There are ~450 nuclear power plants currently operating worldwide with 50 more under construction1. There are 118 plants operating in North America, 99 in the United States and 19 in Canada, accounting for 20% of the total electric energy in both countries2. The United States generates the greatest amount of electricity from nuclear plants in the world, 50% more than the second leading country France1. Until 2011, Japan generated ~30% of its electricity from nuclear reactors3. This decreased to ~2% after the 2011 tsunami triggered the Fukushima nuclear accident and shifted the public’s opinion against nuclear power4.
Nuclear power is an essential source of modern energy but has a potential risk for mass disaster. The International Atomic Energy Agency (IAEA) classifies nuclear accidents into groups from 1 to 7, with 1 being benign anomalies and 7 being Major Accidents resulting in massive release of radioactive material5 (Fig. 1). The worst nuclear accident to occur in the United States, the Three Mile Island, in Pennsylvania is classified as group 5 or an “Accident with Wider Consequences.” Two examples of group 7 or “Major Accidents” are events that occurred at Chernobyl, Ukraine, and Fukushima, Japan.
“Major Accidents” require urgent mass evacuation of people in affected areas and are associated with long-term radioactive contamination of surrounding areas. In contrast, the Three Mile Island accident (group 5) involved emission of gaseous radioactive nuclei with relatively short half-life without heavy metal nuclei. This meant that ~195,000 people evacuated within a 20-mile radius, were able to return to their homes within a few weeks6. The “Major Accidents” (group 7) in Chernobyl and Fukushima were more extreme, essentially permanently displacing over 250,000 people in Chernobyl since 1986 and 150,000 in Fukushima since 20117. As of January 1, 2018, ~370 km2 around the nuclear plant remains designated as an evacuation area due to the ongoing issues with radiation exposure8 (Fig. 2).
The direct health effects of these disasters have been extensively investigated over the last decade9–11. In addition, there have been reports about secondary health problems caused by evacuation such as outbreaks of communicable diseases, mental stress, and cardiovascular diseases12,13. In this review, we briefly summarize the effects of chronic radiation exposure associated with a nuclear plant disaster, secondary health-related issues caused by evacuation, and the influence of disaster-modified ecosystems after nuclear accidents which can be useful for health care workers in disaster environments.
On January 26, 2018, the search was conducted on electronic databases (PubMed and Medline) using the keyword “large nuclear power plant disaster.” Inclusion criteria was original articles and government agency reports that focused on radiation and health effects after Fukushima disaster in early 2011, and the papers that full text was accessible. Focus was placed on immediate health effects that affected humans following a nuclear disaster as well as long-term effects. Effects on wildlife population and environment were also included. Total of 144 publications were identified with the keyword, where 35 were excluded because they were published before 2011, 16 were excluded because they were review articles, and 10 were excluded because only the abstracts were accessible.
Results and discussions
Eighty-three publications were identified in the review. The results are summarized in categories based on direct health effects such as direct immediate health effects, indirect health effects such as related to evacuation, cancer, behavioral, and psychosocial effects and indirect health effects such as proliferation of wildlife and effect on local human populations and other infectious diseases.
Direct health effects related to nuclear power plant disasters
Immediate health effects
The effects of ionizing radiation on human health through occupational and medical radiation exposure, as well as atomic bomb survivors, has been investigated and reported by many studies14–16. Short-term health effect of radiation is known as “acute radiation syndrome.” This involves a cutaneous radiation injury defined as local skin injury at the irradiated or contaminated body parts17,18, and a systemic response caused by cell damage in multiple organ systems. Acute radiation syndrome primarily affects employees at nuclear plants or those who live near highly radioactive sites. However, the bigger health concern amongst the general population and rescue workers following a nuclear plant disaster are the long-term effects of radiation exposure, including cancer, behavioral and psycho-social issues and health problems related to evacuation19,20.
Radiation exposure causes health problems through either exposure or contamination. Radiation “exposure” is defined as receiving energy of ionized radiation waves or particles from external radioactive sources16. If the dose is large, delivered in a short time and penetrates the entire body, it has the potential to result in acute radiation syndrome. This occurred in the past in survivors of Hiroshima and Nagasaki atomic bombs and first responders to the Chernobyl Nuclear Power Plant disaster21. “Contamination” is defined as extended direct contact with radioactive material, which may be via taking material into the body (internal contamination) or placing them on the skin (external contamination)22. Internal contamination often goes unnoticed and has the potential to lead to chronic exposure following a nuclear accident23. Both exposure and contamination cause health problems when the radiation dose is high. For survivors of atomic bombs and workers in highly radioactive environments, the effect of radiation exposure is the main concern24,25. Meanwhile, internal contamination is the primary concern for the general population surrounding nuclear plant accidents26.
Long-term health effects
Health effects related to evacuation. Evacuation imparts significant health risk on patients. Previous reports have demonstrated that people in temporary disaster shelters are at risk for various acute medical conditions like deep vein thrombosis27,28, respiratory infections29,30, viral enterocolitis31, and dehydration32. Evacuation is also associated with the onset of chronic illness including hypertension33, hyperlipidemia34, diabetes mellitus35, metabolic syndrome36, chronic kidney disease37, liver dysfunction38, and obesity39, as well as further deterioration of various chronic illnesses34,40. For elderly people, the stress of evacuation can lead to overall decrease of function41 and even death. Hasegawa et al13 reported that more than 50 elderly people living in hospitals or nursing facilities died of hypothermia, exacerbation of medical illnesses or dehydration, during the evacuation of the Fukushima nuclear disaster, even though there was no direct radiation injuries reported.
Cancer. There is a high prevalence of cancer amongst individuals exposed to high doses of radiation and further, the likelihood of cancer is correlated with the dose of radiation14,24,25,42. Meanwhile, patients subject to internal contamination usually are exposed to lower radiation doses for extended periods. This makes estimation of disease likelihood more complex, due to the minor cell and DNA damage repair mechanism43,44 and the elimination of radioactive materials from organ systems44–48.
In Chernobyl, a higher incidence of cancer has been observed 20 years after the accident, among children and adolescents who were exposed to radioactive fallout48. Radioactive fallout contains a number of potentially harmful nuclei including Iodine (I-131) and Cesium (Cs-134 and Cs-137). Radioactive Iodine (I-131) commonly accumulates in thyroid tissue leading to thyroid cancer. Some researchers suggest that this may be in part due to low baseline iodine intake in affected area, which make individuals more vulnerable to radioactive iodine49–51. It is estimated that more than 6000 cases of thyroid cancer of all ages were caused by the Chernobyl disaster52. In Fukushima, radiation doses to the public were lower than at Chernobyl. Thyroid screening for children and adolescents under 18 has been conducted. In a 4-year continuous survey involving 300,476 people, 113 cases of thyroid cancer have been identified, most of which are thought to be unrelated to radiation exposure53. Coordinated efforts are underway to avoid overdiagnosis that may result from the use of highly sensitive ultrasound equipment and examination protocols which can cause its own health consequences. Furthermore, they also stated the results of thyroid screening in distant areas in Japan were similar to the result of Fukushima54.
The other radioactive nuclei for concern in general population are Cs-134 and Cs-137. These were released largely after Chernobyl and Fukushima and have long half-lives. Radioactive Cs is primarily deposited in muscle tissue in previous animal studies46,55,56. The data of low-level internal contamination with radioactive cesium for cancer occurrence is limited. It is reported that slight but statistically significant dose-correlated increase of cancer incidence was observed among people who lived in radioactive cesium contaminated areas in Sweden after the Chernobyl accident57. Regarding Fukushima, no report has been conducted regarding the relation between radioactive cesium contamination and cancer incidence, but continuous monitoring is needed. High incidence of nonthyroid malignant solid organ tumors, has been noted up to 10 years following radiation exposure14.
Behavioral and psycho-social health effects. Radioactive cesium has been reported to accumulate in neural tissues58. The relation between contamination and cognitive impairment or other neurological disorder is still controversial. Reports have shown that clean-up workers in Chernobyl and people living in highly contaminated areas have a higher incidence of difficulty sleeping, depression, anxiety, posttraumatic stress disorder, and medically unexplained somatic symptoms59. It is very difficult to determine whether the etiology of these symptoms are related to radiation exposure or purely psychological. Behavioral and psycho-social consequences are common after any mass disaster event60–62 and hence it is possible that nuclear plant disasters create greater psychological stress compared to other tragedies, due to fear of an invisible threat, ambiguous information about the event, and/or forced evacuation12,63,64.
Indirect health effects related to nuclear power plant disaster
Proliferation of wildlife and effect on local human populations
While the genetic effects of chronic low level radiation contamination is still under debate, the lack of human pressure in the evacuation area seems to have led to uncontrolled proliferation of large mammals, including erk, deer, and wild boar, such as noted after the Chernobyl nuclear disaster65. In Fukushima, the local government has also found that farmers have increasingly trapped wild boar since the nuclear plant disaster in 201166 (Fig. 3). In fact, herds of wild boars were observed in abandoned farmlands in many evacuation zones, which is very unusual in any other part of Japan. Drop in commercial trade and domestic consumption of wild boar meat from the entire Fukushima prefecture (due to abnormal radiodensity in wild boar meat and decrease in the number of licensed hunters) have limited population control66–68. In Chernobyl, predators such as wolves helped control proliferation of wildlife to some extent, but in Japan no significant predator for wild boar exists, hence, human activity and limited food supply are the only regulatory factors65. This lack of population control seems to also affect animal behavior. Wild boars, which typically have a territory of ~2.5 km2, have been reported to have a 4–5 time larger range after the nuclear accident in Fukushima, compared with nonevacuation zones and have become diurnal instead of nocturnal66. The increase in number of such wildlife and changes in behavior raise the risk of human-wildlife conflicts in these areas.
The wild boar, a fertile animal requiring only 1.5 years for reproductive maturation, can have an average litter of 4–5 piglets. Without human pressure, wild boar can explosively increase their number and break out to neighboring areas69,70. Adult boars are strong and fast and can reach speeds up to 40 km/h, leap 1 m high, and lift over 70 kg objects with their sharp tusks71. Wild boars rarely attack humans, but injuries and deaths have been reported72–78. Attacking boars first charge victims from the back leading to puncture wounds and victims typically have multiple injuries in the posterior aspect of their lower extremities, especially the thigh. Severe anorectal injuries caused by wild boar have also been reported78 (Fig. 4).
There are also several important patient related factors including age and comorbidities with relation to outcomes with boar attacks. In fact, 64% of agricultural workers are over 65 and 32% are over 7579 (Fig. 5). Age related physical limitations may make people more vulnerable to wildlife attack and poorer outcomes as seen in geriatric trauma around the world. Furthermore, elderly people are more likely to have comorbidities, which puts them at a higher risk for postinjury complications80.
Other health effects from wildlife
Wildlife may serve as a reservoir for pathogens. Wild boars carry many pathogens such as hepatitis E, tuberculosis, leptospirosis, and trichinellosis81. Moreover, large mammals are hosts for ticks, which is a reservoir of tick-borne disease like Rickettsia82. Movila et al83 reported an abundance of adult ticks in the evacuation zone of Chernobyl. No direct relation between nuclear plant disaster and tick-borne disease have been reported, but health care workers in surrounding areas should be aware of a potential increase in wildlife related infectious diseases, especially during the resettlement period.
Nuclear plant disasters may result in various immediate and long-term health effects including behavioral and social consequences. Extensive environmental impact also leads to additional unanticipated effects on wildlife making resettlement more complicated. Health care workers should be aware of these potential threats after a nuclear plant accident in the short and long-term.
Sources of funding
This work was supported by the US National Institutes of Health/National Cancer Institute grant 5T32CA108456 to V.M., and US National Cancer Institute Cancer Center support grant P30CA016056 to Roswell Park Comprehensive Cancer Center. The funder was not involved in the study design, collection, analysis, interpretation of data, writing of this article or decision to submit it for publication.
I.O. conceptualized, collected and interpreted data, and prepared the manuscript. K.T. provided supervision of the design of the work and interpretation of the data. I.O., A.R., M.D., V.M., S.J., and K.T. provided critical revisions of the manuscript.
Conflicts of interest disclosure
The authors declare that they have no financial conflict of interest with regard to the content of this report.
Research registration unique identifying number (UIN)
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