Most countries use in medicine, manufacturing, and research radioisotopes, which are naturally- or artificially-produced radioactive isotopes of elements such as cobalt, cesium or iridium. Users of radioisotopes are supposed to adhere to radiation-safety and radiation-security standards created by standards-setting bodies such as the International Atomic Energy Agency (IAEA) (http://www.iaea.org/), and undergo regular inspections to determine their compliance with the standards.
Patient receiving teletherapy treatment to the face/head with a teletherapy unit.
Source: http://www.biochem.szote.u-szeged.hu/astrojan/onko…. Accessed July 8, 2005.
Serious radiation incidents nevertheless have occurred when sealed, radioisotope-containing sources have been damaged, lost, stolen, or abandoned (so-called “orphan sources”), which has happened at least 15 times worldwide between 1981 and 2000, according to one source (see table below). (1) Usually, orphan sources turn out to be commercial materials, most often abandoned medical supplies or radioactive metals that have been blended with scrap for recycling. In the table below, “teletherapy” is radiation therapy administered at a distance from the body, and “brachytherapy” is radiotherapy in which the source of irradiation is placed close to the surface of the body or within a body cavity as for prostate cancer. The Goiania, Brazil, radiation disaster is bolded.
Diagram of cobalt-60 teletherapy unit.
Source: http://www.nrc.gov/reading-rm/doc-collections/nure…. Accessed July 8, 2005.
1. Goiania Cesium Radiation Dispersal Disaster
The cesium-137 radiation-dispersal disaster in 1987 occurred in Goiania, a city of one million residents in the center of Brazil known for its cereal farms and cattle ranches. Relatively unknown to most people, this disaster has been carefully assessed and documented by the IAEA in a 150-page case study available online. (2) The following summary of the disaster is drawn from this fine report. The management of this radiation crisis is a remarkable testament to human beings’ ingenuity, efficiency, and tenacity in a serious regional crisis. As you read the following summary, keep in mind that the local society was able to diagnose and contain the radiation epidemic in just five days (September 28 to October 3) following suspicion by one or two authorities. Cesium has a half life of 30 years.
The dilapidated radiotherapy unit in Goiania from which the cesium source was taken.
Source: “The Radiological Accident in Goiania,” International Atomic Energy Agency, Vienna, 1988, p. 95. Available online at: http://www-pub.iaea.org/MTCD/publications/PDF/Pub8….
In 1985 a new partnership took over a private radiotherapy institute in Goiania, Brazil. This institute was originally built in 1971 by a medical partnership (Instituto Goianoa de Radioterapia or IGR) and subsequently licensed in 1971 by Brazil’s National Nuclear Energy Commission (CNEN). The new partnership removed a cobalt-60 teletherapy unit to a new clinic location but left thecesium-137 teletherapy unit in place because of a legal dispute over the contents of the IGR clinic. Much of the 1971 IGR clinic was demolished, but the cesium teletherapy unit and treatment room in which it was installed remained relatively intact. The CNEN received no notification of the change of ownership or demolition as required under the terms of the license issued in 1971.
Close-up of structure in Photo C, p. 95.
On September 10-13, 1987, “R.A.” heard rumors that valuable equipment had been left in the disused IGR clinic. He and a friend, “W.P.”, dismantled the teletherapy unit, which contained a sealed but “hot” source of cesium-137 (unbeknownst to them), and transported it by wheelbarrow to R.A.’s house. “From the moment they removed the rotating assembly, they would potentially have been exposed to the direct beam, as they would have been if they had rotated the source wheel into the ‘on’ position while it was still in the radiation head.” (p. 23) R.A. placed the rotating assembly under a mango tree in his garden.
On September 13-15, 1987, both men were vomiting, had diarrhea, and felt dizzy, and W.P.’s hand was swollen and burned where he had placed his hand over the cesium beam opening. W.P. upon medical examination at a clinic he visited was diagnosed with some kind of allergic reaction caused by eating bad food.
On September 18, 1987, R.A. managed with a screwdriver to puncture the 1 mm thick window of the source capsule containing the cesium, and tried to light the powder inside thinking it might be gunpowder. He then sold the pieces of the rotating assembly to junkyard owner “D.F.” who noticed a blue glow emanating from the source capsule at night, which he thought “looked pretty” and might be “valuable” or even “supernatural.” He took the source capsule into his family’s house where, over the next three days, neighbors, relatives and acquaintances visited the capsule and fragments were distributed with which some people daubed their skin, “as with the glitter used at carnival time.” (p. 24) D.F.’s wife, “M.F.1” (who eventually died from acute radiation syndrome) became ill with vomiting and diarrhea, but her diagnosis, like that of W.P.’s, was an allergic reaction to bad food. Her mother visited for awhile to provide care and then returned some distance from Goiania taking a significant amount of contamination with her.
September 22-24, 1987, employees at the junkyard extracted the lead from the rotating assembly. W.P., increasingly ill, was admitted to Santa Maria Hospital where he stayed for four days. His skin effects of radiation exposure were diagnosed as some kind of tropical disease, whereupon he was transferred to the Tropical Diseases Hospital. Meanwhile, a six-year old daughter (who eventually died) of the brother of junkyard owner D.F., ate while handling cesium fragments brought into her house. D.F. sold the lead and the remnants of the source assembly to the owner of another junkyard.
By September 28, 1987, approximately two weeks from the time that the two men dismantled the source capsule from the IGR cesium-137 teletherapy unit, many people had become ill following exposure to the hitherto unknown substance. M.F.1, convinced that the glowing powder was killing her and her family, placed it in a bag, and transported it by bus to the public health department called Vigilancia Sanitaria, and plopped it on the desk of “Dr. P.M.” who removed it to a chair in the courtyard. The chair was next to a six-foot tall external wall, which will become important later. M.F.1 and a friend were then admitted to the Tropical Diseases Hospital. There a “Dr. R.P.” first suspected that all the patients who had ended up at the Tropical Diseases Hospital had been damaged by radiation. He contacted a “Dr. A.M.”, who had been contacted independently by Dr. P.M. (at Vigilancia Sanitaria) about source capsule remnants in the bag in his courtyard. Drs. R.P. and A.M. contacted a “Dr. J.P.” at the Department of the Environment of Goias state, who proposed that they have a medical physicist, W.F., examine the suspicious package.
At 8 a.m. on September 29, 1987, W.F., the medical physicist, borrowed a dose rate monitor from a company prospecting for uranium to make measurements around the suspicious package at the Vigilancia Sanitaria. The scintillation detector, which is very sensitive for geological measurements, immediately deflected full scale irrespective of the direction W.F. pointed it while he was still some distance away.
10:20 a.m.: Thinking the meter was defective, W.F., the medical physicist, returned to the uranium prospecting company to fetch a replacement meter, which he turned on immediately to find that there was a major source of radiation in the vicinity. Meanwhile, Dr. P.M., the public health doctor onto whose desk M.F.1. had plopped the source capsule a day earlier, had called the fire brigade, which W.F. intercepted just as the brigade was making ready to throw the source capsule into a river.
11:00 a.m.: W.F. and Dr. P.M. alerted the police and fire brigade to start evacuating the area.
13:00 p.m.:W.F. and others paid a visit to the Secretary for Health of Goias State “to inform the authorities of the incident and its significance and to obtain further assistance…The officials were incredulous of the account of the incident and the assessment of the potential scale of the evacuation necessary. The officials took some persuading that the matter was important enough to warrant the attention of the Secretary for Health. W.F. and others persevered, and were eventually permitted to see him and apprised him of the seriousness of the situation.” (p. 28)
15:00 p.m.: The director of the Department of Nuclear Installations at CNEN suggested contacting the licensed physicist and the physician from the IGR to help identify the radioactive material and manage the response. The former IGR medical director concluded that the dispersal of the radioactive source occurred so easily that it could NOT have been cobalt, which is a metal, and that it was therefore probably cesium in the form of the salt cesium chloride. The staff tentatively identified the source as possibly originating from the IGR disused clinic. The IGR director was deputized deputy coordinator for nuclear emergencies, or “deputy NEC”.
Goiania Olympic stadium where screening for cesium radiation exposure was performed.
16:00 p.m. – 20:00 p.m.: The Goias State Secretary for Health opened the city’s Olympic stadium as a staging area for isolating patients and screening others for contamination. The Tropical Diseases Hospital, police, fire, and civil defense staff were alerted. A resurvey of the Vigilancia Sanitaria and the junkyard (the two main areas of contamination known at the time—there were eventually four main areas of contamination identified) were resurveyed. The press got wind of the incident. “The time spent answering their queries was a constant drain on the resources that were available to bring the situation under control,” said the IAEA report (p. 36). They needed a public information officer.
Example of a bulla (or blister) on the hand of a patient exposed to the cesium radiation.
Source: “The Radiological Accident in Goiania,” International Atomic Energy Agency, Vienna, 1988, p. 109. Available online at: http://www-pub.iaea.org/MTCD/publications/PDF/Pub8….
22:00 p.m.: A junkyard employee found medical physicist W.F. and explained how the source assembly had been broken up and where the pieces had been taken. This enabled the monitoring team to identify more of the sites of major contamination and to evacuate more contaminated persons.
During the night of September 29-30, 1987, Dr. R.P., the original physician from the Tropical Diseases Hospital who had first recognized the possibility that overexposure to radiation had caused the symptoms of the patients he was seeing, identified 22 radiation-exposed people at the stadium. They were put into tents separately from the others based on:
1) contamination measurements,
2) medical symptoms, and
3) family groupings at the sites of major contamination.
Those persons with lesions or severe symptoms were sent to the Tropical Diseases Hospital to join the 11 radiation-exposed patients already there.
At 00:30 a.m . on September 30, 1987,a lead nuclear emergency team from Rio de Janeiro arrived in Goiania and went first to the derelict IGR clinic. Finding no sign of a radioactive source and no trace of contamination, the team proceeded to the Vigilancia Sanitaria and subsequently to the other key places. They confirmed the location of the source remnants in a bag on the chair in the courtyard. W.F., the original medical physicist, worked with the authorities to evacuate residents form areas where the dose rate exceeded a certain very low threshold.
Meanwhile, CNEN personnel at the Olympic stadium directed that all contaminated persons take showers, having found that no attempt had been made to decontaminate them for fear of contaminating the water. Clothes were placed in bags. Additionally, “The physicists set up contamination monitoring equipment to screen the hundreds of people who had heard about the incident and were waiting at the stadium to be checked.” (p. 34)
To deal with the source remnants remaining on the chair in the courtyard, a small crane lifted a section of sewer pipe over the six-foot wall of the courtyard and lowered it over the chair. Concrete was then pumped over the wall and into the pipe, filling it and covering the chair and the source remnants. As a result, the dose rates in the surrounding area were significantly reduced, and since contamination was not a major problem at this site, much of the area cordoned off could be reopened. This operation was completed by early afternoon September 30, 1987.
Before cleanup began, the deputy NEC insisted on making a thorough, well-documented survey of contamination levels, which he learned from a quick reading of a report of a similar incident in Mexico in 1983. Record keeping was possible only on the third day, since workers were overburdened with surveying and training others in screening for contamination. At this point the need for administrative support for the technical staff was recognized. All personnel were housed in a hotel about two kilometers from the contaminated area, which contributed to the efficiency of the operation.
By October 3, 1987, the monitoring team at the stadium had identified 249 people with detectable contamination. Those with external contamination only were readily decontaminated, but 129 people were found also to have internal contamination and were referred for medical care. Maps that had been requested on September 30 arrived on October 2, 1987, and all hot spots received marks. Residents in areas where dose rates were in excess of a threshold were evacuated by October 3. Also by October 3, 1987, ten of the hospitalized patients were transferred to Marcilio Dias Naval Hospital in Rio de Janeiro. The criteria used for transfer were medial history, prodromal signs and symptoms, the time to the onset of vomiting and the number of episodes, the severity of skin lesions, and gross estimations of body content of radioactive cesium based on radiological survey. (p. 43)
Marcilio Dias Naval Hospital in Rio de Janeiro: where the sickest radiation syndrome patients were transferred.
2. The Medical Response to theGoiania Cesium Radiation Dispersal Disaster
The medical consequences of the cesium radiation dispersal disaster in Goiania were serious: four people died of whole body irradiation and the ensuing acute radiation syndrome. Others had severe radiation burns. In general, the incident produced casualties that incurred initial acute whole body external exposures followed by chronic whole body exposure at low dose rates from the internally-deposited cesium 137.
An interesting feature of the Goiania accident was the extensive use of Prussian Blue for the first time ever in a radiation accident. Of note is that the U.S. Food and Drug Administration approved Prussian Blue, known as Radiogardase® and manufactured by HEYL Chemisch-pharmazeutische Fabrik GmbH & Co. KG, on October 2, 2003, 16 years after its use in Goiania.) The stocks of Prussian Blue needed to treat the patients were in jeopardy of depletion. As a result, the Federal Republic of Germany sent additional supplies.
Doctors and nurses placed all patients on a single ward where their medical histories were obtained followed by physical examination. All patients were initially considered to be suffering from the acute radiation syndrome or from minor to extensive radiation-induced skin lesions, and from external and internal cesium-137 contamination. Samples of blood, urine and feces were obtained from each of the patients and internal contamination with cesium-137 confirmed by gross counting of urine and fecal samples. “Skin decontamination was performed on all patients using mild soap and water, acetic acid and titanium dioxide. Decontamination was only partially successful since sweating resulted in recontamination of the skin from internally deposited cesium-137.” (p. 43)
Staffing the hospital was challenging but completed by October 7, 1987. There was fear for personal health by laboratorians and medical staff, but two attending physicians were able to allay this fear with information and informal instruction. The general medical community in Goiania was reluctant to help, according to the IAEA report One physician from the hospital staff joined the medical team.
The emergency treatment of exposed patients had four goals:
1. Managing the critical period of the acute radiation syndrome, manifested by bone marrow depression (low counts of white blood cells—especially lymphocytes, red blood cells, and platelets).
2. Treating local radiation injury.
3. Decorporation of cesium-137 from the body.
4. General support and psychotherapy. (p. 44)
The basic medical handling of the patients consisted of the following:
1. Accommodation in rooms with reverse isolation.
2. Diets without raw vegetables or uncooked food.
3. Nail trimming and scrubbing.
4. Local neomycin in the nasal cavities.
5. Gut sterilization if the concentration of neutrophils was less than a threshold, with oral trimethoprim/sulphamethoxazole and nystatin.
6. Systemic administration of antibiotics for fever greater than 38.5 degrees Centigrade or other signs of infection in a granulocytic patients; empirical antibiotic regimen consisted of intravenous gentamicin, cephalothin and carbenicillin, changed to cefoperazone, imipenem and/or piperacillin as a result of the evolution and/or cultures; persons with persistent fever for more than 48-72 hours received amphotericin B.
7. Administration of irradiated red packed cells and platelet infusions to maintain hemoglobin and platelet levels, or whenever bleeding occurred in a patient with a low platelet count.
8. Acyclovir, commencing about three weeks after radiation exposure, to prevent the activation of herpes virus.
9. Antihelminths, such as mebendazole and thiabendazole, according to the results of stool examinations or empirically (eosinophilia).
No patient required bone marrow transfusion.
To accelerate decorporation of internal cesium, which became a management problem because patients continuously sweat cesium, staff administered Prussian Blue by mouth to 46 persons with internal cesium deposits. Increasing the dose of Prussian Blue resulted in higher radioactivities in fecal samples (this was good). So the of the Prussian Blue dose was increased to expedite the decorporation of cesium-137. Staff had to collect all bodily excreta and fluids and save them for analysis for three months to make sure that they were not being exposed to too much radiation.
Autopsies of the four fatalities showed evidence of gross bleeding tendency and septicemia from infection.
3. Other Sections of the IAEA Report
The IAEA has a well-written and informative section on Dosimetry (pp. 51-60), which includes: 1. internal dosimetry by bioassay and whole body monitoring; 2. cytogenetics: estimation of doses by chromosomal aberration analysis; and 3. external dosimetry: dose estimates from reconstructions and on the basis of radiation effects. In addition, the report covers in great detail Environmental Assessment, Decontamination, and Waste Disposal, which are beyond the scope of this Biot.
Editor’s Note: The Goiania Orphaned Medical Cesium Dispersal Disaster provides a solid case study for local management of radiological dispersal device (“dirty bomb”) detonation by terrorists. Radiological incidents have been infrequent occurrences given the number of radioactive sources in use in various industries around the world. The rarity of accidents probably bears witness to the effectiveness of the safety regulations and security measures in force. But, as the IAEA report says in its Foreword, “”The fact that accidents are uncommon should not…give grounds for complacency. No radiological accident is acceptable, and one that threatens widespread contamination is bound to alarm a public that has not yet come to terms with radioactivity.”
1. “Two Decades of Radiological Accidents Direct Causes, Roots Causes and Consequences” by Jose de Julio Rozental in “Radiation Safety and Regulation.” Brazilian Archives of Biology and Technology 2002. Online at: http://www.scielo.br/scielo.php?script=sci_arttext…. Accessed July 7, 2005.
2. “The Radiological Accident in Goiania,” International Atomic Energy Agency, Vienna, 1988. Available online at: http://www-pub.iaea.org/MTCD/publications/PDF/Pub8…. Accessed July 8, 2005.
3. “Questions and Answers on Prussian Blue” authored by the FDA at the Heyltex website (manufacturer of Prussian Blue capsules). See http://www.heyltex.com/qanda.html#1.
*Additional website for more IAEA radiation disaster incident reports, including the ones in Table 1 above, available at: http://www-pub.iaea.org/MTCD/publications/accres.a… . Accessed July 8, 2005.