2015年12月18日

公衞新知-衛福部:保險制是長照最穩定的制度

資料日期20151123

衛生福利部長蔣丙煌今天(23)表示,長照保險制度是最穩定的制度,不像稅收制,經費會受其他因素影響而出現排擠。針對長照服務打算開放民間參與引發爭議,蔣丙煌強調,重點是維持照顧弱勢的基本品質與水準,之後才能適度開放民間資源投入。

長照服務法在今年5月三讀通過,預計在2017年上路,長照的經費來源依舊是各界關注焦點。
衛生福利部長蔣丙煌23日受訪表示,人口老化及失能人口增加是未來的趨勢,為了要有穩定財源支撐長照體系,他主張長照經費應採取保險制。蔣丙煌說:『(原音)保險制度是最好的、最穩定的制度,如果用稅收,大家都知道錢會進到大水庫,會受到很多因素影響,當經濟不好,其他經費會排擠到長照經費,所以我極力的主張一定要採取保險制度。』

由於行政部門打算鬆綁限制、開放民間營利機構參與長照服務,引發部分民間團體質疑。蔣丙煌重申長照服務品質必須達到一定的水準,之後才能適度開放民間資源,希望讓民眾有不同的選擇。蔣丙煌說:『(原音)用一個比較不恰當的比喻,就是大家不一定都只能吃陽春麵,如果有人要吃牛肉麵的時候,也應該要給他,但很重要的一點,是一定要有基本的水準;換句話講,對所有弱勢必須要有適當照顧,但在那之上,我們覺得能保持一點彈性是比較好。』

另外,全民健康保險會日前決議調降明年的健保費率,蔣丙煌表示,既然已經決定,衛福部就會尊重。他並指出,這次會議最大成就是建立攸關費率調整的收支連動機制,一旦民眾了解這個機制,對未來費率的調升就比較會有心理準備。


2015年12月15日

公衛教學-殘障校正後損失生命年(DALY)與全球疾病負擔(GBD)


領域:衛生行政

題目:殘障校正後損失生命年(DALY)與全球疾病負擔(GBD)

作者:陳秋瑩教授 公共衛生學系


一、DALY的定義

世界衛生組織(WHO)使用”DALY”指標又稱為殘障校正後損失生命年(the disability-adjusted-life-year, DALY)來測量 ”全球的疾病負擔” (global burden of disease)DALY 是一個時間為基礎的測量,並綜合以下兩種狀態的測量: 1) 由於早夭(premature mortality)所損失的生命年數 (years of life lost)2) 沒有完全健康的活著之年數(years of life lived in states of less than full health) [1]
DALYs是計算族群人口健康結果之指標,DALYs的計算簡單而言,是將族群中因提早死亡所損失之生命的年數( the Years of Life Lost, YLL)加上因殘障或殘障導致的結果所損失之年數(the Years Lost due to Disability, YLD)。一個單位的DALY可視為健康生命損失一年 (one lost year of “healthy” life) [2]。依定義DALYs本身是一個「負向」指標,是一種測量非特異性疾病結果的概念。DALYs的計算常牽涉以下幾個因素:1) 健康對不同年齡層有不同程度的價值、2)不同疾病會造成不同的失能狀態、3) 現在獲得健康與未來獲得健康之價值相比,未來的健康價值將比現在的健康價值低,即如經濟學的折現率(discount rate)之概念。這些因素的考量使DALYs之計算會有如年齡加權(age-weighted)、失能加權(disability-weighted)及折現率(discounting) 等參數的考量[3]DALYs可以做為測量某一族群全體人口在目前的和理想的健康狀態間之差距。族群人口之理想健康狀態是指全體的人可以活得更長,且沒有任何疾病或殘障發生的狀態[2,3]

 

二、DALY的緣起與全球疾病負擔

DALY指標 一開始是在1990年全球疾病負擔研究時發展的,由於世界各地族群人口的死亡率和健康之資訊呈現片段和不一致的情形,因此為了進行有效的健康決策和規劃計畫,因此有需要發展出能以較周全及具一致性的架構整合、分析及提高這些資訊的有效性,並藉此評估導致不同族群人口的早夭、健康損失和殘障之疾病、傷害及危險因子的相對重要性。各國可以藉評估所獲得之資訊並參考國家本身的政策及其成本等資訊以決定如何設定國家的健康議題 [4]
1990WHO針對全球八個區域100多種疾病和傷害(injuries)之健康效應進行量化研究,被視為第一個全球疾病負擔(Global Burden Disease; GBD)研究。這研究產生幾個可依性別, 年齡別和區域別,周全且具內部一致性的估計死亡率和疾病率之指標。此外也發展出一新的指標-殘障校正後損失生命年(DALY),作為量化疾病,傷害和危險因素所造成的負擔之指標。20002002WHO除了更新1990年之研究,更進一步使用稱為「相對的危險因子評估 Comparative Risk Factor Assessment(CRA)」之分析架構,分析26個全球的危險因子(global risk factors), 皆為疾病負擔及死亡率可歸因之危險因子。世衛組織於2004年更新這些估計,並發表「全球疾病負擔: 2004年更新及全球健康風險報告」(The global burden of disease: 2004 update and the Global health risks reports)26個危險因子被分成七大類: “兒童期或母體懷孕期之營養不良(childhood and maternal undernutrition) “其他相關的營養不良因素與身體活動(other nutrition-related risk factors and physical activity)、”性和生殖健康 (sexual and reproductive health)”、”成癮的物質(addictive substances)”、”環境危險因子(environmental risks)”、”職業上的危險因子(occupational risks)”及”其他的危險因子(other selected risks)”。WHO的健康指標及評估機構與其他研究夥伴於2010年進行GBD之更新研究,並於2012年發表。這研究提供1990, 2005 2010年死亡和殘障校正後損失生命年的區域性估計[4]2013發表全球健康估計 (global health estimates)亦包括上述的估計,連同DALY估計等相關資訊可至WHO 網站查詢: http://www.who.int/healthinfo/global_burden_disease/enhttp://www.who.int/healthinfo/global_burden_disease/estimates/en/index1.html

 
 
參考來源
世界衛生組織網址 (accessed on December 14th, 2015):
1. http://www.who.int/topics/global_burden_of_disease/en/


3. 吳肖琪楊志良: 衛生統計公共衛生學 第四版台北: 陳拱北預防醫學基金會,2007: 114-119  

公衛新知-解決中部嚴重空污

台灣近來空氣品質欠佳,尤其中南部地區更數度發生「紫爆」的情況,細懸浮微粒(PM2.5)濃度狂飆。針對中彰投地區,中山醫學大學公共衛生系教授翁瑞宏分析相關空污成因,並指出立即減少空污的方法之一,可能就是讓夜間的城市降溫。

《泛科學》一篇「中彰投抗空污,立即可做的,可能就是夜間灑水」文章中,翁瑞宏教授指出,中彰投地區的地形環境及氣候狀況不利於污染物之傳輸與擴散。翁瑞宏分析,秋冬之際台灣多在高壓系統的天氣形態下,綜觀風場偏東風,而中部地區位處中央山脈背風面而受高壓沉降影響,不利污染物擴散;低風速和低相對濕度的氣象環境也有利污染物生成。

翁瑞宏談到海陸風現象和熱島效應也是中部地區空氣品質變差的原因之一,並指出中部地區在秋季時這兩個現象最明顯。熱島效應形成時,城市的上空就像被罩住,新鮮空氣無法進來導致污染物濃度累積;同時氣流輻合現象也會讓污染物質傳輸到熱島中心。另外,地表受太陽輻射加溫影響進而發展出混合層,當台灣受高壓氣團影響而高度受限無法順利向高空發展時,地面污染物就無法有效稀釋,造成高污染事件。

以台中都會區熱島中心大里為例,熱島效應的強度在白天會因為海風影響而下降。但夜間若發生強熱島現象時,微弱的陸風可能會加乘熱島強度,有助熱島幅合現象。因此他認為應該讓夜間的城市降溫,才是立即減少空污的方法之一。
 

2015年11月4日

公衛新知-毒品氾濫 偏鄉更甚都會

編按:吸毒不只戕害健康,隨著新興毒品推陳出新,衍生治安惡化、削弱國家競爭力,甚至動搖國本,是政府最應重視的國安問題。 遺憾的是,近年來政府反毒行動流於口號,吸毒人口有增無減、吸毒年齡層不斷降低,部分偏鄉毒品氾濫問題甚至比都會區更嚴重。 本報動員人力全省調查採訪,將以五篇系列報導,探討毒品氾濫無城鄉差距、夜店淪毒品淵藪、年輕學子沉淪毒品、監所吸毒犯人滿為患,及國內外成功反毒戒毒經驗,供國人及政府省思,打一場有效的新鴉片戰爭!
一般人刻板印象,都會區才會有染毒、吸毒問題,其實不然。毒品氾濫已全面侵蝕國人健康,不但沒有城鄉差別,學者研究更提出警訊:偏鄉農村人口不但吸毒情形更普遍,毒品也更強烈。
「毒品上癮不是特性是人性!」中正大學犯罪防治系副教授戴伸峰直指問題核心,毒品最令人恐懼之處不在隨之而來的犯罪與脫序,而是再偏遠的地區、再少的人口聚落,總是有人抵擋不住毒品魔力。

公衞新知-健保費調降? 最快11月告訴你

2015-10-06 08:59:04 聯合報 記者陳雨鑫、江慧珺/台北報導



健保在補充保費的挹注下,統計七月底止健保安全準備金已破兩千億元,足以支應四點五個月的健保支出,超過法定最高三個月上限,健保委員會建議調降健保費率回饋民眾。衛福部長蔣丙煌表示,保費調整最快十一月出爐,但調整應「審慎考慮」。
補充保費自二○一二年上路,若收入大於支出,將轉入安全準備金。因為今年安全準備金已逾兩千億元,超過法定上限;立委認為補充保費費率百分之二太高,昨提出應降至百分之一點五,讓民眾有財務上的「小確幸」。

2015年9月15日

公衛新知 - 登革熱

登革熱病例新增數略降,疫情仍嚴峻民眾不可掉以輕心,加強孳生源清除及個人防護

昨日(914日)新增296例本土登革熱病例,分別為台南市237例、高雄市50例、屏東縣3例、台北市2例、桃園市、嘉義市、新竹市及台東縣各1例,其中台北市個案各有高雄市及台南市活動史,桃園市、嘉義市及台東縣個案均有台南市活動史;新竹市個案感染地待確認。目前有34例病例於加護病房治療(台南市30例、高雄市4例);新增5例疑似登革熱死亡個案,累計18例死因與登革熱相關,34例待審(台南市32例、高雄市2例)。今年入夏以來累計9,862例本土病例,分布於21個縣市,98.7%集中於南高屏,其餘縣市多為移入之散發疫情。
疾管署呼籲,昨日新增病例數雖較前一日略降(亦較上週一個案新增數略降),但目前處登革熱流行高峰,疫情仍嚴峻,民眾絕不能掉以輕心。清除病媒孳生源為登革熱防治最根本的方法,請民眾加強戶內外積水容器清除,以降低感染風險。此外,重複感染不同型別登革病毒,可能引發較嚴重的登革熱重症,若能儘早正確診斷並給予適當治療,可降低死亡率。民眾如有發燒、頭痛、後眼窩痛、肌肉關節痛、出疹等疑似症狀,應儘速就醫,並主動告知醫師活動史,以利及時通報與治療。
民眾如經確診感染登革熱,請遵照醫師指示服藥、多補充水分,儘量在家休息;發病後五日內,應避免被蚊蟲叮咬,以減少病毒藉由蚊蟲散播;並做好防蚊措施,包括:家中裝設紗窗紗門、穿著淺色長袖衣褲、睡覺時掛蚊帳、使用捕蚊燈或電蚊拍(蚊香僅具驅蚊效果)、必要時使用衛福部或環保署核可的防蚊藥劑。相關資訊可參閱疾管署全球資訊網(http://www.cdc.gov.tw)或撥打國內免費防疫專線1922(或0800-001922)洽詢。

資料來源:衛生福利部
資料日期20150915
衛生福利部疾病管制署更多相關連結http://www.cdc.gov.tw/list.aspx?treeid=d315941f29223d38&nowtreeid=d315941f29223d38

2015年9月7日

公衞教學-手機和健康

領域:流行病學(含預防醫學)
題目:手機和健康

作者:何文照老師 公共衛生學系


我們每天日常生活依賴手機情形日益加重,手機是否引起健康問題也益受關注,美國疾病管制暨預防中心(US CDC-參考資料1)參考世界衛生組織 (WHO-參考資料1)等文獻,彙整提供有關重要資訊,並加註個人所學對可能致癌物質之法規值設定之簡要說明。

手機使用會致癌嗎?
目前沒有足夠科學證據可以充分提供答案回答這個問題,一些組織建議謹慎使用手機,目前需要更多的研究加以進一步探討手機使用和健康等相關議題。

使用手機會有輻射暴露嗎?
是的,手機和無線電話使用的是射頻輻射來發送信號。射頻輻射與我們已知有危害的輻射類型(如X射線)不同。我們無法確知手機的射頻輻射經過數年使用暴露後是否會導致健康相關問題。國際癌症研究機構(IARC)將射頻輻射歸類為一種可能的人類致癌物

人們是否應該停止使用手機?
目前科學上無法下定論,科學研究正在進行中來確定使用手機是否會造成健康影響。同樣重要的是要考慮手機使用的好處,尤其是在必要或緊急狀況手機使用價值重大 - 甚至可以挽救生命。

如果您擔心使用手機,請您參考下面的建議。
可減少射頻輻射靠近你的身體:
1. 使用耳機或揚聲器。
2. 在過去,射頻可能干擾心律調節器的運行。如果您目前使用心律調節器且關心您手機使用如何可能會影響它,請馬上聯繫您的健康照護提供者。

進行中的研究?
科學家們正在繼續研究使用手機可能對健康的影響。例如,世界衛生組織(WHO)目前正在進行研究,探討手機使用是否可能影響:1. 某些類型的腫瘤(腫塊或增生);2. 視覺;3. 睡眠;4. 記憶力,和5, 頭痛。

: 可能的人類致癌物在法規值之設定原則,首先於公式分子部分,考量系統性危害之防範,再者於公式分母部分,考量不確定因子,將致癌危害調控於可接受風險範圍內。

參考資料 1, US CDC:
Frequently Asked Questions about Cell Phones and Your Health

Most of us depend on cell phones every day. Some people wonder if cell phones can cause health problems. Here’s what you should know about cell phones and your health.
Can using a cell phone cause cancer?
There is no scientific evidence that provides a definite answer to that question. Some organizations recommend caution in cell phone use. More research is needed before we know if using cell phones causes health effects.
Do cell phones give off (emit) radiation?
Yes – cell phones and cordless phones use radiofrequency radiation (RF) to send signals. RF is different from other types of radiation (like x-rays) that we know can be harmful. We don’t know for sure if RF radiation from cell phones can cause health problems years later. The International Agency for Research on Cancer (IARC) has classified RF radiation as a “possible human carcinogen.” (A carcinogen is an agent that causes cancer.)
Should people stop using cell phones?
At this time we do not have the science to link health problems to cell phone use. Scientific studies are underway to determine whether cell phone use may cause health effects. It is also important to consider the benefits of cell phones. Their use can be valuable in an urgent or emergency situation – and even save lives.
If you are worried about cell phone use, follow the tips below.
Why has the information on this page been updated?
CDC has not changed its position on health effects associated with the use of cell phones. The agency updated these cell phone FAQs in June 2014 as part of efforts to ensure that health information for the public followed best practices, including the use of plain, easy-to-understand, language. During this process, revisions were introduced which inadvertently led some visitors to the web page to believe that a change in position had occurred. The corrected FAQs are now available on this page.
CDC announces changes in public health policy and recommendations through publication in the peer-reviewed literature, usually accompanied by outreach to partners and a media announcement. We apologize for any confusion that resulted from our efforts to ensure that agency information is presented in easy-to-understand language.
Cell phone tips
To reduce radio frequency radiation near your body:
Get a hands-free headset that connects directly to your phone.
Use speaker-phone more often.
In the past, RF interfered with the operation of some pacemakers. If you have a pacemaker and are concerned about how your cell phone use may affect it, contact your health care provider.
What research is being done to learn more about cell phones and health?
Scientists are continuing to study the possible health effects of cell phone use. For example, the World Health Organization (WHO) is currently looking into how cell phones may affect:
Some types of tumors (a lump or growth)
Our eyes
Sleep
Memory
Headaches
In the News: Acoustic Neuroma
Scientists are looking into a possible link between cell phone use and certain types of tumor. One type is called an acoustic neuroma (“ah-COOS-tik nur-OH-ma”). This type of tumor grows on the nerve that connects the ear to the brain. It doesn’t cause cancer, but it may lead to other health problems, like hearing loss. Another type scientists are looking into is called a glioma (“glee-OH-ma”). This is a tumor found in the brain or central nervous system of the body.
(Page last reviewed: June 9, 2014, Page last updated: June 9, 2014
Content source: Centers for Disease Control and Prevention)

參考資料 2, WHO:
Electromagnetic fields and public health: mobile phones
Fact sheet N°193
Reviewed October 2014
Key facts
Mobile phone use is ubiquitous with an estimated 6.9 billion subscriptions globally.
The electromagnetic fields produced by mobile phones are classified by the International Agency for Research on Cancer as possibly carcinogenic to humans.
Studies are ongoing to more fully assess potential long-term effects of mobile phone use.
WHO will conduct a formal risk assessment of all studied health outcomes from radiofrequency fields exposure by 2016.
Mobile or cellular phones are now an integral part of modern telecommunications. In many countries, over half the population use mobile phones and the market is growing rapidly. In 2014, there is an estimated 6.9 billion subscriptions globally. In some parts of the world, mobile phones are the most reliable or the only phones available.
Given the large number of mobile phone users, it is important to investigate, understand and monitor any potential public health impact.
Mobile phones communicate by transmitting radio waves through a network of fixed antennas called base stations. Radiofrequency waves are electromagnetic fields, and unlike ionizing radiation such as X-rays or gamma rays, can neither break chemical bonds nor cause ionization in the human body.
Exposure levels
Mobile phones are low-powered radiofrequency transmitters, operating at frequencies between 450 and 2700 MHz with peak powers in the range of 0.1 to 2 watts. The handset only transmits power when it is turned on. The power (and hence the radiofrequency exposure to a user) falls off rapidly with increasing distance from the handset. A person using a mobile phone 30–40 cm away from their body – for example when text messaging, accessing the Internet, or using a “hands free” device – will therefore have a much lower exposure to radiofrequency fields than someone holding the handset against their head.
In addition to using "hands-free" devices, which keep mobile phones away from the head and body during phone calls, exposure is also reduced by limiting the number and length of calls. Using the phone in areas of good reception also decreases exposure as it allows the phone to transmit at reduced power. The use of commercial devices for reducing radiofrequency field exposure has not been shown to be effective.
Mobile phones are often prohibited in hospitals and on airplanes, as the radiofrequency signals may interfere with certain electro-medical devices and navigation systems.
Are there any health effects?
A large number of studies have been performed over the last two decades to assess whether mobile phones pose a potential health risk. To date, no adverse health effects have been established as being caused by mobile phone use.
Short-term effects
Tissue heating is the principal mechanism of interaction between radiofrequency energy and the human body. At the frequencies used by mobile phones, most of the energy is absorbed by the skin and other superficial tissues, resulting in negligible temperature rise in the brain or any other organs of the body.
A number of studies have investigated the effects of radiofrequency fields on brain electrical activity, cognitive function, sleep, heart rate and blood pressure in volunteers. To date, research does not suggest any consistent evidence of adverse health effects from exposure to radiofrequency fields at levels below those that cause tissue heating. Further, research has not been able to provide support for a causal relationship between exposure to electromagnetic fields and self-reported symptoms, or “electromagnetic hypersensitivity”.
Long-term effects
Epidemiological research examining potential long-term risks from radiofrequency exposure has mostly looked for an association between brain tumours and mobile phone use. However, because many cancers are not detectable until many years after the interactions that led to the tumour, and since mobile phones were not widely used until the early 1990s, epidemiological studies at present can only assess those cancers that become evident within shorter time periods. However, results of animal studies consistently show no increased cancer risk for long-term exposure to radiofrequency fields.
Several large multinational epidemiological studies have been completed or are ongoing, including case-control studies and prospective cohort studies examining a number of health endpoints in adults. The largest retrospective case-control study to date on adults, Interphone, coordinated by the International Agency for Research on Cancer (IARC), was designed to determine whether there are links between use of mobile phones and head and neck cancers in adults.
The international pooled analysis of data gathered from 13 participating countries found no increased risk of glioma or meningioma with mobile phone use of more than 10 years. There are some indications of an increased risk of glioma for those who reported the highest 10% of cumulative hours of cell phone use, although there was no consistent trend of increasing risk with greater duration of use. The researchers concluded that biases and errors limit the strength of these conclusions and prevent a causal interpretation.
Based largely on these data, IARC has classified radiofrequency electromagnetic fields as possibly carcinogenic to humans (Group 2B), a category used when a causal association is considered credible, but when chance, bias or confounding cannot be ruled out with reasonable confidence.
While an increased risk of brain tumors is not established, the increasing use of mobile phones and the lack of data for mobile phone use over time periods longer than 15 years warrant further research of mobile phone use and brain cancer risk. In particular, with the recent popularity of mobile phone use among younger people, and therefore a potentially longer lifetime of exposure, WHO has promoted further research on this group. Several studies investigating potential health effects in children and adolescents are underway.
Exposure limit guidelines
Radiofrequency exposure limits for mobile phone users are given in terms of Specific Absorption Rate (SAR) – the rate of radiofrequency energy absorption per unit mass of the body. Currently, two international bodies 1, 2 have developed exposure guidelines for workers and for the general public, except patients undergoing medical diagnosis or treatment. These guidelines are based on a detailed assessment of the available scientific evidence.
WHO'S response
In response to public and governmental concern, WHO established the International Electromagnetic Fields (EMF) Project in 1996 to assess the scientific evidence of possible adverse health effects from electromagnetic fields. WHO will conduct a formal risk assessment of all studied health outcomes from radiofrequency fields exposure by 2016. In addition, and as noted above, the International Agency for Research on Cancer (IARC), a WHO specialized agency, has reviewed the carcinogenic potential of radiofrequency fields, as from mobile phones in May 2011.
WHO also identifies and promotes research priorities for radiofrequency fields and health to fill gaps in knowledge through its research agendas.
WHO develops public information materials and promotes dialogue among scientists, governments, industry and the public to raise the level of understanding about potential adverse health risks of mobile phones.

Reference:
1 International Commission on Non-Ionizing Radiation Protection (ICNIRP). Statement on the "Guidelines for limiting exposure to time-varying electric, magnetic and electromagetic fields (up to 300 GHz)", 2009.
2 Institute of Electrical and Electronics Engineers (IEEE). IEEE standard for safety levels with respect to human exposure to radio frequency electromagnetic fields, 3 kHz to 300 GHz, IEEE Std C95.1, 2005.