Radiation Safety Culture in Medicine

AFROSAFERAD

Dr. Rose Nyabanda Consultant Radiologist Kenyatta National Hospital

03/27/2017 Ionizing radiation

-Ionizing radiation carries sufficient energy to free electrons from atoms or molecules - X-rays and Gamma rays are ionizing - Radio waves, infrared and visible light are non ionizing History The discovery of X-rays in 1895

• The dangers of radioactivity and radiation were not immediately recognized.

Taking an X-ray image with early Crookes tube apparatus in 1896 Prof Sievert Louis Harold Gray

Medical physicists who had major contribution in the study of the biological effects of radiation • Becquerel first person to discover evidence of radioactivity, who shared a Nobel Prize for physics in 1903 with Marie and Pierre Curie Atomic bombs/ Nuclear accidents

• 1945- Japanese atomic bomb studies began in 1950 and have formed the basis of radiation protection guidelines ever since.

• 1986- Chernobyl nuclear accident

• 2011 – Fukushima Daiichi nuclear disaster Global increase in the use of radiation Diagnostic Nuclear Radiotherapy radiology medicine 5.1 million radiotherapy treatment courses 3.6 billion procedures 33.5 million procedures annually* annually* (incl. dental) annually*

* UNSCEAR 2008 Report The increasing medical exposure UNSCEAR 1993 Global annual per caput effective dose The increasing medical exposure UNSCEAR 2008 Global annual per caput effective dose The increasing medical exposure NCRP160 2009 U.S. annual per caput effective dose Mechanisms of biological effects

Ionizing radiation causes displacement of an electron which can inflict damage on DNA either directly or indirectly.

Radiosensitive organs

• It is highest in cells which are highly mitotic or undifferentiated. E.g basal epidermis, bone marrow, thymus, gonads, and lens cells

• Relatively low radiosensitivity in muscle, bones, and nervous system tissues

Radiation doses

Deterministic Effects • Deterministic effects only occur once a threshold of exposure has been exceeded 1) Skin burn- 1-24hrs after 2Sv 2) Cataract- after 1-2 Gy 3) Sterility 4) Radiation Sickness - 1 Sv (1000mSv) 5) Fetal death Stochastic Effects • Linear No threshold 1) Cancer 2) Hereditary Defects Radiation protection principles

For Occupational Workers: – Time – Distance – Shielding For Patients: – Justification – Optimization – Dose Limits (diagnostic reference levels) For Public: - Distance -Shielding

A radiation-safety campaign developed by the radiation health workers in Africa AFROSAFE Main Objectives

• Unite the stakeholders with a common goal, to identify and address issues arising from radiation protection in medicine in Africa. Goal

• Encourage adherence to standards, policies, strategies and activities for the promotion of radiation safety and for maximization of benefits from radiological medical procedures. AFROSAFE IMPLEMENTATION TOOL

Tool launched on 5th Nov 2015 during radiation safety week: Nairobi, Kenya AFROSAFE NAIROBI CITY RADIATION SAFETY WALK 5TH NOV 2015 2015 AFROSAFE JOINS OTHER CONTINENTAL IMAGING CAMPAIGNS

2006

2010

2014

2015 AFROSAFE Strategies

1. Strengthen radiation protection of patients, health workers and public. 2. Promote safe and appropriate use of ionizing radiation in medicine. 3. Foster improvement of the benefit-risk dialogue with patients and the public. 4. Enhance the safety and quality of radiological procedures in medicine. 5. Promote safety in radiological equipment and facilities. 6. Promote research in radiation protection and safety. Appropriateness in medical imaging: "Best Test First !" • When choosing a procedure utilizing ionizing radiation, the benefit/risk balance must be carefully considered. • There is unnecessary use of radiation when clinical evaluation or other imaging modalities could provide an accurate diagnosis (e.g. US, MRI). • Clinical effectiveness (evidence based diagnostic/therapeutic impact) • Cost - cheaper and equally effective investigation • local expertise, available resources, accessibility and patient values have to be considered in addition to efficacy.

Causes of unnecessary irradiation

• Repeat exam- already done elsewhere • Wrong Investigation that may not be relevant to the clinical situation • Follow-up exam too quickly • Inadequate history • Over- investigation • Pressure and expectations from patient • Referring physician is also the provider of the service (economic interest) • Referring as a safeguard against possible malpractice liability (defensive medicine)

What are clinical Imaging guidelines?

Clinical decision guidance: In a specific clinical situation, if the clinician is considering an imaging study, what study is most likely to yield the most informative results, and whether another modality is equally or more effective, and therefore more appropriate considering the radiation dose to the patient. Safety culture and use of evidence-based guidelines and procedures • Clinical imaging guidelines were identified as a key element in the framework for enhancing radiation safety culture in health care www.afrosaferad.org Way forward

• Integration of radiation protection and the use of CIG in our education system for both undergraduate and postgraduate programs. • Communicate and disseminate information through our medical societies and professional bodies including PACORI  Awareness campaign to the clinicians and the public through AFROSAFE, to inform them about radiation safety and importance of appropriateness criteria  Involve the Radiation Safety Regulators • Improve infrastructure and IT. RIS/PACS, Repeats of examinations from one centre to another. • Emphasis on safety in Paediatric Imaging. Dedicate a paediatric Xray room and train specific radiographers to handle paediatrics • Develop institutional DRLs, this will assist us with knowing where we are compared to other regions (Research)  Clinical audit for proof of value, evaluation and monitoring Thank you Asante Acknowledgments • Kenya AFROSAFE steering committee ◦ Dr. Rose Nyabanda, Dr. Jessica Wambani, Dr. Gladys Mwango. Dr. Patricia Othieno, Mr. Luke Kanamu, Mrs. Margaret Njuwe, Mr. Caesar Barare, Mr. Kenneth Kariuki, Mr. Antony Mamati, Dr. Laban Thiga, Dr. Veronica Manduku, Dr. David Otwoma, Mr. Felix Wanjala, Mr. Collins Omondi Mr. Arthur Koteng and Ms. Catherine Michuki • ECUREI, Uganda – Prof Kawooya • Bab El Oued, University of Algiers, Algeria- Boudjema Mansouri • IAEA- Debbie Gilley • WHO- Dr. Maria Perez • Image Gently – Prof. Kimberly Applegate