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我国结核病的疫情状况

我国结核病的疫情状况. WHO 93 年宣布 “ 全球结核病紧急状态 ” ，98年又重申遏制结核病的行动刻不容缓。 全球现有结核病人2000万，其中95％在发展中国家，每年还会新发生800-1000万肺结核病，其中75％的病人年龄在15－50岁。如不控制，今后10年还将有9000万人发病。 中国是全球22个结核病高负担国家之一，结核病人数位居世界第二位，仅次于印度. 据调查全国三分之一的人口已感染了结核菌；受感染人数超过4亿,受结核感染人群中有10％的人发生结核病. tuberculosis. factor of tuberculosis incidence rising ：

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我国结核病的疫情状况

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  1. 我国结核病的疫情状况 • WHO 93年宣布“全球结核病紧急状态”，98年又重申遏制结核病的行动刻不容缓。 • 全球现有结核病人2000万，其中95％在发展中国家，每年还会新发生800-1000万肺结核病，其中75％的病人年龄在15－50岁。如不控制，今后10年还将有9000万人发病。 • 中国是全球22个结核病高负担国家之一，结核病人数位居世界第二位，仅次于印度. • 据调查全国三分之一的人口已感染了结核菌；受感染人数超过4亿,受结核感染人群中有10％的人发生结核病

  2. tuberculosis • factor of tuberculosis incidence rising ： • HIV spread. • TB strain occur drug resistance . • fluid population increasing. • Management TB patient not perfect、prevention and cure not efficiency. • Poverty、population increasing.

  3. etiology • Mycobacterium 、 Acid fastness、G+、aerobe。 • Growth torpidity , culture need 4-6 weeks. • Typing : human type 、 bovine type 、 Bird type、mouse type 、 main human type。 • way of infection：respiration tract、digestive track、skin or placenta.

  4. Epidemiology • 1 infection sources：open pulmonary tuberculosis • 2 route of transmission: by respiration way or digestion tract. • 3 susceptible population

  5. Epidemiology • The factors lead Children ill with TB • Contact TB amounts and toxicity. • power of resistance . • hereditary factor .

  6. pathogenesy bacterial number、toxicity、immunization condition • Cell-mediated immune reaction:macrophage swallow TB→antigen presentation Th and macrophage→IL12→CD+4→TH1-IF-γ→to promote mononuclear cell; to gather、activation、proliferation and differentiation→to produce alexin and oxidase 、 digestive enzyme→to kill TB

  7. pathogenesy • IF-reinforcement CD+8 、NK cells activity to phagocytosis TB. meanwhile to lead histoclasia • delayed allergy : T cell media，macrophage to be effector cell，to kill reinfection TB and cause cheesy necrosis or hole formation • After Infection TB : primary disease（5%），Secondary disease （5%）, not to fall ill all live(90%)

  8. diagnose • Objective • to discover focal 。 • Definite disease character、size whether or not deliver bacterium。

  9. diagnose • 1 history • TB toxic symptom • to contact TB patient • BCG vaccination • acute infection:measles，pertussis • Supersensitivity • erythema nodosum、exanthematous conjunctivitis。

  10. diagnose • 2 ：OT test • agent：1/2000 or 1/10000 PPD • dose：0.1ML（OT 5U）（or 1U）。 • position：left forearm palmaris below 1/3 • Infuse intracutaneous form 6-10mm hillock。 • 48~72hr observation reaction。

  11. diagnosis • reaction • <5mm(-) • ≧5mm(+) • 10-19mm(++) • ≧20mm(+++) • Super reaction :induration、vesic 、 local ulceration (++++)。

  12. diagnosis • significance • positive reaction • After BCG vaccination • Older children positive reaction indicate to be ever infected with TB before。 • Infant never BCG vaccination indicate new infection recent。 • Strong positive reactionindicate there is activeness TB.。 • from（-）to（+）、from <10mm to >10mm ,or increase >6mm by activeness TB.。

  13. diagnosis • negative reaction • never infection TB • first Infect TB during 4-8 weeks • false negative reaction，immune function to be pressed down。 • Wrong with test or PPD ineffective

  14. diagnosis • BCG Vaccination and natural infection positive reaction condition

  15. diagnosis 3 ： laboratory examination （1）find TB • specimen：sputum、gastric juice、C.S.F、serous cavity liquid. • method：smear、 fluorescent staining、 • BACTEC system：culture for 2 weeks，test mycobacteria metabolism production，to distinguish TB and atypical .mycobacteria. • L tubercle bacterium：mutation TB，form、construction、acid-fast staining different from common TB。Easy passing placenta，therapeutic inefficacy。

  16. diagnosis （2）immunology and molecular biology test • ELISA（酶联免疫吸附试验） • ELIEP（酶联免疫电泳技术） • DNA探针 • PCR （聚合酶链式反应） • 线条DNA探针杂交试验 • ESR (血沉)。

  17. diagnosis 4 ： chest X-RAY • To definite focus of infection position 、extent、category、activity condition。 • To evaluate and follow up therapeutic efficacy 。 • CT more clear to find the focus、 extent and spread condition。 5：bronchofiberscopy check：to definite Endotracheal membrane TB and tuberculosis of trachebronchial lymph nodes。 6：lymph node puncture smear or lymphaden biopsy to diagnosis。

  18. tuberculotherapy • general treatment • nutrition、to take a rest。 • avoiding to contact infection disease 。 • Primarily TB treatment in out-patient clinic and regularity return visit 。 • Report epidemic situation。

  19. tuberculotherapy • Treatmen target • To kill Bacillus tuberculosis in focus • to prevent disseminate。 • therapeutic principle • early treatment • Reasonable dosage • Combine medicine • Regularity take drug • to insist on whole course • Segmenting treatment.

  20. tuberculotherapy • Anti-tuberculosis drugs • Whole germicide：in acid and alkali，exterior and interior of cell can kill germ。(INH RFP) • Half germicide：in acid or alkali environment kill cell interior or exterior TB，SM /PZA • bacteriostatic：EMB（ethambutol) ETH(ethionamide)

  21. tuberculotherapy • new antituberculosis to Anti drug resistant • Rifamate(contain INH 150mg RFP300mg) • Rifater(INH,RFP PZA) • old drug derivant：Rifapentine • New chemicals：Dipasic，to delay resistant INH drug • standard treatment： • refer to asymptomatic primarily pulmonary tuberculosis • usage：INH+RFP±EMB • course of treatment 9~12 month.

  22. 化疗方案 • Two stage therapy • refer to：activeness primarily pulmonary TB: acute miliary tuberculosis;brain TB; • intensification therapy：（purpose） • Combination 3~4 germicide drugs • Longer 3~4mo、shorter 2mo。 • continue treatment stage • Combination two drugs to keep therapeutic effect for 12~18mo.(longer rang)or 4mo. (Short-rang) 。

  23. 化疗方案 • short-range therapy • WHO important strategy to cure tuberculosis • mechanism of action is fast kill organism inner cell or out cell。 • To sputum bacterium(-)，recovery fast ，recurrence less。 • 2HRZ/4HR、2SHRZ/4HR、2EHRZ/4HR

  24. antituberculosis drugs medicinedoseadverse reaction INH 10~20 多发性神经炎，肝损害 RFP 10~15 可逆性肝损害，消化道症状。尿红色。 PZA 20-30 肝损害，高尿酸血症。 SM 15~20 听神经损害,肾损害。 EMB 15~20 球后视神经炎。

  25. Tuberculosis prevention • to control source of infection：smear(+) patient • Pervasion BCG vaccination：to have an inoculation age is neonate. • contraindication • cellular immunity deficiency • acute infectious disease convalescence stage • Region eczema or general skin disease • OT（+）

  26. Tuberculosis prevention Drug prevention indication: • 1 Close to contact open pulmonary tuberculosis in family • 2 lower 3 years infant have not innoculation BCG; but OT（+） • 3 OT from（-）to （+）recently • 4 OT(+) with toxic symptom • 5 OT（+）and recently ill with measles or pertussis • 6 OT（+）need long-term to take corticosteroids or immunodepressant

  27. Tuberculosis prevention • Approach 1 : INH 10mg/kg course of treatment 6~9mo. • Approach 2 : INH+RFP(10mg/kg) course 3 mo.

  28. 原发性肺结核（primary pulmonary tuberculosis) • 首次侵入肺部发生的原发感染 • 原发综合症（primary complex)原发病灶+局部病变淋巴结+淋巴管 • 支气管淋巴结结核 (胸腔内肿大淋巴结结核)

  29. primary pulmonary tuberculosis • 病理 • 部位:右侧肺上叶底部、下叶上部 • 基本病变：渗出（炎症细胞 单核细胞 纤维蛋白）、增殖（结核结节 结核肉芽肿）、坏死（干酪样坏死）。 • 炎症特征：上皮样细胞结节、langerhans细胞浸润

  30. primary pulmonary tuberculosis • 病理转归 • 吸收好转 • 进展 • 扩大出现空洞 • 支气管内膜结核或干酪性肺结核 • 肿大淋巴结压迫造成肺不张或阻塞性肺气肿 • 结核性胸膜炎 • 恶化：血行播散（肺或全身性粟粒性结核病）

  31. primary pulmonary tuberculosis • 临床表现 • 结核中毒症状 • 过敏症状（眼疱疹性结膜炎、皮肤结节性红斑，多发性一过性关节炎 • 压迫症状：类百日咳样痉挛性咳嗽，喘鸣、声嘶、颈静脉怒张 • 体征：一般无体征、可有周围淋巴节肿大，肺部叩诊浊音，呼吸音减低，或有湿罗音。

  32. primary pulmonary tuberculosis 诊断和鉴别诊断 • 病史（三史） • 临床表现 • 结核菌素试验 • X-线检查（胸正侧位片 • 原发综合症 • 支气管淋巴结结核（炎症型、结节型、微小型 • 纤维支气管镜检查（1管腔狭窄、2炎症、肉芽肿或溃疡3腔内肿块3支气管瘘，孔口火山样突起，干酪样物 • 实验室检查

  33. 治疗 • 无症状原发型肺结核标准疗法用法：INH+RFP±EMB疗程9~12个月 • 活动性原发型肺结核短程疗法2HRZ/4HR

  34. 结核活动参考指标 • OT试验≧20mm<3岁尤其<1岁未接种卡介苗而OT（+）者 • 发热及其它结核中毒症状者 • 排出物找到结核菌 • X-线显示活动性原发性肺结核 • 不明原因ESR升高 • 支气管镜发现有明显结核病变。

  35. primary pulmonary tuberculosis • 鉴别诊断 • 气道异物 • 肿瘤 • 各种肺炎，支气管扩张。

  36. conclusion • Epidemiology • Diagnosis • OT test • therapeutic principle

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