Please use this identifier to cite or link to this item:
http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/31961
Title: | 建立臺灣地區急診為基礎的傳染病症候群偵測系統-ICD-9異常訊號偵測法、流行病學特徵、系統評比與建議 Establishing Emergency Department-Based Infectious Disease Syndromic Surveillance System in Taiwan–Aberration Detection Methods, Epidemiological Characteristics, System Evaluation and Recommendations |
Authors: | Tsung-Shu Wu 吳宗樹 |
Advisor: | 金傳春(Chwan-Chuen King) |
Keyword: | 症候群偵測,傳染流行病學,偵測系統評鑑,醫療資訊,國際疾病分類碼,警示統計法,新興傳染病,腸病毒感染,流行性感冒,國家安全,臺灣公共衛生, Syndromic Surveillance,Emerging Infectious Diseases,Infectious Disease Epidemiology,Evaluation of Surveillance System,Medical Informatics,ICD-9 Codes,Early Detection Statistical Modeling,Enterovirus,Influenza,National Security,Taiwan Public Health, |
Publication Year : | 2006 |
Degree: | 碩士 |
Abstract: | 台灣2003年發生嚴重急性呼吸道症候群的流行,造成民眾健康與經濟的重大損失。為改善傳統的傳染病偵測為被動式醫院通報的低時效性,本研究首度嘗試在台灣醫院急診建立具有高度時效性、自動化資料收集且能提供作為主動調查依據的症候群偵測系統。本研究包括兩部分:(一)建立全國性的189家醫院急診症候群偵測系統,並分析自2004年4月1日至2005年3月31日共2,692,325名來院病患的基本流行病學與經由國際疾病分類碼(international classification of diseases 9th revision, ICD-9)分組的症候群特徵;及(二)以台北市某醫院為例,建立區域性急診症候群偵測系統的日常運作流程、訊號調查、資料品質維護的以及採集病患檢體的『整合性工作流程』,分析自2005年10月1日至2006年4月30日共130,313人的急診症候群資料ICD-9碼型態,進行傳染病切實偵測並提出具體建議。
做法上,參考國外症候群偵測系統的研究經驗以及國內專家學者的建議,以國際疾病分類碼ICD9組成的11種急診症候群組進行分析,對於全國性急診症候群偵測系統各症候群數量均可獲知其年度流行趨勢,尤其冬季的腸胃道病患趨增,夏季也有呼吸道與類流感病患,且類腸病毒感染與每年多在六歲以下成兩波流行。另研究台灣急診來院病人症候群偵測系統資料,發現在周末或例假日時急診就醫病患的總數會有顯著的上升,約為平常日的1.3倍(p<0.001);農曆新年更是約為平常2倍的病患數量(p<0.001)。年齡分布上,以10歲以下幼兒(18.6%)和20-39歲青壯年(17.4%)最多,性別比為1.12:1,同台灣男女性別組成比仍以男多。由2004年7月開始的不同症候群病例數趨勢,發現發燒症候群、呼吸道症候群和類流感症候群的病例數均有逐漸上升現象,顯示台灣可能有夏季呼吸道疾病的流行,值得更進一步研究。因此針對類流行性感冒症候群的部份,特別回顧檢視2004年6月24日–7月28日兩週內的1,281份台北市某醫院C院區急診全部病歷,研究不同的國際疾病分類碼組合對於類流感病患偵測敏感度與特異度的影響,採用增加醫師較常用的類流感ICD-9碼及刪除氣喘、發燒、頭暈後組成後的症候群分組分析,其病例偵測敏感度可提陞為75.5%、特異度增加為84.4%,後續針對台北市類流感症候群病患的偵測,均採此新版本的症候群分組定義。 此外,由全國類腸病毒感染症候群的趨勢,發現以中部病例數上升時間早且最多,病例的年齡群和性別上並無數量變化的明顯差異,且病例數上升的較全國定點醫師偵測系統中的手足口症病例數量提早二週。在其他症候群上,發現消化道症候群自2004年11月起病患數量有逐漸上升的趨勢。此特殊的趨勢也可由台北市急診消化道症候群偵測系統的資料分析得到類似的結果,但台北市某醫院的資料會因不同院區別而有些許差異,顯示該醫院不同院區可能代表其區域性的不同。此外由台北市的30-39歲的男性類流感症候群數量增加的時間較其他年齡層早,顯示此年齡層對流感的社區傳播可能扮演部分重要的角色。 在台灣症候群偵測系統有限的歷史資料下,本研究探討歷史資料設限法與累積和流程控制法二種異常警示統計方法在症候群偵測系統資料分析的適用性,結果發現考慮週日別差異的歷史資料設限統計法之流行偵測敏感度約為67%,但累積和方法則對於資料基值變動過於敏感,以至於週末或假日時容易發生訊號,因此其適用性仍需更進一步改善,但現階段此二種統計方法均可快速地應用至公共衛生防疫工作,但仍需設法減少『偽警訊』。 症候群偵測系統與現有傳染病偵測系統相較下,具有良好的偵測時效性與系統彈性,並能提供公共衛生單位進行主動疫情調查的參考依據,且可作為跨領域研究整合以及防疫的基礎平台。未來應持續增加各項醫療資訊基礎建設、提陞公共衛生防疫專業人才的進用與素質,及改進不同的統計預測模型以發揮此系統最佳的偵測新興傳染病之宏效。 According to the challenges of emerging infectious diseases (EID) and bioterrorist attack in the 21st Century, the traditional infectious disease surveillance systems have lacked active surveillance and failed to detect the 2001 anthrax attacks and the 2003 cross-country spread of severe acute respiratory syndrome (SARS) early. In order to establish scientific evidence-based active infectious disease surveillance system, we initiated a hospital emergency department (ED)-based timely and automatic syndromic surveillance system (ED-SSS) in Taiwan for the basis of further epidemiological investigation. Through the introduction of the real-time outbreak and disease reporting system (RODS) from the University of Pittsburg to Taiwan, we established both a nation-wide ED-SSS involving 189 hospitals and set up more integrative procedures of local ED-SSS for daily operation, signal investigation, checking data quality and specimens taken at one regional hospital with 5 branches in metropolitan Taipei. In this study, we built up the daily operation procedures to perform further implementation and signal investigation and conducted epidemiological syndrome data analysis, using two data set of ICD-9 codes of ED visits: (1) 2,692,325 visits of nation-wide ED-SSS in Taiwan, April 1, 2004 - March 31, 2005. (2) 130,313 visits in one regional Taipei hospital, October 1, 2005- April 30, 2006. Daily patterns and trends of nation-wide ED-SSS ICD-9 codes involving 11 syndrome groups were analyzed, according to the international research experiences and recommendations of infectious disease experts in Taiwan. We found increasing trends in gastro-intestinal (GI) syndromes during winter season, and appearing peaks of respiratory or influenza-like illness (ILI) in summer periods, plus two waves of enterovirus (EV)-like infections under 6 years of age. In addition, striking increase of ED-visits were shown in weekends (1.3-fold p<0.001), and holidays, especially 2.0-fold higher during Chinese Lunar New Year (p<0.001). Most ED visits were children aged <10 y/o (18.6%) and 20-39 year-old young adults (17.4%). Male vs. female ED visits were 1.12:1. Starting from July of 2004, case numbers of fever, respiratory and ILI syndromes gradually increase, indicating possible presence of respiratory infections in Taiwan that had been seldom reported and worthwhile future investigating. Therefore, we examined the sensitivity, specificity and positive-predictive values of different ICD-9 code syndrome groupings of ILI cases from the 1,281 cases through medical charts review at C-hospital in Taipei, June 24, 2004 – July 8, 2004. The modified version of ILI syndrome that deleted asthma, fever and dizziness had 75.5% sensitivity and 84.4% specificity. We then applied it to detect ILI cases in Taipei ED-SSS. Increased numbers and earlier detected EVI syndrome cases of nation-wide ED-SSS were found in central Taiwan, but there was no significant difference in patterns by different age and gender groups. Compared with sentinel physicians’ hand-foot-mouth disease surveillance, the ED-SSS was 2 weeks earlier in detecting the increased EVI syndrome cases in Taiwan. Additionally, the Taipei X-Hospital ED-SSS also showed similar pattern. Among the patterns of other syndrome groups, GI syndrome cases in both nation-wide and Taipei ED-SSS increased from Nov. of 2004. On the other hand, Taipei X-Hospital ED-SSS with different branches showed regional differences. Moreover, 30-39 year-old male adults showed one week earlier in the increasing of ILI syndrome cases implying possible important transmission role in this age group in a metropolitan city. With the limit historical ED-SSS data, both historical control limits (HCL) using past four-week background data and cumulative sum (CUSUM) process control methods were used for our aberration detection and their required conditions in ED-SSS. The weekday and weekend stratified HCL method showed 67% sensitivity to detect the Taiwan-CDC identified outbreaks and the modified CUSUM method was too sensitive to demonstrate signals on weekends and holidays and needed to be improved due to its higher sensitivity for the changes of continuous baseline. Undoubtedly, both methods are applicable to public health use for immediate prevention and control of infectious diseases but they need further researches to reduce false signals. Evaluation of surveillance systems found that ED-SSS, providing more information for further epidemiological investigation, had the best timeliness and better flexibility to integrate with other database for multi-disciplinary research than other infectious disease surveillance systems existed. It can serve two-way frequent communications between public health agencies and medical departments. With the large baseline data of community health, it can also apply to research on other domains in public health. Future efforts are needed for continuous investment of medical informatics, to recruit more high quality infection control public health personnel, and to improve different statistical prediction models for maximizing effectiveness for early EID detection. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/31961 |
Fulltext Rights: | 有償授權 |
Appears in Collections: | 流行病學與預防醫學研究所 |
Files in This Item:
File | Size | Format | |
---|---|---|---|
ntu-95-1.pdf Restricted Access | 2.94 MB | Adobe PDF |
Items in DSpace are protected by copyright, with all rights reserved, unless otherwise indicated.