Joint Circular No. 2237/1999/TTLT-BKHCNMT-BYT guiding the implementation of radiation safety in healthcare

JOINT CIRCULAR

Guidelines for Implementing Radiation Safety in Healthcare

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Based on Article 28 (Clause 2, 3) and Article 29 of the Radiation Safety and Control Ordinance dated June 25, 1996;

Based on Article 34 and Article 48 of Decree No. 50/1998/NĐ-CP dated July 16, 1998 of the Government detailing the implementation of the Radiation Safety and Control Ordinance;

The Ministry of Science, Technology, and Environment and the Ministry of Health issue guidelines for implementing radiation safety in healthcare as follows:

I. OBJECTS AND SCOPE OF APPLICATION

These Circulars apply to medical examination and treatment facilities, research institutions, and training centers for medical staff under state ownership, private ownership, and other forms, including those with foreign investment capital (hereinafter referred to collectively as healthcare facilities) that use X-ray equipment, radiotherapy equipment (hereinafter collectively referred to as radiation equipment), sealed radioactive sources, and unsealed radioactive sources for medical examinations, treatments, scientific research, and training.

II. RESPONSIBILITIES FOR ENSURING RADIATION SAFETY

1. Managers of radiation facilities within healthcare facilities:

Radiation facilities within healthcare facilities are units (departments, rooms, divisions, departments, groups) directly using radiation equipment, sealed radioactive sources, or unsealed radioactive sources for medical examinations, treatments, scientific research, and training.

The manager of a radiation facility within a healthcare facility is the head or person responsible for managing such facility.

The manager of a radiation facility must have knowledge of radiation safety, be thoroughly familiar with, and strictly implement all regulations concerning radiation safety and control.

2. Radiation safety officers at radiation facilities:

a) The radiation safety officer is appointed by the manager of the healthcare facility. The radiation safety officer must undergo training in radiation safety according to a program jointly prescribed by the Ministry of Science, Technology, and Environment and the Ministry of Health, and must hold a certificate of training issued by a training institution authorized by the Ministry of Science, Technology, and Environment. The radiation safety officer may concurrently serve as a medical practitioner who treats patients with radiation.

b) The radiation safety officer is responsible for implementing the provisions set forth in Article 11 of the Radiation Safety and Control Ordinance.

3. Radiation staff at healthcare facilities:

a) Radiation staff includes doctors, nurses, technicians, engineers, and pharmacists working directly with radiation equipment or sealed/unsealed radioactive sources, or caring for patients treated with radioactive isotopes.

b) Radiation staff must comply with the provisions of Article 12 of the Radiation Safety and Control Ordinance. Radiation staff must take every measure to minimize patient dose while still obtaining all necessary clinical information.

III. PROVISIONS ON REPORTING, REGISTRATION, AND PERMIT ISSUANCE

1. Reporting:

a) Radiation facilities using radiation equipment, sealed radioactive sources, unsealed radioactive sources, or radioactive waste must report to the provincial Department of Science, Technology, and Environment within 15 days from the date of acquisition, following the prescribed form (Annex 1, Tables 1, 2, 3, 4, 5, 6). At the same time, a copy of the report must be sent to the provincial Department of Health (for monitoring purposes). In case of sale or transfer of equipment, the selling or transferring entity must notify in writing the provincial Department of Science, Technology, and Environment where the equipment was previously reported. The purchasing or receiving entity must complete the reporting procedures with the provincial Department of Science, Technology, and Environment where their facility is located.

b) The provincial Department of Science, Technology, and Environment is responsible for compiling and managing these reports. Within 15 days of receiving the report form, the provincial Department of Science, Technology, and Environment must send it to the Radiation Safety and Nuclear Safety Board under the Ministry of Science, Technology, and Environment.

2. Application for Registration Certificate:

a) Radiation facilities with radiation equipment, radiotherapy equipment, sealed radioactive sources, or radioactive waste storage sites must apply for a registration certificate if they have not planned to use them within six months. If immediate use is planned, there is no need to apply for a registration certificate.

The application for a registration certificate includes:

- A request for a registration certificate (Annex 2);

- A copy of the equipment's technical specifications, source documentation, or a copy of the design for the radioactive waste storage site.

b) Applications for registration certificates for radiotherapy equipment, sealed radioactive sources, and radioactive waste storage sites should be submitted to the Radiation Safety and Nuclear Safety Board under the Ministry of Science, Technology, and Environment.

c) Applications for registration certificates for X-ray equipment (excluding accelerators) should be submitted to the provincial Department of Science, Technology, and Environment where the radiation facility is located.

d) The provincial Department of Science, Technology, and Environment must submit monthly statistics of issued registration certificates from the previous month to the Radiation Safety and Nuclear Safety Board under the Ministry of Science, Technology, and Environment.

3. Application for Permit to Conduct Radiation Work (hereinafter referred to as permit) and Special Radiation Work:

a) When preparing to conduct radiation work, the following entities must apply for a permit:

- Facilities using radiation equipment, sealed radioactive sources, or unsealed radioactive sources.

- Facilities exporting, importing, or transporting radiotherapy equipment (excluding accelerator transport), sealed radioactive sources, or unsealed radioactive sources.

- Staff performing special radiation work such as operating, installing, or repairing radiotherapy equipment.

b) The application for a permit for facilities using radiation equipment, sealed radioactive sources, or unsealed radioactive sources includes:

- A permit application form (Annex 3, Model 1).

- Production permits for radiation equipment, sealed radioactive sources, or unsealed radioactive sources from the exporting country (if applicable).

- A radiation safety assessment report.

- A copy of the design for the room housing the radiation equipment or nuclear medicine practice room (or layout diagram of the equipment in the room, room dimensions for existing radiation facilities prior to the effective date of this Circular),

- A list of radiation staff, radiation safety officers, and their qualifications. For facilities using radiotherapy equipment, a copy of the special radiation work permit for the operator of that equipment must also be included.

c) The application dossier for obtaining a permit for export, import, transportation of radiation therapy equipment (excluding accelerator transportation), sealed radioactive sources, and unsealed radioactive sources includes:

- Application form for obtaining a permit (Annex 3, Form 2, Form 3).

- Declaration form (Annex 1).

d) The application dossier for obtaining a permit to perform special radiation work: operation, installation, repair of radiation therapy equipment by radiation workers includes:

- Special radiation work permit issuing unit (Annex 3, Form 4).

- Copies of professional certificates and diplomas.

- Copy of radiation safety certificate issued by a training institution authorized by the Ministry of Science and Technology and Environment.

- Health certificate issued by a health center at district level or higher, occupational disease clinics of provincial preventive health centers, or the Institute of Occupational Medicine and Environmental Health.

đ) The application dossier for obtaining a permit for using, exporting, importing, transporting radiation therapy equipment (excluding accelerator transportation), sealed radioactive sources, unsealed radioactive sources, and performing special radiation work shall be submitted to the Radiation Safety and Nuclear Safety Department under the Ministry of Science and Technology and Environment.

e) The application dossier for obtaining a permit for using X-ray emitting devices (excluding accelerators) shall be submitted to the Department of Science and Technology and Environment where the radiation facility is located. The Department of Science and Technology and Environment shall cooperate with the Department of Health to organize a radiation safety review before issuing the permit.

g) The Department of Science and Technology and Environment must send a statistical list of permits issued during the year and a report on the radiation safety and control situation within its jurisdiction for that year to the Radiation Safety and Nuclear Safety Department under the Ministry of Science and Technology and Environment before December 20th each year.

4. Declaration, application for registration, and application for a permit can be done simultaneously.

5. At least 60 days before the expiration date of the permit, radiation facilities must apply for renewal at the place where the permit was originally issued.

The renewal application dossier includes:

- Renewal application form (Annex 4).

- A radiation safety assessment report.

6. When radiation facilities wish to upgrade, expand the scope or purpose of their activities beyond the provisions of the permit, or when they want to upgrade radiation equipment outside the content of the registration, they must comply with the provisions of Article 30 of Decree No. 50/1998/NĐ-CP dated July 16, 1998, of the Government.

7. The revocation of permits shall be carried out according to the provisions of Article 32 of Decree No. 50/1998/NĐ-CP dated July 16, 1998, of the Government.

8. The Ministry of Science and Technology and Environment, and the Departments of Science and Technology and Environment shall issue registrations and permits in accordance with the provisions of Article 23, Clause 2, Points b and c, and Article 24, Clause 2, Points b and c of the Radiation Safety and Control Ordinance.

9. Radiation facilities applying for registration, permit issuance, or renewal and modification of permits must pay the examination fee and stamp duty as prescribed by the Ministry of Finance (Article 27 of the Radiation Safety and Control Ordinance).

IV. TECHNICAL REQUIREMENTS FOR RADIATION EQUIPMENT

1. General requirements for X-ray emitting devices and radiation therapy equipment containing sealed radioactive sources used for diagnosis and treatment:

a) Must comply with international or Vietnamese standards.

b) Must have accompanying documents such as technical specifications, operating instructions, maintenance instructions including safety guidelines, and must be translated into Vietnamese.

c) Must have an automatic beam control system.

d) Must limit exposure in the patient examination and treatment area.

2. Requirements for X-ray emitting devices or radiation therapy equipment using sealed sources for diagnosis:

a) The X-ray emitting device and accessories must ensure low, reasonable exposure levels suitable for information acquisition needs.

b) Parameters set on the X-ray emitting device such as high voltage (kV), high current (mA), exposure time (s), mAs, focal spot size, convergence distance, field size, filter must be clearly specified and accurate.

c) In the imaging mode, the machine must be equipped with a timer to terminate exposure once the predetermined level is reached.

In the exposure mode, the machine must be equipped with a time-limiting device.

3. Requirements for radiation equipment for treatment:

a) Radiation equipment must be equipped with means to control operational parameters such as type of radiation, energy, beam shaping elements (such as filters), irradiation distance, field size, beam direction, and irradiation time or dose.

b) Radiation emitting devices using radioactive sources must automatically return to a safe position in case of failure, and the source must remain shielded until the beam control mechanism is restarted from the control console.

c) Additionally, remote therapy (teletherapy) equipment must also include:

- Two independent systems to return to a safe position in case of failure to terminate exposure.

- A safety interlock or means to terminate exposure if the machine operates under conditions different from those pre-set from the control console.

d) The safety interlock must be designed so that when maintaining the machine, if temporarily disconnected, the equipment can still operate under direct supervision of the maintenance personnel through appropriate tools, codes, or keys.

đ) Radioisotope sources used for remote or close therapy must be constructed in accordance with the definition of sealed sources.

V. ARRANGEMENT OF ROOMS FOR RADIATION EQUIPMENT

Rooms for radiation equipment:

a) Should be located far from densely populated areas, obstetrics and pediatrics departments, other hospital departments not directly related to radiation, and away from public walkways.

b) X-ray rooms should meet the size requirements of Vietnamese standards, with ventilation windows not lower than 2 meters above the external floor.

c) Remote therapy (teletherapy) rooms should have an area of at least 30 square meters, width of at least 4 meters, height of at least 3 meters, and good lighting and ventilation systems.², width not less than 4 meters, height not lower than 3 meters, must have a good lighting and ventilation system.

d) When calculating and designing the thickness of walls, floors, ceilings, and entry doors of rooms housing radiation equipment, attention must be paid to the equipment parameters (voltage, current intensity, or activity of the source), equipment usage factor, and occupancy factor of each external area to ensure that the annual dose limit for the public outside the room is 1 mSv.

d) Equipment must be shielded so that the annual dose limit for machine operators does not exceed 20 mSv.

1. Arrangement of radiation equipment:

a) Each room shall accommodate only one piece of radiation equipment. In cases where two X-ray machines are already installed in a room, they shall not operate simultaneously at the same time. Radiation equipment must be placed such that during use, the beam does not point towards the control cabinet, door, window, or areas with many people.

b) The control cabinet for radiation equipment must be located outside but adjacent to the room housing the equipment, equipped with means to observe patients and communication between the operator and patient. For X-ray equipment operating at less than 150 kV, the control cabinet may be placed inside the room housing the equipment but must have lead shielding.

2. In the room housing the radiotherapy equipment, automatic radiation monitoring devices must be installed to alert about abnormal conditions when using the equipment.

3. The pathway leading to remotely operated radiotherapy equipment must be designed in a zigzag pattern.

4. The exit door of the remote radiotherapy room must be equipped with interlocking locks to:

a) Enable the radiotherapy equipment to start only when the door is fully closed.

b) Automatically stop irradiation when the door is unexpectedly opened.

5. Warning signals:

a) A red light must be placed above the entrance door of the radiation equipment room, which lights up when the radiation equipment begins operation.

b) A radiation warning sign (Annex 1) must be placed on the entrance door of the radiation equipment room.

VI. GENERAL REQUIREMENTS FOR RADIATION SAFETY IN THE DEPARTMENT OF NUCLEAR MEDICINE

1. The nuclear medicine department should be isolated from other departments so that individuals entering other departments do not have to pass through this department.

At the entrance to this department, there must be a radiation warning sign (Annex 5).

2. The arrangement of rooms within the department follows the principle of decreasing radiation dose from inside out or from bottom up if the department spans multiple floors (the radioactive drug storage room and the radioactive drug preparation room being the innermost). Rooms with open radioactive sources should be arranged close together to prevent widespread radioactive contamination.

3. Requirements for rooms with open radioactive sources:

a) Must have good ventilation.

b) The thickness of the walls, floor, ceiling, and entrance doors of the room must be calculated like those of a room housing radiation equipment to shield radiation and ensure that the annual dose limit for the public outside the room is 1 mSv. Walls must be smooth, covered with a waterproof layer that is easy to decontaminate.

c) The floor of the room needs to be covered with a waterproof layer with drainage channels for radioactive waste water.

d) The surface of worktables with radioactive sources must be made of flat material that does not absorb radioactive substances, without cracks or fissures, and is easy to decontaminate.

đ) Foot or elbow-controlled faucets or automatic faucets must be provided.

e) A dedicated fume hood for radioactive work producing gases must be provided.

g) Shielded forceps or syringes must be used to reduce dose exposure to hands.

4. Must be equipped with at least the following measuring instruments:

- Radioactive pharmaceutical dosimeter.

- An appropriate sensitivity radiation dose meter.

- A surface contamination detector sensitive enough to detect emitted radiation.

5. Open radioactive sources must be stored in a separate locked storage area. Storage locations for open radioactive sources, such as wall niches or cabinets, must have multiple compartments so that when arranging or retrieving radioactive materials from these compartments, staff are not exposed to radiation from other compartments. Each compartment has its own door, clearly labeled with the name and activity of each radionuclide inside. Radionuclides must be contained in secure packaging (glass bottles, plastic containers, metal boxes). Records of entry and exit of radionuclides must be kept.

6. There must be a room for patients who have used radioactive drugs. The room must be shielded to ensure that the external dose rate does not exceed the annual dose limit for the public (1 mSv/year). Each room can accommodate only one patient; if multiple patients are in one room, mobile lead shields must be used to ensure that one patient is not affected by radiation from another patient.

Mobile lead shields must be available to protect staff when interacting with patients.

Patients can only be discharged when the radioactivity level in their body drops below the specified threshold (Annex 6).

7. When radioactive contamination occurs, decontamination must be carried out.

Contaminated areas must be decontaminated from the outside in to minimize the spread of contamination.

The radiation safety officer must be present during decontamination operations.

VII. MANAGEMENT OF RADIOACTIVE WASTE

1. Gaseous, liquid, and solid radioactive waste can only be released into the environment after testing and confirming compliance with permissible limits as stipulated by the Ministry of Science and Technology and Environment.

2. Used sealed sources for radiotherapy, once rendered ineffective and becoming radioactive waste, must be stored in a separate, shielded, and theft-proof storage facility.

3. Facilities with short half-life (under 30 days) radioactive waste, with total or individual activities exceeding the exemption level, must be retained for the necessary period until they decay to permissible levels before being released into the environment. Specifically:

a) For liquid waste: Liquid waste (including patient excretions from radioactive drug use) must flow into one of two non-connected underground tanks with sufficient sealing to prevent leakage, providing adequate radiation shielding as required, with a rain cover, and having sufficient capacity to retain liquid waste for the required time (10 half-lives of the longest-lived radionuclide being discharged). One tank receives daily radioactive liquid waste while the other stores radioactive liquid waste awaiting release into the environment or concentrates the liquid waste and dilutes it with regular wastewater in a mixing tank according to the regulations of the Ministry of Science and Technology and Environment.

b) For solid waste: Solid contaminated materials such as syringes, broken glass, etc., are collected in plastic bags, which are then placed in metal drums that can be opened and closed with feet. Daily, these bags are placed in one of the two isolated tanks as for liquid waste. These tanks are constructed in a separate location, shielded and protected until radioactive decay reduces them to permissible levels, after which they can be disposed of as regular waste.

4. The management of small animal carcasses containing radioactive materials in laboratories shall be carried out in accordance with specific regulations.

VIII. QUALITY CONTROL, CALIBRATION OF RADIATION EQUIPMENT, CLINICAL DOSE MEASUREMENTS, AND ENSURING QUALITY IN MEDICAL RADIATION

1. Radioactive sources and radiation equipment used in medicine must be inspected for quality and calibrated at least once a year. After installation or repair, they must be recalibrated before being put into use. Quality control and calibration facilities for radiation equipment shall be designated by the Ministry of Science, Technology, and Environment (these facilities must have qualified personnel and expertise in radiation safety and equipment...).

2. Characteristic values of clinical dose parameters for patients must be determined and recorded in their medical records.

3. Radiation facilities, in addition to complying with regulations on ensuring radiation safety management quality, must establish a separate quality assurance program for medical radiation involving suitable experts in relevant fields such as radiation physics, radiopharmaceuticals, and must adhere to principles set forth by the Ministry of Health and the World Health Organization (WHO).

4. Quality assurance programs for medical radiation must include:

a) Annual measurement of physical parameters of radiation equipment from the time of installation and during subsequent use.

b) Inspection of physical and clinical factors in diagnosis and treatment of patients.

c) Maintenance of records regarding processes and related results.

d) Verification of calibration conditions, operational conditions, and dosimetry and inspection equipment.

đ) Periodic review of independent quality control testing results for radiotherapy procedures.

IX. REQUIREMENTS FOR MEDICAL RADIATION

1. General Provisions.

a) All medical radiation must be considered based on a comparison of benefits and harm caused by other methods and prescribed by a physician. If two treatment methods yield the same effect, the non-radiation method should be used.

b) Only one patient and if necessary, a few helpers may be present in the irradiation room.

2. Irradiation and imaging for diagnosis and treatment.

a) Physicians or technicians performing irradiation and imaging must:

- Ensure that the equipment used is appropriate.

- Select working parameters so that the total radiation dose received by the patient is minimized while maintaining diagnostic image quality, particularly when irradiating children.

- Refer to previous examination information to avoid unnecessary repeat examinations.

b) Portable or mobile irradiation and imaging equipment may only be used when it is impossible to transfer the patient to a fixed facility due to patient condition or other practical reasons, and only after safety measures for equipment use have been implemented.

c) Avoid irradiating the abdominal and pelvic regions of pregnant or potentially pregnant women unless clinically necessary, in which case measures must be taken to minimize fetal exposure.

d) Sensitive body organs of the patient (such as reproductive glands, lens of the eye, breast, thyroid gland) must be adequately shielded.

3. Diagnosis and treatment in nuclear medicine.

a) Physicians prescribing diagnostic or therapeutic radiopharmaceuticals must:

- Ensure that the radiation dose given to the patient is minimal but sufficient for the purpose of diagnosis and treatment.

- Refer to previous examination information to avoid unnecessary additional tests.

- Refer to recommended activity levels for medical radiation of various organs from domestic and international organizations such as the International Atomic Energy Agency (IAEA), WHO...

b) Radiopharmaceuticals should not be used for diagnosis or treatment of pregnant or potentially pregnant women unless absolutely necessary.

c) For nursing mothers, breastfeeding should be temporarily stopped until the radiopharmaceutical has no effect on the child.

d) Radiopharmaceuticals can only be used for diagnosis or treatment of children when absolutely necessary and the prescribed activity level must be reduced according to regulations.

đ) Patients must be informed about potential risks associated with the use of radiopharmaceuticals.

4. Assistance to irradiated patients.

a) No one is allowed to remain in the examination or treatment room during irradiation, except for necessary radiation staff and those permitted to assist the patient during examination or treatment.

b) Pregnant women and individuals under 18 years old are not allowed to assist irradiated patients.

c) Assistants to irradiated patients must wear appropriate protective gear (lead apron, lead gloves, protective clothing, lead shielding). Even with protective gear, no part of their body should be in the path of the useful beam.

d) Caregivers and assistants to irradiated patients or those using radiopharmaceuticals must be monitored for radiation dose.

X. SAFETY DURING OPERATION OF RADIATION EQUIPMENT

1. Radiation facilities must develop and issue operating rules for rooms, procedures for each piece of equipment, and treatment protocols for each type of disease to ensure safety for radiation staff and patients.

2. Radiation staff must:

- Inspect the safety of the source before and after operation.

- Keep doors closed throughout the operation.

- Follow operating procedures.

- Pay attention to abnormal signals from equipment to promptly detect incidents and prevent accidents.

- Not remove faulty components from the depth protection system to operate directly by hand.

- Record operational data.

- Immediately report to the facility manager or radiation safety officer if a radioactive source is lost or there is a risk of a radiation incident. Within their responsibility, they must participate in resolving radiation incidents.

- Use appropriate radiation safety equipment for the job.

3. Equip radiation safety devices.

- Each radiation facility must be equipped with radiation monitoring devices suitable for its equipment.

- Persons directly working with radiation sources must be equipped with necessary protective means such as lead shields, rubber lead aprons, lead rubber gloves, protective goggles, laboratory coats, shoes, appropriate personal dosimeters, and lead containers for transporting radioactive isotopes.

- The manager of the medical facility must ensure the provision of all such equipment.

XI. INVESTIGATION OF MEDICAL RADIATION ACCIDENTS FOR PATIENTS

1. The manager of the radiation facility must immediately investigate the following incidents:

a) Incorrect radiation therapy on patients, incorrect irradiation of tissues, incorrect administration of radioactive drugs, or incorrect radiation doses significantly different from those prescribed by the doctor.

b) Radiation dose during diagnosis significantly higher than the prescribed level or repeated diagnostic radiation doses significantly exceeding the prescribed levels.

c) Any damage to equipment, accidents, risks, and other abnormalities that could cause patients to receive radiation doses significantly exceeding the prescribed levels.

2. After investigating the incidents mentioned above, the manager of the radiation facility must:

a) Recalculate or reassess the radiation dose received by the patient.

b) Propose measures to treat and prevent recurrence of the incident.

c) Report in writing to the superior authority after investigation and conclusion regarding the cause of the incident. In cases of serious consequences, report to the Radiation and Nuclear Safety Board under the Ministry of Science, Technology, and Environment.

d) Inform the patient about the incident.

XII. STORAGE

1. Radiation facilities must retain and store the following patient records for at least five years:

a) In diagnostic radiology: necessary information (voltage, current intensity, time) to evaluate future radiation dose, including the number of exposures, date, and month of imaging.

b) In nuclear medicine: types of radioactive drugs used and their activity levels, date and month of use.

c) In radiation therapy: description of the irradiated area, dose at the center of the irradiated area, dose to related tissues, number of exposures, date and month of exposure.

2. Radiation facilities must store calibration results, periodic inspection results, and relevant physical parameters selected during each radiation therapy session for at least five years.

3. The retention period for health records and radiation dose records of radiation workers is governed by Clause 5, Article 9 of Decree No. 50/1998/NĐ-CP dated July 16, 1998 of the Government.

XIII. IMPLEMENTATION ORGANIZATION

1. Provincial Departments of Science, Technology, and Environment and Health Departments implement state management functions to supervise and inspect the implementation of radiation safety at radiation facilities within their jurisdiction.

2. Radiation facilities that have been put into operation or are storing and using radiation equipment, sealed radioactive sources, unsealed radioactive sources, and radioactive waste before this Circular takes effect, within ninety days from the date of its effectiveness, must complete declaration procedures, then apply for permits according to the provisions of Section III of this Circular.

During the waiting period for permit issuance, these radiation facilities may continue to use the aforementioned radiation equipment and radioactive materials.

Within three years from the date of the Circular's effectiveness, radiation facilities that have not met the requirements stipulated in Sections II, IV, V, VI, VII, VIII, X, and XII must comply with the provisions of this Circular.

3. The Ministry of Health designates healthcare facilities to examine and monitor the health of individuals who have received excessive radiation doses and have been affected by radiation-induced diseases.

4. After private radiation facilities and foreign-invested radiation facilities have obtained the required radiation safety permits as stipulated in Section III of this Circular, the Ministry of Health and Health Departments will consider issuing certificates of qualification and conditions for practice in accordance with laws governing private medical practice and laws on foreign-invested medical services.

XIV. EFFECTIVE IMPLEMENTATION

This Circular takes effect fifteen days from the date of signature.

During implementation, if there are any difficulties, they should be promptly reported to the Joint Ministries for resolution./.