[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.

[The background of drug-resistant tuberculosis patients on the basis of the annual report database for 2007-2009 in Japan].

In this study, the background of drug-resistant tuberculosis (TB) patients in Japan was analyzed using the annual report database for 2007-2009. The results of the drug susceptibility test of 15,425 patients who were diagnosed with pulmonary TB between 2007 and 2009 were obtained and analyzed. The chi-square test for independence between susceptibility test results and parameters (i.e., sex, age, nationality, etc.) was conducted. Logistic regression analysis was performed using the variables (20s, 30s, 40s ..., new treatment, retreatment, etc.) of parameters that were statistically significant by chi-square test. The risk of multi-drug resistance (MDR) among TB patients who underwent retreatment was significantly high (odds ratio = 11.3, 95% CI: 7.7-16.6, p < 0.001, reference = new treatment), and the risk of MDR among foreigners who had entered Japan within the last 5 years was also high (odds ratio = 9.5, 95% CI: 4.6-19.4, p < 0.001, reference = Japanese). Moreover, logistic regression analysis was performed for TB patients who had previously undergone treatment. The risk of MDR was higher among the patients treated after 1970 than those treated before 1970. Especially, the risk of MDR among the patients previously treated in 1990-1999 was extremely high (odds ratio = 20.8, 95% CI: 5.7-75.0, p < 0.001, reference = before 1970). The risk of MDR among previously treated foreigners who had entered Japan within the last 5 years was also high (odds ratio = 3.8, 95% CI: 1.1-13.2, p = 0.036). Similar to the results for MDR, the risk of resistance to one or more drugs was significantly high among TB patients who underwent retreatment for TB (odds ratio = 2.2, 95% CI: 1.9-2.6, p < 0.001) and foreigners who had entered Japan within the last 5 years (odds ratio = 1.8, 95% CI: 1.3-2.5, p < 0.001); however, their risk of resistance to one or more drugs was lower than that for MDR. In addition, the odds ratios of age groups younger than 80 years to those over 80 years were obtained. They were 2.1 (95% CI: 1.5-2.9) in 0-29 years, 2.2 (95% CI: 1.6-3.0) in 30-39 years, 2.2 (95% CI: 1.7-3.0) in 40-49 years, 2.1 (95% CI: 1.6-2.8) in 50-59 years, 1.9 (95% CI: 1.4-2.5) in 60-69 years, and 1.5 (95% CI: 1.2-1.8) in 70-79 years. With respect to the background of high MDR among TB patients who underwent retreatment and foreigners who have recently entered Japan, the usage of RFP and poor adherence to drugs and entry from high-prevalence countries with high MDR risk were suspected. Regarding the background of generational differences in resistance to one or more drugs, it was suspected that most people over 80 years of age had been infected with TB bacilli in the distant past, before anti-TB drugs were available, when drug-resistant bacilli had not yet emerged. However, the younger generations have become more susceptible to drug-resistant TB bacilli because anti-TB drugs were being widely used when they were born, and drug-resistant bacilli were prevalent in the world.

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.

[Nontuberculous mycobacteriosis mortality in Japan].

UNLABELLED: The aim of this research was to clarify epidemiological characteristics of nontuberculous mycobacteriosis deaths in Japan. We analyzed the frequency of deaths due to nontuberculous mycobacteriosis (NTM) and regional differences using the Vital Statistics of Japan, published by the Ministry of Health, Labour and Welfare. The crude death rate was calculated using the Population Census of Japan published every 5 years (Ministry of Internal Affairs and Communications). In addition, changes in the proportions of death cases due to NTM disease among total autopsies were calculated using the Annual of the Pathological Autopsy in Japan (The Japanese Society of Pathology). RESULTS: NTM disease deaths appeared for the first time in 1970, with a marked increase by 2007, when there were 912 certified deaths. The increase was more marked after the mid-1990s. The number of women's deaths exceeded 300 in 1999 and reached 570 in 2007, while that of men exceeded 300 in 2001 and remained at nearly the same level until 2007. The death rate increased in all eight regions of Japan. The highest single-year regional death rate was 212 in Kanto in 2005. However, correcting by population size, the crude death rate was higher in the western regions of Japan than in the eastern ones. The proportion of NTM among total autopsies also showed an increase from 0.066% in 1993 to 0.304% in 2007. Included in the report is a comparison of trends of NTM deaths with those of major respiratory diseases including tuberculosis, emphysema, bronchial asthma and airway cancers.

[Trends in tuberculosis infection among foreigners in Japan according to work status].

PURPOSE: TB among foreigners is presently a serious issue in some developed countries and could become so in Japan. The purpose of this report is to assess the epidemiological situation of TB among foreigners in Japan. MATERIALS AND METHODS: The trend of TB reporting among foreigners in Japan was examined with regard to work status. RESULTS: The number of reported TB cases among employees and students in Japan increased between 1998 and 2008, but that among housekeepers was level throughout the same period. The increase among employees and students might be due to the increased numbers of foreign employees and students. In the case of housekeepers, the increase in the number of permanent residents did not lead to an increase in TB among these housekeepers. Estimates of TB reporting rates decreased during the study period, so the changes in reporting rates would not have caused the increase in TB cases. This downward trend may have been caused by an increase in longer-term residents and a decrease in TB incidence in home countries. Even though the TB reporting rate is decreasing, the rates in those countries are much higher than in Japan in the same work categories. DISCUSSION: To control the spread of TB, it is important to identify high-risk individuals. The Japanese TB control program should further strengthen mass health examination programs for foreign housekeepers and employees (especially temporary and daily employees), case-finding based on individuals' access to hospitals or clinics when suffering from TB symptoms, and flexible and periodic adjustment of TB control activities for foreigners according to future changes in the number and distribution of foreigners in Japan. Furthermore, improving the TB epidemiological situation in home countries might contribute to the downward trend of TB reporting rates among foreigners in Japan. Therefore, Japanese assistance in TB control activities in surrounding countries such as China, South Korea, and the Philippines might contribute to TB control activities for foreigners in Japan.

[Use of a risk assessment inventory in implementation of the community DOTS in Shinjuku, Japan].

PURPOSES: To investigate the effectiveness of a risk assessment for implementing the DOTS of outpatients in the Japanese city of Shinjuku. SUBJECTS: A total of 435 patients with tuberculosis or latent tuberculosis infection who were registered in the city of Shinjuku between 1 April 2005 and 31 December 2007. METHODS: Soon after their diagnosis or registration and again 4 months thereafter, the patients were interviewed by the public health nurse in charge using a risk assessment inventory that had 17 scales related to the risk of defaulting from the treatment. Based on the results of the risk assessment, the patients were provided with an appropriately adapted DOTS. RESULTS: Out of all patients, 386 (88.7%) were assessed twice, of whom 338 (77.7%) were those with active disease. The patients were classified into three groups according to their risk scales: high-, medium-, and low-risk groups. There was no change in the risk grouping during the 4 months in 307 (90.8%) patients. However, in 12 patients (3.6%) the risk level was increased after 4 months, because of the development of side effects and problems with regular outpatient visits. The common methods of support in drug taking were daily DOT at the health center for patients in the high-risk group, and DOT at pharmacy shops once or twice weekly with self-medication on the other days for patients in the medium-risk group. For the low-risk group, the public health nurses made interview once or twice a month. There was no significant difference in the treatment success rate, default rate, or mortality rate among these three groups. DISCUSSION: The treatment outcome suggests that the community DOTS in this area may be effective. It was important to assess possible risks in treatment for each patient in order to identify the support needs and means. Also, it is necessary to develop a good risk assessment inventory scale.

Transmission of specific genotype streptomycin resistant strains of Mycobacterium tuberculosis in the Tokyo Metropolitan Area in Japan.

BACKGROUND: From 2003 through to 2004, an outbreak of tuberculosis was identified at a university campus in Yokohama City, located in the southern part of the Tokyo Metropolitan Area (TMA). All Mycobacterium tuberculosis (M. tuberculosis) strains detected with regards to this outbreak turned out to be Streptomycin resistant with matched patterns of 14 IS6110 bands of Restriction Fragment Length Polymorphism (RFLP). The M. tuberculosis bacilli, which had the matched IS6110 band patterns with resistance to Streptomycin to those of bacilli isolated in the outbreak, were also concurrently detected through either the population-based or the hospital-based DNA fingerprinting surveillance of M. tuberculosis either in Shinjuku City or in Kawasaki City respectively. The aim of the present study is to describe the spread of the specific genotype strains of M. tuberculosis in the TMA as observed in the above incident, and to identify the possible transmission routes of the strains among people living in urban settings in Japan. METHODS: We applied Variable Numbers of Tandem Repeats (VNTR) analysis to all M. tuberculosis isolates which were resistant to Streptomycin with a matched IS6110-RFLP band pattern (M-strains). They were isolated either from cases related to the tuberculosis outbreak that happened at a university, or through DNA fingerprinting surveillance of M. tuberculosis both in Shinjuku City and in Kawasaki City. For VNTR analysis, 12MIRU loci, 4ETR loci, seven loci by Supply, four loci by Murase (QUB15, Mtub24, VNTR2372, VNTR3336) were selected. RESULTS: Out of a total of 664 isolates collected during the study period, 46 isolates (6.9%) were identified as M-strains. There was a tendency that there was a higher proportion of those patients whose isolates belonged to M4-substrains, with four copies of tandem repeat at the ETR-C locus, to have visited some of the internet-cafés in the TMA than those whose isolates belonged to M5-substrains, with five copies at the ETR-C locus, although statistically not significant (38.1% vs. 10.0%, Exact p = 0.150). CONCLUSION: Although firm conclusions could not be reached through the present study, it suggested that we have to take into consideration that tuberculosis can be transmitted in congregated facilities like internet cafés where tuberculosis high-risk people and general people share common spaces.

[Tuberculosis control in Shinjuku Ward, Tokyo--promoting the DOTS program and its outcome].

OBJECTIVES: The objectives were to report how to promote tuberculosis (TB) control including DOTS (Directly Observed Treatment, Short-course) programs, and to evaluate the results of TB control programs in Shinjuku Ward (Shinjuku-ku). SETTING AND CHARACTERISTICS: Inhabitants and TB patients in Shinjuku Ward. Shinjuku Ward is located in the center of metropolitan Tokyo and has typical urban TB problems, such as high incidence rate and TB among foreigners and the homeless. The TB incidence rates in Shinjuku Ward decreased from 83.9 per 100,000 population in 1999 to 42.5 per 100,000 population in 2006, however, the rates were still two times higher than the national average. Therefore, one of the important TB programs in Shinjuku has been to actively detect cases among high-risk groups such as foreigners and the homeless. METHODS: We observed the trend of case detection rates by health examination with chest X-ray among different high-risk groups, and compared the treatment outcomes before and after DOTS program execution. We also reviewed the changes of re-treatment rates and drug resistance rates. RESULTS: The case detection rates of TB by health examinations of foreign students at Japanese language schools decreased from 0.49% in 1996 to 0.13% in 2006 (p = 0.021). Although the case detection rates decreased, they were still about 26 times higher than those of Japanese students. While, the case detection rates among the homeless remained high with 4.7%, 3.3%, 4.5% and 3.6% in 1999-2002, respectively, since 2003, however, they had decreased and no TB cases were detected in 2005-2006. The DOTS program for homeless TB patients has been carried out since 2000 and that for the foreigners since 2003. The rates of defaulting during treatment before DOTS were very high among both homeless patients (21.4%) and foreigners (29.8%) in 1998-1999. However, after the introduction of DOTS program, those rates declined to 10.4% (p = 0.014) among the homeless and 7.8% (p = 0.002) among foreigners in 2002-2004. The proportion of newly notified patients with previous TB treatment and those with multi-drug resistant TB (MDR-TB) have also decreased after the introduction of DOTS programs. From 2000-2002 to 2003-2006, the re-treatment rates decreased from 19.4% to 10.0% (p < 0.001) and MDR-TB rates decreased from 1.6% to 0.2% (p = 0.042), respectively. DISCUSSION: The key points of TB control in Shinjuku Ward are to detect TB cases early especially among the high-risk groups, and to assist all TB patients to complete their treatment. In order to expand this strategy, besides promoting active case findings among high-risk groups, we have developed many types of DOTS programs, considering each patient's lifestyle and cooperating with school teachers at schools, pharmacists at pharmacies, home-care specialists at homes or facilities for the elderly, and so on. Among others, a major premise for the homeless and some other socially disadvantaged patients was to guarantee the provision of medicine and living by introducing social welfare services, before starting DOTS programs. This approach might have helped to reduce the defaulting rate, relapse rate and MDR-TB rate.

[TB epidemiology in an elderly group in Japan].

PURPOSE: To analyze the epidemiological situation of TB among the elderly in Japan. METHODS: By using the data of TB surveillance, national survey statistics and national basic survey of life. RESULTS: TB incidence in both sexes increased with age in all survey years. TB incidence among the jobless was higher than among employees in both sexes. TB incidence among female housekeepers was consistently lower than among other groups. TB incidence among both the employed and unemployed has declined rapidly in the last 15 years. The main mode of TB detection was the detection at clinics/hospitals irrespective of presence or absence of TB symptoms. The death rate was higher in cases with immunosuppressive therapy and cases with malignancy. CONCLUSION: Causes of higher TB incidence in the elderly unemployed population should be analyzed. Better detection of TB by improving passive case-finding for TB symptomatic and high-risk groups at clinics/hospitals will be recommended. To reduce the death rate, early diagnosis of TB with immunosuppressive therapy could be strengthened, however its impact might be limited.

[Relapse rate of pulmonary tuberculosis within two years following completion of twice weekly intermittent chemotherapy].

OBJECTIVE: To evaluate the relapse rate after treatment of a twice weekly intermittent chemotherapy during continuation phase in the patients with pulmonary tuberculosis in two years period after completion of chemotherapy. METHODS: The patients with drug susceptible pulmonary tuberculosis treated with 2HRZE/4H2R2 under the supervision by the pharmacists or the patients treated with 2HRZE/4HR by self-administration were followed-up for two years after completion of chemotherapy. RESULTS: A total number of 135 pulmonary tuberculosis patients were treated with 2HRZE/4H2R2, 3 of 135 discontinued this intermittent treatment, and 11 of 135 completed chemotherapy was excluded from the relapse analysis, 105 out of the remaining 121 were followed-up for more than 6 months. On the other hand 240 patients were treated with 2HRZE/4HR, 37 out of 240 were excluded from the analysis, 147 of the remaining 203 were followed-up for more than 6 months. The relapse rate of this intermittent chemotherapy 1.89/100 person-year was similar to the relapse rate 1.86/100 person-year among 147 treated with daily regimen by self-administration. This difference was not statistically significant (z = 0.36, P = 0.14). CONCLUSION: As regards relapse rate, this 2HRZE/4H2R2 regimen is effective and useful for the expansion of DOT, and it should be expanded nationally in Japan.

[Estimation of the future epidemiological situation of tuberculosis in Japan].

OBJECTIVE: To estimate the future trends of all forms of tuberculosis (TB) and sputum smear positive pulmonary TB in order to consider the emerging issues of TB control and eliminating TB in Japan. MATERIALS AND METHODS] Annual reports of TB registrations were used for observing past trends of TB, and predictions were then made assuming that past trends would continue. At first, to obtain the number of TB patients by sex and age-group, sex-age-specific incidence rates were estimated for the years 2010, 2015, 2020, 2025 and 2030, and then applied to a sex-age-specific population which was projected by the National Institution of Population and Social Security Research. According to the different methods used to calculate the reduction rates of incidence, we adopted model A and model B. In model A, the reduction rate was calculated by using two groups of the same age group but different members by calendar year. In model B, the reduction rate was calculated by using the same birth cohort but different age by calendar year. We also adopted two sub-models by the observation period of past trends. The incidence rates for the period from 1987 to 2005 were used in model 1 and the incidence rates for the period from 1998 to 2005 were used in model 2. The incidence rate in 1999 was excluded from both model 1 and 2, because the TB incidence rate increased abnormally due to the declaration of a state of emergency concerning tuberculosis in 1999. The speed of decline among particular several sex-age-groups was weighted taking into account the influence of foreign, homeless and elderly cases. The future number of sex-age-specific sputum smear positive pulmonary patients was estimated by applying various parameters, i.e. pulmonary TB rate, sputum smear positive rate and its trend, to the estimated future number of TB incidence. RESULTS: The TB incidence rate, which was 22.2 per 100,000 population as of 2005, would reach 9.8 in model A-1, 5.4 in model A-2, 7.5 in model B-1 and 3.2 in model B-2 by 2030. On the other hand, the sputum smear positive pulmonary incidence rate, which was 8.9 per 100,000 population as of 2005, would decline to 5.5 in model A-1, 3.0 in model A-2, 4.2 in model B-1 and 1.7 in model B-2 by 2030. The future number of TB patients and incidence rates by sex and age were discussed based on a mixed model which used the middle series of estimates, and was obtained by combining model A-2 and model B-1. The number of TB patients by the mixed model will become about 12 thousand with 10.1 per 100,000 population in 2020, and about 7.4 thousand with 6.5 per 100,000 population in 2030. From 2005 to 2020, the age composition of TB patients will change from 0.4% to 0.2% at 0-14 years old, 4% to 4% at 15-24 years old, from 10% to 11% at 25-34 years old, 8% to 11% at 35-44 years old, from 9% to 12% at 45-54 years old, from 15% to 10% at 55-64 years old, 18% to 15% at 64-74 years old, from 24% to 17% at 75-84 years old, and from 11% to 20% at 85 years of age or older. Although the proportion of the elderly aged 65 years or higher will not be so different, the proportion of TB patients aged 85 years or older will almost double. CONCLUSION: The year when the TB incidence rate will reach the level of low-incidence countries, which is defined as a country with a TB incidence rate of less than 10 per 100,000 population, might be around 2020 in Japan. At that time, the age composition of TB patients will tend to be very old patients, and the young adult and middle-aged patients. Problems such as delay in diagnosis and difficulty of treatment are expected among very old patients.

[Implementation and evaluation by a population-based RFLP analysis in an urban area, Shinjuku city, Tokyo--the possibility of application for contact investigations].

OBJECTIVES: The objectives were to examine Mycobacterium tuberculosis transmission patterns by RFLP analysis in Shinjuku city, and to elucidate more effective methods of contact investigations. METHODS: We applied RFLP analysis to 389 M. tuberculosis isolates from 402 TB patients registered in Shinjuku city from September 2002 though August 2006. RESULTS: Forty-six clusters consisting of 155 TB patients (average 3.4 people per cluster) were identified (proportion of clustering: 39.8%). The clustering rates were 34.5% among general patients, and 57.8% among homeless patients, and the latter was higher than that of non-homeless patients (odds ratio: 2.6, 95% CI; 1.6-4.1, p < 0.001). On the other hand, the clustering rates were only 19.4% among foreigners (odds ratio: 0.5, 95% CI; 0.2-1.2, p = 0.090). Twenty-eight of 46 clusters (60.9%) were consisted of mixture of general patients, homeless patients and foreigner patients. Thus, RFLP analysis can detect the transmission route which can not be identified by the routine contact examination, thus enabling contact investigations extended to the appropriate persons. DISCUSSION: The homeless clustering rate was significantly high. This suggests that the proportion of transmission among the homeless patients might be high. However, many clusters were composed of a mixture of homeless patients and non-homeless patients, so transmission patterns are not easy to identify. It is not always true that transmission of tuberculosis to non-homeless patients took place from homeless patients. Clustering rates among homeless patients are high, therefore taking countermeasures for the homeless patients is an effective way to prevent the spread of tuberculosis. Introduction of RFLP analysis is a practical epidemiological methodology to investigate the source of infection and transmission route of infection, and can be applied to contact investigations. If RFLP analysis can be applied in a larger area, yearly changes of notification rates and molecular epidemiological clustering rates will provide indices for preventive measures against tuberculosis.

[Evaluation of the tuberculosis control program through tuberculosis surveillance].

Tuberculosis (TB) surveillance has involved three main functions: (1) data collection, (2) data analysis, and (3) feedback. There is now one more important function: (4) a new action plan based on the results of feedback. If all four functions are operating smoothly, the result will be effective so-called "program surveillance". In Japan, the first nationwide computerized TB surveillance system was established in 1987 and it was revised in 1992, 1998 and 2007. Treatment outcomes have been decided automatically in this system since 1998, based on data concerning treatment status, bacteriological test results and so on. Two optional systems, the recording of DOTS and managing of contact tracing, were added to this system in 2007. Since we can thus obtain and use a large amount of surveillance data, we have developed assessment indicators and methods of evaluating the national or regional TB control programs (Fig. 1). However, the accuracy of surveillance data entered into computers at public health centers has been inadequate. Therefore, one of the objectives of evaluating regional TB control program activities is to improve the quality of surveillance data. As regional governments have responsibility for TB control programs in Japan, TB control is generally evaluated at the regional level; i.e. prefecture and designated city. This evaluation process should be done in the cycle of "Plan-Do-See" (planning, execution, evaluation). However, the priority of "See" in this cycle seems to be low, because of the heavy workload of TB control activities. Nevertheless, the evaluation of TB control is very important, so I have introduced some examples of evaluation methods in WHO and Osaka city, and propose the optimum approach to evaluating TB control programs at the regional level. This approach is: (1) to observe the correct epidemiological situation, (2) to set a clear goal, (3) to announce the strategy, and (4) to carry out an annual evaluation. It might also be possible to evaluate the national TB control program by the same process. However, unfortunately there is no national organization such as a TB surveillance committee. I therefore propose setting up a TB surveillance committee in Japan as soon as possible. Since the number of TB specialists has been decreasing in Japan, advice and support for regional TB control will become increasingly important. An organization such as a TB surveillance committee would serve as supervisor.

[Outbreaks of tuberculosis in facilities used by an unspecified number of people near a train station - problems regarding tuberculosis in urban areas ].

OBJECTIVES: To report on the mass outbreak of tuberculosis (TB) in an urban area and to discuss current issues regarding the problem of TB in the metropolis. MATERIALS AND METHODS: Case studies were mainly carried out. Discussions on the route of infection are based on the results of DNA fingerprinting analysis for M. tuberculosis and on information obtained by epidemiological research. RESULTS: In an approximately 500-meter vicinity around Kawasaki Station in Kawasaki City, nine incidences of people contracting TB were reported during the period of one year and five months starting February 2005. Seven of the nine patients were resistant for streptomycin, and the tubercle bacilli of five patients showed identical patterns based on DNA fingerprinting analysis. These nine patients were relatively young, ranging from 16 years to 55 years in age, and three of the patients were homeless. The area for daily activities for all nine patients is a neighborhood of Kawasaki Station. Based on results from an epidemiologic survey, it is suspected that nine patients had come into contact with each other TB patient in places such as "Net cafes" before they developed TB. DISCUSSION: Based on the epidemiological and bacteriological results, the route of infection related to this series of TB outbreak is considered to be facilities used by an unspecified number of people such as "Net cafes." Such "Net cafes" are open 24 hours a day and are used by an unspecified number of people, who go to such places to Internet or enjoy comic books. Recently, there are many "Net cafes" in the city, and has become to be used as temporary places to sleep, not only by young people but also by socially vulnerable people, such as the homeless. This study suggests that infection can happen easily once someone begins to discharge TB bacilli in such environments, due to young people, who for the most part are not infected with TB bacilli, and high-risk people, who have higher probability of developing the disease, sharing a closed space for a long period of time. Such social environments may also affect the distribution of TB to lean towards urban areas. The TB control program in the metropolis should be planned and carried out giving consideration to social aspects.

[Estimation of TB incidence by labor status].

OBJECTIVE: To estimate TB incidences by labor status in 2005 and trend since 1987. METHODS: TB cases registered in 2005 are derived from TB surveillance system and categorized by labor status. Populations by labor status in 2005 are derived from national labor force survey. TB incidences by sex, age and labor status (attending school, regular employee, self-employed, temporary & daily employee, housekeepers, jobless & others) were estimated. Differences of TB incidence are discussed with data of population surveys of foreign students/workers and medical/health workers, and other resources of national surveys. Trend of TB incidence by labor status and sex were estimated since 1987 and current problems in tuberculosis control were discussed. RESULTS: Estimates of 2005 show higher TB incidences in male and female unemployed/others and male temporary/daily employees and that of housekeepers shows lower incidence. Regular employees and self-employed/house-workers show intermediate level incidences. Incidence of students was highest in 20s due to foreigners from TB prevalent countries. Female regular workers in 20s show higher incidence than male due to higher incidence among public health/medical employees. Trend of TB incidence since 1987 to 2005 shows stagnation in all labor status during second half of 1990s. In recent years, lower reduction rate was seen in most labor statuses. CONCLUSION: Present estimates of TB incidence by labor status show high TB incidences among unemployed/others, male temporary/daily employees, foreigners, and female public health/medical employees. Recent stagnation in incidence among most labor statuses (especially students and unemployed/others) should be followed-up carefully.

[Evaluation of accuracy of clinical diagnosis of TB by annual autopsy report].

PURPOSE: To investigate the accuracy of clinical diagnosis of TB in Japan in recent years and to compare them with previous studies. METHOD: Data (sex, age, clinical diagnosis, pathological diagnosis as cause of death) on deceased cases clinically or pathologically diagnosed ante mortem as having tuberculosis was collected from annual reports of the pathological autopsy cases in 1984, 1989, 1994, and 1999-2004. Information on TB death from population statistics in those 9 years also was collected and compared with data of autopsied cases. RESULT: Autopsy rate in these years was stably around 10 %. Comparison of gender ratio and mean age between the two surveys showed similar numbers. During 1999-2004, 1725 death cases were diagnosed as TB clinically or pathologically. Number of pathologically proven pulmonary TB cases was 429 and that of miliary TB was 283. 55.7% of pulmonary tuberculosis and only 21.9% of miliary tuberculosis were correctly diagnosed before death. Out of 156 cases clinically diagnosed as non-TB diseases but proven as TB pathologically, 30.8% of clinical diagnosis was pneumonia and/or bronchitis, followed by diagnoses of interstitial pneumonia, respiratory failure, pneumoconiosis and lung cancer. However, the main clinical diagnoses of 175 miss-diagnosed miliary TB cases were diseases other than pulmonary diseases such as renal failure, malignant diseases and sepsis. CONCLUSION: In order to reduce undiagnosed pulmonary TB cases and to prevent nosocomial TB infection, differential diagnosis among pneumonia and/or bronchitis cases should be done. In case of miliary TB, not only pneumonia but also diseases other than pulmonary diseases such as renal failure, malignant diseases and sepsis should be included in the list differential diagnosis.

[Current epidemiological situation of tuberculosis in the workplace: considering the risk of tuberculosis among nurses].

OBJECTIVE: To observe the trends and methods of tuberculosis (TB) detection in different occupations; to estimate the incidence of TB among nurses, and calculate the relative risk by comparing with the aged-matched general population; and to estimate the incidence of TB and relative risk also for teachers and doctors. MATERIALS AND METHODS: The background of TB patients was analyzed using the annual reports of TB registry for the period between 1987 and 2004. The population obtained from the national census, which was conducted every five years, was used for the calculation of TB incidence by specific occupation. The annual population between the two census years was obtained by interpolation. The TB registry assigns the same occupation code for nurses, public nurses and nursery teachers, and similarly assigns a common code for teachers and medical doctors. Therefore, TB incidence of nurses was calculated by subtracting the estimated number in nursery teachers. The number of nursery teachers contracting TB was obtained assuming that their TB incidence was the same as that for the 20-59 year-old population of the same sex. On the other hand, TB incidence for teachers and doctors was calculated together, because of the difficulties in separating the two occupations. RESULTS: Among nurses with TB, the proportion of cases detected by periodic mass screening in the workplace increased gradually from 21.4% in 1987 to 40.4% in 2004. Conversely, the proportion of cases detected by symptomatic vist to medical institutions declined from 69.4% in 1987 to 43.9% in 2004. In general population, the proportion of cases detected by contact tracing is low. Among nurses, however, cases detected by contact tracing had increased since around 1995 ; the proportion was 1-2% before 1995, increased to 7.0% in 1999 and leveled off at around 6-9%. TB incidence of female nurses declined slightly from 54.1 per 100,000 population in 1987 to 46.3 in 2004 (14.4%), and that of male nurses also declined from 127.0 in 1987 to 82.5 in 2004 (35.0%). However, the relative risk of female nurses increased from 2.1 (95%CI: 1.9-2.3) in 1987 to 4.3 (95% CI: 3.9-4.8) in 2004, and that of male nurses also increased from 2.4 (95%CI: 1.6-3.4) in 1987 to 3.8 (95%CI: 2.8-5.2) in 2004. The relative risk had increased gradually from the middle of 1990s in both sexes. TB incidence of female teachers and doctors decreased from 14.8 per 100,000 population in 1987 to 10.0 in 2004 (32.4%), and that of male teachers and doctors decreased from 39.3 in 1987 to 18.8 in 2004 (52.2%). While the relative risk was below 1 in both sexes, the relative risk in females increased from 0.6 (95%CI: 0.5-0.7) in 1987 to 0.8 (95% Cl: 0.7-1.1) in 2004, and that in males also increased from 0.7 (95%CI: 0.7-0.8) in 1987 to 0.9 (95%CI: 0.8-1.0) in 2004. CONCLUSION: Based on the relative risk data, approximately 80% of nurses with TB might have been infected by nosocomial infection and developed the disease. Since about half of them were detected in an early stage by mass screening in the workplace or contact tracing, TB control measures for nurses may be considered effective. However, the relative risk of TB among nurses had continued to increase without any trend of decline. The infection control at the hospitals may be inadequate, and should be reinforced by evaluating the methods or contents of control measures conducted so far.

[Frequency of MDR-TB/XDR-TB strains isolated from chronic pulmonary tuberculosis patients in Japan].

PURPOSE: To observe the frequency of MDR-TB/XDR-TB strains isolated from chronic pulmonary tuberculosis patients in Japan. OBJECT: Ad hoc National Tuberculosis Survey 2000 on frequency of MDR-TB and XDR-TB strains. MATERIALS AND METHOD: Four hundred and thirty four clinical isolates were collected by the Ad hoc National Tuberculosis Survey 2000, the drug susceptibility testings (proportion method, MGIT Middlebrook, and BrothMIC NTM) were conducted on these strains. These clinical isolates were obtained from patients registered at Health Centers in Japan by the end of 1999 who were culture-positive in 1999 and were registered before January 1st, 1998. The isolates used in this study were selected from patients who were culture-positive at shortest 2 years after the registration. RESULT: The clinical isolates resistant to both INH and RFP were 321 out of 434 (74.0%). The 180 MDR-resistant clinical isolates were also resistant to levofloxacin and amikacin and/or kanamycin. These phenotypes are XDR-TB. No previously registered cases were 165, and previously registered cases were 143 and unknown cases were 13 out of 321 MDR-TB. In 180 XDR-TB cases, no previously registered cases were 95, previously registered cases were 78 and unknown cases were 7. In no previously registered cases, more than 50% cases started treatment in 1990s. Approximately 50% of previously registered patients started treatment in 1960s and 1970s. CONCLUSION: We performed drug susceptibility testing for 434 clinical isolates which were culture-positive at shortest 2 years after registration. No. of MDR-TB patients was 321 and that of XDR-TB patients was 180. The treatment outcome of these patients have to be followed up carefully at Health Centers. The frequency of amikacin resistance was relatively high. This may be due to either common use of amikacin or cross-resistance against streptomycin and kanamycin.