不明原因疾病的流行病学调查方法

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,*,不明原因疾病的流行病学调查方法,The Epidemiologic Approach to Disease of Unknown Cause.,1,调查,+,控制,+,调查,+,控制,+,未知,调查,+,控制,+,调查,+,控制,+,已知,未知,已知,传染源或传播模式,病原体,2,疾病聚集,报告增多原因,健康知识的传播,电影：“,Erin,Brockovich,”,（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,“,A little knowledge is a dangerous thing.”,“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,种类,Classification,Total,Percent,胃肠道,Gastrointestinal,125,23,肿瘤,Cancers,80,15,命名的综合症,Named syndromes,75,14,神经,Neurological,55,10,其他,Other,50,9,呼吸道,Respiratory,45,8,出生缺陷,Birth defects,40,7,不明原因死亡,Unexplained death,20,4,医疗反应,Medical reactions,20,4,实验室人为错误,Laboratory artifacts,15,3,群体反应,Mass,sociogenic,reactions,10,2,皮疹,Rashes,10,2,所有不明原因,All unknown cause,545,100,美国,CDC,调查的不明原因疾病,Investigations of diseases of unknown etiology, US CDC 1946-1999,7,不明原因综合症,Syndromes of unknown cause identified in sample,Kawasaki Disease,Brainerd diarrhea,传染性单核细胞增多综合症,Infectious mononucleosis,格林巴例综合症,Guillian-Barre,Syndrome,系统性红斑狼疮,Systemic Lupus,erythematosis,雷氏综合症,Reyes syndrome,溶血性尿毒综合症,Hemolytic-Uremic Syndrome,海湾战争综合症,Gulf War Syndrome,8,不明原因死亡调查,Unexplained death investigations,婴幼儿突然死亡综合症,Sudden infant death syndrome (SIDS),夜间突然死亡,Sudden unexplained nocturnal death,家族性肾上腺脑白质营养不良聚集性,Familial clusters,医疗错误,Medical malpractice,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,Nebraska 1984,42,个病例,Elevated T4 and symptoms,（焦虑、呼吸短促、心悸、心跳加快、体重减轻）,6 Counties,Case control study for,Dietary iodine,Cold and cough medicines,“viral illness” 53%,vs,32% p=0.05,Viral cultures, HLA typing, Urinary Iodine,16,南达科他,明尼苏达,17,June 1985 a specialist reports 8 cases from a neighboring state,Onset Max. 24hr.,Age,Sex,Residence,date,T4*,RAIU (%),53MValley Springs, S.D.384 20 0.6,34FValley Springs, S.D.585 18 17.0,57MBeaver Creek, S.D. 585 22 1.0,41FValley Springs, S.D.585 18 2.6,76FValley Springs, S.D.685 14 7.8,?M,Luverne, Minn. 685 high 1.0,29MValley Springs, S.D. ? 27 2.2,?M,Luverne, Minn. ? high low,*normal range = 512.,RAIU ,甲状腺低放射性碘摄入,; normal range = 10%35%.,18,Initial steps,Verify the diagnosis,Is this a laboratory error?,Will other specialists confirm the diagnosis?,Interview Patients,Notify adjacent states,Find more,hyperthyroisism,19,20,Symptoms of 28 patients with elevated T4,Symptom,Percent,Fatigue 92,Weakness 83,Tachycardia or palpitations79,Shortness of breath 68,Weight loss 66,Tremor 62,Nervousness 60,Sleeplessness 51,Headaches 45,Heat intolerance 38,Excessive sweating 34,Diarrhea 16,21,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 doctors in area,Describe the outbreak,Request reporting,22,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, sweating, tremor, diarrhea, heat intolerance, weight loss.,Excluded Graves disease, T4 replacement,23,Case finding identified 121 cases that fit the definition.,Age group,M,F,Total,(years) #(%),09 112(2),1019 358(7),2029 7815(12),3039 151429(24),4049 81018(15),5059 16622(18),6069 9514(12),70+,3,10,13,(11),Total 6259121(100),24,Thyrotoxicosis,by month,25,Incidence of,thyrotoxicosis,per 10,000 by county,26,New information,Experts opinion,Viral cause,Iodine-induced hyperthyroidism,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?,27,The second case control study showed a very specific association,28,调查暴发的10个步骤,10,steps of an outbreak investigation,准备现场工作,Prepare for field work,证实暴发存在,Establish existence of an outbreak,Time,Verify the diagnosis,验证诊断,Define, count, and interview cases,定义，计数，采访病例,确定人、地点和时间特征,Characterize person, place and time,Develop a hypothesis,提出假设,Develop analytic study to test hypothesis,通过分析研究验证假说,Reconsider, refine, retest hypothesis,再推敲，修正和再检验假说,实施控制措施,Implement Control,将调查结果进行交流,Communicate Findings,29,知道病原体有很大的优势，比如：伤寒,Knowing the etiology is a major advantage. E.g. Typhoid,食物或者水源传播,Transmission by food or water,人是唯一宿主,Human reservoir only,人传人罕见,Person to person transmission very rare,70%,病例是隐形感染,70% infections asymptomatic,潜伏期,8-24,天,8-24 day incubation period,治疗方法明确,Treatment well defined,病例定义和确诊方法,Case definitions and confirmatory tests,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,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 and other respiratory,pathogens yielded no cause.,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,10,steps of an outbreak investigation,准备现场工作,Prepare for field work,证实暴发存在,Establish existence of an outbreak,Time,Verify the diagnosis,验证诊断,Define, count, and interview cases,定义，计数，采访病例,确定人、地点和时间特征,Characterize person, place and time,Develop a hypothesis,提出假设,Develop analytic study to test hypothesis,通过分析研究验证假说,Reconsider, refine, retest hypothesis,再推敲，修正和再检验假说,实施控制措施,Implement Control,将调查结果进行交流,Communicate Findings,39,要重点考查实验室检测,已经做过什么检测？,What diagnostic tests have been done,什么应该做的检测还没有做呢？,What diagnostic tests have not been done,40,什么检测做了？什么检测没有做？,What tests were done or not done?,检测,Test,Result,Timing,痰涂片,Sputum smear,ND,血培养,Blood Culture,ND,鼠疫,F1,抗体,Plague F-1 antibody,-,early,SARS PCR,-,OK,AI PCR,-,OK,兔拉热免疫荧光,Tularemia CF,-,early,鹦鹉热免疫荧光,Psittacosis CF,ND,呼吸道合 胞病毒,IgM,RSV,IgM,+-,early,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,10,steps of an outbreak investigation,准备现场工作,Prepare for field work,证实暴发存在,Establish existence of an outbreak,Time,Verify the diagnosis,验证诊断,Define, count, and interview cases,定义，计数，采访病例,确定人、地点和时间特征,Characterize person, place and time,Develop a hypothesis,提出假设,Develop analytic study to test hypothesis,通过分析研究验证假说,Reconsider, refine, retest hypothesis,再推敲，修正和再检验假说,实施控制措施,Implement Control,将调查结果进行交流,Communicate Findings,45,疾病的标识符：,Disease Identifiers:,症状,Symptomatology,体征（物理检查）,Signs (Physical examination),临床评价（肌电图，脑电图，等）,Clinical evaluations (EKG, EEG, etc.),不符合其他疾病,Lack of compatibility with other diseases,对治疗的反应,Response to treatment,实验室检测（病毒分离、血糖等）,Laboratory tests (virus isolation, blood sugar, etc.),46,使用能够包括多数病例或者所有病例的一个症状,Use one characteristic that will include most or all cases,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,Use a number of more specific characteristics,草莓舌,Strawberry tongue,柯氏斑,Koplicks,spots,脑脊液,Spinal fluid WBCs 50/ml,冠状动脉瘤,Coronary artery aneurisms,48,与其他疾病不符,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,没有那些能明确引起嗜酸性粒细胞增多的原因的记录,No re,c,ord of any known cause of,eosinophilia,尸检不能发现死亡原因,Postmortem examination fails to demonstrate an adequate cause of death,49,Epidemiologic criteria,流行病学标准,时间,Time,地点,Place,人,Person,宿主因素（基础疾病）,Host factors (underlying illness),与其他病例的关系,Linkages to other cases,与危险因素的关系,Associations with risk factors,50,避免包括怀疑的暴露,Avoid including suspected exposure,吃过,A,牌爆米花后,72,小时出现腹泻或者呕吐,diarrhea or vomiting occurring up to 72 hours after eating Brand A popcorn.,51,暴发期间，特异度增加,During outbreaks specificity improves,90% Specificity,50% Specificity,52,在封闭人群中的病例定义,Case definition in a closed group,真正的病例,True Case,类似的病例,Similar disease,53,在开放人群中的病例定义,Case definition in an open group,True Case,Similar disease,54,调查暴发的10个步骤,10,steps of an outbreak investigation,准备现场工作,Prepare for field work,证实暴发存在,Establish existence of an outbreak,Time,Verify the diagnosis,验证诊断,Define, count, and interview cases,定义，计数，采访病例,确定人、地点和时间特征,Characterize person, place and time,Develop a hypothesis,提出假设,Develop analytic study to test hypothesis,通过分析研究验证假说,Reconsider, refine, retest hypothesis,再推敲，修正和再检验假说,实施控制措施,Implement Control,将调查结果进行交流,Communicate Findings,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,Person to person transmission,Time,Place,58,35% did know the person with whom they had contact,Time,Place,59,35% did know the person with whom they had contact,Time,Place,60,10% are pneumonia and 90% Upper respiratory infection,Time,Place,61,90% of infections are asymptomatic (e.g. polio),Time,Place,62,Without identification of asymptomatic infection you see this,Time,Place,63,A,zoonosis,10% of animal infections transmit to man.,Time,Place,64,Without knowledge of the animal disease it will look like this,Time,Place,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,1,4,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,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,心跳停止病例数,69,1983,1984,1985,0,15,10,5,25,20,季度和年度,Quarter and Year,Number of Cardiac Arrests,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,Cardiac arrests, by shift, PGH ICU, Maryland, 1983-1985,夜班,Night shift,晚班,Evening shift,白班,Day shift,心跳停止病例数,70,00-03,04-07,08-11,12-15,16-19,20-23,0,20,40,60,80,每日各时段 （军队时间）,Hour of Day (Military time,),Number of Cardiac Arrests,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,Cardiac arrests, by time and period, PGH ICU, 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,Relative risk of cardiac arrest by nurse,护士,Nurse,1983-85,Epidemic,Epidemic PM,14,3.9,5.0,11.2,13,1.9,1.6,2.4,196,1.4,0.7,5.0,106,1.3,1.7,2.8,118,1.0,0.6,5.0,30,0.7,0.4,0.7,129,0.7,0.9,1.7,72,心跳骤停的重复发生,Recurrent cardiac arrests,病人,Pt,日期,Date,护士,Nur,病人,Pt,日期,Date,护士,Nur,A,1983/07/10,26,D,1984/05/17,14,A,1983/08/04,118,D,1084/06/05,14,B,1984/01/02,14,E,09/01,113,B,1984/01/02,14,E,09/03,14,B,1984/01/05,14,F,10/02,14,C,1995/03/15,154,F,10/11,14,C,1995/03/19,33,F,10/12,14,73,同一个病例的心跳骤停：发生多次心跳骤停的病例,Arrests on same patient: patients with multiple arrests,同一个病例的心跳骤停次数,Arrests on,护士,Nurses,One patient,14,0thers,1,1,13,2,3,0,3,4,0,74,不同因素和不同护士护理发生心跳骤停的危险,Risk of cardiac arrest by factor and nurse,危险因素,Risk factor,Nurse 14,0thers,术后,Post operative,50%,(24),3.8%,(314),非术后,Not Post Operative,35%,(37),10%,(475),年龄,Age,69,50%,(12),14%,(153),75,其他关键因素的联系,Other key associations,与下列因素无关系,No association with,基础疾病,underlying illness,用药或者治疗,medication or treatment,与一个床位有关联,Association with one bed,与工作时间无关系,No association with hours worked,死亡的时间和病人的状况无特征可循,Deaths unexpected by timing and patients condition,死亡与高钾有关联,Deaths associated with,hyperkalemia,76,1983,1984,1985,0,15,10,5,25,20,季度和年度,Quarter and Year,Number of Cardiac Arrests,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,Cardiac arrests, by shift, PGH ICU, Maryland, 1983-1985,夜班,Night shift,晚班,Evening shift,白班,Day shift,心跳停止病例数,77,病因确定环节,研究可以从一个点开始，从三个方面收集证据；,证据的积累强化假说的强度，无需所有证据或证据簇均为阳性结果；,重视不支持假设病因证据的意义；,相似特征事件的类比（经验）引导研究的重要方法。,78,“凳子”模型,79,专家诊断意见,80,Simple case definitions,Be aware of,Mass,sociogenic,reactions,Publicity,Multiple diseases,Laboratory errors,Extend case finding,Consider mild and asymptomatic,Look for exposures not causes,Do not quit ask for help,81,要有扎实的理论基础和专业技能,要有内外两支工作团队,要有良好的体魄,要有必胜的信心,要有无功而返的心理准备,要善于思考，善于总结,要有应对媒体（）的思想准备,82,