SOURCES AND EFFECTS
OF IONIZING RADIATION
United Nations Scientific Committee on the Effectsof Atomic Radiation
UNSCEAR 1993 Report to the General Assembly,
with Scientific Annexes

UNITED NATIONSNew York, 1993

NOTE
The report of the Committee without its annexes appears as Official Records of theGeneral Assembly, Forty-eighth Session, Supplement No. 46 (N48/46).
ll1e designation employed and the presentation of material in this publication do not imply
tl1e expression of any opinion whatsoever on the part of tlie Secretariat of the United Nations
concerning the legal status of any country, territory, city or area, or of its authorities, or concerning
tl1e delimitation of its frontiers or boundaries.
The country names used in this document are, in most cases, those tliat were in use at thetime the data were collected or the text prepared. In other cases, however, the names have been
updated, where tliis was possible and appropriate, to reflect political changes.

UNITED NATIONS PUBLICATION
Sales No. E.94.IX.2
ISBN 92-1-142200-0

ANNEX C
Medical radiation exposures

CONTENTS

Page.......................................... 2 2
I. ANALYSIS OF MEDICAL EXPOSURES . . . . . . . . . . . . . . . . . . . . . . 223
A . MEDICAL RADIATION USAGE . . . . . . . . . . . . . . . . . . . . . . . . 223
B. DOSE EVALUATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
C. BENEFITS AND RISKS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
D. SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
I1. DIAGNOSTIC X RAY E W I N A T I O N S . . . . . . . . . . . . . . . . . . . . . . 218
A. FREQUENCIES OF EXAMINATIONS . . . . . . . . . . . . . . . . . . . . . 2 3
B. AGE- AND SEX-DISTRIBUTIONS . . . . . . . . . . . . . . . . . . . . . . . 230
C. DOSES IN EXAMINATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
1. Fluoroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232

INTRODUCTION

2 . Computed tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
3 Chest examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
4 . Mammography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .236
5 . Chiropractic examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
6 . Neonatal and child cxaniinations . . . . . . . . . . . . . . . . . . . . . . 237
DENTAL X-RAY EXAMINATIONS . . . . . . . . . . . . . . . . . . . . . . 238
WORLDWIDE EXPOSURES . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
TRENDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
1. Specific x-ray examinations and techniques . . . . . . . . . . . . . . . 243
2. Alternatives to x-ray examination . . . . . . . . . . . . . . . . . . . . . . 244
3 Particular patient groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246
4 . Effects of quality assurance programmes . . . . . . . . . . . . . . . . . 247
SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249

.

D.
E

.

F.

.

G.

111. DIAGNOSTIC USE OF RADIOPHARMACEUTICALS ............ 250
A. FREQUENCIES OF EXAMINATIONS ..................... 250
B. DOSES IN EXAMINATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
C. WORLDWIDE EXPOSURES . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
D . TRENDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .254
1 Spccific melhods in nuclear n~cdicine ................... 254

.

Page

2 . Alternatives to nuclcar nlcdicine . . . . . . . . . . . . . . . . . . . . . . 256
3 . Effccts of quality assurance prograninlcs . . . . . . . . . . . . . . . . . 256
E. SUhiMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .256
IV. THERAPEUTIC USE OF RADIATION . . . . . . . . . . . . . . . . . . . . . . . . 257
A. FREQUENCIES OF TREATMENTS . . . . . . . . . . . . . . . . . . . . . . 257
B . DOSES IN TREATMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
C. WORLDWIDE EXPOSURES . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
D. TRENDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
E. SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .261
V. THERAPEUTIC USE OF R A D I O P H A M C E U n C A L S . . . . . . . . . . . 262

A.
B.
C.
D.
E.

FREQUENCIES OF TREATMENTS ...................... 262
DOSES IN TREATMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
WORLDWIDE EXPOSURES . . . . . . . . . . . . . . . . . . . . . . . . . . .262
TRENDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .263
SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263.

VI EXPOSURES OF THE GENERAL PUBLIC . . . . . . . . . . . . . . . . . . . . 263
A. DIAGNOSTIC X-RAY EXAMINATIONS . . . . . . . . . . . . . . . . . . 263
B. RADIOPHARMACEUTICALS . . . . . . . . . . . . . . . . . . . . . . . . . . 263
C RADIATION THERAPY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
D . VOLUNTEERS IN MEDICAL RESEARCH . . . . . . . . . . . . . . . . . 265
E SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265.
.

VII . EXPOSURES FROM ACCIDENTS
IN MEDICAL RADIATION USAGE. . . . . . . . . . . . . . . . . . . . . . . . . 266
CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266

Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355

INTRODUCTION
1. Ionizing radiation is widcly uscd for both h ediagnosis and treatment of injuries and disease. As aresult of his practice. individuals and populations
receive significant exposure to radiation. allhough theynormally receive in retuni the direct benefi~rin hcallhcare Nevertheless, there is a continuing nced toanalyse the Gequencies. doscs and trends of diagnostic
and therapeutic medical radiation procedurcs worldwide . Such information permits the evaluation ofregional difrcrcnces in mcdical radiation usage. comparisons wih other sources of radiation. the identification of areas of concern. and the estimation ofpresumed detriment.It can also be used by ministriesof health and other bodies involved in optimizationand other aspects of radiation protection .

.

2. The Comn~ittee has repeatedly assessed exposures from thc medical uses of radiation. The
available data have been evaluated and extrapolated toworldwide usage. In tbe UNSCEAR 1988 Report[Ul 1. the Commitlcc estimated that medical radiation
cxposurcs ranged from 0.4 to 1 mSv annually percapul Exposures from medical radiation. whichamount to less than half the exposure to natural background radiation. excccd those from all other manmadc sources.

.

3. The purpose of this Annex is to provide an
updated review and assessment of medical radiation
exposures worldwide. Within this framework. there are
specific objectives. such as to detcrniine temporal andANNEX C: MEDICAL RADIATION EXPOSURFS

rcgional trcnds in doscs and pracliccs; to asscss llow
UIC ilitroduction of ncw tcchniqucs, radiation protcction nicasurcs or quality assurance prograninics affectthcsc trcnds; to cvaluate the variations in dosc for
givcn proccdurcs and for total pracliccs as wcll as thc
rcasons for such variations; and to cxaminc thc agc
distributions of paticnts subjcctcd to various proccdurcs. Whilc somc of thcsc objcctives arc descriptive,
Lhcy could also scrvc as quantitative inputs foranalysis. c.g. risk-hcncfit analysts.

4. Mcdical radiation cxposures arisc from the diagnostic usc of x rays and other cxtcrnal radiation
sources and internally adniinistcrcd radioisotopes as
wcll as from thc thcrapcutic use of external and scalcd
intcrnal sourccs of radiation and radiophamaccuticals.
Thc basic information nccdcd for assessing mcdical
radiation cxposurcs is thc frcqucncy of cach typc ofdiagnostic or thcrapcutic procedure arid thc doscs toall parts of thc body. Siricc thcrc arc considerable
variations in valucs from country to country, comprchcnsivc data arc rcquircd to makc the assessment

I.

223

con~plctcarid accuratc. From data asscrnblcd in a consistcrit nianncr over timc, ilnporbat trcnds should bc
apparcnt in cxposurcs froni mcdici~lradiation usagc.
5.
One impcdinicnt to UIC accuratc asscssmcnt of
mcdical radiation cxposurcs has bccn thc incomplctcncss or unavailability of data for many rcgions of
the world. T o improvc this situation, the Comniittcc
scnt a qucstionnairc on medical radiation usage to all
Statcs Mcmbcrs of thc Unitcd Nations. Information
was rcqucstcd on cxaniination and trcatmcrit facilities;
the number, age- and SCX-distributionof patients; anddoses from proccdures. Not all countries wcrc ablc toprovidc Lhe information rcqucstcd, but thc rcsporiscs
received constitutc a valuable databasc for theCommittee's evaluation, supplenicnting publishcd
scicntific papcrs and reports and p c m i t t i ~ ~ag Inore
complctc and accurate analysis of mcdical radiation
exposures. Thc Conlrnit~ccgratefully acknowledges the
response of s o many countries to thc UNSCEAR
Survey of Medical Radiation Usagc and Exposures.
The countries are listcd in Part A of the Rcfcrcnccs.

ANALYSIS OF MEDICAL EXPOSURES

6. Ionizing radiation is used for two main purposesin mcdicinc: diagnosis and U~crapy.Of hcsc, diagnosis
is much more common and is cxpcrienccd by niany
morc peoplc. The doscs to pcrsons being cxamincd areusually quitc low. Radiation therapy, by contrast, isuscd mainly to trcat cancer paticnts. Whilc a high dosc
dclivcrcd to a limited, predetermined location is
rcquircd to kill malignant tissue, it is neccssary to
restrict thc irradiation of surrounding nornial tissues.

that were available, thc Committee undertook a survcy
in 1990-1991 of mcdical radiation usagc and exposures worldwide. Questionnaires wcrc scnt to 140
countries, and over 50 rcspondcd. The data containedin thcsc responses, combincd with data i n publishcd
papers, cover more mcdical radiation scrviccs andcxposures than the data available for previous Reports
ofthc Committee and thus pcnnit iniprovcd worldwide
dosc estimates.

Radiation exposures from mcdical examinations
7.
and trcalrnents are determined by thc type andfrcqucncy of the procedure and by the doscs to tissucs
in thc radiation ficlds. Because of the great regional
diffcrcnccs in thc availability of mcdical radiation
scnficcs, it is necessary to have an cxtcnsive databaseto evaluate the radiation cxposurcs worldwide. Although morc counlrics arc now collecting statistics on
mcdical radiation usagc, the Committee is still forccd
to make rather largc extrapolations to dctcrmine thetotal dosc to all pcoplc. Thc availability of mcdical
radiation data and the proccdures for extrapolation anddosc evaluations arc discussed in this Chapter.

An analogous survey. but limitcd to six common
9.
types of x-ray examination in 24 x-ray dcpartmcnts in
10 Europcan countries, was carried out by the Commission of the Europcan Communities [M23]. Hitherto, h a t survcy has scnlcd mainly for optimizing x-ray
examination procedures rather than for describing theimpact on the population of the doscs from the examinations [M23, M261. A survcy of x-ray cxaminationsin the USSR is dcscribcd in a prclinii~~ary
rcport [N4].
Two rclatcd surveys, one in China 1261 arid one in
India (S401, hascd on sound statistical sampling havebeen made available to thc Committee.

A.

h1 EDICAL Hn1)MTION USAGE

8.
Xot all countries are able to provide statistics on
mcdical radiation cxposures. To supplement the data

10. The improved databasc docs not obviatc the nccd
for ex~rapolationof the available data, cspccially forthe least dcvcloped rcgion~ of dlc world. In the
UNSCEAR 1988 Report [UI 1, a good correlation wasshown to exist betwecn thc nunlbcr of x-ray cxaniinations per unit of population and the numbcr of224

UNSCMR 1993 REPORT

physiciar~spcr unit of population. Accordingly, data on
diagnostic x-ray frcqucncics in a small numbcr of
c o u ~ ~ t r i couldcs
bc cxtrapolatcd to cstimatc diagnostic
in all rcgions of thc world, bascd on
x-ray frcquc~~cics
a nlorc widcly available statistic, thc numbcr ofphysicians pcr unit population. Countries wcrc
catcgorizcd as to lcvcl of hcalth carc, bascd on thc
population pcr physician [Ul].In countrics of hcalthcarc lcvcl I , thcrc is at lcast onc physician for cvcry
1,000 population; hcalth-carc lcvcl 11, onc physician
for 1.000-3,000 population; hcalth-care lcvcl 111, onc
for 3,000-10,000 population and hcalth-carc lcvcl IV,
onc for more than 10,000 population.
11. Although thcrc will in futurc bc greatcr rcliancc
on thc dircct reporting of examination or trcatmcnt
frcqucncics, thc grouping of countrics according to
Icvcl of health care is rctaincd here for the analysis of
mcdical radiation cxposurcs. Thc use of hcalth-carc
lcvcls has scvcral advantages: it givcs a basis for
extrapolating data on mcdical radiation usage to thecntirc world: it allows comparing trends for diffcrcnt
Icvcls of hcalth carc; and it is consistcrit with thc
analysis in thc UNSCEAR 1988 Report [Ul].
12. Thc World Hcalth Organization (WHO) has
carricd out two major surveys of physician dcnsitics(nurnbcr of physicians pcr 1,000 population) 12118,
Wl]. Thc first set of data ccntrcd on thc ycar 1977
and thc second on 1984. The 1977 data wcrc used by
thc Committee to evaluate medical radiation exposuresfor h c UNSCEAR 1988 Report [Ul]. It should be
notcd that thcrc arc unccflainties in the WHO databccausc physicians arc dcfined differently in difkrcnt
countries.
13. Thcrc may wcll also be questions of the validityof assigning an avcragc hcalth-care levcl to an cntirc
muatry, for such a valuc may obscure widc variations.
As an cxamplc, Brazil, at lcvel I1 (it has one physician
pcr 1,035 population), is geographically and demograpl~icallyhctcrogcncous, and its lcvcl of develop
mcnt varies greatly [C14, D4]. Urban areas such as
Brasilia (one physician pcr 500 population) arc typicalof lcvcl I, while the states of Acrc and Maranhao (onephysician pcr 3,000 population) approach levcl 111.
Largc countrics at lcvcl I may also contain Iess-dcvelopcd arcas, and in most countries, there arc diffcrcnccs in h e availability of mcdical radiation in urban
and rural arcas. Since thc correlation between medical
radiation facilities and numbcr of physicians is notahsolutc, thc availability of n~cdicalradiology in aparticular country may be bcttcr or worse than
indicated by its health-care levcl. particularly duringpcriods of rapid dcvclopmcnt. Ecuador moved fromlcvcl I1 to lcvcl I bctwcen the two WHO sunleys, but
h e dcnsity of equipment and frcquencics of cxamination and trcatmcnt arc still typical oflevcl I I countrics.

14. As hcalth care islprovcs, i t can be cxpcctcd thath e distribution of thc world population in the four
hcalth-carc c;~tcgoricswill shift. In thc 1977 survcy,
the distribution was as follows: 29%, 35%, 23% and
13% in lcvcls I-IV, rcspcctivcly. In h c 1984 survcy,
it was 27%, SO%, 15% and 8%. The most significant
change was thc incrcasc in ttlc proportion of pcoplc
living in countrics at lcvcl 11, as improvcmcnts in
hcalth a r c ~ i u s c dcountrics formcrly at lcvcls 111 andIV to rnovc up. Using the 1984 WHO survcy to
dctcrniinc a country's I~calth-carcIcvcl and taking into
account population growth, the numbcr of pcoplc incach hcalth-carc lcvcl in 1990 was as follows: lcvcl I,
1,350 million; lcvel 11, 2,630 million; lcvcl 111, 850
million; and lcvcl IV, 460 million.
15. Tablc 1 indicates the lcvcl of health carc and the
population of thc 93 countries appearing in subscqucnt
tables or othcrwisc discussed in this Annex. The tablealso lists thc infornlation obtaincd by thc UNSCEAR
Survey of Mcdical Radiation Usagc and Exposures on
the numbcr of radiologists and the nurnbcr of x-ray
units, therapy units and rluclcar mcdicinc clinics. The
availability of mcdical radiation services in the four
hcalth-care lcvcls of the world is summarized in
Tablc 2, which givcs t l ~ cnumbcr of radiologists andthe number of facilitics per 1,000 population. Tablc 3
lists the numbers of diagnostic examinations andtherapeutic treatments. While some of thc rcspondcrlts
gave the number of patients, others may have givcn
the nurnbcr of examinations and proccdures. Although
thc one may be a first approximation of the other, thc
two quantities can diffcr by a factor of 3 or more,
dcpcnding on the procedure.
16. Therc arc s o n ~ cgeneral limitations in dataobtaincd in surveys of mcdical radiation uses andcxposures. Thus, estimates of countrywide values areoncn bascd on cxtcnsivc extrapolations from small
samples. Some data arc very coarsely rounded, whileothers may bc spuriously prccisc. Varying definitions(of, for example, "radiologist", "examinationn or "x-ray
unit") and diffcrcnt ways of categorizing individual
procedures contribute to thc variations and inexactness of all data. In sornc cases, national x-ray statistics
may be co~ifoundedby staristics on ultrasound cxarninations, cntercd as "radiological" proccdures. Thcse
unccrtaintics underlie thc data obtaincd in the
UNSCEAR Survcy of Medical Radiation Usagc andExposures. Although Ihc data in the Tables arc givcn
to two or sonlctimcs cvcn thrce significant figurcs,
thc statistical precision is obviously alrnost always
less.
17. Thesc unccrtaintics notwithstanding, a reasonable
degree of compilation and analysis scc~ncdfcasihle.
The number of responses from lcvcl I cour~tricsand
the completeness of these responses, should give

ANNEX C: MEDICAL RADlATION EXPOSURES

adcquatc statistical rcliability. With data available for
China and India, thc rcprcscntativc~icss of data on
lcvcl I1 countries is also quitc high. For countrics with
Icss-dcvclopcd mcdical scrviccs the precision is lowcr,
but on a worldwide basis, this has littlc impact on theestimation of Lhc pcr caput effcctivc dose or thc
collcctivc dosc from nlcdical radiation usagc.
18. Mcdical radiation facilitics arc vcry uncvcnly
distributed throughout thc world. Table 2 shows thatthc numbcrs of facilities pcr 1,000 population are from
20 to 1,000 timcs smallcr in countrics of health-care
lcvcl IV than of level I, the numbers differing by afactor of up to 50 bctwccn diffcrcnt hcalth-care levcls.
Within hcalth-carc levcls thcrc is gcncrally a closcr
relationship bctwccn the number of facilitics and thc
size of thc population, but even herc the variations arenotablc.
19. Thc trends obsenlcd in mcdical radiation
facilities arc uncvcn. At lcvcls 11-TV the availability offacilities has generally been increasing with time. At
Icvcl 1 the numbcr of mcdical and dcntal x-ray units
and therapeutic x-ray units per unit population havedecrcascd somcwhat Since the countrics constituting
thc health-carc lcvcl may be different for the different
periods, somc caution must bc exercised in attributing
rcal differences.
20. The data in Tables 2 and 3 can be used toestimate the total numbers of medical radiation
facilities and usage in the world. These results are
given in Table 4. The average normalized quantities
havc been applicd to Lhc total population of eachregion. Thc main point to note is that level I, with
25% of the world population, accounts for some 70%of thc diagnostic x-ray cxaminations and for 90% of
the patients for therapy and nuclear medicine trcatmcnts. Thcrc is still a far from cquitablc distributionof mcdical radiation scntices in the world.

B. DOSE EVALUATION
21. Doscs to tissues and organs from nicdical radialion exposures are evaluated in terms of absorbed
dose. For x-ray examinations, the dose without backscattcr at the entrance side of the patient is specified
by thc air kerma. The effect of backscatter is includedin the specification of the entrance surface dose. T ofacilitate thc summary of results and the comparison
with exposurcs from othcr sources of radiation, it has
been the practicc of the Committee to evaluate
effective doscs from the procedures. Along with its
simplifying advantages, this quantity has limitations
whcn applied to nlcdical radiation exposures.

2 2 Earlier assessments by the Committee of medical
radiation exposures in the UNSCEAR 1958, 1962 and225

1972 Repolis [ U s , U9, UlO] strcsscd t l ~ cgcricticallysignificant dose. This gavc sonlc common nlcasurc forthc uncvcn dose distributions from various proccdurcs
and also rccognizcd that thc agc distribtrtion ofpaticnts or individuals cxanlincd diffcrcd from that ofthc gcncral population. Thc ~ ~ S Cto Sbonc nianow
werc also cvaluatcd. Doscs to additional organs wcrc
estimated in the UNSCEAR 1977 Rcport [U4]. Beginning with tllc UNSCEAR 1982 Rcport [U3] and continuing in the UNSCEAR 1988 Rcport [Ul]. thc cffcctive dose cquivalcnt was cvaluatcd. Thc Conimittcc's
decision to express patient doscs in tcrms of cffcctive
dose is bascd mainly on the potential for comparisons
this provides. Effcctive doses pcrmit, in principle atleast, comparisons betwccn time periods, countries,
health-care levels, medical mcthods and sources ofradiation.
23. It is not possible to obtain a correct estimate of
detriment from multiplication of effcctive doscs topatients by the nominal fatality probability coefficients
given by ICRP P8]. This has several reasons [D13]. In
the f m t place, patients are by their very nature agroup which can expect to benefit from medical
radiation exposure. Thus, for paticnts, radiationinduced detriment cannot be computed or regarded as,
for example, an occupational hazard. Any analysis
would not be fair without consideration of the increasein health obtained from the medical radiation usage.
This is usually easily done in individual cases, butthere are no gencral methods to compare overall
hazards and benefits.
24. Anothcr difficulty is that paticnts, because of
their health status, may respond differently to theradiation exposurcs than thc base population. Mcthodsof deriving separate risk estimates for paticnts, which
would take account of thcir hcallh status, have not yct
been fully dcvelopcd [H17, H341. Furthermore, theage and sex distribution of patients will rarely matchthat of the population for whom the nominal fatality
probability coefficicnts of ICRP p8] were derived.
Several ways to adjust for diffcrcnt age and sex
distributions havc been suggested [S47, V9], but thesc
have not bccn applicd to thc data in this Annex, since
the purpose of using cffcctive dose herc is not toprovide input for calculations of estimated detriment,
but to facilitate comparisons bctwcen exposed groups.

25. Most, but not all. of the values giver1 in thisAnnex were calculated as effective dose equivalcnts.
Therefore, throughout this AMCX, a distinction ismade between effective dose equivalents, HE 1111 andeffective doscs, E 118). Typical values arc indicated forspecific examinations. Average cffectivc doses or
effective dose equivalcnts rcfcr to the arithmetical
average among examined paticnls. Per caput doses
refer to the arithmetical average in the entire popula-

226

UNSCMR 1993 REPORT

tion (including non-examined individuals). Both of
thcse may refcr to specific examinations or to total
doses for an cntire medical radiation practice. When
avcragc or pcr caput doses from different countries are
combincd, this is normally done on a populationwcightcd basis.

and modcls uscd affcct thc numerical results for bothorgan doscs and effective doses. The influence of thc
modcls for thc radiation sourcc, thc human body, theradiation transport calculation and the definition ofdose equivalent havc been investigated in scvcral
papers IB2, D2, V7, 2151.

26. Thc relationship bctwecn E and HEis discussed
in a nunlbcr of publications IH36, L22, R27, S44,
W28, 271. The results of dosc calculations areincludcd in Tablc 5. Generally lower values ofcffective dose compared to effective dose equivalent
are obtained for examinations of the chest and skull,for mamnlography and for computed tomography.
Higher values arc obtained for examinations of theabdomen and gastro-intestinal tract. The specificvalues are not always consistent in the various
calculations. In particular, Hutla et al. [H36] obtaincd
lower E m E estimates for the chest and skull andhigher estimates for the abdomen than other authors.
This difference is mainly attributable to the way the"rcmaindcr" dose was computed for HE IL22, H291.
However, while the range of EMEvalues of Huda etal. [H36] is widest, with. individual values ranging
from 0.24 to 2.1, their average value for all
cxaminations of 0.9 seems similar to average EME
values from other sources. Thus, although WEvalues
for specific types of examination may deviate Gom
unity, the total effective doses for diagnostic x-ray
examinations should be fairly similar whether
computed with thc 1977 or the 1990 weighting factors.
This has bccn vcrified for a range of typicalcxaminations in scvcral countries. The E M E values
ranged from 0.93 to 1.13, a variation that is certainly
no grcatcr than the variation in effective dose resulting
from differences bctween countries in avcrage patient
size (G21, M43]. The average of all E m E values is
1.01, supporting the notion that effective doses for
entire practices, such as diagnosticx-ray examinations,should be insensitive to the choice of weighting
factors, even if individual examinations deviate
somewhat morc. It should be noted, however, that theconclation between energy imparted and effective
dosc becomes weaker with the ICRP 1990 1181
weighting factors [H36].

29. When cited papcrs statc exposurc only
(expressed in C kg-' or in non-SI units), this has bccn
convcrted to surfacc air kcrma using the relationshipthat 2.58 lo4 C kg-' is equivalent to 8.7
Gy. Fortherapy, cffectivc doscs are not easily used for
purposes of comparison. Although effectivc doses toradiotherapy patients are bricfly discussed in thisAnnex, thc impact of therapy is primarily described by
the number of patients trcated and the age- andsex-distribution of these patients.

27.

The situation is similar for nuclear medicine
cxaminations [H36, G21, G22, J8]. The average of all
EME values is, as for x-ray examinations, around 0.9(Tablc 5). E/HE values cxcceding 1 occur mainly
when the lhyroid is exposed. Values of the effective
dose equivalent (HE) for most radiopharmaceuticals
are listed in lCRP Publication 5 3 [IS]; values of theeffective dose (E) for thcse substances are alsoavailable 1114, J91.

28. Since organ doses are in most cases notmeasured but calculated, the underlying assumptions

C. IlENEFITS AND RISKS
30. Exposures to patients in mcdical diagnostic
examinations and treatments arc made in anticipationof the direct benefits to be rcceived by the paticnt.
Usually the risk to the individual is small in
conlparison with the benefit, and it is easy to justify
the exposure. Risk can be assessed for the exposed
populations, although thc procedures are not sostraightforward. The dosc quantities to be used in
detriment evaluations wcrc considered in the previous
Section. Some general considerations on benefits andrisks in medical uses of radiation are presented below.
31. In diagnostic radiography, the dose must be
sufficient to obtain the desired information. If too low
a dose is chosen, the image may be of unacceptably
low quality [G19]. Within a relatively narrow doseband, the amount of infonnalion is generally correlatedwith the dose used. This is, of coursc, not the casewhen high doscs arc simply the result of unsatisfactory
technique, for example, too large a ficld, the incorrect
positioning of the patient or incorrect film processing(undcrdevelopnicnt) in x-ray examinations. Even quite
small deviations from satisfactory techniques canremove the correlation [Llg]. But to some extent,
there is a posilive correlation between dose andinformation for a given technique: doses that are too
low permit random noise to blur thc images so thatthey arc not clinically useful [G2]. Particularly influoroscopy, images may appear to improve in quality
with increasing dose to the patient [B4].
32 In therapy, it is ncccssary that deterministic
effects be induced in the target organ. In conscqucnce.
the dose to the targct organ must usually exceed somethreshold. Bclow this threshold, no bcncfit at all islikely to result. Above the lhreshold, the dose imparted
to lhe target volume must be delivered within a

A N N M C: MEDICAL RN>lr\nON L Y P O S U R ~narrow range, sincc higher doses do not produce anextra bcnefit but may cause scrious injury or death.
This description is simplified, sincc thc height of thc
thrcshold can be mar~ipulatcdin various ways, such aswith concuncnt chemotherapy, but it indicates that thc
amount of bcncfit is not lincarly corrclatcd wit11 thedosc in radiotherapy.
33. The risks associatcd with the diagnostic uscs ofionizing radiation arc normally limitcd to late stochastic cffccts, which are estimated to occur at a frcqucncy of perhaps 0.01% for an avcragc examination(deterministic skin damage may occur after fluoroscopy in extreme cases). At the individual levcl, theserisks are almost always small compared to the benefitof diagnosis and treatment. They may also help toavert a competing risk; for instance, cardiac fluoroscopy could entail entrance surface doses of several
gray, possibly even inducing deterministic skindamage, but might obviate the need for open heart
surgery. In contrast, the risks associated withradiotherapy treatment involve deterministic effects,
which must be induced to a sufficient extent, and alsolate stochastic effects, which can occur in about 10%of therapy courses [WlO]. In fact, second cancers inradiotherapy patients are important sources of data forthe assessment of radiation risks.

34. From a radiation protection point of view, doscs
should be maintained as low as reasonably achievable.
This means that exposures above clinically acceptable
minimum doscs, must be avoided. Thcrc is muchpotential for reducing the risks associated with medical
radiation exposures for diagnostic or therapeutic
purposes. While radiation protection is outside thescope of this Annex, the considerations involved
influence the doses encountcred and therefore merit
mention here. The A N I ~ Xdiscusses some ways of
reducing doses from specific procedures. In particular,
quality control programmes are setting targets forfacilities whose doses are excessive, thereby reducing
average doscs.
35. Mass screening programmes continue to comc
undcr scrutiny, and in most countrics mass lungscreening programmes have bccn reduced orcliminatcd. Mammography screening prograrnmcs,
however, are expanding. Nationwide breast screening
programmes and policies are in effect in Finland, theNetherlands, Swcdcn and thc United Kingdom. Scveral
other European countries, Australia, New Zealand andseveral provinces in Canada have dccided to start suchprograrnmcs [V17]. The bcncfits of such programmes
are diminished if the scrcening procedures subsequently induce brcast canccrs. Since the frequencyof breast cancer increases with age and the radiosensitivity of the breast decreases with age, the relative
benefit of scrcening is much greater in oldcr women.

227

The qucstion of sui~ablcage to start scrccning andhow oncn to rcpcat it (in olhcr words, the qucstion of
whcn the bcncfit outweighs thc dctrimcnt) has bccn
studied by scvcral authors (A6, A8, D3, D6.110, M25,
V1, W l l ] . Thcsc considcrations apply only to mass
screening programnics. In clinical cxarni~~ationsof
women in urhom brcast cancer is alrcady suspected,
corrcclly pcrformed mammography will virtuallyalways be bcncficial.
36. There is certainly mcrit in sccking to restrict
doses whcn thc radiological proccdurcs arc readily
available. For most of the developing countrics,
however, the more important need may be to expand
the availability of mcdical radiation senriccs. Hcalthwill improve wilh such an expansion, and lhcrefore an
increased collective dose to the population due tohigher examination frequency would be justified. Evcn
here, however, it is important to maintain cquipmcnt
in proper order and to introduce modern techniques tooptimize the radiation exposures that are made for
medical purposes.

D. SUMMARY
37. Medical radiation facilities are very unevenly
distributcd in the world. Four levels of hcalth carehave been defined, based on physician densities.
Level I comprises countries with fewer than 1,000
pcrsons per physician, level I1 countries have 1,0003,000, level 111, 3,000-10,000 and level IV, more than
10,000 persons per physician. Some 26% of the world
population resides in lcvel I countrics, 50% in Ievcl 11,
16% in level 111 and 9% in levcl IV countries. The
data provided in response to the UNSCEAR Survey ofMedical Radiation Usage and Exposures indicate h a t
in 1990, there were 210,000 radiologists worldwide,
720,000 diagnostic x-ray units, 1.6 billion x-ray
examinations performed and 6 million patients
undergoing some form of radiotherapy. Sonic 70% of
these medical radiation services wcre available incountries of health-care levcl 1 and the remaining 30%
to the three quarters of the world population that live
in countries of health-care levels 11-IV.
38. Medical irradiation entails benefits to the patient
as well as detriment from the radiation exposure.
Radiation protection is not in itself a subjcct of thisAnnex, but its effect on medical exposure is discussed
wherc relevant. Doses to patients are described interms of eflcctive dose or effective dose equivalent,
depending on which of thcse quantities wcre available.
The quantity effective dose (or effective dosc
equivalent) was chosen to facilitate comparisons, but
it is not used in any calculations aimed at assessmentsof detriment to patients. Instead, effective doscs havebccn supplcmcntcd, whcrc possible, with basic data on
cntrancc surface doscs or administcrcd activity tofacilitate comparisons. For thcrapy patients, no single
type of dosc quantity permits a valid dctcrmination ofradiological impact, so t l ~ casscssnicnt of this practice
is bascd primarily on the nurnbcrs ofpaticnts receiving
various trcatmcnts, with effectivc dose ~ s c das supplcmentary infornlation.

11. DIAGNOSTIC X RAY EXAMINATIONS
39. Of thc medical uscs of radiation, the exan~inationof paticnts with x rays for diagnostic purposcs is by
far the most frequcnt practice. Such examinations arc
pcrformcd in all kinds of hcalth care establishments,
including hospitals and medical clinics but also, e.g.
chiropractic and pediatric clinics in many countries.
40. Although the doscs from diagnostic x-ray
cxaminations are gcncrally relatively low, themagnitude of the practice makes for a significant
radiological impact. National data on diagnostic medical x-ray cxaminations, provided in response to the
UNSCEAR Survey of Medical Radiation Usage andExposures and supplemented with published data, areevaluated in this Chapter.
41. Although the frequcncies of examinations anddosc data are becoming available for many more
counwies than in earlier UNSCEAR Reports, it isimportant to remember the limitations of thesc data.
Often, estimates in the Tables are based on quite small
and not necessarily unbiased samples. Minor differcnccs between countries or examinations should
tbcrcforc not be ovcrintcrprcted. In general, values forexan~inationsand proccdurcs are given to two significant figures, while summary data are shown with one
significant figurc.

A.

FREQUENCIES OF EXAhIINATIONS

42. Annual nurnbcrs of diagnostic medical x-ray
cxarninations rcportcd by different countries span
scvcral orders of magnitude. Tbey are shown in
rclation to the population of the country and its levelof health care in Figure 1; data for 1985-1990 are used
for level I and data for 1980-1990 are used for levcls
11-1V to encompass a greater number of countries.
Countries of health-care level I fall on the upper edgeof thc distribution; countries of lower health-carelevels show fcwer cxaminations at the same relative
populations. Whcn the same data (numbers ofcxaniina~ions) are plotted against the number ofphysicians, a much tighter conelation is evidenL Only
four countries fall somewhat below the general distri-bution: Ecuador, Honduras, Myanmar and Pcru. It
could be lhat the pattern of cxaminations is diffcrcnt
in thesc countries, but it is more likely that the numbcr
of examinations has been undcrestimated. For instance,
information Gom private practice is often unavailable.
It could also be that the number of physicians has
been ovcrcstimatcd; the definition of a physician is notstandard, so this possibility should also be considered.
On the whole, however, using the number ofphysicians as the basis for extrapolating bom averaged
reported data to the nunlbcr of examinations
worldwide seems well founded.
43. The total annual frequencies (number of
examinations per 1,000 population) of all diagnostic
medical x-ray examinations performed in a country arc
listcd in Table 6 and illustrated in Figure 11. The
distribution of frequencies at each level is approximately log-nornlal. The range in level I countries isa factor of 6 (200-1,280 cxaminations per 1,000
population) and an order of magnitude or more inlevels 11 and I11 (15-520 and 10-180 cxaminations per
1,000 population, respectively). Only one value isavailable for level IV from the prcsent survey(Rwanda: 9 examinations per 1,000 population); thishas been supplemented in this Figure by values
available for Cote d'Ivoire and Nigeria for 1977
(40 and 25 cxaminations per 1,000 population).
Examination frequencies for individual patients or
years may of course deviate considerably from theseannual average values. Repcatcd exan~inationsof small
subsets of the population arc discussed in Section
II.F.3.
44. Most data on examination Gequencies were obtaincd by surveys or registrations that were completeenough to give reprcsentativc results. In some cases.
however, only small saniplirlgs were available that
may not adequately rcflcct the availability of medical
radiation services in the country. Thc frequency for
Turkey, for example, is bascd on data from a single
urban centre scrving only 1 % of the population of thecountry. This vcry likely explains why it is s odifferent from the frequencies in other countries ofhealth-care level 11, and this should be recognized indcriving thc avcragc valucs. In othcr cascs. samplcs
may bc adcquatc in sizc but not completcly
rcprcscntativc. For cxaniplc, thc frcqucricy for Brazil
sccrns to be bascd on public hospitals only.
45. Thcrc arc questions about the results for othcr
countrics as wcll. According to thc 1984 WHO survcyof thc numbcr of physiciaris in various countrics[U18], Ecuador has movcd from lcvcl I1 to the bordcrliric of lcvcl I. Thc frcqucncy of cxaminations remains,
howcvcr, clcarly typical of lcvcl 11, so thc classification has not yct bccn changed in this analysis.
46. Thcrc is no question about thc health-carc levcl
for the Unitcd States, but the valuc for cxamination
frcqucncy in 1985-1990 of 800 per 1,000 population
rests on considcrablc extrapolation. Some information
indicates that the estimate could be an underestimate
by up to 60% [BlO, G8, M2]. Comprchcnsive statistics on mcdical radiation arc often inadequate forcollective dose evaluation. Many countrics emphasize
thc dclivcry of medical S C N ~ C C Sand pay less attention
to the collection of data that might be needed to
cvaluatc the collcctivc radiological impact, which isanyway a secondary consideration. That said, howcvcr,
cstimatcs of cxamiriation frcqucncies are more broadly
bascd than cver and are contributing to more reliable
cstirnatcs of worldwide values.
47. The population-weighted frcquencics of examinations in 57 countrics are summarized in Table 6.
Since the values for somc larger countrics are usually
abovc the median values, slightly highcr values arc
dcrivcd for the population-weighted avcrages. These
valucs arc 890 and 120 examinations pcr 1,000 population in countries of health-care lcvels I and 11,
rcspcctivcly, for 1985-1990 and 64 cxaniinations per
1,000 population in countries of health-care levels III
and IV combined. Average frcquencics of cxamination
have gcncrally bccn inncasing. Data are not available
to show trends in individual countrics to any great
cxtcnt, cxccpt at lcvcl I. Examinations in Thailand(Icvcl 111) increascd by 50% bctwecn the first period
and the successive pcriods, and examinations in China
increascd by 30% betwccn the second and third
pcriods. At health-care levcl I, a few countries showed
downward trcnds: Czechoslovakia, Finland, theNetherlands, Norway, Romania and Sweden. Increases
wcre apparent for Canada, Cuba, the Federal Republicof Germany, France, Japan and Malta.

48. Data on specific types of cxaminations are
summarized in Table 7. The average frequencies are
the population-weighted valucs (i.e. the total numberof cxaminations dividcd by the total population ofrcporting countrics). They arc best suited for thc
evaluation of collective doses. These and other statistical parameters arc summarized in Table 8. The

standard dcviations on thc unweightcd avcragc valucs
may bc uscd to idcntify unusually high or low frcqucncics of cxaniinations. For cxamplc, cxaminationsof the chcst in thc RSFSR of chc former Sovict Union,
cxaminations of thc abdomcn and gastro-intcstinal
tract and computcd tomography in Japan and urography, angiography and mammography in t l ~ FcdcralcRepublic of Gcrmany excccdcd thc avcragc valucs in
1985-1990 by morc than two timcs thc standard
deviations. Thcre may be mcdical or othcr cxplanalions for the grcatcr frequcncy of spccific cxaminations.
49. The trcnds in examination frequcncics arc illustrated in Figure 111. Thcse are the populationweighted avcrages of availablc data. The compositionof the groups may vary from one period to another,thus affecting the comparisons. Countries of bcalthcare level I are well represented. At lcvcl 11, China
and India are represented in the more recent periods,
which helps the reliability of results. Too few data are
available for countrics of health-care lcvels 111 and IV
to give reliable averages.
50. The rtlain type of examination at all lcvels is thatof the chcst This examination made up 60% of thetotal in lcvcl I countrics during 1985-1990 and 70% in
all other countrics. Examinations of cxtrcmities, theremainder of the skeleton and the digestive systcm(abdomen and gastro-intestinal tract) accountcd for justover 10% cach of thc total in levcl I countries and justunder 10% in other countrics. This leaves about 10%
for other more specialized examinations in countrics ofhealth-care level I and only a few per ccnt for thcsc
cxaminations in all other countrics.
51. Almost all examinations arc bcing performed
with increasing frcqucncy, cspccially in countries ofhealth-care levels 11-IV. Thcre arc dilfcrcnces bctwcen
countries wilh respect to the most prominent trends,
howevcr. In countrics of hcalth-care level 11-IV thelargest incrcase is in cxaminations of the chcst (from10 to 100 and from 20 to 50 cxaminations pcr 1,000
population in levels I1 and 111-IV,rcspectivcly). In
countries of health-care Icvcl I, the most notable
increases arc in computcd tomography and examinations of thc skull and abdomen. Mammography
cxaminations incrcascd threefold in lcvcl I countrics in
1985-1990, compared with carlicr pcriods.
5 2 A dccrcasing trcnd is notcd for cxaminations of
the chcst in level I countries. This could be the rcsultof the decreasing emphasis on mass screening
programmes. Examinations of the extremities, thespine and the gastro-intestinal tract and urographycholecystography reached stable levels during the last
two five-year periods.

53. There arc wide variations in exaniination
frequencies between countries, even if they are
geographically close and culturally and economicallysimilar. The total frequencies of examinations in
European countries diTlcr by a factor of 3. A comparative investigation in France, Italy and the Unitcd
Kingdom found differenccs which indicate that medical exposures are not justified in the same way inthcse countries [C2]. The frequencies of x-ray examinations in the Nordic countries varied by over 50% in
1982 from 500 to 800 per 1,000 population [S14],
with the highest frequcncy in Finland, prinlarily
because more radiological examinations took placeoutside of hospitals at health centres and private
clinics. The frequcncy of colon examinations is fairly
similar in the five Nordic countries, while stomach
cxaminations are morc frequent in Noway, primarily
because endoscopy is less used. Cholecystography is
performed about twice as frequently in Sweden as inother Nordic countries, presumably because there arefewer radiologists who could perform ultrasonographic
cxaminations. Sweden has the highest frequcncy of
mammography, because the Government recommends
screening, while Denmark and Norway have noscreening apart from minor research projects.
54. Statistics may be less accessible in health caresystems where medical care is largely private and thus
decentralized. They may also be less reliable; for instance, the incrcase in the number of x-ray examinations at hospitals in the United States could be due toa shift from private clinics to hospitals, making thechange more apparent than real [Nl]. While comparisons may be indicative, they must always be treatedvery cautiously. The definitions, methods of examination, methods of measurement and other conditions
may vary gready between studies. Thus, similarities
and differenccs may be spurious and conclusions may
be false, even in the rare cases where a formal
analysis of statistical significance seems technicallyfeasible. There may also be regional differences withincountries. The frequencies of diagnostic x-ray examinations in the diffirent republics o f the form& USSR
are estimated to have ranged from 500 to over 1,100
per 1,000 population in 1987 [S18]. Thus, even withcentrally organized health care systems, differences
may occur.
55. Computed tomography is rapidly becoming avery important diagnostic technique. The number ofcomputcd tomography scanners in the Unitcd States in1980 was 6.7 pcr million population, while the figure
for Japan was 25 per million in 1984. In the United
Slates, the number of computcd tomography scanners
in hospitals increased from 3 million in 1980 to 12.3
million in 1990 [M2]. In New Zealand, them wereabout 5 per million in early 1988, expected to be 20
per million within a few years [PI 11. A study in

Manitoba, Canada, sllowed the number of conlputcd
ton~ographyscans steadily increasing, from 200 per
month in 1977 to 1,500 per month in 1987 [H4]. The
number of computcd tomography scanners in the
Unitcd Kingdom has increased from 1 scanner in 1972
to over 200 in 1990 [S42]. The relative frequcncy ofsuch examinations in thc Unitcd Kingdom is now
estimated to be over 20 per 1,000 population [S42],
contributing 20% of the collective effective dosc from
x-ray examinations [S43].
56. The data in Tablc 8 show an unweighted average
tomography examinations pervalue of 22 cor~~puted
1,000 population in countries of health-care level I,with morc than 3 0 per 1,000 population in Australia
and the Federal Republic of Gemany, 5 0 per 1,000
population in Belgium and 97 per 1,000 population in
Japan. In the UNSCEAR 1988 Report [Ul], theaverage frequency of computcd tomography examinations in countries of health-care level I was estimatedto be 9 pcr 1,000 population. An upward revision
would, therefore, seem justified. The procedure is usedat negligible frcquency in all countries of health-carelevels 11-IV:sollie 2 examinations per 1,000 population, at most, with many countries reporting none ofthcsc examinations.

57. The age- and sex-distribution of patients in diagnostic x-ray cxaminations, and the populationweighted averages of these for each of the health-carelevels, are given in Tablc 9. Broadly speaking, patientssubjected to x-ray examinations are older than randomly chosen members of the public. This does not
riecessarily mean that x-ray cxaminations of children
arc rare. Many examinations are in fact rather frequentin children (in particular, those of the chest, theextremities, the skull, the pelviships and the abdomen,
and urography).

58. For level 11-IV countries, the fraction of thepatients that arc children is larger than for level I
countrics. This difference is statistically significant.
However, the frequency of child examinations may
still be lower than in level 1 countries, since the total
examination frequency is much lower. Although thedetail is not given in Tablc 9, reports indicate b a t theexamination of infants and young children is notinirequent. The per caput cffective dose equivalent tochildrcn in the Federal Republic of Germany in 1983
was estimated to be 30% of the effective dose
equivalent to an adult (M151.
59. These general conclusions from Table 9 are inagreement with observations in the UNSCEAR 1988

ANNEX C: MEDICAL RADIATION EXPOSURFS

Rcport [Ul], whcrc it was also poinlcd out that the
grcatcr proportion of children in thc populations ofcountrics of hcaltll-carc lcvcls II-IV is rcflectcd in ahigher sharc (con~parcd to level I countrics) ofchildren among cxamincd paticnts. The diffcrcnces in
population agc structure appcar to be sufficient to
cxplain the dilfcrcnccs in paticnt age. The avcrage
agcs lor countrics contributing data for Table 9 could
bc roughly calculatcd to bc 34 ycars at lcvel I, 27
ycan at lcvel I1 and 24 ycars at lcvcl 111. Similarly,
thc roughly calculated avcragc agcs for patients are 44,
36 and 38 ycars. Thus, Ihc averagc pcrson in a lcvcl I1
or I11 country is 7-10 ycars younger than the average
pcrson in a lcvcl I country, and the average patient inlcvcl I1 or 111 countries is 6-8 ycars younger than the
avcragc paticnt in a level I country.
60. Thc sex distributions do not dcviatc widely fromthc distribution of malcs and fcmales in the
population. The cxccss of womcn undergoing cholecystography in countrics of hcalth-care levcl I is wellknown and may possibly be related to diet. Likewise,
the exccss of womcn in lcvcl I counlries having lower
gastro-intestinal tract examinations was recognized in
the UNSCEAR 1988 Report [Ul]. The excess of
womcn in countrics of health-care lcvel I having
pclvis/bip cxaminations is probably associated withfemoral fractures and hip joint rcplaccments in older
womcn. Thc data indicate consistently fewcr female
paticnts in Icvcl II and level I11 countries than inlcvcl I countries, which, if correct, may rcflcct an
uncvcn distribution of medical care in diffcrcnt
countries.

C.

DOSES IN EXMXXNATIONS

61. Estimates of doses to patients in diagnostic x-ray
cxaminations, derived largely from the UNSCEAR
Survey of Medical Radiation Usage and Exposures,arc listed in Table 10. The primary quantity shown is
avcrage entrance surface dose, ESD, pcr examination.
The dose-area product, DAY, was reported in one or
two cases, but these values arc not included in the
Table. Both quantities are readily measurable. Whenreportcd in response to the UNSCEAR Survey of
Mcdical Radiation Usagc and Exposures, effective
doses (or effective dose equivalents) are also listed inTable 10. Effective dose can be calculatcd from ESD
or DAP if the projcction, tube kilovoltage and beamfiltration arc known IB23, G23, H27, J3, R23, R24,
R38, S45) and, if necessary, corrected for patient size
and anatomy [L24, L25, S46). A reasonablc
approximation of effective dose without such detailed
information is possible from DAP [ L D ] but difficultfrom ESD. In the absence of such data, effective doses
were not calculated.

231

6 2 Population-wcightcd avcragc valucs of cffcctivc
dose equivalent for spccific cxaminations arc suniniarizrd in Tablc 11 and illustratcd in Figure IV. In
linc with carlicr studics, avcragc doscs are coniparatively high for gastro-intestinal tract examinations,about 4 7 mSv at health-carc lcvcl I. Angiography andcomputcd tomography also confcr rclativcly highdoses, about 4-7 mSv. Urography doscs arc about
3 mSv. Cholccystography and lumhosacral spinal
cxaminations givc doscs of 1.5-2 mSv. Effcctivc dosc
equivalents Iiom cxaminations of the abdomen or of
the pclvis/hip arc of about 1 mSv. Ruoroscopic chcst
examinations arc also associated with doses around
1 mSv, whilc chcst radiography gives avcragc doses of
0.14 mSv, and fluorographic mass miniature exaniinations, 0.5 mSv. Examinations of the skull or extremities cause avcragc effective dosc equivalents of
0.05-0.15 mSv. The average for mimmography,
1 mSv, may be spuriously high due to a very highvalue ( 9 5 mSv) reportcd from Czechoslovakia (valucsof about 0.5 mSv are reported from scvcral countrics).
63. The average effective dosc equivalents in countries of health-care level I, illustratcd in Figure IV,
indicate that, for the same examination, the doses wereconsistently higher in 1970-1979 than in 1980-1990.
This does not necessarily mean, howevcr, that per
caput effective dose equivalents arc decreasing, sincc
the spectrum of examination changes as wcll. Computed tomography was alrcady mcntioncd above as
one example of the developments that alfcct collcctivc
doses appreciably.

64. Comparison of the average doscs from cxamination in countries of health-care lcvcls I and I1 in
1980-1990 is also illustrated in Figurc IV (carlicr data
are not available for lcvcl 11, and data arc altogcthcr
insufficient for lcvels 111 and IV). No consistentdifference is apparent: reported doses for lcvcl I1 areabout twice those for lcvel I for cxaminations of thelumbosanal spine, pelvis and hip, 20% higher thanlcvel 1 doses for upper gaslro-intestinal tract
examinations, similar to lcvel I doses for cholecystography and for skull cxaminations; half thelcvel I doses for urography and for examinations of
the extremities: and less than half the level I doses for
examinations of the chcst, abdomen and the lowcr
gastro-intestinal tract. While bascd on only two
countries (China and India), the averages for level I1
refer to a large population. Nevertheless, apparent
differences betwcen health-care levels should beinterpreted very cautiously. Somc reportcd differences
between China and India arc biggcr than the apparent
differences bctwccn the avcragcs of diffcrcnt healthcare levels. 11seems highly likely that dose differencesof similar magnitude occur within thcse large
countries. Conditions in China or India may also bequite different from conditions in other countries oflevel I1 or in countries of level 111 or IV, where thenlorc frequent use of fluoroscopy may cause higher
doscs.
65. Numerous factors of technique contribute to thedosc variation observed. Several such factors are listed
in Table 12, which compiles both general information
IN51 and information originally aimed at mammography [R18, S56] but relevant also in a generalcontext. Patient size is not listed in Table 12, since it
is not a controllable factor of technique, but it conbibutcs appreciably to variation [L24, L25, V31, also
bctween countrics. For instance, the weight of thereference Japanese adult male is 61.5 kg and thefc~nale51.5 kg [TS], compared with 70 kg (male) and
60 kg (female) of the ICRP reference man [12].
66. Variations in dosc for specific procedurcs arc
discussed in more detail below. These include (a)fluoroscopy, because of its significant impact on procedures and per caput doses; @) computed tomography, because of its rapid growth; (c) chest examinations, since thcy are so frequent; (d) mammography, with a view to its use in screening programmes; (e) chiropractic examinations, since they are
not well known; and (0 neonatal and child examinations, because these patients may be more radiosensitive than adults.

1. Fluoroscopy

67. Traditional fluoroscopy (in which a fluorescentscreen receives an image) and photofluorography (inwhich the imagc on the screen is recorded
photographically or electronically) often cause highabsorbed doses in the patient. Tbere are two reasonsfor this: dose rates may be high and exposure times
may be long. There are wide variations in patient
exposures, even for the same type of examination,
between patients, between equipment and between
radiologists (see, e.g. [Rl]). Modem equipment withimage intensifiers may mean that fluoroscopy andphotofluorography do not cause relatively higher
doses. The imaging properties of image intensifiers
have improved, and the input screen size can now belarge. Based on these technical developments, a dose
reduction of about onehalf was possible withlarge-screen image intensifier photofluorography
instcad of screenlfilm radiography (with full-size
images) in posteriorlanterior (PA) projection inscoliosis examinations [MS]. A Swiss study of older
and newer fluoroscopy units for chest screening
purposes rcvealed a 30-fold range in dosc rates.
Entrance surface doses ranging from 0.1 mGy for themost modem unit to 2.2 mGy for an old mobile unit
were observed, the lower value being one third of theentrance surface dosc observed in the same study for

scrcc~~/film
radiography [M37]. Nonc~hclcss,modern
equipment may also have a potential for high doses,
but for son~cwhat different reasons. For instance,high-level fluoroscopic boost options for imagc
enhancement can contribute to high doses and may beeasily activated, c.g. by a simple foot pedal [C12].
68. Thus, fluoroscopy can cause a high dose to an
examined paticnt. Furthenuore, its widespread use incountrics of health-care levels 11-IV contributes to highcollective patient doses [Ul]. But where the BasicRadiology System developed by the World HealthOrganization [W3] is installed, there seems to be apotential for substantial dosc reductions, which are notyet reflected in reported data (see Table 10). Trials at
a Swedish hospital [H7] indicate that doses forconlnlon examinations could be reduced by 80% [C2]or even more in comparison with older fluorographic
systems. Trials in Colombia [W3], which show doses
less than half of those observed in the United States,
seem to corroborate these results. Furthermore, theeffective dose equivalents for specific examinations(see Table 10) do not appcar to be consistently higher
in level 11 countries than in level I countries. For
levels I11 and IV, information is insufficient to draw
any conclusion, but highcr doses may be suspected,
owing to, for one thing, the absence of stable voltage
in many countries [B18].
69. Intervcntional radiology describes procedurcs inwhich the physician utilizcs radiology for guidance
before, during or after surgery or in relation to otherexaminations or treatments. Some examples are theplacement of catheters for drainage, stone extraction,
recanalization, the dilatation or occlusion of vessels
and the infusion of pharmaceuticals, as well as theneedle biopsy of various lesions. The dilatation ofvcsscls by pcrcutancous transluminal angioplasty may
be peripheral (PTA) or cardiac (PTCA). Most of theseprocedures require lengthy periods of fluoroscopy andmay impart high doscs to patients and staff. On theother hand, the frequency of these often life-saving
procedures is low. The total frequency of interventional radiology in Nordic countries varies from 0.3 to
0.8 per 1,000 population [S14]. Of these, the higher
values are obtained in countries with a high frequency
of pcrcutancous nephrostomy. PTCA, with potentiallyvery high doses, is practised at a rate of 0.03 to 0.05
procedures pcr 1,000 population [S14]. The number of
PTCA procedurcs in the Unitcd Statcs increased to an
estimated 400,000 in 1990 [K29].
70. Average effective dose equivalents ininterventional radiology were determined by DiazRomero ct al. [Dl81 for 1,389 patients at Tcnerife,
Canary Islands. The results included an adjustment
factor of 0.85 to take account of the age distributionof patients (see Section 1.B and [H4]). After recalcula-A N N M C: MEDICAL R

tion to rcmovc the adjustment factor, the cffcctivc
dosc equivalcnts (HE) rarlgcd from 1.9 niSv (forncphro-urinary procedures) to 15 mSv (for abdominal
artcriography). Some spccific dosc data and otl~cr
information arc given bclow for cardiac, ccrcbral andnephro-urogenital intcrvcntional radiology, as wcll as
for othcr typcs of fluoroscopy. Gonad doscs for somc
intcrvcntional radiology procedures are available[V14].Fluoroscopically guidcd fallopian tubc rccanalijation as a treatment for infertility has been attracting
intcrcst rcccntly. Average absorbed ovarian doscs of
8.5 + 5.6 mGy (corresponding to an effcctive dosc
equivalcnt of about 2 mSv) wcrc recorded by
Hcdgpcth ct al. [H45].
71. Thc grcatest radiation dose to individual paticnts
in fluoroscopy is associatcd with the imaging of theheart (intcrventional or otherwise). Skin doses in
cardiac angiogaphy often approach 1 Gy, and during
coronary angioplasty skin doses between 1 and 5 Gy
were recorded for 31 patients in an Australian study[HI]. A maximum skin dosc of 43 Gy (for 1 hour of
fluoroscopy and 2 minutes of digital subtraction angiography) is quotcd in Finland [P12], corresponding toan cffectivc dosc equivalcnt of about 1,400 mSv. This
was a unique casc, and typical skin doses were around
1 Gy (corresponding to an effcctive dosc equivalcnt of
about 10 mSv). In a French study, Moroni el al.
[M30] highlighted some special situations with very
long exposure times in angiography or catheterization,such as the sampling of pancrcatic hormone to detect
mute cancer or hepatic cmbolizadons. Entrance surface
doses of 2 Gy and gonad doses (outside the primarybeam) of 3.2 mGy were observed in single
examinations. A study in the Unitcd Kingdom [T9]reportcd that cntrancc surface doses of up to 1 Gy
were in the normal range for digital subtraction
angiography (including the associatcd fluoroscopy).
7 2 Some variations are difficult to assess. Paticnt
doscs diffcrcd significantly between cardiologisls in
onc hospital in the Netherlands, but not in another one[Kl]. Digital subtraction angiography @SA) withpulsed high dose-rate fluoroscopy should permit
patient doses to bc reduced to about one third of the
dosc in conventional angiogaphy. To some extcnt,
however, this may be offset by more liberal use of theprocedure [J6, P2]. Thc rangc of cntrancc surface
doscs and organ absorbed doses in angiography
cnumeratcd in two reviews IS37, V14] are summarized in Table 13. For cercbral angiography during
the embolization of artcriovcnous malformations,effcctive dose equivalents to patients of 6-43 mSv
were recorded [B29] for entrance surface doses of
170-1,400 mGy, a rangc exceeding that given in
Table 13. In another study [F3], effective dose
equivalents in cerebral angiography ranged from 2.7 to
23 mSv (average: 10.6 mSv). Of this dose. fluoro-

scopy contributed 6755, cut filnis 26% and DSA 7%.
Absorbed doses to organs in thc hcad in convcntionaland DSA in the Fcdcral Rcpublic of Germany wcrc
given in [G17]. DSA causcd lowcr orbital doscs;
convcntional angiography produced lowcr doscs in thc
cervical marrow, the ccrcbcllum and thc parotid
glands.

73. Whilc imaging of thc hcart causes high individual doses, the collcclivc dosc is mainly influcnccd
by the much more frcqucnt fluoroscopic exanlinationsof the gastro-intestinal tract. In the Unitcd Statcs, thcse
causc avcragc cffcctive dosc equivalents pcr cxamination of 2 4 mSv (uppcr gastro-intestinal tract examination) and 4.1 mSv (barium cncma). Due to thc frcquent use of thcsc examinations, thcy producc annual
collective effective dose equivalents of 18,500 and
19,900 man Sv, rcspectivcly. Togcther, this is ovcr
40% of the annual collective dose due to diagnostic
x rays in the United Statcs [Nl]. Fluoroscopy time ingastro-intestinal tract examinations is an importantsource of dose variation [H33]. Screening time can be
reduced significantly with no loss of examination
quality [H14]. Tbis, coupled with radiation protection
attention [B4, S541, means that dencasing doses per
examination are to be expected. Of course, examinations causing very low doses have little impact cvcn ifthey are frequent Fluoroscopy of the extremities
produces absorbed doses of a fcw milligray [ C l l ] andeffective dose equivalents of'O.1 mSv or less.
74. In Japan, effcctive dose equivalcnts pcr cxamination of the upper gastro-intestinal tract were foundto be 2.1 mSv for radiography and 2.8 mSv for fluoroscopy, with a total of 5 mSv when both proccdurcs
were utilized. Owing to the frequent use of thcsc
examinations, thcy cause annual collective effective
dose equivalents of about 35,200 man Sv (radiography) and about 43,400 man Sv (fluoroscopy). Thisis about 43% of the total annual collective effective
dose equivalcnt from all x-ray diagnostic examinationsin Japan [M4]. Suleiman et al. [S34] reported thefollowing absorbed doscs for upper gastro-intestinal
tract examinations in the United States, apparently
indicating somewhat lowcr cffcctivc dosc equivalents
than in Japan: thyroid, 0.2-3.5 mGy, lung, 0.9-4.2
mGy, red bone marrow, 0.8-5.4 mGy and uterus, 0.21.0 mGy (all numbers rcfcr to the sum of radiography
and fluoroscopy). In another survey in the Unitcd
States, cntcroclysis caused cntrance surfacc doscs thrcc
times higher &an dedicated peroral small bowcl study(123 + 60 mGy as opposcd to 46 2 21 mGy) [T14].

75. In extracorporeal shock-wave lithotripsy, fluoroscopic x-ray imaging is used to localizc renal stones.
One estimate from the Unitcd States of a likely
surface air kerma was about 225 mGy [Ll]. Other
estimates, also from the United States, gavc surface

UNSCEAR 1993 REPORT

234

doses of 10-300 mGy, with average female gonadal
doscs of about 1 mGy ( B l , G13). The dose increased
with increasing stone burden and paticnt weight, andstones in the uretcr resulted in higher average doses
than renal stoncs [CB]. The introduction of a radiation
control programme in the United States permitted
cxposurc reductions of between 20% and 60% [G5].
An invesligation in Canada produced similar values,
with an average entrance surface dose of 140 mGy,
corresponding to an effective dose equivalent of about
0.8 mSv [H5]. Average surface doses of 30-34 mGy
wcre observed in Taiwan [C20]. The authors attributed
their relatively low doses to, among other things, small
average patient size, which permilted low current for
spot films.
76. An alternative to extracorporeal lithotripsy is
percutaneous lithotomy. In this procedure, fluoroscopy
is uscd to localize the renal stones for extraction. A
Swedish study reported an average effective dose
equivalent to the patient of 4.2 mSv (range: 0.608.3 mSv) [G4]. In Finland, percutaneous nephrostomy(which is a part of percutaneous lithotripsy) generated
entrance surface doses to patients of 160 mGy [V13].
Thus, the newer technique of extracorporeal lithotripsy
does not seem to cause higher radiation exposure; ifanything it does the reverse [V13]. An investigation in
the United Kingdom [R3] gave similar results. Extracorporeal renal stone lithotripsy has been much more
successful than the corresponding technique for gallstones [M33]. Although gallstones are more frequent,
only a limited number of patients are suited to sucb
treatments [Z5], so the frequency of this procedure is
not expected to increase markedly.
77. Numerous suggestions for reducing doses influoroscopy have been made. During placement offeeding t u b a , a procedure that is not diagnostic anddoes not rcquire an image of high quality, ordcrof-magnitude dose reductions (from entrance surface
doses of about 300 mGy) were achieved by removing
the anti-scatter grid and increasing the iris of the video
camera [R20]. Similar reductions were possible fornasocntcral tube placements [R13]. This is of significance, since many of the patients in question are
exposed to these procedures repeatedly. A broader
overview of measures to reduce doscs in fluoroscopy
has been published 11131.

2.

Computed tomography

78. In computcd tomography ( C T ) , the conditions of
exposure are quite difircnt from those in conventional
x-ray imaging. This has required the development ofspecific techniques for assessing patient dose fromcomputed tomography. Usually, the dose in a single
CT slicc is estimated using either the computed tom&graphy dose index (ml)or the multipl~-scan
average dose (MSAD) [C23, C241. CTDI is dcfined as
the integral along the axial, z, direction of a singleslice dose profile, D(z), dividcd by the nominal slice
width. MSAD is the average dose across the central
slice from several contiguous slices. These two paranleters are related, and, under certain conditions, areidentical for 7 mm thick slices. For thicker slices,
MSAD underestimates CTDI, by 10%-15% for a
10 mm slice [C23]. Entries under ESD in Table 10 are
actually such slice doses, as indicated in a footnote.
From slice doses, organ doses and, ultin~ately,
effective doses can be estimated [J7, S43, 2161.
Studies in the Nationwide Evaluation of X-ray Trends(NEXT) programme in the United States in 1990
[C23] indicated MSADs in examinations of the headof, usually, 34-55 mGy, although doses as high as
140 mGy were encountered.
79. The dose per examination by computed tomography varies with the type of examination. On
average, the effective dose equivalent to patients
undergoing such examinations was 3.2 mSv in a studyin Manitoba, Canada, in 1987 [H4]. Since there were18.2 examinations per 1,000 inhabitants in Manitoba,
computed tomography contributed 0.06 mSv to theannual per caput dose from nledical exposure. Effective doses, as well as effective dose equivalents, in1989 for specific cxaminations and for all computed
tomography in the United Kingdom were compiled by
Shrimpton et al. [S43]. On average, the effective doseis lower than the effective dose equivalent by a factorof 0.7, with ratios for specific examinations ranging
from 0.5 to 1.5. Only for the cervical spine is the ratio
greater than unity. Their results, and associated dataon examination frequency [S42], are summarized inTable 14. Absorbed organ doses recorded in the same
project are given by Jones and Shrimpton [J7].
Dctailcd information on eye lens and gonadal doses
during computed tomography were given by Rosenkranz et al. [R2].
80. In computed tomography, the absorbed dose fora given examination varied by a factor of 3 in New
Zcaland [ P l l ] , and a factor of 5 in Sweden [ M I ] andthe United Kingdom 1-1. In Japan, the effective dose
equivalent for the same examination varied by a factor
of up to 3.5, depending on the scanner unit [N8].
Table 15 summarizes some of the dose data obtainedin that study. Panzer et al. p 3 ] noted even greater
variation, by a factor of up to 10, with 122 scanners in
the Federal Republic of Germany. Researchers in the
USSR found that some dose variability was unavoidable due to the clinical situation [All, but apparently
some of the variation could be removed. This would
be important, since the general use of computed
tomography is increasing at Ihe same time as doses
per examination arc also increasing [H4]. Siddlc et al.

discussed variation between scanner units [S29] andbetween procedures IS301 in Australia in connection
with the risk of causing cataracts in the eye lens. They
concludcd that while ncithcr scanner variation nor
procedure variation led to doses approaching the thrcshold for cataracts in thcir studies, a potential for suchdoscs does exist A low-dose technique for computcd
tomography orbital volume measurements reduces lens
doscs from over 100 to 11 mGy [M24].
81. In somc cases, thc dosc from a computed
tomography examination is lower than h e dose fromsimilar examinations with conventional techniques. For
instance, conventional myelography of the lumbar
spine gives effective doscs equivalents that are five tonine times higher than those for computcd tomographyof the same region (HE = 9-18 mSv compared to
1-2 mSv), whilc cffectivc dose cquivalcnts are similar
for the two techniques for cervical spine myelography(about 2 mSv) FBI. However, patient doses fromcomputed tomography examinations are typically anorder of magnitude higher than those from conventional x-ray diagnostic examination, as reported in theFederal Republic of Germany [PlO] and in the United
Kingdom [S43].
82. Fetal doses in computed tomography
examinations of pregnant patients were evaluated byFelmlce et al. [F6] and Panzer et al. [P9]. Both articles
provide the necessary formulae for dose calculation.
Felmlee et al. concluded that clinically required headscans can be performed with little or no dose to thefetus, and that the prudent use of body scans can beconsidered.

83. Several European countries arc at present
collaborating on quality assurance measures to reducethe variability in doscs from comparable computed
tomography scans [C9]. Such efforts at reduction are
expected to reduce average doses (or rather, since boththe number of examinations and the dose per examination are increasing for other reasons, as detailed above,to limit the rate of increase). Equipment failure can, ofcourse, increase doses; as an example, the accidental
loss of filtration increased entrance surface doses inhead and body scans by somc 25% [Y2].

3. Chest examinations

84. Individual doses are usually low in radiographic
chest examinations. Digital computcd radiography
could permit even smaller doses than screentfilm
radiography (although some effort might be required
to achieve acceptable image quality) [JlO, K24, L19,
M34]. As an example of doses in conventional cbest
radiography, the effective dose equivalcnt averaged
over all chest x-ray units in Manitoba, Canada, andover all projections in 1987 was 0.07 mSv [H241. Thc
authors stressed that lateral projections (takcn inaddition to postcrior/antcrior or anterior/postcrior in
70% of the Manitoba examinations) contributed mostto the cffectivc dose equivalent for a chest cxamination. For posterior/antcrior only, the avcragc entrance
surface dose was 0.12 mGy, corresponding to aneffective dosc equivalent of about 0.02 mSv. For
lateral projections, an avcragc cntrance surface dosc of
0.59 mGy (corresponding to an effective dose cquivalent of about 0.06 mSv) was calculated based onphanto~i~measurements [H6].
85. A collaborative study in Sweden and the UnitedStates [ M I found that the entrance surface air k c m afor posterior/anterior chest projections was 0.16 mGy
in Sweden and 0.14 mGy in the United States (allSwedish facilities and 75% of United Statcs facilities
use scatter suppression, mostly grids and in a few
cases air gap). These similar average doses are theresult of quite different underlying conditions. Since
grids typically increase the dose by a factor of 2 or 3,
an even higher dose could have been expected in
Sweden. Slower screenlfilm systcms in Sweden would
act in the same direction. On the other hand, in
Sweden, higher tube voltage, more appropriate total
filtration, the absence of singlc-phase units, overprocessing and a mandatory quality assurance programme all act in the directi6n of lower doses. As arough approximation, the air kernla values divided by
0.75 correspond to entrance surface doses with backscatter. Using this approximation, the entrance surface
doses are 0.16 + 0.75 = 0.21 mGy in Sweden and 0.14
+ 0.75 = 0.19 mGy in the United Statcs. Thus, they
are of the same order of magnitude as the doscs inManitoba. As usual, there was considerable variation
around the averages. In Sweden, the air kerma values
ranged from 0.022 to 0.58 mGy, a 26-fold difference[ M I , while in the United States they ranged from0.004 to 0.70 mGy, a 175-fold difference [R14].

86.

Studies within the Nationwide Evaluation of
X-ray Trends (NEXT) programme of chest examinations in United States hospilals in 1984 and private
practices in 1986 [R14] showed no overall difference
in doses (an entrance surface air kcrma of 0.14 mGy
in both cases). Fewer private practices use scatter
suppression grids. For each technique (with or without
grid), doses were slightly higher in private practices.
One of the causes of higher doses may be that 41% of
the private practices, as opposed to 17% of thehospitals, undcrprocesscd thcir films.
87. In spite of low doses, cbest examinations contribute 5,100 man Sv annually in the United States,
over 5 % of the collective effective dose equivalentfrom medical x-ray usage, reflecting the fact that thisis the most frequent type of x-ray exar~iinationapartfrom dental x-ray exan~inations[Nl 1. Some countries
conduct extellsive chest screening programmes, oficnwith photofluoroscopy rather than radiography. For
conventional equipnicnt, photofluorography causes
doses at least some five times higher than radiography
in chest examinations [ U l ] , and depending on the typeof fluoroscopy, the duration ctc., it can cause doses 10
times higher [Ul].
88. Entrance surface doses in chest radiography havebeen studied in Hunan Province, China (health-care
Icvel 11) [YI]. For photofluorography, the average
dose was 6.1 mGy. while for full-size image radiography, the dose was 0.6 mGy. The average entrance
surface dose during fluoroscopy was 9.6 mGy.

89. Mammography is used in two contexts: forclinical examinations in order to investigate suspected
breast cancers and for the mass screening of healthy
women in order to detect such cancers. The preferreddose quantity in mammography is the mean absorbed
dose in glandular tissue [ I l l , N14]. A summary ofrecent results of dose studies in mammography incountries of health-care lcvel I is given in Table 16.
The average of mean glandular doses ranged from 0.6
to 4.8 mGy per film. Reported effective dose equivalents spanned an even widcr rangc: results of the
UNSCEAR Survey of Medical Radiation Usage andExposures gave an average effective dose equivalentof about 1 mSv and a rangc of 0.03-9.5 mSv. Sincen~ammography is probably subject to more quality
control and standardization than many other examinations, at least in countries whcre here aremammography screening programmes in effect [K16,
L10, N12, P15, T11, Z8], the degree of variation isremarkable.

wcrc not in compliance with various quality assurance
reconimendations [F7]. This sul)ject is further discussed in Section lI.F.4. An important diffcrcnce
exists bctwecn xcron~amn~ographic
systems (typicalmean absorbed breast dose: 4 mGy) and scrcenlfilm
systems (typical v;ilue 1 mGy) [H42, L17, R18]. The
scrcen/Piln~value is, in fact, an average of results
without anti-scatter grids (0.6 mGy) and with grids(1.3 mGy); the latter, in turn, is an average of moving
grid (1.1 mGy) and stationary grid (1.5 mGy) [D17].
91. In a study in Italy, low-dose plates pcrmit~edthe
surface air kerma to be reduced by 15%: to 4.4 mGy;a further 15% reduction was possible with an increased film-focus distance [Cl]. In the United States,
15 new mammographic units of 8 different models
were tested, using identical scrccnffilm combinations
with and without grids [K2]. The mean glandular dose
varied between 0.4 and 2.2 nlGy with a grid, 0.4 and2.1 mGy without a grid, at 28 kVp. In another study
in the United States, four different screen/film systems
were tested [PI]. The mean glandular dose varied
from 0.6 to 3.2 mGy at 25 kVp and from 0.5 to
1.8 mGy at 30 kVp. Five different types of filn~weretested in a study in the United Statcs of the effects ofprolonged exposure, delayed processing and increased
film darkening [K21]. Each of these increased dose,by 20%-30%, and optimal viewing dcnsity wasdifferel~tfor each film type. i'he Nationwide Evaluation of X-ray Trends (NEXT) programme, also in the
Unitcd States, observed average mean glandular dosesof '0.93 mGy in 1985 and 1.6 mGy in 1988 forsacen/film mainniography [R12]. For xeromarnmography, the values were 3.9 mGy in 1984 and4.3 mGy in 1988. In 1985, 36% of facilities had anunacceptable image quality, but by 1988 this
proportion had dropped to 13%.

5.
90. For a state-of-the-art screening programme,
1 mGy may be a representative breast dose (2-3 mGy
if an anti-scatter grid is used). The dose varies withbreast thickness [T20, W32] and composition [AlS].
There are, as noted in the UNSCEAR 1988 Report[Ul], considerable performance variations between
systems, e.g. in Italy [ C l ] and the United States [K2,PI]. One source of variation is lack of a quality assurance programme. In the report from Italy cited inTable 16 [R19], it is observed that wilh the criteria
used by the authors, 24% of the centres surveyed used
too high a dose, 24% had a poor image quality and
14% had both high doses and poor images, illustrating
the potential for quality assurance. To meet this need.
the Comnlission of h e European Communities has introduced European guidelines for quality assurance inmammography screening [C19]. In Washington Slate,
United States, 30%-70% of 131 mammography centresChin)prnclic examinations

9 2 X-ray examinations are also performed in connection with chiropractic, either at the chiropractic
office or by a collaborating medical radiologist. The
main types of examination are cervical spine, thoracic
spine and lumbar spine. In the province of Manitoba,
Canada, the entrance surface doses for these three
types of examinations were 0.6, 1.8 and 3.5 mGy,
respectively, corresponding to effective dose cquivalents of 0.03, 0.24 and 0.41 n ~ S vper examinationand collective effective dose equivalents of 0.4, 0.8
and 6.2 man SV for a population of 1 million [HS].
This averaged 0.22 mSv per patient and gave a percaput effective dose equivalent of 0.007 mSv. These
values agree closely with corresponding values for the
Unitcd States [Nl ] and indicate that chiropractic
exa~nirlationsdo not make a significant contribution toeither individual or t l ~ ecollective radiation dose.

A N N M C: MEDICAL H

93. Ncvcrthclcss, these avcragcs do not reflect thc
cxtent of the dose variatio~icncountcrcd among rhiropractic officcs. In the Manitoba study, the ratio of
maximum to niinisiun~dosc was as great as 23 IH8j.
This is similar in magnitude to the variations found inn~cdicaldiagnostic radiology [S23]. In its response to
the U N S C f 3 R Survey of Medical Radiation Usagc
and Exposures, the National Radiation Laboratory of
New Zcaland pointed out that entrance surface doscs
niay be difficult to interpret, because chiropractors use
a conlplcx systcnl of plane and wedge filters and diaphragn~sto obtain even irradiation of contrasting tissue
regions. According to the Laboratory, the filter anddiaphragm systems lcad to doses lowcr than those obtained in approximately equivalent medical procedures.
6.

Neonatal and child examinations

94. The pattern of diagnostic examinations is suchthat children may get highcr doses than adults. For
instance, a study in the Netherlands reported thehighest doscs per examined patient for persons underage 5 years or between ages 25 and 50 years. The
reason was that the most frequent examinations wereabdomcn, lumbar spine, intravenous pyelogram andcomputed tomography of the head, all of which cause
doscs in the middle to upper range [V16]. Furthermore, the exposure conditions and field sizes must be
adapted, otherwise the cffcctive dose from examinations of infants would be highcr than that to an
adult. This also applies to high-dose procedures, suchas interventional cardiac catheterization, which is used
on infants with a variety of congeni~alheart diseases[W16]. Phantoms [ V l l ] and tables are available forthe determination of absorbed organ doscs to children
in various x-ray examinations [T12]. With theoreticalmethods, Zankl et al. [Z2, ZlS] obtained organ doses
for an infant and a child for the most common radiographic examinations and demonstrated the strong
dependence of organ doses on body size [V3]. Lindskoug P l l ] providcd tables of suitable exposure
parameter settings.
95. Fetal doses in computed tomography wcrediscussed above in Section II.C.2. Fetal absorbed
doses in Japan during screening of the upper gastrointestinal tract ranged from 0.3 to 5.5 mGy [02]. To
the cxtent that pelvimetry is performed by x rays
instead of ultrasound, doses (including possible fctal
doses) are decreasing where computed tomographyscanners are available, but not using their cornpuled
tomography feature. Pelvinictry with Scan Projection
Tomography (a non-tomographic survey view with thescanner) causcs doses about one tenth of those withconventional x rays [G9, W331.
96. For premature infants, chest examinations can bemedically very important Weingartner et ai. [W2]stressed the iniportancc of suitable equipment andcareful patient referral for x-ray imaging for thissensitive group of patients. Faulkncr ct al. IF41 listed
various ways to rcducc doses per film but also pointed
out that neonates may be subjected to l a g c numbersof examinations during thcir stay in hospilal. Thcy
also nicntioned that thc average dosc to the infantpatient is dctcrmincd mainly by the number of
examinations, which depends on clinical symptoms. In
the UNSCEAR 1988 Report [Ul], other examinationsof nconatcs (barium, computed tomography, angiocardiography) wcrc discussed.
97. Ruiz et al. [R22] studied entrance surfacc doses
to children of different age groups from frequent
simple examinations of the abdomcn, hip and pelvis,
skull, spine and chest Thc ranges of doses theyobserved in the Madrid area to children less than 1
year of age (AP projection) wcre 0.8-1.7 mGy (abdomen), 0.8-1.3 mGy (pelvis), 1.1-3.2 mGy (skull) and
0.1-0.5 mGy (chest). The variations observed, as wellas the fact that skull doses for some examinations
exceeded suggested reference values for adults [M38],
were said to demonstrate the need for quality assurance programmes. Similar data collected from theUnited Kingdom [C22] showed that some skull doses
exceeded the CEC reference dose values.
98. A study covering 11 member States of theEuropean Community [S19], which considered typical
x-ray examinations performed on infants (abdornen,skull, chest, spine, pelvis), showed large variations inentrance surface doses, far g r a t e r than the known and
expected variations for corresponding examinations ofadults. The maximum entrance surface doses for theabdomen, skull, chest and spine wcrc almost 5 0 times
higher than the minimum doses, and for the pelvis, a76fold difference was found. The study had beenstandardized on the size of the infant so that no
additional variation was introduccd. It should bepossible to remove some of the dosc variation, which
would presumably lcad to lower average doses toinfants in future x-ray examinations.
99. Most of the patients subjected to scoliosis
radiography are females bctween 10 and 16 years ofage, and many of them are examined repeatedly,
perhaps 20 times in all, for prolonged pcriods. so thatconsiderable doses result from the total course of
examinations. It is likely, however, that technicalimprovements will reduce doses pcr examination. As
an example, the filtration systems common inchiropractic practice can rcduce doses to scoliosis
patients significantly [A2]. Computed radiography
seems to reduce doses by about an order ofmagnitude, both with large-screen image intensifiers[M5] and with photostimulable phosphor imaging
plates [K12. U 2 ] . A disadvantage is that neithertechnique permits the er~tirecervical, thoracic andlumbar spine of a tall teenager to be shown on asingle image [M5, K221. One study in Sweden foundlhat the effective dose equivalent with state-of-the-art
technique was 0.07 mSv for one examination. Othertcchniqucs gavc up to 10 times higher doses. Published figures indicated that certain techniques could
give doses a furthcr order of magnitude higher [H39].
100. Several authors have examined the utility offiltration in paediatric radiology. For abdominal
examinations of 10-year-old children, niobium
filtration neither impaired the image quality
substantially nor reduced doses significantly [J4]. Rare
earth (erbium, hafnium) filters have been received
with mixed reviews for paediatric radiology (and forgeneral radiology; they are discussed below wilh
respect to dental examinations). Although they do
permit dose reductions of 20%-25% with unimpaired
image quality, the cost is high [D12, S39, W151.
Adams [A91 advocated rare earth fdtcn but also
pointed out that a number of other items in a quality
assurance programme are at least as important. A
more advanced technical development, computed
radiography using photostimulable phosphor imaging
pla~es,permits dose reductions of 30%-50%, comparedto sacen/film systems, in various examinations ofchildren, infants and premature babies [B24]. An
addcd benefit is that the findings can be highlighted
using image post-processing.

101. In computed tomography, paediatric body scans
using ceramic detectors allow 50% dose reductions
compared to xenon detectors, with a negligible
reduction of image quality [P17]. Naidich et al. [N9]addressed the potential for low-dose mmputed
tomography of children, comparing a 10 rnA setting to
the more routine 140 rnA (at 120 kVp) for lungexaminations. In spite of increased image noise andloss of low-contrast detail, the low-dose examination
produced images of acceptable quality.

D. DENTAL X-RAY
EXAhllNATIONS
102. Although the enective dose to a patient from anoral radiographic examination is low, the frequency of
examinations is high enough to warrant study of dose
distributions. Country-by-country frequencies of dental
examinations arc listed in Table 17, and the entrance
surface doses and effective doses or effective dose
equivalerils per examination, mainly for intraoral films,
are listed in Table 18. Representative frequencies ofdental examination were estimated in the UNSCEAR
1988 Report [Ul] to be 250 and 4 per 1,000 population in countries of health-care levels I and 11,
respectively. Since then many additional studies havebccn performed, providing a wider basis for estimates.
The population-weighted
average examination
frequency for countries of health-care levels I, 11 andIll for 1985-1990 were, according to Table 17, 350,
2.5 and 1.7 per 1,000 population, respectively. Some
data wcrc collcctcd on age- and sex-distributions, butthese appear too scattered to warrant formal analysis.
It is noted, however, that dental examinations ofchildren are rather frequent103. In the UNSCEAR 1988 Report [Ul], the average
effective dose equivalent for a procedure involving
about two dental film exposures was estimated to be
0.03 mSv. The population-weighted average effective
dose equivalent per examination for countries ofhealth-care level 1 in 1985-1990, calculated from thedata of Table 18, was about 0.03 mSv (the weighted
per caput effective dose equivalent is about 0.01 mSv).
For countries of health-care levels TI-IV, the effective
dose equivalent per exanlination is probably muchhigher; according to Table 18, the average dose per
examination was 0.2 niSv at level I1 (based mainly on
Brazil) and 0.32 mSv at level 111 (based on Myanmar).
These averages correspond, however, to per caput
effective dose equivalents of only 0.001 mSv atlevel I1 and 0.0003 mSv at level 111, due to the low
examination frequencies.
104. For dental x-ray examinations, the collective
effective dose equivalent in Sweden was estimated to
be 79 man Sv in 1984 [Sl], while a similar estimate
for Finland in 1981-1985 was 15 man Sv [H2]. The
population of Sweden, 8.3 million in 1984, is twicethat of Finland. However, individual doses wereslightly higher in Finland. The results mainly reflect
differences in examination frequency; the examination
frequency in Sweden is rather high, 1.9 films per
inhabitant in 1986, due to a national dental service
programme that provides relatively frequent examinations.
105. In contrast, the dental x-ray collective cffective
dose equivalent of 2,000 man Sv in France in 1984
[BS] cannot be explained just by the largcr populationof France (54.9 million in 1984) or by the examination
frequency (0.5 films per inhabitant in 1984 [BS]).
Instead, the difference arises from the average doses
per examination, which are at least 2-3 timcs higher
than in the Nordic countries [BS]. Benedittini et al.
[B5] noted that the bitewing entrance surface air kerma was halved in the United States between 1973 and1981, and that the value of 6.9 n ~ G yin France in 1984
was comparable to the value of 5.7 rnGy in the UnitedStates in 1973. According to the authors, an important
explanatory factor is that there is no nationwide
quality assurance programme for dental radiography inFrance, while quality assurance programmes have been
implemented in lhe United States [BS].

ANNIX C: MEDICAL RhDlAnON MI'OSUKIS

106. Doses due to intraoral exa~~iinations
span anorder of magnitude, with cffeclive dosc equivalents for
a complete mouth examination ranging from 0.02 to
0.28 mSv, according to a survcy in the Netherlarids[V2]. For rotational panoramic radiography of an adultfcmalc, Gibbs ct al. estimate the cffective dosc
equivalent to be 0.01-0.03 mSv [G12]. A later study
in the Netherlands [VlO] found a fourfold differencein avcrage entrance surface doscs for various bitcwing
radiography techniqucs (2.5-9 mGy), and a 35-foldrange for individual measurenlents (0.9-31 mGy). A
review of recent studies in countrics of health-carelevel I found effcctive dose equivalents for single
ir~traoralexposures from 0.001 to 0.05 mSv and forpanoramic exposures from 0.007 to 0.08 mSv [S33].
A similar rcview [W30] that calculated effective doscs
using ICRP 1990 weighting factors found a range ofvalues for full-mouth examinations of 0.03-0.14 mSv,
average 0.08 mSv, and a range for panoramic
examination of 0.003-0.016 mSv, avcrage 0.007 mSv.
107. With such small effective doses, treatment
courses involving several examinations over a longer
period will also cause relatively small doses. Sewerin[ S l l ] estimated the total effective dose equivalent toa patient during a seven-year treatment with osseointegrated implants, with concomitant x-ray examinations, to be about 1.7 mSv. The study assumed, however, that two-dimensional imaging is suflicient in
pre-operative examinations. Ohen, cross-sectional
information is requested, using computed tomographyof the skull, which gives doses that are higher by
several orders of magnitude [ClO]. The extent towhich computed radiography is needed in this situation is somewhat controversial [M36, S321, but given
its increasing availability, cor~lputedtomography will
presumably be uscd more often in the future. The
doses in computed tomogaphy of the mouth region
can bc higher than in conventional dcntal x-ray
examinations [K13, S55] and similar to those in othercomputed tomography examinations of the hcad andneck.
108. The average organ doses encountered in various
dental x-ray examinations in France arc summarizedin Table 1 9 [Bj]. The doses were dctermined bymeans of a phantom and are presented here because of
the detailed anatomical subdivision. A few doscs arc
in the range one to several milligray, but most are lessthan 0.2 mGy. Absorbed doses to the thyroid and theeye lens in a study in the United States [TI31 werequite similar to those in Table 19. According to another study in France [P14], entrance surface doscs
were about 15 niGy for intraoral films and about
1 0 mGy for panoramic examination. Since image
quality is slighlly inferior with panoramic
examinations and since rectangular collimation,lead-backed film and lead aprons are likely to reduce239

h e thyroid doses from intraoral films [B26],
panoramic examination is not expected to supplant
intraoral films. No~iethclcss. the frequency of
panoramic examinations merits study. In a number ofcountries, they arc uscd lo screen orthodontal
anomalies in children (W191.
109. Computation arid intcrprctation of the cffcctivc
dose or effective dose equivalent are not entirely
straightforward for oral radiology [H38, S3]. Th'IS wasparticularly problematic bcforc the ICRP recommendatio~~sof 1990 (181 were publishcd, since most of
the organs exposed belonged to the "remainder" group,
for which the ICRP 1977 rccommcndations p l ] provided only average weighting factors. As an illustration, whcn the effective dosc equivalent [ I l l was
calculated for a single bitewing film with 60-70 kVp
machines in New Zealand, the result was 0.067 mSv.
When effective dose was calculated from the samedata according to the ICRP recommendations of 1990
[I8], which provide specific weighting factors forsome additional organs, the result was only 0.005
mSv, about 7% of the former value [W12].
110. Maruyama [M31] obtained a similar rcsult inJapan: effcctive dosescalculated with 1990 weighting
factors p8] were 539446% of the effective dose
equivalents calculated with 1977 [ I l l weighting
factors. However, this calculation was quite sensitive
to whethcr the skin was considered a target organ. If
it was, the trend was reversed, and the cffective doses
were about twice the effective dose equivalents p31].
Velders et al. [V12] in the Netherlands obtained
bitewing cffective dose equivalents of 2-11 pSv for
various parameter combinations and effective doscs of
1-4 ~ S V .
111. Several reviews in the United Kingdom, theUnited States and elsewhere summarize reccnt developments in dental x-ray exposure reduction [B27,
H44, K3, K4, K25, T2, T3, T7]. For instance, in
panoramic radiography, exposures were reduced 34%
79% with rare earth intensifying screens and heavy
metal filtration, and image quality was the same or
better [K3, SlO]. However. the advantages of rareearth and other thin I<-edge filters are not uncontcstcd.
Byrne et al. [ B E ] in Canada found a surface air
kcrma reduction for intraoral films of about 15% (asopposed to the filter manufacturer's claim of 40%).
but thyroid dosc was actually incrcascd. MacDonaldJankowski et al. in the United Kingdom conlirmcd thesurface air kerma reduction but noted the possible
disadvantages (unsharp images due to movement andx-ray tube wear) of the associated prolongation of
exposure time [M35]. In a subsequent study [M42],
the authors concluded that while thin K-edge filters
reduced entrance surface dosc and, to a certain extent,
total dose to thc hcad, orbital dose might be increased.

UNSCEAR 1993 REPORT

240112. White ct al. [W31] rcgardcd niobium filtration,with a 20%-30% dose reduction, compatible with
acccptablc images on D-speed film. With faster (Especd) filni, niobium filtration significantly degradedthe quality of the image. Other theoretical andpractical studies suggest the limitations of niobium
filtration [J 12, M21).
113. Exposure varies widely with technique, also inlcss frcqucntly performed cxaminations. Correctly
performed [B28], video fluorographic examination of
vclopharyngcal function causes one tenth of the dose
obtained with cinefluorogaphy, which causes entrance
surface doses in the 6-30 mGy range [I3].

E. WORLDWIDE EXPOSURES
114. The collective effective dose equivalent fromdiagnostic medical x-ray examinations performed
worldwide is presented in Table 20. Estimates of thefrequencies of each examination and the average doses
havc bcen combined to detcnnine the collective dosefor each health-care level and for the entire world. The
average frequencies of examinations given in Table 7
have been used to indicate the relative frequencies,
with the total corresponding to the populationweighted average for all examinations (Table 8). The
data for level IV are insufficient for separate analysis
and are instead included with h o s e of level 111.
115. The average doses per examination werc derived
from data in Table 10 and listed in Table 11. Where
estimates of dosc were not available for level TI
countries, they werc assumed to be the same as forlevel I countries. Moreover, for lack of data, the doses
in level In-IV are assumed to be the same as doses inlevcl 11. The data for level I1 are the populationwcighted data reported for China and India, which
may be expected to be representative. However, somedoses are less than the more widely based averages forlevel I; recognizing that the values in level I1 areunlikely to be lower than those in level I and in order
not to undcrestiniate the collective dose, the higher
values (i.e. level I values) have been assumed also forlevcl 11. This applies to examinations of the chest(radiographic and fluoroscopic), extremities, skull,
abdomen and lower gastro-intestinal tract and tourography.
116. The estimate of the collective dose lrom all
diagnostic x-ray examinations performed in one year
on the world population of 1990 is 1,600,000 man Sv.
The corresponding estimate in the UNSCEAR 1988
Report [Ul j was 1,760,000 man Sv. The difference
may well be no more than a sampling effecL The
results for level I are little changed. The per caput
effective dose (and effective dose equivalent) is

0.9 niSv, compared to 1.0 n1Sv in the earlier analysis.
However, the value of 0.9 niSv includes data of 1980
for the United States, which probably underestimate
h e present examination frequency lM2]. For level 11,
h e cstimatcd per caput effcctive dose has been
reduced, from 0.2 mSv to 0.1 mSv. Few data had been
available for the earlier analysis, but the situation ismuch improved now that data from both China andIndia arc available. For levels I11 and IV the previous
range of 0.03-0.07 mSv, again based on very few data,
has now bcen set at 0.04 mSv. There is still uncertainty in the collective doses from Icvcls II-IV, but
their significance is less than that of levcl I, whichalone contributes 78% of the estimated worldwide
collcctive dosc.
117. Previous uncertainties regarding the use offluoroscopy in developing cou~ltriesare lessened now
that data are available for China. While chest photofluoroscopy is still a common examination, accounting
for 43% of all examinations in the country (Table 7),
the effective dose per examination is now reported tobe 0.3 mSv (although 1.0 mSv has been used in Table20), compared with 3.4 mSv reported previously [Ul].
Assuming that the higher dose still prevails would
increase the estimated collective dose worldwide to
1,940,000 man Sv.
118. Specific examinations contribute to the totalcollective dose from diagnostic medical x-ray cxaminations as shown in Table 21. The examinations arelisted in decreasing order of their contribution to theworldwide collective dose. The most prominent contributors in level I are upper gastro-intestinal tract,computed tomography, chest mass miniature, spine
and lower gastro-intestinal tract. The doses are
relatively high for the examinations of the gastrointestinal tract, and togetl~crupper and lowcr gastrointestinal tract examinations contribute more than 30%of the collcctive dose in level I and 1 9 7 ~ 2 2 %inlevels 11-IV. The importance of chest fluoroscopy inlevcl I1 countries is apparcrit (it conlributed 42% of
the total collective dose). The relative frequency ofthis examination in levels 111 and IV was less than inlevels I and 11, but it was also tbe highest contributor
to the total collective dosc at this level. Otherexaminations of the chest were important in level 11(mass miniature) and levels I11 and IV (radiography).
Examinations of the abdomen and pelvis/hip weremore important in levels 11-1V than in levcl I, but
computed tomography contributrd much lcss to. thetotal collcctive dose at the lower health-care levels.
119. Doses from all diagnostic x-ray examinations
havc been evaluated in a number of countries. The
resulting effective dose equivalents, provided in
responses to the UNSCEAR Survey of Medical Radiation Usage and Exposures or available in publishedarc summarized in Table 22. In a few cascs, cffective
doscs or cffcctive dose equivalcn& for all cxaminations were calculated from data provided for specificexaminations in Tahlcs 7 and 10. Tablc 22 indicatesthat thc latest annual cffcctive dose equivalent per
caput attributable to x-ray cxaminations in countries o lhcal~h-carelevel I rangcd from 0.3 to 2.2 mSv.
120. The population-wcightcd per caput cffcctive dosc
equivalcnt in hcalth-care Icvcl I countries, based on
Table 22, for 1980-1990 is 1 mSv. This is the samc
value as that given in thc UNSCEAR 1988 Report[Ul] for available data rcported for 1976-1984. The
data for Canada, Czcchoslovakia and the United Statcs
in Tablc 22 arc for 1980. Updated values might haveincrcascd thc 1980-1990 average somewhat, especiallyin vicw of the increasing trends in computcd tomography [M2]. Thus, the wcighted average for 19821990 is 1.2 mSv. The unweighted average and medianvalucs of data for level I rcported in Table 22 are bothabout 0.8 mSv. This agrees with the fact that relatively
high doscs are reported from Japan and the former
USSR (RSFSR only), both of which have large
populations.
121. The reported estimatcs of effective dose orcffective dose equivalent from diagnostic medical
x-ray examinations arc less extensive for levels 11-IV
than for level I. An overall range of 0.02-0.2 mSv isevident from the data in Table 22. The values at thelower end of the range were underestimated when
fluoroscopy was not included. The estimates at thc
uppcr end of the range werc made before 1980. It can
only be said that the estimates of collective dose basedon the frequencies of examinations and average doses
in Table 20 appear reasonable. The per caput doses inthat analysis were 0.1 mSv in level I1 anb 0.04 mSv
in levels 111-IV.

122. The estimated annual per caput and collective
effective dose (equivalent) from diagnostic x-ray
examinations, taking resulls of the different sampling
melhods used into account, are summarized inTable 23. The collective dose totals arc the values
rounded subsequent to calculation. The values for the
medical examinations for levels 11-IV are thosedetermined in Table 20. The per caput effective doses
and the collective dose from dental examinations were
determined from average frequencics and doses citedin Section 1I.D. These doses are less by a factor of
100 than those from medical examinations. The totalcollective dose from diagnostic x-ray examinations
worldwide is just over 1.6 million man Sv.

F. TRENDS
123. It is anticipated that both the total number ofdiagnostic x-ray examinations and the frequency of

cxaniir~ations pcr unit population will incrcasc
worldwide for simple demographic reasons, at lcast up
to the year 2000 and probably to 2025 [Ul]. Thcrc are
rliree main reasons lor this cxpccta~ion:
(a)

@)

(c)

population growth. Even if the rclativc frcquency
of cxaminations per unit population rcmaincd
constant, thc absolute number of examinations
would grow by 60% from 1988 to 2025 as aresult of population increase;growing urbanization. In gcneral, urban populations have more acccss to health care and amuch higher frequency of radiological examinations than rural ones, and the percentage of thc
urban population is expected to rise from 41% to
65% between 1988 and 2025;
agcing of the population, particularly in Europe.
Since the older population accounts for adisproportionately high utilization of medical
radiation procedures, the ageing of populations
leads to increasing examination frequencies.
However, in Africa and Latin America, theproportion of young persons will increase, Al-'
though the frequency of examinations increases
as the population ages, an older population
would be less at risk for stochastic effects
because of the time periods required for thcir
induction.

124. In general terms, these factors governing
long-term trends in examination frequencies and doses
are likely to remain valid. For specific countries andgroups of countries, over a shorter period and forspecific examinations, trends may be more complex and difficult to discern, analyse or forecast.
125. It was mentioned above that according to the
UNSCEAR Survey of Medical Radiation Usage andExposures, the total frcquency of all x-ray examinations at health-care level I increased from 810 per
1,000 population in the mid-1970s to 890 pcr 1,000
population in 1985-1990, representing a 4 % increasein the population-weighted average per 5-ycar period.
The unweighted average increased by 2 % per 5-year
pcriod (not statistically significant). This observation
is supported by independent estimates that thcre
should be at least a slowing in the rate of increase of
frequencies in the future conlpared to the 1970s [S7,S14]. The composition of the examination types
changes, however: there are, for examplc, fewer chest
examinations and more con~puted tomography in. .
recent years.
-

126. Trends in individual countries deviate from theaverage. Increasing total frequencies of x-ray
examinations are evident in France (+18% per fiveyear period), the Federal Republic of Germany(+lo%), Japan (+13%), Malta (+69%), United King-dom (+lo%) and particularly in Cuba (+342%). Sonic
diffcrcnccs may rcflcct changcs in survcy mcthods thatgivc morc complctc rcsults rathcr than real changcs incxanlination frcqucncics. Dccrcasing total frcqucncics
of examinations arc rcportcd in Finland (-10% per 5ycar pcriod), Norway (-16%) and Romania (-16%).
Thc Ncthcrlands [B21, B22] and also the Russian
Fcdcration show first incrcasing, thcn decreasing
trends, with pcak cxamination frcquencics in the carly
1980s. In Japan, the incrcasc is duc chicfly loradiographic cxaminations; thc incrcascd usc offluoroscopy has bccn relatively moderate since 1970,
with a slight decline since 1987 [M32].
127. In countries of health-care levels 11-IV, thc
frcqucncy of examinations appears to be incrcasing,with a 1985-1990 population-weighted frequency of
about 100 pcr 1,000 population. Unwcightcd avcragcs
incrcascd by some 25% pcr 5-year period, and thetrend appears to be statistically significant. In the fcw
countries that could supply data for more than one
timc pcriod, trends are less scattered than at healthcare lcvel I. Very clear increases occur in Ecuador andin India. Decreasing examination frequcncics wcrc
rcportcd for Brazil and Nicaragua.
128. One reason for slower rates of incrcase or slightdccrcascs in cxamination Gequcncics in countries ofhealth-carc lcvcl I is that ncwcr modalities, such asm a p c t i c rcsonancc tomography, endoscopy and ultrasonography, are replacing some x-ray examinations.
X-ray cxaminations condnuc, however, to be the mostimponant imaging mcthod, accounting for 79% of
diagnostic imagcs in Europe in 1988 and a projected
77% in 1993 [H40]. Hill [ H a ] expects the relative
usc of computed tomography and of nuclear mcdicinc
examinations to rcmain constant, at 2% each. Thisprediction appcars low for computed tomography
considcring its rapid incrcasc, which more than offsets
h c dccrease of othcr examinations in the United
Kingdom [S42], cvcn if a constant percentage may
mcan an incrcascd number in some countrics. Finally,
Hill expects thc sharc of ultrasound examinations toincrcase from 17% to 19% and that of magnetic
rcsonancc imaging to remain constant, at 1% [H40],
although the intcrprctation of these pcrcentages is
hampcrcd by thc omission of endoscopy.
129. Broadly, the UNSCEAR Survey of Mcdical
Radiation Usage and Exposures shows that doses pcr
cxamination arc decreasing for most procedures incountrics of hcalth-care lcvcl I (not cnough information is available from othcr countrics to draw
conclusions about trends). This gencralization is
supported by indcpcndcnt reports from, for example,
Australia [H37], thc Federal Republic of Germany[G7], Japan [M4], Sweden [V4], thc United Statcs
IS61 and the USSR [S18]. The decrease from the

1930s to the 1980s may bc by a faclor of 5-15, andh a t 1970 to 1980, by a factor of 1.5-3 [G7, HIS,
V19].
130. TIICtrcnds for spccific procedures or countries
arc morc complicated. Tablc 10 indicatcs dccrcasing
doscs pcr proccdurc in Auslralia, Finland and Swcdcn:
dccrcasirig doscs for gastro-intestinal tract imaging(important, sincc thcy arc at the uppcr cnd of thc dosc
rangc) but not for othcr cxan~inations in Czcchoslovakia; and no strong changc in Romania. Trcnds incomputed tomography doscs cannot bc disccrncd
dirccrly Gom Tablc 10, but as was shown in Scction IT.C.2, thcsc doscs arc incrcasing. Hcnce, the total
dosc for all x-ray cxaminations per cxamincd paticnt
may be unchanged or only slightly decreased. This
agrccs with thc impression of doscs per cxamincd
paticnt in Tablc 11. Thc population-weighted annual
per caput cffcctivc dosc equivalent is 0.93 mSv for
1985-1990 from analyses of ficqucncies and doses(Tablc 20) and 1.2 mSv for 1982-1990 from available
estimates from countrics (Tablc 22), indicating that
there has been no significant change for countrics ofhcalth-care lcvcl I from thc estimate of 1 mSv givenin thc UNSCEAR 1988 Rcport [Ul].
131. The rapid dcvelopnicnt of morc powerful yet
cheaper computers is revolutionizing all imaging
mcthods, with and without ionizing radiation. As an
example, data obtaincd in computed tomography (ormagnetic resonance tomography or nuclear medicine)
can now be assembled into three-dimensional picturesthat can easily be rotated by the analyst [F12, F13,
T17, W171. This may permit lower doses per examination: with pelvic trauma, for example, a thrce-dimensional examination obviatcs the need for plain radiographs to supplcrnent a coniputcd tomographic examination [Sg], eliminating an average entrance surface
dosc of 23 mGy per cxamination. Thus, new information is obtained, and morc uscs of lhcsc techniques
become possible.
132. The transition to digital systcrns in industrializedcountrics is likely to continuc. At prcscnt 15%-30% of
exanlinations arc digital [B9, 031. Digital radiographyuscs large image intensifiers or photostimulable
phosphor imaging platcs. Chest cxaminations using
digital tcchniqucs can produce substantial savings oftimc and moncy for film, chemicals and archiving[)(23]. Whilc the quality of the imagc with a large
iniagc intcnsilicr is not as good as with full-size
imagcs'on film, thc diffcrcrrcc can bc snlall cnough to
be clinically ncgligiblc. If fluoroscopy is not uscd, an
image intcnsificr can rcducc paticnt cxposure lo one
third that of full-sizc images on film [K23, MlG] or,in situations such as pcriphcral angiography, to one
tenth IP211.

ANNEX C: MEDICAL RADIATION EXPOSURES

133. The alternative technology of imaging plates withphotostimulahle phosphor [TlOj scclns to havc been
more widcly adopted in Japan than large image intcnsificr computed radiography. Worldwide, about 1,000
such systcnis had becn installed by thc end of 1991,
700 of them in Japan [Bg]. This systcm also pcmiits
substantial dosc reductions, partly becausc it scparatcs
the two functions of dctcction and display, which arc
combined in convcntional radiographical film [W5].
For chest radiopaphy, cxposurc was 20%-44% of thestandard cxposurc with a screcnlfilln con~bination[R17, S24, S25] or cvcn 15% in pacdiarric chest
imaging [K19]. In cxaminations of the uppcr gastrointestinal tract, cxposure was 32% of that with ascrcen/film combination [S26]. For urethrocystography
the dose-area product was reduced iron) 1 3 mGy an2
to 1.3 mGy cm2 [Z9]. As the technology improves,
digital imaging is also becoming a mcthod of choice
in difficult situations like cardiac imaging [DlS].
134. Digital computed radiography with imaging
platcs not only gives a potential for lower doses pcr
image but also permits more sophisticated experiments
in dose reduction. Using stacked imaging plates, such
experiments can also be made in the course of actual
diagnosis on paticnts without undue cxposure [R17].
However, persistent anecdotal evidcncc (see, e.g. [J5,F8J) indicates that somc of the dosc reduction per
image in computcd radiography may be offset by atendency of radiologists to obtain more images per
patient than they would have done with conventionalsnccn/fim systems. Also, while ovcr- or underexposure shows up in conventional radiology as
incorrect blackening of the film, considerablc ovcrcxposure can go undetected in a digital systcm unlessexposure is specifically monitored [B9,W5].

243

likely that iniplem~ntation[C16, NS] of the rccommcndatiot~swould truncatc thc upper end of the dosc
range for many examinations. Since doscs per examination vary by a factor of 10 or more, cvcn in asingle hospital [H37, 071, such a truncation could be
cxpcctcd to rcducc averagc doscs.
137. National recommcndations arc also likely to lcad
to rcduccd doscs. Scrccn/film speed is the overriding
cause of paticnt dose variation in the Unitcd Kingdom,and fluoroscopy time in gaslro-intestinal tract examinations is the sccond b i a c s t causc [H33]. A United
Kingdom report IN51 gives dctailcd rccommendations
for reducing patient doscs (a second report [ N l l ] dcals
specifically with computcd tomography). It cstimatcs
that about half of the currcnt collcctivc cffcctivc doseto patients from x rays could bc avoided. This conclusion is drawn in spite of the relatively low frcquency of examinations (about twice as many examinations per caput are performed in France and tbe
United States).
138. Recommendations to restrict doses raise anumber of questions: more stringent referral criteria
are a subject of some dispute [Fl, K7, Kg], the valueof access to old radiographs may be limited [ O l ] andh e benefits of rare earth filtration arc challenged.
However, sincc it has been suggested that in the
United Kingdom the collective effective dosc fromdiagnostic x rays could be halved
there isprobably a potential for similar dose reductions inmany countries. If this potential is realized, as itprobably will be in a number of countries, doscs will
go down.

1. Specific x-ray examinations and techniques

135. Thc use of rare earth intensifying screens is oneof thc more important technical developments leading
to lower doses per examination. While such screensarc by no means ncw, having becn available sincc theearly 1970s, they are not yet utilized in all relevant
situations. For instance, sample studics indicate thatfewcr than 50% of thc radiographic cxaminations in
the United Kingdom were carricd out with rare earth
scrccns in 1986 [NS]. Other factors remaining constant, a complete transition to rare earth Screens would
reduce the collective effcctivc dose from x-ray cxaminations in the United Kingdom by 3,000 man SV[NS]. It sccms highly likcly that rare earth snccns willcontinue to be more widely used, reducing the doscs
per examination.

139. Fluoroscopy and photofluorography usually cause
highcr doscs than scrcen/film radiography, particularly
with older equipment, and are thus largely being
replaced in industrialized countries. It is less clear if,
or how quickly, this change will occur in developing
countries. There, the higher cost of scrccnltiim
radiography is a more important consideration than inindustrialized countrics [T8]. In Tunisia, where over
50% of the equipment is fluoroscopic, the technique isthought to be excessively utilized [G16]. The authors
judge that 6096-7096 of the general practitioners
equipped with fluoroscopy use thc examination only toplease patients, not for diagnostic advantage. Information campaigns are under way to reduce thedemand for fluoroscopy.

136. The lCRP rccommendations of 1990 [I81suggcst
h a t dose cons~raintsor investigation lcvcls should beconsidcred for some common diagnostic proccdurcs.
While this is not to be construed as advocating thc
introduction of limits for medical exposures, it is140. In general, chest screening is becoming lessfrequent. For conventional postcrior/antcrior chest
examinations with full-size images on film, doscs arc
decreasing. In Manitoba, Canada. thc average entrance
surface dosc decreased from 0.3 mGy in 1979 to244

UNSCFAR 1993 REPORT

0.07-0.12 mGy in 1987 IH6, H241. Some techniques
may give a higher dose to patients, howcvcr. The
difference in transmission between mediastinum andlungs is a complication that can be alleviated withshaped filters or with image processing in coniputcd
radiology. Alternatively, the problem can be circurnvcntcd by bcani modulation, a technique that produces high image quality but with an increase in doscof up to 25% compared to air-gap scrcen/film systems[AlO]. Beam modulation may, however, obviate theneed for additional examinations, which could reduce
patient dosc for the entire diagnostic procedure.
However, such specialized equipment is not expected
to be in wide usage in the near future.
141. The growing use of computed tomography has
been noted, with greater numbers of scanners andhigl~er frequencies of examination in countries ofhealth-care level I [C9, N5, S14). In the Unitcd States,computed tomography is the most frequently pcrformed x-ray examination in hospitals, accounting for
56% of ihe total examinations [G8]; including all othermedical centres and practices, computed tomography
constitutes some 9% of all examinations [BlO].
Furthermore, the number 'of slices imaged on eachpatient has risen as the time required to perform scans
and reconstruct images has decreased: However, sincelittle change has occurred in the dose required perslice, the dose per examination is likely to haveincrcased substantially [NS]. Indeed, the averagc
effective dose equivalent due to a body scan at theMayo Clinic in the Unitcd States was 15.6 mSv(range: 9-60 mSv) in 1988 [V8]; in 1980, the comparable figure for the Unitcd States was 1.1 mSv [N11.
142. About half of the computcd tomographies in theNordic countries in 1987 were head examinations[S14]. Computed tomography has largely replaced
encephalography and cerebral angiography that was
performed in cases of trauma, tumours or apoplectic
strokes. In these applications, magnetic resonancetomographs may tend to replace computcd tomography, although the latter is expected to remain an
important tool, along wilh ultrasound, for abdominal
examinations. Likewise, computed tomography willprobably remain important in oncology, for therapy
planning and for follow-up examinations after treatments [S14]. Judging from United Kingdom statistics,
computed tomography now contributes more than any
other single type of diagnostic procedure to thecolicctivc dosc from x-ray examinations (about 20%),and the trend is still rising [S42, S431.
143. As indicated in the UNSCEAR 1988 Report[ U l ] , the nuniber of skull x-ray examinations
incrcased significanlly between 1964 and 1980. The
more recent data in Tables 7 and 8 reflects mixed
trends, but a report from the United States [MI81shows that several investigators suspected over-utili7ation of skull radiography bccausc of concerns ofpossit~lcmalpractice suits. The attention drawn to thismay have altered this trend. Also. plain film skull
examinations arc increasingly being replaced bycomputed tomography examinations.
144. The number of countries with nia~nmography
screening programmes has been increasing [C6, M9,
R6, T I , V6]. While doses per cxamination arereasonably low, with surface doses now in the rangeof 1 mGy [Vl], the impact of mammography screening on the collective dose is not negligible. For
instance, it is estimated that, when fully implemented,
a nationwide screening programme in Sweden will
increase the collective effective dose equivalent due todiagnostic x rays by about 5% [V4]. However,
because doses per exaniination are decreasing, thecollcctive dose docs not increase as fast as the numberof examinations. For instance, in Manitoba, Canada,
the number of examinations in a population of about
1 million increased from 4,800 in 1978 to 24,000 in
1988, i.e. about fivefold. The collective breast dose
has also increased, but at a much slower rate, from 40
man Gy in 1978 to 97 miin Gy in 1988 [H31] (theaveragc breast dosc decreased by 50% during that
period).
145. In dental radiology, the trend is very clearly
towards reduced doses per examination [G3, K4, Sl].
Thus, the absorbed dose to the parotid glands forcommon radiographic techniques decreased by one
order of magnitude for every 20-year period between
1920 and 1980 [B15]. This trend is expected tocontitiue. Goren ct al. [G3] reported a dosc reductionby half in the Unitcd States but noted that only 13%
of surveyed dental practices used high-speed
class E films. According to them, if such films wereused at all dental practices, the dose would again be
halved. However, it must be noted that the slower
class D film is someti~ncsused owing to its higher
averagc film contrast [W12]. Nevertheless, some dose
reduction attributable to the use of class E film is
expected. Other factors, such as reduced beam size,
are also expected to lead to dose reductions. Digitalconiputcd dental radiology cxists, but apparently the
resolution and latitude are still inferior to that ofstandard dental film [W18].
Thc relatively bulky
sensors may impede projcclions and the small image
area hampers the evaluation of bone lcsions andneutralizes dose reductions because more views are
required [G20]. Thus, the technique is not expected tospread rapidly in the near future.

2.

Alternatives to x-ray exnnliriation

146. Conventional radiology still dominates clinicalradiology (over 80% of all examinations in the Nordic
countries are done using conventional methods), andANNil3 C: MEDICAL

dccrcasc in the numbcr of urographics is that indicano radical dccrcasc in tllc nccd for convcntionaltions, c.g. for calculus checking, have changcd [S14].
radiology is cxpcctcd [S14]. Nevcrthclcss, in nlanySome contrast urography has been rcplaccd hy srinticases, the information nccdcd clinically can begraphy and othcr mclhods in nuclcar mcdici~lc,whichobtail~cdin rnorc than one way. Bcsidcs diagnostic
usually impart effective doses that arc an ordcr of
x-ray examination, dlcrc may be mcthods in nuclcar
magnitude or so lowcr [NlO, W211.
medicine, or cndoscopy, ultrasonography, niagnctic
resonance tomography or othcr altcrnativcs. Of thcsc,150. According to the samc report [S14], urcthroultrasonography is the most rapidly growing imaging
cystography and hyslcrosalpingography l~avc also
modality, with salcs of cquiprncnt growing 20% annudecrcascd, at least in the Nordic countries in theally, an cstimatcd 60,000-90,000 unils in operation
1980s. In Swcden, the numbcr of cholecystographies
worldwide and somc 60-90 million cxaminations
dccrcascd by about 70% aftcr 1975, to sonlc 24 perannually [M8]. This corresponds to 4%-6% of the
1,000 inhabitants in 1987 (a 72% dccrcase from1,600 million x-ray cxaminations pcrformcd annuallyworldwide. T o somc extcnt, x-ray examinatio~~s 1970-1974 to 5 pcr 1,000 in 1985-1989). This dcaease was due to the rcplacemcnt of cholccystocausing high individual doscs are being replaced. Forgraphy with ultrasonogaphy. The other Nordic couninstance, magnetic resonance tomography, or sometries have even lower currcnt frequencies of cholctimes transcranial-Doppler sonography, may be subcystography: a frequency of 0.4 per 1,000 inhabitants
stituted for cranial angiography [R8].
was repofled for Norway in 1988.
147. An example of a diagnostic situation where nuc151. Some trends in x-ray diagnostics, ultrasonolear medicine is an alternative to x rays is provided bygraphy and endoscopy have been investigated in the
non-cutaneous melanomas. A study in Italy indicatcd
Federal Republic of Gcrmany [Kg].For abdominal orthat radioimmunoscinti raphy, using monoclonal antitotal body (paediatric) examinations, h e r e wcre
bodies labclled witb 'In
or w m ~ c bad,a signifimarked decreases (309b-60%) during 1978-1984 incantly highcr diagnostic sensitivity than conventional
x-ray diagnostic examinations in hospitals and corx-ray cxaminations [C9]. The investigators plan toresponding increaks in sonographic examinations.
compare radiation doses and to pcrform cost-bcncfit
Abdominal x-ray examinations also decreased byanalyses.
about 60%, while endoscopy increased (mainly gastroscopy,
but also some coloscopy). During a similar
148. The inacasing use of alternative methods is notperiod,1981-1984, the frequency of abdominal x-ray
always accompanied by a corresponding decrease in
examinations
made by radiologists in private practice
conventional x-ray usage. The use of diagnostic ultra(whorarelyuse
sonography) increased, but by thesound during pregnancy more than doubled in therelatively
smallamountof about 20% [K9]. It was
Unitcd Statcs between 1980 and 1987 [CS]. Prcnatal
also
found
that
orthopaedic
practitioners in the Fcdcral
x-ray examinations arc rare, but considering that
Republic of Germany were increasingly favouring
radiation exposure of the fetus can now be avoided, itsonography for screening and follow-up examinations
might have bccn cxpectcd that thcy would be evenof hip joint diseases in infants [Kg]. Before therarcr instead of having remained about the same
introduction of hip joint sonography, 1.45 x-ray
during tbe period. A possible explanation is that the
exposures wcre takcn per examined infant: in 1984;use of x rays is rclated to the numbcr of Caesarcan
after the introduction of sonography, 0.95 x-ray
sections, since pelvic x-ray examinations are still used
exposures per infant werc takcn. In the Unitcd Statcs,
to assess the nccd for such delivery [C5]. Trcnds inthe number of ultra-sonographic cxaminations inobstetric radiography arc discussed further in theradiology departments of hospitals increased from 3.5
following Scction.
million in 1980 to 1 2 1 million in 1990 [M2]. During
the same period, the number of x-ray cxaminations
149. In contrast, urography docs seem to indicate
also increased from 114 million in 1980 to 181 million
dccrcasing use of x rays as thcre is increasing accessin 1990.
to ultrasound. The frequcncy of x-ray urogaphy
examinations was 16.8 pcr 1,000 inhabitants in Italy in
152. Endoscopy not only complemcnts but to a large
1978 and 10.5 per 1,000 in 1988 [C9]. Doses per
extent replaces x-ray. examination of the gastroexamination in Italy werc 7.1 mSv in 1983 and 4.8
intestinal tract, as was obscrvcd in the Ncthcrlands
mSv in 1988, corresponding to pcr caput doscs of 0.09
[GIs]. In Swcden the number of x-ray cxaminations
and 0.05 mSv, rcspcctivcly [C9]. I t should be notcd
of the stomach also dccrcascd, from 187,000 in 1975
that not only ultrasound but also more sensitive
to 33,000 in 1987, and will presumably decrcasc
saecn/film combinations and fewcr films per examfurther, as endoscopy is now available at almost all
ination contribute to the dcaeasing doscs per caput
Swedishhospitals [S14]. In contrast, colon exam[C9].Furthermore, computed tomography is also
inations
remained
rclalively constant over the period,
replacing urography, and an important reason for the

UNSCMR I

246

partly because coloscopy is more painful for thepatient and more difficult to manage. These trends
may not bc universal, even in countries of health-care
lcvcl I (see Table 7).
153. The number of magnetic resonance tomographs
has almost doubled each year in the United Statcs[SS]. According to one estimate, which is almost certainly too low, the total number of units in operationworldwide was about 1,200 in 1989, with 800 of thesein the United States, 150 in Japan, 60 in the Federal
Republic of Germany, 30 in France, 30 in Italy, 24 in
the United Kingdom and 40 in other countries [ B l l ] .
Another estimate, based on interviews with all
suppliers of such tomographs, indicated that about
3,500 units were in opcration worldwide in January
1990. Of these, about 1,800 were in the Unitcd Statcs
and 550 in Japan. About 375 units were mobile [S12].
With regard to h e examination profile, 48% of themagnetic resonance tomographies in Sweden in 1989
involved the brain and 36% the back [S12]. Other
applications included studies of the abdomen, joints
and limbs. Recently, magnetic resonance mammography has also become available [KS].
154. In spite of this development, computed
tomographs using x rays also continue to increase.
Smathcrs IS61 believes that magnetic resonance tomography will largely supplant computed tomography.
Equally, it can be postulated that, instead of decreasing, as Smathers believes, computed tomography willcontinue to increase and eventually reach a plateau. Infact, the use of computed tomography of the skull has
been increasing at such a pace in several countries thatthe use of magnetic resonance tomography of the skull
has been decreasing. This particular trend is notexpected to continue for long, since if it did, measureswould be presumably taken to limit the possible
ovcruse of computed tomography.

3.

Particular patient p u p s

155. Trends in obstetric radiography are a source ofparticular concern because of the risks to the irradiatedfetus. It has been suggested that the abdominal inadiation of pregnant women has been virtually replacedby other diagnostic techniques [M6]. This notion is
supported to some degree by a Swedish study, whichshows that the number of x-ray examinations during
pregnancy in 1987 was 38% of the number in 1975
[S14]. In h e United Kingdom the number of x-ray
examinations during pregnancy did not seem to belower in 1970-1981 than in 1950-1959 or 1960-1969[G6], but the number of films per examination did
decrease, and h e timing of x-ray examinations shifted
towards late pregnancy with practically no firsttrimester exposures after 1972. Gilman et al. [G6]estimated that 12% of all pregnant women in the
United Kingdom had been examined with x rays in
1976-1981. An indrpendcnt study by the National
Radiological Protection Board (NRPB) [K14] gave an
estimatc of 4.2% in 1977. The difference may be due
in part to the NRPB estimate being low and in part toa statistical uncertainty of the Gilman estimate [K14].
According to Gilrnan et al. [G6], the withdrawal of theso-called "10-day rule" of ICRP [I91 may lead to anincrease in the frequency of x-ray examinations ofpregnant women.
156. From time to time concern is expressed about theundue medical exposure of children [Dg]. It may be
expected that various radiation protection recommendations will be introduced in response to such concern;
as a result, the rate of increase of examinations ofchildren may be restrained in the future. The pattern
may be more complex in developing countries: asshown in Table 9, the fraction of examinations performed on children is larger in developing countries
than in industrialized countries (an exception are
hip/femur examinations, which are performed on ahigher fraction of children in level I countries than incountries of levels 11-IV).
157. In most cases, while a smaller fiaction of thepatients at health-care level I are children, the fiequency of examination of children is still greater thanat other health-care levels because the total x-ray
examination frequency is high. However, because
chest fluoroscopy is frequent at all health-care levels
and because there is a higher fraction of children
among patients at lower health-care levels, the frequency of examination for children under 16 is about
2, 12 and 4 per 1,000 population at levels I, I1 and 111,
respectively. It was mentioned in Section 1I.B that thehigher fraction of children among patients in levels I1
and 111 countries is probably due partly to the demographic structure in developing countries, where agreater part of the population consists of children.
Since h e frequencies of examinations are generally
increasing in dcvcloping countries, the frequency of
examinations of children can also be expected toincrcase.
158. A somewhat different kind of exposurc occurs if
x-ray examinations are performed intentionally on
persons who are not really patients. For instance,
healthy persons may be subjected to examination inconnection with employment or for insurance purposes. Thus, an estimated l million pre-employment
lunibar spinal x-ray examinations were performed in
the United Statcs in 1978 w 1 7 ] , conesponding to 4.4
examinations per 1,000 population. Due to their
dubious predictive value [M17], these examinations
are being eliminated in several countries, albeit atdiffering rates. There were 140.000 employment-

ANNIX C: MEDICAL RADIATION LYI'OSIJRES

rclatcd x-ray examinations in the Unitcd Kingdonl in1983 [W9], representing as many as 2.5 per 1,000
population. These exarliinations (mostly of the chcsl)
causcd a collective effective dosc equivalent of about
5 man Sv, corresponding to a per caput dosc of about
0.1 psv.
159. In connection with the increased incidence ofostcoporotic fractures among elderly pcrsons. bonedcnsitometry has beconic an iniportant tool formeasuring bone mineral content, especially inindustrialized countrics. There are two typcs of boneabsorptiomcters besides computed tomography: single
photon absorptionletry (SPA) and dual photon absorptiomctry (DPA). SPA is mainly used for cortical bone,
DPA mainly for cancellous bone. Formerly, 1 5 3 ~wasdused as a photon source, but more recent equipment is
bascd on x rays [W13] or '*'I. The entrance surface
dose sustained by the patient in an examination of thistype is about 0.02-0.05 niGy for x-ray equipment[K15, H411, corresponding to an effective dose equivalent of about 0.8 pSv, and 0.01-0.18 niGy for 1 5 3 ~ dequipment, with the lower doses in more recent tests[S27]. Computed tomography can also be used, but theeffective dose equivalents may be up to three orders ofmagnitude greater [K15].

.

160. The Committee is aware that small subsets of the
population of paticnts are subjected to rcpeatcd examinations to an extent that allows substantially higher
doscs than average. It has, howcvcr, proved difficult
to obtain data illustrating the full extent of thisvariation. A well-known study of breast cancer incidence in tuberculosis paticnts in Massachusetts involved 2,573 women who had been examined by x-ray
fluoroscopy on avcrage 88 times, with an average ofthe mean absorbed dosc to the breast of 790 mGy[B30]. However, it is believed that this study is notrcprescntative of current conditions. It might bc
expected that many of the paticnts concerned were old,
meaning that the potential for expression of lateeffects of radiation should be limitcd. However,scoliosis patients are routinely subjectcd to periodic
cxaminations in childhood [DlO]. Sonic prematurebabies may be subjected to rcpcatcd chcst x-ray
cxaminations. Preston-Martin ct al. [PI81 assert thatpatients with parotid gland tumours had cxpcrienccd a
greatcr amount of prior radiography (nioslly dental)
than controls.
161. In theory, it should be possible to compile
further statistics on multiple examinations in countrics
such as Germany, where a document is available topaticnts on request for the recording of radiologicalprocedures (Rontgenpuj?). In reality, few patients seem
to avail themselves of this opportunity IB311, so theinformation to be had may be limited. A study at
major hospitals in Nurnberg and Munich indicated that247

of tl~osc paticnts undcrgoing x-ray cxaminations,which was two thirds of all admittcd paticnts, about
52% had 4 or niore films taken, including 12% withmorc than 20 films and 1% with morc than 100 films[S16]. The county council of Stockholm, Sweden,
kceps a computerized record of all patients, bascd onsocial security number (B371. The record shows thatno niorc than nine paticnts, i.e. 0.001% of the population concerned, had 14 or more cxaminations in 20
years. In the U ~ ~ i t cKingdom,dabout 1% of the population accumulated a lifetime effective dosc equivalent
due to diagnostic x rays of morc than 100 nlSv [H15].
The maximum dose encountcrcd in the study was
about 200 mSv. Most of the paticnts with thc highest
doses had no more than 10-15 examinations, albeit
almost always they included several cxaminations of
the lower gastro-intestinal tract and urographic cxaminations. In a Canadian case study [R5],a 60-ycar-old
male had 29 different examinations between 1957 and1983, apparently resulting in an effective dosc
equivalent of 283 mSv, 41% of which came fromfluoroscopy.

4.

Effects of quality nssumnce programmes

162. The technical and physical parameters involvedin quality assurance are discussed at length in a British
Institute of Radiology Report [M7]. Standardized
mcthods, guides, training and involvement of manufacturers must be implemented in quality assurance.
The standards adopted in several countrics for diagnostic x-ray examinations describe indications andcontraindications for proccdures, patient preparation,
contrast agent, positioning, technical parameters (e-g.
voltage, grid, screens), number of views, other possible examinations and special regulations for radiation
protection. A complementary report on the optimization of image quality and patient exposure [MI91 puts
quality assurancc in diagnostic radiology in a wider
perspective (see also [G19]). A report from the UnitedStates [N3] discusses quality assurancc for all types ofdiagnostic imaging equipment. Numerous authors
stress the importance of patient dose sunteys inauditing the optimizalion process, s o that not only
theoretical output from technical paramctcrs but also
actual results are asscssed [B9, F2, N5, N11, V9).
163. Quality assurance programmes for x-ray
diagnostics were begun in the United States in theearly 1970s and bccame firmly established in 1980,
when federal recommendations were made [B33].
Their success is easily explained: h e y have led toboth economic savings and dose reductions IB34, P5].
Nonetheless, such programmes are likely to gain stillwider acceptance in the future, as evidenced by asurvey of over 2,000 automatic film processors in the
United States, whicb revealed underprocessing in 9%

24 8

UNSCWR 1993 REPORTof mammography facilities, 33% of hospilals and 42%of private practices IS53). In dental radiology in the
United States, quality assurance programmes became
generally acccptcd more rcccnlly: about 80% of thedental hygiene prograninlcs surveyed had sonic sort ofprogramme in 1990, as opposed to about 50% in 1985
[FlO]. Quality assurancc programmcs arc likely to
become cstablishcd all over the world (see, e.g. [P4]).
In fact, the cost reductions attainable should makequality assurance even more attractive in devcloping
countrics [Bg].
164. The introduction of quality assurance is expected
to dccrcasc doses per examination worldwide, as i t
results in lower doses per projection, fewer retakes
and fewer unnecessary examinations [G18, NS]. MikuSovii el al. [M39] attributed 15-18-fold variation inentrance surface doses in gastro-intestinal tract cxaminations to the lack of a quality assurance programmeand calculated that effective doses in such cxaminations can be reduced 70% or more. They stated thatthcir results showed the need of a quality assurance
programme in Czechoslovakia.
165. It is difficult to predict the pace at which quality
assurancc will be introduced in different countries.
Data from the UNSCEAR Survey of Medical Radiation Usage and Exposures arc summarized in Table
24. It appears that quality assurance is relatively wellcstablishcd for x-ray diagnostics, even in devcloping
countrics (although a few responses from countries ofhealth-care level I mention a reluctance to accept
quality assurancc). Note that in Canada and in the
Unitcd States, while there are only recommendations
at the national level, thcre are provincial or state
regulations that are lcgally binding.
166. Some observations on the effect of quality
assurance can be quoted. In the United States, percapul doses in dental radiography arc decreasing. In
Spain, quality assurancc programmes are being started
in collaboration with the Commission of European
Communities, which has adopted (M22, M38] thereference dosc levels originally suggested by
Shrimpton et al. IS381 and chosen as guidclincs in the
United Kingdom [NS].Before quality assurancc wasimplemented, entrance doses were up to fwe times
higher than thcsc maximum values, but with quality
assurancc at least some of the causes of higher doses
could immediately be successfully corrected [C9,V18]. For lower gastro-intestinal tract examinations in
the Madrid arca. eUective dose equivalents at one
centre were 0.8 2 0.1 mSv, while they ranged from5 5 2 1.0 to 14.1 % 2.2 mSv at four others [C13]. The
authors concluded that quality assurance programmes
should yield significant dose reductions. In Sweden,
mandatory quality assurance requirements wereintroduced in 1981 and are an important explanatory
factor behind dose reductions [G19].

167. Several quality assurancc programmcs of varying
scope are in effcct in European countrics and elsewhere [B35, DS, E4, G19, H21, IA,V15, W4]. For a
discussion of patient exposure criteria in the Europcan
Community, see (H46, M38, W20). The Commissionof chc European Coniniunities has prepared two
documents to provide guidance for optinkation ofimage quality and patient dosc in adult and paediatricradiology [C3, C17]. Organ doses under optimal
cxposurc conditions arc available for examinations ofadults [P7]. As shown in Denmark [HI21 with respect
to fluoroscopic systems, such programmcs need notdepend on the availability of health physicists;
provided a suitable test protocol is devised, radiographers on site can perform very useful quality
assurancc. A study by the European Federation of
Medical Physicists [C4] tabulated the occurrence in 20
European countrics of assessment protocols (17countries had from 5 to 1 3 protocols for equipment,
16 countries had from 2 to 10 protocols for image
quality), of routine quality assurance procedures (6countries required quality assurance procedures atregular intervals, 1 2 others required such proceduresoccasionally or at least on installation); and of auxiliary equipment checks; and it recorded the implementation of various recommendations.
168. Reject and repeat ratcs, which reflect the qualityof radiographs, have been reported by many groups
but rarely from developing countries. Bassey et al.
[B32] provide an analysis from Nigeria (health-carelevel III since 1980). At first, the rcpcat rate was124%. As a result of increasing awareness andcorrective actions in response to the project, the rcpcat
rate dropped rapidly, to an average of 2.5% (averagefor the entire year analysed: 3.7%). The authors notedthat a formal quality assurarice programme would
reduce repeat ratcs and exposures further. As such,these repeat rates were not particularly high, in fact,
3.7% is low compared to the Unitcd Kingdom INS].
But, as chc authors say, criteria for repeating may
differ, and films of marginal quality may have been
accepted in Nigeria for economic or practicalreasons [B32].
169. Quality assurance can certainly be applied not
only in hospitals but also in general medical practice,although general practitioners may be less aware ofquality assurance methods. In New Zealand, a study
using an anthropomorphic ankle phantom examined by
22 general practitioners resulted in 2 fully acceptablesets of radiographs, 8 dcficient sets and 12 rejected
sets, 4 of which were completely undiagnostic [L5].
Nevertheless, the authors were not overly concerned,
since the range and number of radiographic procedures
performed in general practice is small and presents
very litde radiation hazard to patients and staff.

170. For countrics of health-carc lcvcl I, thc p p u lalion-wcightcd avcragc annual frcqucncy of diagnostic
x-ray exalninations in 1985-1990 was 890 per 1,000
population, rathcr similar to thc cstimate in the
UNSCEAR 1988 Report [U 1 ] of 800 per 1,000 population. Examination frcqucncics in individual countrics
of hcalth-care lcvel I rangcd from 320 to 1,290 pcr
1,000 population, and both increasing and dccrcasing
national trcnds arc evident. For hcalth-care levels IIIV, data arc lcss cornprchensivc, but at a first
approximation the avcragc frequency is 120 examinations per 1,000 population at lcvel I1 and 64 per 1,000
population for levels I11 and IV combined. While thetotal x-ray cxamination ircquency seems to be relativcly constant at health-care level I, indications arethat the frequencies of cxarninations arc increasing at
lcvels 11-IV. During the 1980s, some 60% of all examinations were of the chest, 15% of the extrcmitics,
10% of other skclcton and 10% of the digestivesystem. The pattcnl of cxaminations varies with time
and with health-care Icvel.

171. Broadly spcaking, the total examination frequencies arc expected to continue to increase at all hcalthcare Icvels. There arc two main reasons for this: theincreasing proportion of oldcr people in populations
and increasing urbani7ation. The increasing availabilityof altcrnativc modalities, in particular ultrasound, may,
howcver, limit somewhat the rate of increase. Patients
subjcctcd to x-ray cxamination arc, on average, oldcr
than randomly choscn mcmbers of the public. Nonetheless, many cxaminations are rather frequently
pcrformcd on childrcn undcr 16 ycars of age. With the
exception of hiplfcmur examinations, a greater fractionof examined patients are childrcn in countries ofhealth-care lcvel I1 and 111, pcrhaps bccause thosecountries have younger populations. However, examination frequencies exceed those of hcalth-care level I
only in the case of chest fluoroscopy.
172. The doses to paticnts from diagnostic x-ray
examinations vary widely. In certain cardiac procedures, entrancc surface doscs of scvcral gray occur.
High doses are delivered in fluoroscopy with conventional equipment. This does not mean that fluoroscopy
is an unfavourablc procedure, even from the restrictedvicw of dose limitation, since with modem image
intcnsificrs low doscs can he achicvcd. Ruoroscopy
during extracorporeal lithotripsy causes smaller doscs
than those encountered in conventional renal stone
extraction. Computed tomography is being used more
frequenlly, and effective doses (at prescnt averaging
about 5 mSv per examination) arc increasing. Chest
x-ray doses are decreasing, with effective doses per
examination now often under 0.1 mSv, but lhe vast
numbcr performed still causes chest examination tocontribule scvcral tens of pcr rent of thc collcctivc
cffcctive dosc. Mammography cxaminations now givc
low absorbed doscs to brcasts, oftcn undcr 1 n ~ G ybut,
cxtcndcd screening prograninlcs, commonly ainied at
all wonlcn ovcr age 40 years, could add scvcral pcr
cent to collective doses. Dcntal x rays oftcn cntail
effective doscs less than 0.1 mSv pcr cxamination but
affect large groups, and thus add a pcr ccnt or s o tothc collcctivc dose. Chiropractic x-ray cxan~i~iations
cause low doses per examination and affect fcw
people. Children arc a particularly sensitive group.
Chcst examination of neonatcs and scoliosis testing of
teenage girls wcre mcntioncd as problcm areas.
173. Pcr caput annual effcctive dosc equivalents fromthe diagnostic use of x rays rcportcd from a numbcr ofcountrics of hcalth-care level I rangcd from 0.3 to
2.2 mSv. For countries of hcalth-care Icvel I, thc
population-weighted average of values from 1982 to1990 is 1.2 mSv. The estimate of per caput dose fromanalysis of population-weightcd frcqucncics and dosesof cxaminations is 0.9 mSv, which is littlc different
from the estimate of 1.0 mSv given in the UNSCEAR
1988 Report. For countrics of hcalth-arc levcl 11,
which have a population of 2.6 billion, information isstill limited, yet more complete than for the
UNSCEAR 1988 Rcport [Ul]. Thc estimated pcr
caput effective dose equivalent is 0.1 mSv (1988 estimate: 0.2-1.0 mSv). Doscs at health-care levels III andIV (0.04 mSv) are more uncertain, but they do notmuch affect the worldwide avcragc due to thc low
examination frequencies.
174. These overall trcnds are derived from non-homogeneous data. Both examination frequencies andpatient doses vary rather widely, between neighbouring
countries and even within countries. Also, similar total
cxamination frequencies or total effective doses may
be composed in different ways in different countrics.
Particular importance is attached to the trcnds forcomputed tomography, which is characterized by increasing examination frequency as well as increasing
doses. Quality assurance programmes have amply dcmonstrated that dose variation can be decrcascd arid
unnecessary exposurc reduced.
175. The estimates of average individual and collective doses to the world population from diagnostic
medical x-ray examinations (0.3 mSv and 1.6 million
man Sv) are at the lower end of the ranges suggested
in thc UNSCEAR 1988 Rcport [ U l ] (0.35-1.0 mSv
and 1.8-5 million man Sv). There is, at prescnt, somewhat less uncertainty about the frequencies and doses
from fluoroscopy examination in countries of hcalthcare levels 11-IV. The doscs from dental x-ray examinations are less than those from medical x-ray examinations by two orders of magnitudc.

UNSCMR 1993 REPORT

250

Ill.

DIAGNOSTIC USE OF

176. Thc rapid pacc of change in nuclcar mcdicinc~nakcsasscssnlcnt difficult, but a fcw trcnds can bc
idcntificd. Of the many diffcrcnt radionuclides uscd innuclcar nlcdici~~ccxaminations, Q g m ~andc 1311 are thc
most in1 rtant. As a rulc, the dosc pcr procedure isless for '"'Tc,
which has a shorter half-life, so it isprcfcncd and uscd in the majority of cascs. Evcn so,
the usage of 1 3 1 is
~ grcat c~loughto rnakc an important
nominal contribution to thc collcctive dose. In 1986,
for example, only 13% of all nuclear mcdicinc
cxaminations in Swcdcn cmploycd I3lI, but it
contributcd 51% of the collcctivc dosc of 420 man Sv[V4]. By comparison, 56% of thc cxaminations in1971 wcrc made with I3l1, which contributcd 92% of
the collcctive dose of 520 man Sv. In the USSR, 77%of all examinations in 1981 utilized l3'1 [N4]. The
most commonly uscd radionuclide in dcvclopirlg
countrics is l3'1, and this is the main reason the
average cffcctivc dose per cxamination is highcr inthese countrics than in industrializcd countries.

A.

FREQUENCIES OF EXAhlINATIONS

177. The frequcncies of diagnostic nuclcar mcdicinc
cxaminations performed in countries are listed inTable 25 (total frequency) and Table 26 (frcqucncy ofthe main types of examinations). The results aremainly from the mSCEAR Survey of Medical Radiation Usagc and Exposurcs, supplcrncntcd wilh
published data. As a first approximation, the totalfrequency of all nuclcar mcdicine cxaminations isabout 16 pcr 1,000 population in countrics of hcalthcare levcl I, 0.5 pcr 1,000 population in countrics at
lcvcl 11, 0.3 per 1.000 population at lcvcl U1, and 0.1
per 1,000 population at level IV. The numbcr ofcounlrics at levels 111 and IV reporting information ismuch too small to be considcred rcprescntative. Thc
distributions of available data for 1985-1990 arc illustrated in Figure V.
178. Gcncrally highcr examination frcqucncies (20-40
per 1,000 population) arc reported for Bclgium,
Czechoslovakia, the Fcdcral Republic of Germany,
Luxembourg and the Unitcd States. The reasons forthe higher frequency seem to differ: there are manyliiter/splecn and rcnal cxaminations in Czechoslovakia;
many bone examinations, lung perfusions and thyroid
scans in thc Federal Rcpublic of Gcrmany; many
cardiovascular examinations and lung pcrfusions in the
United Statcs; and all cxaminations arc more frequent
in Belgium and Luxen~bourg. Although the lotal
nuclear mcdicinc cxanlination frequency in Canada (13cxarninations per 1,000 population) is typical of

hcalth-care lcvcl 1 countries, thcrc arc about 10 times
as many brain cxanlinations (4 pcr 1,000 population)
as thc ;lvcrage for hcalth-care Icvcl I (0.4 pcr 1,000
population). In sonlc countrics, all practitioners arc
permittcd to use radiopharmaccuticals, while in manyothcr countries, they arc availablc only in hospitals or
clinics.
179. In nuclcar mcdicinc, not only the total examination frcqucncics but also the patterns of exan~inations appcar to diffcr more than the frequencies andpattcrris of x-ray cxaminations- Averages for the main
kinds of cxamination at different health-care lcvcls are
given in Table 27 and illustratcd in Figure VI, whichshows that bone and cardiovascular examinations are
the most frequcnt. However, thcsc averages may conccal widely diffcring practices. Some such diffcrcnces
are discussed below. Three types of avcrage measure
are given in Table 27: the population-weighted
average, the unwcighted average with its standard
deviation, and median values. Of these, the populationweighted averages arc the most relevant for purposesof collcctivc dosc estimation, while unweightcd averages and medians may be of interest when individual
countries are compared to others.
180. Huda et al. [HI71 point out differenccs between
North American and European countries: P P " ' ~ ~is
uscd rnorc frcquc~ltlyin Manitoba, in Canada, and in
thc Unitcd States. Examinations of the brain are lessfrcqucnt in Europc than in North Amcrica, andcardiovascular cxarninations are somewhat lessfrequcnt. Within Europe therc are no differcnccs in
cxamination frequcncics bctwccn Sweden and theFederal Republic of Germany [H18, KlO]. However,the use of w m is~ as~ common in the Federal
Republic of Germany as in North America but not as
common in Sweden. There could, of course, be local
deviations from this pattern within North America.
The data for the United Statcs are averaged over alargc number of states; thc data for hlanitoba andNova Scotia quotcd in the text and Tables rcfcr toonly small parts of Canada, so that the extrapolations
made from tlicsc must bc rcgardcd as tentative
approximations.
181. Intra-regional differences in examination patlcrns
may occur cven where nuclear ~ncdicinehas a similar
total radiological impact. For instance, the Netherlands
and Swcdcn are similar in many respects, and the impact of diagnostic nuclear mcdicine is similar in thetwo countrics. Nevcrthcless, there are several important diffcrcnces bctwccn the two countries IB3, V4].
Thus, while the usc of 9 9 m ~isc similar (used in 65%

of cxaminatior~s in the Netherlarids and 6 3 % in
Sweden), much more 1231and much lcss 1 3 1 are~ usedin the Netherlands tllan in Swcdcn (in 10.1% and3.0% of examinations in the Netherlands comparedwith 0.6% and 14.1% of examinations in Sweden).
T h e use of 201Tl is morc common in the Netherlands
than in Sweden (6.8% and 2.5% of cxaminatio~ls,
rcspectivcly).
also differs in countrics with
182. The use ofsimilar nuclear medicine practice. Renal clearance w i h
5 1 ~arcr important in Swcdcn (9.1% of examinations),
but the radionuclide is hardly used at all in the
Netherlands (0.2% of examinations). Canada [HI71and Germany [KlO], with sorncwhat higher per caput
doses from nuclear medicine, report little or no use of"~r-EDTA, altl~oughother "Cr radiopharn~aceuticals
are used in Canada (sodium chromate and chromiccthan 5 1 ~ isr used for inulin andchloride); w m ~ rather
creatinine clearance measurements of the glomerular
filtration rate.
183. Figure VI shows that nuclear medicine
examinations in countrics of health-care level I aremorc frequent by an order of magnitude or more thanin countries of lower health-care levels. Only forthyroid uptake studies arc the relative differences notquite s o great. A t health-care level I some 3 0 % of
examinations were of bone, some 20% were of thelung and some 1 5 % were cardiovascular. These
examinations are all being performed more frequently.
The percentages ofbrain (5%), Iivcr/splecn (5%-lo%),
renal (59"-10%) and thyroid (15%) examinations are
decreasing. Trends in individual countries may deviate
from this general pattern. Generally, the data indicate
increased frequencies with time in the total number ofnuclear medicine examinations. Myanmar reports a
steadily decreasing examination frequency, from 0.54
per 1,000 population in 1976-1980 to 0.1 1 per 1,OM)
population in 1985-1990.
184. Nuclear medicine is continuing to develop in
China, and morc than 8 0 0 hospitals now practicenuclear medicine [W7]. The most frequent imaging
procedures are liver scintigraphy, thyroid imaging, andlung, kidney, bone, brain and heart imaging, in [hatorder [W7]. The most conlmon function tests are
thyroid uptake, r c n o g a m and cardiac function [W7].
In function tests, w m ~ isc the most frequently usedisotope [L14, W7]. Thus, the data cited in the
UNSCEAR 1988 Report [Ul], according to which
w mwas~ not~used in China, were not representative.
Wang and Liu [W7] regard 113m~nas the prin~ary
alternative when w m ~ isc unavailable and stress thatthe long half-life of the '13sn parent makes 113m~ngenerators suitable in developing countries, where low
cost and long transport times are imporbnt
considerations. Nonetheless, 1 3 1 ~ is still a big

conlrihutor to effective dose i l l China 1261 and ill
India.

185. Information from other dcvcloping countrics isvery limited. In Tunisia, diagnostic nuclear medicine
in vivo is practised at one clinic in Tunis, which isequipped with scintiscanncrs. Radionuclides arc
brought from France on a regular basis, which ensures
supply but excludes short-lived isotopc! [M13]. In
Nigeria, with a population of about 1 0 0 million, one
scanner is available in Lagos. About 79% of the 1,000
patients referred in 1982-1984 had thyroid-related
pathology, and most of the other examinations concerned h e liver, the brain or bone [F5]. In Zaire, witha population of 3 0 million, one nuclear medicine
facility exists in Kinshasa, but apparently work thereis hampered by many very difficult problenls [I6].
186. Most of the examinations in nuclear medicine are
perfonncd on adult paticnts. For instance, 98% of all
examinations in the United States are performed on
patients who are at least 15 years old (and 90% were
3 0 years o r older) [Ul].Examinations of children
appear to b e somewhat more frequent in eastern
Europe [ D l , U l ] . There is no particular type of
examination specifically aimed at children, apart perhaps from neonatal hypothyroidism screening, whichis performed by radioimmunoassay in viao and thus
causes no patient dose [16].
187. T h e age- and sex-distributions of patientssubjected to diagnostic nuclear medicine examinations
are given in Table 28. On average, the population
examined is older than the general population and also
older than tilose receiving x-ray cxaminations.
Relatively high proportions of renal examinations are
performed on children in countries of health-carelevel I. At health-care level 11, bone and brain
examinations of children are relatively frequent. T h eproportion of children examined is higher in countrics
at health-care levels 11-IV, as w a s also the case fordiagnostic x-ray examinations, but the difference
between health-care levels is smaller than for x-ray
examinations. As with x-ray examinations, the excess
of children among examined patients may well dependon demographic factors (there are more children inthese countries). Since total nuclear medicine
examination frequencies are much lower at health-carelevels 11-IV, the frequency of examined children isconsistently smaller at these health-care levels than a tlevel 1, in spite of the higher percentage of children
among examined persons.

188. As expected, more women have thyroid
examinations and more men have cardiovascularexaminations (with the exception of China).
Olherwise, the sex distributions appear to b e fairlys~ndard.

189. The average amounts of radioisotopc compounds
administered for some imporlant procedures indiagnostic nuclear medicine arc listed in Table 29.
Only the major radiopharmaceuticals reported in use
arc included. The listing must ncccssarily compress
the information received, which was of uneven detailto bcgin with, making it difficult to calculate effcctive
doscs. Some comments are, however, relcvanL
190. The activity administercd per examination seems
to be more standardized than the factors that influcnce
dose in diagnostic x-ray examinations. This is also true
for different levels of health a r c . Thus, the vastdifferences in dose per examination between countriesof different levels are due to the choice of radiopharmaceuticals not to different amounts of activity
for any given procedure.
191. Thyroid examinations contribute as much as halfof the collective dose from all diagnostic nuclear
medicine procedures. Typical cffective dose equivalents in the province of Manitoba, Canada, in 19811985 were 3.9 mSv for 13'1, 1.2 mSv forand. substitution of other nuclides
1.5 mSv for * m ~ ~The
for 1311 in most cases reduced the estimated collective
dose by a factor of 3.6 [H35]. Cardiovascular cxaminations caused comparatively high doscs, from aboutcto about 20 mSv (201Tl
10 mSv ( 9 9 m ~erythrocytes)
chloride). Brain examinations with w m gluconate~ ~caused 8-10 mSv, bone examinations with 99mT~
phosphate up to about 7 mSv.
192. Tomographic investigations with single photon
emission computed tomography (SPECT) require, on
average, higher activities per examination than similar
planar examinations. Consequently, SPECT tcsts could
lead to higher patient doscs [El], at least for
examinations such as myocardial scintigraphy, regional
cerebral blood flow, bone scintigraphy, liver
scintigraphy, radionuclide ventriculography and t a t s
with tagged monoclonal antibodies. In principle,
positron emission tomography (PIX) should also
require high activities per examination, but thc doscs
do not seen1 to be extrcmcly high, at least not with
"F substances, which result in effective dose
equivalents o i up to 6 mSv per procedure [M43].
193. Examinations of children form an important partof the evaluation of patient doses, since the dosc perunit activity can be much higher for children than for
adults [IS, T6]. Two important differences between
children and adults should be taken into account when
considering cbe use of radiopharmaceuticals andevaluating doses. Physiological differences such as
differing body weights can lead to a different (higher

or lower) effective dosc for children after administration of a given amount of activity [S15, T6].
Age-related dose coen?cicnts [IS, 1141 lake these
physiological differences into account. Another difference is the greatcr sensitivity of children, reflectedin the higher risks per unit dose. As nlcntioned in
Scctior~I.B., this could in pri~~ciple
also be taken into
account.
194. Absorbed doscs, cffective dosc equivalents andeffective doses per unit activity of various
radiopharmaceuticals adn~inistered to patients havebeen derived and arc listed in ICRP Publication 53(for H3 [I51 and in its Addendum (for E) [I14].
Supplementary information can be found in the MIRD
(medical internal radiation dose) reports, most recently
on wm~c-labelledbone imaging agents [W6], redblood cells [As], l l l ~ ~ ~ - l a b e l lplatelets
ed[R21] andw m ~ c aerosol- ~ [A13].
~ ~ Some~ MIRD estimates
may be inexact, (K26,T15], particularly with respect
to Auger emitters [HZ, K27,S481.

195. Thcrc is not yet a wide basis for calculating
cffective doses from nuclear medicine examinations.
For instance, individual differences in metabolism
could contribute to variability. Furthermore, individualorgan doses may vary with disease conditions, although effective dosc may be a more robust quantity.
Table 30 lists typical effective dose equivalents fromexaminations. The effectivc dose equivalents were
calculated using the dose factors in ICRP Publication
5 3 [I5], but patient ages or sizes were not considered.
There are three further sources of variation inestimated effective doscs (cffective dose equivalents):
(a)

@)

(c)

each examination category represents several
types of procedure. Perhaps the most extreme
example is kidney examinations: renograms areoccasionally made with 12S~-hippuratewith atypical effective dosc of 0.01 n ~ S vwhile renal
scintigraphy with 9 9 " ' ~ cgives at lcast 1 nlSv per
examination;
a givcn procedure can be done with different
radionuclides. A good example is thyroid
scintigraphy: performed with w m ~ cthe
, effective
doscs are under 1 mSv; performed with 1311,
they approach 100 mSv. The diffcrcnce isimportant since *"'Tc is typically less accessible
in developing countries;
Lhe amount of activity administered for a proccdurc differs; Ihis, howcver, is not a major sourceof variation in doscs.

1%. I11 principle, it is desirable for analytical purposesto specify the age distributions of patients; however,these are likely to be different for each type of examination. To illustrate the dependence of dose on age,Tablc 31 providcs thc avcragc and pcr caput effcclivc
dose equivalents from thc avcragc activities administcrcd and the frcqucncics of cxaminations dctcrnlincd
for Manitoba, Canada [H17]. Thc agc-dcpcndcnt doscs
pcr unit activity administcrcd wcrc takcn from ICRP
Publication 53 1151.

respcctivcly. Most of thc collcctivc dosc (81%) is
rcccivcd at lcvcl I. Thc dose per cxamination averagcs
5.7 mSv at lcvcl 1, but it is about four timcs highcr at
lcvcls 11-IV. Thc pcr caput dosc is 0.09 nlSv at lcvcl I
but is, bccausc of much lower frcqucncics, an ordcr ofmagnitude lcss at lcvcls 11-IV.

197. Thc cffcctivc dosc cquivalcnts to childrcn in
Tablc 31 wcrc cornputcd with agc-rclatcd doscco~~vcrsion
factors whcrc possible, but when no data
wcrc availablc it was assumcd that the activity administcrcd to a child was the same as that to an adult. The
cffectivc dosc to children pcr unit activity can bemuch higher than that to adults, and examinations ofchildrcn are not all that rarc. This is particularly truein thc case of renal examinations, which constitute
some 10% of all procedures.

201. Thc contributions of the various cxaminations tothe collcctive doscs arc given in Table 33. At hcalthcare lcvcl I, cardiovascular and bonc scans account for
70% of the collcctive dosc. Bccause of thc high dosc
assumcd for thyroid scans at lcvcl 11-IV, thisexamination is by far thc largest contributor to totalcollectivc dosc from nuclear mcdicinc in thcse
countrics.

198. Doses to unborn children after the administrationof radiophamaccuticals to prcgnant patients may,according to Cox ct al. [C18], bc seriously underestimated by current methodology. Although their primaryconccrn is with thcrapcutic administrations, the also
discuss lung pcrfusion scintigrams using '"Tc
albumin aggregates, which they bclievc is thc most
frcqucnt examination in prcgnant womcn. In theiropinion, it results in a utcrine dosc of 10 mSv rather
than thc 0.3 mSv calculated by conventional methods.

C . WORLIIWIDE EXTOSURES

199. Representative frequencies of nuclear medicine
cxaminations for cach health-care lcvel and doses per
examination cannot be well cstablishcd from theavailable data. Nevertheless, the approximate values
do give an indication of the collcctive dose from thispractice. This analysis is shown in Table 32. The
population-weighted frequencies of examinations were
dcrived in Tablc 26 and listed in Table 27. The
effective dosc equivalents from typical examinations
urcrc given in Table 31, with the valucs for adults
being uscd in Table 32. Higher doses were indicatedin Tablc 30 for China for thyroid scans and livcrl
s lccn examinations whenever the preferred isotope,'"Tc,
was not availablc. It is not known how often
this occurs, but in order not to underestimate thecollcctivc dose, the highcr doses havc hcen assumcd
for thesc cxaminations in health-care lcvcls 11-IV. The
product of frequency and dose per examination gives
the estimatcd collectivc effective dose from eachexamination.
200. Thc collcctive eflcctive dose equivalent from
nuclear medicine examinations worldwide is estimatedto be 156,000 man Sv, with 127,000, 20,000 and
10,000 man Sv from health-care lcvels I, 11 and 111-IV,

202. This analysis of collcctive dose is very approximate since only a single typical examination has
been assumed in each case, and the represcntativcnessof the frequencies and doses applied cannot be established. It docs, however, indicate that the collective
dose from nuclcar medicine examinations worldwide
is about 10% of that from diagnostic medical x-ray
examinations.
203. Estimates of collcctivc dose from nuclcar mcdicine examinations in a number of countrics have been
published or supplied in direct response to the
UNSCEAR Survcy of Radiation Usage and Exposures.
These estimates are summarized in Tablc 34. Because
the conditions, assumptions and mcthods underlying
thesc rcsults vary widely, dircct comparison may notalways be valid.
204. The collective doscs shown in Table 34 can becomparcd with total medical radiation doscs to dctermine the relative contribution of doses from nuclear
mcdicinc exan~inations.Thc collcctive cffcctivc dose
cquivalent from nuclear medicine examinations in the
United States in 1982, 32,100 man Sv, amounted toabout 35% of Ule 92,000 man Sv from diagnostic
x-ray usage [Nl]. In contrast, the 1,000 man Sv from
nuclcar medicine in the United Kingdom in 1982
constituted only about 5% of the 20,000 man Sv fromdiagnostic x-ray usage.
205. Alternative estimates could be derived for theeffective dose equivalent from nuclear medicine cxaminations in Canada by extrapolating the cstimatcs for
Manitoba and Quebec to thc entire country. These
results would be 3,200 and 9,900 man Sv. rcspcctively, to be compared with the estimate given in
Table 34, 4,200 man Sv. The difference in the threecstimatcs stcrns mainly from different assumptions
about Lbc number of cxaminations [L7].Of the 260
nuclear medicine clinics in Canada, over half arelocated in Ontario and only 10 in Manitoba F12], so
extrapolation Gom Manitoba may be uncertain. The

arithmetic avcrage of the three estimalcs of dose per
examination is 5.1 mSv, which is similar to the valuc
dcrivcd in Table 3 2 for level I countries.
206. hlaruyania ct al. studied the usage of radiopharmaceuticals in Japan in 1982 [MlO, M11, M12j.
Thcy provided dctailed agc- and sex-distributions ofpatients for each radiopharmaceutical used in several
general procedures (c.g. renogram, scintigam, bloodflow) [MlO]. They also dcrivcd age- and sex-specificorgan-dose conversion factors and a set of sex-spccificeffective dose equivalcnts for each radiopharmaccutical used [ M l l ] . Most of the numeric values werefairly similar to the values in ICRP Publication 53[IS]. This comprchensivc material underlies the cntry
for Japan in Table 34. The distribution of the collective dose over age groups and for different radiopharmaceuticals is given by Mamyama el al. p 1 2 ] .
207. The per caput effective dose equivalcnts inTable 34 vary by two orders of magnitude, partly
owing to variation in cxamination frequencies. In contrast, most of the effective dose equivalents per
examined patient fall within a fairly narrow range,
2-5 niSv, in countries of health-care level I. The
exceptions, with effcctive dose equivalents in the
10-30 mSv range, are countries in which the use oflong-lived radionuclides, such as 1 3 1 ~and 1 9 8 ~ u is,
proportionally higher. Doscs in Poland are in the upper
rangc, with an effective dose equivalent per examination which is three times that observed in India. The
main reason is that half of all examinations are
performed with 1311, resulting in some 20 mSv per
examination. The range of the average effcctive dose
equivalent per cxamination in China (15-34 mSv) [Z6]encompasses the value derived in Table 32 (20 mSv).
208. For countries of health-care level I, a population-weighted annual per caput effective dose equivalent of 0.073 mSv can be derived from Table 34.
This gives some corroboration to the value derived inTable 32. In the UNSCEAR 1988 Report P I ] theestimated value was 0.05 mSv, although weighting for
population would, in fact, have given 0.07 mSv. The
present estimate (0.09 mSv) is hardly different, but as
it is based on data from more countries, it is more
re1 iable.
209. For health-care level 11, the previous estimate ofb e per caput dose from nuclear medicine examinations was 0.003 mSv [Ul]. The present estimate,0.008 niSv, is again more soundly based, especiallybecause there are data from China and India. There
are still inadequate data for levels 111 and IV. With the
Iiequency of all cxaniinations only slightly less thanTor level I1 and the important thyroid scans comparable in frequency, the similar per caput dose derived
for level 111 should mean that the collective dose will
not be underestimated.

210. Annual pcr caput and ~ollcctiveeffcetivc dose
equivalents from nuclear mcdicine examinations
worldwide arc sunimarized in Table 35. The totalcollective dose froni the practice (160,000 man Sv) isabout twice as great as the estimate in the UNSCEAR
1988 Report [Ul]. Evcn the present estimate is highly
approxin~atc,but tllc underlyillg database has becn
strengthened.

I).

TRENDS

211. The number of diagnostic nuclear medicine examinations increased in industrialized countries in the
1970s, but remained relatively constant in the 1980s[H17, H181. However, thc frequency of nuclear medicine examinations in hospitals in the United States
increased from 5.6 million in 1980 to 7.5 million in1990 [M2]. The frequency of cxaniinations is expected
to increase in developing countries. The data from the
UNSCEAR Survey of Medical Radiation Usage andExposures arc too incomplete to allow quantifying
trends.
212. One of the iniportant developments is that new
wm~c-labelledcompounds are replacing establishedcompounds containing other radionuclides in level I
and to some extent level II countries [P13]. Usually,
this leads to lower doses per examination. Other important trends are the introduction of complex biological agents (such as radiolabelled monoclonal antibodies) for novel imaging applications andthe proliferation of new compounds for studies withpositron emission tomography (PET). These developments can be expected to lead to more examinations
per caput. The proliferation of single photon emission
computed tomography (SPECT) and positron emission
tomography are also expected to lead to the wider useof three-dimensional rendering [H23, P22, W171, as
was already discussed for x rays in Section 1I.F.
Computed x-ray tomography and m a p e t i c resonancetomography both provide higher resolution, however,which rtieans that purcly anatomical imaging is not an
important procedure in current nuclear medicine
practice [E2]. Instead, measurements of flow and biochemical reactions are important.

1.

Specilic n ~ e l h o d sin nuclear medicine

213. While the total number of nuclear medicine
exaniinations may have remained relatively constant inindustrialized countries from 1980 to 1990, the choiceor pattern certainly has changed. As an example, datafrom Sweden (H18, V4] reveal a very coniplex pattern. The two most importa~~tchanges concern therelative use of 9 9 m (19%
~ ~ of all tests in 1971, 65%
in 1987) and 1 3 1 ~(52% in 1971 and 12% in 1987).

M4NI:X C: MEDICAL RADIATON MPOSLJRW

Gold-198 was phascd out in 1977. The use of 12'1 isdecreasing, whilc that of " ~ r , 1 2 3 ~and 'Otn isincreasing. All of these trcnds refcr specifically to thc
onc country studied. Whilc the trcnd in relative use of
9 9 m ~andc 13'1 is presumably widcsprcad, there may
bc national diffcrcnccs for othcr radionuclidcs. For
instance, thc usc of 201Tl (and of 'llln) is probably
dccrcasing in the Fcdcral Rcpublic of Germany. In
particular, myocardial scintigraphy with 201Tl is bcing
rcplaccd with antimyosinc immune scintigraphy, radionuclide vcntriculography and othcr mcthods that give
lowcr patient doses [B7]. One reason for national
diffcrcnccs is the varying availability of radionuclides
with short half-lifc (this factor is particularly relevantin dcvcloping countrics).
214. The ficld of pacdiatric nuclear medicine will
possibly grow [P13]. Table 28 shows that renal inlaging is the most frcqucnt examination in children, atleast in countrics at hcalth-carc levcl I. For adults,
distributions vary, but on average, bonc scans appear
to bc the most common examination. MAG-3, a
recently introduced wm~c-labelledmimic of hippuran(wbich is labcllcd with iodine) is particularly suitablefor pacdiatric renal imaging [H22, P131. Sincc w m ~ cgives smaller doses than iodine, doscs arc not cxpectcd
to increase at the same rate as the number of
examinations.
215. Radioactively labcllcd n~onoclonalantibodies area valuablc diagnostic tool for Ending tumours andrnctastases through radioin~munoscintigraphy. Theirusc for thcrapcutic purposes is mentioned in Chaptcr
V. In a diagnostic context, they are associated withrelatively high effective dosc equivalenls: 34 mSv (forll11n), 30 mSv (13'1) and 7 mSv ( w m ~ c [R15].
)
216. Single photon emission computed tomography
has cvolvcd rapidly sincc thc carly 1980s, whcn it was
still rare [P22]. Not only it is now a standard mctbod
for tumour localization but it is also uscd in a varictyof applications, such as functional brain studies [ H Z ] ,cardiac studies, bonc imaging and abdominal imaging
IP22j. It can also be used in conjunction with labcllcd
monoclonal antibodics. In contrast to thc very cxpcnsive positron emission tomography techniquc, single
photon emission computcd tomography may be affordable in at least some developing countries IP231, inparticular if personal computer algorithms for tomography gain widcr acceptance, permitting significant
rcductions in equipment costs [S49].
217. Positron cmission tomography provides
quantitative, locational, functional and biochemical
infornlation that would be difficult to obtain by othermeans [B13].Whilc positron emission tomographybegan as a technique for brain studies [J2], it is now
used also for myocardial examination and ontological255

work [ R l l , T161. Whole-body imaging in oncology isan cxpcctcd development [D14]. Thc use of labcllcd
anticancer drugs will allow in \<\*a dosimetry, anapplication likcly to bcconlc i~nportantin the trcatmcnt
of diffuse discase 1041. Howcvcr, there arc two problems: cquipmcnt is costly, and thc short-livcd isotopes uscd require cyclotron facilitics ncarby.
218. Ott (041 has strcsscd that it is hardly nccessary
to havc a cyclotron at each hospital: regional cyclotron
facilities within one or two hours distance could servc
many users in dcnscly populated arcas. Whilc positroncameras are expected to bccomc less expensive, Ott
did not forcscc a price reduction by rtiorc than half inthe near future (041. Sonic university institutions havebccn ablc to fabricate carncras at low costs [ 0 4 , S8],
but the cyclotron rcquircment is likely to continue tokeep positron en~issiontomography generally inacccssible to developing countries. In industrialized countries, the number of positron cmission tomography
centres is likely to grow rapidly. Thcre were 9 9 ofthem in 1991 and 122 in 1992 [G14]; 80% of thesewere in the United States (75) and Japan (21) in 1992,
with 2 each in Australia, the Federal Republic of Germany and Sweden and 5 each in Belgium, Canada,
Italy and the United Kingdom. Generator-produced
positron emitters may contribute to further growth.
They would allow limited positron cmission tomography studies without having to invest in a c clotron[T16]. Generators producing = ~ bfrom 'Sr
arealrcady available, and a "CU (from 6 2 ~ ngcnerator)isbcing developed.
219. Hill [H40] expects a rapid increase in the use of
positron cmission tomography for general imaging
purposes. He points out that gamma camera images
arc greatly inferior to othcr radiological imagcs interms of spatial resolution, contrast discrimination andacquisition speed, because the collimator of the
gamma camera reduces photon efficiency by at least
thrce orders of magnitude and introduces scatter. Hill
stresses that while positron emission tomography lends
itsclf to high-lcvcl studics of human metabolism, it
should also be an appropriate tool for nuclear medicine in general [H40]. Sincc the cxtra information
gained with the most advanced positron cmission
tomography tcchniqucs is not necessarily of clinicalsignificancc [W29], radiation protcction considerations
will presumably rcslrain some of thc futurc growth of
positron cmission tomography.
220. Limited access to positron emission tomography
is likely to rcstrict this nuclcar mcdicinc usage indcveloping countries in thc ncar futurc. Howcvcr, thisdoes not mean that nuclcar medicine will be nonexistent Some advanced mcthods, such as thrcedimensional rendering, may be available with rcasonable inveslment costs. Howcver, the high cost of

1993 REPORT

radiophannaceuticals, as wcll as infraslructure
problems that limit the availability of short-lived
radionuclides, will prcsun~ablylead to other cxaniination patterns than in industrialized countrics. Thus,
radionuclidc imaging will presumably not grow very
fast, since tllcre arc alternatives [I6]. Howcvcr, there
arc no obvious altcrnatives to functional studies which
may spread somewhat faster [I6, 171. Diagnostic invirro analysis with ready-made radioimmunoassay kits
is likely to increase, since thc technique will work
under various conditions and is useful in diagnosis ofparasitic infections, which arc important in developing
countries 116, 11.51.
221. It should not be assumed that the evolution of
nuclcar mcdicinc practice will be similar in all
developing countrics. On the contrary, there arc great
diffcrcnces between individual countries [16, 171. At
this stage, however, the quantity of nuclear medicinc
performed seems to be small in most developing
countries, even if the methods that do find use differ
greatly from country to country. Of course, there are
local interruptions in the practice of nuclear medicinc,caused not so much by equipment failure as by theerratic supply of radjonuclides [I6, 17). The potentialof diagnostic nuclear medicine to detect diseases at an
earlier stage and, accordingly, to reduce the direct andindirect costs of illness will presumably encourage
developing wuntrics to increase the availability of
nuclear medicine, in spite of the diflicultics.

2. Alternatives to nuclear medicine
222. The main alternative to nuclear medicinc
examinations is ultrasonography. Livcr scintigraphy
with 9 9 m ~andc renal localization witharc tending
to be replaced by ultrasonogaphy [V4]. The frequcncyof thyroid scintigraphies in the Federal Republic of
Germany decreased by 40% from 1978 to 1984, andat the same time the frequcncy of thyroid ultrasonicexaminations increased by 272% [K9]. Scintigraphy is
still the basic procedure for thyroid examination, while
ultrasound is used for screening. Ultrasonography isused not only for thyroid and abdominal studies but
also increasingly for cardiovascular, renal, locomotive(including hip-joint in children), infant skull, gynaecological and ear, nose and throat examinations.

223. The trend is, however, not universal, In private
radiology practices ultrasound equipment is lcss common. In this case the frequencies of nuclcar medicinc
procedures (e.g. thyroid and bone scintigraphics) havebeen steadily increasing [K9].
224. Echocardiography is generally regarded as usefulfor the screening of patients with suspected early cardiomyopathy, while angiography with radiopharmaceuticals is expected to remain the normal pro-cedure when the disease has progressed [C9]. Magnetic resonance tomography is expected to complement (and to some cxtclit supplant) computcd
tomography with x rays, as was discussed in thiscontext in Section II.F.2. But it can also be regarded
as an alternative to some types of radionuclidc imaging, including single photon cmission computcd tonioP P F61.
~Y
3.

EfTects of quality assurance progmnlmes

225. Quality assurance programmes, first introduccd
by the World Health Organization around 1980, arewcll established for nuclear medicine use in countriesof health-care level I. Early efforts in the UnitedStates, in particular, helped to establish these programmes [S28]. Table 24 summarizes the regulations
and recornmendations in countries responding to the
UNSCEAR Survey of Medical Radiation Usage andExposures. It should be noted that responscs to thesurvey are not always consistent, perhaps reflecting
differences at the state and federal levels in countrics.
Bauml [I3401 has compiled references to quality
assurance methods and their implementation andresults. Further discussior~ of quality control
procedures in nuclear medicine is given in an NCRP
report from the United States IN31 and, for radiopharmaceuticals, in an Australian Radiation Laboratory
Report [B38].
226. Results of quality assurance testing demonstrate
the need for such programmes. This is illustrated bytests of 125 batches of 3 2 different types of radiopharmaceutical in Australia 1989 [B39]. No lcss than
23 batches (18%) failed to meet full.specifications. A
test in Sweden of 81 of the 91 gamma cameras in the
country revealed inferior properties for general planar
imaging in a third of the cameras, considerable variations in bone imaging and insufficient uniformity in athird of the single photon cmission computed tomography systems [L13].

E. SUMMARY
227. In diagnostic nuclear medicine practice, the tworl~ostimportant isotopes arc 9 9 m ~ cthe
, use of whichis increasing, and 13'1, the use of which is decreasing
rapidly but which still contributes much to the collectivc dose. In industrialized countries, the per caput
doses due to exposures of patients in nuclear medicine
examinations range from 0.02 to 0.2 mSv (populationweighted per caput effective dose equivalent: 0.09
mSv). The dose per examination is a few millisievert
in most ir~dustrialized countries and 10-40 mSv indeveloping countries. The difference is due to themore frequent use of long-lived radionuclides in developing countries.

2%. Examination frcqucncics and, hcncc, per capul
dnscs arc highcr in North Arncrica than in Europc andn ~ u c l~iglicrl~in industrialii.cd c o u ~ ~ t r i cthans in dcvcloping countrics. In countrics with similar pcr caput
doscs, thcrc can still bc important diffcrcnccs inchoicc of proccdurc. In industrializcd countrics, cxarliination frcqucncics arc probably no longcr incrcasing
as quickly as thcy did 10 ycars ago. Onc of thc
rcasorLs for this is thc cornpctir~g usc of computcd
toniography and ultrasonography. Ncw tcchniqucs,
such as positron cmission tomography, arc cxpcctcd tobccomc cstablishcd in industrializcd countrics. In
dcvcloping countries, in virro kits as well as sonlc
functional study proccdurcs arc likely to find inncasi ~ use.
~ g229. Thc estimated cffcctivc dose equivalents fromdiagnostic nuclear medicine examinations for diffcrcnt

IV.

levels of hcalth carc and worldwide arc summarized in
Tahlc 35. For hc;~lth-carclcvcl I, thc annual pcr caput
dosc has hcen adjustcd from thc prcvious cstimatc[ U l ] of 0.05 mSv, to 0.09 ~ S VAccess.
to imporlant
ncw data from China and India pcrmit an imlxovcd
cstinlatc of thc annual pcr caput cffcctivc dosc
cquivalcnt for countrics of hcalth-carc lcvcl 11, now
estirnatcd to bc 0.008 mSv (~)rcviouscstirnatc: 0.004
mSv). For hcalth-care Icvcls 111 and IV, pcr caput
doscs arc assumed to be comparable to thosc inlcvcl 11. Howcvcr, bccausc of thc low cxaminatio~~frcqucncics, this cstimatc has littlc influcr~ccon thc
collcctive dose. Thc cstimatcd per caput cffcctivc dosc
equivalent worldwide is now 0.03 niSv annually, andthe estirnatcd collectivc dosc from the practicc is
160,000 man Sv. This is twice thc 1988 cstiniatc, but
it is still only 10% of thc cstimatcd collcctivc doscfrom diagnostic x-ray examinations.

THERAPEUTIC USE OF RADIATION

230. In telcthcrapy, an cxtcrnal sourcc of radiation
allows a bcam of photons to be dircctcd towards thc
paticnt. For dccp-seatcd tumours, high cncrgy photons
arc obtaincd primarily from 6 0 ~ osources or lincar
accelerators [P8]. Oldcr 1 3 7 sourccs~ ~arc bcing rcplaccd for various reasons. Other, lcss common typesof tclcthcrapy apparatus are mentioned in Scction 1V.D.For the tclcthcrapy of superficial tumours,
x rays arc utilized. Very soft Bucky x rays arc uscd
for skin disorders. In brachythcrapy [T18], scalcd
radioactive sourccs arc inscrtcd into a body cavity(intracavitary or intraluminal application), placcd on
thc surfacc of a tumour or on the skin (superficial
application), or implanted through a tumour (interstitial
therapy). Commonly uscd sourccs arc l P 8 ~ uor 12'1
for pcrmancnt implants, 1 3 7 ~orsfor low-doscratc tcmporary applications, and 6 0 ~ oor lQ21r for
high-dosc-ntc tcmporary applications (in the case of"CO or lP21r,always using rcmotc aftcrloading). Oldcr
for low-dose-rate tcmporary applications
2 2 6 ~sourccsa
arc now much lcss uscd.
231. In thcrapy, the objective is to deliver a radiationdose to the paticnt. Neither individual nor collective
effective doscs arc directly relevant for comparisonswith doses from othcr sources, not even with diagnostic procedures. Furthcrmorc, although they are
mentioned below, per caput doses of any kind are
difficult to interpret, since thcy result from averaging
very high doscs to very few pcople over an entire
population. I n the present context. the radiologicalimpact of therapy can perhaps bcst bc dcscrihedsimply by the number of paticnts and the target doses.

Such information was collected in the UNSCEAR
Survey of Medical Radiation Usage and Exposures.
Effective doses are also discussed below, but thelimitations are stressed. Although the numbcrs oftreatments are discussed in this Anncx, thc data arc
assumed to refcr to the overall courscs of treatment
and, therefore, to the numbers of trcated paticnts.

A.

FREQUENCIES OF TRWThlENTS

232. The frcqucncies of radiothcrapeutic trcalmcnts
reportcd in response to the UNSCEAR Suntcy ofMedical Radiation Usage and Exposures are givcn inTable 36 (total frcqucncy) and Tablc 37 (frcqucncics
of major trcatmcnts). In a fcw cascs, it is not clear
whether thc number of trcalments (which may be
sevcral dozen pcr trcatcd paticnt) or thc numbcr ofpaticnts was rcportcd. Some totals may be undcrestimates because certain trcatmcnts wcrc cxcludcd.
The population-wcightcd average frcqucncics oftreatments are somewhat lcss than those givcn in thc
UNSCEAR 1988 Report [UI]. The data wcrc dominated at levcl I by thc Unitcd Kingdom and thc Unitcd
Statcs, both of which reportcd 2 4 treatments pcr 1.000
population but which arc missing from thc 1985-1990
pcriod. China and India, with lowcr Gcqucncies, havebeen added to the listing for lcvcl 11 for 1985-1990.
The distributions of the total frcqucncics ofradiotherapy treatments in countrics are illustrated in
Figure VII. The average annual frcqucncics of themain types of treatments arc shown in Figure V111.

25 8

UNSCMR

233. Rcsults from individual countrics sccm at timcs
to bc incor~sistcnt.In many cascs, the sums of rcportcd
frcqucncics of spccific trcalrncnts in Tablc 37 dcviatc
considcrably from thc totals listcd in Table 36, which
may bc sniallcr or largcr. Thc varying nunibcr ofcountrics in lhc pcriods rcportcd and thc diffcrcnt
included under thc broad catcgorics
t y ~ c s o trcatmcnt
fintroduce uncertainty and makc it difficult to colnparc
rcsults. For thc Nordic countrics, the total frcqucncics
arc bciicvcd to bc based on bcttcr statistics, whilc thc
frcqucncics for spccific thcrapics arc extrapolations
from sniall saniplcs. Turkcy rcports vcry high frcqucncics of trcatmcnt for lcukacmia, lymphoma,
Wilms' tumour and ncuroblastoma compared to breast,
respiratory system or female genital organ thcrapics.
Thcse frcqucncics, from onc hospital, may reflect a
non-random sclcction of paticnts. In somc countrics,
Lhcrc arc large diffcrcnces bctwcen regions. As onc
cxampie, which is probably typical of many countrics,
adequate facilities and advanced scrvices are available
at Lima, Pcru, but access to radiothcrapy is much lesssatisfactory in rural areas [ Z l l , 212, 213, 2141.
234. AIthough thcrc arc uncertainties in specific data,thc gcncral trcnd agrees with earlier data, whichsuggested increased telethcrapy treatment frequencies
in most countrics. Thc number of telclherapy machines
in developing countries is considered to bc only
one tenth thc number that would be justified by cancer
incidcnccs [R7].
235. Markcd variation has bccn noted betwccn theNordic countries, in spite of their homogeneity [L16].
This variation is not fully cvidcnt from Tablc 36.
Thus, in 1987 according to Lotc ct al. [L16], 25%
26% of canccr patients in Denmark and Norway rcccivcd mcgavollage radiothcrapy, as compared with36%-38% in Finland, Iceland and Swcdcn. The numbcr of radiation ficlds givcn pcr paticnt was 45 in
Finland and 34-37 in thc othcr Nordic countrics.
236. The age- and sex-distributions of radiolhcrapy
paticnts arc givcn in Table 38. In general, thc age distributions conform with expcctations. Thus, Wilms'
tumour paticnts and neuroblastonia paticnts arc usually
undcr agc 15 ycars, lcukacmia and lymphoma paticnls
arc of all ages, and patients with other canccrs arc
usually ovcr agc 15 ycars, with a sizable fraction ovcr
40. The scx distributions arc also as expected. Ovcrall,
ncithcr agc- nor sex-distributions diffcr significantly
bctwccn hcalth-care lcvcls. Some specific deviations
may be mcntioncd, howcvcr: for lcukacmia, the 0-15
ycars age group is vcry small in Myanmar, for no
obvious reason. This may be a random fluctuation.
The age distribution for lymphoma paticnts includcs asignificantly higher proportion of children in countricsof health-carc lcvel 11 than in counlrics of health-carelcvels I and 111, whcre the proportions arc not signi-

ficantly difrcrcnt. This may rcflcct UIC distributions of
Burkitt's lymphoma and of Hodgkin's discasc.

11.

DOSES IN TREAThiENlS

237. Infor~nationon targct organ doscs and entrance
surfacc doscs in tclcthcrapy and brachythcrapy trcatnicnts is givcn in Tablc 39. The doscs uscd diffcr, but
no particular diffcrcncc distinguishes thc levels of
hcalth care Gom one another.
238. Absorbed doscs in tissues or organs other than
the targct of the trcatment could be uscd in assessmentof paticnt doses, although general comparisons would
be difficult. Some such absorbed doscs wcre listed in
the UNSCEAR 1982 Report [U3], but effcctive dose
cquivalcnki wcre not evaluated for four rcasons:
(a)

@)

(c)
(d)

Ihc proportionality bctwccn dose and response
assumed for effcctive dose or effective dose
cquivalcnt calculations does not hold if organ
doses exceed a fcw gray;the short life expectancy of the paticnts invalidatcs assumptions underlying the choice oforgan weighting factors for effective dose orcffcctivc dose cquivalcnt calculations;little is known about the dose distribution outside
the target volume;in thcrapeutic nuclcar mcdicinc, the metabolic
data assumed in normal dose assessments may
not be valid.

239. Since the UNSCEAR 1982 Rcport [U3], thesituation has changcd somewhat, at Icast with respect
to the first three reasons: (a) a tcntativc first estimateof the risk of canccr induction in targct organs exists[I4], which facilitates the approximative considerationof bcam and target organ doses in effective dose oreffective dose equivalcnt caIculations [B19]; @) cancer~hcrapics are becoming morc succcssful, and theaverage lifc-span of surviving cancer patients isincreasing, with particularly dramatic in~provcments
for childhood cancers; (c) extensive calculations by
Willianis ct al. [W34] of organ doses outside the beamarc available and summarized in ICRP Publication 44(141. Thus, it is now at least fcasiblc to computecffcctivc doscs.
240. However, thc dctrirnent associated with such
effective doscs cannot be calculated in the samemanncr as for hcallhy workers, nor cven as forpatients in diagnostic examinations, and it is in any
case a by-product of indispensable, life-saving treatnicnt. Furthermore, radiothcrapy paticnls arc unique inthat dctcrrninistic harm constitutes a sizable pan of theradiation-induced detriment. Such complications oftreatment are discusscd in ICRP Publication 44 1141.

Effcctivc doscs arc not wcll suikd to dcscribc suchcffccts. Still, cffcctivc doscs nlay bc useful as supplcmcntary information, to allow for comparisonsbctwccn trcatmcnts and countries.
241. Even with the new data in ICRP Publication 44[I4], cffcctivc dosc co~nputationsin radiothcrapy rnusl
be simplifications. For instance, as suggestcd by
Bccntjcs [B19], it is assumcd for thc present purposethat all radiothcrapy dclivcrs dose distributions similar
to thosc from 60Co sources. Using data from Bccntjcs[B19], absorbed doscs to non-target organs fromscattcrcd radiation from "CO treatments of four major
target areas have bccn calculated (Tablc 40). It was
assumcd that thcse arcas are representative of allradiotherapy cxccpt skin and female breast radiotherapy, and that thc dose to t a g c t organs is always
60 Gy. Lcakage radiation (a few per cent of thescattered radiation) is disregarded.

At lcast 22 cascs of skin canccr following Bucky trcatmcnt arc known, all with doses higbcr than 50-200
Gy. For cumulatcd doses under 100 Gy, no exccss
canccr risk has bccrr provcn [MI.

C . W 0RLI)WII)K EXI'OSUKES- -242. Cancer mortality following radium treatment for
fibrosis with utcrinc blccding may illustrate therclcvance or otherwise of cffcctive doses in non-target
organs. In a study of 4,153 women treated bctwecn
1925 and 1965 [I16], averagc doses werc provided forall organs, allowing the calculation of an average
effective dosc from scattcrcd radiation of 1,070 mSv.
To this a correction for target organ doscs should be
added. Bascd on the considerations of ICRP [I41 andthe interpretation of Bccntjcs [B19], one may assume
at most two fatal second cancers, i.e. less than 0.1%
with a cure rate of 50% of 4,153, and a canccr fatality
probability cocfficicnt of 0.05 [I8], which corrcspor~ds
to 40 man Sv, or 10 mSv per woman. The cumulated
cffcctivc dosc, 1,080 mSv, corresponds to a collective
effcctive dosc of 4,440 man Sv. With a fatality probability cocfficient of 0.05 pcr man Sv, 222 extra canccr
deaths would be expected in the cohort. Actually, afteran average observation period of 26.5 years, an excess
of 147 canccr deaths was recorded [I16]. Thus, theestimate from cffcctive dose calculations agrees
reasonably wcll with observations.
243. The so-called Bucky, or grcnz ray, thcrapy,
which uses 8-17 kV x rays to trcat skin disorders,cannot be directly compared to other radiotherapy.
Bucky thcrapy is rclativcly popular in. for instance,
the Unitcd States and in Swcden, which has some 15
facilities offering this trcatmcnt. The short penetration(half-value layer in tissuc: 0.5 mm) prccludcs any
effccts in othcr organs than skin from Bucky therapy.
Nevcrlhcless, skin doses of 5-50 Gy are rcccived fora proccdurc (thcrapy course) consisting of 10 consecutive trcalmcnts; for foot vcrrucae up to 200 Gy
pcr proccdurc of 10 trcalmcnts arc dclivcrcd, i.e. 20
Gy per treatment with 4-6 weeks between treatmenk[La].In this particular application, skin surrounding
the vcrrucac is shielded from radiation with vasclinc.

244. According to thc UNSCEAR 1988 Rcport [Ul],about 2.4 persons per 1,000 population wcrc subjected
to either tclcthcrapy or brachythcrapy annually. Resulls
from the UNSCEAR Survey of Medical Radiation
Usage and Exposures show a lower frequency (about
1.4 pcr 1,000), but this is only a sari~plingdiffcrcnce.
It is expectcd that treatment frequencies will increase
gradually, based on olher considerations. The trcatmcnt frequency in countrics of health-care levcl II isabout 25% of that in level I countrics, in conformity
with the earlier observation [Ul].
245. The UNSCEAR Survcy of Mcdical Radiation
Usage and Exposures responses are insufficient topermit analysis for health-care levcls I n and IV,but
there is no particular reason to expcct any significant
change from the estimates in the UNSCEAR 1988 Rcport [Ul]: 0.1 procedures per 1.000 population for
health-care lcvel 111 and 0.05 per 1,000 population forlevel IV, i.e. 4 % and 2% of the treatmcnt frequency inlevel I countries.
246. The age- and sex-distributions of tele- andbrachytherapy patients appcar to a g c c fairly well withexpectations based on age and sex statistics for thecorresponding diseases. The doses used for trcatmcnt
vary, but no particular trcnd seems to distinguish thedifferent levels of health care. Some new technologies
may lead to fewer sidc effects and/or bcttcr results
than conventional therapy.
247. The number of radiothcrapy paticnb is suggestcd
as a simple measure that is conelatcd with the radiological impact associated with therapy (including
deterministic trcatmcnt complications). Sincc morc
reliable numbcrs are unavailable, the trcatmcnt frcqucncics rcportcd in the UNSCEAR 1988 Rcport [ U l ]have bcen combined with data on populations in thehealth-care levcls, Icading to an estirnatcd 4.9 million
procedures annually (0.9 pcr 1,000 population).
248. It may also bc of intcrcst to assess thc cffcctivc
dose, using the approach of Bccntjcs [B19. B36] but
modifying it to obtain cffcctive dose rathcr thansomatic effective dosc as he did. Thc collective
cffcctive dose cquivalcnt and collective effcctive dosc
due to radiothcrapy in thc Netherlands in 1978-1979
is computed in Tablc 41 using the normalized organ
doses of Tablc 40 and various furtl~crassu~nptions
slated in the Tables. Thc result is a collcctivc effcctivc

dosc cquivalcnt of 19,100 man Sv and a collcctivc
cffcclivc dosc of 10,400 nlarl Sv. Thc latlcr valuc willt ~ cuscd for cxtraplalion to worldwidc cxposurcs. For
this purposc, it was assur~~cd
that thc distribution ofdiffcrcnt typcs of canccr is similar in countrics ofdiffcrc~~thcalth-carc Icvcl. 111 fact, both distrihu~ionand frcqucncy of canccrs vary considcrahly. Howcvcr,
it is bclic\rcd that variations in distribution do notseriously affcct the collcctivc dosc estimate, which can
indicatc only tbc o:dcr of magnitude of the worldwide
collcctivc dosc. Variations in thc frcqucncy of diffcrcnt canccrs arc to somc cxtcnt taken into accountwhcn thcrapy frcqucncics arc uscd as multipliers in thc
dosc calculation.
249. Table 42 lists collective effective doscs, cstimatcd on the assumption that they are proportional tothc cffcctivc doscs in thc Ncthcrlands [B19], corrccting for size of population and for treatment frcqucncy(but, to retain compatibility with effcctivc dosc fordiagnostic practices as far as possible, not correcting
for paticnt agc [B36]). Thc rcsult is rather imprccisc.
The cstimatcd annual collective effcctivc dose in
Table 42,1,500,000 man Sv worldwide, docs howcvcr
show that the secondary effects of radiothcrapy arc not
ncgligiblc. Probably, thcy arc of the same ordcr ofmagnitude as those causcd by diagnostic practiccs. It
is important, howcvcr, to vicw h e secondary effects
from thcrapy in rclation to the conscqucnccs of no
trcatmcnt, in which casc continuing dcbilitics and carly
dcaths would surcly prcvail.

D. TRENDS
250. Increasing life-span will make canccr thcrapy
morc rclcvant; incrcasing affluence will make morecquipmcnt available. Radiothcrapy is thus likcly to
bccomc nlorc frcqucnt in most countrics [ZI I]. Incrcascd awarcncss of the carly symptoms and signs ofcanccr will prcsuniably also incrcase demand forradiotherapy. In Pcru, 60% of cervical canccr paticnts
now conic for trcatmcnt in the latcr stagcs of thc
discasc, while for instancc only 17% of Swcdish
paticnls arc a t the latc slagcs [Z3].
251. Thc cancer incidcncc in industrialized countrics
is roughly 3 5 0 0 cascs per n~illionpopulation pcr ycar.
About half of thc cascs arc suitable for radiation
thcrapy. On a global basis, somc 10 million ncw
canccr cases occur cach ycar, 6 million of which
would be aidcd by radiothcrapy. Since thc trcatmcnt
capacity of one radiothcrapy unit is about 500 paticnts
annually [WIO], an incrcasc up to about four units pcr
million population could bc cxpccted in the long run.
I n othcr words, somc 3,000 units arc probably nccdcd
to supplcmcnt the 6,000-7,000 units cxisting worldwide today. Howcvcr, whilc more than half of all

cascs corric from dcvcloping countrics, acccss to radiotherapy is lirnitcd p 1 6 ) . 111 Africa, 45% of thc 560
r~lillio~linhahitants are undcr 15 ycars old, so it isalmost c c r i a i ~th;lt~ canccr will hccomc a higgcr problcrn ;IS t l ~ cpol)ulation agcs. Yct only a third of African rountrics havc any radiothcrapy facilities, and inmany cascs thcsc arc ill-cquippcd and undcrstaffcd.
252. Radiothcrapy is bcing dcvclopcd to achicvc
highcr thcrapcutic cffccts and bcttcr tolerability, usingc.g. hypcrfractionation [HI 1, P8, P24, W271. Sonlc
promising idcas arc undcr consideration. Althoughthcir succcss has so far bccn lin~itcd[H40], somc
possible advanccs will bc mcn~ioncdhcre. For instance, invcrsc dose planning mcans that instcad of
calculati~~gthe dosc distribution for a proposed bcam
configuration, the optimal bcam conditions for adcsircd dosc distribution in thc paticnt's body are calcuiatcd [A3,B16, K6]. As this technique becomcs
common, fcwcr paticnts will suffer radiation-induced
coniplications aftcr trcahncnt. Another possibility isthat targct doscs could bc adjustcd to take account of
the paticnt's genetically dctcrmincd radiation scnsitivity [A7, S3.51. Such adjustments may be quite
important, sincc gcncs confcrring radiosensitivity may
be much niorc frcqucnt than in thc population at large,
possibly occurring in as many as 15% of all canccr
patic~~ts[B3, H3, N2, S20]. Attention to this factor
would also rcduce thc nunibcr of complications andthus thc radiological insult to thc population. Thc usc
of whole-body treatment for lcukacnlia is increasing.
Thc UNSCEAR 1988 Report [ U I ] considcrcd bricfly
the doscs to fetuses in the radiotherapy of pregnant
womcn. Supplemental information is now available on
the usc of lead shiclding in such cascs [L15].
253. Trcatmcnt accelerators with highcr cncrgics andcxtcrnal bcams of fast neutrons havc been mcntioncd
as likcly ncw devclopnicnts [S6], and hcre is somc
prclirninary cxpcricncc of fast neutron thcrapy, which
has had, howcvcr, only liniitcd success [B8, H13,
K11, P16j. Anolhcr possiblc rcfincmcnt would bc
photon activation using Mossbaucr rcsonance absorption, i n which (for cxamplc) an "FC con~poundadministcrcd to tllc paticnt is ir~duccd to produce Augcr
cascadcs through photon irradiation. In principle, tbis
tcchniquc should permit Icthal doscs to canccr cells at
thc cxpcnsc of only vcry low doscs to normal ccll.
Thcrc arc, howcvcr, still doubts urhcthcr thc techniquewill work in humans, at lcast for othcr than vcry
supcrficial tumours, [or which many altcrnativc
mc~.hodsalrcady cxist [H20].
254. Proton thcrapy consti~utcs anothcr advallcc[C27]. Thus far, sonlc 7,000 paticnts havc bccn
trcatcd. Morc than 2,000 wcrc trcatcd in the USSR
alonc, whcrc clinical work shrtcd at thrcc ccntrcs inthc 1960s, and thcrc wcrc a fairly constant numhcr ofpaticnLs (a fcw hundrcd cach ycar) during thc 1980s( G l l ] . Thc advantage of protons is that lhcy cause
stccp dosc gradicn~sat thc latcral and back sidcs of
UIC targct dosc distributions, thus rcducirlg llic irradiation of oU1cr than targct orgJns, albcit at grcat
costs for thc complicated facility.
invcsln~cn~

255. Extcrnal thcrapy has bccn uscd not only for
trcating canccr but also for trcating bcnign conditions.
For instancc, 20,012 paticnts (99% of t h n l youngcr
than 2 ycars of agc) wcrc trcatcd for hacmangionias at
Radiun~hclnnictin Stockholn~bctwccn 1909 and 1959.
\\'hilt sonic ccntres still advocatc the radiation thcrapyof hacmangiomas, it has dcclincd rapidly sincc the
carly 1960s [F9]. It appcars likcly that such thcrapy
will in thc future be applicd only in spccial cascs, suchas bony hacmangiomas.
256. Altcrnativc and supplcrncntary trcatrncnt options
will continuc to appear, and in some cascs they will bc
prcfcrrcd in paticnt groups at high risk. For instancc,
childrcn with brain tumours arc conventionally trcatcd
with radiothcrapy, but mental retardation is a frcqucnt
sidc cffcct, occurring in 38% of all long-tcr~nsun-ivors in olrc study, with youngcr children bcing
morc seriously affcctcd [L9]. Therefore, the tcndcncy
is to dclay radiation thcrapy and use chcrnothcrapy forchildrcn undcr 2-3 ycars of agc, who arc most scnsitivc to radiation [L9]. It is not known, howcvcr,
whcthcr dclaying irradiation rcally improves thc
functional status of the patients [M14].

I

257. Quality assurancc programmes, instigated inparticular by thc World Hcalth Organization, arc cvcn
morc important (but also more difficult) in therapy use
than in diagnostic usc. A nunibcr of incidents mighthavc bccn avoidcd by a morc systematic approach toquality assurancc. In onc Unitcd Kingdom ccntrc,
morc than 200 paticnts wcre trcatcd with overdoses of
25% in 1988 [S36]. A listing of rcports that containtechnical details on quality assurancc programmcs inradiotlicrapy has bccn published [B40]. A particularly
important collection of papcrs [H9] discusscs radiotherapy quality assurancc from Europcan. North Amcrican arid Latin Amcrican pcrspcctivcs. Brahnic [B17]discusscd quality assurancc for cxtcrnal bcam thcrapy.
5 8 . Thcre is scope for othcr crrors in a computercontrolled trcatmcnt than in a convcntional trcatmcnt.
Not only must all normal quality assurancc bc pcrformcd, but it is also necessary to check thc computcr

control [M201. Input of data il~tochcck-and-conlir111
crrors,systcn1s rllay actually co~ltributrto systc~~iatic
if uscd :is an u~lcontrollcdsctup systcnl IL3j.
259. A joint study in Finland and thc USSR [K30]
found unacccpti~hlc variations in dosc distributionbctwccr~trcatnicllt planning systcnis and suggcstcd thatthe quality assurancc programnlcs hc iniprovcd.
Zaharia [Z3, Z10] discusscd quality assurancc inradiotlicrapy in dcvcloping countries, with spccialemphasis on Latin Amcrica, pointing out thc liniitations imposed by a lack of rcsourccs. For instancc,
accelcraton and quality assurancc programmcs arc
unlikely to be availahlc, and cobalt units must hc uscd.

260. Trcatmcnts by radiothcrapy arc intcndcd todclivcr high doses to targct organs to eliniinatc
malignant or bcnign conditions. All attcmpts tocalculate cffcctivc doscs from data on non-target
organs will inevitably bc open to scrious criticism. Thc
secondary effccts associated with such doscs arc
difficult to estimate and cannot be dircctly coniparcd
with cffccts of radiation in othcr situations. They must
be asscsscd bearing in mind that they arc a by-productof indispensable lifc-saving trcatmcnt. Thus, thefrcqucncy of trcatmcnt5 and thc targct doscs arc
primary estimators of thc impact of radiothcrapy.
Nevcrthclcss, cffcctivc dosc calculations niay provide
valuablc supplcnientary information.
261. Thc frcqucncy of radiothcrapy trcatmcnts by
tclcthcrapy and brachythcrapy is cstimatcd to be
2.4 pcr 1,000 population in countries of hcalth-carc
level I and 25%, 4% and 2% of this valuc in countrics
of hcalth-carc lcvcls 11, 111 and IV, rcspccti\~cly.The
total nunibcr of procedures pcrfornicd annually worldwide is cstimatcd to hc 4.9 million.

262. Estimates havc bccn niadc of thc collcctivc
effective dosc from radiothcrapy, dctcrmincd byconsidcring tissues and organs othcr than gonads
outside the targct area. The rcsults. summarizcd in
Tablc 42, indicate an annual collcctivc somaticallycffcctive dose of 1,500,000 man Sv worldwide. Some
66% of this collcctivc dosc concerns hcalth-carelevcl I countrics, which is dircctly proportional totrcatmcnt frcqucncics.

V.

THERAPEUTIC USE OF RADIOPIIARMACEUTICALS

263. Relatively few data arc available or were submitted to the Committee for the assessment of therapeutic nuclcar medicine. The problems of effective
dose, discussed for tclctherapy and brachythcrapy in
Chapter lV, arc equally evident for therapy withradiopharmaccuticals, As in those other types ofradiotherapy, simple information on the number ofpatients and doscs may be the most suitable measureof the secondary effects of therapy with radiophamaccuticals.

A.

FREQUENCIES OF TREATMENTS

264. A number of different radio-pharmaceuticals are
uscd in the lreatmcnts o i various diseases, but the useof 13'1 to treat thyroid conditions predominates. Much
less frequent procedures include the treatment of~ of hepatic tumours
polycythaemia Vera with 3 2 andFrequencies of thcraas well as arthritis with
pcutic treatments using radiopharmaceuticals incountries responding to the UNSCEAR Survey ofMedical Radiation Usage and Exposures are listed inTables 43 and 44. The population-weighted averagefrequency of all treatments in 1985-1990 for countriesof health-care level I is 0.1 per 1,000 population; theunwcightcd average of reported values is 0.2. Considering statistical fluctuation, these estimates are hardly
diffcrcnt from the estimate of the UNSCEAR 1988
Report [Ul], which was 0.4 per 1,000 population. In
confom~ity with other observatio~~sfrom the
UNSCEAR Survey of Medical Radiation Usage andExposures, the treatment frequencies at health-carelevels 11 and 111 are about an order of magnitude lower
than at levell. The distributions of the totalfrequencies of treatments with radiopharmaceuticals
and the average annual frequencies of the main typesof treatment are illustrated in Figures IX and X.
265. The age- and sex-distributions of patients are
given in Table 45. As expected, thyroid disorders
occur more frequently in women. No difiercnces in
the age or sex ratio of these patients can be detected
between health-care levels. As with tele- and brachytherapy, no trends with time in lrcatmcnt frequencies
arc obvious.

267. The average activities administered in thetherapeutic use of radiopl~arniaccuticalsare listed in
Tat~lc46. The amounts uscd for similar treatments arc
coniparablc in most cases, although a 20-fold difference between the extreme values of activity can be
identified for thyroid tumour treatment using 13'1,

268. While this conventional treatment and its
properties are well known, some attention is being
given to potential problems with other therapeutic usesof radiopharmaccuticals. Thus, since around 1980,
monoclonal antibodies labelled with 9 0 or~ 12'1, forexample, have been used for radioimmunotherapy(albeit apparently in few cases). In the present context,
the question has been raised whether better estimatesof bremsstrahlung organ doses are needed whenhigh-energy beta sources such as
are used forradiotherapy [W8]. In the case ofmeasurements
indicate that the bremsstrahlung doses are usually lessthan 1% of the beta doses, but Williams et al. [W8]conclude that bremsstrahlung doses are not negligible.
269. Table 47 givcs the absorbed doses to non-target
organs from 13'1 thyroid therapy in Japan in 1982,
using Maruyama's data on activity and patient number[MlO] and the dose conversion factors for adults given
in ICRP Publication 53 [IS]. Using these data and an
approach similar to that of Beentjes [B19], it ispossible to calculate the effective dose equivalent andeffective dose. In this case, there is a marked difference between HE (180 mSv) and E (23 mSv), since
the higher absorbed doses appear in remainder organs.
The HE value corresponds to about 530 man Sv, or a
per caput effective dose equivalent in Japan fromthyroid radionuclide therapy of about 4.4 pSv. This
demonstrates that radionuclide therapy contributes but
a small part of the per caput dose to the population.
270. Cox et al. [C18] state that radionuclide therapy
on pregnant women, particularly in unsuspected earlypregnancy, may be associated with much higher fetal
doses than would be expected from current methods
for dose estimation.

C. WORI,,I)WII)E EXPOSURES
266. Blaauboer and Vaas [B6] have estimated that thefrcqucncy of thyroid therapy courses using I3'l in the
Netherlands is 0.35 per 1,000 population. This is
somewhat higher than the value of 0.097 per 1,000
population given in Table 44. There are no doubt large
uncertainties in estimates depending on the reliabilityof the underlying samples.

271. The data in Table 43 indicate somewhat lower
frequencies of treatments with radiopharmaceuti~als
than were estimated in the UNSCEAR 1988 Report.
However, the data are broader-based than the earlier
data. The population-weighted average for 1985-1990
is 0.10 per 1,000 population in countries of health-carem m C: MEDICAL RADIATION MpOSURL!
lcvcl I, 0.02 pcr 1,000 population for lcvcl 11 and0.025 pcr 1,000 population for lcvcl 111. Thc 1988
valucs [Ul] wcrc 0.4, 0.1 and 0.016 pcr 1,000
population, rcspcctivcly, and for lcvcl IV, 0.008 pcr
1,000 population, mostly bascd on extrapolation fromdiagnostic nuclear mcdicinc frcqucncics.
272. As in thc cvaluation of tclc- and brachyhcrapy
in Scction IV.C, an extrapolatcd collcctive effcctive
dosc was cstimatcd analogous to that uscd by Bccntjcs[B19] and bascd on thc dosc data for Japan given in
Table 47. This amounts to about 9,300 man Sv worldwide, of which some 6,000 man Sv arise in countrics
of hcalth-care level I (Table 48). Thus, the estimatcd
secondary effects from thcrapy with radiophamaccuticals are negligible in comparison with those from
othcr mcdical radiation usage.

D. TRENDS
273. Indications arc that 1311 continues to bc uscd in
99% of therapies [Ul]. In the early 1980s, radioimmunotherapy using monoclonal antibodies, which
concentratc selectively in tumours, was regarded as"the magic bullet", but the technique still seems to be
in development [GI].
A possible refinement is theincreased potential for and usc of boron ncutron capture therapy [A4, F l l ] . In this technique a compoundVI.

or mor~oclonalantibody is tagged wid1 'OB. Ncutro~lirradiatio~rof this targct produccs "B, which fissions
instantaneously, yiclding alpha particles. Thc tcchniquc
will presumably affcct only a few patients in thc ncar
futurc, but it could lcad to cxposurcs of staff [ S 6 ] .

274. In thcrapy using radiopharmaccuticals, thc
trcatmcnt of thyroid conditions with 13'1 is by far thc
most common procedure. Polycytbacmia vcra istreated with 3 2 ~ ,and somc benign discascs arc
sometimes treated with radiopharmaccuticals. Although
new procedures may be inlroduccd, thcy arc unlikcly
to significantly alter current use patterns in thc ncar
futurc.
275. Thc estimated frequency of treatments withradiopharmaceuticals in countries of health-arc levcl I
is 0.1 per 1,000 population. The Gequcncics arc 20%
and 10% of this value in countrics of health-carc
levels 11-111 and IV,respectively. The total numbcr ofprocedures performed worldwide is cstimatcd to bc
210,000 (Table 48). The collective effective dose fromsuch treatments (9,300 man Sv) corrcsponds to a pcr
caput effective dose of 1.8pSv; it is a minor
component of the total effective dosc from all uses of
medical radiation.

EXPOSURES OF THE GENERAL PUBLIC

276. Inevitably, medical radiation procedures, likeother practices involving radiation, will cause someinadvertent exposure of members of the gcncral
public. Thcre arc difficulties in putting these cxposurcs
into perspective, expressing thc exposurcs per unit
practice, for example. There may bc somc mcrit incontinuing to consider the levels of hcalth carc incountries. Most data arc available only for countries ofhealth-care level I. Hcncc, to the extent that information is at all available, the discussion below islimited to doses to exposed persons, numbcrs of cxposed pcrsons, and per caput doses obtaincd by averaging ovcr populations.

A.

263

proper shielding has not been providcd. Bccausc ofthese difficulties, the Basic Radiology Systcm of theWorld Hcallh Organization has becn dcviscd asnon-mobile cquipmcnt [W3].
278. Somc cxposurc is possiblc of parcnts who arc
rcqucsted ro hold andlor calm childrcn subjcctcd to
x-ray examinations. Few publications address thisproblcm specifically, but it sccms rcasor~ablc toassume that the doses pcr cxamination would be
similar to those cncountcrcd occupationally. Parcnts
would not be involved as GcqucnUy, nor for as longtimes, as medical staff, so in most cases tbc integral
doses over Iongcr periods of timc should be lowcr
than those sustaincd by exposed medical stall.

DIAGNOSTIC X-RAY EXAMINATIONS

277. It appcars vcry rare that unintentional irradiationof the general public from x-ray facilities occurs, withthe possible exception of certain uses of mobile
equipment. Use of portable equipment under field
conditions could cause some inadvertcnt exposures, if

279. Thcre arc few data on exposures of thc publicfrom use of radiopharmaccuticals, but b e problem
could be larger than that corresponding to use of

x rays, since the sourccs can hc brought outsidc of thc
clinic and bcyond UIC radiation protcctio~~nlcasurcs
prcsclit thcre. Thcrc arc, in principlc, two routcs ofsuch cxposurc: faniily nicn~bcrs (or so~ric othcr
individuals or visitors) could bc cxposcd to radiatiou
from radiopharmaccuticals in thc patient's body, andradioactivc wastcs rclcascd inlo scwagc systcms or
dcpositcd at rcfusc dumps could incrcase backgroundcxposurcs. Excretion of radionuclidcs froni paticnts, as
wcll as radioactivc wastc from hospitals and cxposurcs
duc to radioisotope production, arc cvaluatcd inAnncx B, "Exposures from man-madc sources ofradiation". Howcvcr, cxposurcs of nicmbers of thc
public from radioisotopes prcscnt in thc bodics ofpatients arc considcrcd in this Annex. The
contamination of restroom facilities in hospitals, isrcvicwcd by Ho and Shcarcr [H16].
280. The probicm of radiation from radiophamaccuticals prcscnt in paticnts is not trivial if the patientis a sniall child or a parent to a small child. In suchcases, faniily mcmbcrs arc likcly to be moderately
cxposcd. However, estimated doscs to family mcmbcrs
arc low, usually bclow 1 mSv, in diagnostic practicc,
cvcn if the pcrsons involvcd are in close bodily
contact morc or less continuously IM3, M28).
Lcucocyte scans with ll'ln constitute a possible
exception whcre special actions may be necessary, if
doscs cxcccding about 1 mSv are to be avoidcd[M27]. Equivalcnt dosc ratcs from paticnts undcrgoingsome typical examinations arc given in Tablc 49 [N6].
The dosc rates arc of coursc highcr, and the problcm
can bc much morc difficult in therapy cases (scc
Scction C bclow).
281. A study conccming diagnostic nuclcar mcdicinc
refcrrcd to thc situation in the Unitcd Slates [B12].
Paticnts were equipped with dosimetcrs in order tocstimatc the cffcctivc dosc equivalents to criticalgroups (family nicmbcrs and co-workcrs) as wcll as tothc cntirc population. For practical rcasons, thc
dosimctcrs wcrc put on the paticnts rathcr than on thc
mcmhcrs of thc critical groups thcmsclvcs, and thendoscs to critical groups wcrc computcd using suitablc
modcls. The avcragc effcctivc dosc equivalcnls to
mcmhcrs of critical groups wcre 7-20 pSv annually,
and thc per caput cffcctivc dose equivalent to a
mcmbcr of the gcncral public was 0.4 @v annually[B12]. Since thc population of the Unitcd States isabout 250 million, cvcn this vcry low individual figurc
corresponds to a not negligible collcctivc cffcctivc
dosc cquivalcnt of some 100 man Sv (thc cstimale is,of course, not vcry precise).
282. Oftcn, paticnts have to wait betwccn injection
and imaging. In some countries, such as the Unitcd
States, separate waiting rooms are recommended for
injccted patients, but in othcr countries this is not thecasc. Harding ct al. [H26] studied doscs incurrcd byrclativcs, otllcr staff and acco~npanyingnurscs in thc
waiting room at a l~ospital in thc Unitcd Kingdom.
Median doscs wcrc about 2 p S v or Icss, with amaxin~um (for a relative) of 33pSv. Similar
concl~~sionswcrc drawn by Sicwcrt IS41 for thc
Fcdcral Republic of Gcrniany.
283. OIIC aspcct of inadvcrtcnt cxposurcs is thatbrcast-l'cd infants niay bc cxposcd via exaction ofradiopharmaccuticals in milk of examined molhcrs.
Many studies have bccn ~ t ~ a dofc this subject (e.g.
[T4]). A numbcr of rcfcrcnccs appear in reports of
NCRP and UNSCEAR [ N l , Ul]. Tablc 50 shows thatin some cascs, the cffcctivc dosc cquivalent to abrcast-fccding child could bc two orders of magnitude
highcr tllan that to UIC nlothcr [15, Jl]. On the other
hand, thc concentrations of a radiopharmaceuticals inmilk usually dccrcase vcry rapidly to insignificant
Icvcls. Discarding the Erst, or the first few, milk
fractions during thc day of administration, thus,
usually rcndcrs the dose to the infant ncgligible (asmall Gaction of a mSv) [Jl]. Fibrinogen tagged withis a rare exception, whcre breast-feeding within
three wccks can lead to cffcctive dosc equivalents toinfants of 10-15 mSv, will1 a concurrent effective dosc
equivalent to the mother of about 0.5 mSv [Jl].
Inadvertent exposure of lhe fetus is possible in casesof undcclarcd carly pregnancy. Uterine doses, relevantin such circunistances, arc available in ICRP
Publication 5 3 [I5].
284. Little is known about the geographic variationsof exposures of the gencral public from diagnostic
nuclear mcdicinc practice. The numbcr of cxaminations are highcr in developed coun~rics,and it sccms
safc lo assume that thc dascs incurrcd in the Unitcd
Statcs due to radiation froni radiophamaccuticals inpatients (0.4 pSv per caput annually [B12]) represent
the upper end of the possible dosc range.

285. If potential exposures due to accidents orincorrect shielding of facilities arc disrcgarded, themain cxposures to thc gcncral public may be due toradialion from paticnts undcrgoing brachythcrapy.
Approximate dosc ratcs around the beds of such
paticnts have bccn coniputcd, for example 0.3 mSv h' 1
at 1 ni and 0.1 n ~ S vh-l at 2 rn from a aticnt containing 3,700 MBq 1 3 7 ~ors 5,500 MBq "1 [Sl4]. It is
worth noting that aftcrloading is probably very
uncommon in countries of heallh-care levels 11 to IV,
which means that doses to the public (and to slaff)
may bc highcr pcr trealnlcnt than in countries ofhcalth-care levcl 1. Dosc rates of 0.01 mSv h*' havebeen observed in rooms above or bclow a brachy-

ANNEX C: MEDICAL RADIATION LXPOSURIS

thcrapy paticnt's room in a hospital in the Uriitcd
St;itcs [B14].Propcr shiclding rcduccd this dosc ralc
by somc 20%-45%. Although thc authors primarily
dcal with doscs to staff, rncmbcrs of thc public (otherpaticnts, visitors, staff not involvcd in radiation work)
could also bc cxposcd to thcsc radi;~tionIiclds.
286. Thus, givcn a suitablc sct of conditions, public
cxposurc could bc modcllcd. In the Unitcd Statcs
study just discussed 18141, the nlodcl choscn suggcstcd that shiclding rcduccd inadvcrtcnt cxposurc ofstaff and public by 0.0006 man Sv pcr avcragebrachythcrapy. Of this cxposurc reduction, 0.00025
man Sv was occupational. so the public cxposurc
without cxtra shielding should be at most (total minus
occupational)/(rcmaining fraction of dose ratc) =(0.0006 - 0.00025)/(1 - 0.45) = 0.0006 man Sv. On thc
vcry approximatc assumption that all brachythcrapy
causes doscs similar to the doses in 13'cs gynaccological trcatmcnts at the spccific hospital in the Unitcd
States, and that the average frcqucncy of brachythcrapy for treatment of nialignancics in countries ofhcalth-carc Icvcl I is 0.08 pcr 1,000 population (seeTable 42, assuming one third of total trcatrncnts arebrachythcrapy), the pcr caput dosc to the gcncral
public duc to brachythcrapy in countries of health-care
lcvcl I would bc sornc 0.05 pSv.
287. The problem of radiation from radiophamaceuticals in thc bodies of paticnts undergoing thcrapy
is more complicated than in diagnostic nuclear mcdicine. Relatively few paticnts are involvcd, but theactivities arc high enough to cause doses that could
cxcccd a fcw niSv to cxposcd mcmbcrs of the public.
Hcncc, various precautions against inadvertcnt exposure of fcllow patients or fanlily members arc common[CZl]. Ar an example, Koshida ct al. [K18]suggestthat 3 1 ~therapy paticnts should nor be discharged
from the hospital unless the maximum residual activity
is lcss than 510 MBq, the patient's children are aged
over 1 ycar and thcy keep a t a distance of at least
50 cm. In a later paper, they rcduced this value to lessthan 100 MBq [ U 8 ] .
For rhc patient to return to thegcncral ward, or for the paticrlt to be discharged fromthe hospital when childrcn arc youngcr and/or will becloscr than 5 0 cm,stricter rccommeridations apply.
258. Approxirnatc dosc ratcs around the hcds of such
paticnts are similar to those givcn above. Furthcr
illuslratiolis showing how such dosc ratcs changc due
to radioactivc dccay after 13'1 administration can belound in Orito ct al. 105, 0 6 ) . Family mcmbcrs may
wish to ignorc radiation cxposure in ordcr to be able
to spend as much time as possible with the patient[H18]. Other problcms in the therapeutic usc ofradiopharmaccuticals are the same as those fordiagnostic uses.

265289. Thc Comnlittce has not previously bccn atilc to
cvaluatc dic doscs to hcalthy voluntccrs in nicdical
research. Such voluntccrs ruight bc considcrcd a sriiall
subgroup of tlic gcncral public. Data on tiicsc cxposurcs arc not rcadily available, but sonic statistics for
thc Fcdcral Rcpublic of Gcmiany and for t l ~ cUnitcd
Kingdom arc prcscntcd in Tablc 51. Gcrnian rcgulations arc somewhat different for thrcc typcs of rcscarcl~(gcncral nlcdical rcscarch using labcllcd compounds, clinical trials of phamaccuticals labclled forsomc specific purpose during thc trial, and trials ofradiophamiaccuticals), hcncc thc separation of theconcsponding volunteer groups in Tablc 51. This
Table clcarly shows that thc number of voluntccrs issmall enough not to dominate the collcctivc dosc tothc general population, but it is theoretically possiblethat some individual doses could be relatively high(i.c. comparable to the dosc limit for radiation workcrs
of 50 mSv in a single ycar). It should bc rememberedthat radioactivc labelling in research projccts may
differ from that normally encountered in radiophamaceuticals, and can include long-lived nuciidcs such as
1 4 c [L26].One difficulty may be to idcntify thevoluntccrs. In diagnostic use of x rays, cxtra exposures
may be given to paticnts for rcscarch purposes, thus
making it difficult to distinguish paticnts andvoluntccrs.

290. Some factors act towards rcducing doses tovolunteers. Ethics cornmittccs that cxist in many
countries, albeit with varying regulatory status, usually
attcmpt to prcvcnt unricccssary cxposure of vo\untecrs.
Thc 1990 recommendations of the ICRP [I81 suggestthat appropriate national bodies might consider dose
constraints for voluntccrs. Such constraints would
truncate the upper end of the dose range, thus reducing
thc average dosc to voluntccrs. Even formal limits
have bccn discussed (Canada [C?'])or implcmcntcd(thc Federal Rcpublic of Gcmany [K9] and the Unitcd
Statcs [U16]), in spite of objections [P6] that dose
limits are inappropriate in mcdical rcscarch. To theextcnt that such limits are uscd, thcy can be cxpccted
to rcducc the avcragc of doscs to voluntccrs, by
cutting off thc upper tail of thc dosc distribution.

291. Whilc x-ray cxanlinations arc morc lrcqucnt,
examinatior~sarid thcrapy with radiopharmaccuticals
constitute the morc important roulc of cxposure of thc
general public. The annual pcr caput effective dose
equivalent caused to members of the public by patientswith radionuclides in their bodies is estimated to be
0.4 pSv or less.

UNSCEAR 1993 REPORT

266

VII.

EXPOSURES FROM ACCIDEN TS IN MEDICAL RADIATION USAGE

292. Most of the available rcports on accide~~ts
arccasc studies of pi~rticularcvcnts. So far, the material
pcrnlits littlc in the way of estimating of the accident
frcqucncy per unit population or per unil of practice.
It must bc cniphasizcd [hat all of the frcqucncy cstimates givcn bclow arc highly imprecise and, owing toerratic reporting, arc vcry likcly to be undercstimatcs.
293. Accidents in diagnostic x-ray cxaminations arc
not likely to have grave individual consequences. Of
the 38 incidents of patient overexposure due to faulty
radiation equipment that were rcported to the United
Kingdom Health and Safcty Executive between 1986
and 1990, 30 involved diagnostic x-ray equipment. In
thesc incidents, about 760 patients (about 0.003 per
1,000 population annually, corresponding to about 6
per million x-ray exan~inationsin the United Kingdom) were ovcrexposcd, with effective dose equivalents from 0.5 to 13 mSv and a collective effective
dose equivalent of some 5 man Sv [GlO].
293. In nuclear mcdicine misadministrations occur,
sometimes with fatal results [M29]. The extravasationof correctly measured but incorrectly injectcd
radiopharmaccuticals can also lead to radiation injury[SSO]. In the Unitcd Statcs about 75 misadministrations in thcrapy and about 1,300 misadministrations
in diagnostic nuclear medicine arc reported annually(in all, aboul 0.006 per 1,000 population annually, or
about 140 per million nuclear mcdicine examinationsin the Unitcd Stales). Some 40 of lhese concern
which can easily be injected in therapeutic quantity[N13]. About 95% of all diagnostic misadministrations
involve the correct prescribed activity but the wrong
radiopharmaceutical or the wrong patienL
295. While various accidcnts in tcletherapy havecaused lcthal damage, the serious underexposure of
canccr patients may also well have led to fatal results[SSl]. It is vcry difficult to assess the frequency ofthcse accidcnts. Apart from the general problem of
undeneporting, thcsc particular accidents are so rarethat it is a problem to establish a baseline population
or time period. Arias [A141 discusses three tclcthcrapy

accidcnts: Texas, United SLltcs, 1956, where twopaticnts dicd of ovcrcxposurcs frorn a lincar accclcrator; Maryland, Unitcd States, 1987-1988, whcrc 33
patients wcrc ovcrcxposcd by up to 7 5 % Zaragoza,
Spain, 1990, whcrc 27 patients 14 of whom died, were
ovcrcxposcd from a lincar accclcrator. Dis~ributing
thcsc 62 paticnts over Ole conlbincd population of
Spain and the U ~ ~ i t cStatcs
dand, rather arbitrarily,
over 10 years, there would be some 0.00002 victims
annually per 1,000 population, or about 10 per million
thcrapy procedurcs. A separate kind of accident canoccur if a disused tclctherapy source is removed fromthe hospital and the public is exposed. A well-known
example, thc Goiania accident, is discussed in Annex
B, "Exposurcs fiom man-madc sources of radiation".
2%. The European Federation of Medical Physicists
has initiated a scheme to share information about
accidents to patients. S o far, only radiotherapy
accidcnts have bcen reported. Reports obtained to datefrom Czechoslovakia, the Federal Republic of
Germany, Norway, Poland, Russia, Spain, Turkey andthe United Kingdom indicate that 1,344 paticnts inthese countries wcrc exposed to higher than prescribed
doses and 989 patients to lower than prescribed doses
betwccn 1982 and 1991 [H19]. These 134.4 patientsannually would correspond to some 0.0003 victims per
1,000 population (the nun~bcris of course higher thanthat given in thc preceding paragraph, which deals
exclusively with grave accidents).
297. A total of 9 1 incidents concerning ionizing
radiation were rcported in the Federal Republic of
Germany in 1990 [B7].Of these, 21 had some connection to medical uses of radiation. Radiopharmaceuticals for diagnostic purposes were lost or stolen ineight cascs. There were various failures of remote
afterloading equipment for brachylhcrapy in ninecases, failure of linear accelerators in two cases,
failure of one gamma teletherapy device and leakage
of faeces contaminated with 1311 from the drain of athcrapy ward in one casc. Thcrc were minor exposuresof staff in five of the afterloading cvcnts. No exposureof patients took place in any of the 21 evcnts.

CONCLUSIONS
298. The use of ionizing radiation in medical
diagnostic and thcrapeutic examinations and treatments
convey radiation doses to the individuals involved
along with direct benefik in health care. Because ofwidesprcad usage of radiation and radioactive

materials in medical procedures, the collective dose to
the world population is significant. With additional
information available on radiation exposures ofpatienk, particularly that reccived in response to the
UNSCEAR Survey of Mcdical Radiation Usage andANNEX C: MEDICAL k u l l A T l O N MPOSURlB

267

database available, the pcr caput cffcctivc dose
cquivalent~at levels I1 and 111-IV are cstirnatcd to bc
0.1 and 0.04 nlSv (previously 0.2, 0.07 and 0.03 mSv
at lcvels 11-IV, rcspectivcly [Ul]). The use of299. The Committcc has previously extrapolated
availablc data on mcdical radiation usage to the c ~ ~ t i r e fluoroscopy for chest examinations has bccn clarified
for China (level II), but the prevalence of thisworltl on the basis of the number of physicians pcr
procedure, which gives highcr doses, cannot be certain
1,000 population, a statistic that is available for all
for othcr countries at health-care lcvels 11-IV.
countries. This procedure has been maintained for the
analysis of this Annex. Four lcvcls of hcalh care arc
303. The estimated effective dosc cquivalcnt fromdefined to characterize medical radiation usage.
diagnostic nuclcar medicine cxaminations increased in
Relatively complete data are available on examination
countries of health-care level I (0.09 mSv comparedand treatment frequencies for countries of hcallh-carewith 0.05 mSv previously [Ul]) and also in countries
lcvels I and 11. At health-care lcvels 111 and, inof health-care lcvels 11-IV (0.008 mSv compared withparticular, IV, information is still insufficient in many
less than 0.004 mSv previously [Ul]). The estimatc
respects, although the contribution to the worldwide
for developing countries is higher, since it has become
collective dose from these countries is small.
clear that the main radionuclides being uscd there arc
long-lived ones. However, the radiological impact of
300.There are indications that exposures ofdiagnostic nuclear medicine remains small in
populations fiom the diagnostic and therapeutic uses
comparison with that of diagnostic x-ray examinations.
of ionizing radiation are increasing worldwide. Muchof this increase can be justified on clinical grounds,
304. For tele- and brachytherapy, the treatment
particularly in developing countries, where medical
frequencies reported in the UNSCEAR Survey o fservices are obviously not yet sufficienliy availablc.
Medical Radiation Usage and Exposures are lower
The general trends observed with time and between
than those obtained in 1988. This is interpreted aslevels of health care cannot be used to anticipate
sampling variation as the treatment frequencies are no
particular conditions in individual countries.
doubt continuing to increase. The primary measure of
Circumstances vary widely, and national trends may
the impact of therapy on the population uscd here isdiffer greatly from the average trends. Nevertheless,simply the number of patients treated. In addition,
the averages for several countries of each lcvcl of
estimates of the effective dose and the collective
health care and for five-year time periods should be
effcctive dose are shown for illustrative purposes.
reasonably representative, i.e. the conclusions drawn
Therapy with radiopharmaceuticals appears to behere about worldwide exposures should be generallyslightly less frcquent than had previously bccn
valid.
estimatcd lull. The frcquc~icicsof treatmcnls worldwide
are estimatcd and the effective doses calculated.
301. For countries of health-care level I, thepopulation-weightcd estimate of the frequency of305. The estimatcd doscs to the world population
diagnostic medical x-ray cxaminations (890 per 1,000
from all medical uses of radiation are summarized in
population) is slightly higher than the estiniatc in theTable
52. The per caput cffcclive dosc cquivalcnt fromUNSCEAR 1988 Report (800 per 1,000 population),
diagnostic examinations ranges from 1.1 mSv at
although it seems unlikely that the difference would be
lcvcl I to 0.05 mSv at levels In-IV. The worldwide
statistically significant. Thus, at health-care lcvcl I, thepcr caput cffective dose equivalent is 0.3 mSv. From
total frequency of all x-ray examination was relatively
therapy treatments, the pcr caput effcctive dose
constant during the 1980s. Reduccd rates of incrcase
equivalents computed from scattered radiation inor, in a few countries, decreases are due to the
non-target organs are estimatcd to be 0.7, 0.2, 0.03
introduction of alternative methods, such as ultrasoundand 0.02 at lcvels I-IV, respectively and 0.3 mSv
and cndoscopy. For countries of health-care lcvels IIIV, examination frcqucncics appear to be increasing,worldwide. The collective cffective dosc equivalentfrom diagnostic cxaminations is estimated to be
as expected on the basis of needs for the services and1,800,000 man Sv, with nearly 90% from x-ray
on demographic trcnds.
examinations and the remainder from nuclcar medicine
and dental examinations. The collectivc cffective dose
302. The estimatcd per caput effeclivc dose cquivalcnt
from therapeutic treat1ncnt.5 is estimated to be
Liom x-ray examinations at health-care lcvcl I is
1,500,000 man Sv, but this is not stricliy con~parable
1.0 mSv, unchanged from the estiniatc in theto other doses.
UNSCEAR 1988 Report [UI].Some examinations
with higher doses, such as computed tomography, are306. Effective doses to patients Gom mcdical uses of
beconling more frequent. At the same time, however,radiation cannot, in general, be used directly inbetter equipment and techniques are allowing doses incalculations to infer detriment. In Section 1.B, various
other cxaminations to be reduced. From the wider

Exposures, improved estimates
exposures can be madc.

ofworldwide

problcms with thc cstiniation of dctrin~cntfror~idoscs
to palicnts wcrc nicntioncd. For thcrapcutic uscs ofradiation, an addcd difficulty is Lhat much of Ihc
secondary cflcck arc not canccr or hcrcditary discasc
but dctcrniinistic radiation harni.

307. Much, and optimally most, of thc collcclivc doscfrom mcdical uses of radiation is offset by direct bcncfits to thc cxamincd or trcatcd paticnts. Thcrc arc two
basic ways to rcduce thc risks of radiation dctrimcnt
to palicnls: (a) by rcducing thc collective dosc bylowering the numbcr of patients cxposcd to ionizing
radiation or (b) by reducing Ihc individual dose in

cxposcd
particular ~)roccdurcs.Tilt 11umbcrof patic~~ts
can hc lowcrcd by using strict rcl'crral critcria. Guidclincs oir tllc sclcclion of patic1iL5 for various x-ray
cxaminations have bccri givcn [R26, S2, U11, U12,
U13, U14, U1.51. Rcfcrral critcria that arc particularly
appropriatc for radiology ill dcvcloping countrics arc
givcn by WHO IW23, W24, W25, W26j. Thc usc ofaltcrnativc niclliods, such as ultrasound and cndoscopy, also rcduccs Ibc numbcr of cxposcd paticnk.
Thc dosc pcr proccdurc can bc rcduccd if the proccdurc is oplimizcd and if quelily assurance prograninics arc sct up to cliniinatc deviations from theoptimum.

Spain1985-1969

38558

1645

9000

18000

Sweden1970-1974
1980.1984
1985-1989

8129
8327
84 14

542
645
920

2700
2400
2WO

5500
12500
12900

1972
1962
1990

6193
6335
6509

92
173

6000

7500

4000
5500

6000

6000

1980
1986

265542283682

USSR. RSFSR

1976-1980
1981-1985
1986-1990

136528140228146237

15660
16770
17080

24760
29550
31550

2880
3680
4840

United Kingdom

1981-1985

54600

1600

11000

United S:ata

1970-1974
1980-1984
1985-1989

21366934238
248630

12216
lZS95
12381

97768
129695108903

Uruguay

1978-1982

2908

33

Vcncruda

1978-1982

15024

150

Yugoslana

1970-1974
1980-1984
1985-1989

4776
10788
18681

318
568
1624

Sni~zcriand

USSR

31
24
22

150
120

23
17
14

12
27
33

125
120

25

6
14
20

43
43

26
19

288

110974
187772142699

3441
3299
1324

99
239
74 I

7
6
27

2
6
14

1
10

4

3

1

2
2

1
1

0

1
1

230
1399

50
99

38
133

68
147

8

2

1

0
37
80

5

22
36

nrmlth-care Ievd 11

Algnia1966-1969

22200

Barbados

1980-1984
1985-1989

250
250

Uoi~via

1978-1982

46 13

Brazil1982
1990

127100150238

Gilc

19M

12748

Gina

1970-1974
1981-1985
1986-1990

27056
lOlOOOOl(K10000

1990

20300

1978-1982

25892

1811

1981

5648

71

Gina, Taiwan Prw.

Colombia
Daninican RcpuMic

5

20

1

0

171

12432

734
81500
12aMO

13400
10-!QO

315
0066300
120300

315

4

600

4
250
264

ANNIX C: MEDICAL RADIATION M P O S U R I S

27 1

272

U N S C M H 1993 REPORT

Tnhlc 1 ( r n n l i n u e d )The cntriu in this Table are qualified as follows:
Data from L4EA (Intanatiorul k o m i c Eongy Agency) and from [Ul, U17.
The number d radiologists cxcludcs 2,149 non-radidoist physicians licensed lo usc x rays.
The value givcn for nuclur mcdianc d l m a IS the estirntcd numbcr of scamcrs/wmeras.
Data alw f r a n PAHO (Pan Ammica Hulth 0rganizat.on).
Survey r w p o n v published as [All]. Data also f r a n [CI:. D4. Ul]. Numbcr of radiolo~stsindudw 200 n d i a h n a p s ~and 232 n u d t usnumb= la 1990mcdionc spccialisls. Nurnba d n w i e u mcdronc d i n i c s f a 1962 is ut~rnatcdfrom numbcr of s a ~ c r d c a r n c n(207);
rncludw 450 scannudcarnaas; 401 further un~trd o in vine work only. Number d
137Cstelcthcrapy unltr exdudc 7 non-operailvc
units; numbcr f a a m l c r a t a s cxdudw 10 non-opaativc units.
Data from IAEA (Inlanational Atomic Encrgy Agcncy)and from [Ul. U171.
Cameroon:'176 tclcthaapy unlts rcprucnts liccnseu. soole probably uqth more than one umt.
Conado:The numbers given for
Chile:
Data born PAkiO and from [U17).
Conto:
Data from IAEA and f r a n [UI. U17j.
Cuh:
Data horn P N 1 0 and from [U17].
L)ominico:
Data horn PNIO.
Numbcrs of radiologists. &agncxric x-ray units and clinics estimated from h s r - E l l511i Ccntrc, which scrvw ca. 3%of pnucnts using
Empr:
ndiat~on.Data on therapy units from IAEA
Data from [M40.5.17. The numbers given f u Lagnartic x-ray units cxcludc 339 military medical and dcntal urutr.
France:Gobon:
Data fran IAEA ( l n t a n r t l w l Atomic Enngy Agency) and from [Ul. U 1 7 .
40% cf a11 x-ray examlnatrms arc performed by n o n - r a & d o ~ r phyrinans.
t
7hc 3300 x-ray units (gencntorr) In 1965-1966 c a r n p o n dGerman Dcm. Rep.:
to 5100 tubcs.
55% of all x-ray cxaminntionr arc pnlorrnd by non-raholo~rtphysiciilns. 75% of dil~goslicnuclear mcdxcinc ir perfumed outaidc
German?.:rpccialized clinics.
Modwpr:Data born PAL10 (Pan A m n l a n Ilcalth Organ~utim).
Icrld:
Data also f r a n fL14 S141.
Idk'Ihc number d ra&oloprtr cxcludcd 31.000 non-rpccral~stp h y n a n s using x rayr.
Data also from [Ul, U17j. O!hn cntrin than populat~onsizc refcr lo thc Institulc 01 I(rr&dogy and Nuclear Mc&cinc. Baghdad whichIraq:e r v u on unknown f r a a ~ mof the populauon.
Kcny:
Data horn IAEA and f r a n [Ul. U17.
Libcrio:
Data from lAEA m d (ran [Ul. U17.
Libym Arab Jamahirnn: Dala from 1and f r a n [Ul. U171.
M&gnrrar:
Data from lAEA and f r a n [Ul. U171.
Mawiriur:
Data fiom ID16. L'l. V17).
Morocco:Data horn lAEA and ( r a n [Ul. U17).
Moznmbiquc:
Data hom [D16. U1. U171.

Algmia:Argcnrino:
Amria:
Bnrbndos:
Brccil:

273

ANNEX C: MEDICAL RADIATION MPosUHG

Numhcr of radiologists includn 9. 22 and 28 rnrliothcrapisls and 4, 7 and 7 nuclcar medicine specialists in 1970.1974. 1980-1984 and1985-1989, rcspcctively. Number o l m d c a l x-ray units ~ n c l u d u9, 5 and 0 mass miniature chcsl unlls and 70, RO end 65 chlropaclicc
units in 1970-1974. 1960-1984 and 1985-1969, respcclivcly.
h'icaragua:
Dats from I'A110.
h'igcrio:
Data hom IAEA and f r a n [UI, U171.
Numher given for diagnostic medial and dcntnl x-ray uniu rcpreaent fatililict.
Philippines:
Data from [CIS].
Porru~d:Data from PAJIO.
Sainr Lucia:.Qncga/:Data from I X A and from [UI. U17).
Population sire from jU17]. Othu catria refer lo the Nalional University Ilcspital, uhich scrvu an unknoun fraction d the population.
Singapme:
S o u h Africa:
Data from IAEA and from [Ul, U171.
'Ihc n m b a given for dagntatic x-ray units la medical examinations cxdudea units In u,hich lewcr than 1,000 cxamlnatlons per ycar
Gain:
arc pcdomcd.
Data also from [S21]. Nurnba of radidogists i n c l u d ~8L 120 and 155 radiothaapistr in 1970-1974, 1980-1984 and 1985-1989.
Sweden:respectively. X-ray lclcthcrapy units cxcludes nucky units.
Bcsidw radiologists, all gcncralisu, surgeom, internists, paediatricianr (sum 1982: 5,970) and dentists (numbcr 1962 2.728) arc llccnscd
Su~ux~ld:
to use x rays.
Data also from [G16]. Nurnbcr d radidogists includes foreign doctors; d the 76 Tunisian dmors. 4 were ndiothcrrpists. 3 nud-r
Twbk
medicine specialists. Accelcrrtor not token into use (1990).
Data from [Dlb. U1. U171.
Ugondn:USZR:
Data also horn p17].
Data for one republic. the Russian Smiet Fcdcrativc Sccialist Republic. Radiologists indude diagnostic x-ray spccialisls d y .
U W WSR:
Unired Rep. o J T a m n i a : Data hom IAEA and from p18. Ul. U17].
Yugosiavin:
1970-1974data indude Bosnia and Iiaregwina and Slovenia: in 1980-1964. data include Bosnia and Ilcrrcgodna. Croatia and Slovenia;
1965.1969 dnta include all d Y u g d a v i a except for Montenegro. Ktaovo and Vojvodina.
Zimbabwe:
Data &om IAEA and f r u n [Dlb. U1. U17).

Tnblc 2Average number of medical radiation faciliUes per 1,000 populaUon by health-cam level
Data from UNSCEnR Survey of Medical Radiation Usuge and Erposures

M c d t d rodiarion sraffl
Joriliricr
Radtdogsts

M d c a l x.ray units

Dental x-ray units

Thnapy x-ray units

6 t a l t - 5 0 lhclapy units

Accelerators

Nuclear mediane cliwcd

Hcolrh-cwc Imel
Ycnr

I

n

III

nr

1970-1974
1960-1984
1985-1990

0.062
0.076
0.072

0.03
0.064
0.041

0.004
0.W

0.0003

1970-1974
3960-1964
1965-1990

0.45
0.36
0.35

0.014
0.071
0.066

0.016
0.018

0.00060.010
0.004

1970-1974
1980-1984
1985-1990

0.44
0.1
0.38

0.012
0.077
0.066

0.005
0.003

0.0001

1970-1974
1980-1984
1985-1990

0.014
0.013
O.(Kl480.00020.00170.00SO

0.W
0.00010.0001

1970-1974
1960-1964
1965-1990

0.00310.00340.00260.00010.00010.00010.00010.00040.00020.00009

1970-1974
1960-1964
1985-1990

0.00;O
0.W12
0.00200.00010.00010.00002
O.OMX)9

1970-1974
1980-1964
1985-1990

0.00480.W
0.W78

0.00030.00030.00030.00010.00004

0.MaOS

0.M002

Tnhle 3
Annual medical radlatlon exarnlnations and h a t r n e n B
Dora from UNSCEAR Survey of Medical Radiation Usage and Exposures unless o~hern.iseindicatedCovrnyDiatnasric a a m i n o ; i w(rhou&))'ern

Mcdirdx roys

DenialI rqirntallh-7hsapcvtic rrcaimcnu(ihowcndr)

Rdie
uoropu

,Fray

Tclc-

Brachy-therapyrhaapylhaopyRndb
Loropu

29.0

6.0

5.3

4.4

17.5

24

Ievd 1
415

Argentina

1985-1989

Auslnli8

1970.1974
1985-1989

46.15
9149

lo00

Belgium

1986.1990

12n2

28%

Canada1970-1974
1985-1986

18660
26563

Cub.

1988.1990

63%

Qcchoslovrldr

1976-1980
1981-1985
1986-1990

Ill12
10882
9498

Denmark

1985-1989

Ewda
F~nlmdp l b ]5211249.9 '
5.4

365

*

3.0
432 '
519 *

10

23"

920
883
884

660
94 3
1183

0.9
0.6
0.3

2600

2400

n

1985-1989

530

65.4

8.5

1977
1984
1986-1987

5100
4600
4300

955

59
85
100

1982
1988-1990

45350
55060

Gcrman Dan. Rep.

1974-1978
1981-1988

19000
19000

2500
2500

115
160

G m a n y . Fed. Rcp. of

1976-1980
1981-1990

71600

16600

1899
2450

France [UO, M a ]

1100

0.5

0.4

29
3.6
3.7

0.2
0.2
0.3

4.9
6.2
9.4

7.0

7.0

0.6

0.1

0.5

0.9

0.2

0.07
L5
1.8

0.7 "

387

1974
1983-1985
1989

42700

Japan

1970.1974
1980-1984
1985.1969

73064
96x0
141500

91500
99MO
95768

168
54 1
989

132
13

1656
1762

15.5
13.6

4.4
3.0

Kuwi I

1985-1989

1137

I90

24.3

0.3

0.9

0.02

0.03

1988

294

69.1

9.2

3.4

4.0

0.03

0.07

1970-1974
1960-1984
1985-1989

33.2
84.7
110

0.9
23
3.2

0.1
0.1
0.1

0.2
0.4
0.5

0.01
0.01
0.01

0.03

Nc~herlvrh

1980-1984

7900

5700

200

25

23

1.1

1.5

Ncw Zuland

1970-1974
1960-1984
1985-1989

1790
2263
21 14

-1000
913

18.9
25.9
24.5

3.9
1.5
1.1

3.2
6.0
8.6

0.3
0.3
0.2

0.5
0.6
0.5

1970-1974
1980-1984
1985-1989

1600
2200
2200

2SM
3300
3500

16.0
36.0
39.0

1.0

Poland1985-1989

24949

2300

Ponugd [CIS. S52j

1988-1989

5900

Rwrun~sI980
1985-1989
1990

13205

706

66.9

10688

704

55.8

1966-1990

0290

90a)

luly

h

h

g

Malta

Sauay

Spun

4QO

579
551

0.06
0.3
0.6

0.04

33.9
9.1
111

3.8
4.8
46

0.1
1.5

1.2

ANNEX C: h(EDIC/U, RADIATION ~ P O S l J K ~275

Tnl~lc3 (continued)

CovlmyThaapcuric rrcammu(lhourd)Uinfnasric a n m i n n l i n u(1hOrrrMdr)

Ycur

Mcdicdx rrryr

DcnralRadiotoropu:

X-ray

Tdr

Arlrihyx rm)sfkrnpylhaapylhanpyRaiioiroropu

1970.1974
1980.1984
1985-1969

4600

36DO
7000
7000

n.0
12s
122

6.8
22
1.6

9.2
11.4
133

20
1.6
1.5

27
3.3
3.6

1972-1976
1982

6446

1834
2059

284

1981

34400

USSR. RSFSR

1976-1965
1986-1990

1368001442508570
11740

Unild Kingdan

1976-1980
1981-1989

22700
25230

6055
90iX)

369

United States

1985-1989

ZOOOOO

1003006783

Yugculada

1985-1989

3350

83000

140

Su~dcnSuiltnland
USSR

4700
6UX)

6582

9.8

150

11

15.1

50.2

20

24

0.1
0.1

0.3
0.3

0.04
0.05

0.02
0.01

Ucalth-cam Icvd 11
1980-1984
1965-1989

51.2

0.2
0.3

1982
1990

22750
15037

256

1982

1911

1985

15a087

2233

615

h d a

1970-1974
1980-1984

167
385

10.0
35.7

3.1
7.4

Hmdurss

1990

106

1965-196981480

ban (Islamic Rep.09 [Ul]

1981

7221

h'laragua

1990

191

Pau

1985-1969

300

Tunida1985-1989

Turkey1981-1985
1986-1990

Baltador

Brazil [All.ClQUl]
Qlilc
0;lu

[a]

%

0.3
0.5

0.2
0.5

44
0.04
0.09

0.05
0.05
-

India

169

106

20.6

28

27

0.9

0.3

7.0

6.5

3.0

0.3

174

50
33

4.8
100

16663
3840

0.3

0.5

llcalth-cuc lrvd Ill

Belizc1990

15.1

Chpc Vadc

1985-1989

227

Dom~n~a

1990

12.9

1976-1980
1981-1985
1986-1990

11.0

lnd~r

1970-1974

19600

Mymnur1986-1990

397

h3gcris [Ul]

197

2014

Ph~l~pp~ncr

1985-1989

6148

1990

19.0

Egypl

Sa~nlLuna
Sudan

1976.1980
1981-1985
1986-1990

1380

0

4.1

26
9.4
25

0

0

22
40.9

0

0

0.02

26
28
3.2

11.4

64

d.01
0.6

21
5.7
7.1

0.2

1.7

0.04

0.02
0.06
0.1

counny'Ihniland

Vanuatu

YXaapturir rrcormcnrr(rhowd)Diatnarrk a o m i n u i m(rhurd)

Yea-

Rldie
iraropu

S-ray

Tclr-

Hrachy.

rh~apyrl~rrnpy~hnapyRldie
irotopa

0.M
0.04

0.008
0.01 10.013

00Medicdx raysDrnralx ITS

1976.1980
1981-1985
1986-1990

276
3749
4318

64

II

llS
115

9.1
14

0.09 '

1985-1969

11.1

0

0

0

Ilcstth-cur lrvd I\'
E~hiopia

1981-1985
1986-1990

Rwanda1970-1974
1988.1989

0.6
4.8
28.0
61.1

The entries in this Table arc qualified as follows:?he value given for medical x-ray examinations is estimated from the number examined in the public senor (35.200)
and the numbn of picccs of equipment in the public sector (13 of 20 in Barbados).
5eli:c:Data from PAHO. Number of patients: 13,036.
Therapy numbers refer to treatments, not patients.
Conodo:Chile:
Data also from P I ] .
Data from PAHO (Pan American Health Organization). X-ray examinations refcr to 5.7 million patients.
Cuba:
The values given for x-ray therapy. tclcthnapy and brachytherapy lor the ycars 1976-1980. 1981-1985 and 1986-1990
C:cchoslovokia:
exclude treatment of benign conditions (39.000 patients annually 1976-1985. 24.000 patients annually 1986-1991).
The value given for medical x-ray examinations includes 7,000 intm,cntional radiology.
Dcmark:Data from PAHO. Number of patients: 10.816.
Domi~uca:
The value given for medical x-ray examinations for the years 1980-1984 includes 19 inten*cntional radiology; for h e
Ecrrodor:ycars 1985-1989 27.00G interventional radiology.
The value given for dental x rays includes 400,WO pantomograpl~icexaminations; the value of 0.7 given for x-ray
Fitrlond:
thnapy, tclc- and brachytherapy represents primary stage radiotllcrapy only; the value of 2.2 represents total number ofpatients.
The value given for radioisotope examinations is estimated from 116pital Henri Mondor, which serves about 2% of tile
I:ronce:population of France.
German Dem. Rcp.: Total numbcr of thnapeulic treatments in 1985 = 40.000 of which 20.000 for cancer.
G c r m a q ; FedXcp.: The numbcr of diagnostic cxaminations with radioisotopes is estimated from data covcring 7% of the population for theycars 1976-1980 and from data covcring 21% of the population for the years 1981-1985 and 1986-1990. Total numberof therapeutic treatments in East Germany 1985 = 40,000 of which 20.000 for cancer.
Ilonduros:
Data from PAI-10.
flab:
Data also from [Ul].
Dental examinations include 1.650,000,9.640,000 and 11.229.00 pantomographic exanlinations in the years 1970-1974,
Japan:
1980-1984 and 1985-1989. Numbers for x-ray therapy and tclctbcrapy refer to treatmcnls. not patients.
The value for mcdical x-ray examinations includes 3.000 intcwentional radiology examinations.
Kuuvzir:
Numbers for x-ray therapy and telc~herapyrefer to treatments, not patients.
Liucmbourg:
The value for medical x-ray examinations in the years 1985-1989 includes 150 inte~entionalradiology examinstions.
hfal~a:N e w Zealand:
The value for medical x-ray examinations includfs 359. 129 and 67 mass miniature chest examinations and 30. 41 and47 chiropractic cxaminations in the years 1970-1974, 1980-1984 and 1985-1989. respectively.
Nicaragua:
Data from PNiO.
h'orntay:
The values given for x-ray lherapy are from one hospital only, to indicate trend.
The values given lor medical and dental x rays as well as lor x-ray tlicrapy and tclcthcrapy are estimated from data
Nomonia:
comprising 60%-65%of the population. Numbns for 1990 x-ray therapy and tclethcrapy rcfcr lo treatments. not paticnts.
Spain:The value given for medical x-rays exclu&s military, legal and pre-employment examinations.
Saitrr Lucia:
Data from PN 10. Number o l patients: 16.300.
Sweden:The valuc for medical x-ray examinations includes 6.000 intcwcntional radiology exaniina~ions.
Switxrland:
The values given lor radioisotope cxaminations and treatments are estimated from data covering 4% of the populationThe values given for diagnostic examinations and therapeutic treatments with radioisotopes are estimated from data
Turkey:covering 1 % of the popula~ion;the valucs for therapeutic trcatrncnts from data covcring 2% of the population.
USTX:
Data also from [Ul].
Value for medical x-ray examina~ionsincludes 1.700 intcwcn~ionalradiology. Values given for thcrapcutic treatments
l'ugoslavia:
arc for Dosnia and Hcnegovina, Croatia, Slovenia and Serbia, excluding Kosovo and Vojvodina (73% of the populationof Yugoslavia).

Barbadar:"Value I S fm dl Lhcrapcutlc trealrncnts.
Valuc IS for bdh mcdral and dental x nyr.

A N N 1 3 C: MEDICAL RADIATION EXPOSUKES

277

T l ~ l ) l e4
h l c d i c r l l r t ~ d i n l i o nscr~~iccr
worldwide, 1%5-1990

Normali:ed quanli~iescle~erminedfrom U N S C M R Survey 01hfedical Radiarion Usage and Exposures
1

L n * c l or h r d ~ h<arc
iVorldQuanrity

I

II

111

nj

N m s l i u d rulucs
Physicians per 1 . W populal~on

26

0.55

0.18

0.053

0.98

Radidogists per physician

0.028

0.075

0.032

0.W6

0.0:

Radidogish per 1,000 population

0.072

0.03 10.006

0.0003

0.0;

X-ray units per 1,000 population

0.35

O.OB6

0.018

0.0042

0.14

X-ray units per radioloist

4.9

21

3.1

14

3.4

X-raycxaminations per x-ray unit '

2400

1600

3900

?000

2100

X-raycxaminzttms per 1,000 population '

860

140

70

9

300

Nuclczr mdicinc cxarninatims pcr 1.000 population

16

0.5

0.3

0.1

4.5

Tclc- and txachy-thcrapy patients per million population

24

0.6

0.1

0.05

0.9

Radiophamaccuticds therapy patients per miilioo population

0.4

0.02

0.02

c0.13

Ab~nlutcvnlucs '"'Population (millions)

1350

2630

850 '

460

5290

Physicians (~housands)

3600

1400

150

24

5200

Radidogisls (rhousan&)

97

106

5.2

0.13

210

X-ray units (thousands)

470

230

15

1.9

720

X-ray cxaminatims (millicns) "

1160

360

60

4.0

1600

Suclear medicinc examinations (millims)

22

1.4

0.3

0.05

24

Tcle- and bachytherapy patients (thousands)

3200

16W

85

23

4900

Radiaphamaccuticals therapy paticnts (thousands)

600

65

21

-700

Diagnostic medical x-ray cxarninatiom (docs no( include dental x-ray cxaminations): number of ccxlntries and population in sample: level I: 3 (935 million= 68% o i entire level 1 population); level 11: 8 (2,062 millim = 78%); lcvcl UI: 9 (175 million = 215); lcvcl TV: 1 (7.1 millim = 1.55).
Number of countriu and population in sample: levcl 1: 19 (634 million = 47% d entire population o r Icvcl I muntries); levcl II: 10 (2065 millroo = 79%);
lcvel In: 4 (171 million = 20%); level IV: 1 (50 million = 11%).
Because ~TinconsistcnciwIn data reputed in TaMc 3 (i.e. numbcr or separate trcalmcnts or d ecatcd patients), the data d the UNSCEhR 1988 Reparc [UI]
have been used.
Number d countria and population in samplc: lcvel I: 16 (181 millim = 13% of entire In2cl population); level 11: 6 (1.940 million = 74%); llcvel In: 5(133 million = 16%). It is assumed that the unknmn frqucncy in level IV countriu is lower than the frqucncy in levcl rU c w n t r i a .
Absdute r a l u u refer to 1990.

Tnhlc 5
Con~pnrlsonof elT'ccUvc dose and efreclivc dmc equivnlcnl

R a ~ bo f f l a - t i ~ udare to flccri\r dare c~ivalciU(EIIIE) as rcpwted bykinnunuion[/136/

P-221

I

lsJJl

P 71

lL21

lrt28l

Di.gnalic x-ray ersminstionn

AP

Chest

PA
LAT

AP

Skull

PA
IAT

0.794.90
0.85-0.92
0.65-0.76

0.99
0.76

0.38-0.43
0.2843 1
0.24-0.27

0.67
0.59
0.55

Ribs

0.83
0.83

0.51
0.75

0.80

0.62
1.27

T h a a a c rpinc AJ
IAT

0.86-1.15
0.85

AP

Lumbar spine

1.36.1.40

M

Atdanen

PA
LAT

G.I. tnd

1.01

o.n

IAT
Pcl\Ss1.11

1.00-1.20

0.60

1.80-210
0.68-1.10

1.0

0.66
1.43
1.00
0.94

Upper

1.20
1.14

Lwtr

1.05

Urogaphy (I.V.)
0.33

M m o ~ a P h ~

Head
Olut
Atdomco

CT

0.52
0.91
0.81
0.77

PCIM'KR u b of flccliru dare to flcclive dosc eqtiivale~(EIHd as repared by
Examinmion

Radwphmmnccuricd
IHj6l

1G2U

IG221

1J81

Nuclear medicine examinslion8
Brain

Tc-9% g i u m a t c

0.62

O r c b n l Mood flmv

Tc-9% m V A O
Tc-9% ECD
Tc-9% ,W 20

Bone

Tc-99m pyrophosphalc

0.74

0.74

Lvn/spleen

Tc-99m sulphur c d l a d

0.56

0.65

Biliary

Tc-99m I D A

0.63

0.76

n

0.94

0.61
0.91
0.78
1.01

0.73

Blood pd,muli~ga~edTc-9% erythrocytes

0.

Myocard~al

Tc-9% pyrophoaphate
Tc-99m Mml
Tc-9% \eboroxime
11-20] d o r i d c

0.74

O.E3

0.8 I

Lung

Tc-99m MAA

1.0

0.92

Ldncy

Tc-9% giucms~e

0.62

0.61

Inflammation

Gn67 atrate

0.83

0.86

Thyroid r u m

Tc-9% pcrtuhnetatc

1.1

1.1

Thyoid uptnkcES'Z

1-13] rc&m iodide
1-123sodium iodide

1.6
1.6

1.7
1.6

0.74
0.73
0.83

T ~ h l c6
Total annual n u n ~ b c rof dlrlgnmUc x-ray exemlnutlons per 1,000 populellon a
Data from UNSCUR Surwy o/ hfcdical Radiation Usage and Exposurcr
COIV~~~

1970-1979

1980-1 984

Counhy1985-1940

1970.1979

1980-1984

1985.1990

ncnlth-cam Icvd l
Awlralia
Belgium
Gnnh
Cuba
Gahlalwaha

490

SO
1290

860
1110

1020
140
1050

Denmark
FinlandFranccGcrmln Dan. Rep.
Gomany, Fed. Rep. of
Itlly
Japan
KuwaitLuxembcwg

1080
1100
860

840
1100

1050
620
920
510
870
990
1100
1030

740
1160
720
810

830

Malta
Nethnlandc
Ncw b l a n d
Naway
Pdrnd
P0nuga.I
Ronunia
Spain
SwedenSuiturland
USSR. R S E R
UnitdKingdan
Unitd States

Avarge

100

no
610

550
710
640

790

600

590
1040
950
420

820

1040
1020
460
790

810

320
530
640
610
660
700
470
90
520
990
800

690

ncailh-cam I C V11~
BubadmBrazil
mlc

180
170
110
210

China
Colanbia
Cork R i o
D a n i n i u n Rcpublic

160
93
150

EcuadorIndia
Irur (Islamic Rep. d)
Mcem
N~aragua

26

53
110
180
70
57

no

Pcru

13
IS

20

Turkey524

Avaagc

26

140

120

Ucsllh-crvr Icvd IU
BelizeIipc Vndc
Daninim
Ghana P I ]India [Ul]Liberia [UI]Myuunu

83
69
160

22
23
80

Philippine
Saint Lucia
Sri Lnb [Ul]SudanThailand
Vanuatu

110
130
21
.73

50

75

79
100

23

75

67

10
AverageU e n 1 t h - c . ~lcvd~ 1V

CMe d'lvoirc [Ul]k n y a [UI]

40

M

Dental x-my uaminatims no1 included

N~gaiaRuanda

25
8.0

8.8

Amage

n

8.8

UNSCEAR 1993 REPORT

280--

Chr.tr r x o r n i n ~ i o n ~C n v ~kar

RodiographyMassminiafwr

Fluor+
scrspyF~rrem.
;ria

GI wacr
Spine

Pehis

SkrN

,

AbdomrnryrroUpprr

New Zealand

1980-1984

130

40

0

I20

40

30

25

I5

Noruay1980-1984
1985-lW0

IZO
140

84
44

5.2
26

I -50
1 SO

38
35

46
55

6.3
4.0

8.0
7.5

22
13

Pdand

1985-1990

1.10

160

5.8

79

67

12

43

33

Rananin1910-1974
1980-1984
1985-1090

20
24

410
210
140

242
I91
115

36
36
44

27
8.1
10

9.3
9.2
13

24
12
21

Spain

lq85-1090

IS0

88

1M

18

Swrdcn1970-1974
1985-1990

120

65
55

22
21

1970-1974
1980-1984

160
1 .W

226
64

210
210

42

340

41

1975-1979
1980-1984
1985-1090

51
60
60

510
5W
570

165
110
45

84
R7
96

United Kingdom

1975-1979
1980-1984

1-10
1.50

26
12

Unilcd Sbtn

1980-1984

280

Swilznland

CJSSR, RSFSR

IM
180

Ill

Cholr-

LOHW

graphy(Jrb

An~io-

M-

Kraphyxraphy

F

0th~

Y

CT

(ucrpr
ddal)

270

5.0

35

Ill
9.2

3.O
0.40

20
12

0.0
5.8

2.5
18

10.0
24

16
80

35

19

11

9.2

0

037

1 .O

61

2.0
4.9
6.6

11
57
51

4.8
16
12

12
5.0
4

5.3
3.1
8.2

1.7

1.7

0.06

20
16

I8

52

29

15

21

13

41

35
43

44
15

12
7.7

30
12

16
13

18
5

23

3.1
46

II

94
1 5(1

36
57

69
77

12
21

46
25

13
13

28
19

30
25

8.I
8.8
9.2

9.1

II
II

24
27
26

2.3
3.6
5.5

40
44
40

4.9
5.4
5.5

5.5
8.6
16

4.4
7.5
13

1 10
l I0

18
20

32
36

31
35

17
19

10
12

5.9
6.8

6.1
5.9

6.9
10

200

93

21

36

35

33

22

I5

18

23

4.4

2.0

0.3 1

7.7

4.2

2.0

14

14

1.2
0.24

46
57
79

1 .O
1.8
1.3
3.6
2.5

0.9
4.0

13
4.7

27
38

5.7

14.5

19

1.2

1.4

ncslth<arc Irvcl I1
Bnrhndos

1985.1990

30

47

!8

Bradl

1985-1990

25

29

9.3

China

1960-1984
1985-1990

5.9
12

0
26

74
64

7.7

II

1.7
1.9

0.4
1.3

1.5
0

14
11

2.217
4.6

0.453
1.4

0.292
0.40

0.057
0.30

030

1970.1974
1985-1990

5.9
15

3.2
0

1.5
3.6

3.3
5.6

1.7
2.9

2.7
4.6

23
3.9

4.1
7.1

0.58
2.2

0.34
1.2

0.14
0.8

0.21
1.3

2.5

1985.1990

54

0

0

17

6

4.3

5.3

3.0

2.3

1.1

7.4

0.4

0.2

Erunda

India

9.5

11
8.9

0.12

3.7
6.2
10

0.08

0.07
0.55
7

5.0

n ~ ~ l h ICVCI- . ~nl
Drlize1985-1990

24

0

0

26

10

5.3

6.2

1.4

1.3

0

0

0

0.39

ANNM C: MEDICAL M D I A n O N EXPOSURE

283

Tnhlc R
Avcrn~cannut11numhcr of diagnostic x-ray cxnrnlnallons pcr 1,000 populaUon by health-care lcvcl

Data from UNSCEAR Surwy of hfedical Radiation Usage and Exposures
Aw a x e *kaminaim

Chert

Lrwl
I

Lo&

L d

n

nl-IV

I

n

11

413 r 234
3485 183
261 r 149

Lnel

M d i '~

Mron :
SD

Lnrl

LcwLr

Level

Lnrl

LC,&

111-IV

I

n

RI,N

11 '
BDd
46 + Y

17 + 1745
21 + 27

429
305
240

11
60
30

17
45
5.4

1970-1979
1980-1984
1985-1990

588
586
527

116

18
45
51

1970-1979
1980.1984
1985-1990

87
151
137

3.3
7.8
15

3.2
7.4
6.2

99 r 59
143 r 61
143 r 71

3.3 '7.7
22 r 17

3.0 r 23
7.4
8.7 r 14

82
142
138

3.3
7.7
17

7.4
1.5

Spine

1970-1979
1980-1984
1985-1990

25
58
61

1.7
1.7
3.9

1.9
5
2

2S r 1445 2 M
59 + 45

1.7
1.7
7.6 r 6.5

1.7 2 225.0 '21 r 3.3

23
39
9

1.7
1.7
5.7

1.7
5
0.3

Pelviship

1970-1979
1980-1964
1985-1990

22
31

0.9
1.5
2

'23 + 1441 2 28
40 r 30

27
0.4
3.9 r 3.7

0.5 r 0.5
1.5 '
1.4 + 1.9

20

38

27
0.44
3.4

27
0.4
4.3

0.5
1.5
0.3

1970-1979
1980-1984
1985.1990

13
37
46

23
1.5
5.8

1.8
3.4
3.7

42 + 26
38 + 2245 r 3523 '
5.9 2 4.4

1.6 z 2.0
3.4
2 2 r 26

35

1.46

23
1.46 .
5.3

3.4
1

1970-1979
1960-1964
1985-1990

15

4.1
14
7.9

4.7
6.5
3.4

1 1 + 7.8
16 r 9.928 2 224.1 '14
8.9 2 9.1

23 r 33
6.5 '26 z 3.2

12

22

15
19

4.1
14
7.1

23
6J
0.6

0.92
27
5

1.6
26
1.8

59 = 3944 2 3944 2 ?o0.9 c
27
5.1 +- 1.5

1.3 2 0.9
26 '0.7 r 1.1

42
46
33

0.9
27
6

1.3
26
0.3

1.2
26
22

25 2 16
28: 1218 r 90.5'
0.3
3.9 r 28

1.1 + 1.3
26 '1.0 r 1.4

20
26
16

0.4
0.3
3.7

1.1
26
0.3

0

Earcmilio

Skull

Momen

G.I.tracti9m-1979
1980-1984
1985-1990

36

n
51
72

80

38
30

M
34

3

1.6

Llrognphy.
cholec~toP P ~ Y

197001979
1980-1984
1985-1990

2E

26

0.48
0.35
27

Angiography

1970-1979
1980-1984
1985-1990

1.6
5.7
7.1

0
0
0.27

0.3
0.3
0.11

21 2.2
5.1 2 3.1
5.8 4.9=Oc0
0.7 + 1.0

0.2 r 0.2
0.3 '0.M r 0.12

1.4
4.2
4.4

0
0.3

0.2
0.3
0

Mammography

1970-1979
1980-1984
1985-1990

5.2
4.6
14

0.07
0.09
0.57

0.12
0.2
0.07

4.4r 8.9
5.1 + 3.4
17 + 17

0.07
0.M
0.3 t 0.5

0.06 + 0.09
0.2
0.04 r 0.12

1
4.4
12

0.07
0.M
0

0.06
0.2
0

Computedtaography

1970-1979
1960-1964
1985.1990

6.1
11
44

0
0
0 42

0.14
1.3
0.42

28 r 3.1
8.7 r 4.2
22 r 2300
0.9 2 0.9

0.07 + 0.10
1.3 '0.3 r 0.8

1.3
9.9
14

0
0
0.4

0.M
1.3
0

Taal

1970-1980
1980-1985
1965-1990

814
804
887

26
141
124

29
75
64

737 r 286
738 :267
755 + 247

26
151 r 80
136 z 167

36 r 2275 '82 + 52

606
744
696

26
173
99

32
75
81

19

" Overall average: tdal number of examinat~omdivided by the total populalion of countries (~houands).
Mean a m d a n d individual values of countries.
Dntn from E a a d a only.
Data Irw Olina only (except tdal).
Data hom Thailand only.

UNSCMR 1993 EPOK'I'

284

i'Tnblc 9

Agc- and s c x - d l s t r i b u l i o n of p i t i c n l s u n d e r g o i n g x-ray e u ~ r n l n ~ ~ l l o n1985-1990s,
Data /ram UNSCMR Suney 01hfedical Radiotion Usage and Fspo.cures

S a duniburion (5)Age dirniburion (Ti)

Iledth-cmc
lmrl

cowhy

&I5 ycms

1-5-40p a r s>40 years

Male

Femdc

68
58
74
72
57
78
63

51
55
53
52
52
54

49
45
47
48
48
46

M

44

55

n

45
43
43
51
43

52

48

Chr11 r d i o g r a p h yIAwlrdir
Grchalwaba
Germany, Fat. Rcp, of
Japnn
Kuwai I

Netherlands

II

UI

New Zulnnd
Pdand
Ranania
Spin
SwcdcnSuilzcrland
USSR. RSFSR
U n i l d Kingdom

22
31
21
22
37
16
24

10
11
5
6
6.9
5.6
13

U

.57
57

8.5
4.6
8
13
6

31
21
16
31
24
24

35
69
80
61
63
70

Avnrgc

6%

23%

69%

53%

47%

China
h d a
India
Jamaica

13
8.2
28
7.6

45
57
38

M

30

63
59
63
49
60

37

Turkey

43
35
34
43
40

A\nage

20%

42%

394

63%

375

Djibti
MyanmarPhilippincs

32
10

33
M
37

52

12

35
40
50

$I

48
40
44

Abrragr

11%

4b%

42%

58%

42%

53
51
55
56
55

47
49
45

50

49

W

41

37
51

40

Cheat photdluoropraphyI

nr

Aurtralia
Japan
KuuaitPolandRomania
USSR (RSFSR)
Yugorlavia

9.5
7.7
19

14
47
46

76
45
35

5.6
6
0

71

23

SO

4.1

35

65

55

45

Avnagc

72

48 5

46%

53%

47%

hiylnmu
Philippines

3
4

37
58

60
36

54
45

46
55

A\nag+

45

49%

47%

49%

515;

82

n

47
56

59
53
52

43
41
47
48

ch-I

I

0

UI

44

45

~ U O ~ I C O ~ Y

Nc~hnlands
PolandHwnanir
Sviunland
USSR. R S K R
Yugodabia

3.9
IS
10
2
17

33

50

50

50

Avcrngc

5%

33%

62%

55%

455

Chrm
Twkcy

20
5

53
65

27
30

57
50

43

Arcrage

19%

54%

27%

57%

43%

Phil~pp~ner
Vrnua~

35
27

23
45

46

56

44

28

59

41

Average

355

3%

46%

S6%

44%

14
38
34
34

M

50

ANNEX C: MEDICAL RADIATION MPOSUKLS-

285

Tnhlc 9 (con~inucd)
Age rlisniburim (9EJ

Iledlh-rmc
lo,elScr dimiburion (4E)

coun 00-15 ycms

1 6 4 0 )YWS

> I 0 yews

Molc

Fcmole

41
37

50

-W

59
-50
50
51
52

41
50
50
49
46

56

44

53
58
46
58

47
42
42

53
50

47
50

52%

4.8%

Erhrni~irs

1

U

Dl

Australia
Gcchralwalda
Gcnnany. Fd.Rcp, ofJapan
KuwaitNetherlands
New Zealand
PolandRomania
SwedenSwiecrlnd
USSR, RSFSR
United &ngdan
Yugoslavia

22
17
11
22

37

46
33
19
45
43
47

3
20
26

25

M
69
32
37
27
38

15
22
15
21
17

37
27
39
33
50
33

Average

18%

32%

52%

China
EcuadaIndia
Jamaica
Turkey

19
6.5
25

50
50
48

32
43
28

25

55

Avcrag:22%

M yanrnar

P

Philippines
Vanuatun

Average

n

38
52
29
50

5.i

64

M
24
29

u)

76
71
52
65

49%

30%

67%

33%

26

40
47
60

36
25
13

68
69
70

32
32
30

'JR

44%

30%

695;

32%

37
33
49
46
34
38
35
40

49

48

51
47
46
51
46
52

M

44

SB
51
54
52
45

42

48

45

Skull

I

U

m

Autralia
Gcchasiovakia
Germany, Fed. Rcp. ofJapan
Kuu,aitNetherlands
Ncw ZlalandtiawayPolandRomania
Spain
SwedcnSwitzerland
USSR. RSFSR
United K i n g d m
Yugoslawa

22
17
16
74
22
22
24
16

41
50
33
30

16
19
8.4
19
15
21
6.3

42
35
36
43
40
25

53
38
41
39
69

Avenge

195

372

Emda
India
Turkey

29
22

56

rn

Average

44

41
41
44

41

42

41

53
52
49
52

Y
52

49
46

4.8
55
46

60

48
40

44%

510

49F;

56
68

44

40

41
19
40

60

32
40

22%

58%

21%

675

33 %

Djibouti
MyanmarPhilippines
Vanuatu

19
39
24
16

34

37
19
27

30

52
70
63
62

48

42
50
54

Average

301

47%

24 %

66%

34 %

61
65

44
50

M

64

46

64

56

59

30
37
38

Lurnbc~nscnlspineI

Aus~ralia
Gcchoslovalda
Gcrmany. Fad. Rep. of
Japan

3.3
3.9
4
1.2

36
31
32
35

50
N
44

UNSCMR 1993 REPORT

286

Tnhle 9 (mnlinucd)

1 I ~ d l h - c ~ ~lor1I(continued)

I1

Ate diswiburion 19E)
0 1 5 ycms

16-40 )mars.JO years

Male

F d e

8.4
5.9
5.4
1 .5

45
40
40
39

47

44
49
51
47

%

M
4.2
3.2
4
9

55
67
49
62
54
63

50

50
50

43

Sl

50

50

46
40

54

13

41
30
47
39
38
25

Average

6%

36%

611

50%

50%

chi^

46
56
48
M

47
40
47
35

58

Turkey

7.2
4
5.3
IS

64
62
60

42
36
38
40

Amage

7%

47%

47%

60%

40%

DjibardMpma~
Philippines
Vanua~

12
7.2
15
7.4

38
39
42
52

50
53
43
41

44

55
62
59

56
45
38
41

Avaagc

12%

41%

474

59%

411

38
52
49
46
40
38
42
43
47
35

62
48
51
54
60
62
58

M

50

40
20

60
80

Kwit
Netherim&
New b l a n d
Noury
P d andRormnia
Swedm
Suillnlrnd
USSR, RSFSR
United h n g d u n
Yugodavia

'

h d a
India

[U

Sa dutribwion (96)

covlw

'

8

54
55
59

51
49
53

60

PelvisI

11

n1

Aurtrdia
Crcthcriovakia
Germany, Fad. Rep. of
Jopln
h
it
h'cChal~&Nctu Zealand
Romania
Spain
Swedm
Suillnlmd
USSR. RSFSR
United h n g d a n
Yugorlaws

14
11
5
3.5
1s
17
19
33
15
3.6
20
7
14
25

26
29
15
17
31
17
25
34
25
11
25
41
30
38

61
60
80
79

Average

9%

27%

64%

44%

36%

Ou na
h d a
India
Turkey

58

10
16
15

65
M
50

25
34
35

40
68
50

42
60
32
50

Amage

16%

SO%

34%

62%

38%

Mpnw
Philippines
Vmuatu

9.4
17
20

M

61

37
20

52
52
48

48

46
60

Awage

141

39%

47%

52%

75
9
87
51
63

38
43
52
43
41

66
58

38

62

54

46

42
81
58

n

43
65
47

54

66
55
34
61
85
5s
52
56
60

n
53
65

48

52
.

485

nipllcmur

I

Australia
Gschalovakia
Germany, Fad. Rcp. of
Japan
Kwit
Ncchulands
New b l a n d

4

Swtdm

24
14
17
19
21
12

Suiuallnd

6

RUNN~

L

11
87

14
4
9
25
P
17
23
37
7.7
33

35
53

62

n
48
9
59

ANNEX C: MEDICAL RADIATION MPOSUHES

287

Tnblc 9 (conlinucd)
Alc dimibwim fi)

Ilcdrh-cmc
lnrl

I(continued)nIll

Sn distribution (%)

covlrry
0.15 ycms

1640 years>40 years

Mole

Fadr

USSR, RSFSR
United k n g d a n
Yugcularia

28
IS
17

23
32
33

49
53
50

42

58

M

50

Average

21k

23%

56%

452

555

k d o
bdia
Turkey

16
16
15

9
50

26

42

SR

34

68

40

45

55

32
45

Average

16%

494

35%

674

33%

Djibouti
MyanPhilippines
Vanuatu

30
16
19
29

45
30
45
47

23
54
37
24

51
5-3
61
66

49
47
39
34

Average

18%

39%

44%

565

42%

53
53
41
54
43
9
49
47
54
54
52
47

47
47
59
46
fl
47
51

Abdomen
I

10
8.6
8
8.2
11
6.1
13
17

24
27
24
24
38
23
2
31

66
64
68
68
51
71
59
53

15
11
11
4
17
10
5.9

36
39
17
31
20
27
35

48
51
65
63
63
59

54

46
46
53
46

44

%

M

50

Average

11%

T%

632

50%

50%

Emado
India
Junaia
Tukey

4.9
16

39
45

M

55

45

39

30

30

40

64
46
50

52
50

Average

17%

44%

39%

63%

375

Djibouti
MyanmarPhilippines
Vanuatu

25
17
19
10

40
39
45
66

35
44
36
23

42
51
50
35

58
49
50
65

Average

18%

43k

39%

50%

33%

79

40
52
41
2
49
51
50
45

60
48

Australia
Qtchcslda
Germany, Fed. Rep. ofJapan

Kunai I
Nclhulands
New Zealand
Nauay
PolandRomania
Spain
swcdm
Switzerland
USSR, RSWR
Uni~edKingdan
Yugdavia

U

U1

n

a
46

M

Upper GI tract

I

Australia
Crechcslovakia
Gamany. Fed. Rep. ofJapan
KuwaitNethalands
New b l a n d
Noway
PolandRomania
Spain
SwedenSuiwldUSSR, RSFSR
United k n @ m
Yugorlavia

1.4
1.2
4
0.7
1.6
3
5.1
0.5

20
35
21
24
43
29
30
33

8.9
5
1.8
2
4
2
0

39
28
17
40
28
30
33

52
67
81
S8
68
68
67

52
51
45
3

48

49
50

51

Avuage

3%

27%

10%

$95

51%

64

75
76
%

69
66
66

47

59
47
51
49
50
55
53
49
55
42

50
A

UNSCMR 1993 REPORT

288

Tnhle 9 (continued)

Agc dimibufim (%)

Ilcalih-rcp-c
Imrl

I1

111

Scr dLRiburion /%Jcolurrr).

0-15 y e m s

16-40 yews

>JO ycnrs

hfalc

Fcmde

China
Ewdo
lndia
Jamaica
Turksy

5.4
10
11

46
60

49

57

M

45

45

43
67
31
55

IS

50

35

33
69
45
60

40

Abnagc

6%

46%

474

6256

38%

MyanmarPhilippinw
Vanuatu

5.5
10
9.1

41

54
44
55

54

46

46
36

60

52

40
48

Avcragc

8%

44%

48%

57%

43%

42
44
52
46
40
41
38

56
56

h w r r GI Lrnd

I

Ausealia
Crcchmlwakia
Gcrmmy, F d . Rep. ofJapan
KuwaitNcthulanh
New ZcalandNau-ay

4
25
0.5
1.9
7.2
22
0.6
0.2

30
16
6
13

20
24
Z?
24

66

81
94
85
65
74
78
76

Pdand

n

m

RomaniaSpain
Su*cden
Suitzaland
USSR, RSFSR
United Kngdan
Yugoslavia

16
4
3.4
1
1
1
0

Avcragc

olim
Ecuada

14
22

51
71
82
76
74
85
78

2%

19%
46

India

5.4
9.9
7.2

Jamaica
Twkcy

33
2s

15
23

25

48
54

60
59

62

46

54

48
42
40

52
58
60
50

50
39

50

61
50

79%

46%

54 4

n

43

60
28

49
30
65

43
76
36

n

10

40

50

50

50

Avcragc

6 2

39%

55%

64%

36%

Mpmar
Philipinw
Vanuatu

3
13
17

48
50

49
59
33

58
55
60

42
45
40

Average

9%

37%

554

56%

4%

24
34
59
30
37
33

29

24
64

Cholrcnbgraphy

I

II

Autrilia
Crechalwakia
Germany. F d . Rep.
Japan
Kusai tSctkrlanb
New ZealandNcruayPolandRomania
Swcdm
Suitzcrland
USSR. RSFSR
Unitd Kngdan
Yugdavia

0.5
0.7
1
0
0.4
0
1.7
0

33
29
12
21
44
20
38
22

67
70
87
79
55
80
61
78

0.8
0.3
1
3
0.5
0

40

24
36
30
19
20

59
76
63
67
81
80

29
38
37
38

76
66
41
70
63
67
65
71
62
63
62

30
90

70
10

Avcragc

1%

24 5

75%

44%

56%

h d a
Ind~s
TwLy

1
14
2

80
18

66
60

34

20

19
68
70

30

40
70

Avcragc

13%

19%

681

58%

42%

35

ANNFX C: h4EDICfi M D I A I O N MPOSURES

289

Tablr 9 (conlinucd)

Age disrrihutim (%)

Ilrdrh-ra-c
Inrl

111

S a dirnibution (5)-counm
0-15 ycms

16-40 )rars>40 ycars

.Vale

Fcmdc

Myanmat
Philippines

0.9
7.6

55
61

44

50
53

50

32

Avcragc

5%

58%

37%

52%

48%

62
66
76
67
44
63
52
65

51
51
54
55
55
50
49
51
46
47
56

49
49
46
45
45
50
51
49
54
53
4.

47

-

U~R'~P~YI

nnl

Auslrnlia
Gcchalwalia
Germany, Fed. Rep. ofJapan
Kuwai 1
Ncrhalands
New k l a n dNaurayPolvrdRomaniaSpain
swcdcnSwirrcrland
USSR, RSFSR
United Klngdcm
Yugdlria

9
4.3
5
8.3
I5
11
17
3.5

29
30
19
24
41

5.2
3.1
9.7
27
7
9
0

37
35

Abua gc
Emda
India
Jamaica
Turkey

n
31
31

79

43
21

35
21
13

58
62
70
35
58
70
87

68
100

32
0

7%

28%

651

5l%

43%

18
19

45
48

36
33

45

10

50

40

47
55

55
16
53
45

Avcragc

18%

48%

34%

81%

19%

MyanmarPhilippines
Vanua~u

2

46
39
59

52
48
35

52
64
65

46

13
5.9

36
35

Avengc

8%

42%

50%

59%

41%

58
58

36
5.9
21

89
81
87
73
62
94
79

29
29
4

46

51

2)
22

n

67
49

42
42
41
53
47
37
46
52
33
51

74

Avcragc

2%

21%

77%

532

472

EcuadaIndia
Turkey

I5
17
5

50

35
50
60

72

33
35

55

28
10
45

Avcrage

16%

33%

50%

87%

13%

MyanmuPhil~ppinu

11

45

M

34

45

60
68

40

?1

Avcragc

172

39%

452

65%

35%

0
1.7
0
0

100
983
100
1W

20
38

n

84

Angiogrephy

I

n

DI

Austnlir
Crcchoslwatia
Germany. Fad. Rep. ofJapan
Kuwair
Ncrhcrlands
Kcw h l a n dPolandRomania
Sweden
USSR, RSFSR

1.7
1.6
J

0.2
1.9
0
0

6.9
18
9

t7

59

47
53
63

54
46

W

32

htsmmnprsphy

I

Australia
Crechalwatia
Gcrmany. Fed. Rcp. ofJapan
Kuwvil

0.1
0
0
0
0

30
35
27
51

70
65
75
49

44

56

'I'ublc 9 (continued)

A K distiburiat~(96)

Ilcdrh-cmc
lnrl

I(continued)m

Scr diruibvrwn (5)covlnyFemale&IS yea-s

1640 yars>40 y e w s

Malt

Ncthnlanlk
Ncw h l n n dNawy
Romania
Spun
SwedcnUSSR. RSFSR
United k n g d a n
Yugorlavia

0
0
0
0.3

28

0
0
0
0

25
58
37
8.9
25
0
44

72
75
75
42
62
91
75
100

1
0
0.3
0
0.6
0.2

99.7
100
W .4
W.8

56

0
0

100
100

Avaagc

0.10%

32%

68%

0.41%

99.59%

MpnrmrPhilippinu

0
0

40
11

60
89

0
0.5

WJ

Avcrage

05;

23%

n%

0.29%

99.71%

66
58
79
80
49
69
62
67

46

Y

52

1.2

P

W
100

100

Computed Lornogmphy

4.5
8.9
7
5
5.4
5.8
12
6.1

30
33
14
IS
45
2S
26

7.4
6.8

39
21

54

67

n

9

48
52
45
49
47
47
47
44
33
47

6
1
10

27

50

50

30

67
76
60

52
40

60

Avrrage

62

22%

73%

52%

48%

n

T W ~ Y

30

30

40

50

50

m

Mr-

.I

40

M

52

48

I

Australia
Gcchslovabr
Gemmy, Fed. Rep. of
Japm

Kwir
Nahalandt
New U a n d
N-Y
Pdrod
Ronunia
SwulcnUnited Kingdun
HadMY
Yugdavia

n

48
55
51
53

53
53
56

23

48

The entries In l h i ~Table arc q d i f i e d a&follow:

Chino:
Djitnnui:Gemany, Fcd. Rtp. of:
J&n:

hfy-:
R0man;n:5-rdm:
SwicalMd:

Tw*:
Unirad f f i ~ d o n r :Y u ~ ~ a ~ i n . ~Data arc f a Bcijing 1 r u d y ( a b u t 3% d the population).
Data from l ~ t i t u r cP. P a l a l only.
h t a arc from hospit.11 only.
Data arc from IGnptoo H c q ~ i b lmly.
Data arc from Gyangcm Gcnml Hospital d y .
Data arc f a 1990.
Data arc f a StocLhdm caJnly d y ( a h 1 W m of h e population): age distribution: 0-14yura, 15-39 yeon, 4 0 y w r .
h t a arc f a 1982.
Valua arc estimated f r a n urnplc d 1% d h c poplarion.
Data arc f a 1981-1985.c r c q f a nvmmogaphy m d ccmputd ranogaphy.
Data arc f a Scrba only ( a h 1 40% d h e popdabon).

Tlahle 1 0
E n t n ~ n ms~~rftlce
dtaes nrld clTecUve d w e cqulvnlents to paUenk undergoing dlt~gnostlcx-my exnmlnntions a

Doro from UNSCEAR Survcy o/ Afcdicol Rodiarion Usage ond Exposures unless orhem,ise indicatedChul aaminnrr'ons
CarnfryDoscpwylfiryRadioilrofiyPhoto.
lluwotraphy

Mlmmo-

G I bacf

.

Year

Emc-

Skull

Flvcro-Lv&

Prlbissmal

1 hiprAMomcnspine

JCW

Chalc-

Ur*

Angio-p&y

CTgraphypophy

Scrrrnin~(slierklinirnl

daru)

-122
(7-35)

30(15.55)-114(0.4-58)60(20-550)

Uppo

LOU-

rydotrophy

55(4-10)

6.5(4.10)

28

57(4671)
40(8-126)

I i c n 1 l h - u ~Irvrl I
Argentina

EFD

1985-1989

0.65(0.315)

6.5(4.12)

Australia

ESD

1970-1974

2.6

1.4(0.1-16)

1985-1989

CanadaGcchoslo~kia

FSD
ESD

1985-1989
1970.1974
3986-3990

0.4(0.1-15)

3
(1.5)

2
(1-3)

30
(20-45)1.31 8(0.8-15)

4
(3.7)

8
(1.5-20)8(1.5-20)3

17(0.1-92)
3.6
(2-5)

63
(0.7-348)
28(10-90)9.8111(0.1-99)
4.0 14.4(0.7014)11(0.2-88)7.0(1.2-25)

25(5.360)24

9.4(8.7-101)

3.1(5 2.1)

2.2

3.0(5 2.1)15(0.2-41)2.3(0.6-4.2)(8.3-109)
18

0.13

0.14

0.84

(2 0.07)(: 0.40)12(2 5 3

3.6 1 1.6

( z 0.10)

2.5(0.2-40)1.5(0.2-3s)9(3-46)
8(34.7)

31(5-150)26(4-130)13 1 12(2.8-715)lWl0(3-59)

9(4-30)
8(4-29)

14(3-280)12(3.260)20(3-100)18(3-98)

11(2-30)
10(2-30)

14(3-100)12(3-97)

0.4
0.5

2.9
3.1

1.9
1.9

2.9
2.8

4.5
2.5

127
7.7

1.9
1.9

3
3

95 1
9.51-

42
(880)

( 1-200)

0.5(0.5-29)0.45(0.05-28)

6.1(0.7-39)6(0.6-38)

IfE

1976.1980
1986-1990

0.07
0.07

0.7
0.7

FSD

1978

1.2 '
(0.3-5.7)
0.27

1.7(0.9-3.6)

2.3( 2 1.0)(0.M4d)3.1(1.0-8.0)

60 '(8.90)
8(3-30)

1978
1988

0.2 1
0.05

0.01

7.6
1.O

HE

1982

0.3

1.4

4.7

l .G

2.6

6.7

10

7.2

10

Garnany,
Fad. Rep. of

ESD

1989-1991

0.18(0. W-20)

3.7(1.9-18)I8(9.0-130)3.7(2.0-36)

4.0(2.061)2.4(1.3-3.7)

2.0(0.8-33)

5.0(3.0-82)

2.4(2.0-73)

Ihly(wrlh.cnrl)(P19, Ul]

ESD

1983

Rnland

1988

IIE
France (1111

FSD

'

ESD '

I983
1983

5
(34)

0.12
C'J.wlJ

0.5

2.6(+ 0.7)(2 0.9)1.3(2 1 ~ 7 )2.7(2 2.8)'4.6(2 2.9)4.1(2 2.9)2.6(t 1.9)290(55-1400)

9.5

10.613.7( Z 8.3)(2 lrdn.7)

28.3(+ 24.9)(2-n.7)-14.3

300(100800)
4a)(lP-800)

60/37(-1145)20

5(1-20)

631(2-14)

0.9 1

1.01.

6.6

5.5-5.8(2 3.1)( t 2A1.7)

8.1(2 4.7)(I 4 6 6 6 )6.9-9.2

Chur crominnfion~
Carnfry

Dose

Year

quMIi4'

H~

1983

ESD

1970-1974

llrly

G I nocr.
Radio-

Photo-

Flumo-

baphy/luoroffoph?/

sCV.V

0.18

0.25

Fsrrcmiries

W l

L u b
s x r lPel&
I hips

2.5

3.5
10

5.3

0.30.90.09
0.05

1.5-1.6
0.60

2.310.9

Cholccysr~

r

An&

rev

grey

grophySrrcoling

Uppa

Lo-a

1.9

9.3

9.0

7.1

3.6

3.5
46

4.3
72

3.0

13-14
1.2
2.7

1.0-1.2
2.0
3.0

spine

0.22

Mnmmo-

Abdomen/clinical

graphyCT(sliccdm-)*(untinuai)

Japan

2.3 f
(% 0.38)

HE

1.7 f

1985-1989
1989

0.52

1976-1080
19R6
19RO

0.10
0.05
O M

0.30

0.12

0.25

0.29

1Cuwa11

ESD

1985.1989

0.43
I0.m.l.o)

0.033(0.03.O.(M)

4.2
3.0 12.8
2.2
0.15
2.4
(1.8.2.S) (0.01-0.29 (0.7-4.7) (2.1-5.7) (143.9)

New 7raland

LSD

1983-1984

0.83(0.02-47)

0.6(0.2-1.8)

9.5 15.9
5.6
33
0.62
(0.01.~) (0.13-39) (0.01-31) (0.01.242)

Fit

IORI-IOU5

0.1 I

0.10

Norway

H~

1988

0.15

PolandESD

1985-1989

1.5

PortugalED'l989.1WO

0.41(0.m-4.2)

ESD

1980
1990

6.3
2.4
(1.58)

8.3
5.9(3.9-15)

9.7
13(6.6-27)24
20(6.4-35)62
53(21-82)30R6
W 19(43-60)18
19(11-36)46
55(18-162)

1980
1WO

0.50
0.23

0.72
0.66

0.74
1.0

0.1 1
0.12

24
1.9

3.111.6
2.711.3

1.1
1.4

3.4

5.2

1986-1990

1.0(0.2.1.0)

39(15-50)

19
(740)

I2
(6-20)

2.1

2.0

1.2

5.5

9.7

[a,
SsZ]
Ranania

IIE
Spain

ESD

t

1970.1974

0.30(0.19-0.40)

1085-1989(0.01.1.0)

0.3

0.23
6.0

10

1 .O

IS

6.7
0.9
(0.1-1.8)' (2-1s)
0.10

1 .O
(O.Sl.3.1)

0.14
0.97

-

9.0
(o.cn.l~a)36

41

1.1m.8

0.7

7.2

I3

1.6

0.7 1 0.4

0.9

2.515

6.41 10

22

15.9

42

8.0

0.55

2.9

0.6
0.70
0.5-6.9

0.4

3(1.519)70(32-128)29 1

9(0.4-26)

32-78(28-48)

0.5

0.5

2, 12

2.9
2.1
(1.4-3.8) (1.0-4.3)

10
9.6(0.01-39) (0.51-71)
1.8
2.6
28

II
7.0
(0.76-31)

6.1(0.80-14)

1.U1.7
5.9( I ) (OS'-ZO)
0.6410.86
0.19
0.08
2.4
(O.OrO.20) (0.17-0.20) (034.4)
0.29

U-32

2.3
2.8
(0.8-3.0) ( 6 3 8 )

1.4

9.6
7.9
0.82
(0.98-14) (0.65-28) (1.8-31)

0.29

H~
Swedrn-0.0013.8
2.3(2.0-4.3) (0.8-3.0)

1.6

TI(26-92)

3.0

4.4
(1.6)
1.8
4.6
(0.47-3.9) (0.M-17)

8.6(5.3-13)6.1(1.0.27)70(12-231)3540(2058)

71
48(28-91)

21(13-33)12
18(11-27)

1.3
1.4

4.3
35

0.15

1.3
1.9

6.7
1.3
(OJ7.l.')0.86(".26z1)

7.3(5.1-7.3)
3.6(0.21-14)

11.2

3.8

9.7
5

Tahle 10 (mntinued)

Dorc

I'cnr

4yd"fi'Y

RadiovofiyMammn-

GI martC k r aamindionscc."wPhoco-

Fluwo-/luwornphY

SCVY

Exhemirier

1Lu&srrrol

PclYir
1 hiprAbdomen

spine

UPF

Low%T

Chale-

Url~

pa&

CT

we

An*

v
L
1
P
h
Y

drDPky*-x(ficc

kliniral

dma)

F&Y

*

Utdlh-care lcvcl UIMyanmar-Thniland

ESD

1970-1980
1981-1985
1986-1990

0.7
0.80
0.32

3.6
3.5
2.9

0.26
0.24
0.23

3.7
3.5
2.9

4.7
4.0
3.9

3.8 13.8
3.3 / 3.5
2.9 1 3.0

4.7
3.7
3.3

3.4
3.3
2.8

4.0
3.4
3.0

3.4
3.3
3.0

4.2
3.7
3.3

4.2
3.9
3.8

10.65
10.60
10.55

HE

1976-1980
1981-1985
1986-1990

0.039
0.040
0.016

0.18
0.18
0.14

0.003
0.002
0.002

0.035
0.035
0.029

0.045
0.040
0.039

0.036
0.035
0.029n.m

0.23
0.19
0.16

0.4 1
0.40
0.34

0.43
0.4 1
0.35

0.17
0.17
0.15

0.22
0.19
0.17

0.21
0.20
0.19

1 0.0310.03
1 0.030.07(0.Mb.l)

4.1(3.5-3.7)
2.4(2.2-2.5)

3.2 12.5(2.3.35)

4.2(3.9-4.5)
2.6(2.5.2.6)

3.1(2.7-3.5)

4.9(4.7-5.1)
2.9(2.8-3.0)

2.6(2.2-2.9)-

ESD

1976-1980

0.29(0.26433)

1986-1990

0.21(O.'7"90.09(0.08-0.09)

6.5(3.4-9.5)

2.8(2.4-3.1)

3.4(3.1-3.6)'Ihc cntria in this Table are qualified ar follows:
Aultrdin:Cmlodo:chino:'
1'

Valuc undn CT is fa skull C T only.
Dab are f a one Ottawa haspibl only.
Dab f a Bdjing area rcpraar 3% d the population; data for cntiic natim arc f a 1986-1990.
Dab arc also f r m [J 111.
Vduc for chat radiography induda fluoroscopy (20% d cxaminatims.)
Data arc also frrm [I332 R q .
Dab arc also fran p 4 , Ul).
Value unda lumbcsand is f a lumbar spine. Gastrantatinal mct ESDs rcfa to fluoroscopy
only. W~cns a i d and followup films arc addad, Ida1 ESD is 75 mGy f a uppcr GI and 99 mGy
f a Iowa GI tract. Valuc undn angiography is f a caonary carhctcrizadcn. liE f amammography 1976-1980. 1.6 mSv. 1986-1990. 0.6 mSv. ESD value unda CT is multiple
a v m g dosc to hcad f a amage years 1983-1984, to body f a range. IJE value f a CT is 2 forhad, 12 foc rbdomcn.
Valun unda GI ma are f a bariddcuHc contrast.

Pau:
Poland:Romania:
Spin:

SIucdol:

Thailand:urn (Wsry:
Unifcd Kingdom:

Data are from Institu~oPcruano dc Enn,ja Nudcar cmly ( b a ~ t60% of all cxaminationr).
Valuc unda abdomm is for fluamcopy.
Vducs unda CT arc, with the cxocptim of chc last cntry (E, 1990). f a k t .
Valua unda lumbosaaai are f a all spix cxaminatims.
Value unda l u m b a a d includa lumbar spine; value uoda angiography is f a m&d
examination
Data arc fran Natiwal Can= Institute d From h e Rajavirhi Hospital only.
Valua uada GI tna arc f a fluamcopy examinations.
Dab alrofiom [WZZ]. Entry unda angiography is f a lymphangiogrsphy only. Val- unda CT.
first vduc r d a s to head; s a d valuc to body.
Data also fran [Ul].Value unda mammogaphy is f a mostly saecning; range unda CT is
multiple-scan sbsabcd d m in a samplc d is o a conddacd statis~icallyrcprcunbtivl
Data arc for Sabia only (about 40% d !he populatim).

The cntram w f a a dou ( E D ) is givcn in mGy and the d a t i v e dose equivalent ( H 3 is given in mSv. Avnagc f a years as indicated and range in parcnlhacs.
Daa arc canpltcd tomography dose index (ClDI)a multiple-scan a m a p dose (MSAD).
PAprojcctim.
LAT pojcctim.
AP projection.
Cm\rrrred from entrancz surface exposure assuming that 1 mR = 0.008710.75 mGy ED. Applia also f a rang- whac g i v a
All but
Cmvcrtcd from energy imparced assuming Ihat 1 mJ caresponds lo 0.0143 mSv. CT data Iran [S58).
F a molt hajumt pmjcctioru.

ANNEX C: MEDICAL lUDlA"fl0N W P O S U R ~ S

295

Table 11
Average elTeclive dosc equivalent from dlagnoslic medical x-ray exan~inalions
Dora from UNSCMR Suruy of Afedical Radialion Usage and Exposures

A $ w a l r c/lcrtirr dnrr c q ~ h ~ o l c(nd
~ l1970-1979

1980-1990

1980-1990

0.25
0.52
0.72
0.02
22
21
1.5
0.50
1.9
9.8
8.9
1.9
3.0
9.2
1.8
1.3

0.14
0.52
0.98
0.M
1.7
1.2
0.92
0.16
1.1
4.1
7.2
1.5
3.1
6.8
1.0
4.3

0.OI

(hest radiagrrphy
Q l a t miniature
Qlest fluorcsccpy
Exvemitia
Lumtosaaal spinc
PclvistLp/fnnw
Skull
AMorncn
L m c r GI tract
Uppu GI tract
Qldccystcgraphy'-'r"Pphy
An6ogaph~
Mammography
Computed tomogaphy

L N ~nI

LCU~I~rnmin~tiart~i~c

I

0.29
0.03
26
20
20
0.13
0.22
5.0
1.6
1.6
1.7

Table 12
Factors of technique affecting doses to paUenk Trum x-ray exarninaUons[C26,D8,J12, L10, M21, NS, R4, R18, S13. S31,S53,SS6. S57,W14]
Fmror

Efccr
Pmdurr-mlmkd

Rcfcnal criteria
Availability d pfiiiarsly hkm f i l m
Numba of radiognphs p a cuminatim
Fluoolcopy time and cutrent
Quality assurance programmu, including rcpeaUrcjectn r c arvumeots and patient d a c survey6
X-my team mllimation
Shielding of sensitive orgrns
Qlcice d projection
Optical dauity d radiographs
Comprcvim of attenuating tiuuc
Matching exposure factors to patient stature

Slrisla critaia r e d u a p a s p u r d r a w by r m & n g d i n i a l l y unhdphtl ex~minationr
May eliminate s a n e r a a k a and thus r c d u a pa a p t dorcr
Pwtively c a c l a t d uith dracPoatively conelated with d ~ c
May reduce p n caput doArea pmitivcly correlated uih d a w
May reduce d o x a
DCK dcpcnda m pojcctim
Pmtivcly oardated with d a c
R e d u m d a e m d s a t t n and improves image quality
May reduce dmcs

Equipment-rcl.trd
F-xpaurc 6me
ti~lovoltage
X-my lube voltage w v e 4 o n n
X-ray lube target metal
Filtn typeAnlircatta griC
Distance (air gap)
Artmuation betpatient and image rcccpln
S a d ~ l mcunhnrtion
F ~ l mpromsing
Image intenifin
R t e a Q n g mdhod
Pulled f l u a a c q r y uith imagc storage device
S p a film fluaogaphy
G m p u l d ri&opphy

h g time, low current cunbirutions m y increase d a c due to reciprocity law failure
Highn Llovdtage may reduce d a c and contraat
T h r ~ p h a s eand omstant potcotial x-ray b u m s reduce d a c and cootnst
MdyMcnum m y increase d a c and contrast compared to tungstm
R a r e a r t h Kcdgc filtns a olhu 6 1 t a producing a bum oC highnhalf-mlue l a p rcduce d a e rrrd -rut
L n a o u dae and image quality
Adjustment f a i n a u u d m a p i f i a t i o n naninally i n a u a a dosetut m y d w obviate aced f a a gridLow anentalion (e.g. arbm f i h c couch top) reduca &u
Faster rare a n h aaccns reduce dose, s a n d m a also image quality
L m g pr-ing
tlmc or chcmialr and tanpnnture that inncane
rpeed d devdopmcnt reduce do=
Semitive (e.& GI)photoathoda and d i d d image proc-sing may rcduce d a c
to cine u m n a
Video r c u n d u redurn f l u a a m p y dose -pared
Reduca f l u a o c ~ p ydrwe
W ~ t hmodem cquipnent. may r d u a d a c mmpared to radiography
Potential f a rcduNon d d a c and of image quality

LS
61
EE

bt' 1

9Z
LZZ
El
6Z-E

Z

LO'O

80'0
I
I'0

z

6

TWO>

US

10.0,

U)VBL

vd ' I ~ I * P W v @ l l q n s%olwu ' r n ~ ~ ) w q n ~Vd 'IN'JPWw.3
l~w!1wrn3

EES-101

Vd 'lel@!P'w!PuqnS
dV 'l~l@!P'wFalrlnSd V 'IPUOPWm3
I-P-oD3

rCyd1~3osm~ow~

fZS'Z8V

vd 'I~F!P ' ~ P I ) = W S
Vd 'I-Qm'm3
INOQLU*~~WU'CQ‘W

S'UZ'O

8O'V 10'0'

1-2'0

01-9'0Z'O
Z
E'O
62-2'06'0
1
L0.0
6'Upo'OWO
2'0
2.0
61-2'062zZ'O62-2'01-80'0

9'1
Z
6-E

TI
6.1
E'VZ-0

68-09

1-60

ZE-LZ

I FEE

S- 10.0'
S

Z-IO.O>
Z

bZ
08

E-E'O
9

ZZ-OZ
LZ

01-E
6L

10'0'
I.VlO'O>LO'O
SO'O
Z I -M'O

2'0
E'&IO'O>

6'0
6'0

V
b 0.0

I
I

v.0
b'O

EO'O

Z€Z-IZ

02
EL-8'007.
EL-1'09
ZE-Z

6'0
VS-S'O

2.0

10'0>
PO'O

U)'O
E0'0

I

L
P
LWS

9'0
ZI
ZI-S

2'0
Z
LOI-Zt

(0'0
10'0
1-2'0

10'0
1'0
Z.O-U)'O

kMo

?J-J!

10'0'

I
9PS'O

10'0'

E'VZ'O

1 11-98

Z8V

50'0

PFIU

L-1'0

CL-OI

VI-2'0

ZS-L

tm>lg

E O J ~ ~Sun7

m o ~ ruoqnpa^

no1 >igU)S-VZxvat~,LE
ZoS
OCL-ZVII ~ @'l~tproqns
P
aolwr 'rwvuqng
I-P-oD3

19.4

ZWZ8Z

Vd 'l.l!%I
Vd 'I-PW'"3
IN09-l='3

P4am3

CkY)
2sop
awjms

WOp pqY)SQO ~061~0(@I)

6qdeGiorprm~~

vd 'IEI?!~ ' m p l q n s%olwu 'rntpenqns
Vd 'IWOP-"3JV 'IUUO!I~UAW~
INOPWOD3

Z' 0

I 1-ZO'O

Bolmt 'mpeoqns
INOPWm3'MPd

2INUUU~" " ! w q

A N N M C: MEDICAL RADIATION MPOSUKES

297-

Fxnminarion

Collerri~rf l e c r i ~ rdate c g r i ~ , a l e r'

Collerritu c/fccri~,c
dare

m Sv)
~

(m M 51)

1.80
0.71
0.59
0.34
0.60
0.61
269
5.82
8.33
7.09
7.16
7.18
4.P
5.81
3.01
3.60
7.26

1035 (235)
64.0 (1.9%)
19.6 (0.4%)
8.0 (0.25)
18.2 (0.4%)
5.9 (0.1%)
29.7 (0.7%)
46.2 (1.0%)613 (14%)251 (5.5%)
870 (19%)
M 3 (6.75)
154 (3.4%)
125 (2.8%)
31.8 (0.7%)356 (7.9%)
446 (9.9%)
108 (24%)534 (16%)48.9 (1.55)
10.5 (0.3%)
6.4 (0.25)
9.7 (0.35)
S.? (0.25)
43.2 (1.35)
34.6 (1.15)
559 (17%)241 (7.35)
706 (21%)214 (6.55)
105 (3.2%)
84.0 (2.655)
25.8 (0.8%)214 (6.52)
U S (1%)lo0 (3E6)

3.945a (Im)33m (1Wc)

Eficriru
dare eqiwlenl 'Effcrri~cdare

Numbcr

W v )

fnfw

Adrcnals
Lumbar spinc
Pelvis rcutinc
0th-

296650 (35%)
66850 (8.1%)
17850 (21%)
18700 (22%)
16150 (1.95)
8500(1.05)
15300 (1.8%)3950 (0.75)
67150 (7.9%)34000 (4.0%)
98600 (11.65)
29750 (3.5%)
22950 (2.7%)
14450 (1.75)
8500 (1.05)
S9soO (7.05)
47600 (5.6%)
19550 (235)

3.49
1.22
1.10
0.43
1.13
0.69
1.94
7.76
9.13
7.39
8.82
10.20
6.71
8.62
3.74
5.98
9.38

Tdal

SSLWO (lOC%)

5.3

7).~e

l1wQ roulinc
Poslnia foara
P~tuilary
Internal auditay nlearw
Orhts
Facial bona
Grvical spine
Thoracic spine
a&.roudnc
Mhaslinurn
Abdomm, rcuhnc
Liver

PannasGdncys("ICRP 1977 weighling factors.
* Using
Using lCRP 1990 weighting factors

T~iblc15
Doses b patients fmm computed lnrnography exnminalions In Japnn

[ N81
Dare
ErMILtarim

llcad

DPTCq u m l i p

A t s a b c d d a c (rnGy)

Dnrr roBon: marrow
T h p id
Eye

ERcctive d a c quitalcnt (rnSv)
Chat

Abrabcd dose (mGy)Brezs~

b 5
Bone rnanou
Thyroid
Fflcctivc dou q u ~ % a l c n( td v )Upper abdanen

Lower abdancn

Absnbcd dose (rnGy)

Largc inlerllnc
Charyhcstis
Bone manow

EITcctivc dow equlvalcnt (mSv)

FemaleMalc

Ataabed d a c (rnGy)

Largc inlatinc
O%aryhestis
h n e marrow

IXcctivc d m q u ~ m l c n (mSv)t

FemaleMale

Minimum

MnrLNvn

Aw a ~ c

0.7
0.2
8.7

21
0.8
47.2

1.5
0.5
22.4

0.2

0.7

0.5

8.7
12.6
3.9
1.2

39.6
35.0
11.5
3.0

15.9
19.6
5.7
1.9

4.3

14.1

6.9

0.7
0.4 10.04
1.4

1.7
1.0 10.2
3.7

1.0
0.6 I 0.1
22

26
25

7.4
7.2

3.8
3.7

11.3
8.110.5
3.5

34.5
27.1 1 1.6
9.5

19.2
15.1 1 1.0
5.6

4.1
20

12.5
6.2

7.1
3.6

UNSCWR 1993 WPORT

298

Tnblc 16

Dnscs rrorn rnnmrnn~raphyexamlnalions
AArorbad dare in breast (miiy) 'Cowrny and yew

P a flmA u t ~ a l i l .1989[I1371

Pilicnts
All with grid ~ c r t e n f i l m

Australia
1989-'1990[TI91

48 mrn phantom
Xcrotadiognph
Scrd1lm:
With grid 'No grid
Overlll

Gnada, Mmitotn
1988
IH3 1147 mm phantan
Xuorndiopph
Sncmlf~lm
Ovcrall

Italy. 1987-1990
p19]

50 mm phantan
39% with grid

Ireland 1989
11143160 mm phantan
Scrd~lrn

New Zealand

All l a d l m :30 mrn phantan
No grid
Ovcrall

1988-1989,W11] andUNSCEAR Swvey

Magnitiatim

Pdand. 1966

P"lPatug41986-1989

lcul

Sweden1989-1990[L1O]

r SD: range in parcnthaa.
2% dl11 -ha.
80% of d l cmtru.

Eff‘errivc dan c + d m(&)

T~hnqvc

1.3

P a pnrimr

P a parirnr

P a rquf

0.82
0.30
0.60

0.014

= 0.4 (0.5-23)
23

1.8 2 0.8
0.8 2 0.5
1.7 E 0.8 (0.14.8)

3.6
1.6
3.4

3.3
1.4 (0.8-1.9)
4.0

1.5 (63%)
1.0 (39%)

1.5 (0.9-23)

0.6 :0.3
1.0 r 0.6
2 5 (0.7-7.2)

45 mm phantan
No gridWlh grid
Omdl

1.1 r 0.4
2 3 z 1.0
2 0 z 1.1 (054.8)

30 m m phantom
Xcroradiopph

4.8

All r c r d l m :40 mm phantan
No p i d
Sutionnry gridMoving p i d
Ovcrdl

0.8
1.0
20
1.4

All rcremhilm:
45 mm phantan
No gridMoving grid

0.7 (0.5-1.1)
1.5 (1.2-1.9)

0.30

0.60

6.4

ANNEX C: MEDICAL MDIATION EXPOSURFS

299

T a h l c 17
A v c r t l g c a n n u e l n u r n h c r of dcnlal x-ray e x a m l n a l l o n s per 1,000 p o p u l n t l o n

Data from UNSCFAR S i r m y of Atcdical Radiation Usage and Expo.wres unless othem~ireindicated1970-1979

Country

1980-1984

Country

1985-3990

1970-1979

1980-1984

1985-1990

150
32 1
64 1

399

a0

32

411
275
833
61
86
42
232

403
296

84 1

Iirsllh-cur lev4 l
Australia
Belgium
Cuba
Ckchoslwatia
h a r kFinlandFranceGermany. Fed. Rep. cf
llaly
Japan
Kuwri Ihvnbwg
Ma111

80
288
72

M

85
471
223

540
2a4

83 1

3

119
834

6.2

783
219
186
8.2

Ndhnlanda
Ncw Zcaland
Namy
P d d

605

pmkl
Romania
Spain
Swcdm
Suitzerland
USSR. RSFSR
Lkitcd Kinglun
U n i t 4 Stales

Avaagc

832

112
3SO

325
74
165
456

402

320

390

350

1.5

4.4

6.2
1.3

0.8

25

23

21

0.8

1.7

50

60

Iieslth-cur levd Il
4.7

Brazil
Qule
&nr

3.9
0.8

b d a
Tunisia

2I
AvaagcHealth-cam Ievd III

Egypt
Myanmar

0.7
1.6

Sri L n L aThailandAverageThc cntriu in this Tablc arc qualified as fdlour:
Frnnre:Valuc rcprucnts number of films.

G m n y . Fad. Rq. o/: Paatomogrrma nol irrdudul.
Valuc is for n a t h c l l t of 11aly.
Irdy:

Jnpnn:
Ncrholamis:
hbv Zcdand:
Sweden:Data also limn [Ul].
Lh11 also from [VLV10).
Data also from [W12].
Data also f r u n [SI. 531.

0.8
1.4

Tai>lc 18
Fstlnlr~tcsof cKcclivc dose cqulvalcnl from dental x-my exnmlnetlons
D a r a jrom 1JN.SCI;AH Survey of Aledical Radialion Usogc and Exposures, unless orhemi.ve indicared

Cotuttry,

E n n m r r sw/orc
d a r c (mCy)

Eflecri1.e dare
e+i"alcnr(ms)

I?nWmcc sw/ore
dose (mCy)

Year

Country&finhe d a r e
cq~i~~alc~
fdlJ

n c m l t h i u t lcrrl I
Argentina
Awlralia
Gcchmlovaba
Francc 185)
Japan
Kuua~~
Nclherlands

1985-1989
1970.1974
1970-1979
1966-1990
1984
1970-1974
1980-1984
1985-1989
1974-1985

Ncw Zealand

4 (1.5-40)
7.4
2
5 (0.1-30)
16 (0.1-25)(3.9-13.5)
5.8 (3.5-8.7)
3.1
3.2 (0.76.9.7)(0.9-3 1)

0.15
0.15
0.07
0.03. 0.M
0.02-0.28

PolandRomania
Spain
Supcdcn
USSR, RSFSR
U ~ t Gd n g d a n

1975-1979
1985-1989
1985-1989
1980-1984
1985-1990
1986-1990
1980-1984
1985-1990
1981-1985

1987
1985-1989

0.11
0.005
0.01
0.03
0.02
0.02 0.03

n c s l t h - c a r e l c v d 111

U c s l t h i a m Icvd Il
Brad
Ecuada5.2 (1.2-19)
4.9 (1.2-22)
3
10.7
28 ( 3 . 3 4 )
6.0 (0.9-12)
5

1985-1990

Myanmar

0.2

6.4

0.32

1.9 (1.3-27)?hc entries in h i s T d c are qualified as fdlovn:

Romnnia:
Spain:

urn:
Linired Kingdom:

E D given is pcr film.
Thc rangc d thc ESD is thc a v m g e f a diffncnt p o j c d m s . Thc n l u c given for lhc effcnivc dcsc q u i ~ l m ist p a lilm, thc &cc(ivedcu c q u i n l m t per caw is 0.037 mSv.
Data also I r a n [UI]. ?he ESD has becn Mimated from crporurc (mR)mulliplicd by 0.0067m.75. ' h e firsf value f a cflcctivc dosecn l u e for e n r a a a l cxaminalions. Thc per w p u t cffcctivc dcsc quivalcnl for Japan
quikalcnt for 1985-1989 is for intraoral. ~ h second
is 0.027 mSv pl2]. For 1989. 1IE: 0.024 mSv. E: 0.052 mSv F(44].
Data also f r a n [VZ.VlO]. Range of ESD: on avcrafi 2.4 films arc w c d p a cxaminalion. Effcaivc d m e q u i n l e n t is f a complae mornh
ruwcy; for pantornogram it is 0.13 mSv.
Data also f r a n [WIZ]. Thc FSD s a l u u arc per film. Thc ESD value for the p a i o d 1965-1989 is qualifid by thc f a n that on average 1.6
films w a c used pcr cxamination.
Effcctivc d o w q u i s a l c n t is per caput.
The r a l u u f a ESD (and range) arc f a iruraonl cxaminalions.
Data also f r a n [SI. S3]. On average, 1.25 filrr~u . a c used per cxamination; 1985-1989: on avcragc. 2.4 films w n c used per cxarnimtim.
The cffcct~vcdose cquivalcnl pcr u p u t is 0.01 mSv. for thc canplclc mouth survey it is 0.14-0.23 mSv.
The ~ l u fcn &cctivc d m c q u i n l c n ! Is givm for l n t r a a d cxaminatiffls.
The first n l u c o f t h c c f f c a ~ v cdore q u i v a l m t is f a ~ntraoral,thc r m n d onc for cxtraoral examinalims. On average 2 4 films u u c used
per e u m i n a t i m (1981-1965).

T ~ ~ h 19lehfcan abtorbcd doses from dentnl x-ray examinalions In France a

IS51
Mean ahsorbed d a r c fmGy)
Paiopiral k L a

P a n o r m i projecrions

P a w p i c a I mdar

Orgm

Lcru
ThyroidP a r a i dr
Tmyc
SuMinguals
PhuynxSinwcrBack of ncrk
Brain
Bone surface

Uppc

L o w

0.10
0.14
0.01
0.12
0.03
cO.0 1
0.08
0.M
d.01
0.07

0.07
0.08
0.02
0.27
0.03
0.01
0.M
0.02
<0.01
0.09

-

L'ppa

L o w

0.05
0.W
040
0.05
0.10
0.06
0.28
0. M
0.01
0.65

0.02
0.06
0 41
0. 06
0.13
0.04
0.04
0.03
a0.0 1
0.74

-

-

-

MorJlqaclurcrl

3.60
0.07
0.04
0.12
0.04
0.01
4.35
0.W
0.01
0.10

-

Circular.

&Ilipud
2 rcnrcrs of rornrion

3 r e n r n s ofrolnrion

0.03
0.01
0.90
0.40

0.03
0.05
1.40
3.10

-

0.08
0.M
0.08
OW
.

0.19

0.80

a.40

0.10

0. 15

0.15

-

ANNM
C: MEDICAL RADIATION E

S

1

l

~

~

~

~

~

~

301

'1'kll)lc 20
Collcctivc dosc Iron1 d l ~ ~ t ~ o sXt- 1i- 1c1 ~ cxaniin~tionsn'orldwidc, 1985-1990

Chcst ramogaphy
Ches! minialurc
Chert f l u a m c q y
hrcmitia
Lumbosacral rprnc
PclrirILpKcmur
Skull
AMomcnUppn GI traa
Lawcr GI tract
Chdccystographyurognphy
Angiograph~hfarnmogaphy
(JT

Ton1

I.c\.clI

1,ctrlII

Lnds
111-nr

171
260
33
121
54
21
12
40
32
52
11
9
15
6
12
39

22
20
48
I1
3.0
1.5
1.1
4.4
6.0
28
0.99
0.21
1.8
0.21
0.43
0.32

34
1.5
9.0
5.6
1.8
0.89
0.89
3.3
3.0
0.89
0.69
0.76
1.2
0.10
0.06
0.38

63
77

687

124

64

304

Awrage per cxa-

mi nation (mSv)

Average dose
per wpuc (mSv)

Annual c d l a r i v r c f i c r i ~ rdosc cquit~alcr(man Sv)

f$Jccrit'c dare rqui~,olcnr
p aominnrion (rn71~)

Number of u m i n o r i n n r
per 1,000 ppulorinn

F~eminarionlsirc

I,,orld

3
36
16
6
4
13
12
15
4
3
5
2
3
10

Lnrl
I

Lcrd
11

Lnwb
I I I - ~ ~

0.14
0.52
0.98
0.06
1.7
1.2
0.92
0.16
1.1
4.1
7.2
1.5
3.1
6.6
1.0
4.3

0.14
0.52
0.98
0.06
26
20
20
0.16
1.1
5.0
7.2
1.6
3.1
6.8
1.0
4.3

0.14
0.52
0.96
0.06
26
20
20
0.16
1.1
5.0
7.2
1.6
3.1
6.8
1.0
4.3

Lnrl

I

0.14
0.52
0.96
0.06
1.8
1.3
1.1
0.16
1.1
4 .
7.2
1.5
3.1
6.8
1.0
4.3

31MO
18200043100
10600
12;mX1
3200
15300
8560

44700
285000llZDOO
18100
56200
9300
17000
2240001262000

1.05

0.90

0.67

1.0

0.93

0.11

0.013

0.30

LMI
II

L ~ w b111-nf

8130
2710
124000
1800
M400
7710
5740
1860
16600
36700
16800

45POO
21000017800012600
146000
42W
3MO
11100
65500
328000137000
20600

14700
3670
1170
3610

6240
1040
llMO
440
6130
2320
2320
690
4160
5800
6520
1630
4660
680
&
2110

29200056500

1610000

900

nm
61900
18300
230000

Table 21
Contribution or dill'crcnl t y p a of dir~gnasticexaminalions to the collective dmc

C o m i b v i o n to roral cdlecrivc dosc (96)Exnminnrionlsuc

Upper GI tract
Ccmputcd tomography
C h a mass m~nracwe
Chut fluoroscopy
LMlbouaal sptnc
Lowcr GI tract
Urography
h&?oi?aphy
AtdomenPclb~rChest radography
I Lp/iernur
Chdccystography
Mammographyhrcm~ttw.
Skull

Lnrl 1

L o r 1 I1

L o r & III.IV

Hbrld

3
18
14
3
10
9

13
1

10
4
2
20
11
12
8
2
7
4
11
4
3
0.1
0.8
1

20
14
13
11
9

5
5

J

3
2
1
1
I
08
07

9

42
7
6
5
1
6
3
3
0.3
04
0.6
3.6

U'orld

9

5
4
4
5

3
1
1
1
0.8
0.7

Table 22
Annual indlvlduai and collective effective dose from dlagnosll~x-ray rxnrnlnutlons
Data {rom UNSCE4R Survey of Medical Radiation Usage and Exposures unless othern~iseindicatedrEffccrirr dare cq~irwlcnr( d r gCountryYew

P s Ldividvnl p r i c n r

Collccri~u.$zcrirv
dose c p i v d c n t

P a capU(m M Sv)

Rcfaencc

Ucalth-cuc lcvd I
Gna&

1980

0.8

1.0 "

24000 '

[Ull

Gechoslwahe

1980

a9

0.6

8600

w71

Denmark

1986-1990

1.4

0.7

3600

Rnland

1978
1987

0.6
0.8

0.7
0.7

3300
3500

lull

Frnncc

1982

20

1.6

89000

p11

Gumany. Fed. Rep. of

1979
1983
1988

20'

102000

1.0

1.7
1.5
1.0

61000

lull
IB7l
1~171

Italy

1983

1.1

0.8

46000

P'19, u11

Japan

1979
1989

lSlOO0

1.9

1.3
22

266000

New b l a n d

1981-1985

0.67

0.4

1400

Nclhcrlads

1980
1987

0.57
0.56

0.34
0.31

4800
4500

Pal

1988

0.9

0.6

2SW

[sul

1976
1988

1.2

1.7
0.8

56700
30000

Itr11
Iull

Ponugal

1988-1989

0.76

0.53

5400

1S521

Romania

1980
1990

1.1
1.1

0.6
0.5

14100
12300

Spin

1985-1986

1.4

0.8

31100

vs]

Sweden

1985

1.1

0.6

4600

Iv41

Switzerland

1985-1990

0.4

0.4

n00

USSR

1980
1986-1987

1.1
1.15

1.1
1.15

292000326000

USSR. RSFSR

1976-1980
1981-1985
1986-1990

1.18
1.14
1.14

1.13
1.16
1.10

153700163300161000U m t d &-ngdan

1983
1989

0.7

0.3
0.35

uxyx)

IS431

1980

0.5

0.4

92000

p'l. u l ]NauilyPolandUnild Stata

90000

I6000

(R 91

PI1
w21

[B61

jN41
p 4 . S18]

[H 101

ncalth-cam lcvd 11
Quna

1983
1985

0.6
0.6

0.4
0.09

3600
94000

[Zl. 241

India

1989

0.2

0.02

16800

[s401

lrnn (Islamic Rep. d)

1980

0.5

0.09

3500

lull

Iraq

1972

0.7 '

0.2 "

1700 "

lull

0.2 "

7000 a

lull

0.05

2000

Beijing n r u
Entirc naticm-rwlcey19n

iz61

Hcallh-cuc lcvd Ill
Myanmar1986-1990

Thailand

1970

5

0.2 '

full

The entrio In thir Table arc qualified rr Idlour:&la for chc n o r l h u s f d o o u n l r y have been carnpdntcd to (he -lire mmlry.
Cnlleaivc effcclivc d a c quivrlcnl indudu 16,lM) man Sv lrom r~cmnchm n u nnceninp: 69,000 man Sv [ran chat m u roccninp;
5,W man SV from computed lomogrnphy; '2.900 man Sv lrom dmtal radiopphy.
and prcimploymmt m c c ~ n g .
kduding---

Erlimated fran p e l i d l y rimifinn1 ~LI: GSD [OJ d v and awragc ratio GSDRIB for h d h c r r c level 1(03/1; range d level I nlia: 0.14/1-O.Ul)].
Appually exdud- fluoraccpy. F a npproimale adjulmcn4 it could bc lvumcd ()ut50% d d l craminrhons arc Oua-c
ud that h e caw masrrafi IS lirna highu abrorbcd d u e s p a examination [UI].

Table 23
EsLLmakd doses to the world population from dlagnostlc medlcal and dental x-ray examinations

Hrdrh-care
ledI

Popularion

13%

2630

N

BSO
460

Tctd
AruagtA n n u l c d l a r i w cffecrix

dare e q u * t d c (18~ mnn sv)

(millwnr)nmAnnual per c a p u
r/lecriw d m cgrivnlarr ( d v )

Madud

Dwni

Madud

Dwnl

1
0.1
0.M
0.01

0.01
0.001
O.M)(n
0 . W

13M)
290

14

0.3

0.003

5290

40
20

3
0.3
0.1

1600

11

Tnlllc 24
Hcyulritlans or rcconinicndrillons on qur~lilyrtssumnm
Dafa Jrom UNSCEAR Surwy o/ hfedical Radiation Usage and Expos~rres,unless o~l~ern-ise
indicated.Y.rqv dingnarrics
Cowrr).

L cgolrcgulorionr

Rrcom~ n d a rwnr

H a d h i a ~r h c r q y

,do
Q.'

L cgnlrcg~rnrionr

Rrcommndntionr

h'uclear mcdkine

N,:cI.r~nlregulorionr

Rrcom-

mdrionr

N o QA

rvlu

IIrslth-cuc level I

Arpnlitu
Australia

*

*

v

*

Gcchcslwatia**kDenmarkf

Ecrrada

f

*

*

*

*

*
*

k

*
*

finland**rt

Belgium
Canada a

*

i

*

*

*

France***Germany. Faf. Rep. d

*

*

*
*

*

Japan

*

Kuua~c*t*

Luxcrnbourg

*

*

*

Malta
Ncu,7zaland*

NauZly**-Romanla1:**

Pol and

*

t

t

*

*

*

*

*
*

SinppacI

Lhlcd h n g d a n

.
i

*

8

L

*

I

U N I CS~I ~ I U '*Yugorlann

*

Taal

12

*
I?

4

12

*
8

6

10

12

4

ANNEX C: hlEDICAL RADIATION ~ I ' O S U K ~ S

R d i a ~ i o nt k c r ) .

. Y - r q diagnosfics

Lcxal
rrgdatwnr

Corrnby

RccommcndaI innr

305

rdo

Rrcommendalions

Lctd
rrtdalions

Nuclcm mdicinc
N o Q.4

Rccom-

Lcxal
rqulalions

mowid-

tiom

Q.4

rulrr

ncullh-ewe Irvd I1
Barbodor

*

Chinn

i

*

limduras

1:

India

*

*

*

*

Jamaica*hrcaragua*

Pcru '

*

*

3

Total

3

*

*

t

*

*

t

Turkey

*

*

*

baq

=

t

3

3

2

*
2

2

3

3

2

1

U c s l h - c u t Irvd Ill
Cape Vcrdc

Tan1

\ * I

I

1

5

I

3

1

I

2

1

1

n r s l h - c a r e 1c.d IV*

Etluop~n
Rum&
Tan1

"

*

i~

1

i

1

*
1

I

For x-ray &agnmtia. Icgal provincial rcgulat~omprevail and fcdcrul rccommcndut~mshave heen made. For radiatim thcrapy, rccommcnht~onrc x i r ~in somep o n n c u . In practice, rccommcndationr m nuclear m d c i n c arc c n f a d as Icgal rcgulatimr.
The Japmcsc Industr~alStandards sre used ar technical gudu f a x-ray d i a p m t l c s and radiatim therapy.

'*

For x-ray &agnostics, a few states h a w l c g l rcgulatimr and faderal rccommcn&t~onrhavc been made.
Data hom PAIlO.
Rcgulstims in preparation.

UNSCEnR 1993 REPORT

306

T ~ ~ h 25lc
Tohl annunl nunrher of n~~cletlr
nirdicine examinaUons per 1,000 populauon
Dota lrom UN-SCEARSunvy n/ A4rdical Radiation Usage and Exposures unless otlrern*ise indicatedCovrhy1970.1979

1980-1984

COW^^

198.5-1990

1970-1979

1980-I984

19U-1990

7.3

13.1
23.5
11.6
7.5
9.3
3.5
126

Hrallh-cv. Itvd l
Asgcmina
Ailrtralia
Austria [Ul]Belgium
Bulgaria [Ul]

3.8
18.0

8.9

36.6
13.0

Goah

Czcchcrlovatia

Denmark
Finland [AlZ LIB]
France 1120, Ul]
Germany. Fd.Rcp.
ltal y
Japan

115
8.3

13.6
14.0
126
31.1
6.0

16.3
14.2
17.7
9.0
39.7

12.6
22.9
U.4
6.9
39.8
7.3
6.3

h i t
Luxcmbowg

Nahcrlands
New %land
N m ayRomania
Swdcn
SwimlandUSSR [N4]
United k n g d a n
U ~ l SlaladYugoslavia

9.8
44.9

Amagc

11

5.6
3.9

3.0

3.9
6.8
25.7
6.1
6.9

16

Ucallh-cmrr lev4 11
Bartador
Brazil [C14]

1.0
1.7
0.6

Oliru

Cuh [Ul]
Ecuada
lndia

0.8
0.5
0.1

0.8
0.2

Iraq
Jamaica
Peru
Tdua
Twky

1.2
28

20
0.2
LO
25

0.9

0.1

0.5

Sudan
Thiland

0.12
0.25

0.28
a18

0.28
0.26

A~rragc

0.25

0.25

0.M

Average

Uralth-cuc Icvd 111
Egypt
M~IIIYUI

0.07
0.54

0.21
0.3

0.48
0.11

Hrmlth-cu. Irvd 1V
Ethiopia

0.014

0.10

l'ahle 26
Averrrge annusl number of dingnmlic nuclenr medicine examin~~tions
per 1,000 population
Data from UNSCEAR Survey OJ Medical Radiation llsage and Exposures, unless othem~iseindicated

CauVrY

Year

Bow

Brain

Cmdiob9rdar

Libwlsplcm

Lunx

.

77rpidKLlnryVolrilorion&aPafwionI

Orha

UptakeHeallh<src level I
Argentina

1985.1989

2.8

0.4

Australia

1970
1980
I984
1991

0.05
2.0
2.6
3.4

1.0
1.5
0.3

C~nada1985-1989

16.8

G&oslovakia

1970-1974
1976-1980
1981.1985
1986.1990

45

0.8

1.6

1.1

0.24

0.2
I .0
1.5

0.6
1.7
1.2
0.2

0.001
0.3
0.6
1.5 *

0.5
0.9
0.9

0.1
0.1
0.5
0.8

1.5
0.8
0.8
0.6

0.05
0.07
0.01

0.3
0.9
0.3

4.0

0.8

1.O

0.2

0.4

0.3

0.9

0.8

0.5

0.09
2.1
3.4
4.6

1.3
0.4
0.5
0.6

0.02
0.2
0.5

0.05
0.2
0.4
0.6

0.1
0.4
1.1
1.8

6.1
4.3
6.7

1.2

3.6
2.6
1.9
2.2

8.4

1.7
1.8
1.9
1.8

1.0
0.5
0.2
0.2

0.6 '
1.6
1.6 '

1977-1980
1981-1989
1986-1990

2.2
2.7
2.5

2.4
1.4
O.8

0.6
1.O
1.1

1.2
0.7
0.1

0.1

0.4
0.4

0.5
0.7
0.7

3.9
4.5
4.8

1.3
1.O
1.6

0.7
0.5
0.3

1.1
1.3
1.1

finland [A121

1975
1982

0.6
3.1

3.4
4.9

0.3
0.6

1.9
2.2

0.06
0.05

0.6
1.1

3.3
3.0

1.3
1.8

0.6
0.2

0.5
0.7

Franrc [LZO. UI]

1990

2.6

1976.1980
1981-1985
1986-1990

4.4
9.6
10.3

4.0
1.4
1.1

0.2
2.4
2.8

4.0

ltrl y

1974
1985

0.06
2.0

0.6
0.2

0.09
0.3

Japan

1985.1989

2.1

0.3

Kuuait1985-1989

1.7

Netherlands

1985.1989

New 7 ~ l n n d

1970-1974
1975-1979
1980-1964
1985-1989

Denmarkh n y ,

Fed. Rep. of

1.4

0.7

0.4

1.9

0.05
0.2
0.2

2.2
2.9
3.1

3.9
2.7
2.5

9.3
18.2
17.7

1.8
0.2
0.2

1.2
0.9
0.9

1.2
1.5

0.06
0.02

0.04
0.2

0.7
0.3

0.2
2.0

3.0
0.7

0.2
0.1

0.9

0.9

0.3

1.8

0.4

0.4

1.4

0.2

1.8

1.1

0.4

0.8

3.9

3.2

0.03

3.6

1.2

IJ

I.S

0.4

0.7

0.8

1.1

0.3

0.4

0.3
I .5
2.2
2.8

1.2
2.4
1.3
1.0

0.3
0.1
0.4
0.4

0.7
1.3
1.2
0.6

0.3
0.6
0.5
0.6

0.06
0.2
0.5
0.8

0.4
0.7
0.7
0.7

1.2
0.7 '
0.3 f
0.3

0.2

0.1
0.4

13

0.9

'

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6861-S8bl
PL61-0L61

I-N

mqdrl~l!7

mp>mco!pm3

Fl
V'O
7x0

L'O

CO
Z'O

9'0
8.0

1'1
L'O

vldn

Wx

PYlO

E'O

9'0
I'0

I0.0

""!m/pd

W!lD/!JU2A

kvpl?l

RO*U

tun7

PO'O

"!"JR

.

'"061

MEDICAL MDIATION IJXPOSURFS

I'uhlc 27
Avcrc~gcilnnurtl nunil)cr or dlt~gnoslicnuclcnr rncdlcinc cxanilnaUons pcr I,(HH)populutlon hy hctillh-care lcvcl
D a t a Jrom UNSCkCAN Sunuy o j hfedicol Radialion Usage and Exposrrres

A\aaxeExaminarim

Bonc

Brain

Grdimuular

L~vcrfsplcen

Lung vcnt~latiar

Lung pcrfurim

Kdncy

Thyroid scan

Thyrcid uptak

Taal

Meon 2 SD

Median

)'car

Lor1
I

Lnrl
11

Lnrl
111-N

Loel
I

Lovl

1970-1980
1980-1985
1985-1990

O.RJ
26
4.8

0

0.001
0.011
0.084

1.42202 4 r 2.7
3.3 2 2.6

01970-1980
1980-1085
1965-1990

1.3
1.1
0.42

0.022
0.013
0.007

1.9 r 1.6
1.1 r 1.3
0.63 r 0.92

1970.1980
1980-1985
1965-1990

0.53
0.58
26

0.Mnn
0.003
0.014

0 . ~ 71 2 1
0.92 0.74
1.3 r 1.7

1970-1960
1980-1965
1985.1990

1.7
1.2
1.4

0.087

0.086
0.034
0.016

1.6 2 1.4
1.0 r 0.75
0.89 r 0.62

1970-1960
1960-1985
1985-1990

0.13
0.26
1.2

0

0.00010.0001
0.008

0.16r0.32
0.19 r 0.17
0.49 r 0.62

1970-1980
1980-1985
1985-1990

0.34
0.94
22

0.024

0.00030.002
0.008

0.58 r 0.65
0.71r0.61
0.78 :0.98

0.036

1970-1960
1980-1985
1985-1990

1.8
1.3
1.4

0.611

0.m
0.009
0.E3

1.9 r 1.9
1.6 r 2.2
1.9 r 2 1

0.051 r 0.079

1970-1980
1080-1085
1985.1990

1.3
25
1.8

0.40

0.066
0.618
0.066

2 1 :2.7
2 3 z 5.1
2 4 r 4.0

0.42 f 0.55

1070-1980
1980-1985
1985.1990

22
0.17
0.55

0.25

1.4 :1.5
0.15 0.16
0-3
0.3

0.083 r 0.143

0.17

0.10
0.063
0.052

=

1970-1960
19EO-1985
1985-1990

10.9
6.9
16.2

0.86
0.10
0

0.25
0.19
0.25

15 r 1312.7 r 9.8
15 r 10

0.016
0.23
0.006
0
0.008

OD23

0.001

0.002

0.096

0.062

LnjclsI I I . ~ ~

Lnrl
I

Lor1
11

Lo,&
nl-N

0 . 0 5 r O.OO(%
0.024 r 0.045
0.056 r 0.099

0.64
21
28

0

0.00000.002
0.011

0.017 r 0.014
0.01 1 2 0.01 1
0.007 :0.008

1.5
1.0
0.35

0.0005 r 0.0005
0.002 r 0.002
0.008 r 0.013

0.1 1
a28
0.99

0.617 :0.069
0.029 r 0.035
0.014 r 0.012

1.2
1.1
0.68

0.013

0.0000m.00003
0.00003r0.00006
0.003 r 0.007

0.06
0.15
0.25

0

0.0001rO.MX)2
0.001 r 0.002
0.005 2 0.010

0.46
0.67
0.58

0

0.0039 :0.0037
0.001 2 0.012
0.020: 0.036

0.71
0.48
0.88

0,012

0.067 2 0.042
0.059 2 0.049
0.079 r 0.087

1.3
0.90
1.4

0.21

0.n
0.15
0.32

0

0.091 r 0.13

0.104 r 0.092
0.078 r 0.085
0.051 r 0.049

0.52

0.080
0.0s 10.028

1.35 t 1.23
0.10
1.1 r 0.76

0.24 r 0.21
0.21 :0.13
0.25 2 0.15

12.6
10.3
12.0

0.80
0.10
1.0

0.18
0.21
0.26

R

0.11 r 0.11
0.34 :0.59
0.12 r 0.24
00.014 r 0.11
0.12:

0.19

0.076 2 0.06
00.0001t0.0003
0.062

0.M6 t 0.071

0.053 r 0.062

0.39 r 0.46

Chnall aimgc: tad nmbcr of cxaminationr divided by tk lad populabsn d counlriu (thousands).
Mcan a rncdtan d ~nd~wdual
vrlucr or counlna.
ma from lnd~amly.

0.10
0
0.010
0
0.001

0.018
0.01 10.003
0.00000.00 1
0
0.021
0.012

0.066

0

0.018

0.27

0.25

0
0
0
0.0001
0.001
0
0.005
0.00 1
0.006
0.063
0.056
0.063

A N N M C: MEDICAL RADIATION MPOSURU

31 1

Table 211
Age- and sex-distrihullon or pullcnts undergolny dlagnmllc nuclear mcdlclnc extlrnlnatlons, 1985-1990
Data Jrom UNSCWR Survey o/ hfedical Rudialion Usage and Exposures

Age dimibur;a,I/etllrh-care

Scx dirPihvrion (%)(I)

counrryIn,cl

0-15 years> d 0 years

Mole

Female

69
87
49
94
91

47
36
48
48

33

10
49
4
8.2

30

75

24
13
11
19
13

72
81

60
53

30

1 6 4 0 wars

Bone
1

n

n~

25

Auslrdia&a&
Qechalwakir
Gcrmnny. Fai.Rcp.
Italy
Kuwaith'ethnlmds
New M a n d
Saway
ROMN~
SwcdcnYugoslavia

6
3.4
1.9
2
0.8
45
3.9
5.8
26
3.5
27
3.4

Average

3%

14%

(hi-

Ecvrda

21
5.1

Pnu

78

52
65

85

46

67

41

64
52
52
66
40
47
56
48
35
54
59

83 5

45%

55%

35

44

75

70

63
63

30

37
37
70

20

41

40

40

60

Average

18%

354

47%

SI Z

49%

EWP~

4.4
0
0
0.3

40

M

Myanmar
Sudan
Shniland

40

3I
60

2
33

60
98
67

49
17

69
40
51
83

Averagc

1%

32%

67 %

36%

64 %

20

22
25
18

58
72
82
75
90
20

52
49
54

48
51
46
75
47

90

10

80

58

Yugalana

26
0
0
0
4.7
3.6
4.5
1.6
6.6
0.1
0

Averagea i mEcuada
Iraq
Pcru

48

26

Average-!rmc4

Mylnnur
Sudan
%land

86

U

44

Brain

I

Australia
CanadaGechorlwaha
Germany. Fed. Rcp. of
Italy
KuwaitNclhcrlmds
h'cw Zuland
Sauxy
Romania

10
76
17

30

25
53

53

42
47

46

-%

9

43

50

50

45

55

30

66
60
43
74
70

3%

23%

74 2

46%

54 5

17
0

24
14

59
86

60

40

10

90

26

48
40

52
60

23%

535

46%

-54 $6

0
21
1.4

0
18
26

100
61
73

SO

50

42
45

58

Aver a gc

5%

16%

79%

46 %

54 Lk

Ethiopia

12

64

24

58

42

91
87
85

62
62
62

38
38

Swedm

n

25

19
46
26

-

nl

N

55

CdievucularI

Ausvdia (thallium)
Autrdia (lcch~lium)
Gnab

0.1

2
6

9
11
9.5

3

~ b distributionc(96)

Ilcalrh-cmc
lrVrl

I(con~inucd)

0 1 5 ).ems

1640 .war+>40 years

Kuuu I
Nahalanh
New Zuland
Nauay
Romania
Sweden (Mood pod)
Swcdm (rnyaardiul)
Yugoslabia

3.8
0
0
0.6
0.6
0.7
0.1
0
0
0
2

52
17
11
29
9.1
13
23
14
46
1.4
25

45
83
89
70
90
86
77
86

73

75
76
55
66
66
58
50
66
64
75

Average

1%

16%

63%

682

32%

h d a

0

10

90

33
75

67
U

Avnagc

ffd

10%

907:-

43%

575

Ern
Thailand

0
0
0
0.3

0
0
2
33

100
100
98
67

70
75
49
17

30
25
51
83

Avmage

054

11%

89%

51%

49%

68
79

45
44
58
52
45

55

Gtchalwakia
Germany, Fed. Rep. or

Italy

U

UI

Sa distribution (%)

Cowlrry

54
W

ClGo

9
-

Sudan

Male

F d e

M

36
25
24
45
34
34
42
50
34

M
25

Livrrlsplcm
I

Australia
Canada~ m l w a k i a
Italy
Kuwar I
Nelherlandr
Ncu. b l a n dh'auryRomania
SwedenYugorlana

16
55
62
25
13
14
22
34
41
11
30

AW~F

5%

n5

Quna
Ewda
Iraq

24
5.6

Pcri

Romania

U

Ill

22

10
5.7
4.7
37
1.6
1.2
1.2
0.7
29
6.6
1.7
6

40

48
73
86
85

TI
63
52
67
62

54

42
66
55

56

44

50

50
49
50
21

51
50
79
44

56

66

34

67%

56%

445

32
32

66
62

29

5.6

47

46

71
50
34
40

Amage

3%

Y%

63%

62%

38%

Em'
Sudan
Thailand

10
0
4
0.3

33
50
45
27

57
50
51
73

66
50
50
50

49
50

Average

4%

37%

60%

550

45%

42
66
53
38
54
50
61
54
40
67
49

5s
47
62
46
50
39
46
60
33
51

.Uyanmr

50
66

60

34

50

Lung rtntiblion

I

Australia
CnnadaQechalwaba
Gamany. Fed. Rep. ofI~dyKuuai~
Ncthmlandr
New h l a n d
Nm%y
Romania
Swcdm

1
1.7

1.4

l.5

0
0

37
21

82
88
37
100
94
65
85
72
83
63
79

13%

86%

51 Z

49%

58

42

48

52

0

0
0
0
0.6
0.8

Amage
Dl

Ern

17
10
63
0
5.6
35
14
28

0

34

. k r d u n i h i o n ('3)

ARC disnibutim (%)

Ilrdih-ra-r
loel

Cowny
0-15 yrms

Id40 .wars

d 0 ycnrs

Malr

Fcmdc

E4

44

-56

M

50
50
56
54

50

42
65

58

67

l w n ~perfusion

I

U

m

Gns&
Chchalmaha
Kwait
Nccholandr
New Zraland
Naway
SwcdcnYugorla\ia

0.6
0.5
0.4
0.6
0.5
0.1
0

16
64
35
18
24
16
15
33

Avera gc

Wm

26%

732

51%

46%

h d a
Peru

0
8.3

25

75

33

58

36
50

62
50

Avcrage

5%

30%

645

465%

548

M)anmar
Sudan

0
0

0
0

100
100

50
100

50
0

Avcragc

Orm

0%

1Wo

69%

314

0

65
82
75
83
84

4.4

50

44

46
56
35

liidncyI

Australia
Gnada(icchorlovaba
Gcrnlany, Fed. Rcp. of
Italy
KuwaitNcthcrlanh
Ncw Zc~land
Naway
Romania
SwcdcnYugoda~ia

31
25
21
10
14
I5
14
15
3.8
0.9
21
5.7

?3

46

54

46

31
39
30
21

30
50

70
50
40

n

44
40
60
65
13

36

48

32
36
26
32

53
70
63
53
62

54
70
4s
55
49
45
52
29

Average

14%

3%

57%

50%

50%

Olim

5.2
0

49
69

46
11

59
10

41

26

60

46

30
55
45
51

55
SS

71
-

U

Emada
Pcru

9.9

50

41

50

90
42
50

Average

5%

52%

43%

54%

46C

EWP~
Myanmar

56
100

27

2

0
49
76

62
75
52
14

38
3

hiland

18
0
15
1.7

Amap

8%

52%

40%

48%

2%

Ethiopia

7.7

74

18

33

67

14
18

75
31
29
29
24
30

51
33
20
69
69
69
75
70

66
82
80
69
84

58

[II

Sudan

N

36

48

66

Thgruid scan

1

n

Gnada
Gcchmlovaha
KuwaitNclhnlandr
Sew Laland
Naway
SwedenYu~orlaria

0.8
3.3
5
0.7
1.7
24
0.9
0.5

Awrage

1%

40%

48
64

aim

4.5

h d a
Peru

9

9.8

53
22
39

Avnagc

6%

49%

al
31
16
16
IP

64
81

28

n

59%

21%

791

43
69
51

22
14
20

78
86
80

46 5%

215

79%
I

UNSCUR 1993 REPORT

314

corvlny

Inrl
111

tV

Sa durriburion (%)

A l c dishibulim (%)

Ilealrh-rme

0 1 5 yc-s

16-40 ,wars>40 ?cars

Afalc

FcmnlcEwt
M ylnmarSubn
Ttuilnnd

9.5
0
4
1.9

62

24

71
52

33
82
25
46

II

76
75
66
89

Amage

4%

50%

47%

19%

81%

Ethiopia

0.7

60

20

40

bo

62

Is

65

58

14
24

18

25
14

Thyroid uplakc

I

Aushalia
Gna&
Czechalovaha
Germany, Fad. Rep, 01
ltaly
Kuu-ritNetherlands
Ncw U a n d

16
37
90
37
20

44
84
62
10
63
60

22

n

Romania
Yugorlrda

37
45

58
SS

Amage

1%

332

aim
h d a
Iraq
Pcru

6.5
9.1

N~~~~

n

n1

36
42

2
0
0
0
1
0
0.4
0
1.5
4.5
0

M

M

26

76
74

16

84

30
40
20
17
33

70

bo
60

18

63
67
62

66%

222

78%

60
22

34

n

12

47

41

23
14
24
20

Average

7%

55%

38%

22%

78%

Myanmar

Sudan
Thailand

0
4
1.8

35
71
52

65
25
46

30
14
12

70
86
68

Amagc

2%

50%

48%

18%

82%

50
43
48
50
51
0
50

69

86
76
60

Other
I

U

G n a d a (Ga47)
Canada (In-l l I)
C E K h a l o n h a , b l d cells
Italy (Ga47)
Nahcrlmdc
Romania
Yugala\ia

21
0

33

65

12

68

6

59

0
4.4
0
0

26
31
63
50

35
74
64
37
50

50
57
52
50
49
100
50

Amagc

1%

35%

64%

58%

42%

olirv

2

27

71

64

36

89

54

46

All a g n n l

I

I

Japm

3

7.7

The cnalcs In t h ~ sTaMc arc as lollour:
Cnda:

Pcru:
Hom511in:Svaden:Thdond:Yugnrla win:

Data arc la Nova S c d ~ aProvince m l y (abcut 33% of tht population).
01 all examinntiom are n n i c d cut.
Data are from l n r l ~ l u ~Pemanoode E n a g i a N u d a r mly, where about
D a b are f a 1990.
Data arc f a Stockhdm county only (about 20%-o f t h c population). Agc d~rtlibutim:0-14years, 15-39 yeorr. >40 y u n .
Data arc from the National G n c c r Institute and Rajabithi ffospital mly.
Datr mrc f a Scrbia only (about 40% o f t h c population).

Values arc m m n i n ~ u 101
l early pnrt a 1 the period only, since CT and magnetic rcaonance imaging (MRI) have replaced Tc.99m.

* lndudcs lung palwion.

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OLZ

005

.00S
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.

~ S Z

r p m ~ r ~ ~6861-S@bI"Yd

6861-5861
PL61-OL61

e~!euc[(osL-OS9)6801-5861

bwl

k 6 t - 1 ~ O~ L) ~6861-5861

e!PUl

kz6- 1 OPL

6861-21161
VL61-Of61"P ="3--(OPL- 1 OLE(OW- 1 281(09~- )>Z81(OPL- 1 , OLE,(0SL-059)(111-9s) 9L(01 II-LOP) 659(OPL* ) SSS

k 6 - O L E ) 91s(OPk ). SSS(~'6- ) V'L

.TI

.

8't

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(SSS-962) OLE(81S-222) OLE(526-ss) oeL

6861-98bl
6861.S861

uopou > 1 g q
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I1 I * A 4 =.'wl'*II(we-ssl)!9%/,f9P(001-UV) 89(021-0s)
ZL SS(OPLM)~) SSS(OPL-OLE). SSS( 0 0 ~ 9 6 Z )829

(OPL.OLE)
,9fS

SSS

Ill

(KL-OLE) US(OPL-EEE) 16P(WL-OSE) ocs
OOP(006-0d 059
OLE~ 8 5 1 ~ 0 9 ~',6'1 1 V'O

sss

I WL

OLE

( W L - O S ~SSS)

6861.E961(OPL-Elf)81s

S861.1861

SSS

9161

(009-091) OZP
Ot-E

6861-S86I
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ESV
OLE

0661
6861-0861

emourox1861

l Inl pUR~od

E'S
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I

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J&

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l ~U!DJII( n n y n u m d u! >YuD& (bgjv) pDrs?u.wpo k!l!r>o ~ 8 o a r v

uvu(dn~~P%UI

P3i!unPu'l"TllmS

3 r q d s q d 21,~

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m2.t

Lm.3

A i w a ~ encriviry d m i n i s r c r d (Mnq) (Ro~tfrin pmcn~hercs)
C~nrry" T c phnxphoreSudan

1986-IWO

555

h~land1976-1980
1981-1985
1986-1990

275
269
197

Cardro, atcdor

Broin

Ronr

Ycnr

O~halunkmtnown

P g m ~pcrrechncrarecw m ~ c~luconnrc

O~hcrlunknuun

OP'Tc eryrhrocyrer

312 '
350'
359

740
584
475

chloride

Orhcrlunknmn

444

llrttlthcarc Ir\rl I V
Ethiq~a500 ' (370-555)

1970-1989

503 (370-555)

PART 11: LIVERISPLEEN,LUNG. ICIDhFY

A trragc rrc~iviryalminirrncd (MI#(Hangc in p m r t u h u u )Counrr?.

L i l a I ~plclcm

Ycm
"'TC

colloid

OPmrc1IIL)A

Lunl
Orhrrlunhonn

OPmrcMA4

OPmrc
micicrorphcru

E;&qOrhcrlunlnown'"1 hippwolc'Y hippworc

1-29

108

IIrnlIh-csrr Icvrl I
Argentina

1985-1989

Australia

1970
I980
1984
IWI

61
115
121
17'9

1970-1974
1985-1989

I l l (37-148)

1970-1974
1976-1985
1986-1990

60 (40.120)240
240 (R0.300)

160
160

1989-1990

65-129

183

1975
1982

74 (19-.W)
120 (40.220)

1986-IWO

135-143

CanadaGrchcnlovnkin

Dcnmark
Finland IAIZJ

Germany. Fed Rep.

74

I I1

120
110
174

60
97
102

Ill q

18.5
111 (37-148)

185 (148-222)

160 (100-400)
240
280 (200400)

I60 (100.400)
240 ( 2 0 4 0 0 )

80 P
RO p

102

260 1 10.5 r

130 (74.220)
120 (74-200)
168

141-160 'D.7 '111
434
3711222''252 '

0.9 (0.4.3.7)
1.0 (0.4-1.6)
129

148

1.4 '11 1 '40.4

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(Pw

) %Z

(EI-

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6861-S861
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6861-S861
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5961-1861

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6861-S861
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6861-2861~~61-0~61

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9V6

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(-1E"'J)
KP( n l ~ w WE
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ElI

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(L'P

PP'V

9L61

581

S'f V
LE
LE

1'1

S861-11161(SSS-LE).&Ol/r')PZ(ooz-9'0) YL-I I(uor-81.0) ,so11e'r

LC

OE

6861-S861
PLbl-OL61(0~1.09) VL[ZIVIPUUIUYq ' Y L U qeR-ImlfmgrPKur3~ r a u o m / YJJ Ybd'"JA

air urn^

A ~ w o g ccrcli~,if,v~mlminis~rral(Affjq) (Rangc in p c r r c t ~ h o r ~ )Carntty7hyroid

KidneyYrar~luona~c

W " ~ coork

Olhrrluntuoun

w m ~ pcrcchnrrorcc'jll rrp~akc

l"1

scm

Ilcnllh<arr lcvcl 11
Ctuna
Dcijing arm
Iintirc nntim

h d n

1970-1974
19R5-19R0
19R6.lW0

2W (222-2%)
23

0. l l (0.07-0.I s)
0.1 l (0.07-0.15)
0.10

3.7 ( 1.5-9.3)
1I. I (7.4.18.5)
5.9

3.0 ( -5.6)
3.0 ( 4.4)

3.0 ( -5.6)
3.0 ( 4.4)

0.74 (0.2- 1.9)

1.7 (0.9-3.7)

10 ( -25)

10( -26)

1970-1974
1985.1989

296 ' (

India

19R5-IW9194 (74-555)

Iraq

IPRS.198q(2(Xl-400) 'Jamaica

1970-1974
1985-19R9

74 (

-182)

7 4 ( -148)

Peru

1985-IOU9740 (555-925)

18s (1 11-259)

0.4 (0.2-0.4)

Tunisia1970.1974
1985-1989

185
111 '

111
II I

3.7
1.1

RI

0.28

2.7

0.37
0.37
0.37

1
1
1

444)
94 (15-148)"

IIcallh-caiT lcvrl Ill
Eg~pt

1986-lo90

Myanmar

1976-1080
1981-1985
1086-1990

Sudan

1976.19R0
I98I.lQPS
1986-1990

na~lnncl

1976.1980
1981.1985
1986-1990

RI'. 1.15"
74 Y
74 Y
74 Y

148

:74Y

37

12'
20 '
21

1.1

1.1

1.1
1.3

1.1
1.3

0.5
0.35
0.12

0.45
0.47
0.23

1.7 (1.7-2.2)

1.7

IIrmlth<niT lwcl I V
Ethirpin

1970-1989

74 y (37-74)

I'sf

rrp~akc

12'1

~ c m

UNSCFAR 1993 REPORT322

1 h c entries in this TaMc arc qualified as Follows:
Awrrolio:

Czecharlo~~otja:
Co~da:
H n s s 2 raland:)L~oslo\.in:

T and MRI f a Tc-9%. ~ h cnumber la brain cxa~ninulinisuith Tc-99m pmccfinctrtc and Tc-99mTcOIving to the subti~ulirmo l C
duconatc lor IVY I ir too small to statc svcragc. Informalion pertaining lo Par1 111 olTuhlc: "Cia Citralc lun~ourfirifection,1980: 166 MBq;
1984: 210 MHq; 1991: 212 MBq.
Infamatim pertaining lo P u t Ill d Taldc: Tc-Wm ILhPAO blood cdlr. 1976-3990; 160 MDq.
I h t a arc la Nova Scdin Probincc mly (&cut 3.5% of the population).
N m a t a11 1'11 uptskcr arc d m c on patienu rccciring l a r p thcrapcu~ic'"1 doses. In cllictivc dcsc u~imatioruuptakc should beavumcd = 0. Ahou~one lhird o l W c thyroid scam arc also uced lo r u c u uptake.
Data arc f a Scrha and Mnccdonia only (about 5m of thc population). Data f a 1970-1974 arc lor Scrhia only.

Radicirdopc used is Sr-85.
Radiciraope compound used is 1-131 RIISA
Radiasuope compound used is Tc-9% IIMPAO.
Rahcisdopc compound used is Tc-9% MIBl.
Waditisdope compo-md used is Tc-9% DTPA
I Radicisuope compound uscs is Tc-99m PP.
R a d ~ d s d c p ccompound used is 1-123 amphclminc.
Radicisuopc used is Tc-99m.
' Radiasuopc used is Tc-99m patcchnctatc.
J
Radicisdopc used is Sc-75 mahioninc.
RaQtisuope compounds used arc Tc-99m phcsphatciphosphon.~c.
I
Radicisuopc compound used is Fc-59 d ~ a l c .
Radicisuopc compwnd used is 0 - 5 1 dlnte.
" Raditisdopc used is 1-13].
O
R a d i t i a o p e used is Xe-133.
p
Raditisotope Cwm wed is Tc-Wm aerosol.
q
Raditisotopc compound used is I n - l l l m c d l a d .
' Radici-opc compound, d Tc-9% arc m i l l i m i n s p h n a . denatured q h r o c ) z u urd phpatc.
' Radicimopc fonn wed arc 0 - 5 1 denatured cr)hocyccr.
a

'

*

WG.
" Scqumcc.
Radiasdopc used is Au-196.
R a d i t i a o p c used is In.113.
' Radicisuopc used is Ilg-197.
yRaditisdopc compound used is Tc-99m DMSA:Raditisdopc compound uscd is Tc.99m MAG3.
"" Radicisdopc compound used is Tc-9% gluconalc.
bb Roditisaopc compound uscd is 0 - 5 1 EDTA""

Table 30
Errcctivc dosc cqulvulcnts to patlcnls from diagnostic nuclear medicine examinaUons (mSv)
Iicdth-rare l n r l I1

Hedrh-cmr In.*/ I
Ewninolion

C:ccharlo~pLin. 1987 IIUO]

Drnmorf 1990 [E3]

Irdy, I199 [Dl11

4.5
3.5-6
4.3-17.2
1.4-3.5

0.5
3.7
13
1.9

4.5

Bran
Grdwucularl~vcrhplccn
Lung rcnlilarim
Lung perfusion
hdncy
Thyroid r a n
Thyroid uplakc

1.?
0.01-21
1-36.3
3.1

1.1-6.6
0.6-1 1 3
3.0-215
0.9-:.6
0.070.3
1.1
0.01-13
2.1-13.7
3

Avtragc

24

3

Iknc

When Tc-Wm 1s available. Standard proccdurc: Au.196.
When Tc.Wm is available. Standard procedure: 1.131.

1.4
1.7
2.1

Chi-

I983 1261

1.8

P 1.2 '
<O.l
94, 0 3
1.5
15-30

*

ANNEX C: MEDlChL RADlAnON MPOSUKrS

323

Tahlc 31
Ayc-dcpcndcnt analysis of cffcclivc dosc cqulvalents lo patlcnl from dla~nmtlcnuclear rnfdlclnc exerninallons

Dart JorrurO r l ~

Rdiopha-mnceuricd(rnFvIMBq).4w7a#encririy '(MBd

Efecriu dnse
tqu'valmr p acraminorion (rnTt,)

E+Mlinnrimr

9.5
11.1
73
13.9

0.17
0.05
0.004
0.006

1.6
0.6
0.3
0.08

5.7
7.6
19.7
9.1

0.20
0.19
0.004
0.006

1.1
1-5
0.08
0.05

6.3
8.7
17.5
9.8
1.6
5.4
1.4
4.7
3.8
25

6.39
4.47
0.79
1.19
4.81
0.16
1.83
0.75
1.12
1.36

40.3
38.7
13.8
11.7
7.9
0.9
25
3.5
4.5
3.4

23.6

127.2

Pa 1,0@'popularion *E l f C c r i ~dW~t p i i ~ l pae ~
C

V

W1.J

~

Agc ~ r o u p :0-9 y e a n

hnc
Brain
CIr&ovascular

Tc-9% phosphate
Tc49m ducorulc
ll-201 chlaidc
Tc-99m ciythrocyta

0.025
0.E4
20
0.W

380
460
37
555
Age ~ r w p :10-19 y e a n

Bone
Brnio
Gr&onrcuhr

Tc-99m p h ~ p h ~ c
Tc-9% glucoru~c
ll-201 chlaidc
Tc-99m crythrocytcs

0.010
0.011
0.36
0.011

no
690
55
830
Agc group: adulu

Bone
Brain
Grdimnscular
Livrrhplccn

Kdncy
ThyroidTdal

Tc-99m phorphale
Tc-99m g l u c o ~ t c
ll-201 chlaidc
Tc-9% e r y t h r q a
Tc.99m cdlad
Tc39m lm)A
Tc-99m MMA
Tc-9% giucomtc
Tc-99m patuhnctatc
1-131 imic

0.008
0.009
0.23
0.0085
0.014
0.024
0.012
0.009
0.015
6.6

790
962
76
1156
117
226
114
523
3 0

0.38

Activity admininered and cxaminalion h q u c n c y for Manitoba. h n d a [H17]. For c h i l d r ~it uas assumed here lhal acti%ilics administered were reduced
accading to B c c n ~ j a[BIO].
Auumcd lhyoid uprake: 15%.

UNSCMR 1993 REPORT

321

Tnhlc 32
Collccllve doses rmni nuclear medicine cxaniinatlons, 1985-1990
Numb of a M l i ~ 1 i o n . r
pa 1,000 popularion

AMUI r d l a t i t r f l c c r i ~ rdnrc( m S ~I ~E f i r r i w dart
po aominaion (mT4

Examinnrim
Lnrl

I
4.8
0.42
26
1.4
1.2

Ln~cl
I1

Lnrk
Ill-n

Il'orld

0.W4
0.007
0.014
0.016
0.W8
0.008
0.023
0.M6
0.052

1.3
0.11
0.68
0.38
0.30
0.55
0.41
0.51
0.24

0.28

-.-

lbnc
Dram
GrQovsscuhr
Lvnlsplccn
Lung ventilation
I-un g perfurron
Lhcy
Thyroid scan
Thyroid uptake

0.55

0.016
0.006
0.008
0.0?3
0.001
0.002
0.096
0.M2
0.167

Tall

16.4

0.38

22
1.4
1.0

..

Lo,</

Lavl

I

n

6.3
8.7
I4

6.3
5.7
14

3.5

22

0.3
1.4
4.7
3.8
25

0.3
1.4
4.7
94
25

Lads
111.n~

6.3
8.7
14
22
0.3
1.4
4.7
94
25

Lovl

Il'orld

6.3
6.7
14
4.3
0.3
1.4
4.7
12
25

Avnagc dcsc p n
cxamina~icn(mSv)

5.7

20

27

6.7

A m a g e dose
per capur (mSv)

0.094

0.00750.0076

0.030

I

Lor1
I1

Lark
Ill-w

40700
4930
49900
6660
470
4160
BS80
9290
1860

270
140
300
1330
1
7
1190
15300
1100

690
60
260
460
3
I5
140
8130
170

41700
5150

12700019600

WOO

156000Tuhle 33
Conlrihulion or various types or nuclear rncdicine examinations la lhc collcclive dose, 1985-1990
Dara jrom U h ' S C E 4 R S u r v e y ojhledical R a d i a t i o n Usage and E x p o s u r e s

Conmibuton to r ~ a cdlerritrldosc (7%)
GdarionCardovascularEonc
T h y o l d scan
Ldncy
Lvcrlsplcrn
Brain
Lung pcifusi on
Thyroid uptake
Lung ventilat~on

Lad 1~ c r rnl

L m c k 1II.IV

World

3'9

1
1
78
6
7
1
0.4
6
0.m

3
7
82
1
5
1
0.2
2
0.03

32
27
21
7
5
3
3
2
0.3

32
7
7

5
4
3
1
0.4

It'orld

3MOO

8
1
9
480
4160
1WiDO
32700
3130

ANNM C: MEDICAL RADlAnON I'XI'OSUHIS

-.

325
-

T n b i e 34
A n n u a l Indivlduul ~ r n dcollccllvc c r k c t i v e d o s c from n u c l e ~ ~r nr ~ d l c l n ce x a n ~ i n a t i o n s
D o r a Jrom UN.YCI3R S u r v e y o j b t e d i c a l R a d i a t i o n U s a g e a n d E x p o s u r e s u n l e s s orhern.ise i n d i c a r c dt'flccri~rdate c q ~ i ~ ~ a l c/ InEr (my1 J
Coung,Yea-

Per indiiidual parirnr

Per capu

Collrcrit~c
cflccri~~r110sc( m S I~)

Rrfrrrnce

Ilrallh-cuc lrvd I
Aurtralin
Dulgaria
Gna&
Manitoba&kc
G.cchcslma!cia
Denmark
EnlandGcrmnn Danocra~icRcpuMic
Germany, Fed. Rcp. of(Baeria and Wul Berlin)
Cnocce (northern part)
Italy

Japan
Ncthcrhnds

1980
1980
1980
I985
1969
1983
1987
1985
1990
1982
1978
1981

2.5
8.4
3.8
5.2
6.4
22
24
3
3

0.02
0.11
0.17
0.13
0.42
O.M
0.06
0.05
0.05

3.4
22

0.03
0.02

430
610
250
250
430 '
480
3 0

1985-1986
1984-1988
1982
1983
1989
1982
1984

27-32 '
25
29
3.3
4.5
4.1
29
27
25.7
3.5
8.2
25
5.0

0.11-0.12

7000

0.03
0.03
0.04
0.055
0.034
0.03 1
0.06
0.05
0.032
0.02
0.14

1510
1890
2450
42401
480'
450 '

0.005
0.m

4960
21000

O.M2

1340

1981
1986
1981
1982
I982

PolandSwedm

ussn

Lhitcd Kingdun
United Stata

30
970
$200
127
3Otl

XKl

420
8600
loo0
32100

lull
lull
11-11
11117)In 101
IIIMl

~31
lA121
lE5l

[K1O]
IP20]
ID111

[Mll. M12)
fU2Ol
lR20l
(S41. UI]
IV41
[sol
[I1101[MJI. XI]

Urslth-cnrr Itvd 11

'
f

8

1

(3hiru1981-1985

6'
15-34

Lndia

1985-1989

7.9 1

'

[ u l . z]

Valuc f a Bavaria and W& Berlin cnrapdatcd to thc cntirc wuntry (cxcql new BundalSndcr).
~ o n a p o ~ lod r2.0 mSv/uarninalion (rornc patimlr had rnnc than onc cxaminat~on).
Ltirnatc amounting for agc dis~ributiond population.
lligh ~xluccausal by ubiquitous wc o i 1-131, 4 7 4 d all cxarninalims wilh an abrragc collcct~vcdate pet plicnl d 51.5 mSv.
Of this valuc 51% is duc to Tc-99m. 4 7 5 to 1-131 and 21% lo all ahc: nuclidca.
Gllceivc dosc cunponcnt to worncn is 1,910 nun Sv.
Thc cdlectivc dare due to thc somatic part d thc clTectlvc dose qulval:nl is rcpatcd lo bc 575 man Sv [B20].
Probably undcra~irne~cdue to low prccisim In cornpulatim.
Using two difTcrcnt rncthdr to utirna~ccallecr~vcdose p a cxaminrlion h m 1761. lLgh wluc depends on 1-131 rhycid scint~grphy~ 7 t hcdlcct~vrd m c pn
cuminatim tmng 94 msv.
Mainly duc to use d 1-131.

-

Ttrhie 31
E s t l r n a l c d d m e s lo the w o r l d p o p u l n l l o n t r o r n n u c l e a r r n c d l c l n c e x n m i n n t i o n s

Iledrhcwr
loel

Popdolion(rnillwnr)

Annual pa copw rficti\edarc c ~ i v a l e n r(mSt.)

Annual collari~,cflecrit.c
dose cqui~mlcn~( I # man St.)

I

1350
26%
850
460

0.09
0.008
0.008
0.006

130

n
Ill
IV
T d
Average

zn
6
4

160

5290
0.03

Tn hl e -36
Tolal annunl number of rndiolherapy h a i m e n l s per 1,000 populullon
Data /ram U-RSurvey ofhfedical Radiation Usage and Exposures unless orhenr~iscindicared
Brrrzhyrhaapy

Tclcrhaap

cowq
1970-1979

1980-1984

1985-1990

1970-1979

1980-1981

198.5-1990

nrnllh-cuc fcvd I

0.2
0.2

Argcntina

Awlralia
CanadaCuba
Gcchmlmkia
Dcnmark
Finland
Iceland [L16)

20

law

0.7

1.6
29

4.2

Kuwait

1.5
29
0.2
27
1.2
1.2
1.2
0.7
0.2

0.8

0.2

0.1

0.2

0.2
0.M

Luxembourg

MduE;&alan&

New Z n l m d
N-Y

0.4
0.5 =

R m - r

Sdcn
Switzerland
Uni~edKngdan
United Slates

0.4
1.7

0.6

0.1
0.2
0.3

0.08
0.06
0.2

0.07
0.03
0.1
0.07
a1
0.1
0.1

24
24

Yugarl~ria
Avcngc

1.8
0.6
3.9
6.8
0.8
1.8

0.05
0.1
0.1

0.6
1.0

24

1.2

0.9
0.26

0.17

0.25

Ilcmllh-con Icvd 11

Barbdcs
china
Ecuadcr

0.03

India
Iraq
JamaiaPcru
Turkey0.09
0.7

Avnagc

0.9

0.1

0.6
0.2
0.08
0.1
0.1
0.1
0.1
0.7
0.2

0.03

0.2
0.08
0.02
0.03
0.009
0.07
0.04

0.02

0.M

0.006

nrnlth-cux lcvd 111

0.04

E m
India
Myanmar
Sudan'Thailand

Avuagc*M a l ~ p a nl r~c s r c only.
Value rncludcr bnchphnapy.

0.07
0.2

0.2
0.08
0.09
0.1

0.0005
0.02
0.01

0.02

0.01
0.00

0.02
0.0003
0.04

0.03

0.02

ANNEX C: MEDICAL ~ D I A T I O NWPOSUKFS

327

Tnhlc 37
Avcrngc nnnuul nunlttcr of tclcthcn~pytind brachythcrapy treatnicnlc pcr 1,tK)o papulnlion
Dora from UNSCbjlR S~rrveyof Medical Radialion Ilsage and Exposures, unless o~hern~ise
indicared
PART I: TEIlTllERAPY

CovnnyY

Lcukacmia

Lymphoma

BrcasfRupirday

IYN)W

qam

gcnimlagam

fmur

NcwoMa~romadLcpru

0.041
0.001

1.3
0.9

0.0001

1.2
3.4
3.8
23

Wilmr'

Ilcallh-crc Icvrl 1
Aurtralia

1970-1974
1985.1989

0.010
0.021

0.12
0.017

0.27
0.19

0.16
0.29

0.012
0.11

0.003
0.0006~olovalda

1970-1974
1976-1960
1981-1965
1986-1990

0.W
0.006
0.006
0.W

0.058
0.028
0.024
0.017

0.19
0.15
0.16
0.16

0.19
0.15
0.17
0.16

0.19
0.071
0.076
0.075

0.001
0.001
0.W

0.11

0.14

h a r k1985-1989

Rnlaad

1967

Japan

1970-1974
1975-1979
1985-1990

0.0%

0.009
0.016

0.18

0.032

0.29

0.m

0.06 10.75 '
0.m
0.M

3.33
0.075
0.059

234 '
0.093
0.17

0.12
0.061

0.35
0.013
0.002
0.002

0.012

0.086
0.09
0.062
0.078

0.001

0.002

0.007

0.047
0.16

0.27
0.17

0.00010.0003
0.001

3.3

0.12
0.53

0.12
0.49

0.13
1.1

0.075
0.093

0.36
0.41

0.054
0.077

0.069
0.14

0.002
0.002

0.007
0.00 1

0.W
0.023

0.017

0.03 1

0. 12

0.13

0.26

0.010

0.06 1

0.007

0.010
0.029
0.018

0.038
0.m
0.045

0.12
0.13
0.16

0.1 1
0.14
0.20

0.11
0.11
0.16

0.001
0.001
0.008

0.020

0.40
20
0.48

0.24

0.064

0.24

0.016

1965-1989

0.016

0.021

0.059

0.029

0.022

h'clhcrlmds

1987
1986-1989

0.028
0.045

0.076
0.1s

0.49
0.98

0.44
0.85

0.11
0.22

Hew &land

1970-1974
1975-1979
1980-1984
1985-1989

0.003
0.009
0.016

0.033
0.027
0.027
0.053

0.14
0.086
0.077
0.21

0.13
0.014
0.16
0.20

1970-1974
1985-1989

0.001
0.002

0.044
0.074

0.18
0.18

1980
1990

0.043
0.m

0.028

Swcdcn1970-1974
1985-1969

0.029
0.024

Yugdaria

1985-1989

Avmgc

1970-1979
1980-1984
1985-1990

Ranis

0.002

0.002

&wail

Nauny

0.11
0.004

1.2

3.8

Ilrnlth-rut Icvcl Il
BuhdosQl~na
Bcijing area

1965-1989
1970-1974
1985-1986
1986-1990

0<0.0001

0.016
0.014

C.019
0.021
0.036

0.023
0.034
0.037

0.009
0.010
0.045

0
0.0001

0.003
0.009

0.001
0.004

Ecwda

1970-1974
1985-1989

0.0005
0.002

0.002
0.007

0.008
0.02 1

0.002
0.005

0.015
0.012

0
0.0001

0
0.001

0.002
0.005

lndla

1965-1989

0.00320.W7

0.01 10.00670.036

0.00070.00010.0036

Iraq

1985-1989

0.009

0.005

0.041

0.037

0.015

0.001

0.M09

0

Jama~a1985-1989

0.W

0.055

0.005

0.002

0.W06

Peru

1970-1974
1985-1989

0.013
0.016

0.005
0.009

0.053
0.068

0.00060.00 10.00030.000rTurkey1976-1979
1980-1984
1985-1990

0.19
0.22
0.17

0.16
0.28
0.18

0.10
0.10
0. I0

0.13
0.12
0.046

0.04
0.06
0.040

0.04
0.07
0.042

0.03
0.02
0.006

1970-1960
1985-1990

0.016
0.004

0.015
0.005

0016
0.026

0.011
0.025

0.N:
O.Ml

0.003
0.001

0.002

Enlirc mlicn

Avcnp

0.014
0.012

0 . ~ ~ 4
0.01 30.004

UNSCMR 1993 REPORT

328

Tnl~lc37 (conrinucd)
+

Cnunm

Y e

Leukocmia

RrcnrrrumourLymphoma

Rcrpirday
sysronH'ilmr'genital
aganr

rumow

NnuoMmomoHcnizndiscmcrI I ~ . I ~ ~ I -C CV ~In~
Eppt

1965-1990

0.002

0.006

0.026

0.003

O.(Y)05

0.01

0.0005

0.004

India

1970-1974

0.00070.00 170.00470.00220.020

0.00030.00010.0035M>anmar1980-1984
1985-1990

0.002
0.001

0.004
0. 03.l

0.01 2
0.013

0.023
0.024

0.019
0.018

0.00020.00010.00010.0002

Sudan

1995-1990

0.05

0.008

0.009

0.003

0.008

0.002

0.002

Thziland

1986-1990

0.010

0.010

0.019

0.008

0.037

0.001

1970-1980
1980-1984
1985-1990

0.0007
0.002
0.005

0.002
0.004
0.007

0.005
0.012
0.018

0.002
0.023
0.009

0.019
0.017

Average

0.00030.0002O.MX)80.00020.00010.00010.0006

0.004
0.004

PART 11: B W I M E R A P Y
F d e gcnilol organr

CounfyYew

Brcnrrrumour

ProsrareAfmlooding

RdLun

IIY)(OIY

BrainrumourOrkrrumowsBenigndiscnrrr

0.18
0.076

0.51

0.003

0.006
0.002
0.0003n c a l t h i s r r lrvd I
Ainealia

Crcchcslmab'a

1970-1974
1965-1989

0.001
0.016

1970-1974
1976-1980
1981-1985
1986-1990

Denmark

1985-1989

0.020

Japan

1970-1974
1975-1979
1980-1984

0.001

0 . W

0.068
0.019 '

0.034

0.064
0.16
0.09 1
0.034

0.16
0.031
0.016
0.10

0.073

0.012

1985-1969

Netherlands

1968.1989

New Zcaland

1985-1989

Nauay

1970-1974
1965-1989

Romania

1980

Sweden1970-1974
1985-1989

0.003
0.024
0.0007

0.082
0.19
0.025

0.035
0.006
0.054
-

Kuwait1985-1989
Malta

0.002

0.028
0.017

0.019

0.001

0.066
0.13
0.013

0.001
0.00050.019

0.00020.054
0.0001
0.002

0.037
0.029

0.006

0.010
0.005
0.005
0.001
0.004

0.14

Yugoslavia

1985-1989

0.029

0.015

0.15

0.63

Avcrngc

1970-1979
1980-1984
1985-1990

0.00010.0005

0.019

0.005

0.16
0.034
0.062

0.022

0.004

0.M8
0.035
0.22

0.010

0.016
0.004
0.024

0.0004

0.007

0.W8

0.047

0.W
0.015

0.002

0.008
0.002

0.012
0.022

0.16
0.002
0.021

n r ~ l t h - c mlcvd 11
Barbed-1965-1989

0l1m

1986-1990

Ecuada1970-1974
1985-1989

lnd~a1970-1974
1985-1989

0.24 '
0.02

0.00030.00001

0.00060.002

0.000?
0.0307-

Table 37 ( c o n l i n u c d )F c d c fenilol W ~ O N
Cowtm
Year

Brcmt
r v ~ w

hatrafc
1-w

*

Brain

R u f k~firrlodinff

rvnow

Orb
lwnoyrsIraq

1985-1989

O.ID9 '

Jama~ca

1985-1989

0.06 1Peru

1970-1974
1985-1989

0.031
0.044

O.MI
0 . W

1970-1979
1980- 1984
1985-1990

0.024

0.cOLvAvcrage

0.012

0.00001

0.002

Hcm~n
duemu

0.012

0.013

0.00s

0.W2

O.M1

0.00060.0002

ncnllh-cur lcvd 111

Ew@

1985-1990

0.005

Myanmar

1975-1979
1960-1984
1985-1990

0.01 I
0.012
0.016

Sudan

1985-1990

nailand

1981-1985
1986-1990

0.041
0.016

1970-1979
1960-1984
1985-1990

0.008
0.029
0.010

Avmagc

0.M03

0.m
0.012
0.016

Oualifinlions d cnaiw in this Table have t u n given as f d l o u l :Cuba:

Denmark:
FinlandIraq:

Data for 1985-1969 from Nova Scotia nnd Rincc Edwrrd l d a d about 4 2 ofthc population of the muntry. D a n for urlicr periods f r a n
Nova Scuia only, about 3.5% of the population of thc country.
Data from PIUfO.
Data also f r a n p 1 6 j .
Data also f r m [Llbj.
Data from lmtitutc 01R a d i d o p md S u d u r Mcdicinc, Baghdad.
D a ~ aborn Kingston I1mpit.l only.
Data also irom [06]. Values f a 1988-1989 ore numbcr of trcatmenls, not padcnts.
Data also from [Llbj. Vnluu include palliatlvc trcatmcnts: d m u f a curativc trcatmmts only arc about lo% higher. Valuc gvcn for k n i g n
discax is f a 1990.
Data also f ~ o mbib]. Data lor telnhmpy arc scaled up hom non-random sample of 33% d patients (ncithn af~aloadtngnor hcadmak
arc cvcnly dirlrilutd in the country.) Data f a hachyhrrapy arc scaled up horn nm-random sample of 2 8 5 of patients: thcrc were m a cchildrcn than average.
Data from Ilaccttepc Univcrsi~y(2% d thc papulatim).
Data la tclctherapy exclude Montmcgro. Vojvodina and );omlo. Dab f a bnchythc:apy arc for Goatia mly (about 20%d thc pcpulatim
d the famer Yu@awa).

"of trcatmcnts, not patients.
* NumberVal* is for buh Ieukcmia and lymphana.
L i L u m nd n d ~ u m .
RaLum and acrlurn.
Manual adrnrninralion d ucrium-137.

UNSCMR 1993 REPORT

330

Tnhle 38
Agc- nnd scw-dlslrihullon or pnllcnls undergoing Lclclhcmpy nnd t)rnchylherepy Lrculmenls, 3985-1990
Dora /ram UNSCW R Sunvy of Medical Radiution Usage and Exposures
--

- - -

PART I: 7EEllERAF'Y
Scr diswibvrion (5%)

A#c dhributicm (%)
Cowhy

Ilcdth-care

0-15 ycars

ln,cl16-40 )uws

I

>40 ycnrs

hfalr

34

63
60
53
60
70
71

n

37
do
47
40
30
29
43

M

M

61

39

50

50

63

F d e

LukxrnisI

Awtr~lia
Czcchohlovaki~
Kuuqi lNcw b l a n d

u)

52
6.7
23
40
78
29
0

swcdrnYugoslavia

41
95/\wage

43

17

39

M

Tutkey

34
60
87

33
39
21
10

11
27
18
29

M

37
a
44

Avaage

35

38

27

63

37

ED?[
Mpnmzr

34

47

66

34

46
13

50

50

Thailand

19
4.2
83

4

51

50
49

Average

39

29

32

56

44

53

55
50

47
47
44
31
36
43
45
50

Eada
India
lraq

nr

45
9.6
30
35
0
30
5

Kauay
Rcmunia

I1

21
38
73
47
25
22

Lymphan.

I

Su,cdcoYugoslavia

4
0
13
24
23
1
3.8
17

41
28
31
18
33

70
61
64
35
69
68
79
50

Arnap

11

2.5

64

55

45

Ewda
In&a
baq

40

22
2.5

zz

a

?3

57
39
27
13

78
75

Turkey

18
23
20
63

13

67

Arnage

23

36

39

75

2.5

ED?!

Myanmar7h.iland

16
5.4
9.3

37
21
26

46
73
64

62
63
60

37
do

Arcrage

11

3

60

62

38

1
1
0
1

99

0

5
6.3

69
86
60
92
89
93
95
92

0.0?

9.7

3.1
0
0
0
0.1

M

b d a
lndla
Iraq
TwLy
Avnrge0.1

Aurcralia
Gcchorlovakia

Japan
Kuu-ifNcw Zealand
Naway

D

n~

21,

39

23

38
53

53
56
69
64

n

38

Rrr.11 cumour

I

Atntral~aGechelwabr
Kuua~tNew Zealand

Nuway
RmunraSurdcll
Yugdavia

Amsgc

n

mim

0
0
0.9
0
01
0
0

1I
14
39

2
0

99
100
99
100
1W
98
100

90.4

0.5

99.5

29

67
71
72
60
71

5
0
1
0
0

95
100
99
1W
100

28.3

71.5

1.1

98.9

7.6

II
7.3

29
28
40

0

0

Scr dirrrihrrion (SF)Agc dkoiburim (St)

Cowrrry

Ilcdrh-rmc

O15 .vcnr~

16-40 years>10 years

.Udc

Fcmdc

0.7
0
0

36

63

MyanmarThailand

17
41

83

99
99

59

1
1
0

100

Average

0.2

32.8

66.9

0.6

99.4

1.3
3.2
5
3.6
1.5
1.4
5.1
3.4
13

99
97
95
95
98
99
95

75
59
81
85
67
75

23

Y

66

%

87

69
90

31
10

lnvl

ni

E
m

lun%thoru

1

Yugoslavis

0
0
0.2
1.8
0
0
0
0.2
0

Average

0.1

5.1

94.9

76

24

Olina
Ecuada
India
Iraq
TUw

1.6
0
0
1
0.7

32
12
13
8.4
11

67
88
87
91
88

71

29
12

Amage

0.2

15.1

E m
MyannurThailand000Avcragc

0

Australia
Crccholwaha
Japan
&wait
New &land
Nauay
RomrnimSweden

n

UI

1

11
19
15
33
23

68
80

20

83
94

17
6

84.7

79

21

18
3.3
23

82
97

n

61
71
23

19
29

'77

16

84

.57

43

Gynsrcdqicd

I

0
0
0.3
25
0

12
11
12
30

88
89
87

0
0
0

66

0

Z

0.8
0

0
0

7.9
42
5.9
14

78
91
58
94
86

0
0
0
0
0

100
100
100
100
100
100
100
100
100

Avcragt

0.2

15.4

04 .O

0

100

10
14

89

a

P

64

100
100
100
100

Aufralia

Czcch~lwaha
Japan
Kumi 1
Ncw Zuland
Nuuay
Romania
SwedenYugorlam

D

ana

0.6

Ecuada

1.4

bdi a

25

Turkey

0
1.6
11

41
21

75
58
68

0
0
0
0

Avcragc

01

23.4

76.4

0

100

EWPc

0
06
0.1

33
6.4
30

67
93
70

0
0
0

100

MyanmarThailandAvnagc

0.2

24.7

75.1

0

100

%

44

55

45

33
50
0

40

Iraq

ll1

100
100

Wilm~'lunlour1

Ncw b l a n d
Nuway '
SwedenYugalana

!00
95
100
100
100
100
100

0
5.5
0
0
0
0
0

0
0
0
0
0
0

67
50
100
80
50

Avcragc

99

1

0

60

Auatrdia(lechalovaha
liu\nil

020
50

UNSCEAR 1993 REPORT

332Tul)lc 38 (conlinucd)

S a duwibu~ion(%IAge dirpib~ia(5)Jlralrh-cmr
lor1

UCovlby0.15 yews

I M O .WS

>10 years

Male

Frdr

Fmda '
India
lrnq
TwLy

100
65
100
100

0
II
0
0

0
24
0
0

100
68

50
68

0
32
50
32

A~rrage

66

11

23

68

32

%
100
100

0
0
0

4
0
5

40

Myanmar 'Thailand

60
67

Average

99

0

1

40

60

56

44
0
50
50

Ill

33
44

M

SrumblmLorrw

1

50
33
75
100
16
100
30

44

0
33
0
40

50

71

0
30

80
50

29
20
50

Avaagc

49

37

14

65

35

Enuda
India
La¶
Twky

50
73

50

100
89

17
0
11

0
10
0
0

50
64
67
67

50
36
33
33

Average

73

17

10

64

36

EQ~I
Mpnmar ''Ihailand

90
100
100

10
0
0

o
0
0

47
0
63

100

Average

%

4

0

40

59

90
99
58

*

n

UI

6
0
0
0

Australia
Gcchmlwaha
Kumit
Ncw 7xaiand 'h'au*ay 'SwcdcnYu~avia

67

25

100

50
50

n
36

Benip ditcun

I

I1

60

52
39

65
36
58
50
55
42

3

34

63

56

44

0
3

8.3

92

lnd~a

43

54

96
51

25
49

A\nngc

3

43

55

52

48

49

51

37

63

9

Alattal~aGccharlovaba
Japan
KunaitNew Zuland
Sndm

1
0
4.2
4
1.6

Amage
Enuda

9
1.4
38

u
41

35
64

42
50
45

58

All malipml tumoun

I

U

Japan
Nahcrlandr
Romann

24
0.2
1.3

13
6.4
14

85
93
85

Amagc

2

13

86

47

u

Oun~

4.3

24

72

44

56

India

3

25

72

19

81

Average

3

25

72

22

78

PART 11: BRAC1fi-ll W A P Y
Age-dimib~ion0l/cdfh~c~r
Inrl.k-dLhihuion 0

counrry

0 1 5 yews

16-40 ycars>40 years

Mole

Fcdr

n

0

100

Brrnal l u m w r

I

n

II1

Auswalia

0

23

aim

3.1

M

67

5

India

0

0

100

0

95
100

Asrrsgc

2

17

61

3

97

Thailand

0

63

37

0

100

P r m m k Lurnour
1

U

Australia
Crechatlavakia
Naua y

0
0
0

0
0
0

100
100
100

100
100
100

0

Avetagc

0

0

100

100

0

Turkey

0

0

100

100

0

0
0
0

100
100
100

0
0

Cynarcdogicnl (radium)

1

0
0
0

19

(itEhmlova!sia
Naua y

10

81
100
90

Avcragc

0

12

66

0

100

China

0.6
0
0
0

10
22

0

0

16

69
78
60
1M)
64

0

12

66

0
0

100
100
100
100
100
100

Average

0.3

22.2

77.2

0

100

'Ihailaad

0

56

41

0

100

91
63
74
86

0
0
0

0

95

0

100
100
100
100
100

86

0

100

90

0
0
0
0

100
100
100
100

Australia

II

EcuaduIndia
kaq
Jamaica
Pcru

Ul

0

40
0

0
0

0

Cynnccdo@icd(dtrrloading)

1

n

1

Australia
Gcchatla!sir
Now Zcalandh'orway
Swcdm

0
0
0

0

6.9
17
25
12
4.7

Average

0

12

Qioa

0.6
0

10
42

0

lndit

0

n

Turkey

0

45

58
73
55

Avoage

0.3

17.3

E?.7

0

100

o

Ecuada

o

0

33
34

67

Thailand

6(,

0

100
100

Avc~agc

0

34

66

0

100

ni

Rrsin tumour

I

II
1

Australia
Ncrway '

0
0

100

0

100

0

0

100

0

100

Avnagc

0

81

19

61

19

China

7.3

37

55

64

3

-

Tuhlc 38 (continued)
k.dimiburion 0~~c-diruibwim
0

Iledlh-rmc
lor1

covnhy0.15 yews

Id40 y c u s+ I 0 ycors

Male

F d e

Other turnaun
Australia
Oechalwakia
Nau-rySwcdcn

0
4-5
0
0

100
95.96

0
0

100
11-66

0
3-89

0
0

100
100

58
50

50

Amagc

1

66

31

60

IS

n

India

0

12

88

68

32

nl

hiland

0

46

54

30

70

100

0
80

100

12

88

48

30

52
70

22

48

2

I

'

42

Benign d i a e r nIn0Ctcchcalovoldr
k a it0

Avcslgc

0

0

100

India
Jamaica

7

71

22

Avaagc771

20

All malignsnt Lumoun

I

Romania

1.3

14

85

37

63

D

China

4.3

24

72

44

56

Thc cntriu in this Table arc qualified as follow+:hfyannw:
Romania:
Thdand:Turkey:Yugalavia:'
1

Three paticn~s.
Fivc paticnu.
One patient.
Four patients.
Six palicnts.
T w o patimu.

Data horn Ynngon Gcnual Hospital only.
Data arc from a u m p l c o f 4 of thc popula~ionin 1990. F a Ieukacmia, values indudc lymphoma. F a 'All m l i p n n t turnours', data are
for Cod0 only, namely Y d all palienu; moll a h a patients wcfc t r u t e d u i t h x mys.
Data horn Department of Radidogy, N a t i d CUK;Q Institute, Bangkok. only.
Data arc la 1986-1990.
Dala arc fa S c r h a only ( a h 1 40% of Ihc population).

Tnhle 39
Doses to paticnk undcrgolng rndiaUon tclclhcrapy nnd brnchythcmpy, 1985-1989
Data jrom UNSCWN Survey o j Medical Radiation 1/sage and i3posures

PART I: lELETl tIXAl'Y

TargetSurface22 (10-35)

40 (3040)
36 (7.5-69

55 (30-75)
42 (9-86)

30 (1540)(3.30)

44 (9.9-71)

51 (25-70)
41 (11-70)

30 (1540)

17 (640)

19 (15.35)

20 ( 5 . 6 4 9(0.949

Lraq

Targd

20 (18-24)

35 (3540)

45 (4045)

30 (3010)

50 (45-59

35 (3040)

40

Jamaica

Tafgd
Surface

35
40

40

40
46

50

40
47

40
47

15
18

(25.50)32(15.30)60 (50-70)
66(41-58)50 (60)50 ( a d o )21(20-70)30 (2040)21(14-28)30 (25-35)
20(17-24)17(12-23)40

Pcru

TargetSurface18 (18-24)
12.6(12.6-17)

47 (35-70)

47

45
( -3)

R

'

Ilr~lth-carrlrvd m50(5040)

M

24-35

40 (2040)
42(2142)M (4040)52(4 1.5423

40 (2040)
42(2142)

40 (4040)
41.9(41.9628)

30 (2040)
M.1(20.140.2)

I5
20

45

40
(3640)

30
24

60

40
32

30

26

24 (21-24)

44 (4046)

SO (45-50)

Z.4(24-?7.6)

30(27-30)65 ( 6 0 4 9
39(36-39)45 (40-50)
27(24-30)30 (27-30)
18(16.2-18)

40 (40.50)

14.4(1.6-4.4

Egypt

TargetMyanmar

Target40 (2040)
40
Surf~~c(2040)

Sudan

TargelSuriacc
TargetSurfaceThailand3
24(24-30)(9-15) 'PART 11: DRACIIYTIEMPY
T a r ~ ahsabufadose (Cy) (RMXC in porenihcru)
CovnnyRrensrrumourGynaecdogkd

Prasrorc
IIYMWErnin rumow

Rdiwn

Orher rruwurs

Afmloadin#

Bcnign&rare

Urslth-cuc lcvd I
20 (10.30)

Aurtrdia

ZS (20-50)

Gcchulcmlda
Kuwai I

20 (2040)

3 4 (10- )25 (2040)

25 (2040)

40 (3040)

40 (3040)(4040)(20-25) f

20

70 (65-75)

Maltn

29 (1440

Nctherlandr

35 (15.75)

Xew & l a n d
N a u ay

160 (160- )40 (40- )25 (25. )Sweden20 (15-20)60(2045)

9 (54- )20-30 (20- )(3040)

Ilrmlth-cnrr I r v d I1
60 (4040)

Barbador

26

QIma
W d a
India

15 (10-20)(30-35)38

33

30 (40)30 (32)49 (15-82)

29 (15-75)

Iraq

201

Jamaica26 (39)Pcru

44 (3045)u)(8-75)

20 (10-30)

36

38-60 W40)

U c a l t h - c m lcrrl 111

30

EBF'

24

40 (30-50)

Myanmar48

Sudan
25 (20-30)

mailand

30 (=-30)

30 (25-30)

Ihc cnlrics in this T ~ b l carc q u l ~ f i e da t i d l o w
China:

U n d n telclhcrapy, thc scsond n l u a roc the surface d s c region under breast tumow. lunghhaax twnour and gyruccologid t m w arc
from a n;rtimuidc study.
Lhta h o m Yangon flcrpital mly.
Data h m Lkpartmcnt of Radrdogy. National G n u r Inn~tutc,Rang)tok, mly.
Exdudtng Monrencgro, Vojvodiru and Kaovo.

hf~o.0~101:
7'hailond:t'u~oslaiia:

'

.

,

?he c n t l a n a rmfacc d m c (Gy) has bcm c s t ~ m a ~ eIrand exparwc (R) multipl~cdby 0.008710.75. This applies also l o range

E;rlcid.

ANNIL, C: MEDICAL W D I A T I O N IXI'OSURES

337

Table 40I)oses from scatkrcd n i d i i i l l o n from lhcrtrpy using c o h a i l - 6 011319, 141h'ormalirad d m lo rirsuc ( d l ! per Gy ro r a r g a q n n )O r g ~

GooadsBreastRed bone manow aLug
Thyroid
Bone surface
Remainder
Brain
IcdncyParlacar
Splem
Utaw
Effective dose
cquivalcnl (HJ
Effenivc dcsc (E)Targct in pancrrm

T q e l in b o n c h w

Targel in ~ c kFcmalc

Male

Fmde

Malc

Fcmale

Lfolc

0.1
0.3
6.7
0.9

0.1

0.1
19
66
127

0.1

4.0

0.5

5.0

4.8

30

1.7
0.1
0.1
0.1
0.1

1.9
0.1
0.1
0.1

1.8
1.1

1.5
0.95

6.1
0.9

T a r ~ c inl ccnrrd pclrit

11

Frmdc

Male

b

47

0.5
65
0.5
0
13

60
0.5
0
13

0.1
4.0
1.9
1.8

22
17

62
95
78
31

67
21
0.8
24

58
18
0.7
23

3.3
1.9
3.6
3.8
0.2

3.4
1.4
3.5
3.0

0.2

0.1

212
6.2

183

0.1
4.5
27
26

37

26

30

23

55
16

32
11

11
8.3

82

" Arruming bone marrow in bum gels 60% of d u e to urge1 agan.

* O r p in beam.

Table 41
Collective eTlective dose from radiothcrtrpy In the Netherlands, 1978-1979 a
[B191
I

K
&

ofparknu

Effmritr d m cquivalmr(dr,)

Effccrirr dasc ' ( d t )T n ~ c regionr

NeckThoraxPanncar and gall blsddu
PelvisCdl&vedow (man Sv)

Addition for t a r e r c ~ o n

T d

''

Male

F d e

414
317
1635
4533

626
33 1
18%
4078

Male

F d c

Male

F d c

108

92
1540
1910
1300

64
1790
963
496

1370
680
1020

2210

3320
671
18630
420

'

19050

fl

10330
105
10435

Breast cancer and skin ancer disregarded becawc lhcrc arc no &la on scallered radialion: lung cancer disregarded because tralment is in most asu only
palliative.
A large1 dose of 60 Gy i s arsurncd.
Per patient.
21.000 ndiolhtapy paticaw cure rate 50%. at m u 1 0.1% r c c a d canctrs in urgct a g a n s [IJ].yield 5.25 ' J l h from seccnd cancers. With a probbility
uxlficient of0.0125 p a man Sv [Ill. 5.25 d u t h r c a r r u p d to 5.25rn.0125= 4?0 man Sv.
G n c n falalily prcbatility d ~ c i e isn 0~.05 pec man Sv [18].

Tehlc 42
Ejtimutcd dmcs lo thc world popul~Uonlmm telclherapy and brachytherapy
1

I

n
III

N
Taal
A~rragc'

Number 01

procaluru

AMW/ cdlatirer/licrirr d m(millioru)

AMW/ nrunbn
q(pror&es
p 1.000 popdarion [UI]

(millionr)(ld man .Sr$ '

1350
~ 3 0
850
460

24
0.6
0.1
0.05

3.2
1.6
0.085
O.M3

980
a 0

4.9

15M

Popdali0n

Ilralrh-cmc
/me1

5190

26

7

0.9

V d u u u c baed m cffcaivc dose. E assuming 10,403 rnm Sv p a 14.3 &llim pcpulation (ligwes from Ihc Nelhnlandr 18191) = 730 nun Sv per millim
population rl healthcue lcvel I and r lrutmmt frequency d 0.0024, i.c. 730124 = 300 m a Sv p u 1,000 procedwu.

Table 43
Total annual number of treatments with radiopharmaceuticals per 1,000 population
Data from UNSCEAR Survey of Medical Radiarion Usage and Exposures

Corrnhy

1970-1979

1980-1984

1985-1990

Counlry

1970-1979

1980-1984

1985-1990

B c a l t h s v e Icvcl I
Argcnlina
Australia
Belgium
CanadaCzechoslovaha
Denmark
FinlandJapan
Kwit
Lucmbourg

0.15
4
0.073
0.13
0.32
0.049

0.15

0.12
0.18
0.36
0.025

0.16
0.14
0.31
0.88
0.18
0.21
0.030
0.018
0.19

Malta
Netkrlan&
New k l a n d
N w yRomania
Swcdm
Suimrlmd
Unild Kingdm
Yugoslavia

Avnagc

0.075
0.16
0.059

0.097
0.051

0.34
1.55

0.17
0.12
0.052
0.43

0.3
0.11

0.086

0.093

0.10

Ucalth-cuc Icvcl I1
Barbados

h d a
India

0.007

0.15

Iraq

RQ35

Jarnlia

0.0065
O.OOM

Pcru

0.013
O.MS
0.01 10.008

0.17

TurteyAverage

0.014

0.021

f l r m l t h c u c ltvcl In

E m
M>anrmr
Sudan

0.064
0.014
0.001

0.06 10.01 1
0.003

0.062
0.005
0.006

ThailandTuruua

Amsge

0.008
0.035

0.011

0.013
0.042

0.025

0.W

0.025

ANNEX C: MEDICAL M D I A I ~ O NM P O S U R ~ S

339

l'nblc 44
Avcragc nnnuul nunibcr or lhcnipcutlc lrcatnicnts wllh mdlopharni~cl.ullcnlsper 1,000 popultlllon
Data from UNSCEAR Surwy o/hicdicol Radiation Usage and Exposures unless orhernice indicoled

ColrnmyYew

Jh?~oidIY-s

Ilypm~hyrdirm

Pdycy~haemiat w o

01hcr ~unwlos

Benign d b r p r u

ntsllh-cuc lrvd I
Argentina

1965-1989

Aurlmlia

1970
1980
1984
1991

0.16
0.00 1
0.024
0.022
0.11 C

0.13
0.12
0.063

0.013
0.012
0.024
0.010

0.P2
0.01 1

0.023

Belgium

1966-1990

Gnada

1985-1989

0.009

0.9

0.28

Gechcslovatia

1970-1974
1976-1980
1981.1985
1986-1990

0.016
0.031
0.035
0.050

0.013
0.022
0.022
0.046

0.011
0.007
0.008
0.009

Denmark

1977-1980
1981-1985
1989-1990

0.023
0.029
0.023

0.097
0.15
0.19

1975
1982

0.005
0.038

0.29
0.28

Japan

1985-1989

0.025

0.005

limit

1985-1989

0.016

Malta

1985-1969

0.003

finlaad [A1210.012
0 . ~ 0

0.064

0.08

New Laland

1970-1974
1985-1989

0.01 1
0.018

0.14
0.11

0.014
0.036

Nauay

1970-1974
1985-1989

0.004
0.019

0.033
0.084

0.00080.001

1980
1985-1989
1990

O.W 1
0.013
0.038

0.010
0.009
0.004

Suilrcrl~nd

0.008
0.005

0.097

1984

S d c a

0
0.024
0.038
0.055

0.006
0.005
0.001

Nclhcrlanb

Romania

0.001
0.012
0.018
0.022

0.022
0.012

0.006

<0.001
0.52

1970-1974
1985-1989

0.31
0.39

0.032
0.034

1976

1.0

0.022

0.001
O.M3

0.003
0.001
0.52

U n i ~ dIGngdan

1981-1985

0.015

0.14

0.025

0.013

Yugda\in1985-1989

0.009

0.029

0.005

0.053

0.014

Avcragc

1970-1979
1980-1964
1985-1990

0.059
0.033
0.063

0.068
0.10
0.022

0.014
0.024
0.016

0.009
0.013
0.PJ

0.013
0.025
0.018

0.01 1

0.016

ncnlth-csrr Irtd II

Barbadoa

0.15

1985.1989

mna
1985.1989
1986-1990

0.00006

0.005
0.0056

Ecuada1970-1974
1985-1969

0.002
0.003

0.005
0.00J

India

IVBS-1989

0.0006

0.(UY

Iraq

1985.1989

0.012

Bcijing area
Entire nnlim

0.W1
0.001

UNSCMR 1993 REPORT

34 0l'nble 44 (conlinucd)

Counrry

Yew

Th,+oid 1-1

I f y p ~ h ~ r a L i i s m Pdyc?.rhocmin turn

Jamnica

1970-1974
1985-1989

0.093

0.077
0.005

Pcru

1985-1989

O.MZ

0.a

Twkcy

1991

Avnage1970.1979
1960-1984
1985-1990

0 1 b I-WS

Benign diseasu

0.008
0.m
0.OOE.i

0.0001

0.M01

0.011

0.018

nrallhsur k v c l

Ei3P

1975-1979
1960-1984
1985-1989

0.024
0.017
0.012

0.010
0.014
0.039

Myanmar

1975-1979
1960-1984
1985-1989

0.00060.001
0.00020.013
0.OlD
0.0038Sudan

1975-1979
1960-1984
1985-1989

0.001
0.M01
0.W3

0.00050.002
0.0038

O.Wo6
O.Wl5

0.008
0.011
0.013

<0.0001~0.0001
0

Thailand

1976-1980
1981-1985
1966-1990

Tunisia

1970-1974
1985-1989

0.01 1
0.013

0.023
0.027

0.00090.002

1970-1979
1960-1984
1985-1990

0.010
0.009
0.01 1

0.012
0.025
0.020

0.00 1
0.002

Avcragc

0 . W
0.00003

The cntriu in this Table arc qualified as follour:
Ca~dn:

Tub:)irgarlavw:

Nma S a i a Prorincc mly (abart 3.5% of the population).
Khta are from Gad Univartty (1% of the population).
Lhu exdude Mmtcncgr~Vojvdna and Korovo, *othergturnours and benign drsuscs b a r d on Goatia data mly ( a h 20% d the
population)

Valuc rs f a bolh lhyrad turnoar and hypmhyroidim.

A N N U C: MEDICAL RADIATION I:XPOSURI:S

34 I

Ttlblc 45
ARC-and sex-dlstrihutlon of pallcnlc undcrgolng treatment wllh rwdlopharmaceuticuls, 1985-19!MDora from UNSCFAR Survey oJAIedica1 Radiation Usage and Exposures

S a dirbibu~ion(%)

Agr disbiburim (%)

IIcd~h-cwc
lnrl

Cowtny@IS ycars

14-40 )uws

> I 0 years

Male

Female

10
31
37
33
7

25
50

90
69
63
67
93
60
75
M

Thyroid l u m o u n
Qna&Gechaluvatia
Kwil
Nethcrlan&
New Zcaland
Nawy
Romania
Yugmlana

0
0

25
74

75

2
0
0

3
40

32

78
60
68

0

0

100

U

Enuda
Iraq
Pcru

0

32

68

10
40
20

90
60
60

III

Thailand

0.7

15

84

13

n

25

14

74
51
68
72
66

0

100

75
74
61
75
78
75
90

0

67
55
33

33
43
67

21

79

0

58

42

33
30

67
70

0

31

69

17

63

43
100
63

51

53
90

49
47
10

90

n

61
0

39
100

100
100

50
19

61

36

64

I

26

U)

IIypcrthyroidirm

I

I1

m

CanadaCzechalwrba
Netherlands
Ncw ZulandXm-ry
R m i aYugoslaviaa i mBeijing arm
Entire naticn
Emdahq
Jamaica
Peru
Thailand

o

26

0
0
0
0
0
0

49

0
1.5

32

28

26
19

25
22

25
10

29
26

I5

71

74
65

Pdyrylhacmia vrraI

Gcchmlovnkia
New Zuland
Yugdavir

0
0
0

57
0
17
Other t u r n o u nIGcchalwrha
Naury

0
0

9.8
23
Benign d i a c v nI

Gna&Czccholovaba
Romania0000

5he rnrrlcr in this Table are qualified as lollour:
CnnndarHamnnin:Thailand:Yugaslav~:

Nova Scotin Prownte cnly (ahout 3.55 ct the popitlalion).
Data arc for 1990 mly.
Data arc from Dcpartmcn! d Had~dogy.Natimal C a n m lrxtitutc, Bangkok and Rajaslth~Ilcspiml only.
b t a arc la S c r h a only (about 40% o l the populnlion).

50

T i ~ h l c46
Avcrngc acllvlly edmlnlslcrcd In Lhcrepy hetrnents wllh mdlophnrmnccutlc~~ls
Dara from UNSCbAN Sun~cyoj Medical Radiarion Usage and Exposures
A%.ongc 0crivi.y cvlminirfoad (MHq) (Range in pnrcnrhuer)country

)'car

ntpid

Ilypcr-IY~OWS

thyroid&Pdyryrhocmia
1-0

3 2 p~h p h a ~ t

lJJ1iodidel J l l iodidc

Other r w w s

PO^ cdloid

01hm

Bcnizn d u e m u
l P d ~cdloidu

OfhaIIcallhsut lcvd I
Atstralia

Chub

5550
4225
4950
963

1970
1960
1964
1991
1970-1974

35 1
310
430

3700
-5550)
3700( -3550)

Gechaslovakia

1970.1974
1965

111( -18s)(111( -16s)200

6500(5000-l2ooo)
6500(5500-220!85(lo@=')i85(l0o=-c')(150-300)

200(150-300)

Japan

1976.1980
1981.1985

Kuwait1985-1989

3630(1700-7770)

535(399671)

Malh

1985-19693700

U 9 ( -370)

Ncthcrlands

1963-1990

5500(3700.5800)(isalsoo)

3145(2220-3700)
1632(370-4200)

400(74-1480)
4U(150-2700)

Ncw Ztaland

1973
1985-1989

1970-1974
1965-1969

RomanlaSweden600-3000(400-5509
600-3000(400-5500)-

MOO(1000-Moo)
3600(2100-5100)

I(131-39)310(152-466)

1980
1965-1989

3700
3700

222

1974

1700

344

160

150

150
(110-185)167(150-200)

3700

3001

222

30

165
374
(2000-3700)

2 4

92s

1976

74

165

1961.1965

3301(110-5000)

335(120-1550)

Yugoda\ia1970. 1974
1985.1989

3700
3700

I65 (100-?OD)
I85 (100-200)

207(111-434)

191(55-280)

Ilcalth-cnrr lcvd I1

Entlrc nat~m

750 r

:54
(111-204)172(100-39)

Llm~cdLngdan

ollna
Bcij~ngarea

110

500

(140-335)

brhdor185(150-450)

176(152-180)1985.1969

Swuoland185(150450)

180
400

-

Kaway

183
265

185
-1100)
185( -1110)(

1985-1969

157
160
162
169

1985-1989

296 (222.296)

1970-1974
1965-1969
1966-1990

296 (148-740)
259 (111-740)
162

2 9 A (222-370)

8.7t.

ANNEX C: MEDICAL RADIATION EXPOSUR~S

343

Tablc 46 (con~inucd)
A t a n r e acritiry &inisrard

ThyDidIiypo-

Pdycyrhocmia

IunlaWS

lm7oidk\WO

1Jl1a i d e

I J 1 / iodide"P p h p h o r e3700-9250)
3700( -9250)296( 4-44]296

5330(3700-7400)

190(74-226)127(74-296)

196s-1989

1850 ( -5550)

200 ( -1000)

200 ( 400)

Jamaia1970-1974
1985-1989

370

182
370

Peru

1985-1989

3700(2960440)2s9(185-370)

Corrnny

b d a

Yelp

1970-1974(
1985-1989

lndia.---------baq

1985-1989( 4'4)

Uealth-cur level 111
1976.1980
1981-1985
1986-1990

nix
40a)

600
800
loo0

Myanmar

1976-1980
1981-1985
1966-1990

1850
1850
1850

185
185
185

Sudan

1976-1980
1981-1985
1966-1990

3700
3700

185
185
222

1985-1989

noEmThailand

2500

185
259

The en~ricrin lhir Tablc arc qualified as idloux:
Camdc
Jamaica:Yugarlovia:

Nova Scuia Pronncr cnly (about 3.5% of the population).
Value fa thyrid tumows treated ~ 7 t h'"1 iodide to be checked.
Excluding Montenegro. Vojvodina and Kcswo.

Value is lor bah thyroid turnours and hyperthyroidism.
Ynrim-90 cdloid.
QvDmic phephaur-32.
P-32 Na+i PO, (600 MBq). Au.198. P-31 colloid (3.000MBq).
Gdd-198.
Phcsphaus-32.
Iodine-131.
Iodine-131 MIGB.

(MBq) ( R m ~ inc pawuheru)
0 t hr ~ o w s

Y cdloid

01ha

Benign dircprcr

1 v 8 ~ cdloidu0thTnhle 47
Ahsorhed dose lo non-lnrgct organs from therapy h a t m e n l s of adult thyrnld with iodlnc-131 lodidc
In Jspnn, 1982 a

Absorbad d w ch'umlxr ofrhaopiu(mGy/MBq)

WY)

/MI01

0.52
0.047
0.043
0.46
0.26
0.059
0.06
0.053
0.054
0.043
0.028

209
18.9
17.3
185
113
23.7
24.1
21.3
21.7
17.3
11.3

29%
29%
2956
2956
2956
2956
2956
2956
29%
2326
626

Dare focror
Organ

llsl

Bladder u d l
k c surfact
f31u~tStomach uall
Small intestineU p p o large inicstinciiidncy

Red bone marrow
~

I

Y

Tu~ir

" 402 MBq administud [MIO]; assumed thyroid uplakc: 15%.

Tnble 48
Estimaled dmes ln the world population rrom therapeutic Lrealmenis by nuclear medicine proccdurcs a'oo cnrapdation of data horn \he NclhnlanL ID19).
* Basedb u r n i n g an cffenivc dou per trcatd paticnr d 40 mSvKl.9 (40 mSv c a l d a t d lor thyroid therapy in Japan; thyroid thcnpy a u m d to bc 0.9 d all
autmcnts), as calculard fa Japan wilh the methodology d Dccntjcs 10191.

Table 49
Equivalent dose rates rrnm adult patlenls undergoing nuclear mcdiclne examinations
IN61
AmountErnminoion

Rodiophmmaccuruddminirrcred

Time o j r oodminunorion

IMBq)
Bone

L vcr

Tc-99m MDP

n l d pool

Tc-9% S cdlcid
Tc.99m RDC

TwnourGad7 citra~c(SF

ln.111 DTPA
Tl.201 chlaidc
Tc-9% llSA
Tc-9% MDP
Tc-99m RDC

llcrn
liean
Bone

llun

740

150
740
110
19
740
190
740
loo0

0
1h
2h
3h
0
0

0
0

0
0
0
20 minDkrancr

Ecpivalrnr dose
rare

(cm)

(US
h")

100
100
100
100
100
100
I00
100

9
6.3
4.7

3.5
2
14
3.5
0.8

20
100

15
3
18

ANNMC: MEDICAL RADIATIONMPOSURES

345

Tt~hlc50
ENrctive dme equlvnlcnl lo mothcr trnd hrcast-fcwllng child Tor common nuclcar medlclne exarnln~Uonr[Jll
Eflccriw dose e ~ ' v a l c r( d b j

Arriviy
nlmtrlrcrd

Nldiopharmxcwicd

Morha

I

Child

-

Tc-99m pcrtcchnetrtc
1-131 icdohippurstc
G-51 EDTA
1-13 tibrogcn

Thyroid rcintigraphy
Rmogra~hy
Qcarrnce
Thrunbair Icst

1.3
0.02
0.01
0.44

120
0.4
4
4

3.6
28
0.a%
13

I Table 51

I

1

Exposures of volunteers In m e d i a l research and clinical trlals

cowl-

Ycm

Rdionurlidc

Nwnbcr of

ldminirmcd

nvdiu

-N

of

rdunrrrrs "Activity ndmininad
pcr bolwucff

Cornmined
cffcctiw d m

Rcjl

(dv)

Clinical t r i a l s or lnbcllcd phumsceutical
Gcrmany,
Fed. Rcp. d

1978-1988

Taal

11 years

11-3
C-14
S-35

I5
62
2

85 (3-8)452 (3-30)
1.4 (7)79551

3.7 (1.9-16.7)
3.7 (0.37-11)
3.7

0.03-03
0.28
0.4

P'l

Use d r d i ~ c t i v suhsLnncntin medical r r u u r h
Gctmany.
Fed. Rep. d

1988

G-51
Fe-59
Tc-9%
In.lll
1.123
Xe-133

2
1
5
1
3
1

I05 (15-70)

3.79
1
35074
20
150-185

M900

18 (6-12)12
I07 (10-32)
80

PSI

Clinical t r i l l s or ndiophannaceutic.*
Germany.
Fcd. Rep. d

1988

Tc-9% MAR
In-Ill M A E
1-15
1-131 MAR

32
6
3

2

1286 (15-120)
175 (10-80)
500 (100-200)
35 (15-20)

220-1300
74-75
3.7
185

PSI

Clinical t r i a l s of lsbcllcd phumwruticals
United Lngdan

1978-1986

11-3

4

C -14

55
1

S-35

40 (3-1s)
201 (2-10)
3

-10.5
-1-3
2.8

0.03-0.3
0.01 4.5
0.3

w'l
A

of vduntccrr per study in parenthas.
* Kumbcr
Acrlvity administered p a study in pivrnthuu.

'

Ert~matedto givc upper Ilmit vdluu.

Table 52
Fslirnakd dmes lo the world populaUon from rnedlcal uses of rndla(lonEflrrrivr d m cgu'rolmr pa c a p u
Madkd rndio~ionuw

Lovl
I

Lnrl

n

Ln*l
nl

(a

Lor1

CY

Collccri~acffecri~r
dnrr cwvoluu

Hbrld

Lovl
I

Lwl

n

(18man Sv)

Lnrl
111

Lovl

20
0.1
4

1600
17
160

H'orldDiqnaii

McQcal x-ray cxrmimtionr
Dental x-ray u n m i m ~ i m c
Nuclear medicine
Taal

1.0
0.01
0.09

0.1
0.001
0.008

0.W
0.00030.008

0.W
0.0003
0.008

0.3
0.003
0.03

1300
14
130

290
3

20

40
0.3
6

1.1

0.1

0.05

0.05

0.3

1400

310

46

24

1600

7

'Ihrnpy

Radidhnapy
Nuclear medicine

T~
Evaluated fa d c a i v c dorcr

0.7
0.004

0.2
0.00090.03
0.0009

0.02
0.004

0.3
0.002

980
6

460
2

26
0.8

0.2

1500
9

0.7

0.2

0.03

0.02

0.3

990

480

n

7

1m

ANNM C: MEDICAL RADIAT~oNEXPOSURES

lo9'

0
m

E<

!3
x

W

lo'-

lrvcl I coun~rics
Lcvcl I 1 counlrics
Lrvcl Ill munrrics
LVCI

IV cuuntrics

Io7-

1o6-

.

ioS-

V)

347

0

2
0

'CIW

n lo3lo3
1o4

0

I

I o5

1

I

1 o6

'1:

lo8

I
lo9

I
1o1O

POPULnTlON

Figum I.
Diagnostic mcdical x-ray examinations In relation to population and number of physicians.

U N S C M R 1993 REPORT

348

100'I
I
[
0.2 0.5 1

I

I

2

5

10

I

I

I

1

I

I

I

20

30 40 50 M) 70

80

90

95

98 99 99.5 99.8

I

I

I

l

l

PERCENTAGE

Figure 11.
Distribution of bhl annual frequency o f diagnnslic medical x-ray examinations.

1

0 1975-1979
0 1980-1984
0 1985-1990

cbolecys~o-gnphy
graphy

ities

Chest

Spine

Pclvis

Skull

Eyt!em- AMorncn
I

1

I

G.I.

Urn-1 Angio- Mammocholccysto- gnphy graphygraphyG.I.

Urn-1 Angio- '~arnrno-. CT
cholccys~o-gnphy graphy
grarhy~LEVELS 111 and IV

Chat

Spine

PclvisSkull

Enrern- Ahdorncn
itia

graphyFlgum I l l .
Average annual frequency or dlagnostlc medical x-ray examlnatlons.

Figure IV.
Populalion-weighted average clTerUvc dose in dingnostlc medial x-my exnmlnalions.

A N N M C: MEDICAL RADIATION FXPOSURrLS

10'

1

35 1

Lrvcl 1 councrics

0 Level ll councrics
Irvcl I11 councries
Lcvcl IV countn'alo5 I 1

1

[

I

I

I

I

I

0.2 0.5 1

2

5

10

20

30 40 50 60 70

I

I

I

I

I
80

I

I

I

90

95

98 99 99.5 99.8ll

PERCENTAGE
Figure V.
Distribution of total annual frequency of diagnostic nuclear medicine examinations
In 1985-1990.

l 1

1

0 Levcl I
0 Lcvcl I1

E3 Levcl 111

Figunt VI.
Average annwxl frequency of diagnostlc nuclear medicine examinations in 1985-1990.

I

UNSCEAR 1993 REPORT

352

Levcl I coun~ries
Lcvcl ll countria
l r v c l I l l coun~rics

0

0.2

0.5 1

2

I

I

I

I

I

I

I

I

I

5

10

20

30 40 50 60 70

80

90

95

98 99 99.5 99.8

I

I

I

l

l

I

PERCENTAGE

,

1

I

I

I

I

I

I

I

I

I

0.2 0.5 1

2

5

10

20

30 4 0 5 0 60 70

80

90

95

98 9999.599.8

l o - ' l

1

I

I

I

PERCENTAGE
Figure VII.
Dlstrlhutlon of tole1 annual frequency of radlolherapy trcatmenls.

l

l

1

F i p m VIII.
Avcrnge annunl frequency of mdlolhempy trentrnenk in 1985-1990.

UNSCMR 1993 REPORT

35 4

Levcl
Levcl
Levcl

10-311II

0.2 0.5 1

2

I

I
5

1

10

I
20

I
I
I
I
I
30 40 50 60 70

I
80

I

90

I
95

1

1

1

1

98 99 99.5 99.8

PERCENTAGE
Figure IX.
Distribution o f total annual lrequency o f therapy lrcatrncnt 4 t h rndlopharmaceuticals.

Levcl 10
Lrvcl 11loo

1

0

Thyroid~urnounI lypc!thyroldlsrn

Polycythacmia
vera

O~her
rurnou~Benigndiscascs

I

Total
including benign

I

Figure X.
Avcmgc unnual rrequcncy or thcrnpy lreatrncnts with radioplmnnoccuticals in 1985-1990.

ANNEX C: MEDICAL RADIATION LXPOSUKIS355

Responses Lo UNSCEAR Survey of hlcdicnl RndinUon Usagc tind Exposures
Response fromCountry

Argentina

J. Skvarca. Ministerio de Salud y Accidn Social, Departamento dc Radiofisica, Buenos Aircs.
Argentina. (September 1990 and Deccmber 1991).

Australia

D. Webb. Medical Radiation Section, Australian Radiation Laboratory, Victoria. Australia.
(May 1990, December and April 1991).

Barbados

J. Rajendran. Queen Elizabeth Flospital, St. Michael, Barbados. (February 1990).

Belgium

SPRI-DBIS, Ministere Volksgezondheid & Leefmilieu, Bruxelles, Belgium. (November 1991).

BelizeC. Bords. Pan-American Iiealth Organization, Washington. (December 1991).

Burma

S. Tun Aung and U. Maung Gyi. Radiotherapy and Radiology Department. Mandalay General
Hospital, Myanmar. Burma. (1990).

T. Than 00 and S. Than Tun Aung. Radiotherapy Department, Yangon General Hospital.
Myanmar, Burma. (April 1990).
CanadaP. Dvorak. Bureau of Radiation and Medical Devices, Health and Welfare, Ottawa, Canada.
(April, March 1990 and October 1991).

Cape Verde

D. Dantas Dos Reis. Dr. Agostinho Neto Hospital, Ministry CI; Health, Praia, Cape Verde.
(April 1990 and October 1991).

Chile

C. Bords. Pan-American Health Organization, Washington. (December 1991).

China

Z. Liangan. Institute of Radiation Medicine, Chinese A a d e m y of Medial Sciences, China.
(November 1991 and January 1992).
Wu Shengcai. Yue Baoreng and Cui Jianguo. Laboratory of Industrial Hygiene, Ministry of
Public Iiealth, China. (June 1990).

Costa Rica

C. Rorris. Pan-American Ilealth Organization, Washington. (December 1991).

Cuba

C. Borris. Pan-American Health Organization, Washington. (December 1991).

Czechoslovakia

E. Kunz. National Institute of Public licalth, Centre of Radiation Hygiene, Praha.
~ e c h o s l o v a k i a .(April 1990).
V. Klener. National Institute of Public Health, Centre of Radiation Hygiene, Praha,
Czechoslovakia. (November 1991).

Denmark

K. Ennow and 0. Iljardemaal. National Institute of Radiation Ilygiene. Brnnshnj, Denmark.
(June 1990 and January 1992).

Djibouti

Ministry of Public llealth and Social NTairs, Djibouti. (April 1990).

Ecuador

M.F. CampaAa. Direccicin de Ciencias Riofisicas. Comision Ecuatoriana de Energia Atomica,
Quito, Ecuador. (February 1990j.

Ethiopia

S. Demena. Department of lnlemal Medicine. Nuclear Medicine Unit, Addis Ababa, Ethiopia.
(April 1990 and October 1991).

Finland

S. Rannikko. Finnish Centre for Radiation and Nuclear Safety, Department of Inspection andMetrology, Ilelsinki. Finland. (April and October 1991).

FranceP. I'ellerin. Senlice Central de Protection contre les Rayonnemcnts Ionisants, Le Vbinet,
Fra nce. (April 1990).

UNSCEAR 1993 REPORT

356

Country

Response from

Germany, I:cd.Rcp.

W. Rurkart. nundcsamt firr StrahlcnschuQ, Institut fur Striihlcnhygicnc, Ncuhcrbcrg, Gcrmijny.
(October 1991).

GuatemalaC. 13orl;cls.Pan-American llcalth Organization, Washington. (1)ccembcr 1991).

lndin

U. Madhvanath. Division of Radiological Protection, Bhabhzi Atomic Rcscarch Centrc.
Bombay, India. (December 1991).

Iraq

A. Al-Douri. Physics Department, lnstitutc of Radiology and Nuclear Medicine, Baghdad, Iraq.
(1991).

Italy

Ministcro dclla Sanith. D.G.S.I.P., Div. Vlla. Rome, Italy. (June 1990).

F. Dobici. ENEA, Divisione Radioisotopi e Macchine Radiogcne, Rome, Italy. (October 1991).
Jamaica

A. Beach. Radiotherapy Department. Kingston Public IJospital, Kingston, Jamaica. (July 1990).

Japan

T. Maruyama. Division of Physics, National Inslitute of Radiological Sciences. Chiba-shi,
Japan. (1991).

KuwaitF. Sulaiman. X-ray Office, Ministry or Public llealth, Safat, Kuwait. (April 1990 andNovember 1991).

Luxembourg

P. Kayser. Direction de la SantC. Division de la Radioprotection, Luxembourg. (February1990).

Malta

M. Gauci. Occupational fjealth Unit, Department of Health, Valletta, Malta. (April 1990).

Mcxiu,

R. Ortiz Magab. Comisi6n Nacional de Seyridad Nuclear y Salvaguardias, Mcxico.
(October 1991).

Ncthcrlands

L.B. Beentjes. Health Physics Department, University of Nijmegen, Netherlands. (July 1990
and October 1991).

Ncw Zealand

B.D.P. Williamson and V.G. Smyth. National Radiation Laboratory, Christchurch, New
Zcaland. (July 1990).

NorwayJ. Unhjcm. National Institute of Radiation Ilygiene, BstcrAs, Norway. (April 1990).

G. Saxcbl. National Institute of Radiation I.lygiene. OsterAs, Noway. (August 1990).
Peru

R. Ramirez Quijada. Institute Peruano de Energia Nuclcar, Lima, Peru. (1990).

L. Pinilios Ashton. Ministry of Ilcalth, Lima, Peru. (1990).
Philippines

M. Elesango. Radiation FIcalth Service. Department of Health, Manila, Philippines.
(April 1990).

Polandiil
Department of
M.A. Staniszcwska and J. Jankouxki. Institute of O ~ ~ ~ p a t i o nMcdicinc,Radiation Dosimctry. Lbdi. Poland. (April 1990).

ftomania

C. Milu. Radiation Ilygicnc Laboratory. Institute of Flygicnc and Public Ilcalth, Bucharest.
Romania. (April 1990).
C. Diamncscu. Radiation llygiene Laboratory, lnslitute of Public lIealth and Medical
Rcscarches. Iassy, Romania. (November 1991).

RwandaDivision Survcillancc Epidemiologique. Ministcrc dc la Santc, Kigali, Rwanda. (June 1990).

Singapow

T. Goh. Diagnostic Imaging Scrviccs, National University llospital, Singapore. (1990).

Spin

E. VaR6 Canuana. Catedra dc Fisica Medica, Facultad dc Mcdicina, Univcrsidad Cornplutcnse,
Madrid, Spain. (April 1990 and Odober 1991).

SwedenW. Leitz, J. Karlbcrg and P. Ilofvandcr. Nalional Institute of Radialion Protection. Stockholm,
Swcdcn. (May 1990 and October 1991).

ANNFX C: MEDICAL RADIATION FSPOSURES

357

Response /ram

Country

Switzerland

J. Marti. Radiation Protcction Division, 1:cdcral Oficc or I'ublic Ilcalth, Bcrn. Switzerland.
(Novcmbcr 1991).

Thailand

Ministry of Public Ilcalth, Bangkok, Thailand. (1:cbruary 1990).

Tunisia

S. M'Timct. Ccntrc National dc Radioprotcction, Ministcrc dc la Santc Publiquc. Tunis Jcbbari,
Tunisic. (August 1990).

TurkcyA. G6niil Buyan, I:. Goztxtxk and B. Ccyhan. Turkish Atomic Encrgy Authority, Ankara,
Turkcy. (Octobcr 1991).

United Kingdom

B.F. Wall. National Radiological Protection Board, Chilton, Grcat Britain. (March 1990 and
Octobcr 1991).

Unitcd Statcs

R.L. Burkhart. Centre for Dcviccs and Radiological Health, Food and Drug Administration,
Maryland, Unitcd States. (April 1990).

Vanuatu

R.E. Fcy. Ministry and Department of llcalth, Port Vila, Vanuatu. (April 1990).

Yugoslavia

V. RadmiloviC. Fcdcral Sccrctariat for Labor, flcalth, Veterans Affair and Social Policy of
Yugoslavia. Belgrade, Yugoslavia. (October 1990 and Novcmbcr 1991).

PART B

Anisirnov, S.I.. V.N. Popov. R.V. Chepiga ct al.
Radiation dosc to patients and informativeness of theimages obtained during eyc examinations using x-ray
mmputed tomography. Med. Tekh. (July/Aug): 38-40(1987). (in Russian).
Aikcnhead, J.. J. Triano and J. Baker. Rclativc
efficacy for radiation reducing methods in smliotic
patients. J. Manip. Physiol. Thcr. 12: 259-264 (1989).
Arranz. L. Radiation protection implications of
dcvcloping technologies and practices. in: Radiation
Protection Toward the Turn of the Ccntury, Pans, (inpress, 1993).
Allen, BJ., D.E. Moore and B.V. flarrington. Progress
in Neutron Capture Thcrapy for Cancer. Plenum
Prcss. New York & London, 1992.
Atkins, H.L., S.R. Thomas, U. Buddcmeyer ct al.
MlRD dose estimate Report No. 14: Radiation
absorbed dosc from technctiurn-99m-lat~lcdred blood
cells. J. Nud. Mcd. 31: 378-380 (1990).
American Canccr Society. Mammography guidclincs
1983: Background statement and update of cancerrclatcd checkup guidclincs for breast cancer detectionin asymptomatic women age 40-49. CA-Cancer J.
a i n . 33: 225 (1983).
j\grcn, A., A. Urahme and I. Turcsson. Optimizationof uncomplicated control for head and neck tumors.
11-11.J. Radiat. Onml. Uiol. Phys. 19: 1077-1085(1990).
American Cancer Socicly. Guidelines for the canccrrclatcd checkup - recornmcndations and rationale:
Cancer of the breast. CA-Canccr J. Clin. 30: 224-240(1980).
Adarns. 1. Thc establishment or dose reducing
protocols using rare earth filters in pacdiatricradiography. Radiogr. Today 56: 11-12 (1990).

hwclsson. B., 11. Forsberg, B. Hansson ct al. Multiplebcam equali;ration radiography in chcst radiology.
Acta Radiol. 32: 12-17 (1991).
Araujo. A.M.C., M.T. Carlos, L.R.F. Cruz et al.
Fontcs de Radiapo Ionizante Utiliradas cm Mcdicinano Brasil. Comissao Nacional de Energia Nudcar. Rio
dc Janciro, Brazil, 1991.
Asikainen, M. Radionuclides used in diagnostic
nuclear medicine and doses 1982. STUK-B60 (1984).
Atkins, 1i.L.. D.A. Webcr, H. Susskind et al. MlRD
dosc cstimatc rcport no. 16: Radiation absorbed dosefrom technetium-99m-dicthylcnetriamincpentaacetic
acid acrosol. J. Nucl. Mcd. 33: 1717-1719 (1992).
Arias, C.F. Potential exposures in radiation medicine.
p. 356-359 in: Worldwide Achievement in Public andOccupational Ilealth Protection Against Radiation.
Worldwidc Achicvcmcnt in Public and Occupational
Health Protection Against Radiation. ~roceedingsof
thc 8th International Congress of the International
Radiation Protcction Assodation, Montrbl, 1992.
N m Carisson, G. and D.R. Dancc. Breast absorbed
doscs in mammography: evaluation of experimental
and thcorctial approaches. Radiat. Prot. Dosim. 43:
197-200 (1992).
Bush. W.11.. D. Jones and R.P. Gibbons. Radiation
dosc to paticnt and personnel during extracorporeal
shock wave lithotripsy. J. Urol. 138: 716-719 (1967).
Bcrtclli. L., 1.E.C. Nascimcnlo and G. Drcxlcr.
lnflucnce of tissuc weighting factors on risk wcightcd
dosc cquivalcnt quantities. Radiat. Pmt. Dosim. 37:
85-88 (1991).
Bsrresen, A.-L. Role of genetic factors in brcast
c a n a r susceptibility. Acta Oncol. 31: 151-155 (1992).
Benson. J.S. I'aticnt and physician radiation c x p s u r eduring Iluoroscopy. Radiology 186: 286 (1992).

UNSCWR

Dcncdittini, hl., C. Maccia, C. LcFaut-6 ct al. Doscs topaticnts from dcnL3I radiology in Francc. Ilcalth Phys.
56: 903-910 (1989).
13laaubocr. R.O. and L.11. Vaas. htimatcd radiation
cxposurc in thc Nethcrlands in 1987 (?'wcntiethrcport). RIVM Rcprt No. 248601002. Dutch National
Institute of I'ublic llcalth and Environmental
Protection (1989). (in Dutch).
Bundcsministcr Tir Umwclt, Naturxhutz und Kcaktorsichcrhcit (BR Dcukchland). Bcrichte dcr Bundesrcgicrung an dcn Dcutschcn Bundcstag Gbcr Umwcltradioaktivitit und Strdhlenbclastung in dcn Jahrcn
1983,1984, 1985, 1986, 1987,1988, 1989, 1990 and1991 an dcn Dcutschen Bundestag. Bonn, 1984-1992.
Budach. V. Thc rolc of fast neutrons in radioonmlogy- a critical appraisal. Strahlcnthcr. Onkol. 167: 677692 (1991).
Uusch, M.P. and M. Gcorgi (eds.). Digital radiography. Workshop Quality Assurance and Radiation
Protection, Mannhcim 7-9 May 1992. SchnctztorVerlag, Konstanz. 1992.
Bansal, S. and J.H. Sunshine. Hospital and officepractices o l radiology groups. Radiology 183: 729-736(1992).
Bydder, G.M. Magnctic resonance imaging: prcsent
status and future perspectives. Br. J. Radiol. 61:
889-897 (1988).
Bcncdetto, A.R., T.W. Dziuk and M.L. Nusynowitz.
Population exposure from nuclear medicine
proocdurcs: mcasurcrncnt data. Health Phys. 57:
725-731 (1989).
Bergstr6rn, K., S. Aquilonius, M. Bcrgstrom ct al.
PET. a new imaging technique. Ukartidn 86:
2371-237 (1989). (in Swedish).
Black, R.E. and KJ. Stchlik. Reducing radiation frombrachythcrapy patients with a cmt-ellective bcdshicld.
llealth Phys. 56: 939-941 (1989).
Bomnan. H. and P. Ilolmberg. Radiation doses andrisks in dcnto-maxillofacial radiology. Proc. Finn.
Dent. Soc. 85: 457-479 (1989).
Rrahrne, A. Treatment optimization using physical andbiological objective functions. in: Radiation Thcrapy
Physics. (A. Smith. ed.) Springer Vcrlag, Berlin. 1992.
Brahmc, A. (cd.). Accuracy requirements and quality
assurance of external beam therapy with photons andelectrons. Acta Oncol. (Suppl.) 1: (1988).
Raker, M.E.and F.R. Portcr. A report on radiology at
Muhimbili Medical Ccntcr. Dar es Salaam, Tanzania.
hm. J. Rocntgcnol. 159: 195 (1992).
Bccntja, L.B. Thc risks. expressed in collective
doscs, from radiotherapy in the Netherlands. Nin.
Fysica 3: 116-121 (1987). (in Dutch).
Beentja. L B . and C.W.M. Timmcrmans. Age and scx
specific population doses (SED and GSD) due tonuclear medicine procedurcs in thc Ncthcrlandc. Nucl.
Mcd. Biol. 17: 261-268 (1990).
Beentjes, L.B. and C.W.M. Timmcrmans. Annual
frequency of diagnostic x-ray examinations in the
Netherlands. I4ealth Phys. 59: 357-358 (1990).
Beentjes. L.B. and C.W.M. Timmcrmam. Age and sex
spccific radiographic examination frequency in the
Netherlands. Br. J. Radiol. 63: 691-697 (1990).

B23 Ilouhnik, 11.. JJ. Bard, J. Chavaudra ct al. 6valuation
dcs doscs dClivr&s au tours d'cxamcns radiologiqucs.
J. Hediol. 72: 403-420 (1991).
B24 Ijick, U., W. Wicsmann, 11. Irnzcn ct al. Utilizing
digital luminesccncc rridiography in pcdialricriidiology: a report of initial cxpcricnccs. Elcctromcdica 59: 26-30 (1991).
B25 Dymc, C.M., M J . Phnroah and R.E. Wood. Skin
cxposurc and thyroid dosc distribution using niobium
filtration. J. Can. Dcnt. ASSOC.57: 663-665 (1991).
B26 Bristow, R.G., R.E. Wood and G.M. Clark. Thyroid
dose distribution in dental radiography. Oral Surg.,
Oral Med., Oral Pathol. 68: 482-487 (1989).
B27 Dcnazzi, A., G. Cucchi and V. D'Arcangclo.
Radiazioni ioninanti assorbitc dal pazicntc. Dcnt.
Cadmos 7: 77-78 (1991).
B28 Bcck, TJ. and B.W. Gaylcr. Image quality andradiation levels in videofluoroscopy for swallowing
studics: a rcvicw. Dysphagia 5: 118-128 (1990).
B29 Berthelsen, B. and A. Ccdcrblad. Radiation doses topatients and personnel involved in ernbolization of
intracercbral arteriovcnous malformations. Acta
Radiol. 32: 492-497 (1991).
B30 Boice J.D., D. Preston, F.C. Davis ct al. Frequent
chcst x-ray fluoroscopy and breast canocr incidencr:
among tuberculosis patients in Massachusetts. Radiat.
Rcs. 125: 214-222 (1991).
B31 Uartcls, G. Die Aufzeichnungspflicht der R6ntgcnvcrordnung. Dtsch. Krankenpflcgcz. 43: 22-26 (1990).
B32 Basscy, C.E., 0.0. Ojo and I. Nrpabio. Kepcat profile
analysis in an x-ray department. J. Radiol. Prot. 11:
179-183 (1991).
833 Burkhart, R.L. Quality assurancc programs for diagnostic radiology facilities. HEW (FDA) 80-8110(1980).
B34 Bluml. A. Qualitatssicherung in dcr RBntgcndiagnostik - eine preiswerte Maonahme der Strahlcnhygiene. Roentgen praxis 42: 112-1 14 (1989).
R35 Biuml, A. Proposed limiting values for performance
critcria in acceptance tcsting of diagnostic X-ray
equipment in thc Fcdcral Republic of Gcrmany. p. 2526 in: Tcchnical and Physical Parameters for Quality
Assurance in Medical Diagnostic Radiology. (B.M.
Moorcs, F.E. Stieve, 11. Eriskat ct al.. eds.) British
Institute of Radiology, Rcport 18, London, 1989.
B36 Dccntjes, L.B. and C.W.M. Tmmermans. Patient
doscs in the Nethcrlands. Radiat. Prot. Dosim. 36:
265-268 (1991).
837 Bcckman, M. Unpublished statistics from thc
Stockholm County Council Paticnt Register (1992).
838 Baldas, J., J. Bonnyman, S.F. Colmanct et al. Quality
assurancc of radiophamaceuticals spccifications andlcst procedures. A R m 0 9 3 (1990).
B39 Baldas, J., J. Ronnymnn, Z. lvanov et al. Results ofthc quality assurance testing programme for radiopharmaceuticals 1989. ARLfIR100 (1991).
R40 Bluml, A. Qualitllskontrolle und Quali~ksichcrungin dcr Kadiologie. Bundcsgcsundhcitsbla~t2914: 128132 (1986).
C1 Cimzzi, A., A. Tesh, M. Bultrini et al. Dosimctria
dinica in xeromamrnografia con sistcma "low dose".
Radiol. Mcd. 74: 567-568 (1987).

-

I
I
I

i
I

I

ANNEX C: MEDICAL KI\DIATIONIIXI'OSUKILS

C2Contcnto, G., M.R. Malisan, H. I'adovani ct aI. A
comparison of diagnostic radiology praclicc andpalicnt cxposurc in Ikilain, Izrance and Ilaly. I3r. J.
Kadiol. 61: 143-152 (1988).
C3 Commission of thc Europcan Communities. Qualily
criteria for diagnostic radiographic imagcs inI'rogrammc,
pacdiatrics. Radiation I'rotcction
Documcnt X111307/91, 1992.
C4 Clifton, J.S. Imagc quality - a Europcan dimension.
hlitt. Dkch. Ges. Mcd. Phys. 2012: 47-54 (1988).
C5 Ccntrc for Dcvices and Radiological Ilcalth. Ccntrc
participates in national matcrnal and infant hcalthsurvcy. Radiol. Iiealth Bull. 23/11: 1-2 (1989).
C6 Colcttc, I{., N. Day, J. Rombach et al. Evaluation of
scrccning for breast cancer in a non-randomized study(the DOM-project) by means of a case-control study.
Lancet 1: 829 (1985).
C7 Cohcn, M. Irradiation of human subjects in mcdical
rcscarch: proposal for a Canadian policy. J. Can.
Assoc. Radiol. 35: 97 (1984).
C8 Carter, H.B., E.B. Nislund and R.A. Riehlc Jr.
Variables influencing radiation exposure during
extracorporal shock wave lithotripsy. Urology 30:
546-550 (1987).
C9 Commission of the European Communitics. Progress
report - radiation protection programme - 1988.
EUR-12064 (1989).
C10 Clark, D.E., R.A. Danforth, R.W. Barnes ct al.
Radiation absorbed from dcnlal implant radiography:
a comparison of linear tomography, fl scan, andpanoramic and intra-oral techniques. J. Oral Implantol.
16: 156-164 (1990).
C11 Clcmentz, B.-G.. C. Ytterbergh and I. Telenius.
Radiation dose in assessment of tibia1 torsion with amobile C-arm fluoroscope. Upps. J. Med. S a . 94: 6772 (1989).
C12 Cagnon, C.II., S.H. Rcncdict, N.J. Mankovich ct al.
Exposure rates in high-level-oontrol fluoroscopy for
imagc cnhanccmcnt. Radiology 178: 643-646 (1991).
C13 Calzado, A.. E. Vafi6, P. Mordn et al. Estimation ofdoses to paticnk from "complex" conventional X-ray
examinations. Dr. J. Radiol. 64: 539-546 (1991).
C14 C a m p s de Araujo, A.M., P.G. Cunha, G. Drcxlcr etal. Occupational and medical cxposurcs in Brazil.
p. 639-644 in: Strahlenschutz Tur Mensch und
Umwelt. (11. Jacobs and H. Bonka, eds.) Fachverband
fcr Suahlenschutz. FS-91-55-T. 1991.
C15 Carvalho. A.F., M.P. Rocha. J.G. N v c s ct al.
Radiation doses from mammography in Portugal.
Radiat. Prot. Dosim. 36: 261-263 (1991).
C16 Conference of Radiation Control Program Directors,lnc. Avcrage patient e x p s u r c guide. CRCPD l'ublication 88(5) (1988).
C17 Commission of the Europcan Communities. Quality
critcria for diagnostic radiographic imagcs. Radiation
Protection Programmc, Documcnt X11/173PO, 1990.
C18 Cox. P.11., J.G.M. Klijn, M. Pillay ct al. Utcrinc
radiation dose from opcn sources: the potential forunderestimation. Eur. J. Nud. Med. 17: 94-95 (1990).
C19 Commission of the European Communities. European
guidelines for quality assurance in mammography
screening. Europe Against Cancer. Document CEC
V/l75/92. 1992.

359

Chcn, W.-C., Y.-11. Lcc, M.-l'. Chcn ct al. Factors
influencing radiation cxposurc during thc cxtramrporcal sliock wavc lithotripsy. Scand. J. Ncphml.
25: 223-226 (1991).
Culvcr. C.M. and I I J . Dworkin. Radiation safcty
mnsidcrations for pst-iodine-131 hypcrthyroid
thcrapy. J. Nucl. Mcd. 32: 169-173 (1991).
Chapple, C.-L.. K. Faulkner, R.EJ. Lcc ct al. Rcsul~sof a survcy of doscc to pacdiatric patients undergoing
common radiological examinations. Dr. J. Radiol. 65:
225-231 (1992).
Conway, BJ., J.L. McCrohan, R.G. Antonscn ct al.
Avcragc radiation dosc in slandard CI' examinationsof the head: Rcsults of thc 1990 NEXT sunrcy.
Radiology 184: 135-140 (1992).
Cllristcnsen, J.J., L.C. Jcnscn, K.A. Jesscn ct al.
I)osimetnc i nvesligalions in computed tomography.
Radiat. Prot. Dosim. 43: 233-236 (1992).
Carvalho, A.F.. A.D. Olivcira. E.M. h a r a l ct al.
Assessment oC patient doscs and image quality incomputed tomography. Laboratorio Naaonal de
Engcnharia c Tecnologia Industrial, Dcpartamcnto dc
Prote@o c Scguranp Radiol6gica, Portugal, 1991.
Cranage, R.W.. C J . Iloward and A.D. Welsh. Dose
reduction by the use of erbium filtration in a generalradiographic room. Br. J. Radiol. 65: 232-237 (1992).
Coutrakon. G.. M. Bauman, D. Lesyna et al. A prototype bcam delivery system for the proton mcdical
accelerator at Loma Linda. Med. Phys. 18: 1093-1099(1991).
Dicnstbier. Z. and Z. Prouza. Thc radiation burdcn
during nuclear-medicine diagnostic in children in the
Czech Soaalist Republic. Radiol. Diagn. 29: 181-185(1988).
Drcxler, G., 11. Eckerl and M. Zankl. On the influenceof thc e x p s u r c model on organ doses. Radiat. Prot.
Dosim. 28: 181-188 (1989).
Dubin. N. Effcct oCdiffcrent mammographic radiation
cxposurcs on predicted benefits of saccning for brcast
canccr. Stat. Med. 1: 15-24 (1982).
Drcxler, G.. P. Cunha and J.E. Pcixoto. Medical andoccupational exposure in Brazil. Radiat. Prot. Dosim.
36: 101-105 (1991).
Drcxler, G., 11. Eriskat and H. Schibilla (eds.). Critcria
and methods for quality assurance in medical x-ray
diagnosis. Br. J. Radiol. (Suppl.) 18: (1985).
Dubin. N. Rcnefits of screening for breast canccr:
application of a probabilistic model to a breast cancer
detection project. J. Chronic Dis. 32: 145-151 (1979).
Dabrowski, K., M. W y l a i Aska, B. Gwiazdowska ct al.
X-ray doscs absorbcd by patients during Xeroxmammography. Postcpy Fiz. Med. 23: 137-147(1988). (in Polish).
Dcsponds, L, C. Dcpcursingc, M. Grccesco ct al.
Influence of anode and filter material on image
quality and glandular dosc for saeen-film
mammography. Phys. Mcd. Biol. 36: 1165-1182(1991).
Dawood, R.M. and C.M. ilall. Too much radiation for
too many children? Ur. Mcd. J. 296: 1277-1278(1988).
Dutkowsky, J.P.. D. Shearcr. B. Schepps ct al.
Radiation exposure to patients receiving mutincscolimis radiography measured at depth in ananthropomorphic phantom. J. Pediatr. Orthop. 10:
532-534 (1990).
Dobid. F., A. Susanna and J. Wells. Radiation exposure of the Iblian population due to nuclear medicine
examinations. in: World Congress on Medical Physics
and 13iomedical Engineering, Kyoto, Japan. 1991.
Dvorak. P. and C. Lavoie. Exotic filter materials fordiagnostic x-ray equipment - are they superior tooommonly available materials? p. 211-214 in:Worldwide Achicvcmenl in Public and Occupational
Health Protection Against Radiation. Worldwide
Achievement in Public and Occupational HealthProtection Against Radiation. Proceedings of the 8thInternational Congress of the International Radiation
Protection Acsociation, Montdal, 1992.
Drexler, G. Das Konzept der effektiven Dmis in dcr
Rbntgendiagnostik. Strahlcnschutz Forsch. Prax. 34: 114 (1993).
Dahlbom, M.. E.J. Hoffman, C.K. lloh et al. Wholebody positron emission tomography: Part I. Methods
and performance characteristics. J. Nud. Med. 33:
1191-1199 (1992).
Dyct, J.F., W. I-lartley, A.R. Cowen et al. Digital
cardiac imaging the death knell of cineangiography?
Br. J. Radiol. 65: 818-821 (1992).
Durosinmi-Etti, F.A., M. Nofal and M.M. Mahfouz.
Radiotherapy in Africa: Current needs and prospects.
Int. At. Energy Agency Bull. 4: 24- 28 (1991).
Dance, D.R.. J. Penlidcn and G. A m Carlsson.
Calculation of dose and contrast for two mammographic grids. Phys. Med. Biol. 37: 235-248 (1992).
Diaz-Romero, F. and J. Hernandez-Armas. Doses anddetriment to patients from vascular and interventional
radiology. p. 363-366 in: Worldwide Achievement in
Public and Occupational Health Protection Against
Radiation. Proceedings of the 8th International
Congress of the International Radiation Protection
Association, Mont&l, 1992.
Eillcs, C. Strahlenexposition bei der SPECT nlit
M6glichkeitcn der Reduktion der Strahlenexpition
bei Patienten und Personal. Strahlenxhutz Fonch.
P ~ x 31:
. 119-131 (1990).
Edrelman, W.C. The status of radiopharmaceuticalresearch. Nucl. Med. Biol. 18(7): iii-vi (1991).
Ennow, K Use of radiopharmaceuticals in Denmarkin 1990. National Institute for Radiation Hygiene,
Denmark 1991. (in Danish).
Ewen, K. Wclche Auswirkungen hat die novellicr~c
Rontgenverordnung auf die Strahlenexposition dcs
Patienten und dcs Personals in der Medizin? p. 635638 in: Strahlcnschutz far Mensch und Umwelt. (11.
Jacobs and 11. Bonka, eds.) Fachverband fiir
Strahlenschutz, FS-91-55-T, 1991.
E d , S., H. Dcckart and M. Tautz. Radiation dose andrisk of patients through nuclear medicine proceduresin the GDR: A mmparison of 1978 and 1981. Eur. J.
Nud. Med. 9: 241-24.1 (1984).
Fraser. G.M. Patient dose reduction. Clin. Radiol. 44:
212-213 (1991).
Fitzgerald, M. and J.-M. Couradcs. Medical radiation
proledion practice within the EEC. British Institute orRadiology, London, 1991.

-

Fcygclman, V.M., W. IIuda and K.R. Peters. Effective
dose cquivalcnts to patients undergoing cerebral
angiography. Am. J. Ncuroradiol. 13: 845-849 (1992).
I;aulkncr, K.. J.1-. Barry and P. Srnallcy. Radiationdose to neonates on a special care baby unit. Dr. J.
liadiol. 62: 230-233 (1989).
Frcgcnc, A.O. Nuclmr medicine in Nigeria. p. 575 in:
Nudcar Medicine and Related Radionuclide Applications in Developing Countries. IM:A, Vienna, 1986.
1-elmlee, J.P., J.E. Gray, M.L. Leetzow et al.
Brimatcd fetal radiatiorl dose from multislicestudies. Am. J. Rocntgenol. 154: 185-190 (1990).
Frost, F., V. Taylor and M. Odlaug. Mammography
quality assurance in Washington Slate. IIcalth Phys.
62: 131-135 (1992).
Fosmark, II. and J.F. Unhjcm. Radiation in C O M C U ~ O ~with angiography. National Institute for Radiation
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