肺結核

英文條目:https://en.wikipedia.org/wiki/Tuberculosis

中文條目:https://zh.wikipedia.org/wiki/%E7%B5%90%E6%A0%B8

無國界譯者翻譯

肺結核已整合存檔區

Prognosis

Progression from TB infection to overt TB disease occurs when the bacilli overcome the immune system defenses and begin to multiply. In primary TB disease (some 1–5% of cases), this occurs soon after the initial infection.[10]However, in the majority of cases, a latent infection occurs with no obvious symptoms.[10] These dormant bacilli produce active tuberculosis in 5–10% of these latent cases, often many years after infection.[13]

The risk of reactivation increases with immunosuppression, such as that caused by infection with HIV. In people coinfected with M. tuberculosis and HIV, the risk of reactivation increases to 10% per year.[10] Studies using DNA fingerprinting of M. tuberculosis strains have shown reinfection contributes more substantially to recurrent TB than previously thought,[98] with estimates that it might account for more than 50% of reactivated cases in areas where TB is common.[99] The chance of death from a case of tuberculosis is about 4% as of 2008, down from 8% in 1995.[11]

==預後==

當細菌超越免疫系統的防禦而開始增生時,疾病會由結核菌感染進展到症狀明顯的結核病。在原發型結核病 (佔 1-5% 的比例),這種現象會在感染剛開始的時候很快的發生 [10] 。然而佔率較多的潛伏結核感染,大多沒有明顯症狀 [10]。在5-10%潛伏結合感染的案例中,這些休眠的細菌經常會在感染後數年的時間製造出活動的結核 [13]。

疾病再活化的機率會隨著免疫抑制增加,例如因為感染了人類免疫缺陷病毒。同時感染有結核菌和人類免疫缺陷病毒的患者,結核再活化得機率會上升到每年10%之多 [10]。利用[[遺傳指紋分析]]鑑定結核菌的菌株的研究指出,「再度感染」在結核病復發的角色比先前的認知更重要 [98],估計在結核病盛行區域佔了疾病再活化的個案中的50% [99]。結合病得致死率在2008年大約為4%,相較於1995年的8%已有下降 [11]。

Epidemiology

Main article: Epidemiology of tuberculosis

In 2007, the prevalence of TB per 100,000 people was highest in sub-Saharan Africa, and was also relatively high in Asia.[100]

Roughly one-third of the world’s population has been infected with M. tuberculosis,[50] with new infections occurring in about 1% of the population each year.[9]However, most infections with M. tuberculosis do not cause TB disease,[101] and 90–95% of infections remain asymptomatic.[53] In 2012, an estimated 8.6 million chronic cases were active.[102] In 2010, 8.8 million new cases of TB were diagnosed, and 1.20–1.45 million deaths occurred, most of these occurring in developing countries(发展中国家).[39][103] Of these 1.45 million deaths, about 0.35 million occur in those also infected with HIV.[104]

==流行病學==

在2007年,撒哈拉以南非洲的百萬人中結核病流行度最高,而亞洲的流行度也相對較高[100]。

大約世界三分之一人口都已感染結核桿菌[50],並且新感染數正以每年全世界人口的百分之一增長[9]。但大多數的結核桿菌感染不會引起結核病[101],而且百分之九十至九十五的感染均無症狀[53]。在2012年,約有八百六十萬的慢性感染是有活性的[102]。在2010年,有八百八十萬的結核病病例被診斷出,一百二十萬至一百四十五萬人死於結核病,這些病例中大多數均分佈於[[發展中國家]][39][103]。在一百四十五萬的死亡病例中,約有三十五萬人同時感染愛滋病病毒[104]。

Tuberculosis is the second-most common cause of death from infectious disease (after those due to HIV/AIDS).[3]The total number of tuberculosis cases has been decreasing since 2005, while new cases have decreased since 2002.[39] China has achieved particularly dramatic progress, with about an 80% reduction in its TB mortality rate between 1990 and 2010.[104] The number of new cases has declined by 17% between 2004–2014.[94] Tuberculosis is more common in developing countries; about 80% of the population in many Asian and African countries test positive in tuberculin tests, while only 5–10% of the US population test positive.[10] Hopes of totally controlling the disease have been dramatically dampened because of a number of factors, including the difficulty of developing an effective vaccine, the expensive and time-consuming diagnostic process, the necessity of many months of treatment, the increase in HIV-associated tuberculosis, and the emergence of drug-resistant cases in the 1980s.[11]

結核病是繼[[愛滋病]]後,最常見的傳染病死因[3]。2002年開始,結核病的新病例數開始減少。而2005年的總病例數開始下降[39]。其中中國更在控制結核病方面達到卓越成效,1990年至2010年間,結核病的死亡率降低了80%[104]。2004年至2014年間,全球肺結核的病例數下降了17%[94]。結核病常見於開發中國家;約有80%的亞洲人的結核菌素皮下測試為陽性,只有5-10%的美國人皮下測試呈陽性[10]。由於多重因素,結核病很難完全得到控制,這些因素包括難以研發出有效的疫苗、診斷該病花費昂貴且耗時、結核病的治療時間需花費數月時間、因HIV感染而引起的結核病病例不斷增加,以及在二十世紀八十年代出現的抗藥性結核病病例[11]。

In 2007, the country with the highest estimated incidence rate of TB was Swaziland(史瓦濟蘭), with 1,200 cases per 100,000 people. India had the largest total incidence, with an estimated 2.0 million new cases.[105] In developed countries, tuberculosis is less common and is found mainly in urban areas. Rates per 100,000 people in different areas of the world were: globally 178, Africa 332, the Americas 36, Eastern Mediterranean 173, Europe 63, Southeast Asia 278, and Western Pacific 139 in 2010.[104] In Canada and Australia, tuberculosis is many times more common among the aboriginal peoples(原住民), especially in remote areas.[106][107] In the United States Native Americans have a fivefold greater mortality from TB,[108] and racial and ethnic minorities accounted for 84% of all reported TB cases.[109]

在2007年,經估算[[史瓦濟蘭]]是世界上結核病發病率最高的國家,每十萬人中約有1200人還有結核病;而印度則是結核病患病人數最多的國家,約有兩百萬新病例被發現[105]。在已開發國家中,結核病相對並不算流行,而且病患集中於城鎮地區。在2010年,世界各地的每百萬人中病例數目如下:全球平均178例、非洲332例、美洲36例、東地中海地區173例、歐洲63例、東南亞278例、西太平洋地區139例[104]。在加拿大和澳大利亞,結核病數倍更常發於[[原住民群]]中,特別是在偏遠地區[106][107]。在美國,結核病在[[土著人群]]中的致死率約是平均水平的五倍[108],而且84%的結核病例均發生於種族和族裔少數人群中[109]。

The rates of TB varies with age. In Africa, it primarily affects adolescents and young adults.[110] However, in countries where incidence rates have declined dramatically (such as the United States), TB is mainly a disease of older people and the immunocompromised (risk factors are listed above).[10][111] Worldwide, 22 "high-burden" states or countries together experience 80% of cases as well as 83% of deaths.[94]

結核病發病率因年齡而相異。在非洲,結核病主要發病於青少年及年輕成年[110]。但是在結核病發病率已急遽下降的國家裡(如美國),結核病主要發病於老年人群及免疫力低下人群(風險因子見上文)[10][111]。全世界範圍內,百分之八十的結核病病例及百分之八十三的死亡病例集中於22個結核病高負擔國家和地區[94]。

History

Main article: History of tuberculosis

==歷史==

{{main|結核病歷史}}

在保存於[[大英博物館]]的埃及[[木乃伊]]脊椎內有發現有結核病病灶的痕跡。

從[[古代史]]中就有人類得到結核病的紀錄[11]。最早可追溯回大約17,000年前在懷俄明州的野牛遺骸中所探測到的結核桿菌,可做為結核病的證據。然而,不管結核病的源頭是由牛傳染給人類,或是結核病是由共同祖先分歧而形成,這些理論都尚未明瞭[113]。比較人體內的結核桿菌基因及動物體內結核桿菌基因後發現,人類並不會在飼養動物的過程中感染結核桿菌,就像之前所認知的。這兩種結核桿菌有相同的共同祖先,也就是說在[[新石器革命]]時,它可能會傳染給人類[114]。

Egyptian mummy(木乃伊) in theBritish Museum(大英博物馆) – tubercular decay has been found in the spines of Egyptian(埃及) mummies(木乃伊).

Tuberculosis has been present in humans since antiquity(古代史).[11] The earliest unambiguous detection of M. tuberculosis involves evidence of the disease in the remains of bison in Wyoming dated to around 17,000 years ago.[112] However, whether tuberculosis originated in bovines, then was transferred to humans, or whether it diverged from a common ancestor, is currently unclear.[113] A comparison of the genes(基因) of M. tuberculosis complex (MTBC) in humans to MTBC in animals suggests humans did not acquire MTBC from animals during animal domestication, as was previously believed. Both strains of the tuberculosis bacteria share a common ancestor, which could have infected humans as early as the Neolithic Revolution(新石器革命).[114]

Skeletal remains show prehistoric humans (4000 BC(公元)) had TB, and researchers have found tubercular decay in the spines of Egyptian(埃及) mummies(木乃伊) dating from 3000–2400 BC.[115] Genetic studies suggest TB was present in the Americas(美洲) from about 100 AD.[116]

Before the Industrial Revolution(工业革命), folklore often associated tuberculosis with vampires(吸血鬼). When one member of a family died from it, the other infected members would lose their health slowly. People believed this was caused by the original person with TB draining the life from the other family members.[117]

遺骸顯示史前人類(約[[公元前]]4000年)即有患有結核病的病例,研究人員也在公元前3000至2400年的[[古埃及]][[木乃伊]]的脊椎內發現結核病病灶痕跡[115]。基因體學研究顯示結核病約在公元100年開始出現於[[美洲]][116]。

在工業革命興起前,西方民間常將結核病與吸血鬼聯繫在一起。在家中有一位成員因結核病而去世後,其他感染結核病的家庭成員慢慢失去往日的健康。人們曾認為這是因為家中第一位患有結核病的成員吸乾了其他成員的性命[117]。

Although the pulmonary form associated with tubercles was established as a pathology by Dr Richard Morton in 1689,[118][119] due to the variety of its symptoms, TB was not identified as a single disease until the 1820s. It was not named "tuberculosis" until 1839, by J. L. Schönlein(约翰·卢卡斯·舍恩来因).[120]

儘管[[理查德・莫頓醫師]]在1689年將[[結核]]病變解釋為肺結核病的病理學基礎[118][119],但因為結核病的症狀各異,直到19世紀20年代結核病才被歸類為一單一病症。1839年,這種病症才被[[約翰・盧卡斯・舍恩]]來因命名為「tuberculosis」[120]。

During 1838–1845, Dr. John Croghan, the owner of Mammoth Cave(猛犸洞国家公园), brought a number of people with tuberculosis into the cave in the hope of curing the disease with the constant temperature and purity of the cave air; they died within a year.[121] Hermann Brehmer opened the first TB sanatorium(療養院) in 1859 in Görbersdorf (now Sokołowsko), Silesia(西里西亞).[122]

在1838至1845年間,美國的約翰・克羅根醫師,[[猛獁洞國家公園]]的所有者,曾将許多結核病患者帶至洞穴內,希望可以藉洞穴中的恆溫與純淨的空氣治癒他們;但他們都在一年之內死亡[121]。於1859年,德國的赫爾曼・布萊梅醫師在Görbersdorf(今屬波蘭低地[[西里西亞]]省[[Sokołowsko]]村)建立了世界上第一個結核病[[療養院]]。

The bacillus causing tuberculosis, M. tuberculosis, was identified and described on 24 March 1882 by Robert Koch(罗伯特·科赫). He received the Nobel Prize in physiology or medicine(诺贝尔生理学或医学奖) in 1905 for this discovery.[123] Koch did not believe the bovine (cattle) and human tuberculosis diseases were similar, which delayed the recognition of infected milk as a source of infection. Later, the risk of transmission from this source was dramatically reduced by the invention of the pasteurization(巴斯德消毒法) process. Koch announced a glycerine(甘油) extract of the tubercle bacilli as a "remedy" for tuberculosis in 1890, calling it "tuberculin". While it was not effective, it was later successfully adapted as a screening test for the presence of pre-symptomatic tuberculosis.[124] The World Tuberculosis Day(世界结核病日) was established on 24 March for this reason.

引起結核病的從屬於桿菌屬的細菌——結核桿菌,在1882年三月二十四日由德國醫師兼微生物學家[[罗伯特·科赫]]發現並描述,他也因此於1905年獲得[[諾貝爾生理學或醫學獎]]。科赫不認為牛型結核病與人結核病具有相似性,這耽擱了感染結核桿菌的牛乳可做為傳染源的發現。之後,牛乳傳播因[[巴斯德消毒法]]的發明而急劇減少。科赫在1890年曾聲稱一種成份為[[甘油]]的結核菌提取物是治療結核病的特效藥,並取名「tuberculin(結核菌素)」。儘管隨後經證實它對結核病的治療並沒有效果,它隨後被製成結核病的篩選試劑以發現潛伏肺結核感染。因此三月二十四日被定為[[世界結核病日]]。

Albert Calmette and Camille Guérin achieved the first genuine success in immunization against tuberculosis in 1906, using attenuated bovine-strain tuberculosis. It was called bacille Calmette–Guérin(卡介苗) (BCG). The BCG vaccine was first used on humans in 1921 in France,[125] but received widespread acceptance in the US, Great Britain, and Germany only after World War II.[126]

法國醫師[[愛伯特·卡脈特]]與[[卡米約·芥蘭]]使用減毒性牛型結核桿菌,於1906年率先在結核病免疫方面得到成功。這種疫苗因此被稱作[[卡介苗]](BCG)。1921年,卡介苗在法國首先於人體上使用[125],但二戰後才在美國、英國、德國廣泛使用[126]。

Tuberculosis caused the most widespread public concern in the 19th and early 20th centuries as an endemic(地方性流行) disease of the urban poor. In 1815, one in four deaths in England was due to "consumption". By 1918, one in six deaths in France was still caused by TB. After TB was determined to be contagious, in the 1880s, it was put on a notifiable disease list in Britain; campaigns were started to stop people from spitting in public places, and the infected poor were "encouraged" to enter sanatoria(療養院) that resembled prisons (the sanatoria for the middle and upper classes offered excellent care and constant medical attention).[122] Whatever the (purported) benefits of the "fresh air" and labor in the sanatoria, even under the best conditions, 50% of those who entered died within five years (circa 1916).[122]

在19世紀與20世紀初,結核病作為城鎮貧民區的[[地方性流行]]疾病引起了最廣泛關注。在1815年,英格蘭地區每四個死亡病例中就有一個是死於「消耗」(consumption:肺結核的英文舊稱)。直至1918年,法國的每六個死亡病例中仍然就有一個是死於結核病。在結核病被認定為傳染性疾病後,19世紀80年代英國將其認定為[[法定傳染病]],需上報至政府部門;英國政府也發起社會運動以防止人們在公共場所隨地吐痰。感染結核病的窮人被英國政府「鼓勵」進入專門設立的像监狱一样的療養院(中產階級與上層階級的療養院提供極好的照護與不間斷的醫療服務)[122]。儘管(官方聲稱)結核病患者可在療養院內享受「清新的空氣」以及一定的勞動有益於結核病的康復,即使療養院擁有最好的條件,百分之五十進入療養院的病患仍在五年內死亡[122]。

In Europe, rates of tuberculosis began to rise in the early 1600s to a peak level in the 1800s, when it caused nearly 25% of all deaths.[127] By the 1950s, mortality had decreased nearly 90%.[128] Improvements in public health began significantly reducing rates of tuberculosis even before the arrival of streptomycin(鏈黴素) and other antibiotics, although the disease remained a significant threat to public health such that when the Medical Research Council was formed in Britain in 1913, its initial focus was tuberculosis research.[129]

在歐洲,結核病發病率在17世紀早期開始上升,並在19世紀達到峰值:此時因結核病死亡的病例幾乎佔據所有死亡病例中的四分之一[127]。至20世紀50年代,結核病死亡率已降低接近百分之九十[128]。公衛條件的改善顯著降低了結核病發病率(甚至是在[[鏈黴素]]與其他抗生素發明之前),儘管其仍是對公眾健康的極大威脅。例如1913年英國設立[[醫學研究委員會]](MRC),起初的研究重點即是結核病[129]。

In 1946, the development of the antibiotic streptomycin(鏈黴素) made effective treatment and cure of TB a reality. Prior to the introduction of this drug, the only treatment (except sanatoria) was surgical intervention, including the "pneumothorax(氣胸) technique", which involved collapsing an infected lung to "rest" it and allow tuberculous lesions to heal.[130]

Because of the emergence of MDR-TB, surgery has been re-introduced as an option within the generally accepted standard of care in treating TB infections. Current surgical interventions involve removal of pathological chest cavities ("bullae") in the lungs to reduce the number of bacteria and to increase the exposure of the remaining bacteria to drugs in the bloodstream, thereby simultaneously reducing the total bacterial load and increasing the effectiveness of systemic antibiotic therapy.[131]

1946年研製成功的抗生素——[[鏈黴素]]使得結核病的有效治療與治癒成為現實。而在此之前,(除療養院法外)治療肺結核唯一的途徑是通過外科手術。「[[氣胸]]法」即是其中一種術式,通過使感染結核桿菌的肺坍塌以使其「休息」,使結核桿菌感染的肺部得以癒合[130]。由於多重抗藥性結核病的出現,手術法被重新引入治療結核病的常規方法。現今結核病的手術路徑包括清除肺部空洞性病變以減少細菌,並增加剩餘細菌對血液中藥物的暴露面積,以此減少總細菌負荷並增強系統性抗生素療效[131]。

Hopes of completely eliminating TB (cf. smallpox(天花)) from the population were dashed after the rise of drug-resistant(抗生素抗藥性) strains in the 1980s. The subsequent resurgence of tuberculosis resulted in the declaration of a global health emergency by the World Health Organization in 1993.[132]

20世紀80年代,[[抗生素抗藥性]]的大幅增加使得完全清除結核病的希望破滅。隨後的1993年,結核病的重新爆發使得世界衛生組織(WHO)宣布進入全球衛生緊急狀態[132]。

Society and culture

Names

Phthisis is a Greek word for consumption, an old term for pulmonary tuberculosis;[2] around 460 BC, Hippocrates(希波克拉底) described phthisis as a disease of dry seasons.[133]The abbreviation "TB" is short for tubercle bacillus(杆菌).

==結核病的社會與文化影響==

===命名===

Phthisis在希臘文的意思是消耗,一個古老的專有名詞專指肺結核。[2]大約在西元前460年,[[希波克拉底]]描述Phthisis為乾季時的疾病。[133]縮寫TB是由[[tubercle bacillus(桿菌)]]而來

Public health efforts

The World Health Organization(世界卫生组织), Bill and Melinda Gates Foundation(比爾與美琳達·蓋茨基金會), and US government are subsidizing a fast-acting diagnostic tuberculosis test for use in low- and middle-income countries.[134][135][136] In addition to being fast-acting, the test can determine if there is resistance to the antibiotic rifampicin which may indicate multi-drug resistant tuberculosis and is accurate in those who are also infected with HIV.[134][137] Many resource-poor places as of 2011 have access to only sputum microscopy.[138]

===公衛組織的應對===

[[世界衛生組織]]、[[比爾與美琳達·蓋茨基金會]]以及美國政府正在資助一種結核病分子檢驗法的推廣,以供低收入與中等收入國家使用[134][135][136]。這種檢測方法不僅快速,而且可以檢測患者感染的菌株是否具有利福平(一種抗生素)抗性,這可以顯示該菌株是否有多重抗藥性;這種檢測方法對於感染HIV的患者的檢測準確性也相當高[134][137]。至2011年,許多缺少醫療設備資源的地區仍只能使用痰液細菌塗片檢查[138]。

India had the highest total number of TB cases worldwide in 2010, in part due to poor disease management within the private and public health care sector.[139] Programs such as the Revised National Tuberculosis Control Program are working to reduce TB levels amongst people receiving public health care.[140][141]

在2010年,印度是擁有結核病例數最高的國家,一部分是由於公衛組織與基層醫療單位的管控不善所導致的[139]。類似像[[新國家結核病防治項目(RNTCP)]]等項目正在接受公共醫療照護的人群中減少結核病的發生[140][141]。

A 2014 the EIU(经济学人信息社)-healthcare report that the need to address apathy and urging for increased funding. The report cites among others Lucica Ditui "[TB] is like an orphan. It has been neglected even in countries with a high burden and often forgotten by donors and those investing in health interventions."[94]

2014年,[[經濟學人信息社]]發布報告——《古老的敵人,迫切的任務:是時候該採取更強手段控制結核病了》,稱結核病需要更多關注與更多的資金以支持其研究。報告援引盧奇卡·第提尤(Lucica Ditiu) 博士說法稱「(結核病)像是孤兒一樣。甚至在因結核病流行而造成較大負擔的國家,結核病也已被忽視,衛生領域的投資者與捐助者也常忘記對結核病診治的投資。[94]

Slow progress has led to frustration, expressed by executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria – Mark Dybul: "we have the tools to end TB as a pandemic and public health threat on the planet, but we are not doing it."[94] Several international organizations are pushing for more transparency in treatment, and more countries are implementing mandatory reporting of cases to the government, although adherence is often sketchy. Commercial treatment-providers may at times overprescribe second-line drugs as well as supplementary treatment, promoting demands for further regulations.[94] The government of Brazil provides universal TB-care, which reduces this problem.[94] Conversely, falling rates of TB-infection may not relate to the number of programs directed at reducing infection rates, but may be tied to increased level of education, income and health of the population.[94] Costs of the disease, as calculated by the World Bank in 2009 may exceed 150 billion USD per year in "high burden" countries.[94] Lack of progress eradicating the disease may also be due to lack of patient follow-up – as among the 250M rural migrants in China(流动人口).[94]

防治結核病的緩慢進度已引起了相關人士的失望。[[全球抗擊愛滋病、結核病與瘧疾基金會]]執行董事馬克·戴布爾表示:「我們本有阻止結核病大規模流行、威脅公眾健康的武器,但我們就是不採取措施。」[94]一些國際組織正在呼籲結核病治療變得更加透明;更多國家也正在實施結核病例強制上報制度,儘管執行效果不佳。營利性治療提供商時常會過量開立二線藥物以及輔助用藥,這使得對更多監管措施的需求愈加強烈[94]。巴西政府由此提供全民結核病照護,以減少這種現象的發生。但是,結核病感染率的下降卻可能與為減少結核病感染率而開展的項目數量無關,而與教育程度的上升、收入增加以及人口健康程度有關[94]。世界銀行計算,2009年在「高負擔國家」每年結核病的各項支出可能超過一千五百億元[94]。難以根除結核病的另一個可能原因是由於個案難以跟進——例如對於中國的[[流動人口]][94]。

Stigma

Slow progress in preventing the disease may in part be due to stigma associated with TB.[94] Stigma may be due to the fear of transmission from affected individuals. This stigma may additionally arise due to links between TB and poverty, and in Africa, AIDS.[94] Such stigmatization may be both real and perceived, for example; in Ghana individuals with TB are banned from attending public gatherings.[142]

===患病帶來的羞恥感===

難以防治結核病的另一個可能原因是由結核病而帶來的[[羞恥感]][94],這可能是由於害怕被感染者傳染所致。這種羞恥感還可能會因結核病與貧困的聯繫而增加;在[[非洲]],羞恥感還會因患有[[愛滋病]]而增加[94]。這種獲得羞恥的方式既真實又易於察覺,例如在迦納,結核病病患被禁止參加公眾聚會[142]。

Stigma towards TB may result in delays in seeking treatment,[94] lower treatment compliance, and family members keeping cause of death secret[142] – allowing the disease to spread further.[94] At odds is Russia, where stigma was associated with increased treatment compliance.[142] TB stigma also affects socially marginalized individuals to a greater degree and varies between regions.[142]

由結核病帶來的羞恥感可能會導致耽誤治療[94]、難以接受治療以及家庭成員不願透露死因[142]——這導致結核病的傳播更為猛烈[94]。但在俄羅斯,結核病帶來的羞恥感卻能增加患者對治療的接受度[142]。雖存在地區差異,但結核病帶來的羞恥感還是可以使社會邊緣個體更加被邊緣化[142]。

One way to decrease stigma may be through the promotion of "TB clubs", where those infected may share experiences and offer support, or through counseling.[142] Some studies have shown TB education programs to be effective in decreasing stigma, and may thus be effective in increasing treatment adherence.[142] Despite this, studies on relationship between reduced stigma and mortality are lacking as of 2010, and similar efforts to decrease stigma surrounding AIDS have been minimally effective.[142] Some have claimed the stigma to be worse than the disease, and healthcare providers may unintentionally reinforce stigma, as those with TB are often perceived as difficult or otherwise undesirable.[94] A greater understanding of the social and cultural dimensions of tuberculosis may also help with stigma reduction.[143]

發展「結核病互援會」是減少結核病帶來的羞恥感的一種方式,在互援會中感染者可議互相分享治療經驗、互相支持;諮商也可減少結核病帶來的羞恥感[142]。研究顯示結核病衛教項目可有效降低其帶來的羞恥感,這可以增加患者對治療的配合度[142]。儘管如此,直至2010年,研究人員並未發現結核病羞恥感的降低與死亡率存在一定關聯;相比之下,降低因愛滋病而帶來的羞恥感從而降低愛滋病死亡率的努力已初見成效[142]。一些研究者指出結核病帶來的羞恥感比疾病本身更能帶給患者痛苦,而醫務人員因在治療過程中視結核病人難以應付或不受歡迎,又會無意中增加患者的羞恥感[94]。對結核病人社會與文化性的理解與包容也可減輕患者的羞恥感[143]。

Research

The BCG vaccine has limitations, and research to develop new TB vaccines is ongoing.[144] A number of potential candidates are currently in phase I and II clinical trials(臨床試驗).[144] Two main approaches are being used to attempt to improve the efficacy of available vaccines. One approach involves adding a subunit vaccine to BCG, while the other strategy is attempting to create new and better live vaccines.[144] MVA85A, an example of a subunit vaccine, currently in trials in South Africa, is based on a genetically modified vaccinia virus.[145] Vaccines are hoped to play a significant role in treatment of both latent and active disease.[146]

===結核病研究===

卡介苗疫苗仍有其侷限,目前正在研究開發新的結核病疫苗[144]。目前已有一些潛在的候選疫苗正處於第一期和[[二期臨床試驗]][144]。主要有兩種方法用來嘗試提高現有疫苗的功效。一種是涉及將一個次單位疫苗加入BCG,而另一種策略是試圖做出全新且更好的活疫苗[144] 。[[MVA85A]]是一種次單位疫苗,目前在南非進行試驗,此疫苗發展基礎是以[[牛痘]]病毒作基因改造[145]。這些新興疫苗主要是希望對潛在性和活動性肺結核能有顯著的角色。[146]

To encourage further discovery, researchers and policymakers are promoting new economic models of vaccine development, including prizes, tax incentives, and advance market commitments.[147][148] A number of groups, including the Stop TB Partnership,[149] the South African Tuberculosis Vaccine Initiative, and the Aeras Global TB Vaccine Foundation, are involved with research.[150] Among these, the Aeras Global TB Vaccine Foundation received a gift of more than $280 million (US) from the Bill and Melinda Gates Foundation(比爾與美琳達·蓋茨基金會) to develop and license an improved vaccine against tuberculosis for use in high burden countries.[151][152]

為鼓勵結核病研究,研究人員與政策制定者正在促進疫苗研發經濟模式的轉變,其中包括價格、減稅政策以及[[預先市場承諾]]等[147][148]。一些社會組織也加入了結核病研究,包括[[防治結核病合作組織]][149]、南非結核病疫苗行動組織,以及[[Aeras全球結核病疫苗基金會]]等[150]。這些組織中,Aeras全球結核病疫苗基金會曾被[[比爾與美琳達·蓋茨基金會]]贈與超過兩億八千萬美元以開發一種改進的結核病疫苗並推動其批准,以在結核病高負擔國家使用[151][152]。

A number of medications are being studied for multi drug resistant tuberculosis including: bedaquiline and delamanid.[153] Bedaquiline received U.S. Food and Drug Administration(美国食品药品监督管理局) (FDA) approval in late 2012.[154] The safety and effectiveness of these new agents are still uncertain, because they are based on the results of a relatively small studies.[153][155] However, existing data suggest that patients taking bedaquiline in addition to standard TB therapy are five times more likely to die than those without the new drug,[156] which has resulted in medical journal articles raising health policy questions about why the FDA approved the drug and whether financial ties to the company making bedaquiline influenced physicians’ support for its use [155][157]

研究人員正在研究多種治療多重抗藥性結核病的藥物,包括[[贝达喹啉]](Sirturo)以及[[德拉马尼]](Deltyba)[153]。贝达喹啉在2012年年末時經[[美国食品药品监督管理局]]批准上市[154]。由於這些新藥並未經過大規模研究,其安全性和藥效尚不明確[153][155]。但是現有資料顯示,新藥贝达喹啉與常規結核病治療聯合使用相比不使用新藥,可使患者死亡率上升五倍[156],這使得醫學期刊文章質疑美國食品藥品監督管理局為何批准該藥上市,以及質疑藥廠是否有賄賂行為以鼓勵醫師使用該藥[155][157]。

Other animals

Mycobacteria infect many different animals, including birds,[158] rodents,[159] and reptile.[160] The subspecies Mycobacterium tuberculosis, though, is rarely present in wild animals.[161] An effort to eradicate bovine tuberculosis caused by Mycobacterium bovis from the cattle and deer herds of New Zealand(新西兰) has been relatively successful.[162]Efforts in Great Britain have been less successful.[163][164]

===其他動物的結核病===

分枝桿菌屬的細菌也可感染其他動物,包括鳥類[158]、齧齒動物[159]以及爬行動物[160],但結核分枝桿菌亞種的細菌卻很少在野生動物身上出現[161]。在[[新西蘭]],根除牛與鹿因感染牛結核桿菌而患有的[[牛結核病(真珠病)]]的工作已相對大有成效。相比之下,英國的相關工作進展地卻不盡順利。

As of 2015, tuberculosis appears to be widespread among captive elephants() in the US. It is believed that the animals originally acquired the disease from humans, a process called reverse zoonosis(人畜共通傳染病). Because the disease can spread through the air to infect both humans and other animals, it is a public health concern affectingcircuses(马戏) and zoos(動物園).[165][166]

截止2015年,結核病似乎在美國馴養的[[象]]中廣為流行。這被解釋為動物起初從人類身上獲得此病,因結核病是一種[[人畜共同傳染病]]。由於結核病可通過空氣感染人或動物,因此是一影響[[馬戲團]]和動物園的[[公共衛生問題]][165][166]。