COVID-19大流行期公共衛生防疫策略對結核病造成的影響

Abstract

研究背景 根據世界衛生組織（WHO）2020年公佈的數據顯示，在2019年結核病仍是全球十大死因之一。我國結核病防治工作從2001年建立結核病實驗室檢驗網與2006年力行結核病人直接觀察治療計畫（Directly Observed Treatment, Short Course，DOTS）起實行已久，期以透過更強力的公共衛生防疫措施，朝向 2035 年消除結核病之目標前進。自2019年底COVID-19新興傳染病席捲全世界，各國紛紛採以邊境管制與國內感染控制措施，政府也推廣防疫新生活運動，民眾疾病易感性上升、改善個人衛生，間接影響其他呼吸道相關傳染病的散播。本研究欲結合COVID-19、結核病確診資料分析COVID-19疫情期間非藥物介入措施（Non-Pharmaceutical Interventions，NPI）策略對結核病造成的影響。 研究目的 本研究評估COVID-19流行前後結核病的發生如何受NPI的影響，並考慮DOTS策略下NPI對結核病影響的成效評估，進一步提供公共衛生建議，有利於達成評估清除結核之實證參考。 研究方法 本研究採類實驗前後測研究設計，探討COVID-19流行前2017-2019年及流行後2020-2021年結核病確診個案如何受NPI影響，採用資料係擷取2020-2021年COVID-19確診個案數描述疫情，結合近五年(2017-2021年)結核病確診新案資料共2,956人，分析在COVID-19疫情下結核病確診新案基本背景、疾病樣態差異與發展趨勢；另外再回溯1990-2021年結核病確診新案發生率，使用長期時間序列曲線評估結核病防治成效。其資料庫分別源自中央結核病追蹤管理系統、結核病BO倉儲資料庫、傳染病統計資料庫。統計分析採Poisson Regression 比較2017-2021年結核病確診新案人口學背景與COVID-19疫情前後之相關；在1990-2021年結核病發生率預測部分則採Bayesian hierarchical change-point model預測結核病至2035年之發生率趨勢，該模型假設各年齡層所受之影響具差異化，並將公共衛生干預變化點納入模型，以觀察至2016年的結核病實際發生率預估未來至2035年的各年度發生率，藉以評估COVID-19時期NPI策略在DOTS政策後對結核病防治所帶來的影響。 研究結果 分析結果顯示2020年彰化縣COVID-19疫情尚在可控制範圍，直到2021年5月COVID-19確診人數暴增為此波疫情最高峰，疫情漸趨穩定後結核病確診數又有上升趨勢。而結核病確診新案在疫情前(2017-2019年)與疫情後(2020-2021年)的人口學背景結構組成差異不明顯，但X光診斷、痰液檢驗與結核感染部位檢驗結果則有較明顯之差異，經短期觀察結核病發生率亦有下降。觀察本國籍整體結核病發生率從1990年起到2001年達最高點(每十萬人76.2例)，爾後逐年遞減至2021年為每十萬人35.8例，但根據預測模型顯示如依照目前DOTS策略執行結核病防治，即使COVID-19疫情下的NPI會使結核病發生率下降，但仍未達到WHO到2035年結核病根除至十萬分之5之目標。 結論 本研究發現在COVID-19大流行期多種NPI政策與廣泛覆蓋率可為結核病防治帶來顯著成效，在DOTS計畫實施後執行嚴格的NPI措施對結核病防治是有所助益的，NPI與DOTS兩者相輔相成，聯手促進公共衛生發展，以達WHO 2035年根除結核病之目標。

Background According to data released by the World Health Organization (WHO) in 2020, tuberculosis is still one of the top ten causes of death worldwide in 2019. Tuberculosis prevention and control work of Taiwan has been carried out for a long time since the establishment of the tuberculosis laboratory inspection network in 2001 and the implementation of the DOTS plan in 2006, with a view to advancing towards the goal of eliminating tuberculosis by 2035 through stronger front-end prevention and intervention measures. Since the end of 2019, the emerging infectious disease of COVID-19 has swept the world, countries have adopted border control and domestic infection control measures, and the government has also promoted the “Epidemic New Life Movement”. People increased susceptibility to disease and improved personal hygiene. This study will analyze the impact of NPI strategies on tuberculosis in combination with COVID-19 and tuberculosis diagnosis data. Aims The aim of the study is to quantify the occurrence of TB observed during the COVID-19 pandemic as an evaluation of the effectiveness of NPI prevention and control, and to study the impact of NPI on TB after the DOTS strategy. On the basis the empirical findings, public health recommendations were further provided to help achieve the vision of TB eradication. Methods In this study, a quasi-experimental before and after study was used. The number of confirmed cases of COVID-19 from 2020 to 2021 was collected from the data. Combined with the data of 2,956 new confirmed cases of tuberculosis in the past five years (2017-2021) , the basic background and disease samples of new confirmed cases of tuberculosis under the COVID-19 epidemic were analyzed. In addition, the incidence of new confirmed cases of tuberculosis from 1990 to 2021 was traced back, and the long-term curve was used to assess the effectiveness of tuberculosis prevention and treatment, which was a secondary data analysis. The databases are derived from the Central Tuberculosis Tracking and Management System, the Tuberculosis BO Storage Database, and the Infectious Disease Statistics Database. The study analyzed the correlation between the demographic background of new cases of tuberculosis diagnosed from 2017 to 2021 and before and after the COVID-19 epidemic by using the Poisson regression model. The Bayesian hierarchical change-point model was used to predict the incidence trend of tuberculosis with 2035 regardless of the incidence of tuberculosis from 1990 to 2021. The model assumes that each age group were differentially affected, and incorporates the change points of public health interventions into the model. The actual incidence of tuberculosis to 2016 was estimated to be the annual incidence in the future of to 2035. So as to assess the impact of NPI strategies on tuberculosis control in the COVID-19 epidemic period after DOTS policies. Result The COVID-19 epidemic in Changhua County in 2020 is still under control. Until May 2021, the number of Covid-19 confirmed cases increased sharply, and the number of confirmed cases of tuberculosis increased again after the epidemic gradually stabilized. The demographic background and X-ray diagnosis of newly diagnosed TB cases before and after the epidemic were not statistically significant. There was a significant difference between sputum test and tuberculosis infection site. Short-term observation of tuberculosis incidence also decreased. Note that the overall incidence of tuberculosis in the country reached the highest point from 1990 to 2001, and then decreased year by year to 35.8 cases per 100,000 people-years in 2021. However, according to the prediction model, if the current DOTS strategy combined with NPI has implemented for tuberculosis prevention and control, it still fails to achieve the elimination of WHO level, 5/100000, in 2035. Conclusion This study found that during the COVID-19 pandemic, a variety of NPI policies and extensive coverage can bring about significant results in tuberculosis control. The implementation of strict NPI measures after the implementation of the DOTS plan is beneficial to tuberculosis control. Although NPI and DOTS jointly promote the development of public health to achieve the WHO 2035 goal of eradicating tuberculosis, the goal still leaves room for implement.