Managing Terrorism or Accidental Nuclear Errors, Preparing for Iodine-131 Emergencies: A Comprehensive Review
2. Review and Recommendations
KI Agency Recommendations
3. Potassium Iodide Prophylaxis Review
3.1. Potassium Iodide Prophylactic Historical Success
3.2. Potassium Iodide Prophylaxis—Lowest Effective Prophylactic Dose
|Time of KI prophylaxis||Effectiveness|
|96 h before radioiodine exposure||5%|
|72 h before radioiodine exposure||32%|
|48 h before radioiodine exposure||75%|
|24 h before radioiodine exposure||93%|
|At radioiodine exposure||99%|
|1–2 h after radioiodine exposure||85%–90%|
|3–4 h after radioiodine exposure||50%|
|8 h after radioiodine exposure||40%|
|24 h after radioiodine exposure||7%|
|Age Group||Individual Weight||KI Dosage||Number of KI 15 mg Tablets|
|Adults over 18 years||> 200 lbs||45 mg||3|
|Between 12–18 years||> 200 lbs||45 mg||3|
|Adults over 18 years||100–200 lbs||30 mg||2|
|Between 12–18 years||100–200 lbs||30 mg||2|
|Between 3–12 years||100–200 lbs||30 mg||2|
|Between 12–18 years||50–100 lbs||15 mg||1|
|Between 3–12 years||50–100 lbs||15 mg||1|
|Between 3–12 years||< 50 lbs||7.5 mg||½|
|Birth to 3 years||< 50 lbs||7.5 mg||½|
|Pregnant or lactating||-||45 mg||3|
3.3. Iodine-131 Biological and Physical Analysis
3.4. Shelf-Life of Potassium Iodide
3.5. Potential Use of Food for Iodine Prophylaxis
|Food||Iodine Concentration||Food||Iodine Concentration|
|Kelp Flakes *||13 mg/tsp||Iodized Table Salt||0.3 mg/tsp|
|Kombu Seaweed *||4 mg/tsp||Fish Sticks||0.2 mg/6 fish sticks|
|Laminaria Kelp *||3 mg/tsp||Shrimp||0.2 mg/lb|
|Hijiki *||0.5 mg/gram||Baked Turkey Breast||0.2 mg/lb|
|Himalayan Crystal Salt||2 mg/tsp||Plain Yoghurt||0.15 mg/lb|
|Life-flo Liquid Plus||1 mg/20 drops||Canned Tuna||0.1 mg/lb|
|Cod or Haddock||0.5 mg/lb||Navy Beans||0.1 mg/cup|
|Lobster||0.45 mg/lb||Baked Potato||0.1 mg/med. Potato|
3.6. Iodine Deficiency and Dietary Iodine
3.7. Side Effects of KI Prophylaxis
4. KI Distribution Review
4.1. KI Pre-Distribution and Radiological Plumes
4.2. Meteorological Conditions and Plume Size
4.3. Iodine 131 Dispersal Methods
4.4. Iodine 131 Historical Radiological Exposures
|Total Estimated Amount of 131I Released from the Site (Ci)||Total Estimated 131I Release from Site (PBq)||Site of Event||Time Period|
|6,300,000,000||233,100||Marshall Islands Nuclear Testing Program||1946–1958|
|150,000,000||5,550||Nevada Test Site, Nevada||1952–1970|
|50,000,000||1,850||Chernobyl (former Soviet Union)||1986|
|740,000||27.38||Hanford Reservation, Washington||1944–1972|
|60,000||2.22||Savannah River Site, South Carolina||1955–1990|
|8,000 – 42,000||0.296 – 1.554||Oak Ridge National Laboratory, Tennessee||1944–1956|
|20,000||0.74||Windscale, United Kingdom||1957|
|15 – 21||5.55 × 10-4 – 7.77 × 10-4||Three Mile Island, Pennsylvania||1979|
5. Iodine 131 Physiology, Health, and Therapeutics
5.1. Iodine 131 Routes to Exposure
5.2. Iodine 131 Field Detection Methods
5.3. Radiation Phobias and Psychological Effects
5.4. Federal and State Emergency Preparedness Plans
|Governmental Body/Agency||Distribution Recommended||Pre-Distribution Recommended||Pre-Distribution Effectiveness||Pre-Distribution Distance||KI Dose|
|United States of America||Yes||Yes||N/A||20 miles||FDA-Endorse|
|New Jersey State||Yes||Yes at public education & Distribution sessions||~10%||10 miles EPZ||FDA-Endorse|
|New York State||Yes||Distribution by county; Pick-up locations; Via mail||15% in EPZ||Offered KI regardless of distance||FDA-Endorse|
|World Health Organization||Yes||Yes||N/A||N/A||N/A|
|United States Nuclear Regulatory Commission||Yes||Yes||N/A||10 miles radius||FDA-Endorse|
|American Thyroid Association||Yes||Yes||N/A||50 miles Pre-Distribution; 50–200 miles Stockpile Local Public Facilities; >200 miles National stockpile||FDA-Endorse|
|Food and Drug Agency||Yes||Yes||N/A||10 miles radius of USNRC mentioned|
|Centers for Disease Control and Prevention||N/A||N/A||N/A||Public health or Emergency managers to decide||FDA-Endorse|
|Federal Emergenct Management Agency||Yes||Yes||N/A||10 miles radius||FDA-Endorse|
5.5. Iodine 131 Industrial Usage
|United States of America||100||Sweden||10||Bulgaria||2|
|Republic of Korea||23||Chech Republic||6||Argentina||2|
5.6. Health Effects and Medical/Therapeutic Use
5.7. Iodine 131 Medical Dosage and Public Legal Limit
5.8. Iodine-131 Exposure Side Effects and Condition Co-Morbidities
|Transient (high dose)||Radiation sickness (nausea, vomiting, fatigue)|
|Hypersensitivity or allergic reactions (extremely rare)|
|Sialadenitis (pain and swelling of salivary glands)|
|Loss of taste|
|Radiation-induced thyroiditis (swelling and tenderness in the neck)|
|Bone marrow suppression (platelet count most sensitive)|
|Decreased sperm count (can last up to 6 months)|
|Chromosomal abnormalities in circulating lymphocytes|
|Permanent (high dose)||Dry mouth (due to decreased production of saliva)|
|Excessive tearing (due to fibrosis of tear ducts)|
|Infertility – rare even with very large cumulative doses of 131I|
|Bone marrow suppression (anemia, leukopenia, thrombocytopenia)|
|Pulmonary fibrosis (only in patients with diffuse lung uptake)|
|Leukemia and other secondary cancers|
5.9. Post Iodine 131 Exposure Patient Precautions
6. Future Perspectives
6.1. Iodine 131 Potential in a Dirty Bomb
6.2. Worldwide Iodine Deficiency
|Moderate Iodine Deficient Nations||Mild Iodine Deficient Nations|
|(Median Urinary Iodine Concentrations 20–49 μg/L)||(Median Urinary Iodine Moderate, 50–99μg/L)|
|Central African Republic||Democratic People’s Republic of Korea|
|Papua New Guinea||Haiti|
|Life Stage (Age)||Recommended Daily Dietary Iodine Allowance|
|Infancy (Birth to 6 months)||110 mcg|
|Infancy (7 to 12 months)||130 mcg|
|Childhood (1 to 8 years)||90 mcg|
|Preteen (9 to 13 years)||120 mcg|
|Teens and Adults (14+ years)||150 mcg|
|Pregnant Adults||220 mcg *|
|Lactacting Adults||290 mcg *|
7. Our Recommendations Based on This Review
7.1. Potassium Iodide Prophylaxis is Effective and Necessary
7.2. The Effectiveness of KI Prophylaxis is Lost if Administration is Delayed
7.3. Extension of the Thyroid Disease Risk Area to Exceed 300 Miles
7.4. Reduce Costs of Stable Iodide Prophylaxis to Extended Thyroid Disease Risk Area
7.5. Give Information and Clear Instructions
7.6. Facilitate Good Nutrition in Populations with Iodine Deficiency
7.7. Avoidance of Exposure Is No Longer an Adequate Response to a Nuclear Event
7.8. Plan for Swift Access to Radiation Isotope Identification Device (RIID)
- 131I, a primary byproduct of uranium-235 fission, is released from nuclear accidents and can be released in the event of a dirty bomb.
- Radiological plumes containing 131I cause benign and malignant thyroid nodules to develop within a 300 mile radius ; radiological plumes travel at an average speed of 10 mph.
- Two billion people are at risk for IDD the world’s leading cause of preventable brain damage . Iodine deficiency disorder causes learning disabilities, cretinism and psychomotor impairment and can also result in IQ decreases of 10 to 15 points [119,120,121,122]. Importantly, iodine deficiencies predispose people to harmful effects of 131I exposure [17,21].
- Potassium iodide blocks the uptake of 131I by the thyroid. Ideally KI should be taken within two hours of 131I exposure to be effective. Prophylaxis is most successful if administered at the time of or just prior to exposure: 98%–99% effective. 1–2 h following exposure, prophylaxis with KI can be up to 85%–90% effective in blocking radioiodine.
- Potassium iodide prophylactic dosages should be based on the principles of a lowest effective prophylactic; dependent on a 15 mg, 7.5 mg scored, KI tablet; the rule of thumb is 1–2 mg KI per 10 lbs in weight. For euthyroid 150 lb adults 10 mg of stable iodine taken at radioiodine exposure is 87%–88% effective in blocking radioiodine and 30 mg of stable iodine is 98%–99% effective in blocking radioiodine .
- Seaweed, especially kelp, is the only alimentary alternative for prophylaxis; an associated limitation is the high variability in the iodine content of kelp. Studies of the pharmacokinetics of kelp could be investigated to accurately assess kelp as an alternative in prophylaxis. Interestingly, 131I uptake is reduced when the supply of alimentary iodine is increased [21,34,35,36].
- Pre-distribution of KI is necessary within 50 miles of any potential nuclear accident, and thyroid cancer risk areas extend 300 miles for children. This necessitates KI pre-distribution to all schools, hospitals and other of-interest sites extending 300 miles from any nuclear reactor. Evacuation or sequestering is impossible in congested urban areas. Evacuation protocols such as the plan recommended by the NYS Indian Point nuclear power plant do not extend past emergency planning zones and thus do not effectively address emergency procedures at distances exceeding 20 miles . There is currently virtually no compliance with Senator Markey’s 20 miles radius KI pre-distribution law, section 127 of the Bioterrorism Act of 2002. In fact, there is little compliance with the 10 miles Ki pre-distribution radius law in the United States. Current dosage regimens are contributing to the failures to comply.
- Children, pregnant or lactating women, and people with iodine deficiencies are most vulnerable groups to the effects of radioiodine exposure. The best preparation for radiological emergencies is maintaining iodine sufficiency. By improving national and global iodine sufficiency, thyroid health as measured in thyroid nodule prevalence may be improved, and people will effectively mitigate vulnerability to radiation exposures. Iodine deficiency has been implicated as increasing the risk for the development of certain cancers: including breast, endometrial, ovarian, prostate, stomach, thyroid and uterus cancer [134,135,136]. Iodine sufficiency beyond adequacy would have the additional benefit of mitigating risk for the development of certain cancers, especially breast cancer. Iodine adequacy beyond sufficiency may provide protection against various diseases (i.e., Iodine prophylaxis at higher iodine intake levels protects against radiation exposures). This same effect also occurs with other nutrients; for example, niacin sufficiency protects against pellagra, but only high doses beyond sufficiency can adequately lower cholesterol . Nutritionally, some patients have iodide sufficiency, some are insufficient, and ultimately, iodide adequacy is measured by specific disease and radiation side effect prevention.
- Fast food and pre-prepared food industries can utilize iodized salt to help mitigate iodine deficiencies in at-risk regions. A country that is well iodized has additional thyroid reserves against thyroid radiation. An average euthyroid person contains 15–20 mg of iodine in their bodies, with ~75% aggregating in their thyroids ; the maximum iodine a thyroid can hold is upwards of 50 mg of iodine . Higher thyroidal iodine content provides protection against radioiodine exposure.
- Following the Chernobyl nuclear accident, Poland utilizes KI in prophylaxis, reducing the estimated thyroid exposure by 40% in those distributed KI within 24 h . Japan did not utilize KI for prophylaxis of the general public, acknowledging it was not prepared to act accordingly . In the Polish radiological response to Chernobyl, a bolus dose of stable iodine was distributed to the 11 most effected regions; 15 mg KI was administered to newborns, 50 mg KI was given to children under 5 years of age, and 70 mg KI was distributed to all other age groups . Without considering digestive adsorption issues; individual metabolic rates via the P450 drug metabolizing system; epigenetic effects; DNA polymorphic traits and other conditions, the above bolus dosage extrapolated for a week could result in as little as 2 mg KI/day for newborns, 7 mg KI/day for children 5 and under, and 10 mg KI/day for all other age groups. Single doses were advised by the authorities and multiple doses were not recommended . Remarkably, this recommendation was effective . A low dose, prolonged daily prophylaxis is well established and effective. Maintenance with lower dosages of KI is more effective in long-term thyroid dose aversion than large single doses . In consideration with this recommendation, a 15 mg KI tablet would work for newborns. Approximately 6% of the Polish prophylaxis occurred prior to the decision to distribute KI to the public, through panic-driven, self-administering of iodine tincture . Such occurrences necessitate improved education. It is very unlikely in a sophisticated U.S. population that individuals will trust a single dose to be effective for a prolonged period.
- There are 23 nuclear reactors with the same design as the Fukushima Dai-ichi nuclear power plant operating in the USA, 100 total operating nuclear power plants in the United States and 428 globally . There is an inevitable and inherent risk that an accident to occur.
- Dosages as low as 20 mg KI, when administered at the time of radioiodine exposure, are 90% effective in blocking radioiodine intake . Dosages of 1.8 mg KI in ~50 lb euthyroid children was up to 48% effective in thyroidal blockage, and dosages of 4.2 mg KI in euthyroid young adults was up to 69% effective in blocking radioiodine uptake . Additional research should be conducted in infants, children and adolescents.
- The instructions of current KI prophylactic labels are unclear and may lead to over-dosing. Pro-KI, a 65 mg KI supplement for radiation protection, states that its protective effect lasts only ~24 h . In instances of prolonged exposure risk, individuals will continue to take the high dosage KI supplements, which will increase the side effects from prophylaxis while not significantly increasing efficacy in thyroid blockage. Labels need to be made clear and accurate.
Conflicts of Interest
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|No underlying thyroid disease||Underlying thyroid disease||Other|
|Fetus and neonate, mostly preterm: Secondary to transplacental passage of iodine or exposure of neonate to topical or parenteral iodine-rich substances;|
Infant: Occasionally reported in infants drinking iodine-rich water (China);
Adult: In Japanese subjects with high iodine intake where Hashimoto’s thyroiditis has been excluded;
Elderly: Reported in elderly subjects with and without possible defective organification and autoimmune thyroiditis;
Chronic nonthyroidal illness: Cystic fibrosis; Chronic lung disease (including Hashimoto’s thyroiditis); Chronic dialysis treatment; Thalassemia major; Anorexia nervosa.
|All ages: Hashimoto’s thyroiditis; |
Euthyroid patients previously treated for Graves disease with 131I, thyroidectomy, or antithyroid drugs;
After transient postpartum thyroiditis;
After subacute painful thyroiditis;
After hemithyroidectomy for benign nodules.
Elderly: subclinical hypothyroidism.
|All ages: Euthyroid patients with a previous episode of amiodarone-induced destructive thyrotoxicosis; |
Euthyroid patients with a previous episode of interferon-alpha-induced thyroid disorders;
Patients receiving lithium therapy.
|Life Stage||Underlying thyroid disease||No underlying thyroid disease|
|All ages||Iodine supplementation for endemic iodine-deficiency goiter; Iodine administration to patients with euthyroid Graves disease, especially those in remission after antithyroid drug therapy; Nontoxic nodular goiter; Autonomous nodules; Nontoxic diffuse goiter.||Iodine administration to patients with no recognized underlying thyroid disease, especially in areas of mild to moderate iodine|
|The curie (Ci) is replaced by the becquerel (Bq)||Becquerel (Bq) replaces the curie (Ci)|
|Unit||Unit Conversion||Unit||Unit Conversion|
|1 kilocurie (kCi) =||37 terabecquerel (TBq)||1 terabecquerel (TBq) =||~ 27 curie (Ci)|
|1 curie (Ci) =||37 gigabecquerel (GBq)||1 gigabecquerel (GBq) =||~ 27 millicurie (mCi)|
|1 millicurie (mCi) =||37 megabecquerel (MBq)||1 megabecquerel (MBq) =||~ 27 microcurie (µCi)|
|1 microcurie (µCi) =||37 kilobecquerel (kBq)||1 kilobecquerel (kBq) =||~ 27 nanocurie (nCi)|
|1 nanocurie (nCi) =||37 becquerel (Bq)||1 becquerel (Bq) =||~ 27 picocurie (pCi)|
|1 picocurie (pCi) =||37 millibecquerel (mBq)||1 becquerel (Bq) =||1s-1|
|The rad (rad) is replaced by the gray (Gy)||The gray (Gy) replaces the rad (rad)|
|Unit||Unit Conversion||Unit||Unit Conversion|
|1 kilorad (krad) =||10 gray (Gy)||1 gray (Gy) =||100 rad (rad)|
|1 rad (rad) =||10 milligray (mGy)||1 milligray (mGy) =||100 millirad (mrad)|
|1 millirad (mrad) =||10 microgray (µGy)||1 microgray (µGy) =||100 microrad (µrad)|
|1 microrad (µrad) =||10 nanogray (nGy)||1 nanogray (nGy) =||100 nanorad (nrad)|
|The roentgen (R) is replaced by coulomb/kg (C/kg)||Coulomb/kg (C/kg) replaces the roentgen (R)|
|Unit||Unit Conversion||Unit||Unit Conversion|
|1 kiloroentgen (kR) =||~ 258 millicoulomb/kg (mC/kg)||1 coulomb/kg (C/kg) =||~ 3,876 roentgen (R)|
|1 roentgen (R) =||~ 258 microcoulomb/kg (µC/kg)||1 millicoulomb/kg (mC/kg) =||~ 3,876 milliroentgen (mR)|
|1 milliroentgen (mR) =||~ 258 nanocoulomb/kg (nC/kg)||1 microcoulomb/kg (µC/kg) =||~ 3,876 microroentgen (µR)|
|1 microroentgen (µR) =||~ 258 picocoulomb/kg (pC/kg)||1 nanocoulomb/kg (nC/kg) =||~ 3,876 nanoroentgen (nR)|
|The rem (rem) is replaced by the sievert (Sv)||The sievert (Sv) replaces the rem (rem)|
|Unit||Unit Conversion||Unit||Unit Conversion|
|1 kilorem (krem) =||10 sievert (Sv)||1 sievert (Sv) =||100 rem (rem)|
|1 rem (rem) =||10 millisievert (mSv)||1 millisievert (mSv) =||100 millirem (mrem)|
|1 millirem (mrem) =||10 microsievert (µSv)||1 microsievert (µSv) =||100 microrem (µrem)|
|1 microrem (µrem) =||10 nanosievert (nSv)||1 nanosievert (nSv) =||100 nanorem (nrem)|
|Radiation Measurement Unit||Definition||Measurement of Absorption or Emission|
|Rem (rem)||Measures biological effects of radiation absorbed by a non-radioactive substance||Absorption|
|Sievert (Sv)||Measures biological effects of radiation absorbed by a non-radioactive substance||Absorption|
|Gray (Gy)||Measures dose of radiation absorbed by a non-radioactive substance||Absorption|
|Rad (rad)||Measures dose of radiation absorbed by a non-radioactive substance||Absorption|
|Becquerel (Bq)||The level of radioactivity in a radioactive substance (radiation emitted)||Emission|
|Life Stage||Median urinary iodine (µg/L)||Status of Iodine Intake|
|Life Stage||Median urinary iodine (µg/L)||Status of Iodine Intake|
|Child (6–17 years old)||<20||Severely insufficient|
|Child (6–17 years old)||20–49||Moderately insufficient|
|Child (6–17 years old)||50–99||Mildly insufficient|
|Child (6–17 years old)||100–199||Adequate|
|Child (6–17 years old)||200–299||Above normal|
|Child (6–17 years old)||≥300||Excessive|
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Braverman, E.R.; Blum, K.; Loeffke, B.; Baker, R.; Kreuk, F.; Yang, S.P.; Hurley, J.R. Managing Terrorism or Accidental Nuclear Errors, Preparing for Iodine-131 Emergencies: A Comprehensive Review. Int. J. Environ. Res. Public Health 2014, 11, 4158-4200. https://doi.org/10.3390/ijerph110404158
Braverman ER, Blum K, Loeffke B, Baker R, Kreuk F, Yang SP, Hurley JR. Managing Terrorism or Accidental Nuclear Errors, Preparing for Iodine-131 Emergencies: A Comprehensive Review. International Journal of Environmental Research and Public Health. 2014; 11(4):4158-4200. https://doi.org/10.3390/ijerph110404158Chicago/Turabian Style
Braverman, Eric R., Kenneth Blum, Bernard Loeffke, Robert Baker, Florian Kreuk, Samantha Peiling Yang, and James R. Hurley. 2014. "Managing Terrorism or Accidental Nuclear Errors, Preparing for Iodine-131 Emergencies: A Comprehensive Review" International Journal of Environmental Research and Public Health 11, no. 4: 4158-4200. https://doi.org/10.3390/ijerph110404158