DOTS in Osaka City]

The tuberculosis (TB) incidence rate and the smear positive TB incident rate in Osaka City were 107.7 and 34.7 per 100,000 respectively in 1999, which were approximately 3 times higher than the national average. The TB mortality rate in Osaka City was 6.9 per 100,000 in 1999, which was highest in Japan. The TB incidence in the "AIRIN" area, where about 20% TB patients are homeless, shows highest rate of above 1,000/100,000. The treatment defaulter rate in Osaka City is about 10% against the average rate of 4% in Japan. A new strategic plan to intensify TB control is now being prepared by Osaka City government. A goal has been set up to make the TB incidence half in ten years. The plans consists of 4 points of "DOTS", "early detection of patient", "education and campaign", and "cohort analysis of treatment outcome". "DOTS" is being expanded in Osaka City. DOT is applied not only to the special group of homeless patients but also to the patients in the hospitals and in the community. Further systematic development of "DOTS" is necessary to achieve the goal.     

Estimation of the future epidemiological situation of tuberculosis in Japan

OBJECTIVE: To estimate the future trends of all forms of tuberculosis (TB) and sputum smear positive pulmonary TB in order to consider the emerging issues of TB control and eliminating TB in Japan. MATERIALS AND METHODS] Annual reports of TB registrations were used for observing past trends of TB, and predictions were then made assuming that past trends would continue. At first, to obtain the number of TB patients by sex and age-group, sex-age-specific incidence rates were estimated for the years 2010, 2015, 2020, 2025 and 2030, and then applied to a sex-age-specific population which was projected by the National Institution of Population and Social Security Research. According to the different methods used to calculate the reduction rates of incidence, we adopted model A and model B. In model A, the reduction rate was calculated by using two groups of the same age group but different members by calendar year. In model B, the reduction rate was calculated by using the same birth cohort but different age by calendar year. We also adopted two sub-models by the observation period of past trends. The incidence rates for the period from 1987 to 2005 were used in model 1 and the incidence rates for the period from 1998 to 2005 were used in model 2. The incidence rate in 1999 was excluded from both model 1 and 2, because the TB incidence rate increased abnormally due to the declaration of a state of emergency concerning tuberculosis in 1999. The speed of decline among particular several sex-age-groups was weighted taking into account the influence of foreign, homeless and elderly cases. The future number of sex-age-specific sputum smear positive pulmonary patients was estimated by applying various parameters, i.e. pulmonary TB rate, sputum smear positive rate and its trend, to the estimated future number of TB incidence. RESULTS: The TB incidence rate, which was 22.2 per 100,000 population as of 2005, would reach 9.8 in model A-1, 5.4 in model A-2, 7.5 in model B-1 and 3.2 in model B-2 by 2030. On the other hand, the sputum smear positive pulmonary incidence rate, which was 8.9 per 100,000 population as of 2005, would decline to 5.5 in model A-1, 3.0 in model A-2, 4.2 in model B-1 and 1.7 in model B-2 by 2030. The future number of TB patients and incidence rates by sex and age were discussed based on a mixed model which used the middle series of estimates, and was obtained by combining model A-2 and model B-1. The number of TB patients by the mixed model will become about 12 thousand with 10.1 per 100,000 population in 2020, and about 7.4 thousand with 6.5 per 100,000 population in 2030. From 2005 to 2020, the age composition of TB patients will change from 0.4% to 0.2% at 0-14 years old, 4% to 4% at 15-24 years old, from 10% to 11% at 25-34 years old, 8% to 11% at 35-44 years old, from 9% to 12% at 45-54 years old, from 15% to 10% at 55-64 years old, 18% to 15% at 64-74 years old, from 24% to 17% at 75-84 years old, and from 11% to 20% at 85 years of age or older. Although the proportion of the elderly aged 65 years or higher will not be so different, the proportion of TB patients aged 85 years or older will almost double. CONCLUSION: The year when the TB incidence rate will reach the level of low-incidence countries, which is defined as a country with a TB incidence rate of less than 10 per 100,000 population, might be around 2020 in Japan. At that time, the age composition of TB patients will tend to be very old patients, and the young adult and middle-aged patients. Problems such as delay in diagnosis and difficulty of treatment are expected among very old patients.     

The use of nationwide tuberculosis surveillance system data to determine geographical differences in drug resistance--consideration of the representativeness of the drug resistance rate in Japan

Annual reports of tuberculosis (TB) statistics have been compiled using a database built through the nationwide computerized TB surveillance system in Japan. Using the annual report database for 2007-2009, this study compared the drug resistance rates among eight geographical districts. The proportion of bacteriological test results obtained at public health centers, which enter data into their computers that can then be accessed by the central computer, improved greatly from 2007 to 2009. The proportion of initial culture test results obtained among pulmonary TB increased from 63.8% to 74.8% and the proportion of drug susceptibility test results obtained among culture-positive pulmonary TB cases increased from 41.8% to 63.5%. As a result, susceptibility test results among 15,425 (26.5%) of 58,198 newly notified pulmonary TB cases during the three-year study period were obtained. The proportion of multi-drug resistant (MDR) TB among new treatment patients was 0.6% in the whole country. Although there were no particular districts having a significantly high rate of MDR-TB, the Kinki district showed the highest rate at 0.8%. In the case of retreatment patients, the MDR-TB rate was 5.1% in the whole country and there was no statistical difference among the eight districts. The proportion having resistance to any INH among new treatment patients was 4.5% in the whole country, with the Kinki and Kanto districts showing significantly high rates of 5.3% and 5.2%, respectively. In the case of retreatment patients, the proportion having resistance to any INH was 13.3% in the whole country, and there was no district where the proportion was significantly high. The proportion having resistance to one or more drugs among new treatment patients was 12.7% in the whole country, with the Kinki district showing a significantly higher rate of 15.4%. In the case of retreatment patients, the proportion having resistance to one or more drugs was 22.2% in the whole country, and there was no district where the proportion was significantly high. It is important to monitor drug susceptibility results for a comprehensive TB control program. The results of drug susceptibility tests through the nationwide TB surveillance system revealed a tendency toward higher drug resistance in districts that included large cities. Although many problems remain to be solved in order to optimize the use of results from the nationwide computerized TB surveillance system to represent the drug resistance rates in Japan, this practice is expected to yield great benefits.     

Survey on nosocomial infection of tuberculosis in nursing homes for elderly in Osaka City

PURPOSE: To ascertain tuberculosis (TB) infection control measures and incidence of TB in nursing homes for elder. SUBJECTS AND METHOD: The questionnaire on TB infection control was distributed to all nursing homes in Osaka City in 2005. RESULTS: The questionnaire was returned from 197 (90%) out of 219 facilities. In more than half of facilities, infection control committee was organized (57%) and automated ventilation system was installed (59%). In almost all facilities, residents had annual chest X-ray screening (94%). Respiratory symptoms were checked for residents and "day service" users in majority of facilities. 100% of employees had annual chest X-ray screening. However TB education session for employees was held annually in only 40% of facilities. Education materials on TB were distributed in 19%. Tuberculin skin test (TST) was conducted for new employees in 31%. TB patients were diagnosed in 22% of facilities in the past 3 years from 2002 to 2004. Incidence rate of TB is 75.2 per 100,000 for residents and 24.1 per 100,000 for employees. Analysis showed that TB incidence rate is higher in facilities with larger number of residents and in facilities where infection control committee is organized, and facilities where TST is conducted for new employees. DISCUSSION: In Osaka City, TB infection control was more often implemented in facilities where TB patient was diagnosed. When age structure is taken into consideration, TB incidence rate of employees or residents was lower than general population. Nosocomial TB infection does not seem to be occurring in nursing homes. However, as TB patients were diagnosed occasionally, TB infection control measures should be strengthened in Osaka City.     

Discussing the current situation of tuberculosis case-finding by mass miniature radiography in Japan

The system of tuberculosis (TB) case-finding by mass miniature radiography (MMR) was established and expanded for almost all Japanese citizens in the 1950s. And, as stipulated by the TB Prevention Law, periodic mass screenings for schools, inhabitants, employees and institutions have been carried out. Among those aged over 25 years, the proportion of people screened by MMR was estimated to be 60.3%. This means that about 54 million people aged over 25 years are receiving medical service with MMR every year. However, the detection rates of TB cases by MMR have declined markedly compared with those in 1950s. As of 1998, the detection rate was 0.03 per 1,000 for school children and students, 0.06 per 1,000 for employees, and 0.16 per 1,000 for inhabitants. The proportion of cases detected by MMR among newly notified TB cases was 12.8% in 1998, and this ratio has been almost constant for the last 10 years. This ratio was greater among young adult TB cases. Approximately 20% of notified TB cases aged 20-39 years were detected by MMR for employees. Although the purpose of MMR is to find the cases before discharging TB bacilli, 35.1% of the cases were bacteriologically confirmed, and this proportion was greater among elderly TB cases. The Japan Anti-Tuberculosis Association (JATA) has been carrying out MMR for a long time. Eight selected branches of JATA that has been doing high quality case-finding reported 228 TB cases out of 965,440 inhabitants aged over 40 years examined by MMR in 1996. Based on these results, the cost per TB case detected by MMR was calculated. The cost was 4.4 millions yen (yen) per case for all forms of TB, yen 2.3 millions for male, yen 8.4 millions for female, yen 7.3 millions for those aged 40-49 years and yen 1.8 millions for those aged over 80 years. TB detection rate by MMR for inhabitants was correlated with TB incidence rate in various areas, and based on this correlation, the cost was calculated for various incidence rates. For all forms of TB, the cost was yen 4.0 millions per case for an incidence rate of 30 per 100,000, and yen 6.7 millions for an incidence rate of 20 per 100,000. MMR is not economically cost-effective even among elderly people and in areas with incidence rate less than 50 per 100,000, because the medical expense for a TB patient treated under hospitalization for 2 months and outpatient's clinic for 4 months is approximately yen 0.9 millions in 1996. The decision making in continuation or abolition or limitation of MMR should be discussed from a wide range of cost-effectiveness analyses as well as from the view of public health service and willingness of people. For the purpose of decision making, this study provides the detection rates; the costs stratified by sex, age and incidence; and the proportion of cases detected by MMR among newly notified TB cases by age-group and bacteriological status.     

Occupational risk of tuberculosis among health care workers at the Institute for Pulmonary Diseases of Serbia.

SETTING: The Institute for Pulmonary Diseases of Serbia, which specialises in diagnosis and treatment of lung diseases in a region with approximately 550-600 TB admissions per year. OBJECTIVE: To assess the occupational risk of tuberculosis (TB) among health care workers (HCWs) employed at this institution. DESIGN: Retrospective analysis of morbidity of TB among HCWs over a 12-year period (1986-1997). The incidence of TB among HCWs was estimated by the frequency of bacteriologically or histologically confirmed active disease. All HCWs at our institution underwent routine pre-employment screening, consisting of verification of BCG vaccination, PPD tuberculin reactivity, chest X-ray and laboratory evaluation. RESULTS: Of an average 267 employed HCWs, pulmonary TB occurred in nine (six nurses and three laboratory technicians). Cumulative incidence for HCWs was 3451/100,000, compared to 454/100,000 in the general population, for an incidence rate ratio of 7.6. CONCLUSION: The risk of TB among HCWs employed at the Institute for Pulmonary Diseases of Serbia in Belgrade is 7.6 times higher than that observed in the general population, suggesting occupational acquisition of TB.     

Geographic clustering of myeloma in Tokushima.

Between 1978-1988, seven cases of multiple myeloma were found in T Town (population 9,000), which is located at the mouth of a large river within the boundaries of Tokushima City, Japan. This is a significantly high incidence, 7.06 per 100,000 as compared with an incidence of 1.20 in Tokushima City itself and 1.53 in Japan as a whole. The clinical and laboratory features of these patients were typical of myeloma. Although the causes of this small but apparent cluster of multiple myeloma remain obscure, the fact that five of the seven patients had been working for long periods as fishermen was notable.     

Tuberculosis infection in patients with rheumatoid arthritis and the effect of infliximab therapy

OBJECTIVE: According to the Centers for Disease Control and Prevention, the 1999 and 2000 incidence rates for tuberculosis (TB) in the US population were 6.4 and 5.8, respectively, per 100,000 persons. Recently, reports of TB following infliximab administration have raised questions regarding the rate of TB in patients with rheumatoid arthritis (RA) generally and in those treated with infliximab in clinical practice. We undertook this study to determine the baseline rate of TB in RA prior to the introduction of infliximab and to determine the rate of TB among those currently receiving infliximab. METHODS: We surveyed patients with questionnaires, followed by detailed validation from medical records and physician reports. In study 1, we evaluated 10,782 RA patients in 1998-1999 prior to the widespread use of infliximab. In study 2, we evaluated 6,460 infliximab-treated patients in 2000-2002. RESULTS: In study 1, the lifetime rate of TB was 696 per 100,000 patients (95% confidence interval [95% CI] 547-872). Of these cases, 76.8% occurred prior to the onset of RA. During the period of prospective followup, 1 case of TB developed during 16,173 patient-years of followup, yielding a rate of 6.2 cases (95% CI 1.6-34.4) per 100,000 patients. In study 2, the TB incidence rate among infliximab-treated patients was 52.5 cases (95% CI 14.3-134.4) per 100,000 patient-years of exposure. Three of the 4 cases occurred in patients with a history of TB exposure, and no cases occurred in persons with recent TB skin tests or prophylaxis. CONCLUSION: The rate of TB is not increased in RA patients generally. Among infliximab-treated patients, the rate is 52.5 cases (95% CI 14.3-134.4) per 100,000 patient-years of exposure. A thorough medical history regarding TB, as well as tuberculin testing and radiographic examination (if indicated), should be an essential component of anti-tumor necrosis factor therapy.     

Increasing trends in HIV and TB rates in Odessa and the Ukraine

Notification rates for HIV and tuberculosis (TB) have increased in the Ukraine and particularly in Odessa. In 1962, the incidence of TB in Odessa region was 178 cases per 100,000 cases, declining to 73.0, 42.0 and 41.6 cases per 100,000 in 1972, 1982 and 1992, respectively. In 2002, TB incidence and prevalence were 80.4 and 330.1/100,000 population, respectively. TB mortality in the port almost doubled from 10.2/100,000 to 21.6/100,000 between 1990 and 2001. In 2002, the HIV incidence and prevalence and AIDS incidence and prevalence were 46.4 and 241.0 cases/100,000 population and 14.5/100,000 and 26.9/100,000, respectively. There are increasing numbers of TB cases co-infected with HIV (200 in 2002), suggesting that the HIV and TB epidemics are converging. Significant effort is needed for the effective control of these two outbreaks to prevent high levels of morbidity and mortality from these diseases.     

Tuberculosis annual report 2009. Series 1. Summary of TB notification statistics in 2009

Annual reports of tuberculosis (TB) statistics in Japan have been compiled mainly using the output of the database obtained through the nationwide computerized tuberculosis surveillance system which has been operated since 1987. This system has been revised several times, with the latest revision conducted in 2007 when much new information was added. Therefore, a plan was drawn up to provide TB epidemiological statistics in Japan on "Kekkaku" and a series of ten reports was already issued as "TB Annual Report 2008". This is the first report of a new series for "TB Annual Report 2009". The report can be summarized as follows. The TB notification (incidence) rate fell below 20 per 100,000 in 2007 and continued to decline, reaching 19.0 in 2009. However, 24,170 TB patients were newly notified in 2009. For sputum smear positive pulmonary TB, the patient count was 9,675 with an incidence rate of 7.6 per 100,000 in 2009. Since June 2007, it has been legally compulsory to notify latent TB infections (LTBI) requiring treatment; the number in 2009 was 4119 cases.     

Results of tuberculosis screening in applicants for migration in Vietnam and Cambodia.

SETTING: Pre-migration medical screening programmes in Ho Chi Minh City, Vietnam and Phnom Penh, Cambodia. OBJECTIVE: To compare the rates of newly diagnosed bacteriologically confirmed tuberculosis (TB) in a cohort of migration applicants in Vietnam and Cambodia with current estimates of the TB burden in these countries. DESIGN: Interviews and medical screening of 5108 Vietnamese and 910 Cambodian migration applicants who applied for an Australian visa. RESULTS: On initial testing, the rate of bacteriologically confirmed TB among the Vietnamese cohort was 157 per 100,000 population compared to 989/100,000 among the Cambodian cohort. When cases detected during follow-up testing were included, the rate in the Vietnamese cohort was 489/100,000 compared to 1209/100,000 in the Cambodian cohort. CONCLUSIONS: Although it has been suggested that the rate of newly diagnosed bacteriologically confirmed TB among migration applicants would underestimate the prevalence of TB in the Vietnamese and Cambodian populations, the rates found were substantially higher than current point estimates of the prevalence of TB, particularly for Vietnam. Our findings suggest that current published estimates of the tuberculosis burden in Vietnam and Cambodia may be conservative.     

Rheumatoid arthritis,its treatments,and the risk of tuberculosis in Quebec,Canada

Objective

To determine the risk of tuberculosis (TB) among a cohort of patients with rheumatoid arthritis (RA) in Quebec and assess whether this risk is associated with exposure to nonbiologic disease‐modifying antirheumatic drugs (DMARDs).

Methods

We studied a cohort of patients with RA identified from the Quebec provincial physician billing and hospitalization databases for 1980–2003. TB incidence rates were determined for the period 1992–2003 and compared with the general population, standardized for age and sex using the standardized incidence ratio (SIR). Conditional logistic regression was used in a nested case–control analysis to estimate the rate ratio (RR) of TB related to nonbiologic DMARD exposure during the year before the index date.

Results

Of the 24,282 patients with RA in the cohort, 50 cases of TB were identified. The standardized incidence rate was 45.8 cases per 100,000 person‐years compared with 4.2 cases per 100,000 person‐years in the general population of Quebec (SIR 10.9, 95% confidence interval [95% CI] 7.9–15.0). The adjusted RR of TB was 2.4 (95% CI 1.1–5.4) with corticosteroid use and 3.0 (95% CI 1.6–5.8) with nonbiologic DMARD use.

Conclusion

The age‐ and sex‐standardized incidence rate of TB in RA patients is 10 times that of the general population. At least some of this risk may be related to nonbiologic DMARD and corticosteroid therapies. Our data support the role of TB screening before initiation of any immunosuppressive therapy.     

Incidence of tuberculosis in Korean patients with rheumatoid arthritis (RA): effects of RA itself and of tumor necrosis factor blockers

OBJECTIVE: To elucidate the incidence rate and relative risk of tuberculosis (TB) in patients with rheumatoid arthritis (RA) and in patients with RA treated with tumor-necrosis-factor (TNF) blockers in Korea. METHODS: Using data from the Korean National Tuberculosis Association (KNTA) as a control and data from a single-center cohort of patients with RA, we conducted an evaluation of 1285 patients with RA not exposed to TNF blockers and reviewed medical records of 90 and 103 patients with RA treated with infliximab and etanercept, respectively, between 2001 and 2005. RESULTS: The mean incidence rate of TB, reported by the KNTA, was 67.2 per 100,000 person years (PY) from 2001 to 2004. In the TNF-blocker-na?ve RA cohort, 9 cases of TB developed during 3497 PY of followup (257 per 100,000). In the infliximab-treated RA group, 2 cases of TB developed during 78.17 PY of followup (2558 per 100,000 PY), and there was no case of TB during 73.67 PY of followup in the etanercept-treated RA group. The risk of TB was higher in RA patients not treated with TNF blockers (sex- and age-adjusted risk ratio 8.9; 95% confidence interval 4.6-17.2), and in those treated with infliximab (sex- and age-adjusted risk ratio, 30.1; 95% confidence interval, 7.4-122.3) compared with the general Korean population. CONCLUSION: The risk of TB infection is 8.9-fold higher in Korean patients with RA and 30.1-fold higher in RA patients treated with infliximab, compared with the general Korean population.     

Factors for the onset of and the exacerbation of tuberculosis. 6. Recent socio-medical characteristics of tuberculosis and their perspectives in Japan

In the late 1970s the decline of TB incidence rate has begun to slow down among both elderly population and younger one. This phenomenon mostly owed the reactivation of dormant M. tuberculosis infection among the elderly people and small TB outbreaks in the younger generation. The micro-epidemics among adolescent and young adults have been reported since 1980. The latest data showed the TB incidence in 1997 was 33.9 per 100,000 population, increased from 33.7 per 100,000 in 1996. To explain the situation above, several sociomedical factors were discussed as follow: (1) Age distribution of TB: The highest peak of newly registered TB patients shifted to the elder age cohorts and was the age group between 65 and 74 years in 1997, contrasting small peaks observed in 20-29 years age group remained unchanged. (2) Characteristics of infection route: Overall incidence rates of smear positive TB cases slightly increased in 1980s and leveled off thereafter. However, the number of smear positive cases among persons elder than 70 years old sharply increased, 1,779, 3,744, 5,728, in 1977, 1987 and 1997, respectively. Several papers showed that about one quarter of TB patients was diagnosed as TB while being treated for diseases other than TB. This may have contributed to the current TB infection. (3) Delay in case-finding: Patient's delay in symptomatic smear positive cases, especially among male patients in 30-54 age group, has been increased during last 10 years. This may also contribute to the current TB issue to the younger people. (4) TB problems in the cities: TB incidence rate in a certain area of some big cities was much higher than the other areas and the regional difference became magnificent due to serial socioeconomic problems of vulnerable population there. (5) Notification of TB: One study using mailed questionnaires showed that only 76 percent of medical doctors knew the TB notification system under the TB control law. It concluded that contact tracing would become more important issue in case-finding and the 100 percent of TB notification in medical institutions would be indispensable.     

Incidence of aplastic anemia in a defined subpopulation from Mexico City

Aplastic anemia (AA) is a hematological disease characterized by the deficient production of blood cells. The incidence of AA worldwide is low (1-5 new cases per 10(6) individuals per year). In contrast to other countries, no current reports exist on the incidence of this disorder in Mexico. In the present study, we have determined the incidence of AA in a defined subpopulation from Mexico City during the period 1996-2000. For the purpose of this study, we focused on the experience from a single medical institution: the Mexican Institute of Social Security (IMSS), which covers around 50% of Mexico's population. The incidence of AA was determined based on the actual number of patients diagnosed with this disease at the IMSS in Mexico City in a given year and the total number of individuals registered at the IMSS in Mexico City in the same year. Considering the IMSS population as a whole, the annual incidence of AA was 3.9 new cases per 10(6) individuals per year. In the pediatric population, the annual incidence was 4.2 new cases per 10(6) individuals per year, whereas in people 15-years-old and older the incidence was 3.8 new cases per 10(6) individuals per year. These incidences were higher than those reported in most studies from the USA, Europe and Israel. Compared to the incidence in Thailand, the incidence we observed in children was considerably higher, whereas the one in adults was similar to the one in that country. The results of the present study suggest that the incidence of AA in Mexico City is one of the highest worldwide, particularly in terms of the pediatric population; however, these results must be taken with caution since this study comprises only a subpopulation from Mexico City and not the entire population. Thus, further studies including a broader population, both in Mexico City and other urban and rural areas of this country, will be necessary in order to obtain better and more complete estimates of the actual incidence of AA in Mexico.     

Incidence and risk factors for pulmonary tuberculosis among the poor in the northern region of Poland

SETTING: The falling trends in pulmonary tuberculosis (PTB) incidence observed in European countries may be due both to an improving epidemiological situation and to a shift of tuberculosis (TB) towards socially important subpopulations; this trend may cause some TB cases to go unnoticed. Identification of such risk groups should be the basis for prevention programmes aimed at containing the spread of the disease. OBJECTIVE: To evaluate the incidence and risk factors for PTB among the poor. DESIGN: The study material was based on the data of 7380 people living in poverty, including 243 homeless adults, aged between 18 and 96 years. Potential medical and socio-economic risk factors were evaluated with regard to PTB incidence. RESULTS: The TB incidence rate in the group studied was estimated at 730 per 100,000 population. The main risk factor was homelessness, with a TB incidence rate in the homeless group of 4290/100,000. According to our data, socio-economic factors correlated much more closely with a final TB diagnosis than subjective disease symptoms. CONCLUSIONS: Efficient TB control requires prevention programmes aimed at systematic monitoring of the homeless. A population with such a high proportion of TB patients is a dangerous source of TB.     

Incidence rate of acute myocardial infarction in Hokkaido, Japan

A survey of acute myocardial infarctions (AMI) that occurred from October 1990 through September 1993 in Obihiro City, Hokkaido, was conducted. A total of 114 new cases of AMI was registered over the 3-year period. The incidence rate of AMI was 33.4 cases per 100,000 men per year and 137 cases per 100,000 women per year (total, 23.2 cases). The mean age at which AMI occurred was 11 years higher in women (71.1 +/- 9.4 years) than in men (60.0 +/- 11.8 years). In men, AMI was most common during the eighth decade of life, while in women the incidence of AMI increased after menopause. The ratio of cases of AMI to cases of stroke in the same period was 1:4.5. These results did not differ from the results of other surveys done over the same period in seven other area of Japan. To study risk factors for myocardial infarction, the data were grouped according to the results of medical examinations. Hypertension, diabetes, obesity and smoking were common among people with AMI. The incidence rate of hypercholesterolemia did not differ between those with AMI and those without, and only a relatively small number of people with AMI drank alcohol. Past reports have pointed out changes in the 'structure' of cardiovascular disease in Japan, which have accompanied changes in diet and lifestyle. This study has shows that aging hypertension, diabetes, obesity, and smoking are risk factors for myocardial infarction. Proper management, including early detection of these factors, will help to prevent of ischemic heart disease in Japan.     

Tuberculosis in California dialysis patients.

SETTING: Kaiser Permanente Northern California dialysis registry. OBJECTIVE: To examine the incidence of tuberculosis disease (TB) in a large, insured population of dialysis patients and to describe the disease characteristics and outcomes of these cases. DESIGN: Cohort study of all Kaiser patients who initiated dialysis between 1 January 1995 and 31 December 1999. TB incidence in our cohort between 1 January 1995 and 31 December 2000 was determined through electronic databases of out-patient diagnoses, laboratory results, and pharmacy records. The incidence of TB in the general population was determined from mandatory reporting of TB cases compiled by the California Department of Health Services. RESULTS: During the 6-year period of observation, 13 cases of TB occurred among 2806 dialysis initiators. The incidence of TB in the dialysis cohort was 134 per 100,000 person-years, compared to an incidence of 11.9/100,000 in the California population, yielding a relative risk of 11.3. Extra-pulmonary disease occurred in eight of 11 patients for whom site of disease was recorded. Five of 13 patients died within 3 months of TB diagnosis. CONCLUSIONS: The dialysis population is at high risk of TB. Physicians caring for dialysis patients must remain vigilant for signs of TB in this vulnerable population.     

Tuberculosis annual report 2010--(1) Summary of tuberculosis notification statistics in 2010

Annual reports of tuberculosis (TB) statistics in Japan have been compiled mainly from the database of the nationwide computerized tuberculosis surveillance system, which has been in operation since 1987. This system has been revised several times. The latest revision was conducted in 2007, and much new information was added. This summary of tuberculosis notification statistics is the first report of a new series for the Tuberculosis Annual Report 2010. The statistics are summarized as follows: The TB notification rate fell below 20 per 100,000 in 2007 and continued to decline, reaching 18.2 in 2010. However, there were still 23,261 TB patients newly notified in 2010. For sputum-smear positive pulmonary TB, the patient count was 9,019, with an incidence rate of 7.0 per 100,000 in 2010. Since June 2007, it has been compulsory to notify patients with latent TB infections (LTBI) requiring treatment; the number notified in 2010 was 4,930.