Review Paper
SUMMARY OF NCRP 2019 ANNUAL MEETING, NCRP MEETING THE
CHALLENGE AT 90: PROVIDING BEST ANSWERS TO YOUR MOST PRESSING
QUESTIONS ABOUT RADIATION
Richard J. Vetter,1 Jerrold T. Bushberg,2 and Fred A. Mettler, Jr3
Abstract—The National Council on Radiation Protection and
Downloaded from http://journals.lww.com/health-physics by BhDMf5ePHKbH4TTImqenVHwXmMsAVI5g3ImrOchK92T03N3D9xVeOjTrGTRrYpdB on 03/02/2020
Measurements (NCRP) held its 55th Annual Meeting 1-2 April
2019 in Bethesda, Maryland. The 2019 meeting was a special year
for NCRP as it marked the 90th Anniversary of the founding of the
predecessor organization, US Advisory Committee on X-Ray and
Radium Protection. Leaders for the scientific portion of the
meeting were Fred A. Mettler, Jr., M.D. (Chair), University of
New Mexico School of Medicine; Jerrold T. Bushberg, Ph.D.
(Co-Chair), University of California Davis; and Richard J. Vetter,
Ph.D. (Co-Chair), Mayo Clinic. The meeting was designed to
explore important areas of inquiry associated with use of ionizing
radiation relevant to radiation protection, addressing frequently
asked questions and concerns from both members of the public
and radiation professionals. The meeting was organized into six
sessions plus three honorary lectures and a special presentation.
This paper summarizes the scientific content of the six sessions
and is based on the notes of the co-chairs and the slides of the
speakers. The three honorary lectures are included as other
papers in this issue.
Health Phys. 118(4):335–348; 2020
Key words: emergency planning; linear hypothesis; medical radi-
ation; National Council on Radiation Protection and Measure-
ments (NCRP)
INTRODUCTION
WELL BEFORE its Congressional charter was approved in 1964,
the National Council on Radiation Protection and Measure-
ments (NCRP) devoted itself to collecting, analyzing, develop-
ing, and disseminating in the public interest information and
recommendations about radiation protection. For 90 y, NCRP
has been fulfilling its mission to support radiation protection
1
Mayo Clinic, 200 1st Street SW, Rochester, MN 55905; 2Health and
Medical Physics Consulting, Sacramento, CA; 3University of New Mexico,
Albuquerque, NM.
The authors declare no conflicts of interest.
For correspondence contact: Richard J. Vetter, Mayo Clinic, 200 1st
Street SW, Rochester, MN 55905, or email at rvetter@mayo.edu.
(Manuscript accepted 21 October 2019)
0017-9078/20/0
Copyright © 2020 Health Physics Society
DOI: 10.1097/HP.0000000000001239
www.health-physics.com
Copyright © 2020 Health Physics Society. Unauthorized reproduction of this article is prohibited.
by providing independent scientific analysis, information,
and recommendations that represent the consensus of lead-
ing scientists. The Council and its Program Area Committees
(Boice 2019) have addressed questions in virtually every in-
dustrial, scientific, and medical endeavor that uses sources of
radiation. Over those 90 y, the societal uses of radiation have
increased significantly, both in terms of the variety of radi-
ation uses and frequency of use. During the same period,
scientific studies have revealed many details of radiation
interactions within the human body at the cellular and
molecular levels, which have led to more applications in
science, industry, and medicine. These increased uses and
expanding knowledge continue to generate questions about
new applications and consequences of radiation, which lead
to discussion of the potential benefits and risks to society
from the uses of various radiation sources.
NCRP has responded to these questions principally
through the generation of consensus NCRP reports, com-
mentaries, and statements to educate members of the public,
government, and professional communities. These docu-
ments receive extensive review by the Council and the NCRP
leadership and represent the consensus recommendations of
leading scientists in the field to allow for the beneficial uses
of radiation while protecting workers, patients, members of
the public, and the environment from the risks of radiation
exposure. Despite the fact that the biological effects of radia-
tion have been studied for longer and more thoroughly than
almost any other physical or chemical agent, the perceived,
theoretical, and known risks associated with exposure to vari-
ous radiation sources continue to raise public and professional
concerns and generate controversies about the continued and
increasing use of radiation sources.
ORGANIZATION OF THE MEETING
The meeting was divided into six topical areas to explore
important and relevant areas of inquiries associated with use
of ionizing radiation in various settings.
335
336 Health Physics
The first session of this meeting, “Exploring the Red
Planet: A Focus on the Radiation Environment and Crew
Health,” examined the challenges to human health associ-
ated with long-duration manned space missions. At the
National Aeronautics and Space Administration’s (NASA)
request, NCRP has assembled expert committees that have
produced several reports and commentaries (NCRP 2019)
on radiation effects and protection in low-Earth orbit and
is now giving advanced thought to the consequences of
long-duration exposure to the complex radiation environ-
ment of outer space. With the heightened interest in travel
to Mars, NCRP Commentary No. 25, Potential for Central
Nervous System Effects from Radiation Exposure During
Space Activities. Phase I: Overview (NCRP 2016a), attracted
considerable attention.
The second session, “Low-Dose Epidemiology and
Regulatory Issues,” examined fundamental questions on the
relationship of dose to risk and the meaning of “reasonable”
in one of the most important pillars of radiation safety, the as
low as reasonably achievable (ALARA) principle. NCRP re-
cently published Commentary No. 27, Implications of Recent
Epidemiologic Studies for the Linear No-Threshold Model
and Radiation Protection (NCRP 2018), in which the last
few decades of reports on the health risks associated with
exposure to low levels of ionizing radiation were reviewed
to assess the reliability of the human epidemiologic data
on cancer induction in the low-dose region. This session
also explored the interface between radiation epidemiologic
studies and applications to radiation protection, including
the process of developing radiation protection standards
and consideration of alternative risk models.
The third session, “Tissue Reactions,” examined com-
pelling epidemiological data that suggest risks of cataracts
and circulatory diseases may be higher than previously
thought and considered the possible mechanisms of biolog-
ical effects of ionizing radiation in the lens of the eye and
circulatory system, especially at doses <1 Gy. The most re-
cent NCRP published guidance in this area is Commentary
No. 26, Guidance on Radiation Dose Limits for the Lens of
the Eye (NCRP 2016b).
The fourth session of this meeting, “Emergency Plan-
ning, Response, and Communications,” examined the impor-
tant role of NCRP in providing sound guidance on national
preparedness for radiological or nuclear terrorism. This ses-
sion reviewed the challenges faced by the emergency response
community and the efforts that are underway in NCRP to
assist the federal government and academia to address these
challenges. The 2017 NCRP Annual Meeting (Ansari et al.
2017) examined key aspects of preparation for radiological
and nuclear terrorism.
The fifth session, “Waste Management,” examined
three important aspects of radioactive waste disposal that
our nation faces: treatment of liquid high-level radioactive
www.health-physics.com
Copyright © 2020 Health Physics Society. Unauthorized reproduction of this article is prohibited.
April 2020, Volume 118, Number 4
material for safe disposal, recovery from the accident at the
Waste Isolation Pilot Plant (WIPP) in New Mexico, and
continuing safe disposal of low-level radioactive waste. The
importance of radioactive waste management expands with
the increased use of radioactive material.
The final session, “Frequently Asked Questions: Medical
and Other Topics,” reflected on how the radiation community
is addressing common questions from and misperceptions of
the public related to radiation, including concern about medi-
cal treatment to emergency responses.
EXPLORING THE RED PLANET: A FOCUS ON
THE RADIATION ENVIRONMENT AND
CREW HEALTH
Janice L. Huff, National Aeronautics and Space Ad-
ministration, Session Chair. The radiation environment
in space poses significant challenges to human health and
is a major concern for long-duration, manned space missions.
Outside Earth’s protective magnetosphere, interplanetary
crews will experience greater levels of radiation exposure
from high-energy protons and highly energetic atomic nu-
clei, known as galactic cosmic rays (GCRs), and from solar
particle events (SPEs). The trip to Mars provides no oppor-
tunity to turn around; it will take 6 mo to get there, 1.5 y will
be spent exploring Mars, and it will take 6 mo to get back.
The session covered key aspects of the space radiation envi-
ronment, the major health risks of concern, and strategies for
risk mitigation for the astronauts. Health issues other than
radiation will include zero-gravity issues; fluid redistribu-
tion; effects on the brain, eyes, cardiovascular system, and
bone density; as well as psychological and privacy issues.
Is the low-earth orbit radiation environment a good
proxy for Mars?
Cary J. Zeitlin, Leidos Innovations Corporation.
Cosmic radiation impacting Earth’s atmosphere is reduced
to low linear energy transfer (LET), low dose-rate radiation
by Earth’s atmosphere. At sea level, the annual effective
dose is <1 mSv from background. In space, the dose rates
from GCRs are ~100–200 mGy y−1, and within the Interna-
tional Space Station (ISS), high-energy heavy ions, which
are capable of penetrating shielding, and neutrons (behind
shielding) contribute high-LET components to the dose rate.
Occasionally, SPEs contribute to the dose. SPEs are spo-
radic, and exposures depend strongly on the event spectrum
and shielding because most events are relatively low energy.
Earth’s magnetic field influences the radiation environment
strongly in LEO depending on latitude; thus, the ISS in
LEO is shielded by Earth’s magnetic field. Spikes in
dose occur within the ISS when it passes through an anom-
aly in the magnetic field located off the coast of Brazil
(South Atlantic Anomaly), a region populated by magneti-
cally trapped protons and electrons that reach the ISS on
 Summary of NCRP 2019 Annual Meeting c R. J. VETTER ET AL.
average about five times per day. Magnetic shielding at low
latitudes reduces GCR flux. At high latitudes, dose rates are
approximately the same as those in free space, and solar parti-
cles can enter the ISS. While the physics of GCR is reasonably
well understood, with small gaps in knowledge, the associated
health risks from chronic exposure to this radiation are not.
Radiation data have been accumulated over many years
from low earth orbit (LEO) but for only 6.5 y from Mars.
The Mars Science Laboratory Rover (Curiosity), launched
25 November 2011 and landed 6 August 2012, contained
10 science instruments including the Radiation Assessment
Detector (RAD). RAD measured an average dose rate of
0.46 mGy d−1 on the journey to Mars. Using the ICRP Pub-
lication 60 (ICRP 1991) quality factor of 3.8 for these parti-
cles, the effective dose was 1.7 mSv d−1. Curiosity landed in
Gale Crater, 4.4 km below the mean elevation on Mars. Due
to the greater atmospheric column depth (23 g cm−2 of CO2
compared to 16 g cm−2 at mean level), a dose reduction of 2
could be expected. The actual reduction observed was 2.2 due
to atmosphere. When anticipating a weak solar maximum
(SPEs are negligible), the surface dose rate is expected to be
~0.3 mSv d−1. A Mars voyage would include 6 mo each
way plus 500 d on the surface. Thus, the total effective dose
equivalent is expected to be ~1 Sv. Using a risk coefficient
of 5% Sv−1, the risk of dying from a future cancer from the ra-
diation received during a Mars mission would be ~5%. The
current NASA paradigm limits the increase in cancer mor-
tality risk from exposure to space radiation to 3% with a
confidence interval of 95% (effectively a 1% limit in current
paradigm). Thus, if no improvements are made to radiation
protection or NASA administrative rules for astronauts are
not changed (or exemptions for special missions are
granted), NASA astronauts would not be allowed to under-
take such a mission.
RAD measurements on the surface of Mars show many
similarities to LEO, especially for dose rates. Measurements
on Mars, in LEO, in lunar orbit, and at accelerators are
helping to fill knowledge gaps. Health risks remain by far
the largest unknown.
Overview of health risks associated with
deep-space exploration
Eleanor A. Blakely, Lawrence Berkeley National Lab-
oratory. One of the challenges of space exploration is
gaining an understanding of the biological effects of chronic
exposure to relatively low doses of a complex radiation field
in an environment of additional stressors. More than 550
people have traveled into LEO and beyond and returned to
Earth. From the Mercury through ISS missions, radiation
doses per astronaut have ranged from 200 mSv to nearly
100 mSv. The hazards of spaceflight depend on the dura-
tion of the mission. Physical effects of being in space include
altered gravity, exposure to ultraviolet light, decreased
www.health-physics.com
Copyright © 2020 Health Physics Society. Unauthorized reproduction of this article is prohibited.
337
hydrostatic pressure, increased acoustic noise, numerous
conditions of life different from those on Earth, extravehic-
ular activity, and many combined effects.
Today the only permanent human outpost in space is
the ISS, slated for shut down in 2025. There are plans for
a return mission to the moon, and Mars is a planned destina-
tion, if deemed safe, sometime after 2030. The risks can be
summarized into three broad categories: physiological prob-
lems caused by microgravity, psychological and medical
problems caused by isolation, and risks caused by exposure
to radiation. Most notable is the fact that these categories
have many overlaps.
Animal studies have provided evidence that acute ex-
posure of neural stem cells and the central nervous system
to very low doses (0–15 cGy) can elicit a persistent oxida-
tive stress lasting weeks to months, which is associated with
impaired cognition. Data suggest that astronauts subjected to
space radiation may develop a heightened risk for mission-
critical performance decrement in space along with a risk of
developing long-term neurocognitive sequelae. Radiation-
induced reactive oxygen species and microgravity-induced
molecular changes include prodromal effects such as nausea
and fatigue and alterations in hematopoietic and immune re-
sponse, the gastrointestinal tract, cognition, behavior, and
sleep patterns.
In another longitudinal analysis, increased extracellular
fluid was observed in widespread areas at the base of the
cerebellum with decreases along the posterior aspect of
the vertex following spaceflight. After adjusting for extra-
cellular fluid, there was altered white matter microstructure
in various areas of the brain. It was concluded that space-
flight is associated with redistribution of brain extracellular
fluid. White matter changes occur throughout the brain and
in some cases are significantly associated with mission du-
ration. Post-flight declines in balance were also observed.
Mortality of space travelers has been studied repeatedly
since the early 1990s in both astronauts and cosmonauts. Most
studies show reduced risk of cardiovascular disease (CVD)
mortality for space travelers in comparison to the general pop-
ulation. Recent publications suggest higher CVD mortality in
Apollo lunar astronauts, which has raised concerns about
deep-space exploration. No excess radiation–associated car-
diovascular risk has been observed overall. Discussions are
ongoing, and some considerations include the healthy worker
effect, the reference population, the number of subjects, and
other confounding factors such as lifestyle and genetic factors.
The prevalence of atrial fibrillation in astronauts is
~5%, which is similar to that of the general population but
presents at a younger age. Studies show that a 6-mo space-
flight is sufficient to cause transient changes in left atrial
structure and changes in certain aspects of atrial electro-
physiology. It is believed that individuals in the astronaut
corps are not at an increased risk of developing CVD. The
338 Health Physics
broadly defined spaceflight experiences do not appear to
put astronauts at greater risk of critical CVD in points across
the lifespan.
To date, there is no evidence for space radiation-
induced cancer in astronauts or cosmonauts. Reliable in-
formation is available for the types and doses of radiation
to which astronauts would be subjected during a transit to
and from Mars (either with or without a prolonged stay on
the surface). No human has yet experienced protracted
exposure to the expected radiation types, doses, and dose
rates from a Mars expedition. Because of the many uncer-
tainties associated with animal studies when applied to
humans and because of the uncertainties associated with
the biological response to combined stressors, the magni-
tude of the total risk faced by humans traveling to Mars is
currently unknown.
The sky is the limit: radiation protection for
human spaceflight
Mark Shavers, Wylie Laboratories. From 1981 to 2011,
the space-shuttle program launched 134 flights of 1 to 17 d in
duration with 14 flights exceeding 13 d. Crews ranged from
two to eight men and women. Earth orbit ranged from 284.5
to 620 km. From 2001–2017, the ISS program launched 51
crewmembers from the United States and 109 from all coun-
tries. The program consisted of 56 expeditions, 215 space-
walks (1,350 h), and 48- to 340-d durations with the longest
cumulative for one astronaut of 665 d. The LEO of ISS is con-
stant at 516 km. Crew average single mission doses have
ranged from 0.2 to nearly 100 mGy. The main space radiation
concern is GCR, which consists mostly of high-energy pro-
tons but also heavy ions, all of which are highly penetrating.
Because of the high proton component, the best shielding
consists of hydrogenous materials.
Space radiation associated risks may include increased
cancer morbidity or mortality; degenerative tissue diseases
such as CVD; central nervous system damage leading to
acute and/or late changes in cognition, motor function, behav-
ior and mood, or neurological disorders; and acute radiation
syndrome (prodromal effects of nausea, vomiting, and fa-
tigue; skin damage; and/or potential hematological/immune
changes). Protection against these effects includes shielding
with hydrogenous materials and practicing ALARA to the
extent feasible. Managing radiation exposures with “time,
distance, and shielding” involves the timing and duration of
space walks; accounting for the trajectory, which may reduce
exposure to radiation belts and SPEs; use of vehicle- and
mission-designed shielding; and other countermeasures, such
as real-time monitoring and alerting.
Exposure management requires the meeting of all expo-
sure limits and ALARA requirements, assigning crew who
will not exceed career cancer risk limits, radiation monitor-
ing and dosimetry, shielding enhancements in high exposure
www.health-physics.com
Copyright © 2020 Health Physics Society. Unauthorized reproduction of this article is prohibited.
April 2020, Volume 118, Number 4
locations, alert and shelter during transit events, and when
possible, managing the ionizing radiation and nonionizing
radiation exposures through mission design, engineering,
and operational controls.
The space permissible exposure limit is 3% risk of
radiation-induced death from cancer. This limit was arrived
at through use of Monte Carlo simulations and a consider-
able amount of modeling including ion transport models,
cancer risk models, and use of various radiation quality fac-
tors based on the energy of the particles. Females are gener-
ally at higher risk than males due to different organ risk
coefficients and the fact that, even in the same radiation en-
vironment, males and females will not experience the same
dose (i.e., organ dose equivalents for females are a few per-
cent larger than males due to less body mass).
More than half of the radiation on the Mars surface
consists of high-energy protons and secondary neutrons. Ap-
proximately one-third of the radiation consists of particles
with an atomic number of 3 to 10. The permissible mission
duration for each astronaut relates risk of exposure-induced
death to flight eligibility for assignment to a specific mission.
This exercise determines how long an astronaut can be in a
specific radiation environment and remain below the risk
limit. The permissible mission duration is expressed in days.
Dependencies include individual parameters, such as previ-
ous space and biomedical exposures along with age, gender,
and smoking status. Mission parameters include altitude,
trajectory, shielding, mission duration, and solar-cycle pro-
jection. Table 1 shows the permissible mission duration for
males and females for various missions.
It is estimated that a voyage to Mars will involve a tran-
sit time of 180 d each direction and 1 y (or longer) on the
surface of Mars. Table 1 shows that such a journey will ex-
ceed the space-permissible exposure limit.
Perspectives from the Office of the Chief Health and
Medical Officer of the National Aeronautics and
Space Administration
Neal Zapp, National Aeronautics and Space Admin-
istration. As distance from Earth increases, the risks inherent
in human spaceflight become amplified, at times through
channels and mechanisms that may not always be completely
obvious. It is patently clear that with increasing distance
comes an associated increasing need for the capabilities
Table 1. Permissible mission duration (days to limit).
Mission Malea Femalea Vehicle shielding
ISS 519 355 (LEO) Heaviest shielded
Free space 279 192 Lighter shielding
Mars transit 301 212 Less shielding
Mars surface 441 296 Lightest shielding
a
47-y-old never smoker, first mission.
 Summary of NCRP 2019 Annual Meeting c R. J. VETTER ET AL.
associated with increasing mission autonomy. For example,
the risk mitigations provided by any direct abort capability
are decreased with increasing mission distance from Earth,
up to a point where abort to Earth is simply no longer possi-
ble. Similarly, as distance increases, so does the complexity
and potentially the literal time involved in communication
between a crew and support personnel on Earth. Guidance
and navigation schemes are complicated by the need to rely
on vehicle-autonomous calculation. Overall, the system
designed to support a crew through these missions will
correspondingly have to evolve into more and more robust
capabilities associated with both sustaining humans and
also with the monitoring, response, and medical care facili-
ties associated with a wide range of contingency and emer-
gency scenarios.
Human risk considerations for long-duration, exploration-
class space missions happens on three broad fronts: defining
and evaluating against both fitness for duty and permissible
outcome standards, maintaining acceptable risks associated
with natural and induced environments (and their associated
possible physiologic insults), and the broader issues associ-
ated with defining and evaluating what constitutes accept-
able risk. There remain today significant challenges in each
of these areas.
Some of the more impactful examples of natural and
induced environments in this context include the physiolog-
ical changes associated with reduced gravity, both the acute
and protracted effects of exposure to the space radiation
environment, both neuro-vestibular and musculoskeletal
adaptation; behavioral health effects associated with the
isolation of space travel; and the induced environments ap-
plied by the vehicle architecture itself (i.e., acoustic and
chemical environments). The specifics of the causal rela-
tionships involved in many of these cases are not yet under-
stood well enough to provide for direct planning of either
mitigations or potential treatment.
Each of these risks is associated with architectural de-
sign and operational response limits and/or thresholds de-
fined by allowable risk in each case. In the aggregate, then,
arriving at specific decisions as to whether to conduct a space
mission that may fail to meet health and medical standards
defined for individual risks or involve significant risks where
there are no applicable standards, NASA follows ethical prin-
ciples and responsibilities similar to those used in the practice
of medicine. Based on guidance provided by the National
Academies’ Standing Committee on Aerospace Medicine
and the Medicine of Extreme Environments, NASA will
step through a predetermined ethical framework for the ac-
ceptance of risk and thus determine the criteria that should
be used to determine whether individual, one-time exceptions
for specific scenarios may be accepted.
In summary, myriad risks to the human are associated
with spaceflight. Most are associated with relatively high
www.health-physics.com
Copyright © 2020 Health Physics Society. Unauthorized reproduction of this article is prohibited.
339
uncertainties in estimating risk. The number of people
who have flown in space is not large enough to lend itself
well to population statistical analysis of effects nor to direct
investigation of mechanisms in the way in which clinical
practice for general terrestrial medicine has been formu-
lated. A framework exists to allow NASA to step ethically
through decisions associated with missions that may exceed
predetermined health and medical standards. Radiation dif-
fers from the majority of other risks in two important ways:
astronauts do not take the insult with them, and the insult is
not well controlled through engineering. A framework ex-
ists to allow NASA to step ethically through decisions asso-
ciated with missions that may exceed predetermined health
and medical standards.
Low-dose epidemiology and regulatory issues
Roy E. Shore, New York University Langone School of
Medicine, Session Chair. Speakers in this session pointed
out that regulatory constructs for radiation protection began
with guidelines to prevent severe tissue reactions (deterministic
effects). Over time, issues of induction of cancer and genetic
effects became known, and these “stochastic” effects became
the drivers for regulatory standards. Several challenges remain,
including fundamental questions on the relationship of dose
to risk and the question of what does “reasonable” mean in
the phrase “as low as reasonably achievable.” It was pointed
out that the excess relative risk (ERR) Gy−1 from both
atomic-bomb mortality and incidence is ~0.5 Gy−1 and that
risk estimates at lower doses have less accuracy and preci-
sion and are more susceptible to bias. The session explored
epidemiologic areas of importance for the radiation protec-
tion community and implications for radiation protection
recommendations and regulation of alternative models.
What is the Life Span Study telling us about cancer risks
at low to moderate doses?
Eric J. Grant, Radiation Effects Research Founda-
tion. Estimates from four major reports between 2003 and
2017 for the excess relative risk (ERR Gy−1) in the Life Span
Study (LSS) for solid cancer have ranged from 0.42–0.50.
The representative population in the cohort was exposed
to doses that rapidly decreased with distance, leaving little
chance for bias or confounding by major cancer risk factors.
The risks by dose for all solid cancers as a group were highly
significant. Despite the large size of the LSS, statistical
power is limited at lower doses resulting in larger uncer-
tainties in those risk estimates. Further, there is less accuracy
of radiation dose parameters at longer distances as proximal
survivors had detailed shielding histories, while distal survi-
vors had fewer interviews. Over time, medical radiation ex-
posures have become larger compared to the direct exposure
from the bombs. At lower doses, there is a higher probability
of bias and confounding factors associated with survivors’
340 Health Physics
geospatial distribution, socioeconomic factors, and urban vs.
rural differences.
Solid cancer incidence for major cancer sites (including
stomach, lung, liver, and colon) showed little or no evidence
of curvature in the dose-response curves, while other sites
such as esophageal cancer showed curvature. After adjusting
for lifestyle factors associated with cancer, there was almost
no change in the relative risk estimates or curvature infer-
ence. In the “all solid cancer” analyses, curvature was evident
among males only.
The LSS shows a strong dose response over the full
dose range. Curvature has been observed for the most recent
report of solid cancer incidence in males but not females.
Curvature was observed in the latest mortality report in a
gender-averaged analysis but was only evident in the most
recent follow-up period. The reasons for these curvature dis-
parities are still under investigation. They may be influenced
by the heterogeneity across cancer sites in their background
rates or by other age modifiers of excess relative risk when
aggregating solid cancers. At this time, uncertainties in the
shape of the dose-response curve preclude definitive conclu-
sions to guide radiation protection policies confidently, but
conclusions regarding the positive dose response are robust.
Risk estimates from studies of low doses and low
dose rates
Richard Wakeford, Centre for Occupational and
Environmental Health, University of Manchester, United
Kingdom. Owing to inevitable variations in background dis-
ease rates, we should not expect to obtain definitive risk esti-
mates from small changes in risk potentially attributable to
low-level exposures to ionizing radiation from epidemiologi-
cal studies alone. However, the pattern of results from a range
of epidemiological studies provides an indicative guide to
risks consequent to low levels of radiation exposure. Low-
level exposure to ionizing radiation is conventionally taken
to be either low doses (<100 mGy) or low dose rates
(<0.1 mGy min−1) of low-LET radiation when averaged
over ~1 h (i.e., less than ~5 mGy h−1). The populations in
these epidemiological studies of low-level exposures are
the low-dose Japanese atomic-bomb survivors and medi-
cally, environmentally, and occupationally exposed groups.
Although medically exposed groups offer a valuable com-
plement to evidence derived from Japanese atomic-bomb
survivors, care is required in interpretation of results. Expo-
sure to radiation in medically exposed groups occurs be-
cause of known or suspected disease, and this may affect
the risk estimates obtained from medical studies through,
for example, reverse causation and confounding by indica-
tion. Also, accurate dose estimates are often lacking, espe-
cially for untargeted organs. Medical sources of diagnostic
radiation exposure include antenatal radiography and com-
puted tomography (CT) scanning. Environmental studies
www.health-physics.com
Copyright © 2020 Health Physics Society. Unauthorized reproduction of this article is prohibited.
April 2020, Volume 118, Number 4
include riverside residents of the contaminated Techa River
and high natural background radiation areas such as in Kerala,
India. Studies of occupational exposures at early nuclear facil-
ities, such as Sellafield, Mayak, Chalk River, and Hanford, are
of value because they include workers with high cumulative
doses received in small increments. Recent pooled studies in-
clude an international study based on cumulative occupational
exposures and mortality data for over 300,000 nuclear workers
in the United States, United Kingdom, and France.
Cancer risk estimates obtained from these studies of low
doses or low dose rates are indicative of some radiation-related
excess risk for some cancer sites. The magnitude of these risk
estimates is broadly comparable to predictions based on the
Japanese atomic-bomb survivor data. However, interpretation
is not straightforward, and additional research is required to
further reduce uncertainties as much as possible.
Nuclear Regulatory Commission rulemaking process
and current regulatory activities
Patricia K. Holahan, US Nuclear Regulatory Com-
mission. Rulemaking is triggered by events that are identified
by the US Nuclear Regulatory Commission (NRC) staff, leg-
islation, or executive orders, or directed by the Commission.
Following review by the Commission, a rulemaking plan is
developed for approval. A draft of the regulatory basis for
the plan is published to obtain public involvement and stake-
holder input. Following input, a draft proposed rule is devel-
oped and approved by the Commission. Public comments
obtained in response to the proposed rule are evaluated,
and a draft final rule is developed and approved by the
Commission. Subsequently, a final rule is published and
the rule takes effect.
In the Petition for Rulemaking Process, the NRC receives
a petition for rulemaking under 10 CFR 2.802 (US NRC
2018) whereby the petitioner(s) present specific problems or
issues to be addressed through rulemaking. Following a suffi-
ciency review, either a letter to the petitioner explains why the
petition was insufficient or a docket number is assigned, and
the petitioner is notified. Following publication in the Federal
Register, analysis of the petition, and review of any comments
received, a determination is made on whether a rule should
be developed. NRC’s determination is based, in part, on the
merits of the petition; immediacy of the safety, environmen-
tal, or security concern raised; and availability of NRC re-
sources; and the priority of the issues raised in relation to
the other NRC rulemakings. Final action is published in the
Federal Register.
US regulatory agencies make changes in their regulations
based upon science, national and international recommenda-
tions, and the participatory rulemaking process. Stakeholder
engagement and communication support are needed for a
paradigm shift in regulations. NRC regulations should pro-
vide flexibility to use risk-informed, performance-based
 Summary of NCRP 2019 Annual Meeting c R. J. VETTER ET AL.
approaches for implementation and requests for exemp-
tions using new models or methodology. More details on
these processes can be obtained at the NRC’s website (US
NRC 2019).
Can radiation epidemiology affect current radiation
standards?
Michael A. Boyd, US Environmental Protection
Agency. The US Environmental Protection Agency’s (EPA)
mission is to protect human health and the environment. To
protect human health, EPA must estimate risk at low doses
to limit risk of radiogenic cancers to a defined range. EPA
is charged with providing advice to federal agencies in the
formulation of radiation protection standards. The path from
science to policy includes basic research, science synthesis,
guidance and policy, peer-reviewed publication, and consid-
eration of recommendations both national and international.
Current radiation standards are based largely on epidemi-
ologic core studies (e.g., the LSS). Interpolation and extrapo-
lation from the high dose range, generally >100 mSv, provides
risk estimates for low doses. This approach has been used by
authoritative scientific bodies including NCRP, the Inter-
national Commission on Radiological Protection (ICRP),
the United Nations Scientific Committee on the Effects of
Atomic Radiation (UNSCEAR), and the National Academy
of Sciences (NAS).
A change in radiation regulations would require a scientific
consensus as reflected in reports from NCRP, ICRP, NAS, etc. It
would also require acceptance among federal agencies in
consideration of advice and comments from EPA’s Science
Advisory Board. Such a change would be a transparent pub-
lic process for considering scientific evidence.
Historical challenges in low-dose radiation research have
included uncertainties at low doses, impracticality of using
large sample sizes, addressing biases, the dose-rate effective-
ness factor, and bridging the gap between epidemiology and
radiobiology. Evolving approaches include statistical analy-
ses, improvements in technology such as the electronic med-
ical record, DNA sequencing, and various new approaches
including biomarker research.
In summary, EPA is required to estimate the health risks
of radiation exposure at low doses. The agency relies heavily
on epidemiological studies to estimate radiation risk. Changes
to radiation standards would require a consensus of the scien-
tific community. Advances in epidemiology and radiobiology
may improve estimates of radiation risk at low doses.
TISSUE REACTIONS
Lawrence T. Dauer, Memorial Sloan Kettering Can-
cer Center, Session Chair. While not certain, suggestions
of elevated risks of both circulatory diseases and cataracts
associated with lower levels of radiation have been building
www.health-physics.com
Copyright © 2020 Health Physics Society. Unauthorized reproduction of this article is prohibited.
341
over the last decade. Several disparate populations exposed
to low doses of ionizing radiation are being studied. This
session addressed the following questions: Do currently
available data from epidemiology and the developing under-
standing of the mechanisms of biological effects provide
new insights into effects in the lens of the eye or circulatory
system, especially at doses <1 Gy? If so, what are some of
the implications? The attendees learned that the etiology
of CVDs may be inflammatory. Although radiation doses
increase some long-lasting inflammatory proteins and de-
crease others, what happens at <0.5 Gy is unclear. Vision
impairing cataracts probably have a threshold of ~0.5 Gy
but may also occur at protracted doses of <0.5 Gy.
Low-dose radiation and circulatory diseases
Mark P. Little, National Cancer Institute. Subtypes
of circulatory disease associated with atherosclerosis are of
largely inflammatory etiology. Increases in circulatory dis-
ease are associated with baseline increases in many inflam-
matory biomarkers (e.g., C− reactive protein). Endothelial
cell activation results in regulation of inflammation at high
doses, >0.5 Gy, but generally downregulation at lower doses.
Cellular senescence is also affected by radiation. For
example, vascular smooth muscle cells in atherosclerotic
plaques are prone to accelerated senescence. A dose of
10 Gy of radiation can induce monocyte adhesion produced
by radiation-induced cell senescence.
A significant dose response for circulatory disease in
atomic-bomb survivors has been observed, but the excess
risk is significant at only >0.7 Gy. The dose response is the
same when adjusted for smoking, drinking, and other CVD
risk factors. The shape of the dose-response curve is uncer-
tain, but there are weak indications of upward curvature for
stroke and none for heart disease.
Among occupational groups, a significant excess risk
has been observed for all circulatory diseases, ischemic heart
disease, acute myocardial infarction, and cerebrovascular dis-
ease. There is some evidence of downward curvature for cere-
brovascular disease. Some studies have collected information
on the impact of lifestyle and medical risk factors on circula-
tory disease. There is little evidence that these risk factors in-
teract with radiation dose response.
The mechanisms for low-dose circulatory disease re-
main unclear. Inflammation is likely to play a role but not
at low doses, <0.5 Gy. Cellular senescence may play a role
at both low and high doses. Excess risk of circulatory dis-
eases has been observed in various moderate and low-dose
exposed groups but only in occupational cohorts and tuber-
culosis fluoroscopy. The growing body of evidence that ra-
diation may impact ischemic heart disease and stroke risks
is particularly interesting and important. High-dose radia-
tion therapy studies have similar excess risk per gray as
moderate-to-low-dose cohorts. Many low-dose studies lack
342 Health Physics
information on potential impact of lifestyle and medical risk
factors. There is a little indication that such factors, when
known, confound dose response.
Low-dose radiation and cataracts
Nobuyuki Hamada, Central Research Institute of
Electric Power Industry, Japan. Cataracts are a common
age-related disease involving a clouding of the normally
transparent crystalline lens of the eye. They are easily treated
by a replacement of the biological lens with an artificial lens.
Radiation cataracts have been reported in animals since
shortly after the discovery of x rays. Observation of cataracts
in atomic-bomb survivors and cyclotron workers stimulated
an interest in radiation protection of the eyes. ICRP has rec-
ommended dose limits for the lens since 1954.
Nearly 100 papers published by 2010 have provided a
scientific basis for a 0.5-Gy threshold for cataracts. Evidence
for cataracts has been observed in Mayak workers, US radio-
logic technologists, and Japanese atomic-bomb survivors.
High sensitivity of the lens to low-LET radiation may in-
volve abnormal proliferation and differentiation of lens epithe-
lial cells, oxidative stress, and denaturation of lens crystalline
proteins. Human lens epithelial cells contain a subset of cells
whose proliferation is stimulated by radiation and another sub-
set sensitive to radiogenic premature senescence. The lens also
appears to be more sensitive to high-LET radiation than other
tissues. The mechanisms may involve low oxygen, high nitro-
gen, and cellular quiescence. More research efforts are needed
to understand biological and mechanistic developments.
Epidemiological evidence tends to demonstrate that a
threshold for cataracts becomes less clear with a longer
follow-up. There may be early onset cataracts with a thresh-
old (for example, those occurring within a decade post-
exposure) and late onset cataracts with no threshold. The
lens has not developed primary tumors, but various tumor–
related genes are involved in cataractogenesis.
Radiation cataracts are no longer recognized as a typical
tissue reaction with a clear threshold of relatively high dose. Bi-
ological and epidemiological developments and continued
assessment of implications would be indispensable to evidence-
based judgments for radiation protection purposes. Studies
of cataracts and other ocular impacts are useful for radiation
protection purposes, but information from these studies is
also useful for radiotherapy and space missions.
EMERGENCY PLANNING, RESPONSE,
AND COMMUNICATIONS
Brooke Buddemeier, Lawrence Livermore National
Laboratory; William E. Irwin, Vermont Department of
Health; and Jessica S. Wieder, US Environmental Protec-
tion Agency, Session Co-Chairs. The panel reported that the
2017 NCRP Annual Meeting (Ansari et al. 2017) identified
www.health-physics.com
Copyright © 2020 Health Physics Society. Unauthorized reproduction of this article is prohibited.
April 2020, Volume 118, Number 4
critical gaps in the national preparedness to radiological or nu-
clear terrorism. The good news is that sound guidance exists,
though better ways need to be found to communicate the guid-
ance, incentivize local-level planning, and support informed-
response decision making. The panel pointed out that response
guidance needs to be combined and not limited to radiation.
The complex technical and psychosocial aspects of radiologi-
cal and nuclear incidents complicate emergency response de-
cision making and can lead to unnecessary cost and/or loss
of life. NCRP can play an important role in providing sound
science but must understand how to best temper and commu-
nicate this science to be operationally relevant and accessible
to the people who need it most. Numerous social media mes-
sages as well as educational videos have been produced to
meet this need. This session reviewed the challenges faced
by the emergency response community for radiological and
nuclear events, including the complex needs following the
use of a radiological dispersal device or a nuclear detonation.
Efforts are underway at NCRP, the federal government, and ac-
ademia to address these challenges.
Response issues identified in the 2017 NCRP
Annual Meeting
William Irwin, Vermont Department of Health.
NCRP has consistently anticipated the needs for emergency
preparedness, including anticipating where terrorists might
use radiological or nuclear devices. At the 2017 Annual Meet-
ing (Ansari et al. 2017), presenters described what must be
done to make radiation emergency preparedness more main-
stream. The rarity of radiological and nuclear incidents has
limited the attention and funding to this area even after 11
September 2001 and Fukushima in 2011. The bulk of funding
goes to support responses to more common incidents like nat-
ural disasters and emerging infectious diseases.
Discussion at the 2017 NCRP Annual Meeting in-
cluded the ability to provide medical care even in the worst
scenario, such as a nuclear detonation. One approach is to
identify zones that represent priority areas for life-saving.
This zone is where responders can safely enter (if even for
a short period) and where those requiring lifesaving care
are most likely to be found. This system would optimize ra-
diation triage, treatment, and transport.
Discussion at the 2017 Meeting included successful ef-
forts to plan for and to build a cadre of subject-matter experts
prepared for the worst. One shortage identified is the lack of
radiological subject-matter experts. To meet this need, the US
Department of Homeland Security (DHS) is training individ-
uals to fill the position of Radiological Operations Support
Specialist (ROSS). In 2017, there were 18 ROSS personnel
trained; today there are more than 100. Presenters described
how messages are still not adequately reaching those who
need them most. For example, the majority of Americans
do not know life-saving fallout intervention. More education
 Summary of NCRP 2019 Annual Meeting c R. J. VETTER ET AL.
in this area should be done with the hope that some of the
public’s fear of radiation would be replaced by knowledge
of what to do to protect themselves during a serious radiolog-
ical emergency.
Don’t blame the PAGs
Sara DeCair, US Environmental Protection Agency.
Radiation protective action guides (PAGs) developed by
the EPA are based on international recommendations, a sci-
entific basis, interagency consensus, and practical consider-
ations. The PAG for evacuation in the United States sets an
intervention level of 10–50 mSv total effective dose equiva-
lent over 4 d. The PAG developed by the International
Atomic Energy Agency is 100 mSv over 7 d. To put into per-
spective the risk of death from radiation exposure following a
severe accident, following the tsunami at Fukushima Prefec-
ture, more than 400,000 people were displaced across Japan.
Nearly 100,000 were displaced in Fukushima Prefecture.
The total number of casualties including earthquake related
deaths was nearly 20,000. Media outlets reported one casualty
from radiation exposure following the Daiichi reactor events.
The press asserted that the overprotective PAG’s prompted
an unnecessary evacuation that led to nearly 2,000 deaths.
However, it must be remembered that predetermined action
levels are among the many factors that inform the decision
to evacuate.
No one can definitively say that, had people remained,
the death toll would have been lower. Other possible out-
comes may have been that people could have remained in
place; spent fuel could have caught fire releasing unprece-
dented levels of radioactive material; meteorological condi-
tions could have changed; resources such as food, water,
and power may not have been available; and public concerns
could have resulted in self-evacuation.
In light of the Fukushima disaster, consideration of PAGs
implementation is certainly warranted. Consideration could be
given to raising the PAG level, PAG levels could take into con-
sideration a psychosocial detriment, and further consideration
could be given to hard-to-move populations. However, consid-
eration of these factors is complicated. For example, how
would psychosocial detriment be quantified? How would
adequate resources be provided to those who remain?
The robust preparedness program in the United States
will enable authorities and decision makers to better navi-
gate uncertainties in a nuclear or radiological disaster. It is
important to plan, exercise, hold drills, and practice imple-
mentation of the PAGs
New guidance and tools for radiological/nuclear
response: National Urban Security Technology
Laboratory support to state and local planning
Benjamin Stevenson, US Department of Homeland
Security. DHS provides technical support and equipment
for detection, interdiction, and other capabilities. The Federal
www.health-physics.com
Copyright © 2020 Health Physics Society. Unauthorized reproduction of this article is prohibited.
343
Emergency Management Agency (FEMA) provides techni-
cal support for preparedness and planning. FEMA coordi-
nates an integrated federal response. The US Department of
Energy (DOE), EPA, and other federal agencies provide tech-
nical support and specialized assets. DHS Science and Tech-
nology provides technical support, tools, and guidance in
advance, so state and local communities can initiate a re-
sponse in the first few minutes and hours following a nuclear
or radiological incident. Products, tools, and documents must
be actionable; research and development solutions must be
compatible with existing capabilities and national response
protocols; and tools and resources must be comprehensive
to support the complexity and scope of a radiological re-
sponse and recovery. A radiological emergency should not
center on the radiological hazard or measurements. Instead,
it should focus on supporting the individuals, families, and
businesses impacted by the incident or hazard. Response
guidance, job aids for responders, and a resource library
can be found on the RadResponder (FEMA/DOE/NNSA/
EPA 2019) website.
The ROSS provides a means for use of local health
physicists and other personnel with radiological knowledge
to support radiological response operations in an emergency.
As envisioned, ROSS will support emergency operations by
supporting the incident command structure, helping to ac-
cess specialized federal resources and tools, interpreting
and explaining health physics response to data and predic-
tive modeling results, providing guidance to others involved
in the response, and heading public and responder commu-
nication efforts.
Communication issues identified and efforts to close
the gaps
Jessica Wieder, US Environmental Protection Agency.
The 2017 NCRP Annual Meeting (Ansari et al. 2017) identi-
fied priority communication gaps in emergency preparedness.
One of those tools developed to help fill the gaps was a series
of videos on how to protect oneself in a radiation emergency.
Booklets were developed that provide messages for emer-
gency responders. Social media messages were developed
for use following a nuclear detonation. Topics include nu-
clear attack warning, immediate safety messages, decontam-
ination, food and water guidance, medical needs including
potassium iodide, family and children concerns, evacuation,
plume maps, and fallout. Access to these tools is provided
on the PAG Publication Communication Resources webpage
(US EPA 2017).
Gamma gear: a video game to teach radiation detection
and protection to members of the public
Tristan Barr, Canadian Nuclear Safety Commission.
The Canadian Nuclear Safety Commission identified a need
for an outreach program that included use of instruments.
The program needed to encourage students to engage in
344 Health Physics
the training activities. The program needed to be scientifi-
cally and technically accurate and unique to attract and
maintain interest. The decision was made to develop an in-
teractive video game, Gamma Gear (CNSC 2018), which
teaches basic radiation protection concepts as well as basic
radiation physics and methods of detection. The game is bi-
lingual (French and English) and playable on PC, Mac, and
netbook (Chromebook) computers. Users learned the phys-
ical elements of an atom (neutrons, protons, electrons); radio-
active decay; alpha, beta and gamma radiation; radiation
interaction with matter including shielding; time, distance,
and shielding to control doses; and units of measurement.
The game explained the difference between radioactivity
and radiation doses as well as contamination and exposure.
It explained how to operate a radiation detector, how to find
radioactive sources, and how to apply all elements of the les-
son plan to find radioactive sources while limiting the dose
of radiation.
The game has been a very effective training tool for
youth. It is not always effective for the analog (40+ y of
age) generation. The game provides training when and
where training is needed and has been shown to be better
than videos or online training. The game can be used to train
emergency responders before and after an emergency. It has
been useful in building trust and disseminating information.
WASTE MANAGEMENT
William E. Kennedy, Jr., WE Kennedy Consulting,
Session Chair. Generation of radioactive waste has been a
routine part of industrial activities involving the use of radioac-
tive materials for more than a century. The waste classifica-
tions, disposal technologies, and regulations for radioactive
waste disposal, both nationally and internationally, have
changed over that time. As technology changes, new wastes
are generated, and disposal methods and systems are created.
This session addressed three important aspects of radioac-
tive waste disposal that our nation currently faces: treatment
of liquid high-level radioactive waste for safe disposal, re-
covery from the accident at the WIPP in New Mexico, and
continuing safe disposal of low-level radioactive waste.
High-level waste tank closure at the Savannah River
Site: What is being done to stabilize liquid radioactive
waste from the Cold War at Savannah River?
Kent Rosenberger, Savannah River Remediation
LLC. Tank closure at Savannah River Site involves both op-
erational and regulatory activities that can span many years
between the beginning of operations and the end of closure.
Although many challenges exist, the Savannah River Site
has been highly successful in operationally closing tanks
that formerly stored high-level waste. Three of the tanks
held 750,000 gallons of liquid waste; one held just over
www.health-physics.com
Copyright © 2020 Health Physics Society. Unauthorized reproduction of this article is prohibited.
April 2020, Volume 118, Number 4
1,000,000 gallons of waste; and four held 1.3 million gal-
lons each.
Steps to operational closure typically involved bulk
waste removal, tank cleaning to the maximum extent practi-
cal, isolation in residual sampling, and tank stabilization.
Waste removal equipment and use of chemical cleaning
was dependent on the type of tank and nature or form of
the materials to be removed. For example, use of purely me-
chanical cleaning was efficient in tanks without cooling
coils but potentially not as effective in those with coils.
Plans were different for each waste tank and involved selec-
tion from a menu of available equipment and technology
options. An example of the inventory from one of the tanks
included the radionuclides 90Sr, 99Tc, 129I, 137Cs, 233U,
234
U, 235U, 237Np, 238Pu, 239Pu, 240Pu, 241Am, and 243Am.
The final closure step involved grouting a cleaned tank.
This provided structural stability for the tank and prevented
subsidence. It also provided a barrier to intrusion and mini-
mized any voids in the tank. Successful tank closure is a
process that involves many organizations and stakeholders.
In general, stakeholders have been pleased with closure ac-
tions and are looking forward to completing more closures
in the future.
Contamination mitigation at the Waste Isolation Pilot
Plant in New Mexico: What has been done in the
aftermath of the americium accident at the Waste
Isolation Pilot Plant?
Casey Gadbury, US Department of Energy. WIPP is
a 4,144 ha facility located in southeastern New Mexico. It
is a deep geological repository mine within a 610 m thick
salt formation that begins ~260 m beneath the surface with
a waste horizon of 655 m. It was formed 250 million y ago
and is a stable geological area with no flowing water. The
waste is placed in chambers mined within the salt formation
that closes in on and encapsulates the waste permanently.
Rockfalls are potentially the single highest hazard to
workers in the WIPP mission. Salt rock is constantly mov-
ing at a rate of 7.6 to 12.7 cm y−1. The mine requires daily
inspections and mitigation, if needed. Ground control requires
remilling of floors, bolting and bolt replacement, installation
of chain mesh, and scaling operations. Waste containers are
placed on a waste hoist for descent underground. Once under-
ground, waste is removed from the hoist and transported to a
disposal room. Waste is placed in recently mined rooms, and
magnesium oxide is placed on waste stacks to control solubil-
ity of radionuclides in the event of hypothetical brine intrusion.
The mine is ventilated at a rate of 425,000 CFM. Ventilation is
required to remove volatile organic compounds that off-gas
from waste containers. The ventilation also removes carbon
monoxide and provides fresh air. Unlike fixed nuclear facili-
ties, air volumes and flow routes are regularly changed to sup-
port different activities.
 Summary of NCRP 2019 Annual Meeting c R. J. VETTER ET AL.
WIPP was opened 26 March 1999. As of 18 March
2019, 12,381 shipments have been received, and 95,454
m3 of waste have been disposed. The waste is contained in
176,411 containers disposed in the underground. WIPP is
the only deep geologic repository in the United States for
the permanent disposal of defense-generated transuranic ra-
dioactive waste from research and production of nuclear
weapons. While WIPP has been operated safely, it did expe-
rience a radioactive release event in February 2014. Approx-
imately 9 mo were needed to return to limited underground
operations. However, restart authorization was not granted
until December 2016. The first emplacement after the event
occurred on 4 January 2017. Shipping has increased to 10
shipments per week. Past average shipping rates ranged from
25 to 30 shipments per week.
Low-level waste disposal: An operator's perspective:
What is the day-to-day reality of “routine” low-level
radioactive waste operations?
Joseph J. Weismann, US Ecology, Inc. US Ecology is
the leading North American provider of environmental services.
The company operates five hazardous/nonhazardous landfills,
one radioactive waste landfill, 22 treatment and recycling facil-
ities, rail-accessible facilities and infrastructure, and 24 field ser-
vice centers and retail satellites. It services over 4,000 customers
covering a diverse mix of industries and segments.
US Ecology operates a 10 CFR Part 61 low-level radio-
active waste facility, one of four in the United States, located
on 40.47 ha (100 acres) within the DOE Hanford reserva-
tion near Richland, Washington. It was originally licensed
in 1965 and operates through a lease agreement with the
state of Washington. It is rate regulated by the Washington
Utility and Transportation Commission. The type of waste
accepted includes compact Class A/B/C low-level radioac-
tive waste, 10 CFR 61.55 (US NRC 2017), naturally occur-
ring and accelerator-produced radioactive material waste
nationwide, including radium, and exempt waste nation-
wide. Annual disposal volumes for the last 7 y have ranged
from nearly 400 m3 to nearly 700 m3. Routine operations
include environmental monitoring, groundwater sampling,
monitoring of incoming vehicles and containers, physical
inspections, waste placement, large component placement,
secondary containment, and liner placement.
FREQUENTLY ASKED QUESTIONS: MEDICAL
AND OTHER TOPICS
Jerrold T. Bushberg, Ph.D., University of California
Davis, and Richard J. Vetter, Mayo Clinic, Session
Co-Chairs
Exposure to ionizing radiation is a common experience
during medical evaluation of patients in hospitals and clinics.
While most people are not fearful or simply assume medical
www.health-physics.com
Copyright © 2020 Health Physics Society. Unauthorized reproduction of this article is prohibited.
345
personnel would not expose them to harm, some patients
experience a range of emotions from slight anxiety to signif-
icant fear. Some patients will research their questions by surf-
ing the internet while others will direct their questions to
reputable organizations, such as the NCRP or the Health
Physics Society. In this session, individual panel members re-
sponded to selected frequently asked questions and misstate-
ments that have appeared in the scientific literature and
popular media. The panel presentations were followed by
comments and discussion by other panel members offered
in response to questions from the audience.
• Common Statement: Medical Radiation and the Increase
in Cancer. "DESPITE great strides in prevention and
treatment, cancer rates remain stubbornly high and may
soon surpass heart disease as the leading cause of death
in the United States. Increasingly, we and many other ex-
perts believe that an important culprit maybe our own
medical practices: we are silently irradiating ourselves
to death."
Jerrold T. Bushberg: University of California Davis
School of Medicine. This quote from a New York Times
(2014) editorial decrying the increased radiation exposure
to the population from the use of CT scans in medicine is
not only misguided and inflammatory, it is also misleading.
While most imaging professionals would agree there is a
need for some improvement in following established appro-
priateness criteria when ordering CT scans, it can hardly be ar-
gued that this has any relationship to the fact that cancer may
soon surpass heart disease as the leading cause of death in the
United States. In fact, the reason that death from cancer may
eclipse death from heart disease is not because of soaring can-
cer rates (as implied in the editorial) but rather the dramatic de-
crease in cardiovascular mortality over the last several decades
resulting from significant improvement in cardiovascular pre-
ventive health initiatives and new medications, which have
improved both morbidly and mortality statistics.
No one argues that experts should not inform patients
about serious risks of medical procedures. However, which
procedures should be included and how to inform the pa-
tient is controversial. Studies have shown that only 70% of
parents were willing or very willing to proceed with a head
CT scan of their child thought to be necessary by the emer-
gency department physician for evaluation of a head injury
after being informed of the risk of radiation-induced cancer,
compared with 90% before being informed. This risk aver-
sion is particularly troubling given the well-established ben-
efit of CT scanning in this setting. The yield (1–8%) of
detecting acute traumatic brain injury on a pediatric head
CT following clinical decision rules at the point of care is
more than 100 times greater than the theoretical future risk
of radiation-induced cancer.
346 Health Physics
Patients have a right to expect that everyone associated
with their care will do their best to make judgments in the
best interest of their patients. This rightly includes a quality
control and quality assurance program in the imaging cen-
ters that, among other things, endeavors to see that patients
receive the most appropriate exam for the clinical question
at hand, performed at a dose that is optimized for the diag-
nostic purpose for which it is intended. Too little radiation
may reduce image quality to a point that either lowers the
confidence of the radiologist’s interpretation of the exam
or requires the exam to be repeated. Too much radiation
adds only additional risk and does nothing to improve the
interpretation. While it is correct for patients to be informed
of potential risks, it is misguided to scare patients to the
point where they may refuse a critically needed exam out
of an exaggerated fear of the potential consequences. Physi-
cians take an oath to care for their patients to the best of their
ability, to treat them with respect and dignity, and treat them
as whole persons. Although the guiding principle for all
physicians, “first do no harm,” was not actually in the orig-
inal Hippocratic oath, this well-known phrase summarizes
their intent and promise.
• Common Statement: “In a nuclear detonation, we are all
dead anyway.” (The most common excuse for not prepar-
ing for the consequences of a nuclear detonation.)
Brooke R. Buddemeier, Lawrence Livermore Na-
tional Laboratory. The top myth for not being prepared to
survive a nuclear detonation is, “It doesn’t matter, we are
all dead anyway.” The example used in this presentation is
a 10 KT yield ground-level detonation at Times Square dur-
ing the workday. Fallout particles will collect on the ground
under the cloud, creating dangerous radiation levels close to
the detonation. Within 2 h, winds will spread the cloud
downwind, resulting in contamination of the ground under the
cloud. A lack of any sheltering whatsoever will result in serious
exposures (enough dose to make a person sick or to be lethal)
of nearly 1.5 million people. Poor sheltering will cut this num-
ber in half. Adequate sheltering will reduce the number of se-
rious exposures by one-half again, and good sheltering will
reduce the number by approximately one-half again.
People should be taught that when seeking shelter, get
inside a building and stay there. Listen for public announce-
ments on what to do next. If possible, go to the basement or
middle of a building. Plan to stay inside 12–24 h unless pro-
vided updated guidance. An AM/FM radio is best for
staying connected; cellular and internet should be used if
available. Interviews with people in Hawaii after the false
alert showed that significant anxiety was generated by peo-
ple not knowing what to do. For imminent nuclear threats, it
is best to get inside a basement or central room in a building
away from windows and doors. Stay inside and listen for
www.health-physics.com
Copyright © 2020 Health Physics Society. Unauthorized reproduction of this article is prohibited.
April 2020, Volume 118, Number 4
more information. For nuclear fallout, people generally have
15 min or more to take action after a detonation.
The best public protection strategy for these events is to
get inside, stay inside, and stay tuned. In a large city over
one million people can be saved through proper action, both
individual action and community leadership. The first hour
is the most critical. A prepared public is critical; just a little
information can save many lives.
• Common Question: “Are the health risks from exposure
to internally deposited radionuclides different from those
from acute external exposure?”
Raymond A. Guilmette, Lovelace Respiratory Re-
search Institute. During acute whole-body exposure to ra-
diation, the radiation dose occurs at the same time as
exposure to the radiation. For penetrating radiation, the
dose is relatively uniform over all organs. For internal ra-
dionuclides that distribute throughout the body, dose ac-
cumulates over time as the radionuclide decays. Dose is
often nonuniform because it is distributed among the or-
gans at various rates. For example, when 238U is inhaled
as an oxide, the largest fraction is deposited in the liver
and skeleton. Next is soft tissue including lungs and kid-
ney, and the lowest fraction is deposited in the lymph
nodes. The physical distribution of radiation dose will
vary depending upon the penetration for alpha, beta, and
gamma radiations. It will also vary due to different distri-
butions of radionuclides among organs and tissues. Some
radioactive chemicals will be distributed somewhat uni-
formly in the body while others are deposited in larger frac-
tions in specific organs such as radioactive iodine, which is
preferentially distributed in the thyroid, and strontium, which
is deposited in bone. Research has shown that the decreased
dose rate from internally deposited radionuclides also de-
creases the biological effects at all levels of the biological or-
ganism compared to acute dose rate external exposures.
• Common Statement: “Experience has shown that most
people faced with a large-scale disaster will either panic
or suffer from psychological incapacitation.”
Randall N. Hyer, Center for Risk Communication.
True panic is rare and is associated with intense contagious fear.
Panic is often associated with inaccurate or misleading informa-
tion, unfounded reassurance, incompetent spokespersons, or
absence of a plan. Panic risk factors include belief that
there is a small chance of escape; seeing oneself as being
at high risk of being harmed; highly limited information
and resources for assistance; perceptions of a first-
come, first-serve response system; perceived lack of ef-
fective crisis management; and loss of credibility by crisis
management authorities.
 Summary of NCRP 2019 Annual Meeting c R. J. VETTER ET AL.
Panic can be avoided by providing frequent information
from highly visible leaders and spokespersons trained in cri-
sis communication. The message should include meaningful
actions that increase resilience, group interaction, connected-
ness, and perceptions of personal control and self-efficacy.
Messages should be clear, brief, timely, and contain consis-
tent information from trusted, competent, honest, caring,
and empathetic sources.
We have learned (from large-scale events such as
Fukushima, pandemic, and severe acute respiratory syn-
drome) that the spokespersons must be caring, trustworthy,
consistent, and credible. They must be truthful, open, trans-
parent, and honest. Panic is rare when the message is real-
istic and people are given time to adjust to the situation.
Messages must educate and inform and encourage helpful
behaviors. When communications are clear, factual, verified,
and acknowledge uncertainties of the situation and are regu-
larly timed, people are unlikely to panic and are likely to take
appropriate action to protect themselves.
• Common Question: “Do CT exams give you cancer?
Fred A. Mettler, Jr., University of New Mexico
School of Medicine. In terms of cancer causation, there
is nothing unique about a CT scan. Human tissue has no
idea where the radiation comes from. The absorbed dose
is the issue. Many CT examination protocols make two to
three passes through the same tissues doubling or tripling
the dose. In an unusual case, a number of scans may pass
through the same tissue during one examination, resulting
in relatively high organ doses. In rare cases, patients have
received more than 100 CT scans of the same area of the
body. In such cases, the risk of cancer is increased. However,
even when radiation doses are high enough to cause a
localized erythema or hair loss, the risk of cancer induction
from the CT scan is very low, comparable to normal or
spontaneous risk of cancer.
• Common Statement: “The linear no-threshold model
doesn’t accurately represent radiation effects at low doses.”
Richard J. Vetter, Mayo Clinic. Presentations in this
meeting by Eric J. Grant and Richard Wakeford examined
the issue of threshold vs. no-threshold effects from low
doses of radiation. In none of the studies discussed was
there a beneficial effect of radiation observed. Adaptive ra-
diation doses have been observed, but such affects are very
time dependent and may be due to immune stimulation. The
bottom line is that the question of whether radiation re-
sponse is linear, no-threshold, or threshold is really not in
play during most medical decisions due to the large benefit
vs. risk ratio.
Incorporation of a threshold model into regulatory
space would be difficult because most radiation workers
www.health-physics.com
Copyright © 2020 Health Physics Society. Unauthorized reproduction of this article is prohibited.
347
receive cumulative doses that are <100 mGy. Not all popu-
lations are equally sensitive to radiation, and not all tissues
have the same response to radiation. This would require
some form of differentiation between threshold and no-
threshold radiation-induced cancers. NCRP has carefully
assessed the most currently available epidemiologic evi-
dence and has concluded that the LNT model, perhaps mod-
ified by a dose rate effectiveness factor, should continue to
be used for radiation protection purposes.
- “Low-dose radiation exposure, 100 to 200 mSv, is likely
beneficial, not harmful.”
- “Is the linear no–threshold model still suitable for setting
standards for protection against radiation?”
- “Radiation safety programs must establish compliance
with radiation regulations which continue to be based on
the linear no-threshold (LNT) hypothesis and the ALARA
principle, despite overwhelming sound, peer reviewed sci-
ence that demonstrates the existence of a carcinogenic thresh-
old and/or hormesis at low doses. Yet despite compelling
evidence revealing LNT to be fraudulent, the consistent re-
sponse taken by regulatory agencies and scientific bodies
whose recommendations are cited as the basis of regulatory
actions is to deflect or rationalize away the science at best
or simply pretend it doesn't exist at worst so as to maintain al-
legiance to a world view of radiation safety built on ALARA
and LNT.”
These quotations are representative of a number of pa-
pers of an inflammatory nature. However, some anti-LNT
papers are thoughtful and professional. The word fraudulent
means obtained, done by, or involving deception. Some-
thing fraudulent is intentionally false and meant to harm
or deceive. The epidemiological studies that support the
LNT hypothesis were not fraudulent. During the review of
epidemiological studies, papers that suggested a threshold
response were not ignored. Since many cancers occur naturally,
demonstration of a threshold by experiment is difficult. Studies
that have been reviewed and provide support for the LNT hy-
pothesis include the lifespan study, worker studies including
INWORKS and Mayak, environmental studies including Techa
River and Chernobyl, studies of high background radiation
areas, and childhood and adolescence radiation studies. The
studies have included evaluation of the dosimetry, epidemi-
ologic methods, strengths and weaknesses of the study, and
implications for the LNT model and radiation protection.
Most of these studies have demonstrated support for the
LNT model. The preponderance of study subjects had cumu-
lative doses under 100 mGy, therefore qualifying as low-dose
studies. These studies also show that low-dose or low dose-
rate exposures may be linear with a shallower slope than is
seen for high acute doses.
• Common Question: “How much radiation is safe?”
348 Health Physics
Jessica S. Wieder, US Environmental Protection
Agency. The answer to this question is, “It depends.” The bi-
ological response to radiation exposure depends on a variety
of factors such as the source of radiation, the radionuclide,
the activity, dose or concentration, the exposure pathway
(e.g., external, inhalation, ingestion), whether the exposure
was whole body or limited to specific organs, the time over
which the dose is deposited, age, and gender of those ex-
posed, among others. Whether radiation is safe also depends
on the individual’s perception of risk, because “safety” is as
much a feeling as it is a number. Statistics show that nearly
11 out of 100,000 members of the population in the United
States die in a car accident. Yet, many people consider driv-
ing to be a safe activity. The LNT model shows that ~99%
of individuals would never get cancer as a result of a uniform
whole body exposure of 100 mGy. Nearly 40% of men and
women will be diagnosed with cancer at some point during
their lifetimes. For most of these cancers, when they began
or what caused them to occur is unknown. Yet people are
fearful of small doses of radiation.
Opportunities for improvement of the perception of
risk include development of a consensus on a practical def-
inition of “safe.” This would help people to determine what
risk is acceptable for them or for a child. When communi-
cating risk to individuals, it is helpful to show compassion
for the individual, validate their feelings, and demonstrate
a commitment to their health.
Acknowledgments—The 2019 Program Committee: Fred A. Mettler, Jr., Chair,
University of New Mexico School of Medicine; Jerrold T. Bushberg, Co-Chair,
University of California Davis School of Medicine; Richard J. Vetter, Co-
Chair, Mayo Clinic (Emeritus); and Members: Brooke R. Buddemeier,
Lawrence Livermore National Laboratory; Donald A. Cool, Electric Power
Research Institute; Lawrence T. Dauer, Memorial Sloan-Kettering Cancer
Center; Raymond A. Guilmette, Lovelace Respiratory Research Institute (retired);
Janice L. Huff, National Aeronautics and Space Administration; Randall N. Hyer,
Center for Risk Communication; William E. Irwin, Vermont Department of
Health; William E. Kennedy, Jr., WE Kennedy Consulting; R. Julian Preston, US
Environmental Protection Agency; Roy E. Shore, New York University Langone
School of Medicine; and Jessica S. Wieder, US Environmental Protection Agency.
REFERENCES
Ansari A, Salame-Alfie A, Toohey R. Assessment of national ef-
forts in emergency preparedness for nuclear terrorism: is there
a need for realignment to close remaining gaps? Health Phys
News XLV:1–5; 2017. Available at https://ncrponline.org/
www.health-physics.com
Copyright © 2020 Health Physics Society. Unauthorized reproduction of this article is prohibited.
April 2020, Volume 118, Number 4
wp-content/themes/ncrp/PDFs/2017/HPNews_NCRP2017_
AnnMtg_Summary.pdf. Accessed 20 July 2019.
Boice JD Jr. NCRP vision for the future and program area com-
mittee activities in 2018. Health Phys 116:282–294; 2019.
Canadian Nuclear Safety Commission. Gamma Gear video game
[online]. 2018. Available at https://nuclearsafety.gc.ca/eng/
resources/learning-portal/gamma-gear-game.cfm. Accessed
20 July 2019.
Federal Emergency Management Agency/US Department of Energy/
National Nuclear Security Administration/US Environmental
Protection Agency. RadResponder [onliner]. 2019. Available
at https://www.radresponder.net/. Accessed 20 July 2019.
International Commission on Radiological Protection. 1990 rec-
ommendations of the International Commission on Radiolog-
ical Protection. Thousand Oaks, CA: Sage Publications; ICRP
Publication; 60; 1991.
National Council on Radiation Protection and Measurements. Po-
tential for central nervous system effects from radiation exposure
during space activities. Phase I: overview. Bethesda, MD: NCRP;
Commentary No. 25; 2016a.
National Council on Radiation Protection and Measurements. Guid-
ance on radiation dose limits for the lens of the eye. Bethesda,
MD: NCRP; Commentary No. 26; 2016b.
National Council on Radiation Protection and Measurements. Impli-
cations of recent epidemiologic studies for the linear-nonthreshold
model and radiation protection. Bethesda, MD: NCRP; Commen-
tary No. 27; 2018.
National Council on Radiation Protection and Measurements. [online].
NCRP website homepage; 2019. Available at https://ncrponline.
org/. Accessed 20 July 2019.
New York Times. We are giving ourselves cancer [online]. Avail-
able at http://nyti.ms/lhUyUlq. Accessed 30 January 2014.
US Environmental Protection Agency. PAG Public Communica-
tion Resources [online]. 2017. Available at https://www.epa.
gov/radiation/pag-public-Communication-resources.
Accessed 20 July 2019.
US Nuclear Regulatory Commission. Waste classification. Washington,
DC: NRC; 10 CFR 61.55; 2017. Available at: https://www.nrc.
gov/reading-rm/doc-collections/cfr/part061/part061-0055.
html. Accessed 20 July 2019.
US Nuclear Regulatory Commission. Petition for rulemaking—
requirements for filing. Washington, DC: US NRC; 10 CFR
2. 802; 2018. Available at https://www.nrc.gov/reading-rm/
doc-collections/cfr/part002/part002-0802.html. Accessed 20
July 2019.
US Nuclear Regulatory Commission. [online]. US NRC website
homepage; 2019. Available at https://www.nrc.gov. Accessed
20 July 2019.
■■