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The author:(作者)delvpublished in(发表于) 2014/1/27 8:56:13 Health Planning Commission announces 2014 Edition of human infection H7N9 avian flu diagnosis and treatment programme
January 26, according to the National Board of health and family planning website for further medical treatment of human infections H7N9 avian influenza cases, to better guide the level and type of medical institutions to conduct standardized diagnosis and treatment of human infections H7N9 avian influenza cases, State health and family planning organizations have developed the human H7N9 avian flu infection diagnosis and treatment programmes (2014). Following is the full text:
People H7N9 avian flu infection diagnosis and treatment programme
(2014)
People H7N9 avian flu infection is caused by H7N9 Avian acute respiratory infectious diseases, including cases of severe pneumonia complicated with acute respiratory distress syndrome, septic shock, multiple organ failure. Early discovery, early reports, early diagnosis, early treatment, strengthening of severe cases where attention to both traditional Chinese and Western medicine is an effective prevention and control, the key to improve the cure rate, lowering the fatality rate.
First, the pathogen
Avian influenza virus influenza virus influenza virus-imperial examination is. Influenza a virus particle is Pleomorphic, spherical diameter 80~120nm, capsule. Genomic segments single strand chain of RNA. Based on the film besides the hemagglutinin (h) and the neuraminidase enzyme (n) protein antigens of different and can now be divided into 16 h subtypes (H1~H16) and 9 n subtypes (N1~N9). Among infected poultry, avian influenza virus can also infect humans, pigs, horses, mink, and marine mammals. Can be transmitted to humans ' avian influenza virus subtype H5N1, H9N2, H7N7, H7N2, H7N3 etc, the H7N9 avian influenza virus. The virus for new reassortant virus code HA genes from H7N3, the gene encoding NA came from H7N9, 6 internal genes from H9N2 avian influenza virus.
Avian influenza viruses are generally sensitive to heat, temperatures are more resistant to 65 ℃ for 30 minutes or boiling (100 ° c) for more than 2 minutes can be inactivated. Viruses can survive for 1 week in lower temperatures, water or glycerol at 4 ℃ active cases can be more than 1 year.
Second, epidemiology
(A) the infection. Now in birds and their secretions or excrement and live bird market environment detection and isolation to H7N9 avian flu virus samples, and people H7N9 avian flu virus highly homologous. Infection may carry H7N9 avian influenza virus in poultry. At present, most of the sporadic cases, some families gather onset phenomenon, but there is no evidence of interpersonal communication.
(B) the route of transmission. Specific way can be transmitted or close contact with respiratory secretions or feces of infected poultry have acquired her infection; or spread to people through contact with contaminated environment; do not rule out limited non-sustained person to person.
(C) the high risk groups. Within 1 week prior to the onset of close contact with live poultry or poultry markets, especially the elderly.
Third, the pathogenesis and pathology
H7N9 avian influenza virus can while combined saliva acid α -2,3 type receptor (avian influenza virus receptor) and saliva acid α -2,6 type receptor (people flu virus receptor), more H5N1 avian influenza virus more and people Shang respiratory epithelial cells (saliva acid α -2,6 type receptor mainly) combined, relative Yu seasonal flu virus more easy infection people of Xia respiratory epithelial cells (saliva acid α -2,3 type receptor mainly). H7N9 avian influenza virus after being infected by the human body, can induce cytokine storm, causing systemic inflammatory response, ARDS can occur, shock and multiple organ failure. Individual cases of severe lower respiratory tract viruses can be positive until the course of 3 weeks or more.
Four, manifestation
Based on the incubation period and flu human infection H7N9 avian flu findings, the incubation period is generally 3-4 day.
(A) the symptoms, signs, and clinical features. Generally manifested in patients with flu-like symptoms, such as fever, cough, phlegm-less, and may be accompanied by systemic symptoms such as headaches, muscle aches, diarrhea. In patients with severe disease progression is rapid, 3-7 days of onset of severe pneumonia, mostly sustained in body temperature at 39 ° c or more, breathing difficulties, and sputum may be accompanied by hemoptysis. Often rapid progression to acute respiratory distress syndrome, sepsis, septic shock, multiple organ dysfunction, part of the show such as can occur in patients with pleural effusion.
(B) laboratory examinations.
1. blood. Total number of white blood cells are generally not higher or lower. Critically ill patients have reduced total number of leukocytes and lymphocytes, platelets decreased.
2. blood biochemical examinations. Creatine kinase, lactate dehydrogenase, aspartate amino transferase, alanine aminotransferase increased, elevated c-reactive protein, Myoglobin can rise.
3. the etiology and detection. Antiviral therapy respiratory tract specimens must be collected before submission (such as nasopharyngeal secretions, respiratory secretions, oral mouthrinses, tracheal aspirates), the deep expectoration in the trachea or tracheal aspirates higher than upper respiratory specimens testing positive rate. Sick etiological detection medical institution as soon as possible the conditions of detection, pathogen-free conditions should be brought as soon as possible, collecting specimens for medical institutions designated agency testing.
(1) the nucleic acid detection. For patients with suspected respiratory tract specimens by real-time PCR (or normal RT-PCR) testing H7N9 avian influenza virus nucleic acid, on early recognition of infected H7N9 avian influenza virus nucleic acid detection should be preferred. Severe cases should be periodically for nucleic acid detection in respiratory secretion until Yam go. Preferred collection artificial airway airway lessons (ETA).
(2) influenza a viral antigen detection. Rapid detection of influenza a viral antigen-positive respiratory specimens. Applies no nucleic acid testing conditions as a screening test for medical institutions.
(3) virus isolation. Separating H7N9 avian influenza viruses in respiratory specimens from patients.
(4) dynamic detection at acute stage and restoration stage double serum H7N9 avian influenza virus specific antibody levels increased 4 times or more.
(C) breast imaging. Flake within the shadow of the Lung in patients with pneumonia. Severe lesions in patients with progressing rapidly, usually double lung lung consolidation of multiple ground-glass shadows and images, you can merge a small amount of pleural fluid. When the ARDS occurs, lesions are widely distributed.
(D) the prognosis. Human infection H7N9 avian flu critically ill patients with poor prognosis. Prognostic factors may include patient age, underlying diseases, complications, etc. 1
Five, diagnosis and differential diagnosis
(A) diagnosis. According to the epidemiological history of exposure, clinical manifestation and laboratory examination result, human infection H7N9 avian influenza diagnosis could be made. An unknown in the history of epidemiology of cases, according to the clinical manifestations, auxiliary examination and laboratory test results, particularly in specimens from respiratory secretions from patients H7N9 avian influenza viruses isolated or H7N9 avian influenza virus nucleic acid testing positive, dynamic measuring twin or H7N9 avian influenza virus specific antibody levels in serum were increased 4 times or more, human infection H7N9 avian influenza diagnosis could be made.
1. epidemiological history. Within 1 week before the onset of contact with poultry and their secretions, excretions or to a live poultry market, or contact with infected H7N9 avian influenza epidemiology.
2. diagnostic criteria.
(1) suspected cases: meet the clinical manifestations, influenza virus Antigen-positive, or has a history of epidemiology.
(2) the confirmed case: meet the clinical manifestations, or history of epidemiological exposure and H7N9 avian influenza viruses isolated in specimens from respiratory secretions or H7N9 avian influenza virus nucleic acid testing positive dynamic measuring twin or H7N9 avian influenza virus specific antibody levels in serum were increased 4 times or more.
(3) severe cases:
Meet one of the following criteria, namely, diagnosis in cases of:
1.X-ray appears as much leaf lesions or lesions progress >50% within 48 hours;
2. difficulty in breathing, respiratory rate > 24 times per minute;
3. severe hypoxemia, 3~5 oxygen flow l/min condition, patients SpO2 ≤ 92%;
4. There is a shock, ARDS or MODS (multiple organ dysfunction syndrome).
Easily develop heart disease risk factors include:
1. age > 60 years;
2. severe underlying diseases or special clinical situations, basis such as heart or lung disease, high blood pressure, diabetes, obesity, cancer, immunosuppression, pregnant women;
3. after the onset of high fever (T>39 ° c) for 3 days and more than 3 days;
4. the lymphocyte count continues to drop;
5.CRP, CK and LDH increases;
6. chest imaging tips to pneumonia.
Patients with any of these conditions occur, progress of cases or deaths occurred, should be given high attention.
(B) the differential diagnosis. Should pay attention to people infected with highly pathogenic H5N1 avian influenza, avian influenza, seasonal influenza (swine flu), bacterial pneumonia, severe acute respiratory syndrome (SARS), the Middle East and respiratory syndrome (MERS), adenovirus pneumonia, Chlamydia pneumonia, Mycoplasma pneumonia and other diseases in the differential diagnosis. Diagnosis relies mainly on etiological identification checks.
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中新网1月26日电 据国家卫生和计划生育委员会网站消息，为进一步做好人感染H7N9禽流感病例的医疗救治工作，更好地指导各级各类医疗机构开展人感染H7N9禽流感病例的规范化诊疗工作，国家卫生计生委组织制定了《人感染H7N9禽流感诊疗方案(2014年版)》。全文如下：
人感染H7N9禽流感诊疗方案
(2014年版)
人感染H7N9禽流感是由H7N9禽流感病毒引起的急性呼吸道感染性疾病，其中重症肺炎病例常可合并急性呼吸窘迫综合征、感染性休克，甚至多器官功能衰竭。早发现、早报告、早诊断、早治疗，加强重症病例救治，注意中西医并重，是有效防控、提高治愈率、降低病死率的关键。
一、病原学
禽流感病毒属正粘病毒科甲型流感病毒属。甲型流感病毒颗粒呈多形性，其中球形直径80～120nm，有囊膜。基因组为分节段单股负链RNA。依据其外膜血凝素(H)和神经氨酸酶(N)蛋白抗原性不同，目前可分为16个H亚型(H1～H16)和9个N亚型(N1～N9)。禽甲型流感病毒除感染禽外，还可感染人、猪、马、水貂和海洋哺乳动物。可感染人的禽流感病毒亚型为H5N1、H9N2、H7N7、H7N2、H7N3等，此次为H7N9禽流感病毒。该病毒为新型重配病毒，编码HA的基因来源于H7N3，编码NA的基因来源于H7N9，其6个内部基因来自于H9N2禽流感病毒。
禽流感病毒普遍对热敏感，对低温抵抗力较强，65℃加热30分钟或煮沸(100℃)2分钟以上可灭活。病毒在较低温下可存活1周，在4℃水中或有甘油存在的情况下可保持活力1年以上。
二、流行病学
(一)传染源。目前已经在禽类及其分泌物或排泄物以及活禽市场环境标本中检测和分离到H7N9禽流感病毒，与人感染H7N9禽流感病毒高度同源。传染源可能为携带H7N9禽流感病毒的禽类。目前，大部分为散发病例，有个别家庭聚集发病现象，但尚无持续人际间传播的证据。
(二)传播途径。具体途径可经呼吸道传播或密切接触感染禽类的分泌物或排泄物而获得感染；或通过接触病毒污染的环境传播至人；不排除有限的非持续的人传人。
(三)高危人群。在发病前1周内接触过禽类或者到过活禽市场者，特别是老年人。
三、发病机制和病理
H7N9禽流感病毒可以同时结合唾液酸α-2，3型受体(禽流感病毒受体)和唾液酸α-2，6型受体(人流感病毒受体)，较H5N1禽流感病毒更易与人上呼吸道上皮细胞(唾液酸α-2，6型受体为主)结合，相对于季节性流感病毒更容易感染人的下呼吸道上皮细胞(唾液酸α-2，3型受体为主)。H7N9禽流感病毒感染人体后，可以诱发细胞因子风暴，导致全身炎症反应，可出现ARDS、休克及多脏器功能衰竭。个别重症病例下呼吸道病毒可持续阳性至病程的3周以上。
四、临床表现
根据流感的潜伏期及现有人感染H7N9禽流感病例的调查结果，潜伏期一般为3～4天。
(一)症状、体征和临床特点。患者一般表现为流感样症状，如发热、咳嗽、少痰，可伴有头痛、肌肉酸痛、腹泻等全身症状。重症患者病情发展迅速，多在发病3～7天出现重症肺炎，体温大多持续在39℃以上，出现呼吸困难，可伴有咯血痰。常快速进展为急性呼吸窘迫综合征、脓毒症、感染性休克，甚至多器官功能障碍，部分患者可出现胸腔积液等表现。
(二)实验室检查。
1.血常规。白细胞总数一般不高或降低。重症患者多有白细胞总数及淋巴细胞减少，可有血小板降低。
2.血生化检查。多有肌酸激酶、乳酸脱氢酶、天门冬氨酸氨基转移酶、丙氨酸氨基转移酶升高，C反应蛋白升高，肌红蛋白可升高。
3.病原学及相关检测。抗病毒治疗之前必须采集呼吸道标本送检(如鼻咽分泌物、口腔含漱液、呼吸道分泌物、气管吸出物)，气管深部咳痰或气管吸出物检测阳性率高于上呼吸道标本。有病原学检测条件的医疗机构应尽快检测，无病原学检测条件的医疗机构应留取标本尽快送指定机构检测。
(1)核酸检测。对可疑患者呼吸道标本采用real－time PCR(或普通RT-PCR)检测H7N9禽流感病毒核酸，在人感染H7N9禽流感病毒病例早期识别中宜首选核酸检测。对重症病例应定期行呼吸道分泌物核酸检测，直至阴转。有人工气道者优先采集气道内吸取物(ETA)。
(2)甲型流感病毒抗原检测。呼吸道标本甲型流感病毒抗原快速检测阳性。仅适用于没有核酸检测条件的医疗机构作为初筛实验。
(3)病毒分离。从患者呼吸道标本中分离H7N9禽流感病毒。
(4)动态检测急性期和恢复期双份血清H7N9禽流感病毒特异性抗体水平呈4倍或以上升高。
(三)胸部影像学检查。发生肺炎的患者肺内出现片状阴影。重症患者病变进展迅速，常呈双肺多发磨玻璃影及肺实变影像，可合并少量胸腔积液。发生ARDS时，病变分布广泛。
(四)预后。人感染H7N9禽流感重症患者预后差。影响预后的因素可能包括患者年龄、基础疾病、并发症等。1
五、诊断与鉴别诊断
(一)诊断。根据流行病学接触史、临床表现及实验室检查结果，可作出人感染H7N9禽流感的诊断。在流行病学史不详的情况下，根据临床表现、辅助检查和实验室检测结果，特别是从患者呼吸道分泌物标本中分离出H7N9禽流感病毒，或H7N9禽流感病毒核酸检测阳性，或动态检测双份血清H7N9禽流感病毒特异性抗体水平呈4倍或以上升高，可作出人感染H7N9禽流感的诊断。
1.流行病学史。发病前1周内接触禽类及其分泌物、排泄物或者到过活禽市场，或者与人感染H7N9禽流感病例有流行病学联系。
2.诊断标准。
(1)疑似病例：符合上述临床表现，甲型流感病毒抗原阳性，或有流行病学史。
(2)确诊病例：符合上述临床表现，或有流行病学接触史，并且呼吸道分泌物标本中分离出H7N9禽流感病毒或H7N9禽流感病毒核酸检测阳性或动态检测双份血清H7N9禽流感病毒特异性抗体水平呈4倍或以上升高。
(3)重症病例：
符合下列任一条标准，即诊断为重症病例：
1.X线胸片显示为多叶病变或48小时内病灶进展＞50% ；
2.呼吸困难，呼吸频率＞24次/分；
3.严重低氧血症，吸氧流量在3～5升/分条件下，患者SpO2≤92%；
4.出现休克、ARDS或MODS(多器官功能障碍综合征)。
易发展为重症的危险因素包括：
1.年龄＞60岁；
2.合并严重基础病或特殊临床情况，如心脏或肺部基础疾病、高血压、糖尿病、肥胖、肿瘤，免疫抑制状态、孕妇等；
3.发病后持续高热(T＞39℃)3天及3天以上；
4.淋巴细胞计数持续降低；
5.CRP、LDH及CK持续增高；
6.胸部影像学提示肺炎。
出现以上任一条情况的患者，可能进展为重症病例或出现死亡，应当高度重视。
(二)鉴别诊断。应注意与人感染高致病性H5N1禽流感等其他禽流感、季节性流感(含甲型H1N1流感)、细菌性肺炎、传染性非典型肺炎(SARS)、中东呼吸综合征(MERS)、腺病毒肺炎、衣原体肺炎、支原体肺炎等疾病进行鉴别诊断。鉴别诊断主要依靠病原学检查。
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