不明原因疾病的流行病学调查方法PPT参考幻灯片

不明原因疾病的流行病学调查方法TheEpidemiologicApproachtoDiseaseofUnknownCause.,1,2,疾病聚集报告增多原因,健康知识的传播电影：“ErinBrockovich”（布罗克维奇/永不妥协/伊人当自强）互联网：信息渠道分享信息传播谣言、怀疑、恐慌,3,“Alittleknowledgeisadangerousthing.”“一知半解，更加危险”（英谚）,4,疾病聚集报告增多原因,健康知识的传播对政府的不信任（美国）政府刻意掩盖个别流氓科学家的作为Tuskegee（Alabama）事件（1943-1973）一粒老鼠屎害了一锅粥,5,疾病聚集报告增多原因,健康知识的传播对政府的不信任非传染病发病率增加传染病的减少人均寿命增加疾病监测的加强环境污染、行为危险因素报告能力和发现意识,6,美国CDC调查的不明原因疾病Investigationsofdiseasesofunknownetiology,USCDC1946-1999,7,不明原因综合症Syndromesofunknowncauseidentifiedinsample,KawasakiDisease,Brainerddiarrhea,传染性单核细胞增多综合症Infectiousmononucleosis格林巴例综合症Guillian-BarreSyndrome系统性红斑狼疮SystemicLupuserythematosis雷氏综合症Reyessyndrome溶血性尿毒综合症Hemolytic-UremicSyndrome海湾战争综合症GulfWarSyndrome,8,不明原因死亡调查Unexplaineddeathinvestigations,婴幼儿突然死亡综合症Suddeninfantdeathsyndrome(SIDS)夜间突然死亡Suddenunexplainednocturnaldeath家族性肾上腺脑白质营养不良聚集性Familialclusters医疗错误Medicalmalpractice,9,现场流行病学（暴发疫情）调查步骤,组织准备核实诊断确定暴发或流行的存在建立病例定义核实病例并计算病例数,描述性分析（三间分布）建立并检验假设迅速采取控制措施完善现场调查报告交流反馈,一般是10个步骤,10,11,12,13,14,美国四个州的无痛性甲状腺炎调查,南达科他,明尼苏达,艾奥瓦,内布拉斯加,15,内布拉斯加Nebraska1984,42个病例ElevatedT4andsymptoms（焦虑、呼吸短促、心悸、心跳加快、体重减轻）6CountiesCasecontrolstudyforDietaryiodineColdandcoughmedicines“viralillness”53%vs32%p=0.05Viralcultures,HLAtyping,UrinaryIodine,16,南达科他,明尼苏达,17,June1985aspecialistreports8casesfromaneighboringstate,18,Initialsteps,VerifythediagnosisIsthisalaboratoryerror?Willotherspecialistsconfirmthediagnosis?InterviewPatientsNotifyadjacentstatesFindmorehyperthyroisism,19,20,Symptomsof28patientswithelevatedT4,21,WidenedCaseFinding,Surveyofpatientrecordsfrommedicalclinics(4states)forpast18monthsTelephonesurveyofdoctorsinareaLetterstoalldoctorsinareaDescribetheoutbreakRequestreporting,22,Casedefinitionappliedtoallreports,T4,freeT4orT325%higherthanupperlimitofnormalforthelaboratory2ofthefollowing:Sleeplessness,nervousness,headache,increasedheartrate,palpitations,shortofbreath,fatigue,sweating,tremor,diarrhea,heatintolerance,weightloss.ExcludedGravesdisease,T4replacement,23,Casefindingidentified121casesthatfitthedefinition.,24,Thyrotoxicosisbymonth,25,Incidenceofthyrotoxicosisper10,000bycounty,26,Newinformation,ExpertsopinionViralcauseIodine-inducedhyperthyroidismInformationfromnewcasesFamilyof54casesatemeat1non-caseavegetarianFoodfromonestoreallnationalexceptlocal“beeftrimmings”Wasbeefcontaminatedwithiodine?,27,Thesecondcasecontrolstudyshowedaveryspecificassociation,28,调查暴发的10个步骤10stepsofanoutbreakinvestigation,准备现场工作Prepareforfieldwork,证实暴发存在Establishexistenceofanoutbreak,Time,Verifythediagnosis验证诊断,Define,count,andinterviewcases定义，计数，采访病例,确定人、地点和时间特征Characterizeperson,placeandtime,Developahypothesis提出假设,Developanalyticstudytotesthypothesis通过分析研究验证假说,Reconsider,refine,retesthypothesis再推敲，修正和再检验假说,实施控制措施ImplementControl,将调查结果进行交流CommunicateFindings,29,知道病原体有很大的优势，比如：伤寒Knowingtheetiologyisamajoradvantage.E.g.Typhoid,食物或者水源传播Transmissionbyfoodorwater人是唯一宿主Humanreservoironly人传人罕见Persontopersontransmissionveryrare70%病例是隐形感染70%infectionsasymptomatic潜伏期8-24天8-24dayincubationperiod治疗方法明确Treatmentwelldefined病例定义和确诊方法Casedefinitionsandconfirmatorytests,30,受关注的程度不一样：领导关注度,截至5月19日第362人次国家类专家：国家共派49批170人次，国家临床29批，122人次流行病等专家20批，48人次。省级类专家：总共派43批105人临床专家30批75人流行病学等专家13批30人。行政领导和司机87人（列表）花名册，文件、简讯、工作报告流调信息组、临床救治组、宣传教育组、样本采集运输组、综合组,31,Unexplainedrespiratorydiseaseanddeathinfourstates,Otherindividualpersonswithsimilarillnessinsamelargearea.,May141993,twomembersofthesamefamilydiewithin5days,Fever,myalgias,headache,andcough,Rapiddevelopmentofrespiratoryfailure.,Testsforplagueandotherrespiratorypathogensyieldednocause.,32,33,34,35,36,37,新浪、雅虎、腾讯对阜阳的报道,38,调查暴发的10个步骤10stepsofanoutbreakinvestigation,准备现场工作Prepareforfieldwork,证实暴发存在Establishexistenceofanoutbreak,Time,Verifythediagnosis验证诊断,Define,count,andinterviewcases定义，计数，采访病例,确定人、地点和时间特征Characterizeperson,placeandtime,Developahypothesis提出假设,Developanalyticstudytotesthypothesis通过分析研究验证假说,Reconsider,refine,retesthypothesis再推敲，修正和再检验假说,实施控制措施ImplementControl,将调查结果进行交流CommunicateFindings,39,要重点考查实验室检测,已经做过什么检测？Whatdiagnostictestshavebeendone什么应该做的检测还没有做呢？Whatdiagnostictestshavenotbeendone,40,什么检测做了？什么检测没有做？Whattestsweredoneornotdone?,41,6期的麻疹阜阳的第一份流调报告,42,要敢于怀疑他们的同质性,癌症村2002年9月14日南京汤山中毒事件42人死亡，最终确诊为毒鼠强和氟乙酰胺联合中毒；,43,要注意假疫情,癔病空姐的皮疹小孩身上的沥青,44,调查暴发的10个步骤10stepsofanoutbreakinvestigation,准备现场工作Prepareforfieldwork,证实暴发存在Establishexistenceofanoutbreak,Time,Verifythediagnosis验证诊断,Define,count,andinterviewcases定义，计数，采访病例,确定人、地点和时间特征Characterizeperson,placeandtime,Developahypothesis提出假设,Developanalyticstudytotesthypothesis通过分析研究验证假说,Reconsider,refine,retesthypothesis再推敲，修正和再检验假说,实施控制措施ImplementControl,将调查结果进行交流CommunicateFindings,45,疾病的标识符：DiseaseIdentifiers:,症状Symptomatology体征（物理检查）Signs(Physicalexamination)临床评价（肌电图，脑电图，等）Clinicalevaluations(EKG,EEG,etc.)不符合其他疾病Lackofcompatibilitywithotherdiseases对治疗的反应Responsetotreatment实验室检测（病毒分离、血糖等）Laboratorytests(virusisolation,bloodsugar,etc.),46,使用能够包括多数病例或者所有病例的一个症状Useonecharacteristicthatwillincludemostorallcases,腹泻Diarrhea发烧Fever皮疹Rash皮疹+发烧Rash+fever黄疸Jaundice咳嗽+发烧Cough+fever,47,使用一些更特异的症状Useanumberofmorespecificcharacteristics,草莓舌Strawberrytongue柯氏斑Koplicksspots脑脊液SpinalfluidWBCs50/ml冠状动脉瘤Coronaryarteryaneurisms,48,与其他疾病不符Lackofcompatibilitywithotherdiseases,不是其他已知病因的皮疹Rashnotknowntobeduetoanotheretiology没有那些能明确引起嗜酸性粒细胞增多的原因的记录Norecordofanyknowncauseofeosinophilia尸检不能发现死亡原因Postmortemexaminationfailstodemonstrateanadequatecauseofdeath,49,Epidemiologiccriteria流行病学标准,时间Time地点Place人Person宿主因素（基础疾病）Hostfactors(underlyingillness)与其他病例的关系Linkagestoothercases与危险因素的关系Associationswithriskfactors,50,避免包括怀疑的暴露Avoidincludingsuspectedexposure,吃过A牌爆米花后72小时出现腹泻或者呕吐diarrheaorvomitingoccurringupto72hoursaftereatingBrandApopcorn.,51,暴发期间，特异度增加Duringoutbreaksspecificityimproves,90%Specificity,50%Specificity,52,在封闭人群中的病例定义Casedefinitioninaclosedgroup,真正的病例TrueCase,类似的病例Similardisease,53,在开放人群中的病例定义Casedefinitioninanopengroup,TrueCase,Similardisease,54,调查暴发的10个步骤10stepsofanoutbreakinvestigation,准备现场工作Prepareforfieldwork,证实暴发存在Establishexistenceofanoutbreak,Time,Verifythediagnosis验证诊断,Define,count,andinterviewcases定义，计数，采访病例,确定人、地点和时间特征Characterizeperson,placeandtime,Developahypothesis提出假设,Developanalyticstudytotesthypothesis通过分析研究验证假说,Reconsider,refine,retesthypothesis再推敲，修正和再检验假说,实施控制措施ImplementControl,将调查结果进行交流CommunicateFindings,55,31例重症病例,年龄分组,死亡年龄3岁以内平均1.5岁,56,18例死亡病例,发病到死亡1-11天平均3天,57,Persontopersontransmission,58,35%didknowthepersonwithwhomtheyhadcontact,59,35%didknowthepersonwithwhomtheyhadcontact,60,10%arepneumoniaand90%Upperrespiratoryinfection,61,90%ofinfectionsareasymptomatic(e.g.polio),62,Withoutidentificationofasymptomaticinfectionyouseethis,63,Azoonosis10%ofanimalinfectionstransmittoman.,64,Withoutknowledgeoftheanimaldiseaseitwilllooklikethis,65,在阜阳手足口病中差点发挥更大的作用（或可能发挥了重大的作用）,补阜阳日记,66,67,阜阳市2008年14月份手足口病发病情况而且不少病例有手足口皮疹症状（50%）,68,1983-1985马里兰州各季度PGH重症监护病房心跳停止病人Cardiacarrests,byquarterandyear,PGHICU,Maryland,1983-1985,1983,1984,1985,NumberofCardiacArrests,季度和年度QuarterandYear,0,20,30,40,10,心跳停止病例数,69,季度和年度QuarterandYear,NumberofCardiacArrests,1983-1985马里兰州各季度各班次PGH重症监护病房心跳停止病人数Cardiacarrests,byshift,PGHICU,Maryland,1983-1985,夜班Nightshift,晚班Eveningshift,白班Dayshift,心跳停止病例数,70,每日各时段（军队时间）HourofDay(Militarytime),NumberofCardiacArrests,1983-1985马里兰州每日各时段PGH重症监护病房心跳停止病人数Cardiacarrests,bytimeandperiod,PGHICU,Maryland,1983-1985,流行前Pre-epidemic,流行中Epidemic,流行后Post-epidemic,心跳停止病例数,71,不同护士管理病人的心跳骤停的危险Relativeriskofcardiacarrestbynurse,72,心跳骤停的重复发生Recurrentcardiacarrests,73,同一个病例的心跳骤停：发生多次心跳骤停的病例Arrestsonsamepatient:patientswithmultiplearrests,74,不同因素和不同护士护理发生心跳骤停的危险Riskofcardiacarrestbyfactorandnurs