Michael. G. Kawooya: ECUREI. Uganda.

OBJECTIVES  List the challenges to enhancing justification  List the opportunities to enhancing justification

“Doing the Right thing Right”

CHALLENGES

Challenges  Insufficient risk awareness, arising from insufficient risk assessment  Absence of referral guidelines  Lack of a radiation safety culture  Resorting to imaging as means of diagnosis & as a substitute to thorough clinical assessment  Self-referral  Self –presentation  Litigation pressure  Unnecessary information void between referrers, and radiologists, radiographers & patients. 

Challenges 2 (i) Poor or absent legislative and regulatory framework for radiation protection in many countries (ii) Challenges to match health work force supply and demand: few physicians & radiology personnel

Challenges 3 iii) some prescriptions for medical imaging are probably written by none-physician staff (iv)There are no imaging RGs and no national policy on their application (v) A significant proportion of imaging equipment including CT, privately owned : self- referral (v) (vi) Imaging professional societies are in their formative stages and yield little influence on policy.

Insufficient human resource

Global Summit on Radiological Quality and Safety October 2015, Barcelona Approximate number of radiologists per country COUNTR Y Total number of radiologists National populationRadiologist to population. South Korea 3,76449,115,1961:13,049 Australia and N. Zealand Australia 1950, N. Zealand ,222,0141:11,593 Denmark8005,678,3481:7,097 France7,50064,641,2791:8,618 UK3,00064, 679, 7001:21,559 US33,659321,216,3971:9543 Canada2,00035,344,962.1: 17,672 Latin America (Chile) ******

Global Summit on Radiological Quality and Safety October 2015, Barcelona Approximate numbers of radiologists per country COUNTRYTotal number of radiologists National populationRadiologist to population Egypt1,250 (By year 2012) 83,386,7391:66,709 Tunisia450+ (By year 2012)10,225,1001:22,722 Kenya17046, :27,3206 Uganda4540, :897,470 Tanzania4052,290,7951:1,307,269 Nigeria350178,516,9041:510,048 S. Africa799 54, :68,548 Ethiopia16098,942,1021:618,388 D.R. Congo4274,834,2311:1, Malawi217, : 8,801,129 Angola3019,088,1061:636,270 Mozambique524,692,1441: 4,938,428 Sao Tome2190,4281:95,214 Guinea -Bissau21,693,3981: 846,699 Cape-Verde3538,5351:179,511

Global Summit on Radiological Quality and Safety October 2015, Barcelona Proportion of Radiologists in Rural areas COUNTRYPROPORTION WORKING IN RURAL (%) Korea47.3 Australia and N. Z.Australia = 13.5, N.Z.= 10 DenmarkHardly any( no rural areas) FranceFrance : unknown UK30 US 10 Canada5-10 Latin America******

Global Summit on Radiological Quality and Safety October 2015, Barcelona Proportion of Radiologists in Rural areas COUNTRYPROPORTION WORKING IN RURAL (%) Egypt******** Tunisia********* Kenya 10% Uganda10 Tanzania<1 Nigeria10-15 S. Africa<1 Ethiopia 5-10 D.R. Congo10

OPPORTUNITIES 1  Global interest in safety and justification  Global agencies IAEA, WHO that offer assistance through workshops, sponsorships of trainees and provision of standards, guidelines and tools for justification.  BSS and Bonn call for action  Interest from several national health authorities in radiation safety  Creation of professional societies

OPPORTUNITIES 2  Evidence-based guidelines which can be adopted and adapted are already available Eg ACR appropriate criteria, Royal College of Radiologists (UK), Diagnostic Imaging Pathways (Australia) and the ISR- ICRQS.  Imaging campaigns (AFROSAFE, Eurosafe, Latin-SAFE, Image Gently, Image Wisely etc).  Wider range of Imaging equipment, including none- ionising alternatives like MRI and Ultrasound now available in several countries.  Training institutions and trained personnel becoming more available in several countries.  Increased patient awareness and synergies with Patient for Patient Safety (PFPs) initiatives.

THE ROLE OF GLOBAL AGENCIES

WORKSHOPS FACILITATED BY IAEA & WHO TARGETTED TO AFRICA ADDRESSING JUSTIFICATION AND REFERRAL GUIDELINES 9 TH TO 13 TH NOV 2015

The Bonn Call for Action (Dec 2012) 1. Enhancing implementation of justification of procedures 2. Enhancing implementation of optimization of protection and safety 3. Strengthening manufacturers’ contribution to radiation safety 4. Strengthening RP education and training of health professionals 5. Shaping & promoting a strategic research agenda for RP in medicine 6. Improving data collection on radiation exposures of patients and workers 7. Improving primary prevention of incidents and adverse events 8. Strengthening radiation safety culture in health care 9. Fostering an improved radiation benefit-risk-dialogue 10.Strengthening the implementation of safety requirements (BSS) globally position-statement.htm

The New BBS and the Justification Principal

Justification principle: 3 levels  Overarching justification of medical exposures: use of radiation in medicine does more good than harm.  Generic justification : ( carried out by the health authority in conjunction with appropriate professional bodies), for a given radiological procedure, a new technologies or techniques.  Final level of justification: application of the radiological procedure to a given individual has to be considered. IAEA Safety Standards For Protecting People And The Environment International Atomic Energy Agency, Vienna 2014.

Requirement 37: New BSS: Justification of Medical procedures (Level 1 &2)

Justification for an individual patient (level 3)

TOOLS FOR FACILITATING DIALOGUE AND JUSTIFICATION

Adapted from Maria Perez. WHO WHO in consultation with experts including ISR members is finalizing a tool on radiation benefit and risk communication in pediatrics. Health authorities to support its use. RADIAITON SAFETY AWARENESS: TOOL FOR RADIATION BENEFIT & RISK COMMUNICATION IN PEDIATRIC IMAING WHA GENEVA MAY 2015

INTEREST BY AFRICAN NATIONAL HEALTH AUTHORITIES IN RADIATION SAFETY

WHA 68-SIDE EVENT SPONSORED BY GOVTS OF KENYA, UGANDA, MALAYSIA AND SPAIN

KENYA DIRECTOR GENERAL OF HEALTH LAUNCHES AFROSAFE; 17TH FEBRUARY 2015 UGANDA COMMISIONE MINISTRY OF HEALTH LAUNCHES UGANDA CHAPTER AFROSAFE 7 TH NOV 2015 INTEREST BY AFRICAN NATIONAL HEALTH AUTHORITIES IN RADIATION SAFETY

FORMATION OF AFRICAN RADIOLOGY SOCIETIES

CONTINENTAL IMAGING CAMPAIGNS

LATIN- SAFE!!!! 2015?

AFROSAFE

AFROSAFE LAUNCH FEB 8 TH 2015; PACORI NAIROBI KENYA Health authorities to support these campaigns WHA GENEVA MAY 2015

AFROSAFE IMPEMENTATION TOOL AND LAUNCH OF UGANDA CHAPTER

PATIENT ENGAGEMENT: PATIENT SAFETY

Patient engagement through Patient for Patient Safety Justification should be contextual and patient centered: patients’ values, opinions & perspectives have to be considered.

Imaging Referral Guidelines: A Key Tool for Justification

Few available regularly updated evidence-based (EB) referral guidelines IRQN (ICRQS), in liaison with WHO developed referral guidelines (RG): published in 2014 thru adopting & adapting available E-B guidelines. RG guide referring medical practitioners in justification of imaging for children & adults Available for use on ISR website QN_RGDI2014PilotVersion.pdf REFERRAL GUIDELINES

HEADACHE Imaging in a child with headache but without associated neurological symptoms, signs or ‘red flags’; is rarely beneficial and is not indicated. In a child with neurological symptoms, signs or ‘red flags’, the imaging modality of choice is either MRI or CT (Lewis et al 2002, Millichap 2011). In general, MRI is preferred since it avoids the use of ionizing radiation.

Some African countries offering training for radiologists COUNTRYTYPE OF TRAININGDURATION OF TRAINING IN YRS EgyptMasters degree and FellowshipMasters 3, Fellowship 4 Kenya Masters degree4 UgandaMasters degree3 TanzaniaMasters degree3 EthiopiaMasters degree3 D.R. CongoMasters degree5 NigeriaFellowship5 S. AfricaFellowship5 TunisiaFellowship5

SUMMARY  Major challenges which include awareness and insufficient human resource  Opportunities including collaboration with global agencies, global campaigns, AFROSAFE, available guidelines for adopting and adapting. 