h1n1新型流感流行期间之因应

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H1N1新型流感流行期間之因應衛生署疾病管制局中區傳染病防治醫療網王任賢指揮官 Influenzavirus Historyofinfluenza430-427BC:PlagueinAthensepidemicinfluenzacomplicatedbytoxigenicstaphylococcaldiseases1901:firstisolatefromchicken1918:pandemic,20milliondeath1931:firstisolatefromswine1933:firstisolatefromhuman InfluenzavirusFamilyOrthomyxoviridae(segmentednegativestrandRNAvirus)InfluenzaA:8segmentsInfluenzaB:8segmentsInfluenzaC:7segmentsTyping:CFantibodyagainstcoreproteinsM1:matrixproteinNP:nucleoprotein NeuraminidaseHemagglutininRNA+nucleoproteinM2protein(ionchannel,onlyontypeA)InfluenzaSurfaceProteinsM1protein InfluenzaAvirusRNAsegmentandproteinRNAsegmentProteinFunction/Activity1PB2Cap-binding,endonuclease2PB1RNApolymerase3PAProteolysis4HAAttachmenttosialicacid,fusion5NPStructuralprotein6NASialidase,releaseofvirus7M1,M2Structuralprotein,Ionchannel8NS1,2RNAtransport,splicing,translate AntigenicchangeofinfluenzavirusAntigenicdrift:epidemicpointmutationingeneofHAorNAresultfromincreaseimmunitypressurerate:0.5-1%peryearepidemic:>2siteschangeAntigenicshift:pandemicacquireofnewgenesegment OriginofpandemicstrainDormancyinafrozenstateMutationofanimalinfluenzavirusGenereassortmentbetweenanimal＆humanAvian:virusinrespiratory＆GItractlittleantigenicvariationrarelytransmittohumanSwine:mixingvessel AntigenicShiftSwinecell HostrangeofinfluenzavirusInfluenzaA:broadhostrangehuman,swine,horse,duck,bird,ruminant,marinemammal,reindeer,minkInfluenzaB:primarilypathogensofhumanshuman,(dog,cat,swine)InfluenzaC:primarilypathogensofhumanshuman 流感病毒之分類上呼吸道流感病毒H1N1,H3N2,B高傳染率,低死亡率以社區傳染為主Immuneprotection：治療以抗病毒藥為主下呼吸道流感病毒H5N1低傳染率,高死亡率以院內傳染為主Immunedestruction：治療以類固醇為主 YearsFluVirusMortality1918-1919“Spanish”TypeA(H1N1)20millionworldwide550,000US1957-1958“Asian”TypeA(H2N2)70,000US1968-1969“HongKong”TypeA(H3N2)34,000US1977-1978“Russian”TypeA(H1N1)negligableGlezenWP.EpidemiolRev.1996;18:65.CentersforDiseaseControlandPrevention.InfluenzaPreventionandControl.Influenza.Availableat:http://www.cdc.gov/ncidod/diseases/flu/fluinfo.htm.InfluenzaPandemicsinthe20thCentury SeasonalinfluenzavirusAcontagiousrespiratoryillnesscausedbyinfluenzavirusesVirusescirculatinginthehumanpopulation-InfluenzaA(H3N2,H1N1andBstrains)AvianinfluenzavirusAnimalinfluenzavirusesinfectiousforhumansunderspecialcircumstances.CurrentH5N1infectionsPandemicinfluenzavirusFluthatcausesaglobaloutbreaksandspreadeasilyfromhumantohumanThreetypesofinfluenzaviruses 3pre-requisitesforaPandemicTheemergenceofanewvirusstrainwithnocirculatingimmunitywithinthehumanpopulationTheabilityofthisstraintoinfecthumansThepotentialforthenewvirustobeeasilytransmittedfrompersontoperson WHO疫情分級大流行警示狀況人類風險狀況疫情分級大流行間期(Inter-pandemic)出現動物新病毒但無人類個案人類低風險期Phase1人類高風險期Phase2大流行警示期(Pandemicalert)新病毒引發人類個案尚未出現人傳人或已出現有限性人傳人的新病毒Phase3證據顯示新病毒可人傳人機會增加Phase4證據顯示新病毒已可以有效人傳人Phase5大流行期(Pandemic)已證實出現有效性人傳人Phase6 Pandemicphasesandtransmissionpatterns1-3Phases5-6SustainedH-2-HtransmissionTimePredominantlyanimalInfections;LimitedtransmissibilityamongpeopleGeographicspread5-64PostPeakPostPandemic 流感病毒之季節性夏季流感Semi-closedpopulation冬季流感Northernhemisphere：OcttoAprilSouthernhemisphere：ApriltoSept 馬其諾防線該設在何處？防止感染發生，切斷感染源僅適用於極早期防止重症病患死亡 衛生局之因應作為 指揮中心之因應作為:I加強人口密集機構之通報及查核由衛生局於短期內對轄區內之人口密集機構實施硬體、防疫物資、篩檢、通報、人員訓練進行查核要求推動呼吸道衛生及咳嗽禮節社區推動呼吸道衛生及咳嗽禮節訂定區域內停止上班上課之規定區域內出現有效人傳人之證據時即可逕行執行加強定點醫師類流感實驗室通報 指揮中心之因應作為:II全面掌控克流感，只允許使用於鑑定成立之重症病例區域成立重症病例鑑定委員會，每日開會執行區域內重症通報病例之鑑定召開區域內醫療院所之教育訓練，就流感重症病例通報、重症病例鑑定、克流感政策、感控措施進行說明由縣市衛生局就現有之志工進行組訓，協助執行輕症病例之居家隔離及居家治療政策 指揮中心之因應作為:III衛生局、醫療院所、人口密集機構均須備足口罩及消毒劑等防疫物資鼓勵老百姓自備可換洗之布口罩 醫院之因應作為 醫院之因應作為前提醫療作為並不會增加感染風險感染並不一定成為重症，而且輕症較多因應作為執行呼吸道衛生及咳嗽禮節有病的人不要來上班員工體溫監測發燒的人自行戴上口罩上班或回家有呼吸道症狀的人自行戴上外科口罩盡量保持人與人之生物安全距離1公尺持續第一線傳染病篩檢及員工體溫監測 口罩政策直接執行照顧H1N1新型流感病人者，由醫院配發N95口罩每日一個其他人員醫院不主動提供口罩有病的人應自行戴上外科口罩等級之口罩（外科口罩、紙口罩、布口罩），建議員工每人自備二個可換洗之布口罩，以備不時之需照顧非H1N1新型流感病人之其他呼吸道病患，由醫院配發外科口罩每日一個醫院應廣設平價外科口罩販賣機及免費乾洗手液 DropletPrecautionsPrivateroomWearasurgicalmaskforclosepatientcontactForSARSandAvianinfluenza,wearN-95respiratorandalsoweareyeprotectionLimitpatienttransportInstructpatienttowearasurgicalmaskandfollowrespiratoryhygiene/coughetiquette.Notifyreceiversofprecautions RoleofSurgicalMasks?AsurgicalmaskisNOTrespiratoryprotection1ºintent:preventingwoundcontaminationbyinfectiousdropletsfromHCW’srespiratorytract2ºuse:barrierprotectingHCW’snoseandmouthfromlargedropletsplashes,spraysofinfectiousmaterialParticlescanenteratedgesofmaskSomenotconstructedusingparticulatefiltermediaSource:RosieSokas,MDMOHUILatChicago AssumptionsforRespiratorUseNeedtoprotectHCWsfrompossiblesecondarytransmissionfromillpatients(not1ºrelease)2.Respiratorswillbeusedinthecontextofacompleterespiratoryprotectionprogram N-95FilteringFacepieceRespirators BenefitsoffittestingStudy:25volunteers,21modelsofN-95respiratorsWithoutfittesting,95%ofthetestshadupto33%leakageWithfittesting,95%ofthetestshadnomorethan4%leakage H1N1新型流感病患收治政策疫情初期之政策輕症病患在負壓隔離房內或戶外通風良好處採檢完後，原則上以居家治療合併自我健康管理為處理原則重症病患仿效SARS收治在負壓病房或單人房，同一感染源者可收治於同一間病患在病房內不需戴口罩，出外應配戴外科口罩 克流感政策大流行時之政策只限於經臨床或實驗室鑑定之流感重症使用接觸者、輕症、預防性投藥均不建議防疫的馬其諾防線設在減少重症死亡，而非減少感染，克流感鎖碼勢在必行疫情初期之政策比照H5N1流感之政策 SensitivityofInfluenzaVirusIsolatestoOseltamivirVirusOseltamivirIC50H1N1(H274):wildtype0.69H1N1(Y274):resistantmutant85.92H3N2(R292):wildtype1.99H3N2(K292):resistantmutant1,600.00HongKong/483/974.86HongKong/213/035.07Vietnam/1194/042.49Vietnam/1203/047.68Chicken/VN/NCVD1/045.87Chicken/VN/NCVD8/039.90EID11:10;1515-21,2005 其他門禁管制：不必要發燒篩檢門診：不必要員工體溫監測：持續進行流感疫苗施打：不鼓勵不禁止增加防疫物資之儲備：不必要，只需依疾病管制局之規定辦理，但須及時遞補消耗防護衣：依現行規定辦理 因應政策之起跑點除克流感政策自即日起開始實施外，其他政策之起跑點均為國內出現第一起確認案例之後 H1N1新型流感防疫戰之思維馬拉松戰役大格局的戰役之防疫主軸人口密集機構，防止出現“和平社區”重症醫療執行方法：呼吸道衛生及咳嗽禮節 懇請賜教