大流行到地方性流行:如何做好临床准备?
讲者丨张文宏(复旦大学华山医院 国家传染病医学中心)整理丨陈维(成都市新都区人民医院)审核丨蓝雪0816来源丨SIFIC 2024“全国感控与耐药感染”联合大会
在SIFIC 2024“全国感控与耐药感染”联合大会上来自复旦大学华山医院的张文宏教授通过历史的镜头回顾了传染病的演变,并探讨了未来的策略和挑战。
一、人类传染病的流行与演化
在遥远的未来,感染病将以何种形式存在?临床微生物以何种形式存在?院感又将以何种形式存在?一直在憧憬和讨论中,且不断变化。感染性疾病从大流行到地方性流行,到目前传染病的流行,包括脓毒症也是一样。希波克拉底首次描述了公元前431年感染病一次重大的流行事件,他说:“我认为针对大流行最好的药物似乎是什么都不要用”。他发现,大流行过后,人体都会建立一种免疫力,而且建立免疫力的人再去接种、接触同一种病原体的时候,它并不具备被感染的风险。观察到在疫情中存活下来的人似乎获得了对疾病的自然防护,他通过这场大流行发现了“免疫力”的概念。
对于历史上的大流行,人们最初的反应往往是无助的,但随着时间的推移,人类逐渐发展出应对策略,例如建立免疫屏障,当再次接触同种病原体时,感染风险显著降低。
(一)历史视角下的传染病自古以来,传染病并不是人类历史的常态,而是伴随着人类社会及农业革命的出现而逐渐形成,由于人类聚集生活,产生了称为“communicable disease”的疾病,即传染性疾病称。直到今天,传染病的流行都是因为人类聚集而发生的。
1981年首次在美国发现的HIV,其起源可追溯至1920年的西非,并在1960年传入中非,最终扩展至全球。新冠病毒于2020年开始大流行,也是这样的规律,从大流行的形成到地方性流行。
历史上还有一些主动和被动消除的传染病。公元1531年,西班牙探险家皮扎罗进入美洲时,带来了天花和麻疹等病毒,麻疹和天花是导致毫无免疫力的新大陆人群死亡的主要病原体,这些病毒在新大陆造成了大量原住民的死亡。标志着新旧大陆间病原体的首次大碰撞这一历史事件加深了人们对传染病影响的认知,尤其是在没有建立免疫屏障的情况下传染病所带来的致命性。在老的大陆,因为畜养动物包括牛,包括羊、狗、鸡、鸭这些动物在美洲大陆全部没有。
这使得病原体从这些动物跳跃到人身上发生感染性疾病,包括天花、麻疹、流感在美洲大陆都是没有。所以当1531年这两个大陆重新“碰撞”的时候,我们第一次认识到传染病,当你不具备免疫屏障的时候,将是一场大流行,将会有大量的人死亡。但是大流行过后会形成我们老大陆那样具有一定的免疫力,每年都有天花、流感,但是并不会造成大批量的人员的死亡。我们人类通过什么来维持自然界的平衡呢?只要人类生育的速度比自然界灭亡的速度更快,我们人类就能发展。也说明人类应对传染病的方式依赖于生育,生育率大于2.17,通过人口的增加才能维持正常社会的发展。
(二)近年来的大流行有一本书里描述2003年SARS疫情,SARS在2003年的这一场大流行是怎么被终止的?当时医院里是不具备SARS的诊断能力,也没有N95口罩,但是SARS就被控制住了,这是什么原因?书中说:“we are lucky this time”(我们这次太运气了)。
事实上,SARS疫情的控制得益于其传播特性,SARS患者在无发热症状时传播率极低,筛查发热患者并将其隔离,成为疫情控制的关键措施。SARS疫情的成功控制案例展示了通过控制症状来遏制疫情的可能性,通过隔离发病区域的个案病例以及及早诊断结合,成功地控制了疫情的扩散。
但是,2020年新冠疫情的时候,就不一样了。因为SARS时没有发烧的人不具有传染性,新冠疫情没有发烧的人很多,但具有了传染性。所以SARS的时候we are lucky,新冠疫情就不一定。自然界是具有偶然性的,每一次大流行都不一样。
然而,2009年的H1N1流感和2019年底的COVID-19疫情再次考验了全球的公共卫生体系。这些事件强调了迅速反应和全球合作的重要性。尤其2009年H1N1病毒首次传入中国,最初引起了全球的恐慌,但最终未造成大规模影响,这证明了每次大流行的起因和发展方式各有不同。
自2003年SARS以来,人类社会经历了如H1N1流感、H7N9禽流感、狂犬病毒和埃博拉等多次新发传染病,如何有效应对新发传染病已成为当今社会的重要任务。
再去回顾这疫情时的时候得出一个结论,几次大的流行,大家都用lucky都用fortune来形容,那就意味着每一次大流行引起的原因、发展都是各不一样的,因为不会每一次都这么lucky,这一次lucky的原因是病情不那么重,所以他说我们very fortune的主要原因它是not more severe(不怎么危重)。但每次流行都不一样,世卫组织一直为此在做准备。
二、大流行的形成与应对
(一)早期识别及监测准备早期识别是阻止大流行形成的关键,有效的监测网络和公共卫生能在疫情萌芽阶段及时采取措施。在英国的100天计划中,强调了诊断、治疗和疫苗的紧迫性,只有建立全方位监测体系,才能在大流行形成之初就加以控制。
(二)建立精准感染病诊疗体系,精准诊断data:image/png;base64,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
(三)流行病学研究中心(ERC)的建立目前,全国已有23个省的100多家医院与500名研究员形成了强大的疾病监控和研究网络,对医院内疾病流行进行实时监控,第一时间对病原体进行检测,为传染病的防控提供数据支持,全面提高对新出现疾病的诊断能力和迅速响应能力。
(四)共同促进临床研究质量和网络世卫组织提出临床研究也是生产力,当我们国家提出新质生产力时,临床医生能力、临床研究均占其重要分量。如今,我们开展持续性抗生素研究时,需要建立临床体系的支持,持续开展呼吸道合胞病毒(RSV)与慢性乙肝的临床研究,准备未来大流行的应对措施及临床研究。重症救治能力的提升同样重要,成立IDC(in disease center)网络,持续提升重症感染治疗的能力和课程。
(五)如何应对大流行大流行的应对并非易事,面对新冠病毒的挑战,感染病学科尤为重要,成为应对的关键。我们的生存能力不在于强壮或聪明,而在于快速应对变化的能力。如今,我们不仅需要面对传染病的生物学挑战,还必须在政策与科技之间找到平衡。期待未来在院感管理、感染控制、精准诊断和重症救治上有更多的合作与交流,只有在不断地实践与反思中,才能够有效应对传染病的威胁,继续强化国际合作,共同构建一个更健康的全球社会。
小结张文宏教授在《大流行到地方性流行:如何做好临床准备?》中给出了许多实用的建议,强调了从临床出发的重要性。这些建议为突发传染病的早期应对提供了良好的指导作用,推动我们不断改进应对策略,提升公共卫生防控能力。随着全球疫情的变化,唯有持续学习和适应,才能更好地保护人类的健康安全。
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