新型流感科学预防的最新指南，相信对中国政策也会发生重大影响
反映美国SHEA立场，关于新型流感科学预防的最新指南，相信对中国政策也会发生重大影响！2009年6月12日美国感染控制领域的权威学会SHEA，发布新型流感预防和控制的指南。
一些观点是颠覆性的，但是又不得不承认其科学依据。
原文是英文，希望好心的朋友，能将其翻译成中文，功德无量呀！
摘录：
SHEA强烈支持和鼓励CDC更新医疗机构预防和控制新型流感的指南。根据目前获得的资料和对H1N1暴发的评估，SHEA建议执行用于预防季节性流感传播的方法。特别是：我们建议对疑似和确诊病例，使用标准预防和飞沫预防方法就可以了。给疑似或确诊病例在医疗机构与他人有接触时，戴外科口罩；可能的话安置于单人病房，或与其他同类感染合住；严格执行手卫生，呼吸道卫生和咳嗽礼仪；病人来就诊时，医疗机构要能早期识别和确诊；限制探视者和医务人员与有发热的呼吸系统疾病患者的接触；处理这些病人时，通常不需要负压病房。
SHEA Position Statement: Interim Guidance on Infection Control Precautions for Novel Swine-Origin Influenza A H1N1 in HealthcareFacilities
【This position statement has been endorsed by the Infectious Diseases Society of America (IDSA) and the Association for Professionals in Infection Control and Epidemiology (APIC).】
The emergence of a novel swine-origin influenza A H1N1 (novel H1N1) virus has dramatically impacted healthcare institutions across the globe.1, 2 Fortunately, most public health and healthcare organizations have participated in pandemic preparedness activities for the past few years. Key components of pandemic influenza preparedness include rapid implementation of infection prevention and control procedures and practices to prevent transmission of both existing and novel pathogens. Such prevention practices should be rooted in the best available evidence, provide appropriate protection based upon proposed or established modes of disease transmission, and be coupled with additional community-based public health measures, such as social distancing. As additional information regarding the transmission patterns and disease severity of the specific pathogen becomes available, infection prevention and control guidance can and should be amended to provide effective protection of healthcare workers and their patients.
As an organization representing over 1,400 physicians and other professionals who direct infection prevention and control programs in our nation’s healthcare facilities, the Society for Healthcare Epidemiology of America (SHEA) is directly involved in the ongoing discussions between the Centers for Disease Control and Prevention (CDC) and key stakeholders on recommended infection prevention and control measures for use in healthcare facilities during the evaluation and care of patients with suspected or confirmed novel H1N1 infection. Our primary goal is to ensure effective and sustainable delivery of patient care while protecting healthcare workers and patients from influenza acquisition in healthcare settings.
At the start of the 2009 outbreak, there was uncertainty regarding the transmission dynamics of the novel H1N1 virus. While seasonal influenza is spread by large respiratory droplets, a concern at the onset of any potential influenza pandemic is whether the pathogen will have different transmission dynamics or methods of spread (e.g. via airborne spread such as tuberculosis). Evidence for airborne transmission of seasonal influenza is lacking outside of laboratory-based experiments involving artificial aerosolization of influenza virus and rare events in closed environments with minimal air circulation and opportunities for indirect contact (e.g. airplanes).3-5 Based upon the available evidence regarding seasonal influenza transmission, the CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) has recommended the use of droplet precautions when caring for patients with either suspected or confirmed seasonal influenza.6 HICPAC does not recommend the use of particulate respirators or negative pressure rooms for seasonal influenza, rather these measures are recommended for pathogens which are transmitted predominantly via airborne spread by small particles that remain infective over time and may be dispersed over long distances. Such “airborne” spread is not clearly documented for influenza.
At the onset of the 2009 novel H1N1 outbreak, the CDC recommended that healthcare workers wear a fit-tested disposable N95 respirator, disposable non-sterile gloves, gowns, and eye protection (e.g., goggles) while providing direct patient care to or collecting clinical specimens from patients with suspected or confirmed novel H1N1.7 Placing patients in a negative pressure room was suggested for all patient care activities if such rooms were available and was only required for performance of aerosol-generating procedures (e.g. airway suctioning, bronchoscopy, or intubation). This guidance applied to all types of patient care areas (including ambulatory care). SHEA endorsed the initial approach taken by the CDC and other organizations to recommend enhanced precautions, as the exact transmission mode of the novel H1N1 virus was not known at the outbreak’s onset. As the outbreak has evolved, additional knowledge and experience regarding the transmission dynamics and severity of novel H1N1 has become available. Consistent with current scientific knowledge concerning the dynamics of transmission of seasonal influenza, available data and clinical experiences suggest that novel H1N1 transmission also occurs, like seasonal influenza, via droplet spread.
Just as other recommendations have been revised to reflect the increased understanding of the current wave of the novel H1N1 influenza outbreak,8 SHEA strongly supports and encourages updating the CDC guidance on recommended infection prevention and control practices in healthcare settings for the current wave of the novel H1N1 outbreak. Based on available data and the evolution of the H1N1 outbreak, SHEA endorses implementing the same practices recommended to prevent the transmission of seasonal influenza for the novel H1N1 virus at this time. Specifically, we recommend the use of standard and droplet precautions for suspected or confirmed cases of novel H1N1 influenza; placing surgical masks on patients with suspected or confirmed novel H1N1 infection at the point of contact with the healthcare facility; placing such patients in a single room, if available, or cohorting them with other infected patients; strict adherence to hand hygiene, respiratory hygiene and cough etiquette; early recognition and identification of suspected novel H1N1-infected patients upon presentation to a healthcare facility; and restriction of visitors and healthcare workers with febrile respiratory illnesses. Negative pressure rooms are not needed for the routine care of such patients. In recent weeks, similar guidance has been recommended and implemented by an increasing number of organizations, including healthcare facilities and public health departments.9-18
One unresolved issue involves recommendations for enhanced respiratory precautions for healthcare workers performing aerosol-generating procedures for suspect or confirmed novel H1N1. The current recommended precautions include the use of fit-tested N95 particulate respirators, gloves, eye protection and a gown when performing these activities. While the use of gloves, surgical mask, eye protection and a gown in these clinical settings is appropriate and consistent with standard precautions for aerosol-generating procedures where splashing of body fluid and/or secretions is anticipated, the use of a particulate respirator during aerosol-generating procedures is not recommended as a part of standard precautions nor to prevent seasonal influenza transmission in healthcare facilities.
The rationale, to date, for such enhanced respiratory protection for novel H1N1 stems from experiences with aerosol-generating procedures and transmission of the severe acute
respiratory syndrome (SARS), the absence of an available vaccine against the new virus, and the increased susceptibility of the population to the novel H1N1 virus (with reported secondary attack rates ranging from 22-33% vs. 5-15% noted with seasonal influenza).19 While a more controversial issue, we are supportive of recommendations for enhanced respiratory protection when performing certain aerosol-generating procedures on patients with suspected or confirmed novel H1N1. However, these specific recommendations should be re-evaluated over the coming weeks as more data are available from the current outbreak. We hope that as more data become available, the guidance for aerosol-generating procedures for novel H1N1 can be aligned to match that provided for seasonal influenza.
The specific practices included as “aerosol-generating” procedures for novel H1N1 guidance must also be clarified. Various recommendations have included bronchoscopy, collection of nasopharyngeal specimens (e.g. nasal washes or nasopharyngeal aspirates and swabs) , administration of nebulized medications, airway suctioning, resuscitation involving emergency intubation or cardiac pulmonary resuscitation, and endotracheal intubation as aerosol-generating procedures that require enhanced respiratory precautions if performed on patients with suspected or confirmed novel H1N1. We, however, recommend following HICPAC standard precautions guidance to include only the following as aerosol-generating procedures: bronchoscopy, open suctioning of airway secretions, resuscitation involving emergency intubation or cardiac pulmonary resuscitation, and endotracheal intubation. Collection of nasopharyngeal specimens from patients with suspected or confirmed novel H1N1, closed suctioning of airway secretions and administration of nebulized medications should not be considered aerosol-generating and, therefore, do not require enhanced respiratory protection.
As noted earlier, we recommend the use of surgical masks for respiratory protection during routine patient care activities as opposed to continued universal use of N95 particulate respirators. Inappropriate and widespread use of N95 respirators for all novel H1N1 patient care activities does not provide increased protection against the virus and may have an adverse impact on patient and healthcare worker safety. Namely, reports of limited supplies of N-95 respirators during the current novel H1N1 outbreak raise concerns of respirator availability in healthcare settings at times when they are actually needed. Since respirators are essential components of infection prevention and control strategies for truly obligate airborne pathogens such as M. tuberculosis, a shortage of respirators could put healthcare workers at increased risk in the event proper respiratory protection is unavailable for the care of patients infected with airborne-transmissible pathogens.
Transmission of influenza in acute care hospitals is a risk many magnitudes lower than the risk of community transmission and strategies that place excessive focus on preventing influenza transmission within healthcare facilities are of limited utility in an outbreak and divert attention from important community control strategies. Therefore, the precautions recommended to prevent transmission of novel H1N1 in healthcare facilities must be part of a larger program to prevent spread of illness in the community. Effective influenza control programs require coordinated application of a variety of strategies including the use of vaccines (when available), administration of both therapeutic and prophylactic antiviral agents, and targeted containment strategies such as social distancing in a manner which limits or delays disease transmission while preserving other essential societal functions. The basis of all pandemic planning is the recognition that both seasonal and pandemic influenza are predominantly community diseases (i.e., transmission occurs primarily in the community setting rather than in healthcare settings). Unlike other concerning pathogens, effective therapy for seasonal influenza (including the novel
H1N1 strain) is available and its administration rapidly decreases viral shedding in infected patients. Hence, influenza prevention and control programs must emphasize early recognition, physical separation of infected patients for the duration of illness (i.e. self-quarantine) and avoidance of unnecessary public gatherings where influenza may be transmitted.
The current strain of novel H1N1 has the same transmission dynamics as seasonal influenza and should be managed accordingly based on the currently available scientific evidence. Although the current H1N1 strain is behaving like seasonal influenza, this could change. The virus could mutate, or new reassorted viruses could emerge. Therefore, we urge vigilant monitoring of the novel H1N1 virus as it circulates in the Southern hemisphere throughout the summer and into the fall. If further evidence suggests that the transmission dynamics of the virus are changing, the current interim recommendations should be re-evaluated and updated accordingly.
1. Centers for Disease Control and Prevention. H1N1 Flu (Swine Flu). Accessed on May 15, 2009 at http://www.cdc.gov/h1n1flu/.
2. World Health Organization. Influenza A H1N1. Accessed on May 15, 2009 at http://www.who.int/csr/disease/swineflu/en/index.html.
3. Lemieux C, Brankston G, Gitterman L, Hirji Z, Gardam M. Questioning aerosol transmission of influenza. Emerg Infect Dis 2007; 13:173-4; author reply 174-5.
4. Bridges CB, Kuehnert MJ, Hall CB. Transmission of influenza: implications for control in health care settings. Clin Infect Dis 2003; 37:1094-101.
5. Brankston G, Gitterman L, Hirji Z, Lemieux C, Gardam M. Transmission of influenza A in human beings. Lancet Infect Dis 2007; 7:257-65.
6. Centers or Disease Control and Prevention. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007. Available at http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf. Accessed on May 12, 2009.
7. Healthcare Infection Control Practices Advisory Committee (HICPAC). Interim Guidance for Infection Control for Care of Patients with Confirmed or Suspected Swine Influenza A (H1N1) Virus Infection in a Healthcare Setting. Atlanta, GA: Centers for Disease Control and Prevention, April 24, 2009.
8. Centers for Disease Control and Prevention. Update on School (K – 12) and Child Care Programs: Interim CDC Guidance in Response to Human Infections with the Novel Influenza A (H1N1) Virus. Accessed on May 15, 2009 at http://www.cdc.gov/h1n1flu/K12_dismissal.htm.
9. World Health Organization. Infection prevention and control in health care in providing care for confirmed or suspected A(H1N1) swine influenza patients, (Interim guidance, April 29, 2009). Accessed on May 15, 2009 at http://www.who.int/csr/resources/publications/infection_control/en/index.html.
10. BJC HealthCare. 2009 HiN1 Flu Patient Management (May 7, 2009). Accessed on May 15, 2009 at http://www.bjc.org/uploadedFiles/BJC_HealthCare/About_BJC/05-07%202009%20H1N1%20Flu%20Patient%20Management%20Grid.pdf.
11. Infectious Diseases Society of Washington. Statement of the Infectious Diseases Society of Washington (IDSW) on Swine Influenza A (H1N1) and Personal Protective Equipment for Healthcare Workers (May 7, 2009). Accessed on May 15, 2009 at
http://www.kingcounty.gov/healthservices/health/communicable/providers/advisories/2009/advisory090507.aspx.
12. Iowa Department of Public Health. Infection Control and the Use of Surgical Masks and Respirators in Health Care Settings With Regard to Novel Influenza A (H1N1) 13 May 2009. Accessed on May 18, 2009 at http://www.idph.state.ia.us/h1n1/common/pdf/infection_control_use_of_masks_and_respirators_ins_hc_settings.pdf.
13. Minnesota Department of Public Health. Minnesota Department of Health Interim Infection Control Guidelines for Healthcare Workers: H1N1 Novel Influenza. Accessed on May 18, 2009 at http://www.health.state.mn.us/divs/idepc/diseases/flu/h1n1/hcp/ichcp.pdf.
14. New York City Department of Health and Mental Hygiene. 2009 New York City Department of Health and Mental Hygiene Health Alert #16: Influenza A H1N1 (Swine Origin) Update May 6, 2009. Accessed on May 18, 2009 at http://www.nyc.gov/html/doh/downloads/pdf/cd/2009/09md16.pdf.
15. Public Health Seattle & King County. For King County health care providers: Communicable diseases, epidemiology and immunization resources and guidelines. Accessed on May 15, 2009 at http://www.kingcounty.gov/healthservices/health/preparedness/pandemicflu/swineflu/providers.aspx.
16. T. R. Talbot (personal communication). Vanderbilt Medical Center Interim Infection Control Guidance for Inpatient Settings, effective May 5, 2009.
17. County of Los Angeles Public Health. Novel Influenza A H1N1— Medical, Testing, and Antiviral Guidance, revised May 15, 2009. Accessed on May 20, 2009 at http://www.lapublichealth.org/acd/docs/Swine/MTAguidance.pdf.
18. Colorado Department of Public Health and Environment. Infection Control Guidelines for Healthcare Workers for Novel Influenza A (H1N1) May 8, 2009. Accessed on May 20, 2009 at http://www.cdphe.state.co.us/epr/Public/H1N1/0508HANUpdate.pdf.
19. World Health Organization. Assessing the severity of an influenza pandemic, May 11, 2009. Accessed on May 15, 2009 at http://www.who.int/csr/disease/swineflu/assess/disease_swineflu_assess_20090511/en/index.html. Just as other recommendations have been revised to reflect the increased understanding of the current wave of the novel H1N1 influenza outbreak, SHEA strongly supports and encourages updating the CDC guidance on recommended infection prevention and control practices in healthcare settings for the current wave of the novel H1N1 outbreak. Based on available data and the evolution of the H1N1 outbreak, SHEA endorses implementing the same practices recommended to prevent the transmission of seasonal influenza for the novel H1N1 virus at this time. Specifically, we recommend the use of standard and droplet precautions for suspected or confirmed cases of novel H1N1 influenza; placing surgical masks on patients with suspected or confirmed novel H1N1 infection at the point of contact with the healthcare facility; , if available, or cohorting them with other infected patients; strict adherence to hand hygiene, respiratory hygiene and cough etiquette; early recognition and identification of suspected novel H1N1-infected patients upon presentation to a healthcare facility; and restriction of visitors and healthcare workers with febrile respiratory illnesses. Negative pressure rooms are not needed for the routine care of such patients. In recent weeks, similar guidance has been recommended and implemented by an increasing number of organizations, including healthcare facilities and public health departments.
摘录：
SHEA强烈支持和鼓励CDC更新医疗机构预防和控制新型流感的指南。根据目前获得的资料和对H1N1暴发的评估，SHEA建议执行用于预防季节性流感传播的方法。特别是：我们建议对疑似和确诊病例，使用标准预防和飞沫预防方法就可以了。给疑似或确诊病例在医疗机构与他人有接触时，戴外科口罩；可能的话安置于单人病房，或与其他同类感染合住；严格执行手卫生，呼吸道卫生和咳嗽礼仪；病人来就诊时，医疗机构要能早期识别和确诊；限制探视者和医务人员与有发热的呼吸系统疾病患者的接触；处理这些病人时，通常不需要负压病房。 认真学习！ 很有道理. 根据甲型H1N1流感的特点已和季节性流感相似,因此,SHEA建议执行用于预防季节性流感传播的方法是很有科学道理的.
有专家建议将甲型H1N1流感作为丙类传染病管理,我认为是一个长期预防与控制的对策.重要的是向大众进行有效的预防宣传,从而养成良好的卫生习惯是预防流感流行爆发的根本. 向大众进行有效的预防宣传,养成良好的卫生习惯是预防流感流行爆发的根本.越来越科学防控了，这样更能让大家所理解和接受。 科学、正确防控HINI！:lol
不过度不轻视！:lol 很有借鉴，学习！
国情和甲型流感历史提醒，加之SARS教训，1918年的大流行大死亡等，对新的甲型HINI流感实施谨慎策略较好！ 如果进一步证据本建议病毒的流行病学改变，应该相应地复评和更新当前暂时的推荐。
应严密监测和总结流行趋势，及时评估该建议？ 希望有人帮助翻译，供大多数人学习 处理这些病人时，通常不需要负压病房。Just as other recommendations have been revised to reflect the increased understanding of the current wave of the novel H1N1 influenza outbreak, SHEA strongly supports and encourages updating the CDC...
icchina 发表于 2009-6-15 00:00 http://bbs.sific.com.cn/images/common/back.gif
这些观点，好像对我们的很多做法是明显颠覆哦！嗯，我们怎样能科学防控，怎样正确处置呢？值得我们好好反思！ 认真学习，能指导实际工作，就是看英文版有点吃力。 老大是我们的一盏灯，总是给我们最新的指导，等待翻译！ 赞同像流感样防护即可。 希望翻成中文，更好学习最新理念。 有时候要讲科学的真话很难，一般的人讲根本就没有声音，只有像icchina这样首先有份量而又愿意、又有勇气和责任感、敢于讲真话的人站出来，院感人才能够走正确的路！ 赞同“一天”观念，等待翻译！唉，英文太差 就是，希望能及时译为中文，大家学习学习．希望它能为卫生行政部门和医院决策提供参考依据，让大家少走弯路！！！ 顶“一天”非常有同感！ 我国因为是疫苗生产和救治药物储备不足，所以只能把重心放在防控，一不小心就会过了头。