台州市农村地区结核病流行特征及结核杆菌基因分型研究

发布时间：2018-05-17 04:38

本文选题：农村地区 + 结核病　；参考：《复旦大学》2012年硕士论文

【摘要】：结核病(tuberculosis TB)主要是由于感染结核分枝杆菌(Mycobacterium tuberculosis M. TB)引起的一种严重危害人民健康的呼吸道传染病,被列为我国重大传染病之一。由于耐药结核病的出现、结核病控制措施的减弱以及艾滋病(HIV/AIDS)的流行,在20世纪80年代结核病重新复发流行,1993年WHO宣布全球结核病处于紧急状态。WHO估计每年有800万人患结核病,每年有200万人死于结核病。我国自1991年起实施直接监督短程化疗法(directly observed treatment short-course, DOTC),从2001年开始,全面推行了现代结核病控制策略,10年间全国共发现并治疗肺结核患者829万例,其中涂阳肺结核患者450万例,避免了4000多万健康人感染结核菌。2010年全国涂阳肺结核患病率降至66/10万,比2000年下降了61%。然而我国结核病防治工作还面临着诸多新的问题与挑战。我国仍是全球22个结核病高负担国家之一,WHO评估,目前我国结核病年发病人数约为130万,占全球发病人数的14%,位居全球第二位。近年来,我国每年报告肺结核发病人数约100万,始终位居全国甲乙类传染病的前列；耐多药肺结核危害日益凸显,每年新发患者人数约12万,未来数年内可能出现以耐药菌为主的结核病流行态势；结核菌/艾滋病病毒双重感染患者人数持续增加,防治工作亟待加强；中西部地区、农村地区结核病防治形势严峻。我国现行结核病防治服务体系和防治能力还不能满足新形势下防治工作的需要,防治基础设施建设滞后,基层防治力量薄弱,流动人口患者治疗管理难度加大,公众对结核病危害的认识不足,防治任务尤其是农村地区仍然十分艰巨,需要长期不懈的努力。本研究以台州市农业县-仙居县实施结核病DOTC控制项目县为研究现场,采用现场流行病学和分子生物学技术方法对当地县级疾控中心结核病防治所2011年4月～2012年3月登记的所有痰培养阳性的结核病患者进行系统的研究,通过收集患者的基本信息,采集患者的痰液进行抗酸染色镜检,对所有痰标本分离培养结核菌,以比例法对分离的M.TB进行两种一线抗结核菌药物敏感试验(RFP和INH),采用15位点MIRU-VNTR基因分型方法对所有的M.TB进行基因分型,用BioNumerics软件对结果进行聚类分析,同时用多重PCR方法检测RD105片段是否缺失来区分北京基因型和非北京基因型菌株,掌握台州市农村地区M.TB的流行菌株和药物敏感情况,以及该地区的M.TB的基因多态性。分析台州市农村地区结核病的基本特征及可能传播途径,为台州市农村地区的结核病预防与控制提供科学依据。主要结果和结论如下 1.结核病基本流行特征本次纳入研究对象共89人,男性67人,占75.3%,女性22人,占24.7%。结核患者的平均年龄为51.4±18.2岁,最大88岁,最小15岁,中位数为52岁,其中30-60年龄段人数最多,为44人,占49.4%,其次是≥60年龄段31人,占34.8%。职业以农民为最多,73人,占82%,非农民16人,占18%。初治患者78人,占87.6%,复治患者11人,占12.4%。本地病例79人,占88.8%,外地病例10人占11.2%。痰涂片阳性的47例,占51.7%,阴性42例,占48.3%。 2.结核患者结核杆菌分离及耐药情况从所有患者中共分离到M. TB80株,占89.9%；鸟-胞内分枝杆菌8株,占9.0%；堪萨斯分枝杆菌1株,占1.1%。80株M.TB菌中对INH或RFP单一耐药有7株,占8.8%,均为初治患者；对INH和RFP均耐药率有6株,占7.5%,其中3例为复治患者。11例复治患者中4例分离出鸟-胞内分枝杆菌,7例分离出M.TB有3例耐多药。 3.不同治疗史患者M.TB药敏结果比较 80例分离出M.TB的结核病患者中初治患者74例,占92.5%；复治患者6例,占7.5%。74例初治患者中对INH和RFP均敏感的有64例,占86.5%(95%CI76.5%-93.3%),对药物耐药的有10例,占13.5%(95%CI6.7%-23.5%)；6例复治患者中对INH和RFP均敏感的有3例,占50.0%(95%CI11.8%-88.2%),对药物耐药的有3例,占50.0%(95%CI11.8%-88.2%)。初治患者和复治患者在总耐药率方面(敏感vs耐药)无显著性差异(7=3.08,P=0.0510.05),初治患者和复治患者在耐药类型(单耐药vs耐多药)方面无显著性差异(χ2=4.55,P=0.1020.05)。 4.M.TB不同基因型鉴定及药敏结果比较 80株M.TB中北京基因型菌株39株,占48.7%；非北京基因型菌株41株,占51.3%。39株北京基因型菌株中对INH和RFP均敏感的有33例,占84.6%(95%CI69.5%-94.1%),对药物耐药的有6例,占15.4%(95%CI5.9%-30.1%)；41株非北京基因型菌株中对INH和RFP均敏感的有34例,占82.9%(95%CI67.9%-92.8%),对药物耐药的有7例,占17.1%(95%CI7.2%～32.1%)。北京基因型和非北京基因型菌株在总耐药率方面(全敏感vs耐药)无显著性差异(χ2=0.04,P=0.8380.05),北京基因型和非北京基因型菌株在耐药类型方面(单耐药vs耐多药)也无显著性差异(χ2=1.93,P=0.3800.05) 5.耐药结核病影响因素分析单因素logistic分析发现复治与MDR-TB人群分布有关(P0.05),年龄、性别、职业、户籍、治疗史、痰涂片、菌株基因型等因素与单耐药病人人群分布均无明显的关联。多因素logistic研究分析发现结核病人的既往治疗史与耐多药病人的人群分布有关,复治的结核病人是发生耐多药结核病的主要人群(复治/初治：OR:15.854;95%CI:1.866～134.677)。 6.M.TB基因分型情况采用15个MIRU-VNTR位点对80株M.TB的分辨力最高的是MIRU26(HGI=0.865),分辨力最低的是ETRC (HGI=0.165), HGI0.5的有10个位点。 15位点MIRU-VNTR基因分型结果显示80株M.TB共得到78个基因型,76株有独立基因型,另外4株两两成簇,成簇率为2.5%。经Bionumberics5.0软件聚类分析,可78个基因型分为8个基因群(Ⅰ群、Ⅱ群、Ⅲ群、Ⅳ群、V群、Ⅵ群、Ⅶ群、Ⅷ群)。分别为Ⅰ群占8.75%,含7个基因型；Ⅱ群占11.25%,含8个基因型；Ⅲ群占55.0%,含43个基因型；Ⅳ群占6.25%,含5个基因型；V群占2.5%,含2个基因型；Ⅵ群占8.75%,含7个基因型；Ⅶ群占5.0%,含4个基因型；Ⅷ群占2.5%,含2个基因型。台州市农村地区结核病呈低水平流行,M.TB的耐药率低于全国水平,初治患者和复治患者在总耐药率方面无显著性差异,M.TB中以非北京基因型为优势菌,北京基因型呈低流行,北京基因型和非北京基因型菌株在总耐药率方面无显著性差异,15位点MIRU-VNTR基因分型结果显示菌株间成簇率低,基因多态性明显,说明该地区的结核病以独立感染或内源性复燃为主,近期传播少。
[Abstract]:Tuberculosis (tuberculosis TB) is mainly caused by the infection of Mycobacterium tuberculosis (Mycobacterium tuberculosis M. TB), a kind of respiratory infectious disease which seriously endangers the people's health. It is listed as one of the major infectious diseases in our country. Because of the emergence of drug-resistant tuberculosis, the reduction of tuberculosis control measures and the epidemic of AIDS (HIV/AIDS), in 20 In 80s, tuberculosis was relapsed. In 1993, WHO announced that global tuberculosis was in a state of emergency,.WHO estimated that 8 million people had TB each year, and 2 million people died of tuberculosis each year. China has implemented direct supervision short course therapy (directly observed treatment short-course, DOTC) since 1991. Since 2001, it has been carried out in an all-round way. In the past 10 years, 8 million 290 thousand cases of tuberculosis patients were found and treated in the country, of which 4 million 500 thousand cases were smear positive tuberculosis patients, which prevented about 40000000 healthy people from infection of TB bacteria to 66/10 million in.2010, and decreased 61%. than in 2000.
However, our country is still facing a lot of new problems and challenges in the prevention and control of tuberculosis. China is still one of the 22 countries with high tuberculosis burden in the world, WHO assessment. At present, the number of TB patients in our country is about 1 million 300 thousand, accounting for 14% of the global number of people in the world. In recent years, the number of tuberculosis cases in China has been reported to be about 1 million every year. In the end, it is the forefront of infectious diseases of class A and B in the country; the number of multi drug resistant tuberculosis is becoming more and more serious, the number of new patients is about 120 thousand every year, and the epidemic situation of tuberculosis which is mainly resistant bacteria may appear in the next few years; the number of TB / AIDS virus double infection patients continues to increase, and the prevention and control work needs to be strengthened urgently; the central and western regions, rural areas The situation of tuberculosis prevention and control in the region is severe. The current system of tuberculosis control and prevention and control in our country can not meet the needs of the prevention and control work under the new situation, the construction of the prevention and control infrastructure is lagging behind, the prevention and control force at the grass-roots level is weak, the treatment management of the patients with the floating population is more difficult, the public is not aware of the harm of tuberculosis, and the prevention and control task is especially important. Rural areas are still very arduous and require long-term and unremitting efforts.
In this study, the tuberculosis DOTC control project county in Taizhou agricultural county Xianju county was used as the research site. The field epidemiology and molecular biological techniques were used to systematically study all the tuberculosis patients who were registered in the tuberculosis control center of the county CDC from April 2011 to March 2012. The basic information of the patients was collected from the sputum of the patients, and all the sputum specimens were isolated and cultured. Two kinds of first-line anti tuberculosis drug sensitivity tests (RFP and INH) were carried out by the proportional method, and all M.TB was classified by the 15 locus MIRU-VNTR genotyping method, and the results were obtained by BioNumerics software. The cluster analysis was carried out, and the multiple PCR method was used to detect whether the RD105 fragment was missing to distinguish the Beijing genotypes and non Beijing genotypes. The epidemic strains and drug sensitivity of M.TB in rural areas of Taizhou and the genetic polymorphism of M.TB in this area were used to analyze the basic characteristics and possible transmission of tuberculosis in rural areas of Taizhou. To provide scientific basis for tuberculosis prevention and control in rural areas of Taizhou.
The main results and conclusions are as follows
1. basic epidemic characteristics of tuberculosis
The study included 89 people, 67 men, 75.3% and 22 women. The average age of 24.7%. tuberculosis patients was 51.4 + 18.2 years old, the largest was 88 years, the smallest 15 years old, and the median of 52 years old. 30-60 age groups were the largest, 44, 49.4%, and the largest of the 34.8%. occupations. People accounted for 78 of the first 18%. patients, accounting for 87.6%, and 11 of the retreated patients, accounting for 79 local cases, accounting for 88.8%. 10 people in the field accounted for 47 cases of 11.2%. sputum smear positive, accounting for 51.7% and negative in 42 cases, accounting for 48.3%..
2. tuberculosis bacilli isolation and drug resistance
M. TB80 strains were isolated from all patients, accounting for 89.9%, 8 strains of Mycobacterium tumefaciens, 9%, 1 strains of Mycobacterium in Kansas, 7 strains of INH or RFP in 1.1%.80 strains, 8.8% of them, and 6 of INH and RFP, 7.5% of them, and 4 of the retreated patients were isolated from the retreated patients. Mycobacterium bacilli isolated from 7 cases of M.TB, 3 cases were multi drug resistant.
Comparison of M.TB drug sensitivity results in 3. patients with different history of treatment
In 80 cases of M.TB tuberculosis, 74 were first treated, 92.5% were treated, 6 were retreated, 64 were sensitive to INH and RFP in the first 7.5%.74 cases, 86.5% (95%CI76.5%-93.3%), 10 of drug resistance, 13.5% (95%CI6.7%-23.5%); 3 cases were sensitive to INH and RFP in 6 patients, accounting for 50% (95%CI11.8%-). 88.2%) there were 3 cases of drug resistance, accounting for 50% (95%CI11.8%-88.2%). There was no significant difference between the initial and retreated patients (7=3.08, P=0.0510.05) in the total drug resistance rate (7=3.08, P=0.0510.05). There was no significant difference between the first treated and retreated patients (P=0.1020.05) in the drug resistance type (single drug resistant vs multidrug resistance).
Identification of different genotypes and comparison of drug sensitivity results of 4.M.TB
There were 39 strains of Beijing genotypes and 41 strains of non Beijing genotypes, 33 of which were sensitive to INH and RFP in Beijing genotypes, 84.6% (95%CI69.5%-94.1%), 6 of drug resistance and 15.4% (95%CI5.9%-30.1%), and 34 of non Beijing genotype strains susceptible to INH and RFP in 34, 34, and 34, respectively. 82.9% (95%CI67.9%-92.8%), 7 cases of drug resistance, accounting for 17.1% (95%CI7.2% to 32.1%). There was no significant difference between Beijing genotypes and non Beijing genotypes (all sensitive vs resistance) (x 2=0.04, P=0.8380.05), and Beijing genotypes and non Beijing genotype strains (single drug resistant vs MDR) were also not significant Sexual differences (x 2=1.93, P=0.3800.05)
Analysis of the influencing factors of 5. drug resistant tuberculosis
Single factor Logistic analysis found that retreatment was associated with the distribution of MDR-TB population (P0.05). Age, sex, occupation, household registration, treatment history, sputum smear, and strain genotypes were not associated with the distribution of single drug resistant patients. Multiple factor Logistic analysis found that the history of tuberculosis patients was associated with the distribution of multidrug resistant patients. Retreated TB patients are the main group of patients with multidrug-resistant tuberculosis (retreatment / initial treatment: OR:15.854; 95%CI:1.866 to 134.677).
6.M.TB genotyping
The highest resolution of 15 MIRU-VNTR loci for 80 M.TB was MIRU26 (HGI=0.865), the lowest resolution was ETRC (HGI=0.165), and HGI0.5 had 10 loci.
The results of 15 loci MIRU-VNTR genotyping showed that 80 strains of M.TB had 78 genotypes, 76 had independent genotypes, and 4 other 22 were clustered. The cluster rate was 2.5%. by Bionumberics5.0 software cluster analysis, and 78 genotypes were divided into 8 gene groups (group I, group II, group III, IV group, V group, VI group, VII group, VIII group). The group I accounted for 8.75% and 7 Genotypes; II group accounted for 11.25%, containing 8 genotypes; III group accounted for 55% and 43 genotypes; IV group accounted for 6.25% and 5 genotypes; V group accounted for 2.5% and 2 genotypes; VI group accounted for 8.75%, 7 genotypes, VII group 5%, containing 4 genotypes; VIII group accounted 2.5%, containing 2 genotypes.
The prevalence of tuberculosis in the rural areas of Taizhou was low. The resistance rate of M.TB was lower than the national level. There was no significant difference in the total drug resistance rate between the first treated and retreated patients. In M.TB, the non Beijing genotypes were the dominant bacteria, the Beijing genotype was low, and the Beijing genotype and the non Beijing genotype had no significant difference in the total resistance rate. The results of MIRU-VNTR genotyping at 15 loci showed that the rate of clustering among the strains was low and the gene polymorphism was obvious, indicating that the region was mainly infected by independent infection or endogenous reburning, and the recent transmission was less.
【学位授予单位】：复旦大学
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R52;R181.3

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