To X-ray or not to X-ray?

Safety campaign reduces medical radiation risks in Africa

When Dr Michael Kawooya, a radiologist at Mengo Hospital in Kampala, Uganda, performs an ultrasonography on pregnant patients he’s often asked, “Doctor, is this dangerous?”
His answer is always “No”.

“Ultrasonographies do not use ionizing radiation, so they aren’t dangerous,” says Dr Kawooya, who is also Director of Ernest Cook Ultrasound Research and Education Institute in Kampala.

Yet many of the procedures his patients do have or ask for, including X-rays, CT-scans and fluoroscopy-guided interventions, do use ionizing radiation. These have the potential to cause cancer and skin injuries, particularly in children. Many referrers, patients and caregivers are unaware of these risks.

“Often patients think that an X-ray is part of a cure without any knowledge of the risks involved,” explains Dr Kawooya. “This is our opportunity to educate them.”

Improving radiation safety

Worldwide, an estimated 3.6 billion diagnostic medical examinations, such as X-rays, are performed every year. This number continues to grow as more people access medical care. About 350 million of these are performed on children under 15 years of age.

“If patients and families are not properly informed about the risks and benefits of an imaging procedure, they may make choices that are more harmful rather than beneficial to their health, such as refusing a CT that is needed or demanding a CT that is not justified,”

Dr Maria del Rosario Perez, scientist with WHO’s Department of Public Health

Using radiation in medical imaging can save lives and prevent the need for more invasive procedures, but inappropriate use may lead to unnecessary and unintended radiation doses for patients. Because children are smaller and have a longer lifespan than adults their risk of developing radiation-induced effects is greater.

“If patients and families are not properly informed about the risks and benefits of an imaging procedure, they may make choices that are more harmful rather than beneficial to their health, such as refusing a CT that is needed or demanding a CT that is not justified,” says Dr Maria del Rosario Perez, a scientist with WHO’s Department of Public Health.

To improve safety WHO launched a Global Initiative on Radiation Safety in Health Care Settings in 2008 with the aim to mobilize the health sector towards safe and effective use of radiation in medicine.
One key priority is to improve the communication of radiation risk in paediatric imaging to ensure an effective and balanced benefit-risk dialogue between health care providers, families and patients.
A new WHO publication, “Communicating radiation risks in paediatric imaging”, helps health-care providers communicate known or potential radiation risks associated with paediatric imaging procedures. The document provides several approaches to help medical professionals answer questions, like “How much radiation will my child receive?” and “How much medical radiation is too much?”

In Uganda, Dr Kawooya and other medical professionals are using the new publication as part of a regional campaign to improve radiation safety and raise awareness to develop national radiation policies and regulations.

A campaign for Africa

In many parts of Africa protecting patients from radiation risks can be a challenge. Radiation guidelines are often inadequate and rarely adhered to. Training for medical professionals is unregulated, and procedures for maintenance, decommissioning and disposal of radiology equipment are not always followed.

In February 2015, the Pan African Congress of Radiology and Imaging launched AFROSAFE, a campaign to ensure all radiation-based medical procedures in Africa are necessary and performed safely. As part of the campaign, medical professionals are learning to conduct risk-benefit discussions about paediatric imaging with patients and families utilizing WHO’s new risk communications tool.

“AFROSAFE is bringing the African medical community together in the struggle to ensure radiation safety,” says Dr Kawooya. “WHO’s new tool will help us create more awareness about the risks associated with radiation exposure, and help use develop communication skills needed to pass on the messages.”
Through AFROSAFE Uganda, Dr Kawooya is teaching doctors and technicians in his country to enhance the safety and quality of radiology. In November 2015, he helped organize the first training session, which was attended by more than 100 Ugandan medical professionals and patient advocates.

On of the training sessions, “To X-ray or not to X-ray,” presented different patient scenarios and asked participants to discuss whether they would refer the patient to medical imaging or not. This scenario reminded medical professionals of the guidelines they should be following to protect all patients.

“We are encouraging radiologists at hospitals throughout Uganda to use referral guidelines when making decisions about using radiation on children and their families,” says Dr Kawooya. “It is our responsibility to help our patients make informed decisions while keeping them safe.”
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The new communication tool will serve as a basis to further develop training packages to improve communication skills of health care workers, as well as advocacy and information materials targeting patients, parents, family members, and the community.
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​Radiation in Medicine: Medical Imaging Procedures

Medical imaging tests are non-invasive procedures that allow doctors to diagnose diseases and injuries without being intrusive. Some of these tests involve exposure to ionizing radiation, which can present risks to patients. However, if patients understand the benefits and risks, they can make the best decisions about choosing a particular medical imaging procedure.
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Most people have had one or more medical imaging tests. Imaging procedures are medical tests that allow doctors to see inside the body in order to diagnose, treat, and monitor health conditions. Doctors often use medical imaging procedures to determine the best treatment options for patients. The type of imaging procedure that your doctor may suggest will depend on your health concern and the part of the body that is being examined. Some common examples of imaging tests include:

• X-rays (including dental x-rays, chest x-rays, spine x-rays)
• CT or CAT (computed tomography) scans
• Fluoroscopy

If your doctor suggests x-rays or other medical imaging tests, you should consider the following:

• Medical imaging tests should be performed only when necessary.
• The U.S. Food and Drug Administration (FDA) recommends discussing the benefits and risks of medical imaging procedures with your doctor.

Benefits and Risks of Medical Imaging Procedures That Use Ionizing Radiation
Medical imaging tests can help doctors:

• Obtain a better view of organs, blood vessels, tissues and bones.
• Determine whether surgery is a good treatment option.
• Guide medical procedures involving placement of catheters, stents, or other devices inside the body, locate tumors for treatment and locate blood clots or other blockages.
• Guide joint replacement options and treatment of fractures.

As in many areas of medicine, there are risks associated with the use of medical imaging which uses ionizing radiation to create images of the body. Risks from exposure to ionizing radiation include:

• A small increase in the likelihood that a person exposed to radiation will develop cancer later in life.
• Health effects that could occur after a large acute exposure to ionizing radiation such as skin reddening and hair loss.
• Possible allergic reactions associated with a contrast dye injected into the veins to better see body structures being examined.

How can you reduce your exposure to diagnostic ionizing radiation?

In the case of x-rays or other tests involving exposure to ionizing radiation, doctors and radiation experts can help reduce your exposure to and risk of harm from diagnostic ionizing radiation by:

• Checking to see if you have had a similar test done recently that can provide them with the background information they need.
• Checking to see if a test that does not use ionizing radiation can provide similar information.
• Making certain the least possible amount of radiation needed to obtain a good quality image is used for your procedure.
• Providing protective lead shielding to prevent exposing other areas of the body to radiation.

What are the risks of medical imaging procedures for pregnant women?

Talk to your physician about the potential risks and benefits from the medical procedures. In many cases, the risk of an x-ray procedure to the mother and the unborn child is very small compared to the benefit of finding out about the medical condition of the mother or the child.

However, small risks should not be taken if they're unnecessary. You can reduce risks from medical imaging procedures by telling your doctor if you are, or think you might be, pregnant whenever an abdominal x-ray is suggested by your doctor. Other options suggested by FDA that may be considered are as follows:

• If you are pregnant, the doctor may decide that it would be best to cancel the medical imaging procedure, to postpone it, or to modify it to reduce the amount of radiation.
• Depending on your medical needs, and realizing that the risk is very small, the doctor may feel that it is best to proceed with using a medical imaging procedure as planned.

In any case, you should feel free to discuss the decision with your doctor. For more information on medical imaging and pregnancy, please see X-rays, Pregnancy and You. Also, for more information on radiation safety in adult medical imaging, please visit the Image Wisely website.

Are there special considerations for children?

It is important that x-rays and other imaging procedures performed on children use the lowest exposure setting needed to obtain a good clinical image. The Image Gently Alliance, part of the Alliance for Radiation in Pediatric Imaging, suggests the following for imaging of children:

• Use imaging examinations when the medical benefit outweighs the risk.
• Use the most appropriate imaging techniques, matched to the size of the child.
• Use alternative imaging methods (such as ultrasound or MRI) when possible.

For more information about medical imaging procedures that do not use ionizing radiation, please see Radiation in Medicine: Medical Imaging Procedures.
 

​X-Rays, Pregnancy and You

Pregnancy is a time to take good care of yourself and your unborn child. Many things are especially important during pregnancy, such as eating right, cutting out cigarettes and alcohol, and being careful about the prescription and over-the-counter drugs you take. Diagnostic x-rays and other medical radiation procedures of the abdominal area also deserve extra attention during pregnancy. This brochure is to help you understand the issues concerning x-ray exposure during pregnancy.

Diagnostic x-rays can give the doctor important and even life-saving information about a person's medical condition.  But like many things, diagnostic x-rays have risks as well as benefits. They should be used only when they will give the doctor information needed to treat you.

You'll probably never need an abdominal x-ray during pregnancy. But sometimes, because of a particular medical condition, your physician may feel that a diagnostic x-ray of your abdomen or lower torso is needed. If this should happen - don't be upset. The risk to you and your unborn child is very small, and the benefit of finding out about your medical condition is far greater. In fact, the risk of not having a needed x-ray could be much greater than the risk from the radiation. But even small risks should not be taken if they're unnecessary.

You can reduce those risks by telling your doctor if you are, or think you might be, pregnant whenever an abdominal x-ray is prescribed. If you are pregnant, the doctor may decide that it would be best to cancel the x-ray examination, to postpone it, or to modify it to reduce the amount of radiation. Or, depending on your medical needs, and realizing that the risk is very small, the doctor may feel that it is best to proceed with the x-ray as planned.   In any case, you should feel free to discuss the decision with your doctor.

What Kind of X-Rays Can Affect the Unborn Child?

During most x-ray examinations - like those of the arms, legs, head, teeth, or chest - your reproductive organs are not exposed to the direct x-ray beam. So these kinds of procedures, when properly done, do not involve any risk to the unborn child. However, x-rays of the mother's lower torso - abdomen, stomach, pelvis, lower back, or kidneys - may expose the unborn child to the direct x-ray beam. They are of more concern. 

What Are the Possible Effects of X-Rays?

There is scientific disagreement about whether the small amounts of radiation used in diagnostic radiology can actually harm the unborn child, but it is known that the unborn child is very sensitive to the effects of things like radiation, certain drugs, excess alcohol, and infection. This is true, in part, because the cells are rapidly dividing and growing into specialized cells and tissues. If radiation or other agents were to cause changes in these cells, there could be a slightly increased chance of birth defects or certain illnesses, such as leukemia, later in life.

It should be pointed out, however, that the majority of birth defects and childhood diseases occur even if the mother is not exposed to any known harmful agent during pregnancy. Scientists believe that heredity and random errors in the developmental process are responsible for most of these problems.

What If I'm X-Rayed Before I Know I'm Pregnant?

Don't be alarmed. Remember that the possibility of any harm to you and your unborn child from an x-ray is very small. There are, however, rare situations in which a woman who is unaware of her pregnancy may receive a very large number of abdominal x-rays over a short period. Or she may receive radiation treatment of the lower torso. Under these circumstances, the woman should discuss the possible risks with her doctor.
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How You Can Help Minimize the Risks

• Most important, tell your physician if you are pregnant or think you might be. This is important for many medical decisions, such as drug prescriptions and nuclear medicine procedures, as well as x-rays. And remember, this is true even in the very early weeks of pregnancy.
• Occasionally, a woman may mistake the symptoms of pregnancy for the symptoms of a disease. If you have any of the symptoms of pregnancy - nausea, vomiting, breast tenderness, fatigue - consider whether you might be pregnant and tell your doctor or x-ray technologist (the person doing the examination) before having an x-ray of the lower torso. A pregnancy test may be called for.
• If you are pregnant, or think you might be, do not hold a child who is being x-rayed. If you are not pregnant and you are asked to hold a child during an x-ray, be sure to ask for a lead apron to protect your reproductive organs. This is to prevent damage to your genes that could be passed on and cause harmful effects in your future descendants.
• Whenever an x-ray is requested, tell your doctor about any similar x-rays you have had recently. It may not be necessary to do another. It is a good idea to keep a record of the x-ray examinations you and your family have had taken so you can provide this kind of information accurately.
• Feel free to talk with your doctor about the need for an x-ray examination. You should understand the reason x-rays are requested in your particular case.

​Sources:  Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO)  

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