本文關(guān)鍵詞： 腹瀉 輪狀病毒 諾如病毒 腺病毒 星狀病毒 流動人口 監(jiān)測　出處：《南方醫(yī)科大學(xué)》2012年碩士論文　論文類型：學(xué)位論文

【摘要】：研究背景： 感染性腹瀉是人類最常見的疾病之一,是由細(xì)菌、病毒、原蟲等多種病原體所引起的、以腹瀉癥狀為主并廣泛存在并流行于世界各地的腸道傳染病,也是當(dāng)今全球性重要的公共衛(wèi)生問題,位居三大傳染病死亡原因之一,尤其在兒童中更是一種常見病和多發(fā)病,是導(dǎo)致兒童死亡的兩大病因之一。特別在發(fā)展中國家,腹瀉是導(dǎo)致兒童死亡的主要原因�！�2003年世界衛(wèi)生報告》中披露,發(fā)展中國家感染性腹瀉導(dǎo)致兒童死亡達(dá)156.6萬人,占死亡人數(shù)的15.2%,居死因第三位。在我國感染性腹瀉的發(fā)病率居所有傳染病之首。目前,病毒已成為感染性腹瀉的重要病原體。1972年發(fā)現(xiàn)諾瓦克病毒后,已相繼發(fā)現(xiàn)和確立引起腹瀉的病毒有呼腸孤病毒科(輪狀病毒)、腺病毒(腸腺病毒)、杯狀病毒科(諾如病毒和扎幌樣病毒)、星狀病毒科(星狀病毒)和冠狀病毒科的成員。 輪狀病毒(Rotavirs, RV)是嬰幼兒腹瀉的最主要病因之一,根據(jù)抗原性的不同將輪狀病毒分為7個組(A-G)。輪狀病毒感染常無癥狀,有癥狀感染的潛伏期為1-3天,病程常5-7天,主要臨床表現(xiàn)是發(fā)熱、頻繁的嘔吐、水樣腹瀉、輕度失水和酸中毒。據(jù)報道,RV腸炎好發(fā)于6-24個月的嬰幼兒。在氣候隨四季變化的地區(qū),RV感染的高峰季節(jié)隨時間和區(qū)域不同而有所變動,多發(fā)生在寒冷干燥的秋冬季節(jié),在終年炎熱的地區(qū)全年均可發(fā)生,亞熱帶地區(qū)嬰幼兒RV腹瀉多發(fā)生于秋冬季,流行高峰在10-12月,而春季3-5月份又可有一小高峰,突然的環(huán)境改變亦可能影響流行,世界各地均有散發(fā)和流行的報道。 國內(nèi)外大量研究表明,諾如病毒(Norovirus, NVs)是僅次于RV導(dǎo)致人類急性非細(xì)菌性胃腸炎(acute gastroenteritis, AGE)的重要病原體,NVs主要通過糞-口傳播,是導(dǎo)致食源或水源性急性腹瀉的主要病原,世界范圍內(nèi)引起低齡兒童急性病毒性胃腸炎的主要病原,同時也是造成包括學(xué)校、家庭、旅游區(qū)、醫(yī)院、食堂、軍隊的爆發(fā)性胃腸炎流行的重要病原,對社會生產(chǎn)力產(chǎn)生巨大破壞力,其地位僅次于RV。該病毒的特點是發(fā)病率高、致病劑量低和抵抗力強。 腺病毒(Adenovirus, AdV)在兒童腹瀉標(biāo)本中的檢出率雖不如RV高,但近兩年隨著對AdV的了解越來越深入,檢測方法不斷增加,商品化的檢測試劑盒越來越快速簡便,各國對AdV引起的兒童腹瀉越來越重視。 世界大部分地區(qū)均有星狀病毒(Astrivirus, AstV)感染的報道,已證實它是引起嬰幼兒、老年人及免疫低下者腹瀉的重要病原之一。資料顯示AstV成為嬰幼兒病毒性胃腸炎的第2或第3位病原體。AstV感染常見于秋冬季,多為散發(fā),亦可在醫(yī)院、幼兒園、老人院、學(xué)校和軍隊引起爆發(fā)流行。 然而,隨著我國城市化進(jìn)程和經(jīng)濟建設(shè)的發(fā)展,大量外來人口融入大城市,使得城鄉(xiāng)結(jié)合部、城中村等經(jīng)濟條件相對落后、人員構(gòu)成復(fù)雜、流動性大的地區(qū)腹瀉病的情況不容樂觀。由于城市流動人口存在流動性強、知識水平低、經(jīng)濟條件差等問題,整體上影響了城市流動人口的衛(wèi)生保健服務(wù)狀況。 研究目的： 1.了解廣州市某社區(qū)2010-2011年流動人口病毒性腹瀉RV、NVs、AdV和AstV感染狀況、臨床表現(xiàn)及流行病學(xué)特征； 2.了解該地區(qū)病毒性腹瀉中NVs、AdV和AstV基因型別,探討流動人口中三種病毒的流行優(yōu)勢毒株； 3.豐富南方病毒感染性腹瀉的流行病學(xué)資料,為流動人口病毒性腹瀉的防治提供一定的參考依據(jù)。 研究方法： 1.標(biāo)本來源：收集2010年5月～2011年12月期間在廣州市白云區(qū)某社區(qū)衛(wèi)生服務(wù)中心就診的383例流動人口腹瀉患者糞便標(biāo)本、人口學(xué)資料、臨床及流行病學(xué)資料。 2.標(biāo)本處理方法：每份糞便標(biāo)本2g,分別各加2mlPBS,震蕩混勻,分裝后-80℃保存?zhèn)溆谩?3.標(biāo)本病毒檢測方法：利用RT-PCR和PCR方法,用引物JV12Y/JV13I、 AD1/AD2和Mon269/Mon270分別對所有標(biāo)本進(jìn)行NVs、AdV和AstV感染的檢測,對PCR陽性產(chǎn)物進(jìn)行純化回收、測序,應(yīng)用BLAST將測序結(jié)果在GenBank上尋找各陽性株的同源序列,使用MEGA5.0生物軟件進(jìn)行序列的相似性比對,分析NVs、AdV和AstV的基因型別,判斷NVs、AdV和AstV的流行優(yōu)勢毒株。 4.統(tǒng)計分析方法：運用統(tǒng)計軟件SPSS13.0對收集的患者資料進(jìn)行統(tǒng)計分析,采用描述性分析,計數(shù)資料單因素分析采用卡方檢驗,多因素分析運用logistic逐步回歸,檢驗水準(zhǔn)α為0.05。 結(jié)果： 1.人口學(xué)資料：2010年5月～2011年12月共收集廣州市某社區(qū)腹瀉患者糞便標(biāo)本和問卷共383分。檢測情況：5歲以下兒童占90.9%(348/383),來自廣東省(除廣州市外)其他地區(qū)、湖南和江西等周邊地區(qū)。流動兒童其監(jiān)護(hù)人文化水平較低,以中學(xué)水平為主,占89.7%(323/383),多數(shù)監(jiān)護(hù)人為無業(yè)。 2.病毒性腹瀉流行病學(xué)特征：病毒性腹瀉在監(jiān)測期內(nèi)均可發(fā)生,于秋冬季節(jié)病例較多,感染高峰出現(xiàn)在10、11月,但8月出現(xiàn)小高峰；4種病毒的陽性病例為214例,檢出率為55.9%(214/383),混合感染率為10.4%(40/383)；主要感染5歲以下兒童,占94.4%(202/214)；其中,男性患者139例,女性75例,男女患者比例為1.85：1。 3. RV、 NVs、AdV和AstV的檢測結(jié)果和流行病學(xué)特征：RV、NVs、AdV和AstV的檢出率分別為43.1%(165/383)、10.7%(41/383)、7.0%(27/383)和6.0%(23/383),四種病毒陽性檢出者年齡均主要集中在5歲以下,年齡組間和性別間各種病毒的檢出情況差異無統(tǒng)計學(xué)義,RV感染高峰發(fā)生在秋冬季,NVs和AdV的高峰均顯示在溫度較高的夏季,而AstV在2010年5月-2010年12月期間,8月檢出率最高,2011年全部AstV感染均發(fā)生在秋冬季(10月-12月)。 4.無病毒檢出組(A組)和病毒檢出組(B組)相關(guān)分析：單因素分析顯示,A和B兩組在患者職業(yè)(Fisher檢驗,P=0.032)和文化程度(Fisher檢驗,P=0.034)方面差異有統(tǒng)計學(xué)意義,表明感染性腹瀉主要感染學(xué)齡前兒童；兩組的糞便量()(χ2=5.496,P=0.019)、糞便性狀(Fisher檢驗,P=0.007)、腹瀉方式(χ2=9.296,P=0.026)、食欲(χ2=11.968,P=0.001)及乏力(χ2=6.647,P=0.010)情況等臨床表現(xiàn)方面差異有統(tǒng)計學(xué)意義；而其他人口學(xué)資料、臨床表現(xiàn)和流行病學(xué)接觸史等方面差異無統(tǒng)計學(xué)意義。 5. NVs、AdV和AstV的序列分析結(jié)果：383份糞便標(biāo)本中,共檢出NVs41例,系統(tǒng)進(jìn)化樹和相似性分析顯示：以GII-4型為主(38例),其中35株為GII.4-2006b亞型、2株為GII.4-2006a亞型、1株為經(jīng)典GII-4型,另外分別為GII-6、GⅡ-14和GI-2型；檢出27株AdV,系統(tǒng)進(jìn)化和相似性分析顯示：16株為AdV41型,其中2株為AdV41型GTC1型,14株為AdV41型GTC2型,AdVl、2和12各檢出兩株,AdV3和AdV7各檢出1株,AdV31檢出3株；而檢出23株AstV均為AstV-1. 結(jié)論： 1.監(jiān)測情況顯示：腹瀉患者或患者家屬(14歲以下患兒家屬)文化層次較低,以中學(xué)文化水平為主,符合流動人口整體文化程度較低的趨勢。 2.病毒性腹瀉的檢出率為55.9%(214/383),該病全年均有散發(fā),發(fā)病高峰在秋冬季,但是夏季有小高峰出現(xiàn)；兩種及兩種以上病毒混合感染較常見,檢出率為10.4%,患者主要是2歲以下嬰幼兒�；旌细腥臼欠駮又夭∏�,是應(yīng)該受到關(guān)注的問題。 3.病毒為流動兒童腹瀉的重要病因,其中輪狀病毒是最主要的病原體,其次依次為NVs、 AdV和AstV。 RV以秋冬季高發(fā)；NVs夏季為感染高峰,NVs GⅡ.4基因型為廣州流動人口NVs感染的流行優(yōu)勢毒株,與我國國內(nèi)情況相同。其中變異株GII.4-2006b38株、GII.4-2006a2株,而GII.4-2006b曾引起2007年后世界范圍內(nèi)多個國家腹瀉疫情大量增加,我國較多地區(qū)均已檢測到2006b,但未見2006a相關(guān)報道,本次研究檢出兩株NVs2006a引起的腹瀉,顯示2006a亞型在我國境內(nèi)也有發(fā)病,應(yīng)增加相關(guān)研究。此次研究中夏季較多AdV感染,表明AdV41型仍為我國腺病毒感染腹瀉的主要流行毒株,同時存在其他多個AdV型別的散在感染,但并未見AdV40型感染。2010年AstV感染主要發(fā)生在夏季,而2011年則全部發(fā)生在秋冬季節(jié),AstV陽性均為AstV-1型,顯示AstV-1為廣州流動人口AstV感染的流行優(yōu)勢型別。 4.無病毒檢出組(A組)和病毒檢出組(B組)在患者職業(yè)和文化程度方面差異有統(tǒng)計學(xué)意義,說明主要為學(xué)齡前兒童,顯示腹瀉病原體主要感染年齡較小兒童；兩組的糞便量、糞便性狀、腹瀉方式、食欲及乏力情況等臨床表現(xiàn)方面差異有統(tǒng)計學(xué)意義,表現(xiàn)為病毒檢出組患者糞便量較無檢出組偏多,主要為水樣便或蛋花樣便,并對患者食欲影響較大,伴有乏力,因此對病毒感染患者盡早進(jìn)行對癥支持治療,防止因失水而加重病情。
[Abstract]:Research background:
Infectious diarrhea is one of the most common diseases of mankind, is caused by bacteria, viruses, parasites and other pathogens caused by diarrhea, intestinal infectious disease symptoms and are widespread and popular in the world, is also the important global public health problem, is one of the causes of three infectious diseases, especially in children it is a common and frequently occurring disease, is the two leading cause of death in children, especially in developing countries, resulting in disclosure.<2003 diarrhea is the leading cause of death among children in the World Health Report "in developing countries, infectious diarrhea in children killed up to 1 million 566 thousand people, accounting for 15.2% of the number of deaths, the leading cause of death in third. The incidence of infectious diarrhea in China's first rate in all infectious diseases. At present, the virus has become the important pathogens of infectious diarrhea by.1972 years after the virus has been found in Novak, and found the The establishment of diarrhea caused by the virus Reoviridae (rotavirus), adenovirus (enteric adenovirus), Caliciviridae (norovirus and Sapporo), astrovirus (astrovirus) and members of the coronaviridae family.
Rotavirus (Rotavirs, RV) is one of the main causes of infantile diarrhea, according to the antigenicity of different rotavirus were divided into 7 groups (A-G). Rotavirus infection is often asymptomatic, symptomatic infection incubation period is 1-3 days, the duration of the disease was 5-7 days, the main clinical manifestations were fever, frequent vomiting, watery diarrhea, mild dehydration and acidosis. According to reports, RV enteritis occurs in 6-24 months infants. In the regional climate changes with the seasons, the peak season of RV infection with time and area vary, occurred in the cold and dry autumn winter festival, occurred in the area year-round hot throughout the year may, subtropical infant RV diarrhea occur in autumn and winter, the epidemic peak in 10-12 months, and 3-5 months in spring may have a small peak, sudden environmental change may also affect the popular all over the world, sporadic and epidemic reports.
A large number of domestic and foreign research shows that norovirus (Norovirus, NVs) is next to the RV cause of acute nonbacterial gastroenteritis in humans (acute gastroenteritis, AGE) an important pathogen, NVs mainly through the fecal oral transmission is the main food source disease or waterborne acute diarrhea, the main pathogen of children acute viral gastroenteritis worldwide, but also causes include schools, families, tourist areas, hospitals, canteens, an important pathogen of military explosive epidemic gastroenteritis, produce great damage to social productivity, the characteristics of its position after the RV. of the virus is a high incidence rate, low dose of pathogenic and strong resistance.
Although the detection rate of Adenovirus (AdV) in children's diarrhoea specimens is not as high as that of RV, in recent two years, with the increasing understanding of AdV, the detection methods are increasing. Commercialized detection kits are more and more fast and simple. All countries pay more and more attention to the diarrhea caused by AdV.
Have astrovirus in most parts of the world (Astrivirus, AstV) infection reports, has confirmed that it is one of the most important pathogens causing infant, the elderly and immunocompromised diarrhea. Data show that AstV of infant viral gastroenteritis second or third pathogen.AstV infection is common in autumn and winter, more distributed, but also at the hospital. Kindergarten, homes, schools and army outbreaks.
However, with the development of China's city development and economic construction, a large number of foreign population into the city, making the urban and rural areas, villages and other economic conditions are relatively backward, in a complex flow area of diarrhea of the big city. The situation is not optimistic because of the existence of floating population mobility, the low level of knowledge, problem poor economic conditions, the overall effect of the health care service of floating population in the city.
The purpose of the study is:
1. to understand the infection status of RV, NVs, AdV and AstV, clinical manifestations and epidemiological characteristics of viral diarrhea in a community of 2010-2011 years in a community of Guangzhou.
2. to understand the genotypes of NVs, AdV and AstV in viral diarrhea in this area, and to explore the dominant strains of three viruses in the floating population.
3. to enrich the epidemiological data of infectious diarrhea of the southern virus, and to provide some reference for the prevention and treatment of viral diarrhea of the floating population.
Research methods:
1. source of specimens: collected 383 stools, demographic data, clinical and epidemiological data of floating population diarrhoea patients in a community health service center in Baiyun District of Guangzhou from May 2010 to December 2011.
2. sample treatment method: each faecal specimen 2G, each adding 2 mlPBS respectively, concussion and mixing, after loading, -80 centigrade preservation.
Methods 3. specimens of virus detection: using RT-PCR and PCR methods, using primers JV12Y/JV13I, AD1/AD2 and Mon269/Mon270 respectively by NVs for all the samples, the detection of AdV and AstV infection, the positive PCR products were purified and sequenced by BLAST sequencing results in GenBank to find the homologous sequences of positive strains, similarity comparison the sequence using the MEGA5.0 biological analysis software NVs, AdV and AstV genotypes, NVs AdV and AstV of the judgment, the prevailing strain.
4. statistical analysis: statistical software SPSS13.0 was used to analyze the collected data. Descriptive analysis, counting data, single factor analysis, chi square test, multivariate analysis and logistic stepwise regression were used to test the level of alpha 0.05..
Result錛，

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