结核医学课件与结核抗争

上海市(复旦大学附属)公共卫生临床中心 复旦大学附属华山医院 卢洪洲,与结核抗争,结核杆菌的发现,TB incidence, 2009 (WHO),(WHO, 2008),WHO, 2008,WHO, 2008,Estimated TB cases not detected in 2009 (McNerney and Daley, Nat Med, 2011),Spread of Beijing clade of M. tuberculosis,影响中国结核发病率的关键因素,人口流动问题？ 耐药结核？ 艾滋病合并结核？ 诊断问题？ 潜伏感染活动？ ,高度人口流动,每年流动人口人次达两亿两千万: 主要从农村到城市，以青、壮年为主 每年出国旅游达几百万; 国内旅游有六亿六千万 每年从海外入境人数 两千万 经常有短期内 大量人口聚集 活动, 例如2010 上海Expo， 来上海参加人数达七千三百万之多,耐药结核,Multidrug-resistant (MDR) tuberculosis is defined as disease caused by strains of Mycobacterium tuberculosis that are at least resistant to treatment with isoniazid and rifampicin. Extensively drug-resistant (XDR) tuberculosis refers to disease caused by multidrug-resistant strains that are also resistant to treatment with any fluoroquinolone and any of the injectable drugs used in treatment with second-line anti-tuberculosis drugs (amikacin, capreomycin, and kanamycin),截至2009，报道过泛耐药结核的国家,The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2009. All rights reserved,耐药结核的治疗,TB Epidemic,DOTS,HIV Epidemic,HIV 合并结核感染,估计的HIV/TB患者地理分布图,Kenneth Mayer. CID. 2010,Poorly Formed to No Significant Granuloma Formation in Severely Immunosuppressed HIV (+) Compared to well Formed Granulomas in HIV (-),TB in HIV,结核菌素试验 Tuberculin Test,5 mm is classified as positive in HIV-positive persons False negative in late HIV stage and overwhelming TB disease False positive: Infected with Mycobacteria other than TB, e.g, MAC BCG vaccination,对HIV/TB 感染诊断的意义有限,免疫学诊断方法：ELISPOT,A fairly sensitive method to diagnose HIV/TB Can be used to detect latent TB in HIV-infected patients Can be influenced by CD4 counts? Can distinguish MTB from other mycobacterial infection or previous BCG vaccination,T-SPOT (ELISPOT) test,ESAT-6 and CFP-10: two common used mycobacterial tuberculosis antigens,分子生物学诊断方法：Nucleic acid amplification (NAA) test,MTB/RIF 的快速分子诊断,WHO建议的HIV/TB合作内容,预防HIV/TB,异烟肼预防治疗 (IPT) 诊断 (ICF) 感染控制 (IC),抗反转录病毒治疗（ART）,3IS,LTBI New inpatients and outpatients IFN- release assays (IGRAs) TSPOT.TB test INH daily or twice weekly for 9 months Vitamin B6 prevent peripheral neuritis,HIV / TB 治疗和诊断的调整 根据 WHO 治疗指南，2009年,HIV/TB治疗的挑战,HIV检测和咨询率低 复方新诺明预防使用率低 进行ART的人群比率低 全球防治TB计划中关于H