2023年南部某醫院慢性呼吸照護病房結核病聚集事件調查

Tuberculosis Outbreak in a Chronic Respiratory Care Ward at a Hospital in Southern Taiwan, 2023

慢性呼吸照護病房收治對象為長期依賴呼吸器之病患，大部分係合併多重慢性病、免疫低下之長期臥床者，屬罹患結核病之高危險群，且因常進行抽痰等產生氣溶膠處置（aerosol generating procedure），若環境通風不佳或感染管制措施不良，便容易發生結核病聚集事件。於2022年6月至2023年5月間，南部某醫院慢性呼吸照護病房共4名病患確診結核病，菌株基因型別均相同，為一起具有流行病學關聯的結核病聚集事件。衛生單位偵測到疫情後，即邀請胸腔科醫師、感染管制專家及環境空調換氣專家進行現勘，研判造成本聚集案的可能原因，包含不完善的感控措施，如未即早警覺疑似傳染性病患並適當隔離、匡列接觸者檢查與治療未完整到位、環境通風系統設計不佳等問題；後續院方依建議逐一改善，有效遏止疫情蔓延。

Patients admitted to chronic respiratory care wards are long-term ventilator-dependent, who often are bedridden, have multiple chronic conditions and weakened immune systems. These patients are at high-risk for tuberculosis. Additionally, because of the frequent use of aerosol-generating procedures such as suctioning, tuberculosis outbreaks can easily occur if the ward has poor ventilation or inadequate infection control measures.
During June 2022 to May 2023, four patients in a chronic respiratory care ward at a hospital in southern Taiwan were diagnosed with tuberculosis. Genetic typing found that patients were infected with identical bacterial strains, indicating a tuberculosis outbreak. Following the detection of the outbreak, health authorities invited pulmonologists, infection-control experts, and environmental-ventilation specialists to conduct an on-site investigation. They identified the likely causes of the outbreak, including failure to promptly identify and isolate potentially infectious patients, incomplete screening and treatment of contacts, and poorly designed ventilation systems.
Based on the experts' recommendations, the hospital implemented improvements and effectively prevented further spread of the outbreak.