乡村医生重大传染病防治工作影响因素及对策研究

目的了解乡村医生重大传染病防治工作情况及影响因素,为提升农村重大传染病防治水平提供依据。方法运用现场调查的方法对乡村医生的基本情况、专业培训、收入情况、结核病和艾滋病知识及其所开展的卫生服务情况等进行问卷调查;通过深入访谈对乡村医生重大传染病卫生服务行为和能力所存在的问题进行定性分析。结果60%的乡村医生发现过可疑的肺结核病人;所发现的肺结核可疑病人大部分转到结核病防治所;80%的乡村医生监督过结核病病人服药;24.3%的乡村医生过去1年没有做过防治结核病健康教育工作。39.7%的乡村医生不愿意接触艾滋病病人/感染者,57.7%以上的乡村医生不愿意为艾滋病人/感染者提供服务。57.7%的乡村医生过去1年没有做过防治艾滋病健康教育工作。结论乡村医生重大传染病防治工作状况不容乐观。应加大对重大传染病防治工作的投入,建立健全补偿机制,加强专业培训,完善农村卫生监管机制,提高乡村医生重大传染病防治工作意识与能力。     

Editorial

Worldwide, more than 8500 people are newly infected with HIV each day and there are 21 million cumulative HIV/AIDS cases worldwide, 90% in developing countries. HIV infection and AIDS are firmly entrenched and spreading in India. World Health Organization projections suggest that India may have the highest number of HIV-positive cases by 2000. The double challenge is therefore presented of preventing personal infection and caring for others who are infected. While AIDS research is making some progress, it is clear that the war against HIV/AIDS will be long. Global efforts to prevent the spread of HIV infection are beginning to show positive results, with evidence of the slowing down of the HIV infection rate and the stabilization of the spread reported from some areas. Coordination, commitment, and social policy together with alternative people-oriented and socioculturally appropriate strategies must be brought to bear against the epidemic in India. The country's HIV/AIDS surveillance and blood banking systems also must be improved. Finally, efforts must be taken to ensure that all people have access to care.     

Tuberculosis and children: the missing diagnosis. A growing problem

About 33% of the world's population (2 billion people) are infected with Mycobacterium tuberculosis. Annually, 3 million people die from tuberculosis (TB) and 8 million acquire TB. Most TB cases are in developing countries. TB can attack the lungs or other organs. Pulmonary TB is most common in adults. Extrapulmonary TB, which is not infectious, is most common in children. Adults are the main source of TB infection in the community. When a TB-infected adult coughs or sneezes, he/she sprays many M bacterium into the air in tiny droplets. TB is curable, yet it is responsible for more deaths in adults than any other infectious disease. About 170,000 children die each year from tuberculous meningitis and disseminated TB disease. The increase in TB in adults will put more children at risk. Children most vulnerable to TB's effects are those younger than 2 and those whose parents suffer or die from TB. Increasing poverty, neglect of TB programs, and the spread of HIV account for the increase in TB cases. TB spreads best in overcrowded, badly ventilated places and among the malnourished. Health systems worldwide have undergone deep cuts and wide-ranging reforms, resulting in reduced access to vital TB services for the poorest members of society. Effective TB control requires properly operating, well-managed health services with adequate diagnostic facilities, trained staff, and available drugs. Limited community education results in people with active TB not seeking treatment and continuing to infect 20-28 others, including children. The HIV epidemic is causing an increase in TB in adults and in young children in some countries. Children infected with both HIV and TB have a poor prognosis. Health workers must be able to identify and treat TB with antibiotics. Proper treatment makes TB patients no longer infectious after 2-3 weeks. The BCG vaccination can protect children against the most severe forms of TB.     

The new tuberculosis

Despite the fact that there are 8 million new cases of tuberculosis (TB) annually and 3 million deaths, TB has been a neglected public health priority, primarily because effective chemotherapy has led to a dramatic decrease in cases in industrialized countries and most cases in developing countries occur in adults. It has only been recently that the emergence of multi-drug resistant TB and the rapid disease progression in HIV-infected persons has led to the application of the methods of modern basic science to TB. Population movement among refugees and immigrants and the neglect of the public health infrastructure have also led to increases in the number of cases worldwide. TB and HIV interact in 4 ways: TB may become reactivated in an HIV-infected person; there may be a primary TB infection, an HIV-positive person may suffer reinfection; or TB may alter the natural history of the HIV infection. In developing countries, the TB seen in association with HIV is believed to be reactivation of latent infection. HIV seropositivity is associated with a 30-50% lifetime risk of TB as compared with a 10% risk in the uninfected. Reactivation of TB in HIV positive people causes an additional 250,000 cases in Africa each year. HIV changes the course of TB; first time exposure is associated with 30-40% attack rates, short incubation periods, and rapid progression of the disease. It is also suggested that TB may hasten the progression of HIV, although this has not been proved. HIV-associated cases of TB will continue to increase in Africa, but in the future the largest number of co-infected persons will be in Asia. The clinical manifestations of HIV-related TB become more severe according to the progression of the immunodeficiency. Patients dying of AIDS who also have TB usually have extremely heavy mycobacterial burdens with widespread, probably incurable, TB. Being HIV-positive is also associated more often with sputum-negative pulmonary or extrapulmonary TB and with atypical radiological manifestations such as absence of cavitation, absence of localization to the upper zones, and the presence of hilar adenopathy, effusions, or infiltrates. Diagnosis may, therefore, be more difficult in cases of HIV infection. Although a greater mortality is found in HIV-positive patients (perhaps associated with complications of other bacterial infections), TB can be treated successfully in HIV-infected people. The World Health Organization recommends short-course chemotherapy of isoniazid, rifampicin, ethambutol, and pyrazinamind for 2 months followed by 4 months of isoiazid and rifampicin or 6 months of isoniazid and ethambutol. The risk of recurrence is greater if non-rifampicin regimens are used and is 3-34 times greater than in seronegative cases. Treatment is complicated by the fact that 18-20% of HIV-positive people have adverse reactions to thiacetazone which presents as a skin condition and can lead to death. Proposed solutions to this problem are to replace thiacetazone with another drug, replace thiacetazone only in HIV-positive persons (testing all patients for HIV), or educating staff and patients about the need to discontinue the drug if a rash occurs. Donor funding will be necessary to adopt a single worldwide approach with the least side effects. Policy decisions must also be made to create a programmatic approach to preventing HIV-associated TB.     

HIV epidemic -- a global update. Excerpts from the UN World AIDS Day report

According to the 1997 United Nations World AIDS Day Report, over 30 million adults and children worldwide are HIV-infected and, if current transmission rates remain constant, 40 million people will be infected by the year 2000. In 1997, an estimated 5.8 million people became HIV-infected and 2.3 million died of AIDS-related infections. Nearly half of these deaths were in women and 460,000 were in children under 15 years. In sub-Saharan Africa, where the epidemic is progressing most rapidly, 7.4% of the population aged 15-49 years is HIV-positive. Unprotected sex accounted for most of the 3.4 million new HIV infections among adults in sub-Saharan Africa in 1997. In Asia, the epidemic is more diverse, both in terms of intercountry variation and modes of transmission. In the developed world, newly available antiretroviral drugs are reducing the speed at which HIV-infected people develop AIDS. Of particular concern is the impact of HIV/AIDS on reversing gains in life expectancy and child survival in developing countries. Moreover, an estimated 9 out of 10 HIV-positive people worldwide are not aware they are infected. The future course of the epidemic depends in large part on expanded access to information about how HIV is transmitted and how to avoid infection.     

The cost to health services of human immunodeficiency virus (HIV) co-infection among tuberculosis patients in Sudan

OBJECTIVE: To compare the cost of managing HIV-positive and HIV-negative tuberculosis (TB) patients in Sudan. METHODS: A prospective cohort of 1797 consecutive TB patients referred to the chest clinics within the general health services from March 1998 to March 2000 were included in this study. Patients were tested blindly for HIV; 1724 were HIV-negative and 73 were HIV-positive. FINDINGS: The total cost associated with management of tuberculosis was significantly higher for HIV-positive, as compared with HIV-negative TB patients (105.08 US dollars versus 73.92, p=0.003). This difference was due mainly to greater costs for hospitalization of those HIV-positive, as compared with those HIV-negative (190.80 versus 141.00, p=0.001). The differences in cost for diagnostic tests, for drugs, for management of adverse reactions and for intercurrent symptoms were not significant (p>0.05) between HIV-positive TB patients and HIV-negative TB patients. Side effects of treatment were slightly more common among persons without HIV infection than among HIV-positive patients (14 and 9.6%, respectively). The total cost of management of HIV-positive patients in this series of patients was 6% of all costs for TB case management and the marginal cost attributable to HIV-positivity was 0.9% of the total cost. CONCLUSION: The management of the HIV-positive TB case was more costly than that of the HIV-negative case in this stage of the HIV/AIDS epidemic in Sudan.     

Tuberculosis in the era of HIV: problems,challenges and hopes for Africa

After years of declining incidence, Mycobacterium tuberculosis has re-emerged as a major global pathogen. An estimated one-third of the world's population is infected with M. tuberculosis, 8 million new cases of active tuberculosis (TB) occur annually, and 2.6-2.9 million people die annually from TB-related causes. More than 95% of new TB cases and TB-related deaths occur among people living in developing countries, mainly in Asia and Africa. The number of reported TB cases in Africa increased markedly during the 1980s and 1990s, making sub-Saharan Africa the region with the highest incidence of TB. Worldwide, there were 9.4 million people co-infected with TB and HIV, of whom 6.6 million were in sub-Saharan Africa. An estimated 26% of TB cases in sub-Saharan Africa in 1995 were attributable to HIV infection. The observed increase in TB in sub-Saharan Africa may have resulted from several factors, including civil conflict leading to displacement, overcrowding, famine, and malnutrition. Together with economic decline, these factors have in many cases led to a breakdown in health infrastructure. Reduced case-finding and poor contact tracing are expected to lead to an increase in the number of chronic TB-excretors. The interaction between TB and HIV, clinical features, treatment, preventive therapy, and innovative approaches are discussed. TB and AIDS together threaten to reverse the social and economic gains achieved in Africa over the past 30 years, and to impede further development.     

HIV / AIDS in South-East Asia: an update

As of July 1, 1996, 1,393,649 cumulative AIDS cases in adults and children had been reported to the World Health Organization (WHO) from 193 countries since the beginning of the pandemic. HIV infection is a serious public health and developmental problem in southeast Asia, with the WHO estimating more than 3.7 million people to be infected with HIV in the region. This infection extends into the general population and is not confined among people who practice high risk behaviors. As of July 1, 1996, Thailand, India, and Myanmar had reported the largest number of AIDS cases: 41,230, 2940, and 1093, respectively. However, WHO estimates that 2.5 million people are actually infected in India, 800,000 in Thailand, 350,000 in Myanmar, and 95,000 in Indonesia. While Bhutan and North Korea have not yet reported AIDS cases, people in Bhutan have been diagnosed with HIV infection. The health and socioeconomic impact of HIV/AIDS, national plans and programs, the 100% condom use program in Thailand, peer education among sex workers in Calcutta, WHO support for country responses, advocacy and support, promoting appropriate HIV prevention strategies and interventions, HIV/AIDS care as part of primary health care, HIV/AIDS and STD surveillance, and the future role of WHO are discussed.     

AIDS scenarios for The Netherlands; the economic impact on hospitals

OBJECTIVE: To assess the economic impact of HIV/AIDS on the health care system in The Netherlands. Data and methods: Two types of data are used: (i) routine surveillance data on AIDS incidence and (ii) information on hospital resource utilisation and corresponding monetary costs. Progression of disease is modelled using a multi-stage model, with stages corresponding to clinical classifications and to different phases of health care need. Economic impact is analysed for all stages in three scenarios: the reference and two alternative scenarios. RESULTS: In the year 2000 hospital bed need would reach 220 beds if yearly new HIV infections in the 1990s remain at the level estimated for the end of the 1980s, and if the intensity of hospital care remains constant. A minimum need of 125 beds is projected if no new HIV infections occur in the 1990s. Hospital costs in 1993 are estimated to amount to 33.8 million ECUs. Scenarios indicate a range of 26.7-50.7 million ECUs for the year 2000 (price level: 1993). The proportion of the costs of hospital inpatient care and cure in total hospital costs increases, whereas the proportion for outpatient services decreases. Conclusions: Projected hospital bed need of 125-220 for HIV/AIDS in the year 2000 is limited compared to the projections for coronary heart disease and stroke, but approaches that for lung cancer, pneumonia and diabetes. We estimate hospital costs to have been 85% of total health care costs for HIV/AIDS in 1993. In 1993, the estimated proportions in hospital costs are 41% for inpatient care, 20% for inpatient cure and 39% for outpatient facilities. Our scenarios indicate a decreasing share of outpatient costs--possibly to 30% of total hospital costs for HIV/AIDS in 2000--illustrating the growing relative importance of the AIDS stage for the hospital costs. We project hospital costs for HIV/AIDS in 2000 to reach up to 0.53% of projected hospital costs for all diseases. A present value of 38 million ECUs (23%) of hospital costs projected in the reference scenario might be avoidable, during the period 1994-2000. However, with unchanged treatment patterns a present value of 127 million ECUs for hospital costs during the same period is projected to represent unavoidable costs (discount rate: 5%). In The Netherlands, data needs in the field of economic impact assessment of HIV/AIDS especially refer to registrations of non-hospital outpatient resource utilisation and costs.     

Estimating HIV levels and trends among patients of tuberculosis clinics

Symptomatic tuberculosis (TB) can occur as an opportunistic disease in immunosuppressed persons who are infected with human immunodeficiency virus (HIV) and who have been previously infected with Mycobacterium tuberculosis. Increases in TB cases have occurred in areas which have reported large numbers of cases of the acquired immunodeficiency syndrome (AIDS), and a high proportion of these TB cases have been HIV seropositive. Therefore, increasing numbers of HIV-infected persons may be found in TB clinics and hospitals. HIV serologic surveys in TB clinics and hospitals providing clinical services to TB patients are needed to assess the local prevalence of HIV infection in TB patients and the consequent need for public health intervention to prevent further spread of HIV and TB infection. The Centers for Disease Control (CDC), in collaboration with State and local health departments, has initiated HIV surveillance of patients with confirmed and suspected TB in TB clinics and hospitals in the United States. Blinded (serologic test results not linked to identifiable persons) HIV seroprevalence surveys are conducted in sentinel TB clinics and hospitals that provide TB clinical services each year to obtain estimates of the level of HIV infection in TB patients and to follow trends in infection over time. Nonblinded (voluntary) surveys will also be conducted to evaluate behaviors that have placed TB patients at risk for or protected them against HIV infection. Data from these surveys will be used to target education and prevention and control programs for TB and HIV infection and to monitor changes in behavior in response to such programs.     

Internalized stigma, discrimination, and depression among men and women living with HIV/AIDS in Cape Town, South Africa

AIDS stigmas interfere with HIV prevention, diagnosis, and treatment and can become internalized by people living with HIV/AIDS. However, the effects of internalized AIDS stigmas have not been investigated in Africa, home to two-thirds of the more than 40 million people living with AIDS in the world. The current study examined the prevalence of discrimination experiences and internalized stigmas among 420 HIV-positive men and 643 HIV-positive women recruited from AIDS services in Cape Town, South Africa. The anonymous surveys found that 40% of persons with HIV/AIDS had experienced discrimination resulting from having HIV infection and one in five had lost a place to stay or a job because of their HIV status. More than one in three participants indicated feeling dirty, ashamed, or guilty because of their HIV status. A hierarchical regression model that included demographic characteristics, health and treatment status, social support, substance use, and internalized stigma significantly predicted cognitive-affective depression. Internalized stigma accounted for 4.8% of the variance in cognitive-affective depression scores over and above the other variables. These results indicate an urgent need for social reform to reduce AIDS stigmas and the design of interventions to assist people living with HIV/AIDS to adjust and adapt to the social conditions of AIDS in South Africa.     

艾滋病与结核病患者双重感染检出率及其影响因素的调查

[目的]了解广西艾滋病人中结核病患病率,结核病患者中HIV感染检出率;调查广西艾滋病患者发生结核病及结核病患者感染HIV的影响因素。[方法]对260例艾滋病患者及580例结核病患者进行双重感染检出率及其影响因素的问卷调查,并查看病例。[结果]260例HIV/AIDS患者中结核病患病率为35.0%（肺结核为29.2%,肺外结核为5.8%）,580例结核病患者HIV感染检出率为2.8%;影响260例艾滋病患者发生结核病的主要影响因素为月收入,影响580例结核病患者感染HIV的主要影响因素为吸毒和商业性行为。[结论]艾滋病患者发生结核病的机率高,月收入低者易发生结核病;结核病患者中HIV感染检出率高于一般人群,吸毒和商业性行为是结核病患者感染HIV的主要途径。     

HIV与输血传播病毒的母婴传播的调查

目的 了解艾滋病高发区HIV与输血传播病毒(TTV)母婴传播情况。方法 对华中地区某艾滋病高发农村228名母亲及其年龄小于15岁的子女180名进行入户流行病学调查，采集静脉血检测抗HIV、抗TTV，回顾性分析2种病毒的母婴传播特点。结果 82例HIV阳性母亲1993年后生的103名儿童中，39例HIV阳性，母婴传播率为37.9％；59例抗TTV阳性母亲所生的76名儿童中，5例抗TTV阳性，母婴传播率为6.6％。结论 HIV与TTV在当地均存在母婴传播；母婴传播是儿童感染HIV的主要途径。未对HIV流行地区高危生育期妇女进行有效的HIV监测与咨询，未及时采取有效干预措施是造成该地区儿童感染HIV的主要原因，亟需制定实施相应的对策，控制HIV进一步蔓延，保护HIV感染高发区妇女及儿童的健康。     

输入性HIV/AIDS危险因素分析及风险管理措施初探

目的分析输入性艾滋病病毒感染病例(HIV/AIDS)对我国艾滋病防控的风险,探讨有效的风险管理措施。方法回顾上海口岸2003—2012年出入境人群HIV/AIDS监测结果,与全国艾滋病疫情情况比较,分析口岸HIV/AIDS的流行病学特征。结果 2003—2012年上海口岸共对598 104名出入境人群进行HIV感染监测,共检出HIV/AIDS感染184例,总检出率为30.76/10万,男女比例为7:1。其中,入境人群HIV感染总检出率为42.19/10万,年度检出率呈逐年上升趋势,出境人群检出率为12.57/10万。20~50岁感染者占90.76%;性接触传播占77.18%,其中异性传播占43.48%,男男性传播占33.70%。入境留学生HIV感染率(54.65/10万)与入境就业人群感染率(45.01/10万)相当。结论入境人群HIV/AIDS检出率较高,输入性HIV/AIDS感染存在人数增加、人员流动性大、高危行为机率高,易导致疾病向普通人群扩散等风险。应通过口岸把关、源头监管、协作保障等风险管理措施予以应对。     

Host genes and infectious diseases. HIV, other pathogens, and a public health perspective.

INTRODUCTION: The global impact of infectious diseases is tremendous. In 1996, the 17 million deaths from infectious diseases accounted for one third of all deaths worldwide, while the acute and chronic morbidity from infectious diseases adds an additional great burden on global health. Multiple factors, host and nonhost, influence the susceptibility of individuals and populations to infectious diseases, as well as the severity of the illness once infected. METHODS: We review the influence of host genes on the susceptibility to and severity of viral, bacterial, parasitic and fungal infectious diseases, on vaccine responsiveness and on treatments for infections. HIV/AIDS is discussed in detail because it is an example of an infectious disease influenced by multiple host genes and because of its impact. Although the HIV/AIDS pandemic dates only since the late 1970s, it has claimed the lives of 11 million people worldwide and, today, more than 30 million people are estimated to be HIV infected. CONCLUSION: Our greater understanding of the genetic factors that influence morbidity and mortality of infectious disease leads to new avenues of prevention and treatment that can improve the health of individuals and populations.     

Multidrug-resistant Mycobacterium tuberculosis in HIV-infected persons, Peru

During 1999 to 2000, we identified HIV-infected persons with new episodes of tuberculosis (TB) at 10 hospitals in Lima, Peru, and a random sample of other Lima residents with TB. Multidrug-resistant (MDR)-TB was documented in 35 (43%) of 81 HIV-positive patients and 38 (3.9%) of 965 patients who were HIV-negative or of unknown HIV status (p<0.001). HIV-positive patients with MDR-TB were concentrated at three hospitals that treat the greatest numbers of HIV-infected persons with TB. Of patients with TB, those with HIV infection differed from those without known HIV infection in having more frequent prior exposure to clinical services and more frequent previous TB therapy or prophylaxis. However, MDR-TB in HIV-infected patients was not associated with previous TB therapy or prophylaxis. MDR-TB is an ongoing problem in HIV-infected persons receiving care in public hospitals in Lima and Callao; they represent sentinel cases for a potentially larger epidemic of nosocomial MDR-TB.     

Towards effective policies and strategies for control of HIV / AIDS

As of July 31, 1996, 2639 AIDS cases had been reported to India's National AIDS Control Organization, more than 75% of which are thought to be the result of HIV transmission through unprotected heterosexual intercourse. The screening of blood samples from almost 3 million individuals found an HIV-seropositivity rate of 15.97/1000 population. The level of HIV prevalence varies across the country. An estimated 5 million people will have been infected with HIV in India by 2000 if the rate of infection remains at the current level. The National AIDS Control Program launched in India in 1987 has been strengthened and consolidated for 1992-97. However, with HIV infection and AIDS continuing to spread in India, a new and better approach to prevention and control is needed. The HIV pandemic is most severe in places and among people facing obstacles to learning and effecting behavioral change. Belonging to a discriminated, marginalized, or stigmatized groups reduces personal capacity to learn and respond. Interventions are therefore needed to reduce the societal risk factor of discrimination in order to strengthen the personal capacity of people who are most vulnerable to HIV/AIDS. Policies and strategies to address various HIV/AIDS-related concerns are offered.     

Country watch: Cuba

Health authorities in Cuba made a serious effort to fight HIV/AIDS in their country. In 1986, the government launched a National Programme of Control and Prevention of HIV/AIDS, aimed at controlling the epidemic and providing quality of care for HIV-positive people. Initially, people with HIV/AIDS (PHA) were interned in sanitariums to prevent HIV infection from spreading further. The sanitariums provided good medical and psychological support. However, ambulatory care was introduced in 1993, mitigating the mandatory character of the original system and focusing more on PHA. Additional services were made available to PHA in December 1998 with the creation of a National Centre for the Prevention of Sexually Transmitted Disease/HIV/AIDS, an integral part of the Ministry of Public Health. The center offers an AIDS prevention hotline and counseling services that include a pilot project, ?Mobile Project?, an outreach project for people at risk. The PHA Project was launched in March 1999 with a workshop for 30 PHA from Havana; a guide, "Living with HIV", was created to address the problem of unavailability of information concerning the disease. The guide discusses basic clinical information about HIV/AIDS; PHA and their social environment; nutrition, diet, and hygiene; sexuality; and legal aspects.     

大连口岸出入境人员HIV监测及高危性行为统计分析

目的了解大连口岸出入境人员的艾滋病病毒感染情况和高危性行为,为有效开展艾滋病监测和防止传播提供科学依据。方法对2010—2013年大连口岸出入境人员的艾滋病监测资料和流行病学调查结果进行分类统计、对比分析。结果 2010—2013年共进行艾滋病监测体检150 232人,检出艾滋病病毒抗体阳性24例,主要是未婚或离异的青壮年男性。其中62.50%的人有婚前性行为;33.33%的人有多个性伙伴;25.00%的人承认有冶游史;12.50%的人是同性传播;8.33%的人采取过安全措施;4.16%的人正在接受正规治疗;95.84%的人为首次检出。不同职业、不同年龄段和不同性别艾滋病检出率有统计学意义(P0.01或P0.05)。结论身处异乡的职业性质和高危性行为是出入境人员感染艾滋病的主要原因,应加强对出入境人员的卫生知识宣传和教育,提高其自我防范意识,进而制定相应的干预措施。     

2010年衢州市柯城区艾滋病自愿咨询检测结果分析

目的：了解2010年衢州市柯城区艾滋病病毒自愿咨询检测者的艾滋病病毒感染状况、人群类型、分布情况以及求询动机,为进一步深化VCT服务提供科学依据。方法：通过艾滋病网络直报系统导出2010年柯城区艾滋病自愿咨询检测点的相关信息,并进行统计分析。结果：2010年共有609人接受HIV检测,求询原因主要为发生危险性行为（66.83%）,检出HIV阳性数4例,HIV感染检出率为0.66%。其中男男同性性接触传播2例,HIV感染检出率为10.53%。结论：VCT服务有助于早期发现HIV感染者,减少HIV的进一步传播,是艾滋病防治的有效措施之一。