甲型H1N1 流感诊疗方案（2009 年第三版）的制定及临床应用体会北京朝阳医院呼吸与危重症医学科曹志新2009-10-27 流行病学-传播途径主要通过飞沫经呼吸道传播，……通过气溶胶经呼吸道传播有待进一步确证。流行病学-高危人群CDC. September 8, 2009.  Updated Interim Recommendations for the Use of Antiviral Medications in the Treatment and Prevention of Influenza for the 2009-2010 Season.  临床表现-轻症患者国内1054 例A/H1N1 患者体征特点重症患者的临床表现呈多样性国内重症病例特点需进一步总结提示对A/H1N1 流感监测的调整WHO. 10 July 2009. Human infection with pandemic (H1N1) 2009 virus: updated interim WHO guidance on global surveillance. CDC. September 8, 2009. Interim Guidance for State and Local Health Departments for Reporting Influenza-Associated Hospitalizations and Deaths for the 2009-2010 Season. 关于甲型H1N1 流感的诊断标准“诊断标准”的条件流行病学史疫源地或确诊病例接触史暴发疫情中的病例临床表现流感样病例（ILI ）特异性检查检测是否为甲型流感检测是否为新型A/H1N1 流感real-time RT-PCR 或RT-PCR 方法检测A/H1N1 病毒核酸阳性分离到A/H1N1 病毒双份血清A/H1N1 病毒的特异性抗体水平呈4倍或4倍以上升高两类不同的诊断标准三分类法疑似病例临床诊断病例确诊病例两分类疑似病例确诊病例三分类法：美国CDC 诊断标准Confirmed case a person with an influenza-like illness with laboratory confirmed novel influenza A (H1N1) virus infection by one or more of the following tests: real-time RT-PCR viral culture Probable case a person with an influenza-like-illness who is positive for influenza A, but negative for human H1 and H3 by influenza RT_PCR Suspected case a person who does not meet the confirmed or probable case definition, and is not novel H1N1 test negative, and is/has: a previously healthy person < 65 years hospitalized for ILI OR ILI and resides in a state without confirmed cases, but has traveled to a state or country where there are one or more confirmed or probable cases OR ILI and has an epidemiologic link in the past 7 days to a confirmed case or probable case  两分类法：WHO 诊断标准Confirmed case an individual with laboratory confirmed swine influenza A(H1N1) virus infection by one or more of the following tests real-time RT-PCR viral culture four-fold rise in swine influenza A(H1N1) virus specific neutralizing antibodies Probable case an individual with an influenza test that is positive for influenza A, but is unsubtypable by reagents used to detect seasonal influenza virus infection OR A individual with a clinically compatible illness or who died of an unexplained acute respiratory illness who is considered to be epidemiologically linked to a probable or confirmed case  我国“诊疗方案”中诊断标准的制定原则诊断条件的不同组合构成各“病例诊断标准”各“病例诊断标准”与“临床分类处理原则”对应卫生部《甲型H1N1 流感诊疗方案（2009 年第三版）》中采用了三分类方式确诊病例诊断标准临床表现+A/H1N1 病毒特异性检测阳性临床分类处理原则在通风条件良好的房间进行隔离住院病例可多人同室卫生部《甲型H1N1 流感诊疗方案（2009 年第三版）》应尽可能在“确诊病例”的层次上进行临床分类处理，以利于院内感染的控制和患者的及时治疗疑似病例诊断标准流行病学史（疫源地或确诊病例接触史）+ 临床表现特异性检查（仅甲型流感病毒检测阳性）+ 临床表现临床分类处理原则在通风条件良好的房间单独隔离住院病例须做A/H1N1 流感病毒特异性检测临床诊断病例诊断标准流行病学史（A/H1N1 暴发疫情中的病例）+临床表现临床分类处理原则：与“疑似病例”相同疫情上报与病例诊断间存在矛盾疑似病例→临床诊断病例可能出现大量“假阳性”疑似病例→确定诊断病例带来巨大的检测量治疗对于临床症状较轻且无合并症、病情趋于自限的甲型H1N1 流感病例，无需积极应用神经氨酸酶抑制剂。……对于较易成为重症病例的高危人群，一旦出现流感样症状，不一定等待病毒核酸检测结果，即可开始抗病毒治疗。孕妇在出现流感样症状之后，宜尽早给予神经氨酸酶抑制剂治疗。治疗（2）糖皮质激素的应用在“方案”中未涉及WHO. 21 May 2009.  Clinical management of human infection with new influenza A (H1N1) virus: initial guidance. Corticosteroids should not be used routinely to treat patients with the new influenza A(H1N1). Low doses of corticosteroids may be considered for patients in septic shock who require vasopressors and have suspected adrenal insufficiency. ……住院原则与出院标准根据患者病情及当地医疗资源状况，按照重症优先的原则安排住院治疗。……“诊疗方案”的应用体会针对“方案”组织学习十分重要“方案”是指导原则，需结合具体情况与CDC 密切配合特异性实验室检测流行病学资料* * 传播途径决定个人防护装备（PPE ）的配置普通医用口罩？N95 口罩？Mark Loeb; et al.JAMA. published online Oct 1, 2009;(doi:10.1001/www.book118.com) Kenneth I. Shine, et al.N Engl J Med .10.1056/NEJMp0908437 不同的医疗环境更与PPE 的配置有关进行易产生气溶胶的医疗操作（经呼吸道吸痰、气管插管、支气管镜检查）时，需要N95 口罩Infection prevention and control in health care for confirmed or suspected cases of pandemic (H1N1) 2009 and influenza-like illnesses .WHO,25 June 2009  下列人群出现流感样症状后，较易发展为重症病例，应当给予高度重视，尽早进行甲型H1N1 流感病毒核酸检测及其他必要检查。……3. 肥胖者（体重指数≥40 危险度高，体重指数在30-39 可能是高危因素）通常表现为流感样症状，包括发热、咽痛、流涕、鼻塞、咳嗽、咯痰、头痛、全身酸痛、乏力。部分病例出现呕吐和/或腹泻。少数病例仅有轻微的上呼吸道症状，无发热。体征主要包括咽部充血和扁桃体肿大。……国内1054 例A/H1N1 患者症状特点中国人外国人中国人外国人可发生肺炎等并发症。少数病例病情进展迅速，出现呼吸衰竭、多脏器功能不全或衰竭。可诱发原有基础疾病的加重，呈现相应的临床表现。病情严重者可以导致死亡。无论采用哪种诊断分类，依据的条件均为“流行病学”“临床表现”“特异性检查”Interim Guidance on Case Definitions to be Used For Investigations of Novel Influenza A (H1N1) Cases.1 June 2009 Interim WHO guidance for the surveillance of human infection with swine influenza A(H1N1) virus.29 April 2009  卫生部《甲型H1N1 流感诊疗方案（2009 年第三版）》卫生部《甲型H1N1 流感诊疗方案（2009 年第三版）》从严制定“临床诊断病例”标准，避免纳入过多的“假阳性”病例，干扰疫情判断和防控体温正常3天，其他流感样症状基本消失，临床情况稳定，可以出院。因基础疾病或合并症较重，需较长时间住院治疗的甲型H1N1 流感病例，在咽拭子甲型H1N1 流感病毒核酸检测转为阴性后，可从隔离病房转至相应病房做进一步治疗。*  Sheet3
Sheet2
Sheet1
Chart1
825(90.7)
116(80.6)
659(72.4)
77(53.5)
246（27.0）20（13.9）378（41.5）31（21.5）Rhinorrhea
193（21.2）29（20.1）Nasal congestion
129(14.2)
12(8.3)
149（16.4）18（12.5）Fatigue
193(21.2)
29(20.1)
Myalgia, arthralgia
84(9.2)
8(5.6)
Chill
65(7.1)
9(6.2)
Diarrhea
17(1.9)
4(2.8)
Nausea, vomiting
24(2.6)
3(2.1)
748(82.2)
97(67.4)
Congestion of throat
Swelling of tonsils
Fever
Cough
Sputum
Sore throat
Headache
P
Chinese=910
Foreigners=144 
中国人=910
外国人=144
发热咳嗽咽痛咯痰鼻塞头痛疲劳恶心、呕吐腹泻流涕肌肉、关节痛