Overview Comprehensive Health Risk Management after the Fukushima Nuclear Power Plant Accident S. Yamashita*y on behalf of the Radiation Medical Science Center for the Fukushima Health Management Survey *Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima Medical University, Fukushima, Japan yAtomic Bomb Disease Institute, Nagasaki University, Nagasaki, Japan Received 4 January 2015; accepted 4 January 2015 Abstract Five years have passed since the Great East Japan Earthquake and the subsequent Fukushima Daiichi Nuclear Power Plant accident on 11 March 2011. Countermeasures aimed at human protection during the emergency period, including evacuation, sheltering and control of the food chain were implemented in a timely manner by the Japanese Government. However, there is an apparent need for improvement, especially in the areas of nuclear safety and protection, and also in the management of radiation health risk during and even after the accident. Continuous monitoring and characterisation of the levels of radioactivity in the environment and foods in Fukushima are now essential for obtaining informed consent to the decisions on living in the radio-contaminated areas and also on returning back to the evacuated areas once re-entry is allowed; it is also important to carry out a realistic assessment of the radiation doses on the basis of measurements. Until now, various types of radiation health risk management projects and research have been implemented in Fukushima, among which the Fukushima Health Management Survey is the largest health monitoring project. It includes the Basic Survey for the estimation of external radiation doses received during the first 4 months after the accident and four detailed surveys: thyroid ultrasound examination, comprehensive health check-up, mental health andlifestylesurvey,andsurveyonpregnantwomen andnursing mothers,withthe aimtoprospectivelytake careof thehealth of alltheresidents of Fukushima Prefecture for a long time. In particular, among evacuees of the Fukushima Nuclear Power Plant accident, concern about radiation risk is associated with psychological stresses. Here, ongoing health risk management will be reviewed, focusing on the difficult challenge of post-disaster recovery and resilience in Fukushima.
2016 The Royal College of Radiologists. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/). Key words: Fukushima; health management; health risk; mental care; radiation exposure Statement of Search Strategies Used and Sources of Information This paper reflects expert opinion and current literature accessedbytheauthors;noformalsearchstrategyhasbeen defined. Introduction Before the Fukushima Nuclear Power Plant (NPP) accident, we were, unfortunately, enchanted, without reserve, by the myth of the safety of nuclear power in Japan, although the importance of emergency radiation medicine was seriously discussed on the global radiation protection arenas, such as the International Atomic Energy Agency (IAEA) Incident and Emergency Center [1] and the World HealthOrganization (WHO) RadiationEmergencyMedicine Preparedness and Response Network [2]. The WHO International Project on the Health Effects of the Chernobyl Accident had previously identified health issues as a result of the Chernobyl NPP accident [3]. A review of comprehensive health risk management after the Fukushima NPP accident Address for correspondence: 1-12-4 Sakamoto, Atomic Bomb Disease Institute, Nagasaki University, Nagasaki 8528523, Japan. Tel: þ81-95-8197116; Fax: þ81-95-819-7117. E-mail address: [email protected] Contents lists available at ScienceDirect Clinical Oncology journal homepage: www.clinicaloncologyonline.net http://dx.doi.org/10.1016/j.clon.2016.01.001 0936-6555/
2016 The Royal College of Radiologists. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). Clinical Oncology 28 (2016) 255e262 [4]andusefulinformationontheradiationriskofchildhood thyroid cancer at the standpoint of rehabilitation and revival for Fukushima [5] have also been reported. One of the most important lessons learned from Chernobyl was to avoid the initial exposure to radioactive iodines released from nuclear accidents, thus reducing or preventing the risk of radiation-associated childhood thyroid cancers [6,7]. Therefore, retrospective analysis of thyroid dose is of paramount importance in Fukushima, and the tentative data available so far have suggested no future possibility of increased risk of childhood thyroid cancer [8,9]. However, psychosocial and mental health consequences, including post-traumatic stress disorders, arevery important issues to be solved in Fukushima and are similar to those seen after Chernobyl [10]. Previous epidemiological studies of human health risk from low dose and low dose rate exposure, as well as those on the atomic bomb survivors cohort form a background on which to develop a radiation health management programme. The identification of a cause-anddisease relationship, however, is very difficult after any radiological and nuclear accident because many confounding and modifying factors affect the chance of late occurrence of malignancy. Three recent papers included in the special issues of The Lancet commemorating 70 years of caring for survivors of the atomic bombing in Hiroshima and Nagasaki reviewed the health effects associated with exposure to radiation, which can be used to inform the probable consequences of the accident at Fukushima Daiichi [11e13]. The accidents at Chernobyl and Fukushima have highlighted similarities in potential public health effects of radiation, including health issues unrelated to direct radiation exposure. Long-term responses are needed in order to overcome the difficult tasks of risk management with respect to health in different categories of Fukushima’s residents (evacuees, children, mothers and aged people), and these should be provided to achieve an effective care for the complex problem that people confront [14]. The recent progress of the Fukushima Health ManagementSurveyprojectwillbesummarisedanddiscussedhere to identify the future direction of appropriate and wellbalanced radiation risk management in Fukushima, including the model of recovery used in the village of Kawauchi [15]. Fukushima Nuclear Power Plant Accident and Radiation Dose The WHO promptly released its estimation of the doses receivedbythepopulationsaroundFukushimainMay2012 [16]. By applying incomplete data from the System for Prediction of Environmental Emergency Dose Information (SPEEDI) at first and then using the airborne monitoring survey data by the Ministry of Education, Culture, Sports, Science and Technology of Japan (MEXT), based on conservative and theoretical assumptions, not taking into account refuge and sheltering during 4 months after the accident in the evacuation prepared area or the measures that were implemented to limit the consumption of food and restrictions on shipment, the WHO dose estimates were calculated from the viewpoint of protection. It has been not too surprising that these ‘worse case scenario’ assumptions resulted in overestimated values. According to these, a 1year-oldchild’sthyroidequivalentdosewasestimatedtobe in the range of 10e100 mSv in Minami-soma, Iwaki and Iitate-mura, and 1e10 mSv in prefectures adjacent to Fukushima. However, these thyroid equivalent doses are markedly different from the actual values derived from the thyroidal screening and examination with a whole body counter. According to the report on the thyroid internal exposure examination, which the Japanese Nuclear Safety Commissionconducted from26 to30 March, just afterthe accident, a thyroid equivalent dose of 100 mSv was considered to be an overestimate [17]. As a result, there would hardly be any increase in thyroid cancer. On the other hand, according to the report by Hirosaki University [18], the thyroid equivalent dose might have reached several 10 mSv in the infants whostayed within a distance of 20 km from the reactor site at the time of the accident and it is necessary to observe them for a long period of time. Furthermore, using theoretical assumptions on the preliminary dose estimates mentioned above, the WHO has subsequentlyreportedtheprojectedhealthriskassessment in Fukushima [19]. The estimates stemming from inappropriate retrospective dose assumptions are far above the reality and may mislead the public into thinking there is a more serious radiation health risk than actually exists. By contrast, according to the United Nations Scientific Committee on the Effects of Atomic Radiation 2013 report [20] and the IAEA Fukushima report [21], no discernible increased incidence of radiation-related health effects is expected on the basis of more accurate dose estimates in Fukushima. Unfortunately, however, the public concern over the fear of childhood thyroid cancer risk due to the Fukushimaaccidenthasneverdisappeared.Fromnowon,it is necessary to develop a consensus of the accurate dose estimation based on the actual conditions, together with the continuation of regular health check-ups in Fukushima. Outline of the Fukushima Health Management Survey FollowingtheFukushimaNPPaccidentsinMarch2011,it becameapparentthattheresidentsofFukushimaPrefecture were unavoidably exposed to some amount of radiation fallout, even if this might be comparable with the natural yearly background levels in other areas of the world. Thus, the Fukushima Mimamori Project (Health Management Survey) was initiated in May 2011 to treat and manage residents’ long-term health [22]. Owing tothe vigorous efforts of the Fukushima Health Management Survey Group, the studyprotocolreachedamutualagreementwithFukushima Prefecture and was endorsed by international radiation medicine and radiation protection experts [23]. Fukushima S. Yamashita / Clinical Oncology 28 (2016) 255e262256 Medical University has been carrying out this project from its initiation, as requested by the prefecture, with the supportofnationalfunding.TheestablishmentoftheRadiation Medical Science Center on 1 September 2011 is an official realisation of the earnest efforts of those involved in the FukushimaHealthManagementSurvey.Anewbuildingwill be completed in summer 2016 to strengthen the daily activities of the health survey, data management, and disease prevention and treatment for the patients who are newly diagnosed by this survey programme. Atpresent, the Basic Surveyand fourdetailed studies are being conducted targeting mainly the evacuees, children and mothers in the entire Fukushima Prefecture. The Fukushima Health Management Survey Review Committee has met 20 times (four times per year) in the past 5 years, overcoming a myriad of obstacles. Fukushima Medical University is also involved in academic co-operation with various domestic and international research organisations to reinforce its role in radiation medical science research and education [24]. Basic Survey The Basic Survey includes self-questionnaires mailed to all prefecture residents, which primarily enquire into each person’s habits, conduct and whereabouts during the 4 month period after the earthquake; participation in the survey is not compulsory. The aim is to estimate each person’s external radiation dose for the period when the airborne radioactivity was at its peak. The individual external radiation doses are estimated by using digitised behaviourdataandacomputerprogramthatconsidersdaily gamma ray dose rate maps drawn after the accident [25]. As the details of methods and results have been separately described [26], overall results of the estimation of external radiation doses are introduced as a dose distribution by area in Fukushima and are accessible online to the public in Japanese [27] and in English [24]. Among 2.05 million, the individual external doses of 422 394 residents forthe first 4months (excluding radiationworkers)hadthe following distribution: 62.0% less than 1 mSv; 94.0% less than 2 mSv; 99.4% less than 3 mSv. The average was less than 1 mSv in the entire population analysed. The Review Committee judged these data as an indication that ‘the impacts of radiation on health are minimal’. However, futureeffortsarerequiredforthehealthmanagementofthe residents and to reduce their total radiation dose. On the basis of geographical distribution, more than 90% of the local residents in the middle and northern regions of Fukushima received less than 2 mSv/4 months, about 91% less than 1 mSv/4 months in the southern region of Fukushima and morethan 99%less than1 mSv/4 months in the Aizu and South Aizu regions of Fukushima, which are relatively far from the NPP site. Apart from the first 4 month external radiation exposure dose estimation in Fukushima, the data obtained from internal dose measurement using whole body counters have been collated [28e33], indicating no alarming evidence of radiation doses that would probably lead to health consequences. Four Detailed Surveys Thefourdetailedsurveysbeingconductedare:(i)thyroid ultrasoundexamination;(ii)comprehensivemedicalcheckup; (iii) mental health and lifestyle surveys; (iv) survey on pregnant women and nursing mothers (http://fukushimamimamori.jp/). The study protocol for this health management has been previously described [22]. Here, radiation healthrisk,especiallyriskofradiation-associatedcancers,is the main issue to be analysed, but apart from that, noncancer effects of radiation or issues not directly related to radiation, such as chronic lifestyle diseases and psychosocial/mental problems, are important issues to be taken care ofintheresidentsofFukushima.Severalimportantpointsof the survey results are briefly discussed below. Thyroid Ultrasound Examination Although health effects directly related to radiation exposure are highly unlikely under the current circumstances and radiation levels in Fukushima, an increase in childhood thyroid cancer in Chernobyl due to internal exposure to radioactive iodine exaggerated the uncertainty oflowdoseradiationhealthriskandalsostirredupafearof radiation. As a result of the strong requests from people in Fukushima, as well as the central and local governments, thyroid ultrasound examinations were started in October 2011, targeting around 370 000 childrenwho wereyounger than 18 years old at the time of the accident. Children will be examined every 2 years until they reach the age of 20 years old and then every 5 years after that. These examinations will be repeated for a long time and will follow a standardisedprotocoldevelopedbytheFukushimaMedical University in co-operation with related hospitals and organisations.Theprotocolofthyroidultrasoundexamination is well established so that a highly advanced diagnostic approach is implemented with standardised data collection (for further information, see [34] in this special issue). From the standpoint of clinical oncology, the risk of the development of cancer and the role of the environment are critically important to understand the mechanism of any carcinogenesis, especially of thyroid cancer after the Fukushima NPP accident. Simultaneously, to avoid any misinterpretation of the data obtained in Fukushima, a sound knowledge of biology, epidemiology, statistics and otherscientificdisciplinesisneeded.Inparticular,theeffect of enhanced detection on the increase in thyroid cancer by ultrasound examination is well documented all over the world [35e40]. The debates about high detection rates of thyroid cancer by ultrasound screening and/or overdiagnosis should therefore be carefully examined [41,42]. The results of the first round ultrasound examination during the first 4 years after the Fukushima NPP accident are presented below; further details are presented in [34]. Among300476children,2275werediagnosedwiththyroid S. Yamashita / Clinical Oncology 28 (2016) 255e262 257 nodules and referred to further secondary examination; fine needle aspiration biopsy and cytological assessment was carried out in 537 cases. In total, 113 cases were diagnosedorwerestronglysuspiciousforthyroidcarcinoma(38 males and 75 females, 14.27.8 years old at the time of diagnosis). The overall prevalence of childhood and adolescent thyroid cancer was calculated as 37.3 per 100 000 and the prevalence of thyroid cancer and other thyroid abnormalities did not differ across Fukushima Prefecture. It should again be emphasised that the sophisticated screening activities for thyroid disease in Fukushima led to an increase in the incidence of thyroid cancer due to earlier detection of non-symptomatic cases. Indeed, the ultrasound examination data using the same diagnostic criteria as in Fukushima clearly indicate a similar prevalence of childhood and adolescent thyroid diseases, including cancer in other regions of Japan [43]. A recent molecular analytical study showed that the genetic profile of Fukushima thyroid cancers was completely different from that of post-Chernobyl radiation-associated thyroid cancers in young patients [44]. In this respect, it is necessary to establish a system for a long-term follow-up for the children in Fukushima in careful comparison with the control areas, as reviewed previously [45]. The by-products of this survey have separately contributed to the discovery of several new findings of thyroid development, such as ectopic intrathyroidal thymus [46] and age-dependent systemic thyroid volume determination [47]. Now, after completion of the first round of thyroid ultrasound examination aimed at understanding the basal prevalence of thyroid diseases, including cancers, within the first3yearsinFukushima,thesecondroundoffull-scale thyroidexaminationswasstartedinApril2014,targetingan established cohort of around 370 000 children from the entireFukushimaPrefectureatthetimeoftheNPPaccident. Health Check-up Detailedhealthexaminationsarebeingcarriedoutinthe residents of evacuation zones and also in those deemed to be in need of healthcare based on their responses to the Basic Survey. The target population is around 210 000, including children who resided in the evacuated zones at the time of the accident. The main objectives are to assess the examinees’ health conditions and achieve early diagnoses and treatment of lifestyle and/or other illnesses. The content of the examinations differs depending on the examinee’s age, although all tests included in ‘specified medical check-ups’ are typically conducted. For persons aged 16 years or older, the Special Health Check-up as part of the Municipal National Health Insurance System has been carried out, with additional items for the comprehensive health check among adults aged 40 years or older. Also, visiting mass health check-up clinics have been held 104timesat29locationssinceJanuary2012forpeopleaged 16 years or older who do not participate in the Special Health Check-up. Forchildren aged15 years or younger, the health check-up has been held at 102 paediatric medical institutions in the prefecture since January 2012. Comprehensive health checks have been carried out outside the prefecture, with the co-operation of the Japan AntiTuberculosis Association. Across Japan, 554 paediatric medical institutions are helping to conduct health checks for children aged 15 years or younger. In summary, the 2011 Comprehensive Health Check, whichcomprises around 70 000examinations,has clarified the general health conditions of evacuees from the government-designated evacuation zone after the Great East Japan Disaster [48,49]. Obesity and hyperlipidaemia exist, even at young ages, and are increased in comparison with the previous years’ data on Fukushima Prefecture in adults of both genders. Liver dysfunction and hyperuricemia increased at relatively young ages in males. Hypertension, glucose dysmetabolism and renal dysfunction increasedinadulthoodandaremostcommoninolderages. According to the comparative data of the health check results before and after the Fukushima NPP accident in children and adults, the rates of obesity, glucose metabolic dysfunction, hyperlipidaemia and liver dysfunction after the disaster were higher compared with those before the disaster. After the Fukushima NPP accident, the prevalence of diabetes increased significantly among the evacuees compared with those among non-evacuees [50]. Furthermore, a hypo-high density lipoprotein cholesterolaemia was observed among the evacuees after the accident [51]. Regarding the factors that contributed to these results, changes in lifestyle, diet, exercise and other personal habits caused by forced evacuation are suggested, although there were interfering factors, such as the difference in health check periods, age distribution, region distribution and participation rate. In addition, the prevalence of atrial fibrillation increased among residents of the evacuation zone after the NPP accident, with excess of alcohol intake andobesityassociatedwithit[52].Fromthepointofviewof haematology, evacuation was also associated with changes in blood cell count, haemoglobin and haematocrit levels after the NPP accident, indicating the increased prevalence ofpolycythemiastratifiedbysmokingstatusorobesity[53]; there was no specific change in the distribution of white blood cell counts, including neutrophil and lymphocyte counts, within 1 year after the NPP disaster in the evacuationzone[54].Thus,theinitialresultsofthecomprehensive healthcheck-upamongevacueesindicatetheimportanceof periodic health checks to develop lifestyle recommendations and to systemically prevent various diseases, including lifestyle-related diseases. Mental Health and Lifestyle Surveys Changes in mental and physical health were indicated as one of the long-term effects of the Chernobyl disaster [55]. As psychological stress is conceivable in residents coping with life in evacuee shelters and anxiety towards the radiation, surveys are being conducted to enable the provision of appropriate care. Residents in evacuation zones and individuals (about 210 000 people) deemed in need of healthcare based on the Basic Survey results are asked to S. Yamashita / Clinical Oncology 28 (2016) 255e262258 respond to questions about their current physical and mental condition, and lifestyle (diet, sleeping habits, tobacco use, alcohol use and exercise). So far, the mental health and lifestyle surveys have been conducted twice (10 and 22 months after the NPP accident) to provide adequate mental care and lifestyle support for evacuees who are at higher risk [56]. Among them, around 60 000 people responded to the specific questionnaire that included the SDQ, K6 and PCL scoring issues [56]. An analysis of the relationship between the perception of radiation risk and psychological condition among evacuees in Fukushima using the K6 scale showed that the responders who believed that radiation exposure was very likely to cause health effects were significantly more likely to be psychologically distressed than other responders [57]. This means that the earthquake and tsunami followed by the NPP accident caused psychological distress among residents in Fukushima. These data reveal the persistence of acute phase reaction and the possibility that they might have been confounded by other factors included in the survey should betakenintoconsideration.Clearly,theresidentsneedtobe followedupforalongtimetodetectthetransitionfromthe acute to chronic reactions and also to clarify the quality of psychosocial and mental changes in order to support the recovery of corresponding health conditions. Although studies of populations exposed to low doses are limited in their ability to account for important lifestyle factors, such as smoking, dietary habit and medical X-ray exposures, our investigations should be and are being considered for reassurance and healthcare reasons. The mental care provision in Fukushima is, therefore, essential for a long time, as recommended by several experts, similarly to that indicated after Chernobyl [55,58,59]. Survey of Expectant and Nursing Mothers Asurveywasadministeredtowomenwhoreceivedtheir Maternal and Child Health Handbooks within and outside the prefecture, and to those who underwent pregnancy check-ups or gave birth after 11 March 2011. They were asked to respond to questions including health and pregnancy check-ups they received since the earthquake, their physical condition during their pregnancy, thebirth of their child and their mental wellbeing. In total, 15 972 questionnaires were distributed from January 2012 and 9298 responses were returned by 31 August 2012 (response rate 58.2%) [60]. Telephone counselling was provided by midwives and public health nurses for 1393 respondents of 9228 (counselling rate 15.1%), who had been identified as respondents requiring support on the basis of the survey response. The post-disaster incidences of stillbirth, preterm birth, low birth weight and congenital anomalies were 0.25%, 4.4%, 8.7% and 2.7%, respectively. These incidences are similar to recent averages in Japan. At the Center, maternity and public health nurses are always on duty, handling calls and e-mails related to childcare and child rearing. For consultees who require further support, Fukushima Medical University maternity nurses and hospital nurses are available by telephone. According to local reports, there has not been any increase in miscarriage or artificial abortion owing to the extensive efforts of the Japanese Medical Association, especially obstetricians and gynaecologists. However, it is necessary to gather more cases to drawa conclusion. Every year we mail the same, but slightly modified, questionnaires are mailed to newly pregnant women to support their healthy life and replyanxietyandconcernaboutradiationandhealthissues. Discussion The surveys in Fukushima are intended as a specific response to initial radiation exposure and to mental traumas caused by the accident and evacuation. The primary purposes of the surveys are to assess residents’ radiation doses and to monitor residents’ health conditions, which result in disease prevention, early detection and early medical treatment, thereby maintaining and promoting their future health. The standardisation and close monitoring of diagnostic examinations outside of these surveys remain a pending issue in the context of long-term health management efforts, including mental care. In particular, it is important not only for patients but for the public to understand the relationship of cause-and-disease. Clinical manifestation of a radiation-related disease has a latent period, especially cancer, occurring as a late-onset stochastic effect. If an ultrasound thyroid examination shows signs of cancer in less than 3 or 4 years after the accident, there is no tenable argument that could link that cancer to radiation exposure from the accident. Going forward, we need to address the issue of latency periods regarding examination results and the development of cancer from the standpoint of cancer biology and epidemiology. Indeed, the high prevalence of BRAFV600E mutation inFukushimachildrenstronglysuggestsnotonlyadifferent oncogenic profile from Chernobyl but also an early detection in children and adolescents of asymptomatic thyroid cancers that otherwise would (or would not) clinically manifest later in adulthood [44]. Also, we need to improve health risk communication on thyroid findings, not only to target population but also to their parents, and to devise a regional cancer registry for patients to avoid misunderstanding of the results of screening. The risk of radiation-associated physical health consequences for residents in Fukushima is quite different from that in Chernobyl, being considerably low or undetectable accordingtotheradiationdoseestimatesfromtheaccident. However, there is a similarity of social, psychological and economic impact between the two serious NPP accidents. One of the confusions and perplexities is the issue of uncertainty of thyroid cancer risk, especially after low dose exposure; it is difficult to communicate with the public and variousstakeholdersbeyonddoseestimates.Forinstance,it is well known that the worldwide incidence of thyroid cancer is steadily increasing [61]. However, further investigations are required to determine additional factors apart from radiation exposure contributing to this growth, either in children and adolescents or adults [62]. Another S. Yamashita / Clinical Oncology 28 (2016) 255e262 259 important point is that the over-diagnosis and overtreatment of asymptomatic thyroid cancer should be carefully analysed because of good prognosis of this malignancy; many latent cases are detected. Therefore, the current ongoing programme of the Fukushima Health ManagementSurveyisimportanttounderstandthenatural historyof thyroid diseases detected by ultrasound, together with long-term health and mental care, which should be appropriately updated. The most difficult challenge is to categorise the physical and somatic health effects that may result from radiation exposure, and also non-radiation-related health effects, such as post-disaster mental impact and lifestyle changes, especially for the evacuees in Fukushima. As we support residents in their recovery and return to their homes, understandingeachindividual’sstatewithrespecttoradiation and regular monitoring of their health conditions contributetotheregion’srebirthandrestoration[63].Incooperation with the International Commission on Radiological Protection, on-site dialogue seminars in Fukushima have been successfully implemented and several guidelines for post-accident radiation protection for the public are useful for recovery [64,65]. To that end, we plan to build and maintain a framework for residents to self-access information about their radiationdosesandforthemedicalinfrastructuretoofferreadily accessiblehealthconsultationsandexaminationssuchasin Kawauchi village [66,67]. The challenges associated with the healthcare management of Fukushima Prefecture’s residents are numerous, and it is only with the support of everyone that we will be able to move forward with these projects.Wehumblyrequestthekindconsiderationandcooperation of the prefecture’s and country’s healthcare professionals and also of international societies. Acknowledgements The data used on the Fukushima Health Management Survey were referred from the open-access homepage of Fukushima Radiation and Health at the Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima Medical University (http://fmu-global.jp). 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