Potential Radiation Exposure in Military Operations

Protecting the Soldier Before, During, and After

Committee on Battlefield Radiation Exposure Criteria

Fred A. Mettler, Jr., Chairman

Susan Thaul and Heather O'Maonaigh, Editors

Medical Follow-up Agency

INSTITUTE OF MEDICINE


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--> Potential Radiation Exposure in Military Operations Protecting the Soldier Before, During, and After Committee on Battlefield Radiation Exposure Criteria Fred A. Mettler, Jr., Chairman Susan Thaul and Heather O'Maonaigh, Editors Medical Follow-up Agency INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C.

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--> NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. Support for this project was provided by the U.S. Army Medical Research and Materiel Command under Contract No. DAMD17-96-C-6095. The views, opinions, and/or findings contained in this report are those of the authors and should not be construed as an official Department of the Army position, policy, or decision unless so designated by other documentation. International Standard Book No. 0-309-06439-2 Additional copies of this report are available for sale from National Academy Press , 2101 Constitution Avenue, N.W., Lock Box 285, Washington, DC 20055. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), or visit the NAP's online bookstore at www.nap.edu. The full text of this report is available on line at: www.nap.edu/readingroom. For more information about the Institute of Medicine, visit the IOM home page at: www.nas.edu/iom. Copyright 1999 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Cover: Original photograph by Lance Cheung, courtesy of the Joint Combat Camera Center, U.S. Department of Defense. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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--> COMMITTEE ON BATTLEFIELD RADIATION EXPOSURE CRITERIA FRED A. METTLER, JR. (Chairman), Professor and Chair, Department of Radiology, University of New Mexico School of Medicine JOHN F. AHEARNE, Director, Sigma Xi Center, Research Triangle Park, North Carolina, and Adjunct Professor of Civil and Environmental Engineering, Duke University GEORGE J. ANNAS, Professor and Chair, Health Law Department, Boston University School of Public Health WILLIAM J BAIR, Radiation Biologist (retired, Senior Advisor for Health Protection Research, Pacific Northwest National Laboratory), Richland, Washington RUTH R. FADEN, Philip Franklin Wagley Professor of Biomedical Ethics and Director, The Bioethics Institute, Johns Hopkins University SHIRLEY A. FRY, Senior Advisor, Environmental and Health Sciences Division, Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee LAWRENCE O. GOSTIN, Professor of Law and Co-director, Georgetown/ Johns Hopkins University Program on Law and Public Health, Washington, D.C. RAYMOND H. JOHNSON, JR., President, CSI-Radiation Safety Training and Communication Sciences Institute, Inc., Kensington, Maryland LEONARD D. MILLER, Brigadier General, U.S. Army, Retired, Fairfax, Virginia WILLIAM A. MILLS, Consultant, Radiation Safety, Olney, Maryland BERNHARD T. MITTEMEYER, Lieutenant General/Surgeon General, U.S. Army, Retired, and Professor of Urological Surgery, Texas Tech University School of Medicine THEODORE L. PHILLIPS, Wun-kon Fu Distinguished Professor, Department of Radiation Oncology, University of California at San Francisco GENEVIEVE S. ROESSLER, Associate Professor Emerita (Nuclear Engineering and Radiology, University of Florida), Elysian, Minnesota RAYMOND L. SPHAR, Captain, Medical Corps, U.S. Navy, Retired, and U.S. Department of Veterans Affairs, Retired, Washington, D.C. Study Staff SUSAN THAUL, Study Director (since October 1997) J. CHRISTOPHER JOHNSON, Study Director (through October 1997) STEVEN L. SIMON, Senior Program Officer (Board on Radiation Effects Research, Commission on Life Sciences, National Research Council) HEATHER O'MAONAIGH, Research Associate PAMELA C. RAMEY-McCRAY, Administrative Assistant RICHARD N. MILLER, Director, Medical Follow-up Agency

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--> Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the Institute of Medicine in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and the draft manuscript remain confidential to protect the integrity of the deliberative process. The committee wishes to thank the following individuals for their participation in the review of this report: ROBERT ARTER, Lieutenant General, U.S. Army (retired); THOMAS BURKE, Department of Health Policy and Management, and Risk Sciences and Public Policy Institute, Johns Hopkins University School of Public Health; DAVID CHALLONER, Institute for Science and Health Policy, University of Florida; CARON CHESS, Center for Environmental Communication, Rutgers University; KENNETH GOODMAN, Forum for Bioethics and Philosophy, University of Miami; JEFFERY KAHN, Center for Biomedical Ethics, University of Minnesota; DADE MOELLER, Dade Moeller & Associates, Inc., New Bern, North Carolina; PHILIP RUSSELL, Major General, U.S. Army (retired), Department of International Health, Johns Hopkins University School of Public Health; and RICHARD SETLOW, Department of Biology, Brookhaven National Laboratory, Upton, New York. While the individuals listed above have provided constructive comments and suggestions, it must be emphasized that responsibility for the final content of this report rests entirely with the authoring committee and the Institute of Medicine.

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--> Preface In 1996, NATO issued guidance for the exposure of military personnel to radiation doses different from occupational dose levels, but not high enough to cause acute health effects-and in doing so set policy in a new arena. Scientific and technological developments now permit small groups or individuals to use, or threaten to use, destructive devices (nuclear, biological, chemical, and cyber-based weaponry, among others) targeted anywhere in the world. Political developments, such as the loss of political balance once afforded by competing superpowers, have increased the focus on regional and subregional disputes. What doctrine should guide decisionmaking regarding the potential exposure of troops to radiation in this changed theater of military operations? In 1995, the Office of the U.S. Army Surgeon General asked the Medical Follow-up Agency of the Institute of Medicine to provide advice. This report is the final product of the Committee on Battlefield Radiation Exposure Criteria convened for that purpose. In its 1997 interim report, Evaluation of Radiation Exposure Guidance for Military Operations, the committee addressed the technical aspects of the NATO directive. In this final report, the committee reiterates that discussion and places it in an ethical context. Focusing on potential exposure of military personnel to radiation doses up to 700 millisievert, the committee addresses details of dosimetry, radiation physics, and the medical follow-up of potential, subsequent tumor development. The ethical framework presented in this report applies to potential harms beyond those posed by radiation alone. Soldiers face bullets, explosive devices, climatic and weather extremes, and endemic infections, as well as nuclear, chemical, and biological agents. On a daily basis, commanders in the Pentagon and in the field face decisions that affect the safety of the troops in their charge. This committee lays out a framework for those decisions, be they at a mission's planning stage, during its operation, or in its immediate or long-term aftermath. In weighing the risks of a mission that may involve radiation doses to its participants, a com-

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--> mander must somehow quantify not only the immediate and long-term effects of radiation, but also the risks of alternative, radiation-free, approaches to the same mission. To do this, a commander must have information that is understandable and useful. The components of the committee's framework should apply, therefore, in all instances of exposure of military personnel to hazards, during times of war and during times of peace. The committee commends the Office of the U.S. Army Surgeon General for the steps it has taken to protect American soldiers. The committee offers a framework to help ensure that soldiers are not put in harm's way without adequate justification; that, when such exposure is deemed necessary, commanders have the information and training necessary to act to limit its extent; and that government agencies work together in a committed, appropriate way to follow-up the health status of those individuals who are at risk of related long-term consequences. These tasks certainly are not easy; without appropriate training and information, they are impossible. Fred A. Mettler, Jr., Chairman

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--> Acknowledgments The committee and staff are once again grateful to LTC Carl A. Curling (Medical, Nuclear, Biological, and Chemical Staff Officer), program officer at the Office of the U.S. Army Surgeon General, for his support of the project. Many individuals participated in the committee-organized briefings and a workshop. During these sessions, representatives from the Departments of Veterans Affairs and Defense, veterans groups, and others learned how we, as a committee, perceived the scope of our task. In turn, we learned facts, history, and what others hoped to gain from our work. We thank them all (see Appendix B for a full listing) for their contributions to the committee's work and for their efforts to protect military personnel from harm of all kinds. In addition to the staff who worked directly on this project, others at the Institute of Medicine and the National Research Council contributed to this report. We thank Sue Barron, Claudia Carl, Mike Edington, Sharon Galloway, and Linda Kilroy for their efforts. Thank you, also, to consulting editor Michael Hayes and James G. Hodge, Jr., Adjunct Professor of Law, Georgetown University, for assistance with this report. It is difficult to know where to place the next acknowledgment and what exactly to say. We wish that Christopher Johnson could have continued his excellent work with us through to the completion of the project. A little over a year ago, Chris left the Institute of Medicine upon learning that he had a brain tumor. He is at home with his family. We miss him.

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--> Radiation Unit Conversion Chart 0.001 rem = 1 mrem = 0.01 mSv     0.01 rem = 10 mrem = 0.1 mSv     0.1 rem = 100 mrem = 1 mSv = 0.001 Sv I rem = 1,000 mrem = 10 mSv = 0.01 Sv 10 rem =   = 100 mSv = 0.1 Sv 100 rem =   = 1,000 mSv = 1 Sv 1,000 rem =       = 10 Sv 0.001 rad = 1 mrad = 0.01 mGy     0.01 rad = 10 mrad = 0.1 mGy     0.1 rad = 100 mrad = 1 mGy = 0.001 Gy 1 rad = 1,000 mrad = 10 mGy = 0.01 Gy 10 rad =   = 100 mGy = 0.1 Gy 100 rad =   = 1,000 mGy = 1 Gy 1,000 rad =       = 10 Gy NOTE: Sievert is equivalent to rem; gray is equivalent to rad. (Radiation units are discussed in Chapter 2.)

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--> Acronyms ACE Allied Command Europe ACHRE Advisory Committee on Human Radiation Experiments AIDS Acquired immunodeficiency syndrome ALARA As low as reasonably achievable AMC Army Materiel Command ARNGUS Army National Guard of the United States ATSDR Agency for Toxic Substances and Disease Registry BEIR Biological Effects of Ionizing Radiation C kg-1 Coulombs per kilogram CFR Code of Federal Regulations cGy Centigray CT Computerized tomography DA U.S. Department of the Army DLA U.S. Defense Logistics Agency DNA Deoxyribonucleic acid DoD U.S. Department of Defense DoDI U.S. Department of Defense Instruction DOE U.S. Department of Energy DSWA Defense Special Weapons Agency (now the Defense Threat Reduction Agency) DT-236, IM-93 Specific dosimeters EPA U.S. Environmental Protection Agency

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--> FTCA Federal Torts Claims Act GM Geiger-Mueller detector Gy Gray HIV Human immunodeficiency virus HQDA Headquarters, Department of the Army IAC International Advisory Committee, International Atomic Energy Agency IAEA International Atomic Energy Agency IARC International Agency for Research on Cancer ICRP International Commission on Radiological Protection IOM Institute of Medicine IQ Intelligence quotient IRBs Institutional review boards LET Linear energy transfer LLR Low level radiation MFUA Medical Follow-up Agency mGy Milligray mrad Millirad mrem Millirem mSv Millisievert mSv y-1 Millisievert per year NATO North Atlantic Treaty Organization NBC Nuclear, biological, and chemical NCI National Cancer Institute NCRP National Council on Radiation Protection and Measurements NRC U.S. Nuclear Regulatory Commission OPRR Office for Protection from Research Risks, National Institutes of Health OTSG Office of the U.S. Army Surgeon General PTSD Posttraumatic stress disorder R Roentgen RES Radiation Exposure State SHAPE Supreme Headquarters, Allied Powers Europe SI International System of Units

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--> STANAG Standardized Agreement Sv Sievert TLD Thermoluminescent dosimeter UNSCEAR United Nations Scientific Committee on the Effects of Atomic Radiation U.S. United States USAIRDC U.S. Army Ionizing Radiation Dosimetry Center USANCA U.S. Army Nuclear and Chemical Agency USAR U.S. Army Reserve USC United States Code VA U.S. Department of Veterans Affairs wR Radiation weighting factor wT Weighting factors for tissue

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--> Contents     Radiation unit Conversion Chart   ix     Acronyms   xi     Summary   1     Historical Perspective and Rationale,   2     Radiation Physics, Radiation Biology, and Radiation Safety and Protection,   3     Recommendations from the Interim Report,   3     Ethical Framework,   7     Committee Recommendations,   10 1   Introduction   15     Background,   15     Report Layout,   18     Ethics,   19 2   Fundamentals of Radiation Safety and Protection   23     Radiation Physics,   23     Radiation Units and Measurements,   24     Sources of Radiation Exposure,   28     Radiation Dose Reduction,   29     Radiation Biology,   30     Assessment of Radiogenic Tumor Risk,   35

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--> 3   Standard Practices in Occupational Radiation Protection   42     Control Philosophy,   42     Radiation Safety Training for Occupational Exposures,   46     Records and Recordkeeping,   52     Reporting,   54 4   Current Paradigms for Radiation Protection in the U.S. Army   55     Occupational Exposure,   55     Non-Occupational Exposures up to 700 Millisievert,   57     High-Level Exposures in Nuclear War,   57     Summary of Existing Army Programs,   62 5   Army Radiation Protection and Safety Programs in Light of Civilian Standard Practices and Recommendations for Improvement   64     Review of This Committee's Interim Report,   65     Guidance on Radiation Protection,   77 6   Decisionmaking by Commanders   83     Information,   83     Justification,   84     Optimization,   85     Communication,   85 7   Follow-up of Persons with Known or Suspected Exposure to Ionizing Radiation   88     Medical Follow-Up,   90     Epidemiologic Follow-Up,   99     Psychological Effects and Their Management,   105 8   Recommendations   108     Balancing Future and Present Harm,   108     Philosophy of Radiation Protection,   109     Communicating Risk,   110     Radiation Dosimetry, Records, and Reporting,   111     Follow-Up,   111     References   113 Appendix A:   The ACE Directive,   119 Appendix B:   Participants in Committee Meetings and Workshop,   129 Appendix C:   Biographical Summaries,   133

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--> Tables TABLE S-1.   Report Recommendations,   2 TABLE S-2.   Draft (August 2, 1996) Operational Exposure Guidance for Low Level Radiation,   4 TABLE 2-1.   Comparison of Three Expressions of Dose in Biological Tissue,   26 TABLE 2-2.   Distribution of Annual Doses (1996) for Army Personnel (military and civilian) Monitored for Occupational Exposure to Radiation,   29 TABLE 2-3.   Estimated Threshold Doses for Deterministic Effects of Acute Radiation Exposure,   32 TABLE 2-4.   Excess Cancer Mortality Estimates: Lifetime Risks per 100,000 Exposed Persons,   36 TABLE 2-5.   Comparative Susceptibilities (based on percent increases in background incidence) of Different Tissues to Radiation-Induced Cancer,   39 TABLE 2-6.   Lifetime Mortality from Specific Fatal Cancer After Exposure to Low Doses at a Low Dose Rate for a Population of All Ages,   40 TABLE 3-1.   Examples of Typical Radiation Doses and Dose Limits or Reference Levels (mSv),   47 TABLE 4-1.   Draft (August 2, 1996) Operational Exposure Guidance for Low Level Radiation,   58 TABLE 4-2.   Revised, Low Level Radiation Guidance for Military Operations (draft, received May 1998),   60 TABLE 4-3.   Nuclear Radiation Exposure Status and Degree of Risk Exposure,   62

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--> Potential Radiation Exposure in Military Operations

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