1、解读人感染HN禽流感防控技术方案与诊疗方案目前卫生部门对疫情的研判目前卫生部门对疫情的研判 内容简介内容简介一、病原学一、病原学二、流行病学二、流行病学三、临床表现三、临床表现 四、诊断与鉴别诊断四、诊断与鉴别诊断五、治疗五、治疗 六、其它六、其它七、转科或出院标准七、转科或出院标准附件：有疫情地区人感染附件：有疫情地区人感染H7N9禽流感早禽流感早检早治流程图检早治流程图HPAI H7N7、H7N3、H7N1LPAI H7Nx、H7N2、H7N3、H7N1、H7N9HPAI H7N7、H7N3、H7N4HPAI H7N3（Pakistan）HPAI H7N3LPAI H7N9HPAI H7N
2、3LPAI H7N9禽中暴发的禽中暴发的H7H720062006年前暴发的均为年前暴发的均为HPAI H7HPAI H7欧洲：意大利、英国、德国、比利时、荷兰、丹麦、挪威、欧洲：意大利、英国、德国、比利时、荷兰、丹麦、挪威、捷克、西班牙、瑞典捷克、西班牙、瑞典LPAI H7N8、H7N9（Korea）LPAI H7N9近年来人感染禽流感病毒病例血清学证据：人感染H4,H5,H6,H7,H9,H10,H11 AIVs.H7H7感染人（感染人（100100人）人）、英国、意大利、荷兰、英国、意大利、荷兰、加拿大加拿大HPAILPAI19591/USA H7N719771/USA H7N71979-
3、19804/USAH7N719961/EnglandH7N720021/USAH7N220031/USAH7N27/ItalyH7N389/NetherlandsH7N71 died20041/CanadaH7N31/CanadaH7N320061/NorfolkH7N320074/WalesH7N22/MexicoH7N3共25株均为LPAI无感染人病例亚洲：7株均来自野禽5株韩国2株蒙古LPAI H7N9Nose(white bars),lung(black bars)HPAI H7N3HPAI H7N3和和LAPI H7N9LAPI H7N9均不需经过适应便均不需经过适应便可在小鼠体内有
4、效复制，且可在小鼠体内有效复制，且均能在雪貂上均能在雪貂上下呼吸道有效复制下呼吸道有效复制。HPAI H7N3LPAI H7N9LPAI H7N9HPAI H7N3高致病性的高致病性的HPAI H7N3HPAI H7N3致小鼠死亡，致小鼠死亡，在雪貂模型中可通过接触传播，但在雪貂模型中可通过接触传播，但LAPI H7N9LAPI H7N9在雪貂模型中不传播。在雪貂模型中不传播。A/Baers pochard/HuNan/414/(H7N1)A/chicken/Hebei/1/2002(H7N2)A/duck/Guangdong/1/1996(H7N3)A/duck/Hubei/126/1985
5、(H7N8)A/duck/Jiangxi/1742/03(H7N7)A/duck/Jiangxi/1760/03(H7N7)A/duck/Jiangxi/1786/03(H7N7)A/duck/Jiangxi/1814/03(H7N7)A/duck/Nanchang/1904/1992(H7N1)A/duck/Nanchang/1944/92(H7N1)A/duck/Zhejiang/10/(H7N3)A/duck/Zhejiang/12/(H7N3)A/duck/Zhejiang/2/(H7N3)A/magpie-robin/China/28710/93(H7)亚型：H7N1,H7N2,H7
6、N3,H7N7,H7N8野禽居多LPAI病毒分离病毒分离PB2PB1HANPNAMPNSPA6 6个内部片段来源于个内部片段来源于H9N2H9N2序列测定序列测定 A/northern_pintail/Akita/1370/2008_H7N7_Japan A/mallard/Korea/GG3/2007_H7N7_South_Korea A/environment/Mongolia/1-51/2007_H7N7_Mongolia A/duck/Korea/BC10/2007_H7N3_South_Korea A/duck/Mongolia/119/2008_H7N9_Mongolia A/du
7、ck/Korea/A349/2009_H7N2_South_Korea A/duck/Thailand/CU-LM7291T/2010_H7N6_Thailand A/quail/Thailand/CU-J2882/2009_H7N1_Thailand A/wild_bird/Korea/5-77/2005_H7N8_South_Korea A/duck/Zhejiang/12/2011_H7N3_China A/Shanghai/1/2013 A/Shanghai/2/2013 A/Anhui/1/2013 A/duck/Jiangxi/1742/03_H7N7_China A/wild_b
8、ird_feces/Korea/HDR16/2003_H7N2_South_Korea A/duck/Mongolia/867/2002_H7N1_Mongolia AY338455_A/Netherlands/127/03_H7N7_Netherlands AY338457_A/Netherlands/33/03_H7N7_Netherlands AY338459_A/Netherlands/219/2003_H7N7_Netherlands A/chicken/Italy/444/99_H7N1_Italy A/chicken/Italy/322/2001_H7N1_Italy A/qua
9、il/Italy/4610/2003_H7N2_Italy A/turkey/Italy/5425/2007_H7N3_Italy A/mallard/Sweden/100993/2008_H7N7_Sweden A/mute_swan/Hungary/5973/2007_H7N7_Hungary A/mallard/Italy/497-35/2006_H7_Italy A/goose/Czech_Republic/1848-K9/2009_H7N9_Czech_Republic A/mallard/Korea/822/2010_H7N7_South_Korea A/duck/Thailand
10、/CU-10507T/2011_H7N4_Thailand A/wild_goose/Dongting/PC0360/2012_H7N7_China A/spot-billed_duck/Korea/447/2011_H7N9_South_Korea A/parrot/England/1174/94_H7N1_United_Kingdom A/ostrich/South_Africa/5352/92_H7N1_South_Africa AF028020_A/England/268/1996_H7N7_United_Kingdom GU053110_A/England/AV877/1996_H7
11、N7_United_Kingdom A/England/AV877/1996_H7N7_United_Kingdom A/chicken/Pakistan/16/99/95_H7N3_Pakistan A/chicken/Karachi/NARC-23/2003_H7N3_Pakistan A/quail/Aichi/1/2009_H7N6_Japan A/duck/Hong_Kong/301/1978_H7N2_Hong_Kong A/black_kite/Egypt/054/2004_H7N7_Egypt A/chicken/Jena/1816/87_H7N7_Germany A/chic
12、ken/Hebei/1/2002_H7N2_China A/African_starling/England-Q/983/1979_H7N1_United_Kingdom A/duck/Vietnam/OIE-0178/2012_H7N1_Viet_NamEurasian A/mallard/New_Zealand/1365-355/2005_H7N7_New_Zealand A/equine/Prague/1/1956_H7N7_Czech_Republic A/equine/Cambridge/1/63_H7N7_United_Kingdom A/equine/Argentina/1/19
13、77_H7N7_ArgentinaEquine A/chicken/Chile/184240-1/2002_H7N3_Chile A/cinnamon_teal/Bolivia/4537/2001_H7N3_Bolivia A/turkey/Oregon/1971_H7N3_USA A/shorebird/Delaware_Bay/274/1994_H7N5_USA A/mallard/Delaware/418/2005_H7N3_USA A/blue-winged_teal/Ohio/566/2006_H7N9_USA A/green-winged_teal/MD/648/2004_H7N3
14、_USA CY015006_A/Canada/rv504/2004_H7N3_Canada A/goose/Nebraska/17097-4/2011_H7N9_USA CY125728_A/Mexico/InDRE7218/2012_H7N3_Mexico A/chicken/Jalisco/CPA1/2012_H7N3_Mexico A/pheasant/Minnesota/917/1980_H7N3_USA A/green-winged_teal/ALB/228/1985_H7N3_Canada A/laughing_gull/Delaware/22/2002_H7N3_USA A/du
15、ck/Guangdong/1/1996_H7N3_China A/turkey/New_York/Sg-00255/1994_H7N2_USA A/quail/PA/20304/1998_H7N2_USA A/Guinea_fowl/New_York/10196-7/2005_H7N2_USA A/chicken/New_York/63806-12/2005_H7N2_USA A/turkey/VA/66/02_H7N2_USA EU587368_A/New_York/107/2003_H7N2_USA A/Guinea_fowl/New_York/31621-8/2005_H7N2_USAA
16、merican A/chicken/Victoria/1976_H7N7_Australia A/duck/Tasmania/277/2007_H7N2_Australia A/duck/Victoria/512/2007_H7N6_Australia A/chicken/Queensland/1994_H7N3_Australia A/chicken/New_South_Wales/2/1997_H7N4_Australia A/fowl/Egypt/45_H7N1_Egypt A/chicken/Japan/1925_H7N7_Japan A/duck/Taiwan/33/1993_H7N
17、7_Taiwan A/chicken/Rostock/45/1934_H7N1_Germany A/FPV/Dutch/1927_H7N7_United_Kingdom A/chicken/Brescia/1902_H7N7_Italy100100991001001001001008182887399100100911001001001001001007810092100100999499891007810087841008778917896711009888981001007698979810098869992899370990.05H7进化树进化树红色标记为本次病例红色标记为本次病例H7
18、人感染病例人感染病例发生人感染H7N9禽流感疫情的省份，常规流感样病例监测哨点医院采集流感样病例标本数每周不低于15份，并将H7核酸检测纳入常规检测项目。发生人感染H7N9禽流感疫情的省份，常规流感样病例监测哨点医院采集流感样病例标本数每周不低于15份，并将H7核酸检测纳入常规检测项目。禽流感病毒属正粘病毒科甲型流感病毒属。6个内部片段来源于H9N2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（H1H16）和9个N亚型（N1N9）。89/Netherlands由县级卫生行政部门组织对密切接触者进行追踪和管理，对密切接触者实行医学观察/健康随访，不限制其活动，每
19、日晨、晚各1次测体温并了解是否出现急性呼吸道感染症状。一、病原学病例的临床标本采集后，县级疾病预防控制机构和病例收治的医疗机构要密切配合，按照生物安全的相关规定进行包装，在24 小时内送到当地流感监测网络实验室进行检测。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。尚不具备网络直报条件的医疗机构，应当于24小时内以最快的通讯方式（、等）向当地县级疾病预防控制机构报告，并寄出传染病报告卡，县级疾病预防控制机构在接到报告后立即进行网络直报。A/duck/Nanchang/1904/1992(H7N1)可感染人的禽流感病毒亚型为H5N1、H9N
20、2、H7N7、H7N2、H7N3，此次报道的为人感染H7N9禽流感病毒。并填写不明原因肺炎病例/聚集性病例标本送检表。五、病例管理和感染防护 A/mallard/Minnesota/Sg-00177/2007_USA_H12N9 A/mallard/Ohio/2033/2009_USA_H4N9 A/American_black_duck/New_Brunswick/03451/2009_Canada_H3N9 A/mallard/Alberta/64/2000_Canada_H11N9 A/mallard/MN/158/2000_USA_H3N9 A/northern_shoveler/Ca
21、lifornia/8675/2008_USA_H11N9 A/ruddy_turnstone/Delaware_Bay/220/1995_USA_H7N9 A/mallard/Alberta/193/2000_Canada_H11N9 A/black_duck/Ohio/161/1999_USA_H11N9 A/ruddy_turnstone/DE/1538/2000_USA_H7N9 A/American_black_duck/New_Brunswick/02485/2007_Canada_H11N9 A/American_white_pelican/Minnesota/Sg-0611/20
22、08_USA_H13N9 A/shorebird/Delaware_Bay/424/2007_USA_H13N9 A/shorebird/Delaware_Bay/48/2002_USA_H11N9 A/ruddy_turnstone/New_Jersey/980/2002_USA_H2N9 A/ruddy_turnstone/Delaware_Bay/96/2002_USA_H1N9 A/thick-billed_murre/Alaska/44085-090/2006_USA_H11N9 A/glaucous_gull/Alaska/44199-104/2006_USA_H13N9 A/gu
23、inea_fowl/Nebraska/17096-1/2011_USA_H7N9 A/northern_shoverl/Mississippi/11OS145/2011_USA_H7N9 A/king_eider/Alaska/44397-858/2008_USA_H10N9 A/blue-winged_teal/Guatemala/CIP049-01/2008_Guatemala_H7N9 A/turkey/Minnesota/1/1988_USA_H7N9 A/gull/Maryland/18/1977_USA_H2N9 A/pintail/Alberta/293/1977_Canada_
24、H2N9 A/Black_Duck/Ohio/239/1986_USA_H11N9 A/ruddy_turnstone/Delaware/2368/1988_USA_H4N9 A/redhead_duck/Alberta/357/1983_Canada_H11N9 A/turkey/Wisconsin/1/1968_USA_H5N9 A/tern/Australia/G70C/1975_Australia_H11N9American A/duck/Vietnam/OIE-2386/2009_Viet_Nam_H11N9 A/duck/Vietnam/OIE-3301/2011_Viet_Nam
25、_H6N9 A/goose/Zambia/09/2009_Zambia_H11N9 A/mallard/New_Zealand/1440-365/2005_New_Zealand_H11N9 A/mallard/Czech_Republic/15902-18K/2009_Czech_Republic_H6N9 A/goose/Czech_Republic/1848-K9/2009_Czech_Republic_H7N9 A/mallard/Switzerland/WV1071028/2007_Switzerland_H11N9 A/Duck/Nanchang/2-0492/2000_China
26、_H2N9(2)A/mallard/Sweden/48/2002_Sweden_H11N9 A/gadwall/Mongolia/OIE-191/2012_Mongolia_H2N9 A/duck/Hunan/1590/2007_China_H6N9 A/duck/Mongolia/119/2008_Mongolia_H7N9 A/mallard/Czech_Republic/13438-29K/2010_Czech_Republic_H11N9 A/Anas_crecca/Spain/1460/2008_Spain_H7N9 A/duck/Vietnam/LBM81/2012_Viet_Na
27、m_H11N9 A/wild_duck/Korea/SH20-27/2008_South_Korea_H7N9 A/shorebird/Korea/S8/2006_South_Korea_H11N9 A/duck/Chiba/7/2006_Japan_H11N9 A/duck/Hokkaido/W245/2004_Japan_H11N9 A/shorebird/Korea/S331/2006_South_Korea_H10N9 A/wild_bird/Korea/A3/2011_South_Korea_H7N9 A/wild_bird/Korea/A14/2011_South_Korea_H7
28、N9 A/Shanghai/1/2013 A/Shanghai/2/2013 A/Anhui/1/2013Eurasian A/kelp_gull/Argentina/LDC4/2006_Argentina_H13N9 A/emu/NY/12716/1994_USA_H5N9 A/shoveler/Netherlands/19/1999_Netherlands_H11N9 A/chicken/Italy/22A/1998_Italy_H5N9 A/wedge-tailed_shearwater/Western_Australia/2327/1983_Australia_H15N9 A/shea
29、rWater/Australia/2576/1979_Australia_H15N9 A/duck/Hong_Kong/278/1978_Hong_Kong_H2N9 A/duck/Hong_Kong/562/1979_Hong_Kong_H10N910010010010010010010010098100998081100759292898999837396100981009993100999986759777900.02N9 进化树进化树红色标记为本次病例红色标记为本次病例 A/Shanghai/1/2013 A/Shanghai/2/2013 A/Anhui/1/2013 A/bramb
30、ling/Beijing/16/2012_H9N2 A/chicken/Shanghai/C1/2012_H9N2 A/chicken/Zhejiang/329/2011_H9N2 A/chicken/Shandong/02/2010_H9N2 A/chicken/Shandong/H/2009_H9N2 A/equine/Guangxi/3/2011_H9N2 A/chicken/Zhejiang/607/2011_H9N2 A/chicken/Anhui/HF/2010_H9N2 A/chicken/Jiangsu/Q3/2010_H9N2 A/chicken/Shuanggou/1/20
31、11_H9N2 A/duck/Shandong/009/2008_China_H5N1 A/avian/Japan/8KI0162/2008_Japan_H3N8 A/avian/Japan/8KI0068/2008_Japan_H3N6 A/environment/Korea/CSM05/2004_South_Korea_H3N1 A/mallard/Jiangxi/8341/2004_China_H6N5 A/environment/Korea/ESD18/2004_South_Korea_H3N6 A/duck/Guangxi/3333/2006_China_H6N1 A/duck/Gu
32、angxi/1248/2006_China_H6N2 A/wild_bird/Korea/YJ117/2007_South_Korea_H4N6 A/turkey/Italy/977/1999_Italy_H7N1 A/turkey/Italy/1067/99_Italy_H7N1 A/turkey/Italy/1265/1999_Italy_H7N1 A/mallard/Czech_Republic/13438-29K/2010_H11N9 A/avian/Egypt/920431/2006_H9N2 A/spot-billed_duck/Korea/447/2011_H7N9 A/wild
33、_bird/Korea/A14/2011_H7N9 A/wild_bird/Korea/A3/2011_H7N9 A/goose/Czech_Republic/1848-K9/2009_H7N9 A/goose/Czech_Republic/1848-T14/2009_H7N9 PC0360_H7N7-PB2.seq A/duck/Jiangxi/1814/03_China_H7N7 A/wild_duck/Mongolia/1-241/2008_H7N9 A/Anas_crecca/Spain/1460/2008_H7N9 A/mallard/Sweden/105/2002_Sweden_H
34、7N7 A/gadwall/Netherlands/1/2006_H9N2 A/Netherlands/219/2003_Netherlands_H7N7 A/chicken/Netherlands/2586/2003_Netherlands_H7N7 A/England/AV877/1996_United_Kingdom_H7N7 A/chicken/Israel/184/2009_H9N2 A/chicken/Korea/MS96-CE6/1996_H9N2 A/chicken/China/Guangxi14/2000_H9N2 A/chicken/Guangdong/6/97_H9N2
35、A/chicken/Pakistan/4/99_H9N2 A/chicken/Pakistan/UDL-03/2008_H9N2 A/duck/Zhejiang/12/2011_H7N3 A/swine/Hong_Kong/9/98_H9N2 A/swine/Guangxi/7/2007_H9N2 A/chicken/Yokohama/aq120/2001_H9N2 A/wild_bird/Korea/A9/2011_H7N9 A/chicken/Korea/A146/2009_H9N2 A/chicken/Guangxi/55/2005_H9N2 A/duck/Nanchang/4-361/
36、2001_H9N2 A/chicken/Shandong/KD/2009_H9N2 A/chicken/Hebei/A/2007_H9N2 A/duck/Fujian/FQ2/2007_H9N2 A/swine/Guangxi/S11/2005_H9N2 A/chicken/Yokohama/aq134/2002_H9N2 A/turkey/Minnesota/1/1988_H7N9 A/Canada/rv504/2004_Canada_H7N3 A/New_York/107/2003_USA_H7N2 A/ruddy_turnstone/Delaware_Bay/220/1995_H7N9
37、A/northern_shoverl/Mississippi/11OS145/2011_H7N9 A/blue-winged_teal/Ohio/566/2006_H7N9 A/ruddy_turnstone/DE/1538/2000_H7N9 A/Mexico/InDRE7218/2012_Mexico_H7N3 A/blue-winged_teal/Guatemala/CIP049-01/2008_H7N9 A/blue-winged_teal/Guatemala/CIP049-02/2008_H7N910086907099881001001001008378991001001007191
38、1001008982981001009993991009990100818810088909881740.02PB2进化树进化树红色标记为本次病例红色标记为本次病例H7 人感染病例人感染病例Nose(white bars),lung(black bars)传染源可能为携带H7N9禽流感病毒的禽类。附件2 人感染H7N9禽流感病毒标本采集及实验室检测策略若病例无上述三项接触史时，重点调查其发病前7天内的活动情况，以了解其可能的环境暴露情况，如是否到过禽流感疫区或曾出现病、死禽畜的地区旅行，是否到过农贸市场及动物养殖场所等。（三）病例发病前活动范围及暴露史。从患者呼吸道标本中分离H7N9禽流感病毒
39、。应当尽量采集病例发病早期的呼吸道标本（尤其是下呼吸道标本）和发病7天内急性期血清以及间隔2-4周的恢复期血清。2002/北美（Virginia）如果H5或H7亚型检测阳性，在生物安全三级实验室进行流感病毒的分离鉴定，无病毒分离条件的实验室，将标本在24小时内送国家流感中心进行复核鉴定和病毒分离。LPAI H7Nx、H7N2、H7N3、H7N1、H7N9二、标本检测结果反馈和报告经呼吸道传播，也可通过密切接触感染的禽类分泌物或排泄物，或直接接触病毒感染。疾病预防控制机构负责标本采集和实验室检测工作。H7N9的致病力和传播力专项调查方案另行制定。7/上呼吸道感染症状、结膜炎发病前1周内与禽类及其分泌物、排泄物等有接触史。目前临床应用数据有限，应严密观察不良反应。HA蛋白339位连接肽由单个（PKGRGLFG）碱性氨基酸组成，根据既往研究，具有这种序列特点的病毒对禽类呈低致病性。
