IRPA TG on the Eye Lens Dose Limits Action 7

1. IRPA TG on the Eye Lens Dose Limits Action 7 Marie Claire Cantone and MercèGinjaume IRPA EC Madrid 10-12 November 2016

2. IRPA ToR – Phase 2 TG on the impact of the implementation of Eye Lens Dose Limits January 9 th , 2015 Madrid EC Meeting, November 2016

3. TG objectives To contribute to create a positive and complete awareness about RP at the working places, with attention to exposure of the lens of the eye and the revised dose limit for workers. Madrid EC Meeting, November 2016

4. TG objectives To report the evolution of the RP community after the first TG Report, 2013 the best applied methods for monitoring dose to the lens the ongoing path toward the implementation at the legislative level in the different countries the possible critical points in relation to the eye lens dose limit and its monitoring To monitor how the RP community is taking into consideration the wider generic issue of tissue reactions. Madrid EC Meeting, November 2016

5. IRPA TG Chair: Marie Claire Cantone (AIRP) Vice-Chair: MercèGinjaume (SEPR) Members:SavetaMiljanic (CRPA, Croatia) Colin Martin (SRP, UK) Keiichi Akahane (JHPS, Japan) LouisaMpete (SARPA, South Africa) Severino C Michelin (SAR, Argentina) Cynthia M Flannery (HPS, US) Lawrence T Dauer (HPS, US) Stephen Balter (HPS, US) Composition of the group, March 21th, 2015 Madrid EC Meeting, November 2016

6. sent toall the IRPA ASs, by Bernard Le-Guen on April 23rd, 2015 Madrid EC Meeting, November 2016

7. IRPA Task Group on the Impact of the Implementation of the Eye Dose Limits Questionnaire 23th April 2015 Topic 1 Implications for Dosimetry Q1 – Q8 - implications for monitoring and assessing dose to the lens of the eye and the interpretation of the results. Topic 2 Implications for Methods of Protection Q9 – Q12 - implications for methods (e.g., procedures or the design phase of equipment, facilities, and protective equipment) used to reduce dose to the eye, in the context of optimization of protection. Topic3WiderImplicationsofImplementingtheRevised Limit Q13 – Q18 - long term impact on working activities; -changes in Health survelliance; - more claim for compensation Topic 4 Legislative and other general aspects Q19 – Q22 - guidelines addressing monitoring related to new limit; -consultation for a legislation; -wider issue of tissue reactions, also circulatory disease Madrid EC Meeting, November 2016

8. 22 IRPA ASs contributed actively in collecting views and comments from their professionals • 1. Argentine • 2. Australia-New Zealand • 3. Austria • 4. Belgium • 5. Canada • 6. Croatia • 7. East Africa • 8. France • 9. German-Swiss • 10.Hungary • 11. Israel • 12. Italy • 13. Japan • 14. Korea • 15. Netherland • 16. Nordic • 17. Romania • 18. Russia • 19. South Africa • 20.Spain • 21.UK • 22.US Madrid EC Meeting, November 2016

9. Responses from 22 ASs, covering40 countries reporting fromAfrica,NorthandSouthAmerica,Asia,Australia,Europe Madrid EC Meeting, November 2016

10. An opportunitytodiscusswith the JHPS Expert Committee onRadiationDose Limit of the Lens Tokyo, May 29th, 2015 Classification of radiationeffectsfor the dose limitationpurposes:history, currentsituations and future prospects. N.Hamada, Y.Fujimichi, J.Radiat.Research, 2014 Madrid EC Meeting, November 2016

13. Madrid EC Meeting, November 2016

14. Madrid EC Meeting, November 2016

15. ASsreceived the draft TG Report, on April 25th, 2016 after Cape Town Congress ASsreceivedfinalversionforcomments, on May19th, 2016 Madrid EC Meeting, November 2016

16. Madrid EC Meeting, November 2016

17. Madrid EC Meeting, November 2016

18. After Cape Town Congress, the ASsreceived ‘IRPA guidelineprotocolforeye dose monitoring and eyeprotectionofworkers’ on July 6th 2016 Madrid EC Meeting, November 2016

19. Guideline protocol for eye dose monitoring and eye protection of workers To provide practical recommendations about when and howeye lens dose should be monitored in the framework of the implementation of the new dose limit for the lens of the eye, as well as guidance on use of protective devices depending on the exposure levels. Workers for whom lens of the eyes monitoring might be needed Proposed dose levels for implementation of dose monitoring Eye lens monitoring procedures Guidance on use of eye protective devices Madrid EC Meeting, November 2016

20. A topical area: Lens of the eye July 2016 Madrid EC Meeting, November 2016

21. IRP13 Glasgow, May 2012

22. October 31st , 2016 April 25th, 2016 ASsreceived the draft May19th, 2016 After Cape Town ASsreceived a revised Report TG receivedcommentsby IRPA ASstill October 31st , 2016 - Japan - Korea - Netherland - Nordic Madrid EC Meeting, November 2016

23. April 25th, 2016 ASsreceived the draft May19th, 2016 After Cape Town ASsreceived a revised Report TG receivedcommentsby IRPA ASstill October 31st , 2016 - Japan – Korea - Netherland - Nordic July 6th, 2016 ASsreceived the document TG receivedcommentsby IRPA ASstill October 31st , 2016 -Canada - Japan – UK - France – Netherland - Nordic Madrid EC Meeting, November 2016

24. 5. Conclusions 5.1 Direct implication in dosimetry and protection 5. Conclusions 5.1 Direct implication in dosimetry and protection 5.1.2 In the area of nuclear or other non-medical sectors, the use of a whole body dosimeter worn on the trunk is considered to be sufficient, while special dosimeters will be required to measure Hp(3) for neutrons, where the workers are exposed to mixed radiation fields. It is also recognized that in this area protective measures are already in use and no major changes are foreseen, except attention to possible non uniform external exposure as in the case of hot cells. 5.1.2 In the area of nuclear or other non-medical sectors, the use of a whole body dosimeter worn on the trunk is, in general, considered to be sufficient. It is also recognized that in this area protective measures are usually in use and no major changes are foreseen, except attention to possible mixed radiation fields and non-uniform external exposure as in the case of hot cells. IRPA REPORT Madrid EC Meeting, November 2016

25. 5.3 Implications related to dose recording and itinerant workers. 5.3 Implications related to dose recording and itinerant workers. • In relation to this point, specific and new issues are emerging: • where a form of National Dose Register is already in use, with a continuous summation of doses especially in the nuclear field, if the eye lens dose is not specifically included in the register, but recorded by the dosimetry services, recording results from additional dosimeters used to monitor the eye dose, will increase the administrative burden; • dose recording for itinerant workers in the medical sector, such as clinicians working in several hospitals, both public and private, is a major challenge, since different practices are likely to be used as regards the provision of dosimeters by employers; and the responsibility for collation of doses; • within the nuclear sector procedures for tracking itinerant workers are thought usually to be in place, however movement of workers between plants occurs widely and good measures need to be in place for efficient dose recording to avoid under-recording. • In relation to this point, specific and new issues are emerging: • where a form of National Dose Register is already in use, with a continuous summation of doses especially in the nuclear field, if the eye lens dose is not specifically included in the register, but recorded by the dosimetry services, recording results from additional dosimeters used to monitor the eye dose, will increase the administrative burden; • dose recording for itinerant workers in the medical sector, such as clinicians working in several hospitals, both public and private, is a major challenge, since different practices are likely to be used as regards the provision of dosimeters by employers; and the responsibility for collation of doses. IRPA REPORT Madrid EC Meeting, November 2016

26. 6.5 Additional matters requiring attention 6.5 Consideration of tissue effects more than eye lens effects IRPA REPORT 6.6 Additional matters of attention 6.6 Consideration of effects on tissues other than the eye lens Madrid EC Meeting, November 2016

27. 6.6 Consideration of effects on tissues other than the eye lens • Addressing the aspects emerging on the wider issue of tissue reactions, a need was expressed for adequate international guidance, specifically on the implication of circulatory disease risk for radiation protection and by addressing the different areas of practice; • By considering that uncertainty tends to inhibit direct impact on guidelines, there is a need to continue research: • On better understanding about the mechanism of a possible change in circulatory diseases, following the exposure of low- moderate-dose of radiation; • On examining the impact of possible confounding factors, e.g. smoking and other lifestyle factors; • On considering and characterizing uncertainties, e.g. associated with epidemiological studies, and how they may be incorporated into the risk evaluation. • •There is a lot of uncertainty, more research is inevitable (and ongoing): there are issues that could become very important, but the ASs are having difficulty in following the debate and the possible implications. There is definitely here a role to be played by IRPA, to do more to follow this issue more closely, and to identify and address, at the earliest opportunity, possible future implications for the profession . • The wider issue of tissue reactions and the case of circulatory diseases are recognized and there is a need to continue research: • On better understanding about the mechanism of a possible change in circulatory diseases, following the exposure of low- moderate-dose of radiation; • On examining the impact of possible confounding factors, e.g. smoking and other lifestyle factors; • On considering and characterizing uncertainties, e.g. associated with epidemiological studies, and how they may be incorporated into the risk evaluation. • There is a lot of uncertainty, more research is inevitable (and ongoing): there are issues that could become very important, but the ASs are having difficulty in following the debate and the possible implications. There is definitely here a role to be played by IRPA, to do more to follow this issue more closely, and to identify and address future possible implications in the practice. IRPA REPORT Madrid EC Meeting, November 2016

28. 7. About the trend in the ASs views from first to second TG phase • It has been five years from the ICRP Statementon tissue reactions containing the recommendations for an equivalent dose limit for the lens of the eye of 20 mSv in a year for workers, and has been 3 years since the first survey carried out by IRPAon the implications concerning this topic. • If we look at how the ASs community has reacted to the survey, some aspects come to our attention: • A greater involvement and a larger number of answers on the subject; • Despite the number of questions in this survey being doubled (from 11 to 22), the participating ASs have increased by almost 90% (from 12 to 22); • The process of taking into account changes to monitoring the lens of the eye and protection is now clearly being addressed and no longer being postponed. • By referring to the Report and publications of the first phase IRPA TG [J. Broughton et al., 2013, a2015, b2015] some aspects of the trend can be summarized as follows: • The need for ‘harmonisation of radiological protection criteria to monitor the eye lens for workers’as indicated in 2013 is still a challenge, but now three quarters of the ASs reported that some pilot studies related to doses to the lens of the eye are being conducted in their countries, No changes IRPA REPORT Madrid EC Meeting, November 2016

29. continue • The attention to a ‘confusion among radiation practitioners about the rational for the change in the dose limit’ indicated in 2013 is now less evident in the answers.This is likely to be a result of meetings, events and documents on the subject, through which practitioners have become involved and engaged, but we also think that this is the result of a shift in attention now towards a greater concern about the implementation of the new dose limit. However, there is still a residual concern that the new dose limit is not thoroughly scientifically underpinned; • From this second survey, it emerges that the ASs are no longer focused on the motivations of the significant reduction of the dose limit ('The relationship between dose and cataractformation is not well understood and the causality should be clarified' in 2013), but more focused on the implication in dosimetry and protection even though at the international scientific research level, the matter of whether radiation cataracts are deterministic effects, stochastic effects or both is still open to question, and the need for further epidemiological and mechanistic studies is acknowledged. The attention to these aspects, in ASs seems to have shifted to the field of the wider issue of tissue reactions, with the case of circulatory disease and the uncertainties in the available data and studies supporting the question; IRPA REPORT Madrid EC Meeting, November 2016

30. continue • Great differences were present in the ASs answers, in the first survey, about cost implications for the reduction of the eye dose, and the perception of future compensations caused by the new limit. Now, great differences still remain about cost implications: for instance, in the health surveillance of the workers the answers span from no cost to significant costs, while on future compensations, a large majority of ASs agree that there are likely to be an increased number of claims for compensation in the future; • Now, more attention appears to be dedicated to implications related to dose recording compared to the first survey, e.g. from additional dosimeters to monitor the eye dose, to dose recording for itinerant workers, from possible differences in provision of dosimeters, and to the responsibility for collation of doses. This attention could also be the result of the ASs community naturally focusing on practical aspects aimed at reduction of the eye dose; IRPA REPORT The Report is ready to be published Madrid EC Meeting, November 2016

31. IRPA guideline protocol for eye dose monitoring and eye protection of workers This document was prepared and edited by the IRPA TG on the impact of the Eye Lens Dose Limits. The TG members: Marie Claire Cantone, Merce Ginjaume, Saveta Miljanic, Colin J. Martin, Keiichi Akahane, Louisa Mpete, Severino C Michelin, Cynthia M Flannery, Lawrence T Dauer, Stephen Balter. Madrid EC Meeting, November 2016

32. IRPA guideline protocol for eye dose monitoring and eye protection of workers IRPA GUIDELINE Madrid EC Meeting, November 2016

33. 2. WORKERS FOR WHOM LENS OF THE EYE MONITORING MIGHT BE NEEDED Occupational exposure to the lens of the eye is considered in the nuclear industry mainly in the use of hot cells, decommissioning of nuclear facilities, in the vicinity of contaminated large areas or in case of handling Pu or depleted U(5). For example, in the fields of mechanical work (such as work in the containment and valve overhaul, e.g.), handling of liquid waste, decontamination work (not only in a glove box) and cleaning, radiation protection work, melting contaminated metal at a waste handling facility, preparing uranium powder and control of fuel assemblies at a nuclear fuel fabrication facility. Occupational exposure to the lens of the eye is considered in the nuclear industry mainly in the use of hot cells, decommissioning of nuclear facilities, in the vicinity of contaminated large areas or in case of handling Pu or depleted U(5). IRPA GUIDELINE Madrid EC Meeting, November 2016

34. 4. EYE LENS MONITORING PROCEDURES ICRP recommends the use of one dosimeter worn on the trunk of the body inside the apron, and a second dosimeter worn outside the apron at the level of the collar for interventional radiologists, and cardiologists, vascular surgeons and other groups e.g. surgical nurse undertaking interventional procedures (21, 22). For other users of fluoroscopy, and staff present during interventional procedures, but at a larger distance from the patient, the need for a dose assessment to the lens of the eye must be borne in mind (23). Use of a collar badge should be based on practice patterns and workload. In some cases, initial collar monitoring will support the desirability of continuing requirements for the collar dosimeter. In institutions where all staff always wear lead aprons, it may only be necessary for the interventional clinician performing the procedure will need to wear two dosimeters. For the remaining staff, wearing the lead apron and working far from the x-ray tube and from the patient, it may be sufficient to wear a collar or eye dosimeter, since the quantity of possible significance in this situation is the dose to the eye, which moreover provides a measure to the parts of the body that are not protected. (19). The ICRP recommends the use of one dosimeter worn on the trunk of the body inside the apron, and a second dosimeter worn outside the apron at the level of the collar for interventional radiologists, and cardiologists, vascular surgeons and other groups undertaking interventional procedures. For other users of fluoroscopy, and staff present during interventional procedures, but larger distance from the patient, the need for an assessment of dose to the eye must be borne in mind. Use of a collar badge should be based on practice patterns and workload. In some cases, initial collar monitoring will support the desirability of continuing requirements for the collar dosimeter. In institutions where all staff always wear lead aprons, it may only be necessary for the interventional clinician performing the procedure to wear two dosimeters,while other staff only wear a collar or eye dosimeter. IRPA GUIDELINE Madrid EC Meeting, November 2016

35. 5. GUIDANCE ON USE OF EYE PROTECTIVE DEVICES 5.1 In the medical field The distribution of scattered radiation around x-ray units is important, and higher doses will be received from direct scatter of the primary beam from the surface of the patient. The dose to the head is lower if the x-ray tube is below the couch, but under table shielding should be included to minimize exposure of the legs(24, 25). The lead apron is the most essential component of personal shielding in an x-ray room, and must be worn by all those present. It should be noted that the level of protection of the lead apron depends on the x-ray energy, which is represented by the voltage applied across the x-ray tube (kV). The lead apron is the most essential component of personal shielding in an x-ray room, and must be worn by all those present. It should be noted that the level of protection of the lead apron depends on the x-ray energy, which is represented by the voltage applied across the x-ray tube (kV). IRPA GUIDELINE Madrid EC Meeting, November 2016

36. April 2016 Before Cape Town May 2016 After Cape Town and before the distribution to ASs IRP13 Glasgow, May 2012 Madrid EC Meeting, November 2016

37. May 2016 After ASs comments, internal TG discussion Madrid EC Meeting, November 2016

38. The TG thanks the ASs for the comments to the draft of Report and of the Guideline protocol A positive note to be made : by comparing answers received for the questionnaire with the comments presented now by the Ass, there is a clear change indicating a real movement towards implementation Madrid EC Meeting, November 2016