[Objective] To estimate the number of necessary beds for tuberculosis patients in Japan from the view point of isolation of the source of infection.
[Methods] We calculated the number of necessary beds for tuberculosis cases separately for the initial phase and for the chronic excreters. For the initial phase we calculated by multiplying the number of detected tuberculosis cases and the duration of hospitalization. The number of detected cases is based on the figures in 2002 and the duration of hospitaliza tion is assumed to be 90 days for sputum smear positive cases and 60 days for sputum smear negative cases. We calculated the number of necessary beds using the Monte Carlo simula tion for each prefecture on the assumption that the incidence and the duration of diseases will be under the effect of random fluctuation with the Poisson's distribution for the number of cases and with the log normal distribution for the duration of hospitalization. We also considered the seasonal fluctuation.
[Results] Our calculation revealed that around 6, 413 beds would be necessary for the initial phase and 200-400 beds for chronic excreters in Japan. There are several prefectures which only requires less than 30 beds.
[Discussion] Currently, Japan has around 17, 000 beds secur ed for tuberculosis patients. Our calculation showed that this was much more than needed. In many areas, one ward will provide more than sufficient number of tuberculosis beds. Specialist consultation system must be improved because of the reduction in the number of TB cases treated at hospitals with TB wards and TB specialists. For the treatment of non infectious TB, ambulatory DOT system, TB shelter and nurs ing care facilities would be necessary to guarantee compliance to treatment.

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[Purpose] To investigate the risk factor of treat ment failure of pulmonary tuberculosis excluding multi-drug resistant cases from the standpoint of both clinical manage ment and tuberculosis control.
[Object and Method] Retrospective chart review of patients who admitted to Fukujuji Hospital for treatment failure of pul monary tuberculosis excluding multi-drug resistant cases from Jan. 1993 to Dec. 2003.
[Results] Out of 24 treatment failure cases available for analysis, 4 cases were associated with chronic tuberculous empyema with broncho-pleural fistula, and among them, chronic empyema was considered to be the main cause of treatment failure in one case. In 6 cases, poor adherence to medication was confirmed or suspected, and 2 of these 6 cases was also associated with miss-management. In 9 cases miss management was found without poor adherence or chronic empyema, and in 8 out of these 9 cases, miss-management was considered to be the main cause of treatment failure. In 5 cases no apparent risk factor was found, but in 2 out of these 5 cases the ignorance of the results of drug sensitivity tests (and, therefore, miss-management) was strongly suspected. Sum ming up, in 10 out of 24 cases (41.7%), the miss-management was considered to be the main cause of treatment failure, and it was more frequently seen than poor adherence to medication.
[Conclusion] Clinicians should be aware of these risk factors of treatment failure such as chronic empyema, weak regimen in bacteriological negative cases, rifampicin+etham butol regimen, and miss-management of drug adverse effect. From the standpoint of tuberculosis control in Japan we considered that, in addition to DOT, strategy to secure the quality of tuberculosis treatment is by all means needed.

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A 28-year-old woman who was a nurse was admitted to our hospital because her sputum was positive for M. tuberculosis. She was pregnancy of 35 weeks. First, she was administered INH, RFP, PZA and was treated with cesarean section on the 21st day after starting tuberculosis chemotherapy. The operation was done in operating room of negative pressure ventilation. The patient returned to the tuberculosis ward, and the newborn infant entered to a new born nursery room after confirming negative tubercle bacilli in amnionic fluid by PCR examination. EB was added to the regimen of chemotherapy after childbirth. In general hospitals, infection control is an important issue as seen in this case.

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We report a case of pulmonary Mycobacterium fortuitum infection with multiple nodular shadows. A 52 yearold male was admitted complaining of fever and chest abnormal shadows. He didn't have pulmonary or systemic underlying diseases. Chest radiograph and computed tomography scan showed multiple nodular shadows in the both lung fields. Isoniazid, rifampicin and ethambutol were administered based on the presumptive diagnosis of tuberculosis. Cultures of the sputum and bronchial washing fluid were repeatedly positive for M. fortuitum, and the case was diagnosed as pulmonary M. fortuitum infection. Although the in vitro susceptibility was resistant to isoniazid, rifampicin and ethambutol, abnormal shadows on the X-ray showed improvement by the combined use of INH, RFP and EB. There are no signs of recurrence after completion of the treatment for 12 months.

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A descriptive epidemiology on an outbreak of tuberculosis (TB) in a long-term care unit of a mental hospital was conducted.
A female inpatient of 60 years with pulmonary TB was reported to the local health department (LHD) from the hospital in July 1999. Her sputum was negative both by smear and culture. From then to Mar 2001, a total of ten TB cases were reported. All of them were inpatients or workers of the hospital. Among them, four cases turned out to be culture positive and for three out of them a Restriction Fragment Length Polymorphism (RFLP) analysis was performed. All three turned out to be the identical strain suggesting that the outbreak was derived from one index case.
After November 1999, the active case findings were conducted by the LHD, however no case of possible source of the outbreak was found. On the other hand, the retrospective investigation revealed that a female inpatient (case Z) of 70 years must have been pulmonary TB. She had had respiratory symptoms such as severe cough and sputum for two years and consequently died of pneumonia in February 1999, five months before the onset of the TB outbreak. She had a thoracic CT scan test and a sputum PCR test just before her death in another outpatient clinic and turned out to have a cavity in a lung and to be PCR positive for Mycobacterium tuberculosis complex. However the result was never reported to the hospital nor to the LHD, because she died before the PCR test was completed. She had had close contact with all of the TB cases except one for over two years.
Considering all these epidemiological results, case Z was suggested to be the source of this outbreak.
To prevent this kind of TB outbreak, institutions like mental and/or long-term care units should carefully prepare a proper precaution plan against the nosocomial infection of TB. In addition, if two or more TB cases are reported from the same unit or institution, LHDs should pay special attention and investigate the possibility of nosocomial infection.

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The 1951 Tuberculosis Control Law of Japan is now faced with tremendous changes that have occurred during the last 50 years in tuberculosis epidemiology and in the environment in tuberculosis control implementation. The law is also challenged with the shift of the paradigm for the National Tuberculosis (TB) Programme. In order to respond properly to these changes, the Tuberculosis Panel of the Health Science Council of the Ministry of Health, Labor and Welfare submitted its report for the amendment of the law in March 2002. Based on this report, a new Tuberculosis Control Law was passed in Parliament last June, and related decrees of the Cabinet and the Ministry are now being revised in preparation for it's enactment in April 2005. In this special lecture, the main points and framework of the revisions were discussed with the perspective of the development of new technical innovations relevant to each area of the revised TB control legislation.
1. Case detection. There will be a shift from the current “indiscriminate” screening scheme to a selective one regarding periodic mass health examination. Only subjects aged 65 or older will be eligible for the screening, supplemented with selected occupational groups who are considered to be at a higher risk of TB, or may be a danger to others if they develop TB, such as health-care providers and school teachers. In addition, local autonomies are responsible for offering screening to the socio-economic high-risk populations, such as homeless people, slum residents, day laborers, and/or workers in small businesses. This means that the efforts of the autonomies are critical for the new system to be effective. The extraordinary examination will be limited to only the patient's contacts, and will be mandatory for those contacts so they cannot refuse to be examined by the Health Center. The public services used in the contact investigations will be greatly facilitated by such new technologies as DNA fingerprinting of TB bacilli and a new diagnostic of TB infection using wholeblood interferon-gamma determination (QuantiFERON). The quality of clinical diagnosis and monitoring of treatment should also be improved by introducing an external quality assurance system of commercial laboratory services.
2. Chemoprophylaxis. Although not explicitly defined in the new legislation, the expansion and improvement of chemoprophylaxis to cover anyone with any risk of clinical development of TB would have a tremendous effect in Japan, especially since 90% of patients who developed TB were infected tens of years ago. These technical innovations in diagnosis of TB infection will be very helpful. Development of new drug regimens for the preventive treatment is also badly needed.

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[Introduction] The issue of implementing tuberculosis countermeasures in the city of Osaka is of an incomparably large scale with that in regional areas, and is accompanied by a correspondingly level of difficulty. The national government has no intention of solving the problem in a single blow by concentrating assistance in areas of human, monetary and physical resources, but rather has deployed a more widespread approach in the name of regional decentralization of authority. Although attention tends to be focused on large cities, progress has also been slow in regional areas, and although effects are difficult to be seen, “hardworking tuberculosis health care personnel” are striving with what little resources they have to continue with the struggle of implementing countermeasures against tuberculosis.
Dr. Makito Sato discussed screening in the city of Sendai from the viewpoint of finding tuberculosis patients as related to the present state of regional tuberculosis health care and future accommodations. Even the city of Sendai with its population of one million residents is confronted with considerable problems, and its screening program, including new efforts such as early evening screening times, has entered its third year. Dr. Sato discussed the present state of that program along with its track record. Next, Dr. Hideo Maeda discussed the present state and countermeasures regarding patient transport. Last year, patients in the Tohoku region presenting with multi-drug resistant tuberculosis were brought in from across three prefectures, exposing specific problems including their accommodation and transport. Dr. Maeda provided a detailed description of these topics by focusing primarily on the tuberculosis emergency care network in Tokyo.
There are also facilities in large cities where public health centers have been reorganized and integrated into a single tuberculosis screening center for testing numerous cases. In regional areas however, there are locations that have difficulties even in establishing such screening centers. There is the problem of the absence of tuberculosis specialists. Dr. Takayoshi Miyakawa discussed the real problems facing regional areas in view of the current situation while also offering some suggestions.
Next, a presentation was also made by a physician who is actively involved in tuberculosis countermeasures despite working at a regional facility having only a small number of beds. Dr. Kiyoyasu Fukushima introduced the concept of critical path to tuberculosis treatment, and is concentrating efforts on the implementation of educational activities by holding information meetings with patients and their family members. Dr. Fukushima has also held numerous conferences from the viewpoint of the importance of patient education.
Finally, Dr. Kosho Yoshikawa, the progenitor of the theme of this gathering, provided a discussion of the accommodations made by acute stage hospitals and their collaboration with regional public health centers. There is considerable need for collaboration between hospitals and public health centers in regional areas, and this has gotten underway in some areas. However there are also locations where collaboration is not proceeding smoothly. Dr. Yoshikawa discussed some of the problems and solutions actually encountered at such facilities.
Although the results of these discussions may not have led to a definitive conclusion, it was found that regional areas have their own concerns and problems and that so-called “hard-working tuberculosis health care personnel” are doing the best they can to deal with these concerns and problems. It appears that an approach involving the deployment of a “TB package”, in which local public health centers play a central role in providing services ranging from uncovering tuberculosis patients, diagnosing and treating those patients and finally providing support, is likely to be the most effective.

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