Prevalence of Shielding in Diagnostic X-ray Centers in the Islamic Republic of Iran: A Systematic Review

  • Mohammad Chavideh Student Research Committee, Dezful University of Medical Sciences, Dezful, Iran
  • Seyed Reza Khorshidi Department of Medical Engineering, School of Technical and Engineering, Islamic Azad University, Iran
  • Alireza Bagzahedi Baghmalek Department of Medical Engineering, School of Technical and Engineering, Islamic Azad University, Iran
  • Raheleh Hassanvand Amoozadeh Department of Medical Engineering, School of Technical and Engineering, Islamic Azad University, Iran
  • Razieh Naserifar Department of Medical Engineering, School of Technical and Engineering, Islamic Azad University, Iran
  • Araf Alekasir Department of Medical Engineering, School of Technical and Engineering, Islamic Azad University, Iran
  • Yousef Bolandnazar Department of Medical Engineering, School of Technical and Engineering, Islamic Azad University, Iran
  • Mohammad Najafi Department of Medical Engineering, School of Technical and Engineering, Islamic Azad University, Iran
  • Ali Arianezhad Department of General Medicine, Dezful University of Medical Sciences, Dezful, Iran
Keywords: prevalence, shielding, diagnostic X-ray, radiation exposure, Iran


Shielding has been recommended as an effective tool against radiation exposure. Several studies have published on the availability and use of shielding tools in diagnostic X-ray centers across the country and contradictory results been reported. Therefore, the aim of this systematic review was to find out the status of radiation protection in term of availability and use of shielding tools in diagnostic X-ray centers in Iran. An extensive literature search was conducted in the PubMed/Medline, Embase, ISI, Cochrane Library, SID, Magiran, IranMedex, Irandoc and Google-Scholar search engine. We also manually searched the reference lists of the relevant studies. Two authors independently assessed the eligibility of all studies and extracted data. Thirty-seven studies published from 1998 to 2019 were included in this systematic review. In all, 1089 diagnostic X-ray centers, 4439 radiographs and performance of 1472 radiographers were covered in these studies. The availability of lead apron, gonad shield and thyroid collar were ranged from 7 to 95.5%, 26.6 to 94% and 7 to 94%, respectively. Moreover, their usage was ranged from 0 to 85.5%, 0 to 35% and 0 to 38.4%, respectively. In addition, lens shield was discussed in one study with availability of 0%. During 1998 to 2019, the status of shielding had not improved across the country. Therefore adherence to the safety guideline as far as possible is required to protection patients from undue exposure to radiation.


[1] Karami, V., & Gholami, M. (2018). Addressing as Low as Reasonably Achievable (ALARA) in Pediatric Computed Tomography (CT) Procedures. Journal of Research in Medical and Dental Science, 6(5),104-14.
[2]Karami, V., & Zabihzadeh, M. (2016). Review on radiation protection in diagnostic radiology. Tehran University Medical Journal TUMS Publications, 74(7), 457-66.
[3]Rothenberg, B. M., & Korn, A. (2005). The opportunities and challenges posed by the rapid growth of diagnostic imaging. Journal of the American College of Radiology, 2(5), 407-410.
[4] Zabihzadeh, M., & Karami, V. (2016). The challenge of unnecessary radiological procedures. Hong Kong Journal of Radiology, 19(3), 23-4.
[5] Karami, V., & Zabihzadeh, M. (2017). Beam collimation during lumbar spine radiography: A retrospective study. Journal of Biomedical Physics & Engineering, 7(2), 101-106.
[6]Shrieve, D. C., & Loeffler, J. S. (2010). Human radiation injury: Lippincott Williams & Wilkins.
]7] Karami, V. (2018). Fetography: The global outdated procedure, the national prevalent procedure: letters to the editor. Tehran University Medical Journal TUMS Publications, 76(2):153.
[8] Karami, V., & Zabihzadeh, M. (2016). Radiation protection in diagnostic X-ray imaging departments in Iran: a systematic review of published articles. Journal of Mazandaran University of Medical Sciences, 26(135), 175-88.
[9] Karami, V., & Zabihzadeh, M., Danyaei, A., & Shams, N. (2016). Efficacy of increasing focus to film distance (FFD) for patient’s dose and image quality in pediatric chest radiography. International Journal of Pediatrics, 4(9), 3421-9.
[10] Karami, V., Zabihzadeh, M., & Keshtkar, M. (2017). Evaluation of the Entrance Surface Dose (ESD) and Radiation Dose to the Radiosensitive Organs in Pediatric Pelvic Radiography. International Journal of Pediatrics, 5(6), 5013-5022.
[11] Zabihzadeh, M., & Karami, V. (2016). Letter to Editor: Poor collimation in digital radiology: A growing concern. Internet Journal of Medical Update-EJOURNAL, 11(2), 29-30.
[12] Karami, V., Zabihzadeh, M., Shams, N., & Gholami, M. (2017). Evaluation of the anode heel effect on the testes dose during pelvic radiography. Tehran University Medical Journal TUMS Publications, 75(2), 113-9.
[13] Karami, V., Zabihzadeh, M., Shams, N., & Malehi, A. S. (2017). Gonad Shielding during Pelvic Radiography: A Systematic Review and Meta-analysis. Archives of Iranian Medicine, 20(2), 113-23.
[14] Zabihzadeh M, Karami V. Current status of the fetography: Preventing of the future radiation induced cancer. Iranian Journal of Cancer Prevention, 10(1), e5209.
[15] Karami, V., Zabihzadeh, M., Shams, N., & Gilavand, A. (2017). Optimization of Radiological Protection in Pediatric Patients Undergoing Common Conventional Radiological Procedures: Effectiveness of Increasing the Film to Focus Distance (FFD). International Journal of Pediatrics, 5(4), 4771-4782.
[16] Hassanpour, N., Panahi, F., Naserpour, F., Karami, V., Asl, J. F., & Gholami, M. (2018). A Study on Radiation Dose Received by Patients during Extracorporeal Shock Wave Lithotripsy. Archives of Iranian Medicine (AIM), 21(12), 585-588.
[17] Behroozi, H., Tahmasebi, M., Mohebifar, B. (2018). Evaluation of the Prevalence of Shielding in Patients Undergoing Conventional Radiological Procedures (1 Work Shift–1 X-ray Room). Journal of Patient Safety, 14(3), 133-137.
[18] Karami, V., Zabihzadeh, M., Shams, N., Gholami, M. (2017). Radioprotection to the Gonads in Pediatric Pelvic Radiography: Effectiveness of Developed Bismuth Shield. Int. J. Pediatr, 5(6), 5153-5166.
[19] Karami, V., Zabihzadeh, M., Gilavand, A., & Shams, N. (2016). Survey of the use of X-ray beam collimator and shielding tools during infant chest radiography. International Journal of Pediatrics, 4(4), 1637-1642.
[20] Karami, V., Zabihzadeh, M., Gholami, M., Shams, N. F., & Nezhad. Z. (2016). Dose reduction to the thyroid gland in pediatric chest radiography. Int. J. Pediatr, 4(7), 2183-91.
[21] Karami, V. (2015). Report a concern: Letter to the editor. Tehran Univ. Med. J., 73(7), 544.
[22] Morford, K., & Watts, L. K. (2012) .Bismuth Shielding Durint CT Exams: A Literature Review. Radiology Management, 34(3).
[23] Hopper, K. D., Neuman, J. D., King, S. H., & Kunselman, A. R. (2001). Radioprotection to the eye during CT scanning. American Journal of Neuroradiology, 22(6), 1194-1198.
[24] Karami, V., Zabihzadeh, M., & Shams, N. (2018). Bismuth radioprotective gonadal shields: Prevalence of use and effect on image quality during paediatric pelvic radiography. Hong Kong Journal of Radiology, 21(3), 178-183.
[25] Karami, V., & Zabihzadeh, M. (2015). Prevalence of radiosensitive organ shielding in patients undergoing computed tomography examinations: An observational service audit in Ahvaz, Iran. Asian Biomedicine, 9(6), 771-775.
[26] Winfeld, M., Strubel, N., Pinkney, L., Lala, S., Milla, S., Babb, J., et al. (2013). Relative distribution of pertinent findings on portable neonatal abdominal radiographs: can we shield the gonads? Pediatric Radiology, 43(10), 1295-1302.
[27] Kim, S., Frush, D. P., & Yoshizumi, T. T. (2010). Bismuth shielding in CT: support for use in children. Pediatric Radiology, 40(11), 1739-43.
[28] Karami, V., Zabihzadeh, M., & Gholami, M. (2016). Gonad Shielding for Patients Undergoing Conventional Radiological Examinations: Is There Cause for Concern? Jentashapir Journal of Health Research, 7(2), e31170.
[29] Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., et al. (2015). Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Reviews. 4(1), 1.
[30] 34th Iranian Congress of Radiology. Retrieved October 2018, from
[31] 34th Iranian Congress of Radiology. Retrieved October 2018, from
[32] Dowd, S. B., & Tilson, E. R. (2004). Practical radiation protection and applied radiobiology: WB Saunders; 1999.
[33] Doolan, A., Brennan, P. C., Rainford, L. A., & Healy, J. (2004). Gonad protection for the antero-posterior projection of the pelvis in diagnostic radiography in Dublin hospitals. Radiography, 10(1), 15-21.
[34] Karami, V., Tahmasebi, M., Fatahi, & Asl, J. (2013). The protection knowledge and performance of Radiographers in some hospitals of Ahvaz County. Jentashapir Journal of Health Research, 4(5), 405-12.
[35] Borhani, P., & Mohammad, A. S. (2003). Evaluation of radiology personnel practice of Kerman university of medical sciences hospitals. 2003.
[36] Chaparian, A., Shamsi, F., & Heydari, A. (2013). Assessment of awareness, attitude, and practice of radiographers about radiation protection in Yazd Province. Occupational Medicine Quarterly Journal, 5(1), 16-23.
[37] Karami, V., Zabihzadeh, M., & Sarikhani, S. (2016). Evaluation of the frequency and accuracy of gonad shield placement in patients undergoing pelvic radiography. Brazilian Journal of Radiation Sciences, 4(1), 1-8.
[38] Karami, V., Zabihzadeh, M., Shams, N., & Sarikhani, S. (2016). Evaluation of the prevalence and utility of gonad shielding in pediatrics undergoing pelvic X-ray. International Journal of Pediatrics, 4(11), 3735-3740.
[39] MacKay, M., Hancy, C., Crowe, A., D'Rozario, R., & Ng, C. (2012). Attitudes of medical imaging technologists on use of gonad shielding in general radiography. Radiographer, 59(2), 35-9.
[40] Karami, V., & Zabihzadeh, M. (2012). Ovarian shielding during pelvis radiography: risk versus benefit. International Journal of Radiology and Radiation Therapy, 85, 442-447.
[41] Mehnati, P., & Refahi, S. (2007). Assessment of radiation protection in the radiological centers: A pilot study in Ardebil. Proceedings of the 1th congress of radiation protection in radiotherapy, diagnostic and interventionaal radiology; June 8-9 Tehran: shahid beheshti university of medical science, p. 1.
[42] Mirdoraghi, M., & Fatahi, A. J. (2017). Evaluation of Radiation Protection Condition in Educational Hospital Radiological Centers of Ahwaz University of Medical Sciences. Paramedical Sciences and Military Health, 11(4), 1-8.
[43] Rostamzadeh, A., Farzizadeh, M., & Fatehi, D. (2015). Evaluation of the level of protection in radiology departments of Kermanshah, Iran. Iranian Journal of Medical Physics, 12(3), 200-208.
[44] Bazrafshan, E., Mohamadi, J. L., Naroei, K., Parvaneh, H., & Mohamadrigi, F. (2012). Survey of health and protection status of radiology centers covered by Zahedan University of Medical Sciences during 2010-2011.
[45] Rahimi, S., Salar, S., & Asadi, A. (2007). Evaluation of technical, protective and technological operation of radiologists in hospitals of Mazandaran medical science universities. Journal of Mazandaran University of Medical Sciences, 17(61), 131-140.
[46] Tamjidi, A. (2001). Evaluation of applying protective principles against different rays in radiological centers in bushehr province, 2001.
[47] Praveen, B., Shubhasini, A., Bhanushree, R., Sumsum, P., & Sushma, C. (2013). Radiation in dental practice: awareness, protection and recommendations. The Journal of Contemporary Dental Practice, 14(1), 143.
[48] Evaz-Zadeh, N. (2001). Evaluation of the personal and environmental dosimetric status of diagnostic radiology departments in eastern Azarbayjan province: [MSc Thesis in medical physics]. Iran. Ahvaz Jundishapour Univercity of Medical Science 2001.
[49] Davoudiantalab, A. (2017). Survey of Compliance with Radiation Protection Standards in Diagnostic Imaging Centers of Khuzestan Province in 2015. Journal of Health Research in Community, 2(4), 1-10.
[50] Sheikhi, M., Khalilian, M., & Raisi, N. (1998). Evaluation of radiation protection principles observance in dental x-ray centers in Isfahan county. Journal of Research In Medical Sciences, 3(4), 57-60.
[51] Goodarzi, P. D., Ebrahimi, M. S. (2004). Evaluation of x-ray protective measurements in intraoral radiography equipped centers in Yazd. Journal of Dental Medicine, 17(4), 61-7.
[52] Tavakkoli, A., Nikneshan, S., & Varshousaz, M. (2004). Protection against X-Ray in dental clinics of Shahid Beheshti University of Medical Sciences in 1381.
[53] GhazikhanlouSani, K., Eskandarlou, A. (2009). Evaluation of radiation protection principles observance in Iranian dental schools. Journal of Dental Medicine, 22(3), 125-31.
[54] Halaji, A. (2006). Survey of dentist's knowledge & behavior about radiation health in Tehran dental clinics: Thesis. Tehran: School of Dental, Tehran University of Medical Sciences, 2006.
[55] Badrian, H., Sheikhi, M., & Abdinian, M. (2013). Knowledge, attitudes and performance of dental practitioners in Isfahan-Iran about biologic effects of ionizing radiation and protection against them in 2011. J. Mashad Dent. Sch., 37(1),19-26.
[56] Haghani, J., Raoof, M., Rad, M., Torabi-Parizi, M., & Lotfi, S. (2017). Evaluation of X-ray protective shielding used in dental offices in Kerman, Iran, in 2014. Journal of Oral Health and Oral Epidemiology, 6(1), 27-32.
[57] Ahmadian, Y. A., Mortazavi, S., & Rahmannia, G. (2018). Evaluation of the Compliance with the Principles of Radiation Protection in the Dental Offices in Mashhad, Iran. Journal of Mashhad Dental School, 42(1), 1-10.
[58] Shahab, S., Kavosi, A., Nazarinia, H., Mehralizadeh, S., Mohammadpour, M., & Emami, M. (2012). Compliance of Iranian dentists with safety standards of oral radiology. Dentomaxillofacial Radiology, 41(2), 159-64.
[59] Javadzadeh, A., & Alipour, H. (2011). Knowledge of general dentists about radiation protection in oral radiographic examinations in the city of Rasht-Iran in 2009. Recall, 3(2).
[60] Shahabi, N., Ghorbani-Shahna, F., Roknian, M., Goodarzi, S., Samavat, H., (Ed. 2004). Evaluation of radiation exposure to radiographers in teaching hospitals and private dental offices of Hamadan city in 2004. Proceedings of the 4th congress of environmental health of Iran 2004. Hamadan University of Medical Sciences.
[61] Karami, V., Zabihzadeh, M., Isavand-Faraji, A., Karampour, H. (2019). Radiological Protection in the Neonatal Intensive Care Units (NICU): A Retrospective and Observational Audit at Two Teaching Hospitals Supervised by Dezful University of Medical Sciences. Journal of Pediatric and Neonatal Individualized Medicine. 2019 In press.
[62] Tohidniya, M. R., Amiri, F., Khoshgard, K., & Hormozi, M. Z. (2017). Evaluation of the Observance of Radiation Protection Principles in Intensive Care Units at Imam Reza Hospital of Kermanshah. Journal of Payavard Salamat, 10(6), 470-478.
[63] Mojiri, M., & Moghimbeigi, A. (2011). Awareness and attitude of radiographers towards radiation protection.
[64] Bezanjani, N. J. (Ed. 2009). Study of personal protection performance for technologists and patients in diagnostic radiology departments of Kerman. Proceedings of the 12th congress of environmental health of Iran.
[65] Amirzadeh, F., Tabatabaie, S. (2006). Study of protection knowledge of technologists in Shiraz hospitals. Iran J. Nuclear Med., 13(24), 38-44.
[66] Rahimi, S. A., & Salar, S. (2005). A study on the performance of recommended standards in the diagnostic radiology units of the hospitals affiliated to the Mazandaran University of Medical sciences. Journal of Mazandaran University of Medical Sciences, 15(49), 69-76.
[67] Siavashpour, Z., Mehdizadeh, S., Farshadi, A., & Baradaran-Ghahfarokhi, M. (2012). Radiation protection principles observance in mammography divisions in Shiraz. Iranian Red Crescent Medical Journal, 14(12), 840.
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