Radiological protection in medical exposure

Medical uses of radiation sources in Tajikistan include 1828 diagnostic X-ray devices (150 not operational), one Co-60 radiotherapy unit, one Co-60 brachytherapy after-loader, and one gamma-camera within a nuclear medicine department. A register of all radiation sources is held by the NRSA.

Laws and Regulations related to radiological protection in medical exposure have been drafted with the help of the IAEA and NRPA (DSA) experts to be in conformity with IAEA Safety Standards. Drafts of regulations related to medical exposure (diagnostic radiology, interventional radiology, nuclear medicine and radiotherapy), as well as on education and training for radiation protection of patients and medical physicist’s education and training are due to be finalized. Codes of Practice have been issued for both X-ray diagnostics and radiotherapy and a code of practice for nuclear medicine is under development.

Licensing, inspection and enforcement activities are in place in compliance with IAEA recommendations.

Qualified experts are available in the field of medical physics (diagnostic radiology) and radiotherapy to implement radiation protection programs and medical and paramedical staff receive appropriate radiation protection training. A formal procedure is in place for recognizing qualified experts in medical physics.

In order to establish systematic training program for medical physicists, medical and paramedical personnel performing radiotherapy procedures, a national project was implemented TAD/0/003

"Establishing a National Educational and Training Centre on Radiation Protection". The aim of the project was to establish a National Educational and Training Centre on Radiation Protection for the development of sufficient human resources to strengthen the radiation safety and radiation protection infrastructure in Tajikistan. Three national courses have already been held on train-the-trainers. Instructors and lecturers for this training center were trained through IAEA fellowships.

A national strategy for education and training in the field of radiation safety has been elaborated and agreed with all ministries and authorities and is currently in the Parliament of the Republic of Tajikistan for approval. A set of legal documents on education and training in the field of radiation safety and security have also been elaborated. A training syllabus has been developed on Radiation Protection for systematic training of qualified experts in diagnostic radiology. A training syllabus for appropriate medical physicists, medical and paramedical personnel performing radiotherapy procedures has also been elaborated which is in full compliance with IAEA standards. The center also promotes awareness about the potential for radiation injuries in interventional procedures using X-rays. Master’s degree courses on radiation safety have also been introduced that cover topics related to medical exposure and an annual syllabus for training students from medical universities, radiation workers and RPOs has been developed. There are also short-term courses focused on physicians performing interventional procedures and refresher training for medical physicists in diagnostic radiology is provided. Medical physicists are also regularly trained through the IAEA regional training events related to medical exposure. Special training software was installed at the training center in 2017 by experts from Belarus State University that enables the knowledge of the students and physicians undertaking training to be evaluated and an appraisal of the training infrastructure was undertaken as part of an IAEA EduTA mission in 2018.

Two new IAEA National Projects have been implemented and submitted:

 TAD/6/006 "Providing Radiotherapy Services in the Sugd Regional Cancer Centre" for 2014-2015 with further extension to 2017

 A new project concept for 2018-2021 cycles "Upgrading Capabilities of the Central and Northern Oncology Centers in Tajikistan".

The objectives of these projects are to upgrade radiotherapy and brachytherapy services, particularly in the Sugd region of northern Tajikistan through the provision of modern equipment, training and expert advice on relevant technical and clinical aspects, and to establish a regional radiotherapy service in the north and strengthen the capacity of the central radiotherapy service in Tajikistan. Through these projects’ oncologists, technologists and medical physicists of both centers have been trained.

OPTIMIZATION IN DIAGNOSTIC RADIOLOGY

Reject/retake analysis in diagnostic radiology facilities and measurement of patient doses are governed by Rules of Ensuring Radiation Safety (PORB-08) [4], specifically chapter 3 "Radiation protection of patients and population during medical exposure". However, not all hospitals have the necessary infrastructure for monitoring patient doses to be in compliance with this legislation.

Diagnostic Reference Levels (DRLs) have been adopted but, due to the fact that the X-ray apparatus used in all hospitals is too old, it has not been possible to implement the DRLs. Currently activities are ongoing to monitor the average doses released by all X-ray apparatus in the country and to issue new average DRLs based on these data. The new DRL values will be reflected in new Norms of Radiation Safety.

In accordance with Appendix 10 of “hygienic requirements to facilities and operation of X-ray rooms, apparatus and carrying out X-ray examinations” (No. 257), registered in the Ministry of Justice from 16 April 2007, and “requirements for carrying out quality control in medical X-ray diagnostics” (No. 573), registered in the Ministry of Justice from 23 April 2010, surveys on image quality is an obligation of users which should be fulfilled. Diagnostic radiology quality assurance services are provided by different companies, including NRSA's Technical Services Department that regulated licensees can make use of.

The format and content of quality assurance programs are regulated by the above-mentioned documents and regulated by NRSA's inspection checklists. Common protocols have been adopted and introduced.

Earth screens are primarily only used in private hospitals since there is limited budget available for providing rare earth screens to governmental hospitals. However, some screens are provided to governmental hospitals by support of international donors. With the use of rate earth screens being primarily by private companies, doses have not been confirmed although from the limited use in governmental hospitals doses appear to be reduced by changing to rare earth screens for diagnostic radiology.

OPTIMIZATION IN RADIOGRAPHY, FLUOROSCOPY, MAMMOGRAPHY, COMPUTED TOMOGRAPHY (CT) AND INTERVENTIONAL PROCEDURES USING X-RAYS

Some digital radiography units delivered by private companies have started to operate under license. Old direct-viewing fluoroscopic units are no longer used in Tajikistan; fluoroscopic units are used only with X-ray image amplifiers. There are four modern mammography units in the country, as well as 40 CT units (in 2019), most of which are modern. Special low dose protocols haven't been introduced for CT units, but special protocols for pediatric examinations have been developed and introduced. Four interventional X-ray units are also present in the country that, with support from the IAEA, have dose monitors installed.

All the requirements and provisions stated in the hygienic requirements to facilities and operation of X-ray rooms, apparatus and carrying out X-ray examinations (No. 257) and the requirements for carrying out quality control in medical X-ray diagnostics (No. 573) are applied to digital radiography, fluoroscopic, mammography, CT and interventional procedures using X-rays. The requirements ensure optimization in each field. The format and content of quality assurance programs are also regulated by these

requirements and are regulated by NRSA's inspection checklists. Common protocols have been adopted and introduced.

The TSO to NRSA provides technical services to users which covers also quality control and quality assurance programs for fluoroscopic systems, mammography and CT. Regulated licensees make use of these services on a regular basis to fulfil their obligations under the requirements for carrying out quality control in medical X-ray diagnostics (No. 573), which are in full compliance with IAEA standards.

Currently there is no program approved by the Ministry of Health on changing old fluoroscopic units and other X-ray apparatus to new ones. Delivery of new units is taking place mostly in private hospitals. Some

funds have been allocated from the State budget to change old units, but mostly this occurs through international donors.

OPTIMIZATION IN NUCLEAR MEDICINE AND RADIOTHERAPY

There is only one nuclear medicine department for the whole of Tajikistan, which is under the Institute of Gastroenterology of the Ministry of Health. There is also only one oncology center with a radiotherapy unit separate from nuclear medicine center, which is in Dushanbe. Under the IAEA national project TAD/6/003

"Upgrading Radiotherapy Services at the Republican Clinical Centre of Oncology", the center was

upgraded to provide radiotherapy services for the treatment of cancer at the Republican Clinical Centre of Oncology (RCCO). The radiotherapy unit is staffed by qualified experts that are available to implement radiation protection programs, and appropriately qualified medical and paramedical staff with appropriate radiation protection training. All staff of the radiotherapy unit have been trained via several IAEA training courses, fellowships and scientific visits and continue to refresh their knowledge by means of IAEA regional training courses, workshops and attendance in technical meetings. RCCO's staff have, to date, undertaken 11 fellowships and 1 scientific visit in very experienced hospitals in Europe.

There are no companies in Tajikistan for the maintenance and servicing of nuclear medicine/radiotherapy equipment and radiation measuring instruments of regulated licensees are not calibrated by an accredited organization.

Protocols for calibration and radiation protection quality assurance programs in the nuclear medicine facility and for optimization of radiation protection in nuclear medicine are under elaboration. The protocols are fully completed and have been checked by IAEA experts although approval is pending since Law 42 [1] is currently under revision in order to bring it in full compliance with IAEA GSR Part 3 [10].

National procedures require that the Law should be approved first and, based on the Law provisions, the secondary legislation will be approved.

Guidance levels for radiopharmaceutical activities have been adopted from the BSS [10] and checked by NRSA's inspectors. Guidelines for the release of patients after radionuclide therapy are being developed, but meanwhile the Nuclear Medicine Department is making use of IAEA standards since this department was established by IAEA project TAD/6/002 "Upgrading Nuclear Medicine Services". This project helped improve the technical capabilities of the Institute of Gastroenterology in providing nuclear medicine for better patient care and treatment and currently they are making use of all IAEA standards in their area, despite of the fact that there are no requirements issued by NRSA.

Mechanisms for reporting the misadministration of therapeutic amounts of radiopharmaceuticals and for reporting accidental medical exposures in radiotherapy are under elaboration.