102

Radiation Poisoning

The London Polonium Poisoning: Events and Medical

Implications

Perkins AC

Academic Medical Physics, Medical School, University of Nottingham, Nottingham, NG7 2UH, UK.

Abstract been used as a lethal poison resulted in many hospital

management teams throughout the world seeking advice
The poisoning of Alexander Litvinenko on 23 November from their local Nuclear Medicine and Medical Physics
2006 was an unprecedented event. Po-210 is a highly toxic staff, most of whom would only previously be aware that
radioactive heavy metal with a physical half-life of 138 Po-210 was a radioactive element in the U-238 decay chain
days. Dispersal of the material by the perpetrators and the and would not at the time have had any idea of the nature or
victim resulted in widespread contamination that led to a characteristics of this now infamous radionuclide.
trail across London and abroad. This resulted in a massive The London poisoning was well organized, sophisticated
operation for health protection staff and the police service. and carefully executed. The surreptitious nature of the
The surreptitious nature of this act almost escaped Litvinenko murder almost escaped detection by the
detection. The fact that the nature of the poison was not medical staff and UK authorities. It is believed that there
known for a number of weeks after admission to hospital may have been previous killings of this nature outside the
indicates the difficulty in detecting alpha radiation. In this UK, however they have not formally been confirmed or
article, the sequence of events, the nature and uses of this reported. There have certainly been other high profile
radioactive element and the medical consequences of poisonings in Europe, the most notable being the
ingestion are outlined. The illicit use of radioactive “immunotoxin umbrella” killing of George Markov, a
materials raises important health and security issues. Bulgarian dissident in London in 1978 and the poisoning of
Medical and scientific staff in nuclear medicine and Viktor Yushchenko with dioxins in Ukraine in 2004.
hospital emergency departments should be aware of these As the events unfolded in London the medical, public
issues. health, security and political implications became evident.
Key words: Polonium-210, Litvinenko, alpha therapy, Although Alexander Litvenenko's symptoms of radiation
radiological security sickness were apparent (Figure 1), the fact that the nature of
the poison was not detected by the medical team until a few
World J Nucl Med 2007;6:102-106 days before his death, a number of weeks following his
admission to hospital, indicates the difficulty in detecting
Introduction alpha radiation poisoning. At one point it was considered
that he had been poisoned with thallium but that was ruled
The death of Alexander Litvinenko in London on 23 out prior to his death.
November 2006 elevated the prospect of a deliberate The manufacture of a lethal amount of alpha radiation that
radiation poisoning from a theoretical possibility to a could be brought across international boundries without
reality. This was an unprecedented incident that has detection and administered in an unobtrusive manner
implications for health teams and security officials would at first sight seem more like the fictional plot of a 007
throughout the world. The revelation that radioactivity had thriller. In reality the incident has raised important issues
for medical teams. These issues are particularly relevant for
nuclear medicine and medical physics staff. This paper
outlines the events and highlights the implications that
Correspondence: should be considered by hospital staff.
Prof. A C Perkins
Academic Medical Physics The events
Medical School
Queen's Medical Centre The sequence of events that took place in London in
Nottingham November and December 2006 are given in Table 1. The
NG7 2UH implications of the poisoning led to a great deal of media
E-mail: [email protected]

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Perkins AC

Figure 1. Photograph of Alexander Litvinenko released on 20

November 2006. His appearance is tytpical of toxic radiation
poisoning with loss of hair and a jaundiced appearance due to
impaired liver function.

attention both within the UK and abroad. The fact that this on an accepted background level of Po-210 from natural
type of poisoning was previously unheard of before sources being typically less than 20mBq/day. A reporting
November 2006 meant that newspaper and television level of 30mBq/day was used as a basis for determining any
broadcasters were avidly seeking information relating to significant increase in ingested activity. The total number of
the incident. As a result numerous medical and scientific urine samples tested was 738 out of which 601 were below
societies and academic institutions were contacted for the reporting level. The number of people presumed in
information on the nature of the poison and its medical contact with Po-210 was 137.
effects. Because of the widespread health implications and Once the nature of the poison had been identified further
public concern many hospital managers sought advice from monitoring revealed a trail of contamination across London
their local nuclear medicine and medical physics at sites viited by Alaxander Litvinenko. Including the Itsu
departments for further information on how a local incident Sushi Bar at 167 Piccadilly, London, the Pine Bar at the
could be handled and what reassurance could be given to Millenium Hotel in Mayfair, his London home and The
the worried but well members of the general public. Emirates Football Stadium. Radioactivity was also found
The medical team caring for Alexander Litvinenko was on British Airways aircraft and subsequently at a London
initially confused as to the nature of the poison. Bedside lap-dancing club.
monitoring failed to detect evidence of radiation since Po- Litvinenko's death became a major criminal investigation
210 only produces 1 gamma ray in every 100,000 decays. and as a result of the public concern following the Press
The final diagnosis was made by assay of 24 hour urine release the National Health Service telephone enquiry
collection. This was carried out with the assistance of the offices received almost 4000 calls. In London management
UK Health Protection Agency (HPA), previously known as of the events resulted in an overall cost of $4 million. The
the National Radiological Protection Board. City of Westminster spent $500,000 on environmental
Alpha emitters are currently being developed in a small health staff to close and clear sites of contamination. The
number of centers for targeted radionuclide therapy, but HPA checked 47 sites and more than 1,000 people. The
most hospital departments would not possess the necessary London Metropolitan Police spent nearly $2 million on the
counting facilities for the assessment of the body burden of investigation.
an alpha emitter. Data released from the HPA (1) was based

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Perkins AC

1 NOVEMBER 2006: Mr Litvinenko meets 2 Russian men at The Millennium Hotel in London. He also meets the academic Mario
Scaramella at a sushi bar where he said he received documents about the death of Russian journalist Anna Politkovskaya. Several hours
after his meetings, Mr Litvinenko complains of feeling sick and spends the night vomiting.
4 NOVEMBER: After 3 days of sickness and stomach pains Mr Litvinenko is admitted to Barnet General Hospital, north London.
17 NOVEMBER: Mr Litvinenko is transferred to the University College Hospital (UCH), London, as his condition worsens. He is placed
under armed police guard.
19 NOVEMBER: It was reported that Mr Litvinenko was poisoned with thallium.
20 NOVEMBER: Mr Litvinenko is moved to intensive care. Pictures were released showing his dramatic weight and hair loss (Figure 1).
Scotland Yard's counter-terrorism unit takes over the police investigation.
The police suspect "deliberate poisoning" but await toxicology test results.
21 NOVEMBER: Confusion over what made Mr Litvinenko ill. Professor John Henry, a toxicologist at St Mary's Hospital London, says Mr
Litvinenko may have been poisoned with "radioactive thallium".
22 NOVEMBER: Mr Litvinenko is described as "critically ill". Dr Geoff Bellingan, director of critical care at UCH rules out thallium as the
cause of his sickness. The ex-agent has a heart attack overnight.
23 NOVEMBER: Mr Litvinenko dies in intensive care. Scotland Yard investigations concentrating on "an unexplained death".
24 NOVEMBER: A statement made by Mr Litvinenko before he died accuses Russian President Vladimir Putin of involvement in his
death. Mr Litvinenko's father Walter tells reporters his son was killed by a "tiny little nuclear bomb". Health experts say they believe Mr
Litvinenko was deliberately poisoned by radioactive matter, believed to be polonium-210.
Police find traces of radioactivity at the Itsu sushi bar, the Millennium Hotel and at his north London home.
25 NOVEMBER: Tests are carried out on people who may have come into contact with Mr Litvinenko, including clients and staff at the Itsu
Sushi Bar and the Pine Bar at the Millennium Hotel.
26 NOVEMBER: Hundreds of people contact the NHS telephone hotline to seek advice about radiation poisoning.
27 NOVEMBER: An emergency statement was made in the House of Commons, by Home Secretary John Reid.
Police confirmed that traces of radioactive Po-210 had been discovered at 2 more central London addresses. Three people linked to the
venues Mr Litvinenko visited on 1 November are referred for radiological tests, after reporting possible radiation symptoms.

Table 1. Events leading to the death of Alexander Litvinenko in December 2006

Plonium-210 making it difficult to separate into a form for use as poison.

Po-210 is soluble in aqueous solution and forms simple
Po-210 is a highly toxic radioactive heavy metal with a salts (e.g. chloride) in dilute acids. Just how someone would
physical half-life of 138 days. It decays to stable lead-206 get hold of polonium for criminal acts is uncertain. Around
giving off 5.3MeV alpha particles that have a range of 40- 100 grams a year of Po-210 are manufactured worldwide in
50 µm in tissue. It occurs naturally in the earth's crust and nuclear reactors. At the time of writing there have been no
was the first element to be discovered by Marie and Pierre reported thefts of materials, although there is some concern
Curie as they worked to discover the nature of radioactivity of lack of security in some eastern European countries.
in pitchblend ore in 1898. It is thought that the London poisoning was carried out by
Artificial production normally requires a reactor for the the surreptitious addition of a small volume of radioactive
bombardment of Bi-209 with neutrons. It is used liquid to a drink, probably a cup of tea taken in the
industrially in static eliminators (the alpha particles ionise Millennium Hotel. The subsequent dispersal of the
the air neutralising static electricity) for processes such as radioactivity resulted in widespread contamination that was
paper rolling, production of plastic sheeting, spinning detected across London and on British Airways flights to
synthetic fibres and spray-painting processes. Po-210 is the east. In the weeks following the event the main task of
also used in brushes to remove dust from photographic film the UK Health Protection Agency was of contamination
and camera lenses. Substantial amounts of Po-210 generate monitoring and reassurance of the general public.
much heat as the atoms decay. It has been used in Human data on the biological effects of Po-210 are limited
thermoelectric power generators and heaters for a range of (2,3). There are a few recorded events implicating the toxic
military and space applications, for example it was used in nature of polonium poisoning starting with the death of
Russian lunar landers to warm the instruments at night. One Nobus Yamada in 1927 after working with polonium in
early application was for use in automobile spark plugs as Marie Curie's lab. Irene Curie died of leukaemia in 1956.
described in an early patent held by the Firestone Tyre and During World War II Dr Robert Fink of the University of
Rubber Company. The emission of alpha particles was Rochester gave Po-210 water to a patient with myeloid
considered to result in a more responsive and relaible spark leukaemia and 4 others as part of a medical experiment. The
for engine ignition, however this was never adopted cancer patient died the other 5 individuals survived. In the
commercially. years following the Second World War physicist Dror
Polonium is usually electroplated onto other metals, Sedah working with Po-210 on Israel's nuclear program

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Perkins AC

Figure 2. Diagram showing the metabolic pathway of Po-210 following ingestion.

reported widespread contamination on everything he bone marrow as well as the skin and hair follicles (Figure 2).
touched in his lab and his home. One of his students Approximately 5% is deposited in bone. The intense alpha
subsequently died of leukaemia. There is one reported case radiation within these tissues results in massive destruction
of a Russian male worker who accidentally inhaled an of cells, leading to a rapid decline in health. Animal studies
aerosol estimated to contain approximately 530MBq of Po- have shown that 0.1-0.3GBq or greater of Po-210 absorbed
210. The total retention was estimated as being into the blood of an adult male is likely to be fatal within 1
approximately 100MBq, with 13.3MBq in the lungs, month (2). This corresponds to ingestion of 1-3GBq or
4.5MBq in the kidneys and 21MBq in the liver. At the time greater assuming 10% gastrointestinal absorption to blood.
of admission to hospital 2 to 3 days after ingestion the Remedial medical treatments are considered unhelpful
patient had a fever and severe vomiting, but no diarrhoea. within a few hours following ingestion!
He died after 13 days. Anyone receiving such doses would
show symptoms of acute radiation sickness syndrome with Nuclear Medicine scenarios
bone marrow failure. About 5% of Po-210 reaching the
blood will be deposited in the bones. Subsequent damage to With many researchers now investigating the use of tumor
the liver and kidneys will contribute to death from multiple targeted alpha therapy (4) this incident has highlighted the
organ failure. Remedial medical treatment strategies are importance of possible effects from the uptake of alpha
considered to be unsuccessful within a few hours of emitters into sensitive normal tissues. Alpha particles have
ingestion, once significant amounts of Po-210 have entered a mass 7000 times greater and energy typically 30 times
the blood stream and deposited in tissues. greater than that of beta particles. The effective range of
Weight for weight Po-210 is a million times more toxic than particles in tissue is approx 5 cell diameters compared with
hydrogen cyanide. A microgram, (no larger than a speck of hundreds/thousands for particles. As a result the LET for
dust), would deliver a fatal dose of radiation. The maximum alpha particles is of the order of 100 times greater delivering
safe body burden of Po-210 is only seven picograms. around 0.25Gy in 10µm cell diameter. These characteristics
Following ingestion Po-210 has a biological half-life of 50 have made alpha emitters such as At-211, Bi-213 and Ra-
days. Approximately 10% is absorbed from the gut into the 223 attractive candidates for targeted radionuclide therapy.
blood. Once within the bloodstream it is rapidly deposited If delivered appropriately the short range and short physical
in major organs and tissues including the liver, kidneys and half-life of therapeutic alpha conjugates can result in

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Perkins AC

minimal effects on normal tissues and minimal residual investigations to characterise intercepted illicit sources in
accumulation of radiation in the body, resulting in greater order to gain evidence on their identification and
overall therapeutic benefit. However if appropriate tumor production history. The process of nuclear attribution
targeting is not achieved the detrimental biological effects involves the characterisation of nuclear and radioactive
can be severe. materials and determining their time and point of origin.
Nuclear medicine departments should be aware of the These have become important tools in the fight against
potential difficulties encountered by patients if they work at illicit nuclear shipping.
border control points, such as airports or intend to
undertake international travel. It is possible that patients Conclusions
may trigger radiation alarms 3 days after receiving Tc-99m,
30 days after Tl-20l and up to 95 days for I-131 (5). In such The London poisoning has alerted medical teams to the
cases departments should consider issuing a yellow travel reality of lethal poisoning with an alpha emitting
card similar to the one routinely given to patients receiving radionuclide. The toxic effects are now appreciated
therapeutic radioiodine. This should contain telephone together with the problems of detection and diagnosis. In
contact details for validation of the record by immigration the hospital environment it is important to make staff aware
authorities. of the potential risks associated with the receipt, storage and
The Litvinenko poisoning has also raised important issues use of radioactive materials such as teletherapy sources,
for health emergency teams who may receive casualties radionuclide generators and therapy doses. However even
contaminated with radioactivity. It is important to be aware with the rigorous training of medical teams it is difficult to
of the range of potential radiological scenarios involving envisage the consequences of all possible events. A
the use of nuclear materials (6). Illicit use of radioactivity criminal act involving the theft of nuclear material at a
may involve one or a combination of theft, smuggling, production site would require some degree of skill and
poisoning, attack or placement of materials. The main types knowledge, however the theft of sources held in hospital,
of criminal/terrorist nuclear threat could include: academic or commercial premises would be a great deal
? Radiation poisoning easier. As highlighted in this communication range of illicit
? Radioactive contamination of food or water uses of radioactive materials is broad and whilst recent
? “Dirty bomb” or Radiological Dispersal Device attention has been on preparing for the consequences of
(RDD) potential terrorist activities it is clear that other actions such
? Radiological Emplaced Device (RED) as extortion, assassination and suicide are real possibilities.
? Attack on a nuclear reactor Any such event will have political and socioeconomic
? Construction of an improvised nuclear device (IND) consequences and will inevitably attract a plethora of media
The criminal use of radioactive materials raises important attention. It is important that medical practitioners and
security issues. Most countries have high security control researchers involved with therapeutic radionuclides and
over radionuclide production sites and transportation. In the emergency room staff should be aware of these issues.
UK security has been increased in hospital radiotherapy
and nuclear medicine departments in view of the potential References
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radiopharmaceuticals have effective security measures in Polonium-210 as a Poison. J Radiol Prot 2007; 27:17-
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