Tuberculosis annual report 2009--series 2. TB in foreigners

Statistics on tuberculosis (TB) in foreigners in Japan have been collected since 1998. The number of foreign TB patients increased from 739 in 1998 to 938 in 2009. In contrast, the number of Japanese TB patients decreased during this period. Hence, the proportion of foreigners among TB patients increased from 2.1% in 1998 to 4.0% in 2009, excluding those of unknown nationality. Especially, the proportion of foreigners among TB patients aged 20-29 years increased greatly from 9.1% in 1998 to 25.4% in 2009. Although the number of nationalities was 38, the majority of patients in 2009 were from China (28.4%), the Philippines (23.6%) and Korea (13.8%). The number of foreign TB patients aged 20-29 years was 427, accounting for 45.5% of all foreign TB patients in 2009. Eighty-one percent of foreign TB patients aged 20-29 years had developed TB within 5 years of entering Japan. The equivalent proportions in those aged 30-39 years and 40-49 years were 49% and 29%. Regarding occupation, 37.2% of foreign TB patients aged 20-29 years were students, 27.2% were full-time workers and 11.7% were part-time workers.     

Tuberculosis annual report 2009 --series 10. Treatment outcome and TB deaths

Evaluation of the treatment outcome by the cohort analysis method is an important part of tuberculosis (TB) control. In the Japanese TB surveillance system, the treatment outcome is automatically classified by computer according to a pre-set algorithm, so the treatment outcome is evaluated very rigidly. In the case of new sputum smear positive pulmonary TB cases (n = 8,999) newly notified in 2008, the patients' treatment outcomes based on the annual report 2009 database were as follows: "success," which combined "cured" and "completed," was 47.7%, "died" was 19.1%, "failed" was 1.1%, "defaulted" was 3.8%, "transferred out" was 2.8%, "on treatment after 12 months" was 11.8% and "not evaluated" was 13.6%. In addition to evaluation of the treatment outcome by the cohort method, the proportion of deaths was observed among all forms of TB patients (n = 24,571) who were newly registered in 2008. In total, 17.3% of all forms of TB cases died within one year after the beginning of treatment. The proportion corresponding to this was 23.7% for new sputum smear positive pulmonary TB and 23.5% for re-treatment sputum smear positive pulmonary TB. Among the new sputum smear positive pulmonary TB patients (n = 2,136) who died within one year after the beginning of treatment, 37.0% of them died within one month after the beginning of treatment, 51.6% died within two months and 61.9% died within three months.     

Tuberculosis annual report 2009--series 7. Condition of TB (2)

We report on the TB surveillance data for 2009 in Japan regarding HIV infection, diabetes, and drug susceptibility test results, which were added to the central TB surveillance database from 2007. In the present TB surveillance system, we cannot obtain reliable data about whether or not HIV tests were done in each case. Thus, we report only the number of TB patients diagnosed as having HIV infection. The number of newly notified TB cases reported as having HIV from 2007-2009 is 176. Of those, 155 (88.1%) were male and 21 (11.9%) were female, and 39 (22.2%) were foreigners. The frequency of TB-associated diabetes in newly notified TB cases in 2009 was 12.6% (3,043/24,170) in total, 14.5% in males, and 9.5% in females. Drug susceptibility test results were obtained in 6,920 culture-positive pulmonary TB cases through the surveillance system in 2009. This figure accounted for 63.5% of all culture-positive pulmonary cases. In primary cases, the frequencies of MDR, any INH resistance, and any RFP resistance were 0.5%, 4.4%, and 0.8%, respectively, and in re-treatment cases, they were 3.6%, 11.6%, and 5.0%, respectively. In primary pulmonary cases theses drug resistance rates have been stable over this 3-year period (2007-2009), but in pulmonary cases undergoing re-treatment, the frequency has decreased (for example, the MDR rate in re-treatment pulmonary cases was 7.2% in 2007, 5.1% in 2008, and 3.6% in 2009). Of all MDR pulmonary cases, 17.9% (10/56) were foreigners in 2009.     

Tuberculosis annual report 2009--series 8. Treatment of TB(1)

The standard treatment of tuberculosis (TB) is the key to its control. Here we report the statistics of treatment history and the initial regimen for treating TB in 2009. In 2009, 24,170 TB patients were newly notified. Of those, 1751 cases were reported as having had previous treatment and 410 cases were reported as having an unknown treatment history. The proportion of patients receiving retreatment was 7.4%, excluding those of unknown treatment history. The proportion of those receiving retreatment among newly notified TB patients increased with age from those at 20-24 years old (3.2%) to those at 80-84 years old (9.3%). The frequency of retreatment among newly notified TB patients might be partly an indicator of previous insufficient treatment. Regarding the year of previous treatment, the greatest number of cases reported having received previous treatment in 2008 (n=194). The total number of cases whose previous treatment had begun in 2008 or 2009 was 224, i.e. 12.8% of all retreatment cases in 2009. On the other hand, the number of cases having received previous treatment in the 1950s was also significant (n=219, 12.5%). As the initial treatment regimen, the combination of INH (isoniazid), RFP (rifampicin), PZA (pyrazinamide)+EB (ethambutol) or SM (streptomycin) is recommended by the Japanese Society for Tuberculosis. This regimen was initially used in 80.8% of all forms of TB patients aged 15-79 years old, excluding those cases whose treatment regimen was unknown. The data on duration of having actually received PZA was added to the central TB surveillance database starting in 2007. The number of cases who started TB treatment including PZA in 2008 was 15,146. Of those, 11,997 cases had completed TB treatment by the end of 2009, but 9.9% of them could not take PZA fully for 2 months.     

Tuberculosis annual report 2009--series 9. Treatment of TB (2)

The standard treatment for tuberculosis (TB) is the key to its control. Here, we report on the statistics of treatment status and the duration of hospitalization/treatment. The place of initial treatment was observed among newly notified TB patients (n = 24,170) in 2009. The proportion receiving treatment in hospital was highest (91.8%) in sputum smear-positive pulmonary TB patients (n = 9,675) including 2.3% hospitalized mainly due to other diseases. The proportion receiving treatment in hospital was the least (25.1%) among bacteriologically negative pulmonary TB cases, including 10.4 % hospitalized mainly due to other diseases. Among sputum smear-positive pulmonary TB cases the proportion of patients receiving treatment in hospital did not differ with age, but among bacteriologically negative pulmonary TB cases, this proportion differed markedly according to age group (e.g., 7.7% of those in their 20s, 24.4% of those in their 50s and 48.8% of those in their 80s). The duration of hospitalization for TB treatment among newly notified cases in 2008 was observed. The median hospitalization periods were 73 days, 78 days, 45 days, 36 days and 46 days, among new sputum smear-positive pulmonary TB cases, retreatment sputum smear-positive pulmonary TB cases, other bacillus-positive pulmonary TB cases, bacilli-negative pulmonary TB cases and extra-pulmonary TB cases, respectively. The duration of TB treatment among newly notified cases in 2008 was observed at the end of 2009. The median treatment duration among all forms of TB was 272 days. The longest median treatment duration was 286 days for retreatment of sputum smear-positive pulmonary TB cases and the shortest was 198 days for bacteriologically negative pulmonary TB cases.     

Tuberculosis annual report 2009 --Series 4. Elderly TB

In 2009 the tuberculosis (TB) incidence rates of the elderly population aged 65-74, 75-84 and 85 or older were 26.5, 63.4 and 98.1 per 100,000 in Japan, respectively. The TB incidence rate of those aged 65-79 showed a substantial decrease compared to 2000, with the rate decrease of those aged 85 or older being less pronounced. The proportion of TB cases aged 65 or older among all TB patients increased 1.6 times to 58.0% in 2009 from 36.8% in 1987; in particular, the proportion of those aged 80 or older increased 3.6 times to 28.8% from 7.9% in 1987. The proportion of elderly TB cases showed substantial differences between prefectures. The proportion of extra-pulmonary TB among elderly female TB patients aged 65-74 was 34.3% (22.4% for female TB patients aged 15-64). The proportion of bacillary TB among elderly pulmonary TB (PTB) patients was larger than that of young patients, but the proportion of cavitary PTB among elderly PTB patients was smaller than that of young PTB patients. The proportion of TB patients whose cases did not include respiratory symptoms increased with age. Among this group, the proportions of those aged 65-74, 75-84 and 85 or older were 15.9%, 21.3% and 22.7%, respectively. The elderly TB "patient's delay" was shorter than young TB "patient's delay", although the "doctor's delay" for elderly TB patients was longer than that for young TB patients. Most TB patients including elderly TB patients were detected upon their visit to a medical institution with some symptoms; in the case of elderly TB, more patients were detected as outpatients or inpatients for diseases other than TB. The prognosis of newly notified TB patients in 2008 was followed up until the end of 2009. Among TB patients aged 65 or older, 27.6% died within one year and 15.5% died within 3 months. The proportion of death showed a substantial increase with age; the increase was particularly accelerated among those aged 75 years or older.     

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.     

Tuberculosis Annual Report 2009--Series 6. Condition of TB (1)

The condition of tuberculosis (TB) at the time at which an individual is diagnosed with TB influences the patient's prognosis. This paper focuses on the condition of TB at the time of the diagnosis based on bacteriological status and X-ray findings. The proportion of bacteriologically confirmed cases among newly notified pulmonary TB patients increased greatly from 25.7% in 1979 to 82.7% in 2009. During this period, the proportion of far-advanced cavitary cases among pulmonary TB patients was around 2% and remained stable. This may mean that the diagnosis had come to be performed bacteriologically rather than radiologically. The proportion of bacteriologically confirmed cases among newly notified pulmonary TB patients in 2009 was studied by sex and 5-year age group. The proportion of bacteriologically confirmed cases increased with age in both male and female TB patients. In male TB patients, the proportion of cavitary cases increased in patients aged up to the end of the 50s and then decreased with age. This tendency was not observed in females. Although the proportion of cavitary cases among elderly TB patients was lower than among youths, the proportion having extensive lesions was greater than that among youths. The proportion of sputum-smear-positive cases with cavities among pulmonary TB patients aged 30-59 years was 32.9 % in male TB patients and 17.1% in female TB patients. According to occupation, this proportion was highest in "temporary workers" (52.6%) for male TB cases and "jobless/ others" (24.9%) for female TB cases, and lowest among "medical workers" in both sexes: 8.3% of male TB cases and 7.4% of female TB cases.     

Childhood Tuberculosis in the Kilimanjaro region: lessons from and for the TB Programme

Objective To determine the magnitude of childhood TB and treatment outcome in Kilimanjaro region. Methods Retrospective review of registration‐based data on TB notifications in Kilimanjaro region for the period 2002–2006. Results Between 2002 and 2006, there were 1615 patients of childhood TB in Kilimanjaro region constituting 13% of total TB burden and the average case detection rate was 147/100 000 for urban and 41.8/100 000 for rural populations. Of them, 54.2% were men and 75.2% had pulmonary TB (PTB); 24.9% were tested for acid‐fast bacilli (AFB) by Ziehl‐Neelsen staining showing that 5.8% of all patients with TB were AFB smear positive. The remaining 94.2% were presumptively treated for TB. Treatment success rate was 79.9%, mortality 10.9% and default rate was 7%. Unfavourable outcome was more common among unconfirmed TB patients. HIV testing was very rare but increased after 2004 (<2% before 2005, 11–16% afterwards.) Conclusion The rate of childhood TB in Kilimanjaro region is among the highest in the world. Microbiological diagnosis for TB and AFB smear positivity is very low. Treatment outcome in this region is poor. These findings argue for specific TB control strategies to be designed for children such as more AFB testing using new tools such as induced sputum and laryngeal swabs, active case finding, HIV testing of all suspected TB children, promoting and monitoring adherence. Regular epidemiological studies are also needed.     

Evaluation of accuracy of clinical diagnosis of TB by annual autopsy report

PURPOSE: To investigate the accuracy of clinical diagnosis of TB in Japan in recent years and to compare them with previous studies. METHOD: Data (sex, age, clinical diagnosis, pathological diagnosis as cause of death) on deceased cases clinically or pathologically diagnosed ante mortem as having tuberculosis was collected from annual reports of the pathological autopsy cases in 1984, 1989, 1994, and 1999-2004. Information on TB death from population statistics in those 9 years also was collected and compared with data of autopsied cases. RESULT: Autopsy rate in these years was stably around 10 %. Comparison of gender ratio and mean age between the two surveys showed similar numbers. During 1999-2004, 1725 death cases were diagnosed as TB clinically or pathologically. Number of pathologically proven pulmonary TB cases was 429 and that of miliary TB was 283. 55.7% of pulmonary tuberculosis and only 21.9% of miliary tuberculosis were correctly diagnosed before death. Out of 156 cases clinically diagnosed as non-TB diseases but proven as TB pathologically, 30.8% of clinical diagnosis was pneumonia and/or bronchitis, followed by diagnoses of interstitial pneumonia, respiratory failure, pneumoconiosis and lung cancer. However, the main clinical diagnoses of 175 miss-diagnosed miliary TB cases were diseases other than pulmonary diseases such as renal failure, malignant diseases and sepsis. CONCLUSION: In order to reduce undiagnosed pulmonary TB cases and to prevent nosocomial TB infection, differential diagnosis among pneumonia and/or bronchitis cases should be done. In case of miliary TB, not only pneumonia but also diseases other than pulmonary diseases such as renal failure, malignant diseases and sepsis should be included in the list differential diagnosis.     

GRAPPA Trainees Symposium 2009: a report from the GRAPPA 2009 annual meeting

At the 2009 annual meeting of GRAPPA (Group for Assessment of Psoriasis and Psoriatic Arthritis) in Stockholm, Sweden, 15 fellows involved in research in psoriatic disease were invited to present their work at a Trainees Symposium, which was also attended by members of the GRAPPA Faculty Committee. All of the fellows held poster sessions of their work and 4 of them gave oral presentations, including identification of soluble biomarkers for psoriatic arthritis (PsA), validation of minimal disease activity criteria for PsA, disease progression using the modified Sharp score, and discussion of a new composite disease activity score for PsA. Senior GRAPPA members also instructed the fellows on other composite scoring methods and on training videos and other GRAPPA projects to date. All of the posters and presentations from the Trainees Symposium are summarized herein.     

2007-2009年乐山市非结防机构网络报告肺结核转诊追踪分析

目的分析2007-2009年乐山市非结防机构网络报告肺结核患者转诊追踪情况,为有效推进结核病控制工作提供科学依据。方法对乐山市11个县(区、市)结核病控制工作月报表和新结核病信息管理系统数据进行分析。结果在2007-2009年间,全市非结防机构网报患者转诊到位率为55.79%,追踪率为96.74%,追踪到位率为84.22%,总体到位率为90.49%;追踪到位可疑患者中的55.13%被确诊为肺结核,其中涂阳、涂阴和未查痰患者的肺结核确诊率分别为96.30%,67.00%和53.21%。结论乐山市通过实施第四轮全球基金结核病二期项目,加强医疗机构和结防机构合作,通过提高患者报告、转诊和追踪等手段来加大患者发现力度,项目实施效果较显著。     

Childhood Tuberculosis Presenting with Haemophagocytic Syndrome

Haemophagocytic syndrome is a life threatening complication of systemic infection resulting from an exaggerated immune response to a triggering agent. Prompt recognition and treatment of this disorder can abrogate otherwise high fatality associated with this disorder. A 2 year old girl presented with acute enteritis, developed prolonged fever and organomegaly complicated by multi-organ failure. She fulfilled the diagnostic criteria for haemophagocytic lymphohistiocytosis including bone marrow evidence of haemophagocytosis. In addition she had serological evidence of tubercular infection as well as a positive family history of tuberculosis. She responded rapidly to immunosuppressive therapy and anti-tubercular therapy. Our case illustrates the association of haemophagocytic syndrome with tuberculosis as well as the favourable response obtained with prompt diagnosis and treatment.     

Tuberculosis Annual Report 2009--Series 5. case findings

The mode of detection, delays in detection, patient's occupation and so on were examined using the tuberculosis (TB) surveillance data from 2009. Of the 24,170 TB patients newly notified in 2009, 82.1% were detected at medical institutions. Of those, 11.4% were detected during hospitalization with a disease other than TB and 9.2% were detected as outpatients with a disease other than TB. On the other hand, a significant proportion of adolescents and young adults were also detected by active case findings (mass screening+contact examination). For example, 23.0% of TB patients aged 15-19 years were detected by periodic school mass screening, and 23.7% of TB patients aged 25-29 years were detected by periodic health examinations for employees. The proportion of TB patients detected by contact examination was only 2.6%; this figure was larger among younger TB patients. For example, 43.9% of those aged 0-14 years were detected by contact examinations. In terms of the symptoms of 18,912 pulmonary TB patients, 28.0% had only respiratory symptoms, 30.9% had both respiratory and other symptoms, and 16.1% had only nonrespiratory symptoms. The proportion of TB patients having only non-respiratory symptoms increased among the elderly. More than 20.0% of symptomatic pulmonary TB patients over 75 years had only non-respiratory symptoms. Regarding the delay of case detection among 14,511 symptomatic pulmonary TB patients, the patient's delay was shorter while the doctor's delay longer in the older age group, compared with the younger age group. Generally, sputum smear-positive symptomatic pulmonary TB patients showed longer total delays. The proportion and number of nurses/public health nurses among female patients of 20-59 years were 10.2% and 322, increasing slightly from 9.3% and 300, respectively, in 2008.     

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.     

Composite Measures in Psoriatic Arthritis: a report from the GRAPPA 2009 annual meeting

A composite measure is one way of incorporating an assessment of all relevant clinical outcomes into one single measure. By definition it incorporates several dimensions of disease status often by combining these different domains into a single score. Such instruments are well established in rheumatoid arthritis (RA), and these RA-specific measures have successfully been adopted for use in clinical trials involving patients with psoriatic arthritis (PsA). However, the need for a more PsA-specific composite measure has led to a number of proposals, which, for the large part, incorporate only peripheral articular disease activity. New indices that combine the diverse clinical manifestations of PsA are now under development. These issues were discussed at the 2009 annual meeting of GRAPPA (Group for Research and Assessment of Psoriasis and Psoriatic Arthritis) in Stockholm, Sweden, and are summarized here.