Department of epidemiology ，Harbin Medical University 地方病 Endemic Diseases 哈尔滨医科大学流行病学教研室 Department of epidemiology ，Harbin Medical University 1

目 录 第一节 概述 (Introduction) 第二节 地方性碘缺乏病 第二节 地方性碘缺乏病 (Endemic iodine deficiency diseases) 2

第一节 概 述 Introduction 地方病的判断依据及分类 我国主要的地方病 几种主要地方病的流行特征 预防策略与措施 Criteria and classification of endemic diseases The major endemic diseases in China Prevalence characteristics of several major endemic diseases Prevention strategies and measures 3

一、地方病的判断依据及分类 Criteria and classification of endemic diseases 该地区的居民任何民族其发病率 其他地区居住的相似人群，该病的发病频率 ，甚至不发病 Criteria of endemic disease incidence of the disease in any ethnic may increase in the residents in the area similar residents lived in other areas have the lower incidence, or even not occur the disease 4

一、地方病的判断依据及分类 Criteria and classification of endemic diseases Criteria of endemic disease who immigrate the area over a period of time, its incidence approaches that in local population the people emigrate the area, the incidence would reduce, or symptoms alleviate or self-healing in addition, the local animals are also susceptible to the same disease 地方病的判断依据 迁入该地区的人经一段时间后，其发病率和当地居民一致 人群迁出该地区后，发病率 或患病症状减轻或自愈 除人之外，当地的易感动物也可发生同样的疾病 5

地方病的分类 (Classification of endemic diseases) 地球化学性地方病 自然疫源性地方病 与特定生产生活方式有 关地方病 病因未明地方病 Geochemistry endemic diseases Natural foci endemic disease particular production and Lifestyle-related endemic diseases Endemic disease of unknown etiology 6

地球化学性地方病 碘缺乏病 饮水型地方性氟中毒 砷中毒 自然疫源性地方病 血吸虫病 鼠疫 布氏杆菌病 碘缺乏病 饮水型地方性氟中毒 砷中毒 自然疫源性地方病 血吸虫病 鼠疫 布氏杆菌病 Geochemistry endemic diseases Iodine deficiency endemic; drinking water type fluorosis and arsenic poisoning Natural foci endemic disease Schistosomiasis; plague ; Brucellosis 7

与特定生产生活方式有关地方病 燃煤污染型氟中毒 饮茶型氟中毒 燃煤污染型砷中毒 病因未明地方病 克山病 大骨节病 趴子病 乌脚病 克山病 大骨节病 趴子病 乌脚病 Particular production and lifestyle-related endemic diseases Burning coal polluted type fluorosis Drinking tea type fluorosis Burning coal polluted type arsenic poisoning Endemic disease of unknown etiology Keshan disease; Kaschin-Beck disease; Pazhi disease; black foot disease 8

The major endemic diseases in China 二、我国主要的地方病 The major endemic diseases in China Focused endemic diseases of prevention and control includes:        IDD         Endemic fluorosis         Endemic arsenic poisoning         Keshan disease         Kaschin-Beck disease         Plague         Brucellosis disease         Schistosomiasis disease 　 纳入重点防治的地方病： 碘缺乏病 地方性氟中毒 地方性砷中毒 克山病 大骨节病 鼠疫 布鲁氏杆菌病 血吸虫病 9

表28-1 全国8种主要地方病病区范围及病例数 10

Prevalent characteristics of several major endemic diseases 三、几种主要地方病的流行特征 Prevalent characteristics of several major endemic diseases Endemic fluorosis Kaschin-Beck disease Keshan disease Endemic arsenic poisoning 地方性氟中毒 大骨节病 克山病 地方性砷中毒 11

(一)地方性氟中毒(地氟病) （Endemic fluorosis） 定义 在特定的地理环境中发生的一种地球化学性疾病，人体长期摄入过量氟而导致的全身慢性蓄积性中毒。 A geochemical disease occurred in a particular geographical environment , for chronic systemic accumulated poisoning caused by long-term intake of excessive fluoride in human 主要临床表现(The main clinical manifestations) 氟斑牙（dental fluorosis） 氟骨症（skeletal flurosis） 12

氟斑牙 牙釉质形成期摄入高氟引起的 表现为牙釉质白垩、着色或缺损改变 一旦形成，残留终生 Dental fluorosis caused by high fluoride intake the performance of enamel is chalk, coloring, or defect Once formed, enamel formation would be left over the full life 13

氟斑牙 Dental fluorosis 14

氟骨症 Skeletal fluorosis 15

Skeletal fluorosis 氟骨症 16

(一)地方性氟中毒(地氟病) （Endemic fluorosis） 按氟的来源不同分为 饮水型 燃煤型 饮茶型 Divided according to different sources of fluorine: Drinking water type Burning coal type Drinking tea Type 17

地区分布 (Regional distribution) 世界广范分布: 中国、印度最为严重 国内 Distribution in world wide : China and India are the most serious Domestic 18

饮茶型氟中毒病区分布

时间分布 (Time distribution) 该病的发生与季节年份无明显相关 The occurrence of the disease has no significant correlation with the seasonal and year 人群分布: Population distribution: 氟斑牙 无明显的性别、种族差异 婴幼儿症状较轻，主要表现为白垩样改变 氟骨症 主要发生在成年16岁以后，特别是30岁以后 年龄 患病率 病情通常女性比男性严重 Dental fluorosis No significant gender and ethnic differences Infants and young children suffering from moderate, mainly for the chalk-like change Skeletal fluorosis Mainly occurred in adults after 16 years old, and especially after the age of 30, and the prevalence increases with the increased age Condition of illness is usually severe in women than in men. 20

人群分布 (Population distribution) 氟斑牙 无明显的性别、种族差异 婴幼儿症状较轻，主要表现为白垩样改变 氟骨症 主要发生在成年16岁以后，特别是30岁以后 年龄 患病率 病情通常女性比男性严重 Dental fluorosis No significant gender and ethnic differences Infants and young children suffering from moderate, mainly for the chalk-like change Skeletal fluorosis Mainly occurred in adults after 16 years old, and especially after the age of 30, and the prevalence increases with the increased age Condition of illness is usually severe in women than in men. 21

氟斑牙（白垩样改变） Dental fluorosis (chalk-like change) 22

（Kashin-Beck disease） （二）大骨节病 （Kashin-Beck disease） It is a endemic, multiple, deformation osteoarthropathy. Primary lesion to children in a developmental stages is the articular hyaline cartilage degeneration, necrosis and secondary bone arthritis, severe cases can lead to short stature deformities, permanent disability. 一种地方性、多发性、变形性骨关节病 主要病变是发育期儿童的关节透明软骨变性、坏死及继发的骨关节炎，严重者可导致矮小畸形，终生残疾 23

大骨节病 Kashin-Beck disease 变形性骨关节病 Deformation osteoarthropathy 24

大骨节病 矮小畸形 Kashin-Beck disease Dwarf deformity 25

The geographical distribution of Kashin-Beck disease 大骨节病地区分布 The geographical distribution of Kashin-Beck disease 26

时间分布 (Time distribution) 1.霜期早、秋雨大、粮食水分高的次年多是大骨节病的高发年 2.各病区多发季节有所不同，一般春季多发 3.致病因子活跃的地方，四季都有新发病人 The early frosty period, autumn large rain in autumn with high moisture over the next year is a high incidence of Kashin-Beck disease in years The season is different from many wards, and the general spring-prone. In causative agent active area, the incidence of this disease will could be seen in the four seasons. 27

人群分布 (Population distribution) 1.多发生于儿童和少年，成人中新发病例极少 2.未见明显的性别差异 3.民族间患病率差异取决于主食的粮食种类和生活方式 Mostly occurs in children and adolescents, and very few new cases in adults, No significant gender differences Differences in the prevalence among nationality depends on categories of staple food and lifestyle 28

（三）克山病（地方性心肌病） （keshan disease） 　一种病因未明的、以心肌坏死为主要病理改变的坏死性心病。 A kind of unknown etiology, and the main pathological changes in necrotic heart disease is myocardial necrosis. 29

克山病的病因学 The etiology of Keshan disease 地球化学说 生物病因学说 Theory of geochemical hypothesis Theory of biological causes 30

地区分布（Regional distribution）

时间分布 (Time distribution) Annual Multi-place A high incidence of seasonal 　年度多发 　　 　季节性高发 32

人群分布 (Population distribution) Age: women of childbearing age and children are the high-risk population. Gender: North Keshan disease incidence in women is age 1 ~ 2 times higher than it in men with the same age, up to 4 ~ 7 times. 年龄 生育期妇女和儿童为高 发人群 性别 北方急型克山病女性发 病比同龄男性多1～2倍以 上，高时可达4～7倍 33

人群分布 (Population distribution) 职业 绝大多数是自产自给的农业人口 家庭集聚性 克山病有家庭多发现象 民族 民族混居地区，若其生产、生活方式无相似则发病无明显差 异 Occupation: Most self-summary-grown agricultural population. Family clustering: Keshan disease have the phenomenon of multiple. National: if their production and way of life have no similar, and there are no significant difference in the incidence of this disease in ethnically mixed areas. 34

（四）地方性砷中毒（地砷病） （四）地方性砷中毒（地砷病） Endemic arsenic poisoning 　　　居住在特定地理条件下的居民，通过饮水、空气和食物长期摄入过量的砷而引起的以皮肤色素脱失、着色、角化及癌变为主的全身性慢性中毒性疾病。 The residents lives in a specific geographical conditions, through drinking water, air and long-term intake of food, intake an excessive amount of arsenic, caused the skin depigmentation, coloring, keratosis, and cancer-based systemic chronic toxic illnesses. 35

皮肤角化 色素沉着 Pigmentation Skin Keratosis 36

手/趾掌角化 花肚皮-腹部色素沉着与脱失 地砷病的危害 The hazard of endemic arsenic disease Hand / toe palm keratosis 花肚皮-腹部色素沉着与脱失 Flower belly- abdominal pigmentation and deletion 37

皮肤癌 Skin cancer 38

（四）地方性砷中毒（地砷病） Endemic arsenic poisoning 地区分布（Regional distribution） 39

时间分布 (Time distribution) （四）地方性砷中毒（地砷病） Endemic arsenic poisoning 时间分布 (Time distribution) 该病没有多发季节和多发年 There is not multiple seasons and multiple years to this disease. 40

人群分布 (Population distribution) Age distribution 年龄分布 　任何年龄摄入过多的砷均可患病 　年龄 该病的检出率 性别分布 　调查结果不相一致，多数为男性>女性 Excessive intake of arsenic at any age may be sick. The detection rate of the disease increases with the increased age Gender distribution Survey results are not consistent, and the number of male beyond the Female In most cases. 41

四、预防策略与措施 Prevention strategies and measures 预防策略与措施 防治机构 监 测 监 测 Prevention strategies and measures Institutions of prevention and control Surveillance 42

（一）预防策略与措施 Prevention strategies and measures 地方病的预防与控制原则： 预防为主，兼顾救治 Endemic disease prevention and control principles: Focusing on prevention and also give consideration to remedy. Government leading, department co-participating and mass participation. Sustainability 地方病的预防与控制原则： 预防为主，兼顾救治 政府领导、部门配合， 群众参与 可持续性 43

Strategies and measures for different diseases 不同疾病的策略与措施 Strategies and measures for different diseases 碘缺乏病 “全民食盐加碘” 克山病 “根据其病因采用综合性施” Lodine deficiency disease " National salt iodization " Keshan disease " Adopting integrated measure according to etiological factor " 44

Strategies and measures for different diseases 不同疾病的策略与措施 Strategies and measures for different diseases Kashin-Beck disease “changing grain, intaking Se, immigration, returning farmland to forest and grass" Endemic fluorosis and endemic arsenic poisoning "reforming water and changing cooking stoves" 大骨节病 “换粮、补硒、移民、退耕还林还草” 地方性氟中毒和地方性砷中毒 “改水、改灶” 45

地区 国家 省 县 （二）防治机构 （二）防治机构 The institutions of prevention and control National Province Area County 46

中国疾控地方病控制中心 国家 卫生部 全国鼠疫布病防治基地 寄生虫病预防控制所 （二）防治机构 （二）防治机构 The institutions of prevention and control The institutions of prevention and control 中国疾控地方病控制中心 Endemic Disease Control center of Chinese Center for Disease Control and Prevention 国家 卫生部 全国鼠疫布病防治基地 National base for the prevention and control of Brucellosis and Plague National The Ministry of Health 寄生虫病预防控制所 Institute for the prevention and control of parasitic diseases 47

地方病防治所 省（区、市） 省、市疾病控制中心地方病防治科 （二）防治机构 （二）防治机构 The institutions of prevention and control The institutions of prevention and control 地方病防治所 Institute for the prevention and control of endemic disease 省（区、市） Provinces (regions and municipalities) 省、市疾病控制中心地方病防治科 Endemic disease department of provincial and municipal Center for Disease Control and prevention 48

The institutions of prevention and control （二）防治机构 The institutions of prevention and control 县（旗）疾控中心地方病科 县 乡 镇 Counties (banners) CDC endemic Division 乡镇卫生院 County Countryside Town Township hospitals 49

（三）监测 （surveillance） 病区地方病发病、患病情况 病区外环境状况 防治措施落实情况 The morbidity and prevalence of Endemic endemic disease The state of the environment outside endemic desease The implementation of prevention and control measures 50

第二节 地方性碘缺乏病 Iodine deficiency disorders 病因学 流行特征 预防策略与措施 地方性甲状腺肿的分型、分度及诊断标准 Etiology Epidemiologic feature Strategies and measures Types、degrees and diagnostic standard for endemic goiter

碘缺乏病是由于自然环境碘缺乏造成机体甲状腺激素不足所表现的一组地方病的总称。包括 地方性甲状腺肿(地甲肿)、地方性克汀病(地克病)、地方性亚临床克汀病(亚克汀)、由于碘缺乏引起的胎儿流产、早产、死产、先天畸形等。 Iodine deficiency disorders are a general term for a group of endemic diseases due to environmental iodine deficiency leading to the insufficiency of thyroid hormone in the body. Include: endemic goiter, endemic cretinism , subclinical cretinism, abortions, preterm birth, stillbirths, and congenital anomalies because of iodine deficiency.

地方性甲状腺肿Endemic goiter Iodine deficiency disorders

地方性甲状腺肿Endemic goiter Iodine deficiency disorders 正位

地方性克汀病 Endemic cretinism

Cretinism patient giggle 一代甲、二代傻、三代四代断根芽 First generation goiter, second generation idiot, third and fourth eneration no offspring. 克汀病患者的傻笑 Cretinism patient giggle

一、病因学 (Etiology) Iodine deficiency 碘缺乏 Risk factors for IDD 碘缺乏病的影响因素 Goitrogenous substance Nutritional factors   Environmental pollution Hereditary factor 碘缺乏 碘缺乏病的影响因素 致甲状腺肿物质 营养因素 环境污染 遗传因素

二、流行特征 Epidemiology feature 地区分布 时间分布 人群分布 Geographical distribution Temporal distribution Population distribution

地区分布（Regional distribution） IDD是世界上分布最广、受威胁人口最多的一种地方病 IDD is the world's most widely distributed endemic disease, and the largest population are under it’s threat.

地区分布（Regional distribution） 流行较重 亚洲的喜马拉雅山区 欧洲的阿尔卑斯和比里牛斯山区 南美的安第斯山区 非洲的刚果河流域 大洋洲的巴布亚新几内亚 北美洲的五大湖盆地 Epidemic seriously Himalayan regions in Asia Alps and Pyrenees in Europe Andes in South America Congo River Basin in Africa Papua New Guinea in Oceania Great Lakes in North America 60

地区分布（Regional distribution） 全球共有22亿人口（占全世界人口的38%）生活在缺碘地区 A total of 220 million people worldwide (accounting for 38% of the world's population) live in iodine-deficient regions. 我国是世界上IDD分布广泛、病情严重的国家之一,主要流行 特征是山区多于平原，内陆多于沿海，乡村多于城市 China is one of the countries where IDD have been widely distributed and severely prevalent, the main epidemiologic feature is that mountains are more than plains, inland more than coastal, rural more than urban.

图28-2 世界碘缺乏病波及的国家

时间分布 (Time distribution) 表28-2 1994、2000年度中国碘缺乏病范围例数 Table 28-2 Scope and cases of IDD in China for1994 and 2000

人群分布 (Population distribution) 流行地区的人群任何年龄均可发病 People of any age in endemic areas can be ill. 5岁以下儿童发病较少，一般在青春发育期开始发病，随着年龄 患病率 ， 40岁以后逐渐 Children under 5 years of age have a low incidence of IDD, generally beginning at puberty. Prevalence increases with age, but prevalence decreases after 40 years of age with age.

人群分布 (Population distribution) 愈是病情严重的地区，甲状腺肿发病的年龄愈早 The more serious condition of the area, the earlier the age of goiter. 10岁以前男女患病率无显著差异 There is no significant difference in the prevalence between boys and girls before the age of 10. 成人患病率女性>男性,但重病区患病率性别差异小 Adult prevalence rate of women is more than men, but gender differences in the prevalence of serious IDD area are small. 65

Strategies and measures 三、预防的策略与措施 Strategies and measures 监测 掌握流行强度、流行趋势 评价干预措施的效果 为制定新的防治策略与措施提供依据 现况调查 碘盐调查 病情调查 Surveillance To master the epidemic strength , epidemic tendency To evaluate the effectiveness of interventions To provide a basis for new control and prevention  strategies and measures Cross-sectional investigation diodized salt survey disease survey

不加碘食盐 加碘食盐iodized salt Non-iodized salt 加碘食盐iodized salt

碘盐调查 Iodized salt survey 以县为单位进行 合格碘盐的碘含量标准: 35 ± 15mg/kg The county as a unit Qualifying standards for iodine content of iodized salt: 35 ± 15mg/kg

常用的统计学指标为 Commonly used statistical indicators Coverage rate of iodized salt The qualified iodized salt rate

Gotier prevalence Gotier rate

四、地方性甲状腺肿的分型、分度及诊断标准 Types、degrees and diagnostic standard for endemic goiter 分型标准 分度标准 诊断标准 Types standard Degrees standard Diagnostic standard

谢 谢 ！