Executive Summary

Introduction

In 1998, the U.S. Congress requested that the U.S. Department of Health
and Human Services (DHHS) conduct an initial assessment of the
feasibility and public health implications of a detailed study of the
health impact on the American people of radioactive fallout from the
testing of nuclear weapons. In response to the Congressional request,
DHHS (primarily two DHHS agencies---the Centers for Disease Control and
Prevention \[CDC\] and the National Cancer Institute \[NCI\]) made crude
estimates of doses and health risks from exposure to radioactive fallout
from nuclear weapons tests conducted from 1951 through 1962 at the
Nevada Test Site (NTS) and other sites throughout the world ("global"
tests). Those dose and risk estimates, though sufficient for purposes of
the feasibility study, were rudimentary in their nature and precision
and could likely be improved, as discussed in this report.

In developing this assessment, DHHS has actively solicited input from
the public and from the DHHS Advisory Committee for Energy-Related
Epidemiologic Research (ACERER) (the charter for the committee has
expired and it no longer exists) during the initial stages of this
project. Both written and oral progress reports were given to ACERER and
Congressional staff during the course of the project. Copies of written
progress reports were available for public review, and all written and
oral comments received on these progress reports were carefully
considered in the preparation of the draft technical report that was
sent to Congress and posted on the CDC website in 2002.

The draft technical report, titled *A Feasibility Study of the Health
Consequences to the American Population from Nuclear Weapons Tests
Conducted by the United States and Other Nations*, was peer reviewed by
the National Academy of Sciences/National Research Council (NAS/NRC)
Committee to Review the CDC-NCI Feasibility Study of the Health
Consequences from Nuclear Weapons Tests (NAS/NRC 2003). The
recommendations and comments of the NAS/NRC committee were carefully
considered. This final report was prepared in consideration of those
recommendations. A copy of this final report is available on the
Internet at <http://www.cdc.gov/nceh/radiation/>, and a printed copy is
also available from the Radiation Studies Branch, Division of
Environmental Hazards and Health Effects, National Center for
Environmental Health, Centers for Disease Control and Prevention (CDC),
Mail Stop E39, 1600 Clifton Road NE, Atlanta, Georgia 30333.

Findings

**Radiation Dose Estimates.** In this study, for the first time, doses
for representative persons in all counties of the contiguous United
States have been estimated from exposure to the most important
radionuclides produced as a result of nuclear weapons testing from 1951
through 1962 by the United States and other nations. Any person living
in the contiguous United States since 1951 has been exposed to
radioactive fallout, and all organs and tissues of the body have
received some radiation exposure. Doses were estimated separately for
the tests conducted at NTS and the tests conducted at other sites
throughout the world (global testing).

Lifetime dose estimates were calculated separately for external and
internal irradiation. External irradiation results from exposure to
radiation emitted outside of the body, for example, by radionuclides
present on the ground. The corresponding doses are similar in most body
organs and vary little with the age of the person. On the other hand,
internal irradiation results from the decay of radionuclides
incorporated in the body by inhalation or ingestion, with levels of
exposure varying according to age and to the distribution of
radionuclides in the organs and tissues of the body. For example,
radioiodines concentrate in the thyroid gland, whereas radiostrontium is
found mainly in bone tissues.

Because the purpose of the project was only to determine the feasibility
of doing a study, there was no intention in the allowed time to develop
new tools or to gather all data needed to complete an extensive study of
doses to Americans from nuclear weapons tests conducted by the United
States and other nations. Instead, crude dose estimates were made on the
basis of reviewing a limited number of reports in details and using
available dose assessment models. In some cases---particularly for the
doses resulting from the intake of shorter-lived radionuclides (e.g.,
iodine-131) in global fallout---the doses calculated may have
considerable error. Future work would improve the precision of these
calculations.

The usefulness of the doses estimated in this project is limited to
rudimentary evaluations of the average impact on limited health outcomes
for the population of the United States. Because of the low precision of
the dose estimates, they should not be used to estimate health effects
for specific individuals or for subpopulations. The goal of these
calculations was to determine only the feasibility of a study;
therefore, the magnitude of uncertainty of these doses has not been
fully evaluated. However, though the computed county-specific deposition
densities and doses are uncertain, dose maps presented in this report
are useful for illustrating general spatial patterns of fallout exposure
for average individuals across the United States.

A summary of doses averaged over the contiguous United States is
presented in Table 1 as an example of the findings from this study.
Because the thyroid and red bone marrow are among the most
radiosensitive organs and tissues of the body, their doses were selected
as examples for presentation (Table 1). Thyroid cancer, noncancer
thyroid disease, and leukemia, which arises from the red bone marrow,
are the health effects that are discussed in this report.

**Table 1. Summary of average thyroid and red bone marrow doses
(milliGray \[mGy\]) from Nevada Test Site and global fallout received as
a result of exposure to the most important radionuclides.** The values
are for adults at the time of the tests, unless otherwise specified.
Blank spaces reflect negligible values of dose.

<table>
<colgroup>
<col style="width: 22%" />
<col style="width: 11%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 8%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 11%" />
<col style="width: 10%" />
<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td></td>
<td colspan="3"><strong>NTS Fallout</strong></td>
<td colspan="2"></td>
<td colspan="3"><strong>Global Fallout</strong></td>
</tr>
<tr class="even">
<td><strong>Radionuclide</strong></td>
<td><strong>Half-life</strong></td>
<td><p><strong>External dose<em><sup>a</sup></em></strong></p>
<p><strong>(mGy)</strong></p></td>
<td><strong>Thyroid internal dose (mGy)</strong></td>
<td colspan="2"><strong>Red bone marrow internal dose
(mGy)</strong></td>
<td colspan="2"><p><strong>External
dose<em><sup>a</sup></em></strong></p>
<p><strong>(mGy)</strong></p></td>
<td><strong>Thyroid internal dose (mGy)</strong></td>
<td><strong>Red bone marrow internal dose (mGy)</strong></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Tritium</p>
</blockquote></td>
<td>12.3 years</td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td>0.07</td>
<td>0.07</td>
</tr>
<tr class="even">
<td><blockquote>
<p>Carbon-14</p>
</blockquote></td>
<td>5730 years</td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td>0.1</td>
<td>0.1</td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Manganese-54</p>
</blockquote></td>
<td>313 days</td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2">0.04</td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>Strontium-89</p>
</blockquote></td>
<td>52 days</td>
<td></td>
<td>0.001</td>
<td colspan="2">0.03</td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Strontium-90</p>
</blockquote></td>
<td>28.5 years</td>
<td></td>
<td></td>
<td colspan="2">0.02</td>
<td colspan="2"></td>
<td><p>0.0009</p>
<p>[0.002]<em><sup>b</sup></em></p></td>
<td><p>0.2</p>
<p>[0.5]<em><sup>b</sup></em></p></td>
</tr>
<tr class="even">
<td><blockquote>
<p>Zirconium/Niobium-95</p>
</blockquote></td>
<td>64 days</td>
<td>0.08</td>
<td></td>
<td colspan="2"></td>
<td colspan="2">0.2</td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Zirconium/Niobium-97</p>
</blockquote></td>
<td>17 hours</td>
<td>0.02</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>Ruthenium-103</p>
</blockquote></td>
<td>39 days</td>
<td>0.03</td>
<td></td>
<td colspan="2"></td>
<td colspan="2">0.02</td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Ruthenium-106</p>
</blockquote></td>
<td>368 days</td>
<td></td>
<td>0.001</td>
<td colspan="2">0.002</td>
<td colspan="2">0.04</td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>Antimony-125</p>
</blockquote></td>
<td>2.7 years</td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2">0.03</td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Iodine-131</p>
</blockquote></td>
<td>8 days</td>
<td>0.02</td>
<td><p>5</p>
<p>[30]<em><sup>b</sup></em></p></td>
<td colspan="2">0.001</td>
<td colspan="2"></td>
<td><p>0.4</p>
<p>[2]<em><sup>b</sup></em></p></td>
<td><p>0.00009</p>
<p>[0.0002]<em><sup>b</sup></em></p></td>
</tr>
<tr class="even">
<td><blockquote>
<p>Tellurium/iodine-132</p>
</blockquote></td>
<td>3.3 days</td>
<td>0.1</td>
<td>0.06</td>
<td colspan="2">0.001</td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Iodine-133</p>
</blockquote></td>
<td>0.9 days</td>
<td>0.02</td>
<td>0.04</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>Cesium-136</p>
</blockquote></td>
<td>13 days</td>
<td></td>
<td>0.002</td>
<td colspan="2">0.002</td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Cesium-137</p>
</blockquote></td>
<td>30 years</td>
<td>0.01</td>
<td>0.009</td>
<td colspan="2">0.009</td>
<td colspan="2">0.3</td>
<td>0.1</td>
<td>0.1</td>
</tr>
<tr class="even">
<td><blockquote>
<p>Barium/lanthanum-140</p>
</blockquote></td>
<td>13 days</td>
<td>0.2</td>
<td></td>
<td colspan="2">0.006</td>
<td colspan="2">0.05</td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Cerium-144</p>
</blockquote></td>
<td>284 days</td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2">0.02</td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>Neptunium-239</p>
</blockquote></td>
<td>2.4 days</td>
<td>0.02</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Rounded totals:</p>
</blockquote>
<ul>
<li><p>Adults</p></li>
<li><p>Child born 1 January 1951.</p></li>
</ul></td>
<td></td>
<td>0.5</td>
<td><p>5</p>
<p>[30]<em><sup>b</sup></em></p></td>
<td colspan="2">0.1</td>
<td colspan="2">0.7</td>
<td><p>0.7</p>
<p>[2]<em><sup>b</sup></em></p></td>
<td><p>0.6</p>
<p>[0.9]<em><sup>b</sup></em></p></td>
</tr>
<tr class="even">
<td colspan="10"><p><em><sup>a</sup></em>The external dose is equal for
all organs of the body.</p>
<p><em><sup>b</sup></em>Values in brackets are for a child born 1
January 1951.</p></td>
</tr>
</tbody>
</table>

As shown in Table 1, the estimated average total internal doses from
global fallout are considerably smaller for the thyroid but greater for
the red bone marrow than those from NTS fallout, whereas the doses from
external irradiation are similar for NTS and global fallout.
Additionally, as illustrated in Table 1, the mixture of radionuclides
contained in fallout is different for the two sources of fallout. As a
result, the temporal and geographic distributions of doses from NTS and
global fallout differ substantially. For the nuclear weapons tests
conducted at NTS, fallout occurred predominantly in the western states
surrounding NTS; the short-lived radionuclides, identified by a short
half-life (column 2 in Table 1), were key components of the NTS fallout,
and the highest doses to Americans were from iodine-131. In contrast,
global fallout exposures were higher in areas with high precipitation
rates, such as the eastern states; the long-lived radionuclides, such as
cesium-137 and strontium-90, were in much greater abundance in global
fallout than in NTS fallout.

**Risk Assessment.** The relation between the dose from radioactive
materials and the risk of disease in a population may be described by
models that express health risk as a function of dose and factors that
modify risk, such as age at exposure and gender. Because some of the
components of these models are uncertain, estimates of risk are
uncertain. Any evaluation of risk depends on the development of more
refined dose estimates that account for the uncertainties. To the extent
that reliable dose estimates can be provided, it is feasible to estimate
the lifetime risks of developing organ-specific cancer associated with
fallout exposures for populations or population subgroups. It is also
feasible, but difficult, to quantify the very large uncertainties in
these risk estimates.

Some estimates of the average risk to the United States population for
the categories of all cancers, leukemia, and thyroid cancer have been
developed using the crude doses estimated in this feasibility study.
With the exception of thyroid cancer, the risk estimates were developed
using simple approaches, and are provided in this report for
illustration only. These risks are used to illustrate the feasibility of
a more detailed study, and to provide an approximate estimate of the
potential impact of fallout radiation on the American population.

The NCI previously conducted a detailed reconstruction of doses to the
thyroid gland for iodine-131 from tests at the Nevada Test Site (NCI
1997). Those dose reconstructions were subsequently used to estimate
that between 11,300 and 212,000 (median value of 49,000) thyroid cancers
would be expected to occur among the United States population from
exposure to iodine-131 from NTS (IOM 1999). The wide range in the number
of thyroid cancers predicted (11,300 to 212,000) illustrates the large
uncertainty that such estimates carry. Consideration of global fallout
would likely increase those estimates by about 15%. However, the global
dose estimates have a larger degree of uncertainty; therefore, the range
of the number of predicted cancers would become relatively larger. This
example for thyroid cancer illustrates the issue of estimating risks
with their inherent uncertainties.

The average external dose from all radionuclides over the period
1951--2000 from both NTS and global fallout is estimated to be about 1.2
mGy (Table 1), and estimates of the total cancer risk from that exposure
have been made in this report. For example, the population of 3.8
million people born in the United States in 1951 will likely experience
fewer than 1,000 extra fatal cancers as a result of fallout exposures, a
lifetime risk of less than 0.03% or about 1 in 3800. This number may be
compared with the approximately 760,000 fatal cancers that would be
predicted in the absence of fallout. It is expected that the largest
number of excess cancer deaths would occur in the group of people born
in 1951, because, on average, this group received higher doses at
younger ages than groups born earlier or later. It is also estimated
that about 11,000 extra cancer deaths from all cancers, including
leukemia, would be predicted to occur among the population of the United
States alive at any time during the years 1951--2000 as a result of
external exposure to fallout. (The predicted number of incident cases
\[including nonfatal cases\] would be about double the number of deaths,
or about 22,000.) Radiation doses from external exposure are more
uniform over geographic areas than are thyroid doses and do not vary
substantially according to age or lifestyle habits. Thus, cancer risks
for all cancers from external exposure are likely to vary less by
geographic location, birth cohort, and other factors than are risks for
thyroid cancer from NTS iodine-131 exposure. This lack of obvious
high-exposure areas or populations makes it less likely that there will
be groups with particularly large risks.

Leukemia is perhaps of special interest because it has been strongly
linked with radiation in many epidemiologic studies and because
bone-seeking radionuclides, such as strontium-90, are found in fallout.
About 10%, or 1,100, of the 11,000 extra cancer deaths from external
exposure might be predicted to result from leukemia. It is estimated
that as a result of internal exposure of the red bone marrow to fallout
radionuclides, an additional 550 cases of leukemia may occur among the
population of the United States that comprises people who were alive at
any time during the years 1951--2000. For the approximately 3.8 million
people born in 1951, it is estimated that 17 extra cases of
fallout-related leukemia will occur (a risk of 1 in 220,000) from
internal exposure.

On the basis of the crude estimates of dose and risk developed in this
feasibility study, fallout radiation appears to have the greatest effect
on risk for thyroid tumors. Risk for leukemia would be lower. Risk for
cancers of other organs or tissues could be assessed as well, but
because of the smaller amount of information available about
radiation-associated health effects for those organs and tissues and the
lower doses received by most organs, the uncertainties associated with
such estimates would be extremely large.

Characterization of the cancer risk to the American people could be
enhanced through improvements in methodology, for example, better
quantification of uncertainties in models for expressing risks for
specific cancers, identification of potentially highly exposed
populations, and characterization of lifestyle and other behavioral
factors that could affect the potential for exposure and for risk.
However, even with these improvements, risk estimates that are developed
for fallout exposures would remain highly uncertain. Additionally, such
estimates represent the average risk to members of a population group
who share common characteristics such as age, place of residence, and
dietary factors. The true risk to individuals in the United States may
vary substantially from the average for many reasons, for example, a
difference between their actual dose and the predicted value, other
environmental exposures, their lifestyle patterns, their individual
susceptibility to radiation effects, and the random nature of the
predicted risk. Hence, although it should be possible to give
individuals an indication of whether their geographic location, age, or
lifestyle during the years of nuclear testing have increased the
likelihood of their developing certain radiation-related cancers,
accurately determining the risk for specific individuals is not
possible.

With regard to noncancer health outcomes, a quantitative risk analysis
is not feasible in the near term. For most noncancer outcomes, more
fundamental research is needed to quantify the relation between low,
protracted radiation dose and disease and/or the uncertainty associated
with the estimated risk. Among these noncancer physical health outcomes,
diseases of the thyroid gland have the greatest potential for
occurrence.

**Development of a Health Communication Strategy.** One of the most
important public health requisites of performing a detailed dosimetric
and risk analysis study is the need to clearly communicate the results
of the study to the American public and to health care providers. The
results obtained during this feasibility study are too rudimentary to
warrant developing a plan for comprehensive nationwide education. The
effort to communicate the results from the research carried out in a
more detailed study would be extremely challenging. However, if a more
detailed study is done, it would be especially important to carefully
explain the potential health consequences associated with exposure to
numerous radionuclides in fallout, the limitations of what science can
provide (in particular, the uncertainty in estimates of dose and risk),
and information regarding possible implications.

In regard to communication and education for the general public and for
health care providers, it would be important to include right-to-know
issues and to educate the American public about estimates of fallout
exposures and risk factors for diseases related to radiation. With this
information, people could determine their probable risk category and
decide what health steps are necessary on the basis of that information.
It would be equally important that a component of the communication and
education be directed toward physicians and other health care providers
so they can serve as a source of information to the public and can help
with patients' decision making.

A communication plan as described would require significant funding and
personnel resources. Whereas communication is an integral part of a more
detailed study, the scope and design of any communication plans would
need to carefully balance the desires of stakeholders with the public
health priority of fallout exposures. For example, the public could
receive information on the potential health consequences from nuclear
test fallout in a phased approach, drawing on the efforts under way by
NCI for the iodine-131/NTS communications project. If the model for that
project proves effective, it could be used by federal agencies and
nonfederal groups to communicate information regarding dose estimates
and health risks from other exposures from the NTS and global testing as
they are developed.

Options for Future Work

The findings of this feasibility study suggest that the health risks
from exposure to fallout from past nuclear weapons tests may be small,
but the findings also demonstrate that conducting a detailed study of
the health impact on the American people as a result of exposure to
radioactive fallout from the testing of nuclear weapons in the United
States and abroad is technically possible. Significant resources would
be required to implement this detailed study, however, and careful
consideration should be given to public health priorities before this
path is taken.

To assist decision-makers in the process of determining whether future
fallout-related work is warranted, CDC and NCI have developed five
different options for consideration. CDC and NCI have not developed
detailed estimates of the resources needed to complete each option
considered. However, the actual cost of some past projects is presented
for purposes of comparison only.

Option 1. Conduct no additional fallout-related work.

The dose and risk estimates presented in this report are crude in
nature, as has been discussed. Estimates of uncertainty have not been
quantified for many of these estimates, they are subject to a variety of
errors, and they are incomplete. Nevertheless, the dose and risk
estimates presented here may be sufficient for making decisions on
appropriate public health follow-up.

Option 2. Retrieve and archive the historic documentation related to
radioactive fallout from nuclear weapons testing conducted by the United
States and other nations.

Although a large number of summary reports related to nuclear weapons
fallout have been published, many of the primary documents upon which
these summary reports are based will be lost forever if they are not
protected soon. Hence, documents could be collected and protected
immediately. The National Center for Environmental Health (NCEH) of the
Centers for Disease Control and Prevention (CDC) has been actively
involved in document retrieval and document database development since
1992. Document location, retrieval, and database development have cost
\$3 million to \$5 million and have taken 2--4 years to complete at each
of three nuclear weapons research and development sites where CDC has
worked.

Option 3. Conduct a more detailed dose reconstruction of radioactive
fallout from global nuclear weapons testing for iodine-131, the most
significant radionuclide identified in this study.

As noted earlier, the crude estimates of dose and risk discussed in this
report indicate that fallout radiation has the greatest impact on risks
of thyroid tumors. NCI previously completed a detailed dose
reconstruction and basic risk analysis for iodine-131 fallout received
from the Nevada Test Site (NCI 1997, IOM 1999). The NCI project cost
approximately \$3 million and took many years to complete. Follow-up
activities included developing an Internet site where people can obtain
an estimate of their individual dose and implementing a communications
project to inform people in the United States about the results of this
study and its potential public health implications
(<http://www.nci.nih.gov/i131>).

Considering global fallout would likely increase the dose and risk
estimates previously developed for iodine-131 from NTS fallout by about
15% over the entire population of the United States. However, the
distribution of thyroid dose among the U.S. population would be
different for NTS and global fallout because the tests occurred at
several years' intervals, and the geographic patterns of deposition of
iodine-131 on the ground were significantly different for the two types
of tests. Therefore, it might be desirable to perform a detailed dose
reconstruction and basic risk analysis for Iodine-131 in global fallout,
and incorporate that information into the existing NCI Internet site and
communications plan. This effort should also include collecting and
protecting primary documents related to nuclear weapons testing (Option
2).

Option 4. Conduct a more detailed dose reconstruction for multiple
radionuclides in radioactive fallout from both Nevada Test Site and
global nuclear weapons testing.

The work that has now been completed demonstrates that it is technically
possible to conduct a more detailed study of the health consequences to
American people from exposure to radioactive fallout from the testing of
nuclear weapons in the United States and abroad. Numerous possible
subject areas exist that can be investigated to improve the present
crude dose estimates provided in this report and to provide a more
complete historical record of the nature of the releases from the
weapons testing and the resulting exposures received by Americans from
NTS and global fallout.

It would be feasible to expand on Option 3, above, and perform a
detailed dose reconstruction and basic risk analysis not only for
iodine-131 in global fallout but also for other radionuclides found in
both NTS and global fallout. The results of that dose reconstruction and
risk analysis could then be incorporated into the existing NCI Internet
site and communications plan. This effort should also include collecting
and protecting primary documents related to nuclear weapons testing
(Option 2).

The cost and staffing requirements for implementing Option 4 would
depend on the level of detail undertaken beyond that presented in the
report in this report. For example, CDC's NCEH has been involved in a
comprehensive dose reconstruction for the Department of Energy's nuclear
weapons production site at Hanford, Washington, since 1992. That project
involves portions of the states of Washington, Oregon, and Idaho, and it
includes nine Native American nations. The Hanford project has cost
approximately \$30 million to date. Option 4 would, of course, involve
50 states, and it could include numerous population subgroups; however,
the study could not be carried out with the same level of detail as the
Hanford project, because the relevant information would not be available
for many of the states, and because much higher staffing levels would be
required.

Option 5. Conduct a detailed study of the health effects of nuclear
weapons testing fallout, including, in a single project, dose
estimation, risk analysis, and communication of the results to
interested parties.

This option differs from Option 4 primarily in the type of communication
campaign and in the level of risk characterization that would be
undertaken. Option 4 proposes to use existing communication planning
being undertaken by NCI. Option 5 would expand NCI's effort to develop a
nationwide communications campaign.

Costs and staffing requirements for communications efforts are dependent
on the results of the dose reconstruction and the risk assessment work
and on what public health implications are learned through that work.
However, other issues will also need to be considered. For example, even
if results from the dose reconstruction and risk analysis do not provide
a risk-based rationale for conducting a large-scale, nationwide
communications campaign, public right-to-know and social justice issues
may affect the scale and reach of the campaign. CDC and NCI's
diethylstilbestrol (DES) National Education Campaign (a smaller-scale
national campaign specific to individuals exposed to DES *in utero* and
their health-care providers) is estimated to have cost \$3 million to
\$5 million for the planning phase alone. Funding and resource needs for
the implementation phase of the DES campaign are expected to increase
exponentially during the implementation and distribution phase. In
another example, in the late 1980s CDC mailed information on Acquired
Immune Deficiency Syndrome (AIDS) to every household in the United
States. This mailing cost more than \$30 million.

Also, many issues have been raised in this feasibility study that
transcend the mandate of DHHS. For example, the Department of Energy is
responsible for maintaining many of the environmental monitoring records
that are needed for a detailed study, and the Department of Defense may
need to grant access to classified records required for improving some
of the dose estimates. If additional research is directed, a
trans-federal advisory committee could be established to provide advice
on conducting future activities. Such a committee could be composed of
independent scientists familiar with technical aspects of the proposed
activities and representatives from appropriate federal agencies, state
public health agencies, and public stakeholder groups.

For the past 8 years, CDC's NCEH has been actively working with a number
of committees chartered in accordance with the Federal Advisory
Committee Act, including the former ACERER. The annual cost of each of
the remaining health effects advisory committees is approximately
\$500,000. In addition, two full-time professionals and one or two
support staff members or the equivalent is required to support the
activities of each advisory committee.

Recommendations of the National Academy of Sciences Committee

The recommendations of the NAS/NRC Committee to Review the CDC-NCI
Feasibility Study of the Health Consequences from Nuclear Weapons Tests
regarding further fallout-related work are reproduced below from the
committee's report (NAS/NRC 2003). Only recommendations not already
implemented are abstracted here. The previous discussion of challenges
to implementing Options 1-5 also address some of the barriers to
carrying out these recommendations.

*[Estimates of dose from Nevada Test Site and global
fallout]{.underline}*

> "CDC and NCI should consider performing a reanalysis of the ^131^I
> exposures to the American public that would incorporate new
> dosimetry-related information from Chernobyl and elsewhere, the
> contribution of global fallout, a more comprehensive uncertainty
> analysis, and correction of acknowledged errors in previous
> dosimetry."

*[Document location and retrieval]{.underline}*

> "The committee recommends an effort to retrieve and archive additional
> relevant information about the nuclear-weapons testing program."

*[Estimates of cancer and non-cancer risks]{.underline}*

> "The committee recommends that more emphasis be placed on levels of
> individual risk and the associated uncertainty and less on population
> risk from collective dose."

*[Communication with the public about exposure and cancer
risk]{.underline}*

> "The committee recommends that CDC follow these steps related to
> communication issues:

1.  Develop a detailed public summary and a communication plan for its
    distribution. The public summary should provide information that can
    be readily understood by the lay public, including comparison of
    background radiation with the radiation doses discussed in the
    report of the feasibility study and a description of the important
    uncertainties (related to dose and risk) that apply to the
    feasibility study.

2.  Phase information from the feasibility study into the ^131^I/Nevada
    Test Site Communication Plan in a timely fashion to give interested
    American citizens a more complete picture of their exposure to NTS
    and global fallout with appropriate explanations of relative health
    risks.

3.  If Option 5 is adopted and important new scientific work develops,
    produce a timely major educational effort that builds on the efforts
    of the communication plan for the ^131^I/Nevada Test Site study.

4.  Make studies on radiation exposure of US citizens transparent and
    accessible to interested individuals. The committee recommends that
    interested citizens take part in the study process and, with
    scientific and social science experts, serve as members of advisory
    boards for such studies.

5.  Hold a follow-up conference, similar to the one sponsored by NCI on
    risk communication (January 2000), as part of the continuing CDC
    effort to develop effective guidelines for communicating radiation
    risk to the American public."

Conclusions

Radiation doses and health risks to representative Americans as a
consequence of exposure to radioactive fallout from NTS and testing
sites located in other countries were estimated. The estimated doses and
health risks should be considered as preliminary, because not all
methods and sources of data to improve them have been explored yet.
However, the calculations presented demonstrate that it is feasible to
make such estimates and it is possible to improve the precision of the
estimated doses and health risks.

The findings of this feasibility study suggest that the health risks
from exposure to fallout from past nuclear weapons tests may be small
but that it is technically feasible to conduct a detailed study of the
health effect on American people as a result of exposure to radioactive
fallout from the testing of nuclear weapons in the United States and
abroad. The draft of this technical report was peer reviewed by the
NAS/NRC Committee to Review the CDC-NCI Feasibility Study of the Health
Consequences from Nuclear Weapons Tests. To the extent possible, the
NAS/NRC committee's recommendations were taken into account in this
final report.

References

IOM. Institute of Medicine. National Research Council. Exposure of the
American people to iodine-131 from Nevada atomic bomb tests: review of
the National Cancer Institute report and public health implications.
National Academy Press; Washington, DC; 1999.

NCI. National Cancer Institute. Estimated Exposures and Thyroid Doses
Received by the American People from Iodine-131 in Fallout Following
Nevada Atmospheric Nuclear Bomb Tests. Bethesda, MD; 1997.

NAS/NRC. National Academy of Sciences/National Research Council.
Exposure of the American Population to Radioactive Fallout from Nuclear
Weapons Tests. A Review of the CDC-NCI Draft Report on a Feasibility
Study of the Health Consequences to the American Population from Nuclear
Weapons Tests Conducted by the United States and Other Nations. National
Academy Press, Washington, DC; 2003.