Original Article

Relationships among health, safety and environment (HSE) factors and the radiation received and incidence of cancer among the radiologic technologists

Introduction

Radiation constitutes a significant component of the human physical environment and is categorized into two main groups: ionizing and non-ionizing radiation. Of these, ionizing radiation garners greater attention due to its potential impact on public health. It poses a significant occupational hazard, capable of causing severe, irreversible, and incurable harm to those exposed.^1,2 Ionizing radiation transfers energy to cells and tissues, initiating a cascade of biological reactions ranging from immediate cellular interactions to long-term biological effects,^3-9 some of which may manifest decades later. These effects encompass a spectrum from immediate symptoms such as nausea, vomiting, and fatigue to long-term conditions including various cancers (such as leukemia, bone cancer, thyroid cancer, and lung cancer) and genetic abnormalities in offspring of exposed individuals.⁹

Globally, healthcare professionals constitute approximately 12% of the workforce, operating within environments recognized as among the most hazardous occupational settings. ^10,11 Radiologic technologists, in particular, are regularly exposed to substantial levels of radiation.¹² According to the United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR), the number of individuals exposed to radiation has increased significantly in recent years, leading to heightened concerns regarding cumulative radiation doses and potential health impacts over time. ^13-14 consequently, ensuring radiation safety, particularly within healthcare facilities, is paramount.¹⁵

Occupational Health and Safety Management Systems (OHSMSs) represent a comprehensive approach encompassing planning, consultation, and specific program elements aimed at enhancing health and safety performance. ^16,17 Safety, in this context, refers to the extent to which potential hazards are avoided through a range of practices and ongoing activities designed to identify, eliminate, or mitigate risks. ¹⁸ Given the presence of patients, employees, students, and complex equipment within hospital environments, prioritizing safety is essential.¹⁸

This survey was undertaken to assess the prevalence of cancer among radiologists and radiologic technologists, who are routinely exposed to radiation, while also evaluating health, safety, and environmental conditions within radiation centers. Additionally, the survey aimed to develop a Health, Safety, and Environment (HSE) checklist to gauge the level of HSE compliance in diagnostic imaging services and ensure the well-being of personnel. The findings of this survey can inform the development and implementation of health and safety protocols, with potential applications including regulatory inspections and ongoing monitoring of HSE standards.

Material and Methods

Data Collection

This cross-sectional survey was conducted across eight hospitals, encompassing seventeen diagnostic imaging services in Tabriz, Iran. All personnel working in diagnostic imaging services with potential radiation exposure were included in the survey. The study comprises two main parts:

1) HSE Survey of Diagnostic Imaging Services: This section involved assessing the health, safety, and environment conditions in hospital diagnostic imaging and radiotherapy services, including radiology, radiotherapy, nuclear medicine, and CT scan departments. Information was collected using checklists developed by the research team, drawing on previous studies and similar checklists such as radiation safety checklist and radiation safety inspection checklist.^19,20 The final checklist comprised five sections: (a) Basic information (hospital name, department name, number of personnel, date), (b) Radiation safety (40 items), (c) Radioactive waste management (11 items), (d) General safety (20 items), and (e) Emergency safety (6 items). The reliability of the checklist was assessed using Cronbach’s alpha coefficient, yielding a coefficient of 0.76, indicating acceptable reliability. Additionally, checklist validity was confirmed through expert review, ensuring alignment with the survey’s objectives. Following verification of validity and reliability, scores were normalized on a scale of 0-100. Based on expert opinion, scores were categorized into four levels: weak (0-25), average (26-50), good (51-75), and very good (76-100).

2) Investigation of Radiation Dose Exposure: This part involved evaluating the radiation doses received by workers in diagnostic imaging services over two- and twelve-month periods, utilizing dosimeter results reports. These reports included data on effective doses HP10 (in mSv) and HP 0.07, as well as the total effective dose over the past 12 months, obtained from the Atomic Energy Organization of Iran (AEOI). HP (d) represents the dose equivalent at a specified depth in the human body, typically where a dosimeter is worn. HP (10) is assessed at a depth of 10 mm, representing the individual effective whole-body dose, while HP (0.07), at a depth of 0.07 mm, represents the equivalent dose to the skin and extremities.²¹ Additionally, periodic tests (every 6 months) were conducted for suspected cancer cases, including complete blood count (CBC), thyroid stimulating hormone (TSH), urinalysis (U/A), triglycerides, fasting blood sugar (FBS), urea, creatinine, LDL, and HDL.

Study population

In this study, we investigated 8 hospitals, each housing a total of 17 diagnostic imaging services, including radiology, radiotherapy, nuclear medicine, angiography, among others. The collective workforce in these units comprised 303 employees, all of whom underwent evaluation to assess the dose of radiation received. Among the participants, 120 (56%) were male and 96 (44%) were female, with a mean age of 38 years old. The study focused on examining the radiation dose received by employees working in the radiation section under three conditions: HP (10) mSv, HP (0.07) mSv, and the dose received over a 12-month period.

Statistical analysis

Quantitative data were presented as mean ± standard deviation, while qualitative data were expressed as frequency and percentage. To compare the number of employees with normal and abnormal doses, as well as to compare checklist section adherence between normal and abnormal groups, the chi-square test and t-test were employed, respectively. Additionally, to compare hospitals based on checklist item adherence, analysis of variance (ANOVA) and the Tukey post hoc test were utilized.

Results

Among the subjects examined, the maximum dose received was 0.96 mSv, the minimum was 0, and the mean total dose received was 0.031 ± 0.11 mSv, which is below 0.05 mSv over a two-month period. Notably, the dose received in terms of HP (0.07) mSv over two months for all subjects was below the standard level (under 0.05 mSv). However, the dose received in terms of HP (10) over two months exceeded the standard level for 29 individuals (10%). Additionally, the annual dose received analysis revealed that among the 303 individuals, no cases were found where the effective dose of HP (10) over twelve months exceeded the standard limit of 20 mSv.

Regarding health, safety, and environment assessments, as detailed in Table 1, the overall scores obtained across all hospitals were 75.5 ± 10.2 for radiation safety, 88.2 ± 8.6 for general safety, and 47 ± 10.6 for emergency safety. It was observed that general safety scored higher than other sections of the checklist in all hospitals. Upon reviewing the final results in terms of adherence to safety protocols across all hospitals, it was noted that 3 (18%) of the departments were in very good condition, 13 (76%) were in good condition, and 1 (6%) was in average condition. Regarding health and waste management, only two hospitals had radioactive waste management systems in compliance with internal regulations set by the Atomic Energy Organization of Iran (AEOI).

Furthermore, an analysis of the relationship between the number of individuals receiving standard and non-standard doses revealed a significant correlation (P < 0.001). Similarly, a significant correlation (P < 0.001) was observed between adherence to checklist sections and cases of standard and non-standard received doses. This indicates that hospitals or departments with better adherence to radiation safety checklist items tended to have lower levels of radiation exposure among personnel. (Table 2).

Discussion

This study aimed to assess the impact of Health, Safety, and Environment (HSE) conditions on employees in radiology and diagnostic imaging services, particularly regarding the incidence of cancer. ²² The annual dose limit of 20 mSv for whole-body effective dose was selected based on the International Commission on Radiological Protection guidelines, 1991, in order to enhance study sensitivity. Comparable to our findings, A. Szumska et al. reported that in the majority of cases, HP (10) and HP (0.07) doses remained below 0.1 mSv per 3 months, with only a negligible percentage exceeding the average annual dose limit for workers.²³

Furthermore, our investigation of Radiologic technologists for suspected cancer symptoms related to radiation exposure yielded no confirmed cases, with only three individuals exhibiting minor health issues such as thyroid inflammation and platelet deficiency. This aligns with the findings of Orme et al.²⁴ Previous studies have not conclusively linked cancer incidence to doses below 200-400 mSv, possibly explaining the absence of cancer cases in our study.^25-27 However, some research has associated cancers among radiologists with radiation exposure.

Our study underscores the importance of adherence to health and safety principles, as evidenced by the positive correlation between high scores on items such as individual dosimeter usage, proper personal protective equipment utilization, equipment safety checks, device leak testing, presence of safety warnings, and attention to HSE issues, and reduced radiation exposure among participants. Notably, no statistically significant relationship was found between these safety measures and cancer incidence among radiologists working in radiation departments. Hence, it can be inferred that maintaining a positive attitude and adhering to safety and health protocols positively impacts the overall health of employees in these departments.

Conclusion

Concerns regarding radiation exposure, particularly among radiologists, have garnered increased attention in recent decades due to their frequent exposure to ionizing radiation. The findings of this study emphasize that adherence to safety principles not only leads to reduced radiation doses but also alleviates anxiety surrounding the risk of occupational diseases. Thus, ensuring the health and occupational safety of radiologists is of paramount importance.

In light of these findings, it is imperative to prioritize the safety of radiology departments and ensure strict adherence to health and safety protocols across all departments involved in radiation-related work. Continuous monitoring and controls should be implemented to maintain optimal safety conditions.

Efforts should be directed towards ongoing education and training for radiologists and other personnel to enhance their awareness of radiation safety practices. Additionally, regular assessments of workplace conditions, equipment maintenance, and adherence to safety guidelines are essential to mitigate risks associated with radiation exposure.By prioritizing safety and implementing robust measures to protect radiologists and other healthcare professionals, we can safeguard their well-being and promote a healthier work environment in radiology departments and beyond.

Competing Interests

The authors declare that they have no competing interest.

Ethical Approval

This study was approved by Ethical Committee of Tabriz University of Medical Sciences (Ethical Number: IR.TBZMED.VCR.REC.59633).

Funding

This research protocol was supported by Health and Environment Research Center (HERC), Tabriz University of Medical Sciences (grant number: IR.TBZMED.VCR.REC. 59633).

References

1. Wrzesień M, Napolska K. Investigation of radiation protection of medical staff performing medical diagnostic examinations by using PET/CT technique. J Radiol Prot 2015; 35(1):197-207. doi: 10.1088/0952-4746/35/1/197 [Crossref] [ Google Scholar]
2. Mettler FA. Medical effects and risks of exposure to ionising radiation. J Radiol Prot 2012; 32(1):N9-13. doi: 10.1088/0952-4746/32/1/n9 [Crossref] [ Google Scholar]
3. Le Heron J, Padovani R, Smith I, Czarwinski R. Radiation protection of medical staff. Eur J Radiol 2010; 76(1):20-3. doi: 10.1016/j.ejrad.2010.06.034 [Crossref] [ Google Scholar]
4. Shubayr N, Alashban Y, Almalki M, Aldawood S, Aldosari A. Occupational radiation exposure among diagnostic radiology workers in the Saudi ministry of health hospitals and medical centers: a five-year national retrospective study. J King Saud Univ Sci 2021; 33(1):101249. doi: 10.1016/j.jksus.2020.101249 [Crossref] [ Google Scholar]
5. Wakeford R. Radiation in the workplace-a review of studies of the risks of occupational exposure to ionising radiation. J Radiol Prot 2009; 29(2A):A61-79. doi: 10.1088/0952-4746/29/2a/s05 [Crossref] [ Google Scholar]
6. Linet MS, Kim KP, Miller DL, Kleinerman RA, Simon SL, Berrington de Gonzalez A. Historical review of occupational exposures and cancer risks in medical radiation workers. Radiat Res 2010; 174(6):793-808. doi: 10.1667/rr2014.1 [Crossref] [ Google Scholar]
7. Margulis AR, Eisenberg RL. Gastrointestinal radiology from the time of Walter B Cannon to the 21st century. Radiology 1991; 178(2):297-302. doi: 10.1148/radiology.178.2.1987582 [Crossref] [ Google Scholar]
8. Oyar O, Gülsoy U.K. Medical Imaging Physics. Ankara: Rekmay Print; 2003.
9. Saygin M, Yasar S, Kayan M, Balci UG, Öngel K. Effects of ionizing radiation on respiratory function tests and blood parameters in radiology staff. West Indian Med J 2014; 63(1):40-5. doi: 10.7727/wimj.2012.311 [Crossref] [ Google Scholar]
10. Inaba Y, Chida K, Kobayashi R, Kaga Y, Zuguchi M. Fundamental study of a real-time occupational dosimetry system for interventional radiology staff. J Radiol Prot 2014; 34(3):N65-71. doi: 10.1088/0952-4746/34/3/n65 [Crossref] [ Google Scholar]
11. Ito S, Fujita S, Seto K, Kitazawa T, Matsumoto K, Hasegawa T. Occupational stress among healthcare workers in Japan. Work 2014; 49(2):225-34. doi: 10.3233/wor-131656 [Crossref] [ Google Scholar]
12. Parikh JR, Geise RA, Bluth EI, Bender CE, Sze G, Jones AK. Potential radiation-related effects on radiologists. AJR Am J Roentgenol 2017; 208(3):595-602. doi: 10.2214/ajr.16.17212 [Crossref] [ Google Scholar]
13. Shortt CP, Al-Hashimi H, Malone L, Lee MJ. Staff radiation doses to the lower extremities in interventional radiology. Cardiovasc Intervent Radiol 2007; 30(6):1206-9. doi: 10.1007/s00270-007-9071-0 [Crossref] [ Google Scholar]
14. Sánchez RM, Vano E, Fernández JM, Rosales F, Sotil J, Carrera F. Staff doses in interventional radiology: a national survey. J Vasc Interv Radiol 2012; 23(11):1496-501. doi: 10.1016/j.jvir.2012.05.056 [Crossref] [ Google Scholar]
15. Wang T, Voss JG, Dolansky MA. Promote radiation safety for nurses: a policy perspective. J Radiol Nurs 2021; 40(2):179-82. doi: 10.1016/j.jradnu.2020.12.003 [Crossref] [ Google Scholar]
16. Ramli AA, Watada J, Pedrycz W. Possibilistic regression analysis of influential factors for occupational health and safety management systems. Saf Sci 2011; 49(8-9):1110-7. doi: 10.1016/j.ssci.2011.02.014 [Crossref] [ Google Scholar]
17. Almost JM, VanDenKerkhof EG, Strahlendorf P, Caicco Tett L, Noonan J, Hayes T. A study of leading indicators for occupational health and safety management systems in healthcare. BMC Health Serv Res 2018; 18(1):296. doi: 10.1186/s12913-018-3103-0 [Crossref] [ Google Scholar]
18. Norozi MA, Jahangiri M, Ahmadinezhad P, Zare Derisi F. Evaluation of the safety conditions of shiraz university of medical sciences educational hospitals using safety audit technique. Payavard Salamat 2012;6(1):42-51. [Persian].
19. Rafiei P, Walser EM, Duncan JR, Rana H, Ross JR, Kerlan RK Jr. Society of interventional radiology IR pre-procedure patient safety checklist by the safety and health committee. J Vasc Interv Radiol 2016; 27(5):695-9. doi: 10.1016/j.jvir.2016.03.002 [Crossref] [ Google Scholar]
20. Dianati M, Zaheri A, Talari HR, Deris F, Rezaei S. Intensive care nurses’ knowledge of radiation safety and their behaviors towards portable radiological examinations. Nurs Midwifery Stud 2014; 3(4):e23354. doi: 10.17795/nmsjournal23354 [Crossref] [ Google Scholar]
21. Szumska A, Budzanowski M, Kopeć R. Occupational exposure to the whole body, extremities and to the eye lens in interventional radiology in Poland, as based on personnel dosimetry records at IFJ PAN. Radiat Phys Chem Oxf Engl 1993 2014; 104:72-5. doi: 10.1016/j.radphyschem.2014.04.039 [Crossref] [ Google Scholar]
22. Valentin J. Radiation risks and the ICRP. In: Oughton D, Hansson SO, eds. Radioactivity in the Environment. Vol 19. Elsevier; 2013. p. 17-32. 10.1016/b978-0-08-045015-5.00002-2.
23. Szumska A, Kopeć R, Budzanowski M. Occupational doses of medical staff and their relation to patient exposure incurred in coronary angiography and intervention. Radiat Meas 2016; 84:34-40. doi: 10.1016/j.radmeas.2015.11.003 [Crossref] [ Google Scholar]
24. Orme NM, Rihal CS, Gulati R, Holmes DR Jr, Lennon RJ, Lewis BR. Occupational health hazards of working in the interventional laboratory: a multisite case control study of physicians and allied staff. J Am Coll Cardiol 2015; 65(8):820-6. doi: 10.1016/j.jacc.2014.11.056 [Crossref] [ Google Scholar]
25. Wang F, Sun Q, Wang J, Yu N. Risk of developing cancers due to low-dose radiation exposure among medical X-ray workers in China—results of a prospective study. Int J Clin Exp Pathol 2016; 9(11):11897-903. [ Google Scholar]
26. Sun Z, Inskip PD, Wang J, Kwon D, Zhao Y, Zhang L. Solid cancer incidence among Chinese medical diagnostic x-ray workers, 1950-1995: estimation of radiation-related risks. Int J Cancer 2016; 138(12):2875-83. doi: 10.1002/ijc.30036 [Crossref] [ Google Scholar]
27. Richardson DB, Cardis E, Daniels RD, Gillies M, O’Hagan JA, Hamra GB. Risk of cancer from occupational exposure to ionising radiation: retrospective cohort study of workers in France, the United Kingdom, and the United States (INWORKS). BMJ 2015; 351:h5359. doi: 10.1136/bmj.h5359 [Crossref] [ Google Scholar]