Aug 28, 2012

〈Thyroid Examination〉 The Cabinet Office policy to compare with children outside Fukushima Prefecture
This is a complete translation of a Mainichi Shimbun article linked above and published online on August 26, 2012.

In relation to the thyroid examination of children started by Fukushima Prefecture after the Fukushima Dai-ichi nuclear accident, the Japanese government decided to implement a similar examination outside Fukushima Prefecture in order to assess the effect of radiation on children.  Comparative data will be obtained by the end of the current fiscal year (the end of March, 2013).  In Fukushima Prefecture, about 35% of children examined had thyroid abnormalities such as nodules.  Even though Fukushima Prefecture explains that “Small, benign cysts and nodules are not unusual,” parents are anxious and worried as there is no good comparison data of normal prevalence.  The government official says, “We would like to collect data that can be used for comparison to relieve anxiety of Fukushima residents.”

Because pediatric thyroid cancer increased after the Chernobyl nuclear accident, Fukushima Prefecture began thyroid ultrasound examination in approximately 360,000 children who were between the ages of 0 and 18 at the time of the accident.  Of 38,114 children who were examined by the end of March, 2012, 35.8% or 13, 646 children had either nodules (lumps) or cysts (fluid-filled sac); 186 children went on to receive secondary examinations.  No cases of cancer have been found.

For details about the thyroid examination by Fukushima Prefecture, please refer to this article:

Professor Shinichi Suzuki from Fukushima Medical University, which is implementing the examination, says that “There should be no effect of radiation seen at this point of time.” as pediatric thyroid cancer cases began to increase 4 to 5 years after the Chernobyl accident.  On the other hand, radiation specialists have pointed out that “There is no way to judge the presence or absence of the effect of radiation exposure unless the results are compared to prevalence of thyroid nodules/cysts in an average population of children.”

According to the Team in Charge of Assisting the Lives of Disaster Victims in the Cabinet Office, the project will be commissioned to an organization which wins an open competitive bidding.  A free examination will be performed on a total of over 4,500 children under age 18 in more than three locations in Japan.  The examination will be performed by specialists belonging to the Japan Thyroid Association, just as in Fukushima Prefecture, and the quality of ultrasound equipments and the result assessment guidelines will be standardized.  Professor Toshihide Tsuda of Okayama University (environmental epidemiology) says, “This is a meaningful investigation, as the current situation is too insufficient for residents to accept explanation by Fukushima Prefecture.”

Data from examination will be compiled into a report by the end of March 2013.  Before the start of the examination, an investigation committee consisting of specialists, such as epidemiologists, will be established to make concrete plans.  Selection of areas to be examined will most likely require agreements by the Board of Education, schools, and parents/guardians.

Examination results will be sent to those examined.  The government will provide counseling and advice as needed and hold information sessions when most results come out.

Insufficient explanation causing anxiety

The thyroid examination for children under age 18, offered free of charge by Fukushima Prefecture, in order to “watch over children’s health to bring a sense of relief,” is increasing anxiety of parents/guardians.  Many are taking their children to hospitals outside Fukushima Prefecture, looking for a second opinion.  The reason for that is the insufficient explanation about the result from the prefecture.

A sixty-year-old woman from Kawamata-machi, Fukushima, took her four-year-old grandchild to Nakadori General Hospital in Akita-city, Akita Prefecture, in June.  It took them three hours each way by car and Shinkansen bullet train.  They stayed there the night before in order for the grandchild to undergo palpatory and ultrasound examinations of thyroid gland as well as blood test for thyroid function.  As the visit was considered a health check-up, insurance could not be applied.  They paid about 14,000 yen ($178) for the visit, in addition to about 40,000 yen ($509) for travel expenses.

The family received the prefectural examination result from Fukushima Medical University in February.  All it said was, “There are small nodules and cysts (fluid-filled sacs), but there is no need for secondary examination.”  They grew anxious about having to wait until the next examination two years later.  They were upset when multiple cysts were confirmed at the Akita hospital.  The doctor recommended a follow-up examination six months later and told them, “Now that there is a diagnosis, you will be able to use insurance next time.”

This hospital has seen 65 children from Fukushima Prefecture in the last five months since March 14, 2012.  Similar visits are seen in Niigata, Hokkaido, and Tokyo Metropolitan region.  The prefecture examination implemented by Fukushima Medical University restricts examining physicians to specialists belonging to one of seven specialty associations, such as the Japan Thyroid Association, but an examination can be done at any medical facility with the right equipment and experience.

However, there are quite a few cases of people traveling far for the examination after being denied medical care in Fukushima Prefecture.  A 38-year-old mother of two who evacuated to Aizu wakamatsu-city called five hospitals in the city, yet nobody agreed to examine them.  She resented that “It is just not right that we can’t be seen by a doctor when we want to be seen.”

We asked physicians the reason for refusal to provide medical care and received the following responses.

A pediatrician in Fukushima-city:  “It will be confusing if our result is different from the result by Fukushima Medical University.”

A hospital in Aizu district:  “It’s not a duty of a private hospital to relieve the anxiety of parents/guardians.”

One of the physicians involved with the prefectural examination:  “This examination by Fukushima Medical University is an unprecedented epidemiological study in the world to follow up on health effects by radiation.  If some undergo examinations at another hospital instead of the prefectural examination, it will interfere with the study. 

Some point out the influence by a letter sent in January by Fukushima Medical University vice president Shunichi Yamashita to seven specialty associations including the Japan Thyroid Association. The letter tells members of those specialty associations to “Please explain to them well to make sure they understand that any further testing is not necessary before the next examination unless symptoms appear,” in case they receive inquiries or consultations from parents regarding the results of the prefectural examination.  One of the physicians belonging to the Japan Thyroid Association said, “If I follow what’s in this letter, I will be going against the Medical Act which says physicians cannot refuse to provide medical care.”

For the letter sent by Shunichi Yamashita, please refer to this article.

Regarding this letter, Yamashita explained, “It tells them to explain to parents/guardian the fact the prefecture is conducting an extremely accurate examination.  It does not tell them not to give a second opinion.”

As the anxiety of parents/guardians spreads, Namie-machi began an independent project in July:  Town clinic will provide thyroid examination in the year it’s not provided by the prefecture.

Norio Konno, the chief for health insurance section, said, “The prefecture does not understand how parents/guardians and children feel.  They need to provide more detailed support and offer the data.

Request for information disclosure needed for detailed results

Results of the thyroid examination by Fukushima Prefecture are divided into four assessment categories [A1], [A2], [B] and [C], based on the presence or absence of nodules and/or cysts and their sizes.  Those in categories [B] and [C] will undergo secondary examination.

For details about the thyroid examination by Fukushima Prefecture, please refer to this article:

The category that attracts the most anxiety from parents/guardians is [A2].  Thyroid nodules and/or cysts found are too small to qualify for secondary examination.  Moreover, the notification does not have detailed information about the number, location, and size of the nodules and/or cysts.  Fukushima Medical University began improving the process after receiving over 250 phone calls.  From now on they plan on informational meetings to explain the results to the residents.

However, there are other issues.  Consent forms signed by parents/guardians prior to the examination clearly states that the result “can be released any time upon request (by parents/guardians or examinees themselves),” yet request for information disclosure must be filed according to the prefecture regulations in order to obtain physician’s diagnosis or see ultrasound images.

There have been six requests for information disclosure.  Three of them had information disclosed three weeks later, but the still image of ultrasound was printed on a regular copy paper, and the actual digital image data which is more clear was not given to them “for fear of alteration” (per Fukushima Medical University).  Professor Shiro Matsui, Fukushima Medical University Public Relations Officer, explains, “We have to be extremely careful in handling information relating to physical body. In order to confirm that it’s actually the person the information belongs to, the best way is for them to file a request for information disclosure.

To this, an attorney Tsutomu Shimizu, a chairman of the Japan Federation of Bar Association Information Issue Countermeasure Committee, states, “This is meant to be an examination to protect children, and they have their priorities wrong.  Information like test results which is compelling to both children and parents/guardians should be promptly disclosed to them once it is being given out to the right person.”  Even if the image given out might be altered, “All they have to do is keep track of the original data, and it is no excuse for nondisclosure,” he says.

Listening to parents’ voices humbly

We asked Fukushima Medical University vice president Shunichi Yamashita, who is in charge of the thyroid examination, about his challenges.

Reporter:: What is the objective of the examination?

Yamashita:  It is a medical service to promote the health of prefectural residents.  It is by no means a research study.  WHO dose estimation study says radiation exposure dose of Fukushima residents is at most 100 mSv.  International consensus by scientists says that the health risk under 100 mSv has either been not clearly shown or extremely small.

Reporter:  What do you think about more and more parents/guardians seeking second opinions outside Fukushima Prefecture?

Yamashita:  We must figure out a better way of dealing with it.  There is a gap between physician’s opinions and mothers’ understandings.  We need to listen to them humbly to establish a trusting relationship.  

Reporter:  What do you think about the effect of radiation?

Yamashita:  We might find small cancer, but thyroid cancer can occur at a certain frequency under normal circumstances.  We won’t know the conclusive trend until over 10 years later.  We cannot get into oppositional relationships with the prefectural residents.  I would like to guide them so that Japan as a country will not fall apart.  After the Chernobyl accident, many lawsuits happened regarding health effects, with compensatory expenses cut into the national budget.  When that happens, the ultimate victims are people of the country.


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