赴歐洲參加現場流行病學訓練計畫

European Programme for Intervention Epidemiology Training (EPIET):A Two-Year Training Experience

簡淑婉(Shu-Wan Jian)

指導教授 ： 方啟泰

國立臺灣大學/公共衛生學院/公共衛生碩士學位學程/碩士(2015年)

https://doi.org/10.6342/NTU.2015.02535

摘要

歐洲現場流行病學訓練計畫(European Programme for Intervention Epidemiology Training, EPIET)，是歐洲疾病預防及控制中心（European Centre for Disease Prevention and Control, ECDC）重點長期訓練計畫之一。經2007年我國行政院衛生福利部疾病管制署（下稱疾管署）與奧地利健康暨食品安全署（Osterreichische Agentur fur Gesundheit und Ernahrungssicherheit, 下稱AGES )簽定合作備忘錄下，我國得派員以奧地利衛生調查訓練班訓練員身分，參加為期兩年之EPIET計畫。學生有幸通過疾管署遴選流程，自 2011年9 月至2013年11月在AGES進行EPIET訓練及實務實習。

EPIET訓練內容包含10週流行病學相關課程及於代訓機構進行實務實習，以具備疫病調查、監測系統評估或建立、研究計畫撰寫及執行、教學經驗、學術發表等能力。受訓期間學生參與疫病調查及監測系統評估與學術成果發表等經驗摘要如下：1. 以回溯性世代研究法調查一起校園學生諾羅病毒感染事件，經分析結果顯示男住宿生（Risk Ratio: 3.4; 95%CI: 1.4-8.2）、食用酸奶醬（RR: 16.2; 95%CI: 3.9-67.5）及火雞肉片沙拉（RR: 5.2; 95%CI: 2.3-11.8）為經分層分析後感染諾羅病毒之危險因子，推測因該校學生餐廳廚房未依相關規定，執行危害分析重要管制點系統制度(Hazard Analysis Critical Control Point, HACCP)， 在餐點配製及料理過程中造成食物交叉污染。2. 奧地利流行性感冒季節性監測，以結合定點醫師監測、非定點病毒監測、類流感監測等，掌握流感季期間，類流感趨勢及病毒型別變化與疾病負擔。3. 闡述奧地利李斯特菌監測系統監測架構及評估其簡易性及時效性，於2009年該國法定傳染病線上通報系統啟用後顯著提升。4. 為評估省市間百日咳通報率差異，進行奧地利一般科醫師、小兒科醫生及肺專科醫生通報百日咳感染病例之知識、態度、行為（knowledge, attitude, practices, KAP）調查研究，發現於高通報率省份之教學醫院執業（Prevalence Ratio: 1.6; 95%CI: 1.1-2.2），及百日咳病原體實驗室診斷相關知識程度較高(PR: 1.4; 95%CI: 1.0-1.8)者，為具百日咳確定病例通報行為之獨立因子，推測醫師通報行為可能是造成省市間百日咳通報率差異原因之一。5. 於四場奧地利學術研討會或國際研討會進行口頭或壁報報告。6. 籌辦食媒性疾病疫情調查教育訓練，進行教材設計及教學 。

回國後，學生應用EPIET受訓期間所學，協助疾管署評估國際間H7N9及H10N8等新型流感疫情發生於我國之可能風險及衝擊，評估結果研判H7N9流感病毒於冬季流行期間境外移入風險提高，預期我國仍可能出現中國大陸移入病例，惟目前證據顯示病毒不具持續性人傳人之能力且造成社區感染風險低。另中國大陸H10N8流感疫情僅出現零星個案，推測我國出現境外移入個案之風險極低，惟仍建議加強我國禽畜相關從業人員及台商與入境陸客之健康監測，及持續掌握新型流感病毒特性及疫情變化，於必要時更新風險評估報告。

關鍵字

EPIET ； 奧地利 ； 諾羅病毒 ； 李斯特菌 ； 百日咳

並列摘要

The European Programme for Intervention Epidemiology Training (EPIET) hosted at the European Centre for Disease Prevention and Control (ECDC) in Sweden, provides training and practical experience in intervention epidemiology at the national centres for surveillance and control of communicable diseases in the European Union. In 2007, Taiwan Centers for Disease Control (TCDC) and Austrian Agency for Health and Food Safety (AGES) agreed the Memorandum of Understanding that set down the mechanisms and scope of cooperation, which enabled a Taiwanese trainee to join EPIET. It's a great honour for me to be elected as the representative of TCDC and AGES to participate in the programme during September 2011and November 2013.

The ten-week EPIET modules and practising in the training site provide knowledge and skills that lead the trainees to acquire the ECDC core competencies for field epidemiologist. During the training, I have accomplished the following learning objectives: 1. Investigation of a foodborne outbreak due to norovirus in a school in 2011, which indicated sour cream sauce (Relative risk: 16.1; 95% CI: 3.9–67.5) and turkey-strip salad (RR: 5.2; 95% CI: 2.3–11.8) prepared by the school kitchen as the most likely sources of the outbreak. The lack of a hazard analysis critical control point soncept (HACCP) in the school kitchen might have caused the failure of food safety procedures. 2. Analysis of influenza surveillance data during flu seasons (Week 40- Week 15), 2011-2013. 3. Evaluation of the surveillance system for listeriosis in Austria before and after implementation of the national electronic web-based reporting system (EMS) in terms of simplicity and timeliness. The implementation of the EMS eliminated two steps from the data reporting process and reduced the time needed between case identification and case reporting. 4. A knowledge, attitude and practice survey for pertussis among general practitioners, paediatricians and pulmonologists in Austria. We found that in the provinces of high notification rate of pertussis, paediatricians and pulmonologists who have high level of knowledge on laboratory diagnostics for pertussis and practice in a university hospital were independently associated with the behaviour of reporting a laboratory confirmed case of pertussis (adjusted PR: 1.4, 95%CI: 1.0-1.8 and adjusted PR: 1.6, 95%CI: 1.1-2.2 respectively). The observations may partly explain the differences of pertussis notification rates between Austrian provinces. 5. Oral and poster presentations in four Austrian or international conferences. 6. Obtaining teaching experience through organizing a workshop about introduction of foodborne outbreak investigations.

After EPIET training, I assisted TCDC to assess the risk associated with emergence of avian influenza A (H7N9) and A (H10N8) virus and formulated appropriate prevention and control strategies. The result showed that risk of diseases widely spreading in Taiwan via humans in the near future is considered low, while a higher likelihood at the moment is imported case-patients who have acquired the infection in mainland China. Health monitoring and serological surveys of poultry workers were recommended to evaluate the risk of poultry-to-human transmission of the viruses. It is essential to continuously monitor the variations of H7N9, H10N8 and other influenza viruses and update the assessment of estimated risks.

並列關鍵字

EPIET ； Austria ； Norovirus ； Listeriosis ； Pertussis

參考文獻

1. Kuo, H.-W. et al. A foodborne outbreak due to norovirus in Austria, 2007. J. Food Prot. 72, 193–196 (2009).

3. Dabrera, G. et al. A case-control study to estimate the effectiveness of maternal pertussis vaccination in protecting newborn infants in England and Wales, 2012-2013. Clin. Infect. Dis. ciu821 (2014). doi:10.1093/cid/ciu821

4. Kharbanda EO, et al. EValuation of the association of maternal pertussis vaccination with obstetric events and birth outcomes. JAMA 312, 1897–1904 (2014).

5. Koopmans, M. Progress in understanding norovirus epidemiology. Curr. Opin. Infect. Dis. 21, 544–552 (2008).

6. Dreyfuss, M. S. Is norovirus a foodborne or pandemic pathogen? An analysis of the transmission of norovirus-associated gastroenteritis and the roles of food and food handlers. Foodborne Pathog. Dis. 6, 1219–1228 (2009).