R. William Field, Ph.D., M.S.R. William Field, Ph.D., M.S.

Associate ProfessorAssociate Professor

Department of Occupational Department of Occupational and Environmental Healthand Environmental Health

Department of Department of EpidemiologyEpidemiology

College of Public HealthCollege of Public Health

104 IREH104 IREH

University of IowaUniversity of Iowa

Iowa City, IA 52242Iowa City, IA 52242bill-bill-field@uiowa.edufield@uiowa.edu

Current National and International Scientific Radon-Related Activities and Educational Initiatives

Keynote Address

Fifteenth National Radon MeetingShelter Pointe Hotel and MarinaSan Diego, CaliforniaSeptember 25–28, 2005

Current National and International Current National and International Scientific Radon-Related Activities and Scientific Radon-Related Activities and Educational InitiativesEducational Initiatives

• Residential Radon EpidemiologyResidential Radon Epidemiology– European Residential Radon PoolingEuropean Residential Radon Pooling– North American Residential Radon PoolingNorth American Residential Radon Pooling– Global Residential Radon PoolingGlobal Residential Radon Pooling– Iowa and Missouri Glass-based ResidentialIowa and Missouri Glass-based Residential Pooling (Laboratory and Field Studies - Steck)Pooling (Laboratory and Field Studies - Steck)– Genetic polymorphimsGenetic polymorphims– Other diseases related to radon exposure?Other diseases related to radon exposure?

• Educational InitiativesEducational Initiatives– Coordination of stakeholders within regions and Coordination of stakeholders within regions and

statesstates– World Health Organization InitiativeWorld Health Organization Initiative

Radon Epidemiology1556 Agricola - Miners in Europe1879 Harting & Hesse - Lung Cancer in Miners1921 Uhlig - Radium Emanations & Lung Cancer1950s Peller - First Review of Mining Related Cancers 1970s Studies of Underground Miners (ongoing)1990s Residential Radon Studies1994 NCI Pooled Analyses of Miners1999 NAS BEIR VI Report2005 North American and European Pooled Residential Radon Studies2007 Global Pooling of Residential Radon Studies2007 Pooling of Glass-based Residential Radon Studies

European Residential Radon European Residential Radon PoolingPooling

Radon in homes and risk of lung cancer:Radon in homes and risk of lung cancer:European case-control studies collaborativeEuropean case-control studies collaborative

analysis of individual data from 13 European analysis of individual data from 13 European Case-control studies.Case-control studies.

S Darby, D Hill, A Auvinen, J M Barros-Dios, H Baysson, F Bochicchio, H Deo, R S Darby, D Hill, A Auvinen, J M Barros-Dios, H Baysson, F Bochicchio, H Deo, R Falk, F Forastiere, M Hakama, I Heid, L Kreienbrock, M Kreuzer, F Lagarde, I Falk, F Forastiere, M Hakama, I Heid, L Kreienbrock, M Kreuzer, F Lagarde, I

Mäkeläinen, C Muirhead, W Oberaigner, G Pershagen, A Ruano-Ravina, E Mäkeläinen, C Muirhead, W Oberaigner, G Pershagen, A Ruano-Ravina, E Ruosteenoja, A Schaffrath Rosario, M Tirmarche, L Tomácek, E Whitley, H-E Ruosteenoja, A Schaffrath Rosario, M Tirmarche, L Tomácek, E Whitley, H-E

Wichmann, and R Doll Wichmann, and R Doll

British Medical Journal 330: 223, Jan 2005British Medical Journal 330: 223, Jan 20057,148 Cases, 14,208 controls

StudyStudy CasesCases ControlsControls % increase of % increase of risk at 100 risk at 100

Bq/mBq/m33

AustriaAustria 183183 188188 4646

Czech RepublicCzech Republic 171171 713713 1919

Finland (nationwide)Finland (nationwide) 881881 14351435 33

Finland (south)Finland (south) 160160 328328 66

FranceFrance 571571 12091209 1111

Germany (eastern)Germany (eastern) 945945 15161516 1818

Germany (western)Germany (western) 13231323 21462146 -2-2

ItalyItaly 384384 405405 1010

SpainSpain 156156 235235 -11-11

Sweden (nationwide)Sweden (nationwide) 960960 20452045 1111

Sweden (never smokers)Sweden (never smokers) 258258 487487 2424

Sweden (Stockholm)Sweden (Stockholm) 196196 375375 1212

United KingdomUnited Kingdom 960960 31263126 44

European Pooling SummaryEuropean Pooling Summary

• The risk of lung cancer increased by The risk of lung cancer increased by 8.4% (95% confidence interval 3.0% to 8.4% (95% confidence interval 3.0% to 15.8%) per 100 Bq/m15.8%) per 100 Bq/m33

• After correction for the dilution caused After correction for the dilution caused by random uncertainties in measuring by random uncertainties in measuring radon concentrations, an increase of radon concentrations, an increase of 16% (5% to 31%) per 100 Bq/m16% (5% to 31%) per 100 Bq/m33 was was notednoted

• Small cell histologic type most Small cell histologic type most associated with radon exposureassociated with radon exposure

Bq/m3

25-49 50-99 100-199 200-399 400-799 >800

OD

DS

RA

TIO

0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

North American Residential North American Residential Radon Pooled AnalysesRadon Pooled Analyses

Residential Radon and Risk of Lung Residential Radon and Risk of Lung Cancer: a Combined Analysis of 7 Cancer: a Combined Analysis of 7

North American Case-control North American Case-control StudiesStudies

Krewski D, Lubin JH, Zielinski JM, Alavanja M, Catalan Krewski D, Lubin JH, Zielinski JM, Alavanja M, Catalan

VS,Field RW,Klotz JB, Letourneau EG, Lynch CF, Lyon VS,Field RW,Klotz JB, Letourneau EG, Lynch CF, Lyon JI,Sandler DP, Schoenberg JB, Steck DJ, Stolwijk JA, JI,Sandler DP, Schoenberg JB, Steck DJ, Stolwijk JA,

Weinberg C, Wilcox HBWeinberg C, Wilcox HB

Epidemiology 16(2):137-45. Mar 2005Epidemiology 16(2):137-45. Mar 2005

3,662 cases, 4,966 controls

Basement and Living Area Radon Concentrations for U.S. Residential Radon Studies.

Study Location

Geometric Mean in pCi/L

Basement Level 1 Level 2

New Jersey 0.5 0.7

Missouri-I 2.4 1.2 1.2

Missouri-II 2.4 1.2 1.2

Iowa 4.6 2.5 2.0

Connecticut, Utah Southern Idaho2

1.51.8

0.51.2

0.41.0

1Summary data represent those homes that were measured with no imputed (values added to replace missing values) values.

StudyStudy CasesCases ControlsControls % Excess Risk at 100 Bq/m3

New JerseyNew Jersey 480 442 56Winnipeg Winnipeg

Health CanadaHealth Canada738 738 2

Missouri IMissouri I

NCINCI538 1183 1

Missouri II (Gas Phase)Missouri II (Gas Phase)

NCINCI512 553 27

Iowa (Gas Phase)Iowa (Gas Phase)

NIEHS, NCI, EPANIEHS, NCI, EPA413 614 44

ConnecticutConnecticut

NIEHSNIEHS963 949 2

Utah-South IdahoUtah-South Idaho

NIEHSNIEHS511 862 3

North American Pooling North American Pooling SummarySummary

• The The 11% estimated risk at 100 Bq/m11% estimated risk at 100 Bq/m33 is is consistent with the predicted excess risk consistent with the predicted excess risk of 12% per 100 Bq/mof 12% per 100 Bq/m33 based on a linear based on a linear model developed by the National model developed by the National Research CouncilResearch Council

• When the analyses were restricted to When the analyses were restricted to individuals living in one or two homes individuals living in one or two homes for at least 20 years, the risk estimates for at least 20 years, the risk estimates increased to 18% at 100 Bq/mincreased to 18% at 100 Bq/m33

Bq/m3

25-49 50-74 75-99 100-149150-199 >200

OD

DS

RA

TIO

1.0

1.2

1.4

1.6

1.8

2.0

2.2

New Jersey, Missouri I, Canada, Iowa, New Jersey, Missouri I, Canada, Iowa, Missouri II, a combined study from Missouri II, a combined study from Connecticut, Utah and S. IdahoConnecticut, Utah and S. Idaho

Shenyang, China, Stockholm, Shenyang, China, Stockholm, Sweden, Swedish nationwide, Sweden, Swedish nationwide, Winnipeg, Canada, S. Finland, Winnipeg, Canada, S. Finland, Finnish nationwide, SW England, W. Finnish nationwide, SW England, W. Germany, Sweden, Czech Republic, Germany, Sweden, Czech Republic, Italy-Trento, Spain, Austria, France, Italy-Trento, Spain, Austria, France, China - Gansu Province, E. GermanyChina - Gansu Province, E. Germany

10% – 18%

10% – 18%

16%16%

Pooled Analyses Agreement ??

We have “demonstrated that empiric We have “demonstrated that empiric models with improved retrospective models with improved retrospective radon exposure estimates were more radon exposure estimates were more likely to detect an association likely to detect an association between prolonged residential radon between prolonged residential radon exposure and lung cancer.”exposure and lung cancer.”

Therefore, estimated pooled risk Therefore, estimated pooled risk estimates are likely low. estimates are likely low.

Journal of Exposure Analysis and Environmental EpidemiologyJournal of Exposure Analysis and Environmental Epidemiology 12(3):197-203, 2002 12(3):197-203, 2002..

Risk Estimates for Alternative Models (live cases and controls)

0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

Od

ds

Rat

io

WLM201st StoryBRBR/LRLRBasement

Complete Complete exposureexposure

Other location radon

concentrations only

JEAEE 12(3): 197-203, 2002JEAEE 12(3): 197-203, 2002

20-39% 40-59% 60-79% 80+%

Special Residential Radon Publication

Samet, J. Residential Radon Epidemiology

Zielinski, J, Field, R.W., Residential Radon and Lung Cancer - Preface

Krewski et al. A Combined Analysis of North American Case-Control Studies of Residential Radon and Lung Cancer.

Field et al. An Overview of the North American Case-Control Studies of Residential Radon and Lung Cancer.

Sandler et al. Connecticut, Utah/S. Idaho Residential Radon Studies

Steck, D., Field, R.W. Dosimetric Challenges for Residential Radon Epidemiology.

February 2006 issue

GLOBAL RESIDENTIAL RADON POOLINGGLOBAL RESIDENTIAL RADON POOLING

New Jersey, Missouri I, Canada, Iowa, Missouri II, Connecticut, Utah and S. Idaho, Shenyang, China, Stockholm, Sweden, Swedish nationwide, Winnipeg, Canada, S. Finland, Finnish nationwide, SW England, W. Germany, Sweden, Czech Republic, Italy-Trento, Spain, Austria, France, China - Gansu Province, E. Germany

Led by Sarah Darby at Oxford, U.K.

Next meeting of investigators – Geneva, March 2006

Anticipated completion 2007

10,810 cases; 19,174 controls

Current Activities

Current collaboration between the University of Iowa and the National Cancer Institute involve pooling of the glass-based retrospective radon detectors used in the two studies. We believe the glass-based detectors provide both improved retrospective radon and radon progeny dosimetry.

“Glass-Based” Residential Radon Studies

Glass-based detectors measure embedded radon progeny in glass surfaces and can be used to reconstruct the average radon concentration for periods as long as several decades.

Retrospective Radon

Detectors

Lead-210Lead-210

Polonium-214Polonium-214

Bismuth-214Bismuth-214

Lead-214Lead-214

Polonium-218Polonium-218

Radon-222Radon-222

Lead-206Lead-206(Stable)(Stable)

Polonium-210Polonium-210

Bismuth-210Bismuth-210

• Progeny adhere to solid objectsProgeny adhere to solid objects• Can become embedded in glass Can become embedded in glass

surfacessurfaces

22 yrs22 yrs

• Alphas can be detected from Po 210Alphas can be detected from Po 210 decay.decay.• Can provide a long-term indication ofCan provide a long-term indication of radon decay deposition on objects inradon decay deposition on objects in home.home.• A means to look back in time at radon A means to look back in time at radon levels.levels.

4 day

3 min

27 min

20 min

0.2 ms

5 day

138 day

Recent results for retrospective radon-related dose reconstruction from radon

progeny implanted in glass

Dose per unit radon

Exposure room studies

Simplified Models

Comparison with exposure room results

Dose Conversion Factor• Concept

– Improve dose rate estimate using a dose delivery efficiency factor to interpret the radon or radon progeny concentration

• Basis– Small radon progeny (nanoparticles) are much more

effective at delivering dose to sensitive lung tissues than either radon or progeny attached to aerosols

– Different home atmospheres have different mixtures of small and large progeny

Radon Dose Conversion FactorsDose rate per unit radon concentration

measured in a radon exposure room

0

20

40

60

80

100

120

140

160D

CF

Deposition – ResultsNormalized activities of select runs

0

10

20

30

40

50

60

70

80

90

100

Po218 Pb214 Bi-Po214

su

rfa

ce

ac

t. n

orm

ed

to

Rn

((B

q/m

2)/

(kB

q/m

3)=

mm

)

Hepa filter

candle

Smoke

med R.H.

Introduction and Background

• Each of these processes must be modeled for all the progeny

Model correlations

• Look for strong correlations between measurable activities and dose

• Non-linear or linear functions

• single or multiple variables

Test dose predictions against exposure room data

What’s the situation in homes?

• Long-term, integrated measurements of airborne radon progeny, radon, and deposited radon progeny in a variety of homes to test the model

• Fieldwork started in Iowa and Minnesota with a goal of at least 20 houses, depending on funding, in each state split between smoking and non-smoking.

• Extremely challenging work

Residential Radon Epidemiology: Do the risk estimates indicate that everyone has

the same risk of developing radon induced lung cancer?

• First degree relatives of a lung cancer victim have a 2 to 3 fold increased risk of developing lung cancer.

• Genetic polymorphisms play a role in susceptibility.

Genetic polymorphisms are defined as variations in

DNA that are observed in 1% or more of the population.

Ionizing radiation can directly and indirectly damage DNA

Alpha Alpha ParticleParticle

Defects in tumor Defects in tumor suppressor genes – p53suppressor genes – p53

At risk individuals–GSTMAt risk individuals–GSTM11

(glutathione S-transferase M1)(glutathione S-transferase M1)

Dou

ble

–stra

nd

Dou

ble

–stra

nd

DN

A br

eaks

DN

A br

eaks

Free

radi

cal

Free

radi

cal

form

atio

n

form

atio

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Bonner MR, Bennett WP, Lan Q,Wright ME, Lubin JH, Field RW, Brownson RC, Alavanja MCR,Radon, Environmental Tobacco Smoke,

Glutathione-s-transferase M1 and Lung Cancer in US Women.

• Recent work with collaborators at the NCI and City of Hope (Los Angeles) have explored gene-environment interactions between residential radon, environmental tobacco smoke (ETS), and the GSTM1 null genotype.

• The sample series included lung cancer cases pooled from three previously completed case-control studies.

• Recent results show a statistically significant 3-fold increase in the interaction OR for GSTM1 null cases compared with GSTM1 present cases.

• These findings have just been submitted for publication.

Educational Initiatives

Why is it so hard to get people to Why is it so hard to get people to take action on radon ??take action on radon ?? Invisible, odorless, colorlessInvisible, odorless, colorless Naturally occurring (no villains)Naturally occurring (no villains) Can not link deaths to radon exposureCan not link deaths to radon exposure Long latency periodLong latency period Not a disease affecting childrenNot a disease affecting children Not a dread hazardNot a dread hazard Cancers occur one at a timeCancers occur one at a time Voluntary riskVoluntary risk Lack of press – no sensational storyLack of press – no sensational story No sensory reminders to repetitively No sensory reminders to repetitively

stimulate stimulate us to think about itus to think about it

“Motivation is the art of getting people to do what you want them to do because they want to do it.” Dwight D. Eisenhower

“Motivation is a fire from within. If someone else tries to light that fire under you, chances are it will burn very briefly.”

Stephen R. Covey

Education is the starting point• Lead by example – Develop a “Top 10”

reasons I am concerned about radon presentation. Describe why you have a fire inside to take action on radon.

• Provide sample health-based presentations to local civics groups etc.

• Team up with local health organizations

Comparing Radon Related Comparing Radon Related Cancer to Other Cancer TypesCancer to Other Cancer Types

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100001200014000160001800020000

An

nu

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an

cer

De

ath

s

Lung Cancer (radon)

Liver Cancer

Brain Cancer

Stomach Cancer

Melanoma

Oral Cancer

Gallbladder Cancer

Bone Cancer

CA Cancer J Clin 2005 55: 10-30.

NetworkingNetworkingMaximize Educational EffortsMaximize Educational Efforts

• National Institute of Environmental Health Sciences, Environmental Health Sciences Research Center, University of Iowa

• U.S. EPA Region VII• Iowa Department of Public Health• American Lung Association• Iowa Consortium for Comprehensive Cancer

Control• Holden Comprehensive Cancer Center• Iowa Air Coalition• American Cancer Society

International Radon Initiative January 2005

Develop guidelines for member countries to reduce radon exposure and develop radon measurement and mitigation guidelines.

http://www.who.int/ionizing_radiation/env/radon/en/index.html

What are the benefits of an international action agenda on radon?

• Provide scientific consensus on radon health risks• Promote public awareness of health risks associated

with residential radon• Promote action at national level• Increase homeowner compliance with

voluntary/advisory radon guidelines• Set minimum criteria for radon risk management (e.g.

measurement and mitigation) that allow for country specific needs)

WHO Jan 17-18 Geneva Consensus Statements

• For many people, radon represents the largest source of exposure to ionizing radiation in humans.

• Radon is known to cause lung cancer in humans.

• Radon is an important contributor to the human lung cancer burden, after tobacco smoking.

• Radon is considered responsible for some 10 percent of the human lung cancer burden in developed countries/worldwide (will differ between developed and undeveloped countries).

• The BEIR VI Report estimated there are approximately 22,000 deaths annually from radon in the United States alone (European results will be added).

• Radon related lung cancer risk is affected by tobacco smoking with most radon-related lung cancers occurring in smokers; however, radon is one of the leading causes of cancer in nonsmokers.

• Radon should be a priority public health issue for national environmental and radiation safety programs.

• There is a need to carefully evaluate the costs and benefits of national and international radon mitigation programs.

• Based on existing knowledge of geological conditions and building types, and consideration of the total lung cancer burden, countries should consider developing cost-effective national or regional policies on testing and mitigation.

• Where appropriate, countries should build capacity within the public and or/private sectors to provide testing, mitigation and radon resistant new construction.

• Where appropriate, countries should issue and widely disseminate statements that address the importance of radon risk reduction and the steps that can be taken to reduce such risks.

• Countries should explore ways to address radon health risks in a cost-effective manner, considering both the installation of preventive measures in new buildings and remediation of existing buildings.

• National governments should team with other stakeholders to ensure radon risk communication messages are delivered from multiple sources

• Governments should strive to include radon health messages and action steps with other national efforts on green buildings, housing policy and the built environment.

Radon Working Groups

• Risk Assessment – “World burden of disease”Risk Assessment – “World burden of disease”

• Exposure GuidelinesExposure Guidelines

• Measurement and MitigationMeasurement and Mitigation

• Cost EffectivenessCost Effectiveness

• Risk CommunicationRisk Communication

• Program EvaluationProgram Evaluation

Measurement and Mitigation Working Group

• Radon Entry and Fate• Measurement Methods and Devices• Measurement Practices, Protocols, and Standards• Quality Management, Assurance, and Control• Mitigation Methods• Mitigation Practices and Standards• Prevention Strategies and Codes• Recommended Content for Training Programs for

Radon Testers and Mitigators• Gaps of Knowledge and Research Recommendations

Measurement Methods and Devices

• Recommended detector needs to be able to perform well under a variety of field conditions (good accuracy and precision in the field setting)

• Factors that affect validity of the measurement need to be examined (e.g. humidity, gamma radiation, thoron, etc.)

Summary• Residential radon epidemiology has made major

advances the past few years. • We no longer need to rely solely on We no longer need to rely solely on

extrapolations from miners to predict risk for extrapolations from miners to predict risk for people exposed to residential radon.people exposed to residential radon.

• We now have direct evidence that prolonged residential radon is one of our leading public health risks and major cause of cancer.

• The challenge now is to use this information so that a fire can be lit within people to test and mitigate as well as to promote radon resistant new construction.