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中国防痨杂志 ›› 2025, Vol. 47 ›› Issue (7): 846-854.doi: 10.19982/j.issn.1000-6621.20250032

• 论著 • 上一篇    下一篇

基于社区的老年人肺结核主动筛查:一项基于多中心队列研究的策略与效果分析

张灿有1,2, 夏愔愔1,2, 陈卉1,2, 赵飞3, 王黎霞4, 张慧1,2(), 成君1,2()   

  1. 1 中国疾病预防控制中心结核病预防控制中心,北京 102206
    2 中国疾病预防控制中心传染病溯源预警与智能决策全国重点实验室,北京 102206
    3 北京医院药学部, 国家老年医学中心,中国医学科学院老年医学研究院,药物临床风险与个体化应用评价北京市重点实验室,北京 100730
    4 《中国防痨杂志》期刊社,北京 100035
  • 收稿日期:2025-01-20 出版日期:2025-07-10 发布日期:2025-07-03
  • 通信作者: 张慧,Email:zhanghui@chinacdc.cn; 成君,Email:chengjun@chinacdc.cn
  • 基金资助:
    国家“十二五”科技重大专项结核病流行与干预模式研究(2013ZX10003004001);国家“十三五”科技重大专项结核病重点人群干预策略研究(2017ZX10201302001);结核病预防控制项目(2528)

Community-based active case-finding for pulmonary tuberculosis in the elderly: analysis of strategies and effectiveness based on a multicenter cohort study

Zhang Canyou1,2, Xia Yinyin1,2, Chen Hui1,2, Zhao Fei3, Wang Lixia4, Zhang Hui1,2(), Cheng Jun1,2()   

  1. 1 National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China
    2 National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, Chinese Center for Disease Control and Prevention, Beijing 102206, China
    3 Department of Pharmacy, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Key Laboratory of Assessment of Clinical Drugs Risk and Individual Application (Beijing Hospital), Beijing 100730, China
    4 Chinese Journal of Antituberculosis Publishing House, Beijing 100035, China
  • Received:2025-01-20 Online:2025-07-10 Published:2025-07-03
  • Contact: Zhang Hui, Email: zhanghui@chinacdc.cn; Cheng Jun, Email: chengjun@chinacdc.cn
  • Supported by:
    Study on the Tuberculosis Epidemic and Intervention Mode of the National Twelfth Five-year Mega-Scientific Projects of Infectious Diseases in China(2013ZX10003004001);Study on the Intervention Strategy of the Key population of Tuberculosis of the National Thirteenth Five-year Mega-Scientific Projects of Infectious Diseases in China(2017ZX10201302001);National Tuberculosis Control and Prevention Programme(2528)

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摘要：

目的:评价基于社区的老年人肺结核主动筛查不同策略的筛查工作量和产出。方法:采用回顾性研究方法,收集2013—2015年中国疾病预防控制中心在我国东、中、西部10个省份的10个县、区中27个乡镇/社区针对65岁及以上老年人连续3年开展的肺结核主动筛查数据(包括发病因素、可疑症状和胸部影像学检查)进行再分析,模拟形成8种老年人群肺结核主动筛查策略,包括症状筛查策略(策略1~3)、高危人群筛查策略(策略4~7)和普查策略(策略8),分析老年人群的受检情况、肺结核筛查情况、肺结核可疑症状者发现情况、不同主动筛查策略的筛查工作量和患者发现产出。结果:2013—2015年,符合筛查条件的65岁及以上老年人口分别有38888、40909和43006名,接受症状筛查的老年人分别有37989名(97.69%)、37219名(90.98%)和37771名(87.83%),进行胸部影像学检查的老年人分别有33717名(86.70%)、33686名(82.34%)和33268名(77.36%),均呈逐年下降趋势(Z值分别为-51.651、-34.802,P值均<0.001)。2013年首次症状筛查中,采用策略3中世界卫生组织推荐的4种可疑症状可检出3.75%(1424/37989)的肺结核可疑症状者,明显多于采用策略1中国家指南症状和策略2中本研究定义症状检出的可疑症状者[分别为1.92%(731/37989)和2.10%(798/37989)],并较策略1多发现5例活动性肺结核患者;策略1、2、3需分别对1.79%(696/38888)、1.96%(762/38888)、3.39%(1317/38888)的老年人开展胸部影像学筛查,能够分别发现25.00%(14/56)、26.79%(15/56)、28.57%(16/56)的菌阳肺结核患者和18.39%(32/174)、18.97%(33/174)、21.26%(37/174)的活动性肺结核患者,每发现1例菌阳肺结核和活动性肺结核患者需分别筛查50、51、83名和22、24、36名;与症状筛查策略相比,高危人群筛查策略则需对更多的研究对象开展胸部影像学检查,应筛查比例从策略4的9.07%(3527/38888)提高至策略7的36.81%(14314/38888),菌阳肺结核患者和活动性肺结核患者的检出比例及每发现1例肺结核患者需筛查的人数(NNS)也分别从策略4的37.50%(21/56)、30.46%(53/174)、168名、67名提高到策略7的64.29%(36/56)、66.09%(115/174)、398名、125名;而普查策略能够检测出最多的菌阳和活动性肺结核患者[均为100.00%(56/56,174/174)]。另外,第2年的高危人群筛查策略发现的患者比例和NNS均与第1年的筛查结果基本一致,但第3年的筛查效率显著下降。结论:基于社区的老年人肺结核主动筛查建议采取更为敏感的可疑症状定义以提高患者发现率,且结合高危因素以提高筛查效率,而连续的主动筛查实施周期不应超过2次,应及时评估并调整筛查策略。

关键词: 结核,肺, 老年人, 社区卫生服务, 人群监测, 队列研究

Abstract:

Objective: To evaluate the screening workload and yield for different community-based active case-finding (ACF) strategies for pulmonary tuberculosis (TB) in the elderly. Methods: A retrospective study was conducted. Data from three consecutive years (2013—2015) of active TB screening among individuals aged ≥65 years were re-analyzed. The screening, implemented by the China CDC across 27 townships/communities in 10 counties/districts spanning eastern, central, and western China, collected data on risk factors, presumptive TB symptoms, and chest radiography (CXR). Eight ACF strategies for the elderly were simulated: symptom screening (Strategies 1-3), high-risk group screening (Strategies 4-7), and universal screening (Strategy 8). Analyses focused on screening participation, TB screening outcomes, detection of individuals with presumptive TB symptoms, screening workload, and case detection yield for each strategy. Results: From 2013 to 2015, the eligible elderly populations (≥65 years) were 38888, 40909, and 43006 individuals, respectively. The numbers undergoing symptom screening were 37989 (97.69%), 37219 (90.98%), and 37771 (87.83%), and those receiving CXR were 33717 (86.70%), 33686 (82.34%), and 33268 (77.36%), showing a significant declining trend year-on-year (Z=-51.651 and -34.802, respectively; P<0.001 for both). During the 2013 initial symptom screening, Strategy 3 (using the WHO-recommended 4-symptom screen) identified significantly more individuals with presumptive TB symptoms (3.75%, 1424/37989) compared to Strategy 1 (national guideline symptoms: 1.92%, 731/37989) and Strategy 2 (study-defined symptoms: 2.10%, 798/37989), and detected 5 more active TB cases than Strategy 1. Strategies 1, 2, and 3 required CXR for 1.79% (696/38888), 1.96% (762/38888), and 3.39% (1317/38888) of the elderly, respectively. These strategies detected 25.00% (14/56), 26.79% (15/56), and 28.57% (16/56) of bacteriologically confirmed pulmonary TB cases, and 18.39% (32/174), 18.97% (33/174), and 21.26% (37/174) of active TB cases. The number needed to screen (NNS) to detect one bacteriologically confirmed TB case was 50, 51, and 83, respectively, and to detect one active TB case was 22, 24, and 36, respectively. Compared to symptom screening, high-risk group strategies (4-7) required CXR for a larger proportion of participants, ranging from 9.07% (Strategy 4, 3527/38888) to 36.81% (Strategy 7, 14314/38888). The detection proportions for bacteriologically confirmed TB and active TB increased from Strategy 4 (37.50% (21/56); 30.46% (53/174)) to Strategy 7 (64.29% (36/56); 66.09% (115/174)). Correspondingly, the NNS increased from 168 and 67 (Strategy 4) to 398 and 125 (Strategy 7). Universal screening (Strategy 8) detected all cases (100.00%; 56/56 bacteriologically confirmed, 174/174 active TB). Screening efficiency in the second year for high-risk strategies was comparable to the first year, but declined significantly in the third year. Conclusion: Community-based ACF for pulmonary TB in the elderly should employ a more sensitive symptom definition to improve case detection. Incorporating high-risk factors enhances screening efficiency. Continuous ACF implementation should not exceed two consecutive rounds; strategies require timely evaluation and adjustment.

Key words: Tuberculosis, pulmonary, Elderly, Community health services, Public health surveillance, Cohort studies

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