1. Khon Kaen Medical Journal Vol. 34 No. 1 January - April 2010 1
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Tuberculosis update
∏√√¡ √≥å æ‘√‘¬ ÿæß»å; M.D., M.Sc., Ph.D., Board of Preventive Medicine (Epidemiology)
‚√ß欓∫“≈¢Õπ·°àπ
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∑’˺à“π¡“ ´÷Ëß¡’ Theme „πªïπ’ȧ◊Õ çOn the Move ‡∑’¬∫°“√Õ¬Ÿà„π∫â“π∑’Ë¡’ºŸâ Ÿ∫∫ÿÀ√’ËÕ¬à“ßπâÕ¬Àπ÷Ëߧπ°—∫°“√
Against Tuberculosis: Innovate to Accelerate Õ¬Ÿà„π∫â“π∑’ˉ¡à¡’ºŸâ Ÿ∫∫ÿÀ√’ˇ≈¬æ∫«à“„π°“√‡°Á∫¢âÕ¡Ÿ≈‡ªìπ
Actioné ‚¥¬‰¥â ¡’ ° “√ª√–¡“≥‰«â «à “ 1 „π 3 ¢Õß √–¬–‡«≈“Õ¬à“ßπâÕ¬ 6 ªïæ∫«à“ºŸâ∑’Ë Ÿ∫∫ÿÀ√’Ë∑“ßÕâÕ¡À√◊Õ
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È È Ÿ∫∫ÿÀ√’Ë¡◊Õ Õß (secondhand smoke) ¡’§«“¡‡ ’ˬß
·≈–®“°°“√ª√–¡“≥°“√¢ÕßÕß§å ° “√Õπ“¡— ¬ ‚≈°„π ‡æ‘Ë¡¢÷Èπ 1.5 ‡∑à“„π°“√ªÉ«¬‡ªìπ«—≥‚√§ ·≈–¬—ß¡’‚Õ°“
ªï 2551 æ∫«à“ °«à“ 11.1 ≈â“π§π∑—Ë«‚≈°ªÉ«¬‡ªìπ«—≥‚√§ „π°“√‡°‘¥‚√§Õÿ¥°—Èπ∑“߇¥‘πÀ“¬„®·≈–‡∫“À«“π¥â«¬
·∫∫ Active ´÷Ëß “¡“√∂·æ√à‡™◊ÈÕ‰¥â ·≈–„πªï 2551 ‡æ’¬ß ‡™àπ°—π ß“π«‘®—¬¥—ß°≈à“«‰¥â√—∫°“√¬◊π¬—π®“°ß“π«‘®—¬∑’Ë
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ª√–¡“≥ 5 · π§π‡ªìπºŸâªÉ«¬∑’˵‘¥‡™◊ÈÕ HIV √à«¡¥â«¬ ¬—߇æ‘Ë¡‚Õ°“ °“√ªÉ«¬‡ªìπ¡–‡√Áߪե ‚√§À—«„® ·≈–°“√
·≈–ªí≠À“∑’Ëæ∫¡“°¢÷Èπ §◊Õ °“√¥◊ÈÕ¬“ ‚¥¬‡©æ“–„𠵑¥‡™◊ÈÕ„πªÕ¥·∫∫µà“ßÊ √«¡∑—Èß«—≥‚√§¥â«¬ ªí≠À“
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ªï 2558 π—πµâÕßÕ“»—¬§«“¡À«—ß®“°«‘®¬„À¡à∑°”≈—ß»÷°…“
È — ’Ë ∑’Ëπà“°—ß«≈‰¡àπâÕ¬ ‡π◊ËÕß®“°æ∫«à“ ∫ÿ§≈“°√∑“ß°“√
„πªí®®ÿ∫π — ·æ∑¬å√«¡∂÷ß欓∫“≈´÷Ë߇ªìπ°≈ÿà¡ Latent infection ¡’
µ—«Õ¬à“ßß“π«‘®—¬∑’Ëπ”¡“´÷Ëߧ«“¡À«—ß ‰¥â·°à ·π«‚πâ¡„π°“√À¬ÿ¥°‘𬓇æ◊ËÕ°“√√—°…“°«à“√âÕ¬≈– 40
ß“π«‘®—¬«—§´’πªÑÕß°—π«—≥‚√§ ”À√—∫ºŸâµ‘¥‡™◊ÈÕ HIV „π ¢Õß°“√‡ΩÑ“µ‘¥µ“¡∑—Èß„π À√—∞Õ‡¡√‘°“·≈–·§π“¥“ ·≈–
ªí®®ÿ∫—πÕ¬Ÿà„π clinical trial Phase III ´÷Ëß¡’ºŸâ‡¢â“√à«¡°“√ ®“°°“√»÷°…“°àÕπÀπâ“π’È æ∫«à“ ∫ÿ§≈“°√∑“ß°“√·æ∑¬å
»÷°…“°«à“ 2 æ—π§π´÷Ëßµ‘¥‡™◊ÈÕ HIV „πª√–‡∑»·∑π´“‡π’¬ ¡’·π«‚πâ¡„π°“√°‘𬓉¡à°‘𬓇æ◊ËÕ°“√√—°…“ Ÿß°«à“§π
‚¥¬æ∫«à“ «—§´’π¥—ß°≈à“« “¡“√∂≈¥°“√µ‘¥‡™◊ÈÕ«—≥‚√§‰¥â ∑—Ë«‰ª∂÷ß 5 ‡∑à“ πÕ°®“°π’È °≈ÿà¡∫ÿ§≈“°√∑“ß°“√·æ∑¬å
ª√–¡“≥√âÕ¬≈– 39 ‚¥¬ß“π«‘®¬¥—ß°≈à“«‰¥â√∫°“√µ’æ¡æå
— — ‘ ¬—ß°‘𬓉¥â§√∫µ“¡§”·π–π”πâÕ¬°«à“ª°µ‘¥â«¬ ‰¥â¡’°“√
„π«“√ “√ AIDS ‚¥¬π—°«‘®—¬‰¥â°≈à“««à“¢—ÈπµàÕ‰ª§◊Õ°“√ ª√–¡“≥°— π «à “ ¡’ ª √–™“°√°«à “ 15 ≈â “ π§π„π À√— ∞
‡¢â“‰ª¡’ «π√à«¡„π°“√æ—≤π“«—§´’π¥—ß°≈à“«√à«¡°—∫∫√‘…∑
à — Õ‡¡√‘°“∑’˪ɫ¬‡ªìπ Latent infection §◊Õ ¡’°“√µ‘¥‡™◊ÈÕ·µà
ºŸâº≈‘µ«—§´’π ·≈–¡’§«“¡®”‡ªìπ∑’Ë®–µâÕß„Àâ«—§´’ππ’È·°à ‰¡à¡’Õ“°“√‡π◊ËÕß®“°§«“¡ “¡“√∂¢Õß¿Ÿ¡‘§ÿâ¡°—π„π°“√
ºŸâµ‘¥‡™◊ÈÕ°àÕπ∑’Ë®–‰¥â√—∫°“√√—°…“¥â«¬¬“µâ“π‰«√— ‡æ√“– °¥∑—∫Õ“°“√‰¡à„Àâ· ¥ßÕÕ°¡“‰¥â ∑’π“°—ß«≈ §◊Õ ·¡â®–‡ªìπ
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ºŸâµ‘¥‡™‘ÈÕ HIV ¡’·π«‚πâ¡∑’Ë®–‰¥â√—∫°“√µ‘¥‡™◊ÈÕ«—≥‚√§·¡â Latent infection °Á¬—ß “¡“√∂·æ√à‡™◊ÈÕ ŸàºŸâÕ◊Ëπ‰¥â·¡â®–
®–¬—߉¡à¡’Õ“°“√„¥Ê ‰¡à¡’Õ“°“√„¥Ê ‡≈¬ ·≈–¥â«¬‡Àµÿπ’ȇÕß∑“ß The U.S.
πÕ°®“°°“√µ‘¥‡™◊ÈÕ HIV ·≈â«°“√ Ÿ∫∫ÿÀ√’ˬ—߇æ‘Ë¡ Centers for Disease Control and Prevention (CDC)
§«“¡‡ ’¬ßµàÕ°“√µ‘¥‡™◊Õ«—≥‚√§¥â«¬‡™àπ°—π ‚¥¬°“√»÷°…“
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2. 2 ¢Õπ·°àπ‡«™ “√ ªï∑’Ë 34 ©∫—∫∑’Ë 1 ¡°√“§¡ - ‡¡…“¬π 2553
‡√◊ËÕß¿Ÿ¡‘§ÿâ¡°—π ·≈–ºŸâ∑’Ë —¡º— °—∫ºŸâªÉ«¬∑’Ë¡’°“√µ‘¥‡™◊ÈÕ·≈– «‘π‘®©—¬‡∫◊ÈÕßµâπ “¡“√∂·¬°≈—°…≥–∑“ß√—ß ’∑’Ë·µ°µà“ß
· ¥ßÕ“°“√ ´÷Ëß√«¡∂÷ß∫ÿ§≈“°√∑“ß°“√·æ∑¬å¥â«¬ ·µà √–À«à“߇™◊ÈÕ∑’ˇªìπ Multidrug-resistant tuberculosis
§«“¡‡¢â“„®«à“‡Àµÿ„¥§π°≈ÿà¡π’È®÷ßÀ¬ÿ¥°“√√—°…“‡Õ߬—߇ªìπ °—∫‡™◊ÈÕ∑’ˉ¡à¥È◊Õ¬“ 5 ·≈–¢âÕ¡Ÿ≈¥â“π°“√«‘π‘®©—¬¬—ßæ∫
‡√◊Õß∑’µÕ߉¥â√∫°“√»÷°…“µàÕ‰ª ·µà¡§«“¡πà“®–‡ªìπ‰¥â«“
Ë Ë â — ’ à ‡æ‘Ë¡‡µ‘¡Õ’°«à“ ‡¡Á¥‡≈◊Õ¥¢“«™π‘¥ Lymphocyte ∫“ß™π‘¥
Õ—µ√“„π°“√ªÉ«¬®π‡ªìπ Full-blown tuberculosis π—Èπ ¡’ —¥ à«π∑’Ë·µ°µà“ß√–À«à“ߺŸâ∑’ˇªìπ Active °—∫Õ“ “ ¡—§√
¡’‡æ’¬ß 1 „π 20 ·≈–‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫°“√°‘𬓇æ◊ËÕ ‚¥¬æ∫«à“ „πºŸâªÉ«¬∑’ˇªìπ Active tuberculosis π—Èπ®–¡’
√—°…“π—Èπ„™â‡«≈“Õ¬à“ߵ˔ 4-6 ‡¥◊Õπ ·≈–¬“ à«π„À≠à°Á¡’ CD3(+) ·≈– CD3(+)CD4(+) cells ∑’ˇæ‘Ë¡¢÷Èπ ·≈–¡’
º≈¢â“߇§’¬ß∑’Ë¡’º≈°√–∑∫µàÕ™’«‘µª√–®”«—π¢ÕߺŸâ∑’Ë°‘π¬“ Õ—µ√“ à«π¢Õß CD3(+)CD4(+) µàÕ CD3(+)CD8(+)
¥â«¬ ·≈–‡π◊ËÕß®“°«à“°“√°‘π¬“∑’ˬ“«π“ππ—Èπ¡’º≈µàÕ°“√ cells ≈¥≈ß ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫ºŸâªÉ«¬ª°µ‘ 6 ·≈–æ∫«à“
°‘π¬“∑’ˉ¡à§√∫µ“¡§”·π–π” ©–π—Èπ ®÷߉¥â¡’°“√·π–π” „π°≈ÿࡺŸâªÉ«¬∑’ˇªìπ Pulmonary tuberculosis ∑’Ë√—∫°“√
„Àâ¡’°“√°‘π¬“∑’Ë¡’√–¬– —Èπ ‚¥¬¢≥–π’ȉ¥â¡’°“√∑¥≈Õß √—°…“Õ¬Ÿà„π Intensive care unit π—Èπ °“√«‘π‘®©—¬¥â«¬
√—°…“ºŸâªÉ«¬°≈ÿà¡π’ȥ⫬¬“ Isoniazide °—∫¬“Õ’°µ—« §◊Õ °“√∑” Chest X ray Õ“®‰¡à ‰ ¥â √— ∫ ª√–‚¬™πå ¡ “°π— °
Rifapentine „π√–¬–‡«≈“ 3 ‡¥◊Õπ ‚¥¬§“¥«à“®– “¡“√∂ ‡æ√“–¡’§«“¡®”‡æ“–µàÕ°“√«‘π‘®©—¬§àÕπ¢â“ߵ˔
∑”„À⇰‘¥°“√°‘π¬“∑’˧√∫µ“¡∑’Ë·π–π” ·≈–√—°…“°≈ÿà¡ °“√»÷°…“∂÷ߧ«“¡™ÿ°µàÕ°“√‡°‘¥ Multidrug
Latent infection ‰¥â¡“°¢÷Èπ¥â«¬ resistant tuberculosis ®“°°“√»÷°…“„πª√–™“°√°«à“
„π à«πµàÕ‰ª®–¢Õ°≈à“«∂÷ß°“√√«∫√«¡ß“π«‘®—¬ 9 À¡◊Ëπ§π®“° 83 ª√–‡∑»∑—Ë«‚≈° æ∫«à“ §à“ Median
ª√–‡¿∑ Review ∑’ˇªìπº≈ß“π≈à“ ÿ¥ ‡æ◊ËÕ∑ÿ°∑à“π®–‰¥â ¢Õߧ«“¡™ÿ°Õ¬Ÿà∑’˪√–¡“≥ 11.1% „π°≈ÿࡺŸâªÉ«¬„À¡à∑’ˬ—ß
“¡“√∂𔉪ª√— ∫ „™â · ≈–√— ° …“ºŸâ ªÉ « ¬«— ≥ ‚√§µà Õ ‰ª ‰¡à‰¥â√—∫°“√√—°…“Õ¬à“ß„¥‡≈¬ 7 ·≈–¡’§«“¡™ÿ°¡“°„π
ß“π«‘®—¬·√°∑’Ë®–¢Õ°≈à“«∂÷ß §◊Õ °“√‡ª√’¬∫‡∑’¬∫°“√„™â¬“ ª√–‡∑»®’π·≈–ª√–‡∑» À¿“æ‚´‡«’¬µ‡¥‘¡ „π¢≥–∑’Ë
Rifampicin ‡ªìπ√–¬–‡«≈“ 4 ‡¥◊Õπ °—∫¬“ Isoniazid ¢â Õ ¡Ÿ ≈ §«“¡™ÿ ° ¬— ß ‰¡à · πà ™— ¥ „πª√–‡∑»·∂∫·Õø√‘ ° “
‡ªìπ√–¬–‡«≈“ 9 ‡¥◊Õπ„π°“√√—°…“°≈ÿࡺŸâ∑’ˇªìπ Latent à«π„À≠à
tuberculosis æ∫«à“ Systematic review „πªï 2552 ¡’°“√∂“¡À≈“¬§√—ß«à“¡’ß“π«‘®¬„¥∑’· ¥ß„Àâ‡ÀÁπ
È — Ë
· ¥ß„Àâ‡ÀÁπ«à“ °“√„™â¬“ Rifampicin “¡“√∂‡æ‘Ë¡‚Õ°“ ∂÷ߧ«“¡ —¡æ—π∏å√–À«à“ß°“√µ‘¥‡™◊ÈÕ HIV ·≈–°“√‡°‘¥
„π°“√∑’Ë®–∑”„À⺟âªÉ«¬∑’ˇªìπ Latent infection “¡“√∂ Multi drug resistant tuberculosis (MDR-TB) „π
°‘𬓉¥â§√∫¡“°¢÷Èπ ¡’º≈¢â“߇§’¬ß®“°°“√„™â¬“∑’ËπâÕ¬≈ß ß“π«‘®—¬ Systematic review ‡¡◊ËÕªï 2009 √ÿª‰«âÕ¬à“ß
·≈–¬—ß¡’ª√– ‘∑∏‘¿“æ (Cost-effectiveness) Õ’°¥â«¬ 1 πà“ π„®«à“ °“√‡°‘¥ MDR-TB π—Èπ¬—߉¡à¡’À≈—°∞“π∑’Ë
„π¥â“𧫓¡√«¥‡√Á«¢Õß°“√√—°…“æ∫«à“ À“°‰¥â√—∫°“√ · ¥ß„Àâ‡ÀÁπ∂÷ߧ«“¡ —¡æ—π∏å∑’Ë™—¥‡®π√–À«à“ß°“√µ‘¥‡™◊ÈÕ
√—°…“∑’Ë√«¥‡√Á«®–¡’‚Õ°“ √—°…“„ÀâÀ“¬¢“¥‰¥â¡“°°«à“ HIV ·≈–°“√‡°‘¥ MDR-TB ‡æ√“–«à“√–¥—∫°“√‡°‘¥
π—Ë π · ¥ß∂÷ ß §«“¡®”‡ªì π ∑’Ë ® –µâ Õ ß¡’ √ –∫∫°“√«‘ π‘ ® ©— ¬ ∑’Ë MDR-TB „π∑’ËÊ ¡’ Prevalence ¢Õß°“√µ‘¥‡™◊ÈÕ HIV
√«¥‡√Á« 2 ·≈–„π‡√◊ËÕß°“√«‘π‘®©—¬∑’Ë≈à“™â“æ∫«à“ ‰¡à¡’§«“¡ ∑’Ë·µ°µà“ß°—πµ—Èß·µà 0.2-41.5% Õ¬à“߉√°Áµ“¡ À≈—°∞“π
·µ°µà“ß√–À«à“ߪ√–‡∑»∑’Ëæ—≤π“·≈â«°—∫ª√–‡∑»∑’Ë°”≈—ß ‡∫◊Õßµâπ· ¥ß„Àâ‡ÀÁπ«à“ °“√µ‘¥‡™◊Õ HIV Õ“®¡’§«“¡ —¡æ—π∏å
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æ—≤π“ 2 ‚¥¬∑’˧«“¡ ”§—≠„π°“√√—°…“°≈ÿà¡ Latent 8
°—∫°“√‡°‘¥ Primary MDR-TB „π à«πº≈¢Õß°“√√—°…“
infection π—ÈπµâÕßæ‘®“√≥“„π°≈ÿࡺŸâªÉ«¬‡¥Á°¥â«¬‡™àπ°—π 3 MDR-TB π—Èπ æ∫«à“ ¡’ß“π«‘®—¬ Systematic reviews
·≈–„π°≈ÿà¡∑’˵‘¥‡™◊ÈÕ HIV ‚¥¬‡©æ“–ºŸâ∑’Ë¡’º≈∫«°®“° ∑’Ë√«∫√«¡ß“π«‘®—¬°«à“ 36 ™‘Èπ®“° 21 ª√–‡∑» æ∫«à“
º≈ Tuberculin skin test ´÷Ëßπ’ˇªìπ¢âÕ √ÿª®“°°“√∑” °“√√—°…“ MDR-TB π—Èπ¡’§«“¡ ”‡√Á®Õ¬Ÿà∑’˪√–¡“≥ 62%
Systematic review ‚¥¬ Cochrane systematic review ‚¥¬∑’Ë 13% π—Èπ¡’°“√À¬ÿ¥°“√√—°…“ 11% ‡ ’¬™’«‘µ à«π
group „πªï 2009 ®“°°“√√«∫√«¡ß“π«‘®—¬ 12 Ran- ªí®®—¬∑’Ë¡’º≈µàÕ°“√√—°…“∑’ˉ¡à¥’π—Èπ ‰¥â·°à ‡æ»™“¬ °“√
domized controlled trial 4 ¥◊Ë¡·Õ≈°ÕŒÕ≈å à«πªí®®—¬∑’ˇ°’ˬ«¢âÕß°—∫§«“¡ ”‡√Á®„π
„π¥â“π¢Õß°“√«‘π‘®©—¬ ¡’°“√»÷°…“‡æ‘Ë¡‡µ‘¡∑’Ë∫àß °“√√—°…“ ‰¥â·°à ªí®®—¬¥â“π°“√„™â°“√ºà“µ—¥™à«¬„π°“√
∂÷ß°“√„™â‡§√◊ËÕ߇հ´‡√¬å§Õ¡æ‘«‡µÕ√å (CT scan) „π°“√ √—°…“ °“√‰¡à‡§¬‰¥â√∫°“√√—°…“¥â«¬¬“µâ“π«—≥‚√§¡“°àÕπ
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3. ¢Õπ·°àπ‡«™ “√ ªï∑’Ë 34 ©∫—∫∑’Ë 1 ¡°√“§¡ - ‡¡…“¬π 2553 3
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„π°“√√—°…“ 9 „π©∫—∫π’È¢Õ𔇠πÕ§«“¡§◊∫Àπâ“ß“π«‘®—¬ ‡æ‘Ë¡‡µ‘¡„π‚Õ°“ µàÕ‰ª
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1. Ziakas PD, Mylonakis E. 4 months of 4. Akolo C, Adetifa I, Shepperd S, 7. Wright A, Zignol M, Van Deun A,
rifampin compared with 9 months of Volmink J. Treatment of latent tuberculosis Falzon D, Gerdes SR, Feldman K, et al.
isoniazid for the management of latent infection in HIV infected persons. Cochrane Epidemiology of antituberculosis drug
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