SOURCES AND EFFECTS
OF IONIZING RADIATION
United Nations Scientific Committee on the Effectsof Atomic Radiation
UNSCEAR 2000 Report to the General Assembly,
with Scientific Annexes
VOLUME I: SOURCES

UNITED NATIONSNew York, 2000

NOTE
The report of the Committee without its annexes appears as Official Records of theGeneral Assembly, Fifty-fifth Session, Supplement No. 46 (A/55/46).
The designation employed and the presentation of material in this publication do not
imply the expression of any opinion whatsoever on the part of the Secretariat of the United
Nations concerning the legal status of any country, territory, city or area, or of its authorities,
or concerning the delimitation of its frontiers or boundaries.
The country names used in this document are, in most cases, those that were in use
at the time the data were collected or the text prepared. In other cases, however, the names
have been updated, where this was possible and appropriate, to reflect political changes.

UNITED NATIONS PUBLICATION
Sales No. E.00.IX.3
ISBN 92-1-142238-8

ANNEX D
Medical radiation exposures

CONTENTSPage

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
I.

SCOPE AND BASIS FOR THE ANALYSIS . . . . . . . . . . . . . . . . . . . . . . . . . .
A. MEDICAL RADIATION PROCEDURES . . . . . . . . . . . . . . . . . . . . . . . .
B. SOURCES OF DATA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C. DOSIMETRIC ASPECTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D. ASSESSMENT OF GLOBAL PRACTICE . . . . . . . . . . . . . . . . . . . . . . . .
E. SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

295
295
296
296
297
297

II.

DIAGNOSTIC RADIOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
A. TECHNIQUES OF EXAMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . .
B. DOSIMETRY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C. ANALYSIS OF EXPOSURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Frequency of examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Exposed populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Doses from specific types of examination . . . . . . . . . . . . . . . . . . . . .
D. ASSESSMENT OF GLOBAL PRACTICE . . . . . . . . . . . . . . . . . . . . . . . .
E. TRENDS IN DIAGNOSTIC RADIOLOGY . . . . . . . . . . . . . . . . . . . . . . .
1. Frequencies of examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Doses per examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Quality assurance and patient protection initiatives . . . . . . . . . . . . .
F. SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

300
300
300
302
302
302
303
309
309
310
312
313
314

III. DIAGNOSTIC ADMINISTRATIONS OF RADIOPHARMACEUTICALS . . .
A. TECHNIQUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
B. DOSIMETRY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C. ANALYSIS OF EXPOSURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Frequency of examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Exposed populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Doses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D. ASSESSMENT OF GLOBAL PRACTICE . . . . . . . . . . . . . . . . . . . . . . . .
E. TRENDS IN DIAGNOSTIC PRACTICE WITH
RADIOPHARMACEUTICALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Frequencies of examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Diagnostic practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
F. SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

315
315
316
316
316
317
317
318
318
318
319
320

ANNEX D: MEDICAL RADIATION EXPOSURES

294

Page

IV. TELETHERAPY AND BRACHYTHERAPY . . . . . . . . . . . . . . . . . . . . . . . . . .
A. TECHNIQUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
B. DOSIMETRY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C. ANALYSIS OF EXPOSURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Frequency of treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Exposed populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Doses from treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D. ASSESSMENT OF GLOBAL PRACTICE . . . . . . . . . . . . . . . . . . . . . . . .
E. TRENDS IN TELETHERAPY AND BRACHYTHERAPY . . . . . . . . . . .
1. Frequencies of treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Therapeutic practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
F. SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

320
321
321
322
322
323
323
324
325
325
325
328

V.

328
328
329
329
329
330
330
330
330
330
331
331

THERAPEUTIC ADMINISTRATIONS OF RADIOPHARMACEUTICALS . .
A. TECHNIQUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
B. DOSIMETRY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C. ANALYSIS OF EXPOSURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Frequency of treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Exposed populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Doses from treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D. ASSESSMENT OF GLOBAL PRACTICE . . . . . . . . . . . . . . . . . . . . . . . .
E. TRENDS IN THERAPY WITH RADIOPHARMACEUTICALS . . . . . . .
1. Frequencies of treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Therapeutic practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
F. SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

VI. EXPOSURES OF VOLUNTEERS IN MEDICAL RESEARCH . . . . . . . . . . . . 332
VII. ACCIDENTAL EXPOSURES OF PATIENTS . . . . . . . . . . . . . . . . . . . . . . . . . 332
CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333

Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467

ANNEX D: MEDICAL RADIATION EXPOSURES

295

INTRODUCTION
1. Over the last 100 years, ionizing radiation has been
increasingly applied in medicine and is now firmly established as an essential tool for diagnosis and therapy. The
overwhelming benefits accruing to patients from properly
conducted procedures have fostered the widespread practice of
medical radiology [A22], with the result that medical
radiation exposures have become an important component of
the total radiation exposure of populations.
2. Since beginning its work in 1955, the Committee has
regularly monitored the medical uses of radiation as part of its
continuing review of sources of exposure. The most recent
analysis, included in the UNSCEAR 1993 Report [U3],covered the period 19851990, but information available since1970 was cited in order to investigate trends in usage anddoses. The Committee concluded that medical applications are
the largest man-made source of radiation exposure for theworld’s population, although there was still a far fromequitable distribution of medical radiation services in different
countries with different levels of health care; whereas the 1993
worldwide estimate for the annual per caput dose fromdiagnostic examinations was 0.3 mSv, corresponding averagevalues for countries of the upper and lower health-care levels
were 1.1 mSv and 0.05 mSv, respectively. A century after
Röntgen's seminal discovery of x rays, some two thirds of theworld's population still lacks adequate diagnostic imaging andradiation therapy services [W12].
3.
The Committee also concluded that population exposures from the diagnostic and therapeutic uses of ionizing
radiation were likely to be increasing worldwide, particularly

in countries where medical services are in the earlier stages ofdevelopment [U3]. However, further and morecomprehensive analyses would be required in order to refine
global estimates and establish important trends.
4.
The need for such analysis is heightened by a number ofunderlying factors that could affect the practice of radiology,
in terms of both the type and frequency of procedures carriedout and the associated levels of dose to individual patients[S60]. For example, population growth, urbanization, andlonger lifespans can be expected to result in growing demands
for medical radiology [U3]. Conversely, as a general trendsome reductions in dose can be expected to arise fromcontinuing advances in the technology for ionizing radiationand its substitution by non-ionizing radiations, morewidespread and formalized implementation of quality
assurance procedures in radiologydepartments, better trainingof staff involved in medical radiology [I2], and more rigorous
standards for patient protection [I3, I5, I17].
5.
Accordingly, this Annex presents the results of an
updated, broad review of medical radiation exposures. Its
purpose is to provide new qualitative and quantitative
information on the frequencies and doses for diagnostic
and therapeutic procedures, to assess medical radiation
exposures worldwide, to make comparisons with data fromprevious reviews, and to explore temporal or regional
trends in the practice of medical radiology. Although thereview is not intended as a means to optimize proceduresor as a guideline for radiation protection, it will nevertheless provide the background for such work.

I. SCOPE AND BASIS FOR THE ANALYSIS
A. MEDICAL RADIATION PROCEDURES
6. This Annex is principally concerned with exposures
received by patients from the use of radiation generators orradionuclides as part of their diagnosis or treatment (Chapters
IIV). Medical exposures are also conducted for medico-legal
reasons and on volunteers (patients or healthy persons) for the
purposes of research; this latter category of exposures is
considered in Chapter VI. The information on patient
exposures reported for different types of procedure in various
countries is assumed to reflect routine practice, although abrief discussion of radiation incidents in medicine is included
in Chapter VII for the purpose of illustration. Exposures
received by medical staff from medical radiology are
discussed elsewhere, in Annex E, “Occupational radiation
exposures”. Exposures of the general public arising fromcontact with patients undergoing therapy with sealed or

unsealed radio-nuclides, the disposal of radioactive wastefrom hospitals, and the production of radionuclides for
medicine are considered in Annex C, “Exposures to the
public from man-made sources of radiation”.
7.
Diagnostic procedures, in particular the widespread useof x rays, are the most common application of radiation in
medicine. The range of x-ray techniques used, such asradiography, fluoroscopy, computed tomography,
interventional radiology, and bone densitometry, are discussed
in Chapter II. There is also significant practice in imaging andother functional studies involving administrations to patientsof unsealed radionuclides; these uses are described in Chapter
III. Such nuclear medicine and x-ray procedures are intended
toprovide doctors with diagnostic information and in principle
are conducted with the lowest practicable levels of patient doseto meet clinical objectives [M39, S54].

296

ANNEX D: MEDICAL RADIATION EXPOSURES

8. In contrast, therapeutic exposures are less frequent andthe levels of dose are very much higher in view of the quite
different purpose. Radiotherapy is used mainly for thetreatment of cancer, where the intention is to deliver a lethal
dose to malignant tissue within a well-defined target volume,
while minimizing the irradiation of surrounding healthy
tissue. Many patients receiving radiotherapy have a limited
life expectancy owing to their age or disease. Treatments aremost often carried out using radiation generators and sealed
radionuclide sources. Teletherapy and brachytherapy techniques are considered in Chapter IV. A small amount oftherapy practice involves the administration of unsealed
radionuclides, and this technique is discussed in Chapter V.

instances of extrapolation are generally identified in thefootnotes to the tables. The interpretation of non-standard
or incomplete dosimetric information provided in thequestionnaires is discussed in detail in the appropriate
Sections below.

9. In addition to diagnostic imaging or therapy, there arealso some other applications of ionizing radiation for tissue
analysis in the clinical assessment of health or disease, mostly
in the course of research projects. For example, in vivo
neutron activation analysis, based on the detection ofcharacteristic gamma rays produced by the interaction ofneutrons within the body, has been used to measure calcium,
nitrogen, and cadmium, with whole-body doses up to 10 mSv[C12, S28]. Also, x-ray fluorescence techniques have beenused for in vivo measurements of iodine, lead, and cadmium[C12]. However, such exposures are not a widespread practiceand are not considered further in this review.

C. DOSIMETRIC ASPECTS

B. SOURCES OF DATA
10. The broad characterization of practice in medical
radiology requires a knowledge of the frequency of each typeof procedure and the associated levels of patient dose. To beable to provide as complete an assessment as possible of global
practice in medical radiology, the Committee conducted aworldwide surveyof medical radiation usage and exposures bymeans of a widely distributed questionnaire soliciting
systematic information for the years 19911996. This Annexsummarizes all data submitted to the Committee up to the endof 1999. The questionnaire was similar to that employed forthe previous review [U3], although the format was revised to
improve the quality and utility of the data collected.
Information was sought on national facilities for radiologicalexaminations and treatments, together with specific data forimportant types of procedure: annual numbers of procedures,age and sex distributions of patients, and representative doses.
Respondents to the UNSCEAR Survey of Medical Radiation
Usage and Exposures are listed in the References, Part A.
11. The availability of detailed national data on medical
radiology practice varies considerably even in developed
countries. For example, periodic surveys of national
practice are conducted in some countries (see, inter alia,[O6, S61, S62, S63, T16, Z17]). The information on, say,frequency and dose provided to the Committee in thepresent survey was therefore often based on limited datafrom a particular region or even an individual hospital;
these data were then assumed, with appropriate scaling, tobe representative of the entire country. When known, such

12. The valuable information provided by responses tothe UNSCEAR Survey of Medical Radiation Usage andExposures has been supplemented by selected data frompublications following an extensive review of the literature.
These are used in particular when discussing specificpractices and illustrating trends.

13. Medical exposures to individual patients are
summarized most completely in terms of the absorbed doseto each organ or tissue of the body, although this approach
is often difficult to realize in practice, particularly for any
large-scale dose survey. Weighted-organ dose quantities,
such as effective dose equivalent [I7] and effective dose[I3], represent convenient indicators of overall exposure in
the assessment of diagnostic practice (see, for example,[M33, O6]). They broadly reflect in a qualitative manner
the risks to health of the stochastic (though notdeterministic) effects associated with exposure to ionizing
radiation. The Committee has previously used such
quantities to evaluate patient doses [U3, U4, U6], with theexpress purpose of allowing a robust comparison ofpractice between, inter alia, types of procedure, countries,
health-care levels, time periods, and sources of radiation.
14. However, the Committee has always indicated moststrongly that these effective doses should not be useddirectly for estimating detriment (to individuals or
populations) from medical exposures by application, forexample, of the nominal fatality probability coefficients
given by ICRP [I3]. Such assessments would beinappropriate and serve no purpose in view of theuncertainties arising from potential demographic
differences (in terms of health status, age, and sex)
between particular populations of patients and thosegeneral populations for whom the ICRP derived the risk
coefficients. It has been suggested, for example, that
effective dose could broadly underestimate the detrimentfrom diagnostic exposures of young patients by a factor of
about 2 and, conversely, could overestimate the detrimentfrom the exposure of old patients by a factor of at least 5[N1]. The analysis of radiation risk from diagnostic
medical exposures requires detailed knowledge of organ
doses and the age and sex of patients. Such analyses havebeen carried out (see, for example, [H18 , K12, K13,
M23]), although this important topic is beyond the scopeof this review and is not considered further.
15. Notwithstanding the above caveat, practice indiagnostic radiology is summarized in this Annex, forcomparative purposes, principally in terms of effective

ANNEX D: MEDICAL RADIATION EXPOSURES

doses to exposed individuals undergoing each type ofprocedure and, taking into account numbers of procedures,
collective effective doses over exposed populations. Other
more practical dose descriptors are also used, as
appropriate, in analysing diagnostic exposures. These are
discussed more fully below for examinations with x rays
(Section II.B) and radiopharmaceuticals (Section III.B).
The typical dose values quoted for specific examinations
are generally arithmetic mean values, summarizing
distributions of measurements over groups of patients or
hospitals that are often wide and highly skewed.
16. Diagnostic practices may also be characterized interms of per caput doses, by averaging collective effective
doses over entire populations (including non-exposed
individuals). Although such doses provide a broad indication of practice, they tend to conceal significant variationsin the patterns of exposure received by individuals; someindividuals might have a considerable number of x-ray
examinations in their lifetime and others might have noneat all. For example, it was estimated in 1992 that about 1%of the population of the United Kingdom received alifetime dose of more than 100 mSv from medical x rays,
yet the annual per caput effective dose was about 0.4 mSv[H9]. It has also been observed that radiological examinations are performed somewhat more frequently interminally ill patients [M50], with about 5% of all the
diagnostic x-ray and nuclear medicine procedures at one
institution in the United States involving patients in theirlast six months of life, who collectively represented about
2% of the total number of patients examined [M19]. A
study in Germany found that of the 60% of patients
admitted into two large hospitals who underwent diagnostic x-ray procedures, about 6% received only 1
exposure, although the proportions receiving more than 12,
50 and 100 exposures were 24%, 6% and 1%, respectively[M73].
17. Although effective dose is used in this Annex, withsome caution as discussed above, in the evaluation ofpatient doses from diagnostic exposures, this quantity isinappropriate for characterizing therapeutic exposures, inwhich levels of irradiation are by intent high enough tocause deterministic effects in the target volume. After due
consideration of the complex issues involved, the Committee previously included broad estimates of collective
effective dose for therapeutic exposures, computed on thebasis of scattered radiation outside the target volumes. Thiswas done to provide a robust assessment of practice for the
purposes of comparison within a comprehensive review[U3]. The present analysis, by contrast, summarizes
therapy largely in terms of frequency of practice, together
with some information on prescribed doses. It is
recognized, however, that assessing risk from theirradiation of non-target organs may be of particularimportance for young patients who are successfully cured
by radiotherapy for, say, Hodgkin’s disease (see, forexample [V27]), or for patients undergoing radiotherapy
for inflammatory disease.

297

D. ASSESSMENT OF GLOBAL PRACTICE
18. The availability, complexity, and utilization of radiological equipment for imaging and therapy varies widelyfrom
country to country. In the inevitable absence of comprehensive information on national practice from all countries,
particularly those in the least developed regions of the world,
the assessment of global activities in medical radiology
requires extrapolation from the limited data available from thequestionnaires or the published literature. Models for doing
this were developed in the UNSCEAR 1988 and 1993
Reports [U3, U4] on the basis of observed broad correlations
between the number of x-ray examinations per unit of
population and the number of physicians per unit of
population. Accordingly, information on the number ofphysicians per million popula-tion, which is in general a more
widely available statistic, can be used to scale diagnostic x-ray
frequencies from a few countries to all regions of the world.
As part of this global model, countries are categorized into
four levels of health care according to broad ranges for thenumber of physicians per unit of population: health-carelevel I (at least 1 physician per 1,000 population), health-carelevel II (1 physician for 1,0003,000 population), health-carelevel III (1 physician for 3,00010,000 population), andhealth-care level IV (1 physician for more than 10,000
population). It should be emphasized that this classification ofcountries is used solely for the purposes of modeling and does
not imply any judgements on the quality of health care.
19. Since diagnostic x-ray examinations represent the main
source of exposure for populations, stratifying countries
according to health-care level provides a robust model forassessing general worldwide frequencies and collective doses
from practice in medical radiology. For the present analysis,
information on the number of physicians per unit of
population has been taken principally from data provided to
the Committee in the questionnaires or from survey data
published byWHO on human resources for health in the years
19881991 [W20]. The annual numbers ofdiagnostic medical
x-rayexaminations reportedbydifferent countries span several
orders of magnitude. Figure I illustrates correlations between
these annual totals in countries of different health-care levels
and either the population or the total number of physicians in
those countries. In general, annual numbers of examinations
appear broadly to correlate better with national totals ofphysicians (Figure Ib) than with populations (Figure Ia), thisbeing in general agreement with the model. For completeness,
Figure II presents the relationship between dental x-ray
examinations and either the population (Figure IIa) or thenumber of dentists (Figure IIb). However, there could be
confusion as to whether the reported national totals for dental
x rays refer to numbers of examinations or numbers of films.
Also, it is likely in developing countries that significant
numbers of dental x-ray examinations are conducted in
hospitals rather than in dental practices.
20. There are clearly limitations to this broadclassification system. For example, there will be differencesin how different countries define a “physician”, and these298

ANNEX D: MEDICAL RADIATION EXPOSURES

10 9

10 9

Level I

Level I
Level II

Level III108

MEDICAL X-RAY EXAMINATIONSMEDICAL X-RAY EXAMINATIONS

Level II
Level IV

107
106
105

10

4

10

Level IV

107
106
105

10

4

(a) Size of population

3

10
4

10

105

106

9

108

107

10

Level III108(a) Number of physicians

3

10 10

101

102

POPULATION

103

104

105

106

107

PHYSICIANS

Figure I. Annual number of diagnostic medical x-ray examinations in relation to(a) size of population and (b) number of physicians.
10 9

10 9

(a) Size of population

Level I

Level I

Level III108

Level IV

107
106
105

10

(a) Number of dentists

Level II
DENTAL X-RAY EXAMINATIONSDENTAL X-RAY EXAMINATIONS

Level II

4

Level IV

107
106
105

10

103

Level III

108

4

103
105

106

7

10

108

9

10

10

10

POPULATION

101

102

103

104

105

DENTISTS

Figure II. Annual number of diagnostic dental x-ray examinations in relation to(a) size of population and (b) number of dentists.

lead to uncertainties in the data on numbers of physicians.
Also, assigning countries to health-care levels on the basisof average national data will hide possibly significant
regional variations within countries, particularly for large
ones [U3]. Some examples can be given below in relation
to Latin America [B33]. In Argentina, Brazil, Colombia,
Costa Rica, Mexico, and Venezuela, the numbers andvariety of radiological studies performed in university andregional hospitals are comparable to those performed insimilar centres in more developed countries. In those large
countries with high levels of urbanization, the main
hospitals often tend to be private, and these establishments
have relativelymodern and sophisticated imaging services.
In those countries with intermediate-sized populations, therange of diagnostic equipment and services available isusually not as great, with resources concentrated in capitalcities and regional centres.

21. The global model can be expected to provide only a verybroad characterization of overall national practice in medical
radiology. For example, South Africa is assumed in thepresent analysis to fall in health-care level I, althoughsignificant variations are reported in the frequency of x-ray
examinations between race groups, ranging from 67 per 1,000
blacks to 460 per 1,000 whites [H29, M22]. Ecuador isclassified in health-care level I, although the indicators ofnational radiology practice are rather less than the averagelevels for this category. Some countries have been classified inlevels different from those to which they would have been
assigned based strictlyon the number of physicians. Examples
are Jordan, Libyan Arab Jamahiriya, Mexico and Turkey(level II rather than level I) and Sudan (level III rather thanlevel II). The provision of health-care is broadly influenced bynational economic status, and WHO has, for analytical
purposes, also classified countries according to the following

ANNEX D: MEDICAL RADIATION EXPOSURES

scheme [W21]: least developed countries (LDCs); developing
countries (excluding LDCs); economies in transition; anddeveloped market economies. The Committee might wish to
explore this approach for potential application in futureassessments of global medical exposures.
22. Continued use of the same global model in thisAnnex as that adopted by the Committee for its previous
analyses [U3, U4] ensures consistency of approach andallows the comparing of practice between different levelsof health care and periods of time. The total population of
the world in 1996 was estimated to be 5,800 million[W21]. Table 1 presents a breakdown of this present total
byhealth-care level according to the global model, together
with similar data reported for analyses in previous years.
Ideally, this model should have access to additional
national data on medical radiation usage. For example,
information on the frequency of medical x-ray
examinations is presently available from 36 countries inhealth-care level I, which collectively represent 67% of thetotal population of that health-care level; for other healthcare levels, data are available from 14 countries in level II(representing 50% of the total population in the level), 4
countries in level III (representing 13% of the total
population in the level), and only 1 country in level IV(representing 5% of total population in the level). Overall,
information on x-ray usage is available for 46% of theworld population. Such relatively small sample sizes
necessarily demand that some caution is exercised wheninterpreting the results of the present analyses.
23. Medical radiology is practiced under widely differing
circumstances, even in well-developed countries in the upper
levels of health care, in terms of the size and nature of the
facilities where the procedures are conducted, whether they
are in the public or private domain, and the specialist trainingof the medical doctors and support staff. Basic data on
medical radiation resources for 19911996, acquired from
responses to the questionnaire and other sources, are tabulated
in Tables 28: numbers of physicians and dentists (Table 2),
diagnostic imaging equipment (Table 3), diagnostic imaging
equipment per million population (Table 4), radiotherapy
equipment (Table 5), radiotherapy equipment per million
population (Table 6), temporal trends in average provision for
medical radiology per million population by health-care level(Table 7), and annual numbers of medical radiation
examinations and treatments (Table 8). The global use of
medical radiology is summarized in Table 9. The symbol «-»is used in these and subsequent tables to indicate where data
were not available, whereas zeros indicate the complete
absence of a practice or type of equipment.

299

24. In general, there are broad trends for lower mean levelsof resources and practice when comparing values derived for
health-care level I with those derived for the lower levels (IIto IV). However, significant differences are often apparent
between individual countries within the same health-carelevel. Also, the amounts of data available in particular for the
lower health-care levels (III and IV) are limited. The resultsof such reviews should always be used with some caution andinterpreted only in the full knowledge of uncertainties in thereliability and representativeness of the national data
presented [R21]. These data will have been derived using avariety of different methods and designs of survey and there
may, for example, be significant bias in national estimates
extrapolated from data for a single region or institution
because of the wide variations in practice that inevitably exist
within countries [A15, A21, K18, P16, S38, W33]. There will
also be differences in interpretation between countries inrelation to categories of staff (for example physician), equipment (for example brachytherapy units) and procedure (forexample, the potential confusion between x-ray film or
examination). In addition, the detailed data on frequency anddose subsequently reported in this review are subject touncertainties arising from the exact scope of the examinationgroupings used (in relation, for example, to the broad x-ray
categories of “Abdomen” or “Head”) and the methods (including calibration) employed for dose assessments. Furthermore,
it should be noted that the averaging of data within healthcare levels has often been carried out over different populations and this could be important when comparisons of meanvalues are being made, particularly in relation to temporal
trends utilizing data for the different periods of time fromprevious reviews.

E. SUMMARY
25. The exposure of patients to ionizing radiations for
medical diagnosis and therapy has been assessed on a global
scale utilizing survey data on national practice provided by aquestionnaire on the resources for medical radiology and thefrequencies and doses for different types of procedure,
supplemented by a review of the published literature.
Available data have been scaled up to provide estimates forthe world population on the basis of a global model in whichcountries are categorized intofour health-care levels according
to the commonly-available metric of number of physicians perunit of population. Notwithstanding some differences in thequality and reliability of the national data and the broad
method of extrapolation, the model provides a robust
assessment of global practice in medical radiology for the
purposes of comparison with previous data and the assessmentof trends.

300

ANNEX D: MEDICAL RADIATION EXPOSURES

II. DIAGNOSTIC RADIOLOGY
26. Diagnostic examinations with x rays have been used in
medicine for over a century, although with increasing sophistication; keytechnical advances are summarized in Table 10.
During the last 20 years in particular, medical imaging has
experienced a technological revolution, and it now allows the
improved imaging of anatomy, physiology, and metabolism[H1]. Steady advances in the quality of x-ray images and inpatient protection have ensured a continuing role for diagnostic x rays in health care, although alternative modalities
for diagnosis are becoming increasingly available, such as
ultrasound, endoscopy, and, particularly in developed
countries, MRI. Nevertheless, because x-ray examinations
remain the most frequent use of ionizing radiation in
medicine, they are the most significant source of medical
exposure for the world population. An increasinglywide rangeof equipment and techniques is employed to meet a diversityof diagnostic clinical purposes.

A. TECHNIQUES OF EXAMINATION
27. Traditional x-ray examinations involve static imaging,which uses film in cassettes with intensifying screens (radiography), and dynamic imaging, which uses (electronic) image
intensifiers (fluoroscopy). Cine film (35 mm) is also used inradiological studies of the heart. Radiographic exposures arecommonly performed during fluoroscopy, often using a
100 mm film camera linked to the intensifier (photofluorography), although digital radiographic techniques are
increasingly being introduced. The visibility of particular
tissues can be enhanced by the introduction of contrast media
into the patient, such as barium for the gastrointestinal (GI)tract and iodine for the blood vessels (angiography), theurinary system (urography) or the biliary system (cholecystography). In addition to fixed installations in hospital departments and practices, mobile equipment for radiography or
fluoroscopy allows imaging in the wards or operating
theatres. Radiography is occasionally conducted in the homesof patients by visiting radiographers using portable x-ray
units.
28. Digital methods for the processing and display of
x-ray images were first introduced into clinical practicewith the advent of CT in 1972. This revolutionary technology was able to provide high-quality images of isolated
slices of the patient using a thin rotating beam of x rays,
albeit with relatively high patient doses. The subsequentdevelopment of helical CT has lead to further scanningtechniques such as CT endoscopy and CT fluoroscopy.
Continuing advances in computer technology have also
promoted the general development of digital radiography,
where images are acquired in digital form, most commonlyfrom an image intensifier (digital fluorography) or from astorage phosphor plate (computed radiography) [H1].
Other detector systems for indirect (with an intermediate
phosphor) or direct digital radiography, utilizing forexample amorphous selenium and amorphous silicon, areunder development [R22, Y4]. The technique of digital
subtraction angiography (DSA) is based on digital image
processing with logarithmic subtraction and edge enhancement; it is used increasingly for the visualization of bloodvessels throughout the body. Such improvements in imaging
and innovations in other equipment, such as needles, guidewires, catheters, stents, and contrast media, have facilitatedthe development of interventional radiological techniques, inwhich imaging helps to guide therapeutic procedures and todeliver therapeutic agents [A19]. Digital technology also
provides for the storage and transfer of images within andbetween hospitals and their transmission for remoteconsultation (teleradiology) using digital networks known as
picture archive and communications systems (PACS).
29. In addition to examinations on symptomatic patientswith specific clinical indications, diagnostic x-ray examinations are also undertaken in connection with mass screening
programmes of sections of the population. These may be forthe purposes of, for example, diagnosing tuberculosis, breast
cancer or, particularly in Japan, stomach cancer, andmanaging occupational health [N1]. Furthermore, someexaminations are conducted for medico-legal reasons andothers on volunteers participating in medical research.

B. DOSIMETRY
30. The levels of dose to patients undergoing diagnostic
examinations with x rays are in principle determined by thequality of images required and the extent of investigationnecessary to meet specific clinical objectives. In practice,numerous factors relating to both the radiological equipment
and the procedures in use have an influence on the imaging
process. Some of the more important aspects of practice thathave a broad impact on patient dose are summarized inTable 11; this information represents an updated version of asimilar list given in the UNSCEAR 1993 Report [U3]. Patient
size is, of course, an additional determinant of dose forindividual examinations [S58], although this factor cannot be
used generally to improve practice. Accordingly, comparisonsof dose to assess relative performance are made in terms ofmean values observed over groups of patients or in relation to
standard-sized patients.
31. Because x-ray procedures characteristically involvea series of partial-body exposures, they produce complex
patterns of energydeposition within the patient and various
dose measurement strategies are necessarily employed[F17, N27]. Organ doses are in general difficult to assess,and in practice routine patient monitoring is usually basedon directly measurable dose quantities, such as entrance
surface dose (with backscatter [P17]) per radiograph and,particularly for complex procedures involving fluoroscopy,
dose-area product per examination [B46, K25, L14, L27,

ANNEX D: MEDICAL RADIATION EXPOSURES

N9]. Dose-area product meters are increasinglybeing fitted
to x-ray equipment and their development has continued so
as to allow also the display in real-time of dose rate andcumulative dose [G14, R23]. The quantities entrance
surface dose and dose-area product are often measured aspart of quality assurance programmes or in other surveys
of practice [B55, M41, P27]. Dose assessments reported inthis manner are widely used in this Annex and assumed tobe reliable, although essential details of dosemeter
calibration [D30, G27, G52, N9] are often unknown. Froma radiation protection point of view, the types of dose
measurement discussed above have also formed thepractical basis, both nationally [L16, N1, Z17] andinternationally [C6, I5, N24, S57], for specifying reference
values (diagnostic reference levels) for common diagnostic
x-ray examinations, as a way of promoting improvements
in practice [I17, O11, W38]. In addition to measurements
on patients, assessments of dose performance at x-ray
facilities are also conducted by calculation [B50] and byusing patient-equivalent phantoms to provide indicationsof dose and dose rates under standard conditions of
exposure [M28, M40, R15, S44, W39].
32. Organ dose and effective dose [B45] are generally
estimated from routine dose measurements using conversion
factors appropriate to the conditions of exposure; coefficientsthat have been used in various dose studies are reviewed
elsewhere [R11]. These coefficients may be derived
experimentally on the basis of physical anthropomorphic
phantoms (see, for example, [M21, M44, R11]) or calculatedusing Monte Carlo simulation techniques with mathematicalphantoms (see, for example, [S56, T9, Z15, Z16]). Theoreticalnormalized organ dose data are available inter alia in relation
to routine examinations of adults (see, for example, [D7, H15,
R9, S11]), paediatric patients (see, for example, [H16, R10]),and cardiac [S9] and angiographic [K27] examinations,although care is needed when applying such coefficients toclinical practice [P19, W35]. The comparison of organ andeffective doses derived from measurements and calculations
under similar conditions of exposure indicates reasonableagreement between the methods and highlights the limitations
and uncertainties in both approaches [M48]. Computational
methods of dosimetry in particular are advancing steadily,with the development of more realistic (voxel) phantoms
based on digital images of humans [D5, J6, V24, X1, Z24].
Differences in the results from calculations for different
anthropomorphic phantoms under similar conditions of
exposure underline the uncertainties in such computed dosecoefficients, which should not be applied to examinations ofindividual patients [Z25].
33. Assessment of the weighted dose quantity of effective
dose is particularly problematic for the very localized and low
levels of exposure involved in dental radiology, in which doses
to the so-called “remainder organs” are dominant [L37]. For
example, for given sets of organ dose data from dental
exposures, the values of effective dose [I3] have been reported
to be less than the corresponding values of effective dose
equivalent [I7] by factors of 210 [K42, U3]. Such differences301

in interpretation represent an additional source of uncertainty
that should be borne in mind when comparing reported
effective dose data.
34. For the intensive imaging procedures used ininterventional radiology, a knowledge of the localized dose toskin is also important with respect to the potential for
deterministic effects of irradiation [C2, G34]. Such
cumulative skin doses can be assessed by calculation (see, forexample, [G17]) or measured directly on the patient using
film (see, for example, [F14, K21, L25, V10]) or
thermoluminescent dosemeters (TLDs) (see, for example,[G18]) or solid-state detectors (see, for example, [P18]), or byportal monitoring [W43]. It is also possible to makesimultaneous measurements of cumulative dose and dose-area
product during fluoroscopic examinations using a single
transmission ionization chamber [G14].
35. Special dosimetric techniques are often employed in
the case of mammography and CT in view of the peculiar
conditions of irradiation for these examinations [D40, J13,
Y13, Z19]. Practice in mammography is generallyassessedin terms of the mean dose to glandular tissue, derived inrelation to a standard breast thickness using coefficientsnormalized to measurements of air kerma made free-in-air(see, for example, [B67, F20, H17, H49, K44, L15, N37,
S83, Y2, Z2, Z20]), although direct measurements ofentrance surface dose on patients have also been employed[G11, Z2]. Effective doses from mammography areincluded in the present analysis for completeness, although
this quantity is not an appropriate indicator of risk for such
exposures of female patients. Estimates of risk should bebased on the mean dose to glandular tissue and age-specificrisk factors.
36. CT generally involves the irradiation of thin slices ofthe patient in rotational geometry by a fan beam of x rays.
The principal dosimetric quantity in CT is the computed
tomography dose index (CTDI), in which the dose profile
along the axis of rotation for a single slice is averaged overthe nominal slice thickness [S7]. The CTDI can bemeasured free-in-air [S8] or in homogeneous CT dosimetry
phantoms for the head and body [C36, K11, L20], althoughsuch reported values can reflect subtle differences in thedefinition of CTDI [E3]. A related quantity, the multiple
scan average dose (MSAD), provides an indication of thedose in a phantom for a series of multiple scans with aconstant separation [S7]. Organ doses and effective doses
to patients for particular scanning protocols can be
estimated [K41, S30] using dose coefficients provided bymathematical modeling, which are normalized to a free-inair axial dose [B64, C37, H43, J3, J12, W49, Z5, Z6], or bydose measurements with TLDs in phantoms [N16]. Other
dosimetric quantities of interest that are under development
for characterizing practice in CT include dose-area product[P5] and dose-length product [E4, S40] in relation to CTDI
measurements in standard phantoms; these quantities inturn allow the broad estimation of effective dose to patients[H42, J13].

302

ANNEX D: MEDICAL RADIATION EXPOSURES

37. Whereas organ doses and effective doses generally
provide the most complete assessment of x-ray exposures, analternative dosimetric method focuses on the energy imparted
as a practical measure of patient dose [A7, A24, G13, P6].
Such values of energy imparted allow estimates of effective
dose to be derived for the exposure of both adult andpaediatric patients [A1, A3, H5, H38]. Biological dosimetry,based on an analysis of chromosome aberrations in human
lymphocytes, has also been reported for patients who received
extensive exposure to diagnostic x rays [W17]. However, thistechnique is of limited importance in routine practice.

C. ANALYSIS OF EXPOSURES
1. Frequency of examinations
38. The annual numbers of diagnostic medical x-ray
examinations reported by different countries for 19911996
span several orders of magnitude. The annual frequencies(numbers of examinations per 1,000 population) aresummarized by type of procedure in Table 12, with countries
grouped according to health-care level. Part A includes
information for some common types of examination andPart B for some special procedures and also the total of all
medical x-ray examinations. The percentage contributions ofeach type of examination to total frequency are given in
Table 13. Mean values of frequencies have been derived foreach health-care level by dividing the total numbers ofprocedures by the total population.
39. There are significant differences in the patterns ofpractice from one country to another, even within the same
health-care level. Many of the reported data were obtained
from surveys or registrations that were complete enough togive representative results. In other cases, however, figures
have been estimated from smaller or more localized
samples that might not adequatelyreflect national practice.
There may also be some differences in the examination
categories used in national surveys. Some particularqualifications noted for the present data are given in
footnotes to Tables 12 and 13. National annual frequencies
for the total of all medical x-ray examinations vary by afactor of nearly 10 within the sample of 36 countries listed
in health-care level I (1511,477 examinations per 1,000
population); smaller variations exist in the samples of 14
countries in level II (98306 examinations per 1,000
population), and 4 countries in level III (737
examinations per 1,000 population). Information wasavailable from only one country in health-care level IV (theUnited Republic of Tanzania: 29 examinations per 1,000
population). The average total frequencies for levels II and
III are factors of 6 and 50, respectively, smaller than the
average for level I, 920 examinations per 1,000 population.
40. The relative use of fluoroscopy and photofluorography
also varies between countries. For example, the percentage
contribution from fluoroscopic procedures to the annual totalof all medical x-ray examinations is about 4% in Russia, 9%

in Ukraine [K18], 10% in Germany (with many of these
examinations involving long exposure times) and 28% inRomania [D28]. In China [Z13], chest fluoroscopy accounts
for 62% of all x-ray examinations. Photofluorography
accounts for about 16% and 32% of all x-ray examinations in
Romania [D28] and Russia, respectively, and for 55% of allchest radiography in Poland [S49].
41. In general, examinations of the chest are the single mostimportant type of procedure; the relatively low frequencies
reported for Sudan and the United Republic of Tanzania, forexample, are apparently due to incomplete survey data.
Significant contributions to practice in all health-care levels
are made by examinations of the limbs and joints and thespine. The more complex procedures summarized in Part B of
Tables 12 and 13 are in general performed less frequently inthe countries of lower health-care levels. The decreased use of
CT in levels IIIV relative to level I can, however, be viewed
against a relative increase in conventional examinations of thehead. Temporal trends in the frequency of examinations are
discussed Section II.E.
2. Exposed populations
42. The distributions by age and sex of patients
undergoing various diagnostic x-ray examinations in
19911996 are presented in Table 14 for selected countriesof the four health-care levels; some known limitations in
the reported data are given in the footnotes. The analysis
uses the same three broad ranges of patient age as the
UNSCEAR 1993 Report [U3]. It has already been notedthat the populations of patients undergoing diagnostic
examinations with x rays are in general older than thecorresponding whole populations, although significant
numbers of procedures are conducted on children [U3].
Some differences in patient age distribution are apparent
from country to country for a particular type of
examination, even when considering a single health-carelevel. However, the population-weighted mean values foreach level suggest some general trends in the age/type of
examination and age/health-care level relationships. For
example, older patients predominate for examinations of
the gastrointestinal tract, urography, and cholecystography,
whereas children form a substantial fraction of the patients
undergoing examinations of the limbs and joints, head, andpelvis and hip. In general, greater proportions of
examinations are conducted on patients in the two younger
age groups for countries in levels IIIV than for level I
countries. This finding is broadly consistent with theobservation that there is a bias towards younger ages in thegeneral population for many developing countries [U3].
43. Notwithstanding specific examinations such as
mammography and pelvimetry, the male vs. female
distributions of diagnostic x-ray examinations do notdeviate greatly from the underlying patterns for whole
populations. There are, however, some variations between
countries in the data reported for each particular type ofprocedure.

ANNEX D: MEDICAL RADIATION EXPOSURES

3. Doses from specific types of examination
44. The typical effective doses to patients from medical
x rays reported by different countries for 19911996 arepresented in Table 15. Part A includes mean values ofeffective dose for some common types of examination andPart B for some special procedures and also the annual
total of all medical x-ray examinations. Representativevalues of other dosimetric quantities used to characterizepatient doses from x-ray examinations are summarized for
different countries in Table 16. Part A includes meanvalues of entrance surface dose for some common types ofradiograph and Part B mean values of dose-area productfor some specific, more complex diagnostic x-ray
examinations involving fluoroscopy. Further patient dose
data have been published in connection, for example, withexaminations of the cervical spine [M22, N15, O3, R11],
extremities [H21, M22, O3], hysterosalpingography [C29,F16, G28, S51], barium studies of the gastrointestinal tract[C30, D29, G29, G30, L29, L49, M38, S52, W37, Y10,
Z14] and extracorporeal shock wave lithotripsy (ESWL)[M47]. Studies have also been conducted of the dose rates
during fluoroscopy (see, for example [B51, B52, S53]).
Dose rates have been reported in relation to some different
organs of patients undergoing x-ray examinations in
Bangladesh [B44]. X rays are also used in chiropractic[B29, E12] and podiatry [A23]. The dosimetric aspects ofsome specific procedures are discussed further below.
(a) Angiographic and interventional procedures
45. Advances in technology for imaging and ancillaryequipment have facilitated the development of increasingly
complex radiological procedures for angiography andinterventional radiology [B49, C25] and specific methods
are required for assessing and monitoring the resultant
patient doses [B57, F18, G34, G35, G36]. Angiographic
examinations involve complex patterns of imaging [K28]
and are often complementary to interventional procedures,providing evaluations before and after treatment. Some
reported dose data for different types of angiographic
procedure are given in Table 17. Doses to patients frominterventional radiology procedures are summarized inTable 18.
46. A survey of practice in five European countries
identified over 400 different types of interventional
procedures involving a range of medical imaging
specialities, such as neuroradiology, vascular radiology,
and cardioangiography [M8]; typical data from Germany
for 1990 indicated that nearly 60% of such procedures fallwithin the broad category of angioplasty (dilatation), withsignificant applications also in biopsy/drainage (11%),pain therapy (11%), embolization (7%), and genitourinary(7%) and biliary (5%) interventions. Such interventional
procedures are generally complex and can involve
significant periods of patient exposure, although thesetypes of therapy often represent alternatives to morehazardous surgery or are the sole method of treatment.

303

Interventional radiology is already an established part ofmainstream medicine and is likely to expand further withthe continuing development and adoption of newprocedures [B1], particularly in countries with welldeveloped health-care systems [J9, L11]. In Europe, theaverage rate of percutaneous transluminal coronary
angioplasty (PTCA) procedures in 1993 was 343 per
million population, an annual increase of 12% overprevious data for 1992, but with considerable variation
among national practices, from Romania (1 per million) to
Iceland (876 per million) [U15]. Information on interventional cardiology in Spain (practiced at 81 hospitals)
indicated a total of 90,915 procedures in 1997 (a rate of
2,270 per million population), with 72,370 (80%) being
diagnostic (increase of 13% relative to 1996) and 18,545(20%) being therapeutic (increase of 24% relative to 1996).
47. Dose rates during such sophisticated procedures canbe relatively high, for example up to a regulatory
maximum of 180 mGy min1 at the patient surface duringhigh-level-mode fluoroscopy in the United States [C4].
Lower dose rates are technically possible, however, whenusing new techniques such as pulsed progressive
fluoroscopy [H26]. The combination in interventional
radiology of prolonged localized fluoroscopy, multiple
radiographic exposures, and repeated procedures onparticular patients can cause patient doses to reach levels
associated with acute radiation injury of skin [C2, C14,
W31]. Procedures of particular concern in this respectinclude radiofrequency cardiac catheter ablation,
percutaneous transluminal angioplasty, vascular embolization, stent and filter replacement, thrombolytic andfibrinolytic procedures, percutaneous transhepatic cholangiography, endoscopic retrograde cholangiopancreatography, transjugular intrahepatic portosystemic shunt,
percutaneous nephrostomy, and biliary drainage or
urinary/biliary stone removal [F9]. However, there may ingeneral be some under-reporting of skin injuries in view of
the time delay between exposure and manifestation ofdamage. In the United States from 1992 to 1995, there
were 26 reports to the Food and Drug Administration(FDA) of radiation-induced skin injuries from fluoroscopy[S46]. By 1999, the FDA had documented some 50 casesof radiation-induced burns, many involving cardiologicalprocedures [A25]. Details have been published, forexample, ofoccurrences of epilation [H23, K29], dermatitis[C21, D31, K22, P13, R24, S65, S66, V11], and erythematous lesions [S46, V11]. In one study of arrhythmia
ablation procedures, about 6% of 500 patients were foundto have received enough radiation exposure to reach thethreshold dose (2 Gy) for early transient erythema,
although no clinical manifestations of acute radiationinduced skin injury were observed [P14]. Another analysisof neurological procedures on 426 patients has suggested
that long-term erythema may be encountered in 1%2% ofembolizations, with there being a potential for temporary
erythema in 11% of both carotid procedures and cerebral
angiograms, 3% of nerve block procedures, 7% of lumbar
procedures, and 23% of embolization procedures [O7].

ANNEX D: MEDICAL RADIATION EXPOSURES

48. Dose data for different types of interventional procedure
are summarized in Table 18: fluoroscopy time and, with due
account of exposures from radiography, localized surface dose(measured or estimated assuming static beam), dose-area
product, and effective dose. In general, fluoroscopy times areappreciable, and skin doses may approach or exceed thethresholds for deterministic effects [U3]. Some examples
reported for particular patients can be given: a fluoroscopic
exposure of 190 minutes and a localized dose of 8.4 Gyduring
radiofrequency ablation [C3]; an estimated maximum skindose of 6.6 Gy from 110 minutes of fluoroscopy and 46 DSA
acquisitions in the course of neurological embolization [H23];
an accumulated skin dose of 1116 Gy from an estimated90120 minutes of fluoroscopyduring cardiac radiofrequency
ablation [V11]; and estimated maxima of 20 Gy and 3.5 Gy
for skin exposure from fluoroscopy and DSA acquisitions,
respectively, for a patient undergoing a series of biliary
procedures over a four-week period [S46]. Doses may besignificantly underestimated if contributions from cine
exposures are not fully taken into account; the potential forskin injury will be underestimated if only fluoroscopy time ismonitored, but overestimated when doses from different beam
projections are combined [O14]. Notwithstanding significant
variations between individual patients, values of dose-area
product and effective dose for interventional procedures are
typically larger than those for common diagnostic x-ray
examinations; for example, dose-area product values of up to
918 Gy cm2 have been reported during embolization
procedures [B9]. One studycomparing the use of conventionaland digital systems for a range of interventional vascular
procedures found mean values of dose-area product to behigher for the digital equipment in 13 out of 15 patient groups[R12]. Guidance concerning efficacy and radiation safety ininterventional radiology is being prepared by WHO [B30,W9].
(b) Computed tomography
49. Technological developments to improve the quality
and speed with which images are obtained have fostered
the growth of CT practice throughout the world over thelast two decades, allowing the routine performance of more
and more extensive and elaborate examinations withrelatively high levels of patient dose. The expanding use of
CT in the diagnosis and assessment of cancer and otherpathological conditions [D37, N35, R31] has made asubstantial impact on both patient care and population
exposure from medical x rays. In the United Kingdom, forexample, the number of CT scanners in clinical use
increased steadily following introduction of the techniquein 1972 before finally reaching a plateau in 1995, as
illustrated in Figure III. Whereas CT was estimated in
1989 to account for about 2% of the national total of all
x-ray examinations and about 20% of the resultant
collective dose, a further analysis for 1997 suggests that thelatter figure may have risen to about 40% [S30]. Data fromnational surveys in eight other countries have confirmed asa general pattern the increasing importance of CT as asource of exposure for populations [S5]. In Germany

during the years 19901992, CT accounted for, on
average, about 3.5% of all x-ray examinations and about
35% of the associated collective effective dose, and further
increases are foreseen [B31]. A similar analysis for Norway
in 1993 indicated contributions from CT to x-ray frequency
and collective dose of 7% and 30%, respectively [O12].
400350
SCANNERS IN CLINICAL USE

304

CT

300
250
200
150

MRI

100
50
0
1970

1975

1980

1985
YEAR

1990

1995

2000

Figure III. CT and MRI equipment in the United Kingdom.

50. Mean values of effective dose reported by somesurveys of CT practice are summarized in Table 19 forcommon types of procedure. In addition to apparent
differences between such mean national data, there are alsosignificant variations, for a given general type ofprocedure, in the typical doses at individual CT centres[O12, S40, S69, V15] and in the particular doses forindividual patients [S70, W44]. Organ doses for CT
procedures have been estimated in various studies on thebasis of measurements [D32, E9, L31, M50, M51, N16,
N30, N31, N32, P21] or calculations [H33, H34, O12, P22,
T17]. In general, comparisons between sets of organ doses
derived from measurements and calculations for a given
examination technique demonstrate reasonable agreement
when due account is taken of any differences in the
exposure conditions being modeled [C31, G38, S71].
Absorbed dose to the lens of the eye may be above 50 mGy
for certain CT procedures on the head [M52, M53, M54,
M55, W45]. Doses to the thyroid, breast and testes fromscattered radiation are significantly reduced when leadshielding is used [B59, H35, P23]. Reductions in breast
dose during direct scanning have also been reported using
an overlying bismuth filter [H36]. Lower levels of patient
dose are often possible in CT with attention to choice of
scanning technique [G39, K30], particularlywith regard tolower settings [K32, M56, P24, R26, S72] or dynamic
modulation [G40, H37, K31] of tube current. With the useof standard techniques, the energy imparted to the patient
has been shown to increase with patient size, although thecalculated effective dose is higher in children than adults[W46]: 6.0 mSv (newborn) and 1.5 mSv (adult) during
head examinations, and 5.3 mSv (newborn) and 3.1 mSv(adult) during abdomen examinations [H38]. Significant

ANNEX D: MEDICAL RADIATION EXPOSURES

dose reductions have been reported in paediatric CT by theappropriate lowering of exposure settings [C32, S73,
W47].
51. Clinical practice in CT has been stimulated inparticular by the notable technical development in 1989 ofhelical (spiral) scanning [K33, K34]. This techniqueprovides significant clinical advantages by allowing the
rapid acquisition of image data over large volumes of thepatient during a single breath hold [D33, H39]. Althoughimage quality and patient dose in helical CT are broadly
similar to those for conventional slice-by-slice imaging
when equal or equivalent scan parameters are chosen, thespeed and convenience of helical scanning is likely topromote increases in both the frequency of CT procedures
and the levels of patient effective dose from procedures ofincreasing complexity [D34, M57, S10, T18, Z18].
However, the use of an increased pitch (>1) in helicalscanning leads to a reduction in patient dose [M58] andsuch techniques have been successfully applied to clinicalexaminations to achieve lower doses for adults [C33, D35,
H40, K35, P21, S74, S75, V16, W48] and children [R27].
The advent of the technology for helical CT has also
facilitated the development of new techniques such as CT
angiography [K36, K37, R28, R29], virtual CT endoscopy[P25], lung cancer screening CT [I26, N30, N33], and CT
fluoroscopy [D36, K38, K39, S75]. This latter techniqueprovides real-time reconstruction and display of CT
images, with the potential for significantly high patient(and staff) exposure; preliminary studies have indicated,for example, patient skin dose rates of 190830 mGy per
minute during interventional CT fluoroscopy [N34] and an
effective dose rate of 3.6 mSv per minute for abdominal
scanning [A26]. The most recent innovation in CT has
been the development of multidetector-array scanners thatallow, for example, two [S93] or four [B60, H41, K40,
O13] slices to be acquired in a single rotation in order toreduce scanning times for volume acquisition of data andimprove longitudinal resolution. However, the radiation
slice profiles and doses may be larger at all scan width
settings for multi-slice scanners in comparison with singleslice systems under similar conditions of exposure [M59].
Such multislice scanning may also facilitate the further
development of complex examinations with increased
imaging of the patient and so potentially lead to increases
in patient dose from CT.
52. Ultra-fast (sub-100ms) CT was proposed in the
1970's [I27] and developed in the 1980s using electron
beam (EB) technology [B61, M60]. Such EBCT scanners
have found particular application in the investigation ofcoronary artery disease [B62, L32, R30, T19], although
their total number has remained relatively small: about 73
worldwide in 1997, with installations in the United States
and Japan accounting for 47% and 26%, respectively[M61]. Doses from EBCT have been shown to becomparable to those from conventional CT scanning [M62,
M63, S76], but higher than those from helical scanning[B63]. Analysis of EBCT practice at one institution

305

indicates the following typical effective doses by type ofprocedure: 6.0 mSv for chest (25% of all EBCT), 7.2 mSv
for abdomen (20%), 6.8 mSv for pelvis (10%), 2.4 mSv forhead (3%), 2.0 mSv for cardiac function (multi-slice mode)(7%), 0.5 mSv for coronary artery calcification (singleslice mode) (30%), and 2.0 mSv for pulmonary emboli(5%) [M61].
53. In the longer term, CT may be partially replaced by
MRI. This is already the imaging modality of choice forthe central nervous and musculoskeletal systems, andapplications are being refined for the chest and abdomen
and in angiography [Z1]. The pace of change will begoverned by the high cost and availability of MRI
equipment [C34]. The provision for CT and MRI varies
widely from country to country, even within the same
health-care level; numbers of scanners per million
population are summarized in Table 4. Whereas thenumber of CT scanners has probably reached a plateau in
the United States, for example, increases can be expected
elsewhere for some time. Further refinements in CT
technology are likely [C35, D38, M64].

(c) Chest examinations
54. X-ray examinations of the chest are worthy of special
mention in view of their high frequency. The thorax is oneof the most technically challenging anatomic regions toimage radiographically due to the large differences intissue density and thickness present in the chest [R32]. The
conventional chest radiograph, utilizing a film-screen
detector, has proved a robust diagnostic aid over the lastcentury [H44]. However, technological innovations havecontinued over the last decade in the quest for optimal
imaging [L35, W50]; such advances include changes inapplied potential [A27, S80], improvements in films andscreens [H45, M66, V17], asymmetric [M67] and twin
[M65] screen-film combinations, beam equalization
systems [V18], and digital techniques such as storage
phosphor (computed) radiography [H46, I29], image
intensifier radiography [B65] and selenium drum detectors[C39, H47, L36]. Mobile x-ray units are used in hospitals
for radiography on patients who cannot be moved fromtheir beds. Such examinations are routinely performed inintensive therapy units [L34] and frequently in otherwards; collectively, they may account for nearly one half of
all chest radiographs in large hospitals [W7]. Reported
doses from some different techniques in chest radiography
are summarized in Table 20. Gonad doses are low(<0.03 mGy per exposure) when there is adequate beamcollimation [L34, N36].
55. Fluoroscopy is widely used in some countries for
conducting radiological examinations of the chest (seeTable 12). Reported patient doses are summarized in Table 15.
In general, the effective doses when using fluoroscopy arelarger than those from radiographic or photofluorographic
imaging of the chest.

306

ANNEX D: MEDICAL RADIATION EXPOSURES(d) Dental radiography
56. Dental radiography is one of the most frequent types ofradiological procedure, although the exposures to individual
patients are low. The most common techniques involve
intraoral non-screen films either to provide an image of theupper and lower teeth together (bitewing radiography) [C19]or to demonstrate full tooth structure, including pulp, root, andgum anatomy (periapical radiography). Digital subtraction
radiography techniques are also used in longitudinal studies[R14]. Alternatively, narrow-beam rotational tomography isused to view the teeth and jaw bones in a single image; suchpanoramic radiographyuses an external film in a cassette withintensifying screens and an x-ray tube that rotates around thehead to provide a tomographic image of the whole mouth[G26]. Data on frequencies and effective doses in dental
radiology reported for various countries are presented inTable 21. Entrance surface doses are summarized in Table 22.
57. Notwithstanding the relatively low levels of individual
exposure from dental radiology, the dose to the patient can besignificantly influenced by the equipment and technique used
and the quality assurance measures in place [C13, N3]. Sometypical values of effective dose per dental x-ray examination
for a range of exposure conditions are shown in Table 23;
these data indicate broad variations by factors of 8 and 2 forchanges in technique for intraoral and panoral procedures,
respectively. The effective dose from intraoral radiography isless dependent on the radiation quality of the x-ray beam thanis the case for general radiography [K42]. Optimized
techniques of periapical radiography have been shown frommeasurements in an anthropomorphic phantom to result inentrance doses of 0.51.3 mGy and effective doses of
1.13.3 µSv per exposure [L17]. In contrast, the mean
entrance surface dose for conventional dental x-ray
examinations in Romania apparently rose by about 250%
between 1980 (10.7 mGy) and 1990 (27.5 mGy), with aconcomitant tenfold increase in effective dose (0.01 mSv to0.11 mSv); this trend was attributed largely to shortcomings
in x-ray technology [D9].
58. The planning of dental implant surgeryoften requires
tomographic imaging to evaluate the dimensions of thepotential implant sites and the location of anatomical
structures. Both conventional tomography and CT areroutinely employed in dento-maxillofacial radiography[E9]. Using hypocycloidal or spiral conventional tomography, the absorbed doses to radiosensitive organs are
below 0.2 mGy. Doses from CT can be considerably
higher, with, for example, maximum doses of 38 mGy and
31 mGy being measured at the skin surface and the parotid
gland, respectively [E9], although methods for reduced
doses from helical CT have also been demonstrated [D32,
D39]. The dose from a new volumetric CT scanner,
developed specifically for dental imaging, is reported to beapproximately one sixth of that from traditional spiral CT[M27]. The use of a dedicated multimodal dental imaging
system has also been shown to involve lower doses thanalternative CT techniques [L26]. On the basis of measure-ments in a human phantom, estimates of effective dose forsuch complex film tomography range from <1 µSv to
30 µSv, depending on the anatomical location of theimaging plane and the collimation option used [F13];
similar measurements for panoramic radiography gave aneffective dose of 26 µSv.
59. Orthodontic analysis in the diagnosis and treatment ofmalocclusion disorders uses the standard imaging techniqueof cephalometry to generate reproducible images of the skull,
dentition, and facial profile soft tissues. Such cephalometricradiographs involve lateral views of the skull from a fixed
distance. The doses produced at particular anatomical sites in
the head by different experimental techniques have beenshown to vary by up to an order of magnitude [T14].
60. Direct digital imaging systems, which can provide
adequate image quality at significantly reduced doses incomparison to conventional techniques, are becoming
increasingly available for both intraoral [B28] and panoral[N4] radiography. Doses associated with charge coupleddevices (CCDs) and computed radiographysystems (photostimulable phosphor luminescence technology) have beenreported to be up to approximately 50% and 80% lower,
respectively, than those associated with conventional
techniques.
(e) Mammography
61. The number of countries with mammographyscreening
programmes has been increasing, and this trend is likely tocontinue [U3]. Initially, routine screening was generally not
carried out for women under the age of 50 [B68, D8],
although younger women have now been included in somecountries. National screening programmes are broadly
characterized by good quality control and standardization ofpractice. The doses to patients from mammography reported
for various countries are summarized in Table 24. Periodic
surveys in some countries have demonstrated reductions indose over the last decade due to improvements in quality
control and changes in technique (see, for example, [C5, C40,
F10, M7]); in other countries [L38, S82], doses have increased
due to trends for higher film optical densities and the use ofgrids for improved image quality [R34, W51]. There is no
general consensus in Europe concerning the best way forbalancing dose and image quality [V19, Z21].
62. Mammographyis generally carried out using dedicated,
special x-ray equipment that employs relatively low applied
potentials (2530 kV) and tubes with molybdenum anode/filter combinations; such equipment is sometimes mounted in
vehicles to provide mobile units for screening programmes[D41]. The mean dose to the glandular tissue is affected by thesize and composition of the breast, with the former varying
both within and between populations and the latter throughout
a woman’s life [E13]. Standard phantoms and models of thebreast are generally adopted to facilitate comparisons ofpractice, although surveys of doses to individual patients are
increasingly also being conducted (see Table 24). Recent

ANNEX D: MEDICAL RADIATION EXPOSURES

innovations in equipment that allow a choice of different
anode/filter materials (such as rhodium) and automatic
selection of applied potential offer advantages in dose andimage quality, particularly for women with relatively thickbreasts on compression [T20, Y14, Y15].
63. Digital imaging techniques are being developed that
potentially could provide lower doses than at present, while
also allowing improvements in image quality, although
their improper application could result in higher doses[A28, C41, C42, G16, K6, K45, K46, K48, N38, P1].
Other developments include the use of niobium filtration[C43], equalization techniques [P29, S84], phase contrast
imaging [A36, I32, K51], a laser-based micro-focused
x-ray source [K47], and synchrotron radiation [A29, B13,
J5]. MRI is also being developed for mammography [K1,
W52]. However, in the short term at least, conventionalfilm-screen mammography is likely to be the primarybreast imaging modality, supplemented by ultrasoundtechniques [S18].
(f) In utero exposures
64. X-ray examinations on pregnant patients may also
expose the fetus [D42]. For this reason, many such types ofprocedure are not carried out routinely without there being
overriding clinical indications, although there may also be
inadvertent fetal exposure from examinations conducted in
the very early stages of pregnancy [E14, S85]. Precise
estimates of fetal dose may require special techniques,
although uterus dose is often assumed as a surrogate [A30,
M68, O16, O17]. Typical doses to the uterus from common
types of x-ray procedure are summarized in Table 25[W30] (see also various other sources of data, including,for example [O15, S85]). The wide range of doses reported
is due to differences in equipment and technique. For
example, one study of maximum absorbed dose to anembryo from intravenous urography demonstrated a range
between hospitals of 5.8 to 35 mGy [D25].
65. X rays have also been used for more than 50 years toassess the dimensions of the maternal pelvis in pregnancy.
Such pelvimetry is usually performed in the late stages ofpregnancy if cephalopelvic disproportion or breech presentation is suspected. In the United Kingdom, for example,
pelvimetry is typically performed in connection with 1%4%
of all deliveries in an obstetric department, with over two
thirds of the centres in a national survey reporting its use as
being either static or decreasing [M29]. A range of techniques
are employed, including conventional plain film radiographyusing a grid or air-gap technique (generally involving a single
erect lateral projection, but with up to three films for postnatal
investigations), CT (generally a single lateral scan projection
radiograph, but with antero-posterior (AP) projection andaxial slices also being used), and digital radiography; MRI
pelvimetry is also under investigation. Differences in x-ray
technique lead to wide variations in the resulting dose to thefetus [T21]. Measurements at 20 centres in the United
Kingdom with an anthropomorphic phantom of a pregnant

307

woman at full term revealed mean fetal doses varying by afactor of up to about 40 [B47]. Those from conventional
pelvimetrywere in the range 0.150.75 mGy, with doses fromCT pelvimetry spanning 0.050.35 mGy. Conventional
pelvimetry (erect lateral projection) gave, on average, fourtimes the dose from CT pelvimetry (lateral scan projection
radiographs), although the use of an air gap technique resulted
in doses that were comparable to those with CT. Digitalpelvimetryusingstorage phosphor plate technology(computed
radiography) can be conducted with doses that are about 50%of those from high sensitivity screen-film systems [H50, K52].
Digital fluorography has also successfully been utilized inpelvimetry, where it allows a tenfold reduction in entrance
surface dose compared with conventional techniques [W10],
although the potential for lower fetal doses with this techniquedepends on the ease of patient positioning [B47].
(g) Bone densitometry
66. Assessment of the mineral content of bones bydensitometry is used in the diagnosis and management ofpatients with metabolic bone disease. Over the last 30 years,
a number of non-invasive radiological techniques have beendeveloped for performing quantitative measurements on bone
[G8, G41, G42, S23, S28, S87, W13]. Notwithstanding theearly use of quantitative measurements based on conventional
radiography [J14], the first commercially available specialist
technique was that of single-photon absorptiometry (SPA), in
which transmission through the patient of a scanning pencil
beam from a radionuclide source is measured with a detector.
Such measurements on bones in the arm or heel typicallyinvolve surface doses of 50 µGy and effective doses of <1 µSv[G5]. Truscott et al. [T3] have developed a portable system formeasuring bone mineral density in the pre-term neonatal
forearm, with an absorbed dose to the skin of 6 µGy.
67. Broadly similar levels of dose are achieved when theradionuclide source used in SPA is replaced by an x-ray tube,
as in the technique of single photon x-ray absorptiometry(SXA). Measurements at more clinically relevant sites weremade possible with the development of dual photon
absorptiometry(DPA), although since 1988 this technique haslargely been superseded by dual photon x-ray absorptiometry(DXA). Depending on the manufacturer, the dual energy
x-ray beam required for DXA is generated either by rapidly
switching the applied potential between 70 kV and 140 kV or
by using an energy-selective rare earth filter [B4]; flash pulses
from a portable, field emission x-ray tube have also been
investigated [S86]. First-generation DXA scanners used a
pencil beam, but the subsequent introduction of fan beams has
allowed more rapid scanning. The dose to the patient depends
on the precision of the measurement, as well as the site ofinvestigation, which is commonly the spine, femur, hip, or
whole body. Effective doses are typically 0.18 µSv per
examination, with an entrance dose of 21,400 µGy [B69,
G5, H12, K7, L9, N11, N12, N39]. The latest DXA scanners
with fan beams provide improved images with a neardiagnostic radiographic quality, although the patient dose issomewhat increased (entrance surface dose of about 900 µGy

308

ANNEX D: MEDICAL RADIATION EXPOSURES

and effective dose of 775 µSv [N12, N39]). Doses have also
been reported for DXA measurements on a 5 year old child:an entrance surface dose of 6.0 µGy and an effective dose of
0.28 µSv for PA scans of the spine, and an entrance surface
dose of 0.12 µGy and an effective dose of 0.03 µSv for total
body scans [N40].
68. Experimental devices for bone densitometry have also
been developed that are based on radiation scattering(Compton or Rayleigh) techniques, although such equipment
is not in widespread use [M69, W53]. The absorbed dose overthe volume of measurement is typically below 2 mGy withradionuclide sources [D12] and 0.1 mGywith a polychromatic
x-ray source [S23].
69. A differential measurement of cortical and cancellous
bone can be obtained from digital images provided by CT
scanners using the techniques of quantitative computed
tomography (QCT) [G5, P30]. Patient doses are relatively
high, although they are critically dependent on the detailsof the method used. For measurements on the spine with asingle energy technique, reported effective doses are
0.052.2 mSv and the surface doses between 10.4 mGy
and 33.8 mGy; corresponding effective dose data with adual energy technique range from 0.1 to 1 mSv [G5, H12,
K7, N11, N39]. QCT measurements are also performed on
the peripheral skeleton (pQCT) [L39], with an effective
dose typically of about 3 µSv [G5].
70. Bone densitometry has an important role in the
diagnosis of osteoporosis in high-risk groups and in themonitoring of treatment in particular patients, although thetechnique is not at present widely used in population-based
screening for, say, low bone mass in perimenopausal women[C10]. DXA has become the most widely used technique.
Variations in the levels of provision for DXA in different
countries are indicated in Table 26. It has been estimated thatclinical practice in the United Kingdom would ideally entail
about 175 bone scans per 100,000 population per year. The
annual collective dose from this enhanced level of
examinations would typically be around 1 man Sv; bycomparison, the total from all diagnostic examinations withx rays in the United Kingdom is about 20,000 man Sv.
71. DXA could become a tool for population screening. The
estimated worldwide total of axial DXA scanners has
increased steadily from over 6,000 in 1995 [L5] to 12,500 in
1998 [L40]; there are also over 9,000 peripheral x-ray
systems [L40]. Notwithstanding such worldwide growth in thepractice of bone densitometry, patient doses per examination
are at the lower end of the exposure range normallyencountered in diagnostic radiology. Accordingly, thecontribution to collective dose from increased numbers ofthese procedures is still likely to remain insignificant.
(h) Paediatric radiology
72. Over the last decade, paediatric radiology has become
internationallyrecognized as a subspecialitywithin diagnostic

radiology, with increasing numbers ofspecialized radiologists,
departments, and imaging equipment. Examinations ofchildren (aged 015 years) merit special consideration in viewof the increased radiation risk [R35]; the increased risk forthyroid, skin, brain, and breast cancer arising from theexposure of children is discussed further in Annex I,“Epidemiological evaluation of radiation-induced cancer”.
Specific techniques are required for assessing organ andeffective doses to paediatric patients (see Section II.B and, forexample, [A31, A32, H16, H38, H51, H52, P32, V20, V21,Z22]). There is, however, a relative lack of information on the
typical levels of dose for such examinations. A preliminary
analysis based mainly on data from the United Kingdom
suggests that effective doses to children from conventional(not digital) radiographic x-ray examinations are, in general,lower than those from conventional examinations of adults byfactors of between 2 and 10, depending on the age group[W11]. For examinations of the chest, which are by far themost frequent procedure for children, doses are generally noless than about one half of those for adults, whereas doses for
examinations of the head appear broadly independent of age.
For complex examinations involving many radiographs andfluoroscopy, such as barium meals, effective doses to children
are generally about 30%60% of those for adults. However,doses to paediatric patients from CT may be similar, or evenhigher, than the relatively high levels observed for adults[H38]. Age-specific dose data for x-ray examinations in
Poland indicate patterns similar to those described above [L7].
73. As part of the development of quality criteria fordiagnostic radiographic images in paediatrics [P31], threesurveys of entrance surface dose measurements werecarried out in Europe between 1989 and 1995 for frequent
x-ray examinations [K4]. The results of over 1,500 suchmeasurements are summarized in Table 27. For chest andskull examinations, there is a remarkable similarity
between the median values for the three age groups, withno distinct increase with age. In all cases, the distributionsof dose were very wide. Other local surveys havedemonstrated variations in practice [B70, C44, L41, O3]
and reduced levels of dose attributable to the careful choiceof equipment and technique [C45, K19, M30, M31, M32,
S88]. The main factors influencing dose for radiographic
procedures are the speed of the film-screen combinationand the use of an antiscatter grid. The main factors forfluoroscopy are the use of a grid and the operating
characteristics (dose rate level) of the image intensifier[T22]. Differences in practice have been reported between
non-specialist and specialist paediatric imaging centres.
The latter often delivered higher doses to younger children
as a result of the widespread use of a grid; doses influoroscopywere significantlylower, however [K19]. Some
examples of the doses achievable with best practice [C20]
are given in Table 28.
74. Reduced doses have also been reported from the useof digital imaging techniques in paediatric radiography.
Computed radiography has been used successfully at
speeds (using the analogy of speed classification for film-

ANNEX D: MEDICAL RADIATION EXPOSURES

screen systems) corresponding to 600 for chests and 1,000
for other examinations on children [H22]. Since few
departments in the United Kingdom appear to employ filmscreen systems with speeds greater than 400, such practicewith computed radiography is equivalent, on average, todose reductions of at least 60% (or 30% for chests). Initial
results with a novel digital x-ray device incorporating a
multiwire chamber show that it could significantly reduce
doses in paediatric imaging [K20]. The mean values ofentrance surface dose measured on samples of children
undergoing different types of radiograph were 0.08 mGy(AP spine), 0.07 mGy (PA spine), 0.13 mGy (LAT spine),
and 0.06 mGy (pelvis); entrance surface doses for aconventional imaging system were higher by a factor of
between 12 and 19.
75. Reductions have been reported in the frequency of
x-ray examinations of the urinary system and skeletal
surveys for malignant disease when radionuclide studies
are integrated into strategies for paediatric imaging [G2].
For older children, the effective dose from intravenous
urography (IVU) may be double the dose of about 1 mSv
from the alternative diagnostic technique for renal
investigation, 99mTc DMSA scintigraphy [S45].

D. ASSESSMENT OF GLOBAL PRACTICE
76. Table 29 shows some reported national averageannual individual doses (per patient and per caput) andcollective effective doses from diagnostic medical x-ray
examinations. The assessment of global practice according
to the model described in Section I.D, however, requires
knowledge of the mean values, by health-care level, of thefrequency and the dose for each type of diagnostic x-ray
examination. Although the data in Table 12 provide robust
estimates of the total numbers of examinations per 1,000
population within health-care levels I and II, the values forthe individual types of examination have had to beaveraged over different populations due to the lack ofcomprehensive information for all countries listed and so
do not represent a self-consistent set of data. Estimates of
the relative frequencies by type of examination havetherefore been made using selected national data for eachhealth-care level. When appropriatelyscaled and combinedwith typical values of effective dose per examination, thesefrequencies lead to the estimates of annual collective doses
for 19911996 shown in Table 30; the limited data
available for health-care levels III and IV have been pooled
so as to provide more reliable estimates for a combined
population. Analyses are presented separately for both
medical and dental x-ray examinations. The roundedvalues of effective dose for each examination category are
either based on the data in Table 15 or, particularly in thecase of health-care levels IIIIV, are estimates in theabsence of more specific data. Derived average effective
doses per examination and per caput are also shown. The
percentage contributions to annual frequencyand collective
dose due to the various types of diagnostic medical x-ray

309

examination are analysed by health-care level in Table 31.
The uncertainties inherent in the estimates of meanfrequencies and doses provided by the global model are
difficult to quantify, but will be significant, particularly
when extrapolations have been made on the basis of small
samples of data.
77. According to the model developed, the global annual
frequencies and doses assessed for 19911996 aredominated by the national practices in health-care level I;
about 80% of the estimated global collective dose frommedical x rays arises from examinations conducted in theseparticular countries, which together account for about onequarter of the world population. The most important
examinations in terms of the overall frequency of medical
x rays are those of the chest and the limbs and joints,
whereas the global collective dose is dominated by themore complex, but less frequent, procedures such as CT
and examinations of the gastrointestinal tract. Significant
differences are also apparent between the mean frequencies
and doses for the different health-care levels. For example,
the contributions from CT are markedlyless for health-carelevels IIIV relative to level I, and chest fluoroscopy
appears particularly important for health-care level II due
to its very high utilization for the large population ofChina. Practice with dental x rays has been assessed to beconsiderably smaller than that from medical x rays; theglobal frequency and collective dose are less than thecorresponding values for medical x rays by factors of morethan 3 and 100, respectively.

E. TRENDS IN DIAGNOSTIC RADIOLOGY
78. Trends in the global use of medical x rays are
summarized in Figure IV in terms of increases, relative to theprevious assessment for 19851990 [U3], in some key
indicators of annual practice; small changes are unlikely to besignificant in view of sampling differences and uncertainties
in the estimated values. Whereas there has been an increasein global population by about 10% between studies, theestimated global total number of examinations has grown by
about 20% and therefore the frequency per 1,000 population
has increased by about 10%. The overall mean effective dose
per examination has risen by about 20% and the annual
collective effective dose by nearly 50%. Differences in thepatterns of practice between the assessments for 19851990
and 19911996 are highlighted in Figure V, which illustrates
the relative contributions by examination type to the global
collective dose from medical x rays. Most notably, increases
in contributions are apparent from CT, angiography andinterventional procedures, with there being decreased
contributions for examinations of the gastrointestinal tract andchest photofluorography. The global annual collective
effective dose from dental x-ray examinations estimated for19911996 is about 20% lower than the collective effective
dose equivalent estimated for the previous assessment [U3];
the inherent differences in magnitude between these two dosequantities expected for dental exposures have already been

310

ANNEX D: MEDICAL RADIATION EXPOSURES

35
CONTRIBUTION TO COLLECTIVE DOSE (%)

1.5

1.3

1.2

1.1

30

1991-1996

25
20
15
10
5

Head

Cholecystography

Mammography

Limbs and joints

Pelvis and hip

Chest photofluoroscopy

Abdomen

Urography

Chest radiography

Interventional

Angiography

Lower GI tract

Lumbar spine

Upper GI tract

Global population

Annual totalof examinations

Annual frequency
per 1,000 population

Annual collective dose

Effective dose
per examination

Annual effective dose
per caput

Chest fluoroscopy

0

1

CT

RELATIVE INCREASE

1.4

1985-1990

Figure IV. Temporal trends in global practice with medical
x-ray examinations: average frequencies and doses for
1991-1996 relative to previous estimates for 1985-1990.

Figure V. Percentage contributions by examination typeto global collective dose from medical x-ray examinations: comparison of data for 1955-1990 and 1991-1996.

noted (Section II.B). The present estimate of effective dose
per caput is about 30% lower than the figure assessed
previously for dental x rays. In light of the considerable
variations in the reported national data concerning the
distributions by age and sex of patients undergoing various
types of diagnostic x-ray examination (Table 14), it is difficult
to discern any specific trends in the mean values relative toprevious data. The average levels of x-ray equipment per
million population estimated for the various health-care levels
and time periods are summarized in Table 7, although thesignificant differences that exist between individual countriesof the same health-care level and the limited sample sizes
should also be noted (Table 4). However, the analysis suggests
a broad trend for reducing numbers of medical x-ray
generators per million population in health-care level I andhence also in the world. There is an apparent increase in the
average number of medical x-ray examinations per medical
x-ray generator, with estimates of 2,500 for 19911996 and2,100 for 19851990.

1. Frequencies of examinations

79. Overall trends in radiation exposures from diagnostic
examinations with x rays are due to two kinds of change:changes in both the type and frequency of the procedures
carried out, as determined by the prevailing patterns ofdisease and clinical practice; and changes in the associatedlevels of dose to individual patients for given procedures.
Doses are influenced by the continuing advances intechniques for the production, detection, and control ofradiation, including the development of alternative modalities
for diagnosis, as well as by initiatives in quality assurance andpatient protection [A34, H54, H55, R36, R37]. Trends in thefrequencies of examinations and doses per examination are
discussed further in the two Sections following.

80. Temporal trends in the annual frequencies of all diagnostic medical x-ray examinations per 1,000 population aresummarized in Table 32. The present estimates of average
total frequency for health-care levels I (920 per 1,000) and II(154 per 1,000) are larger than the previous values for19851990 (890 and 120 per 1,000, respectively), although
the averages for each time period have been made overdifferent populations; any comparisons of data for health-carelevels III and IV are less reliable owing to the limited sample
sizes involved. Notwithstanding these overall trends inaverage frequency for the different health-care levels of the
global model, national frequencies have increased in somecountries and decreased in others between 19851990 and19911996; some specific examples are given below.
Temporal trends in the average annual numbers of different
types of diagnostic medical x-ray examination per 1,000
population by health-care level are summarized in Table 33.
The annual frequencies of diagnostic dental x-ray examinations per 1,000 population for different countries and time
periods are summarized in Table 34, together with theaverage values for each health-care level.
81. Increases in the annual total numbers of examinations
and frequencies per 1,000 population have been reported forsome countries, accompanied also by significant changes in
the patterns of practice for individual types of procedure. For
example, in the Czech Republic, the annual number of
medical x-ray examinations rose from 8,100,000 in 1990 to
9,150,000 in 1994, with particularly large increases observedfor CT and mammography due to the installation of new
equipment and also some changes in the system of healthANNEX D: MEDICAL RADIATION EXPOSURES

82. Elsewhere, practice has remained more static or has
shown some decreases. In Bulgaria, the annual frequency of
medical x-ray examinations rose from 220 per 1,000
population in 1950 to a peak of 1,170 per 1,000 in 1980,
before falling to a level of 560 per 1,000 in 1992;
corresponding values of effective dose per caput were
0.4 mSv, 1.79 mSv and 0.72 mSv, respectively for theseparticular years. In Russia, the annual frequency of medical
x-ray examinations rose from 1,340 per 1,000 population in1980 to a rate of 1,560 per 1,000 in 1985, since when it has
fallen to a level of 1,230 per 1,000 in 1997; corresponding
values of effective dose per caput for these particular years
were 1.26 mSv, 1.32 mSv and 0.80 mSv, respectively.
However, the frequency of dental x-ray examinations in
Russia rose steadily from 74 per 1,000 population in 1985 to
96 per 1,000 in 1997. In the Ukraine, the frequency of x-ray
examinations has decreased from 948 per 1,000 population in
1987 to 600 per 1,000 population in 1994, with the effective
dose per caput decreasing correspondingly by about a factor 2[K18]; these reductions were due in particular to decreases in
the numbers of examinations being performed in the regions
contaminated by the accident at Chernobyl and in theutilization of the higher-dose fluoroscopic procedures. In
Ghana, estimates of the annual frequency of x-ray examinations during the period 1990 to 1996 ranged from 6 to 11 per
1,000 population, with there being no simple pattern [S38]. In
Germany, the increase in the annual frequency of x-ray
procedures between 1988 and 1992 has been slight overall,with increasing practice in CT, angiography, and interventional radiology offsetting a marked decrease in examinations of the gastrointestinal, biliary, and urinary tracts [A2].
The frequency of medical x-ray examinations has also
remained fairlyconstant in the United Kingdom between 1983
and 1993, although the frequency of dental x-ray examina-

tions has increased by over 30% [T15]. Large increases werealso reported for CT, mammography, angiography and interventional procedures, with substantial decreases apparent for
examinations that have been partially replaced by endoscopy(barium meals) and ultrasound (biliary and urinary systems).
In contrast, the overall frequency of medical (excluding
dental) x-ray examinations in Romania decreased by about
20% between 1980 and 1990, with the somewhat larger
decreases (over 30%) for fluoroscopy and photofluorography
being offset by an increase of over 20% for radiography [D1];a subsequent analysis of all types of x-ray examination during
19901995 has suggested a fairlystatic total annual frequency(495 versus 511 per 1,000 population), although there havebeen further reductions in collective dose [D28]. In South
Africa, the overall annual frequency of x-ray examinations(excluding mass miniature and dental) in 1990 was reported
to be 180 per 1,000 population, although marked differenceswere observed between race groups, with rates of 67 per 1,000
for blacks, 110 for coloureds, 230 for Asians, and 460 for
whites [M22]. In Canada, variations in the frequency of
medical x-ray examinations between the different provinces
ranged from 708 per 1,000 population to 1,043 per 1,000,
with the national mean value being 892 per 1,000 [A15].
83. Developments in imaging technology, particularlythose
involving non-ionizing radiation, will have a significant
influence on the practice of radiology and on the medical
exposure of populations. Transfer of technology is likely to be
most rapid in developed countries, categorized as health-carelevel I. MRI is becoming the imaging modality of choice formany areas of anatomical examination, although its widescale adoption was initially hampered by relatively long
imaging times and high equipment cost [Z1]. The number of500

Conventional x rays

450
NUMBER OF EXAMINATIONSPER 1,000 POPULATION

insurance. In Cyprus, the annual frequency of medical x-ray
examinations rose steadily from 794 per 1,000 population in1990 to 1,021 per 1,000 in 1995. In Poland, the annual
number of x-ray examinations per 1,000 population rose from
572 to 715 between 1986 and 1996 [S49]. Increases wereobserved for examinations of the spine, CT, photofluorography and mammography, with there being decreases forurographyand examinations of the upper gastrointestinal tract
due probablyto an increased use of ultrasound. In Norway, thetotal frequency of radiological examinations increased from
641 to 710 per 1,000 inhabitants between 1983 and 1993,
with the most significant trends being for increased numbersof CT examinations and, owing to the introduction ofalternative procedures, reduced numbers of examinations of
the gastrointestinal tract [O6]. In Malaysia, almost all
examinations experienced increasing frequency from 1990 to
1994, with the exceptions of barium studies, cholecystography
and urography owing to an increasing use of ultrasound andfibre-optic endoscopy [N26]. The most notable increases wereobserved for CT, cardiac procedures and mammography. Datafor the United States indicate an estimated increase of between
30% and 60% in the numbers of radiological examinations in
hospitals between 1980 and 1990, with CT being an important
influence [M1].

311

400
Ultrasound
60
40

CT

20
MRI
10
5
Vascular intervention
01987 1988 1989 1990 1991 1992 1993 1994 1995 1996
YEAR

Figure VI. Trends in diagnostic radiology practice in the
Netherlands [B89].

MRI studies worldwide grew from 6 million in 1989 to 18
million in 1995, with the total number of installed MRI
systems having risen from 2,800 to 9,400 over this period[D23]. In contrast to MRI, ultrasound represents a relatively
cheap, portable, and increasingly sophisticated form ofimaging [W1]. Fibre-optic endoscopes allow direct visualiza-

312

ANNEX D: MEDICAL RADIATION EXPOSUREStion of the gastrointestinal tract and not only complement but
also replace some x-ray examinations [W2]. For example,
surveys in the United Kingdom for one particular region(population 4.7 million) from 1986 to 1992 showed a steadyincrease in the annual frequency of endoscopies (uppergastrointestinal endoscopies and colonoscopies), from 8.4 to
10.0 procedures per 1,000 population, whereas there was acorresponding decline in barium studies (meals and enemas),from 12.9 to 10.1 procedures per 1,000 population [S36]. The
trends in diagnostic radiology practice in the Netherlands
between 1987 and 1996 are summarized in Figure VI [B89];
although the number of conventional x-ray examinations per
1,000 population has remained fairly constant, there havebeen increases in practice with CT, MRI and ultrasound.
84. Economic growth in South-East Asia is allowing
significant improvements in general health care, and basic
x-ray services are becoming available in most rural areas[M2]. Disease patterns in urban centres are becoming
similar to those in Europe and North America, although ashortage of staff and a lack of standardization in training
remain areas of concern in this part of the world.

13.9 Gy cm2 and 25.3 Gy cm2, respectively, for enemas [B14].
A second study, however, reported similar or even higher
levels of dose from digital compared with conventional
equipment (4.9 Gy cm2 and 3.8 Gy cm2, respectively, formeals and 16.7 Gy cm2 and 20 Gy cm2 for enemas), owing toincreased levels of exposure during the fluoroscopic part ofsuch examinations [H10].
87. For digital radiography systems, exposure can bepreselected in a broad range so that patient dose can beadapted to the diagnostic problem and the image quality
necessary. Photostimulable phosphor computed radiographyoffers the important advantages of high imaging efficiency
over a wide exposure range and the presentation of images atconsistent display levels independent of exposure levels [B71,
F21]. The greater reliability of the image reproduction canlead to a reduction in the numbers of repeat films needed
because of incorrect exposure [C1, P33, W55]. Reduction ofpatient dose per image is in general limited by considerationsof image quality (signal to noise ratio), although lower doses
have been reported for particular applications of computed
radiography compared with doses from conventional
techniques [J15, S89,W8].

2. Doses per examination
85. The average values of effective dose per examination
derived from surveys by UNSCEAR are summarized inTable 35 by type of examination, health-care level and time
period. Any analysis for trends is hampered by the averaging
of doses over different populations and the uncertainties in thedata. However, there are perhaps broad suggestions for
reductions in typical dose with time for some radiographic
examinations, such as pelvis and hip, and head, and for an
increase in the dose per CT procedure between 198090 and19911996. Overall, the estimate of 1.2 mSv for the global
mean effective dose per medical x-ray examination during
19911996 (Table 30) is larger than the corresponding valueof 1.0 mSv estimated for 19851990. This trend is likely to be
due to the increasing use of complex and higher dose imaging
procedures, particularly CT, in developed countries.
86. There are continuing developments in equipment andtechniques for imaging [S90]. Film technology continues toadvance, focusing on grain and emulsion structure in both thefilm and intensifying screen and on better spectral matchingof the screen-film combination [F22, S1]. Conventional film
images of high quality can be obtained with comparatively
low patient doses, although there are still large differences inimage quality for similar speed systems, depending on the
manufacturer and on the screen-film combination [G1].
Digital radiological techniques offer the potential for improved
image quality, although this is in general at the expense ofhigher patient doses. The impact of introducing such
equipment depends somewhat on the choice of exposure
settings and the techniques in use [K55]. For example, digital
fluoroscopic systems were shown in one particular analysis toresult in significantly lower levels of dose-area product during
barium studies compared with non-digital systems:
7.8 Gy cm2 and 24.2 Gy cm2, respectively, for meals, and

88. For digital fluorography, spatial resolution is comparable to that with the 100 mm film technique, although
lower than that for full-size, film-screen radiography. Imageintensifier-TV-based digital systems were shown in one study
to reduce patient effective dose during examination of theabdomen by factors of at least 5 for a given projection whencompared with conventional medium-fast film-screen combinations [M3]. In digital subtraction vascular imaging, theinput dose to the image intensifier can vary significantly(typically 520 µGy per frame) depending on the particularsettings selected [S3]; this dose is considerablyhigher than formodern digital fluorography(typically0.51.5 µGyper frame)or for standard radiography with a fast (400 speed) filmscreen combination (typicallyless than 5 µGyper radiograph).
Accordingly, there is a potential for high patient doses in DSA
as a result of the capability for rapid acquisition of images andthe frequent use of long series of images for subtraction.
89. The introduction of digital imaging leads tosignificant changes in operational practices in radiology
departments [C46, D43, K53, L42, V22]. The use of
improper technique could result in higher patient doses.
The increasing adoption of digital technology provides
opportunities for advances in the post-processing ofimages, computer-aided diagnosis, and medical image
management within and between hospitals using PACS
systems [S91]. Such systems will allow better monitoringof radiology practice and help reduce patient exposuresfrom the loss of films [H1, W56]. Initial developments
came in the United States and Japan, but both large- andsmall-scale projects are now under way in European
radiology departments [S4]. The transmission of digitalradiographic images for remote consultation (teleradiology)
promises to enhance practice in radiology, particularly forfacilities at which services are otherwise deficient [L12,ANNEX D: MEDICAL RADIATION EXPOSURES

W54]. However, the increasing utilization of digital
imaging technology in developed countries, particularly
CT and advances such as helical and dynamic CT
scanning, is likely to result in further increases in the
global average dose per examination.
90. Notwithstanding the proliferation of increasingly
complex x-ray technology in developed countries, WHO has
since the 1970s concentrated on developing design criteria forequipment to provide basic radiography, so as to lessen theinequity in imaging services around the world. The mostrecent version is known as the WHO Imaging SystemRadiography(WHIS-RAD) [W12]. WHO-specified equipment
is currentlyproduced byseveral leading manufacturers, and by
1995 about 1,000 units had been installed in 60 countries.
However, health services have failed to adopt the system to thedegree that had been expected, despite its ease of use; there
were, for example, only 39 units operating in nine countriesof the Americas in 1997 [B33].
91. Novel digital x-ray imaging systems that employ
improved detector technologyand offer potential reductions inpatient dose by up to two orders of magnitude in comparison
with film-screen systems are under development [A35, L43,
Y4]. These devices employ various approaches based on
phosphor x-ray converters, where light quanta are produced
as an intermediate stage, as well as direct x-ray-to-charge
conversion materials such as gases and, using thin-film
transistor andcharge-coupled device (CCD) technologies, zinccadmium telluride, amorphous selenium, and amorphoussilicon [A33, C47, H53, M70, R38]. Self-scanned flat-panel
detectors could in principle provide high-qualityradiographic,
fluoroscopic, or fluorographic images [S92, Z23]. In addition
to such large-area devices, trials are in progress of a prototype
low-dose imaging system based on a scanning beam geometry[S2].
92. More speculative developments in imaging are underinvestigation, including the use ofsynchrotron radiation [C48,
K56, L44, M5], phase-contrast imaging using polychromatic
hard x rays [W6], time-gated imaging using x rays from alaser-produced plasma [G44], and a compact radiologicalsource based on electron cyclotron resonance magnetic mirror
discharge [B2]. Also, the recent availability of large-arraybiomagnetometer systems is facilitating the development oftechniques of magnetic source imaging, in whichmagnetoencephalographyis combined with MRI to map brain
activity for the purposes of guiding neurosurgicalinterventional procedures [G15]. It has been argued, however,that radiology practice is on balance likely to be more affectedin the medium term by the maturing of existing technologies
than by the innovative modalities under development [Y1].

3. Quality assurance and patient protection
initiatives
93. Measures that facilitate the achievement and maintenance of good practice in diagnostic radiology will have313

some influence on the frequency of examinations and levels ofpatient dose [T16]. In general, such initiatives can be
expected to decrease doses per examination and per caput
doses worldwide, owing to reductions in repeated and unnecessary exposures [D44, K54, M71]. Among the topics ofrelevance will be the implementation of quality assurance
measures in radiology departments, including accreditation
under formal quality systems [I1] and audits of practice [G43,M72, V23, W58, W59]; the training and education of persons
involved with medical radiation, including clinicians,
technicians, physicists, and administrators [I2]; the promulgation ofbasic recommendations on patient protection [I3,I5, I17]; and guidance on the rational and effective use ofimaging [H30, W3, W4, W5].
94. Several studies have highlighted the problem of
unnecessary exposures. An analysis in the United
Kingdom, for example, suggested that at least 20% of
examinations were clinically unhelpful to patientmanagement and, without any clear justification, should
not have been performed [N2]. Guidelines [C49, R1] forthe appropriate use of diagnostic radiology have beenfound to reduce selectively the rates of referral by primarycare physicians (general practitioners) [R2]. Clinical audit,
which is a retrospective analysis of performance that isclosely linked to the mainly prospective process of quality
assurance, is likely to play an increasingly important rolein the control of radiology. In Romania, a study ofradiology practice at a sample of 130 hospitals in 1995
observed that about 23% of the radiographs produced wereof no diagnostic utility; this rate equates, on a national
scale, to a total of 2 million such radiographs [D6]. Over
50% of darkrooms in the study were found to haveexcessive illumination.
95. Dose reductions attributable to the influence of
patient protection measures have been reported in several
large studies. A review in 1995 of national dose data in the
United Kingdom revealed an average 30% reduction overa 10-year period in the mean levels of entrance surface
dose and dose-area product for common types ofradiograph and x-ray examination [H11, W57]. The main
identifiable reason for this dose reduction was the more
extensive use of faster film-screen combinations, facilitatedby the coherent combination of a national protocol forpatient dose measurements and systematic advice on
patient protection, including national reference dose levels[N41, S6]. Fewer than 10% of hospitals exceeded thenational reference doses in 1995, compared with 25% in
1985. Such reductions in the collective dose fromconventional x-ray examinations in the United Kingdom
will, however, have been offset by the much increased useof CT [S10]. Practice in CT can be expected to be
influenced in due course by the development of quality
criteria for CT examinations, which include reference doselevels [E4]. The applicability of similar European quality
criteria to radiographic images of adult patients has beenassessed widely in surveys involving some 3,000 dose andimage quality measurements in about 100 hospitals [C6].

314

ANNEX D: MEDICAL RADIATION EXPOSURES

Even as these surveys show the persistence of wide
variations in performance, they provide clear evidence thathigher doses prevailed when there was little or nocompliance with recommended techniques [M11].
96. Significant dose reductions have also been demonstrated over a 5-year period at a large teaching hospital in
Madrid as the result of a systematic programme for the
optimization of patient protection, which included
implementation of patient dosimetry and quality control[V1]; in particular, between 1986 and 1990 effective doses
for studies of the gastrointestinal tract were reduced byabout 50% as a result of replacing deficient fluoroscopic
equipment (from 10.7 mSv to 4.9 mSv for barium meals
and from 9.4 mSv to 6.8 mSv for barium enemas), whiledoses from examinations of the spine fell by about 40%
owing to changes in film cassettes and tube filtration (from0.31 mSv to 0.18 mSv for cervical spine and from 2.2 mSv
to 1.4 mSv for lumbar spine). In contrast, there wereincreases over this period in the mean doses per
examination from CT (from 5.7 mSv to 6.5 mSv) andangiography (from 12 mSv to 13 mSv) and increases by afactor of 2 in the contributions from these procedures tototal collective dose (with 25% due to CT and 17% fromangiography in 1990).
97. A pilot international programme on radiation doses
in diagnostic radiology, which involved two series ofmeasurements in seven countries on three continents,
achieved considerable reductions in dose, without
deterioration of diagnostic information, by the applicationof simple and inexpensive methods [I4, O8, O18]. Average
reductions of about 50% in entrance surface dose werereported following increases in tube filtration, applied
potential and film-screen speed. These methods led tosignificant improvements between surveys in thepercentage of x-ray rooms complying with reference dosevalues suggested bythe European Commission [C6]: initialand final levels of compliance were 20% and 75% forlumbar spine (PA), 29% and 36% for chest (PA), 75% and100% for abdomen, and 0% and 100% for breast.
98. Dose reductions from changes in equipment or
technique, without any significant effect on the diagnostic
efficacy of examinations, have also been reported bynumerous individual studies. These include, for example,
the use of rare earth intensifying screens for radiography[G33, J4, S55], lower tube currents during fluoroscopy[S21], pulsed fluoroscopy [V12], review of grid usage influoroscopy [L30, S52], additional filtration [G30], andregion-of-interest (ROI) radiologic imaging [G32, K25,
M43, S59]. The latter involves placement, between the
x-ray source and the patient, of a filter which attenuates thebeam peripheral to the ROI. Reported dose reductions
associated with the introduction of such filters are as
follows: 70% in dose-area product during fluoroscopy [L1]and factors of 310 in skin dose during imaging inneurointerventional radiology [R5].

F. SUMMARY
99. The utilization of x rays for diagnosis in medicine
varies significantly between countries (Tables 4, 8 and 12).
Information on national practices that has been provided to
the Committee by a sample of countries has been
extrapolated to allow a broad assessment of global practice,although inevitably there may be significant uncertainties
in many of the calculated results. On the basis of a global
model in which countries are stratified into four healthcare levels depending on the number of physicians relative
to the size of population, the world annual total number of
medical x-ray examinations for 19911996 is estimated to
be about 1,900 million, corresponding to a frequency of
330 per 1,000 world population (Table 9); previous
estimates of these quantities for 19851990 were 1,600
million and 300 per 1,000 population, respectively. The
present global total of examinations is distributed amongst
the different health-care levels of the model as follows:
74% in countries of level I (at a mean rate of 920 per 1,000
population), 25% in countries of level II (150 per 1,000
population) and 1% in countries of health-care levels
IIIIV (20 per 1,000 population). In addition to such
medical x rays, there is also an estimated global annual
total of about 520 million dental x-ray examinations,corresponding to a frequency of 90 per 1,000 world
population; the assumed distribution between health-carelevels is for over 90% to occur in level I and <0.1% inlevels IIIIV. Notwithstanding the estimated meanfrequencies of examination for each health-care level
quoted above, there are also significant variations in thenational frequencies between countries in the same healthcare level (Tables 32 and 34).
100. The estimated doses to the world population fromdiagnostic medical and dental x-ray examinations are
summarized in Table 36. The global annual collective
effective dose from medical x rays for 19911996 isestimated to be about 2,330,000 man Sv, equating to an
average dose per caput of 0.4 mSv; previous estimates ofthese quantities for 19851990 were 1,600,000 man Sv
and 0.3 mSv, respectively. The distribution of collective
dose among the different health-care levels of the global
model is presently as follows: 80% in countries of level I(giving a mean dose of 1.2 mSv per caput), 18% in
countries of level II (corresponding to 0.14 mSv per caput)
and 2% in countries of health-care levels IIIIV(corresponding to 0.02 mSv per caput). Diagnostic dental
x-ray examinations are estimated to provide a further
annual collective dose to the world population of about
14,000 man Sv, equating to about 0.002 mSv per caput;
these values are less than the corresponding estimates for19851990 of 18,000 man Sv and 0.003 mSv per caput,
although uncertainties in all these estimates are
considerable and this apparent trend may not be real.
Approximately 68% of the present global collective dosefrom dental x rays arises from countries in health-carelevel I, with contributions of about 31% and <1% fromhealth-care levels II and IIIIV, respectively.

ANNEX D: MEDICAL RADIATION EXPOSURES

101. The numbers of x-ray generators (excluding dental
units) available for diagnostic radiology vary considerably
between countries and the health-care levels of the global
model (Table 4), with estimated averages per million
population of 0.5, 0.2 and 0.02 for levels I, II and IIIIV,
respectively (Table 9). The estimated average annual
number of medical x-ray examinations per medical x-ray
generator is lower for countries of health-care levels IIIIV(value of 1,100) than for those of level II (2,300) or level I(2,700). The estimated average values of annual collective
dose per medical x-ray generator follow a similar global
pattern: 1.2 man Sv per unit in levels IIIIV, 2.0 man Sv
per unit in level II, and 3.6 man Sv per unit in level I.
102. The estimated global mean effective dose per medical
x-ray examination for 19911996 is 1.2 mSv (Table 30),
which may be compared with the level of 1.0 mSv estimated315

for 19851990. However, the levels of dose to individual
patients vary significantly between the different types of
examination and also countries (Tables 15 and 16). The
contributions to collective dose provided by the different
categories of examination are summarized in Table 31 byhealth-care level. On a global scale, population exposure frommedical x rays is now dominated by CT (which provides 34%of the annual collective dose), rather than examinations of theupper gastrointestinal tract (12%) which was estimated to be
the most important procedure for 19851990 (Figure V). This
new pattern also applies for countries of health-care level I,
where the mean contribution from CT is presently 41%,
although the dominant practices elsewhere are chest
fluoroscopyin health-care level II (50% of collective dose) andexaminations of the lower gastrointestinal tract in levels
IIIIV (34%), with CT providing contributions of only 5%
and 2%, respectively.

III. DIAGNOSTIC ADMINISTRATIONS OF RADIOPHARMACEUTICALS
103. Administration of radionuclide preparations (radiopharmaceuticals) to patients, broadly referred to as nuclear
medicine, is widely practiced throughout the world. The
procedures are primarily intended for diagnostic purposes.
Many of the diagnostic applications of radionuclides are
conducted in vitro rather than in vivo. For example, about
100 million procedures with such material were performedin the United States in 1989, although only 10% of these
involved the administration of radiopharmaceuticals directly
to patients [N13]. The remaining 90% of practice comprised
radioimmunoassay procedures, which use small amounts ofradioactive material in the analysis of biological specimenssuch as blood and urine and do not give rise to the exposureof patients; these uses are not considered further in thisreview. Diagnostic in vivo examinations are discussed in thisSection, and less-frequent therapeutic nuclear medicine
procedures are considered in Chapter V.

A. TECHNIQUES
104. Whereas the broad aim in diagnostic radiology is theimaging of anatomy, the practice of nuclear medicine is moreclosely linked to the investigation of patho-physiologicalprocesses. In essence, radionuclides are used as a biologicaltracer by incorporating them into a pharmaceutical
appropriate to the nature of an investigation; key technicaladvances are summarized in Table 37. Following administration of the radiopharmaceutical to the patient, the resulting
biodistribution and localization is dictated by the pharmaceutical preparation used, with the radionuclide label providing the means of detection. Most procedures involve some
type of measurement concerning the retention or excretion of
the tracer so as to quantify organ or tissue function. Probe
detectors can be used to measure uptake in particular organs
such as the thyroid, whereas imaging is carried out using

rectilinear scanners with single or double detectors or, morecommonly, with a large field of view gamma camera.
105. Diagnostic techniques with radiopharmaceuticals arewidely utilized in medicine; clinical applications include
oncology [B80, M83, M84, R41, V26], cardiology [B81, P40,
P41, Z26, Z27], neurology and psychiatry [E17], andendocrinology, as well as the investigation of infection andinflammation [N47, P38, P39] and various biological systems(musculo-skeletal, respiratory, gastrointestinal and genitourinary) [M25, P8]. In oncology, for example, important roles
for nuclear medicine include detecting unknown primarysitesof cancer, differentiating between benign and malignant disease, staging the extent of disease (local, nodes andmetastases), planning and assessing the response to therapy,
and detecting recurrence [C18]. Alternatively, dilution
techniques, based on the measurement of activity in samples
of body fluids, can be used, for example, in haematology toassess plasma volume, red cell mass, total body water,
extracellular fluid, and exchangeable electrolytes [P8]. The
activities administered are determined by the diagnostic
information required within the chosen period of theprocedure [M86]. International [E10, E16, G48, I5] andnational (for example, [A20, F25, M85]) guidance is available
concerning the techniques and typical activities for common
procedures.
106. In practice, a range of radionuclides are used indiagnostic nuclear medicine that meet the necessary
requirements for effective and efficient imaging. All are
produced artificially, using four principal routes ofmanufacture: cyclotron bombardment (producing, forexample, 67Ga, 111In, 201Tl, 57Co, 123I, 11C, 15O, 13N, and 18F);
reactor irradiation (51Cr, 75Se, 59Fe, 58Co, 125I, and 131I, forexample); fission products (yielding, for example, 131I,
133
Xe and 90Sr); and generators that provide secondary

316

ANNEX D: MEDICAL RADIATION EXPOSURES

decayproducts from longer-lived parent radionuclides. The
most common example of the latter is the column
generator incorporating 99Mo for the provision of 99mTc
which, because of its highly suitable physicalcharacteristics for a wide range of applications, forms thebasis for over 80% of the radiopharmaceuticals used innuclear medicine. Most 99mTc generators utilize fissionproduced 99Mo, although techniques of neutron irradiation
could provide a viable alternative source of this importantparent radionuclide [B82, K61]. Other examples ofgenerators include those incorporating 113Sn (for theprovision of 113mIn), 81Rb (for 81mKr), and 68Ge (for 68Ga).
107. In addition to conventional planar imaging,techniques have also been developed to allow emission
tomographywhich, like x-rayCT, can demonstrate internal
structures or functional information from cross-sectionalslices of the patient [I24]. Two basic modalities have
evolved. The most common is that of single-photon
emission computed tomography (SPECT). This utilizes
conventional gamma-emitting radiopharmaceuticals and isoften performed in combination with planar imaging.
SPECT imaging requires a scanning system incorporatinga circular array of detectors or, more often, a rotating
gamma camera system with up to four detector heads. The
second modality is the more specialized technique of
positron emission tomography (PET). This is based on thesimultaneous detection of the pairs of photons (511 keV)arising from positron annihilation and mostly uses theshort-lived biologically active radionuclides 15O, 11C, 18F,
and 13N. Dedicated PET scanners comprise a circular arrayof detectors, although PET imaging can also be performed
using coincidence-adapted gamma camera systems [B83,
J8, L50]. Quantitative functional tomographic imaging
requires correction for the attenuation of photons by thepatient, and this can be accomplished by transmission
measurements made before, after, or during the emission
scan, using an external radionuclide source [B39]. Suchtransmission measurements add little to the typical doseroutinely received in clinical SPECT or PET; theadditional dose is typically <0.1 mSv [A40, T12].
108. Radionuclides are also used for the intraoperative
localization of tumours and lymph nodes using surgical
nuclear probes and a range of radiopharmaceuticals [C53, P9,
R13, S104, T13, W62]. Such practice has, for example,
increased steadily in the United Kingdom since 1980, with a
total of 68 surgical procedures being undertaken at 35
hospitals over a 15year period [P10]. Probe detectors andmobile gamma cameras also allow bedside nuclear medicine
investigation in the intensive-care unit [P11].

the route of administration, the biokinetics and physiologicalfate of the radiopharmaceutical, and the decay scheme of theradionuclide [I35, M87, R42]. Absorbed doses to the variousorgans and tissues are generally estimated using the dosimetric formalism developed by the Medical Internal
Radiation Dose Committee of the United States Society of
Nuclear Medicine (MIRD) [L51, S105]. Broadly, thisapproach involves knowledge of the cumulative activities ineach source organ, together with estimates and summation of
the absorbed fractions of energy in every target organ fromeach source organ. Cumulative activities are derived on thebasis of quantification of organ uptake in human studies
using, for example, SPECT and PET imaging, or
extrapolation from animal models [D47, L52, M87, S105].
Specific absorbed fractions are estimated by Monte Carlocalculations [L53, Z28] using anthropomorphic mathematicalphantoms; values are available for standardized phantoms
representing typical adult, paediatric and pregnant patients[S105, S106]; more realistic voxel phantoms are also being
developed for use in internal dosimetry [J19, P42, Y18].
110. Coefficients derived using this methodology havebeen published that allow the estimation of organ andeffective doses to adults and children from administeredactivities for a wide range of commonly usedradiopharmaceuticals [I19, I37, I39]. Data are alsoavailable for some new radiopharmaceuticals (see, forexample, [A41]) and for other computational techniques[J20, J21]. The administration of radiopharmaceuticals topatients also gives rise to the exposure of other populationgroups, such as breast-feeding infants [M88, M89],
although these doses are not considered further in thisreview. The average doses to specific organs provided byconventional macroscopic dosimetry can grossly
underestimate radiation exposures to individual cells[A42]. New methods of cellular dosimetry are being
developed for assessing the risks associated with newpharmaceuticals that target specific cells and cellularcomponents with short-range radiations, such as Auger
electrons [B84, F24, H63].
111. Patient doses for common types of procedure aresummarized principally in this review in terms of theadministered activities for each radiopharmaceutical,
although some typical values of effective dose are included
and estimates of collective effective dose are used broadly
to characterize overall practice.

C. ANALYSIS OF EXPOSURES
1. Frequency of examinations

B. DOSIMETRY
109. The radiation doses to patients resulting fromadministrations of radiopharmaceuticals are determined bya range of physical and biological factors which include theamount and form of the radioactive material administered,112. The use of radiopharmaceuticals in medical diagnosis isless widespread than the use of x rays. There are large
variations in practice from country to country, with nuclear
medicine examinations not being performed at all in somesmaller countries or LDCs. Annual numbers of diagnostic
administrations of radiopharmaceuticals reported by different

ANNEX D: MEDICAL RADIATION EXPOSURES

countries for the years 19911996 are summarized inTable 38 by type of procedure and for all diagnostic practice.
Data are presented in terms of numbers of administrations per
1,000 population, with some analysis byradionuclide and withcountries grouped according to health-care level. Thesenational figures were often estimated in quite different ways,
and some particular qualifications to the data are given in thefootnotes. The percentage contributions of each type of
examination to total frequency are given in Table 39. Meanvalues of frequencies have been derived for each health-carelevel by averaging total numbers of procedures over total
populations.
113. There are significant differences in the patterns ofpractice between countries, even for those within the same
health-care level. National annual total frequencies vary by afactor of over 100 in the 36 countries in health-care level I
utilizing nuclear medicine (0.565 examinations per 1,000
population); disregarding countries with zeropractice, smaller
variations exist in level II (0.62.1 examinations per 1,000
population in a sample of nine countries), level III (0.050.6
examinations per 1,000 population in a sample of three
countries), and level IV (0.010.02 examinations per 1,000
population in a sample of two countries). The average totalfrequencies for levels II, III, and IV are smaller than the
average for level I (about 19 examinations per 1,000
population) by factors of about 17, 70, and 1,000, respectively.
These averages are less (by at least a factor of 50 in the caseof level I) than the corresponding average use of x rays fordiagnostic examinations at each level.
114. Notwithstanding differences between the individual
countries, some general differences are apparent in thepatterns of use between the broad health-care levels. For
countries in level I, practice is dominated by bone scans, withsignificant contributions also from thyroid scans,
cardiovascular studies, liver/spleen scans, and lung studies. In
the United States, for example, 90% of practice in 1991 wasaccounted for by just 10 in vivo diagnostic procedures,
although over 150 different types of nuclear medicine
procedure were in use [N13]. For countries in levels IIIV,
thyroid studies are the most important type of procedure.
Temporal trends in the frequency of examinations are
discussed in Section III.E.
2. Exposed populations
115. The distributions by age and sex of patients undergoing
various types of diagnostic nuclear medicine procedure in
19911996 are presented in Table 40 for selected countries ofthe four health-care levels; additional information about someof these data is included in the footnotes. This analysis uses
the same three broad ranges of patient age as were used for
x-ray examinations, above, and in the UNSCEAR 1993
Report [U3]. Some country-to-country differences in age
distribution are evident for each particular type of examination, even within the same health-care level. Previous
analyses have suggested that diagnostic nuclear medicine islargely conducted on populations of patients who are in

317

general older than those undergoing x-ray examinations andthus also older in comparison with whole populations [U3].
This conclusion is broadly supported by the present survey,
although significant numbers of procedures, particularlyrenal
and brain scans, are conducted on children. As for broaddifferences in practice between the health-care levels, there isfor most types of procedure a shift towards the two younger
age ranges for countries in levels IIIV compared withcountries in level I. This is likely to reflect the known
differences in national population age structures [U3].
116. Notwithstanding the preponderance of cardiovascularstudies on males and thyroid studies on females, thedistributions of nuclear medicine examinations between thesexes do not deviate greatly from the underlying patterns forwhole populations, although some national variations areapparent in the data reported for particular types of procedure.
3. Doses
117. The typical activities administered in different countries
for different types of diagnostic procedure in 19911996 arepresented in Table 41. The average activities shown for key
radiopharmaceuticals within each health-care level include
weightings for the numbers of such administrations in eachcountry. Some reported values of effective dose for common
procedures, calculated from administered activities using
standard dosimetric methods [I19, I37], are shown in
Table 42. Typical effective doses from PET imaging arepresented in Table 43, together with estimates of thecorresponding mean doses to the uterus. Further data are
given elsewhere concerning uterine doses for other nuclear
medicine procedures (for example, [A20]) and doses to theembryo/fetus of pregnant patients [M90, R43, R44, S107]. In
general, the typical effective doses from diagnostic nuclear
medicine procedures span a similar range to those fromdiagnostic x-ray examinations.
118. Diagnostic procedures on children are conducted usinglevels of administered activity that are lower than thecorresponding values for adult patients [E16, S41]. The
administered activities are generally scaled according to bodysurface area or weight [A20]. When following the latter
scheme, the resultant effective doses tochildren will in general
be roughly the same as those to an adult. Examples of theeffectivedosestopaediatric patients undergoing some common
procedures are given in Table 44 [G47].
119. Abnormally high local tissue doses may result when
there is partial or complete extravasation of the activity
intended for intravenous administration [K64, P8]. For
example, maximum local doses of 128 Gy (from 740 MBq
99m
Tc extravasated into 0.5 ml) and 378 Gy (74 MBq of
201Tl) have been estimated on the assumption of no
biological clearance, although doses in practice are likely
to be substantially lower and no deterministic effects havebeen observed [B85, T24]. The absorbed doses to particularorgans can be reduced through modifications to practiceduring some nuclear medicine procedures [I38].

318

ANNEX D: MEDICAL RADIATION EXPOSURES

D. ASSESSMENT OF GLOBAL PRACTICE
120. Table 45 shows some reported national average annual
individual doses (per patient and per caput) and collective
effective doses from diagnostic nuclear medicine procedures.
In order to provide a systematic assessment of practiceworldwide, national data from the UNSCEAR Survey ofMedical Radiation Usage and Exposures have been combinedon the basis of the global model of population described in
Section I.D. The resulting annual frequencies estimated forcommon types of diagnostic nuclear medicine procedures are
summarized in Table 46. These data have been derived withrounding by scaling the average relative frequencies observedfor each health-care level (Table 39) by the average totalfrequencies per 1,000 population (Table 38); the mean
procedure-specific frequencies in Table 38 can not be useddirectly since averaging has been carried out over different
populations as a result of the incomplete sets of national data
available. Table 46 also includes final estimates of collective
dose on the basis of the doses per procedure shown, which areassumed broadly to be representative of practices for thedifferent health-care levels. Derived average effective doses
per procedure and per caput are also shown. The percentage
contributions to annual frequency and collective dose due tothe various types of diagnostic nuclear medicine procedure are
analysed by health-care level in Table 47. The uncertainties
inherent in the estimates of mean frequencies and doses
provided by the global model are difficult to quantify, but will
be significant, particularly when extrapolations have been
made on the basis of small samples of data. In particular,
uncertainties are likely in the frequencies of thyroid studies,
where uptake scans will sometimes have been included in thenational frequencies reported for thyroid scans, and in theeffective doses from such studies, which can depend criticallyon the level of uptake in the thyroid. In general, the present
analysis of patient exposures has been hampered bythe variety
of different radiopharmaceuticals in use for each type ofprocedure and the often incomplete data provided on national
practices.

different health-care levels. In particular, thyroid studies
are dominant in the lower health-care levels (III and IV).

E. TRENDS IN DIAGNOSTIC PRACTICE
WITH RADIOPHARMACEUTICALS
1. Frequencies of examinations
123. Temporal trends in the annual frequencies of all
diagnostic nuclear medicine procedures per 1,000 population
are summarized in Table 48. The present estimates of average
total frequency for health-care levels I (19 per 1,000) and II(1.1 per 1,000) are larger than the previous values for19851990 (16 and 0.5 per 1,000, respectively), although theaverages for each time period have been made over different
populations; comparisons of data for health-care levels III and
IV are less reliable owing to the limited sample sizes involved.
Notwithstanding these overall trends in average frequency forthe different health-care levels of the global model, nationalfrequencies for individual countries have increased in someand decreased in others between 19851990 and 19911996;
some specific examples are given below. Temporal trends inthe average annual numbers of different types of diagnostic
nuclear medicine procedures per 1,000 population by healthcare level are summarized in Table 49.

121. The present analysis suggests that the global annual
frequencies and doses for diagnostic nuclear medicine in19911996 are dominated by the national practices in healthcare level I, with about 80% of the estimated global collective
dose arising from procedures conducted in these particularcountries. This finding is similar to that for diagnostic x-ray
examinations, although the magnitudes of the two practices
are quite different; the annual numbers of nuclear medicine
procedures and their collective dose are less than thecorresponding figures for medical x rays byfactors of about 60
and 15, respectively. However, the overall mean dose per
nuclear medicine procedure (4.6 mSv) is larger than that per
medical x-ray examination (1.2 mSv).

124. The annual number of in vivo nuclear medicine
examinations performed in hospitals in the United States
increased by about 16%, from approximately 6.4 million to
7.4 million (30 per 1,000 population) between 1980 and 1990,
slower than the projected growth rate of 8% per year for thisperiod [M1]. This was mainly the result of the virtual
disappearance of 99mTc pertechnetate brain scintigraphy and99m
Tc sulphur colloid liver imaging, which have been replacedby other modalities such as CT and MRI, although cardiac
and pulmonary procedures doubled their share of total studies.
This pattern reflects different underlying trends. On the one
hand there has been increasing use of alternative techniques
providing high-contrast, high-resolution imaging as
replacements for poorer-resolution nuclear medicine procedures for the detection and definition of pathologicalanatomy. On the other hand, pathophysiologically oriented
nuclear medicine studies made significant progress as new
radiopharmaceuticals (such as myocardial perfusion andcerebral blood flow agents), instrumentation (such as SPECTand PET), and computers and hardware (allowing, forexample, renal function evaluation) became available [N13].
A further analysis of procedure volume in the United States
showed virtuallyno increase on a national scale between 1992
and 1993 [T2]. The frequency of procedures in Canada is also
likely to have remained fairly static between 1989 and 1993
[A15].

122. The most important procedures in terms of both theoverall frequency of nuclear medicine procedures and theglobal collective dose are bone scans, cardiovascularstudies and thyroid studies, although significant differences
are apparent between the practices assessed for the125. Similar trends for increases in overall practice havebeen observed elsewhere. For example, in the Slovak
Republic, annual numbers of diagnostic procedures increasedby an average of 2.5% per year between 1985 (4.7 per 1,000
population) and 1992 (5.6 per 1,000) [F8]. Comparison of

ANNEX D: MEDICAL RADIATION EXPOSURES

319

national data for the United Kingdom in 1982 and 1990
indicates an overall increase of 14% (to a level of 8 per 1,000
population) in the annual number of administrations(corresponding to an average of about 2% per year); a rise of
22% in imaging studies was, however, offset by a 30%
decrease in the number of non-imaging investigations [E1].
There was less frequent use of radionuclides for brain andliver investigations owing to the greater availability of CT and
ultrasound, whereas bone, lung, renal, and cardiac nuclear
medicine studies increased in frequency. The estimatedcollective dose of 1,400 man Sv for 1990 represents anincrease of about 50% over the estimate for 1982 [H3].
Practice in the United Kingdom increased by a further 15%
between 1990 and 1993, probably due to a greater usage of
myocardial perfusion and lung ventilation/ perfusion studies[E11, W63]. The trends observed in Germanyfor the different
types of procedure have been broadly similar to those in the
United Kingdom described above [K12]. In New Zealand, thefrequency of diagnostic administrations rose by 12% between
1983 (7.5 per 1,000 population) and 1993 (8.4 per 1,000),with a large increase in bone scans offsetting reduced numbersof brain scans and liver/ spleen studies [L28]. Analyses ofpractices in Romania for 1990 and 1995 have shown a 12%
increase in examination frequency and a 15% decrease incollective dose [I36]. A reduction in collective dose has also
been observed in Finland between 1994 (220 man Sv) and1997 (207 man Sv) as a result of reduced usage of 131I andessentially constant total numbers of procedures [K59]. In
Denmark, total numbers of diagnostic procedures rose from76,433 in 1993 to 77,483 in 1995. Numbers of procedures
have also risen in the Czech Republic, with totals of 236,819
in 1990 and 292,927 in 1994.

are changing nuclear medicine practices [M91, P2]. The
general trend is from diagnosis to prognosis, with the focus ofresearch in pharmaceuticals moving from organs to cells,
extracellular to intracellular processes, chemistry to biology
and diagnosis to therapy [G49, I34]. In particular, there isincreasing interest in the labelling of bioconjugates, such as
antibodies, peptides and receptor-specific molecules, sincethese bioactive molecules offer the promise of selectively
carrying radionuclides to specific sites for effective imaging(and therapy) [B86, P44]. Over 80% of the radiopharmaceuticals presently used in diagnostic nuclear medicine arebased on 99mTc; this dominance is likely to continue throughthe development of new complexes for functional imaging.
New 99mTc-labelled agents are able to replace a number of
established agents on the basis of improved convenience,
imaging, and dosimetry. There is, for example, increasing
interest in 99mTc-based agents for myocardial perfusion
imaging, brain perfusion, renal function, infection andinflammation, and tumour imaging [C54, D2]. Advances incell labelling and the formulation of complex biologicalagents, such as monoclonal antibodies, are providing novel
imaging applications using radioimmunoscintigraphy [K2].
However, 131I is still widely used in many countries and has
been the main reason for the observed higher effective doses
per examination in developing countries compared withindustrialized countries [U3]. The contribution of 131I to thecollective dose from diagnostic nuclear medicine practicevaries considerably between countries: for example, about
90% for Romania [I6], 59% for the Islamic Republic of Iran
[M10], 39% for the Slovak Republic [F8], 17% for Taiwan
Province of China [L6], 10% for Finland [K59], 3% for theUnited Kingdom [H3], and 0.1% for Australia [C7].

126. Somewhat greater increases in practice have beenreported elsewhere. For example, in Australia there was a
50% increase in the frequency of nuclear medicine procedures
between 1980 (8 per 1,000 population) and 1991 (12 per
1,000), corresponding to an average of 4.5% per year [C7];
the annual per caput effective dose from diagnostic procedures
doubled, however, over this period (to 64 µSv). The number
ofradiopharmaceuticals in use grew to approximately60, with
99m
Tc-, 201Tl-, 67Ga-, and 131I-based materials dominating. In
Cyprus, diagnostic practice rose from a total frequency of 2.7
procedures per 1,000 population in 1990 to 6.4 per 1,000 in
1996. In the Islamic Republic of Iran, the annual number ofdiagnostic nuclear medicine procedures increased by 42%
over the years 19851989 (average annual rate of about
10.5% per year), to 1.9 per 1,000 population [M10]. In
Russia, however, the frequency of nuclear medicine
procedures fell from 15 per 1,000 population in 1990 to 13 per
1,000 in 1997.

128. Continuing developments in physics and instrumentation are improving the utility of nuclear medicine and arelikely to influence patterns of practice, particularly indeveloped countries [K65, L54, S90]. The SPECT
technique is becoming increasingly important in threedimensional imaging, facilitated by the use of multiheaded
camera systems, digital circuitry, and increased computer
power [G3, T25]. Hybrid systems have also been developed
to allow both SPECT and PET imaging (so-called
coincidence-adapted cameras). The development of newcompounds for labelling with short-lived positron-emitting
radionuclides, such as 15O, 11C, 13N, and 18F, is creating an
enormous potential for metabolic tracer imaging andphysiological studies through the use of PET [G51, H64,
J22, L55, L56, M92, S42, U16, W64]. Over 1,000
compounds have been labelled to study specific biochemical processes and physiologic function by PET [I34].
One estimate for the extent of PET in 1997 suggested a
total of about 70 centres worldwide conducting studies at
a rate of 46 patients per working day [A15]. There are
now over 60 scanners installed in Germany and 30 inJapan; elsewhere the availability of PET is more limited,
with, for example, Russia having 2 functioning scanners(with a further 2 in planning) [K16] and Argentina having
the only PET scanner in Latin America [B88]. The
expansion of PET on a larger scale will depend on the

2. Diagnostic practices
127. The role of nuclear medicine in patient care is beingenhanced through advances in physics, computer sciences,medicinal chemistry, molecular biology and clinical care
[B87, G50]. Important developments in radiopharmaceuticals

320

ANNEX D: MEDICAL RADIATION EXPOSURES

availability in hospitals of cheaper equipment, appropriate
radionuclides, and approved radiopharmaceuticals [F26,J23, W65]; technical developments can be expected toprovide solutions to some of these problems [C8].
129. Significant reductions in patient dose during cardiac
clinical investigations have been reported from the use of
a novel camera employing a gas-filled multiwire chamber
detector in combination with the short-lived radionuclide
178
Ta [L2]. This equipment is now commercially available
and, in comparison with a conventional gamma camera, isclaimed to involve dose levels that are 20 times lower thanthose for 99mTc and 200 times lower than those for 201Tl.

F. SUMMARY
130. A wide variety of radiopharmaceuticals are administered diagnostically to patients to study tissue physiology andorgan function. The utilization of diagnostic nuclear medicine
varies significantlybetween countries (Tables 4, 8 and 38) andbroad estimates of worldwide practice have been made fromthe limited national survey data available using a global
model, although the uncertainties in this approach are likely
to be significant. The world annual total number of proceduresfor 19911996 is estimated to be about 32.5 million,
corresponding to a frequency of 5.6 per 1,000 world population (Table 9); previous estimates of these quantities for19851990 were 24 million and 4.5 per 1,000 population,
respectively. The present global total of procedures is
distributed amongst the different health-care levels of themodel as follows: 89% in countries of level I (at a mean rateof 19 per 1,000 population), 11% in countries of level II (1.1
per 1,000 population), and <1% collectively in countries ofhealth-care levels III (0.3 per 1,000 population) and IV (0.02

per 1,000 population). Notwithstanding the estimated meanfrequencies of examination for each health-care level quoted
above, there are also significant variations in the nationalfrequencies between countries in the same health-care level(Table 48).
131. The estimated doses to the world population fromdiagnostic nuclear medicine procedures are summarized inTable 50. The global annual collective effective dose for19911996 is estimated to be about 150,000 man Sv,
equating to an average dose per caput of 0.03 mSv; theseestimates are similar to previous figures for 19851990(160,000 man Sv and 0.03 mSv, respectively), despite theincrease (by over 20%) in the frequency of procedures. The
distribution of collective dose amongst the different healthcare levels of the global model is presently as follows: 82% incountries of level I (giving a mean dose of 0.08 mSv per
caput), 15% in countries of level II (corresponding to
0.008 mSv per caput), 2% in countries of health-care level III(corresponding to 0.006 mSv per caput), and 0.1% incountries of health-care level IV (corresponding to<0.001 mSv per caput). The contributions to collective dosefrom the different categories of procedure are summarized inTable 37. Globally, practice is dominated by bone scans,
cardiovascular studies and thyroid studies, with the latterbeing particularly important in countries of the lower healthcare levels (III and IV).
132. Overall, diagnostic practices with radiopharmaceuticals
remain small in comparison with the use of x rays; the annual
numbers of nuclear medicine procedures and their collective
dose are only 2% and 6%, respectively, of the corresponding
values for medical x rays. However, the mean dose perprocedure is larger for nuclear medicine (4.6 mSv) than for
medical x rays (1.2 mSv).

IV. TELETHERAPY AND BRACHYTHERAPY
133. Therapeutic uses of ionizing radiations are quite
different in purpose from diagnostic radiologicalprocedures. The aim in radiotherapy is to achieve cytotoxic
levels of irradiation to well-defined target volumes of thepatient, while as far as possible sparing the exposure ofsurrounding healthy tissues. Treatments generally involve
multiple exposures (fractions) spaced over a period of time
for maximum therapeutic effect. Radiotherapy is an
important treatment modality for malignant disease, often
in combination with surgery or chemotherapy [M77, S97,
S98, W22]. The utilization of radiation treatment inoncology varies significantly between the different sites of
disease and also countries. In the United States, forexample, about 41% of all new patients with cancer in1995 received radiation treatment, with specific rates forsome particular sites/conditions being 80% for lung, 70%
for breast, 30% for uterine cervix, 75% for uterine bodyand 1% for leukaemia [I23]. Corresponding radiotherapy
utilization rates for cancer patients in Russia in 1995 were23% (all cancer patients), 21% (lung cancer), 2% (breast
cancer), 68% (uterine cervix), 7% (uterine body) and 3%(leukaemia) [C50]. Less commonly, radiation is also usedin the treatment of benign disease [O19].
134. The clinical intention in radiotherapy may be either
the eradication of cancer (curative treatment) or the reliefof symptoms associated with it (palliative treatment [U14]).
Most radiotherapy is carried out with radiation generators
or encapsulated (sealed) radionuclide sources using thetechniques of teletherapy and brachytherapy, as discussed
below; these techniques are often used together. Less
frequent therapeutic practice with unsealed radionuclides(radiopharmaceuticals) is considered in Chapter V. In viewof the intense radiation sources used in radiotherapy andANNEX D: MEDICAL RADIATION EXPOSURES

the very nature of such treatments, there is a significant
potential for accidents that would have serious
consequences for the health of both patients and staff; such
incidents are discussed further in Chapter VII.

A. TECHNIQUES
135. The principal treatment modality in radiotherapy iswith external beams of radiation from x-ray or sealed
radionuclide sources focused on the target volume (teletherapy). X-ray beam therapy machines are broadlyclassified into kilovoltage units (40300 kV) and, for deepseated tumours, megavoltage (or supervoltage) units (above
1 MV) [P34]. Kilovoltage units are further classified into
contact units (4050 kV), superficial units (50150 kV),and orthovoltage (deep therapy) units (150300 kV).
Contact, superficial and orthovoltage machines utilize
conventional x-ray tubes, whereas megavoltage therapy isbased on photon beams from linear accelerators (LINACS)
typically operating up to 25 MV or sealed radionuclide
sources, principally 60Co. Superficial treatments can also be
carried out using electron beams from LINACS. In the
United Kingdom, for example, approximately 15% of
patients at the larger radiotherapy centres are treated withelectrons, mostly using a single static field technique[A18]. Therapeutic irradiations are generally partial-bodyin nature, although large-field techniques are also used:
total-body irradiation in conjunction with bone marrowtransplantation for the treatment of leukaemias, hemi-body
irradiation for the palliation of painful bone metastases,
mantle irradiation in the treatment of lymphomas, andirradiation of the whole central nervous system in thetreatment of medulloblastoma [S24, W22]. Radiotherapy
with external beams seeks to provide an optimal
distribution of dose to the target volume relative to normal
tissue. This aim is pursued through careful planning anddelivery of treatment. The process involves appropriate
attention to radiation type, beam energy, and field size as wellas the use ofmultifield techniques, individual blocks, multileaf
collimators, wedges, bolus material, compensators,
immobilization devices, simulation, port films, on-line digital
imaging devices, and in vivo dosimetry.
136. The second important treatment modality in radiotherapy is brachytherapy, in which an encapsulated source
or a group of such sources is positioned on or in the patient
by surface, intracavitary, or interstitial application so as todeliver gamma or beta radiation at a distance of up to a few
centimetres [D46]. Radium-226 sources, on the basis ofwhich many brachytherapy techniques were developed, are
not ideal, and the trend, particularly in developed
countries, is for their replacement by a variety of artificial
radionuclides [T4]. Sources may be implanted temporarilyor permanently using four basic techniques of application:
direct implantation into body tissues, as in conventional
interstitial therapy; implantation of holders, applicators, ormoulds preloaded with sources (as in intracavitary andsurface therapy); positioning of empty sleeves, containers,

321

or applicators for the manual afterloading of sources; andremote afterloading of sources into applicators bymechanical transport along a coupling to a storage safe
[S25].
137. Permanent brachytherapyimplants are generallyusedfor deep-seated tumours such as cancers of the pancreas,
lung, brain, pelvis, and prostate, often for palliative
treatment [S25]. The most commonly used sources are 125I,
198
Au, and 103Pd, either as individual grains (seeds) or
loaded in sutures. Temporary implants of 192Ir (wire orpellets), 137Cs (needles or pellets), and 60Co (pellets) areused for superficial and easily accessible tumours.
Interstitial applications are used in treatments of the breast,
head and neck, cervix, vagina, rectum, and prostate. The
intracavitary implant technique is routinely used in thetreatment of carcinomas of the cervix, vagina, andendometrium. Intraluminal implants, using a special
applicator or catheter, are used in the treatment ofcarcinomas of the oesophagus, bronchus, and bile ducts[S26]. Removable ophthalmic plaques are used for treating
malignant melanoma of the uvea and other tumours of theeye [H19]; medium-sized and large tumours are usuallytreated with 103Pd or 125I applicators, and small tumours
with beta-ray applicators incorporating 106Ru or 90Sr.
138. Brachytherapy is often used in combination withexternal beam therapy [W22]. For example, in the
management of cancer of the cervix, teletherapy is used totreat the parametria and pelvic nodes, with intracavitary
treatment being used principally for the primary tumour.
Tumours of the tongue and breast are often given preliminary
treatment byteletherapy, with brachytherapyproviding a boost
in the dose to the primary tumour. Various multi-centre
studies are in progress to investigate the efficacy ofendovascular brachytherapy treatment for the inhibition ofrestenosis after angioplasty [W29].
139. Conventional low-dose-rate (LDR) brachytherapy
using 137Cs (or 226Ra) sources involves dose rates at theprescribed point or surface in the range 0.42.0 Gy h1,with most treatments given over a period of several days in
one or possibly two fractions; higher-activity 137Cs sources
can provide medium dose rates (MDR) of up to 12 Gy h1.
High-dose-rate (HDR) brachytherapy utilizes 192Ir or 60Co
sources to provide even higher dose rates, generally
25 Gy min1, with treatment times reduced to hours oreven less and perhaps using several fractions [B5, I14].
Remote afterloading is essential, from a radiologicalprotection point of view, for HDR and MDR techniques.
Other developments in radiotherapy are discussed below in
Section IV.E.2 in relation to trends in the practice.

B. DOSIMETRY
140. The success of radiotherapy depends on the accurate
and consistent delivery of high doses of radiation to
specified volumes of the patient, while minimizing the322

ANNEX D: MEDICAL RADIATION EXPOSURES

irradiation of healthy tissue. Detailed assessment of thedose for individual patients is critical to this aim, andtechniques for dosimetry and treatment planning are welldocumented; see, for example, publications from ICRU
[I11, I12, I13, I14, I15, I16, I21, I33], IAEA [I8, I9, I10,
I20], and others [A12, B18, B19, W24], as well as various
codes of practice (see, for example, [K10, N14, N17, N43,T6]). Special treatment and dosimetry techniques are
required for pregnant patients to minimize potential risks
to the fetus from exposure in utero [A37, M74, S27];
approximately 4,000 such women required treatment for
malignancy in the United States in 1995. Radiotherapy cancause permanently implanted cardiac pacemakers tomalfunction, and special techniques have been
recommended for the planning and administration oftreatment on such patients [L21]. Quality assurance
measures and dosimetry intercomparisons are widely
recommended to ensure continuing performance toaccepted standards [D3, D13, K3, K14, N18, N44, W14].
141. Broadly, the elements of clinical radiation oncology
include assessment of the extent of the disease (staging);
identification of the appropriate treatment; specification ofa prescription defining the treatment volume (encompassing the tumour volume), intended tumour doses andconsideration of critical normal tissues, number of fractions, dose per fraction, frequency of treatment, and overall
treatment period; preparation of a treatment plan toprovide optimal exposure; and delivery of treatment andfollow-up. X-ray imaging, and CT in particular, is widelyused throughout this process; applications include theassessment of disease, preparation of the plan, checking thelocation of brachytherapy sources, or, using treatment
simulators, checking correct patient set-up for externalbeam therapy. In view of the largely empirical nature ofcurrent practice in radiotherapy, significant variations areapparent in the dose/time schedules used in the treatmentof specific clinical problems [D19, D24, G20, N19, P4,
U14].
142. In vivo dosimetry is conducted to monitor the actual
dose received by the patient during treatment in order tocheck the accuracy of delivery and as a means of determining the dose to critical organs, such as the lens of the eyeor the spinal cord [E5, M17]. Both TLD [D18, K24] andsolid state [A9, B34, C15, E6, S94, V4, W36] detectors areused. In vivo dosimetry is particularly useful duringconformal radiotherapy [L46]. Also, electron spin resonance (ESR) in dental enamel has been investigated as apotential means of retrospective dosimetry for validating
doses delivered to the head and neck regions [P7]. Portal
films and digital imaging devices visualizing exit fields areused to verify the positional accuracy of external beams
during treatment and, increasingly, to provide quantitative
dosimetric information [A8, S31, T10]. Radiochromic filmis also used for quantitative planar dosimetry to map dose
distributions, for example, in low- and high-dose-ratebrachytherapy, stereotactic radiosurgery, and beta-ray
ophthalmic plaque therapy [N42, Z7].

C. ANALYSIS OF EXPOSURES
1. Frequency of treatments
143. Differences in the resources available for radiotherapy lead to wide variations in national practice, with manysmaller countries or LDCs having no treatment facilities or
only a few. Annual numbers of treatments reported bydifferent countries from 1991 to 1996 are summarized inTables 51 and 52 for teletherapy and brachytherapy
procedures, respectively. The data are presented in termsof numbers of treatments per 1,000 population by diseasecategory, with countries grouped according to health-carelevel. Important qualifications regarding the derivation ofsome of these figures are given in the footnotes. The
percentage contributions by disease category to the annual
total frequencies of radiotherapy treatments are shown in
Tables 53 and 54 for teletherapy and brachytherapy,
respectively. Mean values of frequencies have been derived
for each health-care level by averaging total numbers ofprocedures over total populations.
144. Patterns of practice vary significantly from country tocountry, even within a single health-care level. Annual
frequencies of teletherapy treatments differ by a factor of over
30 within the sample of 28 countries in health-care level I(0.13.7 treatments per 1,000 population); disregarding
countries with zero practice, similarly large variations exist inlevel II (0.053.1 treatments per 1,000 population in a sample
of 19 countries) and level III (0.052.1 treatments per 1,000
population in a sample of 6 countries). Information wasavailable from only one country in health-care level IV(United Republic of Tanzania: 0.05 treatments per 1,000
population). The average total frequencies for teletherapy inlevels II and III are smaller by factors of 2.2 and 3.2, respectively, than the average for level I (about 1.5 treatments per
1,000 population). These averages are verymuch less than thecorresponding average for the use of x rays in each level.
Teletherapytreatments are, in general, also less common than
diagnostic nuclear medicine procedures, by a factor of over 10
in the case of level I, but by nearer a factor of 2 for the lower
levels. The average frequency of brachytherapy treatments inlevel I (0.2 treatments per 1,000 population) is less than one
seventh of that for teletherapy. In levels II and III, practice inbrachytherapy is lower by a factor of about 10 compared withlevel I.
145. Notwithstanding differences between the individual
countries, some broad patterns of practice in radiotherapy
are apparent from the average frequencies of use for thedifferent health-care levels. In general, teletherapy is
widely used in the treatment of breast and gynaecologicaltumours, although there is also significant use for treatments of the prostate and lung/thorax in countries oflevel I, and for treatments of the head/neck in levels II and
III. Brachytherapy practice is universally dominated bytreatments of gynaecological tumours. Temporal trends inthe frequency of examinations are discussed in
Section IV.E.

ANNEX D: MEDICAL RADIATION EXPOSURES

2. Exposed populations
146. The distributions reported by different countries of
the age and sex of patients undergoing teletherapy andbrachytherapy treatments for various diseases in19911996 are presented in Tables 55 and 56, respectively.
As was done for previous analyses of exposed populations,
three ranges of patient age have been used, and the countries are listed by health-care level; some qualifications to
the data are given in the footnotes. As might be expected
since radiotherapy is primarily employed in the treatmentof cancer, therapeutic exposures are largely conducted onolder patients (>40 years), with the skew in ages being
even more pronounced than for the populations of patients
undergoing diagnostic examinations with x rays orradiopharmaceuticals. However, significant numbers ofchildren undergo teletherapy for the treatment of leukaemia and lymphoma. Once again, countries in the lower
health-care levels exhibit a shift towards the younger age
ranges for most treatments, relative to level I countries,
probably as a result of underlying differences in national
population age structures [U3].
147. For certain teletherapyand brachytherapyprocedures,
there are obvious links to patient sex, for example, thetreatment of breast and gynaecological tumours in females
and prostate tumours in males. For other treatments, there
is a general bias towards males in the populations ofpatients.
3. Doses from treatments
148. In the present review, the doses received by patientsfrom radiotherapy are summarized in terms of the prescribed doses to target volumes for complete courses oftreatment, as discussed in Section I.C. The typical prescribed doses reported bydifferent countries for 19911996
are presented in Tables 57 and 58 for practices inteletherapy and brachytherapy, respectively. The average
doses shown for each type of treatment and health-carelevel include weightings for the numbers of treatments ineach country. Prescribed doses are typically in the range
4060 Gy for most treatments, with somewhat lower doses
being used in relation to radiotherapy for leukaemia andbenign disease.
149. Some information is available concerning the doses
to individual organs and tissues during radiotherapy
treatments and examples can be given (see, for example,[D45, G46, H56, H57, L47, T23]). In vivo and phantom
measurements have been performed to study inhomogeneities in dose during total body irradiation prior to bonemarrow transplant [B37, B38]. A comparison of two
commonly used techniques for external beam therapy ofnasopharyngeal carcinoma concluded that the extended
neck technique generally resulted in lower doses to mostnormal structures, although the flexed neck techniqueprovided better coverage and uniformity of dose to thetarget volume [W27]. Measurements have been reported in323

relation to the distributions of dose over different bodyparts for patients undergoing radiotherapy treatments in
Bangladesh [B44, M26]. A study of the doses to 13 specificsites in children undergoing radiotherapy for Hodgkin’s
disease has demonstrated wide variations between individual patients in a multicentre European cohort [S43].
During the treatment of cervical cancer with external 60Co
therapy in Mexico, the mean doses to the circulating bloodand lymphocytes were estimated by probabilistic modelingto be about 2% and 7%, respectively, of the tumour dose[B24]. Dosimetric modeling for ophthalmic brachytherapyof the sclera with an ideal 90Sr applicator has indicated adose rate to the most radiosensitive areas of the lens of theeye ranging from 88 to 155 mGy s1 [G24].
150. In teletherapy with photon beams, the doses at great
distances from the target volume arise from several
sources: radiation scattered in the patient; leakage andscattered radiation from the treatment head of the machine(the collimator-related radiation); and radiation scatteredfrom the floor, walls, or ceiling [V6]. The first and thirdcontributions depend on field size, distance, and photon
energy and can be measured and applied generally. The
second contribution is machine-dependent and in principle
requires measurement for individual machines; collimator
scatter varies according to specific design, although levelsof leakage radiation are rather similar for all modern
equipment, corresponding to an average value of 0.03 ±0.01% (relative to the central axis dose maximum) in thepatient plane at a distance of 50 cm from the beam axis.
When the distance between the gonads and the primarybeam is large (around 40 cm, for example, in the treatmentof breast cancer), gonad dose is determined primarily by
the leakage radiation. Specific data have also been reported
in relation to the peripheral dose during therapy using a
LINAC equipped with multileaf collimation [S96]. Leakage radiation might not be insignificant during highenergy electron treatments, although the associated risks topatients should be judged in the context of the therapy[M14].
151. The broad ranges of gonad doses from photon
teletherapy treatments for some specific tumour sites
shown in Table 59 are based on measurements in a patient
population [V6]. The minimum and maximum values are
determined not only by the range of tumour doses considered but also by the range of field sizes and distances
encountered in clinical practice, with due account taken of
the variation in distance to the gonads between men andwomen. For treatments in the pelvic region, gonad doses
can range from tens of milligrays to several grays, depending on the exact distance from the centre of the treatment
volume to the gonads.
152. In brachytherapy, where radiation sources areinserted directly into the body, the dose to peripheralorgans is determined primarily by their distance from thetarget volume. The decrease in dose with distance from abrachytherapy point source can be described by the inverse

324

ANNEX D: MEDICAL RADIATION EXPOSURES

square law, modified by a factor to account for scatter andabsorption in tissue, and experimental data have beenreported to allow the estimation of dose in the range
1060 cm from 60Co, 137Cs, and 192Ir sources [V6].
153. The skin-sparing nature and clinical efficacy of highenergy photon beams can be compromised by electron
contamination arising from the treatment head of themachine and the air volume, and comprehensive
dosimetric assessment requires taking into consideration
the effect of this component on the depth-dose distribution[H58, S12, Z8]. Electrons and photons with energies above
8 MeV can produce neutrons through interactions withvarious materials in the target, the flattening filter, and thecollimation system of the LINAC, as well as in the patient[K17]. For a typical treatment of 50 Gy to the target
volume using a four-field box irradiation technique with
25 MV x rays, the additional average dose over the irradiated volume from such photoneutrons is estimated to beless than 2 mGy and quite negligible in comparison withthe therapeutic dose delivered by the photons [A10]. The
average photoneutron dose outside the target volume would
be about 0.5 mGy under the same circumstances, and for
peripheral doses this component could be similar inmagnitude to the contribution from photons [V6]. Highenergy x-ray beams will also undergo photonuclear
reactions in tissue to produce protons and alpha particles[S95], with total charged particle emissions exceedingneutron emissions above 11 MeV [A11]. However, thesecharged particles have a short range, so any additional doseto the patient will mostly be imparted within the treatment
volume and will be insignificant.

D. ASSESSMENT OF GLOBAL PRACTICE
154. The data in Tables 51 and 52 provide robust estimates of the annual total numbers of teletherapy andbrachytherapytreatments per 1,000 population within eachhealth-care level; the frequencies of teletherapy in levels II
and III may have been overestimated since some of thenational data used refer to numbers of cancer patients
rather than treatments, although these sources of uncertainty will be reduced when considering global practice.
However, the mean values shown in Table 51 and 52 forthe individual types of treatment within each health-carelevel have had to be averaged over different populations
due to the lack of comprehensive information for all
countries listed and so do not represent a self-consistent setof data. More robust estimates have therefore been derived
by scaling the observed average relative frequencies foreach type of treatment (Tables 53 and 54) by the mean totalfrequencies calculated for each health-care level. These
final data for the global model of radiotherapy practice for19911996 are shown in Table 60. Analyses are presented
separatelyfor both teletherapyand brachytherapy, although
the limited data available for the latter practice in healthcare levels III and IV have been pooled so as to provide
more reliable estimates for a combined population. The

estimates of world practice have been calculated using the
global model of population described in Section I.D. The
uncertainties inherent in the estimates of mean frequencies
provided by the global model are difficult to quantify, butwill be significant, particularly when extrapolations havebeen made on the basis of small samples of data.
155. According to the model developed, the global annual
frequencies assessed for radiotherapy treatments during
19911996 are dominated by the national practices inhealth-care level I, which provide contributions of about
50% and 80% to the total numbers of teletherapy andbrachytherapy treatments, respectively, in the world(Table 9). The most important uses of teletherapy are fortreatments of breast, lung and gynaecological tumours,
whilst practice in brachytherapy is principally concernedwith the treatment of gynaecological tumours, althoughsome differences are apparent between the mean frequencies for the different health-care levels. The global frequency assessed for brachytherapy treatments (0.07 per
1,000 population) is less than one tenth that for teletherapy
treatments (0.8 per 1,000).
156. Global resources for high-energy radiation therapy
using teletherapy equipment with 60Co sources or higherenergy photon beams were summarized for the 1980's by
WHO [H20]. This analysis suggested that in some parts of
the world, such as Africa and South-East Asia, there might
have been only one high-energy radiation therapy machinefor 2040 million people, and one machine might be used
to treat more than 600 new patients per year. Many cancer
patients had no access to radiotherapy services [B33]. The
results of a more recent analysis for 1998 are presented inTable 61 [D27]. The resources for radiotherapy are still
very unevenly distributed around the world, with equipment numbers per million population being much higher
in North America, Australasia and Western Europe, thanin Central Africa, the Indian Subcontinent and East Asia.
Only 22 out of 56 countries in Africa were known withconfidence to have megavoltage therapy, and these areconcentrated in the southern and northern extremes of thecontinent [L45]. The total of 155 megavoltage units
operating in Africa in 1998 represented an increase by
more than a factor of 2 over the total for 1991. The population served by each megavoltage machine ranged from 0.6
to 70 million; overall, only half of the population of Africa
had some access to radiation oncology services.
157. Radiation therapy equipment and services are also
very unevenly distributed in the Latin American and
Caribbean countries [B33]. In 1994, there were approximately 500 60Co units, 10 137Cs units, and 124 LINACS.
Services tend to be concentrated in the larger countries ofSouth America (especially Argentina, Brazil, Colombia,
and Venezuela) and in Mexico. A similar pattern prevails
in the countries of the English-speaking Caribbean; themost well-equipped services are found in Barbados (which
also treats patients from some other countries), Jamaica,
and Trinidad and Tobago.

ANNEX D: MEDICAL RADIATION EXPOSURES

1. Frequencies of treatments
158. Temporal trends in the normalized annual frequencies of teletherapytreatments and brachytherapytreatments
are summarized in Table 62. When comparing these data,
it should be remembered that the averages for each time
period have been made over different populations and oftenwith small sample sizes. The present estimates of average
total frequency of teletherapy treatments per 1,000 population in each health-care level are larger than the previous
values for 19851990: 1.5 versus 1.2 in level I, 0.7 versus
0.2 in level II, and 0.5 versus 0.1 in level III, respectively.
These apparent increases will be due in part to the inclusion in the present analysis of some data concerning
numbers of new cancer patients in lieu of more specifictreatment data. No particular trends with time are apparent
from the estimated data concerning the frequencies ofbrachytherapy treatments. Notwithstanding these overall
trends in average frequency for the different health-carelevels of the global model, national frequencies for individual countries have increased in some and decreased inothers between 19851990 and 19911996; some specificexamples are given below. The available data concerning
temporal trends in the average annual numbers of different
types of treatment per 1,000 population by health-care levelare summarized in Table 63.
159. In many countries, the utilization of radiotherapy has
increased steadily over the last thirty years. In the UnitedStates, for example, the resources available for radiotherapy rose from 1,047 facilities (with a total of 1,377 treatment machines) in 1975 to 1,321 facilities (and 2,397
machines) in 1990 [I23]. Over this period, the annual
number of new patients undergoing radiation therapy hascorrespondingly increased from 1.5 to 2.0 per 1,000
population. In Russia, the annual number of radiotherapy
treatments increased steadily from a rate of 1.0 per 1,000
population in 1980 to 1.7 per 1,000 in 1997. Steadyincreases have also been reported elsewhere, such as in
New Zealand and Sweden (Table 62). In other countries,
rates of practice have either remained fairly static (inAustralia and Japan, for example) or have apparently
declined (in Romania, for example).
2. Therapeutic practices(a) Teletherapy
160. Over the last 50 years, there have been continuing
advances in engineering, the planning and delivery oftreatment, and clinical radiotherapy practice, all with theaim of improving performance [B75]; some key technicaldevelopments in teletherapy are listed in Table 64. In
developed countries at least, there has been growing use ofhigh-energy linear accelerators for the effective treatment
of deep-seated tumours; Figure VII illustrates the decline

in the number of telecobalt units and the increase in linear
accelerators in France over the last 10 years [L13]. Similar
trends are broadly apparent in Table 7 for the mean
numbers of the different types of radiotherapy equipment
per million population in the different health-care levels.
It has been suggested that the energy ranges 415 MV for
photons and 420 MeV for electrons are those optimallysuited to the treatment of cancer in humans [D14]. Units
with 60Co sources remain important for developing countries in view of the lower initial and maintenance costs andsimpler dosimetry in comparison with LINACS, althoughreplacement sources of the longer-lived radionuclide 152Eu
are under consideration as being potentially more efficientfor such units [A5].
250

Cobalt units
LINACsMV centres

200
NUMBER OF EQUIPMENT

E. TRENDS IN TELETHERAPY AND
BRACHYTHERAPY

325

150

100

50

0
1955

1960

1965

1970

1975
YEAR

1980

1985

1990

1995

Figure VII. Radiotherapy centres (with mega-voltage
equipment), telecobalt units and linear accelerators inFrance [L13].

161. Developments in diagnostic imaging, such as CT and
MRI, have benefitted the assessment of disease and also theplanning and delivery of therapy [C52, R39]. Treatment
plans are calculated using sophisticated computer algorithms to provide three-dimensional dose distributions,
including so-called beams-eye views, and Monte Carlosimulation techniques are being adopted [M76, S100].
Computer control of the linear accelerator has facilitatedthe development of new treatment techniques. Multileaf
collimators can not only replace the use of individual
shielding blocks in routine treatments with static fields asa tool for sparing healthy tissues, but can also allow theachievement of computer-controlled conformal radiation
therapy [G23]. This type of therapy seeks to provide
optimal shaping of the dose distribution in three dimensions so as to fit the target volume [D26, F3, L10, S34];
developments include tomotherapy, which uses slit beams
provided by dynamic control of multileaf collimators
coupled with movement of the gantry during treatment[Y7]; intensity-modulated arc therapy, which combines
spatial and temporal intensity modulation [B36, K15, Y3];
and adaptive radiation therapy, in which treatment plansfor individual patients are automatically re-optimized
during the course of therapy on the basis of systematic

326

ANNEX D: MEDICAL RADIATION EXPOSURES

monitoring of treatment variations [Y5]. The success ofsuch therapies is compromised by intrafraction organ
motion [Y6], and synchronous gating of the radiation beamwith respiration is being investigated [K8]. In vivo dosimetry [B20, B26, M17, S17], phantom dosimetry [D17, M15,
O5] and imaging [H59, R39] are increasingly being used
to verify that the machine and patient set-up are as required for the prescribed treatment and to assure theaccuracy of plans. In particular, electronic portal imaging
provides real-time verification of patient position and isbeing developed for transit dosimetry so as to allow
comparison of the delivered dose distribution relative to thetreatment plan [H4, H13, K58, M16, P36, S32].
162. Technical advances in the execution of radiotherapy
have stimulated further research into clinical radiobiology[D20, G19, L10, S99, W23]. New methods are required tosummarize and report the inhomogeneous dose distributions delivered to irradiated organs and volumes of interest[N20]. Studies in cellular and tissue biology have provided
a scientific rationale for developments in hyper-fractionation and accelerated treatments to improve the therapeutic
ratio in radiotherapy (normal tissue tolerance dose relative
to tumoricidal dose). Several clinical trials are in progress[B21, D4, S33], and the use of hyperfractionation is likely
to increase.
163. Radiotherapy is performed less often to treat benign
disorders, because there is no clear biological rationale orexperimental data, and also because there are concerns thatsuch treatments might induce cancer in the exposed patients[B79, S22]. A survey conducted in 1996 detected large
variations in practice throughout the world in relation to theindications and treatment schedules for radiotherapyofbenign
diseases [L24]. In the United States and Europe (especially
Germany), low-dose orthovoltage therapy is currently wellaccepted practice for the treatment of several selected benign
conditions such as the prevention of heterotopic ossification
after hip replacement, the stabilization and improvement ofpatients with Graves disease, keloid prevention, andachillodynia syndrome. Radiotherapy is also employed in thetreatment of benign tumours and, using radiosurgery, vascularmalformation. It has been argued that radiation therapyshould
also be considered as the primary modality for treatingrefractory pain in plantar heel spur [S22]. It has also beensuggested, on the basis of experiments with animal coronarymodels and anecdotal reports of treatment to human femoral
arteries, that acute localized delivery of 1520 Gy to the wallsof blood vessels can reduce the rate of restenosis following
angioplasty [A4, W29]. Although external beam therapy has
been proposed as one possible approach, most interest has
centred on the development of endovascular brachytherapy
techniques [F23, N45], and these are reviewed briefly in thenext Section.
(b) Brachytherapy
164. Intracavitarybrachytherapyfor gynaecological cancer
using radium (226Ra) was one of the first radiotherapeutictechniques to be developed. This radionuclide has now
largely been replaced in developed countries by 137Cs,
although radium sources are still utilized for economic
reasons in some areas of the developing world and eastern
Europe [B5]. The remote afterloading technique is becoming standard practice in Europe for the treatment ofcarcinoma of the cervix and is increasingly being used forinterstitial implants in relation to the bronchus, breast, andprostate [S25]. HDR brachytherapy offers advantages over
the LDR technique in terms, for example, of improved
geometrical stabilityduring the shorter treatment times andreduced staff exposures; however, the relative loss oftherapeutic ratio requires modified treatment schedules toavoid late normal tissue damage and so allow cost-effective
therapy [J1, J17, T5]. Pulsed dose-rate (PDR) brachytherapy has been developed in the hope of combining theadvantages of the two techniques, while avoiding theirdisadvantages [B25, M18]. In essence, a continuous LDR
interstitial treatment lasting several days is replaced witha series of short HDR irradiations, each about 10 minutes
long, for example, and given on a hourly basis, so as todeliver the same average dose. Each pulse involves the
stepping of a single high-activity source through allcatheters of an implant, with computer-controlled dwell
times in each position to reflect the required dose distribution.
165. Endovascular brachytherapy treatments to inhibit
restenosis after angioplasty have been performed experimentally using catheters for the temporary implantation ofradioactive seeds and wires (192Ir and 90Sr/90Y) and also forthe permanent implantation of radioactive stents (32P)[C16, J7, J18, T11, V7]. The proton-beam activation ofnickel-titanium alloy stents to produce 48V could provide a
unique mixed gamma/beta source to allow an improved
dose distribution for this application [L22]. One otherpossible irradiation technique in the course of anangioplasty procedure would involve filling the dilatation
catheter balloon with a high-activity beta-emitter such as
90
Y [A4] or 188Re [K60]. Preliminary human trials of suchendovascular treatments are in progress at several centres
around the world [P45, W29].
(c) Other modalities
166. The continuing obstacle to definitive radiotherapy is
the difficulty of delivering lethal doses to tumours while
minimizing the doses to adjacent critical organs. Various
special techniques have been developed to overcome thislimitation, although such modalities are less common
practice than the techniques discussed above.
Intraoperative radiation therapy (IORT) involves surgery
to expose the tumour or tumour bed for subsequent irradiation, usually with a beam of electrons in the energy range
617 MeV, while normal organs are shifted from the field[D15]. The entire dose is delivered as a single fraction incomplex configuration, which makes dose control andmeasurement particularlycritical [B22]. A total of approximately 3,000 patients are estimated to have been treatedANNEX D: MEDICAL RADIATION EXPOSURES

327

with IORT worldwide by 1989, mostly in Japan and theUnited States. A recent development for the treatment ofprimary bone sarcomas is extracorporeal radiotherapy, inwhich the afflicted bone is temporarily excised surgicallyso that it can undergo high-level irradiation in isolation
before immediate re-implanting [W15]. Studies have also
been made of the potential enhancement of dose to thetarget volume using the technique of photon activation, in
which increased photoelectric absorption is achieved byloading the tissue with an appropriate element prior toirradiation. Modeling has been reported for therapeutic
applications of iodine contrast agents in association with a
CT scanner modified for rotation x-ray therapy [M75, S35]
and for a silver metalloporphyrin for use in interstitialbrachytherapy with 125I seeds [Y8].

168. New and improved radiation sources for radiotherapy
are also being developed. Pencil beams of high-energy
photons can theoretically be produced by the Compton
backscattering process during collisions between lowenergy photons and high-energy electrons stored inmagnetic ring structures [W25]. Such photon beams could
be used for the production of radionuclides, the generationof positrons and neutrons, conventional high-energy
teletherapy, and, for example, functional radiosurgery
through the intact skull of small deep-lying targets within
the brain [G9]. Whereas most radionuclides for medical
use are produced in a nuclear reactor or cyclotron, it ispossible that small amounts of radionuclides could be
produced by the mechanism of direct electron activation
using a medical linear accelerator [W26].

167. Stereotactic radiosurgery (SRS) refers to the use ofthin, well-defined beams of ionizing radiation for the
precise destruction of a well-defined intracranial target
volume at the focus of a stereotactic guiding device,without significant damage to adjacent (healthy) tissues.
Since introduction of the technique in 1951, clinicalstudies have been undertaken with high-energy photons
from linear accelerators [F12] and 60Co sources, with
protons, and with heavy particles. The Leksell Gamma
Knife (LGK) contains 201 fixed 60Co sources arranged ina concave half-spherical surface and is the most common
equipment for conducting SRS [E7, G25]. There were 90
such devices in use worldwide in 1997, of which 32 werein the United States. Data from the present UNSCEAR
Survey of Medical Radiation Usage and Exposures indicate
a total of 20 gamma knives in Japan and 36 in China; some
limited additional information is given in Table 5. An
analysis published in 1996 indicated that nearly 30,000
patients had been treated with the LGK since 1968. Doses
to extracranial sites during LGK treatments have beenreported to be relatively low, with the eyes receiving about
0.7% of the maximum target dose and doses to other sites
decreasing exponentiallywith increasing distance from theisocentre of the LGK unit [N22]. SRS treatments for small
lesions (up to approximately 4 cm in diameter) are delivered in a single session, although fractionated regimes areunder development for larger tumours. Isocentric 60Co units
could represent viable alternatives to LINACS as radiation
sources for conducting SRS [P35]. Diamond detectors are
expected to allow more accurate dosimetry for SRS incomparison with traditional methods involving diodes,
films, ionization chambers, or TLDs [E8, H14, V5]. A
frameless robotic radiosurgery system has been developedin which real-time x-ray imaging of the patient locates andtracks the treatment site during exposure and so provides
automatic targeting of a 6 MV photon beam [M20]. Trials
are also in progress with a novel miniature x-ray source forstereotactic interstitial radiosurgery, in which a needle-likeprobe is used to deliver relatively low-energy photons
directly into a lesion. The intensity and peak energy are
adjustable for optimal tumour dose while minimizing
damage to surrounding healthy tissue [B23, B74, D10,
Y17].

169. There are potential advantages in conducting radiotherapy with high-energy, heavy charged-particles such as
protons and heavy ions. Such charged-particle beams canprovide superior localization of dose at depth within target
volumes. Furthermore, heavy ions with high linear energy
transfer (LET) components can damage cells in locallyadvanced radioresistant tumours more effectivelythan lowLET radiations such as photons or protons [B72]. Proton
beams have been used therapeutically since 1955 andrepresent the treatment of choice for ocular melanoma[B73, I33]. Protons have also been used to treat deep-seatedtumours. As of 1996, there had been approximately 17,000
patient treatments worldwide, with 17 facilities actively
engaged in proton therapy and another 14 in various stagesof planning [M12, S13, S108]. Secondary neutrons andphotons make small contributions to the patient dose
during proton therapy [A17]. Over 2,500 patients havebeen treated worldwide with heavy ions (helium or carbon)
on the basis of their favourable physical and radiobiological characteristics, such as high relative biological effectiveness, small oxygen effect and small cell-cycle dependence [K9]. In 1996, only two facilities were operational in
the world: HIMAC, Japan and GSI, Germany [J16]. About
600 patients with various types of tumour located invarious organs have already been treated with a carbon
beam at the HIMAC facility since 1994 [K57]. In addition,
about 1,100 patients were treated with negative pi mesons
between 1974 and 1994, although with no active facilities
in 1996, this is not a significant modality [J16].
170. Fast neutron radiation therapy was first used as acancer treatment tool in 1938 in the United States, but it
was not successful, because the radiobiology was not fully
understood [G10]. Later studies in the United Kingdom in
the 1960s with appropriate fractionation paved the way forclinical trials at various centres around the world. In
particular, a 20year multiphase project was begun in the
United States in 1971; the project has involved 10 separate
neutron facilities and several thousand patients to establish
the efficacy of neutron therapy. Clinical experience overtwo decades with neutron therapy for pancreatic cancer has
demonstrated high complication rates and overall survival
rates that are no better than those achieved with conven-328

ANNEX D: MEDICAL RADIATION EXPOSURES

tional radiotherapy alone [D21]. Neutron brachytherapy
using 252Cf sources is being carried out at one medical
centre in the United States [M24].
171. There is also renewed interest in the bimodal treatment technique of boron neutron capture therapy (BNCT),
in which boron (10B) is selectively concentrated in malignant tissue for subsequent activation (transmutation to 11B
with the emission of alpha particles and 7Li ions) whenirradiated with thermal neutrons [B35, C51, D16, G21].
Early clinical trials in the United States in the 1950s were
followed by large studies in Japan and proposals for further
work in the United States and Europe as a result of thedevelopment of second-generation boron compounds andthe availability of reactor-based epithermal neutron beams[A6, G45, R8]. Particle accelerators can also be used toprovide beams of neutrons for BNCT, and this approach
offers the potential for application in hospitals [G22]. By
its nature, BNCT will be most suited to the treatment oflocalized tumours such as high-grade gliomas that cannot
be treated effectively by other types of therapy. The technique is also under investigation for synovial ablation in
the treatment of rheumatoid arthritis [Y16].
172. Cancer is likely to remain an increasingly importantdisease in populations with increasing lifespans, and thiswill probably cause radiotherapy practice to grow in mostcountries. WHO estimates that, worldwide, by the year
2015 the annual number of new cancer cases will haverisen from 9 million in 1995 to about 15 million, with
about two thirds of these occurring in developing countries[W12]. If one half of these are treated with radiation, atleast 10,000 external beam therapy machines will be
required at that time in developing countries, in addition toa large number of brachytherapy units.
173. Radiotherapy involves the delivery of high doses topatients and accordingly there is an attendant potential for
accidents with serious consequences for the health ofpatients (arising from over- or under-exposure relative toprescription) and also staff; this topic is discussed further
in Chapter VII. Quality assurance programmes help ensurehigh and consistent standards of practice so as to minimize

the risks ofsuch accidents. Effective programmes comprehensively address all aspects of radiotherapy, including inter alia
the evaluation of patients during and after treatment; theeducation and training of physicians, technologists andphysicists; the commissioning, calibration and maintenance ofequipment; independent audits for dosimetry and treatment
planning; and protocols for treatment procedures and thesupervision of delivery [D3, D13, K3, W14].

F. SUMMARY
174. Radiotherapy involves the delivery to patients of highabsorbed doses to target volumes for the treatment ofmalignant or benign conditions. Resources for radiation
therapy are distributed unevenly around the world (Tables
61, 6 and 9), with there being significant variations inradiotherapy practice both between and often within
individual countries (Tables 51 and 52); many cancer
patients have little or no access to radiotherapy services.
Global annual numbers of complete treatments by the twomain modalities of teletherapy and brachytherapy havebeen estimated from the scarce national survey data
available using a global model, although the uncertainties
in this approach are likely to be significant; the results ofthis analysis are summarized in Table 65. The world
annual total number of treatments for 19911996 isestimated to be about 5.1 million, with over 90% arisingfrom teletherapy. The corresponding average frequency of
0.9 treatments per 1,000 world population is similar to thelevel quoted for 19851990 [U3] on the basis of an estimated total number of 4.9 million treatments. The present
global total of treatments is distributed amongst thedifferent health-care levels of the model as follows: 51% incountries of level I (at a mean rate of 1.7 per 1,000 population), 43% in countries of level II (0.7 per 1,000 population), 6% in countries of level III (0.5 per 1,000 population) and 1% in countries of health-care level IV (0.07 per
1,000 population). Radiation treatments by teletherapy andbrachytherapy are very much less common than diagnostic
medical and dental examinations with x rays (annual
global totals of 1,910 million and 520 million examinations, respectively).

V. THERAPEUTIC ADMINISTRATIONS OF RADIOPHARMACEUTICALS
175. Unsealed radionuclides (radiopharmaceuticals) havealso been used as therapeutic agents for over 60 years bydirect administration to the patient. Such treatments playa small but important role in the management of patientswith cancer, generally from a palliative point of view, andwith other conditions such as thyroid disease and arthritis[B76]. For several benign disorders, radionuclide therapy
provides an alternative to surgical or medical treatment; forthe treatment of malignant disease, this modality combines

the advantage of being selective (like teletherapy orbrachytherapy) with that of being systemic (like chemotherapy) [H60].

A. TECHNIQUES
176. Radiotherapy with unsealed radionuclides offers thepotential advantage of allowing the biological targeting of
the radiation absorbed dose to particular tissues or regions

ANNEX D: MEDICAL RADIATION EXPOSURESof the body. In clinical practice, biologically targeted radiotherapy for cancer requires a molecule that has a relative
specificity for tumour tissue (delivery to the target tissue)
coupled to a radionuclide with appropriate physical characteristics (imparting the dose) [G6]. When administered systemically (by ingestion or injection) or regionally (by infusion) toa patient, this combination in principle allows for the selective
irradiation of target tumour cells, even in widespread disease,with relative sparing of normal tissues. The choice of an
appropriate radionuclide is governed by the quality and path
length of the radiation (relative to target size), physical halflife, gamma yield, chemistry, cost, and availability. Clinicalpractice at present is centred on radionuclides that emit
medium-energy beta radiation with a range of a few millimeters in tissue.
177. The most common examples of such biologicallytargeted therapies involve simple ions and small moleculesthat follow physiological pathways, such as 131I sodium iodide
for the treatment of thyroid carcinoma, 32P sodium orthophosphate for the treatment of polycythemia rubra vera, 89Sr
strontium chloride for the management of painful bonemetastases, and 131I meta-iodobenzylguanidine (mIBG) for thetreatment of neuroblastoma [O21]. Efficient biologicaltargeting is also possible through the use of tumour-specificmonoclonal antibodies (MAbs) for delivery of appropriate
radionuclides such as 186Re and 188Re [G6, R40]. Suchtechniques of radioimmunotherapy are not yet common inroutine practice, although it is likely that these new therapeutic approaches will become increasingly important [B76].
Some current clinical applications of radionuclide therapy incancer are summarized in Table 66 [Z3]; only the first four
examples can be considered as established treatments. Clinicaldata on cancer therapy using a range of bone-seeking radionuclides has been reviewed by Lewington [L8].
178. Radionuclide therapy is important for the treatment ofboth malignant and benign diseases. Most of this type ofcancer therapy is palliative in nature, although the treatmentof thyroid carcinomas with radioiodine, which represents theearliest and most established form of therapy with unsealed
radionuclides, is reliably curative [G6]. For treatment to beeffective, activities of 131I in the range 310 GBq are given toablate the normal thyroid gland and to treat metastases [N5].
These doses may be repeated at intervals of 46 months until
there is no clinical evidence of residual functioning thyroid
tissue or metastases [G7]. Iodine-131 is also commonly usedin the treatment of hyperthyroidism, although activities are
generally1001,000 MBq, depending on the size of the glandand its ability to take up the sodium iodide [N5]. In Germany,for example, such treatments of benign thyroid diseaseaccounted for the majority (70%) of all radionuclide therapy
in 1991, with the use of 131I for thyroid malignancies accounting for 22% of the total [B32].
179. Radionuclide therapy is also carried out by the direct
introduction of a radiopharmaceutical into a body cavity [G7].
Colloidal yttrium silicate labelled with 90Y is used for the
intrapleural, intraperitoneal, and occasionallyintrapericardial

329

therapy of malignant effusions and intracavitary therapy for
carcinomas of the bladder, intracystic treatment of craniopharyngioma, and intra-articular treatment of arthritic conditions of various joints (radiation synovectomies). Intracavitary
injections of colloidal suspension of 198Au are used for thetreatment ofmalignant pleural effusions and malignant ascites
in the abdomen. Intra-arterial administrations ofmicrospheres
labelled with 90Y or 166Ho are also in limited clinical use forthe treatment of liver tumours [Z4].

B. DOSIMETRY
180. Radionuclide therapyrequires detailed patient dosimetry
in order to balance the therapeutic aim of treatment against
the protection of normal tissues. A wide range of complex
techniques is used, including macroscopic approaches to
dosimetry on the scale of organs. These methods are similar
to those used for diagnostic examinations with unsealed
radionuclides [I35] and are based on information about uptake
and retention in target and other tissues derived from quantitative imaging [B16, F1, F2, O2]. Microdosimetric techniques
at the cellular and subcellular levels are under development
for radioimmunotherapy in order to model heterogeneities indose distributions [B15, O22] and so evaluate and improve theefficacy of such treatments [D11, N10]. Pre-therapy imagingof patients is used to plan individual treatments, whereas
imaging during therapy allows confirmation or correction of
the dosimetry [E2]. Studies have also been undertaken into
biological dosimetry [M81], cancer death [M82] and fetal
thyroid doses [P43] following 131I therapy for thyrotoxicosis.
Recommendations are available concerning standard administered activities for the different types of treatment (see, forexample, [A38, L48]).
181. For the purposes of this review, the practice in radionuclide therapyis summarized in terms of the broad frequency
of procedures with radiopharmaceuticals and the typical levelsof administered activities, for the reasons already discussed in
Section I.C.

C. ANALYSIS OF EXPOSURES
1. Frequency of treatments
182. Annual numbers of therapeutic administrations ofradiopharmaceuticals reported by different countries for19911996 are summarized in Table 67 by category of
disease. Data are presented in terms of administrations per
1,000 population, with some analysis by radionuclide andwith countries grouped according to health-care level.
Some important qualifications to the data are given in thefootnotes. The percentage contributions bydisease category
to the annual total frequencies of treatments are shown in
Table 68. Mean values have been derived for each healthcare level by dividing the total number of procedures by the
total population.

330

ANNEX D: MEDICAL RADIATION EXPOSURES

183. Patterns of practice vary significantly from countryto
country, with some not conducting these types of treatment
at all. Annual total frequencies range from 0.01 to 0.5
treatments per 1,000 population in the sample of 33
countries of health-care level I. The average total frequencies for levels II, III, and IV are smaller by factors of 5, 8,
and 400, respectively, than the average for level I, about
0.2 examinations per 1,000 population. Relative to averagediagnostic practice with radiopharmaceuticals in eachlevel, frequencies of therapeutic administrations are
typically lower by factors of between 13 (in the case oflevel III) and 110 (level I). In turn, radionuclide therapy isless common than teletherapy, with ratios of averagefrequencies ranging from about 9 (for level I) to 125(level IV), although it is broadly similar in frequency topractice in brachytherapy.
184. In all countries, practice is dominated by 131I therapy
for hyperthyroidism, with other conditions, particularly
thyroid malignancy, also being treated in the upper healthcare levels (III). Temporal trends in the frequency of
examinations are discussed in Section V.C.
2. Exposed populations
185. The distributions by age and sex of patients undergoing various types of therapy with radiopharmaecuticals in
19911996 are presented in Table 69 for different countries, grouped by health-care level; some of these data arederived from surveys of limited scope, as indicated in thefootnotes. There are considerable variations in the national
distributions reported for the various types of treatment,
although the data often relate to quite small numbers ofpatients. In general, few treatments are carried out onchildren. However, since practice is dominated by treatments of the thyroid, the populations of patients receiving
radionuclide therapy are younger than those undergoing
most other types of radiotherapy (teletherapy andbrachytherapy). Averages for the four health-care levels
once again suggest in general a downward shift in age forpatients in countries classified in the lower levels, relative
to the distribution for level I. In line with underlying
patterns of disease, the majority of thyroid treatments are
conducted on female patients.
3. Doses from treatments
186. The doses from treatments with radiopharmaceuticals
are presently characterized in terms of the activities ofradionuclide administered to the patient (Section I.C). The
typical activities per treatment reported by different
countries for practice during 19911996 are presented inTable 70. The average activities shown for each type ofradionuclide treatment and health-care level include
weightings for the numbers of such treatments in eachcountry. In general, the activities of 131I administered forthe treatment of thyroid malignancy are about ten times
higher than those used for therapy of hyperthyroidism.

D. ASSESSMENT OF GLOBAL PRACTICE
187. The estimated annual numbers of patients undergoing
common types of radionuclide therapy in the world aresummarized in Table 71. This analysis is based on the global
model of population described in Section I.D and the averagerelative frequencies observed for each type of treatment(Table 68) in combination with the mean total frequencies
calculated for each health-care level (Table 67). The uncertainties in this approach are difficult to quantify, but will besignificant, particularly when extrapolations have been madeon the basis of small samples of data.
188. The global annual frequency assessed for therapy
with radiopharmaceuticals during 19911996 is dominatedby the national practices in health-care level I, which
provide a contribution of about 70% to the global total
number of such treatments (Table 9). Nearly 90% of global
practice is concerned with the thyroid, with about two
thirds of all treatments being for hyperthyroidism, andabout one quarter for thyroid cancer.

E. TRENDS IN THERAPY WITH
RADIOPHARMACEUTICALS
189. The role of therapeutic nuclear medicine is expanding with the development of more pharmaceuticals, theemergence of new indications for treatment and improvements in results [I34, S101]. A survey in Europe suggested
that nuclear medicine was underutilized as a therapeuticmodality and numbers of such treatments were likely toundergo a rapid increase, particularly for oncologicalindications requiring high-dose radionuclide treatmentswith isolation of the patient [E15, H60]. Specific trends inpractice are discussed further in the two sections following.
1. Frequencies of treatment
190. Temporal trends in the normalized annual frequenciesof radiopharmaceutical treatments are summarized inTable 72. When comparing these data, it should be remembered that the averages for each time period have been madeover different populations and often with small sample sizes.
In general, the trend from data reported by individual countries is for an increase in their national frequency ofradionuclide treatments per 1,000 population between
19851990 and 19911996. The average frequencies estimated for health-care levels I and II have also increased overthis period: from 0.10 to 0.17 per 1,000 in level I, and from0.021 to 0.036 per 1,000 in level II. No particular trend withtime is apparent for the practice in health-care level III. The
estimated total annual number of treatments in the world has
risen from 0.21 million for 19851990 to 0.38 million for
19911996 (Table 9). The available data concerning temporal
trends in the average annual numbers of different types oftreatment per 1,000 population by health-care level aresummarized in Table 73.

ANNEX D: MEDICAL RADIATION EXPOSURES

191. Some examples can be given of the trends reported byparticular countries. Surveys in the United Kingdom for 1993
[E11] and 1995 [C27] have confirmed both an overall
increasing use of radionuclide therapy and also a widening
spectrum of the therapies being undertaken; annual numbersof treatments rose from 13,000 to 14,500, and the annual
cumulative administered activity of 131I, the most commonlyused radionuclide, increased by 100%. In Denmark, the total
number of treatments increased from 1,819 in 1993 to 2,337
in 1995. In New Zealand, the annual frequency of therapeutic
administrations per 1,000 population rose from 0.09 in 1960
to a peak level of 0.18 in 1983, before falling slightly to 0.16
in 1993 [L28]. Recent levels of practice have also been fairly
static in Finland, where the total numbers of treatments were2,150 in 1994 and 2,240 in 1997 [K59]. In contrast, theannual frequency of radionuclide treatments in Russia has
fallen from 0.02 per 1,000 population in 1980 to 0.01 per
1,000 in 1997.
192. On a national scale, therapeutic administrations ofradionuclides are reported to account for only small fractionsof the annual totals of all nuclear medicine procedures carriedout: approximately 1% of practice in Australia in 1991 [C7],2% of practices in the United States in 1991 [N13] and in New
Zealand in 1993 [L28], 3% of practice in the United Kingdom
in 1990 [E1], and 4% of practice in Finland in 1997 [K59].

331

of continuing irradiation [K61]. In the longer term, it has beensuggested that 124I has the potential to become a universal
radionuclide in nuclear oncology, with applications for both
imaging and therapy [W60].
194. In addition to the treatment of cancer, there is also
continuing development and growth in therapeutic applications of radiopharmaceuticals for the palliation of bone
pain [K62] (using 89Sr, 153Sm, 186Re, 117mSn and 177Lu [A38,A39]) and radiation synovectomy for the treatment ofrheumatoid arthritis (using 90Y, 198Au, 169Er, 153Sm, 188Re,
186
Re and 166Ho [K63, O20, P37, W61]).
195. Computer simulations have suggested that someradionuclide therapies could be made much more effectiveby the use of magnetic fields to constrain the paths of beta
particles and so increase the absorbed dose delivered tosmall tumours [R3] or to enhance the protection of bonemarrow in therapeutic uses of bone-seeking radionuclides[R6]. The development of measurement methods thatprovide estimates of absorbed dose in bone using techniques of electron paramagnetic resonance (EPR) could
lead to improvements in the dosimetry of systemic radiotherapy for osseous masses [B27].

F. SUMMARY
2. Therapeutic practices
193. Targeted radionuclide therapy is becoming an increasingly popular treatment modality for cancer as an alternative
or as an adjunct to external beam radiotherapy or chemotherapy [O2]. However, the full potential of such techniques will
only be realized with the introduction of new radionuclides
whose radiations have physical properties to match tumour
size and, in particular, with the development of target-specificcarrier molecules such as monoclonal antibodies [B77]. The
most attractive candidates for radioimmunotherapy (RIT) areradionuclides with medium energy beta emission and a halflife of several days, such as 47Sc, 67Cu, 153Sm, 188Re and 199Au[M78]; however, it has been suggested [H61] that longer-lived
radionuclides such as 114mIn and 91Y could prove more
effective for RIT than the shorter-lived 90Y currently in use[S102]. More effective therapy should be possible using a
cocktail of radioisotopes with differing beta particle energies
and ranges so as to optimize energy deposition [Z3]. Also,
work is in progress on DNA-targeting molecules in combination with Auger-emitting radionuclides (such as 125I, 193mPt, or
195mPt) [O1] and with alpha-emitters (such as 211At, 212Bi, 213Bi,
233
Ra and 255Fm) [M79, M80, V2] to provide enhanced
specificity of tumour-cell cytotoxicity. Another concept underconsideration is that of the in vivo generator, in which aparent radionuclide (such as 166Dy) is administered to thepatient and attached to the target molecule, with subsequent
decay in situ to the daughter radionuclide (166Ho) as a source

196. Radiopharmaceuticals are administered systemicallyor regionally to patients in order to deliver therapeuticradiation absorbed doses to particular target tissues, inparticular the thyroid, for the treatment of benign diseaseand cancer. The utilization of such therapy varies significantly between countries (Table 67). Global annual
numbers of radiopharmaceutical treatments have beenbroadly estimated from the limited national survey data
available using a global model and the results are summarized in Table 74; the uncertainties in these data are likely
to be significant. The world annual total number oftreatments for 19911996 is estimated to be about 0.4
million, corresponding to an average frequency of 0.065
treatments per 1,000 world population; previous estimatesof these quantities for 19851990 were 0.2 million and0.04 per 1,000 population, respectively. The present global
total of treatments is distributed amongst the different
health-care levels of the model as follows: 68% in countries of level I (at a mean rate of 0.2 per 1,000 population),
29% in countries of level II (0.04 per 1,000 population),
3% in countries of level III (0.02 per 1,000 population) and<0.1% in countries of health-care level IV (0.0004 per
1,000 population). In comparison with the practices
assessed for the other modes of radiotherapy, radionuclide
therapy is much less common than teletherapy (annual
global total of 4.7 million treatments), but similar infrequency to brachytherapy (total of 0.4 million).

332

ANNEX D: MEDICAL RADIATION EXPOSURES

VI. EXPOSURES OF VOLUNTEERS IN MEDICAL RESEARCH
197. The vast majority of medical exposures are conducted
on individual patients or selected subgroups of the populationin the routine management of health. There will also be someuse of medical radiations in medical research programmes,
which will involve the exposure of patients in experimental
trials of diagnosis or treatment, or of healthy volunteers, forexample, in the development and clinical testing of newpharmaceuticals [I22, W28]. No systematic information onsuch exposures of volunteers is readily available, althoughsome examples can be given from particular countries.
198. An analysis of the research studies involving administrations of radiopharmaceuticals to volunteers conducted inGermany during 1997 and 1998 is presented in Table 75[B78]; the majority of these studies involved PET imaging.
The calculated doses exceeded 10 mSv for 70% of thevolunteers in 1997 and 57% in 1998; in general, the doses tovolunteers who were patients were higher than those whowere
healthy persons. In the United States, an analysis for theperiod 19961998 of the effective doses to 2,709 volunteers
receiving administrations of radiopharmaceuticals in thecourse of research studies at a large hospital yielded a collective dose of 24.5 man Sv (17% of this being to healthy volunteers, 83% to diseased volunteers) [V25]; the distribution ofindividual effective doses was as follows: 12% of thesevolunteers received <0.1 mSv, 72% 0.110 mSv and 16%>10 mSv. In general, onlysmall fractions ofwhole populations
are likely to be exposed to medical radiations as volunteers inmedical research programmes. For example, the number ofvolunteers reported to have received administrations ofradionuclides in the course of medical or clinical research in
the Federal Republic ofGermanyin 1988 represented less than
0.1% of the annual total number of routine diagnostic nuclear
medicine procedures performed on patients [U3].

VII. ACCIDENTAL EXPOSURES OF PATIENTS
199. In the context of this review, an accident is any unintended event, including an operating mistake, equipment
failure, or other mishap, that causes an exposure to a patientthat is significantly different from an exposure received innormal practice. Such accidents can occur during diagnostic
examinations utilizing x rays and administrations ofradionuclides, as well as during radiotherapy. There are nouniversally accepted definitions of the deviations in dose
inherent in “accidents”, although some examples can be given
from the practices in particular countries. In the United States,for example, the misadministration of radioactive material in
medicine is defined bythe regulatoryauthorityas the administering of: a radiopharmaceutical or radiation from a sealed
source other than the one intended; a radiopharmaceutical orradiation to the wrong patient; a radiopharmaceutical orradiation by a route of administration other than that intended
by the prescribing physician; a diagnostic dosage of aradiopharmaceutical differing from the prescribed dosage bymore than 50%; a therapy dosage of a radiopharmaceuticaldiffering from the prescribed dosage by more than 10%; or atherapy radiation dose from a sealed source such that errors inthe source calibration, time of exposure, and treatment
geometry result in a calculated total treatment dose differingfrom the final prescribed total treatment dose by more than
10% [N46]. Guidelines from the United Kingdom aresummarized in Table 76 in relation to the formal notificationof incidents involving radiation equipment used for medical
exposure [H62].
200. Radiotherapy, by its very nature, has the greatest
potential for accidents with serious consequences, because
the patients are deliberately exposed to intense sources ofradiation. From the standpoint of the health care of a radiotherapy patient, the delivery of a dose that is too small could
be just as important as the delivery of one that is too large. In
general, accidents are relatively infrequent as a result of theradiation protection and quality assurance measures that are
applied. However, accidental exposures continue to occur,owing to scientific, technical, and managerial failures. An
analysis of two serious radiotherapy accidents in the United
Kingdom argued that they might well have been avoided if aformal quality system had been adopted [M13]. A study ofaccidental exposures to patients in Germany yielded similar
conclusions [S103].
201. In the absence of more systematic information, it isdifficult from isolated reports of particular incidents (seefor example [I25]) and only a limited number of broader
reviews to assess with confidence the extent of accidental
exposures on a global scale. However, some sources of dataand examples of the different types of accident can begiven. Further useful information is expected to be provided by databases on incidents involving medical radiations that are under development [H2, O4, T7]. In particular, IAEA has conducted a review of 90 accidents inradiotherapy (including teletherapy, brachytherapy, andsome therapy with unsealed radionuclides) that werereported to regulatory authorities and professional associations or published in scientific journals [I40, O4]. An
analysis of the initiating events and contributing factors forthese accidents will allow the development of lessons to belearned and measures for prevention. The most importantcauses identified by IAEA, often found in combination,
were the following: deficiencies in education and training;ANNEX D: MEDICAL RADIATION EXPOSURES

lack of procedures and protocols for essential tasks (suchas commissioning, calibration, and treatment delivery);
deficient communication and information transfer; absenceof defence-in-depth; and deficiencies in design, manufacturing, testing, and maintenance of equipment. A detailed
study has also been conducted on the causes and impact ofhuman error in remote afterloading brachytherapy [N21].
202. Manycountries have systems for the central reportingof incidents involving medical radiations. Some of these
programmes include minor occurrences not of direct
relevance to the present review of accidental exposures ofpatients. In the United States, for example, health professionals and consumers voluntarily submit reports on all
types of safety hazard encountered in radiation therapy
devices to the Food and Drug Administration under the
MedWatch programme. Summaries are published by theCenter for Devices and Radiological Health every six
months as a means of improving the quality of equipment.
Formal reporting of adverse incidents in the United States
is required for some diagnostic and therapeutic practice
involving radionuclides. Such instances of errors andunintended events reported to the Nuclear Regulatory
Commission have been used to derive some estimates ofnational rates of misadministration, expressed as percentages of the total number of administrations in 1992: theseamounted to about 0.0002% for diagnostic nuclear medicine administrations and 0.004% for therapeutic administrations (fractions) using teletherapy and brachytherapy[I23]. However, these estimates should be regarded as very
approximate.
203. In the United Kingdom, 54 instances of unnecessaryor excessive medical exposures to radiation (excluding
overexposures due to faulty radiation equipment) were
investigated by the regulatory inspectorate between 1988

333

and 1994 [W18]. Since the reporting of such incidents is
not mandatory, this figure is likely to be an underestimateof the true rate. Analysis by discipline reveals 39% involved diagnostic radiology, 37% radiotherapy, 20%
nuclear medicine, and 4% dental radiology. Reports weremost frequent in radiotherapy (involving one in three of all
such departments nationally), followed by nuclear medicine (1 in 25 departments); reports were least frequent indiagnostic radiology (1 in 100 departments). About one
half of the incidents involved only one patient and ingeneral “one-off” errors. Between 1982 and 1994 in the
United Kingdom, there were 47 incidents in dental radiology conducted by general dental practitioners in which
ionizing radiation played a part, although only 6 of these
involved possible excessive exposure [L18].
204. Some examples can also be given of audits of practiceundertaken in radiotherapy departments. The detailed
analysis of incident reports at one radiotherapy departmentin the United Kingdom indicated that problems of atechnical nature affected, on average, the delivery oftreatment for 4 in every 1,000 patients, although none ofthese incidents was regarded as being of clinical significance [W19]. Elsewhere, independent checks on dosimetryat two other departments showed serious errors in delivered
doses (a deviation of more than 5% from the prescribed
dose for a single field) occurring at rates of up to 11 per
1,000 [C17] and 50 per 1,000 patients [A13] in the two
departments, with appropriate corrective actions having
been taken where necessary.
205. Overall, it is not possible to make any worthwhilequantitative estimates of the extent worldwide of accidental
exposures with medical radiations, although it can beconcluded that the numbers of patients involved will
generally be small in comparison with normal practice.

CONCLUSIONS
206. The use of ionizing radiation for medical diagnosis andtherapy is widespread throughout the world, although there
are significant country-to-country variations in national
resources for and practice in medical radiology (Tables 4, 6,
8 and 9). In general, medical exposures are confined to an
anatomical region of interest and dispensed for specificclinical purposes so as to be of direct benefit to the examinedor treated individuals. Diagnostic exposures are characterized
by relatively low doses to individual patients (effective doses
are typically in the range 0.110 mSv) that in principle arejust sufficient to provide the required clinical information,although the resulting collective doses to populations are
significant. In contrast, therapeutic exposures involve verymuch higher doses precisely delivered to target volumes(prescribed doses typicallyin the range 2060 Gy) to eradicate
disease, principally cancer, or to alleviate symptoms. Rela-

tively small numbers of diagnostic or therapeutic exposures
are conducted on volunteers in controlled studies for the
purposes of research.
207. Medical radiology involves a broad range of wellestablished techniques, and practice continues to evolve withnew developments in technology. Examinations that use
x rays are the most common source of medical exposure,while diagnostic nuclear medicine is conducted byadministering radiopharmaceuticals to patients. Radiotherapy is mostly
carried out using external beams of radiation (teletherapy),
although some patients receive direct applications of sealed
radionuclide sources (brachytherapy) or therapeutic administrations of radiopharmaceuticals. In general, practice in
medical radiology is conducted systematically and accidents
are relatively infrequent.

ANNEX D: MEDICAL RADIATION EXPOSURES

208. Information on medical radiation usage and theresulting exposures in different countries has been obtainedby means of a widely distributed questionnaire, the
UNSCEAR Survey of Medical Radiation Usage andExposures, together with results from published studies.
Assessments of practice for the entire world have once
again been made on the basis of a global model in whichcountries are stratified into four levels of health caredetermined by the number of physicians per unit population; level I (at least 1 physician per 1,000 population),level II (1 physician per 1,0003,000 population), level III(1 physician per 3,00010,000 population), and level IV (1physician for more than 10,000 population). The available
data within each level have been averaged to provide
representative frequencies or exposures that allow extrapolation to total populations.
209. The present estimates of global practice from the
medical uses of radiation are summarized in Table 77, interms of the numbers of procedures and, for diagnostic
examinations, collective doses and per caput doses. These
exposures are distributed unevenlyamongst the population,
often to elderly and sick patients, and the doses should not
be used to assess detriment. Practice is concentrated in the
countries of health-care level I, which collectively represent only one quarter of the world population, yet accountfor over 80% of the collective dose from all diagnostic
procedures and over 50% of the total number of treatments.
The global estimates for the annual frequencies of diagnostic and therapeutic procedures and the annual per caput
doses from diagnostic practices are summarized in Figures
VIII and IX, respectively. Detailed analyses of practicehave already been given for medical and dental x rays
(Table 30), diagnostic nuclear medicine (Table 46),
teletherapy and brachytherapy (Table 60), and therapeutic
radiopharmaceuticals (Table 71).

FREQUENCY PER 1,000 POPULATION

10 3
10 2
10 1
10 0
10 -1
10 -2
10 -3
10 -4
I

II

III
IV
HEALTH-CARE LEVEL

World

Figure VIII. Estimated global annual frequencies of medical diagnostic and therapeutic procedures (1991-1996).
The six columns in each group represent medical x rays, dental
x rays, nuclear medicine (diagnosis), teletherapy, brachytherapy, and nuclear medicine (therapy), respectively.

10 1

10 0
PER CAPUT DOSE (mSv)

334

10 -1

10 -2

10 -3

10 -4

10 -5
I

II

III

IV

World

HEALTH-CARE LEVEL

Figure IX. Estimated global annual per caput doses frommedical diagnostic radiological procedures (1991-1996).
The four columns in each group represent medical x rays,
dental x rays, nuclear medicine (diagnosis), and all diagnostic practices, respectively.

210. Diagnostic exposures (2,500 million in total) outweighthe number of therapeutic exposures (5.5 million) by about
450 to 1, largely through the widespread use of x rays.
Medical x rays account for 78% of this diagnostic total (at amean rate of 330 per 1,000 population); dental x rays provide
21% (mean rate 90 per 1,000) and nuclear medicine only 1%(mean rate 5.6 per 1,000). The total collective dose from all
diagnostic exposures is estimated to be about 2,500 million
man Sv (corresponding to 0.4 mSv per caput); nuclear
medicine provides only 6% of this total (at 0.03 mSv per
caput). Over 90% of the total of radiation treatments are
conducted by teletherapy or brachytherapy, with mean rates of
0.8 and 0.07 per 1,000 population, respectively;
radiopharmaceuticals are used in only 7% of all treatments(with a mean rate of 0.065 per 1,000 population).
211. Notwithstanding such global average values, there
are wide differences in the radiology practices between
different countries (Tables 32, 34, 48, 62 and 72) and, on
average, between the four levels of health-care adopted inthis review (Figures VIII and IX). For example, the meanfrequencies of diagnostic examinations per 1,000 population vary between the health-care levels by factors of about
50 for medical x-ray examinations, 1,500 for dental x-ray
examinations and 1,000 for nuclear medicine procedures.
Corresponding variations in the mean frequencies ofradiation treatments amount to factors of about 30 for
teletherapy, 10 for brachytherapy and more than 200 for
nuclear medicine treatments. The mean per caput doses
from each diagnostic practice vary between the health-carelevels by factors of about 60 for medical x-ray examinations, more than 100 for dental x-ray examinations and
300 for diagnostic nuclear medicine procedures.
212. Temporal trends in the estimates of global practice in
medical radiology from the various reviews undertaken by

ANNEX D: MEDICAL RADIATION EXPOSURES

the Committee are summarized in Table 78 for diagnostic
uses and in Table 79 for therapeutic uses. Relative to theprevious analysis for 1993, the world population has risen
by about 10% to a total of 5,800 million in 1996 and there
have been increases in the estimated annual numbers of all
types of exposure and, importantly, in the per caput dosefrom medical x rays; the present mean effective dose per
examination of 1.2 mSv is larger than the estimate of
1.0 mSv for 19851990. Estimates of the collective doses
from diagnostic examinations with dental x rays andradiopharmaceuticals remain largely unchanged. In
consequence, the estimated per caput global exposure fromall diagnostic medical procedures has been revised from
0.3 to 0.4 mSv per person per year. The present estimatesof the corresponding per caput dose by health-care level(with previous estimates for 19851990 in brackets) are as
follows: 1.3 (1.1) mSv per person per year in level I, 0.15(0.1) mSv in level II, 0.03 (0.05) mSv in level III, and 0.02
(0.05) mSv in level IV. Overall, the global annual per
caput dose from diagnostic procedures worldwide isbroadly similar to previous estimates made since 1982 [U3,U4, U6], although the present analysis is made on asomewhat firmer basis. Nevertheless, in general theestimates of global frequencies and doses remain fairly
crude and should not be overinterpreted.

335

213. Further increases in the uses of medical radiations andresultant doses can be expected following changes in thepatterns of health care that are being facilitated by advancesin technology and economic developments. For example,
increases are likely in the utilization of x rays, with inparticular a growth in importance for CT, digital imaging
and, with the attendant potential for deterministic effects on
skin, interventional procedures; practice in nuclear medicine
will be driven by the use of new and more specificradiopharmaceuticals for diagnosis and therapy, and there will
be increased demand for radiotherapy owing to population
ageing. In addition, further growth in medical radiology canbe expected in developing countries where present facilities
and services are often lacking.
214. Accordingly, there is a need for the Committee toundertake further authoritative reviews ofglobal practice, withthe systematic compilation of new national survey data,
particularlyfrom regions where knowledge is presentlysparse,
and the exploration of improved modeling in order to provide
refined assessments of worldwide exposures. This major task
will help monitor and inform on levels and trends in dosefrom the rapidly evolving and important practice of medical
radiology, and also stimulate further assessments and criticalreview of practices by individual countries.

336

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 1
Population distribution over the four health-care levels as used in global assessments of medical exposures
Percentage of population by health-care level
I

II

III

IV

Globalpopulation(millions)

29
27
25
26

35
50
50
53

23
15
16
11

13
8
9
10

4 200
5 000
5 290
5 800

Year

1977
1984
1990
1996

Ref.

[U6]
[U4]
[U3]
Present

Table 2
Physicians and dentists per million population (1991-1996)
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicatedCountry / area

Number per million population

Population(thousands)
All physicians

Physicians conducting
radiological procedures

Dentists

50
22
-c
107
113
113
94
74
29
30
93
3
71
141
59
15
111
119 d
405
171
126
77
106 d
94
56
50
155
246
87
49
88
21
39 d
54
38
100

340 a
614
515
90 b
130 a
358
660 a
674
515
353
348
382
590 a
834
592
1 353
615
923
670 a
726
1 048
473
452
497 b
190 a
633
384
875
461
499
467
538
1 208
440
480 a
65 b
288 b
267
480 a

Health-care level I
Albania
Argentina
Armenia
Australia
Austria
Bahrain
BelarusBelgium
Bulgaria
CanadaCayman Islands
China, Taiwan Province
Croatia
Cuba
CyprusCzech Republic
Denmark
EcuadorEstonia
FinlandFranceGermany
GreeceHungary
IrelandIsraelItaly
Japan
Kazakhstan
KuwaitKyrgyzstan
LatviaLebanonLithuania
Luxembourg
Netherlands
New Zealand
NorwayPanamaPolandPortugal [F11]Qatar
Republic of Moldova
Romania
Russian Federation

3 400
35 6723 638
17 6848 000
570
10 31210 0008 492
27 95234
21 7434 760
10 906651
10 3635 100
13 000
1 500
5 117
57 66081 50010 500
10 3003 626
5 664
56 411125 034
16 820
1 691
4 469
2 504
4 000
3 710
407
15 000
3 643
4 325
2 674
38 601
9 860
540
4 444
22 681
148 300

1 370 a2 489
2 590
3 008 b1 290 a4 102
3 360 a
3 249
1 891
1 559
1 183
2 056
3 010 a
2 540
3 371
3 039
2 000
3 261
3 000 a
3 279
3 810
3 592
3 000
2 415 b
4 750 a
1 766
1 959
1 825
4440
2 086
3 558
2 196
3 554
1 751
2 140 a2 870
1 958 b
1 771
4 100

ANNEX D: MEDICAL RADIATION EXPOSURES

337

Table 2, continued

Country / area

Slovakia
Slovenia
South Africa
Spain
SwedenSwitzerland
UkraineUnited Arab Emirates
United Kingdom
United States [M2]
Uruguay
Uzbekistan
Venezuela

Number per million population

Population(thousands)

5 325
1 987
42 39339 6748 800
7 097
52 4642 390
58 200260 000
3 168
23 20921 377

Average for level

All physicians

Physicians conducting
radiological procedures

Dentists

3 335
2 139
3 820 a
2 841
3 839
2 056
1 660
2 381
1 881 b1 282 b

83
63
125
95
31
41
92
3
5

389
568
270 a
1 364
641
255
388
752 b
-

2 784

106

526

Health-care level II
Algeria
Antigua and Barbuda
BahamasBarbados
BelizeBolivia
Bosnia and Herzegovina
BrazilChile
China
Colombia
Costa Rica
Dominica
Dominican Republic
El Salvador
GrenadaHonduras
India
JordanLibyan Arab Jamahiriya
Malaysia
Mauritius
MexicoNicaragua
Oman
Pakistan
Paraguay
Peru
Philippines
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
and the Grenadines
Trinidad and Tobago
Tunisia
Turkey28 784
65
272
250
189
7 238
3 628
150 000
13 994
1 196 360
34 545
3 500
80
7 684
5 530
95
5 494
944 580
5 198
5 225
19 570
1 129
92 7184 008
2 256
140 000
4 703
23 50073 000
3 818
36
140
110

940 a
908 a
900 b
1 176 a
450 a
390 a
1 111
1 060 a
839 b
940 a
880 a
475 a
1 070 a
640 a
537 a
790 a
410 a
1 540 a1 040 a
451
850 a
392
500 a
852
500 a
630 a
979
1 160
1 190 b1 194 a
421 a
500 a

31
56
2
222
3
1
0
1
1
11
0.4
5
33
1
13
1
11
8
3
0
7
9

290 a
200 a
129 b
132 a
63 a
50 a
667
400 a
30 b
440 a
50 a
100 a
160 a
42 a
90 a
10 a
356 a
150 a
80 a
130 a
17
100 a
37
20 a
250 a
240
486
217 b
306 a
64 a
55 a

1 292
9 000
63 898

730 a
944
1 036

3
19
35

90 a
60
261

695

76

87

0.3
0.6
0.4
14
6

20 a
20 a
158 b
2a
30 a
11 b
10 a
20 a
50
59

Average for level

Health-care level III
Afghanistan
Congo
Egypt
Ghana
Guatamala
GuyanaHaiti
JamaicaMadagascar
Morocco20 8832 668
63 271
17 832
9 715
838
7 035
2 429
14 00026 702

130 a
280 a
185 b
241
250 a
124 b
140 a
140 a
400
205 b

338

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 2, continued

Country / area

1 575
115 020
26 000432
11 439Namibia
Nigeria
Sudan
Suriname
Zimbabwe

Number per million population

Population(thousands)

Average for level

All physicians

Physicians conducting
radiological procedures

Dentists

220 a
170 a
409
130 a

3
-

30 a
10 a
39
10 a

208

5

49

40 a
80 a
34
50 a
30 a
60 a
60 a
40 a
45

0.02
0.4

1a
4a
10 a
1a
0a
10 a
1b
1

45

0.1

3

Health-care level IV
AngolaCameroon
Ethiopia
Kenya
Liberia
Mozambique
Nepal
SenegalUgandaUnited Rep. of Tanzania

11 18513 56060 00027 8002 245
17 79622 000
8 532
20 25628 400

Average for levelabcdData from reference [W20].
Data from reference [S37].
No data available.
Data from reference [R19].

The entries in this Table are qualified as follows:
Albania:
Argentina:
Barbados:
Belgium:Brazil:Dominica:
Ghana:
Russia:Trinidadand Tobago:
Ukraine:

Data on physicians conducting radiological procedures from reference [C28].
Data for physicians conducting radiological procedures refer only to practice in nuclear medicine, teletherapy, and brachytherapy.
Data for physicians conducting radiological procedures from reference [B43].
Data for physicians conducting radiological procedures from reference [C26].
Data for Paraná State (with a population of 9 million and a social and economic profile above the average for Brazil).
Data for physicians conducting radiological procedures from reference [B43].
Data on physicians from reference [S38].
Number of dentists refers to data for USSR in 1990 from reference [W20].
Data for physicians conducting radiological procedures refer only to radiotherapy practice from reference [B43].
Data on physicians conducting radiological procedures from reference [W33].

Bolivia, Chile, Colombia, Cuba, Dominican Rep., El Salvador, Guatemala, Honduras, Jamaica, Nicaragua, Paraguay, Puerto Rico, Trinidad and Tobago,
Uruguay, and Venezuela:
Data for physicians conducting radiological procedures refer only to radiotherapy practice from reference [B43].
Antigua, Grenada, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines:
Data for physicians conducting radiological procedures in public sector from reference [B43].

ANNEX D: MEDICAL RADIATION EXPOSURES

339

Table 3
Diagnostic imaging equipment (1991-1996)
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicated
X-ray generators

Nuclear medicine equipment

Country / area
MedicalMammography

DentalCTscanners

MRI
scanners

Gamma
camerasRectilinear
scanners

PET
scanners

0
42
4
36
1
35
0
47
2
4
2
7
18
8
1
22
146
400
20
13
6
210
1 559
2
5
0
1
55
6
15
2
11
1
1
100
3
2
131
50
99
18
2
140
3 500
-

311
15
12
500
0
87
6
9
4
80
58
12
2
58
350
850
150
53
23
315
1 387
19
26
4
4
180
22
43
7
2
300
17
13
190
90
110
9
365
2 000
-

122
0
37
0
2
3
0
35
0
7
0
43
50
15
34
0
20
0
11
0
0
4
0
0
3
0
1
0
7
-

1
0
0
5
0
2
0
0
0
3
0
1
40
0
1
0
5
33
0
0
0
1
0
0
0
0
1
0
5
7
0
5
-

Health-care level I
Albania [C28]
Argentina
Australia
BelarusBelgium
Bulgaria
CanadaCayman Islands
China, Taiwan Province
Croatia
Cuba
CyprusCzech Republic
Denmark
EcuadorEstonia [S29]FinlandFrance [A14]
Germany
GreeceHungary
IrelandIsrael [S48]
Italy
Japan
KuwaitLebanonLithuania
Luxembourg
Netherlands
New Zealand
NorwayPanamaPoland [R25]
Qatar
Romania
Russian Federation
Slovakia
Slovenia
Spain
SwedenSwitzerland
Ukraine [W33]
United Arab Emirates
United Kingdom
United States
Uruguay
Venezuela [B33]

12 000
2 400
1 813
9 725
6
3 662
620
1 000
72
2 380
1 225
619
392
1 600
18 31250 000
1 200
1 170
360
9 946
77 000
217
400
847
70
3 000
734
2 000
416
38
2 529
27 340
1 351
270
6 371
1 400
8 419
342
55 177
350
3 000

258
3
26
565
0
61
21
13
68
55
26
21
192
2 431
3 550
170
46
29
1 354
1 461 a
11
50
21
10
130
66
60
16
2
37
1 210
48
15
170
240
22
258
10 022-92431
36 978
0
6 212
250
550
3 100
4 970
771
107
4 746
36 38674 000
7 000
350
1 305
57 515
155
400
308
313
7 500
1 790
6 000
0
7
900
6 730
551
259
13 500
8 583
790
20 350
-

1
332
14
210
22
223
0
293
29
10
8
62
50
27
3
60
561
1 400
150
54
26
42
550
7 959
13
45
15
9
120
30
75
10
75
2
35
320
31
9
226
115
187
70
17
350
6 800
-

Health-care level II
Algeria [V9]Antigua and Barbuda[B33, B43]
Bahamas [B33]
Barbados [B33]
Belize [B33]
Bolivia [B33]
BrazilChile [B33]
China
Colombia [B33]
Costa Rica [B33]
Dominica [B33, B43]

4

-

-

8
-

1
0

7
0

0

0

5
20
12
1 458
16 6671 350
65 522
1 500
190
6

2
393
0

1
75 000
1 633
5

2
800
2 750
0

0
242
0

150 a
287
0

362
0

0a
3
0

340

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 3 (continued)
X-ray generators

Nuclear medicine equipment

Country / area

Dominican Republic[B33]
El Salvador [B33]
Grenada [B33, B43]
Honduras [B33]
India [R20]
Libyan Arab Jamahiriya
Malaysia
MexicoNicaragua [B33]
Oman
Paraguay
Peru
Philippines
Saint Kitts and Nevis[B33, B43]
Saint Lucia
Saint Vincent and the
Grenadines [B33, B43]
Trinidad and Tobago
Tunisia
TurkeyCTscanners

MRI
scanners

Gamma
camerasRectilinear
scanners

PET
scanners

-

-

-

-

0
14
38
56
7
30
95
0

0
40
2
8
2
1
5
6
0

0
4
8
26
2
10
27
0

0
0
0
2
1
0

0
0
0
0
0
0

0
-

1
0

0
0

0
0

0
0

0
0

400
10 000

24
173

1
35

8
100

0
6

0
0

7
0

1
5
3

4
1

0
0

2
0

1
2
1

1
0

0
0

MedicalMammography

Dental

180

-

-

-

136
3
87
1 270
1 469
50
94
100
1 400
2 079
3

0
23
10
2
40
56
-

635
12
1 800
140
-

14
4

-

20
538
5 000

23
120

Health-care level III
Ghana
Guatamala [B33]
Haiti
JamaicaMadagascar
Morocco
Sudan

121
95
20
30
66
3272
344

4
1
6
4

300
411
47

3
1
29
4

Health-care level IV
Ethiopia
Kenya [B41]
United Rep. of Tanzania
a

125

4

2

4
2

These revised data were received by the Committee after completion of the global analysis.

The entries in this Table are qualified as follows:
Argentina:
Belgium:Brazil:Data for medical x-ray units from reference [B33]. Total for gamma cameras includes 100 SPECT scanners.
Data for CT scanners from reference [C26]. Data for MRI scanners from reference [R33].
Except for data on gamma cameras and PET scanners, numbers extrapolated from data for Paraná State (with a population of 9 million anda social and economic profile above the average for Brazil). Estimate for national total of CT scanners from M. T. Carlos, University of Riode Janeiro (1998).
Canada:Total for dental x-ray generators extrapolated from data for province of Alberta (representing about 9.5% of population); totals for medical
x-ray generators and gamma cameras extrapolated from data for province of Manitoba (representing about 4% of population).
Cuba:
Data for medical x-ray units from reference [B33]. Other data from reference [H32].
Ghana:
Data from reference [S38]. Nuclear medicine conducted only at Korle Bu Teaching Hospital [A16].
Italy:
Data on x-ray generators (medical and mammography), and CT and MRI scanners from reference [B40]; total for medical x-ray generators
includes dental equipment.
Oman:
Total for dental x-ray generators refers to panoramic equipment.
Philippines:
Totals shown for medical and dental x-ray generators refer to facilities and not individual machines.
Russian Federation: Data for MRI scanners and gamma cameras from reference [W33].
Saint Lucia:
Data from references [B33] and [B43]. Total for dental x-ray generators refers to public sector.
Spain:
Data from reference[B40]. Total for medical x-ray generators includes dental equipment. Total for gamma cameras includes public sector
only.
Turkey:Data for CT scanners from reference [S47]; 60% of the total operate in the private sector.
United States: Data from reference [B40]. Total for medical x-ray generators includes dental equipment. Total for gamma cameras includes all nuclear
medicine imaging equipment.
Haiti, Jamaica, Paraguay, Trinidad and Tobago, Uruguay: Estimated number of medical x-ray generators from reference [B33].

ANNEX D: MEDICAL RADIATION EXPOSURES

341

Table 4
Diagnostic imaging equipment per million population (1991-1996)
Based on data and qualifications from Table 3
X-ray generators

Nuclear medicine equipment

Country / area
MedicalMammography

DentalCTscanners

MRI
scanners

Gamma
camerasRectilinear
scanners

PET
scanners

Health-care level I
Albania
Argentina
Australia
BelarusBelgium
Bulgaria
CanadaCayman Islands
China, Taiwan Province
Croatia
Cuba
CyprusCzech Republic
Denmark
EcuadorEstonia
FinlandFranceGermany
GreeceHungary
IrelandIsraelItaly
Japan
KuwaitLebanonLithuania
Luxembourg
Netherlands
New Zealand
NorwayPanamaPolandQatar
Romania
Russian Federation
Slovakia
Slovenia
Spain
SwedenSwitzerland
UkraineUnited Arab Emirates
United Kingdom
United States
Uruguay
Venezuela

336
233
213
348
176
168
130
92
111
230
240
48
261
313
318
614
114
114
99
176
616
128
100
228
172
200
202
462
156
70
112
184
254
136
161
159
1 186
143
212
110
140

14.6
0.3
3.1
20.2
0
2.8
4.4
20.0
6.6
10.8
2.0
14.0
37.5
42.2
43.6
16.2
4.5
8.0
24.0
11.7
6.5
12.5
5.7
24.6
8.7
18.1
13.9
6.0
3.7
1.6
8.2
9.0
7.6
19.3
33.8
9.2
4.4
38.6
-

9
51
1 323
0
286
53
844
299
975
59
71
928
631
908
667
34
360
460
92
100
83
770
500
491
1 387
0
13
40
45
103
130
1 534
1 209
331
350
-

0.3
18.8
1.4
21.0
2.6
8.0
0
13.5
6.1
0.9
12.3
6.0
9.8
2.1
2.0
11.7
9.7
17.2
14.3
5.2
7.2
7.4
9.8
63.7
7.7
11.3
4.0
22.1
8.0
8.2
17.3
3.7
1.9
3.7
1.5
2.2
5.8
4.5
5.7
13.1
26.4
1.3
7.1
6.0
26.2
-

0
2.37
0.39
3.60
0.12
1.25
0
2.16
0.42
0.37
3.07
0.68
3.53
0.62
0.67
4.30
2.53
4.91
1.90
1.26
1.65
3.72
12.5
1.18
1.25
0
2.46
3.67
1.65
3.47
0.75
0.28
1.85
0.04
0.67
0.56
1.01
3.30
5.68
14.0
0.34
0.84
2.41
13.5
-

8.72
1.45
1.41
17.9
0
4.00
1.26
0.83
6.14
7.72
11.4
0.92
1.33
11.3
6.07
10.4
14.3
5.15
6.34
5.58
11.1
11.2
6.50
1.08
9.84
12.0
6.04
9.94
2.62
3.70
2.02
3.19
6.54
4.79
10.2
15.5
3.77
6.27
7.69
-

3.42
0
4.36
0
0.09
0.63
0
3.38
0
0.54
0
0.75
0.61
1.43
3.30
0
0.35
0
2.97
0
0
0.92
0
0
0.56
0
0.11
0
0.12
-

0.03
0
0
0.18
0
0.09
0
0
0
0.59
0
0.20
0.49
0
0.10
0

Average

293

23.7

440

17.4

5.71

7.19

0.92

0.20

0.03
0
0
0.20
-

0.24
0
1.0
0.24
-

0
0.30
-

0
0.003
-

0.09
0.26
0
0
0
0.07
0
0
0
0
0.19
0
0.57
0.99
0
0.09
-

Health-care level II
Algeria
Antigua and Barbuda
BahamasBarbados
BelizeBolivia
BrazilChile
China
Colombia
Costa Rica

62
18
80
63
201
111
96
55
43
54

8.0
0.33
-

4.0
500
1.4
-

0.28
8.00
5.33
2.30
-

342

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 4 (continued)
X-ray generators

Nuclear medicine equipment

Country / areaCT
scanners

MRI
scanners

Gamma
camerasRectilinear
scanners

PET
scanners

0
0
0.04
0.38
0.41
0.02
0.44
0.21
0.08
0
0
0

0
0
0.77
0.41
0.28
0.89
0.43
0.37
0
0
0

0
0
0
0
0.09
0.01
0
0
0

0
0
0
0
0
0
0
0
0

2.7
2.9

0.11
0.55

0.89
1.56

0
0.09

0
0

2.4

0.14

0.32

0.25

0.002

MedicalMammography

DentalDominica
Dominican Republic
El Salvador
GrenadaHonduras
India
Libyan Arab Jamahiriya
Malaysia
MexicoNicaragua
Oman
Paraguay
Peru
Philippines
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and
the Grenadines
Trinidad and Tobago
Tunisia
Turkey

75
23
25
32
16
65
16
12
42
21
60
28
83
100
36

0
0
1.2
0.11
0.89
1.7
0.77
-

63
6.9
5.3
77
1.9
0
-

0
0
2.7
1.9
0.60
3.1
1.3
1.3
0
7.1
0

15
60
78

2.6
1.9

44
157

Average

58

0.45

56

Health-care level III
Ghana
Guatamala
Haiti
JamaicaMadagascar
Morocco
Sudan

6.8
9.8
2.8
12.4
4.7
123
13.2

0.22
0.07
0.22
0.15

21.4
15.4
1.8

0.17
0.07
1.09
0.15

0.26
0

0.07
0.19
0.12

0.15
0.04

0
0

Average

38

0.18

11.4

0.44

0.13

0.13

0.09

0

Health-care level IV
Ethiopia
Kenya
United Rep. of Tanzania

4.4

0.14

0.07

0.14
0.07

0.07
0

0.02
0.07
0.04

0.02
0

0
0

Average

4.4

0.14

0.07

0.11

0.04

0.03

0.01

0

ANNEX D: MEDICAL RADIATION EXPOSURES

343

Table 5
Radiotherapy equipment (1991-1996)
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicated

Teletherapy units

Clinical therapy
facilities

Brachytherapy afterloading units

Country / area
X-ray

Radionuclide a

LINACsSRS b

Manual c

RemoteLDR dRemote
HDR e

Total

Neutrons

Heavy
ions

0
16
2
15
0
28
0
0
0
4
0
6
3
2
3
3
173
0
0
1
1
1
4
3
0
0
25 f
1
0
0
12
0
4
4
2
12
7
5
0
30
0
2

3
2
12
10
1
20
0
36
0
0
6
3
0
7
21
10
11
2
0
5
0
12 f
1
3
0
0
4
9
0
5
14
2
20
0
0

77
38
14
41
10
78
0
42
2
12
1
33
7
4
3
11
194
190
10
11
4
219
1
1
4
3
6
0
37 f
8
4
2
15
0
10
15
5
17
12
19
4
53
0
32

0
0
0
0
0
0
0
0
0
0
3
2
0
0
0
1
0
1
0
0
0
0
0
0
0
0
0
0
-

0
0
1
0
0
1
0
0
0
0
0
0
0
0
2
0
0
0
0
0
0
0
0
0
1
1
0
1
-

Health-care level I
Albania [D27]
Argentina
Armenia [D27]
Australia
BelarusBelgium
Bulgaria
CanadaCayman Islands
China, Taiwan Province
Croatia
Cuba
CyprusCzech Republic
Denmark
EcuadorEstonia
FinlandFrance [A14]
Germany
GreeceHungary
IrelandJapan
Kazakhstan
KuwaitKyrgyzstan
LatviaLebanonLithuania
Luxembourg
Netherlands
New Zealand
NorwayPanamaPolandQatar
Rep. of Moldova [D27]
Romania
Russian Federation [D27]
Slovakia
Slovenia
South Africa
SwedenSwitzerland
Ukraine [D27]
United Arab Emirates
United Kingdom
United States
Uruguay [B43]
Uzbekistan [D27]Venezuela

40
15
14
35
10
0
3
10
30
2
48
5
7
11
138
800
3
25
3
0
2
9
0
34
11
30
2
0
140
25
5
26
77
0
70
-

3 (0)
103(2)
42 (0)
29 (0)
16
12 (0)
44 (0)0
23 (0)
14 (8)9 (0)2 (0)59 (23)
1 (0)
9 (0)
3
1 (0)
133
160
24 (0)
12 (2)3 (0)298 (0)12 (0)25
11 (6)
12 (0)
0
0
2 (1)
1 (0)
3 (0)
17
0
3
21 (0)
21 (5)
2 (0)
23
3 (0)
12(0)
10
2 (0)
15 (0)504
10 (0)
24 (0)

0
41
0
77
4
34
0
107
0
56
2
1
0
18
25
0
2
23
223
230
14
10
8
564
2
1
1
5
6
0
0
60 f
14
19
0
24
0
0
3
5
5
3
24
56
38
1
4
150
1893
3
1
15

0
1
0
3
0
0
0
0
1
0
0
1
0
0
0
1
1
2
1
0
0
7
0
0
1
1
1
0
0
0
0
0
0
1
1
1
1
-

74
20
0
16
9
30
0
6
2
8
1
21
1
2
1
0
0
1
0
1
0
6
1
2
3
0
2
2
3
5
0
0
2
3
0
30

Health-care level II
Algeria [D27]
Antigua and Barbuda[B33, B43]
Bahamas [B43]
Barbados
Belize [B43]
Bolivia
Bosnia andHerzegovina [D27]0

15 (0)
0

8
0

0

5
0

7
0

0

12
0

0

0

0
0
0
-

0
1 (0)
0
0
2

0
0
0
0
1

0
0
0
-

0
2
0
0
-

0
1
0
0
-

0
0
0
-

0
3
0
0
-

0
0
0
-

0
0
0
-

344

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 5 (continued)

Teletherapy units

Clinical therapy
facilities

Brachytherapy afterloading units

Country / area

BrazilChile
China
Colombia
Costa Rica
Dominica [B43]
Dominican Republic
El Salvador
Grenada [B43]
Honduras
JordanLibyan Arab Jamahiriya
Malaysia
Mauritius [D27]
MexicoNicaragua
Oman
Pakistan [L57]
Paraguay [B43]Peru
Philippines
Puerto Rico
Saint Kitts
and Nevis [B43]
Saint Lucia [B43]
Saint Vincent and the
Grenadines [B43]
Trinidad & Tobago
Tunisia
TurkeyX-ray

Radionuclide a

LINACsSRS b

Manual c

RemoteLDR dRemote
HDR e

Total

Neutrons

Heavy
ions

169 f
225
2
0
0
1
2
1
7
0
10
2
0

126 f
21 (0)
541(40)28 (0)
3 (0)
0
8 (0)
3 (0)
0
2 (0)
2(0)
3
8 (1)
2
92 (0)
1 (0)
0
2 (0)
4 (0)
9 (0)
12 (0)
2
0

68 f
14
282
11
0
0
1
0
0
0
3
7
2
24
0
0
1
3
3
3
2
0

3f
36
0
0
0
0
0
2
0

100 f
19
0
15
7
0
3
9
0
2
0
7
2
65
5
0
0
25
1
0
0

-f
1
0
7
0
0
1
0
0
0
1
0
7
0
0
0
0
2
0
0

22 f
309
0
0
0
0
0
0
0
0
0
0
0
2
0
0

124
20
309
22
7
0
4
9
0
2
1
7
2
72
5
0
0
25
5
0
0

0
1
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

2
22

2 (0)
7 (0)
41 (0)

0
1
20

3

2
5
6

0
10
3

0
9

2
15
18

0
0

0
0

0
2
4
1
0
0
3
2
0
2

0
0
0
0
1
0
-

0
6
8
9
0
0
5
3
0
3

0
0
0

0
0
0

3
1
1
0
0

1
0
1

5
1
4
0
1
1

0
0
0

0
0
0

Health-care level III
Afghanistan [L57]
Congo [D27]
Egypt
Ghana
Guatamala
Guyana [D27]
Haiti [B33]
Jamaica [B43]
Madagascar
MoroccoNamibia [D27]
Nigeria
Sudan
Suriname [D27]Zimbabwe [B42]

0
1
1
1
-

0
1
13
2
6 (0)
0
2 (0)
2 (0)
1
9 (4)
1
5
3 (0)
0
3 (0)

0
0
13
0
0
0
0
0
1
0
0
1
0
3

0
0
0
0
0
0
0
0
-

0
4
4
8
0
0
2
0
0
1

Health-care level IV
Angola [D27]
Cameroon
Ethiopia
Kenya [B41]
Liberia [D27]
Mozambique [D27]
Nepal [D22]Senegal [D27]
Uganda [D27]
United Rep. of Tanzania
a
b
c
d
e
f

0
1

1
2
1
3 (0)
1
1
1 (0)
1
2
2 (1)

0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0

2
0
2
0
1
0

Includes both 60Co and 137Cs units; total of the latter type shown in brackets.
Stereotactic radiosurgery; includes units based on radionuclides (Gammaknife), Linacs and other specialist radiation sources.
Number of treatment rooms.
Remote low dose rate.
Remote high dose rate.
These revised data were received by the Committee after completion of the global analysis.

ANNEX D: MEDICAL RADIATION EXPOSURES

345

Table 5 (continued)
The entries in this Table are qualified as follows:Afghanistan:
Algeria:
Belgium:

No radiotherapy or oncology services in country [L57].
Total for LDR refers to all types of remote unit.
Total for manual afterloading brachytherapy units refers to the sum, over all centres performing this technique, of the number of diferent
radionuclides in use at each centre.
Cameroon:
Data from reference [D27]. Total for LDR refers to all types of remote unit.
Canada:Total for x-ray teletherapy units extrapolated from data for province of Alberta (representing about 9.5% of population). 77 of the 107 Linacs
operate above 10 MeV. Data for manual and remote-HDR brachytherapy afterloading units refer to number of licenses issued by Atomic
Energy Control Board of Canada for practice; data for remote-LDR units refer to number of devices listed on licenses. Heavy ion facility
refers to proton therapy.
Costa Rica:
Data for 60Co units and Linacs from reference [B33]. Data for x-ray teletherapy units from reference [I25]. Data for brachytherapy
afterloading units from reference [D27].
Croatia:
Heavy ion facility refers to betatron.
Egypt:
Data from reference [D27]. Total for LDR refers to all types of remote unit.
Estonia:
Data from reference [D27]. Total for LDR refers to all types of remote unit.
Ethopia:
Data from reference [D27]. Total for LDR refers to all types of remote unit.
Ghana:
Data from reference [D27]. Total for LDR refers to all types of remote unit.
Kazakstan:
Data from reference [D27]. Total for LDR refers to all types of remote unit.
Kyrgyztan:
Data from reference [D27]. Total for LDR refers to all types of remote unit.
Latvia:Data from reference [D27]. Total for LDR refers to all types of remote unit.
Mexico:All data from reference [D27], except in relation to x-ray teletherapy units. Total for LDR refers to all types of remote unit.
Nigeria:
Data from reference [D27]. Total for LDR refers to all types of remote unit.
Pakistan:
Data for IRNUM, Peshawar, North-West Frontier Province (serving population of 200 million including Afghanistan) [L57].
Poland:Data from reference [D27]. Total for LDR refers to all types of remote unit.
South Africa:
Data from reference [D27]. Total for LDR refers to all types of remote unit.
Sweden:Heavy ion facility refers to the Svedberg Laboratory, Uppsala (180 MeV protons).
Tunisia:
Data for brachytherapy afterloading units from reference [D27]. Total for LDR refers to all types of remote unit.
United Kingdom: Heavy ion facility refers to the use of protons at the Clatterbridge Centre for Oncolgy.
United States: Data for 1990 from reference [I23].
Zimbabwe:
Data for brachytherapy afterloading units from reference [D27]. Total for LDR refers to all types of remote unit.
Barbados, Bolivia, Chile, Colombia, Cuba, Dominican Republic, Guatemala, Puerto Rico and Venezuela:
Data from reference [B43]. In relation to brachytherapy afterloading equipment, total for manual refers to number of sources and total for
LDR refers to all types of remote unit.
El Salvador, Honduras, Nicaragua, Honduras, Tiniidad and Tobago:
Data from reference [B43]. In relation to brachytherapy afterloading equipment, total for manual refers to number of sources.

346

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 6
Radiotherapy equipment per million population (19911996)
Based on data and qualifications from Table 5
Teletherapy units
Country / area
X-ray

Radionuclide

LINACsBrachytherapy
afterloading
units

Health-care level I
Albania
Argentina
Armenia
Australia
BelarusBelgium
Bulgaria
CanadaCayman Islands
China, Taiwan Province
Croatia
Cuba
CyprusCzech Republic
Denmark
EcuadorEstonia
FinlandFranceGermany
GreeceHungary
IrelandJapan
Kazakhstan
KuwaitKyrgyzstan
LatviaLebanonLithuania
Luxembourg
Netherlands
New Zealand
NorwayPanamaPolandQatar
Republic of Moldova
Romania
Russian Federation
Slovakia
Slovenia
South Africa
SwedenSwitzerland
UkraineUnited Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Venezuela
Average




2.26
1.45
1.40
4.12
0.36
0
0.14
2.10
2.75
3.07
4.63
0.98
0.54



2.15
2.39
9.82
0.29
2.43
0.83
0



1.18





2.43
0
2.27
3.02
6.94
0.75


0


6.17



4.70
2.52



2.95
10.9



0
1.20






2.84

0.88
2.89
1.10
0.11
2.81
1.60
1.41
1.57
0
1.06
2.94
0.83
3.07
5.69
0.20
0.69
2.00
0.20
2.31
1.96
2.29
1.17
0.83
2.38
0.06
1.18
0.45
2.00
2.75
3.23
0
0
0.55
0.23
1.12
0.44
0
0.68
0.93



1.12

0
1.15
0
4.35
0.39
3.40
0
3.83
0
2.58
0.42
0.09
0
1.74
4.90
0
1.33
4.49
3.87
2.82
1.33
0.97
2.21
4.51
0.12
0.59
0.22
2.00
1.75
0
0
4.00
3.84
4.39
0
0.62
0
0
0.13
0.03
0.94
1.51
0.57
6.36
5.35
0.02
1.67
2.58
7.28
0.95
0.04
0.70

1.56

3.04

1.69

0.28
0
0
0
0
0
0.28
0.45
1.00

0.42
0
0
12.0
0
0



3.94
1.01
0.54
0.34
1.69
0.19
0.84
0.26
1.94
3.16



2.16



2.15
1.36
4.10
1.18
2.79
0
1.93
0.42
1.10
1.54
3.18
1.37
0.31
2.00
2.15
3.36
2.33
0.95
1.07
1.10
1.75
0.06
0.59
0.90
1.20



1.62
0
2.47
2.20
0.92
0.75
0.39
0



0.44



2.82
2.52
0.40
1.36
2.68



1.67
0.91


0


1.50

Health-care level II
Algeria
Antigua and Barbuda
BahamasBarbados
BelizeBolivia
Bosnia and Herzegovina
Brazil
Chile


0
0


0
0


1.1



0.52
0
0
4.00
0
0
0.55
0.84
1.50



0.83
1.43

ANNEX D: MEDICAL RADIATION EXPOSURES

347

Table 6 (continued)
Teletherapy units
X-ray

Radionuclide

LINACsBrachytherapy
afterloading
units

China
Colombia
Costa Rica
Dominica
Dominican Republic
El Salvador
GrenadaHonduras
JordanLibyan Arab Jamahiriya
Malaysia
Mauritius
MexicoNicaragua
Oman
Pakistan
Paraguay
Peru
Philippines
Puerto Rico
Saint Kits and Nevis
Saint Lucia
Saint Vincent and
the Grenadines
Trinidad and Tobago
Tunisia
Turkey

0.19

0.45
0.81
0.86
0
1.04
0.54
0
0.36
0.38
0.57
0.41
1.77
0.99
0.25
0
0.01
0.85
0.38
0.16
0.52
0
0
0

0.24
0.32
0
0
0.13
0
0
0
0.58

0.26
0.64
2.00
0
0.52
1.63
0
0.36
0.19

0.36
1.77
0.26
0
0
0.01
0.64
0.13
0.04
0.52
0
0
0

0.36
1.77
0.78
1.25
0

0.22
0.34

1.55
0.78
0.64

0
0.11
0.31

1.55
1.67
0.28

Average

0.22

0.52

0.26

0.38

Country / area



0.57
0



0


0.19
0.38
0.05



0.08


0



0.43
0.03


0
0
0









0
1.06
0.07
0
0
0
0

Health-care level III
Afghanistan
Congo
Egypt
Ghana
Guatemala
GuyanaHaiti
JamaicaMadagascar
MoroccoNamibia
Nigeria
Sudan
Suriname
Zimbabwe
Average

0

0
0
0.21
0
0
0
0
0

0




0
0.37
0.21
0.11
0.62
0
0.28
0.82
0.07
0.34
0.63
0.04
0.12
0
0.26

0.04
0
0
0.04
0
0.26

0.04
0.12
0
0.26

0.03

0.15

0.06

0.13








0.07
0.04




0.04




0.09
0.45
0.93
0


0





Health-care level IV
AngolaCameroon
Ethiopia
Kenya
Liberia
Mozambique
Nepal
SenegalUgandaUnited Rep. of Tanzania
Average





0.02
0.04

0.09
0.15
0.02
0.11
0.45
0.06
0.05
0.12
0.07
0.07

0
0
0
0
0
0
0
0
0
0

0.02

0.07

0

0



0




0.37
0.02
0.14



0


0.07
0.04
0.07

348

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 7
Temporal trends in average provision for medical radiology per million population
Data from UNSCEAR Surveys of Medical Radiation Usage and Exposures
Number per million population at health-care level
Resource

Years
I

II

III

IV

197019741980198419851990
19911996













2 600
2 780

550
695

180
210

53
45

197019741980198419851990
19911996

62
76
72
106

23
64
41
76


4
6
5



0.3
0.1

Dentists

19911996

530

87

49

3

Medical x-ray generators197019741980198419851990
19911996

450
380
350
290

14
71
86
60


16
18
40

0.6
10
4
4

Mammography x-ray generators

19911996

24

0.5

0.2

0.1

Dental x-ray generators197019741980198419851990
19911996

440
460
380
440

12
77
86
56



0.04

5
3
11

0.4
0.1

Computed tomography scanners

19911996

17

2.4

0.4

0.1

Nuclear medicine gamma cameras

19911996

7.2

0.3

0.1

0.03

Nuclear medicine rectilinear scanners

19911996

0.9

0.3

0.1

0.01

Nuclear medicine PET scanners

19911996

0.2

0.002

0

0

Therapy x-ray units

197019741980198419851990
19911996

14
13
4.8
2.8

0.2
1.7
5.0
0.2


0.7
0.1
0.03




197019741980198419851990
19911996

3.1
3.4
2.6
1.6

0.1
0.4
0.4
0.5

0.1
0.4
0.2
0.2

197019741980198419851990
19911996

1.0
1.2
2.0
3.0





0.1
0.1
0.3

0.02
0.09
0.06

Brachytherapy afterloading units

19911996

1.7

0.4

0.1

0.1

Stereotactic radiosurgery units

19911996

0.04

0.03

0

0

Neutron therapy facilities

19911996

0.02

0.001

0

0

Heavy ion therapy facilities

19911996

0.01

0

0

0

Physicians

Physicians conducting radiological proceduresRadionuclide teletherapy units

LINACs



0.1
0.02



0.09
0.1




0

ANNEX D: MEDICAL RADIATION EXPOSURES

349

Table 8Annual numbers of medical radiation examinations and treatments (19911996)
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicatedTherapeutic treatments a (thousands)

Diagnostic examinations (thousands)
Country / area
Medical x rays

Dental x rays b

Radionuclide
administrations

Brachytherapy

Radionuclide
administrations





6.85

32.5

1.13

Teletherapy

Health-care level I
Argentina
Australia
Austria [H60]
Bahrain
Belarus
Bulgaria
CanadaCayman Islands
China, Taiwan Province
Croatia
Cuba
CyprusCzech Republic
Denmark
EcuadorEstonia [S29]FinlandFranceGermany
Greece [H60]
Hungary
IrelandIsrael [H60]
Italy
Japan
KuwaitLithuania
Luxembourg
Netherlands
New Zealand
NorwayPanamaPolandPortugal [F11]
Qatar
Romania
Russian Federation
Slovakia
Slovenia
South Africa
Spain
SwedenSwitzerland
UkraineUnited Arab Emirates
United Kingdom
United States [I23]
Uruguay
Venezuela
10 000



115
7 489
5 000
24 933

10 446
4 300







396
212




28
835

4.98
27.7
1 805
0
135
11.3






1 100










2.30




4.68
1.57
47.3
0

0.986
4.73
1.95
0

0.258
8.37
0

9.43
22.2
0.605
36.2
7.85
1.35

0.350

0.145

0.012
2.83

0.052
2.60
2.34
0.452









610
9 154
2 600
1 959
1 500
3 600
92 000102 240

1 484

4.33
293
77.5
10.3
12.0
50.9

100

22 520

2 780












4 891

420

158
22.3

37.7
5.87

3.20
0.339

95.2 c0.386

5.51 c
0.025

0
34 c
6.25

0
2.3 c
0.172

9.22

0.790

0.141

39.4
2.56
68.5
1 869
49.9
22.2

0
10.5
144
4.07
4.84

0
3.67
65.3
1.38
0.278

45.7 c11.5

2.64 c0.964

8.38 c
3.50
1.607

0.552
135
515
4.78
34.3

0.022

0.058
14.5

30.0
0







0

0

0











184 652
1 515
3 287
425
9 000



3 062
803
24 7608 381
248
10 197170 700
4 261
691
5 580
25 059 c
5 000
5 320
31 478904
28 876250 000




7.87
2 000
2 400
184
















104 860
168
400
191
2 700 c





2 840
986



632
14 240503
110



5 515 c
6 500
4 050



36.7
12 500





621
1 460
21.5
39.2
21.2
240
29.1






474 c
120
67.5
262
17.3
478
8 202




















0.124















2.24
7.00
31.4
1.63
1.08
0.445
0.30
6.00
3.78 c
0.227
1.087



4.3 c
0.562
1.02




0.682
0.024
1.53
1.483
0.612
0.591




Health-care level II
Antigua and Barbuda[B33, B43]
Bahamas [B43]
Barbados
BelizeBolivia
BrazilChile
China [Z9, Z13, Z29]
Colombia
Dominica
Dominican Republic

17.6



0

0















39 08316 6671 000 c207 000 c

2 000

620 c

0
0.783
0
6.00
200
30.0
410 c
54.7
0
14.6

43.4




14.8










0




0



5.5 c




0



5.00



48 c


0



350

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 8 (continued)
Therapeutic treatments a (thousands)

Diagnostic examinations (thousands)
Country / area

El Salvador
GrenadaHonduras
Iran (Islamic Republic of)
JordanLibyan Arab Jamahiriya
Malaysia
MexicoNicaragua
Oman
Pakistan
Paraguay
Peru
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and
the Grenadines
Trinidad and Tobago
Tunisia
TurkeyMedical x rays

Dental x rays b

Radionuclide
administrations












15.0

235

16.0






0


110
8.13




3 578
28 365

106

98.0

606

5.18

1.44
77.1









7.30
18.7
16.2















6 262

2 000




13.7


0
0
0


7.08
132

Teletherapy

Brachytherapy

Radionuclide
administrations

11.2
0
11.0







1.39
0.411



10.3
8.80
0
7.47
10.0
3.28
5.54
0
0
0
1.96
1.20
24.6

0

0







0.701

1.99

3.53

0
0.158
0
0.850

0
3.93
0.800

0
0
0

0
0
0

















0.200
2.37

0.380
3.03














0.800
0.024

0.920
0.167




0.025
0.007

Health-care level III
Afghanistan [L57]
Ghana
Guatamala
Haiti
JamaicaMadagascar
Morocco
Sudan







118

4.42

0.970



16.5
2.21

20.0
13.0
5.00
0.904
9.60
1.17





151
216
956













0

0

Health-care level IV
Ethiopia
United Rep. of Tanzania
a
b
c





831

1.90

0.848
0.666


1.42

Complete courses of treatment.
Some values may refer to number of films.
These revised data were received by the Committee after completion of the global analysis.

The entries in this Table are qualified as follows:Afghanistan:
Argentina:
Barbados:

No radiotherapy or oncology services in country [L57].
Totals for diagnostic and therapeutic procedures with radionuclides inferred from data for about 25% of Nuclear Medicine Centres.
Data from reference [B43]. Total for medical x-ray examinations refers to public sector. Total for teletherapy refers to estimated annual
number of new patients with cancer.
Brazil:Except for data on diagnostic radionuclide administrations and brachytherapy treatments, numbers extrapolated from data for Paraná State(with a population of 9 million and a social and economic profile above the average for Brazil). Data for diagnostic dental x-ray examinations
include only intraoral procedures.
Canada:Total for diagnostic medical x-ray examinations from reference [A15]. Totals for diagnostic and therapeutic radionuclide procedures
extrapolated from data for the province of Ontario (representing about 37% of population). Totals for teletherapy and brachytherapy
treatments extrapolated from data for the Nova Scotia Cancer Treatment and Research Foundation, the Cross Cancer Institute (Northern
Alberta) and the province of Manitoba (collectively representing about 14% of the population).
China:
Data shown for teletherapy also include brachytherapy.
China (Taiwan): Data on diagnostic radionuclide procedures from reference [L6].
Cyprus:Data for medical and dental x rays extrapolated from information for 50% of poulation; data for diagnostic and therapeutic radionuclide
procedures extrapolated from information for 90% of population.
Finland:
Data for therapeutic radionuclide administrations from reference [K59].
France:Data on diagnostic medical x rays from reference [B40]; this total includes dental x rays. Data for therapeutic treatments represents annual
number of patients undergoing radiotherapy [S50]. Data on therapeutic radionuclide administrations from reference [H60].
Ghana:
Data on diagnostic medical and dental x rays from reference [S38]. Data on diagnostic radionuclide examinations from reference [A16].
Italy:
Data on diagnostic medical x-rays from reference [B40]; this total includes dental x rays.
Japan:
Data on diagnostic dental x-rays from reference [I30].
Mexico:Total for diagnostic medical x-ray examinations inferred from data for about 35% of radiology Institutions. Data for diagnostic dental x-ray
examinations include only panoramic procedures.
Morocco:Total for brachytherapy treatments includes only gynaecological tumours.
New Zealand: Data for therapeutic radionuclide administrations from reference [L28].
Norway:Data on therapeutic radionuclide administrations from reference [H60].

ANNEX D: MEDICAL RADIATION EXPOSURES

351

Table 8 (continued)
Poland:Data on diagnostic x-rays from reference [S49].
Portugal:
Data on diagnostic exminations from reference [F11]. Data on therapeutic radionuclide administrations from reference [H60].
Switzerland:
Data on therapeutic radionuclide administrations from reference [H60].
Ukraine:Total for medical x-ray examinations includes dental x-ry examinations.
United Kingdom: Data for medical and dental x-ray examinations from reference [T15]. Data for diagnostic examinations with radionuclides fromreference [E11]. Estimated total for ‘Teletherapy’ includes also brachytherapy treatments. Data for therapeutic radionuclide administrations
from reference [C27].
Uruguay:
Data from reference [B43]. Total for teletherapy refers to estimated annual number of new patients with cancer.
Dominica, Grenada, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines:
Data from reference [B43]. Total for medical x-ray examinations refers to public sector.
Bolivia, Chile, Colombia, Cuba, Dominican Republic, El Salvador, Guatemala, Haiti, Honduras, Jamaica, Nicaragua, Paraguay, Puerto Rico, Trinidad
and Tobago, Venezuela:
Data from reference [B43]. Total for teletherapy refers to estimated annual number of new patients with cancer.

352

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 9Global use of medical radiology (1991-1996)
Estimates derived from UNSCEAR Survey of Medical Radiation Usage and Exposures a
P A R T A: NORMALIZED VALUES
Number per million population at health-care level
Quantity
I

II

III

IV

Globally

Physicians
All physicians

2 800

700

210

45

1 100

Physicians conducting radiological procedures

110

80

5

0.1

70

X-ray imaging
Equipment

Annual numberof examinations

Medical

290

60

40

4

110

Dental

440

60

10

0.1

150

Mammography

24

0.5

0.2

0.1

7

CT

17

2

0.4

0.1

6

Medical b

920 000

150 000

20 000330 000

Dental c

310 000

14 000200

90 000Radionuclide imaging
Equipment

Gamma cameras

7.2

0.3

0.1

0.03

2.1

Rectilinear scanners

0.9

0.3

0.1

0.01

0.4

PET scanners

0.2

0.002

0

0

0.05

19 000

1 100

280

17

5 600

20

0.4

65

Annual number of examinations dRadionuclide therapy
Annual number of patients

e

170

40
Teletherapy

Equipment

X-ray

2.8

0.2

0.03

0.02

0.9

Radionuclide

1.6

0.5

0.2

0.1

0.7

LINAC

3.0

0.3

0.06

0

0.9

1 500

690

470

50

820

0.1

0.1

Annual number of patients f

Brachytherapy
Afterloading units

1.7

Annual number of patients

g

0.4

200

17

P A R T B:

15

(15)

0.7
h

70

TOTAL VALUES
Total number (millions) at health-care level

Quantity
I

II

III

IV

Globally

Physicians
All physicians

4.3

2.1

0.13

0.03

6.6

Physicians conducting radiological procedures

0.16

0.23

0.003

0.0001

0.4

ANNEX D: MEDICAL RADIATION EXPOSURES

353

Table 9 (continued)
Total number (millions) at health-care level
Quantity
I

II

III

IV

Globally

X-ray imaging
Equipment

Annual numberof examinations

Medical

0.45

0.2

0.02

0.002

0.7

Dental

0.67

0.2

0.01

< 0.0001

0.9

Mammography

0.04

0.001

0.00010.0001

0.04

CT

0.027

0.007

0.00030.0001

0.034

Medical b

1 410

470

24

1 910

Dental c

475

42

0.24

520

Radionuclide imaging
Equipment

Gamma cameras

0.011

0.001

0.00010.00002

0.012

Rectilinear scanners

0.001

0.001

0.00010.00001

0.002

PET scanners

0.00030.00001

000.00031

29

3.5

0.2

0.01

32.5

0.01

0.0002

0.4

Annual number of examinations dRadionuclide therapy
Annual number of patients e

0.3

0.1
Teletherapy

Equipment

X-ray

0.004

0.001

0.000020.00001

0.005

Radionuclide

0.002

0.002

0.00010.00004

0.004

LINAC

0.005

0.001

0.00004

0

0.005

2.3

2.1

0.3

0.03

4.7

0.00010.00004

Annual number of patients f

Brachytherapy
Afterloading units
Annual number of patients

0.003
g

0.3

0.001
0.05

0.01

(0.01)

640

565

h

0.004
0.4

Population
Total Population
a
b
c
d
e
f
g
h

1 530

3 070

5 800

Extrapolated, with rounding, from limited samples of data.
Estimates based on following population sample sizes for global model: 67% for level I, 50% for level II, 9% for levels III/IV, and 46% overall.
Estimates based on following population sample sizes for global model: 39% for level I, 49% for level II, 4% for levels III/IV, and 37% overall.
Estimates based on following population sample sizes for global model: 68% for level I, 18% for level II, 11% for level III, 16% for level IV, and 30%
overall.
Estimates based on following population sample sizes in relation to global model: 44% for level I, 16% for level II, 8% for level III, 16% for level IV,
and 22% overall.
Estimates based on following population sample sizes in relation to global model: 56% for level I, 19% for level II, 17% for level III, 5% for level IV,
and 27% overall.
Estimates based on following population sample sizes in relation to global model: 38% for level I, 11% for level II, 9% for level III, 0% for level IV,
and 17% overall.
Assumed value in the absence of survey data.

354

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 10Chronology of key technical advances in diagnostic radiology
Date

Development
Discovery of x rays (Röntgen); first clinical image
Barium contrast studies
Intravenous contrast media
Angiography
Fluoroscopic image intensifiers; catheter techniques
Early work on rare-earth intensifying screensComputed tomography (CT)
Magnetic resonance imaging (MRI); digital radiology
Interventional radiological techniques; picture archive and communications systems (PACS); teleradiology

1895
1920s
1930s
1940s
1950s
1960s
1970s
1980s
1990s

Table 11
Aspects of practice that influence doses to patients from x-ray examinations[B11, B53, C1, C3, C11, G30, G31, G32, H1, H10, H11, J2, L1, L4, L30, M42, M43, M49, N7, N8, N28, S3, S19, S20, S21, S52, S59,
S64, T1, U3, V3, V13, W16, W40]

AspectInfluence
Procedure-related

Strict referral criteria
Availability of previously taken films
Number of radiographs per examination
Fluoroscopy time and current
Quality assurance programmes
Routine patient dosimetry and reference doses
X-ray beam collimation
Shielding of sensitive organs
Choice of projection
Optical density of radiographs
Compression of attenuating tissue
Matching exposure factors to patient stature

Reduce per caput doses by removing clinically unhelpful examinations
Promotes elimination of retakes and thus reduction of per caput doses
Positively correlated with dose
Positively correlated with dose
Promote reductions in per caput doses
Promote reductions in per caput doses
Beam area positively correlated with dose
Facilitates dose reduction
Organ doses can depend on beam projection
Positively correlated with dose
Reduces dose and scatter and improves image quality
May reduce doses
Equipment-related

Exposure time
Applied potential
X-ray tube voltage waveform
X-ray target material
Beam filtration, thickness
Beam filtration, material
Beam filtration, shapeAnti-scatter grids
Air gap techniqueAttenuation between patient and image receptor
Screen/film combination
Film processing
Image intensifiers
Digital image processing
Fluoroscopy recording method
Pulsed fluoroscopy with image storage device
Spot film photofluorography
Picture archiving and communications systems (PACS)
Computed radiography
Digital imaging techniques

Use of long times and low currents may increase dose due to reciprocity law failure
Higher settings may reduce dose and contrast
Three-phase and constant potential generators reduce dose and contrast
Molybdenum may increase dose and contrast compared with tungsten
Increasing thickness reduces dose and contrast
Rare-earth K-edge filters and other materials can reduce dose and contrast
Dose reduction with special semitransparent filters in radiography and fluoroscopy
Appropriate design and use to increase image quality and dose when required
May obviate need for gridLow attenuation materials (e.g. carbon fibre tables) reduce dose
Dose reductions through appropriate use of faster (rare earth) screens
Reductions in per caput doses through adherence to manufacturers instructions
Sensitive (e.g. CsI) photocathodes facilitate dose reduction
May facilitate dose reduction
Video recorder reduces fluoroscopy dose compared with cine camera
Reduces fluoroscopy dose
Dose reduction with 100 mm camera compared with radiography
Potential reductions in per caput doses from improved availability of images
Potential for dose reduction from greater reliability of image reproduction
Potential for improved image quality, but often at expense of increased dose

236

181
0.04
106
449
64

2.6

0.70

34

112
9.5

94
13
21
11
31

23
3.3
11
4.4
21

119
27
21
12
42

40
322
62
106

21

212

147

202

136
247
79

0.09
0.52
0.56
19
45

7.3
16
39
28

12

5.0

2.2
7.4
11
2.1

30

14

6.1
11
23
2.7

9.2

3.6

10

14

57
31

306
126
172
181
332
320
67
181
36
108
88
35

6.6
16

5.9
6.1

11
20

26

7.2
65










Average

22
15
0
69



141

24
17
145
108
1.5

















45
240
266
50
616
323
79
205
120
146
117
149
235
54
127
145
83
69
136
207
111

24
42
151
33
159

100

40

62
56
16
34
73
33

36

31

33
6.3
8.3
40
49
9.2

60

28

8.0
36
23

64
9.5

63
33
2.6
26
46
26
20

26
25
59
9.4
15
112
14

236
43
53
27
94
30
21

13
51
138
90
63
71

15
14
99
51
15
19

41

21

43
12
7.7
8.0
22
26

97
63
92
18
9.3
7.6
17
11
35
15

9.7
8.2
32

54

38

55

147
20
65

292
229





11
0
5.0
0













59
23
25
0

22
58
168
47
20

25

1.0
12

54

4.9

7.8
12
8.1
13
10
2.4
45
104
38
3.1
2.9
5.1
3.0
2.9

2.7
0.07
6.0
0.11

1.2
5.6
5.5
19
15
0.77

2.0

8.6

6.1

3.1

1.2

0.74
1.7
0.19

1.1
0.09

12

4.6

13
3.9
3.7
11
8.5
3.3

4.3
0
0.06
2.7
17
0.53
1.5
11
3.9
1.1

22
11
9.3
20
6.0
7.5
3.0

6.6
7.0
8.7
11
2.3
1.5
10

1.4
0

0.17
1.0

0

3.8

0.57

0.47

0
0.50

0

0.91
0.29

7.9
2.9
28
2.7
14
5.7

5.2

0.04
5.0
11
12

1.3
1.0
11
12
118
4.7

0.38
0.12

Pelvimetry

7.8

0.15
3.7

15

19
12

36
51

11
2.8
3.8
0.85
0.03
0.48
5.8
1.0
3.9

8.1
2.7
27

15
19
2.8

23
21
12

Lower

37
6.8
4.7

Upper

100
13
12
44
29
147
81
87



112
112
252
95
150



284



0.38

3.9

2.0

5.8

123

435

15

44

28

160
64
84



0.57











b



0.0003



113
49
11
260
260
200
147
254
145










Australia
Bahrain
BelarusBelgium [C26]
CanadaChina, Taiwan Prov.
Croatia
CyprusCzech Republic
Denmark
EcuadorFinlandGermany
HungaryJapan
KuwaitLithuania
Luxembourg
Netherlands
NorwayPanamaPoland [S49]
Qatar
Romania
Russian Federation
Slovakia
Slovenia
South Africa [M22]
SwedenSwitzerland
United ArabEmirates
United Kingdom

Health-care level IAllCervical

ThoracicLumbarUrographyFluoroscopyPhotofluorography























Radiography

Cholecystography






















































Country / area

0.56














GI tract






















Abdomen



Head



Pelvis
and
hips







Spine



Limbs
and
joints



Chest





PART A













Table 12Annual numbers of examinations per 1,000 population for common types of diagnostic medical a x-ray procedures (1991-1996)
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicated

ANNEX D: MEDICAL RADIATION EXPOSURES
355

Australia
Bahrain
BelarusBelgium [C26]
Bulgaria
Canada

7.4
7.4

0
0

28
2.0

24
3.4

27
1.4

22

Body

Head

All

Cerebral

52
5.4
5.6

41

2.8

2.8

3.5

0.55
1.9
6.5

30

4.9

Cardiac

Angiography

0.35

Health care level I

All

PART B

2.1

1.5

3.5

Clinical

19

3.6

2.2

2.1

Screening

79

0.94

3.6

Health care level IV

0.72

0.94

0.54

14

3.5

CT

0

0

Mammography

4.9

AverageCountry / area

4.9

United Rep. Tanzania

1.4

6.5





4.9





Average

2.0

0.72

0.62

2.4
8.7

Health care level III




3.0
4.9
6.2

8.9

34
27
10

25

12
6.8
3.7







Ghana
Madagascar
Sudan

2.4

5.3

20

72

0.50

28
34
14

8.3
5.7

1.9
3.2







24




































Average

0
0.84
0
0.02

0
0.24
0
1.1

36

20

All

33
4.0
12
4.4

25







2.4





5.3

70
11
1.8
5.1
41
60
89
15



83






77
11
29
10
115
88
81
29

Cervical

Health care level II

ThoracicBrazilChina [Z9, Z13]
Costa Rica
Jordan
Malaysia
MexicoOman
TurkeyLumbarFluoroscopy

7.0

6.8
0.21
1.0

All

2.3

2.3

1.8

1.1
2.2

13

7.1
12
8.6
6.8
15
33
22
6.8






Photofluorography

1.6

1.6

0.96

0.06
1.4

4.8

0.34
4.3
2.5
0.96

2.6
5.4

Upper

2.7

0.19

0.01

0.01

0.17

0.001
0.26

0.94

0.52

PTCA

0.31

0.02

All

Interventional procedures

1.4

1.4

1.9

0.03
2.9

1.5

0.49

0.02
0.02
1.9
0.12
0.03

0.003

0.003

1.4

0.05
2.2

4.7

0.58
0.65
7.1
2.2
1.9

5.0

0.89

0

0

0.47

0.006
0.72

1.7

2.9
0
0.0003Pelvimetry

589
892

565
202
726

Total of all
medicalexaminations

Urography

1.1

Lower

















Radiography

Cholecystography













Country / area

GI tract

Abdomen














Head






























Pelvis
and
hips




Spine






Limbs
and
joints






Chest









Table 12 (continued)

356
ANNEX D: MEDICAL RADIATION EXPOSURES

1.1

76
32
48
10
4.4
30
8.3
0.02

25

14

19

48

27

5.6

21

7.1

21
91

12

9.5

1.3

0.52

0.79

21

15
39
43
2.8
12

18
26
1.8
2.7

20
16
1.0
9.2

80
29

17

1.9

63

54
25

3.5



34

7.0



20






45
19
27
3.8
1.4






31
13
21
6.4
3.0





8.8
7.3
20
0.72
1.8
4.6
11
14

50
47 c

0.99

1.2

2.1

5.2

2.8

0.21

0.68

1.8

6.8

1.5
4.2
4.4
0.51
1.4

0.75

4.5

0.45

0.02

0.09

5.6
3.7
1.2
2.0
8.1
11

0.69

2.0

0.13

1.0
1.3
0.6
3.0
4.7

0.58

0.80

1.3

0.80

0.32
0.68
1.2

0.21
0.63

5.6
1.0
4.2
13
0.63
11
0.90
2.8

2.7

920

489
962

568
750
600
378

1 477
896
886
1 046
600
708
300
641
850
459
450
1 151
800
348
180

475

0.30

0.08

2.2

1.1

24
1.2

1 254

1.7

480
903
937
883
510
151
1 000
704

Total of all
medicalexaminations

0.20

0.38

0.52
0.80

0.22
0.20

0.09

0.12
31

All


































17
35 c

1.1
0.06

12

4.2

7.5

2.0

0.07

PTCA









5.2
2.0
4.8
33
12
43

0.96

0.16

0.89
0.80
6.4
5.6

All

Interventional procedures

















0

2.1

0.13

0.45

44
61
17

25
33
64
87
43
78
29

0.21
5.4
1.1

0.13

20
25
26

68

9.4

15

34

6.4

27

3.5

21
9.7
69
34

Cardiac

Angiography




















Average

11

22

12

Cerebral

Health care level I (continued)

All




















0

0.18
1.7
17
12









China, Taiwan Prov.
Croatia
CyprusCzech Republic
Denmark
EcuadorEstonia [S29]FinlandFrance [B40]
Germany
Greece [P12]
Hungary
Israel [S48]
Italy [B40]Japan
KuwaitLithuania
Luxembourg
Netherlands
NorwayPanamaPoland [S49]
Portugal [F11]
Qatar
Romania
Russian Federation
Slovakia
Slovenia
South Africa [M22]Spain
SwedenSwitzerland
Ukraine [K18]
United ArabEmirates
United Kingdom
United States

Body

Head

All

ClinicalScreening


















































CT












































Mammography







































Country / area























































Table 12 (continued)

ANNEX D: MEDICAL RADIATION EXPOSURES
357

Average

Excluding dental x-ray examinations.
No data available.
These revised data were received by the Committee after completion of the global analysis.

China:

Brazil:Canada:

0

17

29
29

0

0
0

0

0
0

Survey data for Paraná State (with a population of 9 million and a social and economic profile above the average for Brazil).
Data for total of all medical x-ray examinations from reference [A15]; data for specific examinations on the basis of information (excluding procedures in private clinics) for the province of Ontario(representing about 37% of population).
Data for ‘GI tract’ include both ‘Upper’ and ‘Lower’ categories.

Health-care level IV

0.21

United Rep. Tanzania

0.08

0

0.08
0.09

Health-care level III

0.48

0.25

0.06

0.21

0.01

Average

7
11
8
37

0.011
0.003

Ghana
Madagascar
Morocco
Sudan

154

0.94

6.7

2.3

3.5

13

2.7

98

0.45

0.54

0.42

0.10

1.3
0.003

0.68
0.52

0.24

0.05

1.9
1.4
7.0
2.0

0.33

0.86
0.58
2.8

4.8
10.3 c

271
174
261
173 c
185
158
45
183
306
269
203
134
147

1.0
0.79
4.2

1.7

1.5

0.25
1.3
2.9
0.49

0.25
1.3
1.8

0
0
1.1

The entries in this Table are qualified as follows:

a
b
c

3.3

0.85

Average

Antigua and Barbuda
Barbados
BrazilChina [Z9, Z13]
Dominica
GrenadaJordan
Malaysia
MexicoOman
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and
the Grenadines
TurkeyHealth-care level II

All

PTCA

All

All

Total of all
medicalexaminations

Cardiac


























Cerebral

Body

Head

Interventional procedures



All







ClinicalAngiography










Screening

CT








Mammography













Country / area



























































































































































































Table 12 (continued)

358
ANNEX D: MEDICAL RADIATION EXPOSURES

Antigua, Barbados, Dominica,, Grenada, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines: Data for public sector from [B43].

China, Taiwan Province: Data for ‘Chest radiography’ include all chest examinations. Data for ‘GI tract’ include both ‘Upper’ and ‘Lower’ categories.
Costa Rica:
Data from Hospital Calderón Guardia (serving one third of the population).
CyprusSurvey data relating to 50% of population.
Ghana:
Data from reference [S38]. Data for ‘Pelvis/hip’ include ‘Abdomen’ examinations.
Lithuania:
Data from Vilnius University Hospital.
Madagascar:
Data for ‘Head’ include examinations of the spine.
Malaysia:
Data for ‘Limbs and joints’ include ‘Head’ examinations. Data for ‘GI tract’ include both ‘Upper’ and ‘Lower’ categories.
Mexico:Data for ‘Head’ include examinations of the neck.
Oman:
Data for ‘GI tract’ include both ‘Upper’ and ‘Lower’ categories.
Romania:
Data from all counties except Bucharest.
Russian Federation: Data for ‘Limbs and joints’ include all examinations of the skeleton. Data for ‘GI tract’ include all examinations of digestive organs.
Slovakia:
Survey data relating to population base of about 2 million.
Slovenia:
Survey data relating to population base of about 1.8 million.
Spain:
Data for CT from reference [B40]; data for angiography and interventional procedures from reference [V8].
Sweden:Survey data from a sample of health districts covering about one quarter of the population.
Turkey:On the basis of data from Hacettepe University Hospital.
United Arab Emirates: 1% of pelvimetry examinations conducted using CT/digital techniques.
United Kingdom: Data from reference [T15]. Data for ‘Chest radiography’ include all chest examinations.
United States:
Data for CT from reference [B40]. Data for total of all medical examinations from [I23].



Table 12 (continued)

ANNEX D: MEDICAL RADIATION EXPOSURES
359

Average

25

28
0.01
23
39
7.9

0.4

0.1

4.8

25
1.2

0.5

6.1

0.3

4.3

0.8

6.2

31
26

2.1

21

30

19

24
33
21

0.02
0.07
0.2
3.9
5.2

4.1
2.8
5.2
7.3

2..3

1.5

1.0

1.2
1.3
1.5
0.6

3.6

2.9

3.4
1.9
3.0
0.7

11

8.1

7.7
16
8.7
6.0
9.7
8.6

4.0

6.3

6.5

5.8

1.4
4.8
6.1

8.0
2.7

2.0

0.8

9.0
28
7.7
30

4.2
1.8
4.6
7.0
6.6
2.4

6.0
5.5
0.4
8.6
7.1
5.6
4.5

2.5
4.2
8.3
3.1
2.3
24
3.2

23
7.2
7.5
9.1
15
6.5
4.6

9.0
2.2
3.0
3.6
4.8

2.2
0.6
1.5
1.5
3.2

0.9

3.9
3.5

11
4.5
3.0
4.1
6.6

6.0
3.9

24
27
12
20
37
31
11
26
12
17

8.8
7.2
11
19
4.3
7.9

9.9
1.9
7.9
11
1.0
2.1

4.4
2.2

3.9
0.9

7.3
2.9

16
6.0
12
6.9
11

4.6

4.2

5.4
3.4
4.3
1.4
2.9
6.9

6.5
7.0
10
1.7
1.6
1.1
5.6
1.7
7.6
3.3

6.4
1.2
2.5

0.6

0.2
0.02
0.4
0.01

1.3

0.8
0.8
0.4
4.0
1.0
0.1

0.9
0.2
0.8
2.6
8.0
0.5

5.7

1.0

0.8
2.0
1.1
4.3
1.6
0.5
10
9.0
4.8
0.9
1.6
0.9
0.4
0.8

2.0
1.4
0.5
0.9

Urography

1.0

1.2

0.3

0.2

0.1
0.2
0.1

0.1
0.03

1.3

0.9

1.6
1.1
2.1
2.0
1.1
0.9

1.4
0
0.01
0.6
2.1
0.2
0.8
2.0
0.5
0.3

2.1
1.8
1.3
6.6
0.9
1.6
0.7

0.6
1.2
1.2
3.6
0.4
0.3
2.3

0.1
0

0.1
0.1

0

0.004

0.07
0.06

Pelvimetry

1.0

0.1

0.1

0
0.1

0

0.06
0.03

5.3
0.4
2.2
0.6
0.9
0.6

0.6
1.2
1.4

0.2
0.01
0.07
0.1
2.6

Cholecystography

0.02
0.4

2.0
1.4

16
2.1
7.4

1.0
0.5
0.5
1.7

2.7
9.3
0.4
2.4
12
19
5.1
2.3
1.4
1.3
3.7
4.1
11

Lower

4.0
10
1.7
4.9
6.1
16
8.7
9.9

6.6
3.4
0.7
2.8

Upper

GI tract

18
6.7
1.6
13
23
28
10
17

17

1.0
17










29

4.6
1.0
0
7.8



b

5.0
1.2
16
12
0.14

1.2
0
0.6
0

6.5
2.4
2.8
0



30
34
21
10
42
36
8.9
20
20
21
39
23
51
12
11
18
24
38
24
28
29

17
0.04













60

2.6

7.7

5.0

28
31
12
32







0.1





0.0001

All









20
24
1.5
29
42
16
27
16

Cervical

Health-care level I

Thoracic




















Australia
Bahrain
BelarusCanadaChina, Taiwan Prov.
Croatia
CyprusCzech Republic
Denmark
EcuadorFinlandGermany
HungaryJapan
KuwaitLithuania
Luxembourg
Netherlands
NorwayPanamaPolandQatar
Romania
Russian Federation
Slovakia
Slovenia
South Africa
SwedenSwitzerland
United ArabEmirates
United Kingdom

LumbarFluoroscopy
















PhotofluorographyRadiography



























Country / area

Abdomen





Head





Pelvis
and
hips





Spine





Limbs
and
joints















Chest



PART A

0.1



























































Table 13
Percentage contributions by types of procedure to annual total numbers of diagnostic medical a x-ray examinations (1991 1996)
Based on data and qualifications from Table 12360
ANNEX D: MEDICAL RADIATION EXPOSURES

16

45
46
17

23

17

17

Average b

Ghana
Madagascar
Sudan

Average b

United Rep. TanzaniabAustralia
Bahrain
BelarusCanadaChina, Taiwan Prov.
Croatia

Country / area

5.3
5.7

23

25
25

9.8

9.8

5.0
1.0

4.2
1.7

4.7
0.7
2.5

Body

Head

All

ClinicalScreening

2.1

CT
Cerebral

9.2
2.7
0.8
4.6
4.3
1.1

0.01

0.02

0.9

Cardiac

0.06

Health care level I

All

9.6

9.6

17

8.3
17
18

13

11
10
10

Angiography

7.2

12

PART B

7.2

6.1

5.9

8.1

5.9

3.9
2.5
3.8

12

Mammography

8.9
0.04
0.2

2.6

2.6

Health care level III

9.2
13
14

Health care level IV

2.0

2.0

9.3

22
24

5.8

9.7

0.9

2.1

13

50

0.2

13

7.2

11
22
20
33
15

0
0.3
0
0.02

14

7.6

9.7

13
3.0

9.7

0.9

0
0.08
0
1.1

2.1











Average

22
63
29
30
29

27
8.1

All





























63
























29
8.1

















BrazilChina
Costa Rica
Jordan
Malaysia
MexicoOman
TurkeyCervical

Health care level II

ThoracicLumbarFluoroscopyPhotofluorography

1.2
0.1
0.1
0.8
0.2
0.1

All

7.8

7.8

6.5

11
5.9

8.2

15
8.3
11
8.2
6.9

5.4

5.4

3.5

0.6
3.9

3.0

0.2
1.4
0.9
1.0

1.0
4.1

2.7
9.1

Upper

0.9

0.4

0.02

0.02

0.6

0.01
0.7

0.4

PTCA

0.003
0.04

All

Interventional procedures

4.8

4.8

6.8

0.2
7.8

0.6

0.5

0.04
0.01
0.6
0.05
0.03

0.01

0.01

5.2

0.5
5.9

2.0

1.3
0.4
2.3
0.8
2.0

1.9

0.3

0

0

1.7

0.05
2.0

0.8

0.9
0
0.0003Pelvimetry

100
100
100
100
100
100

Total of all
medicalexaminations

Urography

0.4

Lower























Radiography

Cholecystography

























Country / area

GI tract

Abdomen





Head
































Pelvis
and
hips




Spine




Limbs
and
joints






Chest









Table 13 (continued)

ANNEX D: MEDICAL RADIATION EXPOSURES
361

1.6
5.8c

Average b

0.3

0.6

1.2

1.3
0.5
0.7
1.0
0.2
1.6

0.5
0.7
0.6

0
0
0.4

BrazilJordan
Malaysia
MexicoOman
Turkey
1.3

0.8

1.9
0.3
0.9

2.2
0.4
1.4

0.09

0.03
0.08
0.01

0.05

2.9

1.8
4.1
0.8
2.3
0.8
13

0.1

0.08

100
100
100

100
100
100
100
100
100
100

0.9

0.4

0.4
0.001
0.5
0.4

0.1

0.5
0.6

0.1
0.2
0.1
1.1

0.7
0.6
0.01
0.6

0.09
0.2
0.02
0.04

0.1
0.2

0.03
0.04

0.03

0.1

0.1

0.2

0.2
0.2
0.6

0.8

0.2

0.1

0.03

0.1
0.4

0.05

0.1

0.1

0.2

0.7
1.1
0.7
1.4
1.4

0.3

0.05
0.1

0.2

0.1

0.03
0.09
0.02

100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100

0.01
3.5
0.06
0.2
0.2
0.06

All

Total of all
medicalexaminations

0.01

PTCA

0.1

0.2
0.1

1.9
0.3
0.4
0.1
0.5
1.2
0.1
1.5
0.4
0.4

0.7
0.6
0.1

0.6
0.1

0.07
0.03

Health-care level II

6.4

2.5

1.7

2.9

0.7

3.7

Average b

4.4
9.5

2.4

1.9

5.5

1.1




4.4

0.3

0.1

0.2

6.8
5.7
0.5
3.1

1.1
3.2
3.5
0.3
0.7

3.6
2.2
0.2
2.4

14
3.8

3.0

6.8
7.3

11

7.3
5.3
6.7
3.4
0.7
3.5
1.8
0.004

4.2

4.3
3.2
3.8
1.3
0.2

3.0
2.1
2.9
2.1
0.5

2.5

0.9






0.4

2.9
1.1
2.4
0.2
0.4
0.4
1.3
4.0

4.8
7.8 c

1.3

0.5

0.8

0.2




0




0.4
0.2
0.5
3.2
2.0
6.1

1.3
3.5
3.5

7.3
3.8
2.3
3.5
5.1
9.0

2.2
1.6
5.5

0.9

3.9

1.3

2.5

1.8
1.3
0.8
4.8
5.4
0.4

1.3

All



0

Cardiac






































































CyprusCzech Republic
EcuadorFinlandGermany
HungaryJapan
KuwaitLithuania
Luxembourg
Netherlands
NorwayPanamaPolandPortugal
Qatar
Romania
Russian Federation
Slovakia
Slovenia
South Africa
SwedenSwitzerland
UkraineUnited ArabEmirates
United Kingdom
United States

Cerebral

Health care level I (continued)

All






Body









Head





All





ClinicalScreening

Interventional procedures


















































Angiography






































CT


























Mammography


















Country / area








Table 13 (continued)

362
ANNEX D: MEDICAL RADIATION EXPOSURES

1.0

0.1











Ghana
Madagascar

Average b

United Rep. Tanzania

Average b

0.7
0.7






100
100
100

100
100

All

0

0

0
0

PTCA

All

0

0

0
0

Cardiac

CerebralExcluding dental x-ray examinations.
Overall averages for sample calculated as total number of each particular type of examination divided by total number of all examinations.
These revised data were received by the Committee after completion of the global analysis.

Health-care level IV





a
b
c

1.2
0.8

0.2
0.02








Health-care level III

Head

All






All

Body






ClinicalScreeningTotal of all
medicalexaminations

Interventional procedures








Angiography






CT





MammographyCountry / area

Table 13 (continued)

ANNEX D: MEDICAL RADIATION EXPOSURES
363

364

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 14
Distribution by age and sex of patients undergoing types of diagnostic x-ray examination (19911996)
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicatedHealthcarelevel

Age distribution (%)
Country / area

015 years

1640 years

Sex distribution (%)>40 years

Male

FemaleChest radiography
Australia
Bahrain
China, Taiwan Province
Croatia
Czech Republic
EcuadorJapan
KuwaitNew Zealand
NorwayPanamaPolandRomania
Slovakia
South Africa [M22]
SwedenSwitzerland
United Arab Emirates

9
21
6
0
10
31
7
19
10
15
17
9
22
14
20
7
5
15

18
33
27
30
18
34
21
53
18
14
22
24
31
33
40
14
15
70

73
46
67
70
72
35
72
28
72
71
61
67
47
53
40
79
80
15

49
59
58
55
50
53
56
62
58
54
46
54
64
47
54
55
52
60

51
41
42
45
50
47
44
38
42
46
54
46
36
53
46
45
48
40

Average

8

22

70

56

44

Brazil
Costa Rica
MexicoTurkey

a





4
23
22

31
37
40

65
40
38

44
47
52
59

56
53
48
41

Average

23

37

40

48

52

III

Sudan

22

58

20

39

61

IV

United Republic of Tanzania

15

65

20

50

50

I

II

Chest photofluorography
I

II

Australia
Croatia
KuwaitPolandRomania
Russian Federation
Slovakia
United Arab Emirates







0
0
0
3
22
11
0

35
73
60
58
31
43
80

65
27
40
39
47
46
20

50
55
62
59
56
64
48
55

50
45
38
41
44
36
52
45

Average

19

35

46

63

37

MexicoTurkey

29
0

47
80

24
20

51
78

49
22

Average

7

72

21

71

29

Chest fluoroscopy
I

II

Australia
CroatiaJapan
PolandRomania
Slovakia

20
0
1
0
11
8

23
40
33
61
38
50

57
60
66
39
51
42

40
50
66
68
55
56

60
50
34
32
45
44

Average

7

36

57

60

40

MexicoTurkey

15
10

43
63

42
27

50
69

50
31

Average

15

43

42

50

50

ANNEX D: MEDICAL RADIATION EXPOSURES

365

Table 14 (continued)
Healthcarelevel

Age distribution (%)
Country / area

015 years

1640 years

Sex distribution (%)>40 years

Male

FemaleLimbs and joints
Australia
BahrainCzech Republic
EcuadorJapan
KuwaitNew Zealand
PanamaPolandRomania
Slovakia
SwedenSwitzerland
United Arab Emirates

16
31
18
32
16
22
21
22
16
24
22
15
15
20

33
45
31
42
28
58
46
28
35
36
35
30
31
50

51
24
51
26
56
20
33
50
49
40
43
55
54
30

52
67
48
61
49
63
57
55
55
60
53
45
50
60

48
33
52
39
51
37
43
45
45
40
47
55
50
40

Average

17

30

53

50

50

Costa Rica
MexicoTurkey

0
21
18

5
44
45

95
35
37

24
56
59

76
44
41

Average

21

44

35

56

44

III

Sudan

8

25

67

67

33

IV

United Republic of Tanzania

10

50

40

50

50

I

II

Lumbar spine
I

III

Australia
Czech RepublicJapan
KuwaitNew Zealand
NorwayPanamaPolandRomania
Slovakia
South Africa [M22]
SwedenSwitzerland

3
6
3
9
6
1
9
2
5
17
4
4
2

27
28
21
65
36
38
25
26
34
37
53
26
29

70
66
76
26
58
61
66
72
61
46
43
70
69

44
43
51
59
49
44
44
47
49
52
51
45
47

56
57
49
41
51
56
56
53
51
48
49
55
53

Average

3

23

74

50

50

Sudan

19

37

44

74

26

Thoracic spine
I

III

Australia
Czech Republic
EcuadorJapan
New Zealand
NorwayPanamaPolandRomania
Slovakia
South Africa [M22]
SwedenSwitzerland

6
10
8
9
8
3
9
11
8
17
8
4
6

27
35
59
25
36
40
29
31
31
39
56
19
36

67
55
33
66
56
57
62
58
61
44
36
77
58

36
44
58
57
45
42
45
48
53
52
47
45
43

64
56
42
43
55
58
55
52
47
48
53
55
57

Average

9

29

62

49

51

Sudan

20

30

50

60

40

68
64

38
37

62
63

Cervical spine
I

Australia
Czech Republic

4
6

28
30

366

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 14 (continued)
Healthcare
level
I

III

Age distribution (%)
Country / area

Sex distribution (%)

015 years

1640 years>40 years

Male

FemaleJapan
KuwaitNew Zealand
NorwayPanamaPolandRomania
Slovakia
South Africa [M22]
SwedenSwitzerland

3
13
9
2
8
1
5
21
7
3
4

29
60
53
39
27
25
34
37
58
24
32

68
29
38
59
65
74
61
42
35
73
64

51
60
57
43
44
41
48
50
53
45
42

49
40
43
57
56
59
52
50
47
55
58

Average

3

30

67

48

52

Sudan

16

46

38

62

38

Spine (general)
Australia
Bahrain
China, Taiwan Province
Croatia
PolandSwitzerland
United Arab Emirates

5
8
7
13
4
3
0

29
56
31
25
27
31
60

66
36
62
63
69
66
40

40
59
53
40
45
45
55

60
41
47
60
55
55
45

Average

6

29

65

46

54

Costa Rica
MexicoTurkey

6
9
9

49
48
42

45
43
49

43
55
61

57
45
39

Average

9

46

45

56

44

III

Sudan

18

38

44

68

32

IV

United Republic of Tanzania

5

20

75

50

50

I

II

Pelvis and hipAustralia
Bahrain
Croatia
Czech Republic
EcuadorJapan
KuwaitNew Zealand
NorwayPanamaPolandRomania
Slovakia
South Africa [M22]
SwedenSwitzerland
United Arab Emirates

8
28
2
20
33
7
20
8
3
21
25
19
34
8
7
5
5

16
35
38
15
47
30
54
49
14
19
17
26
27
44
7
16
70

76
38
60
65
20
63
26
43
83
60
58
55
39
48
86
79
25

37
58
30
35
40
50
61
42
29
52
43
48
50
47
35
45
53

63
42
70
65
60
50
39
58
71
48
57
52
50
53
65
55
47

Average

12

25

63

42

58

Costa Rica
MexicoTurkey

13
22
23

30
42
39

57
36
38

19
37
53

81
63
47

Average

22

41

37

40

60

III

Sudan

20

20

60

50

50

IV

United Republic of Tanzania

5

40

55

40

60

I

II

ANNEX D: MEDICAL RADIATION EXPOSURES

367

Table 14 (continued)
Healthcarelevel

Age distribution (%)
Country / area

015 years

1640 years

Sex distribution (%)>40 years

Male

FemaleHead
Australia
Bahrain
China, Taiwan Province
Czech Republic
EcuadorJapan
KuwaitNew Zealand
PanamaPolandRomania
Slovakia
SwedenSwitzerland
United Arab Emirates

27
36
10
24
45
24
30
29
26
16
14
20
30
21
15

41
47
37
36
35
30
53
48
40
43
45
49
9
40
60

32
17
53
40
20
46
17
23
34
41
41
31
61
39
25

45
62
57
48
62
55
63
62
47
51
48
49
45
54
65

55
38
43
52
38
45
37
38
53
49
52
51
55
46
35

Average

22

34

44

53

47

Costa Rica
MexicoTurkey

22
30
20

51
42
39

27
28
41

47
55
62

53
45
38

Average

28

42

30

56

44

III

Sudan

11

67

22

67

33

IV

United Republic of Tanzania

10

50

40

50

50

I

II

AbdomenAustralia
Bahrain
China, Taiwan Province
Croatia
Czech Republic
EcuadorJapan
KuwaitNew Zealand
NorwayPanamaPolandRomania
Slovakia
South Africa [M22]
SwedenSwitzeland
United Arab Emirates

13
15
6
6
5
28
5
12
15
10
21
7
8
11
15
14
7
18

22
53
26
35
20
44
18
61
65
24
25
26
39
38
48
16
22
57

65
32
68
59
75
28
77
27
20
66
54
67
53
51
37
70
71
25

45
65
55
50
49
55
55
63
51
48
47
53
51
48
53
45
48
70

55
35
45
50
51
45
45
37
49
52
53
47
49
52
47
55
52
30

Average

6

22

72

54

46

Brazil
Costa Rica
MexicoTurkey







5
22
21

56
45
42

39
33
47

28
50
48
62

72
50
52
38

Average

21

44

35

45

55

III

Sudan

33

37

30

40

60

IV

United Republic of Tanzania

10

35

55

35

65

69
45
32
67
72

45
47
82
50
43

55
53
18
50
57

I

II

Upper gastrointestinal tract
I

Australia
Bahrain
China, Taiwan Province
Croatia
Czech Republic

6
12
3
0
3

25
43
65
33
25

368

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 14 (continued)
Healthcarelevel

Age distribution (%)
Country / area

Sex distribution (%)

015 years

1640 years>40 years

Male

FemaleEcuadorJapan
KuwaitNew Zealand
NorwayPanamaPolandRomania
Slovakia
South Africa [M22]
SwedenSwitzerland
United Arab Emirates

5
1
15
31
2
11
2
4
4
9
11
4
8

35
22
50
7
20
25
25
31
46
39
18
12
60

60
77
35
62
78
64
73
65
50
52
71
84
32

58
62
59
60
35
43
51
55
57
48
45
43
55

42
38
41
40
65
57
49
45
43
52
55
57
45

Average

1

26

73

62

38

MexicoTurkey

11
6

51
57

38
37

53
57

47
43

Average

10

52

38

54

46

III

Sudan

20

33

47

60

40

IV

United Republic of Tanzania

10

15

75

50

50

I

II

Lower gastrointestinal tract
Australia
Bahrain
Croatia
Czech Republic
EcuadorJapan
KuwaitNew Zealand
NorwayPanamaPolandRomania
Slovakia
South Africa [M22]
SwedenSwitzerland
United Arab Emirates

1
18
0
2
5
1
11
4
1
5
1
4
6
3
3
2
12

3
33
22
16
35
22
49
9
21
18
6
33
49
34
17
13
58

86
49
78
82
60
77
40
87
78
77
93
63
45
63
80
85
30

42
55
50
41
58
54
51
49
35
45
50
54
52
33
40
42
59

58
45
50
59
42
46
49
51
65
55
50
46
48
67
60
58
41

Average

2

23

75

52

48

MexicoTurkey

6
3

52
43

42
54

42
57

58
43

Average

6

51

43

44

56

III

Sudan

20

30

50

70

30

IV

United Republic of Tanzania

5

15

80

50

50

I

II

Cholecystography
I

Australia
China, Taiwan Province
Croatia
Czech Republic
EcuadorJapan
KuwaitPanamaRomania
Slovakia
SwedenSwitzerland

0
2
0
0
0
0
0
6
2
2
0
0

17
23
20
11
55
17
55
32
38
42
25
13

83
75
80
89
45
83
45
62
60
56
75
87

30
56
80
36
39
51
55
44
24
51
40
37

70
44
20
64
61
49
45
56
76
49
60
63

Average

1

20

79

49

51

ANNEX D: MEDICAL RADIATION EXPOSURES

369

Table 14 (continued)
Healthcarelevel

Age distribution (%)
Country / area

Sex distribution (%)

015 years

1640 years>40 years

Male

FemaleMexicoTurkey

1
0

51
39

48
61

31
35

69
65

Average

1

51

48

31

69

III

Sudan

0

73

27

44

56

IV

United Republic of Tanzania

10

25

65





II

Urography
Australia
Bahrain
Croatia
Czech Republic
EcuadorJapan
KuwaitNew Zealand
NorwayPanamaPolandRomania
Slovakia
South Africa [M22]
SwedenSwitzerland
United Arab Emirates

10
4
0
11
2
3
5
22
3
10
13
7
14
9
6
16
5

23
59
20
18
70
21
63
30
26
29
23
33
38
47
29
25
65

67
37
80
71
28
76
32
48
71
61
64
60
48
44
65
59
30

55
66
100
55
57
58
64
55
51
59
52
55
58
54
45
51
70

45
34
0
45
43
42
36
45
49
41
48
45
42
46
55
49
30

Average

6

25

69

57

43

MexicoTurkey

7
10

48
48

45
42

54
54

46
46

Average

7

48

45

54

46

III

Sudan

13

60

27

50

50

IV

United Republic of Tanzania

0

10

90

75

25

I

II

Mammography (screening)I

II

Slovakia
SwedenUnited Arab Emirates

0
0
0

32
0
0

68
100
100

0
0
0

100
100
100

Average

0

1

99

0

100

Mexico

2

27

71

5

95

Average

2

27

71

5

95

Mammography (clinical)
I

II

Czech RepublicJapan
KuwaitNew Zealand
NorwaySwedenUnited Arab Emirates

0
0
0
0
0
0
0

37
29
68
14
17
15
0

63
71
32
86
83
85
100

1
0
1
0
0
0
0

99
100
99
100
100
100
100

Average

0

26

74

0.1

99.9

Mexico

0

37

63

3

97

73
66
59

0
1
1

100
99
99

Mammography (general)
I

Australia
Bahrain
China, Taiwan Province

0
0
1

27
33
40

370

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 14 (continued)
Healthcare
level
I

II

Age distribution (%)
Country / area

Sex distribution (%)

015 years

1640 years>40 years

Male

FemaleCroatia
Ecuador
KuwaitPanamaPolandRomania
Switzerland
United Arab Emirates

0
0
0
0
0
1
0.1
0

30
28
68
28
21
43
9
4

70
72
32
72
79
56
91
96

0
0
1
2
0
1
0.2
0

100
100
99
98
100
99
99.9
100

Average

0.1

23

77

0.1

99.9

MexicoTurkey

1
0

33
38

66
62

4
1

96
99

Average

1

34

65

3

97

Computed tomography (head)
I

II

Australia
BahrainCzech Republic
KuwaitNew Zealand
PanamaPolandSlovakia
SwedenSwitzerland
United Arab Emirates

6
23
8
17
10
17
13
3
5
4
15

30
36
23
39
26
25
20
42
19
23
50

64
42
69
44
64
58
67
55
76
73
35

44
56
47
60
53
51
50
48
50
51
60

56
44
53
40
47
49
50
52
50
49
40

Average

7

27

67

48

52

Mexico

9

40

51

48

52

Computed tomography (body)I

II

Australia
BahrainCzech Republic
KuwaitNew Zealand
PanamaPolandSlovakia
South Africa [M22]
SwedenSwitzerland
United Arab Emirates

1
7
5
6
4
5
8
4
5
3
2
10

21
40
15
43
26
29
23
44
46
20
17
55

78
53
80
51
70
66
69
52
49
77
81
35

48
53
49
56
52
50
55
51
52
55
54
55

52
47
51
44
48
50
45
49
48
45
46
45

Average

3

24

73

51

49

Mexico

21

33

46

47

53

Computed tomography (general)
I

II

China, Taiwan Province
Croatia
Ecuador
NorwayPolandRomania
Switzerland
UkraineUnited Arab Emirates

5
10
6
8
11
0
3
7
14

24
30
24
25
21
21
19
27
51

71
60
70
67
68
79
78
66
35

60
40
50
50
52
83
53

40
60
50
50
48
17
47

59

41

Average

6

24

70

54

46

MexicoTurkey

14
16

37
46

49
38

48
57

52
43

Average

15

42

43

53

47





ANNEX D: MEDICAL RADIATION EXPOSURES

371

Table 14 (continued)
Healthcare
level
IV

Age distribution (%)
Country / area

United Republic of Tanzania

Sex distribution (%)

015 years

1640 years>40 years

Male

Female

5

35

60

50

50

Angiography (cerebral)
I

Australia
Czech RepublicJapan
KuwaitPanamaPolandSlovakia
SwedenSwitzerland

1
4
0
0
17
8
6
2
2

10
22
16
28
25
30
41
27
22

89
74
84
72
58
62
53
71
76

55
56
54
67
70
59
52
50
50

45
44
46
33
30
41
48
50
50

Average

1

19

80

54

46

Angiography (cardiac)I

Australia
Czech Republic
Japan
New Zealand
PanamaPolandSlovakia
SwedenSwitzerland

1
0
14
0
17
4
7
2
1

2
5
0
7
24
7
41
7
11

97
95
86
93
59
89
52
91
88

66
76
53
71
66
78
50
70
62

34
24
47
29
34
22
50
30
38

Average

7

4

89

62

38

Angiography (other)I

II

Australia
Croatia
Czech RepublicJapan
KuwaitPanamaPolandSlovakia
SwedenSwitzerland

1
0
6
4
0
4
11
12
2
1

5
25
9
1
28
22
17
40
10
17

94
75
85
95
72
74
72
48
88
82

60
55
66
64
67
42
38
55
50
55

40
45
34
36
33
58
62
45
50
45

Average

5

6

89

60

40

Mexico

0

30

70

55

45

Angiography (general)
I

II

Bahrain
China, Taiwan Province
EcuadorPolandRomaniaSouth Africa [M22]
Switzerland

4
4
30
8
0
2
1

45
20
40
15
25
23
15

51
76
30
77
75
75
84

63
60
55
54
92
70
57

37
40
45
46
8
30
53

Average

5

17

78

60

40

MexicoTurkey

6
9

38
51

56
40

59
59

41
41

Average

7

43

50

59

41

Interventional (PTCA)I

Slovakia
SwedenSwitzerland

6
0
0

44
15
3

50
85
97

48
75
79

52
25
21

Average

1

12

87

74

26

372

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 14 (continued)
Healthcarelevel

Age distribution (%)
Country / area

015 years

1640 years

Sex distribution (%)>40 years

Male

FemaleInterventional (other)I

SwedenSwitzerland

2
1

11
14

87
85

60
58

40
42

Average

1

13

86

59

41

Interventional (general)
I

II

Czech Republic
Ecuador
KuwaitPolandSwitzerland
United Arab Emirates

9
7
2
7
0
1

16
60
43
19
12
80

75
33
55
74
88
19

59
50
69
59
63
15

41
50
31
41
37
85

Average

8

16

76

59

41

MexicoTurkey

9
4

51
36

40
60

39
51

61
49

Average

8

48

44

41

59

Pelvimetry
I

II

III

Australia
BahrainCzech Republic
EcuadorJapan
KuwaitSwedenUnited Arab Emirates

2
1
3
0
0
0
0
0

97
97
87
82
100
98
98
100

1
1
10
18
0
2
2
0

1
10
15
0
0
0
0
0

99
90
85
100
100
100
100
100

Average

0.1

99.5

0.4

0.1

99.9

MexicoTurkey

8
0

82
100

10
0

22
0

78
100

Average

8

82

10

22

78

Sudan

0

100

0

0

100

54
72
62
64
42
0
54
98
70

50
54
50
58
2
0
68
6
44

50
46
50
42
98
100
32
94
56

55
38
55
46
37
55
53
48
44
50
60
54
51

Other examinations
I

Australia (CT extremities)
Australia (tomography)
Australia (ribs)
Australia (arthrography)
Poland (densitometry)
Romania (hysterosalpingography)
Romania (lung tomog.)
Switzerland (bone mineral dens.)
Switzerland (tomography)

8
2
5
4
3
0
13
1
0

38
26
33
32
55
100
33
1
30
All medical b x rays

I

Australia
BahrainCzech Republic
Ecuador
KuwaitNetherlands
PanamaPolandRomania
Slovakia
SwedenSwitzerland

10
24
13
26
17
7
13

27
42
25
43
59
18
26

63
34
62
31
24
74
61

10
17
9
9

41
38
20
19

49
45
71
72

45
62
45
54
63
45
47
52
56
50
40
46

Average

11

29

60

49







ANNEX D: MEDICAL RADIATION EXPOSURES

373

Table 14 (continued)
Healthcarelevel

Age distribution (%)
Country / area

Sex distribution (%)

015 years

1640 years>40 years

Male

FemaleII

Mexico

20

43

37

52

48

III

Morocco

16

54

30

43

57

Dental (intraoral)
I

IV

EcuadorJapan
PolandRomania
Slovakia
Switzerland

8
8
5
11
10
5

73
32
56
54
53
38

19
60
38
35
37
57

31
45
45
44
45
45

69
55
55
56
55
55

Average

8

33

59

45

55

United Republic of Tanzania

25

35

40





Dental (panoramic)
I

II

EcuadorJapan
PolandSlovakia
Switzerland

16
8
7
13
21

66
40
49
45
39

18
52
44
42
40

48
44
54
46
45

52
56
46
54
55

Average

8

40

52

44

56

Mexico

33

50

17

36

64

Dental (general)
I

IV
a
b

Bahrain
EcuadorPolandRomania
Slovakia
Switzerland

21
8
6
11
11
9

33
73
56
54
52
38

46
19
38
35
37
53

59
31
45
44
45
45

41
69
55
56
55
55

Average

8

47

45

45

55

United Republic of Tanzania

25

35

40





No data available.
Excluding dental xray examinations.

The entries in this Table are qualified as follows:
Brazil:Survey data for Paraná State (with a population of 9 million and a social and economic profile above the average for Brazil).
China, Taiwan Province: Data for ‘Upper GI tract’ relate to all barium studies.
Costa Rica:
Data from Hospital Calderón Guardia (serving one-third of the population).
Czech Republic: Survey data relating to Prague (about 10% of national population).
New Zealand: Data from one large teaching hospital in public sector.
Romania:
Data from 8 counties in East and South-East of country (with population of about 5.7 million).
Slovakia:
Survey data relating to population base of about 660,000.
Sweden:Survey data from a small sample of health districts.
Turkey:Survey data from Hacettepe University Hospital, Atatürk University Hospital, Gülhane Military Hospital and Ankara University Hospital.

0.65

2

1.45

0.06
(0.001-0.5)

1.14

0.053

0.3
(0.01 5.5)

0.057

0.06
(±0.08)GermanyJapan

Netherlands

New Zealand

0.021(±0.013)

0.11

0.25
(±0.11)

PanamaPolandRomania0.63(±0.3)

0.82
0.95(±0.4)

4.1
0.08(±0.03)0.02

3(±1.4)

4.33

2.1(±1.2)

3.03

1.20(±0.43)2.6

0.17(±0.12)

0.1

0.61
0.21
(±0.1)

0.045(±0.02)0.44(±0.13)0.07(±0.01)

1.9
(±1)

2.2

0.30
(±0.12)

4.1(±1.9)

14

6.9(±2.9)

49(±3.8)

22.7

3.12(±0.76)8

2.17(±1.0)

1

0.003(±0.003)



0.2

0.23



0.5



0.2

0.5

1.1





0.13

10

5





Norway4.7(±2.4)

6.4(±3.4)

1

0.1

1

1

1

2



2.68

17.7
(0.2-85)

9.7



3.33

8.3
(0.1-38)

9



0.24

1.2
(0.1-5.3)

2.2



0.09

0.03
(0.001-0.7)

0.1



0.58

0.8
(0.1-4.8)

1.3



0.26

0.2

0.2

8.5





0.7

1

2.3

3

0.1

3

Finland

0.28

1.26

0.88

7.1
(0.7-36)0.87(±0.14)1.6(±0.9)



1.26

0.05

Czech Republic







0.28

1.76

2

0.7

0.02

China, Taiwan Prov.



4.1

3.8

0.19

0.48

1.85
(1.6 2.1)

0.91(0.77 1.05)

0.16(0.04-0.18)

Bulgaria

0.2(30-50%)1(30-50%)0.6(30-50%)1.4(30-50%)0.12(30-50%)1.1(30-50%)1.1(30-50%)1.6(±30-50%)1.1(30-50%)0.2(30-50%)1.0(30-50%)1(±0.7)

0.5(30 50%)0.25(30 50%)

0.6

Lower

Upper



2
(±1)

Cervical

Health-care level I

Thoracic

LumbarCholecystography

GI tractAbdomen





Head







Belarus

Fluoroscopy

Pelvis
and
hips





c

Photofluorography

Spine



Limbs
and
joints

0.025(±0.008)

Radiography

Chest



Australia

Country

Typical effective dose per procedure b (mSv)

PART A


















































Table 15
Typical effective doses to patients undergoing some common types of diagnostic medical a x-ray procedures (1991 1996)
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicated374
ANNEX D: MEDICAL RADIATION EXPOSURES

3

0.1




0.67



0.4

0.15

Russian Federation

Sweden

1.4

1.8

0.06

1.08

0.5
(±0.2)

0.018(0.011-0.028)

0.65



0.1
(±0.03)

0.059

0.02

0.14

0.053

0.03

0.05

Switzerland

United ArabEmirates

United Kingdom

Average dBrazilMalaysia [N26]

Average
1.0

0.04



0.03

0.74

0.74

Cardiac

6.9

10.6(±7.5)

2.6(±2.0)




All

0.4
(±0.16)ClinicalScreening

2 (±30-50%)Australia

Belarus

Bulgaria

Canada

1.33

1.28
1.05












Total of all
medicalexaminations

1.5







6









PTCA

1.5

6

2.3

6.4

3.6







All

8
(±4)

7.2

9.8

5
(±4)

2.6

4.4

5
(±4)

6

3.3

8

Lower

Upper

3

Cholecystography

GI tract

Health care level I

Head







Cerebral

Body





All

Angiography

0.62

1.05

Computed tomography

0.04

0.04

0.5
(± 0.36)

0.03

0.53

0.07

0.83

0.27

Typical effective dose per procedure (mSv)

PART B

0.46

0.46

0.7

0.04

0.7

0.43

0.5
(±0.3)

2.5

1.06

0.1
(±0.1)

0.1

0.35(0.11-0.67)

1(±0.5)

1.5

0.28

0.2
(±0.2)

0.2

Mammography

1.04

0.04










Urography

0.7

1.3

0.2
(±0.1)

Country

0.35

0.47

0.05
(±0.05)
Health-care level II

0.8(±0.5)

1.5(±0.5)










1

CervicalThoracic

LumbarFluoroscopy







PhotofluorographyRadiography

Abdomen

Head

Pelvis
and
hips





Spine







Limbs
and
joints





Chest









CountryTypical effective dose per procedure b (mSv)

Table 15 (continued)

ANNEX D: MEDICAL RADIATION EXPOSURES
375

2

2.07
(±0.39)New Zealand

NorwayPanama

6.5

6.7 e

1.0 e

5e
16.2
(±9.2)

5e

5e
12.3(±5.4)

2

0.62(±0.3)
0.56



0.2







0.1





3.1



5.8
(±2.9)



5

4
(±2)



PolandPortugal

Romania

Russian Federation

Sweden92

0.11(0.01 0.14)



6

9.83
(6.8 11.8)
2.62(1.75 3.3)



0.06

3.9

5
(±2)

2
(±1)

0.1
(±0.1)





2.4

2
(±1)





United Kingdom

10
(±1)





2.66

6.7







United ArabEmirates

0.83

10







Ukraine0.8(±0.4)

























0.13

10

0.4

1
(±0.3)



Switzerland

5.8





1.2

3.5







22







9.2

0.73

0.22







12

1.35
(±0.63)

25






1

0.83




5.8

1.2

7







3.7
(±1.1)

4





2.1

0.12





3.8
(±0.51)

10

2

0.07
(±0.02)

1.06(±0.12)

7.8
(±4)

2.2
(±1.1)

0.1

0.1 e




0.24
(±0.11)

10.2 e

1.7 e

0.1 e





Netherlands

5.56

2.47



Japan

1.5
(0.001 190)

23
(1 190)12.3(1 190)11.3

15.4(4 50)

2.6
(1 5)

0.5
(0.1 2)4.9(0.2 19)

Germany

0.64

Finland
14.8

3.8

7.9

1.3

0.2

0.1

4.5

Denmark

0.43

0.7

7.3

3.6

2.8

3.8

9.2

1.1

2.04

Total of all
medicalexaminations

PTCA































0.5

Czech Republic

China, Taiwan Prov.

All

Cardiac

Cerebral

All

Body

Head

All

Angiography

ClinicalComputed tomography

Screening

Mammography









UrographyCountry

Typical effective dose per procedure (mSv)

















































































Table 15 (continued)

376
ANNEX D: MEDICAL RADIATION EXPOSURES

13.3

2.8

7.8

4.9

6.8

6.8

Brazil:Survey data for Paraná State (with a population of 9 million and a social and economic profile above the average for Brazil).
China (Taiwan): Data for lumbar spine, GI tract and total of all medical examinations from reference [L23].
Germany: Mean effective dose for general classification of spine is 1.2 mSv (range: 0.1 20 mSv).
Malaysia: Data for chest, spine and head refer to AP/PA projections. Data for ‘GI tract’ relate to both ‘Upper’ and ‘Lower’ categories.
Norway:Data from national survey involving about 50 hospitals and 5000 measurements.
Romania: Additional survey data in relation to ‘Chest fluoroscopy’: mean entrance surface dose of 13.4 mGy and mean dose-area product of 3.6 mGy cm2 [I28].
Russia:Additional survey data in relation to effective doses from ‘Chest fluoroscopy’: dose rates without and with electronic image intensification of 1.4 mSv per minute and 0.9 mSv per minute, respectively. Datashown for ‘GI tract’ relate to both ‘Upper’ and ‘Lower’ categories. Effective dose rates from fluoroscopy without and with electronic image intensification of 4.2 mSv per minute and 2.3 mSv per minute,respectively during upper GI examinations, and 3.6 mSv per minute and 2.2 mSv per minute, respectively, during lower GI examinations. Data for ‘CT - Body’ refer to examinations of the abdomen; meaneffective dose for CT chest is 2.8 mSv.
United Arab Emirates: Survey data from one hospital, except those for chest radiography and pelvis/hip (from seven hospitals), and chest photofluorography (from four units at two hospitals).

The entries in this Table are qualified as follows:

Excluding dental x-ray examinations.
Variations shown in brackets (standard deviation, coefficient of variation or range).
No data available.
Frequency-weighted average of national values.
These revised data were received by the Committee after completion of the global analysis.

0.56

0.1

0.1

3.9

Average

6.8

0.28

7.8

6.8

0.1

0.1

2.4

Malaysia [N26]
4.9

0.57

China [Z10]
2.8

0.26

3.89
(±2.8)

BrazilHealth-care level II

0.83

22

12.4

7.3

2.0

8.8

2.3

0.51

0.21

0.07

3.7

Average



a
b
c
d
e

0.52

United States



6





9



2



0.06



2.4





United Kingdom

All

Cardiac

Cerebral

All





Body





Head

Total of all
medicalexaminations

Angiography
PTCA

Computed tomography







All

Mammography









Clinical

UrographyScreening

Country

Typical effective dose per procedure (mSv)













































Table 15 (continued)

ANNEX D: MEDICAL RADIATION EXPOSURES
377

State3 hospitals

Regional

National

3 hospitals

4 hospitals

National

National

1 hospital

Australia [B29]

Argentina [I4]CanadaChina, Taiwan
Province [Y9]

Czech Republic [I4]

Estonia [S29]Finland [R11]

Germany [B9]Greece [O3]Country / area

E

ESD

DAP

E

DAP

ESD

ESD

ESD

ESD

E

ESD

ESD

ESD

ESD

ESD

0.38 (pre)(0.24-0.48)
0.33 (post)(0.31-0.34)
0.11 (man.)(± 0.03)0.13 (auto.)(± 0.04)0.040(± 0.12)0.41 (pre.)(0.08-0.99)
0.12 (post.)(0.1-0.13)
0.30(0.15-0.49)

0.68 (man.)(± 0.23)0.74 (auto.)(± 0.21)8.1(1.1 14.3)

15.1(2.2 30.1)

3.5(± 1.95)
0.094

2.68
(± 1.49)
0.034

1.93
(0.57-8.01)

1.07

3.37
(1.06-8.53)
1.63(020-5.82)
0.12(0.03-0.42)

0.69(± 0.4)0.11

3.9(1.5 7.0)

4.2(1.4 7.3)
5.10 (pre)22.4(5.3 43.3)

15.1(3.7 32.5)

c

0.86

2.94
(± 1.57)
0.22

8.25(± 4.63)
0.74

3.51

4.89
(0.49-11.3)
4.14(1.10-22.2)
1.02(0.23-3.92)

6.15(2.02-22.0)
3.80(0.79-16.0)
1.25(0.31-4.49)
3.62
12.5
(± 6.85)
1.35

7.08(0.76-19.0)
6.90(0.86-20.8)
2.22(0.60-5.89)
3.62
11.2
(± 7.3)1.45

13.8(0.84-31.7)

10.9(±8.1)
0.33

18.9(± 6.76)
1.88

8.80(0.49-43.5)
8.25(0.88-68.8)
2.27(0.25-11.4)

15.8(2.5 29.9)
14.0(2.2 26.8)

30.3(7.3 61.0)

8.36 (pre.)(5.56-10.8)
5.64 (post.)
3.87-8.39)

11.6(2.10-26.2)

6.37 (pre.)(5.59-6.99)
4.12 (post.)
3.09-6.99)

0.21(± 0.10)3.34 (man.)(± 1.0)3.69 (auto.)(± 1.3)

1.82 (man.)(± 0.6)1.50 (auto.)(± 0.05)

3.31 (post)

2.35 (man.)(± 0.5)1.64 (auto.)(± 0.5)

6.1(2.3 19.7)

0.73(0.15-4.44)

1.37

0.24
(0.06-3.28)
0.44(0.08-3.47)
0.10(0.03-1.10)

0.63(0.22-1.42)

0.12(0.02-0.21)

1.2(0.5 2.3)

AP

AP

LSJ

LAT

AP

PelvisAbdomenLumbar spine

LAT

AP

Thoracic spine

Mean value of dose quantity per radiograph b

Health-care level I

1.9(0.9 2.7)

LAT

PA

Chest
LAT

Skull

AP / PA

Dosequantity a





Scope
of data

PART A

44.9(± 22.9)
0.94

9.32

18.2
(2.10-111)





















































































Table 16
Patient dose from diagnostic x-ray examinations
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicated378
ANNEX D: MEDICAL RADIATION EXPOSURES

21
hospitals

National

National

Romania [I28]

Russian Federation

New Zealand

National

National

United States

Local

National

United Kingdom[H11]

United ArabEmiratesSouth Africa[M22, H29]

Local

National

PolandSlovenia

National

Panama

ESD

E

ESD

E

ESD

ESD
E

E

DAP

ESD

E

ESD

E

ESD

ESD

DAP
E

3.6

6.4

0.68

4.4
(1.0 16.0)
0.66

5.6
(0.75-16.6)
0.7

29.0
(4.2 84.0)
0.29

16.0
(3.9 75.0)
0.29

6.1
(1.4 31.0)
0.69

13.0
(1.3 43.0)
0.29

4.7
(1.3 18.0)
0.40

0.57
(0.11 2.6)
0.04

0.16
(0.01-0.94)
0.02
0.15

1.5
(0.56-4.43)
0.01

3.0
(0.5 10.0)
0.03

0.039
(0.0084
0.094)

15.4

13.1
59.1

27.3

35.6

13.1

0.020
(0.0050.028)

4.72
0.65

3.52
0.04

3.98
(± 2.33)
2.37(± 1.49)
0.63(± 0.38)
15.00
0.14

4.57
(± 2.57)
2.67(± 1.61)0.58(± 0.33)
15.65
0.48

18.9
(± 11.6)
3.92(± 2.33)0.47(± 0.29)
6.11
0.63

5.47
(± 2.89)
1.88(± 1.16)0.6(± 0.33)

1.2

31.2(± 21.8)
3.83(± 2.79)
0.36(± 0.24)

0.75

1.7

7.22
0.21

13.3
(± 9.72)
3.53(± 2.68)0.31(± 0.21)

0.3

4.89
0.37

4.32
(± 2.67)
1.54(± 1.01)
0.44(± 0.26)

0.8

0.38

3.2

1.02
0.06

0.29
0.05
1.5

1.24
(± 1.92)
0.62(± 0.67)0.1(± 0.11)0.22(± 0.25)0.17(± 0.2)0.03(± 0.03)1.56(± 1.04)
0.57(± 0.37)0.02(± 0.05)

3.0(± 2.04)
0.96(± 0.65)0.03(± 0.02)

0.6

0.4

13.2
(1.9 35)
10.9(2.1 37)42.0(4.4 162)17.6(2.0 71)

24.0(3.5 97)

4.2(0.7 13)1.7(0.3 6.0)

9.4(1.2 28)11.0(1.0 31)11.2(2.0 41)

0.10

2.54
(1.97-25.8)
0.61(0.40-10.3)

4.7(0.75-23.2)
2.18(0.12-7.12)
12.0(3.45-38.4)
0.9(0.71-2.27)

7.50(1.38-25.3)
3.43(0.77-11.5)

8.3(1.2-23.2)
2.13(0.98-8.9)

5.1(0.7-18.5)
0.9(0.63-12.6)

0.20(0.16-2.76)
0.06(0.06-0.49)

3.28(±1.0)

2.33(±0.91)0.88

0.17(±0.10)

3.48

7.61

0.64
0.12



NationalNorway [O6]

21.43

20.43

37.4

35.5

22.8

1.39

0.81

2.73

2.11



ESD



National

5.63(1.2 26.5)

4.75(0.5 18.3)

36.9(1.5 102)Lithuania

16.9(1.8 67.1)

6.47(0.27-20.3)

0.22(0.02-0.65)



ESD

AP

AP

LSJ



National

PelvisAbdomen

Ireland [J10]

LAT

AP

LAT

AP

LAT

Lumbar spinePA

Thoracic spine

LAT

Chest

AP / PA

Skull



















































Country / area

Mean value of dose quantity per radiograph b

Dosequantity a



Scope
of data







































































Table 16 (continued)

ANNEX D: MEDICAL RADIATION EXPOSURES
379

3.5
(±1.0)

3.61(± 1.24)

9.39
(± 2)

ESD
E

ESD

ESD

ESD

ESD

ESD

ESD

12
hospitals

Local

14
hospitals

12
hospitals

4 hospitals

Malaysia[N15, N26]

Egypt [H28]

Ghana [S39]

Indonesia [L19]

Thailand [L19]

MoroccoTurkey

Peru

ESD

ESD

E

ESD

6.39
(±3.3)

8.41

6.0(± 3.0)19.35(± 1.16)

7.74(±5.3)
3.57 (pre.)(2.83-4.25)
1.87 (post.)
1.47 2.08)
10.0

8.5
(± 2.0)10.73(± 2.01)

1.37 (pre.)(± 0.76)0.72 (post.)(± 0.26)0.72(± 0.2)0.51(± 0.18)0.23(± 0.2)

3.52(± 1.48)

1.10 (pre.)(± 0.64)
0.52 (post.)(± 0.17)

9.2(3.1 16.0)
1.61(±52%)

0.74(0.1 1.5)
0.10(±61%)

5.7(2.7 9.1)
0.08(±38%)

3.3

0.3

0.26 (pre.)(± 0.16)
0.16 (post.)(± 0.09)

Health care level III
0.5

2.81
(± 1.49)

7.45(± 0.54)

4.27(± 0.88)0.70(± 0.20)

7.0(±3.0)

0.4(± 0.3)0.32(± 0.05)

18.7

10.6
1.04

16.5

7.03
0.46

1.40
0.09

0.28
0.03

0.21 (pre.)(0.19-0.26)
0.06 (post.)(0.04-0.09)

3.34
0.04

27.9
(±18.1)

10.6(±12.0)12.4(±8.9)

7.14(±4.6)

5.33(±5.3)

1.97(±2.3)

0.97 (pre.)(± 0.48)
0.52 (post.)(± 0.27)

1.52 (pre.)(± 1.09)
0.93 (post.)(± 0.47)

7.97 (pre.)(± 5.3)4.08 (post.)(± 3.5)2.81 (pre.)(± 2.1)
1.21 (post.)(± 0.65)

10.2

12.3

3.72
(±1.23)

9.57(± 6.22)9.36(± 3.0)6.30(± 1.50)7.9(2.0 13.1)
1.71(±40%)

1.5

1.5



4 hospitals

4.78
0.04

ESD

2 hospitals

Iran (Islam. Rep. of)
[I4]

2.92
(±2.4)

4.45(±2.3)ESD

1 hospital

Costa Rica

0.032(±0.02)0.021(±0.01)

5.28(4.35-6.20)

7.88

6.82
(4.36 9.38)









E

1.01

0.33

AP

AP

LSJ

PelvisLAT

AbdomenAP

Lumbar spine

LAT

Thoracic spine
AP

Health-care level II

4.55(3.08-7.34)

ESD

3 hospitals

Brazil

LAT

PA

LAT



AP / PA

Chest












































































Skull









Country / area

Mean value of dose quantity per radiograph b





Dose
quantity a





Scope
of data

















Table 16 (continued)

380
ANNEX D: MEDICAL RADIATION EXPOSURES

a
b
c

DAP

E

DAP
E

DAP
E
DAP

5 hospitals

National

National

5 hospitals

21 hospitals

Iceland [W42]

New Zealand

Norway [O6]

Romania [I18][I28]

National
Regional

DAP
DAP(43.6 77.4)
9
49.1
13.7
32.2 (± 3.3)
8.12
34.7 (2 116)

3
24.8
5.9
37.7 (± 17.5)
3.7
22.0 (2 100)

7.41
1.5

9.3
5.63

13.5
(± 10.2)

61.5

35.9

13.05

13.0
7.60

68.5
(± 42.9)

Health care level I

Meal

LAT

25.8
15.7

9.0

13.4

3.8
1.92

31.8
8.3

18.1
3.8

37.1
(± 32.8)4

0.4

Venogram

7.8

ERCP

6.4
(± 4.5)

33.7

Urography

AP

8.3(± 5.6)AP

Pelvis5.26 (pre.)5.11 5.41)
10.57(post)(9.74-11.4)

LSJ

Abdomen

20.3

Colonoscopy

Lower GI tract

Mean value of dose quantity per examination b

Enema

PART B

ESD: entrance surface dose with backscatter (mGy); DAP: dose-area product (Gy cm2); E: effective dose (mSv).
Variations shown in brackets (standard deviation or range).
No data available.

United Kingdom [H11][B56]

Switzerland [M45]

DAP

DAP

National

Germany [B9]

AP

17.5
(± 8.5)

LAT

7.7(± 3.8)

Swallow

Upper GI tract

0.5(± 0.3)

Dosequantity aCountry

Scopeof dataESD

5 hospitals



Unitd Rep. of
Tanzania [M37]ESD

1.34 (pre.)(0.94-1.74)
0.57 (post.)(0.43-0.70)








ESD



2 hospitals

Ethiopia [I4]AP

Health care level IV

LAT





































PA



LAT

Lumbar spineAP / PAThoracic spine







Chest



Skull



Country / area

Mean value of dose quantity per radiograph b





Dose
quantity a



Scope
of dataTable 16 (continued)

ANNEX D: MEDICAL RADIATION EXPOSURES
381



 



Argentina:
Pairs of values represent surveys before and after the introduction of a programme of quality control. Interhospital variation in brackets.
Brazil:Survey data for Paraná State (with a population of 9 million and a social and economic profile above the average for Brazil); data for skull, lumbar spine, and pelvis from reference [I4].
Brazil:Pairs of values represent surveys before and after the introduction of a programme of quality control. Interhospital variation in brackets.
Canada:Survey data from Manitoba (4% of Canadian population) for standard pressed wood phantoms (unit density) under manual and automatic exposure control and for rare earth intensifying techniques.
Costa Rica:
Data from Hospital Calderón Guardia (serving one third of the population).
Czech Republic: Pairs of values represent surveys before and after the introduction of a programme of quality control. Interhospital variation in brackets.
Egypt:
Maximum recommended doses derived from the following published maximum entrance surface exposures: 26 mR skull; 45 mR chest; 272 mR lumbar spine; 125 mR abdomen; 125 mR pelvis [H28].
Estonia:Interhospital variation in brackets.
Ethiopia:
Pairs of values represent surveys before and after the introduction of a programme of quality control. Interhospital variation in brackets.
Finland:
DAP and E data represent mean values for complete examinations.
Germany:
DAP data refer to complete examinations (rather than doses per radiograph).
Ghana:
Data for AP pelvis also includes radiography of the abdomen.
Iceland:
Data for barium enema examinations refer to range of mean DAP values observed in survey of 5 hospitals.
Iran (Islamic Rep. of): Pairs of values represent surveys before and after the introduction of a programme of quality control. Interhospital variation in brackets.
Lithuania:
Data from Vilnius University Hospital.
Morocco:Data from IAEA Coordinated Research Programme.
Norway:Data for ‘Upper GI- Meal’ and ‘Lower GI - Enema’ refer to double contrast technique (corresponding data for single contrast technique: 14.0 Gy cm2 & 3.4 mSv, and 32.3 Gy cm2 & 9.0 mSv, respectively).
Peru:
Data may refer to complete examinations.
Romania:
Pairs of values represent surveys before and after the introduction of a programme of quality control. Inter hospital variation in brackets.
South Africa:
Derived from free in air data calculated for average exposure conditions.
United Rep.
of Tanzania: Survey data for 500 patients per examination spread over 4 referral hospitals and 1 regional hospital; these hospitals are collectively responsible for nearly 50% of the annual national total of patients
examined with x rays.
Thailand:
Pairs of values represent surveys before and after the introduction of a programme of quality control.
Turkey:Survey data from Ankara University Hospital and Gülhane Military Hospital.
United Arab Emirates: Survey data for ‘Head’ examinations from one hospital, data for ‘Chest’ from seven hospitals.
United Kingdom: Inter hospital variation in brackets. Data from reference [B56] represent median values from regional survey.
United States: On the basis of entrance surface exposure of 0.12 mGy from NEXT programme for 1994.

The entries in this Table are qualified as follows:

Table 16 (continued)

382
ANNEX D: MEDICAL RADIATION EXPOSURESANNEX D: MEDICAL RADIATION EXPOSURES

383

Table 17
Patient dose per procedure from diagnostic angiographic examinations
Technique

Procedure
Coronary

CerebralChildren b
Cine film cCine film dCinefluorography e
Digital cine f
No. frames a: 878 (302 SD)
Cine film g
DSA

DSA/conventional
Carotid (DSA)
DSA/conventional
DigitaljCarotid
Abdominal

Peripheral

a
b
c
d
e
f
g
h
i
j
k

Fluoroscopy time a(min)Dose-area product a(Gy cm2)

Effective dose a
(mSv)



13.3 (1.498)
41 (228 max.)(2140)16.1 h(29)3.1 (112)8 (70 max.)
4.3 (1.515)
3.9
7 (SD 3.6)

3.6 (3.3 SD)(3.15.6)

55.9
30.4 ( ± 57%)
38.9
47.7
58.7 i39.3 (18 SD)(2379)4.7

48.5

9.8 ( ± 65%)



5.7





3.9 (1.211.8)
15 ( ± 10)12.1 (2.936)
7.8 (3.117.9)



27.4 (9.580)
59 (12120)
74 (21196)
55.2
50
98 (44208)

Hepatic (DSA)
Renal (DSA)
Renal (DSA)
Mesenteric and/or coeliac art.
DSA/conventional
DigitalRenal angiography
Renal angiography
DigitalAortagram
Mesenteric10.3 (2.328.6)
12.1 (5.521)
5.1
14.7
1.0 ( ± 0.5)
8.0 (1.827)
5.1 (2.97.6)
2.8 (0.59.3)
6.7 ( ± 6.5)

137 (28279)
95 (41186)
43
65
57 (3189)
118 (21.6301)
39.8 (17.472)
177 (90327)
61 (8192)
98 (297 max.)
112 (352 max.)Femoral (DSA)
Aortoiliac + 1 leg
Aortoiliac + 2 legs
Aortoiliac + thighs
Aortogram/femoral runoff
Femoral arteriogram
Femoral (DSA/conventional)
Femoral (DSA)
Femoral (DSA)
FemoralFemoralLower limbs
Lower limbs (arteries)
Lower limbs (veins)
Lower limb
Venography (arm)

3.7 (1.219)
2.9 ( ± 2.8)
4.5 ( ± 1.2)
1.2 ( ± 0.4)
3.9 (1.810.8)
2.4 ( ± 1.9)
1.7 (0.46.7)
2.3 (0.913.7)

42.9 (13122)
13 (252)
32 (1968)47 (16100)

7.2 (1.817.2)
2.4 (138.3)
3.7 ( ± 3.1)








26
24.4 (5.6100)
74 (19.8184)13
46.7 (3114)
16 (891)
30 (977)
35.5
4.9
78 (306 max.)
23 (57 max.)

Mean values of parameters (with range, standard deviation, or coefficient of variation in parentheses).
Ages 0.01-12 years. Calculated entrance surface doses: mean 99 mGy, range 10-526 mGy.
Mean length of cine film 28 m (maximum 85 m).
Range of cine film length: 25-100 m.
Mean time of cinefluorography (25-30 frames per second) was 60 seconds (standard deviation 30 seconds).
Mean number of frames: 689.
Range of cine film length: 16-43 m.
61% of total DAP from radiography.
Data refer to right and left heart angiography.
Mean contributions to effective dose: 67% from fluoroscopy, 26% from cut films, and 7% from DSA.
Maximum dose to right ocular lens of 125 mGy; maximum dose to thyroid of 88 mGy.

10.6



5.6
8.9
9.4



(4.615.8)
3.6
Eye/thyroid data k
10.6 (2.723.4)
4 (112)

7.4 (2.119.6)
1.6




23 (448)
16 (634)610



18.9 (3.548)
6.4 (2.811.5)



8.2




4 (116)

14.0 (7.021.8)
4
2.7
9.0
3.1 ( ± 1.8)
7.5 (0.518.2)



6.2
6.4
0.9




Ref.
[B48]
[H6]
[C22]
[L3]
[K5]
[Z12]
[B3]
[O6]
[B54]
[W41]
[P20]
[N29]
[M9]
[H24]
[F15]
[S3]
[K23]
[M34]
[O6]
[V14]
[M46]
[S3]
[S3]
[K26]
[K26]
[K23]
[M34]
[M34]
[M46]
[R17]
[W32]
[W32]
[S3]
[K23]
[K23]
[K23]
[C23]
[T8]
[H25]
[H25]
[C24]
[M34]
[M46]
[R17]
[O6]
[O6]
[W32]
[W32]

384

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 18
Patient dose per procedure a during interventional radiology

Procedure
PTCA (Percutaneoustransluminal coronary
angioplasty)

Fluoroscopy time(min)
11.5 (2.428)
30 (970)
15(56 max.)
11 (92 max.)
31.3
43.8 b31 c (862)43 d (353)







18.7



21 ( ± 63%)
12.4

PTA (Percutaneoustransluminal angioplasty)

28.9 (7.557)






0.46 c0.39 d(15)0.1 (1 max.)





1.1



0.038 (at spine)1419.7 (5.326)(21.868) f
6

0.4

24 b (545)

0.3b

46



48.4 (21.7100)
32 (979)
59 (26115)
48
42 (27108)
50 (31 SD)
21.4 (142 max.)(190 max.)
28 (3109)













1.7
0.4
1.2 (5 max.)
0.9 (6.2 max.)(8.4 max.)








0.07 (1.4 max.)

53 ( ± 50)

1.3 ( ± 1.3)
0.93 ( ± 0.62)
1.0 (0.083.1)


65 (5195)










10

42 (266 max.)







87.5 (67122)
110 (40340)
143 (83 SD)















22

91.8
37.6 ( ± 41%)
72.2



45.8
102 (85 SD)
75
68.5 (22150)

65.1
43.5 (5184)
140 b (73223)
67.3 (289 max.)
68 (15338)(19109)354
525 (2731131)
226 (111354)
77 (7240)
220
182 (470 max.)
116 (26217)
103 (7516)
56.4 g (12184)
77.5 h (13367)
97.3 i (9532)







6.9
14.2





10






12.5 b83.9 (43.7181)
27 (1444)
8 (240)
50




17









17 / 25 j




Ref.
[N6]
[F4]
[P3]
[K5]
[H6]
[G4]
[G4]
[B6]
[B6]
[H7]
[V3]
[B9]
[B10]
[L4]
[P15]
[Z12]
[B3]
[B54]
[V14]
[W41]
[P20]
[S14]
[F5]
[N6]
[F6]
[B9]
[H27]
[W32]
[M46]
[K50]
[M8]
[V3]
[M34]
[Z11]
[Z11]
[S14]
[W32]
[N6]
[L4]
[B7]
[C3]
[F6]
[C9]
[H8]
[H8]
[H8]
[R16]
[P14]
[N25]
[B54]
[W41]

28.9




53 (40120)
31.8





56
44 l
162

29.3

[S15]
[S15]
[B54]

21







[M8]

25
37.4 (8.158)(8.46.4) m(17.590) n
23 o (175)(0.21.4) p
0.5 q

180
121 (34286)

25

[S14]
[F5]
[N6]
[N6]
[F6]
[B8]
[V3]
[B9]



Embolization

93 (33402)
28.5 (2050.5)

0.14 (LAO proj.)



Lysis

e

0.15 (0.050.3)
1

18.5 (15.5 SD)

17.9 (6.957.3)(6.326.3)

Valvuloplasty

Effective dose(mSv)

0.5 (0.012.2)

Radiofrequency ablation

Dose-area product(Gy cm2)

TIPS (Transjugular
intrahepatic portosystemic
shunt)

Localized dose toskin (Gy)

k









91.1
43.6
k




114 o (7394)

81.7 q391 (93918)

17.3









(643)


ANNEX D: MEDICAL RADIATION EXPOSURES

385

Table 18 (continued)

Procedure
Embolization (continued)

Fluoroscopy time(min)

Localized dose toskin (Gy)

Dose-area product(Gy cm2)

Effective dose(mSv)

21 p (654)
34.1 p (15.255.8)
43 o (3174)
24.3 m (548)

0.34 p (0190.66)
0.62 o (0.131.34)
0.44 m

122 p
105 p (57.2201)
116 o (29243)
79 m (55100)

10.6 p10.5 p (5.720)
1.67 o (0.443.44)
15.9m
20 o ( ± 14) adult68 o ( ± 51) child.

[M9][M34,M36]
[B17]
[H27]
[G12]
[G12]
[W32]




[V3]
[M34,M36]
[M35]
[R17]
[W32]

5.8

[O9]






Biliary

a
b
c
d
e
f
g
h
i
j
k
l
m
n
o
p
q






105 (352 max.)







68.9 (30163)
43.1 (3.8149)
20.1 (1.2122)
150 (51291)
43 (167)

17 ( ± 9)

2 (max.)42 ( ± 29)

7.1 (0.626.3)
30.4 (3.6141)34.2 ( ± 11.5)

Stent (superior vena cava)





2.1
0.11 (0.010.37)

Ref.

6.9 (0.623.9)



38.2

Mean values of parameters (with range, standard deviation, or coefficient of variation in parentheses).
Procedure carried out with laser.
Total occlusion.
Subtotal stenosis.
No data available.
Leg.
Atrioventricular.
Atrioventricular nodal reentry.
WolffParkinsonWhite.
Values for males and females, respectively.
Children (116 years).
Infants (<1 year).
Liver.
Kidney.
Neurological.
Cerebral.
Hepatic.

Table 19
Doses to patients from computed tomography
Mean effective dose per procedure (mSv)
Country / area

Year

Head

Cervical
spine

Chest

Abdomen

Liver

Kidneys

PelvisLumbar
spine

16.7
11.6
27.4
6.7-13.3 c
6-24 a
9.7
12.8
10 d
12.0

12.7
6.5
11.9
10 d
10.3

7.6
9.9
10 d
9.1

11.0
6.9
9.8
10 d
9.8

5.2
5.0
9b
2-12 a
4.7
4.5
6b
3.3

9.5

-

-

-

-

Health-care level I
Australia [T17]
Finland [S67]Germany [B58]
Japan [N16]
Netherlands [V15]
New Zealand [P5]
Norway [O12]
Sweden [S68]
United Kingdom (Wales) [H33]

1995
1994
1993
1994
1993
1992
1993
1991
1994

2.6
1.3
2.6
0.8-5.0 a
1.8
2.0
2.1
1.6

5.2
9b
3.3
6
1.5

10.4
5.1
20.5
4.6-10.8 c
6-18
8.9
11.5
10 d
9.7

Health-care level II
Oman [G37]
a
b
c
d

1998

Reported range for survey of 22 scanners.
Published value for spine.
Reported range for survey of 4 scanners.
Published value for trunk.

2.4

3.5

3.4

386

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 20
Patient dose a per procedure from chest radiography

TechniqueEffective dose(mSv)

Projection

0.168

With lung filter
With gridWithout gridWith air gap
Asymmetric combination
Twin combinations

PA
PA
PA
PA
PA
PA
PA
PA

0.128
0.087
0.025
0.131
0.4







[S77]
[S78]
[S78]
[C38]
[C38]
[C38]
[C38]
[M65]

Computed radiography




PA
LAT

0.68
1.70

0.10
0.15

[M4]
[M4]

Beam equalization (AMBER)




PA
LAT

0.16
0.65

0.024
0.066

[M4]
[M4]

Selenium drum

150 kV
90 kV Standard dose
90 kV Low dose

PA
PA
PA

0.145
0.16
0.07





[L33]
[L33]
[L33]

Digital Image Intensifier




PA
LAT

0.11
0.15

0.016
0.013

[M4]
[M4]

100 mm film




PA
LAT

0.10
0.77

0.015
0.069

[M4]
[M4]

Photofluorography

Survey of 80 units

5.8

0.36 (0.052.4)[P26]

Mobile



PA



0.013
0.15

[S78]
[L34]
[S79]
[S79]

Film-screenIntensive therapy unit
Intensive therapy unit
WardsaEntrance surface dose(mGy)

Conditions

Mean value, standard deviation or range.








0.310.56
0.33 ± 0.11
0.2



0.0070.017
0.0080.011




Ref.

ANNEX D: MEDICAL RADIATION EXPOSURES

387

Table 21Frequencies of examinations and doses in dental radiology (1991-1996)
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicatedNumber of examinations a per 1,000 population

Effective dose per examination b (µSv)

Country / area
Intraoral

PanoralAll

Intraoral

PanoralAll80 (3050%)





5 (124)
10 (11 000)150 (3050%)

















10 (11 000)


14

11

14

8d
5

10
26

8d

Health-care level I
Australia
Bahrain
Belarus
Croatia
CyprusCzech Republic
Denmark
EcuadorFinlandGermany
HungaryJapan cKuwaitLithuania
Luxembourg
Netherlands d
New Zealand c
Poland [S49]
Portugal [F11]Romania
Russian Federation
Slovakia
Slovenia
SwedenSwitzerland
United Arab Emirates
United Kingdom
Average




23

75
168

6
63
12









14
254
276

0.24
36






743

88

438
170 d

31
8d

70

3.4










49
81
231
12
193
471
14
290
276
41
839
100
108
469
182 d







77
46
682
524
7.8
161

17
9.8
57
34
7.6
49

74
100
28
96
94
55
739
571
15
212

365

47

309



28


0











100



















100 (± 70)
361010 (± 10)1050 (± 20)1030 (± 30)

10 (319)

11

10

13

12

16








































100 (± 70)









Health-care level II
BrazilChina
JordanMexicoOman
Turkey

111




3.0
0

0.1
1.2
2.3



111
1.7
3.1
1.2
2.3
31

Average

106

1.1

14





Health-care level III
Ghana





0.25
Health-care level IV

United Rep. of Tanzania
a
b
c
d

0.07

0

0.07

Some values may represent numbers of films rather than complete examinations.
Some doses may relate to individual films rather than complete examinations. Variations in parentheses (standard deviation, coefficient of variation or
range).
Data refer to individual films.
These revised data were received by the Committee after completion of the global analysis.

388

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 22
Doses to patients from dental x-ray examinations
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicatedCountry

Year

Technique

Condition of measurement

Typical entrance surface dose a per
exposure (mGy)
Survey mean

S.D. b

2.5
6.5
4.9
3.1
1.9
4.9
3.2
2.77
0.72
3.3
2.6
5.0
2.2
57.4 mGy mm c
1.9
0.21

(1.63.6)
4.9
3.7
1.2
0.9
4.3
3.6
(2.613.2)

Health-care level I
CanadaGreece [Y11]

1995
1997

Denmark [H31]1993

United Arab Emirates

1997

United Kingdom [N23]1998

United States

1993

Intraoral
Intraoral (50 kV)
Intraoral (60 kV)
Intraoral (65 kV)
Intraoral (70 kV)
Intraoral (D speed film)
Intraoral (E speed film)
Intraoral
Intraoral
Intraoral (All)Intraoral (E speed film)
Intraoral (45-55 kV)
Intraoral (60-70 kV)
PanoralIntraoral
Cephalometric

Survey of 56 units

National survey
National survey
4 units
RVG filmless system
Sample of 6344 measurements
Sample of 1577 measurements
Sample of 2175 measurements
Sample of 3105 measurements
Sample of 387 measurements
NEXT programmeNEXT programme(0.1446)(0.1421)(0.646)(0.29.6)(2328 mGy mm) c

Health-care level II
Brazilabc

1996

Intraoral

Survey data for Paraná State(0.961)

7.9

Without backscatter.
Dose range given in parentheses.
Dose-width product [N23].

Table 23
Variation with technique of the typical effective dose from dental radiography[N3]
Radiographic techniqueabEffective dose (µSv)

Two bitewing films

70 kV a, 200 mm fsd b, rectangular collimation, E speed film
70 kV, 200 mm fsd, circular collimation, E speed film
50-60 kV, 100 mm fsd, circular collimation, E speed film
50-60 kV, 100 mm fsd, circular collimation, D speed film

2
4
8
16

Single panoral film

Rare-earth intensifying screens
Calcium tungstate intensifying screens7
14

Applied potential.
Focus to skin distance.

ANNEX D: MEDICAL RADIATION EXPOSURES

389

Table 24
Doses to patients from mammography
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicatedTypical dose per film (mGy)Country

Year

Technique

Condition of measurement

Entrance surface
dose a

Dose to glandular
tissueSurveymean

S.D. bSurveymean

S.D.b

11.08 (pre)7.26 (post)












(0.47.2)

7.5
8.0

2.4
2.9

6.3
15.2
8.5
8.36
11.0
8.5
5.2
7.9
9.5

3.1

Health-care level I
Argentina c

[I4]

1993

Australia
Belgium

[H48]
[P28]

1996
1997

FinlandFrance

[F19]
[S16]
[M7]

Germany[K49]

Greece

[F7]

1994
1999
1993
1991
1993
1992
1993
1990

Italy

[M6]

1997

Japan
New Zealand

[S81]

1994
1996
1993
1994

CanadaNorwayPanamaSlovenia
Spain

[B12]
[O10]

[C40]

SwedenUnited ArabEmirates dUnited Kingdom [Y12][B66]
United States

[S82]
[K43]

1995
1996
1997
1997
1996
1998

1991
1996
1995
1995
1992
1997
1999

400 speed
film/screen
Screening
Screening
Screening
Screening
Screening
Screening
Screening
W anodeMo/W anode
Grid
Non-grid
Screening
Screening
Non-grid
Grid
Screening
Screening
Screening
Screening
ClinicalClinical e
Screening
Screening
Screening
Screening-

Patient surveys
Patient survey (2 units; 2051 films)
24 centres (4.5 cm phantom)
24 centres (patient survey)
Standard breast phantom
Survey in Ontario (phantom)
4.5 cm Acrylic phantom
Survey in Bas-Rhin (phantom)
Survey in Bas-Rhin (phantom)
Patient survey (1678 women)
Patient survey (945 women)
4 cm Acrylic phantom
4 cm Acrylic phantom
Tuscany region (phantom)
Tuscany region (patients)
4 cm compressed breast
Average breast thickness
Patient survey in Otago (phantom)
Standard phantom
Standard phantom
Standard phantom
4.5 cm Acrylic phantom
Patient survey
Standard breast phantom
Standard breast phantom
Standard breast phantom
Standard breast phantom
Standard breast phantom
Standard breast phantom
Patient survey (4 633 women)
Patient survey (4 633 women)Standard breast phantom
Standard breast phantom
Survey of 6 000 patients (phantom)









4.22
5.05
(515)(125)















5.97
6.82
6.1
5.7

2.70
2.59
2.0
2.6

























2.26
1.4
1.5
1.1
1.5
1.0

0.4
0.5
(0.364.68)

1.59
2.07

0.56
0.66








1.80
1.45









0.48









0.47
(0.78.5)(0.40.8)(0.72.0)




1.3
1.0
1.5
2.65
2.71
0.23
1.28
1.36
2.0 f
1.6 g
1.49
1.60
2.6

0.4
0.4
(0.73.2)(2.482.81)(2.662.76)











(0.62.6)(0.72.5)







Health-care level II
Iran (Islamic
Republic of) h
Turkey
a
b
c
d
e
f
g
h

1993




Patient surveys

1997

-

Localized survey[I4]

5.45 (pre)4.27 (post)
3.29

1.94



0.23

Entrance surface dose or entrance surface air kerma; backscatter factor is generally <1.1 for mammographic exposures.
Dose range given in parentheses.
Values represent surveys before and after the introduction of a programme of quality control; data from two hospitals.
Diagnostic data from four units with grid and one without grid; screening data from two units.
Without grid.
Mediolateral oblique view (mean breast thickness 57 mm).
Craniocaudal view (mean breast thickness 52 mm).
Data from one hospital. Values represent surveys (with mean breast thickness of 3 cm) before and after the introduction of a programme of quality
control.

390

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 25
Estimates of mean absorbed dose to the uterus from x-ray examinations[W30]
Examination

Typical dose (mGy)

Reported range (mGy)










0.00030.001<0.0050.03<0.0050.18<0.0050.03<0.100.55
0.0020.43
0.0090.40<0.1
0.2519.0
0.0512.0
0.0516.0
0.2740.0
0.3024.0
0.7055.0
2.741.0
0.281302.7920.5522.0
0.7314.0
0.010.50aDentalHead / cervical spine
Extremities
ShoulderThoracic spine
Chest (radiography)
Chest (photofluorography)
Mammography
AbdomenUpper GI
Cholecystography / cholangiography
Lumbar spine
Lumbosacral spine
Urography
Urethrocystography
Barium enema
Hysterosalpingography
PelvisHips and femur
Femur (distal)
a

2.5
1
1
4
4
6



10
10
2
3



No data available.

Table 26
Provision for dual energy x-ray absorptiometry in various countries[C10]
Health-care level

Country

Scanners per million population

I

Australia
Austria
Belgium
CanadaCyprusDenmark
FinlandFranceGermany
GreeceIsraelJapan
Malta
Netherlands
Portugal
Spain
Switzerland
United Kingdom
United States

3.4
6.5
10.4
2.3
7.1
3.5
3.4
6.6
6.8
13.5
2.6
2.6
2.5
1.8
1.6
3.5
4.1
1.6
2.9

II

Chile

1.6

ANNEX D: MEDICAL RADIATION EXPOSURES

391

Table 27
Summary of entrance surface dose measurements from surveys of paediatric radiography in Europe(1989-1995)[K4]
Entrance surface dose (µGy)
Infant (10 months)

X-ray examination
MedianChest AP (1 kg newborn)
Chest PA/AP
Chest AP (mobile)
Chest lateral
Skull PA/AP
Skull lateral
Pelvis AP (4 month)Pelvis AP
Full spine PA/AP
Thoracic spine AP
Thoracic spine lateral
Lumbar spine AP
Lumbar spine lateral
Abdomen AP/PAa

Minimum

5-year old

Maximum

Median



45
75
90

11
21
34

386
979
718

930

152

4 514

260

18

1 369





867






440











107






77

Maximum

MedianMinimum

Maximum

a











67
68
140
967
703

19
29
37
242
138

1 347
333
554
4 626
2 358

71
91
153
1 036
577

17
29
39
130
113

1 157
760
1 976
5 210
3 787

485

86

2 785

812

89

4 167

2 917

887
1 629
1 146
2 427
729

204
303
131
249
148

4 312
6 660
5 685
23 465
3 981














3 210

588

4 351

Minimum

10-year old








56



















No data available.

Table 28
Examples of reduced doses in paediatric radiography with attention to good technique[C20]
Age orweightEntrance surface dose a(mGy)

Dose-area product(Gy cm2)

Effective dose
(mSv)

Chest - neonatal b

1 kg
2 kg
3 kg

0.01
0.02
0.03





0.02
0.04
0.07

Chest - AP/PA

01 month112 months
14 years
59 years
1015 years

0.02
0.02
0.03
0.04
0.05

0.002
0.003
0.005
0.016
0.029

0.01
0.01
0.01
0.01
0.01

Abdomen - AP

01 month112 months
14 years c
59 years
1015 years

0.05
0.05
0.09 / 0.16
0.25
0.66

0.004
0.009
0.017 / 0.030
0.074
0.36

0.01
0.01

01 month112 months
14 years c
59 years
1015 years

0.05
0.07
0.08 / 0.22
0.42
1.13

0.003
0.005
0.011 / 0.068
0.15
0.29

0.01 / 0.03

Skull - AP

01 month112 months
14 years
59 years
1015 years

0.12
0.15
0.48
0.73
0.94

0.015
0.022
0.08
0.11
0.20

0.01
0.01
0.01
0.01
0.01

Skull - LAT

01 month112 months
14 years
59 years
1015 years

0.07
0.09
0.30
0.36
0.46

0.009
0.014
0.053
0.060
0.11

0.01
0.01
0.01
0.01
0.01

Radiograph

Pelvis/hips - AP/Frog LAT

0.02 / 0.04
0.06
0.13

0.01
0.01
0.06
0.17

392

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 28 (continued)
Lumbar spine - AP

Lumbar spine

Full spine (scoliosis) - PA

0.07
0.19
0.37
0.98
1.75

0.006
0.010
0.048
0.23
0.54

0.01

01 month112 months
14 years
59 years
1015 years

0.08
0.14
0.70
1.52
8.46

0.006
0.012
0.10
0.30
2.22

0.01
0.01

01 month112 months
14 years
59 years
1015 years







0.21
0.22
0.30

0.069
0.070
0.095







0.02
0.05
0.14
0.22

0.04
0.09
0.43

01 month112 months
14 years
59 years
1015 years







0.37
0.40
0.54

0.086
0.12
0.14







Barium meal / barium swallow< 1 years
15 years

0.34 d (0.180.56)
0.60 d (0.360.94)Micturating cystourethrography (MCU)< 1 years
14 years
510 years

0.26 d (0.060.62)
0.25 d (0.100.49)
0.45 d (0.290.60)Full spine (scoliosis) - LAT

a
b
c
d

01 month112 months
14 years
59 years
1015 years

With backscatter.
Examinations conducted in a special care baby unit using mobile x-ray equipment. Data given by patient weight (kg).
Dual dose data refer to small and large children, respectively.
Mean and range from survey with screening times of 0.55.2 min and 310 films (100 mm format).

ANNEX D: MEDICAL RADIATION EXPOSURES

393

Table 29
Some reported annual individual and collective effective doses from diagnostic medical x-ray examinations a
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicatedEffective dose (mSv)
Country
Per examination

Per caput

Collective effective dose(man Sv)

Ref.

13 0006 400
26 200
4 700
1 820
2 270
57 660153 360
9 000
32 3007 000
13 800128 000
6 000
26 250130 000

[W34]
[A15]
[L23]
[S50]
[F11]
[K18]
-

91 600
1 000

[Z10]
[N26]

Health-care level I
Australia
Bulgaria
CanadaChina, Taiwan Province
Denmark
FinlandFranceGermany
Netherlands
PolandPortugal
Romania
Russian Federation
SwedenUkraineUnited States

1.3
1.28
1.05
0.43
0.7
0.63
1.5
1.0
1.2
0.83
1.35
0.7
1.2
0.83
0.5

0.8
0.75
0.94
0.23
0.36
0.45
1.0
1.9
0.6
0.8
0.71
0.61
0.9
0.68
0.50
0.5
Health-care level II

Brazil b
China
Malaysia
a

b

0.26
0.57
0.28

0.09
0.08
0.05

Since, as discussed in Section I.C, many of these exposures are received by patients nearing the end of their lives and the doses are not distributed
evenly amongst the population, these doses should not be used for the assessment of detriment. Some data may erroneously include dental
examinations.
Data for Paraná State (with a population of 9 million and a social and economic profile above the average for Brazil).

b

a

920

Total

150

23
0.1
63
19
4.4
1.2
2.9
2.8
6.0
12
3.2
1.7
0.19
0.97
0.58
1.5
0.10
0.10

Level II

20

3.8
0.01
0.01
4.8
0.92
0.42
0.64
1.5
2.8
1.4
0.85
1.2
0.07
0.59
0.01
0.07
0.01
0.01

Levels III-IV

310

14

0.2

90

330

87
9.4
37
55
15
4.1
10
11
19
18
13
3.4
0.94
3.8
7.0
16
2.1
0.84

World

0.14
0.65
1.1
0.06
1.8
1.4
0.27
0.83
0.1
0.5
3.6
6.4
2
3.7
0.5
8.8
12
20

0.02

-

1.3

-

Level II

0.1-

Dental examinations

0.9

-

0.14
0.65
1.1
0.06
1.8
1.4
0.27
0.83
0.1
0.6
4
6.4
2
3.9
0.5
5
12
20

0.1

-

1.1

-

0.20
0.65
1.1
0.1
2
1.5
0.3
1
0.15
1
4
6.4
2
4
0.5
5
12
20

Levels III-IV

Medical examinations

Level I

Effective dose per examination (mSv)

0.03

-

1.2

-

0.14
0.65
1.1
0.06
1.8
1.4
0.27
0.83
0.1
0.55
3.7
6.4
2
3.7
0.5
8.6
12
20

World

0.01

9 500

1.2

1 875 000

60 20035 10020 90015 200132 000
27 60013 30044 3009 050
31 100231 000
85 1009 500
66 80019 400762 000
140 000
91 800Level I

0.001

4 300

0.14

425 000

10 050200
214 000
3 600
24 200
5 000
2 400
7 200
1 850
22 60039 50032 500
1 200
11 700900
22 4003 600
6 000

Level II

0.00002

24

0.02

27 000

920
10
10
600
2 200
770
230
1 800
510
1 700
4 080
9 260
170
2 860
10
430
100
170

Levels III-IV

Annual collective dose (man Sv)

0.002

14 0000.40

2 330 000

71 20035 300234 700
19 400
159 000
33 40015 90053 30011 40055 400274 000
127 000
10 90081 30020 300785 000
143 000
98 000World

Since, as discussed in Section I.C, many of these exposures are received by patients nearing the end of their lives and the doses are not distributed evenly amongst the population, these doses should not be used for theassessment of detriment.
Rounded estimates based on self-consistent frequency data from a selected sample of representative countries and typical (or assumed) doses from the UNSCEAR Survey of Medical Radiation Usage and Exposures.

Average effective dose per caput from dental x-ray examinations (mSv)

Average effective dose per dental x-ray examination (mSv)

Total

Average effective dose per caput from medical x-ray examinations (mSv)

Average effective dose per medical x-ray examination (mSv)

281
35
12
166
48
13
32
35
59
41
42
8.7
3.1
12
25
57
7.6
3.0

Level I

Number of examinations per 1,000 population

Chest radiography
Chest photofluoroscopy
Chest fluoroscopy
Limbs and joints
Lumbar spine
Thoracic spine
Cervical spine
Pelvis and hip
HeadAbdomenUpper GI tract
Lower GI tract
Cholecystography
Urography
Mammography
CT
Angiography
Interventiona1 procedures

Examination

Table 30
Frequencies, effective doses and collective dosesa assumed in global model for diagnostic practice with medical and dental x-ray examinationsb (1991-1996)

394
ANNEX D: MEDICAL RADIATION EXPOSURESANNEX D: MEDICAL RADIATION EXPOSURES

395

Table 31
Contributions to frequency and collective dose from the various types of diagnostic medical x-ray
examinations assumed for global model (1991-1996)
Contribution (%)
Examination
Level I

Level II

Levels III-IV

World

Contribution to total annual frequency
Chest radiography
Chest photofluorography
Chest fluoroscopy
Limbs and joints
Lumbar spine
Thoracic spine
Cervical spine
Pelvis and hip
HeadAbdomenUpper GI tract
Lower GI tract
Cholecystography
Urography
Mammography
CT
Angiography
Interventional procedures
Other

31
4
1
18
5
1
4
4
6
4
5
0.9
0.3
1
3
6
0.8
0.3
4

16
0.1
42
13
3
0.8
2
2
4
8
2
1
0.1
0.6
0.4
1.0
0.1
0.1
4

19
< 0.1
< 0.1
24
5
2
3
7
14
7
4
6
0.4
3
< 0.1
0.4
< 0.1
<0.1
4

27
3
11
17
5
1
3
3
6
5
4
1
0.3
1
2
5
0.6
0.3
4

All

100

100

100

100

Contribution to total annual collective dose
Chest radiography
Chest photofluorography
Chest fluoroscopy
Limbs and joints
Lumbar spine
Thoracic spine
Cervical spine
Pelvis and hip
HeadAbdomenUpper GI tract
Lower GI tract
Cholecystography
Urography
Mammography
CT
Angiography
Interventional procedures
Other

3
2
1
0.8
7
1
0.7
2
0.5
2
12
5
0.5
4
1
41
7
5
4

2
< 0.1
50
0.8
6
1
0.6
2
0.4
5
9
8
0.3
3
0.2
5
0.8
1
4

3
< 0.1
< 0.1
2
8
3
0.9
7
2
6
15
34
0.6
11
< 0.1
2
0.4
0.6
4

3
2
10
0.8
7
1
0.7
2
0.5
2
12
5
0.5
3
0.9
34
6
4
4

All

100

100

100

100

396

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 32
Temporal trends in the annual frequency of diagnostic medical x-ray examinations per 1,000 population a
Data from UNSCEAR Surveys of Medical Radiation Usage and Exposures unless otherwise indicated.

Country / area

1970-1979

1980-1984

1985-1990

1991-1996

560

565
202
726

Health-care level I
Australia
Bahrain
BelarusBelgium
Bulgaria
CanadaChina, Taiwan Province
Croatia
Cuba
CyprusCzechoslovakia
Czech Republic
Denmark
EcuadorEstonia
FinlandFranceGermany
Hungary
Italy
Japan
KuwaitLithuania
Luxembourg
Malta
Netherlands
New Zealand
NorwayPanamaPoland [S49]
Portugal
Qatar
Romania
Russian Federation
Slovakia
Slovenia
South Africa
Spain
SwedenSwitzerland
Ukraine [K18]
United Arab Emirates
United Kingdom
United States
Average

490





b




(980)
860

(1100)
1020

1290
(800)
1050

140

620






1110




(26)



1080



900




830





100
570
610








1050







840




740







550
710
640

900









790
(1340)

600(1560)






590
1040













920



510
(53)



870
990
1050




1160
720



810
320
530
640
620



540
700



470
(1260)





570
520



589
892
480
903



937



883
510
151
1000
704



1254
475



1477
896
886
1046



598



708
300
641
850
495
450
1151
800
348
180





460
790

800

568
750
600
378
489
962

820

810

890

920


160
93

271
174
261

150

173 c

(180)

185




420

1040






948




Health-care level II
Antigua and Barbuda
Barbados
BrazilChile
China
Colombia
Costa Rica
Dominica
Dominican Republic
GrenadaIndia
Iran (Islamic Rep. of)
Jordan
Malaysia
MexicoNicaragua
Oman
Peru











(23)











180
170
110
210
270



20




180




70
57










110






13



15






158




45
183
306



269



ANNEX D: MEDICAL RADIATION EXPOSURES

397

Table 32 (continued)
Country / area

1970-1979

1980-1984

1985-1990

1991-1996

Saint Kitts and Nevis
Saint Lucia
Saint Vincent and
the Grenadines
Turkey










(130)



203
134
147





524

98

Average

26

140

120

154

83
69




Health-care level III
BelizeCape Verde
Ghana
Liberia
Madagascar
MoroccoMyanmarPhilippines
Sri Lanka
Sudan
Thailand
Vanuatu
Average














50

75



53
79
100

23

75

67

17












22
80






21








7


11
8

10
110





37






Health-care level IVabcCote d’Ivoire
Kenya
Nigeria
RwandaTanzania

40
36
25
8.0









Average

27



8.8



29

8.8

29

Dental x-ray examinations not included.
No data available.
These revised data were received by the Committee after completion of the global analysis.

The entries in this Table are qualified as follows:
Bulgaria:
Historical data were not included in previous analyses.
Czechoslovakia: Historical data.
Dominica:
Categorized in health-care level III in previous analysis.
Ecuador:Categorized in health-care level II in previous analyses.
Germany:
Data for 19701979 and 19851990 represent combined historical data for German Democratic Republic and Federal Republic of Germany.
India:
Categorized in health-care level III for period 19701979.
Russian Federation : Historical data were not included in previous analyses.
Saint Lucia:
Categorized in health-care level III in previous analysis.

398

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 33
Temporal trends in the average annual number of diagnostic x-ray examinations per 1,000 population
Data from UNSCEAR Surveys of Medical Radiation Usage and Exposures
Average annual number of examinations per 1,000 population a
ExaminationaPeriodHealth-care level I

Health-care level II

Health-care levels III-IV

Chest

197019791980198419851990
19911996

588
588
527(52%)368 (39%)1180
118 (73%)
89 (58%)1845
51 (70%)4.9 (21%)

Limbs and joints

197019791980198419851990
19911996

87
151
137 (14%)212 (21%)3.3
7.8
15 (8.9%)20 (13%)

3.2
7.4
6.2 (8.8%)
6.8 (24%)

Spine

197019791980198419851990
19911996

25
58
61 (6.1%)
100 (11%)1.7
1.7
3.9 (2.4%)
8.9 (5.8%)

1.9
52 (2.8%)3.6 (11%)Pelvis and hip

197019791980198419851990
19911996

22
31
38 (3.7%)
36 (4.0%)

2.7
0.44
3.4 (2.1%)
14 (5.9%)

0.57
1.5
2 (2.8%)1.7 (6.6%)

Head197019791980198419851990
19911996

13
37
46 (4.5%)
60 (6.5%)

2.3
1.5
5.8 (3.5%)30 (13%)1.8
3.4
3.7 (5.2%)
3.3 (14%)

Abdomen197019791980198419851990
19911996

15
22
36 (3.6%)
41 (4.6%)

4.1
14
7.9 (4.8%)
13 (8.2%)

4.7
6.5
3.4 (4.7%)
2.0 (7.1%)

GI tract197019791980198419851990
19911996

73
51
72 (7.1%)
60 (6.4%)

0.92
2.7
5 (3.1%)5.1 (3.3%)

1.6
2.6
1.8 (2.5%)
2.9 (10%)Cholecystography
and urography

197019791980198419851990
19911996

19
28
26 (2.6%)
15 (1.6%)

0.48
0.35
2.7 (1.6%)
5.6 (2.4%)

1.2
2.6
2.2 (3.1%)
0.9 (3.3%)

Mammography

197019791980198419851990
19911996

5.2
4.6
14 (1.4%)
25 (2.9%)

0.07
0.09
0.57 (0.3%)
2.7 (1.2%)(0.1%)
0.01 (0.1%)

CT197019791980198419851990
19911996

6.1
11
44 (4.4%)
48 (6.4%)

000.42 (0.3%)
6.7 (2.9%)

0.14
1.3
0.42 (0.6%)
0.14 (0.8%)

Angiography

197019791980198419851990
19911996

1.6
5.7
7.1 (0.7%)
6.8 (0.8%)

000.27 (0.2%)
0.48 (0.2%)

0.3
0.3
0.11 (0.2%)
0Interventional procedures

19911996

2.7 (0.4%)

0.94 (0.4%)

0Pelvimetry

19911996

0.6 (0.1%)

1.7 (0.8%)

0.3 (1.0%)

Total197019791980198419851990
19911996

814
804
887 (100%)920 (100%)26
141
124 (100%)
154 (100%)

29
75
64 (100%)
20 (100%)

Overall averages calculated from national data as the total number of examinations divided by the total population for each examination category. The
figures in parentheses indicate an average percentage contribution of each examination category to total frequency, calculated on a similar basis. Data
for 19911996 from Tables 12 and 13; since the total population is not the same for each examination category due to the lack of comprehensive
national data for all countries listed in the tables, these average numbers can not be expected to be additive.

ANNEX D: MEDICAL RADIATION EXPOSURES

399

Table 34
Temporal trends in annual frequency of diagnostic dental x-ray examinations per 1,000 population
Data from UNSCEAR Surveys of Medical Radiation Usage and Exposures
Country

1970-1979

1980-1984

1985-1990

1991-1996





49
81

Health-care level I
Australia
Bahrain
BelarusBelgium
Croatia
CyprusCzechoslovakia a
Czech Republic
Denmark
Ecuador b
FinlandFranceGermany c
Hungary
Italy
Japan
KuwaitLithuania
Luxembourg
Malta
Netherlands
New Zealand
NorwayPoland [S49]
Portugal
Romania
Russian Federation d
Slovakia
Slovenia
Spain
SwedenSwitzerland
United Arab Emirates
United Kingdom
United States
Average














72

86

80




(1.5)







831





3
(75) e
321
641




20









(4.4)



540




119
834





6.2
(200) e



805




32
(74)





288







231
12

85



471
(6.2)
223

193
471
14
290






264

276
41

783
219

839
100
108
469





186
8.2
(205) e
275
833
32
86
42
(82)




232
832





182 e




74
100
28
96
94
55



433
296

841
325

112
350

165
456

402



320

390

350

310



4.7

111

3.9
0.8

2.1

1.7
3.1
1.2
2.3









739
571
15
212

Healthcare level II
BrazilChile
China
JordanMexicoOman
Tunisia
Turkey










Average









0.8






1.3







31

2.5

14




0.3

Healthcare level III








Egypt
Ghana
Myanmar
Sri Lanka
Thailand

0.7

0.8
1.4

2.3

2.1





Average



0.8

1.7

0.3




1.6



400

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 34 (continued)
Healthcare level IV

a
b
c
d
e

United Rep. of Tanzania







0.1

Average







0.1

Historical data.
Categorized in health-care level II in previous analyses.
Data for 19851990 represent historical data for Federal Republic of Germany.
Historical data were not included in previous analyses.
These revised data were received by the Committee after completion of the global analysis.

Table 35
Trends in average effective doses from diagnostic medical x-ray examinations
Data from UNSCEAR Surveys of Medical Radiation Usage and Exposures
Average a effective dose per examination (mSv)
Health-care level I

Examination

Chest radiography
Chest photofluoroscopy
Chest fluoroscopy
Limbs and joints
Lumbar spine
Pelvis and hip
HeadAbdomenUpper GI tract
Lower GI tract
Cholecystography
Urography
Mammography
CT
Angiography
PTCAaHealth-care level II

1970197919801990

19911996

19801990

19911996

0.25
0.52
0.72
0.02
2.2
2.1
0.50
1.9
8.9
9.8
1.9
3.0
1.8
1.3
9.2

0.14
0.52
0.98
0.06
1.7
1.2
0.16
1.1
7.2
4.1
1.5
3.1
1.0
4.3
6.8

0.14
0.65
1.1
0.06
1.8
0.83
0.07
0.53
3.6
6.4
2.3
3.7
0.51
8.8
12
22

0.04

0.05





Frequency-weighted average of national values from survey data. Values for 19911996 from Table 15.



0.29
0.04
2.6
2.0
0.13
0.22
1.6
5.0
1.6
1.7









0.04
1.0
0.74
0.04
0.62
6.0
6.0
1.5
3.9
0.1
4.9
6.8



ANNEX D: MEDICAL RADIATION EXPOSURES

401

Table 36
Estimated doses to the world population from diagnostic medical and dental x-ray examinations a19911996

Health-care levela

Population(millions)

Annual per caput effective dose (mSv)

Annual collective effective dose (man Sv)

MedicalDentalMedicalDental

I
II
III
IV

1 530
3 070
640
565

1.2
0.14
0.02
0.02

0.01
0.001
< 0.0001< 0.0001

1 875 000
425 000
14 000
13 000

9 500
4 300
13
11

World

5 800

0.4

0.002

2 330 000

14 000Since, as discussed in Section I.C, many of these exposures are received by patients nearing the end of their lives and the doses are not distributed
evenly amongst the population, these doses should not be used for the assessment of detriment.

Table 37
Chronology of key technical advances in diagnostic nuclear medicine
Date
1896
1920s
1930s
1940s
1950s
1960s
1970s
1980s
1990s

Development
Discovery of natural radioactivity (Becquerel)
Biological tracer studies with radionuclides in plants and animals (Hevesey)First cyclotron; production of artificial radioactivity (Fermi)
Controlled uranium fission; early clinical nuclear medicine with radioiodine; first artificial radioactive element named (99mTc)
Invention of rectilinear scanner (Cassen); invention of gamma camera (Anger)
Invention of 99mTc generator; early development of single-photon computed tomography (SPECT)
Increased use of computers; early development of positron emission tomography (PET)
Growth in SPECT
Growth in PET; more specific radiopharmaceuticals

5.85

Average

0.016
0.40
0.25

1.34
0.68

0.86



0.007
0
0





0.60
0.20
0.97

0
0.67
0.39
0
0

0.33
0.83
0.44
2.55
0.013

0
0
0.34

2.33

3.57

0.24
1.35
1.08
0.54
1.11
4.05

0
1.14
0.57
0.22

0

0.17
0

0
0

0.40
0.22

0.45
0.60
0.61
0.020

0.35

0.41
0
0

0
0
0
0

0.042
0.60
0
0.020

0.087
0.15
0.063

0

0

0
0

0
0

0.15
0.063
















1.29
0.057
0.90

0.0063
0
0.40
0.54
0.015
0.22

0
0
0
0.18
0
0.002

0
0
0
0.34
0
0

0.0063
0
0.40
0.024
0.015
0.22





0.066
0.12
2.67
0.90
0.029
1.18
2.58
[1.05]
0.66
0.44
0.27
0.27
0.025
1.10
0.75
0.19
0.17
0.032
1.54
0.70
1.48
1.30
0.17
5.08





0.27
1.82
2.43
1.29
0.057
1.25
2.82
1.00
0.33
1.50
0.84
2.55
0.013
3.12
0.61
0.20
0.97



0.23
1.42







0.033
0.40










0.53
1.83
5.14
2.91
0.25
3.86
8.96
[3.93]
2.74
3.68
2.74
0.90
0.33
6.12
4.10
0.18
1.18
0.37
2.69
2.00
3.84
4.09
1.93
7.72

0







0













0
0.43









0
0.55

0

0

0.95

4.04

0.19
0.21

2.33
1.01

0.041
0
0
0.69

0.62
1.73
0.58
0.14

0
0.11
0.58
0
1.65

0.047
2.40
0.36
3.95
0

0
0.21
0.051
0

0.071
0.065

0.47
1.33
2.05
0
0.11
17.2

0.54
1.39
2.60
2.05
0.21
0.17
17.2
4.08
0.047
2.51
0.94
3.95
1.65
0.84
0.66
1.73
0.58
0.82
2.50
2.52
1.22
1.44
0.95

0
0

0
0.31

0.014
0.94
0

0

0

0.014











0.047
0.17
0
0.14







0.065
30.4
0
0.98

1.74
0.012
1.23
2.79
0
0.31

1.09
0

0.65
0.012

0.26

0

0

0.26

0.32

3.01

1.88

1.12

Health-care level I

131

Total

Tc

Thyroid scanI / 123I

99m

Total

Xe

133



3.38
0.23
0.068
22.0
0
1.55

Kr

81m



Argentina
Belarus
Bulgaria
CanadaCayman Islands
China, Taiwan
Province [L6]
Croatia
CyprusCzech Republic
Denmark
EcuadorFinlandGermany
Hungary
Ireland
Italy
Japan
KuwaitLithuania
Netherlands
New Zealand [L28]
PanamaQatar
Romania
Slovakia
Slovenia
SwedenSwitzerland
United Arab Emirates
United States [I23]

Tc

99m

Total

Total

Tl

201

Tc

99m



Total





Country /area

Lung ventilation







Lung perfusion(99mTc)

Cardiovascular



















Bone
(99mTc)PART A





































Table 38
Annual numbers of diagnostic nuclear medicine procedures per 1,000 population by broad category and radionuclide (1991-1996)
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicated402
ANNEX D: MEDICAL RADIATION EXPOSURESArgentina
Australia [C7]Belarus
Bulgaria

0.004100
1.48

0.0041
1.48

0.17
0.22

0.03

0.79

1.24

0

1.19

0
0

0.17
0.22

0.00200.057

0.00200.052

000.0020
0.052

0.22

0

0.22

0.13

0.82

Total

Tc

Other

99m

Total

Total

Health-care level II / 123I

Tc

Total



131

99m







I/125I



123

Brain



I

Liver / spleen(99mTc)



Renal



Thyroid uptake

11
12
0.48
3.26

Total of all
nuclearmedicine
examinations

0.00330PART B

0.004800.0048
0

0
0

0
0

0
0

0
0

0
0

Health-care level IV131

0.000100.0014

Average

0.16

0



Country / area

0.00010.00007

0
0

0
0

0
0

0.00010.0043

Ethiopia
Tanzania

0.0095

0.023

0.054

0

0.024
0.37
0.046

0
0
0



0
0



0
0



0
0

0.024
0.37
0.046

0
0

0
0
0.008900.00490.015
0.000900.0034
0
0.023



0

0.26

0

0.53

0
0

0
0.023

0
0.026

0.22
0.073

0

0

0.73
0.13
0.043
0.22
0.099
0.56
0.53

0
0

0
0

0.00490.015

Health-care level III

Average

0.019
0

0.045
0

0.20

Average

0.0022
0.13
0.011

0.017

0.15

0.34
0.16
[0.17]
0.071
0.41[0.033]0.49

Ghana [A16]
Morocco
Sudan

0.008
0.023
[0.020]0.00300.0085[0.056]
0.038

0.011
0.32
0
0.00690.0068
0.020
0.30

0.004
0
0
0
0

0.00660.32
00.00690.0068JordanMexicoOman
PakistanPeru
Tunisia
TurkeyTotal

131

I / 123I

99m

Tc

133

Total

Kr

81m

Xe

Tc

99m

Health-care level II

Total

Total














Tl





201





Tc

Thyroid scan





Total

Lung ventilation












99m

Lung perfusion(99mTc)Cardiovascular










Bone
(99mTc)Country /area



























Table 38 (continued)

ANNEX D: MEDICAL RADIATION EXPOSURES
403

18.8

1.62

6.83
2.60

1.01
1.11

0.95

0.80

0

0



0.28
0.52






Average

3.46

0

0.044

0.097

1.38

0

1.38

0.0051
0.38
0.52




0

1.45
0.43






0.044
0.47
0.093
0.17

0
0.11

0.044

0.039 (11C)






0.044
0.44
0.055

0.62
0.17
0.077
0.049

0.88
1.45
0.43
0.39

0
0







0

0
0

0
0.11

0.25
0.25
0.13

0






0

0.065
0.73

1.39
0.28

0
0.21

1.39
0.072

0.62

0

0.62

0
0

0.25
0.13

0.094
0.086
0.17

1.19
0.85
0.25

0
0
0

1.19
0.79
0.25

0.48
0.022
0.38

0
0

0.022
0.38

0
0


































2.07
1.66

0
0

2.07
1.66

0.28
0.49
0.34
0.010
0.35
1.24
0.045
0.0013
0.010
0.35
0.53
0.045

0
0

0
0.29

0

0.26

1.50
1.07
0.40
0.97
1.11

0.68
0.10
0.26

0.044 (123I)
0

0.24
0.49

0.013
0.037
[0.39]
0.023
0.36
0.61
0.075
0.13

1.66
1.60
2.54
1.50
1.35
0.69
0.97
1.11

0.12

1.54

0.090

0.035

0.055

2.38
6.65
28.3
15.2
0.79
8.00
9.95
34.1
15.3
6.15
11.0
11.7
12.7
10.6
52.2
16.0
8.35
3.45
4.00
4.73
3.02
12.6
9.37
11.2
13.6
9.51
5.00
7.25
8.21
31.5
0.13
0
2.17
0.34
0.00170000.17 (133Xe)
0

0.13
0
2.17
0.17
0.0017

0.057
0.020
1.15
0.018
0.021

0.64
1.07
8.15
3.44
0.029

0
0
0
0
0

0.64
1.07
8.15
3.44
0.029

0.037
0.0015
1.00
0.31
0.17

0
0
0
0
0

0.037
0.015
1.00
0.31
0.17

64.6
0
6.63

1.54
0
0.65

0
0
0

1.54
0
0.65

0.59
0
1.33

Total

Total of all
nuclearmedicine
examinations

1.63
0
0.29

0
0
0

1.63
0
0.29

2.95
0
0.35

0




0

Other



CanadaCayman Islands
China, Taiwan Province[L6]
Croatia
CyprusCzech Republic
Denmark
EcuadorEstonia [S29]FinlandGermany
Hungary
Ireland
Italy
Japan
KuwaitLithuania
Luxembourg
Netherlands
New Zealand [L28]
PanamaPortugal [F11]
Qatar
Romania
Russian Federation
Slovakia
Slovenia
SwedenSwitzerland
Ukraine [K18]
United Arab Emirates
United Kingdom [E11]United States [I23]



Tc



99m

Total




Total

I / 123I

Tc

131

99m

Total

I/125I

Brain



123

I

Liver / spleen(99mTc)







131

Renal







Thyroid uptakeCountry / area



































































































Table 38 (continued)

404
ANNEX D: MEDICAL RADIATION EXPOSURES

0
1.11
0
0
1.89

0
0

0.18
0.16

0
0

0.18
0.022

0
0.020

0
0



0.048
0



AverageGhana [A16]
Morocco
Sudan

Average

0.000300.00020.00030.00610.0021000.00030.0061

00.00480.012
0.007200

Average

0.00450.019

Health-care level IV

0.00090.00670.00460.0007
0.038
0.014

0.054
0.62
0.085
0.28

0.014
0.024
0.017

0.027
0
0.00920.010

0.00380.00080.0028

0
0
0

0
0

0.027
0
0.00920.00380.0008



0
0
0





0.0007
0.038
0.014





Ethiopia
United Rep. of Tanzania






0
0

0.025





0

0.056

0
0





Health-care level III

0.32

0.18
0.022
0.051
0.020
0.020







1.13

0.064
0.015










0.042

0.078

0.14

0










0.79
2.07








0
0.037

0
0.14

0.056
0.32

0
0






0
0

0
0

0.18
0.16
0.22
0.064
0.015





0
0.037

1.56
1.06
0.64
0.55
0.58
0
0.075
0
0.032
0.0034

0
0
0
0

0.075
0
0.032
0.00340.040
0.093[0.0035]
0.056
0.017






Antigua and Barbuda[B43]
BrazilDominica [B43]
Grenada [B43]
Iran (Islamic Rep of[M10]
JordanMexicoOman
Pakistan
Peru
Saint Kitts and Nevis[B43]
Saint Lucia [B43]
Saint Vincent and
the Grenadines [B43]
Tunisia
TurkeyHealth-care level II

Total

Other

Tc

99m




















Total



Total

I






I / 123I

Total

I/125I








131










Tc








99m








Total of all
nuclearmedicine
examinations








Brain










Liver / spleen(99mTc)










123

Renal










131

Thyroid uptake








Country / area

Table 38 (continued)

ANNEX D: MEDICAL RADIATION EXPOSURES
405

Argentina: On the basis of data from a sample of 25% of nuclear medicine centres. Total shown for lung perfusion includes use of 67Ga (frequency of 0.0017). Total shown for thyroid uptake includes use of 99mTc(frequency of 0.056). Total shown for bone scan includes use of 67Ga (frequency of 0.034).
Brazil:Survey data for Paraná State (with a population of 9 million and a social and economic profile above the average for Brazil).
Canada:On the basis of data from Ontario (representing about 37% of population).
Cyprus:Survey data relating to 90% of population.
Finland:
Total shown for lung perfusion scans includes use of 133Xe (frequency of 0.002).
Ghana:
Data for thyroid scan represent total of all thyroid studies.
Japan:
Total frequency for bone scans is 2.77; total frequency for lung perfusion scans is 0.45.
Lithuania: Data from Vilnius Oncology Centre.
New Zealand: Total shown for renal scans includes use of 51Cr (frequency of 0.064).
Peru:
Survey data from IPEN (Centre of Nuclear Medicine, serving population of about 5 million).
Romania: Survey data relating to population base of about 4.5 million. Total for liver/spleen is 0.79 (includes use of 198Au with frequency of 0.065).
Slovakia:
Survey data relating to population base of about 2 million. Total for thyroid uptake includes use of 99mTc (frequency of 0.096).
Slovenia:
Survey data relating to population base of about 1.8 million. Total frequency for lung perfusion is 0.82; total for thyroid uptake includes use of 99mTc (with frequency of 0.096).
Switzerland: Total for lung ventilation refers to use of 133Xe and 127Xe. Data for thyroid scans include uptake studies.
Turkey:On the basis of data from Hacettepe University Hospital.
United Arab Emirates: Thyroid uptake done simultaneously with thyroid scan using a single dose of 99mTc.
United Republic of Tanzania: Total shown for thyroid uptake refers to use of 99mTc.
Hungary, Oman, Tunisia: No information available on radionuclides used.

The entries in this Table are qualified as follows:

Table 38 (continued)

406
ANNEX D: MEDICAL RADIATION EXPOSURES

26

22
15
26
13

Average a

JordanMexicoOman
Pakistan

13



0.7
30
0
1.3

15

2.6
12
7.9
5.6
15
13

0.5
2.2
3.1
0.6

10

0.4
1.5
0.3
0
1.4
3.6
1.9
2.2
0.6
2.5
0.6

0
7.3
6.9
6.5

0.3
1.4
0.1
0

2.0

4.0
4.4
6.4
0.3





1.4
0.3
2.1
2.8
1.8
9.5
5.9
3.7
12
7.6
6.8
11
4.0
3.9
2.1
0.2
7.0
9.0
5.5
3.5
1.0
16
7.3
11
14
2.3
16




2.0
47
15
11
27
8.6
8.5
7.2
13
8.3
6.5
5.3
14
7.0
20
0.1
20
7.3
5.7
20

47
13
6.8
41

Health-care level II

23

20
0.05
3.4
3.8

16
16
3.1
0.3
11

4.4
1.7
2.3

11
0.8
45
4.6
5.3
1.5
0.02
3.5
2.0
21
0.9

16
2.4
38
4.3
4.7
23
21
9.2
13
27
1.7
50
27
0.8
23
8.1
31
16
5.3
7.9
50
12
27
27
23
9.0
15
13

2.3

2.9

27



30
48
2.1
34
23
22
27
18
19
32
39
26
26
45
33
24
7.1
3.2
39
49
5.2
25
12
29
18
28
43
27
24



Argentina
Belarus
Bulgaria
CanadaChina, Taiwan Prov.
Croatia
CyprusCzech Republic
Denmark
EcuadorFinlandGermany
Hungary
Ireland
Italy
Japan
KuwaitLithuania
Netherlands
New Zealand
PanamaQatar
Romania
Slovakia
Slovenia
SwedenSwitzerland
United Arab Emirates
United States

Health-care level I

Thyroid uptake

Lung perfusion

Cardiovascular

11
2.1
7.9
3.6

5.3









Thyroid scan

Lung ventilation





Bone





Country / area

11
15
34
12

5.0

7.4
35
6.8
2.5
4.4
27
16
29
23
3.6
17
4.7
17
24
12
6.0
7.7
10
7.6
10
7.1
29
9.4
9.4
13
3.1
4.2
19
3.2

Renal

2.6
8.8
0.6
10

12

1.2
0.4
1.7
0.9
20
2.4
0.3
4.1
0.1
2.7
0.1
0.1
2.5
0.4
3.2
5.3
0.6
1.3
0.6
1.0
5.0
1.4
26
6.6
1.5
0.6
0.5
1.3
22

Liver/spleen

100

100
100
100
100

7.3

7.1
0
5.9

100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100

Total of allprocedures

1.9
0.4
1.6
2.4
9.8
5.3
0
7.7
2.2
0.2
2.8
1.4
2.2
0.2
3.2
11
0.4
0.01
1.6
3.0
3.8
0
3.5
0.5
4.3
0.7
1.8
0.6
11

Brain







Table 39
Percentage contributions by types of procedure to annual total numbers of diagnostic nuclear medicine procedures (1991-1996)
Based on data and qualifications from Table 38

ANNEX D: MEDICAL RADIATION EXPOSURES
407

a

20

4.1
21
13

19

0.7
18

8.4

Average a

Ghana
Morocco
Sudan

Average a

Ethiopia
United Republicof Tanzania

Average a

0

0
0

6.4

0.4

0.5
0.3

2.7

3.0
0

0

0
0

0

0
0

26

0.9

1.7

15

7.3
0

17
71
26

0.6
0
1.1

1.5
7.1
1.8

19

34
0

Health-care level IV

59

44
61
54

Health-care level III
1.7
1.1
5.4

1.3
6.1
16

42

34
52

0

0
0

13

1.9
26

7.0

7.7

14

3.3

1.0

1.8
0

1.6

2.9
0
6.7

2.6
7.1
15

3.5
7.1

Health-care level II (continued)

1.2
2.5
14

Liver/spleen

Renal

Thyroid uptake

Overall averages for sample calculated as total number of each particular type of examination divided by total number of all examinations.

70
4.2
24

Peru
Tunisia
TurkeyThyroid scan

Cardiovascular

Lung ventilation

Lung perfusion



Bone



Country / area

Table 39 (continued)

16

27
3.6

3.7

49
0
11

4.2

0.6
0
1.8

Brain

100

100
100

100

100
100
100

100

100
100
100

Total of allprocedures

408
ANNEX D: MEDICAL RADIATION EXPOSURESANNEX D: MEDICAL RADIATION EXPOSURES

409

Table 40
Distribution by age and sex of patients undergoing diagnostic nuclear medicine procedures (1991-1996)
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicatedHealthcarelevel

Age distribution (%)
Country015 years

1640 years

Sex distribution (%)>40 years

Male

FemaleBone scan
I

II

III

IV

Argentina
Bulgaria
CanadaCroatia
Czech Republic
EcuadorFinland
Ireland
Italy
Japan
KuwaitNew Zealand [L28]
PanamaRomania
Slovakia
Slovenia
SwedenUnited Arab Emirates

6
0
6
4
7
9
3
<1
1

22
22
15
33
7
34

72
78
79
63
86
57

41
41
50
47
41
44

59
59
50
53
59
56





8

91

8
6
12
17
3
3
3
12

42
23
18
12
37
13

50
71
70
71
60
84

34
56
58

66
44
42

52
36

48
64

45

55

44

44

53

47

Average

5

15

80

48

52

JordanMexicoPakistan
Peru
Turkey

3
7
19
10
6

32
18
38
30
28

65
75
43
60
66

20
45
49
30
52

80
55
51
70
48

Average

9

27

64

46

54

Morocco
Sudan

0
0

100
80

0
20

30
25

70
75

Average

0

98

2

30

70

Ethiopia
United Rep. of Tanzania

17
4

66
24

17
72

67
36

33
64

Average

5

26

69

37

63
























Cardiovascular scan
I

II

Argentina
Bulgaria
CanadaCroatia
Czech Republic
EcuadorFinland
Italy
Japan
KuwaitNew Zealand [L28]
PanamaSlovakia
Slovenia
United Arab Emirates

0
0
0
5
13
0
3
0

12
22
6
38
22
19

88
78
94
57
65
81

68
62
58
64
54
66

32
38
42
36
46
34

11

89

0
1
14
0
0
0

20
7
30
30
8
42

80
92
56
70
92
58

76
63
73
0
30

24
37
27
0
70

38

62

Average

0

7

93

60

40

JordanMecixoPakistan
Peru
Turkey

0
0
0
0
0

14
14
14
40
11

86
86
86
60
89

50
58
80
45
60

50
42
30
55
40



















410

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 40 (continued)
Healthcare
level

III

Age distribution (%)
Country

Sex distribution (%)

015 years

1640 years>40 years

Male

FemaleAverage

0

13

87

59

41

Morocco

0

100

0





Lung perfusion study
Argentina
Bulgaria
CanadaCroatia
Czech Republic
EcuadorFinland
Ireland
Italy
Japan
KuwaitNew Zealand [L28]
PanamaRomania
Slovakia
Slovenia
SwedenUnited Arab Emirates

6
25
2
2
2
1
0.1
<1
0

10
50
17
38
9
38

84
25
81
60
89
61

47
50
51
51
45
46

53
50
49
49
55
54





6

94

7
1
15
1
0
1
0.3
15

41
17
28
28
36
10

52
82
57
71
64
89

54
49
66

46
51
34

38
77







62
23

45

40

60

40

Average

2

13

85

49

51

JordanMexicoPakistan
Peru
Turkey

9
5
18
0
3

36
19
31
40
40

55
76
51
60
57

29
51
57
30
45

71
49
43
70
55

Average

5

31

64

48

52

III

Morocco

90









IV

Ethiopia
United Rep. of Tanzania

0
0

75
50

25
50

50
0

50
100

Average

0

67

33

33

67

I

II





















Lung ventilation study
I

II

Argentina
Bulgaria
CanadaCroatia
Czech Republic
EcuadorFinlandItaly
PanamaSlovenia
SwedenUnited Arab Emirates

4
17
1
0
1
0
1
0
14
1
0.1
23

10
66
18
33
7
40

86
17
81
67
92
60

47
58
51
48
45
40

53
42
49
52
55
60

6
29
14

94
57
85

54
30

46
70

23

54

64

36

Average

2

15

83

50

50

JordanMexicoPeru
Turkey

0
2
0
0

65
10
40
33

35
88
60
67

90
36
30
67

10
64
70
33

Average

1

23

76

52

48

44
48
61
46
77

18
10
20
21
17

82
90
80
79
83















Thyroid scan
I

Argentina
Bulgaria
CanadaCroatia
Czech Republic

3
4
2
3
1

53
48
37
51
22

ANNEX D: MEDICAL RADIATION EXPOSURES

411

Table 40 (continued)
Healthcare
level
I

II

III

IV

Age distribution (%)
Country

Sex distribution (%)

015 years

1640 years>40 years

Male

FemaleEcuadorFinland
IrelandItaly
Japan
New Zealand [L28]
PanamaRomania
Slovakia
Slovenia
United Arab Emirates

5
1
<1
1

46

49

17

83

37

62

16
19

84
81

2
18
1
2
1
3

29
39
48
45
16
50

69
43
51
53
83
47

17
19

83
81

30

70

Average

2

40

58

18

82

JordanMexicoPakistan
Peru
Turkey

13
7
15
15
1

63
51
64
32
64

24
42
21
53
35

7
23
31
37
13

93
77
69
63
87

Average

8

61

31

22

78

Morocco
Sudan

10
10

85
60

5
30

35
10

65
90

Average

10

82

8

32

68

Ethiopia

6

72

22

18

82























Thyroid uptake
I

II

IV

Argentina
Bulgaria
CanadaCroatia
Czech Republic
EcuadorFinland
IrelandItaly
Japan
PanamaRomania
Slovakia
United Arab Emirates

4
4
3
0
0
5
0
<1
1
0
4
1
0
3

50
50
39
37
15
46

46
46
58
63
85
49

13
19
21
19
15
16

87
81
79
81
85
84

37

62

16

84

45
44
23
50

51
55
77
47

22
23

78
77

30

70

Average

3

41

56

18

82

JordanMexicoPakistan
Peru

2
4
9
0

52
5
53
40

46
91
38
60

19
19
41
10

81
81
59
90

Average

6

36

58

28

72

Ethiopia
United Rep. of Tanzania

6
3

72
31

22
66

18
16

82
84

Average

4

50

46

17

83

41
56
15
34
24
47

52
41
56
36
43
31

47
48
52
50
47
55

53
52
48
50
53
45

21

65

54

46



















Renal scan
I

Argentina
Bulgaria
CanadaCroatia
Czech Republic
EcuadorFinland
Ireland
Italy

7
3
29
30
33
22
25
22
14













412

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 40 (continued)
Healthcare
level
I

II

III

IV

Age distribution (%)
Country

Sex distribution (%)

015 years

1640 years>40 years

Male

FemaleKuwaitNew Zealand [L28]
PanamaRomania
Slovakia
SwedenUnited Arab Emirates

48
33
17
1
20
16
10

28
24
27
35
38

24
43
56
64
42

57

43

45
40






55
60

43

47

67

33

Average

22

25

53

51

49

JordanMexicoPakistan
Peru
Turkey

50
12
21
61
36

21
41
37
23
46

29
47
42
16
18

53
39
62
50
74

47
61
38
50
26

Average

26

42

32

60

40

Morocco
Sudan

90
20









70

10

50

50

Ethiopia
United Rep. of Tanzania

6
7

69
45

25
48

63
38

37
62

Average

7

47

46

40

60









Liver/spleen study
I

II

III

IV

Argentina
Bulgaria
CanadaCroatia
Czech Republic
EcuadorFinland
Italy
Japan
KuwaitPanamaRomania
Slovakia
United Arab Emirates

6
9
16
0
14
7
1
1

22
62
16
37
25
42

72
29
68
63
61
51

31
36
55
50
48
47

69
64
45
50
52
53

37

62

29
4
1
5
5

12
11
22
30
20

59
85
77
65
75

48
62
65
54
57

52
38
35
46
43

45

55

Average

7

26

67

56

44

JordanMexicoPakistan
Peru
Turkey

8
10
12
20
1

35
33
41
30
83

57
57
47
50
16

53
43
50
30
14

47
57
50
70
86

Average

8

52

40

35

65

Morocco
Sudan

100
0

0
5

0
95





25

75

Average

60

2

38

25

75

Ethiopia

0

67

33

73

27

















Brain scan
I

Argentina
Bulgaria
CanadaCroatia
Czech Republic
EcuadorFinlandItaly
Japan
PanamaRomania

4
54
36
0
7
0
9
0

10
34
36
49
21
100

86
12
28
51
72
0

33
48
68
41
45
50

67
52
32
59
55
50

10

90

33
3

24
20

43
77

53
56
40
69

47
44
60
31













ANNEX D: MEDICAL RADIATION EXPOSURES

413

Table 40 (continued)
Healthcarelevel

Age distribution (%)
Country

Sex distribution (%)

015 years

1640 years>40 years

Male

FemaleSlovakia
SwedenUnited Arab Emirates

8
20
0

46

46









42

58

42

58

Average

18

25

57

56

43

MexicoPakistan
Peru
Turkey

11
25
0
8

38
40
0
45

51
35
100
47

51
55
30
63

49
45
70
37

Average

15

40

45

54

46

III

Sudan

0

10

90

30

70

IV

Ethiopia
United Rep. of Tanzania

9
4

67
50

24
46

60
33

40
67

Average

9

65

26

57

43

I

II



Other procedures
I

Bulgaria (Testicles)
Croatia (Infection)
Croatia (GI bleeding)Croatia (Haemangioma)
Coatia (Adrenal)
Croatia (Biliary tract)

27
0
2
0
0
21

50
41
42
37
41
28

23
59
56
63
59
51

100
42
58
35
42
58

0
58
42
65
58
42

II

Peru (Cysternography)
Peru (Gall bladder)
Peru (VPT)

50
50
0

30
30
20

20
20
80

30
30
30

70
70
70

III

Morocco (sur. renal)

60

40

0





IV

Ethiopia (Meckel’s divert.)

0

100

0

50

50

28
49
15
39

68
46
72
54

42
21
44
33

58
79
56
67

9
14
21
28
39

88
83
72
57
58

49
44

51
56

37

63

44

49

46

54

All diagnostic procedures
Argentina
Bulgaria
Czech Republic
EcuadorFinlandJapan
Netherlands
New Zealand [L28]
PanamaSlovakia
UkraineUnited Arab Emirates

4
5
13
7
7
3
3
7
15
3
3
7

Average

5

12

83

47

53

II

Mexico

8

28

64

45

55

IV

Ethiopia

7

70

23

31

69

I



















The entries in this Table are qualified as follows:
Argentina:
Canada:Czech Republic:
Jordan:New Zealand:
Peru:
Romania:
Slovakia:
Turkey:On the basis of data from a sample of 25% of nuclear medicine centres.
Data from London Health Sciences Centre, SW Ontario (representing 50% of the services provided to population of about 1 million).
Survey data relating to Prague (about 10% of national population).
Survey data from one hospital.
Data shown for ‘Lung Perfusion’ refer to both perfusion and ventiliation studies.
Survey data from IPEN (Centre of Nuclear Medicine, serving population of about 5 million).
Survey data relating to population base of about 4.5 million.
Survey data relating to population base of about 2 million.
Survey data from Gülhane Military Hospital, Hacettepe University Hospital and Samsun Ondokuz Mayis University Hospital.



660 (480 840)
740 (260 740)
500 (370 740)740
450 (60 600)
670 (150-1 000)720 (74 820)
600

719









Average

674 (50 920)
555 (292 618)

500 a (400 800)925 (740-1 110)600 (400 600)

620 b (555 740)
740 a



























600
500 (40 660)
630 (555 740)

620 a

300 (150 450)925 (±10%)545 (370 750)555 (100 740)
630
730 (350-1 210)
637 (180 820)
740 (±5%)620

781 (± 192)
720 a (680-760)
666
600 (±10%)

Tl chloride

740 a
925 c (555 925)

585 c (250 944)

622

800 c

400 (37 555)
740
800 (400-1 400)570 (110 740)
740 (700-1 000)300 (400 SPECT)

740 a

740 a

75

600 (185 740)

700 c
800 c (600-1 100)

100

890 a

1000

540 c
370 a (185 740)
600 1 100

1 100 (±5%)

420

74

555 b
70
80 (70 111)75
90 (80 100)

(550 740)

89 (±11)710 c (73 1 110)650 (600 700)
688 (341-1 080)
555 (292 818)

Tc DTPA99m

877 (±192)680
615 (450 860)
1 100 (±5%)

























Argentina
Belarus
Bulgaria
CanadaChina, Taiwan Pr. [L6]
Croatia
CyprusCzech Republic
Denmark
EcuadorFinlandFrance [E10]
Germany
Ireland
Italy
Japan [J11]
KuwaitLithuania
Netherlands
New Zealand [L28]
PanamaPortugal [E10]Romania
Slovakia
Slovenia
Spain [E10]
SwedenSwitzerland
United Arab Emirates
United Kingdom [A20]210

Health-care level I





a

Tc other

99m



































a

Tc MIBI

99m

744 (710 750)555 (424 686)

500 (800 SPECT)
482

100

460 (330 590)

80 (60 120)
80 (70 110)
93 (80 95)
80

100
74

125 (100 150)
80 (37 111)

630 (555 740)
740

90 (74 111)
131










Tc other



























99m

740 (460 860)
667 (125 945)

740 (±5%)

Tc HMPAO

99m

750
700
575 (550 600)
720 (555 925)787
555 (185 555)

99m
Tc
pertechnetate740
940 (600 1 000)610 (370 740)
740 (700 760)

600

721

355 (210 500)
740 (200 740)

740

650 a (740 555)

655 d; 124 f

1629 e (60-3 000)555 d (185 740)
650 (600 700)

866 d (±137)740 d (700 780)

Other

420

500
705 (450 907)

















































99m
Tc
phosphates

500 d (500 740)

200 f

419

500

550 g (400 570)930 e
620 (460 930)

500 h



Brain









Cardiovascular

























Bone













































Country / area
















Average activity administered (MBq) (range or standard deviation in parentheses)



























PART A

Table 41
Average activities administered in diagnostic examinations with radiopharmaceuticals (1991 1996)
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicated414
ANNEX D: MEDICAL RADIATION EXPOSURESArgentina
Belarus
Bulgaria
CanadaChina, Taiwan Pr. [L6]
Croatia

Country / area

74
185 (±10%)120148 (111 222)

Other

181 d (±78); 200 i(±33)

Lung perfusion

Tc MAA

99m



Average598

555
600 (±5%)









Ethiopia
United Rep. of Tanzania

546

925

Tc DTPA

99m

Lung ventilation

37 (17 74)

Health-care level I
988 d (±281)

Other

Average activity administered (MBq) (range in parentheses)

PART B99m

185
111 (±10%)150148 (74 222)

Tc colloid

679

140

333

Tc IDA

Liver/spleen
99m

229 d (±107)
120 d (111 129)

Other

666

666 (370 740)
800 (±5%)93

Health-care level IV

Tc aerosol

666 (370 740)

601

601 (368 834)

740

Health-care level III

99m

5 610 d409

262 (80 444)

Other

99m
Tc
pertechnetate

Tc HMPAO

99m

75

262 (80 444)
740 (700 800)

Tc DTPA99m

97 (79 115)

92.5 (92.5 111)

Average

75

925 a

560

1000 a379 b (111 647)
740 c (700 800)

740 a (555 925)

446

Ghana [A16]
MoroccoSudan

Tl chloride

740

730

Average148 (111 185)
740 (700 800)
1 221 (858-1 584)










750 (±10%)463 (185 740)
740 (700 800)
851 (638-1 064)

210

Health-care level II

Tc other

99m











JordanMexicoPeru
TurkeyTc MIBI









99m










Tc other









99m
































99m
Tc
phosphates

Brain







Cardiovascular


























































Bone








Country / area

Average activity administered (MBq) (range or standard deviation in parentheses)































Table 41 (continued)

ANNEX D: MEDICAL RADIATION EXPOSURES
415

150
188 (90 210)
112 (50 185)
870 (±5%)
105 d
300
100
80 (60 110)150 (111 185)460 e

100 (27 150)
140 (70 230)
140 (111 260)
100 (200 SPECT)

444

396 e (200 826)
580 d; 185e185
148 (80 230)
83 (45 217)
370 (±10%)

Tc colloid

99m

110 (100 130)150 (111 370)
185 (74 185)
80 (80 100)80
196 (110 278)
241 (110 372)185
140 (35 245)

(450 750 min 1) j
734 e (370 1 112)140 e (100 200)

Average

150

87
740
454

185 (150 200)



703






185 d (185 259)




147







AverageGhana [A16]
MoroccoSudan

296 d (37 740)150
111 (36 185)
185 (150 200)
148 (96 200)







Health-care level III







925





131 (40 222)







a

1 000
463 (185 740)150
130 (74 185)
185 (150 200)
159 (124 194)

JordanMexicoPeru
Turkey141

Health-care level II

9 l (7.4 10.6)
185 d (40 185)
(296 500) d

148 d (111 185)
200 d

180 d

Other

100 (10 200)

400e; 6 000j (max)222 (200 300)
80

185
180

390 e (110-750); 220 k (100-370)

200 (7 1 500)150
110 (100 130)

Tc IDA

99m

Liver/spleen185
170 (20 800)
120 (20 160)
148 (140 185)80370
240 (15-1 700)

175 (84 185)

81 (37 136)
925 (662 1188)100

13 (7 80)

662

118

Average

74 a (37 84)

111 (74 185)
100 (80 100)100145 (56 286)185
111
125 (55 195)
185 (80 185)
170 (120 222)

240 d

80
555 (370 700)
740
1 480 (1 110-1 850)

370 (±5%)970 (600 1 200)



CyprusCzech Republic
Denmark
EcuadorFinlandFrance [E10]
Germany
Ireland
Italy
Japan [J11]
KuwaitLithuania
Netherlands
New Zealand [L28]
PanamaPortugal [E10]Romania
Slovakia
Slovenia
Spain [E10]
SwedenSwitzerland
United Arab Emirates
United Kingdom [A20]

Other

Tc aerosol

99m

Tc DTPA

































































































99m

Other























Tc MAA














99m






















Lung ventilation










































































Lung perfusion


















Country / area










Average activity administered (MBq) (range in parentheses)












Table 41 (continued)

416
ANNEX D: MEDICAL RADIATION EXPOSURES

80
148 (111-222)

248 (±107)
111 (101-121)(37 74)

192

200 d

1.1 (0.74-1.85)26

185 (74 185)

100 (80 180)
168 (23-740)
463 (332-594)50
27 (11 72)

50
110 (27 130)111 (74 185)

1.6 (0.6 2.6)













90 (34 146)

113 (21 200)

60 (60 80)

185

12

130

20 f






3.7 (±10%)
f

150 d

7 (±3)

130 (70 180)
150 (37 370)

148 (74 185)75
8 (8 12)(1 10) m
185 d (±10%)

3 (±1)

99m
Tc
pertechnetate









Argentina
Belarus
Bulgaria
CanadaChina (Taiwan) [L6]
Croatia
CyprusCzech Republic
Denmark
EcuadorFinlandFrance [E10]
Germany
Ireland
Italy
Japan [J11]
KuwaitLithuania
Netherlands
New Zealand [L28]
PanamaPortugal [E10]Romania

Other

I iodide131

I iodide

0.185
1.1 (0.74-1.85)
23
1.5 (1.1 2.6)

0.8
17
75
0.62 (0.4 1)
86 (0.3-3 700)
3.7 (±10%)32 (±1)
0.4 (0.35-0.45)

Health-care level I

131

0.2
5.5 (2 20)
1.85
1.3 (0.6 2)



99m
Tc
pertechnetate

Thyroid uptake
123

20

8.8

6

20

I iodide

Tc DMSATc MAG3

Other

92 (3 210)
370 (±10%)150
74 (37 111)75
188 (80 250)

150 (100 150)
65 (12 155)
56 (30 82)
111

84 (26 185)
148 (111 180)377
370 (185 370)
(40 350)314 (22 617)
463 (432 594)111
300 (100 500)80228 (130 444)
185 (107 263)
111

3.3 o (1 5)370 (185 370)

26 n (18.5 37)
49 m

84 (26 185)280

200 (74 740)200
75
84 (26 185)
148 (111 180)
197

9 n; 150 d(74 740) f
25 f

185 (85 285)

185 (85 285)
400 (±15%)150
74 (37 111)220
250 (110 360)
165 (20 350)
370 (±10%)99m

60 (40 80)

Tc DTPA

99m

Renal scan

215d (±122); 6n (±2)
185 d (174 196)

99m







Thyroid scan

Average activity administered (MBq) (range in parentheses)

PART C














































Country / area

111























111



























Average

111 (111 185)

1 180 d (±5%)

Other

111 f
1.5 n (0.7 2.3)


Health-care level IV





























111

Tc IDA

99m










































Ethiopia
United Rep. of Tanzania

99m

Tc colloid

Tc aerosol

99m

Other

Tc DTPA



99m





Other


































Tc MAA

99m

Liver/spleenLung ventilation

Lung perfusionCountry / area









Average activity administered (MBq) (range in parentheses)















Table 41 (continued)

ANNEX D: MEDICAL RADIATION EXPOSURES
417

130 (74 185)
185 (150-200)
134 (99 169)

JordanMexicoPeru
TurkeyAverage

0.2
3.1

185 (148 260)
40

17

20

4.4

170

740
170 (80 259)
740 (700 800)
321 (167 475)
181

99
1800

140
370 (300 min)161 (118 204)
370

740

170 (80 259)

127

3o
100

236

20 f (5 40)

140

18.5 nOther

85 (67 175)
110 (100 150)360 (10 800)
148 (140 185)300

40 (10 200)
60 (20 130)
148 (140 185)80100

185 (80 370)185

185 (80 370)
80

Tc MAG3

99m

Tc DTPA

99m

Tc DMSA

99m

200

74





1.7 (1.3 2)


1.7



200







185



1.7 (1.3 2)



1.7

136

97
130 (93 167)
560

173






Average

Ethiopia
United Rep. of Tanzania

Average

No further information available.
Pertechnetate.
Red blood cells.
99m
Tc.
133
Xe.
123
I.
11
C metiomin.
99m
Tc ECD.

Ga.
Kr.
Xe.
128
Au colloid.
131 125 123
I, I, I.
131
I.
51
Cr EDTA.

127

81m

Health-care level IV



67

200

74





111 d (74 222)











Ghana [A16]
Morocco
Sudan












Health-care level III










i
j
k
l
m
n
o

3.7
5.6 (3.8 7.4)
1 (0.5 1.2)

5.6 (3.8 7.4)
185 (150 200)

Health-care level II

2 (0.2 6)

13 f (5 20)
2(0.18 1.8)
2 (1.5 3.7)

74
75 (50 100)

I iodide







a
b
c
d
e
f
g
h

65

Average

1.8 (0.18 1.8)
5 (3.7 7.4)
1.1
2 (0.1 80)
2 (1 7)

123















120 (10 220)
90 (30 200)
185 (148-260)
80

70 (40 110)
74 (37 74)


































Slovakia
Slovenia
Spain [E10]
SwedenSwitzerland
United Arab Emirates
United Kingdom [A20]

I iodide

131

99m
Tc
pertechnetate



Other







I iodide






131

Renal scan














99m
Tc
pertechnetate

Thyroid uptake






























Thyroid scan



































Country / area























Average activity administered (MBq) (range in parentheses)







Table 41 (continued)

418
ANNEX D: MEDICAL RADIATION EXPOSURES

4.3

3.3

3.5

3.4

4.3

Canada [A15]

China, Taiwan Province[L6]

Germany [K12]Romania [I36]

New Zealand [L28]

Lung perfusion b

1.5

1.4

1.1

1.4

1.6

Cardiovascular99m

4.9 ( Tc)
11.8 (201Tl)

3.2 (99mTc)
13.3 (201Tl)

4.6 (99mTc)
17 (201Tl)

3.9 (99mTc RBC)
7.6 (99mTc MIBI)

1.7 (S colloid)

0.5 (DTPA)
1.6 (MAG3)
1.3 (DMSA)

1.7 (123I)

0.4 (DTPA)

2.0 (99mTc)

9.9 (198Au)
1.4 (colloid)
1.8 (Sn colloid)

2.0 (DTPA)
0.6 (DMSA)

1.1 (99mTc)
38.4 (131I)

0.1 (131I)
1.6 (DTPA)

2.3 (HIDA)

0.3 (123I)
0.7 (DMSA)

0.6 (99mTc)

31.2 (131I)

1.2 (colloid)
2.1 (HIDA)

0.84

14.4 (131I)

1.1 (99mTc)

Tc)

99m

1.0 (

Liver / spleen c

Renal cThyroid uptake

Thyroid scan

Health-care level I

Lung ventilation

Bone aEffective dose per procedure (mSv)









Country

Table 42
Typical effective doses to patients from common types of diagnostic nuclear medicine procedures

Argentina:
On the basis of data from a sample of 25% of nuclear medicine centres. Bone scans also performed using 67Ga (204 ± 41 MBq).
Canada:Data from London Health Sciences Centre, SW Ontario (representing 50% of the services provided to population of about 1 million).
CyprusSurvey data relating to 90% of population.
Ghana:
Data for thyroid scan refer to all thyroid studies.
Jordan:Survey data from one hospital.
Lithuania:
Data from Vilnius Oncology Centre.
Morocco:Bone scans also performed using 131I (mean 111 MBq; range 92.5 111 MBq).
Peru:
Survey data from IPEN (Centre of Nuclear Medicine, serving population of about 5 million).
Portugal:
Data from one large department and some additional data.
Romania:
Survey data relating to population base of about 4.5 million. Alternative technique employed for bone scans using 99mTc phosphates: mean 110 MBq, range 60 160 MBq.
Slovakia:
Survey data relating to population base of about 2 million.
Switzerland:
Lung ventilation studies also performed using 127Xe (mean 220 MBq; range 100 370 MBq).
Turkey:Survey data from Gülhane Military Hospital, Hacettepe University Hospital and Samsun Ondokuz Mayis University Hospital.
United Arab Emirates: Thyroid uptake done simultaneously with thyroid scan using a single dose.
United Kingdom: Data represent recommended maximum usual activities (diagnostic reference levels).

The entries in this Table are qualified as follows:

Table 41 (continued)

4.8 (DTPA)

2.0

6.6 (HMPAO)

2.4

6.9 (HMPAO)

Brain cANNEX D: MEDICAL RADIATION EXPOSURES
419

a
b
c
d
e
f

2.85

Ghana [A16]99m

Tc phosphonates.
Tc MAA.
99m
Tc.
35% uptake.
SPECT.
Uptake and scan.

99m

6.5

Iran (Islam. Rep. of)[M10]

1.4 (99mTc)
25 (131I) f

1 (99mTc)

Health-care level III

2.5

2.9 ( Tc)
6.9 (201Tl)

Health-care level II
1.9 (S colloid)
0.6 (113mIn)

0.62

0.4

5.4

12.4 (TcO4)
5.9 (DTPA)

4.8 (DTPA)
0.5 (131I)

3.3 (DTPA)
10 (DMSA)

5

0.8 (2 e) (colloid)

2 (DTPA)
0.7 (DMSA)
0.7 (MAG3)
0.2 (123I)

14.6 (131I)

2 (99mTc)
59 (131I)
0.2 (123I)

10.4 (201Tl)

4.4

United States [I23]99m

6 (131I)
0.4 (123I)
0.5 (99mTc)

1 (99mTc)

0.2 (81mKr)
0.4 (99mTc)
0.4 (133Xe)

1 (2 e)8 (99mTc)
18 (201Tl)

3 (5 e)

United Kingdom [A20]8.4 (HMPAO)

0.7 (MAG3)
0.008 (51Cr EDTA)

72 d ( 3 MBq 131I)
6 d ( 0.5 MBq 131I)

2.4 (99mTc)

0.2 (99mTc)

1.1

10 (99mTc MIBI)
20 (201Tl)

3.5

Sweden [M87]Brain c8.8

Liver / spleen c
2.1

0.5

4.4

8.9

1.8

6.5

7.4 (99mTc RBC)
20.3 (201Tl)

Renal cThyroid uptake

Thyroid scan

Lung ventilation

Lung perfusion b

Cardiovascular

Effective dose per procedure (mSv)

Slovakia [F8]Bone a











Country











Table 42 (continued)

420
ANNEX D: MEDICAL RADIATION EXPOSURESANNEX D: MEDICAL RADIATION EXPOSURES

421

Table 43
Typical effective doses to patients from diagnostic PET imaging[A20]

Radionuclide
11

C
C
N
15
O
15
O
18
F
18
F
18
F
11

13

Investigation

Administeredactivity (MBq)

Effective dose
(mSv)

Dose to uterus(mGy)

Brain tumour imaging
Parathyroid imaging
Myocardial blood flow imaging
Cerebral blood flow imaging
Myocardial blood flow imaging
Tumour imaging
Myocardial imaging
Bone imaging

400
400
550
2 000
2 000
400
400
250

2
2
2
2
2
10
10
7

1
1
1
1
1
7
7
5

Chemical form
L-methyl-methionine
L-methyl-methionine
Ammonia
Water (bolus)
Water (bolus)
FDG
FDG
Fluoride

Table 44
Typical effective doses to paediatric patients from diagnostic nuclear medicine procedures[G47]

Radiopharmaceutical99m

Tc-MAG3 (normal renal function)
Tc-MAG3 (abnormal renal function)
99m
Tc-DTPA (normal renal function)
99m
Tc-DTPA (abnormal renal function)
99m
Tc-DMSA (normal renal function)99m
Tc-pertechnetate (no thryoid block)99m
Tc-IDA (normal biliary function)
99m
Tc-HMPAO
99m
Tc-leukocytes
99m
Tc-erythrocytes
99m
Tc-phosphates
99m
Tc-MIBI (resting)201
Tl-chloride
123
I-iodide (55% thyroid uptake)123
I-iodide (total thyroid block)
123
I-MIBG (no impurity)
67
Ga-citrate
99ma

Activity for
adult
patient
(MBq)

100
100
300
300
80
80
150
500
200
800
600
400
80
20
20
400
150

Effective dose per procedure by patient age a (mSv)
Adult
70 kg
[1.0]

15 years-old
55 kg
[0.9]

10 years-old
33 kg[0.69]

5 years-old
18 kg[0.44]

1 year-old
10 kg[0.27]

0.7
0.6
1.6
1.4
0.7
1.0
2.3
4.7
2.2
5.3
3.6
3.3
20
7.2
0.2
5.6
15

0.8
0.7
1.8
1.6
0.7
1.2
2.4
5.0
2.7
6.0
3.7
4.0
30
10.2
0.3
6.5
18.9

0.7
0.7
2.1
1.9
0.8
1.3
2.9
5.9
3.0
6.6
4.1
4.4
129
12.1
0.3
9.1
22.8

0.6
0.5
1.8
1.8
0.8
1.4
3.0
5.7
2.9
6.7
4.2
4.8
95
16.3
0.3
8.8
23.1

0.6
0.5
2.2
2.0
0.8
1.4
3.7
6.5
3.4
7.6
4.9
5.4
86
18.8
0.3
10.1
27.9

Figures in brackets are scaling factors for activity based on body weights shown. Doses calculated using age-specific coefficients from [I19].

422

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 45
Some reported annual individual and collective effective doses from diagnostic nuclear medicine procedures a
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicatedEffective dose (mSv)
Country /area
Per examination

Per caput

Collective effective dose(man Sv)

Ref.

1 110
4 500
600
207
5 000 b
1 000
90
1 124
10 000
111
300
320
2 000
35 400

[C7]
[A15]
[L6]
[K59]
[K12]
[L28]
[I36]
[F8]
[R18]
[K18]
[E11]
[I23]

450

[M10]

3

[A16]

Health-care level I
Australia
CanadaChina, Taiwan Province
FinlandGermany
Netherlands
New Zealand
Romania
Russian Federation
Slovakia
Switzerland
UkraineUnited Kingdom
United States

5.3
4
4.4
4.0
3
4.2
3.1
16.2
5.4
4.0
4.2
1.2
4.2
4.4

0.064
0.16
0.029
0.04
0.1
0.067
0.026
0.049
0.075
0.022
0.04
0.006
0.036
0.14
Health-care level II

Iran (Islam. Rep. of)

4.3

0.008
Health-care level III

Ghana
a
b

3

0.0002Since, as discussed in Section I.C, many of these exposures are received by patients nearing the end of their lives and the doses are not distributed
evenly amongst the population, these doses should not be used for the assessment of detriment.
Collective dose data refer only to states of former Federal Republic of Germany.

b

a

19

Total

1.1

0.24
0.17
0.023
0.011
0.30
0.038
0.16
0.090
0.050

Level II

0.28

0.053
0.018
0.007
0.0003
0.16
0.020
0.005
0.010

Level III

5.6

1.3
0.80
0.49
0.095
1.3
0.26
0.32
0.59
0.37

World

4.3

-

4.5
8
1.5
1
2
15
1.5
1.7
6

Level I

6.7

-

4.5
8
2
1
10
20
3
2
6

Level II

20

-

4
12
2
1
30
30
3
2
6

Level III

20

-

4
12
2
1
30
30
3
2
6

Level IV

Effective dose per procedure (mSv)

4.6

-

4.5
8
1.5
1
3.4
15
1.9
1.7
6

World

0.081

123 000

31 00033 0004 150
520
12 500
21 0002 000
5 300
12 000Level I

0.008

23 000

3 300
4 150
140
35
9 300
2 400
1 500
600
900

Level II

0.006

3 500

140
140
9
0.2
3 200
40
6
40

Level III0.0003

200

3
0.1
0.1
0.01
55
120
4
0.2
9

Level III

Annual collective dose (man Sv)

35 00037 0004 300
600
25 00024 0003 500
5 900
13 000

World

0.026

150 000

Since, as discussed in Section I.C, many of these exposures are received by patients nearing the end of their lives and the doses are not distributed evenly amongst the population, these doses should not be used for theassessment of detriment.
Rounded estimates based on frequency data and typical (or assumed) doses from the UNSCEAR Survey of Medical Radiation Usage and Exposures.

Average effective dose per caput from diagnostic nuclear medicine procedures (mSv)

0.02

0.001
0.000020.00010.00002
0.003
0.007
0.002
0.00020.003

Level IV

Number of procedures per 1,000 population

Average effective dose per diagnostic nuclear medicine procedure (mSv)

4.5
2.7
1.8
0.34
4.1
0.92
0.89
2.1
1.3

Level I

Bone
Cardiovascular
Lung perfusion
Lung ventilation
Thyroid scan
Thyroid uptake
Renal
Liver / spleen
Brain

Procedure

Table 46
Frequencies, effective doses and collective doses a assumed in global model for diagnostic practice with radiopharmaceuticals b (1991-1996)

ANNEX D: MEDICAL RADIATION EXPOSURES
423

424

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 47
Contributions to frequency and collective dose from the various types of diagnostic nuclear medicine
procedures assumed for global model (1991-1996)
Contribution (%)
Procedure
Level I

Level II

Level III

Level IV

World

Contribution to total annual frequency
Bone
Cardiovascular
Lung perfusion
Lung ventilation
Thyroid scan
Thyroid uptake
Renal
Liver / spleen
Brain

24
14
10
2
22
5
5
11
7

21
15
2
1
27
3
14
8
4

19
6
2
0.1
59
7
2
4

8
0.1
0.4
0.1
19
42
13
1
16

24
14
9
2
22
5
6
11
7

All

100

100

100

100

100

Contribution to total annual collective dose
Bone
Cardiovascular
Lung perfusion
Lung ventilation
Thyroid scan
Thyroid uptake
Renal
Liver / spleen
Brain

25
27
3
0.4
10
17
2
4
10

14
18
0.6
0.1
40
10
6
2
4

4
4
0.3
<0.1
89
1
0.2
1

2
0.1
<0.1
<0.1
28
62
2
0.1
5

23
25
3
0.4
17
16
2
4
8

All

100

100

100

100

100

Table 48
Temporal trends in annual frequency of diagnostic nuclear medicine procedures per 1,000 population
Data from UNSCEAR Surveys of Medical Radiation Usage and Exposures
Country / area197019791980198419851990

19911996

11.5
8.3

11.1
12.0

Health-care level I
Argentina
Australia
Austria
BelarusBelgium
Bulgaria
CanadaCayman Islands
China, Taiwan Province
Croatia
Cuba aCyprusCzechoslovakia b
Czech Republic
Denmark
Ecuador a
Estonia
FinlandFranceGermany c
Hungary
Ireland
Italy
Japan





3.8
18.0

8.9













13.0




36.8



12.6










13.6

18.3

22.9

(0.8)





14.0
(0.5)

14.2

12.6

17.7
9.0
39.7




31.1




6.0

















13.4
(0.8)




6.9
39.8




7.3
8.3



0.5



3.3
64.6
0
6.6
2.4



6.6



28.3
15.2
0.8
8.0
10.0



34.1
15.3
6.1
11.0
11.7

ANNEX D: MEDICAL RADIATION EXPOSURES

425

Table 48, continued
Country / area
KuwaitLithuania
Luxembourg
Netherlands
New Zealand
NorwayPanamaPortugal
Qatar
Romania
Russian Federation d
Slovakia d
Slovenia
SwedenSwitzerland
UkraineUnited Arab Emirates
United Kingdom
United States
Yugoslavia
Average197019791980198419851990

19911996











13.1

5.6
3.9

7.3

12.7
10.6
52.2
15.7
8.3






(9)




9.8
44.9






3.0
(11)










23.5
11.6
7.5
9.3





3.5
(15)
(4.9)



12.6












6.8




25.7
6.1

11

6.9

16



3.4
4.0
4.7
3.0
12.6
9.4
11.2
13.6
9.5
5.0
7.2
8.2
31.5



19

Health-care level II
Antigua and Barbuda
Barbados
BrazilChina
Dominica
GrenadaIndia
Iran (Islamic Rep. of)
Iraq
JordanMexicoOman
Pakistan
Peru
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and
the Grenadines
Tunisia
Turkey





















Average

0.9








1.0
1.7
0.6

0.1

0.2

















1.2






0


1.1


0
0


1.9







1.6
1.1
0.6
0.6
0.6
0
0
0




1.0
2.5

0.8
2.1

0.1

0.5

1.1

0.2

Health-care level III
Egypt
Ghana
Jamaica a
MoroccoMyanmar
Sudan
ThailandAverage

0.07



0.21

0.48



(2.0)



0.62

0.54
0.12
0.25

0.36
0.28
0.18

0.11
0.28
0.26

0.09

0.25

0.25

0.30

0.28

(2.8)









0.05





Health-care level IV

a
b
c
d

Ethiopia
United Rep. of Tanzania




0.014

0.10



0.014
0.024

Average







0.02



Categorized in health-care level II in previous analyses.
Historical data.
Historical data for 19701979, 19801984 and 19851990 refer to Federal Republic of Germany.
Historical data were not included in previous analyses.

426

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 49
Temporal trends in the average annual number a of the various types of diagnostic radionuclide procedures
per 1,000 population
Data from UNSCEAR Surveys of Medical Radiation Usage and Exposures
Average annual number of procedures per 1,000 population
Type of study

PeriodHealth-care level I

Bone scan

Cardiovascular

Lung perfusion

Lung ventilation

Thyroid scan

Thyroid uptake

Renal

Liver / spleen

Brain

Total of all diagnostic
radionuclide proceduresa

Health-care level II

Health-care level III

Health-care level IV

0

0.001
0.041
0.084
0.054

0.001
0.041
0.084
0.001

0.0007
0.003
0.014
0.023

0.0007
0.003
0.014
0

0.0003
0.002
0.008
0.009

0.00030.002
0.008
0.00010.00010.00010.008
00.00010.0001
0.008
0

0.066
0.048
0.066
0.16

0.066
0.048
0.066
0.003

0.10
0.063
0.052
0

0.10
0.063
0.052
0.007

0.006
0.009
0.023
0.019

0.006
0.009
0.023
0.002

0.086
0.034
0.016
0.004

0.086
0.034
0.016
0.0002
0.022
0.013
0.007
0.003
0.25
0.19
0.25
0.02

197019791980198419851990
19911996

0.84
2.6
4.8
5.8

197019791980198419851990
19911996

0.53
0.58
2.6
3.6

197019791980198419851990
19911996

0.34
0.94
2.2
2.3

197019791980198419851990
19911996

0.13
0.26
1.2
0.35

197019791980198419851990
19911996

1.3
2.5
1.8
4.0

197019791980198419851990
19911996

2.2
0.17
0.55
0.80

197019791980198419851990
19911996

1.8
1.3
1.4
1.1

197019791980198419851990
19911996

1.7
1.2
1.4
2.6

197019791980198419851990
19911996

1.3
1.1
0.42
1.6

0.006
0.04

0.022
0.013
0.007
0.010

197019791980198419851990
19911996

10.9
6.9
16.2
18.8

0.86
0.10
0.54
1.13

0.25
0.19
0.25
0.28


0.016
0.20
0


0.008
0.15
0.024



0.002
0.017
0


0.001
0.009
0.4



0.062
0.26
0.25



0.17
0.03
0.041



0.096
0.14
0.087



0.023
0.078
0.23



Overall averages calculated from national data as the total number of procedures divided by the total population for each type of procedure. Data for19911996 from Table 38; since the total population is not the same for each type of procedure due to the lack of comprehensive national data for all
countries included in the analysis, these average numbers can not be expected to be additive.

ANNEX D: MEDICAL RADIATION EXPOSURES

427

Table 50
Estimated doses to the world population from diagnostic nuclear medicine procedures a 19911996

a

Health-care level

Population(millions)

Annual per caput effective dose(mSv)

Annual collective effective dose(man Sv)

I
II
III
IV

1 530
3 070
640
565

0.08
0.008
0.006
0.0003123 000
23 000
3 500
200

World

5 800

0.03

150 000

Since, as discussed in Section I.C, many of these exposures are received by patients nearing the end of their lives and the doses are not distributed
evenly amongst the population, these doses should not be used for the assessment of detriment.

0.058
0.027
0.005
0.158
0
0.063
0.018
0.029
0.098
0.007
0.070
0.050
0.015
0
0.053
0.092
0.005
0
0.006
0.013
0.081
0.093
0.011
0.069
-

0.051
0.001
0.004
0.008
0
0.001
0.003
0.008
0.029
0.004
0.005
0.018
0
0.017
0.006
0
0.0009
0.001
0.011
0.007
0.001
-

0.005

Australia
Belarus
Bulgaria
CanadaCayman Islands
Croatia
Cuba b [B43]
CyprusCzech Republic
Denmark
EcuadorFrance [S50]
Hungary
IrelandJapan cKuwaitLuxembourg
Netherlands
New Zealand
PanamaQatar
Romania
Russian Federation
Slovakia
Slovenia
SwedenUnited Arab Emirates
United Kingdom
United States [I23]
Uruguay d [B43]
Venezuela b [B43]

Average

0.060

Lymphoma

Leukaemia

Country / area

0.401

0.320
0.078
0.061
0.351
0
0.789
0.256
0.197
0.275
0.015
0.267
0.083
0.063
0
0.553
0.395
0.058
0
0.106
0.145
0.232
0.391
0.046
0.494
-

Breasttumour

0.355

0.281
0.082
0.007
0.442
0
0.182
0.077
0.141
0.069
0.003
0.180
0.178
0.022
0
0.447
0.231
0.031
0
0.053
0.096
0.341
0.151
0.021
0.548
-

Lung/
thoraxtumour

0.113

0.099
0.073
0.033
0.101
0
0.194
0.028
0.166
0.157
0.040
0.095
0.059
0.016
0
0.122
0.077
0.077
0
0.114
0.160
0.188
0.142
0.016
0.135
-

Head/necktumour

0.054

0.153
0.056
0.024
0.082
0
0.273
0.015
0.057
0.275
0.010
0.127
0.065
0.033
0
0.103
0.064
0.059
0
0.061
0.080
0.242
0.073
0.027
0.033
-

Health-care level I

Gynaecologicaltumour

0.046

0.045
0.011
0.004
0.036
0
0.059
0.031
0.029
0.098
0.007
0.044
0.028
0.010
0
0.024
0.040
0.022
0
0.012
0.024
0.030
0.049
0.011
0.056
-

Brain
tumourTable 51
Annual numbers of teletherapy treatments a per 1,000 population by disease category (1991-1996)
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicated

0.047

0.123
0.033
0.003
0.045
0
0.131
0.184
0.044
0.059
0.003
0.431
0.070
0.0006
0
0.083
0.220
0.003
0
0.060
0.039
0.120
0.038
0.004
0.013
-

Skin
tumour

0.039

0.039
0.017
0.001
0.029
0
0.017
0.015
0.021
0.078
0.002
0.019
0.015
0.007
0
0.225
0.035
0.003
0
0.004
0.012
0.026
0.044
0.010
0.046
-

Bladdertumour

0.206

0.154
0.006
0.120
0
0.012
0.034
0.027
0
0.003
0.050
0.019
0.009
0
0.259
0.023
0
0.003
0.009
0.034
0.214
0.008
0.282
-

Prostatetumour

0.069

0.069
0.019
0.003
0.051
0
0.060
0.031
0.081
0.049
0.005
0.065
0.099
0.007
0
0.073
0.103
0.008
0
0.012
0.045
0.061
0.071
0.006
0.074
-

Tumour of
rectum

0.088

0.050
0.030
0.036
0
0.004
0.006
2.68
0.0006
1.214
0
0
0.021
0.025
0.001
0
0.002
0.0008
0.017
0.039
0.003
0.017
-

Benigndisease

1.50

1.838
0.454
0.185
1.693
0
1.981
2.036
0.929
3.493
1.539
0.104
1.734
3.655
1.619
0.762
0.228
0
2.2 c
1.715
0.295
0
0.461
0.970
0.764
2.437
1.305
0.231
2.320
1.981
1.509
1.603

Total of all
teletherapy
treatments

428
ANNEX D: MEDICAL RADIATION EXPOSURES

0.003

0.014

0.003

0.003
0.009

0.017
0.005

0.004

0.008
0.002

0.00040.00010.0006

0.001

0.002
0.001

0.001

0.0004
0.002

0.003

0.00080.0008
-

0.004

0.001

0.002
0.0008

0.004

0.002

0.002
-

0.001

0.465

0
2.059
1.848
2.059
0.065
0.360
0.045

0.694

0.002

0.022
0.010

0.004

Average

0.004
0.003

Health-care level III

0.019

0.011

0.00010.0009
0.005

0.021

Afghanistan
Guatemala b [B43]
Haiti b [B43]
Jamaica b [B43]
Madagascar
Morocco
Sudan

0.015

0.007

Average

0.025

1.516
0.133
0.385
0.002
0.011
0.006
0.010
0.006
0.039

0.044

0.029

0.056

0.066

0.024

0.022

0.009

0
0
3.132
0
0.829
1.333
2.144
1.583
0
1.900
2.025
0
2.002
0.268
0.079
0.111
2.196
0
0.053
2.126
0.139
1.450
0
0
0
0.005
0.002
0
0.0006
0.009
0.003
0.002
0
0.002
0.002
0.006
0.002
0.004
0
0.002
0.004
0.009
0.007
0.001
0
0.002
0.001
-

Health-care level II
0.004
0.005
0.003
0
0.003
0.002
-

Total of all
teletherapy
treatments

0.022
0.012
0.006
0
0.002
0.006
-

Benigndisease

0.023
0.015
0.016
0
0.010
0.013
-

Tumour of
rectum

0.013
0.005
0.029
0
0.005
0.068
-

Prostatetumour

0.024
0.014
0.007
0
0.004
0.006
-

Bladdertumour

0.052
0.009
0.025
0
0.007
0.013
-

Skin
tumour

0.026
0.006
0.005
0
0.004
0.007
-

Brain
tumour

0.018
0.002
0.005
0
0.003
0.002
-

Head/necktumourAntigua and Barbuda [B43]
Bahamas [B43]
Barbados d [B43]
Belize [B43]
Bolivia d [B43]BrazilChile b [B43]
Colombia b [B43]
Dominica [B43]
Dominican Republic b
El Salvador b [B43]
Grenada [B43]
Honduras b [B43]
JordanLibyan Arab Jamahiriya
MexicoNicaragua b [B43]
Oman
Pakistan
Paraguay b [B43]Peru
Puerto Rico b
Saint Kitts and Nevis [B43]
Saint Lucia [B43]
Saint Vincent and
the Grenadines [B43]
Trinidad and Tobago d [B43]
Tunisia
TurkeyGynaecologicaltumourLung/thoraxtumourBreasttumourLymphoma

Leukaemia

Country / area

Table 51 (continued)

ANNEX D: MEDICAL RADIATION EXPOSURES
429

0.003

0.003

Lymphoma

0.003

0.003

Breasttumour

0.004

0.004

Lung/
thoraxtumourComplete courses of treatment.
Data referring to number of new patients with cancer.
These revised data were received by the Committee after completion of the global analysis.
Data referring to estimated number of new patients with cancer.

0.0004

Average

Head/necktumour

0.020

0.020
0.001

0.001

Health-care level IV

Gynaecologicaltumour00

Braintumour

0.003

0.003

Skin
tumour0.00040.0004

Bladdertumour0.00050.0005

Prostatetumour00

Tumour of
rectum

0.002

0.002

Benigndisease

0.050

0.050

Total of all
teletherapy
treatments

Survey data from only 8 of 31 radiotherapy treatment centres (representing about 42% of national practice).
Survey data for Paraná State (with a population of 9 million and a social and economic profile above the average for Brazil).
On the basis of data from the Nova Scotia Cancer Treatment and Research Foundation, the Cross Cancer Institute (Northern Alberta), and the province of Manitoba (collectively representing about 14% of
the population).
Croatia:
Data from one large centre serving about one-fifth of population.
France:Data represent annual number of patients undergoing radiotherapy [S50].
Peru:
Survey data from INEN (Cancer Institute, Lima, serving population of about 7 million).
New Zealand: Data from 50% of radiotherapy centres (serving about two-thirds of population).
United Rep. of Tanzania: 98% of the total shown for ‘Lung/thorax tumour’ are treatments of the oesophagus.
Turkey:On the basis of data from Hacettepe University Hospital.
United States: Value shown for ‘Benign’ includes the general category of ‘Others/Unspecified’ [I23].

Australia:
Brazil:Canada:The entries in this Table are qualified as follows:

a
b
c
d

0.0004

Leukaemia

United Rep. of Tanzania

Country / area

Table 51 (continued)

430
ANNEX D: MEDICAL RADIATION EXPOSURESANNEX D: MEDICAL RADIATION EXPOSURES

431

Table 52
Annual numbers of brachytherapy treatments a per 1,000 population by disease category (1991-1996)
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicatedCountry / area

Head/necktumourBreasttumourGynaecologicaltumour

ProstatetumourTotal of allbrachytherapy
treatments

Health-care level I
Australia
Belarus
Bulgaria
CanadaCayman Islands
Croatia
CyprusCzech Republic
Denmark
EcuadorHungary
Ireland
KuwaitLuxembourg
Netherlands
New Zealand
PanamaQatar
Romania
Russian Federation
Slovakia
Slovenia
SwedenUnited Arab Emirates
United States [I23]
Uruguay

0.001
0.021
0.001
0
0
0
0.002
0
0.004
0
0
0.008
0.005
0.001
0
0.002
0.010
0.044
0.002
-

0.002
0.003
0
0
0
0
0.010
0
0.0008
0
0
0.062
0.002
0
0
0.004
0.054
0
0
-

0.055
0.059
0.055
0
0.074
0.018
0.247
0.009
0.010
0.082
0.015
0
0.027
0.035
0.051
0
0.143
0.154
0.088
0.110
0.007
-

0
0.001
0.009
0
0
0
0.0005
0
0
0
0.003
0
0
0
0.00070.0004
0.001
0
-

0.064
0.096
0.556
0.070
0
0.074
0.018
0.273
0.010
0.311
0.094
0.015
0
0.15 b
0.047
0.053
0
0.162
0.440
0.258
0.140
0.110
0.009
0.115
0

Average

0.005

0.011

0.078

0.002

0.20

Health-care level II
Antigua and Barbuda[B43]
Bahamas [B43]
Belize [B43]
Dominica [B43]
Grenada [B43]
MexicoOman
Pakistan
Paraguay
Peru
Saint Kitts and Nevis[B43]
Saint Lucia [B43]
Saint Vincent and
the Grenadines [B43]
Tunisia
TurkeyAverage

-

-

-

-

0

0.002
0
0
0
-

0.004
0
0
0
-

0.0001
0
0.001
0.036
-

0
0
0
0
-

0
0
0
0
0.021
0
0.001
0
0.036
0

-

-

-

-

0
0

0.003
0.003

0
0.002

0.014
0.028

0
-

0.022
0.037

0.00080.0005

0.009

0

0.017

Health-care level IIIab

Jamaica [B43]
Morocco
Sudan

0

0

0.030
0.0009000.030
0.0009Average

0

0

0.016

0

0.015

Complete courses of treatment.
These revised data were received by the Committee after completion of the global analysis.

Australia
Belarus
Bulgaria
CanadaCroatia
CyprusCzech Republic
Denmark
EcuadorHungary
IrelandJapan
KuwaitNetherlands
New Zealand
PanamaRomania

Country

2.8
0.2
2.2
0.5
0.1
0.3
0.2
1.9
3.4
0.3
8.0
1.0
1.9
0.2

Leukaemia

3.2
5.9
2.7
9.3
3.2
2.0
0.8
6.4
6.7
4.3
6.7
6.7
2.9
5.4
1.5
1.2

Lymphoma

17
17
33
21
40
28
5.6
18
14
17
27
30
23
19
23

Breasttumour

15
18
3.6
26
9.2
8.3
4.0
4.5
2.7
11
24
9.6
24
13
11
11

Lung/
thoraxtumour

5.4
16
18
6.0
9.8
3.0
4.8
10
38
5.8
12
7.0
6.6
4.5
26
25

Head/necktumour

8.3
12
13
4.8
14
1.7
1.6
18
9.2
7.9
8.1
14
5.6
3.7
20
13

Health-care level I

Gynaecologicaltumour

2.5
2.4
1.9
2.2
3.0
3.3
0.8
6.4
6.7
2.7
4.4
1.3
2.3
7.3
2.6

Brain
tumour

6.7
7.2
1.9
2.7
6.6
20
1.3
3.8
3.3
12
4.3
10
0.3
4.5
13
0.9
13

Skin
tumour

2.2
3.8
0.6
1.7
0.9
1.7
0.6
5.1
1.9
1.2
3.6
2.9
12
2.0
1.0
0.8

Bladdertumour

8.4
1.4
7.1
0.6
3.6
0.8
0
2.5
3.1
4.2
15
7.9
0.6

Prostatetumour

3.7
4.1
1.6
3.0
3.0
3.3
2.3
3.2
4.4
4.0
13
3.1
4.0
6.0
2.7
2.6

Tumour of
rectum

2.8
16
2.1
0.2
0.7
77
0.6
33
0.3
0
1.1
1.4
0.5
0.3

Benigndisease

100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100

Total of all
teletherapy
treatments

Survey data from only 8 of 31 radiotherapy treatment centres (representing about 42% of national practice).
On the basis of data from the Nova Scotia Cancer Treatment and Research Foundation, the Cross Cancer Institute (Northern Alberta), and the province of Manitoba (collectively representing about 14% of the
population).
Data from one large centre serving about one-fifth of population.
Data from 50% of radiotherapy centres (serving about two-thirds of population).
Survey data from INEN (Cancer Institute, Lima, serving population of about 7 million).
On the basis of data from Hacettepe University Hospital.

Table 53
Percentage contributions by disease category to annual total numbers of teletherapy treatments a (1991-1996)
Based on data and qualifications from Table 51

Croatia:
New Zealand:
Peru:
Turkey:Australia:
Canada:The entries in this Table are qualified as follows:

432
ANNEX D: MEDICAL RADIATION EXPOSURES

a
b

0.3

6.7
2.7
4.1
6.2
1.3
5.7

5.1

0.2
0.3
11

1.4

0.7

0.7

Average b

JordanLibyan Arab Jamahiriya
MexicoPakistan
Peru
TurkeyAverage b

Madagascar
Morocco
Sudan

Average b

United Rep. of Tanzania

Average b

6.6

6.6

6.0

6.6
5.5

6.0

9.6
8.0
4.1
7.5
5.3
6.3

4.1

1.7
3.3
7.1
4.5
3.5

Lymphoma

5.0

5.0

28

34
22

17

19
12
22
14
9.4
17

23

19
9.5
30
20
25

Breasttumour

8.6

8.6

4.7

4.7
-

11

8.9
18
6.3
7.0
4.6
14

24

13
14
12
8.9
28

Lung/
thoraxtumour

41

41

18

26
11

14

4.7
6.1
26
8.8
48
7.5

7.7

21
7.7
11
7.1
6.8
3.7

11
9.9
5.6
12
1.7

Head/necktumour

2.9

2.9

Health-care level IV

7.8

13
4.2

Health-care level III

13

8.4
19
15
18
9.2
11

Health-care level II

Gynaecologicaltumour

0

0

0.8

0.2
1.3

7.8

8.2
15
5.6
4.0
4.6
10

2.7

3.1
1.2
3.8
4.7
2.8

Brain
tumourComplete courses of treatment.
Overall averages for sample calculated as total number of each particular type of treatment divided by total number of all treatments.

0.2
0.4
2.9
0.1

Leukaemia

Slovakia
Slovenia
SwedenUnited Arab Emirates
United States [I23]Country

Table 53 (continued)

5.1

5.1

2.5

2.5
2.4

2.6

1.3
6.1
3.0
6.3
1.1
1.5

3.1

5.1
4.9
2.9
1.8
0.7

Skin
tumour

0.8

0.8

2.3

0.6
3.7

2.3

3.2
8.3
1.3
3.5
0.7
2.5

2.7

1.6
1.1
3.3
4.4
2.3

Bladdertumour

1.1

1.1

1.2

1.2
-

2.4

2.2
2.4
3.9
2.7
3.1
1.7

12

1.2
1.4
16
3.3
14

Prostatetumour

0

0

2.2

2.8
1.8

2.7

3.5
3.7
2.2
2.7
1.6
3.0

4.7

5.9
2.5
5.4
2.7
3.7

Tumour of
rectum

4.7

4.7

3.3

3.3
-

0.9

1.8
1.5
1.2
0.6

5.8

0.1
0.7
3
1.3
0.9

Benigndisease

100

100

100

100
100
100

100

100
100
100
100
100
100

100

100
100
100
100
100

Total of all
teletherapy
treatments

ANNEX D: MEDICAL RADIATION EXPOSURES
433

434

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 54
Percentage contributions by disease category to annual total numbers of brachytherapy treatments a (1991-1996)
Based on data and qualifications from Table 52

Country / area

Head/necktumourBreasttumourGynaecologicaltumour

ProstatetumourTotal of allbrachytherapy
treatments

Health-care level I
Australia
BelarusCanadaCroatia
CyprusCzech Republic
EcuadorIreland
KuwaitNetherlands
New Zealand
PanamaRomania
Slovakia
Slovenia
SwedenUnited Arab Emirates

2.1
22
1.9
0
0
0.6
0
4.4
0
7.9
11
2.8
1.2
3.9
32
23

3.8
3.7
0
0
0
3.7
0
0.9
0
59
4.7
0
2.5
21
0
0

86
61
79
100
100
91
100
88
100
26
75
97
88
59
63
100
77

0
1.4
12
0
0
0.2
0
0
2.4
0
0
0.4
0.2
0.7
0

100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100

Average b

4.3

10

78

2.2

100

Health-care level II
MexicoPakistanPeru
Tunisia
Turkey

1.0
0
0
13
8.6

1.8
0
0
0
4.9

0.4
96
100
63
75

0
0
0
0
-

100
100
100
100
100

Average b

4.5

2.8

52

0

100

Health-care level III

ab

Morocco
Sudan

0

0

100
100

-

100
100

Average b

0

0

100

-

100

Complete courses of treatment.
Overall averages for sample calculated as total number of each particular type of treatment divided by total number of all treatments.

ANNEX D: MEDICAL RADIATION EXPOSURES

435

Table 55
Distribution by age and sex of patients undergoing teletherapy treatment for a range of conditions (1991-1996)
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures
Healthcarelevel

Age distribution (%)
Country / area

015 years

1640 years

Sex distribution (%)>40 years

Male

FemaleLeukaemia
I

II

III

IV

Australia
Belarus
Bulgaria
CanadaCroatia
CyprusCzech Republic
EcuadorIreland
KuwaitNew Zealand
PanamaRomania
Slovakia
Slovenia
United Arab Emirates

22
0
100
67
0
100
96
63
18
77
36
40
5
66
23
62

18
0
0
33
0
0
4
34
36
23
23
47
48
17
26
19

60
100
0
0
100
0
0
3
45
0
41
13
47
17
51
19

71
80
68

29
20
32

0
50
60
54
45
58
62
67
50
83
65
88

100
50
40
46
55
42
38
33
50
17
35
12

Average

38

21

41

68

32

JordanLibyan Arab Jamahiriya
MexicoPakistan
Peru
Turkey

26
73
65
41
55
53

38
18
20
37
32
37

36
9
15
22
13
10

69
64
61
66
18
80

31
36
39
34
82
20

Average

52

34

14

72

28

Madagascar
Morocco
Sudan

100
80
80





0

50

50

11

9

51

49

Average

80

11

9

51

49

United Republic of
Tanzania

67

11

22

70

30

50
50
57
55
42
53
54
48

50
50
43
45
58
47
46
52
46
45
42
67
39
45
43
32

0









LymphomaI

II

Australia
Belarus
Bulgaria
Croatia
CyprusCzech Republic
EcuadorIrelandJapan
KuwaitNetherlands
New Zealand
PanamaRomania
Slovakia
Slovenia
United Arab Emirates

2
10
48
3
0
6
6
1
13
19

21
67
11
48
25
28
39
20
23
31

77
23
41
49
75
66
55
78
64
50

1
0
20
3
5
20

31
25
32
20
55
48

68
75
48
77
40
32

54
55
58
33
61
55
57
68

Average

10

26

64

53

47

JordanLibyan Arab Jamahiriya
MexicoPakistan
Peru
Turkey

13
31
3
16
11
26

43
49
42
42
29
28

44
20
55
42
60
46

68
62
57
67
52
60

32
38
43
33
48
40











436

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 55 (continued)
Healthcarelevel

Age distribution (%)
Country / area

Sex distribution (%)

015 years

1640 years>40 years

Male

FemaleII

Average

19

34

47

61

39

III

Madagascar
Morocco
Sudan

0
10
14

60
80
27

40
10
59

60

40

64

36

Average

7

43

50

62

38

United Rep. of Tanzania

30

50

20

62

38

99.5
98.5
99.5
99
99
98
100
99
84
100
99.7
99
100
98.5
99
99
91

IV





Breast tumour
I

II

III

IV

0
0
0
0
0

14
16
12
16
6

86
84
88
84
94

0
0
0
0

5
19
8
30

95
81
92
70

0
0
0
0
0
0

23
16
16
10
10
19

77
84
84
90
90
81

0.5
1.5
0.5
1
1
2
0
1
16
0
0.3
1
0
1.5
1
1
9

Average

0

13

87

1.2

98.8

JordanLibyan Arab Jamahiriya
MexicoPakistan
Peru
Turkey

0
0
0
0
0
0

23
31
30
41
31
26

77
69
70
59
69
74

4
6
0.3
7
0
2

96
94
99.7
93
100
98

Average

0

29

71

2

98

Madagascar
Morocco
Sudan



0

66





1

99

0

34
80
40

60

3

97

Average

0

37

63

2

98

United Rep. of Tanzania

0

2

98

3

97

28
6
6
39
17
20
13
50
33



94
96
98
97
99
100
99
77
99
95
92

72
94
94
61
83
80
87
50
66



6
4
2
3
1
0
1
9
1
5
8

8
20
32
31
15
12
30
20
28

Australia
Belarus
Bulgaria
CanadaCroatia
CyprusCzech Republic
EcuadorIreland
KuwaitNetherlands
New Zealand
PanamaRomania
Slovakia
Slovenia
United Arab Emirates















Lung/thorax tumour
I

Australia
Belarus
Bulgaria
CanadaCroatia
CyprusCzech Republic
EcuadorIrelandJapan
KuwaitNetherlands
New Zealand
PanamaRomania
Slovakia
Slovenia
United Arab Emirates

0
0
0
0
0
0
0
14
0
0
0
0
0
1
0
0
0

2
0
8
2
3
2

98
100
91
98
97
98

92
80
68
69
85
88
70
80

Average

0

4

96

72







ANNEX D: MEDICAL RADIATION EXPOSURES

437

Table 55 (continued)
Healthcarelevel

Age distribution (%)
Country / area

Sex distribution (%)

015 years

1640 years>40 years

Male

FemaleJordanLibyan Arab Jamahiriya
MexicoPakistan
Peru
Turkey

2
1
0
1
0
0

10
13
11
28
11
8

88
86
89
71
89
92

86
86
70
65
76
95

14
14
30
35
24
5

Average

0

11

89

88

12

III

Madagascar

0

45

55

90

10

IV

United Rep. of Tanzania

0

0

100

76

24

100
100
100
100
100
100
100
100
99
100
100
100
100
100
100
100
100
100

II

Gynaecological tumour
I

II

III

IV

0
0
0
0
0
0
0
0
0
0
0

11
12
18
17
15
17
11
18
10
12
37

89
88
82
83
85
83
89
82
89
88
63

1
0
1
0
0
0

30
25
27
20
32
18

69
75
72
80
68
82

0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0

Average

0

15

85

0

100

JordanLibyan Arab Jamahiriya
MexicoPakistan
Peru
Turkey

0
0
0
2
1
4

23
24
34
48
21
8

77
76
66
50
78
88

0
0
0
0
0
0

100
100
100
100
100
100

Average

2

25

73

0

100

Madagascar
Sudan

1
0

45
23

54
77

0
0

100
100

Average

1

37

62

0

100

United Republic of
Tanzania

0

40

60

0

100

75
79
81
66
87
80
73
43
67

25
21
19
34
13
20
27
57
33

56
75
63
69
79
87

44
25
37
31
21
13

Australia
Belarus
Bulgaria
CanadaCroatia
CyprusCzech Republic
EcuadorIrelandJapan
KuwaitNetherlands
New Zealand
PanamaRomania
Slovakia
Slovenia
United Arab Emirates







Head/neck tumour
I

Australia
Belarus
Bulgaria
CanadaCroatia
CyprusCzech Republic
EcuadorIrelandJapan
KuwaitNetherlands
New Zealand
PanamaRomania
Slovakia

0
3
1
0
0
0
0
3
1
0
0

9
8
6
11
4
0
4
10
4
10
35

91
89
93
89
96
100
96
87
95
90
65

0
4
3
0

19
4
15
6

81
92
82
94











438

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 55 (continued)
Healthcare
level
I

II

III

IV

Age distribution (%)
Country / area

Sex distribution (%)

015 years

1640 years>40 years

Male

FemaleSlovenia
United Arab Emirates

1
0

16
34

83
66

88
72

12
28

Average

0

10

90

75

25

JordanLibyan Arab Jamahiriya
MexicoPakistan
Peru
Turkey

10
4
0
3
0
4

10
17
18
37
27
20

80
79
82
60
73
76

76
74
96
58
48
76

24
26
4
42
52
24

Average

3

23

74

76

24

Madagascar
Morocco
Sudan

0
10
4

35

65

91





17

79

66

34

Average

1

30

69

83

17

United Rep. of Tanzania

0

1

99

44

56

37
43
44
42
50
50
46
49
27
53
40
39
45
34
39
50
23





9

Brain tumour
I

II

III

Australia
Belarus
Bulgaria
CanadaCroatia
CyprusCzech Republic
EcuadorIreland
KuwaitNetherlands
New Zealand
PanamaRomania
Slovakia
Slovenia
United Arab Emirates

3
68
36
0
4
0
11
28
4
12

23
21
4
8
14
0
21
34
2
41

74
11
60
92
82
100
68
38
75
47

13
19
15
7
1
23

32
26
37
35
14
23

55
55
48
58
85
54

63
57
56
58
50
50
54
51
63
47
60
61
55
66
61
50
77

Average

8

19

73

59

41

JordanLibyan Arab Jamahiriya
MexicoPakistan
Peru
Turkey

28
28
26
20
18
11

34
25
28
46
33
39

38
47
46
34
49
50

56
66
53
67
63
58

44
34
47
33
37
42

Average

15

37

48

58

42

Madagascar
Morocco
Sudan

0
10
0

50
80
33

50
10
67

50

50

67

33

Average

0

35

65

65

35

89
93
100
90
95
100
95
77
97
73

71
40
75
60
53
50
75
55
59

29
60
25
40
47
50
25
45
41











Skin tumour
I

Australia
Belarus
Bulgaria
CanadaCroatia
CyprusCzech Republic
EcuadorIreland
Japan

0
0
0
0
0
0
0
3
0
2

11
7
0
10
5
0
5
20
3
25





ANNEX D: MEDICAL RADIATION EXPOSURES

439

Table 55 (continued)
Healthcare
level
I

II

III

IV

Age distribution (%)
Country / area

Sex distribution (%)

015 years

1640 years>40 years

Male

FemaleKuwaitNetherlands
New Zealand
PanamaSlovakia
Slovenia
United Arab Emirates

0
0
14
0
0
10

0
8
14
4
7
10

100
92
72
96
93
80

100
65
64
57
50
65
90

0
35
36
43
50
35
10

Average

1

18

81

63

37

JordanLibyan Arab Jamahiriya
MexicoPakistan
Peru
Turkey

6
8
1
6
0
0

6
20
12
32
18
18

88
72
87
62
82
82

67
50
52
70
53
69

33
50
48
30
47
31

Average

3

22

75

64

36

Madagascar
Morocco
Sudan

0
0
4

40
100
29

60
0
67

60

40

Average

2

34

64

60

40

United Rep. of Tanzania

0

80

20

63

37

67
74
75
66
69
80
53
85
100

33
26
25
34
31
20
47
15
0
27
20
27
50
20
8
46
12







Bladder tumour
I

II

III

IV

0
0
0
0
0
0
0
0
0
0
0

8
3
0
6
0
0
1
0
0
13
18

92
97
100
94
100
100
99
100
100
87
82

0
0
0
0
0
0

1
0
0
0
0
4

99
100
100
100
100
96

73
80
73
50
80
92
54
88

Average

0

9

91

75

25

JordanLibyan Arab Jamahiriya
MexicoPakistan
Peru
Turkey

0
0
0
1
0
0

0
6
12
31
9
2

100
94
88
68
91
98

93
88
64
75
70
91

7
12
36
25
30
9

Average

0

10

90

84

16

Madagascar
Morocco
Sudan

0
0
0

50
100
7

50
0
93

60

40

70

30

Average

0

11

89

69

31

United Rep. of Tanzania

0

80

20

64

36

88
97

100
100

0
0

Australia
Belarus
Bulgaria
CanadaCroatia
CyprusCzech Republic
EcuadorIrelandJapan
KuwaitNetherlands
New Zealand
PanamaRomania
Slovakia
Slovenia
United Arab Emirates















Prostate tumour
I

Australia
Belarus

0
3

12
0

440

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 55 (continued)
Healthcarelevel

Age distribution (%)
Country / area

Sex distribution (%)

015 years

1640 years>40 years

Male

FemaleCanadaCroatia
CyprusCzech Republic
EcuadorIreland
KuwaitNew Zealand
PanamaRomania
Slovakia
Slovenia
United Arab Emirates

0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
1
0
12
0
5
0

100
100
100
100
100
100
100
99
100
88
100
95
100

100
100
100
100
100
100
100
100
100
100
100
100
100

0
0
0
0
0
0
0
0
0
0
0
0
0

Average

0

4

96

100

0

JordanLibyan Arab Jamahiriya
MexicoPakistan
Peru
Turkey

0
0
0
0
0
0

0
10
5
19
4
0

100
90
95
81
96
100

100
100
100
100
100
100

0
0
0
0
0
0

Average

0

6

94

100

0

III

Madagascar

0

0

100

100

0

IV

United Rep. of Tanzania

0

1

99

100

0

70
49
81
47
42
75
59
44
73

30
51
19
53
58
25
41
56
27
33
45
42
52
41
39
30
27

I

II

Tumour of the rectum
I

II

III

0
0
0
0
0
0
0
0
0
0
0

6
8
5
11
10
0
2
13
2
5
25

94
92
95
89
90
100
98
87
98
95
75

0
0
0
0
0
0

10
0
7
5
8
20

90
100
93
95
92
80

67
55
58
48
59
61
70
73

Average

0

6

94

57

43

JordanLibyan Arab Jamahiriya
MexicoPakistan
Peru
Turkey

0
0
0
1
0
1

22
35
16
36
13
16

78
65
84
63
87
83

47
67
63
71
62
66

53
33
37
29
38
34

Average

1

19

80

65

35

Madagascar
Sudan

0
5

33
35

67
60

55
54

45
46

Average

2

34

64

55

45

76
85
25

43
34
50

57
66
50

Australia
Belarus
Bulgaria
CanadaCroatia
CyprusCzech Republic
EcuadorIrelandJapan
KuwaitNetherlands
New Zealand
PanamaRomania
Slovakia
Slovenia
United Arab Emirates











Benign disease
I

Australia
Bulgaria
Croatia

1
2
0

23
13
75

ANNEX D: MEDICAL RADIATION EXPOSURES

441

Table 55 (continued)
Healthcarelevel

Age distribution (%)
Country / area

Sex distribution (%)

015 years

1640 years>40 years

Male

FemaleCyprusCzech Republic
EcuadorJapan
New Zealand
PanamaRomania
Slovenia
United Arab Emirates

0
0
100
4
0
0
10
0
14

100
0
0
37
39
50
80
0
14

0
100
0
59
61
50
10
100
72

50
40
100

50
60
0

47
25
20
50
57

53
75
80
50
43

Average

0

1

99

40

60

JordanMexicoPakistan
Turkey

0
5
5
4

48
43
54
23

52
52
41
73

40
43
75
45

60
57
25
55

Average

4

39

57

50

50

III

Madagascar

0

60

40

50

50

IV

United Rep. of Tanzania

2

80

18

36

64

I

II





Other
I

Australia (digestive)
Cyprus (brain mets.)
Cyprus (bone mets.)
Czech Republic (colon)

0
0
0
0

8
0
0
1

92
100
100
99

75
80
60
51

25
20
40
49

II

Turkey (opthalmopathy)

37

15

48

69

31

IV

United Republic of
Tanzania (Kaposis sarc.)

0

50

50

68

32

58
48
30
35
25
58
45
44
52
45

42
52
70
65
75
42
55
56
48
55

55

45

All teletherapy treatments
I

II

2
4
6
0
7

13
14
12
9
19

85
82
82
91
74

9
0
1
1
1
5

28
7
14
11
8
19

63
93
85
88
91
76

Average

1

11

88

49

51

JordanLibyan Arab Jamahiriya
MexicoPakistan

8
10
4
8

24
22
26
37

68
68
70
55

52
61
37
60

48
39
63
40

Average

6

30

64

47

53

Australia
Belarus
Bulgaria
Croatia
EcuadorIreland
KuwaitNetherlands
New Zealand
Slovakia
SwedenUnited Arab Emirates











The entries in this Table are qualified as follows:
Australia:
Canada:Survey data from only 8 of 31 radiotherapy treatment centres (representing about 42% of national practice).
On the basis of data from the Nova Scotia Cancer Treatment and Research Foundation and the province of Manitoba (collectively
representing about 8% of the population).
Croatia:
Data from one large centre serving about one-fifth of population.
Jordan:Survey data from one hospital.
New Zealand: Data from 50% of radiotherapy centres (serving about two-thirds of population).
Peru:
Survey data from INEN (Cancer Institute, Lima, serving population of about 7 million).
United Republic of Tanzania: Data for ‘Lung/thorax tumour’ include treatments of the oesophagus.
Turkey:Survey data from Hacettepe University Hospital, Çukurova University Hospital, Istanbul University Hospital, Cerrahpaşa Hospital andGülhane Military Hospital.

442

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 56
Distribution by age and sex of patients undergoing brachytherapy treatment for a range of conditions (1991-1996)
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures
Healthcarelevel

Age distribution (%)
Country015 years

1640 years

Sex distribution (%)>40 years

Male

FemaleHead/neck tumour
I

II

III

Australia
Belarus
Czech Republic
IrelandPanamaSlovakia
Slovenia
United Arab Emirates

0
0
0
0
0
0
1
0

0
11
4
0
25
24
20
20

100
89
96
100
75
76
79
80

59
70
73
60
25
81
25
80

41
30
27
40
75
19
75
20

Average

0

14

86

61

39

MexicoTurkey

0
0

5
30

95
70

85
84

15
16

Average

0

28

72

84

16

Morocco

10









Breast tumour
I

II

Australia
Belarus
Czech Republic
Ireland
Slovakia

0
0
0
0
0

0
17
5
0
20

100
83
95
100
80

0
0
0
0
0

100
100
100
100
100

Average

0

15

85

0

100

MexicoTurkey

0
0

34
24

66
76

0
3

100
97

Average

0

26

74

2

98

Gynaecological tumour
I

II

III

Australia
BelarusCanadaCroatia
CyprusCzech Republic
EcuadorIreland
KuwaitPanamaSlovakia
Slovenia
United Arab Emirates

0
0
0
0
0
0
0
0
0
0
0
0
0

9
10
13
10
17
11
12
0
30
25
13
6
24

91
90
87
90
83
89
88
100
70
75
87
94
76

0
0
0
0
0
0
0
0
0
0
0
0
0

100
100
100
100
100
100
100
100
100
100
100
100
100

Average

0

11

89

0

100

MexicoPakistan
Peru
Turkey

0
0
0
0

48
52
20
2

52
48
80
98

0
0
0
0

100
100
100
100

Average

0

10

90

0

100

Sudan

0

60

40

0

100

100
100
100

100
100
100

0
0
0

Prostate tumour
I

BelarusCanadaCzech Republic

0
0
0

0
0
0

ANNEX D: MEDICAL RADIATION EXPOSURES

443

Table 56 (continued)
Healthcare
level
I

Age distribution (%)
Country

Sex distribution (%)

015 years

1640 years>40 years

Male

FemaleSlovakia
Slovenia

0
0

0
0

100
100

100
100

0
0

Average

0

0

100

100

0

Other brachytherapy treatments
I

II

Australia (bile duct)
Australia (oesophagus)
Czech Republic (bronchus)
Czech Republic (skin)
Ireland (oesophagus)
Ireland (rectum)
Slovakia (bronchus)
Slovakia (GI tract)

0
0
0
0
0
0
0
0

0
6
3
5
0
0
6
4

100
94
97
95
100
100
94
96

88
50
87
75

12
50
13
25

89
100

11
0

Turkey (genitals)

0

3

97

100

0







All brachytherapy treatments
I

II

Australia
Belarus
Bulgaria
Croatia
EcuadorIreland
KuwaitSlovakia
United Arab Emirates

0
0
0.5
0
0
0
0
0
0

5
13
8
10
12
0
30
14
23

95
87
91.5
90
88
100
70
86
77

42
22
36
0
0
20
0
18
18

58
78
64
100
100
80
100
82
82

Average

0

9

91

30

70

MexicoPakistan

0
0

49
65

51
35

3
38

97
62

Average

0

50

50

6

94

The entries in this Table are qualified as follows:
Australia:
Canada:Croatia:
New Zealand:
Peru:
Turkey:Survey data from only 8 of 31 radiotherapy treatment centres (representing about 42% of national practice).
On the basis of data from the Nova Scotia Cancer Treatment and Research Foundation and the province of Manitoba (collectively
representing about 8% of the population).
Data from one large centre serving about one-fifth of population.
Data from 50% of radiotherapy centres (serving about two-thirds of population).
Survey data from INEN (Cancer Institute, Lima, serving population of about 7 million).
Survey data from Hacettepe University Hospital, Çukurova University Hospital, Istanbul University Hospital, Cerrahpaşa Hospital andGülhane Military Hospital.

49

30 (20 60)
30 (30 60)
55 (50 65)
50 (30 60)(45 65)59 (45 66)

50 (42 50)
50 (50 60)
50 (50 65)
60 (45 60)
50 (50 75)
50 (45 70)

35 (25 40)
45 (45 50)
40 (35 45)
44 (30 50)(45 55)34 (20 58)

20 (6 24)
18 (18 24)
24 (18 24)
18 (18 30)
35
22 (10 30)



22

36








54








39

50

57










Average(40 70)50 (46 50)
50 (50 60)
49 (35 b)
50 (45 65)(45 50)60 (40 66)
60 (60 66)
66 (64 70)
60 (40 70)
60 (60 70)(2 87)(40 70)60 (60 80)
60 (50 70)
59 (37 b)
66 (60 66)

40
46 (40 46)
46 (42 48)
45 (27 65)
50 (50 70)(18 70)(40 60)60 (60 80)
50 (50 60)
55 (35 b)
45 (40 60)(40 55)60 (55 60)
64 (60 68)
50 (8 60)
50 (50 60)(2 74)(40 70)6050 (30 60)
51 (34 b)
60 (50 60)

45 (40 50)
50 (50 65)
66 (64 68)
50 (8 65)
50 (50 60)








17

12 (12 24)

18 (18 24)
5 (5 12)

15 (6 28)
12 (12 24)(10 40)(30 60)36 (30 40)
40 (40 48)
40 (8 50)40 (40 45)(6 45)(25 60)36 (35 40)
30 (20 40)
37 (26 b)
40 (35 44)60

44 (30 50)
50 (50 60)
80 (50 80)
50 (45 55)(20 60)51 (45 62)
63

67

60 (40 66)
66 (60 66)
75 (50 75)
60 (50 75)
75 (55 75)
63 (50 70)

Health care level II

50





JordanLibyan Arab Jamahiriya
MexicoPeru
Tunisia
Turkey30 (25 30)
18 (18 24)



























Average70 (45 75)
56 (28 67)
60 (40 70)
60 (60 70)
60 (50 70)
60 (60 70)
60 (20 70)
60 (45 65)
64 (62 68)
50 (±20%)50 (45 60)
49 (32 57)
40 (40 60)
56 (50 60)
45 (25 70)
60 (52 65)
45 (45 50)
60 (45 65)
46 c
50 ( (±30%)

66 (45 70)
44 (22 63)
60 (40 70)
56 (40 60)
40 (17 60)
60 (52 68)(20 60)55 (50 60)(30 50)50 (±10%)60 (55 65)
53 (26 64)
50 (30 70)
50 (40 60)
50 (40 60)
52 (50 60)50
50 (50 60)
48 (48 58)
60 (±16%)36 (25 45)
34 (17 46)
40 (30 46)
36 (36 44)
40 (20 50)
48 (40 55)
40 (35 45)
30 (30 40)
40 (35 40)
40 (±10%)14 (10 20)
15 (11 22)
30 (20 40)
24 (24 30)
25 (12 30)30
18
12 (12 24)12
25 (±25%)(15 75)15 (6 26)55 (45 60)
49 (26 54)
75 (40 80)
60 (50 70)
50 (40 60)
55 (55 65)
54
50 (45 60)
46 d
50 ( (±20%)70 (50 76)
52 (33 62)
60 (40 60)
60 (50 70)
60 (50 66)
60 (60 65)
64
65 (60 70)
50 (±10%)58 (50 64)
49 (27 62)
60 (40 60)
60 (50 70)
50 (20 70)
60 (54 66)
66 (20 66)
60 (55 60)
60
50 (±20%)75 (60 78)
45 (25 62)
65 (60 70)
60 (50 70)
35 (20 50)
60 (60 70)
50
55 (50 60)
48
50 (12 72)

65 (40 65)
50 (29 58)
60 (40 70)
55 (50 60)
50 (20 60)
60 (50 66)
60
60 (45 65)
54
40 (±30%)60 (60 70)
60 (60 64)
60 (60 64)
60 (30 64)
50(16 74)(40 60)6050 (40 60)
48 (31 b)
64 (60 64)

35 (35 50)
40 (30 40)
60 (60 64)
40 (18 64)50(40 70)60 (60 70)
60 (50 70)
46 (31 b)
50 (50 64)

56 (56 60)
40 (30 50)
52 (37 b)
54 (50 60)

40
60 (55 60)
60 (60 64)
50 (20 66)
50 (40 60)(16 60)50 (30 60)
55 (50 60)
65 (55 65)
60 (30 70)
55
55 (45 60)

53

57



























Argentina
Australia
Belarus
Bulgaria
CanadaCroatia
CyprusCzech Republic
Denmark
EcuadorHungary
Ireland
KuwaitNetherlands
New Zealand
PanamaRomania
Russian Federation
Slovakia
Slovenia
SwedenUnited Arab Emirates
United States [I23]50 (40 55)
45 (45 50)
65 (55 65)
50 (45 55)(65 75)58 (40 70)

48

60





































Health-care level I

BenigndiseaseTumourof rectum

ProstatetumourBladdertumourSkintumourBraintumour

Head/necktumour62

66 (30 66)
60 (60 65)
65 (65 70)
60 (55 65)
65 (55 65)
61 (50 66)

57

50 (45 50)
50 (50 54)(45 60)45 (18 60)
50 (50 60)(20 70)(40 60)50 (50 60)
50 (20 60)
38 (36 b)
45 (40 60)

66 (66 70)
60 (60 66)
65 (60 68)
60 (60 70)(12 70)(40 60)60 (60 66)
50 (20 60)
64 (35 b)
64 (60 66)(60 72)64

60 (30 60)
65 (60 65)
65 (65 70)
70 (60 72)
65 (55 65)
61 (50 60)

59

50 (30 50)
60 (50 60)
65 (65 70)
50 (45 55)(35 65)50 (40 60)

49

53








Gynaecological tumour








Lung/thorax
tumour10 (10 40)

630 (30 45)(0.5 5)
4 (4 20)20 (20 50)

30 (8 50)
15 (15 20)30
4 (1 5)5 (1 50)(6 20)
15 (8 40)
12 (6 18)
6 (4 8)24 (24 32)
20
14 (9 25)
18










Breasttumour










Lymphoma






























































































































Leukaemia

























Country / area












































































































Typical dose a to target volume (Gy)Table 57
Prescribed doses to patients undergoing radiation teletherapy by disease category (1991-1996)
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicated444
ANNEX D: MEDICAL RADIATION EXPOSURES

64 (30 64)

60 (30 60)4560

45 (30 45)45

60 (30 60)

53

50
70
55 (50 60)

Skintumour60 (30 60)

54

50
70
55 (50 60)

Bladdertumour60 (30 60)

45

45
70
25 (20 30)

Prostatetumour60 (30 60)4545(50 70)45 (40 50)

Tumourof rectum

On the basis of data from one large national centre.
Survey data from only 8 of 31 radiotherapy treatment centres (representing about 42% of national practice).
On the basis of data from the Nova Scotia Cancer Treatment and Research Foundation and the province of Manitoba (collectively representing about 8% of the population).
Data from one large centre serving about one-fifth of population.
Target dose of 50 Gy for breast tumour refers to treatment with 60Co unit; this is supplemented by treatment with x rays (target dose of 14 Gy); target dose of 45 Gy for gynaecological tumour refers totreatment with 60Co unit; this is supplemented by treatment with x rays (target dose of 15 Gy).
Jordan:Survey data from one hospital.
Madagascar:
Treatments shown for Breast, Lung/thorax, Gynaecological, Head/neck, Brain, Skin, Bladder, Prostate and Rectum tumours supplemented by additional irradiation with x rays.
New Zealand: Data from 50% of radiotherapy centres (serving about two thirds of population).
Peru:
Survey data from INEN (Cancer Institute, Lima, serving population of about 7 million).
United Republic of Tanzania: Data for ‘Lung/thorax tumour’ include treatments of the oesophagus.
Turkey:Survey data from Hacettepe University Hospital, Çukurova University Hospital, Istanbul University Hospital, Cerrahpa a Hospital, and Gülhane Military Hospital.
United Arab Emirates: Doses for radical treatments only.
United States: Breast tumours receive an additional 10 20 Gy “boost” with either electrons or brachytherapy.

Argentina:
Australia:
Canada:Croatia:
Cyprus:

The entries in this Table are qualified as follows:

625

25 (20 30)

BenigndiseasePrescribed dose for complete course of treatment. Range or standard deviation in parentheses. Mean doses for each health-care level are frequency-weighted averages of national values. These doses should not be used
to infer deterministic or stochastic risks since these depend inter alia strongly on irradiation technique (dose distribution) and fractionation.
Palliative treatment.
Plus brachytherapy.
Plus boost.



b
c
d

30 (30 45)

50 (30 50)

30 (20 30)

30 (20 30)

48

45
70
55 (50 60)

Health care level IV

49

45
46
55 (50 60)

Braintumourşa

United Rep. of Tanzania



45



45



45

45
(30 70)45 (40 50)



29




Average




45
50
45





40
36 (36 40)
50 (40 50)





24
24 (18 24)
30 (20 30)

Madagascar
MoroccoSudan



Health care level III

Head/necktumour

Gynaecolo
gical tumourLung/thorax
tumourBreasttumour

LymphomaLeukaemiaTypical dose to target volume (Gy)Country










Table 57 (continued)

ANNEX D: MEDICAL RADIATION EXPOSURES
445

446

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 58
Prescribed doses to patients undergoing radiation brachytherapy by disease category (1991-1996)
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicatedTypical dose a to target volume (Gy)Country / area
Head/neck tumour

Breast tumour

Gynaecological tumour

Prostate tumour

60 (5065)32 (1542)45 (3050)70 (3070)45 (1150)
30
60 (6070)35 (plus teletherapy)
35 (±15%)15 (1020)
36 (3036)(3060)70 (1570)
20 (2030)(2040)30 (1060)70

Health-care level I
Argentina
Australia
Belarus
Bulgaria
CanadaCyprusCzech Republic
Denmark
EcuadorIreland
KuwaitNetherlands
New Zealand
PanamaRussiaSlovakia
Slovenia
United Arab Emirates
Average75 (6878)
30 (2245)
40 (3050)60 (6070)60

10 (1025)40 (3040)40 (3040)65 (6070)

12 (1012)30 (3060)

30






60 (2030 boost)
45 (2565)
20 (2030)(3050)20 (2030)10 (510)
44








(2024)15(2040)
15




16



40 (3060)30 (2540)



65 (6070)






60

20 (1520)








45

35



Healthcare level II
MexicoPeru
Tunisia
Turkey30 (2040)(5575)21 (1840)

15 (1020)

20 (2025)30 (2030)40 (3080)(2060)24 (1624)






Average

22

19

29



Healthcare level III

a

Morocco
Sudan

24






24
35 (3040)



Average

24



24



Prescribed dose for complete treatment. Range or standard deviation in parentheses. Mean doses for each health-care level are frequency-weighted
averages of national values. These doses should not be used to infer deterministic or stochastic risks since these depend inter alia strongly on
irradiation technique (dose distribution) and fractionation.

The entries in this Table are qualified as follows:
Argentina:
Australia:
Canada:On the basis of data from one large national centre.
Survey data from only 8 of 31 radiotherapy treatment centres (representing about 42% of national practice).
On the basis of data from the Nova Scotia Cancer Treatment and Research Foundation and the province of Manitoba (collectively
representing about 8% of the population).
New Zealand: Data from 50% of radiotherapy centres (serving about two-thirds of population).
Peru:
Survey data from INEN (Cancer Institute, Lima, serving population of about 7 million).
Turkey:Survey data from Hacettepe University Hospital, Çukurova University Hospital, Istanbul University Hospital, Cerrahpaşa Hospital, andGülhane Military Hospital.
United Arab Emirates: Doses for radical treatments only.

ANNEX D: MEDICAL RADIATION EXPOSURES

447

Table 59
Gonad doses from photon teletherapy treatments for some specific tumour sites[V6]
Gonad dose (mGy)
Tumour site/disease

Target dose a (Gy)Treatment techniqueCo

425 MV1040
110170508080100

1030
2050
3050
6080

60

Brain
BreastThorax: lung cancer
Thorax: Hodgkin’s disease
a

2060
50
4555
3640

2 lateral opposed beams
2 tangential beams
AP/PA parallel opposed beams
AP/PA mantle fields

These doses should not be used to infer deterministic or stochastic risks since these depend inter alia strongly on irradiation technique (dosedistribution) and fractionation.

Table 60
Annual numbers a of treatments per 1,000 population assumed in global model for radiotherapy practice(1991-1996)

Disease/site

Level I

Level II

Level III

Level IV

World

Contribution toworld total (%)

Teletherapy
Leukaemia
Lymphoma
Breast tumour
Lung/thorax tumour
Gynaecological tumour
Head/neck tumour
Brain tumour
Skin tumour
Bladder tumour
Prostate tumour
Tumour of rectum
Benign disease
Other

0.01
0.06
0.35
0.36
0.12
0.06
0.04
0.05
0.04
0.18
0.07
0.09
0.09

0.04
0.04
0.12
0.08
0.10
0.09
0.05
0.02
0.02
0.02
0.02
0.01
0.10

0.01
0.03
0.13
0.02
0.09
0.04
0.004
0.01
0.01
0.01
0.01
0.02
0.10

0.0004
0.003
0.003
0.004
0.02
0.001
0
0.003
0.00040.0005
0
0.002
0.01

0.021
0.042
0.17
0.14
0.09
0.07
0.04
0.02
0.02
0.06
0.03
0.03
0.09

3
5
21
17
11
8
5
3
2
7
4
3
11

Total

1.5

0.69

0.47

0.05

0.82

100

BrachytherapyaHead/neck tumour
Breast tumour
Gynaecological tumour
Prostate tumour
Other

0.01
0.02
0.16
0.004
0.01

0.001
0.0005
0.009
0
0.007

0
0
0.015
0
0

0.003
0.006
0.05
0.001
0.007

4
9
75
2
10

Total

0.20

0.02

0.02

0.07

100

Estimated on the basis of average percentage distributions by treatment type (Tables 53 and 54) and average total frequencies (Tables 51 and 52)
observed for each health-care level.

448

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 61
Global resources for high-energy radiation therapy
[D27]

a

RegionNumber of radiation
therapy centres

Number of 60Co
machines

Number of clinicalaccelerators

Teletherapy machines a
per million population

North America
Central America
Tropical South America
Temperate South America
Caribbean
Western Europe
Eastern Europe
Northern Africa
Middle Africa
Southern Africa
Middle East
Indian SubcontinentSouth East Asia
East Asia
Australia and the Pacific Islands

1 909
139
266
139
18
1 027
327
59
22
21
92
221
81
1 107
49

202
115
219
128
23
410
491
49
25
19
64
286
71
606
5

2 238
30
122
46
1
1 109
148
35
3
27
56
46
59
948
113

8.1
1.1
1.2
3.2
0.8
3.9
1.6
0.6
0.1
0.8
0.5
0.3
0.3
1.1
5.2

The World

5 500

2 700

5 000

1.4

Cobalt-60 unit or linear accelerator.

ANNEX D: MEDICAL RADIATION EXPOSURES

449

Table 62
Temporal trends in annual frequency of radiotherapy treatments a per 1,000 population
Data from UNSCEAR Surveys of Medical Radiation Usage and Exposures unless otherwise indicated
Teletherapy
Country / area

1970
1979

1980
1984

Brachytherapy

1985
1990

1991
1996 b

1970
1979

1980
1984

1985
1990



















0.2
0.2

0.2

0.1

1991
1996 cHealth-care level I
Argentina
Australia
Belarus
Bulgaria
CanadaCayman Islands
Croatia
Cuba
CyprusCzechoslovakia
Czech Republic
Denmark
EcuadorFinlandFranceHungary
Iceland
IrelandJapan
KuwaitLuxembourg
Malta
Netherlands
New Zealand
NorwayPanamaQatar
Romania
Russian Federation
Slovakia
Slovenia
SwedenSwitzerland
United Arab Emirates
United Kingdom
United States [I23]
Uruguay
Venezuela
Yugoslavia
Average


2.0









2.9




(0.03)







0.7






0.4
0.5 d





(0.6)




0.6





(1.5)





1.0












1.5

0.8

1.6

2.9

1.8
0.5
0.2
1.7
0
2.0
2.0 e
0.9









0.2



4.2















2.7



1.2
(0.08)
1.2




0.7
0.2

1.6
0.7
0.2
0

1.8
0.6
3.9




1.7
(0.7)

6.8
(0.8)




0.8
1.8
d

2.4
(1.7)





2.4 d



1.7
3.7












3.5
1.5
0.1

1.2



0.4












2.2 f
1.7



0.3
0
0.5
1.0
0.8
2.4
1.3
















0.2

0.2

(0.006)






0.1
0.2









0.3

0.2






1.2

1.5

0.26



















0.08

0.06
(0.4)

0.6

(1.9)

0.2
2.3
2.0
1.5 e
1.6 e






(0.3)

































0.05



0.1


0.06
0.1
0.6
0.07
0
0.07



0.02





0.3

0.1
(0.02)

0.01








0.06
0.07
0.03
0.1
0.07
0.1





(0.3)




0.1
0.1











0.3



0.09



0.02
0



0.15 f
0.05



0.05
0
0.2
0.4
0.3
0.1
0.1



0.009



0.1
0

0.9




0.17

0.24

0.2























0
0

Health-care level II
Antigua and Barbuda
BahamasBarbados
BelizeBolivia
BrazilChile
China
Colombia
Dominica
Dominican Republic
El Salvador
GrenadaHonduras
India
Iraq
JordanLibyan Arab Jamahiriya
















(0.07)
































0
0
3.1 e
0
0.8 e
1.3
2.1 e








1.6 e
0
1.9 e
2.0 e
0
2.0 e

0.6

0.2

0.1
0.1









0.3
0.08

(0.02)





0.2






0.08








0.03
0.009





0






0



0







450

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 62 (continued)
Teletherapy
Country / area

MexicoNicaragua
Oman
Pakistan
Paraguay
Peru
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and
the Grenadines
Trinidad and Tobago
Tunisia
TurkeyAverage

Brachytherapy

1970
1979

1980
1984

1985
1990

1991
1996 b

1970
1979

1980
1984

1985
1990

1991
1996 c













0.1
2.2 e
0
0.05
2.2 e
0.1
1.5 e
0
0
0







0.02
















































0.7

0.9

0.7

1.5 e
0.1
0.4













0.02
0.04

0.1



0.2

0.7

0.02



0.06

0.02
























0.01

0.01

0.09

0.1






0.03

0.04








0
0.001
0
0.04


0
0
0



Health-care level III
Afghanistan
Egypt
Guatemala
Haiti
JamaicaMadagascar
MoroccoMyanmar
Sudan
Thailand












Average










0.2


0.04




(0.1)




0



2.1 e
1.8 e
2.1 e
0.07
0.4






0.2
0.08
0.09

0.05








0.1

0.5

0.0005

(0.07)




0


0.03



0.00090.04

0.02
0.0003
0.04

0.02

0.03

0.02

0.02













Health-care level IV
United Rep. of Tanzania
a
b
c
d
e
f







0.05

Complete course of treatment.
See qualifications to national data shown in Tables 8 and 51.
See qualifications to national data shown in Tables 8 and 52.
Value includes brachytherapy.
Number of new cancer patients.
These revised data were received by the Committee after completion of the global analysis.

The entries in this Table are qualified as follows:
Czechoslovakia: Historical data.
Ecuador:Categorized in health-care level II in previous analyses.
India:
Categorized in health-care level III for period 19701979.
Jamaica:
Categorized in health-care level II in previous analyses.
Russian Federation: Historical data were not included in previous analyses.
United States: Historical data from reference [I23] were not included in previous analyses.

ANNEX D: MEDICAL RADIATION EXPOSURES

451

Table 63
Temporal trends in the average annual number a of the various types of radiotherapy treatments
per 1,000 population
Data from UNSCEAR Surveys of Medical Radiation Usage and Exposures
Average annual number of treatments per 1,000 population
Disease/site

PeriodHealth-care level I

Health-care level II

Health-care level III

Health-care level IV

0.0007
0.002
0.005
0.002





Teletherapy
Leukaemia

Lymphoma

Breast tumour

Lung/thorax tumour

Gynaecological tumour

Benign disease

Total of all teletherapy

197019791980198419851990
19911996

0.010
0.029
0.018
0.005

0.016

197019791980198419851990
19911996

0.038
0.025
0.045
0.060

0.015

197019791980198419851990
19911996

0.12
0.13
0.16
0.40

0.016

197019791980198419851990
19911996

0.11
0.14
0.20
0.36

0.011

197019791980198419851990
19911996

0.11
0.11
0.16
0.11

0.042



0.041
0.021

0.019
0.017
0.009

197019791980198419851990
19911996

0.40
2.0
0.48
0.09




0.004

0.004
0.001

0.004
0.002

197019791980198419851990
19911996

1.0
2.4
1.2
1.5

0.1






0.2
0.7

0.1
0.5

0.050
































0.004
0.007



0.005
0.009



0.026
0.025



0.025
0.015



0.002
0.004
0.007
0.003
0.005
0.012
0.018
0.014
0.002
0.023
0.009
0.003



0.0004




0.003




0.003




0.004




0.020




0.002





Brachytherapy
Breast tumour

Prostate

Total of all brachytherapya197019791980198419851990
19911996

0.0001






0.019
0.011

0.012
0.0005197019791980198419851990
19911996

0.0005






0.005
0.002

0.000010197019791980198419851990
19911996

0.26
0.17
0.24
0.20

0.02



0.06
0.02

0.02

Complete courses of treatment. Overall averages calculated from national data as the total number of treatments divided by the total population foreach treatment category. Data for 1991-1996 from Tables 51 and 52; since the total population is not the same for each treatment category due to thelack of comprehensive national data for all countries included in the analysis, these average numbers can not be expected to be additive.

452

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 64
Chronology of technical advances in teletherapy[R4, R7]
Date

Limitation

Development

Radiation energy
Difficulty in planning
Lack of anatomical information
Lack of flexibility in field shaping
Lack of flexibility in beam intensity
Lack of real-time verification

1950s
1960s
1970s
1980s
Early 1990s
Late 1990s

60

Co teletherapy equipment; linear accelerators (LINACs)
Computer-based treatment planning systems
Computed tomography
Multileaf collimators for conformal therapy
Intensity modulated beams for improved conformal therapy
Transit dosimetry from electronic portal imaging devices

Table 65
Estimated annual numbers of radiotherapy treatments a in the world 1991-1996

Health-care
level

a
b
c

Population(millions)

Annual number of teletherapy
tretments

Annual number of brachytherapy
tretments

Annual number of allradiotherapy treatments b

Millions

Per 1,000
population

Millions

Per 1,000
population

Millions

Per 1,000
population

I
II
III
IV

1 530
3 070
640
565

2.3
2.1
0.3
0.03

1.5
0.7
0.5
0.05

0.3
0.05
0.01
0.01 c

0.2
0.02
0.02
0.02 c

2.6
2.2
0.3
0.04

1.7
0.7
0.5
0.07

World

5 800

4.7

0.8

0.4

0.07

5.1

0.9

Complete courses of treatment.
Excluding treatments with radiopharmaceuticals.
Assumed value in the absence of data.

Table 66
Examples of clinically used radionuclides in cancer therapy[Z3]Radionuclide
131

I
P
89
Sr
131
I
153
Sm
186
Re
32
P
90
Y
90
Y
114m
In
131
I
131
I
32

PharmaceuticalNaI
NaH2PO4
SrCl2
mIBG
EDTMP
HEDP
CrPO4
Microspheres
Antibodies
Lymphocytes
Antibodies
LipiodolClinical use
Differentiated thyroid carcinomas
Polycythaemia vera
Bone metastases
Neural crest tumours
Bone metastases
Bone metastases
Intracavitary
Hepatic tumours
Various tumours
Lymphoma
Various tumours
Hepatic tumours

ANNEX D: MEDICAL RADIATION EXPOSURES

453

Table 67
Annual numbers of therapeutic treatments with radiopharmaceuticals per 1,000 population (1991-1996)
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicatedCountry / area

Thyroidmalignancy

Hyperthyroidism

Polycythaemia
vera

131

131

32

I

I

P

Bone metastases
89

Sr

Synovitis

Other

Total

90

0

0
0.007500.0047
0
0
0.012
0.044
0.00120.00170.011
0.00910.00490.017
00.00280.000200[0.0025][0.0092]
0.018
0
0
0
[0.10]
00
0.008400
0.020
0.0046[0.0010]0[0.0004]
0
0

Y

Total
numberof alltreatments

Health-care level I
Argentina
Austria [H60]
Bulgaria
CanadaCayman Islands
Croatia
CyprusCzech Republic
Denmark
EcuadorFinland [K59]
France [H60]
Germany
Greece [H60]
Hungary
IrelandIsrael [H60]
Italy
Japan
KuwaitLithuania
Netherlands
New Zealand [L28]
Norway [H60]
PanamaPortugal [H60]
Qatar
Romania
Russian Federation
Slovakia
Slovenia
Spain [H60]
SwedenSwitzerland [H60]
United Arab Emirates
United Kingdom [C27]
United States [I23]
Average

0.073
0.018
0.010
0.031
0
0.014
0.048
[0.047]
0.031
0.011
0.089

0.12
0.18
0.0094
0.24
0
0.017
0.020
[0.055]
0.43
0.022
0.28

0
0.00060.00150.003900
0[0.0009]
0
0
0.050

0.086
0.047
[0.020]0.00830.00080.054
0.00730.039[0.067]
0.030
0.033
0.036
0.021
0.035
0
0.050

0.27
0.081
[0.082]0.10

0.0025

[0.0010]0.006900.0028







0.048
0.023
0.091
[0.23]
0.19
0.10
0.20





0.00110

00.0047
0
0
0.012

0
0
0
0
0





0.00120.00080.001000.0009 (32P)(153Sm, 186Re)



186

Re


0
0





0

0







0.0041
0

0
0
186
Re
0.0003(32P)

0.030
0.044
0.018

0
0
0.010
0.012
0.000800.0005
0
0



0.078
0

0.035
0.27

0
0.0010

0.013
0.028
0.013
0.020
0.039

0.32
0.15
0.011
0.20
0.19

0.034
0.0017
0
0.012





0
0.0092

0.038

0.15

0.0046
















0.017
[0.011][0.0019]

[0.0002]
0



0.19
0.29
0.030
0.30
0
0.031
0.080
0.25
0.46
0.035
0.44
0.13
0.39
0.16
0.11
0.12
0.060
0.11







0
0



0
0



0.004100.013
0.00860.016
00.00260000.0070



0
0



0
0.0070[0.0009]
0.014

0.032

0



0
0



0.032
0.013
0
0.00920.0014[0.031]00.0070

0.068
0.044
0.068
0.010
0.11
0.30
0.20
0.40
0.27
0.024
0.25





0.0063

0.098

0.17



0.0083





0

0











0.13
0.29
0.29 a
0.16
0.26





Health-care level II
Antigua and Barbuda[B43]
BrazilDominica [B43]
Grenada [B43]
JordanMexicoOman
Pakistan
Peru
Saint Kitts and Nevis[B43]
Saintt Lucia [B43]
St Vincent and the
Grenadines [B43]
Tunisia
TurkeyAverage















0








0.047
0.031
0
0.016
0.0085











0.0000100.00004
0

0
0
0




0.000200.00010.017

0.000200P, 153Sm
0
131
I
32
153
P, Sm










0.021
0.006400.00340.0085











0.033
0
0
0.13
0.038
0
0.028
0.034
0






















0
0

0.020
0.031

0.022
0.014

0
0.000500.00230000.0023

0
0

0.042
0.048

0.011

0.020

0.0001

0.00170.0001

0.036





32



454

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 67 (continued)

Country / area

Thyroidmalignancy

Hyperthyroidism

Polycythaemia
vera

131

131

32

I

I

P

Bone metastases
89

Sr

Synovitis

Other

Total

90

Y

Total
numberof alltreatments

Health-care level III
MoroccoSudan

0.00450.00080.030
0.0033000000.0023 (32P)

00.002300

0.035
0.0064

Average

0.0027

0.017

0





0.0011

0

0.021

Health-care level IVaEthiopia
United Rep. of Tanzania

000.00040.0002

0
0

0
0

0
0

0
0

0
0

0.00040.0002Average00.0004

0





0

0

0.0004

These revised data were received by the Committee after completion of the global analysis.

The entries in this Table are qualified as follows:
Argentina:
Brazil:Bulgaria:
Canada:Cyprus:Finland:

On the basis of data from a sample of 25% of nuclear medicine centres.
Survey data for Paraná State (with a population of 9 million and a social and economic profile above the average for Brazil).
Data for ‘Synovitis’ relate to use of 198Au.
On the basis of data for the province of Ontario (representing about 37% of population).
Survey data relating to 90% of population.
‘Bone metastases’treatments also conducted using 153Sm (with a frequency of 0.0098 per 1,000 population) and 186Re (with a frequency of
0.0004 per 1,000); total for synovitis also includes use of 166Ho (with a frequency of 0.0002 per 1,000).
Germany:
Total for ‘Bone metastases’ relates to use of 89Sr and 186Re; total for synovitis also includes use of 169Er and 186Re.
Mexico:No information on radionuclide for synovitis.
Netherlands:
Total for ‘Bone metastases’ relates to use of 186Re and 89Sr.
Peru:
Total for ‘Bone metastases’ relates to use of 153Sm, 32P and 89Sr.
Turkey:On the basis of data from Hacettepe University Hospital.
Austria, Czech Republic, France, Greece, Hungary, Israel, Lithuania, Norway, Portugal, Switzerland: No information available on radionuclides used.

ANNEX D: MEDICAL RADIATION EXPOSURES

455

Table 68
Percentage contributions by treatment type to annual total numbers of therapeutic administrations ofradiopharmaceuticals (1991-1996)
Based on data and qualifications from Table 67

Country / area

Thyroidmalignancy

Hyperthyroidism

Polycythaemia
vera

Bone metastases

Synovitis

Totalof all treatments

Health-care level I
Argentina
Austria [H60]
Bulgaria
CanadaCroatia
CyprusCzech Republic
Denmark
EcuadorFinland [K59]
France [H60]
Germany
Greece [H60]
Hungary
IrelandIsrael [H60]
Italy
KuwaitLithuania
Netherlands
New Zealand [L28]
Norway [H60]
Portugal [H60]
Qatar
Romania
Slovakia
Slovenia
SwedenSwitzerland [H60]
United Arab Emirates
United Kingdom [C27]

38
6.3
34
10
45
60
19
6.8
31
20
22
30
19
6.7
1.3
51
29
23
11
20
14
51
0
74
68
0
3.3
10
55
8.0

62
61
31
80
55
25
22
93
64
64
70
52
78
85
45
68
77
72
64
78
43
100
26
30
92
81
56
45
80

0
0.2
5.0
1.3
0
0
0.4
0
0
12
0.6
0.9
5.6
1
0
0
3.9
7.3
0.3
0.7
0
0
0
0.3
8.6
0.6
0
5.0

0
2.6
0
1.6
0
15
18
0.3
4.9
2.5
7.1
1.3
11
0
2.3
0.3
0
3.1
0
5.1
5.3
6.2
3.8
0
0
0
2.4
8.0
4.8
0
3.7

0
0.9
30
5.9
0
0
41
0
0
1.9
4.5
7.1
1.9
0.3
0
0
0
7.7
2.9
0.4
0.6
0
0
0.8
4.7
0.3
12
0
2.8

100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100

Average a

21

68

2.0

3.0

4.4

100

Health-care level II
JordanMexicoPakistanPeru
Tunisia
Turkey

16
17
12
25
47
65

35
82
58
25
53
29

0.03
0.2
0
0
1.0

0.7
0.2
50
0
4.8

0.7
0
0
0

100
100
100
100
100
100

Average a

29

54

0.3

5.0

0.2

100

Health-care level III
Morocco
Sudan

13
13

87
51

0
0

0
36

0
0

100
100

Average a

13

81

0

5.5

0

100

Health-care level IVaEthiopia
United Rep. of Tanzania

0
14

100
86

0
0

0
0

0
0

100
100

Average a

3.1

97

0

0

0

100

Overall averages for sample calculated as total number of each particular type of treatment divided by total number of all treatments.

456

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 69
Distribution by age and sex of patients undergoing therapeutic treatments with radiopharmaceuticals (19911996)
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures
Healthcarelevel

Age distribution (%)
Country015 years

1640 years

Sex distribution (%)>40 years

Male

FemaleThyroid malignancy
I

II

III

IV

Argentina
Bulgaria
CanadaCroatia
Czech Republic
EcuadorFinland
IrelandJapan
KuwaitPanamaRomania
Slovakia
United Arab Emirates

5
0
0
0
4
4
0
0
0
3
0
4
0
0

49
43
43
14
29
50

46
57
57
86
67
46

20
27
20
12
29
29

80
73
80
88
71
71

30
9
64
38
30
40
41

70
91
33
62
66
60
59

25
23
27
20
34

75
77
73
80
66

57

43

Average

3

37

60

24

76

JordanMexicoPakistan
Peru
Turkey

2
2
11
0
0

43
46
56
30
51

55
52
33
70
49

12
20
48
30
40

88
80
52
70
60

Average

2

49

49

36

64

Morocco
Sudan

0
0

100
60

0
40

65

35

Average

0

94

6

65

35

United Rep. of Tanzania

0

0

100

0

100

















Hyperthyroidism
I

II

III

IV

Argentina
Bulgaria
CanadaCroatia
Czech Republic
EcuadorFinlandJapan
JordanKuwaitRomania
Slovakia
United Arab Emirates

2
0
4
0
0
9
0
0
3
0
0
0
8

46
81
39
13
9
58

52
19
57
87
91
33

19
3
27
14
9
19

81
97
73
86
91
81

23
43
60
35
35
23

77
54
40
65
65
69

18
32
40
20

82
68
60
80

35

65

Average

3

37

60

22

78

JordanMexicoPakistan
Peru

3
2
14
0

43
49
54
70

54
49
32
30

32
16
39
20

68
84
61
80

Average

7

51

42

26

74

Morocco
Sudan

0
0

100
75

0
25


6

94

Average

0

98

2

6

94

Ethiopia
United Rep. of Tanzania

0
0

0
100

100
0

8
15

92
85

Average

0

19

81

9

91















ANNEX D: MEDICAL RADIATION EXPOSURES

457

Table 69 (continued)
Healthcarelevel

Age distribution (%)
Country015 years

1640 years

Sex distribution (%)>40 years

Male

Female

0
0

100
100

90
68

10
32

Polycythaemia vera
I

II

Bulgaria
CanadaFinland
Ireland

0
0
0
0


0

100

50

50

Average

0

0

100

67

33

MexicoPakistan

0
0

0
17

100
83

100
100

0
0

Average

0

15

85

100

0







Bone metastases
I

II

III

CanadaCzech Republic
Ecuador
Kuwait

0
0
0



0
0
10

100
100
90



67
77
65
100

33
23
35
0

Average

0

0

100

75

25

MexicoPakistan
Peru
Turkey

0
33
0
0

0
33
0
1

100
34
100
99

70
100
50
51

30
0
50
49

Average

0

1

99

52

48

Sudan

0

30

70

50

50



Synovitis
I

II

Bulgaria
CanadaCzech Republic
Slovakia

0
0
36
0

47
0
37
0

53
100
27
100

63
50
73

37
50
27

Average

23

26

51

66

34

Mexico

0

87

13

83

17





All therapeutic procedures
I

II

IV

Argentina
Bulgaria
Croatia
Czech Republic
Ecuador
KuwaitSlovakia
United Arab Emirates

3
0
0
4
7
1
0
3

47
54
13
9
53
61
38
33

50
46
87
87
40
38
62
64

19
34
16
53
24
38

81
66
84
47
76
64

47

53

Average

3

38

59

28

72

JordanMexicoPakistan

2
2
16

53
48
37

45
50
47

29
17
72

71
83
28

Average

9

43

48

45

55

Ethiopia
United Rep. of Tanzania

0
0

0
85

100
15

8
13

92
87

Average

0

19

81

9

91





The entries in this Table are qualified as follows:
Argentina:
Canada:Turkey:On the basis of data from a sample of 25% of nuclear medicine centres.
Data from London Health Sciences Centre, SW Ontario (representing 50% of the services provided to population of about 1 million).
Survey data from Gülhane Military Hospital, Hacettepe University Hospital and Samsun Ondokuz Mayis University Hospital.



154 (110 222)
(150 200)
148 (111 185)
185
148
150
150

550 (±20%)370 (185 555)
260 (200 300)
185

3 700 (±20%)
3 700 (1 840 5 560)
5 550 (5 000 6 000)
3 238

3 510

JordanMexicoPeru
TurkeyAverage

148 e (111 185)

170

415

4 760

166

148

148

111

148
111

Health-care level II

140

136

150
150 (125 150)37200 (160 400)

Average

340

150
148
150
150

(250 400)
174 (120 259)















6 800 (4 000 7 400)
3 700 (2 275 5 550)










3 700 (± 50%)
4 334 (3 500 5 550)
(1 000 8 000)
3 700 (1 110 7 400)
5550 (2 500 11 100)
3 330
7 400
5 500 (8 000 max.)
3 303 (1 000 7 000)
5 550 (2 934 8 166)
3 700 (2 600 5 550)

(74 370)185433 (±122)185(300 1 500)
726 (±510)420
370 (±50%)
321 (148 425)(200 2 000)400 (185 500)555 (185 1 110)160106500 (1800 max.)
381 (150 1 000)
463 (±131)
260 (185 370)
350 (185 550)525 (240 1 500)422 (200 462)

4 477 (±1258)
3 300 (3 000 5 500)
(5 500 7 400)
4 706 (3 452 5 960)







Argentina
Bulgaria
CanadaCroatia
Denmark
EcuadorFinland [K59]
Germany
Ireland
Italy
Japan
KuwaitNetherlands
New Zealand [L28]
PanamaSlovakia
Slovenia
SwedenUnited Arab Emirates
United Kingdom[C27]

Sr chloride

Health-care level I

89

32

5

Y

300

Other

90

Other

P phosphate185
170 (110 220)

46 f (37 555)
3 885 (3 500 4 000) f
185
444

200

250

1 300 d

185
185

555 b
(15 30) c, (35 185) d
168 (148 185)168

1 300 d, 2 564 (1 295 3 000) f
1 300 dI iodide






131



I iodide

Synovitis




















131

Bone metastases










Polycythaemia
vera
32
P phosphate
























Hyperthyroidism































Thyroid malignancy



















































Country / area













































Table 70
Average a activities administered (MBq) in therapeutic treatments with radiopharmaceuticals (1991-1996)
Data from UNSCEAR Survey of Medical Radiation Usage and Exposures unless otherwise indicated458
ANNEX D: MEDICAL RADIATION EXPOSURES

300

185 (111 370)
350 (±2%)

3 700

Average

3 500

Average

Range or standard deviation in parentheses.
Data relate to use of 166Ho.
Data relate to use of 169Er.
Data relate to use of 186Re.
Data relate to use of 90Y.
Data relate to use of 153Sm.

3 500

Ethiopia
United Rep.
of Tanzania

Argentina:
Canada:Turkey:220

Health-care level IV

On the basis of data from a sample of 25% of nuclear medicine centres.
Data from London Health Sciences Centre, SW Ontario (representing 50% of the services provided to population of about 1 million).
Survey data from Gülhane Military Hospital, Hacettepe University Hospital, and Samsun Ondokuz Mayis University Hospital.

The entries in this Table are qualified as follows:

a
b
c
d
e
f

291

296 (222 444)300

3 700 (3 330 4 440)
3 710

Morocco
Sudan

Health-care level III

Other

Y

Other

P phosphate

I iodide

I iodideSr chloride

Hyperthyroidism
131

Polycythaemia
vera
32
P phosphate







131






Synovitis
90








Bone metastases








32











89











Thyroid malignancy








Country / area
















Table 70 (continued)

ANNEX D: MEDICAL RADIATION EXPOSURES
459

460

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 71
Annual numbers a of radiopharmaceutical treatments per 1,000 population assumed in global model forradionuclide therapy practice (1991-1996)

Level I

Level II

Level III

Level IV

World

% Contribution toworld total

Thyroid malignancy
Hyperthyroidism
Polycythaemia vera
Bone metastases
Synovitis

0.035
0.11
0.003
0.005
0.007

0.010
0.019
0.0001
0.002
0.0001

0.003
0.017
0
0.001
0

0.00001
0.00035
0
0
0

0.015
0.042
0.001
0.002
0.002

23
65
1
4
3

Total

0.17

0.036

0.021

0.0004

0.065

100

Diseasea

Estimated on the basis of average percentage distributions by treatment type (Table 68) and average total frequencies (Tables 67) observed for eachhealth-care level.

Table 72
Temporal trends in annual frequency of radiopharmaceutical treatments per 1,000 population
Data from UNSCEAR Surveys of Medical Radiation Usage and Exposures
Country197019791980198419851990

19911996

0.16
0.14

0.19

Health-care level I
Argentina
Australia
Austria
Belgium
Bulgaria
CanadaCayman Islands
Croatia
CyprusCzechoslovakia a
Czech Republic
Denmark
Ecuador b
FinlandFranceGermany
GreeceHungary
IrelandIsraelItaly
Japan
KuwaitLithuania
Luxembourg
Malta
Netherlands
New Zealand
NorwayPortugal
Qatar
Romania
Russian Federation c
Slovakia
Slovenia
Spain
SwedenSwitzerland
United Arab Emirates
United Kingdom
Yugoslavia a
Average



0.15


4







0.073





0.15









0.12



0.13
(0.007)
0.32

0.18

0.049

0.025














0.16
0.059





(0.02)





0.34
1.55



0.36


















0.29



0.03
0.30
0
0.031
0.080

0.31
0.88





0.18
















0.25
0.46
0.035
0.44
0.13
0.39
0.16
0.11
0.12
0.060
0.11



0.13
0.29

0.21
(0.0065)

0.030
0.018
0.19
0.075













0.29 d
0.16
0.26
0.068
0.044
0.068
0.010
0.11
0.30
0.20
0.4
0.27
0.024
0.25

0.11



0.093

0.10

0.17

0.18





0.051
(0.02)












0.20

0.086

0.17
0.12




0.052
(0.00)





0.43

ANNEX D: MEDICAL RADIATION EXPOSURES

461

Table 72 (continued)
Country197019791980198419851990

19911996

Health-care level II
Antigua and Barbuda
Barbados
BrazilChina
Dominica
GrenadaIndia
Iraq
JordanMexicoOman
Pakistan
Peru
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and
the Grenadines
Tunisia e
TurkeyAverage



































(0.35)



0.044


0.15



0.035




0.0036
0.013






0


0.033


0
0








0.13
0.038
0
0.028
0.034
0
0
0




(0.042)
0.008

0.042
0.048



0.021

0.036




0.011

Health-care level III
Egypt
Jamaica b
MoroccoMyanmar
Sudan
Thailand

0.064(0.17)

0.061






0.062
(0.005)



0.035

0.014
0.001
0.008

0.011
0.003
0.011

0.005
0.006
0.013

0.0064

Average

0.025

0.025

0.025

0.021




Health-care level IV

a
b
c
d
e

Ethiopia
United Rep. of Tanzania










0.00040.0002Average

0.0004

Historical data.
Categorized in health-care level II in previous analyses.
Historical data were not included in previous analyses.
These revised data were received by the Committee after completion of the global analysis.
Categorized in health-care level III in previous analyses.

462

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 73
Temporal trends in the average annual number a of the various types of radionuclide therapy treatments
per 1,000 population
Data from UNSCEAR Surveys of Medical Radiation Usage and Exposures
Average annual number of treatments per 1,000 population
Disease/site
Thyroid malignancy

Hyperthyroidism

Polycythaemia vera

Total of all radionuclide
therapyaPeriodHealth-care level I

Health-care level II

Health-care level III

Health-care level IV

197019791980198419851990
19911996

0.059
0.033
0.063
0.038

0.023

0.010
0.009
0.011
0.003





197019791980198419851990
19911996

0.088
0.10
0.022
0.15

0.023
0.024
0.020
0.017





197019791980198419851990
19911996

0.014
0.024
0.016
0.005

197019791980198419851990
19911996

0.086
0.093
0.10
0.17



0.00040.011


0.00040.020


0.00010.0001
0.044



0.021
0.036

0

0.0004







0.001
0.002
0

0





0.025
0.025
0.025
0.021

0.0004Overall averages calculated from national data as the total number of treatments divided by the total population for each treatment category. Data for19911996 from Table 67; since the total population is not the same for each treatment category due to the lack of comprehensive national data for all
countries included in the analysis, these average numbers can not be expected to be additive.

Table 74
Estimated annual numbers of therapeutic treatments with radiopharmaceuticals in the world 19911996

Health-care level

Population(millions)

Annual number of treatments
Millions

Per 1,000 population

I
II
III
IV

1 530
3 070
640
565

0.3
0.1
0.01
0.0002

0.2
0.04
0.02
0.0004

World

5 800

0.4

0.065

ANNEX D: MEDICAL RADIATION EXPOSURES

463

Table 75
Distributions of effective doses to volunteers from administrations of radiopharmaceuticals during
participation in research studies in Germany[B78]
No of research studies
Year

a
b
c
d

PET

Other

1997

17 a

19 b

1998

28 c

15 d

Range of effective dose(mSv)

Fraction of population by volunteer category (%)
Healthy persons

Patients

All

1
>16
>6  10>10  20>20  50
>50

50.5
16.7
3.0
23.8
6.0
0

0
8.1
17.9
68.3
5.0
0.7

3.6
8.7
16.8
65.1
5.1
0.7

1
>16
>6  10>10  20>20  50
>50

11.6
41.3
0
41.3
5.8
0

6.8
30.4
4.1
44.2
14.1
0.4

7.2
31.4
3.8
44.0
13.3
0.3

Distribution by radionuclide: 13 18F, 2 15O, 2 11C, and 1 68Ga. Distribution by speciality: 4 neurology/psychiatry, 12 oncology and 1 cardiology.
Distribution by radionuclide: 8 99mTc, 7 123I, 2 131I, and 1 81mKr. Distribution: 6 neurology/psychiatry, 9 oncology, 1 cardiology and 3 other.
Distribution by radionuclide: 14 18F, 6 15O, 8 11C, and 1 13N. Distribution: 18 neurology/psychiatry, 6 oncology , 3 cardiology and 2 other.
Distribution by radionuclide: 13 99mTc, 1 123I, 1 201Tl, and 1 81mKr. Distribution: 4 neurology/psychiatry, 5 oncology, 2 cardiology and 4 other.

Table 76
Guidelines for notification of incidents in the United Kingdom involving radiation equipment used for
medical exposure[H62]
Type of diagnostic examination
Barium enemas, barium meals, IVUs, angiography and other such procedures involving fluoroscopy(including digital radiology) and CT
Nuclear medicine: intended effective dose > 5mSv
Lumbar spine, abdomen, pelvis, mammography and all other examinations not otherwise included
Nuclear medicine: intended effective dose in the range 0.55 mSv
Extremities, skull, chest, dental examinations and other simple examinations such as elbow,
knee and shoulder
Nuclear medicine: intended effective dose < 0.5 mSv
Type of treatment
Beam therapy, brachytherapy
Radionuclide therapyaGuideline multiplying factor a
3
3
10
10
20
20
Guideline multiplying factor a
1.1 (whole course)
1.2 (any fraction)
1.2 (any administration)

For application to the ratio of suspected dose to intended dose, when deciding whether the patient exposure from an incident was ‘much greater thanintended’.

29

Nuclear medicine procedures

c

b

a

2.3

0.1

2.2

520

3

42

470

Level II

0.3

0.01

0.3

13

0.2

0.1

13

Level III

0.04

0.0002

0.04

11

0.01

0.1

11

Level IV

Number of procedures (millions)

5.5

0.4

5.1

2 500

32

520

1 910

World

1.3

0.08

0.01

1.2

Level I

Therapy c

0.15

0.008

0.001

0.14

Diagnosis

Level II

0.03

0.006

<0.0001

0.02

Level III

0.02

0.0003<0.0001

0.02

Level IV

Effective dose per caput (mSv)

0.4

0.03

0.002

0.4

World

2 000

120

9

1 900

Level I

450

23

4

425

Level II

18

4

0.01

14

Level III

13

0.2

0.01

13

Level IV

Collective effective dose (103 man Sv)

2 500

150

14

2 300

World

World population estimated to be 5,800 million in 1996 with following distribution between health-care levels of global model: 1,530 million (26%) in level I; 3,070 million (53%) in level II; 640 million (11%) in level
III; and 565 million (10%) in level IV.
Since, as discussed in Section I.C, many of these exposures are received by patients nearing the end of their lives and the doses are not distributed evenly amongst the population, these doses should not be used for theassessment of detriment.
Complete courses of treatment.

2.9

0.3

Nuclear medicine treatments

Total

2.6

Radiotherapy treatments

1 900

475

Dental x-ray examinations

Total

1 410

Level I

Medical x-ray examinations

Medical radiation use

Table 77
Estimated annual global practice and doses to the world population a from medical uses of radiation b (1991 1996)

464
ANNEX D: MEDICAL RADIATION EXPOSURES



1 800
1 600
2 300

1
0.35
0.3
0.4

h

520

90

70

340

j

i

17
18
14

(103 man Sv)

Collective
dose

0.003
0.003
0.002

23.5
24
32.5

10 40
4.7
4.5
5.6

l

m

(millions)kFrequency
per
1,000
population

Number of
exams

Per
caput
dose
(mSv)

Includes diagnostic uses of x rays and radiopharmaceuticals.
Annual increases by a few percent noted for technically developed countries.
Range of 380 1,270 per 1,000 in survey data from 9 developed countries.
Range of 260 410 per 1,000 in survey data from 12 countries.
Range of 39 1,240 per 1,000 in survey data from 12 countries.
Range of 35 1,660 per 1,000 in survey data from 11 countries.
Survey data (excluding mass surveys) for industrialized countries; 100 200 per 1,000 in developing countries.
Estimate for industrialized countries; lower value for developing countries where examinations are less frequent.
Range of 21 400 per 1,000 in survey data from 4 developed countries.
Range of 10 400 per 1,000 in survey data from 10 developed countries.
Range of 0.1 1.7 per 1,000 in survey data from 8 countries.
Range of 1.7 10.1 per 1,000 in survey data from 7 countries.
Range for industrialized countries; 0.2 2 per 1,000 in developing countries.
Range of 0.02 0.15 mSv for industrialized countries.
GSD same order as from natural sources (estimated range 0.2 2 mGy per year). Per capita mean marrow dose similar to that from natural sources (2.3 mGy per year).
Relative to risk from natural radiation: 0.3 for hereditary effects and 0.4 0.8 for risk of leukaemia.
Limited survey data (relative to annual doses from natural sources): GSD in range 0.1 0.5, per caput marrow dose in range 0.3 2.
0.5 1 mSv in countries with developed radiological facilities; 0.01 mSv in countries with limited facilities. Globally, 0.2 relative to dose from natural sources.













a
b
c
d
e
f
g
h
i
j
k
l
m
n
o
p
q
r

300 900
280
300
330






1 380
1 600
1 910

f

e



b

g

c

d








1958 [U13]1962 [U12]1972 [U8]1977 [U7]1982 [U6]1988 [U4]1993 [U3]2000 [Present](millions)(103 man Sv)









(millions)

Frequency
per
1,000
population

Number of
exams



Per
caput
dose
(mSv)










Collective
dose









Frequency
per
1,000
population










Number of
exams







UNSCEAR Report







74
160
150

(103 man Sv)

Collective
dose

Annual use of radiopharmaceuticals



Annual use of dental x rays







Annual use of medical x rays

0.015
0.03
0.03

n

Per caput
dose
(mSv)






Table 78
Trends in annual global use of radiation for diagnosis

0.4
0.4
0.3
0.4

r

q

p

o

Annual per
caput dosefrom
globalpractice a(mSv)

ANNEX D: MEDICAL RADIATION EXPOSURES
465

466

ANNEX D: MEDICAL RADIATION EXPOSURES

Table 79
Trends in annual global use of radiation for therapy
Teletherapy and brachytherapy

Radiopharmaceuticals

UNSCEAR Reports
Annual number oftreatments a (millions)

Annual frequency
per 1,000 population

Annual number oftreatments (millions)

Annual frequency
per 1,000 population

4.3
4.9
5.1

0.9
0.9
0.9

0.7
0.2
0.4

0.14
0.04
0.065

1988 [U4]1993 [U3]2000 [Present]aComplete courses of treatment.

ANNEX D: MEDICAL RADIATION EXPOSURES

References
PART A

Responses to UNSCEAR Survey of Medical Radiation Usage and Exposures

Country

Respondent

Argentina

A. Curti. Nuclear Regulatory Authority, Buenos Aires

Australia

D. Webb. Australian Radiation Laboratory, Yallambie

Bahrain

Response submitted by the Permanent Mission of the State of Bahrain to the United Nations in Geneva

BelarusG. Chijz. Ministry of Health, Minsk

Belgium

J. Van Dam. Katholieke Universtitet Leuven

BrazilJ. Tilly. Federal Centre of Technological Education of Paraná, Curitiba

Bulgaria

G. Vasilev. National Centre of Radiobiology and Radiation Protection, Sofia

CanadaS. Vlahovich. Radiation Protection Bureau, Ottawa

Cayman Islands

R Namburi. Cayman Islands Government Hospital, Grand Cayman Island

China

D. Li. China Atomic Energy Authority, Beijing

China (Taiwan Province)

C.-N. Guan. Atomic Energy Council, Taipei

Costa Rica

P. Mora. University of Costa Rica, San José

Croatia

S. Gigi. Ministry of Health, Zagreb

CyprusC. Stelios. Medical Physics Department, Nicosia General Hospital

Czech Republic

Z. Prouza. State Office for Nuclear Safety, Prague

DenmarkO Hjardemaal and K. Ennow. National Institute of Radiation Hygiene, Brønshøj

Ecuador

S. Moreno. Comision Ecuatoriana de Energia Atomica, Quito

Ethiopia

S. Demena and D. Walelign. Nuclear Medicine Unit, Addis Ababa University

Finland

R. Havukainen. Finnish Centre for Radiation and Nuclear Safety, Helsinki

FranceJ.F. Lacronique. Office de Protection contre les Rayonnements Ionisants, Le Vesinet

Germany

B. Bauer. Federal Office for Radiation Protection, Institute of Radiation Hygiene, Munich

GreeceP. Dimitriou. Greek Atomic Energy Commission, Attikis

Hungary

P. Vittay. National Institute for Radiology and Radiation Physics, Budapest

Ireland

D. Fenton. Radiological Protection Institute of Ireland, Dublin

Italy

F. Dobici and J. Wells. National Agency for the Environment Protection, RomeJapan

T. Maruyama. National Institute of Radiological Sciences, Chiba

JordanO. AL-Taleb. Nuclear Medicine Department, Al-Bashir Hospital, Amman

KuwaitJ. Al-Mudaires. Ministry of Health, Dahayat Abdulla Al-Salem

LebanonN. Khoury and M. Nasreddine. Lebanese Atomic Energy Commission, Beirut

Libyan Arab Jamahiriya

D. Abouhadra. Scientific Research, IAEA Division, Tripoli

Lithuania

B. Švykait. Radiation Protection Centre, Vilnius

467

468

ANNEX D: MEDICAL RADIATION EXPOSURESCountry

Respondent

Luxembourg

C. Back. Division de la Radioprotection, Direction de la Santé, Luxembourg

Madagascar

Institut National des Sciences et Techniques Nucleaires, Antanana Rivo

Malaysia

Kwan-Hoong. Ng. University of Malaya Medical Centre, Kuala Lumpur

MexicoC. Medina Villegas. Instituto Mexicano de Seguro Social, Mexico City
M. Verdejo. Secretaría de Salud

MoroccoY. Charif. Centre National de Radioprotection, Sale

Netherlands

L.W. Meinders. Inspectorate for Health Care, Rijswijk

New ZealandJ. Le Heron and V. Smyth. National Radiation Laboratory, Christchurch

NorwayG. Saxebøl. Norwegian Radiation Protection Authority, Østerås

Oman

Director General of Health Affairs, Ministry of Health, Muscat

PakistanHead, Regulation Enforcement Division, Directorate of Nuclear Safety and Radiation Protection, Islamabad

PanamaE. Gibbs. Departmento de Salud Radiologica, Caja de Seguro Social, Panama

Peru

L. Pinillos Ashton and R. Morales. Instituto de Enfermedades Neoplasicas, Lima

Philippines

B. San Juan. Radiation Health Service, Department of Health, Manila

PolandJ. Jankowski and M.A. Staniszewska. Nofer Institute of Occupational Medicine, Lódï

Qatar

A.M. Ismail. Hamed Medical Corporation, Doha

RomaniaC. Milu. Institute of Hygiene and Public Health, Bucharest
C. Diaconescu. Institute of Public Health and Medical Research, Iassy

Russian Federation

S.A. Kalnitsky and Y.O. Yakubovsky-Lipsky. St Petersburg Institute of Radiation Hygienne
G.P. Zharkova. Institute of Biophysics, Moscow

Slovakia

P. Gaál. State Health Institute of the Slovak Republic, Bratislava

Slovenia

M. Kriñman. Slovenian Nuclear Safety Administration, Ljubljana

Spain

E. Vañó and M. Bezares. Ministry of Health, Madrid

Sudan

O.I. Elamin. Sudan Atomic Energy Commission, Khartoum

SwedenW. Leitz. Swedish Radiation Protection Institute, Stockholm

Switzerland

J. Marti. Swiss Federal Office of Public Health, Berne

Tanzania

W. Muhogora. National Radiation Commission, Arusha

TunisiaS. Mtimet. Centre National de Radio Protection, Tunis

TurkeyG. Buyan, N. Turul, B. Okyar, M. Vural, E. Uur, I. Ingeç. Turkish Atomic Energy Authority, Ankara

United Arab Emirates

R. Cheesman. Federal Radiology Department, Ministry of Health, Abu Dhabi

United Kingdom

P. Shrimpton. National Radiological Protection Board, Chilton

United States of America

R. Burkhart. Food and Drug Administration, RockvilleANNEX D: MEDICAL RADIATION EXPOSURES

469

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A2

A3

A4

A5

A6

A7

A8

A9

A10

A11

A12

A13

A14

A15

A16

A17

A18
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M80 Mirzadeh, S. Generator-produced alpha-emitters. Appl.
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M83 Maisey, M. Radionuclide imaging in cancer management.
J. Royal Coll. Phys. London 32(6): 525-529 (1998).

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M84 Macapinlac, H.A., A.M. Scott, S.M. Larson et al. Gallium67-citrate imaging in nuclear oncology. Nucl. Med. Biol.
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M86 McCready, R. and R. A’Hern. A more rational basis fordetermining the activities used for radionuclide imaging?
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N13 National Council on Radiation Protection andMeasurements. Sources and magnitude of occupational andpublic exposures from nuclear medicine procedures. NCRP
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N33 Nitta, N., M. Takahashi, K. Murata et al. Ultra-low-dose
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O6

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ANNEX D: MEDICAL RADIATION EXPOSURES

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S21

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