不明原因疾病的流行病學(xué)調(diào)查方法PPT幻燈片.ppt

1、1,不明原因疾病的流行病學(xué)調(diào)查方法The Epidemiologic Approach to Disease of Unknown Cause.,2,3,疾病聚集報告增多原因,健康知識的傳播 電影：“Erin Brockovich”（布羅克維奇/ 永不妥協(xié)/ 伊人當(dāng)自強(qiáng)） 互聯(lián)網(wǎng)： 信息渠道 分享信息 傳播謠言、懷疑、恐慌,4,“A little knowledge is a dangerous thing.” “一知半解，更加危險”（英諺）,5,疾病聚集報告增多原因,健康知識的傳播 對政府的不信任 （美國）政府刻意掩蓋 個別流氓科學(xué)家的作為 Tuskegee（Alabama） 事件（1943

2、-1973） 一粒老鼠屎害了一鍋粥,6,疾病聚集報告增多原因,健康知識的傳播 對政府的不信任 非傳染病發(fā)病率增加 傳染病的減少 人均壽命增加 疾病監(jiān)測的加強(qiáng) 環(huán)境污染、行為危險因素 報告能力和發(fā)現(xiàn)意識,7,美國CDC調(diào)查的不明原因疾病Investigations of diseases of unknown etiology, US CDC 1946-1999,8,不明原因綜合癥Syndromes of unknown cause identified in sample,Kawasaki Disease, Brainerd diarrhea, 傳染性單核細(xì)胞增多綜合癥Infectious m

3、ononucleosis 格林巴例綜合癥Guillian-Barre Syndrome 系統(tǒng)性紅斑狼瘡Systemic Lupus erythematosis 雷氏綜合癥Reyes syndrome 溶血性尿毒綜合癥Hemolytic-Uremic Syndrome 海灣戰(zhàn)爭綜合癥Gulf War Syndrome,9,不明原因死亡調(diào)查Unexplained death investigations,嬰幼兒突然死亡綜合癥 Sudden infant death syndrome (SIDS) 夜間突然死亡 Sudden unexplained nocturnal death 家族性腎上腺腦白質(zhì)

4、營養(yǎng)不良聚集性 Familial clusters 醫(yī)療錯誤 Medical malpractice,10,現(xiàn)場流行病學(xué)（暴發(fā)疫情）調(diào)查步驟,組織準(zhǔn)備 核實診斷 確定暴發(fā)或流行的存在 建立病例定義 核實病例并計算病例數(shù),描述性分析（三間分布） 建立并檢驗假設(shè) 迅速采取控制措施 完善現(xiàn)場調(diào)查 報告交流反饋,一般是10個步驟,11,12,13,14,15,美國四個州的無痛性甲狀腺炎調(diào)查,南達(dá)科他,明尼蘇達(dá),艾奧瓦,內(nèi)布拉斯加,16,內(nèi)布拉斯加 Nebraska 1984,42 個病例 Elevated T4 and symptoms（焦慮、呼吸短促、心悸、心跳加快、體重減輕） 6 Counties

5、 Case control study for Dietary iodine Cold and cough medicines “viral illness” 53% vs 32% p=0.05 Viral cultures, HLA typing, Urinary Iodine,17,南達(dá)科他,明尼蘇達(dá),18,June 1985 a specialist reports 8 cases from a neighboring state,19,Initial steps,Verify the diagnosis Is this a laboratory error? Will other sp

6、ecialists confirm the diagnosis? Interview Patients Notify adjacent states Find more hyperthyroisism,20,21,Symptoms of 28 patients with elevated T4,22,Widened Case Finding,Survey of patient records from medical clinics (4 states) for past 18 months Telephone survey of doctors in area Letters to all

7、doctors in area Describe the outbreak Request reporting,23,Case definition applied to all reports,T4, free T4 or T3 25% higher than upper limit of normal for the laboratory 2 of the following: Sleeplessness, nervousness, headache, increased heart rate, palpitations, short of breath, fatigue, sweatin

8、g, tremor, diarrhea, heat intolerance, weight loss. Excluded Graves disease, T4 replacement,24,Case finding identified 121 cases that fit the definition.,25,Thyrotoxicosis by month,26,Incidence of thyrotoxicosis per 10,000 by county,27,New information,Experts opinion Viral cause Iodine-induced hyper

9、thyroidism Information from new cases Family of 5 4 cases ate meat 1 non-case a vegetarian Food from one store all national except local “beef trimmings” Was beef contaminated with iodine?,28,The second case control study showed a very specific association,29,調(diào)查暴發(fā)的10個步驟 10 steps of an outbreak inves

10、tigation,準(zhǔn)備現(xiàn)場工作 Prepare for field work,證實暴發(fā)存在 Establish existence of an outbreak,Time,Verify the diagnosis 驗證診斷,Define, count, and interview cases 定義，計數(shù)，采訪病例,確定人、地點和時間特征 Characterize person, place and time,Develop a hypothesis 提出假設(shè),Develop analytic study to test hypothesis 通過分析研究驗證假說,Reconsider, ref

11、ine, retest hypothesis 再推敲，修正和再檢驗假說,實施控制措施 Implement Control,將調(diào)查結(jié)果進(jìn)行交流 Communicate Findings,30,知道病原體有很大的優(yōu)勢，比如：傷寒Knowing the etiology is a major advantage. E.g. Typhoid,食物或者水源傳播Transmission by food or water 人是唯一宿主Human reservoir only 人傳人罕見Person to person transmission very rare 70%病例是隱形感染70% infectio

12、ns asymptomatic 潛伏期8-24天8-24 day incubation period 治療方法明確Treatment well defined 病例定義和確診方法Case definitions and confirmatory tests,31,受關(guān)注的程度不一樣：領(lǐng)導(dǎo)關(guān)注度,截至5月19日第362人次 國家類專家：國家共派49批170人次， 國家臨床29批，122人次 流行病等專家20批，48人次。 省級類專家：總共派43批105人 臨床專家30批75人 流行病學(xué)等專家13批30人。 行政領(lǐng)導(dǎo)和司機(jī)87人（列表） 花名冊，文件、簡訊、工作報告 流調(diào)信息組、臨床救治組、宣傳教

13、育組、樣本采集運輸組、綜合組,32,Unexplained respiratory disease and death in four states,Other individual persons with similar illness in same large area.,May 14 1993, two members of the same family die within 5 days,Fever, myalgias, headache, and cough, Rapid development of respiratory failure.,Tests for plague

14、and other respiratory pathogens yielded no cause.,33,34,35,36,37,38,新浪、雅虎、騰訊對阜陽的報道,39,調(diào)查暴發(fā)的10個步驟 10 steps of an outbreak investigation,準(zhǔn)備現(xiàn)場工作 Prepare for field work,證實暴發(fā)存在 Establish existence of an outbreak,Time,Verify the diagnosis 驗證診斷,Define, count, and interview cases 定義，計數(shù)，采訪病例,確定人、地點和時間特征 Char

15、acterize person, place and time,Develop a hypothesis 提出假設(shè),Develop analytic study to test hypothesis 通過分析研究驗證假說,Reconsider, refine, retest hypothesis 再推敲，修正和再檢驗假說,實施控制措施 Implement Control,將調(diào)查結(jié)果進(jìn)行交流 Communicate Findings,40,要重點考查實驗室檢測,已經(jīng)做過什么檢測？ What diagnostic tests have been done 什么應(yīng)該做的檢測還沒有做呢？ What d

16、iagnostic tests have not been done,41,什么檢測做了？什么檢測沒有做？What tests were done or not done?,42,6期的麻疹 阜陽的第一份流調(diào)報告,43,要敢于懷疑他們的同質(zhì)性,癌癥村 2002年9月14日南京湯山中毒事件42人死亡，最終確診為毒鼠強(qiáng)和氟乙酰胺聯(lián)合中毒；,44,要注意假疫情,癔病 空姐的皮疹 小孩身上的瀝青,45,調(diào)查暴發(fā)的10個步驟 10 steps of an outbreak investigation,準(zhǔn)備現(xiàn)場工作 Prepare for field work,證實暴發(fā)存在 Establish exist

17、ence of an outbreak,Time,Verify the diagnosis 驗證診斷,Define, count, and interview cases 定義，計數(shù)，采訪病例,確定人、地點和時間特征 Characterize person, place and time,Develop a hypothesis 提出假設(shè),Develop analytic study to test hypothesis 通過分析研究驗證假說,Reconsider, refine, retest hypothesis 再推敲，修正和再檢驗假說,實施控制措施 Implement Control,

18、將調(diào)查結(jié)果進(jìn)行交流 Communicate Findings,46,疾病的標(biāo)識符： Disease Identifiers:,癥狀Symptomatology 體征（物理檢查） Signs (Physical examination) 臨床評價（肌電圖，腦電圖，等） Clinical evaluations (EKG, EEG, etc.) 不符合其他疾病Lack of compatibility with other diseases 對治療的反應(yīng)Response to treatment 實驗室檢測（病毒分離、血糖等） Laboratory tests (virus isolation,

19、blood sugar, etc.),47,使用能夠包括多數(shù)病例或者所有病例的一個癥狀Use one characteristic that will include most or all cases,腹瀉Diarrhea 發(fā)燒Fever 皮疹Rash 皮疹+發(fā)燒 Rash+fever 黃疸Jaundice 咳嗽+發(fā)燒 Cough + fever,48,使用一些更特異的癥狀Use a number of more specific characteristics,草莓舌Strawberry tongue 柯氏斑Koplicks spots 腦脊液Spinal fluid WBCs 50/ml

20、 冠狀動脈瘤Coronary artery aneurisms,49,與其他疾病不符Lack of compatibility with other diseases,不是其他已知病因的皮疹 Rash not known to be due to another etiology 沒有那些能明確引起嗜酸性粒細(xì)胞增多的原因的記錄 No record of any known cause of eosinophilia 尸檢不能發(fā)現(xiàn)死亡原因 Postmortem examination fails to demonstrate an adequate cause of death,50,Epide

21、miologic criteria流行病學(xué)標(biāo)準(zhǔn),時間Time 地點Place 人Person 宿主因素（基礎(chǔ)疾病） Host factors (underlying illness) 與其他病例的關(guān)系Linkages to other cases 與危險因素的關(guān)系A(chǔ)ssociations with risk factors,51,避免包括懷疑的暴露Avoid including suspected exposure,吃過A牌爆米花后72小時出現(xiàn)腹瀉或者嘔吐 diarrhea or vomiting occurring up to 72 hours after eating Brand A po

22、pcorn.,52,暴發(fā)期間，特異度增加During outbreaks specificity improves,90% Specificity,50% Specificity,53,在封閉人群中的病例定義Case definition in a closed group,真正的病例 True Case,類似的病例 Similar disease,54,在開放人群中的病例定義Case definition in an open group,True Case,Similar disease,55,調(diào)查暴發(fā)的10個步驟 10 steps of an outbreak investigation

23、,準(zhǔn)備現(xiàn)場工作 Prepare for field work,證實暴發(fā)存在 Establish existence of an outbreak,Time,Verify the diagnosis 驗證診斷,Define, count, and interview cases 定義，計數(shù)，采訪病例,確定人、地點和時間特征 Characterize person, place and time,Develop a hypothesis 提出假設(shè),Develop analytic study to test hypothesis 通過分析研究驗證假說,Reconsider, refine, ret

24、est hypothesis 再推敲，修正和再檢驗假說,實施控制措施 Implement Control,將調(diào)查結(jié)果進(jìn)行交流 Communicate Findings,56,31例重癥病例,年齡分組,死亡年齡3歲以內(nèi) 平均1.5歲,57,18例死亡病例,發(fā)病到死亡1-11天 平均3天,58,Person to person transmission,59,35% did know the person with whom they had contact,60,35% did know the person with whom they had contact,61,10% are pneum

25、onia and 90% Upper respiratory infection,62,90% of infections are asymptomatic (e.g. polio),63,Without identification of asymptomatic infection you see this,64,A zoonosis 10% of animal infections transmit to man.,65,Without knowledge of the animal disease it will look like this,66,在阜陽手足口病中差點發(fā)揮更大的作用（

26、或可能發(fā)揮了重大的作用）,補阜陽日記,67,68,阜陽市2008年14月份手足口病發(fā)病情況 而且不少病例有手足口皮疹癥狀（50%）,69,1983-1985 馬里蘭州各季度PGH重癥監(jiān)護(hù)病房心跳停止病人 Cardiac arrests, by quarter and year, PGH ICU, Maryland, 1983-1985,1983,1984,1985,Number of Cardiac Arrests,季度和年度 Quarter and Year,0,20,30,40,10,心跳停止病例數(shù),70,季度和年度 Quarter and Year,Number of Cardiac A

27、rrests,1983-1985 馬里蘭州各季度各班次PGH重癥監(jiān)護(hù)病房心跳停止病人數(shù) Cardiac arrests, by shift, PGH ICU, Maryland, 1983-1985,夜班Night shift,晚班Evening shift,白班Day shift,心跳停止病例數(shù),71,每日各時段 （軍隊時間）Hour of Day (Military time),Number of Cardiac Arrests,1983-1985 馬里蘭州每日各時段PGH重癥監(jiān)護(hù)病房心跳停止病人數(shù) Cardiac arrests, by time and period, PGH ICU,

28、 Maryland, 1983-1985,流行前Pre-epidemic,流行中 Epidemic,流行后 Post-epidemic,心跳停止病例數(shù),72,不同護(hù)士管理病人的心跳驟停的危險Relative risk of cardiac arrest by nurse,73,心跳驟停的重復(fù)發(fā)生Recurrent cardiac arrests,74,同一個病例的心跳驟停：發(fā)生多次心跳驟停的病例Arrests on same patient: patients with multiple arrests,75,不同因素和不同護(hù)士護(hù)理發(fā)生心跳驟停的危險Risk of cardiac arrest by fa