臺灣博碩士論文加值系統

背景：境外移入為國內登革熱防疫之重要一環，促進疑似登革熱境外移入個案及早就醫，可降低本土登革熱流行及減少住院風險。
目的：探討影響疑似登革熱境外移入個案確診及延遲就醫之因素、並進一步針對確診個案探討發病延遲就醫對住院之影響。
方法：本研究採回溯性世代研究，在疾病管制署資訊中心使用疾病管制署之傳染病通報系統、傳染病問卷調查系統、症狀通報系統、自主健康管理及居家隔離資訊系統等資料進行分析，以2014-2017年疑似登革熱境外移入個案為研究對象，以依變項為登革熱確診、延遲就醫、住院，使用逐步邏輯斯迴歸於控制人口學特質、疾病特質、及旅遊風險後，分別探討確診及延遲就醫之相關因素，並分析延遲就醫對登革熱確診個案住院風險之影響。
結果：2014-2017年台灣國際港埠篩檢疑似登革熱個案之確診率為4.67%，其中外國籍個案為本國籍的兩倍（6.74% vs. 3.29%）；影響本國籍疑似個案較易確診之因素有男性、15歲以上、夏季、秋季、冬季、商務/公務、探親；影響外國籍疑似個案較易確診之因素有秋季、來自疫區國家。國際港埠通報疑似登革熱個案發生入境延遲就醫率為58.54%，其中外籍疑似個案較本國籍高（71.54% vs. 45.34%）；本國籍疑似個案發生入境延遲就醫之高風險因素有女性、15歲以上個案、居住地為台北區、入境當天發病、非確診個案；外國籍疑似個案發生入境延遲就醫之高風險因素有居住地為台北區、非確診個案、入境類別為旅行。醫院通報疑似登革熱個案發生發病延遲就醫率為23.32%，其中本國籍疑似個案較外國籍高（24.84% vs. 18.76%）；本國籍疑似個案發生發病延遲就醫之高風險因素有15-59歲、入境前發病個案；外國籍疑似個案發生發病延遲就醫之高風險因素有居住地為非高屏區個案、入境前發病。國際港埠通報確診登革熱個案總體住院率為10.31%，其住院高風險因素有發病延遲就醫、居住地為北區、中區、南區、高屏區；醫院通報確診登革熱個案總體住院率為39.64%，其中外國籍確診個案較本國籍高（41.18% vs. 39.64%）；不論本國籍或外國籍確診個案，醫師通報病患有腹部疼痛及壓痛等警示徵象皆為住院之高風險因素，非發病延遲就醫亦為本國籍確診個案之住院高風險因素。
結論與建議：台灣國際港埠篩檢疑似登革熱個案中，本國籍之女性、14歲以下、入境類別為旅行，與外國籍入境非來自疫區國家者較不易確診，建議政府宜針對確診率低之次人口群制訂標準作業流程，以提升國際港埠第一線檢疫執勤人員判定疑似個案之辨識能力。疑似登革熱個案中，發生延遲就醫之高風險群包含本國籍之女性、15歲以上、居住在台北區、入境當天發病、非確診個案，及外國籍旅客居住在台北區、非確診個案、入境類別為旅行者，建議未來應針對次人口群強化及時就醫衛教，並於流行期間擇機場捷運、機場巴士、機場高鐵接駁車等重要通路播放宣導影片，使其瞭解儘速就醫之重要性。登革熱確診個案中，有警示徵象者或發病後延遲就醫者有較高住院風險，應強化民眾對發病後及時就醫之警覺性，以避免症狀惡化，進而降低其住院風險。

BACKGROUND: It is an important role that preventing imported Cases spreading dengue virus transmission within the community. Early medical seeking by suspected passengers could reduce the risk of disease transmission and improve prognosis of patients as well as reduce the risk of hospitalization.
PURPOSE: The aim of this study is to explore the factors associated with deasess confirmation, delayed medical seeking in suspected passengers and to further understand the impact of delayed medical treatment on hospitalization risk in dengue cases.
METHOUDS: This study uses a retrospective cohort study, and study subjects consisted of suspected imported dengue cases collected from January 1, 2014 to December 31, 2017 from various surveillance systems (including Notifiable Disease Surveillance, Infectious Disease Questionnaire Management System, and Self-health Management Information System) from Taiwan CDC. Stepwise multiple logistic regression was used to cintrol demographics, disease traits, and travel risk and to analyze factors related to the deases confirmation, medical seeking behavior of imported passengers and the impact of delayed medical seeking behavior on hospitalization risk of overseas dengue infection patients.
RESULTS: The dengue confirmation rate at Taiwan International Ports in 2014-2017 is
4.67%. Foreigner’s confirmation rate is with twice as much Taiwanease’s（6.74% vs. 3.29%）. The Influence factors associate with the diagnosis of suspected dengue passengers of Taiwanease at Taiwan International Ports is include male, cases over 15 years old, summer, autumn, winter, business/official and Tourist. And the Influence factors associate with the diagnosis of suspected dengue cases of forienger is include autumn, entryed from the deasess epidemics countries. The delayed medical seeking rate of suspected dengue passengers who were reported by Taiwan International Ports is 58.54%, and foreigner’s delayed medical seeking rate is more than Taiwanease’s（71.54% vs. 45.34%）. The Influence factors associate with delayed medical seeking behavior of suspected dengue passengers of Taiwanease who were reported by Taiwan International Ports is include felmale, cases over 15 years old, lived in Taipei Region, had deases syndrome at the imported date and non-dengue case. The Influence factors associate with delayed medical seeking behavior of suspected dengue passengers of foreigner who were reported by Taiwan International Ports is include lived in Taipei Region, non-dengue case and Tourist. The delayed medical seeking rate of suspected dengue passengers who were reported by hospital-based reporting system is 23.32%, and Taiwanease’s delayed medical seeking rate is more than foreigner’s（24.84% vs. 18.76%）. The Influence factors associate with delayed medical seeking behavior of suspected dengue passengers of Taiwanease who were reported by hospital-based reporting system is include 15-59 years old cases, the case had deases syndrome before the imported date case. The Influence factors associate with delayed medical seeking behavior of suspected dengue passengers of foreinger who were reported by hospital-based reporting system is include non-Kaohsiung-Pingtung Region cases, the case had deases syndrome before the imported date. The hospitalization rate of dengue infectious people who were reported by International ports is 10.31%. The Influence factors associate with hospitalization of the dengue infectious people who were reported by International ports is include delayed medical seeking cases , Taiwanease, and residents living in the North, Central, Southern, and Kaohsiung-Pingtung Region. The hospitalization rate of dengue infectious people who were reported by hospital-based reporting system is 39.64%, and foreigner’s hospitalization rate is more than Taiwanease’s（41.18% vs. 39.64%）. The Dengue cases who were reported by hospital-based reporting system had delayed medical seeking could has lower risk of hospitalization, but had warning signs could has higher risk of hospitalization.
CONCLUSIONS:
By the result of the study, it is suggested that the policy makers should Customized standard operating procedures for diagnosis suspected dengue passengers, espeasally for female, under 14 years old, tourist taiwanease, and the case come from non-deasess epidemics countries case. Tt is suggested that strengthen suspected passengers seeking medical care immediately, espeasally for taiwanease who were female, cases over 15 years old, lived in Taipei regin, non-dengue case, had deases symdrom at the imported date, and for foreigners who were lived in Taipei Region, non-dengue case, tourist. Tt is also recommended that playing the vedio at the MRT and other important traffic channels during the deases ecdemic period to strengthen the case who had deases syndrome before the imported date should seek medical treatment abroad as soon as possible. Otherwise, it is importance to let public know that having warning signs or delayed medical seeking could has higher risk of hospitalization, and if passengers has any unconfortable symptom should seek medical care immediately to avoid being more sever and to further reduce the risk of hospitalization.

致謝 i
中文摘要 ii
英文摘要 iv
目錄 vii
表目錄 ix
圖目錄 xi
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究目的 3
第三節 研究問題 4
第四節 研究之重要性 5
第五節 重要名詞定義 6
第二章 文獻探討 8
第一節 登革熱及其防疫 8
第二節 登革熱確診影響因素 16
第三節 登革熱延遲就醫影響因素 21
第四節 登革熱住院影響因素 24
第三章 研究方法與設計 30
第一節 研究架構 30
第二節 研究假說 32
第三節 研究設計與研究對象 33
第四節 資料來源 34
第五節 研究變項操作型定義 36
第六節 資料處理流程 40
第七節 統計分析 42
第四章 研究結果 43
第一節 登革熱確診影響因素 43
第二節 登革熱延遲就醫影響因素 47
第三節 登革熱發病延遲就醫對住院之影響 57
第五章 討論 64
第一節 登革熱確診影響因素 64
第二節 延遲就醫影響因素 67
第三節 登革熱發病延遲就醫對住院之影響 71
第四節 研究限制 75
第六章 結論與建議 76
第一節 結論 76
第二節 建議 78
參考文獻 80

表目錄
表2-2-1：登革熱確診率相關研究文獻 16
表2-2-2：影響登革熱確診之相關因素 20
表2-3-1：發病至第一次就醫情形之相關研究 21
表2-3-2：影響延遲就醫之相關因素 23
表2-4-1：不同國家之登革熱個案住院率 24
表2-4-2：延遲就醫對住院及建議住院之影響 28
表2-4-3：影響住院及建議住院之因素 28
表2-4-3：影響住院及建議住院之因素 29
表4-3-1：資料來源 35
表3-5-1：本研究依變項之操作型定義 36
表3-5-2：本研究自變項/控制變項之操作型定義 38
表4-1-1：影響2014-2017年國際港埠通報本國籍疑似登革熱境外移入個案確診之相關因素 45
表4-1-2：影響2014-2017年國際港埠通報外國籍疑似登革熱境外移入個案確診之相關因素 46
表4-2-1：影響2014-2017年國際港埠通報本國籍疑似登革熱境外移入個案入境延遲就醫之相關因素 51
表4-2-2：影響2014-2017年國際港埠通報外國籍疑似登革熱境外移入個案入境延遲就醫之相關因素 52
表4-2-3：影響2014-2017年醫院通報本國籍疑似登革熱境外移入個案發病延遲之基本人口學特質及相關因素 53
表4-2-4：影響2014-2017年醫院通報外國籍疑似登革熱境外移入個案發病延遲之相關因素 55
表4-2-4：影響2014-2017年醫院通報外國籍疑似登革熱境外移入個案發病延遲之相關因素 56
表4-3-1：比較2014-2017年國際港埠通報登革熱境外移入確診個案發病延遲就醫(>2天)對住院之影響 60
表4-3-2：比較2014-2017年醫院通報本國籍登革熱境外移入確診個案發病延遲就醫(>2天)對住院之影響 61
表4-3-3：比較2014-2017年醫院通報外國籍登革熱境外移入確診個案發病延遲就醫(>2天)對住院之影響 62
表4-3-4：2014-2017年醫院通報登革熱境外移入確診個案警示徵象與發病延遲就醫(>2天)對住院影響之列連表分析 63


圖目錄
圖2-1-1：登革熱傳染時程圖 8
圖2-1-2：WHO登革熱臨床分類診斷判定標準 9
圖2-3-1：登革熱檢驗方法與時機 12
圖3-1-1：目的一之研究架構 30
圖3-1-2：目的二與目的三之研究架構 31
圖3-6-1：資料處理流程 41

中文文獻
李佩玲(2015)：登革熱病例通報體系及社區環境危險因子對登革熱疫情之研究。國立高雄大學運動健康與休閒學系碩士學位論文，1-60。
林書弘、林詠青、陳必芳、吳麗珠、何麗莉、吳怡君(2017)：2012-2015國際港埠檢疫站境外移入法定傳染病攔檢敏感度分析。疫情報導，33(12)：210-218。
高雄市政府衛生局(2018)：衛生新聞，
http://khd.kcg.gov.tw/Main.aspx?sn=410&mt=14&gs=21413 (瀏覽日期：2018年6月30日)
張秋蓉(2014)：高雄地區登革熱流行特性分析。國立高雄師範大學生物科技系碩士學位論文，1-128。
張苙雲(1998)：[逛醫師]的邏輯：求醫歷程的分析。臺灣社會學刊(21)，59-87。
郭俊賢、賴淑寬、陳主慈、吳智文、顏哲傑(2014)：2008-2011年國際港埠篩檢疑似登革熱症狀個案之流行病學分析。疫情報導，30(15)：297-303。
衛生福利部疾病管制署(2017a)：2017年登革熱/屈公病防治工作指引。
衛生福利部疾病管制署(2017b)：法定傳染病-登革熱介紹。
衛生福利部統計處(2018)：臺灣地區醫院病床佔床率，https://dep.mohw.gov.tw/DOSAASW/cp-3515-36278-113.html (瀏覽日期：2018年7月10日)


英文文獻
Beauté, J., & Vong, S. (2010). Cost and disease burden of dengue in Cambodia. BMC Public Health, 10(1), 521.
Burattini, M. N., Lopez, L. F., Coutinho, F. A., Siqueira-Jr, J. B., Homsani, S., Sarti, E., & Massad, E. (2016). Age and regional differences in clinical presentation and risk of hospitalization for dengue in Brazil, 2000-2014. Clinics, 71(8), 455-463.
Chanda-Kapata, P., Kapata, N., Masiye, F., Maboshe, M., Klinkenberg, E., Cobelens, F., & Grobusch, M. P. (2016). Health Seeking Behaviour among Individuals with Presumptive Tuberculosis in Zambia. PloS one, 11(10), e0163975.
Chaterji, S., Allen Jr, J. C., Chow, A., Leo, Y.-S., & Ooi, E.-E. (2011). Evaluation of the NS1 rapid test and the WHO dengue classification schemes for use as bedside diagnosis of acute dengue fever in adults. The American journal of tropical medicine and hygiene, 84(2), 224-228.
Chowell, G., Diaz-Duenes, P., Chowell, D., Hews, S., Ceja-Espíritu, G., Hyman, J. M., & Castillo-Chavez, C. (2007). Clinical diagnostic delays and epidemiology of dengue fever during the 2002 outbreak in Colima, Mexico.
da Silva, N. S., Undurraga, E. A., da Silva Ferreira, E. R., Estofolete, C. F., & Nogueira, M. L. (2018). Clinical, laboratory, and demographic determinants of hospitalization due to dengue in 7613 patients: A retrospective study based on hierarchical models. Acta tropica, 177, 25-31.
Elsinga, J., Lizarazo, E. F., Vincenti, M. F., Schmidt, M., Velasco-Salas, Z. I., Arias, L., . . . Tami, A. (2015). Health seeking behaviour and treatment intentions of dengue and fever: a household survey of children and adults in Venezuela. PLoS neglected tropical diseases, 9(12), e0004237.
Ericsson, C. D., Hatz, C., Leder, K., Tong, S., Weld, L., Kain, K. C., . . . Brown, G. V. (2006). Illness in travelers visiting friends and relatives: a review of the GeoSentinel Surveillance Network. Clinical Infectious Diseases, 43(9), 1185-1193.
Freedman, D. O., Weld, L. H., Kozarsky, P. E., Fisk, T., Robins, R., von Sonnenburg, F., . . . Cetron, M. S. (2006). Spectrum of disease and relation to place of exposure among ill returned travelers. New England Journal of Medicine, 354(2), 119-130.
Gan, V. C., Lye, D. C., Thein, T. L., Dimatatac, F., Tan, A. S., & Leo, Y.-S. (2013). Implications of discordance in world health organization 1997 and 2009 dengue classifications in adult dengue. PloS one, 8(4), e60946.
Guha-Sapir, D., & Schimmer, B. (2005). Dengue fever: new paradigms for a changing epidemiology. Emerging themes in epidemiology, 2(1), 1.
Horstick, O., Jaenisch, T., Martinez, E., Kroeger, A., See, L. L. C., Farrar, J., & Ranzinger, S. R. (2014). Comparing the usefulness of the 1997 and 2009 WHO dengue case classification: a systematic literature review. The American journal of tropical medicine and hygiene, 91(3), 621-634.
Horvath, R., McBride, W. J., & Hanna, J. N. (1999). Clinical Features of Hospitalized Patients During Dengue-3 Epidemic in Far North Queensland, 1997-1999.
Khun, S., & Manderson, L. (2007). Health seeking and access to care for children with suspected dengue in Cambodia: an ethnographic study. BMC Public Health, 7(1), 262.
Kuan, M.-M., & Chang, F.-Y. (2012). Airport sentinel surveillance and entry quarantine for dengue infections following a fever screening program in Taiwan. BMC infectious diseases, 12(1), 182.
Lagi, F., Zammarchi, L., Strohmeyer, M., Bartalesi, F., Mantella, A., Meli, M., . . . Zanelli, G. (2014). Imported dengue fever in Tuscany, Italy, in the period 2006 to 2012. Journal of travel medicine, 21(5), 340-343.
Lee, V. J., Lye, D. C., Sun, Y., Fernandez, G., Ong, A., & Leo, Y. S. (2008). Predictive value of simple clinical and laboratory variables for dengue hemorrhagic fever in adults. Journal of Clinical Virology, 42(1), 34-39.
Low, J. G., Ong, A., Tan, L. K., Chaterji, S., Chow, A., Lim, W. Y., . . . Tan, S. W. (2011). The early clinical features of dengue in adults: challenges for early clinical diagnosis. PLoS neglected tropical diseases, 5(5), e1191.
Mallhi, T. H., Khan, A. H., Sarriff, A., Adnan, A. S., & Khan, Y. H. (2016). Patients related diagnostic delay in dengue: An important cause of morbidity and mortality. Clinical Epidemiology and Global Health, 4(4), 200-201.
Mannestål Johansson, C., McBride, W. J., Engström, K., & Mills, J. (2012). Who brings dengue into North Queensland? A descriptive, exploratory study. Australian journal of rural health, 20(3), 150-155.
Martelli, C. M. T., Nascimento, N. E., Suaya, J. A., Siqueira Jr, J. B., Souza, W. V., Turchi, M. D., . . . Shepard, D. S. (2011). Quality of life among adults with confirmed dengue in Brazil. The American journal of tropical medicine and hygiene, 85(4), 732-738.
Mohammed, H. P., Ramos, M. M., Rivera, A., Johansson, M., Muñoz‐Jordan, J. L., Sun, W., & Tomashek, K. M. (2010). Travel‐associated dengue infections in the United States, 1996 to 2005. Journal of travel medicine, 17(1), 8-14.
Nasir, N. H., Mohamad, M., Lum, L. C. S., & Ng, C. J. (2017). Effectiveness of a fluid chart in outpatient management of suspected dengue fever: A pilot study. PloS one, 12(10), e0183544.
O’Brien, D. P., Leder, K., Matchett, E., Brown, G. V., & Torresi, J. (2006). Illness in returned travelers and immigrants/refugees: the 6‐year experience of two Australian infectious diseases units. Journal of travel medicine, 13(3), 145-152.
Okanurak, K., Sommani, S., Mas-Ngammueng, R., Sitaputra, P., Krachangsang, S., & Limsomboon, J. (1997). Treatment seeking behavior of DHF patients in Thailand. Southeast Asian journal of tropical medicine and public health, 28(2), 351-358.
Organization, W. H., Research, S. P. f., Diseases, T. i. T., Diseases, W. H. O. D. o. C. o. N. T., Epidemic, W. H. O., & Alert, P. (2009). Dengue: guidelines for diagnosis, treatment, prevention and control: World Health Organization.
Organization., W. H. (2017). Dengue
Premaratna, R., Pathmeswaran, A., Amarasekara, N., Motha, M., Perera, K., & de Silva, H. (2009). A clinical guide for early detection of dengue fever and timing of investigations to detect patients likely to develop complications☆. Transactions of the Royal Society of Tropical Medicine and Hygiene, 103(2), 127-131.
Rowe, E. K., Leo, Y.-S., Wong, J. G., Thein, T.-L., Gan, V. C., Lee, L. K., & Lye, D. C. (2014). Challenges in dengue fever in the elderly: atypical presentation and risk of severe dengue and hospita-acquired infection. PLoS neglected tropical diseases, 8(4), e2777.
Schwartz, E., Weld, L. H., Wilder-Smith, A., von Sonnenburg, F., Keystone, J. S., Kain, K. C., . . . Network, G. S. (2008). Seasonality, annual trends, and characteristics of dengue among ill returned travelers, 1997–2006. Emerging infectious diseases, 14(7), 1081.
Shu, P.-Y., Chien, L.-J., Chang, S.-F., Su, C.-L., Kuo, Y.-C., Liao, T.-L., . . . Huang, J.-H. (2005). Fever screening at airports and imported dengue. Emerging infectious diseases, 11(3), 460.
Tai, A. Y., McGuinness, S. L., Robosa, R., Turner, D., Huang, G., Leder, K., . . . Padiglione, A. A. (2017). Management of dengue in Australian travellers: a retrospective multicentre analysis. The Medical Journal of Australia, 206(7), 295-300.
Tukasan, C., Furlan, N. B., Estofolete, C. F., Nogueira, M. L., & da Silva, N. S. (2017). Evaluation of the importance of fever with respect to dengue prognosis according to the 2009 WHO classification: a retrospective study. BMC infectious diseases, 17(1), 6.
Vajta, B., Holberg, M., Mills, J., & McBride, W. J. (2015). Weighing up the costs of seeking health care for dengue symptoms: a grounded theory study of backpackers’ decision-making processes. Australian journal of primary health, 21(2), 245-248.
Vicente, C. R., Lauar, J. C., Santos, B. S., Cobe, V. M., & Cerutti Junior, C. (2013). Factors related to severe dengue during an epidemic in Vitoria, State of Espirito Santo, Brazil, 2011. Revista da Sociedade Brasileira de Medicina Tropical, 46(5), 629-632.
Wilder-Smith, A. (2012). Dengue infections in travellers. Paediatrics and international child health, 32(sup1), 28-32.
Yew, Y. W., Ye, T., Ang, L. W., Ng, L. C., Yap, G., James, L., . . . Goh, K. T. (2009). Seroepidemiology of dengue virus infection among adults in Singapore. Ann Acad Med Singapore, 38(8), 667-675.