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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Radon has been a declared lung carcinogen since 1988&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> The seminal paper by Darby et al&#46; showed a dose&#8211;response effect between indoor radon and lung cancer &#40;LC&#41; risk&#44; where each 100<span class="elsevierStyleHsp" style=""></span>Bq&#47;m<span class="elsevierStyleSup">3</span> increase of radon concentration at home increased LC risk by 16&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> This dose&#8211;response effect is present both in ever-smokers and in never smokers&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> Following Darby et al&#46; study&#44; the WHO recommended a target reference level of 100<span class="elsevierStyleHsp" style=""></span>Bq&#47;m<span class="elsevierStyleSup">3</span> with a threshold of 300<span class="elsevierStyleHsp" style=""></span>Bq&#47;m<span class="elsevierStyleSup">3</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> This recommendation was implemented by the European Union &#40;EU&#41; Directive published in 2014&#44; establishing a maximum reference level of 300<span class="elsevierStyleHsp" style=""></span>Bq&#47;m<span class="elsevierStyleSup">3</span> for dwellings and workplaces&#44; to be applied by member states before February 2018&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In December 2022&#44; Spain fully applied this EU directive to its national by-laws on ionizing radiation protection&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> and it shall be enforced as of June 2024&#44; when all underground and ground floor workplaces located in designated radon-priority municipalities<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> have to be measured&#46; If radon concentration exceeds 300<span class="elsevierStyleHsp" style=""></span>Bq&#47;m<span class="elsevierStyleSup">3</span> these workplaces will have to be duly remediated&#46; These workplaces include many belonging to the health sector&#44; e&#46;g&#46; hospitals or primary care facilities&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">To date&#44; thousands of workers in Spain have been exposed to excessive radon concentrations in their workplace&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> but the impact of such exposure on the excess mortality of LC is unknown&#46; The International Commission of Radiological Protection &#40;ICRP&#41; considers that 300<span class="elsevierStyleHsp" style=""></span>Bq&#47;m<span class="elsevierStyleSup">3</span> of radon concentration at home leads to an annual effective dose of 14<span class="elsevierStyleHsp" style=""></span>mSv&#44; whereas the same concentration at work leads to an annual effective dose of 4<span class="elsevierStyleHsp" style=""></span>mSv&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Complying with the current regulation is the starting point for health surveillance of radon exposed workers&#46; If workers reach 6<span class="elsevierStyleHsp" style=""></span>mSv or more annually&#44; they have to be classified as exposed workers and employers are obliged to perform active dose surveillance&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Apart from LC&#44; there is no other disease causally linked to radon&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> The existing health surveillance protocol for ionizing radiation has a broad scope covering an extensive number of organs&#44; and its section on the respiratory tract is insufficient for LC prevention or early diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> According to the Spanish regulation&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> medical surveillance should be applicable to radon exposed workers when indicated by a health professional&#46; Nevertheless&#44; there is no specific surveillance protocol applicable to radon exposed workers&#46; Therefore&#44; the questions are&#58; what kind of medical surveillance should be performed and what should be the eligibility criteria for it&#63;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Currently&#44; there is no specific protocol for the health surveillance of workers exposed to radon in any European country&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> In France&#44; a pilot study is evaluating the applicability of an occupational LC screening with low dose computed tomography &#40;LDCT&#41; in which radon exposed workers are eligible&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> Should we use lung cancer screening with LDCT&#63; Should we add more ionizing radiation to an individual already exposed to a high amount of such radiation at work&#63; LDCT might be considered only in those cases where the risk&#8211;benefit balance is both reasonable and acceptable&#46; We cannot forget that currently proposed screening recommendations only refer to ever-smokers and that there is no evidence on the use of such screening on radon-exposed individuals&#46; Alternatively&#44; the use of a chest X-ray might be a good alternative in these cases&#46; This surveillance should also include an assessment of LC symptoms and tobacco cessation counseling in the case of current smokers&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> proposes some eligibility criteria for medical surveillance&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Lung cancer is a multifactorial disease&#44; with smoking as the main risk factor&#46; Tobacco exposure and indoor radon present a sub multiplicative interaction for LC risk&#44; and most LC cases due to radon exposure occur in ever-smokers&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> Therefore&#44; at a given radon exposure in the workplace&#44; LC risk may be different depending on the smoking history of the worker&#46; Thus&#44; smoking habit is key to determine LC risk&#44; and should be a key element of the eligibility criteria &#40;see <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Regarding radon exposure&#44; we probably need to consider a minimum exposure time of 10 years&#44; as proposed by the French National Authority for Health &#40;HAS&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> This means that the inclusion would start at 60<span class="elsevierStyleHsp" style=""></span>mSv &#40;6<span class="elsevierStyleHsp" style=""></span>mSv&#47;year in 10 years&#41; &#40;see <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Finally&#44; eligibility criteria must consider age&#46; We propose inclusion of those between 55 and 75 years old as usual in LC screening&#44; as in Spain most LC cases are diagnosed within that age frame&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Furthermore&#44; additional LC risk factors should be considered&#44; namely radon exposure at home&#44; other occupational exposures to carcinogenic agents&#44; and pulmonary conditions such as COPD&#46; Of note&#44; multiple occupational exposures to carcinogens are possibly present in certain occupations&#44; e&#46;g&#46; miners &#40;exposed to silica dust or gamma radiation&#41;&#59; metro workers &#40;exposed to asbestos&#41; or carpenters &#40;exposed to wood dust&#44; paint or varnishes&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Medical surveillance should start when the worker fulfills the inclusion criteria commented above and&#44; for workers at the retirement age&#44; it should last for at least five years providing evidence that radon exposure has been reduced after the first measurement&#46; Annual health surveillance should be done during this period&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">We consider essential to have a specific protocol in place for radon exposed workers&#46; Such protocol should define the inclusion criteria&#44; medical imaging tests along with a checklist of symptoms and signs of lung cancer and define a periodicity and length of surveillance&#46; Some of these points might be applied using shared decision making with the worker and pneumologists have a role here&#46; This protocol should consider and quantify the risk derived from smoking&#44; exposure to radon at work and at home&#44; exposures to other occupational carcinogens&#44; age&#44; the presence of a COPD diagnosis and&#44; finally&#44; it should consider the potential risks from any imaging test entailing exposure to ionizing radiation&#46; To our knowledge&#44; such protocol would be the first to be applied in the EU to radon exposed workers&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0060" class="elsevierStylePara elsevierViewall">This editorial has no external funding&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of Interests</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors do not have any conflict of interest related to the content of this manuscript&#46;</p></span></span>"
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Vol. 60. Issue 10.
Pages 607-608 (October 2024)
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Vol. 60. Issue 10.
Pages 607-608 (October 2024)
Editorial
How to Protect Radon Exposed Workers? Advocating for a Specific Health Surveillance Protocol
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Lucía Martín-Gisberta,b, Montserrat García Gómezc, Alberto Ruano Ravinaa,b,d,e,
Corresponding author
alberto.ruano@usc.es

Corresponding author.
a Department of Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
b Cross-disciplinary Research in Environmental Technologies (CRETUS), University of Santiago de Compostela, Santiago de Compostela, Spain
c Occupational Health Area, Ministry of Health, Madrid, Spain
d Health Research Institute of Santiago de Compostela (Instituto de Investigación Sanitaria de Santiago de Compostela – IDIS), Santiago de Compostela, Spain
e CIBER de Epidemiología y Salud Pública, CIBERESP, Spain
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Table 1. Some Eligibility Criteria for Medical Surveillance Among Radon Exposed Workers.

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