Comprehensive Health Risk Management After the Fukushima Nuclear Power Plant Accident

Clinical Oncology xxx (2016) 1e8

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Clinical Oncology

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Overview Comprehensive Health Risk Management after the Fukushima Nuclear Power Plant Accident

y S. Yamashita * on behalf of the Radiation Medical Science Center for the Fukushima Health Management Survey * Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima Medical University, Fukushima, Japan y Atomic Bomb Disease Institute, Nagasaki University, Nagasaki, Japan

Received 4 January 2015; accepted 4 January 2015

Abstract

Five years have passed since the Great East Japan Earthquake and the subsequent Fukushima Daiichi Nuclear Power Plant accident on 11 March 2011. Coun- termeasures aimed at human protection during the emergency period, including evacuation, sheltering and control of the food chain were implemented in a timely manner by the Japanese Government. However, there is an apparent need for improvement, especially in the areas of nuclear safety and protection, and also in the management of radiation health risk during and even after the accident. Continuous monitoring and characterisation of the levels of radioactivity in the environment and foods in Fukushima are now essential for obtaining informed consent to the decisions on living in the radio-contaminated areas and also on returning back to the evacuated areas once re-entry is allowed; it is also important to carry out a realistic assessment of the radiation doses on the basis of measurements. Until now, various types of radiation health risk management projects and research have been implemented in Fukushima, among which the Fukushima Health Management Survey is the largest health monitoring project. It includes the Basic Survey for the estimation of external radiation doses received during the ﬁrst 4 months after the accident and four detailed surveys: thyroid ultrasound examination, comprehensive health check-up, mental health and lifestyle survey, and survey on pregnant women and nursing mothers, with the aim to prospectively take care of the health of all the residents of Fukushima Prefecture for a long time. In particular, among evacuees of the Fukushima Nuclear Power Plant accident, concern about radiation risk is associated with psychological stresses. Here, ongoing health risk management will be reviewed, focusing on the difﬁcult challenge of post-disaster recovery and resilience in Fukushima. Ó 2016 The Royal College of Radiologists. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Key words: Fukushima; health management; health risk; mental care; radiation exposure

Statement of Search Strategies Used and Introduction Sources of Information Before the Fukushima Nuclear Power Plant (NPP) acci- This paper reflects expert opinion and current literature dent, we were, unfortunately, enchanted, without reserve, accessed by the authors; no formal search strategy has been by the myth of the safety of nuclear power in Japan, defined. although the importance of emergency radiation medicine was seriously discussed on the global radiation protection arenas, such as the International Atomic Energy Agency (IAEA) Incident and Emergency Center [1] and the World Health Organization (WHO) Radiation Emergency Medicine Preparedness and Response Network [2]. The WHO Inter- national Project on the Health Effects of the Chernobyl Ac- Address for correspondence: 1-12-4 Sakamoto, Atomic Bomb Disease cident had previously identified health issues as a result of þ Institute, Nagasaki University, Nagasaki 8528523, Japan. Tel: 81-95-819- the Chernobyl NPP accident [3]. A review of comprehensive 7116; Fax: þ81-95-819-7117. E-mail address: [email protected] health risk management after the Fukushima NPP accident http://dx.doi.org/10.1016/j.clon.2016.01.001 0936-6555/Ó 2016 The Royal College of Radiologists. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: Yamashita S, et al., Comprehensive Health Risk Management after the Fukushima Nuclear Power Plant Ac- cident, Clinical Oncology (2016), http://dx.doi.org/10.1016/j.clon.2016.01.001 2 S. Yamashita / Clinical Oncology xxx (2016) 1e8

[4] and useful information on the radiation risk of childhood the evacuation prepared area or the measures that were thyroid cancer at the standpoint of rehabilitation and implemented to limit the consumption of food and re- revival for Fukushima [5] have also been reported. strictions on shipment, the WHO dose estimates were One of the most important lessons learned from Cher- calculated from the viewpoint of protection. It has been not nobyl was to avoid the initial exposure to radioactive io- too surprising that these ‘worse case scenario’ assumptions dines released from nuclear accidents, thus reducing or resulted in overestimated values. According to these, a 1- preventing the risk of radiation-associated childhood thy- year-old child’s thyroid equivalent dose was estimated to be roid cancers [6,7]. Therefore, retrospective analysis of thy- in the range of 10e100 mSv in Minami-soma, Iwaki and roid dose is of paramount importance in Fukushima, and Iitate-mura, and 1e10 mSv in prefectures adjacent to the tentative data available so far have suggested no future Fukushima. However, these thyroid equivalent doses are possibility of increased risk of childhood thyroid cancer markedly different from the actual values derived from the [8,9]. However, psychosocial and mental health conse- thyroidal screening and examination with a whole body quences, including post-traumatic stress disorders, are very counter. important issues to be solved in Fukushima and are similar According to the report on the thyroid internal exposure to those seen after Chernobyl [10]. examination, which the Japanese Nuclear Safety Commis- Previous epidemiological studies of human health risk sion conducted from 26 to 30 March, just after the accident, from low dose and low dose rate exposure, as well as a thyroid equivalent dose of 100 mSv was considered to be those on the atomic bomb survivors cohort form a back- an overestimate [17]. As a result, there would hardly be any ground on which to develop a radiation health manage- increase in thyroid cancer. On the other hand, according to ment programme. The identification of a cause-and- the report by Hirosaki University [18], the thyroid equiva- disease relationship, however, is very difficult after any lent dose might have reached several 10 mSv in the infants radiological and nuclear accident because many con- who stayed within a distance of 20 km from the reactor site founding and modifying factors affect the chance of late at the time of the accident and it is necessary to observe occurrence of malignancy. Three recent papers included in them for a long period of time. the special issues of The Lancet commemorating 70 years Furthermore, using theoretical assumptions on the pre- of caring for survivors of the atomic bombing in Hiroshima liminary dose estimates mentioned above, the WHO has and Nagasaki reviewed the health effects associated with subsequently reported the projected health risk assessment exposure to radiation, which can be used to inform the in Fukushima [19]. The estimates stemming from inappro- probable consequences of the accident at Fukushima Dai- priate retrospective dose assumptions are far above the ichi [11e13]. The accidents at Chernobyl and Fukushima reality and may mislead the public into thinking there is a have highlighted similarities in potential public health more serious radiation health risk than actually exists. By effects of radiation, including health issues unrelated to contrast, according to the United Nations Scientific Com- direct radiation exposure. Long-term responses are mittee on the Effects of Atomic Radiation 2013 report [20] needed in order to overcome the difficult tasks of risk and the IAEA Fukushima report [21], no discernible management with respect to health in different categories increased incidence of radiation-related health effects is of Fukushima’s residents (evacuees, children, mothers and expected on the basis of more accurate dose estimates in aged people), and these should be provided to achieve an Fukushima. Unfortunately, however, the public concern effective care for the complex problem that people over the fear of childhood thyroid cancer risk due to the confront [14]. Fukushima accident has never disappeared. From now on, it The recent progress of the Fukushima Health Manage- is necessary to develop a consensus of the accurate dose ment Survey project will be summarised and discussed here estimation based on the actual conditions, together with to identify the future direction of appropriate and well- the continuation of regular health check-ups in Fukushima. balanced radiation risk management in Fukushima, including the model of recovery used in the village of Kawauchi [15]. Outline of the Fukushima Health Management Survey

Fukushima Nuclear Power Plant Accident Following the Fukushima NPP accidents in March 2011, it and Radiation Dose became apparent that the residents of Fukushima Prefecture were unavoidably exposed to some amount of radiation The WHO promptly released its estimation of the doses fallout, even if this might be comparable with the natural received by the populations around Fukushima in May 2012 yearly background levels in other areas of the world. Thus, [16]. By applying incomplete data from the System for the Fukushima Mimamori Project (Health Management Prediction of Environmental Emergency Dose Information Survey) was initiated in May 2011 to treat and manage res- (SPEEDI) at ﬁrst and then using the airborne monitoring idents’ long-term health [22]. Owing to the vigorous efforts survey data by the Ministry of Education, Culture, Sports, of the Fukushima Health Management Survey Group, the Science and Technology of Japan (MEXT), based on conser- study protocol reached a mutual agreement with Fukushima vative and theoretical assumptions, not taking into account Prefecture and was endorsed by international radiation refuge and sheltering during 4 months after the accident in medicine and radiation protection experts [23]. Fukushima

Medical University has been carrying out this project from radiation doses that would probably lead to health its initiation, as requested by the prefecture, with the sup- consequences. port of national funding. The establishment of the Radiation Medical Science Center on 1 September 2011 is an ofﬁcial realisation of the earnest efforts of those involved in the Four Detailed Surveys Fukushima Health Management Survey. A new building will be completed in summer 2016 to strengthen the daily ac- The four detailed surveys being conducted are: (i) thyroid tivities of the health survey, data management, and disease ultrasound examination; (ii) comprehensive medical check- prevention and treatment for the patients who are newly up; (iii) mental health and lifestyle surveys; (iv) survey on diagnosed by this survey programme. pregnant women and nursing mothers (http://fukushima- At present, the Basic Survey and four detailed studies are mimamori.jp/). The study protocol for this health manage- being conducted targeting mainly the evacuees, children ment has been previously described [22]. Here, radiation and mothers in the entire Fukushima Prefecture. The health risk, especially risk of radiation-associated cancers, is Fukushima Health Management Survey Review Committee the main issue to be analysed, but apart from that, non- has met 20 times (four times per year) in the past 5 years, cancer effects of radiation or issues not directly related to overcoming a myriad of obstacles. Fukushima Medical radiation, such as chronic lifestyle diseases and psychoso- University is also involved in academic co-operation with cial/mental problems, are important issues to be taken care various domestic and international research organisations of in the residents of Fukushima. Several important points of to reinforce its role in radiation medical science research the survey results are brieﬂy discussed below. and education [24]. Thyroid Ultrasound Examination

Basic Survey Although health effects directly related to radiation exposure are highly unlikely under the current circum- The Basic Survey includes self-questionnaires mailed to stances and radiation levels in Fukushima, an increase in all prefecture residents, which primarily enquire into each childhood thyroid cancer in Chernobyl due to internal person’s habits, conduct and whereabouts during the 4 exposure to radioactive iodine exaggerated the uncertainty month period after the earthquake; participation in the of low dose radiation health risk and also stirred up a fear of survey is not compulsory. The aim is to estimate each per- radiation. As a result of the strong requests from people in son’s external radiation dose for the period when the Fukushima, as well as the central and local governments, airborne radioactivity was at its peak. The individual thyroid ultrasound examinations were started in October external radiation doses are estimated by using digitised 2011, targeting around 370 000 children who were younger behaviour data and a computer program that considers daily than 18 years old at the time of the accident. Children will gamma ray dose rate maps drawn after the accident [25]. be examined every 2 years until they reach the age of 20 As the details of methods and results have been sepa- years old and then every 5 years after that. These exami- rately described [26], overall results of the estimation of nations will be repeated for a long time and will follow a external radiation doses are introduced as a dose distribu- standardised protocol developed by the Fukushima Medical tion by area in Fukushima and are accessible online to the University in co-operation with related hospitals and or- public in Japanese [27] and in English [24]. Among 2.05 ganisations. The protocol of thyroid ultrasound examination million, the individual external doses of 422 394 residents is well established so that a highly advanced diagnostic for the first 4 months (excluding radiation workers) had the approach is implemented with standardised data collection following distribution: 62.0% less than 1 mSv; 94.0% less (for further information, see [34] in this special issue). than 2 mSv; 99.4% less than 3 mSv. The average was less From the standpoint of clinical oncology, the risk of the than 1 mSv in the entire population analysed. The Review development of cancer and the role of the environment are Committee judged these data as an indication that ‘the critically important to understand the mechanism of any impacts of radiation on health are minimal’. However, carcinogenesis, especially of thyroid cancer after the future efforts are required for the health management of the Fukushima NPP accident. Simultaneously, to avoid any residents and to reduce their total radiation dose. On the misinterpretation of the data obtained in Fukushima, a basis of geographical distribution, more than 90% of the sound knowledge of biology, epidemiology, statistics and local residents in the middle and northern regions of other scientific disciplines is needed. In particular, the effect Fukushima received less than 2 mSv/4 months, about 91% of enhanced detection on the increase in thyroid cancer by less than 1 mSv/4 months in the southern region of ultrasound examination is well documented all over the Fukushima and more than 99% less than 1 mSv/4 months in world [35e40]. The debates about high detection rates of the Aizu and South Aizu regions of Fukushima, which are thyroid cancer by ultrasound screening and/or over- relatively far from the NPP site. diagnosis should therefore be carefully examined [41,42]. Apart from the first 4 month external radiation exposure The results of the first round ultrasound examination dose estimation in Fukushima, the data obtained from in- during the first 4 years after the Fukushima NPP accident ternal dose measurement using whole body counters have are presented below; further details are presented in [34]. been collated [28e33], indicating no alarming evidence of Among 300 476 children, 2275 were diagnosed with thyroid

Please cite this article in press as: Yamashita S, et al., Comprehensive Health Risk Management after the Fukushima Nuclear Power Plant Ac- cident, Clinical Oncology (2016), http://dx.doi.org/10.1016/j.clon.2016.01.001 4 S. Yamashita / Clinical Oncology xxx (2016) 1e8 nodules and referred to further secondary examination; institutions in the prefecture since January 2012. Compre- fine needle aspiration biopsy and cytological assessment hensive health checks have been carried out outside the was carried out in 537 cases. In total, 113 cases were diag- prefecture, with the co-operation of the Japan Anti- nosed or were strongly suspicious for thyroid carcinoma (38 Tuberculosis Association. Across Japan, 554 paediatric males and 75 females, 14.2 7.8 years old at the time of medical institutions are helping to conduct health checks diagnosis). The overall prevalence of childhood and for children aged 15 years or younger. adolescent thyroid cancer was calculated as 37.3 per In summary, the 2011 Comprehensive Health Check, 100 000 and the prevalence of thyroid cancer and other which comprises around 70 000 examinations, has clarified thyroid abnormalities did not differ across Fukushima Pre- the general health conditions of evacuees from the fecture. It should again be emphasised that the sophisti- government-designated evacuation zone after the Great cated screening activities for thyroid disease in Fukushima East Japan Disaster [48,49]. Obesity and hyperlipidaemia led to an increase in the incidence of thyroid cancer due to exist, even at young ages, and are increased in comparison earlier detection of non-symptomatic cases. Indeed, the with the previous years’ data on Fukushima Prefecture in ultrasound examination data using the same diagnostic adults of both genders. Liver dysfunction and hyperurice- criteria as in Fukushima clearly indicate a similar preva- mia increased at relatively young ages in males. Hyperten- lence of childhood and adolescent thyroid diseases, sion, glucose dysmetabolism and renal dysfunction including cancer in other regions of Japan [43]. A recent increased in adulthood and are most common in older ages. molecular analytical study showed that the genetic profile According to the comparative data of the health check re- of Fukushima thyroid cancers was completely different sults before and after the Fukushima NPP accident in chil- from that of post-Chernobyl radiation-associated thyroid dren and adults, the rates of obesity, glucose metabolic cancers in young patients [44]. dysfunction, hyperlipidaemia and liver dysfunction after In this respect, it is necessary to establish a system for a the disaster were higher compared with those before the long-term follow-up for the children in Fukushima in disaster. After the Fukushima NPP accident, the prevalence careful comparison with the control areas, as reviewed of diabetes increased significantly among the evacuees previously [45]. The by-products of this survey have sepa- compared with those among non-evacuees [50]. Further- rately contributed to the discovery of several new findings more, a hypo-high density lipoprotein cholesterolaemia of thyroid development, such as ectopic intrathyroidal was observed among the evacuees after the accident [51]. thymus [46] and age-dependent systemic thyroid volume Regarding the factors that contributed to these results, determination [47]. changes in lifestyle, diet, exercise and other personal habits Now, after completion of the first round of thyroid ul- caused by forced evacuation are suggested, although there trasound examination aimed at understanding the basal were interfering factors, such as the difference in health prevalence of thyroid diseases, including cancers, within check periods, age distribution, region distribution and the first 3 years in Fukushima, the second round of full-scale participation rate. In addition, the prevalence of atrial thyroid examinations was started in April 2014, targeting an fibrillation increased among residents of the evacuation established cohort of around 370 000 children from the zone after the NPP accident, with excess of alcohol intake entire Fukushima Prefecture at the time of the NPP accident. and obesity associated with it [52]. From the point of view of haematology, evacuation was also associated with changes Health Check-up in blood cell count, haemoglobin and haematocrit levels after the NPP accident, indicating the increased prevalence Detailed health examinations are being carried out in the of polycythemia stratified by smoking status or obesity [53]; residents of evacuation zones and also in those deemed to there was no specific change in the distribution of white be in need of healthcare based on their responses to the blood cell counts, including neutrophil and lymphocyte Basic Survey. The target population is around 210 000, counts, within 1 year after the NPP disaster in the evacua- including children who resided in the evacuated zones at tion zone [54]. Thus, the initial results of the comprehensive the time of the accident. The main objectives are to assess health check-up among evacuees indicate the importance of the examinees’ health conditions and achieve early di- periodic health checks to develop lifestyle recommenda- agnoses and treatment of lifestyle and/or other illnesses. tions and to systemically prevent various diseases, The content of the examinations differs depending on the including lifestyle-related diseases. examinee’s age, although all tests included in ‘specified medical check-ups’ are typically conducted. For persons Mental Health and Lifestyle Surveys aged 16 years or older, the Special Health Check-up as part of the Municipal National Health Insurance System has Changes in mental and physical health were indicated as been carried out, with additional items for the compre- one of the long-term effects of the Chernobyl disaster [55]. hensive health check among adults aged 40 years or older. As psychological stress is conceivable in residents coping Also, visiting mass health check-up clinics have been held with life in evacuee shelters and anxiety towards the radi- 104 times at 29 locations since January 2012 for people aged ation, surveys are being conducted to enable the provision 16 years or older who do not participate in the Special of appropriate care. Residents in evacuation zones and in- Health Check-up. For children aged 15 years or younger, the dividuals (about 210 000 people) deemed in need of health check-up has been held at 102 paediatric medical healthcare based on the Basic Survey results are asked to

Please cite this article in press as: Yamashita S, et al., Comprehensive Health Risk Management after the Fukushima Nuclear Power Plant Ac- cident, Clinical Oncology (2016), http://dx.doi.org/10.1016/j.clon.2016.01.001 S. Yamashita / Clinical Oncology xxx (2016) 1e8 5 respond to questions about their current physical and According to local reports, there has not been any increase mental condition, and lifestyle (diet, sleeping habits, to- in miscarriage or artificial abortion owing to the extensive bacco use, alcohol use and exercise). So far, the mental efforts of the Japanese Medical Association, especially ob- health and lifestyle surveys have been conducted twice (10 stetricians and gynaecologists. However, it is necessary to and 22 months after the NPP accident) to provide adequate gather more cases to draw a conclusion. Every year we mail mental care and lifestyle support for evacuees who are at the same, but slightly modified, questionnaires are mailed higher risk [56]. Among them, around 60 000 people to newly pregnant women to support their healthy life and responded to the specific questionnaire that included the reply anxiety and concern about radiation and health issues. SDQ, K6 and PCL scoring issues [56]. An analysis of the relationship between the perception of radiation risk and psychological condition among evacuees in Fukushima us- Discussion ing the K6 scale showed that the responders who believed that radiation exposure was very likely to cause health ef- The surveys in Fukushima are intended as a specific fects were significantly more likely to be psychologically response to initial radiation exposure and to mental distressed than other responders [57]. This means that the traumas caused by the accident and evacuation. The pri- earthquake and tsunami followed by the NPP accident mary purposes of the surveys are to assess residents’ radi- caused psychological distress among residents in Fukush- ation doses and to monitor residents’ health conditions, ima. These data reveal the persistence of acute phase re- which result in disease prevention, early detection and action and the possibility that they might have been early medical treatment, thereby maintaining and pro- confounded by other factors included in the survey should moting their future health. The standardisation and close be taken into consideration. Clearly, the residents need to be monitoring of diagnostic examinations outside of these followed up for a long time to detect the transition from the surveys remain a pending issue in the context of long-term acute to chronic reactions and also to clarify the quality of health management efforts, including mental care. In psychosocial and mental changes in order to support the particular, it is important not only for patients but for the recovery of corresponding health conditions. public to understand the relationship of cause-and-disease. Although studies of populations exposed to low doses Clinical manifestation of a radiation-related disease has a are limited in their ability to account for important lifestyle latent period, especially cancer, occurring as a late-onset factors, such as smoking, dietary habit and medical X-ray stochastic effect. If an ultrasound thyroid examination exposures, our investigations should be and are being shows signs of cancer in less than 3 or 4 years after the considered for reassurance and healthcare reasons. The accident, there is no tenable argument that could link that mental care provision in Fukushima is, therefore, essential cancer to radiation exposure from the accident. Going for- for a long time, as recommended by several experts, simi- ward, we need to address the issue of latency periods larly to that indicated after Chernobyl [55,58,59]. regarding examination results and the development of cancer from the standpoint of cancer biology and epide- Survey of Expectant and Nursing Mothers miology. Indeed, the high prevalence of BRAFV600E mutation in Fukushima children strongly suggests not only a different A survey was administered to women who received their oncogenic profile from Chernobyl but also an early detec- Maternal and Child Health Handbooks within and outside tion in children and adolescents of asymptomatic thyroid the prefecture, and to those who underwent pregnancy cancers that otherwise would (or would not) clinically check-ups or gave birth after 11 March 2011. They were manifest later in adulthood [44]. Also, we need to improve asked to respond to questions including health and preg- health risk communication on thyroid findings, not only to nancy check-ups they received since the earthquake, their target population but also to their parents, and to devise a physical condition during their pregnancy, the birth of their regional cancer registry for patients to avoid misunder- child and their mental wellbeing. In total, 15 972 ques- standing of the results of screening. tionnaires were distributed from January 2012 and 9298 The risk of radiation-associated physical health conse- responses were returned by 31 August 2012 (response rate quences for residents in Fukushima is quite different from 58.2%) [60]. Telephone counselling was provided by mid- that in Chernobyl, being considerably low or undetectable wives and public health nurses for 1393 respondents of according to the radiation dose estimates from the accident. 9228 (counselling rate 15.1%), who had been identified as However, there is a similarity of social, psychological and respondents requiring support on the basis of the survey economic impact between the two serious NPP accidents. response. The post-disaster incidences of stillbirth, pre- One of the confusions and perplexities is the issue of un- term birth, low birth weight and congenital anomalies certainty of thyroid cancer risk, especially after low dose were 0.25%, 4.4%, 8.7% and 2.7%, respectively. These in- exposure; it is difficult to communicate with the public and cidences are similar to recent averages in Japan. various stakeholders beyond dose estimates. For instance, it At the Center, maternity and public health nurses are is well known that the worldwide incidence of thyroid always on duty, handling calls and e-mails related to cancer is steadily increasing [61]. However, further in- childcare and child rearing. For consultees who require vestigations are required to determine additional factors further support, Fukushima Medical University maternity apart from radiation exposure contributing to this growth, nurses and hospital nurses are available by telephone. either in children and adolescents or adults [62]. Another

Please cite this article in press as: Yamashita S, et al., Comprehensive Health Risk Management after the Fukushima Nuclear Power Plant Ac- cident, Clinical Oncology (2016), http://dx.doi.org/10.1016/j.clon.2016.01.001 6 S. Yamashita / Clinical Oncology xxx (2016) 1e8 important point is that the over-diagnosis and over- [3] Yamashita S, Carr Z, Repacholi M. Long-term health impli- treatment of asymptomatic thyroid cancer should be care- cations of the Chernobyl accident and relevant projects of fully analysed because of good prognosis of this the World Health Organization. Health Phys e malignancy; many latent cases are detected. Therefore, the 2007;93(5):538 541. [4] Yamashita S. Tenth Warren K. Sinclair keynote address e The current ongoing programme of the Fukushima Health Fukushima nuclear power plant accident and comprehensive Management Survey is important to understand the natural health risk management. 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