(Vol.73 No.6 June 1998) <1>Kekkaku Vol.73, No.6 :387-394, 1998 TUBERCULOSIS SATISTICS AMONG THE HOMELESS POPULATION IN NAGOYA CITY FROM 1991 TO 1995 Katsumi YAMANAKA* Tonu AKASHI, Masaru MIYAO, Shin'ya ISHIHARA A survey was conducted to clarify the tuberculosis (TB) situation among the homeless during the period from 1991 to 1995 in Nagoya city, using 5,222 registration cards of TB cases registered at one of Nagoya City's 16 Health Centers. Out of 5,222 TB cases, there were 269 homeless cases (267 male and 2 female). Ninety-seven percent of them were pul- monary TB cases. The incidence and prevalence rates of TB per 100,000 among the home- less were estimated at around 1,500 and around 2,400, respectively, around 20 times higher than those of the non-homeless male over the 19 years of age. A decrease in the incidence rate of TB cases among the homeless was not seen, although the rate among the non-homeless decreased gradually. The percentage of infectious (bacillary and/or cavitary) tuberculous cases among the homeless was higher than in the non-homeless. In the infectious cases, the percentage of smear-positive bacillary cases or far advanced cavitary cases was 52.1% or 9.4% among the homeless compared to 48.1% or 2.6% among the non-homeless, respectively. The detection rate by chest X-ray examination of the homeless was 3.9%. Key words : Pulmonary tuberculosis, Homeless, Incidence *From the Nahoya City Central School of Nursing, 1-4-7 Aoi, Higashi-ku, Nagoya 461-0004 Japan. (Received 13 Nov. 1997/ Accepted 8 Jan. 1998) <2>Kekkaku Vol.73, No.6 :395-401, 1998 KOCH'S PHENOMENON AFTER BCG VACCINATION AND THE TWO-STEP TUBERCULlN TEST IN ELEMENTARY SCHOOL CHILDREN Hidetoshi IGARI, Ikushi ONOZAKI, Yuko SUNAMI, Kimmon SUZUKI Akimitsu SHIMURA, Keiichi NAGAO In Japan, BCG vaccination, which covers more than 90% of infants, has been given ac- cording to the national immunization policy. Moreover, first-grade children in elementary school are screened with tuberculin skin test, and those who show negative reaction in the Japanese standard, i.e. size of erythema less than 10mm, are re-vaccinated with BCG ac- cording to the Tuberculosis Prevention Law. However, since the incidence of tuberculosis among children below age 14 is as low as 1.5/100,000 in Japan, it is time to reconsider the BCG vaccination policy. As the first step to assess the efficiency of the present program, we observed the oc- currence of Koch's phenomenon after BCG vaccination in elementary school children in Chiba City in 1995 and 1996, and we introduced the two-step tuberculin test to elemen- tary school children in 1997. Among 180 BCG vaccinated children in 1995 and 1996, 168 (93.3% ) had been vaccinated by 4 -year of age. We could follow local reaction of BCG re-vaccination and observed Koch's phenomenon in 117 (69.6%, 95% C.I. of 62.7-76.6%). Among 92 tuberculin negative children in 1997, 85 (92.4% ) had been vaccinated by 4- year of age. In the two-step tuberculin test program of 85 initial negative-reactors, 63 (74.1%, 95% C.I. of 64.8-83.4%) turned to positive by the second test. Those results suggest that more than 69% of tuberculin-negative school chidren who were vaccinated previously maintained immunity with BCG. Our studies raised a problem of the current BCG re-vaccination policy that depends on the result of tuberculin test. Due to the discrepancy between tuberculin allergy and immunity in tuberculosis, many school children may be given BCG vaccination unnecessarily. Taking into consideration the incidence of tuberculosis in children, discontinuation of BCG re-vaccination policy at elementary school entrance should be considered. Key words : BCG vaccination, Tuberculin test, Koch's phenomenon, Two -step tuber- culin test, Booster phenomenon *From Chiba Anti-Tuberculosis Association, 1-1-20 Miyako-cho, Chuou-ku, Chiba 260-0001 Japan. (Received 17 Dec. 1997/ Accepted 16 Feb. 1998) <3>Kekkaku Vol.73, No.6 :403-411, 1998 A, SUCCESSFULLY TREATED CASE OF MILIARY TUBERCULOSIS WITH ADULT RESPIRATORY DISTRESS SYNDROME AND TUBERCULOUS ANEURYSM OF ABDOMlNAL AORTA Hideaki ISHIBATAKE* and Reiko ONIZUKA A 52-year-old woman visited a physician on Oct. 17, 1995 because of dizziness, general fatigue and a slight fever. A Chest X - ray film showed micronodulous and infiltrative shadows in the bilateral upper lung fields. Liver dysfunction was also recognized. As dyspnea and hypoxemia progressed very rapidly, the patient was intubated and kept under mechanical ventilation. A diagnosis of miliary tuberculosis with adult respiratory dis- tress syndrome (ARDS) was made based on the detection of acid-fast bacilli from spu- tum obtained from the endotracheal tube. She was admitted to our hospital on Oct. 24, 1995 receiving anti-tuberculous drugs combined with high-dose methylprednisolone. As disseminated intravascular coagulation (DIC) and acute pancreatitis also developed, gabexate mesilate was added to the preceding therapy. This combination therapy was ef- fective and the patient gradually improved. Two months after the admission, aneurysms of the abdominal aorta and left renal ar- tery were discovered. As the size of the aneurysms had been increasing along with ab- dominal and low back pain, the patient was transferred to an other hospital for surgical treatment. She underwent a successful operation for pseudoaneurysms, the etiology of which was tuberculosis according to pathological findings and detection of acid-fast ba- cilli from the resected specimens. This is the 10th case of tuberculous aneurysm of the aorta which was successfully operated on in Japan. ARDS, DIC and aneurysm occure rarely as complications of miliary tuberculosis, but they are life-threatening, and lead to a serious prognosis if untreated. Early diagnosis of miliary tuberculosis and tuberculous aneurysm is very important for a good outcome. Key words : Miliary tuberculosis, ARDS, DIC, methylprednisolone, Tuberculous aneurysm *From the National Sanatorium Miyazakihigashi Hospital, 4374-1 Tayoshi, Miyazaki City, Miyazaki 880-0911 Japan. (Received 10 Dec. 1997/ Accepted 25 Feb.1998)