第76回総会特別講演 新世紀の結核戦略-結核根絶に向けて

抄録

Modern tuberculosis control programme has been launched in 1951 by the major revision of the previous Tb. Control Law in Japan. Main control measures were BCG vaccination programme for tuberculin negatives, annual screening of Tb. by miniature radiophotography (MMR), charge free diagnosis and treatment of Tb. patients, registration and case-olding at Health Centres throughout the country and so on. Thanks to the efforts of the Government and people concerned, Tb. incidence has decreased with the annual reduction rate of 11 % during 1961 and 1977. However, Tb. decrease has stagnated after that, and it is increasing slowly in these 3 years since 1998. Moreover, regional variations of Tb. incidence are considerable, and Tb. is concentrated in specific risk groups such as elderly persons, homeless, foreign born individuals and so on. However, the present Tb. Control measures were introduced prior to the discovery of most major anti-Tb. drugs and all modern internationally accepted Tb. Control strategies, so that it is strongly desired to improve the present control programme from rather classical present Tb. control measures to global standard one to overcome the resurgence of Tb. in Japan.
At first, the author stressed that the priority of Tb. Control Programme should be changed according to the development of science and the change of epidemiological situations. BCG vaccination and Tb. screening by MMR might be very important when the annual risk of Tb. infection was very high-about 4 % in 1950. Now it is around 0.05 % and the incidence of Tb. among 0-14 years of age is 1.1 per 100, 000 so that the priority should be given on treatment of the detected cases instead of BCG vaccination or MMR. The doctors in the public health field should give more strong concern on clinical aspects of Tb. Control Programme at present. It was considered that the main urgent problems to be improved in the present Tb. control measures are as follows.
(1) It is strongly recommended to spread the global standard regimen with 2 HRZE/4HR (E) more widely and rapidly. Because the standard regimen is used in only 50 % of new smear positive cases at present although 15.3% of Tb. patients are 80 years or more, or 56.3 % of them are 60 years or more, and the side effects by PZA are higher among elderly patients.
(2) Shortening of the hospitalization duration is required because 76.7 % of newly detected bacilli positive cases are hospitalized at first, and the median of the period of hospitalization is 4 months, and 18.4 % of them are hospitalized 6 months or more at present.
(3) DOT treatment has been introduced for special groups in the big cities in 2000 for the first time in Japan, but it is needed to spread DOT treatment more widely, for example, by increasing health insurance payment for the institutions where DOT treatment is being implemented.
(4) It is recommended to build special rooms to accept Tb. patient at general hospitals and/or university hospitals to avoid the neglect of Tb. by general medical doctors.
(5) Follow-up of Tb. patients after treatment completion at Health Centres is not needed now, because the relapse rate is so low.
(6) Indiscriminative screening programme for all the people aged 19 years old or more should be stopped, at least up to 39 years of age, because Tb. detection rate has become so low as 0.0069 % at present. As Tb. decrease is so slow, or is increasing in some areas, that the contact surveys among the young aged 20 to 39 should be strengthened in the future.