## 1. What is meant by health risk?

A health risk is generally thought of as something that may endanger health. Scientists consider health risk to be the statistical probability or mathematical chance that personal injury, illness, or death may result from some action. Most people do not think about health risks in terms of mathematics. Instead, most of us consider the health risk of a particular action in terms of whether we believe that particular action will, or will not, cause us some harm. The intent of this appendix is to provide estimates of, and explain the bases for, the risk of injury, illness, or death from occupational radiation exposure. Risk can be quantified in terms of the probability of a health effect per unit of dose received.

When x-rays, gamma rays, and ionizing particles interact with living materials such as our bodies, they may deposit enough energy to cause biological damage. Radiation can cause several different types of events such as the very small physical displacement of molecules, changing a molecule to a different form, or ionization, which is the removal of electrons from atoms and molecules. When the quantity of radiation energy deposited in living tissue is high enough, biological damage can occur as a result of chemical bonds being broken and cells being damaged or killed. These effects can result in observable clinical symptoms.

The basic unit for measuring absorbed radiation is the rad. One rad (0.01 gray in the International System of units) equals the absorption of 100 ergs (a small but measurable amount of energy) in a gram of material such as tissue exposed to radiation. To reflect biological risk, rads must be converted to rems. The new international unit is the sievert (100 rems = 1 Sv). This conversion accounts for the differences in the effectiveness of different types of radiation in causing damage. The rem is used to estimate biological risk. For beta and gamma radiation, a rem is considered equal to a rad.

## 2. What is meant by early effect and delayed or late effects?

Early effects, which are also called immediate or prompt effects, are those that occur shortly after a large exposure that is delivered within hours to a few days. They are observable after receiving a very large dose in a short period of time, for example, 300 rads (3 Gy) received within a few minutes to a few days. Early effects are not caused at the levels of radiation exposure allowed under the Commonwealth's occupational limits.

Early effects occur when the radiation dose is large enough to cause extensive biological damage to cells so that large numbers of cells are killed. For early effects to occur, this radiation dose must be received within a short time period. This type of dose is called an acute dose or acute exposure. The same dose received over a long time period would not cause the same effect. Our body's natural biological processes are constantly repairing damaged cells and replacing dead cells; if the cell damage is spread over time, our body is capable of repairing or replacing some of the damaged cells, reducing the observable adverse conditions.

For example, a dose to the whole body of about 300-500 rads (3-5 Gy), more than 60 times the annual occupational dose limit, if received within a short time period (e.g., a few hours) will cause vomiting and diarrhea within a few hours; loss of hair, fever, and weight loss within a few weeks; and about a 50 percent chance of death if medical treatment is not provided. These effects would not occur if the same dose were accumulated gradually over many weeks or months. Thus, one of the justifications for establishing annual dose limits is to ensure that occupational dose is spread out in time.

It is important to distinguish between whole body and partial body exposure. A localized dose to a small volume of the body would not produce the same effect as a whole body dose of the same magnitude. For example, if only the hand were exposed, the effect would mainly be limited to the skin and underlying tissue of the hand. An acute dose of 400 to 600 rads (4-6 Gy) to the hand would cause skin reddening; recovery would occur over the following months and no long term damage would be expected. An acute dose of this magnitude to the whole body could cause death within a short time without medical treatment. Medical treatment would lessen the magnitude of the effects and the chance of death; however, it would not totally eliminate the effects or the chance of death.

Delayed effects may occur years after exposure. These effects are caused indirectly when the radiation changes parts of the cells in the body, which causes the normal function of the cell to change, for example, normal healthy cells turn into cancer cells. The potential for these delayed health effects is one of the main concerns addressed when setting limits on occupational doses.

A delayed effect of special interest is genetic effects. Genetic effects may occur if there is radiation damage to the cells of the gonads (sperm or eggs). These effects may show up as genetic defects in the children of the exposed individual and succeeding generations. However, if any genetic effects (i.e., effects in addition to the normal expected number) have been caused by radiation, the numbers are too small to have been observed in human populations exposed to radiation. For example, the atomic bomb survivors (from Hiroshima and Nagasaki) have not shown any significant radiation-related increases in genetic defects. Effects have been observed in animal studies conducted at very high levels of exposure and it is known that radiation can cause changes in the genes in cells of the human body. However, it is believed that by maintaining worker exposures below the Commonwealth's limits and consistent with ALARA, a margin of safety is provided such that the risk of genetic effects is almost eliminated.

## 3. What is the difference between acute and chronic radiation dose?

Acute radiation dose usually refers to a large dose of radiation received in a short period of time. Chronic dose refers to the sum of small doses received repeatedly over long time periods, for example, 20 mrem (or millirem, which is 1-thousandth of a rem (0.2 mSv) per week every week for several years. It is assumed for radiation protection purposes that any radiation dose, either acute or chronic, may cause delayed effects. However, only large acute doses cause early effects; chronic doses within the occupational dose limits do not cause early effects. Since the Commonwealth's limits do not permit large acute doses, concern with occupational radiation risk is primarily focused on controlling chronic exposure for which possible delayed effects, such as cancer, are of concern.

The difference between acute and chronic radiation exposure can be shown by using exposure to the sun's rays as an example. An intense exposure to the sun can result in painful burning, peeling, and growing of new skin. However, repeated short exposures provide time for the skin to be repaired between exposures. Whether exposure to the sun's rays is long term or spread over short periods, some of the injury may not be repaired and may eventually result in skin cancer.

Cataracts are an interesting case because they can be caused by both acute and chronic radiation. A certain threshold level of dose to the lens of the eye is required before there is any observable visual impairment, and the impairment remains after the exposure is stopped. The threshold for cataract development from acute exposure is an acute dose of the order of 100 rads (1 Gy). Further, a cumulative dose of 800 rads (8 Gy) from protracted exposures over many years to the lens of the eye has been linked to some level of visual impairment. These doses exceed the amount that may be accumulated by the lens from normal occupational exposure under the current regulations.

## 4. What is meant by external and internal exposure?

A worker's occupational dose may be caused by exposure to radiation that originates outside the body, called 'external exposure', or by exposure to radiation from radioactive material that has been taken into the body, called 'internal exposure." Most licensed activities involve little, if any, internal exposure. It is the current scientific consensus that a rem of radiation dose has the same biological risk regardless of whether it is from an external or an internal source. The Massachusetts Rules for the Control of Radiation (MRCP) requires that dose from external exposure and dose from internal exposure be added together, if each exceeds 10% of the annual limit, and that the total be within occupational limits. The sum of external and internal dose is called the total effective dose equivalent (TEDE) and is expressed in units of rems (Sv).

Although unlikely, radioactive materials may enter the body through breathing, eating, drinking, or open wounds, or they may be absorbed through the skin. The intake of radioactive materials by workers is generally due to breathing contaminated air. Radioactive materials may be present as fine dust or gases in the workplace atmosphere. The surfaces of equipment and workbenches may be contaminated, and these materials can be re-suspended in air during work activities.

If any radioactive material enters the body, the material goes to various organs or is excreted, depending on the biochemistry of the material. Most radioisotopes are excreted from the body in a few days. For example, a fraction of any uranium taken into the body will deposit in the bones, where it remains for a longer time. Uranium is slowly eliminated from the body, mostly by way of the kidneys. Most workers are not exposed to uranium. Radioactive iodine is preferentially deposited in the thyroid gland, which is located in the neck.

To limit risk to specific organs and the total body, an annual limit on intake (ALI) has been established for each radionuclide. When more than one radionuclide is involved, the intake amount of each radionuclide is reduced proportionally. Massachusetts regulations specify the concentrations of radioactive material in the air for which a worker may be exposed for 2,000 working hours in a year [ref. 105 CMR 120.296: Appendix B]. These concentrations are termed the derived air concentrations (DACs). These limits are the total amounts allowed if no external radiation is received. The resulting dose from the internal radiation sources (from breathing air at 1 DAC) is the maximum allowed to an organ or to the worker's whole body.

## 5. How does radiation cause cancer?

The mechanisms of radiation-induced cancer are not completely understood. When radiation interacts with the cells of our bodies, a number of events can occur. The damaged cells can repair themselves and permanent damage is not caused. The cells can die, much like the large numbers of cells that die every day in our bodies, and be replaced through the normal biological processes. Or a change can occur in the cell's reproductive structure, the cells can mutate and subsequently be repaired without effect, or they can form precancerous cells, which may become cancerous. Radiation is only one of many agents with the potential for causing cancer, and cancer caused by radiation cannot be distinguished from cancer attributable to any other cause.

Radiobiologists have studied the relationship between large doses of radiation and cancer. These studies indicate that damage or change to genes in the cell nucleus is the main cause of radiation induced cancer. This damage may occur directly through the interaction of the ionizing radiation in the cell or indirectly through the actions of chemical products produced by radiation interactions within cells. Cells are able to repair most damage within hours; however, some cells may not be repaired properly. Such improperly repaired damage is thought to be the origin of cancer however improper repair does not always cause cancer. Some cell changes are benign or the cell may die; these changes do not lead to cancer.

Many factors such as age, general health, inherited traits, sex, as well as exposure to other cancer causing agents such as cigarette smoke can affect susceptibility to the cancer-causing effects of radiation. Many diseases are caused by the interaction of several factors, and these interactions appear to increase the susceptibility to cancer.

## 6. What are the estimates of the risk of fatal cancer from radiation exposure?

We don't know exactly what the chances are of getting cancer from a low-level radiation dose, primarily because the few effects that may occur cannot be distinguished from normally occurring cancers. However, we can make estimates based on extrapolation from extensive knowledge from scientific research on high dose effects. The estimates of radiation effects at high doses are better known than are those of most chemical carcinogens.

From currently available data, the U.S. Nuclear Regulatory Commission (NRC) has adopted a risk value for an occupational dose of 1 rem (0.01 Sv) Total Effective Dose Equivalent (TEDE) of 4 in 10,000 of developing a fatal cancer, or approximately 1 chance in 2,500 of fatal cancer per rem of TEDE received. The uncertainty associated [1]with this risk estimate does not rule out the possibility of higher risk, or the possibility that the risk may even be zero at low occupational doses and dose rates.

The radiation risk incurred by a worker depends on the amount of dose received. Under the linear model explained above, a worker who receives 5 rems (0.05 Sv) in a year incurs 10 times as much risk as another worker who receives only 0.5 rem (0.005 Sv). Only a very few workers receive doses near 5 rems (0.05 Sv) per year.

According to a report by the National Research Council titled "Health Effects of Exposure to Low Levels of Ionizing Radiation" (commonly called the BEIR V) report, approximately one in five adults normally will die from cancer from all possible causes such as smoking, food, alcohol, drugs, air pollutants, natural background radiation, and inherited traits. Thus, in any group of 10,000 workers, we can estimate that about 2,000 (20%) will die from cancer without any occupational radiation exposure.

To explain the significance of these estimates, we will use as an example a group of 10,000 people, each exposed to 1 rem (0. 0 1 Sv) of ionizing radiation. Using the risk factor of 4 effects per 10,000 rem of dose, we estimate that 4 of the 10,000 people might die from delayed cancer because of that 1-rem dose (although the actual number could be more or less than 4) in addition to the 2,000 normal cancer fatalities expected to occur in that group from all other causes. This means that a 1-rem (0.01 Sv) dose may increase an individual worker's chances of dying from cancer from 20 percent to 20.04 percent. If one's lifetime occupational dose is 10 rems, we could raise the estimate to 20.4 percent. A lifetime dose of 100 rems may increase chances of dying from cancer from 20 to 24 percent. The average measurable dose for radiation workers reported to the NRC was 0.31 rem (0.0031 Sv) for 1993. Today, very few workers ever accumulate 100 rems (1 Sv) in a working lifetime, and the average career dose of workers at NRC-licensed facilities is 1.5 rems (0.015 Sv), which represents an estimated increase from 20 to about 20.06 percent in the risk of dying from cancer.

The normal chance of dying from cancer is about one in five for persons who have not received any occupational radiation dose. The additional chance of developing fatal cancer from an occupational exposure of 1 rem (0. 0 1 Sv) is about the same as the chance of drawing any ace from a full deck of cards three times in a row. The additional chance of dying from cancer from an occupational exposure of 10 rem (0.1 Sv) is about equal to your chance of drawing two aces successively on the first two draws from a full deck of cards.

It is important to realize that these risk numbers are only estimates based on data for people and research animals exposed to high levels of radiation in short periods of time. There is still uncertainty with regard to estimates of radiation risk from low levels of exposure. Many difficulties are involved in designing research studies that can accurately measure the projected small increases in cancer cases that might be caused by low exposures to radiation as compared to the normal rate of cancer.

These estimates are considered by the MA Radiation Control Program (RCP) staff to be the best available for the worker to use to make an informed decision concerning acceptance of the risks associated with exposure to radiation. A worker decides to accept this risk should try to keep exposure to radiation as low as is reasonably achievable (ALARA) to avoid unnecessary risk.

[1]"Health Effects of Exposure to Low Levels of Ionizing Radiation," National Academy Press, 1990.

## 7. How can we compare the risk of cancer from radiation to other kinds of health risks?

One way to make these comparisons is to compare the average number of days of life expectancy lost because of the effects associated with each particular health risk. Estimates are calculated by looking at a large number of persons, recording the age when death occurs from specific causes, and estimating the average number of days of life lost as a result of these early deaths. The total number of days of life lost is then averaged over the total observed group.

Several studies have compared the average days of life lost from exposure to radiation with the number of days lost as a result of being exposed to other health risks. The word "average" is important because an individual who gets cancer loses about 15 years of life expectancy, while his or her coworkers do not suffer any loss.

For categories of NRC-regulated industries with larger doses, the average measurable occupational dose in 1993 was 0.31 rem (0.0031 Sv). A simple calculation based on the article by Cohen and Lee shows that 0.3 rem (0.003 Sv) per year from age 18 to 65 results in an average loss of 15 days. These estimates indicate that the health risks from occupational radiation exposure are smaller than the risks associated with many other events or activities we encounter and accept in normal day-to-day activities.