Best Practices that Advance Safety from the Biological Effects of Radiation among Hospital-Based Radiologic Technicians in Iligan

City

A Thesis Presented to The Faculty of RadTech Department Iligan Medical Center College Iligan City

In Partial Fulfillment of the Requirements Leading to the Degree BS in Radiologic Technology

Arumpac,Ihsmael Basong, Henrylyn Mamongcal, Norhussien Montila, Samira J. Sadic, Sonaya Polayagan, Salahoden

March 2013

Chapter 1 The Problem and Its Background Introduction

Innovation of technology has made possible the cultivation and sharing of best practices among technologists nowadays. Rare are the inventions already being made for the reason that to save Mother Earth, use of its resources should be minimized. What science does now is just to make use of what already exist. Many scientists do study to just modify, and come up with new things, mutating them from one form to another. Spying at what others best practices to make life easy has become common. This is even made evident in the mass production of essential goods aimed to satisfy the needs of man. Since radiation from all forms poses high risks on radiologists, their best practices have also been a matter of priority. Radiation, as a matter of fact, has all been around us. It is naturally present in our environment coming from outer space (cosmic), the ground (terrestrial), from within our own bodies, the air we breathe, the food we eat, the water we drink, and in the construction materials used to build our homes. Furthermore, a lot is from terrestrial radiation of soils enriched in naturally occurring uranium, and from radon, a gas from the earth's crust that is present in the air. Radiologists also get a lot of radiation exposure from medical, commercial, and industrial activities, one of the largest of which is from computed tomography (CT) scans. In addition, some consumer products such as tobacco, fertilizer, welding rods, exit signs, luminous watch dials, and smoke detectors contribute about another 10 mrem to our annual radiation exposure.
Epidemiological studies indicate that without safety practices, radiologic technologists employed are at increased risk of leukemia and skin cancer, most likely due to the lack of use of radiation monitoring and shielding. Ionizing radiation, used in a variety of imaging procedures, can damage cells.

Lead shields are used on the patient and by the radiologic technologist to reduce exposure by shielding areas that do not need to be imaged from the radiation source. While lead is highly toxic, the shields used in medical imaging are coated to prevent lead exposure and are regularly tested for integrity. Radiologic technologists who develop x-ray films are exposed to various chemical hazards such as sulfur dioxide, glutaraldehyde, and acetic acid. These agents can cause asthma and other health issues. Theoretically, the strong static magnetic fields of MRI scanners can cause physiological changes. After a human neural cell culture was exposed to a static magnetic field for 15 minutes, changes in cell morphology occurred along with some modifications in the physiological functions of those cells. However, these effects have not yet been independently replicated or confirmed, and this particular study was performed in vitro. Ultrasound imaging can deform cells in the imaging field, if those cells are in a fluid. However, this effect is not sufficient to damage the cells. As with any allied health professional, exposure to infectious diseases is likely, and proper precautions such as sterile technique must be employed to reduce the risk of infection.

Locally, how should safety be ensured if no empirical data will be given? This study will hopefully address this need.

Conceptual Framework The International Atomic Energy Agency (IAEA) by the Division of Radiation and Waste Safety of Vienna, Austria, together with the World Health Organization, International Labor Organization, OECD Nuclear Energy Agency, Food and Agriculture Organization and Pan American Health Organization, has its International Basic Safety Standards (BSS) for protection against ionizing radiation and the safety of radiation sources. Not yet mandatory, it already serves as a practical guide to all those involved in radiation protection, taking into account local situations, resources, etc. It applies both to practices that add radiation exposure to that which people normally receive due to background radiation like the use of radiation or radioactive substances for

medical, industrial, agricultural, to include the generation of energy by nuclear power, and mines and mills processing radioactive ores and radioactive waste management facilities; and interventions that seek to reduce the existing radiation exposure, or the likelihood of incurring exposure in chronic exposure situations such as radon in buildings, and emergency situations such as those created by contamination in the aftermath of an accident. It sums up protection measures in justification of practice, optimization of protection and limitation of individual risk. The objective of the BSS is to prevent the occurrence of short term effects of high doses of radiation and to restrict the likelihood of occurrence of long term effects. It sets out detailed requirements for practices and interventions to protect workers, patients and the general public from radiation exposure, and recommends procedures for ensuring the safety of sources, for accident prevention, for emergency planning and preparedness and for mitigating the consequences of accidents. Although the majority are of a qualitative nature, the BSS also establishes many requirements expressed in terms of restrictions or guidance on the dose that may be incurred by people. This includes principles of protection, organizational, management and technical requirements, as well as manner of transport among others.

Principles of Protection. The BSS implies that activities adding or reducing radiation exposures should be justified to optimize protection and limit individual risks. Organizational and Management Requirements. To enforce safety standards, the system should have a regulatory authority, education, training and public information and facilities and services for radiation protection and safety. It must promote the development of a safety culture, quality assurance programs, control of human factors, and qualified experts. Technical Requirements. BSS sets security, depth of layer protection, and monitoring and verification of radiation sources. Manner of Transport. Transport of radioactive substances must be according to sound regulations for safety.

Figure 1. The Research Paradigm

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Radiologic Technician

Best Practices towards Biological Effects of Radiation

Radiation Safety

Statement of the Problem This study will gather and analyze the best practices that advance safety from the Biological Effects of Radiation among Hospital-Based Radiologic Technicians in Iligan City. Specifically, it will attempt to answer the following questions: 1. What career profiles do hospital-based radiologic technologists in Iligan City have, in terms of: a. Type of radiologic work done? b. Man-hours as radiologic worker? c. Facilities and services handled? d. Previous trainings as preparation for a radiologic career?

2. What is their level of understanding about Biological Effects of Radiation?

3. What best practices towards this concern do they have to ensure radiologic safety, in terms of : a. Principles involved? b. Organizational and management requirements? c. Technical requirements? d. Transport of radioactive materials?

Assumptions This study assumes that: 1. In every radiation opportunity, radiologic technicians exercise care and attention to ensure the safety of their environment. Their practices, however, need documentation. 2. Sharing of best practices brings improvement to a profession, especially to local professionals who may yet not have organized themselves into one group. 3. Development efforts must always be done towards understanding the Biological Effects of Radiation. Species mutate as the environment changes, not to exclude human beings.

Scope and Delimitation It is the scope of this study to determine the career profiles of radiologic technicians in hospitals of Iligan City. Their best practices are undertaken to ensure safety from the perils on radiation especially on the Biological Effects of Radiation on their human bodies. It is delimited to the collection of data that describe only the present condition of their practices. It is not going to conduct any experiment, as such can be done only in highly select conditions requiring expensive facilities and equipment. More so, this study considers both the natural and artificial sources of radiation. The safety of their biological effect on the radiologic technicians will be the focus of this research.

Significance of the Study This study will be significant in various respects:

1. To students, for it can open their world to the best practices done by the professionals in the radiologic industry; 2. To instructors, for whatever new knowledge is generated from this study, they can help the next batches of students get way ahead in the radiologic profession; 3. To the administration of the school, for good researches can call the attention of research awarding bodies such as the Commission on Higher Education, and the Department of Science and Technology, and thereby assign the school for next research opportunities that get full of funds; 4. To the hospitals, for the results of the study as derived from the interpretation, analyses and conclusions can be new learning for them to improve their services; 5. To the alumni of the department, for knowing updates of their colleagues can help themselves become united for better and common goals in the future; 6. To research in general, for the study will surely end up with recommendations that will spur better refined researches complementing the results of this study.

Definition of Terms The key terms are defined as follows: Best Practices - are any existing activities that seek to reduce the radiation exposure, or the likelihood of incurring exposure; otherwise made short for intervention best practices. Radiation Safety - is the condition of harmless radiation among individuals exposed to either natural or artificial/man-made radiation sources.

Biological Effects of Radiation

- are the radiation effects on the cells of living

organisms, typically those of radiologic technicians. Hospital-Based Radiologic Technicians - are the radiologists who do their radiologic work in hospitals.

Chapter II Review of Literature and Related Studies This chapter deals with the discussion of the conceptual literature and related studies reviewed for the purpose of formulating the concepts and instruments used in the present study. The review likewise provides an extensive background in the investigation, which serves as the framework of the research study.

Conceptual Literature Biological Effects of Radiation The U.S. Nuclear Regulatory Commission has the following facts about radiations biological effects: Radiation is all around us. It is naturally present in our environment and has been since the birth of this planet. Consequently, life has evolved in an environment which has significant levels of ionizing radiation. It comes from outer space (cosmic), the ground (terrestrial), and even from within our own bodies. It is present in the air we breathe, the food we eat, the water we drink, and in the construction materials used to build our homes. Certain foods such as bananas and brazil nuts naturally contain higher levels of radiation than other foods. Brick and stone homes have higher natural radiation levels than homes made of other building materials such as wood. Our nation's Capitol, which is largely constructed of granite, contains higher levels of natural radiation than most homes. Levels of natural or background radiation can vary greatly from one location to the next. For example, people residing in one area are exposed to more natural radiation than residents of another area has more cosmic radiation at a higher altitude and more terrestrial radiation from soils enriched in naturally occurring uranium. Furthermore, a lot of our natural exposure is due to radon, a gas from the earth's crust that is present in the air we breathe. About half of the total annual average U.S. individual's radiation exposure comes from natural sources. The other half is mostly from diagnostic medical procedures. The

average annual radiation exposure from natural sources is about 310 millirem (3.1 millisieverts or mSv). Radon and thoron gases account for two-thirds of this exposure, while cosmic, terrestrial, and internal radiation account for the remainder. No adverse health effects have been discerned from doses arising from these levels of natural radiation exposure.

Figure 2.
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Man-made sources of radiation from medical, commercial, and industrial activities contribute about another 310 mrem to our annual radiation exposure. One of the largest of these sources of exposure is computed tomography (CT) scans, which account for about 150 mrem. Other medical procedures together account for about another 150 mrem each year. In addition, some consumer products such as tobacco, fertilizer, welding rods, exit signs, luminous

watch dials, and smoke detectors contribute about another 10 mrem to our annual radiation exposure. The pie chart herein shows a breakdown of radiation sources that contribute to the average annual U.S. radiation dose of 620 mrem. Nearly three-fourths of this dose is split between radon/thoron gas and diagnostic medical procedures. Although there is a distinction between natural and man-made radiation, they both affect us in the same way. Above background levels of radiation exposure, the NRC requires that its licensee limit maximum radiation exposure to individual members of the public to 100 mrem (1mSv) per year, and limit occupational radiation exposure to adults working with radioactive material to 5,000 mrem (50 mSv) per year. NRC regulations and radiation exposure limits are contained in Title 10 of the Code of Federal Regulations, Part 20. People tend to think of biological effects of radiation in terms of their effect on living cells. For low levels of radiation exposure, the biological effects are so small they may not be detected. The body has repair mechanisms against damage induced by radiation as well as by chemical carcinogens. Consequently, biological effects of radiation on living cells may result in three outcomes: (1) injured or damaged cells repair themselves, resulting in no residual damage; (2) cells die, much like millions of body cells do every day, being replaced through normal biological processes; or (3) cells incorrectly repair themselves resulting in a biophysical change. The associations between radiation exposure and the development of cancer are mostly based on populations exposed to relatively high levels of ionizing radiation (e.g., Japanese atomic bomb survivors, and recipients of selected diagnostic or therapeutic medical procedures). Cancers associated with high-dose exposure (greater than 50,000 mrem) include leukemia, breast, bladder, colon, liver, lung, esophagus, ovarian, multiple myeloma, and stomach cancers. Department of Health and Human Services literature also suggests a possible association between ionizing radiation exposure and prostate, nasal cavity/sinuses, pharyngeal and laryngeal, and pancreatic cancer. The period of time between radiation exposure and the detection of cancer is known as the latent period and can be many years. Those cancers that may develop as a result of

radiation exposure are indistinguishable from those that occur naturally or as a result of exposure to other carcinogens. Furthermore, National Cancer Institute literature indicates that other chemical and physical hazards and lifestyle factors (e.g., smoking, alcohol consumption, and diet) contribute significantly to many of these same diseases. Although radiation may cause cancers at high doses and high dose rates, currently there are no data to establish unequivocally the occurrence of cancer following exposure to low doses and dose rates below about 10,000 mrem (100 mSv). Even so, the radiation protection community conservatively assumes that any amount of radiation may pose some risk for causing cancer and hereditary effect, and that the risk is higher for higher radiation exposures. A linear, no-threshold (LNT) dose response relationship is used to describe the relationship between radiation dose and the occurrence of cancer. This dose-response hypothesis suggests that any increase in dose, no matter how small, results in an incremental increase in risk. The LNT hypothesis is accepted by the NRC as a conservative model for determining radiation dose standards, recognizing that the model may over estimate radiation risk. High radiation doses tend to kill cells, while low doses tend to damage or alter the genetic code (DNA) of irradiated cells. High doses can kill so many cells that tissues and organs are damaged immediately. This in turn may cause a rapid body response often called Acute Radiation Syndrome. The higher the radiation dose, the sooner the effects of radiation will appear, and the higher the probability of death. This syndrome was observed in many atomic bomb survivors in 1945 and emergency workers responding to the 1986 Chernobyl nuclear power plant accident. Approximately 134 plant workers and firefighters battling the fire at the Chernobyl power plant received high radiation doses 80,000 to 1,600,000 mrem (800 to 16,000 mSv) and suffered from acute radiation sickness. Of these, 28 died within the first three months from their radiation injuries. Two more patients died during the first days as a result of combined injuries from the fire and radiation. Because radiation affects different people in different ways, it is not possible to indicate what dose is needed to be fatal. However, it is believed that 50% of a population would die within thirty days after receiving a dose of between 350,000 to 500,000 mrem (3500 to 5000

mSv) to the whole body, over a period ranging from a few minutes to a few hours. This would vary depending on the health of the individuals before the exposure and the medical care received after the exposure. These doses expose the whole body to radiation in a very short period of time (minutes to hours). Similar exposure of only parts of the body will likely lead to more localized effects, such as skin burns. Conversely, low doses less than 10,000 mrem (100 mSv) spread out over long periods of time (years) don't cause an immediate problem to any body organ. The effects of low doses of radiation, if any, would occur at the cell level, and thus changes may not be observed for many years (usually 5-20 years) after exposure. Genetic effects and the development of cancer are the primary health concerns attributed to radiation exposure. The likelihood of cancer occurring after radiation exposure is about five times greater than a genetic effect (e.g., increased still births, congenital abnormalities, infant mortality, childhood mortality, and decreased birth weight). Genetic effects are the result of a mutation produced in the reproductive cells of an exposed individual that are passed on to their offspring. These effects may appear in the exposed person's direct offspring, or may appear several generations later, depending on whether the altered genes are dominant or recessive. Although radiation-induced genetic effects have been observed in laboratory animals (given very high doses of radiation), no evidence of genetic effects has been observed among the children born to atomic bomb survivors from Hiroshima and Nagasaki. NRC regulations strictly limit the amount of radiation that can be emitted by a nuclear facility, such as a nuclear power plant. A 1991 study by the National Cancer Institute, "Cancer in Populations Living Near Nuclear Facilities," concluded that there was no increased risk of death from cancer for people living in counties adjacent to U.S. nuclear facilities. At the NRC's request, the National Academy of Sciences is currently engaged in a state-of-the-art update to the earlier study. The new study will examine cancer rates in communities around operating and decommissioned nuclear power plants, as well as nuclear fuel cycle facilities.

Radiation is one of the best-investigated hazardous agents. Because of the vast accumulation of quantitative dose-response data, specialists are able to set environmental radiation levels so that applications of nuclear technologies may continue at a level of risk that is much less than with many other technologies. A single accidental exposure to a high dose of radiation during a short period of time is referred to as an acute exposure, and may produce biological effects within a short period after exposure. These effects are: nausea and vomiting, malaise and fatigue, increased temperature, blood changes, bone marrow damage, damage to cells lining the small intestine, damage to blood vessels in the brain The above list is given for information purposes only. The doses that can produce such effects are extremely unlikely even in the event of an accident at the U of T. The delayed effects of radiation are due to low-level exposure that is called continuous or chronic exposure. In this case, the results may not be apparent for years. This type of exposure is likely to be the result of improper or inadequate protective measures. In the case of inhalation or ingestion of radioactive materials, a single "acute" event may cause a long period "chronic" internal body exposure due to irradiation of tissue where radioactive material has been fixed. The most common delayed effects are various forms of cancer (leukemia, bone cancer, thyroid cancer, lung cancer) and genetic defects (malformations in children born to parents exposed to radiation). In any radiological situation involving the induction of cancer, there is a certain time period between the exposure to radiation and the onset of disease. This is known as the "latency period" and is an interval in which no symptoms of disease are present. The minimum latency period for leukemia produced by radiation is 2 years and can be up to 10 years or more for other types of cancer. The connection between effects of exposure to radiation and dose (i.e., dose-response relationship) is classified into 2 categories, non-stochastic, and stochastic. Non-stochastic effect, also referred to as deterministic, are specific to each exposed individual. They are characterized by: a certain minimum dose must be exceeded before the particular effect is observed. Because of this minimum dose, the non-stochastic effects are also called

Threshold Effects. The threshold may differ from individual to individual; the magnitude of the effect increases with the size of the dose received by the individual; there is clear relationship between exposure to radiation and the observed effect on the individual Stochastic effects are those that occur by chance, appearing among unexposed people as well. The main stochastic effects are cancer and genetic defects. According to current knowledge of molecular biology, a cancer is initiated by damaging chromosomes in a somatic cell. Genetic defects are caused by damage to chromosomes in a germ cell (sperm or ovum). There is no known existing threshold for stochastic effects. One single photon or electron can produce the effect. For this reason, a stochastic effect is called a Linear or Zero-Threshold DoseResponse Effect. Stochastic effects can also be caused by many other factors, not only by radiation. Since everybody is exposed to natural radiation, and to other factors, stochastic effects can arise in all of us regardless of the type of work (working with radiation or not). Whether or not an individual develops the effect is simply a question of chance. There is a stochastic correlation between the number of cases of cancers or genetic defects developed inside a population and the dose received by the population at relatively large levels of radiation. Attempts have been made to extrapolate the data from these levels of dose to low levels of dose (close to the levels received from background radiation). There is no scientific evidence to prove the results of these attempts. Since there is no evidence of a lower threshold for the appearance of Stochastic Effects, the prudent course is to ensure that all radiation exposures follow a principle known as ALARA (As Low As Reasonable Achievable). We will be referring to the application of this principle at U of T in subsequent modules. It is well known that the foetus is more sensitive to the effects of radiation than the adult human. If an irradiation occurs in the first two months of pregnancy, Delayed Effects may appear in the child. These include mental and behaviour retardation, with a delay period of approximately 4 years. Because of these possible effects, dosimetry during pregnancy differs from the usual protocol. Special attention is paid to both external and internal irradiation. A Radiation Safety

Officer of the U of T must review procedures for handling radioactive materials when a pregnant worker performs such work. It is not possible to accurately measure the dose to the foetus and so it must be inferred from the exposure to the mother. Radiation protection principles limit exposure to the mother in order to achieve minimum risk to the foetus. Exposure to very low levels of radiation is a controversial issue, originating many debates throughout the scientific community. What happens at very low levels of radiation exposure? As was explained earlier, everybody is exposed to a level of radiation called the natural radiation or background radiation. Also, was proved that the background levels vary on earth by a factor greater than 10. What happens when somebody is exposed to levels of radiation within a few percentage of the background, on top of the day to day background irradiation? As stated above, current knowledge in molecular biology shows no evidence of a threshold effect for Stochastic Effects. Therefore, any level of radiation may be considered to cause them. Conversely, some studies show that low levels of irradiation are in fact beneficial to the health (Radiation Hormesis). However, in the absence of clear scientific evidence, the regulators adopted a conservative approach and consider all levels of radiation as being potentially damaging to the human body. Because of this, any procedure that involves radioactive materials must abide by the ALARA principle. Another source relates radiation to have these effects on the human body: Hair. The losing of hair quickly and in clumps occurs with radiation exposure at 200 rems or higher.

Brain. Since brain cells do not reproduce, they won't be damaged directly unless the exposure is 5,000 rems or greater. Like the heart, radiation kills nerve cells and small blood vessels, and can cause seizures and immediate death. Thyroid. The certain body parts are more specifically affected by exposure to different types of radiation sources. The thyroid gland is susceptible to radioactive iodine. In sufficient amounts, radioactive iodine can destroy all or part of the thyroid. By taking potassium iodide, one can reduce the effects of exposure. Blood System. When a person is exposed to around 100 rems, the blood's lymphocyte cell count will be reduced, leaving the victim more susceptible to infection. This is often refered to as mild radiation sickness. Early symptoms of radiation sickness mimic those of flu and may go unnoticed unless a blood count is done.According to data from Hiroshima and Nagaski, show that symptoms may persist for up to 10 years and may also have an increased long-term risk for leukemia and lymphoma. Heart. Intense exposure to radioactive material at 1,000 to 5,000 rems would do immediate damage to small blood vessels and probably cause heart failure and death directly. Gastrointestinal Tract. Radiation damage to the intestinal tract lining will cause nausea, bloody vomiting and diarrhea. This is occurs when the victim's exposure is 200 rems or more. The radiation will begin to destroy the cells in the body that divide rapidly. These including blood, GI tract, reproductive and hair cells, and harms their DNA and RNA of surviving cells. Reproductive Tract. Because reproductive tract cells divide rapidly, these areas of the body can be damaged at rem levels as low as 200. Long-term, some radiation sickness victims will become sterile.

Chapter III Research Design

This chapter presents the research design that includes the research methodology, the respondents of the study, the locale of the study, the research instrument, the data gathering process and the statistical treatment of data.

Research Methodology This study will use the descriptive method of investigation, utilizing a questionnaire as the data gathering instrument. It will obtain facts about existing conditions or significant relationships between current phenomena. It will interpret and describe prevailing conditions or relationships that exist or do not exist, processes that are going on or otherwise, and effects that are being felt on trends that are developing. The method will involve data gathering in order to answer questions concerning the current status of the subjects of the study toward the solutions of problems included in the study.

Respondents of the Study All the radiologic workers of hospitals in Iligan City will be the respondents. They are expected to be few, hence the saturation point will be sought. These hospitals involved are: Dr. Uy Hospital, Inc., E and R Hospital and Pharmacy, Gregorio T. Lluch Memorial Hospital, Iligan Medical Center, Mercy Community Hospital, Inc., and Mindanao Sanitarium and Hospital.

The Locale of the Study This study will be conducted in Iligan City, a city still part of Northern Mindanao. It has a total area of 813.37 sq. km. with a population of 308,046 as of August 2007 NSO Census in 44 barangays. It has short dry season usually running to about a month to three months with rainfall evenly distributed throughout the year. The people are predominantly Roman Catholic who speaks Cebuano. It is a highly urbanized city with at least 11 major industries. There are

five hospitals in the city with four run privately and one a government hospital. It also has 49 barangay health centers and one main health center. Three hydro-power plants are operated in the area. Its means of communications include four digital telephone systems, two wireless telephone systems (Smart and Globe), two cable stations, one TV station, eight radio stations and four internet service companies.

The Research Instrument A questionnaire will be used in gathering data. The questions are designed to elicit answers to the problems posed in the study. They are likewise constructed following the pattern of the conceptual framework.

Validity of the Instrument To ensure validity of the instrument, it will be shown to ten other professionals in the radiologic field, like the instructors teaching the course. They will be made to likewise answer the items in the questionnaire to determine if the items will be well-understood by the respondents. The instrument will be refined in the final stage before it is being fielded to the radiologic workers in the hospitals.

Data Gathering Process The researchers will seek the approval of the hospitals to get the responses of the radiologic workers. Since many items are qualitative, they will find enough time to be with each of the respondents to be able to get enough information from their responses. The data will then be collected for processing and presentation.

Treatment of Data The data gathered will be pooled together and be interpreted. The various standpoints of established researchers in the field as gleaned from Chapter II, and the classroom and laboratory learning of the student researchers will be used to bring about the existing

conditions of the practices of radiologic technicians. The presentation will be aligned according to sound statistical standards.