THl/C TRANG VA KHA NANG TIEP CAN CUA NGlTdl DAN DOlVofl MANG LlTOfl DIEM KINH HIEN VI PHONG CHONG
S 6 T RET TINH BINH THUAN NAM 2005
Nguyen Van Nam Trung tam PCSR Binh Thuan
Tom tdt
Mgt diiu tra ngang 102 diim kinh hien vi phdt hiin binh nhdn sot ret tgi Binh Thudn tic thdng 3 din thdng 9 ndm 2005 cho kit qud:
Din nam 2005, Binh Thudn co 87% sd xd cd diim KHV, vd 100% xd vimg SRLH dugc xdy dung diim KHV. 70% cdc diim KHV dugc trang bi kinh Lien xo cH, logi 1 mdt, v&i 45% so kinh tot.
Cdc phuong tiin, dung cu cdn thiit cho xet nghiim, ,?d ghi chip, theo doi dgt yiu cdu (98%). Trung binh 1 diem KHV co 1,7 XNV, trong do ty li XNV sa cdp Id 89% vd hdu hit XNV dugc ddo tgo tgi tuyen tinh. Co 24%
XNV Id bdc .sy. Ky ndng thuc hdnh cua XNV dgt trlnh do khd gioi la 94% .
Tren 90% Ky thudt vien KHV khong cd sai .sot trong soi lam phdt hiin KSTSR hdng ndm. Trung binh moi XNV xet nghiim 80 lam/thdng.
So BNSR dugc xet nghiim mdu tim KSTSR trin 2 ldn trong qud trlnh dieu tri Id 72% vd 64% BNSR theo doi tdi phdt sau 28 ngdy.
Tren 58% so diem KHV cd tham gia cdc hogt dgng khdc ngodi xet nghiim KSTSR
Trd l&i kit qud XN trong vong 02 gia cita cdc diim kinh hiin vi Id 96%. So benh nhdn dugc diiu tri sam tru&c 02 ngdy tic khi co sot dua tren kit qud xet nghiim KSTSR Id 69%. Trung binh co 86% binh nhdn hdng ndm din khdm binh vd xet nghiim tgi diim KHV.
Cd 99.4% nguai ddn biit khi cd sot din khdm vd xet nghiim vi binh sot ret tgi cdc diim kinh hiin vi.
1. DAT VAN DE
Benh sot ret (SR) vdn con la mot vdn de siic khoe trdm trong va nguy hiem tren the giai va Viet Nam. Hai bien phdp ca ban trong phong chong sot ret (PCSR) la chdn dodn sam, dilu tri som benh nhan s6t ret (BNSR) va tich cue phong ch6ng vee to truySn benh. D6 chdn dodn som, dieu tri sam va diing, BNSR phdi dugc phdt hien va dihw tri tai y t l ca so.
Co-nhilu phuang phdp phdt hien ky sinh triing SR(KSTSR), trong do ky thudt phdt hien KSTSR qua tieu ban mdu nhuom giem sa, soi kinh hien vi (KHV) dugc ddnh gid la tieu chuan vang (gold standard) trong chdn doan benh SR.
Thuat ngii diem phdt hien SR (malaria detection post-MDP) da xudt hien tir giai doan ddu eiia chuang trtnh TDSR a Mexico, Guatemala. 6 My, MDP duge goi la diim thong tin vl cae ca sot ret (information post for fever cases- IPFC). Tai H6 Bdc Trung qu6c, cdc trung tam xet nghien (XN) co nhiem vu chii yeu la soi phdt hien lam mgt edch thu dgng. Tai Viet Nam, sau ndm 1991, Bg Y tl, Chuang trinh qu6c gia PCSR ehii truang xdy dung diim KHV xa, lien xa de thuc hien chdn dodn va dilu tri som BNSR.
Binh Thudn la tinh thugc viing s6t ret luu hanh (SRLH) nang ciia cd nuac, la tinh ddu tien xdy dung va phat triln mang luod diim KHV mgt each toan dien va rgng khdp, gdn liln vai CO so dilu tri, thue hien chan dodn va dilu tri som SR gop phdn giam s6t ret dc tinh (SRAT), tir vong, nghien ciiu KSTSR khdng thu6c.
40 TAP CHI PHONG CHONG BENH SOT RET VA CAC BENH KY SINH TRUNG 5 0 4-2010
Cho den nay chua co mgt nghien ciiu nao ddnh gid ddy dii vl thuc trang, khd ndng tilp can va hieu qud cua mang luai diim KHV trong PCSR cua tinh Binh Thuan. D I gitip chuang trtnh PCSR co them ca sa thuc tien trong viec xay dimg va phdt triln he thdng diim KHV, chiing tor thirc hien nghien cim nay.
Muc tieu cua nghien cim la:
1. Md td thuc trgng cita mgng lu&i diim KHV tuyin xd trong chuang trinh PCSR tinh Binh Thudn ndm 2005.
2. Ddnh gid khd ndng tiip can cua nguai ddn ddi v&i mgng lu&i diim KHV PCSR tinh Binh Thudn ndm 2005.
3. Di xudt cdc Men phdp cung cd vd phdt triin mgng lu&i diim KHV PCSR tgi tinh trong thai gian t&i.
2. DOI TtrONG VA PHtTONG PHAP NGHIEN ClTU 2.1. Doi tuong, dia diem va thoi gian nghien cmi
Tat ed cdc diem KHV hien co tai tuyen xa. Cdc xet nghiem vien KHV tuyen xa. Dai dien cgng dong dan cu tai cdc xd co diem kfnh ciia tinh Binh Thudn. Thai gian dieu tra tir thdng 3- 9/2005
2.2. Thiet ke nghien cihi: Dieu tra ngang mo td, hoi ciiu va dieu tra xa hgi hge
2.2.1. Dieu tra ngang tat cd cdc diem kinh de mo td thuc trang diem KHV. Thi tay nghe ciia XNV dl ddnh gid trtnh do cua XNV.
2.2.2. Dieu tra kha ndng tiep can va sir dung eua nguod ddn doi vdfi mang lu<5i diem KHV tuyen xa.
• Thai gian trung binh (gia) tu nha BN den diem KHV xa nhdt
• Do dai trung binh (km) tir nha BN din diem KHV xa nhdt
• Ty le nguod den diim KHV xet nghiem khi bi 6m hoac co sot;
• So lugng va ty le trung binh nguoi din XN mdu trong thdng/ nam 2.3. Ca mau va phuong phap chon mau:
2.3.1. Chgn mdu cho ddnh gid thuc trang hogt dpng cua cdc diem kinh
« Dieu tra ngang tdt cd cdc diim kinh hien co trong tinh (102 diem kinh).
• Chgn 1/3 s6 diim kfnh theo phuang phdp chgn mau ngau nhien he th6ng dl dilu tra ngang ddnh gid thuc trang va chdt lugng diim kfnh, thi tay nghe XNV.
2.3.2. Mdu dieu tra khd ndng tiep can cda ngudi ddn'ddi vdi mgng ludi diem KHV.
Tai 1/3 s6 diim kfnh da dugc chgn dilu tra ngang ddnh gid thuc trang diim kfnh va thir tay nghe XNV: 15 hg gia dinh/ 1 diim kfnh.
2.3.3. Chpn mdu hdi cieu sd lieu ddnh gid vai trd vd suphdt trien cua Mim KHV: Tdt ca cdc diim Mnh tir nam 2000- 2004 bdng mdu philu/ bang dien so Ueu.
2.4. Phan tich, xir Ii so lieu va phien giai ket qua nghien cihi
• Cdc s6 lieu thu thap dugc nhdp va xit ly bdng chuang trinh STATA 8.0. Sir dung test thdng ke y sinh bgc dl phdn tfch s6 lieu dinh tfnh, dinh lugng.
3. KET QUA NGHIEN ClTU VA BAN LUAN
3.1.Thuc trang mang luoi diim KHV tuyen xa trong PCSR fr Binh Thuan
Din ndm 2005 Binh Thuan co 87% (102/117) s6 xa co diim KHV. 100% xa vimg SRLH diu CO diim KHV. Co 5 xa co 02 diim KHV/ xa. Diim KHV dugc phdt triln diu qua cdc nam nhung nhilu nhat vao cdc nam 1993-1994 (chilm 38.2% s6 lugng KHV va tai thai diim do 53.9% s6 xd co KHV. Vl ehiing Igai: 30% kfnh Olympus, 70% kfnh Lien xo. Kfnh 1 mdt chilm 60%, kfnh 2 mdt 40%. Chdt lugng: 45% kfnh con t6t, 47% dat yeu cdu, 8% hu hong nang. Trung binh co 4-6 CBYT va co 1.7 XNV tren mgt diim kfnh. S6 lugng XNV la bdc sy tuong d6i cao (chilm 23 % s6 XNV va 45 diim KHV co XNV la bdc sy). Nhu vdy s6 lugng va do bao phii diim KHV cua Binh Thudn tuong d6i cao va cao horn binh qudn chung cua.khu vuc MT-TN va cd nuac(ndm 2004, trung binh m6i tinh co 51 diim KHV. Khu vuc MT-TN mSi tinh co 61 diim KHV)
91-98% s6 diim KHV co trang bi ddy du vl thulc men, hod chdt, s6 sdch... phuc vu tit cho cong tdc xet nghiem. Tuy nhien vl dien tfch phong XN, ban ghi, tu dimg va bao qudn kfnh chi dat yeu cdu 45-66%.
3.2. Chat luOTig va ky nang XN phat hien KSTSR
Bdng 1: Ty le lam sai sot qua ddnh gid cua Vien SR- KST-CT Quy nhon nam 2001-2004
Ndm 2001 2002 2003 2004
% So diem kfnh khong sai sot 78
79 90 89
% So diem kfnh co sai sot 22
21 10 11
% lam sai 0.76 0.69 0.50 0.54
Sai sot trong giii lam KTKT ciia Binh thudn tuang doi thdp so cdc tinh.
Bdng 2: Ket qud kiem tra tay nghe XNV
Mon kiem tra Soi lam
Ky thudt Nhugm lam Ly thuyet x l p Igai chung
Gioi 21%
15%
38%
85%
9%
Khd 44%
62%
53%
15%
85%
Trung binh 29%
23%
9%
0 6%
Ylu
6%
0 0 0 0
42 TAP CHI PHONG CHONG BENH SOT RET VA CAC BENH KY SINH TRUNG 50 4-2010
Trtnh do XN qua kilm tra mgt cdch ngau nhien 34 XNV do Vien SR-KST-CT Quy Nhon thuc hien cho thdy co den 94% s6 XNV dat khd gioi, 6% dat trung binh. Theo Le Khanh Thudn, ndm 1995 kiem tra 202 diim KHV khu vuc miin Trung-Tay nguyen, sai sot chung tuyin tinh la 48%, tuyin huyen la 44,3%, tuyin xd la 37,3% va sai sot chu ylu tir (+) sang (-) chiem ban 40% nen da bo sot rdt nhilu benh nhan. Theo H6 Van Hoang nam 1998, kiem tra 98 XNV dugc chgn ngdu nhien trong 5 tinh ciia miin Trung-Tay Nguyen, vod 490 lam, chan doan sai 169 lam, chiem ty le 34,5%.
3.3.Chin doan va dieu tri benh nhan SR tai cac diim KHV
Bdng 3: BNSR,SRAT, KSTSR tai cdc diim KHV tir 2000-2004
Ndm
2000 2001 2002 2003 2004
BNSR 12217
6979 3275 2422 1484
SRAT
11 1 1 1 3
Lam
104161 92917 94565 98808 80980
KSTSR(+) 6750 6276 3059 2223 1386
% KST/BNSR 55.25
89.9 93,4 91,9 93,4
Tir 2000-2004, ty le mdc SR va SRAT tinh Binh Thuan gidm manh so vai eac tinh trong khu virc miin Trung-Tay Nguyen. BNSR ndm 2004 giam ban ndm 2000 la 87,9% va SRAT giam 72,7%. Ty le ehdn doan duong tfnh 93,4% (ed nuac, ty le chdn dodn duang tfnh tren BNSR ehi khoang 19.4%, MT-TN la 35.5%).
Co din 66-70% s6 BNSR dugc phdt hien tai xa. Co 72% s6 benh nhan dugc ldy lam mdu > 2 ldn trong qua trinh dieu tri va 64% so benh nhan dugc dilu tri va theo doi tdi phdt sau 28 ngay. Co 96% s6 diim kfnh ddm bao trd lai kit qud XN trong vong 02 gio. Co 69% so benh nhdn dugc dieu tri som trong vong 02 ngay tir khi co s6t, trung binh hang thang m6i diim KHV soi 80 lam
3.4. Klia nang tiep can cua BN den diim KHV
10%
34% 56%
Hinh 1: Khd nang tilp can ciia nguoi dan den diem KHV
Cdc xd vimg ding bdng co kha ndng tiep can de dang ban. Tuy nhien miic do bao phu dat 100% tai cdc xa co SRLH ndng, 55% s6 xa co SRLH vira va chi 20% tai cae xa vimg ding bdng. Nlu tfnh chung cd 2 ylu t l thi co din 79% s6 diim KHV (80/102) co dilu kien dl nguod ddn tilp can tot. 58% diim KHV co lam them cdc XN khde ngoai SR.
Qua kit qud khdo sat, co 76% nguod dan co benh din khdm va dilu tri tai cdc diem kfnh.
Trung binh m6i diim KHV dilu tri la 3.849 lugt benh nhan, dilu tri cho BNSR la 235 lugt nguai/ ndm. Kit qua nay cung tuang tu cua H6 Van Hoang nam 1998, ty le nguai dan den khdm tai diim KHV la 87.2%, tai cdc xa khong co diim KHV la 58.5%
3.5. Hiiu biit va thai do cua cong dong doi voi PCSR va diem KHV tuyen xa
Khdo sdt 483 hg gia dinh tai 32 xa, m6i xa 15 nguai gim 05 CB xa va 10 nguod dan.
Kit qud: Biit nguyen nhan mdc SR 95.7; Biit trieu chiing ciia benh SR 88%. Tin tuang benh SR CO thi phong ching dugc 97.3%; Biit each phong ngira benh SR 98,6%; Khi mdc SR din tram y tl 99,4%; Biit cdch phong ching muoi dit 97%. Co din 99.4% nguofi ddn cho biit CBYT thuang xuyen tuyen truyin vl PCSR; 97% tin tuang vao boat dgng chan doan, dilu tri tai diem kinh.
Tom lai, diim KHV PCSR cua Binh Thudn dugc bdt dau xdy dung tir nhiing ndm 1992- 1994. Tmh hinh benh SR vao thai diim do rdt ndng nl vai ban 20.000 BNSR, 500 ca SRAT va 100 ea tir vong hang ndm. Trong thai gian qua, ngoai viec giiip chdn doan va dieu tri sam, dung, cdc diem KHV da tham gia nhieu de tai nghien eim khdng thuoc, iing dung thuoc mod vai sir hgp tde, giiip da cua Vien SR-KST-CT Trung uong, Vien SR-KST-CT Quy nhon, Benh Vien Chg Ray, Dai hge Amsterdam/ Ha Lan, Vien SANYA/ Trung Quic. Diim khdc biet ve diem KHV cua Binh Thuan khdc vod cdc quoc gia khdc la no gdn lien voi co sa dieu tri nen cae can bg y te co thi h6 trg ldn nhau, de dang thuc hien cdc XN khdc phii hgp vai ddc diem cu the cua timg diem kfnh. Tuy nhien, do tinh hinh benh SR da giam thap, vdn de nay cang tra nen cap bach de khong lang phf nguon lire hien co da day cong xay dung trong nhieu nam nay.
4. KET LUAN
Din ndm 2005, Binh Thudn eo 87% sl xa eo diim KHV, va 100% xd vimg SRLH dugc xay dung diem KHV. 70% cdc diem KHV dugc trang bi kfnh Lien xo cii, loai 1 mdt, vod 45%
so kinh tot. Cdc phuang tien dung cu can thiet cho xet nghiem, so ghi chep, theo doi... phdn lan dat yeu cdu (98%). Trung binh 1 diim KHV co 1,7 XNV, trong do ty le XNV so cdp la 89% va hdu hit XNV dugc dao tao tai tuyin tinh. Co 24% XNV la bdc sy. Ky ndng thuc hanh va chat lugng va soi lam ciia XNV dat 94% trinh do khd gioi. Co den 90% so diim KHV khong CO sai sot trong soi lam phdt hien KSTSR hang nam. Trung binh moi XNV xet nghiem 80 lam/ thdng. 72% sl BNSR dugc xet nghiem mdu tim KSTSR > 2 ldn trong qud trinh dilu tri va CO 64% BNSR theo doi tdi phdt sau 28 ngay. Co 58% s6 diim KHV tham gia cdc boat dgng khdc ngoai xet nghiem KSTSR
. Co din 79% sl diim KHV (80/102) co dilu kien dl nguai dan tilp can tit. Co 96% sl diim KHV dam bdo trd lai kit qua XN trong vong 02 gia, 69% sl benh nhan dugc dilu tri som truac 02 ngay tir khi co sit. Trung binh co 86% benh nhdn hang nam din khdm benh va xet nghiem tai diim KHV. Co 99.4% nguai dan dugc CBYT tuyen truyin v l PCSR. Hiiu biet va thuc hanh cua nguod dan ve PCSR tuang dii cao 88 - 98,6%.
Kien nghi: Nen tilp tuc duy tri, ciing cl va phdt triln mang luai diim KHV PCSR
tuyin xa eho phu hgp voi tinh hinh benh SR a tung dia phuang va phdt huy dugc hieu sudt
boat dgng eiia tung diem KHV.
44 TAP cm PHONG CHONG BENH SOT RET VA CAC BENH KY SINH TRUNG 5 0 4-2010
TAI LIEU THAM K H A O
ang (2001), Nghien cim ndngcao hieu qud hogt dgng diim kinh hiin vi trong phong chong ' luu hdnh tgi khu vuc miin Trung vd Tdy Nguyen, Tom tat luan an tiin si y hoc, chuyen 1. Ho van Hoan,
sot ret a viing sot ret
nganh ky sinh trung, Truang Dai hoc Y Ha Noi
2. Le Xuan Hung (2002), S6t ret & cdc nu&c Dong Duang: Viet nam mot diin hinh PCSR thdnh cong.
Tap chl PCSR va cac benh KST s6 5/2002, tr 3-10.
3. Nguyen Van Nam (2005), Khdng chi b?nh sdt ret tgi 20 xd cd sdmdc cao tinh Binh thudn 2001-2002, Hoi thao khoa hoc ve s6t ret trong diem khu vuc MiSn Trung- Tay Nguyen 6/2005- Nha xuk ban y hoc, tr 30-35.
4. Le Ngoc Trong (2003), Ddnh gid hieu qud sic dung dich vit y ti, diiu tra y ti quoc gia 2001-2002, Bo YT6.
5. Le Khanh Thuan (2005), Thuc trgng vd tinh hinh hogt dgng ciia diim KHV phuc vu PCSR tgi khu vuc Miin Trung- Tdy Nguyen, http/www.impe-qn.org.vn ngay 07/7/2005
6. Trieu Nguyen Trung (2005), Thuc trgng cdc vilng trgng diem sot ret Miin Trung- Tdy Nguyen vd cdc gidi phdp uu tien. Hoi thao khoa hoc \h s6t ret trong diim khu vuc Miin Trung- Tay Nguyen 6/2005- Nha xuat ban y hoc, tr 7-14.
7. Hung Le Quoc (2002), Control malaria: a successful experience from Viet Nam, Bulletin of the WHO/
print I S S N ' 0 0 4 2 - 9 6 8 6 Bull WHO vol.80, no.8 Genebra Aug 2002.
8. Nam Nguyen Van (2005), Malaria control in Viet nam: the Binh Thuan experience, Tropical Medicine and Intemational health. Vol 10 No 4: 357-365.
EVALUATE MICROSCOPY NETWORK IN MALARIA CONTROL IN BINH THUAN PROVINCE, 2005
Nguyen Van Nam
Binh Thuan Provincial Center for Malaria Control Abstract
A cross-sectional survey of 102 microscopic points (MP) was conducted in Binh Thuan province from March to September 2005. By 2005 the coverage of MP had been established in 87% of the communes, 100% in the malaria endemic communes where 70% of the MP were equiped with microscopes made in the Former Soviet Union, 45% of which were in good conditions. Consumables for microscopy were OK (98%); microscopists 1.7/point of which 89% were primarily trained at provincial level; 24% microscopists were medical doctors.
Most of the microscopists (94%) presented excellent and good microscpy skills with very low rate of mistakes. In average, each microscopist examined 80 slides/month.
Malaria patients (72%) were examined for parasite twice during their treatment course, of which 64% were followed up 28 days. In addition to malaria examination, more than 58%
of the microscopic points took part in examination of other diseases. Feedback result within 02 hours could be done in 96% of the MP, two-day earlier treatment based on the microscopy was 69%; passive detection was 86% (patients come to see the MP for examination and re- examination of malaria). The interview revealed that 99.4% of the local people know that they need to see the MP when they have fever.
Can bo phan bien PGS. TS. Le Xuan Hung Vien S6t KST-CT TU"