Lessons learned from a tuberculosis contact investigation associated with a disaster volunteer after the 2011 Great East Japan Earthquake
Lessons learned from a tuberculosis contact investigation associated with a disaster volunteer after the 2011 Great East Japan Earthquake
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2011 年东日本大地震后与一名救灾志愿者相关的结核病接触者调查的经验教训
DOI：
10.1164/rccm.201212-2150le
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发表时间：
2013
期刊：
影响因子：
--
通讯作者：
Kaku M
中科院分区：
文献类型：
--
作者：
Kanamori H;Uchiyama B;Hirakata Y;Chiba T;Okuda M;Kaku M
2011年3月11日发生的东日本大地震和海啸之后，恢复和重建工作一直在继续（1）。灾区的许多幸存者和撤离者收到了国内和国际机构提供的救济物资和支助。救灾志愿者也在受灾地区发挥了积极作用。截至2012年2月，超过920，000名灾难志愿者在那里工作，为避难所、公共住房或临时住房的疏散人员提供支持（2）。救济工作者面临感染传染病、创伤、事故、暴力以及个人健康状况和基本状况恶化的风险（3）。我们经历了一个活动性肺结核（TB）的灾难志愿者病例，并在此报告从该病例和地震后随后的接触调查中吸取的教训。一名30多岁的志愿者在地震发生后的5月来到受灾地区，为疏散人员提供支持。她在8月中旬出现咳嗽和咳痰，9月初去看了全科医生（GP-A），被告知她患了普通感冒。她的症状继续，她在10月看到了GP-B，做了胸部X光检查，被告知她有支气管炎。去年11月，她还被告知患有GP-C哮喘。12月底，她报告发热、全身不适、咳嗽、咳痰和呼吸困难，并看到GP-D，后者根据胸部X光片诊断她患有肺炎，并用克拉霉素治疗她。然而，由于她的症状恶化，她来到我院就诊，并于2012年1月初被诊断为肺结核。她没有结核病感染或免疫功能受损的历史。计算机断层扫描显示双肺广泛浸润性阴影伴支气管充气征和树芽样改变，但无空洞性病变（图1）。通过痰涂片观察抗酸杆菌（AFB），并将其分级为Gaffky 2（世界卫生组织量表1+级）。聚合酶链反应检测结核分枝杆菌复合群。患者接受了异烟肼、利福平、乙胺丁醇和吡嗪酰胺四药方案治疗肺结核，并接受了头孢吡肟治疗并发肺炎。痰培养为M.结核病对所施用的药剂敏感。在痰涂片和培养多次呈AFB阴性后，她于4月好转出院。她继续在我们的门诊接受直接观察治疗，并完成了6个月的治疗。对指示结核病患者进行了接触者调查，以在总共72名接触者中确定潜伏性结核病感染（LTBI），其中包括26名地震灾民、20名志愿者和26名其他人。通过结核菌素皮肤试验（TST）确定6名接触者（1名婴儿和11岁以下儿童）的LTBI，而使用QuantiFERON-TB Gold In-Tube（QFT-3G）通过全血干扰素g释放试验（IGRA）确定59名接触者（11岁以上儿童和成人）的LTBI
Recovery and reconstruction efforts have been continuing after the Great East Japan Earthquake and subsequent tsunami that occurred on March 11, 2011 (1). Many survivors and evacuees in the disaster areas received relief supplies and support from domestic and international agencies. Disaster volunteers have also played an active part in the affected areas. As of February 2012, more than 920,000 disaster volunteers worked there and contributed to support evacuees at shelters or public or temporary housing (2). Relief workers are at risk for acquisition of infectious diseases, trauma, accidents, violence, and deterioration of personal health status and underlying conditions (3). We have experienced a disaster volunteer case with active pulmonary tuberculosis (TB), and report here lessons learned from this case and subsequent contact investigation after the earthquake. A volunteer in her 30s came to an affected region and supported evacuees in May after the earthquake. She developed cough and sputum in the middle of August and saw a general practitioner (GP-A) at the beginning of September and was told she had a common cold. Her symptoms continued and she saw GP-B in October, had a chest X-ray, and was told she had bronchitis. She was also told she had asthma by GP-C in November. At the end of December, she reported fever, general malaise, cough, sputum production, and dyspnea and saw GP-D, who diagnosed her as having pneumonia based on a chest X-ray and treated her with clarithromycin. However, she visited our hospital because her symptoms worsened, and was diagnosed with pulmonary TB at the beginning of January 2012. She had no history of tuberculosis infection or immunological impairment. Computed tomography revealed extensive infiltrative shadows with air bronchograms and tree-in-bud appearance in both lungs but no cavitary lesions (Figure 1). Acid-fast bacilli (AFB) were observed by sputum smear and were graded Gaffky 2 (grade 1+ on the World Health Organization scale). Mycobacterium tuberculosis complex was detected by polymerase chain reaction. The patient was treated with a four-drug regimen of isoniazid, rifampin, ethambutol, and pyrazinamide for pulmonary TB, as well as administration of cefepime for concurrence of pneumonia. Sputum culture yielded M. tuberculosis susceptible to the agents administered. She improved and was discharged in April after sputum smears and cultures were repeatedly negative for AFB. She continued to receive directly observed treatment at our outpatient clinic and completed 6 months of treatment. Contact investigation for the index TB patient was conducted to identify latent tuberculosis infection (LTBI) among a total of 72 contact persons, including 26 earthquake victims, 20 volunteers, and 26 others. LTBI in 6 contacts (an infant and children aged under 11 yr) was determined by tuberculin skin test (TST), whereas LTBI in 59 contacts (children aged over 11 yr and adults) was done by the whole-blood interferon-g release assay (IGRA) using QuantiFERON-TB Gold In-Tube (QFT-3G)