腸出血性大腸桿菌0104：H4調(diào)查過(guò)程及防控策略課件

腸出血性大腸桿菌0104：H4發(fā)現(xiàn)過(guò)程及防控策略0104：H4電鏡圖片

EHECbacteria,O104:H4outbreakstrain.Scanningelectronmicroscopy.Bar:1μm.Source:Holland,Laue(RobertKochInstitute)

O104:H4

罕見血清型，此前未見暴發(fā)報(bào)道有個(gè)案報(bào)告（2006年韓國(guó)29歲女性HUS）菌株毒力基因志賀樣毒素2基因陽(yáng)性（stx2+）志賀樣毒素1基因陰性（stx1-）粘附基因陰性（eae-）溶血素基因陰性（hly-）腸集聚性大腸桿菌質(zhì)粒（EaggEC）毒力基因aatA、aggR和aap陽(yáng)性臨床救治血液透析/血漿置換幫助排除病菌在患者體內(nèi)釋放的毒素，對(duì)部分患者無(wú)效單克隆抗體Eculizumab(Soliris,依庫(kù)珠單抗）德國(guó)海德堡大學(xué)治療3名年幼HUS成功，但仍需評(píng)估如果血液透析無(wú)效，就注射Soliris如果仍無(wú)好轉(zhuǎn)，則兩種療法同時(shí)使用抗生素因抗生素可增加細(xì)菌毒素釋放，不推薦使用但德國(guó)傳染病學(xué)會(huì)近日建議：可考慮在某些條件下使用碳青霉烯類抗生素、利福平和大環(huán)內(nèi)酯類抗生素德國(guó)應(yīng)對(duì)0104:H4信息流向圖德國(guó)應(yīng)對(duì)0104:H4策略RoutinesurveillancesystemReportstotheEuropeanUnionandtheWorldHealthOrganizationEnhancedsurveillancesystemCentralisingtheepidemiologicalinformationexchangeAcceleratingthedataflowtothenationallevelImplementingasyndromicsurveillancesystemforbloodydiarrhoeainemergencydepartmentsAssessingthecapacitiesforHUS-treatmentinGermanyInitiatingactivelaboratorysurveillance受影響的國(guó)家Source:GermanyRobortKochInstiitute德國(guó)HUS病例年齡別及性別發(fā)病率-截至5月31日Source:GermanyRobortKochInstiitute年齡組發(fā)病率Proportionsofpatientswithbloodydiarrheaamongallpatientsvisitingemergencydepartments,byageandsexaswellasnumberofparticipatingemergencydepartmentsinareasmoreaffectedbytheEHEC/HUSoutbreak,EHEC/HUSoutbreak,Germany,May-June2011(n=1,021)

Source:GermanyRobortKochInstiituteBackprojectionfromthedailyonsetsofdiseasetotheexposureperiodupto90%ofHUScasesprobablyfallswithintheperiodbetween5Mayand24MaySource:GermanyRobortKochInstiituteHUScasespresentedchronologically:Onsetofdisease,dateofhospitalization,ofdiagnosis,ofnotificationtohealthauthorities,andofreceiptofnotificationattheRKI(reporting)

Source:GermanyRobortKochInstiituteResultsoftheunivariateandmultivariateanalysisofriskfactorsforthedevelopmentofbloodydiarrhoeaintwocanteensinFrankfurtamMain

Source:GermanyRobortKochInstiitute

Recipe-BasedRestaurantCohortStudy

10groupswithatotalof176participantscouldbeidentified,whodinedinthesamerestaurantduringtheperiodfrom12to16May2011

Therewere168personsincludedintheanalysis.Atotalof31(18%)personsfromthegroupscontractedbloodydiarrheaorEHEC/HUS.FruitandvegetableexposuresassociatedwiththeincidenceofHUS(p-value<0.1)intheunivariateanalysisoftherawvegetablecase-controlstudyAtotalof26cases(9men,17women)and81controlswithatargetratioof1:3byagegroup(18-34years,35-44years,45yearsorolder),genderandresidenceSource:GermanyRobortKochInstiitute病例數(shù)AsofJuly,25th2011;10.00amDuringtheoutbreakperiodatotalof4,321caseswerereportedtotheRKIincluding3,469EHECcasesand852HUScasesIntotal50patientsdied,including18EHECpatientsand32HUSpatientsAsofJuly,22nd2011AccordingtotheEuropeanCentreforDiseasePreventionandControl76EHECincluding1patientwhodied49HUScaseswerereportedacrossothercountriesoftheEuropeanUnionPressReleaseofRobertKoch-InstituteTheoutbreakisconsideredtobeover

July,26th2011

InthepastseveralweekstheRobertKochInstitutereportedsporadiccasesofEHEC-infection/HUSrelatedtothecurrentoutbreak.Thelastonsetofdiseasetobeattributedtotheoutbreakwasreportedon4July2011.SincethatdatenonewcasesofthediseaserelatedtotheoutbreakhavebeennotifiedtotheRKIandthereforetheRKIconsiderstheoutbreaktobeover.Thethreeweekstimeperiodtakesintoaccounttheincubationperiod,thediagnosticsperiodaswellastheperiodforreportingofacase."ThismeansthatthelargestEHECoutbreakinGermanyisoverSource:GermanyRobortKochInstiituteO104:H4應(yīng)對(duì)準(zhǔn)備做好技術(shù)準(zhǔn)備（國(guó)家CDC)實(shí)驗(yàn)室儲(chǔ)備標(biāo)準(zhǔn)血清建立檢測(cè)毒力基因方法合成特異性PCR檢測(cè)引物起草并在網(wǎng)站發(fā)布實(shí)驗(yàn)室檢測(cè)方案可進(jìn)行菌株血清分型、分子生物學(xué)檢測(cè)和溯源比對(duì)等防控指導(dǎo)根據(jù)部應(yīng)急辦指示，起草防控方案協(xié)助臨床專家修改臨床救治指南7日下午召開（各省市區(qū)、19個(gè)口岸城市CDC及重大專項(xiàng)網(wǎng)絡(luò)實(shí)驗(yàn)室）視頻會(huì)議，通報(bào)疫情進(jìn)展，指導(dǎo)監(jiān)測(cè)和實(shí)驗(yàn)室檢測(cè)O104:H4風(fēng)險(xiǎn)評(píng)估

衛(wèi)生部應(yīng)急辦/國(guó)家CDC暴發(fā)菌株通過(guò)食品傳入我國(guó)風(fēng)險(xiǎn)低暴發(fā)為食源性傳播未發(fā)現(xiàn)人與人之間接觸所致廣泛傳播證據(jù)我國(guó)從歐洲進(jìn)口的生鮮蔬菜和其他食品數(shù)量有限可能出現(xiàn)赴德旅行或歸國(guó)人員在德感染病例，但輸入性病例因糞-口途徑導(dǎo)致該病國(guó)內(nèi)廣泛傳播可能性小如我國(guó)發(fā)現(xiàn)少量輸入性病例，亦不必啟動(dòng)高級(jí)別應(yīng)急反應(yīng)機(jī)制HUS病死率高須關(guān)注病例救治指導(dǎo)各地醫(yī)療機(jī)構(gòu)做好病例的發(fā)現(xiàn)、報(bào)告、檢測(cè)和病例管理腸出血性大腸桿菌防控策略疾病監(jiān)測(cè)腹瀉病人（必要時(shí)增加腎臟科病人）食品宿主動(dòng)物預(yù)防控制預(yù)防措施健康教育及風(fēng)險(xiǎn)溝通風(fēng)險(xiǎn)評(píng)估疫情控制措施全國(guó)腸出血性大腸桿菌O157∶H7感染性腹瀉

應(yīng)急處理預(yù)案疑似病例有鮮血便、低燒或不發(fā)燒、痙攣性腹痛的腹瀉病例腹瀉若干天后繼發(fā)少尿或無(wú)尿等表現(xiàn)的急性腎功能衰竭病例腹瀉病人糞便標(biāo)本O157抗原免疫膠體金方法檢測(cè)陽(yáng)性者

符合以上條件之一者，即為疑似病例

全國(guó)腸出血性大腸桿菌O157∶H7感染性腹瀉

應(yīng)急處理預(yù)案確診病例疑似病例或其他腹瀉病患者，具有以下條件之一者即為確診病例從糞便標(biāo)本中檢出產(chǎn)生志賀毒素的腸出血性大腸桿菌O157：H7或恢復(fù)期血清O157脂多糖(LPS)IgG抗體呈4倍升高或經(jīng)蛋白印記試驗(yàn)證實(shí)血清標(biāo)本有與O157LPS、或腸出血性大腸桿菌溶血素、或志賀毒素分子量一致的特異性抗體腹瀉病例的糞便中分離出不產(chǎn)生志賀毒素1或志賀毒素2及其變種的腸出血性大腸桿菌O157：H7，亦為確診病例(不產(chǎn)毒)臨床病例在流行區(qū)內(nèi)，經(jīng)省級(jí)專家組確認(rèn)，與確診病例流行病學(xué)密切相關(guān)，并排除其它疾病的疑似病例

腸出血性大腸桿菌O104:H4感染防控方案

中疾控疾發(fā)[2011]270號(hào)病例定義疑似病例發(fā)病前10天內(nèi)有腸出血性大腸桿菌感染流行地區(qū)的旅行或居住史，或者發(fā)病前10天內(nèi)與臨床診斷/實(shí)驗(yàn)室確診病例有密切接觸，且符合下列條件之一者有血性腹瀉或腹部痙攣性疼痛等癥狀，無(wú)實(shí)驗(yàn)室證據(jù)診斷為其他非EHECO104:H4病原者；有微血管病性溶血性貧血（外周血涂片破碎紅細(xì)胞≥2％）、血小板減少、腎臟受累（血尿、蛋白尿、急性腎損傷）等HUS臨床表現(xiàn)者。腸出血性大腸桿菌O104:H4感染防控方案

中疾控疾發(fā)[2011]270號(hào)病例定義實(shí)驗(yàn)室確診病例：疑似病例，符合下列二項(xiàng)之一者從糞便標(biāo)本中分離到EHECO104:H4菌株,stx1和/或stx2基因檢測(cè)陽(yáng)性從糞便標(biāo)本中檢測(cè)到stx1和/或stx2基因陽(yáng)性，同時(shí)aggR、wzy（O104)和fliC(H4)基因檢測(cè)全部陽(yáng)性臨床診斷病例：在同一起暴發(fā)疫情中與實(shí)驗(yàn)室確診病例流行病學(xué)密切相關(guān)，并排除其他疾病的疑似病例病例的報(bào)告與處置病例報(bào)告（醫(yī)療機(jī)構(gòu)）大疫情報(bào)告：感染性腹瀉，備注標(biāo)注菌株血清型屬地疾控中心采集