日本における結核対策の問題点

Tuberculosis is the most prevalent infectious disease in the world. It occurs globally but predominantly in developing countries where the standard of living is lagging behind the industrialized nations. In Japan, tuberculosis was once the leading cause of death. With the advent of medical sciences and the improved economic condition, the incidence of tuberculosis in Japan started to decline after the World War II continuing until early 1970 s. It was estimated that tuberculosis would become a disease of the past not in the far distant future. However, this optimistic prediction was proved to be wrong. The continued decline of tuberculosis cases in Japan was eventually replaced by increase in 1997. The subsequent yearly increase of the disease prompted the government to declare the state of emergency in the epidemic of tuberculosis. Clearly, the past policies and efforts to eliminate tuberculosis have not been successful leaving tuberculosis largely uncontrolled in Japan. It is hard to imagine that, despite a huge budget allocated to the tuberculosis elimination activities, the incidence rate in Japan still remains close to those of developing countries. The aims of this article are to describe and discuss the technical and administrative elements impeding the progress of the tuberculosis elimination movement in Japan. Many aspects of this article is based on the extensive personal experiences gained during visits to many medical care facilities, clinical laboratories and professional society meetings both in Japan and in the United States. It is also based on the candid discussion with professionals engaging in tuberculosis control activities at grass root levels. The first and foremost problem blocking the progress of the effective anti-tuberculosis efforts in Japan is the lack of strong leadership by the government. There are no officially published aims or guidelines for tuberculosis elimination programs. The priority of the tuberculosis elimination effort is unclear. Often, the government is not directly involved in the tuberculosis elimination activities assigning its responsibilities to private or semi-government agencies having no authorities to enforce key rules and regulations. The diagnostic technologies currently employed by many clinical laboratories for the diagnosis of tuberculosis is obsolete and outdated. Liquid culture systems now considered globally as gold standard have not been widely used in Japan. Although it is partly due to the lack of new knowledge on the part of laboratory technicians, the main reason for not exploiting the merit of the globally tested and proved technologies is the unreasonably low reimbursement for the test from Japanese health care insurance system. For detecting tubercle bacilli in test specimens, most laboratories use the direct rather than concentrated method. Because of the low sensitivity of the old tests, some active tuberculosis cases are feared undetected resulting in exposing the unsuspecting public to the risk of infection. It must be also pointed out that many clinical laboratories sacrifice their safety for reducing operative cost. The tuberculosis infection rate in the clinical laboratories is unacceptably high. Misdiagnosis and delay in diagnosis by physicians due to negligence, ignorance, and outdated technologies contribute to the continued failure to eliminate infection source from the Japanese society. A considerable numbers of diagnosed tuberculosis cases are not reported to the authority as required by the anti-tuberculosis law, rendering contact tracing activities and data gathering efforts difficult. It is clear from a recent government survey that considerable numbers of diagnosed tuberculosis cases are not treated by the approved standard regimens. Treatment is often initiated without susceptibility testing. DOTS (directly observed therapy short course) has just began to be practiced in selected areas of Japan. Last but not least, the effective progress of the tuberculosis elimination programs is severely hindered by the use of funds on the basis of misplaced priority. The allocation of budget does not seem to be made wisely based on the evidence-based data and real needs. Rather, funds are being spent on a variety of programs already outdated or proved ineffective. Such examples include yearly screening and BCG inoculation stipulated by the anti-tuberculosis law set about a half century ago. The need for change of the law is acute and is widely supported by experts in and out of the country. However, such a move to change the anti-tuberculosis law has met fierce resistance by bureaucratic and misguided professional. It is believed that all factors mentioned above synergistically contribute to the frustratingly slow progress of the tuberculosis elimination movement in Japan. What Japan needs now for the elimination of tuberculosis is not money, human resource, or knowledge. What they need are willingness, determination and courage to do right things rather than sticking to old customs and outdated practice. For this, strong and forceful leadership by the government is absolutely essential. Like defending the country, fighting against tuberculosis is the responsibility of the government.