Annals of the ICRP

Published on behalf of the

lnternational
on Radiological Protection
Gommission Anna
Editor: J. VALENTIN, ICRP, SE-171 16 Stockholm, Sweden

International Commission on Railiological Protection 2001-2005

Chairman: Prof. R. H. Clarke, ICRP, SE-171 16
Vice-Chairman: Dr. L.-E. Holm, Swedrsfr Radiation Protection Authority (SS1), SE-L71 16 Stockholm
Sweden
Scientific Secretary: Dr. J. Valentin, ICRP, SE-171 16 Stockholm, Sweden; fax: +46 8 729 7298

Members of the Main Commission of the ICRP

Protectinp
EX po
R. Alexakhin, Obninsk, Russia C. Streffer, Essen, Germany H. J. Dunster, Oxfortl, tlK (Emeritus)
J. D. Boice Jr, Rockttille, MD A. Sugier, Fontenay-aux-Roses, France B. Lindell, Stockholm, Sweden (Emeritus)
R. Cox, Didcot, UK Z. Pan, Beiiing, China C. B. Meinhold, Brookhauen,
G. J. Dicus, Washington, DC B. C. WinklerE, Centurion, South Africa
A. I. Gonziiez, Vienna, Austria R. J. Pentreath, Bath, UK
USA (Emeritus)
W. K. Sinclair, Escondido, CA (.Emeritus)
R
F. A. Mettler Jr, Albuquerque, NM D. Beninson*, Buenos Aires, L. S. Taylor, Mitchellxille, MD (Emeritus)
Y. Sasaki, Chiba-shi, Japan Argentina (Emeritus)

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 ICRP Publication 96

Protecting people against radiation

exposure in the event of a radiological attack

ICRP Publication 96

Approved by the Commission in October 2004

Abstract–This report responds to a widely perceived need for professional advice on radiolog-
ical protection measures to be undertaken in the event of a radiological attack. The report,
which is mainly concerned with possible attacks involving Ôradioactive dispersion devicesÕ,
re-affirms the applicability of existing ICRP recommendations to such situations, should they
ever occur.
Many aspects of the emergency scenarios expected to arise in the event of a radiological
attack may be similar to those that experience has shown can arise from radiological accidents,
but there may also be important differences. For instance, a radiological attack would prob-
ably be targeted at a public area, possibly in an urban environment, where the presence of
radiation is not anticipated and the dispersion conditions commonly assumed for a nuclear
or radiological emergency, such as at a nuclear installation, may not be applicable.
First responders to a radiological attack and other rescuers need to be adequately trained
and to have the proper equipment for identifying radiation and radioactive contamination,
and specialists in radiological protection must be available to provide advice. It may be pru-
dent to assume that radiological, chemical, and/or biological agents are involved in an attack
until it is proven otherwise. This calls for an Ôall-hazardÕ approach to the response.
In the aftermath of an attack, the main aim of radiological protection must be to prevent the
occurrence of acute health effects attributable to radiation exposure (termed ÔdeterministicÕ
effects) and to restrict the likelihood of late health effects (termed ÔstochasticÕ effects) such as
cancers and some hereditable diseases. A supplementary aim is to minimise environmental
contamination from radioactive residues and the subsequent general disruption of daily life.
The report notes that action taken to avert exposures is a much more effective protective mea-
sure than protective measure the provision of medical treatment after exposure has occurred.
Responders involved in recovery, remediation and eventual restoration should be subject to
the usual international standards for occupational radiological protection, which are based on
ICRP recommendations, including the relevant requirements for occupational dose limitation
established in such standards. These restrictions may be relaxed for informed volunteers
undertaking urgent rescue operations, and they are not applicable for voluntary life-saving
actions. However, specific protection measures are recommended for female workers who
may be pregnant or nursing an infant.
iii
 ICRP Publication 96

The immediate countermeasures to protect the public in the rescue phase are primarily car-
ing for people with traumatic injuries and controlling access. Subsequent actions include respi-
ratory protection, personal decontamination, sheltering, iodine prophylaxis (if radioiodines
are involved), and temporary evacuation. In the recovery phase, the relocation and resettle-
ment of people may be needed in extreme cases. This phase may require remedial action,
including cleanup, management of the resulting radioactive waste, management of any human
remains containing significant amounts of radioactive substances, and dealing with remaining
radioactive residues.
The guidance given in relation to public protection is based solely on radiological protection
considerations and should be seen as a decision-aiding tool to prepare for the aftermath of a
radiological attack. It is expected to serve as input to a final decision-making process that may
include other societal concerns, consideration of lessons learned in the past (especially these
involving the public perception of the risks posed by radioactive contamination) and the par-
ticipation of interested parties.
A radiological attack could also be the cause of radioactive contamination of water, food,
and other widely consumed commodities. This possible outcome is considered unlikely to lead
to significant internal contamination of a large number of people owing to the large amounts
of radioactive material that would be required to cause high levels of contamination of water,
food, and other commodities. Nonetheless, the report recommends radiological criteria for
restricting the use of commodities under such circumstances.
The report concludes by reiterating that the response to radiological attacks should be
planned beforehand following the customary processes for optimisation of radiological pro-
tection recommended by ICRP, and that optimised measures should be prepared in advance.
Such plans should result in a systematic approach that can be modified if necessary to take
into account the prevailing conditions and to invoke actions as warranted by the circum-
stances. Many potential scenarios clearly cannot induce immediate severe radiation injuries.
Therefore, in order to prevent over-reaction, response measures prepared in advance should
reflect the real expected gravity of the various possible scenarios.
Ó 2005 ICRP. Published by Elsevier Ltd. All rights reserved.
Keywords: RDD; Contamination; Radiation protection; Intervention; Emergency planning

iv
 ICRP Publication 96

Guest Editorial

PROTECTING PEOPLE AGAINST RADIATION EXPOSURE IN

THE EVENT OF A RADIOLOGICAL ATTACK

In the wake of the terrorist attacks on the US World Trade Center, the subway
systems in Spain and Japan, embassies, nightclubs, and hotels, authorities have be-
come acutely aware of a need to re-assess existing philosophies and assumptions.
This report examines the changes that need to be made to existing radiation emer-
gency planning and protection so that it is applicable to terrorist events.
There are several clear and unique lessons from the recent attacks. The first of
these is the intent of terrorists to stage multiple events simultaneously. Previously,
most radiation emergency plans were directed towards a single event. The second
factor, which is new in radiation protection, is the concept of suicide scenarios. A
third lesson is that we can no longer rely on historical factors such as the probability
of failure rates of various components to predict the likelihood of an event. Terror-
ists deliberately choose improbable or unexpected events. The fourth lesson is the
realisation of a terrorist event combining multiple hazardous agents. Thus, planning
for a radiological incident alone is an outmoded concept and authorities need to be
able to recognise and respond to a situation where there is a combined chemical, bio-
logical, and radiological hazard.
A final lesson is that emergency planning cannot be static. As plans are developed
for detection devices and stockpiles to neutralise biological and chemical threats, we
must assume that the terrorists will simply move on to other ideas and we might ex-
pect the radiological threat to grow.
Much has been written about Ôdirty bombsÕ, but this is only one of several forms
that nuclear terrorism may take. While we instinctively expect to know when a ter-
rorist event has occurred, this is not necessarily the case. A powdered radioactive
material could be spread in a populated area and the terrorists could just wait until
it had been spread by foot traffic and discovered incidentally. This could certainly
cause great concern and economic damage, but is unlikely to represent a significant
public health threat.
One of the major points to emerge from this report is that prevention of exposure
is much more practical and effective than medical treatment post exposure. In the
event of a large release of radioactivity into the environment, sheltering, control
of the food chain, and, if necessary, evacuation can result in dose reduction or pro-
tection factors of up to 100. In contrast, with current medical treatment of both
external exposure and internal contamination, survival or dose reduction can be af-

v
 ICRP Publication 96

fected by a factor of about 2 or 3. A major exception to this is the use of potassium

iodide in the event of release of radioiodine from a reactor or nuclear weapon.
Currently, many governments are assessing various drugs that might be useful,
and decisions are being made about their potential efficacy, legality, cost, and need
for stockpiling. The need for rapid and automated assessment of radiation doses to
individuals, particularly first responders, has also become clear.
This report also recognises the major psychological impact of terrorism combined
with the fear of radiation. It will be necessary to provide the public with timely and
accurate information. Experience with radiation accidents has shown that if a few
hundred people are actually contaminated, often over 100,000 have presented to
be checked for contamination. These Ôworried wellÕ are likely to overwhelm both lo-
cal resources and local hospitals.
This report includes a much more detailed examination of issues discussed above,
guidance, and a template that will allow the reader to begin to examine the situation
in a particular country or setting. This report is the first step in a longer process. The
reader should not assume that this document can be placed on the shelf until there is
a radiological attack and then be used to provide all the answers.

FRED A. METTLER , JR.

vi
 CONTENTS

ABSTRACT..................................................................................................... iii

GUEST EDITORIAL...................................................................................... v

PREFACE ....................................................................................................... 1

EXECUTIVE SUMMARY ............................................................................. 3

GLOSSARY .................................................................................................... 11

1. INTRODUCTION....................................................................................... 21
1.1. Background .............................................................................................. 21
1.2. Aim of the report ..................................................................................... 23
1.3. Intended audience..................................................................................... 24

2. CHARACTERISING THE SITUATION ................................................... 27

2.1. Potential scenarios.................................................................................... 27
2.2. Special features......................................................................................... 28
2.3. Planning.................................................................................................... 32
2.4. Exposure................................................................................................... 35
2.5. Initial reaction .......................................................................................... 38
2.6. Response phases ....................................................................................... 39
2.7. Links......................................................................................................... 40

3. POTENTIAL HEALTH EFFECTS ATTRIBUTABLE TO

RADIATION EXPOSURE ......................................................................... 43
3.1. Biological health effects............................................................................ 43
3.2. Psychological health effects ...................................................................... 46

4. PROTECTING RESPONDERS .................................................................. 49

4.1. Occupational protection approach........................................................... 49
4.2. Occupational protection techniques ......................................................... 52

5. PROTECTING THE PUBLIC .................................................................... 55

5.1. Rescue phase (immediate actions)............................................................ 55
5.2. Rescue phase (urgent actions) .................................................................. 59
5.3. Recovery phase......................................................................................... 64
5.4. Restoration phase..................................................................................... 67
5.5. Summary of dose criteria for protecting the public................................. 71
5.6. Controlling contamination of consumer goods ....................................... 72
5.7. Particular situations ................................................................................. 75
 ICRP Publication 96

6. MEDICAL INTERVENTION .................................................................... 79

6.1. Essential elements of medical treatment .................................................. 79
6.2. Other important medical issues................................................................ 80

7. COMMUNICATION .................................................................................. 83

ANNEX A. POTENTIAL SCENARIOS ........................................................ 85

ANNEX B. MEDICAL ISSUES ..................................................................... 89

ANNEX C. PSYCHOLOGICAL ISSUES ....................................................... 103

REFERENCES................................................................................................ 107
 PREFACE

After the events of 11 September 2001, there has been increasing worldwide appre-
hension about the use of radioactive materials in malicious acts. Members of the
public, the media, and political representatives have become concerned about the
possible malicious use of sources and devices containing radioactive materials (for
instance, by dispersing their radioactive content into the community and threatening
the public health and welfare of inhabitants), the possibility of sabotage attacks on
nuclear facilities (where the malicious aim might be to trigger uncontrolled releases
of radioactive materials), and the potential diversion of nuclear weapon material and
its use in improvised nuclear devices. These speculations on the possibility of what
has been termed a Ôradiological attackÕ have triggered a widespread request for pro-
fessional advice, not only on radiation and nuclear security measures aimed at pre-
venting the attacks from occurring, but also on radiological protection measures to
be undertaken should such an event actually take place. It has been recognised that
existing radiological emergency contingency plans may be insufficient to cope with
the consequences of an attack, as these have mainly focused on accident scenarios
that can generally be anticipated rather than on a premeditated malicious setting
deliberately designed to maximise harm, anxiety, and fear.
In response to the need for advice, the International Commission on Radiological
Protection (ICRP), hereinafter referred to as the Commission, at its 2003 meeting in
Vienna, Austria, established a Task Group to prepare a report providing advice on
protecting people against radiation exposure in the aftermath of a radiological at-
tack. In preparing the report, the main aim of the Task Group was to collect relevant
available recommendations on radiological protection that might be applicable in
the event of such malicious events, and to provide guidance on additional measures
that may be necessary to prepare for and respond to them. The Task Group consid-
ered, but did not assess, the potential or the likelihood of possible scenarios for a
radiological attack. It assumed that a breach of security leading to a radiological at-
tack could actually occur and, on this basis, developed advice on how to intervene
with actions aimed to protect the health of both responders and members of the pub-
lic in accordance with the CommissionÕs recommendations.
It is neither the CommissionÕs role nor the intention of this report to provide a uni-
versal prescription for solving the difficult issues that authorities may face in the con-
text of a radiological attack. The recommendations in the report are generic in
nature and may require modification in light of prevailing social and political cir-
cumstances, as well as availability of resources at the time and location where such
an event might occur. The report assumes that authorities have allocated a priori
responsibilities for the management of the potential radiological emergency resulting
from an attack, and its recommendations build upon the existing concepts and pro-
cesses for emergency preparedness and response to radiological emergencies that
have been developed over many years. It is stressed that all contingency planning
to provide for such emergencies must contain elements of flexibility, as the nature
and types of emergencies will vary greatly both in scale and in the type of response
required.
1
 ICRP Publication 96

For the preparation of the report, the Task Group met in the headquarters of the
Swedish Radiation Protection Authority in Stockholm, Sweden on 10–12 October
2003, and the headquarters of the International Atomic Energy Agency in Vienna,
Austria on 20–22 April 2004. The Commission wishes to express its appreciation
for the support received from those who hosted those meetings.
The membership of the Task Group was as follows:

A.J. González (Chairman) R.H. Clarke R. Cox

L.-E. Holm F.A. Mettler, Jr. C. Streffer
A. Sugier

The corresponding members were:

C. Conklin D.A. Cool M. Crick

J. Wheatley

At its meeting in Vienna in April 2004, the Commission authorised the inclusion of
the Task GroupÕs draft report on the ICRP website for consultation. The report ap-
peared on the web on 17 May 2004. Many comments were received from the profes-
sional community. These served for a further review and revision of the draft report.
The Commission is extremely grateful to those who dedicated their time and profes-
sional expertise to examine the draft and contributed their comments. At its meeting
in Suzhou, China on 16 October 2004, the Commission finally approved the revised
Task Group report for publication in the Annals of the ICRP.
The membership of the Commission during the period of preparation of this re-
port was:

R.H. Clarke (Chairman) R. Alexakhin J.D. Boice, Jr.

R. Cox G.J. Dicus A.J. González
L.-E. Holm (Vice-Chairman) F.A. Mettler, Jr. Z.Q. Pan
R.J. Pentreath Y. Sasaki C. Streffer
A. Sugier
Scientific Secretary: J. Valentin

2
 EXECUTIVE SUMMARY

(a) This report is intended to respond to a widespread need for professional advice
on measures to be undertaken should a radiological attack occur, leading to the
malicious exposure of people to radiation and radioactive substances. Its main
aim is to provide recommendations for protecting rescuers and affected members
of the public against the radiation exposure that might be incurred as a result of such
an event. The report re-affirms the applicability of the standing CommissionÕs recom-
mendations to those potential situations. The Commission expects that relevant
intergovernmental international organisations would establish guidance to assist na-
tional authorities to develop arrangements to deal with radiological attacks on the
basis of the advice given in this report.
(b) The recommendations in the report are conceptually applicable to a wide range
of conceivable attacks. These include the utilisation of radioactive materials for mali-
cious purposes, such as the use of a Ôradioactive dispersion deviceÕ (RDD), the sab-
otage of a nuclear facility to cause an unplanned release of radioactive material, and,
in extreme cases, the detonation of an improvised nuclear device (IND). Since inter-
national advice and recommendations for dealing with nuclear accidents exist, and
given that the special nuclear materials needed to construct an IND are not expected
to be readily available, this report is mainly concerned with radiological attacks
involving RDDs.
(c) Preparing for and responding to a radiological attack should be aimed at pro-
tecting people against arbitrary and unpredictable radiation exposure situations.
Where national authorities have emergency plans in place for radiological accidents,
the recommendations in the report provide additional or supplemental guidance. It
should be noted, however, that although many aspects of the possible emergency sce-
narios resulting from a radiological attack may be similar to those arising from
radiological accidents, these two types of emergencies differ in many respects. One
difference is that a radiological attack would most likely be targeted at a public area,
possibly located in an urban environment, where the presence of radiation or radio-
active material is not anticipated and where there may be limited preparedness for
responding with radiological protection measures. Moreover, the non-urban envi-
ronmental dispersion conditions commonly assumed for planning emergencies in nu-
clear facilities may not be applicable to urban scenarios. The characterisation of the
radiation source and its impact would probably be different as well. In addition, par-
ticular issues associated with the malicious character of the event, such as the crim-
inal investigation that is likely to follow, will have an influence on the emergency
planning and response.
(d) Planning for radiological protection in the aftermath of a radiological attack
requires the establishment of appropriate programmes at both local and national lev-
els. These programmes need to ensure that first responders and rescuers are ade-
quately trained and have the proper equipment to identify the presence of
radiation and radioactive contamination, and that radiation protection specialists
are available to advise local and other relevant authorities. Whenever there is cred-
ible indication that an emergency is in fact a malicious attack, it may be prudent to
3
 ICRP Publication 96

assume that radiological, chemical, and/or biological agents are involved until pro-
ven otherwise. Therefore, if such credible indication exists, the situation calls for the
adoption of an all-hazard approach to the response, which should be based on uni-
versal precautions combined with a prompt capability to identify all hazards present.
This approach needs extensive co-ordination and co-operation of the responsible
institutions, as well as experts in the fields of biological, chemical, and radiological
threats and their associated hazards.
(e) Radiological attacks are characterised by the presence of radioactive sub-
stances. The quantity describing the amount of radioactive substances is the (radio)
activity.1 According to their activity, radioactive substances emit radiation that may
expose both members of the public and rescuers coming to their aid. Radiation may
be delivered from sources outside the body (external exposure) or by radioactive sub-
stances that may be incorporated into the body via inhalation, ingestion, or through
open wounds or the skin (internal exposure). The potential health consequences
caused by the exposure will depend on the amount of radiation received, the types
of radiation involved, and the organs exposed. The amount of radiation exposure
is measured in terms of the radiation dose2 incurred by the affected individual.
(f) In most postulated scenarios associated with a radiological attack, radiation
doses incurred by the majority of exposed people will probably be relatively small,
perhaps lower than the typically elevated levels of the background radiation that
is ubiquitous in nature, e.g. of the order of tens of millisieverts or less. Nonetheless,
it is assumed that low radiation doses have the potential to induce some health effects
(termed ÔstochasticÕ effects), such as cancer and hereditable harm, that may become
manifest many years after the exposure. The probability of occurrence of stochastic
effects is very small, although it is assumed to increase proportionally with dose, and
at low doses, the such effects are unlikely to be detectable. Conversely, people

1
Activity is a quantity measured in units termed ÔbecquerelsÕ (although, in the past, the unit ÔcurieÕ was
– and still is – widely used). One becquerel represents an extremely small activity (conversely, 1 Ci
represents a significant amount of activity as it equates to 37 thousand million becquerels).
2
Dose is the relevant quantity for expressing the amount of radiation exposure. The radiation dose
received by any substance, including human tissues, is termed Ôabsorbed doseÕ and is assessed in units
called ÔgraysÕ (in the past, the unit ÔradÕ was used). Different types of radiation have different effectiveness to
induce damage, and different organs and tissues have different sensitivity to radiation exposure. Therefore,
the absorbed dose has to be weighted to take account of these differences. The quantities resulting from the
absorbed dose weighting for taking into account the effectiveness of various radiation types and the
sensitivity to radiation of various organs and tissues are termed Ôequivalent doseÕ and Ôeffective doseÕ,
respectively, and are both measured in a unit termed ÔsievertÕ (in the past, the unit ÔremÕ was used). The
equivalent dose, which is used to express tissue and organ doses, and the effective dose, which is used for
assessing the whole body implications, can only be employed for ÔnormalÕ radiation protection purposes,
i.e. for situations causing relatively low doses that may merely induce low-probability delayed health
effects, and cannot be formally used to express high doses. As these radiation protection quantities are not
directly measurable, instruments for assessing doses in people or in the ambience are usually calibrated
against defined operational quantities (termed Ôpersonal dose equivalentÕ and Ôambient dose equivalentÕ)
that correspond approximately to the radiation protection quantities and are formally used for verification
of compliance. For reasons of simplification, the report only uses equivalent dose, effective dose and the
unit termed ÔmillisievertÕ (mSv), which is a submultiple of the sievert equal to a thousandth of a sievert (one
mSv equates to 100 thousandths of 1 rem or 100 millirem).

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(perhaps only a small number) could also be exposed to high radiation doses, e.g. of
the order of thousands of millisieverts. If such dose levels are incurred, clinically vis-
ible health effects (termed ÔdeterministicÕ effects) are almost certain to appear, usually
as burns and other tissue reactions, within days of the exposure. Deterministic effects
affect the functioning of tissues and organs with a severity that increases with dose.
In severe cases, they can cause the death of exposed individuals. In radiological at-
tacks with RDDs, only people closer to the event may incur the high doses required
to induce deterministic effects (and only if large amounts of activity were involved).
People affected by the detonation of an IND, and under some conditions, those af-
fected by the radiological consequences of an act of sabotage in a nuclear installa-
tion, are more likely to be subject to high doses. The effects of different radiation
doses and the likelihood of observable consequences are summarised in Table 1.
(g) The relationship between exposure routes, protective actions, and response
phases in the aftermath of a radiological attack will vary depending on the specific
circumstances. Exposure routes include: direct exposure to the source, source frag-
ments or a damaged facility; external exposure from deposited contamination and
contaminated skin and clothes; external exposure and internal contamination from
the plume of dispersed radioactive substances; inhalation of resuspended material;
inadvertent ingestion of contamination; and ingestion of contaminated food and
water. The response phases are usually classified as rescue, recovery, and restoration.
A large number of protective measures are available, some specific for each phase
and some covering various phases.

Table 1. Summary of radiation induced health effects

Dose Effects on individuals Consequences for an exposed
population
Very low dose: about 10 mSv No acute effects; extremely small No observable increase in the
(effective dose) or less additional cancer risk incidence of cancer, even in a
large exposed group
Low dose: towards 100 mSv No acute effects, subsequent Possible observable increase in
(effective dose) additional cancer risk of less than the incidence of cancer, if the
1% exposed group is large (perhaps
greater than about 100,000
people)
Moderate dose: towards Nausea, vomiting possible, mild Probable observable increase in
1000 mSv (acute whole body bone marrow depression; the incidence of cancer, if the
dose) subsequent additional cancer risk exposed group is more than a few
of about 10% hundred people
High dose: above 1000 mSv Certain nausea, likely bone Observable increase in the
(acute whole body dose) marrow syndrome; high risk of incidence of cancer
death from about 4000 mSv of
acute whole body dose without
medical treatment.
Significant additional cancer risk

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(h) The aim of the protective measures must be to prevent deterministic effects and
restrict the likelihood of stochastic effects. In addition to protecting people against
the unpredictable exposure situations that will be created by an attack, the objectives
include minimising the overall impact in terms of environmental contamination and
general disruption, and attempting to restore normality as quickly as possible. The
response must essentially be to: identify and characterise the emergency situation;
provide medical care for injured people; attempt to avoid further exposures; gain
control of the situation; prevent the spread of radioactive materials; provide accurate
and timely information to the public; and institute a process for returning to normal-
ity, while dealing with psychological issues, such as distress, and misattribution and
fear of illness, which will be major concerns. In the immediate response phase, exclu-
sion distances usually employed in relation to explosives are a good starting point for
controlling the site for radiation levels, and typical precautions at medical facilities
for infectious agents are sufficient as a starting point for handling people that may
be contaminated with radioactive material. It is emphasised that taking actions to
avert exposures is much more effective than possible medical treatment after expo-
sure has occurred. Treatment after an exposure is liable to reduce the number of
health effects slightly (e.g. by a factor of approximately 2–3); in comparison, inter-
ventions with protective actions to avert the exposure occurring is likely to reduce
the number of health effects by up to several orders of magnitude (e.g. by factors
of approximately 10–1000).
(i) Responders undertaking recovery and restoration operations should be pro-
tected according to normal occupational radiological protection standards, and
should not exceed internationally accepted occupational dose limits. This restriction
may be relaxed for informed volunteers undertaking urgent rescue operations, and is
not applicable for volunteered life-saving actions whenever the benefit to others
clearly outweighs the rescuerÕs own risk. However, since specific protection measures
have been recommended for female workers who may be pregnant or are nursing an
infant, and taking account of the unavoidable uncertainties surrounding early re-
sponse measures in the event of a radiological attack, female workers in those con-
ditions should not be employed as first responders undertaking life-saving or other
urgent actions. The recommended dose guidance values for restraining the occupa-
tional exposure of responders are shown in Table 2.
(j) The immediate countermeasures to protect the public in the rescue phase are
primarily caring for people with traumatic injuries and controlling access to the
scene, and subsequently providing affected people with respiratory protection mea-
sures and, whenever necessary and feasible, minimising the possible spread of con-
tamination with radioactive material. Caring for people should be supported by
triage and disposition following quick assessments of the approximate dose incurred
and the physiological status of the affected people. Subsequent urgent actions in this
phase include: personal decontamination, sheltering, iodine prophylaxis (if radioio-
dines are involved), and temporary evacuation. In the recovery phase, definitive relo-
cation and resettlement may be needed in extreme cases. Each of these
countermeasures has a degree of associated penalties, and typically would provide

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Table 2 Guidance for occupational exposure

Type of emergency operation Dose guidance value
Rescue operations* Saving life, preventing serious In principle, for life-saving operations, no
injury, or actions to prevent the dose restrictions are recommended if, and
development of catastrophic ONLY IF, the benefit to others clearly
conditions. outweighs the rescuerÕs own risk
Other immediate and urgent All reasonable efforts should be made to
actions to prevent injuries or keep doses below twice the maximum
large doses to many people single year limits (see below)

Other operations, including recovery and restoration Normal occupational dose limits apply,
operations i.e.:
 a limit on effective dose of 20 mSv/year,
averaged over 5 years (i.e., a limit of
100 mSv in 5 years), with the further
provision that in any single year:
 the effective dose should not exceed
50 mSv and
 the equivalent dose should not exceed
– 150 mSv for the lens of the eye
– 500 mSv for the skin (average dose
over 1 cm2 of the most highly irradi-
ated area of the skin), and
– 500 mSv for the hands and feet
*
Under conditions that may lead to doses above normal occupational exposure limits, workers should
be volunteers and should be instructed in dealing with radiation hazards to allow them to make informed
decisions. Female workers who may be pregnant or nursing should not participate in such operations.

the most benefit if the reduction of the avertable dose for the affected population was
around the levels shown in Table 3.
(k) The recovery phase may require restoration and clean up, the safe management
of the radioactive waste remaining from these operations, management of corpses
containing significant amounts of radioactive substances, and dealing with long-term
prolonged exposure situations caused by remaining radioactive residues. In the latter
case, the recommended generic criteria for justifying intervention with radiation pro-
tection measures are shown in Table 4.
(l) The quantitative recommendations given in Tables 3 and 4 cannot always be
used directly as quantities such as equivalent dose and effective dose are not directly

Table 3. Recommended avertable doses for undertaking countermeasures

Countermeasure Avertable dose (for which the
countermeasure is generically optimised)
Sheltering
10 mSv in 2 days (of effective dose)
Temporary evacuation
50 mSv in 1 week (of effective dose)
Iodine prophylaxis (if radioiodine is present)
100 mSv (of equivalent dose to the thyroid)
Relocation
1000 mSv or
100 mSv first year (of effective dose)

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Table 4. Recommended generic criteria for intervention in prolonged exposure situations

Intervention Criteria (existing annual
effective dose, mSv/year)
Almost always justifiable Towards 100
May be justifiable J 10
Unlikely to be justifiable [10
Source: ICRP (1999, Fig. 6).

measurable. They should be used as the basis for developing (at the planning stage)
operational intervention levels expressed in directly measurable quantities. The rec-
ommended guidance is based solely on radiological protection considerations and
should be seen purely as a decision-aiding tool aimed at helping the competent
authorities to prepare for the aftermath of a radiological attack. The guidance is ex-
pected to serve as input to a final, and usually wider, decision-making process that
may include other societal concerns, consideration of lessons learned in the past
from other events, and the participation of interested parties. Simplification of crite-
ria and corresponding training and exercising would allow for better implementa-
tion; however, during the response to an actual event, emergency managers may
need to take other factors, such as other hazards or specific conditions, into account
in operational decisions.
(m) A potential consequence of a radiological attack is the radioactive contam-
ination of goods such as water, food, and other commodities for public consump-
tion. This possible outcome, however, is unlikely to lead to significant internal
contamination of a large number of people because of the large amounts of radio-
active material that would be required to reach high levels of contamination in
mass-produced or -distributed supplies. While the levels of contamination of con-
sumer goods and the resulting levels of annual effective dose could be very low, the
effective control of contamination for radiation protection purposes could become
amenable and warranted above certain activity concentration levels. The values in
Table 5 represent the approximate levels of activity concentration in contaminated
substances above which control for radiological protection purposes can be consid-
ered in case of a radiological attack. Consumer goods with activity concentration
below the levels in Table 5 are excluded from the scope of the recommendations in
this report.
(n) An intergovernmental international consensus on radiological criteria for
radionuclides in commodities was recently reached under the aegis of the IAEA. Na-

Table 5. Recommended exclusion levels

Nuclides Activity concentration (Bq/g)
Artificial a-emitters 0.01
Artificial b-/c-emitters 0.1
238 232
Head of chain activity level, U, Th 1.0

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 ICRP Publication 96

tional authorities may wish to take these criteria into account for deciding on control
measures following a radiological attack.
(o) The process of radiological protection intervention measures in the aftermath
of a radiological attack should result in a systematic and flexible approach to the re-
sponse, taking into account the conditions present and invoking protective actions as
warranted by the circumstances. It is helpful to understand that there are recommen-
dations that are always applicable, others that are often applicable, and others that
are only applicable in the most severe circumstances (for instance, as many potential
scenarios clearly cannot induce immediate severe radiation injuries, recommenda-
tions on these effects are not always applicable). In order to prevent over reaction,
it is essential that radiological protection decisions reflect the magnitude of the radio-
logical attack.

9
 GLOSSARY

Absorbed dose
The absorbed dose is defined as the average energy absorbed from radiation by a
tissue, organ, or the whole body per unit mass of such tissue, organ, or the whole
body (ICRP, 1991a, Paragraph S2). The special name for the unit of absorbed dose
is ÔgrayÕ (Gy) which is equivalent to J/kg (another unit used in some countries is the
ÔradÕ; 100 rad = 1 Gy).

Accident
Any unintended event, including operating errors, equipment failures, or other
mishaps, the consequences or potential consequences of which are not negligible
from the point of view of radiological protection.

Action level
The level of dose rate or activity concentration above which remedial actions or
protective actions should be carried out in chronic exposure or emergency exposure
situations.

Activation
The production of radionuclides by irradiation.

Activity
The quantity activity, A, for an amount of radionuclide in a given energy state
at a given time is defined as A = dN/dt, where dN is the expectation value of the
number of spontaneous nuclear transformations from the given energy state in the
time interval dt. The unit of activity is the reciprocal second, termed the ÔbecquerelÕ
(Bq).

Annual limit of intake (ALI)

The intake by inhalation, ingestion, or through the skin of a given radionuclide in a
year by the reference man which would result in a committed dose equal to the rele-
vant dose limit. The ALI is expressed in units of activity (see ICRP, 1993b, 1995a,b,
1996).

Anxiety and fear

The term Ôanxiety and fearÕ includes the concepts of horror, dread, fright, alarm,
trepidation, and apprehension that may be caused by the malicious use of radioac-
tive materials.
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 ICRP Publication 96

Avertable (or averted) dose3

The dose to be saved by a protective action; i.e. the difference between the dose to be
expected with the protective action and that to be expected without it is the dose saved
by implementing a protective action for each conceivable pathway of exposure.

Collective dose
An expression for the total radiation dose incurred by a population, defined as the
product of the number of individuals exposed to a source and their average radiation
dose. The collective dose is expressed in man-sieverts (man-Sv).

Committed dose
The committed dose (absorbed dose, equivalent dose, or effective dose) is defined
as the summation integral of the dose rate over time, from the time of exposure to a
time that if not specified will be taken to be 50 years for adults.

Control
In the context of control over radioactive sources, the Commission uses the term
ÔcontrolÕ to include checking, monitoring, and verifying the safety and security of
such sources, as well as ensuring that corrective or enforcement measures are taken
if the results indicate the need for them. Control over radiation sources should be
commensurate with their potential for causing radiation induced health effects.

Countermeasure
An action aimed at alleviating the consequences of an accident.

Critical group
A group of members of the public that is reasonably homogeneous with respect to
its exposure for a given radiation source and given exposure pathway, and is typical
of individuals receiving the highest effective dose or equivalent dose (as applicable)
by the given exposure pathway from the given source.

Decontamination
The removal or reduction of contamination by a physical or chemical process.

Deterministic effect
A radiation effect for which a threshold level of dose generally exists above which
the severity of the effect is greater for a higher dose.

3
The duration of the exposure is an important consideration since protraction of the dose influences
the threshold dose at which deterministic effects may appear. If the interventions are fully effective, the
averted dose is numerically equal to the projected dose, but these are conceptually different quantities (vide
infra). However, it may be appropriate to express the intervention level in terms of a projected dose for
that pathway rather than an averted dose. Intervention may not be fully effective, either because the dose
has already been received, or because the intervention itself may only partly reduce the total projected
dose.

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 ICRP Publication 96

Dose
A measure of the radiation received or ÔabsorbedÕ by a target. The quantities termed
Ôabsorbed doseÕ, Ôorgan doseÕ, Ôequivalent doseÕ, Ôeffective doseÕ, Ôcommitted equivalent
doseÕ, or Ôcommitted effective doseÕ are used, depending on the context. The modifying
terms are often omitted when they are not necessary for defining the quantity of interest
(see Radiation dose, Absorbed dose, Equivalent dose, Effective dose, and Avertable
dose).

Dose limit
The value of the effective dose or the equivalent dose to individuals from con-
trolled practices that shall not be exceeded.

Effective dose
The quantity E, defined as a summation of the tissue equivalent doses, each mul-
tiplied by the appropriate tissue weighting factor
X
ET ¼ wT  H T
where HT is the equivalent dose in tissue T and wT is the tissue weighting factor for
tissue T. From the definition of equivalent dose, it follows that
X X
ET ¼ wT  wR  DT;R ;
R

where wR is the radiation weighting factor for radiation R and DT,R is the average
absorbed dose in the organ or tissue T. The unit of effective dose is J/kg, termed
the ÔsievertÕ (Sv).

Emergency plan
A description of the objectives, policy, and concept of operations for the response
to an emergency, and of the structure, authorities, and responsibilities for a system-
atic, co-ordinated, and effective response.

Employer
Within the context of this document, the employer will be the legal person with
recognised responsibility, commitment, and duties towards workers in the rescue
operations, i.e. in his or her ÔemploymentÕ, by virtue of a mutually agreed relationship.
A self-employed person is regarded as being both an employer and a worker.

Equivalent dose
The quantity HT,R, defined as
H T;R ¼ DT;R  wR ;
where DT,R is the absorbed dose delivered by radiation type R averaged over a tissue
or organ T, and wR is the radiation weighting factor for radiation type R.
When the radiation field is composed of different radiation types with different val-
ues of wR, the equivalent dose is
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 ICRP Publication 96
X
H T;R ¼ wR  DT;R :
The unit of equivalent dose is J/kg, termed the ÔsievertÕ (Sv).

Exposure
The Commission uses the term ÔexposureÕ in a generic sense to mean the process of
being exposed to radiation or radionuclides, the significance of exposure being deter-
mined by the resulting radiation dose (ICRP, 1991a, Paragraph S4). Exposure is the-
refore the act or condition of being subject to irradiation. Exposure can be either
external (irradiation by sources outside the body) or internal (irradiation by sources
inside the body). Exposure can be classified as either normal or potential exposure;
either occupational, medical, or public exposure; and, in intervention situations such
as those following a radiological attack, either emergency or chronic exposure. The
term ÔexposureÕ is also used in radiodosimetry to express the amount of ionisation
produced in air by ionising radiation.

Exposure pathways
The routes by which radioactive material can reach or irradiate humans.

Improvised nuclear device (IND)

A crude weapon made using fissionable nuclear material that has been acquired
illicitly and is capable of sustaining a fission chain reaction. Such a device might
be entirely improvised or might be based on a military nuclear weapon. The hazard
is due to the energy and radiation resulting from a nuclear chain reaction or from the
decay of the products of a chain reaction.

Intake
The process of taking radionuclides into the body by inhalation, ingestion, or
through the skin.

Intervening organisation
An organisation designated or otherwise recognised by a government as being
responsible for managing or implementing any aspect of an intervention.

Intervention
Any action intended to reduce or avert exposure or the likelihood of exposure to
sources that are not part of a controlled practice or which are out of control as a
consequence of an accident or, within the context of this document, are involved
in a radiological attack.

Intervention level
The level of avertable dose at which a specific protective action or remedial action
is taken in an emergency exposure situation or a chronic exposure situation.

Investigation level
The value of a quantity such as effective dose, intake, or contamination per unit
area or volume at or above which an investigation should be conducted.
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 ICRP Publication 96

Ionising radiation
For the purposes of radiation protection, radiation capable of producing ion pairs
in biological material(s).

Irradiation and contamination

The concept of irradiation, either from a source or to a person, is straightforward:
irradiation means the action of either emitting radiation (by a source) or incurring radi-
ation (by a body, e.g. a person, a tissue, an organ). The concept of contamination is
more subtle and prone to be misunderstood. The term is used to mean either radioactive
substances on surfaces, or within solids, liquids, or gases (including the human body),
where their presence is unintended or undesirable, or the process giving rise to their pres-
ence in such places. Also used less formally to refer to a quantity, namely the activity
present on a surface (or on unit area of a surface). It should be noted that the translation
of the term ÔcontaminationÕ into some other languages may introduce a connotation
that is not present in English; while the English language term ÔcontaminationÕ refers
only to the presence of activity, and gives no indication of the magnitude of the hazard
involved, this is not always the connotation given in other languages. A radiological at-
tack may irradiate without contaminating (e.g. if the source used is not dispersible), or
contaminate the environment without a significant irradiation of people, or contami-
nate people externally (e.g. on the skin) or internally (e.g. as a result of an intake of dis-
persed radioactive substances), and these contaminations could irradiate different parts
of the body from inside, or result in a combination of all these scenarios.

Justification
In the aftermath of a radiological attack, one of the issues is to justify the intro-
duction (or continuation) of disruptive countermeasures or what is termed Ôjustifica-
tion of interventionÕ. The Commission recommends that any proposed intervention
should do more good than harm, i.e. the reduction in detriment resulting from the
reduction in dose should be sufficient to justify the harm and the costs, including so-
cial costs, of the intervention.

Member of the public

In a general sense, any individual in the population except, for the purposes of this
document, when subject to occupational exposure (e.g. working in rescue opera-
tions). For the purpose of verifying compliance with dose restrictions for public
exposure, it is the representative individual in the relevant critical group.

Monitoring
The measurement of dose or contamination for reasons related to the assessment
or control of exposure to radiation or radioactive substances, and the interpretation
of the results.

Occupational exposure
All exposures of workers incurred in the course of their work, e.g. the exposure of
rescuers.
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Operational intervention level (OIL)

A calculated level, measured by instruments or determined by laboratory analysis,
that corresponds to an intervention level or action level. OILs are typically expressed
in terms of dose rates or activity of radioactive material released, time-integrated air
concentrations, ground or surface concentrations, or activity concentrations of
radionuclides in environmental, food, or water samples. An OIL is a type of action
level that is used immediately and directly (without further assessment) to determine
the appropriate protective actions on the basis of an environmental measurement.

Optimisation of protection in interventions

The form, scale, and duration of the intervention should be optimised so that the
net benefit of the reduction of dose, i.e. the benefit of the reduction in radiation det-
riment, less the detriment associated with the intervention, should be maximised.
This principle is termed Ôoptimisation of protection in interventionsÕ.

Orphan sources
The terms ÔorphanÕ and ÔorphanedÕ source have been used internationally to de-
scribe a radioactive source that is not under regulatory control, either because it
has never been under regulatory control, or because it has been abandoned, lost, mis-
placed, stolen, or transferred without proper authorisation.

Projected dose
Projected dose is the dose estimated for the population at risk for each exposure
pathway without taking possible protective actions into account.

Prolonged exposure situations

Radioactive residues from a malicious event may remain in the environment for a long
time (e.g. years), adding to the radioactive substances that were present in the environ-
ment before the attack. These residues may contribute to prolonged exposure situations.

Protective action
An intervention intended to avoid or reduce doses to members of the public in
chronic or emergency exposure situations.

Public exposure
Exposure incurred by members of the public from radiation sources, excluding
any occupational or medical exposure and the normal local natural background
radiation, but including exposure from authorised sources and practices and from
intervention situations, e.g. the situation resulting from a radiological attack.

Radiation and radioactive

A substance is considered to be radioactive if it exhibits radioactivity. Radioactivity
is the phenomenon whereby atoms undergo spontaneous random disintegration, usu-
ally accompanied by the emission of radiation (e.g. alpha, beta, gamma, or neutron
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 ICRP Publication 96

radiation). There has been an imprecise use of the terms ÔradiationÕ and ÔradioactiveÕ
to qualify sources potentially amenable for malicious uses. A source of radiation
exposure is not necessarily ÔradioactiveÕ. Typical non-radioactive radiation sources
are various types of electrical generators of radiation, such as x-ray apparatus and
particle accelerators, which emit radiation while in operation but their emitting prop-
erties cease as soon as the electricity supply is cut. Conversely, radioactive radiation
sources (or radioactive sources in short) emit radiation because they contain radioac-
tive substances. Typical examples of radioactive sources are the sealed capsules con-
taining radionuclides, such as 60Co and 137Cs, which never cease to emit radiation
with decaying intensity. Of these, only those containing a significant amount of radio-
active substance are relevant for malicious purposes. (The amount of radioactivity in-
volved in a radiological attack is usually referred to as the Ôsource termÕ.) In summary,
all radiation sources, be they radioactive or non-radioactive, may be a safety concern;
conversely, not all radiation sources but just those radioactive sources containing a
significant amount of radioactive substance may also be a security concern in relation
to potential terrorist attacks.

Radiation dose
The health significance of a radiological attack will be determined by the resulting
radiation exposure of people and, specifically, by the radiation dose incurred by the indi-
viduals being irradiated. The Commission uses the term Ôradiation exposureÕ in a broad
sense to mean the process of being exposed to radiation or radioactive material and,
specifically, it uses the term Ôradiation doseÕ as a generic name expressing the amount
of energy received by matter from radiation exposure (ICRP, 1991a, Paragraph S4).
With different qualifiers, the term ÔdoseÕ gives rise to various dosimetric quantities.

Radioactive half-life
For a radionuclide, the time required for the activity to decrease, by a radioactive
decay process, by half.

Radioactive residues
The Commission uses the term Ôradioactive residuesÕ to mean radioactive materials
that have remained in the environment from early operations (including past prac-
tices) and accidents (ICRP, 1991a, Paragraph 219).

Radioactive waste
The Commission uses the term Ôradioactive wasteÕ to mean any (radioactive) mate-
rial that will be or has been discarded, being of no further use (ICRP, 1997c, Para-
graph 3).

Radioactive dispersion devices (RDDs)

The detonation of conventional explosives shrouding an ordinary radioactive
source, such as those commonly used in medicine and industry, has been dubbed
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 ICRP Publication 96

in the press as a Ôdirty bombÕ, but may be more properly referred to as an ÔRDDÕ. The
dispersion of radioactive material into the environment may be achieved without
explosives, by opening the source container if the material is dispersible, or process-
ing the source to make it dispersible.
Residual dose
Residual dose4 is the remaining dose from each pathway (projected dose minus
averted dose). For long-term decisions that would usually involve prolonged exposure
situations to residual doses that may remain long after the event, the relevant quantity
is the annual (effective) dose, which can be presented as: the existing annual dose, i.e.
the summation of the annual doses caused by all the persisting sources of prolonged
exposure already existing in the human habitat where the situation occurs; the addi-
tional annual dose, i.e. the annual dose that is added to the existing annual dose as
a result of the event; and/or the averted annual dose, i.e. the annual dose that is re-
moved from the existing annual dose by the protective actions that might be taken.

Risk
A multi-attribute quantity expressing hazard, danger, or chance of harmful or
injurious consequences associated with actual or potential exposures. It relates to
quantities such as the probability that specific deleterious consequences may arise
and the magnitude and character of such consequences.

Safety assessment
A review of the aspects of design and operation of the intervention following a
radiological attack that are relevant to the radiological protection of people, includ-
ing analysis of the provisions for safety and protection established, and the analysis
of risks associated with the event.

Security vis-à-vis safety

Although the concept of security of radiation sources is not new in radiation safety
standards, it has acquired new dimensions following international concerns on po-
tential nuclear terrorism. The use of the term ÔsecurityÕ has been widely confused with
the wider concept of safety, the confusion being aggravated by linguistic problems
(in many major languages, the concepts of safety and security are expressed with
the same word). In the CommissionÕs parlance, the safety of a source denotes the
assembly of administrative, technical, and managerial features aimed at diminishing
the likelihood of people incurring radiation harm as a result of radiation exposure
from such a source. In contrast, the security of a source refers to features aimed
at preventing any unauthorised possession of, and actions with, the source, by ensur-
ing that control over it is not relinquished or improperly acquired. Source security is
a necessary, but not sufficient, subsidiary condition for source safety.

4
While each intervention is judged on its merits, the sum of residual doses from all pathways after
implementation of protective actions should be kept under review because of the possibility of serious
deterministic health effects.

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 ICRP Publication 96

Source
The Commission uses the term ÔsourceÕ to indicate what may cause radiation
exposure. Sources range from nuclear installations and other nuclear facilities usu-
ally holding huge inventories of radioactive fission and activation products, to sim-
ple sealed sources of radioactive materials. The term is also used more generally to
indicate the cause of exposure to radiation or to radionuclides in radioactive sub-
stances, and not necessarily an individual physical source of radiation. For in-
stance, if radioactive materials are released from an installation to the
environment, the installation as a whole may be regarded as a source; if they
are already dispersed in the environment, the portion of them to which people
are exposed may be considered a source.

Source term: radioactivity

Except for INDs, which require separate treatment, the strength of a radiological
attack is defined by the amount of radioactive material involved in the event (and
its radioisotopic composition), which is termed the Ôsource termÕ. The principal
quantity defining the source term is the activity (hereinafter referred to as radioac-
tivity)5 of the radioactive substances involved in the event for each of the radionuc-
lides involved. This describes how much radiation the dispersed substances are
emitting. The unit of radioactivity is the reciprocal second, which is termed Ôbec-
querelÕ (Bq) [although another unit of radioactivity used in some countries is the
curie (Ci), which is defined as the radioactivity content of 1 g of radium]. One bec-
querel is an extremely small amount of radioactive substance as it is much smaller
than a billionth of 1 Ci (1 Ci = 3.7 · 1010 Bq). In the event of the explosion of an
IND, in addition to radiation emitted by the radioactivity created in the event,
there may be a significant flux of neutrons that will occur within the first minute
after the explosion.

Special fissionable materials

Special fissionable material includes: plutonium, except that with isotopic concen-
tration exceeding 80% in 238Pu, 233U, and uranium enriched in the isotope 235 or 233.

Stochastic effects of radiation

Radiation effects, generally occurring without a threshold level of dose, whose
probability is proportional to the dose and whose severity is independent of the dose.

Supervised area
Any area not designated as a controlled area but which is kept under review for
occupational exposure conditions, even though specific protective measures and
safety provisions are not normally needed.

5
The Commission defines activity as the average number of spontaneous nuclear transformations
taking place per unit time in an amount of radioactive substance (ICRP, 1991a, Paragraph 37).

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 ICRP Publication 96

Worker
Any person who works, whether full time, part time or temporarily, for an em-
ployer and who has recognised rights and duties in relation to occupational radiation
protection. A self-employed person is regarded as having the duties of both an em-
ployer and a worker. Rescuers are regarded as workers.

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 1. INTRODUCTION

1.1. Background

1.1.1. Security of radiation sources

(1) Over the years, the CommissionÕs recommendations (ICRP, 1959, 1964, 1966,
1977, 1991a) have presumed that, as a precondition for proper radiological protection,
sources of radiation exposure have to be subject to proper security measures. This pre-
sumption is reflected in the International Basic Safety Standards for Protection against
Ionizing Radiation and for the Safety of Radiation Sources (IAEA, 1996a), usually
referred to as the ÔBSSÕ, which follow ICRP recommendations and require that the con-
trol over sources shall not be relinquished under any circumstances. Source security is a
necessary, although not sufficient, condition to ensure source safety. If a source is not
secure, it is not safe; conversely, sources that are secure are not necessarily safe.
(2) Secured sources can, and have, become unsecured through a variety of circum-
stances. Historically, in the most common cases, control over the source was relin-
quished inadvertently, and then the source was misused, without any premeditated
malicious intent. In other cases, many sources have been found to be orphaned of
any control and were therefore completely unsecured. A relatively large number of
radiological accidents have occurred because of these unintentional breaches in
source security or because an orphan source was inadvertently found. The detailed
causes and consequences of some of these accidents have been reported internation-
ally (IAEA, 1988a, 1996b, 1998a,b,c, 2000a,b,c, 2002a,b).
(3) These cases of inadvertent breaches of source security have provided an indi-
cation of what might occur if radioactive materials were used intentionally to create
harm. There is the potential for premeditated criminal breaches in source security
that may eventually lead to the malicious use of radioactive materials. An example
of a radiological attack based on this type of scenario could be the deliberate disper-
sion of the radioactive content of a source in a public area. Such an event has the
potential for exposing people to radiation and causing significant environmental
contamination, which would require specific radiological protection measures. Be-
fore the events of 11 September 2001, information on security of radioactive sources
had been published internationally (IAEA, 1998c, 1999a, 2001c). Following these
events, the issue has been re-addressed both at international level (IAEA, 2003c)
and also by various national organisations (e.g. HPS, 2004; NCRP, 2001), particu-
larly regarding the possibility of malicious uses of unsecured radioactive sources.
An international Code of Conduct on Safety and Security of Radioactive Sources
has been established recently (IAEA, 2001b, 2004a), with a clearly defined scope
of ÔdangerousÕ sources (IAEA, 2003b). More recently, international agreement has
been reached on guidance for export/import of sources (IAEA, 2004e) in order to
implement relevant requisites in the Code. The Commission expects that adherence
to the CodeÕs requirements will strengthen the necessary control of radioactive
sources – a prerequisite to ensure that they are properly secured.

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1.1.2. Radiation-related malevolence

(4) There are a number of reasons why radiation is of unique concern in relation
to malicious events. On the negative side, radiation is perceived as a mysterious
pollutant, and past experience with radiation emergencies has shown that there
are problems in dealing with this perception. The public have, in general, exagger-
ated fears because radiation is invisible and odourless, and its effects may only be
apparent hours, days, weeks, or even many years after exposure. Radiological at-
tacks are more likely than other malicious events to give rise to psychological
problems among members of the public, public officials, and professionals in other
fields because of the fear of radiation and a misunderstanding of its consequences.
The perceived risk is a major contributor to the anxiety and fear that may be in-
duced by a malicious act – an extra dimension presenting additional challenges to
those who will have to manage the health consequences of such an event. There
will be difficulties in responding to a radiological attack because those who handle
the situation at an early stage, if not appropriately trained, will share much of the
anxiety and fear about radiation, and they will probably have little experience in
dealing with such an emergency.
(5) Relatively low levels of radiation exposure, such as those that will likely remain
after a radiological attack, are often mistakenly viewed as a substantial hazard, and
this is the main element in the creation of anxiety and fear. Contrary to public per-
ception, radiation is actually a weak carcinogen. At low levels of exposure, the health
risks attributable to radiation, such as the risk of developing cancer, are very low –
so low that any potential effect is, in fact, undetectable by epidemiological
techniques. Radiation protection professionals should, however, do whatever they
reasonably can to constrain unjustified radiation exposure of people, because the
prevalent scientific opinion is that for protection purposes, a small but finite risk
of deleterious effects should be attributed to radiation exposure above background
levels, even at low levels. Unfortunately, justifiable radiation protection efforts with-
out proper communication with the public can themselves become a contributor to
anxiety and fear as people can misinterpret them as an indication that they are sub-
ject to a high risk.
(6) On the positive side, in comparison with biological or chemical attacks, the
area over which radioactive contamination occurs can be readily delineated if appro-
priate radiation measurement instruments are available (with the possible exception
of contamination due to some alpha-emitting radioisotopes). Moreover, radiation is
one of the most studied agents in toxicology and medicine, including its carcinogenic
potential, and therefore many sources of information on the health effects of radia-
tion are available. As a result of these studies, sound criteria for conventional radio-
logical emergencies have already been developed, which are relevant and can be
applied in the event of a radiological attack. Furthermore, it is generally recognised
that there would be far fewer fatalities following a radiological attack, in contrast to
the number of immediate fatalities that could be caused by biological or chemical
agents, or simply by a large explosive blast.

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 ICRP Publication 96

1.2. Aim of the report

(7) The main aim of this report is to provide radiological protection recommenda-
tions for protecting peopleÕs health in the aftermath of a radiological attack. These
recommendations are based on conceivable scenarios of specific radiological attacks
aimed at exposing people to radiation, or contaminating the environment, creating
anxiety and fear, and resulting in disruption. The report does not address the means
by which the source of radiation was obtained by the attackers.
(8) The Commission notes that whether or not an ÔattackÕ is the trigger of a
situation of radiological concern, the aftermath of either intended or unintended
events of this type are, in fact, very similar: namely, the potential for unexpected
exposure of people to radiation. The intent that caused the radiological condition
may be different, but the outcome and the necessary response actions are essen-
tially the same. However, there are differences between an emergency that may
arise from an accident and those associated with a radiological attack. These dif-
ferences are described in the report. If a radiological attack were to occur,
authorities and radiological protection experts could be faced with a situation
where radiation and/or radioactive material are in a place where it was not ex-
pected or explicitly planned to be. Whatever the scenario, the final objectives
should be to protect people in unpredictable exposure situations, to minimise
the impact, and to quickly restore the situation to normal. When this fact is rea-
lised, the response must essentially:
 identify and characterise the emergency situation;
 provide medical care to those affected;
 quickly attempt to avoid further exposures;
 gain control of the situation;
 prevent the spread of radioactive materials;
 provide accurate and timely information to the public; and
 begin the process of returning to normality.
(9) Capabilities need to be in place to ensure the effective performance of these
response actions, and relevant international requirements and guidance have been
established (IAEA, 2002c, 2003b). These capabilities will include those that are
generic for all types of emergencies (e.g. continuously available emergency contact
points, command and control, public communication arrangements, initial all-
hazards assessment) and those that are specific to radiological emergencies (e.g.
radiological assessment, monitoring, and protection capabilities) (IAEA, 1997c;
1999b; 2000d). These capabilities will need to be applied in a systematic and flex-
ible manner to perform the response functions effectively according to the event
scenario.
(10) It is to be noted that the recommendations in the report are mainly based
on the scientific assessment of the health risks associated with radiation exposure
that may arise in the aftermath of certain scenarios involving radiological attacks.
However, some members of the public and sometimes their political representatives
may have alternative views on the radiation risks attributable to such situations.
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This usually results in differently perceived needs for response and a different level
of protection. The desired level of protection may be higher than that for other
exposure situations. For instance, the risk attributable to living in areas with typ-
ically elevated natural radiation exposures are usually ignored by society, while
relatively minor exposures to artificial radioactive residues remaining in the envi-
ronment are a cause of concern and sometimes prompt unnecessary protective ac-
tions. This reality of social and political attributes, generally unrelated to
radiological protection, will influence the final decision on the level of protection
following a radiological attack.
(11) Therefore, the Commission emphasises that this report should be viewed as
providing decision-aiding recommendations based principally on scientific consider-
ations of radiological protection, rather than an automatic formula for making deci-
sions. The recommendations in the report, therefore, provide supplemental guidance
and input to a wider decision-making process that may include: other societal con-
cerns; other hazards that may be present; consideration of lessons learned in the past
from other events; and the participation of relevant stakeholders. The process of
planning for radiological attacks should result in a systematic, yet flexible, approach
to the response, taking the conditions present into account, and invoking protective
actions as warranted by the circumstances.

1.3. Intended audience

(12) The Commission intends this report to be of help to responsible officials, reg-
ulatory bodies, and advisory agencies with competence in emergency response – in
particular, those agencies dealing with possible radiological attacks and their after-
math at local, regional, national, and international level. The report provides guid-
ance to these bodies on the fundamental principles on which appropriate
intervention with protective actions may be undertaken in response to such an event.
Different conditions are likely to apply in different countries, and the Commission,
therefore, wishes to emphasise that the report should not be viewed as a universal
text on radiological protection in the event of a radiological attack.
(13) The Commission recognises that one of the problems to be faced in rela-
tion to the types of situations discussed in this report is the lack of a common
understanding on the basic issues among scientists, decision makers, the media,
and the public at large. Unfortunately, since the events of 11 September 2001,
reactions of many people have created some confusion in the comprehension of
the security concerns associated with radioactive substances. For instance, the ba-
sic concepts of radiation source vis-à-vis radioactive source and irradiation vis-à-
vis contamination are widely confused, as are source safety vis-à-vis source
security.
(14) The concepts, quantities, and units used in radiological protection are also
often misunderstood. Confused communication, mainly caused by the loose use
of terminology, sometimes exacerbated by difficulties in translation, has contrib-
uted to increased public anxiety on this issue. As the report may also be of inter-
est to people other than radiation protection professionals, such as security
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 ICRP Publication 96

specialists and non-radiation experts involved in decision-making processes relat-

ing to emergency situations, and because of the prevailing misunderstandings on
the topic, the report is supplemented with information intended to help the reader
to understand the CommissionÕs terminology and policies in the context of radio-
logical emergencies. Relevant complementary information is provided in the
Glossary.

25
 2. CHARACTERISING THE SITUATION

2.1. Potential scenarios

2.1.1. Threat

(15) Scenarios for the malicious intent of causing radiation exposure are charac-
terised in terms of their threat. To respond effectively, it is necessary to recognise
and anticipate the type of threat that might trigger such an event. Methodologies
for categorising threats have been developed internationally, for instance, in the
International Handbook on the Physical Protection of Nuclear Materials and Facil-
ities (IAEA, 2002e), but they relate specifically to nuclear materials and facilities
rather than to other radioactive materials or specifically to radiation sources.
However, these methodologies could generally be applied to radiological attacks.
A more important point is that the type and amount of radioactive material
has a greater impact on the response needed, rather than how the source was ob-
tained. This issue is reflected in more generalised emergency planning categorisa-
tion schemes expounded in international requirements (IAEA, 1997b; 2002c,
2003b).

2.1.2. Initiators

(16) It should be recognised that a radiological attack could have many initiators
and that it is impossible to characterise all the possible scenarios. Some conceivable
scenarios are described in Annex A and summarised below.
 The simplest setting is one of blackmail, i.e. the threat to use radioactive material
as a weapon, which does not materialise and therefore differs from all other poten-
tial scenarios in that there is no actual radiological impact.
 Radioactive material may be stolen, either for a perceived financial benefit (e.g. by
selling it) or as a possible precursor to a malicious attack.
 Some conceivable scenarios for a radiological attack are based upon a covert
exposure or dispersal of radioactive material, whereby the first indication that
an event has occurred may be people reporting to hospital(s) with symptoms of
radiation sickness, burns, or other symptoms. Radiation monitors, such as those
used for environmental measurements, could also be the first indicators of a cov-
ert radiological attack.
 Radiation sources could also be used to deliberately and maliciously irradiate spe-
cific individuals, a target group, or people at random.
 The detonation of conventional explosives to disperse an ordinary radioactive
source (such as those commonly used in medicine and industry) is another
conceivable scenario. This has been dubbed as a Ôdirty bombÕ by the media,
but may be more properly referred to as a radioactive dispersion device
(RDD). An RDD could be made from a source that has been stolen, or with
one that is in situ. Furthermore, the dispersion of radioactive material into the
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 ICRP Publication 96

environment may be achieved without explosives, by opening the source con-

tainer if the material is dispersible, or processing the source to make it
dispersible.
 There could be a deliberate act to contaminate food or water supplies, other par-
ticular commodities, or a specific site or environment with radioactive materials.
 Another scenario is the sabotage of safety-related systems at nuclear facilities
holding large inventories of radioactive materials, including nuclear fission and/
or activation products and radioactive wastes. The Commission presumes that
any operating nuclear installation has in place both: (i) strict security measures
that would make a successful radiological attack unlikely; and (ii) radiation emer-
gency arrangements that are based on its previous recommendations on this sub-
ject (ICRP, 1993b).
 Finally, an extreme but possible scenario is the diversion of nuclear materials, par-
ticularly special fissionable materials, such as 235U and 239Pu, and the develop-
ment, construction, and use of a crude nuclear weapon, usually known as an
Ôimprovised nuclear deviceÕ (IND).

2.1.3. Common features

(17) As described above, the possible scenarios vary widely in scale, genesis, and like-
lihood but they are rather similar in their ultimate consequence, namely unexpected
situations of uncontrolled public radiation exposure and possible radioactive contami-
nation of the environment. While no single event can be used as a basis for development
of response plans, a number of common features can be recognised as follows.
 As the location will probably not be known in advance, planning cannot be spe-
cific. Moreover, as other hazards may be present in addition to the radiation, such
planning should be integrated with other emergency response planning. There-
fore, response plans for dealing with potential emergencies will need to have broad
applicability, as the exact site at which the event may occur and the hazards that
actually exist will not be known in advance.
 It is possible that contamination of the immediate area surrounding the attack site
will force the need to restrict access, thus creating response difficulties.
 Except for extreme scenarios, the radiation or radioactive material is not likely to
cause immediately fatal consequences, but the psychological perception will be
one of serious danger; moreover, the presence of long-lived radionuclides will cre-
ate prolonged exposure situations.
 Early detection of the radiation hazards, and prompt actions to control the spread
of contamination, are critical parts of the response to the attack.

2.2. Special features

(18) As is the case for radiological accidents, the radiation emergency arising from
a radiological attack will usually occur unexpectedly. The response to protect people,
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clean up the area, and return to normality would, in principle, be the same for both
situations. However, compared with an emergency at a regulated installation, that
resulting from a radiological attack would present a number of special features.

2.2.1. Location

(19) An emergency resulting from a radiological attack would most likely occur in
a public area where there is no expectation of radiation or radioactive material and
where there may be limited preparedness for responding with radiological protection
measures. The area is most likely to be an urban location, where emergency services
are usually more substantial and concentrated. However, for these locations, the dis-
persion conditions commonly used for emergencies in nuclear facilities may not be
applicable. In this sense, the planning and preparedness are likely to differ from those
usually associated with the radiological scenarios that may result from nuclear
accidents.

2.2.2. Public perception

(20) The public perception of a radiological attack will be different from that of
some radiological accidents, even if the radiation impacts were objectively similar.
The feeling of the public might be that a radiological attack poses the greater risk.
This in turn may cause public alarm far beyond the normal reaction to the actual
hazards, and it may become increasingly difficult to reassure the public or to manage
the consequences effectively. There will, therefore, be a need to keep the media and
public informed with clear and accurate information, and the mechanism for doing
so needs to be addressed at the planning stage.

2.2.3. Source term characterisation

(21) The method to deduce the characteristics of the radioactive material is one of
the most important differences between conventional radiological emergency re-
sponse planning and the planning required for responding to RDD and IND events.
In the former, reasonable assumptions can be made about the radioactive material
involved in the situation as the types of sources, facilities, material inventory, etc.
are usually known a priori. In the case of a radiological attack and indeed for chem-
ical and biological attacks, it is very unlikely that there will be any information avail-
able in the early response phase upon which to characterise the source term,
although the range of credible source terms can be anticipated somewhat. Estimates
of source term, however, usually have less practical bearing on the management of
the response than the use of quantified operational criteria established as part of
the planning process and, critically, identifying the radionuclide(s) involved. Precise
information to evaluate a source term will only be known some time after the event
as a result of environmental monitoring, sampling, and analysis conducted through-
out the emergency response (IAEA, 1999b). The degree of certainty about the mag-
nitude of the source term will improve as additional measurement capability
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 ICRP Publication 96

becomes available. As the results from the measurements are compiled, crude esti-
mates of the source term can be made, working backwards to start estimating
how much radioactive material may have been involved.

2.2.4. Covert situations

(22) An even more difficult situation presents itself when there is a covert radiolog-
ical situation, i.e. the presence of the material is not apparent until someone happens
to measure it or a person presents with a radiation injury. Then the challenge is to
track back from detection to determine where the material is, how much there
was, who else might be involved, and how to make recommendations for protection.
A scenario of particular concern to emergency response planners is an attack involv-
ing chemical, biological, or radioactive material being covertly dispersed in a con-
gested public place, such as a subway system during the rush hour. In a very short
period of time, and long before any one is aware of the situation, small quantities
of material could be all over a large city. Although the quantity of radioactive mate-
rial in any one location would not be at all likely to cause adverse health effects, the
public distress and magnitude of the response might be significant as the forensic
investigation attempted to understand the extent and magnitude of the impacted
areas. While the reaction of the public to a given event has not been fully investi-
gated, the evidence of public reaction to emergencies in the past seems to indicate
that they do not panic, and it appears that the possibility of tremendous panic is
not substantiated by history.

2.2.5. Public sentiment

(23) An important facet of human behaviour that must be recognised as a distinct

characteristic in response to any type of event or accident is that the public are likely
to rush to the scene to try and assist with rescue efforts. Since the presence of radio-
active material is not likely to be known in these first moments, there will be many
individuals who will quickly be in need of survey, treatment, etc. Furthermore, with-
out proper controls, it may be difficult to assess and control the spread of contam-
ination as people enter or exit the scene of the event.

2.2.6. Advance warning

(24) Many law-enforcement agencies, federal agencies, security forces, and emer-
gency services will have intelligence and contingency plans in place to deal with var-
ious types of events. These plans are likely to cater for a wide spectrum of events
including bomb threats, extortion demands, aircraft hijacking, and hostage taking.
It is likely that these plans will have been reviewed and updated in the light of recent
malicious acts.
(25) In cases where a heightened level of threat may exist, e.g. during major events
such as sporting occasions, or in areas that are particularly vulnerable to malicious
acts, such as subway systems, the threat level may justify the installation of instru-
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 ICRP Publication 96

ments to detect the possible ingress of radioactive material or devices. Such large-
scale deployment of detection devices would be expensive and onerous, so its need
must obviously be commensurate with the level of risk. Another option, possibly less
costly, is to equip security personnel with electronic direct reading of radiation expo-
sure, although this method would not be effective for the detection of alpha-emitters
such as 239Pu.
(26) Furthermore, graded systems for communicating assessments of threat may
be introduced that allow first responders to take additional precautions when
responding to events where a heightened level of threat of radiological attack may
exist in a given area. For example, if a fire emergency at an apparently ordinary
building is suspected to have been caused by a terrorist attack, fire fighters may be
required to monitor the scene for the presence of deliberately introduced radioactive
materials; conversely, if there is no question of a terrorist attack (e.g. because of a
low assessed threat level), fire fighters would not normally monitor the scene. Sys-
tems for communicating threat levels may include generic coding systems at national
or regional level and/or of specific buildings or areas identified as potential targets
and therefore at higher threat levels.

2.2.7. Criminal investigation

(27) Another important difference between a conventional radiological accident

and a radiological attack is that after the latter, local police will always be involved
and may need to declare the area a crime scene in order to begin forensic investiga-
tions. If it is confirmed that the event was caused by deliberate act, the emergency
response and forensic investigation will rapidly escalate from local police to regional
and national law-enforcement officials. Unfortunately, the objectives of forensic
investigations and evidence preservation often conflict with those of radiological
protection. Specifically, the very material needed to try to estimate the source term
and make protective action recommendations may be determined to be forensic evi-
dence that must be tightly controlled. This possibility could have two unfortunate
results: first, it could slow down the process of developing critical protective action
recommendations because the law-enforcement officials would have to approve the
release of the information to the decision makers; and second, there might be a con-
flict with communicating the public health information and recommendations be-
cause law-enforcement officials may be reluctant to release any information that
might be considered forensic evidence or hinder the ongoing investigation.
(28) Therefore, one of the most critical preplanning issues is how the various law-
enforcement and investigation groups will work collaboratively with the radiological
protection groups so that use of critical data is effectively accomplished. This is also
essential to ensure that the critical information is available to assessment groups so
that recommendations can be made. Other obviously critical issues are: who is in
charge of the information; how the information flows; and how law enforcement
interfaces with radiological protection. An integrated emergency response organisa-
tion, such as an Ôincident command systemÕ (ICS) (IAEA, 2003b) that is used in
many countries, provides for rapid integration, co-ordination, and expansion of
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 ICRP Publication 96

response for all types of emergencies. It is based on having common terminology,

modular organisation, integrated communications, unified command structure, con-
solidated emergency plans, designated emergency facilities, and comprehensive re-
source management. Law enforcement issues need to be integrated within such a
framework.

2.2.8. Challenges

(29) An emergency resulting from a radiological attack poses a series of distinct

challenges requiring difficult decisions by the responding authorities, as they may of-
fer choices between sets of unwelcome or unattractive alternatives. An unrealised
threat poses the most fundamental dilemma, as the threat may never become a real-
ity and may never become known to the general public. On the one hand, authorities
may wish to demonstrate due diligence in confronting and dealing with a threat,
while on the other hand, they may experience considerable difficulty in committing
extensive resources to combat a threat that may never materialise.

2.3. Planning

(30) In developing an emergency preparedness programme, the following infra-

structure elements are internationally required to be considered at local and national
level: authority; organisation; co-ordination; plans and procedures; logistic support
and facilities; training drills and exercises; and quality assurance (IAEA, 1997b;
2002c, 2003b). Among many other elements, this will include the designation of a
continuously available contact point for receiving and acting on information, an
emergency management organisation (such as the ICS), arrangements for technical
information management, and public communication arrangements. More specifi-
cally, planning for attacks involving radioactive material needs to ensure that: first
responders are trained and have the proper instruments to identify the presence of
radiation; radiological specialists are readily available to respond promptly to sus-
pected hazards to advise first respondersÕ local authorities and others; and robust
operational criteria have been established in advance for taking protective measures
under various scenarios. Given credible indication that an attack has occurred, it
may be prudent to assume that such an attack does involve radiological, chemical,
and/or biological hazards until proven otherwise. This dictates the adoption of an
all-hazard approach to emergency response based on wide-ranging precautions com-
bined with a prompt capability to identify all hazards present. This approach must
consider the need for a subjective assessment of the likelihood of the event and of the
Ôradiation-relatedÕ anxiety and fear that will probably be associated with it.

2.3.1. ‘All-hazard’ planning

(31) Current international guidance emphasises the need for all-hazard planning,
where radiological emergency plans are well integrated with arrangements and re-
sources in place for conventional emergencies. The nature of radiological attacks
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adds a new dimension to this concept of all-hazard planning. It is very difficult to

prejudge what type of toxic compounds (nuclear, chemical, or biological) or weap-
ons (classical or nuclear) will be used. This is further complicated by the possibility
of multiple attacks and the presence of simultaneous hazards, e.g. chemical, biolog-
ical, and radiological, being involved. Multiple simultaneous attacks at different
locations would place an additional strain on the response capabilities of a country.
Moreover, a unique feature to be considered is the possibility that there may be a
suicidal approach for a radiological attack. Nevertheless, the ICS model can be ap-
plied to organising an effective co-ordinated response.

2.3.2. Disaster management

(32) Planning for emergencies resulting from a radiological attack, and managing
unexpected disasters in general, share similar concerns. Disasters are typically han-
dled by civil defence operations and these can provide a useful framework for dealing
with a range of emergencies. Dealing with the aftermath of a radiological attack
may, however, differ in some respects from dealing with a radiological emergency
arising from an accident in a regulated facility, due to the difficulty in planning
for random acts that may occur anywhere in a wide range of circumstances. The lo-
cal authorities at a place where a radiological attack occurs may not have an emer-
gency response plan to deal specifically with radiological emergencies, or have any
experience in dealing with such emergencies. Moreover, they may not have immedi-
ate access to radiation detection equipment or other resources necessary to protect
response personnel and the public. It is necessary to develop at least a basic capabil-
ity for such events.

2.3.3. Medical preparedness

(33) Medical preparedness for a radiological attack is, in many respects, similar to
the preparation needed to respond to other attacks that involve chemical or biolog-
ical materials. The first section of Annex B describes a number of issues related to
medical emergency planning vis-à-vis the various possible threats of radiological at-
tacks. The Commission intends to develop particular guidelines to assist the medical
profession in the preparation for responding to radiological attacks.
(34) If a radiological attack has been threatened, the situation is not unlike the
anticipatory preparations that may be arranged for chemical and biological attacks.
Depending on the planning and arrangements made by local authorities, medical
facilities may receive a notice that some type of threat has been made so that they
can be prepared should the event actually occur.
(35) An important improvement would be for local medical service personnel to be
able to recognise overexposed patients, even if they are not able to deal with their
long-term medical care. In the event that individuals are overexposed, they could
be treated at a specialised regional centre rather than locally. In fact, centres with
specialised burn and haematological units are usually fairly well equipped to handle
radiation overexposure cases. The allocation of scarce resources to develop a local or
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national radiation medical centre to specifically deal with a remote contingency may
not be justified. The medical treatment of patients does not, generally, need to be
hampered by the hazards of the contamination, provided that simple precautions
– not radically different from those normally employed in sterile work – are taken
to reduce the spread of contamination.
(36) One characteristic that will affect medical planning is the fact that the number
of potentially affected people is unknown. Since radiological attacks may occur any-
where, planning should be part of national guidelines for emergency medical services
and hospitals, including smaller, general care facilities (IAEA, 2004c). The guidelines
should ensure that, throughout the country, medical personnel have a user-friendly
reference guide on the basic measures required to deal with the urgent care of poten-
tially overexposed and/or contaminated casualties.

2.3.4. Psychological issues

(37) Psychological impacts are likely to pose a significant challenge, and these is-
sues need to be addressed in planning the response to a radiological attack. Follow-
ing a radiological attack, healthcare providersÕ offices, medical clinics, and hospitals
will be deluged with symptomatic and asymptomatic people seeking evaluation, care,
and guidance for possible radiation exposure or contamination. A well-organised,
effective medical response will instil hope and confidence, reduce anxiety, and sup-
port the continuity of basic community functions. Healthcare providers will need
appropriate training in advance, as they may also be subject to fear and anxiety.
Ensuring clear communications and the availability of advance information are
key elements in the successful preparation for managing the consequences of a radio-
logical attack. Advance planning should also recognise the necessity for dealing with
post-traumatic stress, and the concerns that may be engendered for decades follow-
ing the event.
(38) Responding to the mental health needs of the community as a whole raises
many challenges of preparation. In addition to a dedicated area, staffing, contact
registry, and intensified primary care follow-up efforts, intervention for people
concerned with unexplained symptoms should involve brochures, fact sheets,
and literature about self-management approaches to medically unexplained symp-
toms. The use of an on-site advocate who can help people with unexplained
symptoms to overcome perceived barriers to care helps to defuse peopleÕs notions
that Ôno one caresÕ and affords clinicians a way to reduce the pressure to meet
these peopleÕs needs.

2.3.5. Exercises

(39) An important lesson to be learned from emergency response exercises is that

the results of early monitoring and assessment activities differ widely because of dif-
ferent assumptions in the size of the source term. Therefore, exercises on radiological
attacks often do not give decision makers a true understanding of the difficulties that
would be faced in a real event. The scenario is presumed, and the radiological assess-
34
 ICRP Publication 96

ment team can quickly generate conjectural recommendations that will find little par-
allelism with what will really happen in practice. The likely reality is that the only
information known is that there was an explosion, that radiation detectors are
alarming, and that the wind is blowing in a given direction, and yet government offi-
cials and news reporters will demand immediate answers to questions, such as should
people evacuate and how far away should they move. The lack of early information
will, in fact, have a significant impact on the extent of what might be recommended
for protective actions. In order to maintain confidence and reduce confusion, it is
considered appropriate to establish a ÔstandardÕ response strategy that is triggered
by key observable parameters and criteria, to train all personnel, including political
decision makers, to implement the plan efficiently and effectively, and then adjust the
details of the strategy as better assessments of the circumstances become available.
Despite the above reservations, the Commission recommends that exercises on plau-
sible scenarios of radiological attacks should be performed, that political decision
makers should participate, and that limited drills should be performed on specific re-
sponse functions to ensure that detailed issues are covered adequately.

2.4. Exposure

2.4.1. Quantification

(40) Radiological attacks are likely to result in dispersion of radioactive sub-

stances. ÔRadioactivityÕ is the term used to describe the phenomenon of radiation
emission, which is quantified in terms of the activity of the emitting source. Activity
is a quantity assessed in units termed ÔbecquerelsÕ (Bq) [although, in the past, the
term ÔcurieÕ (Ci) was – and still is – widely used]. One becquerel represents an extre-
mely small amount of activity (conversely, 1 Ci represents a significant amount of
activity, as it equates to 37 thousand million Bq). Both individual members of the
public and rescuers coming to their help may be exposed to the radiation emitted
by the radioactive substances. The types of radiation expected to be emitted from
an RDD include: alpha particles, which have high-linear-energy transfer (LET)
properties but low penetrability into tissue (and therefore are only relevant if the
emitting substance is incorporated into the body); beta particles, which are able to
penetrate relatively thin tissues, such as the skin; and, fundamentally, gamma radi-
ation, which can penetrate the full body. In case of INDs, neutrons will also contrib-
ute to the radiation field.
(41) Depending on the amount of radiation exposure, whether it is from outside
the body (external) or from uptake of radioactive substances (inhalation, ingestion,
or uptake through wounds or skin) (internal), various health effects can occur. The
amount of radiation exposure is measured in terms of the radiation dose incurred by
the affected people. The relevant quantity is termed Ôabsorbed doseÕ and is assessed in
units called ÔgraysÕ (in the past, the unit ÔradÕ was used). However, different types of
radiation have different effectiveness to induce damage. Besides, different organs and
tissues have different sensitivities to radiation exposure. Therefore, the absorbed dose
has to be weighted to take account of these differences. The respective weighting
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 ICRP Publication 96

factors are termed Ôradiation weighting factorsÕ, wR, and Ôtissue weighting factorsÕ,
wT; their values are recommended by the Commission (ICRP, 1991a). The quantities
resulting from the absorbed dose weighting for the effectiveness of the different radi-
ation types and the radiation sensitivity of different organs and tissues are termed
Ôequivalent doseÕ and Ôeffective doseÕ, respectively, and are measured in a unit termed
ÔsievertsÕ (Sv) (in the past, the unit ÔremÕ was used). The equivalent dose is used to
express tissue and organ doses, and the effective dose is used for assessing the whole
body implications. The following scheme provides a visual relation among the rele-
vant quantities, namely: the activity, A; the absorbed dose in a tissue, DT; the equiv-
alent dose in that tissue, HT, that results from weighting the absorbed dose by the
radiation weighting factors, wR; and, finally, the effective dose, E, that results from
weighting the equivalent dose by the tissue weighting factors, wT, and summing up
over all tissues.

(42) It should be noted, however, that the equivalent dose and the effective dose can
only be employed for ÔnormalÕ radiation protection purposes, i.e. for situations caus-
ing relatively low doses that may merely induce low probability and delayed health
effects (stochastic effects). Formally, neither the equivalent dose nor the effective dose
should be used to quantify radiation exposure to the high doses that are able to cause
serious and early pathological effects. Moreover, for radiation with high-LET prop-
erties (such as alpha radiation), the relative biological effectiveness varies depending
upon the type of radiation injury, the organ irradiated, and the time over which the
irradiation is delivered, which will require separate considerations.
(43) An additional difficulty is that radiation detection instruments cannot mea-
sure the dosimetric quantities relating to the human body, such as the equivalent
dose and the effective dose. These can only be estimated from directly measurable
quantities of external exposure, which are termed Ôoperational quantitiesÕ. The oper-
ational quantities are recommended by the International Commission on Radiation
Units and Measurements (ICRU). These have been introduced by the Commission
in Publication 60 (ICRP, 1991a, Paragraph 138), and adopted in international stan-
dards for checking compliance (IAEA, 1996a). There are four operational quantities
of particular interest in the measurement of radiation fields for radiological protec-
tion purposes. These are: the ambient dose equivalent, H*(d); the directional dose
equivalent, H 0 (d); the individual dose equivalent, penetrating, Hp(d); and the individ-
ual dose equivalent, superficial, Hs(d). They are based on the concept of the dose
36
 ICRP Publication 96

equivalent at a point and not on the concept of equivalent dose, and are used for
calibrating measuring instrumentation purposes of radiation protection.
(44) Given the above difficulties, for reasons of simplification and readability, this
report will only use equivalent dose and effective dose to quantify radiation exposure
at both low and high levels. For the same reasons, the report will use a submultiple of
the sievert, termed ÔmillisievertÕ (mSv) as the unit of these quantities, which is equal to
a thousandth of a sievert (1 mSv=100 thousandths of 1 rem or 100 millirem). In order
to put these amounts into perspective, it should be noted that the level of effective
dose that is unavoidably incurred from natural radiation exposure by people living
for 1 year in an area of low background radiation is approximately 1 mSv (the global
average effective dose from natural background radiation is 2.4 mSv/year, and high
background levels are typically approximately 10 mSv/year; in a few areas of the
world, the background levels can be even higher than 100 mSv/year).

2.4.2. Pathways

(45) The potential radiation exposure can vary considerably in magnitude, depend-
ing upon factors such as the particular type and nature of the attack, the total amount
of radioactive material and the different radionuclides involved, the energy with
which they are dispersed into the environment, the nature of the surrounding environ-
ment, and the mechanisms of radionuclide dispersion and transfer. In most cases,
there will be a limited set of exposure routes to consider. When planning protective
actions, it is important to identify the possible exposure pathways and to evaluate
their relative importance. These aspects need to be considered in the development
of response plans, operational criteria, ÔstandardÕ response strategies, and detailed
implementation of protective actions. Different protective actions may need to be
implemented to avoid or reduce the radiation exposure, depending particularly upon
the pathway by which exposure is liable to occur, as well as upon the body organs or
tissues that are likely to be irradiated and the dose that is projected to be received.
(46) People directly involved in a radiological attack will include members of the
public in the affected areas and also rescuers responding to the event. There are two
main mechanisms that may lead to these people being exposed to radiation: external
exposure, that is radiation received from a source outside the body (including radio-
active material deposited on the skin); and internal exposure received from radioac-
tive material that is inhaled, ingested, absorbed through intact skin and wounds, or
introduced into tissues as fragments which are either radioactive or contain radioac-
tive contamination. The overall risk to the individual person represents the summa-
tion of effects of external and internal exposures.
(47) Pathways of external radiation exposure include:
 directly from the source or facility;
 contamination of skin and clothing;
 the plume of dispersed radioactive material;
 residual contamination on the environment, buildings, vehicles etc.; and
 contaminated consumer products and other commodities.
37
 ICRP Publication 96

(48) Pathways of internal radiation exposure include:

 inhalation of radionuclides in the plume;
 inhalation of resuspended radionuclides;
 inadvertent ingestion of contamination directly;
 ingestion of contaminated food and water;
 absorption through skin and wounds; and
 fragments (including Ôhot particlesÕ) that are either radioactive or contaminated
with radioactive material and have penetrated the body.
(49) The ultimate consequences of the event will also be influenced by the particular
characteristics of the affected environment. For example, the external radiation dose
can vary considerably between urban (Kelly, 2002) and rural environments, the type
and amount of deposition on various surfaces, and the living habits of the exposed
population. Seasonal variations in environmental conditions can also influence the
levels of contamination in local products in areas where deposition of radionuclides
has occurred.

2.5. Initial reaction

(50) Initial reaction to a radiological attack will depend upon the initiating
event, e.g. whether it is an explosion or, in extreme cases, an IND. Following
the first response, there will be a number of evolving response phases and different
types of interventions involving specific protective actions, such as: control of ac-
cess to the public; sheltering; evacuation; administration of prophylactic measures;
decontamination of people, land and property; relocation; control of water, foods
and other commodities of public consumption; livestock and animal protection;
waste management and control; refinement of access control; release of personal
property, land and buildings; re-entry of non-emergency workforce; and re-inhab-
itation of homes. Some of these protective actions will be discussed in detail in
Chapter 5.

2.5.1. Reacting to an explosion

(51) Many of the postulated scenarios are for some type of explosive initiating event,
which in fact are the easier events to respond to because the initiation is obvious. Many
countries equip first responders, such as fire fighters, with some type of radiation
detection capability onboard their vehicles. These first responders will usually react
in the same way as they would for any other type of explosion and situations poten-
tially involving hazardous material, namely establishing a perimeter for access con-
trol, taking life-saving measures, and aiming to control the situation. For most
types of situations, the standoff distance that fire brigades typically establish when
responding to an explosion is also adequate when radioactive material is involved.
When the results from radiological surveys are available, the perimeter can be adjusted
as needed.
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 ICRP Publication 96

2.5.2. Reacting to an IND

(52) As described before, an IND is a nuclear weapon originating from diverted

special nuclear material that produces a nuclear explosion. An IND can have a
wide range of nuclear yields depending upon the degree of sophistication in de-
sign. A very simple device may blow itself apart giving a very small explosion
and yield – rather like a criticality accident. If the design is such as to promote
the nuclear explosive power, the yield can be increased so as to be not dissimilar
to the atomic bombs at Hiroshima and Nagasaki. The nuclear yield achieved by
such an IND produces extreme heat, powerful shockwaves, and prompt radiation
that would be acutely lethal for a significant distance. If nuclear yield is not
achieved, the result would likely resemble an RDD in which fissile weapons mate-
rial was utilised.
(53) Given this wide range of yields, and therefore potential impacts on the
public, the Commission has not dealt specifically with the radiological
consequences of an IND. The Commission, however, wishes to stress that the
blast effects are likely to be the most serious aspect although, potentially, large
areas may become contaminated as the plume of radioactive materials (fallout)
disperses. Although the scale may be larger, the basic concepts in the radiological
response to such an event are no different from those for other radiological
attacks; namely, the need to establish control boundaries, to qualify the levels
of contamination, treat people, and take action to protect the rest of the
population.

2.6. Response phases

(54) The response to an emergency, including those that involve a radiological at-
tack, will generally take place in three distinct phases, namely rescue, recovery, and
restoration (some emergency planners use the terms ÔearlyÕ, ÔintermediateÕ, and Ôlong
termÕ in describing these phases of response). Their characteristics will be briefly de-
scribed hereinafter. The recommended protective actions and guidelines will be ad-
dressed in the following chapters.

2.6.1. Rescue and early actions

(55) The rescue phase must recognise that the immediate aftermath of an incident
is likely to be chaotic, and the emergency servicesÕ initial efforts must focus on bring-
ing the scene under a measure of control, which will allow rescue efforts to proceed in
an orderly manner. The priority actions are to save life and to evacuate injured peo-
ple, which may proceed under hazardous and high-risk conditions. The lead agency
at this stage is likely to be the local fire service, which is best equipped and experi-
enced to manage rescue operations, aided by other emergency services. However,
other agencies, such as law enforcement, will also be present and need to be inte-
grated into the management structure.
39
 ICRP Publication 96

2.6.2. Recovery

(56) The recovery phase is geared towards stabilising the scene and ensuring that
all immediate hazards are removed or reduced to a low-risk level. During this phase,
local and national officials will initiate the scene-of-crime examination and will seize
all relevant material that may be required for evidential and forensic purposes. Also
during this phase, the control of the scene may be shared between recovery personnel
and law-enforcement officers. In this phase, first decisions might be made on reloca-
tion, and food and water controls.

2.6.3. Restoration

(57) In the restoration phase, there is a gradual restoration of the site to normal
operations, and the emergency management system, which managed the rescue
and recovery phases, will hand control of the scene to the authorities responsible
for determining the restoration objectives and the process used to remove remaining
hazards to agreed levels.

2.7. Links

(58) The relationship between exposure routes, protective actions, and response
phases varies depending on the unique circumstances of the specific radiological at-
tack. In Table 2.1, which is of a qualitative rather than quantitative nature, an
attempt is made to identify some of the potential scenarios and links to be expected
at various phases during the response. As can be seen, there will be an overlap be-
tween the different phases and the protective actions that may be taken.

40
 ICRP Publication 96

Table 2.1 Emergency phases, exposure routes, and protective actions following a malicious attack ( )

Rescue Recovery Restoration

EXPOSURE ROUTE
Direct from source/fragments/facility
External from deposited contamination
External from contaminated skin/clothes
Plume (internal/external)
Inhalation of resuspended material
Inadvertent ingestion of contamination
Ingestion of contaminated food/water

ACTIONS
Evacuation
Sheltering
Control of access to the public
Administration of prophylactics
Decontamination of people
Decontamination of land and property
Relocation
Food controls
Water controls
Livestock and animal protection
Waste control
Refinement of access control
Release of personal property
Release of land and buildings
Re-entry of non-emergency workforce
Re-entry to homes

41
 3. POTENTIAL HEALTH EFFECTS ATTRIBUTABLE TO RADIATION
EXPOSURE

3.1. Biological health effects

(59) Following radiation exposure, all resulting biological health effects will
generally be attributable to the induction of damage to cells in the tissues and
organs of the body. Of the various types of radiation-induced damage to cellular
components, the most important is that occurring in DNA which acts to genet-
ically control all aspects of cellular function. Much of this radiation-induced
DNA damage can be repaired by cellular systems. Correctly repaired damage will
have no consequences, but unrepaired or incorrectly repaired damage may kill the
cell, prevent its reproduction, or result in a viable but genetically modified (mu-
tated) cell.

3.1.1. Deterministic effects

(60) If enough cells in an organ or tissue are killed or severely damaged, there will
be clinically detectable injury and reduction or loss of tissue or organ functions. This
type of effect is termed ÔdeterministicÕ by the Commission. These effects are observed
in individuals as tissue injuries if the radiation dose is above a level (the dose thresh-
old) that results in the killing or malfunction of sufficient cells. Above the dose
threshold, the severity of these effects, including impairment of the capacity for tissue
recovery, increases with dose.
(61) Few tissues show clinically significant deterministic effects following acute
equivalent doses of less than 2000–3000 mSv of low-LET radiation such as gamma
and beta radiation. For doses spread over a period of months and years, severe ef-
fects are not likely in most tissues at annual equivalent doses of less than about
500 mSv. However, the gonads, the lens of the eye, and the bone marrow show some-
what higher sensitivities. The most important tissues to consider for clinical purposes
following whole body irradiation are skin, bone marrow, the gastrointestinal tract,
lymphatic tissue, and lung. Other tissues may be relevant for circumstances involving
internal contamination by specific radionuclides.
(62) Differences in the structure and radiosensitivity of different tissues are re-
flected in the clinical manifestation, or syndromes, of radiation effects. The second
section of Annex B (see also Chapter 6) presents relevant information for the
immediate medical prognosis and treatment of the radiation effects that may arise
from a radiological attack that principally involves whole body exposure. This in-
cludes: the prodromal phase of acute radiation syndrome; the change of lympho-
cyte counts in the initial days of acute radiation syndrome depending on the
dose of acute whole body exposure; the latent phase of acute radiation syndrome;
the findings of the critical phase of acute radiation syndrome following whole body
exposure; the principal therapeutic measures for acute radiation syndrome accord-
ing to degree; and the time of onset of clinical signs of skin injury depending on
the dose received.
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 ICRP Publication 96

3.1.2. Stochastic effects (67) In Publication 8,

should not require sp
(63) Cancer and hereditary disease are believed to evolve from single mutated cells where the annual dose
that have survived radiation exposure. These effects are termed 'stochastic effects'by from most radiologica
the Commission. Epidemiological studies of large groups of exposed and non- very low probability ol
exposed people are generally required to reveal whether there is a radiation-associ- as a result of in-utero it
ated excess of stochastic effects. These epidemiological studies have allowed the should be expected at
Commission to make estimates of radiation cancer risk but, due to the low risk of
radiation-induced hereditary effects, epidemiological studies have not been directly
informative. Judgements on the risk of hereditable effects are guided by experimental 3.1.4. Other issues witl
studies with animals, particularly mice. It is assumed for radiological protection pur-
poses that an increment in dose will produce an increment in the probability of incur- (68) Siigmatisation c
ring cancer or hereditable effects. For cancer, the Commission uses a factor of expected. This and oth
prJbability per unit dose of nominal fatality of 5
probability x l0 5/mSv at low
this report, can particr
doses. For severe hereditable effects, the nominal probability coefficient for the first pregnant women and v
one or two generations is about l0% of the fatal cancer risk to the exposed popula- logical attack. Pregnan
tion (ICRP, l99la; UNSCEAR, 2001). formations in the new
Commission has dealt
3.1.3. Prenatal exposure effects lication 84 (ICRP, 2(
=100 mSv; above this,
(64) 'Prenatal (or antenatal) exposure effect' is the term used to refer to determin- (69) It should be ass
istic and stochastic effects of radiation on the embryo and fetus. They are discussed cern for child health w
separately because of the complex and special processes involved in the development posed. Reports by par,
of the embryo and fetus. The effects of radiation exposure depend on the develop- the fears of the parenl
mental stage in which the exposure occurs. Due to the high radiosensitivity with assessment of children
respect to possible death of the embryo, significant prenatal exposure in the first 2 health because of the h
weeks following conception is not likely to result in other effects. of new students into ed
(65) During the period of major organogenesis (about 3-8 weeks after concep- cation to education sys
tion), malformations may be caused in the organ under development at the time school nurses can allay
of exposure. These effects are deterministic in character with a threshold in the
range of 100 mSv. Throughout the whole pregnancy, it is likely that radiation
exposure can cause a stochastic effect in the embryo/fetus, which will be expressed
as an increased probability of cancer over a lifetime. The Commission assumes that 3.1.5. Special considera
the risk of such cancer induction is about the same as that caused by exposure dur-
ing early childhood, i.e., no more than a few times that of the avrlrage population (70) Health effects fo
exposure. far as the health conse(
(66) Lower intelligence quotient (IQ) values are expected in children exposed in will significantly
ampliJ
utero, consistent with a general downward shift in the distribution of IQ with resources where they ca
increasing dose, which the Commission assumes to be proportional to dose. A coef- or all infrastructure cal
ficient of about 0.025 IQ points/mSv relates to the dose to the fetus in the period the detonation. For th
from 8 to 15 weeks after conception. Severe mental retardation can be caused by must be considered in
radiation exposures above 300 mSv to the fetus. At a dose of 1 Sv, approximately long been recognised tl
40% offetuses exposed between 8 and l5 weeks after conception will develop severe gamma rays. In Public
mental retardation during postnatal life; in the period from 16 to 25 weeks after con- dependent radiation wt
ception, this effect will be substantially less (ICRP, 2003). energy (ICRP, 1991a).
 ICRP Publication 96

(67) In Publication 82 (ICRP, 1999), the Commission noted that prenatal exposure
should not require specific levels of protection in prolonged exposure situations
where the annual dose is well below about 100 mSv, such as those to be expected
from most radiological attacks with RDDs. This is inter alia because: (i) there is a
very low probability of excess childhood cancer including leukaemia in the liveborn
as a result of in-utero irradiation; (ii) no organ malformations or neurological effects
should be expected at these fetal dose rates.

3.1.4. Other issues with pregnant women and children

(68) Stigmatisation of those exposed or travelling from contaminated areas can be

expected. This and other psychological aspects, which will be treated hereinafter in
this report, can particularly affect pregnant women and children. The concerns of
pregnant women and women with small children will be amplified following a radio-
logical attack. Pregnant women may seek abortion to avoid possible or feared mal-
formations in the newborn child, and family counselling may be necessary. The
Commission has dealt in some detail with radiation exposure in pregnancy in Pub-
lication 84 (ICRP, 2000). Abortion is not recommended for doses less than
100 mSv; above this, medical counselling is advised.
(69) It should be assumed that in the case of a radiological attack, parental con-
cern for child health will be high, whether or not the children in question were ex-
posed. Reports by parents of child distress, fears, and worries may actually reflect
the fears of the parent and the conveyance of those fears to the children. Direct
assessment of children and adolescents is important to determine the childÕs mental
health because of the high levels of distress in the parents. The relocation and entry
of new students into education systems could also be an issue. Outreach health edu-
cation to education systems, parent–teacher education programmes, and training via
school nurses can allay community anxiety.

3.1.5. Special considerations for INDs

(70) Health effects following an IND event present some special characteristics as
far as the health consequences are concerned. The extreme blast and thermal effects
will significantly amplify the health treatment issues, and necessitate triage to place
resources where they can be useful. This will be exacerbated by the likely loss of most
or all infrastructure capability to deal with health issues in the immediate vicinity of
the detonation. For those who survive an attack, the presence of fission neutrons
must be considered in addition to the gamma radiation and contamination. It has
long been recognised that fission neutrons have greater biological effectiveness than
gamma rays. In Publication 60, the Commission recommended the use of energy-
dependent radiation weighting factors for cancer risk based upon incident neutron
energy (ICRP, 1991a).
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 ICRP Publication 96

3.1.6. Summary of biological health consequences

(71) Table 3.1 provides a simplified summary of the expected health consequences
of the exposure of people to whole body irradiation. The health effects from partial
body irradiations of >1000 mSv would need to be assessed on a case-by-case basis,
involving expert input.

3.2. Psychological health effects

(72) Any type of terrorist attack will create uncertainty and fear. The possibility of
radiation exposure resulting from a radiological attack will add to the stresses asso-
ciated with physical trauma, forced dislocation, uncertainty about safety, loss of
homes, jobs, friends, pets, and other factors. Fundamental questions that are unique
to a radiological attack which must be addressed include: Am I and my family safe?
Was I exposed? How much radiation did I get? Am I still contaminated? How will
this affect me, my family, etc.? What will happen next? The acute and delayed psy-
chological and behavioural effects, including stigmatisation, are likely to be at least
as important and challenging as radiation-related biological injuries and illnesses.
The fear and pre-occupation surrounding the radiation exposure and the possibility
of cancer would probably remain high for decades. This may also result in the mis-
attribution of any illness to radiation exposure. Clear, understandable, and empa-
thetic communications are needed, both immediately following the event, and
repeatedly and consistently for extended periods of time after the event.

Table 3.1 Summary of radiation induced health effects

Expected dose Effects Outcome
Very low dose: about 10 mSv No acute effects; extremely small No observable increase in the
(effective dose) or less additional cancer risk incidence of cancer, even in a
large exposed group
Low dose: towards 100 mSv No acute effects, subsequent Possible observable increase in
(effective dose) additional cancer risk of less than the incidence of cancer, if the
1% exposed group is large (perhaps
greater than about 100,000
people)
Moderate dose: towards Nausea, vomiting possible, mild Probable observable increase in
1000 mSv (acute whole body bone marrow depression; the incidence of cancer, if the
dose) subsequent additional cancer risk exposed group is more than a few
of about 10% 100 people
High dose: above 1000 mSv Certain nausea, likely bone Observable increase in the
(acute whole body dose) marrow syndrome; high risk of incidence of cancer
death from about 4000 mSv of
acute whole body dose without
medical treatment.
Significant additional cancer risk

46
 ICRP Publication 96

(73) Radiation presents an invisible, odourless threat that is poorly understood by

the public. It has been a cause of extreme public anxiety in the past, as demonstrated
by the publicÕs response to the Three Mile Island, Chernobyl, and Goiânia accidents
(IAEA, 1988, 1991a,b,c,d). In the aftermath of an event, the public must rely on
healthcare providers and scientists to determine who has been affected through exter-
nal exposure or/and internal contamination. Since the effects of radiation exposure
can be manifested years after the causative exposure and may have consequences
for future generations, those who have been exposed or anticipate possible exposure
may experience feelings of vulnerability, anxiety, and lack of control. Affected indi-
viduals presenting psychological effects can be characterised in three groups: those
who are distressed; those who manifest behavioural changes; and those who may de-
velop psychiatric illness. More information on psychological issues is provided in
Annex C.

3.2.1. Distress

(74) It is important to re-inforce self-protection and to provide information that

can be used to protect individuals and their families to decrease distress. People try-
ing to cope with negative aspects of life unrelated to the malicious event will, in gen-
eral, have more psychological distress and psychiatric illness than those not similarly
afflicted. Depression occurring after an attack or traumatic event increases subse-
quent risk for psychiatric illness and injury. Finally, the psychological value of dis-
tributing appropriate medical countermeasures and information about methods of
self-protection can be substantial.

3.2.2. Fear of cancer and other health effects attributable to radiation

(75) Following a radiological attack, fears about and pre-occupation with cancer
and other health effects attributable to radiation will be a significant psychological
effect and can remain high for years. Responding honestly and acknowledging what
is not known is important. Healthcare providers should understand the basics of the
health consequences of radiation and be trained so as to be ready to explain them to
people in a straightforward manner. Uncertainty about health effects should be
acknowledged and not minimised in communicating to the public (see Chapter 7).
It is of great importance to give all possible information in a transparent way. These
actions should help to avoid misattribution of illness.

47
 4. PROTECTING RESPONDERS

(76) Following a radiological attack, one of the early radiological protection issues
is to protect the first responders. These will be the police, fire fighters, paramedics,
and other support and intervention services personnel. They may have to exercise
their duties with little knowledge of the actual hazards present, and may need to
use an all-hazards approach and assume that biological, chemical, and radiological
hazards may be present. As a result, it is necessary to have criteria as well as methods
for radiation protection of first responders and rescuers who will respond to an event
(IAEA, 1997c; 2002d). It is to be noted that while these recommendations deal with
radiological hazards and protection, the first responders may need additional protec-
tion as a result of the other potential hazards.
(77) In most situations, the radiation dose is likely to be due to external exposure,
inhalation in the plume for a fire or explosion, or inadvertent ingestion. The initial
radiation protection of first responders can be accomplished, in most cases, without
monitoring, by taking some basic precautions that also apply when responding to
emergencies involving other types of hazardous material. These involve restricting
the proximity to, and limiting time near, suspicious objects, avoiding inadvertent
ingestion, using respiratory protection, and staying out of smoke. If a radiological
hazard is suspected, as far as feasible, provisions should be made to provide the first
responders with alarming dosimeters with preset levels based on predefined criteria
that take likely exposure pathways and protective measures into account. The first
responders should have received basic guidance on how to recognise a potential
radiological emergency, the initial actions to take, and how to obtain timely radio-
logical assessment support, and should be provided with some basic radiation mon-
itoring equipment.
(78) Specialised emergency workers will probably arrive at the scene of a radiolog-
ical attack after the first responders. Included among these workers should be a radi-
ation protection specialist who will be able to begin characterising the radiological
hazards present and provide guidance and advice to on-scene emergency response
officials. The assessment and control of their radiation doses are thus usually ame-
nable to more detailed planning.
(79) Both first responders and specialised emergency workers should be subject to
occupational exposure guidelines tailored to the situation rather than to any categor-
isation of the workers. In international occupational radiation protection standards,
the areas of work rather than the workers themselves are categorised.

4.1. Occupational protection approach

(80) The Commission has made general recommendations on the limitation of

occupational exposure in emergencies in Publications 60 and 75 (ICRP, 1991a,
1997a). More detailed and specific recommendations for protection of workers
who, as responders, are involved in intervention following an accident have been rec-
ommended in Publication 63 (ICRP, 1991b). The Commission believes that these rec-
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 ICRP Publication 96

ommendations are generally applicable to workers responding to a radiological at-

tack, although the specific circumstances may differ.
(81) In Publication 60 (ICRP, 1991a) it was noted that, even in serious accidents,
exposures of emergency teams could be limited by operational controls. Since the
doses incurred are likely to be higher than in normal situations, the Commission rec-
ommended that these should be treated separately from any normal doses and that,
because emergencies involving significant exposures of emergency teams are rare,
some relaxation of the controls for normal situations could be permitted without
lowering the long-term level of protection. These criteria were to apply only in the
first response; recovery operations carried out once the emergency was under control
were to be treated as part of normal occupational exposure.
(82) Following Publication 60 (ICRP, 1991a), international occupational protec-
tion requirements have been established in the BSS (IAEA, 1996a), which are co-
sponsored by the International Labour Organisation. The BSS establish specific
requirements for workers undertaking protective actions, including such assisting
personnel as police, fire fighters, medical personnel, and drivers and crews of evacu-
ation vehicles.
(83) In Publication 75 (ICRP, 1997a), the Commission cautioned that although it
had recommended three categories of working conditions in emergency situations,
each with its own protective measures and criteria, it might be difficult to draw clear
lines between these categories. In considering the likely situation in the aftermath of
a radiological attack, the Commission now believes that it would be more appropri-
ate in this case to define just two categories of working conditions: (i) immediate and
urgent actions undertaken by first responders; (ii) actions undertaken subsequently
by workers engaged in recovery and restoration operations.
(84) The Commission also recommended special protection measures for female
workers who may be pregnant or are nursing an infant. Following these recommen-
dations, the BSS requires that the employer of a female worker who has declared
herself pregnant shall adopt the working conditions in respect of occupational expo-
sure so as to ensure that the embryo or fetus is afforded the same broad level of pro-
tection as required for members of the public. Taking into account these
international requirements and the fact that there will be unavoidable uncertainties
surrounding the dose assessment of rescuers undertaking first-response measures fol-
lowing a radiological attack, the Commission believes it to be imprudent to permit
female workers who may be pregnant or are nursing to undertake life-saving or other
urgent actions.

4.1.1. Occupational dose guidelines

(85) The CommissionÕs occupational dose guidelines in the event of a radiological

attack may be summarised as follows:
 For first responders undertaking rescue operations that involve saving life, no
dose restrictions are recommended in principle if, and only if, the benefit to others
clearly outweighs the rescuerÕs own risk. Otherwise, for rescue operations involv-
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 ICRP Publication 96

ing the prevention of serious injury or the development of catastrophic conditions,

every effort should be made to avoid deterministic effects on health - by keeping
effective doses below 1000 mSV to avoid serious deterministic health effects, or
below ten times the maximum single year dose limit to avoid other deterministic
health effects. The latter criterion leaves a margin for error in avoiding determin-
istic effects because of the possible difficulty in determining the exact exposure
conditions immediately after an attack and the possibility that the responders con-
cerned may not have the level of training or experience usually required for
responding to radiological attacks.
 For first responders undertaking other immediate and urgent rescue actions to
prevent injuries or large doses to many people, all reasonable efforts should be
made to keep doses below twice the maximum single year dose limits.
 For actions undertaken by workers engaged in recovery operations, the doses
received should be treated as part of normal occupational exposure and the nor-
mal occupational dose limits apply; namely a limit on effective dose of 20 mSv/
year, averaged over 5 years (100 mSv in 5 years), with the further provision that
the effective dose should not exceed 50 mSv in any single year, and annual equiv-
alent dose limits of 150 mSv for the lens of the eye, 500 mSv for the skin (average
dose over 1 cm2 of the most highly irradiated area of the skin), and 500 mSv for
the hands and feet.

Table 4.1 Guidance for occupational exposure

Type of emergency operation Dose guidance value
Rescue operations* Saving life, preventing In principle, no dose restrictions are recommended if,
serious injury, or actions and ONLY IF, the benefit to others clearly outweighs the
to prevent the rescuerÕs own risk. Otherwise, every effort should be
development of made to avoid deterministic effects on health (i.e.:
catastrophic conditions effective doses below 1000 mSv should avoid serious
deterministic health effects, and below ten times the
maximum single year dose limit as given below should
avoid other deterministic health effects).
Other immediate and  All reasonable efforts should be made to keep doses
urgent actions to prevent below twice the maximum single year limits (see
injuries or large doses to below).
many people
Other operations, including recovery and Normal occupational dose limits apply; i.e.:
restoration operations  a limit on effective dose of 20 mSv/year, averaged over
5 years (i.e., a limit of 100 mSv in 5 years), with the
further provision that in any single year:
 the effective dose should not exceed 50 mSv, and
 the equivalent dose should not exceed
– 150 mSv for the lens of the eye,
– 500 mSv for the skin (average dose over 1 cm2 of
the most highly irradiated area of the skin), and
– 500 mSv for the hands and feet
* Under conditions that may lead to doses above normal occupational exposure limits, workers should

be volunteers and should be instructed in dealing with radiation hazards to allow them to make informed
decisions. Female workers who may be pregnant or nursing should not participate in these operations.

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 ICRP Publication 96

 Taking account of the unavoidable uncertainties surrounding first-response mea-

sures and the specific protection measures recommended for female workers who
may be pregnant or nursing an infant, the Commission strongly advocates that
female workers in those conditions should not be employed as first responders
undertaking life-saving or other urgent actions at the site of a radiological attack.
 Those rescuers undertaking actions in which the dose may exceed the single year
dose limit should be volunteers, and should be well prepared for dealing with the
aftermath of the radiological attack, i.e., they should be clearly and comprehen-
sively informed in advance of the associated health risk and, to the extent feasible,
be trained in the actions that may be required, including the use of protective mea-
sures such as personal protective equipment, means of shielding, and iodine pro-
phylaxis (if warranted). However, the Commission recognises that this may be
difficult to achieve because of the greater uncertainties in predicting the precise
nature of a radiological attack.
(86) The dose guidance values for occupational exposure of responders to a radio-
logical attack are summarised in Table 4.1.

4.2. Occupational protection techniques

4.2.1. Managing field exposures

(87) There are many difficulties in managing the application of occupational

guidance values in the aftermath of a radiological attack. In the scenarios envi-
sioned, the dose rate may vary considerably over short distances, there is unlikely
to be an experienced radiation professional at hand, and dose levels will not usu-
ally be clear until well after the event. As a result, the first responders need to have
a method to assess their individual exposure to external radiation during the event.
First responders should, therefore, be issued alarming detection devices that will
indicate when certain dose rates or total cumulative external doses (to be derived
from the dose guidance described above) have been reached. Noting that such de-
vices will not detect non- penetrating radiation or hazardous levels of airborne
radioactive material, first responders need to made aware of these limitations in
their training.
(88) Therefore, the Commission recommends that integrating alarming dose me-
ters should be provided to the responders, with appropriate alarms corresponding
to the guidance levels in Table 3.1. For instance, the alarm levels should warn first
responders when their doses approach levels of 100, 500, and 1000 mSv, taking ac-
count of both access to and egress from the rescue area, and making allowance
for possible inhalation and inadvertent ingestion hazards (IAEA, 1997c; 2000d).
The dose meter alarm levels should be reviewed throughout the response and low-
ered when appropriate.
(89) Following the detonation of an RDD, the radiation fields in the immediate
vicinity may be extremely inhomogeneous due to the presence of highly radioactive
fragments – resulting in radiation Ôhot-spotsÕ. People managing field exposures need
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 ICRP Publication 96

to be aware of the possibility, especially if the variable ÔtimeÕ is used to manage the
doses to first responders.

4.2.2. Protective clothing

(90) The skin should be protected to reduce potential burns from high levels of rel-
atively non-penetrating beta radiation, and to prevent possible transfer of radioac-
tive material into the body through the skin and inadvertently through the mouth
or nose. The choice of clothing will often be influenced by more immediate hazards
such as fire, heat, or chemicals. Protection against these other hazards will generally
provide protection from radioactive material. For medical personnel, normal barrier
clothing and gloves may provide personal protection against intake of contamina-
tion. Disposable medical scrub suits, high-density polyethylene or other close-weave
coveralls, and hoods should be used if available. Secondary contamination of the
medical staff from handling patients should not be a cause of great concern; however,
to prevent the unnecessary spread of contamination and thereby reducing the need
for clean up, it is prudent to utilise conventional protective clothing.

4.2.3. Respiratory protection

(91) Some countries have specific guidance covering the use of respiratory protec-
tion (USACHPPM, 2003). In most situations, respiratory protection that is designed
to protect responders against chemical or biological agents is likely to offer some de-
gree of respiratory protection in a radiological attack. Concerns about the presence
of chemical or biological contaminants will influence the selection of respiratory pro-
tection. If used properly, simple facemasks provide reasonably good protection
against inhaling particulates, and allow sufficient air transfer for working at high
breathing rates. If available, high-efficiency particulate air filter masks provide even
better protection. Greater hazards must always be considered when selecting breath-
ing protection.

53
 5. PROTECTING THE PUBLIC

(92) Activities to provide protection for members of the public following a radio-
logical attack may be divided into a number of actions, corresponding to the phases
of responding to the event as described in Chapter 2. These actions are grouped
according to whether they are required immediately, urgently following the immedi-
ate actions, more gradually based on the results of surveys and dose assessment, or
during the later aspects of the recovery and restoration phases. The CommissionÕs
fundamental principles of justification of the intervention and optimisation of the
protective actions have to be taken into account on a case-by-case basis. The Com-
mission has provided recommendations for the application of the optimisation prin-
ciple (IAEA, 1986; ICRP, 1973, 1983, 1989) and is working on a new publication on
this subject.

5.1. Rescue phase (immediate actions)

5.1.1. Controlling access and spread of contamination

(93) Control of access to an area affected by a radiological attack should automat-

ically follow its occurrence and may even precede any decision to advise sheltering or
evacuation of affected population groups. Controlling access avoids exposure of peo-
ple who would otherwise enter the area unnecessarily, has the additional benefit of
reducing the spread of contamination out of the area, and minimises interference
with emergency operations and subsequent decontamination and recovery
operations.
(94) The arrangements for control of access should include establishing an
inner-cordoned zone (safety area) at default distances for various hazards or at
the boundary of a relevant protective action zone for a facility. An outer-cordoned
zone (security area) will often be established to immediately encompass the inner
zone. This meets several objectives: it ensures that members of the public cannot
inadvertently enter zones where protective actions are needed or they would be un-
duly exposed to hazards; it helps to prevent opportunist looting of evacuated prop-
erty; it allows emergency responders to work unhampered by the public and media;
and it establishes control over the crime scene in order to avoid interference or tam-
pering with evidence. The arrangements should include mechanisms to ensure rapid
access of authorised personnel to the cordoned zones (e.g., paramedics, radiation
assessors, crime scene investigators, etc.). The inner-cordoned area will be the main
control boundary for limiting the spread of contamination on people and vehicles,
and for managing the safety of staff entering the area to carry out monitoring, decon-
tamination, or investigations. The outer-cordoned area will ensure that the public
and media cannot hamper the safety precautions taken at the inner cordon, such
as personal monitoring and changing of clothing. While the default sizes of the inner-
and outer-cordoned areas are appropriate for initial response actions, they should be
confirmed by actual measurements to determine whether they should be extended or
reduced in parallel with decisions on protective actions.
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 ICRP Publication 96

(95) Difficulties associated with controlling access to large areas mainly comprise
difficulties of enforcement following prolonged implementation of this protective ac-
tion when people may be anxious to return to their homes. While control of access
may only be required as a short-term measure, long-term limitation of access may
result in significant impacts, including the deterioration of the infrastructure within
the area, and these decisions should be considered as part of a relocation as described
later. While it is not possible to give intervention levels of dose for this protective
action, operational criteria are needed that should, to the extent possible, be based
on advance planning that takes account of justification of the intervention and opti-
misation of protection, practical matters, and decisions about other long-term pro-
tective actions, such as relocation, and remedial measures, such as decontamination.
Separate consideration will be needed for control of access in the immediate area of
the event and more widely affected areas.
(96) The spread of radioactive contamination may be an important issue associ-
ated with a number of possible radiological attack scenarios. This spread of contam-
ination may occur through water runoff from fire-fighting activities, smoke from
burning debris, or transit of vehicles or personnel through a contaminated area prior
to control being established. In certain situations, extinguishing a fire may be more
hazardous than leaving it to burn (e.g., fire on a gasoline tanker or fire involving
water-reactant chemicals). This decision is difficult and will require careful assess-
ment of site-specific conditions and potential fire exposures. Normal fire fighting
and hazardous material response doctrine would generally prevail and the conse-
quences of the actions would be mitigated later.

5.1.2. Immediate care of people with traumatic injuries

(97) The immediate response to a malicious event involving high exposure to

ionising radiation includes the medical management of individuals involved, and
depends to a large extent on the type of event that has occurred, i.e., whether
the individuals have been exposed to external sources of radiation or contami-
nated with radioactive material. All affected people should be medically stabilised
for their traumatic injuries before radiation injuries are considered. Subsequently,
they should be evaluated for external radiation exposure and radioactive contam-
ination, depending upon the characteristics of the event. The evaluation should be
for both pathways, unless the specifics of the case clearly rule out one of the
pathways. The suggested initial medical considerations are as follows: early triage
and stabilisation; immediate removal of contaminated clothing; radiological
decontamination of skin and wounds; and medical history and physical
examination.
(98) Key medical response principles in the aftermath of a radiological attack in-
clude the following:

Conventional surgical and medical emergencies have priority over the external
or internal radiological risk, which is characterised by delayed occurrence of
injuries.
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 ICRP Publication 96

External contamination needs to be handled properly at the earliest stage in order

to prevent inadvertent ingestion, to reduce severe exposure to the skin, and to
avoid the secondary dispersion of radionuclides in the environment, the contam-
ination of rescuers, and the subsequent contamination of the casualties and hos-
pital staff. If there is no time or no equipment for control of external
contamination, a systematic undressing and showering of non-critical casualties
must be implemented using any resources available.

If first responders are not properly trained, on-site advice must be provided on
ways to avoid external contamination and intakes of radioactive substances.

Qualified medical personnel and radiation protection specialists must be dis-
patched to the referral hospitals at the earliest opportunity to assist with the
radiological protection aspects of medical treatment. This is particularly impor-
tant in cases involving mass casualties with several hospitals involved in the recep-
tion of potentially contaminated or overexposed casualties.

Preferably, referral hospitals should be those whose staff have been trained in han-
dling contaminated casualties and which are able to set up an emergency radiation
reception area.

In some cases, it may be better to establish an emergency medical facility near the
accident site. However, this would normally take time and it is not realistic as an
effective medical countermeasure when emergency medical care is required. Alter-
natively, a triage and evaluation area can be useful prior to transporting patients
to referral hospitals.

In cases involving a large number of potentially exposed people, special tempo-
rary facilities for screening may be required, in which case the public needs to
be informed of where to go, and staff and supplies need to be dispatched to that
location.

All radioactive waste has to be properly handled at an early stage and at each level
(scene of the event, evacuation, hospital departments, intensive care, radiology,
surgery, etc.). All waste must be treated as potential evidence, but waste should
be evaluated for its significance as evidence, as waste preservation may pose a
greater radiological problem than the potential gain from evaluation. Waste in
materials that do not require preservation should be disposed of properly (see
section 5.4.2. on waste management in this report).

5.1.3. Triage dose assessment

(99) It is important to quickly triage those who have various levels of radiation
exposure into distinct groups, as follows:

those unlikely to survive as a result of high external exposure and who require pal-
liative care;

those who are likely to suffer acute radiation syndrome as a result of external
exposure and will require hospitalisation;

those with doses in excess of several hundred mSv but who do not require special
medical care;
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 ICRP Publication 96

those who present with contamination of the skin;

those with internal contamination; and

those with no significant dose.
For most of the scenarios, it seems unlikely that the doses incurred would be suf-
ficient to achieve the first two levels; however, screening will still be necessary to ex-
clude that possibility (Gusev et al., 2000).
(100) A rapid radiological triage for high external exposure can be most easily
accomplished by observing the symptoms of nausea, vomiting, and diarrhoea. Vom-
iting is likely to be the most useful indicator, depending on the possible complica-
tions of other injuries or the presence of chemical or biological agents.

Exposed people who experience radiation-induced vomiting within approximately
1 h of the event will require extensive and prolonged medical intervention, and an
ultimately fatal outcome is expected in many cases.

If the approximate time to vomiting is 1–4 h, these people are likely to require
hospitalisation and should be referred for immediate medical evaluation (partic-
ularly serial complete blood counts).

If the approximate time to vomiting is greater than 4 h, the person should be
referred for delayed evaluation (approximately 24–72 h) if no concurrent injury
exists. These people may have received doses up to 1000 mSv and may have some
minimal bone marrow depression and increased risk of cancer. However, they do
not require specialised hospitalisation.

For those without vomiting, no medical follow-up is needed in the immediate or
urgent phases, but medical evaluation on a less urgent basis may be indicated.
(101) It should be noted that stress reactions can induce nausea and vomiting.
However, any person exhibiting these symptoms in the time frames listed above
should be assumed to have been exposed until this is excluded by further medical
evaluation. Studies of peripheral blood cell counts, especially lymphocytes, during
the following days can confirm the decisions described above.

5.1.4. Psychological triage and disposition

(102) The need for psychological aid is a challenging problem. It should be

anticipated and provided in the first hours, days, and weeks after exposure to
a traumatic event. The most important elements of psychological first aid are
to provide good medical care, to offer re-evaluation if symptoms persist, and to
educate about the expected process that occurs for most people over time. Among
the people screened, some will have signs and symptoms consistent with acute
radiation sickness although they were not exposed. Physicians caring for people
with medically unexplained physical symptoms should carefully assess and record
the specifics of peopleÕs concerns and make arrangements for follow-up. These
people may feel stigmatised and thus labelled, and should be dealt with in such
a way that they are convinced that their health concerns have been taken seri-
ously. At the other end of the spectrum, there may be many individuals who have
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not received significant exposure, but who exhibit high anxiety over their condi-
tion and their future prognosis. Finally, there will be concerns for family mem-
bers, pets, etc. that will need to be handled. Mental health professionals
including psychiatrists should be an integral part of the pretrained teams that per-
form initial screening and triage.

5.1.5. Respiratory protection

(103) If the presence of airborne radioactive material is suspected, people should

be advised that if they are outdoors, they should cover their nose and mouth with a
handkerchief (or some other form of tight-woven material) and go indoors to shelter.
A handkerchief placed over the nose and mouth is effective in reducing intakes. Once
sheltered, there should be no need for continued respiratory protection. The hand-
kerchief and other material should be deposited in a normal plastic bag until the
authorities produce further instructions. Radioactive particles trapped on the mate-
rial could be an indicator of the intake of radioactive materials.

5.2. Rescue phase (urgent actions)

5.2.1. Personal decontamination

(104) Radioactive material may have been deposited on or in the person. Skin or
wound contamination is never immediately life threatening to affected people or
medical personnel. Therefore, treating conventional trauma injuries is the first prior-
ity. People should be decontaminated only after medical stabilisation. Evacuation of
a group of people should not be delayed by action to decontaminate individuals.
Note should be made that if certain chemical agents are present, it may be necessary
to decontaminate people immediately at the site and this will take priority over deal-
ing with radioactive contamination.
(105) There is no generic intervention level for the protective action of personal
decontamination, but common sense dictates that attention is directed at those indi-
viduals who have been in the most heavily contaminated areas following the event. If
extremely high levels of skin contamination have occurred, specific decontamination
agents may have to be used under medical and health physics supervision. In situa-
tions where immediate medical attention or evacuation is not warranted, emergency
medical service personnel may have the opportunity to decontaminate people at the
scene of an event. As this will not always occur, decontamination procedures should
be part of the operational plans and procedures of all healthcare facilities.
(106) On the whole, surface radioactive contamination can be significantly reduced
by removal of the contaminated clothing. Most remaining contamination will be on
exposed skin and hair, and it may be effectively removed with soap, warm water, and
a washcloth. Skin scrubbing is not recommended, as it would unnecessarily damage
the skin which facilitates incorporation of radioactive material. Clothing can be
stored in plastic bags for checking later when advice can be given on washing or
disposal.
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(107) Wound characteristics affect the absorption and decontamination of radio-

active substances. Abrasions disrupt the skin barrier and increase absorption poten-
tial but are usually easy to decontaminate due to easily accessible contaminants.
Lacerations are also easy to decontaminate because the contaminated tissue can
be irrigated and possibly excised if necessary. Puncture wounds are difficult to decon-
taminate because of poor access to the contaminants and difficulty in determining
the depth and degree of contamination; standard water picks have been used with
success in the past. The absorption of wound contaminants is affected by their sol-
ubility, acidity/alkalinity, tissue reactivity, and particle size, e.g., the more soluble
the contaminant, the greater the absorption rate.
(108) If a radiological attack involved explosives, e.g., following the detonation of
an RDD, people close to the blast may have wounds containing radioactive shrap-
nel. In most cases, conventional medical treatment for removing fragments will be
sufficient to deal with the radiation hazards presented. Simple precautions, such as
not handling the fragment directly (e.g., use forceps) and storing it in a shielded
or remote container, can provide effective short-term solutions, but radiation protec-
tion experts need to be consulted.

5.2.2. Sheltering

(109) Except within the potential explosive blast zone, from which people are
likely to be evacuated, advice from authorities that individuals should stay or go in-
doors (wherever they are), an action usually termed ÔshelteringÕ, may provide a sub-
stantial reduction in their possible exposure. The actual reduction depends upon the
type and construction of the buildings available for sheltering. For example, the dose
averted can increase by up to a factor of 10 or even more if cellars are included. If
windows and doors are closed and any ventilation systems turned off, movement of
particles into the building will be minimised and subsequent doses from inhalation of
radionuclides and skin contamination can also be reduced. After it has been con-
firmed that the plume of radioactivity has passed, it may be advisable to open win-
dows and turn on ventilation systems to reduce doses by diluting the concentration
of any radionuclides that may have entered the building. However, there is some risk
that this will distribute the materials that may be present on the filters or ventilation
into an otherwise unaffected building. Other complicating factors such as resuspen-
sion due to vehicle movement must also be considered.
(110) Sheltering may be a very effective protective action early in the event,
depending upon the type of building available and its location with respect to the site
and type of the event. There is, however, a need to have a rapid and effective means
of communicating with the people who are advised to shelter. Typically, there will be
priority arrangements for the emergency management to provide information on
public radio and television. The disadvantages of sheltering are low if individuals
are in their own homes, and if it is recommended for relatively short periods of time
(i.e., hours). There will be relatively little effort involved in short-term and localised
sheltering, except where important societal activities are disrupted and there are eco-
nomical losses. Sheltering for longer periods can cause social and economic problems
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 ICRP Publication 96

and lead to increased anxiety. There are also problems with sheltering if recom-
mended when members of a family are in different locations, i.e., home, work, and
school.
(111) In the longer term, after passage of the radioactive plume arising from the
event, sheltering continues to avert external radiation dose from ground deposits of
radionuclides. An averted dose factor of at least a few and up to some tens might be
expected, depending upon the type of structure. However, for longer periods of time,
this interferes with normal living and may cause distress, although anxiety may be alle-
viated by advising people that short periods of time spent outdoors for necessary activ-
ities will not, in many situations, result in very high exposures. The advantages and
disadvantages of such a part-time sheltering strategy should be assessed when justify-
ing and optimising the intervention level in advance at the planning stage.
(112) Analyses for justifying the undertaking of sheltering and optimising the con-
ditions should include consideration of damage imposed to individuals and society
(e.g., losses to industry, trade, and agriculture) and doses incurred by those respon-
sible for implementing the intervention (e.g., police). In the justification and optimi-
sation analyses, it may also be appropriate to give separate consideration to
identified groups within the population, in addition to the exposed population as
a whole. Such groups, which should be reasonably well defined and can include ur-
ban and rural populations, pregnant women, small children, sick or handicapped
people, and outdoor workers, may present substantive differences in the sheltering
costs, in their potential for averting doses, and in other factors.
(113) On a generic basis, the Commission estimates that sheltering will almost al-
ways be justified provided that an averted effective dose of 50 mSv can be achieved
during the time considered feasible for sheltering (ICRP, 1991b). Optimised levels
will be lower but not by more than a factor of 10 when consideration is given to spe-
cific emergency conditions and subgroups of the population. As sheltering for the
short term is such a low-risk countermeasure, it is more likely to be implemented
to avert the lowest levels of dose. It reduces exposure during the period when fuller
assessment is made of the dose consequences and thus the action required. The BSS
report that if sheltering cannot avert more than 10 mSv in a period of about 2 days,
the benefit is questionable. The Commission considers this to be a relevant figure for
planning sheltering actions in the event of a radiological attack.
(114) When a decision is made to shelter a population, those members of the pub-
lic who are able to return home should be advised to shower and change clothes as a
simple precaution against any external contamination. Clothes may need to be seg-
regated in normal plastic waste bags and, following indication from the authorities,
could be laundered normally, although it may be advisable to wash them separately
from other clothes to avoid cross-contamination. This is a recommended action as
there is no harm and a potential benefit is associated with it.

5.2.3. Evacuation

(115) Identification or early warning of an attack with a potential explosive device

will require an evacuation of the potentially affected area regardless of whether or
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not it involves radioactive material. The CommissionÕs advice on evacuation pro-

vided hereinafter is for purposes of radiological protection of the population liable
to be affected by the dispersal of radioactive material.
(116) Evacuation means the urgent, temporary removal of people from the af-
fected or potentially affected area, and is intended to avoid serious deterministic ef-
fects and a high risk of stochastic effects from high doses and high dose rates. It is
most effective if taken as a preventive measure; however, preventive evacuation is
the most disruptive of the early protective actions. The difficulty in making a decision
to evacuate people a priori lies in the limited amount of information that may be
available after a radiological attack. Judgement is required on the nature of the
event, the chances of escalation, and whether the doses that might be received are
high enough to warrant the risks, anxiety, disruption, and costs associated with evac-
uation. The decision to implement preventive evacuation is likely to be made on the
assessment of the situation and possible changes in prevailing conditions.
(117) The efficiency of evacuation for keeping the projected doses of those affected
well below the threshold of serious deterministic effects (and in reducing average
individual doses) depends on the ability to notify and transport people quickly,
the timing of the evacuation, and the capability to predict the dispersion of radionuc-
lides in the environment. It is necessary to take account of the doses that may be re-
ceived during evacuation early in the aftermath of the attack; judgement is needed
regarding whether sheltering during this stage might be more effective. This strategy
must be planned in advance, developed into plans and operational criteria, personnel
trained, and then, at the time of the event, implemented, with technical oversight to
adjust the strategy/plan if absolutely necessary.
(118) While the physical risks associated with evacuation have generally been
shown to be low, these will nonetheless depend upon conditions at the time that
evacuation is considered; weather conditions, time of day, and traffic conditions will
all influence the risks involved. Consideration must be given to special groups such
as the ill, the elderly, children, and pregnant women who may be at higher risk.
Authorities should also consider the negative and positive aspects of spontaneous
and/or voluntary evacuation using private means of transport. Such self-evacuation
may occur under conditions where formal advice to evacuate has been given, but
may also occur when such advice has not been given on radiological grounds.
(119) In justifying and optimising the intervention levels for evacuation as part of
the planning process, not only should the exposed population be considered as a
whole, but several particular groups for whom costs and benefits will differ require
separate consideration. These include pregnant women, small children, and hospita-
lised or other institutionalised individuals. Separate optimisation considerations are
needed, for instance, for workers engaged in shutting down vital industries and infra-
structure. As in any justification and optimisation decision, many social, ethical, and
economic factors must be considered in addition to the radiological conditions. So-
cial and psychological costs should be considered when different population groups
are treated differently. For example, socio-economic considerations will include the
type of community (rural, urban, or industrial), the size of the population evacuated,
and the presumed duration of the evacuation. Costs to be considered include trans-
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portation to the new location and back, the additional costs of living (shelter, food,
general medical care, schools, etc.) in the provisional location, compensation for loss
of income and inconvenience, and the costs of surveillance of property left behind.
(120) On a generic basis, the Commission estimates that evacuation is almost al-
ways justified if the projected average individual dose to the whole body is likely
to exceed 500 mSv within 1 day, or the averted average individual effective dose
for the duration of the evacuation is 500 mSv or the averted equivalent dose to
the skin is 5000 mSv. It is expected that, for most foreseeable accident situations,
an optimised level of averted effective dose for evacuation will be lower but not by
more than a factor of 10. The BSS conclude that the generic optimised intervention
level for evacuation is 50 mSv of avertable dose in 1 week, i.e., approximately
100 mSv in 2 weeks. The Commission concurs with this international requirement
and also advises the use of 500 mSv of skin equivalent dose in radiological attacks.
(121) Evacuation is a short-term protective action and its continuation must be
justified by a continuing hazard. This might be the failure to control the source of
the release, a significant risk of a further accident or release, or a persistence of ele-
vated radiation dose rate in the environment. However, beyond a few weeks, this
should be considered as temporary relocation, and justified and optimised
accordingly.

5.2.4. Iodine prophylaxis

(122) There are a number of radioisotopes of iodine that can be involved in a

radiological attack, including 131I, 125I, and 123I. Although the short half-lifes of
these isotopes make their malicious use less likely, they are readily available since
they are in routine use in nuclear medicine for diagnostic and therapeutic purposes.
Radioiodines are also part of the fission product inventory that may be released from
breach of nuclear reactor fuel elements and from IND detonations.
(123) The administration of potassium (stable) iodide (KI) to the public is an effec-
tive early measure for protection of the thyroid to prevent deterministic effects and to
minimise stochastic effects for people of any age. However, this is primarily intended
for the protection of children and embryos/fetuses. It must be clearly stated that KI
is only useful for protecting the thyroid against intake of radioactive iodine and it is
not a generic Ôanti-radiation medicineÕ as is often implied by the media. In relation to
a radiological attack, the administration of KI as a protective action would only be
beneficial if the attack involved the release of radioiodine. Conversely, the sabotage
of a nuclear installation could lead to the release of substantive amounts of radioio-
dine, and the use of KI could well be justified as an effective protective countermea-
sure. It should be noted that side effects of KI administration are few.
(124) A limitation of KI is that its efficacy is dependent on its ingestion either be-
fore or immediately after exposure. Due to the short time available, the distribution
of stable iodine may present a practical problem, especially if large population
groups are involved. Furthermore, within the context of a radiological attack, the
potential use of KI is logistically problematic. Although KI is available through
some pharmacies, there is a need for a well-considered plan for distributing it to a
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large population within a few hours of exposure to radioiodine following an attack.

Therefore, national authorities should give careful consideration to the most effective
way of assuring the availability of stable iodine to populations at risk of radiological
attacks, including renewal of stocks held at appropriate intervals.
(125) Administration of KI will rarely be used as a stand-alone protective action; it
will normally be recommended in conjunction with sheltering or evacuation. More-
over, the use of KI should be considered when inhalation of radioiodine is a major
exposure pathway (its use may also be warranted if radioiodine has been ingested or
absorbed through the skin). For the ingestion pathway, it is more appropriate to re-
duce doses by imposing restrictions on the production and consumption of food-
stuffs, provided that uncontaminated food supplies are readily available.
(126) The efforts involved in iodine prophylaxis should be considered in justifica-
tion and optimisation analyses, and should include the resources needed for iodine
preparation and distribution. It has been estimated, on a generic basis, that iodine
prophylaxis will almost always be justified provided that an average individual thy-
roid equivalent dose of approximately 500 mSv can be averted. However, consider-
ation of specific conditions may indicate that the generically optimised level will be
lower but not by more than a factor of 10, i.e., no lower than 50 mSv equivalent dose
to the thyroid.
(127) Finally, the Commission notes that within the above provisions, the generic
optimised intervention value for iodine prophylaxis established in the BSS is
100 mSv of avertable committed thyroid equivalent dose to the thyroid due to radi-
oiodine. The Commission now recommends that the current generic optimised inter-
vention level for iodine prophylaxis of 100 mSv provides an operational basis for
prompt decision-making and efficient application in the event of a nuclear or radio-
logical emergency. However, since there are strong indications of an age dependence
of the risk of induction of thyroid cancer by radioiodine, the Commission believes
that the administration of stable iodine at significantly lower levels of dose to the
thyroid may be recommended in order to take into account the higher sensitivity
of children and fetuses to radioiodine.

5.3. Recovery phase

5.3.1. Refined dose assessment

(128) More refined estimates of doses to members of the public should be made
during the recovery phase. The first results of environmental monitoring may be
available, leading to identification of the source term for the release, as well as
the first predictions of the extent of the affected area and a forecast of the future
potential progression (IAEA, 1999b). Moreover, very approximate external doses
may be estimated initially from clinical signs such as nausea and erythema. These
people should be hospitalised. Depending upon these dose assessments and predic-
tions, some people who have been sheltered may be allowed to move; alternatively,
a decision may be made that those who have been sheltered need to be evacuated.
Gradually, a more refined biological dose assessment could follow, including blood
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cell counts and biological dosimetry (see below). This is valuable for informing the
public about what has happened, what is likely to happen, and what further ac-
tions are planned.

5.3.2. Biological assays

(129) In the recovery phase from a major event, there is a public health require-
ment for counselling individuals on the longer-term implications of their exposure,
principally cancer risk. An estimate of the dose received by an individual will greatly
facilitate the advice that can be given. There are three principal methods for assessing
doses by biological measures: changes of the haematological parameters (blood cell
counts, especially lymphocytes); cytogenetic changes; and radicals induced by radia-
tion in bone and teeth, measured by electron spin resonance (ESR). It should be
noted that these methods can only be used for a limited period of time after the expo-
sure. Criteria for using such methods need to be determined at the planning stage,
particularly as the use of such methods will depend on their availability.
(130) Lymphocytes in peripheral blood will decrease significantly within days after
exposure to radiation doses of 1000 mSv and higher (whole body or large parts of the
body). The extent of this effect and the time course is dose dependent. After higher
whole body doses (>3000 mSv), the number of granulocytes and (later) thrombo-
cytes and erythrocytes will also decrease. From these changes of blood cell counts,
rough dose estimates can be obtained.
(131) More accurate estimates of the dose to the whole body or large parts of the
body in lower dose ranges can be obtained by cytogenetic measurements. After sig-
nificant radiation exposures, chromosomal aberrations become visible, with the for-
mation of dicentric chromosomes being particularly important for dose estimation.
In recent years, chromosomal translocations have also been measured by the fluores-
cence in-situ hybridisation technique. In specialised laboratories, it is possible to esti-
mate doses in the range of approximately 100 mSv and higher from chromosomal
aberration studies in peripheral blood lymphocytes. The technique needs good exper-
tise and is laborious; it takes approximately 1 week to obtain results. Only a few indi-
viduals can be analysed at a time. An easier technique is the determination of
chromosomal aberrations by measuring micronuclei in lymphocytes; this method
is less sensitive and laborious, quicker, and a higher number of individuals can be
studied. There are few laboratories in the world experienced in these techniques,
therefore international co-operation is necessary.
(132) After radiation exposure, radicals are formed in the exposed material. They
disappear quickly in soft tissues, but remain in bone and teeth for a longer period of
time. With the ESR method, these radicals can be measured and doses can be esti-
mated in ranges of several hundred mSv and higher. It is also possible to measure
these radicals in solid materials such as bricks and use such studies for dose estima-
tion. Again, there are only a few specialised laboratories with this capability, which
means that the cytogenetic and ESR methods are not practicable if dose estimates
are needed for more than a few hundred people.
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5.3.3. Temporary relocation and resettlement

(133) Relocation is distinguished from evacuation mainly by the time over which
this action is taken. It refers to the long-term removal of people from an affected
area. It may be undertaken as an extension to evacuation or it may be introduced
weeks or months after an event has occurred to reduce doses from deposited radio-
nuclides and to allow remedial measures to be carried out. The duration of reloca-
tion may be permanent (usually termed ÔresettlementÕ) or may be for a more
limited period (usually termed Ôtemporary relocationÕ). This will depend upon the
decline in the dose rate (due to radioactive decay, weathering processes, and any
remedial action) and social factors (e.g., provisions for rehabilitation of the affected
area).
(134) The risks and difficulties associated with temporary relocation and resettle-
ment are different from those for evacuation. Although these countermeasures are
usually urgent and movement of population groups can be carefully planned in ad-
vance and controlled in implementation, financial costs may be high and will depend
upon the numbers of people involved and the loss of production in the affected area.
In addition, the social costs of disruption and anxiety will also be substantial. Once
people have been informed that their temporary relocation or resettlement is desir-
able, they will be concerned and understandably anxious. The competent authorities
will need to keep them well informed, to explain the risks, and to proceed with the
relocation without undue delay.
(135) The efficiency of temporary relocation and resettlement in averting average
individual doses, both internal and external, in relation to time should be estimated
based on environmental measurements and modelling. In justifying and optimising
the intervention level, the entire population to be relocated should be considered
with the distribution of averted doses and corresponding costs. Several costs need
to be considered when examining the impact of these countermeasures. These in-
clude: transport costs; the costs of providing new housing, schools, medical care,
and workplaces; any extra food costs; and compensation for lost income, property,
industrial investment, agricultural capital, and health effects associated directly with
relocation itself and associated stress.
(136) Resettlement may cause different social problems that should be considered
in the final decision-making. In order to treat the various factors contributing to the
final decision in a systematic and rational manner, several decision-aiding techniques
can be used. Decision conferences seem to offer a good option to systematically han-
dle complex issues involving socio-economic and political factors together with
radiological and other health problems.
(137) From generic considerations, an average averted effective dose level of about
1000 mSv is almost always justified for relocation. Depending on the circumstances,
relocation may be justified at lower levels of averted dose, but after a very severe inci-
dent, the justified level of averted dose for relocation may be even higher than this
reference level. In Publication 63 (ICRP, 1991b), the Commission estimated the dose
rate from deposited activity above which relocation is optimised at about 10 mSv/
month for continuing and prolonged exposure.
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5.4. Restoration phase

5.4.1. Clean up

(138) The restoration phase is the period when remediation and clean-up actions
designed to reduce radiation levels in the environment to acceptable levels are com-
menced, and it ends when all the remediation actions, including the management of
the radioactive wastes and residues originated in the operations, have been com-
pleted. With the additional time and increased understanding of the situation, there
will be opportunities to involve interested parties in providing sound, cost-effective
recommendations. While the Commission has provided many recommendations
on the use of formal techniques for optimisation of protection (ICRP, 1973, 1983,
1989), the involvement of interested parties may broaden the practical application
of optimisation in the decision-aiding process that should lead to a wider decision-
making process. Generally, early (or rescue) phase decisions will be made directly
by elected public officials, or their designees, with limited interested parties involve-
ment of other parties due to the need to act within a short time frame. Long-term
decisions should be made with stakeholder involvement, and can also include tech-
nical working groups to provide expert advice to decision makers on impacts, costs,
and alternatives.
(139) Clean-up planning and discussions should begin as soon as practicable after
an attack to allow for selection of interested parties and subject matter experts, plan-
ning, analyses, contractual processes, and clean-up activities. National authorities
may choose to predetermine interested parties, and consideration should be given
to discussing and agreeing endpoints for the clean-up activities, as this can make
the withdrawal of intervention measures more acceptable to the public. These activ-
ities should proceed in parallel with ongoing recovery phase activities, and co-ordi-
nation between these sets of activities should be maintained. Preliminary remediation
activities carried out during the recovery phase, such as decontamination, resump-
tion of basic infrastructure function, and some return to normality in accordance
with recovery phase guidelines, should not be delayed for the final site remediation
decision.
(140) Optimisation of protection should be applied to clean-up decisions, as a flex-
ible process in which numerous factors are considered to achieve an end result that
balances local needs and desires, health risks, costs, technical feasibility, and other
factors (IAEA, 1997a). The general process provides decision makers with input
from national technical experts and stakeholder representatives, as well as providing
an opportunity for public comment. The extent and complexity of the clean-up pro-
cess following an attack should be tailored to its specific needs.
(141) Features of the optimisation process for clean up are as follows:

Transparency – the basis for clean-up decisions should be available to interested
parties representatives and, ultimately, to the public at large.

Inclusiveness – representative interested parties should be involved in decision-
making activities.

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Effectiveness – technical subject matter experts should analyse remediation

options including considerations for minimising waste volumes, consider dose
and risk benchmarks, assess various technologies in order to assist in identifying
a final solution that is optimal for the incident, and design a programme of radi-
ation monitoring for before, during, and after remediation to substantiate the
results. Monitoring radiation levels before and after clean up can demonstrate
its effectiveness.

Shared accountability – the final decision to proceed will be made jointly by all
decision makers.
(142) Reliable and accurate dissemination of information is key to establishing
transparency, inclusiveness, and effectiveness. The credibility of the communicator
is an important issue and professional public information personnel should, there-
fore, be involved at all stages. Their task is to gather, process, and rapidly dissemi-
nate information on both the attack and the response efforts, including complex
technical data. A credible and successful communications programme for conse-
quence management should begin with the fundamental objectives of reducing risk
to the public, and enables those affected by the attack to comprehend its scope
and make informed decisions.

5.4.2. Management of radioactive waste

(143) The management of radioactive waste that may be created as a result of a

radiological attack is an important component in the planning of restoration activ-
ities. Account must be taken of the volume of waste, the total activity content that
will have to be disposed, and the presence of long-lived and alpha-emitting materials,
depending on the source of the event. National authorities will have to plan for dis-
posal of radioactive waste and consider if the normal arrangements are acceptable.
The arrangements will include decisions on the conditioning (i.e., packing and stabil-
isation) of the waste in preparation for storage and disposal, and whether existing
disposal sites can be utilised. One of the factors that an authority will have to decide
is whether the waste is treated simply in accordance with the normal radioactive
waste regulations, or whether some special provisions are made because of the vol-
ume or costs in an optimisation of the overall remediation effort. In a radiological
attack, the volumes could be much greater than usually expected, and severely bur-
den the normal capacity available.
(144) The Commission has issued recommendations on Radiation Protection Prin-
ciples for the Disposal of Solid Radioactive Waste (ICRP, 1985); Radiological Protec-
tion Policy for the Disposal of Radioactive Waste (ICRP, 1997c), and Radiation
Protection Recommendations as Applied to the Disposal of Long-lived Solid Radioac-
tive Waste (ICRP, 1998). While these recommendations were obviously issued for a
different intention, they are applicable to radioactive wastes that may result from a
radiological attack. However, the majority of the expected wastes will probably be
large amounts of materials with low-level contamination. The IAEA has issued a
number of waste safety standards establishing specific requirements for handling this
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type of waste. The Commission also notes that a number of countries have under-
taken legally binding commitments through the international Joint Convention on
the Safety of Spent Fuel Management and the Safety of Radioactive Waste
Management.

5.4.3. Radioactive residues

(145) If full decontamination is not feasible after a radiological attack, the long-
term aftermath can result in a situation of prolonged exposure caused by the remain-
ing radioactive residues. Publication 82 (ICRP, 1999) addresses the application of the
CommissionÕs system of radiological protection to controllable radiation exposure
due to long-lived radioactive residues such as those that may remain after a radio-
logical attack.
(146) The Commission recommends the use of generic reference levels for interven-
tion in these situations, which are conveniently expressed in terms of the existing an-
nual dose. It is noted, however, that these levels should be used with extreme caution.
If some controllable components of the existing annual dose are clearly dominant,
the use of the generic reference levels should not prevent protective actions from
being taken to reduce these dominant components. The use of the generic reference
levels should not encourage a Ôtrade-offÕ of protective actions among the various
components of the existing annual dose.
(147) A low level of existing annual dose does not necessarily imply that protective
actions should not be applied to any of its components; conversely, a high level of
existing annual dose does not necessarily require intervention. With these provisos,
an existing annual dose below about 10 mSv may be used as a generic reference level
below which intervention is not likely to be justifiable for some situations. Below this
level, protective actions to reduce a dominant component of the existing annual dose
are still optional and might be justifiable. This is illustrated in Fig. 5.1. In such cases,

Fig. 5.1. Describing the need for intervention in prolonged exposure situations.

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action levels specific to particular components can be established on the basis of

appropriate fractions of the recommended generic reference level. Above an existing
annual dose of about 10 mSv, intervention may be necessary and should be justified
on a case-by-case basis.
(148) Situations that will almost always justify intervention are those in which the
annual (equivalent) dose thresholds for deterministic effects in relevant organs could
be exceeded, or in which the extant annual dose may approach 100 mSv. This numer-
ical criterion, which may be used as a generic reference level for justifying the estab-
lishment of protective actions under nearly any conceivable circumstance, is coherent
with the guidance for resettlement provided here. In fact, mainly because of decay
and weathering, such a level of extant annual dose would rarely commit doses
exceeding approximately 1000 mSv.

5.4.4. Discontinuation of protective actions

(149) The protective actions required in the aftermath of a radiological attack will
generally be disruptive and restrictive of the ÔnormalÕ living conditions of people.
Eventually, in order to return to ÔnormalityÕ, such actions will need to be discontin-
ued at some stage, although, in some situations, the background radiation levels may
be higher than before the event as a result of residual contamination that may be dif-
ficult or impossible to remove. The simplest basis for justifying the discontinuation
of protective actions is to confirm that the exposures have decreased to below the
action levels that would have prompted the authorities to intervene. If such a reduc-
tion in exposure is not feasible, the generic reference level of existing annual dose be-
low which intervention is not likely to be justifiable could provide a basis for
discontinuing intervention.
(150) In practice, the exposed population may find it difficult to accept that pro-
tective actions should be stopped, and the social pressures may override the benefit
of discontinuing the intervention. In these cases, the participation of the stakeholders
in the decision-making process becomes essential and, as mentioned in Paragraph
139, it may be advisable to discuss and agree the endpoints at the outset of the
clean-up activities. After intervention has been discontinued, the remaining existing
annual dose should not influence the normal living conditions in the affected area,
including decisions about the introduction of new practices involving radiation expo-
sures, even if such a dose is higher than that prevailing in the area before the event.

5.4.5. Final dose assessment

(151) As demonstrated by many situations involving radioactive contamination,

such as the accidents of Chernobyl and Goiânia, in the aftermath of a radiological
attack, there will be a significant ongoing issue of determining what dose was in fact
received, and whether contamination continues to be present. Authorities should ex-
pect a heavy demand for surveys and dose estimates. This is likely to include many
people who may not have received significant exposure, but who are seeking some
type of confirmation or proof of their condition. Large numbers of dose estimates
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could be made based upon location and environmental measurements or reconstruc-

tion. Effective screenings will usually require an agreed action level and effective com-
munication of the methods used, the results obtained, and the implications for each
individual.

5.5. Summary of dose criteria for protecting the public

5.5.1. Generic optimised protection levels

(152) The recommended levels of avertable effective doses at which protection of

the public, provided by a number of countermeasures, would be optimised are pre-
sented in Table 5.1.
(153) In the aftermath of a radiological attack, if radioactive residues remain, giv-
ing rise to prolonged exposure, the recommended generic criteria for intervention
with radiation protection measures (such as cleaning up) are presented in Table 5.2.

5.5.2. Operational levels

(154) It should, however, be noted that the numerical dosimetric guidance pro-
vided in these tables cannot be used directly since the quantities will not usually
be directly measurable. The guidance can be used as a basis for the development
of operational intervention levels (OILs), which are expressed in quantities that
are directly measurable, and should be developed at the planning stage.
(155) OILs should be developed in advance for determining when exposure rates
or contamination levels warrant taking protective action and other countermeasures
in the event of a radiological emergency (IAEA, 2002c). Actions for which the devel-
opment of OILs may be required include: control of access and isolation of a

Table 5.1. Recommended avertable doses for undertaking countermeasures

Countermeasure Avertable dose (for which the
countermeasure is generically optimised)
Sheltering 10 mSv in 2 days (of effective dose)
Temporary evacuation 50 mSv in 1 week (of effective dose)
Iodine prophylaxis (if radioiodine is present) 100 mSv (of equivalent dose to the thyroid)
Relocation 1000 or 100 mSv in first year (of effective dose)

Table 5.2. Recommended generic criteria for intervention in prolonged exposure situations (Source: ICRP
1999, Fig. 6)
Intervention Criteria (existing annual
effective dose in mSv/year)
Almost always justifiable )100
May be justifiable J 10
Unlikely to be justifiable [10

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contaminated area or dangerous radioactive source; sheltering; evacuation; and

relocation.

5.6. Controlling contamination of consumer goods

(156) Consumer goods, such as water, food, and other commodities of public
consumption, can be contaminated with radioactive materials, either as a deliber-
ate act or as a consequence of another type of radiological attack. For instance,
the ÔfalloutÕ from a plume of dispersed radioactive material could contaminate all
types of commodities, possibly at significant distances from the dispersal point,
depending on the dispersal method (e.g., detonation of an RDD). These situations
are unlikely to lead to the significant internal contamination of a large number of
people due to the large amounts of radioactive material that would be required to
reach high levels of contamination in mass-produced or distributed supplies.
However, past experience seems to show that the public concern generated by
such an act could present a significant challenge to the authorities. Although it
is unlikely (although not impossible) that there would be a need for emergency
monitoring of a large number of people for internal contamination, there is a
need to co-operate with radiological experts and media specialists to quickly as-
sess the potential medical impact of such acts and provide public information
to alleviate fears in the potentially affected public (IAEA, 1999b). There is also
a need to develop a plan, at national level, to monitor a representative sample
of the potentially affected population to confirm the health risk assessment and
reassure the public.

5.6.1. Basic criteria

(157) Publication 82 (ICRP, 1999) suggested the establishment of intervention

exemption levels for commodities including foodstuffs. Commodities that are above
such exemption levels should be subject to intervention and those that are below
could be ÔexemptedÕ. The Commission noted, moreover, that mainly due to the glob-
alisation of markets, these exemption levels may not be amenable to ad-hoc deci-
sions, i.e., they cannot be established on a case-by-case basis but need to be
standardised internationally. It is not likely that several types of commodities would
be simultaneous sources of high exposure to any given individual. On the basis of
this presumption, the Commission recommends a generic intervention exemption le-
vel of approximately 1 mSv for the maximum individual annual dose expected from
a dominant type of commodity, such as some building materials that may, in some
circumstances, be a significant cause of exposure.
(158) While the levels of contamination of consumer goods and the resulting
levels of annual effective dose can be very low, the effective control of contami-
nation for radiation protection purposes could became amenable and warranted
above certain activity concentration levels. The values portrayed in Table 5.3 rep-
resent the approximate levels of activity concentration in contaminated substances
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Table 5.3 Recommended exclusion levels

Nuclides Activity
concentration (Bq/g)
Artificial alpha-emitters 0.01
Artificial beta-/gamma-emitters 0.1
Head of chain activity level , 238U, 232
Th 1.0
y
For 238U and 232Th chains, this value also applies to any nuclide in a chain that is not in secular
equilibrium excluding 222Rn and daughters in air which in all situations are controlled seperately.

above which control for radiological protection purposes can be considered in

case of a radiological attack. Consumer goods with activity concentration below
the levels in the table may be excluded from the scope of the recommendations in
this report.

5.6.2. International consensus on radiological criteria for radionuclides in commodities

(159) Notwithstanding the above, the Commission welcomes the recent intergov-
ernmental international consensus on radiological criteria for radionuclides in com-
modities (IAEA, 2004b; 2004d). National authorities may wish to consider such a
consensus in deciding control measures on commodities that could be contaminated
as a consequence of a radiological attack.

5.6.3. Radionuclides in bulk amounts of materials

(160) The recent international consensus on radiological criteria for radionuclides

in commodities establishes activity concentration values for radionuclides of artifi-
cial and natural origin in bulk amounts of materials to be used for guidance in ful-
filling requirements of the BSS for exclusion, exemptions, and clearance. The values
are given in Table 5.4.

5.6.4. Radionuclides in foods

(161) In relation to foods, following the Chernobyl accident, the Codex Alimentar-
ius Commission (CAC) adopted generic intervention exemption levels for radionuc-
lides in foodstuffs following a nuclear accident (Codex Alimentarius, 1991). These
levels, which are currently incorporated into the BSS, have been revised recently
by the CACÕs Committee on Food Additives and Contaminants (CFAC) (Codex
Alimentarius, 2004). The CAC is expected to review and formally adopt these levels
in the near future. While the Commission considers that the revised levels for 238Pu,
239
Pu, 240Pu, and 241Am are relatively conservative, it recommends that the levels fi-
nally adopted by the CAC should be applied to manage the distribution of foodstuffs
that could be contaminated as a result of a radiological attack in an internationally
coherent and consistent manner, particularly if international trade is involved. The
CFACÕs revised levels are given in Table 5.5.
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Table 5.4. Radiological criteria for radionuclides in bulk amounts of materials

Radionuclides Level
(Bq/g)
I-129 0.01
Na-22; Sc-46; Mn-54; Co-56; Co-60; Zn-65; Nb-94; Ru-106; Ag-110m; Sb-125; Cs-134; Cs- 0.1
137; Eu-152; Eu-154; Ta-182; Bi-207; Th-229; U-232; Pu-238; Pu-239; Pu-240; Pu-242; Pu-
244; Am-241; Am-242m; Am-243; Cm-245; Cm-246; Cm-247; Cm-248; Cf-249; Cf-251; Es-
254
C-14; Na-24; Cl-36; Sc-48; V-48; Mn-52; Fe-59; Co-57; Co-58; Se-75; Br-82; Sr-85; Sr-90; Zr- 1
95; Nb-95; Tc-96; Tc-99; Ru-103; Ag-105; Cd-109; Sn-113; Sb-124; Te-123m; Te-132; Cs-
136; Ba-140; La-140; Ce-139; Eu-155; Tb-160; Hf-181; Os-185; Ir-190; Ir-192; Tl-204; Bi-206;
Th-232*, U-233; U-235 ; U-238à; Np-237; Pu-236; Cm-243; Cm-244; Cf-248; Cf-250; Cf-252;
Cf-254
Be-7; F-18; Cl-38; K-40; K-43; Ca-47; Mn-51; Mn-52m; Mn-56; Fe-52; Co-55; Co-62m; Ni- 10
65; Zn-69m; Ga-72; As-74; As-76; Sr-91; Sr-92; Zr-93; Zr-97; Nb-93m; Nb-97; Nb-98; Mo-
90; Mo-93; Mo-99; Mo-101; Tc-97; Ru-97; Ru-105; Cd-115; In-111; In-114m; Sn-125; Sb-
122; Te-127m; Te-129m; Te-131m; Te-133; Te-133m; Te-134; I-126; I-130; I-131; I-132; I-
133; I-134; I-135; Cs-129; Cs-132; Cs-138; Ba-131; Ce-143; Ce-144; Gd-153; W-181; W-187;
Pt-191; Au-198; Hg-203; Tl-200; Tl-202; Pb-203; Po-203; Po-205; Po-207; Ra-225; Pa-230;
Pa-233; U-230; U-236; Np-240; Pu-241; Cm-242; Es-254m
H-3; S-35; K-42; Ca-45; Sc-47; Cr-51; Mn-53; Co-61; Ni-59; Ni-63; Cu-64; Rb-86; Sr-85m; 100
Sr-87m; Y-91; Y-91m; Y-92; Y-93; Tc-97m; Tc-99m; Rh-105; Pd-109; Ag-111; Cd-115m; In-
113m; In-115m; Te-129; Te-131; I-123; I-125; Cs-135; Ce-141; Pr-142; Nd-147; Nd-149; Sm-
153; Eu-152m; Gd-159; Dy-166; Ho-166; Er-171; Tm-170; Yb-175; Lu-177; Re-188; Os-191;
Os-193; Ir-194; Pt-197m; Au-199; Hg-197; Hg-197m; Tl-201; Ra-227; U-231; U-237; U-239;
U-240; Np-239; Pu-234; Pu-235; Pu-237; Bk-249; Cf-253; Es-253; Fm-255
Si-31; P-32; P-33; Fe-55; Co-60m; Zn-69; As-73; As-77; Sr-89; Y-90; Tc-96m; Pd-103; Te- 1000
125m; Te-127; Cs-131; Cs-134m; Pr-143; Pm-147; Pm-149; Sm-151; Dy-165; Er-169; Tm-171;
W-185; Re-186; Os-191m; Pt-193m; Pt-197; At-211; Th-226; Pu-243; Am-242; Cf-246
Co-58m; Ge-71; Rh-103m; Fm-254 10,000
232 228 228 228 224 220
*The thorium series, headed by Th and constituted by Ra, Ac, Th, Ra, Rn, 216Po,
212
Pb, 212Bi, 212Po, 208Tl, and 208Pb.
The actinium series, headed by 235U and constituted by 231Th, 231Pa, 227Ac, 227Th, 223Fr, 223Ra, 219Rn,
215
Po, 211Pb, 211Bi, 207Tl, and 207Pb.
à
The uranium series, headed by 238U and constituted by 234Th, 234mPa, 234U, 230Th, 226Ra, 222Rn,
218
Po, 214Pb, 214Bi, 214Po, 210Pb, 210Bi, 210Po, and 206Pb.

Table 5.5. Committee on Food Additives and ContaminantsÕ revised guideline levels for radionuclides in
foods
Radionuclides in foods Guideline level
(Bq/kg)
238
Pu, 239Pu, 240Pu, 241Am 1
90
Sr,106Ru,129I,131I, 235U 100
35 60
S, Co, 89Sr, 103Ru, 134Cs, 137
Cs, 144
Ce, 192
Ir 1000
3 * 14
H , C, 99Tc 10,000
* This represents the most conservative value for tritium (organically bound).

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 ICRP Publication 96

5.6.5. Radionuclides in water supplies

(162) In relation to water supplies, the Commission notes that the World Health
Organisation (WHO) has developed specific guidance levels for radionuclides in
drinking water (WHO, 2004). Again, while the Commission considers that some
of these levels are conservative, it recommends that they should be applied to man-
age the supply of contaminated water following a radiological attack. The WHO lev-
els are given in Table 5.6.

5.6.6. Control in the affected area

(163) Measures for control of contaminated commodities are expected to be ini-

tially applied within the affected area. The Commission continues to note that com-
modities produced or subject to commerce within the area of influence of the event
producing the contamination, e.g., a radiological attack, would present an excep-
tionally difficult situation. If the corresponding activity levels are higher than those
in produce from neighbouring areas, issues of market acceptance could arise, partic-
ularly if there are transboundary movements of the commodities.

5.6.7. Control outside the affected area

(164) If the annual doses in the area affected by the event are acceptable because
the intervention strategy has been optimised, the situation outside the affected area
should also be acceptable because the individual annual doses elsewhere from the use
of commodities produced in the affected area would normally not be higher than
those in the affected area. If the restrictions on commodities produced in the area
affected by the event have not been lifted, production of the restricted commodities
should not be restarted; conversely, if the restrictions have been lifted, production
can be restarted. If an increase in production is proposed, it could proceed subject
to appropriate justification. In circumstances where restrictions have been lifted as
part of a decision to return to ÔnormalÕ living, the resumption and potential increase
of production in the affected area should have been considered as part of that deci-
sion and should not require further consideration.

5.7. Particular situations

5.7.1. Handling situations with Ôhot particlesÕ

(165) In some scenarios, it can be imagined that radioactive residues may become
very sparsely distributed in the environment, usually as Ôhot particlesÕ, giving rise to
situations where there is the potential but not the certainty that the exposure of peo-
ple will actually occur. The Commission has issued recommendations for dealing
with potential exposure situations (IAEA, 1990; ICRP, 1993a, 1997b). Protection
in situations involving hot particles is not a new issue (IAEA, 1998b). For these sit-
uations, the Commission has issued criteria of acceptability on the basis of the
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 ICRP Publication 96

Table 5.6. Guidance levels for radionuclides in drinking water

Radionuclides Guidance Radionuclides Guidance Radionuclides Guidance
level (Bq/l)* level (Bq/l)* level (Bq/l)*
3 93 140
H 10,000 Mo 100 La 100
7 99 139
Be 10,000 Mo 100 Ce 1000
14 96 141
C 100 Tc 100 Ce 100
22 97 143
Na 100 Tc 1000 Ce 100
32 97m 144
P 100 Tc 100 Ce 10
33 99 143
P 1000 Tc 100 Pr 100
35 97 147
S 100 Ru 1000 Nd 100
36 103 147
Cl 100 Ru 100 Pm 1000
45 106 149
Ca 100 Ru 10 Pm 100
47 105 151
Ca 100 Rh 1000 Sm 1000
46 103 153
Sc 100 Pd 1000 Sm 100
47 105 152
Sc 100 Ag 100 Eu 100
48 110 154
Sc 100 Ag 100 Eu 100
48 111 155
V 100 Ag 100 Eu 1000
51 109 153
Cr 10,000 Cd 100 Gd 1000
52 115 160
Mn 100 Cd 100 Tb 100
53 115m 169
Mn 10,000 Cd 100 Er 1000
54 111 171
Mn 100 In 1000 Tm 1000
55 114m 175
Fe 1000 In 100 Yb 1000
59 113 182
Fe 100 Sn 100 Ta 100
56 125 181
Co 100 Sn 100 W 1000
57 125 185
Co 1000 Sb 100 W 1000
58 124 186
Co 100 Sb 100 Re 100
60 125 185
Co 100 Cb 100 Os 100
59 123m 191
Ni 1000 Te 100 Os 100
63 127 193
Ni 1000 Te 1000 Os 100
65 127m 190
Zn 100 Te 100 Ir 100
71 129 192
Ge 10,000 Te 1000 Ir 100
73 129m 191
As 1000 Te 100 Pt 1000
74 131 193m
As 100 Te 1000 Pt 1000
76 131m 198
As 100 Te 100 Au 100
77 132 199
As 1000 Te 100 Au 1000
75 125 197
Se 100 I 10 Hg 1000
82 126 203
Br 100 I 10 Hg 100
86 129 200
Rb 100 I 1000 Tl 1000
85 131 201
Sr 100 I 10 Tl 1000
89 129 202
Sr 100 Cs 1000 Tl 1000
90 131 204
Sr 10 Cs 1000 Tl 100
90 132 203
Y 100 Cs 100 Pb 1000
91 134 206
Y 100 Cs 10 Bi 100
93 135 207
Zr 100 Cs 100 Bi 100
95 136 210
Zr 100 Cs 100 Bi 100
93m 137 210
Nb 1000 Cs 10 Pb 0.1
94 131 210
Nb 100 Ba 1000 Po 0.1
95 140 223
Nb 100 Ba 100 Ra 1
224 235 242
Ra 1 U 1 Cm 10
225 236 243
Ra 1 U 1 Cm 1
226 237 244
Ra 1 U 100 Cm 1
228 238
Ra 0.1 U ,à 10 245
Cm 1
227 237 246
Th 10 Np 1 Cm 1

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 ICRP Publication 96

Table 5.6. (continued)

Radionuclides Guidance Radionuclides Guidance Radionuclides Guidance
level (Bq/l)* level (Bq/l)* level (Bq/l)*
228 239 247
Th 1 Np 100 Cm 1
229 236 248
Th 0.1 Pu 1 Cm 0.1
230 237 249
Th 1 Pu 1000 Bk 100
231 238 246
Th 1000 Pu 1 Cf 100
232 239 248
Th 1 Pu 1 Cf 10
234 240 249
Th 100 Pu 1 Cf 1
230 241 250
Pa 100 Pu 10 Cf 1
231 242 251
Pa 0.1 Pu 1 Cf 1
233 244 252
Pa 100 Pu 1 Cf 1
230 241 253
Cu 1 Am 1 Cf 100
231 242 254
U 1000 Am 1000 Cf 1
232 242m 253
U 1 Am 1 Es 10
233 243 254
U 1 Am 1 Es 10
234 254m
U 10 Es 100
* Guidance levels are rounded according to averaging the log scale values (to 10n if the calculated value
was below 3 · 10n and added above 3 · 10n  1).
Natural radionuclides.
à
The provisional guideline value for uranium in drinking water is 15 lg/l based on its chemical toxicity
for the kidney.

unconditional probability that members of the public would develop fatal stochastic
health effects attributable to the exposure situation (ICRP, 1999), which are expected
to be established by national and international organisations. Such a probability
should be assessed by combining the following probabilities: the probability of being
exposed to the hot particles; the probability of incorporating a hot particle into the
body as a result of such exposure; the incurred average equivalent dose as a result of
such incorporation; and the probability of developing a fatal stochastic effect from
that dose. These probabilities should be integrated over all the range of situations
and possible doses. In establishing such criteria, consideration should be given to
the possibility that localised deterministic effects may also occur as a result of the
incorporation of hot particles. The Commission notes that the risk equivalent to
the public dose limit is about 105/year. An acceptability criterion of approximately
106/year has already been used internationally (IAEA, 1998b).

5.7.2. Handling contaminated corpses

(166) Some corpses may be contaminated with radioactive material. Appropriate

radiation surveys can confirm or rule out such a situation. If a body is known, or
suspected, to be contaminated, personnel engaged in handling the body should be
issued with personal protective equipment. The usual precautions exercised, espe-
cially if there was the potential for infectious disease, probably handle a great deal
of the need. It is important for responders and mortuary personnel to be aware of
other, more acutely hazardous agents that may co-contaminate the human remains
in question. Appropriately higher levels of protection should be used as needed. In
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the event of mass casualties, governments would usually activate the ad-hoc response
plans and national disaster medical systems, which may include disaster mortuary
operational response teams, i.e., response teams, trained in basic radiation protec-
tion, who can provide mortuary assistance.

Autopsies and embalming

(167) Autopsy of minimally radioactively contaminated cadavers does not require
precautions other than contamination control and protective clothing. Autopsies of
highly radioactive cadavers should be restricted to the absolute minimum. The
embalming of a cadaver by a simple injection method is not generally a hazard to
the embalmer if an autopsy has not been performed. Embalmers should wear protec-
tive clothing and it is advisable to have radiation safety staff present.

Burial/cremation
(168) Issues related to both burial and cremation are a function of the amount and
type of radioactive material that remains in the body. Burial is not usually an issue
unless there are extremely long-lived radionuclides present that may ultimately find
their way into the environment in concentrations that exceed regulatory limits.
Whether cremation is allowed depends on what type and amount of radioactive
materials are released to the environment by incineration or by disposal of ashes.
If the radionuclide has a short half-life, it may be possible to wait a few weeks before
cremation occurs. There are a number of national guidelines regarding acceptable
levels of activity in corpses for cremation.

78
 6. MEDICAL INTERVENTION

6.1. Essential elements of medical treatment

(169) The following are essential elements for the medical treatment of people in-
volved in a radiological attack:

All patients should have their traumatic injuries medically stabilised before radi-
ation injuries are considered. Patients should then be evaluated for both external
radiation exposure and radioactive contamination.

People exposed from a source outside the body are said to be Ôexternally exposedÕ.
High external exposure can cause severe tissue damage (e.g., skin burns or bone
marrow depression). This type of ÔexternalÕ exposure does not make the person
radioactive, unless they were exposed to neutron radiation. Even if people have
been exposed to lethal levels of external radiation, they are not a hazard to med-
ical staff.

Nausea, vomiting, diarrhoea, and skin erythaema within 4 h may indicate very
high (but treatable) external radiation exposures. Such patients will show obvious
lymphopenia within 8–24 h, and evaluation for symptomatic patients includes a
complete blood count every 6–12 h for 2–3 days. Primary systems involved will
be skin, intestinal tract, and bone marrow. Treatment should be supported with
fluids, antibiotics, and transfusion stimulating factors. If there are early central
nervous system findings or unexplained hypotension, survival is unlikely (see
Annex B for additional details).

Radioactive material (contamination) may have been deposited on or in the per-
son. More than 90% of surface radioactive contamination is usually removed by
removal of the clothing. Contamination on the skin can be effectively removed
with soap, warm water, and a washcloth. Care should be taken not to damage
the skin by scrubbing. Initial decontamination efforts can usually be stopped
once the contamination level is reduced to two times the background count rate,
or if repeated decontamination efforts are ineffective. These action levels need to
be decided in conjunction with radiation protection experts at the planning
stage. Contaminated clothing should be placed in double-sealed bags/containers
and labelled. Wash water from large numbers of people will usually have to be
disposed of in the sewer system, but this needs to be considered at the planning
stage.

Medical staff can protect themselves against radioactive contamination by observ-
ing standard precautions, including the use of protective clothing, gloves, and a
mask. The principal of time/distance/shielding is key for protection against exter-
nal radiation. Even in the treatment of Chernobyl workers, doses to the medical
staff were not high (about 10 mSv).

From a medical treatment perspective, radioactive contamination in wounds or
burns should be handled as if it were simple dirt. If an unknown metallic object
is encountered, it should only be handled with instruments such as forceps and

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 ICRP Publication 96

should be placed in a protected or shielded area. There is a possibility that the

metallic object could be a fragment from a radioactive source, so radiation pro-
tection experts should be notified and consulted.

There may be:
– continuing exposure of the public that is essential to evaluate;
– initial suggestion of sheltering and a change of clothing or showering;
– the necessity for evacuation; and
– administration of KI when there has been release of radioiodine.

When there is any type of radiation incident, many people will want to know
whether they have been exposed or are contaminated. Provisions need to be made
to deal potentially with thousands of such people.
(170) While the Commission does not intend to use this report to make recommen-
dations for therapeutic medical treatments of radiation injuries, it notes that a num-
ber of therapies are available for reducing the potential health effects to people who,
following a radiological attack, may have been exposed to levels of external radiation
above the thresholds for deterministic effects (US DHS, 2003a). As indicated before,
Annex B presents relevant information for immediate medical prognosis and treat-
ment of the radiation effects that may arise from a radiological attack, including:
the prodromal phase of acute radiation syndrome; the change of lymphocyte counts
in the initial days of acute radiation syndrome depending on the dose of acute whole
body exposure; the latent phase of acute radiation syndrome; the findings of critical
phase of acute radiation syndrome following whole body exposure; the principal
therapeutic measures for acute radiation syndrome according to degree; and the time
of onset of clinical signs of skin injury depending on the dose received. The choice of
treatments depends upon the type and the severity of the exposure and some brief
guidance is also provided in Annex B.
(171) Therapies that are available for the management of internally exposed peo-
ple are described in the last section of Annex B. With the exception of use of KI as a
blocking agent, the other therapies for internal contamination are not recommended
for general population use unless intakes are high. Generally, if the intake is <1 an-
nual limit of intake (ALI), treatment is not usually needed, and if the intake is >10
ALI, treatment is usually indicated. These treatments should be under the direction
of a physician experienced in these matters, and should take individual patient fac-
tors into account.
(172) Other important factors in medical treatment that need to be considered are
summarised in the following sections.

6.2. Other important medical issues

6.2.1. Identification of radionuclides

(173) Medical treatment can be more effective if there is readily available data on
the type of radiation that people were exposed to. Data may be basic – such as
whether the radiation was alpha, beta, gamma, neutron, or x rays, or more sophis-
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 ICRP Publication 96

ticated, and may include knowledge of specific radionuclides. Hand-held spectrom-

eters with the capability to identify up to 300 radionuclides are commercially avail-
able. If these instruments were made available to specially trained personnel in
hospital emergency rooms or to first responders, they could be used not only to im-
prove the effectiveness of treating exposed people, but also to provide authorities
with rapid data relative to the nature and scope of the event.

6.2.2. Secondary treatment centres

(174) Experience with accidents in which there was dispersion of radioactive mate-
rials indicates that many people who are not actually injured, exposed, or contami-
nated will still be concerned and are likely to go to hospitals for evaluation. These
people can easily number in the thousands and may arrive at hospitals by private
car and taxi, even before ambulances are able to bring the casualties who need urgent
attention. It has long been realised that hospitals will need to set up and staff a Ôsec-
ondary assessment centreÕ to attend to these Ôworried wellÕ. Such a secondary assess-
ment centre or area will need to have, at the minimum, detection equipment, an
ability to record patientsÕ names, and identifying information, and will need to be
able to perform a cursory medical evaluation. In spite of the fact that this need
has been long recognised, most hospital facilities have not yet made appropriate
planning arrangements.

6.2.3. Biodosimetry

(175) In the very early phases of response, determination of those individuals who
have received high doses (>1000 mSv) and require medical care should proceed as
outlined earlier. While there are a number of useful tools that can be used to record
patient responses and to estimate doses, medical care should not be based on esti-
mated dose but on actual patient response. As a second-order action, there will be
a need to estimate the doses of those individuals who may have received significant
doses but who do not require medical care in the acute or subacute term. Histori-
cally, this has been done using various chromosome and micronucleus assays, but
these methods are time consuming and labour intensive; over the last decade, most
of the competent laboratories have been phased out. Unless these can be revived or
rapid automated techniques developed, dose estimation for these individuals may
only be made with retrospective environmental data (see also section 5.3.2, Biolog-
ical Assays).

6.2.4. Skilled personnel

(176) In countries with a well-developed emergency preparedness and response

infrastructure, it is likely that a small or medium malicious radiological event could
be handled locally or with regional or national resources, whereas the use of even a
relatively low-yield nuclear weapon in an urban area may require international
medical assistance. It has been estimated that for a 1 kT detonation, there may be
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 ICRP Publication 96

more than 7000 immediate casualties and about 20,000 people who will require
intensive care treatment. Local emergency physicians, radiologists, nuclear medicine
physicians, radiation oncologists, medical physicists, and health physicists will all be
involved in the very early hours. Since there are few physicians with the necessary
expertise, others will need to be identified and mobilised if an event arises. It is pos-
sible that additional personnel resources could also be obtained through professional
societies. These issues need to be considered at the planning stage. A very large event
is likely to require international assistance. This could come in response to a national
government requesting assistance through the IAEA or the WHO under the Conven-
tion on Early Notification of a Nuclear Accident. Both of these organisations have
provided assistance following radiological accidents in the past.

6.2.5. Training medical personnel

(177) Education and training are clear requirements. Unfortunately, physicians

are faced with the need for training in many areas besides radiological attacks.
The degree to which they will attend training is related to the scale and likelihood
of the potential attack. Specific training for radiological incidents is probably a thing
of the past, as the need now is to be able to respond to an unknown but possible
biological, chemical, or radiological contaminant. In addition, physicians obtain
most of their training through their professional societies. Thus they may attend
an annual meeting and receive training on how to deal with terrorist attacks as part
of a much broader educational package.

6.2.6. Long-term follow-up

(178) A radiological attack might be viewed as having a clear and defined end-
point, recognising that there is likely to be a demand for medical follow-up. This
would initially involve at least providing people with a dose estimate as well as some
information on what risks might be associated with that dose. There may also be spe-
cial needs. For example, if there was a large radioiodine release and KI was not
administered promptly, there would be a need to evaluate infants, children, and ado-
lescents for at least the next decade to assess the possibility of thyroid cancer. The
need for a registry of exposed people or medical monitoring should be considered.

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 7. COMMUNICATION

(179) Reliable and accurate communication and dissemination of information is a

key element for successful radiological protection efforts in the aftermath of a radio-
logical attack. Many recommendations are available in the open literature for this
purpose (e.g., ANS, 2003; US DHS, 2003b; Van Tuyle et al., 2003), and the Commis-
sion recommends that national authorities to refer to the available reference material
in establishing their communication strategies.
(180) Professional public information personnel should be involved to gather, pro-
cess, and rapidly disseminate information on both the incident and the response ef-
forts, including complex technical data. A credible and successful communications
programme for consequence management should begin with the fundamental objec-
tives of communicating approaches to risk reduction and enabling those affected by
the disaster to comprehend its scope and make informed decisions. Such a pro-
gramme should disseminate timely, accurate, clear, and consistent information with-
out creating unwarranted fear. The emergency planners and responders must
recognise the short- and long-term information needs of the public, media, and re-
sponse forces, and incorporate that understanding in their plans and actions.
(181) In the early hours and days of the response, communicators will be chal-
lenged to get crucial technical information out to the public quickly and in easy-
to-understand language. Release of radiological information must be concurrent
with protective action guidance. Lack of information only adds to fear and specula-
tion. Basic information should be provided on the amount of radiation or radionu-
clide contamination and areas affected, even if it is qualified as early estimates. The
time between information acquisition, packaging, and release can be critical.
(182) The information personnel will give guidance regarding whether not to in-
form or to inform, and, if so, how to inform. On the one hand, informing the public
may have several advantages: recognition and avoidance of the hazard; creation of a
public network for notification of a malicious act; better chance of avoidance; and
better probability of apprehending the perpetrators of the act. On the other hand,
too much information too early may cause undue anxiety. In a controlled informa-
tion strategy, consideration should be given to the needs, limitations, and other fac-
tors that influence how the different target audiences view risks, and thereby how
able they are to accept the information.
(183) Therefore, media and public information planning must consider the possi-
bility of radiological malicious attacks. Preparedness for radiological attacks should
be based on existing arrangements for responding to other types of attack, with spe-
cial consideration given to the need for establishing clear guidelines on when and
how such information should be provided to the media and the public.
(184) It is vital to establish a good working relationship with the media before the
onset of a radiological attack. To achieve such a relationship, it is necessary to in-
volve media personnel to plan for the interaction in the event. Involvement of infor-
mation and the media in simulations and exercises also helps to improve confidence
in the response.

83
 ANNEX A: POTENTIAL SCENARIOS

A.1. Malicious intent

(A1) Radioactive material could be used, in blackmail, or the blackmailer could

threaten to use such material. The perpetrator would not even have to have the
material to attempt such an ÔattackÕ. An intent to commit a radiological attack that
does not materialise differs from all other potential scenarios in that there is no ac-
tual radiological impact. The motivation could be financial benefit, extortion, black-
mail, or to create physical or psychological harm. Nevertheless, if the threat is
considered serious enough, this situation is in itself a radiation emergency, which re-
quires special provisions to identify, classify, and assess the situation as well as to
respond in order to prevent and/or minimise the potential impact of the act should
it occur. If information or intelligence on intent is available, the responsible author-
ities should be prepared to implement the preplanned measures.

A.2. Unannounced events

(A2) Some scenarios for a radiological attack are based upon a covert exposure or
dispersal of radioactive material. The first indication that an event has materialised
may be people reporting to hospital with symptoms of radiation illness, burns, or
other symptoms. Therefore, medical planning should include information for physi-
cians and facilities on radiation exposure symptoms, and the establishment of an
effective and centralised monitoring network that is aware of the need for early
reporting of any patient suffering from injuries that may have been caused by expo-
sure to ionising radiation.

A.3. Thefts

(A3) Radioactive material may be stolen, either for a perceived financial benefit or
as a possible precursor to a malicious attack. In any case, these acts should be as-
sessed to determine if they might represent a credible threat and, if so, increase pre-
paredness and/or plan a response to apprehend the perpetrators before a malicious
attack (IAEA, 2002d). Public announcements of the hazard of dangerous sources
may sometimes lead to intelligence resulting in retrieval of the stolen sources. It
should be mentioned that public announcements may also produce anxiety and that
authorities should be prepared. It should be kept in mind that it is equally possible
that quasi ÔlegitimateÕ businesses might be established and radioactive material thus
obtained and used maliciously.

A.4. Radiation exposure devices

(A4) Unsecured radiation sources can be used to perpetrate a deliberate act to

irradiate a person or persons. This type of emergency may focus upon a single indi-
vidual, a target group, or it may be designed to attack individuals at random. The
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 ICRP Publication 96

possibilities may include, for example, concealing an unshielded radioactive source

in the clothing, luggage, home, workplace, or vehicle of target individuals or in a
place frequented by the public or on public transport. The main consequences of
such a malicious act include: fatalities or casualties suffering from the effects of radi-
ation exposure; possible radioactive contamination of the location where the radio-
active materials were concealed; and the generation of public fear leading to the
disruption of the economic, transport, and medical infrastructures.

A.5. Radioactive dispersion devices

(A5) The detonation of conventional explosives shrouding an ordinary radioactive

source, such as those commonly used in medicine and industry, has been dubbed in
the press as a Ôdirty bombÕ, but may be more properly referred to as an RDD. Fur-
thermore, the dispersion of radioactive material into the environment may be
achieved without explosives, by opening the source container if the material is dis-
persible, or processing the source to make it dispersible.
(A6) The main hazard from an explosive RDD is from the direct effects of the
blast. The consequences that are directly due to the explosive nature of the RDD in-
clude: buildings collapsing and trapping people; fire in the immediate vicinity of the
explosion; dead or injured people from the effects of the blast and from fragmenta-
tion; and disruption to power, gas, and water supplies and communication links
within the immediate area. The main radiological consequences are likely to be inha-
lation or inadvertent ingestion of radioactive contamination within the immediate
environs of the incident, and the possibility of direct exposure from fragments of
the source remaining in the immediate vicinity of the explosion. In fact, in most
cases, the radioactive material will be in the immediate vicinity of the explosion,
so direct exposure from the remaining source and source fragments will be important
pathways. Downwind, people, vehicles, and other objects in the immediate vicinity
may become contaminated with radioactive materials and there is the possibility that
contamination may spread beyond the immediate area. The radiological conse-
quences can be extremely variable depending on the nature and amount of the radio-
nuclides involved. In comparison with conventional bomb attacks, there are
additional hazards for emergency response personnel, who may be irradiated or con-
taminated with radioactive materials unless they are equipped with radiation detec-
tion equipment to warn them of the radiological hazards.

A.6. Site-specific radioactive contamination

(A7) Another scenario is a deliberate act to contaminate a specific site or environ-

ment with radioactive materials. The consequences of such an event may include: the
long-term loss of use of the site, facility, or businesses; disruption of key infrastruc-
tures; and widespread public alarm or distress. The culprits may attempt to use
radioactive materials in such a way that it becomes impossible to recover the use
of the site without demolition and removal of building debris. Possible methods in-
clude: the introduction of radioactive materials into air-conditioning systems or ven-
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tilation systems; the use of a vehicle to transport a ÔleakingÕ container which streams
radioactive materials behind the vehicle; and the use of a high-rise building to dis-
perse radioactive materials into the air, using normal air currents to disperse the
materials.
(A8) As demonstrated by the accident in Goiânia, Brazil (IAEA, 1988), the disper-
sion of even a relatively limited amount of radioactive material can lead to significant
contamination of an area. The main radiological consequences may include: wide-
spread radioactive contamination of the site; fatalities or casualties suffering from
exposure to radiation, especially if the situation is not immediately recognised or
people intake significant quantities of radioactive materials; and movement of peo-
ple, objects, or vehicles contaminated with radioactive materials away from the site,
causing spread of radioactive contamination.

A.7. Radioactive contamination of food and water supplies

(A9) Yet another scenario for a radiological attack is the contamination of food or
water supplies with radioactive materials. This centres the attack on the ingestion
pathway, where the aims may be to: expose the public who consume the contami-
nated food or drink the contaminated water; stop the provision of food or water sup-
plies to the public; and cause widespread distress and public alarm. The radiological
consequences may include: contamination of water treatment plants, service reser-
voirs, header tanks, and water supply systems; contamination of food products,
wholesale food markets, supermarkets, or food-processing facilities; and the loss
or disruption of the water and/or food supply chain. Examples of this scenario using
chemicals rather than radiation include the contamination of the pharmaceutical
product Tylenol – in 1982, seven people in the Chicago area died after taking Tylenol
capsules that had been deliberately contaminated with cyanide (Wolnik et al., 1984).
The occurrence of immediate fatalities or casualties suffering from the effects of radi-
ation exposure via the ingestion pathway is very unlikely since extremely large
amounts of radioactive material would be required to achieve sufficiently high con-
centrations and, even if this were to occur, it is very unlikely that it would affect a
large number of people.

A.8. Attacking nuclear facilities

(A10) An important scenario is an attack on, or sabotage of, safety-related sys-

tems at nuclear facilities holding large inventories of radioactive materials, including
nuclear fission and activation products and radioactive wastes. A well-planned at-
tack on these types of facilities, which encompass nuclear power plants, research
reactors, nuclear-fuel reprocessing plants, and radioactive waste management instal-
lations, may conceivably result in significant discharges of radioactive materials into
the environment. Moreover, if the attack disrupts a facility that is able to sustain a
nuclear reaction, an uncontrolled release of energy could conceivably occur, which
can lead to significant discharges of fission products. It should be noted, however,
that sophisticated safety systems are usually in place at these facilities to prevent
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radioactive discharges into the environment even following serious accidents. In par-
ticular, nuclear power and research reactors as well as other fuel cycle facilities used
in civilian applications usually have emergency systems in place to prevent radioac-
tive discharges during an accident, which can greatly reduce the potential for radio-
active effluents to be released outside the facility in case of an attack.
(A11) The Commission presumes that any operating nuclear installation has in
place both: (i) strict security measures that would make a successful radiological at-
tack unlikely; and (ii) radiation emergency arrangements that are based on its previ-
ous ad-hoc recommendations (ICRP, 1991b). The technicalities of the radiation
emergency at such facilities may not differ substantially from that expected and
planned for as part of their existing emergency response.

A.9. Improvised nuclear devices

(A12) Finally, an extreme but possible scenario is the diversion of nuclear materi-
als, particularly special fissionable materials6 (such as 235U and 239Pu), and the devel-
opment, construction, and use of a crude nuclear weapon, usually known as an IND.
Even if the IND yield were low, the blast would have devastating consequences.
Moreover, such an event would scatter massive amounts of radioactive fission prod-
ucts into the environment. Significantly, a low-yield IND will disperse the unburned
fissile material.

6
Special fissionable material includes: plutonium, except that with isotopic concentration exceeding
80% in 238Pu; 233U; and uranium enriched in the isotope 235 or 233.

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 ANNEX B: MEDICAL ISSUES

B.1. Planning for public health and medical intervention

B.1.1. Threat of a radiological attack

(B1) Planning the medical response to the threat of a radiological attack is no dif-
ferent than for other types of attack, e.g. chemical or biological attack. In particular,
the standard procedures for managing persons accidentally contaminated with
radionuclides are applicable (NCRP, 1980). Depending on the planning arrange-
ments made by local authorities, medical facilities may receive a notice that some
type of threat has been made so that they can be prepared if the event actually oc-
curs. As long as the threat has not materialised, special medical provisions may not
be needed.

B.1.2. Unannounced events

(B2) Some scenarios for a radiological attack are based upon a covert exposure or
dispersal of radioactive material. The first indication that a covert radiological attack
has occurred may be people reporting to hospital with symptoms of radiation illness,
burns, or other symptoms. Therefore, medical planning should include advance
information to physicians and facilities on radiation health effects so that symptoms
of high radiation exposure can be recognised and proper treatment given. It is essen-
tial that efficient notification arrangements are in place so that a general response can
be initiated rapidly to prevent further exposure. There may also be a need for the
establishment of an effective and centralised monitoring network for the early report-
ing of any patient suffering from injuries that may have been caused by exposure to
ionising radiation.

B.1.3. Irradiation

(B3) The most challenging situation, from a medical perspective, is the possibil-
ity that a very large number of people may have been unknowingly exposed to ion-
ising radiation and that radioactive material may be dispersed throughout the
population. If the identities of the potentially exposed individuals are known,
and if the number is small, existing national medical infrastructures for dealing
with radiological or nuclear emergencies should be sufficient. However, the number
of potentially exposed individuals may overwhelm the existing capabilities and
there may be a need to screen large segments of the population. Furthermore,
the public distress generated by the news could overwhelm the existing infrastruc-
ture. Part of the challenge comes from the fact that many prodromal symptoms of
high radiation overexposure are the same as those of conventional illness, such as
nausea and diarrhoea. For low radiation exposures, no physical symptoms will be
present, potentially leading everyone to believe that they have been exposed. Plan-
ning efforts must, therefore, recognise the need: (i) to establish a national network
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of institutions with various degrees of capabilities in the identification and treat-

ment of overexposed individuals; (ii) to co-operate closely with radiological experts
to set up a system of contamination monitoring for a large number of potentially
contaminated people; (iii) for mass triage procedures for potentially overexposed
individuals; (iv) for all medical specialists to speak with a harmonised voice regard-
ing the potential health impacts; (v) to co-operate with media organisations to in-
form people on what to do and where to go so that the medical infrastructure is
properly utilised; and (vi) to avert mass panic.

B.1.4. Contamination of food and water supplies

(B4) This type of event is unlikely to lead to significant internal contamination

of a large number of people due to the enormous quantities of radioactive mate-
rial that would be required to reach high levels of contamination in mass-
produced or distributed supplies. However, as past experience has demonstrated
(e.g. cyanide contamination of extra-strength Tylenol, 1982), public concern gen-
erated by such an act could present a significant challenge to the authorities.
Although it is unlikely (although not impossible) that there would be a need
for emergency monitoring of a large number of people for internal contamination,
there is a need to co-operate with radiological experts and media specialists to
quickly assess the potential medical impact of such acts and provide public infor-
mation to alleviate fears in the potentially affected public. There is also a need to
develop a plan, at national level, to monitor a representative sample of the poten-
tially affected population to confirm the health risk assessment and reassure the
public.

B.1.5. Radioactive dispersion devices

(B5) This type of emergency could occur anywhere, and it is necessary to have a
national network of medical services capable of dealing with the radiological nature
of this type of event. In addition, plans must recognise the security aspects of the
emergency and the need to work in close co-operation with security forces. However,
this is not fundamentally different from the type of planning required to deal with
any conventional accident involving explosive and/or chemical hazards, be they of
an accidental or criminal nature.

B.1.6. Attack upon a nuclear facility

(B6) Assuming that medical planning and preparedness measures have been made
for response to nuclear facility emergencies, this type of event should not require any
substantive additional planning. Although the cause may be different (deliberate vs
random accident), the medical consequences would be roughly the same as those that
should be envisaged in the existing plans.

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 Table B.1. Prodromal phase of acute radiation syndrome
Symptoms and ARS degree and the approximate
medical response dose of acute WBE (mSv)
Mild (1000–2000) Moderate (2000–4000) Severe (4000–6000) Very severe (6000–8000) Lethal* (>8000)
Vomiting
Onset 2 h after exposure or later 1–2 h after exposure Earlier than 1 h Earlier than 30 min after Earlier than 10 min after
after exposure exposure exposure
% of incidence 10–50 70–90 100 100 100
Diarrhoea None None Mild Heavy Heavy
Onset – – 3–8 h 1–3 h Less than 1 h
% of incidence – – <10 >10 Almost 100

ICRP Publication 96
Headache Slight Mild Moderate Severe Severe
Onset – – 4–24 h 3–4 h 1–2 h
% of incidence – – 50 80 80–90
91

Consciousness Unaffected Unaffected Unaffected May be altered Unconsciousness (may

last seconds/minutes)
Onset – – – – Seconds/minutes
% of incidence – – – – 100 (at >50 Sy)
Body temperature Normal Increased Fever High fever High fever
Onset – 1–3 h 1–2 h <1 h <1 h
% of incidence – 10–80 80–100 100 100
Medical response Outpatient observation Observation in general Treatment in Treatment in specialised Palliative treatment
hospital, treatment in specialised hospital hospital (symptomatic only)
specialised hospital if
needed
ARS, acute radiation syndrome; WBE, whole body exposure.
* With appropriate supportive therapy, individuals may survive for 6–12 months with whole body doses as high as 12,000 mSv.
 ICRP Publication 96

Table B.2. Change of lymphocyte counts in the initial days of acute radiation syndrome (ARS) depending
on the dose of acute whole body exposure
Degree of ARS Dose (mSv) Lymphocyte counts (109/l) after 6 days since first exposure
Preclinical phase 100–1000 1.5–2.5*
Mild 1000–2000 0.7–1.5
Moderate 2000–4000 0.5–0.8
Severe 4000–6000 0.3–0.5
Very severe 6000–8000 0.1–0.3
Lethal >8000 0.0–0.05
* Values in this range can be normal and do not necessarily indicate radiation exposure.

B.2. Relevant information for immediate medical prognosis and initial treatment of
radiation effects attributable to external radiation

(B7) This section presents relevant information for immediate medical prognosis
and treatment of the effects from external radiation that may arise from a radiolog-
ical attack. Although this type of information should correctly be presented in terms
of the absorbed dose and therefore expressed in grays, following the considerations
in Paragraph e of the Executive Summary, doses in the following tables will be ex-
pressed as whole body doses in millisieverts for purposes of simplification. It should
be noted that this simplification does not present serious problems in cases of low-
LET radiation, such as gamma and beta radiation. However, if high-LET external
radiation is involved, such as in an IND, the information in the tables is not appli-
cable. Table B.1 presents the prodromal phase of acute radiation syndrome; Table
B.2 presents the change of lymphocyte counts in the initial days of acute radiation
syndrome depending on the dose of acute whole body exposure; Table B.3 presents
the latent phase of acute radiation syndrome; Table B.4 presents the findings of the
critical phase of acute radiation syndrome following whole body exposure; Table B.5
presents the principal therapeutic measures for acute radiation syndrome according
to degree; and Table B.6 presents the time of onset of clinical signs of skin injury
depending on the dose received (adapted from IAEA, 1998d).

B.3. Therapies for internal contamination

(B8) The procedures recommended for the treatment of people with acute inter-
nally deposited radioactive materials are intended to reduce the radiation dose
and hence the risk of possible future effects which might alter their health. These
aims can be accomplished by the use of two general processes: (i) reduction of
absorption and internal deposition; and (ii) enhanced elimination or excretion of
incorporated radionuclides. Both are more effective when commenced as soon as
possible after exposure. Therefore, the most important considerations in treatment
are selection of the proper drug for the given radionuclide, and timely administration
after exposure. Depending upon the radionuclides used in case of a radiological at-
tack, the main available medical procedures include: (i) blocking, diluting, and dis-
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 Table B.3. Latent phase of acute radiation syndrome
Degree of ARS and approximate dose of acute WBE (mSv)
Mild (1000–2000) Moderate (2000–4000) Severe (4000–6000) Very severe (6000–8000) Lethal (>8000)

ICRP Publication 96
Lymphocytes (109/l) 0.8–1.5 0.5–0.8 0.3–0.5 0.1–0.3 0.0–0.1
(days 3–6)
Granulocytes (109/l) >2.0 1.5–2.0 1.0–1.5 60.5 60.1
93

Diarrhoea None None Rare Appears on days 6–9 Appears on days 4–5
Epilation None Moderate, beginning Moderate, beginning on Complete earlier than Complete earlier than
on day 15 or later day 11–21 day 11 day 10
Latency period (days) 21–35 18–28 8–18 7 or less None
Medical response Hospitalisation not Hospitalisation Hospitalisation Hospitalisation urgently Symptomatic treatment
necessary recommended necessary necessary only
ARS, acute radiation syndrome; WBE, whole body exposure.
 Table B.4. Findings of critical phase of acute radiation syndrome (ARS) following whole body exposure (WBE)
Degree of ARS and approximate dose of acute WBE (mSv)
Mild (1000–2000) Moderate (2000–4000) Severe (4000–6000) Very severe (6000–8000) Lethal (>8000)
Onset of symptoms >30 days 18–28 days 8–18 days <7 days <3 days
Lymphocytes (109/l) 0.8–1.5 0.5–0.8 0.3–0.5 0.1–0.3 0.0–0.1
Platelets (109/l)

ICRP Publication 96
60–100 30–60 25–35 15–25 <20
10–25% 25–40% 40–80% 60–80% 80–100%*
Clinical manifestations Fatigue, weakness Fever, infections, High fever, infections, High fever, diarrhoea, High fever, diarrhoea,
bleeding, weakness, bleeding, epilation vomiting, dizziness and unconsciousness
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epilation disorientation,
hypotension
Lethality (%) 0 0–50 20–70 50–100 100
Onset 6–8 weeks Onset 4–8 weeks Onset 1–2 weeks 1–2 weeks
Medical response Prophylactic Special prophylactic Special prophylactic Special treatment from Symptomatic only
treatment from days 14– treatment from days the first day; isolation
20; isolation from days 7–10; isolation from the from the beginning
10–20 beginning
* In very severe cases, with a dose >50,000 mSv, death precedes cytopenia.
 Table B.5. Principal therapeutic measures for acute radiation syndrome according to degree of severity

Whole body dose 1000-2000 2000-4000 4000-6000 6000-8000 >8000

(mSv)
Degree of severity of Mild Moderate Severe Very severe Lethal
ARS
Medical Outpatient
management observation for
Hospitalisation and treatment; isolation as early as possible
maximum of one
month

ICRP Publication 96
G-CSF or GM-CSF as early as possible (or IL-3 and GM-CSF
within the first week)
95

Antibiotics of broad spectrum activity (from the end of the latent period), antifungal and
antiviral preparations (when necessary)
Blood components transfusion: platelets, erythrocytes (when necessary)
Complete parenteral nutrition (first week) Metabolism correction,
detoxication (when necessary)
HLA-identical Symptomatic
allogene BMT* (first therapy only
week)

BMT, bone marrow transplantation; G-CSF, granulocyte-colony stimulating factor; GM-CSF, granulocyte macrophage-colony stimulating factor; IL-3:
interleukin 3.
* See further discussion of bone marrow transplant in the following section.
 ICRP Publication 96

Table B.6. Onset time of clinical signs of skin injury depending on the dose received
Stage/symptoms Dose range (mSv) Time of onset (days)
Erythaema 3000–10,000 14–21
Epilation >3000 14–18
Dry desquamation 8000–12,000 25–30
Moist desquamation 15,000–20,000 20–28
Blister formation 15,000–25,000 15–25
Ulceration (within skin) >20,000 14–21
Necrosis (deeper penetration) >25,000 >21

placement agents; (ii) reduction of gastrointestinal absorption; and (iii) mobilising

agents. A list and a brief description of the principal therapeutic agents used in these
procedures are provided below. With the exception of KI, these therapies should be
given under the direction of a physician and based on individual patient
circumstances.

B.3.1. Blocking, diluting, and displacement agents

Stable iodine
(B9) A blocking agent saturates the metabolic process in a specific tissue with a
stable element, thereby reducing the uptake of the radionuclide. Administration of
stable iodine is a practical measure for preventing or reducing the uptake of inhaled
and/or ingested radioactive isotopes of iodine; it is described as a protection of the
public in Chapter 5. After an intake of radioactive iodine, the concentration in the
thyroid reaches 50% of the maximum within about 6 h and the maximum in 1–2 days
in a healthy adult. Thus, to obtain the maximum reduction of the radiation dose to
the thyroid, stable iodine should be administered before any intake of radioactive io-
dine or as soon as practicable thereafter. If stable iodine is administered within the 6
h preceding the intake of radioactive iodine, the protection provided is about 98%; it
is about 90% if stable iodine is administered at the time of uptake. Its efficiency de-
creases with time elapsed since uptake, but radioactive iodine in thyroid can still be
reduced to about 50% if stable iodine is administered within 4–6 h after inhalation. A
single iodine tablet provides efficient protection for about 36 h after its administra-
tion. In most cases of an attack, it will be difficult to anticipate and perform a dis-
tribution of iodine tablets before the malicious contamination of the environment;
this is why the decision to distribute the prophylactic drug and its distribution should
be done as quickly as feasible. Difficulties to meet these obligations are directly re-
lated to the number and geographic distribution of people who need to be treated.
The decision regarding whether and how stable iodine should be made available is
one that has to be taken at the stage of developing emergency plans. Nevertheless,
it should be recognised that, contrary to emergency plans in case of an accident
occurring in a nuclear installation, the identification of the population at risk of a
radiological attack will be very difficult and subject to large uncertainties; these
parameters will make any attempt to distribute stable iodine to large populations
after a malicious attack highly problematic, except if the target of the attack is a
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nuclear installation or an IND. This is why national authorities should consider

other means of protection, such as evacuation or sheltering.
(B10) The recommended dosage of stable iodine to adult members of the public is
a single dose of 100 mg (which corresponds to 130 mg of KI or 170 mg of potassium
iodate); this dosage should be reduced to 50 mg for pregnant women and children
between 3 and 12 years of age, and to 25 mg for children under 3 years of age.
The risks associated with the administration of stable iodine to members of the pub-
lic in a single dose of 100 mg are very small in countries with a high dietary iodine
intake, but increase in countries and areas where there is marked iodine deficiency
in the diet. The risk of side effects is relatively small to the very young, whilst it is
somewhat higher for the elderly.
(B11) Intervention levels for the administration of stable iodine are discussed in
Chapter 5. The Commission states that this intervention will almost always be justi-
fied when a dose of 500 mSv (or more) to the thyroid will be averted, and adds that
an optimised level will be lower but not more than a factor of 10, i.e. 50 mSv. The
BSS recommend an optimised intervention level corresponding to an equivalent dose
of 100 mSv. Anyhow, these two recommendations are generally coherent. This re-
port uses the 100-mSv level as its recommended guidance.

Dilution, displacement
(B12) Isotopic dilution is achieved by the administration of large quantities of the
stable element that corresponds chemically to the radioactive element, e.g. a high
level of water uptake that will increase the excretion of tritium. Displacement
therapy is a special form of dilution therapy in which a non-radioactive element
of a different atomic number successfully competes with the radionuclide for uptake
sites. An example of a displacement agent is the administration of calcium to
increase the urinary excretion of radioactive strontium. It is unlikely that these
therapeutic means will be of significant use in case of a radiological attack given
the radionuclides that are expected.

B.3.2. Reduction of gastrointestinal absorption

Prussian blue
(B13) Gastrointestinal absorption can be reduced either by washing out or by
the use of medications selected for specific radionuclides. These medications com-
bine with the radionuclides so that absorption from the gastrointestinal tract is re-
duced and the radionuclides are eliminated in stools. One simple method is
stomach lavage, which may be useful when, in an exceptional circumstance, an oral
intake of a radionuclide is still in the stomach and would result into high doses.
Ferric ferrocyanide, commonly named Prussian blue, is effective in accelerating
the removal of caesium. Orally administered, Prussian blue traps caesium in the
gut, interrupts its re-absorption from the gastrointestinal tract, and thereby in-
creases faecal excretion. Prussian blue is essentially non-absorbed from the gastro-
intestinal tract and has low toxicity. Classical dosages of 3 g/day of Prussian blue
can reduce the biological half-time of 137Cs by a factor of 2–3. Prussian blue was
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used in the Goiânia accident in Brazil (1987) where several people ingested fatal
and near-fatal levels of 137Cs. This therapy is not usually recommended for those
who have had intakes <1 ALI and is usually recommended for those with intakes
>10 ALI. Prussian blue was not used for the general population in villages around
Chernobyl that were contaminated by caesium. In that case, the lifetime popula-
tion dose was estimated to be over 90% from external radiation due to caesium
on the ground. Once food and water supplies were controlled, the lifetime dose
to the general population from internal contamination was only of the order of
1–2%. Even if the general population had been treated with Prussian blue for
the first 4 years post exposure, this would have reduced final exposure by less than
1%. Another problem with the use of Prussian blue for the general public with very
low intakes of caesium is that, at the present time, there is an insufficient global
supply of Prussian blue.

B.3.3. Chelating agents

(B14) Mobilising agents are compounds that increase the natural turnover pro-
cess, thereby effectively eliminating radionuclides from body tissues. These agents
are more effective when given soon after exposure, but some still produce an effect
if given within a few days. Chelating agents may be considered to be a special class
of mobilising agents. Chelation is a process by which organic compounds (ligands)
exchange less firmly bonded ions for other inorganic compounds to form a rela-
tively stable non-ionised ring complex. This soluble complex is excreted readily
by the kidneys. A properly selected and administered chelating drug will therefore
enhance the excretion of some specific radionuclides and thus reduce their resi-
dence times in the organism. Since chelating agents cannot penetrate into cells,
their use is most effective when treatment is commenced immediately after expo-
sure, while the radioactive material ions are still in circulation and before their
incorporation within cells in target organs, such as bone and liver. DTPA is the
most common form of chelating agent used in man, and has shown its effectiveness
in the treatment of contamination by transuranics, such as plutonium, americium,
and curium.

Diethylenetriaminepentaaceticacid (Ca-DTPA)
(B15) The calcium salt of diethylenetriaminepentaacetate (Ca-DTPA) is the
most available form of DTPA. With repeat dosing, Ca-DTPA may deplete the
body of zinc and, to a lesser extent, manganese and other trace elements. Zn-
DTPA is the analogous zinc salt. Ca-DTPA and Zn-DTPA treatments are effica-
cious for treatment of internal contamination with soluble plutonium salts, such
as the nitrates or chlorides (if in a pure chemical form), if treatment is instituted
within several hours of intake. Doses can be reduced by up to 80%. These treat-
ments are, however, ineffective in treating patients contaminated with highly insol-
uble compounds such as the high-fired oxides, or if the radioactive contamination
is associated with other dusts. Prolonged treatment of people internally contami-
nated with poorly soluble plutonium often results in dose reductions of less than
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20%. Ca-DTPA is thought to be more effective than Zn-DTPA for initial chela-
tion of transuranics; therefore, Ca-DTPA should be used, especially in the initial
phase, whenever larger intakes of transuranics are involved, unless contraindi-
cated. Approximately 24 h after exposure, Zn-DTPA is as effective as Ca-DTPA.
This comparable efficacy, coupled with its lesser toxicity, makes Zn-DTPA the
preferred agent for protracted therapy. Ca-DTPA is contra-indicated for children,
pregnant women, and patients with nephrotic syndrome or bone marrow depres-
sion. Zn-DTPA, if clinically indicated, could be administered to children and
pregnant women in all trimesters, although insufficient data exist for both popu-
lations. As with Prussian blue, DTPA therapy is not advised for the general pub-
lic with low or unspecified intakes. It is usually recommended for those with
intakes >10 ALI and not for those with intakes of <1 ALI; between these values,
there is a discretionary element where different actions may be taken depending
on age, health, and likely efficacy of treatment. In most scenarios involving a
radiological attack, the transuranics are likely to be in poorly soluble form. Also,
at the present time, there is an insufficient global supply of Ca-DTPA and Zn-
DTPA to respond to massive malicious events. Furthermore, some countries re-
strict the use of DTPA by limiting it to specified organisations or individuals.
Other countries have yet to authorise DTPA for human use.

Sodium bicarbonate
(B16) Sodium bicarbonate is a useful medical treatment for people exposed to cer-
tain chemical forms of natural, depleted, or enriched uranium. Treatment with so-
dium bicarbonate produces a uranyl bicarbonate complex in tubular urine that is
less nephrotoxic; this complex is stable in biological mediums and is eliminated rap-
idly by the kidneys. The chemical form and particle size of a uranium inhalation
exposure are important factors in determining the clinical effectiveness of sodium
bicarbonate treatment, but unless the uranium is enriched 235U, the hazard is more
chemical than radiological. For example, kidney damage, acute tubular necrosis, is
possible from an exposure of about 4 mg of uranium because in the usual acid urine
pH, the UO2þ2 ion binds to kidney tubules. Treatment of exposure to much lower lev-
els of uranium is not warranted.

B.4. Therapies for external exposure

(B17) Medical treatment of patients with acute radiation syndrome starts with
triage and immediate life-saving actions, if necessary. During the first day, treat-
ment of whole body overexposure will be directed at symptoms and an attempt
should be made to estimate the order of magnitude of the exposure and its distri-
bution within the body, since these two parameters will allow a prognosis and,
consequently, the nature of the most appropriate treatment. The dose, although
there are marked inhomogenities in dose distribution in most cases, will provide
a general guidance. The initial dose will be estimated through various means, such
as presenting symptoms and laboratory evaluations (lymphocyte, granulocyte, and
platelet counts). After whole body exposure to doses of 2000–15,000 mSv, bone
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marrow is the first organ that may cause death. Therefore, all efforts will be pri-
marily directed to the restoration of its functions and, in some cases, to provide
appropriate substitutes, such as transfusions of blood cells (essentially platelets
and erythrocytes).

B.4.1. Prevention and treatment of infections

(B18) Whatever the type of treatment, the worse risk to the exposed person is the
development of infections, localised or generalised, due to the loss of immune de-
fences. The patient requires anti-infectious aggressive treatments. Prevention mea-
sures in immunocompromised patients are now well established and apply to these
type of patients. The first step of the treatment is prevention of exogenous infection.
Independently of current prophylactic measures, patient isolation is mandatory. The
second step is the elimination of micro-organisms that normally exist in any patient.
Administration of oral, non-absorbable antibacterials will preserve anaerobic bacte-
ria. Antiviral agents will be prescribed in a prophylactic manner. Routine culturing
of skin, body orifices, urine, and wounds, if existing, will allow prompt treatment
with appropriate antibiotics if a fever develops.

B.4.2. Maintenance of fluid and electrolyte balance

(B19) Whole body exposure to doses in the lethal range will induce a severe mal-
nutrition syndrome. Nutritional and caloric balance should be maintained, without
waiting for the appearance of the first signs of imbalance. Caloric administration
should be progressive and reach a plateau between 2000 and 3000 calories, while
respecting equilibrium between proteins, glucides, and lipids. The volume of hydra-
tion depends on the loss related to diarrhoea, vomiting, gastric aspiration, and pos-
sible drainage. Without appropriate hydration, imbalance may cause the death of
exposed people, e.g. after profuse vomiting or diarrhoea.

B.4.3. Specific treatments of bone marrow depression

(B20) When it can be expected that bone marrow will recover, either because the
dose was not high enough to destroy all immature cells (including stem cells and pro-
genitors) or because some territories of the marrow were protected (shielding of
about 10% of the active bone marrow will allow survival of people with a dose
around the LD50/60), classical transfusions may be sufficient to avoid severe compli-
cations related to the transitory depression. When the bone marrow depression is ex-
pected to last for unacceptable periods of time or is too deep for a spontaneous
recovery, other methods have been used, such as bone marrow transplantation, cyto-
kines, cord blood transplantation, or stem cell transplantation.

Bone marrow transplantation

(B21) Bone marrow transplantation would initially seem to be a logical treatment
when the dose has been sufficiently high to prevent spontaneous recovery. To date,
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survival of patients who have had bone marrow transplants after accidental radia-
tion exposure is less than 5%. Bone marrow transplantation has very limited indica-
tions and only in the dose range >8000 mSv. Success will be highly compromised and
some complications might be unavoidable, such as graft-vs-host disease (GVHD)
which represents a great risk of death even without prevailing complicating associ-
ated parameters. Experience has confirmed that bone marrow transplantation has
very little use in accidental overexposures; however, this may change if late multi-
organ failure and other complications can be overcome.

Cytokines
(B22) Haematopoiesis is controlled by factors that act on growth and differentia-
tion, and allow adaptation of the organism to new situations by consequently mod-
ulating its own response. Some of these factors are well identified and can be
produced by biotechnology in sufficient quantities for their use in the treatment of
aplasia. Granulocyte colony-stimulating factor (G-CSF) and granulocyte-macro-
phage colony-stimulating factor (GM-CSF) increase the rate of haematopoietic
recovery and may obviate the need for a bone marrow transplantation, provided that
some stem cells are still viable. Both factors have been used in radiation accidents
during the past decades, and seemed to have some influence on both the length of
the neutropenia period and the survival time; they have also been used in conjunc-
tion with bone marrow transplantation and seemed to have a favourable influence.
They were often combined with another factor, interleukin-3 (IL-3), which affects the
lymphoid system and acts in synergy with GM-CSF. These three factors have non-
negligible side effects, which include fever, headache, pains, and thrombocytopenia.
Other haematopoietic growth factors are used in patients with bone marrow depres-
sion, including erythropoietin, thrombopoietin, IL-6, IL-11, and a fusion protein
consisting of GM-CSF and IL-3 with a greater specific activity than either cytokine
alone (PIX-321). Recently, the suggestion has been made to couple cytokines with
the infusion of cultured immature cells, rich in stem cells and progenitors. This tech-
nique would allow transplantations with a lesser risk of GVHD and a quicker
ÔtakingÕ of the transplant. However, it should be stressed that, at present, there is
an insufficient supply of these cytokines to respond to multiple mass casualty that
might conceivably occur following a radiological attack. Use of these medications
for radiation-induced neutropenia after an attack would be Ôoff-labelÕ. Their use
would require establishing protocols, institutional oversight, adequate monitoring,
and informed consent procedures or adequate exceptions.

Fetal cord blood transplantation

(B23) The availability of a compatible transplant is often the major problem for
bone marrow transplantation. The relative urgency related to the circumstances
(accident or malicious attack), which prevent any preliminary planning, combined
with unavoidable delays for finding the appropriate transplant may aggravate the sit-
uation. Fetal cord transplant provides the opportunity to escape from these prob-
lems. In addition, human umbilical cord blood is a viable source of stem cells and
progenitor cells; lymphocytes are also mostly immature. The first cord blood
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 ICRP Publication 96

transplantation was performed in 1988. When non-identical human leukocyte anti-

gen (HLA) system transplantations were performed, very few reactions from the
transplant, such as GVHD, were observed; since then, specific cord blood banks
have been developed, which are particularly useful for rare HLA types. This type
of transplantation has been reserved for children, although the number of stem cells
in the transplant was sufficient for adults. The first cord blood transplantation used
to try to save a highly exposed adult was performed in Japan after the Tokai Mura
accident in 1999; the death of the person was not related to this particular treatment,
but to multiple visceral complications and extended skin radiation injuries. His graft
(chromosome XX) was rejected as the patientÕs own bone marrow (chromosome
XY) regenerated.
(B24) Moreover, radiation levels that cause severe marrow damage or failure usu-
ally produce concomitant life-threatening injury to other organs, particularly the
lungs and intestines. Care of patients or casualties who have radiation-induced mar-
row failure is complicated by these other injuries, and patients who recover marrow
function frequently succumb to non-haematological injuries. To date, comparatively
few transplants, if any, have been performed successfully for radiation casualties,
and lethally irradiated patients receiving marrow or cord blood transplants have
not demonstrated improved survival. As transplantation is a high-risk procedure,
transplants should be performed in established transplant centres using donated
marrow or stem cells from matched siblings, matched unrelated donors, or the
best-available cord blood.
(B25) In summary, the role of marrow or stem cell transplantation in contingency
response to radiation injury is currently limited. Due to the resilience of haematopoi-
etic stem cells, the wide distribution of stem cells in the marrow, the ability of
remaining stem cells to repopulate the entire haematopoietic system, and the likeli-
hood of non-uniform radiation in accidental exposure, many individuals in the dose
range of 4–8 Sv may recover haematopoiesis without a marrow transplant. Serious
radiation injury to the lungs and other organs, as well as burns and physical trauma,
will often be of greater consequence than marrow injury. However, marrow trans-
plantation must be available for carefully selected casualties, and its future applica-
bility may change as transplant procedures improve.

B.4.4. Radioprotective agents

(B26) Radioprotective agents have been of interest for both military and cancer
therapy applications. A considerable number of drugs have been tested and Amifos-
tine (EthyolÒ) is considered to be promising. These drugs need to be absorbed prior
to the exposure. They give rise to important side effects such as hypotension, nausea,
and vomiting which severely limits or precludes current use for first responders. Since
there is no clinical evidence that radioprotective agents offer any protection if given
after exposure, they are of no value after a radiological attack has occurred; how-
ever, there is the theoretical possibility that giving the drug might reduce the risks
to life-saving rescuers before they enter an area where they might be exposed to very
high doses.
102
 ANNEX C: PSYCHOLOGICAL ISSUES

(C1) Malicious actions, by definition, strive to provoke severe psychological reac-

tions in the general public. Where radiation releases are concerned, distress will be
common and manifest as sadness, anger, fear, insomnia, impaired ability to concen-
trate, and disbelief. Psychological distress after a radiological incident may also man-
ifest as non-specific somatic complaints (a presentation sometimes referred to as
multiple idiopathic physical symptoms). General healthcare providers should man-
age these people. Some individuals may exhibit behavioural changes such as decreas-
ing travel, staying home, refusing to send children to school, and increasing
substance use and abuse. Fortunately, for the vast majority of people, distress and
psychological and behavioural symptoms related to the traumatic event exposure
will diminish over time.
(C2) For others, however, symptoms will persist, affect function at home and
work, and may result in psychiatric illness. While acute stress disorder and post-trau-
matic stress disorder (PTSD) are the disorders most people think of in connection
with trauma, major depression, increased substance use, family conflict, and gener-
alised anxiety disorder are also encountered.
(C3) It is important to remember that people with no prior history of psychiatric
illness are vulnerable to psychiatric illness after a malicious exposure. In the after-
math of the Oklahoma City bombing, nearly 40% of those who developed PTSD
and depression had no previous psychiatric disorder. People at high risk of develop-
ing psychiatric disorders include: (i) those directly exposed (e.g. people near the blast
and those participating in rescue and recovery operations of people and remains); (ii)
those who were more vulnerable before the event due to existing mental illness; and
(iii) those who suffered resource losses and disruption of their social supports after
the event.
(C4) Following a malicious event, people will likely turn to healthcare providers
for information and guidance. Following the 2001 anthrax attacks, for example,
77% of a representative sample of Americans reported that they would trust their
own doctor most when seeking a reliable source of information. Healthcare provid-
ers would likely play a key role in determining how the general public respond to a
radiological malicious event. A well-organised, effective medical response will instil
hope and confidence, reduce fear and anxiety, and support the continuity of basic
community functions.
(C5) Addressing psychological and behavioural issues following a radiological at-
tack may be far more challenging, in terms of the number of people affected, than
addressing the consequences of radiation exposure in the affected population. Symp-
toms of depression, bereavement, family conflict, and somatisation will be much
more common than PTSD. Increased smoking and increased alcohol use can be ex-
pected, at least in the short term. Sleep disturbance, hypervigilance, decreased con-
centration, and uncertainty are other early symptoms of psychological distress.
People with multiple somatic complaints may have physical illness or they may show
distress, depression, and/or demoralisation.

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 ICRP Publication 96

(C6) Responding to the mental health needs of the community as a whole raises
many challenges. In the immediate aftermath of an event, the affected community
is likely to draw together, but over time, contaminated communities may manifest
anger or reduced cohesiveness, low morale, and decreased social service due to dis-
tress and economic losses. Handouts on stress and fear management techniques and
activities should be prepared for distribution. Contamination of food supplies call
for long-term education and potential health surveillance. Public health outreach
to senior citizens will be important since their distress may heighten their social with-
drawal. Door-to-door contact programmes for this group and those with chronic
medical needs who stay at home will be needed. Establishment of a clinical registry
and appropriate health surveillance may have important psychological benefits for
affected communities. People who have their contact information recorded in a data-
base will feel more assured that follow-up will be available.
(C7) Relocation of families out of zones of exclusion is complicated and requires
particular attention to familial needs and social justice. Maximising the relocation
choices of families is important. Some (perhaps 10%) will not want to move under
any circumstances. Many of those for whom relocation is not recommended will
leave voluntarily. Still others, who might prefer to move, will be unable to do so
due to reasons of employment or an inability to sell their homes in what is likely
to be a depressed housing market. The perception of inequity in these and other mat-
ters will stress social fault lines and may divide communities.

C.1. Communication between care providers and patients

(C8) The imperceptibility of low-level radiation exposures may cause many people
to develop persistent health concerns or to arbitrarily link idiopathic symptoms to
benign or improbable exposures [even under normal circumstances, one-third of pri-
mary care people assist with medically unexplained physical symptoms (e.g. idio-
pathic fatigue and pain)]. Over 90% of the general population will visit their
primary care provider each year, making primary care a crucial setting for dissemi-
nation of accurate health risk information following suspected radiological expo-
sures to the community.
(C9) In the aftermath of a radiation release, primary care providers should make
an effort to determine the degree of exposure suffered by all people visiting their clin-
ics, regardless of the reason. In some circumstances, this determination will be as-
sisted by the use of biodosimetry, but more commonly, it will be based simply on
a personÕs proximity to the event and subsequent location during a critical period
of exposure. Based on this initial primary assessment of exposure, the presence or
absence of symptoms, and the presence or absence of disease (medical and psychiat-
ric), people may be assigned to categories for treatment, follow-up, and education.
Counselling may be provided on risk, symptoms, and/or disease findings. Assessment
for PTSD, depression or anxiety, and altered alcohol or tobacco consumption are
important.
(C10) After a radiation release, it may be useful for primary care clinics to rou-
tinely assess the degree of concern about exposure-related illness, separate from
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 ICRP Publication 96

actual exposures. This process can be facilitated by asking, ÔIs your visit today
related to terrorism or radiation concerns?Õ at the beginning of every visit. People
who respond ÔyesÕ or ÔmaybeÕ to this question or who express concern about expo-
sure-related illness should receive extra primary care assessment to elucidate the
nature of their expectations and goals for the medical visit. These concerns and
expectations can then guide medical triage and the intensity of risk communica-
tion efforts.
(C11) Often the primary care provider will have the most difficulty in communi-
cating with those who are: (i) possibly exposed but unconcerned and with no symp-
toms or disease; or (ii) either exposed or unexposed with a high level of concern
but asymptomatic (no symptoms or disease) or unexplained symptoms. The latter
group is often categorised as having multiple idiopathic physical symptoms. People
who were possibly exposed but who are unconcerned with no symptoms or disease
will deny or neglect personal medical needs. Assuming medical needs are subacute,
information should be entered into a local registry to facilitate follow-up to ensure
that people have attended appropriately to injuries and exposures. Exposed or
unexposed people with high levels of concern but who are asymptomatic will am-
plify concerns and repeatedly resist clinician reassurance. In a mass casualty situ-
ation, these people can disrupt provision of critical medical care; therefore, it may
be helpful to plan for this by dedicating staff and an area to their care. Develop-
ment of a contact registry with dedicated efforts to provide follow-up contact and
care is one way of communicating compassion and concern without succumbing to
risky or unnecessary testing. Research suggests that a negative test offers only tran-
sient reassurance and can sometimes increase illness concerns, especially when sub-
sequent false-positive results occur. Discussing the basis for peopleÕs concerns and
exploring which tests a person thinks he/she might need prevents many people
from feeling that such concerns have been ignored. Time-contingent follow-up
(planned rather than as-needed visits) reduces illness worry, increases satisfaction
with care, and may mitigate downstream litigation conflicts and concerns. As with
asymptomatic, concerned people, people who are either exposed or unexposed with
high levels of concern and unexplained symptoms or people with idiopathic symp-
toms can disrupt delivery of critical medical care. These people may invoke more
clinician anxiety because, unlike the people with isolated concerns, they are often
visibly suffering and their symptoms may sound potentially catastrophic (e.g. chest
pain and sweating).
(C12) In addition to a dedicated area, staffing, contact registry, and intensified pri-
mary care follow-up efforts, intervention for people concerned with unexplained
symptoms should involve brochures, fact sheets, and literature about self-manage-
ment approaches to medically unexplained symptoms. In an acute crisis, it is helpful
to triage these people in an area distinct from the area used to care for acutely ill
individuals, but the area should not be labelled or perceived as a Ôpsychiatric careÕ
area for Ôworried wellÕ people because of the sense of stigmatisation that such labels
generate. People with unexplained symptoms should therefore receive early and
frequent validation from the clinician that symptoms are important and will be
followed-up quickly and carefully.
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C.2. Debriefing

(C13) Physical safety and security of the public and relief workers must take first
priority. After safety is assured, other interventions such as debriefing may begin.
Debriefing is a popular early intervention following disasters, in which small groups
of people involved in the disaster, such as rescue workers, meet in a single lengthy
session to share individual feelings and experiences. Some of these issues might be
considered at the planning stage.

106
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