【正文】 ? 檢測(cè)和治療肺結(jié)核 ? 檢測(cè)和治療原發(fā)或繼發(fā)感染 ? BCG 接種 措施：檢測(cè)和治療肺結(jié)核患者 ? 問(wèn)題 : 主動(dòng)或被動(dòng)檢測(cè) ? ? 主動(dòng)檢測(cè)目的 : “to detect people before they have symptoms, in order to avoid detecting them when they have already contaminated their environment” 措施：肺結(jié)核患者被動(dòng)檢測(cè) ? 在普通就診中發(fā)現(xiàn)肺結(jié)核的可疑患者 ? 對(duì)可疑患者進(jìn)行對(duì)痰涂片檢查 ? 痰涂片檢查陽(yáng)性中啟動(dòng)足夠的治療 ? 持續(xù)對(duì)已啟動(dòng)治療的患者進(jìn)行治療 被動(dòng)監(jiān)測(cè) (1) 在一般就診中發(fā)現(xiàn)肺結(jié)核可疑患者 What we need, therefore, is a discriminating sign at an early stage of illness, and moreover, one that can easily be operationalised. Discriminating sign Workload (exams to be carried out) Result (sputum positive detected) “cough1 week” 700 44 “cough 2 weeks” 350 43 Marginal cost or marginal return 350 exams 1 case (1)在一般就診中發(fā)現(xiàn)肺結(jié)核可疑患者 ? In this case, “cough 2 weeks? appears to be the most efficient screening sign. ? Other sign: weight loss (wellnourished population) night sweat （ 1）在一般就診中發(fā)現(xiàn)肺結(jié)核可疑患者 ? In conclusion, a decentralized and versatile service is necessary. ? Permanence will be an asset, but rather a secondary one. ? Quality (2) 痰涂片檢查 technical petence: training to acquire the necessary skill sufficient frequency to maintain the skill some kind of quality control system (supervision, quality testing) decentralized structure (3) 痰涂片檢查陽(yáng)性者啟動(dòng)抗結(jié)核治療 mon situation: patients are diagnosed as PTB in the hospital and that treatment is started in the hospital. After 2 or 3 months these patients are referred back to the HC for further continuation of treatment. the initiation of treatment can best be integrated in the package of activities of the same service (multipurpose and decentralized). （ 4）持續(xù)進(jìn)行抗結(jié)核治療 maintaining continuity: accessibility (decentralized service) other factors (social context and individual tendency): sex, age, literacy, degree of schooling. identifying individual causes with the patients, by asking him why he is irregular. search for solutions with patients a capacity to listen and to hear things outside our own ?professional? logic a capacity to ?empathize? 操作性分析（ OA） (?s Model) 通過(guò)對(duì)衛(wèi)生服務(wù)功能進(jìn)行綜合分析，構(gòu)造模型識(shí)別實(shí)施特定健康問(wèn)題干預(yù)時(shí)可能存在的問(wèn)題。以定量分析為主。 (1) 選擇某一健康問(wèn)題，如結(jié)核病防治 (2) 描述已采用的策略（ 根據(jù) VA分析情況） Results of the .: ? Strategy of passive detectiontreatment at FLHS ? Diagnosis = finding AAFB in sputum ? Treatment is started as soon as results are know (3) 對(duì)各干預(yù)環(huán)節(jié)可能環(huán)節(jié)進(jìn)行分析（ 從起點(diǎn)到終點(diǎn)） A: individual is still free of PTB Z: individual is cured of PTB = Attempt to visualise the patient?s health seeking and case management course 3. 構(gòu)造分析模型 識(shí)別干預(yù)過(guò)程的主要環(huán)節(jié)（每一環(huán)節(jié)的概率） A: population of individuals still free of problem X = population for which the health service takes responsibility (1) PTB發(fā)病或患病情況 : Incidence – or prevalence (2) 對(duì)疾病的知曉率（根據(jù)癥狀） : Awareness (3)知曉者接受衛(wèi)生服務(wù)的頻率 : Motivation (4) 就診者中接受痰涂片檢查的頻率 : Examination (5) PTB患者痰涂片檢查陽(yáng)性率 : Sensitivity (6) 實(shí)驗(yàn)室檢測(cè)的一致性 : Reliability (7) 持續(xù)接受規(guī)則治療 : Regularity (8) 治療的有效性 : Efficacy Z: Total N of individuals (timely) cured of PTB = N x Incidence (prevalence) x Awareness x Motivation x Examination x Sensitivity x Reading Reliability x Regularity x Efficacy. 四方面參數(shù) : Epidemiology: Incidence(prevalence) Participation: Awareness x Motivation These patients want access to service Diagnosis: Examination x Sensitivity x Reliability Their status has to be correctly assessed. 4. 治療 Treatment: Regularity x Efficacy Table 1: Model of operational analysis of PTB case management Subsystem Parameter Epidemiologic Incidence (Prevalence) A= 100,000 ↓ Inc = 200 Participation Awareness Motivation ↓ A1 = 190 ↓ M = 95 Diagnosis Examination Sensitivity Reliability ↓ E = 29 ↓ D1 = 25 ↓ R1 = 18 Treatment Regularity Efficacy (INH only) ↓ T = 7 ↓ Q = 5 = Z 評(píng)價(jià) : 流行病學(xué)參數(shù)選擇 176。 Prevalence = calculating needs in terms of planning = at start of a new programme 176。 Incidence = ongoing programme “Z = 5” This means that only 5 PTB cases have been managed optimally. It does not mean that 195 PTB cases will not be cured at all ! But : delays, irregular treatments, etc. 謝 謝！