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 Table of Contents  
Year : 2017  |  Volume : 24  |  Issue : 2  |  Page : 93-96

Routine chest radiograph in pre-employment medical examination for healthcare workers: Time for a review of the protocol

1 Department of Family Medicine, Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria
2 Department of Radiology, Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria

Date of Web Publication24-Jul-2017

Correspondence Address:
Oluseun Oloruntoba Adeko
Department of Family Medicine, Olabisi Onabanjo University Teaching Hospital, Sagamu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/npmj.npmj_55_17

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Background: Pre-employment medical examination (PEME) sought to evaluate the ability of workers to work without risk to their own or others' health and safety. This is important especially in a hospital environment where the patients may be at risk in case of employees harbouring infectious lung conditions or as a result of occupational exposure. Although not all healthcare workers are at risk or pose risk, they are expected to undergo chest X-ray (CXR) as part of PEME. Aims: The aim of this study is to determine the number of prospective employees with abnormal findings on routine CXR, describe their characteristics and reassess the value of CXR in PEME. Settings and Design: This was a retrospective study of all the staffs employed into the Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria, from January 2004 to December 2013. Subjects and Methods: Of the 633 personnel employed during this period, medical records of 416 staffs were available for analysis. Data extracted included age, gender, and CXR report. Descriptive statistics was used for analysis and presentation. Results: The mean age of the prospective employees was 26.6 years ± 5 with a range of 20–49 years. Three hundred and ninety-six (95.2%) employees had normal CXR report while 20 (4.8%) had abnormal CXR. The only abnormality reported was cardiomegaly which was found in 66% of those aged ≥41 years. Cardiomegaly was significantly associated with increasing age (P = 0.003). Conclusions: Routine CXR as part of PEME for prospective employees into this healthcare institution is no longer necessary. It is suggested that its routine use should be limited to older job seekers.

Keywords: Healthcare workers, pre-employment medical examination, routine chest X-ray

How to cite this article:
Adeko OO, Ariba AJ, Olatunji AA, Toyobo OO. Routine chest radiograph in pre-employment medical examination for healthcare workers: Time for a review of the protocol. Niger Postgrad Med J 2017;24:93-6

How to cite this URL:
Adeko OO, Ariba AJ, Olatunji AA, Toyobo OO. Routine chest radiograph in pre-employment medical examination for healthcare workers: Time for a review of the protocol. Niger Postgrad Med J [serial online] 2017 [cited 2022 Oct 7];24:93-6. Available from: https://www.npmj.org/text.asp?2017/24/2/93/211462

  Introduction Top

In addition to possessing prerequisite qualifications and experience, a key step in recruitment process in virtually all industries is the pre-employment medical examination (PEME). This is done with the aim of determining whether the prospective employees are medically fit to perform the job without putting their health and safety as well as that of others at risk.[1] However, recent studies have questioned the effectiveness of PEME given that its contents tend to consist of the same components irrespective of the nature of the job.[2],[3] This has thus given rise to the notion that the practice is more cultural than evidence driven.[2] An example of this is the universal inclusion of chest radiograph as part of PEME in all situations. While chest X-ray (CXR) is readily available and quick to carry out, it nevertheless involves exposure to radiation with its potential hazards. In the tropical countries, it is required to exclude chest pathology, especially tuberculosis which is of public health concern.[4] The usefulness of this practice has been a subject of many studies. In a study of National Health Service staff in which 1000 CXR were reviewed, the total number of abnormalities reported was 8 (0.8%) with only one reported to be related to tuberculosis infection.[5] Similarly, in a study reviewing the 1021 CXR of undergraduate and postgraduate students offered admission at University of Ibadan, Nigeria, the total abnormal reports were 151 (14.8%) with only 29 (2.8%) relating to tuberculosis.[6] A peculiarity of working in the healthcare industry is the risk of occupational exposure for workers and the inadvertent exposure of patients although not all healthcare workers are at risk or pose risk.[5] However, CXR remains a mandatory component of PEME for healthcare workers in Nigeria. It is for this reason that this study was carried out with the objectives of determining the number of prospective employees with abnormal findings on routine CXR, describes the characteristics of those with abnormal findings and reassesses its value as a routine requirement for working in a hospital.

  Subjects and Methods Top

Study location and practice of pre-employment medical examination

The study was carried out at the Olabisi Onabanjo University Teaching Hospital (OOUTH), Sagamu, Nigeria. OOUTH is the first state-owned tertiary hospital in Nigeria established in 1986. After an offer of employment has been given to a prospective employee, she/he presents at the staff clinic of the hospital for PEME. Although this includes clinical evaluation, a CXR (posteroanterior view) is required irrespective of clinical finding, the nature or tenure of the job. The CXR is done in the Radiology Department of the hospital and reported by the Consultant Radiologists. The report is used to open a case file at the Medical Record Unit of the hospital for subsequent clinical use by the employee.

Study design

This was a retrospective study of all the staff employed into the hospital from January 2004 to December 2013. During this period, 633 personnel were employed and we were able to retrieve case files of 416 staff for analysis. Data extracted included age, gender job types and CXR report. The data were analysed using Statistical Package for the Social Sciences version 18 (SPSS Inc, Chicago, IL, USA), and descriptive statistics was used to summarise the results. Chi-squared test was used to investigate the association between the categorical variables. Analysis was done with P< 0.05 considered statistically significant. The study was carried out from January to March 2017 and was approved by the institution's Health Research Ethics Committee.

  Results Top

A total of 416 employees were studied. Their mean age was 26.6 ± 5 years with a range of 20–49 years. [Table 1] shows the demographic distributions. Majority of the employees, 53.1%, were between the ages of 27–33 years while the least numbers, 3.6%, were over 40 years old. There were 154 (37.0%) males and 262 (63.0%) females. As shown in [Figure 1], medical doctors were in majority (33.4%), followed by nurses (18.5%) and hospital attendants (10.8%). The CXR films of 396 (95.2%) participants were reported normal [Figure 2] while 20 (4.8%) were reported abnormal with cardiomegaly being the only abnormality [Figure 3]. [Table 2] and [Table 3] show the distributions of the CXR reports according to the demographics. Below the third decades, there was no abnormal CXR reports while 66.7% of the employees above the fourth decade had cardiomegaly with age showing statistically significant relationship with abnormal CXR report (P = 0.003). There was no statistically significant relationship between CXR reports and gender (P = 0.3). The relationship between the CXR reports and the job types is shown in [Table 4]. Across the different job type, more than 90% of the employees had normal CXR. Of the 20 CXR reports of cardiomegaly, 14 (70%) were found amongst the hospital attendants and medical doctors. Amongst these groups, cardiomegaly was reported in 4 (8.8%) attendants and 10 (7.2%) medical doctors. However, there was no statistical difference in CXR findings across the job type (P = 0.07).
Table 1: Demographic distributions of employees (n=416)

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Table 2: Chest X-ray reports and age

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Table 3: Chest X-ray reports and gender distributions

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Table 4: Chest X-ray reports and job types

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Figure 1: Distributions of the job type of the employees

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Figure 2: Typical normal chest radiograph

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Figure 3: Chest radiograph showing cardiomegaly

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  Discussion Top

The mean age of the employees was 26.6 years ± 5 and 81% participants were between ages 20–33 years, the age bracket of young population usually applying for their first employment. A CXR was a routine component of PEME for these employees. It was regarded as 'routine' because it was requested and carried out in the absence of a clear clinical indication or suspicion of morbidity.[7] Our study showed that over a 10-year period, the rate of abnormal CXR finding was 4.8% and the only abnormality reported was cardiomegaly. Many studies from different populations confirmed the low yield of abnormal finding on routine CXR. A review of PEME over a 5-year period by Kouamé et al. found 7% abnormal CXR findings of which 61.4% was cardiomegaly.[4]

A prospective review of 1021 CXR of newly admitted university students showed 151 (14.8%) as being abnormal and only 2.8% suggestive of tuberculosis.[6] Similar studies by Naz et al., Izamin and Rizal and Ladd et al. amongst others have confirmed the low yield of routine CXR.[8],[9],[10] While these studies covered diverse industries, Jachuck et al. also confirmed similar finding amongst healthcare workers.[5] Given the low yield of abnormal finding on routine CXR that may put the employees and others, especially the patients/prospective employee at risk, its continued use as a mandatory component of PEME appears questionable. This is due to the likelihood of detecting abnormality which may be unrelated to the job. In our study, cardiomegaly was reported across different job categories and was not considered significant enough to affect their capacity for the jobs and hence they were employed. It had been established that the yield of significant abnormality on CXR is increased if it restricted to those with suspected chest or cardiopulmonary diseases; therefore, it is best reserved for those with clinical indications rather than being a routine procedure.[11] Although routine CXR is done as part of determining fitness for work in PEME, a systematic review by Serra et al. had established that this is mainly determined by job safety and physical demands rather than on medical conditions of candidates, with psychiatric conditions and age being possible exceptions; that the assessments of fitness for work focused on job requirements appear to be better predictors of future health outcomes and costs than those focused solely on medical diagnoses and except for high physically demanding, health and safety-sensitive jobs, the available evidence suggests no beneficial impact of PEMEs, either on health risks or company costs.[12]

That detection of abnormality unrelated to job requirement may reduce overall health cost to the company or prevent future workers' compensation claim is doubtful given that similar radiographic screening such as lumbar spine X-ray to predict risk of future back injury has now been jettisoned.[13],[14] However, as a screening tool in apparently healthy individuals as represented by the prospective employees in this study, larger proportion of abnormal finding (66.7%) on routine CXR was amongst those aged 41 years and above (P = 0.003) without significant relationship to gender (P = 0.3) and job type (P = 0.07). The impact of age was also demonstrated by Ogbole et al. where those with abnormal findings were 8 years older than those with normal CXR (P = 0.001).[6] The implication of this is that even as a routine procedure for screening in PEME, its use should be restricted to those above the fourth decade of life irrespective of the gender or job type.

  Conclusions Top

The low yield of abnormal finding of 4.8% on CXR over a period of 10 years in this health facility questions the rationale of compelling the prospective employees to have CXR irrespective of their ages and clinical indication.


There is an urgent need to reconsider the use of CXR as a routine procedure in apparently young healthy population. For the purpose of PEME, findings from this study suggest that request for routine chest radiograph should be limited to older job seekers. However, given that, this study was based on record review in one health facility, further studies across different employment are required to test this hypothesis.


We acknowledge the staff of the Health Information Management Department of OOUTH, especially Mr. Adesina Y and Ogunfuwa O, for being of tremendous assistance in retrieving the case files.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

McCunney R, editor. Occupational medical services. In: A Practical Approach to Occupational and Environmental Medicine. 3rd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2003. p. 1-13.  Back to cited text no. 1
Pachman J. Evidence base for pre-employment medical screening. Bull World Health Organ 2009;87:529-34.  Back to cited text no. 2
Adeko OO, Ariba AJ. Pre-employment medical examination: An update. Nig J Fam Pract 2016;7:1-6.  Back to cited text no. 3
Kouamé N, Ngoan-Domoua AM, Konan AN. Systematic chest radiography during pre-employment check-up. Afr J Resp Med 2012;7:15-8.  Back to cited text no. 4
Jachuck SJ, Bound CL, Jones CE, Bryson M. Is a preemployment chest radiograph necessary for NHS employees? Br Med J (Clin Res Ed) 1988;296:1187-8.  Back to cited text no. 5
Ogbole GI, Agunloye AM, Adeyinka AO. Are routine chest radiographic examinations of students in Nigerian Universities still relevant? An imaging perspective. J Med Med Sci 2012;3:780-3.  Back to cited text no. 6
Stolberg HO. Comments on routine chest radiography. Radiology 2005;236:368.  Back to cited text no. 7
Naz S, Aziz T, Umair MM, Uzair MM. Chest X-ray: An unfair screening tool. J Ayub Med Coll Abbottabad 2014;26:554-8.  Back to cited text no. 8
Izamin I, Rizal AM. Chest X-ray as an essential part of routine medical examination: Is it necessary? Med J Malaysia 2012;67:606-9.  Back to cited text no. 9
Ladd SC, Krause U, Ladd ME. Are chest radiographs justified in pre-employment examinations? Presentation of legal position and medical evidence based on 1760 cases. Radiologe 2006;46:567-73.  Back to cited text no. 10
Samuel VJ, Gibikote S, Kirupakaran H. The routine pre-employment screening chest radiograph: Should it be routine? Indian J Radiol Imaging 2016;26:402-4.  Back to cited text no. 11
[PUBMED]  [Full text]  
Serra C, Rodriguez MC, Delclos GL, Plana M, Gómez López LI, Benavides FG. Criteria and methods used for the assessment of fitness for work: A systematic review. Occup Environ Med 2007;64:304-12.  Back to cited text no. 12
Boswell R, McCunney R. Musculoskeletal disorders. In: McCunney R, editor. A Practical Approach to Occupational and Environmental Medicine. 3rd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2003. p. 314-31.  Back to cited text no. 13
Rowe ML. Are routine spine films on workers in industry cost- or risk-benefit effective? J Occup Med 1982;24:41-3.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4]

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