1. International Residential Radon Project
Radiation and Environmental Health Programme
Department of Protection of the Human Environment
World Health Organization HQ - Geneva, Switzerland

2. Radiation & Environmental Health Program in WHO
Unit
Links to Regional and Country Offices
(RO, CO)
Communicable Diseases
(CDS)
Sustainable Development & Healthy Environments
(SDE)
Evidence and Information for Policy
(EIP)
Non-communicable Diseases & Mental Health (NMH)
Family and Community Health
(FCH)
Health Technology & Pharmaceuticals
(HTP)
External Relations and Governing Bodies
(EGB)
HIV, Tuberculosis, Malaria
(HTM)
Health Action in
Crises
(HAC)
General Management
(GM)
Director General Office (DGO)
WHO HQ Structure
WHO Radiation and Environmental Health Programme

3. WHO Radiation and Environmental Health Programme
RAD Mandate
Develop and promote evidence-based policy for Member States that reduce risks and protect health from exposure to radiation
Provide medical support and public health advice in case of major radiation accidents or terrorist events
Build capacity and provide information to support national programs
WHO Radiation and Environmental Health Programme

4. Ionizing Radiation Risk Factors by Origin
Natural background radiation
Radon in homes
Elevated background radiation areas (e.g. India, Iran, Brazil, etc)
Medical applications
Diagnostic X-rays
Radioactive pollution
Chernobyl and other accidents
Nuclear fallout and waste disposal
Depleted uranium
Occupational exposure
Nuclear workers
Cosmic radiation (Air crews)
WHO Radiation and Environmental Health Programme

5. WHO/RAD: Ionizing Radiation Projects
Radiation Emergency Response (2 UN Conventions)
REMPAN for emergency medical and public health response
Education and Training
Telemedicine
Environmental Radiation
Radon in homes
Depleted Uranium
High Natural Background Radiation Areas (Iran, India, Brazil, China)
Research agenda (With UNSCEAR, IAEA, etc)
Co-ordination of research on exposed populations (Chernobyl, Urals, Semipalatinsk)
International Research Reviews (Chernobyl….)
Global Burden of Disease (GBD) assessment
Occupational Radiation Health Evaluation
Nuclear workers
Cosmic Radiation
Health Aspects of Diagnostic Imaging (X-rays, CT, PET, MRI, Ultrasound)
WHO Radiation and Environmental Health Programme

6. WHO Radiation and Environmental Health Programme
Radon
Scientific literature is now suggesting that 10% of lung
cancers are due to exposure to indoor radon.
People and politicians are not taking enough notice of this problem.
Mitigation is easily
There is a need for an international focus to raise awareness
WHO Radiation and Environmental Health Programme

7. WHO Radiation and Environmental Health Programme
International Radon Project First Meeting of the Expert Group Geneva, Switzerland - January 17-18, 2005
Scope: Establish a global project (3-year), with all key international and national partners participating, to identify and promote programs that reduce the health impact of exposure to residential radon
Objectives:
Estimate the global health impact of exposure to residential radon
Create a global database of residential radon exposure
Identify effective measures to reduce radon's health impact
Promote sound policy options and mitigation programs to Member States
Raise public and political awareness about the consequences of exposure to radon
Monitor and periodically review mitigation measures to ensure effectiveness
Provide annual reports
WHO Radiation and Environmental Health Programme

8. Global Burden of Disease
GBD is the quantification of health impacts (mortality and morbidity) caused by risk factors at population level, using a comparable and internally consistent framework, definitions and outcome measures.
A national burden of disease for radon has already been completed in Canada: protocol could used for a full GBD
First, let me explain you what is environmental global of disease. (read from slide)
Quantification of disease burden at population level caused by various risk factors in a comparative and internally consistent way
Comparative:
same definitions and framework
similar method for combining exposure and risk information
same method for expressing results (mortality and DALYs)
Consistent:
Linkage of disease burden by disease and by risk factor
Estimation of attributable and avoidable risk
attributable: current burden from past exposure
avoidable: future burden if current or future exposure was reduced
It may not seem to make sense to rationalise health and health risks, but if you look at it closer it does appear to be a universal tool to measure health impact of this or another risk factor.
WHO Radiation and Environmental Health Programme

9. WHO Radiation and Environmental Health Programme
Why Assess GBD?
Provides a global picture of health impacts from risks associated with radon
Identifies problem areas to focus resources more effectively
Provides tools for identifying intervention measures and monitoring progress
WHO Radiation and Environmental Health Programme

10. WHO Radiation and Environmental Health Programme
Mitigation programs
Provide policy options for national authorities that lead to a reduction in exposure to radon
Draft international limits on radon concentrations in collaboration with appropriate international and national agencies
Provide elements of model legislation
Others?
WHO Radiation and Environmental Health Programme

11. Advocacy and Risk Communication
Draft scientific reports, fact sheets, press releases and other documents to raise public and political awareness of health concerns about radon exposure
What more would you like WHO to do to assist national programs?
WHO Radiation and Environmental Health Programme

12. International Radon Project: Shaping the Project I
Four questions (Barnes Johnson):
What are the benefits of an international action agenda on radon?
If recommendations were developed to encourage more risk reduction from radon, what would they say?
What are some key opportunities for WHO and us to raise visibility for such recommendations?
How can we get started to develop and implement a step-by-step process?
WHO Radiation and Environmental Health Programme

13. International Radon Project Shaping the Project II
Communication issues
Measurement issues
Modeling issues
Cost issues
WHO Radiation and Environmental Health Programme

14. International Radon Project Shaping the Project III: Workplan
Program elements
Workgroups
Timelines
WHO Radiation and Environmental Health Programme

15. International Radon Project Shaping the Project IV: Conclusion
Consensus statements
Next steps
WHO Radiation and Environmental Health Programme

16. Q1. What are the benefits of an international action agenda on radon?
Provide scientific consensus on radon health risks
Promote public awareness of health risks associated with residential radon
Promote action at national level
Increase homeowner compliance with voluntary/advisory radon guidelines
Set minimum criteria for radon risk management (but allow for country specific needs)
WHO Radiation and Environmental Health Programme

17. WHO Radiation and Environmental Health Programme
Q2. If recommendations were developed to encourage more risk reduction from radon, what would they say?
Better to install mitigation devices at the time of construction, rather than retrofit
Building codes provide a natural point of intervention for control of residential radon (radon levels have increased substantially in Norway because of the use of aerated concrete in foundations; indoor radon levels are also increasing in Finland)
Radon testing and mitigation might also be required when an existing home is sold
Control measures should focus on medium exposure levels, which contribute most to the overall radon lung cancer burden
Since the vast majority of radon related lung cancers occur in smokers, consideration needs to be given to the role of tobacco smoking in radon risk reduction programs
Unburned brick and open floors in homes in developing countries can lead to elevated thoron levels
Since resources will be required to implement radon risk reduction measures, it is important to demonstrate the cost-effectiveness of such measures (cost-effectiveness will vary with radon levels)
WHO Radiation and Environmental Health Programme

18. WHO Radiation and Environmental Health Programme
Q2 (cont’d). If recommendations were developed to encourage more risk reduction from radon, what would they say?
Consideration needs to be given to both guidelines (as is the case in homes in Britain) and enforceable regulations (as is the case in the workplace in Britain)
Both voluntary and enforceable guidelines may be useful for residential exposure (as is the case in Switzerland, where homes exceeding 1,000 Bq/m3 must be mitigated)
Should mitigation focus on new homes only, or include existing homes?
Radon affected areas comprised of high radon levels (defined as those areas in which 1% of homes exceed the action level in Britain) might be selectively targeted for testing
Government grants might be used to support radon mitigation actions in cases of need (may require a means test to administer this type of public support for mitigation)
WHO Radiation and Environmental Health Programme

19. WHO Radiation and Environmental Health Programme
Q2 (cont’d). If recommendations were developed to encourage more risk reduction from radon, what would they say?
Should schools be identified as an environment that require special consideration with respect to radon mitigation?
Should workers be included within the scope of this project?
Should thermal spas with high radon content in the water be included?
Should new buildings have a more stringent radon reference level than existing buildings? (some EU countries have two reference levels, with a lower level for new buildings)
All new homes constructed since 1998 are required to have a radon sump in Ireland (nonetheless, 10% of new homes still have radon levels above the action level of 200 Bq/m3)
WHO Radiation and Environmental Health Programme

20. WHO Radiation and Environmental Health Programme
Q3. What are some key opportunities for WHO and us to raise visibility for such recommendations?
Information programs describing radon as a public health issue
Future (open) meetings to develop WHO International Residential Radon Project
Education materials are available in a number of countries: these might be used to develop an “international” radon information kit
WHO Radiation and Environmental Health Programme

21. WHO Radiation and Environmental Health Programme
Q4. How can we get started to develop and implement a step-by-step process?
Consensus report from the present meeting
Action plan for WHO residential radon project
Obtain international residential (and outdoor?) radon levels from UNSCEAR
Reference levels for radon in 20 European countries have been tabulated as part of ERRICA 2 (advisory levels are largely between 200 and 400 Bq/m3)
WHO Radiation and Environmental Health Programme

22. WHO Radiation and Environmental Health Programme
Communication Issues
Information needs to be made available to the public on how to determine radon levels in their homes, and on ways in which radon in homes can be reduced
Need to put residential radon lung cancer risk in perspective, perhaps by comparison with other agents included in the WHO GBD program
Studies have indicated that people may not elect to take voluntary action to reduce radon in their homes, although this depends on the level of knowledge that they have on radon health risks
Radon is the largest source of environmental exposure to ionizing radiation (approx 40% of total exposure in Switzerland)
Radon is the second leading contributor to the global lung cancer burden, after tobacco smoking
WHO Radiation and Environmental Health Programme

23. Communication Issues (cont’d)
Consider tools developed by ERRICCA 2 Project (European Radon Research and Industry Collaboration Concerted Action): website, public awareness, protection of new building, mitigation, mapping and measurement)
WHO Radiation and Environmental Health Programme

24. 1993 WHO Europe Communications Guidelines
Countries should collect baseline information on existing attitudes and perceptions about radon before initiating a risk communication programme.
The goal of the radon communications programme should be to provide accurate scientific information to reduce radon health risks.
Continuous evaluation and improvement of the risk communication programmes should be undertaken in order to achieve the overall communications goals.
For special target audiences, appropriate (and possibly different) radon risk communication messages should be prepared.
Radon risk communication efforts should be linked to key issues, such as the availability of qualified radon contractors and testing services.
Messages should be repeated and reinforced; a one-time message will not result in behavioural change.
Countries should be encouraged to share information and discuss new findings in the area of radon risk communication.
WHO Radiation and Environmental Health Programme

25. WHO Radiation and Environmental Health Programme
Measurement Issues
Although homeowners may want quick monitoring results based on short-term measurements, it is difficult to determine long-term exposure levels on the basis of short-term measurements
Adjustment for residential radon exposure measurement error results in increased estimates of the lifetime relative risk – what are the implications of exposure measurement error for estimating the population attributable risk?
Spatial patterns in radon concentrations may be related to geographic characteristics, which may help in identifying “radon affected areas”
Twenty EU countries have carried out radon mapping to some extent under the ERRICCA 2 Project (by measuring indoor radon gas concentrations, by soil gas measurements, by geological mapping, and by other radiological techniques)
Maps can be used to plan radon campaigns, to distribute radon dosimeters, for radon prevention in new buildings, and to increase public awareness
Mapping studies have designated 1/3 of Ireland as “high radon areas” (HRAs)
WHO Radiation and Environmental Health Programme

26. Measurement Issues (cont’d)
Identification of high radon areas by direct measurement may take some time (10 years in Switzerland)
Can measurements of less than one year be used to reliably predict annual residential radon concentrations (possibly using seasonal adjustment models developed by Pinel et al., 1995, and Krewski et al., 2004)?
WHO Radiation and Environmental Health Programme

27. WHO Radiation and Environmental Health Programme
Modeling Issues
Develop updated radon risk projection models based on BEIR VI (considering recent modifications by US EPA)
Develop updated risk projection models based on combined analysis of residential studies, including the ongoing combining of European and North American studies
Consider the use of simple approximations to these models, which provide insight into different indices of risk are inter-related, and on how to extrapolate results among different conditions
Characterize sources of uncertainty in radon risk projections
WHO Radiation and Environmental Health Programme

28. Main Program Elements I: Science
Risk models – develop “WHO” model for projecting radon lung cancer risk (build on BEIR VI and European and North American combined analyses, including joint effects of tobacco smoking)
Radon database – develop global database on indoor (and outdoor?) radon levels; describe spatial variation in radon levels using mapping techniques
Population health impact – estimate global burden of disease for radon
WHO Radiation and Environmental Health Programme

29. Main Program Elements II: Policy
Exposure guidelines – develop WHO guidelines for residential radon exposure levels
Cost effectiveness – conduct economic analyses of alternative mitigation strategies
WHO Radiation and Environmental Health Programme

30. Main Program Elements III: Measurement and Mitigation
Measuring residential radon – recommend measurement methods for indoor radon
Radon reduction – recommend technologies for reducing indoor radon levels
WHO Radiation and Environmental Health Programme

31. Main Program Elements IV: Communication
Communications – develop communications materials to promote program to the public and to national public health agencies
WHO Radiation and Environmental Health Programme

32. Main Program Elements V: Program Evaluation
Effectiveness monitoring – track reductions in indoor radon concentrations related to radon mitigation
Reporting – annual project reports
WHO Radiation and Environmental Health Programme

33. WHO Radiation and Environmental Health Programme
Work Groups
Risk assessment (risk modeling , GBD, and global radon database)
WHO exposure guidelines
Cost effectiveness (framework + analyses)
Measurement and mitigation
Risk communication (including education and training)
Program coordination and evaluation
[All groups should identify research and information needs as part of their work]
WHO Radiation and Environmental Health Programme

34. WHO Radiation and Environmental Health Programme
Timelines: Year 1
Develop WHO residential radon risk projection model
Preliminary GBD estimates (based on approximate methods: need average radon concentration, lifetime risk of dying of lung cancer, prevalence of ever-smokers, life-expectancy, geometric standard deviation of indoor radon levels also useful)
Establish global radon database
Review current residential radon exposure guidelines, and recommend radon WHO radon guidelines
Review current radon measurement methods
Review current methods of radon reduction
Outline main elements of communications strategy
Develop framework for cost-effectiveness analysis
Consolidate findings into first annual report
WHO Radiation and Environmental Health Programme

35. WHO Radiation and Environmental Health Programme
Timelines: Year 2
Conduct GBD analysis for radon
Map global residential radon levels
Conduct cost-effectiveness analysis of alternative radon mitigation strategies
Complete communications strategy and develop communications materials, including radon fact sheets
Second annual report
WHO Radiation and Environmental Health Programme

36. WHO Radiation and Environmental Health Programme
Timelines: Year 3
WHO Radon “Handbook” describing radon as a global population health issue (with input from all workgroups)
International symposium on WHO Radon Mitigation Program (showcasing WHO Handbook)
Program evaluation (impact on national public health agencies, changes in building codes, reduction in exposure, other impacts)
Third annual report
WHO Radiation and Environmental Health Programme

37. Workgroup 1: Risk Assessment
J. Zielinski
S. Darby
M. Tirmarche
H. Paretzke
D. Chambers
M. Kreuzer
L. Kreienbrock
K. Brand
D. Krewski
M. Zhukovsky
B. Shang
L. Veiga
D. Hill
M. Pavia
E. Wichmann
J. Puskin
S. Akiba
B. Field
WHO Radiation and Environmental Health Programme

38. Workgroup 2: Exposure Guidelines
J. McLaughlin
E. Ettenhuber
G. Kendall
D. Fenton (to be confirmed)
A-L Soderman
T. Strand
B. Johnson
H. Yonehara
WHO Radiation and Environmental Health Programme

39. Workgroup 3: Cost-effectiveness
A. Gray
K. Brand
T. Strand
B. Johnson
Q. Sun
I. Makelainen
D. Krewski
WHO Radiation and Environmental Health Programme

40. Workgroup 4: Measurement and Mitigation
B. Field (measurement M1)
C. Scivyer (mitigation M2) (to be confirmed)
Y. Yamada (M1)
G. Kendall (M1)
T. Strand (M1, M2)
E. Ettenhuber (M1)
G. Piller (M1, M2)
D. Steck (M1)
G. Fisher (M1, M2)
J. Jankowski (M1, M2)
L. Quindos (M1, M2)
A-L. Soderman (M1, M2)
J. Tschiersch (M1)
H. Arvela (M2, M1) (mitigation) (to be confirmed)
Q. Guo (M1)
W. Zhuo (M1, M2)
B. Shang (M1, M2)
M. Zhukovsky (M1)
WHO Radiation and Environmental Health Programme

41. Workgroup 5: Risk Communication
V. Koukouliou
A-L. Soderman
J. McLaughlin
G. Piller
H.H. Landfermann
L. Quindos
Q. Sun
T. Strand
B. Johnson
H. Walker
D. Fenton
WHO Radiation and Environmental Health Programme

42. Workgroup 6: Program Monitoring and Evaluation
Z. Carr
B. Johnson
H. Walker
A. Gray
A. Auvinen
V. Koukouliou
WHO Radiation and Environmental Health Programme

43. WHO Radiation and Environmental Health Programme
Consensus Statements
For many people, radon represents the largest source of exposure to ionizing radiation in humans.
Radon is a known cause of lung cancer in humans.
Radon is an important contributor to the human lung cancer burden, after tobacco smoking.
Radon is considered to be responsible for some 10% of the human lung cancer burden in developed countries/worldwide (will differ between developed and undeveloped countries)
The BEIR VI Report estimated that there are approximately 22,000 deaths annually from radon in the United States alone. (Add European results here)
Radon related lung cancer risk is affected by tobacco smoking, with most radon related lung cancers occur in smokers; however, radon is one of the leading causes of lung cancer in nonsmokers.
WHO Radiation and Environmental Health Programme

44. Consensus Statements (cont’d)
Radon should be a priority public health issue for national environmental and radiation safety programs
There is a need to carefully evaluate the costs and benefits of national and international radon mitigation programs.
Based on existing knowledge of geological conditions and building types, and consideration of the total lung cancer burden, countries should consider developing cost-effective national or regional policies on testing and mitigation
Where appropriate, countries should build capacity within the public and/or private sectors to provide testing, mitigation, and radon-resistant new construction
Where appropriate, countries should issue and widely disseminate statements which address the importance of radon risk reduction and the steps that can be taken to reduce such risks
WHO Radiation and Environmental Health Programme

45. Consensus Statements (cont’d)
Countries should explore ways to address radon health risks in a cost-effective manner, considering both the installation of preventive measures in new buildings and remediation of existing buildings.
National governments should team with other stakeholders to ensure radon risk communication messages are delivered from multiple sources
Governments should strive to include radon health messages and action steps with other national efforts on green buildings, housing policy, and the built environment.
WHO Radiation and Environmental Health Programme

46. Towards the WHO Radon Guideline
Immediate remedial action at levels exceeding Bq/m3
Guideline of maximum of 400 Bq/m3 for existing homes
Guideline of 200 Bq/m3 for new homes
Efforts should be made to reduce radon to even lower levels, where possible, since there is still some risk of lung cancer below the above guidelines
Group recommended giving risk at different proposed guideline levels, for smokers and nonsmokers.
Explain role of smoking in relation to radon risk?
WHO Radiation and Environmental Health Programme

47. Next Steps & Related Activities
Next annual meeting: January 23-26, 2006 in Geneva) [WHO Geneva]
Four page fact sheet on radon (what radon is, characterizes health effects, testing and mitigation techniques known and easily implemented, cost effectiveness of exposure reduction, raise awareness, what WHO will do) (May 30, 2005) [WHO Geneva]
Press conference to launch WHO project (June, 2005) [WHO Geneva]
WHO Radiation and Environmental Health Programme

48. WHO Radiation and Environmental Health Programme