The profile of prisoners with tuberculosis in Japan.

Purpose Although globally, prisoners are considered one of the vulnerable groups to tuberculosis (TB), little is known about the situation of TB in prison setting in Japan. The purpose of this paper is to examine the characteristics of TB among prisoners in Japan. Design/methodology/approach Records of TB patients from one medical prison were analyzed in terms of general demographic characteristics, clinical manifestations, risk factors and delay in diagnosis and in initiating treatment, and compared with data from the national TB surveillance and other published data on health of inmates, where appropriate. Continuous variables were compared using student independent samples t-test. Proportions were compared using χ2 or Fisher exact test as appropriate. Kaplan-Meier survival analysis was conducted to determine the time from entry to prison institution to diagnosis of TB. Findings A total of 49 patients were analyzed. The mean age was 49.5 (±14.3) and 69.4 percent were males. Being unemployed and homeless prior to incarceration, and several co-morbidities were potential risk factors for TB ( p<0.01). Analysis of diagnosis and treatment delay showed that 16.1 percent of smear positive patients took more than a week to be placed on treatment after being diagnosed of TB. Approximately 50 percent of the patients were diagnosed within four months of entering the prison institution. Practical implications Several potential risk factors identified suggest the need to strengthen screening for specific sub-groups within the prison population, such as those with poor socio-economic status and co-morbidities, as well as to consider the possible role of systematic screening for latent TB infection. Originality/value This study presents some important data to help understand the profile of TB patients in prisons in Japan, as well as showing that a detailed epidemiological analysis of existing records can provide useful insight.

Profile of tuberculosis among the foreign-born population in Japan, 2007-2014.

The proportion of foreign-born people among the newly notified tuberculosis (TB) patients has been increasing in recent years and potentially poses a new challenge to TB control in Japan. In this report, we analysed the data from the Japan TB surveillance system between 2007 and 2014 to gain an overview of the trends and characteristics of foreign-born TB patients in Japan. We found that the proportion of foreign-born TB patients was especially high among the younger age groups - 44.1% among the 20-29 years age group in 2014. The largest groups of foreign-born patients were from China and the Philippines; however, the number of those from Nepal and Viet Nam was on the rise. Students comprised the second largest professional category group for TB after regular workers, and its proportion increased over the study period. Compared to Japan-born TB patients, foreign-born patients were more likely to be diagnosed through routine medical check-ups. Treatment successes and patients still on treatment were significantly lower among foreign-born patients than their Japan-born counterparts; and transferred-out and unknown outcomes were higher. Our results indicated that distinctive subgroups within the foreign-born population in Japan, especially students and regular workers, might have a higher risk of developing TB. Measures to ensure early diagnosis and treatment adherence should be adapted to such populations.

[EFFECT OF EDUCATIONAL LEAFLETS ON KNOWLEDGE AND ATTITUDE TO TUBERCULOSIS AMONG HOMELESS PERSONS IN TOKYO, JAPAN].

SETTING: Delay in seeking care is one of the critical issues in tuberculosis (TB) control among homeless persons in Japan. Yet knowledge of and attitude towards TB among homeless persons have remained unclear and limited efforts have been made to disseminate information related to TB among homeless persons. OBJECTIVE: To evaluate the effect of TB leaflets, produced and distributed to homeless persons by a group of ex-homeless TB patients, and to understand what homeless persons know about TB. DESIGN: Self-administered questionnaire was conducted among homeless persons before and after distribution of the TB leaflets. Changes in the responses to each question were also subjected to principal component analysis to group questions into types according to response patterns and identify constructs of TB-related knowledge. RESULTS: Results of 88 participants were analyzed. TB knowledge score related to risks and symptoms significantly improved after the intervention (from 54.3% to 70.6%, p < 0.05), while knowledge on treatment cost did not. Two components were identified, namely, the "improvement in TB impression" and "improvement in TB knowledge". CONCLUSION: TB leaflets were effective in improving certain aspects of TB knowledge. However, its effect on knowledge regarding treatment cost, which may be crucial in improving delay, was limited and thus the messages need to be revised.

[RISK GROUPS FOR TUBERCULOSIS IN JAPAN: ANALYSIS OF RELATIVE RISK AND POPULATION ATTRIBUTABLE FRACTION].

OBJECTIVE: Despite the decreasing trend in tuberculosis (TB) cases reported within the general population, TB incidence remains high in certain high-risk groups in Japan. Many of the previous discussions and studies have concentrated mainly on the elderly and those with clinical risks; however, no comprehensive evaluation has been conducted to date. Our study thus sought to estimate the relative risk (RR) and the population attributable fraction (PAF) of selected risk groups in Japan and discuss their relevance to programming future research needs and policies. METHOD: PAF and RR were calculated for patients with human immunodeficiency virus infection, diabetes, rheumatoid arthritis, those on dialysis, the elderly, health care workers, the homeless, people receiving public assistance, foreigners, prisoners, smokers, and those with alcohol problems, and were grouped into "high PAF" (PAF ≥ 5%), "middle PAF" (5% > PAF ≥ 1%), and "low PAF" (PAF < 1%) groups. RESULTS: The elderly and patients with diabetes showed the highest PAF and RR and should thus be prioritized for policies.

Detection of Tuberculosis Infection Hotspots Using Activity Spaces Based Spatial Approach in an Urban Tokyo, from 2003 to 2011.

BACKGROUND: Identifying ongoing tuberculosis infection sites is crucial for breaking chains of transmission in tuberculosis-prevalent urban areas. Previous studies have pointed out that detection of local accumulation of tuberculosis patients based on their residential addresses may be limited by a lack of matching between residences and tuberculosis infection sites. This study aimed to identify possible tuberculosis hotspots using TB genotype clustering statuses and a concept of "activity space", a place where patients spend most of their waking hours. We further compared the spatial distribution by different residential statuses and describe urban environmental features of the detected hotspots. METHODS: Culture-positive tuberculosis patients notified to Shinjuku city from 2003 to 2011 were enrolled in this case-based cross-sectional study, and their demographic and clinical information, TB genotype clustering statuses, and activity space were collected. Spatial statistics (Global Moran's I and Getis-Ord Gi* statistics) identified significant hotspots in 152 census tracts, and urban environmental features and tuberculosis patients' characteristics in these hotspots were assessed. RESULTS: Of the enrolled 643 culture-positive tuberculosis patients, 416 (64.2%) were general inhabitants, 42 (6.5%) were foreign-born people, and 184 were homeless people (28.6%). The percentage of overall genotype clustering was 43.7%. Genotype-clustered general inhabitants and homeless people formed significant hotspots around a major railway station, whereas the non-clustered general inhabitants formed no hotspots. This suggested the detected hotspots of activity spaces may reflect ongoing tuberculosis transmission sites and were characterized by smaller residential floor size and a higher proportion of non-working households. CONCLUSIONS: Activity space-based spatial analysis suggested possible TB transmission sites around the major railway station and it can assist in further comprehension of TB transmission dynamics in an urban setting in Japan.

[Socio-economic factors that influence tuberculosis death among the youth and middle-aged population: a systematic review].

OBJECTIVE AND METHOD: The number of tuberculosis (TB) deaths in Japan has decreased by 9% in the past 10 years. As of 2012, the death rate was 1.7 per 100,000 populations. Many studies have reported on the clinical factors associated with the number of TB deaths in Japan, and have identified aging to be a major cause of death among patients with TB. However, death among younger patients with TB is also a serious concern, and although several socio-economic factors have been suggested in the past, these studies have varied in methods and results. Therefore, we conducted a systematic review of previous studies that have focused on the association between TB death and socio-economic factors. RESULTS: Our results revealed unemployment, education, history of homelessness, substance and alcohol abuse, and nationality to be risk factors for TB death. CONCLUSION: Many of these factors are markers of poverty, and in Japan too, various markers of socio-economic vulnerability have been suggested to have an influence on TB death. These factors negatively affect patients' health-seeking behavior and thereby increase the risk of death. It is therefore necessary to encourage persons at risk of TB to seek early care by collaborating not only with public health and medical institutions, but also with welfare services, employment support services, and alcohol and drug support groups.

Strengthened tuberculosis control programme and trend of multi-drug resistant tuberculosis rate in Osaka City, Japan.

Osaka City has the highest tuberculosis (TB) notification rates in Japan. In the period 1999-2003, the TB control programme was strengthened, and the Stop TB Strategy was implemented to reduce the number of notified cases. The objective of this study was to assess the effect of these control activities in Osaka City, including the implementation of directly observed treatment (DOT), by analysing TB surveillance and routinely collected data. We reviewed the surveillance data of all sputum smear-positive pulmonary tuberculosis (PTB) cases registered in the Osaka City Public Health Office from 2001 to 2008 and data collected from the routine TB programme. The DOT implementation rate increased from 0% in 2001 to 68% in 2008 for smear-positive PTB cases of the general public and to 61% for all PTB cases of the homeless. The proportion of smear-positive PTB cases that had treatment failure and default combined, declined from 8.0% (52 of 650) in 2001 to 3.6% (20 of 548) in 2006. The proportion of cases among the homeless with previous treatment declined from 28% in 2001 to 15% in 2008. The proportion of cases with multidrug resistant-TB (MDR-TB) among those without previous treatment declined from 1.7% in 2001 to 0.9% in 2008. It is logical that reduction in the failure and default rate would lead to the reduction of cases with previous treatment and TB transmission, including resistant TB, therefore to the reduction of MDR-TB rates.

Characteristics and treatment outcomes of tuberculosis cases by risk groups, Japan, 2007-2010.

INTRODUCTION: We studied the characteristics and treatment outcomes of the following risk groups for tuberculosis (TB): those with HIV and diabetes mellitus (DM), contact cases, the homeless, foreigners, health care workers (HCW) and the elderly. METHOD: A descriptive cross-sectional study was conducted by analysing the Japanese tuberculosis surveillance data of all cases registered between 2007 and 2010 (n = 96 689). RESULTS: The annual proportion of TB cases by risk group was stable over the study period, although there was a slight but significant increase observed for foreigners and elderly cases. Homeless and elderly TB cases had the highest DM co-morbidity (16.6% and 15.3%). HIV co-infection was low in all TB cases (0.2%) yet highest in foreigners (1.3%). HIV status of 45% of TB cases was unknown. The proportion of multi drug resistant (MDR) TB was similar among all risk groups (0.0-0.9%) except foreigners, at 3.4%. Males in most risk groups had higher mortality than females; the mortality of all TB cases in all age groups for both males and females were 3.6-24 times higher than the general population. DISCUSSION: Reasons for the high proportion of "HIV status unknown" should be investigated and improved. Contact tracing among foreign cases with MDR-TB should be a priority. Homeless persons should be screened for DM together with TB. Programs to enhance health and nutrition status may benefit tuberculosis prevention among the elderly. Tuberculosis screening and TB education are important for HCW.

Engaging women volunteers of high socioeconomic status in supporting socioeconomically disadvantaged tuberculosis patients in Chiang Rai, Thailand.

PROBLEM: The 2008 tuberculosis (TB) surveillance of Chiang Rai Hospital, Chiang Rai, Thailand reported that 8.4% of Thai, 22.7% of hill tribe minority and 25% of migrant patients (n = 736) defaulted from treatment. CONTEXT: TB patient management in Chiang Rai is complicated due to poverty and HIV stigma. A previous study shows unaffordable travel expense was one of the reasons of patient default. ACTION: We engaged Chiang Rai women's organizations whose members are of high socioeconomic status to support poor TB patients financially and socially. A group of women formed a team to support these TB patients (n = 192) by raising and sustaining funds and providing home visits (n = 37). TB surveillance and patient-fund register data were used to evaluate TB treatment outcomes. OUTCOME: THE SUCCESS OF TB TREATMENT WAS SIGNIFICANTLY HIGHER FOR PATIENTS RECEIVING FINANCIAL SUPPORT (RELATIVE RISK [RR]: 1.351; 95% confidence interval [CI] 1.20-1.53; P < 0.000). Lower death rates in all groups were observed among patients receiving financial support. However, financial assistance alone did not improve treatment outcomes for migrant patients. Thirty-seven patients (25 Thai, eight hill tribe, four migrants) who were visited by women volunteers at home achieved 95% TB treatment success. DISCUSSION: It is possible to involve volunteers to support poor TB patients. Willingness to support TB patients was driven by presenting provincial TB epidemiology information, research data on the experience of poor patients and the inspiring experiences of other women volunteers. Future research should investigate the reasons for the high treatment success among patients who received home visits.

[On-the-street DOTS for a homeless tuberculosis patient--case report of a patient who had difficulties with TB treatment adherence].

PURPOSE: A homeless patient with tuberculosis (TB), who had often quit his TB treatment in mid-course and then gone homeless again, succeeded in completing his treatment for over 10 months through on-the-street DOTS ("Bluesky DOTS" is another expression). Based on the analysis of this case, we have discussed how to provide effective countermeasures to non-compliant TB patients. METHOD: An episode of a successful on-the-street DOTS for a 70-year-old homeless man with sputum smear positive pulmonary TB was qualitatively analyzed, with a view toward patient's empowerment. RESULT: The patient had had human-relations problems in his life, and trouble with medical and welfare service staff. During his hospital admissions, he repeatedly self-discharged or was forced to discharge due to violent behavior against staff. Public health nurses at Shinjuku public health center visited the patient frequently at the hospital, and tried to build a good relationship with the patient from the beginning of the treatment. Following a two and half month interruption of the TB treatment after he disappeared from the hospital, he was discovered staying outside at a canal side in the area, and on-the-street TB treatment was carried out, with good cooperation with the hospital and social welfare office. Directly observed TB medication was given to him by a public health nurse and another health center staff member for 293 days, at the park near his living place. The patient often rejected the medication, particularly when he was hungry, but offering lunch to him was a very effective incentive. Through comprehensive supports to the patient, he gradually changed his attitude, and on his own came to consider his health and his future. DISCUSSION: We have analyzed a successfully treated case of a homeless TB patient who had difficulties in maintaining a social life and had not been cooperative in complying with the medication. The level of independence improved during the course of on-the-street DOTS with incentive and other supports. He became receptive to TB treatment and became self-supportive during the course of DOTS, with food as an incentive. This indicates that on-the-street DOTS was successful not only for the treatment completion but also contributed to empowering the TB patient. This approach of adjusting the service to the patient's needs fostered a positive relationship with all stakeholders.

Strengthened tuberculosis control programme and trend of multidrug resistant tuberculosis rate in Osaka City, Japan

Osaka City has the highest tuberculosis (TB) notification rates in Japan. In the period 1999–2003, the TB control programme was strengthened, and the Stop TB Strategy was implemented to reduce the number of notified cases. The objective of this study was to assess the effect of these control activities in Osaka City, including the implementation of directly observed treatment (DOT), by analysing TB surveillance and routinely collected data. We reviewed the surveillance data of all sputum smear-positive pulmonary tuberculosis (PTB) cases registered in the Osaka City Public Health Office from 2001 to 2008 and data collected from the routine TB programme. The DOT implementation rate increased from 0% in 2001 to 68% in 2008 for smear-positive PTB cases of the general public and to 61% for all PTB cases of the homeless. The proportion of smear-positive PTB cases that had treatment failure and default combined, declined from 8.0% (52 of 650) in 2001 to 3.6% (20 of 548) in 2006. The proportion of cases among the homeless with previous treatment declined from 28% in 2001 to 15% in 2008. The proportion of cases with multidrug resistant-TB (MDR-TB) among those without previous treatment declined from 1.7% in 2001 to 0.9% in 2008. It is logical that reduction in the failure and default rate would lead to the reduction of cases with previous treatment and TB transmission, including resistant TB, therefore to the reduction of MDR-TB rates.

Engaging women volunteers of high socioeconomic status in supporting socioeconomically disadvantaged tuberculosis patients in Chiang Rai, Thailand

Problem: The 2008 tuberculosis (TB) surveillance of Chiang Rai Hospital, Chiang Rai, Thailand reported that 8.4% of Thai, 22.7% of hill tribe minority and 25% of migrant patients (n = 736) defaulted from treatment. Context: TB patient management in Chiang Rai is complicated due to poverty and HIV stigma. A previous study shows unaffordable travel expense was one of the reasons of patient default. Action: We engaged Chiang Rai women’s organizations whose members are of high socioeconomic status to support poor TB patients financially and socially. A group of women formed a team to support these TB patients (n = 192) by raising and sustaining funds and providing home visits (n = 37). TB surveillance and patient-fund register data were used to evaluate TB treatment outcomes. Outcome: The success of TB treatment was significantly higher for patients receiving financial support (relative risk [RR]: 1.351; 95% confidence interval [CI] 1.20–1.53; P < 0.000). Lower death rates in all groups were observed among patients receiving financial support. However, financial assistance alone did not improve treatment outcomes for migrant patients. Thirty-seven patients (25 Thai, eight hill tribe, four migrants) who were visited by women volunteers at home achieved 95% TB treatment success. Discussion: It is possible to involve volunteers to support poor TB patients. Willingness to support TB patients was driven by presenting provincial TB epidemiology information, research data on the experience of poor patients and the inspiring experiences of other women volunteers. Future research should investigate the reasons for the high treatment success among patients who received home visits.

[Medical service systems for tuberculosis in low-incidence countries].

OBJECTIVES: Currently, Japan has a near low incidence of tuberculosis (TB); the incidence is below 20/100,000. Considering this incidence, the medical service provision system needs to be restructured and related policies need to be revised. The Revised National Guidelines for TB Control, issued in May 2011 by the Ministry of Health, Labour, and Welfare, provided the policy towards achieving a low incidence of TB. This study aims to provide suggestions for restructuring the medical service system in Japan by analyzing the systems in selected countries with low incidence. METHOD: Between 2004 and 2010, we conducted tours to study TB control and medical services in the UK, the USA, Germany, The Netherlands, and Norway. In these tours, we visited the medical facilities, agencies implementing preventive activities, health departments of central and local governments, reference laboratories, technical agencies, non-governmental organizations, and other organizations involved in TB control in these countries. In addition, we collected information from published papers and related documents through the internet. This paper reports the policies and strategies adopted in these low-incidence countries, especially pertaining to medical service systems, directly observed treatment, short-course (DOTS) services, hospital beds and facilities, objectives and duration of hospitalization, and mechanisms for maintaining quality medical services. RESULTS: In all the visited countries, except Germany, TB patients were diagnosed and treated, as well as provided support such as DOTS, by a single organization or agency. In the US and Norway, DOTs was provided to all TB patients at chest centers and/or health centers. On the other hand, in the UK, guidelines from the National Institute for Health and Clinical Excellence (NICE) stated that DOT is not necessary for managing most active TB cases. In these countries there were 3 modes of treating infectious patients: home isolation, hospitalization for the first 2 weeks after initiating treatment, and hospitalization until smear examination results are negative. None of the countries had official standards for hospitalization. Measures to maintain service quality were integrating service providers, strengthening technical support, training and/or educating experts, and networking of personnel in charge. DISCUSSION: The study tours were conducted over 6 years, but no follow-up surveys were conducted. In each visit, we visited only a limited number of medical facilities, which may not be representative of that country. Obviously, this report does not aim to be a comparative study but to provide useful information for discussing the future direction of the medical service system in Japan. In Japan, TB is diagnosed and treated in hospitals and clinics, but contact surveys and other preventive activities are conducted in health centers. In this regard, Japan seems to be unique in that the ways to achieve collaboration among hospitals, health centers, and related organizations are emphasized in the revised National Guidelines for TB Control. Regardless of the DOT target group of a patient, healthcare providers in Japan are expected to ensure patient's adherence through patient-centered support in order to achieve successful treatment. In Japan, the central Government is expected to take responsibility to prevent infection. We suggest that the standards for lengths of hospital stay of TB patients should be revised such that the lengths are based on each patient's bacteriological condition and social setting. The revised National Guidelines for TB Control provide frameworks for ensuring the quality of medical services, but further discussions are warranted in order to plan and implement an effective strategy.

[Tuberculosis care and new horizon of Japanese society].

Current tuberculosis (TB) problems are reflections of Japanese society. Living or dying alone among the elderly, difficulty in finding jobs or withdrawal into themselves among the youths are features of modem society. The future needs for TB care were discussed on specific topics of TB among the elderly, foreigners and the homeless. Presenters showed the importance of the patient-centered care in collaboration with public health and welfare services. Both patients and staffs will see others shining, as they touch each other in the deep part of human existence. A diabetic ex-TB patient talked his experience in his treatment. His window of mind was gradually opened from inside with the continuous support in DOTS by the staff of the public health center. To accumulate these experiences of a heartwarming atmosphere will have the effective power on establishment of social supporting systems. This symposium can be a step towards humanized society or a new horizon of public health which can answer to another need of inner cry of a sick people particularly among the socially disadvantaged who are the victims of the weakness of society. 1. Current situation and issues of elderly tuberculosis patients: Eriko SHIGETO (NHO Higashihiroshima Medical Center). By the analysis of 102 tuberculosis patients of 70 years old and above who were registered at Hiroshima Prefectural Health Center in 2009, 41 patients had severe complications such as diabetes mellitus, renal insufficiency, malignancy or cerebrovascular disorder. Their prognosis was rather poor and the ADL tended to be worsened during hospitalization. Though 16 of the 34 deaths were caused with non-tuberculosis diseases, the ratio of the tuberculosis deaths was higher (4/17) among the patients living alone. Sufficient care of the elderly for early diagnosis, care system to treat various complications and patient support are required. 2. Provision of medical interpreters to help foreigners with tuberculosis in Tokyo: Takashi SAWADA (Services for Health in Asian & African Regions (SHARE)). In 2006, Tokyo Metropolitan Government started to dispatch interpreters for foreigners to strengthen DOTS program. Collaboration with NGOs made it possible to train 37 volunteer interpreters, and to provide services in 13 languages, as of 2010. In Japan, the treatment defaulter rate among non-Japanese tuberculosis patients had been remarkably high. But with having the assistance of interpreters, the treatment completion rate has become higher than 80%. It is recommended to expand a similar system to other part of Japan, as the proportion of foreigners among total tuberculosis cases keeps on increasing nationwide. 3. Tuberculosis problems in Japan from the view point of homelessness-through the activities of a NPO supporting the homeless in collaboration with a public health center: Sadako KANAZAWA (Volunteer, NPO Medical Care Team of Shinjuku Renraku-Kai). It has been 20 years since the issue of homelessness emerged in Japanese society. The people with a history of both tuberculosis and experience of homelessness tend to show a poor prognosis. Our team has played an active role, working with Shinjuku Public Health Center for conducting a screening for tuberculosis every year. It seems that the screening service itself does not make a fundamental solution for homeless people with tuberculosis. Developing a more basic system of 'from street to apartment' is more essential. We believe that understanding the importance of the system is most essential to the people who are involved in health and medical care. 4. What we have learned from DOTS--Toward care by cuddling the patient's mind: Kazuyo ARIMA (PHN, Osaka City Public Health Center). Osaka City has achieved the goals of DOTS set up by the City's TB Control Guidelines since 2001 such as 80% DOTS implementation rate, halving the defaulter rate and incidence rate. It was shown by analysis that the treatment success depends on 'patient's awareness of the disease', 'appropriate DOTS method for each patient', 'existence of side effects', or 'the relationship between treatment supporters'. Through working for the patients whose treatment management was difficult, we have learned that our attitude towards the patients is a most important first step to build a good relationship and mutual trust with the patients, and DOT is an important tool. For treatment supporters,'the patient-centered care', 'care by staying close to the patients' or 'cuddling the patient' s mind' is most necessary to lead the patients to cure. 5. Patient's view: Through DOTS, my life has been renewed: Kuniyoshi MAEDA (Himawari no kai; Ex-homeless TB patients self-help group). It is an unforgettable memory that I was hospitalized due to TB back in 2009. I was seriously ill with also diabetes mellitus. Because I had lost everything due to my friend's cheating, I could not trust anyone before the TB treatment. But I learned how to think of others through the daily communication with doctors, nurses, other staff at the hospital, and Public Health Center. They encouraged me every day and I came to desire to answer to their expectations. Public health nurses taught me that building the reliable relationship is so essential for humans, and I may not have realized this importance if I had not been treated for TB, or treated outside Shinjuku. I would rather say that I was lucky to have got TB, as I have become able to trust other people through DOTS TB care. DOTS is not only for medication, but also general health care and counseling. I hope that as many as poor people, especially homeless can have a similar experience by knowing more about TB and using a health service. I would like to cooperate with TB services if I can be useful. health: Toshio TAKATORIGE (Graduate School of Safety Science, Kansai University). Tuberculosis was ever the biggest health problem in Japan. Ministry of Health and Welfare and Public Health Centers were founded to push forward tuberculosis control. Local governments, companies and people had to follow the national tuberculosis control program uniformly without exception. Currently a new stream of tuberculosis control has been started by DOTS strategy. The aim of DOTS has made all patients take medicine regardless of their social conditions until cure. Every patient is snuggled up and supported whether he is homeless, criminal or a foreigner. The patients also participate in the program actively. The DOTS may be a new public health movement. The strong public health infrastructure is necessary to maintain tuberculosis control towards the low incidence situation. The role of the local government should be more important. This symposium has also shown that the tuberculosis services must be patients-centered and supported by the people, addressing a new horizon of public health in Japan through tuberculosis control.

Computerized surveillance system of tuberculosis in Japan: its evolution, achievement and challenges.

The nationwide computerized tuberculosis (TB) surveillance system was revised in 2007. It was developed to be user-friendly and to allow the evaluation of current TB problems and control issues in Japan. All public health centers in Japan (518 as of April 2007) have system terminals connected to a central computer, and the data entered at these terminals are sent to the online central computer excluding personal identification data. All the figures and tables in this paper were created using the annual report database which are compiled from this system. The revision in 2007 added many new functions to the system, such as a function for automatically sending data upon transfer. The monitoring information for assisting case management of TB patients by the DOTS was also enhanced. The algorithm for classifying treatment outcomes automatically based on data entered regarding cancellations from registration, bacteriological results and drug usage each month was revised. The proportion of "Failed" and "Defaulted" combined was 4.6% among new sputum smear positive pulmonary TB patients newly registered in 2009, while "Died" accounted for as high as 19.3%, due largely to a high percentage of the elderly. A new system for contact examination management is provided as a subsystem. Feedback of data analyses has been strengthened by various methods. This TB surveillance system is indispensable for implementing the evidence-based TB control program in Japan. An important role of the Research Institute of Tuberculosis is to support the planning and execution of TB control with provision of useful epidemiological information from the system.

[The use of nationwide tuberculosis surveillance system data to determine geographical differences in drug resistance--consideration of the representativeness of the drug resistance rate in Japan].

Annual reports of tuberculosis (TB) statistics have been compiled using a database built through the nationwide computerized TB surveillance system in Japan. Using the annual report database for 2007-2009, this study compared the drug resistance rates among eight geographical districts. The proportion of bacteriological test results obtained at public health centers, which enter data into their computers that can then be accessed by the central computer, improved greatly from 2007 to 2009. The proportion of initial culture test results obtained among pulmonary TB increased from 63.8% to 74.8% and the proportion of drug susceptibility test results obtained among culture-positive pulmonary TB cases increased from 41.8% to 63.5%. As a result, susceptibility test results among 15,425 (26.5%) of 58,198 newly notified pulmonary TB cases during the three-year study period were obtained. The proportion of multi-drug resistant (MDR) TB among new treatment patients was 0.6% in the whole country. Although there were no particular districts having a significantly high rate of MDR-TB, the Kinki district showed the highest rate at 0.8%. In the case of retreatment patients, the MDR-TB rate was 5.1% in the whole country and there was no statistical difference among the eight districts. The proportion having resistance to any INH among new treatment patients was 4.5% in the whole country, with the Kinki and Kanto districts showing significantly high rates of 5.3% and 5.2%, respectively. In the case of retreatment patients, the proportion having resistance to any INH was 13.3% in the whole country, and there was no district where the proportion was significantly high. The proportion having resistance to one or more drugs among new treatment patients was 12.7% in the whole country, with the Kinki district showing a significantly higher rate of 15.4%. In the case of retreatment patients, the proportion having resistance to one or more drugs was 22.2% in the whole country, and there was no district where the proportion was significantly high. It is important to monitor drug susceptibility results for a comprehensive TB control program. The results of drug susceptibility tests through the nationwide TB surveillance system revealed a tendency toward higher drug resistance in districts that included large cities. Although many problems remain to be solved in order to optimize the use of results from the nationwide computerized TB surveillance system to represent the drug resistance rates in Japan, this practice is expected to yield great benefits.

Time of highest tuberculosis death risk and associated factors: an observation of 12 years in Northern Thailand.

PURPOSE: Northern Thailand is a tuberculosis (TB) endemic area with a high TB death rate. We aimed to establish the time of highest death risk during TB treatment, and to identify the risk factors taking place during that period of high risk. PATIENTS AND METHODS: We explored the TB surveillance data of the Chiang Rai province, Northern Thailand, retrospectively for 12 years. A total of 19,174 TB patients (including 5,009 deaths) were investigated from 1997 to 2008, and the proportion of deaths in each month of TB treatment was compared. Furthermore, multiple logistic regression analysis was performed to identify the characteristics of patients who died in the first month of TB treatment. A total of 5,626 TB patients from 2005 to 2008 were included in this regression analysis. RESULT: The numbers of deaths in the first month of TB treatment were 38%, 39%, and 46% in the years 1997-2000, 2001-2004, and 2005-2008, respectively. The first month of TB treatment is the time of the maximum number of deaths. Moreover, advancing age, HIV infection, and being a Thai citizen were significant factors contributing to these earlier deaths in the course of TB treatment. CONCLUSION: Our findings have pointed to the specific time period and patients at higher risk for TB death. These findings would be useful for prioritizing interventions in order to diminish TB-related deaths globally. Studies based on these findings are necessary for the introduction of newer intervention strategies.

Promoting health equity in cities through evidence-based action.

The impact of the urban setting on health and, in particular, health inequities has been widely documented. However, only a few countries have examined their inter- or intra-city health inequalities, and few do so regularly. Information that shows the gaps between cities or within the same city is a crucial requirement to trigger appropriate local actions to promote health equity. To generate relevant evidence and take appropriate actions to tackle health inequities, local authorities need a variety of tools. In order to facilitate a comprehensive understanding of health systems performance, these tools should: (1) adopt a multi-sectorial approach; (2) link evidence to actions; (3) be simple and user-friendly; and (4) be operationally feasible and sustainable. In this paper we have illustrated the use of one such tool, The World Health Organization's Urban HEART, which guides users through a process to identify health inequities, focusing on health determinants and then developing actions based on the evidence generated. In a time of increasing financial constraints, there is a pressing need to allocate scarce resources more efficiently. Tools are needed to guide policy makers in their planning process to identify best-practice interventions that promote health equity in their cities.

[Recent case-finding activities of school children in Japan].

PURPOSE: The procedure for TB mass-screening of elementary and junior-high school students was revised in 2003 in Japan. An interview sheet with questions about the past history of TB, episodes of contact with TB patient, TB symptoms, and BCG vaccination history has been administered to all students to determine high-risk groups for TB infection or TB disease despite previous mass-screening with PPD testing for those in first grade. Our purpose in the present study was to evaluate the effects of revised case-finding activity for these school students. METHOD: We analyzed the case-finding activities for school students from 2003-2008 based on data from the national TB surveillance system and related ad-hoc surveys. RESULT: The total number of notified TB cases among these students was 295 out of which 156 were detected by contact survey, 110 by consultation at medical facilities with symptoms, 19 by mass-screening at schools, and the remaining 10 by other means. Although the contact investigation detected more than half of all cases, there were some more cases with a known source of infection among those who were detected in other modes; 28 cases were identified by consultation at medical facilities and 10 by school mass-screening. Case-finding activities by consultation at medical facilities detected 43 bacteriologically positive cases. There were 97 cases without a known source of infection. Most of the cases detected by school mass-examination had risk factors such as TB history in the family and/or a history of staying in TB-prevalent countries. The TB incidence in urban areas is higher than that in other areas for junior-high school students with known or unknown sources of infection. DISCUSSION: The effectiveness of the contact investigation could be enhanced by improving its way of implementation. Delay of diagnosis for infectious cases should be minimized as much as possible to prevent TB outbreaks among students. For that purpose, parents, school teachers, and school nurses should be aware to prevent a delay in seeking care for the patient. Because the efficiency of the current school mass-screening is quite low, revision of this program is necessary, taking into consideration the reinforcement of other case-finding activities. The difference between urban and other areas might be due to a higher infection risk in junior-high school students in urban areas who have higher social activity and may be exposed to higher TB infection risk due to casual contact.

Operational research in low-income countries: what, why, and how?

Operational research is increasingly being discussed at institutional meetings, donor forums, and scientific conferences, but limited published information exists on its role from a disease-control and programme perspective. We suggest a definition of operational research, clarify its relevance to infectious-disease control programmes, and describe some of the enabling factors and challenges for its integration into programme settings. Particularly in areas where the disease burden is high and resources and time are limited, investment in operational research and promotion of a culture of inquiry are needed so that health care can become more efficient. Thus, research capacity needs to be developed, specific resources allocated, and different stakeholders (academic institutions, national programme managers, and non-governmental organisations) brought together in promoting operational research.