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In Tokyo, Japan, coronavirus disease 2019 (COVID-19) cases have been increasing gradually since late March 2020. This study was aimed to predict the effects of self-restraint against excursions in Tokyo before the emergency declaration of April 7, 2020. Data of symptomatic patients collected between January 14 and March 28, 2020, in Tokyo, were used to formulate a susceptible–infected–recovered (SIR) model using three age classes and estimate the basic reproduction number (R0). Based on the estimated R0, we inferred outbreak outcomes and medical burdens if self-restraint against excursions had not been enacted. Thereafter, we estimated the effects of self-restraint against excursions. The results suggested an R0 value of 2.86, with a 95% confidence interval of 2.73–2.97. It is likely that the exhaustion of medical resources could have occurred on April 28, 2020, if no self-restraint against excursions had occurred. If self-restraint against excursions had been enacted from April 6, 2020, and more than 60% of trips outside the home had been restricted voluntarily, medical care services would then have been predicted to be maintained. Our suggestion might have contributed to countermeasures against COVID-19 in Tokyo.

Background Through test negative designs for visiting a doctor because of influenza-like illness, many studies have found decreasing efficacy of repeated vaccination. Furthermore, waning effectiveness during interseason periods has been reported. This study was conducted to confirm negative effects of repeated vaccination in individuals with the same vaccine strain and to measure waning effects. Methods Our cohort includes 66 participants older than 65 years old recruited from an outpatient department of one hospital. All were vaccinated, with hemagglutination inhibition (HI) antibody titers measured from 2001/02 season through the 2003/04 season. HI antibody titers were measured three times in one season: pre-vaccination, post-vaccination, and post-epidemic. To test negative effects of immune response to the repeated vaccination, differences between protection rates and differences between response rates were analyzed for individuals in the two consecutive seasons. For the test of waning effectiveness, we measured the difference in geometric mean titers of HI antibody between post-epidemic results and pre-vaccination results obtained in the following season. Results Protection rates were 40–55% in A/New Caledonia/20/99 and ≥75% in A/Panama/2007/99 by repeated vaccination. In A/New Caledonia/20/99 and A/Panama/2007/99 in the 2003/04 season, significant decreases were found in protection rates from the earlier seasons, although the rate for A/Panama/2007/99 in the 2002/03 season increased significantly from that of the prior season. The respective response rates in the 2003/04 season in A/New Caledonia/20/99, and in the 2002/03 and 2003/04 seasons in A/Panama/2007/99 decreased significantly from those of earlier seasons. Regarding waning effectiveness, antibody titers for A/New Caledonia/20/99 in 2003/04 season, and A/Panama/2007/99 in 2002/03 and 2003/04 seasons decreased significantly to 37.0–66.7%. Conclusion Results show significant negative effects of immune response by repeated vaccination and show significant waning effectiveness during the interseason for individuals with the same strain of influenza type A. The proportion of elderly people with HI antibody titers of ≥1:40 might be maintained by repeated influenza vaccination.

In Japan, the reported cases of syphilis have been increasing since 2011 especially in large cities such as Tokyo. The objective of this study was to evaluate the risk of HIV infection for syphilis co-infection on the population of Tokyo, Japan. We analyzed data of syphilis cases obtained from additional surveillance by the Tokyo Metropolitan Government in 2018, including those with human immunodeficiency virus (HIV) infection as well as data of HIV/acquired immunodeficiency syndrome (AIDS) cases during 1985-2017. We calculated the incidence of symptomatic syphilis cases among HIV-infected or non-HIV-infected individuals. Similarly, we calculated the incidence of syphilis, including asymptomatic cases, among each population. The relative risk of HIV infection for syphilis, including or excluding asymptomatic syphilis cases, was estimated. The relative risk was calculated by dividing the incidence of syphilis in the HIV-infected population by that in the non-HIV-infected population. Of the 1,775 syphilis cases reported in 2018, 172 cases were infected with HIV, 575 cases were uninfected, and the remainder were either unknown or not reported. The cumulative number of HIV/AIDS cases during 1985-2017 in Tokyo was 9,629; among them, 172 were co-infected with syphilis. The relative risk of HIV infection for syphilis was estimated as 423.29 if asymptomatic syphilis cases were included, and 372.37 if they were excluded. These results showed an extremely high risk of HIV infection. Since many syphilis cases have unknown or unreported HIV infection status, reduction of these cases might contribute to more reliable estimation of HIV infection risk.

Object: Prediction of the COVID-19 epidemic represents a matter of concern not only for public health or medicine but also for Earth’s general population. This study predicts outbreaks in Wuhan and in Japan as of 11 February, 2020.Method: We applied a simple SIR model to data published by Hubei public health authorities. Moreover, into the model, we incorporate mild and asymptomatic cases from experiences of Japanese residents of Wuhan up to the outbreak. Finally, we predict an outbreak in Japan based on 10,000 iterations of a simulation conducted under the assumption of infected people including mild cases visiting Japan according to the estimated distribution of patients in Wuhan since the date on which the initial case occurred to the date when travel from Wuhan to Japan was suspended. Results: Results suggest the basic reproduction number, R0, as 2.84; its 95% confidence interval (CI) was [2.35, 3.33]. The peak is estimated to be reached on March 11. Its 95% CI peak date is 29 February to 27 March. The 95% CI peak date in Japan is 26 April to 2 May. The greatest number of patients at the peak with severe symptoms was estimated as 858.3 thousand. Discussion and Conclusion: Our obtained R0 of 2.84 approximates an earlier estimate. We predicted the greatest number of patients at the peak with severe symptoms as 858.3 thousand in Japan. This number is 63% greater than the highest daily peak of influenza.

Bioterrorism attacks become more probable when important high-profile international or political events are held, such as G7 summit meetings or mass gathering events including Olympic and Paralympic games and FIFA World Cup tournaments. Outbreaks of infectious disease and widespread incidents of food poisoning are also public health concerns at such times. In Japan, the Tokyo Metropolitan Government operates Ambulance Transfer Syndromic Surveillance (ATSS), which can help monitor such incidents. The present study presents and assesses the ATSS framework. During the study period of October 2017 through November 2018, we monitored 33 areas for symptoms of 9 categories: vomiting/nausea, dizziness, palpitation, unconsciousness, breathing disorder, fever, spasm/paralysis, collapse/weakness, and bloody emesis/nasal hemorrhage. Among all symptoms, we found 9929 low-level aberrations, 2537 medium-level aberrations, and 577 high-level aberrations, with respective frequencies of 9.2%, 2.3%, and 0.5%. Of those, Tokyo Metropolitan Institute of Public Health reported the information to Tokyo Metropolitan Government 28 times during the period. Of the 28 identified clusters, Tokyo Metropolitan Government judged the necessity for investigating 7. All of those were investigated at hospitals by the jurisdictional public health center. Because ATSS covers almost the entire Tokyo metropolitan area, with about 13.8 million residents, it is definitely the largest syndromic surveillance in the world.

Only one case of melanoma arising from melanin-producing medullary thyroid carcinoma (MTC) has been reported previously. In the present study, a second such case was reported and compared with the previous one. The patient was an 86-year-old male who presented with a right anterior neck mass. Ultrasound revealed a nodule measuring 49x48x40 mm in the right lobe of the thyroid. The levels of serum calcitonin (2,298 pg/ml) and carcinoembryonic antigen (CEA; 27.0 ng/ml) were markedly elevated. Aspiration cytology revealed suspected malignant anaplastic thyroid carcinoma and total thyroidectomy without neck nodal dissection was performed. On gross observation, the nodule was well encapsulated, soft, solid and black. Light microscopy indicated that the nodule was composed mainly of large, occasionally huge, pleomorphic cells with a solid or alveolar growth pattern. On immunohistochemistry, these cells were positive for melan-A and S-100 protein, and negative for thyroid transcription factor 1, calcitonin, chromogranin A and CEA. In the subcapsular area, melanin-producing MTC was intimately intermingled with the pleomorphic cells. No primary site of the melanoma was detectable in other organs. At three years after surgery, the patient died due to metastasis of the melanoma to the brain. The previously reported case had no detectable recurrence or distant metastasis up to 11 years after surgery. In comparison with that case, the present case had a similar morphology but the outcome was poorer. Thus, the prognosis of melanoma that transforms from MTC appears to remain uncertain.

Introduction The Tokyo Metropolitan Government (TMG) conducted an external quality assessment (EQA) survey of pathogen nucleic acid amplification tests (NAATs) as a TMG EQA program for SARS-CoV-2 for clinical laboratories in Tokyo. Methods We diluted and prepared a standard product manufactured by Company A to about 2,500 copies/mL to make a positive control and distribute it with a negative control. The participants reported the use of the NAATs methods for SARS-CoV-2, the name of the real-time RT-PCR kit, the name of the detection device, the target gene(s), nucleic acid extraction kit, Threshold Cycle value in the case of RT-PCR and the Threshold time value and Differential calculation value in the case of Loop-Mediated Isothermal Amplification (LAMP) method. Results As a result, 17 laboratories using fully automated equipment and 34 laboratories using the RT-PCR method reported generally appropriate results in this EQA survey. On the other hand, among the laboratories that adopted the LAMP method, there were a plurality of laboratories that judged positive samples to be negative. Conclusion The false negative result is considered to be due to the fact that the amount of virus genome contained in the quality control reagent used this time was below the detection limit of the LAMP method combined with the rapid extraction reagent for influenza virus. On the other hand, false positive results are considered to be due to the non-specific reaction of the NAATs. The EQA program must be continued for the proper implementation of the pathogen NAATs.

For elderly people who have low incidence of influenza, calculation of credible vaccine effectiveness (VE) sometimes becomes difficult. Currently, VE for elderly people is insufficient to ascertain the precise efficacy specifically. Cost-effectiveness of influenza vaccination of elderly people is discussed widely in terms of topics and areas. This report describes research results demonstrating influenza vaccination effectiveness among elderly people based on recent findings. Newly available influenza vaccination for elderly people appears to be cost-effective compared with that of trivalent inactiveted influenza vaccine. Overall, for all influenza virus types, it remains unclear whether influenza vaccination shows high VE. A decreasing effect of repeated vaccination was confirmed partially by test negative design and a serological study of cohorts. However, some studies have found no such decreasing effect. Measurement of VE and subsequent analysis of the cost-effectiveness of influenza vaccination for elderly people requires long-term monitoring using serological studies and test negative design.

In the 2012-2013 rubella epidemic in Japan, most transmissions in Tokyo occurred at workplaces, especially among men aged 20-49 years. This tendency was likely related to previous rubella immunization policies that prioritized female adolescents. Since 2015, the Tokyo Metropolitan Government has been promoting a project to prevent rubella and other infectious diseases in workplaces. Companies participate by choosing one or more of three options: (i) acquire fundamental understanding of infectious diseases, (ii) develop a Business Continuity Plan (BCP) for infectious diseases in the workplace, and (iii) increase rubella antibody prevalence in employees.Criteria for accomplishment are (i) at least 80% of employees complete the infectious disease training modules or (ii) produce a BCP and (iii) at least 90% of employees demonstrate the presence of antibodies at levels sufficient for preventing rubella. As of July 2018, 39.8% (n ＝ 90) of the 226 companies that began participating in 2015-2017 had met at least one accomplishment criteria (Option I, 42.7% of 192 companies; Option II, 19.3% of 140; and Option III, 17.0% of 53). The main project challenges were recruiting companies and following participating companies. Although early in its implementation, this project has made considerable contributions toward rubella elimination in Japan.

BackgroundStrict countermeasures for COVID-19 outbreak such as lockdowns and voluntary restrictions against going out might have reduced mortality because of COVID-19 directly, but might have raised suicide rates.ObjectWe examined best policies for minimizing overall mortality attributable to COVID-19 directly, and excess mortality by suicide because of COVID-19.MethodWe regressed the estimated excess mortality attributable to suicide deaths against mobility-restrictive measures. Mortality attributable to COVID-19 directly was estimated through association between the effective reproduction number and mobility. We sought the best mobility restriction for minimizing overall deaths.ResultsSignificant association was found between mobility and suicide, but the data were very few. Results showed the best mobility level as 65.5, which represents a 34.5% reduction in mobility from the normal level.Discussion and ConclusionAn overly restrictive policy inducing lower than optimal mobility led to higher total mortality.

BackgroundCountermeasures against COVID-19 outbreak such as lockdown and voluntary restrictions against going out adversely affect human stress and economic activity. Particularly, this stress might lead to suicide.ObjectWe examined excess mortality attributable to suicide caused by COVID-19. Method: We applied the NIID model to suicide deaths from October 2009 through September, 2021 for the whole of Japan by gender. Effects of the great earthquake that struck in eastern Japan on March 11, 2011 were incorporated into the estimation model. Results: Significant excess mortality in suicide was found between July, 2020 and July, 2021 for both genders. However, in August and September, 2021, excess mortality in suicide was detected only in female. It was greater among females than among males. In total, 2950 excess cases of mortality were identified.Discussion and ConclusionExcess mortality during the four months was more than two times greater than the number of COVID-19 deaths confirmed by PCR testing. Countermeasures against COVID-19 should be chosen carefully in light of suicide effects.

Background In Japan, as a countermeasure against the COVID-19 outbreak, both the national and local governments issued voluntary restrictions against going out from residences at the end of March 2020 in preference to the lockdowns instituted in European and North American countries. The effect of such measures can be studied with mobility data, such as data which is generated by counting the number of requests made to Apple Maps for directions in select countries/regions, sub-regions, and cities. Objective We investigate the associations of mobility data provided by Apple Inc and an estimate an an effective reproduction number R(t). Methods We regressed R(t) on a polynomial function of daily Apple data, estimated using the whole period, and analyzed subperiods delimited by March 10, 2020. Results In the estimation results, R(t) was 1.72 when voluntary restrictions against going out ceased and mobility reverted to a normal level. However, the critical level of reducing R(t) to Conclusions We demonstrated that Apple mobility data are useful for short-term prediction of R(t). The results indicate that the number of trips should decrease by 10% until herd immunity is achieved and that higher voluntary restrictions against going out might not be necessary for avoiding a re-emergence of the outbreak.

BackgroundSince the emergence of COVID-19, cases of excess mortality from all causes have been very few in Japan.ObjectTo evaluate COVID-19 effects precisely, we specifically examine deaths caused by pneumonia and examine excess mortality attributable to pneumonia in Japan.MethodWe applied the NIID model to pneumonia deaths from 2005 up through November, 2020 for the whole of Japan. Introduction of routine pneumococcal vaccination for elderly people and revision in ICD10 were incorporated into the estimation model.ResultsNo excess mortality was found for 2020. However, negative excess mortality was observed as 178 in May, 314 in June, and 75 in July. No negative excess mortality was not found between August and November.Discussion and ConclusionSignificantly negative excess mortality might reflect precautions taken by people including wearing masks, washing hands with alcohol, and maintaining social distance. They reduced the infection risk not only of for COVID-19 but also of other infectious diseases causing pneumonia.

Background To control the COVID-19 outbreak in Japan, sports and entertainment events were canceled and schools were closed throughout Japan from February 26 through March 19. That policy has been designated as voluntary event cancellation and school closure (VECSC). Object This study assesses VECSC effectiveness based on predicted outcomes. Methods A simple susceptible–infected–recovered model was applied to data of patients with symptoms in Japan during January 14 through March 26. The respective reproduction numbers for periods before VECSC (R0), during VECSC (Re), and after VECSC (Ra) were estimated. Results Results suggest R0 before VECSC as 2.534 [2.449, 2.598], Re during VECSC as 1.077 [0.948, 1.228], and Ra after VECSC as 4.455 [3.615, 5.255]. Discussion and conclusion Results demonstrated that VECSC can reduce COVID-19 infectiousness considerably, but after VECSC, the value of the reproduction number rose to exceed 4.0.

BACKGROUND In Japan, as a countermeasure against the COVID-19 outbreak, both the national and local governments issued voluntary restrictions against going out from residences at the end of March 2020 in preference to the lockdowns instituted in European and North American countries. The effect of such measures can be studied with mobility data, such as data which is generated by counting the number of requests made to Apple Maps for directions in select countries/regions, sub-regions, and cities. OBJECTIVE We investigate the associations of mobility data provided by Apple Inc and an estimate an an effective reproduction number R(t). METHODS We regressed R(t) on a polynomial function of daily Apple data, estimated using the whole period, and analyzed subperiods delimited by March 10, 2020. RESULTS In the estimation results, R(t) was 1.72 when voluntary restrictions against going out ceased and mobility reverted to a normal level. However, the critical level of reducing R(t) to CONCLUSIONS We demonstrated that Apple mobility data are useful for short-term prediction of R(t). The results indicate that the number of trips should decrease by 10% until herd immunity is achieved and that higher voluntary restrictions against going out might not be necessary for avoiding a re-emergence of the outbreak.

BackgroundIn Japan, as a measure to inhibit the COVID-19 outbreak, voluntary restrictions against going out (VRG) have been applied.ObjectMobility information provided by Apple Inc. and NTT Docomo were assessed in terms of its usefulness in predicting conditions exacerbating an outbreak.MethodA polynomial function was applied to daily Apple and Docomo data to calculate the observed R(t).ResultsThe correlation coefficient among Apple and Docomo data was 0.91. The adjusted coefficient of determination for R(t) for the whole study period was higher using Docomo data than when Apple data were used. When we regressed R(t) on daily Apple and Docomo data simultaneously, the estimated coefficient of Docomo data was not significant.Discussion and ConclusionWe demonstrated that Apple mobility data might be superior to Docomo data for explaining the entire course of the COVID-19 outbreak in Japan.

ObjectThe COVID-19 outbreak emerged in late 2019 in China, expanding rapidly thereafter. Even in Japan, epidemiological linkage of transmission was probably lost already by February 18, 2020. From that time, it has been necessary to detect clusters using syndromic surveillance.MethodWe identified common symptoms of COVID-19 as fever and respiratory symptoms. Therefore, we constructed a model to predict the number of patients with antipyretic analgesics (AP) and multi-ingredient cold medications (MIC) controlling well-known pediatric infectious diseases including influenza or RS virus infection. To do so, we used the National Official Sentinel Surveillance for Infectious Diseases (NOSSID), even though NOSSID data are weekly data with 10 day delays, on average. The probability of a cluster with unknown febrile disease with respiratory symptoms is a product of the probabilities of aberrations in AP and MIC, which is defined as one minus the probability of the number of patients prescribed a certain type of drug in PS compared to the number predicted using a model. This analysis was conducted prospectively in 2020 using data from October 1, 2010 through 2019 by prefecture and by age-class.ResultsThe probability of unknown febrile disease with respiratory symptom cluster was estimated as less than 60% in 2020.DiscussionThe most severe limitation of the present study is that the proposed model cannot be validated. A large outbreak of an unknown febrile disease with respiratory symptoms must be experienced, at which time, practitioners will have to “wing it”. We expect that no actual cluster of unknown febrile disease with respiratory symptoms will occur, but if it should occur, we hope to detect it.

BackgroundIncidence in children was much less than in adults during the COVID-19 outbreak. Sports and entertainment events were canceled (VEC) in Japan for two weeks during 26 February – 13 March. Most schools were closed (SC).ObjectWe construct a susceptible–infected–recovered model using three age classes and estimate the basic reproduction number (R0) and protection level among children simultaneously. Then we simulate SC and VEC effects.MethodWe used data of patients with symptoms in Japan during 14 January to assess SC and VEC introduction. Effects of SC and VEC were incorporated into the model through change in the contact pattern or frequencies among age classes.ResultsResults suggest R0 as 2.86 [95%CI of 2.73, 2.97]. The protection level was estimated as 0.4 [0.2, 0.7]. SC and VEC can reduce the total number of patients significantly, by 6–7%.Discussion and ConclusionThe estimated R0 was similar to that found from other studies in China and Japan. We found a significant protection level among children, and by effects of SC and VEC. Introduction

BackgroundTo control COVID-19 outbreak in Japan, sports and entertainment events were canceled in Japan for two weeks from 26 February to 11 March. It has been designated as voluntary event cancellation (VEC).ObjectThis study predicts the effectiveness of VEC enduring and after its implementation.MethodWe applied a simple susceptible–infected–recovery model to data of patients with symptoms in Japan during 14 January to VEC introduction and after VEC introduction to 8 March. We adjusted the reporting delay in the latest few days.ResultsResults suggest that the basic reproduction number, R0, before VEC introduced as 2.50 with a 95% confidence interval (CI) was [2.43, 2.55] and the effective reproduction number, Rv, after VEC introduced as 1. 88; its 95% CI was [1.68,2.02].Discussion and ConclusionResults demonstrated that VEC can reduce COVID-19 infectiousness by 35%, but R0 remains higher than one.

In Japan, some measles outbreaks were initiated by a tourist from oversea and foreign workers recently. Moreover, rubella outbreak emerged since July 2018 mainly in the South Kanto, and the outbreak is currently ongoing in 2019. It is important to maintain a high measles-rubella combined vaccine (MR) coverage for measles-rubella control. Vaccination coverage for the second dose of MR (MR2) is 90.8% in Tokyo in 2016, which was the third worst among all prefectures in Japan. The purpose of this study was to clarify determinant factors of vaccination coverage for MR2 in Tokyo. Data were obtained for 49 wards and cities in Tokyo in 2016. We regressed vaccination coverage of MR2 on the times of notification by mail, the proportion of households receiving welfare payments, and the proportion of non-Japanese elementary school students. In addition to the simplest specification, five factors were included separately as explanatory variables: the proportion of public health nurses; the ratio of the number of pediatric medical facilities to the number of preschool and elementary school children; the moving-in rate; the proportion of households with a single parent; and the proportion of households with husband and wife both working. Results show that a high proportion of households receiving welfare payments, notification by two or more letters, and moving-in rate or a lower proportion of non-Japanese elementary school students improve coverage. In conclusion, the health authorities can exert efforts to reduce burden of time spent for vaccination and provide sufficient information to improve coverage.

Objective The treatment completion rate for all latent tuberculosis infection (LTBI) patients in Tokyo was 83.6% in 2014: somewhat lower than the targeted goal of 85%. This study examines the association between risk factors and LTBI patients’ failure to complete treatment. Methods We collected data related to the treatment of LTBI patients who were reported to public health centers in Tokyo from January 2014 through December 2014. Data included potential risk factors affecting treatment, treatment results, and patient characteristics. We used Fisher's exact test to evaluate risk factors affecting failure to complete treatment. The failure rate was defined as the incompletion rate of treatment. Results Of 1060 notified cases, 877 had completed treatment; 116 had not completed treatment. Of these 116 cases, failure to complete treatment in 52 cases was attributable to side effects of anti-tuberculosis drugs. Reasons other than side effects were given for 64 cases. Another 67 cases could not be followed up. In all, 941 cases were analyzed, excluding cases lost to follow-up and cases for which patients had not completed treatment because of anti-tuberculosis drug side effects. Failure rates among foreign-born patients (26.9%) were significantly much higher than those among Japan-born patients (3.9%). Statistical tests indicated no presumed potential risk factor as significant. However, “no supporter for foreign-born LTBI patients” was marginally significant. Conclusion Only “no supporter for foreign-born LTBI patients” was found to be marginally significant. More data must be accumulated to assess the risk factors affecting LTBI treatment.

The number of notified syphilis cases in Tokyo has more than doubled in recent years. The number of reported primary and secondary syphilis cases increased from 108 cases (0.8 per 100,000 population) in 2007 to 245 cases in 2013 (1.9 per 100,000 population). During this period, the majority of cases was male (905/1,024), and the recent increase among primary and secondary syphilis cases was attributed to the increase among males (90/108 [83%] cases in 2007 to 218/245 [89%] cases in 2013); men aged 20-49 years contributed most to the increase, with those aged 30-34 years having the highest notification rate in 2013. Male-to-male transmission was the primary route of infection reported, and men who have sex with men (MSM) accounted for nearly 80% of male cases in 2013. Syphilis appears to be reemerging in Tokyo, and reducing the risk of acquiring syphilis among MSM aged 20-49 years should be a public health priority in Tokyo.

In nursery schools, influenza outbreaks have occurred every year. However, influenza characteristics of its diffusion among nursery schools, within each nursery school, and among classes of different ages in nursery schools remains unclear. This paper presents an examination of these matters using the Nursery School Absenteeism Surveillance System (NSASSy). All nursery schools in ward A in Tokyo introduced to the NSASSy in 2015. The study period was November 2015 through March 2016. The data of influenza patients were extracted from NSASSy. We examined four definitions of 'starting date of community outbreak' (SDCO) of influenza: 1) the first recorded day of influenza patients (SDCO1), 2) the last day of influenza patients recorded for two consecutive days (SDCO2), 3) three consecutive days (SDCO3), and 4) four consecutive days (SDCO4). We evaluated those four definitions by duration of the initial case at each nursery school from SDCO and evaluated the proportion of nursery schools at which the initial case occurred before SDCO. The average durations of initial cases at respective nursery schools from SDCO1-4 were 40.3, 26.3, 23.1 and 13.3 days. The respective proportions of nursery schools at which the initial case occurred before SDCO1-4 were 3.1%, 6.4%, 9.4% and 40.6%. Results demonstrate that SDCO3 is an appropriate definition of SDCO. Robustness checks for other areas, seasons, and population size constitute the next challenge for research in this area.

Telomeres are involved in the maintenance of genomic stability. Telomere alteration has been observed in most human cancer types, and is known to be a feature of malignancy. The aim of the present study was to evaluate whether the telomere length of breast cancer cells correlates with TNM stage and several pathological features. We investigated a total of 44 breast cancers, including 17 scirrhous, 15 papillotubular and 12 solid-tubular carcinomas. Telomere lengths were determined by tissue quantitative fluorescence in situ hybridization (Q-FISH), and compared according to the TNM stage, histological tumor size, lymph node metastases, vascular invasion and immunohistochemical status (ER, PR, HER2 status and Ki67 labeling index). In all histological types, telomeres of cancer cells were significantly shorter than those of normal epithelial cells. Mean telomere length was significantly less in patients with TNM stage III, and in those with large tumors, lymph node metastases and vascular invasion. Our results suggest that the telomere length of cancer cells is strongly correlated with the degree of cancer progression.

Introduction A large rubella outbreak has been occurring in Tokyo, Japan since June 2012. Rubella vaccination, introduced in Japan in 1976, has targeted different age groups, resulting in a large proportion of the current population being unvaccinated. Methods Rubella cases reported in Tokyo from 2 January 2012 to 21 April 2013 were analysed. A clinical case had generalized maculopapular rash, fever and lymphadenopathy; a laboratory-confirmed case was a clinical case with a positive serology or polymerase chain reaction test for rubella. A descriptive analysis of cases by age, sex, vaccination history and other epidemiological information was conducted. Results A total of 2382 cases were reported from all areas of Tokyo. Three-quarters were male (n = 1823; 76.5%); the highest number of cases occurred among males aged 35-39 years and females aged 20-24 years. About a third of males (27%) and females (32%) reported never receiving rubella vaccination, with 68% and 56%, respectively, having an unknown vaccination status. Discussion This outbreak reflects the changing, yet incomplete, immunization policies for rubella in Japan that may increase the risk of congenital rubella syndrome (CRS). To suppress the outbreak of rubella and prevent CRS cases, we recommend vaccination for the entire susceptible population.

The human epidermal growth factor receptor 2 (HER2) proto-oncogene plays an important role in the development and progression of breast and gastric cancer. Monitoring of the HER2 status and treatment with trastuzumab was performed initially in breast cancer, and subsequently in gastric cancer. However, the HER2 status of thyroid cancer remains unexplored. Telomere alteration and telomerase activity have been observed in most human cancers and are known to be a feature of malignancy. The aims of this study were to clarify the HER2 status of thyroid cancer and to examine any correlations to various characteristics of malignancy. We investigated 69 cases of differentiated thyroid cancers with reference to: i) telomere length as measured using tissue quantitative fluorescence in situ hybridization (Q-FISH), ii) expression of human telomerase reverse transcriptase (hTERT) as determined by immunohistochemistry (IHC), and iii) overexpression of the HER2 protein as determined by IHC and amplification of the HER2 gene as determined by fluorescence in situ hybridization (FISH). The telomeres of thyroid cancers, especially follicular carcinomas, were significantly shorter compared to those of adjacent normal tissues. Positivity for hTERT expression and HER2 amplification were observed in approximately 70 and 22% of thyroid cancers, respectively. Our data demonstrated that telomeres in HER2-positive cancers were significantly shorter compared to those in HER2-negative cancers. These results suggest that highly malignant differentiated thyroid cancer can be detected by monitoring HER2 status and telomere shortening, and that trastuzumab therapy may be effective for refractory thyroid cancer.

OBJECT We examined the relationship between syndromic surveillance and laboratory confirmation, at an early stage of an outbreak of hand foot and mouth disease and RS virus infection. METHOD We observed the epidemiological situation from a surveillance system at a day care facility for young children in Tokyo from one week before onset of the indicator until one month thereafter. For laboratory diagnosis, we collected a rectal swab or a nasal swab from one patient in the early stage of the outbreak. RESULT A total of 20 patients, comprising 12 1-year-old, 5 2-year-old and 3 3-year-old children, were found to have hand foot and mouth disease on August 1st, 2011. From a rectal swab from one HFMD patient, enterovirus genome was detected and identified as coxsackievirus type A6 (CA6) with PCR sequencing. The CA6 had 99% identity to CA6 (Genbank No AB663318) in the VP4 coding region. RS virus also was detected from a nasal swab. DISCUSSION The establishment of a surveillance system at day care facilities for children can monitor infectious diseases among young children promptly. Laboratory confirmation, even though from only one patient as shown in this study, can provide critical information regarding the causative agent of the outbreak. This method is easy to conduct and could be used for activating appropriate countermeasures. CONCLUSION We believe that the combination of the timeliness of a surveillance system at day care facility for children and the convenience of laboratory diagnosis of even one patient can detect the causative pathogen, and thus enable the activation of countermeasures before an outbreak become widespread.

PURPOSE The BCG immunization has long been performed in Japan. Although the BCG immunization service is the responsibility of the municipality, the manner in which the BCG immunization is delivered differs from municipality to municipality. The purpose of this study was to clarify how the different manner of the BCG immunization delivery systems influenced the BCG immunization coverage. METHODS The study of BCG immunization coverage was conducted in the Tama area located in the western suburbs of Tokyo in 2004. The birth data and the immunization history by the age of 3 years were collected in the three-year-old health check-up from a total of 2,341 children residing in the Tama area. Based on the age at immunization for each child, the BCG immunization coverage was calculated according to the types of the BCG immunization delivery system. The immunization types were defined as follows; the BCG immunization given on the occasion of the mass health check-up (Group 1); the exclusive mass BCG immunization in a monthly service (Group 2); the exclusive mass BCG immunization in a bimonthly service (Group 3); the exclusive mass BCG immunization in services of fewer than every two months (Group 4); and the immunization given on an individual basis by a general practitioner (Group 5). A univariate analysis was performed to examine the relationship between the BCG immunization coverage by the age of 6 months and the difference among the BCG immunization delivery systems, followed by a multivariate regression analysis to adjust for the factors related to the demography, health care services and the socio-economic status of the municipalities. RESULTS Unadjusted odds ratios and adjusted odds ratios for BCG unimmunized children under the age of 6 months by the BCG immunization delivery manner groups were OR 1 reference, adj. OR 1 reference in Group 1; OR 1.42 CI 0.87-2.29, adj. OR 4.01 CI 2.24-7.11 in Group 2; OR 4.96 CI 3.66-6.82, adj. OR 15.59 CI 10.10-24.49 in Group 3;OR 18.60 CI 13.77-25.49, adj. OR 48.17 CI 29.62-79.75 in Group 4; and OR 4.24 CI 2.86-6.31, adj. OR 15.61 CI 9.05-27.26 in Group 5. The univariate analysis and multivariate regression analysis revealed an influence of the BCG immunization delivery manner on the BCG immunization coverage. CONCLUSION The choice of BCG immunization delivery manner is very important to raise the BCG immunization coverage. The BCG immunization given on the occasion of the mass health check-up and the high-frequent immunization service are thought to improve the BCG immunization coverage.

We conducted syndromic surveillance for the Hokkaido, Japan, Toyako Group of Eight (G8) summit meeting in July 2008 as a counter-measure to bioterrorism attacks and other health emergencies. Surveys were conducted from June 23, two weeks before the summit, to July 23 two weeks after it, with part of those for prescription drugs fully automated, and part by manual input over the World-Wide-Web. Those for ambulance transfer were done similarly. We bought over-the-counter (OTC) sales data from two private research firms in Japan and had the monitor, who had contacts with a private research company, report health conditions via personal computer (PC) or cellphone. We had a virtual conference daily at 9:00 with the local Hokkaido government, local public health center, local Hokkaido public laboratory, the National Institute of Infectious Diseases, and the Ministry of Health, Labor and Welfare to decide whether local public health centers would be required to investigate. Fully automated syndromic surveillance was conducted by 23 pharmacies for prescriptions drugs, and 71 pharmacies provided manual corporate input. One fire department covering Toyako and a VIP support team used fully automated syndromic surveillance and seven Toyako fire departments used manual input. For 79 pharmacies providing OTC sales data, data provision was delayed one day and analysis could not be automated. Four hundred and seventy two households corporate web search for their health conditions. It also automatically analyzed and feed backed. No notable outbreak occurred during the summit, but public health centers investigated seven aberration detected by syndrome surveillance for ambulance transfer. Although a fully automated system was concidered best for early outbreak detection manual input and analysis were also required. Routine, fully automatied syndromic surveillance remains to be realized in Japan.

Rubella is usually a mild illness, with febrile rash being its main symptom. However, serious consequences of rubella infection can result when the infection occurs during the early stages of pregnancy. After the occurrence of a rubella outbreak in Japan that was observed from 2012 to 2013, 45 infants were reportedly born with congenital rubella syndrome (CRS). We prospectively followed the 15 CRS cases reported in Tokyo to determine the virus shedding periods by using nested reverse transcriptase-polymerase chain reaction to detect rubella virus genes. Throast swabs were used for virus detection. The virus shedding period was measured from birth until the time when the sample last tested positive followed by 2 consecutive negative samples. Kaplan-Meier method was used to estimate the proportion of cases remaining positive for rubella virus genes over time. The proportion of CRS cases shedding virus dropped steadily after birth, dropping to 33.8% at 6 months and 16.9% at 12 months. Our findings also suggested that the earlier the mother's onset of rubella during pregnancy, the longer the infant remained positive. Based on our findings, we believe that infants with CRS should be monitored for rubella virus shedding until 1 year of age.

In general, juvenile differentiated thyroid carcinoma (DTC) demonstrate indolent characteristics and favorable prognosis are observed in comparison with many other carcinomas. However, recurrence is frequent, necessitating additional treatment, including radioactive iodine (RAI) therapy. In this report, the probability of recurrence, prognostic factors, treatment, and outcomes in both juvenile- and adult-onset DTC were analyzed and compared. At our institution, a total of 1552 DTC patients underwent thyroidectomy and/or lymph node dissection. The patients included 23 in their teens, 118 in their twenties, and 1412 in their thirties or older. The risk factors for distant metastases for DTC were male gender, follicular carcinoma, size of the PTC primary tumor, cervical lymph node metastases from PTC, and the presence of more than two distant metastatic foci. Patients with the highest risk underwent RAI ablation in line with institutional guidelines. Although the overall outcome in our juvenile patients was excellent, during follow-up, 4 (17.4%) of the 23 patients developed recurrent disease: 91.3% achieved complete remission, 4.35% partial remission, and 4.35% stable disease, with no disease-related deaths. Among the 118 patients in their twenties to thirties, 1 (0.8%) experienced progressive disease and disease-related death. A younger age at diagnosis and less radical primary surgery without subsequent RAI ablation are factors strongly predictive of distant metastases in patients with juvenile-onset DTC. To reduce the rate of relapse and improve surveillance for recurrent disease, total thyroidectomy followed by RAI appears to be the most beneficial initial treatment for patients with high- and intermediate-risk juvenile DTC.

A large rubella outbreak has been observed since June 2012 in Tokyo, Japan, and a rapid increase in the number of congenital rubella syndrome (CRS) cases have also been reported in Japan since October 2012. All the clinically diagnosed and laboratory-confirmed rubella cases reported in Tokyo from January 2012 to December 2013 and all the laboratory-confirmed CRS cases from January 2012 to March 2014 were analyzed. In total, 4,116 rubella cases were reported in Tokyo. Of these, 77.2% (n=3,176) were male; the highest number of cases occurred in males aged 35-39 years and in females aged 20-24 years. Complications included arthralgia/arthritis (19.4%), thrombocytopenic purpura (0.5%), hepatic dysfunction (0.3%), and encephalitis (0.1%). The circulating rubella virus in Tokyo was genotype 2B. The most possible site of transmission was the workplace. Because of the rubella epidemic, 16 CRS cases were reported in Tokyo from March 2013 to February 2014. Domestic infection with rubella was proven for all mothers of 16 cases. This situation suggests that Japan is still working to achieve rubella elimination.

The epidemiological and histopathological characteristics of the mass mortality of cultured Japanese pearl oysters Pinctada fucata martensii were investigated. Rearing experiments with Japanese pearl oysters in farms revealed that the mass mortality occurs as a regular annual event in particular farms in western Japan. Diseased oysters had marked atrophy and red-brown discoloration of the soft parts of the body. Light microscopy revealed that the epithelia of the stomach, the ducts of the digestive diverticula (DD), and the DD themselves showed marked blebbing and necrosis to varying degrees during earlier stages of the disease. At advanced stages, muscle fibers of the adductor muscle, heart, mantle, and other parts of the body and the connective tissues of various organs involving the vascular system also exhibited considerable atrophy and necrosis. There were no remarkable changes in the branchial and pallial epithelia. No viral, bacterial, mycotic, or parasitic causative organisms were found in diseased oysters. The results of a case study of mass mortality at one farm suggested that there is some causal relationship between outbreaks of this disease and the existence of neighboring fish farms. These findings suggest that the mass mortality is not due to an infectious disease. We discuss pathological features and possible causes of this disease., Journal of Aquatic Animal Health, 17(4), pp.323-337; 2005

The effects of exogenous lipid peroxides, suspected to be a cellular injury factor that causes mass mortalities of cultured Japanese pearl oysters Pinctada fucata martensii, were investigated in vivo and in vitro. Cumulative mortalities of experimental oysters exposed to oxidized oils in suspension (fish feed oil) or emulsion (methyl linoleate) were approximately 40% after 8 or 9 weeks, whereas mortalities were 0.0% (suspension) and 5.6% (emulsion) in control oysters exposed to unoxidized oils. Pathological changes observed in experimental oysters were characterized by blebbing and necrosis of cells in various organs that had spread from the digestive organ and were identical to those observed in diseased oysters from natural mass mortalities. The thiobarbituric acid values of experimental oysters were consistently and significantly higher than those of control oysters. An in vitro exposure examination also demonstrated that oxidized oil caused conspicuous blebbing and necrosis in the epithelial cells of the digestive organ. These results suggest that organic pollution caused by suspended solids containing lipid peroxides, emulsion of oxidized oils, or both is a major environmental factor that chronically damages tissues of cultured oysters and can cause mass mortalities., Journal of Aquatic Animal Health, 17(3), pp.233-243; 2005

The study was conducted with the intention of establishing a strategy to eliminate measles on the basis of an analysis of the epidemiological profile of measles cases reported in Tokyo during the year 2011.We investigated measles cases reported to the Tokyo Metropolitan Government in 2011, recorded as part of the National Epidemiological Surveillance of Infectious Diseases. Factors analyzed included age, vaccination status for each patient, cases for which records were discarded after laboratory confirmation, genotype of the measles virus and relationships between dates of specimen collection and results of polymerase chain reaction (PCR) and IgM antibody tests.A total of 178 measles cases were reported in Tokyo during 2011, and the majority of cases (128, 71.9%) were reported during the peak period from epiweeks 13 to 24. The largest age group reported was one to four years of age (40, 22.5%) followed by groups of 20-29 and 30-39 years of age (both 34, 19.1%). Most cases were sporadic, with only six outbreaks occurring. Even then, the numbers of cases for each outbreak was less than five. More than half of the patients in all age groups, except for the 1-4-year-old group, had not been vaccinated or did not have a record of vaccination. Genotypes D4 and D9 of measles virus were detected in most cases. However, genotype D5, which had been circulating in Japan before 2008, was not detected.Imported viruses were the cause of measles cases reported in Tokyo during 2011. The disease control was better than that in 2007 and 2008 because of the swift and appropriate responses to the occurrences. It is also possible that there has been an increase in the proportion of people with immunity to measles. Increasing the rate of immunization, performing effective surveillance, and confirming suspicious measles cases by using molecular methods are important for achieving the elimination of measles.

It was shown in the rat thyroid that thyroglobulin (Tg) stored in the follicular lumen is a potent regulator of thyroid-specific gene expression to maintain the function of individual follicles. However, the actions of Tg as a regulatory molecule in human thyroid have not been studied.Our objective was to determine the effect of Tg on gene expression in normal and diseased human thyroid and to examine whether the proposed model of negative-feedback autocrine regulation of thyroid function by Tg is applicable in the human as well as the rat.Primary cultures of human thyrocytes were established from normal thyroid, Graves' disease thyroid, adenomatous goiter, follicular adenoma, and papillary carcinoma tissues obtained during surgery. Cells were stimulated with physiologic (ie, follicular) concentrations of Tg, and mRNA and protein expression of genes involved in thyroid hormonogenesis were evaluated. The effects of Tg on thyroid-specific gene expression were also assessed in 2 human papillary carcinoma cell lines.Transcript levels of genes participating in thyroid hormone biosynthesis were significantly reduced by Tg in thyrocyte cultures derived from normal and Graves' thyroid, but not in cultures derived from thyroid neoplasms and adenomatous goiter.It was confirmed that Tg acts as a negative-feedback regulator of gene expression in human thyrocytes, suggesting that Tg signaling may constitute a common mechanism for maintaining thyroid homeostasis in species with follicular thyroid morphology. However, certain diseases of intrinsic thyroid overgrowth appear to be associated with an escape from the regulatory mechanism of Tg.

It is well-known that differentiated thyroid carcinoma (DTC) has a generally indolent character and shows a favorable prognosis in comparison with many other carcinomas. The therapeutic strategy for patients with DTC in Japan has differed from that in Western countries. Total thyroidectomy followed by radioactive iodine (RAI) ablation has been standard in Western countries, whereas limited hemi-thyroidectomy and subtotal thyroidectomy has been extensively accepted in Japan. Papillary thyroid carcinoma (PTC) accounts for over 90% of all thyroid cancers in Japan. The majority of patients with PTC are categorized into a low-risk group on the basis of the recent risk-group classification schemes, and they show excellent outcomes. Several management guidelines for thyroid cancers have been published in Western countries. However, the optimal therapeutic options for PTC remain controversial, and high-level clinical evidence aimed at resolving these issues is lacking. Moreover, as socioeconomic differences in medical care exist, conventional policies for the treatment of PTC have differed between Japan and other countries. This review focuses on the special features of treatment in Japan for patients with low-risk DTC involving subtotal thyroidectomy without adjuvant therapies, rather than total thyroidectomy with RAI, with the aim of preserving quality of life. At our institution in Japan, we have had extensive experience with RAI treatment for high-risk DTC patients, and this represents a very rare situation. Here we introduce the therapeutic strategy for low-risk thyroid cancer in Japan, including the measures adopted at our institution.

Background: When high profile events such as mass gatherings or political events are held, syndromic surveillances are enhanced to quickly detect health emergencies. Drawing on past experiences, enhanced surveillance was conducted during the Fourth Japan-China-South Korea Trilateral Summit (May 21-22, 2011). This report describes the details and results of the enhanced syndromic surveillance. Methods: Enhanced surveillance started on May 18, and ended on June 4, two weeks after the meeting, using three existing surveillance systems that operate routinely: Official Syndromic Surveillance, Ambulance Transfer Syndromic Surveillance, and Pharmacy Surveillance. The enhanced surveillance was a joint work between the Tokyo Metropolitan Government and the National Institute of Infectious Diseases. Information from the three surveillance systems was mutually exchanged and daily risk assessment on potential health emergencies such as bioterrorism and potential epidemics of infectious diseases was performed jointly. Results: During the enhanced surveillance period, the only case that required verification was one suspected measles case from the report in the Official Syndromic Surveillance. None of the cases in the Ambulance Transfer Syndromic Surveillance or the Pharmacy Surveillance required additional investigation. All three syndromic surveillance systems that were utilized for the enhanced surveillance are run routinely, and the enhancement areas were simply conducting the daily risk assessment and reporting. Therefore, the enhanced surveillance is conducted only by agreements and arrangements among members. In spite of very short notice, we were able to initiate the enhanced surveillance because the existing surveillance required no baseline or other preparation. The burden of implementation of surveillance was significantly small in comparison with the previous enhanced surveillance. Conclusions: It is possible to activate the enhanced surveillance arrangements whenever needed. We were able to make a comprehensive assessment by utilizing three syndromic surveillance systems, which we believe are useful in detecting a possible case of bioterrorism.

We examined the relationship between syndromic surveillance and laboratory confirmation, at an early stage of an outbreak of hand foot and mouth disease and RS virus infection.We observed the epidemiological situation from a surveillance system at a day care facility for young children in Tokyo from one week before onset of the indicator until one month thereafter. For laboratory diagnosis, we collected a rectal swab or a nasal swab from one patient in the early stage of the outbreak.A total of 20 patients, comprising 12 1-year-old, 5 2-year-old and 3 3-year-old children, were found to have hand foot and mouth disease on August 1st, 2011. From a rectal swab from one HFMD patient, enterovirus genome was detected and identified as coxsackievirus type A6 (CA6) with PCR sequencing. The CA6 had 99% identity to CA6 (Genbank No AB663318) in the VP4 coding region. RS virus also was detected from a nasal swab.The establishment of a surveillance system at day care facilities for children can monitor infectious diseases among young children promptly. Laboratory confirmation, even though from only one patient as shown in this study, can provide critical information regarding the causative agent of the outbreak. This method is easy to conduct and could be used for activating appropriate countermeasures.We believe that the combination of the timeliness of a surveillance system at day care facility for children and the convenience of laboratory diagnosis of even one patient can detect the causative pathogen, and thus enable the activation of countermeasures before an outbreak become widespread.

The BCG immunization has long been performed in Japan. Although the BCG immunization service is the responsibility of the municipality, the manner in which the BCG immunization is delivered differs from municipality to municipality. The purpose of this study was to clarify how the different manner of the BCG immunization delivery systems influenced the BCG immunization coverage.The study of BCG immunization coverage was conducted in the Tama area located in the western suburbs of Tokyo in 2004. The birth data and the immunization history by the age of 3 years were collected in the three-year-old health check-up from a total of 2,341 children residing in the Tama area. Based on the age at immunization for each child, the BCG immunization coverage was calculated according to the types of the BCG immunization delivery system. The immunization types were defined as follows; the BCG immunization given on the occasion of the mass health check-up (Group 1); the exclusive mass BCG immunization in a monthly service (Group 2); the exclusive mass BCG immunization in a bimonthly service (Group 3); the exclusive mass BCG immunization in services of fewer than every two months (Group 4); and the immunization given on an individual basis by a general practitioner (Group 5). A univariate analysis was performed to examine the relationship between the BCG immunization coverage by the age of 6 months and the difference among the BCG immunization delivery systems, followed by a multivariate regression analysis to adjust for the factors related to the demography, health care services and the socio-economic status of the municipalities.Unadjusted odds ratios and adjusted odds ratios for BCG unimmunized children under the age of 6 months by the BCG immunization delivery manner groups were OR 1 reference, adj. OR 1 reference in Group 1; OR 1.42 CI 0.87-2.29, adj. OR 4.01 CI 2.24-7.11 in Group 2; OR 4.96 CI 3.66-6.82, adj. OR 15.59 CI 10.10-24.49 in Group 3;OR 18.60 CI 13.77-25.49, adj. OR 48.17 CI 29.62-79.75 in Group 4; and OR 4.24 CI 2.86-6.31, adj. OR 15.61 CI 9.05-27.26 in Group 5. The univariate analysis and multivariate regression analysis revealed an influence of the BCG immunization delivery manner on the BCG immunization coverage.The choice of BCG immunization delivery manner is very important to raise the BCG immunization coverage. The BCG immunization given on the occasion of the mass health check-up and the high-frequent immunization service are thought to improve the BCG immunization coverage.

BCG vaccination using the multipuncture percutaneous method has long been employed in Japan. The purpose of this study is to clarify whether the number of needle scars achieved the BCG vaccination differs with the vaccinating physician.A total of 218 babies who were vaccinated at the age of 4 months by different physicians at the Public Health Centres of Katsushika-Ward, Tokyo, were examined at the age of 3 years, in the three-year-old health check-up programme. The BCG vaccination with the multipuncture method generates 18 needle scars at a maximum. We examined each child for how many needle scars after BCG vaccination were visible, with reference to the vaccinating physician.The mean number of the visible scars was 9.23 (SD 6.11), and significantly smaller (P0.01) than that for all 22 Wards (12.18 +/- 5.64) investigated with the same method. The mean number of needle scars of the babies in Katsushika Ward was the third smallest among the 22 Wards and significantly smaller (P0.05) than the national average as determined in the nationwide survey conducted in 2000. Significant differences were evident among the 7 physicians performing the vaccination, the best and second best means being 15.26 (SD3.62) and 14.59 (SD3.58) respectively, and significantly larger (P0.01) than the means for the 7 physicians. The worst mean was 3.43 (SD4.46), significantly smaller (P0.01) than the mean for the 7 physicians.The mean number of needle scars after BCG vaccination of babies significantly differed with the 7 physicians in the present study. Poor technique was presumed responsible for small numbers of scars and technical training is therefore necessary in order to improve the BCG vaccination outcome.