/ UNUYH Phu tnmng 79 (2) - 2012 only 9.48% household with standardized latrine. Type of latrines in the survey Prea: septic tank (11.4%); biogas (4.3%); DVC (66.7%); pour flush (0.4%). Using and maintaining without follpw- Ing standard. The risk average score of DVC, septic tank and pcur flush are 0.59; 0.1 and 0.74, respectively Finding some factors relating te using and maintaining hygienic latrine are farm- ing, poor households, the lack ef knowledge about hygienic latrine. Based en the results of the research; the authors have suggested some solutions to improve the situation of using house- hold hygienic latrine with government and citizens.
Key words: hygienic latrine, household, the risk average score
DAC D\tM LAM SANG CAC TRU'D'NG HOP TO" VONG
DO SOT XUAT H U Y ^ T DENGUE TAI VIET NAM, 2008 - 2010Le Bio Thw, Phan Trpng Lan, Vu Sinh Nam, Nguyin Thi Kim Tien BpYli Nghiin eiru hdi euu 288 truirng hap 10" vong do Sit xuit huyit Dengue (SXHD) tai Viit Nam trong 3 nSm tir 2008 -2010d§ cho thiy: Phin lim cic truirng hop tir vong do SXHD ed biiu hipn lim sang diin liinh cQa binh vi d mue dd npng vdt cic biiu hipn: sit, xuit huyil, dau diu, dau minh, dauca- xuang - WlOp, c6 die miu va giim tiiu ciu, giy sie va tiin sic: 100% tnrdng hap tir vong ed sit, vdi die diim dtcao trin SO^C (62,5%; vi sdt keo dii tir 2-7 ngiy (90,3%); 88,2% InrOng hpp cd xuit huyit, vdi cic liiiu hiin thudng gip la diu hipu diy thit (51,4%); chim xuit huyit (49,3%); ndn ra miu (32,6%) va di tigoiiphin den (24,3%); 100% eic trudng hap tir vong diu thupc phin dd lim sing dd 3 va dp 4 {cd sic vi liin sic); 40,7% truang hop ed Hematocrit tang cao > 42% vi 67,7% trudng hpp cd si Itrctng liiu ciu glim rit thip < 50.000/mm^. Y ti luyin linh vi Y ti tuyin huyin li hat tuyin chu yiu trong WiSm binh va diiu tri cho binh nhan (77,1%). Hiu hit cic truirng hpp lir vong duac dua din binh vipn midn sau ngiy IhU 3 tir khi khdi binh (75,7%) din din tf 1$ cao cie trudng hap tir vong nhanh trong vSng 2 ngay sau khi nhip viin (52,1%). Phin idn eic trudng hpp tit vong tU ngay thir 3 - ngay thir 6 ki unite Midi binh. li giai dopn thudng xiy ra si5c (62,3%;.
Tir kh6a: Sit xult huylt Dengue (SXHD), tu- vong, lam sang, Viet Nam
I. DAT V A N Bt 88 trudng hop tir vong, trong dd s l mac tang g l p del, s l tir vong tang 27% so vdi trung binh giai doan 1999 - 2007). Giai dopn 2001 Tpi ViSt Nam, SXHD Id dieh luu hdnh dia
phu-ong, bOng n l thee ehu ky vdi khoang each thing binh 4 - 5 nam. Vy dich Idn g i n ilay nhlt xdy rp vdo npm 1998, cp 234.920 tnrdng hgp mpc, trong do 377 tni-gng hgp tir
- 2005, SXHD la mdt trong 10 bSnh truyen nhiem cd s l mpc CPO nhlt trong 26 benh truyin nhilm gdy dich tpi Vipt Nam [1]. Benh , , , . . dang trd thdnh v l n d l y t l nghidm trpng dp TOng tpi 56/61 tinh/thdnh pho (tinh . Dpc bipt, ^ , . ^., ,. ' . . . , . , . , , . . ,, , . u i tmh ehdt dSn bien djch phuc tpp va ty IP tu
vpng cao [1, 9].
lir nSm 2003 trd lai ddy, bdnh cd ehilu hu-dng quay trg Ipi, d i n nam 2007 cd s l mac
vatu-veng tdng vpt, cao nhlt trong giai dopn BSnh SXHD cd bidu hidn ldm sdng da 1999 - 2007 (vdi 104.465 trudng hgp mac, dpng, dien biln nhanh chdng tir nhe den
TCNCYH Phu tnmng 79 (2) - 2012 npng. Bpnh thudng khdi phdt ddt ngSt vd diln biln qua ba gial dppn: gial dopn sit, gial dopn nguy hilm vp gipl dopn h l l phgc. Phdt hiSn sdm bpnh vd hilu ro nhO-ng v l n d l Idm sdng trong tirng gipi dopn eua bdnh giiip chin dodn sdm, dilu tri diing vd kip thdi, nhlm ciru sing ngudi bdnh.
D l cd nhu-ng bdng chirng khoa hpc tir dd d l xult cdc gidi phdp nhlm giam ty Id tir vong do SXHD trong thdi gian tdi, nghiSn ciru ndy duge tiln hdnh vdi muc tidu: Mi ti die diim lim sing cic truirng hop ICr vong do Sit xuit huyil Dengue lai Viit Nam ((>
nam 2008 din nim 2010.
II. PHU'ONG P H A P N G H l f i N CU"U 1. o i l tu-gng nghidn cuii: Cac trudng hgp tu- vong do SXHD tai 63 tinh/thdnh p h i trdn toan quic tir ndm 2008 d i n nam 2010 dugc cac eg sd y t l chin dean xac dmh Id SXHD dya vac tiSu chuan chin dodn lam sang thee Hudng ddn chin dedn, dilu tri SXHD ciia Bp Y t l ban hdnh nam 2004 [2] vd cd philu dieu tra tir vong duge ghi chSp d l y dii.
2. Dia d i l m nghien cu-u: NghiSn ciru dygc thye hipn tpi Ban D i l u hdnh DA TU" vd TTYTDP 63 tinh trdn phpm vi todn quic.
3. Thd'i gipn nghien cu-u: Tir thdng 12/2010 d i n thdng 11/2011
4. Phu-gng phdp nghien ciru 4.1. Thiit ki nghien ciru: Sir dyng thilt k l nghiSn ciru dich t l hpc md ta ngang, hoi ciru so lipu trong 3 nam tir ndm 2008 - 2010.
4.2. CO mau vi ehpn miu
Chpn tpdn bp cae trudng hgp tir vong do SXHD cup 63 tinh trdn todn q u i c tir nam 2008 den nam 2010 dd dugc eg sd y t l ehin dedn xdc iflnh Id mde SXHD theo tidu chuin Chan doan Idm sang cup Bd Y t l nam 2004
[2]. Tong s l cd 295 trudng hgp tii- vong dp SXHD.
NghiSn ciru t i l n hdnh dilu tra 288 trudng hgp tir vong SXHD (97,63%), lopi trir 7 trydng hgp tir vong do SXHD (2,37%) dp philu d i l u tra tir vong khdng ghi chep d l y dii cdc thdng tin cua bSnh nhdn, bi m i t hope thit Ipc. Ting s l eg m l u cup nghidn cij-u Id 288 trudng hgp.
5. B i l n s l , chi s l nghien cu-u Nhdm biln s l , ehi s l v l ddc dilm Idm sdng, cdn Idm sdng cdc trudng hgp tu- vong dp S i t xult huylt Dengue' dugc ddnh gia thep Hudng ddn c h i n dean vd d i l u tri SXHD eua Be Y t l nam 2004 [2].
Nhdm biln s l , ehi so v l phdn t ) l t u vong do SXHD thpp dpc d i l m Idm sdng, edn Idm sdng. Ty Id tii- vpng dp SXHD thep cac bilu hipn ldm sang S i t , xult huylt, gpn to, dPU d l u , dau minh, dau eg - xugng - khdp, dau byng, s i c va t i l n s i c (%); Ty IS ti> vong do SXHD thep phan dp lam sdng (%); Ty IS tir vong do SXHD thep k i t qua xet nghipm tilu c l u gidm (/mm'); Ty Id t u veng do SXHD thep k i t qua xdt nghiSm Hematpcrit tang (%).
Nhdm biln s l , chi s l v l eg sg y t l kham va dilu trj bpnh nhdn: Ty Id phdn b l ti> vnng dp SXHD thep tuyin d l u bSnh nhdn din khdm (%).
Nhdm biln so, chi so v l thdi gian tir liic khdi bSnh - nhdp vipn - ti> vpng: Ty Id phdn b l tir vong do SXHD theo thgi gian tir lue khdi bpnh d i n lue nhdp vipn (%); Ty IS phdn b l tii- vong do SXHD thee thdi gian tu- liic nhdp vien d i n luc t u vong (%); Ty Id phdn b l tir vong do SXHD theo thdi gian tir luc khdi bSnh d i n liic tir vong (%).
6. Ky thudt vd cong cy thu thdp sd lipu 6.1. Ky thuit thu thip so lipu
282
TCNCYH Phu truung 79 (2) • 2012
• Qua trinh dilu tra vd diln thdng tin philu 3i^u tra tir vong dya vdo;
+ H i sg, bpnh dn lu-u tai eg sd y t l dilu tri cuoi ciing cho bSnh nhdn.
+ Cdc tardng hgp tir vong tpi nhd: k i t hgp ailu tra ngydi nhd bSnh nhdn vd ho so, bpnh an cOa bSnh nhdn luu tpi eg sd dilu tri cull cCing.
- Tiln hdnh dilu tra h i i ciru cdc trudng hyp tir veng da duge chin dodn xdc djnh Id SXHD tpi 63 tinh thee m l u quy dinh in s i n .
- Di^p vdp tidu chuin lyp chpn cOp d l i tiypng nghiSn eiru tiln hdnh sdng Ipc t i t cd nh&ng dli tugng phD hgp vdi tiSu chuin.
6.2. Cdng cy thu thip s l liiu
• Todn bp ho sg, bSnh dn cua cdc trudng hgp tir vong do SXHD tpi 63 tinh trdn tpdn quic tir nam 2008 d i n ndm 2010 dugc luu trO- tpi cdc eg sg y t l dilu trj cull ciing tir ndm 2008 d i n ndm 2010.
- Todn bS philu dilu tra tir vong do SXHD todn quic tir nam 2008 - 2010 duge luu tru- tpi Ban Oilu hdnh dy an Trung uong vd Trung tdm Y t l dy phdng 63 tinh.
- S l sdch luu trO- lien quan d i n tii- veng do SXHD todn quic cua Ban Dilu hdnh DA TU"
tir ndm 2008 d i n ndm 2010.
7. Phu-gng phap phan tich, xis ly va trinh bdy s l lipu
- Ldm spch s l IISu tru-dc khi nhdp lidu.
Nhdp s l lidu blng phln mem EpiData 3.1.
- Phdn tich vd xi> i^ s l lieu bang phln m i m StPtp 10 (thing kd md ta vd phdn tich thing kd suy ludn), sir dgng test thing kS %2, Fisher exact d l kilm dinh sy khac bipt gID-a cdc ti lp, gid tri P < 0,05 Id mu-c y nghTa thing kS xdc djnh sy khde bipt.
8. Dpo du-c trong nghien cu-u: Tudn thii ede quy trinh v l dao dii-c trong nghien eiru Yhpe.
I.
K£T QUA1. Phan b l tip vong do Sot xuat huyet Dengue theo cac bieu hipu lam sang
3
%
Gan t o£>aLi <lSiU
St^'t
O 2 0
Z6,3
4 0 38,7
1
GO 55.4
1 1 1 72.3
S O
i
SS,2
, o o
B i l u d l 1. B i l u hi#n lam sang e i a cdc tru-o-ng hgp tu- vong do SXHD Hlu hit cdc tm-dng hgp tu- vong do SXHD
c6 bilu hipn Idm sdng diln hinh ciia bpnh SXHD, vdi ede bilu hipn thudng gdp Id: Sit, xuat huylt, dau d l u , gan to, dau minh, dau eg -xugng - khdp vd dau bgng. Trong dd, bilu hi^n hay gdp nhlt Id sdt (100,0%); tilp theo Id w^t huylt (88,2%) (bao gdm cd d l u hipu ddy
thit dygng tinh); 72,3% tnrdng hgp cd dau dlu; 59,4% tm-dng hgp cd gan tc. Cdc bilu hiSn Idm sdng it gap hgn nhu: dau minh (38,7%); dau eg - xuong - khdp (29,2%) vd dau byng (26,3%.).
Phan Idn cdc tm-dng hgp tir veng cd bilg hipn s i t a i n hinh eOa bpnh SXHD: 90,3%
TCNCYH Phu tnmng 79 (2) - 2012
tnj-dng hgp ed s i t kSd ddi tir 2 - 7 ngay vd Treng ede bilu NSn Idm sdng xult huylt trdn 62,5% trudng hgp ed s i t eao tren 39°C. cdc tardng hgp tu- vong dp SXHD, bilu hipn hay Trpng 88,2% cdc trygng hgp t u vong de 9^P '*^^ '* '^^ '^'«" '^'^ ^ t.51,4,%): chim xult SXHD cd bilu hidn Idm sdng xult huylt: Cd '"'^ (''9-3%); nSn ra mau (32,6%); di ngodi phdn 35,8% trudng hgp cd xult huylt ngodi da vd * " <2''-3%)- Tilp d i n Id ede bilu hidn Idm sang:
nidm mpc; 14,2% trudng hgp cd xult huylt ^^" ""^ ^ ' " i ' ^ ' CS-S"''''): "^^"9 ""^t ^uylt n i l tpng vd 34,0% trudng hgp xult huylt ed C5-6%); ehdy mdu mOi (12,9%); ehdy mdu chdn da, nidm mpc vd n i l tpng. Cd 4,2% trudng '^"9 C^-''"''")' ^^ '''^" '^^ " " ^ '""^ '*" » " ^ hgp khdng cd xult huylt t y nhlSn nhung d l u ^ ^ " ^ ° - ™"3 ^'" '•'°^ '<'"*i * « " ^°^ * « "
hidu ddy thit dugng tinh "'>') >* ^"^ 3SP (2,8% vd 2,2%).
1 C h * y m * y ohAn r^ng
S M.Ar,„XH
Bi4u dd 2. Bi§u hien lam sang xult huydt cua cac tivang hap tu* vong do SXHD
Oa xung huy A m^nh Da r^nh itn Oau vting gan
v a t v 3 46,2
I
'S Chir^ngbung ^ ^ ^ • ^ • i ^ ^ ^ ^ ^ ^ ^ H H H ^ ^ ^ 47.5
60,7 H u y f t i p tut, k«t
M^ch nhanh nh6
Bilu d l 3. Cdc bilu hipn Idm sdng s i c vd tiln s i c cua cac tru-d-ng hgp tip vong do SXHD Cdc bilu hiln Idm sdng s i c vd t i l n s i c hpy gap d cac trudng hgp tu- vong do SXHD Id.
mpch nhPhh, nho (76,3%), huylt dp tgt kpt (63,4%), bilg hlSn 11 bi (60,7%) vd chdn tay Ipnh (57,6%i). Cdc bilu hiSn ISm sdng khde cup s i c nhu: Chudng bung, vpt vd, dau viing gan thudng xult hipn g ty lp t h i p hgn (tir 36,1%> d i n 47,5%). Cap b i l u hipn it gpp Id da xung huyet manh (14,9%) va da lanh I m (24,6%). 100% cac trudng hgp tir vpng do SXHD dlu thupc phdn dp Idm sang dp 3 va dp 4 (cc bilu hipn lam sdng s i c vd t i l n soc) vol ty lp x i p xi ngang nhpu (dd 3: 47,2%, dp 4: 52,8%).
2. Phdn b l tu- vong do Sdt xult huylt Dengue theo cdc bilu hipn cpn lam sang Phln Idn cdc trygng Itgp tir vong de SXHD cd k i t qua xet nghipm Hematocrit tang a 35%
vdi ty IS 69,6%, trong dd 4^,7% trudng hgp ed k i t qud xet nghipm Hematocrit tang cao £ 42%.
284
TCNCYH Phu tnmng 79 (2) - 2012 4 5
40 ' 35 30 i 25 20 15 10 5 0
30.4
- 35"..
ITV7>
S^^i.?'
AT.
Bieu do 4. Ket qua xet nghiem ty le Hematocrit tang
Hau het cac tru-o'ng h o p tu' v o n g do S X H D co k^t qua xet nghiem so l y g n g tieu cau giam higu < 5 0 . 0 0 0 / m m ^ (67,7%). Chi co 11,9% tru'O'ng h o p co ket qua xet nghiem so lu'gng ti^u
^ u g i a m it > 100 0 0 0 / m m -
3. Phan bo tu' vong do Sot xuat huyet Dengue theo tuyen co- so- y t§ va tho'i gian di6u tn Bang 1. Phan bo ti> v o n g do S X H D theo tuy§n d i u benh nhan d§n kham va tuy§n benh
nhan tiJ vong
Tuyen C S Y T
Y te Y te tuyen Y te tuyen t u y e n T U tinh huyen
Y te xa, tu-
nhan va Tong cong no'i khac
Tuyen c5^u BN den kham Tuyin BN tir vong
n, 7 9
%
2.4 3,1
n;
123 222
%
42,7 77,1
ns 99 28
%
34,4 9,7
n4
59 29
%
20,5 10,1
n 288 288
%
100,0 100,0 Khi xuat hien t n e u chu-ng k h a i b e n h , hau h^t cac tru-ong h g p tiK v o n g do S X H D d§n kham i u tien tai Y te t u y § n t m h ( 4 2 , 7 % ) va Y te tuyen h u y e n (34,4%) Y t^ t u y ^ n tinh cung la tuy§n t6 chinh phuc vu didu tn cu6i cung cho cac tru'ong h g p tu' vong (77.1 %}.
7 0 6 0
»d 40 - 30 1 2 d IO 0
-'
—:24,3
w 1
mt.
<
11°' •
Ti.;K-in i<B - NV I Tp.i.-in NV - TV TBt.nil KB - TV
< 2 ng^iv til' 3 -G iii'.av ^ ^ njMV
Bieu d 6 5. P h a n bd tu- v o n g do S X H D theo tho-i gian k h a i benh - nhap vien - tiK vong
TCNCYH Phu tnmng 79 (2) - 2012 Vi thirl gian tir luc khdi binh din luc nhip viin (Tgian KB - NV): Da s l cdc trudng hgp tir veng do SXHD dugc dua d i n bpnh vipn chdm, sau ngdy thir 3 tir khi khdi bdnh (75,7%), chi cd 24,3%> bdnh nhdn dugc (Jua tdi bdnh vidn trong vdng 2 ngdy k l tir khi khdi bdnh. S l ngdy tir ICe khdi bdnh d i n liie nhdp vidn trung binh ld:X i SD = 3,5 ± 1,9 (Min 0 ngdy IVIax 12 ngdy)
- V l thirl gian tir luc nhip vipn din iOc lir yong (Tgian NV-TV): Cd 52,1%> bdnh nhdn tir veng treng vdng 2 ngdy (48 gid) sau khi nhdp vidn; 35,1%> trudng hgp tir vong sau khi a l n bdnh vidn tir 3 - 6 ngdy vd ehi c6 12,8%
trudng hgp tii- veng sau 7 ngdy S l ngdy nhdp vidn - tir vong trung binh Id: X i SD = 3,6 ± 3,2 (Min 0 ngdy, Mpx 32 ngdy).
- Ve thai gian lu luc khiri bpnh den luc lir vong (Tgian KB - TV):
+ H l u h i t CPC trudng hgp tir veng tir ngdy thir 3 - ngdy thir 6 k l tir liic khdi bpnh (62,3%).
IV. BAN LUAN
Phdn b l tu> vgng S i t xult huylt Dengue theo cac b i l u hipn lam sang
Nghien cO-u 288 trudng hgp tir vdng do SXHD (Bilu d l 1), k i t qua eho thiy phln Idn bpnh nhdn cd bilu hidn Idm sang diln hinh cua bdnh, vdi cdc bilu hidn: S i t , xult huylt, dau d l u , gan tc, dau minh, dau eg - xugng - khdp vd dau bung. So sdnh vdi ede nghidn eiru khde, nghien ciru eiia chiing tdi ed k i t qua tugng t u ve ty Id bpnh nhdn cd bilu hipn sit; Tdc gia Adrian Ong a, Xinh-ga-pe (2007) che rang h l u hit bpnh nhdn cd tripu chirng diln hinh Id sit, nhipt do trung binh Id 38,7°C vd thdi gian sot trung binh la 4,8 ngdy; tdc gia Yee-Sin Leo, Xinh-gp-po (2011) nhpn xet cd 96,4%i trudng hgp tu- vong do SXHD cd s i t vd ede nghien ciru ndy da chi ra ty Id mdt
286
s l bilu hidn Idm sang nhu sot vd gan to, tuy nhidn ty Id bdnh nhdn cd dau d l u gpp 6- ty Id t h i p hgn (tir 6,7 14,3%), ty Id dau khdp t h i p (khoang 7,1%); song ty lp bdnh nhan cd bilu hidn dau byng, ndn Id cae bilu hidn thudng gpp vdi ty lp eao hgn (tir 30 - 57,1%) [7, 10]. Tuy nhidn nghiSn ciru ciia tac gia Vd Thi Hudng, Hoang Anh Vudng v l cdc trudng hgp tir vong do SXHD tpi Dak Lak (2000) cho thdy ede bilu hidn Idm sdng ciia bpnh nhdn khi nhdp vidn chi cd 57,14% bdnh nhdn cd s i t cao, trong khi ed 42,86%i bdnh nhdn cd bilu hidn hp thdn nhipt [3). Cd t h i eae tnrdng hgp tu vong tai Ddk Lak tdi vidn mupn hgn ndn diln biln Idm sang eua bpnh nhdn dd chuyin sang giai dcpn nguy h i l m cd hp nhidt dd spu giai dopn s i t tir 3 - 7 ngdy [2, 9].
Bilu hipn lam sdng xult huylt Id dau hipu dpc trung nhlt ciia bpnh SXHD. Trong cdc bilu hipn lam sdng xuat huylt trdn ede tm-dng hgp tu- vong do SXHD (Bilu d l 2), chiing tdi t h i y cd 4 bleu hidn hay gdp nhlt Id:
d l u hipu ddy thdt (51,4%); c h i m xult huylt (49,3%i); ndn rp mdu (32,6%); di ngddi phdn den (24,3%). K i t qua nay phii hgp vdi hlu h i t ede nghien ciru khac trong nude vd ngodi nude. Tdc gia Vd Vdn Lu-gng (2003) khi nghien eiru v l y l u t l tien lugng trong SXHD eho ring bilu hipn xult huylt tidu hda (non ra mdu vd di ngodi phdn den) Id mgt trong nhi>ng nguyen nhdn ciia suy giam t u i n hodn vd Id d l u hipu bao tru-gc ciJa SXHD do 3 (tiln sic). Tpi nghidn eiru eiia chiing tdi cd 48,2%> cae tm-dng hgp cd xult huylt ndi tpng (XH tidu hda, XH nao, XH tilt nipu...), ddy chinh Id nhti-ng bilu hidn tinh trpng npng ciia bpnh va la nguydn nhdn gdy tir veng eho bpnh nhdn.
Dpc d i l m cup S i t x u l t huylt Dengue Id s i t , x u l t huylt vd thoat huylt tugng, cd t h i d i n d i n s i c giam t h i tich t u i n hoan, r l i lopn dong mdu, suy tpng, n l u khlng
TCNCYH Phu tnmng 79 (2) - 2012 mgc chin dean sdm vd xii tri kjp thdi d l
• dan din tu- vong. D i l u ndy duge khang ajnh ro rang trong nghien ciru eiia chiing tdi (Bilu d l 3.3). 100% cdc trudng hgp tir vong do SXHD d l u thupc phdn dd Idm sdng 36 3 vd 4 (cd bieu hidn Idm sdng s i c vd tiln soc). Tdc gia Sumarmo va cpng su (1983) khi nghidn ciru Idm sdng eua cdc trudng h((p tu- vong do SXHD ed c h i n dodn xde djnh vi rut hpc tpi Jakarta, In-dd-ne-xi-a cho rang cd hon 80% trudng hgp tir vong CO bilu hipn xult huylt tieu hda tuy nhien chi CO 63% cd hgi chirng s i c c l d i l n . Nhu vdy bdnh canh Idm sdng eiia bpnh nhdn tir vong do SXHD cd the cd b i l u hipn s i c vd tiln sic diln hinh ( s i c giam t h i tich) song cung cd t h i cd b i l u hipn x u l t huylt tieu tioa npng md khdng cd soc.
Phan b l tip vong do S i t x u l t h u y l t Dengue theo cac b i l u hien can lam sang
Kit qua nghien ciru eiia ehiing tdi v l xet nghidm cpn Idm sdng CUP cac trudng hgp t u vong de SXHD (bilu d l 4) tugng tg- k i t qua nghidn ciru eua tdc gia Yee-Sin Leo (2011) khi nghien ciru 28 tru-dng hgp tu- vong do SXHD g ngudi trudng thdnh tpi Xinh-ga-pe tir nam 2004 - 2008, eho rang: cd 89,3%i tm-dng hgp ed xet nghidm Hematocrit tang tidn 20% vd 92,9% tm-dng hgp cd tilu elu giam du-di 100.000/mm^ t h i hipn mire dg ed dac mau eao. Ngodi ra tdc gia che rang cae dlu hidu canh bdo sdm eiia tir vong SXHD la non keo ddi trdn 2 ngdy, xet nghiem cd bilu hidn cd dpc mau vdi Hematocrit tang trdn 20% vd tilu elu giam dudi 20.000/mm' nhilu kha ndng d i n d i n tii- vong treng vdng 3 ngdy [10].
I Tuy nhidn, nghidn eiru cua ehiing tdi cung foi nhCrng hpn c h l nhlt dinh treng vipc chua tiSn hdnh thu thdp dugc cae thdng tin v l nhilm Dengue sg nhilm hay tdi nhiem va ket
qua phdn ldp vi rut Dengue theo tirng chung DEN-1, DEN-2, DEN-3 hay DEN-4
Phan b l tu- vgng do S i t xudt h u y l t Dengue theo t u y i n vd thd-i gian dieu trj
V l thdi gian tir luc khdi bpnh den liic nhpp vidn, nghidn ciru ciia chiing tdi (Bleu d l 3.6) oho thay da s l cdc trudng hgp tir vong do SXHD duge du-a d i n bpnh vien cham, sau ngdy thir 3 tir khi khdi bpnh (chilm 75,7%), ehi cd 24,3% trudng hgp tdi vien kham sdm trong vdng 2 ngdy. Cac tdc gia Nguyin Thj Kim Tiln (2000) (2001), Phan Trgng Lan va odng su (2009) vd tdc gia V5 Thj Hudng, Hoang Anh Vudng (2000) eung dua ra nhO-ng nhan xet tugng tu- k i t qua nghien oiru cua chiing tdi ve thdi gian tir liic khdi benh d i n luc nhpp vien ciia cac trudng hop tii- vong do SXHD (ty le bpnh nhan tdi vipn chdm sau 3 ngdy tir 58,8% - 87,2%) [3, 4, 5, 6]. Cac tac gia eho rang nhdp vien mudn lam tdng nguy eo tO- veng ciia bdnh SXHD do tinh trang benh didn biln qua npng, vi neu cdng tdc chdn doan va dilu tn eiia eae co sd y t l du cd t i t nhung nlu bdnh nhan tdi khdm mudn vdi tinh trang benh ndng thi tien lugng k i t qua dilu tri bpnh nhan x l u va ed nguy eg tir vong eae.
Thdi gian tir luc khdi bdnh d i n liic nhpp vidn tmng binh ciia eae trudng hgp tir veng tpi nghien ciru ciia chiing tdi Id 3,5 ngdy. So vdi cdc nghien ciru tpi nude ngodi thi kit qua nghien oiru ciia chiing tdi tugng tu vdi nghidn ciru eua ede tdc gia Jose G. Rigau- Perez va Miriam K. Laufer tpi Puerto - Rieo (2006) va tde gia Yee-Sin Leo tpi Xinh-ga-po (2011) (trung binh tir 3 - 4 ngdy), trong khi nghidn ciru cua tac gia Adrian Ong a tai Xinh- ga-po (2007) cd k i t qua bdnh nhdn nhdp vipn mudn hon tmng binh Id 4,8 ngdy [7, 8, 10].
Chiing tdi cho rang vdi dpc didm Idm sdng cua benh SXHD d giai doan d l u cua benh
TCNCYH Phu tnmng 79 (2) - 2012 (tir 1 - 2 ngdy) cdc bilu hipn Idm sdng chua diln hinh, b|nh nhdn thudng ehi cd sit, dau minh, dau d l u vd chua ed bilu hipn xult huylt, dd vdy ngudi ddn d l ehu quan, ehua nghT tdi khd ndng m l c bdnh Id SXHD, d i n d i n tlnh trpng b|nh nhdn d i n vidn khdm thi dd mudn.
K i t qud nghidn eiru tpi Bilu d l 5 cdn eho thiy hgn nirp s l bdnh nhdn tir vong trong vdng 2 ngdy (48 gid) sau khi nhdp vidn (52,1%) vd phln Idn t u vong tir ngdy thir 3 - ngdy thir 6 k l tir liie khdi bdnh (62,3%).
Trong khi 100% bdnh nhdn tir veng ed bilu hidn Idm sdng s i c vd t i l n s i c (phdn d | lam sdng dd 3 vd dd 4), vdy d i i n biln s i c trdn ede bpnh nhdn tu- vong do SXHD phii hgp vdi tdi lidu hudng d i n ciia T l chirc Y t l T h i gidi che ring giai depn nguy hilm diln biln tir ngdy thir 3 - 7 eiia bdnh: S i c do thodt huylt tugng; xult huylt npng, suy cae tang cd xay ra hipn tugng thoat huylt tugng npng cd t h i gdy ra soc, ed nguy eg tii- vong [9]. Do dd vide trang bi day dii kiln thirc cho ngudi ddn d l hilu bilt rd v l didn bien bdnh SXHD, kha nang tidn lugng tinh trpng bdnh nhdn eiia cdn bg y t l r l t quan trgng d l cd bipn phdp theo ddi, xii- tri s i c SXHD kip thdi.
Nghien ciru eua cdc tdc gia Nguyin Thj Kim Tiln (2000) (2001) vd Phan Trgng Ldn (2009) cd k i t qua ty lp bpnh nhdn tir vong trong vdng 48 gid d l u sau nhpp vidn tir 65%
- 73,5% eao hgn se vdi k i t qua nghidn eiru nay Cdc tde gia cho rang cdc trudng hgp tir vong sdm trong vdng 2 ngay d l u nhdp vipn Id de tinh trpng bdnh liie nhpp vidn qua npng de tdi khdm vd nhpp vipn mupn, khdng t h i d i l u trj khdi. Chiing tdi cho rang cd t h i nhdn thue cua ngudi ddn ngay nay v l s u nguy hilm cua bdnh SXHD da dugc ndng eao hgn so vgi thdi gian tru-dc. Tuy nhidn k i t qua nay cung ggi y c i n tang cudng truyin thdng gido dijc nhdn ddn y thirc phdt
hi|n sdm bpnh vd nhanh chdng chuyin bdnh nhdn tdi cdc eg so y t l d l d i l u trj kjp thdi.
Tir k i t qua v l ty Id cao 47,9% bdnh nhdn tir vong sau 3 ngay tir khi nhdp vidn theo Bilu d l 5, ehiing tdi eho ring cd t h i dnh hudng bdi c h i t lugng ciia cdc eg sd y t l dilu tri bdnh nhdn hode d i l n biln Idm sdng b i t thudng eua bdnh nhdn trong qud trinh dilu trj bdnh. Do vdy c i n t i l n hdnh cdc nghidn ciru ehuydn sdu d l ddnh gid cdc y l u t l tidn lugng hode y l u t l nguy cg gdy tu- vong do SXHD vd thgc t l nhu c l u v l d l u tu trang thilt bj c h i n dodn, d i l u trj thilt y l u cDng nhu ndng cao trinh dg ehuydn mdn cho cdn b | y t l d i l u tn tn/c t i l p cho bdnh nhdn r l t c i n chO trgng n h l m hpn c h l d i n mire t h i p nhlt CPC spi sdt dang t i l e cd t h i xay ra.
K i t qua nghien eiru eiia ehiing tdi v l 288 trudng hgp tii- vong do SXHD (bang 1) cho thiy khi xult hipn tripu chirng khdi bpnh, h l u h i t eae trudng hgp tii- vong do SXHD d i n khdm d l u tidn tpi Y t l tuyin tinh (42,7%) va Y t l tuyin huypn (34,4%). Y t l tuyin tinh cung Id tuyin chii y l u trong d i l u trj culi ciing cho bpnh nhdn, ty lp la 77,1%. Cdc nghidn eiru cua cac tde gia v l tir vong do SXHD tpi miln Npm ndm 1999, 2000 vd todn quic ndm 2001, 2004, 2007 cung chi ra, m l hinh tuyin eg sd y t l kham bpnh dau tidn cho bdnh nhdn tii- vong do SXHD tap trung chu y l u d tuyin tinh vd tuyin huypn (ty Id bpnh nhdn tdi khdm bpnh dau tidn tpi tuyin tinh chilm 22,7 - 41,3% vd tuyin huypn chilm ty lp tir 27,4 - 42,1%). Ty Id tuyin d i l u trj culi ciing eho ede trudng hgp tir vong tdp trung cao g eg sd y t l tuyin tinh ttr 58,1 - 72,7%
[4, 5, 6]. Tir k i t qua tren, chiing tdi cho ring tm-dc h i t c i n ed nghien eiru cy t h i v l thi,rc trpng ndng lgc ehuydn mdn trong c h i n dodn vd d i l u tri bdnh nhan tpi cdc tuyin tinh, huydn d l tir dd xac ffinh nhu c l u d l u tu- 288
TCNCYH Phu truung 79 (2) - 2012 trang bj eg sd vdt ehlt, trang thilt bj chin
doan vd dieu tri thilt y l u eijng nhu tang cifdng b l sung s l lugng vd chit lugng nhdn i\fc cho eg sg y t l tuyin tinh vd tuyin huypn.
Bong thdi khuyin cao theo ddi diln bien benh chat chd d l kjp thdi chuyin bpnh nhdn nang len tuyin tren ed day dii ehuydn mdn vd thilt bj dyng cg y t l d l d p ciru, xir tri kip thdi hpn c h l t h i p nhlt nguy eg tii- vong.
Ngoai ra cd 20,5% bdnh nhdn d i n khdm lln dlu tidn vd 10,1% bdnh nhdn tir veng tpi Cff sd y t l tuyin xd, t u nhdn vd noi khac.
Dilu ndy cho thiy tuyin y t l eg sd cung ddng vai trd rlt quan trpng trong khdm chD-a tJdnh ban d l u eho ngudi ddn tpi dja phugng va doi ngQ edn bg y t l tai tuyin ndy cdn du-gc tang cudng ky nang chuyen mdn d l chin doan dung, sdm tidnh SXHD, nam chac diln biln cac giai doan eiia benh vd cdc ddu hipu canh bde bpnh npng ed t h i cd s i c de kip thdi chuyin bpnh nhdn len tuyin trdn dilu trj hpn c h l ty Id tu- vong.
V. K i T LUAN
- Phln Idn cae tm-dng hgp tu- vong do SXHD 00 bilu hipn lam sdng dien hinh eiia lidnh va a mire dp nang vdi cdc bilu hidn' sot, xult huylt, dau d l u , dau minh, dau eg - xu-gng - khdp, ed dpc mau vd giam tilu elu, gay sic vd tiln sic: 100%) trudng hgp tir vong cd sit, vdi dac dilm s i t cao trdn 39°C (62,6%) va sot kdo ddi tir 2 - 7 ngdy (90,3%);
88,2% trudng hgp ed xuat huylt, vdi cdc bilu hidn thudng gpp Id d l u hipu ddy that (51,4%); Cham xult huylt (49,3%)); ndn ra mau (32,6%) va di ngodi phdn den (24,3%);.
100% cdc trudng hgp tii- vong d l u thupc phdn d | Idm sang dp 3 vd dp 4 (ed soc vd tiln soc); 40,7%) tm-dng hgp ed Hematocrit t5ng cao a 42% vd 67,7% trudng hgp ed s l Itrgng tilu cau giam rat t h i p < 50.000/mm^
- Y t l tuydn tinh vd Y t l tuyin huydn Id hai tuyin chii y l u trong kham benh va dilu tn cho bdnh nhdn (77,1%).
- H l u hit cdc trudng hgp tir veng dugc dua d i n bpnh vidn mupn sau ngdy thir 3 tir khi khdi bpnh (75,7%) d i n din ty lp eao ede trudng hgp tir vong nhanh treng vdng 2 ngay sau khi nhdp vipn (52,1%). Phln Idn cdc trudng hgp tu vong tir ngdy thij 3 - ngdy thir 6 k l tir lOc khdi bpnh. Id giai depn thudng xay ra sie (62,3%).
TAI Ll6U THAM K H A O 1. Bg Y t l (2005). Odnh gia thuc hien giai doan 2001 - 2005, du kiln k l hopch hopt dong 2006 - 2010 Du dn phdng chlng Dengue/Sot xult huylt Dengue quic gia, Cijc Y t l du phdng va phdng chlng HIV/
AIDS, Hd Npi.
2. Bo Y t l (2006). Gidm sat, chdn doan vd dilu tri bdnh Sdt Dengue va Sit xult huyet Dengue, Nhd xult ban Y hoe. Ha Ngi.
3. Vo Thj Hu-dng, Hoang Anh Vu-dng (2000). Mot s l nhpn xet v l 56 tm-dng hgp tii- vong do Sit xult huylt Dengue d Dak Lak trong cdc nam tir nam 1983 - 1999, Tpp chi Y hpc thgc hdnh, 386, Bp Y t l : 125 - 1 2 7 .
4. Phan Trpng Ldn, Nguyin Huy Nga, T r l n Thj Lu-u Nguyen Hu-o-ng (2009).
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5. Nguyin Thj Kim Tiln, Nguyin Trong Toan (2000). Phdn tieh mgt s l dac dilm djch te ve cdc tm-dng hgp tir vong do bdnh Sdt xult huylt Dengue tai khu vuc phia Nam trong nam 1999. Tap ehi Y hpe du phdng, 10 (3): 45.
6. Nguyin Thj Kim T i l n , Nguyin Trgng Toan (2001). Phdn tich mdt s l dpc dilm djch
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t l v l cac trudng hgp tir vong do bdnh S i t vi/ww.ncbi.nlm.nih.gov/PMID:16586382, xult huylt Dengue tpi khu vgc phia Nam 21/9/2011.
trongnam2000. Tpp chl Yhpe d u phdng, 11 g ^ j , ^ u , health Organization (2009).
(2) 48- Dengue: Guidelines for dianogsis, treatment, 7. Adrian Ong a and cglleagues (2007). prevention and control, Worid Health Fatal dengue hemorrhagic fever in adults Organization (WHO) and the Special during a dengue epidemic in Singapore, Programme fer Research and Training in http://www.nebi.nlm.nih.gov/PMID: 16899384, Tropical Diseases (TDR), New edition 2009.
21/9/2011. ,,(, Yee.sin Leo, Tun L. Thein and col- 8. J o s I G.Rjgau - Pdrez and Miriam leagues (2011). Confirmed adult dengue K.Laufer (2006). Dengue - Related Deaths in deaths in Singapore: 5-year multi-center Puerto Rico, 1992 1996: Diagnosis and retrospective study. Lee et al. BMC Infectious C l i n i c a l A l a r m S i g n a l s , h t t p : / / Diseases. 01 - 0 7 .
Summary
CLINICAL CHARACTERISTICS OF DEATHS CAUSED BY DENGUE HEMORRHAGIC FEVER, VIETNAM, 2008-2010
A retrospective study on 288 deaths caused by Dengue Haemorrhagic Fever (DHF) in Vietnam during 2008 - 2010 showed that most of them had typical clinical manifestations of severe degrees with fever, haemorrhage, headache, body pains, muscle/bone/joint pains, hemoconcentration and thrombocytopenia, causing shock and shock-like syndrome. 100%
deaths had fever, ef which 62.5%. with high fever (> 39°C); 90.3%- with prolonged fever (2 to 7 days); 88.2% with haemon'hage. Common manifestations included tourniquet signs (51.4%);
petechiae and ecchymoses (49.3%); blood in vomit (32.6%) and darts stool (24.3%). .100%
deaths belonged to 3" and 4'" clinicpl degrees (with shock and shock-like syndrome);
40.7% had hematocrit Increased (a 42%) and 67.7%) had paletelets significantly lowered {<
50,000/mm'). Key medical services were of provincial and district levels (77.1%). Most of deaths were taken to hospital late, after the 3'" day of onset (75.7%), making fatality high during 2 days after admission (52.1%). A high proportion of deaths occured during the 3"'to 6* days of onset, which was commonly the period of shock (62.3%).
Key words: Dengue Haemorrhagic Fever (DHF), death, clinical, Vietnam
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