The Radiological accident in Goiânia

This is a presentation on the radiation accident in Goiania in 1987

1. The Radiological accident in Goi ânia Presented by_ Champak Mudoi Taushiful Hoque M.Sc. Radiological Physics , 4th Semester Gauhati University – Dr. B. Barooah Cancer Institute

2. Contents Introduction Description of the Source Chronology of the accident Discovery of the accident Initial action after the discovery Medical Responses Dosimetry Used Environmental Contamination Radiation Surveys Decontamination Disposal of the waste International Co-operation Lesson learned

3. The  Goiânia accident was a  radioactive contamination   accident that occurred on September 13, 1987, in  Goiânia , in the state of Goiás ,Brazil ,after an unsecured  radiotherapy  source was stolen from an abandoned hospital site in the city. It was subsequently handled by many people, resulting in 4 deaths. About 112,000 people were examined for radioactive contamination and 249 of them were found to have been contaminated. Introduction

4. Level of the Accident A  nuclear and radiation accident  is defined by the  International Atomic Energy Agency ( IAEA) as "an event that has led to significant consequences to people, the environment or the facility. Examples include  lethal effects to individuals INES : in order to enable prompt communication of  safety significant information in case of  nuclear accidents by IAEA in 1990 Goiania Radiation accident is the 5 INES Level of Radiation accident with wider consequences

5. Competent Authority for Nuclear Energy in Brazil The competent national authority for nuclear energy in Brazil is the National Nuclear Energy Commission (CNEN), whose President reports directly to the President of the Republic. CNEN is the regulatory authority for licensing the purchase and transport of radioactive sources It also has the responsibility and power to regulate the production, use, security and disposal of radioactive materials in their various areas of use. In the area of medical uses, both CNEN & Federal and State Health Secretaries have regulatory responsibilities.

6. Description of the Source Basic data on caesium-137 Source : CsCl - Caesium chloride Radioactivity (1971): 71 TBq (1919 Ci) Radioactivity (Sept, 1987): 50.9 TBq (1375 Ci) CsCl Mass : 93 g Cs-137 Mass : 19.3 g Gamma emissions : 0.66 MeV (84%) Beta emissions : Maximum energies : i) 0.51 MeV (95%) ii)1.17 MeV (5%) Half-life : 30 years

7. Machine Specification The teletherapy unit Make : Barazetti - Generay SpA , Italy. Model : Cesapan F-3000 , 1951 Manufactured : 1970 A wheel type radiotherapy device which has a long  collimator  to focus the radiation into a narrow beam. The caesium chloride radioactive source is the blue rectangle, and gamma rays are represented by the beam emerging from the aperture.

8. Chronology of the accident (1) the demolished clinic of the IGR; (2) removal of the rotating source assembly from an abandoned teletherapy machine by R.A. and W.P. (3) source assembly placed in R.A. 's yard near houses rented out by R.A. 's mother (4) R.A. and W.P. break up source wheel and puncture source capsule (5) R.A. sells pieces of the source assembly to Junkyard I (6) Junkyard I. the caesium chloride is fragmented and dispersed by I. S. and A.S. via public places (7) D.F. 's house: contamination is further dispersed (8) visitors and neighbours , e.g. O.F. I , are contaminated

9. Chronology of the accident (9) E.F.I and E.F 2 contaminated; (10) IF. 's house; other arrows indicate dispersion via visitors and contaminated scrap paper sent to other towns; (11) contamination is spread to Junkyard II; (12) contamination is spread to Junkyard III, (13) K. S returns to the IGR clinic to remove the rest of the teletherapy machine to Junkyard II; (14) M.F.I and G.S. take the source remnants by city bus to the Vigilancia Sanitaria; (15) contamination transferred to other towns by M.A.I. (By courtesy of CNEN, Brazil.)

10. Discovery of the accident On September 28, one of the persons irradiated, named Maria Ferreira, connected the illnesses with the source capsule and took the remnants to the public health department in the city with the help of her husband’s employee by bus. Both were admitted in the hospital and later sent to a tropical hospital because their symptoms were confused with tropical disease. A doctor suspects that the skin lesions had been caused by radiation damage and after consulting with his colleagues, decided to call in a medical physicist to look at the suspicious package. In the morning of September 29, a visiting medical physicist used a scintillation counter to confirm the presence of radioactivity and persuaded the authorities to take immediate action. The city, state, and national governments were all aware of the incident by the end of the day.

11. Initial action after the discovery Medical triage Monitoring of the people and survey the environment Medical treatment of the irradiated/contaminated persons Actions to bring sources of exposure under control Decontamination of the main sites of contamination (houses, public places, vehicles, etc.) Demolition and removal of houses Removal of contaminated soil Clear information to the public

12. Medical Triage Population Triage Period: September 30 - December 21, 1987 Number of persons 112,800 Internal/external contamination 129 Contamination of clothes and shoes 120 Persons hospitalized 2 Local radiation injuries 28 Bone marrow depression 14 Acute radiation syndrome 8 Deaths 4 Basic facts about triage performed Olympic Stadium (112,800 persons monitored)

13. Medical Responses The therapeutic procedures followed during the critical phase of the emergency response included — managing the critical period of the acute radiation syndrome manifested by bone marrow depression treating local radiation injury decorporation of caesium-137 from the body general support and psychotherapy.

14. Decorporation of Cs-137 with Prussian Blue One notable feature of the accident in Goiania was the severe external and internal contamination with caesium-137 that complicated patient care and prompted the extensive use of hexacyanoferrate, [Fe(CN)6] 4 (as Prussian Blue, or Radiogardase ) for the first time in the history of radiological accident In the Goiania accident, Prussian Blue (Radiogardase ) was administered to 46 persons. The doses of Prussian Blue varied from 1 g/day to 10 g/day The initial dose for adults was 3 g/day in three equal doses Patients who intakes more than five times the annual limit of Cs-137 intake, doses varied from 4 g/day to 6 g/day The dose administered to 13 children was initially 1.0-1.5 g/day

15. Fatalities Ages in years are given, with dosages listed in  grays  (Gy) : Leide das Neves Ferreira , aged 6 (6.0 Gy) , was the daughter of Ivo Ferreira. She gradually experienced swelling in the upper body , hair loss , kidney and lung damage , and internal bleeding . She died on October 23, 1987, of " septicemia  and generalized infection " at the Marcilio Dias Navy Hospital, in  Rio de Janeiro. Maria Gabriela Ferreira , aged 37 (5.7 Gy), wife of scrapyard owner Devair Ferreira, she developed hair loss and internal bleeding , especially of the limbs, eyes, and digestive tract. She suffered mental confusion , diarrhea , and acute  renal  insufficiency and died on October 23, 1987 .

16. Fatalities Admilson Alves de Souza , aged 18 (5.3 Gy), was an employee of Devair Ferreira who worked on the radioactive source. He developed lung damage , internal bleeding , and heart damage , and died on October 28, 1987. Israel Batista dos Santos , aged 22 (4.5 Gy), was also an employee of Devair Ferreira who worked on the radioactive source primarily to extract the lead. He developed serious respiratory and  lymphatic  complications , died on October 27, 1987. Devair Ferreira himself survived despite receiving 7 Gy of radiation. He died in 1994 of  cirrhosis  aggravated by  depression  and  binge drinking . Ivo Ferreira died of  emphysema  in 2003.

17. Highly contaminated Individuals 8 ARS patients with estimated doses 1  2-4 Gy 5  4-6 Gy 2  >6 Gy Two patients who received high doses (7.0 and 5.5 Gy) and exhibited bone marrow depression but recovered and survived

18. Dosimetry Used From the initial discovery of the accident in Goiania it was evident that many individuals had been irradiated. Various dosimetry techniques were used to provide inputs to the initial screening of potentially exposed persons, the subsequent medical management of patients, and a general scientific assessment of the accident. The principal techniques used were as follows : Internal dosimetry: bioassay and whole body monitoring Cytogenetics: estimation of doses by chromosomal aberration analysis External dosimetry: dose estimates from reconstructions and on the basis of radiation effects

19. Internal Dosimetry A bioassay is a method of determining the amount of radioactive material in your body. It is used to determine (calculate) the dose from this radioactive material. There are two techniques for bioassays: (1) Measure the amount of radioactivity directly - this is called an in vivo (in life), a “whole body count” (WBC). (2) Measure the amount of radioactivity excreted from your body - this is called an in vitro (in glass) bioassay. The concentration of radioactivity in urine or faecal samples can be used to determine the amount of activity in your body.

20. Cytogenetic Analysis The process of analyzing cells in a sample of tissue, blood, bone marrow to look for changes in chromosomes, including broken, missing, rearranged etc. Cytogenetic dosimetry is an extremely useful technique for estimating the external whole body radiation dose and the inhomogeneity of dose of the irradiated person. It is helpful in providing useful information to the physician responsible for diagnosis and prognosis

21. Medical F ollow-up of the victims S tatus of skin injuries after initial healing 8 patients required surgery in 1989 6 patients required surgery in 1990 1 patients required surgery in 1991 1 cancer death (1993), 1 suicide (1992) 5 year follow-up of children no significant findings (occasional eosinophilia, chronic anaemia) 7 exposed in-utero have no abnormalities 10 conceived post-accident born with no abnormalities

22. Environmental Contamination The environment was severely contaminated in the accident. I nitial surveys conducted in suspect homes and work areas 67 km 2 urban area of Goiania city monitored using helicopter to identify all hotspots (few mGy/hr to >2 Gy/hr) 2000 m 2 c ontaminated S everal household pets (cats and dogs) and some livestock (pigs) slaughtered

23. Environmental contamination The actions taken to clean up the contamination can be divided into two phases The first phase : actions needed to bring all potential sources of contamination under control, completed by 3 October, The second phase : action needed to restore normal living conditions, lasted until March 1988

24. Radiation Surveys For Radiation Surveys 55 dose rate meters, 23 contamination monitors and 450 QFEs (quartz fibre electrometers — dosimetric pens) were used Aerial survey with helicopter equipped with radiation detector (67 km 2 monitored) Terrestrial survey with a car equipped with NaI(Tl) and GM detector

25. Radiation Surveys Aerial survey To do this, an aerial survey of Goiania was carried out by helicopter on 7 and 8 October. A portable battery powered gamma spectrometer having Nal(Tl) detectors with a total volume of 840 cm3 was used. Maximum dose rate it recorded was 21 mSv/h at 1 m

26. Radiation Surveys Survey by car : mounting the detectors used in the helicopter in a car and surveying the areas adjacent to the main foci of contamination Both 100 mm x 100 mm Nal(Tl) detectors and Geiger-Muller (GM) type detectors were used One problem encountered was that the electronics were sensitive to temperature variations Use of hand held monitors More broad dose rates and contamination bands around the several principal foci showed by this precise dose rate measurements

27. Environmental Monitoring To quantify the environmental dispersion of caesium, more than 1300 measurements were made of radioactivity due to caesium-137 in soil, vegetation, water and air. In soil measurements ,the levels ranged from 10 2 to 10 5 Bq/kg and decreased with distance from the main foci. At the same locations as for soil, 263 samples of vegetation were collected and analyzed, including leaves, branches and fruit. The radiation level is below the minimum detectable (1 Bq/L) when measured in pubic water supply.

28. Environmental Monitoring In Ground water measurements, only wells near the main foci had levels of radioactivity above the detection limit (1.5 Bq/L). The highest level of radioactivity detected,30 Bq/L, was in the disused well of a residence. No caesium-137 was detected above the level of the limit of detection (150 Bq/L ), during rainwater measurements. In the Capim Puba creek , Jao Dam , a tributary of the Meia Ponte river that receives flood control water and sewage ,a survey was conducted on the sewerage system of the district. Monitoring showed no significant radioactivity

29. Decontamination was undoubtedly the most resource intensive element of the response to the accident with some 550 workers participating m Goiania This section presents the salient features of this work. 7 main contaminated places 42 additional contaminated places 85 contaminated houses; 7 demolished 50 vehicles decontaminated Decontamination

30. DECONTAMINATION PROCESSES the gamma dose rate was measured. Daily dose limit for workers set as 1.5mSv the area in which the highest dose rate was found was profiled. the soil layer indicated by the profile was removed, and then an additional layer was removed. the gamma dose rate and the soil's average specific radioactivity were measured. if these measurements were close to derived limits, the area was covered with 30 mm of new soil.

31. Disposal of the waste Waste storage site: 20 km away from the city Designed to accommodate 4-5 km 3 of waste Classification and Control system : 1) Non-radioactive: radioactivity <74 kBq/h 2) Low level waste: dose rate < 2 mSv/h close to the surface of the package 3) Intermediate level waste: dose rate > 2 mSv/h but < 20 mSv/h Liquid waste was solidified in cement and classified in the same way.

32. Disposal of waste Types of waste packaging used: 4,500 metal drums (200L) 1,400 metal boxes (5 tones) 10 shipping containers (32m 3 ) 6 sets of concrete packaging Volume of waste stored: 3,500 m 3 , or more than 275 construction lorry loads

33. Disposal of the waste Transport of the waste to the storage site transported in such a way as to meet Brazilian legal requirements and IAEA's Regulations for the Safe Transport of Radioactive Material Between 25 October and 19 December, 275 lorry loads of waste were transported to the temporary storage site Inventory Data on the external dose rates for packages, recorded on the inventory cards, were used later to estimate the radioactivity of each drum About 44 TBq (1200 Ci) of radioactive waste recovered.

34. GUIDELINES FOLLOWED FOR THE DISCHARGE OF PATIENTS It is recommended that monitoring in whole body counters and 24 hour urine collection be carried out for internal contamination. It is further recommended that only those persons whose levels of in-body radioactivity are lower than the applicable values given in Table, and the mean radioactivity of whose urine is less than 15 kBq/L (0.4 µ Ci/L ), should be discharged from hospital to rejoin the community.

35. Radiological Protection Routine contamination measurements were made to define the need of decontamination Air monitoring was undertaken ,Water and solid effluents were also monitored Plastic sheeting was put on floors and walls to facilitate decontamination. Numerous spots where dose rate exceeded 1.0 Sv/h . decontamination had to be planned. Film badge and QFE pens were used to monitor the radiation level in workers To help in this planning and in the general control of doses, authorized dose limits for workers were set for various time periods, namely: 1.5 mSv per day 5.0 mSv per week 15.0 mSv per month 30.0 mSv per quarter

36. Psychological F ollow-up of the victims Psychological alterations Continuation of some early problems Discrimination from the other people Establishment of illness behavior Concern about the consequences of the exposure Stigmatization V ictims blamed for accident by many citizens

37. International Co-operation An IAEA-Brazil co-operation programme on emergency preparedness had made a significant contribution to their preparedness well before the accident in Goiania The Brazilian authorities informed the IAEA of the accident soon after its discovery ,requested assistance under the terms of the international Convention on Assistance in case of a radiological emergency Since the accident, numerous collaborative activities have been undertaken by Brazilian and other experts to evaluate the experiences and to learn lessons from it

38. LESSON LEARNED The following lessons were drawn by CNEN from the accident in Goiania: A radiological accident like Goiania incident can be very much fatal if much time elapses before the discovery of the accident. The physical and chemical properties of a radioactive source are important factors in an accident. The records of sealed sources should contain that information. An adequate system of information is essential to avert panic on the part of the public. An adequate system of social and psychological support should be provided following a radiological accident causing serious contamination.

39. LESSON LEARNED Instrumentation should be capable of being adjusted to withstand field conditions, so that it can be used in high humidities, high temperatures and unstable environmental conditions. Experts in each area of action should be available to be contacted in the event of an emergency to give support to the local radiological protection teams. The provision of a temporary waste storage site near the area affected by a radiological accident is mandatory. Training programme should be arranged to train the radiation worker for radiation emergency situation

40. Bibliography Report “THE RADIOLOGICAL ACCIDENT IN GOIANIA , INTERNATIONAL ATOMIC ENERGY AGENCY VIENNA, 1988” Wikipedia.org/wiki/Goiânia_accident Dosimetric and medical aspects of the radiological accident in Goiânia in 1987, IAEA ,1998 Radiation sources: Lessons from Goi â nia report By IAEA Wikipedia.org/wiki/International_Nuclear_Event_Scale

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