Rehabilitation

GENERAL COMMENTS The CRPPH Expert Group on the Implications of ICRP Recommendations (EGIR) performed a detailed review of the ICRP draft document on Application of the Commission's Recommendations to the Protection of Individuals Living in Long Term Contaminated Territories after a Nuclear Accident or a Radiation Emergency (Version 4 – 22/07/08; 42-141-08). The EGIR appreciates the opportunity to provide comments to ICRP on this draft document, which is viewed as an important area for ICRP to provide recommendations. As an overarching comment on process, it was noted that the ongoing rapid pace of development of various ICRP (and other international) documents may negatively impact the broad participation of interested parties in the review process (due to time and resource issues), and therefore impact the provision of good feedback. The main message of this document seems to be the empowerment of the population in their own radiological protection through those actions affected by their individual behaviour. This is an important message, but it is felt that it could be more clearly and succinctly presented in the document. It is important to avoid give the impression that there is a duality of actions taken by authorities and by affected populations. Rather, it should be clearly expressed that the aim of the authorities will be to optimise the protection of the affected population. This will require actions on the part of the authorities and on the part of the affected populations. Thus, an integrated strategy should be developed in consultation with all stakeholders. To support the outcomes of these consultations and the direct involvement of affected populations in managing their exposure (self-help actions), the authorities should provide the necessary infrastructure and processes. Specific examples (from Chernobyl experience, etc) may be used to illustrate this approach, but ICRP should be cautious about using such examples as internationally-applicable principles. Concerning the details of the recommendations, it is noted that the document is very specific in its scope, dealing with only one type of existing situation, based largely on the Chernobyl experience (post-emergency, rural). However, given the nature of the topic, guidance on other types of existing situations would be useful. This should include recommendations for contaminated urban environments (urban populations, economic activities, etc). While the document largely reflects the Chernobyl experience, it was felt that the public reaction, behaviour and expectations on authorities may be significantly different under different social-political situations, which should be reflected in the recommendations. Currently, the document appears more academic than practical in nature. Thus, it would be useful to include more concrete technical aspects, recommendations and strategies for managing an existing situation, for example, information on actions to reduce contamination levels, planning aspects, etc. It would also be valuable to identify what is needed to improve the management of these exposure situation from perspective of additional information and research for example, research on how to reduce contamination levels, etc. Concerning justification in existing situations, it is important to note that the justification of protection strategies is a continual process, and begins prior to the existing situation. A protection strategy is associated first with its justification, and then its optimisation. Each time a major change in the strategy, or a new protection strategy, is proposed, the justification of such a change should be addressed. While this is implied in later sections of the document, this concept should be clearly stated in Section 3.1 on justification. Additionally, it is felt that the document leaves the impression that optimisation is an endless process, rather than oriented towards reaching an optimised strategy that will be implemented in a manageable fashion. In this regard, justification and optimisation should be presented in a more cohesive manner. The topic of relocation should also be more fully address in terms of criteria, the decision to terminate, etc. The discussion of phases appears very complex, and should be clarified, including clarification on the transition from an emergency situation to an existing situation. Additionally, the document does not talk about ending an existing situation. At some point, the situation may no longer need to be managed as an existing situation, and should become a normal (or non-exposure) situation. The termination of these situations should be addressed. ICRP is requested to clarify what is meant by a normal situation, whether the reference level refers to the additional dose or the total dose, and how it can be set a priori before a specific situation is characterised (e.g., Paragraph 48). Additionally, as the choice of reference level and methods of stakeholder involvement will be country specific, this should be better reflected in the document. Concerning terminology, it is noted that “exposure situation” is not used consistently in the document. Sometime it means the definition from ICRP 103 (planned, emergency, existing), other times it means a specific radiological conditions or characteristics. This should be clarified. References to normal situations, or return to normal conditions, should also be defined or explained. Finally, the use of “equitable”, “ inequity” etc is not clear and should be clarified. Annex A and B are viewed as potentially useful but should be clearly presented as examples. However, it is felt that the annexes do not yet sufficiently support the main text, or bring much added information. For example, the Annex A on past experience could provide more information such as actions taken, costs, results achieved, etc. Annex B should clearly indicated that this is an example of how stakeholder might be done, rather than a recommended approach. Annex C is not relevant to this report and should be removed. In order to achieve a more complete discussion of these types of exposure situations, the ICRP should also consider the adding the following additional sections/topics to the main text: • Management of Wastes Resulting from the Implementation of Protection Strategies. • Termination of an “Existing Situation” • Additional Needs for Improving the Management of Existing Situations (research, knowledge, etc). Finally, coordination with other recent ICRP documents should be addressed (eg, Pub 103, draft recommendations for emergency situations, etc). DETAILED COMMENTS 1. INTRODUCTION Paragraph 4: • The document should recognise that not all emergency situations lead to an existing situation • Text has been proposed to stress that the aim is to reach a condition of normality, rather than simply focusing on exposure (4) … It is characterised by a change in management, from strategies mainly driven by urgency, with potentially high levels of exposures and predominantly central decisions to more decentralised strategies aiming for a return to normality. … Paragraph 5: • “Permanently” is viewed as an unnecessary qualifier. Delete. • Somewhere in the document there should be a discussion on approaches to this decision or to possible approaches that could be adopted, eg, is it voluntary, would resources be supplied for those do not want to return to or stay in the contaminated area, etc? 2. LIVING IN CONTAMINATED TERRITORIES • This section could be more practically oriented, with fewer generalities. More concrete examples should be provided. Paragraph 10: More specific technical information or examples could be provided here Paragraph 11: • 1st sentence - It should be noted that groundwater and surface water pathways may contribute a significant portion of the dose to individuals living in the long-term contaminated territories.Other exposure pathways should be considered, particularly external-inhalation, direct exposure, etc (relevant for urban areas as well) • Concerning transfer through the environment, Some examples could be useful Paragraph 13: • The paragraph addresses the issue of “average individual.” However, the concepts of using “representative person” or “average member of the critical group” are missing from the text. The report should address these concepts and how they related to the “average individual.” • The implication of these variations in the dose distribution on resulting management choices should be specified. • Figure 1: The vertical scale shown on Figure 1 has no definition of units. The vertical scale should read “number of individuals.” It would be also useful to indicate more in detail the contents of the figure (population concerned, mode of exposure and methods of measurement) Paragraph 14: • “Daily intake of becquerels” mixes the quantity and its unit; it is better t use “daily intake off activity (in becquerels)”. Moreover what remains in the body at the end of the period is not significant for the dose (perhaps for the measurement). It should be stressed that it is the activity incorporated which plays a role, and not the activity present at one moment in the body. Alternatively, this teaching of incorporation dosimetry could be removed from the paragraph. • The issue is rather the fraction of contaminated food that is ingested. Perhaps alternative text could be “daily ingestion of contaminated food”. • Figures 2 and 3 are missing designations of the vertical scale units. • The following text changes are proposed: (14) … Figure 2 presents the evolution of the whole body activity associated with a daily intake of activity (in becquerels) of caesium over 1000 days. The curves are provided for different age groups per daily incorporated becquerel. … This illustrates the intrinsic different burden between daily ingestion of contaminated foodstuffs and periodic ingestion. In practice, for people living in contaminated territories, …. Paragraph 15: “As the annual dose is directly proportionate to the daily intake, doses in the range of 1 mSv/y and 10 mSv/y correspond respectively to a daily intake of 100-200 Bq to 1000-2000 Bq.” • The annual dose is related to all exposure pathways, not just ingestion. The text also implies that a single value of dose corresponds to a range of annual intake. It is unclear how to justify intake of 1000 and 2000 Bq to the same dose of 10 mSv/y. The report should provide more information and elaboration on uncertainties, if any, to explain correspondence of intake range to a single dose value. “These upper values are not compatible with “the desire from the exposed individual, as well as from the authorities, to reduce exposures to levels that are close to or similar to situations considered as normal” that is present in many existing situations as indicated by the Commission in Publication 103 (§288)” • The use of the word « desire » is unclear. Does it mean objective or strategy? Clearer language should be used here. Additionally, this statement does not seem to follow from the technical discussion of the relationship between intake and dose. A clearer link should be added to the text Paragraph 16: The focus again appears to be on a rural population, and only on ingestion. The document should be broader in scope of application. Paragraph 17: The discussion in this section should be broadened to include aspects of environment, economic activity, etc Paragraph 18: • The situations presented may not always be the case. Definitive statements should be avoided. Editorial changes proposed. (18) … which could feel helpless in front of the contamination. If experts and professionals in charge of managing the situations use scientific terms, measurement units and technical procedures, which are difficult to understand by non-specialists these could indirectly re-enforce their feeling of loss of control of the situation. Paragraph 19: “… the dilemma to leave the place or to stay. Experience shows that it is difficult to answer to this dilemma relying solely on radiation protection considerations. Many personal aspects are entering into the balance and generally people living in contaminated territories are very reluctant to leave their homes and they are preferably desiring to improve their living conditions.” • This text should make the link to the decision by the authorities to allow people to live in the area. It needs to be stated that it is the duty of the authorities to properly manage the situation and address these questions. Paragraph 20: • Statements regarding individual behavior such as in this paragraph should be supported by references addressing psychological aspects. Additionally, this will be impacted by the efforts of the authorities. These aspects have been included in the proposed change. (20) …This is only possible with a good knowledge of the situation and the possibility to act in a prudent way. It is the responsibility of the authorities to provide such knowledge. It also implies to be personally involved in the rehabilitation process with the objective to improve the daily life. Paragraph 21: • The statement on shifting approaches presents problems in that it may not reflect the approaches that may be taken by different governments (for example, centralised approaches could be effectively adopted). ICRP is requested to reword this, and reflect in this paragraph the broader experience contained in Annex A. • Additional text is proposed to reflect the important role of authorities (21) … In this perspective, authorities could shift after the early phase … The role for the authorities (both national and local) should be to create the best conditions so that the population can return to normality. This includes managing the situation so that populations have confidence in the authorities, as well as creating the conditions that facilitate involvement of the population in their own protection. The aim should be to help individuals to … 3. APPLICATION OF THE COMMISSION’S SYSTEM TO THE PROTECTION OF POPULATIONS LIVING IN CONTAMINATED TERRITORIES Paragraph 22: • This change is proposed in order to give higher focus to the optimisation process (22) …Reference levels are used during the optimisation process to plan protective strategies that would result in estimated residual doses not exceeding this level. Dose limits … Paragraph 24: • It is important to note that the justification of protection strategies is a continual process, and begins prior to the existing situation. This section should note that a protection strategy is associated first with justification, then optimisation. Each time there is a major change in the strategy, or a new protection strategy proposed, the justification of such a change should be addressed. >> see paragraph 31 • The document also appears to not deal with the situation of populations that have been removed and possibly relocated ( not returned to their original location) but for which protection strategies may still need to justified and optimised. • ICRP does not use the terminology “graded approach” very often. It should be clarified in this context. Paragraph 25: The concept of limiting equity is addressed in the optimisation process rather than in justification. This should be deleted here. Paragraph 27: • Text added to highlight that different actions may still be part of the same strategy • Use of words such as “desire” are imprecise and should be avoided (27) In existing exposure situations justification should be considered differently for two broad categories of protective actions that may be included in a protection strategy: those implemented by authorities, experts and professionals and those directly implemented by the exposed individuals as self-help protective actions… Paragraph 28: Maintaining protective actions may be better dealt with as an optimisation issue rather than justification. It is noted that the difference between justification and optimisation in practical circumstances seems difficult to define and should be clarified. Paragraph 29: • Replace “abandon” by “leave”, which is more neutral • The additional propoed changes more closely reflect the possible positions, decisions and actions of authorities (29) …Worldwide experience following nuclear and non-nuclear accidents shows that neither nations nor individuals are willing to leave the affected territories easily. In general, while authorities may require individuals to leave affected territories for health reasons, wherever possible, they will aim at rehabilitating these territories to allow further human activities. 3.2 Optimisation of protection strategies • This section gives the impression that optimisation is an endless process. The point of optimisation is to reach an optimised strategy that will be implemented in a manageable fashion. It is felt that this section can be shortened to remove redundancies. Paragraph 30: • First sentence modified to To make consistent with Pub103. • The word “equity” is considered confusing. It is sufficient to consider the distribution of dose. • Text added to clarify the origin of the benefits (30) The principle of optimisation of protection is a source-related process, which should ensure the selection of the best protection strategy under the prevailing circumstances, i.e., maximising the margin of good over harm. … Therefore, optimisation involves keeping exposures as low as reasonably achievable, taking into account economic and societal factors as well as the distribution of doses and benefits resulting from the protection strategies. Paragraph 31: • “exposure” deleted to avoid confusion with ICRP 103 definitions (31) The process of optimisation of protection is intended for application to those situations for which the implementation of protection strategies has been justified. … Paragraph 32: • Change proposed to clarify text (32) Protection strategies have to be prepared by authorities as part of national planning arrangements. … Paragraph 33: • 2nd bullet: One speaks about an optimisation strategy supporting equity while also speaking about sharing disadvantages between the populations living in contaminated zones and those outside. ICRP is requested to clarify what this means. • 3rd bullet: It is felt that the focus should be on the role of authorities in facilitating this process – should not give impression of authorities giving the problem to the public. The first two sentences of this bullet point are the core of the strategy. It is felt that the original text is too focused on the Chernobyl experience. Changes proposed throughout bullet. • Final part: the focus on ingestion might not be the case in an urban setting. The scope of this should be broader. Also, change optimisation strategies to protection strategies (33) … The multiple decisions taken by the inhabitants in their day-to-day life: in most cases, the level of exposure is driven by individual behaviour. The authorities should facilitate processes to allow inhabitants to define and optimise their own protection strategies if required. A positive aspect is that individuals regain control on their own situation. However, self-help protective actions may be disturbing (e.g. pay constant attention to the food one eats, the places one goes, the material one uses, the things one touches in order to avoid as much as possible internal and external exposure). This supposes that affected individuals are fully aware of the situation and well informed. To support this, various local individuals may also need to be properly equipped and possibly trained (for the use of equipment provided by the authorities). Authorities should also be prepared to assist those segments of the population with particular needs (elderly, mentally handicapped, …). As it was said previously, taking into account that the predominant pathway in contaminated territories is generally ingestion, protection strategies should therefore be based on controlling this pathway in relation with relevant groups of population. Paragraph 34: • This paragraph gives the impression that the optimisation process is without end which is not the case. This should be re-written. • Also, clarify what is meant by normal situation. Paragraph 35: • Change dose restriction to dose criteria. • The ICRP is also requested to clarify if “constrained optimisation” is the correct terminology – constrained optimisation or optimisation with dose constraints. Also ensure consistency with rest of text (35) The Commission has introduced the concept of constrained optimisation. In case of existing exposure situations, like for emergency exposure situations, the dose criteria is termed “reference level”. Reference levels should be set according to Publication 103 recommendations (see below section 3.3). Paragraph 37-39: It is felt that paras 37-39 are general text on the process of optimisation. These should be placed at the beginning of the section, before discussing those aspects that are specific to existing exposure situations. Paragraph 38: The ICRP should look at the use of the term equity throughout the document, and clarify the intent. Also, this appears to be a characteristic of optimisation using reference levels. Paragraph 39: It is recognised that the first and second sentences are quotes, but it is felt that this leaves optimisation open to interpretation. It needs to be clarified in the text that the optimisation process will result in a protective strategy to be implemented (link to chapter 4), to avoid implying that optimisation has no end. 3.3 Reference levels to restrict individual exposures Paragraph 42: Last sentence - It is recommended to use the text from ICRP 103, para 226 to better describe the concept of reference level. Paragraph 43: • This paragraph seems to be mixing planning and implementation. It should be clarified that the optimisation process is part of planning, which results in protection strategies to be implemented. • Suggest to change “will reduce” to “aim to reduce” as there is no guarantee of this. • A clearer distinction needs to be made between the planning process, where strategies should result in doses below the reference level, and implementation, which may result in doses above the reference. Text changes have been proposed to better express this concept (43) The Commission recommends that reference levels, set in terms of individual annual effective residual dose (mSv in a year), should be used in conjunction with the planning and implementation of the optimisation process for exposures in existing exposure situations. The objective is to implement optimised protection strategies, or a progressive range of such strategies, which aim to reduce individual doses below the reference level. During planning, the optimisation process should result in estimated residual doses that are below the reference level . However, exposures below the reference level should not be ignored; they should also be assessed to ascertain whether protection is optimised or whether further protective actions are needed ICRP 2007, §286. Particular attention to specific groups (such as children, pregnant women) should be considered in the optimisation process. Paragraph 44: • The first sentence if too restrictive with regards to when reference levels should be set, and should be modified accordingly. • It is felt that the use of “ambition” is ambiguous, and could be clearer (see ICRP 103, para 225) (44) In case of existing exposure situation following an emergency exposure situation, the reference level is set at the end of the emergency exposure situation, i.e. during the transition between intermediate (if any) and late phases of a nuclear accident or a radiological event, when the decision is taken to allow people to live in a contaminated territory. The selected reference level represents a level of dose above which it is planned to not exceed, with the intention to strive to move all individual exposures below this level as low as reasonably achievable, social and economic factors being taken into account. Paragraph 45: • Change requirements to measures, as this is felt to more correctly reflect the intent • Last sentence: Mandatory in what context? – as a regulatory limit, or in the optimisation process. This must be clarified. (45) …These measures include the need or not to establish protection strategies as well as to provide information, training and/or monitoring to exposed individuals. It is the responsibility of regulatory authorities to decide on the legal status of the reference level set to control a given situation. In general reference levels are not mandatory. Paragraph 46: • Many requirements will be necessary, RP, social, economic, etc. Change requirements to measures • Last sentence: The time frame for the reference level should be given (annual, etc?). Guidance on setting an appropriate reference level should also be provided. Also, according to ICRP 103, the 1-20 mSv band implies individual benefit; for no benefit, a value less than 1 should be used. ICRP should clarify and appropriately express what benefit is being included in this situation. (46) …As previously said, numerous radiological protection measures should be considered to allow people to continue to live in contaminated territories. These considerations suggest that appropriate reference levels should be preferably chosen in the '1 to 20 mSv' band proposed by the Commission. Paragraph 47: Change proposed for first sentence (47) The value of the reference level … Paragraph 48: • ICRP is requested to clarify how the chosen level for a long-term objective can logically be set a priori • ICRP is requested to clarify what is meant by a normal situation, and whether the reference level refers to the additional dose or the total dose. Paragraph 50 : These figures need a vertical line to represent the reference level (see ICRP 103, fig 4) Paragraph 51: Clarify the concept of “maintain exposures comparable to those in normal situations” 4. IMPLEMENTATION OF PROTECTION STRATEGIES • ICRP should clearly expressed that the aim of the authorities is to optimise the protection of the affected population. This will require actions on the part of the authorities and on the part of the affected populations.This section should therefore not give the impression that there is an opposition or duality between actions taken by authorities (4.1) and those taken by populations (4.2) – it should be an integrated strategy with actions taken by both, and developed in consultation with stakeholders. Authorities will be responsible for particular actions, including the provision of infrastructures that support those additional actions taken by populations. Actions taken by populations will generally be based on the support provided by authorities. A better linkage between 4.1, 4.2 is needed. Paragraph 52: • Changes are proposed to show that authorities have the responsibility to support all strategies, and that authority-based actions and self-help actions are not in competition, but should be part of an integrated strategy. (52) The management of an existing exposure situation relies on the implementation of a wide rehabilitation programme coping with numerous dimensions (social, economic, health, environmental…). The radiation protection part of this programme is characterised by the radiation protection strategies that include actions driven by authorities at the national and local levels and self-help protective actions implemented by the affected population within the framework provided by authorities. For these strategies to be successful, authorities should provide the necessary infrastructure as well as practical guidance for their implementation. The implementation of protection strategies will be a dynamic process and will change with time. Paragraph 53: • It is noted that the information in Annex B is a specific example drawn from particular experience, but should not be viewed as a recommendation. The text has been modified to reflect this. (53) It is the role of the authorities to establish the conditions, particularly at the regulatory level, and to implement the means to allow the effective engagement of the affected population in the protection strategies and more globally in the rehabilitation programme. Past experience with the management of contaminated territories has demonstrated that the involvement of local professionals and inhabitants in the implementation of protection strategies is important for the sustainability of the rehabilitation programme Lochard 2004. While mechanisms for stakeholder engagement are driven by national and culture characteristics, practical examples for engaging with stakeholders in the management of the radiological situation in existing exposure situations are given in Annex B. 4.1 Protective actions implemented by authorities • It is suggested to change the titles of 4.1 and 4.2 (Protective actions, rather than strategies) to remove the perception that these are different and distinct strategies. • ICRP is requested to consider the order of the paragraphs in this section to ensure a logical progression of actions, and linkages to actions that might have already been implemented before the existing situation begins. Paragraph 54: • Changes proposed to clarify text (54) The priority of protection strategies implemented by authorities is to protect individuals with the highest exposures and in parallel to reduce all individual exposures associated with the event as low as reasonably achievable. This implies the assessment of the dose distribution, the comparison of all doses with the reference level and subsequent optimisation of protection. Paragraph 55: • First sentence: Is this applicable to a high density area ? Additionally, this does not address external exposure. Changes have been proposed to make the concept more generally applicable (55) This assessment can often most effectively be supported by radiation monitoring. If measurements are not feasible it is possible to estimate the dose likely to be received by the individuals based on local information. In such a situation, the concept of “representative person” as described in Publication 101 ICRP 2006 may be used bearing in mind that this concept is most useful for the purpose of prospective assessments of continuing exposure. In case it is however used, the Commission recommends not to discarding the doses related to the 95-100 % percentile. Paragraph 56: • The discussion of the early phase is considered confusing, and does not need to be mentioned. It is also suggested to change the order of the steps/paragraphs here. First, assessment of pathways, then enhanced monitoring. • ICRP is requested to clarify the strategy that is being recommended. (56) Once the individual dose distribution is characterised, it is necessary to further investigate the main exposure pathways for the affected population (ambient dose rates, soil contamination, foodstuffs contamination…). This will help authorities, in cooperation with the affected population, to decide if they need to pursue protection strategies (decontamination works, foodstuffs restrictions…), to modify them according to the evolution of the radiological situation, or to establish new strategies. Paragraph 57: • ICRP should clarify if these actions are considered as part of the existing situation or in the emergency phase. If these are actions considered as part of the strategies for existing situations, then they highlight the need to look at other exposure pathways beyond ingestion. (57) Typical strategies to be implemented by the authorities in a post-accident situation are clean up of buildings, remediation of soils and vegetation, changes in animal husbandry, monitoring of the environment and produce, provision of clean foodstuffs, managing of waste (resulting from clean up, or from unmarketable contaminated goods), provision of information, guidance, instruction as well as equipment (e.g. for measurements), health surveillance, education of children, and information for particular exposed groups and the public at large, etc. Paragraph 60: • Additional text is proposed through paragraph and bullets for consistency with para 52 • Changes are proposed in bullet 1 to make more balanced. The deletion is considered redundant • Modifications to bullet 3 proposed to highlight importance of access to monitoring results, and that these are examples (60) In this perspective, authorities will have to set up infrastructures to support the implementation of all protective strategies, including the self-help strategies implemented by the affected population. The dissemination of a “practical radiological protection culture” within all segments of the population, and especially within professionals in charge of public health and education is also considered important. Experience has shown that the development of such an infrastructure is based on 3 key pillars: • A radiation monitoring system by which the radiological quality of the environment can be evaluated and levels of internal and external exposure of individuals assessed and allowing direct access of the affected individuals to this information (see Section 5.1). • A health surveillance strategy to follow the health status of the affected population. This calls for a system based on regular clinical investigations as well as the development of registries to monitor important indices in public health, in relation with the level of individual exposure. Such a system should allow the identification of any changes in the health status of the population that could occur and to investigate whether these changes could be related to radiation or other factors (in relation with the early phase or the long-term exposure) – see Section 5.2. • The transmission of practical knowledge about the control of the radiological situation to current and future generations, for example through the education system and direct access to monitoring results. 4.2 Protective actions implemented by the affected population • Title change is proposed • This section is rather detailed and focuses on rural areas based on Chernobyl experience. • The responsibility of authorities for waste management in these areas needs to be addressed here or in 4.1, as this will be an important aspect. • The main message seems to be the empowerment of the population in their own protection in those actions affected by their individual behavior. It is felt that this would be “developed” at the national level in consultation with stakeholders. The authorities should provide the necessary infrastructure and processes to support the outcomes of these consultations. • Specific examples may be used to illustrate this approach, but ICRP should be cautious about using such examples as internationally-applicable principles. Add new paragraph at beginning: “The engagement of the affected populations in the development and implementation of actions by authorities will be the key to their success. In addition, however, many actions to manage exposures will be driven by individual behaviour. These will also require support from the authorities in order to be effective.” Paragraph 61: • Changes proposed in last sentence to highlight importance of optimisation in all cases (61) In case of a radiological accident, the affected population will be confronted to new problems and new preoccupations. Each individual will have questions regarding radioactivity and its effects: how is the environment contaminated, how is one exposed, and at which moments particularly, is one contaminated? One will also wonder how to face to this new situation, what to do concretely, by oneself, to reduce his/her current and future exposure as low as reasonably achievable. Paragraph 62: • Proposed to soften the language. See modified text. (62) Typical actions taken by the inhabitants, in the framework of support from the authorities (self-help protective actions) may be based on the characterisation of their own radiological situation, notably their external and internal exposure. These may mainly consist in monitoring their own exposure as well as the exposure of the people for whom they have responsibility (children, elderly…) and in adapting their way of life to reduce their exposure. Paragraph 63: Changes proposed to text, as it is felt that such actions would be done with support from authorities (63) As far as the evaluation of external exposure is concerned, inhabitants may better manage the situation by establishing local mapping of their living places (house, garden, working place, leisure areas...). … Paragraph 65: • Language qualified in second sentence • It would be useful to provide references for last sentence (65) In rural zones, a significant part of the affected population can own a private garden. As above, the first step may consist in the measurement of radiological quality of the grown foodstuffs. According to the results, they will have to identify how to reduce the contamination of their products: selection of products which are less sensitive to radioactivity, identification of the less contaminated areas in the garden, use of agricultural techniques to limit transfer of radionuclides from soil to plants… Paragraph 66: • The reference to ashes seems to be a very specific example. Language also qualified. (66) …: a particular attention may have to be paid to the management of radioactive house waste as for example ashes from fireplaces in rural areas. Paragraph 67: • Language qualified throughout paragraph (67) As underlined before, authorities should facilitate the implementation of protection strategies by the inhabitants. They should provide inhabitants with existing results of measurements, information and training to help people to understand and manage their radiological situation and monitoring equipment (for example, making the equipment available through local authority offices or local doctors or pharmacies who are trained to make measurements). Furthermore, they should ensure regular whole body measurements of the affected population so that people can evaluate the efficiency of changes in their diet. Paragraph 68: • Language qualified throughout paragraph, and addition of relevant experts proposed (68) Authorities should facilitate the setting-up of local forums involving representatives of the affected population and relevant experts (e.g., health authorities, etc). These forums will allow gathering and sharing of information and favour a common assessment of the effectiveness of both strategies driven by the populations or the authorities. 5. RADIATION MONITORING AND HEALTH SURVEILLANCE Introduction: The discussion of phases is not relevant. Importance of information programme included ( ) As recommended by the Commission in the case of an existing exposure situation, individuals concerned should receive general information on the exposure situation and the means of reducing their doses. In situations where individuals life-styles are key drivers of the exposure, individual monitoring, coupled with an information programme, is an important requirement. Furthermore, even if there are uncertainties concerning future potential effects of the emergency, it is the responsibility of the authorities to implement radiation monitoring and health surveillance programmes. 5.1 Radiation monitoring Paragraph 69: • Monitoring systems do not predict future levels. ICRP should clarify if the intent is to include modeling here. Environmental monitoring is also important • Editorial changes (69) In a situation of long-term contamination, it is essential to establish a radiation monitoring system allowing the follow-up of the radiological situation and the implementation of radiation protection strategies. The key objective of monitoring systems is to assess current levels and allow the prediction of future levels of human exposures (both external and internal) and environmental levels of contamination. Paragraph 70: • Editorial changes (70) In practice, this supposes a radiation monitoring system providing measurements of whole body contamination, of concentrations of radionuclides in foodstuffs and the environment, and of ambient dose rates. Paragraph 71: • Editorial changes (71) The effectiveness of the monitoring system will rely on its ability to cope with specificities of the local affected territory. This will allow the identification of population groups receiving elevated doses and better orientation of radiation protection strategies. Paragraph 72: • Editorial changes • Local stakeholders added (a link to Chapter 4 would be relevant) • Importance of quality assurance of measurements added (72) In this purpose, a key issue will be to take advantage of radiological competence at the local level in combination with the national system. Furthermore, the existence of validated measurements from different origins - authorities, expert bodies, local and national laboratories (NGOs, private institutes, universities, local stakeholders, nuclear installations…) – will allow a better understanding of the radiological local situation and favour confidence in the measurements among the affected population. In this regard, all parties providing measurements should be subject to appropriate quality assurance requirements. Paragraph 73: • Add provision of information to authorities and stakeholders. Editorial changes. (73) The monitoring system should be designed to provide regularly updated information to authorities and stakeholders, and to allow an extended coverage of the affected territory over the long-term. The sustainability of such a system will require the establishment of continued maintenance and training programmes by the national and local authorities. 5.2 Health Surveillance Paragraph 74: Change “event” to make consist with title of document. Add census taking as the first step. (74) Following a nuclear accident of radiological emergency, the exposed population should have an initial medical evaluation. The first step of this is a census of the affected population, possibly as followup to earlier dose assessment activities. Beyond the identification of people who need specific medical care, this first examination may help to determine potentially susceptible or sensitive subgroups that need further health surveillance. … Paragraph 75: Various editorial changes proposed throughout paragraph. Add pregnant women to sensitive subgroups. (75) Taking into account these different individual situations, long-term health surveillance programmes will have to cover the three following objectives WHO 2006: • The follow-up of persons who have received exposures that have resulted (or may eventually result) in clinically significant deterministic effects (such as skin burns, cataracts etc.). • The “medical monitoring” of the general population, which consists of investigating for potential adverse effects (mainly incidence of radiation induced cancers). A subcategory of medical monitoring is the follow-up of potentially “sensitive subgroups” (e.g. children, pregnant women). • And finally, “epidemiological” studies. Paragraph 77: Such studies may also be used to evaluate the effectiveness of certain countermeasures (such as iodine prophylaxis). Add this concept to last bullet. (77) … • Add to the scientific knowledge base, which can then be used to derive and refine risk estimates, develop interventions or evaluate the efficiency of implemented countermeasures. 6. MANAGEMENT OF CONTAMINATED FOODSTUFFS AND OTHER COMMODITIES Paragraph 80: • Add influence of market forces (80) …The development and implementation of such strategies require the full involvement of relevant stakeholders. Market forces will play a significant role in the distribution of products, and therefore reconciling the interests of local farmers and the local population with those of consumers and the food distribution sector from outside the contaminated territory has to be considered carefully. … Paragraph 81: • Change “control” to “manage”. Changes also suggested to focus on ingestion of contaminated foods rather than variations in ground contamination • The concept of reserving food for certain groups implies that there may not be enough clean food – authorities will likely be in a position to ensure that clean food is made available. It is suggested to focus on “advice” to populations (81) …The local population may also be in a position to manage its intake of radionuclides by avoiding or reducing consumption of products with higher levels of contamination. Furthermore, more sensitive groups of population or those perceived to deserve special protection (e.g. children, pregnant or breastfeeding women, people with poor health condition) may be advised to avoid or reduce consumption of certain types of food with higher levels of contamination. Paragraph 82: • It is suggested to shorten this paragraph • The mixing of different uses of reference level is viewed as confusing. Different wording is suggested – change DRL to contamination criteria • This discussion of exemption intervention level and reference level is confusing and not relevant as the two concepts are unrelated. • Remove “Cheap”: The key is uncontaminated food, rather than its cost. (82) In order to help the local population to control foodstuffs, authorities should provide relevant information and set contamination criteria based on directly measurable levels of contamination (expressed in Bq/kg or Bq/l) from the reference level (expressed as annual dose), , taking into account the proportion of locally produced food in the diet. Guideline levels have been developed by the Codex Alimentarius Commission (CAC) for use in international trade (FAO/WHO 2006). These levels are based on a dose level of 1 mSv in a year assuming that a maximum of 10% of the diet consists of contaminated food. The assumption that 10% of the diet is contaminated may not be valid for some local communities, hence the contamination criteria may be set below the Codex Guideline Levels. Conversely, if the contamination affects only a few categories of foodstuffs the contamination criteria may be set to higher values. Higher contamination criteria may also be set to preserve local production, which may be deeply embedded in traditions or which may be essential to the economy of the entire community. Disruption to the local economy through the placing of restrictions on the sale of contaminated foodstuffs, the loss of market share as a result of consumer preferences, or through the provision of uncontaminated food may not be warranted in terms of a benefit in dose reduction. Such decisions must be taken in close cooperation with the local stakeholders as was the case in Norway with reindeer meat produced by the Sami population after the Chernobyl accident (Skuterud et al. 2005). Paragraph 83: • This paragraph should be moved to the front of this section. First apply countermeasures, then manage contaminated foods. • Add influence of market forces (83) … There may be situations where a sustainable agricultural economy is not possible without placing contaminated food on the market. As such foods will be subject to market forces, this will necessitate an effective communication strategy to overcome the negative reactions from consumers outside the contaminated territories. 6.2 Protection of population outside the contaminated territories Paragraph 84: Change DRL to “contamination level” Paragraph 85: Add influence of market forces (85) … Even the free supply of such food as humanitarian aid in regions affected by famine would be perceived as such by the beneficiaries. Bearing in mind market forces, these considerations call for investigating all possible actions to improve the radiological quality of foodstuffs before their placing on the market. 6.3 Management of other commodities Paragraph 90-92 : Change DRL to “contamination level” ANNEXES: Annex A and B are viewed as potentially useful but should be clearly presented as examples. ANNEX A: HISTORICAL EXPERIENCE WITH CONTAMINATED AREAS AND TERRITORIES • It is suggested to delete Äfter Nucelar Events”this as nuclear event is not consistent with the title of the document, and it includes non accident/emergency experience Table A.2. Evolution of the caesium-137 contamination limit in foodstuffs in Belarus from 1986 to 1999 • Drinking Water (Second row) Change “18,5” to either “185” or “18.5.” ANNEX B: PRACTICAL EXAMPLES FOR ENGAGING WITH STAKEHOLDERS IN THE MANAGEMENT OF THE RADIOLOGICAL SITUATION IN EXISTING EXPOSURE SITUATIONS • Change “Recommendations” to “Examples”. • While interesting, the discussion on stakeholders is only a small part of the growing body of information available on stakeholder interactions. It is suggested that the Annex be dropped, in favor of some references in the body of the text, to avoid the perception that the ICRP is endorsing particular stakeholder formats to the exclusion of other possibilities. ANNEX C: CANCER RISK PERSPECTIVES OF LIVING IN CONTAMINATED AREAS AND TERRITORIES • This annex is not relevant to this report and should be removed.