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Ist die Eradikation der Tuberkulose in der Bundesrepublik ein erreichbares Ziel?
Abstract
Tuberculosis as an epidemic is receding during the last 200 years.
This process began already at a time when no specific medical counter measures were available and the aetiology, the method of protective vaccination and specific therapy were unknown. The receding of the epidemic runs parallel with the development of civilization.
Since the discovery of the causative micro-organism and the develpment of antimycobacterial therapy man can further promote this regression. To achieve this, the most important aids are massminiature examinations and masstuber-culinsurveys. A rational use of both these methods must of necessity drop the BCG vaccination of newborns.
For epidemiological purposes and easiest organization the use of the most simple Tuberculintesting equipment in the form of the Tine- or Behringtest is recommended.
The introduction of an effective and uniform campaign against tuberculosis by mutual agreement of all European countries is considered essential.
Das Ziel aller epidemiologisch wirksamer Maßnahmen der Tuberkulosebekämpfung ist die Eradikation dieser Infektionskrankheit. Die im Rahmen der Tuberkulosevorbeugung eingesetzten Methoden wirken jedoch auf verschiedenen Wegen. Die Expositionsprophylaxe gilt der Verhütung der Tuberkuloseinfektion. Ihr dient die Aufdeckung aller, besonders der ansteckungsfähigen Tuberkulosen, ihre ausreichende, d. h. möglichst die Eradikation des Infektes anstrebende, als Mindestergebnis fordernde Beseitigung der Bakterienausscheidung durch die Therapie wie die Überwachung und Isolierung der Keimausscheider. Mit der Dispositionsprophylaxe soll die natürliche Tuberkuloseabwehr verstärkt werden. Dazu gehören alle der Gesundheitsförderung dienenden Maßnahmen für den Einzelnen wie in der Gemeinschaft. Hierzu ist auch die Erhöhung der spezifischen Resistenz durch die Immunprophylaxe zu rechnen. Schließlich sind die der Überwindung, zumindest aber der Eindämmung einer Infektion dienende Chemoprophylaxe wie die präventive Chemotherapie zu nennen.
The author overlooks the development of tuberculin diagnostics. He gives a report of his own intradermic tests according toMendel-Mantoux in the various groups of inhabitants — done with the 5 TU of Hungarian PPD (of mammalian mycobacteria) and with the PPD sensitines of atypical mycobacteria. These tests aimed to determine the degree of virulent mycobacteria tuberculosis infection of children vaccinated again with BCG and to state the degree of sensitivity with atypical mycobacteria in the various groups of inhabitants.
Among the BCG vaccinated patients those who were infected accidentally cannot be separated.
The results of the population's tests show that atypical mycobacteria sensitivity did not occur in great quantities in that county.
Reference is made to the realization of tasks of the betterment of the expressiveness of tuberculin diagnostics in the interest of the total elimination of tuberculosis in Hungary.
In den Jahren 1965–1967 wurden in drei Kreisen des Bezirkes Leipzig (1,512 Mill. Einwohner) bei 42 235 Personen Tuberkulintestungen mit 2 TE durchgeführt. Bei 38 572 Personen konnte das Ergebnis abgelesen werden. Wenn wir die positive Reaktion ab 1 mm rechnen, so finden wir bei den Männern 77,6% positiv und bei den Frauen 68,1%. Wenn wir die Reaktion positiv erst ab 5 mm setzen, so finden wir bei den Männern 57,2% und bei den Frauen 42,4% Positive. Bei einem Vergleich der gesunden Bevölkerung eines Kreises mit den sogenannten gesunden Befundträgern (Patienten mit inaktiven tuberkulösen Lungenbefunden) zeigen sich keine signifikanten Unterschiede bei den Tuberkulinreaktionen, außer in der Gruppe der 30–39jährigen. Auf die zunehmende Bedeutung der Tuberkulin-Reaktion bei der weiteren Bekämpfung der Tuberkulose wird ausdrücklich hingewiesen.
A series of 1,716 BCG-vaccinated and 1,665 nonvaccinated infants, all born at the Cook County Hospital in Chicago between February, 1937, and February, 1948, were followed until February, 1960 (23 years). Among the vaccinated there was a total of 17 cases of tuberculosis (0.43/1,000/yr) and 65 cases in the nonvaccinated 1.7/1,000/yr), a reduction of 75%, statistically highly significant (p 0.001). The morbidity was 0.41/1,000/yr (16 cases in 1,716) in the vaccinated subjects and 1.5/1000/yr (59 cases in 1,665) in the controls, or a reduction of 74% (p 0.001). There was one death from tuberculosis in the vaccinated subjects and six in the controls, or a reduction of 83%. The number of deaths is too small for meaningful statistical analysis.
Comparisons of the control and vaccinated groups were made for subsequent contact to tuberculosis in the home and environment, sex, race, birth weight, observation years, follow-up care, general health and reasons for loss from study. The over-all comparability of the two groups was adequate in most respects. Statistically significant differences were assessed for medical importance. In 639 families in which there were both vaccinated and control siblings, 8 of the 790 vaccinated subjects developed tuberculosis as compared with 30 of the 845 control individuals. The difference is highly significant (p 0.001). Thirteen cases of nonfatal tuberculosis developed in the controls 2 years of age and under and none in the vaccinated. There were three deaths from tuberculosis in the controls under 2½ years of age (miliary tuberculosis plus meningitis in all) and one death in the vaccinated group (meningitis). The latter was an infant who had not converted at 6 months of age and was not revaccinated. Following vaccination, 99.3% became tuberculin positive and 82.4% were still positive, after 8 years, to a single vaccination.
Zusammenfassung 1.Unter den Tuberkulin-negativen Säuglingen aus der Umgebung Offen-Tuberkulöser stammt der größte Teil aus dem Haushalt solcher Kranker, die nur wenig oder keinen Katarrh auf ihren Lungen aufzuweisen haben.2.Ist das hygienische Verhalten dieser Kranken einwandfrei, so haben die betr. Säuglinge noch günstigere Aussichten, von der Infektion verschont zu bleiben.3.Wenn die Vorbedingungen unter 1. und 2. erfüllt sind, ist somit die zwangsweise Entfernung des Kindes seitens der Fürsorgestellen nicht gerechtfertigt.
The usefulness of BCG vaccination in reducing the incidence of tuberculosis in a community depends not only on the extent to which the attack rate in converters is reduced, but also on such epidemiological features of the community as the percentage positive, the attack rate in them, and the conversion rate for tuberculin negatives. The published results of controlled trials of BCG are considered: three show a reduction in tuberculosis of about 80% in vaccinated negatives compared with unvaccinated negative controls. In one trial the reduction is about 60% but, in two parts of another trial, the reduction is only a little over 30%. Possible reasons for these differences are discussed. Assuming that BCG does have a protective effect of about 75%, the circumstances in which it is most likely to be of value are considered. The annual conversion rate to be expected in negative reactors left unvaccinated is the most important measure in this decision-if more than 5-10% of negatives are likely to be infected within ten years, BCG is well worth while. The percentage tuberculin positive in the community is of far less importance, at least in the range 0-25% positive. As tuberculosis comes under control, a position is ultimately reached where the tuberculin conversion rate, and therefore the tuberculosis attack rate in tuberculin negatives, is so low that BCG is no longer justified.
Handbuch der Tuberkuloseforschung, Bd. I. Stuttgart: Verlag Georg Thieme
- F Redeker
- F. Redeker