Title:
[Reconsideration of the admission and discharge criteria of tuberculosis patients in Japan].

Abstract:
Japanese Ministry of Health, Labour and Welfare issued new criteria for admission and discharge of tuberculosis patients in 2007. The criteria for admission are extended for the patients of the risk of Mycobacterium tuberculosis transmission and of the possible risk of treatment failure. The criteria for discharge are consisted of the 3 factors, (1) symptoms (cough, fever, etc.) are free after the standard chemotherapy of more than 2 weeks, (2) three different sputum smears are negative for acid-fast bacilli after the standard chemotherapy of more than 2 weeks, (3) patients are estimated to adhere to the chemotherapy after discharge and understand the infection control of M. tuberculosis. Although the criteria were simple, the goal was to treat tuberculosis patients successfully and improve treatment outcomes. For the effective operation of these criteria, the network of primary care facilities for early diagnosis and treatment after discharge, tuberculosis treatment facilities for hospitalization and local government including health care center is important. Four speakers proposed the problems and revealed their own resolutions. Three speakers from tuberculosis treatment facilities were positive for the shortening of hospitalization length by modifying the discharging criteria, however 1 speaker from the Tokyo Metropolitan Government emphasized that the regional medical system should be established for the treatment of discharged tuberculosis patient. 1. Reconsideration of admission and discharge criteria for tuberculosis patients: Kazunari TSUYUGUCHI (Department of Infectious Diseases, Clinical Research Center, National Hospital Organization Kinki-chuo Chest Medical Center) According to the present guideline in Japan, three consecutive negative sputum results for smear or culture are required for discharge of tuberculosis (TB) patients, making their duration of hospitalization extremely long. On the other hand, most of the TB ward in Japan consists of big rooms without air conditioning which carries a potential risk of nosocomial transmission and reinfection. In order to establish effective TB control, suspected or confirmed TB patient should be isolated in a single room equipped with the capacity for airborne infection isolation during hospitalization, as long as sputum smear or culture remains positive. It is reasonable to discharge patients to home before sputum conversion if effective chemotherapy is provided and all household members have been previously exposed. Rapid drug sensitivity testing will be helpful in assuring the effectiveness of chemotherapy for prompt discharge and detecting multidrug-resistance immediately. 2. Reconsideration of admission and discharge criteria for tuberculosis patient in Japan : Taku NAKAGAWA, Kenji OGAWA (Department of Pulmonary Medicine, National Hospital Organization Higashi Nagoya National Hospital) Admission criteria for tuberculosis patient are based on the positive result of sputum AFB smear test in principle. But admission criteria should be applied flexibly depending on the extent and severity of illness, socioeconomic background of the patient, and adherence to treatment in cooperation with the public health center. The Japanese Tuberculosis Society published "Guidelines for Admission and Discharge of Tuberculosis Patient" in January 2005. This guideline was consistent with the notice from Ministry of Health, Labour and Welfare. Improvement of management of patients with tuberculosis is most important, but bacteriological conversion is not necessary to release isolation from the hospital. The patients treated with standard regimen over two weeks and having improvement of clinical symptoms may be able to go home back in the absence of compromised person. As a result of putting this guideline into practice, there were no problems about infectiousness for tuberculosis. But the modified notice from Ministry of Health, Labour and Welfare based on bacteriological conversion was made public in September 2007. This modified notice brought in a prolonged period of hospitalization and created confusion in clinical practice. Based on the result of our study for infectiousness, it is appropriate to use the guideline in January 2005. 3. Consideration of the standard for leaving TB hospital: Masako WADA (Chemotherapy Research Institute, Kaken Hospital) In Japan, infectious pulmonary tuberculosis patients are ordered to receive chemotherapy in admission to tuberculosis treatment facilities according to Infectious Diseases Control Law. Infectious pulmonary tuberculosis is defined as sputum smear positive for acid-fast bacilli (AFB) even it is questionable. And there consecutive negative sputum smear for AFB is needed as a criteria for discharge. In this study we defined our own admission criteria as follows, medical service is needs owing to serious pulmonary tuberculosis, meningitis and other complications. We simulated the cost for hospitalization. During study period 170 patients were admitted and only 36 patients (21%) were needed hospitalization on our own criteria. The other 134 patients were admitted because of infectiousness. The average hospital stay was 63.0 days and 64.8 days, respectively. Total cost of patients cares were 26 million yen and 100 million yen respectively. On the points of saving medical costs, Infectious Diseases Control Law should be revised. 4. Recent problems in tuberculosis hospitalization and countermeasures related to patients support in urban area: Michihiko YOSHIDA (Infectious Control Section, Health and Safety Division, Bureau of Social Welfare and Public Health, Tokyo Metropolitan Govenment) Standard treatment for tuberculosis led to a shortening of hospitalization days. After discharge most patients are treated as outpatient. In the outpatient, the decreased numbers and the bias in the geographical distribution of tuberculosis hospitals impair patients' accessibility and may lead to increase of drop out cases. And there is possible poor adherence to treatment in such as foreign-born patients from high burden countries, so intensive intervention will,be needed for successful treatment. On the other hand, in the tuberculosis hospitals, there are noninfectious tuberculosis patients with chronic complications such as psychiatric disorders and dialysis. In most cases, these patients cannot be transferred to other hospitals or welfare facilities. To resolve these problems, it is necessary to build community DOTS system including the public health centers, tuberculosis hospitals and related community resources such as clinics and welfare facilities. Also, in the near future, it is necessary to review and rebuild tuberculosis medical system comprehensively at the national level.