Tag Archives: public safety

Multiple Potential Causes for Avian Flu Outbreak

By ThinkReliability Staff

An outbreak of avian influenza (flu) H5N2 centered around Iowa in the United States has resulted in nearly 47 million birds being killed in 21 states. There is a low risk that this outbreak could spread to humans as the 1996 avian flu did. The impacts on the poultry industry have been significant: the number of birds being killed has led to an increase in poultry prices. Says Phil Lempert, “We’ve lost 10 to 13 percent of the laying hens in this country, so we’re going to have this period of time where we have less birds and less eggs. That means higher prices.”

The financial impact isn’t limited to consumers. The United States Department of Agriculture (USDA) estimates it will spend more than $500 million fighting the outbreak. The impact on poultry producers is expected to be even higher. The USDA Animal and Plant Health Inspection Service (APHIS) is studying the outbreak and attempting to put into place measures that will reduce the spread of the outbreak. Finding the causes leading to the outbreak has proven to be challenging.

We can capture the information that is known in cause-and-effect relationships using a Cause Map to better understand what caused this outbreak. The first step in the Cause Mapping process is to fill in an Outline with basic background information, which includes listing how the overall goals are impacted by the issue. The Cause Map is than built by asking “why” questions to lay out the cause-and-effect relationships. In this example, the animal safety goal is impacted due to the deaths of nearly 47 million birds. These birds were killed because of an outbreak of avian flu. An outbreak results from an initial infection (believed to have been transmitted in this case to domestic flocks by wild birds) and the spread of the disease. Based on genetic analyses from APHIS, this outbreak appears to have multiple independent introductions within the outbreak area (i.e. the transmission from wild birds to domestic flocks happened in multiple locations).

According to their Epidemiologic and Other Analysis of HPAI-Affected Poultry Flocks: June 15, 2015 Report: “APHIS concludes that at present, there is not substantial or significant enough evidence to point to a specific pathway or pathways for the current spread of the virus. We have collected data on the characteristics and biosecurity measures of infected farms and studied wind and airborne viruses as possible causes of viral spread, and conducted a genetic analysis of the viruses detected in the United States.” This means that the cause or causes of the spread of the avian flu cannot be definitively determined due to lack of evidence. When an investigation has a lack of evidence, potential causes are included in the analysis with a question mark, indicating insufficient evidence.

In this case, avian flu was potentially spread by air, by wild birds, and by human movement. Data from APHIS research indicates that the virus has been able to spread on windy days up to a half mile. A solution under consideration is more advanced ventilation systems for poultry farms that would prevent transmission of disease from farm to farm. Previous outbreaks have indicated that wild birds can not only cause an initial infection, but can continue to spread the disease from flock to flock. This evidence supports this cause, but is not strong enough to rule out other causes so all should still be included on the Cause Map. Lastly, APHIS found inadequate biosecurity (primarily cleaning and disinfecting) measures on equipment and personnel that traveled from farm to farm, which could also potentially spread the disease.

The issues found with biosecurity are a particular concern. Says Michael T. Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota, “We used to think we had outstanding biosecurity in poultry. But, except for the outbreak in 1983, which was stopped quickly, we have never been tested before.”

Osterholm and other researchers say more research is needed to screen for viruses, and develop drugs and vaccines to ensure public safety. Although the virus has not yet been shown to infect humans, the Centers for Disease Control and Prevention has developed interim guidelines on testing and treatment. APHIS continues research on how to limit the spread and the USDA, in order to offer some relief on prices, has recently allowed poultry imports from the Netherlands.

To view a Cause Map, or root cause analysis presented in a visual cause-and-effect diagram, of the ongoing outbreak, please click “Download PDF” above.

Safely using a treadmill is not quite as simple as it seems

By Kim Smiley

Did you know that treadmills are the riskiest exercise machines?  I sure didn’t, but I have to admit that I have fallen off one before.  (Based on conversations with my coworkers, this isn’t all that uncommon.)  As recent headlines have made clear, using a treadmill safely may not be quite as simple as it seems.

According to data from the National Electronic Injury Surveillance System, about 19,000 people went to the emergency room (ER) because of treadmill injuries in 2009, which is about triple the number of injuries reported in 1991.  More and more people are using treadmills and the number of accidents has increased as well. Although only a small percentage of the injuries are serious, about 30 deaths related to treadmill use were reported between 2003 and 2011.

Understandably, the details surrounding Dave Goldberg’s death have not been released to the public, but it is believed that he slipped while using a treadmill and hit his head when he fell.  Falls off treadmills that result in serious injury are rare, but they have the potential to cause significant injury and even death. More common injuries associated with treadmill use are less serious overuse injuries, such as strains and sprains.

Children are at particular risk of being injured by treadmills.  A motor propels the belt on treadmills and children can get their extremities caught in the moving belt or suffer burns if they accidently turn a treadmill on or one is left running while unattended.  Of the 19,000 ER visits associated with treadmills in 2009, nearly a third were for children under age 9.

So how do you stay safe while using a treadmill?  The number one rule is to limit distractions.  Using a phone or watching TV puts you at a much higher risk of accidently misplacing a foot and falling.  (Trying to write an email while I walked on a treadmill is what resulted in my own fall.  Luckily, only my pride was injured, but I have learned my lesson.)

Treadmills have also risen in complexity and all the buttons and options can be distracting, especially if you are unfamiliar with the specific equipment.  Make sure you understand how to use the treadmill prior to starting the belt.  If you have balance issues or are elderly, you should also check with a doctor prior to using a treadmill.  And lastly, start by walking slowly and gradually increase the pace of the treadmill so that you aren’t caught unaware by how quickly the belt is moving.

To view a Cause Map of this issue, click on “Download PDF” above.

Listeria in Ice Cream Causes 3 Deaths

By ThinkReliability Staff

On April 20, 2015, the Centers for Disease Control and Prevention (CDC) announced a recall of all Blue Bell Creameries products due to possible contamination by Listeria monocytogenes.  While the company has not yet determined the source of the outbreak, they are working with outside agencies to determine potential causes and implementing solutions to reduce the risk of food-borne illness in the future.  Says Paul Kruse, the CEO and president, “We’re committed to doing the 100 percent right thing, and the best way to do that is to take all of our products off the market until we can be confident that they are all safe.  At this point, we cannot say with certainty how Listeria was introduced to our facilities and so we have taken this unprecedented step.  We continue to work with our team of experts to eliminate this problem.”

Performing a root cause analysis can help clarify the goals of an investigation, determine the causes of the problem(s) related to an issue, and provide ideas for action items to reduce the risk of the issue recurring.  We can gather the information known so far about the outbreak in a Cause Map, or visual root cause analysis.

The Cause Mapping process begins by capturing the what, when and where of an incident.  Here, the “what” is the Listeria outbreak.  The “when” in this case is believed to have started in 2010 and continued to the present.  It can be helpful to capture any noted differences about the particular investigation.  For example, most outbreaks don’t last 5 years.  The use of genome sequencing (starting in 2013) allowed investigators to tie Listeria cases from 2010 on to this particular outbreak.  An additional difference is that Listeria can replicate in very cold temperatures.  This is unusual because freezing foods generally reduces the risk of propagating food-borne contamination.  The “where” is across the US – all products have been recalled and all plants have been shutdown, with several having been implicated in spreading Listeria.  Another useful piece of information can be the task being performed.  In this case, the contamination was discovered during random sampling.

The next step is identifying the impacts to the goals.  For this incident, the safety goal was impacted due to the sicknesses and deaths.  The outbreak of Listeria can be considered an impact to both the environmental and customer service goal, while the loss of production (no Blue Bell products are currently available or being produced for consumers) is an impact to the production goal.  The disposal of the estimated 8 million gallons of ice cream covered by the recall impacts the product goal, and the response and investigation impacts the labor goal.

The analysis step begins with an impacted goal.  Asking “why” questions develops the cause-and-effect relationships that led to the impacts.  In this case, the sicknesses and deaths were caused by a Listeria outbreak.  In order to have a food-borne illness outbreak, the food needs to be contaminated AND it needs to be delivered to consumers.  In this case, the contamination was not known because ice cream is not tested for Listeria.  There is no history of Listeria outbreaks in ice cream and testing is difficult on perishable products because of the time required.  Once ice cream products are again manufactured for consumers, Blue Bell has said it will implement a test and hold process (holding product until testing comes back negative).

The Listeria contamination results from the introduction of Listeria into the ice cream.  As discussed before, Listeria can replicate in cold temperatures.  The contamination source is likely surfaces in the production facilities or cross-contamination from other food products.  Because multiple plants are contaminated and cleanliness issues have been a concern in the past, it is likely that the outbreak is due to contamination of surfaces, on which Listeria can remain for a long time if not properly sanitized.

In addition to the test and hold process, Blue Bell is in the process of implementing a number of other changes to reduce the risk of future contamination.  Employees are being trained in microbiology and an expanded cleaning and sanitation program.  Prior to production resuming, equipment is being disassembled, cleaned, and tested for contamination and design changes that would make cleaning easier (reducing the risk of future contamination) are being considered.

While it is sometimes difficult to determine the success of solutions, the test and hold process to be used for future ice cream products should provide almost real-time feedback on the success of the programs and ensure that future problems are quickly identified.

To view a one-page PDF of the analysis and solutions, please click on “Download PDF” above.  To learn more about the ice cream Listeria outbreak, click here.  To read our previous blog about the 2011 fatal Listeria outbreak in cantaloupe, click here.

This year’s flu vaccine only about 23% effective

By Kim Smiley

According to the Centers for Disease Control and Prevention (CDC), the flu vaccine for the 2014-2015 flu season is only about 23% effective among people of all ages.  While the flu vaccine is not perfect, the effectiveness is generally closer to 60% percent.

So what made this year different?  Why is the flu vaccine so much less effective than what has been previously observed?  The short answer is that creating a flu vaccine is not an exact science and that the experts’ best guess of which flu strains would be the most common wasn’t as good this year.

One of the reasons that a flu vaccine is needed each year while many vaccines (like the MMR vaccine) aren’t is that the flu virus changes relatively quickly.  The strains of flu that are circulating generally morph from year to year and a new vaccine is needed to protect against them.  The lag time inherent in developing a new vaccine also makes attacking this moving target  difficult.  It just takes time to develop a new vaccine that needs to be tested, manufactured and distributed to millions of people.  Companies need about six months to manufacture vaccines in the quantities required so the process of developing a new flu vaccine begins long before the predicted start of the flu season.

Every year there are hundreds of different strains of flu circulating and flu vaccines contain antigens for only 3 or 4 specific strains. Deciding which strains to include in the vaccine each year is not a simple cut and dry decision. Scientists monitor which strains of flu are circulating worldwide and use that data to select which strains to include in the vaccine, but it is difficult to predict how the virus will change months out.  The button line is that sometimes the flu virus changes unexpectedly and the vaccine ends up being less effective, as it did this year when the specific type of H3N2 virus included in the vaccine morphed after the development of the vaccine.

The question of how to prevent a similar problem in the future is tricky and doesn’t have simple answers.  There are scientists working to develop antigens that would respond to a part of the flu virus that doesn’t change, which could potentially lead to a longer lasting flu vaccine.  Until then the best way you can protect yourself is to get the flu vaccine each year. The CDC still recommends people receive the vaccine this year, even with the lower effectiveness, because it does offer some protection against the flu.

And wash your hands often with soap…that is always the simplest way to reduce the spread of disease.

To view a high level Cause Map, a visual root cause analysis, of this issue, click on “Download PDF” above.

65 surgeries required for boy who swallowed button battery

By ThinkReliability Staff

As you can imagine, as someone who regularly analyzes and reports on disasters of every kind, my mind is never far from things that could harm my children. Though the types of events I typically include are well-publicized, the real dangers for children tend to be things closer to home, that one might reasonably consider harmless.

Even after our blog about the dangers of children swallowing batteries (regarding a study that said a child in the US visits an emergency room every 3 hours for issues involving a battery and that 84% of these are button batteries), I didn’t really get it. Sure, swallowing anything is bad, and batteries have nasty chemicals in them. But it wasn’t until I read the story of Emmett Rauch that I really got how bad these issues could be.

When Emmett was one, he swallowed a button battery. His parents could tell that something wasn’t right, and Emmett was diagnosed with a cold, then croup. Luckily at a pediatrician visit 3 days after he swallowed the battery, the pediatrician had second thoughts and sent Emmett to the ER for an x-ray. Once the button battery was discovered lodged in his esophagus, the rush to treat him began. Emmett would receive 65 surgeries over the next four-and-a-half years to rebuild his esophagus and vocal chords.

Amazingly, Emmett is a survivor. He’s one of the lucky ones. There have been 15 deaths associated with small batteries over the last 6 years. Emmett’s mother, Karla Rauch, is now an activist for button battery ingestion awareness. The issues resulting in deaths and injuries to children (primarily under the age of 5) regarding button batteries are as follows:

Chemical reaction caused by batteries in the esophagus: Batteries (even “dead” ones) contain chemicals that create current. The moistness of the esophagus can cause a chemical reaction that can burn holes in the tissue.

Accessibility of button batteries: Kids like shiny things and they like to put things in their mouth. The first line of defense is preventing access to small batteries. Here’s how:

– Keep loose batteries out of reach of children

– Ensure battery compartments on products are secured

– Buy products with battery compartments that require a tool to open if possible

– Use duct tape to secure products with batteries that don’t require a tool

Difficulty of diagnosis – at home: Because the batteries are so small, kids will likely still be able to breathe after swallowing them, limiting parent’s ability to figure out that they’ve swallowed something they shouldn’t. Because of the ubiquity of small batteries, parents may not realize they’re missing.

Difficulty of diagnosis – at the hospital: An x-ray is required to determine that a child has swallowed a battery. An x-ray may not be called for if a doctor thinks (as is common) that the coughing or apparent throat damage is due to another sickness. Even though button batteries have been around for a while, they’re still not a risk that is very apparent to most people. So, if you think there is a possibility your child may have swallowed a battery, act quickly:

– Seek immediate medical attention if you believe a battery has been swallowed

– Do not let the child eat or drink

– Do not induce vomiting

– Tell the medical staff it may be a small battery

– If possible, provide information on the battery

To view an overview of this issue and solutions, please click on “Download PDF” above. Thanks to Karla Rauch for sharing her story. To learn more, see www.emmettsfight.com.

Patient With Ebola Sent Home From ER

By Kim Smiley

If you have been paying any attention to the news lately you have heard that a patient was diagnosed with Ebola in the United States for the first time.  The fact that the patient sought treatment at an emergency room (ER) and was sent home is particularly alarming and people are naturally very interested in how such a thing could happen.

The media has been flooded with breaking news about this case. In situations like this, keeping track of what information is current and reliable and what is already outdated or has been determined to be inaccurate can be a moving target.  A Cause Map, a visual format for performing a root cause analysis, can be useful in these situations as a way to document the available information.  A Cause Map visually lays out the causes that contributed to an issue in an intuitive format.  It is relatively easy to quickly expand a Cause Map as more information becomes available.

Generally, a Cause Map is built in an Excel workbook so old versions of the Cause Map can be easily saved as different tabs and that the evolution of the investigation isn’t lost.  Additionally, it’s easy to add evidence supporting each individual cause onto the Cause Map itself so that all relevant information is documented in one location and easily referenced.  There are often things that are being considered that may have played a role in a problem, but lack evidence to determine whether or not they are actually relevant to the investigation.  This situation can be documented on a Cause Map by listing the potential cause and adding a question mark to show that a cause is being considered, but that it needs more evidence.  If that cause is later determined to not have been a factor it can be crossed out to document that it has been considered so that no work is duplicated.

So what information is known at this point about the patient with Ebola who was sent home from the ER?  A man has been diagnosed with Ebola in Dallas, Texas.  Statements by friends and family indicate that he helped transport a sick woman prior to traveling to the US.  It’s not clear whether he knew that she had Ebola or not.  After being exposed to Ebola, he passed through the airport screening because he did not have a fever at that time and he did not indicate possible exposure on the required questionnaire.   He arrived in Dallas, Texas on September 20, 2014.

His family has stated that he started feeling ill on the 24th and he sought treatment at a hospital on September 26.  He was released with a prescription for antibiotics.  Ebola can be difficult to diagnose because the early symptoms, such as fever and muscle pains, are very nonspecific.  The only information the hospital would have had to indicate that patient might have Ebola is his travel history.  Statements by the hospital indicate that the patient told the nurse he had recently been in Liberia.  The travel history information doesn’t seem to have been known by physicians that treated the patient.  Initial statements by the hospital indicated that issues with electronic health records may have played a role in the confusion, but later released more information that modified their position.  Exactly how the risk of Ebola was missed isn’t clear and this portion of the Cause Map will need to be expanded as more information is available.

It is not shocking that an Ebola case would be diagnosed in the US with travelers still arriving from West Africa and the long incubation period.  As long as Ebola is still a problem in Africa, US hospitals could see more patients with Ebola and need to be prepared for the possibility.  But it is concerning that someone who had recently traveled from West Africa with a fever wouldn’t trigger any alarms at an ER.   Individuals with Ebola must be quickly identified and isolated In order to prevent the spread of the deadly disease and hospitals in the US need to ensure that no other potential Ebola patients fall through the cracks.

Click on “Download PDF” above to see an initial intermediate level Cause Map for this example.

Toxic Algae Bloom Makes Toledo’s Water Unsafe

By Kim Smiley

On the evening of August 1, 2014, 400,000 people living in the Toledo, Ohio region were told not to use or consume tap water.  The water ban was imposed after higher levels of a toxin,  microcystin, than were deemed safe were detected in the water supply.   The water ban was lifted on the morning of August 4, but the issue may not be over since many of the factors that lead to the problem are still present.

This issue can be analyzed by building a Cause Map, or visual root cause analysis.  A Cause Map intuitively lays out the cause-and-effect relationships that contributed to an issue.   In order to build the Cause Map, “why” questions are asked and the answers are documented on the Cause Map.

So why were people told not to use their tap water?  Microcystin is a toxin that can cause vomiting, cramps, rashes and even significant liver damage, and it was detected in the water supply at levels officials deemed unsafe.  (No illnesses have been reported as a result of the toxin.)  The investigation is still ongoing, but many scientists believe the microcystin came from a recent algae bloom in Lake Erie, where the area draws their water.  Algae blooms in Lake Erie are relatively common, but recent weather patterns meant that this particular bloom occurred near  the water treatment plants’ inlets.

Algae are always present in Lake Erie; they can reproduce rapidly and may form a bloom when conditions are conducive to growth and there is high nutrient availability.  Scientists are still working to understand more about the algae blooms, but many believe that phosphorus in agricultural runoff is the main source feeding them.  Phosphorus is commonly used in fertilizer and rain washes it into the lake where it may be consumed by algae.  There are also other possible sources of phosphates such as cattle feedlots and leaky septic systems that need to be investigated.

While it’s tempting to over simplify this issue, it really is very complicated.  There is research showing that an invasive species, the zebra mussel, may be adding to the problem by selectively consuming the non-toxic algae so that any blooms that form are more likely to be toxic. There is still debate about what exactly is causing the algae blooms to form. There are limited federal regulations in place to limit or monitor agriculture runoff and there isn’t agreement on what, if anything, should be done.  There are not even federal limits on the allowable levels of microcystin in drinking water.  Toledo officials used the limits set by the World Health Organization because there isn’t a federal standard.

There are many open questions and not enough answers.  One of the things that we do know is that this particular algae bloom wasn’t particularly bigger or more intense than what has been normal in recent history.  Its main distinguishing characteristic was the location near the water plant inlets.  Scientists are predicting that blooms will peak in September this year so the impacts on the water supply may not be over for the year.

Scientists Moving a Lab Find Forgotten Smallpox

By Kim Smiley

On July 1, 2014, vials marked “variola”, the virus that causes smallpox, were found when a fridge was being cleaned out as part of the effort to move a National Institutes of Health campus to a new location. The vials were immediately secured and a CDC team was dispatched to retrieve the vials. No exposure to smallpox is suspected, but the discovery is still alarming. There are only two heavily secured locations where smallpox is supposed to exist in the world so the fact that vials of a dangerous virus were just sitting forgotten in a fridge has raised many issues that that should be investigated.

This issue can be analyzed by building a Cause Map, a visual root cause analysis method.  To build a Cause Map, the problem is first defined by identifying impacts to the overall goals and then “why” questions are asked to lay out all the causes that contributed to an issue to show the cause-and-effect relationships.  For this example, the safety goal was impacted because there was potential for a smallpox outbreak.  This would be the first box on the Cause Map and more boxes would be added by asking “why”.

So “why” was there potential for a smallpox outbreak?  This occurred because there was a potential for people to be exposed to the smallpox virus and the population has little to no immunity to smallpox.  There was potential for exposure to smallpox because “lost” vials of smallpox were in a fridge in an unsecured lab.  The vials, which were created in 1954, appear to have been in the fridge a long time and somewhere along the way, their presence was forgotten.  Smallpox can survive in refrigeration for a long time and testing has shown that the virus was still viable.  The general population has little immunity to smallpox.  The last smallpox case in the United States was in 1949 and the US stopped vaccinating for smallpox in 1972.

The final step of the Cause Mapping process is to use the Cause Map to develop and implement solutions to  reduce the risk of a similar problem occurring in the future.  In this example, the immediate problem was addressed by moving the vials to a secured lab.  Once scientists are done studying the vials, the contents and all traces of the virus will be destroyed.  Longer-term solutions will likely include ensuring that all  government laboratory storerooms are inventoried to ensure that no other potentially dangerous vials have been “lost”.  Inventory procedures should also be reviewed to ensure they are adequate.

To me, the most worrisome part of this issue is that the vials were only discovered because workers were moving the lab to a new location. It naturally raises questions about what else might be out there and how frequently inventory is happening, or not happening as the case may be.   Investigation into this incident has already uncovered a number of other vials filled with potentially dangerous specimens in the same storage facility.   If any other potentially dangerous vials are “lost” in other locations, I hope we find them before 60 years have passed.

To view a high level Cause Map, click on “Download PDF” above.

FDA Ruling Questions Safety and Effectiveness of Antibacterial Soaps

By Kim Smiley

The Federal Drug Agency (FDA) has formally questioned the safety and effectiveness of antibacterial soaps with a ruling on December 16, 2013.   Manufacturers of antibacterial soaps have one year to provide data that proves that anti-bacterial soaps are both safe and more effective than regular soap and water. Any antibacterial products that have not provided sufficient data to satisfy regulators by late 2016 would have to be reformulated, relabeled or removed from the market.

This issue can be analyzed by building a Cause Map, or visual root cause analysis.  A Cause Map visually lays out the many causes that contribute to an incident to intuitively show the cause-and-effect relationships.  When starting the Cause Mapping process, the first step is to fill in an Outline. The Outline documents the basic background information as well as lists how the issue impacts the goals.

In this example, there are a number of impacts to the goals worth considering.  The potential financial impacts are certainly significant.   It is estimated that it will cost companies between $112 million and $368 million to comply with the new regulations.  The safety goal is also a key component of this issue since safety concerns are one of the driving factors for the new push for additional data.

The FDA is concerned about the safety of antibacterial soaps because many contain triclosan and other similar chemicals.  Studies using lab animals have found that triclosan can disrupt hormones, such as sex hormones and thyroid hormones.  Interference with the body’s natural hormone levels can have a huge impact on how the body functions, especially in children who are still growing.  Use of antibacterial agents has also been associated with an increase in allergies, although more data would be needed before a definitive link could be established.  Use of antibacterial products may also lead to increased resistance to antibiotics which is an issue generating increasing concern.

In addition to questions about safety, there are also questions about the effectiveness of the products.  Microbiologists at the FDA have stated that there is currently no evidence that use of over-the-counter antibacterial soap is any more effective at illness prevention than simply washing with soap and water.  Consumers buying the products assume that they are getting some sort of additional protection against illness, but that doesn’t appear to be the case.  It is also worth noting that viruses are the most common cause of infection in the United States and antibacterial products are powerless against them.

The bottom line appears to be that antibacterial soaps are more expensive, have potential risks associated with them and aren’t better at preventing illness.   Manufacturers will have the opportunities to present data about their products to the FDA, but I expect that there will be some significant changes to antibacterial products in the future.

The current ruling does not apply to hand sanitizers which are typically alcohol based so don’t be afraid of using sanitizer if hand washing is unavailable.  Also, studies have proven triclosan is effective at fighting gingivitis in toothpaste.  This current ruling only applies to personal hygiene products (like hand soap), but I suspect this is just the first of many hard questions for the billion dollar anti-bacterial product industry.

To view the Outline and Cause Map, please click “Download PDF” above.

Study Finds that Fukushima Fallout is Affecting Babies in US

By Kim Smiley

A recent study found that babies born on the West Coast of the United States shortly after the Fukushima nuclear reactor meltdown have a higher rate of congenital hypothyroidism than those born a year earlier.  Thyroid issues have long been known to be associated with exposure to radiation and this finding feeds worries about the long term and long distance impact of the reactor disaster.

This issue can be analyzed by building a Cause Map, a visual root cause analysis, which intuitively lays out all the causes that contributed to an issue.  A Cause Map is built by asking “why” questions and adding the answers to the Cause Map to show the cause-and-effect relationships.

Why has the rate of congenital hypothyroidism increased?  This happened because the infants had radioactive iodine in their thyroids and radioactive iodine may affect the functioning of the thyroid if ingested.  If the thyroid doesn’t function properly, it can’t make the necessary hormones for healthy development and both growth and development can be stunted. The impacts of radioactive iodine are predominantly seen in the thyroid because ingested iodine concentrates in the thyroid where it is used to produce hormones.  The body can’t distinguish between stable and radioactive isotopes of iodine and it will store whatever iodine is available so ingested radioactive iodine can be kept within the body long enough to cause damage.

In the cases of fetuses, the mother passes iodine to her baby.  If pregnant woman ingests radioactive iodine, some of it will likely end up in the thyroid of her baby who needs the iodine to develop properly.  In this example, pregnant women on the West Coast were exposed to significantly higher than normal levels of iodione-131 following the Fukushima meltdown. Iodione-131 is a fission product that is created in a nuclear reactor when atoms are split.  When the reactor containment failed, radioactive isotopes of iodine were released into the environment along with other fission products.  Winds carried some of the radiation across the Pacific Ocean. Iodine-131 concentrations in precipitation in the United States were up to 211 times above normal in the days following the accident.  Some of this radioactive iodine found its way into the food supply and was ingested by people, some of them pregnant women causing the increase in cases of congenital hypothyroidism.

The good news is that congenital hypothyroidism with can be treated if found early.  The bad news is that there may be more health issues from the Fukushima meltdown in places outside of Japan discovered in the future.  The reality is that more than two years after the event we still don’t know what all the impacts of the radiation will be, both in Japan which has obviously suffered the most and in other countries.