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
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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.”
"Health impacts of radiation release from nuclear facilities: Lessons past and present" by Steve Wing
Transcription of a lecture by Steve Wing, Three Mile Island epidemiologist, at the March 11-12 New York symposium sponsored by the Helen Caldicott Foundation
Steve Wing, Ph.D.
The Medical and Ecological Consequences of the Fukushima Nuclear Accident
The Helen Caldicott Foundation
March 11-12, 2013
Video archives
I think my title may be able to have been used by any of the speakers at this whole symposium. I wanted to pick something that I can fit into, but a little bit more specifically I would like to talk about how we approach estimating health impacts of radiation releases from nuclear facilities.
And there are two general approaches which you already heard about. I want to identify them and their logical bases and compare them. One approach is risk assessment. That means that we use some estimates of dose and we multiply the estimates of dose to people by some dose-response curve which gives us the estimated number of effects, number of events, or cases of disease for each amount of dose. And the other method is epidemiology, which means that there is some kind of surveillance for disease. And we look at the differences in the rates of disease between exposed and unexposed populations.
So I want to begin with talking about risk estimation or projection and this may be obvious, but I think it’s worth noting or repeating something that we all know is that “Randomized human experiments, looking at the long-term consequences of exposure to various forms of ionizing radiation, are not possible.” So we can’t conduct experiments. We can’t conduct human experiments. So we have to either extrapolate from cellular or animal studies, or conduct non-randomized human studies which are epidemiologic studies. And both of these approaches suffer from problems of bias and selection; measurement errors and selection, which of course experiments also suffer from biases, but we won’t go into that today.
So just recently this document came out of the World Health Organization, and it’s already been referred to, most recently by Ian Fairlie.
And it is a risk assessment or risk estimation. It is based on the dose estimates produced in a previous report last year on Fukushima.
It’s also based on data from the Life Span Study of A-bomb survivors, which you heard about and you will hear about more in just a moment. This dose assessment I want to emphasize just a few of the things Ian Fairlie already has said is that there are a number of components of the doses that are ignored. The committee chose not to assess doses within 20 km of Fukushima nuclear plant. They chose not to assess the radioactive gases such as xenon. They did not assess fetal doses. And I think Dr. Wertelecki has already given us a great introduction to why we might care very much about the fetal doses.
What I want to start out is talking about the Lifespan studies. I am going to show you a little bit of the information that has been around for a long time from a volume that came out in the 1970s as well as very recent information that has just appeared within the last 90 days from Radiation Effects Research Foundation and from our group at University of North Carolina.
These graphs show the immediate casualties at Hiroshima and Nagasaki in relation to the distance from the hypocenters of the atomic explosions.
And I want to make the point that the study upon which all our risk estimates are based did not begin until more than five years after the bombings, and many people did not survive to be in the study. If mortality from the immediate effects of the bombings is related at all to frailty and to longer-term risk, there would have been a harvesting of the most radiosensitive from this population. It’s a very important thing to remember, especially because of the destruction of the physical infrastructure of these cities, food supplies, water supplies, hospitals, Hiroshima was hit by a typhoon, so there are lots of forces selecting for healthier people.
I also would note that the study of cancer incidence, which you already heard about in this symposium, did not begin until 1958. So any estimates of cancers following exposure to radiation based on the LSS, cancer incidence, omit all cancers that occurred within 13 years of exposure. And we know from many other studies that lots of cancers occur in less time than that. And this is something that is routinely omitted when risk estimates from the LSS are applied to the populations including the population of Fukushima and the population of Japan. And especially important in the shorter-term effects are the impacts of in-utero exposure and also shorter-latency cancers such as leukemia and lung cancers.
Now a few other, uh, a little bit more information from the 1970s volume on the Physical, Medical and Social Effects of the Atomic Bombings. This is the depiction of the radiation from the atomic bombing of Nagasaki.
We have the epicenter or hypocenter, and gamma and neutron radiations coming from the blast, all of which were gone within seconds. But there are other sources of radiation as depicted by the arrows coming from the ground below the blast, gamma and beta induced radiation from neutron activation. And then here in the Nishiyama District, a particular radioactive fallout. Now the RERF, which is responsible for the A-bomb studies, has chosen not to estimate any of the radiation doses due to these two other sources, residual radiation being composed of either induced radiation or fallout.
Fallout was also a problem in Hiroshima. You can see in this map the drawings of where the fallout, so-called Black Rain, came in Hiroshima.
Note that in both of these depictions, the fallout is not primarily at the hypocenter. Who is more affected here? People who live at some distance. So this is important in the epidemiologic study because it means that the fallout is disproportionately affecting people with the lowest doses directly from gamma and neutron blasts.
What happened after the blasts? Who was near the ground zero?
Oh, first let me finish with the fallout, the Black Rain. So this report just came out in December from the RERF. And they asked people about exposure to the Black Rain. They asked the survivors. And of the 86,671 survivors in the primary analyses, they give us our risk estimates, 12,000 approximately said “Yes,” but over 21,000 there is no information. This is something I want to emphasize is that the lack of data, missing data, is a big problem in the LSS, that could be investigated more but has been ignored for a half century.
RERF has also reported this December on the mortality rates between 1950 and 2003, on the left, and between 1962 and 2003, on the right, in Hiroshima and Nagasaki.
And the Excess RR which zero indicates the referent group that’s not exposed to fallout, that the group reporting exposure to Black Rain in both cities has no difference in mortality over either time period. But the unknown group in both cities have an excess mortality. It’s 27% in Hiroshima and 46% in Nagasaki. And if you look at the difference between 1950 to 2003, those estimates I just cited, there is basically no difference in the period 1962 to 2003. This means that during the period 1950 and 1962, there was a very large excess mortality among people who provided no information on their exposure to Black Rain. And that’s a very important time period that I will come back to in a minute.
Now let’s talk about the early entrants, the people who could have been exposed to induced radiation near the hypocenter. Here are some dose estimated for Days 2 and 3, for people who had spent 12 hours from RERF. We don’t have any estimates for them from Day 1, but we know that induced radiation fell off very rapidly.
These are photographs from Yosuka Yamahata, taken the day after the bombing of Nagasaki.
And what I want you to notice is that people are there. And these are not the people who were exposed to the hypocenter. These are people who are coming in from other areas. They are going through the city. Some of them are looking for their relatives.
When I was in Nagasaki, I had the opportunity to tour the museum there with a survivor who knew the woman on the left, on the right side of this photograph and explained to me that she was still living. This was just about five years ago. And in this photograph she found her mother.
But people were there. And they were not the people who were most exposed to the blast. They tended to be people who were from farther away. So that’s a differential exposure again to the type of radiation that’s not counted in the Life Span Study.
And the next few slides I want to share from our group at University of North Carolina.
What they show for Hiroshima and Nagasaki are the distances from Hypocenter of three groups of people: the proximal survivors in the first panel; the distant survivors in the second panel; and the survivors with missing dose in the third panel. And you can see that only proximal survivors can have missing dose. That’s because the RERF did not require detailed interviews with distal survivors to produce the dose estimate. They were all assigned the lowest dosing category. This forces a relationship between missing dose and exposure. You can only have a missing dose if you are exposed. Here’s the same situation that occurs in Nagasaki.
Now what does it mean in terms of the Life Span Study? This table shows us that in the 1950s, there were higher rates of mortality among survivors of unknown doses from all causes, from all cancers and from leukemia. So here we are taking out of the high-dose group, people with high mortality rates. What does that to the dose response estimates, if we remove the high mortality individuals from the groups with higher doses? I think it’s obvious.
So let me move on. And first remind you, oh, I must mention one other thing about this period between 1950 and early 1960s. In 1950, all survivors were entered into a follow-up on October 1, 1950. However, all survivors had not completed sufficient interviews to be assigned a dose at that time. Interviews needed to assign a dose continued until 1965. Yet RERF in all their analyses to estimate these risk coefficients that are applied to populations around the world, have entered people on October 1, 1950, who could not be in the study until later. It’s a phenomenon that an epidemiologist calls, “immortal person time.” What this does is, it inflates the denominator of the rates, of the cancer rates for the proximal survivors. So this is another phenomenon that causes an underestimate of the cancer rates for the proximal survivors. So we have another source of bias. I am not aware if this has been written about, but you can find it in our recent paper in the American Journal of Epidemiology.
Now, there are a couple of other things to say about the Life Span Study. We don’t have information about the carcinogenic effects of in-utero exposures, which are clearly and very important. The embryo and fetus are much more sensitive to carcinogenic effects of radiation, probably much more so than the children. But the Life Span Study doesn’t give us information on that at all. And therefore that effect is left out of many of the dose estimates that we typically see.
So now I want to talk quickly about four epidemiologic studies. My message here is what is projected based on the Life Span Study of A-bomb survivors, and what has been seen in epidemiologic studies.
This is a graph from David Brenner who spoke yesterday on estimated number of people who would need to be followed for life to detect an increase in cancer mortality based on the Life Span Study estimates. And you can see that at low doses under 50 mGy or so, we are talking about 100’s of thousands to millions of people, according to these estimates.
So I learned about this first when I started working on radiation in 1998 when I was assigned to lead the study of the mortality in workers from the Oakridge National Laboratory whose radiation doses had been monitored from very early on with individual badges.
You can see here workers putting their radiation meters in proper boxes.
And I was told we would not find any effect of radiation in this population because it was too small and the doses were too low. So my first encounter with the dominant wisdom in this field was when we found that, only after about 20 years latency, we were seeing dose response relationships: the higher the readings in the badges, the higher the cancer rates in the workers.
But this was impossible, I was told.
Chernobyl, you heard a great deal about. I want to call your attention to this passage from a 1991 document, five years years after the accident, by IAEA, International Atomic Energy Agency. “On the basis of the doses estimated by the Project teams and currently accepted radiation risk estimates, future increases over the natural incidence of cancers or hereditary effects would be difficult to discern, even with large and well designed long term epidemiological studies.”
And you’ve seen a plethora of information today and yesterday, that this turned out not to be so.
This is one graph, I won’t dwell on it, from a thyroid cancer study which has individual dose estimates including information from thyroid scans.
Another nuclear event where we were told there were no cancer effects possible was the Three Mile Island nuclear accident in 1979. I have just a few photos here from Bob Del Tredici’s book, The People of Three Mile Island, to give you a sense of what the area was like in 1979.
People lived quite close to the plant. Many reported the symptoms such as reddening of the skin, deaths of pets and animals, nausea and vomiting, and hair loss, and they were told that this was due to stress. Now, I started working on this because of lawsuit involving several thousand people, and I first did look into stress.
I think stress is very important and I am sure the people of the TMI were under tremendous amounts of stress. However my assessment of medical literature was their reports did not fit the scenario of stress-induced acute effects, sometimes called mass hysteria in medical literature.
So we conducted a reanalysis of data on cancer incidence that were collected from local hospitals during the period 1975 to 85, and the dose estimates made by the investigators, and we found, and I want to point out one thing is that this study was designed to avoid a problem that’s a big concern in any well-publicized event, which is that there is detection bias. People report sooner, they get more diagnostic tests. So we expect there to be an effect of detection bias on the disease incidence rate following an event like this. Everyone in this study was within 10 miles. They were all exposed to the same detection bias.
This is a graph showing our results. Radiation levels in the area are shown from very low in the green to high in deep red, and bars indicate relative rates of lung cancer which occurred between two and seven years after the event. And what’s very clear is that the lung cancer incidence rates rose dramatically in the direction of the plumes where the plumes from the emissions were estimated to have traveled in the first days of the accident.
Again, the risk projections said there would be no effects.
Next I want to mention studies of routinely operating NPP, which is the topic of the current interest in the National Academy of Science. Tim Mousseau who spoke yesterday has been on their panel. This is also a situation where the projection is that no cancers will be observed among people who were exposed to routinely operating reactors.
So studies like European studies have never been done in the U.S. I brought one example of a study of childhood leukemia in Germany. These are the study areas around the 16 nuclear plants.
This table shows that in the 0 to 5 age group, the rate ratio, relative risk or odds ratio, all equivalent here, in the 0 to 5 km zone, it’s more than a doubling of childhood leukemia incidence in these areas collectively, compared to the areas that are further away. In each case the comparison group is not from some other place. They are also in the same areas, cases and controls in the study. So the authors conclude, “radiation exposure near German nuclear power plants is a factor of 1,000 to 100,000 times less [than annual average exposure from medical exams, therefore] the observed positive distance trends remain unexplained.”
And I feel that I’m repeating in some ways what we heard this morning from Dr. Wertelecki, that we are not able to conclude anything from studies that have been done because they don’t comport with the projections from the A-bomb survivor studies.
Yesterday Dr. Brenner compared the radiation risks to deaths from violence and earthquake and tsunami in Fukushima. And I think he has a point.
But I would ask the question, what’s the difference between these, energy generation and medical irradiation for that matter. Energy generation is highly profitable. And it’s a public decision made by politicians who are in many cases tied to nuclear companies and weapons contractors that created the nuclear energy industry in the first place. There has been a discussion of public education, and I would argue, yes, we need public education. Not only about radiation but about science and about civic life, because our science is affected by our political system.
In Fukushima, there will be extra challenges to epidemiologic studies when we compare the situation to the others I mentioned today and have been mentioned here earlier. And some of those challenges involve the fact that there was an earthquake and the tsunami. And there were huge disruptions of living conditions. There was a lot of relocation. People were moving around,
Estimating doses for individuals, which is important and critical in epidemiological studies, will be made very much more difficult. Ian Fairlie showed just recently time trends in infant mortality, and we could look for other time trends. Let’s remember that the radiation was not the only thing going on that was different after this event. People were moving, they were relocating, their diets were affected, their medical services were affected, and people died. Many, many thousands of people died. This is all going on at the same time, and it’s going to be difficult to separate out the radiation effects from this.
One of the things I think is very important is that there are risks from conducting research. Some research can be designed in such a way that it is unable to detect an effect even if the effect is there. This is something that the exposed populations need to understand. Because if they come to count on science to help them, they need to know science isn’t perfect and it’s never done in perfect conditions.
There were also comments yesterday and earlier today about biases and objectivity in science.
I would like to leave you with the idea that the main threat here is the lack of critical thinking, and this includes self-critical thinking.
In this area that we are interested in here at this symposium is that one primary problem is the failure to question authority. And that is a great example to me is the Life Span Study, which is applied all the time, every day, from legal situations to workers compensations, to estimating health effects of the Fukushima event. And authority is very important because authorities control access to jobs, to research funding, professional meetings and journals. Tim Mousseau talked about this yesterday.
What we are trying to do is very difficult. It’s not easy. But as we proceed to get more information on the effects of Fukushima to learn more about the population impacts, one of the things that I would ask is that we not confuse narrowly constructed research hypotheses, meaning that there would be an excess of some condition in exposed population, let’s not confuse that with systemic analyses that we are also interested in.
Things like, “Is nuclear power a good policy?”
That’s a different question.
If nuclear power is a bad policy, it doesn’t mean that every study has to find an excess cancer.
That’s a different question.
So, with that I will thank you for your attention and maybe talk to you later.
Eleventh Prefectural Oversight Committee Meeting: Thyroid Ultrasound Examination Results
The Proceedings of the 11th Prefectural Oversight Committee Meeting for Fukushima Health Management Survey was released on June 4, 2013. Below is the translation of the thyroid ultrasound examination, preceded by a summary and a quick analysis of the results.
The original Japanese results for the thyroid ultrasound examination are found here.
The official English translation is found here.
Previous survey results can be found here.
PDF of this post is found here.
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The official English translation is found here.
Previous survey results can be found here.
PDF of this post is found here.
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This report covers the thyroid ultrasound examination results for Fiscal Year Heisei 23 (FYH23 or H23 here) or FY2011 as well as Fiscal Year Heisei 24 (FYH24 or H24 here) or FY2012. It offers more information than previous reports, as in breakdown by municipalities. However, it fails to correlate findings with estimated individual exposure doses, a point repeatedly brought up at the post-committee meeting press conferences, especially in regards to the cancer cases. Previously, the Committee always insisted on privacy protection so as not to reveal even the residing municipality of subjects, let alone the exposure dose. In this respect, the municipality information offered at this time, in a way, may be construed as an improvement.
For the H23 results, additional 2,188 subjects who were examined in H24, from municipalities eligible for the H23 examination (the H23 municipalities), were added to the total reported in the last report which can be viewed here:
With this addition, the percentage of children with thyroid ultrasound abnormalities increased slightly for H23, from 35.8% (13,645 out of 38,114) to 36.3% (14,632 out of 40,302).
For the H24 results, 39,099 subjects were added to the previous report from the H24 municipalities, increasing the percentage of children with thyroid ultrasound abnormalities from 44.2% (41,946 out of 94,975) to 45.3% (60,681 out of 134,074).
Altogether, 43.2% (75,313 out of 174,376) of Fukushima children tested so far have thyroid ultrasound abnormalities.
In H25, 158,783 children from 34 municipalities, that is, the H25 municipalities, will undergo the initial examination.
The most recent results show that with time the overall rate of abnormalities appears to be increasing. The H23 municipalities will have follow-up examinations when the full-scale survey begins in H26 or FY2014. A question arises as to whether this follow-up is soon enough, especially when considering the progression of thyroid abnormalities in the H24 municipalities.
Moreover, a municipality such as Iwaki City, which was in the path of the heavy radioactive plume on March 15, 2011, just began the initial examination, and we don’t have a full picture of their results. In fact, Iwaki City was included in the thyroid dose monitoring, along with Iitate Village and Kawamata Town, in late March 2011, where the thyroid dose was determined, as mentioned here:
Also, Koriyama City produced 442 subjects eligible for secondary examinations from 50,805 who underwent the initial examination. Koriyama City being the most populous city in Fukushima Prefecture, a higher number of subjects with the B assessment, eligible for secondary examination, might not be unreasonable. However, the second most populous city, Fukushima City, had 263 subjects eligible for secondary examination out of 46,367 who underwent the initial examination. (228 of 263 actually underwent the secondary examination, 56 had biopsies, and 9 are suspected of having malignancy). Compared to this, Koriyama City’s 442 appears disproportionate. Moreover, only 5 of 442 have completed the secondary examination as of May 27, 2013, and 2 of the 5 are suspected of having malignancy. This seems ominous, considering how many have not even begun the secondary examination. Incidentally, Koriyama City is known to have numerous hot spots, and the appeal from the collective evacuation trial was recently turned down by the judge although the judge did admit radiation exposure may have a potential for serious health risks for children in Koriyama City.
The results of biopsy have been the center of intense interest at the press conference and also by general public. There were 12 cases, out of 205 eligible for secondary examination, suspected of malignancy upon biopsy and cytological examination in H23, and 16 cases, out of 935 eligible for secondary examination, in H24.
It should be noted that in H23 only 166 out of the 205 eligible actually underwent the secondary examination, and 82 had biopsies, resulting in 12 suspected/confirmed cases of malignancy: 8 had surgeries and one was found to have a benign nodule and 7 had papillary thyroid cancer, the most common form of thyroid cancer in general as well as due to radiation exposure, for instance, from the Chernobyl accident. There were 39 subjects who never underwent the secondary examination. As of May 27, 2013, 160 of the 166 completed the secondary examination. There are also 9,635 from the H23 municipalities who have not undergone the initial examination.
In H24, 255 of 935 eligible actually underwent the secondary examination. 223 of 255 completed the secondary examination, and 63 had biopsies, leading to 16 suspected/confirmed cases of malignancy: so far only 5 had surgeries and all 5 turned out to be papillary thyroid cancers. It should be noted that for the H24 municipalities there are nearly 700 more subjects who await secondary examination. There are also 30,896 who have not undergone the initial examination.
The last part of the report is an attachment from the Ministry of the Environment thyroid survey (MOE survey) results, which have been officially translated here:
Results from this MOE survey have been widely circulated as a proof that the Fukushima results are not any different from three other prefectures selected for the survey and thus the thyroid abnormalities being discovered are merely the screening effect and the thyroid cancers are nothing other than latent cancers discovered early with no relation to radiation exposure. However, it might not be reasonable to compare the two sets of data when the operator variabilities might affect the ultrasound assessment even using the same machine and also because the sample selection might be biased in the MOE survey.
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Note:
H23 refers to Heisei Year 23, which is the same as 2011.
FYH23 refers to Fiscal Year Heisei 23 which runs from April 1, 2011 through March 31, 2012.
H24 refers to Heisei Year 24, which is the same as 2012.
FYH24 refers to Fiscal Year Heisei 24 which runs from April 1, 2012 through March 31, 2012.
H25 refers to Heisei Year 25, which is the same as 2013.
FYH25 refers to Fiscal Year Heisei 25 which runs from April 1, 2013 through March 31, 2014.
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The Proceedings of the 11th Prefectural Oversight Committee Meeting for Fukushima Health Management Survey
Thyroid ultrasound examination
Implementation status of thyroid examination of Fukushima Health Management Survey
1 Initial examination (in-prefecture)
(1) Implementation status
① All municipalities scheduled for the H24 examination completed the examination according to the original plan. In addition, due to the efforts made, mentioned in the following page, the actual examination rate of about 82% was achieved. At the same time, Koriyama City and a part of Iwaki City were examined ahead of the original schedule.
② The H25 examination began on April 22, 2013. By the end of March, 2014, all those eligible in 34 municipalities (158,783 subjects) will be examined.
The H23 municipalities (13 municipalities designated as the evacuation zone by the government). As of March 31, 2013
The H24 municipalities (Iwaki City includes Hisanohama District only). As of March 31, 2013
The H25 municipalities As of May 10, 2013
※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.
● Age shown is the age as of March 11, 2011.
(2) Main efforts made towards enhancing the examination.
① Making certain the eligible subjects have opportunities for examination.
（i）Sending notification for the examination simultaneously to multiple municipalities sharing the living space. Also sending the latest examination schedule to those who have not undergone the examination in order to offer multiple opportunities for examination.
（ii）Conducting examination in school settings for students.
② Making sure the quality of the examination is maintained.
（i）Ensuring the support of thyroid specialists in and outside Fukushima Prefecture by widely publicizing the need for cooperation.
（ii）Ensuring the quality of set standard by offeing examination conducted by thyroid specialists, etc.
③ Accelerating the implementation of the thyroid ultrasound examination.
（i）Ensuring large venues that allow examination of 700 to 800 subjects per day in order to finish the initial examination ahead of the schedule.
④ Preparing the examination center inside Fukushima Prefecture.
（i）Conducting workshops for physicians and technicians in order to enhance the examination system inside Fukushima Prefecture.
2 Initial examination (out-of-prefecture)
(1) Implementation status
① Thyroid ultrasound examinations were started at facilities outside Fukushima Prefecture beginning on November 1, 2012.
② Notices for the initial examination held at examination facilities outside Fukushima Prefecture have been sent to the eligible subjects who were not able to undergo the examinations in the H23 eligible municipalities as well as the H24 eligible municipalities except for Koriyama City and Miharu Town.
③ Notices were sent on May 29, 2013, to the eligible subjects from Koriyama City and Miharu Town who have not undergone the examination.
④ Notices for the out-of-prefecture examination are being sent to the eligible subjects who have not undergone the examination, as they are identified in the order of municipalities which already conducted the examination.
The H23 municipalities for in-prefecture examination As of March 31, 2013 
※1 The number of notices sent to the eligible subjects who have not undergone examinations at their respective municipalities.
● 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.
The H24 municipalities for in-prefecture examination As of March 31, 2013 
The H23/H24 municipalities for in-prefecture examination As of March 31, 2013 
H25 out-of-prefecture examination implementation status (from April 1 to May 16, 2013)
※1 The number of notices sent to the eligible subjects who have not undergone examinations at their respective municipalities.
● 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.
(2) Main efforts made towards enhancing the examination.
① Currently there are agreements made with 76 examination facilities nationwide (Attachment 2: Refer to page ②-13 of the original report in Japanese), and the expansion of the examination system outside Fukushima Prefecture is planned.
② Fukushima Medical University is sending the examination staff to prefectures with a large number of evacuees, such as Niigata and Yamagata Prefectures.
3 Initial examination results summary
(Summaries of results by municipalities are found in Attachments 3 and 4).
(1) Summary of H23 and H24 results
As of March 31, 2013
※1 ”Total number of subjects whose results have been finalized” refers to the total number of subjects who were examined at examination facilities inside and outside Fukushima Prefecture and whose results have been finalized.
※2 Includes the 2,188 subjects who were examined in H24 and whose results have been finalized. 
(For reference) The number of subjects categorized by nodules/cysts and their sizes in H23 and H24.
① Explanation of assessment classification
(i) A: (A1) No nodules or cysts found.
(A2) Nodules 5.0 mm or smaller or cysts 20.0 mm or smaller.
(ii) B: Nodules 5.1 mm or larger or cysts 20.1 mm or larger.
(iii) C: The condition of the thyroid gland warrants an immediate secondary examination.
② Explanation of the assessment results
(i) A1 and A2 will be observed until the next round of the examination beginning on and after H25 (FY2014).
(ii) B and C assessments will undergo secondary examination.
(iii) Some A2 cases might be considered B if the condition of the thyroid gland warrants secondary examination.
(2) H24 examination results: by age and sex
As of March 31, 2013
※1 Age groups are based on ages as of March 31, 2013.
● Refer to Attachment 5 for the H23 examination result detail by municipalities.
(3) Detailed results (H24 examination: nodules)
① Total results for nodules by presence/absence and size of nodules
Total results:
● Of 134,074 who were examined in FYH24, 1.2% (1.0% in H23) of 1,593 had nodules.
● Of 1,593 who had nodules, 922, or 0.7% (0.5% in FYH24) had nodules 5.1 mm or larger.
In addition, of these 922 mentioned above, 635 had nodules between 5.1 mm and 10.0 mm, comprising 68.9% (67.0% in FYH23) of 922 requiring secondary examination.
● 287 had nodules larger than 10.0 mm, comprising 0.21% (0.17% in FYH23).
(4) Detailed results (H24 examination: cysts)
① Total results for cysts by presence/absence and size of cysts
※1 Assessment classification based on the size of the cysts alone.
※2 The reason the size group “〜3.0 mm” is put together with “No cysts present” in the proportion is because in ordinary medical practice cysts smaller than 3.0 mm are treated as no cysts.
Total results:
● Of 134,074 who were examined in FYH24, 44.6% (35.6% in FYH23) of 59,865 had cysts.
Of these, 35,428 had cysts 3.0 mm or smaller, which are considered not to be cysts in ordinary medical practice.
● 24,437 had cysts larger than 3.1 mm, comprising 18.2% (16.8% in FYH24) of the total.
● More female had cysts 3.1 mm or larger (male 43.9% and female 56.1%: male 43.2% and female 56.8% in H23).
4 Secondary examination
(1) Implementation status
① Subjects eligible for secondary examination are being seen at a specific proportion as the initial thyroid ultrasound examination is carried out. A system allowing for a more rapid secondary examination was structured, so that the secondary examination can be carried out along with the initial examination.
H23 eligible municipalities (implementation status as of May 27, 2013)
H24 eligible municipalities (implementation status as of May 27, 2013)
※1 (a) denotes a total of all subjects examined both inside and outside Fukushima Prefecture.
※2 (h) does not include the subjects who underwent blood and urine tests and biopsy who have not received the examination results.
※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.
● Secondary examination requires multiple visits for testing such as blood and urine tests as well as for reporting of the results.
(2) Number of first visits per month (for subjects from H23 as well as H24)
(3) Main efforts made towards enhancing the examination.
① 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.
② A2 assessments which, based on the condition of thyroid gland, might warrant secondary examinations will be reclassified as B assessments and undergo secondary examinations.
③ Those who require urgent clinical assessments will be given priorities for secondary examinations.
④ Results of secondary examination are to be directly explained to the subjects and parents in detail and with adequate time.
⑤ Expansion of secondary examination will be attempted based on the schedule below.
(4) H24 municipalities: Secondary examination schedule (draft)
(5) Secondary examination results summary
② Age and sex distribution of 28 cases confirmed or suspected of maligancy based on biopsy.
③ Results of secondary examination by municipalities in H23 and H24. (As of May 27, 2013)
Results of secondary examination by municipalities in H23.
※1 Initial examination subjects include the subjects who underwent either in-prefecture or out-of-prefecture examinations.
※2 Does not include one case suspected of malignancy upon biopsy and found to be benign 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.
Results of secondary examination by municipalities in H24.
※1 Initial examination subjects include the subjects who underwent either in-prefecture or out-of-prefecture examinations.
※2 Municipalities other than Fukushima City are in the early stage of the secondary examination. Due to the low rate of examination to date, the numbers are not displayed here.
● Those who require urgent clinical assessments will be given priorities for secondary examinations.
● Those who require urgent clinical assessments will be given priorities for secondary examinations.
(Attachment 3)
H23 municipalities: Thyroid examination detailed results (as of March 31, 2013) 
※1 Total number of subjects including in-prefecture and out-of-prefecture examinees.
※2 “Other” includes subjects from outside the municipalities designated as the evacuation zone by the government but underwent thyroid ultrasound examination at schools.
● It is difficult to make a simple comparison between municipalities, as each municipality has its own unique composition of the number of subjects and the age structure.
(Attachment 4)
H23 municipalities: Thyroid examination detailed results (as of March 31, 2013) 
※1 Total number of subjects including in-prefecture and out-of-prefecture examinees.
● It is difficult to make a simple comparison between municipalities, as each municipality has its own unique composition of the number of subjects and the age structure.
(Attachment 5)
(1) H23 municipalities: In-prefecture examination results by age and sex
As of March 31, 2013
※1 Age group shown refers to the age as of March 11, 2011.
Note 1: These revised results include 2,188 children who were examined in H24.
(2) Total results for nodules by presence/absence and size of nodules
※ Assessment classification based on the size of the nodules alone.
(3) Total results for cysts by presence/absence and size of cysts
※1 Assessment classification based on the size of the cysts alone.
※2 The reason the size group “〜3.0 mm” is put together with “No cysts present” in the proportion is because in ordinary medical practice cysts smaller than 3.0 mm are treated as no cysts.
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