臺灣博碩士論文加值系統

研究背景與目的：臺灣地區在2002年為本土最大一次登革熱流行後，直至2006年病例數明顯上升且似有2002年流行的縮影，因此本研究主要目的為瞭解2006年此波登革熱確定病例之特質及地理分佈，且進一步估算登革熱病人門急診及住院醫療費用引起的經濟損失與疾病負荷。
研究方法：以高雄縣鳳山市2006年登革熱確定病例為研究對象，利用三個時間風險指標比較與2002年流行的差異，並進一步探討病例資料與居住地之病媒蚊指數及氣象資料的關係。此外，利用通報前後兩週的門急診與住院費用，計算鳳山市2006年登革熱疑似與確定病例通報前後兩週之醫療費用。
研究結果：(1)在2002年與2006年兩波登革熱流行差異的比較方面，結果發現三個時間指標值與其在空間中的分布都有達到顯著差異，顯示此兩波流行並未十分相似；(2)以Poisson複迴歸分析評估病例數與布氏指數、人口密度及氣象因素的關係，提出相關模式：(當週登革熱發生個案數)＝-13.436＋0.024(前一週布氏指數最大值)＋0.428(前一週溫度)＋0.015(人口密度)，為較好的預測模式；(3)2006年鳳山市登革熱流行期間共計通報病例數329位，估計單獨在醫療費用上共花費了5,977,973.68元。其中確定病例平均每人個人在醫療費用上花費16469.58元，門急診及住院費用分別為平均每人個人花費5815.85元及 16315.13元。
結論：由研究的結果顯示以前一週布氏指數最大值、平均溫度與人口密度會影響疾病個案數發生，為較好的預測模式，利用此緩衝時間，也許可以妥善採取控制行動。除了在流行期間直接成本的推估提供了主要醫療服務資源支出，對於完整評估醫療補助計畫或政策重新審視則有待未來進一歩加入行政機關控制等費用之相關研究。

Objective：Since 2002, the number of reported DF cases has been significant, with moderate yearly variations, except for an unusual increase in 2006. The objectives of this study are to determinate the important epidemiological characteristics of dengue fever in 2006, and to assess the economic burden of dengue-related illness.
Methods：Subjects included in dengue confirmed cases in Fongshan, Kaohsiung County. Comparisons of three temporal risk indices between the years 2002 and 2006 in the same Li, and to investigate the association among the vector index of dengue fever to climate factors and case number. In addition, the reported cases were divided into two groups (excluded and confirmed). By pooling data（including outpatient and inpatient care）, medical cost were estimated by two groups.
Result：(1)There were statistic significant in three temporal risk indices between the years 2002 and 2006 in the same Li. It may imply that two epidemic curves were different.；(2)The correlation of Breteau index, climate factors, population density with the occurrence of DF cases was assessed by Poisson multiple regression analysis. The better forecasting model is as follows:(the occurrence of DF cases)=-13.436+ 0.024(pre-week maximum Breteau index)+ 0.428(mean pre-week temperature)+ 0.015(population density)；and (3)The 2006 epidemic in Fongshan , which had a total of 329 reported cases, cost about 5.98 million dollars. Approximately patient costs were found to be 16469.58 dollars for a confirmed case.
Conclusion：Among the various variables which would effect the occurrence of disease, such as Breteau index, temperature, and population density, only a prior week of precipitation can explain the outbreak of dengue by model. To fully evaluate the economics of prevention programs, epidemiologic and mosquito control data related to program effectiveness should be taken into account.

表目錄 II
圖目錄 IV
摘要 V
Abstract VII
第一章 研究背景 1
第一節 前言 1
第二節 研究目的 3
第二章 文獻探討 4
第一節 登革熱傳播途徑 4
2.1.1 致病原 4
2.1.2 登革熱的病媒蚊 4
第二節 登革熱臨床表現、治療方式及預後 6
第三節 宿主因素 8
2.3.1 年齡 8
2.3.2 性別 9
2.3.3 人口密度 10
第四節 環境因素 11
2.4.1 雨量 11
2.4.2 溫度 12
第五節 監測 15
第六節 疾病風險 19
2.6.1 流行時間 19
2.6.2 地理分佈 20
2.6.3 地圖分析疾病流行的研究 23
2.6.4 時間-空間特性指標 24
第七節 健保醫療費用 28
2.7.1 就醫行為 28
2.7.2 醫療成本估計的相關理論與方法 28
2.7.3 登革熱醫療成本之實証研究 29
第三章 材料與方法 31
第一節 研究架構 31
第二節 研究對象 32
第三節 時空維度的風險指標 33
3.2.1 空間單位 33
3.2.2 時間單位 33
第四節 環境監測 36
3.3.1 氣象資料 36
3.3.2 登革熱病媒蚊幼蟲密度指數資料 37
第五節 醫療費用 38
第六節 資料分析方法 39
第四章 研究結果 41
第一節 2002及2006年登革熱流行的擴散型態 41
第二節 2006年登革熱病例與布氏指數、氣象因素分析 48
第三節 登革熱醫療費用分析 59
第五章 討論 72
第一節 2002年與2006年兩波流行差異的比較 72
第二節 布氏指數、氣象因素與病例數之相關性 76
第三節 相關醫療費用分析 81
第六章 結論與建議 85
參考文獻 86

1.Organization(WHO) WH. Dengue and dengue hemorrhagic fever.: Geneva: WHO 2000.
2.民國76至94年台灣登革熱病例發生數一覽表. In: 疾病管制局, ed.
3.Navarro-Sanchez E, Despres P, Cedillo-Barron L. Innate immune responses to dengue virus. Archives of medical research. 2005 Sep-Oct;36(5):425-35.
4.Kao CL, King CC, Chao DY, Wu HL, Chang GJ. Laboratory diagnosis of dengue virus infection: current and future perspectives in clinical diagnosis and public health. J Microbiol Immunol Infect. 2005 Feb;38(1):5-16.
5.Stephenson JR. Understanding dengue pathogenesis: implications for vaccine design. Bull World Health Organ. 2005 Apr;83(4):308-14.
6.Liew C CC. Horizontal and vertical dispersal of dengue vector mosquitoes, Aedes aegypti and Aedes albopictus, in Singapore. Medical & Veterinary Entomology. 2004;18(4):351-60.
7.謝志偉、賴淑寬、張筱玲、邱展賢. 氣象資料與登革熱病媒蚊幼蟲密度級數之相關性研究. 疫情報導. 2006;22(11):746-65.
8.Sprenger D, Wuithiranyagool T. The discovery and distribution of Aedes albopictus in Harris County, Texas. J Am Mosq Control Assoc. 1986 Jun;2(2):217-9.
9.Forattini OP. Identification of Aedes (Stegomyia) albopictus (Skuse) in Brazil. Revista de saude publica. 1986 Jun;20(3):244-5.
10.登革熱防治工作手冊2006修訂版(第五版): 行政院衛生署疾病管制局 2006.7.
11.Harn MR. [Clinical study on dengue fever during 1987-1988 epidemic at Kaohsiung City, southern Taiwan]. Gaoxiong Yi Xue Ke Xue Za Zhi. 1989 Jan;5(1):58-65.
12.Liu HW, Ho TL, Hwang CS, Liao YH. Clinical observations of virologically confirmed dengue fever in the 1987 outbreak in southern Taiwan. Gaoxiong Yi Xue Ke Xue Za Zhi. 1989 Jan;5(1):42-9.
13.陳再晉. 登革熱/登革出血熱臨床症狀、診斷與治療. 台北市: 行政院衛生署疾病管制局 2002.
14.行政院衛生署疾病管制局. 2007年登革熱防治工作指引. 2007.4.
15.吳民惠、黃高彬、蔡季君、吳宗樹、黃彥彰、金傳春. 2001∼2003年台灣登革熱卅登革出血熱的流行病學探討 台灣公共衛生雜誌. 2005;24(5):452-59.
16.黃志傑、李翠瓊、邱鴻英、吳炳輝. 2004 年台灣地區登革熱疫情防治報告. 疫情報導. 2005;21(6):385-407.
17.Kabilan L, Balasubramanian S, Keshava SM, Satyanarayana K. The 2001 dengue epidemic in Chennai. Indian journal of pediatrics. 2005 Nov;72(11):919-23.
18.DJ G. Dengue. San Juan Laboratories, Dengue Branch, Division of Vector-Borne Viral Diseases, Center for Infections Diseases. Puetro Rico. 1986:20-36.
19.黃高彬. 從高雄市登革熱疫情談登革出血熱. 台灣醫界雜誌. 2002;45(1).
20.行政院衛生署. 台灣地區登革熱流行情形報告. 疫情報導. 1989;5:41-8.
21.McBride WJ B-OH. Dengue viral infections; pathogenesis and epidemiology. Microbes and infection. 2000 Jul;2(9):1041-50.
22.Poblap T, Nitatpattana N, Chaimarin A, Barbazan P, Chauvancy G, Yoksan S, et al. Silent transmission of virus during a Dengue epidemic, Nakhon Pathom Province, Thailand 2001. Southeast Asian J Trop Med Public Health. 2006 Sep;37(5):899-903.
23.邱鴻英、趙黛瑜、羅財樟、黃智雄、陳國東、王躬仁. 民國87年高雄市三民區登革熱流行之危險因子調查. 疫情報導. 1999;15(10):329-45.
24.Likosky WH, Calisher CH, Michelson AL, Correa-Coronas R, Henderson BE, Feldman RA. An epidemiologic study of dengue type 2 in Puerto Rico 1969. Am J Epidemiol. 1973 Apr;97(4):264-75.
25.Ko YC. [Epidemiology of dengue fever in Taiwan]. Gaoxiong Yi Xue Ke Xue Za Zhi. 1989 Jan;5(1):1-11.
26.Chadee DD, Shivnauth B, Rawlins SC, Chen AA. Climate, mosquito indices and the epidemiology of dengue fever in Trinidad (2002-2004). Annals of tropical medicine and parasitology. 2007 Jan;101(1):69-77.
27.Ribeiro AF, Marques GR, Voltolini JC, Condino ML. [Association between dengue incidence and climatic factors]. Revista de saude publica. 2006 Aug;40(4):671-6.
28.Nakhapakorn K, Tripathi NK. An information value based analysis of physical and climatic factors affecting dengue fever and dengue haemorrhagic fever incidence. International journal of health geographics. 2005 Jun 8;4:13.
29.Wiwanitkit V. An observation on correlation between rainfall and the prevalence of clinical cases of dengue in Thailand. Journal of vector borne diseases. 2006 Jun;43(2):73-6.
30.Thammapalo S, Chongsuwiwatwong V, McNeil D, Geater A. The climatic factors influencing the occurrence of dengue hemorrhagic fever in Thailand. Southeast Asian J Trop Med Public Health. 2005 Jan;36(1):191-6.
31.Githeko AK LS, Confalonieri UE, Patz JA. Climate change and vector-borne diseases: a regional analysis. Bulletin of the World Health Organization. 2000;78(9):1136-47.
32.Hales S, de Wet N, Maindonald J, Woodward A. Potential effect of population and climate changes on global distribution of dengue fever: an empirical model. Lancet. 2002 Sep 14;360(9336):830-4.
33.Chowell G, Sanchez F. Climate-based descriptive models of dengue fever: the 2002 epidemic in Colima, Mexico. J Environ Health. 2006 Jun;68(10):40-4, 55.
34.Depradine C, Lovell E. Climatological variables and the incidence of Dengue fever in Barbados. International journal of environmental health research. 2004 Dec;14(6):429-41.
35.Yu SX, Li ZQ, Teng WP, Cai J. [Impact on the potential epidemic of dengue fever under warming winter in Hainan province]. Zhonghua liu xing bing xue za zhi = Zhonghua liuxingbingxue zazhi. 2005 Jan;26(1):25-8.
36.王正雄、陳秀玲. 氣候溫暖化對台灣登革熱流行之影響. 中華公共衛生雜誌. 1997;16(6):455-65.
37.Coutinho FA, Burattini MN, Lopez LF, Massad E. Threshold conditions for a non-autonomous epidemic system describing the population dynamics of dengue. Bulletin of mathematical biology. 2006 Nov;68(8):2263-82.
38.Morrison AC, Getis A, Santiago M, Rigau-Perez JG, Reiter P. Exploratory space-time analysis of reported dengue cases during an outbreak in Florida, Puerto Rico, 1991-1992. Am J Trop Med Hyg. 1998 Mar;58(3):287-98.
39.Rahman M, Rahman K, Siddque AK, Shoma S, Kamal AH, Ali KS, et al. First outbreak of dengue hemorrhagic fever, Bangladesh. Emerg Infect Dis. 2002 Jul;8(7):738-40.
40.方啟泰. 登革熱（Dengue Fever）. 當代醫學月刊. 2004;369:521-4.
41.Chareonsook O, Foy HM, Teeraratkul A, Silarug N. Changing epidemiology of dengue hemorrhagic fever in Thailand. Epidemiol Infect. 1999 Feb;122(1):161-6.
42.Strickman D, Sithiprasasna R, Kittayapong P, Innis BL. Distribution of dengue and Japanese encephalitis among children in rural and suburban Thai villages. Am J Trop Med Hyg. 2000 Jul-Aug;63(1-2):27-35.
43.Vanwambeke SO, van Benthem BH, Khantikul N, Burghoorn-Maas C, Panart K, Oskam L, et al. Multi-level analyses of spatial and temporal determinants for dengue infection. International journal of health geographics. 2006;5:5.
44.Van Benthem BH, Vanwambeke SO, Khantikul N, Burghoorn-Maas C, Panart K, Oskam L, et al. Spatial patterns of and risk factors for seropositivity for dengue infection. Am J Trop Med Hyg. 2005 Feb;72(2):201-8.
45.江博煌、莫喬治. 地理資訊系統與公共衛生 2005.
46.Effler PV PL, Kitsutani P, Vorndam V, Nakata M, Ayers T, Elm J, Tom T, Reiter P, Rigau-Perez JG, Hayes JM, Mills K, Napier M, Clark GG, Gubler DJ; Hawaii Dengue Outbreak Investigation Team. Dengue fever, Hawaii, 2001-2002. Emerging infectious diseases. 2005;11(5):742-9.
47.Su MD, Chang NT. Framework for application of geographic information system to the monitoring of dengue vectors. Gaoxiong Yi Xue Ke Xue Za Zhi. 1994 Dec;10 Suppl:S94-101.
48.Wen TH, Lin NH, Lin CH, King CC, Su MD. Spatial mapping of temporal risk characteristics to improve environmental health risk identification: a case study of a dengue epidemic in Taiwan. Sci Total Environ. 2006 Aug 31;367(2-3):631-40.
49.溫在弘. 登革熱/登革出血熱疫情流行的時間-空間擴散型態及風險模型. 高高屏聯防會議 2006.9.16.
50.魏惠志. 台北市醫療人員對傳染病通報系統意見調查初探-以登革熱病例通報為例. 疫情報導. 2001;17(3):113-26.
51.Rice DP. Measurement and application of illness costs. Public health reports. 1969 Feb;84(2):95-101.
52.Okanurak K, Sornmani S, Indaratna K. The cost of dengue hemorrhagic fever in Thailand. Southeast Asian J Trop Med Public Health. 1997 Dec;28(4):711-7.
53.Hodgson TA, Meiners MR. Cost-of-illness methodology: a guide to current practices and procedures. The Milbank Memorial Fund quarterly. 1982 Summer;60(3):429-62.
54.Von Allmen SD, Lopez-Correa RH, Woodall JP, Morens DM, Chiriboga J, Casta-Velez A. Epidemic dengue fever in Puerto Rico, 1977: a cost analysis. Am J Trop Med Hyg. 1979 Nov;28(6):1040-4.
55.Kouri GP, Guzman MG, Bravo JR, Triana C. Dengue haemorrhagic fever/dengue shock syndrome: lessons from the Cuban epidemic, 1981. Bull World Health Organ. 1989;67(4):375-80.
56.Meltzer MI, Rigau-Perez JG, Clark GG, Reiter P, Gubler DJ. Using disability-adjusted life years to assess the economic impact of dengue in Puerto Rico: 1984-1994. Am J Trop Med Hyg. 1998 Aug;59(2):265-71.
57.Gubler DJ, Reiter P, Ebi KL, Yap W, Nasci R, Patz JA. Climate variability and change in the United States: potential impacts on vector- and rodent-borne diseases. Environmental health perspectives. 2001 May;109 Suppl 2:223-33.