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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.
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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
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.
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-
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
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
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
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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Tables
TABLE S-1. |
Report Recommendations, |
|||
TABLE S-2. |
Draft (August 2, 1996) Operational Exposure Guidance for Low Level Radiation, |
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TABLE 2-1. |
Comparison of Three Expressions of Dose in Biological Tissue, |
|||
TABLE 2-2. |
Distribution of Annual Doses (1996) for Army Personnel (military and civilian) Monitored for Occupational Exposure to Radiation, |
|||
TABLE 2-3. |
Estimated Threshold Doses for Deterministic Effects of Acute Radiation Exposure, |
|||
TABLE 2-4. |
Excess Cancer Mortality Estimates: Lifetime Risks per 100,000 Exposed Persons, |
|||
TABLE 2-5. |
Comparative Susceptibilities (based on percent increases in background incidence) of Different Tissues to Radiation-Induced Cancer, |
|||
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, |
|||
TABLE 3-1. |
Examples of Typical Radiation Doses and Dose Limits or Reference Levels (mSv), |
|||
TABLE 4-1. |
Draft (August 2, 1996) Operational Exposure Guidance for Low Level Radiation, |
|||
TABLE 4-2. |
Revised, Low Level Radiation Guidance for Military Operations (draft, received May 1998), |
|||
TABLE 4-3. |
Nuclear Radiation Exposure Status and Degree of Risk Exposure, |
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