2022年臺灣中部某精神科醫院結核病聚集事件調查

A Tuberculosis Outbreak at a Psychiatric Hospital in Central Taiwan, 2022

中部某精神科醫院於2021年9月至2023年1月共通報11例結核病確診個案，其中5案菌株比對結果相同，研判為結核病聚集事件。經疫調後發現案1與案3具流行病學相關，但案3於案1確診時，並未列入案1之接觸者。建議精神科醫院應確實掌握參與復健治療病人名單，以提升疫情調查完整性。另案3於2021年5月即出現相關症狀，遲至8個月後才因列為案2接觸者而發現確診，確診時痰已雙陽具高傳染性，建議醫院應加強患者健康狀況之監測，以避免延遲診斷情形。

A psychiatric hospital in central Taiwan reported a total of 11 confirmed cases of pulmonary tuberculosis from September 2021 to January 2023. Five of these cases had an identical genotype, indicating a tuberculosis outbreak. Epidemiological investigation revealed an association between Case 1 and Case 3. However, Case 3 was not initially listed as a contact of Case 1 upon Case 1's diagnosis. It was recommended that the psychiatric hospital accurately maintain lists of patients participating in psychiatric rehabilitation programs to enhance the completeness of epidemiological investigations. Furthermore, Case 3 exhibited relevant symptoms as early as May 2021, but was diagnosed after a delay of 8 months when being identified as a contact of Case 2. At the time of diagnosis, Case 3's sputum smear and culture were both positive for tuberculosis, indicating high infectivity. It is advised that the hospital strengthen surveillance of patients' health conditions to prevent diagnostic delays.