【作者】 李潇潇；

【导师】 高钰琪；

【作者基本信息】 第三军医大学 ， 军事后勤学， 2012， 博士

【摘要】 研究背景中国拥有世界上面积最大的高原国土，同时拥有数量众多的高原常住人口和移居人口，而高原地区也是边境争端、极端主义、分离主义、恐怖主义异常活跃的地区。为了保卫和建设这片世界上最辽阔的高原国土，每年都有大批人员进入这一地区，同时有更多数量的移居者长期工作、战斗和生活在这一地区。这一人群的主体是来自低海拔地区的青年汉族群体，而且以男性为主，包括军人、工人、商人、地方干部等等，其中军人是构成这一群体的重要组成部分。进入高原地区后，由于低压缺氧的影响，军人群体中会出现各型高原病。初进高原的军人群体易发生急性高原病，虽然经过一段适应期症状可自行消退，但在进驻初期会严重影响军人的作业能力。对于常驻高原的军队人群而言，即便经过较长的适应期，仍有相当一部分人员因无法很好地适应高原环境而罹患慢性高原病。其初期症状虽然轻微，但迁延难愈，逐渐加重，严重侵蚀高原官兵的健康和军队的战斗力。然而，慢性高原病对军队人群的影响在既往的研究中一直未引起足够的重视。对高原任务部队而言，急、慢性高原病不仅是一类复杂的医学问题，更是一类复杂的公共卫生和军事后勤问题；不仅会造成官兵个人和家庭的痛苦，也会造成高原部队战斗力的损失和巨大的后勤保障负担。因此，需要采取有效的卫勤保障措施，对急、慢性高原病加以预防和控制，以达到减少发病、缓解症状、降低危害、改善健康、提升战斗力的目的。成功的高原病防治工作必须将人群水平因素纳入考虑。对高原病人群水平影响因素的评估，有助于在宏观层面制定更为有效的卫勤保障对策，以防控高原病的流行。然而，目前有关此领域的研究尚少。研究目的本项研究旨在调查当前高原任务部队急、慢性高原病在不同进驻时间、不同地域、不同人群间分布的有关情况，主要包括急、慢性高原病的各类发病指标及失能指标；探讨军事因素、环境因素、社会因素、卫生因素、行为因素、人口统计特征等各类人群水平影响因素与军队急、慢性高原病的关系；发现与军队急、慢性高原病相关的危险因素与保护因素，定量描述其的作用强度，并建立相应的军队高原病发病模型，估计高原病在军队中的流行趋势；有针对性地提出军队急、慢性高原病的卫勤保障对策建议。同时，通过本研究探索新的研究方向、构建新的研究模式、发现新研究线索，为高原卫生勤务学相关领域的科学研究奠定基础、打开局面。研究内容本研究主要由三个部分组成。第一部分为军队急性高原病人群水平健康影响因素研究；第二部分为军队慢性高原病人群水平健康影响因素研究；第三部分为针对军队高原病的卫勤保障对策研究。其中，前两部分为平行研究，第三部分是在前两部分的基础上探讨军队急、慢性高原病的卫勤保障对策。第一部分的研究分为前后两个阶段。在第一阶段，主要依据现有病例资料和比较容易获得的病例资料进行初步分析。第二阶段，在第一阶段研究的基础上深入高原部队单位收集更为详细的病例资料，提取更为详细的指标，做进一步的研究分析，验证第一阶段的发现并寻找其他潜在的急性高原病人群水平影响因素，完成军队急性高原病人群水平影响因素发病模型的构建。第二部分的研究分为两项平行研究，一项为军队慢性高原病生态学调查研究——探讨各类群体水平因素与慢性高原病患病率之间的关系。另一项研究为军队慢性高原病疾病负担研究——探讨慢性高原病给高原部队造成的健康损失及其人群水平相关因素。通过研究发现军队慢性高原病的人群水平因素，并量化评估慢性高原病给军人群体造成的疾病负担。第三部分的研究根据前两部分的发现，分别针对军队急性高原病和慢性高原病提出相应的卫勤保障对策。其中，针对军队急性高原病的卫勤保障对策重点关注高原任务部队进驻高原军事行动前的卫勤准备工作和进驻过程中的卫勤保障工作；针对军队慢性高原病的卫勤保障对策重点关注常驻高原部队慢性高原病防治和官兵健康促进过程中的卫勤保障工作。研究方法第一部分研究采用回顾性研究的方法，在搜集近年来部队进驻高原军事行动病历资料的基础上，提取相关指标，通过统计分析得出各类进驻条件下部队急性高原病的发病率，找出有意义的影响因素，并构建发病模型。第二部分研究采用横断面调查的方法，随机抽取部分有代表性的高原部队单位，进行慢性高原病的现场调查；对抽样单位进行慢性高原病诊断、症状问卷调查、卫生学调查以及单位基本情况调查。第三部分则采用推理归纳、逻辑演绎的方法探讨高原病的卫勤保障对策。在具体研究中，本课题采用现场调查、问卷调查的方法，了解、掌握目标人群的相关情况，获取指标数据；采用病例-对照研究的方法，分析急性高原病人群水平影响因素；采用氰化高铁血红蛋测定法诊断军人慢性高原病；采用生态学调查法查找、分析高原部队单位慢性高原病人群水平影响因素；采用德尔菲—人数权衡法制订军队慢性高原病症状权重；采用伤残调整寿命年的测算方法测算军队慢性高原病的疾病负担；采用相关分析对急、慢性高原病的人群水平影响因素进行初步筛选；采用回归分析验证急、慢性高原病相关的人群水平影响因素，并建立疾病的数学模型。主要结果经过对军队急性高原病人群水平影响因素的分析，进驻高原地区军事行动中急性高原病的人群水平影响因素主要包括：民族（藏族vs.汉族，OR为0.03-0.08）、兵源地（东部省区vs.西北省区，OR为1.32-1.39）、进驻季节（寒季vs.暖季，OR为1.25-1.28）、进驻方式（紧急陆路vs.常规陆路，OR为2.08-2.11；常规空运vs.常规陆路，OR为2.00-2.20；紧急空运vs.常规陆路，OR为2.40-3.34）、药物预防措施（采用vs.未采用，OR为0.75-0.76）等。在制定高原军事行动计划的过程中，低海拔出发地（600-800米vs.1300-1500米，OR为1.32-1.44）以及高海拔目的地（4100-4300米vs.2900-3100米，OR为3.94-4.12；3600-3700米vs.2900-3100米，OR为2.71-2.74）等风险因素也必须给予高度的重视。研究中建立的急性高原病多元回归模型具有一定的预测价值（接受者特征曲线下面积为0.703），可为部队进驻高原前卫勤保障计划提供参考。经调查各类高原部队单位慢性高原病患病率为1.25—36.58%（14.65±8.15%）。一系列的社区水平影响因素，如部队单位药品投入（OR=0.897，P=0.022）、集中供氧系统的使用（可用vs.不可用，OR=0.827，P=0.020）、军兵种差别（工程兵vs.后勤兵，OR=1.240, P=0.029）以及驻地城市化水平（城市vs.乡村，OR=1.228，P=0.019）都会对部队单位慢性高原病的患病率造成影响。研究还显示，军队慢性高原病的疾病负担较重，且不同人群间具有较大差异。在不同军人群体间，个体损失的伤残调整寿命年为0.13至0.33，每千人损失的伤残调整寿命年为3.60至52.78。具有较高的驻地海拔、较大的年龄、较长的高原服役时间、吸烟习惯以及从事工程专业的军队人群，更容易发生慢性高原病，且慢性高原病的疾病负担也更为严重。在制定进驻高原军事行动卫勤保障计划时，卫勤部门可以将各项人群水平影响因素的风险水平作为参考，并利用发病风险预测模型输出部队人群急性高原病风险预测值，从而为科学拟定进驻高原地区军事行动计划提供定量依据。对于常驻高原部队，卫勤保障工作应着力于加大药品补给、供氧系统建设方面的投入；对承担工程任务的军人群体应加强针对性卫生防护与保健支持；在广大高原官兵中推行吸烟控制与健康防护教育；根据驻地海拔、驻守时间、从事专业建立科学合理的轮换机制和补偿机制。政策建议军队急、慢性高原病的卫勤保障工作具有不完全相同的特点和需求，需要有针对性地实施卫勤保障。针对军队急性高原病的卫勤保障工作应重点针对大部队进驻高原军事任务；目标在于提高军人群体进驻高原初期的作业能力，促其快速适应高原环境；关键在于做好急性高原病的发病预测，根据预测正确拟定卫勤保障计划。针对军队慢性高原病的卫勤保障工作应重点针对长期驻守高原的军人群体；减缓、减轻高原环境对官兵的不良影响，促进人群健康，保持部队在高原地区的战斗力；关键在于减轻军人群体慢性高原病的疾病负担，形成长效的卫勤保障机制。急、慢性高原病的根本病因都是高海拔带来的低压缺氧，其在军队人群中的发生、发展会受到医疗条件和行为方式的影响。急性高原病主要和高原军事任务本身的一些特征（方式、季节）有关，慢性高原病则与驻守时间、生活条件、职业类型有更密切的关系。实施针对军队高原病的卫勤保障，需要把握各类高原病人群水平影响因素，从而科学分配卫生资源，合理制定保障计划，有效采取干预措施。更多还原

【Abstract】 BackgroundsChina has the world largest highland territory and a large number of native andimmigrant highlanders. The highland territory also is the flash point of border conflicts,race extremism, separatism, and terrorism. To defense and develop the world largesthighland territory, a great many of people are working and living in the area, and there alsoare a great many of new comers enter the area every year. The population that entering thehighland is mainly make up of young male Chinese Han population. The populationincludes soldiers, workers, merchants, and civil servants, among which soldiers take up alarge part of them.After military population entering highland area, many servicemen will developaltitude disease due to the effectiveness of hypobaric hypoxia. During the early period ofnewly entering high altitude, military population will affect by acute altitude disease.Although the symptoms would subside after a period of acclimation, the symptoms cansignificantly reduce operation capability of the servicemen in the early time of entering.Even if living in highland for a long period, many of the servicemen who were deployed forlong-term highland service cannot fully get acclimation and develop chronic altitudedisease. The early symptoms of the chronic altitude disease are not serious. However, it istreatment-resistance and would deteriorate gradually as time goes on, which disintegratehealth of the highland servicemen and decay combat effectiveness of the highland troops.Unfortunately, there are not enough awareness been paid for the harmful effectiveness ofchronic altitude disease in the highland servicemen population.Altitude diseases are not only a series of complicated medical problems, but also aseries of complicated public health and military logistics’ problems for highland troops. Thediseases not only cause suffering and misery for oneself and his family, but also cause losing of the troops’ combat effectiveness and heavy logistics burden of the army. Hence, itis imperative for the authorities to take effective health service measures to prevent andcontrol both acute and chronic altitude disease. The purposes should be decreasingincidence, alleviating symptoms, reducing harm, improving health status, enhancingcombat effectiveness. To accomplish these purposes of control and heal altitude diseases,population level health related determents should be taken into account. Evaluation ofpopulation level determents of altitude diseases is helpful for countermeasure making foreffective controlling of the diseases in highland troops on the view of macroscopic.However, there is little work on this study field presently.Study purposesThe purposes of this study, firstly, are to investigate the contemporary distributionstatus of acute and chronic altitude disease among different time, different area, anddifferent military populations, including disease indicators and disability indicators.Secondly, to discuss the relationship between altitude diseases and population leveldeterments that include military factor, environmental factor, social factor, hygiene factor,behavior factor, and demographic characteristic factor. Thirdly, to find out and quantify therisk and protect factors of altitude diseases and build up disease model for describing theepidemic tendency of the diseases. Fourthly, to bring forward suggestions of the highlandtroops’ health service for altitude diseases according to the factors. Moreover, through thisstudy, to discover new research direction, build up new research mode, find out new studyclues, and lay the groundwork and pave the way for future studies of military highlandhealth service.Study contentsThis study is composed by three parts. The first part is the study of population levelhealth determents of acute altitude disease in highland troops. The second part is the studyof population level health determents of chronic altitude disease in highland troops. Thethird part is countermeasure study of health service for altitude diseases. The first two partsare parallel study, while the third part gives out the countermeasures that based on thefindings of the first two parts.The first part of this study includes two stages. The first stage is preliminary analysesby using the medical records that already possessed or easy to obtain. The second stage is further analyses based on the first stage by using the advanced medical records thatcollected from highland units. Aims of the second stage are to verify the findings of the firststage, to find out other potential population level determents of acute altitude disease, andto build up acute altitude disease model of highland troops.The second part of this study is composed by two parallel study sections. One of thesections is epidemiological ecological study of chronic altitude disease among permanenthighland units, which is to discuss the relationship between prevalence of chronic altitudedisease and population level determents of highland military unit. The other section is studyon the highland troops’ burden of chronic altitude disease, which is to discuss the highlandtroops’ health lost caused by chronic altitude disease and its related population level factors.The third part of this study is to discuss the highland troops’ health servicecountermeasures for acute and chronic altitude disease separately. The health servicecountermeasures for acute altitude disease are focus on the health service preparationsbefore highland entering operation and health supports during the highland enteringoperation. The health service countermeasures for chronic altitude disease are focus on thehealth service for prevention and heal the disease and servicemen health improvement inpermanent highland units.Study methodologyThe first part of this study based on retrospective strategy. We collected highlandtroops’ recent year medical records during highland entering operations and extracted studyfactors. By statistic analyses we obtained the incidence rates, significant determents, andbuilt up disease model. The second part of this study based on across sectional strategy. Werandomly selected a sample of representative highland military units for chronic altitudedisease field investigation. During the investigation we carried out chronic altitude diseasediagnosis, symptom questionnaire, hygienic survey, and unit base information inquiry in thesample units. The third part of this study discussed health service countermeasures bymethodology of reasonable induction and logical deduction.In specific study, we used field investigation and questionnaire to obtain the status oftarget population; used case-control research to analyze the population level determents ofacute altitude disease; used cyanmethemoglobin technique to diagnose chronic altitudedisease; used epidemiological ecological investigation to find and analyze population level determents of chronic altitude disease; used Delphi processed person-treat-off strategy todeduce the disease weights of chronic altitude disease; used disability adjusted life year tocalculate the disease burden of highland troops; used correlation analysis to preliminarilyselect the population level determents of altitude disease, used regression analysis toconclude the population level determents of altitude diseases and to build up mathematicaldisease model.Main findingsBy the population level determents’ analyses of highland troops, the acute altitudedisease determents were obtained, including: race (Tibetan vs. Han, OR=0.03-0.08), bornprovince (east vs. northwest, OR=1.32-1.39), season (cold vs. warm, OR=1.25-1.28),deployment type (emergency by land vs. normal by land, OR=2.08-2.11; normal by air vs.normal by land, OR=2.00-2.20; emergency by air vs. normal by land, OR=2.40-3.34),prophylaxis (prophylaxis vs. none, OR=0.75-0.76). When draw up highland enteringoperation plan, lower start point (600-800m vs.1300-1500m, OR=1.32-1.44) and higherdestination (4100-4300m vs.2900-3100m, OR=3.94-4.12;3600-3700m vs.2900-3100m, OR=2.71-2.74) also should be seriously take into account. Prediction value of themultiple regression model built in the study is acceptable (the area under receivercharacteristic curve is0.703), which could be used as reference for health service planmaking before troops entering highland.According to this investigation, the prevalence rate of chronic altitude disease amongthe highland troops is from1.25to36.58%(14.65±8.15%). Series community level factorswere verified as significant determents of chronic altitude disease, including pharmacyinvestment (OR=0.897，P=0.022), oxygen generation system (available vs. unavailable,OR=0.827, P=0.020), occupation (construction vs. logistics, OR=1.240, P=0.029), andsocial development level (urban vs. rural, OR=1.228, P=0.019). The study also indicatedthat the disease burden caused by chronic altitude disease is serious among highland troops,although it changes dramatically in different servicemen population. In differentservicemen population, the individual disability adjusted life years lost was form0.13to0.33, while the disability adjusted life years lost by one thousand people was form3.60to52.78. The population who lived in a higher area, got older, serviced for longer years inhighland, had smoking behavior, and engaged in construction occupation, are more likely to develop chronic altitude disease and also more likely to get heavier disease burden.When making health service plan before troops entering highland, the health serviceauthority should take the population level determents of acute altitude disease into account,and use the risk predicting model to export risk value of the disease, so that it could providequantitive reference for scientific military planning before operation of entering highland.For highland permanent military units, the health service should focus on increasing theinvestment of pharmacy and oxygen generation system, giving more attention to the healthcare and health protection of the population of construction occupation, enhancingservicemen’s awareness of giving up smoking and self protection, and establishingscientific and reasonable rotation and compensation mechanism according to one’s livingaltitude, highland service year, and occupation.Policy recommendationThe characteristics of health service are different between acute and chronic altitudedisease, thereby they should be carried out focus on their factors.The health service for acute altitude disease should focus on entering highlandoperation. Its purpose should be to enhance the operation capability and promote highlandacclimation during early time of entering. Its key point should be to advance prediction ofacute altitude disease and correctly make health service plan based on the prediction.The health service for chronic altitude disease should focus on the long-term highlandservice military population. Its purpose should be to reduce and alleviate harmful effectscaused by chronic altitude disease, promote the population health, maintain the highlandtroops’ combat effectiveness. Its key point should be to reduce the disease burden ofhighland troops caused by chronic altitude disease and establish long-term health servicemechanism.Fundamental reason of both acute and chronic altitude disease is hypobaric hypoxiacaused by high altitude, while the occurring developing of the diseases are significantlyaffected by medical facilitate and health behavior. Acute altitude disease mainly relatedwith some characteristics of highland military operation, e.g. deployment type and season;while chronic altitude disease mainly related with highland service year, living condition,occupation. In the implementation of highland troops’ health service for altitude disease,the population level determents of altitude disease should be taken into account, so that medical resources could be distributed scientifically, support plan could be made reasonably,and health intervention could be executed effectively.更多还原