Features Radiation sources: Lessons from Goiania An impressive co-operative response helped limit the accident's consequences and document the lessons learned On 13 September 1987, a shielded, strongly Argentina, France, the Federal Republic of radioactive caesium-137 medical source was Germany, the Soviet Union, the United Kingdom, removed from its housing in a teletherapy machine. and the United States provided other experts and Tne machine had been left in a clinic abandoned by equipment directly to Brazil.) the Instituto Goiano de Radioterapia in Goiania, Twenty persons in all were hospitalized. Despite the capital of the State of Goias in Central Brazil. intensive medical care, four of them died. Twenty- By 18 September, the source assembly had been eight had been seriously contaminated. Over the broken out of its protective shielding and sold to a next two months, a contamination monitoring scrap metal dealer. On 21 September, the source station set up in a stadium screened more than capsule, previously damaged, was broken open. 112 000 people. Hundreds had to be decon- Fragments of the source were distributed to other taminated. areas of the city. Many people were directly irradi- Once the seriousness of the accident had been ated by the source and were externally and inter- recognized, the most severely contaminated areas nally contaminated by caesium-137. Several were identified and closed off within a day. The persons became ill and sought medical attention. highest radiation levels were reduced substantially Finally, on 28 September, a medical physician in by shielding the areas affected. Within two weeks, Goiania recognized the characteristic symptoms of all the contaminated areas had been identified and radiation overexposure. A physicist who was con- isolated and the cleanup had begun. sulted the next day detected high radiation levels By late October, waste from the major decon- and promptly notified Goias health authorities, who tamination work began to be moved to a site desig- then contacted Brazil's National Nuclear Energy nated by Goias State 20 kilometres from Goiania. Commission (CNEN). The Goias officials then By mid-December, restrictions on the main con- evacuated the affected areas and began to identify taminated areas of Goiania had been lifted. More those persons who had been seriously exposed. than 3000 cubic metres of waste were removed and CNEN immediately sent an advance team to stored at the new repository. Goiania to help treat affected persons and to con- trol contaminated areas. CNEN mobilized substan- In all, more than 700 workers participated in the tial additional resources and an emergency response, including CNEN staff and personnel from response centre was set up to co-ordinate activities. the Brazilian army, NUCLEBRAS, FURNAS, the (Brazil informed the IAEA of the emergency and State of Goias, and private companies. Worker requested assistance under the new Convention on doses during the operation were held to an average Assistance in the Case of a Nuclear Accident or of about 20% of annual occupational limits. Radiological Emergency. The IAEA arranged for Details of the accident, the response to it, and assistance by US medical experts, for assistance lessons learned have recently been published by the from IAEA technical co-operation experts and the IAEA in the report The Radiological Accident in provision of dosimeters, and for the provision of Goiania. * The report is based on a review meeting monitoring equipment from France, the Federal of experts held in July 1988 in Rio de Janeiro under Republic of Germany, Hungary, Israel, the Nether- the joint organization of CNEN and the IAEA. The lands, and the United Kingdom. Separately, following summation is drawn from that report. * The report is available from the IAEA Division of Publications. See the Keep abreast section for ordering information. 10 IAEA BULLETIN, 4/1988 Features In Goiania, authorities desig- nated a nearby Olympic Stadium as a staging area for isolating patients and screening others for contamination. Shown here are some people being moni- tored. (Credit: CNEN) ! The accident ated connected the illnesses with the source capsule and It is now known that at about the end of 1985, a took the remnants to the public health department in the private radiotherapy institute, the Instituto Goiano de city. This action began a chain of events which led to th£ Radioterapia in Goiania, Brazil, moved to new discovery of the accident. premises, taking with it a cobalt-60 teletherapy unit and A local physicist was the first to assess, by monitor- leaving in place a caesium-137 teletherapy unit without ing, the scale of the accident and took actions on his own notifying the licensing authority as required under the initiative to evacuate two areas. At the same time, the terms of the institute's license. The former premises authorities were informed, upon which the speed and the were subsequently partly demolished. As a result, the scale of the response was impressive. Several other sites caesium-137 teletherapy unit became totally insecure. of significant contamination were quickly identified and Some time later, in September 1987, two people entered residents evacuated. the premises and, not knowing what the unit was but thinking it might have some scrap value, removed the The human consequences source assembly from the radiation head of the machine. Shortly after it had been recognized that a serious This they took home and tried to dismantle. radiological accident had occurred, specialists — includ- In the attempt, the source capsule was ruptured. The ing physicists and physicians — were dispatched from radioactive source was in the form of caesium chloride Rio de Janeiro and Sao Paulo to Goiania. On arrival, salt, which is highly soluble and readily dispersible. they found that a stadium had been designated as a tem- Contamination of the environment ensued, with one porary holding area where contaminated and/or injured result being the external irradiation and internal con- persons could be identified. Medical triage was carried tamination of several persons. Thus began one of the out, from which 20 persons were identified as needing most serious radiological accidents ever to have hospital treatment. occurred. Fourteen of these people were subsequently admitted After the source capsule was ruptured, the remnants to the Marcilio Dias Naval Hospital in Rio de Janeiro. of the source assembly were sold for scrap to a junkyard The remaining six patients were cared for in the Goiania owner. He noticed that the source material glowed blue General Hospital. A whole-body counter was set up to in the dark. Several persons were fascinated by this and assist in the bioassay programme and to monitor the over a period of days friends and relatives came and saw efficacy of the drug Prussian Blue, which was given to the phenomenon. Fragments of the source the size of patients in both hospitals to promote the decorporation rice grains were distributed to several families. This of caesium. Cytogenetic analysis was very helpful in dis- proceeded for five days, by which time a number of tinguishing the severely irradiated persons from those people were showing gastrointestinal symptoms arising less exposed who did not require intensive medical care. from their exposure to radiation from the source. Decontamination of the patients' skin and dealing The symptoms were not initially recognized as being with desquamation from radiation injuries and contami- due to irradiation. However, one of the persons irradi- nated excreta posed major problems of care. Daily hae- IAEA BULLETIN, 4/1988 11 Features The accident in Goiania in perspective Considerable information has been documented about accidents since 1945 with significant overexposure Serious radiation accidents reported, to radiation. Most of the accidents at nuclear facilities 1945-1987 occurred early in the development of the applications of Type of nuclear energy. Some were criticality accidents and No. of events Overexposures Deaths several were at experimental reactors. Although the inci- facility dence of radiation accidents in nuclear facilities has Nuclear decreased considerably over the years, the number of facilities 27 (34%) 272 (64%) 35 (59%) such accidents elsewhere has risen. Several accidents have affected members of the public. Some resulted in Non-nuclear deaths when control was lost over high strength sources, facilities which, unrecognized for what they were, ended up in the Industry 42 (52<>/o) 84 (20%) 20 (34%) public domain. Research 7(9%) 10(2%) - (-) The general picture seems clear and well documen- Medical 4 (5%) 62 (14%) 4 (1%) ted, even though some serious radiation accidents (for example, hand exposures of industrial radiographers) 80 (100%) 428 (100%) 59 (100%) may not have been reported and, to that extent, informa- An overexposure is taken here as exposure of the whole tion that would be useful for preventing similar accidents body, blood-forming organs, or other critical organs to is unavailable, in comparison with the number of deaths 0.25 Sv or more; of skin to 6 Sv or more; other external caused by other types of industrial accidents every year, exposure of 0.75 Sv or more; and internal contamination those due to accidental radiation exposure reported of half or more of the "maximum permissible organ bur- worldwide over 40 years are not many. However, the rela- den". (The concept of the "maximum permissible organ tively good safety record for applications of radiation burden" has now been superseded by the concept of the gives no grounds for complacency, especially where "annual limit of intake".) The table excludes patient- practicable, effective steps can be taken to reduce the related events and off-site exposures at Chernobyl. risks of such accidents. Fatal radiation accidents reported, 1945-1987 Fatalities Year Location Radiation source Worker Public 1945 Los Alamos, USA Critical assembly 1946 Los Alamos, USA Critical assembly 1958 Vinca, Yugoslavia Experimental reactor 1958 Los Alamos, USA Critical assembly 1961 Switzerland Tritiated paint 1962 Mexico City, Mexico Lost radiography source 1963 China Seed irradiator 1964 Fed.