Research of SARS Disease Symptom Tracking and Effectiveness of Filtering Febrile Patient Policy NSC 922751B002024Y 92 11 01 93 10 31 940111
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Severe Acute Respiratory Syndrome (Epidemiology) (Cough) (Fever) 2003 3 14 Severe Acute Respiratory Syndrome, SARS 2003 7 5 (Word Health Organization, WHO) SARS probable case 671 84 SARS WHO SARS retrospective SARS SARS SARS (cough) (fever) SARS (bias) SARS SARS SARS ( ) 4 SARS SARS II
KeywordsSevere Acute Respiratory SyndromeEpidemiologyCoughFever Severe acute respiratory syndrome (SARS) was firstly diagnosed and confirmed in a Taiwanese businessman who traveled back from China on March 14 th, 2003. Since then, Taiwan was not removed from the list of affected area announced by WHO until July 5, 2003. During this episodic time span, there were 671 probable SARS cases confirmed and reported in Taiwan which resulted 84 deaths. This has become a major public health challenge to human beings in the beginning of the 21 st century. The impact to the public and economic development is hard to estimate. Although the spread of SARS had been controlled in Taiwan since July, WHO had predicted that it will be returning after summer which caused the health authority in Taiwan many concerns and realization the fact of further SARS prevention is absolutely needed. In order to provide any necessary information about the spread of SARS symptoms occurred in Taiwan, a retrospective study of the SARS symptoms with the time sequences is conducted using the data collected from Emergency Room in National Taiwan University Hospital during the SARS outbreak. The control and filtering of possible febrile SARS patients to the University Hospital was also made using questionnaires derived within the time periods. Research of such filtering febrile patients policy will also be conducted within this research proposal. Due to the emergency and uncertain clinical symptom situation of the SARS patients sent to emergency room during the outbreak, it is not easy to record all the symptoms such as fever and cough from the febrile patients especially when all the diseases paths were not so clear. It would make much more efforts to recall all the necessary information and keep it for future reference. Even so, bias will be resulted and conclusion from such data analysis will become unrealistic. However, one can only carefully utilize the available data and perform it with high standard statistical methods; the true relationship among all the symptoms will be shown and presented for the first line medical personnel. Filtering the febrile patients reported to the hospital provides another means in examining SARS suspect and SARS probable cases. The effectiveness of such filtering policy will give more clues in the future. The main purpose of this research grant is to utilize the data collected from the Emergency room and outpatients clinics within NTUH; which to provide information in (1) about how the disease symptoms related with time descriptively and analytically; (2) the effectiveness of providing such filtering febrile policy within NTUH. III
(SARS) 2003226 8,437 5,327 1,775 671 813 84 ( >38) (non-productive cough) (dyspnea) (headache) (myalgia) (chills) (diarrhea) 2,3 Coronavirus 4,5 6 SARS SARS SARS, 徴 SARS, SARS SARS 2003314 2003512 299 1
220 SARS 79 SARS SARS WHO 7 79SARS SARS Disease Model SARS 4 26 7 5 SARS 4 SARS (WHO) SARS SARS SARS 8,9,10 SARS SARS SARS SARS SARS : 1. SARS Case-Control 2. SARS 3. SARS 4. SARS 5. risk factor SARS 6. SARS tree structure Path Analysis 7. SARS 2
SARS baseline demographic data laboratory data time sequence 2 sample t test SARS SARS Fisher s Exact Test correlation univariate multiple logistic regression analysis SARS decision tree decision model SARS (Day0) SARS Non-SARS SARS SARS 349 299 SARS 79 (26.42%) 299 SARS ( 35 (44.30%) 44 (55.70%)) SARS ( 124 (56.4%) 96 (43.6%)) SARS 220 84 (38.18%) 7 (3.23%) SARS 79 SARS 9 (11.39%) 13 (16.46%) SARS SARS SARS 37.83 44.56 SARS SARS 4.3 (4.3±2.23) SAS 1.95 (1.95±1.49) 3
Overall(N=299) SARS(N=79) Non-SARS(N=220) 159 ( 46.82 % ) 35 ( 44.30 % ) 124 ( 56.40 % ) 140 ( 53.18 % ) 44 ( 55.70 % ) 96 ( 43.6 % ) 93 ( 31.10 % ) 9 ( 11.39 % ) 84 ( 38.18 % ) 20 ( 6.69 % ) 13 ( 16.46 % ) 7 ( 3.23 % ) 39.61 44.56 37.83 15.02 15.20 14.59 (15,87) (15,87) (15,82) 95% (37.90,41.32) (41.15,47.96) (35.89,39.77) 2.57 4.30 1.95 2.00 2.23 1.49 (1,12) (1,12) (1,9) 95% (2.34,2.80) (3.8,4.8) (1.75,2.14) 220 SARS 59 (26.8%) ( >38 C) 79 SARS 47 SARS SARS WBCHemoglobinNeutrophil countlymphocyte countthrombocyte countaspartate aminotransferase SodiumC-Reactive Protein Sodium n ± p-value <0.01 * SARS 79 38.7±4.7 Non-SARS 218 37.4±0.9 (mmhg) <0.01 * SARS 79 131±21 Non-SARS 218 141±24 (mmhg) <0.01 * 4
SARS 79 76±15 Non-SARS 219 81±36 (beats/min) 0.623 SARS 78 100±14 Non-SARS 219 101±19 Oxygen saturation (%) 0.778 SARS 77 97±3 Non-SARS 219 98±7 White blood cell count ( 10 9 /liter) 7500±3500 <0.01 * SARS 79 5356±2562 Non-SARS 216 8704±3963 Hemoglobin (g/dl) 13.3±2 0.017 * SARS 79 13.5±2.4 Non-SARS 216 13.3±1.7 Neutrophil count ( 10 9 /liter) 4000±1000 <0.01 * SARS 79 4062±2413 Non-SARS 216 6457±3763 Lymphocyte count ( 10 9 /liter) 2000±500 <0.01 * SARS 79 878±351 Non-SARS 215 1470±790 Thrombocyte count ( 10 9 /liter) 220±100 <0.01 * SARS 79 157±56 Non-SARS 215 225±75 Unine Nitrogen (mg/dl) 4.5-24 0.255 SARS 76 10.5±4.3 Non-SARS 186 11.2±4.5 Creatinine (mg/dl) 0.6-1.2 0.541 SARS 75 0.9±0.2 Non-SARS 188 1.0±1.4 Aspartate aminotransferase (U/l) <35 <0.01 * SARS 77 56.6±73.6 Non-SARS 194 27.6±20.3 Alanine aminotransferase (U/l) <35 0.196 SARS 36 40.5±48.5 Non-SARS 63 29.8±32.2 Sodium (mmole/l) 135-148 <0.01 * SARS 78 137.5±4.2 Non-SARS 192 140.2±3.3 5
Potassium (mmole/l) 3.5-5.3 0.921 SARS 72 4.1±0.5 Non-SARS 181 4.1±0.2 C-Reactive Protein (mg/dl) < 0.8 <0.01 * SARS 65 3.9±2.8 Non-SARS 182 2.1±2.8 Creatine Kinase (U/l) 38-160 <0.01 * SARS 73 467.8±1729.9 Non-SARS 172 121.3±134.7 *: (65.82%) (45.57%) (43.37%) (22.78%) (20.25%)SARS (3.8%) (2.53%) SARS SARS (SARS45.57%Non-SARS58.64% ) (SARS 0%Non-SARS2.74% ) X 79SARS 59(74.68%) 220 SARS 21(9.91%) X SARS (bronchopneumonia) (pulmonary tuberculosis) (empyema).. 79SARS X ( X 59(74.68 %) v.s. 36(45.57 %) ) SARS X X CXR) Overall(N=299) SARS(N=79) Non-SARS(N=220) p-value <.01* 24 ( 20.25 % ) 16 ( 20.25 % ) 8 ( 3.64 % ) 0.05 165 ( 55.18 % ) 36 ( 45.57 % ) 129 ( 58.64 % ) 0.137 6 ( 2.01 % ) 0 ( 0 % ) 6 ( 2.74 % ) ( ) <.01* 79 ( 26.42 % ) 3 ( 3.8 % ) 76 ( 34.55 % ) <.01* 6
49 ( 16.39 % ) 2 ( 2.53 % ) 47 ( 21.36 % ) <.01* 108 ( 36.12 % ) 52 ( 65.82 % ) 56 ( 25.45 % ) <.01* 36 ( 12.04 % ) 18 ( 22.78 % ) 18 ( 8.18 % ) <.01* 83 ( 27.76 % ) 36 ( 43.37 % ) 47 ( 21.36 % ) CXR(+) 1 <.01* 80 ( 27.49 % ) 59 ( 74.68 % ) 21 ( 9.91 % ) 1 : 291, SARS 79, SARS 212 *: X CXR) SARS ( ) X SARS 2.63 SARS 8.94 SARS 6.25 SARS 5 X SARS 7
50 ( v.s. ) 95% p-value (v.s. ) 2.63 (1.16,5.96) 0.020 (v.s. ) 8.94 (2.03,39.16) 0.004 (v.s. ) 0.16 (0.07,0.39) <.001 0.20 (0.08,0.50) 0.001 X ( v.s. ) 0.02 (0.01,0.05) <.001 SARS X SARS (95.1%) X SARS X SARS (37.1%) SARS ay 0 SARS 8
0.67±1.91 2.03 2.60 ( SARS -0.5±2.3 ( 79 SARS 36 27 75 SARS 127 SARS 15 (11.63%) SARS 9 25% SARS 112 (86.82%) SARS N p-value (0) 36 2.03 2.60 (-7,7) <.01 (0) 52 0.35 1.44 (-3,7) 0.09 (0) 18 0.72 2.49 (-2,9) 0.24 (0) 36 0.67 1.91 (-2,9) 0.04 *: significant SARS N p-value 127-0.5 2.3 (-10,7) 0.02 * 76 0 1.22 (-4,4) 1 47 0.15 1.61 (-7,4) 0.53 56 0.3 1.66 (-6,8) 0.18 18-0.01 0.64 (-1,2) 0.72 47-0.02 1.59 (-7,3) 0.92 *:significant 9
SARS SARS 10
SARS 92 4 26 7 5 SARS 4/266/26 7/2 9/15 48,153 4/255/12 1,739 N Mean S.D. Min. Max. 95%C.I. Total=48,153 44,182 36.5 0.5 34.0 39.8 ( 36.5, 36.5 ) Total=1,739 563 37.9 0.9 34.1 42.0 ( 37.8, 37.9 ) Total=18 18 36.7 0.8 35.3 38.6 ( 36.3, 37.1 ) 44,182 36.5 43.5% 46.9% 2.6% 52.1% 7.8% 4.5% 3.7% 3.1% 2.3% 1.1% 0.5% 3.5% 1.5% 1.1% 0.2% 0.9% SARS 40.4% SARS 0.2% SARS 0.3% 0.1% 0.1% 0.1% 0.1% Total = 44182 11
N ( % ) 31651 ( 71.6 ) 12531 ( 28.4 ) 19202 ( 43.5 ) 20711 ( 46.9 ) 1160 ( 2.6 ) 41184 ( 93.2 ) (N=1160) 604 ( 52.1 ) 190 ( 16.4 ) 3460 ( 7.8 ) 2007 ( 4.5 ) 491 ( 1.1 ) 1351 ( 3.1 ) 1630 ( 3.7 ) 1029 ( 2.3 ) 232 ( 0.5 ) 1 ( 0.0 ) 2 ( 0.0 ) 0 ( 0.0 ) 1541 ( 3.5 ) 641 ( 1.5 ) 495 ( 1.1 ) 88 ( 0.2 ) 41418 ( 93.7 ) 77 ( 0.2 ) 405 ( 0.9 ) 12
17 ( 0.0 ) 14 ( 0.0 ) 4 ( 0.0 ) 807 ( 1.8 ) 17833 ( 40.4 ) 24495 ( 55.4 ) SARS 88 ( 0.2 ) 42606 ( 96.4 ) 43 ( 0.1 ) 28 ( 0.1 ) 64 ( 0.1 ) 31 ( 0.1 ) 151 ( 0.3 ) 11 ( 0.0 ) 21 ( 0.0 ) 12 ( 0.0 ) 439 ( 1.0 ) p-value<.0001 Odds Ratio O.R. 95% C.I. p-value Yes ( % ) No ( % ) Total 12.7 ( 11.2, 14.3 ) <.0001 * 13
Yes 545 ( 16.4 ) 2786 ( 83.6 ) 3331 No 577 ( 1.5 ) 37308 ( 98.5 ) 37885 8.0 ( 7.0, 9.3 ) <.0001 * Yes 345 ( 17.9 ) 1585 ( 82.1 ) 1930 No 554 ( 2.6 ) 20471 ( 97.4 ) 21025 11.0 ( 8.7, 13.8 ) <.0001 * Yes 103 ( 22.0 ) 366 ( 78.0 ) 469 No 1019 ( 2.5 ) 39728 ( 97.5 ) 40747 15.7 ( 13.6, 18.1 ) <.0001 * Yes 319 ( 24.4 ) 991 ( 75.7 ) 1310 No 803 ( 2.0 ) 39103 ( 98.0 ) 39906 9.6 ( 8.3, 11.2 ) <.0001 * Yes 275 ( 17.4 ) 1306 ( 82.6 ) 1581 No 847 ( 2.1 ) 38788 ( 97.9 ) 39635 13.0 ( 11.0, 15.3 ) <.0001 * Yes 227 ( 22.8 ) 768 ( 77.2 ) 995 No 895 ( 2.2 ) 39326 ( 97.8 ) 40221 6.9 ( 4.8, 9.9 ) <.0001 * Yes 36 ( 16.1 ) 187 ( 83.9 ) 223 No 1050 ( 2.7 ) 37560 ( 97.3 ) 38610 - - 1.0000 Yes 0 ( 0.0 ) 1 ( 100.0 ) 1 No 3 ( 1.6 ) 182 ( 98.4 ) 185 - - 1.0000 Yes 0 ( 0.0 ) 2 ( 100.0 ) 2 No 3 ( 1.6 ) 181 ( 98.4 ) 184 - - - Yes - - - - - No 3 ( 1.6 ) 183 ( 98.4 ) 186 1,739 563 37.9 47.4% 44.5% 32.6% 42.7% 29.4% 19.0% 17.4% 15.4% 15.2% 7.6% 1.1% 0.3% 0.2% 7.8% 14
3.6% 2.7% 0.1% 1.8% 0.7% SARS 36.6% SARS 1.0% Total = 1739 N ( % ) 731 ( 42.0 ) 1008 ( 58.0 ) 824 ( 47.4 ) 773 ( 44.5 ) 567 ( 32.6 ) 960 ( 55.2 ) (N=567) 242 ( 42.7 ) 137 ( 24.2 ) 511 ( 29.4 ) 331 ( 19.0 ) 132 ( 7.6 ) 302 ( 17.4 ) 267 ( 15.4 ) 265 ( 15.2 ) 19 ( 1.1 ) 5 ( 0.3 ) 4 ( 0.2 ) 0 ( 0.0 ) 135 ( 7.8 ) 15
63 ( 3.6 ) 47 ( 2.7 ) 1 ( 0.1 ) 1519 ( 87.3 ) 12 ( 0.7 ) 32 ( 1.8 ) 2 ( 0.1 ) 1 ( 0.1 ) 0 ( 0.0 ) 76 ( 4.4 ) 637 ( 36.6 ) 993 ( 57.1 ) SARS 18 ( 1.0 ) 1608 ( 92.5 ) p-value<0.01 Odds Ratio O.R. 95% C.I. Yes ( % ) No ( % ) Total p-value 3.6 ( 2.9, 4.6 ) <.0001 * Yes 266 ( 58.7 ) 187 ( 41.3 ) 453 No 275 ( 28.2 ) 701 ( 71.8 ) 976 3.2 ( 2.5, 4.2 ) <.0001 * Yes 182 ( 60.1 ) 121 ( 39.9 ) 303 No 359 ( 31.9 ) 767 ( 68.1 ) 1126 1.2 ( 0.9, 1.8 ) 0.2743 16
Yes 50 ( 42.7 ) 67 ( 57.3 ) 117 No 491 ( 37.4 ) 821 ( 62.6 ) 1312 4.5 ( 3.4, 5.9 ) <.0001 * Yes 183 ( 66.8 ) 91 ( 33.2 ) 274 No 358 ( 31.0 ) 797 ( 69.0 ) 1155 4.1 ( 3.0, 5.5 ) <.0001 * Yes 157 ( 66.0 ) 81 ( 34.0 ) 238 No 384 ( 32.2 ) 807 ( 67.8 ) 1191 4.3 ( 3.2, 5.8 ) <.0001 * Yes 156 ( 67.0 ) 77 ( 33.1 ) 233 No 385 ( 32.2 ) 811 ( 67.8 ) 1196 1.1 ( 0.4, 3.0 ) 1.0000 Yes 6 ( 40.0 ) 9 ( 60.0 ) 15 No 535 ( 37.8 ) 879 ( 62.2 ) 1414 32.0 ( 2.3, 447.8 ) 0.0078 * Yes 4 ( 80.0 ) 1 ( 20.0 ) 5 No 2 ( 11.1 ) 16 ( 88.9 ) 18 3.8 ( 0.5, 29.7 ) 0.2705 Yes 2 ( 50.0 ) 2 ( 50.0 ) 4 No 4 ( 21.1 ) 15 ( 79.0 ) 19 - - - Yes 0 ( 0.0 ) 0 ( 0.0 ) 0 No 6 ( 26.1 ) 17 ( 73.9 ) 23 SARS 18 3 SARS 18 10 8 7 38.9% 6 85.7% 27.8% 27.8% 22.2% 11.1% 5.6% 5.6% 22.2% 16.7% SARS 83.3%% SARS 5.6% Table. 18 17
N ( % ) 10 ( 55.6 ) 8 ( 44.4 ) 7 ( 38.9 ) 10 ( 55.6 ) N=7) 6 ( 85.7 ) 0 ( 0.0 ) 5 ( 27.8 ) 4 ( 22.2 ) 0 ( 0.0 ) 1 ( 5.6 ) 2 ( 11.1 ) 5 ( 27.8 ) 1 ( 5.6 ) - ( - ) - ( - ) - ( - ) 4 ( 22.2 ) 4 ( 22.2 ) 0 ( 0.0 ) 0 ( 0.0 ) 14 ( 77.8 ) 0 ( 0.0 ) 3 ( 16.7 ) 0 ( 0.0 ) 0 ( 0.0 ) 0 ( 0.0 ) 18
0 ( 0.0 ) 15 ( 83.3 ) 2 ( 11.1 ) SARS 1 ( 5.6 ) 16 ( 88.9 ) 500 500 500 r=0.3p-value<.0001 Paired t test p-value=0.0077 N Mean S.D. Min. Max. 95%C.I. p-value 500 36.1 0.6 34.0 39.0 ( 36.1, 36.2 ) 500 36.2 0.5 33.2 37.6 ( 36.1, 36.2 ) Difference ( - ) 500-0.1 0.6-2.0 2.1 ( -0.1, 0.0 ) 0.0077 * SARS SARS SARS 19
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101112叁 SARS 123456789 SARS 5 15 25 35 45 50 55 65 75 85 90 100 SARS SARS 21