流感与肺炎的关系及疫苗联合预防

流感与肺炎的关系及疫苗联合预防,历史数据表明继发性细菌性肺炎是流感大流行期间/流行后以及季节性流感重要的致死因素1,2,“一旦被流感绑架，继发性感染就成了刽子手”- Louis Cruveihier1,Morens DM, Taubenberger JK, Fauci AS. Predominant role of bacterial pneumonia as a cause of death in pandemic influenza: Implications for pandemic influenza preparedness. Journal of Infectious Diseases 2008;198(Oct 1):962-70 Klugman KP, Madhi SA. Pneumococcal vaccines and flu preparedness. Science. 2007 Apr 6;316(5821):49-50,真正的杀手肺炎球菌!1918,1918年全球流感大流行夺走了大约4000-5000万人的生命，而绝大部分死亡病例并非死于单纯流感病毒感染，受害者主要是死于流感病毒感染后发生的细菌性肺炎1,2，其中最主要的致病菌是肺炎球菌 Morens、Taubenberger和Fauci发现，死于流感大流行的患者尸体解剖标本检查结果“均表现出了严重病变，提示感染细菌性肺炎”；对军队和平民的尸检也发现主要的致病菌是肺炎球菌3Brundage和Shanks发现，流感大流行期间死亡患者肺部经常能够分离到3型和4型肺炎球菌4,McCullers JA. Insights into the interaction between influenza virus and pneumococcus. Clinical Microbiology Reviews 2006;19:571-82.Bacterial Pneumonia Caused Most Deaths in 1918 Influenza Pandemic Implications for Future Pandemic Planning. NIH (National Institute of Health) News, August 19, 2008 /news/health/aug2008/niaid-19.htmMorens DM, Taubenberger JK, Fauci AS. Predominant role of bacterial pneumonia as a cause of death in pandemic influenza: Implications for pandemic influenza preparedness. Journal of Infectious Diseases 2008;198(Oct 1):962-70Brundage JF, Shanks GD. Deaths from bacterial pneumonia during 1918-19 influenza pandemic. Emerging Infectious Diseases 2008;14(Aug):1193-9WHO. 23-valent pneumococcal polysaccharide vaccine WHO position paper. Weekly Epidemiological Record. No.42, 2008, pp. 373-584 /entity/immunization/documents/Chinese_PPV23_5-Mar_09.pdf,据WHO估计有720的流感患者继发细菌性肺炎，病死率高达20365,西班牙流感(A/H1N1),真正的杀手肺炎球菌！1957,1957年亚洲流感大流行期间，美国各种呼吸道疾病特别是肺炎造成的住院和死亡数量均显著增加一项病例个案系列分析发现，流感病毒感染后出现肺炎的患者分离到的细菌主要是肺炎球菌、流感嗜血杆菌和金黄色葡萄球菌,Brundage JF. Interactions between influenza and bacterial respiratory pathogens: Implications for pandemic preparedness. Lancet Infectious Diseases 2006;6:303-12,肺炎球菌,亚洲流感(A/H2N2),真正的杀手肺炎球菌！1968,1968年香港流感大流行期间，美国死亡率过高的原因其中大多是由于细菌性肺炎的增加美国明尼苏达州罗切斯特的一项统计，在127例流感患者中16%继发肺炎，其中40%死亡,Brundage JF. Interactions between influenza and bacterial respiratory pathogens: Implications for pandemic preparedness. Lancet Infectious Diseases 2006;6:303-12,香港流感(A/H3N2),真正的杀手肺炎球菌！2009,2009年3月24日-4月29日仅一个多月的时间，墨西哥报告2155例重症肺炎，包括821例住院患者和100例死亡,Chowell G, Bertozzi SM, Colchero MA, Lopez-Gatell H, Alpuche-Aranda C, Hernandez M, Miller MA. Severe Respiratory Disease Concurrent with the Circulation of H1N1 Influenza. N Engl J Med. 2009 Jun 29,墨西哥流感(A/H1N1),历史数据证明：流感肆虐的真正杀手肺炎球菌！,Chowell G, Bertozzi SM, Colchero MA, Lopez-Gatell H, Alpuche-Aranda C, Hernandez M, Miller MA. Severe Respiratory Disease Concurrent with the Circulation of H1N1 Influenza. N Engl J Med. 2009 Jun 29Brundage JF. Interactions between influenza and bacterial respiratory pathogens: Implications for pandemic preparedness. Lancet Infectious Diseases 2006;6:303-12 /csr/disease/influenza/pandemic10things/zh/McCullers JA. Insights into the interaction between influenza virus and pneumococcus. Clinical Microbiology Reviews 2006;19:571-82.Bacterial Pneumonia Caused Most Deaths in 1918 Influenza Pandemic Implications for Future Pandemic Planning. NIH (National Institute of Health) News, August 19, 2008 /news/health/aug2008/niaid-19.htmWHO. 23-valent pneumococcal polysaccharide vaccine WHO position paper. Weekly Epidemiological Record. No.42, 2008, pp. 373-584 /entity/immunization/documents/Chinese_PPV23_5-Mar_09.pdf,季节性流感的真正杀手也是肺炎球菌,流感病毒与病原菌之间的相互影响并不局限于流感大流行的情况下，在季节性流感中同样如此1据报道，在美国流感流行季节中约50%的死亡病例死于肺炎，其中绝大部分是肺炎球菌造成的2,Brundage JF. Interactions between influenza and bacterial respiratory pathogens: Implications for pandemic preparedness. Lancet Infectious Diseases 2006;6:303-12.Gross, Terry. The Next Pandemic: Bird Flu, or Fear? NPR (National Public Radio). February 2, 2006. /templates/story/story.php?storyId=5183999,肺炎球菌,一旦被流感绑架，肺炎球菌就成了刽子手,人体感染流感病毒后呼吸道组织结构被破坏，造成呼吸道及全身免疫功能下降，更容易导致肺炎球菌侵入机体并引起肺部炎症肺炎球菌还可能侵入血流产生菌血症，引发侵袭性肺炎、脑膜炎、心内膜炎等1，严重的甚至造成死亡,Salyers AA, Whitt DD. In: Bacterial Pathogenesis: A Molecular Approach. 2nd ed. Washington, USA: ASM Press; 1994. p. 322-31,流感继发肺炎的高危人群,儿童、老人和慢性疾病患者都是这两种疾病的易感人群感染后都可能引起严重的并发症一旦感染患病，疾病负担都较大，甚至可能威胁生命,Honkanen PO, Keistinen T, Kivel SL. Reactions following administration of influenza vaccine alone or with pneumococcal vaccine to the elderly. Arch Intern Med. 1996 Jan 22;156(2):205-8,高危人群：儿童,儿童是流感发病率最高的人群，每年全世界20%的儿童感染流感1；流感流行期间，学龄前儿童发病率可超过40%，在校学生可达30%2儿童也是肺炎球菌携带率最高的人群，估计在20-40%的儿童鼻咽部能够发现肺炎球菌，而在托儿所、幼儿园等集体生活的儿童高达40-60%3儿童中肺炎球菌性疾病传播迅速、发病率高,Nicholson KG, Wood JM, Zambon M. Influenza. Lancet. 2003 Nov 22;362(9397):1733-45Neuzil KM, Mellen BG, Wright PF, Mitchel EF Jr, Griffin MR. The effect of influenza on hospitalizations, outpatient visits, and courses of antibiotics in children. N Engl J Med. 2000 Jan 27;342(4):225-31Musher DM. Streptococcus pneumoniae. In: Mandell, Douglas and Bennetts principles and practice of infectious diseases. 5th Edition. (PNEUMO23 Product Monograph. Sanofi Pasteur. P9),高危人群：儿童,肺炎是儿童流感最常见的并发症之一，据WHO的统计，肺炎是全球儿童的第一杀手，每年约有200万儿童因肺炎死亡1，也是中国5岁以下儿童的首位死因2WHO估计每年有近100万儿童死于肺炎球菌性疾病，是5岁以下儿童疫苗可预防疾病的第一位死因3,UNICEF/WHO,Pneumonia: The forgotten killer of children.肺炎:被遗忘的儿童杀手. 2006 王艳萍 等. 1996至2000年全国5岁以下儿童死亡监测主要结果分析. 中华预防医学杂志. 2005;39(4):260-264Pneumococcal vaccines WHO position paper WER No.14,2003;78:110119 WHO official mortality rates-June 2003,高危人群：老年人,老年人是流感严重并发症发病率最高的人群，美国90%的流感/肺炎引起的死亡都是65岁以上的老年人1在老年人中，流感/肺炎的超额住院率也很高2患有高危疾病的老年人（65岁）：476-636/10万没有高危疾病的老年人：150-172/10万15-44岁健康成人：23-25/10万在65岁以上的人群中，流感最常见的重要并发症是病毒性或细菌性肺炎，这些患者中约10-20%会导致死亡3,Fiore AE, Shay DK, Broder K, Iskander JK, Uyeki TM, Mootrey G, Bresee JS, Cox NS; Centers for Disease Control and Prevention (CDC); Advisory Committee on Immunization Practices (ACIP).Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008.MMWR Recomm Rep. 2008 Aug 8;57(RR-7):1-60Barker WH, Mullooly JP. Impact of epidemic type A influenza in a defined adult population. Am J Epidemiol. 1980 Dec;112(6):798811Fields BN, Knipe DM, Howley PM.Fields virology. Lippincott-Raven publishers,phildelphia,1996:1397-1445,高危人群：慢性疾病患者,慢性疾病患者的全身及呼吸道免疫机能减退，更容易发生呼吸道感染，一旦感染流感/肺炎，会进一步诱发和加重原有疾病，雪上加霜更危险慢性心血管病慢性肺部疾病（哮喘、慢性支气管炎、肺气肿等）糖尿病慢性肝肾疾患1,2 慢性疾病患者一旦感染菌血症性肺炎球菌性肺炎，病死率将超过50%3,Fiore AE, Shay DK, Broder K, Iskander JK, Uyeki TM, Mootrey G, Bresee JS, Cox NS; Centers for Disease Control and Prevention (CDC); Advisory Committee on Immunization Practices (ACIP).Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008.MMWR Recomm Rep. 2008 Aug 8;57(RR-7):1-60CDC. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1997 Apr 4;46(RR-8):1-24WHO. Pneumococcal vaccines. WHO position paper. Weekly Epidemiological Record. No.14, 2003, pp. 97-120,高危人群防流感，更要警惕背后的杀手肺炎球菌,儿童、老年人及慢性疾病患者等高危人群在流感大流行期间不但应注意预防流感，更应及时接种肺炎球菌疫苗，抵抗肺炎球菌侵袭。我们无法阻止流感流行的脚步，但我们可以帮助高危人群及时接种流感疫苗和肺炎球菌疫苗，共筑防护网，不让惨痛的历史重现！,权威机构建议：接种肺炎球菌疫苗，刻不容缓,大流行间歇期、大流行预警期内和大流行期间努力提高肺炎球菌疫苗覆盖率是预防流感后继发社区获得性肺炎的重要措施之一1 部分国家和国际流感大流行准备方案已经将推广肺炎球菌多糖疫苗做为这些准备计划的一部分 美国CDC与健康与公众服务部2加拿大国家免疫专家委员会（NACI）3法国4WHO：在流感大面积暴发期间接种23价肺炎球菌多糖疫苗可降低肺炎球菌菌血症及相关并发症的威胁5,HHS Pandemic Influenza Plan. U.S. Department of Health and Human Services. November 2005. /pandemicflu/plan/pdf/HHSPandemicInfluenzaPlan.pdfUse of Pneumococcal Vaccines for Influenza Pandemic Preparedness. Pandemic F. US Department of Health and Human Services. /vaccine/pneumococcal.htmlThe Canadian Pandemic Influenza Plan for the Health Sector: Section 4, Response. http:/www.phac-aspc.gc.ca/cpip-pclcpi/s04-eng.phpPlan gouvernemental de prvention et de lutte Pandmie grippale . http:/www.grippeaviaire.gouv.fr/IMG/pdf/Plan_pandemie_grippale_janvier_2006.pdfWHO position paper on 23-valent pneumococcal polysaccharide vaccine. Wkly Epidemiol Rec 2008 Oct 17;83(42):373-84,流感疫苗+肺炎疫苗，给呼吸道带来全面保护,采用不同的注射器并在不同部位接种的情况下，可同时接种流感疫苗和肺炎球菌疫苗1,2,Sanofi Pasteur. Company Core Data Sheet. Pneumo23. July 2007Sanofi Pasteur, Pneumo 23 product prescribing information. June 2005,联合接种流感疫苗+肺炎疫苗高危人群更周全的保护,儿童、老人及各种慢性疾病患者（慢性心血管疾病、慢性肺病、糖尿病等）是流感及肺炎球菌性疾病的高危人群美国预防接种咨询委员会(ACIP)推荐：流感或肺炎高危人群应接种流感疫苗和肺炎球菌疫苗,Fiore AE, Shay DK, Broder K, Iskander JK, Uyeki TM, Mootrey G, Bresee JS, Cox NS; Centers for Disease Control and Prevention (CDC);