Twelfth Prefectural Oversight Committee Meeting: Thyroid Ultrasound Examination Results

The Proceedings of the Twelfth Prefectural Oversight Committee Meeting for Fukushima Health Management Survey were released on August 20, 2013.  Below is the translation of the thyroid ultrasound examination.

Original Japanese document can be found here: http://www.pref.fukushima.jp/imu/kenkoukanri/250820siryou2.pdf

Official English translation can be found here.

For a summary of the thyroid examination results, please refer to this post.

Note: Errata released on November 13, 2013 can be viewed here with an explanation here. 

1. Implementation status of the initial examination (in-prefecture)
   FY2013 examination began on April 22, 2013.  The examination will be conducted in approximately 158,783 subjects in 34 municipalities by the end of March 2014.
   Currently the examination is being conducted in the municipalities shown below, according to the original plan.

【Implementation status table for thyroid examination (initial examination): in-prefecture】(as of July 31, 2013)

FY2013 target municipalities (only five municipalities where the examination is currently conducted are listed). 
(Note: the top line in column "a" shows the current number of eligible subjects, whereas the bottom line shows an overall number of eligible subjects).

FY2012 target municipalities (Iwaki-city only includes Hisanohama District)

FY2011 target municipalities (13 municipalities designated by the national government as the evacuation zone)

※1　The top row shows the number of subjects who actually underwent the initial thyroid ultrasound examination.  The middle row shows the rate of eligible subjects who were examined in each age group.  The bottom row shows the proportion of subjects in each age group who actually underwent the initial thyroid ultrasound examination.

※2   The number of subjects, originally Fukushima residents, now residing outside Fukushima Prefecture, who came back to Fukushima Prefecture to undergo thyroid ultrasound examination.
● Proportions shown to the first decimal point might not add up to 100% due to rounding off.

● Age shown is the age as of March 11, 2011.

2. Implementation status of the initial examination (out-of-prefecture)

   Thyroid examination has been conducted, since November 1, 2012, at examination facilities outside Fukushima Prefecture which singed an an agreement with Fukushima Medical University.
   Currently, notices for out-of-prefecture examinations are being sent to subjects from municipalities where the examination was implemented up to FY2012.  Examinations are conducted in order.  Breakdown by municipalities are shown below.

【Implementation status table for thyroid examination (initial examination): out-of-prefecture】   

FY2012 target municipalities (as of June 30, 2013)

FY2011 target municipalities (as of June 30, 2013)

※1 The number of notices sent to the eligible subjects who have not undergone examinations at their respective municipalities. (Including out-of-prefecture residents)

● Proportions shown to the first decimal point might not add up to 100% due to rounding off.

● Those who have not undergone the examination may be examined either inside or outside Fukushima Prefecture.

● Age shown is the age as of March 11, 2011.

3. Initial examination results summary for FY 2011, 2012 and 2013

The results confirmed up to the June 7, 2013 examination date, are shown below. For results summary by municipalities, refer to the attachments.

【Summary sheet by assessment categories for thyroid examination (initial examination)】  

Results confirmed up to the June 7, 2013, examination date.          (Unit: upper row-persons, bottom row-%)

※1　The number of results confirmed, "b," denotes the number of subjects examined at examination facilities either inside or outside Fukushima Prefecture, whose results were confirmed.

 ① Explanation of the assessment categories

   (i)   Assessment A: (A1) No nodules or cysts.

                                   (A2) Nodules 5.0 mm or smaller, or cysts 20.0 mm or smaller.

   (ii)  Assessment B: Nodules 5.1 mm or larger, or cysts 20.1 mm or larger.

   (iii) Assessment C: The condition of the thyroid gland warrants an immediate secondary examination.

② Explanation of assessment results

(i) A1 and A2 will be under observation until the next round of examination beginning in FY2015.

(ii) B and C will undergo secondary examination.

(iii) Some A2 cases might be considered B if the condition of the thyroid gland warrants secondary examination.

● Proportions shown to the first decimal point might not add up to 100% due to rounding off.

4. Secondary examination

(1) Implementation status

When lumps (nodular lesions) etc. have been found in the initial thyroid ultrasound examination, secondary examinations will be conducted at Fukushima Medical University, including detailed ultrasound, blood and urine tests, and biopsy if needed).

As of June 2013, the secondary examination is being conducted by three physicians per day instead of two.

Also, in addition to Fukushima Medical University, Hoshi General Hospital in Koriyama City and Fukushima Rousai Hospital in Iwaki City began secondary examination on July 24 and July 26, 2013, respectively.

【Implementation status table for thyroid examination (secondary examination)】

FY2013 target municipalities

FY2012 target municipalities

FY2011 target municipalities

FY2011-2013 municipalities grand total

※1   "a" denotes a total number of subjects who were examined by July 31, 2013, at examination facilities either inside or outside Fukushima Prefecture.

※2   "h" does not include the subjects who have not received the examination results for blood and urine tests and biopsy.

※3   "i" and "j" will be followed up in the full-scale examination beginning in April 2014.

※4   "k" denotes subjects who will be followed up in approximately 6 months to one year using regular health insurance.

● FY2013 results are not shown by municipalities as only a few subjects underwent the secondary examination.

● Proportions shown to the first decimal point might not add up to 100% due to rounding off.

● Secondary examination requires multiple visits, as blood and urine tests are conducted first and the results reported at a later date.

   (2) Number of new patients per month

Trend of the number of new patients for secondary examination which began in March 2012 is shown below.

(3) Summary of results

 ① Results of cytological examination

② Age and gender distribution of 44 cases confirmed or suspected of cancer by cytological examination. (As of July 31, 2013)

※1  FT4: thyroid hormone with four iodine atoms; high in Basedow's (Graves') disease and low in Hashimoto's disease.

※2  FT3: thyroid hormone with three iodine atoms; high in Basedow's (Graves') disease and low in Hashimoto's disease.

※3  TSH: hormone secreted by the pituitary gland, which orders the thyroid gland to release thyroid hormones; high in Hashimoto's disease and low in Basedow's (Graves')  disease.

※4  Tg (thyroglobulin): substance used by the thyroid gland to produce thyroid hormones.  Present in the thyroid gland in a large quantity.  High levels indicate destruction of the thyroid gland or overproduction by tumor.

※5  TgAb (anti-thyroglobulin antibody): autoantibody against thyroglobulin; high in Hashimoto's disease or Basedow's (Graves') disease.

※6  TPOAb: autoantibody against an enzyme called peroxidase; high in Hashimoto's disease or Basedow's (Graves') disease.

④ Secondary examination results by municipalities, for in-prefecture examination (as of July 31, 2013)

FY2012 secondary examination results by municipalities for in-prefecture examination

※1  Initial examination subjects include both in-prefecture and out-of-prefecture examinees.

● Those who require urgent clinical assessments will be given priorities for secondary examinations.  

FY2011 secondary examination results by municipalities for in-prefecture examination

※1  Initial examination subjects include both in-prefecture and out-of-prefecture examinees.

※2  Does not include the case that was suspected of cancer after biopsy, which turned out to be a benign nodule after surgery.

※3  Other includes subjects from outside the municipalities designated as the evacuation zone by the government but underwent thyroid ultrasound examination at schools.

(Attachment)

FY2013 thyroid examination results summary for five municipalities (as of July 31, 2013)

FY2012 thyroid examination results summary (as of July 31, 2013)

FY2011 thyroid examination results summary (as of July 31, 2013)

Unexplained Discrepancies in Fukushima Thyroid Cancer Age-Gender Distribution Graphs

The Twelfth Fukushima Prefectural Oversight Committee convened on August 20, 2013, reporting the latest findings of the health survey.  The thyroid examination result showed an increase in the number of children confirmed or suspected of thyroid cancer from 28 to 44, as reported in the previous post: http://fukushimavoice-eng2.blogspot.com/2013/08/18-thyroid-cancer-cases-confirmed-in.html

The information was almost instantly available to the Twitter and social network communities, thanks to the independent journalists attending the committee meeting.  Some members of the public, as well as the journalists attending the meeting noticed a strange discrepancy looking at the age and gender distribution graph of the 44 cases confirmed or suspected of cancer, as shown below.

The June 5, 2013 report showed the graph below for the 28 cases.

(This can be seen on page 32 of the comprehensive report here: http://www.pref.fukushima.jp/imu/kenkoukanri/250625siryouikkatu.pdf. It can also be seen on page 11 of the official English translation of the June report here: http://www.fmu.ac.jp/radiationhealth/results/media/11-2_ThyroidUE.pdf).

In comparing the two graphs, the following observations are made:

1. Both graphs show age as of March 11, 2011, so the basic age distribution should not differ between the two graphs.

2. In age 11, the June graph shows 3 males, yet the August graph shows none.

3. In age 15, the June graph shows 4 females, yet the August graph shows only 2.

4. In age 17, the June graph shows 4 females, yet the August graph shows only 3.

5. In age 18, the June graph shows 2 males, yet the August graph shows only females, totally flipping the gender.

According to the astute observation of a freelance journalist, Mako Oshidori, the Committee released the revised June graph on August 20, 2013, as shown below.

(This can be seen on page 11 of the thyroid examination result file here: http://www.pref.fukushima.jp/imu/kenkoukanri/250605siryou2.pdf).

Comparing the original and revised June graphs, it appears as if the age of the patients, in addition to gender, was categorized totally wrong.

According to Mako Oshidori, who was present at the committee meeting on August 20, 2013, an announcement was made in the beginning of the meeting, in regards to the change that had been made in average age and standard deviation on page 5 of the thyroid examination report.  Apparently, some discrepancies were pointed out by one of the committee members who reviewed the material prior to the meeting.  The announcement was intended to notify the committee members that the material distributed at the meeting contained the corrected version.

http://no-border.asia/archives/13697

Investigation by Mako Oshidori revealed that an official at the Health and Welfare Department of Fukushima Prefecture government, in charge of the Prefectural Health Management Survey, stated that "the original data was handled incorrectly due to the counting error by Fukushima Medical University."

For information, the corrected information that was distributed at the meeting is shown below:

① Results of cytological examination

*****

Apparently, after making the correction, The committee wondered if the previous report in June needed corrections, and it did indeed need corrected.

Here's the June 5, 2013 results prior to the correction:

The revised June 5, 2013 results, published online on August 20, 2013 is shown below, with the correction inserted by the author in red for clarification in this post:

Going back to the discrepancies in the age and gender distribution graphs, the original graph was online for over two months without anybody noticing the discrepancies until the new August data was released.  The gender ratio in thyroid cancer cases is drawing a lot of attention, as can be seen in the July 20, 2013 post of the English translation of the June 9, 2013 article by Mako Oshidori: http://no-border.asia/archives/12034.  

In children who developed thyroid cancer after the Chernobyl nuclear accident, the ratio of females with thyroid cancer was higher than males.  In general population, adult thyroid cancers are found in more females than males.  The June results showed an even male to female ratio at 14:14 overall, but the FY 2012 result had a male to female ratio of 9 : 7, with slight dominance of males, which appears to be an anomaly.  Now the number of cases confirmed or suspected of thyroid cancer has increased from 28 to 44, and the male to female ratio is 18 : 26.  This change in gender ratio might be explained by more cases being discovered and the gender ratio approaching a natural ratio expected of thyroid cancer.  However, the fact that "the original data was handled incorrectly due to the counting error by Fukushima Medical University." raises questions about the integrity of the thyroid examination process itself, especially considering the continued denial by Fukushima Medical University of a possibility that any of these cancer cases could be related to radiation exposure due to the Fukushima nuclear accident.  The committee has repeatedly refused to reveal the exposure dose information for the cancer cases, citing confidentiality.

18 Thyroid Cancer Cases Confirmed in Fukushima Children: Preliminary Results of FY2011-2013 Thyroid Ultrasound Examination

For complete translation of the the thyroid examination results published this time, please refer to this post.

Total number of children examined as of June 7, 2013: 216,809

Total number of children whose initial examination results are confirmed: 192,886

Assessment A1 106,823 (no nodules or cysts found)

Assessment A2 84,783 (nodules 5.0 mm or smaller or cysts 20.0 mm or smaller)

Assessment B 1,279 (requiring secondary examination)

Secondary examination results as of July 31, 2013

(including blood and urine tests, more detailed ultrasound examination, and fine-needle aspiration biopsy if needed)

18 papillary thyroid cancers confirmed after surgery (18 boys, 26 girls, age 8-21)

25 suspected of thyroid cancer, awaiting surgery

1 benign nodule

  The youngest confirmed of cancer is a girl who was 6 years old at the time of the nuclear accident.

1,280 are eligible for secondary examination

771 have actually undergone secondary examination

625 finished the secondary examination

① Results of cytological examination

Shocked UNSCEAR members in Belgium protest "It even goes back behind the lessons of Chernobyl and other studies."

Original post:
Les délégués belges indignés: "On minimise les conséquences de Fukushima" by Marc Molitor
http://www.rtbf.be/info/societe/detail_les-delegues-belges-indignes-on-minimise-les-consequences-de-fukushima?id=8042566

English translation by Alex Rosen, M.D., Vice-chairman, German IPPNW

(posted here with his permission)

*****

Shocked UNSCEAR members in Belgium protest,

"It even goes back behind the lessons of Chernobyl and other studies."

Discussions continue in UNSCEAR, the organization of the United Nations responsible for assessing the consequences of nuclear disasters and radiation. The committee prepared a report submitted for discussion amongst experts from different countries at a recent meeting in Vienna - a report that has aroused the indignation of the Belgian delegation: "Everything seems to be written, its members say, to minimize the consequences of the Fukushima disaster. It even goes back behind the lessons of Chernobyl and other studies." The Belgian delegation includes several experts in the study of nuclear energy. UNSCEAR must submit its report to the General Assembly of the United Nations next fall.

Back in Brussels, the head of delegation, Hans Van Marcke delivered his critical impressions on UNSCEAR's conclusions in a presentation to the ABR, the Belgian Association for Radiation Protection. According to our information, the discussions were so tense and the Belgian were so shocked that they threaten not to sign the report and some thought even of leaving the conference. They were offered to include their objections and those of others, mainly English experts in a new, revised document. But the past has shown that it is the secretariat and the rapporteurs who lead the agenda and who give the text its final orientation, and that the greatest vigilance is needed to see to it that the final versions adequately reflects the discussions.

In general, everyone agrees: Japan has been lucky. An important part of the contamination has gone to the ocean, the population was evacuated fairly quickly, and control of food contamination is satisfactory. The impact will therefore probably be lower than in Chernobyl.

But the impacts on soils are not to be underestimated, nor are impacts on health in the future. And these effects involve an area with densely populated cities like Fukushima or Koriyama (300,000 people).

Much data of the UNSCEAR report is incomplete or presented in a questionable way. Estimates of doses received by populations are diluted by irrelevant mean values, as are those received by the tens of thousands workers on the site of the plant accident. The Japanese government and TEPCO refused to disclose details. It is also obvious that iodine tablets have not been distributed and thyroid exams were performed too late, which prevents some effects from being found.

The analysis of the UNSCEAR automatically excludes a priori any potential risk to the fetus or the genome. For cancer risk, it considers that there is not too much of a risk as the radiation doses are too low to generate a discernible effect. Such assumptions have led to the anger of  experts from Belgium because, on the one hand, as mentioned above, the doses are poorly presented and secondly, the lessons of Chernobyl as well as extensive research in recent years show that low doses can affect health. UNSCEAR is obviously trying to backtrack on these developments in the science of radiation. On several occasions in recent years, and even in the current discussions, representatives of different countries want to convey the idea of a threshold of 100 millisieverts, below which no health effects are to be expected. As a reminder, international ICRP recommendations speak of 1 mSv per year for the population and 20 mSv per year for workers, not to be exceed in the current situation.

Recent studies show that, in several areas, lower doses between 10 and 100 mSv can have effects. It is not only cancer, but also damage to the embryo, hereditary disturbances, cardiovascular disease and cataracts.

Several reports are on the table nearing completion. One for children, a population to protect and monitor, especially in the case of radiation. This report was supported by an American team, led by Professor Fred Mettler. He is an author of the Chernobyl Forum report, which was highly controversial and criticized because it minimizes the effects of the Chernobyl disaster. In any case, in his report on children, he dismisses a priori a number of areas of study and findings that show the different effects of low doses on children. He did not even read the reports from the Euratom panel.

Another serious issue that is denied or misrepresented in the report concerns the question of the relevance of internal contamination of an organism. Indeed it appears increasingly that the effects may be different when radionuclides are dispersed evenly throughout the body, or when they rather are concentrated in certain areas. A similar dose will therefore not have the same effects depending on where it occurs. This is consistent with assumptions by the Belarusian scientist Yuri Bandajevski in the study of the many effects of Chernobyl.

Hereditary effects of chronic low-dose contamination are difficult to study in humans because it takes several generations of observation. One way to approach this is to observe these effects in animals. Several studies have shown that effects do occur (Mousseau and Moller studies show the loss of biodiversity in Chernobyl, for example, or the studies of Goncharova). But they are not taken into account either, nor are important studies of French IRSN, which showed many cardiac and neurological alterations in rats.

Where do the attempts to minimize the consequences of Fukushima (and Chernobyl) and to backtrack on the recent achievements of the various studies in radiation come from? Mostly from experts from Russia, Belarus, U.S. Poland and Argentina. Many of them are working for both UNSCEAR and the IAEA and ICRP. One of them, the Argentine Abel Gonzales has so many different hats on (also in the Argentine nuclear industry) that in a previous session, a Belgian expert criticized the conflict of interest in a letter that UNSCEAR has refused to represent in the minutes. Gonzales, Mettler and the Russian Balanov (retired IAEA member, editor of UNSCEAR reports), together with some Polish scientists, are in direct line with the trend represented by the French Professor Tubiana who firmly rejects any idea of negative effects of low dose radiation. Together they formed a vibrant international center to defend this thesis. And they occupy strategic places in the secretariat of the IAEA and UNSCEAR (UNSCEAR holds its meetings on the premises of the IAEA). The Japanese today share that view, anxious to limit the impact of the disaster and restart nuclear reactors.

Representatives of other countries such as China or India are silent. The French experts from CEA and IRSN expressed little objections, while in the past they deplored the information policy by the Japanese. Swedish and German are also silent. It is obviously tempting to draw a parallel between the results of UNSCEAR and the geopolitics of nuclear power, although in each country different trends can occur among experts.

The Belgian experts, supported by British and Australian members and some Euratom members attending the meeting, are more concerned about the effects of low dose radiation.

Where is the discussion and the scientific doubt in all this? In any case, those who deny the impact of low doses would love to see their position recorded in the UNSCEAR report and endorsed by the UN this fall. For others, including Belgium, it would be an unacceptable regression on recent advances in knowledge in radiation protection.

Marc Molitor

Steve Wing's Critique of Congenital Hypothyroidism Study after Fukushima Accident by Mangano and Sherman

Steve Wing, an epidemiologist from University of South Carolina was asked by a third party to review a manuscript by Mangano and Sherman, “Elevated airborne beta levels in Pacific/West Coast US States and trends in hypothyroidism among newborns after the Fukushima nuclear meltdown,” after it had been accepted for publication on January 29, 2013.  It was not the actual published version in the March 2013 issue of Open Journal of Pediatrics, shown in the following link, http://www.scirp.org/journal/PaperInformation.aspx?PaperID=28599, that Wing reviewed. 

Wing’s critique, dated February 27, 2013, was sent to the authors, but there appeared to be no direct response from them, except the manuscript seemed to have been published with some corrections, as some of the issues brought up by Wing could not be identified in the final published version.

The journal that published this study, the Open Journal of Pediatrics, apparently is a ‘predatory journal’ that is for-profit and does not have a serious scientific peer-review process.  This information might be of interest to some of the readers.

Wing's critique is published below with his permission.  He requested that the details surrounding his critique be mentioned as above.

A related post, "A Letter to the Editor Regarding the Congenital Hypothyroidism Study by Mangano and Sherman" by Alfred Körblein, can be found in the following link.
http://fukushimavoice-eng2.blogspot.com/2013/05/a-letter-to-editor-regarding-congenital.html

*****
Comments and questions on “Elevated airborne beta levels in Pacific/West Coast U.S. states and trends in hypothyroidism among newborns after the Fukushima nuclear meltdown” by Joseph J. Mangano MPH MBA, and Janette D. Sherman MD 

Steve Wing

This article compares the ratios of congenital hypothyroidism (CH) cases between time periods in 2010 and 2011 for five western US states and 36 other US states.
The authors propose that the five western states were more exposed to I-131 fallout from Fukushima than other states, and that, if this impacted CH, the ratios of 2011/2010 CH cases would be elevated for several months after the deposition of fallout in these states compared to the others.  The principle of this comparison appears to be logical as it makes use of both spatial and temporal variation to evaluate the effect of an environmental exposure, however the data collection and analyses are unclear and internally contradictory.

Introduction
The introduction includes results of a comparison of CH cases in four counties around the Indian Point reactor to US rates. Two time periods are compared, however there is no information about whether there was a change in exposure or another reason for choosing these periods. It is stated that Indian Point, from 1970-1993, had the fifth-highest airborne I-131 releases out of 72 US reactors. It is not clear why the authors present emissions data from a period that ended 4 to 13 years before the time of the CH analysis; clearly CH cases from 1997-2007 could not have been exposed to I-131 from 1970-1993. The authors should explain, if their interest is in whether nuclear reactor releases cause CH, why not use release estimates from a time period close to the CH data and analyze records around the nuclear facilities with highest releases rather than the fifth highest?

Methods
The first of two tables labeled “Table 2” presents 77 measurements of I-131 in U.S. precipitation following the Fukushima meltdowns. The url for the source given in the bibliography did not work, but I-131 precipitation at another EPA url provides 157 measurements. Were the omitted values non-detects? If average levels by state are of interest, non-detects should be included in mean values under some assumption, for example, half the detection limit. The authors note that some of the highest measurements came from Florida, which is classified as a “control” state (better described as “lower fallout”) in the later CH analysis, and from Massachusetts, which is omitted from the CH analysis. No rationale is provided for these decisions.

I-131 in precipitation is relevant to the milk pathway for iodine uptake, which dominates thyroid dose estimates for U.S. populations. Why are the exposure groups for the CH analysis based on gross beta in air, which would be influenced by beta-emitting gasses such as xenon and krypton that were not only present in Fukushima emissions but are also routinely present in emissions from U.S. reactors? In the second Table 2, how are non-detects treated? What was the limit of detection?

The authors state that they requested “monthly numbers of CH cases” in a telephone survey. If birth dates for individual cases were not obtained, how could they be classified according to day of birth in subsequent analyses? In the Results the authors state that data from small states were not available due to confidentiality concerns; how were such concerns handled if individual birth dates were acquired for March cases? Furthermore, several of the omitted states, including New York, are not small. This part of the data collection is unclear, and it is important for anyone interpreting the results to know clearly how the more and less exposed groups were formed and whether missing data relate to exposure.

“State programs were also asked to confirm that there was no change in CH definitions between 2010 and 2011 that would bias any temporal comparison.” Did any respond that they had changed their definition, and if so, which ones? In the next sentence, “intra-state” should be “inter-state.” Counts in many surveillance systems are provisional until some closing date for investigation. Were the figures reported in the phone interviews all final? If not, the counts may differ from those that will be reported in official documents, which could lead to inability to replicate the current analysis with final data.

Results
One strength of the study design is the use of time-windows, therefore the choice of dates for CH incidence is important. Is it plausible that CH cases on March 17, 2011, could be caused by Fukushima I-131 that arrived on that same day, essentially with no lag? The milk pathway certainly could not be involved in exposures for some time period. One question is whether CH from Fukushima fallout would be prompted by an initial dose or by cumulative doses over days or weeks. In any case, because March 17 (or March 15, as in one row of Table 3) is the earliest possible beginning of the exposed period, the choice of that time for counting exposed cases deserves discussion and justification.

Table 3 presents the main results, however the labels and counts are confusing. Why use March 15 in the first row rather than March 17? Why are there more cases from March 15 – April 30 than for March 17 – June 30 or March 17 – December 31? The counts in the 5 western states in the two latter periods sum to the first row, suggesting labeling errors, however the values for the other states do not sum up in the same way. The p-values in Table 3 do not match those in the Discussion and it is not sufficiently clear what they refer to and how they were derived.

Discussion
The authors make a number of good points in this paragraph, which could be used as a basis for improving the manuscript: “There are technical improvements that may be made to the data in this report. One of these is to obtain more precise temporal and geographic data on environmental levels of specific radionuclides in the U.S. after Fukushima, including I-131. Moreover, estimating specific exposures to humans as a consequence of the fallout would also be helpful in any future analyses of health risk. In addition, there are technical changes that may be made to data in this report, such as using a period greater than just 2010 as a baseline; including data on CH cases after 2011; and conversion of trends in cases to rates when official numbers of 2010-2011 live births by state and month become available.”