贵州省耐多药结核病患者就医行为及疾病负担研究

China has the second largest number of MDR-TB patients in the world. Guizhou province has the second highest TB burden in China, and the total rate of drug resistance was higher than the national average level. The occurrence of Multidrug-resistant tuberculosis（MDR-TB）is closely related to the patient's health seeking behavior. MDR-TB poses a serious burden of disease for global public health due to its expensive, longtime and intractable treatment and low cure rate. . Our previous research and field work confirmed that MDR-TB epidemic was high in some areas, and most of patients were poor and failed into poverty due to MDR-TB, and they experienced complicated process of treatment, and most of patients were acquired resistance.. In order to know the health seeking behavior and burden of disease due to MDR-TB in Guizhou province and their linkage relationship scientifically, our study summarized process of health seeking into four stages, which cover the stage from occurrence of TB symptoms to having consequences. Then, we will establish a MDR-TB patient’s cohort by retrospective inclusion registered in the recent 3 years and follow them prospectively until all patients have therapeutic outcomes. Then we will do from three main aspects using quantitative and qualitative research methods, and combining population research and laboratory research. Firstly, we will analyze the epidemiological distribution characteristics of MDR-TB in Guizhou province in the past 3 years to identify high epidemic areas and high-risk groups. Then health seeking behavior and its influence factors will be analyzed further especially focus on high MDR-TB epidemic areas and high-risk groups. Secondly, we will analyze the health seeking behavior, financial burden and their influence factors due to MDR-TB in four stages. At last, we will analyze the linkage relationship due to MDR-TB between health seeking behavior and financial burden in four stages. We hope our research will provide some evidence to policy makers for reducing the burden of MDR-TB in Guizhou province in the future.

中国耐多药结核病（MDR-TB）患者数居全球第二。贵州省结核病疫情居全国第二，总耐多药率高于全国平均水平。MDR-TB产生与患者就医行为密切相关。因费贵、时长、难治、低治愈的特点，MDR-TB给全球带来严重的疾病负担，包括流行病学负担和经济负担。本课题组前期研究和现场工作证实贵州省MDR-TB部分地区高发，患者经济困难，就医行为复杂，其来源以获得性耐药为主。为科学了解贵州省MDR-TB患者就医行为和疾病负担现状及二者联动关系，本研究将就医过程归纳为从出现症状到结束治疗四个阶段，回顾性纳入近3年MDR-TB患者，建立队列，并前瞻性随访至所有患者有治疗结局。采取定量和定性，人群与实验室相结合的方法，先从宏观上分析近3年贵州省MDR-TB空间及人群流行分布特征，识别高疫情区和高危人群；再从微观上分析患者四个阶段的就医行为、治疗进展、经济负担及其联动关系，特别关注高疫情区和高危人群是否存在特殊性。

耐多药结核病（MDR-TB)的产生与传播和患者就医行为密切相关。加之其费贵、时长、难治、低治愈的特点，MDR-TB给全球带来严重的疾病负担，包括流行病学负担和经济负担。因此，深入开展MDR-TB患者就医行为和疾病负担的研究对该病高负担地区具有重要的理论和现实意义。中国的MDR-TB估算患者数高居全球第二，仅次于印度。贵州省是全国结核病（TB）高疫情省份，结核菌株中总耐多药率达14.3%，高于全国TB耐药性基线调查8.32%的平均水平。本研究基于历年TB监测数据，从宏观上分析了2014-2020年贵州省登记报告的1666例MDR-TB患者流行病学分布特征，结果显示患者来源以获得性耐药为主，数量呈逐年上升趋势，分布有地区聚集性（毕节市、贵阳市、六盘水市和遵义市居多）。本研究还基于TB患者耐药风险的筛查策略，在18506例开展耐药筛查的病例中对MDR-TB发现效果进行了评价，结果显示贵州省耐药筛查覆盖面不断扩大，耐药高风险人群中MDR-TB的检出率高于低风险人群，但发现的病例中没有密切接触者，这提示对MDR-TB病例的密切接触者筛查是今后的重点工作之一。此外，本研究基于系统性文献回顾，分别对中国MDR-TB患者治疗结局，中国TB患者三类延迟现况及其与经济因素关联进行了Meta分析，结果显示中国MDR-TB患者总治疗成功率为60%，高于贵州省36%的治疗成功率；中国TB患者总就诊延迟率、确诊延迟率和治疗延迟率分别为41%、36%和18%；家庭经济状况与患者三类延迟均具有相关性（P<0.05）。最后，本研究基于贵州省实地现场调研数据，发现调查的MDR-TB患者中：严重治疗中断的发生率为28.7%，其主要原因为药物不良反应和经济困难；就诊延迟和确诊延迟的发生率分别为40.6%和42.4%；3类治疗延迟率分别为43.6%、30.0%和22.7%；MDR-TB患者家庭因病导致的经济负担重，灾难性卫生支出和灾难性总支出的发生率分别为68.3%和87.0%。本研究的系列研究成果科学地呈现了贵州省MDR-TB患者就医行为和疾病负担现状及二者联动关系，帮助识别了贵州省MDR-TB防控的重点地区和人群，提示了下一步重点研究领域和防控环节，为制定和完善其防控策略提供了科学支撑。