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发表于 2013-10-5 12:14:08
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Emerging Infectious Diseases新发感染性疾病Since 1973 more than 30 new diseases have been characterized that have either viral or bacterial etiologies.18 Infectious diseases now comprise a mix of acute and chronic infections, and rapid transmission of infections has been further expedited by global travel. The emergence and spread of West Nile virus (WNV) infections in 1994-1999, the worldwide pandemic influenza A (H1N1) in 2009-2010, the ongoing emergence and global spread of MDR bacterial infections, and MDR tuberculosis portray how infectious diseases continue to thrive, how new strains emerge, and how dissemination occurs.19 These diseases highlight the importance of vigilance, preparedness plans, early case identification, and open communication, which together contribute to effective IPC and preserve patient safety in community and health care-delivery setting.自1973年以来，出现30多种以病毒或细菌病原体为特征的新疾病18。新的感染性疾病由急性和慢性感染混合而产生，感染传播迅速，加速了全球化传播的步伐。1994年至1999年西尼罗河病毒(WNV)出现和传播，2009年至2010年H1N1甲型流感全世界性的大流行，多重耐药菌感染不间断地出现造成全球性传播，多重耐药结核病的出现使感染性疾病越演越烈，新菌株不断出现，传播迅速重现19。这些疾病凸显了警觉、防控计划、早期识别和开放交流的重要性，有助于与有效的IPC策略联系在一起，保护好社区和医疗保健机构中病人的安全。West Nile Virus (WNV)西尼罗河病毒WNV has now been reported in most regions of the world. Outbreaks of WNV encephalitis in human occurred in Algeria in 1994, Romania in 1996-1997, the Czech Republic in 1997, the Democratic Republic of the Congo in 1998, Russia in 1999, Israel in 2000, and the United States in 1999-2003.20 The US public health experience with the emergence, monitoring, and control strategies for WNV illustrates the importance of strong communication networks and coordinated collection of information not only between health care organizations and government agencies but also among physicians, veterinarians, public health providers, and wildlife experts. Sharing of information and transparent data collection can help enhance case detection, optimize clinical decision making, and contribute to disruption of viral transmission.西尼罗河病毒现在已经被世界多个地区报道。1994年阿尔及利亚、1996年至1997年罗马尼亚、1997年捷克共和国、1998年刚果共和国、1999年俄罗斯、2000年以色列、1999年至2003年美国发生人类WNV脑炎暴发20。美国公共卫生部门对WNV的出现、监测和控制策略的经验，说明加强通信网络联系和协作收集信息，不仅对医疗保健机构和政府机构，而且对医生、兽医、公共卫生服务人员和野生动物专家也是非常重要的。信息共享和资料收集的透明化，有助于加速对事件的判断，优化临床的决策，有助于阻止病毒的传播。The Pandemic Influenza—A H1N1H1N1甲型流感的大流行The 2009 pandemic influenza A H1N1 was first detected in Mexico in late March 2009, followed by prompt case detection in the United States and other countries. This virus was a unique combination of six influenza virus genes never previously identified in animals or humans. 21 There was triple-reassortant of North American swine virus lineages and two genes encoding neuraminidase and matrix proteins from Eurasian swine virus lineages. 222009年H1N1甲型流感的大流行最早发生在墨西哥2009年3月下旬，然后迅速地出现在美国和其他国家。这是一种独特的由6种流感病毒基因组合先前没有在动物和人类中出现过的病毒21。是来自北美猪病毒谱系与来自欧亚猪病毒谱系的神经氨酸苷酶和基质蛋白两个基因编码的三方基因重组的病毒22。After the initial case detection, the World Health Organization (WHO) declared the 2009 influenza A H1N1 outbreak a public health emergency of international concern, raising the level of influenza pandemic alert from phase 3 to phase 4, and recommended that countries intensify surveillance for unusual outbreaks of influenza-like illness and severe pneumonia. In June 2009 WHO signaled that a global pandemic of 2009 influenza A H1N1 was under way by further raising the worldwide pandemic alert level to phase 6.23-25 The global pandemic was associated with millions of case infections, more than 19,000 deaths, and several million dollars in health care expenditures.最初病例发现后，世界卫生组织公布2009年H1N1甲型流感暴发是世界关注的公共卫生事件，提升流感大流行警报级别从3级升为4级，建议这些国家对不寻常的流感样疾病和严重肺炎加强监测。2009年6月世界卫生组织发出2009年H1N1甲型流感正在全球性大流行，进一步提升全世界大流行警报级别到6级23-25。全球大流行是与上百万人数的感染，19000多人死亡，几百万美元的医疗保健支出联系在一起的。The mechanisms of person-to-person transmission of the 2009 H1N1 virus appeared similar to those of seasonal influenza, but the relative contributions of small-particle aerosols, large droplets, and fomites are uncertain.22 Rates of secondary outbreaks of illness varied according to the setting and the exposed population, yet estimates ranged from 4% to 28%.23 Household transmission was highest among children and lowest among adults over 50 years of age.232009年的H1N1病毒人传人的传播机制与那些季节性的流感相似，但其小颗粒气溶胶、大的飞沫、污染物的相对作用是不确定的22。继发疾病的暴发率根据环境和暴露人群的不同而变化，但估计变化范围在4%到28%之间23。家庭传播以儿童和年龄超过50岁的成年人为最高23。WHO announced the end of the pandemic period in August 2010. 23 The 2009 pandemic influenza A H1N1 occurred against a backdrop of pandemic response planning after years of developing, refining, and regularly exercising preparedness response plans at the international, federal, state, local, and community level.26 This emergent disease was a major challenge for health care institutions and HCWs, particularly health care epidemiologists and IPC professionals who invested significant resources to control the pandemic.2010年8月，世界卫生组织宣传这次大流行结束23。2009年H1N1甲型流感发生在经过多年的发展，对流感大流行有应急措施和国际、联邦、州、地区和社区有不断改善，定期训练作好准备的应急计划的背景下26。这次突发的疾病是对医疗保健体系和医务人员的重大挑战，特别是为控制大流行付出巨大精力的医疗保健流行病学家和感染预防控制专业人员。Community-Associated MRSA社区相关MRSAStaphylococcus aureus is an important cause of infections in health care settings and in communities. MRSA results from the production of an alternate penicillin-binding protein, PBP2a, which has a low affinity for all β-lactam agents and generates resistant susceptible only to other antibiotic families, such as glycopeptides. Clinical isolates of MRSA were increasingly reported in the 1980s among patients primarily in hospitals and other health care environments. Since the mid- to late 1990s, however, there has been an explosion in the number of MRSA infections reported in persons lacking exposure to health care systems. These infections have been linked to MRSA clones known as community-associated MRSA (CA-MRSA).27 Strains of CA-MRSA differ in phenotype from the older, health care-associated MRSA (HA-MRSA) strains and carry a smaller, more mobile, and less physiologically burdensome chromosomal element, termed SCCmec type IV. This genetic element usually carries only the mecA gene, with no other resistance determinants, differentiating it from genetic elements traditionally found in HA-MRSA strains. 27 These CA-MRSA strains, often spread among healthy people in the community, and have been associated with severe skin and respiratory infections. 28金黄色葡萄球菌是引起医疗保健机构和社区感染的一个重要原因。MRSA产生一种能替代青霉素结合蛋白(PBP)的物质PBP2a, 降低其与β-内酰胺类药物的亲和力，产生耐药性，仅对其他种类的抗菌药物敏感，如糖肽类药物。上世纪80年代，越来越多的报道，在医院和其他医疗环境的患者中，从临床上分离出MRSA菌株。然而，从上世纪90年代中期以来，报道没有医疗保健环境暴露的经历者，感染MRSA的数量巨增。这种感染把MRSA克隆体与社区相关MRSA(CA-MRSA)联系起来27。CA-MRSA菌株在表型上不同于旧的、医疗相关MRSA (HA-MRSA)菌株，携带一个较小的、游离的、很少生理负担的染色体质粒，称作SCCmec IV型。这种遗传因子通常只携带mecA基因，没有其他耐药因子，将它与传统上HA-MRSA菌株能找到的遗传因子区分开来27。这些CA-MRSA菌株常常在社区健康人群传播，与严重的皮肤和呼吸道感染相关28。MDR Gram-Negative Pathogens多重耐药的革兰阴性病原菌Infections caused by MDR gram-negative pathogens are an increasing problem worldwide. Resistance dramatically limits therapeutic options, and, in contrast to new drugs for gram-positive organisms, there has been a paucity of new antimicrobial agents approved for gram-negative bacilli (GNB) in recent years. 29 Furthermore, many GNB are resistant to multiple agents and in some instances are pan-resistant to all commercially available antimicrobial agents.30 Notably, carbapenemases are categorized by hydrolytic mechanisms that permit drug resistance and include β-lactamases in the molecular Class A, B, and D. Epidemiological investing suggests complex and differential patterns of emergence of carbapenem-resistant bacteria. As an example, introduction of the plasmid-mediated Klebsiella pneumoniae carbapenemase (KPC) gene into several geographic regions has been due to intercountry patient transfer. Israel was the first nation outside the United States to report a large outbreak of KPC-producing K. pneumoniae attributed to health care-associated transmission of a strain linked to North America.31 Greece later identified wide-spread clonal KPC pathogens that were indistinguishable from contemporary Israeli clones. 32 In Germany, the likely index case in a single-center outbreak was a patient who had been previously hospitalized in Greece. 33 The Unite Kingdom, France, and other countries have also reported episodes of colonization or infection of patients with KPC pathogens transferred from endemic countries. For additional case studies and outbreaks of carbapenem-resistant K. pneumoniae (CRKP) see Chapter 5 (Case Study 5-9) and Chapter 6 (Case Study 6-2).由多重耐药革兰阴性病原菌引起的感染是世界范围内日益严重的问题。耐药性大大限制了治疗方案。相反，对革兰阴性菌的新药物，近年来，一直缺乏新批准的抗菌药物应对革兰阴性菌29。而且，许多革兰阴性菌是多耐药的，甚至在某些情况下对市场上销售的抗菌药物是泛耐药的30。值得注意的是，碳青霉烯酶依据其水解机理分类产生耐药性物质，包括Ambler分子结构分类中的A、B和D类β-内酰胺酶。流行病学家对耐碳青霉烯类菌的出现提出了复杂的和不同的模型。例如：质粒介导的产碳青霉烯酶肺炎克雷伯菌(KPC)基因在几个不同地区出现是由病人跨国旅行传播的结果。以色列是除美国之外第一个报告由KPC引起克雷伯菌肺炎大暴发的国家，被认为与一个在北美医疗保健相关机构传播着的菌株有关31。希腊后来鉴别出的广泛传播的KPC病原克隆体与同时在以色列出现的克隆体没有区别32。在德国，在一家医疗中心暴发的病案检索中发现有病人可能先前在希腊的医院住过院33。英国、法国和其他国家也报告过从流行国家转移过来的KPC定植或感染病人的情况。更多的案例研究和耐碳青霉烯类克雷伯肺炎(CRKP)暴发情况见第5章(案例研究5-9)和第6章(案例研究6-2)。New Delhi metallo-β-lactamases (NDM) is a plasmid-mediated, class B metallo-β-lactamases that has been identified in a broad range of enterobacteriaceae and non-enterobacteriaceae. Isolates are resistant to carbapenems, aminoglycosides, fluoroquinolones, and most antimicrobial drug classes. Of concern, some isolates have also exhibited resistance to tigecycline and colistin. The index case with an NDM-producing pathogen was a man in Sweden who previously received health care in India.34 Subsequent case report and case series suggest health care contact in India, Bangladesh, and some Balkan nations has been associated with case detection in the United States, Australia, Canada, Japan, and several European nations.35,36 These epidemicological observations require further elucidation but highlight the potential risk of intercountry transmission of MDN GNB.从广泛的肠杆菌科和非肠杆菌科中鉴别出新德里金属β内酰胺酶(NDM)是一种质粒介导的B类金属β内酰胺酶。分离出的菌株耐碳青霉烯类、氨基糖苷类、氟喹诺酮类等多类抗菌药物。更重要的是，一些分离菌株还耐替加环素和粘菌素。检索到的产NDM病原体的瑞典人曾在印度接受过治疗。后来的病例报告及在印度、孟加拉国和巴尔干国家进行过医疗的系列病例发现与在美国、澳大利亚、加拿大和欧洲几个国家检测的病例有关联35,36。流行病学家观察提出需进一步突出阐明MDN GNB在国家间传播的潜在危险。Tuberculosis结核病Tuberculosis (TB) is the most common infectious disease worldwide. It affects one third of the global population and is the leading cause of death from a potentially curable infectious disease. The 2009 global estimate for TB was 9.4 million incident cases (range 8.9-9.9), for a rate of 137 cases per 100,000 population (range 131-145).37 TB rate vary widely by geographic region, with 22 low- and middle-income countries accounting for more than 80% of active TB case worldwide.38 Prevalence rates of TB are highest in Africa and lowest in the Americas and Europe due to the high prevalence of HIV in some African countries and the effect of HIV on susceptibility to TB. 38 Case infection with MCR-TB is defined as a person with Mycobacterium tuberculosis resistant to at least two antitubercular drugs—isoniazid and rifampicin. Recent surveillance data have revealed that prevalence of MCR-TB has risen to the highest rate ever recorded worldwide. 38 The MCR-TB strain generally arises through the selection of resistance mutations that emerge during inadequate treatment. Prior TB treatment, shortage of α-tuberculous drugs, and treatment costs have been the most common reason for the inadequacy of the initial anti-TB regimen.39 Other factors that play an important role in the development of MDR-TB include limited administrative control of purchase and distribution of the drugs, inadequate mechanism for quality control and bioavailability tests, poor patient follow-up, and inadequate administrative infrastructure.结核病是世界范围内最常见的感染性疾病。影响着全世界三分之一的人口，导致一些可治愈的感染性疾病患者死亡。2009年估计有940万(890万-990万之间)人感染结核，比率为10万分之137(131-145之间) 37。结核的比率在各个地理区域变化很大，在22个低、中收入国家中占有全世界超过80%的活动性结核病患者。结核病的患病率在非洲最高，在美国和欧洲最低，因为非洲一些国家是艾滋病的高发地区，而结核对艾滋病很敏感38。多重耐药结核(MCR-TB)感染定义为一个结核分枝杆菌感染者至少对两种抗结核药----异烟肼和利福平耐药。最近的监测数据显示多重耐药结核(MCR-TB)流行的比率上升到最高，超过了全世界曾有的记录38。多重耐药结核(MCR-TB)菌株通常出现在选择不适当的治疗时发生耐药性突变。先前对结核病的治疗，缺少α-结核药物，初始抗结核疗法，治疗费用不足是一个最常见的原因39。促使MDR-TB发展迅速的另一些重要原因是政府限制这些药物的购买和分配，质量控制和生物利用度测试机制不健全，病人随访太少，管理基础设施不足。Many other infectious diseases not discussed above (for example, cholera, meningococcal disease, and dengue hemorrhagic fever) present ongoing challenges to IPC worldwide. Regional IPC strategies should focus on the infections prevalent in the geographic setting and include preparedness plans that can be implemented should an emerging infectious pathogen or outbreak occur.许多其他的感染性疾病(如霍乱、流脑、登革出血热)对世界各地感染预防控制的挑战不再讨论。地方的IPC策略将关注地方普遍流行的感染问题，包括对新发感染病原体或发生暴发实施应对方案。Occupational Risk for Blood-Borne Pathogens血源性病原体的职业风险Twenty-six different viruses have been reported as occupational transmission risks to HCWs.17 The majority of occupational health-related cases are due to one of three viruses—hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). In the year 2000, incident HCW infections worldwide due to percutanous injuries were estimated to be 16,000 for HCV, 66,000 for HBV, and 1,000 for HIV.40 The highest proportion of blood-borne viral transmission occurs through percutaneous injuries with hollow-bore needles for vascular access, although post-exposure risk of infections to HCVs also exists for splashes of blood to skin and mucous membranes.17 Pathogen-specific postexposure risk related to percutaneous injuries is estimated to be 30% for HBV in susceptive HCWs without post-exposure prophylaxis or adequate HBV vaccination, 0.5% after viremic HCV exposure, and less than 0.3% for HIV. 17对医务人员造成职业传播危害的有26种病毒17。与职业保健相关的主要的有三种病毒—乙肝病毒(HBV)、丙肝病毒(HCV)、人类免疫缺陷病毒(HIV)。在2000年，世界各地医务人员因皮肤损伤造成发生感染事件中，16000余人感染HCV，66000余人感染HBV，1000余人感染HIV40。通过空心针孔划伤皮肤暴露的血源性病毒传播引起的感染占的比例最高，虽然接触HIV病人因溅血经皮肤粘膜暴露引起的感染也存在17。对特殊病原体因皮肤损伤的暴露估计，医务人员30%HBV感染是暴露后没有采取预防措施，或没有接种HBV疫苗，0.5%HCV暴露者引起病毒血症，不到0.3%的感染HIV17。From a historical perspective, WHO first established the Safe Injection Global Network in 1989 as an international alliance of all organizations concerned with achieving safer use of injections. Current standard precautions and preventive methods to minimize risk for blood-borne pathogens include hand hygiene, use of barrier methods, minimal manual manipulation of sharp instruments and devices, proper disposal of sharp instruments and devices in specific resistant containers, and occupational health and safety programs that promote HCW vaccination and the reporting of percutaneous injuries. Regular and renewed training sessions are relevant to new and long-term HCWs, students, physician trainees, and physician. A prospective active surveillance program has recently reported lower rates of percutaneous injuries at a large teaching hospital in Saudi Arabia relative to the United States Exposure Prevention Information Network.41 Improved practices and decreased occupational exposure have been associated with safety training compliance and with safety-engineered devices, such as retractable syringes, needle-free intravenous systems, and winged butterfly needles. In addition, reuse of cheap single-use devices (such as needles, syringes, and surgical gloves) remains common in several resource-limited health care settings, leading to large numbers of preventable infections and opportunities for implementation of effective IPC strategies to minimize risk for HBV, HCV, HIV, and other blood-borne infections.42,43历史观察，世界卫生组织作为关心实现使用安全注射的国际联盟组织在1989年首次建立了安全注射全球网。当前，减少血源性病原体风险的标准预防措施和方法包括：手部卫生，使用屏障方法，对锐利器械和设备减少手动操作，锐利器械和设备中特定容器的妥善管理，促使医务人员疫苗接种和皮肤损伤报告的职业保健和安全规程。对新、老医务人员、学生、实习医生、医生定期和重新培训。一个潜在的积极监测项目是最近报道在与美国职业暴露预防信息网相连的一所沙特阿拉伯大型教学医院中皮肤损伤率在下降41。改进措施，减少职业暴露已经与安全法规培训和安全工程设备，如可回缩注射器、无针静脉系统、蝴蝶翼针等相关。另外，便宜的一次性使用的设备(如针头、注射器、外科手套)仍然普遍在一些资源的医疗保健机构重复使用，导致了大量可预防的感染，影响了降低HBV、HCV、HIV和其他血源性感染风险的有效感染预防控制策略实施的机会。Report of HCW-to patient transmission of HBV, HCV, and HIV exist. Although uncommon, patients with blood-exposure to HCWs with HBV, HCV, or HIV should systematically receive the same postexposure assessment and management as HCW protocols.报告医务人员传播HBV、HCV、HIV给病人也存在。尽管不常见，病人因血源暴露从医务人员间获得HBV、HCV、HIV，也将系统地接受暴露后的评估，同医务人员暴露后同样的管理。HIV/AIDS人类免疫缺陷病毒与获得性免疫缺陷综合征Acquired immune deficiency syndrome (AIDS) has no cultural, social, or economic boundaries. According to a joint international program of the United Nations and WHO, as of 2009, an estimated 49.2 million people worldwide living with HIV, 2.6 million of whom were infected in 2009. 44 Form a historical perspective, the term AIDS was first used in 1982, when public health officials reported the occurrence of opportunistic infections in otherwise healthy people. Public fear, international distrust, and limited understanding of the of the natural history of disease, disease progression, and the transmission dynamics led to delays in identification of the viral etiology until 1985, when there was global consensus that a pandemic attributed to HIV infection resulted in AIDS. 44 In the United Stated and elsewhere, AIDS was initially identified in men who had sex with men, and subsequent case detection expanded to include women, injecting drug users, hemophiliacs, newborns, and unscreened blood supplies. Unsafe injection practices, unprotected sex, and the unnecessary use of injections in resource-limited setting continue to contribute to the burden of preventable HIV infection. Initial and ongoing training of HCWs regarding occupational risk for HIV infection and effective IPC strategies to minimize risk of blood-borne infection remains a key component of a sustainable and safe health care environment.获得性免疫缺陷综合征(AIDS)没有文化、社会、经济的界限。根据联合国和世界卫生组织一项联合的国际项目，截至2009年，估计世界各地生活着4920万HIV携带者，2009年有260万人口被感染HIV44。根据一项历史观察，术语AIDS最早使用于1982年。当时公共卫生官员报告在其他方面健康的人群发生机会性感染。公众害怕，国际不信任，对疾病的自然史、疾病进展、传播动力学了解极为有限，直至延迟到1985年病毒的病原学被识别，全球才一直普遍认为AIDS是HIV感染的结果44。在美国和其他地方，AIDS最初在男性同性***者中辨别出来，随后的情况发现扩展到妇女、注射吸毒者、血友病患者、新生儿、未经筛查的献血者。不安全注射行为、不安全性行为、在资源有限的机构继续进行不必要的注射增加了预防HIV感染的负担。自始至终对医务人员进行不间断的HIV感染职业风险教育培训，营造一个持续安全的医疗保健环境是把血源性感染风险降到最低有效的感染预防控制策略措施的关键。Bioterrorism生物恐怖主义Release, or threats of release, of biological agents or materials as weapons of mass destruction has the potential to evoke widespread public fear and panic, human injury, and destruction of physical plant structures. The health care community in each country must work closely with public health officials, law enforcement, and the military to ensure public safety related to deliberate epidemics and bioterrorism.45 A significant challenge in preparing for a potential bioterrorism event is anticipating the nature of the event and predicting what IPC issues will come up. The type of organism, the location of the release, the composition of the infected population, and the use of health care organizations by infected people to get treatment will influence how the specific events of a bioterrorist act unfold. Although a multitude of potential bioterrorism agents exists, following is a brief discussion of anthrax and smallpox, two pathogens that have received major media attention over the past decade. Suggestions regarding how to facilitate communication and prompt response to a biological emergency appear in Chapter 5.释放或威胁释放作为大规模杀伤武器的生物制剂或材料，可能引起公众的恐惧和恐慌，人类的伤害，动植物毁灭性的破坏。面对蓄意传播杀伤性生物武器和生物恐怖主义，各国的医疗服务团体要密切配合公共卫生官员，严格执法，军队要确保公众的安全45。准备面对潜在的生物恐怖主义严峻挑战时，要预先考虑事件的本质，确定制定感染预防控制方案要讨论的问题。受生物恐怖主义事件影响的因素很多，包括生物种类，释放的地理位置，受感染人群的组成，受感染人群寻求帮助的医疗服务机构等。尽管存在多种潜在的生物恐怖主义制剂，下面简要讨论炭疽和天花，在过去十年里，这两种病原体广泛受到主要媒体的关注。对出现生物突发紧急事件如何进行交流和迅速应对的有关建议见第5章。Anthrax炭疽Anthrax infection occurs after direct exposure to Bacillus anthracis spores, not after direct person-to-person contact. In a bioterrorism event, it is most likely that only the individuals coming in contact with spores would be affected. However, massive air-borne dissemination of B. anthracis spores could prove catastrophic if early identification and a rapid response does not occur. If untreated, the clinical progression of anthrax includes septicemia, meningitis, and death. In persons exposed to anthrax, infection can be prevented with antibiotic prophylaxis therapy; early antibiotic treatment can also help increase a person’s chance of survival.45 Early identification of an anthrax bioterrorist attack would lead to rapid antimicrobial distribution and containment, improved case detection, and heightened surveillance.炭疽感染发生于直接接触炭疽杆菌孢子后，而不是人与人之间的直接传播。在生物恐怖事件中，最可能的只是人直接接触到孢子才受影响。然而，如果早期识别迅速应对，大量炭疽杆菌孢子空气传播扩散的灾难将不会发生。如果未经处理，炭疽的临床进展包括败血症、脑膜炎和死亡。人炭疽暴露后，用抗生素预防治疗，能阻止感染；早期抗生素治疗，也能增加人生存的机会45。早期识别炭疽的生物恐怖攻击，能迅速进行抗菌剂的分配和控制，加强病例检测，强化监测机制。Smallpox天花Smallpox infection occurs after direct, fairly prolonged face-to-face contact with someone infected with variola virus, after direct contact with variola virus in infected bodily fluids, or on contaminated objects, such as bedding and clothing. 46 As a potential biological weapon, transmission of smallpox via person-to-person contact could involve suicides terrorists who used interpersonal transmission dynamics to disseminate the virus.46 Multiple countries could be affected, and these nations would need to work cooperatively to interrupt the transmission dynamics under way. Although antiviral agents have been identified and are being actively assessed in human trials, none has reached the licensure stage. As of today, there is no specific treatment for smallpox, and the only prevention is vaccination. Notably, a worldwide vaccination program that started in the 1950s has all but eradicated the disease. By 1984 the only known stocks of smallpox virus were in two WHO-approved laboratories—one in Atlanta and other in Moscow.47 Destruction of these viral stocks was originally planned for 1987 but postponed to permit further studies on the virus genome. Because the disease has been eliminated, in many parts of the world, routine vaccination no longer occurs. People who received the smallpox vaccine prior to 1980 probably have little to no immunity to smallpox today and in the case of an epidemic would require vaccination. 46 If a bioterrorist event involving smallpox were to occur, early case identification and isolation would be essential, and HCWs would need evidence of vaccination to safely provide care to infected case. Transmission would need to be minimized via targeted vaccination of close contacts of the index cases. Depending on the nature of the attack, a large-scale vaccination might be necessary, in which case public health organizations and other health organizations, such as ambulatory clinics, would have to anticipate and plan for the logistics of vaccinating the entire community.天花感染发生于直接与天花病毒的接触，持续地与感染天花病毒的人面对面的接触，接触了被天花病毒感染的体液或被污染的物品(如床上用品或服装)后46。作为一个潜在的生物武器，天花的传播途径是人与人的接触，包括使用人际间传播动力学方式传播病毒的自杀式恐怖分子46。许多国家受到影响，这些国家必须合作工作打断这一正在进行的传播动力学。抗病毒制剂已经研发出来，正在进行人体试验评估，还没达到应用许可阶段。直到今天，对天花还没有特殊的治疗方法，仅仅是疫苗接种预防。尤其是，从上世纪50年代以来开始的世界范围疫苗接种项目，几乎消除了这一疾病。到1984年，知道仅有的天花病毒株在两个世界卫生组织认定的实验室----一个在亚特兰大，另一个在莫斯科47。起初计划1987年毁灭这些病毒株，但为了将来病毒基因研究延期了。由于这一疾病已经淘汰，在世界许多地方，常规的疫苗接种不再出现。人们接种天花疫苗是在1980年以前，可能到今天极少或没有免疫力，有流行情况必须接种疫苗46。如果生物恐怖事件包括天花发生，必须早期识别情况和隔离，医务人员必须证实已经安全接种疫苗才能去治疗感染者。对查到的病例密切接触者进行疫苗接种，使传播最小化。根据攻击的不同性质，大规模的疫苗接种是必要的，在某种情况，公共卫生机构和其他卫生机构，例如流动诊疗所，要为整个国家的疫苗接种提供后勤保障进行预测和计划。Conclusion小结Infection prevention and control strategies are critical to safe, high-quality health care. Organizations that embrace IPC and implement systems to identify, to address, and to prevent the spread of infections help create health cultures based on safety and organizations rooted in quality. To create such a culture, organizations must continually examine, evaluate, and act on IPC issues and view IPC as an integral component of patient safety and HCW occupation health and safety. Successful strategies to prevent or mitigate infections require ongoing collaboration between the professionals and officials in the public health sector, hospitals, and other health care settings.感染预防控制策略对安全、高效的医疗服务很重要。奉行感染预防控制策略和对识别、控制、预防感染传播进行系统实施的团队，能帮助创建基于安全的健康文化和根植于质量的团队。创建如此的文化和团队，必须不断地调查、评估对把病人安全和医务人员职业健康安全作为一个整体起作用的感染预防控制策略的议题和观点。成功的预防和降低感染的策略必须公共卫生部门、医院和其他医疗服务机构的专业人员和行政官员不断地合作。
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楼主: dearhang
