Food System

Nuclear emergencies, WHO updates recommendations on food and drug stockpiles

February 22, 2023

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On January 27, 2023 Word Health Organization (WHO) updated recommendations to member states on food and drug stockpiles to be organized for possible nuclear emergencies (1,2).

Table of Contents

1) Nuclear emergencies, introduction

Nuclear and radiological emergencies have been included, as of 2008, in the scope of the International Health Regulations (2005). Therefore, member countries must fulfill the essential requirements of organization in response to radiation emergencies, and public health must be prepared to provide assistance to those affected. (3)

The document ‘Nationalstockpilesfor radiological and nuclear emergencies, policy advice‘ (2023) replaces the previous WHO report (2007) on stockpile development for radiation emergencies. Offering, among other things, up-to-date information on some drugs to be included of the stockpiles, for the clinical management of radiation injuries in different countries.

2) Radio-nuclear emergencies, the role of WHO.

WHO uses its Collaboration Centers and global expert networks – Radiation Emergency Medical Preparedness and Assistance Network (REMPAN) and BioDoseNet-to assist countries in strengthening their national endowments through the development of technical guidelines and tools, dissemination of information, training, exercises, and support for research and development.

IACRNE(Inter-Agency Committee on Radiological and Nuclear Emergencies) and IAEA(International Atomic Energy Agency) in turn collaborate with WHO to provide policy advice and technical support to national health authorities on preparedness, response, recovery and long-term follow-up for populations affected by radiological emergencies.

3) National stockpiles for nuclear emergencies.

National stockpiles for radiation emergencies should include specific pharmaceuticals, PPE(personal protective equipment) and special devices.
Medical supplies to reduce potential exposure to ionizing radiation and manage its health consequences include KI (potassium iodide. See note 4) tablets, decorporative agents, alkylating agents, cytokines and growth factors, antiemetics, antidiarrheal agents, and antimicrobial agents.

3.1) Approved drugs

Drugs to be included in medical stockpile supplies are subject to national pharmaceutical regulations and approvals. The regulatory status of MCMs(medical countermeasures) varies from country to country (see Figure 1).

Figure 1 – Regulatory status of major MCMs in some countries (October 2022) (1)

3.2) Shared national stocks

There is provision for bilateral or regional agreements with neighboring countries to share national stockpiles, especially for countries at low risk of radiation emergencies, which may choose not to invest in drug storage. RescUE ‘s factsheet, moreover, reveals the total absence of preparedness, in the Old Continent now at risk.

‘The European Commission is currently developing strategic reserves to respond to chemical, biological and radio-nuclear emergencies.
The reserve will include expert teams, equipment and devices to locate and decontaminate affected people or infrastructure. It will also ensure the availability of medical countermeasures such as drugs, vaccines, and therapies‘.

4) Type of radiation and first aid.

The type of radiation (high or low linear energy transfer) also partly determines the expected requirement. In the case of exposure to radioactive material, millions of people may be exposed to low doses of radiation. In this type of scenario, emergency protective actions, such as sheltering and limiting consumption of contaminated food and water, are the most effective measures to reduce the risks associated with radiation exposure.

Radionuclide uptake inhibitors, such as potassium iodide (KI) and decorporative agents, should in any case be administered as soon as possible after exposure or even prophylactically for KI.

5) Internal contamination

Exposure to radiation by inhalation, ingestion or contaminated wounds can result in contamination within the body. Radionuclides can enter the bloodstream, affect various tissues and target organs, and settle in organs. With local and/or systemic, immediate or persistent effects.

Figure 2: Primary target organs for the most common internal emitters

Different radionuclides target different organs and behave differently in the human body. Blocking agents (i.e., potassium iodide) can prevent the incorporation of radionuclides, and decorporation therapies (e.g., chelation) can remove them, reducing their load and thus the health risks associated with radiation.

6) Specific drugs

Some decorporative and blocking agents are indicated by WHO for the prevention and management of internal contamination.

Potassium Iodide

Oral administration of stable iodine(iodized thyroid block, ITB) through potassium iodide (KI) tablets is considered an effective strategy to reduce the risk of thyroid cancer in people exposed to accidental release of radioactive iodine.

IAEA, WHO and others have published guidelines (5,6) on the appropriate use of KI, which is reported to be relatively safe and effective if administered in a timely manner.

Decorporation therapy

Accidental inhalation or ingestion of some radionuclides results in internal contamination (see section 4). In such cases, decorporation therapy can be used to reduce absorption from the gastrointestinal tract, i.e., diuretic agents, adsorbents, and chelating agents to remove radionuclides from the body.

Prussian blue capsules, for example, are approved in some countries for the oral treatment of internal radioactive cesium contamination. The DTPA of Ca and Zn for the treatment of transuranic radionuclide contamination (e.g., Pu, Am, Cm).

7) Acute radiation Sydrome (ARS)

Exposure to a high dose of ionizing radiation can result in acute radiation syndrome (ARS), which manifests as hematopoietic, gastrointestinal, cardiovascular and neurological syndromes.

Treatment is provided only for the first two syndromes (hematopoietic and gastrointestinal), as the cardiovascular and neurological syndromes are considered noncurable and patients need only palliative care.

7.1) Agents for the management of hematopoietic lesions.

Some pharmaceuticals used for the treatment of other clinical conditions have also been effective and approved for the treatment of radiation-induced injuries, including ARS and local injuries.

Growth factors (i.e., cytokines) and myeloid cells (i.e., granulocytes) or granulocytes and macrophages for example increase proliferation of granulocyte progenitors or granulocyte-macrophages, facilitate myeloid maturation, and protect against programmed cell death.

7.2) Agents for the management of gastrointestinal injuries.

Ionizing radiation at doses ≥5 Gray induces disruption of the gastrointestinal mucosal barrier and alteration of the structural integrity of the gastrointestinal tract predisposing to translocation of circulating enteric bacteria, severe secretory diarrhea, dehydration, and electrolyte imbalance, all of which contribute to high mortality rates (8).

Studies of radiation-specific therapies are still ongoing , but none has been approved for the treatment of gastrointestinal radiation injury. The management of these injuries now therefore includes the administration of antiemetic compounds, antidiarrheal drugs, and antimicrobial agents. In addition to fluid and electrolyte replacement.

8) Clinical management of radiation injuries.

Research is currently focused on identifying new cellular and molecular pathways for new drugs that may be better suited to treat large populations in radiological emergencies. Although in fact several approaches are available, they cover only a limited range of radionuclides and some require repeated intravenous administrations.

Investigational drugs include:

HOPO (hydroxypyridinonate compound), for decorporation of radionuclides by complexation (comparable to DTPA),
Surfactants for the treatment of lung injury after inhalation radiation exposure. These are angiotensin-converting enzyme inhibitory agents routinely used to treat hypertension and heart failure,
agents that stimulate erythropoiesis for the management of anemia after exposure to ionizing radiation.

8.1) Stem cell therapy and biobanks

Stem and progenitor cells exposed to ionizing radiation undergo differentiation and proliferation, with apoptosis of stem cells and disruption of those accessory cells. Tissue regeneration and subsequent recovery from radiation injury require new stem cells to cope with these toxic effects.

However, stem cell transplantation is beyond the scope of the WHO document and requires relevant legislation, standards, and procedures to address the broad spectrum of issues related to the development of human biospecies biobanks.

9) Interim Conclusions

Preventing nuclear disasters is the only way to save humanity. However, European and Italian politicians teleguided from overseas indulge in pursuing the opposite direction, exposing us all to the real risk of apocalypse (8,9).

#Pacesubito, #Stopthewarnow!

Dario Dongo and Giulia Pietrollini

Notes

(1) World Health Organization. National stockpiles for radiological and nuclear emergencies, policy advice. 27.1.23. https://www. who.int/publications/i/item/9789240067875, ISBN: 978-92-4-006787-5

(2) Dario Dongo. Nuclear explosions, preparation and vademecum. FT (Food Times). 26.3.22

(3) World Health Organization. Strengthening global preparedness to radiation emergencies https://www.who.int/activities/strengthening-global-preparedness-to-radiation-emergencies

(4) Dario Dongo, Andrea Adelmo Della Penna. Iodine intake in nuclear accidents. FT (Food Times). 9.4.22

(5) WHO (2017). Iodine thyroid blocking. Guidelines for use in planning for and responding to radiological and nuclear emergencies. https://www.who.int/publications/i/item/9789241550185 World Health Organization, Geneva

(6) International Atomic Energy Agency, International Federation of Red Cross and Red Crescent Societies, Pan American Health Organization (2018). Medical management of persons internally contaminated with radionuclides in a nuclear or radiological emergency: A manual for medical personnel. https://www-pub.iaea.org/MTCD/Publications/PDF/ EPR Contamination_web.pdf International Atomic Energy Agency, Vienna

(7) MacVittie TJ, Farese AM, Parker GA, et al. (2019). The Gastrointestinal Subsyndrome of the Acute Radiation Syndrome in Rhesus Macaques: A Systematic Review of the Lethal Dose-response Relationship With and Without Medical Management. Health Phys. Mar;116(3):305-338. doi: 10.1097/HP.0000000000000903.

(8) Benjamin Abelow. How the West Brought War to Ukraine: Understanding How U.S. and NATO Policies Led to Crisis, War, and the Risk of Nuclear Catastrophe. Siland press, 2022. ISBN 0991076702. An excerp on Canadian dimensions https://canadiandimension.com/articles/view/how-the-west-brought-war-to-ukraine

(9) Jürgen Habermas. A Plea for Negotiations. Süddeutsche Zeitung. https://archive.is/2023.02.21-144355/ https://www.sueddeutsche.de/projekte/artikel/kultur/juergen-habermas-ukraine-sz-negotiations-e480179/ 14.2.23