Peaceful Uses of Nuclear EnergyNon-power Applications

A Public Health Perspective

Thematic Seminar on Peaceful Uses of Nuclear Energy – Vienna, Austria, 20th November 2019

Dr Emilie van Deventer

Radiation Team Leader

Department of Public Health, Environmental and Social Determinants of Health

Geneva, Switzerland

Peaceful uses of nuclear energy

Outside the nuclear power sector, nuclear and

radiation technologies are essential in medicine,

and also have industrial and research applications,

such as:

• non-destructive testing (e.g. industrial

gammagraphy), radioactive gauges (e.g.

measurement of density and liquid levels), food

irradiation, sterilization (e.g. medical devices,

blood products), treatment of effluents, security

checks, radiotracers in molecular biology, plague

and vector control (e.g. fruit flies, mosquitoes),

This presentation will focus on medical use of radiation

Early medical use of radiation

Röntgen discovered X-rays and

noted that, while it could pass

through human tissue, it could not

pass through bone or metal

Marie Curie pushed for

radiography to be used

to treat wounded

soldiers in World War I

Outline

• Introduction

• Medical applications (diagnostics to therapy)

• Public health considerations

• Discussion

The World Health Organization

WHO’s objective is the attainment by all peoples

of the highest possible level of health

HEALTH

a state of complete physical,

mental and social well-

being and not merely the

absence of disease or

infirmity"

(WHO Constitution, 1948)

Sustainable Development Goals (2015-30)

The UN Member States made a commitment towards the 17

Sustainable Development Goals (SDGs) by 2030

SDG 3. Ensure healthy lives and promote well-being for all at all ages

Key Themes of WHO’s

13th General Programme of Work

2019-2023

Mission Promote Health - Keep the World Safe - Serve the Vulnerable

Strategic

Priorities

Health Coverage: 1 billion more people with health coverage

Health Emergencies: 1 billion more people made safer

Health Priorities: 1 billion lives improved

2

Modified from , Health systems financing: the path to universal coverage. Executive summary, The World Health Report,

WHO/IER//WHR/10.1, 2010

To achieve SDG3, require universal health coverage,

including financial risk protection, access to quality

essential health-care services for those in need

Priority setting and decision making by income level

Fragile states:

MOH needs to define:

Basic interventions packages

Emergency kits

Disaster planning

Priorities

Low income countries with low coverage,

Primary health care interventions, limited coverage for specialized care

MOH needs to define:

Essential interventions mainly for mother and child and vulnerable population;

Vaccination package

Priority medical devices for diagnostic and limited treatment Essential medicines , Which interventions to add, and to whom.

Middle and high income countries with medium coverage:

MOH has to define:

Package of interventions on prevention, promotion, and diagnostics, limited treatment and rehabilitation.

Need to define extension for :

Specialized NCD interventions depending on local burden of disease.

Vertical programs locally,

For specific or vulnerable populations, depending on resources.

Strong health system, Integrated –care, People-centred, Universal health coverage.

High coverage: Prevention, Diagnostic, Treatment, Rehabilitation, Palliative care, Home care

Vaccines, Medicines, Medical Devices, all interventions

For all: children, Adolescents Mothers and Ageing population

Need to define innovative more cost effective, extra services and disinvestment!

Population Coverage, financial, technological resources and health work force

Health

Syste

ms fo

r UH

C

Need to prioritize

and perform

informed decisions

is higher where

resources are

limited

Outline

• Introduction

• Medical applications (diagnostics to therapy)

• Public health considerations

• Discussion

Diagnostic

radiologyNuclear Medicine

(diagnostic and

therapeutic

applications)

Interventional

radiology

(diagnostic and

therapeutic

applications)

Radiotherapy

Diagnostics Therapy

About 4 billion/y X-ray

exams (> 10% in

children)

About 40 million/y NM

proceduresAbout 8 million/y radiation

oncology treatments

Role of radiation in health care

Diagnostic Radiology

Digital radiography is replacing film-based radiography, with

images instantly available, lower costs and facilitated access.

• Chest radiograph represents 40% of all imaging procedures (about

10% in children e.g. pneumonia diagnosis). It accounts for 13% of

the population collective dose.

Computed tomography (CT) allows for a fast assessment of

illness and injury, often replacing less accurate or more invasive

diagnostic procedures.

• It represents 6% of all medical imaging procedures and accounts

for 43% of the population collective dose.

• Fluoroscopy generates real-time images,

shows organ motion, allows following the

movement of contrast media and radiopaque

objects (e.g. bladder and gastrointestinal tract

studies, orthopaedic procedures).

• Fluoroscopy is increasingly used for guiding

interventional procedures.

• Biopsies, fluid drainages and tube placing.

• More complex image-guided interventions through catheters

inserted in various organs of the cardiovascular,

gastrointestinal, hepatobiliary, genitourinary, respiratory and

central nervous systems (e.g. angiography, angioplasty, stent

placing,).

• Complex interventions may be lengthy and may

result in high radiation doses.

14

Diagnostic RadiologyFluoroscopically guided interventions

Nuclear medicine diagnosis

Diagnostic nuclear medicine uses radioactive tracers

(e.g. radioisotopes or radiolabeled pharmaceutical

products) to visualize organs (heart, brain, tumours, ..)

and provide information on diseases (cardiovascular

diseases, dementia, cancer,..)

Gamma emitters are administered through injection,

inhalation or ingestion, and the emitted radiation is

detected by a g camera which converts into a digital

format.

NM imaging can be performed by using planar gamma

cameras, single photon emission computed

tomography (SPECT) and positron emission

tomography (PET), and now hybrid imaging e.g.

PET/CT, SPECT/CT, PET/MRI).

Bone scintigraphy

(Technesium-99m)

SPECT

(Thallium-201)

myocardial

perfusion

PET-CT scan with Fluorine-18

deoxyglucose (18F-FDG)

(18F has a half-life of 109.8 min and

therefore must be produced in a cyclotron

placed very close to the PET scanner)

Radionuclide therapy

Radionuclide therapy uses beta- and alpha- emitters

that accumulate in a tissue and can selectively destroy

specific targets (e.g. cancer cells).

✓ benign thyroid disease or thyroid cancer using iodine-

131

✓ bone metastasis with labelled bone-seeking agents (e.g.

radium-223, strontium-89 and samarium-153)

✓ non-Hodgkin lymphoma using radiolabeled antibodies

(i.e. radioimmunotherapy) for (e.g. yttrium-90 and

lutetium-177)

✓ neuroblastomas in children and young adults using

iodine-131 mIBG

✓ liver cancer with radiolabeled resin and glass

microspheres (e.g. yttrium-90)

• Theranostics combines the diagnostic properties of

gamma-emitters with the use of beta- and alpha-

emitters for therapy. 16

External Beam Radiotherapy (EBRT)

EBRT plays an essential role in cancer treatment. It most often uses

photon beams (e.g. X-rays from linear accelerators/ LINACs, Co-60

gamma rays from telecobalt therapy units. EBRT is usually delivered as

fractionated treatments repeated once per weekday for several weeks,

depending on the clinical protocol.

Advanced technology allows today delivering EBRT in a more precise way,

(e.g. 3-D conformal RT, intensity-modulated RT /IMRT, image-guided RT

(IGRT). Stereotactic radiosurgery can be used to treat small tumors with

well-defined edges (e.g GammaKnife for brain tumours), usually in one

single session.

Use of heavy-particles, in particular protons shows clinical advantages,

specially for pediatric tumours. New proton therapy centers are being

installed in high- and even middle-income countries, but are very costly.

17

Internal radionuclide therapy (Brachytherapy)

Brachytherapy (BT) uses sealed radioactive sources in

close proximity to the tissues, in different configurations,

e.g.:

• surface plaques or molds (e.g. eye and skin cancer);

• sources inside body cavities (i.e. gynecological cancers);

• intraluminal sources (e.g. esophagus cancer);

• interstitial sources as needles, wires or seeds (e.g. soft tissue

cancers, breast cancer, prostate cancer);

• It is becoming a main means of treatment as they give less

overall radiation to the body, are more localized and cost-

effective

Outline

• Introduction

• Medical applications (diagnostics to therapy)

• Public health considerations

• Discussion

The public health perspectiveGlobal causes of premature deaths

http://vizhub.healthdata.org/gbd-compare/

Causes of premature deaths(Sub-Saharan Africa)

Causes of premature deaths(Austria)

Radiation technology for cancer patient care

Outline

• Introduction

• Medical applications (diagnostics to therapy)

• Public health considerations

• Discussion

Medical use of radiation

• The clinical value of the use of radiation

in radiology is unquestionable: it saves

lives

• Exciting times with many novel

technologies

• Complex medical interventions that need

o Sophisticated infrastructures

o Equipment with adequate QC

(maintenance, calibration, waste

management, …)

o Educated and highly-skilled staff

Skilled workforce for NM

• Nuclear medicine physicians

• Nuclear medicine

technologists

• Radiologists (hybrid imaging)

• Radiographers (hybrid

imaging)

• Medical physics experts

• Biomedical engineers

• Radiopharmacists,

radiochemists

• Nurses, assistants

• IT support, AI engineers, …

Medical use of radiation

Inappropriate or unskilled use may result in unnecessary

exposures, increasing risk without adding any benefit.

A major challenge: to minimize health risks while maximizing

the benefits.

Benefits outweigh the risks when the procedures are

appropriately prescribed and properly performed.

Medical use of radiation

System of radiation protection (justification, optimization, …)

• Justification of procedures:

• While most LMICs cannot provide access to the necessary radiological

medical procedures, high-income countries are facing the challenge of

overuse. It was reported that about 30% of the radiological imaging

procedures are not justified (i.e. do not provide a net benefit)

• Optimization of protection: Optimization of protection in medical exposures

requires the management of the radiation dose to the patient to be

commensurate with the medical purpose

Adverse effects in interventional radiology

• Fluoroscopy-guided interventional procedures are now routinely used and doses to patients and staff may be significant.

• Adverse effects are being increasingly reported in patients (e.g. skin injuries). Need to monitor patient dose in real time and implement clinical follow-up of high-dose patients.

• A higher prevalence of cataract has been reported in staff working in catheterization laboratories, associated to exposure of the lens of the eye. Need to ensure dose monitoring, suitable shielding and personal protective equipment (e.g. lead glasses).

WHO’s norms and guidance on radiopharmaceuticals

1. The International Pharmacopoeia

▪ Source material for reference or adaptation by Member States wishing to establish pharmaceutical requirements.

▪ The pharmacopoeia, or any part of it, shall have legal status, whenever a national or regional authority expressly introduces it into appropriate legislation.

▪ It is free for use by WHO Member States http://apps.who.int/phint/en/p/about/

2. Good Manufacturing Practices (GMPs)

▪ WHO-IAEA guidelines for radiopharmaceutical products, providing a general overview of GMP requirements.

▪ Linked to main principles of GMP, i.e. pharmaceutical products and sterile pharmaceutical products

▪ Unless otherwise specified, GMP requirements for radiopharmaceuticals take precedence over GMP requirements for pharmaceutical products

International Radiation Basic Safety Standards (BSS)

• Global benchmark for radiation safety, cosponsored by 8

international organizations.

• Safety requirements on medical exposures are

substantially expanded in the latest BSS

• Safety guide to support the implementation of BSS safety

requirements in medicine (co-sponsored by IAEA, PAHO,

WHO and ILO).

• WHO cooperates with the IAEA to support the

implementation of the BSS in medical facilities.

Bonn Call for Action10 actions to improve radiation protection in medicine

Conclusions

• Medical applications of nuclear energy for diagnosis and treatment

provide very successful procedures

• It is important to ensure reliable supply of radioisotopes

• Quality and safety of the procedures are key, which requires a trained

workforce

• Some relevant Sustainable Development Goals

• SDG target 3.4 to reduce by one-third by 2030 premature deaths from

NCDs, primarily cardiovascular disease, cancers, diabetes and chronic

respiratory diseases

• SDG target 3.8 to achieve universal health coverage.

Thanks to • Maria Perez, Radiation Programme, Public Health, Environmental

and Social Determinants of Health• Elena Fidarova, Management of Noncommunicable Diseases• Sabine Kopp, Technologies Standards and Norms• Adriana Velazquez, Innovation, Access and Use

World Health OrganizationGeneva Switzerland