Nuclear Accident and Convention on Assistance organisations including, among others, the European Commission (EC),
in the Case of a Nuclear Accident or Radiological Emergency (IAEA Legal the World Health Organization (WHO), the World Meteorological
series 14, 1987) or World Health Organisation's International Health Organisation (WMO), and other organisations.
Regulations (WHO, 2007b). Notwithstanding the binding character of the
existing Emergency Conventions, they do not necessarily eliminate the
2.2 The European Commission Notification system
need for the countries and organisation parties to these conventions, to
have additional bilateral or multilateral agreements relating to information The European Community Urgent Radiological Information Exchange
exchange or assistance. (ECURIE) system is the technical implementation of the Council Decision
87/600/Euratom on Community arrangements for the early notification and
exchange of information in the event of a radiological or nuclear emergency
2 International notification arrangements (Euratom, 1987). This 87/600 Council Decision requires ECURIE Member
In response to nuclear or radiological emergencies countries should use States to promptly notify the EC and all the Member States potentially
established notification channels as laid down by the protocols of the Early affected, when they intend to take countermeasures in order to protect their
Notification Convention. It is therefore the responsibility of the relevant population against the effects of a radiological or nuclear accident. The EC
national authority to follow these arrangements. It is important to be fully will immediately forward this notification to all Member States. Following
aware of these protocols and ensure that local and/or national authorities this first notification, all Member States are required to inform the
are informed about the emergency/threat in a timely manner. Commission at appropriate intervals, about the measures taken and the
radioactivity levels measured. All 27 EU Member States, as well as
Switzerland and Croatia, have signed the ECURIE agreement.
338 339
Chapter L International liaison
2.3 World Health Organization particularly for complex situations. The resources and type of assistance
The current International Health Regulations (IHR) were put in place in needed will be identified and coordinated by the IAEA, and other relevant
response to the increased concerns about global health security (WHO, international organisations, the requesting state and state(s) providing
2007b). The IHR are an international legal instrument that is binding on assistance. The nature of the event will determine the participation of the
194 State Parties around the globe. Their aim is to help the international appropriate international organisations, as defined in the Joint Radiation
community prevent and respond to acute public health risks that have the Emergency Management Plan of the International Organizations (IAEA,
potential to cross borders and threaten people worldwide. EPR-JPLAN, 2006). The Joint Plan defines the mechanism of response and
the roles and responsibilities of each organisation, which can include, but is
The IHR, which entered into force on 15 June 2007, require countries to not limited to, WHO, WMO (World Meteorological Organization), FAO
report emergencies of public health concern to WHO through the national (UN Food and Agriculture Organization), EC (European Commission),
IHR focal point (NFP). NFPs are assigned for each national health Interpol and Europol [Figure L1].
authority. Building on the unique experience of WHO in global disease
surveillance, alert and response, the IHR define the rights and obligations All organisations co-sponsoring the Joint Plan, are members of the Inter-
of countries to report public health events, and establish a number of Agency Committee on Radiological and Nuclear Emergencies (IACRNE),
procedures that WHO must follow in its work to uphold global public which is a coordination mechanism to ensure that an effective emergency
health security and assist its Member States to strengthen national response capability is developed and maintained.
capabilities for response. WHO is also a full party to IAEA's Emergency
Conventions under which the Organization has a responsibility of
providing medical and public health assistance (Carr, 2006; Souchkevitch,
1997).
3 Coordination of international assistance

In addition to standing bilateral and/or regional agreements, the affected
country can request assistance from the IAEA through the Response
Assistance Network (RANET) in the event of a serious emergency, where
the efforts to manage and mitigate its consequences requires additional
resources beyond a country’s capability. One of the network’s major
objectives is to strengthen the IAEA’s capability to provide assistance and/
or to coordinate the provision of assistance, as specified within the
framework of the Assistance Convention. As a result of the Assistance
Convention, the World Health Organization established the Radiation
Emergency Medical Preparedness and Assistance Network (REMPAN) in
1987. The network is designated to provide emergency medical and public
health assistance to people over exposed to radiation. It also facilitates a
long-term care and follow up of radiation accident casualties.
The magnitude and type of requested assistance depends on the situation:
assistance may consist of technical consultations, a group of qualified Figure L1. Framework for inter-agency response to nuclear or radiological emergencies.
experts deployed to the field, or it may consist of several specialised teams, Reproduced courtesy of IAEA (IAEA EPR-JPLAN, 2006).
340 341
Bland, 2004. Bland SA. Mass casualty management for radiological and
References nuclear incidents. Journal of the Royal Army Medical Corps 2004; 150(3
Supplement 1): 27-34.
Bushberg et al, 2007. Bushberg JT et al. Nuclear/radiological terrorism:
Alexander et al, 2007. Alexander GA et al. Biodos EPR-2006 Meeting: emergency department management of radiation casualties. Journal of
Acute Dosimetry Consensus Committee. Recommendations on Emergency Medicine 2007; 32(1): 71-85.
biodosimetry applications in events involving uses of radiation by terrorists
and radiation accidents. Radiation Measurements 2007; 42: 972-96. Bushberg and Miller, 2004. Bushberg JT, Miller KL. Hospital responses
to radiation casualties. In: Brodsky A, Johnson RH, Goans RE, eds. Public
Barkyoumb and Mathur, 2008. Barkyoumb JH, Mathur VK. Epoxy protection from nuclear, chemical, and biological terrorism. Madison, WI:
encapsulant as serendipitous dosimeters during radiological/nuclear events. Health Physics Society/Medical Physics Publishing, 2004: 445-462.
Radiation Measurements 2008; 43(2-6): 841-844. http://www.medicalphysics.org/apps/medicalphysicsedit/HPS04CH25.pdf
Becker, 1997. Becker SM. Psychosocial assistance after environmental (06.03.2009).
accidents: a policy perspective. Environmental Health Perspectives 1997; Caldicott report, 1997. The Caldicott Committee report on the review of
105(6): 1557-1563. patient-identifiable information. London: Department of Health, 1997.
Becker, 2001. Becker SM. Psychosocial effects of radiation accidents. In: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/
Gusev IA, Guskova A, Mettler F, eds. Medical management of radiation PublicationsPolicyAndGuidance/DH_4068403?IdcService=GET_
accidents. Boca Raton: CRC Press, 2001: 519-525. FILE&dID=22658&Rendition=Web (16.03.09).
Berber and Thomas, 1992. Berber GB, Thomas RG, eds. Guidebook for Carr, 2006. Carr Z. The role of the World Health Organization in
the treatment of accidental internal radionuclide contamination of workers. strengthening capacity of the Member States for preparedness and response
Radiation Protection Dosimetry 1992; 41(1): 1-49. to radiation emergencies. Acta Medica Nagasakiensia 2006; 50(Supplement
2): 37-40.
Berger and Sadoff, 2002. Berger ME, Sadoff RL. Psychological support
of radiation-accidents patients, families and staff. In: Ricks RC, Berger CDC DTPA, 2006. CDC. Facts about DTPA. Atlanta, GA: Centers for
ME, O'Hara FM, eds. The medical basis for radiation accident Disease Control and Prevention, 2006.
preparedness: the clinical care of victims. New York: Parthenon Publishers, http://www.bt.cdc.gov/radiation/dtpa.asp (06.03.2009).
2002: 191-200. CDC Neupogen, 2006. CDC. Facts about Neupogen. Atlanta, GA: Centers
Blakely et al, 2009. Blakely W et al. Meeting report: WHO 1st consultation for Disease Control and Prevention, 2006.
on the development of a global biodosimetry laboratories network for http://www.bt.cdc.gov/radiation/neupogenfacts.asp (06.03.2009).
radiation emergencies (BioDoseNet). Radiation Research 2009; 171(1), CDC KI, 2006. CDC. Potassium Iodide (KI). Atlanta, GA: Centers for
127–139. Disease Control and Prevention, 2006.
Blakely et al, 2005. Blakely WF, Salter CA, Prasanna PGS. Early-response http://www.bt.cdc.gov/radiation/ki.asp (06.03.2009).
biological dosimetry - Recommended countermeasure enhancements for CDC Prussian blue, 2006. CDC. Fact sheet Prussian blue. Atlanta, GA:
mass-casualty radiological incidents and terrorism. Health Physics 2005; Centers for Disease Control and Prevention, 2006.
89(5): 494-504. http://www.bt.cdc.gov/radiation/prussianblue.asp (06.03.2009).
342 343
References
CDC Interim guidelines, 2003. CDC. Interim guidelines for hospital EPA, 2007. Communicating radiation risks. Washington DC: US
response to mass casualties from a radiological incident. Atlanta, GA: Environmental Protection Agency, 2007.
Centers for Disease Control and Prevention, 2003. http://www.bt.cdc.gov/ Euratom, 1987. Euratom. Council decision of 14 December 1987 on
radiation/pdf/MassCasualtiesGuidelines.pdf (06.03.2009). Community arrangements for the early exchange of information in the
CDC, 2007. CDC. Population monitoring in radiation emergencies - a event of a radiological emergency. Official journal L 371, 1987: 76-8.
guide for state and local public health planners, 2007. http://emergency.cdc. http://ec.europa.eu/energy/nuclear/radioprotection/doc/legislation/87600_
gov/radiation/pdf/population-monitoring-guide.pdf (06.03.2009). en.pdf (06.03.2009).
Chao, 2007. Chao N. Accidental or intentional exposure to ionizing EBMT, 2007. European approach for the medical management of mass
radiation: biodosimetry and treatment options. Experimental Hematology radiation exposure – the first 48 hours. Leaflet. Editors: European Blood
2007; 35(4 Supplement 1): 24-7. and Marrow Transplantation (EBMT), Ulm University, Institut de
Radioprotection et de Sûreté Nucléaire (IRSN), April 2007.
Covello and Sandman, 2001. Covello V, Sandman PM. Risk http://www.ebmt.org/7directory/committees/nuclear%20accident%20docs/
communication: evolution and revolution. In: Wolbarst VA, ed. Solutions to Pocket_guide.pdf (06.03.2009).
an environment in peril. Baltimore: John Hopkins University Press, 2001:
164–178. http://www.psandman.com/articles/covello.htm (06.03.2009). Fenech et al, 1999. Fenech M et al. Necrosis, apoptosis, cytostasis and
DNA damage in human lymphocytes measured simultaneously within the
Dainiak, 2007. Dainiak, N. Response to and management of a radiological cytokinesis-block micronucleus assay: description of the method and
crisis. New York: Center for Health Information Preparedness, 2007. results for hydrogen peroxide. Mutagenesis 1999; 14: 605-12.
http://chip.med.nyu.edu/course/view.php?id=28 (06.03.2009).
Fliedner, 2006. Fliedner TM. Nuclear terrorism: the role of hematology in
Dainiak, 2002. Dainiak N. Hematologic consequences of exposure to coping with its health consequences. Current Opinion in Hematology 2006;
ionizing radiation. Experimental Hematology 2002; 30(6): 513-28. 13(6): 436-44.
Dainiak et al, 2007. Dainiak N, Berger P, Albanese J. Relevance and Fliedner et al, 2007. Fliedner TM et al. Pathophysiological principles
feasibility of multiparameter assessment for management of mass casualties underlying the blood cell concentration responses used to assess the
from a radiological event. Experimental Hematology 2007; 35: 17-23. severity of effect after accidental whole-body radiation exposure: an
Dainiak et al, 2006. Dainiak N et al. Development of a statewide hospital essential basis for an evidence-based clinical triage. Experimental
plan for radiological emergencies. International Journal of Radiation Hematology 2007; 35: 8-16.
Oncology, Biology, Physics 2006; 65(1):16-24. Fliedner et al, 2005. Fliedner TM, Dorr HD, Meineke V. Multi-organ
Dainiak et al, 2003. Dainiak N et al. The hematologist and radiation involvement as a pathogenetic principle of the radiation syndromes: a study
casualties. Hematology 2003; 473-96. involving 110 case histories documented in SEARCH and classified as the
bases of haematopoietic indicators of effect. British Journal of Radiology,
Delanian and Lefaix, 2007. Delanian S, Lefaix JL. Current management 2005; (Supplement 27): 1-8.
for late normal tissue injury: radiation-induced fibrosis and necrosis.
Seminars in Radiation Oncology 2007; 17(2): 99-107. Fliedner et al, 2001. Fliedner TM, Friesecke I, Beyrer K, eds. Medical
management of radiation accidents: manual on the acute radiation
Durham, 1992. Durham JS. VARSKIN MOD2 and SADDE MOD2: Computer syndrome. London: The British Institute of Radiology, 2001.
codes for assessing skin dose from skin contamination. Richland, WA: Battelle
Pacific Northwest Laboratories; NUREG/CR-5873 (PNL-7913), 1992. http://www. Fliedner et al, 1996. Fliedner TM et al. Stem cell responses after radiation
nrc.gov/reading-rm/doc-collections/nuregs/contract/cr6918/ (06.03.2009). exposure: A key to the evaluation and prediction of its effects. Health
Physics 1996; 70(6): 787-97.
344 345
References
Flynn and Goans, 2006. Flynn DF, Goans RE. Nuclear terrorism: triage IAEA EPR-First responders, 2006. International Atomic Energy Agency.
and medical management of radiation and combined-injury casualties. Manual for first responders to a radiological emergency. EPR-First-
Surgical Clinics of North America 2006; 86(3): 601-36. responders 2006 Vienna: IAEA, 2006. http://www-pub.iaea.org/MTCD/
publications/PDF/EPR_FirstResponder_web.pdf (06.03.2009).
Freisecke et al, 2001. Freisecke I, Beyrer K, Fliedner TM. How to cope
with radiation accidents: the medical management. British Journal of IAEA EPR-JPLAN, 2006. International Atomic Energy Agency. Joint
Radiology 2001; 74(878): 121-122. radiation emergency management plan of the international organizations.
EPR-Jplan 2006. Vienna: IAEA, 2007. http://www-pub.iaea.org/MTCD/
Goans and Waselenko, 2005. Goans RE, Waselenko JK. Medical
publications/PDF/JPLAN2006_web.pdf (06.03.2009).
management of radiological casualties. Health Physics 2005; 89(5): 505-12.
IAEA EPR-Medical, 2005. International Atomic Energy Agency. Generic
Gorin et al, 2006. Gorin NC et al. Consensus conference on European
procedures for medical response during a nuclear or radiological
preparedness for haematological and other medical management of mass
emergency. EPR-Medical 2005. Vienna: IAEA, 2005. http://www-pub.iaea.
radiation accidents. Annals of hematology 2006; 85: 671-79.
org/MTCD/publications/PDF/EPR-MEDICAL-2005_web.pdf (06.03.2009).
Gourmelon et al, 2005. Gourmelon P et al. Involvement of the central
IAEA EPR-Medical/T, 2002. International Atomic Energy Agency.
nervous system in radiation-induced multiorgan dysfunction and/or failure.
Medical Preparedness and Response. IAEA EPR-Medical/T. Vienna:
British Journal of Radiology 2005; (Supplement 27): 62-8.
IAEA, 2002.
Greenstock and Trivedi, 1994. Greenstock CL, Trivedi A. Biological and
IAEA Legal series 14, 1987. International Atomic Energy Agency.
biophysical techniques to assess radiation exposure: a perspective. Progress
Convention on early notification of a nuclear accident and convention on
in biophysics and molecular biology 1994; 61(2): 81-130.
assistance in the case of a nuclear accident or radiological emergency.
Gusev et al, 2001. Gusev I, Guskova A, Mettler F, eds. Medical Legal series; no. 14. Vienna: IAEA, 1987. http://www-pub.iaea.org/MTCD/
management of radiation accidents. 2nd edition. Boca Raton: CRC press, publications/PDF/Pub0765_web.pdf (06.03.2009).
2001.
IAEA Safety report series 18, 2000. International Atomic Energy
Hankins, 1980. Hankins DE. Dosimetry of criticality accidents using Agency. Indirect methods for assessing intakes of radionuclides causing
activations of the blood and hair. Health Physics 1980; 38(4): 529-541. occupational exposure. Safety Report series; no. 18. Vienna: IAEA, 2000.
IAEA, 2000a. International Atomic Energy Agency. The radiological IAEA Safety report series 2, 1998. International Atomic Energy Agency.
accident in Lilo. Vienna: IAEA and WHO, 2000. http://www-pub.iaea.org/ Diagnosis and treatment of radiation injuries. IAEA Safety report series;
MTCD/publications/PDF/Pub1097_web.pdf (06.03.2009). no. 2. Vienna: IAEA, 1998. http://www-pub.iaea.org/MTCD/publications/
IAEA, 2000b. International Atomic Energy Agency. The radiological PDF/P040_scr.pdf (06.03.2009).
accident in Yanango. Vienna: IAEA, 2000. http://www-pub.iaea.org/ IAEA Safety series 114, 1996. International Atomic Energy Agency.
MTCD/publications/PDF/Pub1101_web.pdf (06.03.2009). Direct methods for measurements of radionuclides in the human body.
IAEA, 2002a. International Atomic Energy Agency. The radiological IAEA Safety series; no. 114. Vienna: IAEA, 1996.
accident in Gilan. Vienna: IAEA, 2002. http://www-pub.iaea.org/MTCD/ IAEA Safety series 115, 1996. International Atomic Energy Agency.
publications/PDF/Pub1123_scr.pdf (06.03.2009). International Basic Safety Standards for Protection against Ionizing
IAEA, 2002b. International Atomic Energy Agency. The radiological Radiation and for the Safety of Radiation Sources. IAEA Safety Series no.
accident in Samut Prakarn. Vienna: IAEA, 2002. http://www-pub.iaea.org/ 115. Vienna: IAEA, 1996. http://www-pub.iaea.org/MTCD/publications/
MTCD/publications/PDF/Pub1124_scr.pdf (06.03.2009). PDF/SS-115-Web/Start.pdf (06.03.2009).
346 347
References
IAEA Safety standards series GS-R-2, 2002. International Atomic IAEA TECDOC 746, 1994. International Atomic Energy Agency. Rapid
Energy Agency. Preparedness and response for a nuclear or radiological monitoring of large groups of internally contaminated people following a
emergency. IAEA Safety standards series; no. GS-R-2. Vienna: IAEA, radiation accident. IAEA TECDOC; 746. Vienna: IAEA, 1994.
2002. http://www-pub.iaea.org/MTCD/publications/PDF/Pub1133_scr.pdf http://www-pub.iaea.org/MTCD/publications/PDF/te_746_web.pdf (06.03.2009).
(06.03.2009).
IAEA Technical report series 405, 2001. International Atomic Energy
IAEA Safety standards series TS-G-1.2 (ST-3), 2002. International Agency. Cytogenetic analysis for radiation dose assessment: a manual.
Atomic Energy Agency. Planning and preparing for emergency response to
Technical report series; no. 405. Vienna: IAEA, 2001. http://www-pub.iaea.
transport accidents involving radioactive material. IAEA Safety standards
series; no. TS-G-1.2 (ST-3). Vienna: IAEA, 2002. http://www-pub.iaea.org/ org/MTCD/publications/PDF/TRS405_scr.pdf (06.03.2008).
MTCD/publications/PDF/Pub1119_scr.pdf (16.03.2009). IAEA Technical reports series 260, 1986. International Atomic Energy
IAEA STI/PUB/1290, 2007. IAEA safety glossary: terminology used in Agency. Biological dosimetry: chromosomal aberration analysis for dose
nuclear safety and radiation protection. STI/PUB/1290. Vienna: IAEA, 2007. assessment. Technical reports series; no. 260. Vienna: IAEA, 1986.
http://www-pub.iaea.org/MTCD/publications/PDF/Pub1290_web.pdf (06.03.2009). ICRP Publication 103, 2008. International Commission on Radiological
IAEA TECDOC 1432, 2005. International Atomic Energy Agency. Protection. 2008 Recommendations of the International Commission on
Development of an extended framework for emergency response criteria: Radiological Protection. Annals of the ICRP 2008; 37(2-4). ICRP
interim report for comments. IAEA TECDOC; 1432. Vienna: IAEA, 2005. Publication 103. Oxford: Elsevier, 2008.
http://www-pub.iaea.org/MTCD/publications/PDF/TE_1432_web.pdf ICRP Publication 96, 2005. International Commission on Radiological
(06.03.2009). Protection. Protecting people against radiation exposure in the event of a
IAEA TECDOC 1300, 2002. International Atomic Energy Agency. radiological attack. Edited by Jack Valentin. Annals of ICRP 2005; 35(1).
Follow-up of delayed health consequences of acute accidental radiation ICRP Publication 96. Oxford: Elsevier, 2005.
exposure: lessons to be learned from their medical management. IAEA ICRP Publication 89, 2002. International Commission on Radiological
TECDOC; 1300. Vienna: IAEA, 2002. http://www-pub.iaea.org/MTCD/ Protection. Basic anatomical and physiological data for use in radiological
publications/PDF/te_1300_web.pdf (06.03.2009). protection: reference values. Editor Jack Valentin. Annals of the ICRP
IAEA TECDOC 1331, 2002. International Atomic Energy Agency. Use of 2002; 32(2-4). ICRP Publication 89. Oxford: Pergamon/Elsevier, 2002.
electron paramagnetic resonance dosimetry with tooth enamel for ICRP Publication 78, 1997. International Commission on Radiological
retrospective dose assessment. IAEA TECDOC; 1331. Vienna: IAEA, Protection. Individual Monitoring for Internal Exposure of Workers-
2002. http://www-pub.iaea.org/MTCD/publications/PDF/te_1331_web.pdf Replacement of ICRP Publication 54. Annals of the ICRP 1997; 27(3-4).
(06.03.2009). ICRP Publication 78. Oxford: Pergamon press, 1997.
IAEA TECDOC 1162, 2000. International Atomic Energy Agency. ICRP Publication 71, 1995. International Commission on Radiological
Generic procedures for assessment and response during a radiological Protection. Age-dependent doses to members of the public from intakes of
emergency. IAEA TECDOC; 1162. Vienna: IAEA, 2000. http://www-pub. radionuclides: part 4. Ingestion dose coefficients. Annals of the ICRP 1995;
iaea.org/MTCD/publications/PDF/te_1162_prn.pdf (06.03.2009). 25(3/4). ICRP Publication 71. Oxford: Pergamon Press, 1995.
IAEA TECDOC 1092, 1999. International Atomic Energy Agency. ICRP Publication 69, 1995. International Commission on Radiological
Generic procedures for monitoring in a nuclear or radiological emergency. Protection. Age-dependent doses to members of the public from intakes of
IAEA TECDOC; 1092. Vienna: IAEA, 1999. http://www-pub.iaea.org/ radionuclides: part 3. Ingestion dose coefficients. Annals of the ICRP 1995;
MTCD/publications/PDF/te_1092_web.pdf (06.03.2009). 25(1). ICRP Publication 69. Oxford: Pergamon Press, 1995.
348 349
References
ICRP Publication 68, 1995. International Commission on Radiological ICRP Publication 30, part 1, 1979. International Commission on Radiological
Protection. Dose coefficients for intakes of radionuclides by workers: Protection. Limits for intakes of radionuclides by workers: part 1. Annals of the
Replacement of ICRP publication 61: Summary of the current ICRP ICRP 1979; 2(3/4). ICRP Publication 30, Part 1. Oxford: Pergamon Press, 1979.
principles for protection of the patient in nuclear medicine. Annals of the
ICRP 1994; 24(4). ICRP Publication 68. Oxford: Pergamon/Elsevier, 1995. ICRU Report 69, 2003. International Commission on Radiation Units and
Measurements, Direct determination of the body content of radionuclides.
ICRP Publication 66, 1994. International Commission on Radiological ICRU Report no 69. Journal of the ICRU 2003; 3(1). Ashford: Nuclear
Protection. Human respiratory tract model for radiological protection. Technology Publishing, 2003.
Annals of the ICRP 1994; 24(1-3). ICRP Publication 66. Oxford: Pergamon
Press, 1994. Ilyin et al, 1972. Ilyin LA et al. Radioactive iodine in the problem of
radiation safety. Moscow: Atomizdat, 1992.
ICRP Publication 67, 1993. International Commission on Radiological
Protection. Age-dependent doses to members of the public from intakes of Inrig et al, 2008. Inrig EL, Godfrey-Smith DL, Khanna S. Optically
radionuclides: part 2. Ingestion dose coefficients., Annals of the ICRP stimulated luminescence of electronic components for forensic,
1993; 23(3/4). ICRP Publication 67. Oxford: Pergamon Press, 1993. retrospective and accident dosimetry. Radiation Measurements 2008; 43(2-
6): 841-844.
ICRP Publication 60, 1991. International Commission on Radiological
Protection. 1990 recommendations of the International Commission on ISO 21243, 2008. International Organization for Standardization.
Radiological Protection. Annals of the ICRP 1991; 21(1-3). ICRP Radiation protection: performance criteria for laboratories performing
Publication 60. Oxford: Pergamon press, 1991. cytogenetic triage for assessment of mass casualties in radiological or
nuclear emergencies - General principles and application to dicentric assay.
ICRP Publication 56, 1990. International Commission on Radiological ISO International standard 21243. Geneva: ISO, 2008.
Protection. Age-dependent doses to members of the public from intakes of
radionuclides: part 1. Ingestion dose coefficients., Annals of the ICRP ISO 21482, 2007. International Organization for Standardization. Ionizing
1990; 20(2). ICRP Publication 56. Oxford: Pergamon Press, 1990. radiation warning – supplementary symbol. ISO International standard
21482. Geneva: ISO, 2007.
ICRP Publication 30, part 4, 1988. International Commission on
ISO 19238, 2004. International Organization for Standardization.
Radiological Protection. Limits for intakes of radionuclides by workers: part 4. Radiation protection: performance criteria for service laboratories
Annals of the ICRP 1988; 19(4). ICRP Publication 30. Oxford: Pergamon Press. performing biological dosimetry by cytogenetics. ISO International
ICRP Publication 38, 1983. International Commission on Radiological standard 19238. Geneva: ISO, 2004.
Protection. Radionuclide transformations : Energy and intensity of Lamadrid et al, 2007. Lamadrid AI et al. PCC-ring induction in human
emissions. Annals of the ICRP 1983; 11-13. ICRP Publication 38. Oxford: lymphocytes exposed to gamma and neutron irradiation. Journal of
Pergamon Press, 1983. radiation research (Japan Radiation Research Society) 2007; 48(1): 1-6.
ICRP Publication 30, part 3, 1981. International Commission on Lataillade et al, 2007. Lataillade J et al. New approach to radiation burn
Radiological Protection. Limits for intakes of radionuclides by workers: treatment by dosimetry-guided surgery combined with autologous
part 3. Annals of the ICRP 1981; 6(2/3). ICRP Publication 30, Part 3. mesenchymal stem cell therapy. Regenerative Medicine 2007; 2(5): 785-794.
Oxford: Pergamon Press, 1981. Lloyd et al, 2000. Lloyd DC et al. The role of cytogenetics in early triage
ICRP Publication 30, part 2, 1980. International Commission on of radiation casualties. Applied Radiation and Isotopes 2000; 52: 1107-12.
Radiological Protection. Limits for intakes of radionuclides by workers: MacNeil, 2007. MacNeil S. Progress and opportunities for tissue-
part 2. Annals of the ICRP 1980; 4(3/4). ICRP Publication 30, Part 2. engineered skin. Nature 2007; 445: 874-880.
Oxford: Pergamon Press, 1980.
350 351
References
Marcus et al, 2006. Marcus CS, Siegel JA, Sparks RB. Medical management Picano, 2004. Picano E. Informed consent and communication of risk from
of radiocontaminated patients. Los Angeles County Department of Health radiological and nuclear medicine examinations: how to escape from a
Services, Emergency Medical Services Agency, 2006. communication inferno. British Medical Journal 2004; 329(7470): 849-851.
Meineke, 2005. Meineke V. The role of damage to the cutaneous system in Rahola et al, 2006. Assessment of internal doses in emergency situations.
radiation induced multi-organ failure. British Journal of Radiology 2005; Final report for the NKS-B project 2006. NKS-128, April 2006.
(Supplement 27): 95-9. http://www.risoe.dk/rispubl/NKS/nks-128.pdf (06.03.2009).
Menetrier et al, 2007a. Menetrier F et al. TIARA: Treatment initiatives after REAC/TS Guidance. Guidance for radiation accident management:
radiological accidents. Radiation Protection Dosimetry 2007; 127: 444-48. Managing radiation emergencies: Guidance for hospital management. Oak
Menetrier et al, 2007b. Menetrier F et al. Dose assessment of inhaled Ridge, TN: Radiation Emergency Assistance Center, Training Site, REAC/
radionuclides in emergency situations. Edited by Health Protection Agency, TS. http://orise.orau.gov/reacts/guide/care.htm (06.03.2009).
HPA, Radiation Protection Division. Chilton, Didcot: HPA, 2007.
REMM, 2008. Radiation event medical management: Guidance on
Menetrier et al, 2005. Menetrier F et al. Treatment of accidental intakes of diagnosis & treatment for health care providers. Washington DC:
plutonium and americium: Guidance notes. Applied Radiation and Isotopes Department of Health and Human Services, Office of the Assistant
2005; 62(6): 829-46. Secretary for Preparedness and Response, 2008. http://www.remm.nlm.gov
Mettler, 2005. Mettler F. Medical resources and requirements for (06.03.2009).
responding to radiological terrorism. Health Physics 2005; 89(5): 488-93. Ricks et al, 2002. Ricks RC, Berger ME, O’Hara FM, eds. The medical
NCRP Report 161, 2008. National Council on Radiation Protection and basis for radiation accident preparedness: Clinical care of victims.
Measurements, NCRP. Management of persons contaminated with Proceedings of the Fourth International REAC/TS Conference on the
radionuclides. NCRP Report no. 161. Bethesda, MD: National Council on medical basis for radiation-accident preparedness, March 2001, Orlando,
Radiation Protection and Measurements, 2008. FL. New York: Parthenon, 2002.
NCRP Report 87, 1987. National Council on Radiation Protection and Romanyukha et al, 2005. Romanyukha A et al. Parameters affecting EPR
Measurements, NCRP. Use of bioassay procedures for assessment of dose reconstruction in teeth. Applied Radiation and Isotopes 2005; 62(2):
internal radionuclide deposition. NCRP Report no. 87. Bethesda, MD: 147-54.
National Council on Radiation Protection and Measurements, 1987. Schertan et al, 2007. Schertan H et al. Radiation-induced late-effects in
Pellmar and Ledney, 2005. Pellmar TC, Ledney GD. Combined injury: two affected individuals of the Lilo radiation accident. Radiation Research
radiation in combination with trauma, infectious disease or chemical 2007; 167: 615-23.
exposures. Paper presented at the NATO Human Factors and Medicine Smith et al, 2005. Smith JM, Ansari A, Harper FT. Hospital management
Panel Research Task Group 099 “Radiation Bioeffects and of mass radiological casualties: reassessing exposures from contaminated
Countermeasures” meeting, held in Bethesda, MD, June 2005, published in victims of an exploded radiological dispersal device. Health Physics 2005;
AFRRI CD 05-2. http://www.afrri.usuhs.mil/www/outreach/pdf/pellmar_ 89(5): 513-20.
NATO_2005.pdf (06.03.2009).
Souchkevitch, 1997. Souchkevitch G. The World Health Organization network
Peter and Gottlober, 2002. Peter RU, Gottlober P. Management of for radiation emergency medical preparedness and assistance (REMPAN).
cutaneous radiation injuries: diagnostic and therapeutic principles of the Environmental Health Perspectives 1997; 105(Supplement 6): 1589-93.
cutaneous radiation syndrome. Military Medicine 2002; 16(2 Supplement):
110-12. Swartz et al, 2007. Swartz HM et al. In vivo EPR for dosimetry. Radiation
Measurements 2007; 42: 1075-84.
352 353
References
Swartz et al, 2006. Swartz HM et al. In vivo EPR dosimetry to quantify WHO, 2006. General considerations for health care and medical
exposures to clinically significant doses of ionising radiation. Radiation monitoring. In: Bennet B, Repacholi M, Carr Z, eds. Health effects of the
Protection Dosimetry 2006; 120(1-4): 163-170. Chernobyl accident and special health care programmes: UN Chernobyl
Forum Report. Geneva: World Health Organization: 2006: 109-115. http://
Trompier et al, 2007. Trompier F et al. Protocol for emergency EPR
www.who.int/entity/ionizing_radiation/chernobyl/WHO%20Report%20
dosimetry in fingernails. Radiation Measurements 2007; 42: 1085-88.
on%20Chernobyl%20Health%20Effects%20July%2006.pdf (06.03.2009).
Turai et al, 2004. Turai I et al. Medical response to radiation incidents and
WHO, 2003. Mental Health in emergencies WHO/MSD/MER/03.01.
radionuclear threats. British Medical Journal 2004; 328: 568-572.
Geneva: World Health Organization, 2003.
UNSCEAR Report, 1993. Sources and effects of ionizing radiation: http://www.who.int/mental_health/media/en/640.pdf (06.03.2009).
UNSCEAR 1993 report to the General Assembly, with scientific annexes.
Wood et al, 2000. Wood R et al. Decorporation treatment: Medical
United Nations Scientific Committee on the Effects of Atomic Radiation,
overview. Radiation Protection Dosimetry 2000; 87(1): 51-6.
UNSCEAR. New York: United Nations, 1993.
http://www.unscear.org/unscear/en/publications/1993.html (06.03.2009).
Wallström et al, 1999. Wallström E, Alpsten M, Mattsson S. A gamma
camera for measurements of internal contamination after a radiological
accident. Journal of Radiological Protection 1999; 19(2): 143-54.
Waselenko et al, 2004. Waselenko JK et al. Medical management of the
acute radiation syndrome: recommendations of the Strategic National
Stockpile Radiation Working Group. Annals of Internal Medicine 2004;
140, 1037–51.
Weisdorf et al, 2007. Weisdorf D et al. Radiation emergencies: evaluation,
management, and transplantation. Biology of Blood and Marrow
Transplantation 2007; 13(1):103-6.
Williams et al, 2007. Williams BB et al. Experimental procedures for
sensitive and reproducible in situ EPR tooth dosimetry. Radiation
Measurements 2007; 42: 1094-98.
WHO, 2007a. WHO. Development of stockpiles for radiation emergencies:
Report of the radio-nuclear working group. WHO consultation meeting in
Geneva 2007. Geneva: World Health Organization, WHO, 2007.
https://www.who.int/ionizing_radiation/a_e/emergencies/WHO_stockpile_
report_2007.pdf (06.03.2009).
WHO, 2007b. International Health Regulations, (2005). World Health
Organization, 2007. http://www.who.int/csr/ihr/IHR_2005_en.pdf (06.03.2009).
354 355
Fouillard L et al. Infusion of allogeneic-related HLA mismatched
Bibliography mesenchymal stem cells for the treatment of incomplete engraftment
following autologous haematopoietic stem cell transplantation.
Leukemia 2007; 21(3): 568-70.
Armed Forces Radiobiology Research Institute (AFRRI). Medical Goans RE et al. Early dose assessment following severe radiation
management of radiological casualties handbook. 2nd ed. Bethesda, ML: accidents. Health Physics 1997; 72(4): 513-18.
AFRRI, 2003. http://www.afrri.usuhs.mil/www/outreach/
pdf/2edmmrchandbook.pdf (06.03.2009). Gonzalez, AJ. An international perspective on radiological threats and the
need for retrospective biological dosimetry of acute radiation
Bell WC, Dallas CE. Vulnerability of populations and the urban health care overexposures. Radiation Measurements 2007; 42: 1053-62.
systems to nuclear weapon attack – examples from four American cities.
International Journal of Health Geographics 2007; 6: 5 doi: 10.1186/1476- Hamasaki K et al. Short-term culture and γH2AX flow cytometry
072X-6-5. http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1828719 determine differences in individual radionsensitivity in human peripheral
&blobtype=pdf (06.03.2009). T lymphocytes. RERF report no. 11-06. Hiroshima: Radiation Effects
Research Foundation, 2006.
Berger ME et al. Medical management of radiation injuries: current
approaches. Occupational Medicine 2006; 56(3): 162-72. Harper FT, Musolino SV, Wente WB. Realistic radiological dispersal
device hazard boundaries and ramifi cations for early consequences
Canada B. State and local preparedness for terrorism: Policy issues and management decisions. Health Physics 2007; 93(1): 1-16.
options. CRS report for Congress. Washington DC: Congressional
Research Service. The Library of Congress, 2002. http://fpc.state.gov/ Heinrich J. Bioterrorism preparedness efforts have improved public health
documents/organization/8037.pdf (06.03.2009). response capacity, but gaps remains. GAO-03-654T. Washington DC:
United States General Accounting Office, 2003.
Centers for Disease Control and Prevention (CDC). Strategic national http://www.gao.gov/new.items/d03654t.pdf (06.03.2009).
stockpile. Atlanta, GA: Centers for Disease Control and Prevention, 2008.
http://www.bt.cdc.gov/stockpile/#means (06.03.2009). Heptonstall J, Gent N. CRBN incidents: a guide to clinical management
and health protection. London: Health Protection Agency, HPA, 2006.
Conference of Radiation Control Program Directors, CRCPD. Handbook http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Pag
for responding to a radiological dispersal device. First responder’s guide e/1158934607980?p=1158934607980 (06.03.2009).
– the first 12 hours. CRCPD Publication 06-6. Frankfort, KY: CRCPD,
2006. http://www.crcpd.org/RDD_Handbook/RDDHandbook-ForWeb.pdf Herodin F, Grenier N, Drouet M. Revisiting therapeutic strategies in
(06.03.2009). radiation casualties. Experimental hematology 2007; 35(4): 28-33.
Emergency Medical Services Authority (EMSA). Patient decontamination Herodin F, Drouet M. Cytokine-based treatment of accidentally irradiated
recommendations for hospitals. EMSA no. 233. Sacramento, 2005. victims and new approaches. Experimental hematology 2005; 33(10): 1071-
http://www.emsa.ca.gov/pubs/pdf/emsa233.pdf (06.03.2009). 80.
EUPHIX Public Information System: crude birth rates, version 1.8, 2008. Hertfordshire Resilience multi-agency emergency response plan. Hertford,
Bilthoven: National Institute for Public Health and the Environment, 2006. www.hertsdirect.org/infobase/docs/pdfstore/hrerppub.pdf (06.03.2009).
RIVM, 2008. http://www.euphix.org/object_document/o5407n28149.html
(06.03.2009).
356 357
Bibliography
Hirama T, Akashi M. Multi-organ involvement in the patient who survived International Atomic Energy Agency. Directory of whole-body
the Tokai-mura criticality accident. British Journal of Radiology 2005; radioactivity monitoring. STI/PUB/213. Vienna: IAEA, 1970.
(Supplement 27): 17-20.
Jackson WL et al. Medical management of patients with multiple organ
HM Government. Emergency response and recovery. dysfunction arising from acute radiation syndrome. British Journal of
http://www.ukresilience.gov.uk/media/ukresilience/assets/emergresponse. Radiology 2005; (Supplement 27): 161-68.
pdf (06.03.2009).
Knouss RF. Testimony on combating terrorism: management of medical
International Atomic Energy Agency. Arrangements for preparedness for a stockpiles. Washington DC: Depatment of Health and Human Services,
nuclear or radiological emergency. IAEA Safety standards series; no. GS- Assistance Secretary for Legislation, Department of Health and Human
G-2.1. Vienna: IAEA, 2007. http://www-pub.iaea.org/MTCD/publications/ Services, 1999. http://www.hhs.gov/asl/testify/t000308d.html (06.03.2009).
PDF/Pub1265_web.pdf (06.03.2009).
Koenig KL et al. Medical treatment of radiological casualties: current
International Atomic Energy Agency. Emergency notification and concepts. Annals of Emergency Medicine 2005; 45(6): 643-45.
assistance: technical operations manual. EPR-ENATOM 2007. Vienna:
IAEA, 2007. http://www-pub.iaea.org/MTCD/publications/PDF/ Laroche P, de Carbonnières H, Castagnet X. Risque radiologique: prise en
ENATOM2007_web.pdf (06.03.2009). charge médicale des victimes d’accidents radiologiques. Médecine
d’urgence EMC 2007; 25-030-H-60 1-12.
International Atomic Energy Agency. IAEA response assistance network:
incident and emergency centre. EPR-RANET 2006. Vienna: IAEA, 2006. Manthous CA, Jackson WL Jr. The 9-11 Commission’s invitation to
http://www-pub.iaea.org/MTCD/publications/PDF/Ranet2006_web.pdf imagine: a pathophysiology-based approach to critical care of nuclear
(06.03.2009). explosion victims. Critical Care Medicine 2007; 35(3): 716-23.
International Atomic Energy Agency. Radiation, people and the Meineke V et al. Medical management principles for radiation accidents.
environment. Vienna: IAEA, 2004. http://www.iaea.org/Publications/ Military Medicine 2003; 168(3): 219-22.
Booklets/RadPeopleEnv/pdf/radiation_low.pdf (06.03.2009). MsConnell KW et al. Anti-apoptotic peptides protect against radiation-
International Atomic Energy Agency. Method for the developing induced cell death. Biochemical and Biophysical Research
arrangements for response to a nuclear or radiological emergency. EPR- Communications 2007; 355(2): 501-07.
Method 2003. Vienna: IAEA, 2003. http://www-pub.iaea.org/MTCD/ Müller K, Meineke V. Radiation-induced alterations in cytokine production
publications/PDF/Method2003_web.pdf (06.03.2009). by skin cells. Experimental Hematology 2007; 35: 96-104.
International Atomic Energy Agency. Generic assessment procedures for Musolino SV, Harper FT. Emergency response guidance for the fi rst 48
determining protective actions during a reactor accident. IAEA TECDOC; hours after the outdoor detonation of an explosive radiological dispersal
955. Vienna: IAEA, 1998. http://www-pub.iaea.org/MTCD/publications/ device. Health Physics 2006; 90(4): 377-85.
PDF/te_955_prn.pdf (06.03.2009).
National Council on Radiation Protection, NCRP. Key elements of
International Atomic Energy Agency. Planning the medical response to preparing emergency responders for nuclear and radiological terrorism.
radiological accidents. Safety report series; no. 4. Vienna: IAEA, 1998. NCRP Commentary no.19. Bethesda, MD: NCRP, 2005.
http://www-pub.iaea.org/MTCD/publications/PDF/Pub1055_web.pdf
(06.03.2009).
358 359
Bibliography
National Health Service, NHS. Planning for major incidents: the NHS Weisdorf D et al. Acute radiation injury: contingency planning for triage,
guidance. Annex. London: Department of Health, 1998. supportive care, and transplantation. Biology of Blood and Marrow
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/ Transplantation 2006; 12(6): 672-82.
PublicationsPolicyAndGuidance/DH_4005419 (06.03.2009).
World Health Organization. Radiation accidents and emergencies (website
Peter RU et al. Interferon gamma in survivors of the Chernobyl power plant for radiation emergencies). Geneva: World Health Organization, WHO,
accident: new therapeutic option for radiation-induced fibrosis. 2008. http://www.who.int/ionizing_radiation/a_e/en/ (06.03.2009).
International journal of radiation oncology, biology, physics 1999; 45(1):
147-52. World Health Organization. WHO- Health Action in Crises. Mass casualty
management systems strategies and guidelines for building health sector
Pouget JP et al. PCCFISH in skin fi broblasts for local dose assessment: capacity. Geneva: World Health Organization, WHO, 2007.
Biodosimetric analysis of a victim of the Georgian radiological accident.
Radiation Research 2004; 162: 365-76. World Health Organization. Effective media communication during public
health emergencies: a WHO handbook. Geneva: World Health
Prasanna PG et al. Cytogenetic biodosimetry for radiation disasters: recent Organization, WHO, 2005. http://www.who.int/csr/resources/publications/
advances. Paper presented at the NATO Human Factors and Medicine WHO_CDS_2005_31/en/ (06.03.2009).
Panel Research Task Group 099 “Radiation Bioeffects and
Countermeasures” meeting, held in Bethesda, MD, June 2005, published in Zvonova IA et al. 134-Cs and 137-Cs wholebody measurements and
AFRRI CD 05-2. http://www.afrri.usuhs.mil/outreach/pdf/prasanna_ internal dosimetry of the population living in areas contaminated by
NATO_2005.pdf (06.03.2009). radioactivity after the Chernobyl accident. Radiation Protection Dosimetry
1995; 62(4): 213-21.
Roy L et al. International intercomparison for criticality dosimetry: the
case of biological dosimetry. Radiation Protection Dosimetry 2004; 110(1-
4): 471-76.
The Cochrane Collaboration. Reviews on health care interventions.
http://www.cochrane.org/reviews/clibintro.htm#rev (06.03.2009).
Thierry D et al. Cell therapy for the treatment of accidental radiation
overexposure. British Journal of Radiology, 2005; (Supplement 27): 175-79.
Tochner ZA, Lehavi O, Glatstein E. Radiation bioterrorism. In: Kasper DL
et al, eds. Harrison’s principles of internal medicine. 16th edition. New
York: McGraw-Hill, 2004: 1294-1300.
UK Home Office. The decontamination of people exposed to chemical,
biological, radiological or nuclear (CBRN) substances or material: Strategic
national guidance. Second edition. London 2004.
http://security.homeoffice.gov.uk/news-publications/publication-search/
cbrn-guidance/decon-people?view=Binary (06.03.2009).
360 361
Antiphlogistic: an agent that counteracts inflammation.
Glossary Aplasia: failure to develop. Very often used to talk about haematopoietic
failure (“bone marrow aplasia”).
Asthenia: weakness, lack/loss of energy and strength.
A Authorised personnel: assisting personnel such as police, fire fighters,
Abrasions: scraped area on the skin or on a mucous membrane, resulting medical personnel and drivers and crews of evacuation vehicles called
from injury or irritation. upon to respond within the cordoned zones. In addition, radiation
Absorbed dose: the amount of energy deposited by ionising radiation in a specialists, radiation protection officers and radiological assessors who may
unit mass of tissue, expressed in units of joules per kilogram (J/kg), which respond to emergencies, should be considered as authorised personnel.
is given the special name of "gray" (Gy). Autograft: tissue transplanted from one part of the body to another in the
Absorption Type: materials are absorbed from the respiratory tract to same individual, also called an autotransplant.
body fluids with different rates. Chemical compounds are generally Autologous recovery: functional recovery from cells of the same
allocated to one of three default Absorption Types. These are Type F (i.e. individual.
fast, for very soluble materials), Type M (for moderately soluble materials),
and Type S (i.e. slow, for relatively insoluble materials). B
Activity Median Aerodynamic Diameter (AMAD): in an aerosol Becquerel: measure of the rate of radioactive decay that corresponds to
containing radioactive particles with a range of sizes, fifty percent of the one atomic disintegration per second. It is used as a measure of the amount
activity in the aerosol is associated with particles of aerodynamic diameter of a radioactive material.
greater than the AMAD. Beta (β) radiation: a charged particle ejected from the nucleus of a
Acute Radiation Syndrome (ARS): a set of characteristic signs and decaying atom. It includes electrons (negatively charged) and positrons
symptoms observed after whole body or large volume partial body (positively charged). Beta particles penetrate the outer skin layer, are not
exposure. stopped in tissue as quickly as alpha particles, and produce less damage per
Aerodynamic diameter: the diameter of the unit density spherical particle living cell (low LET).
that has the same settling velocity in air. Bioassay: procedures to evaluate internal contamination, including
Alpha (α) radiation: a positively charged particle emitted from the nucleus external monitoring for gamma emitting radionuclides, whole body
of some radioactive atoms when they decay. It generally carries more counting and lung counting (in vivo analysis), and radiochemical analysis
energy than gamma or beta radiation and deposits that energy very quickly of excreta (e.g. urine) and other samples (in vitro analysis).
while passing through tissue, referred to as "high linear energy transfer" Biodosimetry: see Biological dosimetry.
(high LET). Alpha particles cannot penetrate the outer layer of the skin Biokinetics: in the field of radiation protection it refers to the kinetics of
and, therefore, do not cause damage when outside the body. However, they intake, distribution, retention and excretion of radionuclides in the body.
may be particularly damaging if alpha emitters are inhaled or ingested. Biological dosimetry: use of biological samples, usually taken from
Allogeneic: being genetically different although belonging to, or having individuals who have been exposed to ionising radiation, to directly
been obtained from, the same species. This term is particularly used when measure biological endpoints that can be correlated to absorbed radiation
talking about tissue grafts (e.g. skin graft or bone marrow transplantation). dose. Quantification of chromosome aberrations in peripheral lymphocytes
Alopecia: loss of hair. (cytogenetic dosimetry) is the method of choice. See also Dosimetry.
Analgesic therapy: therapy addressed to control or eliminate pain. Blister: local swelling of the skin that contains watery fluid and is
Anticipatory stress: stress caused by concern over the future. frequently caused by burning, infection, or irritation.
Anti-emetic therapy: therapy addressed to prevent, stop, or relieve nausea Bone marrow: the soft, fatty, vascular tissue that fills most bone cavities
and emesis (vomiting). and is the source of most blood cells.
362 363
Glossary
Brain oedema: also named cerebral swelling, it is an accumulation of D

fluids in the brain very often due to extravasation of fluid, plasma proteins, Decorporation (or internal decontamination): process of treatment for
mainly albumin. Treatment can include diuretics and corticosteroids. persons with internally deposited radionuclides aimed at eliminating the
Buffer zone: region near the border of a protected or controlled area material from the body and reducing the internal dose from exposure and
established as a transition zone. hence, reducing the risk of health effects.
Deterministic health effects: radiation induced health effects which occur
C only above a given threshold level of radiation dose. The severity of the
Cataracts: opacity of the lens of the eye or its capsule (or both) that may effect is greater for a higher dose. Examples include erythema (skin
result from injuries to the eye, ageing, exposure to great heat or radiation, redness) and acute radiation syndrome. Not all deterministic effects are
or inherited factors. early effects.
Category P1: trauma triage category for severely injured people who Detriment: see Health Detriment.
require immediate life saving intervention. Dosemeter: general term applied to devices designed to record personal
Category P2: trauma triage category for people with less severe injuries exposure to ionising radiation. Passive dosemeters include film badges and
(compared to Category P1) who will need hospital care, but whose transfer thermoluminescent dosemeters (TLDs), whilst active dosemeters include
to a medical facility can be delayed for 10 – 12 hours. electronic personal dosemeters (EPDs). EPDs are designed to provide real
Category P3: trauma triage category for injured people who will require time information on dose and dose rate. The dosemeter is the standard way
medical care, but may wait for a number of hours or be told to go home and of measuring personal exposure for the purposes of complying with
return the next day (the “walking wounded”). statutory occupational dose limits.
Chemical burns: tissue destruction caused by caustic agents, irritant Dose rate: the radiation dose delivered per unit of time.
gases, or other chemicals. Dose reconstruction: the process of estimating dose to people from
Clonogenic assays: experimental technique for studying the effectiveness radioactive contamination and/or exposure to an external source.
of specific agents on the survival and proliferation of cells. Dosimetry: methods to measure or assess the radiation dose to people or
Combined injuries: radiation exposure in combination with burn, wound, objects exposed to ionising radiation, including reading of badges worn by
trauma or infection. potentially exposed individuals as well as bioassay (e.g. measurement of
Committed effective dose: the time integral of the effective dose rate that activity in the body through samples of urine, faeces, etc.).
will be received by an individual following an intake of radioactive
material. It is the effective dose that an individual is committed to receive E
once an intake has taken place. The integration period is 50 years for Early effects: radiation induced health effects that occur within some
adults, and from intake to 70 years of age for children. The unit of months after exposure. See also Late effects.
committed effective dose is the sievert (Sv). Effective dose: the sum of the equivalent doses to organs and tissues,
Conjunctival haemorrhage: haemorrhage that occurs beneath the weighted by the appropriate tissue weighting factors. These weighting
conjunctiva, the transparent membrane covering the sclera. factors represent the relative contribution of each organ or tissue to the total
Cord blood: blood collected after the cord has been detached from a health detriment due to stochastic health effects resulting from uniform
newborn baby, which may be utilised as a source of haematopoietic stem irradiation of the whole body. Effective dose provides a single quantity that
cells for transplantation. can be used for radiation protection purposes to represent health detriment
Cross contamination: spreading of radioactive materials from one person, resulting from an intake of a radionuclide. The unit of effective dose is the
object or place to another. sievert (Sv).
Cutaneous radiation syndrome: see Local radiation injury. Emergency services: local public response organisations that are generally
available and that perform emergency response functions. These may
364 365
Glossary
include law enforcement, fire fighters and rescue brigades, ambulance F

services and control teams for hazardous materials. Fibrosis: development of excess fibrous connective tissue in an organ or
Emergency worker: in the context of an incident involving ionising tissue as a reparative or reactive process.
radiation, a worker who may be exposed in excess of occupational dose Field triage: all of those triage procedures that are carried out on the
limits while performing actions to mitigate the consequences of an affected population outside of a hospital or other medical facility, either at
emergency for human health and safety, as well as severe consequences for the site of the incident or at a distance from it.
property and the environment. First Responder: the first members of emergency services to respond at
Emesis: vomiting. the scene of an emergency.
Endarteritis obliterans: extreme degree of inflammation particularly Follow up: in this context, subsequent contact with a person for the
affecting small arteries, accompanied by degeneration of the intima, purpose of monitoring health status following exposure, diagnosis and/or
leading to occlusion of the blood vessel. treatment.
Endogenous microbial flora: microorganisms found in various parts of
the body such as skin, gut, mouth, upper respiratory tracts and genitals. G
Also called normal flora, this micro flora lives in harmony with the host. Gamma dose rate (γ-DR): the absorbed dose that would be received per
However, some types of flora are opportunists and seek to colonise when unit time by human tissue placed in a defined gamma radiation field.
normal mechanisms of preventing disease are overcome (e.g. depression/ Gamma (γ) radiation: high energy photons emitted by the nuclei of
suppression of the immune responses). decaying atoms. Gamma radiation can penetrate through several metres of
Endothelium: layer of cells located at the interior surface of blood vessels, solid material.
forming an interface between circulating blood and the rest of the vessel Gastro-intestinal uptake factor ( f1): the fraction of material taken into
wall. the body by ingestion that is absorbed to body fluids as it passes through
Environmental monitoring: see Monitoring, environmental. the gastro-intestinal tract. Chemical compounds are assigned a default
Epilation: loss of hair. See also Alopecia. value of f1 between 0 and 1.
Equivalent dose: the absorbed dose averaged over a tissue or organ, with Graft rejection: in haematology, the expression is used to describe the
the contribution from each radiation type (alpha, beta, gamma, etc.) situation when bone marrow infused during a transplant is rejected by the
weighted by a radiation weighting factor that reflects the effectiveness of donor.
that radiation in causing stochastic health effects. This effectiveness is Graft Versus Host Disease: a serious complication of bone marrow
sometimes called the radiation quality. The unit of equivalent dose is the transplantation where there is a reaction of donated bone marrow against
sievert (Sv). the patient’s own tissues.
Erythema: redness of skin and/or mucosa. Gray (Gy): the SI unit of absorbed dose, equal to 1 Joule kg-1.
Excoriation: erosion or destruction of the skin by mechanical means. Granulocytopenia: reduced number of blood granulocytes, namely
Exeresis: surgical removal of any part or organ; excision. neutrophils, eosinophils, and basophils.
External contamination: radioactive material in the form of dust, solid
particles, aerosols or liquid attached to a person’s skin or clothes. H
External contamination monitoring: Individual monitoring using Haematopoiesis: formation of blood cellular components, which are
measurements of the amount of radioactive material deposited on skin or derived from haematopoietic stem cells.
clothing. Haematopoietic stem cell: multipotent cells with the ability to become
External monitoring: see Monitoring. several different types of cell in the blood system.
Health detriment: a measure of the harm that would eventually be
experienced by an exposed group and its descendants as a result of the
366 367
Glossary
group’s exposure to a source of ionising radiation. Measurements may be direct (e.g. measurement of activity in the lungs
Health surveillance: tracking and forecasting of any health event or health using external detectors) or indirect (e.g. measurement of activity excreted
determinant through the collection of data, the integration, analysis and in samples of urine).
interpretation of those data into surveillance products (e.g. reports, Internal dosimetry: methods to assess the dose that a person is committed
advisories, alerts, and/or warnings), and the dissemination of those to receive as a result of an intake of a given amount of radioactive material.
surveillance products to relevant public bodies. Surveillance products are Ionising radiation: for the purpose of radiation protection, radiation
produced for a specific public health purpose or policy objective. capable of producing ion pairs in biological material.
Hereditary effects: radiation induced health effects that occur in a Isodose: a radiation dose of equal intensity to more than one body area. An
descendant of the exposed person (the less precise term “genetic effects” is isodose chart is a diagram of depth dose measurement at various positions
also used). They are related to changes in germinal cells. within a radiation beam in which points of equal dose throughout the beam
Histocompatibility: property of having the same, or mostly the same, are joined to give isodose lines.
alleles of a set of genes called the major histocompatibility complex (also
called in humans HLA). These genes are expressed in most tissues as L
antigens to which the immune system makes antibodies. If the body is Laceration: a tear in the skin which results from a mechanical injury.
exposed to foreign antigens, e.g. by getting a tissue graft, it attacks the Late effects: radiation induced health effects that occur years after
foreign material unless it is histocompatible. exposure.
Human mesenchymal stem cells (HMSC): multipotent cells that can Local radiation injury: injury to the skin and underlying tissues resulting
differentiate either in vivo or in vitro into a variety of cell types such as from local exposure to a high external dose of ionising radiation.
myocytes (muscle cells), adipocytes, osteoblasts and hondrocytes. Lymphocyte subpopulations: morphologically identical types of
Hyperkeratosis: thickening of the skin following production of an excess lymphocytes that can be distinguished by their cell surface antigens.
of proteins. Different subpopulations of lymphocytes play essential functions in human
Hypotension: abnormally low blood pressure. humoral or cell mediated immunity (i.e. immunity mediated by cells or by
secreted antibodies).
I Lymphocytosis: abnormal increase in the number or proportion of
Immunocompetent skin cells: skin resident cells originating from the lymphocytes in the blood.
hematopoietic system participating in immune reactions. Lymphopenia: abnormal decrease in the number or proportion of
Immunosuppression: act or effect that reduces the activation or efficacy of lymphocytes in the blood.
the immune system. Deliberately induced immunosuppression may be
done to prevent the body from rejecting an organ transplant, to treat Graft M
Versus Host Disease after bone marrow transplant, or for the treatment of Malevolence: the act of deliberately causing harm.
auto-immune diseases. “Malevolent use”: use characterised by malevolence.
Individual monitoring: see Monitoring, individual. Monitoring: the measurement of radiation dose or contamination, for
Inpatient care: medical services provided to a person admitted for reasons related to the assessment or control of exposure to radiation or
overnight stay in a hospital. radioactive material, and the interpretation of the results.
Internal contamination: radionuclides incorporated within the body as a Monitoring, environmental: the measurement of external dose rates in
result of inhalation, ingestion, direct absorption through open wounds or the environment, or of widespread contamination by radionuclides of
intact skin and mucosa. environmental media.
Internal contamination monitoring: individual monitoring using Monitoring, individual: monitoring using measurements of quantities of
measurements of the amount of radioactive material in the body. radioactive material in or on the body of the individual, or measurements
368 369
Glossary
made by equipment worn by individual workers. It includes the assessment Operational Control Point (OCP): location established in the Red Zone
of radiation doses to the individual from the results of such measurements. on the Safety Perimeter to provide rapid access to the incident location for
Monitoring, radiological: see Monitoring. emergency personnel and where rapid initial screening measurements can
Monitoring, source: the measurement of the activity of radioactive be performed.
material or of external dose rates in the localised area around a source. Outbreaks (or epidemics): occurrence of a disease in excess of its
Morbidity: in medicine this term can refer either to the state of being ill or expected frequency.
to the degree or severity of a disease. In epidemiology, this term is also Outpatient care: medical services that are provided without the need for
used to refer to the prevalence or incidence of a disease. The prevalence is an overnight stay in a hospital, e.g. through an ambulatory care clinic or
the total number of cases, in a particular population at a particular point in emergency department.
time. The incidence is the number of new cases in a particular population
during a particular time interval. The term morbidity rate can refer either P
to the incidence rate or to the prevalence rate of a disease (to compare, see P1, P2, P3: see Category P1, P2, P3.
also mortality). Pancytopenia: medical condition in which there is a reduction in the
Mortality: a measure of the number of deaths in a given population. number of red and white blood cells, as well as platelets.
Mortality rate is the number of people dying during a given time interval, Pemphigus: term that includes a group of rare autoimmune skin disorders
divided by the total number of people in the population. characterised by the development of blisters in the outer layer of the skin
Multiple Organ Dysfunction (MOD): altered organ function involving (epidermis) and mucous membranes.
two or more organ systems which may occur in acutely ill patients such Personal Protective Equipment (PPE): specialised safety clothing or
that homeostasis cannot be maintained without intervention. equipment worn for protection against health and safety hazards, especially
Multiple Organ Failure (MOF): a progressive condition usually in the work environment. Personal protective equipment may be designed
characterised by combined failure of several organs such as the lungs, liver, to protect many parts of the body, i.e. eyes, head, face, hands, feet, and
kidney, along with some clotting mechanisms. ears. Such equipment must be used when the existing risks cannot be
Myelosuppression: condition in which bone marrow activity is decreased, sufficiently limited by other means.
resulting in fewer red blood cells, white blood cells, and platelets. Petechiae: small red or purple spots on the body, caused by a minor
bleeding from broken capillary blood vessels.
N Post traumatic stress disorder (PTSD): anxiety disorder that can develop
Neovascularisation: proliferation of new blood vessels. after exposure to a highly stressful event or ordeal. Severe and ongoing
Neutropenic patient: patient with neutropenia, which is defined emotional reaction to an extreme psychological trauma.
specifically as a decrease in the number of circulating neutrophils. See also Proliferation response tests: in immunology, group of tests to evaluate the
Granulocytopenia. functional status of lymphocytes.
Public health: science and art of preventing disease, prolonging life and
O promoting good health.
Occupancy time: time spent by an individual at a given location. Punctures: incision of tissues for injection of medication or for other
Oedema: swelling of any organ or tissue due to accumulation of excess diagnostic or therapeutic procedures.
lymph fluid, without an increase of the number of cells in the affected tissue.
Omentum flap: omentum or epiplon is a large fold of peritoneum. In R
reconstructive plastic surgery, a segment of omentum, with its supplying Radiation burns: see Local radiation injury.
blood vessels, may be transplanted as a free flap to a distant area. Radiation emergency medicine: emergency medicine related to the
Onycholisis: separation of the nail plate from the nail bed. management of health effects resulting from radiation exposure of
370 371
Glossary
individuals and populations. damage.

Radiation protection: the protection of people from the effects of Reverse isolation: a system designed to protect patients from getting an
exposure to ionising radiation, and the means for achieving this. infection caused by germs – bacteria, viruses or fungi – that may be in the
Radioactive contamination: unwanted radioactive material inside the environment or carried by staff and visitors.
body or on the body surfaces (internal or external contamination,
respectively). Contaminated persons are continually exposed to radiation S
until the contamination is removed. Safety Perimeter: the boundary of the Red Zone.
Radioactive material: material emitting ionising radiation and designated Security Access Control Point (SACP): a “gateway” on the Safety
in national law or by a regulatory body as being subject to regulatory Perimeter providing controlled rapid access between the Red Zone and
control because of its radioactivity. Yellow Zone.
Radiation source: anything that may cause radiation exposure, such as by Security Perimeter: the boundary of the Yellow Zone.
emitting ionising radiation or by releasing radioactive material, and can be Sievert (Sv): the SI unit of equivalent dose and effective dose.
treated as a single entity for protection and safety purposes. Somatic effects: radiation induced health effects that occur in the exposed
Radioactive source: radioactive material that is permanently sealed in a person.
capsule or closely bonded in a solid form and which is not exempt from Source monitoring: see Monitoring, source.
regulatory control. This also includes any radioactive material released if Stab wound: a wound where the depth of injury is greater than the length
the radioactive source is leaking or broken. and may come into contact with vital organs in the chest and abdomen.
Radioactive waste: waste that contains, or is contaminated with, Stochastic health effects: radiation induced health effects where the
radionuclides at concentrations or activities greater than clearance levels probability of occurrence is greater for higher radiation doses, but where
established by the regulatory body. the severity of the effects (if they occur) is independent of dose. They
Radiodermatitis: dermatitis (skin inflammation) due to exposure to generally occur without a threshold level of dose and they may be somatic
ionising radiation. (i.e. they occur in the exposed person e.g. cancer) or hereditary effects (i.e.
Radiological dispersal device (RDD): any device that causes the they occur in the descendant of the exposed person).
purposeful dispersion of radioactive material without a nuclear detonation. Stockpiles: in the context of public health, it refers to medical supplies
Radiological exposure device (RED): devices designed to cause external stored, carefully accrued and maintained, so they can be made rapidly
exposure to ionising radiation. available when needed.
Radiological monitoring: see Monitoring. Strategic Command: the Strategic Command is in overall charge of the
Radiological triage: triage based on a consideration of actual or potential response to the incident, but is not present at the scene. The Strategic
effects on health arising from exposure to ionising radiation. Command is likely to be headed by a senior member of the
Red Zone: the potentially hazardous area immediately surrounding an Security Forces (e.g. Police) or a senior member of local government.
incident location.
Relative Biological Effectiveness (RBE): a relative measure of the T
effectiveness of different radiation types at inducing a specified health Tactical Control Point (TCP): the location in the Yellow Zone from which
effect, expressed as the inverse ratio of the absorbed doses of two different on-site management and coordination takes place.
radiation types that would produce the same degree of a defined health Tactical Incident Command (TIC): the TIC is in overall charge of all
effect (the “degree” being probability for stochastic health effects, and personnel operating at the site of the incident. It is likely to be led by the
severity for deterministic health effects). most senior member of the First Responder teams attending. The TIC
Residual haematopoiesis: in the context of acute radiation syndrome, it reports to Strategic Command.
refers to the functional activity remaining after bone marrow radiation Telangiectasia: small dilated superficial blood vessels giving rise to
372 373
Glossary
tenderness, pain or discomfort when an affected area is touched.

Tenderness: pain or discomfort when an affected area is touched. List of abbreviations
Thermal burns: injuries to tissues caused by heat, characterised by degree,
based on the severity of the tissue damage.
Thrombocytopenia: presence of sub-normal numbers of platelets in blood.
α: alpha radiation
Transdermal absorption: absorption of a substance through the skin. It
occurs through a slow process of diffusion, driven by the gradient between β: beta radiation
the high concentration in the delivery system and the zero concentration γ: gamma radiation
prevailing in the skin. γ-DR: gamma dose rate
Trauma: any injury, whether physically or emotionally inflicted. Physical μm: micro metre (10-6 m)
injury trauma may be caused by violent or disruptive action, or by the
introduction into the body of a toxic substance. Psychological injury μSv: micro Sievert
trauma can result from a severe emotional shock.
Trauma triage: triage based on degree of physical injury, see also ABC: Airway, Breathing and Circulation
Category P1, P2, P3. AL: Action Level
Triage: the use of simple procedures for rapidly sorting people into groups ALI: Annual Limit on Intake
based (a) on their degree of physical injury and (b) on actual or potential
AMAD: Activity Median Aerodynamic Diameter
effects on health, and the allocation of care to these people so as to expedite
treatment and maximise the effective use of resources. ANC: Absolute Neutrophil Count
ARS: Acute Radiation Syndrome
U BM: Bone Marrow
Unrelated or partially matched donors: allogeneic (as opposite to Bq: becquerel
autologous) hematopoietic cell transplantation remains a challenge due to
the risk of graft rejection in the HLA mismatched settings. In the absence BS: Body Surface
of matched sibling donors, alternative donors such as unrelated and/or CBC: Complete Blood Count
partially matched family sources may be options. CBMN: Cytokinesis Block Micronucleus Assay
CBRN: Chemical, Biological, Radiological, Nuclear
W
CCTV: Closed-Circuit Television
Worried well: in emergencies, this term refers to people requesting
assistance because they think they may have been exposed to a chemical, CLOR: Central Laboratory for Radiological Protection in Poland
physical or biological agent, but who have not actually been exposed. cm: centimetre
cps: counts per second
XYZ CRP: C-Reactive Protein
Yellow Zone: the area surrounding the Red Zone from where personnel
responding to the incident may operate, and where members of the public CRS: Cutaneous Radiation Syndrome
being evacuated from the Red Zone may be processed. CT: Computed Tomography
DG Research: Directorate General Research
DTPA: Diethylene Triamine Pentaacetic Acid
374 375
List of abbreviations
E50: Committed Effective Dose (Adult) ID: Identity

E70: Committed Effective Dose to age 70 (Children) IHR: International Health Regulations
EC: Electron Capture IR: Ionising Radiation
EC: European Commission IRSN: Institut de Radioprotection et Sureté Nucléaire
ECG: Electrocardiogram KGF: Keratinocyte Growth Factor
EEG: Electroencephalogram KI: potassium iodide
EPO: Erythropoietin LiI: lithium iodide
EPR: Electron Paramagnetic Resonance LRI: Local Radiation Injury
ESR: Electron Spin Resonance LSA: Low Specific Activity
EU: European Union m: metre
Euratom: European Atomic Energy Community MDA: Minimum Detectable Activity
f1: Gastro-Intestinal Uptake Factor METREPOL: Medical Treatment Protocols for radiation accident victims
FAO: Food and Agriculture Organization MN: Micronucleus
FISH: Fluorescence in situ Hybridisation MOD: Multi-Organ Dysfunction
Flt3: Ligand for the FLT3 Tyrosine Kinase Receptor MOF: Multi-Organ Failure
G-CSF: Granulocyte Colony-Stimulating Factor MRI: Magnetic Resonance Imaging
GI: Gastro Intestinal MSC: Mesenchymal Stem Cells
GM-CSF: Granulocyte-Macrophage Colony-Stimulating Factor mSv: milli sievert
GP: General Practitioner NaI(Tl): sodium iodide doped with thallium
GPS: Global Positioning System NCRP: National Council on Radiation Protection & Measurements
GVHD: Graft Versus Host Disease NFP: National Focal Point
Gy: gray NHS: National Health Service
h: hour NIRS: National Institute of Radiological Sciences
HLA: Human Leukocyte Antigen NMR: Nuclear Magnetic Resonance
HPA: Health Protection Agency NRPA: Norwegian Radiation Protection Authority
HSC: Human Stem Cell NSAID: Non-Steroid Anti-Inflammatory
HSCT: Human Stem Cell Transplantation OCP: Operational Control Point
IACRNE: Inter-Agency Committee on Radiological and Nuclear OILs: Operational Intervention Levels
Emergencies OSL: Optically Stimulated Luminescence
IAEA: International Atomic Energy Agency P1, P2, P3: Category P1, P2 and P3 casualties
ICRP: International Commission on Radiological Protection PCC: Premature Chromosome Condensation
ICU: Intensive Care Unit PPE: Personal Protective Equipment
376 377
List of abbreviations
PRD: Personal Radiation Detector

PTSD: Post Traumatic Stress Disorder
RANET: Response Assistance Network (IAEA)
RBE: Relative Biological Effectiveness
RC: Response Category
RDD: Radiological Dispersal Device
REAC/TS: Radiation Emergency Assistance Center/Training Site
RED: Radiological Exposure Device
REMPAN: Radiation Emergency Medical Preparedness and
Assistance Network
RN: Radionuclide
SACP: Secure Access Control Point
SCF: Stem Cell Factor
SCO: Surface Contaminated Object
SCK•CEN: Studiecentrum voor Kernenergie. Centre d’Étude de
l’Energie Nucléaire (Belgian Nuclear Research Centre)
STUK: Radiation and Nuclear Safety Authority in Finland
Sv: sievert
TBI: Total Body Irradiation
TBSA: Total Body Surface Area
TCP: Tactical Control Point
TIARA: Treatment Initiatives After Radiological Accidents
TIC: Tactical Incident Command
TLD: Thermoluminescent Dosemeter
TMT: Triage, Monitoring, Treatment
TPO: Thrombopoietin
UK: United Kingdom
US: United States
WBC: Whole Body Counter
WBI: Whole Body Irradiation
WHO: World Health Organization
WMO: World Meteorological Organization
378 379
Annex 1: Required facilities
• Geometries with a stretcher or chair and a single or multiple

Annexes detectors could be used;
• Suitable hardware and software for collection and analysis of
spectra. Hardware capable of dealing with high count rates is
Annex 1: Required facilities desirable; and
• Phantoms for efficiency calibration of the measurement system.
This Annex contains brief information on permanent laboratory facilities.
Information relating to temporary facilities is given in Annex 2. The 3. Laboratory for measurement of gamma-ray emitters in bioassay
information presented here is intended to be used for planning relating to and environmental samples
the establishment of laboratory facilities required to deal with the type of Outline specification:
incident addressed by this Handbook. For detailed technical information on • High-purity germanium detector(s);
the equipment needed, reference should be made to the extensive literature • Detector shielded on all sides by 100 mm of lead (or alternative
that exists for such laboratory facilities. material giving similar shielding factors). Graded lining preferred;
• Detector calibrated to cover the energy range of at least 60 keV to
This Handbook may be used by countries with differing levels of 2000 keV;
investment in such permanent facilities. Therefore, a distinction is made • Detectors suitable for measurements of gamma-ray and X-ray
here between the facilities that ought to be available in each country; emissions from about 10 to 60 keV are desirable;
facilities that ought to be available, but not necessarily within the country • Suitable hardware and software for collection and analysis of
(and could be made the subject of arrangements to share resources with spectra. Hardware capable of dealing with high count rates is
neighbouring countries); and facilities that are desirable but not essential, desirable;
either within the country or in neighbouring countries. • A range of sample containers suitable for measurement of liquids,
soils and vegetation samples. Filters suitable for measurement of
Facilities that ought to be available in each country airborne particles must be available;
1. Buildings or establishments that could be used as a Reception • Efficiency calibration factors (relating measured full energy peak
Centre areas to sample activity) for the sample containers and
• Examples are sport centres or schools; environmental materials to be measured; and
• Areas for accommodating large numbers of people are needed; and • Laboratory facilities for preparation of samples.
• Simple decontamination facilities are needed – showers, changing
areas. 4. Peripheral health care centres
The suitability of the general type of building should be confirmed in Outline specification:
advance. • Laboratory with capability for carrying out total blood cell counts
and white blood cell differential counts; and
2. Whole body monitoring laboratory • Primary health care facilities for diagnosis and outpatient care.
Outline specification:
• Room with walls of iron or other shielding material;
• High-purity germanium or NaI(Tl) detector(s);
• Detector(s) calibrated to cover the energy range of at least 60 keV to
2000 keV;
380 381
Annexes Annex 1: Required facilities
5. Local hospitals (health care level 1) - Full intensive care unit;

Outline specification: - Specialised burns intensive care unit;
• Facilities for outpatient, inpatient and emergency care including - Specialised care unit for immunosuppressed patients;
diagnosis technical units (e.g. diagnostic imaging service and - Bone marrow transplantation unit;
laboratory) and capacity to act as a referral hospital for primary - Specialised surgery;
health care centres; - Gastroenterology
• Emergency care service as a 24-hour facility equipped to address - Advanced medical imaging technologies; and
major vital medical or surgical needs, with access to diagnostic - HLA typing and other advanced laboratory technologies.
exams (imaging and laboratory); and
Facilities that ought to be available, but not necessarily
• Laboratory with capability for carrying out:
within the country
- Total blood cell counts and white blood cell differential
counts; 8. Radiochemistry laboratory capable of carrying out the sample
- Basic coagulation profile; preparation necessary for measurements of alpha and beta
- Electrolytes and routine serum biochemical profile; and emitting radionuclides:
- Urine analysis • Equipped for bioassay sample analysis and environmental sample
analysis; and
6. Secondary referral hospitals (health care level 2) • Analytical methods for the radionuclides specified in Table H1
Outline specification: [Section H.2.5].
• Facilities for outpatient, inpatient and emergency care including
9. Laboratory for measurement of alpha emitting and beta emitting
diagnosis technical units (e.g. diagnostic imaging service and
radionuclides.
laboratory) and capacity to act as a referral for primary hospitals in
the field of:
10. Laboratory equipped for cytogenetic measurements on blood
- Internal medicine including emergency care;
samples.
- General surgery;
Outline specification:
- Special care unit;
- Haemotherapy; • Capability for carrying out blood cell counts;
- Haematology; • Cell culture facilities; and
- Obstetrics; • Microscopy and image analysis systems for cytogenetics.
- Gynaecology;
- Pediatrics; 11. Laboratory for electron spin resonance measurements (ESR)
- Mental health care; and • ESR spectrometers.
- Specialised diagnostics, such as CT scans and MRIs.
12. Facilities and equipment for performing dose reconstruction
7. Tertiary referral hospitals (health care level 3) guided surgery in severe local radiation injuries
• Facilities for outpatient, inpatient and emergency care including
diagnosis technical units (e.g. diagnostic imaging service and
laboratory) and capacity to act as a referral for secondary hospitals
in the field of:
382 383
Annexes Annex 1: Required facilities
Desirable facilities 15. Mass decontamination facilities

13. Transportable environmental monitoring unit Outline specification:
Outline specification: • Showers should be used for decontamination; ideally the correct
• Dose rate monitoring; percentage of detergent should be mixed with the water;
• Radionuclide identification; • Areas must be available for undressing and dressing;
• Aerosol sampling; • Consideration must be given to people’s comfort and modesty
• Sample and in situ gamma spectrometry; needs;
• Alpha spectrometry; and • Clean, dry clothing must be provided;
• Data communications tools. • Facility should be capable of being erected in a few minutes;
• System should be designed to decontaminated people at a rate of
Such facilities would be particularly useful in countries where the about 200 per hour;
availability of fixed facilities is limited, or where existing facilities are • Facilities should be available to heat the water used for
centralised at a single location. decontamination;
• It should be possible for people who are unable to walk to use the
14. Transportable body monitoring unit facility (or provide an alternative); and
Outline specification: • Water used for decontamination should be contained if possible.
• Must be readily transportable to the scene of the incident; (However, waste water considerations must not delay
• A high-purity germanium detector is preferable, but a NaI(Tl) decontamination of people).
detector may also be used;
• Detector calibrated to cover the energy range of at least 60 keV to
2000 keV;
• Shielding to reduce the effect of environmental contamination is
preferable;
• Efficiency calibration factors relating full energy peak areas to
activity in whole body. Calibrations factors must be available for
children as well as adults;
• A system suitable for measurement of gamma-ray and X-ray
emitters less than 60 keV in lung is desirable;
• Suitable hardware and software for collection and analysis of
spectra;
• Hardware capable of dealing with high count rates is desirable;
• Measures needed to protect the equipment from radioactive
contamination; and
• Data communications tools.
Such facilities are likely to have a significantly higher throughput than
laboratory facilities.
384 385
Annexes Annex 2: Equipment required for radiological triage and monitoring purposes
Annex 2: Equipment required for radiological triage

and monitoring purposes
This annex provides a list of supplies required to carry out the procedures
described in Chapters E to I. Permanent facilities such as laboratories are
described in Annex 1 and measurement equipment in Annex 8. The
availability of this equipment will need to be confirmed in advance of any
incident.
Figure A2.2. Non-gas-tight (Type 2) protective suits against
Personal Protective Equipment (PPE) liquid and gaseous chemicals are basic protective clothing for
the CBRN units. They provide excellent protection in
In all cases, alternative PPE giving a similar level of protection may be used. radiological emergencies. In most cases, they are not needed
for personnel working outside the Red Zone. Photo: STUK.
A. First responders and emergency workers entering the Red Zone

B. First responders and emergency workers entering the Yellow Zone
and medical staff handling contaminated casualties
• Waterproof gloves (must be abrasion resistant);
• Simple respirators/dust masks;
• Waterproof clothing (all skin and hair must be covered);
• Surgical gloves, which should be changed frequently;
• Coveralls;
• Safety helmet;
• Plastic shoe covers;
• Alarming personal dosemeter (measuring instantaneous dose rate
• Hair cover (e.g. surgical cap); and
as well as cumulative dose);
(TLD) is recommended).
(TLD); and
• High visibility clothing is recommended.
Figure A2.3. Filtering facepieces (FFP) are classified

Figure A2.1. Full face mask and filters are the into three classes FFP1, FFP2 and FFP3 with filter
basic respiratory protection for CBRN units. A material penetration factors less than 20 %, 6 % and
correctly fitted full face mask should not have an 1 %, respectively. Extra inward leakage from the
inward leakage above 0.05 %. Filters are classified edges lead to total allowed inward leakages less than
into P1, P2 and P3 classes with filter penetration 22 %, 8 % and 2 %. Only FFP3 filtering facepieces give
less than 20 %, 6 % and 0.05 %, respectively. Class a good protection factor (NPF 50) for prolonged
P3 filters should be used with full face masks to exposures. They are adequate for personnel working
obtain the best protection factor. Photo: STUK. outside the Red Zone. Photo: STUK.
386 387
• Coveralls of different sizes;

• Plastic shoe covers;
• Paper towels, disposable wipes;
• Adhesive disposable mats;
Figure A2.4. Protective clothing against particulate radioactive • Plastic bags, small for personal belongings and larger for
contamination is categorised into three classes 1, 2 and 3 with contaminated waste;
nominal protection factors of 5, 50 and 500, respectively. Basic
“dust-proof” coveralls fall into class 1. The compatibility with • Coloured and clear tape;
different types of respiratory protection should be checked. All hood
designs do not work well with full face masks. They are usually • Adhesive labels;
designed to be used with filtering facepieces and may leave skin
exposed between the hood and the full face mask. Photo: STUK.
• Blankets or lightweight aluminium wraps; and
• Instrument manuals.
C. Personnel carrying out decontamination of people
As in B. In addition waterproof clothing is recommended. Specification of zone boundaries
• Detailed maps of the area;
Standards for Personal Protective Equipment (PPE)
• Barrier system (vehicles, cones, signage, tape/rope or paint for road/
Respiratory protective devices (EN 133) ground/floor) with well defined exit points; and
• Filtering devices: • Monitoring equipment (see below).
- Full face mask (EN 136) + filter (EN 143)
- Half face mask (EN 140) + filter
Decontamination of people: Personal decontamination
- Filtering facepieces (EN 149, EN 405); and
equipment
• Breathing apparatus:
• Moist towels or disposable wipes;
- Self-contained open-circuit compressed air breathing
apparatus - SCBA (EN 137). • Towels;
• Large plastic bags (a variety of sizes to hold clothing);
Protective clothing • Plastic bags for small personal items;
• Protective clothing against particulate radioactive contamination • Adhesive labels;
(ventilated EN 1073-1, non-ventilated EN 1073-2); and • Soap (mild) or liquid soap;
• Gas-tight (Type 1) or non-gas-tight (Type 2) protective clothing • Shampoo (no conditioner);
against liquid and gaseous chemicals including liquid aerosols and
solid particles (EN 943-1): • Plastic sponges;
- Type 1 suits are reusable • Soft nail brushes;
- Type 2 suits are either reusable or disposable. • Replacement clothing (various sizes are needed including very
large as well as children’s sizes);
Equipment to mark and limit contamination and to cover • Blankets; and
and store items • Saline/medical dressings/gauze.
• Vinyl examination gloves;
388 389
Forms and telecommunications equipment • Portable gamma spectrometry equipment;

• Informational fact sheets to distribute to people at various locations • Equipment to take wipe samples [Annex 8];
[Annex 3]; • Equipment to take nasal swab samples [Section F.3.4.2];
• Record forms for registration, triage and external and internal • Plastic bags to cover monitors (alpha contamination monitors must
monitoring [Annex 3]; not be covered); and
• Notebooks; • Personal protective equipment for monitoring teams (see above).
• A reliable means of 2-way communication with the control centre
(note that mobile phone networks may not be reliable);
• GPS equipment;
• Telephone and facsimile machine;
• Computers (laptops) and internet connectivity (if possible);
• Photocopiers or scanner; and
• Barcode generators and readers for labelling people and forms (if
possible).
Monitoring
Portable monitoring equipment [Annex 8] is needed for:
1. Dose rate monitoring;
2. Contamination surveys;
3. Monitoring external contamination of people; and
4. Monitoring internal contamination of people.
The equipment needed comprises:

• Gamma dose rate monitoring equipment;
• Personal alarming dosemeters (these should be capable of measur-
ing instantaneous dose rate as well as cumulative dose);
• Alpha contamination monitors;
• Beta contamination monitors. Instruments capable of detecting
both alpha and beta contamination could be used, but must be able
to distinguish between alpha and beta contamination;
• Gamma contamination monitors;
• Hand held monitors for measuring neutron dose rate;
• X-ray and low energy gamma contamination monitors;
390 391
Annexes Annex 3: Forms, questionnaires and information leaflets
Annex 3: Forms, questionnaires and information A3.1 Information sheet for Environmental Monitoring Team
Incident code
leaflets
Did the incident Yes/No If yes, please indicate the location:
happen at a Address:
This annex provides examples of forms, questionnaires and information specific location?
leaflets that could be adapted to fit a given incident/accident. Inside / Outside
Floor number:
Room number:
A3.1 Information sheet for Environmental Monitoring Team
What radiation alpha Yes/No beta Yes/ gamma Yes/No neutron
A3.2 Results of field measurement made by the Environmental type is involved? No Yes/No
Monitoring Team
What 1. 2. 3. 4.
A3.3 Registry form for person involved in the emergency radionuclides
are involved?
A3.4 External contamination survey report
Source Intact Yes / No / Unknown Details:
A3.5 Internal contamination report form
A3.6 Radionuclide/Organ specific measurements Contamination Yes / No / Unknown Details:
present
A3.7 In vitro bioassay measurement report Irradiation Yes / No / Unknown Details:
A3.8 Individual dose assessment report form source removed
Map showing Available? Yes /No Provided to team? Yes / No
A3.9 Emergency personnel dose follow up form source location
A3.10 Example report letter to members of the public for measurements Map showing Available? Yes /No Provided to team? Yes / No
less than the method detection limit distribution of
contamination
A3.11 Example report letter for assessed doses less than 1 mSv Conventional Fire / Chemicals / Biological / Unstable buildings / Other
A3.12 Example report letter for assessed doses greater than 1 mSv and Hazard Present Give Details:
less than the lower action level (maximum 20 mSv) Personal Respiratory Yes / No Details
Protective Protection
A3.13 Medical information form Equipment
required
A3.14 Information for family doctors in the event of an incident involving
Gloves Yes / No Details
radiation
Waterproof Yes / No Details
A3.15 Information to people who have been found to be contaminated clothing
with radioactive material Waterproof shoes/ Yes / No Details
boots
A3.16 Information to people who might have been exposed to radiation/
radioactive material Safety Helmet Yes / No Details
A3.17 Examples of press releases Alarming

dosemeter
Yes / No Details
Personal Yes / No Details

dosemeter
High visibility Yes / No Details
clothing
Other Yes / No Details
392 393
Equipment Gamma dose rate Yes / No Details Beta Yes / No Locations? Expected
Required monitor contamination levels, if
known.
Neutron dose rate Yes / No Details
monitor
Beta dose rate Yes / No Details
monitor Gamma Yes / No Locations? Expected
Gamma contami- Yes / No Details contamination levels, if
nation monitor known.
Beta contami- Yes / No Details

nation monitor
Alpha contami- Yes / No Details Air samples Yes / No Locations?
nation monitor
Portable gamma Yes / No Details
spectrometer
Equipment for Yes / No Details
wipe samples
Air sampling Yes / No Details
equipment
Environmental Yes / No Details
sampling
equipment
GPS Yes / No Details
Radio Yes / No Details
Other Yes / No Details
What kind of Gamma dose rate Yes / No Locations? Expected
measurements measurements dose rates,
are requested? if known.
Neutron dose rate Yes / No Locations? Expected

measurements dose rates,
if known.
Alpha Yes / No Locations? Expected

contamination levels, if
known.
394 395
A3.2 Results of field measurement made by the Environmental A3.3 Registry form for person involved in the emergency
Monitoring Team
396 397
398 399
A3.4 External contamination survey report
400 401
A3.5 Internal contamination report form A3.6 Radionuclide/Organ specific measurements
402 403
A3.7 In vitro bioassay measurement report A3.8 Individual dose assessment report form
404 405
A3.9 Emergency personnel dose follow up form A3.10 Example report letter to members of the public for
measurements less than the method detection limit
406 407
A3.11 Example report letter for assessed doses less than 1 mSv A3.12 Example report letter for assessed doses greater than 1
mSv and less than the lower action level (maximum 20 mSv)
408 409
A3.13 Medical information form

Patient code: Date and time
of admission:
Incident information
General Patient Data
(As this information is the same for all casualties, this section can be copied
and attached to the medical record of the other patients) Patient name (last, first):
Accident location: Current local full address:
Date and time of the incident:
Number of persons involved: Permanent full address:
< 10
10-50
50-100 Telephone: Fax: E-mail:
100-500
>500 Date of birth: Sex: Male Female
General incident description:
Information on the person completing this form

Name (last, first):
Source of irradiation: Place of work (i.e. department/service):

Unknown
Known
If known, specify: Status: Physician Health personnel Other:
Additional comments:
Page 1 of 12 Page 2 of 12
410 411
Personal exposure information Dose Estimates (fill in as soon as results are available)
Actions at the time of the accident: Evaluation of Date: Method: Dose (Gy):
Individual incident description:
average Total
(include location, time, duration and use of any personal protective Body Irradiation
equipment) (TBI):
Evaluation of local Date: Method: Dose (Gy):
doses:
Other: Date: Method: Dose (Gy):
Kind of radiation: α-particles β-emitters γ-source X-rays
Other:
SITES OF INJURY, TRAUMA OR CONTAMINATION
Known/suspected: Contamination Incorporation
(identify type of lesion)
If the patient had a dosemeter:
Dosemeter number:
Dosemeter readings:
Body location of the dosemeter:
Use the code:

1 - Thermal burn
2 - Wound
3 - Erythema
4 - Contamination
5 - Other injury/trauma (specify)
Page 4 of 12
Page 3 of 12
412 413
Previous history Additional health information (including date of first diagnosis)

Information of special interest concerning ARS (uk = unknown) Other organ systems
Central nervous system (CNS)
Lung:
Psychiatric uk no yes, if yes, please specify:
disorders: Heart:
Neurological Vascular system:
uk no yes, if yes, please specify:
disorders: Liver:
Neurovascular uk no yes, if yes, please specify: Bone and skeleton:
disorders: Endocrine system:
Malignancies: uk no yes, if yes, please specify: Eyes:
Others: uk no yes, if yes, please specify: Others:
Haematopoietic system Pregnancy:
Leukaemia: uk no yes, if yes, please specify: Unknown No Yes
Date of the beginning of the last menstruation:
Myelodysplasia: uk no yes, if yes, please specify:
Malignancies
Other uk no yes, if yes, please specify:
malignancies:
Others: Allergies
Skin
Past hospitalisations
Scars: uk no yes, if yes, please specify:
Rash: uk no yes, if yes, please specify: Medical exposure to ionising radiation:
Mycotic diseases: uk no yes, if yes, please specify: Diagnostic radiology Radiotherapy
Allergic diseases: uk no yes, if yes, please specify: Interventional radiology Nuclear medicine
Malignancies: Habits
Others: Tobacco:
Alcohol:
Gastro-intestinal tract (GIT)
Others:
Related diseases: uk no yes, if yes, please specify:
Malignancies:
Former occupation
Other relevant information:
Others: uk no yes, if yes, please specify:
414 415
Family History (questions of special interest) Vital signs on admission
Number of siblings: Sisters: Brothers: Date/time Sign Description
Number of children: Daughters: Sons: Blood pressure
Cardiovascular Heart rate

no yes:
diseases: mother father brother sister other Respiratory rate
If yes, please specify: Temperature
Malignancies: no yes: Others
mother father brother sister other
If yes, please specify: Radiation related health impairments of other organ systems
Metabolic Description Consultation

no yes:
disorders: mother father brother sister other Lung no yes
If yes, please specify: Heart no yes
Haematological no yes: Eyes no yes
disorders: mother father brother sister other
If yes, please specify: Liver no yes
Others: no yes: Bone and no yes
skeleton
mother father brother sister other
If yes, please specify: Endocrine no yes
system
Medication
Lymph nodes no yes
Past medication:
Mucous no yes
Current medication: membranes
Salivary glands no yes
Post exposure Others no yes
Chief complaints and timing of symptoms on admission (more
detailed description below):
Date/time Complaint Description
416 417
Measures taken at the hospital

Patient ID : Beginning of Examiner :
Undressing no yes exposure :
Decontamination no yes Degree of severity according to METREPOL system as presented in
If yes, provide details: Table J4
Neuro- Date: Date: Date: Date: Date: Date: Date: Date:
Time: Time: Time: Time: Time: Time: Time: Time:
vascular
Decorporation: no yes system (N)
If yes, provide details: Nausea
Vomiting
Blood samples for cytogenetic dosimetry taken: no yes Anorexia
Blood samples for HLA typing taken: no yes Fatigue
Sample/s for radioactivity measurement taken: no yes syndrome
If yes, provide details as follows: Fever
Blood
Headache
Nose
Mouth Hypotension
Wound Neurological
Urine deficits
Faeces
Other (provide details) Cognitive
deficits
Blood samples for blood cell count with full differential Maximum
Date Time Absolute Absolute Absolute platelet Grading N
lymphocyte count neutrophil count (per μl)
(per μl) count (per μl)
418 419
Degree of severity according to METREPOL system as presented in Onycholysis

Table J5
Maximun
Haema- Date: Date: Date: Date: Date: Date: Date: Date:
Time: Time: Time: Time: Time: Time: Time: Time: Grading C
topoietic
system (H)
Lymphocyte Degree of severity according to METREPOL system as presented in
changes Table J7
Gastro- Date: Date: Date: Date: Date: Date: Date: Date:
Granulocyte Time: Time: Time: Time: Time: Time: Time: Time:
intestinal
changes
system (G)
Thrombocyte
Frequency
changes
(stool)
Infection
Consistency
Blood loss (stool)
Maximum Mucosal
Grading H loss/day
(stool)
Degree of severity according to METREPOL system as presented in Bleeding/day
Table J6 (stool)
Cutaneous Date: Date: Date: Date: Date: Date: Date: Date: Abdominal
Time: Time: Time: Time: Time: Time: Time: Time:
system (C) cramps/pain
Erythema Maximum
Sensation/ Grading G
itching
Swelling/ Highest
oedema grading
code
Blistering
Desquamation
Ulcer/
necrosis
Hair loss
420 421
A3.14 Information for family doctors in the event of an incident A3.15 Information to people who have been found to be
involving radiation contaminated with radioactive material
422 423
A3.16 Information to people who might have been exposed to

radiation/radioactive material
424 425
A3.17 Examples of press releases
426 427
Annexes Annex 4: Allocation of roles
Annex 4: Allocation of roles Strategic Command will report to national or local government.
The following is a list of the roles and teams that are needed to respond to a The function of the Strategic Command includes:
radiological incident. The availability of staff to perform these roles will • Ensure all appropriate resources are activated;
need to be confirmed as part of the planning. All staff will need • Establish communication with TIC at the scene;
appropriate training. Roles which exist under normal circumstances are not
• Approve press releases;
described in detail.
• Approve public information announcements;
Tactical Incident Command (TIC) • Appoint teams of advisors including a press spokesperson;
• Ensure radiological and non radiological situations are assessed
The function of the TIC includes: based on information received from the TIC; and
• Assessment of the situation; • Provide information to central Government.
• Ensure people are rescued;
• Ensure people are evacuated from hazardous areas; First Responders
• Ensure safety and security perimeters are established; The function of the First Responders is to establish the Red and Yellow
• Ensure entry to hazardous areas is limited to essential staff; Zones, to perform life saving actions, to apply first aid to affected people,
to carry out trauma triage, and to perform other actions that are necessary
• Ensure personnel protection guidelines are followed;
for the safety of the public and rescue teams. The term First Responders
• Ensure conventional hazards (such as fire) are dealt with; includes Police, Ambulance Service and Fire Service.
• Request deployment of other teams, such as monitoring and
decontamination; Security Personnel
• Ensure injured are taken to hospital and receiving hospitals are The function of Security Personnel at the scene, is to guard the boundaries
informed; and of the Red and Yellow Zones so that the first responders can perform their
• Ensure zones described in chapter E are established as required. actions and will not be hindered by members of the public. Security
Personnel would normally be police staff, but could include military or
The TIC is in overall charge of all personnel operating at the site of the civil protection staff at the scene.
incident. It is likely that the most senior member of the First Responder
Teams will assume the role of leading the TIC. The TIC could consist of At the hospital, the function of the Security Personnel would be to arrange
several people, including a medical coordinator and a radiological liaison, for arrival of patients (clear necessary areas from other patients and public,
if appropriate. The TIC reports to the Strategic Command. initiate access control, plan for radioactive waste disposal etc.) as described
in chapter J. This function would normally be covered by the existing
Strategic Command hospital security staff.
The Strategic Command is in overall charge of the response to the incident,
but is not present at the scene. It will set priorities and ensure protection of Ambulance Team
the public and emergency workers. The Strategic Command is likely to The function of the Ambulance Team is to supply first aid and take
have advisory teams, such as a team to determine probable health effects. casualties to the hospital.
The Strategic Command is likely to be headed by a senior member of the
Security Forces (e.g. Police) or a senior member of local government. The
428 429
Medical Team techniques are needed so personnel are unlikely to require specific training.
The function of the Medical Team is to carry out trauma triage at the scene The Decontamination Team will report to the TIC.
and to carry out medical interviews of people who may have symptoms of
radiation exposure in support of radiological triage. In addition to usual People Monitoring Team
medical training, these staff will need specific training for incidents The function of the People Monitoring Team will be to monitor people for
involving radioactivity. The Medical Team will report to the TIC. external contamination and possibly also internal contamination [Chapter F
– initial monitoring; Chapter H – later monitoring]. The People Monitoring
Environmental Monitoring Team Team will report to the TIC if working in the People Processing Area
within the Security Perimeter (Yellow Zone) or alternatively indirectly to
The function of the Environmental Monitoring Team is to carry out
the Strategic Command. The People Monitoring Team is likely to be
environmental monitoring at the site of the incident to assess radiation and
staffed by national radiation protection organisations. The team members
contamination levels. The staff in these teams will be familiar with a wide
must be familiar with monitoring techniques and have access to PPE. As
range of monitoring techniques and have available instruments to perform
access to the Red Zone is not foreseen, specific training for working in a
the monitoring tasks described in Chapter E. They will also have access to
strongly contaminated environment would not be required.
Personal Protection Equipment (PPE) and have received training in
responding to a deliberate release. The Environmental Monitoring Team
Dose Assessment Team
will report to the TIC.
The function of the Dose Assessment Team is to calculate doses from
external irradiation and internal or/and external contamination for response
Radiological Triage Team
staff and members of the public [Chapter H]. The team members would
The function of the Radiological Triage Team is to prioritise people for most probably be specialist staff from national radiation protection
medical assessment, radiation measurements and decontamination organisations. The Dose Assessment Team would need to communicate
procedures, using the techniques described in Chapter F. The information with the Environmental Monitoring and People Monitoring Teams to
needed for the triage process may be recorded by others such as a Record obtain the information needed for dose assessments. The Dose Assessment
Team using questionnaires, or from screening measurements. The Team could comprise one of the advisory groups to the Strategic Commander.
Radiological Triage Team would need specific training in how to use the
procedures described in this Handbook. It is probable that the Radiological Records Team
Triage Team would be staffed by national radiation protection organisations The function of the Records Team is to provide administrative support to
supported by public health professions (e.g. medical doctors and nurses). other teams. It is likely that this function is not always performed as a
The Radiological Triage Team will report to the TIC. separate team, but that administrative personnel is added to the other teams
in the field. In the response to an incident there will be a need for recording
Decontamination Team the different actions taken and results gained. Records will be required for:
The function of the Decontamination Team will be to supervise and assist • Details of the movements and cumulative doses to monitoring staff
people with decontamination procedures. For decontamination done very deployed in hazardous area;
soon after the incident, this role may be performed by the Fire Service. For
• The results of environmental monitoring;
decontamination procedures carried out at locations outside of the security
zone this role is likely to be fulfilled by Civil Protection/Army personnel/ • Subject questionnaire forms to register people who have been
Nurses. Training will depend on the role. Staff that would operate specialist affected by the incident and as an aid to radiological triage; and
mass decontamination units will require specific training. For • The results of monitoring people for external and internal
decontamination at locations away from the incident, only simple contamination.
430 431
The Records Team will report to the leader of the relevant team to whom
they are providing assistance.
Emergency Medical Manager

The Emergency Medical Manager is a senior member of the receiving
hospital’s staff who is responsible for activating the hospital’s emergency
plan, responsible for allocating tasks and ensuring that specialist teams are
available. It is likely that specialist training will be needed for this role.
Hospital Emergency Team

The Hospital Emergency Team consists of doctors and nurses who are
designated to deal with emergencies.
Pathology Department
In addition to normal duties, this department will be responsible for
dealing with contaminated corpses. Training for this duty will be required.
Radiation Protection Officer

Some countries have designated Radiation Protection Officers at the
hospitals responsible for all radiation protection issues. It would be
pertinent to involve such officers in radiation emergency work at the
hospital.
Health/Medical Physicists
In addition to their normal role in hospitals, health/medical physicists may
be required for monitoring of people at the hospital due to their knowledge
of working with radiation. Some training would be required to fulfil this
extra task.
432 433
Annexes Annex 5: Interpretation of clinical signs and symptoms
Annex 5: Interpretation of clinical signs and Table A5.1 Prodromal phase of acute radiation syndrome.
Reproduced courtesy of IAEA (IAEA Safety report series 2, 1998).
symptoms
The time from exposure to onset of vomiting is the most important

information in making a prognosis and an estimate of the dose received.
The frequency and severity of nausea and diarrhoea is also important
information (Goans and Waselenko, 2005; Blakely et al, 2005). Table A5.1
summarises the time of onset of vomiting and diarrhoea, and the likelihood
of observing these symptoms, for different levels of severity of prognosis
(Mild – Moderate – Severe – Very Severe – Lethal) and estimated acute
whole body exposure doses (1 – 2 Gy, 2 – 4 Gy, 4 – 6 Gy, 6 – 8 Gy, > 8
Gy).
The following guidelines should also be taken into account when making
decisions on hospital referrals.
• ‘Those patients experiencing emesis (i.e. vomiting) < 4 h post-
incident should be triaged to professional medical care while those
with time to emesis (TE) > 4 h could be sent home initially or
instructed to receive delayed medical attention’ (Goans and
Waselenko et al, 2005).
• Those with TE > 4 h ‘ … should have medical follow up within the
next several days’ (Mettler, 2005).
• ‘For TE < 1 h post-event, the prognosis is much more serious.
Patients…..will generally require extensive and prolonged medical
intervention and an ultimately fatal outcome will occur in many
instances’ (Goans and Waselenko et al, 2005).
Medical treatment issues are addressed in Section J.5.
434 435
436
Therapeutical management European approach
according to the European consensus conference*
Annexes
for the medical

Beyond the first 48 hrs, a second patient scoring is done by organs
management of mass
(Neurovascular, Hemopoesis, Cutaneous, Gut) according to the METREPOL document** radiation exposure
for therapeutical management and Multiple Organ Failure (MOF) prediction.
Cytokines Hematopoietic stem cell (HSC) transplantation
Score I: Monitoring. No cytokine Background

• Outpatient clinical monitoring. • HSC transplantation is not an emergency.
• Blood count: - every day for 6 days, • It is crucial to avoid GVHD in order not to compromise an
- then once a week for 2 months. endogenous recovery.
• If severe aplasia persists under cytokines for more than
Score II: Cytokines (curative) 14 days, the possibility of an hematopoietic stem cell (HSC)
transplantation is discussed.
• G-CSF+ KGF should be used as early as possible for
14-21 days. TPO and agonists, EPO and stem cell factor
questionable. Criteria to transplant
• Symptomatic treatment of gastrointestinal damage. • Severe marrow aplasia persisting 14 - 21 days.
• If severe aplasia ➙ Protected environment. • No residual hematopoiesis.
• Accidental radiation exposure is generally heterogeneous. • No irreversible organ damage (GI tract, lungs...).
Some under-exposed/protected regions of bone marrow can
Reproduced from EBMT, 2007, courtesy of authors.
give rise to endogenous hematopoietic recovery.

Graft
Score III: Cytokines (until reappraisal of score) • Type of graft:
- Bone marrow.
• Palliative/Symptomatic treatment.
- Peripheral blood HSC (depleted or not).
• Re-evaluation during the first week based on laboratory or - Cord blood.
clinical symptoms revealing irreversible organ damage or M. Akashi, B. Allenet-Le Page, D. Blaise, JF. Bottollier-Depois,
• Donor in the following order of priority:
multi organ dysfunction.
- HLA-identical sibling or 7/8 matched. A . Bushmanov, JM. Cosset, T. de Revel, T. Fliedner,
- HLA-identical unrelated donor or 9/10 matched. F. Frassoni, A. Ganser, MH. Gaugler, NC. Gorin, P. Gourmelon,
All blood products should be irradiated - Cord blood > 4/6 matched. N. Griffiths, D. Lloyd, V. Meineke, D. Niederwieser, A. Nikiforov,
• Doses of cells to be grafted: R. Powles, AR. Oliveira, I. Resnick, G. Seitz, J.Sierra,
Severe radiological skin lesions have a peculiar At least: - 2x106 CD34 cells.kg-1 (peripheral blood); B. Sirohi and L. Stenke.
torpid evolution and require specialist treatment. - 2x108 nucleated cells.kg-1 (bone marrow);
- 3x107 nucleated cells (cord blood).
* N.C. Gorin et al., Consensus conference on European preparedness
for haematological and other medical management of mass radiation CONTACTS
accidents, Ann Hematol, 85 : 671- 679, 2006.
Conditioning and GVHD prevention P. Gourmelon (IRSN): [email protected]
** T.M. Fliedner et al., Medical Management of Radiation Accidents –
Manual of the acute radiation syndrome, published by BIR, 2001. N.C Gorin (EBMT/IRSN): [email protected]
• Non myelotoxic conditioning:
- Fludarabine (30 mg.m -2.d -1 for 3 days) ± anti- T. Fliedner (Ulm University): [email protected]
European group for Blood Marrow Transplantation. lymphocyte globulins.
V. Meineke (Bundeswehr): [email protected]
Ulm University - Germany. • GVHD prevention: R. Powles (EBMT) : [email protected]
- No Methotrexate.
April 2007
Institut de Radioprotection et de Sûreté Nucléaire - France. D. Niederwieser (chair EBMT): [email protected]

Figure A5.1. European approach for the medical management of mass radiation exposure.
http://www.ebmt.org/7directory/committees/nuclear%20accident%20docs/Pocket_guide.pdf.
The first 48 hours
Life-threatening wounds and burns should be treated first

Irradiation is not contamination – An irradiated person is not a source of radiation – In case of additional contamination, decontamination comes first
Beware of Multiple Organ Failure (MOF) Physical dosimetry Urgent sampling

The severity of prodromal clinical features is of major • Inquiry: circumstances of the accident, source • Blood cell counts (+ differentials) every 4-8 hours for
importance. characteristics, source-victim geometry, duration of the 1 rst 24 hours, 12-24 h after.
exposure, daily dose rate, shielding, homogeneous/ • Chromosome abberations on blood lymphocytes
• Extensive and immediate erythema.
heterogeneous irradiation. (biodosimetry) (15 ml + heparin).
• Early Transient Incapacitation Syndrome • Red cell group typing.
• Labelling and storage of personal belongings and
(temporary loss of consciousness). • Store serum and cells or DNA for further analyses including
clothes, biological material (hair, nails).
• High fever. HLA typing.
• Standard biochemistry + amylasemia.
• Hypotension.
• Blood (20 ml) to measure 24Na if exposure to neutrons.
• Immediate diarrhoea. • Urine and faeces if radionuclide contamination is suspected.
Primary scoring
R e c o r d a l l c l i n i c a l s y m p t o m s o n a d a t e a n d h o u r- s t a m p e d c h a r t
Score I Score II Score III
Average delay before symptoms appear Less than 12 hours Less than 5 hours Less than 30 minutes
Cutaneous erythema 0 +/- +++; before 3rd hour
Asthenia + ++ +++
Nausea + +++ (-)
Vomiting per 24 hrs Maximum 1 1 to 10 Above 10; intractable
Diarrhea / Number of stools per 24 hrs Maximum 2 - 3; bulky 2 - 9; soft Above 10; watery
Abdominal pain Minimal intense Excruciating
Headaches 0 ++ Excruciating; Signs of intra-cranial HT
Temperature Below 38°C 38 - 40°C Above 40°C
Blood pressure Normal Normal - Possible temporary decrease Systolic below 80
Temporary loss of consciousness 0 0 + / Coma
Depletion of blood lymphocytes

At 24 hours Above 1 500 / μl Below 1 500 / μl Below 500 / μl
At 48 hours Above 1 500 / μl Below 1 500 / μl Below 100 / μl
Outpatient monitoring Hospitalisation for Hospitalisation

curative treatment (MOF predicted)
Warning: the symptoms and values indicated above are reliable only in case the whole body or large parts
of the body have been externally exposed to a high radiation dose delivered within few minutes or few hours.
Fill and fax MED A (radiation accident) to : (+33)1 40 46 96 07
Annex 5: Interpretation of clinical signs and symptoms
437
Annexes Annex 6: Specifying a monitoring strategy for internal contamination
Annex 6: Specifying a monitoring strategy for IAEA Safety series 114, 1996, has given guidance on the direct
internal contamination measurement of body content of radionuclides. Advice has also been issued
by ICRU Report, 69, 2003. Direct (in vivo) bioassay is likely to be the
monitoring method of choice if the radionuclide is a high yield, high energy
Choice of monitoring method
gamma emitter, unless the material is excreted rapidly from the body. The
In most cases, assessment of intakes of radionuclides may be achieved by
gamma radiation emitted by such radionuclides is strongly penetrating, and
body activity measurements (direct bioassay), urine monitoring or faecal
so is readily detected using scintillation or semiconductor detectors
monitoring (indirect bioassay), or a combination of these techniques. The
positioned close to the body. If the material is absorbed rapidly from the
choice of measurement technique will be determined by a number of
respiratory tract, and is then either distributed uniformly in body tissues
factors including:
(e.g. 137Cs in most common chemical forms), or is distributed preferentially
among a number of organs, then whole body monitoring should be chosen.
• The radiation emitted by the radionuclide and its progeny;
If the material deposits preferentially in a single organ such as the thyroid
• The half-life of the radionuclide; (e.g. 125I,131I), then partial body monitoring of the relevant organ should be
• The respiratory tract deposition characteristics of the aerosol; chosen. In the case of materials that are absorbed less rapidly from the
• The respiratory tract absorption characteristics of the material; respiratory tract (e.g. insoluble forms of 60Co oxide), lung monitoring is
preferable to whole body monitoring soon after the intake, as it gives a
• The retention in the body or the excretion rate from the body as a
more accurate measure of lung deposition and retention than a whole body
function of the time between intake and measurement;
measurement.
• Any preferential deposition in particular body organs after systemic
uptake, and retention in those organs; Direct bioassay is also useful for some radionuclides that emit photons
• Any significant differences between the biokinetic behaviour of a (X- or gamma-rays) at lower energies and/or with lower yields (e.g. 241Am).
parent radionuclide and its progeny; However, in the extreme case of radionuclides that mainly emit X-rays
• The excretion pathway (i.e. urine, faeces); and below 25 keV with low yields (notably, the alpha-emitting isotopes of
• The technical feasibility of the measurement. plutonium) direct bioassay cannot achieve the sensitivity required for
radiological protection purposes.
For some radionuclides, only one measurement technique is feasible, e.g.
urine monitoring for intakes of tritium. For radionuclides such as If direct bioassay monitoring is available, it should be chosen in preference
plutonium isotopes that present difficulties for both measurement and to indirect (in vitro) bioassay. Nevertheless, indirect bioassay does have
interpretation, a combination of techniques may have to be employed. If important areas of application. For radionuclides that do not emit
different methods of adequate sensitivity are available, the general order of penetrating radiation with sufficient yields, (e.g. the pure beta emitter 90Sr,
preference in terms of accuracy of interpretation is: the alpha-emitting isotopes of plutonium), indirect bioassay usually has to
be chosen as the primary monitoring method. Urine monitoring provides a
1. Body activity measurements. measure of systemic uptake to organs, and so is useful for materials that
2. Urine analysis. are absorbed relatively rapidly from the respiratory tract (i.e. materials that
have absorption characteristics within the range defined by default types F
3. Faecal analysis. and M).
These techniques are, however, complementary and not mutually exclusive.
Caution should be exercised in using urine monitoring for materials that
are absorbed relatively slowly from the respiratory tract (i.e. “insoluble”
438 439
Annexes Annex 7: Later triage and monitoring
materials). In these circumstances, it is usually the lung dose that makes

the greatest contribution to effective dose, and uncertainties or lack of
Annex 7: Later triage and monitoring
knowledge of the absorption characteristics of the material can then result
Introduction
in significant errors in assessed dose.
The deliberate dispersal of radioactive aerosols into the public environment
will require urgent decisions to be made on whether or not treatment for its
For insoluble materials, significant improvements in sensitivity can be
removal from the body should be considered or implemented, or whether
achieved by using faecal monitoring in preference to, or in addition to,
the public can be reassured that radiation doses are acceptably low.
urine monitoring. This arises because significant fractions of insoluble
However, such decisions are likely to be difficult due to lack of information
material deposited in both the extrathoracic airways and the lungs are
on the chemical form, solubility and particle size distribution of the
cleared via the gastro-intestinal tract to faeces. Interpretation of faecal
aerosol, the biokinetic and retention characteristics of the radionuclide in
monitoring data needs to take account of a number of factors that are
the body and the likely efficacy of treatment for the chemical forms likely
specific to the faecal excretion pathway. Excretion of faeces is of course a
to be present.
discrete process (even though it is usually modelled using first-order
kinetics), and so it is advisable to sum the amounts excreted over a 3-day
A simple dose assessment tool is described that will simplify the decision
period to obtain a daily excretion rate. Although faecal excretion rates after
making process. This approach is considered appropriate for rapid
an acute inhalation are typically highest in the 12 - 72 hour period post
decisions on medical management or public reassurance when potentially
intake, they may be subject to the highest levels of intra- and inter-subject
large numbers of people are involved. It is not intended as a substitute for
variability during this interval, making it advisable to extend the period for
individual dose assessment, when several measurements may be made and
special monitoring to later times. Another important consideration that
where the results of investsigations of material-specific properties such as
applies to both faecal and urine monitoring, is that many of the materials
rates of absorption from the lungs may be taken into account.
for which indirect bioassay is useful are naturally-occurring (e.g. uranium
oxides). For such materials, it is necessary to quantify and take account of
For action level doses of 1, 20 and 200 mSv, the relationship between the
natural background excretion levels and their variability.
radionuclide activity in the body and excreta and the time after acute intake
are expressed graphically. For each monitoring procedure (e.g lung, thyroid
For some actinide compounds (uranium and elements with higher atomic
or whole body monitoring, urine and faecal assay), the graphs show the
number), individual monitoring by direct or indirect bioassay may not
range of values, in Bq or Bq d-1 as appropriate, which correspond to the
reliably quantify doses below a few mSv. This could be the case where the
specified doses. The graphs were derived using the current suite of
biokinetic behaviour of the material results in urine excretion rates that are
biokinetic models (respiratory tract, gastrointestinal tract, and element-
so low that alpha spectrometry does not have adequate sensitivity, more
specific systemic models) published by the International Commission on
sensitive mass spectrometric techniques for urine measurements are not
Radiological Protection (ICRP).
available, and faecal monitoring is not feasible.
Account is taken of the potential variability in:
• Aerosol size (0.1 to 100 μm activity median aerodynamic diameter);
• Solubility and absorption from lungs of the inhaled radionuclides
(default types F, M and S as proposed by ICRP);
• Breathing rates of exposed persons;
• Particle clearance rates of exposed persons; and
440 441
Annexes Annex 7: Later triage and monitoring
• For caesium, whole body retention times of exposed persons. 1.E+08

C
The graphs can be used to deduce whether:
• Doses are acceptably low;
Bq (whole body or organ) or Bq d-1 excreted

1.E+07
Degree of uncertainty
• Treatment should be considered or is unnecessary; B200
• The monitoring procedure considered is optimal; 1.E+06
• The minimum detectable amount (MDA) of the radionuclide by the

preferred monitoring procedure is sufficiently low to assess the 1.E+05
specified dose; B20
• The uncertainty in the assessed dose using a particular monitoring

1.E+04
procedure is acceptable; and
B1
• Measurement times can be reduced compared with those used
1.E+03
routinely.
A
Currently this approach is confined to acute intakes of single radionuclides. 1.E+02
It is recognised that the more challenging problems in dose assessment will 1 10 100
arise from the acute and/or chronic inhalation of mixtures of radionuclides. Days
The information provided here is an essential first stage for addressing

these issues since the interpretation of monitoring data will almost Figure A7.1. The TIARA method (Menetrier et al, 2007b). Figure also presented in
Information H.41.
certainly be based on the measurements of at least one of the radionuclides
considered. Notes
1. The y-axis shows the measured amount of the radionuclide in whole body or organ of
the body, expressed in Bq, or the measured amount of the radionuclide excreted in
Proposed Action Levels urine or faeces per day, expressed in Bq d-1.
2. The x-axis shows the elapsed time of the measurement or sample after intake.
For adults, it has been suggested by medical officers within Europe and the 3. This example is for whole-body measurements of 137Cs.
United States that when the assessed committed effective dose is [Figure
A7.1]:
The reference points mean:
• Below 1 mSv (dark green area), the doses pose a minimum risk to
A: The committed effective dose is definitely below 1 mSv.
health;
B1: The committed effective dose could be above 1 mSv, BUT is
• Between 1 and 20 mSv (light green area), more accurate dose definitely below 20 mSv.
assessment is required. Treatment should not be considered; B20: The committed effective dose could be above 20 mSv, BUT is
• Between 20 and 200 mSv (yellow area), more accurate dose definitely below 200 mSv.
assessment is required. Treatment is subject to medical judgement. B200: The committed effective dose could be above 200 mSv.
Although clinical effects are unlikely to occur, the potential C: The committed effective dose is definitely above 200 mSv.
efficacy of initial short-term treatment should be considered; and The width of the B200 band represents the range of calculated values of the
• Above 200 mSv (red area), treatment should be considered. measured quantity for all combinations of parameters, which in turn
However, psychological factors and the potential efficacy of indicates the potential uncertainty in dose assessment. The same degree of
extended or protracted treatment should be considered. uncertainty applies to the B1 and B20 bands, but may not be shown
because the bands overlap.
442 443
Annexes Annex 8: Monitoring techniques
Annex 8: Monitoring techniques dispersion of radioactive material may also require fallout measurements.
Routine equipment used for emergency response includes:

Introduction
• Geiger-Müller detectors (exposure rate, beta dose rate,
contamination);
External radiation
The goal of a field monitoring mission is to understand the radiological • Ionisation chambers (exposure rate, beta dose rate);
hazard and to map the outer border of the contaminated area. There are • Proportional counters (contamination, neutron dose);
three major technical challenges: • Scintillation detectors (exposure rate, alpha and beta contamination,
• Detection; ground deposition, concentration in air, nuclide identification); and
• Identification; and • Solid state detectors (exposure rate, ground deposition,
• Location of the source. concentration in air, nuclide identification).
If the contaminated area is small, the measurements can be performed on
All these issues have their own characteristics which have to be fully foot with portable radiation detectors. If larger areas have been
understood and related measures implemented. contaminated, specific field missions with mobile equipment may be
needed. Such equipment could be detectors in cars, helicopters or airplanes.
Sensitive instruments are required for radionuclide detection. Field
instruments should be robust and give fast answers. While moving, the Internal contamination
monitoring team must use instruments which have a fast response, Direct measurements, in vivo, could be necessary to assess the internal
typically 1 - 5 s. These measurements are interpreted immediately, and the exposure of members of the public, from malevolent use of radioactive
analysis must take into account the variability of the natural background material. Direct measurements can be used for determination of the body
which in many places varies by a factor of ten or more. content and distribution of radionuclides that emit penetrating radiation
[Table H1]. Three types of in vivo measurements that could be necessary:
Radionuclide identification requires spectrometers. Devices should ideally • Whole-body counting;
be easy to operate and be designed for first responders, not for nuclear
• Organ or partial body counting
scientists. Automated software is needed to handle the analysis and related
statistics correctly. - thyroid
- lung
Location of a point source (RED), particularly if it is moving, may be a - liver
very difficult task in large public areas or public events where 100,000 - bone; and
people, or more, are present. The operation requires team work which is • Wound counting.
carefully planned in advance. In case of large contamination, the location
Detectors that could be used in in vivo monitoring:
task faces another problem - the instrument readings and the coordinates
have to be merged and an overall map needs to be generated. • Scintillation detectors;
• Semiconductor detectors;
A range of instruments are available for emergency response. Dose rate • Gas filled detectors;
measurement, contamination monitoring and concentration measurements • Liquid scintillation detectors; and
of airborne radionuclides are of primary importance. Response to
• Gamma cameras.
444 445
External radiation technique is more advantageous in areas where measurement teams are
In most scenarios the following initial monitoring tasks are usually carried working nearby with other tasks. These include, for example, public
out: processing area where measurement teams are conducting people
monitoring and contamination may spread as a result of the movement of
• Mapping of the Red Zone boundary;
people from more contaminated areas inside the Red Zone.
• Monitoring of the Red Zone expansion;
• Screening for hot spots outside the Red Zone; Effective screening of the hotspots outside the Red Zone requires more
• Monitoring of people coming out of the Red Zone; and sensitive detectors. With more sensitive detectors, sparser search grid can
• Identification of the radionuclides present. be used and the measurement team can move faster through the grid.
Measurement teams should be able to detect hotspots of 100 μSv/h or more
at one meter distance. Such a hotspot will produce only 1 μSv/h at
In case of contamination of food and water supplies, environmental
10 meters distance and could be missed if the most insensitive dose rate
monitoring techniques are usually needed, but in all other scenarios the
meters are used and the team passes the source too fast (brisk walking
above mentioned tasks are usually applicable. In case of beta or alpha
speed). More sensitive GM-tube based dose rate meters or Personal
emitting radionulides, the first four tasks require alpha/beta contamination
Radiation Detectors (PRDs) with solid state detectors should be able to
monitors to be used. This makes the tasks quite straight forward to execute,
detect such hotspots from even greater distances. Detection levels are
but makes them time consuming and tedious.
highly dependent of the ambient dose rate. Near the Red Zone, the ambient
dose rate from the Red Zone could still be several tens of microsieverts and
In case of gamma emitting radionuclides the choice of measurement
thus the search for hotspots must be done with much denser search grid
instruments is much broader, but some instruments are more suitable for
than used further away from the Red Zone.
certain tasks than others. The correct deployment of the available
instruments can speed up the tasks considerably. The following paragraphs
Monitoring of people on the Red Zone border in a gamma radiation
describe the deployment of various detectors in an incident involving
incident is also a quite straight forward task for more sensitive dose rate
gamma radiation.
meters or PRDs. Although the ambient radiation from the Red Zone is
several tens of microsieverts, a person with significant areas of
Mapping of the Red Zone boundary is a relatively easy task to undertake.
contamination above the action limit should produce a clearly detectable
The boundary is marked at the 100 μSv/h dose rate level. Dose rates this
rise in dose rate. With sensitive PRDs, the monitoring can be done
high are easily detected even with the most insensitive Geiger-Müller (GM)
relatively fast (at a pace of one person a minute).
tube based dose rate meter. With this in mind the more sensitive GM-tube
instruments and even more sensitive solid state detectors should not be
Identification of the radionuclides present is a fairly straight forward task
wasted on the Red Zone mapping task, if possible.
in the case of a point source RED. In dispersion scenarios the case is more
complicated. Portable high resolution gamma spectrometers are usually not
Monitoring of the Red Zone expansion is also a task for the less sensitive
available in large numbers, so they should not be used inside the Red Zone
instruments. The goal is to detect the rise of the dose rate above 100 μSv/h,
due to the risk of instrument contamination and the fact that most
which is an easy task for all dose rate meters. Monitoring can be done
spectrometers saturate at dose rates below 100 μSv/h. This means that
either by a measurement team(s) patrolling around the Red Zone or by
sampling and sample measurements are needed to assess the radionuclides
using dose rate meters with loud audible alarms, so that the meter can be
present inside the Red Zone. In the case of an RDD the different nuclides
positioned e.g. on a tripod some distance outside the Red Zone and no
used in the device may have dispersed very differently from each other,
personnel are needed to constantly monitor the reading. The latter
which makes representative sampling difficult or practically impossible.
446 447
This means that a large number of samples must be taken and measured.
However, only short measurement times are usually needed due to the
relatively high activities of the samples.
Dose rate measurements

Dose or dose rate measurements from gamma, beta or neutron sources are
of primary importance in an emergency. The instruments should have a
wide dynamic range from low doses to high doses. Protective clothes and a
wide arsenal of in-field equipment can make it difficult to read the display
of a monitor in a varying environment, including daylight vs. darkness. Figure A8.1. Examples of gamma dose rate monitors. Photos: HPA (left), STUK (right) .
Personal dosemeters equipped with alarm functions are necessary for safe
operation in the field.
The earliest detection methods for ionising radiation were based on the
measurement of ionisation caused by photons in gas. In the ionisation
chamber, ions and electrons are attracted to the cathode and anode,
respectively, using an electric field. When the strength of the field is high,
the gas-filled detectors are known as proportional counters or
Geiger-Müller (GM) counters. Information of the energy distribution of the
photons can be obtained in the proportional mode. In the Geiger-Müller
mode no information on the energy distribution can be obtained.
Proportional or Geiger-Müller detectors can also be used for charged
particle detection using specially-designed probes with a thin entrance Figure A8.2. Examples of personal alarming dosemeters. Photos: HPA, STUK.
window.
Caesium iodide (CsI) scintillator together with a small photodiode is
Gas-filled detectors, especially Geiger-Müller counters, are very widely nowadays frequently used in hand held personal radiation detectors
used in civil defence. They have a simple structure. Portable and battery- (PRDs). Because of high density and high atomic number the sensitivity, as
driven detectors are robust and reliable. The disadvantage is the poor compared with the gas-filled detectors, is superior. The monitor is often
sensitivity which is due to the low gas density. Gas-filled detectors are calibrated using total count rate given by a 137Cs source (662 keV +
therefore sub-optimal to locate orphan sources in the environment. Compton continuum). This simple approach may lead to an error of 50 %
However, because of their poor sensitivity, they can be used in intensive if, for example, the dose rate generated by a high-energy emitter such as
radiation fields. Low sensitivity can be partially avoided using gases with
60
Co is under investigation. More accurate results are obtainable if the
high density. Pressurised ionisation chambers are widely used in entire energy spectrum could be used for the dose rate estimation.
environmental monitoring. They are suitable for applications where
accuracy is required, but their operation may be clumsy, and therefore, they Some PRDs are actually spectrometers and the dose rate can be calculated
are not often used for emergency response purposes. from the spectrum. The conversion, or calibration, is made by measuring
several different spectra and simultaneously recording the ambient dose
equivalent using a well calibrated ionisation chamber as a reference. In field
conditions, software automatically converts the spectrum, acquired in short
448 449
intervals, to dose rate which then is displayed on the screen in addition to

the total count rate. Accuracy of 10 - 20 % is achieved over a wide range of
photon energies.
A neutron detector is often integrated into PRD. The modern PRD is easy
to use, and it provides the essential information on the prevailing radiation
field in a reliable and timely manner.
Figure A8.4. Examples of ThermoLuminescent Dosemeters (TLDs). Photo: HPA.
Detection of beta and alpha emitters

External beta radiation may damage the skin and the tissue underneath.
This is due to the short range of beta particles (less than about 1 cm in
Figure A8.3. Examples of Personal Radiation Detectors (PRDs). All except one (second
tissue). Thus, localised radiation burns are possible, particularly if beta
from right) are also spectrometers. All except one (right) include neutron monitoring emitting sources are in contact with skin. Highly active particles, often
option. Photo: STUK.
referred to as hot particles, may even generate point-like radiation burns to
the skin.
The passive, non-alarming thermoluminescent dosemeters (TLD) are
widely used for estimation of external doses. The TLD consists of a crystal Skin dose rate can be evaluated in different ways depending on the location
which gives off light when heated, the light being proportional to the of the contamination. If the surface activity of the skin is known (Bq/cm2),
degree of exposure of the TLD. The crystal is usually placed in a holder precalculated dose rate conversion factors can be used for the dose
which contains filters which can be used to differentiate between skin estimation. Computer codes, such as VARSKIN, may also be useful
doses and penetrating doses of ionising radiation. The TLD is normally (Durham, 1992). Since neither the nuclide nor its activity is generally
worn on the trunk of the body, but can also be worn on the extremities (e.g. known, the dose can be roughly estimated by measuring the total number
for measuring dose to the fingers). Among the advantages of this method of beta emissions during the skin exposure.
are its high sensitivity, long-term storage of information (accumulated
dose) and the possibility of full automation of measurements and data Surface contamination can be measured using a beta contamination
processing. monitor; a suitable device is a Geiger-Müller counter equipped with a beta
probe which has a thin (aluminium) window. The probe should be
calibrated against the known surface contamination to obtain the correct
number of beta emissions. Beta dose rate monitors can be calibrated to
show equivalent skin doses.
450 451
Figure A8.5. An example of a beta dose rate monitor.

Photo: HPA.
Gas-filled detectors are suitable for the detection of alpha emitters, if the Figure A8.8. An example of alpha, beta and gamma contamination monitor. Photo: STUK.
window material is made of light elements, typically beryllium (25 - 50

μm). With this device, soft gamma rays and X-rays (< 30 keV) may also be Neutron counting
detected. Nuclear materials typically emit alpha particles, photons, X-rays and
neutrons. The neutron radiation is a very characteristic feature of nuclear
materials, such as plutonium, and it is difficult to shield. Neutron detection
is therefore an efficient way to monitor the presence of nuclear materials.
However, neutron detection is more difficult than gamma detection.
Neutrons are detected as a result of the nuclear reaction of a neutron with a

nucleus resulting in detectable charged particles. The most common
neutron detector is a pressurised 3He filled tube. Other widely used
Figure A8.6. Examples of alpha contamination monitors. Photos: HPA.
compounds are 10BF3, 6Li and 10B. 10BF3 is gaseous and is used in
proportional counters. Solid state detectors are either scintillation material
or semiconductors that are doped with boron or lithium. The disintegration
of lithium or boron produces charged particles that further produce
scintillations.
The scintillation materials may be sensitive to gamma radiation, which has

to be discriminated from the neutron pulses. The separation of neutron and
gamma events in a gamma sensitive neutron detector is performed either
by pulse height discrimination or pulse shape discrimination. Table A8.1
contains a summary of neutron detection materials and their main
characteristics.
Figure A8.7. An example of beta and X-ray contamination monitor. Photo: HPA.
452 453
Table A8.1. Neutron detection materials and their properties. Efficiency is defined as Scintillation detectors use crystals that emit light when gamma rays
percentage of detected neutrons/neutron fluence. Detectors based on gamma sensitive
materials require a mean to discriminate between gamma and neutron pulses. interact with the atoms in the crystals. The intensity of the light produced
Material Efficiency Gamma Type
is proportional to the energy deposited in the crystal by the gamma ray.
sensitivity The detectors are joined to photomultipliers that convert the light into
BF3 gas <10 % yes high pressure tube electrons and then amplify the electrical signal provided by those electrons.
3
He gas ~30 % yes high pressure tube Common scintillators include thallium-doped sodium iodide, NaI(Tl), or
LiI 25-30 % ( ~100 % for yes scintillator caesium iodide, CsI(Tl), detectors. Because of the poor resolution of NaI
enriched 6Li) and CsI based detectors, they are not suitable for the identification of
Li in ZnS(Ag) 60 % low scintillator complicated mixtures of gamma ray producing materials. Scenarios
Li doped glass 80 % low scintillator requiring such analyses require detectors with higher resolution, like
B 4C 50-80 % (thin layer) low semiconductor HPGe.
Si Pin diode Cd foil <10 % yes semiconductor
Semiconductor detectors, also called solid state detectors, are
Portable detectors are mainly based on proportional counters. The advan- fundamentally different from scintillation detectors. They use a
tage of the gas-filled tube is the simplicity of the readout electronics and semiconductor to detect traversing charged particles or the absorption of
the discrimination is fairly easy to implement. photons. In these detectors, radiation is measured by means of the number
of charge carriers set free in the detector, which is arranged between two
electrodes. Common semiconductor based detectors include germanium,
cadmium zinc telluride (CZT) and lanthanium bromide (LaBr3). High
purity germanium (HPGe) detectors produce the highest resolution
commonly available today, which makes them optimal for nuclide
identification. A draw back of these detectors is that cryogenic
temperatures are vital to the operation.
Figure A8.9. Example of a hand held monitor for measuring neutron dose rate. Photo: HPA.
Nuclide identification using gamma spectroscopy

Most radioactive substances produce gamma rays of various energies and
intensities. A detailed analysis of a collected gamma spectrum is typically
used to determine the identity and quantity of gamma emitters present in
the source. The equipment used in gamma spectroscopy includes an energy Figure A8.10. Examples of NaI(Tl) detector based monitors used as gamma contamination
sensitive radiation detector, amplifiers, multichannel analyser and data monitors. Photos: HPA.
readout devices. Gamma spectroscopy systems are selected to take
advantage of several performance characteristics. Two important
characteristics are resolution and efficiency. The most common detectors
include sodium iodide (NaI) scintillation counters and semiconductor
detectors, e.g. high purity germanium detectors (HPGe).
454 455
Wipe tests
Wipe tests are used both for determination of environmental surface
contamination [Instructions E.18 and Information E.18:2e] and for skin
contamination. The wipe test measures only the contamination that can be
removed from the surface. For determination of surface contamination a
filter paper may be used to wipe the surface. Wipe approximately an area 10
cm x 10 cm with the dry or moistenned filter paper. A background sample is
also needed. Frequently, the amount of activity removed fram a surface by a
wipe, is assumed to be 10 %. This is known as the removal factor. If the
measurement result of a sample is three to four times higher than the
background, it can be concluded that contamination is present.
Figure A8.11. Example of portable gamma spectrometry
equipment. Photo: STUK.
The contamination monitoring equipment used depends on the type and
energy of the ionising radiation. In general, for beta emitters a GM counter
can be used, while for gamma emitters a scintillation counter or a gamma
spectrometer can be used.
The ISO 7503-1 standard gives a description of the calibration procedure

and sampling for surface contamination measurements. The surface
contamination is measured in Bq/cm². It is proportional to the net counting
Figure A8.12. Examples of Radionuclide Identification Devices. All are gamma
spectrometers with a neutron monitoring option. Photos: STUK.
rate and a calibration factor. The calibration factor is a function of the
instrument’s efficiency for the specified radionuclide, the area wiped, the
source efficiency and the removal factor.
Internal contamination
Whole body measurement with specially designed whole
body counters
Whole body counting with special equipment can only be done in
dedicated laboratories (fixed or transportable). Such measurements are time
consuming and not always suitable for rapid measurements of large groups
of people. No instructions for this type of measurements will be given in
the Handbook. For such measurements, contact experts that will give their
advice on where the whole body counting measurements and the dose
assessments can be made.
Figure A8.13. An example of a radiation surveillance vehicle and mobile laboratory. The
laboratory is equipped for dose rate monitoring, nuclide identification, aerosol sampling, Several commercial systems exist for the rapid monitoring of the whole
sample and in situ gamma spectroscopy measurements and alpha spectroscopy
measurements, as well as operational voice and data communication. Photo: STUK. body in a routine, radiological protection context. These may consist of a
456 457
booth in which the subject stands upright in front of, or possibly between, Improvised in vivo monitoring arrangements
arrays of stationary detectors. In other designs, a single detector (HPGe or As an alternative to importing dedicated or established facilities,
large NaI(Tl)) may perform a scan of the body, with the possibility of arrangements may be improvised, making use of any suitable scintillation
delivering crude indications of how any internal contamination is counter (including possibly a gamma camera with collimator removed) or
distributed. If installed software is employed to produce estimates of body large semi-conductor (germanium etc.) detector. These arrangements can
content based on a built-in library of calibration spectra, the validity of the be made sufficiently flexible to allow:
calibration needs to be assessed in relation to the particular conditions of • For adjustment of detector and subject position in optimising count
measurement. rate and accuracy; and
Some organisations have monitors installed in vehicles for regular • For collimators to be fitted where activity must be assessed in
monitoring of workers. These monitors could conveniently be brought into specific organs.
service.
Various geometries exist for assessment of whole body contamination.
They include:
• Arc geometry: the subject reclines on a curved bed so that all parts
of the body are roughly equidistant from a detector located at 1-2
metres distance;
• Simple arrangements, in which the subject stands or lies with the
abdomen located on the axis of the detector at a 1 metre (or greater)
distance; and
• Chair geometry: the subject is seated with the detector located at
(typically) 0.4 m distance from the trunk and thighs.
The approach adopted will be influenced by several factors including the

detectors available, the anticipated distribution of radionuclides in the body,
the possible need to accommodate sick or injured people, and the
availability of appropriate shielding. At the lower end of the activity range
under consideration (104-107 Bq), partial shielding would be required to
achieve adequate statistical reliability in a short counting time. Local
shielding of the detector, to the extent possible without impairing its
Figure A8.14. An example of a whole
body counter with two HPGe detectors sensitivity to activity in the subject, may be considered. Shielding of the
installed in a truck (top, left), a scanning subject, on all sides except the one exposed to the detector, is
bed type whole body counter (four NaI(Tl)
and three HPGe detectors) (top, right) and
recommended. In the absence of such shielding, the subject’s presence may
a transportable whole body monitor (two modify the ambient radiation field, and it may be important to reproduce
HPGe detectors) (bottom). Photos: STUK
(top), HPA (bottom).
the relevant conditions when recording the background response.
Precautions will include the provision of an appropriate inactive phantom
in place of the subject. As a guide to the thickness of such shielding, the
aim should be for 50 mm of lead or its equivalent in some other material
458 459
such as steel. In practice, weight limitations may dictate less effective case for more rigorous assessment of internal contamination and ensuing
shielding. The frequency of background checks should be chosen taking exposure in a representative subgroup of those monitored with simple
into account the importance of early detection of surface contamination systems.
brought into the shielded region, or of variations in the local background
arising from meteorological changes. Some examples of instruments and calibration factors for whole body
measurements of 137Cs and measurements of 131I in the thyroid are given in
If it is necessary to assess the activity of radionuclides in specific organs or Tables A8.2-A8.5. The calibration factors for the instruments available
regions of the body, the detector used for whole body monitoring may be need to be determined in advance by the local monitoring specialists.
fitted with a suitable collimator. In the specific case of monitoring the
thyroid for radioiodine, it is best to use a small detector, preferably Measurement of 137Cs with gamma cameras
collimated. Suitable materials should be used to shield parts of the body Gamma cameras at hospitals can be used for contamination monitoring
that may have irremovable surface contamination, to avoid erroneous when large groups of people need to be measured in emergency situations
assessments of internal contamination. If the affected areas are so or when no other whole body counting equipment is available. An
extensive that this approach is inapplicable, excretion analysis will be advantage is the trained personnel with experience from such
required to provide a basis for the assessment of committed effective dose. measurements. If the camera is used without collimator and placed close to
the body of the person to be measured, care should be taken to arrange for
mechanical stability of the configuration. The background variations in
certain emergency situations and the shielding effect of other persons close
to the camera cause the highest uncertainties.
Figure A8.15. Examples of simple NaI(Tl) gamma spectrometric equipment for whole body
and thyroid measurements. Photos: STUK.
The accuracy of measurements

The continued validity of an adopted calibration should be confirmed daily,
through measurements of a designated reference point source in a fixed and
reproducible geometry. As further confirmation, there should, in addition,
be occasional re-measurements of the response to a phantom containing a
known quanitity of a single radionuclide. Results with an estimated
accuracy of a factor of 2 or better, are often adequate. There may later be a
460 461
Table A8.2. Calibration of hand held instruments for measurements of 137Cs in humans for 131
Table A8.3. Calibration of hand held instruments for measuring I in the thyroid. The
two different measurement geometries. The activity is calculated by dividing the
instrument placed close to neck (Rahola et al, 2006).
background substracted measurement value by the calibration factor. Detector in contact
with the body (Rahola et al, 2006).
Manufacture Type Detectortype Detector size Calibration factor1
BICRON ANALYST NaI(Tl) 50 × 50 mm 0.041

Type of Measurement Calibration
Manufacture Type Detector size SAPHYMO-STEL SPP2 NaI(Tl) 25 × 50 mm 0.012
detector geometry factor1
BICRON ANALYST NaI(Tl) 50 × 50 mm Back 2.5x10 -3 Exploranium Gr-110s NaI(Tl) 38 × 38 × 50 mm 0.021

BICRON ANALYST NaI(Tl) 50 × 50 mm Palmer (lap) 3.9x10 -3 Mini 6-90 Scaler
NaI(Tl) 25 mm 0.0045
Instruments ratemeter
SAPHYMO-STEL SPP2 NaI(Tl) 25 × 50 mm Palmer (lap) 7.9x10 -4
RNI 10 GM 0.000016
RADOS SRV-2000 GM detector Palmer (lap) 6x10 -7
SAPHYMO-Phy ADB/AD-6 Plastscint. 76 × 76 mm 0.013
Exploranium Gr-110s NaI(Tl) 38 × 38 × 50 mm Palmer (lap) 1x10 -3
SAPHYMO-Phy ADB/AD-3R GM 0.000013
Exploranium Gr-110s NaI(Tl) 38 × 38 × 50 mm Back 1.1x10 -3
-6 Automess AD-b/AD-6 Plastscint. 76 × 76 mm 0.013
RNI 10 GM detector Palmer (lap) 1.3x10
Automess 6150 AD3 R GM 18 × 8 mm 0.000013
RNI 10 GM detector Back 6.3x10 -7
Made in Russia SRP-88 NaI(Tl) 25 × 40 mm 0.0012
Minimonitor -5 Morgan Minimonitor 900 NaI(Tl) 25 × 19 mm 0.0042
Morgan NaI(Tl) 25 × 19 mm Back 9.5x10
900
Morgan Minimonitor 900 NaI(Tl) 25 × 32 mm 0.0093
Minimonitor
Morgan NaI(Tl) 2,5 × 32 mm Back 3.8x10 -4
900
Notes:
Minimonitor
Morgan
900
NaI(Tl) 25 × 19 mm Palmer (lap) 9.5x10 -5 1. The calibration factor is given as microsievert/Bq for the scintilation detectors and in cps/Bq for
the Geiger-Muller detectors.
Minimonitor
Morgan NaI(Tl) 2,5 × 32 mm Palmer (lap) 3.8x10 -4
900
Made in
SRP-88 NaI(Tl) 25 × 40 mm Back 5.7x10 -5
Russia
Made in
SRP-88 NaI(Tl) 25 × 40 mm Palmer (lap) 1x10 -4
Russia
Notes:
1 The calibration factor is given as microsievert/Bq for the scintilation detectors and in cps/Bq for the
Geiger-Muller detectors.
462 463
Table A8.4. MDA and sensitivity for measurement of 137Cs and 131I with gamma camera in Table A8.5. Technical characteristics of detectors used in assessing internal radioactive
different configurations (choice of collimator and detector height). Before the activity calcu- contamination in the local population following the reactor accident at Chernobyl. Table
lation, the background has been subtracted (Wallström et al, 1999). adapted from IAEA TECDOC 746,1994.
Sensitivity 137Cs Sensitivity 131

I
measurements/
thickness, mm)
MDA 137Cs in MDA 131I in
in whole body, in thyroid,
Measurement
Detector size
Energy whole body thyroid
Throughput
centered neck
Application
Colli- Phantom
processing
interval (kBq) (kBq)
(diameter,
(cps/kBq) (cps/kBq)
MDA, kBq
geometry
Mass [kg]
Shielding
mator size (kg) Unit type
(keV)
35 10 40
Signal
5 cm 5 cm 35 cm 10 cm 40 cm
hour
cm cm cm
50-450 None 14 0.25 0.90 78 24

lead SCA,
NC25, ”gamma 150-200 131
61 0.40 1.0 0.10 0.45 46 21 170 47 colli- digital I in
thyroid 120 40, 40 mm from 100 1
mator output thyroid
radiometer” neck
93 0.45 1.1 39 18 analogue
131
close to rate I in
LEGP 14 0.80 2.3 9.1 3.3 thyroid
SRP-68-01, neck meter 6
gamma 6 20, 20 none close to [wide 60 2 whole
61 2.1 3.5 0.80 2.5 3.8 2.2 9.8 3.4 dosemeter abdomen energy body 137Cs
band] + 134Cs
93 2.3 4.2 3.0 1.7
OMEGA800,
450 mm
HEGP 14 3.6 8.5 medical
above whole
gamma
600 500, 8 none supine SCA 35 4 body 137Cs
61 12 13 17 camera
thorax + 134Cs
without
93 11 17 collimator
QBM-1A, partial whole
550-750 None 14 0.30 1.3 12 3.2 ”quick body 200 0.3 m2 8-10 mm chair SCA 60 0.5 body 137Cs
monitor” Pb + 134Cs
61 0.70 2.0 1.5 9.0 5.4 2.2 2.6 0.47
WBC25,
partial, whole
transportable
93 1.6 3.2 2.2 1.2 450 75, 75 20-50 chair MCA 36 1 body 137Cs
whole body
mm Pb + 134Cs
counter
LEGP 14 1.1 2.9 2.9 1.1
WBC22, totally
whole
61 2.5 4.9 4.5 20 1.2 0.64 0.67 0.16 established enclosed
3500 203, 102 chair MCA 10 0.04 body 137Cs
whole body 150 mm
+ 134Cs
93 3.0 5.8 0.93 0.52 counter steel
HEGP 14 7.0 17
61 13 31 26 47
93 11 27
464 465
Annexes Annex 9: Biodosimetry
Annex 9: Biodosimetry No single assay is sufficiently robust to address all potential scenarios,
including mass-casualty events. A multi-parameter biodosimetric approach
would probably be the best strategy, although it should be adapted
1 Recommendations on acute biodosimetry
according to the magnitude of the event.
applications in radiation emergencies:
general concepts
2 Biological dosimetry by cytogenetics
Clinical signs and symptoms, along with haematological parameters (i.e.
kinetics of blood cell counts) provide the basis for medical management in [Additional information to Table H2]
radiation emergencies. Current biological dosimetry methods are mainly
based on cytogenetics and electron paramagnetic resonance (EPR). Other Dicentric assay:
approaches and technologies have been proposed for specific situations, Metaphase spread dicentric assay is the gold standard for biological
such as neutron activation analysis (for neutron exposure). dosimetry. It relates the occurrence of the chromosome aberration called
dicentric which is characteristic for ionising radiation and otherwise
Molecular and enzymatic markers in body fluids and tissues can be used as extremely rare, to the absorbed dose. The method is standardised (ISO
indicators for radiation exposure. These assays are usually not specific for 19238, 2004). The dicentric assay requires special expertise and calibration
radiation, and neither very sensitive nor persistent after radiation exposure. curves (IAEA Technical reports series 260, 1986; IAEA Technical Report
However, many of them can be performed by standard clinical laboratories series 405, 2001).
(C reactive protein, fibrinogen, serum enzymes such as amylase) or
laboratories performing DNA damage and mutation expression techniques. Countries with developed nuclear power industry in Europe usually have
Among these assays H2XA nuclear foci detection is very promising, but biological dosimetry laboratories, but there are several European countries
the assay can only be used if the time interval between exposure and without such facilities. It is vital for every country to establish contact with
detection is very short (i.e. hours). Consequently, this method is not a biological dosimetry laboratory. In Europe there are several leading
practical at the moment for emergency biological dosimetry. laboratories (like HPA in UK, IRSN in France, STUK in Finland, and BfS
in Germany) and several smaller ones. It takes at least 3-4 days to get the
Reconstruction of doses based on biological dosimetry, is most suitable for result, counting from the time the blood sample enters the laboratory. The
exposures to penetrating external irradiation of the whole body or large dicentric assay can be used for different types of radiation providing that
parts of the body. For non-penetrating radiations (e.g. beta irradiation) and the calibration curves exist. However, the method has limited usefulness in
for most cases of exposures from internal contamination (with the case of internal contamination, and especially in cases where
exception of gamma emitting radionuclides uniformly distributed in the contaminating nuclides are incorporated in specific organs. Most
body, like 137Cs), biological dosimetry does not work well. In the case of the commonly the method is used for exposure to sparsely ionising radiations
exposure resulting from internal contamination, bioassay measurements like gamma rays or X-rays. Partial body exposure can be estimated using
can be used to assess internal doses with much greater sensitivity than that statistical approaches. The dicentric assay can be used in the dose range
obtained with cytogenetic dosimetry. In the case of direct measurements from 0.1 to 5 Gy. The time between exposure and analysis is not critical,
(i.e. on whole body or organs), results can be obtained almost immediately, and could extend up to months after exposure. However, for covert
while indirect measurements (i.e. on excreta) could provide initial results exposures that remain undetected for several months, other techniques
within 48-72 hours, depending on the radionuclide. should be used. There is a limited capacity to perform the assay in each
laboratory. Usually, it will not be possible to analyse more than a couple of
tens of samples during one week. Consideration for this limitation has
triggered development of a “triage” dicentric assay (Lloyd et al, 2000;
466 467
Annexes Annex 9: Biodosimetry
Blakely et al, 2005). Such a “triage” approach (ISO 21243, 2008) will make FISH related methods:
it possible to analyse hundreds of samples per week in some laboratories. These methods can be used for small numbers of individuals, but they are
“Triage” dicentric assay applies to more than 10 samples in one scenario labour extensive and the most expensive of all of the cytogenetic
and categorises the dose range rather than exactly estimating it. Dose techniques. These methods are valuable for retrospective evaluation of
categorisation is sufficient for supporting early medical decisions based on exposure, but not for emergency dosimetry. The exception can be
medical triage. The minimum detection level for the “triage” approach is fluorescent staining for the automated version for micronucleus assay. FISH
around 1 Gy. related methods will not be addressed further in this Handbook.
Micronucleus assay:
Unlike the dicentric assay micronuclei occurrence is not specific for
3 EPR biodosimetry
radiation. The method requires one additional day of culturing as compared These methods are based on the capability to measure free radicals that are
to the dicentric assay, but the evaluation step is much faster and does not created in proportion to the absorbed dose to humans exposed to ionising
require the same extensive expertise as dicentric assay. The assay is radiation. These free radical species are extremely stable in non-aqueous
commonly used for toxicity of different compounds. More laboratories are media, including teeth, bone, fingernails and hair. The best results for this
capable of performing the assay, although very few will have the required technique are obtained from measurements in exfoliated or extracted teeth.
calibration information for ionising radiation. The disadvantage of this This is a limitation considering mass casualty situations, and therefore
assay is the variability of the background level due to age and lifestyle attempts have been made to develop EPR dosimetry for in vivo
factors (Fenech et al, 1999). As for dicentric assay, it will take at least 4 measurements (Williams et al, 2007), but so far they are not well
days to perform the assay. The assay can be used in the range from 0.3 to 5 established. EPR is available among others in France, Germany and
Gy. There are approaches under development for the “triage” micronucleus Finland. EPR in nails can be used up to 30 days after an event and is a
assay for mass casualty situations (Lloyd et al, 2000). Micronucleus assay promising assay. The minimum detection level for ESR is relatively high,
is the only technique, among cytogenetic approaches, with a potential for about 1 Gy. The EPR dosimetry requires both very expensive and
high automation. specialised equipment and a high level of expertise. It will have limited
usefulness in the first period after an incident with malevolent use of
Premature chromosome condensation technique (PCC): radiation. Like FISH methods, EPR methods are more useful for
Both the dicentric assay and the micronucleus assay have an upper limit for retrospective dose assessment (IAEA TECDOC 1331, 2002) and can be
detection of dose of about 5 Gy. This disadvantage can be overcome with used in some cases for evaluation in the late phase of an incident.
PCC. The assay can be used for much higher doses, up to 20-30 Gy for
sparsely ionising radiations, and up to 10 Gy for neutrons (Lamadrid et al, 4 Other methods
2007). PCC is not as common or standardised as the dicentric or
micronucleus assay. It will probably be possible to analyse up to several Other methods such as mutation expression and methods related to DNA
tens of samples in a laboratory with three analysing persons during one damage such as H2XA nuclear foci detection are possible, but there are
week. Triage approaches are possible for dose categorisation. The assay concerns about standardisation, lack of the expertise required and costs.
does not have a high sensitivity at low doses, but it is useful as an assay of Some of these methods have been used in previous accidents (in Chernobyl
choice when people are exposed to high doses. In case of smaller numbers of and Goiania), but they do not seem easily applicable for malevolent
samples, PCC may be performed together with the classic dicentric assay. incidents.
PCC in such a case allows estimating the dose when the dicentric assay fails.
468 469
Annexes Annex 10: Action Levels
Annex 10: Action Levels Table A10.1. Radionuclides and monitoring methods for which Action Levels are presented.
Intake mode Absorp. GI uptake Primary
This Annex presents Action Levels for the radionuclides, inhalation Radionuclide Type G factor, f1 monitoring
method
absorption types and primary monitoring methods listed in Table A10.1.
Inhalation or F, M, S Whole body
Data is presented for acute intakes by both inhalation and ingestion. The ingestion (WB)
use of these Action Levels is described in Section H.4. The Action Levels Lung (L)
Thyroid (Th)
are presented in Tables A10.2-A10.18. Urine (U)
54
Manganese-54 Mn Inhalation F 0.1 WB
Calculations were performed using the ICRP Publication 66 Respiratory Manganese-54 54
Mn Inhalation M 0.1 L
Tract Model, the current biokinetic models described in ICRP Publications 54
Manganese-54 Mn Ingestion - 0.1 WB
30, 56, 67 and 69, and the ICRP Publication 30 gastro-intestinal tract 60
Cobalt-60 Co Inhalation M 0.1 L
model. Respiratory tract deposition calculations were made using the 60
Cobalt-60 Co Inhalation S 0.05 L
default physical activity levels given in ICRP Publication 71, and the
60 A
Cobalt-60 Co Ingestion - 0.1 WB
occupational exposure defaults for particle size parameters (including an
Activity Median Aerodynamic Diameter of 5 μm). All calculations were
75
Selenium-75 Se Inhalation F 0.8 WB
performed for adults. Selenium-75 75

Se Inhalation M 0.8 WB C
75 B
Selenium-75 Se Ingestion - 0.8 WB
90
Strontium-90 Sr Inhalation F 0.3 U
90 D
Strontium-90 Sr Inhalation S 0.01 U
90 E
Strontium-90 Sr Ingestion - 0.3 U
110m F
Silver-110m Ag Inhalation F 0.05 WB
110m
Silver-110m Ag Ingestion - 0.05 WB
109 F
Cadmium-109 Cd Inhalation F 0.05 WB
109
Cadmium-109 Cd Ingestion - 0.05 WB
131
Iodine-131 I Inhalation F 1 Th
131
Iodine-131 I Ingestion - 1 Th
133
Barium-133 Ba Inhalation F 0.1 WB
133
Barium-133 Ba Ingestion - 0.1 WB
137
Caesium-137 Cs Inhalation F 1 WB
137
Caesium-137 Cs Ingestion - 1 WB
152
Europium-152 Eu Inhalation M 5E-04 WB
152
Europium-152 Eu Ingestion - 5E-04 WB
154
Europium-154 Eu Inhalation M 5E-04 WB
154
Europium-154 Eu Ingestion - 5E-04 WB
192
Iridium-192 Ir Inhalation F 0.01 WB
192
Iridium-192 Ir Inhalation M 0.01 L
192
Iridium-192 Ir Inhalation S 0.01 L
470 471
192 Table A10.2a. Action Levels for Manganese-54, Inhalation, Type F.

Iridium-192 Ir Ingestion - 0.01 WB
210
Polonium-210 Po Inhalation M 0.1 U nuclide on: value
12 h 1d 3d 7d 14 d for ALU
210
Polonium-210 Po Ingestion - 0.1 U /ALL
226
Radium-226 Ra Inhalation M 0.2 L External External 2.7E+06 1.3E+06 - - - 10
226
contamination scan
Radium-226 Ra Ingestion - 0.2 WB
226
Radium-226 Ra Inhalation M 0.2 U contamination - body
Radium-226 226
Ra Ingestion - 0.2 U Mn-54
screening
Type F
238
Plutonium-238 Pu Inhalation S 1E-05 L Internal Whole 1.2E+08 9.5E+07 5.5E+07 4.0E+07 3.1E+07 10
238
Plutonium-238 Pu Ingestion - 1E-05 WBH primary
238
monitoring
Plutonium-238 Pu Inhalation S 1E-05 U method
238
Plutonium-238 Pu Ingestion - 1E-05 U
Table A10.2b. Action Levels for Manganese-54, Inhalation, Type M.
241
Americium-241 Am Inhalation M 5E-04 L
Americium-241 241
Am Ingestion - 5E-04 WBH nuclide on: value
241
Americium-241 Am Inhalation M 5E-04 U /ALL
Americium-241 241
Am Ingestion - 5E-04 U External External 2.7E+06 1.3E+06 - - - 10
contamination scan
252
Californium-252 Cf Inhalation M 5E-04 U Internal Whole 1.0E+08 7.8E+07 2.9E+07 1.8E+07 1.5E+07 10
Californium-252 252
Cf Ingestion - 5E-04 U contamination - body
Mn-54
screening
Type M
Notes:
Internal Lung 1.1E+07 1.1E+07 1.0E+07 9.6E+06 8.5E+06 10
A. This f 1 value is for “Type M” compounds, which is the worst case in terms of dose per unit contamination -
intake (but not necessarily in terms of dose per unit measurement). f 1 is 0.05 for ingestion of primary
“Type S” compounds. monitoring
method
B. This f 1 value is for “Type F” compounds, which is the worst case in terms of dose per unit intake
(but not necessarily in terms of dose per unit measurement). f 1 is 0.05 for ingestion of “Type M”
Table A10.2c. Action Levels for Manganese-54, Ingestion.
compounds.
C. WB selected because of the high f 1 value Radio- Action Level Method ALU Initial
nuclide on: value
D. Type S is appropriate for strontium titanate; all other compounds are assigned to Type F 12 h 1d 3d 7d 14 d
for ALU
E. This f 1 value is for “Type F” compounds, which is the worst case in terms of dose per unit intake /ALL
(but not necessarily in terms of dose per unit measurement). f 1 is 0.01 for ingestion of “Type S” External External 2.7E+06 1.3E+06 - - - 10
compounds. contamination scan
F. Type F is appropriate for unspecified compounds and the pure metal. Some specified compounds Internal Whole 2.6E+08 2.1E+08 5.8E+07 2.2E+07 1.6E+07 10
are assigned to Type M or S, for which specific calculations would be needed. contamination - body
G. The assignment of Absorption Types to different compounds is given in Table H8. rapid initial (rapid)
Mn-54 screening
H. WB measurements would not normally be recommended as a monitoring method for these
radionuclides. However, WB should have adequate sensitivity for making comparisons with the Internal Whole 2.6E+08 2.1E+08 5.8E+07 2.2E+07 1.6E+07 10
upper Action Level (although it is likely the measurement technique would need development by contamination - body
primary
the measurement laboratory). Urine measurements have much better sensitivity, but may be monitoring
subject to high uncertainties (± an order of magnitude is typical) and could require several days method
or even weeks before results could be obtained. Where exposures could result in doses close to
Notes
the upper Action Level, both techniques should ideally be employed. ALU - Upper Action Level
ALL - Lower Action Level
Action Levels are expressed in Bq, except for external contamination (Bq cm-2) and urinary excretion
(Bq d-1)
Dose calculations were performed using the same assumptions as specified in Annex 13
472 473
Table A10.3a. Action Levels for Cobalt-60, Inhalation, Type M. Table A10.4a. Action Levels for Selenium-75, Inhalation, Type F.
Radio- Action Level Method ALU Initial Radio- Action Level Method ALU Initial
nuclide on: value nuclide on: value
/ALL /ALL
External External 2.1E+05 1.1E+05 - - - 10 External External 1.2E+06 6.0E+05 - - - 10
contamination scan contamination scan
Internal Whole 1.6E+07 1.2E+07 4.0E+06 2.2E+06 1.9E+06 10 Internal Whole 9.4E+07 8.1E+07 6.0E+07 5.2E+07 4.5E+07 10
contamination - body contamination - body
rapid initial (rapid) rapid initial (rapid)
Co-60 Se-75
screening screening
Type M Type F
Internal Lung 1.8E+06 1.7E+06 1.7E+06 1.6E+06 1.4E+06 10 Internal Whole 9.4E+07 8.1E+07 6.0E+07 5.2E+07 4.5E+07 10
contamination - contamination - body
primary primary
monitoring monitoring
method method
Table A10.3b. Action Levels for Cobalt-60, Inhalation, Type S. Table A10.4b. Action Levels for Selenium-75, Inhalation, Type M.
/ALLl /ALL
Co-60 Se-75
screening screening
Type S Type M
Internal Lung 8.3E+05 8.0E+05 7.7E+05 7.4E+05 6.9E+05 10 Internal Whole 7.7E+07 6.5E+07 4.7E+07 4.0E+07 3.5E+07 10
primary primary
method method
Table A10.3c. Action Levels for Cobalt-60, Ingestion. Table A10.4c. Action Levels for Selenium-75, Ingestion.
12 h 1d 3d 7d 14 d 12 h 1d 3d 7d 14 d
for ALU for ALU
/ALL /ALL
Co-60
screening Se-75 screening
Type M
contamination - body contamination body
primary - primary
method method
Notes Notes
ALU - Upper Action Level ALU - Upper Action Level
ALL - Lower Action Level ALL - Lower Action Level
- Comparison with Action Level not valid at these times - Comparison with Action Level not valid at these times
Action Levels are expressed in Bq, except for external contamination (Bq cm-2) and urinary excretion Action Levels are expressed in Bq, except for external contamination (Bq cm-2) and urinary excretion
(Bq d-1) (Bq d-1)
Dose calculations were performed using the same assumptions as specified in Annex 13 Dose calculations were performed using the same assumptions as specified in Annex 13
474 475
Table A10.5a. Action Levels for Strontium-90, Inhalation, Type F. Table A10.6a. Action Levels for Silver-110m, Inhalation, Type F.
/ALL /ALL
Internal Nose ~ ~ ~ ~ ~ 10 Internal Whole 1.9E+07 1.6E+07 9.5E+06 7.6E+06 6.6E+06 10
contamination - blow contamination - body
rapid initial rapid initial (rapid)
Sr-90 Ag-110m
screening screening
Type F Type F
Internal Urine - 4.5E+05 1.0E+05 4.2E+04 1.9E+04 10 Internal Whole 1.9E+07 1.6E+07 9.5E+06 7.6E+06 6.6E+06 10
primary primary
method method
Table A10.5b. Action Levels for Strontium-90, Inhalation, Type S. Table A10. 6b. Action Levels for Silver-110m, Ingestion.
/ALL /ALL
Internal Nose ~ ~ ~ ~ ~ 10 Internal Whole 6.7E+07 5.2E+07 1.2E+07 3.3E+06 2.7E+06 10
contamination - blow contamination - body
rapid initial rapid initial (rapid)
Sr-90
screening Ag-110m screening
Type S
Internal Urine - 1.7E+03 4.7E+02 1.9E+02 9.3E+01 10 Internal Whole 6.7E+07 5.2E+07 1.2E+07 3.3E+06 2.7E+06 10
primary primary
method method
Table A10.5c. Action Levels for Strontium-90, Ingestion.

Notes
Radio- Action Level Method ALU Initial ALU - Upper Action Level
nuclide on: value ALL - Lower Action Level
12 h 1d 3d 7d 14 d
for ALU - Comparison with Action Level not valid at these times
/ALL Action Levels are expressed in Bq, except for external contamination (Bq cm-2) and urinary excretion
External External 4.8E+04 2.4E+04 - - - 10 (Bq d-1)
contamination scan Dose calculations were performed using the same assumptions as specified in Annex 13
Internal None ~ ~ ~ ~ ~ 10
contamination -
rapid initial
Sr-90 screening
contamination -
primary
monitoring
method
Notes
ALU - Upper Action Level
~ No Action Level available
Action Levels are expressed in Bq, except for external contamination (Bq cm-2) and urinary excretion
(Bq d-1)
476 477
Table A10.7a. Action Levels for Cadmium-109, Inhalation, Type F. Table A10.8a. Action Levels for Iodine-131, Inhalation, Type F.
/ALL /ALL
Internal Whole 1.3E+07 1.1E+07 6.8E+06 6.0E+06 5.9E+06 10 Internal Thyroid 1.7E+06 2.3E+06 2.1E+06 1.4E+06 7.3E+05 10
contamination - body contamination - (rapid)
rapid initial (rapid) rapid initial
Cd-109 I-131
screening screening
Type F Type F
contamination - body contamination -
primary primary
method method
Table A10.7b. Action Levels for Cadmium-109, Ingestion. Table A10.8b. Action Levels for Iodine-131, Ingestion.
/ALL /ALL

contamination - body contamination - (rapid)
rapid initial (rapid) rapid initial
Cd-109 screening I-131 screening
contamination - body contamination -
primary primary
method method
Notes Notes
(Bq d-1) (Bq d-1)
478 479
Table A10.9a. Action Levels for Barium-133, Inhalation, Type F. Table A10.10a. Action Levels for Caesium-137, Inhalation, Type F.
Radio- Action Level Method ALU Initial Radio- Action Level Method ALu Initial
12 h 1d 3d 7d 14 d 12 h 1d 3d 7d 14 d
for ALU for ALU
/ALL /ALL
contamination scan External External 1.0E+05 5.2E+04 - - - 10
contamination scan
contamination - body Internal Whole 2.0E+07 1.8E+07 1.4E+07 1.3E+07 1.2E+07 10
rapid initial (rapid) contamination - body
Ba-133 rapid initial (rapid)
screening Cs-137
Type F screening
Internal Whole 6.9E+07 5.3E+07 1.8E+07 6.2E+06 4.0E+06 10 Type F
primary contamination - body
monitoring primary
method monitoring
method
Table A10.9b. Action Levels for Barium-133, Ingestion.
Table A10.10b. Action Levels for Caesium-137, Ingestion.
nuclide on: value Radio- Action Level Method ALU Initial
12 h 1d 3d 7d 14 d
for ALU nuclide on: value
12 h 1d 3d 7d 14 d
/ALL for ALU
/ALL
contamination scan External External 1.0E+05 5.2E+04 - - - 10
contamination scan
rapid initial (rapid) contamination - body
Ba-133 screening rapid initial (rapid)
Cs-137 screening
monitoring primary
method monitoring
method
Notes
ALU - Upper Action Level Notes
ALL - Lower Action Level ALU - Upper Action Level
- Comparison with Action Level not valid at these times ALL - Lower Action Level
Action Levels are expressed in Bq, except for external contamination (Bq cm-2) and urinary excretion - Comparison with Action Level not valid at these times
(Bq d-1) Action Levels are expressed in Bq, except for external contamination (Bq cm-2) and urinary excretion
Dose calculations were performed using the same assumptions as specified in Annex 13 (Bq d-1)
480 481
Table A10.11a. Action Levels for Europium-152, Inhalation, Type M. Table A10.12a. Action Levels for Europium-154, Inhalation, Type M.
12 h 1d 3d 7d 14 d 12 h 1d 3d 7d 14 d
for ALU for ALU
/ALL /ALL
Eu-152 Eu-154
screening screening
Type M Type M
primary primary
method method
Table A10.11b. Action Levels for Europium-152, Ingestion. Table A10.12b. Action Levels for Europium-154, Ingestion.
12 h 1d 3d 7d 14 d 12 h 1d 3d 7d 14 d
for ALU for ALU
/ALL /ALL
Eu-152 screening Eu-154 screening
primary primary
method method
Notes Notes
(Bq d-1) (Bq d-1)
482 483
Table A10.13a. Action Levels for Iridium-192, Inhalation, Type F. Table A10.13d. Action Levels for Iridium-192, Ingestion.
12 h 1d 3d 7d 14 d 12 h 1d 3d 7d 14 d
for ALU for ALU
/ALL /ALL
Ir-192
screening Ir-192 screening
Type F
primary primary
method method
Table A10.13b. Action Levels for Iridium-192, Inhalation, Type M. Notes

ALU - Upper Action Level
Radio- Action Level Method ALU Initial ALL - Lower Action Level
nuclide on: value - Comparison with Action Level not valid at these times
12 h 1d 3d 7d 14 d
for ALU Action Levels are expressed in Bq, except for external contamination (Bq cm-2) and urinary excretion
/ALL (Bq d-1)
contamination scan
Ir-192
screening
Type M
contamination -
primary
monitoring
method
Table A10.13c. Action Levels for Iridium-192, Inhalation, Type S.

nuclide on: value
12 h 1d 3d 7d 14 d
for ALU
/ALL
contamination scan
Ir-192
screening
Type S
contamination -
primary
monitoring
method
484 485
Table A10.14a. Action Levels for Polonium-210, Inhalation, Type M.

Table A10.15a. Action Levels for Radium-226, Inhalation, Type M.
12 h 1d 3d 7d 14 d nuclide on: value
for ALU 12 h 1d 3d 7d 14 d
/ALL for ALU
/ALL
contamination scan External External ~ ~ - - - 10
contamination scan
contamination - Internal Nose ~ ~ ~ ~ ~ 10
rapid initial contamination - blow
Po-210 rapid initial
screening Ra-226
Type M screening
Type M
contamination - Internal Lung 5.7E+03 5.5E+03 5.2E+03 4.9E+03 4.4E+03 10
primary contamination -
monitoring primary
method monitoring
method
Table A10.14b. Action Levels for Polonium-210, Ingestion.

Table A10.15b. Action Levels for Radium-226, Ingestion.
12 h 1d 3d 7d 14 d nuclide on: value
for ALU 12 h 1d 3d 7d 14 d
/ALL for ALU
/ALL
contamination scan External External ~ ~ - - - 10
contamination scan
contamination - Internal None ~ ~ ~ ~ ~ 10
rapid initial contamination -
Po-210 screening rapid initial
Ra-226 screening
contamination - Internal Whole 6.8E+05 5.3E+05 1.4E+05 3.0E+04 1.8E+04 10
monitoring primary
method monitoring
method
Notes
ALU - Upper Action Level Notes
ALL - Lower Action Level ALU - Upper Action Level
- Comparison with Action Level not valid at these times ALL - Lower Action Level
~ No Action Level available - Comparison with Action Level not valid at these times
Action Levels are expressed in Bq, except for external contamination (Bq cm-2) and urinary excretion ~ No Action Level available
(Bq d-1) Action Levels are expressed in Bq, except for external contamination (Bq cm-2) and urinary excretion
(Bq d-1)
486 487
Table A10.16a. Action Levels for Plutonium-238, Inhalation, Type S. Table A10.17a. Action Levels for Americium-241, Inhalation, Type M.
12 h 1d 3d 7d 14 d 12 h 1d 3d 7d 14 d
for ALU for ALU
/ALL /ALL
Internal Nose ~ ~ ~ ~ ~ 10 Internal Nose ~ ~ ~ ~ ~ 10
contamination - blow contamination - blow
rapid initial rapid initial
screening screening
Internal Lung 1.6E+03 1.5E+03 1.5E+03 1.4E+03 1.3E+03 10 Internal Urine - 1.2E+01 9.0E-01 4.1E-01 3.0E-01
Pu-238 contamination - Am-241 contamination -
Type S primary Type M primary
method method
Internal Urine - 4.7E-02 1.7E-02 6.7E-03 4.2E-03 10 Internal Lung 4.7E+02 4.5E+02 4.3E+02 4.1E+02 3.7E+02 10
contamination - contamination -
primary primary
method method
Table A10.16b. Action Levels for Plutonium-238, Ingestion. Table A10.17b. Action Levels for Americium-241, Ingestion.
12 h 1d 3d 7d 14 d 12 h 1d 3d 7d 14 d
for ALU for ALU
/ALL /ALL
External External 4.5E+07 2.3E+07 - - - 10 External External ~ ~ - - - 10
Internal None ~ ~ ~ ~ ~ 10 Internal None ~ ~ ~ ~ ~ 10
contamination - contamination -
rapid initial rapid initial
screening screening
Internal Whole 2.1E+07 1.6E+07 3.0E+06 5.8E+04 2.7E+02 10 Internal Urine - 2.9E+01 2.2E+00 6.5E-01 3.5E-01
Pu-238 contamination - body Am-241 contamination -
primary primary
method method
Internal Urine - 1.5E+00 6.5E-01 1.6E-01 5.0E-02 10 Internal Whole 9.1E+05 7.0E+05 1.3E+05 3.0E+03 4.4E+02 10
primary primary
method method
Notes Notes
~ No Action Level available ~ No Action Level available
(Bq d-1) (Bq d-1)
488 489
Annexes Annex 11: Sampling of excreta and blood
Table A10.18a. Action Levels for Californium-252, Inhalation, Type M.

Annex 11: Sampling of excreta and blood
nuclide on: value
12 h 1d 3d 7d 14 d
for ALU
/ALL All excreta and blood samples can carry hazardous organisms and the
External
contamination
External
scan
5.2E+07 2.6E+07 - - - 10 unsterilised samples must be handled with care, preferably following
Internal Nose ~ ~ ~ ~ ~ 10
guidelines laid down for the handling of biohazardous materials by the
contamination - blow relevant national health and safety authority. Preferably staff handling such
rapid initial
Cf-252
Type M
screening samples should be inoculated against hepatitis A and B and polio. Full
Internal Urine - 1.8E+01 3.3E-01 2.2E-01 2.0E-01 10 protection may not be obtained up until a year after the commencement of
contamination -
primary an inoculation programme [Instructions F.81 - F.84 and H.22].
monitoring
method
Urine samples
Table A10.18b. Action Levels for Californium-252, Ingestion.
The method for collection of urine samples depends on the aim for using
nuclide on:
12 h 1d 3d 7d 14 d
value the result, confirmation of internal contamination or dose assessment. This
for ALU
/ALL can be done if contacts to health care centres are established. There are no
External External ~ ~ - - - 10 internationally agreed procedures for the assay of samples obtained for
contamination scan
indirect assessment of levels of radionuclides in the body.
contamination -
Cf-252
rapid initial
screening
For preliminary determination of radionuclide(s) do a gamma spectrometric
Internal Urine - 4.6E+01 5.7E-01 2.7E-02 2.6E-02 10 measurement. After that, do a beta and/or alpha spectrometric
contamination -
primary
determination, for example using liquid scintillation counting. Remember
monitoring to avoid contamination of the instruments. If high levels of activity are
method
suspected, the sampling should be done under supervision of trained
Notes
medical staff with experience of handling radioactive samples. Remember
ALU - Upper Action Level to clean the body area that could contaminate the urine sample. Also
- Comparison with Action Level not valid at these times continuously take care not to spread contamination during sampling and
~ No Action Level available
Action Levels are expressed in Bq, except for external contamination (Bq cm-2) and urinary excretion handling the sample container.
(Bq d-1)
1. Spot sample
Clean containers must be used for collection. From the container the
sample is transferred to a clean bottle using a funnel if not taken directly
into the bottle. Always take care not to contaminate the bottle or the
sample. During sampling, use disposable gloves. Record date and time of
sampling as well as personal data.
2. Collection of 24 hour urine samples

In the morning, the person studied empties the bladder completely and the
urine is thrown away. The exact clock time is recorded. From this time
onwards all urine excreted is collected, and the following morning at the
490 491
Annexes Annex 11: Sampling of excreta and blood
same time as on the day before, the person empties the bladder the last time larger contamination event. A programme of nose blow sampling could be
into the collection container. It is important to collect all the urine, not initiated for this purpose.
loosing any of it for one reason or another. If the concentration determined
by direct measurement of the sample is below the detection limit a fast way Procedure for taking and transporting blood samples
forward is to concentrate the urine by precipitation (IAEA Safety report (according to ISO standard 19238:2004 E) for cytogenetic
series 18, 2000) and measuring the rest by gamma spectrometry and the biodosimetry
total beta activity by low background beta counter.
[Instruction H.23, Information H.21 and H.23]
Faecal samples
The typical faecal sample is a single voiding. Health care centers or 1. Make sure that a stock of standard lithium heparin tubes is
hospitals should be asked for advice concerning collection of samples. available. If lithium heparin is unavailable then sodium heparin is
Always use clean (new) containers. Remember to record date and time of acceptable.
sampling as well as personal data on the container. Consult the laboratory 2. For each subject, at least 10 ml blood should be taken.
analysing the sample for further instructions. This method is not practical 3. Make sure you have the questionnaire for the subjects giving blood.
for larger contamination events. This questionnaire should include at least:
• Personal data;
Nasal swabs • Relevant medical data (previous medical exposure to radiation,
Radioactivity measured from survey swabs can be used to estimate smoking status, information of possible infections);
pulmonary contamination. Lung contamination is estimated to be about • Available information on the exposure (e.g. type of radiation and
5 % of total radioactivity measured in both nasal swabs. timing of exposure)
• Tube label information; and
To take the nasal swab: • Health service facility identification data.
1. Swab collection should occur before nasal decontamination, 4. Blood sample taking:
sneezing, nasal trauma, etc. • Fill in questionnaire together with the person;
2. Swab each nostril with moistened cotton tipped swab. Use only one • Collect blood samples to the unambiguously labeled tubes (10 ml
swab per nostril. from each subject should be taken);
3. Survey swabs for the amount of radioactivity present. Presence of • Gently rock the tubes for 2 minutes; and
alpha emitting radioisotopes will be masked by the water on the • Maintain the tubes at room temperature before package.
cotton swab. Swabs must therefore be allowed to dry fully when 5. Package and transport of blood samples:
surveying for alpha emitters. It would be advisable to measure the Blood samples should be transported at approximately 20 °C.
sample in a laboratory having a standard procedure for this type of Blood samples must not be frozen.
sample. The standard counting geometry used should minimise the
effects of non-uniform distribution of activity. • Pack blood samples in Styrofoam container (if possible
4. Presence of activity in only one nostril suggests non-respiratory containing room temperature gel-pack; if extreme temperature
source of contamination. are likely to occur, it may be an option to include in the package
maximum-minimum thermometer);
• Mark the package with the labels: “Urgent diagnostic samples”,
Nose blow
“Not to be frozen” and “Do not X-ray”;
It will not be possible to use nasal swabs as a mass screening technique in a
492 493
Annexes Annex 12: Management of internal contamination
• If it is nevertheless possible that the package might be security Annex 12: Management of internal contamination
checked by X-rays, then a physical dosemeter should be included
with the specimen; Table A12.1. Some examples of critical organs following radionuclide intake (internal
contamination).
• The sample should be packaged and labeled according to
Radionuclide Critical organ Observations
national regulations for transport of diagnostic specimens. For
Bromium (82 Br) whole body Monitoring: urine
international transport, by air, IATA regulations require that the Calcium (45Ca,47Ca) bone Monitoring: urine (45Ca
packaging should conform with United Nations Regulation 650 and 47Ca), WBC (47Ca)
for transporting diagnostic specimens. In brief, the specimen Caesium (137Cs) whole body Monitoring: urine,
faeces, WBC
tube(s) must be placed with sufficient absorbent material into a
Chromium (51Cr); Manganese (54 Mn) gastrointestinal Monitoring: urine, WBC
rigid, crush-proof and watertight secondary container. If tract (Cr), lung (Cr
specimen tubes or secondary containers have screw caps these and Mn) and liver
(Mn)
must be reinforced with adhesive tape. The secondary container Cobalt (57Co, 58Co, 60Co) lung (inhalation) If only ingestion,
should then be placed in rigid outer packaging, e.g. a sturdy and parenteral treatment is
cardboard box, with suitable labelling. Some international gastrointestinal not necessary (non-
tract (ingestion) soluble, non-absorbable)
courier firms do supply special packaging that conforms with the Monitoring: urine, WBC
regulation;
Gold (198Au); Copper (Cu) kidney, liver and Monitoring: urine, WBC
• The package itself and the “Nature of Quality of Goods” box of gastrointestinal
the air waybill should show the wording “Diagnostic specimen tract.
packet in compliance with IATA packing instruction 650”; Iodine (123I, 125I, 131I) thyroid Monitoring: urine, WBC,
thyroid monitoring
• Immediately after sampling, ship the sample. The sample must Iron (55Fe 59Fe) bone marrow, Monitoring: urine, WBC
be at the laboratory within 24 h of sampling. For international liver, spleen.
transport, experience has shown that the major courier Mercury (197Hg, 203 Hg); Lead (210 Pb); kidney (Hg, Pb, Monitoring: urine and
Polonium (210Po); Bismuth (Bi); Arsenic Po), bone (Pb), WBC (Hg), urine and
companies provide the most efficient method with least delay; (As); Nickel (Ni). lung (Po). faeces (Pb, Po)
and
• Contact the laboratory and inform about the transport mode and Phosphorus (32P) bone Monitoring: urine
waybill number. This is important for tracking the sample. Rare Earths (La, Ce, Pr, Nd, Pm, Sm, Eu, bone, lung Monitoring: urine,
Gd, Tb, Dy, Ho, Er, Tm, Yb, Lu); (inhalation) and faeces, WBC
Plutonium (238Pu, 239Pu, 241Pu) ; gastrointestinal
Transplutonics (241Am, 249Bk, 242Cm, tract (ingestion)
244
Cm, 252Cf, 253Es); Yttrium (89Y, 90Y); For Yttrium:
Neptunium (Np); Ruthenium (Ru); kidney and
Thorium (Th); Zirconium (Zr). gastrointestinal
tract
Strontium (85Sr, 85Sr, 85Sr); Radium (226Ra) bone Monitoring: urine, faeces
Sulphur (35S) whole body Monitoring: urine
Tritium (3H) whole body Monitoring: urine
Uranium (235U, 238
U) kidney Monitoring: urine
494 495
This list includes some agents for which clinical experience is still limited. Manganese (54Mn) EDTA EDTA
The preferred treatment is indicated in the third column. The status of DTPA
Alternatives: Desferoxamine/BAL
approval of these drugs differs among countries (e.g. some of them are Mercury (197Hg, Dimercaptopropansulphonate (DMPS) DMPS
approved by FDA for other purposes or just for adults, other drugs are not 203
Hg) Alternative: dimercaprol (BAL) Alternative: BAL
approved by FDA but they are commercially available in the EC). EDTA
Penicillamine
Dimercapto succinic acid (Succimer/DMSA)
Table A12.2. Examples of the possible therapeutic agents to be used for treatment of
Neptunium (Np) Dimercaptopropansulphonate (DMPS) DTPA
radionuclide intake (internal contamination).
Trisodium diethylenetriamine DTPA + DFOA
Radionuclide Possible therapeutic agents Preferred treatment pentaacetate (DTPA)
Arsenic (As) Dimercaptopropansulphonate (DMPS) DMPS Nickel (Ni) Trisodium diethylenetriamine DTPA
Alternative: dimercaprol (BAL) Alternative: BAL pentaacetate (DTPA)
Penicillamine Phosphorus (32P) Sodium phosphate/Potassium phosphate Sodium phosphate/
Dimercapto succinic acid (Succimer/DMSA) Aluminium hydroxide/aluminium Potassium phosphate
Barium (140Ba) See strontium See strontium phosphate Aluminium hydroxide/
Bismuth (Bi) Dimercaptopropansulphonate (DMPS) DMPS Calcium aluminium phosphate
Dimercapto succinic acid (Succimer/DMSA) Alternative: BAL Plutonium (238Pu, Trisodium diethylenetriamine pentaacetate DTPA
Penicillamine 239
Pu, 241Pu) (DTPA)
Alternative: dimercaprol (BAL) EDTA
Bromium (82 Br) Water (hyperhydration) Water (hyperhydration) DFOA
Diuretics Polonium (210Po) Dimercaptopropansulphonate (DMPS) DMPS
Calcium (45Ca, See strontium See strontium Alternative: dimercaprol (BAL) Alternative: BAL
47
Ca) Penicillamine
Dimercapto succinic acid (Succimer/DMSA)
Cesium (137Cs) Ferric ferrocyanide (Prussian blue) Ferric ferrocyanide
(Prussian blue) Radium (226Ra) See Strontium See strontium
Chromium (51Cr) DTPA Succimer (DMSA) Rare Earths (La, Trisodium diethylenetriamine pentaacetate DTPA
Dimercapto succinic acid (Succimer/DMSA) Ce, Pr, Nd, Pm, (DTPA)
Dimercaptopropansulphonate (DMPS) Sm, Eu, Gd, Tb,
Alternatives: Desferoxamine/BAL Dy, Ho, Er, Tm,
Yb, Lu)
Cobalt (57Co, 58Co, DTPA Cobalt EDTA
60
Co) Cobalt EDTA Rubidium (Rb) Ferric ferrocyanide (Prussian blue) Ferric ferrocyanide
Cobalt gluconate Potassium bicarbonate (Prussian blue)
Penicillamine Ruthenium (Ru) Trisodium diethylenetriamine pentaacetate DTPA
BAL (DTPA)
Copper (Cu) Penicillamine Penicillamine Strontium (85Sr, Classic regime: Alternate regime:
Dimercapto succinic acid (Succimer/DMSA) 85
Sr, 85Sr) - Aluminium phosphate/Aluminium - Sodium or calcium
Dimercaptopropansulphonate (DMPS) hydroxide alginate
Alternative: dimercaprol (BAL) - Barium sulphate - Ammonium chloride
Gold (198Au) Penicillamine DMPS - Calcium gluconate/
Dimercaptopropansulphonate (DMPS) Alternative: BAL Alternate regime: Calcium phosphate
Alternative: dimercaprol (BAL) - Sodium or calcium alginate
- Ammonium chloride
Iodine (123I, 125I, 131I) Potassium iodide Potassium iodine
- Calcium gluconate/Calcium phosphate
Potassium iodate
Iron (55Fe, 59 Fe) Desferoxamine (DFOA) DFOA Other regime on:
Alternative: DTPA and EDTA Strontium lactate or gluconate
Lead (210 Pb) Dimercapto succinic acid (Succimer/DMSA) Succimer (DMSA) Potassium or sodium
Dimercaptopropansulphonate (DMPS) Potassium or sodium rodhizonate (only rodhizonate (only
Alternative: dimercaprol (BAL) with EDTA externally for wounds contaminated with externally for wounds
Sr) contaminated with Sr)
Sulphur (35S) Sodium thiosulphate Sodium thiosulphate
496 497
Thallium (201Tl) Ferric ferrocyanide (Prussian blue) Ferric ferrocyanide Table A12.3. Recommended protocols for treatment of internal radionuclide contamination.
(Prussian blue) OA: oral administration; IV: intravenous; IM: intramuscular; WBC: whole body count; GI:
gastro-intestinal.
Thorium (Th) Trisodium diethylenetriamine pentaacetate DTPA
(DTPA)
Transplutoniucs Trisodium diethylenetriamine pentaacetate DTPA Therapeutic Therapeutic Scheme Action Contra- Precautions
(241Am, 249Bk, (DTPA) Agent indications
242
Cm, 244Cm, Aluminium OA 100 ml/day, 3 times/ Reduction Renal failure Risk of aluminium
252
Cf, 253Es) hydroxide day aluminium hydroxide of intestinal toxicity (avoid
Tritium (3H) Water (hyperhydration) Water (hyperhydration) (Aludrox®) gel. absorption long-term use)
Aluminium OA 50 mg/day frist day Reduction
Uranium (235U, Sodium bicarbonate Sodium bicarbonate phosphate and 20-30 mg /days the of intestinal
238
U) (Phosphaluge®) following days absorption
Yttrium (89Y, 90Y) Trisodium diethylenetriamine DTPA Ammonium OA 6 g ammonium Increase of Metabolic acidosis,
pentaacetate (DTPA) chloride chloride daily in 3 the uric lithiasis, renal
EDTA divided doses excretion or liver failure.
rate
Zirconium (Zr) Trisodium diethylenetriamine pentaacetate DTPA Barium sulphate OA 100-300 g barium Reduced Known or May lead to
(DTPA) e.g. sulphate aqueous absorption suspected colonic constipation
Micropaque® suspension in single obstruction, acute
dose. GI hemorrhage,
inflammation and
perforation,
hypersensitivity to
barium sulphate
preparations.
British Anti- BAL 2.5 mg/kg deep IM Chelation Hepatic BAL is toxic and it
Lewisite (BAL)/ injection 4 times per day insufficiency, is seldom the first
Dimercaprol for two days, then twice preexisting kidney drug of choice.
per day during the third disease, First test for peanut
day and thereafter, once hypertension and hypersensitivity
daily for 5-10 days. current use of (with 0.25 amp.).
medicinal iron. Pregnancy category
Production of C.
alkaline urine BAL IM may cause
affords protection sterile abscess.
to the kidney.
Since the drug is
presented in a
peanut oil
suspension, peanut
allergy is a contra-
indication.
Calcium Calcium gluconate 10 % Isotopic Renal failure, Monitor blood
gluconate in 500 ml normal saline dilution pressure during
solution or dextrose infusion; caution
solution IV slowly or OA advised in renal
of 10 g powder in a 30 cc impairment.
vial, add water and drink.
Cobalt ethylen- Slow IV administration of Chelation Hypersensitivity Control blood
ediamine 300-600 mg/ 40 ml of (anaphylactic pressure during
tetraacetate Co-EDTA solution reactions have Co-EDTA infusion.
(Co-EDTA) followed by hypertonic been described). Pregnancy category
e.g. Kelocyanor® glucose solution (50 ml) C.
to prevent cobalt toxicity.
498 499
Cobalt Cobalt gluconate 0.9 mg Isotopic Penicillamine OA penicillamine 250-500 Chelation Penicillin allergy High incidence of
gluconate sublingual (2 amp of 0.45 dilution mg every 8 hours Pregnancy is adverse reactions
e.g Cobal mg in 2 ml) Reduction e.g. Duration indicated by the considered a (e.g nephritic
Oligosol of the Cuprimine® bioassays (and according contraindication syndrome,
Labcatal® resorption and to the magnitude of the for this drug unless thrombocytopenia,
rate Metalcaptase® incident) Wilson’s disease or optic neuropathy).
Colloidal OA 5 packages (2.5 g Reduced May lead to cystinuria (preg- Patients should be
aluminium each package) absorption constipation nancy category D)2 under close
phosphate immediately after medical
e.g exposure (single dose). supervision during
Phosphalugel® the treatment.
Desferoxamine Desferoxamine (DFOA) Enhance- Anuria, severe Rapid infusion may Potassium For adolescents and Isotopic Iodine Cautious use in
(DFOA) starting with 1 g IM ment of renal disease. lead to hypotension iodide (KI) adults, including dilution and hypersensitivity3. case of history of
(preferred) or IV in 250 excretion and shock. pregnant and breast thyroid thyroid disease,
normal saline or dextrose rate and Pregnancy category (130 mg feeding women: OA 130 blocking dermatitis herpeti-
solution. Repeat as reduced C. potassium mg/day KI single dose (saturation formis, hypocom-
indicated as 500 mg absorption. iodide contains immediately before or with stable plementemic
every 4 hours for 2 more 100 mg of promptly after the intake. iodine) vasculitis.
doses. Then, 500 mg stable iodine) The efficacy decrease Transient hypothy-
every 12 hours for 3 with time after exposure. roidism may
days. Following days (if Children 3-12 years-old: develop in
necessary) 500 mg/day. 65 mg; 1 month to 3 neonates following
Contaminated wounds: years-old: 32 mg; under KI administration
washing with DFOA 10 % 1 month: 16 mg. (perform TSH
DFOA combined with In scenarios where the measurements).
Ca-DTPA is more effec- risk of incorporation
tive than DFOA alone. continues, the treatment
may continue during 7
Dimercapto OA 1.2 to 2.4 g/day DMPS Chelation DMPS allergy, Analogue of BAL, days. Avoid repeting
propansulpho- (300 mg 4 to 8 times a severe renal more used in administration of KI in
nate (DMPS) day). disease. Europe and Asia neonates, pregnant and
e.g Dimaval® (not FDA approved lactating women.
Heyl for chelation).
Monitor renal
function.
Potassium or Wounds contaminated Reduction
Dimercapto Pediatric dosing approved Chelation DMSA allergy, DMSA is less toxic sodium ro- with strontium: spread 1g of the
succinic acid by FDA for treatment of and preexisting kidney than BAL, it has dhizonate rodhizonate powder resorption
(DMSA) / lead poisoning in increase of or liver disease. fewer and milder (powder) rate
Succimer children as OA 10 mg/kg urinary DMSA is not used side effects (FDA
e.g. Chemet® or 350 mg/m2 every 8 excretion in conjunction with approved for Prussian blue Adults and adolescents: Inhibits Monitor serum
and hours for 5 days. ETDA or chelation) . (PB) /ferric OA 3g/day PB in 3 enterohe- electrolytes and
Succicaptal® Following 2 weeks one penicillamine. Hydration is ferrocyanide divided doses (minimun patic cycle evaluate liver
dose every 12 hours (i.e. essential. e.g. of 2 h between consecu- and function (PB is less
one total course of Pregnancy category Radiogardase® tive administration). In increases effective in
treatment lasts 19 days). C. highly contaminated fecal patients with
Repeated courses may be adults the dose may be excretion. impaired liver
necessary if indicated by scaled up to 10-12 g/day. function). Use with
monitoring of the Children: OA 1-1.5 g/day caution in patients
efficacy of treatment. PB in 2-3 divided doses. with history of GI
Infants (< 2 y) 4: OA 0.2 obstruction (PB is
Edetate calcium 1 g/m2/d added to 500 Chelation Anuria, active renal Monitor renal and - 0.3 mg/kg PB constipating) and/
disodium ml 5 % dextrose or disease, hepatitis heart function. Continue for a minimum or peptic ulcer
(Ca-EDTA) normal saline solution IV Pregnancy category of 4 weeks. disease.
infused over 8-12 hours B. Pregnancy category
or IM 1 g EDTA injection C5
(200 mg/ml total 5 ml).
Administer once as
above, unless indicated
for extended treatment.
500 501
Sodium Slow IV infusion of 250 Alkal- Sodium retention Control blood pH, Trisodium IV administration of 1g Chelation DTPA is contraindi- Control blood
bicarbonate mL isotonic 1.4 % sodium inisation and congestive electrolytes and diethylenetri- DTPA in 250 ml normal cated in patiens pressure during
bicarbonate. Continue of urine; heart failure. renal function. amine pentaac- saline solution/ 5 % with bone marrow DTPA infusion.
over the reduced Sodium bicarbo- etate (DTPA) glucose or Ringer lactate depression, Treatment of
following days according risk of nate may aggravate in 30 minutes or 1g DTPA nephritic syn- pregnant women
to the seriousness of acute hypokalaemia. as undiluted 25 % drome, renal should begin and
contamination (around 3 tubular Monitor urine pH solution in slow IV push insufficiency, and/ continue with
days). necrosis and electrolytes. over 3 to 4 minutes. Use or renal failure. Zn-DTPA (preg-
Ca-DTPA the first day (or nancy category B6)
Alternative: OA of 1g during the first few days), instead of Ca-DTPA
bicarbonate every 4 then for maintenance (pregnancy
hours until the urine change to Zn-DTPA daily category C).
reaches a pH 7-8. up to 5 days, if bioassay Although DTPA
results indicate need for may be effective
Contaminated wounds: additional chelation. In for uranium
wash with isotonic 1.4 % children < 12 y start with decorporation if
solution of sodium Ca-DTPA first dose (14 given within 4
bicarbonate mg/kg IV as above, n hours after intake,
Sodium or OA 10g alginate aqueous Reduced Sodium retention ever exceed 1 g/day) and it should not be
calcium suspension intestinal and congestive then change to Zn-DTPA. used since it could
alginate absorption heart failure. cause uranium
e.g. Gaviscon® Inhalation: nebulize with precipitation in the
4 ml Ca-DTPA 25 % renal tubules.
Sodium Single dose OA 1g Isotopic Sodium retention solution dilutedr 1:1 with
thiosulphate dilution and congestive sterile water or normal
heart failure. saline solution or
Sodium/ OA 1g sodium or potas- Isotopic Renal failure: avoid inhalation of micronized
potassium sium phosphate (the dilution sodium phosphate; Ca-DTPA.
phosphate following days 0.5g) cardiac insuf-
ficiency: avoid Wounds: washing with
potassium Ca-DTPA 25 % solution.
phosphate. Water diuresis OA 3-4 liters/day Isotopic Congestive heart Usually forced to
Strontium After absorption but Isotopic (including water, fruit dilution failure the tolerance level
gluconate shortly after exposure to dilution juice, tea, coffee, beer). Enhance- by patient.
strontium, 600 mg daily May be increased to 6-10 ment of Monitor electrolyte
in slow IV perfusion for litres/day in severe excretion balance (sodium
up to 6 days. contaminations. and potassium).
Strontium After absorption but Isotopic
lactate shortly after exposure to dilution May be performed
strontium OA 0.5-1.5 g/ through IV administration
day for several weeks. of up to 3 litres /day 5 %
glucose in water or saline
(only if fluids cannot be
given orally).
Duration of treatment: 5
days
2 Pregnancy category D: there is positive evidence of human fetal risk, but the benefits from use
in pregnant women may be acceptable despite the risk (e.g. if the drug is needed in a life-
threatening situation or for a serious disease for which safer drugs cannot be used or are
ineffective).
3 In case of hypersensitivity to iodine, thyroid blocking may be induced by OA of 200 mg
potassium perchlorate 3 times daily.
4 Limited clinical experience, not approved by the FDA
5 Pregnancy category C: either studies in animals have revealed adverse effects on the fetus
(teratogenic or embryocidal or other) and there are no controlled studies in women, or studies in
502 503
Annexes Annex 13: Look-up tables for the assessment of internal doses
women and animals are not available. Drugs should be given only if the potential benefit justifies
the potential risk to the fetus.
Annex 13: Look-up tables for the assessment of
6 Pregnancy category B: either animal reproduction studies have not demonstrated a fetal risk but internal doses
there are no controlled studies in pregnant women, or animal reproduction studies have shown
an adverse effect (other than a decrease in fertility) that was not confi rmed in controlled studies
in women in the fi rst trimester (and there is no evidence of a risk in later trimesters). This Annex presents tables that allow committed effective doses and
absorbed doses to organs to be calculated from measurements of bioassay
quantities at specified times after an intake by inhalation or ingestion. The
use of these tables is described in Section H.5.1.
Calculations were performed using the ICRP Publication 66 Respiratory

Tract Model, the current biokinetic models described in ICRP Publications
30, 56, 67 and 69, and the ICRP Publication 30 gastro-intestinal tract
model. Respiratory tract deposition calculations were made using the
default physical activity levels given in ICRP Publication 71, and the
occupational exposure defaults for particle size parameters (including an
Activity Median Aerodynamic Diameter of 5 μm). All calculations were
performed for adults.
Data is presented only for measurements made with the primary

monitoring methods listed in Annex 10, Table A10.1. In some cases, there
could be a need to assess doses from measurements made with a method
other than the primary monitoring method. The most likely case would be
where lung measurements are recommended here, but whole body
measurements are carried out. (An example is the assessment of doses from
intakes by inhalation of 60Co). In such cases, doses can be assessed from
the data in the tables in Annex 10, using the fact that the data presented
corresponds to a committed effective dose of 200 mSv.
Data is presented to allow interpretation of whole body measurements of

the actinides 238Pu, 241Am and 252Cf, for intakes by ingestion. This technique
would not normally be recommended for assessments of internal doses
from occupational exposures. However, whole body monitoring could have
adequate sensitivity for assessment of doses where deterministic levels
could be approached, and has the advantage that results could be obtained
rapidly. It is likely that the technique would need development by the
measurement laboratory. Urine measurements would have much better
sensitivity, but may be subject to high uncertainties (+/- an order of
magnitude is typical) and could require several days or even weeks before
results could be obtained. Where intakes could be relatively high, both
techniques should ideally be employed.
504 505
Note that the data presented here should not be used for the assessment of
Table A13.1a. Doses from an intake by INHALATION of 54Mn (ABSORPTION TYPE F)
internal doses after treatment to reduce doses has been employed (e.g. corresponding to a measurement of 1 Bq in WHOLE BODY at specified times after a
administration of stable iodine, treatment with Prussian Blue or with single intake.
DTPA). In such circumstances, expert advice must be sought. Measured Intake, RBE-weighted absorbed dose, Effective
quantity: Bq Gy-Eq dose, Sv
Whole body
Organ: Lungs Red bone Colon -

marrow
Integration To age 70
30 d
period: y
Measurement
time
6h 1.37 5.0E-10 9.5E-10 1.1E-09 1.6E-09
12 h 1.51 5.5E-10 1.0E-09 1.2E-09 1.7E-09
1d 1.84 6.6E-10 1.3E-09 1.4E-09 2.1E-09
2d 2.57 9.3E-10 1.8E-09 2.0E-09 3.0E-09
3d 3.18 1.1E-09 2.2E-09 2.5E-09 3.7E-09
4d 3.61 1.3E-09 2.5E-09 2.8E-09 4.2E-09
5d 3.92 1.4E-09 2.7E-09 3.1E-09 4.5E-09
6d 4.17 1.5E-09 2.9E-09 3.2E-09 4.8E-09
7d 4.38 1.6E-09 3.0E-09 3.4E-09 5.0E-09
10 d 4.93 1.8E-09 3.4E-09 3.8E-09 5.7E-09
14 d 5.59 2.0E-09 3.9E-09 4.4E-09 6.4E-09
21 d 6.66 2.4E-09 4.6E-09 5.2E-09 7.7E-09
28 d 7.74 2.8E-09 5.3E-09 6.0E-09 8.9E-09
Notes:
Doses calculated for adults
Route of intake: Acute inhalation
Activity median aerodynamic diameter (AMAD) = 5 μm
Absorption Type: F
Organs for which absorbed doses are calculated: Lungs, Red bone marrow or Colon
(IAEA EPR-Medical, 2005)
The RBE-weighted absorbed dose is obtained by multiplying the absorbed dose by the
RBE factor [Table H5]. The units are Gray-Equivalent (Gy-Eq)
Integration period for absorbed dose = 30 d
506 507
Table A13.1b. Doses from an intake by INHALATION of 54Mn (ABSORPTION TYPE M)

Table A13.1c. Doses from an intake by INGESTION of 54Mn (f1 = 0.1) corresponding to a
corresponding to a measurement of 1 Bq in LUNGS at specified times after a single
measurement of 1 Bq in WHOLE BODY at specified times after a single intake.
intake.
Measured Intake, RBE-weighted absorbed dose, Effective
Whole body
Lungs Organ: Lungs Red bone Colon -
marrow
marrow
Integration 30 d To age
period: 70 y
period: 70 y
Measurement
Measurement
time
time
6h 1.01 1.3E-10 3.6E-10 1.7E-09 7.2E-10
6h 13.1 1.4E-08 4.3E-09 9.6E-09 1.7E-08
12 h 1.07 1.3E-10 3.8E-10 1.8E-09 7.6E-10
12 h 13.8 1.5E-08 4.5E-09 1.0E-08 1.8E-08
1d 1.36 1.7E-10 4.8E-10 2.3E-09 9.6E-10
1d 14.4 1.5E-08 4.7E-09 1.1E-08 1.9E-08
2d 2.60 3.3E-10 9.3E-10 4.3E-09 1.8E-09
2d 14.9 1.6E-08 4.8E-09 1.1E-08 1.9E-08
3d 4.87 6.1E-10 1.7E-09 8.1E-09 3.4E-09
3d 15.1 1.6E-08 4.9E-09 1.1E-08 2.0E-08
4d 7.74 9.7E-10 2.7E-09 1.3E-08 5.5E-09
4d 15.4 1.6E-08 5.0E-09 1.1E-08 2.0E-08
5d 10.3 1.3E-09 3.6E-09 1.7E-08 7.3E-09
5d 15.7 1.7E-08 5.1E-09 1.1E-08 2.0E-08
6d 12.0 1.5E-09 4.3E-09 2.0E-08 8.5E-09
6d 15.9 1.7E-08 5.2E-09 1.2E-08 2.1E-08
7d 13.1 1.6E-09 4.7E-09 2.2E-08 9.3E-09
7d 16.2 1.7E-08 5.3E-09 1.2E-08 2.1E-08
10 d 15.2 1.9E-09 5.4E-09 2.5E-08 1.1E-08
10 d 17.0 1.8E-08 5.5E-09 1.2E-08 2.2E-08
14 d 17.3 2.2E-09 6.1E-09 2.9E-08 1.2E-08
14 d 18.2 1.9E-08 5.9E-09 1.3E-08 2.3E-08
21 d 20.6 2.6E-09 7.3E-09 3.4E-08 1.5E-08
21 d 20.2 2.1E-08 6.6E-09 1.5E-08 2.6E-08
28 d 23.9 3.0E-09 8.5E-09 4.0E-08 1.7E-08
28 d 22.4 2.4E-08 7.3E-09 1.6E-08 2.9E-08
Notes:
Notes:
Route of intake: Acute ingestion
Absorption Type: M
RBE factor ([Table H5]. The units are Gray-Equivalent (Gy-Eq)
508 509
Table A13.2a. Doses from an intake by INHALATION of 60Co (Absorption Type M) Table A13.2b. Doses from an intake by INHALATION of 60Co (Absorption Type S)
corresponding to a measurement of 1 Bq in LUNGS at specified times after a single corresponding to a measurement of 1 Bq in LUNGS at specified times after a single
intake. intake.
Measured Intake, RBE-weighted absorbed dose, Effective Measured Intake, RBE-weighted absorbed dose, Effective
quantity: Bq Gy-Eq dose, Sv quantity: Bq Gy-Eq dose, Sv
Lungs Lungs
Organ: Lungs Red bone Colon - Organ: Lungs Red bone Colon -
marrow marrow
Integration 30 d To age 70 Integration 30 d To age
period: y period: 70 y
Measurement Measurement
time time
6h 13.1 2.2E-07 8.0E-09 3.8E-08 1.1E-07 6h 11.8 2.3E-07 7.1E-09 3.7E-08 2.3E-07
12 h 13.8 2.3E-07 8.4E-09 4.0E-08 1.1E-07 12 h 12.4 2.5E-07 7.4E-09 3.8E-08 2.4E-07
1d 14.3 2.4E-07 8.7E-09 4.2E-08 1.1E-07 1d 12.9 2.6E-07 7.7E-09 4.0E-08 2.5E-07
2d 14.8 2.5E-07 9.0E-09 4.3E-08 1.2E-07 2d 13.2 2.6E-07 7.9E-09 4.1E-08 2.6E-07
3d 15.1 2.5E-07 9.2E-09 4.4E-08 1.2E-07 3d 13.4 2.7E-07 8.0E-09 4.1E-08 2.6E-07
4d 15.3 2.6E-07 9.3E-09 4.4E-08 1.2E-07 4d 13.5 2.7E-07 8.1E-09 4.2E-08 2.6E-07
5d 15.5 2.6E-07 9.5E-09 4.5E-08 1.2E-07 5d 13.7 2.7E-07 8.2E-09 4.2E-08 2.7E-07
6d 15.8 2.7E-07 9.6E-09 4.6E-08 1.3E-07 6d 13.8 2.7E-07 8.2E-09 4.3E-08 2.7E-07
7d 16.0 2.7E-07 9.8E-09 4.7E-08 1.3E-07 7d 13.9 2.8E-07 8.3E-09 4.3E-08 2.7E-07
10 d 16.7 2.8E-07 1.0E-08 4.9E-08 1.3E-07 10 d 14.3 2.8E-07 8.6E-09 4.4E-08 2.8E-07
14 d 17.7 3.0E-07 1.1E-08 5.1E-08 1.4E-07 14 d 14.9 3.0E-07 8.9E-09 4.6E-08 2.9E-07
21 d 19.4 3.3E-07 1.2E-08 5.6E-08 1.6E-07 21 d 15.8 3.1E-07 9.4E-09 4.9E-08 3.1E-07
28 d 21.2 3.6E-07 1.3E-08 6.2E-08 1.7E-07 28 d 16.7 3.3E-07 1.0E-08 5.2E-08 3.3E-07
Notes: Notes:
Doses calculated for adults Doses calculated for adults
Route of intake: Acute inhalation Route of intake: Acute inhalation
Activity median aerodynamic diameter (AMAD) = 5 μm Activity median aerodynamic diameter (AMAD) = 5 μm
Absorption Type: M Absorption Type: S
Organs for which absorbed doses are calculated: Lungs, Red bone marrow or Colon Organs for which absorbed doses are calculated: Lungs, Red bone marrow or Colon
(IAEA EPR-Medical, 2005) (IAEA EPR-Medical, 2005)
The RBE-weighted absorbed dose is obtained by multiplying the absorbed dose by the The RBE-weighted absorbed dose is obtained by multiplying the absorbed dose by the
RBE factor [Table H5]. The units are Gray-Equivalent (Gy-Eq) RBE factor [Table H5]. The units are Gray-Equivalent (Gy-Eq)
Integration period for absorbed dose = 30 d Integration period for absorbed dose = 30 d
510 511
Table A13.2c. Doses from an intake by INGESTION of 60Co (f1 = 0.1) corresponding to a Table A13.3a. Doses from an intake by INHALATION of 75Se (Absorption Type F)
measurement of 1 Bq in WHOLE BODY at specified times after a single intake. corresponding to a measurement of 1 Bq in WHOLE BODY at specified times after a
single intake.
quantity: Bq Gy-Eq dose, Sv Measured Intake, RBE-weighted absorbed dose, Effective
Whole body quantity: Bq Gy-Eq dose, Sv
Organ : Lungs Red bone Colon -
Whole body
marrow Organ: Lungs Red bone Colon -
marrow
period : 70 y Integration 30 d To age
period: 70 y
Measurement
time Measurement
time
6h 1.01 2.1E-10 5.8E-10 7.0E-09 3.4E-09
6h 1.37 4.8E-10 4.4E-10 6.1E-10 2.0E-09
12 h 1.09 2.2E-10 6.2E-10 7.5E-09 3.7E-09
12 h 1.49 5.2E-10 4.8E-10 6.7E-10 2.1E-09
1d 1.41 2.9E-10 8.0E-10 9.8E-09 4.8E-09
1d 1.73 6.0E-10 5.6E-10 7.7E-10 2.5E-09
2d 2.89 6.0E-10 1.7E-09 2.0E-08 9.8E-09
2d 2.09 7.3E-10 6.8E-10 9.3E-10 3.0E-09
3d 6.13 1.3E-09 3.5E-09 4.2E-08 2.1E-08
3d 2.32 8.1E-10 7.5E-10 1.0E-09 3.3E-09
4d 11.5 2.4E-09 6.6E-09 8.0E-08 3.9E-08
4d 2.46 8.6E-10 7.9E-10 1.1E-09 3.5E-09
5d 17.9 3.7E-09 1.0E-08 1.2E-07 6.1E-08
5d 2.56 8.9E-10 8.3E-10 1.1E-09 3.7E-09
6d 23.3 4.8E-09 1.3E-08 1.6E-07 7.9E-08
6d 2.64 9.2E-10 8.5E-10 1.2E-09 3.8E-09
7d 27.0 5.6E-09 1.5E-08 1.9E-07 9.2E-08
7d 2.71 9.5E-10 8.7E-10 1.2E-09 3.9E-09
10 d 33.4 6.9E-09 1.9E-08 2.3E-07 1.1E-07
10 d 2.90 1.0E-09 9.3E-10 1.3E-09 4.1E-09
14 d 39.6 8.2E-09 2.3E-08 2.7E-07 1.3E-07
14 d 3.13 1.1E-09 1.0E-09 1.4E-09 4.5E-09
21 d 48.3 1.0E-08 2.8E-08 3.3E-07 1.6E-07
21 d 3.53 1.2E-09 1.1E-09 1.6E-09 5.0E-09
28 d 54.7 1.1E-08 3.1E-08 3.8E-07 1.9E-07
28 d 3.94 1.4E-09 1.3E-09 1.8E-09 5.6E-09
Notes:
Doses calculated for adults Notes:
Route of intake: Acute ingestion Doses calculated for adults
Organs for which absorbed doses are calculated: Lungs, Red bone marrow or Colon Route of intake: Acute inhalation
(IAEA EPR-Medical, 2005) Activity median aerodynamic diameter (AMAD) = 5 μm
The RBE-weighted absorbed dose is obtained by multiplying the absorbed dose by the Absorption Type: F
RBE factor [Table H5]. The units are Gray-Equivalent (Gy-Eq) Organs for which absorbed doses are calculated: Lungs, Red bone marrow or Colon
Integration period for absorbed dose = 30 d (IAEA EPR-Medical, 2005)
512 513
Table A13.3b. Doses from an intake by INHALATION of 75Se (Absorption Type M) Table A13.3c. Doses from an intake by INGESTION of 75Se (f1 = 0.8) corresponding to a
corresponding to a measurement of 1 Bq in WHOLE BODY at specified times after a measurement of 1 Bq in WHOLE BODY at specified times after a single intake.
single intake.
Measured Intake, Bq RBE-weighted absorbed dose, Effective
Measured Intake, Bq RBE-weighted absorbed dose, Effective quantity: Gy-Eq dose, Sv
quantity: Gy-Eq dose, Sv Whole body
Organ: Lungs Red Colon -
Whole Body
Organ: Lungs Red Colon - bone
bone marrow
marrow
Integration 30 d To age period : 70 y
period : 70 y
Measurement
Measurement time
time
6h 1.01 6.2E-10 5.8E-10 9.7E-10 2.6E-09
6h 1.37 2.9E-09 4.2E-10 5.7E-10 2.4E-09
12 h 1.03 6.3E-10 6.0E-10 9.9E-10 2.7E-09
12 h 1.50 3.2E-09 4.6E-10 6.2E-10 2.6E-09
1d 1.09 6.7E-10 6.3E-10 1.1E-09 2.8E-09
1d 1.76 3.8E-09 5.4E-10 7.3E-10 3.1E-09
2d 1.22 7.4E-10 7.1E-10 1.2E-09 3.2E-09
2d 2.19 4.7E-09 6.7E-10 9.1E-10 3.8E-09
3d 1.31 8.0E-10 7.6E-10 1.3E-09 3.4E-09
3d 2.47 5.3E-09 7.5E-10 1.0E-09 4.3E-09
4d 1.38 8.4E-10 8.0E-10 1.3E-09 3.6E-09
4d 2.64 5.7E-09 8.0E-10 1.1E-09 4.6E-09
5d 1.43 8.7E-10 8.2E-10 1.4E-09 3.7E-09
5d 2.74 5.9E-09 8.4E-10 1.1E-09 4.8E-09
6d 1.47 9.0E-10 8.5E-10 1.4E-09 3.8E-09
6d 2.82 6.1E-09 8.6E-10 1.2E-09 4.9E-09
7d 1.51 9.2E-10 8.7E-10 1.5E-09 3.9E-09
7d 2.89 6.2E-09 8.8E-10 1.2E-09 5.0E-09
10 d 1.61 9.8E-10 9.3E-10 1.6E-09 4.2E-09
10 d 3.07 6.6E-09 9.4E-10 1.3E-09 5.3E-09
14 d 1.74 1.1E-09 1.0E-09 1.7E-09 4.5E-09
14 d 3.29 7.1E-09 1.0E-09 1.4E-09 5.7E-09
21 d 1.96 1.2E-09 1.1E-09 1.9E-09 5.1E-09
21 d 3.67 7.9E-09 1.1E-09 1.5E-09 6.4E-09
28 d 2.19 1.3E-09 1.3E-09 2.1E-09 5.7E-09
28 d 4.07 8.7E-09 1.2E-09 1.7E-09 7.1E-09
Notes:
Notes: Doses calculated for adults
Doses calculated for adults Route of intake: Acute ingestion
Route of intake: Acute inhalation Organs for which absorbed doses are calculated: Lungs, Red bone marrow or Colon
Activity median aerodynamic diameter (AMAD) = 5 μm (IAEA EPR-Medical, 2005)
Absorption Type: M The RBE-weighted absorbed dose is obtained by multiplying the absorbed dose by the
Organs for which absorbed doses are calculated: Lungs, Red bone marrow or Colon RBE factor [Table H5]. The units are Gray-Equivalent (Gy-Eq)
(IAEA EPR-Medical, 2005) Integration period for absorbed dose = 30 d
514 515
Table A13.4a. Doses from an intake by INHALATION of 90Sr (Absorption Type F) Table A13.4b. Doses from an intake by INHALATION of 90Sr (Absorption Type S)
corresponding to a measurement of 1 Bq/day in URINE at specified times after a single corresponding to a measurement of 1 Bq/day in URINE at specified times after a single
intake. intake.
Measured Intake, Bq RBE-weighted absorbed dose, Effective Measured Intake, Bq RBE-weighted absorbed dose, Effective
quantity: Gy-Eq dose, Sv quantity: Gy-Eq dose, Sv
Urine Urine
Organ: Lungs Red Colon - Organ : Lungs Red Colon -
bone bone
marrow marrow
Integration 30 d To age Integration 30 d To age
period: 70 y period : 70 y
time time
1d 14.3 5.5E-09 6.7E-08 5.4E-08 4.4E-07 1d 1,270 6.7E-05 7.8E-08 8.4E-06 1.2E-04
2d 41.8 1.6E-08 1.9E-07 1.6E-07 1.3E-06 2d 2,960 1.6E-04 1.8E-07 2.0E-05 2.7E-04
3d 62.6 2.4E-08 2.9E-07 2.4E-07 1.9E-06 3d 4,590 2.4E-04 2.8E-07 3.0E-05 4.3E-04
4d 83.8 3.2E-08 3.9E-07 3.2E-07 2.6E-06 4d 6,180 3.3E-04 3.8E-07 4.1E-05 5.7E-04
5d 106 4.0E-08 4.9E-07 4.0E-07 3.3E-06 5d 7,810 4.1E-04 4.8E-07 5.2E-05 7.2E-04
6d 130 4.9E-08 6.0E-07 4.9E-07 4.0E-06 6d 9,500 5.0E-04 5.8E-07 6.3E-05 8.8E-04
7d 155 5.9E-08 7.2E-07 5.9E-07 4.8E-06 7d 11,200 5.9E-04 6.9E-07 7.4E-05 1.0E-03
10 d 236 9.0E-08 1.1E-06 9.0E-07 7.3E-06 10 d 16,600 8.7E-04 1.0E-06 1.1E-04 1.5E-03
14 d 348 1.3E-07 1.6E-06 1.3E-06 1.1E-05 14 d 23,300 1.2E-03 1.4E-06 1.5E-04 2.2E-03
21 d 579 2.2E-07 2.7E-06 2.2E-06 1.8E-05 21 d 35,300 1.9E-03 2.2E-06 2.3E-04 3.3E-03
28 d 906 3.5E-07 4.2E-06 3.4E-06 2.8E-05 28 d 49400 2.6E-03 3.0E-06 3.3E-04 4.6E-03
Notes: Notes:
Absorption Type: F Absorption Type: S
516 517
Table A13.4c. Doses from an intake by INGESTION of 90Sr (f1 = 0.3) corresponding to a Table A13.5a. Doses from an intake by INHALATION of 110mAg (Absorption Type F)
measurement of 1 Bq/day in URINE at specified times after a single intake. corresponding to a measurement of 1 Bq in WHOLE BODY at specified times after a
single intake.
quantity: Gy-Eq dose, Sv Measured Intake, Bq RBE-weighted absorbed dose, Effective
Urine quantity: Gy-Eq dose, Sv
Whole body
bone Organ: Lungs Red Colon -
marrow bone
marrow
period : 70 y Integration 30 d To age
period: 70 y
Measurement
time Measurement
time
1d 17.7 5.4E-09 7.1E-08 2.1E-07 4.9E-07
6h 1.37 2.4E-09 2.0E-09 5.0E-09 9.4E-09
2d 45.5 1.4E-08 1.8E-07 5.4E-07 1.3E-06
12 h 1.51 2.7E-09 2.2E-09 5.5E-09 1.0E-08
3d 69.7 2.1E-08 2.8E-07 8.3E-07 1.9E-06
1d 1.83 3.2E-09 2.6E-09 6.6E-09 1.3E-08
4d 94.3 2.9E-08 3.8E-07 1.1E-06 2.6E-06
2d 2.52 4.5E-09 3.6E-09 9.1E-09 1.7E-08
5d 120 3.7E-08 4.8E-07 1.4E-06 3.3E-06
3d 3.06 5.4E-09 4.4E-09 1.1E-08 2.1E-08
6d 147 4.5E-08 5.9E-07 1.7E-06 4.1E-06
4d 3.39 6.0E-09 4.9E-09 1.2E-08 2.3E-08
7d 176 5.4E-08 7.1E-07 2.1E-06 4.9E-06
5d 3.59 6.4E-09 5.2E-09 1.3E-08 2.5E-08
10 d 270 8.2E-08 1.1E-06 3.2E-06 7.5E-06
6d 3.73 6.6E-09 5.4E-09 1.4E-08 2.6E-08
14 d 401 1.2E-07 1.6E-06 4.7E-06 1.1E-05
7d 3.83 6.8E-09 5.5E-09 1.4E-08 2.6E-08
21 d 668 2.0E-07 2.7E-06 7.9E-06 1.8E-05
10 d 4.10 7.3E-09 5.9E-09 1.5E-08 2.8E-08
28 d 1050 3.2E-07 4.2E-06 1.2E-05 2.9E-05
14 d 4.41 7.8E-09 6.4E-09 1.6E-08 3.0E-08
Notes:
Doses calculated for adults 21 d 4.94 8.8E-09 7.1E-09 1.8E-08 3.4E-08
28 d 5.50 9.7E-09 7.9E-09 2.0E-08 3.8E-08
(IAEA EPR-Medical, 2005) Notes:
The RBE-weighted absorbed dose is obtained by multiplying the absorbed dose by the Doses calculated for adults
RBE factor [Table H5]. The units are Gray-Equivalent (Gy-Eq) Route of intake: Acute inhalation
Integration period for absorbed dose = 30 d Activity median aerodynamic diameter (AMAD) = 5 μm
Absorption Type: F
518 519
Table A13.5b. Doses from an intake by INGESTION of 110mAg (f1 = 0.05) corresponding to a Table A13.6a. Doses from an intake by INHALATION of 109Cd (Absorption Type F)
single intake.
Whole body quantity: Gy-Eq dose, Sv
Whole body
marrow bone
marrow
period: 70 y Integration 30 d To age
period: 70 y
Measurement
time Measurement
time
6h 1.01 3.4E-10 7.3E-10 7.9E-09 2.8E-09
6h 1.37 1.6E-10 1.0E-10 8.3E-10 1.4E-08
12 h 1.08 3.6E-10 7.7E-10 8.4E-09 3.0E-09
12 h 1.51 1.7E-10 1.1E-10 9.1E-10 1.5E-08
1d 1.38 4.6E-10 9.9E-10 1.1E-08 3.8E-09
1d 1.82 2.1E-10 1.4E-10 1.1E-09 1.8E-08
2d 2.80 9.4E-10 2.0E-09 2.2E-08 7.8E-09
2d 2.48 2.8E-10 1.9E-10 1.5E-09 2.5E-08
3d 5.85 2.0E-09 4.2E-09 4.6E-08 1.6E-08
3d 2.95 3.4E-10 2.2E-10 1.8E-09 2.9E-08
4d 10.7 3.6E-09 7.7E-09 8.3E-08 3.0E-08
4d 3.19 3.6E-10 2.4E-10 1.9E-09 3.2E-08
5d 15.9 5.3E-09 1.1E-08 1.2E-07 4.4E-08
5d 3.29 3.7E-10 2.5E-10 2.0E-09 3.3E-08
6d 19.7 6.6E-09 1.4E-08 1.5E-07 5.4E-08
6d 3.33 3.8E-10 2.5E-10 2.0E-09 3.3E-08
7d 21.9 7.3E-09 1.6E-08 1.7E-07 6.1E-08
7d 3.35 3.8E-10 2.5E-10 2.0E-09 3.3E-08
10 d 24.5 8.2E-09 1.8E-08 1.9E-07 6.8E-08
10 d 3.38 3.8E-10 2.5E-10 2.0E-09 3.4E-08
14 d 26.5 8.9E-09 1.9E-08 2.1E-07 7.3E-08
14 d 3.40 3.9E-10 2.5E-10 2.1E-09 3.4E-08
21 d 29.6 9.9E-09 2.1E-08 2.3E-07 8.2E-08
21 d 3.44 3.9E-10 2.6E-10 2.1E-09 3.4E-08
28 d 33.0 1.1E-08 2.4E-08 2.6E-07 9.1E-08
28 d 3.47 4.0E-10 2.6E-10 2.1E-09 3.4E-08
Notes:
The RBE-weighted absorbed dose is obtained by multiplying the absorbed dose by the Absorption Type: F
520 521
Table A13.6b. Doses from an intake by INGESTION of 109Cd (f1 = 0.05) corresponding to a Table A13.7a. Doses from an intake by INHALATION of 131I (Absorption Type F)
measurement of 1 Bq in WHOLE BODY at specified times after a single intake. corresponding to a measurement of 1 Bq in THYROID at specified times after a single
intake.
Thyroid
bone Organ: Thyroid -
marrow
Integration 30 d To age period: 70 y
period: 70 y
Measurement
Measurement time
time
6h 18.9 7.4E-07 2.0E-07
6h 1.01 1.5E-11 1.6E-11 2.8E-09 2.0E-09
12 h 11.0 4.3E-07 1.2E-07
12 h 1.07 1.6E-11 1.7E-11 3.0E-09 2.1E-09
1d 8.31 3.3E-07 8.8E-08
1d 1.38 2.1E-11 2.1E-11 3.8E-09 2.7E-09
2d 8.35 3.3E-07 8.9E-08
2d 2.79 4.2E-11 4.3E-11 7.7E-09 5.6E-09
3d 9.13 3.6E-07 9.7E-08
3d 5.78 8.8E-11 9.0E-11 1.6E-08 1.2E-08
4d 10.0 3.9E-07 1.1E-07
4d 10.4 1.6E-10 1.6E-10 2.8E-08 2.1E-08
5d 11.0 4.3E-07 1.2E-07
5d 14.9 2.3E-10 2.3E-10 4.1E-08 3.0E-08
6d 12.1 4.8E-07 1.3E-07
6d 17.9 2.7E-10 2.8E-10 4.9E-08 3.6E-08
7d 13.3 5.2E-07 1.4E-07
7d 19.3 2.9E-10 3.0E-10 5.3E-08 3.8E-08
10 d 17.7 6.9E-07 1.9E-07
10 d 20.3 3.1E-10 3.2E-10 5.6E-08 4.0E-08
14 d 25.7 1.0E-06 2.7E-07
14 d 20.4 3.1E-10 3.2E-10 5.6E-08 4.1E-08
21 d 49.5 1.9E-06 5.2E-07
21 d 20.7 3.1E-10 3.2E-10 5.7E-08 4.1E-08
28 d 95.0 3.7E-06 1.0E-06
28 d 20.9 3.2E-10 3.2E-10 5.7E-08 4.2E-08
Notes:
Notes: Doses calculated for adults
Doses calculated for adults Route of intake: Acute inhalation
Route of intake: Acute ingestion Activity median aerodynamic diameter (AMAD) = 5 μm
Organs for which absorbed doses are calculated: Lungs, Red bone marrow or Colon Absorption Type: F
(IAEA EPR-Medical, 2005) Organs for which absorbed doses are calculated: Thyroid
The RBE-weighted absorbed dose is obtained by multiplying the absorbed dose by the (IAEA EPR-Medical, 2005)
RBE factor [Table H5]. The units are Gray-Equivalent (Gy-Eq) The RBE-weighted absorbed dose is obtained by multiplying the absorbed dose by the
Integration period for absorbed dose = 30 d RBE factor [Table H5]. The units are Gray-Equivalent (Gy-Eq)
522 523
Table A13.7b. Doses from an intake by INGESTION of 131I (f1 = 1) corresponding to a

Table A13.8a. Doses from an intake by INHALATION of 133Ba (Absorption Type F)
measurement of 1 Bq in THYROID at specified times after a single intake.
corresponding to a measurement of 1 Bq in WHOLE BODY at specified times after a
Measured Intake, Bq RBE-weighted absorbed dose, Effective single intake.
quantity: Gy-Eq dose, Sv
Thyroid
Organ: Thyroid - quantity: Gy-Eq dose, Sv
Whole body
Integration 30 d To age Organ: Lungs Red Colon -
period: 70 y bone
marrow
Measurement
time Integration 30 d To age
period: 70 y
6h 16.7 1.3E-06 3.6E-07
Measurement
12 h 6.56 5.3E-07 1.4E-07 time
1d 4.19 3.4E-07 9.0E-08 6h 1.40 8.0E-11 4.2E-10 1.7E-09 2.6E-09
2d 4.04 3.3E-07 8.7E-08 12 h 1.58 9.0E-11 4.8E-10 1.9E-09 2.9E-09
3d 4.41 3.5E-07 9.5E-08 1d 2.06 1.2E-10 6.2E-10 2.4E-09 3.8E-09
4d 4.85 3.9E-07 1.0E-07 2d 3.63 2.1E-10 1.1E-09 4.3E-09 6.7E-09
5d 5.33 4.3E-07 1.2E-07 3d 5.98 3.4E-10 1.8E-09 7.1E-09 1.1E-08
6d 5.85 4.7E-07 1.3E-07 4d 8.84 5.0E-10 2.7E-09 1.0E-08 1.6E-08
7d 6.43 5.2E-07 1.4E-07 5d 11.9 6.8E-10 3.6E-09 1.4E-08 2.2E-08
10 d 8.53 6.9E-07 1.8E-07 6d 14.8 8.4E-10 4.5E-09 1.8E-08 2.7E-08
14 d 12.4 1.0E-06 2.7E-07 7d 17.4 9.9E-10 5.3E-09 2.1E-08 3.2E-08
21 d 23.9 1.9E-06 5.2E-07 10 d 23.3 1.3E-09 7.0E-09 2.8E-08 4.3E-08
28 d 45.9 3.7E-06 9.9E-07 14 d 27.0 1.5E-09 8.2E-09 3.2E-08 5.0E-08
Notes: 21 d 29.3 1.7E-09 8.9E-09 3.5E-08 5.4E-08
Route of intake: Acute ingestion 28 d 30.8 1.8E-09 9.3E-09 3.7E-08 5.7E-08
Organs for which absorbed doses are calculated: Thyroid
Notes:
Absorption Type: F
524 525
Table A13.8b. Doses from an intake by INGESTION of 133Ba (f1 = 0.1) corresponding to a Table A13.9a. Doses from an intake by INHALATION of 137Cs (Absorption Type F)
single intake.
Whole body
marrow Organ: Lungs Red Colon -
bone
marrow
period: 70 y
Measurement
period: 70 y
time
Measurement
6h 1.01 2.0E-11 1.7E-10 2.7E-09 1.0E-09
time
12 h 1.08 2.1E-11 1.8E-10 2.9E-09 1.1E-09
6h 1.37 1.5E-09 1.5E-09 1.9E-09 9.2E-09
1d 1.38 2.7E-11 2.3E-10 3.7E-09 1.4E-09
12 h 1.48 1.7E-09 1.7E-09 2.0E-09 1.0E-08
2d 2.85 5.5E-11 4.8E-10 7.6E-09 2.8E-09
1d 1.68 1.9E-09 1.9E-09 2.3E-09 1.1E-08
3d 6.25 1.2E-10 1.0E-09 1.7E-08 6.3E-09
2d 1.97 2.2E-09 2.2E-09 2.7E-09 1.3E-08
4d 12.9 2.5E-10 2.2E-09 3.5E-08 1.3E-08
3d 2.14 2.4E-09 2.4E-09 2.9E-09 1.4E-08
5d 23.3 4.5E-10 3.9E-09 6.2E-08 2.3E-08
4d 2.23 2.5E-09 2.5E-09 3.1E-09 1.5E-08
6d 35.8 7.0E-10 6.0E-09 9.6E-08 3.6E-08
5d 2.28 2.5E-09 2.6E-09 3.1E-09 1.5E-08
7d 47.7 9.3E-10 8.0E-09 1.3E-07 4.8E-08
6d 2.32 2.6E-09 2.6E-09 3.2E-09 1.6E-08
10 d 70.9 1.4E-09 1.2E-08 1.9E-07 7.1E-08
7d 2.35 2.6E-09 2.6E-09 3.2E-09 1.6E-08
14 d 83.4 1.6E-09 1.4E-08 2.2E-07 8.3E-08
10 d 2.42 2.7E-09 2.7E-09 3.3E-09 1.6E-08
21 d 90.9 1.8E-09 1.5E-08 2.4E-07 9.1E-08
14 d 2.50 2.8E-09 2.8E-09 3.4E-09 1.7E-08
28 d 95.4 1.9E-09 1.6E-08 2.6E-07 9.5E-08
21 d 2.61 2.9E-09 2.9E-09 3.6E-09 1.8E-08
Notes:
28 d 2.73 3.0E-09 3.1E-09 3.8E-09 1.8E-08
Route of intake: Acute ingestion Notes:
Organs for which absorbed doses are calculated: Lungs, Red bone marrow or Colon Doses calculated for adults
(IAEA EPR-Medical, 2005) Route of intake: Acute inhalation
The RBE-weighted absorbed dose is obtained by multiplying the absorbed dose by the Activity median aerodynamic diameter (AMAD) = 5 μm
RBE factor [Table H5]. The units are Gray-Equivalent (Gy-Eq) Absorption Type: F
Integration period for absorbed dose = 30 d Organs for which absorbed doses are calculated: Lungs, Red bone marrow or Colon
526 527
Table A13.9b. Doses from an intake by INGESTION of 137Cs (f1 = 1) corresponding to a Table A13.10a. Doses from an intake by INHALATION of 152Eu (Absorption Type M)
single intake.
Whole body
marrow bone
marrow
period: 70 y
Measurement
time Measurement
time
6h 1.00 2.2E-09 2.3E-09 2.9E-09 1.4E-08
6h 1.37 1.8E-08 6.9E-10 3.8E-09 4.2E-08
12 h 1.00 2.2E-09 2.3E-09 2.9E-09 1.4E-08
12 h 1.54 2.1E-08 7.7E-10 4.2E-09 4.7E-08
1d 1.01 2.2E-09 2.3E-09 2.9E-09 1.4E-08
1d 2.03 2.7E-08 1.0E-09 5.6E-09 6.2E-08
2d 1.04 2.3E-09 2.4E-09 3.0E-09 1.4E-08
2d 3.73 5.0E-08 1.9E-09 1.0E-08 1.2E-07
3d 1.07 2.4E-09 2.5E-09 3.1E-09 1.4E-08
3d 6.17 8.2E-08 3.1E-09 1.7E-08 1.9E-07
4d 1.09 2.4E-09 2.5E-09 3.1E-09 1.5E-08
4d 8.42 1.1E-07 4.2E-09 2.3E-08 2.6E-07
5d 1.11 2.5E-09 2.5E-09 3.2E-09 1.5E-08
5d 9.83 1.3E-07 5.0E-09 2.7E-08 3.0E-07
6d 1.12 2.5E-09 2.6E-09 3.2E-09 1.5E-08
6d 10.5 1.4E-07 5.3E-09 2.9E-08 3.2E-07
7d 1.14 2.5E-09 2.6E-09 3.3E-09 1.5E-08
7d 10.9 1.5E-07 5.5E-09 3.0E-08 3.4E-07
10 d 1.17 2.6E-09 2.7E-09 3.4E-09 1.6E-08
10 d 11.3 1.5E-07 5.7E-09 3.1E-08 3.5E-07
14 d 1.21 2.7E-09 2.8E-09 3.5E-09 1.6E-08
14 d 11.7 1.6E-07 5.9E-09 3.2E-08 3.6E-07
21 d 1.26 2.8E-09 2.9E-09 3.6E-09 1.7E-08
21 d 12.3 1.6E-07 6.2E-09 3.4E-08 3.8E-07
28 d 1.32 2.9E-09 3.0E-09 3.8E-09 1.8E-08
28 d 12.8 1.7E-07 6.4E-09 3.5E-08 3.9E-07
Notes:
The RBE-weighted absorbed dose is obtained by multiplying the absorbed dose by the Absorption Type: M
528 529
Table A13.10b. Doses from an intake by INGESTION of 152Eu (f1 = 0.0005) corresponding Table A13.11a. Doses from an intake by INHALATION of 154Eu (Absorption Type M)
to a measurement of 1 Bq in WHOLE BODY at specified times after a single intake. corresponding to a measurement of 1 Bq in WHOLE BODY at specified times after a
single intake.
Whole body
marrow bone
marrow
period: 70 y
Measurement
time Measurement
time
6h 1.01 2.5E-11 2.3E-10 6.7E-09 1.4E-09
6h 1.37 3.9E-08 9.2E-10 6.5E-09 5.4E-08
12 h 1.08 2.6E-11 2.4E-10 7.1E-09 1.5E-09
12 h 1.54 4.4E-08 1.0E-09 7.3E-09 6.1E-08
1d 1.39 3.4E-11 3.1E-10 9.2E-09 1.9E-09
1d 2.03 5.8E-08 1.4E-09 9.6E-09 8.0E-08
2d 3.04 7.4E-11 6.8E-10 2.0E-08 4.1E-09
2d 3.74 1.1E-07 2.5E-09 1.8E-08 1.5E-07
3d 7.58 1.8E-10 1.7E-09 5.0E-08 1.0E-08
3d 6.18 1.8E-07 4.1E-09 2.9E-08 2.4E-07
4d 19.8 4.8E-10 4.5E-09 1.3E-07 2.7E-08
4d 8.42 2.4E-07 5.6E-09 4.0E-08 3.3E-07
5d 52.2 1.3E-09 1.2E-08 3.4E-07 7.1E-08
5d 9.84 2.8E-07 6.6E-09 4.7E-08 3.9E-07
6d 136 3.3E-09 3.1E-08 9.0E-07 1.8E-07
6d 10.6 3.0E-07 7.1E-09 5.0E-08 4.2E-07
7d 336 8.1E-09 7.6E-08 2.2E-06 4.6E-07
7d 10.9 3.1E-07 7.3E-09 5.2E-08 4.3E-07
10 d 1840 4.5E-08 4.1E-07 1.2E-05 2.5E-06
10 d 11.3 3.2E-07 7.6E-09 5.4E-08 4.5E-07
14 d 2420 5.9E-08 5.4E-07 1.6E-05 3.3E-06
14 d 11.7 3.3E-07 7.8E-09 5.6E-08 4.6E-07
21 d 2470 6.0E-08 5.6E-07 1.6E-05 3.4E-06
21 d 12.3 3.5E-07 8.2E-09 5.8E-08 4.9E-07
28 d 2490 6.0E-08 5.6E-07 1.6E-05 3.4E-06
28 d 12.8 3.6E-07 8.6E-09 6.1E-08 5.1E-07
Notes:
The RBE-weighted absorbed dose is obtained by multiplying the absorbed dose by the Absorption Type: M
530 531
Table A13.11b. Doses from an intake by INGESTION of 154Eu (f1 = 0.0005) corresponding to Table A13.12a. Doses from an intake by INHALATION of 192Ir (Absorption Type F)
a measurement of 1 Bq in WHOLE BODY at specified times after a single intake. corresponding to a measurement of 1 Bq in WHOLE BODY at specified times after a
single intake.
Whole body
marrow bone
marrow
period: 70 y
Measurement
time Measurement
time
6h 1.01 2.7E-11 2.4E-10 1.2E-08 2.1E-09
6h 1.39 7.8E-10 7.4E-10 3.6E-09 3.1E-09
12 h 1.08 2.8E-11 2.6E-10 1.2E-08 2.2E-09
12 h 1.56 8.7E-10 8.4E-10 4.0E-09 3.5E-09
1d 1.39 3.7E-11 3.4E-10 1.6E-08 2.8E-09
1d 1.97 1.1E-09 1.1E-09 5.1E-09 4.4E-09
2d 3.04 8.1E-11 7.4E-10 3.5E-08 6.2E-09
2d 2.93 1.6E-09 1.6E-09 7.6E-09 6.5E-09
3d 7.59 2.0E-10 1.8E-09 8.8E-08 1.5E-08
3d 3.78 2.1E-09 2.0E-09 9.8E-09 8.4E-09
4d 19.8 5.2E-10 4.8E-09 2.3E-07 4.0E-08
4d 4.33 2.4E-09 2.3E-09 1.1E-08 9.6E-09
5d 52.3 1.4E-09 1.3E-08 6.1E-07 1.1E-07
5d 4.65 2.6E-09 2.5E-09 1.2E-08 1.0E-08
6d 136 3.6E-09 3.3E-08 1.6E-06 2.8E-07
6d 4.85 2.7E-09 2.6E-09 1.3E-08 1.1E-08
7d 336 8.9E-09 8.1E-08 3.9E-06 6.8E-07
7d 5.01 2.8E-09 2.7E-09 1.3E-08 1.1E-08
10 d 1840 4.9E-08 4.5E-07 2.1E-05 3.7E-06
10 d 5.38 3.0E-09 2.9E-09 1.4E-08 1.2E-08
14 d 2420 6.4E-08 5.9E-07 2.8E-05 4.9E-06
14 d 5.85 3.3E-09 3.1E-09 1.5E-08 1.3E-08
21 d 2470 6.5E-08 6.0E-07 2.9E-05 5.0E-06
21 d 6.63 3.7E-09 3.5E-09 1.7E-08 1.5E-08
28 d 2500 6.6E-08 6.0E-07 2.9E-05 5.1E-06
28 d 7.40 4.1E-09 4.0E-09 1.9E-08 1.6E-08
Notes:
Notes:
Absorption Type: F
532 533
Table A13.12b. Doses from an intake by INHALATION of 192Ir (Absorption Type M) Table A13.12c. Doses from an intake by INHALATION of 192Ir (Absorption Type S)
corresponding to a measurement of 1 Bq in LUNGS at specified times after a single corresponding to a measurement of 1 Bq in LUNGS at specified times after a single
intake. intake.
Measured Intake, Bq RBE-weighted absorbed dose, Effective Measured Intake, Bq RBE-weighted absorbed dose, Effective
quantity: Gy-Eq dose, Sv quantity: Gy-Eq dose, Sv
Lungs Lungs
Organ: Lungs Red Colon - Organ: Lungs Red Colon -
bone bone
marrow marrow
Integration 30 d To age Integration 30 d To age
period: 70 y period: 70 y
time time
6h 13.2 2.5E-07 3.1E-09 4.6E-08 6.0E-08 6h 11.9 2.7E-07 2.4E-09 4.2E-08 6.6E-08
12 h 13.8 2.7E-07 3.3E-09 4.8E-08 6.3E-08 12 h 12.4 2.8E-07 2.6E-09 4.4E-08 6.9E-08
1d 14.5 2.8E-07 3.5E-09 5.0E-08 6.6E-08 1d 13.0 2.9E-07 2.7E-09 4.6E-08 7.2E-08
2d 15.1 2.9E-07 3.6E-09 5.2E-08 6.8E-08 2d 13.4 3.0E-07 2.8E-09 4.8E-08 7.4E-08
3d 15.5 3.0E-07 3.7E-09 5.4E-08 7.0E-08 3d 13.7 3.1E-07 2.8E-09 4.9E-08 7.6E-08
4d 15.9 3.1E-07 3.8E-09 5.5E-08 7.2E-08 4d 14.0 3.2E-07 2.9E-09 5.0E-08 7.7E-08
5d 16.2 3.1E-07 3.9E-09 5.6E-08 7.4E-08 5d 14.3 3.2E-07 2.9E-09 5.1E-08 7.9E-08
6d 16.6 3.2E-07 4.0E-09 5.8E-08 7.6E-08 6d 14.6 3.3E-07 3.0E-09 5.2E-08 8.1E-08
7d 17.0 3.3E-07 4.1E-09 5.9E-08 7.7E-08 7d 14.8 3.4E-07 3.0E-09 5.3E-08 8.2E-08
10 d 18.3 3.5E-07 4.4E-09 6.3E-08 8.3E-08 10 d 15.7 3.6E-07 3.2E-09 5.6E-08 8.7E-08
14 d 20.1 3.9E-07 4.8E-09 6.9E-08 9.1E-08 14 d 16.9 3.8E-07 3.5E-09 6.0E-08 9.3E-08
21 d 23.5 4.5E-07 5.6E-09 8.1E-08 1.1E-07 21 d 19.1 4.3E-07 3.9E-09 6.8E-08 1.1E-07
28 d 27.3 5.3E-07 6.5E-09 9.5E-08 1.2E-07 28 d 21.5 4.9E-07 4.4E-09 7.6E-08 1.2E-07
Notes: Notes:
Absorption Type: M Absorption Type: S
534 535
Table A13.12d. Doses from an intake by INGESTION of 192Ir (f1 = 0.01) corresponding to a Table A13.13a. Doses from an intake by INHALATION of 210Po (Absorption Type M)
measurement of 1 Bq in WHOLE BODY at specified times after a single intake. corresponding to a measurement of 1 Bq/day in URINE at specified times after a single
intake.
Urine
marrow bone
marrow
period: 70 y
Measurement
time Measurement
time
6h 1.01 3.2E-11 1.9E-10 8.5E-09 1.4E-09
1d 6720 3.0E-02 1.1E-04 5.4E-11 1.7E-02
12 h 1.08 3.4E-11 2.0E-10 9.1E-09 1.5E-09
2d 3410 1.5E-02 5.6E-05 2.8E-11 8.6E-03
1d 1.40 4.5E-11 2.6E-10 1.2E-08 1.9E-09
3d 3310 1.5E-02 5.5E-05 2.7E-11 8.4E-03
2d 3.06 9.8E-11 5.7E-10 2.6E-08 4.2E-09
4d 3340 1.5E-02 5.5E-05 2.7E-11 8.4E-03
3d 7.46 2.4E-10 1.4E-09 6.3E-08 1.0E-08
5d 3380 1.5E-02 5.6E-05 2.7E-11 8.6E-03
4d 18.1 5.8E-10 3.4E-09 1.5E-07 2.5E-08
6d 3430 1.5E-02 5.7E-05 2.8E-11 8.7E-03
5d 40.2 1.3E-09 7.5E-09 3.4E-07 5.5E-08
7d 3470 1.6E-02 5.7E-05 2.8E-11 8.8E-03
6d 74.2 2.4E-09 1.4E-08 6.2E-07 1.0E-07
10 d 3610 1.6E-02 6.0E-05 2.9E-11 9.1E-03
7d 109 3.5E-09 2.0E-08 9.2E-07 1.5E-07
14 d 3810 1.7E-02 6.3E-05 3.1E-11 9.6E-03
10 d 155 4.9E-09 2.9E-08 1.3E-06 2.1E-07
21 d 4180 1.9E-02 6.9E-05 3.4E-11 1.1E-02
14 d 171 5.5E-09 3.2E-08 1.4E-06 2.3E-07
28 d 4600 2.1E-02 7.6E-05 3.7E-11 1.2E-02
21 d 194 6.2E-09 3.6E-08 1.6E-06 2.6E-07
Notes:
28 d 217 6.9E-09 4.1E-08 1.8E-06 2.9E-07
Notes: Route of intake: Acute inhalation
Doses calculated for adults Activity median aerodynamic diameter (AMAD) = 5 μm
Route of intake: Acute ingestion Absorption Type: M
536 537
Table A13.13b. Doses from an intake by INGESTION of 210Po (f1 = 0.1) corresponding to a Table A13.14a. Doses from an intake by INHALATION of 226Ra (ABSORPTION TYPE M)
measurement of 1 Bq/day in URINE at specified times after a single intake. corresponding to a measurement of 1 Bq in LUNGS at specified times after a single
intake.
Lungs
marrow bone
marrow
period: 70 y
Measurement
time Measurement
time
1d 5190 4.4E-05 1.2E-04 9.5E-11 1.3E-03
6h 13.1 5.1E-05 6.5E-08 5.2E-08 3.4E-05
2d 2340 2.0E-05 5.3E-05 4.3E-11 5.7E-04
12 h 13.8 5.3E-05 6.8E-08 5.5E-08 3.5E-05
3d 2260 1.9E-05 5.1E-05 4.2E-11 5.5E-04
1d 14.3 5.5E-05 7.1E-08 5.7E-08 3.7E-05
4d 2300 1.9E-05 5.2E-05 4.2E-11 5.6E-04
2d 14.8 5.7E-05 7.3E-08 5.9E-08 3.8E-05
5d 2340 2.0E-05 5.3E-05 4.3E-11 5.7E-04
3d 15.0 5.8E-05 7.4E-08 6.0E-08 3.9E-05
6d 2390 2.0E-05 5.4E-05 4.4E-11 5.8E-04
4d 15.3 5.9E-05 7.5E-08 6.1E-08 3.9E-05
7d 2430 2.1E-05 5.5E-05 4.5E-11 6.0E-04
5d 15.5 6.0E-05 7.7E-08 6.2E-08 4.0E-05
10 d 2570 2.2E-05 5.8E-05 4.7E-11 6.3E-04
6d 15.7 6.1E-05 7.8E-08 6.2E-08 4.0E-05
14 d 2770 2.4E-05 6.2E-05 5.1E-11 6.8E-04
7d 16.0 6.2E-05 7.9E-08 6.3E-08 4.1E-05
21 d 3170 2.7E-05 7.1E-05 5.8E-11 7.8E-04
10 d 16.7 6.4E-05 8.2E-08 6.6E-08 4.3E-05
28 d 3610 3.1E-05 8.1E-05 6.6E-11 8.9E-04
14 d 17.6 6.8E-05 8.7E-08 7.0E-08 4.5E-05
Notes:
28 d 21.0 8.1E-05 1.0E-07 8.3E-08 5.4E-05
Absorption Type: M
538 539
Table A13.14b. Doses from an intake by INGESTION of 226Ra (f1 = 0.2) corresponding to a
Table A13.14c. Doses from an intake by INHALATION of 226Ra (Absorption Type M)
measurement of 1 Bq in WHOLE BODY at specified times after a single intake.
corresponding to a measurement of 1 Bq/day in URINE at specified times after a single
Measured Intake, Bq RBE-weighted absorbed dose, Effective intake.
Whole body
Organ: Lungs Red Colon - quantity: Gy-Eq dose, Sv
bone Urine
marrow
bone
Integration 30 d To age marrow
period: 70 y
Measurement period: 70 y
time
Measurement
6h 1.01 1.0E-09 8.7E-09 8.1E-09 2.8E-07 time
12 h 1.08 1.1E-09 9.3E-09 8.6E-09 3.0E-07 1d 639 2.5E-03 3.2E-06 2.5E-06 1.6E-03
1d 1.36 1.4E-09 1.2E-08 1.1E-08 3.7E-07 2d 3,220 1.2E-02 1.6E-05 1.3E-05 8.2E-03
2d 2.64 2.6E-09 2.3E-08 2.1E-08 7.3E-07 3d 4,860 1.9E-02 2.4E-05 1.9E-05 1.2E-02
3d 5.21 5.2E-09 4.5E-08 4.1E-08 1.4E-06 4d 6,830 2.6E-02 3.4E-05 2.7E-05 1.7E-02
4d 9.30 9.3E-09 8.0E-08 7.4E-08 2.6E-06 5d 9,460 3.7E-02 4.7E-05 3.8E-05 2.4E-02
5d 14.4 1.4E-08 1.2E-07 1.1E-07 4.0E-06 6d 12,900 5.0E-02 6.4E-05 5.1E-05 3.3E-02
6d 19.7 2.0E-08 1.7E-07 1.6E-07 5.4E-06 7d 17,200 6.6E-02 8.5E-05 6.8E-05 4.4E-02
7d 24.3 2.4E-08 2.1E-07 1.9E-07 6.7E-06 10 d 34,900 1.3E-01 1.7E-04 1.4E-04 8.9E-02
10 d 34.0 3.4E-08 2.9E-07 2.7E-07 9.3E-06 14 d 59,400 2.3E-01 2.9E-04 2.4E-04 1.5E-01
14 d 40.3 4.0E-08 3.5E-07 3.2E-07 1.1E-05 21 d 80,100 3.1E-01 4.0E-04 3.2E-04 2.1E-01
21 d 45.6 4.6E-08 3.9E-07 3.6E-07 1.3E-05 28 d 90,500 3.5E-01 4.5E-04 3.6E-04 2.3E-01
28 d 49.7 5.0E-08 4.3E-07 3.9E-07 1.4E-05 Notes:
540 541
Table A13.14d. Doses from an intake by INGESTION of 226Ra (f1 = 0.2) corresponding to a
measurement of 1 Bq/day in URINE at specified times after a single intake. Table A13.15a. Doses from an intake by INHALATION of 238Pu (ABSORPTION TYPE S)
corresponding to a measurement of 1 Bq in LUNGS at specified times after a single
Urine Measured Intake, Bq RBE-weighted absorbed dose, Effective
bone Lungs
marrow Organ: Lungs Red Colon -
bone
period: 70 y
time
Measurement
1d 342 3.4E-07 2.9E-06 2.7E-06 9.4E-05 time
2d 1,750 1.8E-06 1.5E-05 1.4E-05 4.8E-04 6h 11.8 7.2E-05 2.0E-09 1.8E-09 1.2E-04
3d 2,680 2.7E-06 2.3E-05 2.1E-05 7.4E-04 12 h 12.4 7.6E-05 2.1E-09 1.9E-09 1.3E-04
4d 3,840 3.8E-06 3.3E-05 3.1E-05 1.1E-03 1d 12.8 7.9E-05 2.2E-09 1.9E-09 1.3E-04
5d 5,480 5.5E-06 4.7E-05 4.4E-05 1.5E-03 2d 13.2 8.1E-05 2.2E-09 2.0E-09 1.4E-04
6d 7,770 7.8E-06 6.7E-05 6.2E-05 2.1E-03 3d 13.4 8.2E-05 2.3E-09 2.0E-09 1.4E-04
7d 10,900 1.1E-05 9.4E-05 8.7E-05 3.0E-03 4d 13.5 8.2E-05 2.3E-09 2.0E-09 1.4E-04
10 d 28,100 2.8E-05 2.4E-04 2.2E-04 7.7E-03 5d 13.6 8.3E-05 2.3E-09 2.1E-09 1.4E-04
14 d 71,100 7.1E-05 6.1E-04 5.7E-04 2.0E-02 6d 13.8 8.4E-05 2.3E-09 2.1E-09 1.4E-04
21 d 134,000 1.3E-04 1.2E-03 1.1E-03 3.7E-02 7d 13.9 8.5E-05 2.4E-09 2.1E-09 1.4E-04
28 d 160,000 1.6E-04 1.4E-03 1.3E-03 4.4E-02 10 d 14.3 8.7E-05 2.4E-09 2.2E-09 1.5E-04
Notes: 14 d 14.8 9.0E-05 2.5E-09 2.2E-09 1.5E-04
Route of intake: Acute ingestion 21 d 15.7 9.6E-05 2.7E-09 2.4E-09 1.6E-04
28 d 16.5 1.0E-04 2.8E-09 2.5E-09 1.7E-04
The RBE-weighted absorbed dose is obtained by multiplying the absorbed dose by the Notes:
RBE factor [Table H5]. The units are Gray-Equivalent (Gy-Eq) Doses calculated for adults
Integration period for absorbed dose = 30 d Route of intake: Acute inhalation
Absorption Type: S
542 543
Table A13.15b. Doses from an intake by INGESTION of 238Pu (f1 = 1E-05) corresponding to Table A13.15c. Doses from an intake by INHALATION of 238Pu (ABSORPTION TYPE S)
a measurement of 1 Bq in WHOLE BODY at specified times after a single intake. corresponding to a measurement of 1 Bq/day in URINE at specified times after a single
intake.
Urine
marrow bone
marrow
period: 70 y
Measurement
time Measurement
time
6h 1.01 5.4E-13 4.4E-12 3.6E-10 9.0E-09
1d 411,000 2.5E+00 7.0E-05 6.2E-05 4.2E+00
12 h 1.08 5.8E-13 4.7E-12 3.9E-10 9.6E-09
2d 706,000 4.3E+00 1.2E-04 1.1E-04 7.3E+00
1d 1.39 7.5E-13 6.0E-12 5.0E-10 1.2E-08
3d 1,140,000 7.0E+00 1.9E-04 1.7E-04 1.2E+01
2d 3.04 1.6E-12 1.3E-11 1.1E-09 2.7E-08
4d 1,590,000 9.7E+00 2.7E-04 2.4E-04 1.6E+01
3d 7.60 4.1E-12 3.3E-11 2.7E-09 6.8E-08
5d 2,040,000 1.2E+01 3.5E-04 3.1E-04 2.1E+01
4d 19.9 1.1E-11 8.6E-11 7.1E-09 1.8E-07
6d 2,490,000 1.5E+01 4.2E-04 3.8E-04 2.6E+01
5d 53.3 2.9E-11 2.3E-10 1.9E-08 4.7E-07
7d 2,910,000 1.8E+01 4.9E-04 4.4E-04 3.0E+01
6d 144 7.7E-11 6.2E-10 5.2E-08 1.3E-06
10 d 3,930,000 2.4E+01 6.7E-04 6.0E-04 4.0E+01
7d 389 2.1E-10 1.7E-09 1.4E-07 3.5E-06
14 d 4,590,000 2.8E+01 7.8E-04 7.0E-04 4.7E+01
10 d 7,280 3.9E-09 3.1E-08 2.6E-06 6.5E-05
21 d 4,890,000 3.0E+01 8.3E-04 7.4E-04 5.0E+01
14 d 84,000 4.5E-08 3.6E-07 3.0E-05 7.5E-04
28 d 4,970,000 3.0E+01 8.4E-04 7.5E-04 5.1E+01
21 d 104,700 5.6E-08 4.5E-07 3.8E-05 9.3E-04
Notes:
28 d 105,000 5.6E-08 4.5E-07 3.8E-05 9.3E-04
Route of intake: Acute ingestion Absorption Type: S
544 545
Table A13.15d. Doses from an intake by INGESTION of 238Pu (f1 = 1E-05) corresponding to Table A13.16a. Doses from an intake by INHALATION of 241Am (ABSORPTION TYPE M)
a measurement of 1 Bq/day in URINE at specified times after a single intake. corresponding to a measurement of 1 Bq in LUNGS at specified times after a single
intake.
Lungs
marrow bone
marrow
period: 70 y
Measurement
time Measurement
time
1d 14,900,000 8.0E-06 6.4E-05 5.3E-03 1.3E-01
6h 13.1 6.8E-05 1.0E-07 9.7E-09 4.0E-04
2d 19,300,000 1.0E-05 8.4E-05 6.9E-03 1.7E-01
12 h 13.8 7.1E-05 1.1E-07 1.0E-08 4.2E-04
3d 34,600,000 1.9E-05 1.5E-04 1.2E-02 3.1E-01
1d 14.3 7.4E-05 1.1E-07 1.1E-08 4.4E-04
4d 53,900,000 2.9E-05 2.3E-04 1.9E-02 4.8E-01
2d 14.8 7.6E-05 1.2E-07 1.1E-08 4.6E-04
5d 77,300,000 4.1E-05 3.3E-04 2.8E-02 6.9E-01
3d 15.0 7.8E-05 1.2E-07 1.1E-08 4.6E-04
6d 106,000,000 5.7E-05 4.6E-04 3.8E-02 9.4E-01
4d 15.3 7.9E-05 1.2E-07 1.1E-08 4.7E-04
7d 140,000,000 7.5E-05 6.1E-04 5.0E-02 1.2E+00
5d 15.5 8.0E-05 1.2E-07 1.1E-08 4.8E-04
10 d 274,000,000 1.5E-04 1.2E-03 9.8E-02 2.4E+00
6d 15.7 8.1E-05 1.2E-07 1.2E-08 4.8E-04
14 d 450,000,000 2.4E-04 1.9E-03 1.6E-01 4.0E+00
7d 16.0 8.2E-05 1.3E-07 1.2E-08 4.9E-04
21 d 582,000,000 3.1E-04 2.5E-03 2.1E-01 5.2E+00
10 d 16.7 8.6E-05 1.3E-07 1.2E-08 5.1E-04
28 d 632,000,000 3.4E-04 2.7E-03 2.3E-01 5.6E+00
14 d 17.6 9.1E-05 1.4E-07 1.3E-08 5.4E-04
Notes:
28 d 21.0 1.1E-04 1.7E-07 1.5E-08 6.5E-04
Absorption Type: M
546 547
Table A13.16b. Doses from an intake by INGESTION of 241Am (f1 = 0.0005) corresponding Table A13.16c. Doses from an intake by INHALATION of 241Am (ABSORPTION TYPE M)
to a measurement of 1 Bq in WHOLE BODY at specified times after a single intake. corresponding to a measurement of 1 Bq/day in URINE at specified times after a single
intake.
Organ: Lungs Red Colon - Urine
marrow bone
marrow
period: 70 y
Measurement
time Measurement
time
6h 1.01 1.3E-11 1.2E-10 1.9E-09 2.1E-07
1d 544 2.8E-03 4.3E-06 4.0E-07 1.7E-02
12 h 1.08 1.4E-11 1.3E-10 2.0E-09 2.2E-07
2d 4,110 2.1E-02 3.2E-05 3.0E-06 1.3E-01
1d 1.39 1.8E-11 1.7E-10 2.6E-09 2.8E-07
3d 7,200 3.7E-02 5.7E-05 5.3E-06 2.2E-01
2d 3.04 3.9E-11 3.7E-10 5.6E-09 6.2E-07
4d 10,400 5.4E-02 8.2E-05 7.6E-06 3.2E-01
3d 7.58 9.7E-11 9.2E-10 1.4E-08 1.5E-06
5d 12,800 6.6E-02 1.0E-04 9.5E-06 4.0E-01
4d 19.8 2.5E-10 2.4E-09 3.6E-08 4.0E-06
6d 14,500 7.5E-02 1.1E-04 1.1E-05 4.5E-01
5d 52.1 6.6E-10 6.3E-09 9.6E-08 1.1E-05
7d 15,800 8.2E-02 1.2E-04 1.2E-05 4.9E-01
6d 135 1.7E-09 1.6E-08 2.5E-07 2.8E-05
10 d 18,500 9.6E-02 1.5E-04 1.4E-05 5.7E-01
7d 332 4.2E-09 4.0E-08 6.1E-07 6.8E-05
14 d 21,800 1.1E-01 1.7E-04 1.6E-05 6.7E-01
10 d 1730 2.2E-08 2.1E-07 3.2E-06 3.5E-04
21 d 27,100 1.4E-01 2.1E-04 2.0E-05 8.4E-01
14 d 2220 2.8E-08 2.7E-07 4.1E-06 4.5E-04
28 d 31,700 1.6E-01 2.5E-04 2.3E-05 9.8E-01
21 d 2237 2.8E-08 2.7E-07 4.1E-06 4.6E-04
Notes:
28 d 2240 2.9E-08 2.7E-07 4.1E-06 4.6E-04 Doses calculated for adults
548 549
Table A13.16d. Doses from an intake by INGESTION of 241Am (f1 = 0.0005) corresponding
Table A13.17a. Doses from an intake by INHALATION of 252Cf (ABSORPTION TYPE M)
to a measurement of 1 Bq/day in URINE at specified times after a single intake.
corresponding to a measurement of 1 Bq/day in URINE at specified times after a single
Urine
bone Urine
marrow
bone
period: 70 y
time
Measurement
1d 33,700 4.3E-07 4.1E-06 6.2E-05 6.9E-03 time
2d 218,000 2.8E-06 2.6E-05 4.0E-04 4.5E-02 1d 742 5.9E-03 2.8E-05 7.1E-06 1.1E-02
3d 451,000 5.8E-06 5.5E-05 8.3E-04 9.2E-02 2d 7,600 6.1E-02 2.9E-04 7.3E-05 1.1E-01
4d 754,000 9.6E-06 9.1E-05 1.4E-03 1.5E-01 3d 40,500 3.2E-01 1.5E-03 3.9E-04 6.0E-01
5d 1,060,000 1.4E-05 1.3E-04 1.9E-03 2.2E-01 4d 56,400 4.5E-01 2.1E-03 5.4E-04 8.4E-01
6d 1,310,000 1.7E-05 1.6E-04 2.4E-03 2.7E-01 5d 58,700 4.7E-01 2.2E-03 5.6E-04 8.7E-01
7d 1,520,000 1.9E-05 1.8E-04 2.8E-03 3.1E-01 6d 59,600 4.8E-01 2.3E-03 5.7E-04 8.8E-01
10 d 2,040,000 2.6E-05 2.5E-04 3.7E-03 4.2E-01 7d 60,500 4.8E-01 2.3E-03 5.8E-04 8.9E-01
14 d 2,820,000 3.6E-05 3.4E-04 5.2E-03 5.7E-01 10 d 63,000 5.0E-01 2.4E-03 6.1E-04 9.3E-01
21 d 4,640,000 5.9E-05 5.6E-04 8.5E-03 9.5E-01 14 d 66,500 5.3E-01 2.5E-03 6.4E-04 9.8E-01
28 d 6,910,000 8.8E-05 8.4E-04 1.3E-02 1.4E+00 21 d 72,700 5.8E-01 2.7E-03 7.0E-04 1.1E+00
Notes: 28 d 79,000 6.3E-01 3.0E-03 7.6E-04 1.2E+00
Notes:
Absorption Type: M
550 551
Annexes Annex 14: Methodology used for developing Chapters J and K
Table A13.17b. Doses from an intake by INGESTION of 252Cf (f1 = 0.0005) corresponding to
Annex 14: Methodology applied by WHO for
a measurement of 1 Bq/day in URINE at specified times after a single intake. developing guidance on health interventions for
Measured
quantity:
Intake, Bq RBE-weighted absorbed dose,
Gy-Eq
Effective
dose, Sv
Chapters J and K of this Handbook
Urine
bone How the TMT project started
marrow
In response to the EC Euratom’s Sixth Framework Programme call for
period: 70 y
proposals, five organisations in the EU and one organisation in an
Associated Country with relevant expertise in the field of preparedness and
Measurement
time response to radiation emergencies formed a consortium1 and invited WHO
1d 48,200 5.8E-06 8.6E-05 1.1E-03 4.4E-03 to take part in this project. A proposal for a joint project called “Triage,
2d 260,000 3.1E-05 4.6E-04 5.9E-03 2.4E-02 Monitoring and Treatment - handbook for management of the public in the
3d 3,840,000 4.7E-04 6.8E-03 8.7E-02 3.5E-01
event of malevolent use of radiation” (TMT Handbook) was submitted and
4d 36,300,000 4.4E-03 6.4E-02 8.2E-01 3.3E+00
awarded funding. The project started in September 2006 with the aim of
producing a practicable tool for the effective and timely management of
5d 76,800,000 9.3E-03 1.4E-01 1.7E+00 6.9E+00
people following an incident involving malevolent use of radiation,
6d 82,600,000 1.0E-02 1.5E-01 1.9E+00 7.5E+00
building on earlier developments in national and regional European
7d 83,000,000 1.0E-02 1.5E-01 1.9E+00 7.5E+00
programmes.
10 d 83,300,000 1.0E-02 1.5E-01 1.9E+00 7.5E+00
14 d 83,500,000 1.0E-02 1.5E-01 1.9E+00 7.6E+00 How the expert panel on health interventions was
21 d 84,000,000 1.0E-02 1.5E-01 1.9E+00 7.6E+00 identified
28 d 84,400,000 1.0E-02 1.5E-01 1.9E+00 7.6E+00 The handbook was drafted by the scientific staff of the consortium
Notes: organisations, according to their areas of specialisation and expertise.
Route of intake: Acute ingestion WHO took the lead for the development of guidance on health
Organs for which absorbed doses are calculated: Lungs, Red bone marrow or Colon interventions (Chapters J and K of this Handbook: Work Package 4). To
address this task WHO convened an expert panel which brought together
RBE factor [Table H5]. The units are Gray-Equivalent (Gy-Eq) acknowledged professionals from its Radiation Emergency Medical
Preparedness and Assistance network (REMPAN). The selection of these
experts was based on their specialisation field, expertise, and experience in
the field of medical and public health response in radiation emergencies.
The selection ensured participation of experts who were directly involved
in the diagnosis and treatment of people accidentally exposed to radiation
as well as in the management of public health response during past
radiation emergencies. Conflict of interest statements with accompanying
explanatory notes were sent to all the invited experts. No conflicts of
interest have been declared by any of them.
1 Belgian Nuclear Research Centre (SCK•CEN), Belgium; Norwegian Radiation Protection
Authority (NRPA), Norway; Health Protection Agency (HPA), United Kingdom; Radiation and
Nuclear Safety Authority (STUK), Finland; Enviros Consulting, United Kingdom; and Central
Laboratory for Radiation Protection (CLOR), Poland.
552 553
How the best approach was identified The output of the consultation was a report that constituted the basis for the
This Handbook is based on a harmonisation and development of current development of the draft chapters, including:
approaches across the European Union and is consistent with current • A summary of the discussions conducted during working sessions
international guidance. Recommended health interventions are on diagnosis, treatment and follow-up of casualties as well as public
evidence-based statements to assist decision-making. In areas where health response to radiation emergencies resulting from malevolent
clinical evidence was limited, recommendations were based on best acts;
available practice, the experts’ opinion, and lessons identified in recent • Identified areas where evidence-based consensus existed and more
radiation accidents. controversial areas requiring further evidence retrieval;
• Generic recommendations on health interventions in radiation
A comprehensive literature search was conducted using PubMed and emergencies resulting from malevolent acts;
library databases of the consortium organisations, as well as other
international, regional and national databases, with contributions from the • General recommendations on the outline of the respective chapter
REMPAN experts. Particular efforts were made to identify systematic of the TMT Handbook;
literature reviews and evidence related to health effects of ionising • List of relevant terms requiring harmonisation and core definitions
radiation, diagnosis and treatment of radiation injuries, long-term health to be included in a glossary; and
surveillance, prevention and management of psychological impact. A • List of relevant publications to be referenced and used for the
survey of current practice in European countries was also conducted as a Handbook development, and recommendations to expand literature
part of the project (Work Package 2). research.
The expert panel identified some overlapping issues bridging pre-hospital
How the expert panel worked
and hospital responses and recommended further interaction between the
The first consultation was held in August 2007 in WHO Headquarters consortium members involved in Work Packages (WP) 3 and 4 addressing
(Geneva, Switzerland) with a dual purpose: (i) to review and evaluate respective issues. A joint meeting of the WP3 and 4 contributors was held
available evidence on medical and public health preparedness and response in November 2007 in Brussels, Belgium to ensure harmonisation and
to radiation emergencies resulting from malevolent acts; and (ii) to develop consistency between the different chapters. This joint meeting was
as far as possible an outline of particular chapters (J and K) of the TMT attended by the following aforementioned experts: R. N. Gent, S.
Handbook. Joussineau, V. List and D. Lloyd. The TMT project Secretariat was
represented by C. Rojas-Palma (TMT Project Co-ordinator, SCK-CEN,
The consultation was attended by the following REMPAN experts: M. Belgium) and K. Smith (TMT Technical Secretariat, Enviros, UK). The
Akashi (NIRS, Japan); R. N. Gent (HPA, UK); P. Gourmelon (IRSN, following TMT consortium members involved in WP3 attended: G.
France); S. Joussineau (Karolinska University Hospital, Sweden); V. List Etherington (HPA, UK), A. Hodgson (HPA, UK), W. Paile (STUK,
(Karlsruhe Res. Centre, Germany); D. Lloyd (HPA,UK); N. Valverde (Rio Finland), T. Rahola (STUK, Finland). M. R. Pérez (PHE, WHO) attended
University, Brazil), and A. L. Wiley (REAC/TS, USA). The TMT project the meeting representing the consortium members involved in the
Secretariat was represented by C. R. Palma (TMT Project Co-ordinator, development of WP4. The European Commission was represented by M.
SCK-CEN, Belgium) and P. Kruse (TMT Technical Secretariat, Enviros, Hugon.
UK). The WHO Secretariat was represented by Z. Carr and M. R. Pérez
(WHO/PHE). Based on the evidence acquired from the literature search and the
recommendations provided by the expert panel during the two meetings
mentioned above, a draft module including information on hospital
554 555
response and public health actions was prepared in December 2007.

Following internal review and revision, this draft was circulated for
comments among the expert panel members. The first draft of the
Handbook was finalised in March 2008. In addition to its circulation for
review experts, the draft was distributed to a wide range of end-users and
stake-holders, who evaluated the Handbook and/or tested it in suitable
national emergency response exercises.
The feedback on the draft Handbook and experience from its use in
national exercises were collected during the TMT Feedback Workshop held
in December 2008 (Lillehammer, Norway), with the participation of
end-users, technical experts, TMT consortium members and EC
representatives. A Technical Meeting of the consortium members was
convened at the end of the Workshop to address specifically the comments
received during the feedback workshop. A final peer review was conducted
with the contribution of REMPAN experts.
It is anticipated that the recommendations on health interventions provided

in chapters J and K of this Handbook will remain valid at least until 2014.
The Department of Public Health and Environment at WHO Headquarters
in Geneva (WHO/PHE) is responsible for reviewing recommendations on
health interventions. WHO/PHE can, if deemed necessary, publish new or
revised recommendations based on emerging scientific evidence, at any
time.
556 557
At the
scene First
Security Ambulance
personnel responders team
Strategic
Non-radiological Command
incidents
Medical team Tactical
Incident
Radiological Command
incidents
(additional teams) Dose
Environmental
monitoring assessment
team team
People
Radiological
monitoring
triage team
team
Decontamina-
tion team
Consortium members:
STUDIECENTRUM VOOR KERNENERGIE

Belgian Nuclear Research Centre, Belgium
CENTRE D’ETUDE DE L’ENERGIE NUCLEAIRE
Norwegian Radiation Protection Authority, Norway
Health Protection Agency, United Kingdom
World Health Organization
Radiation and Nuclear Safety Authority, Finland
Enviros Consulting Ltd., United Kingdom
Central Laboratory for Radiological Protection, Poland
Financial Support:
Partly financed by the European Commission and the Norwegian Research Council
European Commission
The Research Council of Norway
ISBN: 978-82-90362-27-5

TMT Handbook

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

TMT Handbook

Uploaded by

Copyright:

Available Formats

TMT TMT TMT

Chapter B Handbook structure and how to use it...................................

Chapter E Immediate actions................................................................. 22

Chapter F Triage and monitoring for the purpose of screening.............. 70

Chapter G Decontamination of people in the field.................................. 150

Chapter H Monitoring for dose assessment purposes............................. 168

Chapter I Handling of contaminated casualties and transport

Chapter J Medical management at the hospital..................................... 230

Chapter K Public health response........................................................... 320

Chapter L International liaison............................................................... 338

Monitoring to Establishing Control of

Handling of contaminated casualties Chapter K

Triage, Monitoring and Treatment of people exposed to

Print: Lobo Media AS, Norway

Authors NRPA – Norwegian Radiation Protection Authority (Norway)

Enviros Consulting Ltd. (United Kingdom) David Lloyd

Chapter J Medical management at the hospital ........................................230 Glossary ................................................................................................... 362

List of figures Figure J11. Clinical evolution of LRI.......................................................................................285

consider national feasibility, availability of resources and capabilities, as CHAPTER B

Instructions vs Information panels

Instructions on Additional information

Type of Indicates if the

Figure B1 (both pages). Example of the chosen structure in chapters E to J.

At the scene At the hospital

The teams given in bold are teams specifically designed to respond to

• Radiological Exposure Device;

2.2 Radiological Dispersal Device

The effects of radiological contamination dispersed by an explosion are

To an ever increasing degree, the public can monitor how an emergency or

The following could also be valuable if resources are available:

Introduction Information E.1

5. Minimize time spent within 10 metres of suspected radioactive

threats of serious injuries, immediate treatment of serious

E.4 Limiting exposure if gamma dose rate is known

E.5 Guidelines if self-reading dosemeters are being used

1. Follow Instruction E.1 and Instruction E.3 above.

1.2 Authorised personnel

2. Wear some form of identification (high visibility uniform,

E.8 Members of the public within the Red Zone

evacuation takes place instruct the public to take best available

E.10 Members of the public outside the Red Zone

If there has been an atmospheric release (smoke from fire or bomb)

1. To remain inside building during the release (smoke).

1.4 Dealing with deceased persons

E.11 (CONTAMINATION INCIDENTS) (MEDICAL, AMUBLANCE, FIRST

2 Monitoring to confirm a radiation

• An irradiation source may be damaged.

5. If monitoring is carried out which confirms that the incident

E.15 Environmental contamination and external irradiation incidents

2.1 Contamination and irradiation incidents

E.16 Monitoring teams

minimum, be able to identify elevated gamma dose rates. If

E.17 Safety of monitoring team staff

(d) Hand held monitors for measuring neutron dose rate;

E.20 Post deployment actions

Monitoring teams need to be familiar with the monitoring instrument used

• Surface wipe sampling from approximately 100 cm2 from

5. If gamma dose rate remains below 2x background, carry out the

6. If position of source is identified [Information E.21:2b], or

(a) Peak gamma dose rate;

7. If elevated gamma dose rate is present and no alpha or beta

E.22 Reporting results

2.2 Contaminated food/water incidents