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BACKGROUND AND OBJECTIVE: A directly observed treatment short course (DOTS) trial was launched in Japan in the late 1990s and targeted patients with social depression at urban areas. Based on these findings, the Ministry of Health, Labour and Welfare established the Japanese DOTS Strategy in 2003, which is a comprehensive support service ensuring the adherence of tuberculosis patients to drug administration. DOTS services are initially provided at the hospital to patients with infectious tuberculosis who are hospitalized according to the Infectious Diseases Control Law. After being discharged from the hospital, the patients are referred to a public health center. However, a survey conducted in 2008 indicated that all the patients do not receive appropriate DOTS services at some hospitals. In the present study, we aimed to evaluate the protocols and workload of DOTS at hospitals that are actively involved in tuberculosis medical practice, including DOTS, to assess whether the hospital DOTS services were adequate. METHOD: We reviewed a series of articles on hospital DOTS from a Japanese journal on nursing for tuberculosis patients and identified 25 activities regarding the hospital DOTS service. These 25 items were then classified into 3 categories: health education to patients, support for adherence, and coordination with the health center. In total, 20 hospitals that had > 20 authorized tuberculosis beds were selected--while considering the geographical balance, schedule of this survey, etc.--from 33 hospitals where an ex-trainee of the tuberculosis control expert training program in the Research Institute of Tuberculosis (RIT) was working and 20 hospitals that had collaborated with our previous survey on tuberculosis medical facilities. All the staff associated with the DOTS service were asked to record the total working time as well as the time spent for each activity. The data were collected and analyzed at the RIT. RESULT: The working times for each activity of the DOTS service for nurses, pharmacists, ward clerks, head nurses, and doctors were 100, 90, 87, 86, and 63 min, respectively. For other professions, including medical social workers, nursing aids, nutritionists, and physical therapists, the working times for each activity of the DOTS service were 31, 18, 10, and 8 min, respectively. The professionals who spent a longer time on health education, support for patient adherence, and coordination with the health center were pharmacists, doctors, and head nurses; nurses, pharmacists, and doctors; and head nurses, doctors, and ward clerks, respectively. DISCUSSION: Aging of tuberculosis patients was associated with problems on adherence in many patients, including patients who were not suited for a standard regimen, patients whose activity of daily life had deteriorated due to senile dementia, patients with diabetes mellitus, etc. Smoking cessation and mental care for cases of multi-drug resistant disease are new challenges in tuberculosis patient care. The present study clearly indicated that activities including patient education, support for patient adherence, and coordination with the health center--essential components of the hospital DOTS service according to the Japanese DOTS Strategy--were performed by a team of professionals including doctors, nurses, pharmacists, medical social workers, etc., depending on the features and roles that they serve and the needs of each patient. For good practice of hospital DOTS, it is essential to not only provide DOTS, but also effectively provide individual or group health education and coordinate with health centers, thus aiming towards a better community DOTS service after patient discharge.

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PURPOSE: On the basis of actual field data, we investigated the importance of monitoring the drug dosage and treatment duration for the supportive care of patients with tuberculosis who were being treated at public health centers. PATIENTS & METHODS: Data of the drug dosage of principal anti-tuberculosis drugs and the treatment duration for the registered patients with tuberculosis at the Shinjuku-ku Public Health Center were analyzed. RESULTS: The actual dosage of rifampicin and isoniazid according to the "recommended" dosage was administered to 57.3% (67/117) and 82.0% (114/139), respectively, patients with tuberculosis registered at the Shinjuku-ku Public Health Center. In contrast, in patients with tuberculosis who were treated at a highly specialized tuberculosis hospital, the rates were 81.0% (98/121) and 93.5% (86/92), respectively; for both drugs, the rates were significantly higher in this hospital than in the Shinjuku-ku Public Health Center. For the treatment duration, of 92 patients registered at the Shinjuku-ku Public Health Center who could have completed standard treatment in the standard duration, the actual treatment durations were shorter than the standard duration in 15.2% of the patients (14/92; -32 to -1 days), and longer than the standard duration in 77.2% (71/92; 2 to 146 days); the total superfluous treatment days for the latter 71 patients were 1,877 days. The treatment durations were more than 2 weeks shorter or longer than the standard duration for 31 patients, and in 71.0% (22/31) of these patients, no specific reason could be determined as to why the treatment durations were not standard. CONCLUSION: In a significant number of patients, the drug dosage and treatment duration were not according to the standard values. By using this data about the management of the drug dosage and treatment duration for the supportive care of patients with tuberculosis treated at public health centers, we may improve quality of the provided supportive care.

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PURPOSE: To clarify the situation and suitability of tuberculosis wards for in-hospital tuberculosis care, with a view toward establishing a national standard for tuberculosis wards. METHODS: Data were obtained by sending questionnaires to all 321 tuberculosis wards in Japan. RESULTS: Of the hospitals to which questionnaires were sent, 69.3% returned their responses. In most of these hospitals, the total number of beds in one tuberculosis ward was either less than 20 or more than 40. In approximately two-thirds of the hospitals, tuberculosis wards were incorporated into another (non-tuberculosis) ward. In more than 70% of the hospitals, the mean hospital stay of tuberculosis patients exceeded 40 days. This relatively long hospital stay implies that amenities are a very important issue in tuberculosis wards; however, amenities were generally far from sufficient in most of the hospitals. Of all the tuberculosis beds, 18.2% were in single-occupant rooms and 19.4% had a sufficient floor area (more than 15 m2). Beds in single-occupant rooms with sufficient floor area, equipped with a toilet, bath or shower, washstand, negative-pressure control, and HEPA filter in an air exhaust duct, comprised 2.4% of all tuberculosis beds. CONCLUSION: In spite of the relatively long hospital stays, amenities were generally less than adequate. The conditions in most tuberculosis wards were far below the presumptive recommended standards. When national standards for tuberculosis wards are established, these findings should be taken into consideration.

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PURPOSE: To investigate the possibility of employing in-hospital care for tuberculosis (TB) patients in beds meant for patients with Class 2 infectious diseases and determine the obstacles facing the same. SUBJECTS & METHODS: We conducted a questionnaire survey of all 225 hospitals that had beds meant for patients with Class 2 infectious disease but did not have tuberculosis wards. RESULT: Responses were obtained from 83.1% of the targeted hospitals. Around 60% of the hospitals had used these beds for patients other than those with Class 2 infectious disease (including TB patients). Around 50% and 30% of the hospitals had used these beds for suspected TB patients to ensure hospital infection control, and for treatment of patients diagnosed with TB, respectively. In response to the question on how they would use these hospital beds for TB or suspected TB patients if the regulations allowed such use, around 60% of the hospitals answered that the beds will be used for suspected TB patients until their diagnosis was confirmed, and 25% of the hospitals responded that they will never use their beds for TB patients. Only 10% of the hospitals answered that the beds will be used for in-hospital care of TB patients. With regard to the reasons why the beds cannot be easily used for in-hospital care of TB patients, several issues were pointed out, such as difficulty in appointing sufficient staff for care of TB patients, and a lack of doctors who had sufficient experience in TB medicine. However, there was no single predominant reason. CONCLUSION: To ensure that hospital beds for patients with Class 2 infectious diseases are utilized for in-hospital TB care, we need a flexible policy, which is suited to the specific conditions in each community and hospital.

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