【作者】 陈建；

【导师】 李宁秀；

【作者基本信息】 四川大学 ， 健康与社会行为学， 2007， 博士

【摘要】 结核病是一种严重危害人类健康的传染性疾病，虽然曾经在一定时期内得到有效控制，但最近十多年来，全球结核病发病率和患病率逐年上升，耐药结核，尤其是耐多药结核病患者逐年增多。据世界卫生组织（WHO）估计，全球有近20亿人口感染过结核菌，其中有结核病患者2000多万。每年新发结核病人达800万人以上，每年约200万人死于结核病。我国是世界上结核病高负担国家之一。2000年全国结核病流行病学调查结果显示：我国约有5.5亿人感染结核病，感染率为44.5％，涂阳病人约150万，活动性肺结核患病率367／10万。总之，结核病已成为一种严重的公共卫生问题。随着社会经济的发展，人们的社会行为影响着结核病的流行和传播。结核病患者不规范的治疗，常常引起耐药结核，特别是耐多药结核的出现。结核病患者在治疗过程中的心理状态、社会支持和依从性也影响到结核病的治疗效果。因此，正确认识结核病患者的社会行为因素对结核病的治疗和控制具有十分重要的意义。近几年来，随着分子生物学的迅速发展，耐药结核和基因分型的研究已成为结核病研究的热点问题。据报道，北京家族是一种传播力极强的结核分枝杆菌，该菌是亚洲、北美洲和欧洲东部，尤其是俄罗斯等国家的主要流行株。所以，研究结核分枝杆菌基因分型、主要流行型以及基因型与耐药性的相互关系，对结核分子流行学和耐药结核人群的监测具有十分重要的意义。目的了解四川和安徽两省结核病患者基本生活状况和结核病患者的社会行为方式。探讨四川和安徽两省的耐药结核病患者产生的主要影响因素，为医生和患者在结核病的整个治疗过程中合理用药、避免耐药、促进患者早日康复提供可靠的依据和临床指导。同时选取四川省部分结核病患者的临床分离株进行基因型分析，从而揭示该地区结核分枝杆菌的基因型分布、主要流行型和不同基因型与耐药性的相互关系。方法研究选取四川和安徽省结核病防治所作为研究现场，采用系统抽样的方法抽取1489例结核病患者作为研究对象，其中四川省875例，安徽省614例。运用定性和定量研究相结合的方法对选取的研究对象进行一般人口学特征、生活状况、就医行为和耐药影响因素等方面的问卷调查，并抽取部分患者和医生进行深入访谈。从四川省的结核病患者抽取124例患者的临床分离株，首先对其采用生化反应方法进行菌种鉴定和绝对浓度法进行药物敏感性试验。然后对结核分枝杆菌分别采用MLVA和Spoligotyping方法进行基因分型，并对两种分型方法的结果进行比较。最后，以H₃₇Rv菌株作为对照，采用BioNumerics3.0软件对实验数据进行聚类分析，获得当地基因型和主要流行菌株资料，并采用logistic回归分析主要流行株与耐药结核之间的关系。结果1、四川和安徽两省的结核病患者在年龄、教育程度、婚姻状况等方面存在统计学差异，但在性别，职业，居住类型、居住地区、患者的人均收入和居住面积等方面没有统计学差异。2、在调查的结核病患者中，年轻人的社会支持高于老年人；干部和学生社会支持度高于其他职业组；男性和在婚的结核病患者的客观支持和主观支持分别高于女性和其他婚姻状态组；具有高中以上教育程度的结核病患者客观支持最高。3、两省的结核病患者受到不同程度的社会歧视，其中在工作、人际关系和心理方面的影响最为严重；患者随年龄增加受歧视率有下降趋势；初治患者受性歧视率高于复治患者。4、流动人口的结核病患者主要以30～50岁为主，其获得耐药率和耐多药率高于常住人口；结核病患者患病后对日常生活影响最大，对夫妻和家庭成员感情的影响最小；患者前一年在医院治疗的直接经济花费显著性高于在结防机构治疗的花费。5、定性研究表明，结核病的临床治疗失败与结核病诊疗过程中的人为因素有关。结核病患者就医行为受到多方面因素的影响，绝大多数结核病患者存在诊疗延误，尤其是农村和城市贫困人群的结核病患者延误最为突出。老年结核病患者诊疗延误时间长，治疗依从性较差。结核病患者对结核病知识水平缺乏，医务人员的责任心不强。医患关系需要加强。6、四川和安徽两省结核病患者结核病的总耐药率和耐多药率分别为33.04％和11.08％。耐药结核的发生趋向于对多种药物耐药，但主要趋向于对RIF和／或INH一线抗结核药。7、四川和安徽两省结核病患者耐药的主要危险因素为复治史、DOTS和依从性差。此外，患者居住类型和患病年限与任意耐药有联系；药品供应也是影响耐多药的一个重要因素。8、本研究初始耐药率和获得性耐药率分别9.13％和23.91％。四种抗结核药物的耐药率顺位由高到低依次为：RIF（19.4％）、INH（19.3％）、SM（9.1％）、EMB（7.7％）。9、不同的菌株和同一菌株在不同位点的VNTR DNA指纹图谱呈现出多态性，各位点呈现的等位基因多态性有差异，Mtub21位点的多态性最高，ETR-B位点的多态性最低。10、本研究采用20个位点的VNTR分型方法使分型分辨率大大提高，该方法简便快速、分型结果数字化。分型结果显示了37个基因型，各型成簇率差异较大。成簇最高的Ⅰ型（45.16％）为主导类型。11、VNTR研究结果显示：成簇基因型和单一基因型的分离株在年龄，涂片结果和治疗史的分布上存在统计学上差异，而且成簇类型的获得性耐药率高于单一基因型。12、Spoligotyping分型方法把菌株分为北京家族和非北京家族。北京家族的菌株获得性耐药率高于非北京家族，它是获得性耐药的独立的危险因素。Spoligotiping分型方法和VNTR分型方法有很好的相关性。结论1、四川和安徽两省的结核病患者的主要人口学特征存在很大的相似性；两省的结核病患者社会支持受到年龄、性别、教育程度和职业的影响。结核病患者面临严重的社会歧视，在很大程度上影响结核病的治疗和管理，可以采取有效的措施来减少这种负面影响。流动人口中结核病患者多为家庭主要劳动力，而且获得性耐药率和耐多药率相对较高。2、本研究合理地将定量研究和定性研究相结合探讨医患双方的行为因素对耐药结核的影响。两省的结核病患者诊断和治疗过程中延误状况严重，影响结核病的治愈率，耐药结核是导致当地治疗失败的一个重要原因。严格实施DOTS和保持好的依从性是减少耐药结核和提高治愈率的前提条件。提高结核病患者的结核病知识水平，解决结核防治人员短缺，密切医患关系是有效地解决结核病防治的重要措施。3、四川和安徽两省结核病患者的耐药状况严重，耐药菌株趋向于对多种抗结核药物同时耐药，但以耐RIF和／或INH为主。抗结核药物的耐药率顺位显示了四川和安徽两省两省的结核病治疗有各自的特点。4、四川和安徽的耐药结核与其社会行为因素有关。严格实施DOTS和提高患者的依从性是减少耐药结核的有效措施。确保结核病患者药品供应的质量，提高患者首次治愈率对降低耐多药结核有着重要意义。5、采用20个位点的VNTR分型方法进行基因分型，大大提高了分型的灵敏度和分辨率。首次获到了我国四川结核分枝杆菌种群的VNTR分型和spoligotyping资料，揭示了当地占优势的主导类型Ⅰ型、Ⅱ型和Ⅲ型（北京家族）；成簇基因型与耐药结核之间存在某些联系，而且基因型也是影响获得性耐药结核产生的一个重要因素。更多还原

【Abstract】 Tuberculosis （TB） is a sort of the infectious disease heavily threatening people’s health, and it had been effectively controlled during a certain period, but the incidence rate and the prevalence rate of tuberculosis gradually have been gone up in recent ten years, and drug resistant of tuberculosis, especially multi-drug resistant tuberculosis （MDR-TB） gradually increase year after year. It was reported by World Health Organization （WHO） that about 2 billions of the world’s population were infected with Mycobacterium tuberculosis （M.TB）, including 200 million patients of tuberculosis among them. Every year, new patient is more than 80 millions, and 2 millions died of tuberculosis.China was one of the higher disease burden countries of tuberculosis in the world. The results of epidemiologic investigation of TB in 2000 showed that approximately 0.55 billions infected TB, and the infection rate was 44.5%, there was 15 millions of smear positive patients and the prevalence rate of active tuberculosis was 367/1000000. In a word, Tuberculosis has become a serious public health problem.With the development of society and economy, social behavior of people influence on epidemic and transmission of TB. An irregular treatment of TB patients usually induces drug-resistant TB, especially MDR-TB. During treatment, Psychological state, social support and compliance of TB patients also affect the treatment effect of TB. Therefore, that social behavior factors were rightly understood has a far-reaching significance on curing and controlling of TB patients.Recently several years, with the development of molecular biology, the study of drug-resistant TB and genotyping has become the hotspot problem of TB research. It was reported that Beijing Family was a sort of M.TB having the most epidemic power and which was the main epidemic strain in Asia, North America and East Europe, especially in Russia.So, the studies on genotyping of M.TB, leading epidemic type and correlation between genotype and drug-resistance have an important significance on molecular epidemiology of TB and surveillance of drug resistant population.Objective The study is to comprehend basic condition of living and social behavior style of the TB patients in Sichuan Province and Anhui Province.To explore the main risk factors causing drug resistant TB and provide for reliable basis and clinical guidance for reasonable treatment, avoiding drug resistance and getting well quickly. Clinical isolates of TB in Sichuan Province are sampled for analysis of genotype and find out genotyping of M.TB, leading epidemic type and correlation between different genotype and drug resistance.Methods This study was conducted at the Institute of Tuberculosis Control and Prevention （ITCP） of Sichuan and Anhui Province, and 1489 patients of TB composed of 875 patients of Sichuan Province and 614 patient of Anhui Province were selected as systematic sampling. Using the methods of the qualitative and the quantitative research, the study object was investigated by questionnaires, which included the demographic characteristics, therapeutic behavior and risk factors of drug resistance, and a part of patients and doctors adopted the method of in-depth interview.124 clinical isolates were sampled from the TB patients of Sichuan province and identified by using biochemistry reaction method. The drug-susceptibility of the 124 clinical isolates was identified by absolute concentration method.The 124 clinical isolates were typed by MLVA typing method and spoligotying respectively and the results of the two genotypes were compared. Finally, using H₃₇Rv as reference strains, the data of the tests were dealt with cluster analysis by means of the BioNumerics 3.0 and the main epidemic strains and genotype were obtained. The relationship between the main epidemic strains and drug resistant TB was analyses by logistic regression.Results 1、The distributions of TB patients between Sichuan Province and Anhui Province had significantly differences among the age, degree of education and status of marriage and so on, but There were no difference among the gender, occupation, type of inhabitation, Area of inhabitation, income of per capita and area of per capita inhabitation.2、In the study, social supports of young TB patients were higher than the elder; The social supports of cadres and students of the TB patients were higher than the other TB patients; Objective support and subjective support of the male TB patients were higher than that of the female TB patients; The objective support and the subjective support of being marriage of the TB patients were higher than that of the other’s. The TB patients having high school education or more had higher objective support.3、The TB patients of Sichuan Province and Anhui Province had been discriminated in different aspects, especially in work, social relation and psychology. Social stigma rates of the TB patients had drop trend along with increase of age and social stigma rate of new patients was higher than that of re-treat patients.4、The TB patients of floating population were mostly the age from 30 years to 50 years, and which of the acquired drug resistant rate and multiple-drug resistant rate were higher than that of permanent residents, respectively. The tuberculosis influenced the routine life of the patients at most, and less affected feeling of spouse and family members. Last year the economical cost of patients in hospital was significant higher than that of in ITCP.5、The qualitative research showed that the failure of treatment of tuberculosis is associated with man-made factors in the course of diagnosis and treatment of tuberculosis. Many factors influenced the hospitalizing behavior of the patients of TB, and the majority of TB patients had the diagnosis delay and the treatment delay, especially the TB patients in rural population and the urban poor population. Aged TB patients generally had longer delay time in the course of diagnosis and treatment of tuberculosis and poor compliance to treatment regimens. The TB patients were lacking in the knowledge about TB, and the responsibility of doctors and nurses was weakness. It was necessary to enhance the relationship between doctors and patients.6、The total drug resistant rate and multi-drug resistance rate of the TB patients in Sichuan Province and Anhui Province were 33.04% and 11.08%, respectively. The strains studied were inclined to multiple drugs simultaneously, but drug-resistance to RFP and INH was the most common resistance pattern.7、The main risk factors of drug resistance TB of Sichuan Province and Anhui Province were associated with the re-treat history, bad DOTS and poor compliance. In addition, any drug resistance of TB was associated with type of inhabitation and suffering years, and the Supply of anti-tuberculosis medication was also an important factor for MDR-TB.8、In the study, Drug susceptibility testing showed that the primary and acquired drug resistance rate were 9.13% and 23.91%, respectively. Drug-resistance rates to RFP, INH, SM and EMB were 19.4%, 19.3%, 9.1% and 7.7%, successively.9、DNA fingerprint of VNTR presented polymorphism to different strain or different locus, there was different allelic diversity at each VNTR locus, The ETR-B locus had the lowest diversity （0.309） and the Mtub21 locus has the highest diversity （0.575）.10、The VNTR typing technique of twenty gene loci greatly advanced the power of discrimination, and it was a simple and rapid tool of which generated numerical genotypes. Thirty-seven genotypes were obtained from the study results, and clustering rates of each genotype had significant difference. Genotype （45.16%） having the highest clustering rate was the dominant VNTR pattern.11、In the VNTR results studied, the isolates between clustering genotype and single genotype had significant difference in the distribution of age, smear result and treatment history, and the acquired drug resistance rate of clustering genotype was higher than that of the single genotype’s.12、124 isolates were classified Beijing Family and non- Beijing Family by Spoligotyping method. The acquired drug resistance rate of Beijing Family was higher than that of the non-Beijing Family’s. There was better correlation between Spoligotyping method and VNTR typing technique.Conclusion 1、The TB patients of Sichuan province and Anhui Province had much sameness in main demography characteristics and social support of which were affected by age, gender, educational degree and occupation. The discrimination to the tuberculosis patients had already affected the treatment and management in a serious degree, and effective control measures should be taken to diminish these negative effects. The majority of TB patients of floating population were mostly work force of families, and the rate of ADR and the rate of MDR of TB patients of floating population were higher than that of other’s.2、That the qualitative research was reasonable combined with quantitative research was to explore the behavioral factor influence of both doctor and patient to drug resistance TB. The TB patients both Sichuan Province and Anhui Province had a serous degree delay in the course of diagnosis and treatment, which influence upon cure rate of them, and drug resistance TB was one of the important cause inducing the failure of treatment. A well-functioning DOTS program and keeping good compliance is the precondition in reducing drug resistance TB and improving cure rate. It is the important measures of effectively resolving TB prevention and control to advance the knowledge about TB, to deal with the lack of the TB control worker and enhance the relationship between doctors and patients.3、Status of drug-resistant TB is quite serious in Sichuan Province and Ahui Province, and the strains studied tend to be resistant to multiple drugs simultaneously, especially resistance to INH and RIF. The order of drug resistant rate of anti-tuberculosis drug indicated that the TB treatment had each characteristic in Sichuan Province and Ahui Province.4、The patients of drug-resistant TB in Sichuan Province and Anhui Province were associated with social behavior factors of them. A well-functioning DOTS program and improving compliance are the effective measures to reduce drug resistance TB.To guarantee quality and quantity of supply medication and to improve first cure rate of TB patients have important meaning to decrease MDR-TB.5、The VNTR typing technique of twenty gene loci greatly advanced experimental sensitivity and power of discrimination. This is first study that data of VNTR typing and spoligotyping are obtained from M.TB strains of Sichuan province and indicate local dominant genotype: I type、II type and IIItype （Beijing Family）. In Sichuan Province, The clustering genotype was some associated with drug resistant TB, and the genotype is one of the important factor associated with acquired drug resistance.更多还原