CHEST X-RAY: AN UNFAIR SCREENING TOOL
AbstractBackground: Chest radiography is considered as the sole screening tool for chest pathologies as prerequisite for overseas employment during their medical examinations. The aim was to evaluate the role of CXR as a screening tool in the diagnosis of different lung pathologies in general and TB in particular. Methods: In this descriptive case series, reports of 63,648 Pakistani candidates, who took chest X-rays during medical screening for employment abroad under the rules of Gulf Coordination Council (GCC), were analysed. The reports were collected over a three year period (2008–2011). All the candidates were apparently healthy males of ages ranging between 18–50 years with average age of 27.4 years. Results: Out of 63,648 candidates examined over a three year period, 1368 (2.15%) were declared unfit on the basis of CXR. There were 359 cases of calcified granulomas, 318 of costophrenic angle obliteration, 174 of apical scaring; 144 of pulmonary scars, 123 of fibrocalcific lesion, 82 of soft shadows in lung, 51 of nodular lung shadows, 42 of lymphadenopathy, 30 of pleural effusion, 26 of interstitial lung shadow and 19 of calcification. A closer scrutiny of these cases revealed that over 90% of the CXRs of the candidates declared as having lung pathologies displayed scars rather than active disease. Conclusion: A normal CXR by itself, neither categorically rules out problems in the chest nor does any finding in it confirm some disease. Unfitness on the basis of CXR alone, unless substantiated by further investigation, is questionable to say the least.Keywords: Chest radiography, pre-employment, screening, misdiagnosis, Tuberculosis
WHO Scientific Group on the Indications for and Limitations of Major X-ray Diagnostic Investigations. A rational approach to radiodiagnostic investigations. Geneva: World Health Organization; 1983. (WHO Technical Report Series No. 689)
Tape TG, Mushlin AI. The utility of routine chest radiographs. In Sox HC, editor. Common diagnostic tests: use and interpretation. Philadelphia: American College of Physicians, 1990; p.79–99.
Qayum M, Anwar S, Raza U, Gul R, Qayum E. Quality of tuberculosis control: a case study of displaced population of Jalozai, Pakistan. Pak J of Chest Med 2010;16(4):1–6
Colice GL. Haemoptysis with a normal chest radiograph: how concerned should we be? Thorax 2009;64:829–30.
Briggs GM. Chest imaging: indications and interpretation. Med J Aust 1997;166(10):555–60.
Fauci S, Braunwald E, Isselbacher KJ, editors. Harrisons Principles of Internal Medicine. Edition? New York: McGraw-Hill; 1998.,
Eisenberg RL, Pollock NR . Low yield of chest radiography in a large tuberculosis screening program. Radiology 2010;256(3):998-1004.
Dasgupta K, Menzies D. Cost-effectiveness of tuberculosis control strategies among immigrants and refugees. Eur Respir J 2005;25(6):1107–16.
Tuberculosis radiology. Available from: http://en.wikipedia.org/wiki/Tuberculosis_radiology#Chest_X-Ray_Findings_that_Can_Suggest_INACTIVE_TB
Liu Y, Weinberg.S. M, Ortega LS, Painter JA, Maloney SA. Overseas screening for Tuberculosis in US Bond immigrants and refugees: N Engl J Med 2009;360:2406–15.
Tuberculosis diagnosis. Available from:
Schwartzman K, Menzies D. Tuberculosis screening of immigrants to low-prevalence countries A cost-effectiveness analysis. Am J Respir Crit Care Med 2000; 161(3):780–9.
Menzies D, Immigration Subcommittee, Canadian Tuberculosis Committee. Screening immigrants to Canada for tuberculosis: Chest radiography or tuberculin skin testing? CMAJ 2003;169:1035–6.
Lohiya GS, Tan-Figueroa L, Lohiya P, Bui D . The futility of universal pre-employment chest radiographs. J Natl Med Assoc 2006;98(12):2019–23.
Adeyekun AA, Egbagbe EE, Oni OA. Contact tracing/pre-employment screening for pulmonary tuberculosis: Should positive Mantoux test necessitate routine chest X-ray? Ann Afr Med 2010;9(3):159–63.
Franco A, Aprea L, Conte M, Manzillo E, Marocco A, Martucci F, et al. Use of PCR for TB bacteria on BAL in early diagnosis of tubercular lobitis. Infez Med 2009;17(3):173–7.