認識H1N1(凡H1N1流感資訊，請在此集中發表，勿再發表新帖。)

素食可維持肺部健康能預防流感
許多豬流感病例，對某些人而言，可能有點輕微，但此病屬重度且可致命的疾病。
研究人員發現，那些因此病致命的人，基本上會出現呼吸系統併發症，導致難以吸入氧氣。據美國阿拉巴馬州的科學家指出，豬流感病毒會透過其Ｍ２蛋白質成份，阻止肺部上的液體被移除而導致肺炎，進而傷害肺部。但是當研究人員將Ｍ２蛋白質，聯同一種可去除氧化劑的物質，注入肺細胞中則Ｍ２蛋白質就不再傷害肺部，研究報告合著者馬塔隆（SadisMatalon）表示：「最近爆發的Ｈ１Ｎ１流感疫情，已迅速在全球擴散，顯示我們須更加瞭解病毒如何感染肺部，以便找尋新的治療法。此外，我們的研究證明抗氧化劑對治療流感具有療效。」抗氧化劑可在植物性食品中取得，據知可協助身體抗病。美國麻州波士頓塔夫茲大學（TuftsUniversity）研究人員表示紅豆、花豆及黑豆等食物是蘊藏抗氧化劑最豐富的食物，其次是竹心（artichokehearts）、甜蕃薯，菠菜、茄子等蔬菜。這些新發現將為面臨疫苗短缺的美國帶來希望，美國研究人員又有其他發現，他們發現最初具克流感抗藥性的豬流感病毒，在人與人之間傳染，使這種抗病毒藥物，漸失去療效。另一個研究發現，小孩開始出現症狀後，整整兩個星期，仍持續傳染病毒。
全球豬流感死亡病例仍持續攀升，已確認死亡病例增至6051例。其中公佈死亡病例最多的國家巴西達1368例，其次是美國1004例，阿根廷則585人因豬流感不治。美國疾病控制與預防中心近日報導，自疫情爆發迄今，已有114位兒童因豬流感死亡，其中19位就發生在上個星期。豬流感疫苗接種計畫，從中國到法國已在世界各國展開，但是疫情的嚴重仍遠非官方所能統計。
豬流感病毒造成致命感染
印度的研究團隊發現先前豬流感死亡病例，主要導因於病人肺部遭繼發性細菌感染。自8月下旬以後的死亡病例，則歸因於一種感染力較強的病毒，此病毒囤積一種蛋白質在肺膜的內襯裡，使氧氣無法進入體內，顯示豬流感病毒已產生突變。
同時挪威科學家也著手調查一種可能發生突變的豬流感病毒，因為在挪威，豬流感致死率遠高過其他北歐國家的6倍以上。
自從正式公佈豬流感疫情以來，全球致病總數已多到幾乎無法追蹤。根據政府官方統計，目前豬流感死亡病例總數已達6051例，印度及墨西哥死亡病例已各增至465例及328例，其他如卡達、約旦、阿富汗、保加利亞、伊朗、哥倫比亞等國最近也有更多人因豬流感喪生。英國在1週之內，豬流感病例跳升56％，其中14歲以下的小孩危險性最高，學校是最容易感染豬流感的地方之一。全美各地已有數百家學校關閉，奧地利、芬蘭、蒙古、俄羅斯及其他國家也發生類似情形。挪威國家醫院因豬流感導致員工編制不足，被迫將兒童及心臟病患者的手術作業延後，其他醫院的加護病房也面臨人員不足問題。
流感疫苗安全性堪憂
詹寧斯（DesireeJennings）施打季節性流感疫苗10天後竟出現類流感症狀，然後昏迷並嚴重抽蓄，經診斷，她患了罕見且無藥可醫的神經失調疾病「肌張力異常。」此病會由藥物引發，詹寧斯女士無法自主地行動和說話。她說，她的醫生確信她的症狀與施打流感疫苗有關。美國疾病管制局證實施打流感疫苗可能會出現罕見且嚴重的副作用。許多國家已開始施打豬流感疫苗，但民眾很害怕豬流感疫苗的副作用。因為它主要是用蛋，美國為了培養疫苗以殘忍方式養殖約1200百萬隻雞。美國民調指出不到50%的受訪者願意施打豬流感疫苗，近1/3表示擔心豬流感疫苗風險。中國一份調查也發現54％民眾不想施打豬流感疫苗，因為擔心它的安全性，52％加拿大受訪者也同樣表示不想施打豬流感疫苗。
豬流感持續發威，據官方統計全球死亡病例已增至5938例，以色列、敘利亞、中國、香港、印度、科威特、蒙古、悠樂（越南）和韓國都有新增的死亡病例。
芬蘭和黎巴嫩則首傳豬流感死亡病例，俄國也首傳4宗豬流感死亡病例。近日土耳其出現首宗死亡病例後，衛生部就呼籲土耳其人，未來5個月應避免接吻或握手。伊拉克教育部和衛生部宣佈2500百所學校停課以避免民眾恐慌。自4月以來，可能已有數百萬人感染豬流感，但實際感染數仍無法估算。
美國豬流感死亡病例已逾1000
美國疾病控制與預防中心（CDC, US Centers for Disease Control andPrevention）指出，豬流感疫情已提早幾個月與季節性流感高峰期同時到來，並蔓延至46州。豬流感死亡病例已超過1000。其中有400例發生在過去兩個月，其中近100名是兒童。巴西死亡病例也異常的高，達1368例。全世界確認因豬流感致死通報案例已有5382例。最近報導死亡病例增加的國家包括沙烏地阿拉伯、捷克共和國、英國及悠樂﹝越南﹞。而且預計有更多波的感染潮會在各大洲流行，第一波因傳染太快以致於在數月前就停止官方統計。同時墨西哥首府墨西哥城的醫院，因感染速度加速接近飽和的程度，衛生部長柯多瓦（Jose AngelCordova）宣稱颱風里克造成北部五州感染數增加，東北部與南部許多州正面臨急遽惡化，此情形讓人憂心。該國醫療設施不足以應付患病人數，據報導墨西哥城裡專治急性呼吸窘迫症的醫療設施已近飽和。
轉貼自
緊急求救－全球暖化

H1N1新流感病毒對所有年齡層都有致命性
資料證實，當新流感嚴重的時候，是非常糟糕的。


  
　　Nov. 3, 2009 -- H1N1新流感並不一定會很嚴重，但是當它嚴重的時候，就真的不妙了。來自加州的數據顯示，因為流感大流行而住院的患者死亡率為11％。
　　
　　流感的病毒較有可能攻擊年輕人，但50歲以上、因為H1N1新流感而住院的人，死亡率是所有族群中最高的：達到18％至20％。
　　
　　這個結果是加州衛生署Janice K. Louie醫師與同事們在美國H1N1新流感大流行的前16週（4月23日至8月11日），蒐集加州醫院的資料分析而得。
　　
　　Louie醫師和同事們在最新一期美國醫學協會期刊（Journal of the American Medical Association）中指出，與一般認知不同的是，2009年A型大流感（H1N1）只有造成輕微的病情，各年齡層都有住院和死亡的案例發生，而高達30％的住院病例算是嚴重的。
　　
　　疾病管制中心(CDC)主任Thomas Frieden醫師在記者會中表示，加州的數據顯示，H1N1新流感和季節性流感一樣會致命。
　　
　　Frieden醫師表示，這篇研究與他們自己在全國各地和世界各地蒐集的資料顯示，那些患者的嚴重程度與季節性流感類似。雖然相較於季節性流感，超過65歲罹患H1N1的比例非常非常少，但如果他們罹患H1N1新流感，可能會與季節性流感一樣嚴重。
　　
　　Louie醫師和同事們指出，患有嚴重或致命H1N1新流感的平均年齡偏低，27歲，使得流感與季節性流感「截然不同」。
　　
　　他們指出，大多數的住院者都是病情嚴重，有超過30％需要進加護病房治療；大多數成年人和超過三分之一的兒童需要機械式呼吸器。11％的人死亡，最常見的死亡原因是病毒性肺炎和急性呼吸窘迫綜合症。
　　
　　正如之前數據所顯示的，孕婦嚴重流感的風險比其他健康的婦女更高。
　　
　　Louie醫師和同事們表示，值得注意的是，在他們的系列研究中，有20％住院的孕婦需要加強照顧，大多數是在懷孕的中期或後期。他們指出，類似的觀察在1918年至1919年和1957至1958年的流感大流行時也做過。
　　
　　【肥胖是嚴重H1N1新流感的危險因素】
　　正如其他人所了解的，有超過70％嚴重H1N1新流感的成年人和60％以上的兒童有潛在的疾病。
　　
　　加州的數據增加了越來越多證據顯示，極度肥胖（身體質量指數或BMI 40以上）是嚴重新流感的風險因素之一。加州有將近一半的嚴重案例是肥胖的，43％的BMI在40以上。
　　
　　Louie醫師和同事們指出，將近三分之一患有嚴重新流感的加州肥胖者，沒有既定的風險因素，但許多人有其他症狀，例如高血壓。
　　
　　他們指出，肥胖和嚴重流感之間的關聯雖然還沒有被證實，但似乎是真的。CDC的Frieden醫師同意，肥胖很可能被證明是一個獨立的風險因素。
　　
　　Frieden醫師表示，他們是處在肥胖流行病之中，在過去幾十年來，成人肥胖多了一倍，兒童多了三倍。他們仍在試圖了解這些對民眾的健康有什麼影響。另一個更容易受感染的是，呼吸儲備量和對抗感染的能力降低，這是我們需要進一步了解的事情。


出處: WebMD Health News
作者: Daniel DeNoon
審閱: Louise Chang

失智又罹患流感的年長者比較容易死亡
作者：Janis C. Kelly  
出處：WebMD醫學新聞

　　【24drs.com】November 10, 2009 — 新研究認為，年長者比年輕人更不容易罹患流感，但是，相較於認知正常者，失智患者死於流感的機率增加50%。此外，居住在鄉下或偏遠地區的年長失智患者，其風險更大。
　　
　　第一作者、麻州波士頓Tufts大學醫學院公共衛生與社區醫學教授Elena Naumova博士向Medscape Psychiatry表示，有鑑於全國對於新型流感病毒株的準備，針對美國越來越多的認知障礙年長者，我們的結果對於他們的流感疫苗接種、檢測與治療策略及實務，將有重要影響。
　　
　　這個三叉式研究，分析了肺炎和流感的地理及人口統計學模式，以及這些疾病與健康照護可近性的關係，結果線上登載於10月26日的美國老年醫學會期刊(Journal of the American Geriatrics Society)。
　　
　　【鄉村居民更須注意】
　　這個觀察型研究使用美國醫療保障與醫療救助服務中心(Centers for Medicare and Medicaid Services)的歷史與平均給付資料，輔以其他大型全國資料庫的資訊，對1998至2002年間、超過600萬例肺炎與流感案例進行回顧分析。
　　
　　研究者分析各郡的特定結果、住院天數、住院中死亡百分比、各郡年長人口密度的關聯、護理之家住民的百分比、家庭收入中位數、鄉村性指標。
　　
　　研究顯示，鄉村與比較貧窮的郡，肺炎與流感的比率最高。此外，雖然失智年長者的流感診斷率低，但是他們的死亡率是全國平均值的1.5倍。
　　
　　Naumova博士表示，應特別注意居住於鄉村地區的年長者，必須發展且加強偏遠地區的住院指引，決策者與健康照護提供者必須仔細規劃適合認知缺損病患的服務。
　　
　　就年長者比較容易感染肺炎和流感以及發生併發症來看，Naumova博士表示，這個發現並不全然令人驚訝，不過，她指出，矛頭指向現有體制的一些重要問題。
　　
　　【迅速診斷相當重要】
　　她表示，迅速診斷與治療年長者的流感是重要的，因為延遲會誘發肺炎。失智的年長者特別容易因為一般的呼吸道感染產生併發症，這是因為他們有症狀表達上的困難、不佳的口腔衛生、還有吞嚥問題。Naumova博士表示，社經因素也會影響而延遲接受健康照護，間接增加了併發症風險。
　　
　　她指出，雖然相當多失智病患居住在照護機構內且有健康照護者監督，但失智患者的流感疫苗接種率與檢測率卻都未知。
　　
　　她表示，取得特定健康照護服務的限制也會延遲流感的診斷和治療，而惡化成肺炎這個年長者的第5高死因。本研究幫助我們檢視此一危險族群，現在，需要後續研究，以確認此研究發現且評估年長失智患者的疫苗接種政策。
　　
　　【初步發現】
　　阿茲海默氏症協會醫療與科學辦公室主任William Thies博士受邀對此研究發現發表評論時表示，雖然這些發現相當有趣而複雜，畢竟還是初步結果。
　　
　　他向Medscape Psychiatry表示，事實上，失智患者較少罹患流感可能只是因為較少和社會接觸，此一議題上似乎沒有足夠的資訊可以用來登高一呼而改變健康實務。我們需要有更多研究來充分瞭解流感、肺炎與鄉村地區醫療照護之間的關聯。
　　
　　Naumova博士與 Thies博士皆宣告沒有相關財務關係。國家過敏與感染症研究中心與國家環境健康科學研究中心資助本研究。
　　
　　J Am Geriatr Soc.s線上發表於2009年10月26日。
　　  

Elderly People With Influenza and Dementia More Likely to Die

By Janis C. Kelly
Medscape Medical News

November 10, 2009 — Elderly individuals are less likely than younger people to contract influenza, but those with dementia are 50% more likely to die from the disease compared with their cognitively intact counterparts, new research suggests.

In addition, older individuals with dementia are at even greater risk if they live in a rural or remote area.

"In light of national preparedness for novel influenza strains, our results have important implications for influenza vaccinations, testing, and treatment policies and practices that target the growing fraction of US elderly with cognitive impairment," lead author Elena Naumova, PhD, professor of public health and community medicine at Tufts University School of Medicine in Boston, Massachusetts, told Medscape Psychiatry.

The 3-pronged study, which analyzed geographic and demographic patterns of pneumonia and influenza and the relationship between these diseases and healthcare accessibility, is published online October?26 in the Journal of the American Geriatrics Society.

Special Attention for Rural Residents

The observational study used historical medial claims data from the Centers for Medicare and Medicaid Services supplemented with information from other large national databases to conduct a retrospective analysis of more than 6?million cases of pneumonia and influenza between 1998 and 2002.

The researchers analyzed county-specific outcomes, length of hospital stay, and percentage of deaths in hospital, as well as associations with county-specific elderly population density, percentage of nursing home residents, median household income, and rurality index.

The study showed that rural and poor counties had the highest rates of pneumonia and influenza. In addition, although elderly patients with dementia had a lower frequency of influenza diagnosis, they had a mortality rate that was 1.5-fold higher than the national average.

"Special attention should be paid to the elderly living in rural communities. Clear guidelines for hospitalizations in remote areas have to be developed and reinforced. Policymakers and healthcare administrators should carefully plan appropriate services for patients with cognitive impairment," Dr. Naumova said.

In view of the elderly population's greater vulnerability to infections such as pneumonia and influenza and susceptibility to complications, Dr. Naumova said that the findings were not entirely surprising. However, she added, the data point to some important problems with the current system.

Rapid Diagnosis "Critical"

Rapid diagnosis and treatment of influenza in elderly people is critical because delays can trigger the development of secondary pneumonia, she said. Elderly people with dementia are particularly vulnerable to complications from common respiratory infections because of difficulties in communicating their symptoms, poor oral hygiene, and swallowing problems. Socioeconomic factors may also delay prompt access to healthcare and indirectly increase the risk of complications, said Dr. Naumova.

Although a high proportion of patients with dementia are institutionalized and under supervision of healthcare personnel, rates of influenza vaccination and testing in dementia patients are unknown, she added.

"Limited access to specialized healthcare services can delay diagnosis and treatment of the flu, causing it to progress to pneumonia, the fifth leading cause of death among the elderly. This study has helped us identify this vulnerable population, and now further study is needed to confirm the findings and assess the testing and vaccination policies for older patients with dementia," she said.

Findings "Preliminary"

Commenting on the study's findings, William Thies, PhD, chief medical and scientific officer of the Alzheimer's Association, cautioned that although the findings are "interesting and complex" they are "preliminary."

"The fact that fewer people with dementia get the flu may simply reflect their restricted levels of social contact. There doesn't seem to be sufficient information on this issue to suggest a clarion call for change in health practices. We would need a significant amount of additional research to truly understand the complicated relationships between flu, pneumonia, and rural medical care delivery," he told Medscape Psychiatry.

Dr. Naumova and Dr. Thies have disclosed no relevant financial relationships. The study was funded by the National Institute of Allergy and Infectious Diseases and the National Institute of Environmental Health Sciences.

J Am Geriatr Soc. Published online October 26, 2009.

年長者比較容易死於H1N1流感
作者：Fran Lowry  
出處：WebMD醫學新聞

　　【24drs.com】November 12, 2009 — 根據線上發表於11月12日The Lancet期刊的研究，H1N1流感的死亡率曲線呈現J字型，70歲以上者的死亡率風險最高。
　　
　　墨西哥市墨西哥社會安全研究中心的Santiago Echevaria-Zuna醫師等人寫道，2009年4月，墨西哥首度出現H1N1新型A型流感案例，同時有意料外的死亡案例；目前，這個疾病已經擴散到超過168個國家，我們必須繼續保持警覺，特別是社會人口結構類似墨西哥的國家，可能會有同樣的H1N1死亡率等狀況。
　　
　　本研究的目標是，報告在墨西哥的H1N1流感與擴散情況，並研究與感染、重症及死亡有關的風險因素和保護因素。
　　
　　研究者分析2009年4月28日至7月31日這段期間，前往墨西哥社會安全研究中心所屬診所就醫之類流感患者的流感監控系統資訊。
　　
　　他們發現，墨西哥的第一波H1N1流感大爆發，在4月時發生在墨西哥市都會區聖路易斯波托西以及薩卡特卡斯，持續到6月6日，5月2日時的報告案例數達高峰。
　　
　　這第一波爆發時，死亡率很高，且幾乎所有死亡案例都在墨西哥市區域，而該地也有最多的教學醫院。作者們解釋，這些都在大眾被告知有關H1N1流感症狀資訊之前，而且公共衛生當局尚未準備好因應此新興疾病。
　　
　　第二波大爆發在6月和7月時發生在墨西哥東南部。
　　
　　整體而言，共有63,479例類流感案例，6,945例(11%)確認為H1N1案例，其中，6,407例(92%)為門診病患，475例(7%)住院且存活，63例(<1%)死亡。
　　
　　【年輕人比較容易感染】
　　感染主要發生在年輕人，以10至39歲者最常被感染，這個年齡層共有3,922例(56%)。
　　
　　不過，年長者若感染H1N1會比較嚴重。研究者發現，死亡率曲線呈現J字型，70歲以上者的死亡率風險最高(10.3%)，其他年齡層的死亡率為，60至69歲者為5.7%；50至59歲者為4.5%；40至49歲者為2.7%；30至39歲者為2.0%；20至29歲者為0.9%；10至19歲者為0.2%；1至9歲者為0.3%；1歲以下者為1.6%。
　　
　　分析顯示，H1N1流感的主要症狀為發燒、咳嗽、頭痛、肌肉痛與流鼻水；呼吸困難、呼吸急促、發紺、臥病在床等，則是住院和死亡的預測因素。有慢性疾病的病患，死亡風險增加；有死亡案例報告的慢性疾病，包括高血壓、糖尿病與肥胖。
　　
　　【季節性流感疫苗降低感染風險】
　　作者們也報告指出，接種季節性流感疫苗者的感染風險減少35%。他們認為，包括了H1N1病毒株的季節性疫苗，對於墨西哥人有幫助，該國自從1977年開始使用這種疫苗。
　　
　　作者們寫道，年輕人的高感染率，代表除了與他們的日常活動相關的不同感染源之外，也代表著60歲以上者對於H1N1病毒有某種程度的免疫力。不過，他們也承認，這種可能的保護力理論有所爭論。
　　
　　死亡的63例中有4人(6.3%)是孕婦。這些婦女在發生症狀的最初48小時內都沒有接受抗病毒藥物治療，也都沒有接受流感疫苗。作者們寫道，孕婦們在症狀發生時應立即接受治療，懷孕期間施打疫苗並無禁忌者應考慮接種。
　　
　　研究限制包括，提供資料者的H1N1流感資訊處理能力相關訓練不同、資料不完整，作者們指出，即使是使用最進步的流行病學監控系統也可能如此。
　　
　　作者們結論表示，雖然H1N1病毒擴散到168個國家，還未達1918年流感大流行的程度，有些研究者相信不會那麼嚴重，因為現在對於病毒資訊的掌握更進步。但是，他們警告表示，大流行可能不像我們所預期的那樣；病毒會演化且威脅繼續存在。
　　
　　【知識的迅速進化】
　　編輯評論中，派駐在祕魯的美國海軍醫學研究中心特遣隊V. Alberto Laguna-Torres醫師以及祕魯San Marcos大學的Jorge Gomez Benavides醫師寫道，有關H1N1大流行知識的進化，讓醫界在面對它時建立了更好的能力。
　　
　　他們指出，現在對於季節性流感保護力的瞭解比以前清楚許多，任何年齡層，都可能發生此疫苗對大流行的流感病毒沒有保護力的情況，不過，資料顯示，在1957年大流行之前，在孩童時期曾曝露於H1N1病毒株者，相對上有一些保護力。
　　
　　編輯們支持該研究的結論，他們寫道，必須根據初步結果與有限資源做出決定，有時候無法等到大流行結束來獲得更有力的資訊，目前，我們知道大流行程度未達1918年的高峰，不過，因為全球化與線上溝通的關係，現在的知識進化更勝以往。
　　
　　作者們與編輯們皆宣告沒有相關財務關係。
　　
　　Lancet. 線上發表於2009年11月12日。

Elderly More Likely to Die From H1N1 Influenza

By Fran Lowry
Medscape Medical News

November 12, 2009 — Mortality rates from H1N1 influenza show a J-shaped curve, with those aged 70 years and older having the greatest risk for death, according to the results of a retrospective analysis published online November?12 in The Lancet.

"In April, 2009, the first cases of influenza A H1N1 were registered in Mexico and associated with an unexpected number of deaths," write Santiago Echevaria-Zuna, MD, from the Instituto Mexicano del Seguro Social (Mexican Institute for Social Security), Mexico City, Mexico, and colleagues. "At present the pandemic has spread to more than 168 countries. We therefore need to stay alert — especially in countries with similar sociodemographic characteristics to Mexico, which might share conditions that could potentially contribute to H1N1 mortality."

The aim of this study was to report the timing and spread of H1N1 influenza in Mexico and investigate protective factors and risk factors for infection, severe disease, and death.

The investigators analyzed information from the influenza surveillance system from April 28 to July 31, 2009 for patients with influenza-like illness who attended clinics that were part of the Mexican Institute for Social Security network.

They found that the first large outbreak of H1N1 flu in Mexico affected the Mexico City metropolitan area, San Luis Potosi, and Zacatecas in April, and it lasted until June 6, with a peak number of cases reported on May 2.

During this first outbreak the mortality rate was high and almost all deaths occurred in the Mexico City area, where most teaching hospitals are located. This was before the population had been informed about H1N1 influenza symptoms and health services were not yet prepared for this new disease, the authors explain.

A second large outbreak occurred in southeast Mexico during June and July.

In all, 63,479 cases of influenza-like illness were reported, and 6945 (11%) cases of H1N1 were confirmed. Of these, 6407 (92%) were outpatients, 475 (7%) were admitted and survived, and 63 (<1%) died.

Young People Most Likely to Be Infected

Infection was transmitted mostly among young people, with those aged 10 to 39 years being the most affected. This age group accounted for 3922 cases (56%).

However, H1N1 affected people in the older age groups more severely. The investigators found that mortality rates showed a J-shaped curve. The greatest mortality risk was in those aged 70 years and older (10.3%). Mortality rates in other age groups were 5.7% for 60- to 69-year-olds); 4.5% for 50- to 59-year-olds); 2.7% for 40- to 49-year-olds; 2.0% for 30- to 39-year-olds; 0.9% for 20- to 29-year-olds; 0.2% for 10- to 19-year-olds; 0.3% for 1- to 9-year-olds; and 1.6% for infants younger than 1 year.

The analysis showed that fever, cough, headache, muscle aches, and rhinorrhoea were the main symptoms of H1N1 influenza. Dyspnea, tachypnea, cyanosis, and being confined to bed were prognostic factors for hospital admission and death. Patients with chronic illness had an increased risk for death; reported chronic diseases of those who died were hypertension, diabetes mellitus, and obesity.

Seasonal Influenza Vaccine Lowered Infection Risk

The authors also report that the risk for infection was lowered by 35% in those who had been vaccinated for seasonal influenza. They suggest that the seasonal vaccine, which includes H1N1 components, could have benefited the Mexican population, which has been getting the vaccine since 1977.

"The high incidence of infection in young people could show not only their different exposure related to their daily activities but also that people older than 60 years might have some immunity against the H1N1 virus," the authors write. However, they acknowledge that such possible protection is controversial.

Pregnant women accounted for 4 (6.3%) of 63 deaths. None of these women had received antiviral drugs during the first 48 hours of the onset of their symptoms and none had received influenza vaccine. "Treatment should begin immediately after onset of symptoms in this group, and vaccination during pregnancy is not contraindicated and therefore can be considered," the authors write.

Limitations of the study include provision of information sources by staff who have different training for handling H1N1 influenza infection, and incomplete data, which can occur even when the most advanced epidemiologic surveillance systems are used, the authors point out.

The authors conclude that although the H1N1 virus has spread to 168 countries, it has not reached the dimensions of the 1918 influenza pandemic, and some researchers believe that it will not, given the information on the virus available up to now. But they caution, "This pandemic might not be the one we expected; however, the virus is evolving and the threat continues."

Rapid Evolution of Knowledge

In an accompanying editorial, V. Alberto Laguna-Torres, MD, from the US Naval Medical Research Center Detachment in Lima, Peru, and Jorge Gomez Benavides, MD, from San Marcos University, in Lima, Peru, write that the rapid evolution of knowledge about the H1N1 pandemic has allowed medical groups to establish better capabilities with which to face it.

They add that the likely protection from seasonal influenza vaccine is clearer now than it was previously. "This vaccine fails to protect against the pandemic influenza virus in any age group. However, data show relative protection for people who were exposed to H1N1 strains during childhood before the 1957 pandemic."

The editorialists support the study's conclusion. "Decisions based on preliminary results and limited sources have to be made, and sometimes there is no time to wait for the pandemic to end to have stronger information," they write. "Currently, we know that the pandemic has not reached the dimensions of its predecessor in 1918, but the scientific knowledge has evolved faster than before, probably because of global and online communication."

The authors and editorialists have disclosed no relevant financial relationships.

Lancet. Published online November 12, 2009.

新版H1N1流感指引力主儘快使用抗病毒藥劑
作者：Robert Lowes  
出處：WebMD醫學新聞

　　November 12, 2009 — 世界衛生組織(WHO)的新版H1N1流感治療指引，主張醫師們應儘快開立抗病毒藥物給流感症狀高風險族群、肺炎病患，以及那些無併發症的類流感患者，或過去72小時症狀無改善者。
　　
　　根據週二改版的指引，立即使用抗病毒藥物治療的理由是，輕微的H1N1流感有可能會在24小時內變成致命的肺炎。
　　
　　WHO全球流感計畫醫療官員Nikki Shindo醫師在記者會中表示，這個病毒可能會在一週內奪去性命。就疾病病程而言，一週的治療機會有限，須在病毒侵犯肺部之前就給予藥物。
　　
　　根據Shindo醫師指出，應在出現流感症狀就立即使用抗病毒藥物的高風險病患，包括孕婦、2歲以下孩童、有呼吸道問題的慢性疾病患者。
　　
　　Shindo醫師表示，之前的WHO指引聚焦在治療H1N1病毒造成的重症。她解釋，這次更新的指引可以說是為了預防重症，特別是使用抗病毒藥物。最初的抗病毒藥物指引比較保守，因為WHO對於它們的效果幾乎毫無經驗，而且供貨量有限。現在，WHO有較多有關這些藥物安全性和使用方面的資料，而供應上也比較充沛。
　　
　　更新版的指引中，呼籲醫師們對於疑似H1N1流感患者，不要為了進行試驗確認診斷而延遲使用抗病毒藥物治療，此外，流感快篩檢測陰性也不應作為停止抗病毒藥物治療的依據，因為這些檢測漏失了許多大流行H1N1病毒的感染。
　　
　　根據WHO指出，治療H1N1病毒的第一線抗病毒藥物為oseltamivir (Tamiflu)。如果無法取得oseltamivir、無法給予特定病患、或病毒對oseltamivir有抗藥性，該指引建議醫師使用吸入型的zanamivir(Relenza)。
　　
　　Shindo醫師表示，為了確保輕症患者接受治療，公共衛生當局應提供抗病毒藥物給一般開業醫師，而不是只有給醫院，病患不一定非得到醫院才可以獲得抗病毒藥物處方，這麼做可以確保每個人迅速獲得所需的照護，也能讓醫院有餘力治療較嚴重的案例。
　　
　　雖然Shindo醫師強調需儘快使用抗病毒藥物，但她表示，非屬高風險族群且只有輕微流感症狀者，不需要使用抗病毒藥物治療，健康成人也無需使用抗病毒藥物作為預防策略。
　　
　　【WHO指引和CDC的指令沒有衝突】
　　更新版的WHO指引明定了無併發症的類流感患者、以及沒有足以造成風險之潛在醫療狀況者的72小時觀察期。病情惡化而需使用抗病毒藥物治療的指標包括：
　　* 呼吸短促、低血氧、兒童呼吸急促或無力，可能會造成氧氣不足或心肺損傷。
　　* 精神狀態改變、無意識、困倦、抽搐，可能有中樞神經系統併發症。
　　* 證明有持續的病毒複製或有侵犯性的次級細菌感染。
　　* 嚴重脫水、活動力下降、頭昏眼花、排尿減少、昏睡。
　　
　　Shindo醫師表示，也建議必須進行病患教育，根據WHO指出，對於原本是無併發症的類流感患者，如果發生上述症狀或其他疾病惡化的症狀時、或沒有復原時，應在症狀發生的72小時內回診就醫。
　　
　　疾病控制預防中心(CDC)的國家流感與呼吸道疾病中心流行病學家Anthony Fiore醫師表示，CDC並未對流感病患的追蹤照護提出類似的72小時規定，但是當局認為那些在幾天內沒有改善的病患，可能有二度感染的併發症。
　　
　　Fiore醫師向Medscape Infectious Diseases表示，我不認為WHO的建議和CDC的指定有所衝突。CDC平均每4到6週就更新抗病毒藥物的給藥建議，我們會看看WHO的指引，並根據證據基礎來發展我們的指引。
　　
　　可以在WHO網站獲得這個更新版的治療指引。
　　
　　【CDC的更新資料】
　　今天，CDC國家流感與呼吸道疾病中心主任Anne Schuchat醫師在記者會中，提供了使用CDC新興感染計畫資料推估之估計H1N1案例數的更新資料。
　　
　　CDC估計，在大流行的最初6個月(2009年4月到10月17日)，美國共有2,200萬人(範圍從1400-3400萬)人感染H1N1流感，其中，98,000人(範圍從63,000-153,000) 住院；3900人(範圍從2500 – 6100) 死亡。
　　
　　根據年齡層區分該資料，64歲以下者的案例數、住院數與死亡率，比65歲以上者高很多。
　　
　　她表示，這些數據每3到4週更新。
　　
　　Schuchat醫師也討論了H1N1流感對於糖尿病患的影響，約佔H1N1住院成人的19%。根據Schuchat醫師，糖尿病患應接種疫苗(使用注射型疫苗而非鼻噴型疫苗)以預防H1N1。有糖尿病且有呼吸道疾病者應使用抗病毒藥物治療，且應在檢驗結果出來前就開始治療。糖尿病患者也必須要接種肺炎疫苗。
　　
　　迄今，已經有4,160萬劑H1N1疫苗，Schuchat醫師表示，這遠超過我們過去所有的量，但是還未達我們目前所希望的量，目前，已經提供了9,400萬劑季節性流感疫苗，年底前預計總共有11,400萬劑。
　　
　　Emma Hitt博士撰寫此報告。  


New Guidelines on H1N1 Influenza Urge Quicker Use of Antivirals

By Robert Lowes
Medscape Medical News

November 12, 2009 — Updated treatment guidelines for H1N1 influenza from the World Health Organization (WHO) urge clinicians to administer antiviral medications as soon as possible to patients in at-risk groups with flu symptoms, patients with pneumonia, and those with uncomplicated influenza-like illness that worsens or fails to improve within 72 hours.

The reason for immediate antiviral therapy is that a mild case of H1N1 influenza can morph into a deadly disease such as pneumonia within 24 hours, according to the revised guidelines released Tuesday.

"The virus can take a life within a week," Nikki Shindo, MD, a medical officer in WHO's Global Influenza Programme, said during a press conference today. "The week of opportunity is very narrow in regard to the progression of the disease. The medicine needs to be administered before the virus destroys the lungs."

Patients in at-risk groups who should receive antivirals once they experience flu symptoms include pregnant women, children younger than 2 years, and individuals with chronic illnesses such as respiratory problems, according to Dr. Shindo.

Dr. Shindo said that earlier WHO guidelines focused on treating severe disease stemming from the H1N1 virus. The updated guidelines, she explained, have more to say about preventing severe disease, especially with the use of antiviral medications. Initial guidance about antivirals had been more conservative because WHO "had almost no experience" in regard to their effectiveness and because supplies were limited, said Dr. Shindo. Now, WHO has more data about the safety and usefulness of the medicine, and supplies are more ample.

The updated guidelines state that clinicians should not delay antiviral treatment for patients with suspected H1N1 influenza for the sake of conducting tests to confirm the diagnosis. In addition, a negative result from some rapid influenza diagnostic tests should not justify withholding antiviral therapy because these tests "miss many infections with pandemic H1N1 virus."

The first-line antiviral for treating the H1N1 virus is oseltamivir (Tamiflu), according to WHO. If oseltamivir is not available, it is not possible to administer it to a particular patient, or if the virus is resistant to oseltamivir, the guidelines recommend that clinicians use zanamivir (Relenza), which is inhaled.

To ensure easier access to treatment, public health authorities should distribute antivirals through general practitioners and not primarily through hospitals, said Dr. Shindo. "Patients should not have to visit the hospital to get antivirals prescribed," she said. "This should help ensure that individuals get the care they need faster. This will leave hospitals freer to treat the more severe cases."

Although Dr. Shindo emphasized the need for the earlier use of antivirals, she said that people not in the at-risk groups who are experiencing only mild flu symptoms do not need to take antiviral therapy. Nor should healthy individuals take it as a preventive measure.

WHO Guidelines Do Not Conflict With CDC Directives

The updated WHO guidelines specify watchful waiting for 72 hours for patients who have uncomplicated influenza-like illness and who do not have an underlying medical condition that puts them at risk. Hallmarks of progressive illness that warrant antiviral therapy include:

Shortness of breath, hypoxia, and fast or labored breathing in children, which would suggest oxygen impairment or cardiopulmonary insufficiency.
Altered mental status, unconsciousness, drowsiness, and seizures, which suggest central nervous system complications.
Evidence of sustained virus replication or invasive secondary bacterial infection.
Severe dehydration, expressed as decreased activity, dizziness, decreased urine output, and lethargy.
By necessity, this recommendation for follow-up requires patient education, Dr. Shindo said. Clinicians should instruct patients who initially present with uncomplicated influenza-like illness to return for another visit if they develop these or other symptoms of progressive illness — or do not get better — within 72 hours from the onset of symptoms, according to WHO.

The Centers for Disease Control and Prevention (CDC) have not issued any guidance on follow-up care for influenza patients that stipulates a 72-hour time frame, but the agency does advise patients who do not improve within a few days that they might have a complication like a secondary infection, said Anthony Fiore, MD, a medical epidemiologist with the CDC's National Center for Immunization and Respiratory Diseases.

"I do not see the WHO recommendations as being in conflict [with the CDC directives]," Dr. Fiore told Medscape Infectious Diseases. CDC recommendations on administering antiviral medications are revised on average every 4 to 6 weeks, said Dr. Fiore. "We will look at the WHO guidance and the evidence base used to develop the guidance as part of [our] revision."

The updated treatment guidelines are available on the WHO Web site.

CDC Update

At a CDC press briefing today, Anne Schuchat, MD, director of the CDC's National Center for Immunization and Respiratory Diseases, provided an updated estimate of H1N1 cases using data extrapolated from the CDC’s Emerging Infections Program .

The CDC estimates that during the first 6 months of the pandemic (April through October 17, 2009), a total of 22 million people (range, 14 – 34 million) in the United States became infected with H1N1 influenza. Of these, 98,000 people (range, 63,000 to 153,000) were hospitalized; and 3900 (range, 2500 – 6100) died.

The data are also broken down by age group and highlight that fact that numbers of cases, hospitalizations, and deaths are disproportionately higher in people aged 64 years and younger than in older individuals.

These numbers will be updated every 3 to 4 weeks, she said.

Dr. Schuchat also discussed the effect of H1N1 influenza in patients with diabetes, which afflicts about 19% of adults hospitalized for H1N1. According to Dr. Schuchat, people with diabetes should be vaccinated (with the injectable vaccine not the nasal spray) against H1N1. People with diabetes who also have respiratory illness should receive antiviral therapy, which should be initiated prior to availability of test results. Patients with diabetes should also ensure that they have been vaccinated against pneumococcal infections.

To date, 41.6 million doses of H1N1 vaccine have become available. “This is more than we had before but not as much as we had hoped to have by today,” Dr. Schuchat said. Currently, 94 million doses of seasonal influenza vaccine have been distributed, with 114 million doses total expected by the end of the year.

Emma Hitt, PhD, contributed to this report.

WHO：H1N1疫苗與季節性流感疫苗一樣安全
作者：Emma Hitt, PhD  
出處：WebMD醫學新聞

　　November 19, 2009 — 根據世界衛生組織（WHO）指出，H1N1 2009年大流行流感疫苗顯然與季節性流感疫苗一樣安全。
　　
　　WHO疫苗研究計畫主任Marie-Paule Kieny在網路記者會上表示，根據目前的報告，大約10,000次預防注射才會有1件不良事件；這些不良事件報告中，100件中約有5件被認為是嚴重的。
　　
　　Kieny博士指出，目前這些嚴重不良事件包括30件死亡，以及大約12件格林巴利症候群（Guillain-Barre syndrome）；但她強調，目前並沒有任何1件死亡事件被證實是疫苗造成的。除此之外，所有格林巴利症候群都是暫時的，僅有少數被證實與疫苗有關。
　　
　　Kieny博士附帶表示，季節性與大流行流感疫苗的安全性資料顯然並沒有差異，這兩個疫苗的不良反應事件數目也是相當的。除此之外，不同的大流行流感疫苗安全性也差不多。
　　
　　Kieny博士表示，與大流行流感疫苗有關的不良反應包括不同程度的局部疼痛，注射部位的疼痛、腫脹、發紅、以及發燒、頭痛、肌肉疼痛或是疲倦；這些一般在一、兩天內緩解。
　　
　　她指出，目前接獲的報告並未發現新的安全性問題。
　　
　　Kieny博士表示，迄今至少已經釋出8,000萬劑流感疫苗，其中已接種劑量達6,500萬劑；這些資訊來自16個國家，但我們認為這些是保守估計，因為這些疫苗注射行動目前還在40個國家進行中。
　　
　　WHO預計從這個月底開始將這些疫苗運送到開發中國家。根據Kieny博士表示，這仍有一些延遲，但他們期待在接下來的三個月，疫苗會分配到達95個符合標準的國家。


H1N1 Vaccine as Safe as Seasonal Vaccine, WHO Says

By Emma Hitt, PhD
Medscape Medical News

November 19, 2009 — The H1N1 2009 pandemic influenza vaccine appears to be as safe as the seasonal flu vaccine, according to the World Health Organization (WHO).</p> <p>About 1 adverse event is being reported for every 10,000 doses, said Dr. Marie-Paule Kieny, director of the WHO's Initiative for Vaccine Research, at a virtual press briefing today. Of those adverse event reports, about 5 of 100 are considered serious.</p> <p>According to Dr. Kieny, serious adverse events so far include 30 deaths and about 12 cases of Guillain-Barre syndrome; however, she emphasized that none of the deaths reported to date has been confirmed as being caused by the vaccine. In addition, all cases of Guillain-Barre syndrome have been transient, and only a few have been linked to the vaccine.</p> <p>Dr. Kieny added that there appears to be no difference between the safety profile of the seasonal and pandemic influenza vaccines, and the number of adverse events is comparable between the 2 vaccines. In addition, the safety profiles of the different forms of pandemic vaccine are also similar.</p> <p>Adverse reactions associated with the pandemic vaccine include a variety of local reactions including "pain at injection site, swelling, redness, and reactions such as fever, headache, muscle pain, or fatigue," Dr. Kieny said. "These generally resolve within 1 or 2 days."</p> <p>"No new safety issues have been identified from reports received to date," she said.</p> <p>At least 80 million doses of vaccines have been distributed and 65 million doses have been administered. "These are figures that we have received from 16 countries, but we think they are conservative estimates because immunization campaigns are under way now in 40 countries," Dr. Kieny added.</p> <p>The WHO expects to start shipment of the vaccine to developing countries at the end of this month. According to Dr. Kieny, this represents a slight delay, but they expect that all vaccine doses will reach 95 eligible countries during the next 3 months.

H1N1新流感不像擔心的那麼嚴重
新流感的致死率並沒有比季節性流感高，但死亡者多數為年輕人。


　　Dec. 7, 2009 – 新版預測認為，H1N1新流感並不像擔心的那麼嚴重，但是不可以輕忽大流行。
　　
　　哈佛研究者Marc Lipsitch博士以及英國醫學研究委員會和疾病管制中心(CDC)的研究夥伴預測，當秋冬這一波H1N1新流感結束時，並不會比一般季節性流感更嚴重。
　　
　　Lipsitch博士在新聞稿中表示，好消息是，H1N1的嚴重度比最初擔心的輕微。
　　
　　此次預測有以下重點：
　　* 典型季節性流感的死亡與住院案例多數為年長者；H1N1新流感則多數是造成孩童與年輕人死亡或住院。
　　* 季節性流感致死原因包括心臟病發作、中風與其他流感引起的致命狀況。H1N1新流感的死亡案例幾乎都是因為流感或其細菌併發症。
　　* 新版預測不用機械性輔助呼吸或加護病房照護的人將多出4或5倍。
　　* 如果H1N1新流感轉向年長族群，則所有預測失效。
　　
　　即便如此，新版數據只是令人安心，還不到慶幸的時候。在2009年H1N1新流感到來之前，預估大流行的案例/死亡率比率為0.1%，也就是每1,000位有症狀的感染，就有1人死亡。
　　
　　Lipsitch博士的團隊現在計算的H1N1新流感案例/死亡率比率低於0.048%，依據使用的計算方法不同，還可以低7到9倍。
　　
　　Lipsitch博士在新聞稿中表示，這是一個嚴重的疾病。他指出，有70分之一到600分之一的人因為H1N1新流感而生病住院。
　　
　　CDC謹慎地面對但不強調2009年H1N1新流感的嚴重度特徵。CDC的免疫與呼吸道疾病中心科學副主任Beth Bell醫師表示，新版預測和CDC的研究估計相當一致。
　　
　　Bell醫師向WebMD表示，本研究提出的訊息是，這主要是年輕人的疾病，並強調接種疫苗及採取預防措施的好處和重要性。雖然多數罹患此病者情況大致良好，也可能會相當嚴重－而重症幾乎集中在年輕成人。
　　
　　【H1N1新流感：和1918年流感一樣的肺部傷害】
　　紐約市法醫辦公室的James R. Gill醫師以及國家健康研究中心Jeffrey Taubenberger博士的新研究強調，H1N1新流感可能會變得致命。
　　
　　對34名死於H1N1新流感者仔細驗屍之後發現，此病毒主要傷害上呼吸道，下呼吸道與肺深部傷害不常見。
　　
　　值得注意的是，這個傷害模式相當耳熟。
　　
　　Taubenberger博士在新聞稿中表示，這種呼吸道組織的病理模式和1918及1957年流感大流行的罹難者驗屍報告發現相似。
　　
　　Lipsitch博士的研究登載於12月的線上版期刊PLoS Medicine。Gill醫師的研究於今日線上發表，將登載於2月的病理及實驗室醫學誌(Archives of Pathology and Laboratory Medicine)。


出處: WebMD Health News
作者: Daniel DeNoon
審閱: Louise Chang

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