Epidemiology of tuberculosis in a high HIV prevalence population provided with enhanced diagnosis of symptomatic disease.
Epidemiology of tuberculosis in a high HIV prevalence population provided with enhanced diagnosis of symptomatic disease.
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高艾滋病毒患病率的结核病流行病学和症状疾病的诊断增加。
DOI：
10.1371/journal.pmed.0040022
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发表时间：
2007-01
期刊：
影响因子：
15.8
通讯作者：
Mason, Peter
中科院分区：
文献类型：
--
作者：
Corbett, Elizabeth L.;Bandason, Tsitsi;Cheung, Yin Bun;Munyati, Shungu;Godfrey-Faussett, Peter;Hayes, Richard;Churchyard, Gavin;Butterworth, Anthony;Mason, Peter
直接观察短程治疗（DOTS）是一项旨在通过及时诊断有症状的涂片阳性疾病来控制结核病传播的全球控制战略，但未能预防艾滋病毒流行在非洲造成的结核病发病率上升。然而，发病率上升并不一定意味着无法控制结核病的传播，结核病主要是由流行传染病引起的。我们调查了在初级卫生保健得到加强的艾滋病毒高流行人群中流行和偶发结核病的流行病学。通过职业诊所，向津巴布韦哈拉雷的22家企业免费提供了基于涂片和文化的结核病症状调查。要求所有员工进行匿名艾滋病毒检测。在对偶发性结核病进行了2年的随访后，对未确诊的流行结核病进行了基于文化的调查。在7478名符合条件的雇员中，共有6440人参加了调查。艾滋病毒感染率为19%。对于hiv阳性和阴性参与者，培养阳性结核病的发病率分别为每1000人年25.3例和1.3例（调整后的发病率比= 18.8；95%置信区间[CI] = 10.3至34.5：人群归因分数= 78%），2年后的点患病率为每1000人5.7例和2.6例（调整后的优势比= 1.7;95% CI = 0.5至6.8：人群归因分数= 14%）。大多数流行的培养阳性结核病患者在首次发现时均为亚临床疾病。以及时调查结核病症状为基础的战略，如直接督导下的短程化疗，可能是控制艾滋病毒高流行人群中结核病流行的有效方法。这可能转化为有效控制结核病传播，尽管结核病发病率高，一些患者有一段时间的亚临床传染性。当职业诊所提供免费的涂片和基于培养的结核病症状调查时，它可以导致及时调查，并可能有助于在艾滋病毒高流行人群中控制结核病。每年约有800万人患上结核病，其中近200万人死亡。然而，受感染的人比有症状的人多得多；目前世界上可能有三分之一的人口感染了结核病。大多数感染结核病的人都有所谓的“潜伏感染”，换句话说，他们感染了细菌，但没有出现任何疾病症状。感染结核病的人同时免疫系统也较弱，例如通过艾滋病毒/艾滋病感染的人更有可能患上结核病。在一些地区，艾滋病毒非常普遍——例如，大约11%的撒哈拉以南非洲成年人艾滋病毒呈阳性——因此，随着艾滋病毒的传播，结核病病例大幅增加。世界卫生组织推荐了一项控制结核病的国际战略，称为短程直接观察疗法（DOTS）。直接督导下的短程化疗的五项主要内容包括及时诊断和治疗结核病患者的机制。人们希望这一战略将有助于减少每年诊断出的结核病新病例的数量，因为及时诊断和治疗的个体将不太可能将这种疾病传播给他人。在这项研究中，这组科学家想要弄清楚，在非洲，密集的直接督导下的短程化疗加上让人们更好地利用检测设施来诊断结核病，是否可以有效地减少结核病在人与人之间的传播。目前尚不清楚直接督导下的短程化疗是否能够单独控制结核病在艾滋病毒阳性人群中的传播，这些人群已经感染了结核病，因此具有发展为结核病的高风险。具体来说，他们希望收集每年新诊断的结核病病例数量的数据，以及在任何给定时间点，这与总体人口中未确诊的传染性结核病的比例有何关系。他们还想弄清楚，提供良好的结核病诊断和治疗服务是否会影响新发结核病病例的数量，或者影响患有传染性未确诊结核病的特定人群的比例。这项研究是作为一项试验的一部分进行的，该试验比较了在工作场所提供艾滋病毒检测和咨询的两种不同策略。这项试验是在津巴布韦哈拉雷的22家公司进行的，在哈拉雷，艾滋病毒在成年人中非常普遍。除了艾滋病毒检测和咨询外，该试验还提供了对任何出现结核样症状的人的密切随访和检测，目的是在人群中发现尽可能多的病例。在两年期间结束时，对所有工人进行了未确诊的结核病检查，并进行了培养，以确定这些人中有多少人患有传染性结核病（但不一定有症状）。这项研究招募了6440名工人，其中19%是艾滋病毒阳性。在随访期间，发现了106例结核病病例，艾滋病毒阳性的工人比艾滋病毒阴性的工人患结核病的可能性要大得多。在研究结束时，4668名工人被检查是否存在未确诊的结核病，27人被发现受到影响，但并非所有这些人都有任何疾病症状。在本研究结束时，发现患有未确诊结核病的工人比例相当低——低于在结核病负担高但艾滋病毒负担低的世界其他地区进行的其他研究中发现的水平。这组科学家因此得出结论，在试验中建立的系统（用于密切跟踪和检测结核病）是控制感染性结核病总体比例的一种有效方法，尽管艾滋病毒感染率也很高。这可能意味着结核病感染向他人的传播——这是实现结核病控制的先决条件——也得到了很好的控制。然而，还需要更密集的努力来降低已经感染结核病的艾滋病毒阳性非洲人患结核病的风险，尽管这项研究的目的不是找出这种策略的影响。请通过本摘要的在线版本http://dx.doi.org/10.1371/journal.pmed.0040022访问这些网站。世界卫生组织提供的关于直接督导下的短程化疗这一国际推荐的结核病控制战略的信息；控制结核病伙伴关系是一项国际倡议，涉及几个寻求遏制结核病上升的机构。美国国家过敏和传染病研究所还为美国疾病控制中心出版了一份患者概况介绍，为患者和专业人员提供有关结核病的信息
Directly observed treatment short course (DOTS), the global control strategy aimed at controlling tuberculosis (TB) transmission through prompt diagnosis of symptomatic smear-positive disease, has failed to prevent rising tuberculosis incidence rates in Africa brought about by the HIV epidemic. However, rising incidence does not necessarily imply failure to control tuberculosis transmission, which is primarily driven by prevalent infectious disease. We investigated the epidemiology of prevalent and incident TB in a high HIV prevalence population provided with enhanced primary health care. Twenty-two businesses in Harare, Zimbabwe, were provided with free smear- and culture-based investigation of TB symptoms through occupational clinics. Anonymised HIV tests were requested from all employees. After 2 y of follow-up for incident TB, a culture-based survey for undiagnosed prevalent TB was conducted. A total of 6,440 of 7,478 eligible employees participated. HIV prevalence was 19%. For HIV-positive and -negative participants, the incidence of culture-positive tuberculosis was 25.3 and 1.3 per 1,000 person-years, respectively (adjusted incidence rate ratio = 18.8; 95% confidence interval [CI] = 10.3 to 34.5: population attributable fraction = 78%), and point prevalence after 2 y was 5.7 and 2.6 per 1,000 population (adjusted odds ratio = 1.7; 95% CI = 0.5 to 6.8: population attributable fraction = 14%). Most patients with prevalent culture-positive TB had subclinical disease when first detected. Strategies based on prompt investigation of TB symptoms, such as DOTS, may be an effective way of controlling prevalent TB in high HIV prevalence populations. This may translate into effective control of TB transmission despite high TB incidence rates and a period of subclinical infectiousness in some patients. When occupational clinics provide free smear and culture-based investigation of tuberculosis symptoms, it can lead to prompt investigation and may aid TB control in high HIV-prevalence populations. Around eight million people develop tuberculosis (TB) disease every year and of these nearly two million die. However, many more people are infected than have symptoms; perhaps one-third of the world's population is currently infected with TB. Most people infected with TB have what is termed “latent infection,” or in other words they are infected with the bacterium but do not experience any symptoms of disease. Individuals infected with TB who also have a weakened immune system, for example through HIV/AIDS, are much more likely to develop TB disease. In some regions HIV is very common—for example, approximately 11% of sub-Saharan African adults are HIV positive—and because of this cases of TB disease have risen substantially as HIV spreads. The Word Health Organization has a recommended international strategy for control of TB called “DOTS” (Directly Observed Therapy, Shortcourse). Among the five main elements of DOTS are mechanisms for promptly diagnosing and treating people who have TB disease. It is hoped that this strategy will help to reduce the number of new cases of TB diagnosed each year, because individuals promptly diagnosed and treated will then be less likely to transmit the disease to others. In this study the investigators wanted to find out if intensive DOTS, combined with giving people better access to test facilities to diagnose TB disease, could be effective in reducing the spread of TB from one person to another in Africa. It is not clear whether DOTS alone can control the spread of TB in populations with high numbers of HIV-positive people already infected with TB and so at high risk of going on to develop TB disease. Specifically, they wanted to collect data on the number of new TB cases being diagnosed per year and how that related to the proportion of the overall population that had infectious undiagnosed TB at any given point in time. They also wanted to find out whether providing good access to services for diagnosis and treatment of TB would affect either the number of new TB cases or the proportion of a given population that had infectious undiagnosed TB. This research study was carried out as part of a trial in which two different strategies for providing testing and counseling for HIV in the workplace were being compared. The trial took place within 22 companies in Harare, Zimbabwe, where HIV is very common in the adult population. Along with HIV testing and counseling, the trial provided for close follow-up and testing of anyone presenting with TB-like symptoms, with the aim of detecting as many cases in the population as possible. At the end of the two-year period, all workers were checked for undiagnosed TB disease, and cultures were carried out to find out how many of these people had infectious TB (but who might not necessarily have had symptoms). 6,440 workers were recruited into the study, of whom 19% were HIV positive. During the period of follow-up, 106 cases of TB were seen, and HIV-positive workers were far more likely than HIV-negative workers to experience TB disease. At the end of the study, 4,668 workers were checked for the presence of undiagnosed TB and 27 individuals were found to be affected, but not all of these people experienced any symptoms of disease. At the end of this study, the proportion of workers found to have undiagnosed TB was fairly low—lower than the level found in other studies carried out in other parts of the world with a high burden of TB disease but low burden of HIV. The researchers therefore concluded that the systems set up within the trial (for close follow-up and testing for TB disease) were an effective way of controlling the overall proportion with infectious TB, even though HIV infection rates were also high. This is likely to mean that the spread of TB infection to others—a prerequisite for achieving TB disease control—was also well controlled. However, more intensive efforts to reduce the risk of TB disease in HIV-positive Africans already infected with TB are also needed, although this study did not aim to find out about the impact of such strategies. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040022. Information from the World Health Organization on DOTS, the internationally recommended TB control strategy; a factsheet on TB is also available The STOP TB Partnership is an international initiative involving several agencies seeking to combat the rise of tuberculosis The US National Institute of Allergy and Infectious Diseases also publishes a factsheet for patients US Centers for Disease Control, information for patients and professionals about TB
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影响因子：
15.8
作者：
Corbett EL;Dauya E;Matambo R;Cheung YB;Makamure B;Bassett MT;Chandiwana S;Munyati S;Mason PR;Butterworth AE;Godfrey-Faussett P;Hayes RJ
通讯作者：
Hayes RJ
影响因子：
3.8
作者：
AISU, T;RAVIGLIONE, MC;ENGWAU, FA
通讯作者：
ENGWAU, FA
影响因子：
3.8
作者：
Mwinga, A;Hosp, M;Porter, JDH
通讯作者：
Porter, JDH
影响因子：
3.8
作者：
Burgess, AL;Fitzgerald, DW;Pape, JW
通讯作者：
Pape, JW
影响因子：
4.5
作者：
Currie, CSM;Floyd, K;Dye, C
通讯作者：
Dye, C