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-大家好
-Hello.

我是Philippe Glaziou
My name is Philippe Glaziou.

我是日内瓦世界卫生组织总部的流行病学家
I am an epidemiologist at the World Health Organization headquarters in Geneva.

我的讲解是关于结核病的流行病学
My talk on TB epidemiology

会探讨随时间变化人群中结核病
will describe the distribution of TB disease

和病死者的分布情况
and deaths in human populations over time.

我会介绍结核病发病率
I will cover some of the factors that determine the frequency of TB

和死亡率的决定因素
and its mortality.

并概述未来20年消除肺结核的措施
I will outline what can be done to eliminate the disease in the coming 20 years.

结核病历史悠久
TB has been with us for a very long time.

可能是从现代人类从非洲迁出开始
Probably since modern humans migrated out of Africa.

早期证据显示
Early evidence indicates

7000年前的发病率就很高
a high frequency of disease dating back 7 000 years.

随着生活条件改善
While the burden of TB declines

结核病的发病率逐渐降低
since then in relation to improvements in living conditions,

但在一些时期 情势严重恶化
there have been periods of significant worsening.

如西欧18世纪的工业革命时期
Such as during the Industrial Revolution in the 18th century in Western Europe

或日本19世纪末
or in the late 19th century in Japan.

在两次世界大战期间也是如此
Also, during the two World Wars.

二十年前
Two decades ago,

艾滋病流行最严重的国家
a resurgence of TB has been observed in countries most hit

出现了结核病的重新抬头
by the HIV pandemic.

这张幻灯片显示了20世纪英格兰
This slide shows trends in incidence that is the number of new cases in England

和威尔士新发病例的发病率趋势
and Wales over the 20th century.

新发病例以每10万人口为单位展示
New cases are expressed per 100 000 population.

整个20世纪
Over the whole century,

结核病的发病率大部分时候
TB incidence declined for most of the time period

都是从非常高的水平下降
from very high rates,

此处每10万人中有300人发病
300 per 100 000 population here.

在这张幻灯片上
You can see here on this slide

可以看到二战后
the steady decline in TB incidence rate

结核病发病率加速下降
which accelerated after the Second World War.

然后
Then,

在过去的30年略有增加
it slightly increased in the past 30 years.

在这条线以下
Below that line,

虚线表示在本世纪上半叶大部分时间内
the dashed line shows TB mortality

结核病死亡率和发病率同步下降
which declined in parallel to incidence

然后死亡率下降速度加快
for most of the first half of the century and then faster.

这些时序数据很重要
These time series are important.

这些数据说明了很多结核病患者的命运
They tell us a lot about the fate of TB patients,

特别是在二战后可以治疗结核病之前
particularly before treatment was available after World War II.

如果将死亡率除以发病率
If we take the ratio of mortality divided by incidence,

就可以得到在这张幻灯片上显示的病死率
we obtain what I am showing on this slide which is the case fatality ratio,

即死于结核病的比例
the proportion of TB patients who die from the disease.

您可以看到
You can see that the case fatality ratio,

从二十世纪初到二战的病死率
from the beginning of the century all the way to about World War II,

约为40%-50％
was around 40-50%.

40％到50％的结核病患者死于此病
40 to 50% of TB patients died from the disease.

之后开始使用化学疗法
Then, chemotherapy became available,

即现代抗生素
modern antibiotics,

病死率在很短的时间内骤降到10％以下
and the case fatality ratio drops suddenly,

并自此之后保持在10％以下
within a very short time span, to below 10% and remained below 10% since then.

结核病是一种非常严重的疾病
TB was a very serious disease.

在化学疗法出现之前
Before chemotherapy,

它破坏了肺和其他器官并造成了很大的痛苦
it destroyed lungs, other organs and caused much suffering,

有时甚至会持续多年
sometimes over years,

也会导致群落内持续传播
also causing sustained transmission in the community.

结核杆菌基本上
TB bacilli are essentially transmitted through the air from a contact with a person

是通过与肺结核患者接触的空气传播的
affected by pulmonary TB.

在大多数被感染的人中
In most people who acquire this infection,

杆菌被免疫系统控制
the bacilli are contained by the immune system.

它们保持休眠状态或从体内被除去
They stay dormant or may be cleared from the body.

一小部分感染者
A small proportion of infected people develop the disease

经过或短或长潜伏期之后会发病
after an incubation that can be short or very long,

潜伏时间可长达几十年
up to several decades.

这些与结核病人接触的易感人群会感染
The susceptible people here who come into contact with someone

但不是所有的感染者
with pulmonary TB acquire infection

都会发病
but not all infected people develop the disease.

终生风险约为5％至15％
The lifetime risk is about 5 to 15%.

目前估计全世界约有四分之一的人受到感染
It is currently estimated that about 1 out of 4 people in the world are infected.

也就是17亿人
That is 1.7 billion people.

2015年
In 2015,

约有1040万人发病
about 10.4 million people have developed the disease.

结核杆菌是一种非常成功的病原体
TB is a very successful pathogen.

不是每个被感染的人
Not everyone who has been infected

都有同样的发生这种疾病的风险
has the same risk of developing the disease.

主要是HIV合并感染者
In particular, people who have HIV co-infection

感染后发生结核病的风险
have a much higher risk of developing TB disease after infection

比没有感染HIV的人要高得多
compared with people who do not have HIV infection.

那是因为HIV对免疫系统造成了巨大的破坏
That is because HIV causes great havoc in the immune system.

它会削弱免疫力
By weakening the immunity,

让杆菌自由繁殖
it allows the bacilli to freely multiply.

HIV感染者的结核病相对危险度
The relative risk of TB in HIV-infected people

约为20-35
is about 20-35,

意思是 相较于与其居住于同一地方的
which means that HIV-infected people

非HIV感染人群
have 20 to 35 times more risk of developing TB

HIV感染者的结核病患病风险
compared with people who do not have HIV

要高出20-35倍
and who live in the same places.

还有其他一些与结核病相关的危险因素
There are also other factors associated with a higher risk of TB

如营养不良 糖尿病
such as under-nutrition, diabetes,

尤其是II型糖尿病
particularly type II diabetes

随着肥胖 酗酒 吸烟等其它疾病
which is becoming more and more frequent

或不健康行为的流行
as we are facing a pandemic of obesity,

糖尿病越来越常见
alcohol abuse, cigarette smoking, and others.

其他重要的风险因素包括空气污染和拥挤
Other important risk factors include air pollution, also crowding.

结核病在贫困人群中发生的频率更高
TB occurs more frequently among poor people

而且治疗结果受到无法及时
and the outcome of the disease is negatively affected

获得优质诊疗服务的
by their financial inability to promptly access quality diagnostic

经济状况的负面影响
and care services.

最后
Lastly,

结核病在男性和成年人中尤为多发
TB is notably more frequent in males and in adults.

2015年新增病例1040万
In 2015, there were 10.4 million new cases.

由牛结核分枝杆菌致病的仅占1.4％
Only 1.4% of them were attributed to TB due to Mycobacterium bovis.

这1040万新病例的发病率
These 10.4 million new cases correspond to a rate of incidence

相当于每10万人约140例
of about 140 cases per 100 000 population.

这种发病率在各国之间差别很大
That rate of incidence varied greatly between countries, from very high rates,

特别是撒哈拉以南非洲地区
particularly in Sub-Saharan Africa or in Southeast Asia,

或东南亚地区 相比之下高收入国家
to much lower rates in high-income countries,

西欧
Western Europe,

北美或澳大利亚
Northern America, or Australia,

新西兰的发病率要低得多
New Zealand.

在结核病发病负担较低的高收入国家
In high-income countries with a low burden of TB,

近期移民中发现的结核病发病率
rates of TB incidence observed in recent immigrants

通常反映其原籍国的发病率
generally reflect the rates in their country of origin.

在2015年1040万新发结核病例中
Out of the 10.4 million new TB cases,

有120万人感染了HIV
1.2 million had HIV infection in 2015.

这几乎是12％的病例
That is nearly 12% of cases.

在南部非洲国家的新发结核病例中
In Southern African countries, the proportion of HIV infection,

HIV感染的比例达到50％以上
among new TB cases, reaches 50% or more.

HIV大大增加了患病风险
HIV greatly increases the risk of developing the disease but also,

也恶化了疾病的预后
it worsens the prognosis of the disease.

它增加了死亡的风险
It increases the risk of dying from it,

特别是在未经治疗的HIV晚期
particularly in advanced stages of untreated AIDS.

本幻灯片总结了
This slide summarizes the key statistics

关于全球结核病的主要统计数据
given about the global burden of TB.

在2015年
In 2015,

有180万人死于结核病
there were 1.8 million TB deaths,

其中40万人感染HIV
including 400 000 in people infected with HIV.

如果把死亡率除以新病例
If we take the ratio of mortality divided by the new cases,

就可以得到我前面展示过的近似的病死率
we get an approximation of the case fatality ratio as I showed earlier.

从表中可以看出
You can see in this table

全世界未感染HIV的病死率为15％
that the case fatality ratio is 15% in the world among people

而HIV感染者为33％
who do not have HIV infection compared

在HIV感染者中
with 33% among people who had HIV infection.

尽管治疗有效
The risk of dying is still much higher,

他们的死亡风险仍然高得多
despite effective treatment, among people infected with HIV.

左图显示全球结核病发病率正在下降
Global TB incidence, on the left panel here, is declining.

但是以每年2％左右的速度非常缓慢地下降
But it is declining very slowly at a rate of about 2% per year.

绿线这里几乎看不到下降
It is the green line here we hardly see declining.

并非所有HIV新发病例都被检测并被通知
Not all incident cases represented in the red ribbon are detected and notified.

黑色实线表示的是检测到的和已通知的
The detected and notified are shown here, the solid black line.

这两者之间的差距
The gap between those two

是检测和报告的检测病例的差距
is a gap in detection or reporting of detected cases,

特别是在私营诊所发现病例的情况下
particularly when cases are detected in the private sectors

可能不会向公共卫生部门报告
and may not be reported to public health authorities.

不仅是发病率下降
TB mortality on the right panel is declining faster

而且检测手段和治疗方案的效果
as a result of a declining incidence

也有所提高
but also as a result of increased performance

因此右图的结核病死亡率下降速度更快
in detection and care programs.

所以
So,

病死率也在下降
the case fatality ratio is also declining.

从人群开始使用抗生素以来
Population exposure to antibiotics, since they started to be used,

人群接触会增加细菌
increases the risk of the germs

对药物产生耐药性的风险
becoming resistant to the drugs.

结核杆菌也不例外
TB bacilli are no exception.

在2015年
In 2015,

估计有58万人
there were an estimated 580 000 people

患对利福平耐药结核病
who had TB with bacilli that are resistant to rifampicin.

利福平是最有效的一线抗结核药物
Rifampicin is the most potent first-line anti-TB drug.

利福平耐药的新病例超过五十万
So, more than half a million new cases of rifampicin resistance.

这比药物敏感结核病
This is a form of disease that is much harder to treat

更难以治疗
than drug-susceptible tuberculosis.

在这58万人中
Among these 580 000 people,

约有23％（132 000人）做过药物敏感试验
about 23%, 132 000,were detected using drug-susceptibility testing.

同年
During the same year,

约有125 000人进行二线药物治疗
around 125 000 have been put on second-line treatment.

用二线药物
Lastly, treatment success,

治疗耐药结核的成功率
reatment using second-line drugs for drug-resistant TB,

仅为52％
was only 52%.

治疗效果不是很好
Not a very good outcome of treatment.

在未成功的结果中
Among the non-favorable outcomes,

许多患者死亡
lots of patients died

还有其他一些患有广泛耐药慢性结核病的
but also others had chronic TB with extensively drug-resistant germs.

也就是细菌对绝大部分抗结核抗生素
That is germs that are resistant

都有耐药性
to most antibiotics against TB.

是一种不太可能治疗的疾病
A form of disease that is not really treatable.

目前结核病发病率每年下降约2％
TB incidence declines currently at a rate of about 2% per year.

如果我们什么都不做
If we do not do anything,

预计下降将会以现在的速度继续
we expect the decline to continue at its current pace.

缓慢的下降
A slow decline.

但是 如果我们改进目前的方法
But if we improve the current tools,

改善获得健康的途径
if we improve access to health,

让穷人在生病时能够及时获得医疗服务
so that the poor people can readily seek medical care when they are sick,

如果他们患有结核病
and if they have TB,

可以获得有效的医疗服务
they can access effective care services,

那么由于传播减少
then we can expect a decline in TB incidence

结核病发病率预计会下降
as a result of decreased transmission.

我们已经在西欧看到了这种下降
We have seen this decline in Western Europe.

我已经展示了
I have shown it.

如果我们想要更快的下降速度
If we want a further decline,

除了解决感染人群的问题 别无他法
there is no other way than to address the pool of infection.

正如我所说
As I said,

目前约有17亿人受到感染
about 1.7 billion people are currently infected.

我们预计其中约5％至15％会发病
We expect about 5 to 15% of them to develop the disease in the long term.

如果想要防止这种情况发生
If we want to prevent that,

要么需要一种暴露后预防疫苗
we need either a post-exposure vaccine,

这一新疫苗可以代替卡介苗
a new vaccine that will replace BCG,

也可以预防那些已经受到感染的人发病
that can prevent the disease in people who have already been infected,

要么就是一种安全的预防性治疗
or a safe prophylactic treatment,

一种简单且安全的治疗
a simple treatment that is also safe.

这是我们能够让结核病发病率
It is the only way we could have further accelerations

进一步加速下降的唯一途径
in declining TB incidence.

非常感谢您的聆听
Thank you very much for listening.