1. Lessons learned from Fukushima Daiichi Nuclear Power Plant Accident Koichi Tanigawa Department of Emergency and Critical Care Medicine *1 Radiation Emergency Medicine Promoting Center *2 Hiroshima University

2.  Nearly 20,000 people were killed in the disaster, most of them lost their lives by tsunami.  In Iwate, Miyagi and Fukushima, 78.9% of all hospitals were severely damaged.  In Iwate, the tsunami reached up to the fourth floor of a hospital, more than 100 medical staff and patients were rescued by SDF.  The remaining hospitals provided medical care for more than two thousands injured in the initial 3 days after the quake.  Disruption of communication network was so devastating that some areas were left isolated in spite of vast amount of medical needs.  This natural disaster was accompanied by a severe nuclear accident.

3. Number of patients admitted to Ishinomaki Red Cross Hospital in Miyagi during the first week after the earthquake 3/113/123/133/143/153/163/17

4.  Due to loss of all communication, hospitals and medical facilities in some areas were left isolated. Although many disaster medical assistance teams were dispatched to the disaster strcken areas, they could not reach those who most needed medical care.  People who lost their home were displaced to live in shelters for a long period of time. Providing medical care for elderly and those with chronic illnesses were the priotized issues in the early phase of the post-disaster.

5. Fukushima Pref. Ono Hp Futaba Kosei Hp Imamura Hp H H H Ｏ Fukushima Nuclear disaster management center Fukushima Daiichi NPP Fukushima Daini NPP 10 km zone H Primary radiation emergency hospital Ｏ Off-site center Loss of function of the control center Evacuation of all residents, patients and medical personnel Collapse of radiation emergency medical system Loss of power, communication

6. datetimeevents 2011/3/1114:46A great earthquake hit the eastern Japan, followed by huge tsunamis. 19:03State of atomic emergency was issued by the national government 21:23Evacuation from 2 km zone and in-house evacuation from 2 to 10 km zone was ordered. 2011/3/125:44Evacuation from 10 km zone was ordered for 48,272 residents. 15:36The fisrt hydrogen explosion occurred at the No. 1 reactor. Four workers were injured. 18:25Evacuation from 20 km zone was ordered. Residents left by car and busses. 2011/3/13 Evacuatoion of 2,200 patients at hospitals and facilities was arranged. Most of them were reallocated to out-side hospitals. However, approximately 840 patients remained left within the 20 km zone. 2011/3/140:47 Emergency evacuation order was issued for patients in hospitals and facilities within the 20 km zone. 11:01 The second hydrogen explosion occurred at the No. 3 reactor. Eleven workers were injured. 2011/3/156:00Severe damages of No.2 reactor, and explosion of No. 4 reactor occurred. Radiation levels soared from 0.09 in am to 24.08 μSv/hour in the evening in Fukushima. 11:00In-house evacuation from 20 to 30 km zone was ordered. 15:00Evacuation of all residents within 20 km zone was completed. Chronological order of events in Fukushima

7. 8 Hospitals, 1240 patients 17nursing facilities, 983 patients Fukushima Pref. NHK Hiroshima Fukushima Pref. Gov. Off site center (Command center) Fukushima Medical Unive ｒ sity (FMU) Radiation emergency Hospital

8. In the Fukushima Daiichi Nuclear Power Plant accident, what we have seen, difficulties in reallocating patients forced them to stay in the confined space of the transporting vehicles for long hours. patients died during or soon after evacuation. On the other hand, no significant contamination was found in the evacuated patients from the 20-km area despite the fact that 48 hours had already passed since the first explosion. These facts suggest the effectiveness of indoor sheltering for protection from radioactive plumes.

9. Therefore, we conclude that, In contrast to physical injuries caused by collapse of buildings or tsunami, radiation itself does not create any immediate life-threatening conditions. Rather, ill-prepared evacuation may increase the health risk of hospitalized patients or the elderly. In the case of nuclear disasters, therefore, evacuation for these vulnerable people should be carefully performed with medical arrangements.

10. １Ｆ H H H H H H J-village Ｊ Ｏ Nuclear Disaster Management Center 2Ｆ2Ｆ Ｏ H H closed radiation emergency Hp available radiation emergency Hp H partially functioned radiation emergency Hp Fukushima city Fukushima Medical Unive ｒ sity (FMU) Fukushima Daiichi (No.1) Nuclear PP Iwaki city １Ｆ 2Ｆ2Ｆ Fukushima Daini (No.2) Nuclear PP FMU, NIRS, etc Fukushima Daini (No.2) Nuclear PP FMU Nuclear Disaster Management Center March 14th March 15th March 16th Medical responses for patients who suffered injuries following the explosion of No. 3 reactor on March 14 th

11. As for emergency medical systems, difficulties in finding hospitals to provide care for injured workers with contamination were observed. Fortunately, non of them suffered life-threatening injuries. However, collapse of radiation emergency hospitals may have resulted in preventable death for those with severe trauma. Therefore, more hospitals are required to provide emergency care for patients with radiological contamination, considering combined disasters such as earthquakes and nuclear accidents.

12. 9:00, March 1521:00, March 15 Fukushima Iwaki Simulated radiation levels at 9:00 and 21:00 on March 15th, when massive radioactive materials were released from the No. 2 reactor of the Fukushima Daiichi Nuclear Power Plant. South-west spread of radioactives was observed at 9:00 (left). In the evening, however, the distribution shifted toward the north-west area due to changes in the wind direction (right). The bottom bars indicate radiation levels (μSv/h).

13. μSv/hr Serial changes of radiation levels at 7 sites in Fukushima prefecture from March 12 th through 23 rd. This graph was depicted using the data reported by the Fukushima Prefectural government on March 24 th.

14. Report of the national government and the Energy Ministry of USA, May 6 th. Chernobyl 1,480,000Bq/m2<: Closed Zone 555,000Bq/m 2 <: Permanent Control Zone Estimated accumulation doses of Cs-134 and 137 (Bq/m 2 ) Futaba Namie Okuma Tomioka Fukushima Nihonmatsu Minamisoma Soma Naraha Hirono Iwaki Kohriyama Date Tamura Iitate Kawamata Katsuraomura Motomiya Kawauchimura

15. The medical teams were exposed to radiation risk, due to lack of information on radiation. We should understand the patterns of spread of nuclear plumes. Nuclear plume does not spread in a concentric fashion. It spreads discontinuously and changed its direction quickly by wind direction, geographic, and weather. Therefore, we need more monitoring devices and posts in place. Information on radiation should be readily available for all personnel involved.

16. Fukushima Pref. No death from irradiation No death from explosions Fukushima Pref. Gov. Fukushima Pref. Off site center (Command center) However, evacuation was accompanied by loss of life!! NHK Hiroshima

17. 30 hospitals, 3800 patients 83 nursing facilities, 3144 patients Shimane Pref. NHK 広島 Fukushima Pref. Gov. Off site center (Command center)

18. Residents have no protections themselves in nuclear disasters Local government assumes responsibility in preparation and countermeasures for disasters Prefectural and National government support the efforts made by the local government Take wind direction into consideration in evacuation Evacuation facilities should be equipped with monitoring systems and medical supports should be readily available Establish detailed plans for evacuation in advance. Look into distribution of population, available vehicles, routes and estimate time required for evacuation. In particular, set up specific plans for nurseries, schools, and hospitals as well as for elderly. Yamamoto S, Preparedness for nuclear disasters: Roles of local government and individuals. Katsura publishing Co. 1993

19. Summary 1.Evacuation from 20 km zone was accompanied by loss of life. On the other hand, sheltering was quite effective to avoid nuclear plume. Because irradiation itself does not pose any immediate life-threatening conditions, well planned evacuation should be considered. 2.Significant difficulties were encountered to determine hospitals for evacuated patients. Admitting facilities should be designated in advance. Education for medical personnel and students should be emphasized and Radiation emergency medical system needs to be refined. 3.Due to lack of information, medical teams were exposed to radiation risk. Nuclear plume does not spread in a concentric fashion. It spreads discontinuously and changed its direction quickly by wind direction, geographic, and weather. More monitoring posts should be in place and information on radiation should be readily available for citizens. 4.Proper knowledge on radiation mitigates health risks, overcomes misunderstandings and prejudice for evacuees. 5.We should prepare for combined disasters, i.e. nuclear accidents following a disaster or terrorist attacks. Local residents are the core member of the system, and the local government should assume responsibilities in developing plans.