A NEW APPROACH TO CASE MANAGEMENT IN TUBERCULOSIS CONTROL

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Since the establishment of the tuberculosis registration system in early 1960's, only slight changes have been given to the system of the case management that is principally based on the ideas from the early chemotherapy era. Therefore it is considered as an urgent matter to revise it to well conform to the recent situation with modern philosophy of tuberculosis control, especially with the powerful short course chemotherapy. In the symposium, five reports were presented by experts in public health or in clinical service, and discussions were held from wide viewpoint, which are summarised as follows: 1) Relapse after completion of chemotherapy was observed by Ueda and Higa in the routine service in Osaka and in Okinawa, respectively. About 4-5% of relapse rate during the first three years' follow-up period was seen in their study, in which bacteriologically confirmed relapses occupied 20-50% out of all. Sugita reported a lower rate of 1.5% as a relapse rate from the experience of a tuberculosis hospital's routine service. In Okinawa the follow-up X-ray examination of the inactive cases detected only 20% of the whole relapses, while others were detected by the clinical service for the symtomatics. Cases having some particular characteristics were found to run a higher risk of relapse and these included male sex, the aged, initial positive bacteriology, initial presence of cavity, and presence of known risk factors. The follow-up examination was considered to have rather limited value for the efficient detection of relapses and its efforts should be concentrated on these special risk groups. Also the diagnostic standard of "relapse" should be reviewed more strictly so as rely not too much on X-ray findings. 2) Fujioka made close observations of the deaths and occurrences of chronic excretors among newly registered cases and of the incidence of tuberculosis or infections among contacts. He found that the initially smear positive cases had the poorest prognosis in terms of deaths and treatment failures, and he also confiremed that the contacts of the smear positive cases had the highest probability to develop the disease and to get infected. Current system of "Activity Classification" where either bacillary-positive on smear and/or culture-or cavitary cases grouped under the same category "infectious" should be altered so as to give greater importance to smear positive cases and to chronic exretors from a view point of infection-source control. 3) Some prefectures have their own standards for the indication of chemoprophylaxis as were reported by Higa and Ueda, but medical characteristics of subjects for chemoprophylaxis were shown to vary quite widely. Several cases, though very small in rate, have developed among those having completed prescribed chemoprophylaxis, and almost all of them were from contacts of heavily positive sources of infection. Special emphasis should be put on the chemoprophylaxis cases from contacts-convertors, separately from those diagnosed on mass basis without definite contact 4) In Japan medically prescribed restriction on daily life and on working condition is still considerable, depriving an average of 122 working days, hospitalizing about sixty percent of newly detected cases (including non-infectious ones) and confining them on the average for 5.4 months to hospital or home beds during the first year, as was revealed by Nobutomo's study. Unequality produced by this classical practice supported by "Standards for guiding daily life and work in tuberculosis cases" among areas and medical institutions was also noted.
一般社団法人日本結核病学会の論文

著者

森亨
結核予防会結核研究所

A NEW APPROACH TO CASE MANAGEMENT IN TUBERCULOSIS CONTROL

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