令和 5 年度 労災疾病臨床研究事業

総括・分担研究報告書

健康管理手帳制度による健康診断の諸外国での実施のための研究

研究代表者
菅沼 成文
公益社団法人 全国労働衛生団体連合会 胸部Ｘ線検査専門委員会委員

目

次

Ｉ．総括研究報告
健康管理手帳制度による健康診断の諸外国での実施のための研究----------

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研究代表者 菅沼成文
II．分担研究報告
1. アジア諸国の実情把握

分担研究者 田村太朗、研究協力者 吉川徹
2. 健康管理手帳制度による健康診断のタイでの実施のための研究---------

X

分担研究者 JP Naw Awn
3. 健康管理手帳制度による健康診断のインドネシアでの実施のための研究

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X

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X

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X

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X

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X

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X

研究協力者 梶木繁之

4. 健康管理手帳制度による健康診断のベトナムでの実施のための研究
研究協力者 Leli Hesti Indriyati
5. 健康管理手帳制度による健康診断のフィリピンでの実施のための研究
研究協力者 栄徳勝光
6. 健康管理手帳制度による健康診断のネパールでの実施のための研究
研究協力者 Bijay Maharjan
7. 健康管理手帳制度の国際展開に向けた米国の健康診断実施状況調査
研究協力者 安光ラヴェル香保子
8. アジアじん肺読影医養成プログラム（AIR Pneumo）認定医の分布状況研究代表者 菅沼成文

III．研究成果の刊行に関する一覧表

令和 5 年度労災疾病臨床研究事業費補助金研究 総括研究報告書

健康管理手帳制度による健康診断の諸外国での実施のための研究
研究代表者：菅沼 成文 全国労働衛生団体連合会
胸部Ｘ線検査専門委員会委員
研究分担者：田村 太朗 島根大学 医学部 准教授
JP Naw Awn 高知大学 医学部 特任助教
研究要旨
【目的】
日本の健康管理手帳制度は労働者が特定の有害業務に従事した場合や健康被害を受けた場合に、退職後も無料で健康診断を受けられる制度である。健康管理手帳制度は日本国籍だけでなく外国人も対象となるが、外国人労働者の増加に伴い、帰国後の健康管理が重要となっている。特に、ベトナム、中国、フィリピン、インドネシアなどで技能実習生が多いため、これらの国を中心に健康診断の方法や健康管理手帳制度での健康診断を実施可能な医療機関を調査し、解決策を提案する。
【方法】
本年度は研究計画書の作成、調査対象国の選定、アンケート調査票の開発を行う。各国の健康診断制度等について、文献調査や関係機関訪問、オンライン会議にて収集する。
【結果】
調査対象国として技能実習生の来日状況を元にタイ、インドネシア、ベトナム、フィリ
ピンを選定した。タイでは、研究代表者らがタイを中心に活動してきたアジアじん肺読影医養成プログラム（AIR Pneumo）の協力体制を活かし、労働安全衛生の専門家を招いて情報交換の会議を開催した。インドネシアでは、研究協力者らとインドネシア大学
医学部産業医学部門との協力体制を活かし、研究班で作成したアンケート調査票（英文）を用いて、インドネシア国内での労働安全衛生活動に関する予備調査を行った。ベトナム、ネパールでは、OSH サービスの提供システムや品質保証システムに関して文献調査し、特にネパールでは健康診断実施病院リストも収集した。タイ、ベトナム、フィリピンでは、政府機関等から協力依頼状等が求められた。また、米国の大学を訪問し、移民労働者の退職後の健康管理について調査した。さらに、AIR Pneumo に参加
したじん肺読影医の分布状況や認定試験の傾向を報告した。
【考察】
本年度の調査により、ベトナム等のアジア諸国に、健康管理手帳による健康診断を実施
可能な医療機関の存在することが示唆されたが、詳細情報は不足している。引き続き、

これらの国々の医療体制や設備、読影医の水準についてより詳細な調査が必要である。
研究協力者
吉川徹（労働安全衛生研究所）
梶木繁之（産業医科大学）
金山ひとみ（福井大学）
Leli Hesti Indriyati（高知大学、インドネシア）
Bijay Maharjan（高知大学、ネパール）
栄徳勝光（高知大学）
審良正則（高知大学）
中野真規子（労働安全衛生研究所）
安光ラヴェル香保子（高知大学）
村上武（高知大学）
角田都（高知大学、研究コーディネータ）＜海外＞
中華人民共和国
Dr Ling Mao, Shanghai Pulmonary Hospital, Shanghai, China
Dr Chen Yu, National Institute of Occupational and Poison Control (NIOHP), China CDC,
Beijing, China
大韓民国
Dr. Myong Jun Pyo カソリック大学産業環境医学准教授
タイ王国
Dr. Somkiat Siriruttanapruk, タイ保健省
Dr. Narongpon Dumavibhat マヒドン大学シリラジ病院助教
Dr. Jate Ratanachina, チュラロンコン大学医学部講師
インドネシアDr. Muchtaruddin Mansyur, インドネシア大学教授
ベトナム
Nguyen Thi Thu Huyen, GP, MPH, Occupational Health and Injury Prevention Division
Health Environmental Management Agency, Ministry of Health
フィリピン
Dr. Reynold Sta Ana, Health Control Division, Occupational Safety and Health Center
カンボジア
Sok Seng Yan, Vice President of Royal School of Administration
インド
Dr Prahlad Kumar Sishodiya, Consultant, Expert in Silicosis,
Directorate of Specially Abled Persons, Department of Social Justice and Empowerment,
Government of Rajasthan

A．研究目的る。）

本研究の目的は、我が国の有害業務を行う職場で有害化学物質等に曝露した外

我が国で働く外国人労働者は、令和元年

国人労働者がその職場を退職した際に、には約 166 万人いると言われている（法健康管理手帳交付対象であった場合に務省調べ）が、長期間我が国で働く人々

継続した健康診断を実施可能なのか、にだけでなく、このうち約 23％（約 38.4

ついて、各国の状況を明らかにするとこ

万人）を占める技能実習生は、最大 5 年ろである。すなわち、健康管理手帳制度

間の我が国滞在の後は母国に帰国する

による健康診断を諸外国で実施するたこととなる。

め、受診者数の規模や諸外国での健康診断実施状況を踏まえ、実施方法に関する

健康管理手帳の交付対象となる業務は、

課題及び解決策を検討する。

当該業務を行わなくなった後であっても健康影響が発生するおそれのある業

がんその他の重度の健康障害を生ずる務であることから、帰国した後も継続的

おそれのある業務に従事していた者でな健康診断の受診が必要となるが、健康一定の要件に該当する者については、離管理手帳により健康診断を受診できる職の際又は離職の後に、労働安全衛生法

機関は、都道府県労働局長から指定されの規定に基づき、都道府県労働局長からる当該都道府県内の機関に限られてい健康管理手帳の交付を受け、その都道府るため、現行制度においては、仮にこの県労働局長が指定する医療機関においような外国人労働者が母国に帰国したて、定期的に健康診断を受診することが場合には、母国においては健康管理手帳

できることとなっている。これは、単にによる健康診断は受診できないことと日本国籍を有する労働者だけではなく、なる。

我が国で就労する外国人労働者も対象となる。（我が国で就労する労働者も対2019 年に施行された改正出入国・難民象となり、「特定技能」制度の導入に当

認定法により、段階的に単純労働分野にたり、平成 31 年 3 月 28 日に発出されおいても外国人労働者の受け入れを拡た厚生労働省労働基準局長通達「外国人大することとなっており、今後、一定期労働者に対する安全衛生教育の推進等

間我が国で有害業務に従事した後、母国について」においても、外国人労働者のにおいて健康診断の受診を希望する者

離職時には健康管理手帳の交付についが増加することが予想される。

て必要な説明を行うことが示されていこのようなことを背景として、現在多く

ンマー、インドネシア、フィリピン、ラの技能実習生が来日しているベトナム、

オス、カンボジア等）を対象に、令和 6

中国、フィリピン、インドネシアを中心

年度及び 7 年度に国際会議により詳細に、技能実習に関する二国間取り決めをな情報を収集することを検討する。

行っている国々（主として東南アジア諸国）のうち主要な国等を対象として、健C．研究結果康管理手帳制度に基づく健康診断を行

アジア諸国の実情把握においては、技能

う適切な医療機関等の把握、健康診断の実習生の来日状況をもとにベトナム、フ実施方法・課題等について、海外の関係

ィリピン、インドネシア、タイを対象国機関と連携して調査を行い、外国人労働家として選定した。また、対象とする健者が母国に帰国した後の健康診断を通康診断については、健康管理手帳交付状

じた健康管理の方法について解決法や況を踏まえ、粉じん作業、石綿等業務に提案を行うことを目的とする。

関する健康手帳による健康診断を対象とすることとした。各国における調査実

B．研究方法施のための研究計画書を作成し、情報収（1）調査対象国の検討集のための質問票を開発した。

健康管理手帳の交付対象状況や今後の予想等を踏まえ、調査対象国を検討する。

タイでの調査進捗状況について、研究代検討に当たっては、現在多くの技能実習

表者らのチームが、2008 年以来、タイ生が来日しているベトナム、中国、フィで 7 回実施してきたアジアじん肺読影

リピン、インドネシアや、技能実習や特医養成プログラム（AIR Pneumo）の中定技能に関する二国間取り決めを行っで形成されたネットワークを活用するている国々のうち主要な国等を対象にべくタイを訪問し、労働安全衛生（OSH）

することを想定している。

分野の専門家を招いて情報交換のため（2）基礎的情報の収集・整理の会議を開催した。会議の中で、アンケ

対象国・地域の健康診断に関連する制度

ート調査に関しては倫理委員会（IRB）

や現状等の基礎的な情報について、文献の承認が必要となるが、IRB 承認に 8 ヶ調査や関係機関訪問等により、把握する。

月以上の時間を要するため、IRB の承認

なお、オンライン会議を適宜活用して情が不要なフォーカスグループインタビ

報収集を促進する。

ューにて情報収集するのが良い、という（3）国際会議の準備

意見を得た。

主に東南アジア（タイ、ベトナム、ミャインドネシアでの調査進捗状況につい務があり、医療従事者は 2 年ごとに継続て、研究協力者らのチームが、2010 年

教育を受ける必要がある。産業医専門の以来実施してきた、日経企業の海外事業養成機関はなく、資格取得のためには 3場における労働安全衛生活動のサービ

年以上の臨床経験に加え、NIOEH でのスの質の向上を目的とした様々な取り

3 ヶ月間の研修コース修了ないしハノイ

組みを通じて形成してきたインドネシ

医科大学での 9 ヶ月間の特別指導コー

ア大学医学部産業医学部門との協力体制

ス修了が求められる。

を活かし、研究班で作成した現地国へのアンケート調査票（英文）を用いて、イ

フィリピンでの調査進捗状況について、

ンドネシア国内での労働安全衛生活動

フィリピンで労働安全衛生行政を主管(特にじん肺に対する特殊健康診断の実する労働雇用局の労働安全衛生センタ

施体制並びに医療機関の有無など)に関ーの専門家とのオンライン MTG においする予備調査を行った。予備調査の結果て、フィリピンの医療施設の有無や日本

より、インドネシア国内においては、本との制度の違いが議論され、プロジェク

研究の目的を果たすために必要となる

トは他国展開の段階にあると報告され一定の人材や医療設備並びに医療機関た。フィリピン側の参画には組織間協定の存在の可能性が示唆された。ただし、が必要であり、労働衛生団体連合会や高現地国内で具体的に本取り組みを進め

知大学との協定が提案された。引き続き、る際には、より詳しい情報の入手が必要

研究計画書の改訂やコミュニケーショと思われた。

ンの必要性が議論された。

ベトナムでの調査進捗状況について、ベ

ネパールでの調査進捗状況について、文トナム保健省保健環境管理局での労働献調査を通じて、OSH サービスの提供

安全衛生行政の実務担当者との会議、及システム等についての情報を収集した。

び文献調査を通じて、OSH サービスのネパールの医療制度は連邦、州、地方の提供システム及び品質保証システムに

3 層構造で、保健・人口省（MOHP）のついての情報を収集した。OSH サービ

下に連邦レベルの保健局があるが、スの提供システムについて、管轄部署はOSH 制度との連携が不十分である。ま

労働・傷病兵・社会問題省（MOLISA）

た、職業性疾患の専門的な管理機関は存と保健省（MOH）で、2015 年に OSH在しない。OSH 制度の最高機関は労働・法が制定された。品質保証について、各

雇用・社会保障省（MoLESS）であるが、病院は品質保証システムを導入する義OSH はその優先事項として扱われていない。そのため、OSH の管理体制が脆の AIR Pneumo に関する研究報告（J-P,

弱で、人材不足が深刻な状況である。入2024）が参考になる。この報告を最新情

国前のメディカルチェックを認可され報に更新すると、2008 年からこれまでた医療機関はあり、本調査を通じて 284に 26 回の認定試験を行い、20 カ国から院をリストアップした。しかし、海外就674 人の医師が認定試験に参加してい労から帰国した労働者の健康ニーズにる。参加者の６割はインドネシア、タイ

対応する機能的なシステムはない。

の医師であった。合格者、不合格者の傾向を調べたところ、前者は小空孔の同定

また、先進国での移民労働者の帰国後のにおいて偽陽性が多く、後者は病変同定フォローアップの事例収集をするべく、において偽陽性率が高い傾向が見られ米国の大学２校（UCSF, University ofた。

Arizona）を訪問した。UCSF では、米国の労災補償について遅れがあり、州ごD．考察との法律により情報が散在している状

ベトナムやインドネシア、ネパールなど

況が説明された。アスベストやシリカ曝のアジア諸国での調査により、健康管理

露に関する補償体制の整備が不十分で手帳による健康診断を実施可能な医療あり、退役軍人や多国籍企業の労働者に機関が各国に存在することが示唆され対する補償も課題となっている。また、た。しかし、これらの国々の医療体制のUniversity of Arizona では、ベリリウム

現状や医療機関の能力については、まだ曝露や炭鉱労働者の補償率の低さ、新た

詳細な情報が不足している。今後、これなシステムの導入による情報収集の試らの国々における医療機関の設備や人みが述べられた。さらに、異なる国での材の水準、健康診断の提供範囲などにつ調査実施に際しての課題と助言も示さ

いて、より詳細な情報を収集する必要がれた。

ある。特に、移民労働者が帰国後に適切な健康管理を受けるためには、医療機関

本事業では、粉じん作業、石綿等業務にの選定や診断の品質保証に関する基準

関する健康手帳による健康診断に焦点の整備が不可欠である。これらの取り組を絞って調査を進めている。これらの業み・検討を通じて、移民労働者が帰国後務の関連疾患であるじん肺に関して、調も適切な健康管理を受けることができ

査対象国において、診断・治療に関してる余地が見出されるものと期待される。

一定の技術レベルに達していると思われる読影医の分布状況については、先述

E．結論

本年度の調査によって、各国の研究協力

K. Association between lifestyle habits

者との連携は取れたものの、それぞれのand presenteeism. Occup Med (Lond).

国での事情が異なり、行政担当者と研究

2023 Sep 29;73(6):346–352.

者との両方の協力を取ることのできる

3. Adi NP, Nagata T, Mori K, Kubo T,

体制構築はかなりの努力が必要である

Fujimoto K, Ohtani M, Odagami K,ことが判明した。また、ベトナム、ネパ

Nagata M, Kajiki S, Fujino Y, Matsuda

ールにおける OSH サービスの提供シス

S. Seeking Treatment Profile of Male

テム及び品質保証システムについてのShift Workers With Hypertension and

文献調査を終えることができた。調査対

Diabetes. J Occup Environ Med. 2023

象国の健康診断実施病院候補リストのSep 1;65(9):783–788.

収集と病院調査の実施は次年度以降の課題となった。

2.学会発表［International meeting］

F．健康危険情報

1. Indriyati LH , Eitoku M, Naw Awn

該当なし

J-P , Nishimori M, Hamada N, Sawitri
N, Suganuma N

G．研究発表Assessment of Chest Ray Profile in

1.論文発表Relation to Prevalence of Silicosis

1. J-P NA, Susanto AD, Samoedro E,

aming Tuberculosis Patients in West

Mansyur M, Tungsagunwattana S,

Java,

Lertrojanapunya S, Subhannachart P,

Congress

Siriruttanapruk S, Dumavibhat N,(ICOH), Marrakesh, Morocco, April

Algranti E, Parker JE, Hering KG,

2024

Indonesia,34th
onInternational

Occupational

HealthKanayama H, Tamura T, Kusaka Y,
Suganuma N. Asian Intensive Reader［National meeting］

of

program:

1. Indriyati LH, Eitoku M, Naw Awn J-

examination for certification during

P, Nishimori M, Hamada N, Sawitri N,

2008-2020. Industrial Health 2024. 62,

Suganuma N

143–152.

Prevalence of Radiographic Silicosis

Pneumoconiosis

DOI:

10.2486/indhealth.2023-0010

among Tuberculosis patients in West

2. Adi NP, Nagata T, Odagami K,

Java, Indonesia:

Nagata M, Kajiki S, Kuroishi M, Morifrom Hospital Based Study . The 67th

Preliminary reportChugoku-Shikoku Joint Conference on
Occupational Health 第 67 回中国四国
合同産業衛生学会本, Ehime, December
2023
2. Indriyati LH, Eitoku M, Naw Awn JP, Nishimori M, Hamada N, Sawitri N,
Suganuma N
Prevalence of Radiographic Silicosis
Among Tuberculosis Patients in West
Java, Indonesia
94th Annual Meeting of Japan Societyfor Hygiene, Kagoshima, March 2024
3. Indriyati LH , Eitoku M, Naw Awn
J-P , Nishimori M, Hamada N, Sawitri
N, Suganuma N
Prevalence of Radiographic Silicosis
Cases among MDR-TB and DS-TB
patients in Indonesia.
97thAnnualMeetingofJapan

Society for Occupational Health, 第 97回日本産業衛生学会, Hiroshima, May
2024
Ｈ．知的財産権の出願・登録状況(予定を含む)
1.特許取得
該当なし
2.実用新案登録
該当なし

8-Overseas Health Checkup
Initiative (OHCI):
Notebook of Personal Health
Records (nPHR)
Narufumi Suganuma, MD, PhD, Kahoko Yasumitsu-Lovell, PhD
Takeshi Murakami, MSc, MBA
Professor, Department of Environmental Medicine,
Kochi Medical School⑤

じん肺管理区分等通知書（じん肺施行規則様式第５号）

事業者がじん肺管理区分の決定申請した場合（１２条申請、１６条申請）であって、管理区分が決定したときに、事業者が当該労働者に対し通知する様式です。

健康管理⼿帳の構成
P1 個⼈情報表紙

P3 既往歴、申請前の健診結果等

P2 職歴

P4以降、健診結果

（３頁）

（１頁）

種

類

（４頁以降の頁（最後の頁を除く。））

（２頁）
年月日

申請前の石綿に係る疾病の既往歴及び治療歴

石綿（人事院規則10–4（職員の保健及び安全保持）別表

人事院規則10- 4別表第４の２第６号の業務に係るものに限る。

職

歴

事

期

自

年

月

日

至

年

月

日

年

月

自

年

月

日

年

月

至

年

月

日

自

年

月

日

至

年

月

日

自

年

月

日

自覚症状 及びなし、せき、たん、息切れ、胸痛、

至

年

月

日

他 覚 症 状その他（

第４の２第６号に規定する業務）

年

月

日

年

年月

既往歴及び治療歴

既

往歴なし、せき、たん、息切れ、胸痛、その他（

従（ふりがな）
氏

性

名

・
別

生 年 月 日

年

月

都道
住

男

区
市
郡

所
府県

日

町
村

人事院規則10―４第26条の２の特別健康管理手帳を交付します。

年月

人事院事務総長

日女間

勤 務 官 署 名

自

年

月

日

至

年

月

日

自

年

月

日

至

年

月

日

自

年

月

日

至

年

月

日

自

年

月

日

至

年

月

日

自

年

月

日

至

年

月

日

自

年

月

日

至

年

月

日

従 事 し た 業 務

月

日

項目

年

月

年

月

健

自
及
他

覚

症

覚

症

状
び
状

）

なし、せき、たん、息切れ、胸痛、その他（）

なし、せき、たん、息切れ、なし、せき、たん、息切れ、胸痛、その他（

胸痛、その他（

）

）

康
診
断

胸
エ
線
撮
よ

部
ッ

ク
直
影

る

検

の
ス
接
に
査

申 請 前 直 近 の 健 康 診 断 の 結 果

異常なし、

年

胸部のエ ック

月

日

判

年

月

年月日
項目

日

ス線直接 撮影
による検査

胸部のＣＴ
による検査

定

追
加
健
康
診
断

）、

要 再 検（要追加健診（）

要追加健診（

年

喀
細

痰
胞

の
診

気
鏡

管
検

支
査

日

年

異常なし、
定

要再検査項目(要療養

喀痰の細 胞診

月

月

）、
）

日

胸部のＣＴによ る 検 査

判
かくたん

異常なし、

要 再 検（

医療機関名及び
医
師
名

）

異常なし、
)、

要再検査項目()、要療養

医療機関名及び
医
師名

気管支鏡 検査（平成２９年１１月）

労働安全衛⽣規則 第六章 第⼆節 第五⼗四条（様式第⼋号）:
https://www.japaneselawtranslation.go.jp/en/laws/view/3878#je_pt1ch9sc4at2
https://www.jinji.go.jp/kisoku/tsuuchi/10_nouritu/1003005_S62shokufuku691bessi4-2.pdf

Basic information of Japan
Japanese population estimates

Area: 377,973 km2 (47 prefectures)•• Population in 2023: 124.3 millions• Total Labor Force in 2023: 67.7 millions• Enterprises in 2021: 3.7 millions• GDP in 2023: USD 5,820 billions

Measured values

Estimated values

120
100
80
60
40
20
0

1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060

Population (in Millions)

140

0-14

15-64

≥ 65

Japanese labor force is on the declining trend.

図１-１ 在留資格別外国人労働者数の推移

図１-２ 主な在留資格の外国人労働者数対前年増加率の推移

分野

所管省庁

1 介護
厚⽣労働省

2 ビルクリーニング
3 素形材・産業機械・電気電
経済産業省
⼦情報関連製造業
4 建設
5 造船・舶⽤⼯業
6 ⾃動⾞整備

国⼟交通省

7 航空
8 宿泊
9 農業
10 漁業
農林⽔産省

11 飲⾷料品製造業
12 外⾷業

https://www.nhk.or.jp/heart-net/article/845/

https://www.nhk.or.jp/heart-net/article/845/

2024/02/06 22:59

JITCO

|

12/19

| JITCO -JITCO

https://www.jitco.or.jp/ja/jitco/index.html

https://www.jitco.or.jp/ja/regulation/send/［別表１］国籍別・在留資格別外国人労働者数
令和５年10月末時点（単位：人）
全在留①専門的・技術的分野の在留資格

②特定活動

（注２）

（注３）

資格計
（注１）

全国籍計
ベトナム
中国
（香港、マカオを含む）

フィリピン
ネパール
ブラジル
インドネシア
韓国
ミャンマー
タイ
ペルー
Ｇ７等（注４）
うちアメリカうちイギリス
その他

うち技術・人文計

知識・国際業務③技能実習

うち特定技能④資格外活動⑤身分に基づく在留資格

計

うち留学

計

うち永住者

⑥不明

うち日本人の うち永住者の

うち定住者

配偶者等

配偶者等

595,904

366,168

138,518

71,676

412,501

352,581273,777

615,934

371,296

100,977

18,076

125,58579(29.1%)(17.9%)(6.8%)(3.5%)(20.1%)(17.2%)(13.4%)(30.1%)(18.1%)(4.9%)(0.9%)(6.1%)(0.0%)

518,364

159,962

84,65069,462

27,301

209,305

101,530

82,644

20,262

9,561

5,340

1,605

3,756

4

[25.3%](30.9%)(16.3%)(13.4%)(5.3%)(40.4%)(19.6%)(15.9%)(3.9%)(1.8%)(1.0%)(0.3%)(0.7%)(0.0%)

397,918

148,207

113,016

8,782

4,518

36,55873,62159,501135,004

100,192

17,310

6,501

11,00110[19.4%](37.2%)(28.4%)(2.2%)(1.1%)(9.2%)(18.5%)(15.0%)(33.9%)(25.2%)(4.4%)(1.6%)(2.8%)(0.0%)

226,846

30,458

9,647

14,6805,085

37,856

2,318

2,048,675

149,975

88,08220,807

3,672

37,4149[11.1%](13.4%)(4.3%)(6.5%)(2.2%)(16.7%)(1.5%)(1.0%)(66.1%)(38.8%)(9.2%)(1.6%)(16.5%)(0.0%)

145,587

39,19629,106

3,561

3,024

1,968

95,32560,723

6,072

3,179

1,390

679

824

2

[7.1%](26.9%)(20.0%)(2.4%)(2.1%)(1.4%)(65.5%)(41.7%)(4.2%)(2.2%)(1.0%)(0.5%)(0.6%)(0.0%)

422

137,132

1,017

135,442

67,697

15,767

1,203

50,7751[6.7%](0.7%)(0.5%)(0.0%)(0.1%)(0.0%)(0.3%)(0.3%)(98.8%)(49.4%)(11.5%)(0.9%)(37.0%)(0.0%)

121,507

34,2996,216

25,5895,212

68,236

6,633

6,119

7,127

3,701

1,722

204

1,500

0

[5.9%](28.2%)(5.1%)(21.1%)(4.3%)(56.2%)(5.5%)(5.0%)(5.9%)(3.0%)(1.4%)(0.2%)(1.2%)(0.0%)

71,45430,75826,778

173

2,216

13

7,198

6,124

31,26422,733

6,288

537

1,706

5

[3.5%](43.0%)(37.5%)(0.2%)(3.1%)(0.0%)(10.1%)(8.6%)(43.8%)(31.8%)(8.8%)(0.8%)(2.4%)(0.0%)

71,18824,130

4,131

1,384

626

20

130

63

3,463

479

18,927

9,803

8,364

11,656

12,344

11,546

562

139

2,046

0

[3.5%](26.6%)(13.8%)(11.7%)(16.4%)(33.9%)(17.3%)(16.2%)(5.8%)(1.9%)(0.8%)(0.2%)(2.9%)(0.0%)

36,543

8,495

3,032

2,875

626

12,087

2,038

1,888

13,295

8,004

3,152

368

1,771

2

[1.8%](23.2%)(8.3%)(7.9%)(1.7%)(33.1%)(5.6%)(5.2%)(36.4%)(21.9%)(8.6%)(1.0%)(4.8%)(0.0%)

31,584

209

101

11

43

65

99

91

31,167

21,287

1,403

787

7,690

1

[1.5%](0.7%)(0.3%)(0.0%)(0.1%)(0.2%)(0.3%)(0.3%)(98.7%)(67.4%)(4.4%)(2.5%)(24.3%)(0.0%)

83,882

46,81926,258

61

1,389

13

3,332

2,671

32,28917,338

13,833

298

820

40

[4.1%](55.8%)(31.3%)(0.1%)(1.7%)(0.0%)(4.0%)(3.2%)(38.5%)(20.7%)(16.5%)(0.4%)(1.0%)(0.0%)

34,861

20,580

9,939

9

131

4

902

666

13,207

7,033

5,725

102

347

37

[1.7%](59.0%)(28.5%)(0.0%)(0.4%)(0.0%)(2.6%)(1.9%)(37.9%)(20.2%)(16.4%)(0.3%)(1.0%)(0.1%)

12,945

7,353

4,193

5

204

0

264

194

5,123

2,953

2,047

40

83

1

[0.6%](56.8%)(32.4%)(0.0%)(1.6%)(0.0%)(2.0%)(1.5%)(39.6%)(22.8%)(15.8%)(0.3%)(0.6%)(0.0%)

206,670

77,55756,935

4,940

10,47622,20746,51939,73049,90628,13813,403

2,083

6,282

5

[10.1%](37.5%)(27.5%)(2.4%)(5.1%)(10.7%)(22.5%)(19.2%)(24.1%)(13.6%)(6.5%)(1.0%)(3.0%)(0.0%)

注１： ［ ］内は、外国人労働者総数（全国籍計）に対する当該国籍の外国人労働者数の割合を示す。（ ）内は、国籍別の外国人労働者総数（全在留資格計）に対する当該在留資格の外国人労働者数の割合を示す。なお、割合の数値は小数点以下第２位を四捨五入しているため、合計が100％にならない場合がある。
注２： 「①専門的・技術的分野の在留資格」には、在留資格「教授」、「芸術」、「宗教」、「報道」、「高度専門職１号・２号」、「経営・管理」、「法律・会計業務」、「医療」、「研究」、「教育」、「技術・人文知識・国際業務」、「企業内転勤」、「介護」、「興行」、「技能」、「特定技能１号・２号」が含まれる。
注３： 在留資格「②特定活動」に該当する活動には、外交官等の家事使用人、ワーキング・ホリデー、経済連携協定に基づく外国人看護師・介護福祉士候補者等が含まれる。
注４： G７等とは、フランス、アメリカ、イギリス、ドイツ、イタリア、カナダ、オーストラリア、ニュージーランド、ロシアをいう。

12

Basic information of Vietnam
Vietnamese population estimates• Area: 330,991 km2 (63 provinces/Cities)• Population in 2023: 100.3 millions• Total Labor Force in 2023: 52.4 millions• Enterprises in 2019: 0.7 millions• GDP in 2023: USD 409 billions

Measured values

Estimated values

100
80
60
40
20
0

1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060

Population (in Millions)

120

Total

0-14

15-64

≥ 65

Vietnam's population is on the increase.

Basic information of Philippines
Philippine population estimates• Area: 300,000 km2 (82 provinces)• Population in 2023: 117.3 millions• Total Labor Force in 2023: 50.5 millions• Enterprises in 2019: 1.0 millions• GDP in 2023: USD 404 billions

Measured values

Estimated values

140
120
100
80
60
40
20
0

1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060

Population (in Millions)

160

Total

0-14

15-64

≥ 65

The population of the Philippines is increasing.

Basic information of Nepal
Nepalese Population Estimates

Area: 147,200 km2 (7 provinces)•• Population in 2023: 30.7 millions• Total Labor Force in 2022: 8.7 millions• Enterprises in 2019: 0.4 millions• GDP in 2023: USD 41 billions

Measured values

Estimated values

35
30
25
20
15
10
5
0

1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060

Population (in Millions)

40

Total

0-14

15-64

≥ 65

The population of the Nepal is increasing.

Basic information of Indonesia
Indonesian Population Estimates

Area: 1,904,569 km2 (38 provinces)•• Population in 2023: 277.5 millions• Total Labor Force in 2023: 146.6 millions• Enterprises in 2019: 65.5 millions• GDP in 2023: USD 1,319 billions

Measured values

Estimated values

300
250
200
150
100
50
0

1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060

Population (in Millions)

350

Total

0-14

15-64

≥ 65

The population of the Indonesia is increasing.

Basic information of Thailand
Thai Population Estimates

Area: 513,100 km2 (76 provinces)•• Population in 2023: 71.8 millions• Total Labor Force in 2023: 40.1 millions• Enterprises in 2019: 3.1 millions• GDP in 2023: USD 495 billions

Measured values

Estimated values

70
60
50
40
30
20
10
0

1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060

Population (in Millions)

80

Total

0-14

15-64

≥ 65

The population of the Thailand is increasing.

技能実習計画認定件数の多い上位３か国について、職種別の構成をみると、以下のような結果となっている。
Year 2021
Vietnam, n = 90,753

Construction related

China, n = 22,879

Indonesia, n = 21,651

Metal related

送出国・地域別監理団体許可件数（2-5）【図2-2】
監理団体が許可を受ける際に申請する外国の送出機関を送
出国・地域別にみると、ベト
ナムの180件（296件）が53.3％と最も多く、次いで中国が54件（67件）で16.0％、
ミャンマー26件（47件）とイ
ンドネシア26件（28件）が7.7％となっている。

３職種別技能実習計画認定件数（1–4）【図1-4】
職種別にみると、職種全体のうち、建設関係の職種が最も多く20.8％（22.5％）、次いで⾷品製造関係の職種が19.5％（19.0％）、機械・⾦属関係の職種が14.9％（14.2％）となっている。
また、移⾏対象職種・作業以外の取扱職種による技能実習計画の認定を受けた件数の割合は、全体の1.8％（2.5％）となっている。

健康管理⼿帳新規交付数 (2018-2022)
2018

2019

2020

2021

2022

ベンジジン等業務

4

0

0

1

1

ベーターナフチルアミン等業務

0

0

0

0

0

⽯綿等業務

1,316

1,363

1,229

1,236

939

粉じん作業

292

248

207

302

157

8

4

6

9

3

クロム酸等業務

0

0

0

0

0

59

62

58

93

69

ビス(クロロメチル)エーテル業務

0

0

0

0

0

ベリリウム業務

0

0

0

0

0

ベンゾトリクロリド業務

0

0

0

0

0

35

25

31

31

18

1

2

1

2

2
1

砒素業務
コールタール業務

塩化ビニル業務
ジアニシジン等業務

1

1,2-ジクロロプロパン業務
オルト-トルイジン業務

Year 2021

合計

1,716

4

1

5

20

30

5

4

1,728

1,563

1,684

1,194

(86.2%)

退職後、特定の条件を満たす場合には、健康管理⼿帳を受け取ることができ、それに基づき特定の医療機関で、年に2回(じん肺は年に1回)、無料の健康診断を受けることができる。
健康管理⼿帳により健康診断を受診できる機関は、都道府県労働局⻑から指定される当該都道府県内の機関に限られているため、現⾏制度においては、仮にこのような外国⼈労働者が⺟国に帰国した場合には、⺟国においては健康管理⼿帳による健康診断は受診できな
いこととなる。
このようなことを背景として、技能実習に関する⼆国間取り決めを⾏っている国々のうち主要な国等を対象として、健康管理⼿帳制度に基づく健康診断を⾏う適切な医療機関等の把握、健康診断の実施⽅法・課題等について、海外の関係機関と連携して調査を⾏い、外国⼈労働者が⺟国に帰国した後の健康診断を通じた健康管理の⽅法について解決法や提案
労働安全衛⽣法 第七章 第六⼗七条: https://www.japaneselawtranslation.go.jp/en/laws/view/3440#je_ch7at19
を⾏うことを⽬的とする。
https://laoffice.jp/3667/

労働安全衛⽣法施⾏令 第⼆⼗三条: https://www.japaneselawtranslation.go.jp/en/laws/view/3817#je_at31

8-

健康管理⼿帳の構成（⽯綿等業務の場合）
P1 個⼈情報表紙

P3 既往歴、申請前の健診結果等

P2 職歴

P4以降、健診結果

（３頁）

（１頁）

類

（４頁以降の頁（最後の頁を除く。））

（２頁）
年月日

申請前の石綿に係る疾病の既往歴及び治療歴

石綿（人事院規則10–4（職員の保健及び安全保持）別表種

人事院規則10- 4別表第４の２第６号の業務に係るものに限る。

年

月

日

年

歴

事

期

自

年

月

日

至

年

月

日

年

月

自

年

月

日

年

月

至

年

月

日

自

年

月

日

至

年

月

日

自

年

月

日

自覚症状 及びなし、せき、たん、息切れ、胸痛、

至

年

月

日

他 覚 症 状その他（

年月

既往歴及び治療歴

既

往歴なし、せき、たん、息切れ、胸痛、その他（

従（ふりがな）
氏

性

名

・
別

生 年 月 日

年

月

都道
住

男

区
市
郡

所
府県

女

日

町
村

人事院規則10―４第26条の２の特別健康管理手帳を交付します。

年

月

日

人事院事務総長

間

勤 務 官 署 名

自

年

月

日

至

年

月

日

自

年

月

日

至

年

月

日

自

年

月

日

至

年

月

日

自

年

月

日

至

年

月

日

自

年

月

日

至

年

月

日

自

年

月

日

至

年

月

日

従 事 し た 業 務

月

日

項目

職

第４の２第６号に規定する業務）

年

月

年

月

健

自
及
他

覚

症

覚

症

状
び
状

）

なし、せき、たん、息切れ、胸痛、その他（）

なし、せき、たん、息切れ、なし、せき、たん、息切れ、胸痛、その他（

胸痛、その他（

）

）

康
診
断

胸
エ
線
撮
よ

部
ッ

ク
直
影

る

検

の
ス
接
に
査

申 請 前 直 近 の 健 康 診 断 の 結 果

異常なし、

年

胸部のエ ック

月

日

判

）
年

月

定

異常なし、

要 再 検（）、

要 再 検（要追加健診（）

要追加健診（）、）

医療機関名及び
医
師
名
年月日
項目

日

ス線直接 撮影
による検査

胸部のＣＴ
による検査

追
加
健
康
診
断

年

喀
細

痰
胞

の
診

気
鏡

管
検

支
査

年

異常なし、
定

要再検査項目(要療養

喀痰の細 胞診日

月日

胸部のＣＴによ る 検 査

判
かくたん

月

異常なし、
)、

要再検査項目()、要療養

医療機関名及び
医
師名

気管支鏡 検査（平成２９年１１月）

労働安全衛⽣規則 第六章 第⼆節 第五⼗四条（様式第⼋号）:
https://www.japaneselawtranslation.go.jp/en/laws/view/3878#je_pt1ch9sc4at2
https://www.jinji.go.jp/kisoku/tsuuchi/10_nouritu/1003005_S62shokufuku691bessi4-2.pdf

健康管理⼿帳の交付要件○健康管理⼿帳の交付要件【⽯綿業務の場合】
次のいずれかに該当すること。
（１） 両肺野に⽯綿による不整形陰影があり、⼜は⽯綿による胸膜肥厚があること。（直接業務⼜は周辺業務が該当）（２） 下記の作業に１年以上従事していた⽅。（ただし、初めて⽯綿の粉じんにばく露した⽇から１０
年以上経過していること。）（直接業務のみが該当）• ⽯綿の製造作業• ⽯綿が使⽤されている保温材、耐⽕被覆材等の張付け、補修もしくは除去の作業• ⽯綿の吹付けの作業⼜は⽯綿が吹き付けられた建築物、⼯作物等の解体、破砕等の作業（３） （２）の作業以外の⽯綿を取り扱う作業に１０年以上従事していた⽅。（直接業務のみが該当）【粉じん作業の場合】
じん肺法の規定により決定されたじん 肺管理区分が管理2⼜は管理3であること。

労働安全衛⽣規則 第六章 第⼆節 第五⼗三条: https://www.japaneselawtranslation.go.jp/en/laws/view/3878#je_pt1ch9sc4

健康管理⼿帳制度の仕組み
元勤務先

都道府県労働局
②照会

①交付申請

厚⽣労働省

⓪管轄

労働局⻑

⑤検査費⽤等⽀払③交付

委託医療機関健康管理⼿帳⑤交通費⽀払

作業者

④健康診断

医師

健康管理⼿帳を所持する作業者は、都道府県労働局と契約した委託医療機関にて、国の費⽤で健康診断を受けられる。

委託医療機関の要件
1. 当該健康診断に関し専⾨的知識及び経験を有する医師が充員されており、当該医師がその健康診断の実施に当たること。（中略）なお、⽯綿業務に係る健康管理⼿帳⼜は船員健康管理⼿帳の健康診断の実施に当たる医師は⽯綿関連疾患の診断に関する研修を修了していることが望ましい。
2. 臨床検査技師等当該健康診断に係る検査業務を円滑に遂⾏するために必要な者が充員されていること。
3. 委託する健康診断の種類に応じ、次に掲げる業務に係る健康診断の実施に必要な設備が装備されていること。
l (コ) ⽯綿業務関係
a. エックス線直接撮影装置及びエックス線特殊撮影装置
b. 標本染⾊⽤器具
c. 気管⽀ファイバースコープ⼜は気管⽀鏡
l (イ) 粉じん業務関係
a. エックス線直接撮影装置及びエックス線特殊撮影装置
b. スパイロメーター及びフローボリューム曲線記録装置
c. 動脈⾎ガス分析装置
d. 顕微鏡及び細菌培養装置
e. 標本染⾊⽤器具
4. (公社)全国労働衛⽣団体連合会の⾏う総合精度管理事業に参加している等、精度管理に努めていること。
厚⽣労働省労働基準局超通知：健康管理⼿帳所持者及び船員健康管理⼿帳所持者に対する健康診断実施要綱
https://www.mhlw.go.jp/web/t_doc?dataId=00tb5755&dataType=1&pageNo=1

98.6%

1.4%

https://www.jitco.or.jp/ja/regulation/

OVERVIEW
Objectives:• Identify gaps in providing health examinations to foreign workers after returning to their home countries.
• Investigate the availability of medical institutions capable of providing health examination services at a standard
comparable to that of Japan.

Feasibility of Overseas Health Checkup Initiative

Outcome

Tasks

Aims

Targets(C)

Mixed-methods approach: (A) Document Review,

International
Meetings(B) Questionnaires Surveys (Focus group interview)

1. Governance ofOHS

2. Quality assurance of
OHS

3. Review of medical
institutions providing
OHS

Ministry

Ministry

Ministry

OHS providers

OHS providers

OHS providers

Monitoring
progress

OHS, Occupational health services

TASKS(A) Document Review(C) International Meetings(B) Questionnaires Surveys
1. Identify international collaborator in each country
2. Develop questionnaires for each aim/target
responder
3. Develop survey proposal covering all two aims
and submit to the relevant authorities
4. Obtain ethical clearance from the Institutional
Review Board (IRB) at Kochi Medical School, Kochi
University; Informed consent from interviewees

1. Identify collaborator in each planned country forevent arrangement
2. Identify potential venue in each planned country
3. Prepare meeting schedule
4. Preparations for international guests

5. Prepare reports (interim/final)

TIME FRAME
1. Supplementary data collection
2. Prepare final report---------------3. International meeting (2)4. Dissemination of results

1. Identify target countries and international
collaborators for surveys
2. Questionnaires development

Apr 2023 – Mar 2024

Apr 2024 – Mar 2025

1. Project proposals development
2. IRB clearance (KMS)
3. Data collection
4. Prepare interim report-------------------5. International meeting (1)Apr 2025 – Mar 2026

INFO to collect: Governance of OHS• Legislations/regulations (as well as for hazardous works)• responsible regulatory body• specific requirements: appointment of OH physicians/nurses by industries;
standardized health examination for pneumoconiosis• monitoring system for compliance with regulations• availability and frequency of health examinations for current/retired workers• Public/private hospitals dedicated to OHS• Occupational medicine section; OH physicians/nurses• Types of OHS• In-house; External unit (Health checkup agencies)• Who pays OHS fees?

INFO to collect: Quality assurance of OHS• Governmental laws/regulations• responsible regulatory body• permission to establish OHS clinic/facility; certification to become OH
physicians/nurses; certification to read pneumoconiosis CXR• Formal quality assurance system• hospital accreditation system: registration and proof of quality of service• external quality assurance programs• certification program for OH physicians/nurses------------------------------------------• Availability of investigations/equipments• Obtaining anonymized chest images (DICOM format) for survey

Responsibilities of Participating Countries
1. Conduct a comprehensive document review and submit findings to the principal
investigator by August 2024. The document review will be divided into three sections
to provide a detailed overview of occupational health services (OHS) in eachcollaborating country:• Governance of OHS• Quality assurance of OHS• Review of medical institutions providing OHS, with a focus on health examination services.

2. Conduct a questionnaire survey with key healthcare personnel to explore criticalaspects of occupational health service delivery (Other options include organizing andfacilitating focus group interviews).
3. Actively participate in international meetings convened with relevant ministerial andoccupational healthcare personnel.

Merits for Participation in this Project
1. Facilitating collaboration between medical institutions in foreign countries andJapan, which will have benefits to the workers.
2. Participating countries will receive a financial incentive for each component of
the document review.
3. Individuals in charge from each participating country will be acknowledged andincluded as co-authors in the final report.

ありがとうございました参考資料

Study scheme
List from
Ministry of
HealthFocus group

Site visit

Contact person

address

Hospital A

X

X

X

Dr’s name

Hospital B

X

NA

NA

Dr’s name

Hospital C

X

X

X

Dr’s name

Clinic AA

X

NA

NA

Dr’s name

Clinic BB

X

X

X

Dr’s name

Clinic CC

X

NA

NA

Dr’s nameChest x-ray

PFT

CT

Bacteriology

Tissue staining

Hospital A

X

X

X

X

X

Hospital B

X

X

NA

X

X

Hospital C

X

X

NA

X

X

Clinic AA

X

NA

NA

NA

NA

Clinic BB

NA

X

X

NA

NA

Clinic CC

X

NA

NA

NA

NA

Data collection

Q&A

0.002

1960

1955

1950

1945

1940

1935

1930

1925

1920

1915

1910

1905

1900

0

Cohort [Year]
FIGURE 2. Lifetime risk of death due to mesothelioma among the general male population (based on the Japanese government life
table of1960). Lifetime risk means death rate due to pleural mesothelioma among the general male population. Each year represents acohort which includesit as a middle year.

prediction conducted in several other countries in terms of
the ratio of predicted future deaths to the population.
However, the inferences remain limited because of thevariation in the methodologies applied, notwithstanding thevariable conditions regarding exposure and disease indifferent countries, but this observation seems to favor rather
than disfavor the validity of the present prediction.
This analysis incorporated 10-year birth-cohorts born
between 1895 and 1964, and precluded younger birthcohorts. This was due solely to the limited availability of data

In Japan, the manufacture,import, transfer, provisionand use of asbestos weretotally banned in 2006.

2000
1800
1600

60000

50000

1400

40000

1200
1000

30000

800
20000

600
400

10000

200
2035

2030

2025

2020

2015

2010

2005

2000

1995

1990

1985

1980

1975

1970

1965

1960

1955

1950

0
1945

0

FIGURE 3. Estimatedfuturedeathsfrompleural mesothelioma inJapan.Bargraph showstheimportedamountsofasbestosfor the
5-yearperiodstartingwiththeyearindicated(e.g.,1980representsthe5-yearperiodof1980^1984).Thesearealmostequaltotheamountofasbestosconsumption intheperiodsince asbestosminingcapacity in Japan isnegligible.The solidline showsthepredictedcurvewith
eachdatapointrepresentingtheestimatednumberforthe5-yearperiodstartingwiththeyearindicated.Brokenlinesshowthe95%CIofthepredictedcurve.

predicted number of death every 5 years [person]

Asbestos import and mesothelioma in Japan

1940

6.

1935

5.

10970274, 2006, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ajim.20246 by Cochrane Japan, Wiley Online Library on [23/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

4.

1930

3.

Lifetime Risk

2.

How long is the Technical Intern Training program? Do the trainees stay and work in Japan after completion of the
training?
Ø TIT trainees can stay in Japan for 1~5 years. They can stay longer if they move to SSW.
What are today occupations with potential exposure to asbestos in Japan?
Ø Demolition is one of the major asbestos-related works.
Are Japanese workers included among the numbers in the table of issued nPHR?
Ø Yes.
Is the nPHR issued to all trainees who exposed to hazardous substances?
Ø There is a requirement to issue an nPHR for each hazardous substance related work. The requirement formost hazardous substances was work history (≥ 3 months - ≥ 5 years). The requirement for dust-exposed
Estimationof Future Mesothelioma
Mortality in Japan5
works and Beryllium are pneumoconiosis cases.
The requirement
for asbestos-related
works are CXR
abnormalities or work history .
Workers may move address or change jobs after they returned home. How would you consider in situation where
0.01
the workers are engaged in jobs with potential for exposure to hazardous substances after they returned home?
Ø The requirements for the issuance of nPHRs, except for pneumoconiosis and asbestos-related work, are forwork periods of one0.008
to five years or longer. In these cases, TIT trainees can be issued when they go back totheir country. The cases of pneumoconiosis and asbestos-related work, nPHRs may be issued depend on theworkers condition such as latent duration and exposure history.
0.006
Who pay for the cost of post-retirement health checkup, government or employer?
Ø The Japanese government will pay for the medical examination. Transportation expenses are also paid to the0.004
workers.

imported volume of asbestos every 5 years[metric ton]

1.

Am. J. Ind. Med. 49:1–7, 2006.

Trend of pneumoconiosis in Japan• Major industries creating risk
• manufacturing, construction, mining• Workers in dust-exposed works• 585,507 in 1982 à 492,788 in 2013

• Workers screened for pneumoconiosis• 265,720 in 1982 à 269,763 in 2016

• Prevalence• 17.4% (46,235 cases) in 1982 à 0.7% (1,807 cases)in 2016• New cases• 4,266 in 1982 à 210 in 2016
• Pneumoconiosis with complications• 120 in 2022
(Source: Results of periodic pneumoconiosis examination released by Ministry of Health, Labour and Welfare)

Form 3Which tests are performed inpneumoconiosis health examination?
• Certification program & training foroccupational physicians

The Certificate of Pneumoconiosis Health Examination Results

Work and exposure history• Japan Medical Association• University of Occupational and Environmental Health• Questionnaires, physicalexamination• work and exposure history• clinical symptoms• Chest radiograph• Pulmonary function assessment• arterial blood gas (optional)• Tests for complications (optional)• cytology, biopsy• CT for lung cancer

Chest radiograph

Clinical symptoms

Tests for complications

Pulmonary function assessment

Requirements for Issuance of nPHR
Operations

Requirements

1

Benzidine2

Beta-naphthylamine

12

Dianisidine

13

1,2-Dichloropropane

15

3,3′-Dichloro-4,4′-diaminodiphenylmethane7

Bis (chloromethyl) ether

9Benzotrichloride

4

Chromic acid10

Vinyl Chloride

5

Arsene6

Coal tar

14

Ortho-toluidine

3

Dust-exposed works

11

Asbestos-related works*

8

Beryllium≥ 3 months of work history≥ 2 years of work history* Asbestos-related works
Any of the following applies:
1. To have irregular shadows due to asbestos
exposure on both lungs or pleural thickening due
to asbestos exposure. (Direct or Indirect exposure) (NOTE:
including pleural plaque)2.

≥ 3 years of work history

passed since the date of the first exposure to asbestos dust.) (Only direct
exposure)≥ 5 years of work history

Pneumoconiosis case-

Production of asbestos
Work to attach, repair, or remove heatinsulation materials, fire-resistant cladding
materials, etc. in which asbestos is used
Ø Operation of spraying asbestos ordemolition, crushing, etc. of buildings,
structures, etc. sprayed with asbestos
A person who has been engaged in asbestos
handling work other than the work described in(2) for 10 years or more. (Only direct exposure)ØØ≥ 4 years of work history

Pulmonary berylliosis caseThose who have been engaged in the following
work for one year or more. (However, at least 10 years have3.

Ordinance on Industrial Safety and Health (Order of the Ministry of Labour No. 32 of 1972), Chapter VI, Section 2, Article 53:
https://www.japaneselawtranslation.go.jp/en/laws/view/3878#je_pt1ch9sc4

Items of health checkup
Operations

Frequency

Items

Dust-exposed works (Class 2)

once a year

1.
2.

Dust-exposed works (Class 3)

once a year

1.
2.
l

Asbestos-related works

once every 6 months

work history , CXR(For those who have been diagnosed as having pneumoconiosis) spiral CT and sputum cytology (if necessary)

work history , CXR
Clinical examination of the chest, pulmonary function tests (except for the following persons);Those whose radiographs show large shadows exceeding one-third of one side of lung field (limited to those caused bypneumoconiosis);lThose who have been diagnosed as having pulmonary tuberculosis as a result of detailed examination for tuberculosis.
lThose who have been diagnosed as suffering from complications other than pulmonary tuberculosis as a result of X-ray
examination, clinical examination of the chest, and examination for complications other than pulmonary tuberculosis.
3.
(For those who have been diagnosed as having pneumoconiosis, those who have or are suspected of having pulmonary
tuberculosis) detailed examination for tuberculosis.
(For those who have been diagnosed as having pneumoconiosis) spiral CT and sputum cytology (if necessary)(Of those who have been diagnosed as having pneumoconiosis, those who are suspected of suffering from complications
other than pulmonary tuberculosis and primary lung cancer) examinations for complications other than pulmonary
tuberculosis and primary lung cancer. (excluding those whose radiographs show large shadows exceeding one-third of one
side of lung field)
1.
Investigation of work history
2.
Examination for the presence or absence of a history of symptoms/signs due to asbestos, such as cough, phlegm,
shortness of breath, chest pain, etc.
3.
Examination for the presence or absence of symptoms/signs such as cough, phlegm, shortness of breath, chest pain,etc.
4.
Examination using X-ray photographs of the entire chest
5.
When the results of the examination described in the preceding item fall under any of the following conditions and thephysician deems it necessary, examination by a chest X-ray using a special imaging method (Computed Tomography)
shall perform.
1)
When it is difficult to interpret abnormal shadows (Excluding those caused by fibroproliferative changes due toasbestosis.) due to asbestos-induced diffuse pleural thickening, calcified pleural plaque, etc. (Excluding cases of irregularshadows due to asbestos in both lung fields.)
2)
If there are abnormal shadows6.
If the examination results of the preceding two items (4. and 5.) show abnormal shadows and the physician deems
necessary, performs sputum cytology and/or bronchoscopy (biopsy and pathological examination, if deemed necessary
by the physician)Circular notice of the Labour Standards Bureau of the Ministry of Health, Labour and Welfare No. 653 of 1972https://www.jaish.gr.jp/anzen/hor/hombun/hor1-27/hor1-27-11-1-0.htm

History of TIT
late 1960s
Foreign training by private companies
1982
Creation of the status of residence for "Foreign trainees” (Prototype of TIT)
Be granted "Individual Enterprise Type"1990
Creation of the status of residence for "Training"
Be granted "Supervising Organization Type Training"
1991
Establishment of the "Japan International Training Cooperation Organization (JITCO)*"1993
Establishment of the Technical Intern Training Program
2010
Creation of the status of residence for "Technical Intern Trainees (TIT)"
2017
Establishment of the "Organization for Technical Intern Training (OTIT)"
2019
Creation of the status of residence for "Specified Skilled Worker (SSW)"*Currently, Japan International Trainee & Skilled Worker Cooperation Organization (JITCO)

1.4%

98.6%

https://www.jitco.or.jp/en/regulation/

Japanese Regulation of health checkup based on nPHR
ConstitutionAct

Regulationlevel

Regulation namenPHR
relatedAct

Industrial Safety and Health
Act (Act No. 57 of 1972)

Chapter 7, Basic
Article 67 information ofnPHR

Cabinet
Order

Order for Enforcement of
Article 23
Industrial Safety and Health
Act (Cabinet Order No. 318
of 1972)

Cabinet
Order
Order of the
Ministry
Public noticeIssuance ofnPHR (Works
Issuing thenPHR)

Order of the Ordinance on Industrial
Chapter VI, Requirement for
Ministry
Safety and Health (Order of Section 2, Issuance ofthe Ministry of Labour No. Article 53 nPHR
32 of 1972)
CircularnoticeCircular noticeContents

Circular notice of the Labour
Standards Bureau of the
Ministry of Health, Labourand Welfare• No. 653 of1972• No. 762 of1972
Ø (The latest
versions of
both; No.
0526, Article
12 of 2020)••

Items of healthcheckup
Requirements forcontract medical
institutions

令和 5 年度労災疾病臨床研究事業費補助金研究 分担研究報告書

アジア諸国の実情把握
研究分担者：田村 太朗 島根大学 医学部 准教授
研究協力者：吉川 徹 独立行政法人労働者健康安全機構労働安全衛生総合研究所研究推進・国際協力センター 統括研究員
研究要旨
【目的】
本研究では、健康管理⼿帳制度による健康診断を諸外国で実施するための課題及び解決策を検討することを実現するために、実施対象となり得るアジアを中⼼とした諸外国の実情について調査を⾏ったうえで、対象国の選定と、その調査⽅法についてまとめることを⽬的とした。
【方法】（１）我が国における外国⼈労働者の国籍や就労産業について、厚⽣労働省の統計などの集計をもとに⽂献調査を⾏なった。また、外国⼈労働者の健康管理に関する現状や技能実習⽣の動向についてもあわせて簡易な調査を実施した。
（２）また、我が国における健康管理⼿帳による健診制度の整理を⾏い、調査対象国での調査に必要な項⽬をまとめ、調査票を作成した。あわせて調査対象国の実情を確認すするため、各国のカウンターパートとなる海外協⼒者の選定を⾏ない、調査実施のための協議⽤資料を作成した。
【結果】
調査業種として健康管理⼿帳の交付件数の 9 割弱が⽯綿取り扱い作業と粉じん作業であることから、これらを中⼼として労働者の健康管理状況を把握することとした。
そのため、これらの作業に関連する業種としては、主には建設関係が考えられるが、外国⼈労働者、技能実習⽣の統計より得られた労働者数からは対象として、ベトナム、中国、インドネシア、フィリピン、ミャンマー、カンボジア、タイなどが考えられた。
これらの情報をもとに海外協⼒者に提⽰する提案書と質問票について作成を⾏った。
【考察】
外国⼈労働者・技能実習⽣の就労状況とともに、調査のために⾏政・産業衛⽣・臨床の専⾨家が必要と考えられたため、それら専⾨家チームを持ち、研究班と速やかに協議に⼊れると考えられたタイ、インドネシア、フィリピン等についての調査・協議を⾏うこととした。また、関連情報収集の対象国として外国⼈労働者の受け⼊れの先進国として

アメリカ・ドイツなどを対象として選定した。ただ、法制度・産業保健体制・医療提供体制については各国⼤きな差があることから、調査にあたっては今後さらなる調整が必要と考えられる。
A．研究⽬的

切な医療機関等の把握、健康診断の実施

全体の研究目的は健康管理手帳制度

方法・課題等について、調査対象となるによる健康診断を諸外国で実施するた国の選定と調査内容の詳細について検めの課題及び解決策を検討することと討を行い、諸外国に対する調査の基礎資

なっているが、本研究ではその実現のた料を作成することを目的とした。

めに調査対象となる国の選定と、その調査方法についてまとめることを目的とした。

B．研究⽅法

調査対象国選定のためには、我が国で総括ですでに述べられているように、の対象業務における外国人労働者の現我が国では一定の健康障害のリスクが状を把握する必要があり、厚生労働省

予想される者については、離職の際又は「外国人雇用状況の届け出状況」と 外離職の後に、労働安全衛生法の規定に基

国人技能実習機構による「令和４年度外

づき、健康管理手帳制度のもと、都道府

国人技能実習機構業務統計」を参考にい

県労働局長が指定する医療機関においずれの国の外国人労働者が多いかを調て、定期的に健康診断を受診することが査した。

できることとなっている。これは、我がそこで挙がってきた対象国を中心に国で就労する外国人労働者も対象とな

研究者、研究協力者間で協議を行い、実る。

際のカウンターパートとなり得る専門2019 年に施行された改正出入国・難民家、組織の選定を行った。

認定法により、段階的に単純労働分野にあわせて、日本における技能実習生制

おいても外国人労働者の受け入れを拡度の動向と外国人労働者の健康管理に大することとなっており、今後、一定期関する課題等について法務省出入国在間、我が国で有害業務に従事した後、母留管理庁の技能実習制度および特定技

国において健康診断の受診を希望する

能制度の見直し検討会、及び若干の最近者が増加することが予想される。

の文献をもとにその概略をまとめた。

このような状況を背景として、健康管調査項目については、まず我が国の健理手帳制度に基づく健康診断を行う適康管理手帳制度における健診対象や健表１

健康管理⼿帳の交付状況

業務

C．研究結果１．健康管理⼿帳の交付状況及び外国⼈

交付数

ベンジジン

1,048

労働者の統計β ナフチルアミン

728

健康管理手帳の発行状況について、表

⽯綿取り扱い作業

37,034１に示した。それによると粉じん作業と管理 2

11,739

石綿取り扱い作業の労働者が健康管理

管理 3

10,993

手帳交付の 86.2%と大多数を占めている。

クロム酸

695

これらの作業の大多数は建築業に分類

三酸化砒素

33

されているため、本研究のターゲットと

コークス

4,828

しては建築業に従事する外国人労働者

粉じん作業

ビスエーテル

85

ベリリウム

2

厚生労働省の外国人雇用状況に基づ

ベンゾトリクロリド

9

く国籍分布を表２に、外国人技能実習機

塩化ビニル

1,869

構業務統計から、外国人技能実習生の国

ジアニジン

186

籍分布を表３に示した。特に建築労働者

1･2−ジクロロプロパン

48の人数分布についても取り上げ同じ表

オルソトルイジン

55

に示した。

3・3ʼ-ジクロロ-4・4'-ジア
ミノジフェニルメタン
合計

069,352が主体と考えられる。

我が国の外国人労働者はアジア圏の国籍者が多く、外国人労働者全体でみると、中国や韓国の労働者も多数認めてい診項目、都道府県労働局が医療機関を指定する際の要件などを整理し、対象地域
での健康診断実施のために必要と考えられる項目を含めた調査票の作成を行った。
調査票をもとに調査を行うにあたって、調査目的、調査内容などについてカ
ウンターパートに提示する提案書（Proposal）の作成を行った。

るが、こと建築労働者として見れば、ベ
トナム、フィリピン、インドネシアが多く、技能実習生、技能実習生における建築労働者としてもこの３国の労働者は多数を占めていることがわかる。
これらの調査統計を参照して、実際に健康管理手帳の配布される可能性の高い外国人労働者が従事していると想定される調査対象国を選定した。調査対象
国の実情を確認するため、各国のカウン
ターパートとなる海外協力者の選定を行ない、海外の協力者との協議を行った。

表２

外国⼈雇⽤の国籍分布

国籍
中国

全産業

ベトナム
ネパール

12,760(21.2%)(0.70%)

67,335

1,338(3.7%)(0.07%)

206,050

13,298(11.3%)(0.73%)

462,384

54,099(25.4%)(2.97%)

118,196

1,295(6.5%)(0.07%)

77,88912,138(4.3%)(0.67%)

47,4984,551(2.6%)(0.25%)

135,167

3,865(7.4%)(0.21%)

31,263

1,248(1.7%)(0.07%)

81,175588(4.5%)(0.03%)

209,920

11,609(11.5%)(0.64%)

1,822,725

116,789(100.0%)(6.41%)

インドネシア
ミャンマー
ブラジル
ペルー
Ｇ７等
その他
全国籍計

建設業

385,848

韓国
フィリピン

表３

外国⼈技能実習⽣の国籍分布

国籍
ベトナム
中国
インドネシア
フィリピン
ミャンマー
タイ
カンボジア
モンゴル
その他
全体

合計

建築関係

12450923820(50.6%)(9.7%)

18346

1665

(7.4%)(0.7%)

42836

13545

(17.4%)(5.5%)

22205

5690

(9.0%)(2.3%)

14927

3430

(6.1%)(1.4%)

6801

706(2.8%)(0.3%)

9760

2722(4.0%)(1.1%)

2004

868(0.8%)(0.4%)

4872

1456(2.0%)(0.6%)

24626053902(100.0%)(21.9%)（文献 1）。特に最近では前述の報告の通りベトナム人が最も多い。
厚生労働省は、令和５年 10 月末時点

2. 外国⼈労働者の健康管理に関する現状や技能実習⽣の動向（１）外国⼈雇⽤状況の届出制度と技能実習⽣制度の動向の外国人雇用についての届出状況を取りまとめている。外国人労働者数は初の200 万人超えとなった。
外国人雇用状況の届出制度は、労働施策の総合的な推進並びに労働者の雇用

日本で働く外国人労働者の数は 2023 年の安定及び職業生活の充実等に関する

10 月時点で約 204 万人に達し、前年比法律に基づき、外国人労働者の雇用管理

で約 12.4％の増加を示しており、外国人の改善や再就職支援などを目的とし、す

労働者の数は過去最高を更新している

べての事業主に、外国人の雇入れ・離職

時に、氏名、在留資格、在留期間などを増加。一方、「特定活動」は 71,676 人、確認し、厚生労働大臣（ハローワーク）

前年比 1,687 人（2.3％）減少となった。

へ届け出ることを義務付けている。
届出の対象は、事業主に雇用される外（２）法務省出⼊国在留管理庁による国人労働者（特別永住者、在留資格「外「技能実習制度・特定技能制度の⾒直し」交」
・「公用」の者を除く。）であり、数値

令和 4 年 11 月 22 日に関係閣僚会議

は令和５年 10 月末時点で事業主から提の決定に基づき、「技能実習制度及び特出のあった届出件数を集計したもので

定技能制度の在り方に関する有識者会

ある。

議」が開催され報告書が公開されている

外国人労働者数は 2,048,675 人で前(文献 3)。本会議は、両制度の施行状況

年比 225,950 人増加し、届出が義務化を検証し、外国人材の適正な受け入れ方された平成 19 年以降、過去最高を更新策を検討することを目的としている。

し、対前年増加率は 12.4 ％と前年の技能実習制度は、外国人技能実習の適

5.5 ％から 6.9 ポイント上昇となった。

正な実施及び技能実習生の保護に関す外国人を雇用する事業所数はる法律（平成 28 年法律第 89 号）に基づ

318,775 所で前年比 19,985 所増加、届き設置され、その施行状況を 5 年ごとに出義務化以降、過去最高を更新し、対前検討することが定められている。特定技

年増加率は 6.7 ％と前年の 4.8 ％か

能制度も同様に、出入国管理及び難民認ら 1.9 ポイント上昇した。国籍別では、

定法及び法務省設置法の一部を改正す

ベトナムが最も多く 518,364 人（外国る法律（平成 30 年法律第 102 号）に基人労働者数全体の 25.3％）、次いで中国

づき、施行状況を 2 年ごとに検討するこ

397,918 人（同 19.4％）、フィリピンとが求められている。

226,846 人（同 11.1％）の順であった。

有識者会議では、両制度の運用状況や課在留資格別では、「専門的・技術的分

題を洗い出し、外国人材の受け入れと共野の在留資格」が対前年増加率として最生を進めるための方策を議論している。

も大きく 595,904 人、前年比 115,955

具体的には、監理団体や登録支援機関の人（24.2％）増加、次いで「技能実習」

適正化、人権侵害の防止、技能実習機構

が 412,501 人 、 前 年 比 69,247 人の体制整備、悪質な送出機関の排除、日（ 20.2 ％ ） 増 加 、「 資 格 外 活 動 」 が

本語能力向上の取り組みなどが含まれ352,581 人、前年比 21,671 人（6.5%）

る。

増 加 、「 身 分 に 基 づ く 在 留 資 格 」 が615,934 人、前年比 20,727 人（3.5％）

図１

中間報告書での検討結果概要

中間報告書（令和 5 年 5 月 11 日提出）

内容にとどまり、現在生じている技能習では、深刻な人手不足を背景に、外国人生の人権の問題、健康安全管理の課題なとの共生社会の実現を目指し、その人権どについては記載されておらず、今後検に配慮しつつ、外国人が日本で働きやす討されるものと思われる。

い環境を整えることが強調されている。
これにより、多様性に富んだ活力ある社

報告書では、政府は、技能実習制度と会を実現し、日本の産業及び経済、地域

特定技能制度の見直しを進める中で、新社会を支えることを目指すとされた。有

たな制度の創設を検討しているとした。

識者会議は、外国人が成長しつつ中長期

現行の技能実習制度は、人材確保と育成的に活躍できるキャリアパスの構築、受を目的とした新制度に発展的に解消し、け入れ見込数の設定や転籍の在り方、管特定技能制度は適正化を図りつつ引き理監督や支援体制の整備などを議論し続き活用する方針とされた。

ている。これらの議論を踏まえ、令和 5

最終報告書では、これらの制度改革を

年秋に最終報告書を取りまとめた形と通じて、日本が魅力ある働き先として選なった。

ばれる国となることを目指し、外国人労働者がキャリアアップしつつ活躍でき

図１には中間報告書での検討結果の概要の抜粋を示した。同有識者会議での議論では、制度全体の見直しに関連したる社会の実現に向けた具体的な方策が示されている。

（３）外国⼈労働者の増加と健康管理の指摘できる。

課題
健康管理の面では、外国人労働者が日

3. 提案書（案）、調査票（案）の作成

本の医療システムに適切にアクセスす調査項目としては各国の保健医療制

ることが難しいという問題が指摘され度には大きな差異があるため、各国の法ている。言語の壁や制度の複雑さが主な

制度、産業保健体制、医療提供体制、我障壁となっており、特に低賃金労働者やが国の健康管理手帳制度に合致する医技能実習生においてその傾向が強い。こ

療機関・専門家について、またそういっ

れらの実態は、今後、継続的に外国人労た産業保健・医療サービスの品質管理に

働者の健康管理を行っていく際に重要ついてのシステムについて包括的に調な情報となる。

査することとした。この目的を達するた

辻村らによる技能実習生の健康や生めに、参考資料につけた本研究を理解し活上の問題の文献的検討では、①コミュてもらうための提案書、調査票を作成しニケーションの間題、②健康の間題、③た。

生活や文化の相違、④労働環境の問題、⑤人権にかかわる問題などが指摘されD．考察ている（文献 4）。石丸らは外国人技能実

対象国の選定に当たり、最終的には健習生の監理団体を対象に彼らの健康と康管理手帳制度交付に該当する外国人

安全への支援の状況について調査した労働者が来日している国全体に対する（文献５）。監理団体は技能実習生のメ調査も必要になるが、調査の結果、すでンタルヘルス不調、結婚・妊娠・出産、にある程度の人数来日があること、また、

ハラスメントへの相談対応に最も課題調査のためには法制度・行政の視点、産を抱えていた。監理団体と産業保健職と業衛生の視点、医療現場の視点など幅広の連携促進に、教育機会や教育を計画す

い視点が必要であることから、そういっる安全衛生の担当者の存在が重要だとた専門家を擁している国を当初の調査した。

対象とすることとした。具体的にはタイ、

以前から指摘されてきた外国人労働インドネシア、フィリピン、ネパールの者の健康課題については、その人数の増

専門家との協議に入り、質問票、質問項

加と共に、より複雑化している。その中目の修正もしながら、その他のアジアのには、日本で働くことによって生じた健国での調査についての知見も収集して康障害を抱えたまま母国に帰国する労いるところである。

働者の存在と、その後のケアの重要性がまた、労働者受け入れ側の調査も必要

と考えられ、アメリカ、ドイツなど受け

参考⽂献

入れが進んでいると考えられる国への

1)外国人技能実習機構業務統計

調査も検討している。

https://www.otit.go.jp/research_toukei
_r4/

E．結論

調査票など作成を行い、調査の準備を

2）厚生労働省職業安定局外国人雇用対策課. 外国人雇用状況の届け出状況ま整えたものの、法制度・産業保健体制・とめ

医療提供体制については各国大きな差

https://www.mhlw.go.jp/stf/newpage_3があることから、実際の調査にあたって7084.html

は今後さらなる調整が必要と考えられ

3) 法務省出入国管理局

る。

度・特定技能制度の見直し

技能実習制

https://www.mofa.go.jp/mofaj/files/100
F．健康険情報

該当なし

565011.pdf
4) 辻村弘美. 外国人技能実習生の健康や生活上の問題と今後の課題におけるG．研究発表

文献検討. 日本国際看護学会誌 2020; 3

該当なし(1): 23-31.

Ｈ．知的財産権の出願・登録状況(予定を含む)5）石丸知宏、倉岡宏幸、清水少一、原邦夫. 監理団体による外国人技能実習

1.特許取得生の健康と安全への支援の現状と課題該当なし
2.実⽤新案登録―産業保健職との連携に着目して. 産

該当なし

衛誌 2023; 65(2): 74-81.

To[Details of recipient]
Subject: Proposal for Overseas Health Checkup Initiative
Name of the Research Project:
Assessing the Feasibility of Extending Occupational Health Services to Returning
Overseas Workers: A Collaborative Study.
Principal Investigator:
Narufumi Suganuma, MD, PhD
Professor and Chief, Department of Environmental Medicine
Kochi Medical School, Kochi University
Former Dean of Kochi Medical School
Funding Agency:
Ministry of Health, Labour and Welfare, Government of Japan
Timeframe of the Research:
3 April 2023 to 31 March 2026

Section I. Overview of the Research ProjectIntroduction
The Ministry of Justice of Japan reported approximately 1.66 million foreign workers in
2019, including technical intern trainees comprising roughly 23% (384,000 individuals)of the total workforce, who typically return to their home countries upon completing theirinternships. Furthermore, the revised Immigration and Refugee Recognition Act,
effective in 2019, signals a gradual expansion of foreign worker acceptance in Japan.
In Japan, individuals engaged in occupations with potential health hazards, such as
those prone to developing cancer, are issued Notebooks of Personal Health Record
upon leaving employment. Governed by the provisions of the Industrial Safety and
Health Law and specific requirements outlined by the Ministry of Health, Labour andWelfare, these Notebooks grant access to regular medical assessments at designatedinstitutions, extending coverage to both Japanese nationals and qualifying foreign
workers. However, as of present, this service is exclusively available at designatedmedical facilities within Japan.
Anticipating a desire among individuals to undergo medical examinations in their homecountries after exposure to hazardous substances in Japan, it is imperative to assess
the feasibility of extending health assessment services to returning foreign workers. We
hypothesize that such an extension will not only address critical healthcare gaps but
also enhance overall well-being strategies for returning workers.
Hence, the primary objective of this research project is to evaluate, in collaboration with
relevant overseas partners, the feasibility of extending health assessment services toforeign workers returning to their home countries after employment in Japan.
Specifically, the research aims to:•

Identify gaps in providing health examinations to foreign workers after returning
to their home countries.

•

Investigate the availability of medical institutions capable of providing healthexamination services at a standard comparable to that of Japan.

Methodology
1. Ethical Considerations
Before commencing this research, we will consult the Institutional Review Board at
Kochi Medical School, Kochi University, Japan, regarding ethical issues such asconsent and the handling of information.
2. Study Design
We will use a mixed-methods approach, combining document review and focus groupinterviews with ministerial and occupational healthcare personnel.
3. Participants
We purposively select participating countries from those with a large number oftechnical intern trainees currently visiting Japan, primarily from Southeast Asian
countries, along with other major countries with bilateral agreements on technical interntraining or arrangements on specific skills.
Countries with a significant number of technical intern trainees in Japan, listed indecreasing order, include Viet Nam, China, Indonesia, the Philippines, Myanmar,
Thailand, and Cambodia.
Countries with bilateral agreements on technical intern training or arrangements on
specific skills encompass Bangladesh, Bhutan, Cambodia, India, Indonesia, Laos,
Mongolia, Myanmar, Nepal, Pakistan, the Philippines, Sri Lanka, Thailand, Uzbekistan,and Viet Nam.
4. Data Collection•

Document reviews of occupational health services, with a particular focus on
health examinations, will be conducted by respective collaborators from eachparticipating country. The documents review is divided into three sections toprovide a comprehensive snapshot of occupational health service in eachparticipating country: (1) the governance of occupational health service, (2)quality assurance of occupational health service, and (3) review of medical
institutions providing occupational health service, particularly health examination
service.
•

We designed a mixed survey questionnaire, incorporating both open- and closedended questions, after reviewing existing literature. Using this questionnaire, wewill conduct focus group interviews with healthcare personnel from eachparticipating country. These interviews aim to explore essential elements ofoccupational health service delivery, with a specific focus on health examinations
in each participating country. The number of participants in each country will be
determined through a review of medical institutions providing occupational healthservice.

•

Hold international meetings with participation of research collaborators(ministerial and occupational healthcare personnel) from the countries understudy to gain in-depth insights into the occupational healthcare system andstandards.

5. Data Analysis
Summarize close-ended responses using descriptive statistics and thematicallyanalyzed open ended responses.
6. Dissemination of results
After conducting a three-year survey and study, the current status of occupational
health services, with a specific focus on health examinations in each country, will bethoroughly organized and summarized. Additionally, proposals addressing future
study areas related to the implementation of health examinations in participants'
home countries will be compiled into a comprehensive report.
These findings will also be documented in prominent Asian academic journals suchas the Journal of Occupational Health, Industrial Health, and Environmental

Occupational Health Practice, among others, which specialize in occupational
health.
Timeframe

Significance of the research
The increasing influx of foreign workers into Japan, particularly technical intern trainees,
underscores the pressing need to address their healthcare needs, especially upon theirreturn to their home countries. For instance, approximately 35% of these trainees areengaged in construction, machinery and metal industries, occupations prone to
exposure to hazardous substances, highlighting the potential health risks they faceduring their employment in Japan. Despite the issuance of Notebooks of Personal
Health Record by the Ministry of Health, Labour and Welfare in accordance with theIndustrial Safety and Health Law, the current system lacks provisions for healthexaminations upon the workers' return to their home countries. Given that occupational
hazards may continue to manifest long after cessation of work, the continuity of healthassessments for returning workers is imperative.

This research holds profound significance in bridging this gap by evaluating thefeasibility of extending health assessment services to overseas workers in their homecountries. By identifying medical institutions capable of providing comprehensive healthexaminations in countries with significant numbers of returning workers, this study aims
to establish a crucial foundation for enhancing measures related to the Notebooks of
Personal Health Record for foreign workers. The findings from this research will not only
contribute to the well-being of returning overseas workers but also inform policy
decisions aimed at safeguarding their health and promoting international occupational
health standards.
Moreover, the establishment of networks and collaborations with medical institutions
abroad will not only facilitate continuous health monitoring for returning workers but also
foster cross-border cooperation in addressing occupational health challenges.
Ultimately, this research has the potential to advance global efforts in ensuring thehealth and safety of migrant workers, thereby fostering inclusive and equitable
healthcare systems worldwide.
Section II. Responsibilities of Participating Countries
1. Conduct a comprehensive document review and submit findings to the principal
investigator by August 2024. The document review will be divided into three sections
to provide a detailed overview of occupational health services in each collaborating
country:•

Governance of occupational health services•

Quality assurance of occupational health services•

Review of medical institutions providing occupational health services, with afocus on health examination services.

2. Organize and facilitate focus group interviews with key healthcare personnel toexplore critical aspects of occupational health service delivery. These interviews will
provide valuable insights into the strengths, challenges, and opportunities for
improvement within each country's occupational health system.

3. Actively participate in international meetings convened with relevant ministerial andoccupational healthcare personnel. These meetings will serve as platforms forsharing knowledge, exchanging best practices, and gaining a deeper understandingof the occupational healthcare systems and standards in each collaborating country.
By engaging in these discussions, participating countries can contribute to thedevelopment of collaborative solutions and the advancement of the oversea healthcheckup initiative for returning workers.

Section III. Merits for Participation in this Project
1. Facilitating collaboration between medical institutions in foreign countries and Japan
will foster a culture of continuous improvement in the standard of health examination
services. This collaborative effort not only benefits returning overseas workers but
also extends to Japanese workers deployed in these countries, who can accessthese institutions for medical examinations. By leveraging the expertise andresources of both domestic and international healthcare providers, participating
countries can enhance the quality and accessibility of occupational health services,
thereby promoting the well-being of workers across borders.
2. Participating countries will receive a financial incentive of thirty thousand Japanese
Yen or equivalent currency for each component of the document review, including:•Governance of occupational health services•

Quality assurance of occupational health services•

Review of medical institutions providing occupational health services, with a
specific focus on health examination services.

This monetary reward not only acknowledges the valuable contribution ofparticipating countries to the research endeavor but also serves as an incentive forthorough and timely completion of the document review process. Additionally, by
providing financial support, this initiative demonstrates a commitment to fosteringinternational collaboration and advancing occupational health standards on a global
scale.
3. In acknowledgment of their collaboration in the research, representatives orindividuals in charge from each participating country will be acknowledged andincluded as co-authors in the final report.

Oversea Health Checkup Initiative for Returning Overseas Workers
In Japan, we have a system that provides the personal Health Handbook to individuals engaged
in jobs that may pose health risks, such as the development of cancer, and who meet therequirements specified by the Order of the Ministry of Health, Labor and Welfare of Japan uponleaving their employment. Those in possession of the handbook are entitled to undergo regular
medical assessments at designated medical institutions.
This system is applicable to both Japanese nationals and foreign workers who meet the
aforementioned conditions. However, the services are currently only available at medical
institutions in Japan. Our research group aims to evaluate the feasibility of extending healthassessment service to foreign workers who have returned to their home countries.
This study is supported by the Ministry of Health, Labor and Welfare, and it will report on the
research results regarding the implementation status of health assessment programs, particularly
those related to pneumoconiosis, in Asian countries. These research findings are expected to be
crucial inputs for the Ministry of Health, Labor and Welfare when formulating future healthcare
strategies for foreign workers.

Your understanding of the purpose of this study is greatly appreciated.
Please check one of them.

□ I will cooperate. □ I will not cooperate.

Date: ………………………………..

Questionnaire A. We would like to inquire about the Occupational Health Service (OHS)
Delivery System, with a particular focus on health examination in your country.
Section 1. General Information
1.1.Your Name
1.2. Position/Title
1.3. Name of your Organization/Agency
Section 2. We would like to inquire about the legislations/law enforcements for the occupational
health and safety.
2.1. Is there a specific legislation or law governing occupational health and safety in yourcountry? Example: Industrial Safety and Health Law of 1972 in Japan.

□ Yes

□ No

□ Not sureIf yes, please provide details or examples.
________________________________________________________________________________________________________________________________________________________________________________________________________________________
2.2. Is there a regulatory body responsible for enforcing occupational health and safety laws
in your country? Example: The Ministry of Health, Labour and Welfare (MHLW) in
Japan oversees and enforces occupational health and safety regulations.

□ Yes

□ No

□ Not sureIf yes, please provide details or examples.
________________________________________________________________________________________________________________________________________________________________________________________________________________________
2.3. Are there specific requirements outlined in the legislation regarding occupational healthmanagement? Example: Industrial Safety and Health Law in Japan, which mandates theappointment of an Occupational Health Physician (Chapter III. Article 13).

□ Yes□ No□ Not sureIf yes, please provide details or examples.
________________________________________________________________________________________________________________________________________________________________________________________________________________________
2.4. How are companies monitored or assessed for compliance with occupational health andsafety laws in your country? Example: Regular audits conducted by regulatory authorities
to ensure adherence to occupational health and safety regulations.
If any, please describe.
________________________________________________________________________________________________________________________________________________________________________________________________________________________
2.5. Do occupational health and safety laws in your country include provisions for employee
rights and protections? Example: Employees have the right to receive period healthexamination at no cost.

□ Yes

□ No

□ Not sureIf yes, please provide details or examples.
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Section 3. We would like to inquire about the occupational health service, with a particular focus
on health examinations in general.
3.1. How frequently are medical examinations conducted for employees?
•□ Every 6 Months □ Annually □ Every 2 years □ Every 3 years•□ Never Conducted•

Others (please specify): _________________________________________________

3.2. Are there any public post-retirement health care programs for employees?

□ Yes □ No □ Not sure
3.3. If “yes” to Q:3.2. How frequently are medical examinations conducted for retired
employees?
•□ Every 6 Months □ Annually □ Every 2 years□ Every 3 years•□ Never Conducted•

Others (please specify): _________________________________________________

3.4. Are there any private post-retirement health care programs for employees?

□ Yes

□ No

□ Not sure

3.5. If “yes” to Q:3.4. How frequently are medical examinations conducted for retired
employees?
•□ Every 6 Months □ Annually □ Every 2 years □ Every 3 years•□ Never Conducted•

Others (please specify): _________________________________________________

3.6. Does your country have hospitals dedicated to occupational health service?
•

Are there any public hospitals with dedicated occupational health department/unit?

□ Yes

□ No

□ Not sureIf “yes” please check the appropriate box below.

Available□ only in capital city, □ in some major cities, □ in small cities,

etc. ____________________________________________________•

Are there any private hospitals with occupational health physicians/nurses?

□ Yes

□ No

□ Not sureIf “yes” please check the appropriate box below.
Available□ only in capital city, □ in some major cities, □ in small cities,

etc. ____________________________________________________
3.7. Types of occupational health professionals employed:•□ Occupational health doctors•□ Occupational health nurses•

Others (please specify): ____________________________________________________

3.8. Are the occupational health professionals adequately trained and certified, such as holding
post-graduate degrees?

□ Yes

□ No

□ Not sure

3.9. What are the types of occupational health service available in your country?
•□ In-house, i.e., occupational health personnel (physicians/nurses) are employed byindividual companies.

•□ External, i.e., an external unit (health checkup agencies) serving several companies.

•

Others (please specify): ___________________________________________________

3.10. Who pays occupational health service fees in your country?
•□ Partly paid by public sources•□ Companies•□ Out-of-pocket•

Others (please specify): ___________________________________________________

3.11. How well is the occupational health service integrated into the overall health system of thecountry?

□ Well-integrated □ Partially integrated□ Not integrated □ Not sure

Section 4. We would like to inquire about the legal and healthcare system for workers engaged inhazardous work in your country.
4.1. For pneumoconiosis and asbestos-related diseases, is there any public healthcare or
health examination system for the workers?

□ Yes
•

□ No

□ Not sureIf yes to Q:4.1, how frequently are medical examinations for pneumoconiosis performed?

□ Every 6 Months □ Annually □ Every 2 years □ Every 3 years
Others (please specify): ________________________________________________•

If yes to Q:4.1, what are the items in the medical examination for pneumoconiosis?
Please specify those items.

_______________________________________________________________________________________________________________________________________________________________________________________________________________________•

If yes to Q:4.1, how frequently are medical examinations for asbestos-related diseases
performed?

□ Every 6 Months □ Annually □ Every 2 years □ Every 3 years
Others (please specify): _________________________________________________•

If yes to Q:4.1, what are the items in the medical examination for asbestos-relateddiseases?
Please specify those items.
________________________________________________________________________________________________________________________________________________________________________________________________________________________

4.2. For pneumoconiosis and asbestos-related diseases, are there any post-retirement
healthcare programs for the workers?

□ Yes
•

□ No

□ Not sureIf yes to Q:4.2, how frequently are post-retirement medical examinations forpneumoconiosis performed?

□ Every 6 Months □ Annually □ Every 2 years □ Every 3 years
Others (please specify): _________________________________________________•

If yes to Q:4.2, what are the items in the post-retirement medical examination forpneumoconiosis?
Please specify those items.
________________________________________________________________________________________________________________________________________________________________________________________________________________________

•If yes to Q:4.2, how frequently are post-retirement medical examinations for asbestosrelated diseases performed?
Every 6 Months

Annually

Every 2 years

Every 3 years

Others (please specify): _________________________________________________•

If yes to Q:4.2, what are the items in the post-retirement medical examination forasbestos-related diseases?
Please specify those items.
________________________________________________________________________________________________________________________________________________________________________________________________________________________

4.3. For workers currently engaged in occupations with exposure to known carcinogens(other than silica and asbestos) such as benzidine, Beta-naphthylamine, etc., is there any
public healthcare or health examination system in your country?

□ Yes

□ No

□ Not sure

4.4. For workers previously engaged in occupations with exposure to known carcinogens(other than silica and asbestos) such as benzidine, Beta-naphthylamine, etc., is there any
public healthcare or health examination system in your country?

□ Yes

□ No

□ Not sure

Section 5. We would like to inquire about health examination through the Health Handbook
system for your citizens after employment in Japan.
If there is a request from Japan for post-retirement medical examinations for pneumoconiosis
and asbestos-related diseases for your citizens after employment in Japan:
5.1. Are there any physicians able to evaluate pneumoconiosis and asbestos-relateddiseases?

□ Yes

□ No

□ Not sure

5.2. Are there any physicians able to classify chest radiographs for pneumoconiosis
according to the International Labour Office (ILO) international classification system(or) similar classification system for pneumoconiosis?

□ Yes

□ No

□ Not sure

5.3. Are there any medical institutions, public or private, in your country that employ
specialists who can diagnose pneumoconiosis and asbestos-related diseases?

□ Yes

□ No

□ Not sure

5.4. If yes to Q:5.3, how many medical institutions in your country that employ specialists
who can diagnose pneumoconiosis and asbestos-related diseases?
a. Public medical institution□ One facility in the country (e.g., located in capital city)□ Located in major cities (only in some prefectures)□ Located in small cities (all prefectures)b. Private medical institution□ One facility in the country (e.g., located in capital city)□ Located in major cities (only in some prefectures)□ Located in small cities (all prefectures)
5.5. Are there any medical institutions, public or private, in your country that can provide thefollowing investigations?
a. Digital chest radiography (CXR)

b. Computed tomographyc. Spirometry and flow volume curves examinationd. Bronchoscopye. Arterial blood gas analysis
f. Sputum smear test for tuberculosis
g. Tuberculin test
h. Interferon gamma release testi. Sputum cytology examination
j. Blood sedimentation□ Yes □ No □ Not sure
5.6. If yes to Q:5.5, how many medical institutions in your country that can provide
investigations listed in Q:5.5?
a. Public medical institution□ One facility in the country (e.g., located in capital city)□ Located in major cities (only in some prefectures)□ Located in small cities (all prefectures)b. Private medical institution□ One facility in the country (e.g., located in capital city)□ Located in major cities (only in some prefectures)□ Located in small cities (all prefectures)

Questionnaire B: We would like to inquire about the Quality Assurance System for
Occupational Health Service, with a particular focus on health examination in yourcountry.
1. Does your country have legislations/regulations for quality assurance on occupational healthservice?
1.1. Are organizations required to apply to the authorities for permission to establish an
occupational health service facility or clinic?

□ Yes

□ No

□ Not sure

1.2. Are there specific measures in place to ensure the standardization of health examinations
for occupational diseases?

□ Yes

□ No

□ Not sureIf yes, please provide details or examples.
_____________________________________________________________________________________________________________________________________________________________________________________________________________________•

Example: Japan has established standards for pneumoconiosis health examinations, as
outlined in the Handbook of Pneumoconiosis Health Examination.

1.3. Are there specific medical examination schemes for workers exposed to hazardous
substances, such as asbestos?

□ Yes

□ No

□ Not sureIf yes, please provide details or examples.
________________________________________________________________________________________________________________________________________________________________________________________________________________________•

Example: Japan’s Ministry of Health, Labour and Welfare has implemented a medical
examination scheme for asbestos-exposed workers.

1.4. Are there standards for diagnostic tools, such as radiographs, used in occupational
disease investigations?

□ Yes

□ No

□ Not sureIf yes, please provide details or examples.
_____________________________________________________________________________________________________________________________________________________________________________________________________________________•

Example: Japan has set standards for digital radiography to ensure consistency inpneumoconiosis diagnosis.

1.5. How do regulatory bodies contribute to quality assurance in occupational healthservices?
Please provide details.
_____________________________________________________________________________________________________________________________________________________________________________________________________________________•

Example: Industrial safety and Health Department play a key role in overseeing andensuring compliance with quality assurance standards.

2. Is there a formal quality assurance system in place for occupational health services? For
examples:2.1. Accreditation System.
Example: Hospitals providing occupational health services are required to undergo
accreditation, demonstrating compliance with predefined quality standards.

□ Yes

□ No

2.2. Standardization of Investigations.

Example: Quality assurance is ensured through standardized procedures, such as
interpreting chest radiography for pneumoconiosis using the ILO classification system, tomaintain consistency and accuracy in diagnostic processes.

□ Yes

□ No

2.3. Continuous Monitoring and Improvement.
Example: A continuous monitoring system is in place, with regular assessments andfeedback mechanisms to identify areas for improvement in occupational health services.

□ Yes

□ No

2.4. Compliance Audits.
Example: Regular audits are conducted to ensure that occupational health services
comply with established regulations and quality standards.

□ Yes

□ No

2.5. External Quality Assurance Programs.
Example: Participation in external quality assurance programs, where occupational healthservices are evaluated by independent organizations to validate the quality of services
such as radiological images and blood/laboratory tests.

□ Yes
2.6.

□ No

□ No Formal System in Place. Example: Currently, there is no established formal

system for quality assurance in occupational health services.

2.7.

□ Not Sure/Not Applicable:

3. If “yes” to any of the items in Q:2, how often are evaluations conducted to assess the qualityof occupational health services?

•□ Every 6 Months □ Annually □ Every 2 or 3 years•□ Continuous Monitoring and Feedback Loop•

□ Post-Incident Evaluations. Example: After significant incidents or outbreaks,
immediate evaluations are conducted to analyze the effectiveness of the response andidentify lessons learned.

•□ Upon Introduction of New Policies or Procedures. Example: Evaluations are
conducted whenever new policies, procedures, or technologies are introduced to ensure
their effectiveness in improving occupational health services.

•□ As Needed/On an Ad-hoc Basis

4. Is it mandatory for healthcare professionals to obtain permission or certification from theauthorities to practice occupational health services in your country?

□ Yes

□ No

□ Not sure

5. Does your country have certification programs for occupational health physicians andoccupational health nurses?

□ Yes

□ No

□ Not sureIf yes, please provide details or examples.
_____________________________________________________________________________________________________________________________________________________________________________________________________________________
6. Is it possible to obtain anonymized chest images (in DICOM format) for use in this research?

□ Yes□ No□ Not sure

令和 5 年度労災疾病臨床研究事業費補助金研究 分担研究報告書

健康管理手帳制度による健康診断のタイでの実施のための研究
研究分担者：JP Naw Awn 高知大学 医学部 特任助教
研究代表者：菅沼 成文 全国労働衛生団体連合会
胸部Ｘ線検査専門委員会委員
研究分担者：田村太朗 島根大学 医学部 准教授
研究要旨
【目的】
研究代表者らは、2003 年からタイ政府関係者との間でじん肺読影医認証制度の議論を開始し、2008 年にバンコクでアジアじん肺読影医養成プログラム（AIR Pneumo）を始動し、以来 2023 年までにタイで 7 回、全体で 26 回開催してきた。AIR Pneumo を通じて培った人的ネットワーク等を土台として、タイの労働安全衛生分野の専門家（省庁、大学、国営医療機関）と共に移民労働者が帰国後に健康管理手帳制度の健康診断を受診できるよう研究プロポーザルを作成し、多数の国を対象とする本事業におけるロールモデルを構築することを目指した。
【方法】
タイを訪問し、労働安全衛生分野の専門家を招集して、移民労働者が帰国後に健康管理手帳制度による健康診断を受診することができるよう、研究プロポーザルのドラフト版について議論した。
【結果】
国ごとに異なる会計年度や省庁／規制機関の存在、アンケート調査における倫理委員
会（IRB）の必要性、タイでの IRB 承認にかかる時間の長さ、胸部 X 線画像収集の難しさが明らかにされた。
【考察】
プロジェクト提案においては、明確な目的設定と協力国への責任分担が重要であることが示唆された。タイでの IRB 承認にかかる時間の長さを考慮して、データ収集の方法論として IRB 承認が不要なフォーカスグループインタビューを採用する。
A．研究目的GDP の大きな国で、観光業や製造業がタイは、面積 513,100 平方キロメートル

主要な経済の柱となっている。医療制度の東南アジアのインドシナ半島に位置も比較的整備されており、バンコクや主する国家で、71.8 百万人の人口を抱える。

要都市では高水準の医療サービスが提インドシナ半島の国家群の中では最も供されているが、地方ではインフラが不十分な場合もある。

会議出席者：

研究代表者らのチームは、じん肺を撲滅[Division

するための ILO・WHO による包括的施

Environmental Diseases, Department

策に寄与することを目的に、2003 年、

of Disease Control, Ministry of Public

タイ政府関係者との間でじん肺読影医

Health] （省庁）の認証制度について議論を開始し、Dr. Somkiat Siriruttanapruk, Senior2008 年にバンコクで第一回アジアじん

advisor

肺読影医養成プログラム（AIR Pneumo）

Dr.

を実施し、現在までアジア等の地域で合Ph.D., Director

計 26 回（内、タイは最多の 7 回）開催

Dr. Thanawat Rattanawitoon, Head

してきた。この AIR Peumo の取組の中Dr. Wipada Senanon, Public Healthで形成されたネットワークと比較的発Technical OfficerofOccupational

Yongjua

Laosiritaworn,

and

M.D.,

展した医療制度を土台とし、移民労働者
が帰国後に健康管理手帳制度による健[Raj

PrachaSamasai

Institute,

康診断を受診することができるように、

Department

DiseaseControl,

タイの労働安全衛生分野の専門家と共Ministry of Public Health] （省庁）に研究プロポーザルを作成し、多数の国

Dr. Ueampohn Poonkla, M.D., M.Sc.,を対象とする本事業におけるロールモ

Occupational Medicine Physician

デルを構築することが本調査の目的で

Dr.

ある。

M.Sc.,

of

Suttinate

Wannatrong,

Occupational

M.D.,

Medicine

PhysicianB．研究方法タイを訪問し、労働安全衛生分野の専門[Department of Preventive and Social

家（省庁、大学、国営医療機関）を招集

Medicine, Faculty of Medicine, Siriraj

して、移民労働者が帰国後に健康管理手

Hospital, Mahidol University] （大学）帳制度による健康診断を受診すること

Dr. Narongpon Dumavibhat, M.D.,ができるよう、研究プロポーザルのドラ

Ph.D. Assistant Professor

フト版について議論した。
[DepartmentofCommunity

and

日時：2024 年 2 月 5 日

Family Medicine, Faculty of Medicine,

場 所 ： Grand Richmond Stylish

Thammasat University] （大学）

Convention Hotel

Dr. Sitthiphon Bunman, M.Sc., Ph.D.

⚫

プロジェクトの提案に関しては、[Department of radiology, Central

明確な目的を特定し、協力国に対Chest Institute of Thailand] （国営医

する明確な責任を定めることが療機関）重要であることが示唆された

Dr. Saijai Lertrojanapunya, M.D.

⚫

Dr. Sutarat Tungsagunwattana, M.D.

タイでの国際会議開催については、早急な行動が必要でないとされた

JP Naw Awn

高知大学医学部環境医

学教室
角田都

⚫

タイでの IRB 承認にかかる時間が長いため、計画にはそれを考慮

高知大学医学部環境医する必要がある学教室
E．結論
C．研究結果
会議参加者より、以下の点について指摘を受けた。

タイでの IRB 承認にかかる時間の長さを考慮して、データ収集の方法論として
IRB 承認が不要なフォーカスグループ⚫

国ごとに異なる会計年度

インタビューを採用する。タイでの健康⚫

国ごとに異なる省庁／規制機関

管理手帳制度による健康診断プロジェが存在

クトに関して、タイでの実施方法として、

アンケート調査に関しては倫理

共同研究者の採用や奨学金の可能性、別委員会（IRB）の承認が必要の報告書／出版物の作成が提案された。

フォーカスグループインタビュ

本調査を通じて、タイでの調査を進めるーに関しては IRB の承認が不要

上で必要となる連絡担当候補者を立てタイでの IRB 承認には 8 ヶ月以ることができた。タイにおける OSH サ

上かかる可能性があるービスの提供システム及び品質保証シ

胸部 X 線画像の取得が非常に困

ステムについての文献調査、健康診断実難であることが示唆されており、施病院候補リストの収集、病院調査の実IRB の期間を考慮する必要があ

施は次年度以降の課題となった。

⚫
⚫
⚫
⚫

る
F．健康危険情報
D．考察

該当なし

会議で議論された内容を踏まえ、以下の点が課題として浮かび上がってきた。

G．研究発表1.論文発表

among Tuberculosis patients in WestJ-P NA, Susanto AD, Samoedro E,

Java, Indonesia:

Mansyur M, Tungsagunwattana S,

from Hospital Based Study . The 67th

Lertrojanapunya S, Subhannachart P,

Chugoku-Shikoku Joint Conference on

Siriruttanapruk S, Dumavibhat N,

Occupational Health 第 67 回中国四国

Algranti E, Parker JE, Hering KG,

合同産業衛生学会本, Ehime, December

Kanayama H, Tamura T, Kusaka Y,

2023

Preliminary report

Suganuma N. Asian Intensive ReaderofPneumoconiosis

program:

2. Indriyati LH, Eitoku M, Naw Awn J-

examination for certification during

P, Nishimori M, Hamada N, Sawitri N,

2008-2020. Industrial Health 2024. 62,

Suganuma N

143–152.

Prevalence of Radiographic Silicosis

DOI:

10.2486/indhealth.2023-0010

Among Tuberculosis Patients in West2.学会発表Java, Indonesia［International meeting］

94th Annual Meeting of Japan Society

1. Indriyati LH , Eitoku M, Naw Awn

for Hygiene, Kagoshima, March 2024

J-P , Nishimori M, Hamada N, Sawitri
N, Suganuma N

3. Indriyati LH , Eitoku M, Naw Awn

Assessment of Chest Ray Profile in

J-P , Nishimori M, Hamada N, Sawitri

Relation to Prevalence of Silicosis

N, Suganuma N

aming Tuberculosis Patients in West

Prevalence of Radiographic Silicosis

Java,

Cases among MDR-TB and DS-TB

Indonesia,34th

CongressonInternational

Occupational

Healthpatients in Indonesia.

(ICOH), Marrakesh, Morocco, April

97th

AnnualMeeting

of

Japan

2024

Society for Occupational Health, 第 97回日本産業衛生学会, Hiroshima, May
2024［National meeting］
1. Indriyati LH, Eitoku M, Naw Awn J-

Ｈ．知的財産権の出願・登録状況(予定をP, Nishimori M, Hamada N, Sawitri N,

含む)

Suganuma N

1.特許取得Prevalence of Radiographic Silicosis

該当なし2.実用新案登録
該当なし

令和 5 年度労災疾病臨床研究事業費補助金研究 分担研究報告書

健康管理手帳制度による健康診断のインドネシアでの実施のための研究
研究協力者：梶木 繁之 産業医科大学, 産業保健コンサルティングアルク
研究協力者：Nuri Purwito Adi 産業医科大学, インドネシア大学
研究協力者：Dr Muchtaruddin Mansyur （Dr MM）, インドネシア大学
研究要旨
【目的】
インドネシアは、東南アジア諸国の中核的な国で、世界の人口でも第 4 位を占める大国である。 若年層の人口の増加により、今後も国全体の人口の増加が見込まれている。
我が国の外国人労働者に占める割合も上位に位置し、今後は技能実習生としての渡航者のさらなる増加も見込まれる。本調査は、インドネシアからの渡航労働者が、日本国内において有害業務（特にじん肺関連作業）に暴露し、その後母国に帰国した後に、健康障害の発生の有無を確認する現地国での健康診断（日本国内での健康管理手帳制度
による健康診断に該当）の実現可能性について検討するために、インドネシアの労働安
全衛生（OSH）制度の現状を明らかにすることを目的とした。
【方法】
インドネシアの OSH 制度（特にじん肺に関連するインドネシア国内での特殊健康診断の実施体制並びに特殊健康診断の実施に必要な医療設備等）の現状について、現地国の研究協力者の協力のもと予備調査を行った。
【結果】
今回の予備調査の結果より、インドネシア国内においては、本研究の目的を果たすために必要となる一定の人材や医療設備並びに医療機関の存在の可能性が示唆された。ただし、現地国内で具体的に本取り組みを進める際には、より詳しい情報の入手が必要と思われた。
【考察】
この調査では、インドネシア国内での特殊健康診断（じん肺健康診断）が法令によって行われていないことが確認された。しかし、日本のじん肺検診に類似した健康診断をインドネシアで行うことは可能であると示唆された。本研究はインドネシア大学の専門家を対象に実施した予
備調査の一部であり、今後日本から帰国した労働者に対する特殊健康診断の実施には、対象者の特定、受診可能な医療機関と専門的な診断を行える医師の確保、それらに係る費用に関する詳細な検討が必要であると考えられた。

A．研究目的

活用し、本研究での取り組みの概要につインドネシアは、東南アジア諸国の中核

いて口頭にて直接説明を行った。

的な国で、世界の人口でも第 4 位を占める

インドネシア大学側の窓口は、インド大国である。若年層の人口の増加により、

ネシア大学産業医学部門の教授である

今後も国全体の人口の増加が見込まれて

Dr MM に依頼し、説明は 2023 年 11 月

いる。我が国の外国人労働者に占める割

22 日~25 日の 4 日間にわたり、韓国 の合も上位に位置し、今後は技能実習生とし大邱で開催された、アジア産業保健学会ての渡航者のさらなる増加も見込まれる。

(Asian

研究協力者は 2010 年頃より、日経企業

Health: ACOH) の場において行った。

の海外事業場における労働安全衛生活動

研究への同意が得られた後、 研究班でのサービスの質の向上を目的とした様々な作成した現地国へのアンケート調査票

取り組みを展開しており、その一環として（英文）を用いて、インドネシア国内で労働安全衛生マネジメントシステムの労働安全衛生活動(特にじん肺に対す(OHSMS) を活用したモデルの導入とそのる特殊健康診断の実施体制並びに医療有効性の検証を、インドネシア国内での事機関の有無など)に関する予備調査を行業場とインドネシア大学医学部産業医学った。（回答は、現地国の研究協力者に部門の協力のもと行ってきた。

依頼した）Congresson

Occupational

今回、上記の取り組みの過程を通じて形成した現地国との協力体制を活用し、インC．研究結果ドネシアからの渡航労働者が、日本国内にアンケート調査票を用いた予備調査

おいて有害業務（特にじん肺関連作業）にの結果は、以下の通りである。

暴露し、その後母国に帰国した後に、健康障害の発生の有無を確認する、現地国での健康診断（日本国内での健康管理手帳制度による健康診断に該当）の実現可能

Indonesia report from Prof. MM, Dr Nuri
Questionnaire
Please answer the following questions.
1. We will ask for your team’s basic information.

性について検討するため、インドネシアの

1) What country are you a team from?

労働安全衛生（OSH）制度の現状を明らか

Indonesiaにすることを目的とした。

2) Enter your name, position title, and specialty.

B．研究方法
これまでの共同研究の過程を通じて構築したインドネシア大学医学部産業
医学部門の関係者とのネットワークを

Administrative and legal personnel (eg., people
from Ministry of Health):
MedicalDoctor

(Occupational

Healthphysician):
Medical Doctor (Pulmonologist or Radiologist):Others:
Muchtaruddin

diseases, are there any public post-retirement
Mansyur,

MedicalDoctor

(Occupational Health Physician), Professor at
the University (Universitas Indonesia)

health care program for the workers?
a. Yesb. No

c. don’tknow7) This question is for those who answered “yes”

2. We would like to ask you about the legal andto 6). How often are post-retirement healthoccupational health system of health care forcheckup for pneumoconiosis performed?

hazardous work in your country.

a. Twice a year or more

1) For pneumoconiosis and asbestos-relatedb. 1 time a year

diseases, is there any public health care or healthc. 1 time in 2 years

checkup system for the workers?

d. less than 1 time in 2 years

a. Yesb. No

c. don’te. Othersknow8) This question is for those who answered “yes”

2) This question is for those who answered “yes”to 6). What are the examination items in the post-to 1). How often are health checkup for

retirement health checkup for pneumoconiosis?

pneumoconiosis performed?

Write down the items of examination:a. Twice a year or more

9) This question is for those who answered “yes”

b. 1 time a yearto 6). How often are post-retirement healthc. 1 time in 2 years

checkup for asbestos-related diseases performed.

d. less than 1 time in 2 years

a. Twice a year or moree. Others:b. 1 time a year3) This question is for those who answered “yes”

c. 1 time in 2 yearsto 1). What are the examination items in the healthd. less than 1 time in 2 years

checkup for pneumoconiosis?

e. Others

Write down the items of examination:10) This question is for those who answered “yes”

4) This question is for those who answered “yes”to 6). What are the examination items in the post-to 1). How often are health checkup for asbestos-

retirement health checkup for asbestos-related

related diseases performed?

diseases?

a. Twice a year or more

Write down the items of examination:b. 1 time a year11) If there is a request from Japan for post-c. 1 time in 2 years

retirement health checkups for pneumoconiosis

d. less than 1 time in 2 years

and asbestos-related diseases for the workers, aree. Others:

there any medical institutions that can provide

5) This question is for those who answered “yes”

them based on the systems required of medicalto 1). What are the examination items in the healthinstitutions in Questions 3) and 4)?

checkup for asbestos-related diseases?

a. Yesb. No

c. don’t

Write down the items of examination:know6) For pneumoconiosis and asbestos-related(We have medical institutions for advancescreening for pneumoconiosis and asbestos-a. One facility in the country (e.g., located inrelated disease, but we haven’t have regulation

capital city)

related on it and refer to Question no. 3 and 4)

b. Available in major cities in the country

12) This question is for those who answered “yes”(only in some prefectures)to question 11). What is the name of the medicalc. Located in small cities in the country (allinstitution, address, name of the physician, contact

prefectures)information (email address), etc.

d. At the municipal level

The

name

of

the

medicalinstitution:e. There is no such medical institution in the

Universitas Indonesia Hospital, Universitas

country

Indonesia

f. Don't know

Address:

Universitas Indonesia Campuss,

Depok, West Java, Indonesia

4. We would like to ask about the implementation

Doctor’s name:system

Dr. Dewi Yunia Fitriani,

Occ.Med Physician
Contactforexamining

pneumoconiosis

andasbestos-related diseases.

information(E-mail,etc):1) How many medical institutions can performdewi.yunia.fitriani@gmail.com. Mobile Phone:chest X-rays (direct imaging) and have physicians+628118503727

who can evaluate pneumoconiosis and asbestosrelated diseases?

3. We would like to ask you about the healthcarea. One facility in the country (e.g., located insupply system in your country.

capital city)

1) We will ask about the diagnosis and follow-up

b. Available in major cities in the countryof pneumoconiosis. How many hospitals have

(only in some prefectures)

specialists

c. Located in small cities in the country (all

who

can

diagnose

and

treat

pneumoconiosis?

prefectures)

a. One facility in the country (e.g., located ind. At the municipal level

capital city)e. There are no such medical institutions in theb. Available in major cities in the country

country.

(only in some prefectures)

f. Don't know.

c. Located in small cities in the country (all2) How many medical institutions can perform

prefectures)computed tomography and have physicians who

d. At the municipal level

can evaluate pneumoconiosis and asbestos-related

e. There is no such medical institution in the

diseases?

countrya. One facility in the country (e.g., located inf. Don't know

capital city)2) I will ask about the diagnosis and follow-up ofb. Available in major cities in the country

asbestosis-related diseases. How many hospitals(only in some prefectures)

have specialists who can diagnose and treatc. Located in small cities in the country (allasbestosis-related diseases?

prefectures)

d. At the municipal levelb. Available in major cities in the countrye. There are no such medical institutions in the(only in some prefectures)country.

c. Located in small cities in the country (allf. Don't know.

prefectures)

3) How many medical institutions can perform

d. At the municipal level

sputum cytology examination and have physicianse. There are no such medical institutions in the

who can evaluate pneumoconiosis and asbestos-country.

related diseases?

f. Don't know.

a. One facility in the country (e.g., located in6) How many medical institutions can perform

capital city)

tuberculosis

b. Available in major cities in the country

physicians who can evaluate pneumoconiosis and(only in some prefectures)asbestos-related diseases?

sputum

smear

test

and

have

c. Located in small cities in the country (alla. One facility in the country (e.g., located in

prefectures)

capital city)d. At the municipal levelb. Available in major cities in the countrye. There are no such medical institutions in the(only in some prefectures)country.

c. Located in small cities in the country (allf. Don't know.

prefectures)

4) How many medical institutions can perform

d. At the municipal levelspirometry and flow volume curves examination,e. There are no such medical institutions in theandcountry.

havephysicians

who

can

evaluate

pneumoconiosis and asbestos-related diseases?

f. Don't know.

a. One facility in the country (e.g., located in7) How many medical institutions can perform

capital city)

blood sedimentation and have physicians who canb. Available in major cities in the country

evaluate pneumoconiosis and asbestos-related(only in some prefectures)

diseases?

c. Located in small cities in the country (alla. One facility in the country (e.g., located in

prefectures)

capital city)d. At the municipal levelb. Available in major cities in the countrye. There are no such medical institutions in the(only in some prefectures)country.

c. Located in small cities in the country (allf. Don't know.

prefectures)

5) How many medical institutions can perform

d. At the municipal level

arterial blood gas analysis and have physicianse. There are no such medical institutions in the

who can evaluate pneumoconiosis and asbestos-country.

related diseases?

f. Don't know.

a. One facility in the country (e.g., located in8) How many medical institutions can perform

capital city)

tuberculin test and have physicians who canevaluate pneumoconiosis and asbestos-related

country.

diseases?

f. Don't know.

a. One facility in the country (e.g., located incapital city)b. Available in major cities in the country(only in some prefectures)
c. Located in small cities in the country (all

今回の予備調査の結果より、インドネ
シア国内においては、本研究の目的を果たすために必要となる一定の人材や医

prefectures)

療設備並びに医療機関の存在の可能性

d. At the municipal levelが示唆された。ただし、現地国内で具体

e. There are no such medical institutions in the

的に本取り組みを進める際には、より詳

country.
f. Don't know.

しい情報の入手が必要と思われた。

9) How many medical institutions can perform
Interferon gamma release test and have physicians
who can evaluate pneumoconiosis and asbestosrelated diseases?
a. One facility in the country (e.g., located incapital city)b. Available in major cities in the country(only in some prefectures)
c. Located in small cities in the country (allD．考察
研究班により作成した予備調査の質問紙（英文）を用いて行った、インドネシア国内における特殊健康診断（じん肺健康診断）の実施については、 法令では実施されていないことが確認された。一方、日本国内で行われているじん肺検診に類似した健prefectures)

康診断をインドネシア国内において実施

d. At the municipal level

すると仮定した場合、一定の制限はあるも

e. There are no such medical institutions in theのの、インドネシア国内においての実施もcountry.
f. Don't know.
10) How many medical institutions can perform
bronchoscopy and have physicians who can

可能であることが示唆された。今回の調査
は、インドネシア大学の有識者に対する調査の一環として行われた。

evaluate pneumoconiosis and asbestos-related

今後、日本から帰国した労働者に対する

diseases?

インドネシア国内での特殊健康診断(じんa. One facility in the country (e.g., located incapital city)b. Available in major cities in the country(only in some prefectures)
c. Located in small cities in the country (all

肺健康診断) の実施にあたっては、対象者の把握や受診可能な医療機関の分布、
特殊健康診断(じん肺検診)の結果を適切に判断できる医師の確保、それらに係る費

prefectures)

用面での支援等の詳細についてさらに検d. At the municipal level

討が必要と思われる。

e. There are no such medical institutions in the

該当なし
E．結論
インドネシア国内における特殊健康診断(じん肺検診)の実施体制並びに医療機関、医療設備等の有無についての予備的な調査が行われた。
より詳細な調査が必要ではあるものの、イ
ンドネシア国内における日本からの帰国労働者に対する特殊健康診断の実施可能性が示唆された。

F．健康危険情報
該当なし
G． 研究発表
・

Adi NP, Nagata T, Odagami K, Nagata M,
Kajiki S, Kuroishi M, Mori K. Association
between lifestyle habits and presenteeism.
Occup Med (Lond). 2023 Sep 29;73(6):346–
352.

・

Adi NP, Nagata T, Mori K, Kubo T, Fujimoto
K, Ohtani M, Odagami K, Nagata M, Kajiki S,
Fujino Y, Matsuda S. Seeking Treatment
Profile

of

Male

Shift

WorkersWith

Hypertension and Diabetes. J Occup Environ
Med. 2023 Sep 1;65(9):783–788.

Ｈ．知的財産権の出願・登録状況(予定を含む)
1.特許取得
該当なし
2.実用新案登録

令和 5 年度労災疾病臨床研究事業費補助金研究 分担研究報告書

健康管理手帳制度による健康診断のベトナムでの実施のための研究
研究協力者 Leli Hesti Indriyati 高知大学大学院博士課程研究代表者：菅沼 成文 全国労働衛生団体連合会
胸部Ｘ線検査専門委員会委員
研究分担者：田村 太朗 島根大学 医学部 准教授
JP Naw Awn 高知大学 医学部 特任助教
研究要旨
【目的】
ベトナムは 100.3 百万人の人口を抱える東南アジアの国家で、移民労働者が増加している。世界 40 か国で約 65 万人が活動し、特に日本、台湾、韓国への派遣が多い。2023
年には 13 万人が海外へ移動し、そのうち 7 万人が日本に派遣された。本調査は、日本で就労するベトナム人移民労働者が、帰国後に健康管理手帳制度による健康診断を受診する余地があるかを検討することを目的とする。
【方法】
ベトナムの移民労働者管理、医療システムと品質保証システム、労働安全衛生（OSH）
制度の現状について文献調査を行った。
【結果】
ベトナムの労働者管理は、労働・傷病兵・社会問題省（MOLISA）が主に担当し、移住
資源センターや労働移民企業のライセンス審査を行っている。医療システムは公共部
門と民間部門から構成されており、民間部門には 250 の私立病院がある。品質保証について、各病院は品質保証システムを導入する義務があり、医療従事者は 2 年ごとに継続教育を受ける必要がある。産業医専門の養成機関はなく、資格取得のためには 3 年以上の臨床経験に加え、NIOEH での 3 ヶ月間の研修コース修了ないしハノイ医科大学での 9 ヶ月間の特別指導コース修了が求められる。OSH サービスの提供システムについて、管轄部署は MOLISA と保健省（MOH）で、2015 年に OSH 法が制定された。
【考察】
ベトナムから日本への労働者派遣は歴史も古く、着実に成長している。企業の労働安全衛生の管理体制と法的枠組みは改善されており、医療制度も発展の途上にある。しかし、職業性疾患治療やリハビリテーションの支援が不十分であるため、職業性疾患に対応可能な医療機関や従事者の能力向上が急務である。

A．研究目的

会議出席者：

ベトナムは、面積 331,210 平方キロメー[Health Environment Management

トルの東南アジアのインドシナ半島にAgency (HEMA), Ministry of Health]

位置する国家で、100.3 百万人の人口を

Assoc. Prof. Dr. Luong Mai Anh,抱える。経済の発展に伴い、ベトナム人

Director General

移民労働者も増加している。ベトナムのDr. Tran Anh Thanh, Leader of

移民労働者は、世界 40 か国・地域で約

Occupational Health Division

65 万人が活動しており、特に日本、台Dr. To Thi Phuong Thao, Vice Leader

湾、韓国などへの派遣が多く、2023 年

of Occupational Health Divisionには約 13 万人が海外へ移動した。日本

Dr.

への派遣数は約 7 万人で、これまでで最

Occupational Health Division

NguyenThi

Thu

Huyen,

も多く、累計で 50 万人以上が働いている。ベトナム政府は、労働者の技術向上

栄徳勝光

高知大学医学部環境医や経済的な利益を追求しつつ、海外での学教室労働を支援している。

Leli Hesti Indriyati

本調査は、今後国内で増加が予想される

環境医学教室高知大学医学部

ベトナム人移民労働者が、帰国後に健康管理手帳制度による健康診断を受診す【文献調査での情報収集】る余地があるかを検討することを目的

また、会議で得られた情報等を踏まえ、とする。

ベトナムの移民労働者管理、医療システ
ムと品質保証システム、労働安全衛生制

B．研究方法度の現状について文献調査を行った。

【会議での情報収集】
ベトナム保健省保健環境管理局

C．研究結果（ Health Environment Management【会議での情報収集】

Agency (HEMA), Ministry of Health）

ベトナムにおける労働安全衛生制度のを訪問し、労働安全衛生行政の実務担当

現状について、管轄部署や関連法規、労者と本事業におけるベトナムでの調査

災の現状、産業医養成制度等についての実施方法について議論した。

情報提供を受けた。また、本事業についての説明後、健康管理手帳制度による健

日時：2024 年 2 月 28 日

康診断を実施可能な医療機関の候補に

場所：MOH’s Building Office “Dan so”

関して情報提供を受けた。

産業医の資格【文献調査での情報収集】

産業医を育成する専門の医学校は存在

移民労働者管理しない。産業医となるのに必要な要件は、労働移民に関する管轄部署は労働・傷①医師であること（一般、専門、または病兵・社会問題省（MOLISA）であり、疫学のいずれか）、②少なくとも 3 年間

その一部門である DOLAB は労働移民の臨床経験を有すること、③国立労働衛の戦略や法制度について助言し、ライセ

生研究所（NIOEH）での 3 ヶ月間の労ンスの評価や監査を行う。また、国際移働疾患研修コース修了、またはハノイ医住機関（IOM）の支援により、ハノイに科大学予防医学・公衆衛生研究所での 9

移住資源センター（MRC）が設立され、ヶ月間の特別指導コース修了が求めら

移民労働者の情報と支援が提供される。

れる（2016 年 6 月 1 日以降有効）。

送出機関は、50 億ドン以上の資本を持
つベトナム企業でなければならず、労働労働安全衛生制度

移民の経験やライセンスを取得するた

MOLISA、保健省（MOH）、労働組合

めの要件を満たす必要がある。さらに、（VGCL）、特定の産業に関わる省（農業

ベトナム人労働者の協会（VAMAS）は、農村開発省、運輸省、建設省など）の 4

送出機関の協会であり、情報伝達やトレ種類の組織が OSH 行政に関係しており、ーニング支援などの活動を行っている。

特に国家レベルの管理は MOLISA とMOH が主に担当している。2015 年に医療システムと品質保証システム

労働者の安全と健康を確保することをベトナムの医療システムは公共部門

目的として、OSH 法が制定された。法

と民間部門から構成されており、村や地律の適用範囲には、労働契約の有無に関区レベルでの一次医療から専門医によわらず全ての労働者が含まれ、具体的なる二次、三次医療まで提供される。民間実施ルールや国家的なプログラムが設部門には 250 の私立病院があり、一部のけられている。

私立病院では公立医療機関から有能な
医療スタッフが採用されている。品質保D．考察

証システムは 2013 年に導入され、各病ベトナムから日本への労働者派遣の歴院は品質保証システムを導入する義務

史は古く、現在着実に成長している。こがあり、医療従事者は 2 年ごとに継続教

れには、適切な法整備とともに複数の利育を受ける必要がある。

害関係者の参画を必要とする。
一方で、ベトナムは企業における労働安全衛生の管理体制と法的枠組みの改善

G．研究発表に向けて前進している。また、労働安全

1.論文発表

衛生制度の適用範囲を拡大しようとし該当なしている。このことは、健康診断の結果や、

2.学会発表職業性疾患を発症する労働者数が減少［International meeting］

傾向にあることからも示される。

1. Indriyati LH , Eitoku M, Naw Awn

現在、ベトナムの医療制度は、地方の医J-P , Nishimori M, Hamada N, Sawitri

療機関から中央の医療機関への患者のN, Suganuma N

移送システムの確立などに見られるよ

Assessment of Chest Ray Profile in

うに、発展途上にある。しかし、職業病

Relation to Prevalence of Silicosisの治療やリハビリテーションに関して

aming Tuberculosis Patients in West

支援が不十分であり、医療施設や医療従Java,事者の能力向上が急務だ。

CongressIndonesia,34th
onInternational

Occupational

Health(ICOH), Marrakesh, Morocco, April
E．結論

2024

ベトナムは発展途上国で、移民労働者が増加している。企業の OSH 管理は強化［National meeting］

されているが、医療施設や従事者の能力

1. Indriyati LH, Eitoku M, Naw Awn J-向上が必要である。特に職業病治療のたP, Nishimori M, Hamada N, Sawitri N,

めの診断機器が不足している。本調査をSuganuma N

通じて、ベトナムでの調査を進める上でPrevalence of Radiographic Silicosis

必要となる連絡担当者を立てることがamong Tuberculosis patients in Westできた。また、ベトナムにおける OSH

Java, Indonesia:

サービスの提供システム及び品質保証

from Hospital Based Study . The 67th

システムについての文献調査を終える

Chugoku-Shikoku Joint Conference on

ことができた。一方で、ベトナムの健康

Occupational Health 第 67 回中国四国

診断実施病院リストの収集、病院調査の合同産業衛生学会本, Ehime, December

実施は次年度以降の課題となった。

2023

F．健康危険情報

2. Indriyati LH, Eitoku M, Naw Awn J-

該当なし

P, Nishimori M, Hamada N, Sawitri N,
Suganuma N

Preliminary reportPrevalence of Radiographic Silicosis
Among Tuberculosis Patients in West
Java, Indonesia
94th Annual Meeting of Japan Societyfor Hygiene, Kagoshima, March 2024
3. Indriyati LH , Eitoku M, Naw Awn
J-P , Nishimori M, Hamada N, Sawitri
N, Suganuma N
Prevalence of Radiographic Silicosis
Cases among MDR-TB and DS-TB
patients in Indonesia.
97thAnnualMeetingofJapan

Society for Occupational Health, 第 97回日本産業衛生学会, Hiroshima, May
2024
Ｈ．知的財産権の出願・登録状況(予定を含む)
1.特許取得
該当なし
2.実用新案登録
該当なし

VIETNAM REPORT

1. General Information
1.1. Vietnam Geographic
Vietnam is a tropical Southeast Asian surrounded by China, Laos, and Cambodia,
located on the eastern edge of the Indochina Peninsula. Its entire area is 331 210 square
kilometres on land. On April 25, 1976, the Democratic Republic of Vietnam changed its nameto the Socialist Republic of Vietnam1.

Fig 1. The Map of Vietnam

The country is divided into six geographic socioeconomic regions: Northern midlands
and mountain areas, Red River Delta, North Central area and Central coastal area, Central
highlands, Southeast and Mekong River Delta. Hanoi is the capital of Viet Nam, located in the
Red River Delta. Ho Chi Minh City (formerly Saigon) is the largest city located between theSoutheast and Mekong Delta regions. The nation is divided into 63 provinces and cities. Eachprovince and city are organized into districts, towns, and cities (at the district level). Districts
are organized into communes, wards, and townships (commune level)2.

1.2. Vietnam Population
Vietnam is undergoing rapid demographic and economic development. Vietnam now
has a population of 97.3 million, which is predicted to reach 100 million by the end of 2024.
Vietnam's population is expected to reach its peak of 109.78 million in 2054. Vietnam's
population grows by roughly 1% every year, adding approximately 1 million people each year.
Vietnam, located on the eastern tip of the Indochina peninsula in Southeast Asia, is one of theregion's largest and most densely inhabited countries. The population sex ratio was 99.5 males
per100 females in 2022. With more than fifty different ethnic groups, Vietnam is a multiethnic
nation.3

Fig 2. The Pyramid of Vietnam’s Population

1.3. Vietnam Labor
1.3.1. General
The number of people in the labor force who are 15 years of age or older reached 51.7
million in 2022, up 1,144.4 thousand from the previous year; the number of people in the labor
force who are 15 years of age or older and work in economic sectors was 50.6 million, up
1,532.7 thousand persons. There were over 51.3 million employed individuals in Vietnam in
2023. The nation's labor force participation rate was 68.9 % in that year. The agriculture,
forestry, and fisheries industry in Vietnam employed almost 14 million people in 2022, making
it the industry with the highest number of employees overall. In contrast, the manufacturingsector employed almost 11.8 million people in that year, making it the second most employedsector in the country. In total, 50.6 million people were employed in Vietnam in that particular
year. In 2022, there were 148.5 thousand newly registered businesses nationwide, with a total
registered capital of 1,590.9 trillion VND and 981.3 thousand registered employees.4
1.3.2. Social Insurance
The percentage of workers who have reached retirement age is still low compared tothe potential of the labor force, which puts a lot of strain on security assurance. With 5.18
percentage points more than in 2016 and 9.78 percentage points more than in 2011, the SI
participation rate only made-up 32.55 percent of the working-age population in 2020.
Consequently, around 68% of the labor force of working age did not have access to SI in 2020.
Since 2018, a policy has been in place to encourage workers in the informal sector to participate
in SI, which has improved the coverage of voluntary SI.5

1.3.2. Unemployment Insurance
Between 2011 and 2019, the number of people covered by UI increased by an averageof 6.64 percent year. This resulted in a rise from 7.97 million (17.78 percent of the workingage labor force) in 2011 to 13.43 million (27.2 percent) in 2019. But in 2020, as a result of the
COVID-19 pandemic's effects, this rate marginally dropped to 13.3 million persons (26.82
percent).

1.3.3. Organization
The Vietnam General Confederation of Labour (VGCL), tasked with representing workers'
interests, is Vietnam's sole and unified trade union organization, consisting of the 18 National
Industrial Unions and Labor Federations in all 63 cities and provinces under the Central
Government. VGCL currently has over 6 million members. Mr. Dang Ngoc Tung is the
President of VGCL.6

1.4. Migrant Worker
According to the report of the Ministry of Labor, Invalids and Social Affairs (MOLISA),
currently, around 650,000 Vietnamese labourers are working in 40 nations and territories
around the world. There are more than 500 businesses licensed to send Vietnamese workers
abroad.
Migration from Vietnam has entirely recovered from the COVID-related decline. In the firstten months of 2023 (January-October), 132,645 people (44,669 women and 87,976 men)
moved for employment overseas, exceeding the Vietnamese government's target of 110,000
external migrants for the year. 67,550 people left for Japan, 50,862 for Taiwan, 5,973 for theRepublic of Korea, and 1,669 for the People's Republic of China, among other destinations.
Currently, Viet Nam ranks first among 15 countries sending workers to Japan. This year has
witnessed the biggest number of Vietnamese workers heading to Japan, with over 85,000
workers going each year and over 300,000 presently working in Japan. Apart from traditional
markets such as Japan, Taiwan, and South Korea, the ministry has also moved to explore newmarkets for Vietnamese workers, especially in Europe, such as Hungary, Poland, Slovakia, andCroatia 7

1.4.1. History
Under an agreement called the Program on Sending and Receiving Foreign Internshipin Japan between the Vietnam Ministry of Labor, Invalids and Social Affairs (MOLISA) andthe Japan International Training Cooperation Organization (JITCO), Japan has been accepting
Vietnamese workers since 1992, mostly through the Japanese Industrial Training Program(ITP) and the Technical Internship Program (TIP). Between 1992 and 2010, there were only
approximately 52,000 Vietnamese workers transported to Japan, but the annual intake has risen
to 5,000 or more in recent years. The number of Vietnamese trainees in the 1990s was fewer
than Chinese, Indonesian, Philippine, and Thai trainees. To be selected as a trainee in Japan,
workers must normally achieve rather high technical qualifications. According to MOLISA
figures, up to 80% of workers transported to Japan between 1996 and 2006 had high-leveltechnical capabilities. However, "high-level technical skills (lanh nghe, trinh do cao)" is notclearly defined (Luu Van Hung [2011, 141]).8
In 2012, Vietnam began sending nurses to work in Japan as part of the Vietnam-Japan
Economic Partnership Agreement (VJEPA). Since these agreements, there have been a
consistent rise in the number of Vietnamese employed in Japan, especially in the previous five
years. The number of workers moving to Japan surged by 30% between 2017 and 2018.
Vietnam sent nearly twice as many workers to Japan as the Philippines (164,000 workers), andit became the second-largest source country (317,00 workers) after China (389,000 workers)(Phuong, 2019). Vietnamese immigrants view employment in Japan as a means of developing
their technical job skills in addition to a means of making money.

1.4.2. Labor export policy and legislation
Labor export has been a key socioeconomic development policy of the Party andadministration in doi moi-era Vietnam. The corresponding legal framework for labor export
has been designed. By 2003, Decree 370 has been renewed three times (Decree 07 in 1995,
Decree 152 in 1999, and Decree 81 in 2003). The National Assembly also passed the Law on
Vietnamese migrant workers in 2006. The Law consists of 80 articles divided into eightchapters. Compared to the previous Decree 81, which had 37 articles in seven chapters, a newchapter on "Teaching of Jobs and Foreign Languages and Provision of Necessary Knowledge"(Chapter IV) was added, and provisions on the organization and activities of enterprises
sending migrant workers abroad (hereinafter, sending agencies), contracts and related fees,
guarantees for migrant workers, and policies regarding workers after they returned home wereexpanded or newly added. Overall, if effectively implemented, the new Law is projected tocontribute to better protecting the rights of Vietnamese migrant workers.
The new program, which went into effect on November 1, 2017, saw the sending
countries' governments and the Japanese government signing a Memorandum of Cooperation
with the purpose of removing improper sending organizations. Accredited sendingorganizations were added to the Organization for Technical Intern Training website in April
2018 as part of a Memorandum of Cooperation. Beginning September 1, 2018, technical interntrainees from non-accredited sending organizations will no longer be accepted under the
Memorandum of Cooperation.
Article 17 of the 2013 Constitution stipulates: "Vietnamese citizens abroad areprotected by the State of the Socialist Republic of Viet Nam". With regards to Vietnamese
workers abroad, Clause 1, Article 150 of the Labour Code 2019 regulates that: “The State
encourages enterprises, agencies, organizations, and individuals to seek and expand the labour
market for Vietnamese workers to work overseas. Vietnamese workers working abroad mustcomply with the laws of Viet Nam and the laws of the destination country unless otherwise
provided for by an international treaty of which the Socialist Republic of Viet Nam is amember.”9
In order to protect Vietnamese citizens abroad, especially Vietnamese workers working
abroad, the State of Viet Nam has promulgated a system of legal documents regulating social
relations related to the migration of Vietnamese workers abroad. Such legal documents include:• Law on contract-based Vietnamese workers overseas, promulgated on 13 November, 2020.
This Law consists of eight chapters and 74 articles that stipulate rights, obligations andresponsibilities of contract-based Vietnamese workers abroad, enterprises, non-business units
and agencies, organizations and individuals related to the field of contract-based Vietnamese
workers abroad; vocational skills training, foreign languages, and orientation training for theworkers; the Fund for Overseas Employment Support; policies for the workers; and state
management in the field of contract-based Vietnamese workers abroad. • Decree 38/2020 NDCP dated 03 April 2020 detailing the implementation of a number of articles of the Law onContract-based Vietnamese Workers Abroad.

1.4.3. Key stakeholders in labor migration
1.4.3.1. The Department of Overseas Labor (DOLAB) and other institutions under
MOLISAMOLISA is in charge of the state management of labor export. As part of
MOLISA, DOLAB—which took over from DILACO in the 1980s—advises the Ministryon labor export strategies, plans, and legislation in addition to conducting assessments
for the purpose of granting or rescinding labor export licenses, auditing and inspecting
labor export activities, and handling violations of related provisions.
As a pilot project funded by the International Organization for Migration (IOM),DOLAB established the Migration Resource Center (MRC) in Hanoi in 2012. The MRC
offers reliable information and assistance to Vietnamese migrant laborers who are
considering or have returned home. Additionally, MOLISA is the manager of two stateowned businesses (SOEs) that are authorized to engage in labor export. In addition,
TRIANGLE in ASEAN delivers assistance directly to migrant workers and theircommunities through a network of Migrant Worker Resource Centres (MRCs). These
MRCs are managed in partnership with government institutions, trade unions and civilsociety organizations, and provide a range of services in countries of origin anddestination. 10
1.4.3.2. Sending agencies
A sending agency must be a 100% Vietnamese firm with legal capital of atleast 5 billion dong (about US$250,000), per the present requirements. Prior to the Law
on Vietnamese Migrant Workers and the Implementation Decree, only state-owned
businesses or specific mass groups may provide labor export services. However,domestic private companies are now eligible.
An organization must have a labor export or international cooperation
program, a specialized section that offers pre-departure training to workers, anadministrative leader with a university degree or higher, at least three years ofexperience in labor export, and a deposit of one billion dong (roughly US$50,000) in
order to be granted a license. If a licensed sending agency violates any of theserequirements, does not send workers overseas within a year of receiving a license, ordoes any of the prohibited acts specified in the law (e.g., sending workers to dangerous
areas or forcing them to engage in hazardous activities), their license may be revoked.
There are 439 approved Vietnamese sending organizations listed on the JITCO
website11. A large number of the sending agencies are small-scale businesses.

1.4.3.3. Branches of sending agencies, brokers, and local governments
The Law on Migrant Workers from Vietnam states that sending agencies are required
to hire employees directly, without charging for the service. Sending agencies may
allocate up to three branches in three provinces as part of their labor export services inorder to facilitate services. More precisely, branches are prohibited from signing
contracts for labor supply or migratory workers, as well as from collecting deposits andservice or brokerage fees5 from employees without the enterprise's consent. In reality,
though, the process of hiring foreign laborers is typically very intricate and multi-layered,involving a number of different entities and people.
Sending agencies may have up to three branches, but they also establish"centers." Some sending agencies do not even look for overseas partners,
review labor supply contracts, or recruit workers themselves, instead allowing
their branches and centers to handle all substantive work with little supervision.
Brokers are also quite involved. According to the Supervisory Report of the
National Assembly Standing Committee, in several of the communes visitedby the Supervision Mission, 70-80% of the workers were recruited throughbrokers rather than directly by sending agencies.
According to the Law on Vietnamese Migrant Workers, sending agencies must
notify the provincial Departments of Labor, Invalids, and Social Affairs (DOLISAs)
when recruiting workers in their respective localities, as well as regularly report
recruitment results and the number of workers sent abroad. In reality, municipal
governments are frequently more intimately involved in the recruitment process. Local
governments, particularly district authorities and employment introduction centers, arefrequently tasked by sending agencies to collect and screen applications. Once a
specified number of workers have been registered, the sending agency dispatches its
personnel to make the final decision.
1.4.3.4. Vietnam Association of Manpower Supply (VAMAS)
The Minister of Internal Affairs formed VAMAS, an association of sending
agencies, in 2003. Although participation is voluntary, VAMAS has 136 members,
including all important players. The current chairman of VAMAS is a former viceminister of MOLISA. According to the association's statute, the purpose of VAMAS
is to coordinate and liaise between sending agencies and concerned offices,
organizations, and individuals, as well as to assist member enterprises in improving
knowledge, conducting research, proposing solutions to labor export problems, andeffectively assisting one another, so that all members can develop equally and theirrights and interests are protected.VAMAS activities include fostering informationtransmission and exchange through newsletters, assisting member firms with
employeetraining,
andconsultingonlabor-exportconflicts13.
According to the association's statute, the purpose of VAMAS is to coordinate
and liaise between sending agencies and concerned offices, organizations, and indivi

duals, as well as to assist member enterprises in improving knowledge, conducting research, proposing solutions to labor export problems, and effectively assisting one another, so that all members can develop equally, and their rights and interests are prot
ected.
VAMAS activities include fostering information transmission and exchange t
hrough newsletters, assisting member firms with employee training, and consulting on labor-export conflicts. In 2010, VAMAS collaborated with the ILO to develop a
Code of Conduct (CoC) for sending agencies based on Vietnamese laws andinternational labour standards. In addition, a methodology for assessing sending
agencies' compliance with the CoC was established in 2012. The review is based ondata gathered from a variety of sources, including the media, workers and theirfamilies, other sending agencies, local governments, and concerned organizations inreceiving countries.

2. Healthcare System
2.1. Healthcare Setting
2.1.1 Public Sector
Vietnam's present healthcare system is a combination of public and private elements.
Ensuring that the entire population has access to preventive and curative care is a criticalresponsibility of the public system. After the nation was reunited, the Vietnamese government
worked to enhance public health. In addition, the government launched health education
initiatives and developed national health insurance. The administrative structure for healthcare
facilities in Vietnam is outlined in Article 81 of Chapter VIII of the 2009 Law on Examination
and Treatment, which governs the organization of medical examination and treatment facilities.
There are four levels of administrative hierarchy which are commune, district, provincial,and central.14

Table 1. Administrative structure for healthcare in Vietnam

Primary healthcare services are provided at the commune and district levels. Primarycare is the cornerstone of the Vietnamese national health program and the framework uponwhich the health system is built. Secondary and tertiary care is provided by specialized medical
personnel at the provincial and central levels. Vietnam's Ministry of Health is the top central
government institution tasked with safeguarding the public's health, including the issuance oflaws and other legal instruments pertaining to health treatment, health prevention, and healthprotection.
Health policymaking is often top-down, with central decisions and systemic
implementation. The process begins with the MOH establishing and developing a policy
agenda based on evidence, with collaboration from all relevant MOH. Proposed policies willneed approval from the National Assembly's Government or Social Affairs Committee. The
MOH and local authorities will execute and monitor approved policies, with oversight fromappropriate MOH departments, research institutions, and the National Assembly's Social
Affairs Committee.15
DOHA, or Direction of Healthcare Activities (Chỉ đạo tuyến in Vietnamese), is the
English translation of the Ministry of Health advice on healthcare provision and the relationshipbetween upper and lower-level hospitals. DOHA is altered and adjusted depending on the
demand for medical care, but it remains an important phrase in the context of medical carereform. It monitors a variety of public health indicators to meet goals for improving healthstandards.
2.1.2. Private Sector
In 2020, Vietnam Investment Review reported that there were 250 privately owned
hospitals, and the number of such hospitals was increasing. This accounts for 5.6% of the total
number of hospital beds and 17% of the total number of hospitals in Vietnam, which is 1,400.
Based on a report from 2017, private hospitals play a crucial role in the healthcare system of
the country by offering over 60% of outpatient services. While a few private hospitals boast
considerable resources and a highly competent medical workforce recruited from the publichealth sector, the majority of private hospitals have less than 100 beds. According to theMedical Practitioner Society of Ho Chi Minh City, a significant proportion of private medical
practitioners, up to 70%, also have positions in the public sector.

2.2 Health Facilities
The Ministry of Health is in charge of provincial, district, and commune health facilities
and is in charge of developing and implementing health care services at the appropriate
level.Numerous health facilities are under the management of the Ministry of Health, including
research and Pasteur institutes, universities, colleges, and national hospitals.
Every province has a minimum of one provincial hospital, which serves as a support
system for national hospitals throughout all stages of care. Basic care, emergency services, andcommon disease treatment are provided at the district level. Lastly, basic care, health education,
and awareness programs are provided at the community level.

Fig 3. Organisational chart of Vietnam;s healthcare system, illustrating roles and responsibilities of eachcomponent

According to the Health Statistical Yearbook 2018, there are 47 central health facilities
with 31,436 beds. These institutions consist of 20 general hospitals, 20 specialist hospitals,
three traditional medicine hospitals, three leprosariums, and one dermatology hospital.
The research institutes include the Health Strategy and Policy Institute, Institute ofHygiene and Epidemiology, National Institute of Nutrition, National Institute of Occupational
and Environmental Health, and Pasteur Institutes in Ho Chi Minh City and Nha Trang.
Research institutes offer postgraduate education and prevention services. Health professional
education institutions offer training programs at medical and pharmaceutical universities, aswell as medical colleges. The Ministry of Health directly manages most of these institutes.
Medical universities typically have training hospitals with approximately 200 beds to support
training, research, and healthcare.

Fig 4. Public Healtchare System in Vietnam

Provincial health institutions include state-level departments of health, as well as
medical services including general and specialty hospitals. Provincial hospitals usually havearound 500 beds. The specialist hospitals include maternity, obstetric, and pediatric, traditional
medicine, and tuberculosis and lung disease hospitals. Provinces also have specialized medical
centers overseen by the Department of Health in reproductive health, preventive medicine,
HIV/AIDS prevention, forensics, eye disease, communication and health education, and foodsafety and population.
Each province often has a medical college or secondary medical school that provides
programs in medicine, nursing, midwifery, medical technology, and pharmacy based on theprovince's needs. Both the provincial and district hospitals are under the supervision of the
MOH.Additionally, a number of industries have their own hospital and clinic networks run bygovernment organizations such the Ministries of Transportation, Ministry of Construction,etc.
The military health system is organized separately.

Table 2. The number of health facilities and beds and levels

Hanoi and Ho Chi Minh City are home to the majority of the country's general and specialty
hospitals. These are the provincial hospitals in each region with the highest referral rates.

Table 3. The List of Central Hospitals

2.3. Health Finance
The health system is funded primarily by the Government. Vietnam's social health insurance
system, founded in 1992, is the primary public funding source for healthcare. The MOH statesthat in 2020, approximately 91 % of the population had health insurance. Health insurance isessentially a part of social insurance. There are two types of health insurance:•Compulsory• Voluntary.
A voluntary scheme was started for those not eligible for the compulsory scheme. Social
health insurance is managed by the Vietnam Social Insurance, a single fund that is directly
under the Government and 63 social agencies in provinces. The website Pháp Luật DoanhNghiệp (Corporate Law) explains that employers are required to contribute to the social healthinsurance scheme. The premium is quoted as being 4.5 % of the employee’s monthly salary.
Employees are required to contribute 1.5 % of their salary.
Decree No. 85/2012/ND-CP states that by 2018, health care services will have a pricethat includes all seven cost components. The MoH collaborated extensively with the Vietnam
Social Security (VSS) and other relevant ministries/sectors to draft and complete HI laws andpolicies, most notably the National Assembly-passed Revised Health Insurance Law 2014,
which went into effect on January 1, 2015. There has been an increase in HI coverage from
60.9% in 2010 to 76.52% in 2015.
VSS reimburses hospitals for curative care. The health financing system is different at
district level. The VSS pays district hospitals annually for outpatient services, hospital stays,
and referrals to provincial hospitals for each insured person. This is referred to as ‘capitationbased’ payments. They place district hospitals at significant financial risk if they exceed theirannual budget, with little control over their financial plan and expenditures. District hospitals
are also liable for treatment costs incurred by insured patients at Commune Health Centres
under their jurisdiction. Finally, the Commune Health Centres have a distinct funding
mechanism: the two primary sources of revenue for these centres are budget from the province
which primarily covers staff salaries and other operating expenses such as electricity, and healthinsurance payments for curative care services. However, there are no clear criteria to determine
how much the Commune Health Centres should be reimbursed for curative services.

2.4. Health Information Technology
Vietnam's health information system is improving; however, many medical facilities still use
paper records for patients and diseases. Vietnam has set an objective to promote Electronic
Health Records (EHRs) since June 2018. The government's EHR implementation strategy(Decision No. 5349/QD-BYT) requires at least 80% EHRs will soon be available in provinces
and central cities, with the aim of reaching 95% of the national population by 2025.

2.5 Health Quality Control
2.5.1. Hospital quality management.
In 2013, the hospital constructed a quality management system and developed
assessment standards. The circular mandated that all hospitals establish a quality management
system, which would include a committee, office, or unit dedicated to quality management, as
well as a network of quality management. The provincial health bureaus are in charge ofoverseeing quality control for the medical facilities situated within the province. A pilot
program for a set of metrics for hospital quality assessment was launched in 2013. This set of
metrics was grouped into 5 groups in 2014, and each group consisted of 5 performance levels
for the 83 criteria. Hospitals are required to implement 1487 subcategories of quality standards
in total. Approximately 1233 hospitals across the country used these standards in 2014, and thequality of their services improved in comparison to 2013. Four hospitals in Vietnam haveobtained JCI certification, including 3 hospitals located in Ho Chi Minh City: Cao Thang Eye
Hospital, French-Vietnamese Hospital - FV Hospital, Vinmec International Hospital - Central
Park; and Vinmec International Hospital - Times City in Hanoi 15.
After two years, 55.4% of hospitals nationwide have established quality management
departments. The test quality control system includes three test centers and about 1,400
laboratories. Medical examination methods have been simplified from 12-14 steps to 4-7 steps
for each condition, resulting in an average examination time of 48.5 minutes (approximately50%) compared to the pre-intervention period. Standard competencies for medical practicehave been developed and applied to nurses, midwives, and general practitioners.
Approximately 4,000 clinical guidelines have been developed. Disparities in health service
quality and indicators persist among areas. Overcrowding in Central hospitals and big cities
has been addressed to some extent, but more has to be done in the future. The quality
management system is limited due to the lack of an independent rating agency and the absenceof quality management departments in approximately 44% of hospitals. The clinical audit
process has not been implemented, and resistance to accept test results across health facilities
is nevertheless prevalent.
Every year, under their direction, the MOH and the Provincial Department of Health create andcarry out a strategy for monitoring and assessing hospital quality. For instance, the Ministry of
Health published Decision No. 6328 / QD-BYT on October 18, 2018, which outlined thecontents of hospital quality inspection and assessment as well as a survey of medical staff andpatient satisfaction in 2018.
2.5.2. Certification of Health Practitioner
There are five levels of health professions education in Viet Nam: secondary, college,
university, residency, first level specialist (CK1), second level specialist (CKII) and Doctor ofPhilosophy (PhD). The Ministry of Health oversees postgraduate specialist training programs,
including level 1 and 2 training and residence (Government). 2011a). The Ministry of Healthoversees and supervises. Continuing medical education (CME) and practical training for new
graduates and health system professionals before providing licenses.

Health professionals are required to hold a license in order to practice medicine under
the Law on Examination and Treatment (LET). Every two years, health workers need tocomplete at least 48 hours of continuing education in order to keep their licenses valid. CME
for health professionals is managed centrally by the Ministry of Health. Hospitals, medical
schools, and nursing homes are among the public training facilities that offer the majority of
CME courses. Nevertheless, the majority CME programs are implemented at the central andprovincial levels, and commune health professionals may not have the opportunity toparticipate because several healthcare facilities lack a health workforce. When a healthprofessional's license is revoked for not meeting the CME requirement, they have to reapply
for a new license, which involves submitting extra paperwork to the licensing body along with
their CME certificate.

Figure 5. Health professions education system in Vietnam

2.5.3. Accreditation mechanism applied in competency-based training.
In Vietnam, doctors, nurses, and midwives are not regulated by national examinations.
Both standardized exit exams and standardized examinations during degree programs areabsent. Beginning in 2011, the Law on Medical Examination and Treatment mandated that
medical practitioners obtain a license and regularly update their knowledge. In accordance with
the Law on Medical Examination and Treatment (2009), Decree No. 87/2011/ND-CP, Circular
No. 41/2011/TT-BYT, and Circular No. 03/2013/TT-BTC, the health sector continues to grant
medicalpracticecertificatesandoperatinglicenses.
There is currently no nationwide implementation of the database system for the registration and administration of operating licenses and medical practice certificates.
In 2015, 95% of health facilities and 92% of staff in MoH hospitals, 25% and 67% in otherministries and agencies, and 65% and 89% in hospitals under provincial Departments of Health(DoH) were licensed. Competency standards for healthcare staff, such as nurses (2012),
midwives (2014), and general practitioners (2015), have been issued 16.
2.5.4. Certification for Occupational Health Practitioners
There are no medical schools that specialize on occupational health. To become an occupational
health physician or doctor, you must meet the following conditions:✓ Must be a medical doctor (general, specialty, or epidemiology)✓ At least 3 years of clinical experience✓ Complete a 3-month certificate training course on occupational disease at National
Institute of Occupational Health (NIOEH) or a 9-month special orientation at Hanoi
Medical University's Institute of Preventive Medicine and Public Health (effective asof June 1, 2016)
Prior to June 1, 2016, medical doctors that dealt with the diagnosis and detection of OD only
attended one-week to three-month-long short courses hosted by preventive medicine
institutions including the Ho Chi Minh Institute of Public Health and NIOEH. According to
the training’s data, 69 courses on occupational disease were held for 1,689 MDs working in
the OH area between 2010 and 2015 as part of the National program on OD prevention 2010–2015 and the ADB project on strengthening capacities in OD detection and diagnosis for OD
physicians/doctors at provincial and district levels. These activities were also coordinated by
NIOEH and the Ho Chi Minh Institute of Public Health.
NIOEH and the National Institute of Epidemiology and Hygiene (before to 2015), also Army
Academics (prior to 2015) offer PhD training in occupational health. However, the 9-monthcourse will no longer be available after 2020. Subjects for PhD training include general andspecialized MDs, with the exception of MD specialized in preventive medicine, MSc. inpreventive
medicine,
andSpecializedMD
degreesI
andII.

2.5.5. Medical equipment and infrastructure quality management
The inspection of investment activities and the use of equipment in health facilities has
been intensified. The Ministry of Health collaborates with the Ministry of Science andTechnology, the Medical Equipment Association of Vietnam, and specialists to encourage
research, suggest priority subjects, and manufacture medical equipment.
There are certain pieces of equipment that are limited to a few district hospitals. Table
below shows the specific equipment that is available at district hospitals in survey in 2015. In
Dak Lak and Dien Bien, the percentage of hospitals equipped with HbA1C testing equipment
was relatively low. In contrast to Dien Bien, where there were none, over half of the hospitals
in Hanoi and Dong Nai possessed CT scanners 16.

Table 4. The Medical Equipment in Some District Hospitals

There is still a significant absence of reciprocal acknowledgment of laboratory test
results among healthcare providers. Clinical laboratory testing and diagnostic imaging services
see an annual growth rate of about 10%. On October 14, 2015, the Ministry of Health issued
Decision 4276 / QD-BYT to significantly improve the quality management capabilities of
medical examination and treatment facilities. This Circular recognizes worldwide and foreign
standards for monitoring the quality of medical examination and treatment in Vietnam.
The health sector aims to improve medical equipment storage and maintenance, with afocus on training technologists. The Ministry of Health has partnered with Hanoi Polytechnic
University to train bio-medical electronic engineers. They have also invested in and upgraded
Medical Equipment and Technique College, including a new branch in Hanoi and Hai Duong.
Currently, 62% of province general hospitals, 26.1% of provincial specialty hospitals, and31.9% of district general hospitals have medical equipment maintenance teams. The MoH
collaborated with allied sectors to create and release 135 sectoral and 35 national standards for
medical equipment. The capacity of the network for medical equipment calibration and quality
control has been strengthened.

3. NIOSH Profile
3.1. Authority or Body, Responsible for OSH
In Vietnam, basically, four types of organisations are related to the OSH administration: theMinistry of Labour, Invalids and Social Affairs (MOLISA), the Ministry of Health (MOH), the Trade
Union (Vietnam General Confederation of Labour: VGCL), and Ministries of particular industries(Ministry of Agriculture and Rural Development, Ministry of Transportation, Ministry of Construction,etc) 17.

Fig 6. Occupational Safety and Health Organization in Vietnam

MOLISA and MOH are principally responsible for the state management of Occupational
Safety and Health (OSH). MOLISA is accountable for ensuring work safety, whereas MOH is
accountable for the provision, safeguarding, and advancement of workers' health. The Council for
occupational safety and health is structured into three tiers: National, provincial, and grassroots levels18.
Decision No. 1278/QD-BYT dated April 20, 2010, of the Ministry of Health stipulating
functions, tasks, power and organizational Structure of The Health Environment Management Agency(HEMA) of the ministry of health. This organization is commissioned to advise to the Minister of
Health, to implement functions of the Ministry related to health environment, including: protection ofenvironment of medical establishments, protection of environment in burial activities, environmental
health; hygiene and occupational health, occupational diseases prevention and accident & injury
prevention, control of health impact due to climate change; management of chemicals, disinfectants,
insecticide products for domestic and medical use and other tasks related to health environment
according to Law. HEMA is a legal body, has its own seal, account, and office in Hanoi.

Fig 7. Occupational Health Organization Under the Ministry of Health

Another organization of the MOH is the National Institute of Occupational and Environmental
Health (NIOEH). The National Institute for Occupational Safety and Health (NIOEH) is responsible forthe coordination of occupational and environmental health activities in Vietnam. This includes scientificand technological services, international cooperation, and research pertaining to occupational health(including ergonomics, labor psychophysiology, occupational health, and labor sanitation and safety),the prevention of accidents and injuries, sanitation, and environmental health.
In addition to performing examinations and monitoring, the 63 province-based Preventive
Medicine Centers (PMCs) received professional development and informational consultations, andoccupational and environmental health regulations were revised. Occupational health at the provincial
level falls under the competence of the PMC. Aside from the PMCs, the province also houses medical
centers (MCs) that cater to other important ministries such as Industry, Construction, Transportation,and Mines and Coal. These MCs have the responsibility for overseeing all occupational andenvironmental health initiatives at factories, enterprises, and companies held by the Ministries.
(Vietnam silica exposed)19
The Ministry of Labour, Invalids and Social Affairs (MOLISA) is responsible for employment
and labour matters. This ministry, in particular, the Bureau of Safework, is responsible for theadministration of occupational safety and health in the nation. The MOLISA Inspectorate is the central
authority of the labour inspection system in the country. Labour inspectorates are in charge of ensuring
compliance with general working conditions and occupational safety and health legislation, as well as
collecting social security contributions and investigating workplace accidents. Inspectors are also incharge of assuring legal conformity with relation to the formation of trade unions in businesses, thenegotiation and implementation of collective bargaining agreements, and the resolution of labor
disputes.

Fig 8. Occupational Health Organization Under MOLISAIn the provincial level, there are organizations called Departments of Labour, Invalids andSocial Affairs (DOLISAs). There are 63 DOLISAs at the provincial level. These DOLISA offices
further support and monitor 697 district divisions. The planning and programming between MOLISA
and the DOLISAs is transparent, systematic, and participatory. MOLISA and DOLISA construct annual
inspection plans based on the number of employers in each province, recorded complaints anddenunciations, and the previous year's company self-assessment findings. Every year, the MOLISA
Inspectorate sets inspection plans for targeted industrial and public sectors, which are subsequently
coordinated locally. In addition, the MOLISA Inspectorate deploys district inspectors to work with the
DOLISA Inspectorate. DOLISAs also send quarterly and annual reports to MOLISA. On occasion, the
MOLISA and DOLISA conduct joint inspection visits.
The Institute of Labour Science and Social Affairs is a scientific research unit under the
Ministry of Labour, Invalids and Social Affairs responsible for basic research, strategic and applicableresearch for State’s administration in the field of occupation, vocation, labour, salary, social insurance,labour safety, people who have rendered great service to the country, social sponsor, protecting andtaking care of children, gender equality, social evils prevention; managing research activities of the
Ministry.The National Institute of Labour Protection is an organization under the Vietnam General
Confederation of Labour competent for scientific and technological research on OSH which wasappointed by the State. 22
3.2.National OSH research programme or institute
The National Institute of Labour Protection is the leading national institute in the field of OSH,
established under the Decision of the Government, having its budget and laboratory equipment
sponsored by the State’s budget under the management of Vietnam General Confederation of Labour(VGCL).This is a socio-political organization of the working class, set up to represent, take care andprotect the lawful and legitimate rights and interests of workers; to participate in State administration

and social-economic management, in the control and supervision of the State agencies, economic andsocial entities on issues relating to the rights and obligations of workers.
The National Institute of Labour Protection is financed by the State and has a director who is appointed
by the President of the VGCL. In Vietnam, trade union plays an important role in OSH activities.
Four
National
OSH
programmesareapproved
by
the
Prime
Minister:
1.National programme on labour protection science technology 58.01 phase 1981-1985
2.National programme on labour protection science technology 58 A phase 1986 -1990
3.National programme on labour protection, labour safety and hygiene to 2010
4. National programme on labour safety and hygiene phase 2011-2015
VGCL represents workers and coordinates with relevant ministries to implement the National
programme on labour safety and hygiene during 2011-2015. The State assigned the Vietnam General
Confederation of Labour to implement Project No. 4 of the programme and Vietnam General
Confederation of Labour then assigned the National Institute of Labour Protection to preside it in thename of: “Scientific and technological research and application for labour safety and hygiene”. The
development of a national OSH programme is foreseen by the OSH Law. The OSH Law requires
consultation with trade unions, representative organisations of employers, OSH Councils at all levelsin the development and implementation of OSH policies, legislations and programmes.

3.3. Law for OSH
The Law on Occupational Safety and Health, a law specializing in OSH, was enacted in 2015. (Law
No. 84/2015/QH13).It was passed by the National Assembly of Vietnam on June 25, 2015, which aims
to ensure the safety and health of workers by stipulating various requirements for OSH 20. It will takeeffect on July 1, 2016. The OSH Law applies to workers with and without labor contracts. A legal
system for OSH is currently being built centering on this Law. The law on Occupational Safety and
Health includes seven chapters as well as (1) General Provisions; (2) Measures to Prevent and Control
Hazardous Factors and Toxic Factors for Workers; (3) Measures to Settle Technical Incidents Causing
Occupational Safety and Health Failure and Occupational Accidents and Diseases; (4) Guarantee ofOccupational Safety and Health for Special Workers; (5) Guarantee of Occupational Safety and Healthin Production and Business Establishments; (6) State Management of Occupational Safety and Health;(7) Implementation Provisions 21.
For detailed rules for implementing the Law, the subordinate rules, such as the Decree
specifying and providing guidelines for implementation of certain articles of the law on occupationalsafety and health and circulars that provide implementing rules for the Decree should be referred to.
The Government issued Resolution No. 19/NQ-CP on February 16, 2022, which promulgates the
National Program on Occupational Safety and Health for the period of 2021-2025.
The Program has set clear and defined objectives to be achieved by 2025. The objective is to achieve
an annual reduction of 4% in the number of fatal occupational accidents. To achieve an annual growthrate of 5% in the number of workers undergoing examination for occupational diseases 22.
More than 80% of individuals who have workplace accidents or diseases are eligible to obtaincompensations and allowances as mandated by the legislation. All instances of deadly workplace
accidents shall be documented, examined, and managed, among other actions.
In addition, the Program outlines essential objectives and strategies for implementing it, such asenhancing the framework of regulations and legislation and enhancing the ability to scrutinize, assess,and oversee occupational safety and health, as well as deliver public services in this field. Enhancing
the dissemination of information, public communication, and training to enhance understanding
regarding workplace safety and health. Enhancing research efforts and providing counsel and support
to enhance working conditions and prevent and control occupational accidents and diseases.
This Resolution becomes effective upon its signing.

3.3.1. Law for Health Check Up
Law No. 84/2015/QH13, In Chapter II, section 3 (Labour protection and health care for workers), article
no 21 (Health check-up and treatment of occupational diseases for workers) it’s written that 23:
1. Employers must provide health check-up for workers at least once a year; for workers
performing heavy, toxic, hazardous work/occupations or extremely heavy, hazardous, toxic
work/occupations, workers with disabilities, minor workers, elderly workers, they must be
provided with health check-up at least once every six months.
2. In provision of health check-up as prescribed in Clause 1 of this Article, female workers must
get obstetric care, people working in the environment where there are factors likely to cause
occupational diseases must receive medical examination for detection of occupational diseases.
3. Employers must organize health check-up for workers before assigning jobs to them and before
moving them to heavier, more hazardous, more toxic jobs or after they come back to work fromtreatment of occupational accidents and diseases, except when there is conclusions of theMedical Assessment Council on the degree of their work ability decrease.
4. Employers must provide health check-up for workers and medical examination for detection ofoccupational disease at health facilities that meet technical requirements and standards.
5. Employers must take workers who are diagnosed with occupational diseases to health facilities
that technical standards for treatment in accordance with the regimens regulated by the Ministerof Health.
6. Costs for health check-up, medical examination for detection of occupational diseases,
treatment of occupational diseases for workers paid by employers as specified in Clauses 1, 2,
3 and 5 of this Article shall be accounted as deductible expenses upon the determination of
taxable incomes according to the Law on Enterprise Income Tax and as recurrent expenditures
business in administrative agencies and non-business units with no service activities.

Circular No. 14/2013/TT-BYT, issued by the Ministry of Health on May 06, 2013, provides
guidance on medical examination procedures. This Circular provides instructions on the preparation of
dossiers, the procedures to be followed, the required contents of medical examinations (ME), theclassification of health disorders, and the requirements for medical examination and treatment (ME&T)
facilities authorized to conduct ME, including for the workers24.
There’s also Circular No. 19/2016/TT-BYT by MOH about Guideline for occupational health andsafety management which mentioned about Occupational Health Record including health certificate or
health examination of the employee within are periodic health examination or health examination for
detection of occupational diseases and Occupational disease records. This circular also set up

responsibilities from some organization regarding Occupational Health in Vietnam such as HEMA,
health stations of districts and responsibilities of preventive healthcare providers, universities having
medicine,public health and occupational health faculties for provide and prepare training25.

3.3.2. Law for Occupational Disease
Law No. 84/2015/QH13, In Chapter III (Measures to Handle Technical Incidents Endangering
Occupational Safety and Health and Causing Occupational Accident and Disease), section 1, article 37
about Statistics and reporting on occupational diseases mentioned that all cases of occupational diseases
shall

be

countedandreportedunder

regulations

of

the

Ministerof

Health.

The list of occupational diseases shall be issued by the Minister of Health after consulting the Ministryof Labor, War Invalids and Social Affairs, the Vietnam General Confederation of Labor, employers’
representative organizations, and related social organizations, and reviewed for modification andsupplementation to suit the changes in the working environment, equipment and technology. In section
2 set up about responsibilities of employers to victims of occupational accidents and diseases (article37), while in section 3 mentioned about occupational accident and disease insurance regimes including
cconditions for receiving compensation for occupational diseases in article.
In particular, Decision No. 26/2017/TT-BLDTBXH concerning the Regulations and Guidelines for the
Implementation of Compulsory Labor 6 Accident and Occupational Disease Insurance was issued by
the National Assembly of the Socialist Republic of Vietnam in 2017. This ruling mandated that all
employees, including officers and career military, officials in cipher organizations, those working underindefinite-term labor contracts, definite-term labor contracts, seasonal labor contracts, or a specific job
for a period of three months to less than twelve months, and those working under labor contracts forone month or less than three months, must have occupational disease and accident insurance.
There is also contents of prevention of occupational diseases and health care of employees in Resolution
20-NQ/TU of the Party Central Committee in 2017 on strengthening the protection, care, andimprovement of people's health in the new situation and Resolution No. 139/NQ-CP 2017 of theGovernment. The other is Decision 659/QD-TTg dated May 27, 2020, approving the program to protect,care for and improve workers' health, prevention of occupational diseases in the period of 2020-2030& Decision 3431/QD-BYT dated July 14, 2021, of the Ministry of Health.

3.4. Institutes related to occupational and environmental health.
The Ministry of Health oversees four institutes that are responsible for various aspects ofoccupational and environmental health (OH). These institutes include the National Institute ofOccupational and Environmental Health (NIOEH), the Institute of Public Health in Ho Chi Minh City,
the Tay Nguyen Institute of Hygiene and Epidemiology, the Nha Trang Pasteur Institute, and theInstitute of Marine Medicine. Their functions include research, training, coordination, international
cooperation, and service provision in the field of OH.

The unit in charge of implementing the main contents and related units are as follows:-

Department of Health Environment Management-

Departments/Departments: Health Care Management, HIV/AIDS, Food Safety,
Mother and Child Protection, Communication, Emulation and Reward, General Plan-

Institutes/Schools: Institute of Human Health and Environment, Pasteur Nha Trang,
Ho Chi Minh City Public Health, Hygiene and Epidemiology of Central Highlands,
Institute of Nutrition, Medical Universities,-

Institute of Preventive Medicine, Department of Military Medicine, Ministry of
National Defense-

Departments of Health, CDC of provinces and cities

3.5. Occupational Disease
3.5.1. Situation of workplace
The total number of enterprises as of December 2022 exceeds 800,000, with the sector of
agriculture, forestry, and fisheries accounting for 13.8% of them. The industrial and construction sector
accounts for 17.2% of the economy, while the service sector makes up 20.3%.
Around 5 million people across different companies are exposed to risk factors for occupational
diseases, making up 53% of the entire workforce. Out of a total of 82.053 enterprises, 52.378, or around64%, report dangerous and harmful circumstances in the workplace on a yearly basis. Only 11% ofcompanies that have hazardous and harmful components in their operations actually follow the working
environment process, whereas 22.6% of these establishments have some level of occupational
environment hygiene 26.

3.5.2. Facility for Occupational Disease Examination
In 2015, there are 50 occupational disease clinics were created in 55 Provincial/City Preventive
Medicine Centers, 8 Centers for Occupational Health and Environmental Protection, and 8
Health/Occupational Health Centers at Industrial Branch. This means that not every center has an
occupational disease clinic that can do OD detection, diagnosis, and evaluation. The Ho Chi Minh
City Center for Occupational Medicine and Environment Protection has the greatest equipment, with

91 devices (82 for OSH and 9 for the clinic for occupational disease examination). Ha Giang province
had only one piece of occupational safety and health equipment, a manual dust monitoring meter 27.
Currently, there are 224 units declared eligible for working environment monitoring, and 115 units arelicensed to examine and treat occupational diseases.

3.5.3. List Of Occupational Diseases in Vietnam
Article 3 of Circular 15/2016/TT-BYT specifies 34 occupational diseases covered by social insurance, as
well as diagnostic and examination guidelines, as follows:
1. Occupational silicosis and instructions for diagnosis and assessment are specified inAppendix 1 issued with this Circular.
2. Occupational asbestosis and guidance on diagnosis and assessment are specified inAppendix 2 issued with this Circular.
3. Occupational pneumoconiosis and instructions for diagnosis and assessment are specified
in Appendix 3 issued with this Circular.
4. Occupational talc pneumoconiosis and instructions for diagnosis and assessment are
specified in Appendix 4 issued with this Circular.
5. Occupational coal pneumoconiosis and instructions for diagnosis and assessment are
specified in Appendix 5 issued with this Circular.
6. Occupational chronic bronchitis and instructions for diagnosis and assessment are specified
in Appendix 6 issued with this Circular.
7. Occupational asthma and instructions for diagnosis and assessment are specified inAppendix 7 issued with this Circular.
8. Occupational lead poisoning and instructions for diagnosis and assessment are specified inAppendix 8 issued with this Circular.
9. Occupational poisoning caused by benzene and its analogues and instructions for diagnosis
and assessment are specified in Appendix 9 issued with this Circular.
10. Occupational mercury poisoning and guidance on diagnosis and assessment are specified
in Appendix 10 issued with this Circular.
11. Occupational manganese poisoning and instructions for diagnosis and assessment are
specified in Appendix 11 issued with this Circular.
12. Occupational trinitrotoluene poisoning and instructions for diagnosis and assessment are
specified in Appendix 12 issued with this Circular.
13. Occupational arsenic poisoning and instructions for diagnosis and assessment are specified
in Appendix 13 issued with this Circular.
14. Occupational pesticide poisoning and guidance on diagnosis and assessment are specified
in Appendix 14 issued with this Circular.
15. Occupational nicotine poisoning and instructions for diagnosis and assessment are
specified in Appendix 15 issued with this Circular.
16. Occupational carbon monoxide poisoning and instructions for diagnosis and assessment
are specified in Appendix 16 issued with this Circular.
17. Occupational cadmium poisoning and instructions for diagnosis and assessment are
specified in Appendix 17 issued with this Circular.
18. Occupational deafness caused by noise and guidance on diagnosis and assessment are
specified in Appendix 18 issued with this Circular.
19. Occupational decompression disease and guidance on diagnosis and assessment are
specified in Appendix 19 issued with this Circular.

20. Occupational diseases caused by whole-body vibration and guidance on diagnosis andassessment are specified in Appendix 20 issued with this Circular.
21. Occupational diseases caused by local vibration and guidance on diagnosis and assessment
are specified in Appendix 21 issued with this Circular.
22. Occupational radiation disease and guidance on diagnosis and assessment are specified inAppendix 22 issued with this Circular.
23. Occupational cataracts and guidance on diagnosis and assessment are specified inAppendix 23 issued with this Circular.
24. Occupational oily nevus disease and guidance on diagnosis and assessment are specified inAppendix 24 issued with this Circular.
25. Occupational skin darkening and guidance on diagnosis and assessment are specified inAppendix 25 issued with this Circular.
26. Occupational contact dermatitis caused by chromium and guidance on diagnosis andassessment are specified in Appendix 26 issued with this Circular.
27. Occupational skin diseases caused by prolonged exposure to wet and cold environments
and guidelines for diagnosis and assessment are specified in Appendix 27 issued with thisCircular.
28. Occupational skin diseases caused by contact with natural rubber, chemical rubber
additives and guidance on diagnosis and assessment are specified in Appendix 28 issued
with this Circular.
29. Occupational Leptospira disease and guidance on diagnosis and assessment are specified
in Appendix 29 issued with this Circular.
30. Occupational hepatitis B virus and guidelines for diagnosis and assessment are specified inAppendix 30 issued with this Circular.
31. Occupational tuberculosis and guidance on diagnosis and assessment are specified inAppendix 31 issued with this Circular.
32. HIV infection due to occupational accidents and guidance on diagnosis and assessment are
specified in Appendix 32 issued with this Circular.
33. Occupational hepatitis C virus and guidance on diagnosis and assessment are specified inAppendix 33 issued with this Circular.
34. Occupational mesothelioma and guidelines for diagnosis and assessment are specified inAppendix 34 issued with this Circular.
On February 9, 2023, the Minister of Health of Vietnam issued Circular No. 02/2023/TT-BYT amending
Circular No. 15/2016/TT-BYT on occupational disorders covered by social insurance.
According to the Circular, "occupational COVID-19" has been added to the list of occupational
disorders covered under social insurance. At the same time, Appendix 35 with guidelines foroccupational COVID-19 diagnosis and assessment has been introduced. As a result, as of April 1, 2023,
social insurance covers 35 occupational disease.
3.6. Statistic
3.6.1. Health Check-Up
Every year, close to 2 million workers have regular health check-up examinations. In those
years, 9.6% of the total cases consisted of workers classed as having weak health (category 4, 5).

Time

2016-

Total

Type 1

Type 2Type 3

Type 4

Type 59.256.271

2.273.248

4.040.830

2.061.012

709.302171.876

Percentage

24.6

43.7

22.3

7.7

1.9

2020

Table 5. Results of periodical health examination for employees in the period 2016-2020.
3.6.1. Occupational Disease Data
According to the annual report on occupational health, approximately 100,000 to 300,000 workers
undergo occupational illness examination each year in order to identify and diagnose occupational
disorders. In 2019, occupational illness detection was conducted in 45 out of the 63 provinces acrossthe country, specifically targeting 27 out of the 34 compensated occupational disorders. A total of
243,218 workers employed in hazardous environments underwent examinations for occupational
illnesses, resulting in the detection of 7,265 cases (accounting for 3% of the evaluated workers).
In the periode of 1996-2020, the trends shows that the groups of occupational disease coming fromphysical hazard such as noise and followed by lung disease group, occupational skin, intoxication
and bacterial infections.

1996- 2000

79
490

1531

521

1759

68

2001- 2005
2006- 20102011- 20152016- 2020

9

596
285

150
799
120
458
485
662

5124
4904
2517

6210

13709

0
2000
4000
6000
8000
10000
12000
14000
Bacterial infections Occupational skin Physical Intoxication Lung disease groupFig 9. Trends of occupational disease groups in the period 1996 – 2020

Occupational
diseases nameTT

1 Silicosis
2

2016
332

Asbestos pneumoconiosis

0

3 Cotton pneumoconiosis
4 Talc pneumoconiosis
5

Coal worker pneucomoniosis

6 Occupational bronchitis
7 Chronic bronchial asthma
Lead poisoning and lead
8 compounds
Occupational benzene
9 poisoning disease10

Manganese
poisoning
11 disease
12 TNT poisoning disease
Occupationalarsenic
13 poisoning
Plant protection chemicals
14 poisoning

Occupa ti ona l vi ra l
33 hepa ti ti s C
Occupa ti ona l
34 mes othel i oma
Tổng

0

0

2022
24

0

0

0

0

0

0

0

0

71

0

0

0

0

424

304

21.407
3
278
0
734

69

0

0

0

254

0

0

1.035

1270

0

0

121

350

424

0

0

0

0

41

0

0

0

74

142

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

1

455

0

0

7

0

0

1

0

0

0

0

0

0

0

0

0

0

0

0

321
2
24
0
535
0

14

0

0

14

0

0

0

46

40

38

15

0

0

0

260

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

23 Occupa ti ona l ca ta ra cts
Occupa ti ona l
oi l
a cne
24 di s ea s a e
Occupa
ti
ona
l
mel
a
nos
is
25
Conta ct derma ti ti s due to26 crom
Ski n di s ea s e ca us ed byprol onged wet a nd col d
27 envi ronmenta l expos ure
Ski n di s ea s es ca us ed byexpos ure to na tura l rubber
28 a nd chemi ca l s
29 Occupa ti ona l tubercul os i s
Occupa ti ona lvi ra l30 hepa ti ti s B
Occupa ti ona ll es tos pi ra
31 tors i on
32 Occupa ti ona l HIV/AIDS

0

2021
62

79

17 Cadmium poisoning disease

Di s ea s es
ca us edby
20 s ys temi c vi bra ti on
Di s ea s es ca us ed by l oca l
21 vi bra ti on
22 Ra di a ti on di s ea s e

2020
221

0

105

18 Noi s e-i nduces hea ri ng l os s
19 Decompres s i on di s ea s e

0

2019
104

0

15 Nicotine Intoxication
Carbon monoxide poisoning
16 disease

TT

2018
596

165

Mercury poisoning disease

Occupational
diseases name

2017
310

Accumulate andreceive social
insurance

2016
2105

2017

2018

2766

2.354

2019

2020

2021

4.253

1545

6

0

3

0

297

Accumulate andreceive social
insurance

2022

181

992

0

0

0

2

5.249

0

0

0

225

0

0

14

0

0

0

0

0

0

0

0

58

152

228

0

0

15

0

0

0

0

0

0

0

0

0

0

23

0

0

0

0

129

25

89

11

0

17

0

0

0

0

0

0

0

282

11

0

0

9

0

9

0

0

0

0

0

5

15

1

15

0

0

0

0

0

0

142

0
5

5

3

40

7

0

4

10

0

1

0

0

1

1

0

0
3269

0
3802

0
3535

0
20
0

0
633
0
0

0

0

0

69

1

279

24

0

0

1

6

0

0

7265

3763

0

0

0

249

1328

91
287
6
1
0
0
30.284

Table 6. Occupational diseases in the period 2016-2022

In the table above describes that out of a total case of occupational diseases during those years, the highest
rate was attributed to occupational deafness. This was followed by lung disease group such as occupational
chronic bronchitis, silicosis and chronic bronchial asthma.

4. Conclusion

Vietnam is one of the countries in Southeast Asia that has great potential for rapid
development in the future with a large human resource capacity. Despite ongoing economic
developments, a significant number of Vietnamese workers continue to opt for migration to foreignnations. Currently, in addition to Asian countries, they are also extending their presence to many
European and Australia.
Meanwhile, the organization and law of occupational health in firms has been strengthened inthis country. In addition, they have implemented socialization efforts to enhance the scope ofoccupational health service delivery, as demonstrated by the outcomes of medical check-up
examinations and statistics on workers affected by occupational diseases in the nation. Nevertheless,there is a need to enhance the capacity of health facilities and medical personnel involved in
occupational health. We lack comprehensive data regarding hospitals and clinics that possess thenecessary medical tools to diagnose and treat workers suffering from occupational disorders,
particularly for pneumoconiosis.

References
1.

World Health Organization; Western Pacific Region: Human Resources for Health Country
Profile : Vietnam; World Health Organization 2016; ISBN 978 92 9061 771 6

2.

European Union Agency for Asylum. Medical country of origin information report : Provisionof Healthcare in Vietnam : August 2023.

3.

Vietnam Population 2024. Vietnam Population 2024
https://worldpopulationreview.com/countries/vietnam-population(Live).Available

4.

Statista.Labor
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Vietnam
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International Labour Organization. Labour and Social Trends in Vietnam 2021, Outlook to 2030
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International Labour Organization. TRIANGLE in ASEAN Quarterly Briefing Note.
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Ishizuka F. International Labor Migration in Vietnam and the Impact of Receiving Countries ’
Policies. Inst Dev Econ. 2013;(414).

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International Labour Organization. Revision of the Law on Contract-Based Vietnamese
Overseas Workers 69/2020/QH14. Available from:https://www.ilo.org/dyn/migpractice/migmain.showPractice?p_lang=en&p_practice_id=208

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Flanders Investment & Trade Hanoi . Health Care in Vietnam. December 2023

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Code of Conduct. Applied to Vietnamese agencies sending workers for overseas
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The World Bank. Quality and Equity in Basic Health Care Services in Vietnam: Findings fromthe 2015 Vietnam District and Commune Health Facility Survey. 2016;(June):153. Available
from:file:///C:/Users/user/Downloads/vietnam_health_report_june_27_final_with_cover_page_002_.pdf

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Nguyen Bich Diep The National Institute of Occupational & Environmental Health. The profile
of Occupational Safety and Health inVietnam. Hanoi 2020.

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Ministry of Health. PLAN : For People's Health Protection, Care and Promotion 20162020.Hanoi 201617.

Matsuda S. An analysis of the Vietnamese system of occupational safety and health and setting
priorities with the analytical hierarchy process. Occup Environ Med. 1996;53(4):281–6.

18.

Thi P, Chinh T. Occupational Safety and Health in Vietnam. 2014; Available from:https://www.jisha.or.jp/international/training/pdf/(Vietnam)_Country_report_Chinh_VN.pdf

from

from

:

19.

Lan TN, Son PH, Van Trung L, Tu NTH, Keifer M, Barnhart S. Distribution of silica-exposed
workers by province and industry in Vietnam. Int J Occup Environ Health. 2003;9(2):128–33.

20.

International Labour Organization. The ILO Global Database on Occupational Safety and
HealthLegislation(LEGOSH).
Vietnam2015.
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CODE_CODE,P1100_YEAR:VNM,,2015

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Thi Huyen Trang Nguyen. Working environment and occupational safety among industrial
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Resolution. On Promulgating National Program For Occupational Safety And Health In 2021
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Law on Occupational Safety and Health. No. 84/2015/QH13. The National Assembly Socialist
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Period 2005-2009;1–146.

令和 5 年度労災疾病臨床研究事業費補助金研究 分担研究報告書

健康管理手帳制度による健康診断のフィリピンでの実施のための研究
研究協力者 栄徳 勝光 高知大学 医学部 講師
研究代表者：菅沼 成文 全国労働衛生団体連合会
胸部Ｘ線検査専門委員会委員
研究分担者：田村 太朗 島根大学 医学部 准教授
JP Naw Awn 高知大学 医学部 特任助教
研究要旨
【目的】
フィリピンは 117.3 百万人の人口を抱える東南アジアの島嶼国家で、世界でも有数の移民送出国である。国連の推計によるといわゆる「移民」の数は 6 百万人を超えており、海外在住者が人口の 5%を占めている事になる。東南アジア唯一の英語圏国家ではあるが、渡航先はサウジアラビア、UAE など中東諸国が半数を占めている。本調査は、日本で就労するフィリピン人労働者が、帰国後に健康管理手帳制度による健康診断を受診する余地があるかを検討することを目的とする。
【方法】
フィリピンの労働安全衛生分野の専門家とオンライン MTG を行い、健康管理手帳制度による健康診断を実施可能な医療機関の有無等について議論した。
【結果】
会議では、フィリピンの医療施設の有無や日本との制度の違いについて話し合われた。
フィリピン側は医療制度の違いを指摘し、日本のような検診制度はないと述べた。プロ
ジェクトの進捗状況は申請書が承認されていると報告され、他国での展開可能性が調査される段階にあることが明らかにされた。フィリピン側の参画には正式な組織間協定が必要であり、全国労働衛生団体連合会や高知大学との協定が提案された。フィリピ
ン人労働者の健康管理手帳制度による健康診断の実施可能性について、継続的なコミュニケーションや研究計画書の改訂が議論された。
【考察】
調査研究の進展により、日本で働いたフィリピン人労働者が帰国後に健康管理手帳による健康診断を受診する可能性を模索するために、医療制度の比較調査や法的規制の調査が必要であり、協力体制の構築と利害関係者との意見交換が引き続き必要である。
A．研究目的ートルの東南アジアの島嶼国家で、

フィリピンは、面積 300,000 平方キロメ

117.3 百万人の人口を抱える。フィリピ

ンの GDP は 4,000 億米ドル程度で、そ論した。

の 6 割程度をコールセンター業務などの「ビジネス・プロセス・アウトソーシ

日時：2024 年 3 月 4 日

ング（BPO）産業」、3 割程度を「鉱工会議出席者：

業」が占める。

Engr. Jose Maria S. Batino, CESO IV,

国連の推計によるといわゆる「移民」の

OIC-Executive Director

数は 6 百万人を超えており、海外在住者

Dr. Maria Beatriz G. Villanueva, MD,が人口の 5%を占めている事になる。在MOH, PhD, Division Chief, Health外フィリピン人からの本国への送金額

Control Division (HCD), Occupational

は GDP の 1 割程度の規模に相当し、フSafety and Health Center (OSHC)ィリピン経済に大きな影響力を有する。

Dr. Reynold M. Sta Ana, HCD, OSHC

東南アジア唯一の英語圏国家ではあるが、渡航先はサウジアラビア、UAE など

菅沼成文

中東諸国が半数を占めている。日本で働学教室

くフィリピン人労働者は外国人労働者

田村太朗の中で、ベトナム、中国に次ぐ全体３位

学教室

で 20 万人以上が働いているものの、フJP Naw Awn

ィリピンの移民労働者全体からすると

学教室4%程度に過ぎず、フィリピン人の就労

栄徳勝光

先として日本の位置付けは高くない。

学教室

本調査は、今後国内で増加が予想される

Leli Hesti Indriyati

フィリピン人労働者が、帰国後に健康管

環境医学教室

理手帳制度による健康診断を受診する

安光ラヴェル香保子

余地があるかを検討することを目的と

環境医学教室する。

角田都 高知大学医学部環境医学教 室

高知大学医学部環境医
高知大学医学部環境医

高知大学医学部環境医
高知大学医学部環境医

高知大学医学部
高知大学医学部（コーディネーター）
B．研究方法フィリピンで労働安全衛生行政を主管

C．研究結果する労働雇用局の労働安全衛生センタ

会議では、フィリピンにおける医療施設ーの専門家とオンライン MTG を行い、の有無についての質問や、日本との制度

健康管理手帳制度による健康診断を実の違いについての議論が行われた。フィ

施可能な医療機関の有無等について議

リピン側からの指摘によれば、フィリピ

ンの医療制度は日本と異なり、日本のよ本の医療制度を詳細に比較し、両国でのうな医療検診制度は存在しないことが健康診断の実施可能性を明らかにする明らかにされた。

必要がある。特に、日本の健康管理手帳

また、プロジェクトの進捗状況について制度とフィリピンの健康診断制度の相は、すでに申請書が承認されていること

違点を把握することが重要である。

が報告された。日本側からの説明では、

法的規制の調査: 日本で働いたフィリ

このプロジェクトは他国での展開可能

ピン人労働者が帰国後に健康管理手帳性を調査する段階にあることが強調さによる健康診断を受ける際の法的規制れた。

や手続き上の障壁を調査する必要があ

フィリピン側がプロジェクトに参画する。

るにあたっては、正式な組織間協定の締協力体制の構築: フィリピンの関連機結が必要であることが提示された。政府

関や日本の厚生労働省との協力体制をの財源で行なっている調査なので、所管構築し、帰国後の健康管理手帳による健官庁から依頼文書を出してもらうのが康診断の実現可能性に向けた具体的な

望ましい、という意見も出たが、現実的支援策を検討する必要がある。これには、ではないため、全国労働衛生団体連合会

正式な組織間協定の締結や情報交換のや高知大学との間で協定を結ぶことが仕組みの整備が含まれる。

提案された。

利害関係者との意見交換: フィリピン

フィリピン人労働者の健康管理手帳制

人労働者や関連する団体・組織との意見度による健康診断の実施可能性を検討

交換を通じて、彼らのニーズや課題を把するため、引き続き継続的なコミュニケ

握し、それに基づいて適切な支援策を提ーションと研究計画書、質問票改訂など供する必要がある。

の可能性について議論された。
以上の点を考慮し、引き続きの調査研究
D．考察を進めることで、日本で働いたフィリピ

調査結果から、日本で働いたフィリピン

ン人労働者が帰国後に健康管理手帳に人労働者が帰国後に健康管理手帳によよる健康診断を受診する余地についてる健康診断を受診する余地があるかを

より具体的な答えを見出すことができ

さらに調査研究する上での考察を述べるであろう。

ると、以下の点が挙げられる。
E．結論
医療制度の比較調査: フィリピンと日フィリピンと日本の制度の違いにもかかわらず、両国での協力が可能であるとの見解が示された。本調査を通じて、フィリピンでの調査を進める上で必要となる連絡担当候補者を立てることができた。フィリピンにおける OSH サービ
スの提供システム及び品質保証システ
ムについての文献調査、健康診断実施病院候補リストの収集、病院調査の実施は次年度以降の課題となった。
F．健康危険情報
該当なし
G．研究発表該当なし

Ｈ．知的財産権の出願・登録状況(予定を含む)
1.特許取得
該当なし
2.実用新案登録
該当なし

令和 5 年度労災疾病臨床研究事業費補助金研究 分担研究報告書

健康管理手帳制度による健康診断のネパールでの実施のための研究
研究協力者：Bijay Maharjan 高知大学大学院博士課程研究代表者：菅沼 成文 全国労働衛生団体連合会
胸部Ｘ線検査専門委員会委員
研究分担者：田村 太朗 島根大学 医学部 准教授
JP Naw Awn 高知大学 医学部 特任助教
研究要旨
【目的】
移民労働者は送金を通じてネパールの GDP に大きく貢献している。ネパールの人口の多くが海外雇用に従事している。労働力には熟練労働者と非熟練労働者の両方が含まれ、大多数が建設、接客、製造、家事サービス部門で働いている。労働移動プロセスを規制・管理するため、ネパール政府は、ネパール人移民労働者の採用、訓練、福祉を監督する様々な政策や健康診断システムを確立してきた。海外就労中および海外就労からネパールに帰国した後の健康を確保するための支援体制は不十分であった。本研究の目的は、ネパールにおける労働安全衛生（OSH）制度を評価し、海外労働から帰国した移民労働者が健康診断、治療、リハビリテーションを必要とする場合の支援システ
ム開発の可能性を探ることである。
【方法】
ネパールの移民労働者管理、ヘルスケアシステム、OSH サービスの提供システム、及び品質保証システムの現状について文献調査を行った。また、ネパールで働く OSH の専門家に構造化質問票を用いてインタビューを行った。
【結果】
労働・雇用・社会保障省（MoLESS）は、国内の OSH を含む労働移動を規制する最高機関である。OSH は MoLESS にとって優先順位の低い分野に位置付けられており、そのため OSH の管理体制が弱く、人材不足が深刻である。入国前のメディカルチェックを認可された医療機関はあり、本調査を通じて 284 院をリストアップした。しかし、海外就労から帰国した労働者の健康ニーズに対応する機能的なシステムはない。
【考察】
MoLESS と保健・人口省（MOHP）の間には何の連携もない。国内には、定年退職後の労働者、職業性疾患の健康診断、治療、リハビリテーションのための統合システムは規定されていない。

A．研究目的

加することが予想される。

ネパールは南アジアの内陸国で、このような労働移民の健康は、帰国後の147,516 平方キロメートルの国土を有

健康を保証するシステムがないため、国し、北は中国、南、東、西はインドに隣にとって課題となっている。ネパールの接している。ネパールの人口は 2021 年

医療制度は、不十分なインフラ、特に農に 2,970 万人に達した。2011 年以来、村部における医療従事者の不足、地理的ネパールの人口は約 10％増加している。

な問題による医療サービスへのアクセ

2022 年の一人当たり GDP は 1083 米ドスの悪さ、社会的・経済的障壁、医療保ルである。経済調査 2022/23 によると、

険制度が未成熟であるなどの課題にしネパールの人口の約 15％が貧困線下にばしば直面している。本研究の目的は、ある。ネパールの移民労働者数は人口のネパールにおける労働安全衛生（OSH）

2 割に相当する約 600 万人となってお制度を評価し、海外労働から帰国した労り、そのうち 9 割はマレーシア、カター

働移民が健康診断、治療、リハビリテー

ル、サウジアラビア、UAE に集中してションを必要とする場合の支援システいる。我が国におけるネパール人労働者

ム開発の可能性を探ることである。

については、厚生労働省が発表した
2023 年 10 月末の国籍別・在留資格別外

B．研究方法

国人労働者数によると、14.6 万人と全体研究目的に基づいて 2 つの研究課題をの約 7%を占めている。これは、外国人設定した。

労働者総数で見ると、ベトナム、中国、

1.

フィリピンに次ぐ全体の４位に位置しスの提供システムとは何か？

ている。4 人に 1 人が専門的・技術的分

2.

野の在留資格で就労しているものの、全スの品質保証システムとは何か？

体の約 2/3 が資格外活動で、特に留学が研究課題に基づいて、OSH、職業性疾患、6 万人となっており、語学学校に通いつ

労働法、労働移動などのキーワードを特つ、アルバイトとして働く移民労働者が定した。また、ネパール政府の公式ウェ多くを占めるものと推察される。2024

ブサイトを通じて、ネパール政府の政策

年 1 月 1 日に、法務省、外務省、厚生労文書や報告書を調査した：働省とネパール国労働・雇用・社会保障

https://moless.gov.np/np

省との間で、技能実習に関する二国間取https://www.oshc.gov.np/

決め（協力覚書：MOC）が締結されたこ

https://mohp.gov.np/en/とから、今後は技能実習での就労者が増

https://censusnepal.cbs.gov.np/results

ネパールにおける OSH サービ
ネパールにおける OSH サービ

さらに、その他の文書、研究論文、出版

X 線写真などの診断ツールに関する基済みおよび未発表の報告書も使用した。

準もない。OSH サービスの品質保証に

さらに、構造化質問票を用いて労働者 1寄与する規制組織は、作業環境測定と労名にインタビューを行った。

働者の健康診断関連のものに限られている。

C．研究結果ネパールにおける OSH サービスの提供

移民労働者の健康診断を実施している

システム

医療機関

労働・雇用・社会保障省（MoLESS）は、

移民労働者は MOHP が認める政府公認

ネパールの OSH の最高機関であるが、の医療センターで事前健診を受けなけ

MoLES にとって OSH の優先順位は低ればならない。本調査を通じて、この事い。そのため、OSH を監督・管理する

前健診を行っている医療センターとしための組織体制は弱く、人材不足も深刻て、284 院をリストアップした。医療セで あ る 。 保 健 ・ 人 口 省 （ MOHP ） とンターの大部分は、ネパールの首都カト

MoLESS の間には機能的なつながりは

マンズを含むバグマティ県に位置するない。現在の OSH サービスの提供シス（表 1）。コシ県には約 10％の医療セン

テムは、労働者の健康管理、工場検査、ターがある一方で、カルナリ県には医療労働検査を規定したネパール労働法にセンターがない。医療センターの大部分

よって規定されている。国内の職業性疾は独立した研究所で、外来患者サービス

患や職業傷害の全体的な発生率／有病のみを提供し、入院患者サービスはない。

率に関する統計は、移民労働者向けのサービスも含め、アクセスしやすい形式で表 1 移民労働者の事前健診を行っていは十分にまとめられていない。職業性疾る医療センターの分布
N = 284

患を専門的に管理する組織が存在しな
いため、職業性疾患は一般的な保健サー州
コシ州

28 (10%)マデシ州

3 (1%)

バグマティ州241 (85%)

ネパールにおける OSH サービスの品質

ガンダキ州

3 (1%)

保証システムルンビニ州

8 (3%)

アスベストを含む有害物質にさらされカルナリ州

0 (0%)

た労働者に対する特別な健康診断制度

スドゥパシュチム州

1 (1%)

ビスの枠組みの中で管理されている。

はない。職業性疾患の調査に使用される

表 2 移民労働者の診察を行っている医療機関の分布
番

ベッ

号

医療機関名

州

ド数

1

Norvicバグマ

200

International

ティ州

4

バグマ

International

ティ州

200

Ciwec Hospital

ガンダ

Pokharaキ州

Mediciti Hospital

バグマ

25

Neuro Hospital

バグマ(National Institute

ティ州

7

出国前の事前健診に限られている。本調査を通じて、ネパールでの調査を進める

700

上で必要となる連絡担当者を立てることができた。また、ネパールにおける

100

OSH サービスの提供システム及び品質保証システムについての文献調査を終of Neurology)
6

し、国内の労働力に対するサービスは不十分で、移民労働者に対するサービスは

ティ州
5

E．結論
ぎに行き、日常生活を送っている。しかGrandeHospital3

ネパールにおける OSH サービスには、機能的な品質保証システムが欠如している。

ネパールでは、若者の多くが海外に出稼

Hospital
2⚫

Manipal College of

バグマ

Medical Science

ティ州

CIWEC Clinic

バグマ

700

えることができた。一方で、ネパールの病院調査の実施は次年度以降の課題と

25

なった。

ティ州
8

IOM Nepal

バグマ

Migration Health

ティ州

0

Assessment Center

上記の病院は、ネパールへの外国人移住者や旅行者の健康診断で最もよく知ら

F．健康危険情報
該当なし
G．研究発表該当なし

れている三次病院で、いずれも複数の専門科を有している。

Ｈ．知的財産権の出願・登録状況(予定を
含む)

D．考察
調査結果に基づき、取り組むべき課題として以下の点が浮かび上がった。
⚫ ネパールにおける OSH サービスの提供システムは、労働者の作業環境
測定・健康診断に限られている。

1.特許取得
該当なし
2.実用新案登録
該当なし

Status of Occupational Safety and health and Quality
Assurances of Related Services in Nepal
Overseas Health Checkup Initiative

MAY 14, 2024
BIJAY MAHARJAN

Department of Environmental Medicine, Kochi University, Japan

Contents
Abbreviations .......................................................................................................................................................2
1. General Information of Nepal ..........................................................................................................4
1.1
Nepal Geographic ..........................................................................................................................4
1.2 Nepal Population ..................................................................................................................................4
1.3 Nepal Labour ........................................................................................................................................6
1.3.5 Labour Migration of Nepal ..............................................................................................................7
2. Healthcare System of Nepal ........................................................................................................................... 11
2.1 Healthcare Setting .............................................................................................................................. 12
2.2 Health Facilities .................................................................................................................................. 13
2.3. Health Finance ................................................................................................................................... 14
2.4. Health Information Technology ....................................................................................................... 15
2.5 Health Quality Control ...................................................................................................................... 15
2.6 Certification of Health Practitioner .................................................................................................. 18
3. National occupational safety and health profile of Nepal .............................................................................. 19
3.1 Authority or Body, Responsible for Occupational Safety and Health ........................................... 19
3.2 Mechanisms for ensuring compliance including the systems of inspection ................................... 22
3.3 Occupational health services including industrial hygiene ............................................................. 22
3.4 List of occupational health service providers and their service contents ...................................... 23
3.6 Provision of OSH training ................................................................................................................. 23
3.7 Non-Governmental OSH Organization ............................................................................................ 23
3.8 Mechanism for the collection and analysis of data on occupational injuries and diseases andtheir causes ................................................................................................................................................ 24
3.9 Number of occupational injuries and diseases covered by social security schemes...................... 24
3.10 List of Occupational Diseases .......................................................................................................... 24
3.11 Current status of Occupational diseases/injuries and deaths ....................................................... 29
3.12 Implementation of Occupational Safety and Health Standards ................................................... 30
3.13 Integration of health services with occupational health services ................................................. 30
3.14 Occupational disease and their diagnosis in the country .............................................................. 31
3.15 Budget................................................................................................................................................ 31
4. Social protection and health assessment of Nepalese labour migrants .......................................................... 31
4.1 Social protection ................................................................................................................................. 32
4.2 Health assessment of labour migrants .............................................................................................. 33
Conclusion ......................................................................................................................................................... 46
References .......................................................................................................................................................... 47

Abbreviations
AHMIS-Ayurveda Health Management Information System

CDO- Chief District Officer

COVID-19- Corona virus

CSO- Civil Society Organizations

DDA- Department of Drug Administration

DIN-Drug Information Network

DoAA- Department of Ayurveda and Alternative Medicine

DoEF- Department of Foreign Employment

DoHS- Department of Health Services

EHRs- Electronic health records

EPF- Employees Provident Fund

EWARS

-Early warning and Reporting System,

FCHV- Female Community Health Volunteers

FMIS-Financial Management Information System

GCC-Golf Cooperation Council

GEFONT-General Federation of Nepalese Trade Unions

HIIS-Health Infrastructure Information System

HMIS- Health Management Information System

HuRIS-Human Resource Information System,

ILO-International Labour Organization

LEO- Labour Employment office

LLGs- Local Level Government

LMIS- Logistics Management Information System

MDIS-Malaria Disease Information System

MIS- Management Information Systems

MoHP- Ministry of Health and Population

MoLESS- Ministry of Labour, Employment, and Social Security

MoSD- Ministry of Social Development

MPH- Masters in Public Health

MSS-Minimum Service Standards

NHPC- Nepal Health Professional Council

NMC-Nepal Medical Council (NMC)

OOP- Out-of-Pocket

OSH-Occupational Safety and Health

OSHP-Occupational Safety and Health Project

PHC-Primary Health Care Centres

PLAMAHS- Planning and Management of Assets in Health Care System

QAAS-Quality Assurance and Accreditation Section

SSF- Social Security Fund (SSF)

TIMS-Training Information Management System,UK- United Kingdom

UN-United NationsWHO- World Health Organizations

1. General Information of Nepal

1.1 Nepal Geographic
The Federal Democratic Republic of Nepal is a landlocked country located in South Asia with China in thenorth and India in the south, east and west. The country occupies 147,516 sq. km of land and lies between
coordinates approximately 28°N and 84°E. Within a short distance, Nepal’s topography changes from thealluvial Gangetic plains suitable for agriculture to the frozen lands of the Himalayan mountains. Between
the two extremes lie the middle hills. There are several inner Himalayan valleys with desert conditions
located at altitudes above 3,600m.

Figure: 1 Map of Nepal

The country is divided into three geographical zones, i.e. Terai (plain), hills and mountains. Nepal is divided
into 7 provinces 77 districts and 753 local units including 6 metropolises, 11 sub-metropolises, 246
municipal councils and 481 villages. Kathmandu is the nation’s capital and largest city. (1)1.2 Nepal Population
Nepal is a low-income country situated between China and India. The population of Nepal reached 29.7
million in 2021. Since 2011, Nepal’s population has grown by 10.18%. However, the average annual growthrate is 0.93%, a decrease from the data reported in the census report of 2001-2011, which presented a growthrate of 1.35%. The annual population growth is 1.35%. The Gross Domestic Product per capita is US$1083
in 2022. According to the Economic Survey 2022/23, 15.1% of Nepal's population is under the poverty line
and the Gini coefficient is about 58.5. The Human Development Index value is 0.602 in 2022. The crude
birth rate is 20.0 per 1000 population. The crude death rate is 7.3. The total fertility rate is 2.1. The infantmortality rate is 28 per 1000 live births and the mortality rate under 5 years of age is 33 per 1000 live births.
Life expectancy at birth years has improved from 65.3 years in 2000 to 70.9 years in 2019. The fertility ratein Nepal has declined over the years, from 2.516 in 2011 to 1.853 in 2021. (1)Nepal had the largest population group with 66.8% of the population falling into the working-age group of
15-64 years. Below 15 years, was the second with 27.4% and 65 years and above was the third with 5.8%of the total population in 2021. There is a population of 23958868 aged 10 years and above in the countryof which, 65.5% are economically active while 34.5 are economically inactive. The main sector of the work
is agriculture (57.3%), followed by wholesale and retail trade (12.5%), construction (8.1%), manufacturing(3.8%), transportation and storage (2.2%), accommodation and food service (1.7%). About 0.2% are only
engaged in the mining and quarrying sector. (2)Figure: 2

Population Pyramid of Nepal

Export of workers has driven Nepal’s notable pro-poor economic growth: personal remittances reached
25% of GDP in 2020, contrasted with meagre foreign direct investments at 0.4% of GDP. The labour income
share fell, and labour productivity with weak progress during the 2010s. There are slight shifts in the
structural employment status backed by a tailwind from the service sector. The urbanisation rate stands far
below the neighbouring countries. The relatively low unemployment rate at around 5.1% in 2021 isshadowed by a broader underutilization rate of 39%.(3)Table 1:Socio-demographic indicators of Nepal

Indicators
1.1.1: Working poverty rate (%age of employed living below US$1.9 PPP).
1.3.1: The population is effectively covered by a social protection system,
including social protection floors.

Value

Year

3.4%

2021

17% *

2020

5.5.2: Proportion of Women in senior and middle management positions
5.5.2: Proportion of women in managerial positions
8.2.1: Annual growth rate of output per worker (GDP constant 2011
international $ in PPP).
8.3.1: Proportion of informal employment in non-agriculture employment.
8.3.1: Women
8.3.1: Men
8.5.1: Average hourly earnings of women andmen employees.
8.5.2: Unemployment rate (Total, 15+)
8.5.2: Women, 15+
8.5.2: Women, 15-24 years
8.5.2: Men, 15+
8.5.2: Men, 15-24 years
8.6.1: Proportion of youth (15-24 years) not in education, employment, or
training).
8.7.1: Proportion and number of children
aged 5-17 years engaged in economic
activity (Total).
8.7.1: Girls
8.7.1: Boys
8.1.1: Non-fatal occupational injuries per 100,000 workers
8.8.1: Fatal occupational injuries per 100,000 workers.
8.8.2: Level of national compliance with labour rights (freedom of
association and collective bargaining)
9.2.2: Manufacturing employment as aproportion of total employment.
10.4.1: Labour income share as a % of GDP.

14%

2017

13%

2017

-3.6%

2021

78%

2017

82%

2017

75%

2017

US$1.1

2017

11%
13%
24%
10%
20%

2017
2017
2017
2017
2017

35%

2017

19%

2014

19%

2014

19%

2014

-

-

-

-

-

-

15%

2017

37%

2017

1.3 Nepal Labour
1.3.1 General
Nepal has the largest population group with 66.8% of the population falling into the working-age group of
15-64 years. Below 15 years, is the second largest group with 27.4% and 65 years and above was the thirdlargest group with 5.8% of the total population in 2021. There is a population of 23958868 aged 10 years
and above in the country of which, 65.5% are economically active while 34.5% are economically inactive.
The main sector of work is agriculture (57.3%), followed by wholesale and retail trade (12.5%),
construction (8.1%), manufacturing (3.8%), transportation and storage (2.2%), accommodation and foodservice (1.7%). About 0.2% are only engaged in the mining and quarrying sector.

1.3.2 Social Insurance
Nepal has a long and successful history of provident funds that dates back to 1934 and programs such as
the Employees Provident Fund (EPF) have been in the collective memory of the citizens for a few decades.
The introduction of mandatory social insurance through the Contribution-based Social Security Act (2017)
implemented by the Social Security Fund (SSF), is more recent. The coverage of the existing contributionbased social security programme is less than 15 % of all workers, and the covered are mainly civil servants.
(4)

1.3.3 Unemployment Insurance
The unemployment rate for youth aged 15-29 is 19.2% compared to 2.7 per cent for the whole population.
Over 400,000 young people are estimated to enter the Labour force every year. These figures indicate thequantitative dimension of the employment challenge in Nepal. However, the unemployment insurance has
not been initiated so far. (5)1.3.4 Organization
Established in 1989, the General Federation of Nepalese Trade Unions (GEFONT), with 27 affiliated union
members nationwide, works as an umbrella organization for various trade unions in the fields of agriculture,industry and service sectors. In 2007, with an effort to examine the issues of occupational safety and healththrough social dialogues with industrial stakeholders in the country.

1.3.5 Labour Migration of Nepal
Nepal has continued to prioritise entering into and renewing bilateral labour migration agreements(BLMAs) with various labour destinations to ensure the safe, orderly and dignified migration of Nepali
migrant workers. Between 2019/20 and 2021/22, more than 1.1 million Labour approvals were issued.
While the number of Labour approvals issued saw a significant decline in the COVID-19 years of 2019/20
and 2020/21, there was a revival in 2021/22 when the impacts of the pandemic gradually subsided. Nepal
welcomed back 203,934 returnees in 2020/21 and 470,978 in 2021/22. Labour migration from Nepal is stilla phenomenon dominated by men with women migrant workers accounting for less than 10 per cent of thetotal labour approvals issued in 2021/22. Madhesh and Province 1 account for the largest share of migrant
workers, with each being home to more than a fifth of the total Labour approvals issued in 2021/22. In
contrast, Bagmati accounts for the largest share of women migrant workers in foreign employment. (6)Informality affects countries in this region at varying degrees of economic development, and new forms ofwork continue to bring challenges on this front even in countries that have made substantial progress. Lowand middle-income countries continue to have elevated levels of informal employment. For instance,
Nepal’s informal employment rate was around 82% in 2017 and Pakistan’s around 84% in 2021 (ILO 2023).
The incorporation of effective occupational safety and health (OSH) measures in the informal economy
units needs to be considered as an immediate action to protect workers’ health and improve their standardsof living. It also has to be considered part of a transitional strategy aimed at contributing to poverty
alleviation and formalization by combining measures for strengthening the conditions and principles which
regulate labour relations, working conditions, OSH and employment opportunities, to allow for economic
integration, social cohesion and decent work for all. Identifying the nature, diversity and extent of theinformal economy in each country is a complex task. As the informal economy is not covered by national
recording, notification and compensation systems, there is scarce information on occupational accidents
and diseases arising from hazardous working conditions which could be used for the identification ofpriority areas for prevention. The magnitude and rate of growth of the informal economy are difficult toestablish.
While Nepali citizens migrated to 150 countries between 2019/20 and 2021/22 for employment, the six
GCC countries and Malaysia remain the preferred destinations for the overwhelming majority of Nepali
migrant workers in the reference period. Countries like Croatia, Cyprus, the Maldives, Malta, Poland,
Romania, Turkey, and the UK have also emerged as important employment destinations in the last few

years. Between 2019/20 and 2021/22, although most of the women Nepali migrant workers went to the
GCC countries, countries like Croatia, Cyprus, Jordan, Malta, Romania and Turkey were the more
prominent, and emerging destinations for women compared to men. (6)Table 1:

List of countries approved for Foreign Labour Migration*Currently restricted country

1.3.6 History of Emigration in Nepal
Nepal has a long history (more than 200 years) of emigration and it is an increasing trend. The history offormal Labour migration begins in 1814-1816, after the Nepal-British India war. A total of 4,650 Nepaleseyoungsters were recruited to the British armed forces as a British Gurkha regiment after the conclusion of
the war and the signing of the Treaty of Sugauli in 1816. (7)Similarly, the migration of Nepalese people for other employment purposes, such as working in the tea
estates of Darjeeling and the forest of Assam, India, began in the second half of the 19th century. Economic

migration to the Middle East from South Asia and other parts of the world was spurred on by the oil boomin the early 1970s. International labour migration, mostly to the Gulf States, Malaysia and other South East
Asian countries is a new phenomenon of migration in the Nepali context with about 30 years of history.
Unexpectedly, foreign labour migration has developed in such a way that it has shifted the agriculturalbased Nepali economy towards a remittance-based economy. (7)1.3.7 Labour export policy and legislation
Nepal has a significant history of labour migration, primarily to countries in the Middle East, Southeast
Asia, and parts of Europe. The government of Nepal has established policies and legislation to regulate thismigration and protect the rights of Nepali workers abroad. Here are some key points regarding labour export
policy and legislation in Nepal: The country has a Labour Migration Act that governs the process of Labour
migration from Nepal to foreign countries. This act outlines the procedures, requirements, and regulations
that both the recruiting agencies and the workers need to follow. At present, the country’s Labour Act 1992
and Labour Rules 1993 neither adequately address current OHS problems faced by industrial workers nor
sufficiently provide any standard procedure or system to ensure their good health and safety at workplaces.
(8)
Table 2:
Policies and regulations
Constitution of Nepal

Policies and regulations

Findings
The constitution of Nepal was promulgated in 2015. Although
the constitution does not speak outrightly on directives related
to Occupational Health and Safety, nevertheless, it provides
fundamental premises for attaining, ensuring, and establishing
the highest level of health and safety practices.
Labour Act 2017
The current Labour Act has a mandatory provision of coverageof at least NPR one hundred thousand per year for every worker
as part of the medical treatment cost. Similarly, the Act
demands coverage of at least NPR seven hundred thousand forevery worker as workplace injuries-related treatment cost. The
Act specifies that the premium for medical insurance will be
paid half by the employer and half by the employee, however,the Act requires the premium for accident insurance to be fully
borne by the employer
Public Health Service Act 2018
Clause 44 of this Act speaks on the safety of the health workers
in risky zones and encourages them to adopt safety measures.
the provision of risk allowance to the workers and in case ofserious infection, injury or death, necessary compensation has
also been recommended.
15th Strategic Development Plan setting up and implementation of occupational safety and health(2019/2020- 2023/2024)
standards in enterprises to provide dignified employment
opportunities to the workers in the country
Labour Rule, 2018
The rule encourages for development of an Occupational Safety
and Health Policy for each workplace with the inclusion of asafety preparedness plan, worker’s health, machine operation,use of hazardous substances, etc.
National Health Policy Nepal, 2019
To ensure the constitutional rights of citizens to health services
through a federal health system and ensure universal access tothe health policy. However, does not mention occupationalsafety and health.

There are no province-level Regulations related to occupational safety and health to date in Nepal. The
Labour Act, 2017 and Labour Rules, 2018 which include provisions for occupational safety and health arefederal government legislation. Provisions of occupational safety and health directed in the Labour Act,2017 and its Rules, 2018 apply to all workplaces of seven provinces of Nepal but the provision of safety
and health committee mentioned in section 74 of the Act and rule 37 of the Regulation is only applicablein the enterprises employing 20 or more employees.
Findings:•

The laws and regulations do not specify•

Pre-entry screening and post-entry screening for health. However, mentions the establishment of a
primary health clinic for first aid management.

•

It mentions the rights and duties of the labour migrants and returnees and their health.

1.3.8 Key stakeholders in Labour migration
In the context of labour migration in Nepal, several key stakeholders play significant roles in various aspectsof the migration process. These stakeholders include:
Government of Nepal: The government plays a central role in formulating policies, regulations, and laws
related to labour migration. It oversees the licensing and regulation of recruitment agencies, provides predeparture orientation for migrant workers, negotiates bilateral agreements with destination countries, andestablishes mechanisms for the protection of migrant workers' rights.
Department of Foreign Employment (DoFE): The DoFE is the government body responsible forregulating and overseeing foreign employment in Nepal. It issues licenses to recruitment agencies, monitors
their activities to ensure compliance with the law, provides support services to migrant workers, andfacilitates their safe migration.
Ministry of Labour, Employment, and Social Security: This ministry is responsible for formulating labour
policies, promoting decent work opportunities, and ensuring the protection of workers' rights, including
those of migrant workers. It works closely with other government agencies and international organizations
to address issues related to labour migration.
Recruitment Agencies: Recruitment agencies play a crucial role in facilitating labour migration byconnecting Nepali workers with employment opportunities abroad. They assist workers in obtaining
necessary documentation, provide pre-departure orientation and training, and coordinate with employers
and authorities in destination countries.
Migrant Workers: Migrant workers themselves are key stakeholders in labour migration. They seek
employment opportunities abroad to improve their economic prospects and support their families backhome. Migrant workers rely on recruitment agencies, government services, and support networks tonavigate the migration process safely and successfully.
Employers in Destination Countries: Employers in destination countries hire Nepali migrant workers tomeet their labour needs in various sectors such as construction, manufacturing, hospitality, and domestic
work. They are responsible for providing safe working conditions, fair wages, and other benefits to migrant
workers following local laws and regulations.

Civil Society Organizations (CSOs): CSOs play an important role in advocating for the rights of migrant
workers, raising awareness about migration-related issues, providing support services to migrant workers
and their families, and holding governments and other stakeholders accountable for their actions or lackthereof in protecting migrant workers' rights.
International Organizations and Donor Agencies: International organizations such as the International
Labour Organization (ILO), United Nations agencies, and donor agencies provide technical assistance,
capacity building, and funding support to Nepal in areas related to labour migration, including policy
development, data collection, research, and implementation of programs to promote safe and orderly
migration and protect migrant workers' rights.

2. Healthcare System of Nepal
Nepal’s health system is distinguished by a comprehensive and inclusive approach that incorporates
accessibility, quality assurance, and responsiveness to emerging health challenges. The ongoingcommitment to UHC and alignment with global development goals positions Nepal’s healthcare
system on a trajectory of continuous improvement and resilience. Health service delivery systems in
Nepal encompass Allopathic, Ayurvedic, Homeopathic, Unani, Naturopathy, Amchi,
Acupuncture/Acupressure, Yoga and other indigenous practices, with a mix of both public andprivate sectors. The health system underwent and is in continuous restructuring at the federal,provincial, and LLGs, levels adapting to exercise authority and fulfil constitutional mandates at eachlevel of government. At the federal level, five divisions (Policy, Planning and Monitoring Division,
Health Coordination Division, Quality Standards and Regulation Division, Population Management
Division) and HEOC unit operating under the MoHP, are responsible for managing the policy
framework, planning, setting standards, coordination, monitoring, and supervision. Immediate
implementation and further planning are conducted through departments- DoHS, the Department of
Ayurveda and Alternative Medicine (DoAA), and the Department of Drug Administration (DDA).
These departments, through their respective deconcentrated entities viz divisions, centres, andLaboratories, guide their provincial counterparts under the provincial ministries, which in turnsupport health offices at the district and health coordination units at the Local level of government(LLGs). Public institutions, including Basic health service units/centres and hospitals at the LLGs,
primary and secondary hospitals at the provincial level, and tertiary, super-specialized, andacademia/teaching hospitals at the federal level, are mandated to deliver health services. The
structure encompasses both allopathic, Ayurvedic and alternative medicine health service provisions,extending beyond curative aspects to include promotive, preventive, rehabilitative and palliative
dimensions. Furthermore, private health facilities operate at all levels, complementing public
institutions. Each institution is mandated to allocate 10% of free beds for impoverished citizens toaccess health facilities as needed. Moreover, there is an expansion of the health insurance program
to cover services beyond basic health services, aiming to reduce out-of-pocket (OOP) expenses andprotect against catastrophic health expenditures. This comprehensive network, inclusive of
academia/teaching hospitals and super-specialized hospitals at the federal level, contributes to theholistic and community-centric nature of Nepal’s health service delivery. (9)Figure: 3

Structure Health care system of Nepal

2.1 Healthcare Setting
2.1.1 Public Sector
Nepal’s pluralistic health system comprises public services and the private sector (including profit and nonprofit organizations). The national health system is of three-tier systems i.e. federal, provincial and local
levels. At the federal level, under the Ministry of Health and Population, there is a Department of HealthServices. Under the Department of Health Services, there are 5 divisions and 22 sections. Its major role isin policy formation, technical backstopping and resource allocation.
The Provincial Health Directorates provide technical backstopping and programme monitoring to district
health systems and come directly under the Ministry of Social Development of the Province. The regional,
sub-regional, and district hospitals are categorized into three levels of hospitals; Primary, Secondary andTertiary. There are also training centres, Laboratories, TB centres and medical stores at the provincial level.
The public healthcare system was restructured into local, provincial and state-run facilities in 2015 withPrimary Health Care Centres (PHC), Basic Health Centers and Health Posts as basic units for health service
delivery. The health post (from an institutional perspective) is the first contact point for basic health services.
Besides, the health post is the referral centre of the volunteer cadres of FCHVs as well as a venue forcommunity-based activities such as PHC outreach clinics and EPI clinics. Each level above the HP is areferral point in a network from HP to PHCC, on to district zonal and regional hospitals, and finally to
speciality tertiary care centres in Kathmandu. This referral hierarchy has been designed to ensure that the
majority of the population receives public health and minor treatment in places accessible to them and at a

price they can afford. Inversely, the system works as a supporting mechanism for lower levels by providing
logistical, financial, supervisory, and technical support from the centre to the periphery2.1.2 Private Sector
Private health service providers are mostly located in urban areas and are used predominantly by wealthier
Nepalese patients. In rural areas—where public facilities are accessed more than in urban areas (with autilisation rate of 39.1% and 26.8%, respectively) but are still not the predominant provider—pharmacies
are the chief private providers, mostly used by poor patients. People use private facilities more frequently
than public ones—one study found that about 63% of people with an acute illness used the private sector
regardless of their economic status. As a result, out-of-pocket spending is high (out-of-pocket payments
account for 55% of total health expenditure) and financial protection for patients is poor. Consequently,
poor patients utilise health services less than wealthier patient groups, despite having a higher incidence ofreported illness. (10)2.2 Health Facilities
The Ministry of Health is in charge of provincial, district, and commune health facilities and is in charge ofdeveloping and implementing health care services at the appropriate level. Numerous health facilities areunder the management of the Ministry of Health, including research and Pasteur institutes, universities,
colleges, and national hospitals. Every province has a minimum of one provincial hospital, which serves
as a support system for national hospitals throughout all stages of care. Basic care, emergency services, andcommon disease treatment are provided at the district level. Lastly, basic care, health education, andawareness programs are provided at the community level.

Table 1:
Facility
Public hospitals
Primary Health Centres
Health Posts
Non-public facilities
Basic Health Services Centre
Basic Hospital (5-15 beds)
General Hospitals (25-50 beds)
General Hospitals (100-300 beds)
Specialized hospitals (100 beds and above)
Super Specialty Hospitals (50+ Beds)
Academic and teaching hospitals (300+beds)
Other Types of Health Facilities

Number of health facilities
Number
215
187
3778
2551
7582
246
333
79
28
22
29
2164

Figure: 4 Organisational chart of Nepal healthcare system, illustrating roles and responsibilities ofeach component

2.3. Health Finance
The Nepal Constitution included provisions for four types of grants: equalization grants, conditional grants,
matching grants, and special grants. The variables used for fiscal equalization grants are population, levelof development, and cost-adjusted local government area. Based on the constitutional provisions, thegovernment promulgated two acts related to intergovernmental fiscal transfers (IGFTs) in 2017: theIntergovernmental Fiscal Management Act (IGFMA) and the National Natural Resource and Fiscal
Commission Act. Article 6.1 of IGFMA Schedule 3 established the federal divisible fund (FDF) to divide
the value-added tax and excise duty on domestic production among the federal, provincial, and local
governments. Furthermore, as one of its provisions, Subarticle 2 divided the total amount of the FDF,
allocating 70% to the federal government, 15% to provincial governments, and another 15% to local
governments. The IGFMA also provides guidelines regarding different types of grants. The most crucialpart of an IGFT is the impact on governmental policy objectives, which depends on the formulation of thetransfer system and the operational portion of the transfer fund. IGFTs are contingent on the transfer
mechanism and the effects of fiscal transfers on basic outcomes such as allocative efficiency, equitable
distribution, and macroeconomic stabilization.
The first federal budget was allocated in fiscal year 2017–2018, with fiscal equalization grants and special
grants delivered to the local level. Similarly, the IGFMA provided for general revenue sharing and natural
resource revenue sharing modalities among the different tiers of government. In 2019, the total healthexpenditure per capita in Nepal was US$53.3 Overall, health expenditures represented 4% of the country’s
gross domestic product (GDP), well below the global average of 10%. Healthcare financing in Nepal
involves three principal sources: governmental funding, external contributions, and private expenditures.
Government spending accounted for 25% and external contributions represented 16% of Nepal’s total
health expenditures in 2019. Out-of-pocket spending on health care constituted nearly 58% of all healthexpenditures.
Governmental spending on health has been increasing in Nepal, but the health sector still receives only amodest share of general spending (4%). Although budgeting processes have been shifting as a result of thetransition from a unitary to a decentralized federal system of governance, governmental health allocations
and expenditures continue to be concentrated at the central level, focusing on developing healthinfrastructure, procuring drugs and vaccines and medical equipment, and recently on the COVID-19
response. In the fiscal year 2021–2022, 74% of the health budget was allocated to the central level, 5% to
the provincial level, and 21% to the local level.

2.4. Health Information Technology
All health facilities/programs bear the responsibility of documenting and reporting program/ service
statistics through standardized platforms for Management Information Systems (MIS). These platforms
include Health Management Information System (HMIS), Logistics Management Information System(LMIS/electronic LMIS (eLMIS), Financial Management Information System (FMIS), Health
Infrastructure Information System (HIIS), Planning and Management of Assets in Health Care System(PLAMAHS), Human Resource Information System (HuRIS), Training Information Management System(TIMS), Ayurveda Health Management Information System (AHMIS), Early warning and Reporting
System(EWARS), Malaria Disease Information System (MDIS) and the Drug Information Network (DIN).
Additionally, these facilities contribute data to various health surveillance systems, such as disease
surveillance, vital registration, censuses, sentinel reporting, surveys, rapid assessments, and research
initiatives. DoHS takes the lead in managing information systems except for DIN and AHMIS, which areoverseen by the DDA and DoAA respectively. (9)2.5 Health Quality Control
2.5.1. Hospital quality management.
A Policy on Quality Assurance in Health Care Services 2007 was prepared by the MoHP to provide
guidelines for the integration of quality-of-care components in health, to ensure that a quality assurance
system is in place, and to ensure overall quality improvement activities are well implemented in all healthfacilities to fulfil consumers' needs. This Quality control of health services in Nepal involves various
strategies and mechanisms aimed at ensuring that healthcare provided to the population meets certain
standards of safety, effectiveness, and patient satisfaction. Here are some key aspects of quality control in
health services in Nepal. (11)Regulatory Framework: Nepal has regulatory bodies such as the Ministry of Health and Population (MoHP)
and the Nepal Health Professional Council (NHPC) responsible for setting and enforcing standards forhealthcare providers, facilities, and services.
Accreditation: Accreditation programs evaluate healthcare facilities and providers against establishedstandards to ensure quality of care. In Nepal, the Quality Assurance and Accreditation Section (QAAS)
under MoHP oversees accreditation processes.

Training and Education: Continuous training and education programs for healthcare professionals are
crucial for maintaining and improving quality standards. This includes ongoing medical education, skills
development, and training on patient safety protocols.
Monitoring and Evaluation: Regular monitoring and evaluation of healthcare services help identify areas
for improvement and ensure compliance with standards. This can involve routine inspections, audits, andassessments of healthcare facilities and providers.
Patient Feedback Mechanisms: Collecting feedback from patients about their experiences with healthcare
services is essential for assessing quality and identifying areas for improvement. Patient satisfaction surveys
and complaint mechanisms can help healthcare providers address issues and enhance patient-centred care.
Clinical Guidelines and Protocols: Implementing evidence-based clinical guidelines and protocols helps
standardize care delivery and improve clinical outcomes. Health facilities in Nepal often adopt guidelines
developed by international organizations like the World Health Organization (WHO) and adapt them tolocal contexts.
Technology and Information Systems: Utilizing technology and information systems can improve thequality and efficiency of healthcare delivery. Electronic health records (EHRs), telemedicine, and healthinformation systems enable better coordination of care, patient monitoring, and data-driven decisionmaking.
Community Engagement: Engaging communities in healthcare decision-making and service delivery
processes fosters accountability and responsiveness to local needs. Community health programs andparticipatory approaches can enhance access to quality healthcare in remote areas.
Public Health Initiatives: Addressing broader public health challenges such as infectious disease control,maternal and child health, and non-communicable disease prevention contributes to overall healthcare
quality and population health outcomes.
Capacity Building: Strengthening the capacity of healthcare systems, including infrastructure, humanresources, and supply chains, is essential for delivering quality health services. This involves investments
in training, equipment, facilities, and logistics management.

Table 2:
Authority

Key roles and responsibilities for quality assurance

Key roles and responsibilities for Quality
Assurance

Monitoring Mechanisms

a. Federal Level

MoHP (Quality
Assurance andRegulation
Division)

Preparing, reviewing, and facilitating theimplication of national quality assurance policies
and guidelines
Establishing service standards and monitoring for all
services and types of facilities
Guidance and monitoring of the quality of services
being delivered by all types of health facilities
Review and monitoring of service provision andquality of services delivered
Establishing quality standards for drugs,
commodities, equipment, and medical supplies

National Quality AssuranceCommittees
Periodic Health Sector Review
Meetings

Ensuring requirements as per the International
Health Regulation (IHR)
Facilitating registration, renewal, and monitoring ofhealth facilities based on their established criteria
and norms
Facilitating implementation, monitoring, and reviewof the delivery of health services and quality of
those services
DoHS

Supporting MoHP in preparation of quality-of-carerelated policies, protocols, and guidelines of MoHP

Quality Assurance and Monitoring
Committee

Ensuring delivery of essential services by all basic
health care facilities and other services as per the
protocol and health policies
Divisions/Centers

Developing program-specific technicalguidance and protocols to ensure preparedness
and delivery of health services

Technical Working Groups withthe assigned role of quality
assuranceb. Province Level
Prepare and implement provincial policies, acts,
quality standards, and implementation guidelines
Ensure delivery of essential services by all facilities
and other services as per the policy and protocols
MoSD/MoHP

Directorate/
Centers

Facilitate registration, operation, listing, andregulation of private and cooperative healthfacilities as per the policy and protocols
Facilitate production, and use of health-relatedcommodities, and medicines and ensure the qualityof imported medicines and commodities
Management of logistics and supply chain
system of medicines, health commodities, andsupplies
Facilitate implementation, monitoring, and reviewof the delivery of health services and the quality of
those services by provincial-level health facilities

Provincial Quality AssuranceCommittees

Technical Working Groups

Facilitate dissemination and implementation ofprogram- specific technical guidance and protocols
Health Offices(district level)

Coordinate with the municipal, district, andprovincial level authorities to ensure delivery ofhealth services as per the policy and protocol

Technical Committees (if necessary)c. Local Level

Municipality

Ensure delivery of basic health and sanitation
services as per the federal, provincial, and local
health policies, standards, and protocols
Facilitate dissemination of information for publicawareness and demand creation

Municipal Health Committees

Coordinate with other sections/sectors to createclean, healthy, and resilient societies
Hospital/HealthFacility

Deliver basic health services as outlined in federal,provincial, and local health policies and by ensuring
national standards and protocols

Health Facility Operation andManagement Committee with amandate to review the quality ofhealth services

Minimum Service Standards (MSS) for hospitals are the service readiness and availability of tools for
optimal requirements of the hospitals to provide minimum services that are expected from them. This toolentails for preparation of service provision and elements of service utilization that are deterministic towards
the functionality of the hospital to enable a working environment for providers and provide resources for
quality health service provision. MSS for hospitals reflect the optimally needed minimum criteria forservices to be provided but in itself is not an “ideal” list of the maximum standards. This checklist of MSS
is different from a program-specific quality improvement tool as it will outline the equipment, supplies,
furniture, and human resources required for carrying out service but not detail the standards and operatingprocedures of any service. The results of the Nepal Health Facility Survey 2015 showed that among thehealth facilities that were assessed only 13 % of them had all seven basic equipment items- adult weighing
scale, child weighing scale, infant weighing scale, thermometer, stethoscope, blood pressure apparatus anda light source for service provision. The availability of all supplies and equipment defined for standard
precaution control was as low as 0.2%, all basic Laboratory services in 12% and only 3% of facilities hadclient feedback mechanisms in place. This was an alarming situation. During that period, minimum service
standards were rolled out in 83 district-level hospitals and were evident to contribute to the quality ofservices provided by hospitals with instances of improved governance, management, clinical and support
services. This encouraged MoHP to put its efforts into setting the minimum service standards for hospitals
at secondary and tertiary levels and at the same time contextual revision of MSS for district hospitals to set
MSS for primary level hospitals. The revision and development of the tool took into series of steps
beginning with the formulation of a Technical Working Group and selection of subject experts and technicalcoordinators and consultative workshops and meetings. The key guiding documents are the Constitution of
Nepal 2015, National Health Policy 2014, Policy on Quality Assurance in Health Care Services, 2007,
Public Health Service Act 2015, Nepal Integrated Health Infrastructure Development Standards 2016,
Nepal Health Sector Strategy 2015- 2020 and Guideline on Health Institution Establishment, Operation andUpgrading Standards, 2070 but not limited to them. (12)2.6 Certification of Health Practitioner
Nepal Health Professional Council (NHPC) is an autonomous body established under the Nepal HealthProfessional Council Act 1996. This council aims to register all the "Health professionals" other than
medical doctors, Nurses, Pharmacists, and Ayurveda according to their qualifications; and bring them intoa legal system to make their services effective with quality and timely in a scientific manner.
The Nepal Medical Council (NMC) is the government authority established as per the NMC Act to conductvarious activities, including the registration of medical doctors in Nepal. The primary role of the council is
to assure and promote quality in the medical profession to protect the health care seekers, foster ethicalconduct and develop and maintain high academic and professional standards.
Nepal Nursing Council (NNC) was established under the Nepal Nursing Council Act 1996 and came into
force on 16 June 1996. The first amendment of the act was done on 17th January 2002 A.D.
The power, function and duties of these councils shall be as follows: • To formulate the policy required to operate the profession smoothly• To provide recognition to a teaching institution,• To evaluate and review the curriculum, terms and conditions of admission, examination system andother necessary terms and conditions and infrastructure of a teaching institution

•
•
•
•

If a teaching institution is found from the evaluation and review made according to clause (c) tohave failed to meet the standards determined by the council, to make a recommendation forrevoking the approval for operation of such institution.
To determine the qualifications of the health professionals and to issue certification to the qualified
health professional after registering his /her name in the registration book,To determine the work limit of health professionals,
To formulate a professional code of conduct for health professionals and to take action against those
health professionals who violate such code of conduct.

3. National occupational safety and health profile of Nepal
Occupational health is an area of work in public health to promote and maintain the highest degree ofphysical, mental and social well-being of workers in all occupations. The science and practice ofoccupational health involve several disciplines, such as occupational medicine, nursing, ergonomics,
psychology, hygiene, safety and others. Occupational safety and health (OSH) are crucial for ensuring
workplace efficiency and productivity. Emerging occupational health problems are to be tackled along withthe existing public health problems like communicable and non-communicable diseases. However, theepidemiological profile and analysis of occupation exposure and disease are few and far between, which islimited to some major injuries and deaths. Often, these injuries and deaths are not reported to the national
system due to weak monitoring and evaluation systems, especially in countries like Nepal.

3.1 Authority or Body, Responsible for Occupational Safety and Health
The Ministry of Labour, Employment, and Social Security is the apex body for national Occupational Safety& Health (OSH) supervision and administration in Nepal. There are four divisions in the Ministry of Labour,
Employment, and Social Security. The joint secretary is the chief of each division. According to the job
description of the Child Labour and Occupational Safety and Health section, functions related to OSH are
given to this section. The Undersecretary technical (Mechanical Engineer) is the chief of this section. Thereis one factory inspector (Mechanical Engineer) and one section officer in this section. There are only threestaff (including the undersecretary) posted in this section. According to the job description of this section,
Child labour-related works are also assigned to this section. This section is responsible for OSH-related
works in additional to a broader set of works related to labour management. The main enforcement body at
the local levels and the specified areas are the Labour and Employment offices. The major activities carriedout by these offices are monitoring the labour relations occupational safety and other health aspects in theestablishment and enterprises as specified under the legislation. The Labour and Employment Offices atthe local levels are headed either by the Labour Officer or the Factory inspector. The other staff members
to support the activities of these offices are the non-gazetted officers and the assistants. OSH seems a lesspriority area for the Ministry of Labour, Employment, and Social Security. Due to lack of priority, theinstitutional structure for OSH Supervision and Administration seems weak with a severe lack of humanresources and includes only 3 staff (joint secretary 1, undersecretary technical 1, and factory inspector 1)
responsible for OSH Supervision and Administration.

Figure: 1 Occupational Safety and Health Organization in Nepal

Table 3:

List of universities and other academic institutions related to OSH

Institutions

Affiliations

Courses

Thesis on Occupational
Health and Safety

1. Kathmandu
University School of
Medical Sciences

Kathmandu
University

MD Community
Medicine
MSc in Public HealthYes

2. Manipal College ofMedical Sciences

Kathmandu
University

MD Community Medicine

Yes

3. College of Medical
Sciences, Bharatpur

Kathmandu
University

MD Community Medicine

Not done till now

4. Kathmandu Medical
College, Kathmandu

Kathmandu
University

MD Community Medicine

Yes

5. Nepal Medical
College, Kathmandu

Kathmandu
University

MD Community Medicine

Not done till now

6. Nepalgunj Medical
College, Nepalgunj

Kathmandu
University

MD Community Medicine

Not done till now

7. Nobel Medical
College, Biratnagar

Kathmandu
University

MD Community Medicine

Not done till now

8. Lumbini Medical
College
9. BP Koirala Instituteof Health Sciences,
DharanKathmandu
University
BPKIHSMD Community Medicine

Not done till now

MD Community Medicine

Yes

10. Institute ofMedicine, Kathmandu

Tribhuvan
University

Masters in Public HealthYes

11. KIST Medical
College
12. Universal College ofMedical Sciences,
Bhairahawa

Tribhuvan
University
Tribhuvan
University

Masters in Public HealthNot done till now

Masters in Public HealthNot done till now

13. Chitwan Medical
College, Bharatpur

Tribhuvan
University

Masters in Public HealthNot done till now

14. Gandaki Medical
College, Pokhara

Tribhuvan
University

Masters in Public HealthNot done till now

15. Manmohan Medical
Institute of Health
Sciences, Kathmandu
16. Patan Academy ofHealth Sciences,
Lalitpur
17. School of Health andAllied Sciences, Kaski

Tribhuvan
University

Masters in Public HealthNot done till now

PAHS

Masters in Public HealthNot done till now

Pokhara University

MPH (Public Health andServices Management)

Not done till now

Masters in Public Health

MPH (Health Promotion
and Education)
Promotion and Education)
18. Nobel College,
Kathmandu

Pokhara University

MPH (Public Health andServices Management)

Not done till now

MPH (Health Promotion
and Education)
19. Himalayan Instituteof Science andTechnology, Kathmandu
20. Nepal Engineering
College, Centre for Post
Graduate Studies,
Lalitpur21. Central Departmentof Environmental
SciencePurbanchal
University

M.Sc. (Engineering
Management)

Done

Pokhara University

M.Sc. (Construction
Management)

DoneTribhuvan
University

PhD in Occupational andEnvironmental (Road
Safety)Done

M.Sc. Environment
Science (OHS
management Course)
M.Sc. Environmental
Health in Disaster(13)
3.2 Mechanisms for ensuring compliance including the systems of inspection
The Labour Act 2017 in its section 12 relates to occupational safety and health provisions and the provisions
are stated in clauses 68 to 83. The Act defines the roles responsibilities and procedures for the factoryinspection. Structure and Activities of Labour and Employment Office (LEO) on OSH The first labour
office in Nepal was established in 1970 at Biratnagar under the then Department of Industry. With theformation of the Department of Labour in 1981 under the ministry of labour and social welfare, there werevery few labour offices and the number simultaneously increased to ten labour offices throughout thecountry by 1990. The current offices have been named as Labour and Employment Office (LEO) since2017 with the revised organizational structure. The number of staff at the Labour office has been increasing
as they also need to work along with the issuance of foreign employment permits. Labour and employment
offices are working to protect employees’ rights by settling individual complaints filed by the worker as per
the Labour Act 2017 and participatory collective bargaining. Labour and Employment Offices aim to ensurejustice, promote OSH and foster harmony between workers and employers for good industrial relations
towards sustainable industrial growth in the country. LEOs are responsible for factory inspection to ensurethat enterprises comply with the OSH provisions stated by the Labour Act 2017 and Labour regulations.
LEOs are also responsible for labour inspection to ensure the types of employment and employment
contracts, guaranties of stated minimum wages, and social security provisions such as provident funds,
gratuity, and insurance to the workers. LEOs and their factory inspectors are also liable to ensure appropriate
Occupational Safety and Health conditions for the workers to protect from work-related hazards and risks
on their constraining resources provided. Also, LEOs are assigned to register enterprise-level trade unions
and conduct their union election to ensure workers enjoy the right of freedom of association and the rightfor collective bargaining. The LEOs are also responsible for acting on the assignment and activities stated.

3.3 Occupational health services including industrial hygiene
The Occupational Safety and Health Center used to provide industrial hygiene services such as measuring
light, noise, sound, and dust in the factories based on their annual work plan. However, now due to the lackof adequate equipment and human resources, the service is currently outsourced. The basic Occupational
Safety and Health Services include the following major criteria:
1. Surveillance of work environment and risk assessment.
2. Health surveillance and health examinations.
3. Advice on preventive and control measures.
4. Health education, health promotion, and promotion of workability.
5. Maintaining preparedness for first aid and participation in emergency preparedness.
6. Diagnosis of occupational diseases.
7. Record keeping
The Labour Act 2017 of Nepal ensures the provision of first aid in industrial enterprises with more than 50
employees and the requirements of an academically trained medical assistant in the case of industrial
enterprises with more than 400 workers. If an industrial enterprise has more than 1,000 employees, a
medical doctor and a medical assistant are required. Many registered health centres in Nepal provide healthcare services including Occupational Health Services to the employees of different workplaces under amemorandum of understanding between those institutions. However, their services are limited to thediagnosis and treatment of the diseases of the workers. Some of the institutions like BPKIHS haveestablished the Department of Environment and Occupational Health under the School of Community
Medicine which provides health screening program in some of the industries in the Dharan, Biratnagar
Industrial Corridor. Though Nepal is a signatory to the UN High-Level Meeting political declaration on
Universal Health Coverage, there is no provision yet for the standard occupational health services in theindustries and enterprises in Nepal.

3.4 List of occupational health service providers and their service contents
To date, there are no specialized health service providers in Nepal offering their targeted services related to
Occupational Safety and Health. Although, the Occupational Safety and Health Center is the apex body forproviding these basic occupational health services among other services, currently lacks trained humanresources and advanced monitoring equipment. The Center has not been rendering these services currently,
But a few private institutions are known to provide fragmented occupational health services such as healthscreening, diagnosis, workplace monitoring, etc

3.5 Certification for Occupational Health Practitioners
There are no medical schools that specialize in occupational health in the country. There is no certification
system for occupational health practitioners. However, different universities, autonomous institutions andaffiliated colleges provide courses such as MPH/ MD Community Medicine /MSc/ ME where student
conducts thesis work onoccupational health and safety-related topics

3.6 Provision of OSH training
Occupational Safety and Health Project (OSHP), Bhaisepati, since its inception in 1995 under the Ministryof Labour and Transport Management, has been conducting various types of capacity-building training
programs in the field of occupational safety and health. OSHC by now, since its establishment, has provided
training at the centre and provincial level and or factory site for more than 11 thousand workers, employees,
and government officers. Each year, under the annual program and activities, this project conducts thefollowing training program. The course contents and structure for the training are listed as under: a)Advanced training on OSH for 14 days. b) Boiler Safety and Operation Management for 14 days and 7 days
modules. c) 4 days of training on OSH. d) 4 days of training on OSH for government employers. e) Hazard
analysis and risk assessment training. f) Basic awareness training on OSH. g) Training material, poster, andleaflet development. h) OSH awareness program and seminar in each province or region. i) OSH awarenesssector-specific programs.

3.7 Non-Governmental OSH Organization
There are few Non-Governmental OSH Organizations in Nepal. The Occupational Health and Safety
Society of Nepal is a society of researchers and professionals in the field of OHS in Nepal. The society
publishes the International Journal of Occupational Safety and Health (IJOSH) since 2011. IJOSH is aninternational peer-reviewed, indexed, open-access journal covering occupational health and safety-related
disciplines. IJOSH is published half-yearly. It provides occupational health physicians, doctors, nurses,
engineers, ergonomists, and a wide range of occupational hygiene, health and safety professionals with adependable single source of proficiently written legal, practical and management occupational healthinformation. Occupational Safety and Health Professionals Nepal is a national organization of OHS
professionals in Nepal. Its core objectives are to promote occupational health and safety in workplaces in
Nepal and to form a learning, sharing and networking platform for OSH Development in Nepal. It also
promotes the sharing of ideas, opinions, knowledge, skills, various issues, experiences, and relevant
information in the field of OSH.

3.8 Mechanism for the collection and analysis of data on occupational injuries and diseases
and their causes
The Labour and Employment Offices (LEO) are entitled to collect and analyze data on occupational injuries,
diseases, and their causes. The data gap majorly exists due to poor monitoring and supervision of the factoryinspectors and lack of adequate accident recording and reporting systems. As per the Labour Act 2017, theemployers are responsible for reporting the occurrence of any accident in their enterprises to the respective
Labour and Employment Office and also informing employees at their enterprise. The Labour and
Employment Office is obliged to make further investigations of the incident. However, the reporting ofsuch incidents is very limited on the employer's part. It is known that most of the cases of an accident arenegotiated and solved and negotiated within the industrial premises and never reported. The major causes
for diseases and accidents at the workplace reported by earlier research identify violation of safety rules,
congested workplaces, unsecured workplaces, carrying a heavy load, lack of awareness among workers,
carelessness of both the workers and management, unsecured/old machines or equipment, poor layout,
unavailability of the safety equipment/tools as necessary, low standard tools, unsuitable working conditions
and use of low-quality raw materials. (14) Likewise, lack of training, lack of inspection, supervision, andmonitoring, resource constraints (human and financial), and oversight of facilities are also important factors
responsible for the high incidence of disease and accidents in Nepal. (15)

3.9 Number of occupational injuries and diseases covered by social security schemes
In 2017 a new Labor Act was enacted. The Act added some important provisions on occupational diseases.
After the enactment of the Labour Act 2017, the Labor Regulations, 2018 and the Occupational Safety and
Health Policy, 2019 were also enacted. The regulations made detailed arrangements for occupational
diseases. It included in the regulations that the list of occupational diseases needs to be published in theGazette. However, the government has not yet classified the occupational diseases and published the list in
the Gazette, but instead published it in the “Social Security Scheme Operation Procedure, 2018”. While
preparing the “Social Security Scheme Operation Procedure, 2018” the OSH expert who is responsible forthis National OSH profile suggested to the Government of Nepal that in the absence of Nepal’s list ofoccupational diseases, it would be wise to implement the ILO list of the occupational diseases. The
Government of Nepal agreed to this suggestion and endorsed the ILO list of occupational diseases as
Nepal’s list of occupational diseases. The procedure states that in the event of an illness or accident, whileworking, the company or the organization should protect such a person.

3.10 List of Occupational Diseases
1. Occupational diseases are caused by exposure to agents arising from work activities.
1.1. Diseases caused by chemical agents.

1.1.1. Diseases caused by beryllium or its compounds.
1.1.2. Diseases caused by cadmium or its compounds.
1.1.3. Diseases caused by phosphorus or its compounds.
1.1.4. Diseases caused by chromium or its compounds.
1.1.5. Diseases caused by manganese or its compounds.
1.1.6. Diseases caused by arsenic or its compounds.
1.1.7. Diseases caused by mercury or its compounds.

1.1.8. Diseases caused by lead or its compounds.
1.1.9. Diseases caused by fluorine or its compounds.
1.1.10. Diseases caused by carbon disulfide.
1.1.11. Diseases caused by halogen derivatives of aliphatic or aromatic hydrocarbons.
1.1.12. Diseases caused by benzene or its homologues.
1.1.13. Diseases caused by nitro- and amino-derivatives of benzene or its homologues.
1.1.14. Diseases caused by nitroglycerine or other nitric acid esters.
1.1.15. Diseases caused by alcohols, glycols or ketones.
1.1.16. Diseases caused by asphyxiants like carbon monoxide, hydrogen sulfide, hydrogencyanide or its derivatives.

1.1.17. Diseases caused by acrylonitrile.
1.1.18. Diseases caused by oxides of nitrogen.
1.1.19. Diseases caused by vanadium or its compounds.
1.1.20. Diseases caused by antimony or its compounds.
1.1.21. Diseases caused by hexane.
1.1.22. Diseases caused by mineral acids.
1.1.23. Diseases caused by pharmaceutical agents.
1.1.24. Diseases caused by nickel or its compounds.
1.1.25. Diseases caused by thallium or its compounds.
1.1.26. Diseases caused by osmium or its compounds.
1.1.27. Diseases caused by selenium or its compounds.
1.1.28. Diseases caused by copper or its compounds.
1.1.29. Diseases caused by platinum or its compounds.
1.1.30. Diseases caused by tin or its compounds.
1.1.31. Diseases caused by zinc or its compounds.
1.1.32. Diseases caused by phosgene.
1.1.33. Diseases caused by corneal irritants like benzoquinone.
1.1.34. Diseases caused by ammonia.

1.1.35. Diseases caused by isocyanates.
1.1.36. Diseases caused by pesticides.
1.1.37. Diseases caused by Sulphuroxides.
1.1.38. Diseases caused by organic solvents.
1.1.39. Diseases caused by latex or latex-containing products.
1.1.40. Diseases caused by chlorine.
1.1.41. Diseases caused by other chemical agents at work not mentioned in the preceding items
where a direct link is established scientifically or determined by methods appropriate to national
conditions and practice, between the exposure to these chemical agents arising from work
activities and the disease(s) contracted by the worker. In the application of this list, the degree
and type of exposure and the work or occupation involving a particular risk of exposureshould betaken into account when appropriate.
1.2. Diseases caused by physical agents

1.2.1. Hearing impairment caused by noise.
1.2.2. Diseases caused by vibration (disorders of muscles, tendons, bones, joints, peripheral
blood vessels or peripheral nerves).

1.2.3. Diseases caused by compressed or decompressed air.
1.2.4. Diseases caused by ionizing radiations.
1.2.5. Diseases caused by optical (ultraviolet, visible light, infrared) radiations including
laser.

1.2.6. Diseases are caused by exposure to extreme temperatures.
1.2.7. Diseases caused by other physical agents at work not mentioned in the preceding items
where a direct link is established scientifically or determined by methods appropriate to national
conditions and practice, between the exposure to these physical agents arising from work
activities and the disease(s) contracted by the worker.
1.3. Biological agents and infectious or parasitic diseases

1.3.1. Brucellosis.
1.3.2. Hepatitis viruses.
1.3.3. Human immune deficiency virus (HIV).
1.3.4. Tetanus.
1.3.5. Tuberculosis.
1.3.6. Toxic or inflammatory syndromes associated with bacterial or fungal contaminants.

1.3.7. Anthrax.
1.3.8. Leptospirosis.
1.3.9. Diseases caused by other biological agents at work not mentioned in the preceding items
where a direct link is established scientifically or determined by methods appropriate to national
conditions and practice, between the exposure to these biological agents arising from work
activities and the disease(s) contracted by the worker.
2. Occupational diseases by target organ systems
2.1. Respiratory diseases

2.1.1. Pneumoconioses caused by fibrogenic mineral dust (silicosis, anthraco-silicosis,
asbestosis).

2.1.2. Silicotuberculosis.
2.1.3. Pneumoconioses caused by non-fibrogenic mineral dust.
2.1.4. Siderosis.
2.1.5. Bronchopulmonary diseases caused by hard-metal dust.
2.1.6. Bronchopulmonary diseases caused by the dust of cotton (byssinosis), flax, hemp, sisal
or sugar cane (bagassosis).

2.1.7. Asthma caused by recognized sensitizing agents or irritants inherent to the work process
2.1.8. Extrinsic allergic alveolitis caused by the inhalation of organic dust or microbiallycontaminated aerosols, arising from work activities.

2.1.9. Chronic obstructive pulmonary diseases caused by inhalation of coal dust, dust fromstone quarries, wood dust, dust from cereals and agricultural work, dust in animal stables, dust
from textiles, and paper dust, arising from work activities.

2.1.10. Diseases of the lung caused by aluminum.
2.1.11. Upper airways disorders caused by recognized sensitizing agents or irritants inherent
to the work process.

2.1.12. Other respiratory diseases not mentioned in the preceding items where a direct link is
37 established scientifically or determined by methods appropriate to national conditions andpractice, between the exposure to risk factors arising from work activities and the disease(s)contracted by the worker.
2.2. Skin diseases

2.2.1. Allergic contact dermatoses and contact urticaria caused by other recognized allergy
provoking agents arising from work activities not included in other items.

2.2.2. Irritant contact dermatoses caused by other recognized irritant agents arising from work
activities not included in other items.

2.2.3. Vitiligo caused by other recognized agents arising from work activities not included inother items.

2.2.4. Other skin diseases caused by physical, chemical or biological agents at work notincluded under other items where a direct link is established scientifically or determined bymethods appropriate to national conditions and practice, between the exposure to risk factors
arising from work activities and the skin disease(s) contracted by the worker.
2.3. Musculoskeletal disorders

2.3.1. Radial styloid tenosynovitis due to repetitive movements, forceful exertions and extreme
postures of the wrist.

2.3.2. Chronic tenosynovitis of hand and wrist due to repetitive movements, forceful exertions
and extreme postures of the wrist.

2.3.3. Olecranon bursitis due to prolonged pressure of the elbow region.
2.3.4. Prepatellar bursitis due to prolonged stay in kneeling position.
2.3.5. Epicondylitis due to repetitive forceful work.
2.3.6. Meniscus lesions following extended periods of work in a kneeling or squatting position.
2.3.7. Carpal tunnel syndrome due to extended periods of repetitive forceful work, work
involving vibration, extreme postures of the wrist, or a combination of the three.

2.3.8. Other musculoskeletal disorders not mentioned in the preceding items where a direct linkis established scientifically or determined by methods appropriate to national conditions andpractice, between the exposure to risk factors arising from work activities and themusculoskeletal disorder(s) contracted by the worker.
2.4. Mental and behavioral disorders

2.4.1. Post-traumatic stress disorder
2.4.2. Other mental or behavioural disorders not mentioned in the preceding item where a direct
link is established scientifically or determined by methods appropriate to national conditions andpractice, between the exposure to risk factors arising from work activities and the mental andbehavioural disorder(s) contracted by the worker.
3. Occupational cancer
3.1. Cancer caused by the following agents

3.1.1. Asbestos
3.1.2. Benzidine and its salts
3.1.3. Bis-chloromethyl ether (BCME)
3.1.4. Chromium VI compounds

3.1.5. Coal tars, coal tar pitches or soot
3.1.6. Beta-naphthylamine
3.1.7. Vinyl chloride
3.1.8. Benzene
3.1.9. Toxic nitro- and amino-derivatives of benzene or its homologues
3.1.10. Ionizing radiations
3.1.11. Tar, pitch, bitumen, mineral oil, anthracite, or the compounds, products or residues ofthese substances

3.1.12. Coke oven emissions
3.1.13. Nickel compounds
3.1.14. Wood dust
3.1.15. Arsenic and its compounds
3.1.16. Beryllium and its compounds
3.1.17. Cadmium and its compounds
3.1.18. Erionite
3.1.19. Ethylene oxide
3.1.20. Hepatitis B virus (HBV) and hepatitis C virus (HCV) 3.1.21. Cancers caused by otheragents at work not mentioned in the preceding items where a direct link is establishedscientifically or determined by methods appropriate to national conditions and practice,between
the exposure to these agents arising from work activities and cancer(s) contracted bythe worker.
4. Other diseases
4.1. Miners’ nystagmus
4.2. Other specific diseases caused by occupations or processes not mentioned in this list wherea
direct link is established scientifically or determined by methods appropriate to national
conditions and practice, between the exposure arising from work activities and the disease(s)contracted by the worker.

3.11 Current status of Occupational diseases/injuries and deaths
The information related to occupational injuries is based on the statistics provided by the Department ofLabour and Occupational Safety. The segregated data such as clustered data on the Provincial level, sector
data segregating the enterprise such as manufacturing, construction, etc.), and sex-segregated data of theaccidents are not available in the Department of Labour and Occupational Safety. Most of the accidents
recorded in the Labour and Employment officers’ origins are from the manufacturing industries. It seems
as if occupational accidents are scarce in Nepal. This is largely due to the underreporting of the events

although reporting of any type of accident is mandatory, its implementation is perceived to be lacking. The
law prescribes mandatory notification on any fatal accidents and/or accidents causing -man-day losses. It
is perceived that the majority of these accidents are unreported. Further, the data on the construction sector
with a higher prevalence of accident rate is largely not covered. The magnitude of the problems and thenumber of accidents are much higher than the information provided by the available statistical indicators.
The under-reporting of occupational accidents is primarily attributed to the lower level of awareness of
OSH and the lack of sensitivity among management and workers in general. The causes of accidents arevaried but the common causes of accidents in Nepal are due to lack of safety policy, lack of or poor
implementation of manual and guidelines at the enterprises, the improper layout of workplace / unsafe
workplace design, unsafe handling/use of chemicals, unguarded or inadequately guarded machinery, use ofan unsafe machine (unsafe design and construction of machines), lack of adequate maintenance ofmachinery, inadequate ventilation at the workplace, unsafe electrical connection, inadequate/improper
lighting system, lack of training of the workers, lack of supervision, use of an old or outdated machine orequipment, poor housekeeping and material handling, negligent or no use of safety gears and personal
protective equipment, stretched working hour compounded with overload, lack of awareness on personal
health and hygiene, lack of inspection and violation of safety rules. The accidents are categorized as major
and minor ones. Any accident that does not make an injured person a disabled one and where the injured
person gets first aid and returns to work is called a 75-minor accident. An accident causing permanent or
prolonged disability and death of the employees is called a major accident.

3.12 Implementation of Occupational Safety and Health Standards
The government of Nepal has promulgated OSH standards in the workplace on Noise and Light during
2016 and this standard has been published in Nepal Gazette dated July 9, 2017. Besides these, theGovernment has also formulated the directives/guidelines for Brick industries in 2017. The guideline speaks
about the Occupational Health and Safety of the workers. The permissible exposure limit (PEL) of noisefor the workplace is 90dBAfor 8 hours, 95 dBA for four hours, 100 dBA for two hours, 105 dBA for one
hour, 110 dBA for 30 minutes, and 115 dBA for 15 minutes a day in the workplace. The government has
also recommended the minimum light illumination level for the workplace depending on the type of workand place. The lux (unit of illumination) should not be less than between 10 and 100. For the light, thestandard stipulates, emergency exit and emergency pathways shall have 10 lux, inactive storage 20 lux,
rough active storage, and warehouse 50 lux, machine work 100 lux, checking and sorting 300 lux, weaving
dark-coloured woollen goods 500 lux and jewellery and watch manufacturing 1000 lux. Any local light,that is to say, an artificial light designed to illuminate, particularly the area or part of the area of work of asingle operative or small group of operatives working near each other, shall be provided with a suitable
shade of opaque material to prevent glare with other effective means by which the light source is completely
screened from the eyes of every person employed at a normal working place, or shall be so placed that nosuch person is exposed to glare therefrom.

3.13 Integration of health services with occupational health services
In Nepal, occupational health is not integrated with the healthcare system of Nepal. Occupational safety
and health to date remain under the mandate of the Ministry of labour, employment and Social Security andhave no functional relationship with the structure within the Ministry of Health and Population.
The industrial history of Nepalese is rather short. To keep pace with the contemporary world, Nepal has
been turning wheels at full speed and overlooking issues of occupational health and safety. The major
obstacle to instilling the concept of OHS in Nepalese is the inability of stakeholders to grasp the utility andimportance of OHS. Occupational health and safety procedures require adequate surveillance of the work
environment and risk assessment, both of which are missing completely from most industries in Nepal.
Neither have most industries health status. Control measures for preventive and emergency preparedness
are so absent in most industries. Likewise, diagnostic procedures for occupational disease andrecordkeeping of such events are inadequate. It will therefore take some time to develop the concept of

OHS with preventive, curative and rehabilitative measures under a single umbrella of OHS among
entrepreneurs in Nepal. The barriers to OHS identified in Nepal can be generalized as follows:•
Lack of awareness concerning OHS at all levels•
Faulty legal systems and lack of periodic updates•
Inability to establish OHS as an integral component of working life•
Lack of professional expertise•
Resource constraints

3.14 Occupational disease and their diagnosis in the country
No health programs in Nepal address the prevention and control of occupational-related diseases andconditions. The major facade to installing the concept of OSH in Nepal lies in the inability of concerned
stakeholders to grasp the utility and importance of occupational health services. Major obstacles inenforcing effective OSH practices in Nepal from the nation’s perspective are the least priority of thegovernment, lack of national strategy for OSH management, legal backup mechanism and focal point atgovernment ministries. Few industries have taken prudent measures by establishing OSH setups thereby
decreasing the vulnerability of hazards.

3.15 Budget
It is important that occupational health practitioners critically evaluate their practice and, through theapplication of the iterative audit cycle, improve the quality, effectiveness, and efficiency of their service.
Audit is conventionally divided into structure (resources), process (procedures), and outcome (results). The
use of audits should not be confined to clinical matters, and the inclusion of occupational healthpractitioners from other disciplines—for example, occupational hygiene or safety, will contribute to better
services for all. For a service to report on its activities in a meaningful way, there needs to be in place abasic dataset that allows comparison between periods, different employee groups, or operational divisions.
Data that may be appropriate include new appointments, review appointments, health surveillance activity,
immunisations, referral reason, type of clinician (doctor or nurse), and diagnosis. This information isinvaluable for presentation to management to show changes in activity or areas for which increased fundingis needed when making a business case. It will also be useful when discussing issues from the perspectiveof occupational health in organizational meetings such as health and safety meetings, risk management, andwhen compiling an annual report or business plan. These data are ideally compiled in a computerized
database, either bespoke or a commercially available occupational health software package.
The main enforcement body at the local levels and the specified areas are the Labour and Employment
offices. The major activities carried out by these offices are monitoring the labour relations occupationalsafety and other health aspects in the establishment and enterprises as specified under the legislation. The
Labour and Employment Offices at the local levels are headed either by the Labour Officer or the Factoryinspector. The other staff members to support the activities of these offices are the non-gazette officers andthe assistants.

4. Social protection and health assessment of Nepalese labour migrants
Nepal's National Health Policy 2019 seeks to minimize public health risks due to migration, particularly byensuring accessibility of health services for Nepalese migrants abroad. (16) Health assessment of Nepalese
Labour Migrants (NLMs) is a mandatory procedure before departure, which is done through government-

approved pre-departure private medical assessment centres. The health records from these assessment
centres are first recorded in paper-based form and then entered into an online electronic form to be storedby the DoFE. The filled-up paper forms are sent to District Health Offices, which further report the data to
the Department of Health Services (DoHS), Ministry of Health and Population (MoHP) and associatedgovernmental infectious diseases centres. However, there is no formal health assessment of NLMs upon
arrival to Nepal. (17)In 2021/22, 1395 Nepali migrant workers (including 39 women) were reported to have died, with mostdeaths certified as having occurred due to ‘natural causes’ in and by Country of Department (CoDs). Morethan 150 cases of deaths of Nepali migrant workers have each been reported annually in Malaysia, Saudi
Arabia, Qatar and the UAE in 2019/20–2021/22. In addition, a significant number of Nepali migrant
workers return home with mild to severe injuries and illnesses. The health risks migrant workers face arelinked to their exposure to occupational safety and health hazards, poor working and living conditions, lackof access to social protection, including medical/health services, language and cultural barriers, and forced
overtime labour, among others. The FEB disbursed a total of NPR 769.95 million (USD 5.9 million) as
financial assistance to 1395 families of deceased migrant workers in 2020/21 through the Foreign
Employment Welfare Fund (FEWF). Nepali migrant workers have been subjected to an exploitative
recruitment process, employment contract fraud and abuse by employers. Women migrant workers areespecially vulnerable to violence and face risks of abusive treatment in many countries of destination. Morethan 1300 new cases related to such fraud, abuse and exploitation were filed at the FET between 2019/20
and 2021/22. MoLESS has adopted and implemented a range of policies and legal instruments to addressthese issues. These include a ban on the use of agents, conferring rights to the Chief District Officer (CDO)
to investigate and punish individual agents involved in fraud and cheating, and an ‘employer pays’ model
for recruitment. The government has also prioritized the reintegration of migrant workers through skill
development and certification, and also programmes dealing with financial literacy, vocational training,
recognition of prior learning, psychological support, and shelter. Through the Reintegration Programme(Operation and Management) Directive for Returnee Migrant Workers, 2022, the government has stressed
three diverse yet inter-related dimensions of the reintegration efforts: social integration, employment, andentrepreneurial development.
Health and safety of migrant workers: MoLESS recognizes the need to carry out regular and effective
inspection of the workplace and living conditions of migrant workers. In line with this report’s findings thata large number of Nepali migrant workers are employed in unsafe employment practices, MoLESS notes
the need to organise occupational safety and health training for migrant workers prior to and after theirarrival in the Country of Departsment (CoD)s in coordination with Nepali diplomatic missions. MoLESS
also realises the importance of informed migration, sensitization, greater awareness, and the need for
implementing country-specific PDOT curriculums as well as post-arrival orientation. MoLESS willcontinue engaging with CoDs to ensure that employers implement standard occupational safety and healthprotocols at the workplace.

4.1 Social protection
It has been recognized that the establishment of a bilateral social security mechanism could enhance theprotection of migrant workers. MoLESS will continue to explore ways by engaging with employers’ andworkers’ organisations on how this can be designed and implemented in a way that is gender responsive
and also sensitive to the condition of workers in the informal sector. Priority will be given to the inclusionof migrant workers in the social security scheme in Nepal, namely the Social Security Fund (SSF). The
study conducted by the International Labour Organization found an average death rate of 0.16% (4322
deaths out of a total of 2,723,587 labour permits) in the 7 years from 2008/09 to 2014/15.[14] The major
causes of death, as reported, were cardiac arrest (941 cases or 21.8%), natural causes (847 cases or 19.6%),
and other or unidentified causes (795 cases or 18.4%). Suicide was the major cause of death among female
NLMs (33% of all female migrant worker deaths). Almost 97% of these deaths occurred in GCC countriesand Malaysia with the highest being in Malaysia followed by Saudi Arabia, Qatar, and United ArabEmirates

4.2 Health assessment of labour migrants
The government of Nepal has made legal arrangements in case of migrant worker's health check-ups. (18)A Nepalese migrant worker has to obtain a certificate of fitness from a government-approved medical centre
in Nepal with a government-approved HOLOGRAM issued by NHPF affixed on the Report Card. A
Migrant Worker who has got a medical checkup done from a government-approved medical centre and has
a hologram affixed medical report, if departed due to medical reasons within 2 months from a medical test,
is liable for compensation. Medical Center or Health Institute is not liable to pay compensation to a migrant
worker returning due to sexually transmitted diseases, HIV/AIDS. gonorrhoea, syphilis, hepatitis B or C,
Jaundice, High BP, or Contagious Diseases. There are numerous health institutions in Nepal. However, allof them are not authorized to conduct medical tests for foreign employment purposes. Migrant workers
must make sure that the medical centre is listed by the Government of Nepal to conduct medical checkups
for foreign employment. The list of investigations suggested for foreign manpower employment isrecognized by the Ministry of Health and Population, Nepal. (19)Table 4:

List of investigations suggested for foreign labour migrants

S.N.

TEST

RATE

1

X-RAy

300

2

HB

55

3

TC

60

4

DC

60

5

ESR

65

6

Urine

60

7

Stool

70

8

Sugar

60

9

Urea

110

10

Creatinine

125

11

MP

90

12

MF

95

13

Blood Grouping

80

14

LFT(Billrubin Total/Direct, SOPT and SGOT)

460

15

Syringe (5 ml)

516

Syringe (Vaccumator)

25

17

HIV

420

18

HBSAG

350

19

Anti HCV540

20

VDRL/RPR

130

21

IPHA

385

22

Physical Consultation

As per GoN Standard

23

Pregnancy Test

160

24

Platelet Count75

25

Gama GT450

26

Lipid Profile

600

27

Total Protein

120

28

PFT

300

29

Mantoux test

120

30

Cannabis

350

31

Opaite

350

32

ECGs

205

33

USG

600

34

Audiogram

300

35

MMR Vaccine

500

36

EEG

1100

37

Alkaline Phosphate

190

Source: https://nepalhpf.org.np/

The below listed medical centers have been approved by the Ministry of Health and Population of theGovernment of Nepal to Provide medical checkup services to Nepalese people going abroad on foreign
employment. Thus, they are authorized to conduct medical tests.

Table 5:
SN

Regd.
No.

List of government approved health institutions for health screening to labour
migrants
Name of the Health Institution

Address1

1

Dhorpatan Polyclinic Pvt. Ltd.

Gongabu - 4, Kathmandu

22Singapurgorkha Polyclinic pvt. Ltd.

koteshwor 35, Kathmandu

33Helping Health Medical Centre Pvt. Ltd.

Gongabu - 5, Naya Bus Park,
Kathmandu

44Abida International Medical Center

Itahari-1, Sunsari

55

N.M.C. Diagnostic Medical Center

Linkroad, Birjung,Parsantaj miya

6

6

Helping Health Diagnostic Centre

Basundhara - 3, Kathmandu

7

7

Bishwas Medical And Polyclinic pvt.Ltd.

Tribhuwanpark-10 ,Ghorahi, Dang

89

Munal Diagnostic Center Pvt.Ltd

Itahari-1, Sunsari

910Chhabdi Barahi Tanahu Polyclinic

Gongabu-4, Kathmandu

10

11

Prime Health Care Centre Pvt. Ltd.

Chabahil - 7, Kathmandu

11

13

Janamaitri Hospital Pvt. Ltd.

Balaju Chowk, Kathmandu

12

14

Prudential Medical Center Pvt.Ltd

Baneshwor

13

16

Rakshya polyclinic And Diagnostic center pvt.Ltd.

Gongabu, Nayabaspark, Kathmandu

14

17

Anugraha Polyclinic Pvt. Ltd.

Nayabaspark-29 , Kathmandu

15

18

Family Health Care International & Research Centre
Pvt. Ltd.

Dhumbarahi Chowk, Kathmandu

16

19

Alisa Polyclinic Pvt. Ltd.

Sitamangal Kalimati tol, Kathmandu

17

20

Khajana Medical & Polyclinic Centre Pvt. Ltd.

K.M.C. - 9, Pingalasthan, Kathmandu

18

21

Alkhaleej Medical Center Pvt. Ltd.

Kathmandu - 7, Chucheepati

19

22

Sulav Health Polyclinic And Pathology Pvt. Ltd.

Maitidevi-32,
Kathmandu

20

23

Medidia Diagnostic Center Pvt Ltd

Bansbari. Kathmandu

21

24

Ma Janaki International Polyclinic & Diagnostic
Center Pvt.Ltd

Old Baneshwor, Kathmandu

22

25

Fishtail Imaging & Diagnostic Centre Pvt. Ltd.

Ghairapatan - 4, Pokhara

sastrimargh,

23

26

LifeCare Prince Diagnostic Center Pvt Ltd

Tripureshwor, Kathmandu

24

27

Kantipur Diagnostic Centre Pvt. Ltd.

Kantipath, Jyatha, Kathmadu

25

28

Jaljala Polyclinic And Diagnostic Center Pvt. Ltd.

Nayabaspark-4, Kathmandu

26

29

Sumeru Diagnostic Centre Pvt. Ltd.

Pulchowk - 3, Lalitpur

27

30

Sikhar Medical And Diagnostic Center Pvt.Ltd.

Gongabu, Nayabapark, Kathmandu

28

31

Anurag Polyclinic And Medical Center Pvt.Ltd

Gaushala , Kathmandu

29

32

Samajkalyan Polyclinic And Diagnostic Center
Pvt.Ltd.

Gongabu-3, Kathmandu

30

33

Sai Kripa Polyclinic And Medical Center Pvt.Ltd

Gongabu-5, Kathmandu

31

34

Srijanshi Polyclinic Pvt.Ltd.

Gothatar-8, Kathmandu

32

35

Madina Medical Center Pvt Ltd.

Kalimati Tole-9, Kathmandu

33

36

Saiba Medical Center Pvt Ltd.

Jwagel-10, Lalitpur

34

37

Saudi Medical Centre Pvt. Ltd.

Kupondole, Lalitpur

35

39

Health Care Clinic

Tripureshwor, Kathmandu

3640Life Trust Medi Diagnostic Pvt. Ltd.

Anandanagar
Kathmandu

37

41

Siddhi Polyclinic Health Services Pvt Ltd.

Dillibazar, Kathmandu

38

47

Helping Health Polyclinic Pvt. Ltd.

Maitidevi, Kathmandu

39

48

Pooja Diagnostic Center Pvt.Ltd

Birtamod, Jhapa

40

49

Pradhan Diagnostic Center Pvt.Ltd

Birtamod, Jhapa

41

52

Nishant Medical Diagnostic Center Pvt.Ltd.

Damak-11, Jhapa

42

53

Aarambha medical And Diagnostic Center Pvt.Ltd.

Itahari-1, Sunsari

43

54

Kankai Diagnostic Center Pvt.Ltd.

Anarmani-3, Jhapa

44

55

Sudha Medical & Diagnostic Centre Pvt. Ltd.

Sinamangal, Kathmandu

45

56

Buddha Diagnostic And Medical Services Pvt.Ltd.

Damak-11, Jhapa

46

57

L & R Polyclinic & Diagnostic Center Pvt Ltd

Tilganga, Kathmandu

47

57

Omkar Polyclinic, Medical
Therapeutic Center Pvt.Ltd.

48

58

Samrat Polyclinic And Medical Center Pvt.Ltd.

Diagnostic

And

Marg,

Dhubarahi ,Bagdol-4, Lalitpur

Chhabahil-7, Kathmandu

49

59

Diamond Polyclinic And Diagnostic Center

Samakhusi-29, Kathmandu

50

60

Birtamod Diagnostic Center Pvt.Ltd.

Anarmani-2, Jhapa

51

61

Eon Medical Center Pvt.Ltd.

Lazimpat-2 , Kathmandu

52

62

Ekata Medical Centre Pvt. Ltd.

Anamnagar 32, Kathmandu

53

63

Al Masur Diagnostic Center Pvt Ltd

New Baneshwor, Kathmandu

54

64

Aqua Diagnostic Services Pvt Ltd.

Pinglasthan-9, Kathmandu

55

65

Rajam Medical Centre Pvt. Ltd.

Kathmandu 7, Chabahil, Kathmandu

56

66

Sudha Polyclinic Pvt Ltd

Koteshwor-35, Kathmandu

57

67

South Asian Health Care Centre Pvt. Ltd.

Gaushala - 9, Kathmandu

58

68

Dynasty Medical Centre Pvt. Ltd.

Gaushala, Pingalasthan, Kathmandu

59

69

Green City Hospital Pvt Ltd

Dhapasi-8, Kathmandu

60

72

Chhimeki Polyclinic Pvt.Ltd.

Santinagar, Kathmandu

61

73

Himal International Medical Center Pvt Ltd.

Shantinagar Gate, Kathmandu

62

74

Trishuli Medical & Clinic Pvt. Ltd.

Sinamangal - 9, Kathmandu

63

75

Namaste Nepal Medical Center & Polyclinic Pvt Ltd

Gongabu, Kathmandu

64

76

Kasthamandap Health Care Pvt. Ltd.

Battisputali, Kathmandu

65

77

Kaniska Health Care Centre Pvt. Ltd.

Tinkune, Kathmandu

66

78

Frendship Health care center Pvt.Ltd.

Maharajgunj , Kathmandu

67

79

Remind Polyclinic Diagnostic Center Pvt.Ltd.

ka.ma.na.pa.-9, Kathmandu

6880

Buddha International Medical Center Pvt Ltd

New Baneshwor Kathmandu

69

84

Kantipur Medicla Center

Itahari-1, Sunsari

70

85

Saksham Medical Centre Pvt. Ltd.

Gongabu - 29, Kathmandu

71

85

Sahara Health Care Pvt Ltd

New Baneshwor, Kathmandu

72

86

Panasiya Medical Center Pvt.Ltd

Newbaneshwor,
Kathmandu

73

87

World Wide Medical Center Pvt Ltd

Battisputali-9, Kathmandu

74

87

Moulakali Polyclinic Diagnostic Center Pvt.Ltd.

Samakhusi-9, Kathmandu

75

88

Peace Medical Center Pvt Ltd

Bashundhara-3, Kathmandu

Santinagar,

76

88

Kohalpur Health Care Pvt.Ltd.

Kohalpur-3 , Banke

77

89

Upatyaka Pathology & Clinic Pvt. Ltd.

Pulchowk - 3, Lalitpur

78

90Apple International Polyclinic Pvt. Ltd.

Tripureshwor, Kathmandu

79

91

Nepal Janata Diagnostic And Polyclinic pvt.Ltd.

Koteshwor-35, Kathmandu

80

92

Sunshine Medical Centre Pvt. Ltd.

Naya Baneshwor, Kathmandu

81

92

Sunapati Polyclinic & Health Center Pvt Ltd

Gwarko, Lalitpur

82

92

Cosmos Medical Center Pvt Ltd

Gaushala, Kathmandu

83

93

Sunshine Health care Center Pvt.Ltd

Prithivi chowk, Pokhara

84

94

Lalupate Medical Center Pvt Ltd.

Pinglasthan-9, Kathmandu

85

95

Shree Janasewa Polyclinic And Medical Center
Pvt.Ltd

Koteshwor-35, Kathmandu

86

96

Himalay Diagnostic Clinic

Koteshwor-35, Kathmandu

87

97

Merapick Medical Center Pvt.Ltd.

Mitrapark, Chabahil, Kathmandu

88

98

Glory Medical Centre Pvt. Ltd.

Basundhara - 3, Kathmandu

89

99

Ghumanu LIfecare Medical And Diagnostic Center
Pvt.Ltd

Damak-11, Jhapa

90

100

Royal Medical Center Pvt.Ltd.

Bhagawanbahal, Thamel, Kathmandu

91

101

Titan Health Care Centre Pvt. Ltd.

Basundhara - 3, Kathmandu

92

102

Sudha Medical Center Pvt.Ltd.

Butwal-8, Rupandehi

93

103

Everest International Polyclinic Diagnostic center
Pvt.Ltd

Nepalgunj-13 , Banke

94

104

Alka Hospital Pvt.Ltd.

Jawalakhel, Lalitpur

95

105

Madhyapaschim Polyclinic Pvt. Ltd.

Nepalgunj - 13, Banke

96

106

Subba Pathology And Clinic Pvt.Ltd.

Kupandol, Lalitpur

97

107

Sunsari Diagnostic Center Pvt.Ltd.

Itahari-1 , Sunsari

98

108

All Nepal Hospital Pvt Ltd

Samakhusi-29, Ranibari Marg

99

109

P.K. Diagnostic Center Pvt.Ltd.

Sinamangal-9, Kathmandu

100

110

Community Health Care Cooperative Ltd.

Itahari - 1, Sunsari

101

111

Budha Subba Medical Centre Pvt. Ltd.

Damak 11, Jhapa

102

112

Dikshya Swastya Sewa Kendra Pvt.Ltd.

Janakpur-8, Dhanusha

103

113

Nepolian Health Care Center Pvt.Ltd.

Balaju-16, Kathmandu

104

114

U.V. Swasthya clinic Pvt.Ltd.

Basundhara-3, Kathmandu

105

115

Asian Polyclinic Diagnostic Center Pvt.Ltd

Bagbajar, Kathmandu

106

116

Asian Plus Medical Center Pvt.Ltd.

Gongabu-5, Kathmandu

107

117

Siddhartha Polyclinic Pvt.Ltd.

Bagbajar, Kathmandu

108

118

Nepal Siddharth Sadan Polyclinic Pvt.Ltd

Gongabu-4, Kathmandu

109

121

Nippon Polyclinic And Diagnostic Center Pvt.Ltd.

SherchanKathmandu

110

122

Medicare National Polyclinic Pvt.Ltd.

Bashundhara-3 , Kathmandu

111

123

Kuleshwor Polyclinic Pvt. Ltd.

Kuleshwor - 14, Kathmandu

112

124

Paradise International Medical Centre Pvt. Ltd.

Kupondole - 10, Lalitpur

113

125

Everest Health Home Services Pvt Ltd

Mid Baneshwor, Kathmandu

114

126

Satyasai Diagnostic Center Pvt.Ltd.

Gouridhara, Tukucha, Kathmandu

115

127

Siddhakali Medical And Polyclinic Center Pvt. Ltd.

Gongabu-4, Kathmandu

116

128

Asia Pacific Polyclinic Pvt.Ltd

ka.ma.pa.-11,Thapathali, Kathmandu

117

129

Kist Polyclinic And Medical Center Pvt.Ltd.

Balkumari,Kharibot-8, Lalitpur

118

130

Golfspring Medical Center Pvt.Ltd

Basundhara-3, Kathmandu

119

131

Well Care Hospital & Research Centre Pvt. Ltd.

Maitidevi, Ratopool, Kathmandu

120

132

Universal Diagnostic Center Pvt.Ltd.

Putalisadak-32, Kathmandu

121

134

Goldengate Polyclinic And diabetes Center Pvt.Ltd

Nakkhuchowk-13, Lalitpur

122

135

Siddharth Pathology

Pokhara, Kaski

123

136

Purnima Medical Centre Pvt. Ltd.

Lalitpur - 10, Jwagal

124

137

Purnima Plus Medical Center Pvt.Ltd.

Gongabu-29, Kathmandu

125

138

Purnachandra Diagnostic Center Pvt.Ltd

Gausala, Kathmandu

126

140

Baba Medical Center Pvt.Ltd.

Chappal karkhana-4, Kathmandu

127

141

Aruna Medical Center Pvt.Ltd

Samakhusi-29, Kathmandu

128

142

Pooja Medical Diagnostic Center Pvt.Ltd

Batisputali-9, Kathmandu

Plaza,

Balaju-16,

129

143

Fusion Swasthya Polyclinic Pvt.Ltd

Maharajgunj, Kathmandu

130

145

United Diagnostic Center Pvt.Ltd

Sinamangal-9, Kathmandu

131

146

Maata mahalaxmi Medicare Pvt.Ltd.

Batisputali-9, Kathmandu

132

147

Sinamangal Healthcare And Diagnostic Center
Pvt.Ltd.

Sinamangal-9, Kathmandu

133

149

Sagarmatha Polyclinic And Diagnostic Center
Pvt.Ltd.

Kalimati chowk-13, Kathmandu

134

150

Aashirbad Swasthya sewa clinic

Balkhu-14, Kathmandu

135

152

South Asian Polyclinic And Diagnostic Center
Pvt.Ltd.

Goushala-9, Kathmandu

136

153

Praptee Polyclinc Pvt.Ltd

Tripureshwor, Kathmandu

137

154

Bhanu Memorial Polyclinic And Diagnostic Center
Pvt.Ltd.

Gongabu Chowk-4, Kathmandu

138

155

Bright Polyclinic & Diagnostic Centre Pvt. Ltd.

Samakhusi - 29, Kathmandu

139

156

Bindhyabasini Medical And Research Center Pvt.
Ltd.

Tinkune, Kathmandu

140

157

Lumbini Diagnostic And Research Center Pvt.Ltd

Butwal

141

158

B.B. Health Care Center Pvt.Ltd

Balaju-16 , Kathmandu

142

159

Aishwarya Polyclinic And Diagnostic Center Pvt.Ltd

Balaju-16, Kathmandu

143

160

Janaki International Medical Center Pvt.Ltd.

Nayabuspark, Kathmandu

144

162

Shailung Polyclinic And Diagnostic Center Pvt.Ltd.

Itahari-1, Sunsari

145

163

Saibaba polyclinic And Medical Center Pvt.Ltd.

Gongabu-29, Kathmandu

146

164

Safal Medical Center Pvt.Ltd.

Sinamangal-9, Kathmandu

147

166

Tribeni Devi Polyclinic And Health Care Center
Pvt.Ltd

Samakhusi-29, Kathmandu

148

167

Sewa Polyclinic Pvt.Ltd.

Basundhara-3 , Kathmandu

149

168

Trimurti Medical Center Pvt Ltd

Dhapasi-8,Bashundhara, Kathmandu

150

169

Namuna Medical Center Pvt.Ltd

Oldbaneshwor, Kathmandu

151

170

Sunrise Polyclinic & Diagnostic Center Pvt Ltd

Maharajung, Kathmandu

152

171

Asian Raze Medical Centre Pvt. Ltd.

Chappal Karkhana - 4, Kathmandu

153

173

M.V. Polyclinic And Diagnostic Center

Sinamangal-9, Kathmandu

154

174

Perfect Diagnostic Center Pvt.Ltd.

Battisputali-9, Kathmandu

155

175

Frontline Polyclinic Centre Pvt. Ltd.

Himshikhar Marga - 34, Kathmandu

156

176

H.R. Diagnostic Center Pvt.Ltd.

Battisputali-9, Kathmandu

157

177

Life Medical Center

Kalimatidol-9, Kathmandu

158

178

Syrup Health Care Center Pvt Ltd

Dhapasi-8, Kathmandu

159

179

Syrup Medical Center Pvt.Ltd.

Gongabu-29, Kathmandu

160

181

Nagarjun Health Care Center Pvt.Ltd

Balaju-16, Kathmandu

161

182

Ombuddha Medical Center Pvt.Ltd

Sankhamul-10, Kathmandu

162

183

Fusion Polyclinic & Diagnostic Centre Pvt. Ltd.

Shankhamul Road, Naya Baneshwor,
Kahtmandu

163

184

Suryodaya Medical Center Pvt.Ltd.

Kuleshwor-14, Kathmandu

164

185

Santipur Polyclinic Pvt.Ltd.

Thulobharyang, Kathmandu

165

186

Shikhar Public Polyclinic Center Pvt Ltd

Gongabu - 29, Kathmandu

166

187

City Top Polyclinic & Medical Center Pvt Ltd

Sinamangal-9, Kathmandu

167

188

Relief Health Care Pvt.Ltd.

Lazimpat-2, Kathmandu

168

189

N.S. Medical Center Pvt.Ltd.

Gongabu-4, Kathmandu

169

190

Valley Polyclinic International Health Center Pvt Ltd

Samakhusi-29, Kathmandu

170

191

International Health care And Diagnostic Center
pvt.Ltd.

Newbaneshwor, Kathmandu

171

193

Sudha Health Care Pvt. Ltd.

Maharajgunj, Kathmandu

172

194

Texas Polyclinic & Diagnostic Centre Pvt. Ltd.

Bimansthal - 9, Kathmandu

173

195

Social Medical Health Care Center Pvt.Ltd

Gongabu chowk, Kathmandu

174

196

Markopolo Medical Center Pvt.Ltd

Samakhusi-29 , Kathmandu

175

197

AQuality Health Care & Diagnostic Centre Pvt. Ltd.

Sinamangal - 9, Kathmandu

176

198

Trust Medical Centre Pvt. Ltd.

Dhumbarahi, Kathmandu

177

199

K. R. Medical Centre Pvt. Ltd.

Samakhusi - 29, Kathmandu

178

200

Alfresco Polyclinic Pvt.Ltd.

Balaju-16, Kathmandu

179

201

Shavya Medical Center Pvt.Ltd

Maharajgunj Kathmanu

180

202

A Clinic For Health Nepal Pvt. Ltd.

Narayan Gopal Chowk, Kathmandu

181

205

Paradise Polyclinic & Diagnostic Centre Pvt. Ltd.

Basundhara - 3, Kathmandu

182

206

Unicorn Polyclinic Pvt.Ltd.

Pingalasthan, Kathmandu

183

207

Gurudev Diagnostic & Polyclinic Centre Pvt. Ltd.

Balaju - 16, Kathmandu

184

208

Samrat Medical Hall Pvt.Ltd.

Kalimatidol-9, Kathmandu

185

209

Sarbottam Polyclinic Pvt. Ltd.

Basundhara - 9, Kathmandu

186

210

Sungava Polyclinic Pvt.Ltd.

Newbaneshwor,
Kathmandu

187

211

Revive Polyclinic Pvt.Ltd

Pingalasthan, Kathmandu

188

213

Chetana Swastaha Sewa Kendra Pvt. Ltd.

Minbhawan, Shantinagar, Kathmandu

189

214

Nawadurga Polyclinic Pvt.Ltd.

Anamnagar, Kathmandu

190

215

Top Need Medical Centre Pvt. Ltd.

Gongabu - 04, Samakhusi, Ring Road

191

216

Oscar Medical Center Pvt.Ltd.

Dhapasi-9,
Kathamandu

192

217

Pathivare Medical Center Pvt.Ltd.

Hanumansthan -11, Itahari

193

218

Royal Nepal Polyclinc And Diagnostic Center
Pvt.Ltd.

Gongabu-29, Kathmandu

194

219

Medicine Buddha Polyclinic Pvt.Ltd.

Gongabu-4, Newbuspark, Kathmandu

195

220

Tribeni Medical Center Pvt.Ltd

gaushala, Pingalastan, Kathmandu

196

221

Sampripti Medical Center Pvt.Ltd.

Mitranagar, Newbuspark, Kathmandu

197

222

Maa Laxmi Polyclinic Pvt.Ltd.

Saamakhusi -29, Kathmandu

198

223

Super Healthcare And Diagnostic Center

Gongabu, New buspark, Kathmandu

199

224

Lotus Polyclinic And Diagnostic Center Pvt.Ltd

Gongabu, Newbuspark, Kathmandu

200

225

Super Diagnostic Center Pvt.Ltd.

Saamakhusi-29, Kathmandu

201

226

OM Siddhi Polyclinic And Medical Center pvt.Ltd.

Sundhara-11, Kathmandu

202

227

Bright Medical Center Pvt.Ltd.

Gongabu, Kathmandu

203

228

Nepal Janaswathya Kendra Pvt.Ltd

Balaju-16, Kathmandu

204

229

Dhaulagiri Health Care Center Pvt.Ltd

Newbuspark, Kathmandu

Ekata

marga,

Bashundhara,

205

230

Namo Buddha Medical Centre Pvt. Ltd.

Gaushala, Kathmandu

206

231

Akbar Medical Center Pvt.Ltd.

Tilganga, Kathamndu

207

232

Healthy Life International Medical Center

Anamnagar , Kathmandu

208

233

Nozomy Polyclinic Pvt.Ltd.

Sinamangal-9 , Kathmandu

209

234

Janata Medical Center Pvt.Ltd.

Tinkune, Kathmandu

210

235

Megha Medical Center Pvt.Ltd.

Saamakhusi-29, Kathmandu

211

236

Sai Polyclinic And Diagnostic Center

Sankhamul-10, Newbuspark

212

237

Swarnim Polyclinic Pvt.Ltd.

Sundhara-3, Kathmandu

213

238

Capital Medical Center Pvt.Ltd.

Kathmandu-29, Mitranagar

214

240

Space Medical Center Pvt.Ltd.

Chabil-7, Kathmandu

215

241

Public Health Polyclinic & Diagnostic Centre Pvt.
Ltd.

Samakhusi - 29, Kathmandu

216

242

Shan Health Care & Polyclinic Pvt. Ltd.

Battisputali - 29, Kathmandu

217

243

Reliable Polyclinic And Pyathology Lab Pvt.Ltd.

Kupandol, Laliypur

218

244

Nita Polyclinic And Diagnostic Center Pvt.Ltd.

Maharajgunj-3, Kathmandu

219

245

Reliance Medicare And Research Center Pvt.Ltd

Gaushala, Ratopul, Kathmandu

220

250

Subba Medical Center Pvt.Ltd

Bashundhara-3, Kathmandu

221

251

Prashanti Health Care Center Pvt.Ltd.

Jawalakhel-3, Pulchowk,Lalitpur

222

252

New World View Medical Centre

Basundhara - 3, Kahtmandu

223

254

Clink Medical Centre Pvt. Ltd.

Kalimati Dol, Kathmandu

224

255

Reliance Health Care Center Pvt.Ltd.

Dhapasi-9, Kathmandu

225

256

Amitav Buddha Medical Centre

Narayan Gopal Chowk, Kathmandu

226

256

Universal Medical health Care Center Pvt.Ltd

Mitranagar, Gongabu, Kathmandu

227

259

Srijana Medical Centre & Polyclinic Pvt. Ltd.

Chabahil - 7, Kathmandu

228

260

Om Medical Diagnostic Centre Pvt. Ltd.

Birtamode - 1, Jhapa

229

261

Seasons Polyclinic Pvt.Ltd.

Gongabu-5, Kathmandu

230

262

Merit Multicare Medical Center

Madhyamarga,
Kathmandu

Santinagar,

231

263

Riza Polyclinic And Diagnostic Center Pvt.Ltd.

Chabahil-7, Kathmandu

232

264

Jalbinayak Polyclinic And Medical Center

Gongabu-4, Newbuspark, Kathmandu

233

265

Meridian Health Care Pvt. Ltd.

Maharajgunj, Kathmandu

234

267

Manjushree Medical Center Pvt.Ltd.

Gouridhara, Tukucha, Kathmandu

235

268

Kshemadevi Polyclinic Pvt Ltd

Baneshwor

236

269

Asian Medical Diagnostic Center Pvt.Ltd.

Samakhusi-29, Kathmandu

237

270

Dhorpatan Medical Centre Pvt. Ltd.

Samakhusi - 29, Kathmandu

238

271

D.N.A. Polyclinic And Medical Center Pvt.Ltd

Gongabu, Kathmandu

239

273

Curex Diagnostic Center Pvt.Ltd

Basundhara-3, Kathmandu

240

274

International Polyclinic And Diagnostic Center
Pvt.Ltd.

Birtamod, Jhapa

241

275

Kohinoor Medical Center Pvt.Ltd.

Narayangopal chowk, Kathmandu

242

276

J.M. Medical Center Pvt.Ltd.

Tripureshwor, Kathmandu

243

277

Dynamic Medical Center And Polyclinic Pvt.Ltd

Sukedhara-4, Tamuplaza, Kathmandu

244

278

Kankai Hospital Pvt.Ltd

Birtamod, Jhapa

245

279

Janakpur International Polyclinic And Diagnostic
Center Pvt.Ltd.

Janakpur-7, Dhanusha

246

280

D. And P. Polyclinic And Diagnostic Center Pvt.Ltd

Balaju-16, Kathmandu

247

281

Bharatpur Diagnostic Center Pvt.Ltd

Bharatpur-10, Chitawan

248

282

Biratnagar Hospital Pvt. Ltd.

Biratnagar

249

283

Om Polyclinic & Medical Centre Pvt. Ltd.

Itahari - 1, Sunsari

250

284

Sagarmatha Clinic And Medical Center

Samakhusi-29, Kathmandu

251

286

Subarna Medical & Research Pvt. Ltd.

Ghorahi Municipality, Dang

252

289

Manmohan Memorial
Samudayik Hospital

253

290

Nepal Diagnostic Center Pvt.Ltd.

Sundhara-11, Kathmandu

254

291

Samanantar Polyclinic Medical Center Pvt Ltd.

Bashundhara-3, Kathmandu

255

292

Akhanda Polyclinic Pvt.Ltd.

Battisputali-9, Kathmandu

256

293

Diamond Polyclinic Pvt.Ltd.

Mitranagar-29, Kathmandu

Purwanchal

Chhetriya

Anarmani-3, Jhapa

257

294

Shanti Buddha Medical Center Pvt.Ltd

Laxmipur-4, Jhapa

258

296

Cambridge Medical Institute Pvt.Ltd

Biratnagar, Morang

259

297

Global Medical Center Pvt.Ltd.

Saamakhusi Chowk, Kathmandu

260

298

Green Medical Center Pvt.Ltd

Gousala , Pingalasthan, Kathmandu

261

299

Buddha Sai Diagnostic Center Pvt.Ltd.

Itahari-1, Sunsari

262

301

U. and P. Polyclinci Pvt.Ltd

Suizatar-1, Kalanki , Kathmandu

263

302

Alliance Medical And Research Center Pvt.Ltd

Banasthali chwok, Kathmandu

264

303

S. S. Polyclinic Pvt. Ltd.

Narayan Gopal Chowk, Kathmandu

265

305

Dibyajyoti Polyclinic Pvt.Ltd

Newbaneshwor-34, Kathmandu

266

326

Bindhyawasini Medical Center Pvt Ltd

Dhapasi

267

306s(01)

Shubhalaxmi Diagnostic Center Pvt.Ltd

Anarmani-3 Jhapa

268

307(02)

Godawari Diagnostic Pvt.Ltd.

Anarmani-3, Jhapa

269

308(03)Rose International Medical Center Pvt.Ltd

Gongabu-29, Kathmandu

270

309(04)

Diyas Polyclinic And Medical Center Pvt.Ltd

Sundhara-11, Kathmandu

271

310(05)

Metro Clinic Pvt.Ltd

Thapathali-11, Kathmandu

272

311(06)

Meditech Hospital Anusandhan Kendra

Butwal, Rupandehi273

312(07)

United Medical Center Pvt.Ltd

Lazimpat-2 , Kathmandu274

313(08)Madhu Health Service And Counseling Center

Bashundhara-3, Kathmandu

275

314(09)Nawajiban Hospital Pvt.Ltd.

Dhangadhi, Kailali276

315(10)

Health Care Diagnostic Pvt.Ltd

Sinamangal, Kathmandu

277

316(11)

Kunta Polyclinc Pvt.Ltd

Tilganga, Kathmandu

278

318(13)

Ojaswi Polyclinic Pvt.Ltd.

Narayangopal chowk, Kathmandu279

319(14)

Shubham polyclinic And Diagnostic Center Pvt.Ltd

Newbaneshwor chowk, Kathmandu

280

320(15)

Star Health Care Diagnostic Center

Kupandol-1, Lalitpur281

322(17)

Anmol Medical Center Pvt.Ltd

Sinamangal-9, Kathmandu282

323(18)

Manjushree Polyclinic And Diagnostic Center
Pvt.Ltd

Dharan-9, Sunsari283

324(21)peoples Health Care center

Kathmandu-2

284

325(20)

Himal Medical Center

Swayambhu, Kathmandu

Source:https://nepalhpf.org.np/(20)Table 6:

The general characteristic of medical centers.
N = 284

Province
Koshi

28 (10%)Madhesh3 (1%)

Bagmati241 (85%)

Gandaki

3 (1%)

Lumbini

8 (3%)

Karnali

0 (0%)

Sudurpashchim

1 (1%)

The above listed medical centers have been approved by the Ministry of Health and Population of theGovernment of Nepal to provide medical checkup services to Nepalese people going abroad on foreign
employment. Majority of the medical centre is located in the Bagmati province, which includes the Capital
city of Nepal, i.e., Kathmandu. Around 10% of medical centres in Koshi Province and Karnali province
with no any medical centres. The majority of medical centers are standalone laboratory and provides only
outpatients services with no Inpatient services

Table 7:
S.N
1
2
3
4
5
6
7

The general characteristic of hospitals.

Name of Hospital
Norvic International Hospital
Grande International Hospital
Ciwec Hospital Pokhara
Mediciti Hospital
Neuro Hospital (National Institute of Neurology)
Manipal College of Medical Science
CIWEC Clinic
IOM Nepal Migration Health Assessment Center

Province
BagmatiBagmatiGandakiBagmatiBagmatiBagmatiBagmatiBagmatiCategory of Hospital
Tertiary Hospital
Tertiary Hospital
Tertiary Hospital
Tertiary Hospital
Tertiary Hospital
Tertiary Hospital
Tertiary Hospital
Tertiary Hospital# beds
200
200
25
700
100
700
25
0

The above listed hospitals are tertiary hospitals best known for health screening for foreign migration andtravelers in Nepal. These all the multi-specialty hospitals.

Conclusion
A large proportion of the youth population is migrating to overseas work every day in Nepal. The existing
national health system does not have any functional link to occupational health services delivery. The
management of occupational illness and disease is treated as general health services. There is no specifichealth structure to manage occupational illnesses. The Ministry of Labor, Employment, and Social Security
is the apex body for national Occupational Safety & Health in Nepal. OSH seems a less priority area for
the Ministry of Labor, Employment, and Social Security. Due to a lack of priority, the institutional structure
for OSH supervision and administration seems weak with a severe lack of human resources. There is nofunctional linkage between MOHP. There are no specific measures in place to ensure the standardization ofhealth examination for occupational diseases. There are no specific medical examination schemes forworkers exposed to hazardous substances, including asbestos. There is no standard for diagnostic tools suchas radiographs, used in the occupational disease investigation. The regulatory bodies that contribute toquality assurance in occupational health services are limited to workplace measurement and worker healthexamination. A migrant worker must get a pre-screening medical checkup for the visa application. In thecase of migrant workers, they must get pre-screening medical checkups from the government-approved
health institution recognized by the Ministry of Health and Population, Nepal. The occupational healthservice delivery system in Nepal is limited to pre-screening for labour migrants and workplacemeasurement and screening activities

References
1. Central Bureau in Statistics. Nepal in Figures [Internet]. 2022. Available from: cbs.gov.np/wpcontent/upLoads/2022/08/Neapl-In-Figures-2022.pdf
2. Ministry of Labour, Employment. Nepal Labour Migration Report [Internet]. 2022 [cited 2024 May 5].
Availablefrom:https://moless.gov.np/storage/files/post_files/Nepal%20Labour%20Migration%20Report_2022.pdf
3. Danish Trade Union Development Agency. Labour Market Profile

Nepal – 2022/2023. 2023;

4. Bongestabs AF, Bhandary S. Why Nepal needs a mandatory social insurance system.
5. Employment promotion in Nepal | International Labour Organization [Internet]. 2024 [cited 2024 May
5]. Available from: https://www.ilo.org/regions-and-countries/asia-and-pacific/ilo-nepal/areaswork/employment-promotion-nepal
6. Adhikari J, Rai MK, Baral C, Subedi M. Labour Migration from Nepal: Trends and Explanations. In:
Rajan SI, editor. Migration in South Asia: IMISCOE Regional Reader [Internet]. Cham: Springer
International Publishing; 2023 [cited 2023 Sep 9]. p. 67–81. (IMISCOE Research Series). Available
from: https://doi.org/10.1007/978-3-031-34194-6_5
7. Kunwar LS. Emigration of Nepalese People and Its Impact. Econ J Dev Issues. 2017 Jul 7;77–82.
8. Nepal Government. The Labour Act 2017 [Internet]. 2017 [cited 2024 May 13]. Available from:https://www.lawcommission.gov.np/en/wp-content/uploads/2021/03/The-Labor-Act-2017-2074.pdf
9. Department of Health Services. Annual Health Report 2079/80 [Internet]. [cited 2024 May 10].
Available from: https://hmis.gov.np/wp-content/uploads/2024/03/Annual-Health-Report-2079-80.pdf
10.
Gagan Gurung. Private gain, public pain: does a booming private healthcare industry in Nepal
benefit its people? The BMJ [Internet]. 2016 Sep 30 [cited 2024 May 10]; Available from:https://blogs.bmj.com/bmj/2016/09/30/does-a-booming-private-healthcare-industry-in-nepal-benefitits-people/

11.
Ministry of Health and Population. NATIONAL HEALTH CARE QUALITY ASSURANCE
FRAMEWORK[Internet].
2022[cited
2024
May
10].
Availablefrom:https://mohp.gov.np/uploads/Resources/Quality%20Assurance%20Framework%20_print_06%20Sept%202022.pdf
12.
Ministry of Health and Population. Minimum service standard: Checklist to Identify the Gaps in
Quality Improvement of Tertiary Hospitals [Internet]. 2019 [cited 2024 May 12]. Available from:https://msshealth.org.np/UploadDocument/Tertiary%20MSS%20Book.pdf
13.
Ministry of Labour, Employment, and Social Security, and Social Security. National occupationalsafety and health profile for Nepal, 2022 [Internet]. 2022 [cited 2024 May 11]. Available from:https://webapps.ilo.org/wcmsp5/groups/public/---asia/---ro-bangkok/---ilokathmandu/documents/publication/wcms_866976.pdf
14.
Rudra Prasad Gautam, Jib Nath Prasain. Current Situation of Occupational Safety and Health in
Nepal[Internet].
2011[cited
2024
May
13].
Availablefrom:https://www.gefont.org/files/publication/65bb5e808ba12.pdf
15.

Joshi SK, Dahal P. Occupational health services in Nepal.

16.
Ministry of Health and Population. National Health Policy of Nepal, 2019 [Internet]. 2019 [cited
2024
May
13].
Availablefrom:https://climate.mohp.gov.np/downloads/National_Health_Policy_2076.pdf
17.
Karkee R, Gurung M, Poudel L, Baral C, Adhikary P, Kc RK, et al. Management of healthinformation of nepalese labour migrants. Glob Health. 2023 Apr 25;19(1):30.
18.
Government of Nepal. The Foregin Emplyoment Rule 2008 [Internet]. 2008 [cited 2024 May 14].
Available from: https://janakpur.leo.gov.np/rules/2aebd02207b3c31e10d0f2e88046e38157c438361701329880.pdf
19.
Nepal Health Professional Federation. PROVISION OF HEALTH CHECKUP [Internet]. 2024
[cited 2024 May 14]. Available from: https://nepalhpf.org.np/
20.
Government Approved Medical List | Nepal Health Professional Federation [Internet]. [cited 2024
May 13]. Available from: https://nepalhpf.org.np/government-approved-medical-list/令和 5 年度労災疾病臨床研究事業費補助金研究 分担研究報告書

健康管理手帳制度の国際展開に向けた米国の健康診断実施状況調査
研究協力者 安光ラヴェル 香保子 高知大学 医学部 特任助教
村上 武 高知大学 次世代医療創造センター 副センター長
研究代表者：菅沼 成文 全国労働衛生団体連合会
胸部Ｘ線検査専門委員会委員
研究分担者：田村 太朗 島根大学 医学部 准教授
JP Naw Awn 高知大学 医学部 特任助教
研究要旨
【目的】
多くの移民を受け入れている先進諸国において、外国人労働者の帰国後のフォローア
ップをどのように行なっているのかについて、米国を対象に調査を行った。
【方法】
米国大学２校を訪問し、産業保健の専門家に対して、米国における退職後の健康診断の現状について情報収集を行った。
【結果】
訪問先１では、米国の労災補償制度や特定の健康リスクに焦点を当てた報告が行われた。労災補償は州ごとに異なり、特に外国人労働者の補償情報は多様性がある。特定の疾患に関する情報の集約が不足しており、退職後の補償が不十分であることが指摘された。訪問先２では、国際的な健康管理手帳制度の実施に関する課題やベリリウム曝露などの補償問題についての新たな情報が提供された。異なる国での調査の複雑さや個人情報の保護に関するアドバイスも共有された。
【考察】
先進国である米国は世界各地からの移民を受け入れており、その規模は日本の外国人
労働者の 10 倍以上に及ぶ。しかし、帰国後のフォローアップ体制が整備されておらず、退職後のフォローアップも不十分である現状が浮かび上がった。したがって、本事業は前例のない画期的な取組であり、AI 技術の進歩により言語の壁を超えやすくなった今
後の国際社会においても意義があるものと言える。
A．研究目的インドネシアを中心に健康管理手帳制

本事業では、現在多くの技能実習生が来度に基づく健康診断を行う適切な医療日しているベトナム、中国、フィリピン、

機関等の把握、健康診断の実施方法・課Associate Chief for Research

題等についての文献調査を進めている。
一方で、多くの移民を受け入れている先Brian Graham MD

進諸国において、外国人労働者の帰国後

Pulmonary and Critical Care Medicine,のフォローアップをどのように行なっ

Zuckerberg San Francisco Generalているのかについて、事例を収集するこHospital

とも本事業を推進する上で意義深いこ菅沼成文とである。本研究では、米国を対象とし学教室教授て調査を行った。

村上武 高知大学臨床工学部技師長

of

高知大学医学部環境医

安光ラヴェル香保子
B．研究方法Chief

高知大学医学部

環境医学教室米 国 大 学 ２ 校 （ UCSF, University of
Arizona）を訪問し、産業保健の専門家【訪問先 2】を対象に、米国における退職後の健康診

日時：2024 年 3 月 27 日

断の現状について情報収集を行った。

場所：
Mel & Enid Zukerman College of【訪問先 1】

Public Health, University of Arizona

日時：2024 年 3 月 26 日

会議出席者：

場所：

Philip Harber MD, MPH

Division of Occupational Environment

Professor

and

菅沼成文

ClimateMedicine

Adjunct

高知大学医学部環境医(OECM)University of California, San

学教室教授

Francisco

村上武 高知大学臨床工学部技師長

会議出席者：

安光ラヴェル香保子

Gina Solomon MD,

MPH

高知大学医学部

環境医学教室Division Chief
John Balmes MD

Professor

C．研究結果Emeritus
Paul Blanc

訪問先１：
MD,

MSPH

Professor Emeritus
Bob Kosnik

菅沼より「健康管理手帳制度による健康診断の諸外国での実施のための研究」にMD, DIH

関する概略を説明し、米国の労災（主にBob Harrison MD, MPH

職業性呼吸器疾患）補償の現状についてMatt Gribble PhD.

DABT

ヒアリングを実施した。

労働災害に対する補償については、米国の問題が増加している。

は日本より遅れており、退職後長期にわ

米国では、粉塵暴露による塵肺が発現したる補償はほとんどなく、また、労働者て初めて、患者は公的な医療記録を所持への補償に関する法律は州ごとである

し、補償を受けることとなる。塵肺につため、数例を除いては、全国統一のサー

いてのスクリーニングは、胸部 X 線のみ

ベイランスプログラムは存在せず、労災で CT は基本的には使用されていない。

の情報が散在している状態である。基本

核施設（電力・兵器）でのベリリウム曝的に、連邦政府の法律の下に州ごとの法

露については、政府が検査を実施し、感律があり、カリフォルニアは連邦政府よ

作があった場合には、医療サーベイラン

りさらに厳しい（＝労災に関しては進んスを受ける権利が生じる。

でいる）州であるが、外国人労働者につ

退役軍人については、退役軍人のためのいては、H1B ビザを持つ高スキルの労病院（UCSF にも存在）は、スクリーニ

働者から不法滞在労働者まで幅広く、そングを提供する義務を要するが、退役軍の労災補償の情報は多様である。また、人にスクリーニングを受ける義務はな

退職者が週を跨いで移動した場合にはい（＝退役軍人から声を上げない限りス

さらにフォローアップが難しくなる。

クリーニングは実施していない）。

アスベスト曝露については、複数の集団

最後に、トヨタのような多国籍企業にお訴訟によって補償されることとなり、特ける労災に対する退職後の補償についに軍艦の修理に伴う曝露において補償て、参考になる情報がある可能性が指摘

体制が整備されているが、全国レベルでされた。

のデータは無い。炭鉱労働者の補償体制もあるが全米の体制ではなく、地域レベ

訪問先２：ルでの補償となっている。シリカ曝露に

菅沼より「健康管理手帳制度による健康

ついては、キッチンカウンター資材とし診断の諸外国での実施のための研究」にての需要の増大にも関わらず、小規模の関する概略を説明。全米の現状について

非公式な企業や違法労働者が多く携わも前会議同様の内容について説明があっていることから補償体制が未整備で、った。新たな情報としては、

UCSF でもシリカ曝露に関する助成金

UCSF で説明があった通り、核兵器産業を得て調査が開始されたところである。

でのベリリウム曝露については国レベ

そのほか、カリフォルニア州セントラ

ルでの補償がある炭鉱労働者について

ル・バレーの収監所の囚人や刑務官の間は補償制度はあるものの参加率が低い。

で、シリカおよび Cocciciodes 真菌曝露

その主な理由としては、補償を受けることでその後の収入が下がる可能性があも想定する必要有ること、死後に肺の検体を提出する必要があることなどが考えられる。退役軍人

D．考察への補償については、イラク戦争後にコ先進国の一つである米国は、英国、アイホート調査が始まった（例：Millennium

ルランド、ドイツ、イタリア等の欧州を

cohort, Depleted uranium cohort）ウラ

初め、アフリカ、中南米、アジアなど、ンとシリカの職業曝露は、ネイティブア

世界各地からの移民を受け入れてきた

メリカンが多い。近年、新しいシステム

歴史を持つ。移民はそのまま米国社会にの導入により、各州において死亡情報を定住・不法滞在するか、母国に帰るが、個人情報と繋げる試みが始まっている。

1990 年には既に 2000 万人と日本の外Harber 教授のヨーロッパでの国を跨い国人労働者の規模の 10 倍に及んでいるだ調査の経験をもとに、本調査実施にあことからも推察されるように、帰国後のたり以下の助言があった。

フォローアップ体制は整備されていな•異なる言語・文化などのため、一見いどころか、国内での退職後のフォロー

単純に思える質問票調査ですらもアップもままならないのが現状である

困難になる可能性という事実が浮かび上がってきた。この情報収集にあたり、個人情報を別のことからも、本事業が検討する取組は前国に移すことも困難

例のない画期的な取組であり、AI 技術

ガイドラインの必要性（例：ベトナ

等の進歩により言語の違いを超えやすムなど他国の医師向けの診断に関くなった今後の国際社会においても意するガイドライン）

義のある取組であることが窺える。

•
•

•

•
•

•
•

読影者が異なる場合の目合わせの
必要性

E．結論

胸部 X 線と呼吸機能テストを組み訪問先１と２の報告では、米国の労災補合わせて実施償制度や健康リスクに焦点を当て、補償

Email アドレスは比較的追跡が容の不足や国際的な課題が浮き彫りにな易ではあるが、最も良いのは指紋なった。異なる国での調査の複雑さも指摘

ど生体認証

され、個人情報の保護についてのアドバ

個人情報保護の一つの方法としてイスも共有された。これらの洞察は、労Honest broker の活用

働者の健康と補償制度の改善に向けた診断に関わる医師も放射線医師・内重要な一歩となる。

科医・産業医など多岐にわたる場合

F．健康危険情報
該当なし
G．研究発表該当なし
Ｈ．知的財産権の出願・登録状況(予定を含む)
1.特許取得
該当なし
2.実用新案登録
該当なし

令和 5 年度労災疾病臨床研究事業費補助金研究 分担研究報告書

アジアじん肺読影医養成プログラム（AIR Pneumo）認定医の分布状況研究代表者：菅沼 成文 全国労働衛生団体連合会
胸部Ｘ線検査専門委員会委員
研究分担者：田村太朗 島根大学 医学部 准教授
JP Naw Awn 高知大学 医学部 特任助教
研究要旨
【目的】
本研究の目的は、2008 年から 2023 年までの Asian Intensive Reader of Pneumoconiosis(AIR Pneumo)プログラムに参加した医師の出身国の分布を調べ、AIR Pneumo 試験の成績をまとめて、合格者と不合格者の X 線写真の読影の違いについて述べることである。
【方法】
本研究では、2008 年から 2023 年までに Asian Intensive Reader of Pneumoconiosis (AIRPneumo)プログラムにより実施された認定試験への医師の参加状況と認定試験の成績を調べ、試験に合格した医師と不合格となった医師の読影結果を比較した。
【結果】
2023 年 12 月までに、20 カ国から 674 人の医師が認定試験を受けており、特に近年は参加者が増加している。参加者の人口統計、参加傾向、合否率、習熟度スコアをまとめ、試験に合格した医師と不合格だった医師のじん肺の X 線写真の読影の違いを評価した。背景となる専門医の専門分野、職務経験は様々であった。合格率と合格者の平均技
能スコアは初回の認定試験で 83.4%と 77.6±9.4、再認定試験で 76.8%と 88.1±4.5 であった。試験に合格した医師と比較して、不合格となった医師は、正答では陰性の胸部
X 線写真を陽性と分類し、陰影密度を正答よりも高めに読む傾向があった。また、大きな空孔や胸膜斑を見逃す可能性が高く、小さな空孔の形状を認識する精度が低かった。
【考察】
本研究結果から、不合格となった医師は胸部 X 線写真をじん肺陽性と過剰診断する傾向があり、小陰影の形状を正確に同定することが困難であることが示唆された。

A．研究目的収集され、試験への参加と成績の分析がじん肺の健康管理のためには、働く労働行われ、合格率や不合格率、平均点など者に対するじん肺健康診断が重要となが報告され、医師間の比較も行われる。

る。この健康管理には、国際労働機関がすべての解析は Stata/MP 17.0 ソフト

定 め る 国 際 じ ん 肺 X 線 分 類 （ ILO

ウェアを用いて行われ、倫理委員会の承Internatiional

認を得ている。

ClassificationofRadiograph of Pneumoconioses）が用いられる。

C．研究結果本研究では、研究代表者らを始めとした2008 年から 2023 年にかけて、AIR

日本人専門家らが中心となって、アジア

Pneumo は 26 回の認定試験をインド、諸国で国際じん肺 X 線分類を用いて読フィリピン、ベトナム、インドネシア、影医を養成する取り組みとして、アジア

ブラジル、日本、タイで実施した。認定

じ ん 肺 読 影 医 養 成 プ ロ グ ラ ム （ AIR

試験には 674 人の医師が参加し、その６

Pneumo）を通じて養成した認定医を、割はインドネシア、タイの医師であった。

診断・治療に関して一定の技術レベルに認定試験の合格率は 83.4％であり、再認達していると思われる者とみなし、その定試験の合格率は 76.8％だった。合格し分布状況を調べた。

た医師は、再認定試験を受けた医師を除いて、小空孔の同定で偽陽性が偽陰性よB．研究方法りも多い傾向があった。不合格となった

AIR Pneumo 検査は、胸部 X 線写真を

医師は、病変の同定における偽陽性率お分類する医師の熟練度を評価するもの

よび偽陰性率が高かった。また、であり、医師の正確性と一貫性を評価す

profusion の分類では専門家パネルとのるために、小空孔、大空孔、胸膜斑の分比較で有意な違いがあった。認定試験と類が行われる。精度は感度と特異度を用再認定試験の両方で、合格した医師は小いて測定され、スコアはそれらの組み合

さな混濁の形状を正しく認識する割合

わせで計算される。また、専門家パネルが高かったことが示された。

との一致率も評価される。医師の情報が表 1. 2008~2023 年に実施した AIR Pneumoの認定試験に関する情報国
インドネシア
タイ
インド
ベトナム
日本
ブラジル
フィリピン

試験開催頻度
6
7
1
1
5
5
1

表 2. 2008~2023 年に AIR Pneumo の認定試験を受けた 674 人の医師に関する情報
医師の基本属性

人数(%)

国
インドネシア
タイ
インド
ベトナム
日本
ブラジル†
フィリピン
マレーシア
その他‡
不明
専門分野
産業医
呼吸器内科医
放射線科医
総合診療医
公衆衛生
その他
不明
性別
女性
男性
不明

218 (32.3)
186 (27.6)
58 (8.6)
56 (8.3)
49 (7.3)
48 (7.1)
23 (3.4)
22 (3.3)
13 (1.9)
1 (0.2)195 (28.9)
187 (27.7)
117 (17.4)
59 (8.8)
27 (4.0)
4 (0.6)85 (12.6)304 (45.1)
282 (41.8)
88 (13.1)

表 2 続き卒後年数
中央値 (範囲)
10 (1–41)≤5
173 (25.7)
6-10
129 (19.1)≥11240 (35.6)
不明
132 (19.6)
過去のじん肺胸部X線写真の読影件数（枚）なし
144 (21.4)<10248 (36.8)<50
103 (15.3)≥50
97 (14.4)
不明
82 (12.2)†アルゼンチン、チリ、ペルーの医師を含む。
‡ブルネイ、カンボジア、香港、ブータン王国、
ラオス、モンゴル、台湾の医師を含む。

D．考察
本研究では、2008 年から 2023 年まE．結論

での AIR Pneumo 試験の成績を総括し、アジア諸国におけるじん肺の X 線診

合格者と不合格者の X 線写真の読影の断においては、読影医の訓練プログラム違いを評価した。約 20 カ国から計 674の改善が急務である。特に肺結核や巨大人の医師が参加し、多くは ASEAN 諸国

線維化の診断に対する医師の能力向上出身で呼吸器内科医、産業医、放射線科が重要である。新技術への適応も必要で医のバックグラウンドを持っていた。

あり、ウェブベースのトレーニングプロ

AIR Pneumo への参加者数の増加は、発グラムの開発が進んでいる。ただし、ト

展途上国の医師の ILO 分類システムへ

レーニングプログラムの効果やウェブの関心の高まりを示している。しかし、ベースアプローチの他国での適用性に再認定試験への参加率が低いことから、

ついては、さらなる検討が必要だろう。

医師は主に ILO 分類システムの理解やじん肺に関する知識向上に関心を持っ

F．健康危険情報ている可能性がある。さらに、一部の国

該当なしからの参加率が低いことから、じん肺のX 線写真の読影と報告の資格に関する

G．研究発表具体的な規制の重要性が浮かび上がる。

1.論文発表不合格となった医師は、合格者に比べてJ-P NA, Susanto AD, Samoedro E,

X 線写真をじん肺陽性と誤って分類す

Mansyur M, Tungsagunwattana S,る割合が高く、特に小さな混濁を多く読

Lertrojanapunya S, Subhannachart P,

み取る傾向があった。これらの結果は、Siriruttanapruk S, Dumavibhat N,

今後のトレーニングプログラムの改善

Algranti E, Parker JE, Hering KG,の必要性を示している。具体的には、医Kanayama H, Tamura T, Kusaka Y,

師の肺結核の初期の X 線変化や大きなSuganuma N. Asian Intensive Reader

混濁、胸膜斑を認識し、小さな混濁を分of類する能力の向上に焦点を当てる必要

examination for certification duringがある。また、ウェブベースのトレーニ

2008-2020. Industrial Health 2024. 62,

ングプログラムの開発や医療用のフラ143–152.

ットパネル診断モニターへのアクセス

10.2486/indhealth.2023-0010の確保など、新しい技術やリソースに適2.学会発表応する必要がある。

［International meeting］

Pneumoconiosis

program:

DOI:

1.

Indriyati LH , Eitoku M, Naw

Awn J-P , Nishimori M, Hamada N,

3. Indriyati LH , Eitoku M, Naw Awn

Sawitri N, Suganuma N

J-P , Nishimori M, Hamada N, Sawitri

Assessment of Chest Ray Profile in

N, Suganuma N

Relation to Prevalence of Silicosis

Prevalence of Radiographic Silicosis

aming Tuberculosis Patients in West

Cases among MDR-TB and DS-TB

Java,

patients in Indonesia.

Indonesia,34th

CongressonInternational

Occupational

Health97th

AnnualMeetingofJapan(ICOH), Marrakesh, Morocco, April

Society for Occupational Health, 第 972024

回日本産業衛生学会, Hiroshima, May
2024［National meeting］
1. Indriyati LH, Eitoku M, Naw Awn J-

Ｈ．知的財産権の出願・登録状況(予定をP, Nishimori M, Hamada N, Sawitri N,

含む)

Suganuma N

1.特許取得Prevalence of Radiographic Silicosis

該当なし

among Tuberculosis patients in West

2.実用新案登録

Java, Indonesia:

Preliminary reportfrom Hospital Based Study . The 67th
Chugoku-Shikoku Joint Conference on
Occupational Health 第 67 回中国四国
合同産業衛生学会本, Ehime, December
2023
2. Indriyati LH, Eitoku M, Naw Awn JP, Nishimori M, Hamada N, Sawitri N,
Suganuma N
Prevalence of Radiographic Silicosis
Among Tuberculosis Patients in West
Java, Indonesia
94th Annual Meeting of Japan Societyfor Hygiene, Kagoshima, March 2024

該当なし

Field ReportIndustrial Health 2024, 62, 143–152

Asian Intensive Reader of Pneumoconiosis program:examination for certification during 2008–2020
Naw Awn J-P1, Agus Dwi SUSANTO2, Erlang SAMOEDRO2, Muchtaruddin MANSYUR3,
Sutarat TUNGSAGUNWATTANA4, Saijai LERTROJANAPUNYA4,
Ponglada SUBHANNACHART4, Somkiat SIRIRUTTANAPRUK5, Narongpon DUMAVIBHAT6,
Eduardo ALGRANTI7, John E. PARKER8, Kurt G. HERING9, Hitomi KANAYAMA10,Taro TAMURA11, Yukinori KUSAKA12 and Narufumi SUGANUMA1*
1

Department of Environmental Medicine, Kochi Medical School, Kochi University, Japan
Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Indonesia,
Persahabatan Hospital, Indonesia
3
Department of Community Medicine, Faculty of Medicine, Universitas Indonesia & Southeast Asian Ministersof Education Regional Centre for Food and Nutrition (SEAMEO RECFON), Indonesia
4
Department of Radiology, Central Chest Institute of Thailand, Department of Medical Services, Ministry of
Public Health, Thailand
5
Department of Disease Control, Ministry of Public Health, Thailand
6
Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University,
Thailand
7
Division of Applied Research, FUNDACENTRO, Brazil
8
Pulmonary and Critical Care Medicine, Robert C. Byrd Health Sciences Center, School of Medicine, West
Virginia University, USA
9
Klinikum-Westfalen−Miner’s Hospital (Knappschaftskrankenhaus), Germany
10
Division of Environmental Health, Department of International Social and Health Sciences, Faculty of Medical
Sciences, University of Fukui, Japan
11
Department of Environmental Medicine and Public Health, Faculty of Medicine, Shimane University, Japan
12
Health Care Center, Shimane Prefectural Federation of Agricultural Cooperatives for Health and Welfare (JAShimane Koseiren), Japan
2

Received January 19, 2023 and accepted June 27, 2023
Published online in J-STAGE July 5, 2023
DOI https://doi.org/10.2486/indhealth.2023-0010
Abstract: This study examined physicians’ participation and performance in the examinations
administered by the Asian Intensive Reader of Pneumoconiosis (AIR Pneumo) program from 2008
to 2020 and compared radiograph readings of physicians who passed with those who failed theexaminations. Demography of the participants, participation trends, pass/fail rates, and proficiency
scores were summarized; differences in reading the radiographs for pneumoconiosis of physicians
who passed the examinations and those who failed were evaluated. By December 2020, 555 physicians from 20 countries had taken certification examinations; the number of participants increased
in recent years. Reported background specialty training and work experience varied widely. Passing rate and mean proficiency score for participants who passed were 83.4% and 77.6 ± 9.4 in certification, and 76.8% and 88.1 ± 4.5 in recertification examinations. Compared with physicians who*To whom correspondence should be addressed. E-mail: nsuganuma@kochi-u.ac.jp©2024 National Institute of Occupational Safety and HealthThis is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (by-nc-nd) License.
(CC-BY-NC-ND 4.0: https://creativecommons.org/licenses/by-nc-nd/4.0/)

144

N J-P et al.
passed the examinations, physicians who failed tended to classify test radiographs as positive forpneumoconiosis and read a higher profusion; they likely missed large opacities and pleural plaquesand had a lower accuracy in recognizing the shape of small opacities. Findings suggest that physicians who failed the examination tend to over-diagnose radiographs as positive for pneumoconiosis
with higher profusion and have difficulty in correctly identifying small opacity shape.
Key words: Asian Intensive Reader of Pneumoconiosis (AIR Pneumo), Chest radiograph,
International Labour Office (ILO), Occupational health, Pneumoconiosis, Surveillance

Introduction
Pneumoconiosis is an occupational lung disease caused
by inhaling mineral dust, such as coal mine dust, silica,
and asbestos. It appears as widely distributed nodular or
reticular lesions on a chest radiograph. In 2017, there wereapproximately 60,055 newly diagnosed cases globally,
with over half occurring in Asia (32,205 in China and5,160 in India)1). The risk of exposure to harmful substances increases due to industrialization and the transferof hazardous processes, such as asbestos processing andship breaking to developing countries2–4). Early detection
through health surveillance programs is crucial5). However, implementing such programs can be particularly challenging in developing countries due to limited resources,a lack of experienced physicians skilled in reading chest
radiographs, and various obstacles, including a lack ofawareness of pneumoconiosis, poor cooperation fromindustries, and a lack of policy environment.
Interpreting the radiographic signs of pneumoconiosis ischallenging due to subjectivity and inconsistency among
readers. To ensure uniform reporting, the International
Labour Office (ILO) developed the ILO International
Classification of Radiographs of Pneumoconioses (ILO
classification system) in 19506). The ILO classification
system uses standardized descriptions, guidelines, andreference radiographs. It classifies radiographic abnormalities into small opacities, large opacities (opacities larger
than 1 cm), and pleural abnormalities. Small opacities arefurther defined as rounded or irregular shapes and categorized based on profusion using a twelve-subcategory scale
within four major profusion categories ranging from 0 to
3. Large opacities are encoded as A, B, or C in increasingorder of sizes. Pleural abnormalities are classified as pleural plaques, costophrenic angle obliteration, and diffuse
pleural thickening. This system allows readers to reportpneumoconiosis using identical descriptions of parenchymal and pleural findings.

However, disagreements persist due to unfamiliarity with the ILO classification system and radiographic
manifestations of pneumoconiosis7). To address this, theNational Institute for Occupational Safety and Healthintroduced the B Reader certification program in the
United States in 1974 8, 9). In 2006, a similar initiative
called the Asian Intensive Reader of Pneumoconiosis (AIRPneumo) project was established10). This project, in collaboration with various institutions and organizations (seethe acknowledgment), focuses on providing training andcertification programs to occupational health physiciansin developing countries. The main goal of the project is toimprove their proficiency in utilizing the ILO classification system for classifying and interpreting radiographic
findings associated with pneumoconiosis.
Since 2008, AIR Pneumo has been conducting training
programs in Thailand, and in 2018, it expanded its reachto Indonesia. The program also provides training uponinvitation from governmental agencies of hosting countries. In South America, in collaboration with the ILO,
AIR Pneumo has been offering the program as a national
training course in Brazil since 2009. These programs
contribute to strengthening national systems for workers’
health surveillance.
The AIR Pneumo program includes a two-day training course and a three-hour examination, during which
physicians classify 60 chest radiographs according to the
ILO classification system. To obtain AIR Pneumo-Reader
certification, physicians must achieve a score of 60 or
higher out of 100. After five years, certified readers are
required to take a recertification examination, using thesame test radiographs as the initial certification. A scoreof 80 or higher is required to pass the recertification anddemonstrate improvement. However, maintaining AIR
Pneumo-Reader status only necessitates a score of 60 or
higher. Further details of the AIR Pneumo project havebeen reported elsewhere10–12). This study aims to summarize physician participation and performance in AIR
Industrial Health 2024, 62, 143–152

AIR PNEUMO EXAMINATION FOR READING PNEUMOCONIOSIS CXR
Pneumo examinations from 2008 to 2020 and describe
the differences in reading radiographs between those who
passed and those who failed the examinations.

Subjects and Methods
The AIR Pneumo examination evaluates physicians’
proficiency in classifying 60 chest radiographs according
to the ILO classification system. A detailed assessment
method has been previously reported 12) . In summary,
physicians are assessed on their accuracy in classifying thepresence or absence of small opacities, large opacities, andpleural plaques, as well as their consistency in classifying
the profusion and shape of small opacities. Accuracy ismeasured using sensitivity and specificity, and the score is
calculated as (Sensitivity + Specificity) − 1. Consistency
in profusion classification and shape recognition is determined by comparing the percentage agreement with theexpert panel’s readings. The expert panel consists of 12
B Readers who are recognized experts in the field. They
determine the correct answers for each test radiograph.
The set of 60 radiographs used in the examination includes
20 without nodular or reticular lesions, 9 boundary cases(which fall into the ILO profusion subcategory 0/1 or 1/0),
and 31 radiographs with small opacities (ILO profusionsubcategory 1/1 or greater). Among the radiographs withsmall opacities, 20 have pure rounded opacities, while 4
have pure irregular opacities. Of the 31 radiographs withsmall opacities, 9 also display varying sizes of large opacities. Additionally, 9 of the test radiographs exhibit pleuralplaques.
Since the first certification examination in December
2008, physicians’ information, such as country of residence, specialty, years after graduation, and the numberof reviewed pneumoconiosis chest radiographs, has beencollected through a questionnaire. This information, alongwith physicians’ reading records and test scores, has been
maintained in the AIR Pneumo database. By December
2020, the database contained 652 records for 555 physicians who participated in the examinations, including 565
certification records and 87 recertification records. Ten
physicians attempted the certification examination twice.
For the analysis of participation and performance in thecertification examination, 12 physicians who had notclassify six or more of the test radiographs (i.e., ≥10% of
the total radiographs) in their first attempt were excluded,
resulting in 543 physicians included in the analysis. For
assessing participation and performance in the recertification examination, records of 69 physicians who took the145

test for the first time were used.
Using the collected data, first, we observed the trend
in taking the examinations from December 2008 to December 2020 and physicians’ participation based on theircharacteristics. We also summarized their performanceby examination type (certification or recertification) andpass or fail status. Pass and fail rates, as well as meanscores (with standard deviation), were presented for eachcomponent of proficiency assessment, including accuracy
in identifying small opacities, large opacities, pleuralplaques, and consistency in classifying the profusion andshape of small opacities. Second, we compared physicians
who passed and failed the examinations in the following
reading assessments: (1) Rates of false positives and false
negatives in classifying radiographs for small opacities,
large opacities, and pleural plaques. The rates were determined based on sensitivity and specificity in classifying
the lesions. (2) Assessment of over-reading or under-reading the profusion of small opacities by comparing with theexpert panel’s classification. To determine the profusioncategory for a group of physicians, we analyzed the mostfrequently reported profusion category by the physiciansin that group. (3) Evaluation of small opacity shape recognition by calculating the percentage of physicians withsimilar descriptions for shape (no small opacities, roundedshape, or irregular shape). The percentage was basedon radiographs containing specific shapes (4 with pureirregular opacities and 20 with pure rounded opacities).
Comparisons between physicians’ groups were performed
appropriately using Student’s t-test or χ2 test. Results arepresented separately for the pass or fail and for the certification or recertification examination. All analyses were
performed using Stata/MP 17.0 software (StataCorp., College Station, TX, USA). This study was approved by theinstitutional review board of Kochi Medical School (approval number: 31-68). Due to the nature of this study, i.e.,
using anonymized data from radiograph reading tests, thenoninvasive nature of data collection, and no involvementof biological materials, written informed consent from thephysicians taking AIR Pneumo examinations was waived.

Results
Between 2008 and 2020, AIR Pneumo conducted certification examinations 23 times in several countries: oncein India, the Philippines, and Vietnam; four times in Indonesia; five times each in Brazil and Japan; and six timesin Thailand. Figure 1 illustrates the trend and number ofphysicians who took the certification and recertification

146

N J-P et al.
Table 1. Information on 543 physicians taking AIR
Pneumo examination, 2008–2020
Physicians’ characteristics

Number (%)

Residing country

Fig. 1. Number of physicians taking certification examination andrecertification examination, 2008–2020.

examinations during the study period. The number ofphysicians taking the certification examination fluctuated every other year until 2017. In 2018 and 2019, theparticipation reached its peak, with over 100 physicians
taking the examination. On the other hand, the number ofphysicians taking the recertification remained below 15
throughout the entire period. Table 1 provides a summary
information regarding the participating physicians. Overthe course of twelve years, physicians from 15 Asian
countries, 4 South American countries, and DR Congo
took the examination. Indonesia had the highest participation rate at 31.1%, followed by Thailand (22.5%), Vietnam(10.3%), India (9.6%), Japan (9%), and Brazil (8.7%).
The reported medical specialties of the participating
physicians, in decreasing order of participation, included
pulmonary medicine, occupational medicine, radiology,
general medicine, and public health. The working duration
since medical graduation ranged from 1 to 41 yr. Twentyone percent of the physicians reported they had neverencountered a pneumoconiosis chest radiograph. Table 2
presents the pass and fail rates, as well as the mean scoresfor the total proficiency assessment and each component,in the certification and recertification examinations.
Throughout the study period, the passing rate for the certification examination was 83.4% (453 out of 543), while
the recertification examination had a passing rate of 76.8%(53 out of 69). The mean total score for those who passed
the certification and recertification was 77.6 ± 9.4 and 88.1
± 4.5, respectively. Physicians who failed the certification
examination scored considerably lower than 60% of the
maximum possible score in consistency of classifying
profusion of small opacities (mean score: 11.0 out of 25
points), accuracy in identifying small opacities (meanIndonesia

169 (31.1)

Thailand122 (22.5)

Vietnam

56 (10.3)

India

52 (9.6)

Japan

49 (9.0)

Brazil†47 (8.7)

Philippines

23 (4.2)

Malaysia

15 (2.8)

Others‡10 (1.8)

Specialty
Pulmonology

164 (30.2)

Occupational medicine

147 (27.1)

Radiology

101 (18.6)

General medicine

55 (10.1)

Public health

20 (3.7)

Others4 (0.7)

Not reported

52 (9.6)

Sex
Female251 (46.2)

Male

237 (43.7)

Not reported

55 (10.1)

Time since graduation, yr
Median (range)

10 (1–41)≤5

129 (23.8)

6–10

112 (20.6)≥11

222 (40.9)

Not reported

80 (14.7)

Number of reviewed pneumoconiosis chest
radiograph in the pastNone

114 (21.0)<10 films

194 (35.7)<50 films

90 (16.6)≥50 films

95 (17.5)

Not reported

50 (9.2)†including physicians from Argentina, Chile, and Peru.
‡including physicians from Brunei, Cambodia, People’s Re-

public of China, DR Congo, Hong Kong, Kingdom of Bhutan,
Myanmar, Parkistan, Taiwan.
AIR Pneumo: Asian Intensive Reader of Pneumoconiosis.

score: 14.9 out of 30 points), and pleural plaques (meanscore: 5.7 out of 15 points). Physicians who failed therecertification examination achieved comparable scoresto those who passed the certification examination, except
for slightly lower scores in accuracy of identifying small
opacities (mean score: 21.4 versus 25.0) and consistencyof classifying profusion of small opacities (mean score:
13.5 versus 16.1).
Industrial Health 2024, 62, 143–152

147

AIR PNEUMO EXAMINATION FOR READING PNEUMOCONIOSIS CXRTable 2.

Pass and fail rates and proficiency score, according to type of examination, 2008–2020
Certification (n=543)

Pass and fail rate
% (number of physicians)
Assessment areas

Pass
83.4% (453)
Max score

Fail16.6% (90)

Recertification (n=69)
Pass
76.8% (53)Fail
23.2% (16)Proficiency score (Mean ± standard deviation)

Small opacity
Accuracy in identifying small opacity†30

25.0 ± 4.1

14.9 ± 4.9

28.3 ± 1.9

21.4 ± 5.8

Consistency in classifying profusion‡25

16.1 ± 3.5

11.0 ± 2.7

18.8 ± 2.4

13.5 ± 3.6

Consistency in classifying shape‡

15

12.6 ± 1.9

9.4 ± 2.7

13.7 ± 1.0

12.1 ± 1.6

1513.5 ± 1.7

9.9 ± 3.5

14.3 ± 0.8

12.6 ± 2.0

1510.4 ± 3.1

5.7 ± 3.1

13.0 ± 1.6

10.1 ± 2.5

10077.6 ± 9.4

51.0 ± 7.6

88.1 ± 4.5

69.6 ± 8.4

Large opacity
Accuracy in identifying large opacity†
Pleural plaqueAccuracy in identifying pleural plaque†
Total score

Max score, maximum possible score. Passing score in the examination is 60 for certification and 80 for recertification. †Accuracy scores are calculated by the formula: (sensitivity + specificity) − 1. ‡Consistency scores are calculated as percentage
agreement with the readings of a panel of 12 B Readers.

Fig. 2. False-positive (FP) and false-negative (FN) rates in classifying pneumoconiosis, stratified
according to pass (black bar) or fail (gray bar) status in (A) certification examination and (B)recertification examination. Group comparisons were performed using Student’s t-test; *p<0.01;**p<0.001. Error bars represent standard deviations. The ILO International Classification ofRadiographs of Pneumoconioses defines parenchymal abnormalities as small opacities (opacities
with diameters up to 1 cm) or large opacities (opacities larger than 1 cm) and pleural abnormalities
as localized plaques or diffuse pleural thickening (abnormalities extending up the lateral chest wallwith involvement of obliterated costophrenic angle).

Figure 2 (A) and 2 (B) display the false-positive andfalse-negative rates in classifying radiographs for parenchymal and pleural lesions among physicians who passed
and failed the certification and recertification examina-

tions, respectively. The figures indicate that false positives
are more common than false negatives in identifying
small opacities among physicians (except for physicians
who passed the recertification examination), while the148

N J-P et al.

opposite pattern is observed for identifying large opacities
and pleural plaques. Compared to physicians who passed
the examination, physicians who failed had significantly
higher false-positive and false-negative rates in identifying
the lesions (except for the false-positive rate in identifying
large opacities among physicians taking recertification
examinations). Figure 3 (A) and 3 (B), respectively for thecertification and recertification examinations, demonstrate
an over-reading/under-reading tendency among physiciansin classifying small opacity profusion. The figures indicatethat physicians tend to read higher profusion, particularly
those who failed the examination. Compared with true profusion classified by the expert panel, the classifications ofphysicians’ groups were significantly different: χ2 (9)=98.5,
p<0.001 and χ 2 (9)=78.2, p<0.001 for physicians who
passed and failed the certification examinations, respectively; and χ2 (9)=106.2, p<0.001 and χ2 (9)=83.8, p<0.001
for physicians who passed and failed the recertification
examinations, respectively. Table 3 presents the recogni-tion of small opacity shape by the physicians who passed
and failed the examinations. The percentage of physicians
who correctly recognized the shape of small opacities washigher among physicians who passed the examination
than those who failed, and when the radiographs containedrounded opacities compared with irregular opacities.

Discussion
In the present study, we summarized the AIR Pneumo
examinations conducted between 2008 and 2020 andevaluated the differences in radiograph readings between
physicians who passed and those who failed the examination. During this twelve-year period, a total of 555 physicians from approximately 20 countries participated in theexamination. Most physicians were from ASEAN countries and had background training in pulmonology, occupational medicine, or radiology. The increasing number ofparticipants in the recent AIR Pneumo programs indicatesFig. 3. Distribution of classifications for small opacity profusion of 54 test radiographs, stratified according topass or fail status in (A) certification examination and (B) recertification examination. True distribution=classified
by expert panel of 12 B Readers. To determine the profusion category for a group of physicians, we analyzed themost frequently reported profusion category by the physicians in that group. The profusion classified by physicians’
groups was significantly different from the true profusion; p<0.001 for all χ2 tests. The ILO International
Classification of Radiographs of Pneumoconioses utilizes four major profusion categories, ranging from 0 to 3,
indicating the increasing concentration of small opacities (opacities with diameters up to 1 cm).

Industrial Health 2024, 62, 143–152

149

AIR PNEUMO EXAMINATION FOR READING PNEUMOCONIOSIS CXRTable 3.

Proportion of physicians according to their classifications of the shape of small opacities
Certification

Shape of small opacity in the radiographs

Pass (n=453)

Fail (n=90)

Recertification
Pass (n=53)

Fail (n=16)% of physicians (95% Confidence interval)
Pure irregular opacity (4 radiographs)
Negative†

14.0 (12.4–15.6)

24.9 (20.4–29.5)

8.1 (4.4–11.8)

4.7 (0.5–9.9)

Rounded‡15.1 (13.4–16.7)

30.4 (25.6–35.3)

9.5 (5.6–13.5)

14.1 (5.5–22.6)

Irregular§

70.9 (68.8–73.0)

44.6 (39.4–49.9)

82.4 (77.2–87.5)

81.3 (71.7–90.8)

Pure rounded opacity (20 radiographs)
Negative†

2.1 (1.8–2.3)

8.1 (6.9–9.4)

1.8 (1.0–2.6)

2.8 (1.0–4.6)

Rounded‡87.5 (86.8–88.2)

68.5 (66.3–70.6)

92.7 (91.1–94.3)

87.8 (84.2–91.4)

Irregular§

10.5 (9.8–11.1)

23.4 (21.4–25.4)

5.5 (4.1–6.9)

9.4 (6.2–12.6)% of physicians for a given group was the average for radiographs containing a particular shape of small opacities (i.e., 4 radiographswith pure irregular opacity and 20 with pure rounded opacity). Physicians classified the radiographs as: †having no small opacities in theradiograph; ‡the presence of rounded opacities; §the presence of irregular opacities.

a growing interest among physicians from developing
countries in using the ILO classification system. However,the low rate of participation in the recertification examination suggests that physicians are primarily interested inunderstanding the ILO classification system or improving
their knowledge of pneumoconiosis. Furthermore, the low
participation from some countries highlights the importance of specific regulations regarding qualifications forreading and reporting radiographs for pneumoconiosis.
To prioritize workers’ health, developing countries likethose in the ASEAN should establish comprehensive legal
frameworks, similar to those in Japan13) and the UnitedStates14), to ensure the comprehensive provision of healthservices for workers exposed to dust.
The ability to distinguish the presence or absence ofsmall opacities consistent with pneumoconiosis on a chest
radiograph is crucial for screening, epidemiological data,
and legal processes, and this skill is examined in AIR
Pneumo. Physicians who failed the examination classified substantially more radiographs as the presence ofpneumoconiosis than physicians who passed. Specifically,physicians who failed the certification and recertification
examination incorrectly classified 33% and 19.1% ofnormal radiographs as positive for pneumoconiosis, respectively, while the corresponding figures for physicians
who passed were 10.6% and 2.6%. In addition, physicians
who failed tended to read a higher small opacity profusion
than physicians who passed. Similar findings of higher
false-positive rates for pneumoconiosis were reported
among physicians who failed the B Reader examination8).
Although the technical quality of the radiographs may
influence the reading, this was not the case in the present
study. The expert panel graded all radiographs used in the

AIR Pneumo examination as ILO grade 1 (Good) or grade
2 (Acceptable, with no technical defect likely to impair
the classification of the radiograph for pneumoconiosis).
One possible explanation for the overreading of pneumoconiosis is the different thresholds among physicians for
distinguishing between normal and abnormal chest radiographs. It was also likely that less experienced readersinterpreted increased lung markings, for example, thosecommonly seen in the chest radiographs of heavy smokers15), as pneumoconiosis. Lack of familiarity with the
ILO standard radiographs illustrating profusion of small
opacities might contribute to overreading of profusion. In
cases with large opacities of progressive massive fibrosis,
less experienced readers might mistakenly see the fibrotic
distortion of the surrounding lung as increased profusion.
Chest radiograph readings play a crucial role in healthsurveillance for workers exposed to mineral dust and incompensation claims13). Recognizing early radiographic
changes is essential for preventing pneumoconiosis progression in individual workers. However, falsely identifying the disease and overdiagnosing its severity can lead to
substantial economic and social costs.
In the present study, compared to physicians who
passed the examination, those who failed it had a higher
proportion of overlooking or not recognizing large opacities and pleural plaques in test radiographs. They also
failed to notice or incorrectly classified irregular-shaped
small opacities. Unfamiliarity with the appearance oflarge opacities of progressive massive fibrosis, pleuralplaques (especially face-on plaques), and irregular-shaped
small opacities on a chest radiograph might be a possible
reason for these findings. Pleural plaques, characterized bydiscrete areas of pleural thickening, can be challenging to150visualize in a posteroanterior radiograph, leading to a low
detection rate in their radiographic diagnosis16, 17). Pleuralplaques indicate past asbestos exposure, and asbestosis,
which manifests as linear or reticular lesions (The ILO
classification system describes as irregular opacities.), is adiffuse interstitial fibrosis associated with asbestos exposure18). The increasing number of asbestosis cases globallyemphasizes the importance of recognizing plaques andradiographic features of asbestosis1). As the prognosis
and management of asbestosis differ from other forms ofinterstitial lung diseases, such as idiopathic pulmonary
fibrosis, it is crucial to identify these features. Although
the association between pleural plaques and lung cancer
remains inconclusive 19, 20), their presence necessitates
immediate diagnostic work-up to rule out asbestos-related
malignancies.
Role of AIR Pneumo and areas needing improvement
AIR Pneumo has played a crucial role in strengthening
the national pneumoconiosis surveillance system in developing countries by training physicians to use the ILO classification system effectively. The acquisition of knowledge
regarding the ILO classification system, particularly thestandard radiographs, has shown improvements in pneumoconiosis interpretation21). While only a few countries13,
22)
have a similar classification system, the ILO classification system is widely accepted for reporting pneumoconiosis in surveillance programs, epidemiological studies,and compensation claims. Additionally, the screening andmonitoring of pneumoconiosis among workers exposed tomineral dust, using chest radiography and reporting basedon the ILO classification system, are integral componentsof the ILO/WHO’s Global Program for the Eliminationof Silicosis23). It is well recognized that chest radiographs
alone are insufficient for clinically diagnosing parenchymal or pleural changes in pneumoconiosis, particularly inmild cases24). However, a recent study demonstrated thatchest radiography, when compared to low-dose thin-slice
computed tomography, performed adequately in classifying pneumoconiosis according to the ILO classification
system, as assessed by AIR Pneumo or NIOSH-certified
physicians17). Early identification of pneumoconiosis cases
through surveillance programs is crucial for timely intervention and management. Therefore, the establishment ofa national system for pneumoconiosis screening and theenhancement of diagnostic capabilities among physiciansin each country are utmost importance. While certified
AIR Pneumo readers currently contribute to the screening
and surveillance of pneumocosis25), further studies are

N J-P et al.
required to evaluate the effectiveness of the AIR Pneumo
program.
However, our data indicate the need for improvement in
future training programs. First, there should be a greater
emphasis on improving (1) physicians’ ability to recognize
and distinguish early radiographic changes of pneumoconiosis, large opacities of progressive massive fibrosis,
and pleural plaques, and (2) physicians’ consistency inclassifying the profusion of small opacities. To achievethis, training programs can include more radiographs illustrating boundary cases (i.e., ILO profusion subcategory
0/1 and 1/0) and lower profusion (for example, ILO
profusion subcategory 1/1), increased training time to
study the radiographic appearance of irregular opacities,
large opacities of progressive massive fibrosis, and pleuralplaques, and more exposure to the ILO standard radiographs illustrating profusion of small opacities. Additionally, the number of test radiographs can be increased (forexample, to 80 radiographs), specifically including moreradiographs containing irregular opacities, large opacities,
and pleural abnormalities. Second, apart from proficiency
issues, organizing a training program like AIR Pneumo
involves various considerations, such as transportationof training and examination materials (e.g., sets of ILO
standard films, radiographs for self-practice and the test),
preparation of standard view boxes, and hosting participants. Moreover, as chest radiography has transitioned toa digital environment, with the ILO extending the applicability of its classification system to digital radiographic
images26), it is important to address these developments.
Additionally, the increasing participation of physicians in
AIR Pneumo programs requires adapting to new technologies and overcoming previous limitations. Therefore, AIR
Pneumo is developing a web-based program to facilitate
training and examinations. (The training courses can beaccessed via the link provided: https://kmsx.edunext.io/
courses/course-v1:kmsx+AIRP101+2021_T1/about.)
This web-based approach allows participants to download
and study lecture videos at their convenience. Initial pilot
training courses conducted in Japan using similar topics
covered in on-site training have shown promising results.
However, the applicability of this web-based training inother countries requires further research. Furthermore, thetransition to a web-based examination presents feasibility
concerns, such as ensuring participants have access to
medical-grade flat-panel diagnostic monitors.

Industrial Health 2024, 62, 143–152

AIR PNEUMO EXAMINATION FOR READING PNEUMOCONIOSIS CXRConclusions
We conducted a study to examine the participation andperformance of physicians in AIR Pneumo examinations
from 2008 to 2020. The results of our study show that the
number of physicians taking the initial certification test
has increased in recent years. However, we also found thatphysicians who failed the examinations were more likely
to classify radiographs as positive for pneumoconiosis andshow higher small opacity profusion compared to those
who passed. Furthermore, they had a tendency to overlook
or not recognize pleural plaques and incorrectly classify
irregular-shaped small opacities.
Despite the launch of the ILO/WHO’s Global Program
for the Elimination of Silicosis in 1995, which aimed toaddress the widespread issue of pneumoconiosis and protect workers from hazardous substances, millions of workers are still being exposed to these harmful substances, andpneumoconiosis remains prevalent in many developing
countries. Since chest radiography and reporting based on
the ILO classification system are the current standard in
medical surveillance, research, and compensation claims
related to pneumoconiosis, it is essential to make efforts toincrease the number of competent physicians in developing countries who can effectively use the ILO classification system.

Authors’ Contribution
All authors contributed toward data collection andreviewed and approved this manuscript. NA J-P: Writing
original draft, data curation, data analysis, review & editing. NS: Writing initial draft, data curation, data analysis,
review & editing. ADS: Data curation, review & editing.
ES: Data curation, review & editing. MM: Data curation,
review & editing. ST: Data curation, review & editing. SL:
Data curation, review & editing. PS: Data curation, review& editing. SS: Data curation, review & editing. ND: Data
curation, review & editing. EA: Data curation, review &editing. JEP: Data curation, review & editing. KGH: Data
curation, review & editing. HK: Data curation, review &editing. TT: Data curation, review & editing. YK: Data
curation, review & editing.

Disclosure
Approval of the research protocol: This study was approved by the institutional review board of Kochi Medical
School (approval number: 31-68).

151

Informed consent: Due to the nature of this study, i.e.,
using anonymized data from radiograph reading tests, thenoninvasive nature of data collection, and no involvementof biological materials, written informed consent from thephysicians taking AIR Pneumo examinations was waived.
Registry and Registration No. of the study/trial: N/A.
Animal Studies: N/A.
Conflict of interest: None declared.
Data availability: Data (in an anonymized format) areavailable from the corresponding author upon reasonable
request.

Acknowledgments
The AIR Pneumo project entailed a great amount ofwork, research, and dedication. Still, its training andexamination programs would not have been possible
without support from many individuals and organizations.
Therefore, we would like to extend our sincere gratitude to
all of them, but the list here is not exhaustive. The authors
gratefully acknowledge (1) the Supporting Bodies for the
AIR Pneumo program, which includes the Scientific Committee on Respiratory Diseases, International Commission
on Occupational Health (ICOH), Asian Pacific Societyof Respirology, Japan Society for Occupational Health(JSOH), and University of Fukui (Fukui, Japan); (2) the
co-organizers, which include the Thailand Association of
Occupational and Environmental Diseases and the Central Chest Institute of Thailand, Bureau of Occupational
and Environmental Diseases, Ministry of Public Health(Thailand); (3) the sponsors, which include Thailand
Workmen’s Compensation Fund and Social Security Office (Thailand); (4) personal advisors, which include Dr.
Prahalad K. Sishodiya (India), Kazutaka Kogi (Japan), andYoshiharu Aizawa (Japan), G.R. Wagner (USA), Dr. Tran
Anh Thanhh (Vietnam), Dr. Khuong Van Duy (Vietnam);and (5) the volunteer experts who devoted their time andknowledge in the training programs as lecturers.

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Industrial Health 2022, 60, 459 – 469

Original Article

Inter-observer agreement and accuracy inclassifying radiographs for pneumoconiosis among
Asian physicians taking AIR Pneumo certification
examination
Naw Awn J-P1, Agus Dwi SUSANTO2, Erlang SAMOEDRO2, Muchtaruddin MANSYUR3,
Sutarat TUNGSAGUNWATTANA4, Saijai LERTROJANAPUNYA4,
Ponglada SUBHANNACHART4, Somkiat SIRIRUTTANAPRUK5, Narongpon DUMAVIBHAT6,
Eduardo ALGRANTI7, John E. PARKER8, Kurt G. HERING9, Hitomi KANAYAMA10,Taro TAMURA11, Yukinori KUSAKA12, 13 and Narufumi SUGANUMA1*
1

Department of Environmental Medicine, Kochi Medical School, Kochi University, Japan
Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Indonesia,
Persahabatan Hospital, Indonesia
3
Department of Community Medicine, Faculty of Medicine, Universitas Indonesia & Southeast Asian
Ministers of Education Regional Centre for Food and Nutrition (SEAMEO RECFON), Indonesia
4
Department of radiology, Central Chest Institute of Thailand, Department of Medical Services, Ministry of
Public Health, Thailand
5
Department of Disease Control, Ministry of Public Health, Thailand
6
Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University,
Thailand7
Division of Applied Research, FUNDACENTRO, Brazil
8
Pulmonary and Critical Care Medicine, Robert C. Byrd Health Sciences Center, School of Medicine, West
Virginia University, USA
9
Department of Diagnostic Radiology, Radio-oncology and Nuclear Medicine, Radiological Clinic, Miner’s
Hospital. Klinikum-Westfalen (Knappschaftskrankenhaus), Germany
10
Division of Environmental Health, Department of International Social and Health Sciences, Faculty of
Medical Sciences, University of Fukui, Japan
11
Fukui City Public Health Center, Japan
12
School of Medical Sciences, University of Fukui, Japan
13
Kochi Medical School, Kochi University, Japan2

Received September 14, 2021 and accepted November 13, 2021
Published online in J-STAGE November 23, 2021
DOI https://doi.org/10.2486/indhealth.2021-0210

Abstract: This study examined inter-observer agreement and diagnostic accuracy in classifying
radiographs for pneumoconiosis among Asian physicians taking the AIR Pneumo examination.
We compared agreement and diagnostic accuracy for parenchymal and pleural lesions across*To whom correspondence should be addressed.
E-mail address: nsuganuma@kochi-u.ac.jp©️2022 National Institute of Occupational Safety and HealthThis is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (by-nc-nd) License.
(CC-BY-NC-ND 4.0: https://creativecommons.org/licenses/by-nc-nd/4.0/)

N Awn J-P et al.

460

residing countries, specialty training, and work experience using data on 93 physicians. Physicians
demonstrated fair to good agreement with kappa values 0.30 (95% CI: 0.20–0.40), 0.29 (95% CI:
0.23–0.36), 0.59 (95% CI: 0.52–0.67), and 0.65 (95% CI: 0.55–0.74) in classifying pleural plaques,small opacity shapes, small opacity profusion, and large opacities, respectively. Kappa values
among Asian countries ranging from 0.25 to 0.55 (pleural plaques), 0.47 to 0.73 (small opacity
profusion), and 0.55 to 0.69 (large opacity size). The median Youden’s J index (interquartile range)
for classifying pleural plaque, small opacity, and large opacity was 61.1 (25.5), 76.8 (29.3), and 88.9
(23.3), respectively. Radiologists and recent graduates showed superior performance than othergroups regarding agreement and accuracy in classifying all types of lesions. In conclusion, Asian
physicians taking the AIR Pneumo examination were better at classifying parenchymal lesions thanpleural plaques using the ILO classification. The degree of agreement and accuracy was different
among countries and was associated with background specialty training.

Key words: AIR Pneumo, Chest radiograph, Diagnostic accuracy, Occupational health, Pneumoconiosis,
Reader agreement

Introduction
Pneumoconiosis, a diffuse lung disease caused by inhaled industrial or environmental dust, presents radiographically with multiple reticular or variable-sized nodular opacities1). Pleural plaque, an irregular, circumscribedarea of dense, firm, fibrous tissue, usually resulting fromasbestos exposure, appears radiographically as discrete areas of pleural thickening2). Screening for lung or pleuralchanges in a dust-exposed worker is performed primarily
by periodic reviews of chest radiographs3). The detection
and interpretation of the two conditions in a chest radiograph is highly subjective and reader-dependent. To standardize reports and facilitate international comparison ofdata, the International Labour Office developed a classification system (ILO classification)4). This classification system is composed of guidelines and a set of standard radiographs, exemplifying the spectrum of the disease. The ILO
published the first edition in 1950 and made several revisions to clarify ambiguities in earlier editions but preserved
the basic structure of the system. Since its establishment,
the ILO classification is increasingly being adopted internationally for use in epidemiological research, screening,and surveillance of pneumoconiosis.
Screening and surveillance programs are very effectiveat detecting new cases of pneumoconiosis and also provide
information about trend and burden of disease in workers
exposed to mineral dust5). To promote the efficiency of
screening programs in developing countries, the Asian Intensive Reader of Pneumoconiosis (AIR Pneumo) provides
training and examination programs for raising physicians

who can perform the ILO classification6). At the end of
2019, more than five hundred physicians had received
training since the program began in 2006. The participating
physicians have expertise in general medicine, occupational medicine, public health, pulmonology, and radiology.
They include physicians from several developing Asian
countries who were practicing in hospitals or working in
corporations, government institutions and ministries. Most
importantly, they have been working on pneumoconiosis
screening.
Despite using the ILO classification, substantial variation in the interpretation of radiographs for pneumoconiosis exists among physicians7, 8). Thus, before sharing epidemiological information, it is worth understanding the extent
of inter-observer agreement and diagnostic accuracy among
physicians of Asian countries. Therefore, the objective of
this study was to examine the degree of observer agreement, diagnostic accuracy, and possible causes for reader
variability in classifying radiographs for pneumoconiosis
using reading results of Asian physicians taking the AIR
Pneumo examinations.

Subjects and Methods
AIR Pneumo’s examination film set
The AIR Pneumo’s examination film set is composed of
60 chest radiographs; the diagnosis of each radiograph wasestablished by a panel of experts formed by 12 National
Institute for Occupational Safety and Health of the UnitedStates (NIOSH) certified B Readers. The technical qualityof the radiographs was classified by the 12 B Readers as
ILO grade 1 (Good) or 2 (Acceptable, with no technicalIndustrial Health 2022, 60, 459 – 469

CLASSIFYING PNEUMOCONIOSIS BY AIR PNEUMO READERS
defect likely to impair classification of the radiograph forpneumoconiosis)4). The 60-film set includes 20 radiographswith no reticular or nodular lesions, 9 boundary cases (ILO
profusion classification 0/1 or 1/0), and 31 radiographswith small opacities (ILO profusion classification 1/1 orhigher). Among the radiographs with small opacities, 20
have purely rounded while 4 have purely irregular opacities. Of the 31 radiographs with small opacities, 9 also havevarying sizes of large opacities (opacities with the longest
diameter larger than 1 cm). Nine of the 60 examination
films have pleural plaques with or without calcification.
Details of the AIR Pneumo’s training program, development of training materials (including chest radiographs),
examination, and scoring system have been published previously9, 10).
Physicians’ information and radiograph reading data
Our study used 5,580 readings of 93 physicians from thetwo examinations conducted in Thailand (December 2018)
and Indonesia (February 2019). They had taken the examination after completing an intensive 2-day AIR Pneumo
training course. Physicians’ information, including residing
country, specialty training, and work experience, was collected through self-administered questionnaires. During theexaminations, physicians independently read the chest radiographs on a standard view box in a comfortable reading
room (controllable lighting with no direct sunlight) and reported the findings on reading sheets according to the ILO
classification. They were given three hours to classify 60
radiographs. Each radiograph was graded for technicalquality. Small opacities were classified according to theirshape (rounded or irregular), size (size up to 1.5mm, 1.5–
3mm, or 3–10mm), location (upper, middle, or lower lungzones), and profusion. Profusion was determined by sideby-side comparison with ILO standard radiographs andclassified on a twelve-point scale with increasing order ofconcentration (codify as 0/− to 3/+ within four major profusion classifications: 0, 1, 2, and 3). Large opacities wereclassified as size A, B, or C, corresponding to size up to 5
cm, up to right upper lung zone, or exceeding right upper
lung zone. The presence or absence of pleural plaques, theirextent and width if any were recorded. We extracted dataon the profusion and shape classifications of small opacities. We also obtained the size classifications of large opacities and the presence or absence of pleural plaques. Classifications on the size and location of small opacities and thetechnical quality of radiographs were not the purpose ofthis study.

461

Statistical analysis
We grouped physicians according to their residing country, specialty training, and experiences. Considering thenumber of years required to develop medical experience or
to enroll in specialty training, years after graduation wasgrouped as “5 or fewer years”, “6 to 10 years”, or “11 ormore years”. Information on the total number of reviewed
pneumoconiosis chest radiographs, the participating physicians have encountered since they became physicians, wascollected as “none”, “less than 10”, “10 to 50”, or “50 ormore”. For small opacity profusion, we examined inter-observer agreement on four major profusion classifications as
they showed a close correlation to the clinical severity of“normal,” “mild,” “moderate”, or “severe” conditions11).
When computing agreement on small opacity shape, weused only the data of 40 radiographs, i.e., 9 boundary casesand 31 radiographs with small opacities. For the other analyses, we used data of all 60 radiographs. We used a Stata
module ‘kappaetc’ to compute inter-observer agreement inphysicians overall and each group formed by residing
country, specialty training, or experience12). This command
can handle any number of observers and any number ofcategories. It calculates the agreement coefficient by averaging the observed agreement over all pairs of observers. It
also provides seven prerecorded weights, suitable for any
level of measurement. We computed weighted Fleiss’ kappa to quantify the degree of agreement in classifying small
opacity profusion and large opacity size and unweighted
Fleiss’ kappa for agreement on small opacity shape and thepresence or absence of pleural plaques13). The result wasinterpreted values <0.2 as poor agreement, 0.21–0.4 as fair,
0.41–0.6 as moderate, 0.61–0.8 as good, and 0.81–1.0 as
almost perfect agreement. Accuracy, in this study, was theability to discriminate between normal and abnormal radiographs, i.e., the ability to classify a radiograph for the presence or absence of small opacities, large opacities, or pleural plaque; the true condition for each chest radiograph was
determined based on the reading results of expert panel.
Accuracy of the physicians was assessed by using only thechest radiographs that were in complete agreement for thepresence or absence of small opacities, large opacities, or
pleural plaque by all expert B Readers. There were 31 radiographs with and 20 radiographs without small opacities;
9 radiographs with and 41 radiographs without large opacities; 9 radiographs with and 30 radiographs without pleural plaques. A classification of 1/0 or higher profusion andany of the size classifications for large opacity by the physicians was considered as identification of small opacities

N Awn J-P et al.

462
Table 1. Information of the physicians
Table 1. Information of the physicians
Physicians

CountryTotal(n=93)

1(n=6)

2(n=54)
Number of physicians (%)

3(n=10)

4(n=23)

GenderFemaleMale

50 (53.8)
34 (36.6)

2 (33.3)
4 (66.7)

32 (59.3)
17 (31.5)5 (50.0)
5 (50.0)

11 (47.8)
8 (34.8)9 (9.7)0

5 (9.3)0

4 (17.4)

40 (43.0)
25 (26.9)

0
4 (66.7)

38 (70.4)
10 (18.5)

1 (10.0)
6 (60.0)

1 (4.3)5 (21.7)

4 (4.3)15 (16.1)
9 (9.7)

1 (16.7)
0
1 (16.7)

02 (3.7)4 (7.4)2 (20.0)
1 (10.0)0

1 (4.3)12 (52.2)
4 (17.4)

6 (1–34)
37 (39.8)
27 (29.0)
15 (16.1)

15 (5–30)
1 (16.7)
2 (33.3)
3 (50.0)

6 (1–34)
21 (38.9)
16 (29.6)
7 (13.0)

8.5 (4–23)
1 (10.0)
6 (60.0)
3 (30.0)

3 (1–34)
14 (60.9)
3 (13.0)
2 (8.7)

Missing
14 (15.1)
Number of reviewed pneumoconiosis CXR
None
17 (18.3)<1041 (44.1)

0

10 (18.5)

0

4 (17.4)

02 (33.3)

12 (22.2)
27 (50.0)

3 (30.0)
3 (30.0)

2 (8.7)9 (39.1)

2 (33.3)
2 (33.3)
08 (14.8)
2 (3.7)5 (9.3)4 (40.0)00

6 (26.1)
2 (8.7)4 (17.4)

MissingSpecialty
Pulmonology
Occupational medicine
Public healthRadiology
Missing
Years after graduation
Median (range)
≤5
6–10
≥11

<50
≥50
Missing

20 (21.5)
6 (6.4)9 (9.7)and large opacities, respectively. We examined the accuracy of each physician group by plotting receiver operating
characteristic (ROC) curves and computing area under the
curves (AUC) against experts’ diagnosis as a reference
standard. An ROC curve that plots sensitivity against
1-specificity allows visual inspection of the discriminating
power, while AUC quantifies the power with a value of 1.0
representing perfect discriminatory ability and 0.5 being at
chance level14). We used Stata’s ‘roccomp’ command to execute ROC analysis. Assuming sensitivity and specificity
are equally important in identifying each type of lesion, we
calculated Youden’s J index (i.e., sensitivity + specificity –1) as a global measure of accuracy for every physician15);
multiplying the index by one hundred generated accuracy
scores. For the accuracy score for small opacity shape classification, we computed percent agreement with the reading results of expert panel. There were 20 radiographs withpurely rounded and 4 with purely irregular opacities. We
then compared the accuracy scores between physiciangroups using the Kruskal-Wallis test with Bonferroni correction for multiple comparisons. All analyses were performed using Stata/MP 15.1 software (StataCorp., College

Station, TX, USA). This study was approved by the institutional review board of Kochi Medical School (approval
number: 31-68). Written informed consent from the participating physicians was waived, but opt-out consent was
obtained via e-mails instead.

Results
Table 1 presents information about our physicians. Information on specialty training and experiences (years after
graduation and the number of reviewed pneumoconiosis
chest radiographs) were not reported by some participating
physicians. Physicians resided in India, Indonesia, Malaysia, and Thailand. They had expertise in occupational medicine, public health, respiratory health, and radiology. Specialties’ representation was uneven between countries.
Working duration since medical graduation ranged from 1
to 34 years. Eighteen percent of our physicians reported
they had never seen a pneumoconiosis chest radiograph,
while 44% encountered less than ten in their work.
Table 2 presents the kappa values for classifying chest
radiographs by physicians overall and by the groups studIndustrial Health 2022, 60, 459 – 469

463

CLASSIFYING PNEUMOCONIOSIS BY AIR PNEUMO READERS
Table 2. Inter-observer agreement in classifying radiographs for pneumoconiosisa
Table 2. Inter-observer agreement in classifying radiographs for pneumoconiosisa
Small opacity
profusionb
Physician overall
Country1
2

0.59 (0.52–0.67)

34Specialty
Pulmonology

0.47 (0.38–0.55)
0.73 (0.66–0.80)

Occupational medicine
Public healthRadiology
Years after graduation

0.50 (0.39–0.61)
0.59 (0.51–0.67)

0.62 (0.54–0.69)
0.53 (0.45–0.61)
0.51 (0.39–0.64)
0.69 (0.61–0.77)≤50.67 (0.60–0.75)
6–10
0.52 (0.44–0.61)≥11
0.53 (0.45–0.61)
Number of reviewed pneumoconiosis CXR
None
<10
<50
≥50

0.55 (0.48–0.62)
0.63 (0.55–0.71)
0.56 (0.47–0.64)
0.53 (0.42–0.64)

Small opacity shapec

Large opacity sizeb

Fleiss’ kappa coefficient (95% CI)
0.29 (0.23–0.36)
0.65 (0.55–0.74)
0.18 (0.05–0.32)
0.26 (0.20–0.32)
0.21 (0.13–0.30)
0.56 (0.48–0.65)
0.26 (0.20–0.31)
0.28 (0.20–0.37)
0.12 (0.02–0.22)
0.54 (0.45–0.64)
0.39 (0.32–0.46)
0.21 (0.16–0.27)
0.28 (0.20–0.36)
0.23 (0.15–0.31)
0.32 (0.26–0.39)
0.31 (0.24–0.38)
0.23 (0.11–0.36)

Presence of pleuralplaquec
0.30 (0.20–0.40)

0.57 (0.42–0.72)
0.66 (0.57–0.75)

0.34 (0.19–0.49)
0.25 (0.16–0.34)

0.55 (0.40–0.70)
0.69 (0.59–0.79)

0.31 (0.20–0.42)
0.55 (0.42–0.68)

0.69 (0.61–0.77)

0.29 (0.19–0.38)

0.56 (0.44–0.68)
0.56 (0.38–0.75)
0.74 (0.64–0.83)

0.26 (0.16–0.35)
0.30 (0.12–0.48)
0.58 (0.44–0.71)

0.72 (0.63–0.80)
0.59 (0.48–0.70)
0.55 (0.43–0.67)

0.39 (0.27–0.51)
0.26 (0.17–0.35)
0.24 (0.14–0.34)

0.61 (0.52–0.70)
0.68 (0.58–0.78)
0.60 (0.46–0.73)
0.68 (0.57–0.79)

0.22 (0.14–0.30)
0.33 (0.22–0.43)
0.29 (0.17–0.41)
0.34 (0.19–0.49)

a= Computation included the readings of 40 radiographs (9 boundary cases and 31 radiographs with small opacities) for “small opacity
shape”; included readings of all 60 radiographs for the others. b= Weighted kappa coefficient. c= Unweighted kappa coefficient.
All kappa coefficients were significant at p<0.001.
Interpretation of kappa coefficients: <0.2 = poor, 0.21–0.4 = fair, 0.41–0.6 = moderate, 0.61–0.8 = good, and 0.81–1.0 = almost perfectagreement.

ied. Physicians showed fair to good agreement with kappavalues 0.30 (95% CI: 0.20–0.40), 0.29 (95% CI: 0.23–0.36), 0.59 (95% CI: 0.52–0.67), and 0.65 (95% CI: 0.55–0.74), respectively for classifying pleural plaques, small
opacity shapes, small opacity profusion, and large opacities. The degree of agreement was different among physician groups. Physicians from Country 4, or groups formedby physicians who received radiology training, or were fiveor fewer years working after graduation, achieved the highest agreement in all types of lesion.
Fig. 1 depicts the ROC curves and average AUC valuesof the physician groups for each pneumoconiotic lesion.
Table 3 compares physician groups for their accuracy
scores. Accuracy in identifying small opacities, large opacities, and the pleural plaques, as determined by AUC andaccuracy scores, was different among physician groups.
Physicians from Country 4, or with radiology training, or
who were five or fewer years working after graduation,
showed the highest accuracy (Fig. 1 and Table 3). Accuracy
scores for small opacity shape classification showed a sim-

ilar pattern of differences (Table 3). No substantial difference in accuracy was detected between groups formed by
the reported number of reviewed pneumoconiosis chest radiographs (Table 3).

Discussion
To our knowledge, this study is the first in comparing
inter-observer agreement and accuracy in classifying radiographs for pneumoconiotic lesions using the ILO classification among physicians from different Asian countries. We
observed that the degree of inter-observer agreement anddiagnostic accuracy varied with the observer’s characteristics, namely, residing country, specialty training, and timeafter graduation.
Physicians in this study showed better agreement in classifying parenchymal lesions than pleural plaques using theILO classification. However, they agreed on the shape ofsmall opacities poorly. The degree of agreement varied between countries, with kappa values ranging from 0.47 to464

N Awn J-P et al.

Fig. 1
A

B

C

D

Fig. 1. Accuracy in classifying radiographs for the presence or absence of pneumoconiosis.
Average AUC values of physician groups formed by (A) country, (B) specialty, (C) years
after graduation, and (D) number of reviewed pneumoconiosis chest radiographs.

Industrial Health 2022, 60, 459 – 469

465

CLASSIFYING PNEUMOCONIOSIS BY AIR PNEUMO READERS
Table 3. Comparison between physician groups for accuracy in classifying radiographs for pneumoconiosis
Table 3. Comparison between physician groups for accuracy in classifying radiographs for pneumoconiosis
Physicians

Small opacity

NumberPhysician overall
Country
1
2

Small opacity
Large opacity
shape
Accuracy scorea, Median (Interquartile range)

Pleural plaque93

76.8 (29.3)

83.3 (25)88.9 (23.3)

61.1 (25.5)

6
54
10

63.7 (13.5)***73.9 (30.8)***62.5 (16.8)***79.2 (12.5)
75 (20.8)***66.7 (20.8)***74.1 (27.1)
88.9 (20.9)
77.2 (19.5)**

68.3 (15.6)
56.1 (25.5)***55.0 (15.6)***3
4 (Reference)
Kruskal-Wallis test
Specialty
Radiology (Reference)

23

91.8 (12.9)
p<0.00195.8 (12.5)
p<0.001

97.6 (13.5)
p=0.01285.6 (18.9)
p<0.00115

91.8 (25.0)

100 (16.7)

100 (13.5)

85.6 (18.9)

Pulmonology
Occupational healthPublic health

40
25
4

77.1 (26.0)*
67.1 (35.8)**
74.6 (32.2)
p=0.005

79.2 (22.9)**75 (16.7)**
70.8 (31.2)*
p=0.00295.1 (16.0)
81.6 (30.6)**
72.4 (12.9)*
p=0.00358.3 (25.0)***60.0 (15.5)***47.8 (13.3)***p<0.00137
27
15

87.1 (19.7)
70.0 (34.4)**
67.1 (27.6)**

87.5 (20.8)
66.7 (29.2)***
83.3 (12.5)

97.6 (11.1)
84.0 (20.9)**
85.4 (16.0)*

75.6 (27.8)
55.6 (38.9)**
57.8 (15.6)**

p<0.001p= 0.002

p=0.005

p=0.00170 (27.1)
83.9 (26.8)

75 (25)83.3 (25)88.9 (18.4)
95.1 (16.0)

53.3 (25.6)
67.8 (33.3)

75.2 (30.9)
71.2 (26.4)
p=0.1083.3 (22.9)
70.8 (29.2)
p=0.206

82.8 (25.3)
96.3 (8.7)
p=0.11361.1 (28.9)
67.8 (26.7)
p=0.139

Kruskal-Wallis test
Years after graduation≤5 (Reference)
6–10

≥11
Kruskal-Wallis test
Number of reviewed pneumoconiosis CXRNone (Reference)
17
41
<10
<50
≥50
Kruskal-Wallis test

20
6

a= Accuracy scores are calculated as Youden’s J index x 100, except for “small opacity shape”. Scores for “small opacity shape” are percent
agreement with experts’ classification of small opacities as rounded or irregular.
Reference = reference group in Bonferroni correction for multiple comparisons.
p values of Bonferroni correction for multiple comparisons: * p<0.05, ** p<0.01, *** p<0.001.

0.73 (moderate to good agreement) on the distribution ofsmall opacity profusion, from 0.55 to 0.69 (moderate togood agreement) for large opacity size, from 0.25 to 0.55
(fair to moderate agreement) for the presence or absence of
pleural plaques, and 0.18 to 0.56 (poor to moderate agreement) for small opacity shape classification. The poor
agreement between observers for the shape of small opacities was not unexpected. We have noted that of the 40 radiographs with small opacities from the AIR Pneumo examination film set, the expert panel agreed on small opacity
shapes in only 24 radiographs. Moreover, studies that examined the shape classification of small opacities reported
substantial variation existing between observers16, 17). Not
many studies have examined inter-observer agreement involving multiple readers using the ILO classification. One
Japanese study18), which examined inter-observer agreement between film-screen radiography and two digital sys-tems, reported the kappa values for the distribution of small
opacity profusion on a twelve-point scale ranging from0.55 to 0.64. However, their study involved a relatively
small number of subject radiographs (n=30) and readers(n=3). In an American trial where seven B Readers classified 172 coal workers’ chest radiographs, the reported kappa value of 0.58 for agreement on small opacity profusion
was within the range of our results19). In a German study,
seven physicians interpreted chest radiographs of 636 asbestos-exposed workers8). Their reports of an overall kappavalue of 0.29 for small opacity profusion was considerably
lower than the American study and ours, while 0.42 forpleural lesions was within the range of our findings. Another American study7) evaluated 79,185 matched readings by
A and B Readers from a coal workers’ surveillance program; moderate agreement was seen only on the size oflarge opacities (kappa value 0.50). (A Readers and B Read-466
ers are certified by the NIOSH of the USA. A physician canachieve A Reader status by attending a NIOSH-authorizedcourse on the ILO classification system or submitting radiographs to the NIOSH with ILO classifications for review. To become a B Reader, a physician must pass a rigorous competency-based examination and maintaining B
Reader status requires passing the recertification examination every 5 years. In the referenced study7), B Readersclassified more pneumoconiosis chest radiographs than A
Readers did.) The authors concluded that the differences
between readers in terms of training in the use of ILO classification and reading experiences were the likely reasonsfor the observed unsatisfactory agreement in classifying
pleural changes (kappa value 0.16) and small opacity profusion (kappa value 0.24)7). In addition to the observers’
characteristics, we suggested that the differences in study
designs (including the number of radiographs and readers),
the defined classifications for studied conditions, and thequality of chest radiographs being classified might havealso contributed to the varying degree of inter-observer
agreement found across studies.
Specialty training affects the level of diagnostic accuracy and hence the degree of agreement in classifying chest
radiographs for pneumoconiosis. A past study reported theexistence of differences in diagnostic capability between
specialties in reviewing chest radiographs20). Our observation of the radiologists’ group showing the highest performance, followed by the pulmonologists’ group and the other specialties, also support this (Fig. 1; Table 3). Different
physicians may have different thresholds for judging achest radiograph between normal and abnormal. They may
also have differing abilities to observe and recognize radiological appearances of pneumoconiotic lesions. The training to become a radiologist or a pulmonologist differs fromthat of other specialties. Also, radiologists and pulmonologists may have reviewed many more chest radiographs inroutine work than physicians of other specialties. In ourstudy, we observed that radiologists made up the highest
proportion of “Country 4” and pulmonologists formed the
majority in “Country 2” (Table 1); this uneven representation of specialties between countries was the likely sourcefor differences found between countries.
Physicians’ working years, as determined by years after
graduation, did not ensure for a better agreement or higher
accuracy. We observed better performance from the recent
graduates (i.e., five or fewer years working after graduation) (Tables 2 and 3; Fig. 1). Uneven distribution of radiologists and pulmonologists between groups in our study
might be one possible explanation for this observation. One

N Awn J-P et al.
previous study noted that to achieve high-level expertise inradiology requires a combination of radiology-specifictraining and deliberate practice, rather than an absolute
number of working years21). Other reasons might be related
to the nature of the AIR Pneumo training program. Being
younger, recently graduated physicians might be able to absorb more information during the two days of intensive
training than their seniors. Also, recent graduates would
still be familiar with the time-limited examination environment and manage to produce better results.
Physicians’ familiarity with the ILO classification andstandard radiographs likely plays a significant role in thereading performance of our physicians. A past study suggested that the number of reviewed chest radiographs also
contributed to the poor agreement between A Readers and
B Readers7). However, we observed that relatively morenumbers in reviewed pneumoconiosis chest radiographs
appeared to be of no assistance to better observer agreement or higher accuracy in our physicians. A possible explanation might be that our physicians are not using ILO
classification or the standard radiographs in their routine
work. And thus, their reading experiences could not provide superior results in a test that required the ILO classification. Although we had not tested for it, our physicians’
levels of understanding of the ILO classification mightvary, contributing to the variation seen among groups.
Our physicians’ diagnostic accuracy for pleural plaquesappeared less satisfactory compared with parenchymal lesions. This finding was very similar to that observed in the
U.S. B Reader program. Studies reported that physicians
generally classify pleural changes poorly compared withparenchymal lesions, and this nature was the same for physicians who passed or failed the B Reader examinations22,
23). Without specific radiological expertise, the detection of
pleural plaques in a chest radiograph becomes challenging.
Pleural plaques are irregular, circumscribed lesions on theparietal pleura. Radiographically, they appear as discrete
areas of pleural thickening and are barely visible in somecases2). In posteroanterior chest radiographs, shadows ofanatomical structures (e.g., subcostal fat, serratus anterior
muscles) or pleural thickening secondary to medical conditions (e.g., trauma, infection) may mimic plaques, and distinguishing them required a good knowledge of local anatomy and considerable experience2, 24, 25). A systematic
review reported high false-negative and varying false-positive rates in diagnosing pleural plaques on a chest radiograph24). In a recent chest radiograph reading trial involving
four readers with different clinical and radiography interpretation experiences (one B Reader and three AIR PneuIndustrial Health 2022, 60, 459 – 469

CLASSIFYING PNEUMOCONIOSIS BY AIR PNEUMO READERS
mo-certified physicians), the investigators reported a lower
detection rate for pleural plaques compared with those forparenchymal lesions26). They also demonstrated that the detection rate varied among readers, with the most experienced one showing the highest rate. A similar trend was
also seen in a study using surveillance data, where B Readers having far greater experiences in diagnosing pneumoconiosis identified more pleural plaques than A Readersdid7). In the present study, our physicians, except the radiologists, showed a lower accuracy in identifying pleuralplaques when compared with those of parenchymal lesions,indicating specific training is required to develop diagnostic accuracy and improve agreement in the diagnosis of
pleural plaques.
Accurate diagnosis and reporting from physicians are vital to the success of screening programs and disease prevention. The ILO/WHO’s Global Program for the Elimination of Silicosis (GPES), aiming to eliminate new cases ofsilicosis from all workplaces by 2030, set its strategy on
early detection of diseases through surveillance along withdust exposure control27). Similarly, the WHO’s Global campaign for the elimination of asbestos-related disease works
through improving early diagnosis and establishing registries of people with past and/or current exposures alongwith other primary preventive measures28). A recent article
reported the worldwide occurrence of increasing incidenceof pneumoconiosis for the last three decades. Of the 60,055
incident cases in 2017, more than half occurred in Asia:
32,305 cases in China and 5,160 cases in India29). Moreover, as the importation and use of asbestos in developing
Asian countries has been continuing, a substantial numberof people may have been exposed to asbestos occupationally and non-occupationally30). In these circumstances, ourfindings have several important occupational and publichealth implications. First, we reported the degree of inter-observer agreement and sources for variation in classifying pneumoconiotic lesions among Asian physicians taking AIR Pneumo examination. The awareness of variability
allows a careful comparison of results between different
studies and knowledge of the source enables us to recommend measures to correct the variations. Second, we observed a low-level diagnostic accuracy and poor agreement
in classifying radiographs for pleural plaques. Pleuralplaques indicate past exposure to asbestos31); in most cases,
they are asymptomatic and often identified as incidental
chest radiographic findings32). Attending physician’s familiarity with the radiological appearance of pleural plaques iscentral to their identification. The ILO standards radiographs illustrate a spectrum of radiological appearances467

seen in all types of pneumoconiotic lesions4), the use ofwhich permits physicians’ familiarity with radiological appearances of pneumoconiosis, and thereby, improves diagnostic accuracy, especially for less experienced physicians33). Training in the use of the ILO classification, suchas that provided by the AIR Pneumo, might promote physicians’ reading skill further34).
This study has several limitations. First, we used data
derived from examinations. Participants might expect moreradiographs showing signs of pneumoconiosis and assessthem in a manner different from their routine work. However, we believed that the participants’ enthusiasm andcompliance with the standard assessment procedure madethe data featured their actual performance in applying theILO classification. Second, since our physicians have acommon interest in pneumoconiosis, findings in this study
may not necessarily represent the performance of Asian
physicians in general. However, it should be noted that ourphysicians are grossly representing the physician population in pneumoconiosis screening in their respective countries. Third, we do not have information on the requirements of specialty training in each country. But we believethese might differ between specialties and between countries. We suggested the uneven specialty representation
within each country requires careful interpretation of individual country results. Fourth, the different number of readers among the groups studied might affect the estimatedkappa coefficients.

Conclusion
Reviewing chest radiographs using the ILO classification is the current international standard in screening forpneumoconiosis. Asian physicians taking the AIR Pneumo
examination were better at classifying parenchymal lesions
than pleural plaques using the ILO classification. The degree of inter-observer agreement differed among countries,
and this difference was associated with a physician’s specialty training background. Specific training on the use of
the ILO classification, as provided by the AIR Pneumo, andcontinuing practice would improve diagnostic accuracy
and lessen observer variability.

Acknowledgments
The AIR Pneumo project consumed great amount ofwork, research, and dedication. Still, it’s training and examination programs would not have been possible without
supports from many individuals and organizations. There-

N Awn J-P et al.

468
fore, we would like to extend our sincere gratitude to all ofthem, but the list here is not exhaustive. The authors gratefully acknowledge (1) the Supporting Bodies for AIR
Pneumo program, which includes the Scientific Committee
on Respiratory Diseases, International Commission on Occupational Health (ICOH), Asian Pacific Society of Respirology, Japan Society for Occupational Health (JSOH), andUniversity of Fukui (Fukui, Japan); (2) the co-organizers,
which include the Thailand Association of Occupational
and Environmental Diseases and the Central Chest Instituteof Thailand, Bureau of Occupational and Environmental
Diseases, Ministry of Public Health (Thailand); (3) thesponsors, which include Thailand Workmen’s Compensation Fund and Social Security Office (Thailand); (4) personal advisors, which include Dr. Prahalad K. Sishodiya(India), Kazutaka Kogi (Japan), and Yoshiharu Aizawa (Japan), G.R. Wagner (USA), Dr. Tran Anh Thanhh (Vietnam), Dr. Khuong Van Duy (Vietnam); and (5) the volunteer experts who devoted their time and knowledge in the
training programs as lecturers.

Authors’ Contribution
All authors contributed toward data collection and reviewed and approved this manuscript. NA J-P: Writing
original draft, data curation, data analysis, review & editing. NS: Writing original draft, data curation, data analysis,
review & editing. ADS: Data curation, review & editing.
ES: Data curation, review & editing. MM: Data curation,
review & editing. ST: Data curation, review & editing. SL:
Data curation, review & editing. PS: Data curation, review& editing. SS: Data curation, review & editing. ND: Data
curation, review & editing. EA: Data curation, review &editing. JEP: Data curation, review & editing. KGH: Data
curation, review & editing. HK: Data curation, review &editing. TT: Data curation, review & editing. YK: Data curation, review & editing.

3)

4)

5)

6)

7)

8)

9)

10)

11)

12)

Conflict of Interest
None declared.

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European Journal of Radiology 82 (2013) 169–176

Contents lists available at SciVerse ScienceDirect

European Journal of Radiology
journal homepage: www.elsevier.com/locate/ejrad

Evaluation of the efﬁcacy of the guideline on reading CT images of malignant
pleural mesothelioma with reference CT ﬁlms for improving the proﬁciency ofradiologists
Huashi Zhou a,1 , Taro Tamura a,2 , Yukinori Kusaka a,∗ , Narufumi Suganuma b,3 ,Ponglada Subhannachart c,4 , Chomphunut Vijitsanguan c,4 , Weeraya Noisiri c,4 , Kurt G. Hering d,5 ,Masanori Akira e,6 , Harumi Itoh a,f,7 , Hiroaki Arakawa g,8 , Yuichi Ishikawa h,9 , Shinji Kumagai i,10 ,Norio Kurumatani j,11a

Department of Environmental Health, School of Medicine University of Fukui, 23-3 Shimoaitsuki, Matsuoka, Eihezi-cho, Fukui Prefecture, 910-1193, Japan
Department of Environmental Medicine, Kochi University School of Medicine, Japan
Central Chest Disease Institute of Thailand, 39 Moo 9, Tiwanon Road, Muang Nonthaburi, 11000, ThailanddDepartment of Diagnostic Radiology, Radiooncology and Nuclear Medicine, Radiological Clinic, Miner’s Hospital, Radiologische Klinik, Lansppaschaftskranhaus Dortmund, Wieckesweg 27, 44309, Dortmund, GermanyeDepartment of Radiology, National Hospital Organization Kinki-Chuo Chest Medical Center, 1180 Nagasone-cho, Kita-ku, Sakai, Osaka, 591-8555, Japanf
Department of Radiology, School of Medicine, University of Fukui, 23-3 Shimoaitsuki Matsuoka, Eiheizi-cho, Fukui Prefecture, 910-1193, Japang
Department of Radiology, Dokkyo University School of Medicine, 880 Oaza-Kitakobayashi, Mibu-cho, Shimotsuga-gun, Tochigi, 321-0207, Japanh
Department of Pathology, Cancer Institute, 1-37-1 Kami-ikebukuro, Toshima-ku, Tokyo, 170-8455, Japani
Department of Environmental Management, School of Health Sciences, University of Occupational and Environmental Health, University of Occupational and Environmental Health,
1-1, Iseigaoka, Yahata-nishi-ku, Fukuoka, Kitakyushu, 807-8555, Japanj
Department of Community Health and Epidemiology, Nara Medical University School of Medicine, 840 Shijo-cho Kashihara, Nara, 634-8521, Japanbca r t i c l e

i n f oArticle history:
Received 2 March 2012
Received in revised form 20 May 2012
Accepted 21 May 2012
Keywords:
Computed tomography
Malignant pleural mesothelioma
Guideline
Sensitivity
Speciﬁcity
Agreementa b s t r a c t
Purpose: To assess the efﬁcacy of the developed guideline on reading CT images of malignant pleural
mesothelioma for improving radiologists’ reading proﬁciency.
Materials and Methods: Three radiologists independently read the CT ﬁlms of 22 cases including deﬁnite
mesothelioma and non-mesothelioma cases at two times before and after studying the malignant pleural
mesothelioma CT Guideline. The sensitivity and speciﬁcity for mesothelioma were calculated and compared between the 1st and 2nd trials. The kappa statistics was examined for agreement with experts formesothelioma probability and for mesothelioma features recorded by three radiologists.
Results: After studying the mesothelioma CT Guideline, the sensitivity for mesothelioma shown by thethree radiologists at the 2nd trial was 100%, 100% and 80%, which were higher than 80%, 85% and 60%
at the 1st trial, respectively. The average kappa for agreement between radiologists and experts ondichotomized mesothelioma probability were 0.69 (good) at the 2nd trial vs. 0.38 (fair) at the 1st trial.
The average kappa for the agreement with experts for each of 7 features by three radiologists were0.52–0.80 at the 2nd trial, which were signiﬁcantly higher than 0.34–0.58 at the 1st trial (Wilcoxon
Signed Rank Test: P < 0.01), and as to ﬁve features “unilateral pleural effusion”, “nodular pleural thickening”, “tumoral encasement of lung”, “mediastinal pleural thickening”, and “diminished lung”, they
achieved good agreement with average kappa of 0.61–0.80.
Conclusion: The developed mesothelioma CT Guideline was suggested to have substantial effect in improving the radiologists’ proﬁciency for reading CT images of mesothelioma, and may contribute to accurate
diagnosis of mesothelioma.
© 2012 Elsevier Ireland Ltd. All rights reserved.

∗ Corresponding author. Tel.: +81 776 61 8335; fax: +81 776 61 8107.
E-mail addresses: zhouhua@u-fukui.ac.jp (H. Zhou), tarou@u-fukui.ac.jp(T. Tamura), kusakayk@gmail.com (Y. Kusaka), nsuganuma@kochi-u.ac.jp(N. Suganuma), pongladas@gmail.com (P. Subhannachart), Chompoo vj@yahoo.com(C. Vijitsanguan), weeraya tat@yahoo.com (W. Noisiri), k.g.hering@t-online.de(K.G. Hering), akira@kch.hosp.go.jp (M. Akira), hitoh@fmsrsa.fukui-med.ac.jp(H. Itoh), arakawa@dokkyomed.ac.jp (H. Arakawa), ishikawa@jfcr.or.jp(Y. Ishikawa), shkumagai@health.uoeh-u.ac.jp (S. Kumagai),knorio@naramed-u.ac.jp (N. Kurumatani).
1Tel.: +81 776 61 8338; fax: +81 776 61 8107.
0720-048X/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ejrad.2012.05.022

2

Tel.: +81 776 61 8335; fax: +81 776 61 8107.
Tel.: +81 88 880 2407; fax: +81 88 880 2407.
4
Tel.: +66 2 5803423x7505; fax: +66 2 5806992.
5
Tel.: +49 0 231 9221280; fax: +49 0 231 9221648.
6
Tel.: +81 722 52 3021; fax: +81 722 51 1372.
7
Tel.: +81 776 61 8368; fax: +81 776 61 8137.
8
Tel.: +81 282 87 2171; fax: +81 282 86 4940.
9Tel.: +81 3 3570 0448; fax: +81 3 3570 0558.
10
Tel.: +81 93 691 7282; fax: +81 93 691 2694.
11
Tel.: +81 744 298841; fax: +81 744 290673.
3

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H. Zhou et al. / European Journal of Radiology 82 (2013) 169–176

1. Introduction
The International Classiﬁcation of HRCT for Occupational and Environmental Respiratory Diseases (ICOERD) was developed and used
for occupational diseases screening, epidemiology study, and clinical study for respiratory diseases caused by occupational andenvironmental factors [1]. In order to supply ICOERD, we havedeveloped the Guideline on Reading CT Films of Malignant Pleural
Mesothelioma (MPM-CT Guideline) and selected MPM reference CT
ﬁlms [2]. The MPM-CT Guideline provides the terminology of MPM
CT features and the MPM probability, the judgment for MPM interms of involvement distribution and severity, as well as a method
to record the CT ﬁnding of MPM on the CT reading sheet. The purpose of the current study was to investigate the efﬁcacy of thedeveloped MPM-CT Guideline with the MPM reference CT ﬁlms
for improving the proﬁciency of the inexperienced radiologists inreading CT images of MPM.
2. Materials and methods

asbestos exposure history, and the clinical and histological diagnosis for any cases.
At the 1st CT reading trial, the three radiologists were requested
to read the monograph of ICOERD and the ICOERD CT referenceﬁlms, but not to read the MPM-CT Guideline nor the MPM reference CT ﬁlms, then they read the 22 subject CT ﬁlms independently.
The CT ﬁndings associated with asbestosis were recorded according
to ICOERD guideline; the MPM features and the MPM probability
grade for each case were recorded into the reading sheet according
to their experiences.
The interval between the 1st and the 2nd CT reading trials by
the three radiologists was at least three months. At the 2nd trial,
before reading the subject CT ﬁlms, the three radiologists read the
ICOERD guideline with the ICOERD CT reference ﬁlms again. They
also independently studied the MPM-CT Guideline with the MPM
reference CT ﬁlms, and then independently read the 22 subject CT
ﬁlms. They made use of the ICOERD CT reference ﬁlms and the MPM
reference CT ﬁlms to record the CT ﬁndings for pneumoconiosis, theMPM ﬁndings, and the MPM probability grade in the CT reading
sheets.

2.1. Subject CT ﬁlms
CT ﬁlms of ﬁfty seven cases including MPM, lung cancer, othermalignancies, and benign pleural plaque were collected from thecitizens living in the neighborhood of the Kubota factory, a large
asbestos cement pipe factory in Amagasaki City, Hyogo Prefecture, Japan. Their MPM was caused by environmental exposure toasbestos (mainly crocidolite) air pollution from the Kubota asbestos
factory [3].
Out of the 57 cases, 22 cases including 20 deﬁnite MPM casesand 2 pleural plaque cases were subjected to study. The MPM cases
were clinically diagnosed as MPM at local hospitals and both pathologically and immunohistochemically conﬁrmed [4,5]. Among the
20 cases of MPM, 7 cases were female, and 13 cases were male. The
two cases of pleural plaque were male.
Among the 20 MPM cases, the diffuse type of MPM accounted
for 18 (90%), and the localized type for the other 2 cases (10%). The
numbers of the cases with MPM CT features among 20 MPM casesby MPM probability are shown in Table 1. The CT images of several
representative MPM cases among the 20 MPM cases are shown as
Figs. 1–5.
2.2. The MPM reference CT ﬁlms
The MPM reference CT ﬁlms and CT subject images were usedby radiologists only at the 2nd reading trial for comparison of thesubjects’ CT ﬁndings with MPM reference ﬁlms. The ten typical
MPM features on the reference CT ﬁlms included “unilateral pleural effusion” (“ue”), “nodular pleural thickening” (“nt”), “interlobar
ﬁssure thickening” (“it”), “mediastinal pleural thickening” (“mt”),“tumoral encasement of lung” (“te”), “calciﬁed plaque engulfment” (“pe”), “invasion” (iv”), “diminished lung” (“dl”), “contracted
hemithorax” (“ch”) and “pleural mass” (“pm”). Each MPM feature
was indicated by an arrow on the reference CT digital images andhard-copied CT reference ﬁlms. The CT images of typical MPM features are shown as in Fig. 1 through Fig. 9 in a parallel publication[2].

2.4. Statistical analysis
According to the deﬁnition for the MPM probability in the MPMCT Guideline [2], Grade 1 was negative for MPM, no abnormal
ﬁndings on CT, or the abnormal ﬁndings of other diseases; Grade2 was low probability of MPM; Grade 3 was moderate probability of MPM; Grade 4 was high probability of MPM. Sensitivity
for MPM was the proportion of cases for which MPM probability
Grade ≥2 recorded by radiologists for each among the 20 MPM
cases. Speciﬁcity for MPM was the proportion of cases for which
MPM probability Grade = 1 was recorded by individual radiologists
among the 2 non-MPM cases, shown as Table A in Supplementary Appendix. The sensitivity and speciﬁcity for MPM by the three
radiologists were calculated and compared between the 1st and the
2nd reading trials.
The weighted kappa for the agreement of the three individual
radiologists with the consensus by the four experts (K.G.H., M.A., H.
A., H. I.) on the 4-point scale MPM probability was calculated using
R-software version 2.14.1 (http://www.r-project.org/), as shown in
Table B in Supplementary Appendix. The kappa for the agreement
on dichotomized MPM probability was calculated by stratifying
the cases with MPM probability Grade 2, 3, 4 into one group, andthe cases with MPM probability Grade = 1 into the other group, asshown in Table C in the Supplementary Appendix. The observed
agreement on dichotomized MPM probability between radiologist
and experts was also calculated. The calculation of kappa for theagreement on MPM CT feature between radiologist and experts isshown as Table D in the Supplementary Appendix. A kappa value<0.20 was considered as poor agreement, 0.21–0.40 was as fairagreement, 0.41–0.60 was as moderate agreement, 0.61–0.80 was
as good agreement, and 0.81–1.00 was as excellent agreement [6].
The kappa values for the 7 MPM CT features by the three radiologists
between the 1st trial and 2nd trial were compared by 2-RelatedSamples Nonparametric Test (Wilcoxon Signed Rank Test).

3. Results
2.3. CT reading trials of 22 cases by three radiologists
Three radiologists participated in independent reading of CT
ﬁlms. All of the radiologists had good proﬁciency and rich experience in reading CT for pneumoconioses. However, they had notseen many MPM cases previously. Before achieving the 1st and 2nd
reading trials, they were blinded to the information of the patients’

3.1. The MPM probability and the 7 MPM CT features among the
20 MPM cases
The MPM probability and the 7 MPM CT features (7-MPM-CTfeatures) agreed by the four experienced experts for the 20 subject
cases of MPM are shown as Table 1.

H. Zhou et al. / European Journal of Radiology 82 (2013) 169–176

171

Table 1
The number of cases with the 7-MPM-CT features among the 20 MPM cases according to MPM probability.
Cases with MPM probability

Grade = 1 (n = 0)
Grade = 2 (n = 3)
Grade = 3 (n = 7)
Grade = 4 (n = 10)
Total (n = 20)

The number of cases with the MPM feature
ue

nt

it

mt

te

iv

dl

0
0
5
8
13 (65%)012
10
13 (65%)004
7
11 (55%)007
10
17 (85%)000
55 (25%)02
1
6
9 (45%)004
10
14 (70%)Fig. 1. A 52-year-old women with diffuse epithelioid MPM. CT scans show slight unilateral pleural effusion (A) and ﬂat pleural thickening in the left hemithorax (B). According
to the CT appearance, the MPM probability was agreed as low probability Grade 2 at mild severity by experts.

Fig. 2. A 49-year-old man with biphasic MPM. CT scans show interlobar ﬁssure pleural thickening (“it”) at the left lung (A), and the left-side pleural mass with involvement ofchest wall (B). According the CT appearance, the MPM probability was agreed by experts as low probability Grade 2. The differential diagnosis for this case is mainly sarcoma.

Fig. 3. A 68-year-old man with localized sarcomatoid MPM. CT scan demonstrates a right-sided pleural mass invasion (“iv”) to the chest wall destroying rib structure (arrow)(A). There is a pulmonary nodule on the left lung (B). This case was agreed as MPM of moderate probability Grade 3 at advanced severity. The different diagnosis is ﬁrstly
sarcoma and secondly possible metastasis from other cancer.

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H. Zhou et al. / European Journal of Radiology 82 (2013) 169–176

Fig. 4. A 45-year-old man with diffuse epithelioid MPM. CT scan shows interlobar ﬁssure pleural thickening (A), invasion to the tissue near to the vertebral column (“iv”)(black arrow) (A). There is unilateral pleural effusion (“ue”) (black arrow) on the right hemithorax, leading to the contracted hemithorax (“ch”) (B). Tumoral encasement oflung (“te”) involvement on the right hemithorax (C, D) and an implant metastasis lesion are observed on the chest wall of right lung (D). According the CT appearance, MPM
probability was agreed by experts as high probability Grade 4 at advanced severity. This is a typical MPM case.

Fig. 5. A 58 year-old man with diffuse desmoplastic MPM. CT scan shows contracted hemithorax (“ch”) leading to the right hemithorax volume loss (A). There is interlobar
ﬁssure pleural thickening (“it”), together with unilateral pleural thickening (“ue”), causing the lung volume diminished (“dl”) (B). The involvement of tumoral encasementof lung (“te”) (C), nodular pleural thickening (“nt”) and mediastinal pleural thickening (“mt”) (black arrow) on the right hemithorax are observed (D). MPM probability was
agreed by experts as high MPM probability Grade 4 at advanced severity. This is a typical MPM case.

H. Zhou et al. / European Journal of Radiology 82 (2013) 169–176

173

Table 2Agreement on dichotomized MPM probability with 4 experts’ consensus and sensitivity and speciﬁcity for MPM by three radiologists at the two trials.
ReaderReading trial

Agreement with experts ondichotomized MPM probability

Sensitivity for MPM

Speciﬁcity for MPM

Radiologist 1

1st
2nd

18/22 (81.82%)
21/22 (95.45%)

16/20 (80%)
20/20 (100%)

2/2 (100%)
1/2 (50%)

Radiologist 2

1st
2nd

19/22 (86.36%)
22/22 (100%)

17/20 (85%)
20/20 (100%)

2/2 (100%)
2/2 (100%)

Radiologist 3

1st
2nd

14/22 (63.64%)
18/22 (81.82%)

12/20 (60%)
16/20 (80%)

2/2 (100%)
2/2 (100%)

Among the 20 deﬁnite MPM cases, the cases with MPM probability Grade 2, Grade 3 and Grade 4 accounted for 3/20 (15%), 7/20
(35%) and 10/20 (50%), respectively.
For the 3 cases with MPM probability Grade 2, the caseswith the feature “nodular pleural thickening” (“nt”) accounted for
1/3(33.33%), and the cases with “invasion” (“iv”) accounted for 2/3(66.67%).
Among the 7 cases with MPM probability Grade 3, the caseswith feature “medialstinal pleural thickening” (“mt”) accounted
for 7/7 (100%), the feature of “unilateral pleural effusion” (“ue”)
were present in 5/7 (71.43%), “interlobar ﬁssure thickening” (“it”)
in 4/7 (57.14%), “diminished lung” (“dl”) in 4/7 (57.14%), “nt” in 2/7(28.57%), and “iv” in 1/7 (14.29%).
Among the 10 cases with MPM probability Grade 4, the mostfrequently recorded features were “nt” in 10/10 (100%), “mt” in
100%, and “dl” in 100%. The cases with feature “ue” were in 80%,“it” in 70%, “iv” in 60%, and “tumoral encasement of lung” in 50%.
3.2. The sensitivity and speciﬁcity for MPM by three radiologists,
the agreement on MPM probability by radiologists with experts
The sensitivity for MPM, speciﬁcity for MPM and observed
agreement on the dichotomized MPM probability by 3 radiologists
at two times of CT readings before and after studying the MPM-CT
Guideline are shown as in Table 2.
The sensitivity for MPM by the three radiologists at the 2nd trial
was 100%, 100% and 80%, which was higher than 80%, 85% and 60%,
respectively at the 1st reading trial. The observed agreements ondichotomized MPM probability by radiologists were increased atthe 2nd trial compared with those at the 1st trial.
The values of weighted kappa for the agreement of MPM probability on the 4-point scale by three radiologists with experts wereincreased at the 2nd trial, compared with those at the 1st trial, as
shown in Table 3.
The weighted kappa values for the agreement with experts on
4-point scale MPM probability by three radiologists were 0.32, 0.51
and 0.37 at the 2nd trial vs 0.24, 0.48 and 0.29 at the 1st trial,
respectively. The kappa value for inter-reader agreements on the
dichotomized MPM probability between radiologists and experts
at the 2nd reading trial were 0.65 (good), 1 (excellent) and 0.42
(moderate), respectively, which were signiﬁcantly higher than 0.42
(moderate), 0.51 (moderate) and 0.21 (fair) at the 1st trial, respectively. The average kappa for the agreement on dichotomized MPM

probability between radiologists and experts were 0.69 (good) at
the 2nd trial vs 0.38 (fair) at the 1st trial, which seemed to show an
upgrading in reading skill.
3.3. The agreement on MPM features between radiologists andexperts
The results of the agreements for the recorded MPM features
between the three radiologists and experts are shown as in Table 4.
For radiologist 1, the agreement with experts for 6 features “unilateral pleural effusion” (“ue”), “nodular pleural thickening” (“nt”),“interlobar ﬁssure thickening”(“it”), “mediastinal pleural thickening” (“mt”), “invasion” (“iv”) and “diminished lung” (“dl”) at the
2nd reading trial was better compared with those at the 1st trial.
The agreement for feature “ue” and “nt” at the 2nd trial was good(kappa = 0.62 and 0.61, respectively). The agreement for feature“tumoral encasement of lung” (“te”) at the 2nd trial was excellent
to the same extent as that at the 1st trial (kappa = 0.86). The agreement with experts on 3 features (“mt”, “iv” and “dl”) was markedly
increased to excellent (kappa > 0.8) at the 2nd trial.
For radiologist 2, the kappa values for the agreement withexperts were increased for 5 features (“ue”, “nt”, “mt”, “te” and“dl”) at the 2nd trial in comparison with those at the 1st trial.
The kappa values for the features “ue”, “nt” and “te” showed good
agreement with experts (kappa > 0.6), and “mt” and “dl” showed
excellent agreement (kappa > 0.8). The kappa values for the feature“it” and “iv” was 0.55 and 0.51 at the 2nd trial, which were lower
than 0.73 and 0.61 at the 1st trial, respectively.
For the radiologist 3, the kappa values for 5 features (“nt”, “mt”,“te”, “iv” and “dl”) were increased at the 2nd trial in comparison
with the 1st trial. The feature “nt” and “te” shows good agreementwith expert (kappa = 0.64 and 0.77, respectively). The kappa value
for the feature “it” at the 2nd trial was equal to that one at the 1sttrial. The kappa value for the feature “ue” (0.49) at the 2nd trial was
lower than at the 1st trial (0.65).
The average kappa values of 7 MPM CT features at the 2nd trial
by the three radiologists were signiﬁcantly increased in comparison with the 1st trial, and the six features “ue”, “nt”, “mt”, “te”
and “dl” showed good agreement between radiologists and experts(kappa > 0.60).
Table 5 shows that the kappa values for the agreement on the
7 MPM CT features by the three radiologists with experts weresigniﬁcantly higher than those at the 1st trial.

Table 3
Agreement on 4-point scale MPM probability and dichotomized MPM probability between radiologist and experts in terms of weighted kappa.
Reader4-scale MPM probability Kw (95% CI)

Dichotomized MPM probability Kw (95% CI)

1st trial

2nd trial

1st trial

2nd trial

Radiologist 1
Radiologist 2Radiologist 3

0.24 (−0.06, 0.54)
0.48 (0.19, 0.76)
0.29 (0.04, 0.53)

0.32 (0.06, 0.58)
0.51 (0.24, 0.78)
0.37 (0.12, 0.62)

0.42 (−0.09, 0.93)
0.51 (−0.01, 1)
0.21 (−0.22, 0.65)

0.65 (−0.03, 1)
10.42 (−0.09, 0.93)

Weighted kappa Mean(SD)0.34 (0.13)

0.40 (0.10)

0.38(0.15)

0.69(0.29)

174

H. Zhou et al. / European Journal of Radiology 82 (2013) 169–176

Table 4
Agreement for the recorded MPM CT features between radiologists and experts by kappa statistics.
ReaderReading trial

Experts
ue

nt

it

mt

te

iv

dl

Radiologist 1

1st
2nd

0.32
0.62

0.35
0.61

0.36
0.55

0.20
0.88

0.86
0.86

0.25
0.81

0.49
0.80

Radiologist 2

1st
2nd

0.65
0.72

0.31
0.70

0.73
0.55

0.68
1

0.60
0.77

0.61
0.51

0.73
0.90

Radiologist 3

1st
2nd

0.65
0.49

0.37
0.64

0.45
0.45

0.39
0.47

0.28
0.77

0.25
0.49

0.17
0.57

All radiologists
Mean (SD)

1st

0.54
(0.19)

0.34(0.03)

0.51(0.19)

0.42(0.24)

0.58(0.29)

0.37(0.21)

0.46(0.28)All radiologists
Mean(SD)

2nd

0.61(0.12)

0.65(0.05)

0.52(0.06)

0.78(0.28)

0.80(0.05)

0.60(0.18)

0.76(0.17)

Note: 1st and 2nd indicates the 1st CT reading trial and the 2nd CT reading trial, SD = standard deviation of kappa values.

Table 5Comparative analysis for the kappa values for the agreement with experts on the 7 MPM CT features by all three radiologists between the two reading trials by means of
2-Related-Samples Nonparametric Test (Wicoxon Signed Rank Test).
Kappa 2–Kappa 1*

Number of pairs

Mean rank

Sum of ranks

P

Negative ranks
Positive ranksb
Tiesc

3
16
2

4.67
11

14
176

<0.01

Total

21

a

Note: *Kappa 2: kappa value for the agreement by three radiologists with expert on the 7 features recorded at the 2nd reading trial. Kappa 1: kappa value for the agreementby three radiologists with expert on the 7 features recorded at the 1st reading trial.
aKappa 2 < Kappa 1.
bKappa 2 > Kappa 1.
cKappa 2 = Kappa 1.

4. Discussion
With the development of modern technology, CT scans havenow become routine clinical practice for detecting pleural abnormalities in patients. The diagnosis of MPM is usually based on
the combination of occupational history, physical and laboratory
examination, radiology and the thoracic pathology. CT ﬁndings
are important to provide the clue in the diagnosis of MPM before
any invasive biopsy procedures take place. Diagnosis of MPM
at the early stage may enable patients to obtain a better outcome with multiple modality therapy including extensive surgery,chemotherapy, and radiotherapy, which may offer increases in survival time and the life quality for MPM patients [7].
The MPM-CT Guideline was developed by the international
experts’ efforts [2]. The Guideline provided a standardized way forphysicians to record CT ﬁndings on subject CT ﬁlms with the assistance of the MPM reference CT ﬁlms with typical MPM features.
These allow the physicians to make appropriate judgments for the
MPM probability, which is determined by the overall impressionof the CT ﬁndings as a whole and comprehensive evaluation on CT
ﬁndings being consistent or inconsistent with MPM features, theseverity of the diseases, and the distribution of MPM involvement.
Among the 20 deﬁnite MPM cases in the current study, themostly seen features in the number were “mediastinal pleural
thickening” (“mt”) (85%), and then were “diminished lung” (“dl”)(70%), the “unilateral pleural effusion” (“ue”) (65%), “nodular pleural thickening” (“nt”) (65%) and “interlobar ﬁssure thickening” (“it”)(55%). The cases with “invasion” accounted for 45%. Most of the 7
features are suggestive of MPM to somewhat through quite extent
and frequently common on the CT images of MPM [8].

The relationship between the MPM probability and the numberof 7-MPM-CT features in each case was investigated. Among the
20 MPM cases, those cases with the high MPM probability (Grade3, 4) were found to have more of 7-MPM-CT features. It was suggested that the more features observed on the CT, the higher MPM
probability for the case determined, presenting with a positive correlation. The severity in association with the feature may be thesecond reason related with probability of MPM. When the features are at severe disease stages, the cases may have high MPM
probability, even with only a few features of these.
The relatively high prevalence and frequency of “unilateral pleural effusion” in MPM is of major diagnostic importance [9]. At
the early stage of MPM, irrespective of normal-appearing pleura,“unilateral pleural effusion” can be the only ﬁnding. The main
mechanism of pleural ﬂuid formation in malignancy is lymphatic
obstruction. For the cases with pleural effusion and a history ofasbestos exposure, MPM should be considered and further investigation should be conducted [10].
There were two features listed in the MPM-CT Guideline “contracted hemithorax” (“ch”) and “pleural mass” (“pm”) not includedin the current comparative analysis, because these two features
were later added at the 2nd workshop to the proposed MPM-CT
Guideline. The two features are crucial and helpful to make diagnosis of MPM. Solitary masses may occur at the early stage, while
multiple masses are more common at later stages [11]. MPM tendto spread along the pleural surface in a “sheet-like” fashion [12]. In
CT images with feature “ch”, the involved hemithorax is noticeably
contracted from a comparison with that in the contralateral lung.
The current study showed that after studying the MPM-CT
Guideline, the sensitivity for MPM by all three radiologists was

H. Zhou et al. / European Journal of Radiology 82 (2013) 169–176

increased at the 2nd trial compared with those at the 1st trial. For
the 1st radiologist, although the speciﬁcity for MPM at the 2nd trial
was lower than at the 1st trial, the observed agreement for the MPM
probability was increased to 95.45% at the 2nd trial vs 81.82% at the
1st trial.
Kappa is affected by prevalence of the ﬁnding under observation[13,14]. In the current study, the proportion of the non-MPM cases
among total case was only in 10%, and many cases (50%) had MPM
probability Grade 2 or Grade 3, which had great variances between
readers. Therefore the weighted kappa on 4-scale MPM probability
proved to be low. However, the analysis with the dichotomized
MPM probability showed that two radiologists obtained good andexcellent agreements, i.e., kappa = 0.65 and 1, respectively. The 3rdradiologist had achieved moderate agreement with kappa 0.42 on
dichotomized MPM probability at the 2nd trial vs kappa 0.21 at the
1st trial.
The kappa statistics showed that good through to excellent
agreements with experts by two of the three radiologists wereobtained at the 2nd trial for 5 and 6 features, respectively. For theradiologist 3, there were 5 features including “nt”, “mt”, “tumoral
encasement of lung” (“te”), “invasion” (“iv”) and “dl” with increased
agreements with experts at the 2nd trial compared with those at
the 1st trial. Compared with those at the 1st trial, the average kappavalues of 7 features by the three radiologists were increased at the
2nd trial, in which the ﬁve features, i.e., “ue”, “nt”, “mt”, “te” and“dl”, showed good agreement with experts. Wicoxon Signed Rank
Test showed that the kappa values for the agreement on the 7 MPM
CT features between the three radiologists and experts were signiﬁcantly higher than those at the 1st trial. These revealed that theradiologists had made improvement in recognition of the MPM CT
features at the 2nd trial compared with the 1st trial.
Compared to the other features in the 20 MPM cases, the agreement with experts in the feature “invasion” was relatively lower.
At the 2nd trial, the kappa for “invasion” was 0.51 by the 2nd radiologist and 0.49 by the 3rd radiologist, respectively. This impliedthat the feature “invasion” was difﬁcult to identify compared tothe other MPM features. One reason may be its frequent coexistence with other features that the appearance of this feature may
become less notable. The severity of the invasion to the lung structure may be the second reason. If it was less severe, “invasion” may
not be easy to identify. This feature of “invasion” is quite suggestiveof malignancy. This feature overlaps with metastasis of other carcinoma [15], while the other malignancy also has lung parenchymal
involvement.
The average kappa for the agreements between radiologists andexperts on feature “interlobar ﬁssure thickening” was 0.51 and 0.52
at the 1st and 2nd trials, respectively, which were lower than thoseof other features. The reason may be ascribed to the fact that “interlobar ﬁssure thickening” in some cases is so slight that it may easily
be neglected. The feature “interlobar ﬁssure thickening” reﬂects
tumor growth along the interlobar spaces, and may represent one of
the earliest signiﬁcant MPM features, which is seen less frequently
in other malignancies or in benign pleural diseases [16].
The CT ﬁndings in MPM are not pathognomonic because similar ﬁndings may be found in metastatic carcinoma. Nevertheless,they are characteristic. The MPM features can provide valuable
information to make a diagnosis of MPM. By identifying the MPM
features on CT images, clinicians can recognize MPM [17]. It will be
helpful for occupational physicians during the occupational disease
screening in health surveillance for workers.
One limitation of the study was that there were only two nonMPM cases with pleural plaque. This may affect the speciﬁcity for
MPM. Despite the limitation, the results of the comparative study
showed that all three radiologists had improved their sensitivity for MPM after studying the MPM-CT Guideline. Two of themhad obtained either good or excellent agreements with experts

175

in identifying most of features at the 2nd trial. These suggested
that reliability of the Guideline and the MPM reference CT ﬁlms
to improve the reading proﬁciency of the radiologists may be validated.
5. Conclusions
The current study suggested that the three radiologists
improved the proﬁciency in diagnosis for MPM by identifying of
MPM CT features after studying the MPM-CT Guideline with reference MPM CT features. The MPM-CT Guideline and reference CT
ﬁlms may act as good tool to facilitate physicians in recognitionof MPM features and contribute to early diagnosis of MPM in thehealth surveillance.
Conﬂict of interest statement
None of the authors has a ﬁnancial relationship with a commercial entity that has an interest in the subject of this manuscript.
Role of the funding sourceThis study was supported by a grant from the Ministry of Education, Sports, Culture, Science and Technology, Japan. The fundholder
had no involvement in the study design, collection and analysis andinterpretation of data or in the writing of manuscript and in thedecision to submit the manuscript for publication.
Acknowledgments
The author gratefully acknowledge all concerned: Dr. Mitsunori
Sakatani, Dr. Seiji Hayashi, Dr. Giichi Inoue, Dr. Masanori Kitaichi,
National Hospital Organization Kinki-Chuo Chest Medical Center,
Osaka, Japan; Prof. Hisao Shida, Committee of Compensation ofAsbestos Related Diseases, Ministry of the Environment Protection,
Kawasaki, Japan; Dr. Norihiko Hamada, Department of Radiology,
Kochi University, Japan; and we also express thanks to the bereaved
family of the patient of MPM and other abnormalities to provide us
with the valuable information.
Appendix A. Supplementary data
Supplementary data associated with this article can befound, in the online version, at http://dx.doi.org/10.1016/
j.ejrad.2012.05.022.
References[1] Kusaka Y, Hering KG, Parker JE, editors. International classiﬁcation of HRCT for
occupational and environmental respiratory diseases. Tokyo: Springer-Verlag;
2005.
[2] Zhou H, Tamura T, Kusaka Y, et al. Development of the guideline
on reading CT images of malignant pleural mesothelioma and selection of the reference CT ﬁlms. European Journal of Radiology 2012,
http://dx.doi.org/10.1016/j.ejrad.2012.08.008.
[3] Kurumatani N, Kumagai S. Mapping the risk of mesothelioma due to neighborhood asbestos exposure. American Journal of Respiratory and Critical Care
Medicine 2008;178:624–9.
[4] Inai K. Pathology of mesothelioma. Environmental Health and Preventive
Medicine 2008;13:60–4.
[5] International Mesothelioma Interest Group. A proposed new international TNM
staging system for malignant pleural mesothelioma. Chest 1995;108:1122–8.
[6] Suganuma N, Kusaka Y, Hering KG, et al. Reliability of the proposed international classiﬁcation of high-resolution computed tomography for occupationaland environmental disease. Journal of Occupational Health 2009;51:210–22.
[7] Sterman DH, Albelda SM. Advances in the diagnosis, evaluation, and management of malignant pleural mesothelioma. Respirology 2005;10:266–83.
[8] Yamamuro M, Gerbaudo VH, Gill RR, Jacobson FL, Sugarbaker DJ, Hatabu H. Morphologic and functional imaging of malignant pleural mesothelioma. European
Journal of Radiology 2007;64:356–66.

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H. Zhou et al. / European Journal of Radiology 82 (2013) 169–176[9] Kawashima A, Libshitz HI. Malignant pleural mesothelioma: CT manifestationsin 50 cases. American Journal of Roentgenology 1990;155:965–9.
[10] Fujimoto N, Aoe K, Gemba K, Kato K, Amazaki K, Kishimoto T. Clinical investigation of malignant mesothelioma in Japan. Journal of Cancer Research andClinical Oncology 2010;136:1755–9.
[11] Yilmaz UM, Utkaner G, Yalniz E, Kumcuoglu Z. Computed tomographic ﬁndingsof environmental asbestos-related malignant pleural mesothelioma. Respirology 1998;3:33–8.
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[13] Viera AJ, Garrett JM. Understanding interobserver agreement: the kappa statistic. Family Medicine 2005;37(5):360–3.
[14] Feinstein AR, Cicchetti DV. High agreement but low kappa: I. The problems oftwo paradoxes. Journal of Clinical Epidemiology 1990;43:543–9.
[15] Leung AN, Müller NL, Miller RR. CT in differential diagnosis of diffuse pleuraldisease. American Journal of Roentgenology 1990;154:487–92.
[16] Knuuttila A, Kivisaari L, Kivisaari A, Palomäki M, Tervahartiala P, Mattson K.
Evaluation of pleural disease using MR and CT with special reference to malignant pleural mesothelioma. Acta Radiologica 2001;42:502–7.
[17] Metintas M, Ucgun I, Elbek O, et al. Computed tomography features in malignant
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Short communication

Industrial Health 2012, 50, 142–146

Proficiency in Reading Pneumoconiosis Radiographs
Examined by the 60-film Set with 4-factor
Structuring 8-index
Huashi Zhou1, Yukinori KuSaKa1*, Taro TamuRa1, Narufumi SugaNuma2,
Ponglada SubHaNNacHaRT3, Somkiat SiRiRuTTaNaPRuK4, Narongpon DumavibHaT5,
Xing ZHaNg6, P. K. SiSHoDiYa7, Khuong vaN DuY8, Kurt g. HERiNg9, John E. PaRKER10,
Eduardo algRaNTi11, igor FEDoTov12, Hisao SHiDa13and masanori aKiRa14
1

Department of Environmental Health, School of Medicine, University of Fukui, 23–3 Shimoaitsuki Matsuoka,
Eiheizi-cho, Fukui 910-1193, Japan2
Department of Environmental Medicine, Kochi University School of Medicine, Japan
3
Chest Disease Institute, Thailand
4
Bureau of Occupational and Environmental Diseases, Ministry of Public Health, Thailand
5
Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
6
Institute of Hygiene, Zhejiang Academy of Medical Sciences, Hang Zhou, P. R. China
7
National Institute of Miners’ Health, India
8
Department of Occupational Health, Ha Noi Medical University School of Public Health, Vietnam
9Department of Diagnostic Radiology, Radiooncology and Nuclear Medicine, Radiological Clinic, Miner’s Hospital,
Dortmund, Germany
10
Pulmonary and Critical Care Medicine, Robert C, Byrd Health Sciences Center, School of Medicine, West Virginia
University, Morgantown, U.S.A
11
Divisao de Medicina, Fundacentro, San Paulo, SP, Brazil
12International Labor Office, Geneva, Switzerland
13
Committee of Compensation of Asbestos Related Diseases in Ministry of Environment Protection, Kawasaki, Japan
14
Department of Radiology, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
Received July 25, 2011 and accepted January 27, 2012
Published online in J-STAGE February 3, 2012abstract: 29 physicians (a1-group) and 24 physicians (a2-group) attending the 1st and 2nd “asianintensive Reader of Pneumoconiosis” (aiR Pneumo) training course, respectively, and 22 physicians(b-group) attending the brazilian training course took the examination of reading the 60-film set. The
objective of the study was firstly to investigate the factor structure of physicians’ proficiency of reading
pneumoconiosis chest X-ray, and secondly to examine differences in factor scores between groups. Reading
results in terms of the 8-index of all examinees (Examinee group) were subjected to the exploratory factor
analysis. a 4-factor was analyzed to structure the 8-index: the specificity for pneumoconiosis, specificity
for large opacities, specificity for pleural plaque and shape differentiation for small opacities loaded on
the Factor 1; the sensitivity for pneumoconiosis and sensitivity for large opacities loaded on the Factor 2;
the sensitivity for pleural plaque loaded on the Factor 3; the profusion increment consistency loaded on
the Factor 4. 4-Factor scores were compared between each other of the three groups. The Factor 2 scoresin a1 and a2 groups were significantly higher than in b-group. Four factors could reflect four aspects ofreading proficiency of pneumoconiosis X-ray, and it was suggested that 4-factor scores could also assess
the attained skills appropriately.
Key words: Pneumoconiosis, ILO Classification, Sensitivity, Specificity, Chest X-ray, Factor analysis*To whom correspondence should be addressed. E-mail: yukik@u-fukui.ac.jp©2012 National Institute of Occupational Safety and Health

143

ASSESSING READING SKILLS FOR PNEUMOCONIOSIS CHEST X-RAY
In the current authors’ preceding paper 1) , we havesuggested that 8 indices reflect reading proficiency forpneumoconiosis in individuals and groups and be used appropriately for assessing examination results from reading
60-film sets: sensitivity for pneumoconiosis, specificity forpneumoconiosis, sensitivity for large opacities, specificity
for large opacities, sensitivity for pleural plaque, specificity for pleural plaque, profusion increment consistency forsmall opacities, and shape differentiation for small opacities. The exam films, the correct answers, the criteria for
8 indices in 60 exam films, and the assessment algorithm
were described in the Appendix in the literature1).
There were 29 physicians (A1-Group) and 24 physicians (A2-Group) attending the 1st and 2nd “AsianIntensive Reader of Pneumoconiosis” (AIR Pneumo),
respectively, and 22 physicians attending the Brazilian
Training Course (B-Group) took examination of reading
60-film set described extensively in the authors’ paper1).
The Examinee Group included A1-Group, A2-Group and
B–Group. The summary of the reading results in terms of
the 8 indices for all groups was shown in Table 2 in our
preceding paper1).
Factor analysis is a statistical approach that can be used
to analyze inter-relationships among a large number ofvariables and to explain these variables in terms of theircommon underlying dimensions (factors)2). The statistical
approach involves a way of condensing the information
contained in a number of original variables into a smaller
set of dimensions (factors) with a minimum loss of information. In recently years, factor analysis gradually has
become the most frequently used statistical method in thefield of education and social psychological study3, 4). There
has been only one paper published on pneumoconiosis

concerning the research by factor analysis of the clinicaldata of asbestos exposed workers5) and several papers on
the study by factor analysis of respiratory diseases6, 7).
The current study aimed at investigating the factor
structure of the 8 indices of physicians reading pneumoconiosis chest X-ray, exploring the underlying factors in
the physicians’ proficiency of the reading chest x-ray ofpneumoconiosis, and studying the appropriateness to test
the proficiency of examinees in the three training courses
by calculating the factor scores.
The multivariate exploratory factor analysis was
performed using SPSS 16.0 for the reading results of
Examinee Group (SPSS Inc., USA). An initial principal
component analysis was conducted to determine the final
number of factors. An orthogonal rotation (Varimax rotation) was executed to yield the simple factor structure,facilitating the interpretation of the factors8).
The correlation matrix among the 8 indices of all examinees is shown as Table 1.
For the number of factors extraction, the most frequently used criterion for retaining factors is the Kaiser’s criterion (Eigenvalue >1) 9). However, if we took this criteria,
the communalities were less than 0.7 after extraction witheigenvalues more than 1, therefore, selecting factors withan eigenvalue >1 was not an accurate criterion according
to the literature10, 11), in our study, too. On the other hand,
Jolliffe argued that since Kaiser’s criterion might be toostrict, it discards too much information. And Jolliffe suggested a cut-off of eigenvalue 0.7 for retaining factors, instead of 112, 13). Based on the Jolliffe’s criterion (Eigenvalue>0.7), a 4-factor structure matrix was accurately generated
with a variance of more than 80%, as shown in Table 2.
Table 2 indicates that the cumulative variance from theTable 1. The correlation matrix among the 8 indices of all examinees
X1

X2

X3

X4

X5

X6

X7

X1

1.000

X2

0.172

1.000

X3

0.591

0.155

1.000

X4

0.505

0.468

0.260

1.000

X5

0.264

0.370

0.307

0.372

1.000

X6

0.457

0.521

0.316

0.597

0.262

1.000

X7

0.414

0.343

0.229

0.222

0.126

0.293

1.000

X8

0.491

0.447

0.380

0.444

0.308

0.620

0.308

X8

1.000

X1: Sensitivity for pneumoconiosis, X2: Specificity for pneumoconiosis, X3: Sensitivity forlarge opacities, X4: Specificity for large opacities, X5: Sensitivity for pleural plaque, X6:
Specificity for pleural plaque, X7: Profusion increment consistency, X8: Shape differentiation
for small opacities.

144

H ZHOU et al.
Table 2. varimax rotated factor-loading matrix from factor analysis
Variable

Factor 1

Factor 2

Factor 3

Factor 4

Sensitivity for pneumoconiosis

0.378

0.792*

0.002

0.218

Specificity for pneumoconiosis

0.638*–0.208

0.436

0.395

Sensitivity for large opacities

0.123

0.848*

0.218

0.067

Specificity for large opacities

0.762*

0.213

0.222

–0.006

Sensitivity for pleural plaque

0.175

0.212

0.925*

0.008

Specificity for pleural plaque0.865*

0.195

0.027

0.116

Profusion increment consistency

0.143

0.215

0.016

0.943*

Shape differentiation for small opacities

0.702*

0.335

0.085

0.166

Eigenvalue

3.625

1.101

0.908

0.770

Total variance explained, %

45.31

13.76

11.35

9.62

*Variables with high loading coefficient>0.6.

Table 3. comparative analyses for the factor scores between each other of thethree groups
Factor score

A1-Group (n=29)

A2-Group (n=24)

B-Group (n=22)

Factor score 1–0.118 ± 1.223

0.091 ± 0.650

0.056 ± 1.016

Factor score 2

0.191 ± 0.977*

0.326 ± 0.613#–0.608 ± 1.132*#

Factor score 3–0.103 ± 0.913

0.209 ± 0.870–0.092 ± 1.228

Factor score 4

0.036 ± 0.990

0.026 ± 0.983–0.076 ± 1.072

Values are Mean ± SD. *Comparison between A1 and B-Group by Bonferroni
multiple comparisons test, p<0.05. #Comparison between A2 and B-Group by
Bonferroni multiple comparisons test, p<0.05.

first to the fourth factor explained 80.0% of total variance.
By examining the loading coefficients of the variables oneach factor, the variables that had high loadings on thesame factors were grouped. The larger the factor loading,the stronger the association is between that variable andthat factor. The specificity for pneumoconiosis, specificity
for large opacities, specificity for pleural plaque and shapedifferentiation consistency for small opacities were foundto be loaded significantly on the Factor 1. The sensitivity
for pneumoconiosis, sensitivity for large opacities loaded
largely on the Factor 2. The sensitivity for pleural plaqueloaded largely on the Factor 3. The profusion increment
consistency loaded predominantly on the Factor 4.
A factor score is a composite score based on eachvariable's contribution to the factor. Each factor score
of individual examinee was calculated by the regression
method. The equation for calculating factor score is shownas follows14):

Fj represents the factor score of the jth factor. βji represents the factor score coefficient for the ith variable.
Zi is the value of the ith standardized variable. Zi = (Xixi)/Si, Xi is the observed value of ith variable, Si is thestandardized deviation of variable Xi, xi is the mean of ith
variable over all observations. m is the number of the factors, m is less than or equal to the number of variables.
Factor scores were compared by the Bonfferoni multiple
comparisons method in One way ANOVA test between
each other of the three groups by SPSS 16.0. Table 3
shows that there was a significant difference in the Factor
2 scores between the A1-Group and B-Group, A2-Groupand B-Group (p<0.05). There was no significant difference
for the other factor scores between each other of the threegroups.
Factor analysis is an analytic technique that permits the
reduction of a large number of interrelated variables to asmaller number of latent or hidden dimensions. The variables that are highly correlated are likely influenced by thesame factors, while those that are relatively uncorrelated
are likely influenced by different factors11). Each factor
is interpreted as a latent characteristic of the individuals
Industrial Health 2012, 50, 142–146

ASSESSING READING SKILLS FOR PNEUMOCONIOSIS CHEST X-RAY
revealed by the original variables15), the original variables
are expressed as linear combinations of the factors16).
We reduced the 8 indices into 4 factors by factor
analysis. Accordingly, we can make an interpretation of 4
factors as reflecting 4 different aspects of the reading skill
on pneumoconiosis chest films: Factor 1 reflects the proficiency for recording negative parenchymal and negative
pleural findings; Factor 2 reflects the proficiency for recording positive parenchymal findings including small andlarge opacities; Factor 3 reflects the proficiency recording
positive pleural findings; Factor 4 reflects the proficiency
as to profusion increment consistency alone.
The presence or absence of pneumoconiosis is determined by the cut-off point of profusion 1/0 17). If morefilms with profusion equal to or more than 2/1 than 1/1
or 1/2 are included in the exam films, the sensitivity forpneumoconiosis by examinee is easily increased, whichmimics great proficiency. Thus high sensitivity or highspecificity for pneumoconiosis alone fails to associate withhigh profusion increment consistency. The factor analysis
actually showed that the profusion increment consistency
was an independent factor. If examinees originally havehigh profusion increment consistency, they can necessarily
and comprehensively achieve both high sensitivity andspecificity for pneumoconiosis. In order to obtain good
profusion increment consistency, it requires the examinee to make accurate comparison of all profusions on a
12-point scale with those on the standard films.
Pleural plaque cannot necessarily be seen even inasbestosis patient, while some patients present with thepleural plaque without the parenchymal abnormalities. In
our current factor analysis, there was no close relationshipbetween the sensitivity for parenchymal abnormalities andthe sensitivity for pleural plaque. It is reasonable that sensitivity for pleural plaque was seen as an independent factor.
After summarizing the 8 indices, the calculation offactor scores for each factor for individual can be helpful
to simplify assessment for the proficiency of examinee18).
The factor score of >0 of individual examinee imply thatthe proficiency in this aspect was better than the average
proficiency of the Examinee Group, and the factor scoreof <0 imply that the proficiency of examinee was worse
than the average proficiency of the Examinee Group. Useof factor score could identify whether the individual proficiency was worse or better than the average proficiency of
Examinee Group at each aspect. And it could be helpful inderiving a comprehensive evaluation of the achievementof examinees and making comparison of the proficiency
between each other of the three groups.

145

Factor analysis showed that the Factor 2 scores in the
A1-Group and A2-Group were significantly higher thanthose in the B-Group, which were consistent with theresults as shown in Table 2 in our previous literature thatthe sensitivity for pneumoconiosis of A2-Group, and thesensitivity for large opacities of both A1-Group and A2Group were higher than those in the B-Group 1). This
indicated that A1-Group and A2-Group tended to identify
much more parenchymal abnormalities than the B-Group.
One limitation of this study was that, as to the shape index, there were 20 films with purely rounded small opacity(R/R) subjected, while there were only 4 films with purely
irregular small opacity (IR/IR) subjected. Since morefilms in the exam were in association with rounded opacities than with irregular opacities, recording for absenceof small opacities (specificity for pneumoconiosis) andidentifying of rounded opacities against irregular opacities
might have become effective in the same factor, i.e., factor 1. Therefore including more films with irregular small
opacity for the shape index may be appropriate in the
future AIR Pneumo Program.
In conclusion, four factors could reflect four aspects ofreading proficiency of pneumoconiosis X-ray, and factor scores as well as the 8-index could show differencesin attained skills. The 60-film set providing 8-index and
4-factor was suggested to assess reading proficiency ofphysicians appropriately.

acknowledgements
The acknowledgement is dedicated to the followings:
Supporting Bodies for AIR Pneumo program include Scientific Committee on Respiratory Diseases, International
Commission on Occupational Health (ICOH), Asian PacificSociety of Respirology, Japan Society for Occupational
Health (JSOH), and University of Fukui, Japan; The co-organizers includes Thailand Association of Occupational andEnvironmental Diseases, Research Groups for International
Co-operation and Research Groups for Occupational Respiratory Diseases, JSOH, and Chest Disease Institute (Thailand), Bureau of Occupational and Environmental Diseases,
Ministry of Public Health (Thailand); The sponsors includes
Thailand Women’s Compensation Fund, Social Security
Office (Thailand); Personal Advisors include G.R. Wagner,(U.S.A); Kazutaka Kogi, Yoshiharu Aizawa, (Japan); Tran
Anh Thanh (Vietnam); Do Dinh Hai (Vietnam); NIOSH-B
experts include Nitra Piyavisetpat, Chomphunuj Vijitsanguan, Sutarat Tungsagunwattana, Krisna Dissaneevate,
Kittima Bangpattanasiri, Wiwatana Tanomkiat (Thailand).

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