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1 Infectious Agents Surveillance Report (IASR) / : 3, 5, 6, 7, 1317 CV-A6 8, 9, EV-D68 : 1, 17 EV- A71 11, EV-A71 1, EV-A7113, CV-B : 1, : 16, B : 17, 18 Vol. 38 No Vol.38 No.1 No.5 ISSN Tel , 1,, :,,, ,, , 5 5, 3 3, 1,, 5 mm, , kekkaku-kansenshou11/1-5-.html, kekkaku-kansenshou11/1-5-5.html, A Enterovirus A, A6, A16 CV-A6, CV-A16, A71 EV-A71, A, A6, A1 CV-A, CV-A6, CV-A1, : IASR 33: 55-56, 1, IASR 6: 35-36, 5 : 717 1, 11 11, 13, 15, 17, ,,, 3,, 9 5, 6 5, 15 Lancet Infect Dis 1: , A CV-A6, CV-A16, EV-A71 CV-A6 11, 1, 3 5 EV- A71 1, 13, 1, CV-A, CV-A6, CV-A1, CV-A, CV-A5, CV-A8, ja/iasr-sp/51-graphs/89-iasrgnatsu.html :

2 19 Vol. 38 No , 7 8, RD 9 Vero 1 11, 1 13, 1, , Konno, et al., 16 JJID 6: , 11, go.jp/jjid/6/167.html,,, 7 8, 9 1, VP- 11 VP, VP CODEHOP RT-semi-nested PCR 1 15,, 16 VP1 IASR 3: 1-13, 91, 9 :, CV-A6, 9, IASR 33: 55-56, 1, 1117, CV-A6 3, 5, 6 & 7 5 CV-A6,,,, 38,, 8, Lancet Infect Dis 1: 83-86, 1 : 199,,,,,,, EV-A71, 11,, EV-A71,, , 8,8,,57 Lancet Infect Dis 1: , 1 5, EV-A71, IASR 19: 55, 1998 & 8: 3-3, 7, EV-A71,, EV-A71,, CV-A6 5, EV-A71 IASR 37: 33-35, 16 :,,,, 16, EV- A71 13 :, A, B Enterovirus B,, 93,699 15,185 68, ,1 37,7 7,8 33,339 83,69 381,7 69,139* * * 16,15 113,79 75, ,9 139,78 11,58 9, , 98,1 19,371*

3 Vol. 38 No , ,,, 6/16/181.3, 7 7/3 7/ , 31 7/318/ , , 11, 1, 1a, RD- A, A59, Vero VeroE6 1-3, HPeV , A CV-A6 55, HPeV-3 1, 1 1 CV- A6 9, 11, 13 CV-A6, 15 CV-A6 CV-A16, a11, CV- A16 A71 EV-A71, CV-A6, 17 CV-A6. 17, 8 7/17/161., 31 7/318/6., 9 THE TOPIC OF THIS MONTH-Continued Figure 5. Monthly number of Enterovirus A detected, based on reported clinical diagnosis, January 7 to September 17, Japan No. of detections 5 15 Enterovirus A Coxsackievirus A Other Herpangina Hand, foot, and mouth disease Coxsackievirus A6 Coxsackievirus A1 Coxsackievirus A Month Year 1713 (Infectious Agents Surveillance Report: as of October 3, 17)

4 a Vol. 38 No CV-A6 CV-A1 CV-A16 EV-A a b CV-A CV-A CV-A5 CV-A6 CV-A b. 8177, 1 11., 11, 1 6, 1, 16 1b, , CV-A6, , 1 CV-A, 11 CV- A1, 1 CV-A CV-A5, 1 98 CV-A, 16 CV-A CV- A1, CV-A, CV-A1, b 3. CV-A6 3. CV-A6VP19ntML CV-AHigh Point 11, CV-A6, 817 CV-A6 1 VP1 9nt 3, 9 Group A Group B, 9 Group A Bootstrap : 98, Group B Bootstrap : 89VP1 Group A., Group B 5., Group A Group B 7.7 CV-A6,

5 Vol. 38 No , 9 Group B, 11 1, CV-A6 17 CV-A6,,, 1, 111: , 1997, 8: 55-57, 8 3Nix WA, et al., J Clin Microbiol : 698-7, 6 Harvala H, et al., J Clin Microbiol 6: , EV /, 11, 13, 15, A71 EV-A71, 11, 13, 15, 17 A6 CV-A6,,,, 1 CV-A6, 11 A16 CV-A16, 13 EV-A71, 15 CV-A16, 17 EV-A71, 3. EV EV-A71, CV- A6, CV-A16,,,,,,,,,,, EV-A71, 1, CV-A6, EV-A71,, CV-A CV-A6, 13 1

6 6196 Vol. 38 No EV-A71CV-A6CV-A16 1 CV-A6 15, CV-A6, EV- A71,. EV-A71, CV-A6,,,, CV-A6 n=61ev-a71 n=9, 39. CV- A6 : 1, EV-A71 : 1, CV-A6 : 6, EV-A71 :,, CV-A6 : 61, EV-A71 : 3,, CV-A6 5.,,,,,, /index.html, IASR 5: 6-7, 3, IASR 3: 3-31, 11 17, , 13, 15,,1,,11, 6,386, A6 CV-A , 17 31,878, 17 : , 17 : 3 Real-time RT-PCR EV, CODEHOP PCR 3 CV-A6 viral protein 1 VP1 RT-semi-nested PCR 1 VP1, : EV EV, CV-A6 73.7, 1/19, EV- A71 1.1, /19, Echotype 7 5.3, 1/19CV-A6, 1 :, 3 : 1, 5 : 1, 6 : 5, 7 : 5, EV-A71, 6 :, 7 : : 17, 11, 13, 15 CV-A6, CV-A6, 17

7 CV-A6, EV-A71 EV-A71,,, 1Kanbayashi D, et al., J Med Virol, 17 Aug 3, doi:1.1/jmv.95 Epub ahead of print Kaida A, et al., Jpn J Infect Dis 67: 69-75, 1 3Nix WA, et al., J Clin Microbiol 6: 519-5, 8, IASR 5: 6-7, , 8 5., 3 1., 9 3, 33, , CV-A6 EV-A71 Echo type , , 1, 1, 1,, , 1, RD-A, A59,, RD-A, VP1 CODEHOP VP1 RT-semi-nested PCR 1, 3. : 1 1, A6 CV-A6 3, CV- A16, CV-A1, A71 EV-A71, CV-A5, Echo3 1 CV-A6 17, EV-A71, CV-A16, CV-A5 CV-A1 1 : 13 1, CV-A5 6, CV-A 3, CV- A1, CV-A6, Echo CV- A, CV-A5, CV-A1 CV- A6, 3 CV-A5, CV-A1, CV-A16, EV-A71, EV-A71 3, Vol. 38 No

8 8198, CV-A CV-A5, CV- A1, CV-A6, CV-A1, CV-A CV-A5 CV-A16 EV-A71, 15, 1Nix WA, et al., J Clin Microbiol : 698-7, 6 IASR 33: 55-56, CV-A5 CV-A6 CV-A1 CV-A16 EV-A71 Echo CV-A CV-A5 CV-A6 CV-A1 Echo CV-A6 A6 3 3/3 88., 38.9, 1.5, A16 CV-A16, A6 CV-A6, 1/ A71 EV-A71, CV-A1, 11.8, CV-A9, CV-A, B CV-A6 6/3 76.5, 8 17 CV-A6 3 1, 9, 11 /3 87., 38.9,, 3 1.6, 15/, , 13 17,,,,, 1 3.5, ,, ,, PCR CV-A6, A 13 35, B , 3 CV-A6,, CV-A , 19 89, 6, Vol. 38 No

Vol. 38 No.1 17. 1 9 199 9 1.1, 11 6.3,, 11 5, 1, CV-A6, 1Osterback R, et al.

, Emerg Infect Dis 18: 337-339, 1 3Kobayashi M, et al.

9 Vol. 38 No , ,, 11 5, 1, CV-A6, 1Osterback R, et al., Emerg Infect Dis 15: , 9 Fujimoto T, et al., Emerg Infect Dis 18: , 1 3Kobayashi M, et al., Jpn J Infect Dis 66: 6-61, 13,, OPV IPV 1 9,,, OPV,,, 1981, 1999,,, 5,,, 5,,,,,, A B CV-A6, 1,,,,,,, 1, SOP SOP, SOP,,,, SOP,,,,,,,,, SOP,,,,,, 1,,,

10 1 Vol. 38 No , 1. SOP SOP, SOP,,, SOP SOP SOP SOP SOP SOP ( 5,,,,,,, D68, NESID, 16 1,,,,, , D68 EV-D68,,,,,,, 1 15 A CV-A,, 8 1,, 8 * * ** ** 1. 15

Vol. 38 No.1 17. 1 111. EV-D68 3. CV-A6, 13, CV-A,, EVP/OL68-1 RT-PCR VP, 571 bp BLAST, EV-D68 9 accession no.

11 Vol. 38 No EV-D68 3. CV-A6, 13, CV-A,, EVP/OL68-1 RT-PCR VP, 571 bp BLAST, EV-D68 9 accession no.: LC1815, EV-D68, 1 LD 5,, 13,, EV-D68, CV-A, 3, EV-D68 EV-D68, CV-A, 1-3,, 13 EV-D68,,, EV-D68, 1Schieble JH, et al., Am J Epidemiol 85: 97-31, 1967 Patel MC, et al., PLoS One, DOI:1.1371/journal. pone , 16 3Hixon AM, et al., PLoS Pathog, DOI:1.1371/ journal.ppat.16199, A71, 199,, A71 EV-A71, IASR 3: 9-1, 9 EV-A71,, CDC gov/non-polio-enterovirus/outbreaks-surveillance. html EV- A71 1, EV-A71 3,, 3, 6, 1 13 EV-A , 17 EV-A71, EV- A71, 8 EV-A71,, 8,, , , EV-A71 WPRO: factsheets/hfmd/en/ 3, 111

12 1 Vol. 38 No ,, 11 11, 17, 5, 1 EV-A , EV-A71, 61 7, EV-A71,,, 61, EV-A71 8 EV- A71 9, EV-A71,,,,, 1 EV-A71, EV-A71 13, EV-A71,,, EV-A71, 1Fujimoto T, et al., Microbiol Immunol 69: 61-67, Wu Y, et al., Int J Infect Dis 11: e176- e181, 1 3Xing W, et al., Lancet Infect Dis 1: , 1 Nguyen NT, et al., BMC Infect Dis 11: 31, 1 5Geoghegan JL, et al., J Virol 8917: , 15 6Duong V, et al., Emerg Microbes Infect 5 9: 9, 16 7Teoh H-L, et al., JAMA Neurol 733: 1-8, 16 8Obermeier PE, et al., Emerg Infect Dis 1: , 16 9Schuffenecker I, et al., J Clin Virol 5 1: 5-56, 11 1Chakraborty R, et al., AIDS 18 1: , A71 A71 EV-A71 5,,,,,,,,,,, 1 EV-A71,,,,,, EV-A71,,,, 3 EV-A71 A,,, 1,,,,, 5,

13 Vol. 38 No , EV-A71, tg,, EV-A71 Scavenger receptor B SCARB 6 SCARB,, 7,, SCARB EV-A71, PSGL-1, Annexin II, DC-SIGN, nucleolin, vimentin, heparan sulfate, sialylated glycan 8 attachment receptor,, SCARB, SCARB bacterial artif icial chromosome BAC 9 SCARB, tg,,,,,,,,, Tg SCARBtg, EV-A71,, EV-A71, tg, SCARBtg 1Qiu J, Lancet Neurology 7 1: , 8 Nagata N, et al., J Gen Virol 85 Pt 1: , 3Nagata N, et al., J Med Virol 67 : 7-16, Wang YF, et al., J Virol 78 15: , 5Khong WX, et al., J Virol 86 : , 1 6Yamayoshi S, et al., Nature Medicine 15 7: , 9 7Yamayoshi S, et al., J Virol 87 6: , 13 8Yamayoshi S, et al., Emerg Microbes & Infect 3 7: e53, 1 9Fujii K, et al., PNAS 11 36: , 13 A71,, 1,, virus-like particle,,,,,,,, 8, 81 5, 7,, 8,8 ; 1.1,,57 ;.3

14 1 Vol. 38 No A71,, A71 EV-A71, 3, 3 EV-A71 C,, 1,,,,,, EV-A71,, 56 EV-A71, -6 EV-A71,, EV-A71, 9,, 1516, 3 EV-A71, 7-8, 1998,,, EV-A71 B, 9 Inviragen, Vero EV-A71 B EV-A71, 1 EV-A71, A6 A16,,,, 11, EV-A71,, EV-A71,,,, 1, IASR 33: 65-66, 1 Xing W, et al., Lancet Infect Dis 1: , 1 3Liang Z, et al., Vaccine 9: , 11 Zhu FC, et al., Lancet 381: -3, 13 5Zhu F, et al., N Engl J Med 37: , 1 6Li R, et al., N Engl J Med 37: , 1 7Li L, et al., Vaccine 33: , 1 8Pallansch MA, et al., Lancet 381: , 13 9Cheng A, et al., Vaccine 31: 71-76, 13 1Hwa SH, et al., PLoS Negl Trop Dis 7: e538, 13 11Liu CC, et al., Vaccine 3: , 1 B EV,,,,

15 Vol. 38 No , EV, EV B CV- B 6, CV-B,, , 1, 1 :,,,,, QIAamp Viral RNA Mini Kit QIAGEN RNA, CODEHOP VP1 RT-semi-nested PCR EV, AN89 AN88, Enterovirus Genotyping Tool Version.1, GENETYX ver EV, CV-B 8, 6, A CV-A9 1 CV-B 1 : 1, ,,36g, Apgar 1 9, 5 9, 5, 38., 18 /, 7/8mmHg, 38/, SpO 98,,, 6,7, 1.g/dL, 1.9, 15mg/dL, FDP 8.5g/mL, D-dimer.7g/mL, AST 111 U/L,, -, 6.8,, 15, 5 5,, CV-B, CV-B, CV-B 6, CV-B,, : 8,79, CRP.9mg/dL, /L 96,,, MRI,,, PCR, 7 CV-B, 13, CV-B,, CV-B5, CV-A6, 9, CV- A16, CV-B,, 6,,,

16 A166 Vol. 38 No ,,, A ,, human metapneumovirus HMPV 7 1,, 7 9, 67, , A, B, C E, D E, A, C D,,, A 7 9,,, ,,, 37., 3, 19 93, 16, 78 7, 8, 31 3, 8, 98 63, , A 3 57, B 3 57, C 19 3, D 6 15, B 8 38, C 5 1, D 1 5, 1, 1,, , 36 33, 18, 9 7,, 1 13, 3, 1 A , 7 1 HMPV 17 RT-PCR, HMPV 8 5, A , B 5, C 3, D 1 1, B C 8 HMPV A D 17, A 7 1, 7 9, D, HMPV,,,, 8 3, 8 17, ,, HMPV, HMPV D D C C B B 7/ 7/7 7/8 7/9 7/1 7/11 7/1 7/13 7/1 7/15 7/16 7/17 7/18 7/19 7/ 7/1 7/ 7/3 7/ 7/5 7/6 7/7 7/8 7/9 7/3 7/31 8/1 8/ 8/3 8/ 8/5 8/6 8/7 8/8 8/9 8/1 8/11 8/1 8/13 8/1 8/15 8/16 8/17.

17 Vol. 38 No HMPV,,,,,,,,,, E,,, HMPV,,,, HMPV,,,, 1, 7: 3-6, 11 Degail MA, et al., Euro Surveill 1 Apr 1; , IASR 7: , 6, Vol.18 No. B, ,, B GBS 11 5 GBS,, 37 GBS, GBS,, A 3, GBS, 3 GBS PFGE, CDC, III, MLST ST17, 3 SNPs 1 ; single nucleotide polymorphisms, GBS GBS,, A,, /,,,,,,,,, A,,, 11516F 6 71, 115, 1 1, 13 F 5 11 GBS, GBS,,, GBS,, GBS, GBS, GBS,, GBS GBS,, CDC, MMWR 66 5: , 17 :,

18 188 Vol. 38 No , Eculizumab : :, C5,,, 1,,, The Advisory Committee on Immunization Practices: ACIP, MenACWY B MenB,,,, 17, CDC,, 7, 7 CDC,,, PCR, WGS 1, nongroupable, WGS C,, MenACWY, 816, : 16-83,, : 1-1, 1 : , 5, 1 1, Y, 11 1 MenACWY Y 3 MenACWY MenACWY, in vitro,,,, MenACWY, MenB, B,,,,,,, 1 1, 3, 1,,,, 1, ST 11, ACIP MenACWYMenB,,,,,, CDC, MMWR 667: , 17 :,

19 IASR Vol. 38 No. 1 (No. 5) October 17 Infectious Agents Surveillance Report Hand, foot, and mouth disease and herpangina-notification trends and enterovirus detections in 8-17-Kanagawa Prefecture Detection of enteroviruses from hand, foot, and mouth disease patients including severe cases in 1-17-Hiroshima City Trends in hand, foot, and mouth disease notifications in Osaka City, Hand, foot, and mouth disease and herpangina-notification trends and enterovirus detections in Shimane Prefecture, weeks 1-35, Clinical and epidemiological features of hand, food, and mouth disease caused by coxsackievirus A6 in 13 and Quality assurance of enterovirus laboratory diagnosis ISSN National Institute of Infectious Diseases and Tuberculosis and Infectious Diseases Control Division, Ministry of Health, Labour and Welfare Isolation of enterovirus D68 using suckling mice-akita Prefecture... Trends in detections of enterovirus A71 in Japan and abroad, Analysis of enterovirus A71 pathogenesis using animal models... Development and introduction of enterovirus A71 vaccine in Asian countries... 3 Infant cases of severe coxsackievirus B infection in Nagasaki Prefecture, June-August Outbreak of metapneumovirus infection among adult patients in a psychiatric hospital, July 16-Ibaraki Prefecture... 6 <THE TOPIC OF THIS MONTH> Hand, foot, and mouth disease and herpangina, 7 to September 17 (week 38), Japan Figure 1. Weekly number of hand, foot, and mouth diseasenotification per pediatric sentinel, week 1 of 7 to week 38 of 17, Japan Week No. of cases/sentinel site Year (National Epidemiological Surveillance of Infectious Diseases: as of September 7, 17) Figure. Weekly number of herpangina notification per pediatric sentinel, week 1 of 7 to week 38 of 17, Japan Week No. of cases/sentinel site Year (National Epidemiological Surveillance of Infectious Diseases: as of September 7, 17) Hand, foot, and mouth disease (HFMD) and herpangina are pediatric enteroviral diseases that often occur in the summer. Both are category V infectious diseases under the Infectious Diseases Control Law, notifiable based on clinical diagnosis from ~3, pediatric sentinel sites. Reporting requires the following clinical manifestations: -5mm-sized blisters appearing on the palm, plantar, dorsum of foot or oral mucosa that heal without crust formation for HFMD, and sudden onset of high fever and vesicular rash, ulcers or reddening of the uvula for herpangina. Causative agents are mostly viruses belonging to Enterovirus A. Trends in notifications of patients and detection of viruses: For both HFMD and herpangina, notifications of patient cases peaked in the summer. For HFMD, large and small epidemic years alternated yearly since 11 (large epidemic years occurred in 11, 13, 15 and 17) (Fig. 1). For herpangina, the magnitude of annual fluctuations was smaller (Fig. ). Among the reported cases, both for HFMD and herpangina, 9% of the patients were under 5 years of age (Fig. 3 and in p. 19, respectively). As both are monitored via pediatric sentinel sites, the frequency of disease occurrence among adults is unknown. Findings from HFMD surveillance abroad have similarly found that the annualized HFMD incidence among children 6 months-5 years far exceeded those of other age groups, with particularly low levels among those 15 years of age (Lancet Infect Dis 1: , 1). Annual trends in detection of Enterovirus A by prefectural and municipal public health institutes (PHIs) from 7-17 are shown in Fig. 5 in p From HFMD cases, coxsackievirus (CV) -A6, CV-A16 and enterovirus (EV) -A71 were detected; since 11, CV-A6 was associated with large scale epidemics (Fig. 1 and 5). While EV-A71 was detected in relatively large numbers in 1 and 13, it has not been associated with large epidemics since 1. From herpangina cases, the following were detected, in descending order of frequency: CV-A, CV-A6, CV-A1, CV-A, CV-A5 and CV-A8; the predominant type circulating was found to vary yearly ( For past reports on HFMD and herpangina, please visit the following: HFMD (IASR 33: 55-56, 1) and herpangina (IASR 6: 1191 Continued on page 19

20 THE TOPIC OF THIS MONTH-Continued Figure 3. Age distribution of hand, foot, and mouth disease cases reported from pediatric sentinel sites, 7-16, Japan (National Epidemiological Surveillance of Infectious Diseases) % Year No. of cases 7 93, months 6-11 months 16-5 months 6-11 months , 5). Laboratory diagnosis: Laboratory diagnosis consists of virus isolation and virus genome detection using throat swab or stool specimens during the clinically symptomatic phase. Using multiple cell lines, such as RD cells and Vero cells, has been known to increase virus isolation efficiency for both HFMD and herpangina. As virus isolation efficiency was particularly low for herpangina cases, some PHIs have been conducting virus isolation using suckling mice (see pp. & of this issue). Recently, for more rapid and simpler methods and to also overcome the low isolation efficiency in cultured cells, viral genome detection directly from clinical specimens has been increasing. For identification of enterovirus type, amplification of the partial sequences of the VP-VP region and/or VP1 regions (e.g., CODEHOP RTsemi-nested PCR) has been used (see Laboratory Manual for HFMD and herpangina). For routine testing, amplification of the VP1 region, where there is high correlation with enterovirus serotypes, is preferable (IASR 3: 1-13, 9). Since the amendment of the Infectious Diseases Control Law in 1, quality control and quality assurance for enterovirus laboratory testing have been implemented (see p. 199 of this issue). Characteristics of HFMD in recent years and central nervous system complications: Although CV-A6 had been detected mostly from herpangina patients, the virus became increasingly detected from HFMD patients since 9 (IASR 33: 55-56, 1), becoming the dominant strain isolated from HFMD patients in large epidemic years during (Fig. 5 in p. 193) (see pp. 193, 195, 196 & 197 of this issue). HFMD due to CV-A6 has been characterized by atypical manifestations, such as frequently high fever ( 38 C), extensive blisters in the femoral and gluteal regions and onychomadesis (see p. 198 of this issue). In recent years, atypical HFMD caused by CV-A6 has spread globally, including in Asia. EV-A71 infection spread among infants in Malaysia, Taiwan, China, Vietnam, Cambodia and other countries in eastern Asia since the late 199s; it caused complication of central nervous system (CNS) (such as encephalitis, brain stem encephalitis, and paralysis) with severe and often fatal outcomes (see p. 1 of this issue). Fatality has been high when the patients developed neurogenic pulmonary edema or cardiopulmonary failure. From 8 to 1, China reported about 7,, HFMD cases; among them, 8,8 were severe and,57 were fatal (Lancet Infect Dis 1: , 1). Most patients were under 5 years of age, and the fatality was highest among those aged 1-3 months. Ninety percent of the fatal cases were EV-A71 positive. In Japan, severe or fatal HFMD cases have been rare. However, sporadic occurrences have been reported, and during HFMD epidemics associated with EV-A71, CNS complications increased among infants. While CV-A6 is known to cause less CNS complications, as CV-A6 has also been isolated from encephalitis cases (see p. 195 of this issue), the association between CNS complications and enteroviruses other than EV-A71 warrant further investigation (IASR 37: 33-35, 16). Prevention and other measures: For both HFMD and herpangina, viral transmission is primarily through droplet or contact. Handwashing and appropriate disposal of body waste is therefore important for preventing spread of infection. Treatment for enterovirus infection is, as a rule, symptomatic. Notably, Asian countries that have experienced large scale epidemics involving cases of severe enterovirus infections have been developing vaccines for preventing disease and severe outcomes. In 16, China introduced to the market the world s first inactivated EV-A71 vaccine (see p. 3 of this issue). Concluding remarks: For patients suspected of CNS complications due to enterovirus infection, cerebrospinal fluid is suitable for laboratory diagnosis. However, compared to Enterovirus B which are important causes of aseptic meningitis, Enterovirus A have a lower detection rate from cerebrospinal fluid. Therefore, when infection of Enterovirus A is suspected, testing other samples such as throat swabs and fecal specimens is recommended. Continued laboratory surveillance of enteroviruses and feedback of such information are important. 1 Age group (year) *As of August 3, ,185 68, ,1 37,7 7,8 33,339 83,69 381,7 69,139* % Year No. of cases 7 16, , , , , , , , 15 98,1 1 IASR Vol. 38 No.1 Oct Figure. Age distribution of herpangina cases reported from pediatric sentinel sites, 7-16, Japan (National Epidemiological Surveillance of Infectious Diseases) Age group (year) * As of August 3, ,371* The statistics in this report are based on 1) the data concerning patients and laboratory findings obtained by the National Epidemiological Surveillance of Infectious Diseases undertaken in compliance with the Law Concerning the Prevention of Infectious Diseases and Medical Care for Patients of Infections, and ) other data covering various aspects of infectious diseases. The prefectural and municipal health centers and public health institutes (PHIs), the Department of Food Safety, the Ministry of Health, Labour and Welfare, and quarantine stations, have provided the above data. Infectious Disease Surveillance Center, National Institute of Infectious Diseases Toyama 1-3-1, Shinjuku-ku, Tokyo 16-86, JAPAN Tel (+81-3)

Fig. 1 Trends of TB incidence rates for all forms and smear-positive pulmonary TB in Kawasaki City and Japan. Incidence=newly notified cases of all fo

Kekkaku Vol. 79, No. 1: 17-24, 2004 17 (Received 21 Aug. 2003/Accepted 18 Nov. 2003) Fig. 1 Trends of TB incidence rates for all forms and smear-positive pulmonary TB in Kawasaki City and Japan. Incidence=newly