美国伤寒分析课件

2003年埃及伤寒：

疾病负担和危险因素

TyphoidFeverinEgypt,2003:

Burdenofdiseaseandriskfactorsforinfection概述

Overview伤寒的流行特点和临床特征Backgroundontyphoidfever伤寒发病率Incidenceoftyphoidfever伤寒危险因素Riskfactorsfortyphoidfever控制策略Controlstrategies威廉.巴德

WilliamBuddMoorheadR.JRSM,95(11)p.562疾病负担

Burdenoftyphoidfever全球每年21，000，000人罹患伤寒，200，000人因此死亡21

millionillnessesand200,000deathsworldwide有伤寒疫情的国家缺乏疾病负担的确切数据Burdenill-definedinendemiccountries多重抗药性Multidrug-resistanttyphoidfever疾病传播

TransmissionofS.Typhi人类是传染源和宿主Humansarereservoir粪口途径传播Spreadthroughfecaloralroute两种主要的传播模式Twomajormodesoftransmission水Water食物Food(milk,shellfish,produce)

美国1912-1994年伤寒年发病率TyphoidFever:AnnualIncidence,UnitedStates,1912-1994Water

美国1912-1994年伤寒年发病率TyphoidFever:AnnualIncidence,UnitedStates,1912-1994WaterFood地方性伤寒危险因素

Riskfactorsforendemictyphoidfever印度尼西亚1998水Indonesia1998=Water巴基斯坦1995食物和水Pakistan1995=Foodandwater智利1981食物Chile1981=Sharingfoodatlunch匹兹堡1900-1910年伤寒死亡率和引用安全水源的人口比例Deathratefortyphoidfever,andproportionofpopulationwithtreatedwater,PittsburghPA,1900-1910

Firstwatertreatmentplantopened,1907Typhoidfeverdeathrateper100,000populationPercentofpopulationwithtreatedwaterRosenauMJ.PreventiveMedicineandHygiene,5thed,1927,p111

智利，圣地亚哥南部大城市1984-1991年公共医疗系统伤寒报告病例Reportedcasesoftyphoidfever,SouthMetropolitanHealthService,Santiago,Chile,1984-1991Alcayagaetal.RevChileInfect1993;1:5-10CholeraPreventionProgram伤寒的预防接种

Vaccinesfortyphoidfever接种Vaccines

口服减毒活疫苗Liveattenuatedoral(Ty21a)

注射多聚糖抗原Vipolysaccharideparenteral(Vi)新疫苗NewViconjugate(Vi-rEPA)

为什么不作为常规控制策略

Challengesascontrolstrategy昂贵Expensive保护期较短Limitedduration伤寒控制面临的挑战

Challenges伤寒多发在发病率难以估计，危险因素难以评估的地区Typhoidfeveroccursinplaceswhere:IncidenceisdifficulttomeasureRiskfactorsaredifficulttoassess需要相关信息，以使卫生资源分配最优化Needinformationtoallocatelimitedresources快速评估方法Developmethodforrapidassessment埃及伤寒现况

TyphoidfeverinEgypt国家被动监测Nationalsyndrome-basedsurveillance年发病率15/100,00015/100,000/year不到1%的病例经培养确诊<1%culture-confirmed危险因素尚不明确Riskfactorsnotwellcharacterized埃及某一地区FayoumGovernorate绿洲Oasisarea距开罗100公里100kmfromCairo人口2，238，592Pop.2,238,592FayoumMediterraneanSea发病率

Measuringincidence疾病负担快速评估

Rapidburdenassessment急性发热性疾病监测Acutefebrileillnesssurveillance多级卫生服务部门Multiplelevelsofhealthcare培训医疗服务人员Participatingprovidersandlaboratorypersonneltrained抽样

Sampling政府发热医院(n=1)FayoumFeverhospital(n=1)发热医师(n=15)

Feverspecialists(n=15)主要的医疗服务提供者~20%Primarycareproviders~20%地区医院(n=6)

Districthospitals(n=6)农村医疗机构~20%Ruralhealthunits~20%实验室方法

Laboratorymethods血培养Singlebloodculture相关实验室FayoumFeverHospital,GeneralCommon,andNAMRUlabs多重抗药性Multidrug-resistant

氨比西林ampicillin

氯霉素chloramphenicol

甲氧苄氨嘧啶-磺胺类trimethoprim-sulfamethoxazole血培养结果校正

Bloodcultureadjustments单血培养的敏感度为50％Singlebloodculture50%sensitive阳性结果数乘以2Multipliednumberpositiveculturesby2污染血样Contaminatedbloodcultures假设阳性率与未污染血样相同Similartountestedspecimens抽样校正

SamplingadjustmentProviderlevelCasesoftyphoidParticipatingproviders加权MultiplierFeverHospital311/11DistrictHospital126/61FeverSpecialist4714/151.1RuralHealthUnit2426/1345.2PrimaryCareProvider5234/1845.4研究时间期限校正（使用Fayoum2002年发热医院数据）

Using2002FayoumFeverHospitaldatatoadjustforstudytimeframeNumbercasesStudytimeframe35/108=32%发病率计算

IncidencecalculationsProviderTyphoidcases*SamplingBloodCultureTimeFrameAdjustedcases

PercentTotalFeverHospital321231916%DistrictHospital13123782%Specialist491.12331510%RuralHealthUnit275.62383425%PrimaryCare585.023188957%FAYOUM1793307100%*adjustedforcontaminationrateFayoum伤寒发病率

TyphoidfeverincidenceinFayoum基于全人口Populationbased148/100,000/year基于发热医院Feverhospitalbased9/100,000/year年龄分布

AgedistributionofcasesAge Cases(%)Percent Incidence n=165population 1-14 118(72) 39 272/100,000/yr15+ 47(28) 6168/100,000/yr 伤寒的多重抗药性

Multidrug-resistanttyphoid共实验165例165S.Typhiisolatestested51例（31％）有抗药性Multidrug-resistancein51(31%)为发现抗Ciprofloxacin

NoCiprofloxacinresistance局限性

Limitations未作以下校正Noadjustmentmadefor:未就医的病人Patientswhodonotseekanymedicalcare曾采取抗菌治疗的病人Patientswhohaveusedpriorantibiotictherapy加权系数的不确定性Uncertaintyinmultipliers血培养的敏感度Sensitivityofbloodculture季节效应Effectofseasonality

摘要

Summaryofincidence基于全人口的疾病负担快速评估Population-basedrapidburdenassessmentestablished:Fayoum的伤寒发病率高IncidenceoftyphoidfeverinFayoumhigh大多数伤寒患者是在初级诊疗单位诊治Highestproportionoftyphoidfeverpatientsevaluatedatprimarycarelevel多重抗药性的高流行率Highprevalenceofmultidrug-resistanttyphoidfever危险因素

RiskFactors病例对照研究

Case-controlstudy目的Objective:证实埃及FayoumGovernorate伤寒发病的危险因素ToidentifyriskfactorsfortyphoidfeverinFayoumGovernorate,Egypt在2003年6月到9月开展研究ConductedJune-September,2003方法

Case-controlstudymethods监测病例Casesfromongoingsurveillance血培养发现沙门氏菌S.Typhiinblood大于1岁>1yearofage发热超过3天（包括3天）Febrileillness>3days对照Controlsclinicbased和病例在同一医疗单位就诊的人Seenathealthcarefacilityfollowingcase年龄组匹配Matchedbyagegroup(1-4,5-14,15-50,50+)排除疑似伤寒和肠道疾病Suspectedtyphoidorentericdiseaseexcluded1：2配对2controlspercase方法

Case-controlstudymethods埃及卫生部工作人员担任入户调查工作InhomeinterviewsbytrainedMOHpersonnel询问发病前14天内有关食品和水的暴露Foodandwaterexposuresin14daysbeforeillness家庭用水抽样Sampleofhouseholdwater方法

Case-controlstudymethods主要方法Primarymeasureofassociation

匹配的OR值matchedoddsratio(MOR)特异危险度计算Attributableriskcalculation*P(OR–1)P(OR–1)+1*Gregg,M.FieldEpidemiology,2002,p.146WhereP=percentcontrolsexposed病例和对照的一般特征

Case-controlsubjectcharacteristicsCharacteristic病例Cases 对照Controls (n=97) (n=200)年龄中位数Medianageinyears 10 12女性比例Percentfemale 50 45家庭人口数Numberpeopleinhouse 9.1 8.9农民比例Percentfarmers 47 41家中有电视的比例PercenthouseswithTV 74 79单因素分析：食品因素

Bivariateanalysis:FooditemsExposure %Cases %Controls MOR95%CI (n=97)(n=200)带叶蔬菜Leafyvegetables47 49 0.9 0.4-1.9瓜类Melons 81 79 1.1 0.4-3.6牛奶Milk 57 620.8 0.4-1.4冰淇淋Icecream 68 68 1.0 0.5-1.9街头小吃Streetvendor 23 17 1.8 0.8-4.4

单因素分析：水的因素

Bivariateanalysis:WaterExposure %Cases %ControlsMOR95%CI (n=97)(n=200)家庭管道输水Pipedwater 79 90 0.4 0.2-0.9tohome家庭储备用水Storewater 90 79 4.31.5-14.8athome食用冰Consumeice40 28 2.21.0-4.7在水渠清洗用具Washutensils 15 5 3.71.4-12.9Incanal

在家中用肥皂清洗Soapathome 5970 0.40.2-0.9

多因素分析

MultivariateanalysisExposure ConditionalOR*95%CI Attributable risk

家庭储备用水Storewater 3.5 1.2-9.8 66%athome在水渠清洗器具Washutensils 4.0 1.3-12.1 13%incanal

*controllingforothersignificantexposures不同年龄组多因素分析

Conditionaloddsratiobyagegroupforstoringwaterathomeandwashingutensilsincanal饮用水处理

Drinkingwaterhandling

只有2％的居民每天可获得流动饮用水Only2%ofresidentshavesourceofdrinkingwateravailableeveryday在使用储藏水的居民中，85％用容器或手舀水Amongthosewhostorewater,85%getwaterbyscooping饮用水检测结果

Results:DrinkingwatertestingExposure %Cases%ControlsMOR*95%CI (n=97)(n=192)大肠杆菌培养Coliformgrowth 30 21 1.60.9-2.8

结论

Conclusions大多数Fayoum居民罹患伤寒与家庭储备用水有关LargeproportionoftyphoidfeverinFayoumisassociatedwithstoringwaterinthehome小部分病例的患病与开放式水渠有关Smallproportionassociatedwithopencanal改善水质降低伤寒发病率ImprovedwaterqualitycoulddecreaseincidenceoftyphoidinFayoum局限性

Limitations食品因素尚未定论Foodexposuresnotadequatelydefined从病人中选取对照的影响Illcontrolsmaydecreasestudypower社会经济学情况的估计Measuresofsocioeconomicstatus启示

Wheredoesthisleadus?

由调查结果引发的讨论Severalquestionsfollowfromtheseresults:改善水质的干预措施应采取什么形式？Whatformshouldinterventiontoimprovewaterqualitytake?水质干预是否可行？Iswaterqualityinterventionfeasible?如果不可行，是否还有其他策略？Ifnot,arethereviablealternativestrategies?改善水质

ImprovingwaterqualityCanal水处理装置Watertreatmentfacility家庭Home管道Pipes

增加数量buildmore

改善现有装置improveexistingoperations

煮沸boiling

使用点point-of-use安全用水系统

SafeWaterSystem家庭水处理Householdlevelwatertreatment使腹泻类疾病发病率降低40％Showntodecrease

diarrhealdisease40%尚未评估其对伤寒的效果Notevaluatedfortyphoid摘要

Summary疾病负担快速评估Rapidburdenassessment基于全人口的发病率估计Populationbasedincidenceestimate(148/100,000)选取有代表性的病例进行病例对照研究Representativecasesforcase-controlstudy病例对照研究Case-controlstudy证实危险因素（储藏水，在沟渠中洗涤）Identifiedriskfactors(storedwater,washingincanal)可能的干预策略Potentialinterventionstrategies方法的可变更性Methodpotentiallytransferable感谢

AcknowledgementsEgyptianMinistryofHealthDr.SaidelOunFayoumGovernorate