 Good afternoon, good morning and good evening. I'm Todd Smith, senior level advisor for emergency preparedness and incident response in the Office of Nuclear Security and Incident Response at the NRC. And welcome to this session on exacting the science of emergency preparedness. In radiological emergency preparedness, preparing for tomorrow is our constant work. It's what we do. Whether we're learning from the past or looking to the future, emergency preparedness is constantly evolving. And as you'll learn in this session, it's an international effort. With me today is a distinguished panel of colleagues from around the globe. I'm joined by Dr. Tomohiko Makino, Director for International Cooperation at the Cabinet Office for the Government of Japan. Dr. Makino's contributions include extensive experience in the fields of emergency preparedness, resilient health systems, disaster response, global health diplomacy and biosecurity. Mr. Greg Lemaire, head of the Division of Radiological Protection and Human Aspects of Nuclear Safety at the Nuclear Energy Agency. Mr. Lemaire has over 30 years of experience as a systems engineer and providing world-class technical expertise as a leader in military, government and international organizations. Mr. Tristan Barr, head of the Planning, Outreach, Exercises and Training section within the Radiation Protection Bureau of Health Canada. Mr. Barr has expertise in radiation detection, characterization, dosimetry, radioactive waste management and emergency response. Rounding out this panel will be myself, starting my ninth year here at the NRC, all of which time I've had the pleasure of working on emergency preparedness, regulation, oversight and research. And I'll add that this group of panelists holds a combined total of 12 graduate and undergraduate degrees spanning the fields of medicine, chemical, nuclear engineering, biology, health, physics and business. This is a very knowledgeable panel and we will have time for your questions at the end. So as you listen to today's presentations, please submit your questions. In this session, we're going to take a closer look at how the science of emergency preparedness has evolved to prepare us for tomorrow. To set the stage for this discussion, we need to start with a look at the challenges that have faced us yesterday and still face us today. So it's appropriate that we lead off with a discussion on the impact that the Fukushima Daiichi accident has had on emergency preparedness in Japan. So I'll now turn it over to Dr. Makino. Tomo. Thank you. Thank you very much for the kind introduction and it's my great, great, great pleasure to be here in RIC and have a chance to introduce what Japan has experienced through the Fukushima Daiichi accident. So we have done a lot to reverse our policies, but they're also something we haven't done well. So this session will introduce some of the issues and the concerns to pose in front of you. So next slide, please. That's the first slide as a large-scale evacuation is in the picture. So the figure on the right side describes how long distances and how many times the people traveled and migrated. So the entire village moved one place to the other and then they are actually contaminated. Then they had to travel another time. So over about 100 kilometers traveled, that may also made the community discreet. The next slide, please. This shows some of the areas are still restricted and the people cannot come back. And then the figure on the left or right below shows the people who returned back to the original places. The blue column, the people who traveled out and inside the Fukushima Prefecture and who came back, who are still away, are really reducing a lot. But the orange columns, those who traveled beyond the prefecture border, this likely to come back. That means the repatriation is another issue. Next slide, please. That describes the stable island distribution. At that time, the government stockpiled, but not predistributed the stable island. Then the decision of the local governments to urgently distribute are not expected. And then they even up some of the areas where the people received the stable island urgently and advised to take. But the people didn't take it because of their concern about the scientific or the concern about the next big emergency may happen. So just take it with them. So the education or good communication to the reason was a challenge at the urgent distribution of the islands. These are some of the lessons, but the big, big, big challenge was a long evacuation or process of the hospitalized people. So next slide, please. Next, next slide please. So the picture on the right is a queue of the people, senior citizens, to get on the bus. Then these senior citizens traveled so long way as it's shown in the right below picture. And actually, because of the misinformation or messy communication from the government, the bus travels from to North to West and then eventually settled in the past South. That several hundred kilometers travel journey actually eventually may cause about 40 patient deaths within a month. That is a really big tragedy of that long evacuation, urgent evacuation procedure. But the quick lesson is that the evacuation is risky, but please proceed to the next slide. Slide six. This picture also shows that staying is also risky. The sheltering, shelter in place order was also issued within the 30 kilometers radius from the Dejima Daiichi. So there are many hospitals who are advised where certain place orders. But the health care staff members could not stay because of the disrupted social function, like school closure or no groceries in the community. So the right figure shows that the number of the health care staff members really decreased at the face of the emergency. Some hospitals retained the staff members, but some couldn't get the sufficient number of the staff members. Then as is shown in the left figure at the slide six, survival of the patient inside the hospital where the sheltering place order was issued also decreased. So the staying inside the area of sheltering advice is also risky. That's another lesson. So please proceed to the next slide, slide seven, please. So the question after a decade. This is my more personal observation from listening to the local people and my observation. So there are several learnings. One, that urgent evacuation is actually really risky and led to the 40 urgent deaths as it's introduced. But the sheltering place is also challenging that this very disrupted the social function and then the people cannot stay there for a long time. Maybe one week will be up to the maximum. And the third bullet, the certified disaster-related tests. It means this is not due to the immediate earthquake or tsunami, but those residents who requested the disease are related to the accidents or pretty much bigger in Fukushima compared to other prefectures where the direct deaths are much bigger. That means the long-term effect is severe for such a large-scale evacuation advice. At the first bullet, the community was disrupted because of the prolonged evacuation and then the people got back to the community and who traveled inside that area for work or just migrated. There are really different types of the people were there. So getting a good consensus to rebuild the community has become a big issue over there. And then the people are from the different positions. So even the actual radiological effect may decay, but the mental barrier may stay there to split the community. These are the stations in Fukushima. Next slide, please. Slide eight, please. In terms of the emergency response and management, there are really many lessons such as unexpected situations or unplanned situations or staffs are not skilled. In order to overcome these three big challenges, the government actions. Next slide, please. Slide nine, please. So before Fukushima, user and safety authorities are somewhat mixed in a left figure. So after Fukushima, government restructure, restructured the authorities between two, one is green safety and the preparedness community. And then the other on the right is the user or promoter of the nuclear energy. So so as to divide these two authorities. And next slide, please. The national legal framework for the nuclear emergency was actually built in 1999 criticality event. But it didn't assume such a combined disaster that the nuclear disaster was triggered by the natural disaster. So that special arrangement for nuclear emergency was hugely revised. And then that asked the establishment of the nuclear regulatory authority and also the nuclear regulatory authority asked to be requested to build the EPR guide. Next slide, please. Slide 11, please. So the nuclear based upon the new EPR guide, each local governments are requested to build their revised or renewed emergency response plan. So the each site has combined local governments responding plans, which is called as regional emergency responses. These are these needs to get an approval by the committee led by the prime minister. So far, these yellow regions, EPR plans are approved. And there are four sites operating right now. Let me next slide, please. Let me introduce two examples of the newly introduced protective actions and protect facilities. One is the site number 12, sheltering facilities with radiological protections. So at the Fukushima event, some buildings, including the responding office buildings to the emergency didn't work well. The windows are broken by the earthquake and then the radiological plumes came inside. Then that building couldn't be used for response. People got out and moved to the Fukushima prefecture government 60 kilometers away. So after Fukushima, key buildings such as responding buildings and the facilities for patients to be sheltered inside are equipped with these facilities, like air tightening and the pressurization and the filtration to make the air clean to be placed inside the buildings. This is the pressurization facilities. These facilities are subsidized by the national government. Next slide, please. So this type of iodine blocking methodology. So the Fukushima lesson is that the people will not be clear about whether to take the iodine note. So and also the need of pre-distribution. So after Fukushima, local governments started to distribute the stable iodine to the government and to the local residents. But that process is not just the mail or send, but the government needs to hold town hall meetings to provide information to the residents and what is the right timing to take, what is the effectiveness of these stable iodines and the limitation of these tablets. These are the changes after Fukushima. Now let me introduce some trees and training programs. Responding staff members at the governments are more adjusted public officers who are rotating from different ministries and the government. So the trees and the training programs are mainly targeted for these responding officers at the operation centers. There are various training programs like lecture seminars and discussion sessions and drills that test the actual procedures to go on. The key drill is at the head of the drill box and that's an NETPD. So let me go for that drill. Next slide, please. Slide 15, please. Thank you. So the NETPD, a nuclear energy stop prevention drill is an annual large scale drill led by the national government. The feature of this drill is to invite the prime minister and political leaders as well as local residents about thousands of people joining. The scenario is open. So it is not that much for testing the decision making, but good for checking the procedure to implement the protective actions. So next slide. Slide 21 is the medical drill that the healthcare staff members equipped with the PPE and they are ready to see the contaminated patients. These are the pictures of our national drill. So the last section of my presentation is about our lessons and responses to the COVID-19 pandemic. And now we are on slide 22. Thank you. Thank you. I'm very sorry for the photo sessions. After seeing the COVID-19, we are now some at the challenging station, how to balance the two risks. So the November to December 2020, we issued a kind of guide to the local governments. To think about how to balance the two risks, especially in the station of camping, evacuation camps or endurance transportation. The question was whether to ventilate or not. So our is to stay on the principle to ventilate in the evacuation camps, but try to ventilate during the time that the radiological release is not there. Next slide, please. Slide 23, please. Another side of the COVID-19 response was that they taught us about what we should do during the distribution, especially a good lesson from the COVID-19 was how, what are the essential number of the people to respond? Science, but also big lessons are that no radiological health impacts are so huge, and it's not easy to say whether it's good between stay or stay in place or evacuate. So after all, we are all still on a long way to keep improving our emergency responses. Thank you very much. Thank you, Tom. You made clear in your presentation that the challenges that you faced are multidimensional and the reality of the situation goes beyond just radiological impacts, specifically the social disruption and stigmatization reminds us there are human and societal dimensions to consider. It also indicates the need to integrate the social sciences into planning and response. And recognizing this will now turn to Greg LaMaire to discuss how might we integrate non-radiological health impacts into the field of radiological protection. Greg? Thanks very much, Todd. And good evening, everyone, from Paris. Very happy to be here. And thank you very much to the NRC for this opportunity for us to present some of the work of the Nuclear Energy Agency and some of our groups. As it says, the title of the presentation is any progress to date on those non- radiological health impacts of protective actions from recognition and mitigation. Hopefully I can build on some of what you've heard in Tomo's presentation as well and also compliment what I know Tristan is going to talk about. I've got the pleasure of giving the presentation, but I'd like to also call out my colleagues, Jacqueline Garnier-Laplace and Jan Hendrick-Cruz and also a couple of very important people within our community, Mathias Zaringer, who is the chair of our working party on nuclear emergency matters and Tiedi Schneider, the chair of CRPPH. The work that I'm going to talk about over the next 15 to 20 minutes is largely based upon the work of two expert groups, the expert group on non- radiological health, public health aspects, EGNR and the expert group on recovery management. Maybe just to make a little bit of a plug here, EGRM has got a launch event later in May, 23rd of May in order to launch its report. And then there's also going to be an in-person workshop in October in Paris when we can start to hopefully meet face-to-face again. So please keep your eyes open for both of those events. Next slide, please. So just very quickly on the Nuclear Energy Agency for those of you that aren't familiar, we found it in 1958, 34 member countries plus a number of strategic partners got eight high-level standing technical committees. You can see them along the right-hand side. The work that I'm talking about is under sort of the middle pillar there, CRPPH and some of the expert groups that report up to that. A real myriad of working parties, expert groups and the like, 24 international projects were an organization approximately 110, 120 strong that supports across all of those different committees and working parties. Next slide, please. So to get into the heart of the presentation, I think we can all confirm that internationally much has been learned from the tragic events of Fukushima Daiichi over the last 10 plus years. I think we can also probably all agree that a lot of the work in the early stages of that led to some very significant improvements in the engineering and design of the plants when we looked at robustness, the defense against external events and the like. What we've done now with the support and direction of our member states has really pivoted and turned our attention to some of the other aspects related to emergency preparedness and response. And I'll talk to you now a little bit about where we're going on some of the psychosocial pieces. I think Tomo mentioned quite well in his presentation that when you look at the impacts of an accident like Fukushima, it goes much beyond the radiological consequences. And I think we're also all very aware that although radiation induced illnesses, deaths were very, very minimal, if not nil that some of those psychosocial impacts due to evacuation and some of the other decisions that were made had a much more profound impact. And that's with that in mind that we've moved forward through our expert groups in work in this area. We've also realized through our collective investigation that not only does work need to be done there, but the decision makers are not yet sufficiently equipped to move from what has traditionally been a radiation protection protection-centric approach, i.e. trying to avert a certain dose, a protective action levels that are dose-centric to one that has a more comprehensive approach to the protection of health and well-being in the broader sense. And it's with that in mind that the NEA has moved forward. Next slide. Slide four, please. So a little bit of background, as I mentioned, non-radiological consequences of nuclear and radiological accidents are complex and they're multi-dimensional in nature with human societal dimensions that it's for. That makes it all the more challenging. They are a combination of direct health consequences and indirect public health consequences of those protective strategies. We've learned through the work of the expert group on non-radiological consequences and recovery management that management needs to reassess the risks of the protective actions to reflect a more holistic and inclusive approach throughout the entire cycle of an emergency. Among many lessons, some have been well-documented. For instance, there's a need to consider specific actions for vulnerable groups, elderly, children, parents, pregnant women, clearly one size cannot fit all and a lot of those demographics, specificities need to be considered in the strategy. You need to proactively consider balancing the risks of immediate evacuation against the possible benefits of sheltering in place with continuous care and what's required for continuous care also needs to be considered within your strategy. And I'll talk further about this later on the presentation, the need to further promote stakeholder engagement in a collaborative, inclusive manner from preparedness to recovery all the way through in order to achieve the best possible outcomes. Next slide, please. So how to proceed? Many of you may be aware, perhaps others are not. Last year, we published a Fukushima Daiichi 10 years on report. If you haven't had the opportunity to look at it, I strongly suggest that you do. It's available via link on our NEA website. It looked over the last 10 years and the compendium of work that's gone on from the nuclear regulatory communities, the Committee on Safety of Nuclear Installation, CRPPH, Nuclear Law, came up with nine recommendations on future areas for improvement and how the international community can help. Some of those have to do with more advanced research. Some of them have to do obviously with fuels and physics and some of the science of engineering design. The ones that I wanna talk to you about a little bit here are recommendation six and seven. Recommendation six involves stakeholder involvement of risk communication and the need to promote stakeholder involvement approaches to enhance community engagement and society resilience. And I think that has a lot to do with what we're talking about in this session. Just as an aside, the NEA also in recognition of the risk communication part of that recommendation is later on this year launching a first risk communication training course to be hosted in Slovakia in December. Recommendation seven looks at the recognition of mental health impacts. Important to note that both these recommendations promote an all hazards approach in line with the UN send a framework for disaster risk reduction. Next slide, please. So a little bit more about the problem statement on mental health and psychosocial impacts. Mental health and psychosocial impacts need to be better considered in protection strategies for preparedness, response to and recovery from the events. The work within the expert groups also drew largely on the World Health Organization framework for mental health and psychosocial support and radiological and nuclear emergencies that provided some high level guidance across these areas. It is realized that more work is required to prepare decision makers to move from once again, a radiation centric approach to a more holistic approach that looks at overall health and wellbeing. It's also very important to realize that one size does not fit all. As a stakeholder needs and expectations are very circumstance, population, demographic dependent. Optimization and decision-making for overall public wellbeing must integrate the social, cultural and other relevant factors. And I'll talk in the next few slides about how we're going to try to address that. Slide seven, please. So, action one, action-oriented solution. Stakeholder dialogue through the emergency cycle. Some of what we're looking to do is exploring possible options to improve decision-makers' responses to stakeholders' needs and concerns by involving stakeholders in the protection strategy by starting at the preparatory phase to develop mutual trust that is central to the success. Drawing on existing frameworks, such as the ICRP co-expertise approach that is highlighted at a high level on the right-hand side that brings together people, experts, NGOs, decision-makers to facilitate radiological protection culture dissemination. And the dialogue will provide people with the knowledge on health risks from radiation exposure. The, am I safe? How safe? How safe is safe enough? And methods to put into perspective potential deleterious effects of protective actions allowing informed protection decisions, the ability of the stakeholders to be involved in that risk-benefit consequence decision-making process. Next slide, please. In order to support this, obviously, member countries are also looking for us to assist in the development of tools and data to support these dialogues. Such tools and data are necessary to balance the health risks of radiation exposures against the health risks from protective actions. And there's subsequent disruption of normal life, as Tomo mentioned in his presentation. Excuse me. Data on mental health and psychosocial consequences of actions such as evacuation, sheltering, relocation, societal disruption can be documented from other disasters and brought into the conversation. And it's also, we're also promised, we're very heartened to see good progress being made in a number of NEA countries. I know Tristan's gonna talk about that being done at Health Canada. We're also aware that our partners at the USNRC have moved very boldly forward in this area as well. Next slide, please. So ongoing work and next steps. So NEA member countries are committed to bring forth practical actionable guidance to advance preparedness, response, and recovery using this multi-dimensional approach with human and social dimensions at its core. The NEA expert groups that I've mentioned previously continue to work on operationalizing this World Health Organization framework. First by developing national level guidance on how to better prepare for recovery with health and wellbeing being supported, being one objective of recovery. And by preparing the translation of the framework into a series of operational action sheets. Excuse me, on mental health and psychosocial support during preparedness, response, and recovery. Those action sheets are under development right now. Action sheets on training of first line respondents, how to distribute educational material to the communities on mental health and psychosocial support and other supporting material like that. That work continues. The ultimate goal is to evolve beyond the optimization of radiological protection to the optimization of wellbeing. Ultimately, testing and validating of these new approaches and tools using national and or international exercises will be key. And I would also like to highlight that we're well advanced on the planning of the INEX-6 exercise. It'll happen in 2023, 2024 timeframe that we'll hopefully be able to put to action some of this new learning. Slide, next slide please. Just a little bit more on ongoing and complimentary work. We're in the midst of planning our third stakeholder involvement workshop entitled optimization and decision-making that will get to the key of this decision-maker paradigm and how to most effectively involve the stakeholders in the decision-making process. It's been determined that a series of webinars will be held in 2022, starting in June and going through the fall. And then that the actual workshop itself will be held likely here in Paris, the first part of 2023. The program committee has been convened and is looking at the specific objectives listed at the bottom, improving the common practical understanding of what optimization decision-making means, increasing the consideration of inclusive stakeholder involvement to optimize decision-making and ultimately developing a foundation for a generic multi-dimensional framework to support optimization for policy and regulatory decision-makers. I think with a successful outcome to this workshop, this could really be an important pillar as well for us to build upon as we advance science of emergency preparedness and response. And next slide I think is the last one. Yep, thank you very much for your attention and happy to answer any questions at the end. Over to you Todd, thank you. Great, thank you for sharing that Greg. I'm really glad to be part of the work the NEA is doing in the area of non-realurgical health impacts along with Tristan. For those of you who have joined us today, I do apologize if you missed anything in the slides. I remind you that all the presentations will be available on the RIC website for your review after the session. Greg, getting back to what you discussed, I appreciate that in your presentation you provided not only a concise problem statement, but you also proposed action-oriented solutions. You spoke of the need to develop mutual trust and to be ready to dialogue with people who want to know what are the risks and want to know am I safe? You also spoke of the work that is required to prepare decision-makers and you proposed that we develop tools and data to help optimize protective action decisions. Fortunately, we have Tristan Barr with us and he's been giving that a lot of thought. So he's going to share now with us some ideas, how we can use science to sharpen our tools. Tristan, the floor is yours. Thanks, Todd, for that introduction. And in fact, you took the words out of my mouth. I was taking notes and I was going to refer back to what Greg said and Tomo. And that will save me some time in this presentation. So I wanted to start just with pointing out that while it says I'm a section head and planning out each exercises and training, that is within the nuclear emergency response and preparedness division at Health Canada's Radiation Protection Bureau. So we're currently active. So in the event that I get a call, I may have to drop, but I hope that that won't be the case for the next 20 minutes. If you could, oh, sorry, before we go to the next slide. So I will be presenting on measuring psychosocial impacts. And the title of the presentation was a case for a non-radiological seabird, which I think speaks to what we've heard so far, namely Tomo explained some of the risks associated with the protective actions that we would normally apply in a radiation or nuclear event. And we heard from Greg regarding the things to consider and particularly psychosocial and mental health impacts to be considered. So if you go to the next slide, I reiterate that as the premise for the work that we are doing. And while this presentation will talk to the case that we made to develop a non-radiological seabird, it will also let you know that we failed to do so. However, we did manage to develop a decision-making tool or rather a proof of concept for decision-making tool for decision-makers that would allow them in the concept of a protection strategy to balance the potential impacts of the mental health and psychosocial impacts versus the radiological detriment in the event of an emergency while applying protective actions. So the premise is that Canada is improving and formalizing protection strategies for nuclear emergency response. It's a shared responsibility amongst the provinces that have nuclear power plants, as well as the federal government. We recognize that current nuclear energy response plans are well established and provide clear guidance on radiation dose thresholds for implementing protective actions to minimize those radiation doses. And we heard much of the same from Tomo earlier on. However, we've recognized that protective actions that minimize radiation doses may actually increase the psychosocial impacts to the effective population, in particular the use of evacuation and or relocation. In light of COVID-19 lessons, we also, we note that this highlights how protective actions for nuclear emergencies, although they were, well, protective actions for nuclear emergencies could cause additional harm in the event of combined emergencies, such as COVID. So Tomo discussed this as well, but in Canada, we recommended adjusting the reference levels in the event of a nuclear emergency for the public to 150 millisieverts or 15 REM, rather than 100 millisieverts over seven days in order to account for the potential increase in the spread of COVID where we to relocate or evacuate people into reception centers. So as a consequence, we asked the question, can we develop a unit of psychosocial detriment to compare to the unit of radiation detriment? So effectively, is it possible to develop a non-radiological sever and develop that balancing mechanism between the risks? Next slide, please. To do this, we received funding and put together a team for a research project and for the development of a decision tool. The objective of the research was to attempt to quantify psychosocial detriment and to develop a decision tool for emergency decision makers effectively to balance radiological and psychosocial detriment. To do this, we researched, we did a significant lit review and researched available studies and data sets related to after effects of nuclear disasters. And then we looked to develop a common unit and decision-making tool to compare radiological effects to psychosocial health effects. Next slide, please. And so we recognize that the current gap, the one that we're trying to fill and that one of the ones that's been identified is that challenge that decision makers have in an emergency response to include psychosocial factors in optimizing and justifying protective actions that form the protection strategy. Next slide, please. So a summary of our research and you'll see underlined that we identified no significant difference. The objective here was we took data from Statistics Canada and used a model to evaluate the changes in outcomes measured by psychosocial impacts between a population that was affected by a disaster and one that was not. Now, recognizing that there were significant cultural differences between the information, well, the Japanese population and the Canadian population, we looked to do that with Canadian data following evacuation events in Canada. So we used the Canadian Community Health Survey information to evaluate psychosocial impacts that arise from an evacuation and we used the 2013 Alberta flood data that was available to us. Specifically, we looked at variables such as life satisfaction, the time period, specifically the pre and close flood. We captured population data by postal code, which is similar to a zip code in the United States, which captures an individual's proximity to the floods for those affected. And then we applied control variables. So we used, these were used to control additional factors that we had identified as affecting life satisfaction, such as socioeconomic controls, demographic controls, and physical and mental disorders, existing physical and mental disorders. In the analysis, unfortunately, we actually found no difference in the data before and after the flood. Next slide. So we had to get rid of that model and we moved to, again, look at the literature review and identify the main factors or the main drivers for psychosocial impacts. And from there, we identified that residents-related factors were the key driver, but there were also significant contributions related to risk perception and socioeconomic changes. And the idea that we had was that we could potentially propose a weighting factor for each of these key impacts on psychosocial health that would contribute to an overall psychosocial detriment. If you'll go to the next slide, please. For those of you, and I think many of you are who are knowledgeable in radiation protection and health physics, you'll notice that that concept would be somewhat similar to applying radiation weighting factors and tissue weighting factors that are used to generate the sievert, which is that unit of overall detriment from radiation. And the idea was to propose the unit of psychosocial detriment for decision-makers that will allow them to compare radiation dose averted by protective actions against potential psychosocial impacts that could be exacerbated by those same actions. Next slide, please. And the outcome was that we found that the data was not currently available to generate that non-radiological sievert. Notably, we noted mental health and psychosocial impacts from nuclear emergencies have been measured with general and summary indicators as opposed to indicators that speak to the particular impacts on psychosocial health. We reviewed a paper whose lead author, I believe is Todd, for the NRC paper from 2021 that quantified various non-radiological health effects from evacuations and relocations. But we noted that the paper specified that the impacts were not additive. So we couldn't effectively make some weighting factor out of those numbers to use to compare to the sievert. So the overall conclusion is that we cannot weight the psychosocial impacts and some of them to get a sievert-like unit at this point. And that in order to do so, we would need specific studies on the non-radiological health impacts that measure each health effect and their combined impact as well. So that's the bad news. If you go to the next slide, we can get to the good news. We still had the objective of building a decision tool for emergency planners and emergency managers to balance the psychosocial impacts and the radiological impacts in an emergency and while applying protective actions. So we noted that in the NRC paper of the 14 psychosocial impacts that were assessed, depression had the greatest magnitude of impact on the populations. The prevalence and impact of depression following a nuclear emergency with and without evacuation or relocation was used to model in the decision tool. And we note that the prevalence of depression in a Canadian population following evacuation was estimated to be 19%. And here I indicated 28.9 in the US and this is actually an error and I do apologize. I think that was the upper bound of the impact of depression where 19% was from the United States and was the average prevalence. So we use this number and note that the impact from depression represents a lower bound of what would be combined psychosocial impacts. So again, our model that I'll present to you now is based solely on the impact of depression following a nuclear emergency leading to a potential evacuation and relocation. And again, this is why I note that this is a proof of concept. So as we develop further, we may look to model more impacts into the model but at this point we're basing it solely on the potential for depression. We also had to use quality adjusted life years or qualities to provide a metric for that impact. And we noted that various qualities are the type of application and they vary from 50 to 200,000 US dollars. And then we pulled radiological detriments estimated from the USNRC 2014 dollar value per REM. So again, given that we were using qualities to as a metric for the impact of psychosocial impacts, we needed a dollar value to assign to radiological impacts and these were pulled from that 2014 NRC paper. Next slide, please. So in building the decision tool, we had to establish a life satisfaction quotient which was pulled from a paper by Red Hands at Palm of 2015 which predicts lower life satisfaction with increasing proximity to a nuclear accident based on the Fukushima Daiichi evidence and studies. We estimated costs to unit increases of life satisfaction that are relative to the starting socioeconomic conditions before the accident. So this is based on the review but identifying that it's the relative change in the socioeconomic conditions that are one of the key drivers for life satisfaction. We then broke down the population information as well as the socioeconomic levels of the population by postal code out of Statistics Canada data. And we developed what we call a relative cost ratio, the formula for which you have here and we'll bore you with the details. We can extrapolate it later if we have more time. But what I will show you is the results of this proof of concept model when applied to one particular scenario. So if you run the model, you'll note that it produces actually postal code by postal code recommendations on whether to evacuate or not based on the cost ratio that was developed through our model. And we have here a graphical representation of that same information. So you'll see relative sizes of the populations in each postal code that was modeled. And this was a total of 97 postal codes that are within a 57 kilometer radius of one of the nuclear power plants. And you'll see that there is a line at one which is that relative cost ratio that we developed. And in this model, we have a kind of threshold at distance which turns out to be about 47 kilometers out which you can't really see on the graph but would suggest that there's a tipping point for that cost ratio balance at 47 kilometers given the default parameters that we used. Now those default parameters for any particular evacuation, population location can be changed but to specify in this particular case, the default parameters include that there is zero dose to evacuees whereas there is a 100 millisever or 10 REM potential dose for non-evacuaries. We used a quality adjusted life year of $50,000 which is probably on the low end. And as you increase that the slope would get steeper. We used a life satisfaction quotient of minus 0.08 per three kilometers distance from the accident which can be adjusted as well. And we use the population statistics around the Darlington nuclear power plant near Toronto, Canada and a depression prevalence of 19%. So those are just the key parameters that can be adjusted. Recognizing again, this is a proof of concept and this is not to say that the distance at which the cost ratio changes is 47 kilometers but we're just starting to play with the outputs from the model in order to basically beta test it and come up with a usable decision tool. Next slide, please. So at this point, we'll talk about the proposed usage of the tool. So I wanna highlight again that this really is a proof of concept for a decision tool to balance radiological and psychosocial detriment. It's our first step. What we hope is that this will play, it will have a significant contribution to evidence-based guidance on a justified and optimized protection strategy that would allow us to consider psychosocial impacts in both planning and decision-making. Additionally, recognizing that most people assume that nuclear emergency response plans are based on radiological detriment than they effectively are at the moment. Proposing a tool that allows us to compare the psychosocial impacts for mental health impacts versus the radiological impacts would be a key tool to explain to the population why you might evacuate or why you might not evacuate and start that discussion to maybe better understand what radiological dose represents in terms of risk because currently, I believe that radiological detriment is overvalued in terms of its potential risk in the event of a nuclear emergency and needs to be discussed with stakeholders before anything happens so that we can have more educated discussions going forward. Next slide, please. So just quickly to point out the next steps, I would love to share the decision tool with you but it's not actually finalized and I cannot distribute it. But we do expect the research report to be ready for review in March. I actually received it yesterday and because of our activation and response to the situation in the Ukraine, I have not had a chance to open that email. And then similarly, we expect the, we have the tool which is currently in review as of yesterday. Going forward, we expect to hold a Canadian workshop on recovery planning in the fall of 2022 in Ottawa, Ontario where we would present a recently published paper which is another tool that actually addresses something Greg was mentioning, which was a guidance on planning for recovery following a nuclear radiological emergency. This is geared towards Canadian provinces that have responsibility to generate recovery plans but maybe of interest to this audience as well. It's available online. And then to present the research on psychosocial detriments in a nuclear emergency in order to accompany that discussion on recovery. And then introduce the decision tool to enhance radiological and psychosocial impacts for an nuclear emergency response when applying protective actions. On the last slide, I just wanted to highlight the references that were mentioned throughout this presentation and thank you for your time. Well, thank you for that presentation Tristan. And again, I do apologize for those of you following along. There appears to be a delay in the slides updating but we'll just keep moving forward with this discussion and please visit the RIC website to download these presentations later. Tristan, it was a very novel idea that you had and certainly I think an interesting tool that would seem to have much practical use specifically as you mentioned in the development of evidence-based guidance. I think that evidence-based policy is a key component to building trust. If you listened to our chairman's opening remarks this morning, you heard him talk about a term called truth decay which is the diminishing role of facts and analysis in public life and how that can lead to a loss of trust in government. And this is something we must pay attention to in emergency planning because we know that the foundations of trust have to be established long before any accident occurs. Ultimately that trust translates in the confidence of decision makers and the public to make informed decisions based on the best available information. But how do we produce that information and how do we get the evidence we need to inform protective actions? Let me now share how the NRC is using science to support emergency preparedness and public protection. Next slide please. Emergency preparedness ensures that protective actions can and will be taken in the event of a significant radiological release. Within emergency planning zones, predetermined prompt protective actions are in place to avoid a reduced dose from exposure to radioactive material. The choice of protective action includes primarily evacuation and sheltering. NRC regulations require nuclear power plant operators to promptly notify off-site authorities and to provide a protective action recommendation if conditions warrant. Off-site authorities consider the recommendations and will issue protective action decisions to the public. In the US, both the protective action recommendation and the protective action decision are informed by the US Environmental Protection Agency's protective action guide or PAG. PAG's are the reference levels for action. But while PAG can help decide when to act, it's not always clear which action to take. There are practical guidelines that describe how the protection principles of justification and optimization could be applied to aid in this decision. Even so, it said that selection of evacuation or sheltering is far from an exact science. But if that's the case, then we should be able to exact our science to help decision-makers and the public make informed decisions. Next slide. And the NRC is working to support protective action decisions with science. Just in the past few years, the NRC has published and continues to perform analyses to enhance our guidance and regulations and improve our state of practice. These analyses are providing the scientific evidence needed to better inform protection from radiation in an emergency. I'll now share a few of the insights from the studies listed here. Next slide. Emergency response is broken up into phases. There's an emergency phase when immediate decisions are needed. An intermediate phase lasting weeks to months when releases have been brought under control and measurement data can be used as a basis for action. And a late phase, marking the beginning of recovery, which can last for years. As we heard today, decisions to protect the public continue long after the emergency phase. To better understand this, the NRC performed a study of capabilities and practices in the intermediate phase of a radiological emergency response. We gathered information from state response organizations and exercise reports and identified best practices for communicating to the public, developing partnerships and sharing resources for monitoring, how to base protection decisions on science, how to leverage technology to aid in response and caring for vulnerable populations, including animals throughout the event. These insights have been gathered to promote a shared understanding among offsite response organizations in the public. These insights were also gathered to improve modeling assumptions in NRC consequence analyses, which can be used to provide a technical basis for protective action guidance. Next slide. In fact, the current basis for protective action strategies was informed by a detailed computational study into the benefits of protective actions known as the PAR study. Conclusion of the PAR study is that evacuation should remain a major element of protective action strategies. Another conclusion is that the effectiveness of a protective action is sensitive to the timing of the release in relation to the timing of the action. As such, the NRC requires the use of evacuation time estimates in the formulation of protective action strategies. To inform development of evacuation time estimates, the NRC developed state-of-the-art microscopic traffic simulation models of representative rule, coastal and urban communities, as you see here. And we use these models to examine a multitude of topics and enhance our understanding of evacuation dynamics. The ETE study was then used to update NRC guidance for development of evacuation time estimates. The updated guidance reflects the state-of-the-art in transportation modeling and provides measures of effectiveness useful for verifying the adequacy of ETEs. Updates to ETEs are periodically required, a task which all nuclear power plant licensees are currently performing as part of required 2020 decennial census updates. The updated ETEs will then be used to inform protective action strategies ensuring these strategies are based on the best available information. As part of the ETE study, we also found ways to better protect our first responders. Some evacuation plans rely on traffic control officers to help direct traffic in an emergency. Our study demonstrated that effective evacuation does not always require police officers to control traffic at intersections. And that normal means of traffic control can be just as effective. And this could provide two benefits. First, police officers can avoid exposure to a radioactive plume. And second, it frees up those law enforcement resources for other use in an emergency and where they're most needed. Next slide. While evacuations are a common protective action in response to many hazards and are typically safe and effective, as we've heard, there are other issues brought on by prolonged displacement. That is, after the evacuation event, there are additional stressors unrelated to the hazard that can lead to negative health outcomes. While many individual health effects from specific evacuation events have been widely studied and reported in the literature, holistic view of the risk of prolonged displacement was lacking. To bridge this gap, the NRC published a meta-analysis of the health consequences from evacuation and relocation across all types of emergencies. The meta-analysis identified 14 different health effects common to a response to a variety of events, including natural, technological, and man-made hazards. What we found is that across emergency events, displaced populations were more likely to experience a negative health outcome than those who stayed or returned home. And we gathered qualitative insights to look at which populations like children and the elderly might be more at risk from certain health effects. An important insight was that radiological emergencies did not result in outsized health effects. Rather, the effect size seen in radiation events was generally similar to other hazards. This suggests these insights can be applied to all hazards planning. This also suggests that it was the disruption of the social ties and prolonged displacement from home communities that led to these effects. More importantly, it begs the question, what can we do then to minimize the impacts of prolonged displacement? Is evacuation always the right response? And what about the alternative of sheltering in place? Next slide. Sheltering in place is another protective action common to many hazards, including radiation. The US EPA's Federal Protection Action Guide Manual was updated in 2017 with the latest information on shelter effectiveness for radiological emergencies. But there's still many questions we can ask that are open to scientific inquiry. For example, how does the source term and the characteristics of the release change the effectiveness of shelters in providing protection? Early shelter studies assumed that radiological releases contain large amounts of radioactive iodine, mostly in its elemental or gaseous form, which was assumed to easily penetrate a shelter. But as our knowledge of source terms has evolved, we know now that iodine is released in many chemical forms, many of which are particulates. So how does the chemical form of a release impact shelter effectiveness? And tomorrow's technology will continue to look different with accident-tolerant fuels, small modular reactors, non-lightwater reactor technology. These advances and technology change our understanding of what could be released, in what form, how much, and when, which can then change what actions we take. And we can develop models to examine shelter effectiveness for tomorrow's technology and find better ways to implement sheltering in place. For example, could we use filtered ventilation to our benefit? Many heating and cooling systems do not actually need to draw air in from the outside in order to function. And this suggests that rather than securing air conditioning systems, we could use them to help filter out airborne particulates and maintain livable conditions inside a shelter. This could increase radiological protection and would also avoid shifting the health risk to environmental concerns like heat exhaustion or heat stroke on a hot day. And what can we learn from other fields of study by looking at how shelters are already being used to protect from other hazards like chemical release, dust storms and other airborne contaminants? There's lots of data already out there and the NRC's performing studies to gather this data, build better models and inform implementation strategies for sheltering. Next slide, please. And masks. We've all developed the habit of wearing our masks for protection and masks are now a household item readily available for use. The current guidance suggests that wet towels and handkerchiefs can be useful to reduce dose. So does it make sense to wear a mask in a radiological emergency? If you wear a mask, what is the trade-off between internal or external dose build up on the mask? At the NRC, we have the tools and the talent in place to answer these question. We're using the tools from NRC's Radiation Protection Computer Code Analysis and Maintenance Program or RAMP to quantify the benefit of wearing a mask and to understand the trade-offs. And this will give the public confidence that protection habits they've already developed can be a simple means of protection against radiation. Next slide. And this is what the public wants to know. Are US Centers for Disease Controls perform studies in which they've asked the public what is the information you want to hear? And the reply was just tell us what we need to know to be safe. And as you see illustrated here, we can provide clear, concise messages to decision-makers and the public on simple measures they can take to be safe in a radiological emergency. And by maintaining consistency with the actions the public would use for other emergencies, we can build resilient communities ready to respond to and recover from all hazards, including radiation. So whether it's a tornado, a chemical release, a pandemic or a radiological event, the simple message of go inside, stay inside, tune in. And the decisions made for follow-on action can be trusted because we'll inform these decisions with solid evidence from science. Next slide. So thank you for listening. This concludes our panel presentations, which I trust you found informative. I also hope you found it encouraging and you've come away with a better understanding of the tremendous efforts underway across the globe to prepare us for a safe tomorrow. And with that, I think we'll transition to question and answer period. Okay, first question is a general question. How do NRC emergency preparedness programs compare with US Department of Energy? That's a great question. I think there's a lot of similarity between the US NRC and the DOE in terms of preparedness programs. That information is publicly available. A lot of it comes down into the use of hazard assessments to inform the planning. And then it comes down to how we use those hazard assessments to inform the tools that inform the planning. Like the size of emergency planning zones around the hazards and it informs the development of the emergency planning functions that ensure that protective actions can and will be taken. And I think in both the DOE and NRC requirements, these preparedness functions are scaled commensurate to the risk of the facility. So risk informed approach is used in both.