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Khon Kaen Medical Journal Vol. 34 No. 1 January - April 2010

∑—π ∂“π°“√≥å«—≥‚√§ Tuberculosis update ∏√√¡ √≥å æ‘√‘¬ ÿæß»å; M.D., M.Sc., Ph.D., Board of Preventive Medicine (Epidemiology) ‚√ß欓∫“≈¢Õπ·°àπ

„π©∫— ∫ π’È ¢ Õ𔇠πÕ‡°’Ë ¬ «°— ∫ ‡π◊È Õ À“¢Õß‚√§«— ≥ ‚√§ ‡π◊ËÕß®“°æ÷Ëߺà“π™à«ß«—π«—≥‚√§‚≈°‡¡◊ËÕ«—π∑’Ë 24 ¡’π“§¡ ∑’˺à“π¡“ ´÷Ëß¡’ Theme „πªïπ’ȧ◊Õ çOn the Move Against Tuberculosis: Innovate to Accelerate Actioné ‚¥¬‰¥â ¡’ ° “√ª√–¡“≥‰«â «à “ 1 „π 3 ¢Õß ª√–™“°√‚≈° À√◊Õ°«à“ 2 æ—π≈â“π§ππ—πÈ ¡’°“√µ‘¥‡™◊ÕÈ «—≥‚√§ ·≈–®“°°“√ª√–¡“≥°“√¢ÕßÕß§å ° “√Õπ“¡— ¬ ‚≈°„π ªï 2551 æ∫«à“ °«à“ 11.1 ≈â“π§π∑—Ë«‚≈°ªÉ«¬‡ªìπ«—≥‚√§ ·∫∫ Active ´÷Ëß “¡“√∂·æ√à‡™◊ÈÕ‰¥â ·≈–„πªï 2551 ‡æ’¬ß ªï‡¥’¬« °«à“1.8 ≈â“π§π‰¥âµ“¬®“°‚√§«—≥‚√§ ‚¥¬∑’Ë ª√–¡“≥ 5 · π§π‡ªìπºŸâªÉ«¬∑’˵‘¥‡™◊ÈÕ HIV √à«¡¥â«¬ ·≈–ªí≠À“∑’Ëæ∫¡“°¢÷Èπ §◊Õ °“√¥◊ÈÕ¬“ ‚¥¬‡©æ“–„π ª√–‡∑»∑’°Ë ”≈—ßæ—≤π“ ¡“µ√°“√∑’‡Ë §¬‰¥âº≈„π°“√§«∫§ÿ¡ «—≥‚√§°ÁÕ“®®–‰¡à “¡“√∂§«∫§ÿ¡‚√§‰¥â„πªí®®ÿ∫—π ·≈– ¥Ÿ‡À¡◊Õπ«à“ °“√ª√–°“»∑’Ë®–À¬ÿ¥¬—Èß‚√§«—≥‚√§„À≥â„π ªï 2558 π—πÈ µâÕßÕ“»—¬§«“¡À«—ß®“°«‘®¬— „À¡à∑°’Ë ”≈—ß»÷°…“ „πªí®®ÿ∫π— µ—«Õ¬à“ßß“π«‘®—¬∑’Ëπ”¡“´÷Ëߧ«“¡À«—ß ‰¥â·°à ß“π«‘®—¬«—§´’πªÑÕß°—π«—≥‚√§ ”À√—∫ºŸâµ‘¥‡™◊ÈÕ HIV „π ªí®®ÿ∫—πÕ¬Ÿà„π clinical trial Phase III ´÷Ëß¡’ºŸâ‡¢â“√à«¡°“√ »÷°…“°«à“ 2 æ—π§π´÷Ëßµ‘¥‡™◊ÈÕ HIV „πª√–‡∑»·∑π´“‡π’¬ ‚¥¬æ∫«à“ «—§´’π¥—ß°≈à“« “¡“√∂≈¥°“√µ‘¥‡™◊ÈÕ«—≥‚√§‰¥â ª√–¡“≥√âÕ¬≈– 39 ‚¥¬ß“π«‘®¬— ¥—ß°≈à“«‰¥â√∫— °“√µ’æ¡‘ æå „π«“√ “√ AIDS ‚¥¬π—°«‘®—¬‰¥â°≈à“««à“¢—ÈπµàÕ‰ª§◊Õ°“√ ‡¢â“‰ª¡’ «à π√à«¡„π°“√æ—≤π“«—§´’π¥—ß°≈à“«√à«¡°—∫∫√‘…∑— ºŸâº≈‘µ«—§´’π ·≈–¡’§«“¡®”‡ªìπ∑’Ë®–µâÕß„Àâ«—§´’ππ’È·°à ºŸâµ‘¥‡™◊ÈÕ°àÕπ∑’Ë®–‰¥â√—∫°“√√—°…“¥â«¬¬“µâ“π‰«√—  ‡æ√“– ºŸâµ‘¥‡™‘ÈÕ HIV ¡’·π«‚πâ¡∑’Ë®–‰¥â√—∫°“√µ‘¥‡™◊ÈÕ«—≥‚√§·¡â ®–¬—߉¡à¡’Õ“°“√„¥Ê πÕ°®“°°“√µ‘¥‡™◊ÈÕ HIV ·≈â«°“√ Ÿ∫∫ÿÀ√’ˬ—߇æ‘Ë¡ §«“¡‡ ’¬Ë ßµàÕ°“√µ‘¥‡™◊ÕÈ «—≥‚√§¥â«¬‡™àπ°—π ‚¥¬°“√»÷°…“

®“°ŒàÕß°ßæ∫«à“ °“√ —¡º— °—∫ºŸâ Ÿ∫∫ÿÀ√’Ë ‡æ‘Ë¡·π«‚πâ¡„π °“√ —¡º— °—∫‡™◊ÕÈ ‚√§¥â«¬ ‚¥¬°“√»÷°…“‰¥â∑”°“√‡ª√’¬∫‡∑’¬∫°“√Õ¬Ÿà„π∫â“π∑’Ë¡’ºŸâ Ÿ∫∫ÿÀ√’ËÕ¬à“ßπâÕ¬Àπ÷Ëߧπ°—∫°“√ Õ¬Ÿà„π∫â“π∑’ˉ¡à¡’ºŸâ Ÿ∫∫ÿÀ√’ˇ≈¬æ∫«à“„π°“√‡°Á∫¢âÕ¡Ÿ≈‡ªìπ √–¬–‡«≈“Õ¬à“ßπâÕ¬ 6 ªïæ∫«à“ºŸâ∑’Ë Ÿ∫∫ÿÀ√’Ë∑“ßÕâÕ¡À√◊Õ  Ÿ∫∫ÿÀ√’Ë¡◊Õ Õß (secondhand smoke) ¡’§«“¡‡ ’Ë¬ß ‡æ‘Ë¡¢÷Èπ 1.5 ‡∑à“„π°“√ªÉ«¬‡ªìπ«—≥‚√§ ·≈–¬—ß¡’‚Õ°“  „π°“√‡°‘¥‚√§Õÿ¥°—Èπ∑“߇¥‘πÀ“¬„®·≈–‡∫“À«“π¥â«¬ ‡™àπ°—π ß“π«‘®—¬¥—ß°≈à“«‰¥â√—∫°“√¬◊π¬—π®“°ß“π«‘®—¬∑’Ë §≈⓬°—π®“°ª√–‡∑»Õ‡¡√‘°“«à“°“√ Ÿ∫∫ÿÀ√’Ë∑“ßÕâÕ¡π—Èπ ¬—ß‡æ‘Ë¡‚Õ°“ °“√ªÉ«¬‡ªìπ¡–‡√Áߪե ‚√§À—«„® ·≈–°“√ µ‘¥‡™◊ÈÕ„πªÕ¥·∫∫µà“ßÊ √«¡∑—Èß«—≥‚√§¥â«¬ ªí≠À“ ¥—ß°≈à“«¬—ߧߧàÕπ¢â“ß√⓬·√ß„πª√–‡∑»®’π ‡π◊ËÕß®“° °«à“√âÕ¬≈– 60 ¢Õß™“¬™“«®’π¬—ߧߠŸ∫∫ÿÀ√’Ë °“√»÷°…“‡°’¬Ë «°—∫°“√ªÑÕß°—π°“√µ‘¥‡™◊ÕÈ °Á¡‡’ √◊ÕË ß ∑’Ëπà“°—ß«≈‰¡àπâÕ¬ ‡π◊ËÕß®“°æ∫«à“ ∫ÿ§≈“°√∑“ß°“√ ·æ∑¬å√«¡∂÷ß欓∫“≈´÷Ë߇ªìπ°≈ÿà¡ Latent infection ¡’ ·π«‚πâ¡„π°“√À¬ÿ¥°‘𬓇æ◊ËÕ°“√√—°…“°«à“√âÕ¬≈– 40 ¢Õß°“√‡ΩÑ“µ‘¥µ“¡∑—Èß„π À√—∞Õ‡¡√‘°“·≈–·§π“¥“ ·≈– ®“°°“√»÷°…“°àÕπÀπâ“π’È æ∫«à“ ∫ÿ§≈“°√∑“ß°“√·æ∑¬å ¡’·π«‚πâ¡„π°“√°‘𬓉¡à°‘𬓇æ◊ËÕ°“√√—°…“ Ÿß°«à“§π ∑—Ë«‰ª∂÷ß 5 ‡∑à“ πÕ°®“°π’È °≈ÿà¡∫ÿ§≈“°√∑“ß°“√·æ∑¬å ¬—ß°‘𬓉¥â§√∫µ“¡§”·π–π”πâÕ¬°«à“ª°µ‘¥â«¬ ‰¥â¡’°“√ ª√–¡“≥°— π «à “ ¡’ ª √–™“°√°«à “ 15 ≈â “ π§π„π À√— ∞ Õ‡¡√‘°“∑’˪ɫ¬‡ªìπ Latent infection §◊Õ ¡’°“√µ‘¥‡™◊ÈÕ·µà ‰¡à¡’Õ“°“√‡π◊ËÕß®“°§«“¡ “¡“√∂¢Õß¿Ÿ¡‘§ÿâ¡°—π„π°“√ °¥∑—∫Õ“°“√‰¡à„Àâ· ¥ßÕÕ°¡“‰¥â ∑’πË “à °—ß«≈ §◊Õ ·¡â®–‡ªìπ Latent infection °Á¬—ß “¡“√∂·æ√à‡™◊ÈÕ ŸàºŸâÕ◊Ëπ‰¥â·¡â®– ‰¡à¡’Õ“°“√„¥Ê ‡≈¬ ·≈–¥â«¬‡Àµÿπ’ȇÕß∑“ß The U.S. Centers for Disease Control and Prevention (CDC) ®÷߉¥â·π–π”„Àâ¡°’ “√√—°…“‚¥¬‡©æ“–°≈ÿ¡à ºŸ¡â §’ «“¡º‘¥ª°µ‘


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‡√◊ËÕß¿Ÿ¡‘§ÿâ¡°—π ·≈–ºŸâ∑’Ë —¡º— °—∫ºŸâªÉ«¬∑’Ë¡’°“√µ‘¥‡™◊ÈÕ·≈– · ¥ßÕ“°“√ ´÷Ëß√«¡∂÷ß∫ÿ§≈“°√∑“ß°“√·æ∑¬å¥â«¬ ·µà §«“¡‡¢â“„®«à“‡Àµÿ„¥§π°≈ÿà¡π’È®÷ßÀ¬ÿ¥°“√√—°…“‡Õ߬—߇ªìπ ‡√◊ÕË ß∑’µË Õâ ߉¥â√∫— °“√»÷°…“µàÕ‰ª ·µà¡§’ «“¡πà“®–‡ªìπ‰¥â«“à Õ—µ√“„π°“√ªÉ«¬®π‡ªìπ Full-blown tuberculosis π—Èπ ¡’‡æ’¬ß 1 „π 20 ·≈–‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫°“√°‘𬓇æ◊ËÕ √—°…“π—Èπ„™â‡«≈“Õ¬à“ߵ˔ 4-6 ‡¥◊Õπ ·≈–¬“ à«π„À≠à°Á¡’ º≈¢â“߇§’¬ß∑’Ë¡’º≈°√–∑∫µàÕ™’«‘µª√–®”«—π¢ÕߺŸâ∑’Ë°‘𬓠¥â«¬ ·≈–‡π◊ËÕß®“°«à“°“√°‘π¬“∑’ˬ“«π“ππ—Èπ¡’º≈µàÕ°“√ °‘π¬“∑’ˉ¡à§√∫µ“¡§”·π–π” ©–π—Èπ ®÷߉¥â¡’°“√·π–π” „Àâ¡’°“√°‘π¬“∑’Ë¡’√–¬– —Èπ ‚¥¬¢≥–π’ȉ¥â¡’°“√∑¥≈Õß √—°…“ºŸâªÉ«¬°≈ÿà¡π’ȥ⫬¬“ Isoniazide °—∫¬“Õ’°µ—« §◊Õ Rifapentine „π√–¬–‡«≈“ 3 ‡¥◊Õπ ‚¥¬§“¥«à“®– “¡“√∂ ∑”„À⇰‘¥°“√°‘π¬“∑’˧√∫µ“¡∑’Ë·π–π” ·≈–√—°…“°≈ÿà¡ Latent infection ‰¥â¡“°¢÷Èπ¥â«¬ „π à«πµàÕ‰ª®–¢Õ°≈à“«∂÷ß°“√√«∫√«¡ß“π«‘®—¬ ª√–‡¿∑ Review ∑’ˇªìπº≈ß“π≈à“ ÿ¥ ‡æ◊ËÕ∑ÿ°∑à“π®–‰¥â  “¡“√∂𔉪ª√— ∫ „™â · ≈–√— ° …“ºŸâ ªÉ « ¬«— ≥ ‚√§µà Õ ‰ª ß“π«‘®—¬·√°∑’Ë®–¢Õ°≈à“«∂÷ß §◊Õ °“√‡ª√’¬∫‡∑’¬∫°“√„™â¬“ Rifampicin ‡ªìπ√–¬–‡«≈“ 4 ‡¥◊Õπ °—∫¬“ Isoniazid ‡ªìπ√–¬–‡«≈“ 9 ‡¥◊Õπ„π°“√√—°…“°≈ÿࡺŸâ∑’ˇªìπ Latent tuberculosis æ∫«à“ Systematic review „πªï 2552 · ¥ß„Àâ‡ÀÁπ«à“ °“√„™â¬“ Rifampicin  “¡“√∂‡æ‘Ë¡‚Õ°“  „π°“√∑’Ë®–∑”„À⺟âªÉ«¬∑’ˇªìπ Latent infection  “¡“√∂ °‘𬓉¥â§√∫¡“°¢÷Èπ ¡’º≈¢â“߇§’¬ß®“°°“√„™â¬“∑’ËπâÕ¬≈ß ·≈–¬—ß¡’ª√– ‘∑∏‘¿“æ (Cost-effectiveness) Õ’°¥â«¬ 1 „π¥â“𧫓¡√«¥‡√Á«¢Õß°“√√—°…“æ∫«à“ À“°‰¥â√—∫°“√ √—°…“∑’Ë√«¥‡√Á«®–¡’‚Õ°“ √—°…“„ÀâÀ“¬¢“¥‰¥â¡“°°«à“ π—Ë π · ¥ß∂÷ ß §«“¡®”‡ªì π ∑’Ë ® –µâ Õ ß¡’ √ –∫∫°“√«‘ π‘ ® ©— ¬ ∑’Ë √«¥‡√Á« 2 ·≈–„π‡√◊ËÕß°“√«‘π‘®©—¬∑’Ë≈à“™â“æ∫«à“ ‰¡à¡’§«“¡ ·µ°µà“ß√–À«à“ߪ√–‡∑»∑’Ëæ—≤π“·≈â«°—∫ª√–‡∑»∑’Ë°”≈—ß æ—≤π“ 2 ‚¥¬∑’˧«“¡ ”§—≠„π°“√√—°…“°≈ÿà¡ Latent infection π—ÈπµâÕßæ‘®“√≥“„π°≈ÿࡺŸâªÉ«¬‡¥Á°¥â«¬‡™àπ°—π 3 ·≈–„π°≈ÿà¡∑’˵‘¥‡™◊ÈÕ HIV ‚¥¬‡©æ“–ºŸâ∑’Ë¡’º≈∫«°®“° º≈ Tuberculin skin test ´÷Ëßπ’ˇªìπ¢âÕ √ÿª®“°°“√∑” Systematic review ‚¥¬ Cochrane systematic review group „πªï 2009 ®“°°“√√«∫√«¡ß“π«‘®—¬ 12 Randomized controlled trial 4 „π¥â“π¢Õß°“√«‘π‘®©—¬ ¡’°“√»÷°…“‡æ‘Ë¡‡µ‘¡∑’Ë∫àß ∂÷ß°“√„™â‡§√◊ËÕ߇հ´‡√¬å§Õ¡æ‘«‡µÕ√å (CT scan) „π°“√

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«‘π‘®©—¬‡∫◊ÈÕßµâπ “¡“√∂·¬°≈—°…≥–∑“ß√—ß ’∑’Ë·µ°µà“ß √–À«à“߇™◊ÈÕ∑’ˇªìπ Multidrug-resistant tuberculosis °—∫‡™◊ÈÕ∑’ˉ¡à¥◊ÈÕ¬“ 5 ·≈–¢âÕ¡Ÿ≈¥â“π°“√«‘π‘®©—¬¬—ßæ∫ ‡æ‘Ë¡‡µ‘¡Õ’°«à“ ‡¡Á¥‡≈◊Õ¥¢“«™π‘¥ Lymphocyte ∫“ß™π‘¥ ¡’ —¥ à«π∑’Ë·µ°µà“ß√–À«à“ߺŸâ∑’ˇªìπ Active °—∫Õ“ “ ¡—§√ ‚¥¬æ∫«à“ „πºŸâªÉ«¬∑’ˇªìπ Active tuberculosis π—Èπ®–¡’ CD3(+) ·≈– CD3(+)CD4(+) cells ∑’ˇæ‘Ë¡¢÷Èπ ·≈–¡’ Õ—µ√“ à«π¢Õß CD3(+)CD4(+) µàÕ CD3(+)CD8(+) cells ≈¥≈ß ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫ºŸâªÉ«¬ª°µ‘ 6 ·≈–æ∫«à“ „π°≈ÿࡺŸâªÉ«¬∑’ˇªìπ Pulmonary tuberculosis ∑’Ë√—∫°“√ √—°…“Õ¬Ÿà„π Intensive care unit π—Èπ °“√«‘π‘®©—¬¥â«¬ °“√∑” Chest X ray Õ“®‰¡à ‰ ¥â √— ∫ ª√–‚¬™πå ¡ “°π— ° ‡æ√“–¡’§«“¡®”‡æ“–µàÕ°“√«‘π‘®©—¬§àÕπ¢â“ߵ˔ °“√»÷°…“∂÷ߧ«“¡™ÿ°µàÕ°“√‡°‘¥ Multidrug resistant tuberculosis ®“°°“√»÷°…“„πª√–™“°√°«à“ 9 À¡◊Ëπ§π®“° 83 ª√–‡∑»∑—Ë«‚≈° æ∫«à“ §à“ Median ¢Õߧ«“¡™ÿ°Õ¬Ÿà∑’˪√–¡“≥ 11.1% „π°≈ÿࡺŸâªÉ«¬„À¡à∑’ˬ—ß ‰¡à‰¥â√—∫°“√√—°…“Õ¬à“ß„¥‡≈¬ 7 ·≈–¡’§«“¡™ÿ°¡“°„π ª√–‡∑»®’π·≈–ª√–‡∑» À¿“æ‚´‡«’¬µ‡¥‘¡ „π¢≥–∑’Ë ¢â Õ ¡Ÿ ≈ §«“¡™ÿ ° ¬— ß ‰¡à · πà ™— ¥ „πª√–‡∑»·∂∫·Õø√‘ ° “  à«π„À≠à ¡’°“√∂“¡À≈“¬§√—ßÈ «à“¡’ß“π«‘®¬— „¥∑’·Ë  ¥ß„Àâ‡ÀÁπ ∂÷ߧ«“¡ —¡æ—π∏å√–À«à“ß°“√µ‘¥‡™◊ÈÕ HIV ·≈–°“√‡°‘¥ Multi drug resistant tuberculosis (MDR-TB) „π ß“π«‘®—¬ Systematic review ‡¡◊ËÕªï 2009  √ÿª‰«âÕ¬à“ß πà“ π„®«à“ °“√‡°‘¥ MDR-TB π—Èπ¬—߉¡à¡’À≈—°∞“π∑’Ë · ¥ß„Àâ‡ÀÁπ∂÷ߧ«“¡ —¡æ—π∏å∑’Ë™—¥‡®π√–À«à“ß°“√µ‘¥‡™◊ÈÕ HIV ·≈–°“√‡°‘¥ MDR-TB ‡æ√“–«à“√–¥—∫°“√‡°‘¥ MDR-TB „π∑’ËÊ ¡’ Prevalence ¢Õß°“√µ‘¥‡™◊ÈÕ HIV ∑’Ë·µ°µà“ß°—πµ—Èß·µà 0.2-41.5% Õ¬à“߉√°Áµ“¡ À≈—°∞“π ‡∫◊ÕÈ ßµâπ· ¥ß„Àâ‡ÀÁπ«à“ °“√µ‘¥‡™◊ÕÈ HIV Õ“®¡’§«“¡ —¡æ—π∏å °—∫°“√‡°‘¥ Primary MDR-TB 8 „π à«πº≈¢Õß°“√√—°…“ MDR-TB π—Èπ æ∫«à“ ¡’ß“π«‘®—¬ Systematic reviews ∑’Ë√«∫√«¡ß“π«‘®—¬°«à“ 36 ™‘Èπ®“° 21 ª√–‡∑» æ∫«à“ °“√√—°…“ MDR-TB π—Èπ¡’§«“¡ ”‡√Á®Õ¬Ÿà∑’˪√–¡“≥ 62% ‚¥¬∑’Ë 13% π—Èπ¡’°“√À¬ÿ¥°“√√—°…“ 11% ‡ ’¬™’«‘µ  à«π ªí®®—¬∑’Ë¡’º≈µàÕ°“√√—°…“∑’ˉ¡à¥’π—Èπ ‰¥â·°à ‡æ»™“¬ °“√ ¥◊Ë¡·Õ≈°ÕŒÕ≈å  à«πªí®®—¬∑’ˇ°’ˬ«¢âÕß°—∫§«“¡ ”‡√Á®„π °“√√—°…“ ‰¥â·°à ªí®®—¬¥â“π°“√„™â°“√ºà“µ—¥™à«¬„π°“√ √—°…“ °“√‰¡à‡§¬‰¥â√∫— °“√√—°…“¥â«¬¬“µâ“π«—≥‚√§¡“°àÕπ


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‡Õ° “√Õâ“ßÕ‘ß 1. Ziakas PD, Mylonakis E. 4 months of rifampin compared with 9 months of isoniazid for the management of latent tuberculosis infection: a meta-analysis and cost-effectiveness study that focuses on compliance and liver toxicity. Clin Infect Dis 2009;49(12):1883-9. 2. Sreeramareddy CT, Panduru KV, Menten J, Van den Ende J. Time delays in diagnosis of pulmonary tuberculosis: a systematic review of literature. BMC Infect Dis 2009;9:91. 3. Sablan B. An update on primary care management for tuberculosis in children. Curr Opin Pediatr 2009;21(6):801-4.

4. Akolo C, Adetifa I, Shepperd S, Volmink J. Treatment of latent tuberculosis infection in HIV infected persons. Cochrane Database Syst Rev (1):CD000171. 5. Yeom JA, Jeong YJ, Jeon D, Kim KI, Kim CW, Park HK, et al. Imaging findings of primary multidrug-resistant tuberculosis: a compa-rison with findings of drugsensitive tuber-culosis. J Comput Assist Tomogr 2009;33 (6):956-60. 6. Wu YE, Zhang SW, Peng WG, Li KS, Li K, Jiang JK, et al. Changes in lymphocyte subsets in the peripheral blood of patients with active pulmonary tuberculosis. J Int Med Res 2009; 37(6):1742-9.

7. Wright A, Zignol M, Van Deun A, Falzon D, Gerdes SR, Feldman K, et al. Epidemiology of antituberculosis drug resistance 2002-07: an updated analysis of the Global Project on Anti-Tuberculosis Drug Resistance Surveillance. Lancet 2009; 373(9678):1861-73. 8. Suchindran S, Brouwer ES, Van Rie A. Is HIV infection a risk factor for multi-drug resistant tuberculosis? A systematic review. PLoS One 2009;4(5):e5561. 9. Johnston JC, Shahidi NC, Sadatsafavi M, Fitzgerald JM. Treatment outcomes of multidrug-resistant tuberculosis: a systematic review and meta-analysis. PLoS One 2009;4(9):e6914.


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Tuberculosis update  

รวมบทสรุปงานวิจัยใหม่เพื่อจะหยุดยั้งโรควัณโรคให้ได้ภายในปี 2558 ให้เป็นไปตามการรณรงค์ขององค์การอนามัยโลก ปี 2553 ที่ให้คำขวัญว่า On the mov...