重新審視大規模社區肝炎篩檢：以某基金會的一次篩檢為例

背景：在台灣，與肝臟有關的基金會發展出社區篩選已廣為人知，在報紙與媒體的傳播下，社區篩選被認為是一個很好且常使用的篩檢模式。在這項研究中，我們重新評估了這種社區篩檢模式的效益。目的：回顧性分析基於社區的篩檢數據，了解目前的社區篩檢模式是否真正符合篩檢需求，討論大規模社區篩檢的有效性和未解決的問題。方法：由兩個非政府組織在高雄市大寮區進行了兩階段肝炎社區篩檢。第一階段是抽血檢測HBsAg、Anti-HCV，AST，ALT和AFP。對於HBsAg或Anti-HCV陽性的受檢者，進一步確認HBV DNA和HCV RNA。第二階段是針對上述五種標記中的任何一種呈陽性的受檢者的超音波檢查。該研究是一個對受檢者基本資料進行加密的回顧性分析，並已經由長庚醫院的IRB機構審查委員會批准。結果：總共取得1495名參加了這項篩檢的受檢者資料。大寮區22個里的中覆蓋率為7.93 / 1000。整體上HBsAg和Anti-HCV陽性率分別為11.58％和3.74％。在所有陽性受檢者中，僅有不到一半HBV DNA或HCV RNA呈現陽性。我們也透過REACH-B risk score評分發現HBsAg陽性受檢者中只有16位（9.2％）REACH-B risk score的評分高於10。討論：我們注意到此次篩檢，全體參與的受檢者其地理代表性不是很理想。由於地理取樣偏倚和參與比率過低，因此應在高風險地區進行社區篩檢時，討論如何改善其覆蓋率。在發現HBsAg和Anti-HCV陽性率的比例也未有預期上的高於台灣整體陽性率。另外在HBsAg陽性（11.58%）和Anti-HCV(3.74%)陽性的受檢者中，後續檢驗 HBV DNA（2.94％）或HCV RNA（1.47％）佔全體受檢者呈現陽性的比例也相對不高，對於使用HBsAg和Anti-HCV的檢驗方式是否符合大型社區篩檢的效益，需要進一步研究來探討。另外在本次社區篩檢中並未有新發現的肝癌受檢者。結論：綜合以上發現，我們對於目前常用的肝炎、肝癌社區篩檢方式，是有需要進行篩檢方式及活動安排更進一步的改善。

關鍵字

社區篩檢；肝癌；Ｂ型肝炎；Ｃ型肝炎；肝癌篩檢

並列摘要

Background: Outcomes of Hepatitis B prevention and control in Taiwan is outstanding in the world. Hepatitis B, significant efforts have also been devoted to the prevention and control of Hepatitis C, including reimbursement of oral direct-acting antiviral drugs by the National Health Insurance. DAA can block disease progression for patients with chronic Hepatitis C infection. In Taiwan, screening by liver-related foundations has been widely known under the spread of newspaper media, and also believed by some to be a good screening model. In this study, we re-appraised this screening model from the epidemiological and clinical perspectives. Aims: To retrospectively analyze community-based screening data and discuss the effectiveness and unresolved issues of large-scale community screening from clinical perspectives. Methods: Two non-governmental organizations conducted a two-stage liver cancer screening in Daliao District, Kaohsiung City. The first stage was blood sampling to test HBsAg anti-HCV, AST , ALT and AFP. For those who were positive for HBsAg or anti-HCV, further confirmation were performed on HBV DNA and HCV RNA. The second stage was ultrasonography examination for participants who were positive for any of the above five markers. Results: A total of 1495 subjects participate in this screening. The median coverage rates of 22 villages were 7.93/1000. Overall prevalence of HBsAg and anti-HCV were 11.6% and 3.7%. To identify the candidates of antiviral treatment for chronic Hepatitis B and C virus infection, participants were stratified by viral load and ALT levels. Among the positive subjects, only less than half were positive for HBV DNA (5.3%) or HCV RNA (1.5%). To identify the high risk for HCC by REACH-B risk score, only 16 (9.2%) of HBsAg carrier were with score higher than 10. Five subjects had AFP levels higher than 20 ng/ml. Discussion: In the study area with same prevalence of HBsAg and anti-HCV as the whole of Taiwan, we found that only few candidates for anti-viral treatment or HCC screening can be detected through such a community-based screening. We noted that geographic representation of participants to the whole population was poor. Conclusion: Due to biased geographic sampling and low rate of candidates for intervention, community-based screening should be conducted with well-coverage design in high risk areas.