(Vol.74, No.4 April 1999) <1> Kekkaku Vol.74, No.4: 341-345,1999 A STUDY ON FACTORS RELATING TO AGGRAVATION OF PATIENTS WITH PULMONARY MYCOBACTERIUM AVIUM COMPLEX DISEASE -With Special Reference to Malnutrition- Hideo OKAMURA*, Katsuhiko TSUKAGUCHI, Masashi IKUNO, Atsushi KOBAYASHI, Atsuhiko FUKUOKA, Hideaki TAKENAKA, Chinaru YAMAMOTO, Yukinori OKAMOTO, Akihiro FU, Masanori YOSHIKAWA, Takahiro YONEDA and Nobuhiro NARITA We examined physical and blood statuses of 24 patients with pulmonary M.avium com- plex disease who entered our hospital from April 1993 to March 1997. Ten patients (41.7%) were diagnosed as primary infection type and 14 patients (58.3%) as secondary infection type. Twenty-four patients were classified to the following two groups:Group A was 14 patients who converted to MAC negative within six months after the admission and group B was 10 patients who continued to excrete MAC for more than six months after the admission. We made a comparison between group A and group B as to the re- sults of physical and blood examinations on admission. Mean value of %IBM in group B was significantly lower (group B:74.4}8.9%, group A:82.9%}12.7%, p<0.05) than that of group A. The level of serum albumin in group B was significantly lower (group B:3.39}0.53g/dl, group A:3.99}0.45g/dl, p<0.01) than that of group A. ChE in group B was significantly lower (group B:321.2}94.5 IU/l, group A:442.9}148.4IU/l, p<0.05) than that of group A. Group B was nurtitionally depleted than group A. In conclusion, these findings suggested that nurtitional support should be taken into consideration in combination with conventional chemotherapy in treating chronic, intractable MAC dis- ease. Key words:Nontuberculous mycobacteriosis, Mycobacterium avium complex disease, Chronic excretors, Malnutrition, Nutritional support *From the Second Department of Internal medicine, Nara Medical University, 840 Shijocho Kashihara City, Nara 634-8522 Japan. (Received 21 Jul. 1998/Accepted 23 Oct. 1998) <2> Kekkaku Vol.74, No.4: 347-351, 1999 CLINICAL INVESTIGATION ON ENDOBRONCHIAL TUBERCULOSIS Emiko TOYOTA*, Nobuyuki KOBAYASHI, Makoto TAKAHARA, Atsuto YOSHIZAWA, Hiroshi KAWADA, Tsuneo SUZUKI, Kouichirou KUDO and Keizo INAGAKI In order to assess the clinical features and clinical courses of endobronchial tuberculo- sis, which included trachea to segmental bronchus, we studied 34 cases of patients who were admitted to TB ward of International Medical Center of Japan from 1994 to 1997. We noticed a higher incidence in females and in the main bronchus. Cough was the most common complaint seen in 97% of cases. The duration of symptoms before the initiation of antituberculous chemotherapy was long (on the average 6 months), and they were often treated as bronchial asthma or bronchitis. Bronchoscopic examination is necessary for diagnosis. The scars sometimes gave rise to severe stenosis, especially when the lesion developed to an advanced stage or circumscribed the lumen before treatment. We tried INH inhalation with systemic chemotherapy. Although rapid improvement was suggested by this method, yet no significant difference was seen in the results for the efficaccious prevention of stenosis. Five cases required surgical intervension (bronchoplasty and lobectomy) in order to avoid atelectasis or secondary infection. Early diagnosis and ap- propriate treatment are most importent, and bronchoscopic examination is essencial in early diagnosis. Key words:Endobronchial Tuberculosis, Bronchoscopic examination, Chemotherapy, INH inhalation, Stenosis *From the Respiratory Department, International Medical Center of Japan, 1-21-1 Toyamacho, Shinjuku-ku, Tokyo 162-8655 Japan. (Received 21 Aug. 1998/Accepted 11 Nov. 1998) <3> Kekkaku Vol.74, No.4: 353-360, 1999 SIX-MONTHS CHEMOTHERAPY(2HRZS OR E/4HRE)OF NEW CASES OF PULMONARY TUBERCULOSIS -Six Years Experiences on Its Effectiveness, Toxicity, and Acceptability- Masako WADA*, Takashi YOSHIYAMA, Hideo OGATA Kunihiko ITO, Seiji MIZUTANI and Hironobu SUGITA The incidence of tuberculosis in Japan, 33.7per 100,000 in 1997, is very high compared with USA or Western European countries. The decrease in the incidence has slowed down from the early 1980s, and the average annual rate of decrease has been 3.8% in the last 5 years. About 9 percent of tuberculosis patients defaulted from the nine-month regimen (6HRS or E/3HR) in urban areas. Regimens shorter than nine-month are needed to achieve high effectiveness of tuberculous chemotherapy. Out of 1128 new pulmonary tuberculosis patients, six-hundred twenty started treatment with six-month (2HRZS or E/4HRE) in Fukujuji Hospital, JATA, in Tokyo from January 1991 to December 1996. Out of 620, four-hundred twenty eight were both smear and cluture positive, 136 were smear negative and culture positive and 56 were bacilli negative. Out of 564 bacilli positive cases, 530 were susceptible to INH and RFP. Out of 530 drug susceptible cases three hundred ninety- three patients completed the regimen. Ninety-three percent of these patients had con- verted to negative at two months of chemotherapy and all of them at five months. Out of 450, two-hundred ninety five completed 6-month regimen, one-hundred fifty-five were changed their regimen or prolonged duration of chemotherapy. Out of 295, nine pa- tients (3.1%) relapsed after the completion of 6-month chemotherapy. Mean follow-up period was 17.2 months and the median was 15.5 months. The ralapse rate was 2.2 per 100 person-years. Six of the relapsed cases were complicated with Diabetes Mellitus. Relapse rate was higher patients with Diabetes Mellitus than in patients without (6/54, 7.9per 100 person-years us 3/237, 0.8per 100 person-years)(p<0.001). Drug-induced hepatotoxicity was defined as elevatied serum transaminase level with clinical symptoms of hepatitis or elevated serum transaminase level more than 5 times of upper limit of normal range with or without symptoms. Drug-induced hepatotoxicity developed in 43 (8.0%) of 535 with initial normal liver function test results, this rate was similar to that in patients treated with nine-month regimen (34/420, 8.1%). But the frequency of hepatotoxicity of more than 400 IU/ml of serum transaminase level was higher in patients treated with PZA- containing regimen than with nine-month regimen (16/536, 3.0% us 4/420, 1.0%), but this deference was not statistically significant. Hepatotoxicity developed in 13/85 (15.3%) of patients treated with PZA-containing regimen with abnormal liver function tests at the beginning of chemotherapy, and this frequency was similar to 7/65 (10.8%) in patients with nine-month regimen. The relapse rate in patients with Diabetes Mellitus was statistically higher than in without Diabetes Mellitus (7.9 us 0.8 per 100 person- years). We concluded that the six-month regimen was highly effective, but the frequency of severe hepatotoxicity was relatively higher than in nine-month regimen and the duration of chemotherapy was not enough for patients complicated with Diabetes Mellitus. Further study is needed for sifficient chemotherapy in patients with Diabetes Mellitus. Key words:6-month short course regimen, Pyrazinamide, Drug-induced hepatotoxicity, Relapse rate, Diabetes Mellitus *From the Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, 3-1-24, Matsuyama, Kiyose-shi, Tokyo 204-8533 Japan. (Received 22 Sep. 1998/Accepted 24 Nov. 1998) <4> Kekkaku Vol.74, No.4: 361-364, 1999 A CASE OF PULMONARY TUBERCULOSIS CASE WITH PANCYTOPENIA ACCOMPANIED TO BONE MARROW GELATINOUS TRANSFORMATION Yuka SASAKI*, Fumio YAMAGISHI, Takenori YAGI, Fumio MIZUTANI A 45 year-old man did not visit a doctor in spite of his complains, cough and sputum lasting, for six months, and he finally could not eat without beer, and as a result, he lost his body weight and currently 52 kg. He became unconsciousness, was carried to a hospital, and was reffered to our hospital. His sputum examination for acid fast bacilli was smear positive, Gaffky 6, for M.tuberculosis. His chest roentogenogram revealed large cavitary leisions in bilateral lung fields. On blood examination, WBC was 1100/ƒĘL, RBC was 256~10(4)/ƒĘL, and PLT was 13.4~10(4)/ƒĘL. Total protein was 4.7g/dl, albumin was 1.9mg/dl, and total cholesterol was 65mg/dl. We tried to aspirate bone marrow from his sternum, but it was impossible. Hence we did biopsy of his ilium. The pathol- ogy of his bone marrow revealed gelatinous transformation. It was thought that the marked delay in visiting a doctor caused general consumption and loss of apetite, thus led to gelatinous transformation and finally pancytepenia. Key words:Tuberculosis, Patient's delay, Gelatinous transformation, Pancytopenia *From the Department of Thoracic Disease, National Chiba Higashi Hospital, Nitona-cho 673, Chuou-ku, Chiba City 260-8712 Japan. (Received 14 Aug. 1998/Accepted 25 Nov. 1998) <5> Kekkaku Vol.74, No.4: 365-375, 1999 The 73rd Annual Meeting Educational Lecture THE CURRENT SITUATION AND TREATMENT OF CHILDHOOD TUBERCULOSIS Isamu TAKAMATSU* We performed a retrospective analysis of 394 patients who were treated for active tu- berculosis (TB) at our hospital from 1976 to 1997. The diagnosis criteria for establishing TB were history of direct contact with TB patients, tuberculisn skin test reactivity, posi- tive bacteriology and radiographic findings compatible with TB. There were 192 males and 202 females (age range 1 month to 18 years of age, mean 6.3 years of age). Fifty -four percent of the cases were under 5 years of age. Primary pulmonary TB was pre- sented in 200, post primary pulmonary TB in 97, pleural effusion in 53, endbronchial TB in 4, TB meningitis (TBM) in 28, miliary TB in 28 and other extra-pulmonary TB in 31. A history of contact with the patients was obtained in 72.8% of cases. Two hundred and thirty (58.4%) had received BCG, 134 (34%) no BCG, 30 (7.6%) were unclear. Especially, under 5 years of age, only 29 (13.6%) had received BCG. TBM is not disappeared in Japan and there were 28 cases with TBM. Fifteen patients out of them recovered com- pletely, 8 patients recovered with severe neurological sequelae which included mental re- tardation, motor weakness, seizures and hydrocephalus and 5 patients died. Twenty-six had no BCG. Particularly in 1990s, we had experienced 4 dead TBM cases, 1 multi-drug resistant (MDR) TBM case and 1 TBM case due to nosocomial infection. Children with TBM should received 12-month regimen using initial daily teratment with isoniazid, rifampin, pyrazinamide, and streptmycin, followed by isoniazid and rifampin adminis- tered daily. Pulmonary TB in children is successfully treated with 6-month standard che- motherapy using isoniazid, rifampin, and pyrazinamide daily for 2 months, followed by isoniazid and rifampin daily for 4 months. In order to promote TB control and eliminate childhood TB, especially in infants, the following is necessary;1) early detection and treatment of adult TB patients, source of infection, 2) prompt and appropriate contact examination and chemoprophylaxis, 3) BCG vaccination during early infancy, 4) protection from MDR TB are most important in Japan. *From the Department of Pediatrics, Osaka Prefectural Habikino Hospital, 3-7-1, Habikino, Habikino-shi, Osaka 583-8588 Japan. (Received 4 Jan. 1999) <6> Kekkaku Vol.74, No.4: 377-384, 1999 The 73rd Annual meeting Education Lacture NONTUBERCULOUS MYCOBACTERIOSIS;THE PRESENT STATUS OF EPIDEMIOLOGY AND CLINICAL STUDIES Mitsunori SAKATANI* In Japan, The Mycobacteriosis Research Group of the Japanese National Chest Hospi- tals has continuously made the clinico-epidemiological study of nontubercxulous myco- bacteriosis (NTM) since early 1970s. The prevalence rate was detemined as 0.82, 0.91, 1.22, 1.74 and 2.43 per 100,000 population per year in 1971, 1975, 1980, 1985 and in 1990 respectively. The newest datum in 1997 was 3.52. These data indicates the prevalence rate has continuously increased and became 3.8 times than 25 years ago. While on the other hand, the prevalence rate of lung tuberculosis has decreased from 133.1 to 15.2, becomming one nines in the same period. The numbers of newly detected patients of lung mycobacteriosis in 1996 were also studied at 12 hospitals in Kinki district. The rate of NTM was 16.6% in 4 sanatorium hospitals, being about the same to the datum of The Mycobacteiosis Research Group. The rate of NTM in 8 general hospitals was surpris- ingly high, 40.0%. The 70% of NTM patients were infected with Mycobacterium avium complex (MAC). The 24% were with M.kansasii, and the only 6% were with other miscellaneous species. That is, the about one thirds or more of total NTM patients were female MAC desease patients, another one thirds or less were male MAC patients, and the more than 90% of M.kansasii patients (about one fourth of total patients) were male. These 3 groups took the most part of NTM patients. The rate of female MAC patients with small non- cavitary lesion without underlying deseases showed a tendency to increase, and the rate of male MAC patients with cavitary lesions with underlying lung or sys temic diseases de- creased. In 1997, American Thoracic Society (ATS) published the official statement about the diagnosis and treatment of NTM disease. The table-1 in that statement showed the new criteria for diagnosis of NTM pulmonary disese. It is useful for precise diagnosis of lung NTM disease, and the old criteria made by The Mycobacteriosis Research Grouup of the Japanese National Chest Hospital is also useful for rough diagnosis. In the ATS statement, for adult HIV-negative MAC patients, minimum three drug regimen of clarithromycin (or azithromycin), rifabutin (or rifampin) and ethambutol, with intermittent streptomycin which is option for extensive disease, is recommended. This regimen is the same that most of the Japanese specialists for NTM disease recom- mended. The follow-up study of 47 Japanese MAC patients treated by the regimen con- tained clarithromycin with other anti-tuberculous drugs revealed that 80% of cases converted into bacilli negative and that the ragimen had durable effect for at least 24 months. The resectional surgery may be considered for localized disease, and supportive nuturitional treatment must also be considered for the MAC patients to whom the drug therapy was not effective, as if for the tuberculosis patients of multi-drug registant. Key words:Atypical mycobacteial disese, Non-tuberculous mycobacteriosis, Mycobac- terium avium complex, Mycobacterium kan- sasii, Clarithromycin *From the National Kinki-Central for Chest Diseases, Nagasone-cho 1180, Sakai-shi, Osaka 591-8555 Japan. (Received 1 Feb. 1999) <7> Kekkaku Vol.74, No.4: 385-387, 1999 The 73rd Annual Meeting Symposium ‡V. NOSOCOMIAL TRANSMISSION OF TUBERCULOSIS Chairpersons:Tadayuki AHIKO*, Eriko SHIGETO** Symposium Topics and Presenters: 1. Tuberculosis among health care workers in Okinawa prefecture:Tadashi NAKASONE (Nago Public Health Center) 2. Tuberculosis outbreak among inpatients:Isamu TAKAMATSU, et al. (Devision of Pediatrics, Osaka Prefectural Habikino Hospital) 3. Tuberculosis prevention and control in psychiatric hospitals:Hideo MAEDA(Tokyo Metrpolitan Fuchu-Koganei Public Health Center) 4. The present status and the task of nosocomial tuberculosis infection in Japan: Shinji SHISHIDO (National Matsue Hospital), et al. 5. Tuberculosis infection control practice in hospitals from the viewpoint of occupa- tional health:Kiminori SUZUKI, et al. (Chiba Anti-Tuberculosis Association) Additional Comment:Tuberculin skin testing in students of school of nursing: Eriko SHIGETO (National Hiroshima Hospital) The prevalence of tuberculosis (TB) hasprogressively declined over the past three dec- ades in Japan. On the other hand, this trend has brought decrease of concern about TB not only in general public but in the medical community. Threfore TB patients with de- layed diagnosis or with dealyed initiation of effective therapy are increasing and re- cently the incidence of infectious TB is just on the upward trend. These features normally lead to greater chance of TB outbreaks in health-care facilities. Many health-care work- ers (HCWs), however, have no sense of the current crisis. Since 1994, more than 10 out- breaks of TB in hospitals, including otubrreaks of multidrug-resistant TB, have been reported in Japan and they have heightened concern about nosocomial transmission. Studies presented in this symposium were as follows: 1) Case studies of TB outbreaks among persons in various types of hospitals. These out breaks involved patient to patient transmission or patitent to HCWs. 2) Risk assessment studies of TB infection among HCWs. 3) Researches for effective control measures applicable to nosocomial TB infection (e. g., two-step tuberculin skin testing, applications of preventive therapy.) 4) Nationwide surveys that were conducted to evaluate the current situation of TB infec- tion-control practice in hospitals. The increased risk occupational acquisition of TB by HCWs was discussed. The magni- tude of the risk varied according to the type of hospital, the HCWs occupational group, and the effectiveness of the hospital's TB control program. We aimed at considering the fundamental strategies for the prevention and control of TB infection in health-care facilities from the viewpoint of occupational health and engi- neering control approaches. In conclusion, it was stressed strongly that all medical insti- tutions should be obliged to take maximum precautions against nosocomial transmission of TB. Key words:Nosocomial transmission, Tu- berculosis, Infection control, Health-care worker, Occupational health *From the Yamagata Public Health Center, 1-6-6 Tokamachi, Yamagata 990-0031 Japan. **From the National Hiroshima Hospital, 513 Jike, Saijo-cho, Higashi-hiroshima 739-0041 Japan. (Received 27 Nov. 1998) <8> Kekkaku Vol.74, No.4: 389-395, 1999 The 73rd Annual Meeting Symposium ‡V. NOSOCOMIAL TRANSMISSION OF TUBERCULOSIS 1. TUBERCULOSIS AMONG HEALTH CARE WORKERS IN OKINAWA PREFECTURE Tadashi NAKASONE* In health care setting, transmission of M.tuberculosis (TB) is considerable risk not only to patients but to health care workers (HCWs). The total number of registered TB cases in Okinawa prefecture was 1,202 in 1993-1995 (incidence rate 28.3 per 100,000 in 1995) and that of HCWs was 23. Using data from TB resigtration system, relative risk of tuberculous disease of nurses was estimated to be 2.3 higher than general population. Nosocomial transmission of TB to HCWs in a general hospital was occurred in 1993. After 2 nurses in the same ward were diagnosed as active pulmonary TB routine screening chest X-ray, a contact investigation was performed in their family, friends and the ward staffs. On the result of initial evaluation of PPD test, 22 of 26 HCWs were suspected to be infected and preventivce therapy with isoniazid were given to 16 HCWs. Follow-up chest radiographs for 3 years revealed 5 HCWs were active TB. According to RFLP analysis of M.tuberculosis isolates, 3 HCWs and 1 patient had identical RFLP pattern to 65-year-old female SLE patient, who was admitted for fever in Nov. 1993 and was diag- nosed as miliary tuberculosis after 2 weeks admission. As she had no cough and sputum, the infectiousness of the case was suspected to be increased by cough-inducing procedure. The following TB infection control measures were conducted in the hospital;(1)Educa- tion and training to all HCWs for early identification of TB patient and adequate treat- ment (2)Surveillance and reporting system of TB patient from laboratory and ward to infection-control committee (3)Introduction of PPD test program for HCWs (4)Use of HEPA masks as personal respiratory protection. We need further evaluation of engineer- ing controls e.g. ventilation and isolation room. Key words:Nosocomial transmission, Helth care workers, Tuberculosis, Contact investigation, Restriction fragment length polymorphism (RFLP) analysis *From the Nago Public Health Center, 1617-1 Aza Nago, Nago City, Okinawa 905-0012 Japan. (Receuved 27 Nov. 1998) <9> Kekkaku Vol.74, No.4: 397-404, 1999 The 73rd Annual Meeting Symposium ‡V. NOSOCOMIAL TRANSMISSION OF TUBERCULOSIS 2. TUBERCULOSIS OUTBREAK AMONG INPATIENTS Isamu TAKAMATSU*, Makoto KAMEDA, Toshishige INOUE, Kyoichirou TOYOSHIMA The Index case, 22 year-old pregnant woman, was admitted for threatened abortion among obstetric ward in X Hospital for 17 days. Two months later, she was admitted for delivery among perinatal ward in another Y Hospital for 5 days. She produced persistent cough and sputum, when she had diagnosed pulmonary tuberculosis (TB) with sputum smear-positive and cavity on 2nd Y hospital day. By 2 years after the detection, 15 TB patients were newly diagnosed. Seven of 15 TB patients were culture positive cases and RFLP analysis of the 7 Mycobacterium TB strains demonstrated an identical banding pattern, thus confirming the spread of a unique strain. Of the 15 TB patients, seven were patients on the obstetric ward. Three were visitors. Two were infants with TB meningitis and miliary TB were not confirmed direct contact with the index case. Another two were family member and one was employee. The present outbreak emphasizes the high risk of TB transmission on obstetric and perinatal ward when the diagnosis of smear-positive pul- monary TB was delayed. Key words:Tuberculosis outbreak among inpatients, Obstetric and perinatal ward, Tuber- culosis in children, RFLP analysis *From the Division of Pediatrics, Osaka Prefectural Habikino Hospital, 3-7-1, Habikino, Habikino-shi, Osaka 583-8588 Japan. (Received 27 Nov. 1998) <10> Kekkaku Vol.74, No.4: 405-411, 1999 The 73rd Annual Meeting Symposium ‡V. NOSOCOMIAL TRANSMISSION OF TUBERCULOSIS 4. THE PRESENT STATUS AND THE TASK OF NOSOCOMIAL TUBERCULOSIS INFECTION IN JAPAN Shinji SHISHIDO*, Toru MORI The present study aimed to assess the status of preventive measures for nosocomial tu- berculosis infection and the incidence of tuberculosis among hospital workers in Japan. Data were collected using two types of questionnaires submitted to 333 hospitals with tu- berculosis beds and 247 hospitals without tuberculosis beds. The incidence of tuberculosis among hospital workes was assessed for the period from 1992 to 1996. Handling of the tuberculin test and BCG vaccination at the time of employment was inadequate. Environmental management of the workplace in laboratories and tuberculosis wards was also in adequent. Regarding the incidence of tuberculosis among hospitl workers, nurses at hospitals with tuberculosis beds had the highest incidence especially those in their twenties to thir- ties. Considering these findings, improvement of the prevention of tuberculosis infection in hospitals is important. Key words:Tuberculosis Infection, Nosocomial infection, Prevention of tuberculosis infection *From the Department of Respiratory Disease, National Sanatorium Matsue Hospital, 5-8-31 Agenogi Matsue-shi, Shimane 690-0015 Japan. (Received 27 Nov. 1998) <11> Kekkaku Vol.74, No.4: 413-420, 1999 The 73rd Annual Meeting Symposium ‡V. NOSOCOMIAL TRANSMISSION OF TUBERCULOSIS 5. TUBERCULOSIS INFECTION CONTROL PRACTICE IN HOSPITALS FROM THE VIEWPOINT OF OCCUPATIONAL HEALTH Kiminori SUZUKI*, Ikushi ONOZAKI, Akimitsu SHIMURA Several outbreaks of tuberculosis (TB) among health care workers were reported re- cently in Japan. To assess the current situation of TB infection control practice in hospi- tals in Japan from the viewpoint of occupational health, we carried out a cross sectional survey by mail-questionnaires. The questionnaires with closed and open-ended questions to ask situation of TB infection control program in hospital were mailed to 542 hospital chiefs in and around Tokyo, Kantoh district. 269 replies were received. We analyzed them especially focussing on the prevention of TB among health care workers. Out of 269 hospitals replied, 39 of them had wards and/or beds designated for tubercu- losis patients, 223 did not have, and 7 were unknown. 102 (38.9%) had set written tuber- culosis infection control programs or guidelines, only 21 (53.8%) have set them even in hospitals with TB beds. 110 (42.0%) hospitals had triage system for identifying patients with active TB in the outpatient setting. Although, most health care workers underwent annual health check programs including chest X-rays, only 67 (25.6%) of the hospitals pro- vide tuberculin skin test to their new recruits. 165 (63.0%) of hospitals admit that undi- agnosed patients with respiratory symptoms may stay with immuno-compromised patients in the same room. Since administrative management, staff education, environmental control in work place, personal infection control and individual health care should be carried out from the view- point of occupational health, we showed concrete steps of these in this paper. We recom- mend that a TB infection control manager in each hospital should be designated, and that TB infection control program and/or guideline should be made. Environmental con- trol in work place to prevent infection should be more prioritized in Japan. Key words:Occupational health, Tuberculosis, Nosocomial infection, Infection control practice, Mail-questionnaires *From Chiba Anti-Tuberculosis Association, 1-1-20 Miyako-cho, Chuou-ku, Chiba 260-0001 Japan. (Received 27 Nov. 1998) <12> Kekkaku Vol.74, No.4: 421-423, 1999 The 73rd Annual Meeting Symposium ‡V. NOSOCOMIAL TRANSMISSION OF TUBERCULOSIS Additional Comment:TUBERCULIN SKIN TESTING IN STUDENTS OF SCHOOL OF NURSING Eriko SHIGETO* Tuberculin skin testing in students of the School of Nursing Attached to National Hi- roshima Hospital was analyzed. On initial test using 0.05ƒĘg of PPDs, diameter of erythema in 26.7% of 300 new stu- dents were less than 9mm. Twelve of 24 who were tested by two-step method reacted more than 10mm on the second test. Twenty-seven non-reactors who were vaccinated with BCG all reacted more than 10mm after 9 to 16 weeks after vaccination. They might be vaccinated in the past by insufficient technique and better be revaccinated. Thirty-one of 49 students who graduated in 1998 were tested and their reactions were compared with those on entrance or after BCG vaccination. The two tests were spaced 31 to 34 months apart. The reactions were weakened in the cases after BCG vaccination, and in those who were not vaccinated on entrance, only a little booster effect were observed, except in 3 graduates whose reactions were significantly boosted and thought to be in- fected while in school. As there is considerable variation in tuberculin reactivity after BCG vaccination, diameter of reaction should be kept on personal health record as base line rection to diagnose tuberculous infection henceforce. Key words:Two-step tuberculin testing, Students of school of nursing, Tuberculous infection, BCG vaccination *From the National Hiroshima Hospital, 513 Jike, Saijo-cho, Higashihiroshima, Hiroshima 739-0041 Japan. (Receuved 27 Nov. 1998)