WORLD HEALTH ORGANIZATION Regional Off•~• far the Western Pacific
Fl NAL IE PORli OH THE WHO/JAPAN TUBERCULOSIS COURSE To~yo, Japa ft t970
\'1PRO
0125-E
11 Jvlay 1971
ENGLISH ONLY
FINAL REPORT ON THE
WHO/JAPAN '!U:EERCULOSIS COURSE
Tokyo, Japan 1970
by
Dr. T. Iv1asaki Course Director
.
Manila, Philippines World Health Organization Regional Office for the Western Pacific
WPR/210/71
TABLE OF CONTENTS 1. OBJEariVE OF 'I'!m Ca.JRS.E ••••••••••••••••.•••••••.•••••••• • • ORGANIZATION ••••••••.••••••••••••••••••••••••••••••• • ••• • • TEAC~G
1 1
2.
3.
PROGRAr:Jr.1E ........................................ .
2 2 2
. 4. 5.
3.1 3.2 3·3 3.4 3.5 3.6
General concept on tuberculosis •••••••••••••••••••••• Diagnosis and case-finding ••.•.•••••••.•••••••...•.•. Prevention of tuberculosis .......................... . Treatment .............•.•....••..••......•..•....•..•
Tuberculosis control Field visits and demonstrations
CLOSING CEREr·10NY
................................. ...................... .......................................... .....................................
3 3 3 4 4
EVA!l.JATION OF THE lg[O COURSE •••••••••••••••••••••••.•••••
5/6
ANNEXES: 1 2
LIST OF PARTICIPANTS
SCHEDULE OF T\·10-HEEK POST-COURSE FIELD TRIP LIST OF RESOURCE PERSONNEL
3 4
5
............................... SCHr.IDULE OF COURSES ...................................... SUNloiARY OF EVAWATION .....................................
..............
7 9
ll
15 35
1.
OBJECTIVE OF THE COURSE
The general objectives of the course were to give training in the modern methods and techniques of tuberculosis control, and to PI'ePare the participants for their future worlt in the effective application of control measures on a mass scale under the local, technical and socio-economic conditions in their own countries, The specific objectives were to acquaint the participants with the following subjects: (a) (b) (c) (d) the epidemiological approach to the problem; prevention of tuberculosis; detection of infectious sources in the community; methods of reducing transmission through efficient and economical neutralization of infectious sources on a nationwide basis; planning, organization, execution and evaluation of a national tuberculosis programme in countries w1 th different epidemiological and socio-economic conditions.
(e)
2.
ORGANIZATION
This course, which was held from 25 Nay to 6 October 1970, was organized by the r'linistry of Health and \'Jelfare, Japanese Government, w1 th the assistance of the viorld Health Organization (HHO). It was conducted in the lecture and practice rooms of the Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association (JATA), Tokyo. Dr T. Il'lasaki, Director of the Institute. was concurrently the Director of the Course. Eight participants came from the Western Pacific Region, seven from the South-East Asia Region, two from the East r1edi terrane an Region and one joined from the European Region (see Annex 1). The course in Japan was financed by the Japanese Government under the Colombo Plan and the deviation trip for two weeks to observe the tuberculosis control programme in neighbouring countries uas arranged and financed by vmo (see Annex 2). The facilities of the library were raade available to all participants. Accommodation was provided at a low charge in a dormitory on the compound of the Institute. During the nine-day field trip to the Tohoku District and the seven-day field trip to the Kansai District, the participants travelled by train to the main stations and then moved from one place to another by car. Transport was provided either by the prefectural government or by the branch association of JATA.
... !
./
The staff of the Z.linistry of Health and \'ielfare, the National Institute of Health, the Research Institute of Tuberculosis and other institutions of JATA constituted the main resource personnel. WHO provided four staff members and four temporary advisers who participated in the teaching programme (see Annex 3).
• - 2 Addresses were given during the opening session by Dr H. Takemura, Tuberculosis Prevention Section, Public Health B.lreau, I•tl.nistry of Health and Welfare, as the representative of the f·linistry; Dr H. Beringer, Leader of the \'JHO Regional Tuberculosis Advisory Team, as representative of WHO; Mr T. Sugiyama, Acting Chief, First Training Section, Internal Operations Division, Overseas Technical Cooperation Agency (OTCA); and Dr T. Iv;asaki, the Course Director. Dr Recep Cengiz Yalcin (Turkey) spoke as the representative of the participants. •
3.
TEACHING PROGRANfi!E
The outline of the teaching programme had been thorougly discussed long before the commencement of the course by the staff of the Research Institute of Tuberculosis, JATA, and the WHO Regional Adviser on Tuberculosis, \'IPRO, taking into consideration of the evaluation reports of the participants in the last course. Recommendations contained in the Eighth Report of the 1 WHO Expert Committee on Tuberculosis were generally followed. The weekly schedule which is attached as Annex 4, was distributed to the participants a week in advance. Teaching took place from I'londay through Friday each week. Saturdays were reserved for library reference work, individual discussions or consultations with the resource personnel. Classes were from 9.00 A.fvl. to 12.00 Noon and from 1.30 P.H. to 4.00 P.rl!.; each session had a fifteen-minute break. Discussions took place in the latter part of the day after the lectures and practical sessions had been finished. Reference materials, including many reprints of WHO publications on tuberculosis, were usually distributed before a special subject was introduced for discussion. The subjects taken up in the course were broadly as follows: 3.1 General concept on tuberculosis As the participants' general knowledge varied considerably, a series of lectures on pathogenesis, patho-clinical manifestations of the disease, etc. were given at the beginning of the course. The reference cited were always related to the prevention, case-finding and treatment of the disease. 3.2 Diagnosis and case-finding The HHO Expert Committee on Tuberculosis in its eighth report recommended that, from the epidemiological point of view, a "case" of pulmonary tuberculosis means a person suffering from bacteriologically confirmed disease. The bacteriology of mycobacteria was, therefore, given particular emphasis. Direct microscopic and fluorescent nucroscopic examination of sputum, and culture of tubercle bacilli in a centralized laboratory
..
1
•
Hld Hlth Org. tech. Rep. Ser., (1964), 290.
- 3 were taught through lectures and demonstrations. Topics on the classification and identification of mycobacteria# etc., were discussed in the same wey. The other method of diagnosis and case-finding using X-ray was also considered. The results of the co-operative study recently sponsored by the International Union Against Tuberculosis on the accuracy of radiophotographic diagnosis of pulmonary tuberculosis were presented in detail. Diagnosis and case-finding by the above-mentioned two methods in national tuberculosis control programmes were alweys compared from the financial and practical standpoints. ' · ' Prevention of tuberculosis In this part, the role of tuberculin testing and the importance of ECG vaccination were discussed. The techniques were practised in the field. The other preventive method# chemoprophylaxis, Nhich is difficult to apply on a large scale in the community as a tuberculosis control programme was briefly introduced, The preparation and standardization of tuberculin, techniques of tuberculin testing and the role of tuberculin testing in a tuberculosis control programme were considered. During the practice of testing and reading, an opportunity was taken to compare and adJust the individual reading of the tests w1 th those of the WHO regional tuberculin standard reader. The production and standardization of B::G vaccine; the protective efficacy of ECG vaccines; techniques of ECG vaccination, including vaccination without preliminary testing and that given simultaneously with other vaccinations; the side-effects of vaccination, and the role of ECG vaccination in a tuberculosis control programme in developing countries were thOroughly discussed.
~
•
3.4 Treatment The treatment of pulmonary tuberculosis was introduced by emphasizing the need for a policy on chemotherapy taking into consideration the epidemiological and financial points of view. The characteristics of various antituberculosis drugs, such as their biological background, therapeutic effectiveness. to.xici ty and cost, were considered in detail. The results of the controlled clinical investigations were presented. Institutional and domiciliary treatment of pulmonary tuberculosis was compared from the clinical, epidemiological and financial standpoints. A discussion took place on the rate of relapses after chemotherapy. Self-administration or supervised administration of drugs and the defaulting rate were also considered, Information was also provided on the failure of primary chemotherapy, drug-resistance and drug-resistance surveys.
•
3.5 Tuberculosis control In view of the importance of a fundamental understanding of statistics and epidemiology, sufficient time was given to these two items. Lectures were given on the basic principles in statistics, such as morbidity. mortality and case registration, etc. Statistics relating to tuberculin testing, ECG vaccination, case-finding and treatment in the tuberculosis programme were discUssed. Practice ~ras obtained, using raw sampl.es and data, on the use of calculating machines and slide rules. Epidemiology, methodology and epistemology in connection with tuberculosis were considered. Following the introduction, epidemiological analysis based on the data available in Japan was practised.
~
~
- 4• Planning of a national tuberculosis control programme in developing countries was discussed from the standpoint of socio-economic factors and its implementation on a nationwide scale, with an integrated public health approach based on accurate epidemiological data.
In an open forum, each participant presented an outline of the national tuberculosis control programme in his own country and discussed it ;d th the resource personnel and the lecturer. The need for determining priorities in the selection of methods for the planning and operation of a national tuberculosis programme was particularly emphasized by the lecturers from WHO. Group discussions were held rather frequently between participants and the teaching staff using as reference material the WHO publications distributed by WHO.
3.6 Field visits and demonstrations The primary schools in Hanno and Tokorozawa cities were selected for the demonstration and practice of WHO-recommended techniques of tuberculin testing. Nine days were spent on visits to Niigata where the Maki Health Centre is serving as a demonstration area of the course, Aid ta and Aomori in the Tohoku District. The geographical and socio-economic conditions, epidemiological situation and the tuberculosis control programmes of these prefectures were observed and discussed. The activities of the organization in Akita prefecture were very impressive. Seven days were also spent in Osaka and Kyoto prefectures in the Kansai District. Seven health centres, the Tuberculosis and Chest Disease Research Institute of the National Kyoto University, and a few dispensaries of the prefecture branches of JATA were visited. In addition, the follo;dng institutes, clinics and factories were visited: (a) (b) (c) (d) (e) (f) (g) National Institute of Health (Tuberculosis Department), l!Jinistry of Health and VJelfare (Division of Statistics), Koishikawa Health Centre and !1usashichofu Health Centre, Tokyo Metropolitan Children's Hospital, Japan Anti-Tuberculosis Association (JATA), Meiji Seika Company, Ltd. (Anti-biotic drugs), Shimazu Company,Ltd. (X-ray apparatus). 4. CLOSING CEREMONY
..
The closing ceremony took place at 14oo hours on 6 October 1970 at the Research Institute of Tuberculosis, JATA, Tokyo. Statements were made by Mr. T. Kuroda, Chief of Training Co-ordinators Division, Internal Operations Department, Overseas Technical Cooperation Agency; Dr. H. Takemura, representative of the Ministry of Health and Welfare; Dr. J .c. Tao, Regional Adviser on Tuberculosis, \VHO/WPRO; and Dr. T. Iwasaki, the Director of the Course. Dr. Mir Haider Hessami (Afghanistan) responded on behalf of the participants.
- 5/6 -
5. EVALUATION OF THE COURSE Eighteen participants from ten countries completed a questionnaire distributed to them at the end of the course. Their replies were used to assess the administrative and teclu1ical aspects of the course. Favourable responses on technical aspects of the course were obtained from 78.9% of the replies; 7. 8% were unfavourable. Half of the replies commented favourably on the administrative aspects, while about 48% of the replies gave a less favourable rating. Twelve of the eighteen participants stated that some changes would be made in their own programmes as a result of their attendance at the course. l'.nnox 5-a contains a list of tho lectures. discussions and field visits considered most useful. The suggestions of the participants on the i terns in the curriculum to be extended, shortened or omitted and other i terns to be included are contained in Annex 5-b. Other remarks on the training course are given in Annex 5-c •
•
•
- 7 ANNEX 1
LIST OF PARTICIPANTS Country of origin Dr l>lir Haider Hessami Afghanistan Current position Director Tuberculosis Centre Kabul Chief Resident of Surgery Chung Hsing Hospital Taipei Visiting staff Taiwan Provincial Tuberculosis Control B.!reau Taipei Tuberculosis Contl•ol Centre Bandung Assistant Director Tuberculosis Centre Provincial Heal til Department Djakarta Assistant Director (TB) Directorate General CDC Ministzr.r of Health Djakarta Deputy Director Anti-tuberculosis Center Rasht In-charge. TB \'lard No. 5 Bou-Ali Hospital Teheran Director, Health Centre Taejon City Director, Suchon Health Centre Suchon Gun, Chungchong Namdo Provincial Government Supervisional Medical Officer Cheju Provincial Government Chest Physician General Hospital Malacca
Dr Ya-Hsiung Hsu
China (Taiwan)
Dr Yung-Tung Wu
China (Taiwan)
Dr Theod.oor Bernard Haworuntu Dr Raden Ha.dj i Su 'dan
Indonesia Indonesia
Dr Djajadi Tjinda
Indonesia
Dr Mohammad Java.d Baghai
Iran
• Dr Lotfollah Raissi Dehkordi Iran
Dr Jae-Won Kim Dr Kung-Ne Rho
Republic of Korea Republic of Korea
Dr
Yong-Sup Ro
Republic of Korea Malaysia
!
Dr Vallipuram Meyhandan
- 8 Annex l (cont'd)
• List of Participants (continued) Country of origin Philippines Current position r1edical Specialist Jose Reyes r.lemorial Hospital Department of Health Hanila Senior Resident Physician Quezon Institute (Philippine Ttlberculosis Society, Inc.) Quezon City Senior I-1edical Officer North-Eastern Regional Tuberculosis Control Headquarters Senior ~1edical Officer-inCharge, Northern Regional Tuberculosis Control Heqdquarters Pediatrician Chief,. Children's Department Ataturk Sanatorium Ankara Director Tuberculosis Control Survey (Gaza Strip) fUnis try of Health Alexandria
Name
Dr (Mrs) Catherine P. Ranoa
Dr Tomas r1orales
Philippines
Dr (Mrs) Somsong Kupatavintu
Thailand
•
Dr (Nrs) Kanistha Tharavanich
Thailand
Dr Recep Cengiz Yalcin
Turkey
Dr Loutfy lv'!ohamed El Sayed
United Arab Republic
•
•
, - 9/10 ANNEX 2
SCHEDULE OF TViO-vlEEK FIELD VISIT TO NEIGHB)URING COUNTRIES BY THE PARTICIPANTS AFmR THE COURSE Participants Dr Dr Dr Dr Dr Dr T.B. \1/'aworunto R.H. Su 'dan D.Tjinda M,J. Baghai L.M. El Sayed M. Toyohara;:Dr H. ~7isawa"'< (Indonesia) (Indonesia) (Indonesia) (Iran) (U .A.R.) (RIT/JATA, Japan) {r-1aki Health Centre, Niigata, Japan) (China {Taiwan)) (Afghanis tan) (~1alaysia)
Countries visited Korea, Hong Kong and Bangalore (India)
Dr Y.T. Wu Dr M.H. Hessami
Korea ru1d Hong Kong Korea, Hong Kong and Malaysia Korea, China (TaiHan), and Hong Kong
Dr Dr Dr Dr Dr
V. Meyhandan
(r!Jrs) C. Ranoa (Philippines) T. Morales (Philippines) (Mrs) S. Kupatavintu (Thailand) (Mrs) K. Tharavanich (Thailand)
Dr J
.vl.
Kim
(Republic of Korea)
China (Taiwan), Hong Kong and f,1alaysia
Note:
Dr Y.S. Ro, Dr K.N. Rho (Korea); Dr Y.H. Hsu (China); Dr L. Raissi (Iran); and Dr R.C. Yalcin (Turkey) did not join the field visit.
-~
"vmo Temporary Instructor
- 11-
ANNEX 3 LIST OF RESOURCE PERSONNEL Dr M. Aoki
Chief, Clinical Research Section Research Institute of Tuberculosis Japan Anti-Tuberculosis Association Tokyo, Japan Chief, Library Research Institute of Tuberculosis Japan Anti-Tuberculosis Association Tokyo, Japan Chief, Mass Examination Section Hoseien Sanatorium Japan Anti-Tuberculosis Association Tokyo, Japan Director, Medical Research Council Tuberculosis and Chest Diseases Research Unit London, England Director, Tokyo Metropolitan Children's Hospital Tokyo, Japan Bacteriologist Regional Tuberculosis Advisory Team WHO Regional Office for the Western Pacific Manila, Philippines Chief, Education Department Research Institute of Tuberculosis Japan Anti-Tuberculosis Association Tokyo, Japan Chief, PathologicaJ. Section Research Institute of Tuberculosis Japan Anti-Tuberculosis Association Tokyo, Japan
DrY. Azuma
Dr S. Endo
Dr Wallace Fox*
Dr K. Fukushima
Dr J. J. Huang*
t
Dr S. Imamura
Dr K. Iwai
'
Dr T. Iwasaki
Director Research Institute of Tuberculosis Japan Anti-Tuberculosis Association Tokyo, Japan
*WHO staff member/WHO temporary adviser
- 12 -
Annex 2 (cont'd)
Dr G. Kuchiki
Vice-Director Japan~ Laboratory Tokyo, Japan Tuberculosis Prevention Section Public Heal. th :&lreau tl!inistry of Heal. th and Vlelfare Tokyo, Japan Chief, Clinical. Laboratory Section Attached Sanatorium Research Institute of Tuberculosis Japan Anti-Tuberculosis Association Tokyo, Japan Statistics :&lreau !1inistry of Health and t·lelfare Tokyo, Japan Chef de Travaux Institute of Tropical. fiJedicine Antwerp, Belgium Director National Institute of Radiological. Science Chiba, Tokyo Epidemiological. Section Research Institute of Tuberculosis Japan Anti-Tuberculosis Association Tokyo, Japan Director Musashichofu Health Centre Tokyo, Japan Statistics Bureau Ministry of Health and Welfare Tokyo, Japan Chief, Tuberculosis Department National Institute of Health Tokyo, Japan
Dr T. Kondo
DrS. Kudo
•
DrY. Maeda
Dr P. Iliercenier-:<
Dr K. Ivlisono
Dr T. Mori
•
Dr T. l•lorimoto
Dr T. Murai
Dr T. Murohashi
*WHO
temporary adviser
- 13-
• Dr E. Nassau* Dr f-1. Obata Harefield Hospital iliddlesex, England
Annex 3 (cont'd)
Statistics Bureau Ministry of Health and Welfare Tokyo, Japan Consultant, Attached Sanatorium Research Institute of Tuberculosis Japan Anti-Tuberculosis Association Tokyo. Japan Chief, f.1ed1cal Section Attached Sanatorium Research Institute of Tuberculosis Japan Anti-Tuberculosis Association Tokyo, Japan Director Japan ECG Laboratory Tokyo, Japan Vice-Director Research Institute of Tuberculosis Japan Anti-Tuberculosis Association Tokyo, Japan Director Koishikawa Health Centre Tokyo, Japan Director National Sanatorium Tokyo Hospital Tokyo, Japan Chief, Bacteriological Section Research Institute of Tuberculosis Japan Anti-Tuberculosis Association Tokyo, Japan Chief, Physicians Training Section Research Institute of Tuberculosis Japan Anti-Tuberculosis Association Tokyo, Japan
Dr Y. Obayashi
Dr T. Ohsato
Dr T. Sawada
Dr T. Shimao
Dr K. Shimizu
Dr S. Sunahara t
Dr S, Takahashi
Dr A. Takase
*WHO
temporary adviser
- 14 -
Armex 3
(cont'd) Dr A. Tanaka* Medical Officer (Statistics) Regional Tuberculosis Advisory Team WHO Regional Office for the Western Pacific t-lanila, Philippines Regional Tuberculosis Adviser WHO Regional Office for the vlestern Pacific Manila, Philippines Chief, Radioisotope Research Section Research Institute of Tuberculosis Japan Anti-Tuberculosis Association Tokyo, Japan Statistics Bureau t-linistry of Health and Welfare Tokyo, Japan Public Health Nurse Regional Tuberculosis Advisory Team WHO Regional Office for the Western Pacific Nanila, Philippines Statens Skjermbildefotografering Oslo, Norway Chairman Board of Directors Japan Anti-Tuberculosis Association Tokyo, Japan
Dr J.C. Tao*
Dr M. Toyohara
•
Dr F. Ueda
Miss E. Wilhelmsson*
Mr Hans Th. Waaler*
Dr M. Yamaguchi
'
*WHO
staff member/WHO temporary adviser
•
- 15 ANNEX 4 SCHEDULE OF COURSES WHO/Japan Training Course in Tuberculosis, 1970
25 May (r,londay) A.M. Moving from Tokyo International Center to the Research Institute of Tuberculosis at Kiyose-shi Opening Session at the Research Institute of Tuberculosis. Address by 1. Dr Tatsuro Iwasaki
P.M. (3:00)
Director, Research Institute of Tuberculosis Japan Anti-Tuberculosis Association 2. Dr Hiroyuki Takemura
(Representative of the Ministry of Health and 1-lelfare) ~ 1\ledical officer, Tuberculosis Prevention Section Public Health Bureau
3. Dr H. Beringer Leader of Regional TB Advisory Team Regional Office for the Western Pacific, vJHO
4. Mr T. Sugiyama Acting Chief, First Training Section Internal Operation Division Overseas Technical Cooperation Agency 26 May (Tuesday) A.M. P.M. General concept of tuberculosis Dr T. Iwasaki Group discussion and mutual briefing on situation and problems of TB control programme especially bacteriologicalcase-finding in each participating countries. Dr T. Shimao DrY. Azuma Dr S. Imamura Staff doctors of the Bacteriological Section
27 May (Wednesday) General concept of tuberculosis (continued) Dr T. Iwasaki
P.M.
Orientation (Kiyose, Ikebukuro, etc.)
- 16 Annex 4 (oont'd) 28 May (Thursday)
A.M. P.M. 29 May (Friday)
General concept of tuberculosis (continued) Dr T. Iwasaki Registration at Kiyose Town Hall. Group A
A.M. P.M. 30 loiay (Saturday)
Registration at Kiyose Town Hall. Group B
• Bacteriological basis of tuberculosis. Dr S. Takahashi
A.M. l June (Monday)
Library study.
A.M.
Collection, transportation, storage of specimens and cultivation procedure Dr S. Kudoh Tuberculin and tuberculin testing preparation and assay of tuberculin. Purified tuberculin and stability of tuberculin. Dr T. Sawada
P.M.
2 June (Tuesday)
• Irnmuni ty in tuberculosis; history of .ECG vaccination. Dr Y. Ohbayashi Injection, reading and history of tuberculin test. Dr T. Sawada
A.r.t.
P.M.
3 June (Wednesday)
A.M.
Collection, transportation. storage of specimens and cultivation procedure (continued) Dr s. Kudoh General Concept of Tuberculosis(oontinued) Dr T. I\-msaki I '
P.M.
- 17 Annex 4 (cont'd)
4 June A.M.
(Thursday) Post-vaccination allergy and local lesion after :OCG vaccination. Dr G. Kuchiki
P.M.
Used site and low grade sensitivity of tuberculin reaction; simultaneous ECG vaccination and small pox vaccination. Dr T. Sawada
5 June (Friday)
•
A.r-1.
Factors responsible for the viability of dried BCG vaccination; protective value and safety of BCG vaccination. Dr Y. Ohbayashi Epidemiological and clinical significance of mycobacterial resistance to anti-tuberculosis agents Dr T. Ohosato
P.M.
6 June (Saturday) A.M. 8 June (1\londay) Technique of BCG vaccination 1 role of ECG vaccination in tuberculosis control programme. Dr G. Kuchiki l
Library study.
P.M. 9 June (Tuesday) A.!~.
Principle of identification of mycobacteria Dr K. Toyohara
General concept of tuberculosis (continued) Dr T. Iwasaki Staining and microscopical technique Dr S. Takahashi
P.M. 10 June (Wednesday)
A.M.
Public health activities 1 especially Tuberculosis Control Programme in Japan. Dr T. Kondo
- 18 -
Annex 4 (cont'd) 10 June (Wednesday)
Visiting the Central Office of ti1e Japan AntiTuberculosis Association Dr M. Yamaguchi 11 June (Thursday)
A.M. P.M. 12 June (Friday)
Planning of ECG vaccination programme Miss E. Wilhelmsson Staining and microscopical technique (continued) Dr S • Takahashi
•
A.M.
Reading of tuberculin testing at the Hanno Primary School : Group A - Individual reading of tuberculin tests Group B - Assistant of Group A !>!iss E. Wilhelmsson Dr Y. Ohbayashi Dr S. Imamura Sightseeing bus trip to Mt. Fuji by OTCA
13 June (Saturday) 15 June (!1!onday) A.M.
Preparation for the seminar Technique of ECG vaccination, role of ECG vaccination in tuberculosis control programme (continued) Dr G. Kuchiki
• •
16 June (Tuesda._y) A.M. tllortality, morbidity statistics, case registration Design of survey and experiment : - objectives - methods - examiner - examined (sampling and allocation) Dr A. Tanaka Practice - Operation of calculating machine, illustration of figures Dr A. Tanaka
P.M.
- 19-
Annex 4 (continued)
17 June A.M.
(WeQ~esday)
Statistics relating to tuberculin test and EGG vaccination - Frequency distribution (normal distribution) - Mode, medium, mean - Sum of squares, variance, standard deviation - Confidence limits (t-distribution) - Histogram Practical work Dr A. Tanaka
P.M.
18 June (Thursday) A .Iv!.
Reading of tuberculin testing at the Tokorozawa Middle School : Group B - Individual reading of tuberculin tests Group A - Assistant of Group B Miss E. Hilhelmsson Dr K. Shiozav;a Dr S. Imamura Group discussion and mutual briefing on tuberculin, tuberculin testing and role of tuberculin testing in tuberculosis control progra.r.:r:Je in each participating country Dr T. Sa\"/'ada Hiss E. Wilhelmsson Dr S. Imamura
P.M.
19 June (Friday) A.M. !
BCG assessment and demonstration of standard BCG kit
Miss E. l'lilhelmsson
P.M.
Seminar on v/HO publications 1. Case-finding by microscopy Reporter : Dr V. r.!eyhandan DrY. Azuma Dr S. Imamura Staff doctors of the Bacteriological Section, RIT Library study
20 June (Saturday)
22 June (Monday)
A.M.
Statistics relating to tuberculin test and BCG vaccination (continued) - Significance test of difference of two means (t-distribution) - Significance test of difference of two variances (F-distribution)
- 20 Armex
4
(cont'd) 22 June(r'londay) Practical work Dr A. Tanaka 23 June (Tuesday) General concept of tuberculosis (continued) Dr T. Iwasaki P.M. Group discussion and mutual briefing on BCG and role of BCG vaccination in tuberculosis control programme in each participating country Dr Y. Ohbayashi Dr G.Kuchiki DrY. Azuma Dr 3. Imamura
24 June (Wednesday) A.M. Statistics relating to tuberculin test and ECG vaccination (continued) Correlation Practical work Dr A. Tanaka
P.M.
25 June (Thursday) A.M. Statistics relating to case-finding and treatment Significance test of difference of two percentages(normal distribution) Practical work Dr A. Tanaka
P.H.
26 June (Friday) A .r1.
Statistics relating to case-finding and treatment Significance ~st of difference of two percentages (x -test) Practical work Dr A. Tanaka Library study
P.M.
27 June (Saturday) 29 June (Monday) A.H. & P.f:i,
Evaluation of tuberculin reaction reading by participants Dr A. Tanaka
- 21 Annex 4 (cont'd) 30 June (Tuesday)
A.M.
Visit to the Division of Statistics, Ministry of Health and \'/elf are. Patient survey, national health survey Dr M. Obata 1.
P.M.
Communicable diseases and food poisoning statistics Dr £4. Obata Vi tal statistics Dr T. X.1urai
2.
l July (\1ednesday)
•
A.M.
Continuation of visit to the Division of Statistics, !>1inistry of Health and vlelfare. 1.
Survey of medical institutions Survey of physicians, dentists ru1d pharmacists Dr M. Obata International classification of causes of death, diseases and injuries Dr F. Ueda
2,
P.f-1.
Demonstration of electric computer Mr Y. !-'iaeda
2 July (Thursday)
• !
A.tl!.
Visit to the National Institute of Health Biological significance of acid-fastness of mycobacteria Dr T. r.lurohashi Activity of Tuberculosis Department of the National Institute of Health
P.N. 3 July (Friday) A.M. & P.fft.
Practical work Dr A. Tanaka Library study
4 July (Saturday) 6 July (Monday) A.!II.
& P.!ll.
General concept of epidemiology, including tuberculosis Dr T. Shimao
- 22 -
Annex 4 (cont'd)
7 July (Tuesday) A.JVI.
Individual reading of radio-photograJ!Is Dr A. Tal{ase General concept of tuberculosis (continued) Dr. T. Ivrasaki
P.M. 8 July (Wednesday) A.M.
General concept of epidemiology, including tuberculosis (continued) Dr T. Shimao Seminar on ltiHO publications 1. Some aspects of laboratory investigations in a mass caJ!Ipaign against tuberculosis Reporter : Dr Yong-Sup Ro DrY. Azuma Dr S. Imamura Staff doctors of the Bacteriological Section. RIT
•
P.r.t.
9 July (Thursday) A.r1. & P .r.t. Visit to Koishikawa Health Centre Director : Dr K. Shimizu Lecture : Activity of the Health Centre, especially on tuberculosis Dr K. Shimizu
lO July (Friday) A .l·l.
• Voluntary activity in tuberculosis control programme Dr !1. YaJ!Iaguchi Dual reading of radio-photograms Dr A. Takase. Library study . Visit to f1eiji Seika Kaisha Ltd. Visit to the Musashi-Chofu Health Centre Director : T. Morimoto
P.M. 11 July (Saturday)
13 July (Monday) 14 July (Tueeday)
- 23 Annex 4 (cont'd)
15 July (Wednesday)
A.M.
Fundamental knowledge for reading of radiograms and radio-photograms Dr A. Takase Seminar on v/HO publications 1. Comparative value of sputwn smear examination in assessing the progress of tuberculous patients receiVing chemotherapy Reporter : Dr Recep Cengiz Yalcin DrY. Azwna Dr S • Ir:1amura Staff doctors of the Bacteriological Section, RIT
•
16 July (Thursday) A.r~.
Epidemiology of tuberculosis (continued) Dr. T. Shimao Lecturer and demonstration - Pathological findings of tuberculosis concerning the development of the diseases in child Dr K. Iwai
P.M.
17
July (Friday)
A.M.
Orientation of the demonstration area in Niigata Dr. T. Shimao Lecture and findings of ment of the Dr. K. demonstration - Pathological tuberculosis concerning the developdiseases in adult Iwai
P.M.
18 July (Saturday) 20 July (Monday) to 28 July (Tuesday)
Library study Observation tour to Tohoku District Schedule of Tour
20 July (Monday)
8:05 12:05
Leave Ueno by the special express "Toki No. l" Arrive at Niigata Visit Niigata Prefectural Government Information about tuberculosis control programme in Niigata Prefecture. Stay in Niigata
- 24 Annex. 4 (cont'd) 22 July (WeP~1esday) Visit Niigata Prefectural Government Discussion about tuberculosis control programme at the \m:O demonstration area at tvlaki Health Centre. Stay in Niigata
23 July (Thursday) 7:20 12:09
Leave Niigata by the express "Uetsu Asa.hi No. 1" Arrive at Akita Visit Akita Prefectural Goverrunent Information and discussion about tuberculosis control programme in Akita Prefecture Information and discussion about the organization and activities of the Anti-Tuberculosis Women's Association in Akita Prefecture. Stay in Akita
14:30
24 July (Friday)
Field work at Oga City.
Stay in Oga
25 July (Saturday) 10:00 15:00
Leave Akita by the express "Tsugaru No. 2u Arfive at Yasuraiya. Visit to the Towada Health Centre Discussion about tuberculosis control programme Stay in Towada
26 July (Sunday) 10:00
Sightseeing of Towada Lake.
Stay in Yakeyarna
Z! July (Monday) 10:00
Leave Yakeyarna Visit to Aomori Prefectural Government Information and discussion about tuberculosis control programme in Aomori Prefecture Leave Aomori by the special express "Yuzuru No. 1 11
14:30
19:25 28 July (Tuesday) 6:00
Arrive at Ueno Back to Tokyo from observation trip Free-day
29 July (\iednesday)
- 25 -
Annex 4 (cont'd)
30 July (Thursday) A.M. P.M. Epidemiology of tuberculosis (continued) Dr T. Shimao Fundamental knowledge for reading of radiograms and radio-photograms (continued) Dr A. Takase
3l July (Friday) Epidemiology of tuberculosis (continued) Dr T. Shimao p .r-1.
Fundamental knowledge for reading of radiograms and radio-photograms (continued) Dr A. Takase
1 August (Saturday)
A.M. 3 August (Monday) A .r-1.
Library study.
Fundamental knowledge for reading of radiograms and radio-photograms (continued) Dr A. Takase Fundamental knowledge for reading of radiograms and radio~photograms (continued) Dr A. Takase
4 August (Tuesday) A.rot.
General concept of tuberculosis (continued) Dr T. Iwasaki Tuberculosis in childhood Dr K. Fukushima
P.M.
- 26 -
Annex 4 (cont'd)
5 August (Wednesday) A.N. Seminar of VJHO publications 1. Sirnul taneous :OCG and smallpox vaccination 2. A study of the effect of simultaneous vaccination with :OCG and smallpox vaccine in newborn infants reporter: Dr L.f.l. El Sayed DrY. Azuma Dr T. Sawada Dr S. Imamura Staff doctors of the Bacteriological Section, RIT Radiological diagnosis of respiratory diseases Dr T. Iwasaki
p .!Vi.
6 August (Thursday) A.M. Naintenance of X-ray apparatus Dr K. Misono Protection of X-ray hazard Dr K. f•lisono
P.M.
7 August (Friday) A.!•1. P.M. Tuberculosis in childhood(continued} Dr K. Fukushima Preparation for the report of observation trip
8 August (Saturday) A.til. 10
Library study.
August (Monday)
A.N. & P.Jii.
Visit to Tokyo Shibaura Electric Co. Ltd. 1. The Tamagawa Factory of X-ray Apparatus 2. Toshiba Science Institute
11 August (Tuesday)
A.N. P .r/j.
Dynamic model in tuberculosis epidemiologJ DrY. Azuma Prognosis of various types of pulmonary tuberculosis, a follow-up study of sample population in Japan. Dr !-1. Aoki
- ~Annex
4
(cont'd) 12 August (Wednesday)
A.M.
Evaluation meeting of observation trip DrY. Azuma Dr S • Imamura Meeting with the travel agent for the deviation trip of post-course 1n Japan
P.M.
13 August (Thursday} A.M. &:
Preparation of visas for the deviation trip
P.M.
14 August (F!tiday) A.M. Genetic study on INH metabolism Dr M. Sunahara
P.M.
Dynamic model in tuberculosis epidemiology II. DrY. Azuma
15 August (Saturday) A.M. Library study.
17 August (Monday) A.M.
Generalities on TB control in various countries Historical aspects Dr P. Mercenier Seminar: Problems in case-finding treatment Dr P. Mercenier
p .r--1.
18 August (Tuesday) A.M. Operational and administrative structure of the General Health Services on the basis of fUnctions performed. Dr P. ~rcenier Characteristics of general health services for patient care and management - Alternative approaches: specialized permanent service and mass campaign Dr P. Mercenier
P.M.
- 2$Annex 4 (cont'd)
19 August (Wednesday) A.M. The methods of TB control related to the epidemiology of the disease - The place of chemoprophylaxis. Integration into General Health Services vs !1lass Campaign for B::G vaccination. Dr P. Mercenier The role of laboratory diagnosis in tuberculosis control progrru~ne in practical aspects Dr J .J. Huang
P .ri[.
•
20 August (Thursday)
A.M. p .f·1.
Priorities in Case-finding Treatment Dr P. Mercenier The design of single tuberculosis laboratory unit. Dr J .J. Huang
21 August (Friday)
Non-relevance of !'lass Campaign approach for Case-finding Treatment Functions that are the prime responsibility of the peripheral facilities in a case-finding treatment programme Dr P. Mercenier Distribution of other functions of a case-finding treaunent programme between peripheral and specialized services Dr P. I:Iercenier 22 August (Saturday) A.f·1.
•
The administrative aspects of the inteGrated tuberculosis service Seminar: Resistance towards the integrated programme, in general, from the politicians, from the people
P.M.
-29 -
Annex 4 (cont'd) 24 August (Nonday) A.M. The administrative aspects of the integrated tuberculosis service (2nd part) Seminar: Resistance towards the integrated progrrunme from the specialists Dr P. Hercenier
P.M. 25 August (Tuesday} •
Library study. Preparation of visas for the deviation trip
26 August (vlednesday) A.N. 'l'he Four Basic RequirotJents of a 'J.\lberoulosis Programme
Introduction to Operational Research. The Linear Programming Decision .£Iiedel for TB Control (1st part) Dr P. J.lercenier p .!I'!.
Seminar: Resistance towards the integrated programme from the General Health Services Dr P. Mercenier
27 August (Thursday) A.l.\1. The Linear Programming Decision Hodel for TB Control (2nd part) Dr P, l<lercenier The Linear Programming Decision Nodel for TB Control (3rd part) Dr P. r.tercenier
• P.H.
28 August (Friday) A.M. The Linear Programming Decision Hodel for TB Control (final discussion) A Simulation I'iodel for Case-finding Treatment Dr P. Hercenier P.N. A Simulation Nodel for Case-finding Treatment
(continued) Dr P. l'1ercenier
- 30 Annex 4 (cont'd)
.?9 August (Saturday) A .!,1.
Seminar
General Discussion Dr P. I·!iercenier
31 August (MondayJ. A.!,!. & P .H.
System analysis of tuberculosis in Japan Dr S. Endo
1 September (Tuesday)
A .!·1.
Estimation of the risk of infection by age specific tuberculin positive rate Dr T. Hori DrY. Azuma Preparation for the trip to Kansai District Observation trip to Kansai District Schedule of Tour
•
P.H. 2 September {Wednesday) to 8 September (Tuesday)
2 September (vlednesday)
9:40 12:50
Leave Tokyo by Super Express "Hikari No. 2311 Arrive at Shin-Osaka Stay in Osalca
3 September (Thursday) A .r.J.
Visit to the Tanabe Pharmaceutical Company, Ltd Stay in Osaka
4 September (Friday) A.t,J. p .~1.
Visit to the Osaka Branch of JATA Leave Osaka for Kyoto Stay in Kyoto
5 September (Saturday) A.!>l.
Visit to the Shimazu Seisakusho Free-day
Stay in Kyoto
6 September (Sunday)
7 September (J.londay) A.M.
Visit to the Tuberculosis and Chest Diseases Research Unit, Kyoto University Visit to the Kyoto Branch of JATA
P.M.
• - 31 Annex 4 (cont'd)
8 September (Tuesday) 14: 24 Leave Kyoto by Super Express "Hikari No. 50 11 Arrive at Tokyo Free-day
17:15
9 September (Wednesday) 10 September (Thursday) A.M.
Epidemiology of atypical mycobacteria Dr M. Aoki Comparison of tuberculosis control approaches in the efficiency DrY. Azuma
P.M.
11 September (Friday)
Comparison of tuberculosis control approaches in the efficierrcy ( contirrued) Dr. Y. Azuma Control trial of chemotherapy of tuberculosis in Japan Dr ll!. Sunahara 12 September (Saturday)
Library study
14 September (Monday) A.M. 1.
• 2.
Health economics in developing countries and staff shortages Home and sanatorium treatment - patients and contact studies Drug costs and expenditure on in developing countries
P.M.
3. 4. 5.
dru/5
budgets
Reserve regimens and their role Smears, cultures and sensitivity tests and their place in supervision of treatment Dr i~allace
Fox
15 September (Tuesday)
National holiday
- 32 Annex 4 (cont'd) 16 September (Wednesday)
A.M.
6.
The diagnosis of tuberculosis ambulatory treatment
7. Principal priorities of chemotherapy and P.M.
8.
Isoniazid alone Isoniazid and thiacetazone - (a) (b) Dr regimens toxicity
9.
vr.
Fcx
•
17 September (Thursday)
A.M.
10. Organization of chemotherapy 11. Records and record-keeping
P.M.
12. Intermittent chemotherapy Dr W. Fox
18 September (Friday) 13. Drug resistance and drug resistance development Dr vi. Fox P.M. 19 September (Saturday) Library study
A.M. 21 September (Monday) A.r-1. & P.f.j,
Evaluation meeting by Research Institute of Tuberculosis
•
Bacteriology of tuberculosis Dr E. Nassau
22 September (Tuesday)
A.M. P.M.
Healing changes in tuberculosis and chemotherapy Dr E. Nassau Some basic principles in the planning of antituberculosis programmes Mr Hans Th. Waaler National holiday
23 September (vJednesday)
- 33 !
Ar.nex 4
(cont'd) 24 September (Thursday) A.M. Some basic principles in the planning of anti-tuberculosis programmes (continued) 1\'lr Hans Th. Waaler Morbid anatomy of tuberculosis Dr E. Nassau (Friday} Bacteriology sensitivity tests and their interpretation Dr E. Nassau Presentation of a dynamic model Nr H. Th. Waaler Library study
P.M.
25
~eptember
A.M.
• P.M. 26 September (Saturday} 28 September (Monday)
A.M. P.M. 29 September (Tuesday)
Application of the model Nr H. Th. Waaler Drugs for intenni ttent chemotherapy Dr E. Nassau
A.M.
General discussion Dr E. Nassau Further discussion of the r.1odel Summing up Nr H. Th. Waaler One day bus trip to Nikko by OTCA
'
P.M.
30 September (\l!ednesday) 1 October (Thursday)
A.M.
Evaluation meeting of the course by OTCA Library Study
• - 34 -
Annex 4 (cont'd) 2 October (Friday) A.M. Selective case-finding. An example of rational utilization of available knowledge r·1r H. Th. Vlaaler Final discussion on tuberculosis control Dr J. C. Tao Farewell party by J ATA (in the presence of Her Imperial Highness Princess Chichibu) Library study Preparation for the deviation trip to neighbouring countries
P.M. Evening
•
3 October (Saturday)
5 October (Monday) 6 October (Tuesday) P.M.
Closing session
•
- -'5 -
• ANNEX
5-a
SUi•JMARY OF EVAIJJATION QUESTION WHICH OF THE LECTURES, DISCUSSIONS OR FIELD VISITS DID YOU FIND HOST USEFUL? No. of replies considering topic as most useful Lecture Discussion 4 1 1
Topic
Name of lecturer
General concept of tuberculosis Dr Iwasaki Mass
examination
Case-finding Tuberculin testing Direct smear examination
2 1
3 1 1
..
1
2 1 1 1 1
Chemotherapy Treatment of tuberculosis (tuberculosis control) Tuberculosis control Tuberculosis control programme Domiciliary treatment and first line drug Epidemiology Bacteriology Bacteriological aspects of tuberculosis Radiogram reading Statistics
Dr Fox 11
5 4 2 2 1
Dr Hercenier
Dr Azuma Drs Kudoh &: Takahashi Dr Nassau
2
1 1
3
1 1 1
1
Dr Shimao Dr vlaaler Most of the lectures All of the lectures Host useful field visits to l4aki Health centre Tohoku District Oga City Health Centre •
1 1
1 1 1
1 2
Number of replies 4 4 l
Control office of Japan Anti-TB Association Health Centres, factories, Kansai, Hanno Primary School for reading tuberculin testing, Tokorozarra r·1iddle School, National Institute of Health All
1 1
- 36 -
ANNEX 5-b
QUESTION
IF YOU WERE TO ORGANIZE SUCH A TRAINING COURSE \OOCH PARTICULAR ITEMS IN THE CURRICULill1 \'IOULD YOU -
a)
EXTEND'?
(1) (2) (3)
(4) (5)
(6)
Lectures about treatment and practical work Lectures by Dr vi. Fox should be -extended to eight days Field ~mrk Observation trips and reading of radiophotograms Discussions and visiting field work Bacteriological laboratory work: X-ray reading
(7) Seminar of WHO publication (8) Public health aspects of tuberculosis control ( 9) (10)
Statistics Pathology
b)
SHORTEN? (1) (2) (3) (4) (5)
(6) (7) (8)
Statistics Duplications and repetitions in ECG, statistics and bacteriology. Some lectures in bacteriology and radiology. Field trips Field Hork on the tuberculin test and ECG vaccination The lectures Discussion on the tuberculosis control programme because some of the WHO lectures were too long and repetitious Clinical aspects of tuberculosis X-ray maintenance and hazards
•
c)
ADD?
(1) Practical work (2) (3)
(4) (5) (6)
(7)
More group discussions and seminars and less formal lectures Role of universal and proper recording and reporting system in the tuberculosis control programme, health education, tuberculosis of the animals, tuberculin testing in animals Bacteriological aexamination in the laboratory and sensitivity test ECG, case-finding and treatment, evaluation Differential diagnosis of pulmonary diseases from pulmonary TB Field practice
•
• - "5f -
ANNEX 5-c
ADDITIONAL REMARKS ON THE TRAINING COURSE:
1)
Reduce courses to three months
2 months lectures, discussions and seminar 1/2 month for field trips in Japan 1/2 month for vlHO deviation trip to other countries
2)
To arrange one demonstration area to show how a tuberculosis control progranune in a developing country should be carried out so that the participants can apply it in their own countries. among participants
3) In the training course, there was good social inter-relationship 4) One lecture a day is better than two a day. On the whole the training course is good.
5)