Important individual data of each patient are being input at each health centre, data analysis can be done at health centre or local government if it is needed, but precise analysis is being carried out at the Research Institute of Tbc, JATA.
"Lesson from Japanese experience "
All these four points, they are "integration", "vertical organization", "charge free medication and hospitalization" and "surveillance system" are very important and effective policies if they work as they are expected. For example, it is rather difficult to keep the level of diagnosis and treatment high because of so many institutions, if the programme is integrated into all the existing medical facilities including private sector. To keep the technical level high, advisory committee is organized at each health centre, and committee is opened every two weeks, but the improvement of the problems such as too long treatment, too long hospitalization, too much relying upon X-ray diagnosis and so on, did not achieved so rapidly, or still are unsolved even now. Repeated training and regular evaluation are essential to keep the technical level high.
4. BCG vaccination
Mass BCG vaccination programme has been started in 1942 as can be seen in Fig. 2. BCG vaccination is being given for infants (3 month-<4 years), 1st grade children of primary school (6 years old),and 1st grade children of middle school (12 years old ). Percutaneous multi-puncture method using 80mg/ml BCG suspension is being used to reduce the local side effect in Japan. BCG coverage was 95.7% for infants, 58.6% for school entrance children, and 32.2% for 1st grade children of middle school in 1997. Cessation of re-vaccination for school children is under discussion, now.
"Lesson from Japanese experience"
Incidence of side effect by BCG vaccination is low by multipuncture method. But, it is difficult to give vaccination homogeneous and satisfactory so that this method is not recommended. The effect of re-vaccination is being doubted by WHO and IUATLD and so on. Therefor, it is not recommended to your country.
5. Case-finding
X-ray apparatus for Mass Miniature Radiophotography (MMR) has been developed by Japanese doctor, Prof. Koga in 1986. Active case-finding by MMR has been started in 1951 as shown in Fig 3. At present, all the people aged 19 years or more are to be examined annually by X-ray. Theee X-ray films are used for the early detection of the lung cancer at the same time, too, if the age of the examinee is 40 years old or more. In 1996, total number of examinees was 55 millions, about 63% of the eligible people (Fig 3 shows the number of examinees of general inhabitans, excluding the number of examinees of employees). However, the detection rate of tbc. has become so low (less than 0.02%), and active case-finding detects less than 15% of the newly registered cases, that some policy change is to be necessary. "
"Lesson from Japaneee experience"
As WHO has stated clearly long ago the fact that active case-finding using MMR is very expensive even if the incidence is high, can detect only less than 15% of newly registered smear positive cases, has to employ many doctors and X-ray technicians and so on, active case-finding using MMR should never carry out in the future, too.
6. Contact survey
Health centre has the responsibility to carry out the contact survey of the newly registered cases. Tuberculin convertors and/or suspects of the recent infected are to be given chemoprophylaxis with INH for 6 months. As a total, 5,506 infants, children and/or young adults less than 30 years of age were given preventive treatment in 1998.
"Lesson from Japanese experience"
The detection rate of new patients by contact survey is rather high, and preventive treatment for the recent infected is effective, so that it is recommended to do contact survey if possible. But the biggest difficulty in contact survey in Japan is to differentiate the person infected with tubercle bacilli and BCG vaccinated in the country where BCG vaccination coverage is high.
7. Treatment
The standard regimens of chemotherapy for initial treatment cases are as follows;
2HRZE(or S)/4HR(E)
6HRE(or S)/3-6HR
6-9 HR
For re-treatment cases, chemotherapeutic regimen is to be decided by the results of the sensitivity test, so that no standard regimen is being recommended.
Infectious cases are usually treated in hospital (Fig 4). More than 90% of the newly registered smear positive cases are hospitalized for 2〜3 months or more. At the end of 1998, 11,482 tbc. cases were being treated in hospital.
"Lesson from Japanese experience"
The rate of hospitalization is so high, and the duration of hospitalization is so long that Japan is spending huge amount of budget for hospital treatment.
