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標題: | 流行病學方法在結核病防治上的應用:以全球衛生與院內感染問題為例 Application of Epidemiologic Methods in Tuberculosis Prevention and Control: Examples in Global Health and Nosocomial Infection Control Settings |
作者: | Sung-Ching Pan 盤松青 |
指導教授: | 方啟泰,林先和 |
關鍵字: | 結核病,糖尿病,數理模式,醫療人員,職業風險,結核病暴露,潛伏性結核, tuberculosis,diabetes mellitus,mathematical model,healthcare workers,TB-related mortality,occupational hazards,TB exposure,incident latent tuberculosis, |
出版年 : | 2015 |
學位: | 博士 |
摘要: | Chap 1. 以數理模式分析糖尿病對13個結核高盛行率國家結核防治的影響 一、 背景: 糖尿病會增加患者發生結核病的風險,及造成糖尿-結核患者更高的死亡率,由於糖尿病的盛行率在中低收入國家逐漸上升,而此些國家同時有較高的結核病盛行率,因此預防糖尿病可望能協助全球結核病的防治。 二、 方法: 我們使用結核病傳播的數理模式,來分析糖尿病對13個結核高盛行率國家流行病學的影響。我們使用在各個國家過去糖尿病盛行率的資料,建置未來不同模擬狀態下的糖尿病盛行率情境。各國結核病的模式,同樣以過去結核病的資料加以校正,以推估未來不同糖尿病情境下,結核病盛行率的變化,並計算在不同糖尿病盛行率下,可避免結核患者發生及死亡的人數。 三、 發現: 若各國糖尿病的盛行率如現況增加,則可預期在現有結核病防治策略下,至2035年可避免結核發生率8.8% (95%可信區間為4.0~15.8%),及下降結核死亡率34.0% (95%可信區間30.3~39.6%)。但若能降低糖尿病的盛行率,則可能使結核的發生減少11.5~25.2%及8.7%~19.4%的死亡率。和背景情境相比,停止糖尿病盛行率的上升,在未來20年間(2015~2035)共可減少六百萬結核發生及一百一十萬的結核死亡人口;進一步若能使糖尿病發生率,於2025年下降至35%,則可減少七百八十萬結核發生及一百五十萬結核死亡人口。 四、 結論: 糖尿病的盛行可影響高結核盛行率國家的流行病學。傳染性疾病與非傳染性疾病的防治單位,應去除之間的疆界,以共同防治糖尿病及結核病的發生。 Chap 2.以配對世代研究分析醫療工作者的結核病 一、 背景: 過去研究發現,醫療工作者與其他職業工作者相比,具有較高的結核病死亡率,但這可能同時來自於醫療工作者結核病發生率較高,或醫療工作者結核病治療預後較差,或兩者共同的影響。為了釐清醫療工作者的職業風險,我們分析在台灣醫療工作者結核病的發生率及治療的癒後。 二、 方法: 我們以2004年至2012年間,台灣某大型醫學中心之醫療人員結核病發生率,與全國人口進行比較。肺結核醫療人員,與同時期在同一醫學中心接受治療的結核病患進行年齡、性別配對後,進行治療預後的比較,並與同時期國內結核病通報的病患治療預後進行比較。 三、 結果: 醫療工作者之標準化結核病發生比率為一般民眾的1.9倍(95%信賴區間為1.2~2.9倍)。研究期間內30名肺結核醫療工作人員,與同時期同醫院接受治療的年齡性別配對後之120名病患相比,具有較少的其他疾病、較短的肺結核診斷及治療延後時間,及較少的治療副作用(p值小於0.05)。在治療癒後方面,醫療工作者具有較好的癒後(結核病醫療人員死亡率0.0% VS.病患的死亡率5.8%,p值為0.008),同時期全國結核病患治療中的標準化死亡率為1.08% (95%信賴區間0.96~1.2%)。 四、 結論: 與一般大眾相比,醫療工作者具有較高的結核病發生率,為了減少職業傷害,我們應努力減少醫療工作者在職場暴露的風險;而健康勞工效應,快速診斷及快速的起始治療,均可能為醫療工作者有較少死亡率的原因。 Chap. 3以前瞻性世代研究探討醫療工作者潛伏性結核病的危險因子 一、 背景: 結核病為醫療工作者可能的職業風險之一,但何種情境,可能導致醫療工作者罹患潛伏性結核病仍缺乏相關的資料。 二、 目標: 我們以前瞻性世代研究來追蹤醫療院所中,有結核病暴露後之醫療工作者,以了解其發生潛伏性結核病(丙型干擾素血液測驗IGRA陽轉)的風險。 三、 結果: 自2011年1月1日至2013年12月31日,在台灣某大型醫學中心中共追蹤303位醫療工作新進人員,及104位有肺結核暴露的醫療工作者。在新進人員中,有19位於就職時即為IGRA陽性,除此19位外,後續7位發生陽轉,陽轉發生率為2.5%。在肺結核暴露之醫療工作者中,9位於第一次測試即為陽性,除此9位外,另9位於後續追蹤陽轉,陽轉發生率為9.5%。其中發生陽轉的危險因子,經年齡及性別校正後,為暴露對象痰液抹片4架之患者(風險比188.32倍,95%信賴區間5.90~6013.21倍),及為肺結核患者抽痰(風險比29.92倍,95%信賴區間2.56~349.04倍)。 四、 結論: 在結核中度盛行率之國家,肺結核暴露會造成醫療工作者潛伏性結核病的風險,其主要的危險因子為暴露對象痰液抹片架數高,及為結核病患執行抽痰動作。本研究發現此二項高危險暴露可能增加醫療工作潛伏性結的風險。 1. Impact of diabetes on tuberculosis control in 13 high tuberculosis burden countries: a modelling study Background: Diabetes increases the risk of tuberculosis incidence and the risk of adverse treatment outcomes among tuberculosis patients. Since the diabetes prevalence is increasing in low- and middle-income countries where the burden of tuberculosis is high, prevention of diabetes carries the potential to assist global tuberculosis control. Methods: We used dynamic tuberculosis transmission models to analyze the potential effect of diabetes on tuberculosis epidemiology in 13 high tuberculosis burden countries. We used data on past diabetes prevalence in each country and constructed scenarios to represent the potential ranges of future diabetes prevalence. The country-specific model was calibrated to the estimated trend of tuberculosis incidence. We estimated the tuberculosis burden that can be reduced by alternative scenarios of diabetes prevention. Findings: If the prevalence of diabetes continues to rise as it has been in the 13 countries (base case scenario), the cumulative reduction in tuberculosis incidence and mortality would only be 8.8% (95% credible interval [CrI]: 4.0-15.8%) and 34.0% (95% CrI: 30.3-39.6%) respectively by 2035. Lowering the prevalence of diabetes could accelerate the decline of tuberculosis incidence by an absolute level of 11.5-25.2% and tuberculosis mortality by 8.7-19.4%. Compared to the base case scenario, halting the rise of diabetes would avoid incident tuberculosis cases by 6.0 million (95% CrI: 5.1-6.9) and tuberculosis deaths by 1.1 million (95% CrI: 1.0-1.3) in 13 countries over 20 years. If interventions reduce diabetes incidence by 35% by 2025, 7.8 million (95% CrI: 6.7-9.0) tuberculosis cases and 1.5 million (95% CrI: 1.3-1.7) tuberculosis deaths will be saved. Interpretation: The diabetes epidemic could substantially affect tuberculosis epidemiology in high burden countries. The communicable disease sector and the noncommunicable disease sector need to move beyond the conventional boundary and link with each other to form a joint response to diabetes and tuberculosis. 2. Tuberculosis in healthcare workers: a matched cohort study in Taiwan Background. Proportional mortality ratio data indicate that healthcare workers (HCWs) have an elevated tuberculosis (TB) mortality. Whether this is caused by an increased TB incidence, a worse TB treatment outcome, or a combination of effects, remains unclear. To elucidate the hazard components of occupational TB, we assessed TB incidence and TB treatment outcome among HCWs in Taiwan. Methods. We compared the incidence of active TB among HCWs at a major medical center in Taiwan with that of Taiwan general population in 2004-2012. We also compared the TB treatment outcome of HCWs with that of age/sex-matched non-HCW patients treated at the same hospital, as well as that of nationally registered TB patients. Results. The standardized TB incidence ratio of the HCWs was 1.9 (95% confidence interval [CI]: 1.2-2.9), compared with the general population. HCWs with pulmonary TB (n=30) were less likely to have underlying diseases, delay in diagnosis, delay in treatment, or side effects of treatment, compared with age/sex-matched non-HCW TB patients (n=120) (all Ps<0.05). The TB treatment outcome of HCWs was significantly better than that of non-HCW patients (TB-related mortality: 0.0% vs. 5.8%, P=0.008, Mantel-Haenszel test). The standardized TB-related mortality rate was 1.08% [95% CI: 0.96% - 1.20%] for all of the nationally registered TB patients in Taiwan. Conclusions. HCWs are at increased risk of active TB, compared with general population. To mitigate this occupational hazard, more efforts need to be directed towards the prevention of nosocomial TB transmission. Healthy worker effect, more rapid diagnosis, and less delay in treatment contribute to a lower TB-related mortality in HCWs. 3. Risk factors for incident latent tuberculosis among health care workers: a prospective follow-up study Rationale: TB has been recognized as an occupational hazard for health care workers (HCWs). However, there is a lack of data on specific circumstances that put exposed HCWs at risk for incident latent TB infection (LTBI). Objective: We sought to identify the risk factors for incident LTBI (with IGRA conversion) among HCWs, using a prospective followed study for TB exposed HCWs. Results: During Jan.1, 2011 to Dec.31 2013, there were 303 new HCWs and 104 TB exposed HCWs enrolled. Among new HCWs, 19 HCWs had initial positive IGRAs result and 7 HCWs had conversion during follow-up. The cumulative risk of conversion was 2.5%. For TB exposed HCWs, 9 HCWs had initial positive IGRA result and 9 HCWs with subsequent conversion. The cumulative risk of conversion was 9.5%. The risk of LTBI attributable to TB exposure was 7.0%. The risk factors for conversion was high amount the AFS smear of the index case (4+) (Hazard ratio (HR): 188.32, 95% CI 5.90-6013.21, P value=0.003) and performing suction for the index case (HR: 29.92, 95% CI 2.56-349.04, P value=0.007) after adjusted by age and sex. Conclusion: In countries with an intermediate TB burden, TB exposure significantly increase the risk for acquiring LTBI in HCWs. The risk factors for incident LTBI were performing suction for the index cases and extreme high AFS amount of the index cases. These findings identify the two high-risk circumstances for TB transmission to HCWs. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/4442 |
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