(Vol.77 No.9 September 2002) <1> Kekkaku Vol.77,No.9:589-595,2002 Original Article THE SIGNIFICANCE OF TUBERCULIN SKIN TEST IN THE INVESTIGATION OF MASS OUTBREAK OF TUBERCULOSIS IN SCHOOLS 1Katsuya ANDOH, 2Katsumi YAMANAKA, and 3Tomi AKASHI Abstract A high school teacher was diagnosed as pulmonary tuberculosis. He was 27 years old and taught bookkeeping to the 1st year grade students in classes 3 and 6, the 2nd year grade students in classes 4 and 5. He was also the assistant teacher in charge of class 1 of the 3rd year grade students and the adviser of the badminton club in the school. He first noticed a slight cough in November 1999, and visited his physician. On December 24, he visited again for a moderate cough, fever and chill and was administered medicine and drip infusion for a cold. In the middle of January 2000, he visited another physician for a severe cough. He was referred to hospital N and was admitted due to an abnormal shadow on chest X-ray films. The result of sputum smear examination was positive for AFB, Gaffky 8. Subsequent contacts examination was conducted for 153 students and 63 teachers of the school. A tuberculin skin test survey of 153 students was also carried out, in February 2000. The diameter of erythema revealed a monomodal distribution pattern in students, however, one student was diagnosed as pulmonary tuberculosis by the chest X-ray examination, and 27(18%) showed erythema 40 mm and larger. They were indicated chemoprophylaxis as they were most likely newly infected in this epidemic. After 2 months, a second contact examination was conducted for the students (excluding those who underwent chemoprophylaxis or had tuberculosis) and all teachers. Based on chest X-ray examination, two new students and one teacher were diagnosed as pulmonary tuberculosis, and another one student was diagnosed as tuberculous pleurisy. Comparing the erythema size distribution in the first and second tuberculin tests, the distribution of the latter markedly shifted to right, namely became much larger than the former. It was assumed that students in whom the difference in erythema diameter was larger than 17 mm between the first and second examinations had been newly infected in this epidemic. Chemoprophylaxis was indicated for 45 students and 3 teachers. After 6 months, a third contact examination was conducted for the students and teachers (excluding those who underwent chemoprophylaxis or had tuberculosis). After a year, one teacher was diagnosed as pulmonary tuberculosis by the fourth contact examination(chest X-ray). Restriction fragment length polymorphism (RFLP) analysis was carried out with 2 strains of M.tuberculosis isolated from these patients (the index case and the second teacher patient), and the RFLP pattern of 2 patients was same. Key words:Tuberculin reaction, High school, Epidemic, Tuberculosis, RFLP analysis 1Nagoya City Midori Health Center, 2Department of Nutritional Sciences, Nagoya University of Arts and Sciences, 3Department of Health, Health and Welfare Bureau, Nagoya City Correspondence to:Katsuya Andoh, Nagoya City Midori Health Center, 1-715, Aibaragou, Midori-ku, Nagoya-shi, Aichi 458-0033 Japan. (E-mail:2000ando@chance.ne.jp) <2> Kekkaku Vol.77,No.9 597:603-,2002 Original Article TUBERCULOSIS CONTROL OF CONSTRUCTION WORKERS LIVING IN HANBA 1Tomoko KIMURA, 1Kiminori SUZUKI, 1Tsutomu YABE, 1Yuko SUNAMI, 1Akimitsu SHIMURA, 2Hidetoshi IGARI, 3Hiroshi IKEGAMI, 3Keiichi OGURA, 4Yuka SASAKI, and 4Fumio YAMAGISHI Abstract Construction workers living in temporal quarters, HANBA, rarely have opportunity to receive the routine health screening program such as that for general inhabitants organized by the local government or that for permanent employees by the employer. Long delay in detecting TB and high dropout rate from TB treatment among them have been reported. We carried out the following interventions to cope with the problems:In 1999 and 2000, we organized TB screening with X-ray and further examination in the same day when necessary among workers in 6 HANBA in Chiba City. A total of 382 workers were screened, and they also received structured interviews to assess their health-related behaviors and conditions. Four active pulmonary TB cases were detected, and the incidence of 1,047/1,000,000 was forty times higher than that of Chiba City. All four patients were treated and cured. According to the experiences through our intervention, we developed the following recommendations on TB control of construction workers living in HANBA:1)A system carry out the health examination routinely in the HANBA should be provided, and its implementation be supervised by the public health center and the Labor Standards Inspection Office. 2)It is necessary to guarantee worker's minimum living conditions and medical treatment, and for this regular purpose, close cooperation should be established between clinical service providers and public health, social welfare, and work management authorities. 3)We should start "DOTS" (Directly Observed Treatment Short-Course) not only to the patients in the hospital but also to the outpatients and in the HANBA. To control TB among those workers, further effort is necessary to motivate them to receive basic regular health screening program that is provided in free of charge in Japan. Key words:HANBA, Tuberculosis examination, Computed radiography, Computed tomography, Treatment success, DOTS 1Chiba Anti-Tuberculosis Association, 2Department of Respirology, Graduate School of Medicine, Chiba University, 3Chiba City Public Health Center, 4National Chiba-Higashi Hospital Correspondence to:Tomoko Kimura, Chiba Anti-Tuberculosis Association, 1-1-20, Miyako-cho, Chuo-ku, Chiba-shi, Chiba 260-0001 Japan. (E-mail:inf-cent@cata.or.jp) <3> Kekkaku Vol.77,No.9 605:608-,2002 Report and Information THE TUBERCULIN REACTION TWO YEARS AFTER THE INITIAL TWO-STEP TUBERCULIN SKIN TEST IN OUR HOSPITAL 1Shuichi YANO, 2Shinji SHISHIDO, and 1Kanako KOBAYASHI Abstract The tuberculin skin test was carried out to employees of our hospital one and two years later after the initial two-step tuberculin skin test in 1999 to examine the possibility of new tuberculosis infection. Nineteen weakly positive reactors aged 39-year-old or less in 1999 were followed up by tuberculin reaction for two years. The significant changes were not recognized in either the size of erythema or the size of induration, examined by one-way ANOVA and Tukey-Kramer multiple comparison procedure. Among weakly positive reactors aged 39-year-old or less, it seemed that there had been no new tuberculosis infection during 2 years follow-up. Key words:Two-step tuberculin skin test, Tuberculosis infection countermeasure 1Department of Pulmonary Medicine, National Matsue Hospital, 2Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association Correspondence to:Shuichi Yano, Department of Pulmonary Medicine, National Matsue Hospital, 5-8-31, Agenogi, Matsue-shi, Shimane 690-8556 Japan. (E-mail:yano@matsue.hosp.go.jp) <4> Kekkaku Vol.77,No.9 609:614-,2002 Report and Information THE PRESENT SITUATION OF DAILY LIFE OF TUBERCULOSIS PATIENTS TREATED IN HOSPITALS WITH BEDS FOR TUBERCULOSIS IN JAPAN 1Fumio YAMAGISHI, 1Yuka SASAKI, 2Yoshiko KAWABE, 3Emiko TOYODA, 4Kimio INUZUKA, 5Takeko YAMASHITA, and 5Toru MORI Abstract We sent a questionnaire to hospitals with beds for tuberculosis in Japan to know current situation of daily life of tuberculosis patients treated in hospitals. It was evident that some services of daily life facilities was delayed;e.g. the difficulty in using stores in a hospital, no dining rooms and no installation of a personal television set. The use of personal computers was not allowed in many hospitals. Tuberculosis patients were subjected to a marked restriction in the hospital in spite of their isolation from the family and the society. Patients were prohibited to go out from the ward except when they undergo certain examinations in the hospitals, to take a walk in the hospital compound and to go out or stay overnight outside the hospital. In the majority of hospitals, patients were allowed to take a walk or to stay overnight outside the hospital only after the negative conversion of tubercle bacilli in sputum. Judging from the above findings, it appears that many tuberculosis patients under hospital treatment are not spending a pleasant daily hospital life. Key words:Tuberculosis patients, Daily hospital life, Outing, overnight stay, Isolation from the family and the society 1Department of Respiratory Diseases, National Chiba-Higashi Hospital, 2Department of Respiratory Diseases, National Tokyo Hospital, 3Department of Respiratory Diseases, International Medical Center of Japan, 4Aichi Prefectural Shinshiro Health Center, 5Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association Correspondence to:Fumio Yamagishi, Department of Respiratory Diseases, National Chiba-Higashi Hospital, 673, Nitona-cho, Chuo-ku, Chiba-shi, Chiba 260-8712 Japan. (E-mail:yamagisf@chibae.hosp.go.jp) <5> Kekkaku Vol.77,No.9 615:620-,2002 Case Report PULMONARY MYCOBACTERIUM AVIUM COMPLEX(MAC) DISEASE SHOWING MIDDLE LOBE SYNDROME -Pathological Findings of 2 Cases Suggesting Different Mode of Development- 1Masao OKUMURA, 2Kazuro IWAI, 1Hideo OGATA, 1Seiji MIZUTANI, 1Kouzou YOSHIMORI, 2Kunihiko ITOH, 3Yutuki NAKAJIMA, and 4Shouji KUDOH Abstract Two different processes have been proposed for pathogenesis of Mycobacterium avium complex(MAC) disease which show the middle lobe syndrome:1)middle lobe bronchiectasis followed by MAC infection and 2)MAC disease resulted in secondary bronchiectasis. Two surgical specimen from MAC cases showing middle lobe syndrome were studied histo- pathologically. The first case was a 60 year-old female with frequent bloody sputum, who had been diagnosed as bronchiectasis in her childhood. Pathological examination of the resected middle lobe showed prominent cylindric bronchiectasis in the indurated middle lobe, and epithelioid cell granulomas were scattered limited to the fibrous bronchial walls, without any granulomas in the lung parenchyma. These findings suggested a secondary infection of MAC to the non-specific pre-existed bronchiectasis. The second case of a 55 year-old female having repeated bloody sputum, who was diagnosed to be tuberculosis but no improvement with anti-tuberculosis drugs. Pathological examination of the middle lobe showed scattered epithelioid cell granulomas with lymphocytic infiltration in the lung parenchyma. A few epithelioid cell granulomas were also found in the mucosa of middle lobe bronchi. In this case, pulmonary MAC lesions seemed to precede the central bronchial lesion with later development of bronchiectasis. Summarizing above findings two different mode of pathogenesis ways may be considered; one is non-specific bronchiectasis followed by middle lobe MAC disease and the other is pulmonary MAC lesion in the middle lobe as a primary change. Key words:Pulmonary Mycobacterium avium complex (MAC) disease, Middle lobe syndrome, Bronchiectasis, Epithelioid cell granuloma, Lymphocytic infiltration 1Department of Respiratory Medicine, Fukujuji Hospital, Japan Anti-Tuberculosis Association, 2Resarch Institute of Tuberculosis, Japan Anti-Tuberculosis Association, 3Thoracic Surgery, Fukujuji Hospital, Japan Anti-Tuberculosis Association, 4Fourth Department of Internal Medicine, Nippon Medical School Correspondence to:Masao Okumura, Department of Respiratory Medicine, FukuJuji Hospital, Japan Anti-Tuberculosis Association, 3-1-24, Matsuyama, Kiyose-shi, Tokyo 204-8533 Japan. (E-mail:masao-ok@zd5.sp-net.ne.jp) <6> Kekkaku Vol.77,No.9 621:625-,2002 Memorial Lecture by the Imamura Award Winner, 2002 A STUDY OF CASE FINDINGS IN PULMONARY TUBERCULOSIS PATIENTS Yuka SASAKI Abstract The incidence of tuberculosis patients increased again recently and many outbreaks of pulmonary tuberculosis (PTB) patients were reported. The purpose of this study is to investigate the present situation of the delay in case finding of PTB patients. 1)Of 236PTB patients who were admitted to our hospital for treatment in 1997, 118 patients, who were detected by their symptomatic visits, were enrolled in to this study. 50 percentile patient's delay was 21.0 days, and 50 percentile doctor's delay was 7.2 days. 50 percentile total delay was 42.0 days, which was longer than about 28 days obtained by summing up the 50 percentile patient's delay and doctor's delay. The number of cases detected within 28 days was only 39 cases (33.1%). Doctor's delay was mainly attributable to the performing the examination. Regarding the relationship between the period of total delay and sputum smear positive rate, the positive rate was less than 50% when total delay was less than 4 weeks, and came to more than 60% when the delay exceeded 4 weeks. 2)Of 236 PTB patients admitted to our hospital for treatment in 1997, 49 patients had been treated at medical institutions for other diseases. The majority of the cases were diagnosed as PTB in the routine examination, but early case findings was not made, with 9.5 weeks on an average and 50 percentile total delay was 5.5 weeks. The duration of doctor's delay in undergoing examination directly related to PTB diagnosis was accountable for doctor's delay. 3)The case finding of far-advanced cavitary PTB (bI3) patients was studied. Eighty-four patients were detected by symptomatic visits, 10 patients were detected during medical treatments of other disease, and 1 patients was detected by accident. The duration of patient's delay was 5.5 months on an average, while doctor's delay was 0.3 month on an average. The bI3 patients included many social and economical weak people. The body status on admission of bI3 patients were very severe. Twenty percentile of bI3 patients died of PTB, and 14 cases of 19 dead cases died within 1 month from admission. 4)The duration of case finding of tracheobronchial tuberculosis patients was studied. 50 percentile patient's delay was 14 days, while 50 percentile doctor's delay was 145 days. The delay in examination was considered accountable for doctor's delay, with 12 cases (57%) which were treated as bronchial asthma and 6 cases (29%) in which the sputum examination for tuberculosis bacilli was not performed after the detection of chest abnormal shadows on chest X-rays. 5)The present situation of case findings in Japan was studied. Patient's delay did not improve in recent years, while doctor's delay was improve in 2000, after Declaration of State of Emergency concerning tuberculosis. 6)As the countermeasures against patient's delay, it appears necessary to continue enlightenment on PTB, and selective detection by health examination for high risk groups is necessary. As the countermeasures against doctor's delay, it appears important to recommend to all doctors to pay attention to the patients with cough and sputum and undergo sputum examination. Key words:Case findings, Patient's delay, Doctor's delay, Total delay, Pulmonary tuberculosis Division of Thoracic Disease, National Chiba Higashi Hospital Correspondence to:Yuka Sasaki, Division of Thoracic Disease, National Chiba Higashi Hospital, 673, Nitona-cho, Chuo-ku, Chiba-shi, Chiba 260-8712 Japan. (E-mail:sasakiy@chibae.hosp.go.jp)