不明原因疾病的流行病學(xué)調(diào)查方法

調(diào)查+++控制+調(diào)查+++控制+++未知調(diào)查+++控制+調(diào)查+控制+++已知未知已知傳染源或傳播模式病原體1目前一頁\總數(shù)七十八頁\編于點(diǎn)疾病聚集報(bào)告增多原因健康知識(shí)的傳播電影：“ErinBrockovich”（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2目前二頁\總數(shù)七十八頁\編于點(diǎn)“Alittleknowledgeisadangerousthing.”“一知半解，更加危險(xiǎn)”（英諺）3目前三頁\總數(shù)七十八頁\編于點(diǎn)疾病聚集報(bào)告增多原因健康知識(shí)的傳播對(duì)政府的不信任（美國）政府刻意掩蓋個(gè)別流氓科學(xué)家的作為Tuskegee（Alabama）事件（1943-1973）一粒老鼠屎害了一鍋粥4目前四頁\總數(shù)七十八頁\編于點(diǎn)疾病聚集報(bào)告增多原因健康知識(shí)的傳播對(duì)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(cè)的加強(qiáng)環(huán)境污染、行為危險(xiǎn)因素報(bào)告能力和發(fā)現(xiàn)意識(shí)5目前五頁\總數(shù)七十八頁\編于點(diǎn)種類ClassificationTotalPercent胃腸道Gastrointestinal12523腫瘤Cancers8015命名的綜合癥Namedsyndromes7514神經(jīng)Neurological5510其他Other509呼吸道Respiratory458出生缺陷Birthdefects407不明原因死亡Unexplaineddeath204醫(yī)療反應(yīng)Medicalreactions204實(shí)驗(yàn)室人為錯(cuò)誤Laboratoryartifacts153群體反應(yīng)Masssociogenicreactions102皮疹Rashes102所有不明原因Allunknowncause545100美國CDC調(diào)查的不明原因疾病

Investigationsofdiseasesofunknownetiology,USCDC1946-19996目前六頁\總數(shù)七十八頁\編于點(diǎn)不明原因綜合癥

SyndromesofunknowncauseidentifiedinsampleKawasakiDisease,Brainerddiarrhea,傳染性單核細(xì)胞增多綜合癥Infectiousmononucleosis格林巴例綜合癥Guillian-BarreSyndrome系統(tǒng)性紅斑狼瘡SystemicLupuserythematosis雷氏綜合癥Reye’ssyndrome溶血性尿毒綜合癥Hemolytic-UremicSyndrome海灣戰(zhàn)爭(zhēng)綜合癥GulfWarSyndrome7目前七頁\總數(shù)七十八頁\編于點(diǎn)不明原因死亡調(diào)查

Unexplaineddeathinvestigations嬰幼兒突然死亡綜合癥Suddeninfantdeathsyndrome(SIDS)夜間突然死亡Suddenunexplainednocturnaldeath家族性腎上腺腦白質(zhì)營養(yǎng)不良聚集性Familialclusters醫(yī)療錯(cuò)誤Medicalmalpractice

8目前八頁\總數(shù)七十八頁\編于點(diǎn)現(xiàn)場(chǎng)流行病學(xué)（暴發(fā)疫情）調(diào)查步驟組織準(zhǔn)備核實(shí)診斷確定暴發(fā)或流行的存在建立病例定義核實(shí)病例并計(jì)算病例數(shù)

描述性分析（三間分布）建立并檢驗(yàn)假設(shè)迅速采取控制措施完善現(xiàn)場(chǎng)調(diào)查報(bào)告交流反饋一般是10個(gè)步驟9目前九頁\總數(shù)七十八頁\編于點(diǎn)10目前十頁\總數(shù)七十八頁\編于點(diǎn)11目前十一頁\總數(shù)七十八頁\編于點(diǎn)12目前十二頁\總數(shù)七十八頁\編于點(diǎn)13目前十三頁\總數(shù)七十八頁\編于點(diǎn)美國四個(gè)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14目前十四頁\總數(shù)七十八頁\編于點(diǎn)內(nèi)布拉斯加Nebraska198442個(gè)病例ElevatedT4andsymptoms（焦慮、呼吸短促、心悸、心跳加快、體重減輕）6CountiesCasecontrolstudyforDietaryiodineColdandcoughmedicines“viralillness”53%vs32%p=0.05Viralcultures,HLAtyping,UrinaryIodine15目前十五頁\總數(shù)七十八頁\編于點(diǎn)南達(dá)科他明尼蘇達(dá)16目前十六頁\總數(shù)七十八頁\編于點(diǎn)June1985aspecialistreports8casesfromaneighboringstate

Onset Max. 24?hr.

Age

Sex

Residence

date

T4*

RAIU(%) 53 M ValleySprings,S.D. 3?84 >20 0.6 34 F ValleySprings,S.D. 5?85 18 17.0 57 M BeaverCreek,S.D. 5?85 22 1.0 41 F ValleySprings,S.D. 5?85 18 2.6 76 F ValleySprings,S.D. 6?85 14 7.8 ? M Luverne,Minn. 6?85 "high" 1.0 29 M ValleySprings,S.D. ? 27 2.2 ? M Luverne,Minn. ? "high" "low"*normalrange=5?12.RAIU?甲狀腺低放射性碘攝入;normalrange=10%?35%.17目前十七頁\總數(shù)七十八頁\編于點(diǎn)InitialstepsVerifythediagnosisIsthisalaboratoryerror?Willotherspecialistsconfirmthediagnosis?InterviewPatientsNotifyadjacentstatesFindmorehyperthyroisism18目前十八頁\總數(shù)七十八頁\編于點(diǎn)19目前十九頁\總數(shù)七十八頁\編于點(diǎn)Symptomsof28patientswithelevatedT4

Symptom

Percent Fatigue 92 Weakness 83 Tachycardiaorpalpitations 79 Shortnessofbreath 68 Weightloss 66 Tremor 62 Nervousness 60 Sleeplessness 51 Headaches 45 Heatintolerance 38 Excessivesweating 34 Diarrhea 1620目前二十頁\總數(shù)七十八頁\編于點(diǎn)WidenedCaseFindingSurveyofpatientrecordsfrommedicalclinics(4states)forpast18monthsTelephonesurveyofdoctorsinareaLetterstoalldoctorsinareaDescribetheoutbreakRequestreporting21目前二十一頁\總數(shù)七十八頁\編于點(diǎn)CasedefinitionappliedtoallreportsT4,freeT4orT3>25%higherthanupperlimitofnormalforthelaboratory≥2ofthefollowing:Sleeplessness,nervousness,headache,increasedheartrate,palpitations,shortofbreath,fatigue,sweating,tremor,diarrhea,heatintolerance,weightloss.ExcludedGrave’sdisease,T4replacement22目前二十二頁\總數(shù)七十八頁\編于點(diǎn)Casefindingidentified121casesthatfitthedefinition.

Agegroup

M F Total (years) # (%) 0?9 1 1 2 (2) 10?19 3 5 8 (7) 20?29 7 8 15 (12) 30?39 15 14 29 (24) 40?49 8 10 18 (15) 50?59 16 6 22 (18) 60?69 9 5 14 (12) 70+ 3

10

13

(11) Total 62 59 121 (100)23目前二十三頁\總數(shù)七十八頁\編于點(diǎn)Thyrotoxicosisbymonth24目前二十四頁\總數(shù)七十八頁\編于點(diǎn)Incidenceofthyrotoxicosisper10,000bycounty25目前二十五頁\總數(shù)七十八頁\編于點(diǎn)NewinformationExpertsopinionViralcauseIodine-inducedhyperthyroidismInformationfromnewcasesFamilyof54casesatemeat1non-caseavegetarianFoodfromonestoreallnationalexceptlocal“beeftrimmings”Wasbeefcontaminatedwithiodine?26目前二十六頁\總數(shù)七十八頁\編于點(diǎn)Thesecondcasecontrolstudyshowedaveryspecificassociation27目前二十七頁\總數(shù)七十八頁\編于點(diǎn)調(diào)查暴發(fā)的10個(gè)步驟10stepsofanoutbreakinvestigation準(zhǔn)備現(xiàn)場(chǎng)工作

Prepareforfieldwork證實(shí)暴發(fā)存在EstablishexistenceofanoutbreakTimeVerifythediagnosis驗(yàn)證診斷Define,count,andinterviewcases定義，計(jì)數(shù)，采訪病例確定人、地點(diǎn)和時(shí)間特征Characterizeperson,placeandtimeDevelopahypothesis提出假設(shè)Developanalyticstudytotesthypothesis通過分析研究驗(yàn)證假說Reconsider,refine,retesthypothesis再推敲，修正和再檢驗(yàn)假說實(shí)施控制措施ImplementControl將調(diào)查結(jié)果進(jìn)行交流CommunicateFindings目前二十八頁\總數(shù)七十八頁\編于點(diǎn)知道病原體有很大的優(yōu)勢(shì)，比如：傷寒

Knowingtheetiologyisamajoradvantage.E.g.Typhoid食物或者水源傳播Transmissionbyfoodorwater人是唯一宿主Humanreservoironly人傳人罕見Persontopersontransmissionveryrare70%病例是隱形感染70%infectionsasymptomatic潛伏期8-24天8-24dayincubationperiod治療方法明確Treatmentwelldefined病例定義和確診方法Casedefinitionsandconfirmatorytests目前二十九頁\總數(shù)七十八頁\編于點(diǎn)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(jí)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(cè)，文件、簡訊、工作報(bào)告流調(diào)信息組、臨床救治組、宣傳教育組、樣本采集運(yùn)輸組、綜合組目前三十頁\總數(shù)七十八頁\編于點(diǎn)Unexplainedrespiratorydiseaseanddeathinfourstates

Otherindividualpersonswithsimilarillnessinsamelargearea.

May141993,twomembersofthesamefamilydiewithin5daysFever,myalgias,headache,andcough,Rapiddevelopmentofrespiratoryfailure.Testsforplagueandotherrespiratorypathogensyieldednocause.目前三十一頁\總數(shù)七十八頁\編于點(diǎn)目前三十二頁\總數(shù)七十八頁\編于點(diǎn)目前三十三頁\總數(shù)七十八頁\編于點(diǎn)目前三十四頁\總數(shù)七十八頁\編于點(diǎn)目前三十五頁\總數(shù)七十八頁\編于點(diǎn)目前三十六頁\總數(shù)七十八頁\編于點(diǎn)新浪、雅虎、騰訊對(duì)阜陽的報(bào)道目前三十七頁\總數(shù)七十八頁\編于點(diǎn)調(diào)查暴發(fā)的10個(gè)步驟10stepsofanoutbreakinvestigation準(zhǔn)備現(xiàn)場(chǎng)工作

Prepareforfieldwork證實(shí)暴發(fā)存在EstablishexistenceofanoutbreakTimeVerifythediagnosis驗(yàn)證診斷Define,count,andinterviewcases定義，計(jì)數(shù)，采訪病例確定人、地點(diǎn)和時(shí)間特征Characterizeperson,placeandtimeDevelopahypothesis提出假設(shè)Developanalyticstudytotesthypothesis通過分析研究驗(yàn)證假說Reconsider,refine,retesthypothesis再推敲，修正和再檢驗(yàn)假說實(shí)施控制措施ImplementControl將調(diào)查結(jié)果進(jìn)行交流CommunicateFindings目前三十八頁\總數(shù)七十八頁\編于點(diǎn)要重點(diǎn)考查實(shí)驗(yàn)室檢測(cè)已經(jīng)做過什么檢測(cè)？Whatdiagnostictestshavebeendone什么應(yīng)該做的檢測(cè)還沒有做呢？Whatdiagnostictestshavenotbeendone目前三十九頁\總數(shù)七十八頁\編于點(diǎn)什么檢測(cè)做了？什么檢測(cè)沒有做？

Whattestsweredoneornotdone?檢測(cè)TestResultTiming痰涂片SputumsmearND血培養(yǎng)BloodCultureND鼠疫F1抗體PlagueF-1antibody-earlySARSPCR-OKAIPCR-OK兔拉熱免疫熒光TularemiaCF-early鸚鵡熱免疫熒光PsittacosisCFND呼吸道合胞病毒IgMRSVIgM+-early目前四十頁\總數(shù)七十八頁\編于點(diǎn)6期的麻疹阜陽的第一份流調(diào)報(bào)告目前四十一頁\總數(shù)七十八頁\編于點(diǎn)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；42目前四十二頁\總數(shù)七十八頁\編于點(diǎn)要注意假疫情癔病空姐的皮疹小孩身上的瀝青43目前四十三頁\總數(shù)七十八頁\編于點(diǎn)調(diào)查暴發(fā)的10個(gè)步驟10stepsofanoutbreakinvestigation準(zhǔn)備現(xiàn)場(chǎng)工作

Prepareforfieldwork證實(shí)暴發(fā)存在EstablishexistenceofanoutbreakTimeVerifythediagnosis驗(yàn)證診斷Define,count,andinterviewcases定義，計(jì)數(shù)，采訪病例確定人、地點(diǎn)和時(shí)間特征Characterizeperson,placeandtimeDevelopahypothesis提出假設(shè)Developanalyticstudytotesthypothesis通過分析研究驗(yàn)證假說Reconsider,refine,retesthypothesis再推敲，修正和再檢驗(yàn)假說實(shí)施控制措施ImplementControl將調(diào)查結(jié)果進(jìn)行交流CommunicateFindings目前四十四頁\總數(shù)七十八頁\編于點(diǎn)疾病的標(biāo)識(shí)符：

DiseaseIdentifiers:

癥狀Symptomatology體征（物理檢查）

Signs(Physicalexamination)臨床評(píng)價(jià)（肌電圖，腦電圖，等）Clinicalevaluations(EKG,EEG,etc.)不符合其他疾病Lackofcompatibilitywithotherdiseases對(duì)治療的反應(yīng)Responsetotreatment實(shí)驗(yàn)室檢測(cè)（病毒分離、血糖等）

Laboratorytests(virusisolation,bloodsugar,etc.)目前四十五頁\總數(shù)七十八頁\編于點(diǎn)使用能夠包括多數(shù)病例或者所有病例的一個(gè)癥狀

Useonecharacteristicthatwillincludemostorallcases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目前四十六頁\總數(shù)七十八頁\編于點(diǎn)使用一些更特異的癥狀

Useanumberofmorespecificcharacteristics

草莓舌Strawberrytongue柯氏斑Koplick’sspots腦脊液SpinalfluidWBC’s>50/ml冠狀動(dòng)脈瘤Coronaryarteryaneurisms目前四十七頁\總數(shù)七十八頁\編于點(diǎn)與其他疾病不符

Lackofcompatibilitywithotherdiseases

不是其他已知病因的皮疹Rashnotknowntobeduetoanotheretiology

沒有那些能明確引起嗜酸性粒細(xì)胞增多的原因的記錄Norecordofanyknowncauseofeosinophilia

尸檢不能發(fā)現(xiàn)死亡原因Postmortemexaminationfailstodemonstrateanadequatecauseofdeath

目前四十八頁\總數(shù)七十八頁\編于點(diǎn)Epidemiologiccriteria

流行病學(xué)標(biāo)準(zhǔn)時(shí)間Time地點(diǎn)Place人Person宿主因素（基礎(chǔ)疾?。?/p>

Hostfactors(underlyingillness)與其他病例的關(guān)系Linkagestoothercases與危險(xiǎn)因素的關(guān)系A(chǔ)ssociationswithriskfactors目前四十九頁\總數(shù)七十八頁\編于點(diǎn)避免包括懷疑的暴露

Avoidincludingsuspectedexposure吃過A牌爆米花后72小時(shí)出現(xiàn)腹瀉或者嘔吐diarrheaorvomitingoccurringupto72hoursaftereatingBrandApopcorn.目前五十頁\總數(shù)七十八頁\編于點(diǎn)暴發(fā)期間，特異度增加

Duringoutbreaksspecificityimproves90%Specificity50%Specificity目前五十一頁\總數(shù)七十八頁\編于點(diǎn)在封閉人群中的病例定義

Casedefinitioninaclosedgroup真正的病例TrueCase類似的病例Similardisease目前五十二頁\總數(shù)七十八頁\編于點(diǎn)在開放人群中的病例定義

CasedefinitioninanopengroupTrueCaseSimilardisease目前五十三頁\總數(shù)七十八頁\編于點(diǎn)調(diào)查暴發(fā)的10個(gè)步驟10stepsofanoutbreakinvestigation準(zhǔn)備現(xiàn)場(chǎng)工作

Prepareforfieldwork證實(shí)暴發(fā)存在EstablishexistenceofanoutbreakTimeVerifythediagnosis驗(yàn)證診斷Define,count,andinterviewcases定義，計(jì)數(shù)，采訪病例確定人、地點(diǎn)和時(shí)間特征Characterizeperson,placeandtimeDevelopahypothesis提出假設(shè)Developanalyticstudytotesthypothesis通過分析研究驗(yàn)證假說Reconsider,refine,retesthypothesis再推敲，修正和再檢驗(yàn)假說實(shí)施控制措施ImplementControl將調(diào)查結(jié)果進(jìn)行交流CommunicateFindings目前五十四頁\總數(shù)七十八頁\編于點(diǎn)31例重癥病例年齡分組死亡年齡3歲以內(nèi)平均1.5歲目前五十五頁\總數(shù)七十八頁\編于點(diǎn)18例死亡病例發(fā)病到死亡1-11天平均3天目前五十六頁\總數(shù)七十八頁\編于點(diǎn)PersontopersontransmissionTimePlace目前五十七頁\總數(shù)七十八頁\編于點(diǎn)35%didknowthepersonwithwhomtheyhadcontactTimePlace目前五十八頁\總數(shù)七十八頁\編于點(diǎn)35%didknowthepersonwithwhomtheyhadcontactTimePlace目前五十九頁\總數(shù)七十八頁\編于點(diǎn)10%arepneumoniaand90%UpperrespiratoryinfectionTimePlace目前六十頁\總數(shù)七十八頁\編于點(diǎn)90%ofinfectionsareasymptomatic(e.g.polio)TimePlace目前六十一頁\總數(shù)七十八頁\編于點(diǎn)WithoutidentificationofasymptomaticinfectionyouseethisTimePlace目前六十二頁\總數(shù)七十八頁\編于點(diǎn)Azoonosis10%ofanimalinfectionstransmittoman.TimePlace目前六十三頁\總數(shù)七十八頁\編于點(diǎn)WithoutknowledgeoftheanimaldiseaseitwilllooklikethisTimePlace目前六十四頁\總數(shù)七十八頁\編于點(diǎn)在阜陽手足口病中差點(diǎn)發(fā)揮更大的作用（或可能發(fā)揮了重大的作用）補(bǔ)阜陽日記65目前六十五頁\總數(shù)七十八頁\編于點(diǎn)目前六十六頁\總數(shù)七十八頁\編于點(diǎn)阜陽市2008年1～4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%）目前六十七頁\總數(shù)七十八頁\編于點(diǎn)1983-1985馬里蘭州各季度PGH重癥監(jiān)護(hù)病房心跳停止病人Cardiacarrests,byquarterandyear,PGHICU,Maryland,1983-1985198319841985NumberofCardiacArrests季度和年度QuarterandYear020304010心跳停止病例數(shù)目前六十八頁\總數(shù)七十八頁\編于點(diǎn)1983198419850151052520季度和年度

QuarterandYearNumberofCardiacArrests1983-1985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)Cardiacarrests,byshift,PGHICU,Maryland,1983-1985夜班Nightshift晚班Eveningshift白班Dayshift心跳停止病例數(shù)目前六十九頁\總數(shù)七十八頁\編于點(diǎn)00-0304-0708-1112-1516-1920-23020406080每日各時(shí)段（軍隊(duì)時(shí)間）HourofDay(Militarytime)NumberofCardiacArrests1983-1985馬里蘭州每日各時(shí)段PGH重癥監(jiān)護(hù)病房心跳停止病人數(shù)Cardiacarrests,bytimeandperiod,PGHICU,Maryland,1983-1985流行前Pre-epidemic流行中Epidemic流行后Post-epidemic心跳停止病例數(shù)目前七十頁\總數(shù)七十八頁\編于點(diǎn)不同護(hù)士管理病人的心跳驟停的危險(xiǎn)

Relativeriskofcardiacarrestbynurse護(hù)士Nurse1983-85EpidemicEpidemicPM143.95.011.2131.91.62.41961.40.75.01061.31.72.81181.00.65.0300.70.40.71290.70.91.7目前七十一頁\總數(shù)七十八頁\編于點(diǎn)心跳驟停的重復(fù)發(fā)生

Recurrentcardiacarrests病人Pt日期Date護(hù)士Nur病人Pt日期Date護(hù)士NurA1983/07/1026D1984/05/1714A1983/08/04118D1084/06/0514B1984/01/0214E09/01113