题名

因針扎事件傳染急性C型肝炎之追蹤與治療－兩不同策略下的成本效益分析

并列篇名

Costs and Cost-Effectiveness of Two Different Follow-Up Schedules for Occupational Acute Hepatitis C Virus Infection

DOI

10.6342/NTU.2011.02577

作者

柯威旭

关键词

針扎 ； 急性C型肝炎 ； 慢性C型肝炎 ； 成本效益分析 ； 勞工安全衛生 ； needle stick injury ； acute hepatitis C ； chronic hepatitis C ； cost-effectiveness analysis ； occupational safety and health

期刊名称

臺灣大學財務金融組學位論文

卷期/出版年月

2011年

学位类别

碩士
导师

李存修
内容语文

繁體中文
中文摘要

因針扎事件而得到急性C型肝炎，對於醫療工作者(醫師、護理人員、技術人員，甚至是清潔人員)的健康而言都是一大威脅。第一個理由是：醫院中住院病患的C型肝炎的盛行率較一般人口為高；第二個理由是：一但得到急性C型肝炎，半數以上將會進展到慢性C型肝炎的階段，日後再進展到肝硬化及肝癌的可能性，較無C型肝炎感染者來得高。因此，對於因針扎事件而得到的急性C型肝炎，施予藥物治療，若能成功達到抑制病毒(Sustained Viral Response, SVR)後，將會阻斷上述進展到肝硬化及肝癌的可能。 根據國外文獻，因為針扎事件而受傳染得到急性C型肝炎的比例約為0.5%。但台灣屬C型肝炎中高盛行率的地區，因針扎事件而傳染的急性C型肝炎仍應受到重視。此外，由於C型肝炎並無疫苗注射可提供預防，而且對於急性C型肝炎的治療，達SVR的比例可高達90%，因此早期投予治療，對於因受針扎傳染得到急性C型肝炎的醫護人員中，無法自行廓清病毒者來說，似乎具有臨床意義。 目前，對於因針扎得到急性C型肝炎的治療建議，各專業醫學組織尚未達到一致的共識。本成本效果分析的研究乃是用來比較在台灣地區，在針扎事件發生後，因而得到急性C型肝炎的追踪與治療，對國內現行策略與美國CDC的替代建議策略，以職業災害的補償者－雇主(醫院)和公共衛生政策的制訂者－政府為觀點，做出兩者間成本效果分析的比較。 經成本效果與成本效益分析後的結果得知，美國CDC的替代建議，在因針扎事件感染急性C型肝炎的感染率為0.5%的情況下，比目前台灣官方所建議的方案，更具成本效益。每年將多避免3.6名因針扎事作而感染成慢性C型肝炎的個案。而每避免一個CHC個案需增加220,136元的成本。考慮慢性C型肝炎可能進展至肝硬化、肝癌，乃至於死亡後，美國CDC的替代建議不但可以延長15.8 QALYs，所需的總成本還比目前台灣官方的建議還低22萬元。把上述兩個效益一起考慮後，在美國CDC替代建議下，每增加一元在針扎事件後急性Ｃ型肝炎的治療上，在未來可以帶來1.26元的效益。 吾人建議，台灣衛生署疾病管制局與主管勞工安全衛生的勞工委員會，應速將「醫療保建服務業針扎危害管理指引」中的急性C型肝炎追蹤建議，依美國CDC的替代建議內容做修改。以期提供醫療人員更完整的職業安全衛生保障。
英文摘要

Background Transmission of hepatitis C virus (HCV) via needle stick injury from patients to health-care workers has been well documented. Different follow-up programs for this occupational exposure have been available in different countries. In this study, using a cost-effectiveness analysis, we compared the existing follow-up strategies recommended in Taiwan (wait-and-see) and the USA (early detection). Methods A decision tree simulated these two strategies for 1263 healthcare workers (HCWs) exposed to HCV each year in Taiwan, from exposure to death. Results of a cost-effectiveness analysis concerning the treatment of chronic hepatitis C (CHC) in Taiwan were used to estimate associated parameters once spontaneous resolution did not develop after six months. Results For a HCV transmission risk of 0.5% after exposure, the USA strategy could avert 3.6 CHC cases by extra cost NTD 220,136 per case. Taking together all the costs in treating CHC, the US strategy was dominant with an incremental QALYs 15.8 and cheaper cost. In a cost-benefit analysis, the US strategy had a positive net benefit and carried a benefit-cost ratio 1.26. Conclusion The US strategy based on early HCV-RNA testing could provide early diagnosis and treatment of acute occupational hepatitis C. This strategy also leads to lower risk of progression to CHC and is dominantly cost-effective.
主题分类 管理學院 > 財務金融組
社會科學 > 財金及會計學
参考文献
  1. APASL Hepatitis C Working Party McCaughan GW, Omata M, Amarapurkar D, Bowden S, Chow WC, Chutaputti A, Dore G, Gane E, Guan R, Hamid SS, Hardikar W, Hui CK, Jafri W, Jia JD, Lai MY, Wei L, Leung N, Piratvisuth T, Sarin S, Sollano J, Tateishi R. (2007) Asian Pacific Association for the Study of the Liver consensus statements on the diagnosis, management and treatment of hepatitis C virus infection. J Gastroenterol Hepatol. 2007;22:615-33
    連結：
  2. Arai Y, Noda K, Enomoto N, et al. (1996) Arai K, Yamada Y, Suzuki K, Yoshihara H.A prospective study of hepatitis C virus infection after needlestick accidents. Liver 1996;16:331–4
    連結：
  3. Armstrong GL,WasleyA, Simard EP, Wasley A, Simard EP, McQuillan GM, Kuhnert WL, Alter MJ. et al. (2002) The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med 2006;144:705–14
    連結：
  4. Baldo V, Floreani A, Dal Vecchio L, Floreani A, Dal Vecchio L, Cristofoletti M, Carletti M, Majori S, Di Tommaso A, Trivello R.et al. (2002) Occupational risk of blood-borne viruses in healthcare workers: a 5-year surveillance program. Infect Control Hosp Epidemiol 2002;23:325–7
    連結：
  5. Beasley RP, Hwang LY, Lin CC, Chien CS. (1981) Hepatocellular carcinoma and hepatitis B virus. A prospective study of 22 707 men in Taiwan. Lancet 1981;2:1129-33
    連結：
  6. Chang MH, Chen CJ, Lai MS, Hsu HM, Wu TC, Kong MS, Liang DC, Shau WY, Chen DS. (1997) Universal hepatitis B vaccination in Taiwan and the incidence of hepatocellular carcinoma in children. Taiwan Childhood Hepatoma Study Group. N Engl J Med 1997;336:1855-9
    連結：
  7. Chapman LE, Sullivent EE, Grohskopf LA, Perz JF, Kretsinger K, Panlilio AL, Thompson ND, Ehrenberg RL, Gensheimer KF, Duchin JS, Kilmarx PH, Hunt RC; Centers for Disease Control and Prevention (CDC). (2008) Recommendations for postexposure interventions to prevent infection with hepatitis B virus, hepatitis C virus, or human immunodeficiency virus, and tetanus in persons wounded during bombings and other mass-casualty events--United States, 2008: recommendations of the Centers for Disease Control and Prevention (CDC). MMWR Recomm Rep. 2008 Aug 1;57(RR-6):1-21
    連結：
  8. Chen DS (1990) Hepatitis B virus infection, its sequelae, and prevention in Taiwan. In: Okuda K, Ishak KG, eds. Neoplasms of the liver. Tokyo:Springer-Verlag, 1987. 71-80
    連結：
  9. Chen DS, Kuo GC, Sung JL, Lai MY, Sheu JC, Chen PJ, Yang PM, Hsu HM, Chang MH, Chen CJ,. (1990) Hepatitis C virus infection in an area hyperendemic for hepatitis B and chronic liver disease: the Taiwan experience. J Infect Dis 1990;162:817-22
    連結：
  10. Chen CH, Yang PM, Huang GT, Lee HS, Sung JL, Sheu JC. (2007) Estimation of seroprevalence of hepatitis B virus and hepatitis C virus in Taiwan from a large-scale survey of free hepatitis screening participants. J Formos Med Assoc 2007;106:148-55.
    連結：
  11. Chuang WL, Chang WY, Lu SN, Su WP, Lin ZY, Chen SC, Hsieh MY, Wang LY, You SL, Chen CJ. (1992) The role of hepatitis B and C viruses in hepatocellular carcinoma in a hepatitis B endemic area. A case-control study. Cancer 1992;69:2052-4
    連結：
  12. Chung RT (2005) Acute hepatitis C virus infection. Clin Infect Dis 2005;41:S14–7
    連結：
  13. Corey KE, Ross AS, Wurcel A, Schulze Zur Wiesch J, Kim AY, Lauer GM, Chung RT. (2006) Outcomes and treatment of acute hepatitis C virus infection in a United Statues polulation. Clin Gastroenterol Hepatol 2006;4:1278-82
    連結：
  14. Corey KE, Mendez-Navarro J, Gorospe EC, Zheng H, Chung RT. (2010) Early treatment improves outcomes in acute hepatitis C virus infection: a meta-analysis. J. Viral Hepat. 2010;17:201-7
    連結：
  15. De Rosa FG, Bargiacchi O, Audagnotto S, Garazzino S, Cariti G, Raiteri R, Di Perri G. (2006) Dose-dependent and genotypeindependent sustained virological response of a 12 week pegylated interferon alpha-2b treatment for acute hepatitis C. J Antimicrob Chemother 2006;57:360–3
    連結：
  16. De Rosa FG, Bargiacchi O, Audagnotto S, Garazzino S, Cariti G, Calleri G, Lesioba O, Belloro S, Raiteri R, Di Perri G. (2007) Twelve-week treatment of acute hepatitis C virus with pegylated interferon- alpha -2b in injection drug users. Clin Infect Dis 2007;45:583–8
    連結：
  17. Desenclos JC. (2003) The challenge of hepatitis C surveillance in Europe. Euro Surveill 2003;8:99–100
    連結：
  18. Deterding K, Gruner N, Wiegand J. (2009) Early versus delayed treatment of acute hepatitis C: the German HEP-NET acute HCV-III study- a randomized controlled trial. J Hepatol 2009;50:S380
    連結：
  19. Deuffic-Burban S, Abiteboul D, Lot F, Branger M, Bouvet E, Yazdanpanah Y. (2008) Costs and cost-effectiveness of different follow-up schedules for detection of occupational hepatitis C virus infection. Gut 2009;58:105-10
    連結：
  20. Deuffic-Burban S, Mohamed MK, Larouze B, Carrat F, Valleron AJ. (2006) Expected increase in hepatitis C-related mortality in Egypt due to pre-2000 infections. J Hepatol 2006;44:455–61
    連結：
  21. Dintsios CM, Haverkamp A, Wiegand J, Gerlach T, Wedemeyer H, Pape G, Manns MP, Krauth C. (2010) Economic evaluation of early monotherapy versus delayed monotherapy or combination therapy in patients with acute hepatitis C in Germany
    連結：
  22. EASL Clinical Practice Guidelines: Management of hepatitis C virus infection (2011) Available at: http://www.easl.eu/_clinical-practice-guideline/issue-5-march-2011-management-of-hepatitis-c-virus-infection
    連結：
  23. Ghany MG, Strader DB, Thomas DL, Seeff LB; American Association for the Study of Liver Diseases. (2009) Diagnosis, management, and treatment of hepatitis C: an update. Hepatology. 2009;49:1335-74
    連結：
  24. Grebely J, Matthews GV, Dore GJ (2011) Treatment of acute HCV infection. Nat. Rev. Gastroenterol & Hepatol 2011;8:265-74
    連結：
  25. Henderson DK (2003) Managing Occupational Risks for Hepatitis C Transmission in the Health Care Setting. Clin Microbiol Rev. 2003;16:546-68
    連結：
  26. Hernandez ME, Bruguera M, Puyuelo T, Barrera JM, Sanchez Tapias JM, Rodes J. (1992) Risk of needle-stick injuries in the transmission of hepatitis C virus in hospital personnel. J Hepatol 1992;16:56–8
    連結：
  27. Hofer H, Watkins-Riedel T, Janata O, Penner E, Holzmann H, Steindl-Munda P, Gangl A, Ferenci P. (2003) Spontaneous viral clearance in patients with acute hepatitis C can be predicted by repeated measurements of serum viral load. Hepatology 2003;37:60-4
    連結：
  28. Hoofnagle JH (1997). Hepatitis C: the clinical spectrum of disease. Hepatology 1997;26(3 suppl 1):15S-20S.
    連結：
  29. IARC(International Agency for Research on Cancer) (1994) Hepatitis Viruses IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, vol. 59. IARC: Lyon, France. 1994
    連結：
  30. Jagger J, Puro V, De Carli G. (2002) Occupational transmission of hepatitis C virus. JAMA 2002;288:1469.
    連結：
  31. Kamal (2008) Acute Hepatitis C: A systematic Review Am J Gastroenterol 2008;103:1283-97
    連結：
  32. Kamal SM, Ismail A, Graham CS, He Q, Rasenack JW, Peters T, Tawil AA, Fehr JJ, Khalifa Kel S, Madwar MM, Koziel MJ. (2004) Pegylated interferon alpha therapy in acute hepatitis C: relation to hepatitic C virus-specific T cell response kinetics. Hepatology 2004;39:1721-31
    連結：
  33. Kamal SM, Fouly AE, Kamel RR, Hockenjos B, Al Tawil A, Khalifa KE, He Q, Koziel MJ, El Naggar KM, Rasenack J, Afdhal NH. (2006a) Peginterferon alfa-2b therapy in acute hepatitis C: Impact of onset of therapy on sustained virologic response. Gastroenterology 2006;130:632–8
    連結：
  34. Kamal SM, Moustafa KN, Chen J, Fehr J, Abdel Moneim A, Khalifa KE, El Gohary LA, Ramy AH, Madwar MA, Rasenack J, Afdhal NH. (2006b) Duration of peginterferon therapy in acute hepatitis C: a randomized trial. Hepatology 2006;43:923-31
    連結：
  35. Lai MS, Hsieh MS, Chiu YH, Chen TH. (2006) Type 2 diabetes and hepatocellular carcinoma: A cohort study in high prevalence area of hepatitis virus infection. Hepatology 2006;43:1295-302.
    連結：
  36. Lanphear BP, Linnemann CC Jr, Cannon CG, DeRonde MM, Pendy L, Kerley LM. (1994) Hepatitis C virus infection in healthcare workers: risk of exposure and infection. Infect Control Hosp Epidemiol 1994;15:745–50.
    連結：
  37. Lee CM, Lu SN, Changchien CS, Yeh CT, Hsu TT, Tang JH, Wang JH, Lin DY, Chen CL, Chen WJ. (1999) Age, gender, and local geographic variations of viral etiology of hepatocellular carcinoma in a hyperendemic area for hepatitis B virus infection. Cancer 1999;86:1143-50.
    連結：
  38. Lu SN, Su WW, Yang SS, Chang TT, Cheng KS, Wu JC, Lin HH, Wu SS, Lee CM, Changchien CS, Chen CJ, Sheu JC, Chen DS, Chen CH. (2006) Secular trends and geographic variations of hepatitis B virus and hepatitis C virus-associated hepatocellular carcinoma in Taiwan. Int J Cancer 2006;119:1946-52.
    連結：
  39. Micallef JM, Kaldor JM, Dore GJ. (2006) Spontaneous viral clearance following acute hepatitis C infection: A systematic review of longitudinal studies. J Viral Hepat 2006;13:34–41
    連結：
  40. Mitsui T, Iwano K, Masuko K, Yamazaki C, Okamoto H, Tsuda F, Tanaka T, Mishiro S. (1992) Hepatitis C virus infection in medical personnel after needlestick accident. Hepatology 1992;16:1109–14.
    連結：
  41. Mondelli MU, Cerino A, Cividini A. (2005) Acute hepatitis C: Diagnosis and management. J Hepatol 2005;42:S108–14.
    連結：
  42. Ni YH, Huang LM, Chang MH, Yen CJ, Lu CY, You SL, Kao JH, Lin YC, Chen HL, Hsu HY, Chen DS. (2007) Two decades of universal hepatitis B vaccination in taiwan: impact and implication for future strategies. Gastroenterology 2007;132:1287-93.
    連結：
  43. Perz JF, Armstrong GL, Farrington LA, Hutin YJ, Bell BP. (2006) The contributions of hepatitis B virus and hepatitis C virus infections to cirrhosis and primary liver cancer worldwide. J Hepatol 2006;45:529-38.
    連結：
  44. Schiff (1992) Hepatitis C among health care providers: risk factors and possible prophylaxis. Hepatology 1992;16:1300-01
    連結：
  45. Seeff LB, Hoofnagle JH. (2003) Appendix: The National Institutes of Health Consensus Development Conference Management of Hepatitis C 2002. Clin Liver Dis 2003;7:261–87
    連結：
  46. Shepard CW, Finelli L, Alter MJ. (2005) Global epidemiology of hepatitis C virus infection. Lancet Infect Dis 2005;5:558–67.
    連結：
  47. Shiao JS, McLaws ML, Lin MH, Jagger J, Chen CJ. (2009) Chinese EPINet and Recall rates for Percutaneous Injuries: An Epidemic Proportion of underreporting in the Taiwan Healthcare System. J Occup Health 2009;51:132-6
    連結：
  48. Shiao JS, Lin MS, Shih TS, Jagger J, Chen CJ. (2008) National incidence of percutaneous injury in Taiwan healthcare workers. Res Nurs Health 2008;31:172-179
    連結：
  49. Sodeyama T, Kiyosawa K, Urushihara A, Matsumoto A, Tanaka E, Furuta S, Akahane Y. (1993) Detection of hepatitis C virus markers and hepatitis C virus genomic-RNA after needlestick accidents. Arch Intern Med 1993;153:1565–72.
    連結：
  50. Sun CA, Wu DM, Lin CC, Lu SN, You SL, Wang LY, Wu MH, Chen CJ. (2003) Incidence and cofactors of hepatitis C virus-related hepatocellular carcinoma: a prospective study of 12,008 men in Taiwan. Am J Epidemiol
    連結：
  51. Thomas DL, Seeff LB (2005) Natural history of hepatitis C. Clin Liver Dis 2005;9:383–98.
    連結：
  52. Thorburn D, Roy K, Cameron SO, Johnston J, Hutchinson S, McCruden EA, Mills PR, Goldberg DJ. (2003) Risk of hepatitis C virus transmission from patients to surgeons: model based on an unlinked anonymous study of hepatitis C virus prevalence in hospital patients in Glasgow. Gut 2003;52:1333-8
    連結：
  53. Wang CC, Krantz E, Klarquist J, Krows M, McBride L, Scott EP, Shaw-Stiffel T, Weston SJ, Thiede H, Wald A, Rosen HR. (2007) Acute hepatitis C in a contemporary US cohort: Modes of acquisition and factors influencing viral clearance. J Infect Dis 2007;196:1474–82.
    連結：
  54. WHO, World Health Organization, 2002. Global prevalence of hepatitis A, B, and C Weekly Epidemiological Record, Vol. 77, 6, 2002
    連結：
  55. Wicker S, Cinatl J, Berger A, Doerr HW, Gottschalk R, Rabenau HF. (2008) Determination of Risk of Infeciton with Blood-borne Pathogens Following a Needle stick Injury in Hostpial Worker Ann. Occup. Hyg. 2008;52:615-22
    連結：
  56. Williams IT, Bell BP, Kuhnert W, Alter MJ. (2011) Incidence and Transmission Patterns of Acute Hepatitis C in the United States, 1982-2006. Arch Intern Med. 2011;171(3):242-8
    連結：
  57. Yazdanpanah Y, De Carli G, Migueres B, Lot F, Campins M, Colombo C, Thomas T, Deuffic-Burban S, Prevot MH, Domart M, Tarantola A, Abiteboul D, Deny P, Pol S, Desenclos JC, Puro V, Bouvet E. (2005) Risk Factors for Hepatitis C Virus Transmission to Health Care Workers after Occupational Exposure: A European Case-Control Study. Clinical Infections Disease 2005;41:1423-30
    連結：
  58. Yu MW, You SL, Chang AS, Lu SN, Liaw YF, Chen CJ. (1991) Association between hepatitis C virus antibodies and hepatocellular carcinoma in Taiwan. Cancer Res 1991;51:5621-5.
    連結：
  59. Zuckerman J, Clewley G, Griffiths P, Cockcroft A. (1994) Prevalence of hepatitis C antibodies in clinical health-care workers. Lancet 1994;343:1618–20.
    連結：
  60. 行政院衛生署疾病管制局　急性病毒性C型肝炎 available at: http://www.cdc.gov.tw/sp.asp?xdurl=disease/disease_content.asp&id=788&mp=1&ctnode=1498
    連結：
  61. 陳瑛瑛 等 (2004) 經濟評估在醫院感染管制 感染控制雜誌 2004;14:181-7
    連結：
  62. Calleri G, Cariti G, Gaiottino F, De Rosa FG, Bargiacchi O, Audagnotto S, Quaglia S, De Blasi T, Romano P, Traverso A, Leo G, Carbone R, Del Mastro B, Tinelli M, Caramello P, Di Perri G. (2007) A short course of pegylated interferon-alpha in acute HCV hepatitis. J Viral Hepat 2007;14:116–21
  63. Chinese EPINet Available at: http://www.cmesh.org.tw/EPINET/hp.asp
  64. Courouce AM, Pillonel J. (1996) Transfusion-transmitted viral infections. Retrovirus and Viral Hepatitis Working Groups of the French Society of Blood Transfusion. NEJM 1996;335:1609-10
  65. De Carli G, Puro V, Ippolito G. (2003) Risk of hepatitis C virus transmission following percutaneous exposure in healthcare workers. Infection 2003;31(Suppl 2):22–7
  66. Gerlach JT, Diepolder HM, Zachoval R, Gruener NH, Jung MC, Ulsenheimer A, Schraut WW, Schirren CA, Waechtler M, Backmund M, Pape GR. (2003) Acute hepatitis C: High rate of both spontaneous and treatment-induced viral clearance. Gastroenterology 2003;125:80–8
  67. Hasan F, Askar H, Al Khalidi J, Al Shamali M, Al Kalaoui M, Al Nakib B. (1999) Lack of transmission of hepatitis C virus following needlestick accidents. Hepatogastroenterology 1999;46:1678–81
  68. Kao & Pwu et al. (2006) 「全民健康保險加強慢性B型及C型肝炎治療試辦計畫」之總療效及成本效益評估　Available at:　http://www.cdc.gov.tw/public/data/DOH95-DC-1119%E5%85%A8%E6%B0%91%E5%81%A5%E5%BA%B7%E4%BF%9D%E9%9A%AA%E5%8A%A0%E5%BC%B7%E6%85%A2%E6%80%A7B%E5%9E%8B%E5%8F%8AC%E5%9E%8B%E8%82%9D%E7%82%8E%E6%B2%BB%E7%99%82%E8%A9%A6%E8%BE%A6%E8%A8%88%E7%95%AB%E4%B9%8B%E7%B8%BD%E7%99%82%E6%95%88%E5%8F%8A%E6%88%90%E6%9C%AC%E6%95%88%E7%9B%8A%E8%A9%95%E4%BC%B0.pdf
  69. Puro V, De Carli G, Cicalini S, Soldani F, Balslev U, Begovac J, Boaventura L, Campins Marti M, Hernandez Navarrete MJ, Kammerlander R, Larsen C, Lot F, Lunding S, Marcus U, Payne L, Pereira AA, Thomas T, Ippolito G; European Occupational Post-Exposure Prophylaxis Study Group. (2005) European recommendations for the management of healthcare workers occupationally exposed to hepatitis B virus and hepatitis C virus. Euro Surveill. 2005;10:260-4
  70. Reddy SI, Ukomadu C (2004) Hepatitis C: update on management of chronic infection. J Clin Outcomes Manage 2004;11:523-533.
  71. Takagi H, Uehara M, Kakizaki S, Takahashi H, Takezawa J, Kabeya K, Satoh K, Kojima A, Saito S, Matsumoto T, Hashimoto Y, Abe T, Yamada T, Konaka K, Shimoda R, Takayama H, Takehara K, Nagamine T, Mori M. (1998) Accidental transmission of HCV and treatment with interferon. J Gastroenterol Hepatol 1998;13:238–43.
  72. Wang TY, Kuo HT, Chen LC, Chen YT, Lin CN, Lee MM (2002) Use of Polymerase Chain Reaction for Early Detection and Management of Hepatitsi C Virus after Needlestick Injury Annals of Clinical & Laboratory Science 2002;32:137-41
  73. WHO, World Health Organization, 2003. Available at: http://www.who.int/csr/disease/hepatitis/whocdscsrlyo2003/en/index.html. Accessed June 1, 2011
  74. 行政院衛生署 Available at: http://www.doh.gov.tw/CHT2006/DM/DM2_p01.aspx?class_no=25&level_no=1&doc_no=80728
  75. 陳秀熙 疫苗經濟評估 李慶雲兒童感染暨疫苗發展文教基金會 (http://www.cylfoundation.org.tw/download/inject/3.pdf)
print cancel