|8th Coordination Meeting of World Health Organization Collaborating Centres in Radiation Emergency Medical Preparedness and Assistance Network, REMPAN (WHO - OMS, 2002, 145 p.)|
World Health Organization, Avenue Appia, CH-1211 Geneva 27, Switzerland
The 7th REMPAN meeting was held in Rio-de-Janeiro, Brazil, from 9 to 14 November 1997. Recommendations of this meeting were focused on further strengthening of REMPAN activities at the global level, which are coordinated by WHO/HQ, and at the regional and local levels, coordinated by WHO/ROs and REMPAN centres. My presentation is dealing with the global part of REMPAN activities, which have been initiated by WHO/HQ and carried out in co-operation with WHO/ROs and REMPAN in the last two years with the use of recommendations of the 7th REMPAN meeting. These activities were focused on the following:
· Development of REMPAN infrastructure
· Response to radiological emergencies
· Organizing exercises
· Promotion of training
· Distribution of information about REMPAN
· Follow-up of people affected by the Chernobyl accident
In addition, the 7th REMPAN meeting recommended:
· to establish a radiation emergency fund (WHO/HQ), and
· to discuss responsibilities of REMPAN in case of medical overexposure.
These items have also been in the field of vision of WHO.
Now, let's review some details in progress of the above mentioned WHO/REMPAN activities.
1. Development of REMPAN infrastructure
Activities in this field have been focused on the following:
· Revision of WHO/REMPAN collaborating centres
· Strengthening cooperation between WHO/HQ and WHO/Regional offices for better coordination of REMPAN
· Preparation of basic documents
· Development of policies on the formation and use of an international database
In 1999 - 2000, REMPAN included 14 WHO collaborating centres located in Armenia, Australia, Brazil, France, Germany, Japan, the Russian Federation, United Kingdom, Ukraine and the USA. The Centre in Argentina was not redesigned as a WHO/REMPAN collaborating Centre. The Centre in the Central Roentgen Radiological Institution in St. Petersburg has also changed its activities and now they are not relevant to REMPAN activities. The REMPAN centre in the USA was redesigned with an additional item in its terms of reference related to public health actions. The REMPAN centre in Ulm was redesigned. However, due to reorganization of the German national REMPAN system, the structure of the WHO/REMPAN centre in Ulm may be changed in order to include under its umbrella some other German institutions. As a result of negotiations between WHO and representatives of REMPAN centre in France, its structure includes Institute Curie, Institute of Radiation Protection, and Office of Radiation Protection.
WHO held three internal meetings in order to discuss approaches for further development of co-ordination of REMPAN activities from a position of a current policy of "One WHO". Due to these discussions, WHO/HQ continues its coordination role regarding the whole spectrum of REMPAN activities. In parallel, WHO/HQ is a focal point for medical aspects of REMPAN functions. Regarding public health activities within REMPAN, many aspects are not yet clear and the presented scheme in some cases is a hypothetical one. The responsibility for developing REMPAN activities related to protecting public health in Europe was delegated to the REMPAN centre in Finland, and in the Americas to the REMPAN centre in the USA. It was also recommended to establish one centre with the same functions in Western Pacific Asia. The centre in Finland was defined as a methodological centre on radiation emergency public health actions at a global level. The hypothetical part of this scheme includes the REMPAN centre for WPRO and SEARO and communication pathways between the Finish Centre and AFRO and EMRO. These aspects are subjects for discussion.
One of the important aspects in the functioning of REMPAN at a global level is the coordination of its activities with other relevant international organizations. In this context, WHO collaborates closely with IAEA. Areas of WHO-IAEA mutual interests in the field of radiation protection in general and in REMPAN activities, in particular, have been discussed at regular meetings between these two Organizations. In the framework of WHO-IAEA collaborative activities, IAEA invited WHO to assist in the development of the IAEA performance requirements manual for the emergency response network. The establishment of this IAEA network is in progress and Mr Crick will provide more information on this subject. My intention is to draw your attention on how WHO and IAEA consider a cooperation between WHO/REMPAN and IAEA emergency response network. According to IAEA plans, this network will include radiological emergency response teams and medical emergency response teams. In some cases the formation of the IAEA medical emergency teams may be on the basis of WHO/REMPAN centres. These teams are designed to work in a site of a radiation emergency in order to evaluate medical consequences, to advise local medical staff and health authorities on medical monitoring of overexposed people, and consult medical care to radiation victims if needed. The in-depth diagnosis, treatment, rehabilitation and follow-up of overexposed persons are addressed under the framework of WHO/REMPAN.
The harmonization of radiation emergency response, including medical and public health response, at international level, was a subject for discussion, initiated by IAEA, at a meeting of the Inter-Agency Committee for Response to Nuclear Accidents (Geneva, 1999). WHO participated in this meeting as a member of the Committee and approved the IAEA proposal to develop a Joint Radiation Emergency Response Plan of International Organizations (JPLAN). Due to this, REMPAN collaborating centres, as a technical tool of WHO, have been associated an important role in JPLAN coordinated by IAEA, via WHO/HQ.
WHO-IAEA cooperation has also resulted in the development of a number of publications for global use and also in order to strengthen the REMPAN infrastructure. These following joint documents were published by the IAEA (Vienna) in 1998:
· IAEA-WHO - Diagnosis and Treatment of Radiation Injuries (Safety Report No 2)
· IAEA-WHO - Planning the Medical Response to Radiological Accidents (SR No 4)
· IAEA-ILO-WHO - Health Surveillance of Persons Occupationally Exposed to Ionizing Radiation (Safety Report No 5)
Several IAEA-WHO documents are in preparation for publication. These include:
· Safety Requirements on Preparedness and Response for a Nuclear or Radiological Emergency
· Safety Quide on Safety of Radiation Sources
· Radiological Accident in Lilo, Georgia
WHO has also cooperated with IAEA in developing the Guidelines for iodine prophylaxis following nuclear accidents. However, due to some differences between the procedures of approval of guidance documents by the two organizations. This document has been recently issued on behalf of WHO only, in order to collect more comments from specialists.
The 7th REMPAN meeting recommended to develop polices on the formation and use of an international database on signs and symptoms of radiation injuries. This database, as you are aware, has been established in the REMPAN centre in Ulm, Germany, in cooperation with REMPAN collaborating centres in the Institute of Biophysics (Moscow, Russia), Research Centre of Radiation Medicine (Ukraine), Ural Centre of Radiation Medicine (Chelyabinsk, Russia), Institut Curie (France) and some other relevant institutions. At present, the database includes about 800 case histories of individuals that were exposed to radiation in 70 accidents in 17 different countries. Dr Fliedner, Director of the REMPAN centre in Germany, will provide more information about this database. I would like to draw your attention to what has been done in order to follow the recommendation of the 7th meeting regarding policies on the formation and use of an international database. This matter was discussed between Dr Fliedner and WHO and it was suggested to hold a meeting in Ulm of key representatives of the REMPAN in order to prepare the agreement on the management of the database. However, because a period of reorganization of a national REMPAN system in Germany has not been finished yet, the final decision regarding the meeting has not been taken and it is now under discussion between Dr Fliedner and the German Ministry of Health.
2. REMPAN response to recent radiological emergencies
Since the 7th REMPAN meeting there were four radiological accidents, which caused radiation injuries in people. These accidents occurred in:
· Turkey, 13 December 1998. Ten patients developed Acute Radiation Syndrome (Co-60)
· Peru, 20 February 1999. One patient developed severe local injury (Ir-192)
· Japan, 30 September 1999. Three workers were overexposed due to a criticality accident
· Thailand, February 2000. Ten persons were hospitalized due to exposure to radiation of Co-60
Medical consequences of these accidents and details on medical monitoring of affected persons will be discussed later in our meeting. Here I would like to mention only about the response of members of REMPAN on these accidents. In the framework of Assistance Convention and in close cooperation with IAEA, representatives of REMPAN members in France, UK, Japan and the USA were included in IAEA emergency medical teams. Due to decision of local health authorities all overexposed persons were treated in national hospitals except the patient in Peru who was transported to France for surgical treatment of a very severe local injury. REMPAN members in Germany and Russia informed WHO about their readiness to send medical specialists to these countries where the accidents occurred in order to assist local doctors in the treatment of radiation victims. During the acute phase of these accidents, all REMPAN centres were kept informed by the WHO/REMPAN-Coordinator about every progress in monitoring medical consequences of the accidents.
Communication tests via e-mail or fax have been periodically organized by the REMPAN-Coordinator. As a result of these tests, the WHO directory of communication links between WHO/HQ and REMPAN members was improved.
WHO/HQ and its Regional Offices in Europe and the Americas together with REMPAN collaborating centres in Finland, Brazil and the USA took part in the international exercise INEX-2 organized by NEA/OECD. The communication links during the exercise were established between:
i. WHO/HQ and Regional Offices in Europe and the Americas
ii. EURO and REMPAN centre in Finland
iii. AMRO and REMPAN centres in the USA and Brazil
iv. EURO and AMRO
v. REMPAN centres in Finland and the USA (regarding public health actions)
In addition to WHO staff, whose responsibilities are directly related to radiation protection, other relevant WHO units, primarily emergency departments, were involved in the INEX-2. The participation in the INEX-2 gave the opportunity to improve cooperation within the WHO framework. At present, a special system exists in WHO/HQ for distributing information about real radiation emergencies. If such information with a code word "EMERCON" is sent by IAEA to WHO through an official channel than it will be automatically distributed to all key persons at the Headquarters and WHO/ROs. A REMPAN coordinator will inform REMPAN centres.
4. Training and training materials
WHO jointly with IAEA has participated in the development of standard training programmes and modules for training material on radiation emergency medical preparedness and response. It is planned that these materials will be published by IAEA with WHO co-sponsorship on CD-ROMs and will be used/recommended for one-week courses to train mainly emergency physicians. The REMPAN collaborating centre in USA has also participated in this work. In addition, WHO co-operates with IAEA for preparing the following safety guides:
· Training in Radiation Safety and Protection
· Building Competence in Radiation Protection and for the Safe Use of Radiation Sources
As a result of cooperation between WHO/HQ, WHO/EMRO (Regional Office for the Eastern Mediterranean), WHO/REMPAN centre in the USA and IAEA, a training course on radiation emergency medical preparedness and response was organized and held in Cairo (Egypt) in November 1999.
WHO and IAEA have prepared a leaflet on "How to recognize and initially respond to an accidental radiation injury" designed primarily for education of general practitioners and other medical doctors.
5. Distribution information about REMPAN
An article on REMPAN structure, functions and activities published in the journal "Environmental Health Perspectives has been widely distributed among specialists and health authorities of WHO member states.
WHO created a home page on the Internet. General information about REMPAN and its collaborating centres is available on:
WHO concluded a contract with a REMPAN member in the UK for preparing a booklet about REMPAN. This work is in progress.
6. Follow-up of people affected by the Chernobyl accident
WHO has carried out activities in this field in close cooperation with REMPAN centres located in Russia, Ukraine, Japan, Germany, and Finland. At present, the following projects, that obtained extra-budgetary financial support, are in progress:
Medical relief for children affected by the Chernobyl accident through the development and implementation of health telematics (WHO and SMHF - Sasakawa Memorial Health Foundation, Japan);
Ultrasound screening of 100 000 children and adults of the Russian Federation who were exposed to radiation from the accident at the Chernobyl nuclear power plant for early diagnosis of thyroid diseases (WHO, OCHA/UN - Office for Coordination of Humanitarian Affairs);)
International cooperation to establish post Chernobyl NIS thyroid tissue, nucleic acid and data banks (EC, SMHF, WHO, NCI/USA - National Cancer Institute, USA).
Jointly with the REMPAN collaborating centre in Medical Radiological Research Centre in Obninsk (Russia), WHO has been preparing a monograph "Low doses of ionising radiation: Health effects and assessment of radiation risks for liquidators of the Chernobyl catastrophy".
In cooperation with the Association "Physicians of Chernobyl" and a REMPAN member in Research Centre of Radiation Medicine (Ukraine), WHO is preparing the International Conference on "Health effects of the Chernobyl accident: Results of 15 years follow-up studies". This Conference is planned to be held in Kiev in 2001.
7. Medical overexposure: the role of REMPAN
The 7th REMPAN meeting recommended to clarify REMPAN responsibilities in situations such as the one that occurred in Costa Rica due to overexposure of cancer patients during radiotherapy. This subject was discussed by WHO and IAEA at its consulting meeting on areas of collaboration in the field of radiation protection, Geneva, 1998. Participants of the meeting emphasized that in order to avoid any misunderstandings on how to consider these kind of situations in a particular case, as a radiation emergency or a medical mistake, and, hence, how to respond to them, an urgent communication link should be established between WHO/HQ, IAEA and the relevant WHO/Regional Office where such situation occurred. In addition, IAEA published a Report "Lessons learned from accidental exposures in radiotherapy" which provides useful information on this matter.
8. Radiation emergency funds
This subject was discussed at the 7th REMPAN meeting, which recommended to WHO or IAEA to establish an emergency fund. Following this recommendation, WHO and IAEA discussed this subject at its consulting meeting mentioned above and recognized the importance of this recommendation and agreed that all possibilities related to this matter should be explored. WHO doesn't have a special radiation emergency fund, instead it has a general emergency fund. More information on this matter will be given by the representative of a WHO department on Emergency and Humanitarian Actions. In order to have an idea regarding the needs for radiation emergency funds, WHO has collected data on the cost for medical treatment of radiation victims.
Thus, accordingly data presented to WHO by Dr B. Günalp, Turkey, the cost for treatment of 5 patients who developed acute radiation syndrome of moderate degree (2-4 Gy) due to the Istanbul accident, was about US$ 55,000. Dr. Nagataki and Dr Suzuki (RERF) and Dr. Maekawa (Tokyo University) have kindly provided me with information regarding the cost of treatment of radiation victims due to the Tokai-Mura criticality accident and the cost of compensation of the affected population. The cost of a 3 months treatment of patient "Y" who was exposed to radiation dose of 2.6 Gy equivalent to gamma rays, accounts to US$ 65,000. For patient "S" who was exposed 7.8 Gy equivalent to gamma, is US$ 500,000 for 6 months. The cost for 82 days treatment of a patient "O" who was exposed to radiation in the highest dose (20 Gy) was about US$ 1,200,000.
Concluding my presentation, I would like to say that REMPAN seems to me a living system, which is renewing and passing through different periods of its development. I think that a period in REMPAN's development characterized by a quantitative growth has come to an end and REMPAN is passing to its next period, which will mainly focus on the improvement of the quality of REMPAN's functioning. This way may be successful only in a case of close collaboration between all members of REMPAN and integration of REMPAN in the international infrastructure for response to radiation emergencies. However, thinking about reorganization of REMPAN we should keep in mind lessons learned by our predecessors. One of this lesson is illustrated by words written in Emperor Nero's time:
"We worked hard, but every time we started working well, new reorganisation plans were launched. Later in life, I realized that we are inclined to meet new situation through reorganisation. I also learned what a fantastic method this is, to create an illusion of progress, while in reality it causes chaos, ineffectiveness and demoralisation." (Cajus Petronius, Government Official under Emperor Nero. 66 A.C. !!!)