The notebook of personal health record system in Japan: framework of post-retirement health checkups for those formerly employed in hazardous occupations

Abstract

Objective: Japan is seeing a rapid increase in the numbers of migrant workers from Asian countries amidst a rapidly aging population and declining birthrate. The notebook of personal health record (nPHR) system is a Japanese occupational health service that supports those formerly employed in hazardous work, including migrant workers. This review outlines the structure, scale, and importance of the nPHR scheme and explores Japanese medical institutions that conduct health checkups for former workers with nPHR, offering insights into the potential applicability of similar systems in migrant workers’ home countries. Methods: Information on Japanese and international laws and Japanese statistical data was obtained from government websites. Studies of workers with nPHRs were reviewed using the ICHUSHI database. Results: This review outlines the nPHR scheme established under Japanese legislation, summarizing its framework, issuance requirements, and post-retirement health checkups for 15 designated agents/works. In terms of scale, a gradual decline in newly issued nPHRs for major agents/works has been observed in recent years. The system’s importance is highlighted through a review of studies involving former workers with nPHRs and an international comparison of post-retirement health checkup systems. Conclusion: Because of the relatively small number of patients with nPHRs, public hospitals are candidates that could be contracted as medical institutions in migrant workers’ home countries. Over the past 2 decades, three additional agents/works have been included in the system, and the requirements for asbestos-related nPHRs have been expanded, indicating that the system is actively adapting to evolving occupational health needs.

Introduction

In Japan, workers engaged in work that may cause serious health problems, such as cancer, can receive a notebook of personal health record (nPHR) from the Director General of the Prefectural Labour Bureau at the time they leave work or after they have left¹⁾. For the early detection of occupational cancer and for documenting evidence relevant to workers’ compensation, they can also undergo periodic health checkups after leaving employment — referred to in this review as “post-retirement health checkups” — at contracted medical institutions. This requirement applies to both Japanese and foreign workers, as specified in a circular notice of the Labour Standards Bureau of the Ministry of Health, Labour and Welfare (MHLW) in 2019²⁾.

As of 2024, there were more than 2 million foreign workers in Japan, including approximately 400,000 migrant workers under the Technical Intern Training Program (TITP) who return to their home countries after a maximum of 5 years and approximately 140,000 workers arriving under the Specified Skilled Worker (SSW) system who can stay in Japan beyond 5 years. The TITP began in 1993 and the SSW program started in 2019^2,3). In a 2019 circular issued when the SSW program was introduced, guidance on explaining the nPHR system to foreign workers was strengthened²⁾ and the possibility of these workers continuing their post-retirement health checkups after returning home was considered at the time. However, no medical institutions in the home countries of former workers are currently under contract to provide follow-up care according to the nPHR system.

In response to this issue, there is a need to identify appropriate medical institutions for health checkups in major countries with bilateral agreements on the TITP and the SSW system — particularly in Vietnam, China, the Philippines, and Indonesia. The Japan National Federation of Industrial Health Organization (ZENEIREN) is promoting the Overseas Health Checkup Initiative (OHCI) project. This project, which focuses on target countries — Vietnam, Indonesia, the Philippines, and Thailand — collects insights from local experts, including occupational physicians, to establish a system that enables returning migrant workers who were issued with nPHRs in Japan to continue receiving post-retirement health checkups based on their nPHRs in their home countries. This review aims to provide an overview of the nPHR scheme in terms of the relevant laws and regulations; to examine its scale by using available statistical data; and to clarify its importance by analyzing the characteristics of the workers covered, as well as by comparing it with similar frameworks in other countries to highlight its unique contributions and potential for global adaptation. The review also seeks to identify the characteristics of Japanese medical institutions that conduct health checkups for former workers with nPHR, offering insights into the potential applicability of similar systems in migrant workers’ home countries.

Methods

Regulatory and literature review

Information on Japanese laws and regulations related to nPHRs was collected from MHLW and other government databases and websites^4,5). Information on countries conducting post-retirement health checkups — selected by personal communication with occupational health experts and from other sources — was gathered from each country’s legal websites and other information sources.

A literature search of the Japanese biomedical journals database ICHUSHI⁶⁾ was conducted in October 2025 by two reviewers to evaluate the proportion of former workers with nPHRs who developed lung cancer or mesothelioma. The search was performed in Japanese using the keywords “notebook of personal health record.” Inclusion criteria were research articles focusing on “dust-exposed works” or “asbestos” published after 2000, because relevant literature was extremely limited before that year and became substantially more available thereafter. Exclusion criteria were: (1) studies without data on lung cancer or mesothelioma, and (2) studies that did not include a group of individuals with an nPHR.

Data sources of various statistics

The numbers of former workers in pneumoconiosis supervision Classes II or III refer to calendar year data on the status of pneumoconiosis health management implementation⁷⁾. The numbers of compensated new cases of lung cancer due to asbestos; mesothelioma; asbestosis; benign asbestos pleural effusion; and diffuse pleural thickening refer to fiscal year data from the Survey of Claims and Decisions on Benefits for Health Damage Caused by Asbestos⁸⁾. The total number of workers’ compensations for 15 agents/works covered by nPHRs refers to fiscal year data on the status of workers’ compensation for occupational cancer⁹⁾. The numbers issued each year nPHRs for “dust-exposed works” and “asbestos” are calendar year data provided by MHLW. The total numbers of nPHRs issued (eTable 1) and amount of asbestos imports¹⁰⁾ refer to information collected from official reports published by MHLW.

The annual number of deaths due to industrial accidents and occupational diseases refers to calendar year data from MHLW’s Survey of Industrial Accidents¹¹⁾. The annual number of occupational diseases (not including coronavirus disease 2019 cases) for the period 2020–2022 and the numbers of new cases of pneumoconiosis subject to workers’ compensation refer to calendar year data from the MHLW’s Survey of Occupational Disease Incidences⁷⁾. Death rates and incidence rates were calculated by dividing the annual number by the calendar year data of the annual number of workers in the Statistics Bureau’s Labour Force Survey¹²⁾. Gross domestic product (GDP) per capita refers to calendar year data from the System of National Accounts in the Cabinet Office’s White Paper on Japanese Economy and Public Finance 2023¹³⁾.

Results and discussion

Background and scheme of the nPHR system in Japan

In 1972, the Industrial Safety and Health Act (Act No. 57 of June 8) was enacted to prevent industrial accidents and “illness in the course of employment” (a legal expression for occupational diseases) and to ensure the safety and health of workers in the workplace¹⁾. Previously, the Labor Standards Act (Act No. 49 of April 7, 1947) included provisions for worker safety and health, as well as industrial accidents. It was accompanied by the Industrial Accident Compensation Insurance Act (Act No. 50 of April 7, 1947) to support workers or their families in case of industrial accidents (Figure 1A)^14,15). In addition, the Pneumoconiosis Act (Act No. 30 of March 31, 1960) was established to prevent pneumoconiosis — the most prevalent occupational disease in Japan at that time¹⁶⁾. However, despite these measures, the death rate from industrial accidents and occupational diseases and the incidence rate of occupational diseases remained high under the dynamic social changes brought about by rapid industrial development from the 1960s onward. Contributing factors included a high accident rate among construction workers, frequent use of hazardous chemicals, and an increasing number of untrained workers at high risk of industrial accidents. In response to these issues, the Industrial Safety and Health Act was established on the basis of Chapter 5 (Safety and Health of Workers) of the Labor Standards Act, Chapter 2 (Occupational Accidents Prevention Plan) and Chapter 4 (Rules for Prevention of Industrial Accidents) of the Industrial Accident Prevention Organization Act (Act No. 118 of June 29, 1964)¹⁷⁾. In addition to these Chapters, the Industrial Safety and Health Act included Chapters on a safety and health management system, which for the first time defined “occupational health physician,” as well as the measures to be taken when hiring workers and the health management of workers.

Fig. 1. Basic information on the nPHR system. (A) Background of development of the nPHR system. x axis, year; primary y axis, rate (per 100,000 workers); secondary y axis, GDP per capita (100,000 JPY). Vertical dashed lines with arrows indicate years of enactment of Japan’s major labor laws related to the nPHR. (B) Cover page and entry form for health checkup results of an nPHR. (C) Schematic diagram of health checkups and workers’ compensation. Single-headed arrows indicate periodic health checkups. Double-headed arrow indicates the period covered by workers’ compensation. Triangles beside the arrows indicate health checkups on entering or leaving employment. Pentagons beside the arrows indicate occasional applications by the workers in the rounded rectangles for special health checkups. Striped background, occupational health services covered by government insurance systems; gray background, those covered by company insurance systems; white background, those covered by medical insurance systems. (D) Schematic diagram of the nPHR system. The six steps from application to issuance of the nPHR and subsequent post-retirement health checkups are explained with numbers and arrows.

The nPHR is one of the health management systems for workers employed in Japan, including migrant workers, as stipulated in Chapter 7, Article 67 of the Industrial Safety and Health Act (eTable 2; Figure 1B). Periodic worker health checkups, which are also part of health management systems, include general health checkups for all workers and special health checkups for workers with current or previous exposure to hazards such as dust, asbestos, or specified chemical substances (Figure 1C). General health checkups are stipulated in Chapter 7, Article 66, Item 1 of the Industrial Safety and Health Act. Similarly, special health checkups are stipulated in Chapter 7, Article 66, Items 2 and 3 of the Industrial Safety and Health Act, as well as in Chapter 1, Article 3 of the Pneumoconiosis Act. These provisions mandate employers to conduct these health checkups for employed workers, but not for those who have already left employment. The nPHR system is designed to follow up on workers at high risk of developing cancer after they have left employment. Formerly employed workers with nPHRs are eligible for government-supported special health checkups, the results of which are recorded in the nPHRs. According to information obtained through the OHCI project, no migrant workers have been issued nPHRs to date. If migrant workers were issued nPHRs before returning to their home countries and later came back to Japan, they would be eligible to receive these checkups at contracted medical institutions under the current system. However, government-supported checkups are not available in their home countries. Former workers without nPHRs can apply for special health checkups on occasion when they develop any signs or symptoms (this procedure is legally defined as an occasional application). Through these systems, currently or formerly employed workers who have developed occupational diseases, such as cancer and other serious illnesses, can be identified and treated at an early stage, thus ensuring the proper application of workers’ compensation. Figure 1D illustrates the process of nPHR issuance and the subsequent post-retirement health checkups. Workers who may be eligible for an nPHR may apply for its issuance to the Director General of the Prefectural Labour Bureau at the time they leave work or after they have left. If the Prefectural Labour Bureau confirms, on the basis of information from the former employer, that the former worker meets the requirements for nPHR issuance, it is granted (Table 1). The contracted medical institution where the former worker will undergo post-retirement health checkups is determined at the time of nPHR issuance. Formerly employed workers with nPHRs may receive periodic health checkups at these designated contracted medical institutions, with the costs covered by the Japanese government. This means that they do not have to pay for their checkups or their transport (Figure 1D).

Table 1. Items for which nPHRs are issued, and requirements for issuance

Item	nPHR agent/work	Year*	Operation20)			IARC21)			Regulation	Requirement22)
			Manufacturing	Handling	Other	Group	Cancer site/ type	Industry/occupation		Engagement period	Lung abnormalities
1	Benzidine and its salts	1972	•†	•†		1	Bladder	Pigments	•e	≥ 3 months ¶
2	Beta-naphthylamine and its salts	1972	•†	•†		1	Bladder	Pigments	•e	≥ 3 months ¶
3	Dust-exposed works	1972			•a	1	Lung**	Construction, mining			Pneumoconiosis supervision Class II or III ¶¶, ¶¶¶
4	Chromic acid, dichromic acid, and their salts	1975	•†, ‡	•†, ‡		1	Lung***	Metal plating, pigments	•g	≥ 4 years
5	Arsenic trioxide and arsenic	1975	•b		•b	1	Lung, skin, bladder	Glass, metals, pesticides	•g	≥ 5 years
6	Coke or steelmaking furnace gases	1975	•§			1	Lung	–		≥ 5 years
7	Bis (chloromethyl) ether	1976	•†	•†		1	Lung	Manufacture of plastics, resins, and polymers	•e	≥ 3 years
8	Beryllium and its compounds	1976	•†, ‡‡, §§	•†, ‡‡, §§		1	Lung	Aerospace, metals, nuclear industry	•f		Tubercular shadow of a pervasive nature on both lungs
9	Benzotrichloride	1976	•§§§	•§§§		–	–	–	•f	≥ 3 years
10	Vinyl chloride	1976			•c	1	Liver	Plastics	•g	≥ 4 years
11	Asbestos	1996	•d	•d	•d	1	Larynx, lung, mesothelium, ovary	Insulation, construction, renovation	•e, •f	A) ≥ 1 years ¶¶¶¶ B) ≥ 10 years ¶¶¶¶¶ C) A)×10 +B) ≥ 10 years ¶¶¶¶¶¶	Irregular opacities, or pleural thickening on both lungs ¶¶¶, ¶¶¶¶¶¶¶
12	Dianisidine and its salts	1996	•†	•†		–	–	–	•f	≥ 3 months ¶
13	1,2-Dichloropropane	2013		•†, §§§§		1	Biliary tract	Production of chlorinated chemicals	•g	≥ 2 years
14	ortho-Toluidine	2019	•†	•†		1	Bladder	Pigments	•g	≥ 5 years
15	MOCA/MBOCA	2023	•†	•†		1	Uncertain	Rubber	•g	≥ 2 years

IARC, International Agency for Research on Cancer; MOCA/MBOCA, 3,3’-dichloro-4,4’-diaminodiphenylmethane; nPHR, notebook of personal health record.

* Year when the agent/work was first subject to nPHR

** Silica dust, crystalline, in the form of quartz or cristobalite

*** Chromium (VI) compounds

^† Including preparations and other substances containing those substances exceeding 1% of the weight of the preparations and other substances

^‡ Excluding work in workplaces other than those manufacturing those substances from ores

^‡‡ Excluding work handling those substances other than the powdered substances

^§ Limited to those performed in a coke oven, in areas adjacent to a coke oven, or in a gas producer

^§§ Limited to those containing beryllium exceeding 3% by weight for alloys

^§§§ Limited to work at workplaces in which benzotrichloride is manufactured through the chlorination reaction in the presence of light

^§§§§ Limited to work for cleaning printing presses and other equipment in places specified by an Ordinance of the Ministry of Health, Labour and Welfare

^a Operations pertaining to the dust-exposed works (as prescribed in the Pneumoconiosis Act)

^b Crushing of intermediate products during the manufacturing process of inorganic arsenic compounds (excluding arsine and gallium arsenide); roasting or refining them during the manufacture of arsenic trioxide, or smelting of ores containing arsenic exceeding 3% by weight using the Pott method or Greenawalt method

^c Polymerization of vinyl chloride, or separation of water from a suspension of polyvinyl chloride (including co-polymers of vinyl chloride) by using open-type centrifugal machines

^d Operations at a place where asbestos particulate is released by the manufacture or handling of asbestos, etc.

^e Production-prohibited materials

^f Specified chemical substances: Group 1 substances

^g Specified chemical substances: Group 2 substances

^¶ For “Benzidine and its salts,” “Beta-naphthylamine and its salts,” and “Dianisidine and its salts,” the requirement for issuance is fulfilled if the former worker was engaged in work involving one or more of these three agents for a combined total of at least 3 months.

^¶¶ Defined in the Pneumoconiosis Act

^¶¶¶ A former worker may be eligible for nPHR issuance for a dust-exposed work if they have irregular opacities (indicative of asbestosis) and possess an nPHR for asbestos.

^¶¶¶¶ Work (A) The worker has at least 1 year’s experience in manufacturing asbestos, etc.; in stretching, repairing, or removing heat insulators or fireproof covering materials in which asbestos, etc. is used; in spraying asbestos, etc.; or in demolishing or crushing buildings or structures in which asbestos, etc. has been sprayed (including removal of sprayed asbestos, etc.) and at least 10 years have passed since the first exposure to asbestos dust.

^¶¶¶¶¶ Work (B) The worker has at least 10 years’ experience in handling asbestos, excluding work (A).

^¶¶¶¶¶¶: The sum of 10 times the engagement period in work (A) and the engagement period in work (B) is more than 10 years.

^{¶¶¶¶¶¶¶} This also applies to work other than the manufacture or handling of asbestos, etc. (peripheral work).

Hazardous works subject to the nPHR system and nPHR issuance requirements

As of 2024, the operations associated with the 15 types of agents/works covered by the nPHR system were stipulated in Article 23 of the Order for Enforcement of Industrial Safety and Health Act (Cabinet Order No. 318 of August 19, 1972) (Table 1 and Table 2)¹⁸⁾. The agents/works covered by the nPHR system are those that 1) have the potential to cause serious health problems and therefore have restrictions such as production bans from an occupational health and safety perspective; 2) have a clear causal link to occupational diseases; and 3) have a high risk of occupational diseases in the future¹⁹⁾. Of the 15 types of operations, 10 involve both the manufacture and the handling of agents. In contrast, the operations for “arsenic trioxide and arsenic” and “coke or steelmaking furnace gases” are exclusively manufacturing, whereas for “1,2-dichloropropane” the operation is exclusively handling. “Dust-exposed works” are defined as types of work in which engagement by the individual poses a risk of developing pneumoconiosis; this work is specifically stipulated in the Appendix of the Ordinance on Enforcement of the Pneumoconiosis Act (Order of the Ministry of Labour No. 6 of March 31, 1960)²⁰⁾. Operations where workers are directly exposed to dust, such as drilling, mining and tunneling, quarrying, welding, and asbestos handling, are designated “dust-exposed works.” Of the 15 agents/works covered by nPHRs, 13 are designated as Group 1 carcinogens in the World Cancer Report by the IARC (International Agency for Research on Cancer)²¹⁾. The cancer site for seven of the agents/works is the lung, and that for four is the bladder. Other cancer sites/types are the skin for “arsenic trioxide and arsenic”; the larynx, mesothelium, and ovaries for “asbestos”; and the biliary tract for “1,2-dichloropropane.” Of the 15 agents/works, four are pigment related, three are metals related, two are plastics related, and two are construction related. Similarly, of the 15 agents/works covered by nPHRs, four are designated as production-prohibited materials, the manufacture, importation, or use of which is prohibited; four as Group 1–specified chemical substances requiring production approval; and six as Group 2–specified chemical substances.

Table 2. Frequency of post-retirement health checkups for each hazardous agent/work, and items tested

Item	nPHR agent/work	Disease subject to workers’ compensation*24)	Total no. of workers’ compensations (follow-up period, year)	Frequency23)		Work history	Symptoms/ signs (current/ previous)	Chest X-ray	Urinary tests	Specific tests	Total no. of issued nPHRs in 2018 (% of N)9) §] (N = 71,414) (A)
				once every 6 months	once a year
1	Benzidine and its salts	Urinary tract tumor	553 (48)a	•		•	•		•	•	1,137 (1.6%)
2	Beta-naphthylamine and its salts	Urinary tract tumor	100 (43)b	•		•	•		•	•	800 (1.1%)
3	Dust-exposed works	Pneumoconiosis supervision Class IV** or pneumoconiosis with complications***	47,057 (44)c [1,856 (34)d]†		•	•		•		•	25,804 (36.1%)
4	Chromic acid, dichromic acid, and their salts	Lung cancer or upper respiratory tract cancer	211 (48)a	•		•	•	•		•	738 (1.0%)
5	Arsenic trioxide and arsenic	Lung cancer or skin cancer	80 (48)a	•		•	•	•		•	38 (0.1%)
6	Coke or steelmaking furnace gases	Lung cancer	307 (48)a	•		•	•	•		•	5,176 (7.2%)
7	Bis (chloromethyl) ether	Lung cancer	25 (48)a	•		•	•	•		•	89 (0.1%)
8	Beryllium and its compounds	Lung cancer	1 (10)e	•		•	•	•		•	1 (0.0%)
9	Benzotrichloride	Lung cancer	8 (48)a	•		•	•	•		•	9 (0.0%)
10	Vinyl chloride	HA or HCC	13 (48)a	•		•	•	•		•	2,018 (2.8%)
11	Asbestos	Lung cancer Mesothelioma Asbestosis BAPE DPT	7,769 (47)f 10,815 (47)f 772 (12)g 509 (19)h 763 (19)h	•		•	•	•		•	35,382 (49.5%)
12	Dianisidine and its salts	Urinary tract tumor	7 (35)i	•		•	•		•	•	187 (0.3%)
13	1,2-Dichloropropane	Bile duct cancer	26 (10)e	•		•	•			•	35 (0.0%)
14	ortho-Toluidine	Bladder cancer	2 (4) j	•		•	•		•	•	–
15	MOCA/MBOCA	Urinary tract tumor	3 (1)k	•		•	•		•	•	–

BAPE, benign asbestos pleural effusion; DPT, diffuse pleural thickening; HA, hepatic hemangiosarcoma; HCC, hepatocellular carcinoma; MOCA/MBOCA, 3,3’-dichloro-4,4’-diaminodiphenylmethane; nPHR, notebook of personal health record.

* Diseases in bold are due to carcinogenic substances, carcinogenic factors, or jobs in carcinogenic processes listed in the Appended Table 1-2 of the Ordinance for Enforcement of the Labor Standards Act; ** Defined in the Pneumoconiosis Act; *** Pulmonary tuberculosis, tuberculous pleurisy, secondary pneumothorax, secondary bronchitis, secondary bronchiectasis, primary lung cancer; ^† Primary lung cancer complicated by pneumoconiosis; ^§ When a worker with an nPHR dies, the nPHRs must be returned to the Director General of the Prefectural Labour Bureau. Therefore, the “total number of nPHRs issued” represents the cumulative number of nPHRs issued minus those returned.

^a 1975–2022; ^b 1980–2022; ^c 1979–2022; ^d 1989–2022; ^e 2013–2022; ^f 1976–2022; ^g 2011–2022; ^h 2004–2022; ⁱ 1988–2022; ^j 2019–2022; ^k 2022

The requirements for issuing nPHRs are stipulated in Chapter 6, Section 2, Article 53 of the Ordinance on Industrial Safety and Health (Order of the Ministry of Labour No. 32 of September 20, 1972) (Table 1 and Table 2)²²⁾. Of the 15 agents/works, 13 specify engagement periods ranging from more than 3 months to 10 years as requirements for issuance of an nPHR. For “benzidine and its salts,” “beta-naphthylamine and its salts,” and “dianisidine and its salts,” the minimum engagement period for nPHR issuance is at least 3 months owing to their high carcinogenicity. Because of overlapping exposure to these three agents in the pigment industry, they are controlled under a common nPHR. The requirement for issuance under the three agents/works is defined as lung abnormalities on a chest X-ray. The requirement for nPHR issuance for dust-exposed works is for the worker to be in pneumoconiosis supervision Class II or III. A former worker may be eligible for nPHR issuance for dust-exposed work if they have irregular opacities (indicative of asbestosis) and possess an nPHR for asbestos. If former workers have multiple nPHRs, it is desirable for them to have health checkups for all of their nPHRs at the same contracted medical institution.

Post-retirement health checkups provided by the nPHR system

To ensure early detection of cancer and serious diseases that should be covered by workers’ compensation, the frequency and items of health checkups for each hazardous agent/work were stipulated in the Circular notice of the Labour Standards Bureau of the Ministry of Health, Labour and Welfare No. 653 of 1972 (eTable 2; Table 2)²³⁾. Occupational cancers subject to workers’ compensation are stipulated in the Appended Table 1-2 of the Ordinance for Enforcement of the Labor Standards Act (Ordinance of the Ministry of Health and Welfare No. 23 of August 30, 1947)²⁴⁾. Most of the occupational cancers caused by agents/works overlap with the cancer sites/types listed in the IARC report. “Dust-exposed works” and “asbestos” are covered by workers’ compensation for non-neoplastic diseases, as well as for occupational cancer, which likely explains why this agent and work have the greatest number of workers’ compensation cases. Within the 15 agents/works, five had fewer than 10 cases during assessment period, and four had fewer than 100 cases. Except for the three newest agents/works — “1,2-Dichloropropane”, “ortho-toluidine” and “MOCA/MBOCA” — most agents/works have a follow-up period of more than 20 years. Health checkups are conducted once every 6 months for all agents/works, except for “dust-exposed works,” for which health checkups are conducted once a year (Table 2). Health checkups include a work history for all agents/works, and current and previous symptoms and signs for all except “dust-exposed works.” For the nine agents/works where lung cancer and hepatic hemangiosarcoma/hepatocellular carcinoma are included as subject to workers’ compensation, a chest X-ray is required. Urinary tests are included in the health checkup items for the five agents/works in which bladder cancer are included among the diseases covered by workers’ compensation. The total number of nPHRs issued by 2018 was 71,414, predominantly for “asbestos” and “dust-exposed works,” with 35,382 (49.5%) and 25,804 (36.1%), respectively, issued⁹⁾. This was followed by “coke or steelmaking furnace gases,” “vinyl chloride,” and “benzidine and its salts,” each with more than 1,000. Conversely, nPHRs for “beryllium and its compounds” and “benzotrichloride” numbered fewer than 10, whereas those for “arsenic trioxide and arsenic,” “bis (chloromethyl) ether,” and “1,2-dichloropropane” numbered fewer than 100. In 2018, more than 50% of former workers with nPHRs received post-retirement health checkups for most agents/works, but fewer than 50% did so for “benzidine and its salts,” “dust-exposed works,” “chromic acid, dichromic acid, and their salts,” and “arsenic trioxide and arsenic.”

The requirements for contracted medical institutions to provide special health checkups are stipulated in the Circular notice of the Labour Standards Bureau of the Ministry of Health, Labour and Welfare No. 762 of 1972 (eTable 2)²⁵⁾. This notice specifies that medical institutions must have: (1) doctors, (2) laboratory technicians, (3) equipment for health checkups, and (4) a quality assurance system. Table 3 summarizes the required equipment, noting that most agents/works require X-ray equipment and specimen staining. Compliance with the requirement for appropriate equipment (limited to specimen staining, centrifuges, microscopes, a bacterial culture system, atomic absorption spectrophotometers, and automatic blood cell counters) may be regarded as satisfied if the items can be used under an outsourcing contract with another institution, such as a clinical laboratory. A bacterial culture system is required for medical institutions conducting health checkups of dust-exposed workers for pulmonary tuberculosis and tuberculous pleurisy, which are complications of pneumoconiosis. Atomic absorption spectrophotometers — necessary for measuring metal levels — are required at medical institutions performing health checkups for “arsenic trioxide and arsenic” and “beryllium and its compounds.” Blood-cell counters are essential for health checkups involving “benzotrichloride,” as it can cause anemia. Specimen staining and a bronchoscope are not mandatory if there is at least one contracted medical institution with the same equipment in the same area and a referral system in place. Bronchoscopes are necessary at medical institutions performing health checkups for agents/works causing lung cancer, with the exception of “beryllium and its compounds.” As “beryllium and its compounds” and “dust-exposed works” can cause respiratory functional disorders, spirometers are required at medical institutions conducting health checkups for these agents/works. Medical institutions conducting health checkups for agents/works causing bladder cancer or urinary tract tumors need cystoscopes, ultrasonography equipment, and magnetic resonance imaging equipment.

Table 3. Equipment required by contracted medical institutions

Item	nPHR agent/work	Centrifuge†	Microscope†	Specimen staining†, ‡	Cystoscope	US/MRI	XRI	Bronchoscope‡	Spirometer	AAS †	Other
1	Benzidine and its salts	•	•	•	•	•	•
2	Beta-naphthylamine and its salts	•	•	•	•	•	•
3	Dust-exposed works		•	•			•		•*		•a
4	Chromic acid, dichromic acid, and their salts			•			•	•
5	Arsenic trioxide and arsenic			•			•	•		•
6	Coke or steelmaking furnace gases			•			•	•
7	Bis (chloromethyl) ether			•			•	•
8	Beryllium and its compounds	•					•		•**	•	•b
9	Benzotrichloride	•	•	•			•	•			•c
10	Vinyl Chloride		•	•			•				•d
11	Asbestos			•			•	•
12	Dianisidine and its salts	•	•	•	•	•	•
13	1,2-Dichloropropane					(•)	(•)
14	ortho-Toluidine	•	•	•	•	•	•
15	MOCA/MBOCA	•	•	•	•	•	•

AAS, atomic absorption spectrophotometer; MOCA/MBOCA, 3,3’-dichloro-4,4’-diaminodiphenylmethane; MRI, magnetic resonance imaging equipment; US, ultrasonic examination equipment; XRI, X-ray imaging system.

*Spirometers and flow volume curve recorders; **Douglas bags, gas meters, respirometers (spirometers, etc.), oximeters, and stepladders for stair-climbing tests

^a Arterial blood gas analyzer; ^b Electrocardiograph and patch test kit; ^c Blood-cell counting board or automatic blood-cell counter; ^d Photoelectric spectrophotometer, scintigraphy equipment, and angiography equipment

^† An institution may be regarded as being equipped with the necessary equipment (limited to specimen staining, centrifuges, microscopes, bacterial culture system, AAS, and automatic blood cell counters) if it can be used under an outsourcing contract with another institution, such as a clinical laboratory.

^‡ Specimen staining and a bronchoscope are not mandatory if there is at least one contracted medical institution with the same equipment in the same area and a referral system is in place.

Scale and system transitions of nPHR issuance over time

An understanding of the scale and historical transitions of the nPHR system is essential for grasping how Japan’s occupational health services (OHSs) have evolved in response to changing workplace risks and policy needs. Unlike health checkup and compensation data, which are published annually as official national statistics, the number of nPHRs issued is not systematically reported or publicly available. Although the MHLW collects these figures internally, they are not disclosed in the same way as major datasets, such as vital statistics or occupational disease surveys, reflecting the relatively minor scale of the nPHR system. Given that the majority of nPHRs are issued for cases related to “dust-exposed works” and “asbestos” (Table 2), this section first examines “dust-exposed works” (Figure 2A) and then “asbestos” (Figure 2B).

Fig. 2. Trends in nPHR issuance. (A) Changes in the numbers of nPHRs issued for “dust-exposed works.” x axis, year; primary y axis, numbers; secondary y axis, total numbers of nPHRs issued. Vertical dashed lines with arrows indicate years of events related to health management for pneumoconiosis. (B) Change in numbers of nPHRs issued for “asbestos.” x axis, year; primary y axis, numbers/asbestos imports (100 t); secondary y axis, total numbers of nPHRs issued. Vertical dashed lines with arrows indicate years of events related to asbestos-use regulations in Japan.

Figure 2A illustrates historical trends in the issuance of nPHRs and, as related data, the number of formerly employed workers eligible for nPHRs for “dust-exposed work.” Understanding these trends requires an overview of Japan’s pneumoconiosis health management system, particularly the supervision classes that determine eligibility^16,26). Prevention of pneumoconiosis focuses on early detection and cessation of exposure through periodic health checkups in Japan²⁷⁾. The results of chest radiographs graded from PR0 to PR4 correspond to supervision Classes I to IV, with increasing severity (eTable 3). For workers currently or previously engaged in dust-exposed works, regulations in the workplace and frequencies of health checkup vary depending on supervision class. Within this framework, there are two primary pathways through which workers may become eligible for nPHRs related to “dust-exposed works.”

Pathway A: Workers are classified into pneumoconiosis supervision Class II or III at the time they leave employment.

Pathway B: Workers are not classified into Class II or III at the time they leave employment but are subsequently classified into these categories after they leave.

The number of workers in Pathway B, shown in Figure 2A, has increased markedly following the 1977 amendment to the Pneumoconiosis Act and then gradually declined. This amendment introduced the current classification system combining radiographic findings, pulmonary impairment, and complications^26,28,29). It also extended eligibility for nPHR issuance from only workers in Classes II or III at the time of leaving employment (Pathway A) to those who developed Class III after leaving. The 2003 amendment further included Class II cases, following recognition of silica as a Group 1 carcinogen^30,31,32). As shown in Figure 2A, the total number of nPHRs issued for “dust-exposed works” has remained relatively stable but shows a recent downward trend. This decline reflects the requirement that nPHRs be returned to the Director General of the Prefectural Labour Bureau when a worker with an nPHR dies. The annual number of newly issued nPHRs for “dust-exposed works” also shows a decreasing tendency. Notably, this number remains lower than the number of eligible workers (Pathway B), suggesting that gaps in awareness or communication may prevent some from accessing the system.

Figure 2B illustrates historical trends in the issuance of nPHRs for asbestos, together with related data on compensated new cases of asbestos-related diseases and asbestos imports in Japan. Asbestos imports in Japan peaked at nearly 300,000 metric tons from the 1970s to 1990s³³⁾ and were widely used in manufactured products, such as insulation, brake pads, and water pipes, as well as in building materials, such as cement slate and extruded cement board. Japan used three of the six types of asbestos (chrysotile, crocidolite, and amosite), with crocidolite being the most toxic³⁴⁾. The 2005 asbestos-related accident known as the “Kubota Shock” revealed widespread asbestos-related deaths and led to stricter regulations. Although details will be addressed in another paper, media reports indicated that 79 workers and two residents died from asbestos-related diseases, including mesothelioma and lung cancer, between 1978 and 2005^35,36,37). The impact of this accident is clearly reflected in Figure 2B: the number of compensated new cases, especially mesothelioma and lung cancer due to asbestos, increased markedly in 2005–2006. According to one Japanese study, the total number of issued nPHRs for asbestos rose from 593 in June 2005 to 1,495 in December 2005 and 4,390 in June 2006, representing a more than sevenfold rise within 1 year, largely attributed to media coverage³⁸⁾. The total number of issued nPHRs showed a similar surge during this period, indicating that the increase since 2005 was primarily driven by the issuance of nPHRs for asbestos.

Figure 2B also shows that the number of newly issued nPHRs for asbestos declined from 2018 to 2022, despite compensation cases of asbestos-related diseases remaining stable. This lack of correlation likely reflects the complexity of issuance criteria for asbestos nPHRs, which differ from those for “dust-exposed works.” To better understand these criteria, it is useful to review the regulatory history of asbestos in Japan. Before the Kubota Shock, Japan had gradually regulated asbestos: crocidolite and amosite were banned in 1995, and chrysotile-containing materials in 2004. In 2005, the government strengthened demolition-site controls through a dedicated ordinance³⁹⁾. Following the Kubota Shock, a partial ban on asbestos-containing products (>0.1%) was enacted in 2006, and all asbestos products were banned by 2012. The Act on Asbestos Health Damage Relief was enacted in 2006 to provide compensation to non-workers affected by exposure⁴⁰⁾. Despite a reduction in imports since 1988, mesothelioma cases continue to rise owing to the disease’s long latency⁴¹⁾, with a peak expected in about 2025–2035^33,42). In response, the criteria for issuing asbestos-related nPHRs were expanded between 2006 and 2008. Eligibility now includes workers with sufficient exposure duration, even without radiographic abnormalities, and those indirectly exposed if imaging shows signs of asbestosis or pleural thickening^43,44,45).

Taken together, these findings reveal important trends in nPHR issuance for both “dust-exposed works” and “asbestos.” Both categories have shown a gradual decline in the annual number of newly issued nPHRs, particularly in recent years, reflecting the effectiveness of preventive measures. However, the annual number of newly issued nPHRs probably remains lower than the number of eligible workers, suggesting that gaps in awareness or communication may prevent some from accessing the system. This highlights the need for improved outreach to ensure that all eligible workers benefit from post-retirement health checkups.

Importance of the nPHR system in terms of the characteristics of former workers

To understand the proportion of lung cancer or mesothelioma among former workers with nPHRs, we conducted a literature review using the ICHUSHI database (eFigure 1). Among 149 records with available full text, 11 articles met the inclusion criteria of focusing on “dust-exposed works” or “asbestos” and being published after 2000. Of these, five articles lacked data on lung cancer or mesothelioma, and two additional articles did not include a group of individuals with an nPHR. Consequently, four articles were selected and interpreted using a narrative approach. Yamauchi et al. reported on the occurrence of lung cancer among 356 participants who joined pneumoconiosis health checkups during 2003–2004, after 2003 amendment to the Pneumoconiosis Act⁴⁶⁾. This legal amendment added primary lung cancer as a complication of pneumoconiosis and expanded eligibility for nPHR issuance to former workers classified as supervision Class II after leaving employment (Figure 2A). Participants were allocated to three groups: 1) 236 individuals currently or previously engaged in dust-exposed works; 2) 75 former workers with nPHRs; and 3) 45 individuals who submitted occasional applications, most of whom were former workers without nPHRs. The mean ages of these groups were: 1) 45.8 (standard deviation [SD], 12.0) years; 2) 71.1 (SD, 7.0) years; and 3) 73.6 (SD, 7.6) years. Within the groups, 18 (7.6%), 75 (100.0%), and 30 (66.7%) individuals, respectively, were classified into pneumoconiosis supervision Class II or III. They received follow-up lung cancer tests, which resulted in 1 (0.4%), 2 (2.7%), and 3 (6.7%) cases in the respective groups. According to Japan’s National Cancer Registry, the age-specific incidence rate of cancers of the lung and trachea among individuals aged 70–74 is approximately 300 per 100,000⁴⁷⁾. In addition, patients with silicosis indicates roughly a two-fold elevation in lung cancer risk compared with individuals without silicosis^48,49), supporting that a lung-cancer proportion of 2.6% among former workers with nPHRs is within a plausible range, albeit somewhat higher than population-based expectations. Although Groups 1 and 2 underwent periodic pneumoconiosis health check-ups, both showed a lower detection rate of lung cancer than Group 3. Yamauchi et al. noted that, following the 2003 legal amendment, cancer patients with prior dust exposure who had left employment without nPHR issuance might have learned of the change and presented for evaluation via occasional applications, thereby preferentially entering Group 3 — a pattern consistent with selection bias. Alternatively (and non-exclusively), surveillance/ascertainment bias may have operated: Group 2 received scheduled check-ups, creating a larger denominator under active surveillance — including many without cancer — whereas Group 3 typically presented when symptomatic, enriching detected cases among those more likely to already have cancer. Case-mix differences (age distribution and pneumoconiosis supervision class) could further distort cross-group comparisons.

Tabata conducted a study to assess the occurrence of pneumoconiosis with severe pulmonary dysfunction or complications including lung cancer among 306 former workers with nPHRs in “dust-exposed works” who participated in pneumoconiosis health checkups from 2008 to 2010 (pneumoconiosis group)⁵⁰⁾. This group was compared with two control groups: 1,083 former workers with nPHRs for “asbestos” who underwent asbestos health checkups during the same period (asbestos-exposed group) and 1,050 participants who received complete physical checkups (complete physical checkups group). In the pneumoconiosis group, 92.8% were male, with ages ranging from 44 to 95 years and a median age of 72. Their engagement periods varied from 1 to 55 years, with a median of 28 years. Their occupations included pottery (53.8%), stone processing (11.8%), excavation (4.9%), welding (3.9%), and shipbuilding (3.3%). Among them, 53 (17.3%) had nPHRs for “asbestos,” including 41 (13.4%) cases of asbestosis. Severe pulmonary dysfunction was observed in 2 (0.7%) former workers, lung cancer in 2 (0.7%), and secondary bronchitis in 1 (0.3%). In the asbestos-exposed group, 96.5% were male, with ages ranging from 32 to 90 years and a median age of 70. Engagement periods ranged from 2 months to 64 years, with a median of 20 years. Their occupations included asbestos product manufacturing (18.6%), textile manufacturing (13.9%), shipbuilding (13.3%), construction (11.5%), and building materials (6.3%). This group had 19 (1.8%) cases of lung cancer and 4 (0.4%) cases of mesothelioma. In the group undergoing complete physical checkups, 59.6% were male, with ages ranging from 22 to 84 years and a median age of 51. No cases of lung cancer were found in this group. The study indicated that former workers with nPHRs for “asbestos” had a higher proportion of lung cancer than those with nPHRs for “dust-exposed works.” The authors recommended incorporating computed tomography (CT) scans of the chest into post-retirement health checkups for former workers with nPHRs for “asbestos,” as most lung cancer cases were detected through CT scans.

Kishimoto and Fujimoto reported on the occurrence of lung cancer and mesothelioma among 2,130 asbestos-exposed workers, comprising 2,080 former workers with nPHRs for “asbestos” who participated in asbestos health checkups from 2010 to 2016, and 50 current workers⁵¹⁾. In this group, 96.2% were male, with ages ranging from 48 to 96 years and a median age of 72. Among them, 89.4% had pleural plaques. The proportion of lung cancer and mesothelioma were 2.6% and 0.3%, respectively, consistent with the findings of Tabata in 2012⁵⁰⁾. The incidence rate of lung cancer was calculated to be 433.9 cases per 100,000 person-years — lower than the 645 person-years per 100,000 persons observed in smokers with more than 30 pack-years aged 55–74⁵¹⁾.

Tabata et al. reported the proportion of asbestos-related diseases including lung cancer and mesothelioma among 976 former workers with nPHRs for “asbestos” who joined asbestos health checkups in 2006⁵²⁾. In this group, 98.8% were male, with ages ranging from 38 to 91 years and a median age of 70. Engagement periods ranged from 3 months to 59 years, with a median of 23 years. Their occupations included shipbuilding (48.6%), chemical product manufacturing (13.2%), asbestos product manufacturing (13.1%), construction (8.9%), and seafaring (5.5%) — similar to the findings of Tabata in 2012⁵⁰⁾. All subjects had pleural lesions. Among them, 55 (5.6%) had nPHRs for “dust-exposed works,” comprising 48 (4.9%) cases of asbestosis, 5 (0.5%) cases of silicosis, and 2 (0.2%) cases of welder’s pneumoconiosis. There was 1 (0.1%) case of suspected lung cancer, 1 (0.1%) case of mesothelioma, 1 (0.1%) case of benign asbestos pleural effusion, and 1 (0.1%) case of diffuse pleural thickening.

These previous studies revealed that former workers with nPHRs for “dust-exposed works” or “asbestos” predominantly consist of older males, although younger individuals are included. The proportion of lung cancer cases is higher among those with nPHRs for “asbestos” than in those with nPHRs for “dust-exposed works.” However, occasional applicants, who are typically former workers without nPHRs, had the highest proportion of lung cancer. This group included unemployed individuals, employers, or nonsubscribers to workers’ compensation insurance^46,53,54). These findings, primarily reported from public hospitals, highlight both the importance and the limitations of the nPHR system.

International comparison of post-retirement health checkup/surveillance systems

Occupational exposure to hazardous substances can cause chronic diseases that often appear long after employment ends, making post-retirement health checkups a vital component of occupational health policy. To examine how different countries address this issue, we conducted an international comparison of health checkup/surveillance systems (Table 4). The comparison considered the scope of target populations (currently and formerly employed workers) and the range of hazardous substances covered. The table lists the relevant laws and articles governing health checkups/surveillances for former workers, distinguishing these from systems for currently employed workers who are no longer exposed to hazardous substances. South Korea amended its Occupational Safety and Health Act in 2020 to introduce health management cards, establishing a post-retirement surveillance system similar to Japan’s nPHR. Germany has operated a registry and medical surveillance program for asbestos-exposed workers since 1972; it was renamed Gesundheitsvorsorge Asbest (GVA) in 2008 and covers about 600,000 individuals⁵⁵⁾. Spain launched the PIVISTEA program in 2002, involving multiple stakeholders and covering over 22,000 workers by 2008, although its implementation remains uneven⁵⁶⁾. France introduced the PRMS in 1995 for workers exposed to occupational carcinogens, including asbestos⁵⁷⁾. Despite national funding, the system suffers from low awareness and underutilization. Poland initiated the AMIANTUS program in 2000, offering health checkups and free treatment; it had collected medical data on approximately 7,000 former asbestos workers by 2010^58,59). Finland implemented an Asbestos Program from 1987 to 1992, followed by long-term monitoring of over 25,000 workers until 2005⁶⁰⁾. Brazil mandates employers to provide health surveillances for asbestos-exposed workers for up to 30 years post-retirement⁶¹⁾. The Brazilian Ministry of Health developed the Datamianto system to support healthcare and surveillance, manage procedures within the public health system, and monitor compliance. Italy lacks a national system but operates regional programs, with plans underway to establish a nationwide protocol^62,63).

Table 4. International comparison of health checkups of formerly employed workers engaged in hazardous occupations

Country	Relevant Law or Regulation (year)*	Health checkups of workers formerly employed in hazardous occupations		Health checkup of workers  currently employed in hazardous occupations		Measures against hazardous work
		Name of system Description of articles related to system	Hazardous substances covered (fund; coverage)	Name of system Articles related to system	Hazardous substances covered (fund; coverage)
Japan	Industrial Safety and Health Law (1972)1)	nPHR system Article 67: (1) For persons that meet the requirements specified by Order of the Ministry of Health, Labour and Welfare among those that have been engaged in work operations as specified by Cabinet Order that could give workers cancer or cause workers to sustain any other significant impairment to health, the Director of the Prefectural Labour Bureau is to issue a notebook of personal health record related to the relevant work operations at the time of their separation from employment or thereafter; provided, however, that this does not apply to those already in possession of a personal health record related to those work operations. (2) The Government, pursuant to Order of the Ministry of Health, Labour and Welfare, must take the necessary measures in connection with medical checkups for persons in possession of a notebook of personal health record.	Asbestos and other carcinogens (e.g., dust, arsenic) (government funded; national surveillance)	Special health checkups** Article 66 (2), (3)	Asbestos, dust, organic solvents, lead, and specified chemical substances (e.g., alkylmercurials, cadmium) (employer funded; national surveillance)	Comprehensive asbestos ban (2012)
South Korea	Occupational Safety and Health Act (1981)65)	Health management cards system Article 137: (1) With respect to a person who was or is engaged in any work likely to cause health impairments prescribed by Ordinance of the Ministry of Employment and Labor and who meets the requirements prescribed by Ordinance of the Ministry of Employment and Labor, the Minister of Employment and Labor shall issue a health management card to such person to early detect occupational diseases of such person and to continuously manage his or her health. [...] (4) Among the persons issued a health management card, any person who is no longer engaged in work for which he or she is issued a health management card under paragraph (1) may be entitled to receive a health examination corresponding to a special health examination, as prescribed by Ordinance of the Ministry of Employment and Labor. [...]	Asbestos and other carcinogens (e.g., dust, arsenic) (government funded; national surveillance)	Special health examinations Article 130	Dust (e.g. asbestos, mineral dust), metals (e.g., lead, mercury, cadmium), organic chemicals, acids, alkalis and gases (employer funded; national surveillance)***	Asbestos ban (2009)66)
Germany	Ordinance on Preventive Occupational Health Care [Verordnung zur arbeitsmedizinischen Vorsorge, ArbMedVV] (2008)67,68)	Follow-up prevention (Nachgehende Vorsorge)69) Section 5 (3): The employer must offer workers and former workers follow-up preventive health care in accordance with the provisions of the Annex after they stop performing certain activities which may lead to health problems after extended latency periods. At the end of the employment relationship the employer’s obligation transfers to the competent statutory accident insurance provider, and he or she has to hand over a copy of all the necessary documents insofar as the worker has agreed thereto.68)	Annex Part 1: Asbestos: Gesundheitsvorsorge Asbest (GVA)55) Other carcinogens (e.g., inhalable dust, arsenic), lead, etc.68) (statutory accident- insurance funded; national surveillance)	Optional health care (Angebotsvorsorge) Section 5 (1)	Annex Part 1: Asbestos: Gesundheitsvorsorge Asbest (GVA)55) Other carcinogens (e.g., inhalable dust, arsenic), lead, etc.68) (employer funded; national surveillance)	Asbestos ban (1993)55)
Spain	Act 31/1995 on Prevention of Occupational Risks (Ley 31/1995 de Prevención de Riesgos Laborales)70)	Post-occupational health surveillance (Vigilancia de la salud post-ocupacional)71) Article 22 (5): In the cases where the nature of the risks inherent in the work makes it necessary, the workers’ right to periodical surveillance of their state of health shall be extended beyond the end of labour relationship, in accordance with the terms laid down by regulations.72)	Asbestos and wood dust: PIVISTEA56,71) Silica: Silicosis Protocol (Protocolo de vigilancia sanitaria específica) (health-insurance funded; national surveillance)71)	Health surveillance (Vigilancia de la salud) Article 22 (1)	Asbestos and other carcinogens (e.g., crystalline silica, arsenic), lead, etc.73,74,75) (employer funded; national surveillance)	Asbestos ban (2001)56)
France	1. Laboor Code (Code du travail) (1910) 2. Social Security Code (Code de la Sécurité sociale) (1945)57,76,77,78)	1. Post-professional surveillance (Surveillance post-professionnelle, SPP)78) Article L. 4624-2-1: [...] The purpose of this medical examination is to establish traceability and an inventory, to date, of the exposure to one or more occupational risk factors mentioned in article L. 4161-1 to which the worker has been exposed. If he finds that the worker has been exposed to certain dangerous risks, particularly chemical risks, mentioned in a of 2° of I of the same article L. 4161-1, the occupational physician sets up post-exposure or post-professional surveillance, in conjunction with the attending physician and the medical officer of the social security organisations. [...]79)	1. Article L. 4161-1 I-2°-a): Hazardous chemical agents, including dust and fumes (health-insurance funded; national surveillance)	1. Reinforced individual monitoring (Suivi individuel renforcé, SIR) Article L. 4624-2	1. Article L. 4624-2-1 & R. 4624-23: Hazardous chemical agents (e.g. asbestos, arsenic, lead), including dust and fumes75,76,78) (employer-funded; national surveillance)	Asbestos ban (1997)80)
		2. Post-professional medical surveillance (Surveillance médicale post-professionnelle, SMPP)78) Article D. 461-23: (Author’s translation) Upon request, post-professional medical surveillance supported by the primary health insurance fund, the general social security fund or the special social security organization, the inactive person, jobseeker or retired, who ceases to be exposed to one or more of the following occupational risks: [...]
			2. Post-retirement medical surveillance (PRMS) Asbestos: SPIRALE57) (accident-insurance funded; national surveillance)
Poland	Act on the Ban of Use of Asbestos-Containing Products (o zakazie stosowania wyrobów zawierających azbest) (1997)58,81)	Preventive medical examination (Badań profilaktycznych) Article 7 (1): (Author’s translation) In order to provide special health care for employees and former employees involved in the production of asbestos-containing products, a preventive medical examination booklet shall be introduced for persons who were or are employed in conditions of occupational exposure in establishments using asbestos in technological processes.	Asbestos: AMIANTUS58) (government-funded; national surveillance)	Periodic medical examination (okresowe badania lekarskie)†	Carcinogenic substances and agents or fibrogenic dusts (employer funded; national surveillance)	Asbestos ban (1997)58)
Finland	No legislation for FIOH Asbestos Program	–	Asbestos: FIOH Asbestos Program60) (government funded; national surveillance)	Health examinations (terveystarkastukseen)††	Dust (e.g. asbestos, silica), arsenic, lead, etc. (employer funded; national surveillance)†††	Asbestos ban (1994)82)
Brazil	1. Regulatory Standard No. 7 (Norma Regulamentadoras No. 7 (NR-7)) (2022)83)	1. Periodic medical examination (Periódica de exames médicos) ANNEX III 2.17: The employer must, after the end of the employment contract involving asbestos exposure, provide periodic medical control exams for at least thirty years at no cost to the workers.84)	1. Asbestos: Periodic medical examination61) (employer funded; national surveillance)	1. Periodic examination (exame periódico) 7.5.8:	1. ANNEX I, III, V Asbestos and other carcinogen (e.g., dust containing silica, arsenic), lead, etc. (employer funded; national surveillance)	Asbestos ban (2017)61)
	2. No legislation for Datamianto		2. Datamianto61) (government funded; national surveillance)
Italy	1. Consolidated Law on Health and Safety at Work (Testo unico sulla salute e sicurezza sul Lavoro) (2008)85)	1. Subsequent medical examinations (Successivi accertamenti sanitari) Article 259 (2): (Author’s translation) Workers who, during their employment, have been entered even once in the register of exposed workers referred to in Article 243, paragraph 1, shall undergo a medical examination upon termination of employment; on that occasion, a competent doctor shall provide the worker with information on the medical prescriptions to be observed and the advisability of undergoing subsequent medical examinations.		1. Health surveillance (Sorveglianza sanitaria) Article 229 (1):	1. Asbestos and other carcinogens (e.g., arsenic) etc.75,85) (employer funded; national surveillance)	Asbestos ban (1992)62)
	2. Regional health regulations (e.g., Tuscany: Regional Law No. 51/2013)	2. Regional asbestos health surveillance programs86)	2. Carcinogenic substances: Tuscany, Veneto Asbestos: Friuli Venezia Giulia, Emilia, Romagna, Campania, Lombardy Asbestos-cement products: Sicily (local government-funded; regional surveillance)‡

The bolded sections in the description of articles related to the system indicate provisions that explicitly cover health checkups for workers who were formerly employed in hazardous occupations.

* The year in which the law was first enacted; ** Dust-exposed workers are covered by the Article 3 of the Pneumoconiosis Law (1960)¹⁶⁾; *** Stipulated by Appendix 22 of the Enforcement Decree of the Occupational Safety And Health Act (1982)⁸⁷⁾; ^† Stipulated by Article 229 (5) of the Labour Code (1974)⁸⁸⁾; ^†† Stipulated by Section 13 of the Occupational Health Care Act (1383/2001)⁸⁹⁾; ^††† Stipulated by the ANNEX of the Government Decree on Medical Examinations in Work that Presents a Special Risk of Illness (1485/2001)⁹⁰⁾; ^‡ Protocol for health surveillance of former asbestos workers in the whole of Italy is currently under preparation⁶²⁾.

Countries such as South Korea, Germany, and Spain operate national health checkup/surveillance systems for formerly employed workers; they cover multiple hazardous substances, similar to Japan. In contrast, France, Poland, Finland, and Brazil have national systems limited to asbestos. Among these countries, only Poland has implemented a health checkup system for former workers as part of its asbestos ban legislation, separate from the system for current workers engaged in hazardous occupations. Funding sources are primarily governmental, although some countries, including Germany, France, and Spain, also rely on health or accident insurance funds. Brazil has a distinctive system requiring employers to provide coverage for workers exposed to asbestos during their employment and even after retirement. In Italy, regional programs for formerly employed workers exposed to asbestos are in place, and preparations are underway to expand these measures nationwide. In all countries listed in Table 4, health checkups for current workers cover multiple hazardous substances as mandated by occupational health regulations. In contrast, the range of substances included in post-retirement health checkups for former workers with nPHRs is limited, except in Germany. According to personal communication with a German OHS expert obtained through the OHCI project, migrant workers in Germany are also eligible for follow-up prevention if they meet the requirements. However, similar to Japan, they cannot access these services in their home countries and must return to Germany to receive them. These observations suggest that government- or insurance-funded health surveillance systems for former workers entail substantial costs and logistical challenges, often necessitating restrictions on the range of hazardous substances and the geographic scope of coverage.

Conclusion

This review has summarized the scheme, scale, and importance of the nPHR system — an OHS framework in Japan that plays a unique role in managing workers’ health after their retirement. We overviewed the total number of issued nPHRs and annual number of newly issued nPHRs for “dust-exposed works” and “asbestos,” which account for the majority of nPHRs issued. These numbers showed temporary increases following expansions in eligibility criteria, followed by gradual declines. Over the past 2 decades, the nPHR system has expanded to include three additional agents/works, “1,2-Dichloropropane”, “ortho-toluidine” and “MOCA/MBOCA”, each added shortly after the emergence of serious occupational diseases. These changes in both the scale and scheme of the system reflect its responsiveness to evolving occupational health needs. Currently, no migrant workers have been issued nPHRs, meaning they have not been covered for “dust-exposed works” or “asbestos,” both of which show declining issuance trends. Given the system’s flexibility, nPHRs for newly recognized agents/works could potentially be extended to migrant workers in the future, highlighting the need for effective communication strategies to ensure that all eligible workers are adequately informed.

Our observation of nPHR issuance trends suggests that the number of nPHRs issued is lower than the number of eligible formerly employed workers. This discrepancy likely results from insufficient dissemination of information about the system, resulting in some workers missing the opportunity to apply. Actually, a previous report indicated that migrant workers employed in Japan experience multiple challenges — including cultural and language barriers, limited healthcare access, documentation issues, and the broader political climate⁶⁴⁾ — suggesting the existence of practical barriers to obtaining an nPHR. Although efforts to disseminate information to foreign workers, including migrant workers, were strengthened by the 2019 circular²⁾, these findings highlight the need to improve communication strategies to ensure that all eligible workers, including migrant workers, are adequately informed about the nPHR system.

A literature review showed that the proportion of lung cancer among former workers with nPHRs for “dust-exposed works” was 2.6%, and for “asbestos” the proportions were 0.1–2.6% for lung cancer and 0.1–0.4% for mesothelioma^46,50,51,52). These descriptive findings underscore the value of nPHR-based post-retirement health checkups for case identification and follow-up. Notably, all identified studies involving former workers with nPHRs were conducted in public hospitals. This may reflect the relatively small population of former workers with nPHRs, which makes such cases less attractive to private hospitals. Moreover, as no migrant workers with nPHRs have been reported to date, the initial and operating costs of implementing nPHR-based health check-ups are unlikely to be recoverable, making it difficult for private hospitals in migrant workers’ home countries to justify such investments. These considerations suggest that, during the feasibility assessment phase, public hospitals in these home countries could serve as more realistic candidates for contracted medical institutions to implement nPHR-based health checkups. Furthermore, feedback obtained through the OHCI project from OHS experts in some target countries indicates that conducting these examinations at well-equipped public hospitals in urban areas is considered feasible.

Our international comparison showed that only four out of eight countries with post-retirement health checkup systems cover multiple hazardous substances, indicating that such systems are still under development globally. Currently, no system provides post-retirement health checkups for migrant workers after they return to their home countries. Establishing such systems remains challenging because of increasingly complex worker profiles, including migrant workers. However, advances in technologies, such as artificial intelligence, remote consultations, and wearable devices, offer promising opportunities to overcome these difficulties.

Acknowledgments

We thank our Overseas Health Checkup Initiative collaborators Dr. S. Siriruttanapruk, Dr. T. Rattanawitoon, Dr. U. Poonkla, and Dr. N. Dumavibhat from Thailand; Dr. M. Mansyur and Dr. N.P. Adi from Indonesia; Dr. T.T.H. Nguyen from Vietnam; Dr. R. Sta Ana from the Philippines; Dr. J.P. Myong from South Korea; Dr. T. Kraus from Germany; and Dr. E. Algranti from Brazil. This work was supported financially by a Research of Industrial Disease Clinical Research Grant (230101-01), funded by the Ministry of Health, Labour and Welfare, Japan.

Data availability statement

This article contains supplementary material, which is available in the online version.

Conflict of interest

The authors have no conflicts of interest.

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